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HANDBOUND 
AT  THE 


MEDICAL   RECORD 


A    Weekly  yournal  of  Medicine  and  Surgery 


EDITED     BY 

GEORGE    F.  SHRADY,  A.M.,  IVI.D. 


SUBGEON  TO  ST.    FRANCIS  HOSPITAL,    NEW   YORK;    CONSULTING    SURGEON   TO    THE    NEW  YORK   CANCBR    HOSPITAL,   AND    CONSULTING 
PHYSICIAN-IN-CHIBF   TO   THE    HOSPITALS   OF   THE    HEALTH    DEPARTMENT   OF   THE    CITY    OF    NEW    YORK 


JULY  6,  1895  — DECEMBER  28,  1895 


"b 


NEW    YORK 
WILLIAM     WOOD     &     COMPANY 

1895 


Trow  Directory, 

Prin'ting  and  Bookbinding  Company, 

201-213  ^"^l  i2th  Street, 

New  York. 


N 


LIST    OF  CONTRIBUTORS  TO   VOL.  XLVIII. 


Abrahams,  Dr.  R.,  New  York. 
Allen,  Dr.  Charles  W.,  New  York. 
Allport,  Dr.  F.,  Minneapolis,  Minn. 
Ames,  Dr.  F.  H.  S.,  Denver,  Co', 
Andrews,  Dr.  A.  J.,  Brooklyn,  N.  Y. 
ASHMEAD,  Dr.  Alberts.,  New  York. 
Avers,  Dr.  Edward  A  ,  New  York. 

Babcock,  Dr.  R.  H.,  Chicago,  III. 

Bailey,  Dr.  Pearce,  New  York. 

Baldwin,  Dr.  E.  R.,  Saranac  Lake, 
N.  Y. 

Bannan',  Dr.  T.,  Syracuse,  N.  Y. 

Barkan,  Dr.  Louis,  Brooklyn,  N.  Y. 

Barney,  Dr.  Joseph  N.,  Jr.,  Wood- 
stock, Va. 

Baruch,  Dr.  Simon,  New  York. 

B.^shore,  Dr.  H.  B.,  Fairview,  Pa. 

B.\TES,  Dr.  W.  H.,  New  York. 

Baylies,  Dr.  E.  B.,  Diyton,  O. 

Beatly,  Dr.  W.  Kirker,  Long  Isl- 
anl  City,  N.  Y. 

Bell,  Dr.  J.  N.,  Detroit,  Afich. 

Bennett,  Dr.  C.  L.,  Agues  Calientes, 
Mexico. 

Berry,  Dr.  William  B.,  Passadena, 
Cal. 

Bissell,   Dr.  J.  Douoal,  New  York. 

Blackford,  Dr.  C.  M.,  Lynchburg, 
Va. 

Blech,  Dr.  GusTAvas,  Detr  jit,  Mich. 

Bleyer,  Dr.  J.  Mount   New  York. 

Booth,  Dr.  J.  Arthur,  New  York. 

Boteler,  Dr.  W.  C,  Kansas  City, 
Kan. 

Bower.man,  Dr.  A.  C,  Pictou,  On- 
tario. 

Bradshaw,  Dr.  J.  H.,  Orange,  N.  J. 

Breen,  Dr.  A.  E.,  Rochester,  N.  Y. 

Bre.mer,  Dr.  Ludwig,  St.  Louis,  Mo. 

Brendon,  Dr.  E.  V.,  New  York. 

Brown,  Dr.  J.  S.,  Montcla'r,  N.  J. 

Buchanan,  Dr.  J.  J.,  Pittsburg,  Pa. 

Buck,  Dr.  Albert  H.,  New  York. 

Bulklev,  Dr.  L.  D.,  New  York. 

BuLLARD,  Dr.  William  L.,  Colum- 
bus, Ga. 

Burrall,  D.'.  F.  A.,  New  Yoik. 

Cabot,  Dr.  John,  New  York. 
Cadwall\der,    Dr.   R.,    Fall    River 

Mills,  Gil. 
Chapin,  Dr.  H.  D.,  New  York. 
Chees.man,  Dr.  Hobart,  New  York. 
Cole,  Dr.  Carter  S.,  New  York. 
Cole,  Dr.  W.  F.,  Waco,  Tex. 
Cole.man,  Dr.  Warren,  New  York. 
Collins,  Dr.  C.  C,  Roachdile,  Ind. 
Collins,  Dr.  Joseph,  New  York. 
Corson,  D..  E.  R.,  Savannah,  Ga. 
Con-AM,    Dr.    G.  G.,  Rock  Rapids, 

la. 
Coudert,    Dr.     Frank    Edmonds, 

Wallingford,  Conn. 


Cowl,  Dr.  \V.  G.,  Cincinnati,  O. 
CuRRiE,  Dr.  D.  A.,  Englewood,  N.  J. 

Dana,  Dr.  Charles  L.,  Nrw  York. 
Davis,  Dr.  A.  A.,  NewYoik. 
Davison,    Dr.  W.  A.,    Fort    Benton, 

Mont. 
Dawkarn,  Dr.  R.  H.  M..  New  York. 
Dees,  Dr.  W.  W.,  New  York. 
De  .Mund,  Dr.  J.  T.,  Ringwood,  N.  J. 
Denison,  Dr.  Charles,  Denver,  Co'. 
DoDSON,  L.  W  ,  Binghamton    N.  Y. 
Doege,  Dr.  K.  W.,  Maishfield,  \\'is 
DiLLER,  Dr.  T.,  Pittsburg,  Pa. 

Einhorn,  Dr.  Max,  New  York. 
Elliot,  Dr.  George  T.,  New  York. 
Elliott,  Dr.  H.,  Woodhaven,  N.  Y. 
Ellis,  Dr.  R.,  Danbury,  Conn. 
Ely,  Dr.  John  Si.ade,  New  York. 
Engel,  Dr.  Carl,  Minden,  la. 
Erd.mann,  Dr.  John  F.,  New  York. 
EsKRiDGE,  Dr.  J.  T.,  Denver,  Col. 
Evans,  Dr.  T.  C.,  Louisville,  Ky. 

Fabricius,  Dr.  F.  W.  A.,  New  York. 
Fahrney,  Dr.  E.  C,  Harrisburg,  Pa. 
Flint,  Dr.  Austin,  Jr.,  New  York. 
Fischer,  Dr.  Louis  C,  New  York. 
Fisher,  Dr.  M.  E.,  Dehvan,  N  Y. 
Fitzpatrick,  Dr.  C.  B.,  New  York. 
Eraser,  Dr.  D.  B.,  Stratford,  Ont. 
Free,  Dr.  James  E.,  Billings,  Mont. 
Freeman,  Dr.  L.,  Denver,  Col. 
Fridenberg,  Dr.  Percy,  New  York. 
Fullerton,  Dr.  E.  B.,  Columbus,  O. 
Fulton,  Dr.  J.  A.,  Astoria,  Ore. 

Gage,  Dr.  W.  V.,  McCook,  Neb. 
Galloway,  Dr.  D.  H.,  Chicago,  111. 
Galloway.   Dr.  William  A  ,  Xenia, 

O. 
Gibbons,  Dr.  J.  T.,  Brooklyn,  N.  Y. 
Gilliam,  Dr.  G.  Tod,  Columbus,  O. 
Cleaves,  Dr.  C.  W..  Wytheville,  Va. 
Goelet,  Dr.  AuGUSTiN  H.,  New  York. 
Goldstein,  Dr.  Samuel,  New  York. 
Gradle,  Dr.  H.,  Chicago,  111. 
Graefe,  Dr.  Charles,  Smdusky,  O. 
Grandin,  Dr.  Egbert  H.,  New  York. 
Gray,  Dr.  F.  D.,  Jersey  City,  N.  J. 
Greene,  Dr.  J.  H.,  D.ibuque,  la. 
Greene,  Dr.  ^V.  T  ,  Belvedere,  Kent, 

England. 
Grimm,  Dr.  A.  S.,  St.  Mary's,  W.  Va. 
Gross,  Dr.  M.,  New  York. 
Ground,  Dr.  W.  E.,  Superior,  Wis. 

Hall,  .\.  L.,  Fair  Haven,  N.  Y. 
Hall,  Dr.  H.  C,  Telluride,  Col. 
Hall,  Dr.  Rufus  B.,  Cincinnati,  O. 
Ha.mmond,  Dr.  G.  M.,  New  York. 
Hance,  Dr.  Irwin  H.,  New  York. 
Hartwig,  Dr.  M.,  Buffilo,  N.  Y. 


Hayward,  Dr   C.  E  ,  Cropsey,  111. 
Heiman,  Dr.  Henry,  New  York. 
Henderson,  Dr.  A.   H.,  Mone,  Shan 

States,  Burma. 
Hibbard,  Dr.  S.  Dana,  New  York. 
Higgins,  Dr.  F.  W.,  Cortland,  N.  Y. 
Hi.MOwiCH,  Dr.  A.  A.,  New  York. 
HiNMAN,  Dr.  G.  R.,  Chesaning,  Mich. 
Hitz     Dr.    Henry    B.,    Milwaukee, 

Wis. 
HoGE,  Dr.  M.  D.,  Jr.,  Richmond,  Va. 
Holtzclaw,    Dr.    C,    Chattanooga, 

Tenn. 
Hopkins,  Dr.  F.  E.,  New  York. 
Howard,  Dr.  J.  T.,  Washington,  D.C. 
Howitt,  Dr.  H.,  Guelph,  Ont. 
Hrdlicka,  Dr.  A.,  Middletown,  N.  Y. 
Hughes,  Dr.  M.  E. ,  Adams,  Mass. 
Hughlett,  Dr.  W.  L.,  Cocoa,  Fla. 
Humphrey,  Dr.  W.  D.,  Virginia,  111. 
Hupp,  Dr.  F.  L.,  Wheeling,  W.  Va 
Hutchinson,  Dr.  W.,  Des  Moines, 

la. 

Jaisohn,  Dr.  P.,  Wahington,  D.  C. 
Janewav,  Dr.  Edward  G.,  New  York. 
Johnson,   Dr.   S.  T-,  Mount  Vernon, 

N.  Y. 
Jones,  Dr.  Louis  H.,  Atlanta,  Ga. 
Jones,  Dr.  M.  A.  D.,  New  York. 
Judson,  Dr.  A.  B  ,  New  York. 

Kahn,   Dr.  S.  G.,  Leadville,  Col. 
Kearney,  Dr.  Tho.mas  J.,  New  York. 
Kei.sey,  Dr.  Charles  B.,New  York. 
Kemp,   Dr.  R.   C,  New  York. 
Kent,  Dr.  James  L.,  Bertha,  Va. 
King,  Dr.  John  C,  Banning,  Cal. 
Klingensmith,  Dr.  I.  P.,  Blairsville, 

Pa. 
Koehler,  Dr.  George  F.,  Portland, 

Ore. 

Landes,  Dr.  Leonard,  New  York. 
Lanphear,  Dr.  E.,  St.  Louis,  Mo. 
Law,  Professor  Ja.mes,  Ithaca,  N.  Y. 
Lawrence,  Dr.  F.  F.,  Columbus,  O. 
Leder.man,  Dr.  M.  D.,  New  York. 
Le^fingwell,    Dr.    Albert,    Cam- 
bridge, Mass. 
Lenhart,  Dr.  C.  M.,  Zanesville,  O. 
Lesser,  Dr.  A.  Monae,  N^w  York. 
Lewinthal,  Dr.  D.  C,  New  York." 
Lewis,  Dr.   B.,  St.  Louis,  Mo. 
Lewis,  Dr.  Denslow,  Chicago,  111. 
Lindsay,  Dr.  J   T.  M.,  Cuero,  Tex. 
Linsley,  Dr.  J.  H  ,  Burlington,  Vt. 
Litten,  Dr.  M.,  Berlin,  Germany. 
LoCKWOOD,   Dr.   C.   E.,  New  York. 
Long,  Dr.  J.  W.,  Richmond,  Va. 
LusK,  Dr.  Zera  J.,  Warsaw,  N.  Y. 

.McClain,  Dr.  W.  A.,  Athens,  O. 
McCouRT,  Dr.  P.  J.,  New  York. 


CONTRIBUTORS   TO    VOL.   XLVIII. 


McCuLLOUGH,  Dr.  John  W.  S.,  AUis- 
ton,  Ontario. 

^rcCuf.LY,  Dr.  S.  E.,  Toronto,  Can- 
ada. 

McDonald,  Dr.  A.  C,  Warsaw,  Ind. 

McGiLLicuDDY,  Dr.  T.  J.,  New  York. 

McMahon,  Dr.  A.  Ernest,  Marshall, 
Tex. 

Macartney,  Dr.  W.  N.,  Fort  Cov- 
ington, N.  Y. 

MacDonald,   Dr.  C  F.,  New  York. 

Madison,   Dr.  E.  H.,  Oramel,  N.  Y. 

Maloney,  Dr.  F.  \V.,  Rochester, 
N.  Y. 

Martindai.e,  Dr.  J  H.,  Mnneapc- 
lis,  Minn. 

Matheny,  Dr.  R.  C,  Springfield,  111. 

Mather,  Dr.  F.  G..  Albany,  N.  Y. 

Mayo,   Dr.  C.  H.,  Rochester,  Minn. 

Meisenbach,  Dr.  A.  H.,  St.  Louis, 
Mo. 

Mettler,   [>r.  L.  H.,  Chicigo,  111. 

Miller,  Dr.  D.  J.  M..  Philadelphia, 
Pa. 

Miller,  Dr.  H.  T.,  Springfield,  O. 

Miller,  Dr.  W.  H.  F.,  Clifton  Forge, 
Va. 

Milliken,  Dr.  Samuel,  New  York. 

Mitchell,  Dr.  S.,  Hornellsville, 
N.  Y. 

Monell,  Dr.  S.  H.,  Brooklyn,  N.  Y. 

Moor,  Dr.  William,  New  York. 

Morris,  Dr.  Rohert  T.,  New  York. 

Moser,  Dr.  W.,  Brooklyn,  N.  Y. 

Mosher,  Dr.  J.  M.,  Ogdensburg,  N.Y. 

Moss,    Dr.  Tho.mas  J.,  New  York. 

MuNDfe,  Dr.  Paul  F.,  New  York. 

Murray,  Dr.  D.  H.,  Syracuse,  N.  Y. 

Myers,  Dr.  R.  P.,  Honolulu,  H.  I. 

Na.mmack,  Dr.  Chas.  E  ,  New  York. 
Newton,  Dr.  R.  C,  M  intclair,  N.  J. 
Nichols,  Dr.  J.  B.,  Washington,  D.  C. 
Nichols,  Dr.  W.  R.,  Baden,  Ontario. 

O.NUF,  Dr.  B.,  Brooklyn,  N.  Y. 
Ostran,  Dr.  Homer  I.,  New  York. 
Overton,  Dr.  F. ,  Patchogue,  N.  Y. 

Packard,  Dr.  C.  W.,  New  Yoik. 
Page,  Dr.  Harlan  M.,  Hiram,  O. 
Park,  Dr.  Roswell,  Buffalo,  N.  Y. 
Partridge,  Dr.  E.  L.,  New  York. 
Perkins,  Dr.  J.  M.,  Lebanon,  Mo. 
PErnr,  Dr.  Louis  C.,  New  York. 
Phillii's,  Dr.  H.,  Philadelphia,  Pa. 
Phillips,  Dr.  S.  L.,  Savannah,  Ga. 
PjERSoN,  Dr.  S.,  Stamford,  Conn. 
PoHLY,  Dr.  Albert,  New  York. 
Powers,  Dr.  C.  A  ,  Denver,  Col. 
Preston,  Dr.  G.  J.,  Baltimore,  Md. 
Prettvman,  Dr.  J.  S.,  Milford,  Del. 
Prince,  D-.  John  A.,  Springfield,  111. 
Proben,  Dr.  Charles  L,  New  York. 
Proegler,    Dr.  Carl,  Fort  Wayne, 

Ind. 
Prvor,  Dr.  William   R.,  New  York. 
Puntar,  Dr.  J.,  Kansas  City,  Mo. 
Putnam,  Dr.  W.  E.,  \Vhiting,  Ind. 

Rachford,  Dr.  B.  K.,  Cincinnati,  O. 

Ramsey,  Dr.  Douglas  C,  Mount 
Vernon,  Ind. 

Ransom,  Dr.  J.  B.,  Dannemora,  N.  Y. 

Rice,  Dr.  Clarence  C,  New  York. 

Richardson,  Dr.  John  B.,  Louis- 
ville, Ky. 


Robinson,  Dr.  Beverley,  New  York. 
Robinson,  Dr.  Byron,  Chicago,  111. 
Rockwell,  Dr.  A.  D  ,  New  York. 
Rose,  Dr.  A.,  New  York. 
Ross,  Dr.  John  W.,  U.  S.  Navy. 
ROYSTER,  Dr.  H.  A.,  Raleigh,  N.  C. 
Ruhr.Kh,   Dr.  John,   Baltimore,  Md. 
Russell,  Dr.  W.  H.,  Ipswich,  Mass. 

ScHAVOiR,  Dr.  F.,  Stamford,  Conn. 
Schroeder,  Dr.  H.  H.,  New  York. 
ScHUMPERT,  Dr.   T.   E.,  Shreveport, 

La. 
Se.meleder,  Dr.,  Cordoba,  Mexico. 
Seymour,  Dr.  \V.  W.,  Troy,  N.  Y. 
Shastid,  Dr.  Thomas  H.,  Galesburg, 

HI. 
Shelby,  Dr.  E.  T.,  Atchison,  Kar. 
Sher.man,  Dr.  H.  G.  ,  Cleveland,  O. 
Shrady,  Dr.  George  F.,  New  York. 
Simmons,   Dr.   W.    H.,  Bangor,  Me. 
Skeel,  Dr.  Frank  D.,  New  York. 
Sloan,  Dr.  T.  W.,  Seattle,  Wash. 
S.mall,  Dr.  Sidney  I.,  Saginaw,  Mich. 
Smith,  Dr.  A.  A.,  New  York. 
S.mith,  Dr.  A.  L.,  Montreal,  Can. 
Smith,  Dr.  Andrew  H.,  New  York. 
Smith,  Dr.  E.  H.,  Santa  Clara,  Ca). 
Smith,  Dr.  F.  G.,  Somerville,  Ma?s. 
Smith,  Dr.  George  W.,  Chicago,  111. 
Southgate,  Dr.  F.  H..  Cincinnati,  O. 
Spratling,   Dr.    Edgar  J.,  Fishkill- 

on-Hudson,  N.  Y. 
Spratling,  Dr.  W.  P.,  Craig  Colonv, 

N.  Y. 
Sprecher,  Dr.  D.  B.,  Sykesville,  Mo. 
Stedman,  Dr.  Thomas  L.,  New  York. 
Steele,  Dr.  Whitmore,  New  York. 
Sternberg,  Dr.  G.  M.,  U.  S.  Army. 
Sternberger,  Dr.  Edwin,  New  York. 
Stewart,  Dr.  A.  H..  Richmond,  Ky. 
Stewart,  Dr.  1).  D.,  Philadelphia,  Pa. 
Stickler,     Dr.    Joseph     William, 

Orange,  N.  J. 
Stinson,  Dr.  J.  CoPLiN,   Hamilton, 

Ont. 
Study,    Dr.   J.    N.,    Cambridge  City, 

Ind. 

Taylor,  Dr.  T.  E,  Derver,  Col. 

Thayer,  Dr.  C.  C,  Clifton  Springs, 
N.  Y. 

Thistle,  Dr.  W.  P.,  Toronto,  Ont. 

Thomason,  Dr.  J.  W.,  Huntsville, 
Tex. 

Thompso.n,  Dr.  John  A.,  Cincinnati, 
O. 

Thorner,  Dr.  Max,  Cincinnati,  O. 

Tichener,  Dr.  E.  B.,  Ithaca,  N.  Y. 

Timmermax,  Dr.  C.  F.,  Amsterdam, 
N.  Y. 

Tingley,  Dr.  Hilbert  B.,  Rock- 
away  Beach,  N.  Y. 

Trudeau,  Dr.  E.  L.,  Saranac  Lake, 
N.  Y. 

Tucker,  Dr.  Erwin  A.,  New  York. 

Valentine,  Dr.  Ferd.  C,  New  York. 
Van  Fleet,  Dr.  Frank,  New  York. 
Vertiz,  Dr.,  Mexico,  .Mex. 
Vineberg,  Dr.  Hiram  N.,  New  York. 
Viss.man,  Dr.  William,  New  York. 
VooRHEES,  Dr.  James  D.,  New  York. 

Waldo,  Dr.  H.  L.,  Troy,  N.  Y. 
Walker,  Dr.  Henry  Freeman,  New 
York. 


Wangelin,  Dr.  Hugo  E.,  Belleville, 

III. 
Ward,  Dr.  Milo  Buel,  Topeka,  Kan. 
Warner,    Dr.    F'rederic   M.,    New 

Yoik. 
Weeks,  Dr.  John  E  ,  New  York. 
Weir,   Dr.   James,  Jr.,   Owensboro', 

Ky. 
Weiss,  Dr.  Julius,  New  York. 
Welch,  Dr.  Willia.m  H.,  Baltimore, 

Md. 
Wells,  Dr.  J.  Hunter,  Seoul,  Korea. 
Wendt,  Dr.  Edmund  C,  New  York. 
Whitehead,    Dr.    W.    R.,    Denver, 

Col. 
Wiles,  Dr.  F.  M.,  Indianapolis,  Ind. 
Williams,  Dr.  Cornelius,  St.  Paul, 

Minn. 
Williams,  Dr.  E.  H.,  Decorah,  111. 
Williams,    Dr.   G.   H.,    Fishkill-on- 

Hudson,  N.  Y. 
Williams,    Dr.    Herbert    Upham, 

Buffalo,  N.  Y. 
Williams,   Dr.  Isaac  E.,  St.  Mar)-, 

Ohio. 
Winter,    Dr.    F.  A.,  Fort   Hancock, 

Tex. 
Witha.m,  Dr.  A.  N.,  South  Paris,  Me. 
Wood,  Dr.  C.-isey  A  ,  Chicago,  111. 
Wood,  Dr.  Richard  H.,  Clio,  Mich. 
WoRTHiNGTON,  Dr.  J.  C,  U.  S.  Army. 
WossiDLO,   Dr.   H.   R.,   Berlin,  Ger- 
many. 
Wveth,  Dr.  John  A.,  New  York. 
WvLiE,  Dr.  W.  Gill,  New  York. 

Young,    Dr.     H.    Dudley,    Boston, 
Mass. 

Zwisohn,  Dr.  L.  W.,  New  York. 


Societies  of  -which  Reports  Iiave  been 
received. 

American  Derm.\tological  .Asso- 
ciation. 

American  Laryngological  .Asso- 
ciation. 

American  Neurological  .Associa- 
tion. 

British  Medical  Association. 

Canadian  Medical  Association. 


;l- 


Medical  and  Chirurgical  Facul 
TV  OF  the  State  of  Marylan 

Medical  Society  of  New  Jersey 

Medical  Society  of  the  County 
OF  New  York. 

Mississippi  Valley  Medical  .Asso- 
ciation. 

New  York  Acade.my  of  Medicine, 
New  York  County  Medical  .Asso- 
ciation. 
New  York  Neurological  Society. 
New  York  P.athological  Society. 
New  York  State  Medical  .Assocl\- 

IION. 

Practitioners'  Society  of  New 
York. 

Southern  Surgical  and  Gyneco- 
logical Associ.\tion. 


Medical   Record 

A  IVeekly  yournal  of  Medicine  and  S?tygery 


Vol.  48,  No.  I. 
Whole  No.  1287. 


New  York,  July  6,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


THE  IMPORTANXE  OF  ADMINISTERING 
IODIDE  OF  POTASSIUM  IN  LARYNGEAL 
DISEASES   OF    DOUBTFUL    DIAGNOSIS.' 

By  clarence   C.    RICE,    M.D., 

PROFESSOR   OF   DISEASES   OF   THE    NOSE    AND   TdROAT,    NEW    VORK  POST-GRADL'- 
ATE   MEDICAL   SCHOOL. 

The  clinical  value  of  this  paper  might  be  largely  in- 
creased by  making  this  change  in  its  title  :  ''  The  Impor- 
tance of  Administering  Iodide  of  Potassium  in  Many 
Cases  of  Laryngeal  Disease  which  Apparently  are  Non- 
syphilitic." 

Any  suggestion  as  to  the  advisability  of  prescribing 
the  iodide  will  of  course  be  superfluous  to  those  clini- 
cians who  are  in  the  habit  of  diagnosing  almost  all  cases 
of  inflammation  of  the  upper  air-passages  as  syphilitic. 
We  know  that  there  are  physicians  of  this  frame  of 
mind.  On  the  other  hand,  we  are  satisfied  that  there 
are  many  who  do  not  resort  to  the  administration  of 
mercury  and  potassium  unless  they  are  convinced  that 
the  lesion  under  treatment  is  specific.  They  desire 
conclusive  evidence,  and  it  is  possible  that  they  fre- 
quently are  in  error  in  withholding  specific  treatment 
because  of  lack  of  marked  diagnostic  points.  Further, 
even  expert  laryngologists  may  easily  fall  into  the 
habit  of  quickly  classifying  all  laryngeal  lesions  in  an 
instinctive  way,  and  if  the  first  impression  is  that  the 
disease  is  other  than  specific  it  will  not  occur  to  them 
to  use  the  iodide,  even  though  the  case  is  not  progress- 
ing favorably. 

It  has  always  been  my  habit  of  thought  to  be  slow  in 
believing  a  lesion  was  specific,  unless  the  history 
strongly  indicated  it,  or  unless  the  lesion  presented 
such  an  appearance  in  a  clear  manner.  The  more  ex- 
perience we  obtain  in  clinical  work,  however,  the  more, 
I  believe,  we  appreciate  how  small  is  the  percentage 
of  cases  which  closely  present  the  characteristic  ap- 
pearances portrayed  in  the  text-books.  Authors  are 
not  to  be  blamed  for  describing  pathological  appear- 
ances as  typical  and  constant,  for,  should  they  en- 
deavor to  mention  the  many  great  and  small  variations 
of  behavior  from  the  typical  aspects,  their  work  would 
not  only  be  too  voluminous,  but  so  confusing  that  the 
beginner  in  laryngology  would  have  no  salient  points 
on  which  to  found  his  diagnosis. 

I  was  much  impressed  in  listening  to  a  discussion - 
on  "  Unusual  Manifestations  of  Tuberculosis,"  by  the 
American  Laryngological  Association  a  few  years  ago. 
One  after  another,  men  who  had  been  active  in  laryn- 
gology for  twenty-five  years  or  more  put  themselves 
on  record  as  frequently  being  unable  to  make  a  diag- 
nosis of  laryngeal  inflammation  or  neoplasm,  from  the 
physical  aspect  of  the  lesion,  together  with  the  clinical 
history.  They  confessed  that  they  were  often  com- 
pelled to  withhold  their  opinion  until  more  examini- 
tions  had  been  made,  until  the  microscope  had  aided 
them,  or  the  effect  of  the  iodide  had  been  demon- 
strated. 

'  Read  before  the  Liryngological  Section  of  the  Mew  York  .Acad- 
emy of  Medicitie.  May  22.  189;. 

'Rice;  Unusual  Manifestations  of  Tuberculosis  of  Larynx,  Trans- 
actions of  the  .^inerican  Laryngological  .\ssocialJon,  1889,  p.  95. 


One  of  the  most  prominent  laryngologists  of  this  city 
remarked,  in  this  same  discussion,  that  there  was  such 
a  thing  as  ''diagnostic  instinct;"  and  he  meant  that 
this  had  sometimes  to  be  depended  upon  when  all  the 
other  signs  failed. 

It  cannot  be  denied  that,  there  are  many  cases  of 
laryngeal  disease  which  are  difficult  of  diagnosis,  and  a 
number  where  it  is  impossible  to  state  positively,  for  a 
time  at  least,  the  nature  of  the  disease. 

We  might  commence  by  saying  that  we  have  a  belief, 
founded  on  some  experience,  that  there  are  cases  of 
laryngeal  disease  non-specific,  which  are  benefited  to 
some  degree  by  the  administration  of  small  doses  of 
iodide  of  potassium.  Perhaps  the  beneficial  action  ob- 
tained in  these  cases  is  essenti  illy  by  reason  of  its  so- 
called  alterative  effect,  and  would  not  be  gained  if  the 
drug  was  administered  \\\  large  doses,  or  if  it  was  con- 
tinued for  any  length  of  time.  I  have  frequently  no- 
ticed this  effect  of  the  iodide.  The  benefit  from  five 
grains  three  times  a  day  was  immediate  and  remark- 
able, and  that,  too,  after  diligent  treatment  had  been 
pursued  along  other  lines. 

We  find  a  number  of  writers  who  state  that  they  have 
obtained  the  same  beneficial  result  from  iodide  when 
given  in  the  early  stages  of  laryngeal  tuberculosis  and 
in  chronic  laryngitis. 

I  shall  mention  these  farther  on. 

It  seems  to  me  that  the  habit  of  administering  the 
iodide  depends  largely  upon  the  amount  of  dispensary 
work  one  mav  be  engaged  in.  Certainly  there  was  no 
need  of  advising  its  use  in  Charity  Hospital  in  the  8o's. 
I  often  wonder  what  became  of  the  remarkable  cases 
of  syphilis  of  the  larynx  which  were  in  the  hospital  at 
that  time,  cases  in  which  the  epiglottis  had  been  en- 
tirely destroyed,  others  in  which  the  entire  laryngeal 
mucous  membrane  had  been  replaced  by  cicatricial  tis- 
sue and  the  whole  cavity  distorted,  and  those  in  which 
the  vocal  bands  were  adherent  to  each  other  through 
the  medium  of  webbed  formations.  I  personally  see 
few  of  such  patients  at  the  present  day.  I  dare  say 
this  decrease  in  cases  of  such  extensive  lesions  is  due 
to  the  better  and  more  intelligent  treatment  which  pa- 
tients now  receive.  The  attention  which  is  paid  to  the 
cleanliness  of  the  nose  and  pharynx  would  diminish 
very  much  the  likelihood  of  such  severe  syphilitic  le- 
sions. Patients,  too,  are  more  often  seen  at  an  earlier 
stage  of  the  disease  than  they  were  fifteen  years  ago. 

There  is  not  time  here  to  mention  the  characteristic 
diagnostic  points  of  each  of  the  many  diseases  of  the 
larynx.  The  typical  lesions  of  each  laryngeal  disease 
we  are  all  familiar  with,  and  when  present  they  furnish 
readily  the  means  of  diagnosis,  but  we  often  see  ul- 
cerations characteristic  of  no  special  process,  but  which 
might  be  the  result  of  several,  and  we  find  enlargements 
or  neoplasms  about  which  no  intelligent  opinion  can  be 
at  first  formed.  There  are  several  laryngeal  diseases 
other  than  syphilis  which  frequently  present,  during 
some  part  of  their  development,  pathological  conditions 
which  in  general  aspect  are  quite  similar  to  syphilitic 
lesions,  and  it  is  in  these  cases  we  would  advise  the 
administration  of  iodide  of  potassium  for  a  time,  even 
though  there  is  strong  belief  that  the  disease  is  not 
syphilis. 

First  let  us  say  a  few  words  in  regard  to  laryngeal 
tuberculosis.  In  the  typical  cases  one  would  hardly  be 
tempted  to  prescribe  the  iodides,  but  there  are  many 


MEDICAL   RECORD. 


[July  6,  1895 


which  are  not  so  easy  of  diagnosis  unless  we  find  the  ba- 
cilli and  are  satisfied  that  their  presence  is  conclusive. 
If  we  find  the  characteristic  epiglottis,  club-shaped 
arytenoids,  the  general  anremia,  and  the  superficial  gray 
ulcerations,  we  cannot  of  course  be  in  doubt,  but  there 
are  many  cases  of  tubercular  ulceration  which  I  am  sat- 
isfied are  complicated  by  the  coexistence  of  a  syphilitic 
process. 

In   1889,  I  cited  a  case'  (Fig.  i)  under  the  title  of 
"  Unusual  Manifestations  of  Tuberculosis,"  in  which. 


Fig.    1.—  Coexistence  (>f  Larj'ngeal  Syphilis  and  Tuberculosis. 

in  addition  to  apparently  typical  tubercular  ulcerations 
in  the  laryn.v,  there  was  extensive  loss  of  tissue  of  the 
epiglottis.  The  ulceration  of  the  epiglottis  was  out  of 
proportion  to  the  progress  of  the  ulceration  in  the 
larynx.  The  arytenoids  were  characteristically  tuber- 
cular. The  patient  had  advanced  pulmonary  involve- 
ment, but  in  spite  of  this  the  ulceration  on  the  epiglot- 
tis was  healed  by  the  use  of  iodide  of  potassium, 
although  it  had  no  effect  whatever  upon  the  intra- 
laryngeal  tubercular  ulcerations.  I  think  it  possible 
that  the  coexistence  of  these  two  diseases  is  more  fre- 
quent than  we  are  apt  to  believe.  There  is  no  doubt  that 
patients  often  contract  syphilis  early  in  life  and  tuber- 
culosis later.  Many  of  the  cures  of  laryngeal  tubercu- 
losis which  we  see  in  print  are  probably  syphilitic.  If 
we  have  any  doubt  as  to  the  character  of  an  ulceration 
it  should  have  the  benefit  of  the  iodide. 

Is  it  not  possible  that  a  patient  may  have  at  the  same 
time  pulmonary  tuberculosis  and  syphilis  of  the  larjn.x  ? 
We  see  cases  of  ulceration  of  the  larynx  in  patients 
having  pulmonary  tuberculosis  with  tubercle  bacilli  in 
the' sputa,  which  are  healed  by  the  iodide. 

Dr.  Woodward,  of  Burlington,  Vt.,''  a  laryngologist 
of  experience,  reports  two  cases  of  laryngeal  ulcer- 
ation in  both  of  which  tubercle  bacilli  were  found, 
and  the  lungs  showed  evidences  of  tuberculosis.  In 
both  cases  the  laryngeal  ulcerations  were  healed  by 
iodides.  He  believes  the  cases  to  have  been  syphi- 
litic. 

Dr.  F.  I.  Knight,  of  Boston,  in  discussing  the  paper 
on  the  "  Unusual  Manifestations  of  Tuberculosis  of 
the  Larynx,"  remarked  that  in  some  cases  where  he  had 
been  sure  enough  of  the  presence  of  tubercular  disease 
of  the  larynx  to  allow  the  patient  to  go  without  consti- 
tutional treatment,  he  had  been  hajipily  disappointed 
to  see  the  ulcerations  disappear  under  specific  treat- 
ment. 

Dr.  jo.iathan  \V'right,'' in  a  paper,  saiti  that  two  cases 
of  tracheal  and  one  of  laryngeal  disease  had  been  re- 
ferred to  him.  They  both  had  marked  pulmonary 
signs.  The  thickening  was  so  great  that  tracheotomy 
was  performed,  I  believe,  in  both  cases.  An  unc[ues- 
tioned  diagnosis  of  tubercular  laryngitis  was  made. 
They  died  some  time  after  the  tracheotomies.  The 
autopsies  demonstrated  syphilis  of  the  larynx. 

It  is  a  good  diagnostic  point  that  tuberculosis  of  the 

'  Transactions  of  the  .American  Laryngological  Asfociation,  1889, 
p.  97. 

''  Woodward  ;  Tnbercle  Bacilli  and  the  Diagno.sis  of  Tubercnlosis, 
etc.,  New  York  Medical  Journ.il,  December  5,  1893. 

a  Wright :  Some  Remarks  on  Laryngeal  Literature,  etc..  New 
York  Medical  Journal,  September  22,  1894.  p.  364. 


larynx  seldom   produces  occlusion  enough  to  necessi- 
tate tracheotomy. 

Cases  which  might  be  tubercular  or  syphilitic,  so  far 
as  the  physical  aspect  of  the  laryngeal  lesions  are  con- 
cerned, are  those  in  which,  neither  the  epiglottis  or 
arytenoids  being  involved,  a  single  ulceration  presents 
itself  on  the  vocal  band  or  upon  the  side  of  the  larynx, 
with  no  qualities  whereby  its  character  may  easily  be 
determined.  Of  course,  we  depend  here  upon  the 
presence  of  lung  disease  and  of  bacilli,  but  even  if  they 
are  both  found  the  ulceration  of  the  larynx  may  be 
syphilitic. 

Almost  all  the  diseases  of  the  larynx  which  go 
through  an  ulcerative  stage  are  capable  of  producing 
so-called  granulation  tissue  upon  the  surface  of  the  ul- 
ceration. We  have  the  "'  vegetative  "  form  of  tubercu- 
losis, and  the  granular  thickening  of  the  vocal  bands 
in  trachoma.  Benign  neoplasms  of  the  vocal  bands 
may  present  nearly  the  same  appearances  at  times  as 
the  condylomata  of  secondary  syphilis,  and  the  wart-like 
excrescences  of  the  tertiary  stage.  All  of  these  condi- 
tions look  much  alike,  and  at  times  it  will  be  difficult 
to  exclude  syphilis.  It  will  be  wise  to  see  if  they  are 
benefited  by  the  administration  of  the  iodide. 

There  is  considerable  confusion  as  to  the  identity  of 
the  pathological  conditions  known  by  some  as  "  chordi- 
tis  tuberosa  ;  "  by  others  as  "  singers'  nodes,"  and  by 
others  as  "  trachoma  vocalis."  Bosworth  '  and  Ingals  " 
think  "  chorditis  tuberosa  "  and  trachoma  are  the  same 
thing.  F.  I.  Knight  ^  says  they  may  be  the  same  patho- 
logically, but  that  they  differ  in  clinical  behavior. 
John  Mackenzie  says  we  should  distinguish  between  a 
granular  condition  of  the  vocal  bands  and  true  "  chor- 
ditis tuberosa."  But  the  point  which  is  most  pertinent 
to  this  paper  is  that  these  processes  of  hypertrophy  of 
the  vocal  bands  often  present  appearances  which  closely 
simulate  syphilitic  lesions,  and,  therefore,  clearly  indi- 
cate the  treatment. 

Ingals,^  in  his  text-book,  gives  an  illustration  of  a 
thickening  in  a  simple  catarrhal  laryngitis,  which  is  for- 
midable enough  to  be  a  syphilitic  enlargement. 

John  Mackenzie  speaks  of  "  hypertrophic  laryngitis," 
and  says  that  it  is  with  difficulty  diagnosed  from  syphi- 
lis. 

We  fre(|uently  see  changes  in  the  vocal  bands  in  sim- 
ple catarrhal  processes,  in  which  we  are  tempted  to  use 
the  iodide. 

I  will  cite  a  case  in  which  the  lesions  were  almost  en- 
tirely confined  to  the  vocal  bands,  because  of  its  un- 
usual behavior  and  because  of  the  effect  of  iodide 
upon  it. 

Case. — Male,  aged  fifty-five.  First  saw  him  in  Sep- 
tember, 1894.  Patient  was  hoarse,  and  consequently 
much  troubled  because  he  was  a  school-teacher.  Gen- 
eral condition  good.  No  syphilitic  history,  and  no 
lesion  in  other  parts  of  the  body  to  indicate  that  he  had 
ever  had  disease  of  this  nature.  Growth  the  size  of  two 
large  peas  attached  to  right  vocal  band  posterior  third. 
Band  itself  slightly  congested,  but  not  markedly  so. 
Growth  was  removed  and  examined  in  the  laboratory 
of  the  Post-Graduate  Hospital,  and  pronounced  a  sim- 
ple papillomatous  growth.  (Fig.  2.)  When  next  the 
patient  was  seen,  a  few  weeks  later,  I  found  that  the 
entire  vocal  band  «'as  thickened,  reddened,  and  granu- 
lar, in  the  sense  of  being  very  uneven.  There  were  no 
ulcerations,  but  the  band  presented  a  very  ragged  ap- 
pearance. Astringent  applications  were  made.  Later, 
growth  somewhat  similar  to  the  first  one,  well  localized. 
but  smaller,  appeared  on  the  opposite  chord,  and  after 
a  few  weeks  that  vocal  band  became  generally  thickened 
and  congested.  .\t  one  time  it  looked  as  if  the  inflam- 
matory process  would  extend  to  the  side  of  the  larynx, 
but  that  was  probably  due  to  the  operative  work.     The 

'  Bosworth  :  Diseases  of  the  Nose  .and  Throat,  vol.  ii. .  p.  533. 
''  Ingals :  Diseases  of  the  Chest  and  Throat,  p.  40a. 
s  Knight :  Singers'  Nodes,  New  York  Medical  Journal,  December 
I,  1894. 
<  Ingals  ;  Diseases  of  the  Chest  .and  Throat,  p.  ^95,  Fig.  104. 


i 


July  6,  1895] 


MEDICAL    RECORD. 


projections  were  removed  by  forceps  and  guillotine 
wherever  they  were  large  enough  to  be  taken  hold  of, 
and  several  times  the  galvano-cautery  was  used.  The 
larynx  behaved  very  well  after  operation,  and  the  sub- 
sequent   inflammation  was  moderate.     Not  much  im- 


F'G.  2. — S>*philit'c  inflainmator>'  growth  of  vocal  band. 

provement  of  the  voice  was  obtained,  because  of  the 
great  amount  of  general  thickening  of  the  vocal  chords. 
(Fig.  3.)  Patient  was  put  upon  iodide  of  potassium  in 
small  doses  and  the  larynx  commenced  to  improve  at 
once.  The  warty  excrescences  became  smaller  day  by 
day  and  the  congestion  and  general  thickening  dimin- 
ished. The  case  at  first  was  naturally  supposed  to  be 
one  of  simple  papilloma  of  the  larynx,  but  the  rapid 
involvement  of  the  entire  vocal  bands  later  on  pointed 
toward  epithelioma.  The  appearance  of  the  bands 
after  they  became  thickened  and  jagged  was  very  simi- 
lar to  trachoma  vocalis.  The  effect  of  the  iodide  upon 
this  case  was  so  remarkable  that  we  shall  perhaps  be 
compelled  to  call  it  a  syphilitic  process.     The   patient 


Fig.  3.  — Syphilitic  hj-pertropVy  of  the  vocal  bands. 

never  took  more  than  ten  grains  of  the  iodide  three 
times  a  day.     A  polypus  was  removed  from  left  nostril. 

Some  of  the  reasons  why  we  cannot  always  decide 
easily  whether  a  pathological  condition  is  syphilitic  or 
not,  are,  that  it  is  very  frequently  impossible  to  obtain 
any  corroborative  history.  The  patient  has  had  some 
venereal  disease,  but  there  are  no  evidences  of  syphilis 
elsewhere.  Of  course,  where  the  scars  of  old  inflamma- 
tions are  found  in  the  nose  or  pharynx,  the  diagnosis  is 
made.  We  have  already  mentioned  that  the  tertiary 
manifestations,  which  are  by  far  the  most  common  in 
the  larynx,  are  frequently  obscured  by  a  coexisting 
tubercular  process.  The  primary  sore  of  syphilis  most 
of  us  will  probably  never  see  in  the  larynx,  and  very 
rarely  shall  we  be  called  upon  to  diagnose  mucous 
patches.  Secondary  ulcerations  of  the  larynx  are  usu- 
ally accompanied  with  a  clear  recent  history,  and  syphi- 
litic manifestations  of  the  mouth.  Congestions  or  ery- 
themas due  to  syphilis  have  some  distinguishing  signs, 
and  are  most  apt  to  be  accompanied  by  the  same  path- 
ological conditions  of  the  pharynx. 

The  tertiary  lesions  of  syphilis,  growths,  gummata, 
and  extensive  ulcerations,  are  attended  by  more  diffi- 
culties of  diagnosis.  Almost  always  the  gummatous 
enlargements  have  undergone  ulceration  by  the  time 


they  reach  us,  so  that  we  have  to  deal  with  ulcerations 
of  most  varied  appearances  in  the  larynx.  If  such  ul- 
cerations occur,  as  they  very  frequently  do,  in  patients 
much  debilitated  and  generally  anaemic,  they  present 
conditions  which  are  but  slightly,  if  at  all,  different 
from  those  of  tuberculosis.  If  we  cannot  obtain  a 
syphilitic  history,  or  find  specific  lesions  in  the  pharynx, 
or  other  parts  of  the  body,  then  it  will  be  necessary  to 
exclude  tuberculosis. 

Now,  in  regard  to  perichondrial  inflammation  of  the 
laryngeal  cartilages.  We  know  that  as  a  primary  dis- 
ease it  exists  very  rarely,  but  is  on  the  other  hand  an 
indication  of  tuberculosis  or  syphilis.  In  33  cases 
tabulated  by  Bosworth,^  9  were  syphilitic  and  about 
the  same  number  followed  typhoid  fever.  The  tuber- 
cular cases  were  not  included  in  this  list. 

Several  authors  agree  that  when  the  arytenoids  are 
attacked  by  perichondrial  inflammation  the  strong  in- 
ference is  that  the  process  is  tubercular,  because  the 
other  inflammatory  diseases  seem  to  prefer  the  cricoid 
and  thyroid. 

Bilateral  enlargements  of  the  arytenoids  present  no 
special  interest,  and  may  usually  be  put  down  at  once 
as  being  tubercular,  and  we  occasionally  see  marked  er- 
largement  of  one  arytenoid  with  anchylosis  at  the  joint, 
in  which  all  the  phases  of  tubercular  laryngitis  rapidly 
follow.  I  cite  the  following  case  :  First,  because  it 
was  supposed  to  be  tubercular  ;  second,  because  there 
were  reasons  why  an  acquired  syphilitic  condition  was 
not  supposed  possible  ;  and  third,  to  note  the  effect  of 
iodide  upon  it. 

Case. — Male,  about  forty  years  of  age,  works  in  an 
office.  Very  small,  weighing,  I  should  think,  about 
ninety  pounds.  Heredity  good.  Chronic  conjuncti- 
vitis, granular  lids,  decided  scrofulous  appearance. 
Slight  cough  for  a  year.  Husky  voice.  Rough  and 
high-pitched  breathing  at  apices.  Tubercle  bacilli, 
very  few  found  in  expectoration.  Laryngeal  appear- 
ance as  follows  :  Left  vocal  band  immovable,  markedly 
congested  throughout  its  entire  length  and  thickened. 
Marked  enlargement  of  left  arytenoid  cartilage.  Posi- 
tively asserted  that  there  was  no  specific  history.  Pa- 
tient asserted  that  he  had  never  had  intercourse  with 
women,  and  his  statement  seemed  probable  as  his 
genital  organs  were  very  much  undeveloped  ;  his  penis 
was  no  larger  than  a  child's  five  years  of  age.  Diag- 
nosis at  first  thought  to  be  tubercular  perichondritis, 
although  the  uniform  redness  of  the  vocal  band  with- 
out ulceration  did  not  seem  like  a  tubercular  lesion. 
(Fig.  4.) 

I  need  not  enlarge  upon  this  case,  except  to  say  that 
the  patient  was  not  improved  by  ordinary  laryngeal 
medications,  nor  by  cod-liver  oil  and  tonics.  Iodide 
was  commenced  in  small  doses  and  the  benefit  was  im- 
mediate, and  after  three  weeks  of  its  administration,  in 


Fig.  4. — S>*philitic  perichondritis. 

ten-drop  doses,  the  enlargement  of  the  arytenoid  had 
almost  entirely  disappeared,  the  vocal  band  moved,  and 
its  congestion  was  so  decreased  that  the  voice  was  al- 
most entirely  restored.  Before  treatment  the  swelling 
'  Bosworth  :   Diseases  of  the  Throat,  p.  565. 


MEDICAL   RECORD. 


[July  6,  1895 


of  the  arytenoid  was  so  great  that  there  was  some 
dyspncea  and  he  was  unable  to  swallow  solid  food.  I 
have  never  seen  the  effect  of  the  iodide  more  marked 
than  in  this  case. 

Bosworth  says  that  the  iodide  is  useful  in  perichon- 
dritis, whether  it  is  sy[)hilitic  or  not. 

We  have  spokei.  of  the  ulcerative  lesions  of  the  larynx, 
and  of  the  confusion  which  may  attend  their  diagnosis, 
and  also  of  the  tissue  hypertrophies  which  are  caused 
by  a  number  of  different  inflammatory  processes. 

It  remains  to  allude  briefly  to  the  growths  or  neo- 
plasms of  the  larynx,  benign  and  malignant,  and  to 
note  their  similarity  to  syphilitic  lesions,  and  the  diffi- 
culty oftentimes  in  their  earlier  stages  of  diagnosing 
them,  and  consequently  the  advisability  of  administer- 
ing iodide  until  the  diagnosis  is  confirmed  by  micro- 
scopical examination. 

In  our  first  case  we  referred  to  a  supposed  simple 
papilloma  of  the  vocal  band,  the  base  of  which  was  ab- 
sorbed by  the  action  of  iodide. 

Before  speaking  in  detail  of  growths  in  the  larynx  of 
whatever  nature,  I  cannot  help  alluding  to  a  review,  by 
Dr.  Jonathan  Wright,'  of  a  paper  by  Chiari"'  on  "The 
Structure  of  the  So-called  Fibromata  of  the  Vocal 
Bands."  The  ground  taken  by  the  author  of  the  pa- 
per was  that  these  growths  are  inflammatory  and  not 
neoplastic,  as  they  often  show  such  inflammatory  phe- 
nomena as  oedema  and  hemorrhagic  extravasations. 
This  view  seems  to  me  to  be  thoroughly  in  accord  with 
clinical  observation. 

Dr.  Wright  says  that  "  it  is  a  superficial,  misleading, 
and  dangerous  proceeding  to  calmly  describe  growths 
as  fibromata,  myxomata,  etc.,  when  they  are,  in  the  vast 
majority  of  instances,  nothing  but  different  manifesta- 
tions of  chronic  inflammation." 

If  such  a  palhology  is  correct,  our  views  must  be 
changed  as  to  the  relation  of  so  called  neoplasms  to  all 
inflammatory  processes,  not  only  to  that  of  a  simple 
catarrh,  but  to  the  processes  of  syphilis  and  tuberculo- 
sis. In  other  words,  what  we  have  considered  typical 
papilloma  or  fibromata  of  the  larynx,  accidents  existing 
without  apparent  cause,  may  be  rather  manifestations 
of  a  simple  catarrhal  process,  or  a  syphilitic  condition, 
or  perhaps  the  result  of  a  tubercular  germ. 

This  is  most  interesting  pathologically,  and  impor- 
tant clinically,  because  it  is  quite  possible  that  some  of 
the  pases  which  we  have  been  in  the  habit  of  diagnos- 
ing as  forms  of  benign  or  malignant  neoplasms  are 
rather  the  manifestation  of  syphilis,  and  so  may  be 
benefited  by  the  iodides.  We  do  not  believe  that  it 
has  been  the  habit  of  laryngologists  to  prescribe  iodides 
in  cases  of  laryngeal  growths.  They  have  only  been 
regarded  and  treated  surgically.  This  pathology  of 
laryngeal  neoplasms,  if  true,  will  aid  very  much  in  the 
diagnosis  of  many  growths  which  have  been  very  dif- 
ficult to  classify  ;  growths  not  typical,  and  which  always 
have  seemed  to  bear  an  intimate  relation  to  some  con- 
stitutional disease.  If  these  growths  are  inflammatory, 
we  shall  be  encouraged  to  ascertain  what  kind  of  in- 
flammatory process  is  behind  them. 

A  benign  growth  may  therefore  be  an  earlier  manifes- 
tation of  tuberculosis  than  we  have  hitherto  recognized. 
A  causative  relation  of  some  of  them  to  syphilis  may  be 
established,  and  the  remedy  will  then  be  apparent. 

All  laryngologists  admit  the  difliculty  of  always  being 
able  to  diagnose  growths  in  the  larynx.  Dr.  Delavan,^ 
in  a  carefully  written  article  on  the  "  Early  Diagnosis 
of  Malignant  Disease  of  the  Larynx,"  said  :  "  We  are 
taught  that  cancer,  syphilis,  tuberculosis,  and  lupus  all 
present  characteristics  which  distinguish  them  to  the 
eye,  but  unfortunately  this  is  not  true."  And  further 
he  said  that  "a  large  number  of  cases  in  which  the 
microscope  has  revealed  tubercular  disease  have  proved 

'  Wright :  Remarks  on  Laryngoljgy  Lileraturf,  New  York  Medical 
Journal,  March  16,  1895 

'Chiari:   Fraenkel's  Archiv.  vol.  ii  ,  No.  i. 

"  Delavan  :  Transactions  of  the  American  Laryngological  Associa- 
tion, 1890,  p.  87. 


to  be  malignant  when  more  carefully  examined  micro- 
scopically later  on."  We  know  that  malignant  disease 
in  its  early  stage  may  easily  be  mistaken  for  some  phase 
of  syphilis  or  tuberculosis. 

Dr.  Mulhall,  of  St.  Louis,  in  the  "Transactions  of 
the  American  Laryngological  Association  "(1890,  p.  96), 
said  that  he  had  had  two  cases  of  cancer  of  the  larynx 
which  had  been  greatly  improved  by  the  iodide  of  po- 
tassium. 

The  late  Dr.  Hooper,'  of  Boston,  in  examining  7,500 
patients  having  laryngeal  disease,  found  only  21  benign 
neoplasms.  Papilloma  occurs  more  frequently  than  all 
the  other  forms  combined.  A  good  diagnostic  point 
about  benign  growths  is  that  they  are  rarely  subglottic. 

Sarcoma  exists  still  more  infrequently.  Butlin  ^  found 
only  23  cases  recorded.  In  84S  cases  of  sarcoma 
Gurlt^  found  only  one  of  the  larynx.  Sarcoma  seems 
to  involve  the  lymphatics  much  less  frequently  than 
does  the  more  common  form  of  cancer — epithelioma. 
Gurlt,^  in  reviewing  the  literature,  found  that  epithelio- 
ma involved  the  larynx  but  sixty-three  times  out  of 
11,131  cases  of  epithelioma  occurring  everywhere. 

The  terms  carcinoma  and  epithelioma  seem  to  be 
used  synonymously.  Of  24  cases  of  carcinoma,  23 
were  epithelioma  and  i  was  of  medullary  character. 

I  cannot  enlarge  here  upon  the  diagnostic  points  of 
malignant  disease.  It  is  easy  sometimes  to  mistake  it 
for  syphilis  and  tuberculosis.  A  discussion  on  the 
diagnosis  of  malignant  disease  brought  out  such  salient 
diagnostic  points,  as  greater  general  thickening  and  in- 
filtration of  the  larynx  than  in  other  diseases,  and  an 
inflammatory  areola  surrounding  the  base  of  the 
growth  ;  and  with  this  infiltration  there  generally  fol- 
lows loss  of  motion  of  the  side  of  the  larynx  involved, 
and  this  often  without  involvement  of  the  crico-ary- 
tenoid  articulation,  the  immobility  being  caused  by  in- 
filtration of  the  muscular  tissue. 

Pain  in  the  ear  is  considered  a  significant  symptom. 
But,  after  all,  the  microscope  must  be  the  final  court 
of  appeal.  But  it  is  often  necessary  to  wait  for  some 
months  before  a  satisfactory  portion  of  the  growth  can 
be  obtained  for  microscopical  examination.  It  would 
be  unwise  to  dig  into  a  deeply  situated  enlargement  of 
the  larynx  beneath  unbroken  mucous  membrane,  just 
for  the  purpose  of  obtaining  a  microscopical  specimen, 
so  that  it  is  wise  to  ascertain  the  efi'ect  of  the  iodide 
while  we  are  waiting.  There  is  difficulty,  too,  in  se- 
curing enough  of  the  growth  to  positively  acquaint  us 
with  its  histological  character.  Wright  says  that 
"  small,  round  -  celled  sarcoma,  granulation  tissue 
(syphilitic  or  tubercular),  and  lymphoid  hypertrophy, 
are  frecjuently  indistinguishable  under  the  microscope." 
But  even  in  cases  which  have  every  appearance  of  ma- 
lignant disease,  I  believe  the  conservative  physician 
will  always  give  the  patient  the  benefit  of  the  iodide 
and  mercury. 

It  is  my  belief  that  extirpations  of  half  the  larynx 
have  been  performed  by  surgeons  at  an  early  stage,  in 
undoubted  cases  of  syphilis,  where  anti- syphilitic  treat- 
ment would  probably  have  effected  a  cure. 

Dunn,  of  Richmond,'  reports  a  case  of  laryngeal 
growth,  which  had  every  appearance  of  malignancy, 
which  disa])peared  after  the  application  of  compound 
tincture  of  iodine. 

We  might  continue  to  cite  cases  of  most  varied  path- 
ological appearances — ulcerations  which  seemed  to  be 
tubercular,  small  growths  which  were  apparently  be- 
nign, large  swellings  with  every  appearance  of  malig- 
nancy— which  were  afterward  proven  to  be  specific,  or 
which  disappeared,  at  least,  through  the  effect  of  io- 
dide of  potash.  This  drug  and  the  microscope  cannot 
be  ignored  in  searching  for  a  truthful  diagnosis. 

'  Hooper :  Case  of  Tumor   of   the    Laryn.x,   Mbuicai.    Rbcord, 
March  7,  1891. 
"  Butlin  :  NIalignant  Disease  of  the  Larvnx.     London.  1883. 
'Gurlt :  Arch,  fijr  klin.  Chir.,  1880,  voK  x.\v.,  p.  436. 
<  Ibid.,  p.  436. 
'Dunn  :  New  York  Medical  Journ.M,  December  17.  1852. 


July  6,  1895] 


MEDICAL    RECORD. 


A  FURTHER  REPORT  ON  ACHYLIA  GAS- 
TRICA.' 

Bv  MAX  EINHORN,   M.D., 


In  1892  I  suggested  the  term  "  Achylia  Gastrica  "  -  for 
those  conditions  in  which  the  stomach  apparently 
secretes  no  juice  and  in  which  clinically  the  diagnosis 
of  "atrophy  of  the  gastric  mucosa"  seems  to  be  justi- 
fiable. In  my  paper  referring  to  this  subject  I  endeav- 
ored to  show  that  cases  of  achylia  gastrica  and  cases 
of  pernicious  anaemia  ought  to  be  kept  strictly  apart. 
Whereas  the  latter,  as  a  rule,  ends  fatally,  the  former 
does  not  necessarily  endanger  the  life  of  the  patient. 
As  a  proof  of  this  view  I  described  a  case  of  achylia 
gastrica  which  I  had  under  observation  for  four  years 
and  whose  condition  had,  meanwhile,  rather  improved, 
and  another  case  in  which  the  obtained  historical 
points  made  it  probable  that  the  stomach  had  persisted 
in  this  state  of  juicelessness  for  forty  years.  In  this 
case  there  were  no  subjective  symptoms  present  and 
the  patient  used  to  partake  of  the  heaviest  food  with 
perfect  impunity.  In  all  these  cases  the  small  intes- 
tine acts  vicariously  and  completely  replaces  the  lack 
of  digestion  of  the  stomach. 

In  regard  to  the  literature  of  "atrophy  of  the  gastric 
mucosa "  the  same  can  be  found  in  my  above  men- 
tioned paper.  I  would  like,  however,  again  to  pay  my 
tribute  to  the  excellent  work  done  in  this  line  by  Henry 
and  Osier  ^  and  F.  P.  Kinnicutt.'  Both  papers  describe 
cases  of  pernicious  anaemia  in  which  the  autopsy  showed 
the  disappearance  of  the  gastric  glands.  Henry  and 
Osier  have  given  various  characteristic  drawings  illus- 
trating the  microscopic  picture  of  this  condition. 

The  recent  literature  on  cases  of  pure  achylia  gas- 
trica (not  complicated  with  pernicious  anaemia)  is  not 
very  e.\tensive.  Simultaneously  with  my  article  on 
"Achylia  Gastrica"  Ewald^  published  a  paper  entitled  : 
"  A  Case  of  Chronic  Disability  of  Gastric  Secretion 
(Anadenia  Ventriculi  ?)."  Ewald's  views  are  in  perfect 
accordance  with  mine.  The  patient  reported  in  the 
paper  had  been  observed  by  Ewald  for  tsvo  and  a  half 
years.  Whereas  this  patient  improved  considerably  in 
every  respect  and  gained  forty-two  pounds  in  weight, 
the  chemical  examination  of  the  gastric  contents  showed 
a  total  lack  of  juice. 

Th.  Rosenheim"  reports  a  patient,  aged  eighteen,  who 
presented  all  the  symptoms  of  achylia  gastrica  in  1889, 
and  when  examined  anew  in  July,  1894,  the  same  con- 
dition of  the  stomach  was  found. 

Westphalen"  described  a  case  of  achylia  gastrica 
complicated  with  motor  insufficiency.  Here  the  diag- 
nosis made  during  life  was  verified  by  autopsy  after 
patient's  death  a  few  days  after  an  operation. 

In  his  textbook  on  "  Diseases  of  the  Stomach,"  J. 
Boas'*  says  :  "  There  is  at  present  no  doubt  that  an  ab- 
solute and  permanent  lack  of  gastric  secretion  may  be 
compatible  with  a  subjectively  and  objectively  perfect 
welfare.  .  .  .  Instead  of  many  one  striking  in- 
stance. .  .  .  The  patient,  under  observation  for  over 
three  years,  partakes  of  the  heaviest  foodstuffs  without 
any  discomfort  whatever,  notwithstanding  the  abso- 
lute lack  of  HCl  and  almost  entire  absence  of  the 
enzyms." 

In  this  country  Allen  A.  Jones'  has  described  under 

'  Read  before  the  Xew  York  Academy  of  Medicine,   Section  on 
General  Medicine,  May  21.  1895. 
'  Max  Einhom  :  Meoical  Record,  June  11.  1892. 

*  Henry  and  Osier  :  American  Journal  of  the  Medical  Sciences,  vol. 
91,  1886,  p.  498. 

*  F.  P.  Kinnicutt ;  American  Journal  of  the  Medical  Sciences,  vol. 
94.  1887,  p.  419. 

^  C.  .A  Ewald  :  Berliner  klin.  Wochenschrift.  1892,  Nos.  26  and  27. 

'  Th.  Rosenheim  :  Berliner  klin.  Wochenschrift,  1894,  No.  39.  p. 
887. 

'  H.  Westphalen  :  St.  Petershurger  med.  Wochenschnfi,  1890.  Nos. 
37.38. 

'  J.  Boas :  Specielle  Diagnostik  und  Therapie  der  ^fagenkrank- 
heiten.  Leipzig,  1893,  p.  18. 

*  .Allen  A.  Jones  ;  New  York  Medical  Journal,  May  27.  1893,  p.  573. 


the  name  of  "  Gastric  .\nacidity  "  four  cases  belong- 
ing to  this  class  of  affections. 

It  would  have  been  hardly  necessary  to  again  discuss 
this  subject  but  for  two  new  facts  observ'ed  which  ap- 
pear to  be  of  value  for  the  affection  in  question. 

As  yet  it  is  uncertain  whether  in  all  cases  of  achylia 
gastrica  there  necessarily  exists  an  anatomical  lesion 
(atrophy  of  the  glands)  or  not — i.e.,  whether  cases  of 
achylia  might  not  perhaps  occur,  in  which  the  gastric 
mucosa  is  not  much  altered.  The  question  of  the  pos- 
sible existence  of  achylia  when  there  are  no  considera- 
ble changes  of  the  gastric  mucosa  is  closely  connected 
with  the  further  question,  whether  a  repair  of  this  con- 
dition be  possible. 

The  two  following  observations  will  perhaps  throw 
some  light  on  these  questions  : 

Case  I. — M.    G .     Diai^nosis  :    Achylia  gastrica, 

Erosiones  ventriculi. — The  details  of  this  case  are  given 
in  my  paper'  on  "  Erosions  of  the  Stomach."  Here  it 
will  suffice  to  state  that  the  chemical  examination  of 
the  gastric  contents  of  this  patient — which  analysis  has 
been  made  far  more  frequently  than  described  in  my 
paper — always  revealed  a  total  absence  of  HCl,  an 
acidity  of  four  or  even  below  that,  absence  of  the  biu- 
ret reaction,  and  absolute  deficiency  of  the  rennet  and 
pepsin  ferments.  In  this  way  the  diagnosis  of  achylia 
gastrica  had  been  established.  In  the  same  patient 
lavage,  in  the  fasting  condition,  used  to  bring  up  sev- 
eral small  pieces  of  gastric  mucosa,  which,  microscop- 
ically, showed  the  presence  of  rather  normal  glands. 
(In  my  above-named  paper  on  "  Erosions  of  the  Stom- 
ach "  there  is  a  drawing  of  the  microscopic  picture  of 
a  piece  of  gastric  mucosa  of  the  patient.) 

It  is  evident  from  this  observation  that  there  might 
exist  an  achylia  even  when  the  glandular  layer  of  the 
stomach  has  not  been  totally  destroyed.  The  suppres- 
sion of  the  gastric  secretion  is,  then,  probably  caused 
by  certain  nervous  disturbances. 

Case  II. — Louis  T ,  now  twenty-eight  years  of 

age,  with  previous  diagnosis  :  Achylia  gastrica  (re- 
ported in  1 888  in  the  Xeii'  York  Medical  Press,  and 
thereafter,  in  1892,  in  the  Medical  Record) — still 
presented  the  symptoms  of  achylia  gastrica  in  1893. 
In  1894,  however,  the  patient  began  to  show  a  different 
aspect  of  his  gastric  functions.  At  first  it  was  notice- 
able that  the  gastric  contents  consisted  of  a  much  finer 
mixture — the  solid  particles  being  much  more  minute 
— contained  the  two  characteristic  ferments,  presented 
a  low  degree  of  acidity  (though  higher  than  heretofore), 
and  revealed  the  presence  of  peptone.  .\  few  months 
later  the  acidity  increased  to  thirty,  and  now  even  free 
HCl  could  be  easily  detected. 

In  this  case,  in  testing  the  gastric  contents  in  1893,  I 
also  applied  Sjoequist's  method  as  modified  by  Ewald - 
in  order  to  determine  whether  there  was  combined 
HCl.  The  result  was  always  negative.  I  have  applied 
the  same  method  (Sjoequist- Ewald)  in  three  other 
cases  of  achylia  gastrica,  and  could  always  determine 
a  complete  absence  of  combined  HCl. 

.\ccording  to  my  belief,  in  cases  in  which  the  acidity 
has  either  disappeared  or  is  so  low  that  it  does  not 
exceed  four  or  six  for  a  long  period  of  time,  it  is 
sufficient,  for  practical  purposes,  to  ascertain  the  ab- 
sence of  the  ferments  (pepsin  and  rennet),  of  Giinz- 
burg's  reaction  and  of  the  biuret  test,  in  order  to  make 
the  diagnosis  of  achylia  gastrica.  I  am  quite  certain 
that  one  would  find  also  in  all  these  cases  a  total  lack 
of  the  combined  HCl,  just  in  the  same  manner  as  I 
found  it  in  the  three  cases  I  have  especially  examined 
with  regard  to  this  point. 

If  I  now  return  to  case  Louis  T ,  it  appears  quite 

evident  that  even  a  typical  case  of  achylia,  where  this 

■  M.  Einhom  :  MEDICAL  RECORD,  June  23,  1894. 

'  Proceed  as  follows  :  To  10  c.c.  of  the  filtrate  add  BaCOj,  evapo- 
rate to  dryness,  and  reduce  to  ash.  Dissolve  the  residue  in  H,0. 
If,  on  addition  of  a  solution  of  NajCOj.  no  precipitate  is  formed,  it 
shows  that  no  barium  chloride  is  present,  or  that  there  was  no  com- 
bined HCl  prestn'. 


MEDICAL   RECORD. 


[July  6,  1895 


condition  has  remained  unchanged  for  seven  years  (five 
years  thereof  under  constant  observation),  may  take  a 
turn  for  the  better  and  the  stomach  may  slowly  regain 
its  secretory  function.  This  fact  appears  to  find  only 
an  explanation  under  the  supposition  that  the  suppres- 
sion of  gastric  secretion  in  this  case  was  not  due  to  a 
total  disappearance  of  the  glandular  layers,  but  rather 
to  certain  thus  far  unknown  nervous  disturbances. 

Both  cases  mentioned  prove  that  achylia  gastrica 
may  e.xist  in  a  person  notwithstanding  the  presence  of 
gastric  glands. 

From  the  above  it  is  apparent  that  the  clinical  pict- 
ure of  achylia  gastrica  does  not  suffice  to  establish  the 
diagnosis  of  anadenia  ventriculi  (Ewald).  It  does  not, 
however,  by  any  means  follow  that  some  cases  of  achy- 
lia gastrica  might  not  be  complicated  or  rather  caused 
by  anadenia. 

The  following  case  that  was  observed  for  several 
years,  and  on  which  ultimately  an  autopsy  was  made, 
will  be  of  great  interest  with  regard  to  the  point  in 
question  : 

Mrs.  Augusta  G ,  about  thirty-eight  years  of  age, 

came  under  my  care  through  the  kindness  of  Dr.  J. 
Rudisch  in  18S8.  The  patient  stated  she  had  suffered 
severely  from  the  stomach  for  the  last  five  years.  She 
frequently  had  pains  after  meals.  There  was  no  vom- 
iting. Constipation.  During  these  five  years  patient 
had  lost  considerably  in  weight — about  twenty  pounds 
altogether. 

The  examination  of  the  chest  organs  did  not  show 
anything  abnormal.  Palpation  of  the  abdomen  did 
not  reveal  any  tumor.  There  was  no  splashing  sound 
in  the  gastric  region  and  the  contours  of  the  stomach 
could  not  be  mapped  out.  By  abundant  food  and 
massage  the  condition  of  the  patient  greatly  improved. 
She  increased  seven  pounds  in  weight  during  the  win- 
ter, and  the  pains  were  slight  or  absent.  During  the 
summer  of  18S8  I  examined  the  gastric  contents  one 
hour  after  Ewald's  test-breakfast.  The  contents  ob- 
tained were  small  in  quantity  and  thick.  The  bread 
particles  were  not  minute  and  looked  unchanged.  The 
a.nount  of  fluid  was  extremely  small.  The  filtrate 
showed  :  HCl  =  o  ;  acidity  =  4  ;  rennet  =  o  ;  biuret  re- 
action =  o  ;  erythrodextrin  =  o  ;  sugar  -I- . 

In  the  fall  of  18S8  I  again  examined  the  gastric  con- 
tents and  obtained  exactly  the  same  result.  Patient  in 
the^summer  of  1889,  although  feeling  quite  well,  left 
for  Europe.  She  stayed  a  few  weeks  in  Franzensbad, 
and  then  about  two  months  in  a  hydropathic  insti- 
tute near  Vienna.  When  patient  returned  to  New 
York  she  was  not  not,  on  the  whole,  better  than  hereto- 
fore. During  the  winter  of  1889-90  she  had  a 
severe  attack  of  pleurisy,  from  w^hich  she  recovered 
perfectly.  Patient  spent  the  summer  of  1890  in  the 
Catskill  Mountains.  While  there  she  caught  cold  and 
suffered  from  a  new  attack  of  pleurisy  with  consider- 
able exudation.  After  aspirating  over  a  quart  of 
liquid  with  the  Dieulafois  apparatus  patient  seemed  to 
recover  quickly.  Soon  afterward,  however,  a  new  seri- 
ous ailment — carcinoma  uteri — made  its  appearance  and 
ended  her  life  on  September  11,  1891. 

During  the  last  eighteen  months  of  patient's  life  the 
gastric  symptoms  were  not  very  pronounced.  Patient 
used  to  eat  very  slowly,  and  al«'ays  made  intermis- 
sions (for  about  two  to  three  minutes)  after  every  few 
mouthfuls  of  food.  She  asserted  that  without  the  in- 
termissions the  food  would  not  go  down  and  remained 
in  the  oesophagus.  Patient,  however,  partook  of  a  quite 
manifold  and  varied  diet  (meat,  green  peas,  spinach, 
asparagus,  different  soups,  white  bread  and  butter, 
milk,  coffee).  In  order  to  alleviate  the  pains  caused  by 
the  cancer — -pronounced  inoperable  by  the  best  gyne- 
cologists of  this  city — methyl-blue  0.2  once  a  day  was 
administered  first  per  os,  then  per  rectum.  This 
medicament  was  used  in  this  case  a  whole  year  with 
the  greatest  benefit.  During  the  entire  sickness  the  nu- 
trition  of  the  patient   remained  quite   good.     About 


three  months  before  death  a  resistancy  was  felt  below 
the  ensiform  process  which  was  ascribed  to  the  stomach. 
It  was  quite  natural  to  think  of  a  cancerous  growth  in 
this  organ  also.  This,  however,  was  not  the  case,  as  the 
autopsy  afterward  showed. 

At  the  autopsy  the  uterus  was  found  to  be  of  the  size 
of  a  child's  head,  and  taken  up  by  a  scirrhous  cancer. 
At  the  beginning  of  the  colon  ascendens  there  was  a  per- 
foration (caused  by  the  pressure  of  the  tumor  on  that 
organ)  ;  pus  in  the  abdominal  cavity. 

For  a  better  conception  I  give  the  following  draw- 
ings : 


,■^'■■■:^■■ 


'•^iM 


•Sj^-H" 


Cflf 


Fig.  I. — Cross-section  through  the  Stomach-wall  under  Low  Power,  showing 
Relations  of  the  Layers  :  a,  mucosa  ;  ^,  submucosa ;  f,  ^,  muscularis ;  r,  peri- 
toneum.    No  glands  in  the  i 


i>s 


Fig.  3. — One  part  of  the  i 


r  layers  highly  m  ignilied :  *i,  mucosa  :  ^,  sub- 


The  stomach  was  not  adherent  to  the  neighboring  or- 
gans ;  it  looked  extraordinarily  small  and  firm,  of  large 


July  6,  1895] 


MEDICAL   RECORD. 


pear's  size,  and  measured  10  ctm.  in  length  and  6  ctm. 
in  width,  the  walls  being  about  i  ctm.  thick.  In 
opening  the  stomach  the  interior  appeared  quite  smooth, 
presenting  a  whitish  gray  surface.  The  pylorus  was 
not  stenosed,  and  could  be  passed  with  the  finger. 

From  two  different  spots  of  the  fundus  ventriculi  nu- 
merous microscopical  specimens  were  made,  showing 
the  entire  cross-cut  of  the  wall  of  the  stomach.  No 
glands  could  be  found  anywhere,  and  instead  of  them 
there  was  a  thin  layer  consisting  principally  of  round 
cells.  The  submucosa  was  greatly  hypertrophied  and 
filled  with  numerous  cyst-like  meshes.  The  muscularis 
was  also  very  much  thickened. 

Conclnsions. — In  this  case  the  diagnosis  of  achylia 
gastrica  had  been  made  three  to  four  years  before  death. 
An  abundant  and  well-regulated  dietary  regimen  had 
considerably  improved  the  patient's  condition.  The 
state  of  the  stomach  was  bearable  and  remained  so.  A 
cancer  of  the  uterus,  however,  developed  and  ended  the 
life  of  the  patient.  At  the  autopsy  the  stomach  was 
found  to  be  very  small  in  size  and  its  walls  uniformly 
thickened.  The  inner  surface  presented  a  smooth  and 
whitish  appearance  ;  microscopically  the  inner  layer 
was  found  to  contain  no  glands,  and  consisted  merely 
of  cells  and  scanty  fibrous  tissue.  The  other  layers  of 
the  stomach,  the  submucosa  and  muscularis,  were  greatly 
hypertrophied,  not  containing,  however,  any  foreign 
elements.  Thus,  the  condition  of  the  stomach  found 
at  the  autopsy  corresponded  to  that  of  cirrhosis  ventric- 
uli, as  described  by  Nothnagel,'  Henry  and  Osier,'  and 
von  Kahlden.^ 

In  this  case  it  seems  justifiable  to  assume  that  the 
achylia  gastrica,  which  was  diagnosticated  about  three 
years  before  the  exitus,  was  due  to  a  real  anadenia  of 
the  organ.  It  appears,  however,  more  than  probable 
that  the  great  diminution  in  the  size  of  the  stomach 
developed  in  the  last  three  or  five  months  before  death, 
at  the  time  when  the  resistancy  began  to  be  felt  at  the 
ensiform  process. 

Out  of  the  entire  number  of  my  newly  observed 
cases  of  achylia  gastrica  (they  amounted  to  thirteen 
after  deducting  the  above-narrated  cases),  I  may  be 
allowed  to  report  two  typical  cases  of  this  affection,  one 
of  which  was  interesting,  inasmuch  as  there  were  no 
gastric  symptoms  whatever  and  the  complaints  apper- 
tained merely  to  the  intestinal  trace. 

Typical  Cases  of  Achylia  Gastrica. — The  following 
cases  are  of  great  interest  ; 

C.\SE  I.  (October  24,  1892). — Mrs.  G ,  aged  about 

forty-five,  complains  of  her  stomach  for  the  last  twelve 
years.  She  is  almost  always  troubled  with  pains  after 
meals  in  her  gastric  and  epigastric  region.  Appetite 
poor.  Bowels  inclined  to  be  constipated.  Vomiting 
appeared  very  seldom.  Patient  had  lost  consider- 
ably in  weight  during  the  first  years  of  her  ailment  ; 
thereafter  her  weight  remained  stationary.  In  1S91 
she  visited  Carlsbad,  but  her  condition  did  not  im- 
prove any. 

Present  Condition. — Patient  of  small  stature  and  quite 
thin.  Panniculus  adiposus  looks  somewhat  thin.  Lips 
and  cheeks  of  a  pale  color.  Tongue  not  coated. 
Chest  organs  in  good  shape.  The  palpation  of  the 
abdomen  reveals  the  absence  of  any  tumor.  The  epi- 
gastric region  is  sensitive  to  pressure,  but  not  e.xactly 
painful.  A  splashing  sound  can  be  produced  to  about 
three  fingers'  width  below  the  navel.  The  urine  does 
not  contain  either  sugar  or  albumin. 

October  27th. — E.xamination  of  the  stomach  one 
hour  after  Ewald's  test-breakfast  :  HCl  =  o  ;  lactic 
acid  =  o  ;  acidity  =  6  ;  rennet  =  o  ;  biuret  reaction 
=  o  ;  erythrode.xtrin  =  o  ;  sugar  +.  The  quantity  of 
the  gastric  contents  is  not  large,  and  contains  a  very 
small  amount  of  liquid.  The  bread  particles  are  not 
minute.     No  mucus. 

'  Xothnagel  :  Deutsch.  Arch,  fur  klio.  Med.,  1879,   Bd.  24,  p.   353. 

^  Henry  and  Osier  ;  Loc.  cit. 

^  Von  kahlden  :  Centralbl.  f.  klin.  Med.,  1887,  No.  16,  p.  281. 


October  30th. — When  fasting  :  stomach  empty. 

January  8,  1893. — E.xamination  of  the  stomach  one 
hour  after  Ewald's  test-breakfast  :  HCl  =  o  ;  lactic 
acid  =  o  ;  acidity  =  4  ;  rennet  =  o  ;  pepsin  =  o  ;  bi- 
uret reaction  =  o  ;  erythrodextrin  =  o  :  sugar  +. 

During  the  year  1893  several  other  examinations  of 
the  gastric  contents  had  been  made,  with  the  same 
analytical  data  as  just  mentioned. 

Taking  into  consideration  the  very  long  period  of 
the  ailment  and  the  result  of  the  chemical  examination 
of  the  gastric  contents,  achylia  gastrica  was  diag- 
nosticated, and  cancer  excluded.  The  further  course 
of  the  patient's  condition  has  fully  verified  this  as- 
sumption, for  the  patient  now  (two  to  three  years 
after  the  reported  examinations)  is  in  rather  a  better 
condition  than  heretofore. 

The  treatment  consisted  in  occasional  lavage  and  in- 
tragastric faradization. 

C.\SE  II.  (October  i,   1894) — Mrs.  A.  S ,  aged 

about  twenty-five,  had  suffered  five  years  ago  from 
severe  diarrhoea  for  about  three  months.  Eighteen 
months  later  patient  had  a  new  attack  of  diarrhoea  last- 
ing over  a  month.  About  a  year  ago  she  began  to 
complain  of  pains  after  meals.  These  pains,  as  a  rule, 
appeared  right  after  the  partaking  of  food  and  lasted 
for  about  three  hours.  At  times,  patient  would  ex- 
perience a  mere  feeling  of  pressure,  at  times,  however, 
the  pain  was  very  intense  in  character.  Bowels  regular. 
For  the  last  two  years  she  suffered  from  very  severe 
headaches.  Patient  had  lost  seven  pounds  during  the 
last  year.  She  greatly  suffers  from  belching  without 
any  bad  odor.  Appetite  very  good.  Patient,  at  times, 
feels  very  sleepy,  at  times  again  she  is  subject  to  faint- 
ing spells  of  very  short  duration. 

Present  Condition. — Patient  looks  well  nourished, 
though  somewhat  pale.  Tongue  slightly  coated.  Chest 
organs  intact.  The  stomach  is  situated  quite  low  (gas- 
troptosis)  and  the  right  kidney  movable.  The  epigas- 
tric region  is  sensitive  to  pressure,  although  not  pain- 
ful.    The  urine  does  not  contain  anything  abnormal. 

October  2,  1894. — Examination  of  the  stomach  one 
hour  after  Ewald's  test-breakfast.  Only  a  small  quan- 
tity of  thick  contents  could  be  obtained.  The  bread 
particles  are  not  minute  and  they  obstruct  the  tube. 

The  filtrate  shows  :  HCl  =  o  ;  reaction  hardly  acid  ; 
acidity  =  2  ;  lactic  acid  =  o  ;  biuret  reaction  =  o;  ren- 
net =  o  ;  pepsine  =  o  ;  erythrodextrin  =  o  ;  sugar  -I-. 

October  4th. — In  the  fasting  condition  :  stomach 
empty.  Patient  is  treated  every  other  day  with  intra- 
gastric faradization.  She  feels  better  and  can  eat  with- 
out pains  ;  the  headaches  have  meanwhile  disappeared. 

October  17th. — Examination  of  the  stomach  one 
hour  after  Ewald's  test-breakfast  :  HCl  =  o,  of  hardly 
acid  reaction;  acidity  =  2  ;  lactic  acid  not  present  ;  biu- 
ret reaction  =  o  ;  rennet  =  o  ;  pepsin  =  o  ;  erythrodex- 
trin =  o  ;  sugar  -f .  The  bread  particles  not  minute  ; 
small  quantity  of  fluid  ;  no  mucus. 

At  the  end  of  November,  1894,  patient  was  dis- 
missed from  treatment.  During  the  last  two  months 
she  had  gained  eight  pounds  in  weight  and  was  be- 
lieved to  be  perfectly  well.  The  examination  of  the 
gastric  contents  of  November  29,  1894,  however,  re- 
vealed exactly  the  same  condition  as  previously  de- 
scribed. 

.April  5,  1895. — Patient  felt  well  all  the  time  without 
any  treatment.  The  gastric  contents  were  again  ex- 
amined and  found  to  contain  the  same  characteristic 
properties  as  above  stated. 

A  Case  of  Achylia  Gastrica  with  Predominant  In- 
testinal Symptoms  (.\pril  14,  1S94). — Solomon  S , 

fifty-seven  and  a  half  years  of  age,  always  enjoyed  good 
health  until  August,  1892,  when  he  had  a  severe  attack 
of  dysentery  (patient  had  to  stay  in  bed  for  over  three 
weeks  and  felt  afterward  extraordinarily  weak).  Since 
that  time  patient  had  attacks  of  severe  diarrhoea  (much 
mucus,  sometimes  blood  in  the  passages)  every  two 
to  three  weeks.     This  diarrhoea  used  to  alternate  with 


MEDICAL    RECORD. 


[July  6,  1895 


constipation.  From  August  to  October,  1S92,  patient 
had  lost  forty  pounds  in  weight.  From  that  time 
on  he  felt  weak  and  miserable  and  complained  of 
thirst.  This  condition  remained  unchanged  during  this 
time.  He  complains  at  present  principally  of  ex- 
treme weakness,  of  intense  thirst,  and  of  very  weaken- 
ing diarrhoeal  attacks. 

Present  Condition. — Color  of  lips  and  cheeks  very 
pale,  ansmic.  Tongue  furred  with  a  whitish  coat. 
Chest  organs  intact.  The  stomach  extends  to  one  fin- 
ger's width  below  the  navel.  A  splashing  sound  can 
be  easily  produced  in  the  gastric  region.  There  is  no- 
where any  tumor.  There  are  no  sensitive  spots  discov- 
erable in  the  abdomen.  The  knee  reflex  is  present. 
The  urine  contains  neither  sugar  nor  albumin. 

Patient  was  treated  for  some  time,  at  first,  with  in- 
jections into  the  bowels  (acid,  tannic.  2.0  to  a  quart 
of  water  once  daily),  thereafter  with  the  administration 
of  peptonate  of  iron.  All  these  means,  however,  failed 
to  be  of  any  benefit  whatever  ;  the  tired  feeling  and 
weakness  persisted,  and  the  frequent  attacks  of  diar- 
rhoea likewise  remained  unchanged. 

November  21,  1S94. — Examination  of  the  stomach 
one  hour  after  Ewald's  test-breakfast :  HCl  =  o  ;  acidity 
=  2  ;  lactic  acid  =  o  ;  rennet  =  o  ;  pepsin  =  o  ;  biuret 
reaction  =  o  ;  erythrodextrin  =  o  ;  sugar  -1-.  Quantity 
of  liquid  very  small  ;  the  bread  particles  not  minute  ;  no 
admixture  of  mucus. 

November  23d. —  When  fasting  :  stomach  empty. 
Achylia  gastrica  is  diagnosticated,  and  the  patient 
treated  with  intragastric  faradization.  The  diet  is  ar- 
ranged in  such  a  manner  that  it  does  not  contain  very 
much  meat,  and  is,  instead,  rich  in  food  taken  from  the 
vegetable  kingdom. 

After  two  weeks  of  this  treatment  the  sensation  of 


weakness  remained  away.  Patient  began  to  look  be*- 
ter.  His  cheeks  had  a  red  color,  the  bowels  were  reg- 
ular, and  the  troublesome  sensation  of  thirst  that 
formerly  was  so  annoying  to  the  patient  disappeared. 

December  17th. — Examination  of  the  stomach  one 
hour  after  Ewald's  test-breakfast ;  HCl  =  o,  of  neutral 
reaction  ;  biuret  reaction  =  o  ;  rennet  =  o  ;  pepsin  =  o  ; 
erythrodextrin  =  o  ;  sugar  -1-.  Small  quantity  of  fluid  ; 
the  bread  particles  not  minute  ;  no  mucus. 

Patient  asserts  that  he  feels  well  ;  he  can  walk  great 
distances  without  feeling  tired. 

December  20th. — One  and  a  half  hour  after  the  test- 
breakfast  :  stomach  empty. 

December  31st. — Patient  takes  one  glassful  of  milk  ; 
one  hour  afterward,  he  takes  a  glassful  of  water,  and 
his  stomach  is  directly  faradized  for  ten  minutes. 
Then  the  gastric  contents  are  obtained  by  means  of  a 
tube ;  they  consist  of  uncurdled  milk  diluted  with 
water  and  are  of  neutral  reaction. 

Patient  was  examined  at  various  times  in  January 
and  February,  1895,  and  there  was  always  found  a  com- 
plete absence  of  gastric  juice.  The  absorption  of  the 
stomach  was  examined  by  means  of  the  KJ  test,  and 
the  iodine  could  be  detected  in  the  saliva  after  a  lapse 
of  eleven  minutes.  Patient's  health  was  and  remained 
thus  far  in  very  good  state  ;  his  appetite  is  fair,  bowels 
regular,  and  stools  well  formed  ;  no  attacks  of  diarrhoea. 

April  15,  1895. — Patient  has  gained  ten  pounds  in 
weight. 

(Several  examinations  that  have  been  made  with  re- 
gard to  the  acidity  of  the  urine  are  here  omitted,  as 
they  will  be  mentioned  later.) 

Of  the  remaining  patients  with  achylia  gastrica  I  may 
be  permitted  to  give  in  table  form  a  short  review  of  the 
subjective  complaints  and  of  the  objective  data  found. 


Table  of  the  Remaining  Cases  of  Achvlia  Gastrica. 


Disease  I 
,(  Yeats). 


Principal 
Complaints. 


Result  of  the  Chemical  Ex 
I      tion  One  Hour  after  Ewald's 
1     Test-breaklast. 


Patrick  M 46 


Crtorge  H.  J.. 


Isaac  S 46 


Dizziness,  prind- 
j      pally    after 
meals. 


'ain?:,  beginning 
at  meals  and 
lasting  for  about 


tends  to  one 
hand's  width 
below  navel. 


after  meals;    (lasiroptosU. 


Pains  after  meals; 
freqtient  vomit- 
ing ;  constipa- 
tion. 

Pams  after  meals; 
at  times  vomit- 
i  n  5  :  frrquent 
diarrhoea. 


largcd. 
In  normal  po- 


not  enlarged 


The  particles  of  roll  not  minute. 
HCl  =  o.   acidity  =  4.   rennet 

=  o,  biuret  =  o,  erj'throdexirin 
=  o.  sugar  +. 

The  pieces  of  bread  not  small. 
HCl  =  o,  lactic  acid  =  o,  acid- 
ity =  4,  rennet  =  o.  biuret  = 
o;  no  mucus;  small  quantity 
of  fluid. 

Three-quarters  of  an  hour  after 
test- breakfast :  The  bread  par- 
ticles not  minute.  HCl  =  o. 
acidit>'  =  2,    rennet  =  o.  pcp- 

The  particles  of  bread  unchanged- 
HCI  =  o.  hardly  aad  ;  acidity 
=  2.  rennet  =  o,  biuret  =  o, 
erythrodextrin  =  o,  sugar  +. 

The  particles  of  food  not  ^mall : 
small  quantity  of  fluid.  HCl 
=  c,  acidity  =  2,  rennet  =  o, 
pepsin  =  o,     biuret  =  o  ;     no 


Pains  after  meals; 
poor  appetite; 


ins  after  meals; 
ometimeshead- 
che  :    frequent 


Gasiroptosi 


Extends  to  the    The  pieces  of  roll  not  minute  and 
navel.  vmchanged.      HCl  =  o,   lactic 

acid  =:  o,  acidity  =  4,   rennet 
'  =  o.    pepsin  =  a.    biuret  =  o, 

erj'throde-virin  =  o,  sugar  +. 
The  particles  of  bread  unchani^ed. 
HCl  =  o,  lactic  acid  =  o.  acid- 
ity* =  4.  rennet  =  o,  pepsin  = 
o,     biuret  =  o,    eryibrodcxuin 

Three-quarters  of  an  hour  after 
test- breakfast :  The  pieces  of 
bread  not  mmutc.  HCl  =  o. 
lactic  acid  =  o,  acidity  =  4. 
rennet  =  o.  pepsin  =  o.  biuret 
=  o,    erythrodexuin  =  o.    su- 


car 


Pjins  after  mcils: 
frequent  bclch- 
mg  ;  s  -metimes 
\omiting  :  obsti- 
nate diarrhcua. 


N'j  gastric  symp- 
toms :  obstuiatc 
diarrhnra.  alter- 
nating with  con- 
stipation. 


r.astroptOiis.  The  pieces  of  bread  not  small. 
HCl  =  o,  acidity  =  ■»,  rennet 
=  o,  pepsin  —  <'',  biuret  =  o, 
erythrodc.xtrn  =  o,  sugar  +. 


he  panicles  of  bread  not  mi- 
nute. HCl  =  o.  acidity  -  4. 
rennet  =  o,  biuret  =  o.  ery- 
ihroJcxtnn  =  o,  su;;ar  -t-. 


Stomach,  when  fasting,  ain'ays  empty. 


Stomach,  when  fasting,  empty.     Paderi  has  i 
weight,  and  looks  well  nourished. 


One  hour  after  the  test-breakfast  the  stomach  had  been  fre- 
quently found  empt)'.  Patient  had  gained  eight  pounds 
during  three  months  of  treatment.  The  condition  of  the 
stomach,  however,  has  not  changed  in  any  way.  Right 
kidney  movable. 

Stomach  empt>-  in  the  fasting  condition. 


Stomach  empt>-.  when  fasting,  .\fter  a  few  times  of  Ia\-a5e 
the  pains  subsided,  the  vomiting  and  diarrhoea  disap- 
peared ;  notwiih>>tanding  this,  the  chemical  condition  of 
the  gastric  contents  did  not  change  in  any  way. 

Stomach  empty  when  fasting.  Patient  looks  perfecriy  »-eII 
and  robust,  has  a  good  appetite  (slightly  iDcrcased).  and 
partakes  of  the  heaviest  food  with  tmpunit>*. 


Right  kidney  mo\-abIc.  Stomach  empty  when  fasting.  One 
hour  after  the  test- breakfast  the  stomach  «-as  found  empty 
several  times.  Patient  was  under  observation  for  a  who'e 
year  and  had  gained  seven  pounds  :  she  then  died,  after 
a  short  illness,  with  pneumonia. 

One  hour  after  the  test-breakfast  the  stomach,  as  a  rule, 
used  to  be  found  empty.  The  absorption  of  the  stomach 
was  e.vamined  by  me.ins  of  K,I  ;  in  twelve  minutes  iodine 
could  be  detected  in  the  sali\-a.  Patient  was  under  ub- 
servaiion  for  over  a  year.  There  was  a  decided  impro\Te- 
ment  in  the  patient's  condition.  He  has  gained  six  pounds 
in  weight;  there  were  hardly  any  pains,  and  the  diar- 
rhoea appeared  only  very  seldom.  The  chemical  exam- 
ination of  the  stomach,  however,  showed  the  same  condi- 
tion as  describe.*. 

Right  kidney  movable.  Here  ?j«-»ccquisi's  method,  as  modi- 
fied by  Kwald,  was  applied  in  order  to  determine  the 
quantity  of  combined  HCl :  no  traces.  howe\-cr,  could  be 
detected.  The  treatment  consisted  principally  in  intra- 
gastric faradization.  There  was  marked  impn>\-cmeni. 
Patient  gained  six  pounds  in  weight ;  the  pams  and  the 
diarrhica  entirely  disappeared. 

Riqht  kidney  movable.  Pronounced  ner\*ous  symptoms. 
Tongue  aUva\-s  clean.  P.itient  was  under  observation  for 
four  years,  hi<  condition  has  not  chanced  in  anyway 
during  this  period  of  time.  His  weight  remained  the 
same,  and  his  subjective  and  objective  symptoms  per- 
sisted in  an  unchanged  manner. 


July  6,  1895] 


MEDICAL    RECORD. 


Symptomatology.  —  Whereas  the  subjective  com- 
plaints, as  is  easily  apparent  from  the  above-mentioned 
cases,  may  be  of  quite  a  manifold  nature  and  may 
often  be  entirely  absent,  particularly  as  regards  the 
stomach,  the  objective  symptoms  are  always  present. 
In  reference  to  this  point  I  expressed  myself  in  my 
paper  on  "Achylia  Gastrica  "  in  the  following  way  : 

"  In  all  four  cases  the  stomach  contents  showed,  one 
to  one  and  a  half  hours  after  Ewald's  test-breakfast, 
the  following  peculiarities  :  i.  The  pieces  of  roll  are 
not  minutely  minced  and  unchanged.  2.  The  reaction 
very  weakly  acid  or  neutral,  usually  the  acidity  was  4 
{i.e.,  100  c.c.  of  the  filtrate  of  the  stomach  contents  are 
saturated  by  4  c.c.  of  a  one-tenth  standard  solution  of 
sodium  hydrate).  3.  Hydrochloric  acid  not  present. 
4.  Lactic  acid  present,  but  could  be  discovered  only 
after  a  thorough  shaking  with  ether.  5.  Neither  pro- 
peptone  nor  peptone  present.  6.  The  tests  for  the  pep- 
sin and  rennet'  ferments  gave  negative  results.  7. 
The  stomach  contents  did  not  smell  badly,  and  did 
not  otherwise  give  the  appearance  of  decomposition." 

To  these  seven  points  I  would  now  add  as  point 
8,  absence  of  mucus,  and  9,  the  remarkably  small 
quantity  of  liquid  found  in  the  stomach  of  these  pa- 
tients one  hour  after  the  test-breakfast.  Aside  from 
the  fluids  soaked  in  and  around  the  particles  of  bread 
there  is  hardly  any  liquid  at  all.  The  gastric  contents 
thereby  acquire  a  peculiar,  characteristic  appearance, 
and  look  different  from  what  they  do  in  other  affec- 
tions of  the  stomach.  This  small  amount  of  fluid  in 
the  gastric  contents  of  patients  with  achylia  may  be  ex- 
plained in  the  following  w^ay  :  Besides  the  water  (or 
tea)  ingested  into  the  stomach  with  the  test-meal,  there 
is  no  addition  of  juice  (or  liquid)  during  the  stay  of 
the  food  in  this  organ.  As  the  more  liquid  chyme,  as 
a  rule,  leaves  the  stomach  quicker  than  the  more  solid 
substances  these  latter  alone  will  then,  after  awhile 
(about  one  hour  after  Ewald's  test-breakfast),  be  found 
present. 

The  motor  function  of  the  stomach  was  not  impaired 
or  slackened  in  any  of  my  patients  ;  in  some  of  them 

rather    somewhat    hastened    (I.   S and    Solomon 

S ). 

The  absorption  faculty  of  the  stomach  I  have  ex- 
amined in  three  of  these  patients  and  did  not  find  it  in 

any   way   retarded.     (In  patient   L.   T after   0.2 

KJ  the  reaction  for  iodine  appeared  in  the  saliva  after 

eight  minutes,  in  I.  S after  twelve,  and  in  Solomon 

S after  eleven  minutes.) 

In  what  condition  is  the  acidity  of  the  urine  in  pa- 
tients with  achylia  gastrica  ? 

It  appeared  to  me  of  interest  to  pay  attention  to  this 
point,  and  more  especially  to  ascertain  whether  there  is 
any  difference  in  the  degree  of  acidity  of  the  urine 
passed  in  the  fasting  condition  and  that  emptied  dur- 
ing the  act  of  digestion.  As  is  well  known,  normally 
there  is  a  decrease  of  the  degree  of  acidity  of  the  urine 
during  gastric  digestion.  This  is  explained  by  the  fact 
that  at  that  time  the  acid  elements  are  conducted,  so 
to  say,  to  the  stomach.  This  point,  however,  does  not 
apply  to  achylia  gastrica,  for  there  is  no  acid  secretion 
in  the  stomach.  For  this  reason  it  would  theoretically 
appear  correct  to  assume  that  in  achylia  gastrica  the 
acidity  of  the  urine  in  the  fasting  condition  and  during 
digestion  would  not  vary  very  much.  The  following 
experiments  go  to  show  that  this  is  really  the  case. 

The  experiments  were  conducted  in  the  following 
manner  :  The  patient  arising  early  in  the  morning 
empties  his  bladder  ;  half  an  hour  later  he  urinates 
and  puts  it  in  a  bottle  with  the  mark  "  U.  I."  (urine 
first  =  fasting;.  He  then  takes  Ewald's  test-breakfast. 
One  hour  afterward  he  again  urinates  and  marks  the 
bottle  with  "  U.  II."  (urine  second  =  during  digestion). 
His  gastric  contents  are  then  obtained.  All  the  sam- 
ples are   thereupon  examined.      In  this  way  the  rela- 

'  The  rennet  zymogen,  however,  may  still  be  found  present. 


tion  between  the  acidity  of  both  urines  and  the  gastric 
contents  can  best  be  studied. 

Case  I. — L.  T ,  September  28,  1888.     One  and 

a  quarter  hours  after  Ewald's  test-breakfast ;  HCl  = 
o  ;    neutral  reaction  ;    rennet  =  o  ;    biuret  reaction  =^ 

0  :  erythrodextrin  =  o,    sugar  -I-  . 

U.  I.,  acidity  =  28.     U.  II.,  acidity  ;=  30. 

Case  II. — S.  S — — ,  February  16,  1895.  One  hour 
after  the  test-breakfast  :  HCl  =  o  ;  reaction  hardly 
acid  ;  acidity  =  4  ;  biuret  reaction  =  o  ;  rennet  =  o  ; 
rennet  zymogen,  hardly  traces.  Bread  particles  not 
minute  ;  small  amount  of  fluid. 

U.  I.  (specific  gravity  =  1.030),  acidity  =  44. 

U.  II.  (specific  gravity  =  1.020),  acidity  =  44. 

Experiment  III. — Same  patient,  April  12,  1895. 

U.  I.  (specific  gravity  =  1,020),  acidity  =  52. 

U.  II.  (specific  gravity  —  1,022),  acidity  =54. 

Thus,  in  these  two  cases  of  achylia  gastrica  the  acid- 
ity of  the  urine  before  and  during  gastric  digestion 
hardly  varied  at  all. 

Etiology. — With  regard  to  the  etiology  of  achylia 
gastrica  it  is  generally  assumed  that  same  develops  after 
preceding  grave  chronic  catarrhal  conditions  of  the 
stomach.  The  newer  text-books  on  "  Diseases  of  the 
Stomach  "  (Ewald,  Boas,  Bouveret)  mention  this  affec- 
tion in  the  chapter  on  "  Gastritis  Glandularis  Chronica." 

1  certainly  believe  that  such  an  origin  of  achylia  gas- 
trica is  sometimes  the  case.  The  cases  of  chronic  gas- 
tric catarrh  in  which  the  acidity  is  pretty  low  (10  to  20), 
no  free  HCl  exists,  but  biuret  reaction  and  likewise 
rennet  are  present,  speak  in  favor  of  this  view.  They 
represent,  so  to  say,  the  preceding  stage  of  achylia  gas- 
trica. Notwithstanding  this,  it  seems  to  me  more  than 
probable  that  the  affection  in  question  may  establish 
itself  also  in  some  other  way  (in  consequence  of  ner- 
vous disturbances).  In  such  instances  the  glandular 
layers  of  the  stomach  need  not,  necessarily,  be  greatly 
altered,  although  it  appears  probable  that  after  a 
long  persistence  of  inactivity  of  the  glands  these  may 
begin    to    atrophy.      The    above-mentioned  cases,   M. 

G-- —  and  L.  T ,  prove  the  possibility  of  a  nervous 

origin  of  achylia  gastrica. 

Prognosis. — The  prognosis  of  cases  of  achylia  gas- 
trica is  good  quoad vitam,  which  view  I  have  represented 
in  my  previous  papers  and  is  now  generally  accepted  by 
most  writers.  The  small  intestine  perfectly  replaces  the 
digestive  work  of  the  stomach,  and  the  organism  is  not 
only  enabled  to  maintain  its  equilibrium  but  also  to  gain 
in  weight.  The  above  case  of  Ewald  shows  that  very 
clearly  (patient  had  gained  forty-two  pounds)  ;  some  of 
my  own  cases  likewise  prove  this  fact. 

Treatment. — With  regard  to  the  therapy,  such  will 
be  necessary  only  in  those  cases  in  which  there  are  some 
subjective  complaints. 

The  treatment  will  have  to  be  carried  out  in  the  two 
following  directions  :  i.  To  stimulate  the  mechanical 
action  of  the  stomach.  2.  To  arrange  the  diet  in  such 
a  way  that  same  is  easily  accessible  for  the  intestinal  di- 
gestion. 

The  first  point  is  best  achieved  by  stimulating  the 
stomach,  as  by  lavage  and,  principally,  direct  faradiza- 
tion of  the  organ.  In  some  of  the  cases  I  have  not  ap- 
plied any  medicaments  whatever,  in  some  I  have  ad- 
ministered condurango  or  nux  vomica. 

In  reference  to  diet  it  is  of  utmost  importance  to  see 
that  the  food  is  broken  into  very  minute  particles 
or  can  be  easily  done  so  by  chewing.  For,  on  the  one 
hand,  all  kinds  of  meat  are  not  altered  in  any  way  in 
the  stomach  and  reach  the  intestine  in  the  same  shape 
as  when  they  entered  the  cardiac  orifice  ;  on  the  other 
hand,  the  starchy  substances  contained  in  the  vege- 
table food  cannot  become  converted  into  maltose  as 
long  as  the  albuminous  membrane  occluding  them  has 
not  been  opened. 

In  the  stomach  of  these  patients  starch,  as  such, 
when  accessible  to  the  action  of  ptyalin,  undergoes 
conversion  into  sugar  very  rapidly. 


MEDICAL   RECORD. 


[July  6,  1895 


The  vegetable  food  is,  as  a  rule,  here  very  well  borne. 
Strained  pea-  and  bean-soups  may  be  recommended 
very  highly  on  account  of  their  richness  in  albumen. 
Kumyss  or  matzoon,  or  sometimes  bonny-clabber  well 
beaten  with  a  spoon,  or  plain  milk  with  the  addition  of 
bread  or  crackers  with  butter  are  highly  commendable. 
Permit  meats  only  in  small  quantities,  best  well  hashed 
and  broiled  or  the  white  part  of  chicken.  Pirain,  sweet- 
bread, fish,  and  raw  oysters  are  very  suitable.  In  the 
grave  cases  it  is  advantageous  to  administer  meat  pow- 
der (two  to  three  tablespoonfuls  or  even  more,  pro  die, 
in  soup  or  milk).  The  usual  beverages,  as  tea,  coffee, 
cocoa  with  milk  and  sugar,  besides  small  quantities  of 
beer  or  stout,  are  allowed. 

Here  also,  like  in  all  other  chronic  disturbances  of 
the  digestive  tract,  it  will  be  of  importance  to  pay  at- 
tention not  only  to  the  quality  but  also  to  the  quantity 
of  food  taken.  And  here  the  greatest  stress  must  be 
laid  that  a  sufficient  quantity  of  food  is  taken.  It  is 
always  preferable  to  have  patient  partake  of  a  too  big 
quantity  of  food  rather  than  of  a  too  small  one,  by  which 
a  condition  of  subnutrition  is  so  often  established. 

When  the  intestine  has  adapted  itself  to  the  greater 
amount  of  work  and  the  nutrition  goes  on  a  well-regu- 
lated basis,  the  achylia  gastrica  need  not  cause  any 
trouble  whatever,  and  the  patient  may  enjoy  perfect 
euphoria. 

20  East  SixTV-THiRD  Street. 


A  CASE  OF  ICHTHYOSIS  CONGENITA  WITH 
SOME   UNUSUAL   FEATURES.' 


By  JOHN  CABOT,  M.D., 


CLINICAL  .-VSSISTAN 


ERMATOLOGICAL 


Mv  aim  being  to  present  a  practical  contribution,  I 
shall  omit  all  general  references  and  discussion,  and 
confine  myself  to  reporting  the  case,  with  a  brief  resume 
in  conclusion. 

Bertha  Z ,  fourteen  months  old,  born  in  this  coun- 
try of  German  parentage,  sent  to  me  through  the  kind- 
ness of  Dr.  Philip  Roth,  Jr.,  of  Newark,  N.  J.,  and  first 
seen  November  10,  1894. 

The  history,  as  gathered  from  the  mother,  is  that 
both  parents  and  two  older  children,  of  ten  and  seven 
years  of  age  respectively,  are  healthy.  The  mother 
has^  had  no  miscarriages  or  premature  births  before, 
but  says  that  this  child  was  born  at  seven  months  of 
utero-gestation,  although  her  abdomen  was  more  dis- 
tended than  with  either  of  her  other  children  at  full 
time.  She  was  four  days  in  labor,  with  gushes  of  a 
watery  fluid,  accompanied  by  uterine  pain,  every  half- 
hour  or  so,  with  constant  dribbling  between  pains. 
The  child  was  weak  and  marasmic  when  born.  The 
mucous  membrane  of  the  eyelids  was  much  inflamed, 
ectropion  existing.  The  eyes  were  open,  and  there  was 
inability  to  close  them.  The  nostrils  were  occluded, 
and  there  was  difficulty  in  breathing,  so  that  for  some 
days  it  was  e.xpected  to  die  at  any  moment. 

The  skin  was  thickened,  dry,  red,  and  scaly  over  the 
entire  body  at  birth,  with  scales  from  pin-head  size  to 
one  and  a  half  inch  square,  the  largest  being  on  the 
trunk. 

Dr.  Roth  writes,  in  answer  to  my  inquiry;  "In  re- 
gard to  Bertha  Z 's  case,  would  say  that  there  was 

a  great  deal  of  hydramnios,  so  mucli  so  that  when  I 
ruptured  the  bag  it  seemed  to  me  that  it  might  have 
been  about  two  gallons.  The  child  was  in  normal 
position,  L.O.A.,  and  delivered  easily.  I  will  state  here 
that  I  delivered  the  woman  three  times,  the  other  chil- 
dren being  perfectly  healthy.  When  Bertha  was  born 
she  presented  the  appearance  of  a  Chinese  baby,  the 
outer  canthi  of  the  eyelids  were  drawn  downward  and 
inward,  almost  completely  closing  eyeballs  from  view. 

'  Read  before  the  New  York  Society  of  Dermatology  and  Geniio- 
Urinary  Surgery,  March  20,  1895. 


There  was  no  vernix  caseosa  on  child's  head  or  body, 
it  being  perfectly  dry  when  born.  The  nose  was  like  a 
white,  bony  prominence  protruding  from  the  face,  giving 
it  a  most  ghastly  look  ;  the  angles  of  the  mouth  were 
tightly  drawn  downward  and  inward,  and  had  a  cracked 
appearance.  The  ears  were  bound  down  to  the  head 
and  were  immovable,  and  looked  as  though  they  were 
gangrenous.  There  was  no  hair  on  the  child's  head  ; 
both  nares  were  closed,  so  that  I  had  to  make  an  in- 
cision into  each  one  to  allow  the  child  to  breathe  ;  the 
rest  of  the  body,  that  is  the  skin,  had  the  appearance 
as  though  the  child  was  enveloped  in  oil-silk,  shriv- 
elled, and  not  glistening,  but  dull." 

The  baby  was  nursed  at  the  breast  for  a  short  time, 
but  there  was  so  much  difficulty  from  the  inability  of 
the  child  to  suck  that  it  was  spoon-fed  with  condensed 
milk  and  water. 

The  marasmus  continued  for  two  months,  after  which 
time  the  child  gradually  gained  in  weight,  and  became 
healthy  except  for  the  skin  lesion,  and  occasional  at- 
tacks of  bronchitis.  At  five  months  of  age  it  had  per- 
tussis, followed  by  diarrhoea  during  the  hot  weather, 
when  it  again  became  marasmic,  reviving  slowly  after 
a  number  of  weeks'  illness,  and  for  the  last  two  months 
has  gained  decidedly. 

The  eyelids  were  at  first  held  firmly  open,  with  about 
three-quarters  of  an  inch  inter\'al  between  the  upper 
and  lower  lids,  the  conjunctivae  being  forced  outward, 
thus  diminishing  the  space  of  uncovered  eyeball  to 
about  one-half  an  inch  ;  this  condition  gradually  im- 
proved under  simple  treatment  to  the  point  that  the 
child  is  now  able  to  bring  the  lids  within  half  an  inch 
of  each  other  when  asleep,  the  mucous  membrane  ap- 
proaching to  within  one-eighth  inch. 

The  hair  was  absent  at  birth,  but  has  grown  sparsely, 
and  fallen  out  twice.  The  finger-nails  have  never  been 
entirely  normal,  growing  very  long,  rupial  in  character 
of  late,  beginning  to  drop  from  the  fingers  about  three 
months  ago  until  there  is  only  one  left. 

The  entire  skin  has  been  shed  in  different  portions 
of  the  body  from  three  to  five  times,  that  on  the  face 
and  upper  part  of  the  body  being  most  frequently 
thrown  off,  that  of  the  lower  limbs  and  scalp  the  least 
so  ;  the  skin  peeling  off  in  large  and  small  flakes,  leav- 
ing a  reddened  surface  almost  like  natural  skin, 
but  which  after  a  few  days  again  becomes  dry  and 
wrinkled.  In  peeling  off,  islands  of  the  old  skin,  tense 
and  smooth,  were  often  left,  which  when  extending 
around  the  limb,  formed  tight  bands  and  gave  the  ap- 
pearance as  if  the  child  was  outgrowing  its  own  skin. 

There  has  always  been  more  or  less  heat  in  the  skin  ; 
no  moisture  or  perspiration  was  ever  noticed. 

The  child  has  had  much  and  varied  treatment  by 
many  doctors,  but  without  any  effect. 

Status  Presens. — The  child  is  well  nourished,  though 
somewhat  smaller  than  it  should  be  at  fourteen  months. 
Weight,  13  lbs.  Length  of  body,  24  inches.  Circum- 
ference of  head,  17'^  inches.  Chest,  18  inches.  An- 
terior fontanelle  still  open  one-half  inch.  It  is  active 
and  intelligent,  but  makes  no  effort  to  crawl  or  walk  ; 
is  good-natured,  and  only  restless  when  the  clothing  is 
too  warm  ;  takes  cold  easily.  Heart,  lungs,  liver,  and 
spleen  negative  ;  bowels  regular.  Pulse,  106.  Respi- 
ration, 38.  Lfrine  clear,  acid,  1.022  ;  no  albumin  or 
sugar.  No  hair  on  the  head.  There  is  only  one  finger- 
nail, that  on  third  finger  of  right  hand  ;  toe-nails  nor- 
mal. Ears  thickened  and  lumpy  in  jilaces  ;  hearing 
normal.  Eyes  staring,  from  inability  to  close  the 
thickened  and  stiff  lids  ;  ectropion.  Sight  good.  The 
mouth  is  held  half  open,  and  the  tongue  is  slightly  en- 
larged ;  there  are  only  two  teeth,  the  lower  incisors. 

The  hands  and  feet  are  stiffened,  with  almost  no 
power  of  flexion  or  extension  ;  the  child  being  unable 
to  grasp  even  large  objects  with  the  fingers. 

The  surface  of  the  body  feels  warm  to  the  touch,  the 
thermometer  showing  101.2°  F.  in  axilla  ;  100.4°  F.  in 
rectum. 


July  6,  1895] 


MEDICAL    RECORD. 


II 


The  skin  over  the  entire  body  is  slightly  reddened,  dry, 
hard,  and  scaly  ;  scales  light  gray  in  color,  of  papery  con- 
sistency and  from  one  thirty-second  inch  to  i  x  2  inches  ; 
outlines  polygonal,  formed  by  the  natural  furrows  in 
the  skin.  The  skin  is  tense  in  places,  notably  on  the 
left  forearm,  right  leg,  and  left  thigh  and  leg,  where 
deep  creases  are  formed  by  bands  of  the  older  skin  ex- 
tending round  the  limb,  above  and  below  which  the  flesh 
has  seemingly  filled  out  by  recent  growth,  being  raised 
one-quarter  inch  or  more  above  the  constricting  bands, 
giving  it  a  "  hide-bound  "  appearance,  which  can  be 
seen  on  the  left  leg  in  the  photograph.  This  was  taken 
soon  after  I  first  saw  the  child,  and  being  necessarily 
an  instantaneous  exposure,  is  not  as  good  as  could  be 
desired,  but  it  serves  to  give  an  idea  of  the  general  ap- 
pearance. 

Surrounding  the  mouth,  for  an  inch  or  more,  the  skin 
is  almost  natural,  thin  and  white.  On  the  upper  part 
of  the  forehead  is  a  line  of  demarcation  where  the  old 
and  new  skin  are  in  contact,  that  on  the  face  being  the 
fourth  reproduction,  that  on  the  scalp  the  second  or 
third. 


November  28th. — On  admission  temperature  102° 
F.     (Other  physical  conditions  as  noted  above.) 

November  29th. — Temperature,  a.m.,  100.8°  F.;  noon, 
99.6°  F.  ;  P.M.,  102°  F.  Constipated.  Olive-oil  inunc- 
tions.    Cascara,   3  ss. 

November  30th. — Temperature,  a.m.,  99.8°  F.;  noon, 
100°  F.;  P.M.,  99°  F.     Stool,  yellow  and  lumpy. 

December  ist. — Temperature,  a.m.,  100°  F.;  noon, 
101°  F.  ;  P.M.,  103°  F.  Ice  cap.  Cloths  wet  with 
equal  parts  linseed  and  cotton-seed  oils  to  body. 
Wash  of  ichthyol  and  alcohol,  aii  3  ij.,  aqua,  |j.,  to  head, 
neck,  and  face.     Liquid  peptonoids. 

December  2d. — Temperature,  a.m.,  100°  F. ;  noon, 
102.4°  F.;   P.M.,  101°  F. 

December  3d. — Temperature,  a.m.,  102,4°  F.;  noon, 
102.8°  F.;  P.M.,  101.5°  F.  Ichthyol  wash  discontinued. 
Restless.     Phenacetine,  gr.  j.,  at  10  p.m. 

December  4th. — Temperature,  a.m.,  103.4°  F.  Ice 
cap.  Noon,  101°  F.;  p.m.,  103°  F.  Phenacetine,  gr.  j., 
at  9  and  i  p.m. 

December  5th. — Temperature,  a.m.,  104°  F.  Ice  cap. 
Noon,  101°  F.;  p.m.,  100.8°  F. 


Treatment. — The  child  was  put  upon  raw  linseed  oil, 
one  drachm  t.i.d.,  and  enveloped  in  cloths  wet  with  same 
material.     Boric  acid  solution  to  eyelids. 

November  16,  1894. — Skin  about  the  same  condi- 
tion. Temperature,  rectum,  100.2°  F.  ;  axilla,  101.2° 
F.  ;  with  surface  thermometer  on  chest,  100.6°  F. 
Pulse,  98.     Respiration,  38. 

November  23d. — Skin  decidedly  softer,  eyelids 
come  close  together.  Temperature,  rectum,  99.8°  F.  ; 
axilla,  100.2°  F.  ;  on  chest,  100°  F.  Pulse,  96.  Res- 
piration, 36. 

November  28th. — No  change  in  skin.  Temperature, 
rectum,  101.8°  F.  ;  axilla,  102.6°  F.  ;  on  chest,  102.4°  F- 
Pulse,  no.  Respiration,  44.  Cough,  with  fever  and 
restlessness,  since  last  visit.  Physical  examination 
shows  no  dulness  on  percussion  ;  auscultation  is  impos- 
sible, the  crackling  of  the  skin  under  the  ear  covering 
all  other  sounds.  The  mother  says  it  always  takes 
more  or  less  cold  in  journeying  back  and  forth  from 
Newark  to  New  York.  On  this  account,  and  because 
it  was  thought  that  better  facilities  for  constant  obser- 
vation and  more  regular  applications  could  be  had  in  a 
hospital  than  the  mother  could  give  at  home,  with  her 
hands  full  of  family  matters,  she  was  induced  to  leave 
the  child  at  the  Babies'  Hospital,  where  it  came  under 
the  care  of  Drs.  L.  Emmett  Holt  and  E.  B.  Bronson. 

Dr.  Holt  has  obligingly  placed  the  hospital  records 
at  my  disposal,  and  from  them  I  make  extracts  on  the 
course  of  the  disease  as  follows  : 


December  6th. — Temperature  a.m.,  100.2°  F. ;  noon, 
101°  F.;  p.m.,  100.8°  F.  Considerable  discharge  from 
eyes.  Boric  acid  eye-wash.  Lanoline  and  vaselene, 
equal  parts,  to  head.  Cotton  and  linseed  oils  continued 
on  body. 

December  9th. — Temperature,  a.m.,  101.8°  F. ;  noon, 
102°  F.;  P.M.,  104°  F.  Ice  cap.  Phenacetine,  gr.  j., 
at  9  and  11  p.m.  Completely  peptonized  milk.  Liq- 
uid peptonoids. 

December  10th. — Temperature,  a.m.,  99,6°  F.;  noon, 
102.4°  F.;  P.M.,  100.4°  F.  Very  restless  in  evening. 
8  P.M.,  temperature,  104°  F.  Ice  cap.  Took  very 
little  of  7  A.M.  bottle. 

December  nth. — Temperature,  a.m.,  100.3°  F-!  noon, 
102.4°  F.  Restlessness  increasing,  with  short,  sharp  cry 
with  every  breath.  Temperature,  10  p.m.,  107°  F.  Ice 
pack  for  ten  minutes  gave  great  relief,  and  half  an  hour 
later  temperature  100.2°  F.  Patient  slept  quietly. 
Stool  yellow  and  smooth. 

December  12th. — Temperature,  a.m.,  100.8°  F.;  9 
a.m.,  108°  F.  Restless,  with  short,  sharp  cry.  Four  or 
five  small  round  spots  filled  with  serum  over  chest.  Ice 
pack.  Temperature  falling  to  100°  F.  Temperature 
at  4.45  P.M.,  107.6°  F.  Ice  pack,  after  which  tempera- 
ture did  not  reach  103°  F.,  and  patient  slept  quietly 
through  the  night.  Whiskey,  3  j.,  in  twenty-four  hours. 

December  13th. — Temperature,  a.m.,  100.6°  F.;  noon, 
103.5°  F.;  P.M.,  101°  F.  Seen  by  Dr.  G.  H.  Fox,  who 
pronounced  it  keratosis. 


MEDICAL    RECORD. 


[July  6,  1895 


December  14th. — Temperature,  a.m.,  100.4°  ¥.;  noon, 
102.5°  F.;  P.M.,  98.4°  F.     Vomited  at  5  p..m. 

December  15th. — Temperature,  .■v.m.,  100°  F.;  noon, 
104.2°  F.;  P.M.,  101.4°  F-     Vomited  7  a.m. 

December  i6th. — Temperature,  a.m.,  101.4°  F.;  noon, 
104.2°  F.;  P.M.,  101°  F. 

December  17th. — Temperature,  a.m.,  103°  F.;  noon, 
102°  F.;  7  p.m.,  107°  F.  Ice  pack  for  eight  minutes. 
Temperature,  8  p.m.,  98.6°  F.  Peroxide  of  hydrogen 
to  suppurating  places  on  head. 

December  i8th. — Temperature,  3  a.m.,  105°  F.  Ice 
pack.  Temperature,  3.30  a.m.,  98.6°  F.  At  3  p.m. 
vomited.     Temperature,  100.2°  F. 

December  19th. — Temperature,  98.6°  F.  ;  11  a.m., 
vomited.  Noon  temperature,  101.8°  F.;  9  p.m.,  105°  F. 
Ice  pack.  11  p.m.,  temperature,  97°  F.  Hot-water 
bags.  Whole  back  of  head  is  boggy  and  oedematous  ; 
stools  gray. 

December  20th. — -Temperature,  a.m.,  100.2°  F.  Vom- 
ited at  8  a.m.  Taken  home  by  mother  against  advice. 
Skin  slightly  softer  than  on  entrance. 

December  22d. — Died  with  continuance  of  fever. 

In  reply  to  my  inquiry  as  to  what  was,  in  his  opin- 
ion, the  direct  cause  of  death.  Dr.  Holt  writes  :  "  The 
thing  which  interested  me  most,  while  the  baby  was  in 
the  hospital,  was  the  hyperpyrexia,  and  particularly  the 
wide  and  rapid  fluctuations  in  the  course  of  the  tem- 
perature. This  is  something  which  I  have  never  seen 
paralleled  in  any  other  infant.  It  seemed  to  me  to  be 
due  to  the  fact  that  radiation  was  very  imperfect  and 
at  times  almost  impossible,  since  with  a  comparatively 
small  amount  of  bronchitis  the  temperature  would  rise 
in  an  hour  or  two  to  108°  F.,  and  drop  in  the  course 
of  an  hour,  under  the  influence  of  a  bath,  nearly  to 
normal. 

"  I  made  repeated  examinations  of  the  chest  while 
the  baby  was  in  the  hospital,  but  never  found  evidence 
of  anything  more  than  a  generalized  bronchitis  of  the 
large  tubes.  It  was  to  the  general  malnutrition  rather 
than  to  any  local  disease  that  the  child's  decline  and 
final  death  seemed  to  me  to  be  due." 

Resnmd. — The  etiology  in  this  case  would  seem  to 
be  defective  intra-uterine  nutrition,  resulting  in  hy- 
dramnios,  imperfectly  developed  skin,  and  premature 
birth.  A  curious  fact  noted  by  Schroeder  is  that  over 
seventy-five  per  cent,  of  such  infants  are  females.  Ac- 
cording to  modem  obstetricians,  hydramnios  may  be 
due  to  a  morbid  condition  in  either  mother  or  foetus. 
There  was  here  no  history  of  syphilis  or  other  disease 
in  father  or  mother,  they  always  having  been  in  the 
best  of  health.  Playfair  says  hydramnios  is  due  to  ob- 
structed umbilical  circulation,  but  the  condition  of 
placenta  and  cord  was  not  noted  in  this  case. 

No  microscopical  examination  of  the  skin  was  made, 
a  small  piece  taken  for  this  purpose  being  mislaid  after 
it  was  in  the  microscopist's  hands,  and  I  was  not  aware 
of  its  loss  until  it  was  too  late  to  procure  another. 
Neuman  says  that  the  papillje  are  enlarged,  their  blood- 
vessels dilated,  the  cutis  dense,  the  lumen  of  veins  nar- 
rowed by  growth  from  their  interior,  the  corneous  layer 
thickened,  composed  of  superimposed  lamellae,  and  the 
rete  between  the  papillae  much  hypertrophied.  Hair 
follicles  are  absent  or  lengthened,  and  contained  long 
hairs,  the  external  root-sheath  hypertrophied,  the  se- 
baceous glands  dilated  to  a  cyst  form,  the  sweat-glands 
dilated,  and  the  subcutaneous  fat  diminished.  Differ- 
ent observers  have  noted  slightly  differing  morbid  con- 
ditions, but  agree  in  the  main  with  the  above.  Crocker 
has  shown  that  the  horny  cells  dip  down  deeper  into 
the  regions  occupied  in  the  normal  skin  by  the  rete- 
pegs,  and  that  the  adherent  and  stratified  layer  of  each 
horny  cap  is  composed  at  the  apex  of  the  papillary 
growth.  The  child  was  born  without  "  vernix  case- 
osa,"  and  there  was  at  no  time  any  hyper-secretion  of 
sebaceous  material,  so  that  it  would  be  proper  to  clas- 
sify it  under  the  head  of  "  simplex,"  as  distinguished 
from  "  sebacea."     The  skin  disease  was  fairlv  well-de- 


veloped at  birth,  and  the  thickening  increased  as  time         ; 
went  on,  although  there  was  a  slight  modification  of        ™ 
the  skin  around  the  mouth  and  eyes,  where  it  softened 
to  a  moderate  extent,  as  shown  by  the  gain  in  control 
over  the  muscles  of  these  regions. 

This  child  lived  much  longer  than  is  usual  in  con- 
genital ichthyosis,  it  being  verj'  exceptional  to  see  them 
live  more  than  a  few  days  when  affected  to  such  a 
marked  degree.  The  well-nourished  condition  and 
continuous  growth  for  sixteen  months  also  indicate  an 
unusually  good  set  of  digestive  apparatus  and  a  large 
amount  of  vitality.  The  constant  hyperaemic  condi- 
tion of  the  skin,  the  surface  temperature  on  the  three 
occasions  when  it  was  taken  showing  a  rise  of  from 
two-tenths  to  six-tenths  of  a  degree  over  that  in  the 
rectum,  the  axillary  temperature  rising  from  four- 
tenths  to  one  degree  over  the  rectal,  is  worthy  of  note, 
and  it  would  have  been  interesting  if  these  observations 
had  been  continued  in  the  hospital.  The  rapid  des- 
quamation is  also  somewhat  unusual  in  a  simple  ich- 
thyosis, where  the  scales  are  generally  adherent.  It 
seems  to  me  fair  to  infer  that  there  was  also  a  derma- 
titis present. 

The  extreme  fluctuations  of  temperature  from  seem- 
ingly slight  causes,  as  noted  by  Dr.  Holt,  are  unequal 
and  difficult  to  account  for,  except  on  his  theory  of 
imperfect  radiation  from  the  surface,  though  in  look- 
ing over  the  history  it  has  some  points  that  make  one 
think  of  a  possible  pneumonia  or  meningitis.  Landois 
says  that  cutting  off  the  cutaneous  respiration  in  warm- 
blooded animals  by  coating  with  an  impermeable  var- 
nish, or  by  destruction  of  skin,  as  in  burns,  causes 
death  sooner  or  later,  according  to  the  extent  of  sur- 
face involved,  probably  from  a  loss  of  too  much  heat. 
It  is  accompanied  by  a  fall  in  bodily  temperature  and 
increased  frequency  in  respiration.  Neither  of  these 
symptoms  were  present  in  this  case,  leaving  us  to  infer 
that  the  insensible  perspiration  was  about  normal. 

No  autopsy  was  obtained. 

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July  6,  1895] 


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Transactions  of  the  Clinical  Society,  London,  1882.  xv. ,  250. 

Paolini,  M.  :  Nuove  richerche  suU'  ittiosi.  Bull.  d.  sc.  med.  di  Bo- 
logna, 1862,  4  s. ,  xvii. ,  209 

Pelletier,  L.  :  Considerations  historiques  ethistologiquessur  I'ichthy- 
osi  en  general  et  en  particulier  quelques  cas  teratologiques.     410, 
Paris,  1879. 
Pickells.  W.  :  Cases  of  Ichthyosis  L. ,  and  Hirsuties.  Edinburgh  Medi- 
cal and  Surgical  Journal,  1851,  Ixxvi. ,  308. 
Planellas,  A.  :  Del  histricismo  y  otras  formas  de  ictiosis.     Independ. 

med.,  Barcelona.  1881-82,  xiii.,  85. 
Playfair,  \V.  S.  :  System  of  Midwifery,  Philadelphia,  1885,  206. 
Porcher,  E.  P.  :  Ichthyosis  Successfully  Treated  by  Arsenic.   Charles- 
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8vo,  1878.  73. 
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1864,  XVI.  ,  278. 

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compl.  du  diet.  d.  sc.  med..  Paris,  1819,  v.,  220. 

Schabel,  A.  :  Ichthyosis  congenita.     8vo,  Stuttgart,  1856. 

Schroeder  :  Lehrbuch,  1880,  237. 


Schwimmer,  E.  :  Ichthyosis  sebacea  seborrhoea  universalis.  Wien. 
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268. 

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168  West  Forty-eighth  Street. 


THE  REDUCTION  OF  MODERATE  DEGREES 
OF  DEFORMITY  IN  HIP  DISE-\SE.i 

By  a.  B.  JUDSON,  M.D., 


Extreme  deformity  occurring  during  the  progress  of 
hip  disease  is  common  only  in  patients  who,  for  some 
reason  or  other,  have  failed  to  come  under  the  ordinary 
methods  of  treatment.  .\  distressing  clinical  picture 
is  that  of  a  child  lying  in  bed  with  the  thigh  extremely 
flexed  and  adducted.  But  the  deformity  diminishes 
with  marvellous  rapidity  if  the  weight  and  pulley,  or 
any  of  the  ordinary  forms  of  traction  apparatus  is  ap- 
plied. These  methods,  while  they  compel  a  change  in 
the  direction  of  the  limb,  at  the  same  time  protect  from 
inadvertent  and  painful  disturbance  of  the  joint. 

The  statement  may  seem  unreasonable,  but  it  is  nev- 
ertheless true,  that  the  more  exaggerated  the  deformity 
the  more  easily  it  is  affected  by  traction.  This  is  due 
to  the  mechanical   conditions  present.     -\n   iron    rod 


bent  as  in  Fig.  i.  may  be  readily  straightened  to  a  cer- 
tain extent,  as  in  Fig.  2,  by  traction  and  counter-trac- 


tion manually  applied.     Traction  may  then  be  applied 
by  machinery,  as  in  Fig.  3,  and  the  rod  may  thus  be 

'  Read  before  the  New  York  County  Medical  Association,  May  20, 
1895- 


H 


MEDICAL    RECORD. 


[July  6,  1895 


still  further  straightened,  but  the  straighter  it  becomes 
the  more  difficult  it  is  to  make  any  further  advance, 
and  it  soon  becomes  evident  that  absolute  straightness 
cannot  be  produced  in  a  rod  by  traction.  Another 
kind  of  force  may  then  be  employed.  Pressure  may 
be  made  at  the  convexity  of  the  bent  rod  and  counter- 
pressure  at  its  two  ends,  as  in  Fig.  4,  when  the  rod  may 
be  easily  straightened  and  even  bent  the  other  way. 
This  latter  force,  pressure  and  counter-pressure,  is  ap- 
plicable and  very  effective  when  applied  to  the  knee, 
represented  in  Fig.  4,  in  which  case  the  leverage  above 
and  below  the  joint  is  sufficient.     But  there  is  no  such 


Fig.  4.  Fic.  5. 

leverage  found  in  an  effort  to  correct  in  this  way  a  de- 
formed hip-joint  represented  in  Fig.  5.  We  are  re- 
duced, then,  to  this,  traction  loses  its  power  when  the 
joint  is  partly  straightened,  and  pressure  and  counter- 
pressure  fail  for  the  want  of  suitable  leverage  above  the 
joint.  The  mechanical  disadvantages  thus  revealed  are 
certainly  not  encouraging.  A  ray  of  hope,  however,  is 
found  in  the  reflection  that  the  immobility  is  not  of  a 
hard-and-fast  kind,  and  that,  as  the  bad  position  is  that 
which  furnishes  the  most  convenience  in  ordinary 
movements,  it  may  be  possible  to  accustom  the  patient 
to  other  habitual  movements  in  which  he  will  have  most 
convenience  with  the  limb  in  a  good  position. 

I  propose  to  give  up  the  various  theories  which  have 
been  advanced  to  explain  why  the  limb  is  flexed  and 
adducted,  and  to  find  a  simple  and  sufficient  explana- 
tion in  the  proposition  that  the  patient  unconsciously 
assumes  deformity  because,  when  it  is  flexed  and  ad- 
ducted, the  disabled  limb  is  less  liable  to  painful  dis- 
turbance and  less  in  the  way  of  the  well  limb,  which 
now  does  almost  all  of  the  work  of  locomotion.  The 
limb  is  apparently  shortened  (adducted)  to  keep  it 
from  unnecessarily  touching  the  ground,  and  the  ap- 
pearance of  lameness  is  increased  by  the  action  of  the 
well  foot  which  violates  the  natural  rhythm,  which,  as 
we  ajl  know,  is  expressed  thus  :  one — two — one — two 
— one — two.  As  the  well  foot  hastens  forward  to  re- 
lieve the  affected  foot  of  the  weight  of  the  body,  and 
prolongs  its  stay  on  the  ground  with  the  same  object  in 
view,  the  rhythm  becomes  unnatural  and  may  be  ex- 
pressed thus  :  one — two one — two one — two. 

Now,  if  the  patient  can  be  induced  to  resume  the 
natural  rhythm,  in  which  the  time  is  evenly  divided  be- 
tween the  two  feet,  he  will  unconsciously  surrender 
flexion  and  adduction,  because  in  that  way  only  is  it 
convenient  or  possible  for  him  to  walk  in  the  prescribed 
normal  rhythm  of  locomotion.  To  put  it  in  other 
words  :  He  acquires  adduction  or  apparent  shortening 
because  he  habitually  keeps  the  affected  foot  on  the 
ground  less  than  half  the  time,  to  the  destruction  of 
natural  rhythm.  If  he  restores  the  natural  rhythm,  and 
keeps  the  foot  on  the  ground  half  the  time,  adduction 
or  apparent  shortening  will  disappear.  But  this  cannot 
be  done  during  the  progress  of  the  disease  without  me- 
chanical assistance.  Unsymmetrical  walking  is  nat- 
ure's conservative  method  of  keeping  the  affected  limb 
off  the  ground  as  much  as  possible  in  the  act  of  walk- 
ing, in  order  to  avoid  pressure  and  concussion  ;  but 
with  an  ischiatic  support  which  keeps  the  heel  clear  of 
the  ground,  there  is  no  reason  why  tiie  affected  side, 
splint  and  all,  should  not  come  to  the  ground  as 
promptly  and  stay  on  the  ground  as  long  as  the  well 
side.  If  the  patient  does  this  and  thus  lets  the  affected 
side  do  its  share  of  the  work,  it  will  be  found  that  with- 
out knowing  it  he  is  reducing  his  flexion  and  adduc- 


tion and  parting  with  the  chief  elements  of  his  deform- 
ity, and  this  in  accordance  with  the  proposition  above 
made,  that  the  position  of  the  limb  in  hip  disease  is 
that  which  affords  the  most  comfort  and  convenience 
in  habitual  attitudes  and  movements. 

We  may  glance  at  the  comparative  advantages  of  this 
method  :  i.  The  jiermanence  of  the  result.  If  the  de- 
formity is  once  reduced  in  this  way  all  that  is  necessary 
to  make  the  result  permanent  is  for  the  patient  to  per- 
sist in  walking  in  correct  rhythm.  If,  however,  a  mod- 
erate deformity  is  reduced  by  forcible  or  operative 
methods,  it  will  return  if  the  patient  maintains  an  un- 
symmetrical gait.  The  only  exception  to  this  would 
be  a  rare  case  of  bony  anchylosis  and  deformity  cor- 
rected by  fracture  below  the  joint  and  union  in  a  better 
position.  2.  The  early  applicability  of  the  method. 
Deformity  may  be  thus  reduced  at  the  earliest  stage  of 
the  disease  and  at  the  very  beginning  of  treatment. 
^^xceptions  would  be  found  to  this  in  those  acute  pe- 
riods in  which  the  patient  is  averse  to  locomotion.  3. 
The  late  applicability  of  this  method  to  patients  who 
have  recovered  with  deformity.  Even  in  middle  life 
the  deformity  following  early  hip  disease  may  thus  be 
reduced  in  an  important  degree. 

I  speak  from  experience  when  I  say  that  by  this 
method  a  great  deal  of  the  deformity  attending  hip  dis- 
ease may  be  removed  and  prevented.  Success  is  not 
attained  in  every  case,  because  some  children  can  only 
with  great  difficulty  be  taught  to  w^alk  properly,  or  in 
fact  to  do  anything  which  they  ought  to  do,  especially 
if  the  parents  are  preoccupied  or  lack  intelligence. 
But  the  great  majority  of  patients  are  benefited  in  this 
way  and  readily  acquire  a  new  manner  of  walking,  if  a 
little  of  the  time  and  attention  w^hich  is  given  to  their 
training  in  general  be  turned  in  this  direction. 


'^voQV&ss  at  pXietUcaX  ^ci-ence. 

Total  Extirpation  of  the  Rectum. — Vanderlinden  and 
de  Buck  {La  Flandrc  MM.,  March  7th)  claim  that 
partial  resection,  or  even  total  extirpation,  of  the  rectum 
for  cancer  is  abundantly  justified  where  at  all  practi- 
cable from  the  point  of  view  both  of  its  immediate  and 
ultimate  results.  They  record  two  successful  cases  of 
this  kind.  Case  I. — A  multipara,  aged  thirty-one,  in 
August,  1892,  gave  a  history  of  a  year  and  a  half  of  pain 
in  the  lower  belly,  constipation,  difficult  defecation, 
grooved  fseces.  For  a  year  glairy  mucus,  blood,  and 
yellowish  fetid  sanious  liquid  had  been  passed  with  the 
fjEces  ;  marked  loss  of  appetite  and  body  weight.  Per 
anum  a  growth  was  felt,  ulcerated  in  places,  extending 
7  ctm.  from  below,  and  invading  the  whole  circumference 
of  the  rectum,  with  its  greatest  thickness  posteriorly. 
The  summit  of  the  growth  was  easily  reached,  and  the 
whole  tumor  could  be  moved  downward.  The  opera- 
tion was  performed  on  October  30,  1892.  The  dorsal 
position  was  used,  with  the  pelvis  raised,  and  thighs 
strongly  flexed  on  the  abdomen.  The  anus  was  sur- 
rounded by  two  short  incisions,  which  joined  in  front 
and  behind.  A  posterior  median  incision  was  prolonged 
from  these  to  the  coccyx.  The  anal  canal  and  rectum 
were  dissected  out  as  far  as  3  ctm.  above  the  growth, 
where  section  of  the  bowel  was  made.  Suture  of  the 
bow'el  walls  to  the  skin  wound  completed  the  operation, 
which  lasted  an  hour.  The  patient  returned  home  at 
the  end  of  four  weeks,  and  three  months  after  had 
gained  10  kilos,  in  weight,  and  could  already  retain  firm 
stools.  There  has  been  no  recurrence  up  to  the  pres- 
ent time.  The  growth  proved  microscopically  to  be  a 
lobulated  epithelioma.  Case  II. — C.  D ,  aged  fifty- 
two,  married  ;  no  children.  Three  years'  history,  com- 
mencing from  the  climacteric,  and  in  its  details  very 
similar  to  Case  I.  Two  indurated  ulcerated  masses 
were  found  in  the  anal  region.     The  rectum  was  in- 


July  6,  1895] 


MEDICAL    RECORD. 


15 


vaded  in  its  whole  girth  by  a  soft,  yielding,  easily  bleed- 
ing tumor,  whose  summit  was  reached  with  difficulty  10 
to  II  ctm.  above  the  anus.  Operation  February  24,  1895. 
Left  lateral  position,  thighs  strongly  flexed  and  pelvis 
raised.  The  incision  ran  from  two  fingers'  breadth  be- 
low the  posterior  superior  iliac  spine  along  the  groove 
between  the  gluteus  maximus  and  sacrum  toward  the 
median  line  as  far  as  the  summit  of  the  coccyx,  then 
surrounding  the  anus.  The  musculature  of  the  buttock 
was  detached,  the  insertions  of  the  great  and  small 
sacro-sciatic  ligaments  cut,  and  the  coccyx  extirpated. 
A  part  of  the  left  side  of  the  sacrum  was  removed,  the 
abundant  bleeding  controlled,  and  the  rectum  isolated, 
commencing  with  the  anal  aperture.  The  peritoneum 
was  opened  after  isolation  of  the  anterior  rectal  wall. 
The  bowel  was  cut  transversely  2  ctm.  above  the  growth, 
and  its  end,  slightly  twisted  on  its  axis,  was  sutured  to 
the  borders  of  the  skin  wound.  The  operation  lasted 
an  hour  and  three-quarters,  much  blood  being  lost.  A 
large  quantity  of  NaCl  solution  was  therefore  injected, 
and,  except  for  two  days'  fever,  the  patient  did  well, 
and  at  the  date  of  report  was  convalescent. — British 
Medical  Journal. 

The  Microbiology  of  Acute  Peritonitis. — Courtois- 
Suffit,  in  his  recent  monograph  on  '"  Diseases  of  the 
Peritoneum,"  classes  first  in  order  among  the  pathogenic 
microbes  in  peritoneal  inflammations  the  bacillus  coli 
communis  (77?t'  Boston  Medical  and  Surgical  Journal^. 
This  micro-organism  is  a  facultative  anaerobic,  a  nor- 
mal inhabitant  of  the  intestines,  but  pathogenic  under 
morbid  conditions  such  as  occur  in  all  kinds  of  peri- 
tonitis of  intestinal  origin.  Its  presence  has  long  been 
recognized  in  peritoneal  exudations,  while  it  is  con- 
stantly found  in  septic  peritonitis  following  intestinal 
wounds,  perforating  (gastric,  typhoid,  enteric,  appen- 
dicular) ulcers,  ischio-rectal  abscess,  cancer  of  the 
colon,  hernia,  thrombosis  of  the  mesenteric  vessels,  etc. 
It  has  been  affirmed  that  under  certain  circumstances, 
as  when  disordered  circulation,  strangulation,  extreme 
fecal  distention,  undue  pressure,  or  mechanical  injury 
has  impaired  the  integrity  of  the  bowel  and  lowered  tis- 
sue-resistance, this  bacterium  may  become  migratory, 
gain  the  peritoneum,  and  excite  inflammation.  Cornil 
found  such  bacteria  actually  in  the  substance  of  the 
wall  of  a  partly  necrosed  intestine.  The  possibility  of 
such  migration  may  explain  many  cases  of  so-called 
idiopathic  peritonitis  attending  stercoral  impaction, 
severe  bowel  inflammations,  etc.;  the  germs  passed 
through  the  intestinal  walls  and  provoked  peritonitis. 
It  is  doubtful  if  peritonitis  has  ever  followed  cystitis, 
yet  Achard  and  Renaut  have  proved  the  identity  of  the 
colon-bacillus  with  the  bacterium  pyogenes  of  the 
bladder.  The  pneumococcus  has  very  rarely  any 
causal  relation  to  acute  peritonitis,  whether  the  infec- 
tion occur  as  a  sequel  to  pneumonia  or  independently 
of  that  disease.  The  streptococcus  pyogenes  has  been 
found  in  the  pus  of  a  great  many  cases  of  peritonitis, 
where  it  existed  to  the  exclusion  of  every  other  micro- 
organism (post-operative  and  puerperal  peritonitis). 
Cases  of  streptococcus-peritonitis  following  erysipelas 
of  the  face  have  been  reported  by  Cheurlin  and  others, 
and  in  rare  instances  this  disease  has  succeeded  scarlet 
fever,  a  malady  in  which  the  streptococcus  seems  to 
have  a  predominant  part.  Penetration,  by  the  mi- 
crobes, of  the  abdominal  wall  is  said  in  rare  instances 
to  have  taken  place  in  cases  of  erysipelas  of  the  ab- 
dominal integument  ;  and  puerperal  peritonitis  from 
extension  of  a  streptococcus-inflammation  from  the 
pelvic  peritoneum  and  uterine  cavity  is  of  very  com- 
mon occurrence.  Acute  peritonitis  has  been  in  numer- 
ous instances  ascribed  to  the  staphylococcus  (aureus 
and  albus)  found  apart  from  other  micro-organisms  in 
the  pus.  In  other  cases,  the  staphylococcus  was  asso- 
ciated with  the  streptococcus,  or  with  the  rod-shaped  or 
round  micro-organisms  of  putrefaction.  The  'sapro- 
genous microbes  seem  to  have  been  influential  in  cer- 


tain cases.  The  colon-bacillus  is  probably  a  bacterium 
of  saprogenous  character,  with  possibilities  of  greatly 
exalted  virulence.  Suppurative  salpingitis  is  a  recog- 
nized cause  of  acute  peritonitis.  When  the  salpingitis 
has  developed  under  the  influence  of  the  true  pyogenic 
organisms  (streptococci  and  staphylococci),  a  general- 
ized peritonitis  which  is  almost  always  fatal  follows 
the  rupture  of  the  tube.  The  case  is  not  so  serious, 
according  to  Bumm,  when  the  salpingitis  succeeds 
gonorrhoeal  infection,  and  in  which  the  exudates  con- 
tain only  the  diplococcus  of  Neisser.  The  latter  micro- 
organism, Bumm  says,  can  exert  its  action  only  on 
mucous  membranes,  being  inoffensive  to  the  serosa  and 
cellular  tissue.  Naturally,  then,  the  rupture  of  such  a 
pus  tube,  or  the  leakage  of  pus  from  the  fimbriated  end 
into  the  peritoneum,  would  not  be  followed  by  a  gen- 
eral septic  peritonitis,  but  the  exudate  would  be  re- 
sorbed  like  any  aseptic  fluid.  With'regard  to  the  effect 
on  the  peritoneum  of  rupture  of  one  of  the  hollow 
organs  of  the  abdomen,  the  result,  as  Courtois-Suffit 
remarks,  is  variable,  depending  on  the  presence  or 
absence  of  microbes  in  the  extravasated  fluid.  The 
bursting  of  the  healthy  bladder  with  effusion  of  normal 
urine  into  the  peritoneal  cavity  is  not  followed  by  acute 
peritonitis.  This  has  been  proved  by  the  experiments 
of  Gosselin,  Robin,  Albarran,  and  others.  The  case  is 
altogether  different  when  the  urinary  passages  are 
infected  and  the  urine  contains  the  streptococcus  pyo- 
genes, the  septic  bacterium  of  Clado,  or  other  pyogenic 
organisms. 

What  is  true  for  the  urine  is  equally  exact  for  the 
bile,  as  abundant  experiments  on  animals  have  shown. 
This  is  made  plain  by  Dupre  in  his  now  classic  work  on 
"  The  Biliary  Infections."  But  the  biliary  passages  and 
the  bile  may  become  infected  from  various  causes,  and 
rupture  of  the  gall-bladder  would  then  be  followed  by 
a  fatal  peritonitis.  A  case  of  this  kind  has  been  re- 
ported by  Frankel,  who  found  in  the  peritoneal  exu- 
date streptococci  and  staphylococci. 

Penetrating  wounds  of  the  stomach,  allowing  small 
quantities  of  gastric  juice  and  other  contents  to  escape 
into  the  peritoneal  cavity,  are  not  necessarily  fatal  if 
the  wound  be  not  large  and  the  leakage  not  great. 
The  stomach  is  not  a  good  culture-field  for  pathogenic 
microbes,  the  gastric  juice  being  aseptic  and  antiseptic. 
The  result  of  a  penetrating  wound  of  the  stomach  or  a 
perforating  ulcer  will,  of  course,  be  far  graver  if  the 
stomach  or  its  secretions  has  become  pathologically 
altered,  and  if  there  be  considerable  escape  of  its  con- 
tents into  the  peritoneum. 

When  the  intestine  is  the  source  of  the  peritoneal 
lesion,  whether  by  traumatism  or  profound  ulceration, 
the  peritonitis  is  likely  to  be  spreading  and  fatal,  espe- 
cially if  there  be  a  massive  infection.  The  microbes 
which  are  chiefly  concerned  are  those  which  are  found 
in  a  normal  state  in  the  intestine  :  the  coli  communis, 
the  bacillus  albuminis,  the  bacillus  mesentericus  vul- 
gatus,  the  septic  vibrio  of  Pasteur.  There  is  a  law  laid 
down  by  Malvoz,  which,  as  far  as  it  is  accurate,  may  be 
of  help  from  a  medico-legal  point  of  view.  If  the 
peritonitis  be  of  intestinal  origin,  the  bacterium  coli 
will  show  it  ;  if  it  be  of  uterine  origin  (as  when  consecu- 
tive to  abortion),  the  presence  of  the  streptococcus  will 
prove  this,  even  though  there  should  be  no  visible  in- 
flammatory lesions  of  the  genital  organs. 

The  Pathology  of  the  Pancreas. — It  is  only  within 
comparatively  recent  years  that  any  notable  additions 
have  been  made  to  our  knowledge  of  the  pathology  of 
diseases  of  the  pancreas.  A  decided  impetus  was  given 
to  the  subject  by  the  researches  of  Fitz,  who  practical- 
ly established  upon  a  firm  clinical  basis  the  symptoma- 
tology and  diagnosis  of  acute  pancreatitis  and  allied 
conditions.  Of  the  etiology  of  these  we  practically 
know  nothing,  and  this  line  of  reseach  affords  a  field 
for  investigation  that  promises  to  yield  important  and 
interesting    results  {Medical  News').     Recent  clinical 


i6 


MEDICAL   RECORD. 


[July  6,  1895 


and  experimental  observations  have  shown  that  some 
lesions  of  the  pancreas  are  attended  with  glycosuria, 
but  an  even  more  obscure  association  is  that  with  the 
peculiar  condition  known  as  fat-necrosis.  While  this 
has  been  observed  most  commonly  in  connection  with 
pancreatic  disease,  it  has  also  been  found  in  some  cases 
in  which  such  disease  could  not  be  demonstrated.  An 
interesting  contribution  to  this  subject  has  recently 
been  made  by  Hildebrand,  who,  in  a  series  of  e.\peri- 
mental  observations  on  cats,  succeeded  in  inducing  fat- 
necrosis  by  ligation  of  the  pancreas  or  its  vessels,  and 
by  transplantation  of  the  organ  in  whole  or  in  part. 
In  two  animals  the  pancreas  alone  was  ligated  ;  in  six 
others  ligatures  were  also  applied  to  all  of  the  veins. 
Sugar  was  found  in  the  urine  of  one  of  these.  In  one 
instance  a  bit  of  pancreas,  two  by  three  centimetres, 
was  excised  from  the  continuity  of  the  organ  and  fixed 
with  a  suture  in  the  omentum  of  another  animal  ;  and, 
again,  an  entire  pancreas  was  treated  in  the  same  way. 
In  another  experiment  a  whole  pancreas  was  scarified 
and  made  to  surround  a  portion  of  the  small  intestine. 
The  animals  withstood  the  operations  well,  but  in  all 
the  characteristic  white  areas  of  fat-necrosis  appeared 
in  the  peritoneum  comparable  to  that  observed  in  man. 

Growing  Pains. — Growing  pains,  defined  as  pains  in 
the  limbs  caused  by  and  during  rapid  growth,  and 
sometimes  so  severe  as  to  give  rise  to  growing  fever, 
have  been  diagnosed  by  the  author  less  and  less  fre- 
quently as  the  years  rolled  by,  until  the  vanishing  point 
was  reached.  Cases  which  have  been  classed  together 
under  this  name  are  the  following  : 

Myalgia  from  Fatigue. — This  is  the  commonest  vari- 
ety, usually  about  the  knees  and  ankles  after  unusual 
exertion.  They  are  probably  due  to  autoinfection 
brought  about  by  excessive  production  of  effete  materi- 
als in  the  blood  and  their  inefficient  elimination.  Ele- 
vating the  limbs  and  rubbing  with  the  palm  of  the  hand 
in  a  direction  toward  the  heart,  relieving  venous  stasis 
and  facilitating  a  supply  of  healthy  blood  to  the  ex- 
hausted muscles,  promptly  relieves  the  pain. 

Rheumatism. — This  is  second,  if  not  first,  in  fre- 
quency. There  is  slight  pain  in  the  joints,  little  or  no 
swelling,  and  very  mild  fever,  and  hence  the  true  cause 
is  not  recognized  ;  but  rheumatic  endocarditis  fre- 
quently develops  in  these  cases. 

Diseases  of  Joints  and  Bones  of  the  Lower  Extremi- 
ties.— Cases  of  hip-joint  disease  and  suppurative  epi- 
physitis of  the  upper  end  of  the  fibula,  diagnosed  by 
the  laity  and  allowed  to  go  on  untreated,  are  related 
under  this  heading. 

Fevers,  accompanied  by  pains  in  the  limbs,  in  one 
instance  proving  to  be  inception  of  typhoid  fever,  con- 
stitute this  class. 

Adenitis^ — Here,  again,  the  mother  still  supposes  that 
the  lad  of  sixteen  years  suffered  from  "  growing  pains," 
but  he  was  treated  for  gonorrhoea  and  a  sympathetic 
bubo.  The  malady  "growing  pains,"  with  its  frequent 
concomitant  growing  fever,  like  its  congener  disorders 
of  dentition,  as  a  separate  morbid  entity  exists  princi- 
pally as  an  article  of  faith.  The  complaint  still  main- 
tains, however,  a  strong  hold  of  the  lay  mind,  and  forms 
an  extremely  common  lay  diagnosis  which  is  often  the 
cause  of  much  suffering,  and  even  death,  by  leading  to 
the  neglect  of  curative  measures  at  a  time  when  they 
are  most  effective. — Archives  of  Pediatrics. 

Chronic  Lacunar  Tonsillitis. — Dr.  Ball  holds  that  the 
essential  cause  of  this  disease  is  some  narrowing  of  the 
lacunar  tract  or  orifice  impeding  the  free  egress  of  the 
contents,  together  with  an  abnormally  free  desquama- 
tion of  the  epithelial  cells.  The  cheesy  masses  are 
mainly  composed  of  these  elements  more  or  less  altered. 
The  epithelial  cells  are  arranged  in  layers,  those  on  the 
outer  surface,  and  therefore  most  recently  shed,  being 
the  least  altered.  A  certain  proportion  of  leucocytes 
is  present,  but  rarely  in  any  number.  Toward  the  cen- 
tral part  of  the  plug  especially  are  found  fatty  particles 


and  cholesterine.  Leptothrix  filaments  and  various 
other  micro-organisms  are  also  found  in  abundance. 
The  functional  troubles  bear  relation  to  the  nervous 
irritability  of  the  individual.  Pain  is  a  common  symp- 
tom. This  often  radiates  toward  the  ears,  and  is  apt 
to  be  felt  more  especially  when  swallowing  saliva,  and 
less  when  swallowing  food.  Troublesome  coughing  fits 
may  be  present,  especially  in  the  morning.  The  breath 
has  a  slightly  fetid  odor,  and  the  cheesy  masses  at  times 
attract  the  attention  of  the  patient.  On  examining  the 
throat,  the  tonsils  are  usually  found  enlarged  ;  often 
there  are  adhesions  between  the  tonsil  and  the  anterior 
pillar  concealing  the  tonsil  from  view.  In  some  cases 
it  may  be  necessary  to  retract  the  pillar  or  to  examine 
the  posterior  or  upper  part  of  the  tonsil  with  the  rhino- 
scopic  mirror.  Sometimes  a  careful  search  will  fail  to 
discover  any  concretion  in  the  lacunar  orifices.  In 
this  case  pressure  with  the  tongue-depressor,  or  the  in- 
troduction of  a  probe  into  a  lacuna,  may  bring  to  view 
one  of  these  chessy  masses.  When  the  tonsils  are 
small,  there  are  two  points  which  should  be  particularly 
explored— namely,  a  large  crypt,  the  orifice  of  which 
is  covered  by  the  anterior  pillar,  and  the  upper  extrem- 
ity of  the  tonsil  between  the  pillars,  the  region  of  the 
epitonsillar  fossa.  The  cheesy  plugs  will  be  found  to 
be  easily  removed  by  means  of  a  probe  or  spud  passed 
into  the  crypt.  Subacute  exacerbations  of  the  S)'mp- 
toms  occur  from  time  to  time,  lasting  two  or  three  days 
or  longer,  and  causing  general  malaise,  more  marked 
throat-pains,  otalgia,  and  pain  on  eating  and  speaking. 
The  author  holds  that  the  most  rational  and  effective 
treatment  is  opening  up  the  crypts  by  free  division  of 
the  crypt-walls.  This  is  best  accomplished  by  a  hook- 
shaped  blade  fixed  at  right  angles  to  the  handle.  The 
point  of  the  knife  is  blunt,  but  sufficiently  fine  to  allow 
of  its  insertion  into  the  smallest  cryptic  orifice.  The 
method  of  procedure  is  as  follows  :  The  operator  sits 
in  front  of  the  patient  and  throws  a  good  light  into  the 
throat  by  means  of  the  ordinary  forehead  reflector. 
The  tonsil  to  be  operated  upon  is  anaesthetized  by  the 
application  of  a  ten  or  twenty  per  cent,  solution  of  co- 
caine. This,  however,  is  by  no  means  necessar)-,  as  the 
operation  is  not  really  painful.  The  tongue  being 
depressed  with  a  spatula,  the  point  of  the  instrument 
is  inserted  into  one  of  the  cryptic  orifices  and  is 
brought  out  at  a  neighboring  orifice,  or,  if  necessan,-,  it 
is  forced  through  the  tissue.  The  intervening  tonsil 
tissue  is  then  cut  through,  and  this  can  usually  be 
effected  by  simple  rotation  of  the  handle  of  the  instru- 
ment. In  this  way  several  crypts  can  be  opened  up  at 
a  sitting  and  any  cheesy  masses  that  may  be  present 
are  evacuated.  The  bleeding  is  never  considerable. 
Sometimes,  especially  if  the  tonsil  operated  on  is  large, 
there  will  be  left  some  loose  tags  of  tissue,  which 
should  be  trimmed  oft'  with  a  pair  of  curved  scissors. 
Adhesions  between  the  tonsils  and  faucial  pillars  can 
be  divided  in  the  same  manner  as  the  crypt-walls. 
From  two  to  three  sittings,  or  even  more,  may  be  re- 
quired for  each  tonsil,  and  a  week  may  be  allowed  to 
elapse  between  each  sitting.  To  diminish  the  tendency 
of  the  cut  surfaces  to  unite,  a  strong  solution  of  iodine 
(iodine,  90  grains  ;  iodide  of  potassium,  90  grains  ; 
water,  i  ounce)  should  be  applied  at  the  termination  of 
each  sitting.  In  any  case  this  is  a  good  antiseptic  ap- 
plication and  should  never  be  omitted.  A  little  sore- 
ness may  be  felt  after  the  operation,  but  this  never 
continues  more  than  a  day.  .\  boric-acid  gargle  may 
be  used  during  the  intervals  between  the  sittings. — 
The  Practitioner. 

An  Early  Instance  of  the  Bath  Treatment  of  Typhoid 
Fever. — Pope  Leo  XIII.,  when  a  young  man  residing  in 
Benevento.  suffered  from  typhoid  fever,  and  was  treated 
by  Dr.  N'ulpe  by  means  of  cold  baths.  That  was  fifty 
years  ago. 

There  is  a  Duty  of  Fifty  Per  Cent,  ad  Valorem  on 
diphtheritic  antitoxin  imported  into  Canada. 


July  6,  1895] 


MEDICAL   RECORD. 


17 


Medical   Record: 

A  Weekly  yotirnal  of  Medicitie  and  Sjirgery. 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  July  6,  1895. 


THE     ENLARGEMENT     OF     THE     MEDICAL 

RECORD. 
We  are  again  called  to  do  a  pleasant  duty  to  our 
readers  and  contributors.  The  Medical  Record  has 
grown  so  steadily  in  the  capacity  and  worth  of  its  ma- 
terial that  it  has  been  deemed  advisable  to  increase 
still  further  the  number  of  its  pages  and  to  enlarge  cor- 
respondingly its  capacity  for  usefulness  to  its  sub- 
scribers, contributors,  and  advertisers.  With  the  com- 
mencement of  the  present  volume  there  will  be  an  in- 
crease of  four  extra  pages  to  each  issue,  making  an 
aggregate  addition  for  the  year  of  over  four  hundred 
double  columns,  an  equivalent  in  their  turn  to  an  ordi- 
nar)'-sized  octavo  of  nearly  eight  hundred  pages,  with 
no  increase  of  cost  to  its  subscribers. 

In  view  of  this  fact  the  conviction  must  continue  to 
force  itself  upon  every  one  that  such  a  course  is  war- 
ranted by  a  success  unprecedented  not  only  in  Ameri- 
can medical  journalism,  but,  we  believe,  in  the  world. 
It  must  also  be  e\-ident,  judging  from  these  tangible  and 
uncontrovertible  evidences  of  success,  that  the  end  has 
been  gained  by  a  wide-spread  appreciation  of  our  policy 
of  independence,  fairness,  and  enterprise. 

It  will  be  our  aim,  with  the  increased  facilities  at  our 
command  and  the  liberal  and  expansive  purpose  of 
compassing  a  still  larger  field,  to  make  the  Medical 
Record  more  than  ever  a  thoroughly  cosmopolitan 
journal,  in  which  not  only  the  interests  of  the  great 
medical  centre  are  represented  but  those  of  the  entire 
country  are  duly  and  impartially  considered. 

Numerous  changes  will  be  made  in  the  course  of  the 
year  to  realize  this  policy,  and  no  pains  nor  e.xpense  will 
be  spared  to  make  it  still  more  representative  of  the 
practical  needs  of  the  profession  of  the  entire  country. 
We  will  thus  strive  to  give  a  metropolitan  journal  a 
thoroughly  cosmopolitan  scope,  being  only  systematized 
in  its  efforts  by  the  convenience  and  necessity  of  an  ac- 
tively working  focal  centre.  In  following  such  a  course 
there  is  no  intention  of  interfering  with  or  militating 
against  the  interests  of  local  journalism  in  near  or  far- 
off  districts  ;  such  periodicals  have  functions  of  their 
own,  and  their  proper  fulfilment  is  as  necessary  and  as 
important  as  those  that  apply  to  the  larger  publications. 
The  wide-awake  practitioner  must  be  informed  of  the 
doings  of  his  local  societies  and  of  all  matters  within 
the  direct  touch  of  his  individual  work,  and  must  neces- 
sarily leave  the  consideration  of  wider  interests  to  the 


larger  and  more  widely  circulated  metropolitan  week- 
lies. Each  journal  has  its  place,  and  each,  to  do  its 
work  faithfully,  supplements  and  amplifies  that  of  the 
other.  We  believe  in  local  journals  as  well  as  cosmo- 
politan ones.  They  have  a  common  interest,  only  the 
lines  of  usefulness  stretch  in  different  directions. 

Thus  we  can  help  each  other  on  the  broad  principle 
of  a  generous  rivalry  in  the  common  cause,  and  in  the 
ultimately  laudable  aim  of  advancing  the  interests  of 
the  profession  and  promoting  that  active  dissemination 
of  scientific  truths  which  makes  medicine  the  most 
progressive  of  all  the  sciences. 


THE    PRESENT     MEDICAL    L.\W     OF     NEW 
YORK. 

Elsewhere  we  publish  a  full  text  of  the  medical 
law  of  the  State.  Some  day,  perhaps,  the  few  fa- 
miliar with  the  struggle  involved  in  securing  these 
legislative  enactments,  now  compiled  in  one  law,  will 
relate  the  history  of  the  conquest.  In  the  near  fut- 
ure we  propose  to  ca'.l  attention  to  some  of  the 
more  important  features  of  the  law's  requirements. 
Of  course  the  general  theory  of  the  law  is  that  the 
State  should  be  the  final  adjudicator  of  the  credentials 
presented  by  those  who  desire  to  practise  medicine 
within  its  borders.  The  M.D.  degree  has  thus  ceased 
to  be  anything  more  than  an  honorary  title  conferred 
by  a  private  corporation.  Although  it  is  true  that  no 
one  without  it  can  be  admitted  to  the  State  licensing 
examination,  the  supreme  test  of  ability  to  practise  is 
now  vested  in  the  State,  which  in  turn  delegates  its 
power  to  twenty-one  examiners  (seven  from  each  of 
the  incorporated  State  Medical  Societies)  who  are 
sworn  to  do  their  duty  as  State  officials. 

L'nder  paragraph  14S  of  the  law  licenses  conferred 
by  other  State  examining  boards  may  be  indorsed  by  our 
State  regents,  but  the  standards  of  these  other  State 
boards  must  not  be  "  lower  than  those  provided  by  this 
article."  Because  of  these  quoted  lines  no  license  from 
a  sister  State  has  yet  been  indorsed,  as  no  other  State 
meets  the  standard  of  our  preliminary  requirements. 
It  would  be  manifestly  unfair  to  our  o\nti  State  medical 
colleges,  and  would  constitute  an  unjust  discrimination 
against  our  own  students,  were  we  to  enforce  No.  5  of 
paragraph  145,  and  in  turn  permit  licentiates  of  other 
boards,  no  matter  how  severe  the  medical  tests,  to 
register  in  our  State  without  having  submitted  to  the 
same  or  to  similar  preliminary  academic  tests.  Our 
New  York  medical  colleges  may  for  a  time  lose  stu- 
dents because  of  the  prohibitive  features  of  paragraph 
145  ;  but  in  the  long  run  this  advance  of  standard  will 
redound  to  their  financial  status,  as  it  now  advertises 
their  determination  to  build  up  medical  colleges  of 
which  the  citizens  may  be  proud  and  their  graduates 
boastful.  The  effect  of  the  recent  medical  laws  thus 
far  has  been  to  drive  incompetent  doctors  from  our 
doors,  to  prolong  courses  of  medical  study,  to  add  new 
studies  to  the  curriculum,  and  to  elevate  the  tone  of 
the  profession  as  well  as  to  improve  its  personnel. 
Thus  it  will  be  seen  that  much  has  been  accomplished, 
but  until  the  average  longevity  is  increased,  and  the 
average  mortality  of  the  community  is  decreased,  the 


IJ 


MEDICAL    RECORD. 


[July  6.  1895 


full  measure  of  the  law's  beneficence  will  not  be  appar- 
ent to  the  laity  nor  will  it  be  satisfactory  to  the  profes- 
sion. 


IS  CHOLERA  ENDEMIC  IN  EUROPE? 

Certain  alarmists,  moved  by  the  regularly  recurring 
reports  of  the  ravages  of  cholera  in  Europe,  especially 
in  Russia  and  the  eastern  provinces  of  Austria  and 
Prussia,  each  summer,  have  asserted  that  the  disease 
has  established  for  itself  another  nidus,  outside  of 
India,  whence  it  may  make  irruptions  into  Western 
Europe.  It  is  true  that  nearly  every  summer  during 
the  past  ten  years  there  have  been  outbreaks  of  cholera 
in  some  parts  of  the  continent  of  Europe,  in  Spain, 
Italy,  France,  Germany,  Russia,  and  Turkey,  but  many 
of  these  have  been  local  and  traceable  to  very  differing 
sources.  There  have,  indeed,  been  two  distinct  epi- 
demics during  this  period,  one  around  the  shores  of 
the  Mediterranean,  spreading  inland  to  a  slight  e.xtent, 
the  other  taking  the  ordinary  course  across  central 
Asia,  entering  Europe  through  southern  Russia. 

If  we  look  back  over  the  successive  epidemics  of 
cholera  that  have  passed  over  Europe,  we  shall  see  that 
most  of  them  lasted  several  years,  though  varying  in 
intensity  and  in  the  locality  of  greatest  prevalence. 
The  first  appearance  of  cholera  in  Europe  was  in  1823, 
when  it  invaded  southern  Russia.  This  outbreak  was 
of  short  duration,  and  nothing  more  was  seen  of  the 
disease  until  six  years  later,  when  it  reappeared  in  the 
Russian  province  of  Astrakhan.  This  time  it  did  not 
remain  confined  to  the  shores  of  the  Caspian,  but  spread 
throughout  Russia,  invaded  the  rest  of  continental 
Europe,  reached  England  two  years  later,  and  crossed 
the  ocean  the  following  year.  Every  country  in  Europe 
and  North  America,  with  the  exception  of  Greece  and 
Switzerland,  suffered  from  the  ravages  of  the  disease. 
The  epidemic  did  not  finally  die  out  until  1837.  Since 
then  there  have  been  epidemics  of  larger  or  shorter 
duration  in  1846,  1865,  and  1884.  The  third  epidemic 
.persisted  for  ten  years,  from  1846  to  1855,  the  fourth 
for' nine  years,  or  until  1873.  The  present  epidemic 
has  existed  in  Russia  only  since  1892,  so  that  this  is  its 
fourth  summer  in  that  country.  As  three  of  the  former 
epidemics  lasted  eight,  nine,  and  ten  years,  respectively, 
it  seems  rather  premature,  at  the  beginning  of  the 
fourth  year  of  this  visitation,  to  cry  out  that  the  disease 
is  no  longer  epidemic  but  endemic,  and  that  it  has 
found  a  new  home  far  from  the  Ganges  on  the  banks 
of  the  Vistula  and  about  the  shores  of  the  Caspian  Sea. 


PROGRESS    OF    SERUM-THERAI'Y    AND    OR- 
GAN-THERAPY. 

A  SHORT  time  ago  Drs.  Emmerich  and  Scholl  reported 
some  favorable  experiments  with  the  use  of  the  erysip- 
elas serum  in  the  treatment  of  cancer.  A  few  weeks 
after  this  report  Dr.  Bruns  published  a  criticism  deny- 
ing the  alleged  improvement  in  the  cases.  Still  later 
Dr.  Angerer,  of  Munich,  has  re])orted  some  cases  of 
cancer  of  the  breast  treated  with  erysipelas  serum  with- 
out any  good  effects.  Drs.  Richet  and  Hericourt  re- 
cently publislied  the  account  of  a  case  of  osteo-sarcoma 
of  the  leg  which  they  treated  with  injections  of  serum. 


The  result  in  this  case,  as  well  as  in  another  case  of 
fibro-sarcoma  of  the  breast,  was  so  brilliant  that  the 
doctors  are  questioning  now  whether  or  not  they  did 
not  make  a  mistake  in  diagnosis. 

The  most  curious  perversion,  if  we  may  call  it  so,  of 
serum-therapeutics  is  that  in  which  the  serum  of  horses, 
which  are  supposed  to  be  immune  against  tuberculosis, 
is  used  in  the  treatment  of  tuberculosis  in  human  be- 
ings. Dr.  Paquin,  of  St.  Louis,  is  responsible  for  this 
extremely  unique  method  of  applying  the  immunizing 
injections.  He  reports  twenty-two  cases  of  tubercu- 
losis in  which  patients  were  treated  with  this  serum 
with  more  or  less  favorable  results.  His  statistics  were 
not  very  encouraging,  and  the  theory  on  which  his 
treatment  is  based,  if  it  can  be  called  such,  has  no 
rational  basis  whatever.  While  there  may  be  certain 
animals  who  are  immune  to  tuberculosis,  there  is  noth- 
ing in  medicine  to  show  that  in  human  beings  an  attack 
of  tuberculosis  produces  immunity  in  the  slightest 
degree. 

Syphilis  has  also  reached  the  stage  of  serum-thera- 
peutics. Dr.  Richet  communicated  in  April  last  to  the 
Society  of  Biology  a  report  of  the  case  of  a  woman 
who  had  suffered  for  three  and  a  half  years  with  multi- 
ple ulcerating  gummata.  She  was  injected  with  the 
anti-syphilitic  serum  and  in  fourteen  days  was  well  I 
This  serum  was  obtained  from  a  donkey  who  had  fifty- 
four  days  before  been  injected  with  the  blood-serum 
of  a  syphilitic  in  the  secondary  stage.  Gilbert  and 
Fournier  have  collected  the  work  of  other  experiment- 
ers in  this  same  line,  and  they  detail  the  methods  and 
results  of  some  new  experiments  which  they  have  them- 
selves undertaken  in  the  treatment  of  syphilis  with  the 
serum  of  immune  animals  and  men.  The  practical  re- 
sults are  as  yet  very  slight. 

More  recent  reports  upon  the  value  of  the  serum- 
therapy  of  diphtheria  continue  to  be  favorable,  and 
there  has  nothing  yet  appeared  in  current  literature  to 
justify  us  in  doubting  that  this  treatment  will  continue 
to  prove  a  valuable  help  in  our  fight  with  this  serious 
disease. 

Closely  related  to  serum-therapy  is  what  is  now  gen- 
erally termed  organ-therapy,  or  treatment  with  organic 
extracts.  Dr.  Drummond,  in  the  British  Mt\iiial  Jour- 
nal oi  May  1 8th,  reports  the  case  of  a  woman  seventy- 
three  years  old,  who  was  suffering  from  what  appeared 
to  be  pernicious  anajmia.  She  had  only  seven  hundred 
thousand  red  blood-cells  to  the  cubic  centimetre. 
Under  the  use  of  bone-marrow  given  in  milk  she  im- 
proved very  rapidly. 

Dr.  Walter  Clark  reports  a  case  of  diabetes  insipidus 
in  which  the  patient  was  treated  with  extracts  of  the 
suprarenal  capsules.  The  patient  was  a  woman  thirty- 
nine  years  old,  who  had  been  for  a  long  time  under 
observation,  and  who  was  passing  about  four  gallons  of 
urine  daily.  Under  the  use  of  the  suprarenal-capsule 
feeding  the  urine  was  reduced  in  amount  to  about  three 
pints  daily  and  its  specific  gravity  increased  from  1.005 
to  1.009.  As  soon  as  the  use  of  the  suprarenals  was 
stopped  the  symptoms  began  to  return. 

Dr.  liyrom  Bramwell,  in  the  British  Mt-ifiidl  Jour- 
nal of  June  ist,  reports  a  case  of  tetany  treated  with 
thyroid  extract.  The  patient  was  a  boy  eight  years 
old,  and  the  disease  began  in  the  fall  of  1893.     During 


July  6,  1895] 


MEDICAL   RECORD. 


19 


the  winter  and  spring  of  1893  and  1894  he  was  under 
treatment  by  Dr.  Bramwell  with  some  improvement. 
In  March,  1895,  he  was  placed  upon  thyroid  e.xtract. 
After  three  weeks  his  attending  physician  stated  that 
the  improvement  was  something  phenomenal,  and  five 
weeks  later  he  writes  that  the  case  continued  to  im- 
prove in  every  way. 


THE    PLETHORA    OF    MEDICAL   SOCIETIES. 

Both  Paris  and  London  are  suffering  from  a  plethora 
of  medical  societies.  This  is  the  statement  made  by 
Dr.  Morris  in  The  Practitioner,  and  it  is  confirmed  by 
the  comments  of  Parisian  and  London  contemporaries. 
The  remedy  suggested,  of  course,  is  that  some  of  the 
societies  amalgamate.  We  have  no  doubt  that  the  ad- 
vice is  excellent.  It  has  often  been  tendered  to  the 
medical  men  of  New  York,  where  societies  are  also 
extremely  numerous,  but  the  advice  does  not  seem  to 
be  taken.  Societies  go  on  multiplying  in  New  York 
and  everywhere  else  ;  and  we  take  it  that  it  must  be 
because  there  is  some  actual  need  for  them.  In  this 
city  the  problem  has  been  pretty  well  solved  by  the  suc- 
cess of  our  Academy  of  Medicine.  In  this  organiza- 
tion there  are  so  many  and  such  excellent  opportunities 
for  societies  of  specialists  to  organize  under  the  foster- 
ing wing  of  the  Academy  that  we  do  not  recall  any  new 
organization  since  the  sections  of  the  Academy  were 
fairly  started.  New  societies  continue  to  spring  up, 
but  they  are  general  in  character  and  have  for  their 
e.xcuse  social  and  local  causes  rather  than  scientific. 
They  fulfil  their  purpose  in  enabling  the  medical  men 
in  certain  parts  of  the  town  to  get  together  and  become 
acquainted  with  each  other,  and  in  this  way  they  do 
\  ery  good  work. 

REFORM  IN  INTERNATIONAL  CONGRESSES. 

Now  that  the  majority  of  the  annual  meetings  of  our 
State  and  International  Medical  Associations  are  over,  a 
criticism  upon  these  meetings  by  Dr.  Pistor,  in  the  Quar- 
terly Journal  of  Public  Health,  may  seem  very  timely. 
Dr.  Pistor  thinks  that  there  are  too  many  formal  din- 
ners, too  many  evening  parties,  and  too  many  invita- 
tions to  visit  industrial  establishments,  hospitals,  fac- 
tories, or[)han  asylums,  and  so  on.  He  asserts  that  al' 
these  interesting  functions  should  be  entirely  done  away 
with,  and  that  visitors  who  desire  to  live  sumptuously 
should  do  it  at  their  own  expense.  Many  cities  in 
Europe,  he  says,  are  unwilling  to  receive  international 
congresses  on  account  of  the  heavy  expense  connected 
with  them.  This  is  not  the  case,  we  may  say,  paren- 
thetically, in  the  United  States,  but  then  we  have  not 
the  thrifty  habits  of  the  older  countries.  Another 
trouble  with  these  congresses  is  that  there  are  too  many 
papers  announced  to  be  read,  and  the  discussions,  he 
thinks,  are  on  this  account  usually  very  unsatisfactory. 
The  number  of  sections  also  should  be  limited.  In 
fact.  Dr.  Pistor  enumerates  all  the  well-known  and  well- 
worn  criticisms  upon  the  conduct  of  the  medical  con- 
gresses of  the  present  day.  The  defect  in  Dr.  Pistor's 
position  is  that  he  expects  too  much  of  this  imperfect 
world.  Medical  congresses  are  not  meant  solely  for 
the    production,    or    even  the    exploitation    of   great 


scientific  truths,  but  rather  for  the  personal  benefit  that 
is  produced  by  the  contact  of  men  from  different  parts 
of  the  world  with  each  other.  It  is  at  dinners  and  at 
the  various  other  reunions  and  festivities  that  visitors 
to  congresses  really  learn  the  most.  Dr.  Pistor,  when 
he  gets  older  and  has  had  more  experience  with  con- 
gresses, will  probably  acknowledge  the  truth  of  this 
statement. 


THE    STATE   AND    LOCAL  CHARITIES. 

The  State  of  Pennsylvania  has  always  been  peculiar  in 
its  relations  to  medical  charities.  Unlike  most  other 
States,  it  has  often  and  generously  appropriated  the  funds 
of  the  taxpayers  from  all  over  the  State  to  the  promo- 
tion of  local  medical  interests.  The  Medical  and  Sur- 
t^ical  Reporter  furnishes  a  list  of  the  appropriations  as 
reported  by  the  Appropriation  Committee  at  the  pres- 
ent session  of  the  Pennsylvania  State  Legislature. 
These  include  sums  of  $150,000  to  the  Medico-Chirur- 
gical  Hospital,  $200,000  to  the  University  of  Pennsyl- 
vania, $55,000  more  to  the  hospital  of  that  university, 
$112,000  to  Jefferson  Medical  College,  $8,000  to  the 
Woman's  Hospital,  $3,000  to  the  Samaritan  Hospital, 
$4,000  to  the  Children's  Hospital,  and  $25,000  to  the 
Gynecean  Hospital.  Of  course,  if  the  hospitals  of  Phil- 
adelphia get  State  appropriations  the  hospitals  of  the 
smaller  cities  must  also  have  their  share,  and  we  find  a 
list  of  forty  different  hospitals  scattered  throughout  the 
State,  to  each  of  which  an  appropriation  is  given.  If 
the  general  principle  of  State  help  to  local  institutions 
is  considered  by  Pennsylvania  economists  to  be  a  sound 
one,  no  objection  can  be  raised  against  any  such  widely 
extended  generosity  as  that  which  the  Pennsylvania 
Legislature  shows  ;  but  it  seems  to  us  that  the  State  will 
find  itself  eventually  in  a  very  embarrassing  situation 
if  it  continues  the  policy  which  it  has  adopted  of  help- 
ing along  almost  any  private  medical  institution  just  be- 
cause it  has  a  medical  charity  annex. 


The  Brain  of  Buchanan,  the  murderer,  executed  July 
I  St,  is  said  to  have  weighed  only  thirty-one  ounces.  He 
was  a  small  man. 

The  Heaviest  Woman  in  America  died  at  Millers- 
burg,  O.,  on  July  I  St.      Her  weight  was  675  pounds. 

The  Woman's  Medical  College  of  Cincinnati,  O.,  has 
united  itself  with  the  Laura  Memorial  Medical  College. 
There  did  not  seem  to  be  room  enough  in  Cincinnati 
for  two  medical  colleges  for  women. 

Doctors  and  Athletics. — The  medical  profession  has 
its  full  share  of  athletic  honors.  Dr.  tlrace  has  proved 
himself  the  champion  cricket-player  of  England,  and 
therefore  of  the  world,  and  Dr.  Pym,  of  Ireland,  hav- 
ing beaten  all  the  tennis  experts  of  Great  Britain,  has 
come  over  to  this  country  and  done  the  same  to  the 
American  tennis-players.  We  have  in  this  city  Dr. 
Hammond,  who  is  the  champion  at  foils  and  broad- 
swords of  the  United  States,  and  doubtless  there  is 
rich  material  for  a  bicycle  champion  among  the  numer- 
ous medical  men  who  have  taken  up  that  pastime. 


MEDICAL    RECORD. 


[July  6,  1895 


The  Galactogogues. — Dr.  Grinewitch  has  been  making 
a  study  of  the  drugs  which  increase  the  flow  of  milk 
without  in  any  way  injuring  the  quality  of  it.  He 
finds  that  the  most  efficient  of  them  is  a  plant  which  is 
practically  unknown  in  medicine,  the  common  goat's 
rue  {Gah'ga  officinalis).  He  gives  a  drachm  of  the 
tincture  about  five  times  a  day.  The  next  drug  in  the 
scale  is  the  common  stinging  nettle,  of  which  he  gives 
from  two  hundred  and  fifty  to  five  hundred  drops  of 
the  tincture  daily. 

The  Thyroid  Treatment  of  Tetany.— We  referred  to 
the  successful  treatment  of  tetany  by  thyroid  feeding  a 
short  time  ago.  Since  then  Dr.  Bramwell  refers  to  cer- 
tain e.xperiments  made  by  Dr.  Gottstein,  in  which  he 
had  success  by  grafting  the  thyroid  in  a  case  of  tetany. 
Dr.  John  Thompson,  however,  states  that  he  has  used 
the  thyroid  in  tetany  without  any  success. 

The  Meeting  of  Bacteriologists,  held  in  this  city  June 
2ist,  resulted  in  the  appointment  of  a  committee  to 
consider  both  the  papers  presented  and  the  discussion 
that  followed,  and  to  make  a  report  to  the  American 
Health  Association  as  to  the  most  desirable  methods 
to  be  observed  to  secure  the  greatest  uniformity  in  the 
results  of  the  bacteriological  examination  of  water. 
The  names  of  this  committee  are  :  Professor  W.  H. 
Welch,  M.D.,  chairman  ;  Professor  W.  Sedgwick,  Ph.D.; 
Professor  Theobald  Smith,  M.D.;  Professor  T.  M. 
Prudden,  M.D.;  Professor  J.  G.  Adami,  M.D.;  George 
W.  Fuller,  S.B.;  Professor  A.  C.  Abbott,  M.D.;  Pro- 
fessor V.  A.  Moore,  B.A.,  M.D. 

Bequests  to  St.  Luke's  Hospital.— By  the  will  of  the 
late  Rufus  Waterhouse  the  bulk  of  his  estate,  amount- 
ing to  about  two  hundred  thousand  dollars,  is  left 
to  St.  Luke's  Hospital  for  the  purpose  of  establishing 
ind  maintaining  the  "  Mary  S.  Waterhouse  Memorial 
Ward  "  for  consumptive  sewing-women  or  consump- 
tives dependent  upon  sewing-women. 

Bartmouth  Medical  College. — By  vote  of  the  Trus- 
tees it  has  been  decided  to  raise  the  standard  of  ad- 
mission to  the  college. 

Meetings  of  Societies.— The  Sixty-third  Annu.^l 
Meetinq  of  the  British  Medical  Association  will 
be  held  in  London  on  Tuesday,  Wednesday,  Thurs- 
day, and  Friday,  July  30th  to  August  2d,  Dr.  E.  Long 
Fox  presiding.  The  meeting  promises  to  be  an  unusu- 
ally large  one,  owing  to  the  choice  of  the  place  in 
which  it  is  to  be  held,  and  a  large  number  of  American 
physicians  will  be  present.  Sir  William  Broadbent  de- 
livers the  Address  on  Medicine,  and  Mr.  Jonathan 
Hutchinson  that  on  Surgery.  In  the  Section  on  Medi- 
cine there  are  to  be  discussions  on  diphtheria,  on  pneu- 
monia, and  on  the  causes  of  acute  rheumatism.  In  the 
Section  on  Surgery  there  are  to  be  discussions  on  fract- 
ures of  the  upper  third  part  of  the  femur,  and  on  the 
surgical  treatment  of  cysts,  tumors,  and  cancer  of  the 
thyroid  gland.  There  will  be  on  the  first  day  a  recep- 
tion at  the  Imperial  Institute  in  the  evening,  following 
the  President's  address,  and  on  the  third  day  there 
will  be  a  dinner  at  Langham  Place. — The  Ameuuan 
AcADKMV  OK  Railway  Surceons  will  meet  in  Chi- 
cago on  September  25th,  jfith,  and  27th. — Thk  Thiku 


International  Congress  of  Physiologists. — The 
Third  International  Congress  of  Physiologists  will  be 
held  in  September,  1895,  from  the  loth  to  the  14th  of 
the  month,  at  Bern,  Switzerland. 

New  Medical  Law  for  Delaware. — The  Governor  of 

Delaware,  acting  under  the  medical  law  passed  by  that 
State,  has  ajjpointed  two  Boards  of  Examiners,  one  to 
represent  each  of  the  chief  schools  of  medicine.  The 
law  provides  that  the  Chief  Justice  and  the  Chairman 
of  each  Board  shall  constitute  a  Council  of  Medicine 
empowered  to  issue  licenses  to  persons  that  have  passed 
the  required  examination.  The  law  provides  a  fine  of 
$500  or  not  more  than  one  year's  imprisonment  for  per- 
sons convicted  of  practising  without  a  license.  The 
new  Boards  of  Examiners  will  meet  the  first  week  in 
July  to  organize,  and  the  Council  of  Medicine  will  then 
be  constituted.  Thereafter  newcomers  must  submit  to 
examination. 

Obituary  Notes. — Dr.  Henry  D.  Hall  died  at  Ja- 
maica, L.  I.,  July  I  St.  He  was  born  in  Clinton  County 
eighty-seven  years  ago.  He  was  Assistant  Surgeon  in 
the  United  States  Army  during  the  war,  and  for  a  num- 
ber of  years  practised  his  profession  at  Glen  Cove,  . 
L.  I. — Dr.  Ezra  Graves,  a  prominent  physician  of 
Amsterdam,  N.  Y.,  died  on  June  30th.  He  was  fifty- 
six  years  old.  He  had  served  as  coroner  of  Montgom- 
ery County,  and  also  as  city  physician  of  Amsterdam. 
He  was  a  graduate  of  the  Buffalo  Medical  College. — Dr. 
J.  B.  Wilbur,  formerly  a  well-known  Brooklyn  prac- 
titioner, died  at  Montclair,  N.  J.,  recently,  aged  seventy. 
He  was  a  graduate  of  Harvard  College  and  Harvard 
Medical  School,  and  served  as  surgeon  of  a  Massa- 
chusetts regiment  during  the  war. 

The  New  Health  Commissioner. — Dr.  George  B. 
Fowler  has  been  appointed  Health  Commissioner  of 
this  city  in  place  of  Dr.  Cyrus  Edson,  resigned.  Dr. 
Fowler  is  a  native  of  Alabama,  but  came  to  this  city 
during  the  war,  and  graduated  from  the  College  of 
Physicians  and  Surgeons  in  1871.  Dr.  Fowler  is  a 
well-known  and  very  popular  member  of  the  profession 
of  this  city,  and  his  appointment  will  give  pleasure  to 
his  very  large  circle  of  friends.  Dr.  Edson's  career  as 
a  member  of  the  City  Board  of  Health  was  most  cred- 
itable to  him,  and  he  retires  with  a  reputation  of  the 
highest  kind  as  a  sanitary  and  executive  officer. 

Monument  to  Dr.  Guerin. — The  friends  of  the  late 
Dr.  A.  Guerin  liave  raised  sufficient  money  to  erect  a 
statue  to  him  in  his  native  city. 

Doctors'  Bills. — The  Chicago  Tribune  publishes  an 
account  of  an  interview  with  a  member  of  a  firm  in 
that  city  whose  business  consists  entirely  in  the  collec- 
tion of  doctors'  bills.  He  was  asked  if  the  majority 
of  patients  paid  their  accounts,  and  said  that  they  did 
not.  From  this  it  would  be  inferred  that  in  Chicago 
over  one-half  of  the  patients  failed  to  pay  their  doctors' 
fees — a  statement  that  is  extraordinary  and  improbable. 
We  believe  that  in  most  American  cities  from  seventy 
to  eighty  per  cent,  of  the  fees  charged  are  paid  and 
collected,  and  probably  a  larger  percentage  would  be 
obtained  if  doctors  rendered  better  service  or  managed 
the  business  side  of  their  profession  in  a  more  rational 
manner. 


July  6,  1895] 


MEDICAL   RECORD. 


©liuical  gepartmeut 

CASES    SIMULATING   TYPHUS    FEVER. 
By   S.    DANA   HUBBARD,    M.D., 


The  following  histories  of  two  very  interesting  cases 
came  under  my  observation  while  at  the  Riverside  Hos- 
pital, and  I  deem  them  worthy  of  record  : 

Case  L— A.  T ,  German  ;  married  ;  thirty  years 

of  age  :  laborer  ;  residence,  New  York  City.  Habits  : 
Alcoholic,  vagabond  ;  family  history  not  obtainable  ; 
past  history  not  obtainable.  Present  history  :  As  per- 
fect as  could  be  obtained,  was  to  the  effect  that  having 
"  cold  and  cough  "  went  to  a  dispensary  for  medicine, 
and  here  they  said  he  had  measles,  which  was  con- 
firmed by  the  diagnostician  of  the  Health  Department, 
and  in  the  course  of  events  he  was  transferred  to  North 
Brother  Island,  where  he  came  under  my  observation. 

On  admission  he  had  a  general  bronchitis,  with  suf- 
fused eyes  and  watery  discharge  from  nose,  and  an 
eruption  over  entire  trunk,  face,  and  extremities — the 
eruption  consisting  of  large,  multiform,  coalescent 
blotches,  with  curvilinear  borders  crescentically  ar- 
ranged and  of  a  deep  pinkish  red  color.  His  face  in  ad- 
dition was  much  swollen.  His  temperature  was  1054° 
F.  ;  pulse,  100  ;  respiration,  28.  Patient  was  slightly 
delirious.  Stimulants,  antipyretics,  and  enema  were 
ordered.  At  7  p.m.  the  temperature  had  fallen  to  102!° 
F.,  and  patient  was  resting  easy.  During  the  night  the 
patient  was  restless,  though  delirum  had  disappeared. 

October  13th. — Diarrhoea  set  in  and  continued  in 
spite  of  treatment.  Pulse  irregular  and  compressible. 
Patient  sighing  and  has  gloomy  forebodings. 

October  14th. — Temperature  elevated  and  persists 
above  102°  F.,  in  spite  of  antipyretics  and  cold  packs. 
Patient  apparently  losing  ground  rapidly.  Stimulants 
pushed  without  effect.  Pulse  very  weak  and  irregular. 
Patient  very  delirious.  Eruption  fading  and  I  consid- 
ered him  improving  as  regard  his  measles  ;  but  what 
underlying  condition  was  causing  all  this  constitutional 
disturbance  I  was  at  a  loss  to  explain.  Consultations 
were  held  and  a  change  of  diagnosis  was  made  from 
measles  to  typhus  fever,  I  disagreed,  but  was  willing  to 
use  all  precautions  and  accordingly  the  patient  was  iso- 
lated and  observed  just  as  if  it  were  a  bona  fide  case 
of  typhus. 

Here  was  a  man,  a  tramp,  filthy,  unkempt,  com- 
ing from  a  lodging-house  (where  we  got  nearly  all 
of  the  second  epidemic  of  typhus  cases),  having  a  pur- 
plish (for  the  rash  was  now  fading),  mottled  eruption, 
with  high  temperature  (persistent),  congested  eyes, 
contracted  pupils,  with  a  dull,  listless  expression,  and  a 
delirium  of  a  talkative  character. 

Surely  one  would  be  justified  in  diagnosing  typhus 
in  a  case  of  this  kind  if  we  had  no  history  previous 
to  this  examination  ;  and  we  had,  for  on  the  12th  it  was 
as  clear  a  case  of  measles  as  one  would  wish  to  see  ; 
but  on  the  14th  it  most  assuredly  resembled  a  typical 
case  of  typhus  fever. 

On  the  15th,  as  the  patient  was  sinking,  the  darkness 
of  our  difficulties  grew  deeper,  but  with  the  morning 
the  star  of  clearer  vision  began  to  rise,  and  when  the 
brightness  of  the  day  shone  our  mysteries  were  fading 
as  fast  as  the  dew  before  the  summer's  sun,  for  at  5 
P.M.  the  patient  began  to  vomit,  the  ejecta  being  of  a 
bright  red  color  streaked  with  a  darker  red,  and  clotted 
and  lumpy.  He  was  examined  quickly  to  find  the 
source  of  this  ejecta.  The  lungs  showed  nothing  and 
the  stomach  was  empty.  More  trouble.  The  dark 
blood,  no  doubt,  came  from  the  stomach  ;  but  had  it 
not  come  from  another  source,  been  swallowed  and 
then  ejected  ?  Acting  on  this  theory  and  believing  my- 
self sufficiently  clear,  I  diagnosed  hemorrhage  from  the 
alimentary  tract  between  the  stomach  and  mouth  ;  but 


where  ?  I  still  felt  uncertain  about  the  lungs  and  ex- 
amined again,  when  lo  !  the  stomach  was  partly  filled. 
Had  I  not  an  hour  and  a  half  ago  examined  him  and 
found  this  organ  empty,  and  now  it  was  partly  filled  ? 
No  food  (fluid)  had  been  given,  and  he  had  not  swal- 
lowed any,  for  I  watched  him  to  see  if  he  would  bleed 
from  the  lungs,  and  if  it  would  come  up  the  trachea 
and  then  go  down  the  oesophagus,  and  I  found  the 
trachea  clear.  Treatment  was  accordingly  given  for 
hemorrhage  from  the  stomach,  but  after  repeated 
vomiting  the  patient  finally  sank  rapidly,  dying  in  con- 
vulsions at  9  A.M.  on  October  i6th.  At  5  a.m.  on  the 
1 6th  his  temperature  rose  up  to  108°  F.  (rectal),  but 
declined  gradually  to  102-^°  F.  (rectal)  when  he  died. 

Autopsy. — Evidences  in  general  of  an  acute  infec- 
tious process,  and  in  addition  the  stomach  and  entire 
intestines  to  within  three  inches  of  caput  coli,  where  it 
terminated  abruptly,  were  filled  with  a  dark  grumous 
mass,  apparently  clotted  blood. 

At  the  lower  end  of  the  oesophagus  was  found 
the  cause  of  all  this  hemorrhage.  There  were  three 
lineal  ulcers  of  varying  length,  arranged  in  a  circular 
manner  around  the  lower  opening  ;  the  largest  ulcer 
being  about  an  inch  and  a  quarter  long  and  its  depth 
extending  through  to  the  outer  coat  of  the  oesophagus. 
This  latter  one  evidently  was  the  cause  of  all  this  hem- 
orrhage and  of  the  fatal  termination,  for  it  had  eroded 
an  artery. 

Owing  to  the  peculiar  shape  and  position  of  these 
ulcers  one  might  suppose  them  to  have  been  traumatic, 
as  caused  by  sword-swallowing,  though  this  could  not 
be  verified. 

Case  II. — Michael  N ,  aged  twenty-three  ;  Ire- 
land. No  history.  This  case  occurred  during  the 
epidemic  of  typhus  fever  in  1892-93,  and  is  one  of  in- 
terest in  many  ways.  The  case  on  admission  was  de- 
lirious and  the  previous  history  could  not  be  obtained. 
Here  was  a  young  man,  a  blonde,  of  an  alcoholic,  vaga- 
bondic  appearance,  filthy  and  unkempt,  ill  with  a  high 
temperature — 105°  F.  (rectal) — delirious,  with  a  general 
mottled  eruption.  The  case  occurred  during  the 
prevalence  of  typhus  fever  in  this  class  of  citizens. 

The  case  was  diagnosed  as  typhus  by  the  Health 
Department  diagnosticians,  and  passed  as  such  by  both 
the  resident  physicians  of  the  Reception  Hospital 
and  of  the  Riverside  Hospital.  Accordingly  the  case 
was  transferred  to  the  typhus  ward  and  treated  as 
such. 

Attention  was  now  called  to  this  patient,  and  I  was  in- 
formed that  if  this  was  a  case  of  typhus  then  the  place 
from  whence  he  came  (which  was  a  lodging-house) 
was  a  new  centre  of  infection,  and  wanting  to  be  more 
certain  than  in  a  general  routine  way  I  visited  the 
case  again,  examined  him  more  carefully,  with  this  re- 
sult : 

A  young  man,  blonde,  body  fairly  well  nourished, 
with  a  delirium  of  low  type,  with  features  pinched 
and  face  cyanotic  ;  sordes  abundant,  tongue  dry, 
coated,  hard,  and  cracked.  Eyes  :  Conjunctivae  normal, 
rather  "  glassy,"  with  pupils  dilated  if  changed  at  all  ; 
subsultus  tendinum,  and  carphologia  present,  and  pa- 
tient tossing,  in  bed.  His  skin  was  dry  and  hot, 
and  another  interesting  condition  was  the  eruption, 
which  was  all  over  trunk,  anteriorly  and  posteriorly,  up- 
per and  lower  extremities,  and  a  few  spots  on  forehead. 
The  eruption  was  of  a  mottled,  macular  character  and 
flat,  disappearing  on  pressure,  and  color  deeper  than  pink 
and  lighter  than  chocolate.  The  macules  were  numer- 
ous and  the  mottling  slight,  but  easily  distinguished  on 
account  of  his  fair  skin.  His  abdomen  was  tympanitic, 
pressure  gently  exercised  caused  no  evidence  of  pain. 

An  enema  was  given  as  was  usual,  and  a  movement, 
partly  formed,  brown  and  odorous,  was  the  result. 
Urine  :  Nothing  special.  Not  examined  microscopi- 
cally. Antipyretics,  sedatives,  and  stimulants  ordered, 
and  spots  marked  out  as  best  as  was  possible. 

July  nth. — Patient  semi-unconscious,  takes  nourish- 


MEDICAL    RECORD. 


[July  6,  1895 


ment  and  medicines.  No  change  in  his  condition  or 
eruption,  constipated,  and  voided  very  little  urine. 

July  1 2th. — Bowels  moved  once,  partly  formed,  brown 
and  odorous.  Temperature  continues  high,  subsultus 
and  carphologia  absent.  Patient  restful  and  very  weak. 
Pulse  very  rapid  and  compressible.  Has  difficulty  in 
swallowing.  Tympanites  still  present,  though  not  so 
marked.  Spots  looked  out  for  as  well  as  possible,  and 
no  new  ones  found,  therefore  no  crops.  Eruption 
brownish  and  apparently  fading. 

July  13th. — Patient  at  i  a.m.  had  temperature  105  f  *^ 
F.,  and  was  failing  rapidly,  and  at  3.30  a.m.  he  died. 

Autopsy. — Beyond  the  evidences  of  an  acute  infec- 
tious process  we  found  several  ulcers,  some  very  large. 
The  presence  of  these  undoubtedly  clear  the  diagnosis. 

This  case  is  interesting,  for  here  was  an  irregular 
typhoid  case,  and  that  it  was  a  mi.xture  of  the  two  dis- 
eases I  do  not  believe,  but  lean  toward  the  former  diag- 
nosis, for  we  do  have  irregularities  during  the  course 
of  a  disease,  and  rarely  have  the  two  existing  at  one 
and  the  same  time.  Now  this  case  is  interesting  be- 
cause it  happened  at  the  time  of  a  typhus  epidemic,  and 
secondly,  having  symptoms  of  both  diseases. 

Tympanites  is  frequent  in  typhoid,  and  while  some 
say  it  is  absent  in  typhus  this  is  not  the  fact,  for  I,  in 
my  limited  experience,  have  seen  two  cases,  one  of 
which  died. 

The  eye  in  typhus  is  peculiar  of  itself.  It  has  to  be 
seen  to  be  appreciated,  and  a  typical  typhus-fever  eye 
is  not  soon  forgotten.  The  pupils  are  contracted, 
sometimes  finely  so.  The  conjunctiva;  are  injected  pe- 
culiarly, the  little  vessels  radiate  from  the  iris  toward 
the  periphery  like  lines  from  a  light,  with  smaller  ves- 
sels forming  a  net-work  between  the  larger  radiating 
vessels.  The  surface  of  the  conjunctiva  is  moist.  The 
eyelids  are  thin,  and  the  cartilages  are  prominent,  the 
edges  red  and  dry,  giving  to  the  countenance  a  peculiar 
cast  and  spoken  of  as  the  "  typhus  eye,"  in  contra- 
distinction to  the  smooth,  shiny,  white  "china  eye  "  of 
typhoid. 

Now  in  measles  the  eye  is  injected  and  the  surface 
moist,  accumulations  of  secretions  forming  and  fre- 
quently running  over  lids.  The  lids  are  red,  swollen, 
and  moist,  just  the  opposite  of  the  "  typhus  eye." 

I  exhibit  this  relic  of  a  very  interesting  case,  and  hope 
that  future  diagnosticians  will  not  be  so  hasty  in  mak- 
ing diagnoses,  but  use  the  safest  two  methods,  that  of 
isolation  and  observation  ;  and  with  our  surgical 
friend  exclusion  I  know  all  will  be  helped  on  the 
road  to  success  with  greater  speed. 

79  West  104TH  Street. 


MORNING    DIARRHCEA. 
By  L.  W.  ZWISOIIN,  M.D., 

NEW   YORK. 

I  HAVE  read  with  great  interest  the  article  of  Dr.  F. 
Delafield,  in  the  Medical  Record,  May  nth,  entitled 
"Morning  Diarrhoea,"  and  I  would  venture  to  suggest 
the  etiology  of  the  disease  of  which  the  author  says  he 
has  not  been  able  to  determine  satisfactorily.  As  there 
can  be  no  better  experience  for  a  physician  than  to  study 
a  disease  in  his  own  person,  I  will  cite  my  experience, 
for  I  have  been  suffering  from  morning  diarrhoea  for 
years. 

Dr.  Delafield  describes  five  varieties,  all  of  which  I 
have  observed  in  my  case,  of  course  at  different  periods. 
At  the  beginning  I  had  the  first  variety,  the  simplest  ; 
after  a  few  months  the  disease  progressed  and  took  the 
form  of  the  second  variety,  z.c,  the  colicky  pains,  the 
exhaustion  after  the  passage,  the  mental  and  nervous 
disturbances,  the  apprehension,  etc.  Then  there  ap- 
peared the  fourth  variety,  i.e.,  there  was  a  sort  of  rela- 
tion between  the  stomach  and  the  colon,  so  that  when- 
ever I  took  food  into  the  stomach  there  was  a  movement 


from  the  bowels.  Then  the  disease  took  the  form  of 
the  fifth  variety,  marked  by  the  presence  of  consider- 
able mucus  in  the  discharge.  This  state  of  affairs  kept 
up  for  years,  passing  alternately  from  the  simplest  form 
to  the  severest,  and  vice  versa. 

From  my  own  experience  I  believe,  i.  The  chief 
cause  is  indigestion,  aggravated  by  cold,  anxiety,  etc. 
2.  The  main  treatment  is  dietetic.  Of  course  the  prog- 
ress is  very  slow,  and  some  patients  will  think  they  get 
worse,  and  will  never  follow  the  directions  of  the  phy- 
sician. My  patients,  when  I  put  them  on  a  milk  diet, 
after  a  w-eek  or  two  frequently  say  that  they  are  not 
well  yet,  or  they  are  getting  worse.  Some,  or  the  ma- 
jority of  patients,  as  soon  as  they  are  better,  will  return 
to  their  old  habits  and  suffer  a  relapse,  and  that  is  the 
reason  why  they  get  worse.  I  was  obliged  to  keep  up 
strict  diet  for  a  year  before  I  was  cured,  and  even  at 
the  present  day  I  am  careful  with  my  diet.  3.  I  am  of 
the  opinion  that  the  five  varieties  described  by  Dr. 
Delafield  are  all  only  degrees  of  the  same  affection, 
which  begins  with  the  simplest  form  and  gradually 
comes  to  the  severest. 


A  CASE  OF  PNEUMONLA.  SUCCESSFULLY 
TREATED  BY  COLD  APPLICATIONS,  GUAI- 
ACOL,   AND    STRYCHNINE. 

By  J.  C.  WORTHINGTON,  M.D., 


SURGEON,   U.  S. 


,  FORT  THOMAS,  NEWPORT, 


Private  F ,  Company  G,  6th  Infantry,  aged  twen- 
ty-three, of  temperate  habits,  was  admitted  to  hospital, 
December  29,  1894,  at  5.15  p.m.,  with  a  temperature  of 
103°  F.  ;  respiration,  36;  pulse,  120.  He  had  had  pain 
in  the  left  infra-mammary  region  all  day.  On  auscul- 
tation at  the  time  of  admission,  normal  vesicular  breath- 
ing was  found  at  the  seat  of  the  pain  and  over  the  base 
of  the  lung  posteriorly.  Incipient  lobar  pneumonia 
was  suspected.  He  was  given  Dover's  powder,  gm. 
I,  and  four  dry  cups  were  applied  to  the  painful  side. 
Strychnine  sulphate,  gm.  0.002,  was  given  at  once. 

December  30th,  7  a.m. — Temperature,  104  6°  F.  ; 
respiration,  36  ;  pulse,  116.  Drowsy.  It  was  ordered 
to  continue  the  strychnine  sulphate  gm.  0.002,  t.  i.  d., 
and  to  give  tincture  of  digitalis  t.  i.  d.,  and  warm  milk 
and  beef-tea  as  nourishment.  There  was  dulness  and 
absence  of  respiratory  sounds  over  the  whole  lower 
lobe  of  the  left  lung.  Ordered  cotton  wadding  and 
oiled-silk  jacket  to  cover  the  whole  chest.  12  m.  : 
Temperature,  104°  F.  7  p.m.  :  Temperature,  104.2°  F.  ; 
respiration,  28  ;  pulse,  116.  Drowsy.  No  pain.  Or- 
dered strychnine  sulphate  gm.  0.00 1,  hypodermically, 
at  once,  and  at  midnight.  Also  whiskey,  15  c.c,  in  milk, 
every  two  hours,  -"^pply  to  side  a  flat  rubber  ice-bag 
filled  with  hydrant  water  (temperature,  54°  F.),  so  as  to 
cover  the  affected  lobe  of  the  left  lung,  this  to  be  re- 
filled every  half  hour  during  the  night,  but  to  be  kept 
up  only  if  grateful  to  the  ])atient.  The  patient  found 
this  application  comfortable  and  preferred  to  have  it, 
and  it  was  kept  up  regularly  all  night  and  until  10  a.m. 
on  the  31st.     It  did  not  reduce  his  temperature. 

December  31st,  7  a.m. — Temperature,  104.2°  F.  : 
respiration,  36  ;  pulse,  n6.  Patient  drowsy,  but  not 
delirious.  Fine  crepitant  rales  can  be  heard  at  the 
upper  part  of  the  lower  lobe.  Dulness  over  the  whole 
lower  lobe  is  marked.  The  patient  still  expresses  him- 
self as  feeling  a  sense  of  comfort  whenever  the  ice-bag 
is  refilled  with  cold  water.  9  a.m.  :  Temperature, 
104.4°  F.  ;  respiration,  28;  pulse,  112.  .\s  the  tem- 
perature had  now  been  over  104°  F.  for  more  than 
twenty-four  hours  and  showed  a  tendency  to  rise,  and 
having  ordinarily  seen  cases  of  pneumonia  prove  fatal 
where  such  a  high  temperature  persisted  in  the  early 
stages,  I  determined  to  try  the  effect  of  the  external 
application  of  guaiacol  as  a  means  of  reducing  the 
temjierature.     I   accordingly  applied,  with  a  camel's- 


July  6,  1895] 


MEDICAL    RECORD. 


hair  brush,  at  9.52  a.m.,  2  c.c.  of  guaiacol  to  the  inner 
side  of  the  left  thigh,  from  the  groin  half  way  to  the 
knee,  applying  a  brushful  and  briskly  rubbing  it  in, 
and  then  another  brushful  until  the  2  c.c.  were  ab- 
sorbed :  this  required  just  eight  minutes.  The  skin 
on  which  the  guaiacol  was  applied  was  then  covered 
with  cotton  batting  and  paraffined  paper  and  a  light 
bandage.  The  patient  was  well  covered  and  it  was 
directed  that  the  cold-water  bag  on  the  side  should 
not  be  refilled  again.  In  fifteen  minutes  the  patient 
began  to  perspire,  the  perspiration  soon  became  very 
profuse.  At  II  a.m.  the  temperature  was  101.6°  F.  ; 
respiration,  28;  pulse,  112,  but  not  weakened.  The 
profuse  perspiration  continued.  At  12  M.  the  temper- 
ature was  100.6°  F.  Strychnine  sulphate,  gm.  0.00 1, 
was  then  given  hypodermically.  Shortly  after  this  the 
perspiration  was  checked.  I  believe  that  this  was  an 
effect  of  the  strychnine,  and  that  it  was  beneficial  in 
preventing  a  too  great  fall  of  temperature.  At  i  p.m. 
the  temperature  was  100°  F.  The  patient  was  no 
longer  drowsy,  said  his  head  felt  clearer,  and  seemed 
altogether  better.  There  was  no  indication  in  the 
pulse  or  voice  that  the  profuse  perspiration  or  rapid 
fall  of  the  temperature  had  weakened  the  patient.  It 
seemed,  however,  to  produce  a  marked  pallor  of  the 
face  that  was  apparent  for  several  days,  as  well  as  con- 
siderable emaciation.  At  3  p.m.  the  temperature  was 
102°  F.  ;  at  5  P.M.,  102.4°  F.  No  alarming  symptoms 
accompanied  this  reaction,  and  at  7  p.m.  the  tempera- 
ture was  101.6°  F.,  and  at  midnight  99.4°  F. 

January  1st. — Patient  feels  well.  7  a..m.  ;  Tempera- 
ture, 99.4°  F.  10  A.M.  :  Vesicular  sounds  are  return- 
ing in  diseased  lobe  ;  respiration,  22.  No  cough  or 
expectoration.  There  was  none  of  either  after  the 
guaiacol  was  used.  12  m.  :  Temperature,  99.2°  F.  ; 
7  P.M.  :  Temperature,  100°  F.  After  this  convales- 
cence was  uneventful,  and  the  temperature  remained 
normal  throughout. 

The  cold  application  to  the  chest  in  this  case  ap- 
peared to  have  no  bad  effect.  If  it  did  no  good  it 
made  the  patient  more  comfortable.  The  local  appli- 
cation of  guaiacol  produced  a  crisis  on  the  third  day 
such  as  we  might  expect  a  few  days  later  in  a  favorable 
case,  but  this  was  not  the  sort  of  case  that  I  should 
have  expected  to  terminate  in  that  way.  A  steady  rise 
in  temperature  and  death  during  the  night  of  the  31st, 
would  have  been  the  most  natural  prognosis  to  be  given 
from  the  history  of  the  case  up  to  9  a.m.  on  the  31st. 

The  use  of  the  strychnine,  gm.  0.00 1  every  six  hours, 
hypodermically,  I  consider  to  have  played  an  important 
part  in  this  case  and  to  have  prevented  any  undue  de- 
pressing effect  or  subnormal  temperature  from  the 
guaiacol.  The  whiskey,  15  c.c.  every  two  hours  day 
and  night,  may  have  contributed  to  the  same  result. 

The  man  made  a  favorable  recovery  under  tonics 
and  a  liberal  diet,  and  was  returned  to  duty  with,  to 
all  appearances,  a  perfectly  sound  pair  of  lungs  on 
February  3,  1895. 


A  CASE  OF  OPIUM  AND  CHLORAL  POISON- 
ING. 

By  frank  EDMONDS  COUDERT.    M.D., 

WALLINGFORD,   CONN. 

The  following  case  may  be  of  interest  to  the  profes- 
sion on  account  of  the  dual  combination — chloral  and 
opium. 

On  March   18,  1895,  R.  R consulted  me  at  my 

office  for  some  nervous  trouble  complicated  with  in- 
somnia, for  which  I  prescribed  chloral  in  ten-grain 
doses,  to  be  repeated  in  two  hours  if  necessary.  A  few 
days  later  he  returned  complaining  bitterly  about  his 
insomnia.  This  time  I  gave  him  a  four-ounce  mixture 
containing  two  grains  morphia  acetate  and  two  and  a 
half  drachms  of  chloral  hydrate,  two  teaspoonfuls  at  a 


dose,  representing  one-eighth  grain  of  morphia  and  ten 
grains  of  chloral. 

The  following  information  was  obtained  from  Mrs. 
R :  During  the  forenoon  R was  in  an  unusu- 
ally happy  state,  and  his  wife,  thinking  it  safe,  left  him 
shortly  after  the  mid-day  meal  to  take  a  much-needed 
walk.  Three  hours  later  she  returned  to  find  her  hus- 
band lying  on  the  floor  in  a  state  of  profound  coma. 
She  hurriedly  summoned  assistance,  and  a  neighboring 
physician  was  called  in,  who  administered  potassium 
permanganate  in  full  doses,  some  eight  or  ten  grains 
being  given  with  one-fortieth  grain  strychnia,  hj'poder- 
matically.  I  saw  the  patient  shortly  after  and  he  was 
reacting  well,  complaining  of  being  somewhat  chilly, 
due,  no  doubt,  to  the  chloral.  He  now  confessed  to 
having  taken  the  whole  contents  of  the  chloral  mixture. 
The  following  day  my  patient  had  quite  recovered 
from  the  toxic  dose.  The  question  that  now  arises  in 
my  mind  is  whether  the  permanganate  has  antidotal  ef- 
fect upon  the  chloral  as  well  as  the  morphine  ?  AVhen 
first  seen  he  was  breathing  about  five  times  to  the  min- 
ute and  was  extremely  cold.  Soon  after  the  perman- 
ganate was  given  reaction  commenced,  and  inside  of 
three  hours  all  symptoms  of  chloral  and  opium  poison- 
ing had  vanished. 


R.\TIOXAL  TREATMENT    OF    ERYSIPELAS. 
By  carl  ENGEL,  M.D., 


The  treatment  of  erysipelas  has  been  undoubtedly  dis- 
appointing to  the  majority  of  medical  practitioners. 
The  different  methods  described  by  different  authors 
have  been  faithfully  tried  in  their  turn  without  producing 
the  desired  end.  Nitrate  of  silver,  iodine,  and  the  drug 
treatment  with  oxide  of  zinc  or  starch-powder,  covered 
with  cotton,  served  only  to  increase  the  patient's  suf- 
ferings. Many  a  physician  has  believed  that  he  has 
found  a  specific,  when  in  his  very  next  case  the  same 
remedy  will  fail  utterly. 

In  the  last  few  years  I  have  treated  quite  a  number 
of  erysipelas  cases,  and  believed  at  one  time  I  had  in 
corrosive  sublimate  an  unfailing  remedy,  but  it  will  not 
do  in  every  case. 

On  Wednesday,  March  13,  1895,  I  was  called  to  see 

Mr.  John  H ,  barber  by  occupation,  and  intemperate 

in  habits.  Being  a  bachelor,  food  was  of  minor  impor- 
tance to  him,  his  mainstay  being  whiskey.  I  ordered 
his  face  painted  with  a  solution  of  four  and  a  half 
grains  of  corrosive  sublimate  in  an  ounce  of  glycerine, 
and  had  this  covered  by  cold,  wet,  i  to  1,000  corrosive 
sublimate  gauze.  In  addition  I  applied  a  rubber 
bandage  around  the  head  just  above  his  eyes,  waited  a 
few  minutes,  and,  after  removing  the  tourniquet,  pasted 
adhesive  plaster,  one-quarter  of  an  inch  wide,  in  its 
place.  I  have  yet  to  see  the  case  where  the  inflamma- 
tion will  overrun  this  line.  The  same  procedure  I  em- 
ployed at  the  temples.  I  gave  no  iron,  in  order  to 
test  whether  the  tincture  of  iron  is  "  the  remedy"  in 
erysipelas  or  not. 

Vesicles  of  double-pinhead  size,  containing  yellow- 
ish serum,  appeared  on  the  face  April  14th.  There  was 
the  genuine  pig-eye  appearance,  but  the  eyelids  were 
not  closed  yet.  Two  sulphonal  tablets  of  five  grains 
each  left  for  the  night.  The  wet-pack  was  kept  on  con- 
tinually. The  patient's  condition  remained  about  the 
same  up  to  the  16th,  when  the  cheeks  looked  dusky, 
and  the  nose  more  natural.  On  March  17  th  I  changed 
to  carbolic-acid  solution,  i  to  20,  and  plugged  his  ears 
with  cotton  soaked  in  carbolic  oil,  i  to  40.  On  March 
19th  he  was  much  improved;  swelling  of  face  down, 
ears  better.  Painted  face  with  i  to  40  carbolized  oil. 
On  March  23d  patient  was  bright.  Several  abscesses 
developed,  which  I  lanced,  and  introduced  iodoform 
gauze  strips. 


24 


MEDICAL    RECORD. 


[July  6,  1895 


Sulphonal  and  chloralamid  were  employed  for  the 
night,  beside  the  following  : 

I}.   Acetaiiilide gr.  xx. 

Quinine gr.  iv. 

M.   ft.  pulv.  Chart,  iv.     Sig.  :   One  powder  ever)-  three  hours. 

Thirty  grains  of  chloralamid  in  four  capsules  were 
given  at  one  time,  March  19th,  p.m.  This  dose  kept  the 
patient  drowsy  for  several  days,  and  though  rest  was 
desirable,  its  action  was  so  prolonged  that  I  would  not 
repeat  this  dose  in  another  case.  The  patient  had  the 
very  worst  of  nursing  during  the  first  days,  until  his  sis- 
ter arrived  from  a  distance.  Now,  as  far  as  iron  is 
concerned,  I  think  we  can  safely  dispense  with  it.  The 
cold  wet  compresses  were  very  grateful  to  the  patient. 


HYDRAMNIOS   AND    SPINA   BIFIDA. 
By  a.    N.    with  am,    M.D., 

SOUTH    PARIS,    MK. 

I  WAS  called  October  3,  1894,  to  attend  Mrs.  M- in 

her  fifth  labor.  I  found  an  enormous  abdomen — the 
largest  that  I  had  ever  seen  in  a  pregnant  woman  of 
her  size.  All  the  wise  old  ladies  said,  "  Twins,"  as  she 
had  given  birth  to  twins  eight  years  before.  Abdom- 
inal palpation  failed  to  show  part  of  the  child.  Vaginal 
examination  showed  a  large  bag  of  water  protruding 
from  a  well-dilated  cervix,  but  no  part  of  the  child  was 
presenting.  Pains  were  regular  and  strong,  but  labor 
did  not  advance.  I  became  satisfied  that  it  was  a  case 
of  hydramnios,  and  told  the  lady  her  condition.  I 
then  ruptured  the  membranes,  and  the  water  gushed 
out  like  a  brook,  and  ran  off  the  rubber  sheet  over  the 
edge  of  the  bed  into  a  vessel,  and  continued  till  I  had 
caught  nearly  five  vessels  full.  This,  with  what  had 
run  on  the  floor  and  had  soaked  into  her  clothes  and 
the  sheets,  was  certainly  five  gallons,  or  nearly  forty 
pounds  weight  of  fluid.  I  then  found  the  feet  pre- 
senting, gave  ether,  and  delivered  the  woman  readily. 

The  child  was  stillborn.  It  had  no  occipital  bone, 
and  the  brain  and  spinal  cord  were  exposed  down  to 
the  last  dorsal  vertebra.  The  posterior  convolutions 
of  the  brain  and  the  fourth  ventricle  were  plainly  dis- 
tinguished. The  lower  vertebra;  were  normal.  The 
sac  that  had  held  the  spinal  fluid  was  ruptured  and 
there  was  no  tumor.  The  head  was  greatly  extended, 
which  made  some  defonnity  in  this  respect,  but  other- 
wise it  was  a  perfect  child. 


A  LARGE   DOSE   OF    DIGITALIS. 
By  GEORGE  F.  KOEHLER,  M.D., 


PORTL.\ND,   ORE, 


Being  called  to  attend  a  case  of  confinement  at  Sunny 
Side  I  had  pre-arranged  a  small  table  near  the  bed  of 
the  patient,  upon  which  I  had  placed  bottles  containing 
fluid  extract  of  ergot,  persulphate  of  iron,  tincture  of 
digitalis,  and  several  other  drugs  which  might  be  re- 
quired in  an  emergency,  as  is  my  usual  custom,  .\fter 
the  birth  of  the  child  the  placenta  remained  adherent. 
Waiting  a  reasonable  length  of  time,  I  inserted  my  hand 
into  the  uterus.  While  detaching  the  placenta  a  great 
amount  of  hemorrhage  ensued.  Not  wishing  to  remove 
my  hand,  I  requested  the  husband  of  the  woman  (the 
only  assistance  at  my  command)  to  give  the  patient  a 
teaspoonful  of  the  dark  medicine  labelled  ergot,  and  he 
promptly  administered  the  remedy.  Still  retaining  hold 
of  the  uterus,  and  after  getting  it  well  cleaned  out,  I 
ordered  the  husband  to  repeat  the  dose,  which  he  did. 
The  uterus  now  well  contracted,  I  left  the  jiatient  to 
wash  my  hands,  when,  to  my  surprise  and  annoyance,  I 
discovered  that  my  digitalis  bottle  was  almost  empty, 
while  the  bottle  containing  the   ergot  remained  full. 


Sure  enough  my  worthy  assistant  had  given  the  patient 
two  heaping  teaspoonfuls  of  tincture  of  digitalis.  I 
now  gave  the  patient  a  teaspoonful  of  the  fluid  extract 
of  ergot,  and  awaited  with  some  anxiety  the  effect  of 
the  digitalis.  In  one  hour  the  temperature  rose  to  102° 
F.;  pulse,  strong  and  full,  106  pulsations  per  minute  ; 
the  face  flushed  ;  patient  complaining  of  feeling  warm  ; 
otherwise  comfortable. 

Two  hours  after  the  last  dose  of  the  digitalis,  patient 
resting  easy.  Temperature,  101°  F.;  pulse,  100.  After- 
pains  well  marked,  i  a.m.,  four  hours  later,  patient 
perspiring  freely.  Temperature,  99°  F.:  pulse,  108  and 
weaker.  Opium,  carbonate  of  ammonia,  and  whisky  ad- 
ministered. At  2  .\.M.,  temperature  normal  ;  pulse,  100 
and  stronger.  Patient  comfortable.  At  7  a.m.,  tem- 
perature normal ;  pulse,  88. 

From  this  time  on  patient  remained  comfortable  with 
the  exception  of  severe  after-pains,  which  lasted  almost 
continuously  for  forty-eight  hours,  interrupted  by  the 
administration  of  opium.  From  the  fact  that  about 
three  fluid  drachms  of  tincture  of  digitalis  was  taken 
and  retained  (no  emetic  being  used),  the  moderate 
amount  of  systemic  disturbance,  the  severity  of  the  after- 
pains,  and  the  apparent  antagonistic  action  of  the  eigot, 
tend  to  make  the  case  one  of  clinical  interest. 


FAILURE  OF  THYROID  EXTR.\CT  IN  A  CASE 
OF  MVXCEDEMA. 

By  H.  T.  miller,  M.D., 

SPRINGFIELD,   O. 

The  case  of  myxoedema  reported  by  Dr.  Abrahams  in 
the  Medical  Record  of  April  6,  1895,  has  prompted 
me  to  report  the  following  interesting  case.  It  dates 
back  to  June,  1S92.  Just  previous  to  this  date  he  had 
an  acute  attack  of  muscular  rheumatism,  and  it  was 
while  treating  him  for  this  that  my  attention  was  drawn 
to  an  insulated  dropsical  condition  in  both  supra-clavic- 
ular spaces  that  did  not  obey  the  physical  law  of  grav- 
ity, did  not  pit  on  pressure,  and  would  suddenly  appear 
and  disappear,  without  the  least  fluctuation  in  the  quan- 
tity of  urine  secreted. 

Physical  examination  revealed  only  a  slightly  hyper- 
trophied  heart  ;  pulse  full  and  strong,  and  averaging 
sixty-five  beats  to  the  minute  ;  urine  secreted  was 
high  colored,  of  low  specific  gravity,  looS  to  loio  : 
acid  in  reaction  ;  non-albuminous  ;  no  sugar  ;  small  in 
quantity  ;  twenty-four  to  thirty  ounces  in  twenty-four 
hours,  and  contained  a  diminished  quantity  of  urea. 
The  specific  gravity  at  present  has  changed  to  1030 
and  the  color  is  normal  ;  this  is  likely  to  change  sud- 
denly, but  the  quantity  remains  always  the  same. 

I  will  frankly  confess  that  I  was  at  a  loss  for  a  diag- 
nosis, until  the  club-shaped  nose,  thickened  lips  and 
porcelain-like  appearance  of  the  face  led  me  to  believe 
that  here  was  a  case  of  myxoedema.  The  subjoined 
history  of  the  case  will,  I  believe,  bear  me  out  in  my 
conclusions. 

Mr.  P ,  aged  seventy-one;  weight  formerly  170 

now  140  pounds  ;  height,  5  feet  3,'/  inches  ;  nativity. 
England,  but  has  lived  in  this  countr)-  for  the  past 
forty  years.  His  own  and  family  history  is  excellent. 
Occupation,  that  of  an  expert  machinist.  I  would 
here  interject  that  he  used  daily,  for  years,  cyanide  of 
potassium  in  his  work.  Whether  this  had  anything  to 
do  with  his  present  condition,  I  am  not  prepared  to 
say,  yet  the  following  interesting  fact,  that  no  article  of 
food,  such  as  butter,  meats,  bread,  milk,  etc.,  can  be 
left  in  his  room  for  a  length  of  time  without  assuming 
a  decidedly  greenish  tint,  should  be  noted  in  detailing 
this  history. 

Memory  is  defective,  he  will  forget  one  moment 
what  he  intended  doing  the  moment  before,  he  is  fret- 
ful, and  at  times  becomes  maniacal,  with  suicidal  ten- 
dencies.    The  latter  condition  is  preceded   by  a  de- 


July  6,  1895] 


MEDICAL    RECORD. 


termination  of  blood  to  the  head,  as  manifested  by  the 
livid  appearance  of  the  face  ;  the  appearance  of  pallor 
is  always  followed  by  a  subsidence  of  the  paroxysm. 
At  times  there  is  an  incoherency  of  speech,  and  when 
talking  on  a  particular  subject  he  is  apt  to  go  off  at  a 
tangent  on  some  other  subject.  The  nose  is  club- 
shaped  ;  the  lips  are  thickened  ;  the  eyes  are  expres- 
sionless ;  the  face  is  puffed  and  porcelain-like  in  ap- 
pearance, and  the  whole  countenance  marked  for  its 
stupid  appearance — cretinoid.  The  tongue  is  hyper- 
trophied  and  mapped  ;  breath  exceedingly  offensive  : 
the  hair  is  shaggy  and  is  falling  off. 

As  stated  before  there  are  insulated  collections  of 
fluid  over  clavicles  in  supra-clavicular  spaces,  that  do 
not  pit  on  pressure  and  feel  like  cushions  of  air. 
There  is  a  noticeable  depression  where  the  thyroid 
formerly  was.  Insulated  collections  of  fluid  have  been 
observed  on  the  chest.  The  hands  are  puffed  and  are 
closed  with  difficulty  ;  the  tips  of  the  fingers  are  like 
cushions  of  air  ;  there  is  dyspnosa  ;  the  body  is  nearly 
always  cold,  this  is  not  only  seemingly  but  actually  so, 
as  shown  by  the  temperature  vary-ing  from  g6j4°  to  98° 
F..  yet  a  peculiar  feature  noted  is  an  occasional  cold- 
ness of  the  knees  with  the  legs  and  rest  of  the  body 
warm.  An  herpetic  eruption  is  at  times  noticeably 
prominent.  The  bowels  are  generally  constipated,  and 
the  stools  hard  and  clay  colored  ;  there  is  a  slight 
oedema  of  the  feet,  which  pit  slightly  on  pressure.  The 
odor  of  the  room  which  he  occupies  resembles  that  of 
decaying  animal  matter. 

Little  good  was  accomplished  by  the  use  of  diapho- 
retics and  diuretics,  in  fact  nothing  seemed  to  avail. 
Thyroid  extract  never  caused  any  improvement  in  the 
case.  For  over  four  months  he  has  not  taken  any 
medicine  at  all,  and  I  cannot  see  that  he  is  in  any  way 
worse,  excepting,  perhaps,  that  he  has  grown  weaker, 
yet  he  is  able  to  be  out  of  bed  and  to  walk  from  room 
to  room.  I  have  little  confidence  that  a  change  for  the 
better  will  take  place,  as  his  age  is  against  him.  The 
failure  of  the  thyroid  extract  in  this  case  would  not  pre- 
clude my  using  it  in  another  should  it  present  itself. 


A    WELL-MARKED    CASE    OF    KAHLBAUM'S 
SO-CALLED    KATATOXLA.. 

By  L.  W.  DODSON,  M.D., 

ASSISTANT   PHYSICIAN"  TO  THE   BINGHAMTON   STATE  HOSPITAL. 

F.  G.  D ,  United  States,  male,  aged  twenty-seven, 

single,  laborer  ;  family  histor}'  good  ;  alleged  causes, 
insolation  and  masturbation.  Second  admission.  Was 
first  admitted  in  Januarj-,  1894,  remained  three  months, 
and  was  then  discharged  unimproved.  During  that 
time  was  depressed,  had  delusions  of  persecution,  but 
showed  little  if  any  agitation  when  discussing  his 
troubles.  After  discharge  gradually  grew  worse,  re- 
fused to  talk  to  parents,  laughed  inanely  when  accosted, 
broke  windows,  destroyed  furniture,  and  would  only 
eat  when  food  was  placed  in  his  room  at  night.  Re- 
mained home  five  months,  and  was  readmitted  to  the 
State  Hospital,  October,  1894.  Was  transferred  to  the 
infirmary  ward  in  November,  being  confined  in  bed 
with  the  following  sjTnptoms  :  Limbs  rigid  and  immo- 
bile, hands  clenched,  jaws  fixed,  rhythmical  movements 
of  oral,  brow,  and  cheek  muscles,  causing  continual  gri- 
macing and  frowning.  Muscles  of  extremities  in  a 
state  of  tonic  contraction,  with  marked  resistance  to 
passive  motion.  When  an  attempt  was  made  to  move 
the  arm  or  leg  on  one  side,  the  corresponding  limb  on 
the  opposite  side  moved  in  unison  with  it.  When  the 
limbs  were  released  they  immediately  sprang  back  to 
their  original  position,  not  remaining  wherever  placed, 
as  in  catalepsy.  Sensibility  to  tactile  and  painful  im- 
pressions diminished.  Titillation  of  soles  of  feet  elicited 
no  movement  ;  pin  pricks  on  arms  and  legs  gave  no  re- 
sponse, but  on  soles  of  feet  were  responded  to  by  a 


slight  grimace  after  an  interval  of  about  three  seconds. 
Tendon  reflexes  absent.  Laid  in  bed  with  thighs  ab- 
ducted and  widely  separated,  the  legs  flexed  on  thighs 
with  soles  of  feet  together,  the  head  extended,  the 
hands  tightly  gripping  the  scrotum.  At  times  would 
suddenly  straighten  the  legs,  arch  the  back,  and  sup- 
port the  entire  body  weight  on  occiput  and  heels,  re- 
maining in  the  position  of  opisthotonos  for  from  fifteen 
to  twenty  minutes.  L'sually  preserves  an  unbroken 
silence,  but  at  night  free^uently  shrieks,  and  at  times 
monotonously  repeats  the  same  profane  words  over  and 
over.  Refuses  food  when  the  attendants  are  near,  but 
has  bulimia,  and  when  not  watched  will  not  only  bolt 
his  own  meal,  but  suddenly  jump  from  bed  and  gorman- 
dize that  of  the  other  patients.  Passes  his  urine  and 
fjeces  in  bed.  All  the  symptoms  are  intensified  when 
he  is  under  obsenation.  Lender  treatment  his  condition 
ameliorated  somewhat,  but  he  has  relapsed,  and  now 
presents  almost  all  of  the  above-mentioned  features. 

This  case  appears  to  fill  all  the  requirements  for  the 
diagnosis  of  katatonia.  The  insidious  onset  with  mel- 
ancholy and  unsystematized  persecutory  delusions,  the 
marked  resistance  to  passive  motion  (symptom  of  nega- 
ti\Tsm),  the  sudden  spasmodic  contraction  of  the  ex- 
tensor muscles  with  opisthotonos,  the  athethoid  move- 
ments of  the  facial  muscle,  the  obstinate  silence 
alternating  with  the  monotonous  verbigeration  of  pro- 
fane words,  the  sudden  shriek,  due  probably  to  halluci- 
nation, the  bulimia,  the  state  of  pseudo- pathos  rather 
than  true  pathos,  the  melancholy  being  more  apparent 
than  real,  and  the  hysterical  element  in  that  all  S)-mp- 
toms  are  intensified  when  he  is  under  observation, 
present  in  toto,  a  symptom-complex  characteristic  of 
no  other  disease. 

There  is  another  case  in  the  hospital  at  present  sim- 
ulating katatonia,  yet  clearly  distinct.  It  is  that  of  a 
young  female,  aged  twenty-three,  with  stuporous  mel- 
ancholia and  catalepsy.  There  is  no  resistance  to  pas- 
sive motion,  no  sudden  spasm  of  the  muscles  :  they  re- 
main in  whatever  position  placed.  No  verbigeration. 
She  refuses  all  food,  and  the  mental  condition  is  one  of 
acutely  intense  melancholy. 

Certainly,  the  symptoms  in  these  two  cases'  can  be 
clearly  differentiated.  Etiologically  and  pathologi- 
cally, it  is  impossible  to  draw  a  sharp  line  between  the 
so-called  katatonia  and  stuporous  melancholia  with 
cataleptoid  sraptoms.  Clinically,  however,  the  differ- 
ence would  be  obvious  to  the  most  casual  observer,  and 
all  honor  is  due  Kahlbaum  and  Kiernan  for  having 
clearly  and  concisely  marked  out  the  characteristic 
features  of  katatonia. 


ESSENTIAL    DROPSY. 
By   MARCELL  HARTWIG.  M.D.. 

BfFFALO,  K.   V. 

Ix  my  first  communication  about  this  subject,  in  the 
Medical  Record  of  September  27,  1890,  I  had  al- 
ready ventured  the  hypothesis  of  bacterial  origin.     A 


26 


MEDICAL    RECORD. 


[July  6,  1895 


Perforating  ITlcer  of  Stomach. — Many  surgeons  are  dis- 
posed to  attach  more  importance  to  the  toilet  of  the 
peritoneum  than  to  the  actual  searching  out  and  sewing 
up  of  the  point  of  perforation. 

Symphyseotomy  is  indicated  in  flat  pelves  with  a  con- 
jugate of  from  67  to  88  mm.;  in  funnel-shaped  pelves 
with  a  transverse  diameter  of  pelvic  outlet  of  88  mm., 
or  less  ;  in  cases  of  dystocia  caused  by  tumors  of  the 
pelvic  cavity  ;  in  cases  of  abnormal  size  of  the  foetus, 
but  with  normal  pelvis.     It  is  easily  performed. — Wix- 

TERBERG. 

Ganglion. — -Inject  five  to  ten  drops  of  tincture  of 
iodine  and  bandage. — Duplay. 

Use  Black  Pins  in  surgical  dressings,  since  they  will 
not  rust  and  can  be  more  readily  seen. — Medical  .\ge. 

niae  Abscess. — The  indications  for  operation  are  : 
I.  Where  the  abscess  is  large  and  making  pressure 
upon  important  organs  ;  2.  Where  the  abscess  is  increas- 
ing rapidly  in  size  ;  3.  AVhere  there  is  danger  of  rupture 
of  the  abscess  into  the  peritoneal  cavity. — Young. 

Iliac  Abscess  may  not  be  of  spinal  origin,  but  arise 
from  hip  disease,  perforating  the  acetabulum,  innom- 
inate disease,  etc.     Sarcoma  also  occurs  in  this  region. 

WiLLARD. 

Appendicitis. — i.  The  first  inference  from  a  general 
consideration  of  ileo-ca;cal  troubles  is  that  all  collec- 
tions of  pus  should  be  evacuated  by  free  incision  fol- 
lowed by  gauze  drainage.  2.  Should  the  appendix  be 
involved  in  the  abscess  and  already  in  a  necrosed  state, 
it  is  fair  to  infer  that  the  canal  is  closed  so  that  there  is 
no  communication  with  the  ccecum,  and  hence  excision 
is  not  requisite.  3.  If,  on  the  contrary,  the  appendix  is 
found  to  be  enlarged  and  indurated  without  perforation, 
it  should  be  ligated  and  removed  at  once.  4.  In  sus- 
pected cases  of  appendicitis,  without  the  signs  of  sup- 
puration or  the  presence  of  a  local  swelling  or  indura- 
tion, an  exploratory  operation  by  a  transverse  incision 
above  Poupart's  ligament,  with  separation  of  the  mus- 
cular fibres,  should  be  resorted  to  without  delay.  5. 
With  a  clear  diagnosis  of  appendicitis,  a  longitudinal 
incision  on  the  outer  border  of  the  right  rectus  muscle, 
exj:ending  downward  over  the  caecum,  is  best  adapted 
to  reach  the  appendix.  6.  In  all  cases  of  recent  occur- 
rence, in  which  suppuration  has  not  appeared,  but  there 
exists  an  inflammatory  process  of  the  appendix,  it  should 
be  removed. — Gaston. 

Empyema. — The  indiscriminate  use  of  antiseptic  in- 
jections cannot  be  too  strongly  condemned,  since  many 
fatal  results  have  immediately  followed  its  practice. 
Immediate  washing  out  of  the  pleural  cavity  after 
operation,  for  ordinary  empyema,  is  always  an  inadvisa- 
ble and  hazardous  procedure,  and  is  only  permissible  at 
later  periods  when  practised  with  the  greatest  caution. 

Wi.i-rtr 


Fisttila  in  Ano.— After  the  sphincter  is  thoroughly 
stretched,  the  rectum  is  washed  out  carefully  with  bi- 
chloride solution  I  to  4,000  ;  the  fistula  is  split  open. 
Then  the  indurated  tissue  is  thoroughly  removed,  tak- 
ing care  to  cut  out  clean  both  ends  of  the  fistula,  not 
leaving  any  unhealthy  skin  or  mucous  membrane  at 
these  points.  Search  for  branch  channels,  treat  them 
in  the  same  way,  and  finally  close  the  wound  with  cat- 
gut, using  only  a  single  row  of  sutures. — Cook. 

Chancroid  beneath  the  Prepuce. — Wash  out  with 
boric  solution,  inject  beneath  the  foreskin  a  saturated 
solution  of  chloride  of  zinc,  after  about  a  minute  wash 
again  with  boric  acid  and  perform  immediate  circum- 
cision.— Cordier. 

Watch  the  Hespiration  in  chloroform  anaesthesia.  If 
this  keeps  good,  the  heart  is  not  apt  to  give  trouble. 


^octety  lleports. 

MEDICAL    SOCIETY    OF    THE    COUNTY    OF 
NEW   YORK. 

Stated  Meeting,  April  22,  iSgj. 

Egbert    H.    Grandin,    M.D.,    President,   in    the 
Chair. 

Refracting  Opticians. — In  accord  with  a  resolution  of- 
ferred  by  Dr.  Van  Fleet  at  the  last  meeting  of  the 
Society,  Mr.  Taylor,  counsel  for  the  Society,  sent  a 
written  opinion  to  the  effect  that  opticians,  like  other 
manufacturers  and  dealers  in  instruments,  were  per- 
mitted by  the  statute  regulating  the  practice  of  medi- 
cine to  fit  instruments,  such  as  trusses  and  glasses,  for 
those  in  need  of  them.  Mr.  Taylor  doubted,  therefore, 
whether  the  optician  who  advertised  to  fit  glasses  gj 
could  be  held  for  violation  of  the  law.  H 

Dr.  Van  Fleet  thought  there  could  be  no  doubt 
but  what  advertising  opticians  violated  the  spirit  of  the 
law,  whether  they  violated  the  letter  or  not.  At  least 
one  of  them  had  an  advertisement  in  the  County 
Directory,  which  he  thought  amounted  practically  to 
an  endorsement  of  his  work  by  the  County  Medical 
Society.  That  advertisement,  he  said,  ought  to  be 
expunged,  and  he  offered  a  resolution  to  that  effect. 

Drs.  S.  D.  Powell  and  Daniel  Lewis  doubted 
whether  the  advertisement  in  question  led  physicians 
and  other  persons  astray  to  the  extent  implied  in  Dr. 
Van  Fleet's  remarks.  .\t  any  rate,  since  it  seemed  to 
be  within  the  law,  and  a  written  agreement  had  been 
entered  into  with  the  advertiser,  to  cancel  it  without 
his  consent  would  render  the  Society  liable  to  an  ac- 
tion at  law. 

Dr.  Van  Fleet  still  strenuously  opposed  such  mis- 
leading advertisements,  but  withdrew  his  original  mo- 
tion and  moved  that  the  comitia  minora  be  instructed 
to  consider  the  best  method  of  having  this  particular 
advertisement  taken  from  the  Directory.     Carried. 

The  Status  of  the  Physician  when  Called  to  Cases  of 
Abortion. — The  following  are  extracts  from  a  com- 
munication from  the  counsel  of  the  Society,  Mr.  Rob- 
ert C.  Taylor  : 

The  Medical  Society  of  the  County  of  New  York  has 
requested  me,  as  their  counsel,  to  advise  them  what  is 
the  status  of  a  physician  who  has  been  called  in  to  at- 
tend a  case  where  a  miscarriage  or  abortion  has  been 
brought  about,  in  order  that  the  rights  of  a  professional 
man  in  such  a  delicate  predicament  may  be  more  dis- 
tinctly understood  and  he  may  be  able  to  render  the 
offices  of  humanity  freely,  without  fear  of  himself  being 
suspected  as  accessory  to  a  crime. 

It  may  be  said,  by  way  of  preface,  that  there  is  no 
definite  or  positive  rule  by  which  a  physician  may  be 
guided   in  such   a  case  ;  and  the  question,  therefore. 


July  6,  1895] 


MEDICAL   RECORD. 


27 


becomes  one  rather  of  general  good  sense  and  pru- 
dence. It  is  assumed  that  the  physician  is  brought 
face  to  face  with  a  state  of  facts  in  which  he  has  reason 
to  fear  that  a  criminal  operation  has  been  performed, 
and  yet  cannot  positively  so  conclude. 

At  common  law  there  was  a  certain  crime  kno^ii  as 
misprision,  but  in  New  York  State  the  common  law  has 
been  superseded  by  the  penal  code,  and  misprision  [fail- 
ure to  report  a  suspected  crime]  as  such  is  not  a  crime 
here. 

There  are  many  laws  requiring  reports  to  boards  of 
health  of  contagious  diseases,  deaths,  etc.  As  to  the 
duty  of  reporting  matters  to  the  coroner,  we  find  no 
statute  of  general  application  throughout  the  State,  but 
note  the  following  sections  of  the  consolidation  act  af- 
fecting New  York  City.  Section  1773  [on  the  cases  of 
death  which  shall  be  reported  to  the  coroner].  Section 
1775.  It  shall  be  the  duty  of  any  citizen  who  may  be- 
come aware  of  the  death  of  a  person  who  shall  have 
died  in  the  manner  stated,  to  report  such  death  forth- 
with to  one  of  the  coroners,  or  to  any  police  officer, 
and  such  officer  shall,  without  delay,  notify  the  coroner 
of  such  death,  and  any  person  who  shall  wilfully  neg- 
lect or  refuse  to  report  such  death  to  the  coroner  shall, 
upon  conviction,  be  adjudged  guilty  of  a  misdemeanor, 
and  shall  be  punished  by  imprisonment  in  the  county 
prison  not  exceeding  one  year,  or  by  a  fine  not  exceed- 
ing five  hundred  dollars,  or  by  both  such  fine  and  im- 
prisonment. 

It  would  thus  seem  that  by  the  verj-  wording  of  the 
statute  there  could  be  no  crime  in  the  mere  failure  to 
report  any  suspicious  case  which  did  not  result  in  death. 

It  therefore  follows  that  the  physician's  duty  to  report 
a  case  of  illness  which  he  suspects  to  involve  criminal 
malpractice,  is  not  a  duty  imposed  upon  him  by  any 
statute  :  and  that  for  his  failure  so  to  report,  he  is  not 
liable  to  any  specific  punishment. 

The  practical  aspect  of  the  case  is,  that  if  the  circum- 
stances are  such  as  to  lead  one  to  believe  that  malprac- 
tice has  been  committed,  the  physician  runs  the  risk  of 
suspicion  as  an  accessory.  His  duty  under  the  circum- 
stances, then,  relates  only  to  himself  ;  and  his  conduct 
should  be  such  as  to  conduce  to  his  own  protection. 
If  he  receives  a  call  to  attend  an  urgent  case,  he  can- 
not decline  it,  even  though  it  be  suspicious.  If  the  pa- 
tient is  in  the  house  of  a  midwife,  or  where  there  is  the 
slightest  reason  to  believe  that  a  criminal  act  has  been 
committed,  or  that  death  might  ensue,  he  should  call  in 
a  consultant  who  could  prove  the  integrity  and  wisdom 
of  the  treatment.  His  suspicions  should  be  communi- 
cated to  the  coroner,  thus  casting  upon  that  official  the 
duty  of  ferreting  out  the  crime.  In  all  that  he  does  he 
should  be  open  and  above  board,  so  that  suspicion,  if 
any  arise,  may  be  disarmed.  This  is,  after  all,  all  the 
advice  that  can  be  given. 

If  it  be  suggested  that  the  physician  is,  by  law,  in- 
competent to  divulge  information  professionally  ac- 
quired, a  sufficient  answer  is  found  in  the  statute  creat- 
ing the  incapacity  :  A  person,  duly  authorized  to 
practise  physic  or  surgery,  shall  not  be  allowed  to  dis- 
close any  information  which  he  acquired  in  attending  a 
patient,  in  a  professional  capacity,  and  which  was  nec- 
essary to  enable  him  to  act  in  that  capacity. — Code 
Civ.  Proc,  Sect.  834. 

A  most  embarrassing  mass  of  adjudication  has  been 
the  result  of  the  effort  to  construe  this  enactment ;  and 
its  true  meaning  is  much  in  doubt.  His  clear  duty  to 
protect  himself  by  making  the  disclosure  would  not, 
therefore,  be  complicated  by  any  supposed  duty  of  si- 
lence existing  toward  the  patient.  As  far  as  the  risk 
of  being  held  liable  for  slanderous  or  libellous  state- 
ments is  concerned,  it  is  enough  to  say  that  a  physi- 
cian who,  in  good  faith,  had  reason  to  believe  that  the 
crime  of  procuring  an  abortion  had  been  committed, 
would  be  protected  from  any  action  for  damages,  if  he 
communicated  his  suspicions  to  the  proper  authorities, 
even  if  it  afterward  turned  out  that  the  person  as  to 


whom  he  had  given  the  information  was  not  guilty  of 
the  suspected  crime.  If  the  physician  idly  dissemi- 
nated his  suspicions,  and  they  turned  out  to  be  false,  he 
would  then  plainly  and  justly  be  liable  to  the  individ- 
ual whom  he  had  carelessly  slandered. 

Nevertheless,  if,  after  all  precautions,  a  physician 
should  be  arrested  upon  suspicion  of  being  accessory 
to  an  act  of  criminal  malpractice,  his  remedy,  if  he  is 
innocent,  is  to  prosecute  those  who  caused  his  arrest. 
As  against  the  newspapers,  if  he  was  in  fact  arrested 
and  they  published  annoying  accounts  of  the  matter, 
he  would  have  no  remedy  ;  but  this  is  an  unfortunate 
case  for  which  it  is  impossible  to  provide. 

Health  Board  gets  Thanks.— Dr.  S.  D.  Powell  said 
he  had  noticed  that  the  Board  of  Health  had  seen  fit 
to  instruct  their  inspectors  as  to  their  duties  relating 
to  medical  practitioners  and  their  patients.  As  this 
was  in  line  with  a  resolution  passed  during  his  term  of 
service  as  president  of  the  Society,  he  moved  that  a 
vote  of  thanks  be  extended  the  Board  of  Health  for 
the  fair  and  just  treatment  which  they  had  extended 
the  practitioners  of  the  city.     Carried. 

Apoplexy. — This  was  the  scientific  subject  for  dis- 
cussion during  the  evening.     Three  papers  were  read. 

Etiology  and  Pathology. — Dr.  Edward  D.  Fisher 
read  a  paper  on  this  division  of  the  subject.  Under 
cerebral  apoplexy  he  considered  cerebral  hemorrhage, 
embolism,  and  thrombosis.  The  term  apoplexy  signi- 
fied to  strike  down,  and  an  essential  symptom  was  loss 
of  consciousness,  and  associated  with  it  there  was  usu- 
ally paralysis  of  one-half  of  the  body,  due  to  impair- 
ment or  destruction  of  some  part  of  the  brain.  The 
commonest  cause  was  hemorrhage,  and  this  was  due  to 
disease  of  the  blood-vessels.  There  was  a  natural 
tendency  to  atheromatous  changes  in  the  vessels  in  ad- 
vanced life.  Alcohol  and  syphilis  were  also  predispos- 
ing causes  of  arterial  disease.  Associated  with  the  ar- 
terial sclerosis,  there  was  usually  sclerosis  of  the  kidneys 
and  concomitant  h)-pertrophy  of  the  left  ventricle  of 
the  heart.  Hemorrhage  in  early  life  was  likely  to  oc- 
cur in  persons  of  sedentary  habit,  who  ate  excessively, 
the  tendency  to  arterial  sclerosis  being  much  aug- 
mented if  alcohol  were  used  even  in  moderation. 
Chronic  lead-poisoning  would  produce  arterio-sclerosis 
and  interstitial  nephritis.  Heredity  might  be  a  predis- 
posing cause,  especially  in  showing  a  tendency  to  arte- 
rial degeneration  and  kidney  disease.  The  old  idea 
that  short-necked  persons  were  especially  liable  to  apo- 
plexy had  hardly  any  scientific  support,  except  so  far 
as  increased  adipose  tissue  was  an  indication  of  exces- 
sive eating. 

Dr.  Fisher  thought  syphilis  was  rarely  the  cause  of 
cerebral  hemorrhage,  although  it  was  a  common  cause 
of  thrombosis.  In  many  cases  alcohol  and  sj-philis 
were  combined  and  had  a  deleterious  influence  on  the 
kidneys.  Hemorrhage  might  occur  during  acute  infec- 
tious fevers,  also  in  scur\y  and  purpura.  Intra-uterine 
hemorrhage  into  the  brain  might  take  place  as  a  result 
of  operation  or  tedious  delivery,  but  later,  when  the 
cases  came  to  autopsy,  it  was  very  difficult  to  state 
what  was  the  original  cause  of  the  brain  sclerosis.  In 
cases  seen  by  him  it  probably  had  been  occlusion  of 
some  vessel.  The  cerebral  hemorrhage  might  be  in- 
duced immediately  by  some  strong  emotion,  as  public 
speaking,  bad  news,  or  taking  a  cold  bath,  which  drove 
the  blood  into  the  diseased  vessels. 

The  next  most  frequent  cause  of  apoplexy  was 
thrombosis  of  the  cerebral  vessels.  It  occurred  often- 
est  in  early  life — twenty-five  to  forty — and  was  usually 
due  to  syphilis,  but  might  be  due  to  alcohol,  etc.  Dr. 
Fisher  believed  that  thrombosis  occurred  oftener  in  old 
people  than  was  generally  supposed.  Sudden  and  com- 
plete recovery  from  attacks  of  apoplexy  in  the  aged 
suggested  incomplete  thrombosis.  There  might  be  lit- 
tle evidence  of  disease  at  autopsy.  There  was  probably 
interference  with  the  circulation,  especially  in  the  mid- 
dle cerebral.     He  believed,  also,  that  cedema  or  cere- 


MEDICAL   RECORD. 


[July  6.  1895 


bral  effusion  was  sometimes  a  cause,  notwithstanding 
Watson's  old  theory  of  serous  apoplexy  had  been  largely 
discarded.  The  local  serous  effusion  was  apt  to  disap- 
pear on  cutting  into  the  dura,  and  be  overlooked. 

The  next  most  frequent  cause  of  apoplexy  was  em- 
bolism, which  usually  was  due  to  a  clot  starting  from 
the  heart,  and  which  was  more  apt  to  proceed  to  the 
left  half  of  the  brain  than  to  the  right,  and  to  involve  the 
middle  cerebral  and  its  branches.  Brief  allusion  was 
also  made  to  meningeal  lesions  resulting  in  symptoms 
like  in  apoplexy  —  unconsciousness  and  hemiplegia. 
So-called  birth  palsy  was  often  due  to  meningeal  hemor- 
rhage. Pachymeningitis  and  an  alcoholic  history  were 
frequently  combined  in  the  paralysis  of  the  insane. 

The  pathological  changes  were  due,  first  of  all,  to 
disease  of  the  blood-vessels.  The  hemorrhage  \vas 
usually  from  the  smaller  vessels.  The  larger  vessels 
being  rigid,  from  changes  in  their  walls,  allowed  the 
blood  to  pass  with  unrestricted  force  into  the  smaller 
ones  whose  weakened  walls  gave  way.  The  blood-clot 
changed  in  appearance  with  time.  A  cyst  might  form, 
its  contents  might  become  absorbed  and  leave  scar-like 
tissue.  In  plugging  of  the  vessels  there  was  anaemia, 
later  softening.  According  to  the  vascularity  of  the 
parts  there  was  gray  or  white  softening.  The  changes 
seen  would  vary  according  to  the  remoteness  of  the  au- 
topsy from  the  time  of  the  stroke.  In  old  cases  there 
were  structural  changes  in  the  nervous  areas  and  cor- 
responding tracts  proceeding  to  the  cord.  As  early  as 
two  weeks  descending  degeneration  was  found  in  ani- 
mals, somewhat  later  in  man.  The  lateral  sclerosis  left 
by  such  degenerated  tracts  was  on  the  same  side  as  the 
hemiplegia  in  the  cord,  on  the  opposite  side  above  the 
crossing  of  the  tracts  in  the  medulla.  The  most  com- 
mon site  of  the  hemorrhage  or  occlusion  of  vessels  was 
in  the  internal  capsule. 

Symptomatology  and  Treatment. — Dr.  William  H. 
Dr.\per  said  that  since  the  term  apoplexy  was  gener- 
ally restricted  to  cases  of  intra-cranial  hemorrhage,  he 
would  ask  attention  to  the  symptomatology  of  that 
condition.  Although  he  knew  perfectly  well  the  diffi- 
culty of  differentiating  the  unconsciousness  or  the  apo- 
plectic fit  the  result  of  hemorrhage  from  that  which 
was  the  result  of  embolism  or  thrombosis,  yet  he 
thought  the  differential  diagnosis  could  usually  be 
made.  In  describing  the  symptoms  of  apoplexy  he 
spoke  of  those  which  were  primary  and  those  which 
were  secondary.  The  primary  symptoms  were  those 
belonging  to  the  attack,  the  Secondary  those  associated 
with  the  lesion.  The  primary  were  divided  into  those 
preceding  and  those  accompanying  the  attack.  The 
symptoms  which  preceded  it  consisted  of  disturbed 
sensation,  as  pain  in  the  head,  nausea,  parssthesiie  of 
the  extremities,  which  could  hardly  be  regarded  as 
premonitory  of  the  attack,  as  they  were  often  absent, 
and  were  often  present  in  derangements  of  the  cere- 
bral circulation  and  disease  of  the  peripheral  nerves. 
Severe  pain  in  the  head  had  preceded  the  attack  in  a 
few  of  his  cases,  but  usually  this  symptom  pointed  to 
intra-cranial  syphilis  unless  present  only  a  few  hours 
before  the  hemorrhage. 

The  symptoms  of  the  onset  varied.  There  might 
be  sudden  agonizing  pain  in  the  head  while  the  victim 
was  at  his  work  or  in  the  enjoyment  of  perfect  health. 
He  might  cry  out,  and  exclaim  that  he  was  giddy  and 
could  not  see,  or  that  he  had  no  feeling  in  the  limbs, 
and  within  a  few  minutes  become  unconscious,  with  or 
without  convulsions.  Instead  of  this  sudden  attack, 
the  patient  might  be  taken  with  a  sense  of  general  ex- 
haustion, perhaps  nausea  and  vomiting,  and  then  in- 
ability to  use  one  leg  or  arm.  Indeed,  the  attack 
might  be  of  varying  degrees  of  suddenness,  depending 
upon  the  location  and  extent  of  the  hemorrhage.  If 
the  patient  were  attacked  in  his  sleep,  he  would  awake 
to  find  himself  paralyzed  on  one  side.  Whether  in 
such  cases  the  attack  had  been  preceded  by  convul- 
sion or  coma  was  usually  impossible  to  determine. 


When  called  to  cases  of  apoplexy  we  obsers'e  con- 
siderable variation  in  the  degree  of  unconsciousness. 
It  might  be  complete,  with  absolute  loss  of  pain  sense 
and  relaxation  of  the  muscles,  even  of  the  sphincters. 
There  might  be  an  effort  to  answer  simple  questions. 
The  head  might  be  turned  away  from  the  paralyzed 
side,  the  pupils  might  be  equal  or  unequal,  the  reflexes 
more  or  less  completely  abolished,  the  surface  might 
be  bathed  in  perspiration,  the  lips  cyanotic,  the  tem- 
perature might  be  below  normal  one,  two  or  three 
degrees,  but  it  might  rise  in  twenty-four  hours,  and 
register  in  fatal  cases  toward  the  end  106°  F.  or  more. 
In  favorable  cases  it  usually  returned  to  normal  in 
from  one  to  three  days.  The  pulse  might  be  increased 
or  diminished,  and  vary  in  force  and  rhythm.  Dr. 
Draper  gave  a  graphic  picture  of  the  respiratory  diffi- 
culty in  these  cases,  which  might  be  due  partly  to  the 
influence  of  the  stroke  on  the  respiratory  centre,  partly 
to  mechanical  obstruction.  The  unconsciousness  might 
last  forty-eight  hours  and  be  recovered  from  slowly,  or 
it  might  disappear  in  a  much  shorter  period.  In  his 
experience  the  longer  the  unconsciousness  the  more 
serious  the  prognosis. 

In  distinguishing  cerebral  hemorrhage  from  embol- 
ism and  thrombosis,  the  former  was  characterized 
more  by  suddenness.  The  previous  history,  the  con- 
dition of  the  heart,  and  the  age  of  the  patient  were  fur- 
ther aids  in  differentiation.  The  secondary  symptoms 
of  apoplexy  were  omitted. 

Treatment.  —  Regarding  treatment.  Dr.  Draper 
thought  there  was  probably  no  other  condition  in 
which  the  doctor  felt  himself  so  helpless  as  in  cerebral 
hemorrhage.  Something  had  to  be  done  quickly,  and 
Dr.  Draper  felt  disposed  to  try  bleeding.  To  relieve 
the  breathing  and  prevent  stertor,  turn  the  patient  on 
the  side,  or  pull  the  jaw  forward  and  thus  prevent  the 
tongue  from  falling  back  into  the  throat.  The  ice-bag, 
recumbent  posture,  purge,  mustard  foot-bath,  all  had 
reference  to  the  circulation,  being  intended  to  drive 
the  blood  from  the  head. 

Points  in  Differential  Diagnosis.  — Dr.  Charles  L. 
Dana  read  the  last  paper.  He  used  the  term  apo- 
plexy in  the  sense  described  by  Dr.  Fisher,  including 
cerebral  hemorrhage,  embolism,  and  thrombosis.  A 
person  whom  we  found  in  a  state  of  coma  suggesting 
apoplexy  might  be  suffering  from  one  of  a  dozen  or 
more  conditions.  The  more  probable  ones  were  hem- 
orrhage, thrombosis,  embolism,  hysteria,  syncope,  al- 
coholism, concussion  of  the  brain  with  shock,  poisons 
of  various  kinds,  urjemia,  sudden  bursting  of  an  ab- 
scess, epileptic  attack.  He  would  not  undertake  to 
point  out  all  the  differential  points  relating  to  these 
conditions.  The  more  common  of  these  states  which 
we  were  called  upon  to  dift'erentiate  from  apoplexy 
were  syncope,  alcoholism,  concussion  and  shock,  epi- 
lepsy, and  opium  poisoning.  Most  of  these  could  be 
readily  excluded  after  the  physician  had  learned  the 
history  and  mode  of  onset  of  the  attack,  the  condition 
of  the  pupils,  urine,  and  heart. 

In  syncope  there  was  loss  of  consciousness  but  no 
paralysis.  In  the  condition  which  gave  ambulance 
surgeons  so  much  trouble,  alcoholism  with  blow  on  the 
head,  against  apoplexy  there  was  alcoholic  breath, 
usually  absence  of  hemiplegia  and  facial  paralysis,  no 
stertor  to  the  breathing,  the  patient  could  almost  in- 
variably be  aroused  and  muttered  some  incoherent 
words.  In  hysterical  ajioplexy  the  patient  could  be 
slightly  aroused,  there  was  no  stertorous  breathing,  no 
facial  paralysis,  only  hemiplegia  affecting  arm  and  leg  ; 
the  hemianesthesia  often  responded  to  pricking  with 
the  pin,  there  was  no  rigidity  of  the  affected  side,  no 
exaggeration  of  reflexes,  the  pupils  were  equal. 

In  difterentiating  between  cerebral  hemorrhage, 
thrombosis,  and  embolism,  one  should  remember,  when 
in  the  presence  of  a  case  of  apoplexy  that,  so  far  as 
chance  was  concerned,  it  was  two  to  one  in  favor  of 
hemorrhage,  and  if  the  patient  were  in  the  prime  of 


July  6,  1895] 


MEDICAL   RECORD. 


29 


life,  between  forty  and  sixty,  it  was  six  to  one  in  favor 
of  hemorrhage.  Suddenness  of  onset,  profoundness  of 
coma  and  of  hemiplegia  favored  hemorrhage,  next  em- 
bolism. The  extremes  of  adult  life  pointed  to  throm- 
bosis. \\here  the  attack  came  on  gradually,  with 
symptoms  of  headache,  vertigo,  and  there  had  been 
slight  hemiplegia  a  few  days  before  which  had  disap- 
peared, the  probability  was  strongly  in  favor  of  throm- 
bosis. 

Stout  people,  or  those  with  the  so-called  apoplectic 
temperament,  were  rarely  subject  to  thrombosis.  If 
the  attack  were  sudden  and  cardiac  disease  existed, 
paralysis  following  loss  of  consciousness,  there  was 
probably  embolism.  In  thrombosis  there  was  often 
considerable  paralysis  before  loss  of  consciousness. 
Anaesthesia  and  moderate  hemiplegia  pointed  to  throm- 
bosis. 

Regarding  the  temperature,  which  should  be  taken 
in  both  axillK,  in  thrombosis  and  embolism  there  was 
hardly  ever  any  disturbance  of  the  temperature  the 
first  days,  it  being  even  on  the  two  sides  of  the  body, 
whereas  in  hemorrhage  he  had  found  the  temperature 
a  degree  or  a  degree  and  a  half  higher  on  the  hemiple- 
gic  side.  In  acute  softening  from  embolism  and  throm- 
bosis he  had  found  the  temperature  rise  about  one 
degree  perhaps  one  or  two  days  after  the  attack,  while 
in  hemorrhage  it  rose  to  two  or  three  degrees  by  this 
time,  and  began  to  fall  the  third  day  if  the  case  got 
better,  but  continued  to  rise  if  it  went  on  to  get  worse. 
The  temperature,  therefore,  was  of  value  in  diagnosis 
and  in  prognosis.  It  had  not  received  the  attention 
which  it  deserved. 

Syphilis  and  Apoplexy. — Dr.  Joseph  Collins  laid 
stress  on  the  sinister  effects  of  syphilis  in  leading  up  to 
arterial  degeneration  and  apoplexy,  whether  the  apo- 
plexy were  due  to  thrombosis  or  to  embolism.  It  was 
of  extreme  importance  because  of  its  frequency  and 
the  valuable  indication  which  it  furnished  in  treatment. 

Dr.  Willi.^m  H.  McEnroe,  speaking  of  the  differ- 
ential diagnosis  between  hemorrhage  into  the  pons  and 
opium  poisoning,  said  that  in  the  former  the  coma  was 
more  profound,  in  the  latter  the  patient  could  be 
roused  to  an  extent  and  would  answer  intelligently,  as 
far  as  he  answered  at  all.  The  pulse  was  full  and 
healthy  in  the  early  stage  of  opium  poisoning,  while  in 
hemorrhage  it  was  wiry,  sometimes  slow,  sometimes 
rapid,  but  never  full,  strong,  and  regular.  In  opium 
poisoning  the  whole  body  was  bathed  in  perspiration, 
and  the  respirations  were  less  frequent  than  in  hemor- 
rhage. 

Dr.  Van  Santvoord  spoke  of  drugs.  They  were 
used  to  check  continuous  hemorrhage.  He  had  given 
aconite  with  the  intention  of  weakening  the  heart- 
action  and  reducing  ihe  blood-pressure  in  the  vessels. 
He  thought  nitrate  of  sodium  being  slower  in  its  action 
than  nitrite  of  amyl,  would  be  safer.  Atropia  com- 
mended itself  to  him  as  the  best  remedy. 

Physicians  and  the  Presidency  of  the  Board  of 
Health. — Dr.  Warner  read  some  resolutions  sent  by 
Dr.  H.  D.  Chapin,  endorsing  the  bill  before  the  Legis- 
lature giving  the  Mayor  power  to  appoint  either  a  lay- 
man or  a  physician  president  of  the  Board  of  Health. 
The  present  law  made  it  obligatory  upon  him  to  appoint 
only  a  layman.     The  resolutions  were  adopted. 


Similarity  of  Features  in  Trades.— Dr.  Louis  Robin- 
son has  shown  to  the  world  the  interesting  fact  that 
new  born  babies  can  hang  in  mid-air  from  a  stick.  He 
now  assures  us  that  people  who  follow  the  same  trade 
get  to  look  alike.  He  does  not  say  whether  this  applies 
to  doctors. 

Berlin  Physicians  are  supplied  with  diphtheria  anti- 
toxin tree  of  cost,  on  condition  that  they  return  accu- 
rate reports  of  the  cases  in  which  it  has  been  used. 


NEW    YORK    COUNTY    MEDICAL     ASSOCIA- 
TION. 

Stateii  Meeting,  May  20,  iSgj. 

Samuel    B.  W.  McLeod,  M.D.,  President,  in    the 
Chair. 

Deformity  Caused  by  Adduction  and  Flexion  in  Hip- dis- 
ease, with  a  Mechanical  Demonstration  Thereof — Dr. 

A.  B.  JUDSi.iN  read  a  paper  with  this  title  (see  page  13). 

Dr.  Lewis  A.  Sayre  was  requested  to  open  the  dis- 
cussion. He  thought  the  demonstration  had  been  so 
clear  as  to  leave  nothing  to  discuss.  It  was  a  simple 
statement  of  facts  with  a  clear  demonstration.  He  was 
very  glad  to  have  heard  the  author  impress  the  great 
importance  of  educating  children  with  deformity  from 
hip-disease  to  walk.  If  one  would  get  them  off  of  the 
lame  limb  by  giving  them  a  crutch  and  then  teach  them 
how  to  walk  with  proper  rhythm,  he  would  accomplish  a 
great  deal.  Keep  concussion  away  from  the  joint  and 
the  motion  could  be  increased  a  great  deal.  Deform- 
ity resulted  largely  from  muscular  contraction,  and  this 
took  place  in  order  to  protect  the  joint  from  concus- 
sion. Have  the  child  walk  with  a  crutch  under  the 
arm  or  perineum,  make  gentle  traction,  then  instruct  it 
to  walk  properly,  and  a  large  amount  of  good  would  be 
accomplished. 

Tincture  of  Iodine  in  the  Treatment  of  Chronic 
Suppurative  Inflammations  of  the  Ear. — Dr.  F.  P. 
Hoover  read  the  paper.  He  had  tried  to  stop  the 
discharge  from  the  ear  in  chronic  suppuration  by 
such  agents  as  nitrate  of  silver,  bichloride  solution, 
boracic  acid,  iodoform,  but  with  indifferent  success, 
and  at  last  had  decided  to  test  tincture  of  iodine.  This 
was  applied  on  a  probe  wrapped  with  cotton.  If  the 
perforation  in  the  drum  membrane  was  small,  it  was 
enlarged.  The  applications  were  made  two  or  three 
times  a  week.  The  patient  complained  at  first  of  a 
tingling  sensation,  but  this  soon  passed  off.  When 
freely  applied  some  of  the  medicine  trickled  down  into 
the  Eustachian  tube  and  caused  a  taste  of  iodine. 
There  had  been  no  ill  effects. 

The  curative  results  had  been  striking,  as  shown  by 
the  recital  of  several  illustrative  cases.  Case  I. — Age  of 
patient  twenty  years,  duration  of  suppurative  discharge 
five  years  ;  no  permanent  results  under  various  remedies 
until  tincture  of  iodine  was  tried.  After  its  use  for 
three  weeks  the  discharge  ceased  and  had  not  returned. 
Case  II. — Discharge  for  fourteen  years,  failure  under  ni- 
trate of  silver,  etc.;  recovery  in  three  weeks  after  com- 
mencing tincture  of  iodine  applications.  In  Case  IV.  the 
man  was  thirty  years  old,  had  had  aural  discharge  for 
twenty  years  ;  was  cured  with  tincture  of  iodine  in 
eight  weeks  ;  saying  he  then  felt  like  another  man.  The 
treatment  was  best  carried  out  in  private  practice,  since 
it  required  regular  attendance. 

Dr.  N.  J.  Hepburn  said  he  had  used  tincture  of 
iodine  in  suppurative  discharges  from  the  ear  at  inter- 
vals for  ten  years,  and  had  found  it  valuable  in  some 
of  the  obstinate  cases  with,  as  one  might  say,  a  pyogenic 
lining  membrane.  A  young  woman  came  to  the  clinic 
about  1884,  with  a  history  of  suppurative  discharge 
which  had  not  ceased  entirely  at  any  time  during 
twenty  years.  Since  she  said  everything  else  had  been 
tried  and  failed,  he  resorted  to  tincture  of  iodine,  and 
the  suppuration  ceased  entirely  after  the  third  applica- 
tion. It  had  not  returned  when  he  saw  her  about  six 
months  later.  One  advantage  of  tincture  of  iodine 
was  the  absence  of  pain  attending  its  application.  The 
burning  sensation  ceased  as  soon  as  air  was  shut  off  by 
putting  cotton  into  the  ear. 

Dr.  S.  M.  Pavne  had  been  using  tincture  of  iodine 
since  the  summer  of  1892.  At  first  he  used  it  very 
cautiously,  but  later,  finding  no  injurious  results,  he 
saturated  the  cotton  with  it  and  then  obtained  much 
better  results  ;  all  the  patients  recovered.  By  its  free 
use  some  of  the  iodine  ran  down  the  Eustachian  tube 


30 


MEDICAL    RECORD. 


[July  6,  1895 


and  was  tasted,  and  it  was  only  after  such  free  use  that 
all  the  patients  were  cured  of  their  chronic  discharge. 
But  where  there  were  granulations  this  method  of 
treatment  had  to  be  supplemented  by  curettage  or  ap- 
plication of  trichloracetic  acid.  The  treatment  was 
also  followed  by  marked  improvement  in  hearing. 

Dr.  Quinlan  said  that  about  seventy-five  or  eighty 
per  cent,  of  all  cases  of  chronic  inflammation  of  the 
middle  ear,  whether  suppurative  or  catarrhal,  depended 
upon  rhino-pharyngeal  irritation,  and  it  seemed  to  him 
that  the  best  way  to  get  rid  of  the  ear  trouble  was  to 
remove  the  cause. 

Dr.  Hoover  replied  to  Dr.  Quinlan  that  in  one  of 
his  cases  there  were  enlarged  tonsils  and  hypertrophy 
of  the  turbinate  on  the  left  side.  These  were  cured, 
but  the  ear  was  still  running  at  the  end  of  five  or  six 
weeks,  and  ceased  to  do  so  only  after  the  use  of  tincture 
of  iodine. 

Multiple  Cerebro-spinal  Sclerosis. — Dr.  W.  C.  Gil- 
DAV  reported  a  case  in  which  he  had  made  the  diag- 
nosis of  multiple  cerebro-spinal  sclerosis  and  stated 
that  the  diagnosis  was  confirmed  by  autopsy,  sclerotic 
patches  varying  in  size  from  the  head  of  a  pin  to  a 
bean  being  found  on  the  cerebellum,  pons,  medulla, 
cord,  and  sciatic  nerve.  The  symptoms  had  come  on 
gradually,  beginning  about  1875,  and  resulting  when 
Dr.  Gilday  first  saw  the  patient  (1893),  three  months 
before  death,  in  complete  paralysis  of  the  entire  body 
excepting  the  neck.  The  muscles  were  flabby  but  not 
atrophied.  Passage  of  the  fseces  could  not  be  re- 
strained when  the  desire  came.  No  analgesia,  no  loss 
of  tem|)erature  sense,  perception  of  odor  diminished. 
Almost  complete  loss  of  vision.  Marked  nystagmus. 
The  mind  was  not  affected.  Prior  to  these  marked 
symptoms,  the  patient  felt  as  if  he  would  "  topple  " 
over  on  attempting  to  cross  the  room  ;  there  were  some 
pain  sensations,  paralysis  of  the  legs  occurred  some 
years  before  paralysis  of  the  hands.  There  had  been  a 
history  of  a  fall  some  time  before  the  commencement  of 
the  symptoms.     Death  came  suddenly. 

Dr.  Von  Doxhoff  thought  the  clinical  history  of 
the  case  was  not  that  of  disseminated  sclerosis.  It  im- 
pressed him  rather  as  one  of  spinal  irritation  from  se- 
vere shock,  which  finally  ended  in  changes,  perhaps  un- 
discovered, which  caused  paralysis  and  death. 


NEW   YORK   ACADEMY   OF   MEDICINE. 

Stated  Alecting,  May  16,  iSgj. 

Joseph  D.  Bryant,  M.D.,  President,  in  the  Chair. 

Donation  to  the  Library.— Dr.  George  Thomas  Jack- 
son announced  recent  donations  to  the  library,  in- 
cluding the  sum  of  $200,  given  by  Mrs.  Elizabeth  A. 
Galloway,  through  D.  Ellsworth  Eliot  ;  also  a  portrait 
of  Professor  Thiersch,  drawn  and  presented  by  Dr. 
Arpad  G.  Gerster.  A  vote  of  thanks  was  extended 
the  donors. 

A  Clinical  and  Bacteriological  Study  of  the  Gonococ- 
cus  as  Found  in  the  Male  Urethra  and  in  the  Vulvo-vag- 
inal  Tract  of  Children.— Dk.  Henry  Heiman  read  the 
paper,  which  was  illustrated  by  lantern  slides  and  cul- 
tures of  gonococci  on  various  media,  as  well  as  of  other 
diplococci  obtained  from  the  genito-urinary  tract.  (See 
page  769,  vol.  47,  Medical  Record.) 

Dr.  Sigmund  Lustgarten  said  he  appreciated  the 
great  task  performed  by  Dr.  Heinian,  and  the  fact  that 
it  offered  little  room  for  criticism  e.xceiit  it  were  founded 
on  work  of  like  positive  character,  yet  he  felt  like  mak- 
ing a  few  remarks  on  one  point,  namely,  the  diagnostic 
value  of  the  gonococcus  under  the  microscoi)e.  His 
own  researches  were  published  in  1887,  in  which  he 
stated  that  there  was  a  diplococcus  found  in  the  nor- 
mal male  urethra  closely  resembling  the  gonococcus, 
and  which  could  not  always  be  distinguished  from  this 


by  the  Gram  test.  He  had  since  given  attention  to  the 
same  point,  and  had  been  compelled  to  retain  the  same 
opinion.  Even  a  pupil  of  Neisser  had  admitted  the 
possibility  of  a  mistake  in  the  differential  diagnosis 
between  the  two  in  at  least  five  per  cent,  of  the  cases. 
Of  late  the  opinion  had  again  been  brought  forward 
that  the  secretions  from  the  male  urethra  might  be  con- 
tagious even  if  the  gonococcus  were  not  present.  He 
must  confess  that  personally  he  had  often  been  very 
much  embarrassed  to  decide  this  question,  and  he 
thought  we  must  admit  that  at  present  there  were  a 
number  of  cases  in  which  we  could  not  give  a  positive 
opinion  based  on  the  microscope.  Probably,  like  in 
diphtheria,  we  would  have  to  fall  back  on  cultures  for 
assistance,  and  chest  serum,  which  Dr.  Heiman  had  so 
highly  commended  ;  could  always  be  obtained  as  a 
culture  medium.  Microscopic  examination,  in  spite  of 
the  much-praised  method  of  Gram,  was  not  alone  re- 
liable. 

Dr.  Ira  Van  Gieson  was  glad  to  be  able  to  speak 
of  Dr.  Heiman's  work  in  terms  of  highest  commenda- 
tion. It  had  been  careful  and  painstaking,  and  little 
disposition  had  been  shown  to  draw  deductions  which 
were  not  substantiated  by  facts.  Few  could  realize  the 
amount  of  work  embodied  in  such  a  paper.  Yet  it  was 
of  enormous  importance  because  of  the  danger  of  one 
affected  with  gleet  and  contemplating  marriage  infect- 
ing the  wife  and  giving  rise  to  serious  uterine  and  tubal 
trouble.  He  thought  we  were  ready  to  go  back  to 
Xoeggerath's  original  dictum,  that  fully  eighty  per 
cent,  of  these  troubles  were  due  to  the  gonococcus. 

Referring  to  the  practical  bearing  of  the  work,  he 
might  say  that  in  antiseptic  therapeusis  the  discovery 
of  the  gonococcus  had  been  of  little  value.  The  best 
treatment  of  the  urethritis  had  been  found  empirically 
before  the  discovery  of  the  gonococcus,  and  the  med- 
dling with  antiseptics  later  had  probably  done  more 
harm  than  good.  But  the  value  of  the  discovery  of  the 
gonococcus  had  been  great  in  the  management  of  the 
later  stages  of  the  disease,  for  it  had  led  to  a  better 
knowledge  of  its  pathology  and  thereby  to  a  more 
rational  management. 

Dr.  Van  Gieson  would  say  deliberately  that  a  great 
deal  of  work  in  identifying  the  gonococcus  in  the  later 
stages  of  gonorrhoea  had  been  careless  and  unreliable, 
consisting  simply  in  observing  its  shape  and  size  on  the 
cover-glass.  If  we  would  make  the  diagnosis  purely 
on  morphological  ground  in  the  stage  of  gleet,  it  should 
always  be  supplemented  by  Gram's  method.  The 
pseudo-gonococcus  was  frequently  mistaken  for  the 
gonococcus.  As  to  its  persistence  for  months,  and 
even  years,  after  the  primary  urethritis,  he  thought  we 
were  not  yet  able  to  say,  and  the  only  way  to  settle  the 
(juestion  was  by  work  of  just  the  character  perfomied 
by  Dr.  Heiman. 

As  to  the  case  referred  to  in  the  paper  in  which  Dr. 
Van  Gieson  made  the  autopsy  thirteen  days  after  the 
acute  gonorrhceal  urethritis  from  inoculation,  he  would 
say  that  the  urethral  membrane  simply  looked  red,  per- 
haps redder  than  usual  in  the  anterior  portion,  but  in 
the  deep  or  jirostatic  portion  there  was  severe  damage. 
It  was  crowded  in  the  prostatic  portion  with  small 
round  cells  beneath  the  e[)ithelium.  The  epithelium. 
was  abraded  in  many  places,  there  were  extravasations 
of  red  blood-cells  beneath  the  epithelium,  and  many  of 
them  had  found  their  way  to  the  free  surface  of  the 
urethra. 

It  was  to  be  remarked  that  the  first  urethritis  was  al- 
together different,  both  clinically  and  pathologically, 
from  subsequent  attacks,  doing  much  less  damage  to 
the  urethra.  The  first  attack  was  something  which  one 
could  recover  from,  as  few  changes  were  present,  but 
after  several  attacks  there  were  extensive  changes,  lead- 
ing to  connective  tissue  and  contractions. 

He  could  confirm  the  statement  in  the  paper,  that  a 
discharge  from  the  urethra  might  show  no  gonococci  for 
days  and  weeks,  yet  after  irritation,  as  by  division  of  a 


July  6,  1895] 


MEDICAL    RECORD. 


real  or  imaginary  stricture,  their  presence  would  be  de- 
tected. Examination  on  three  successive  days  was  not 
sufficient.  In  conclusion,  he  impressed  the  necessity 
for  applying  Gram's  method,  and  of  deciding  the  ques- 
tions, if  it  were  possible,  how  long  the  gonococcus  was 
capable  of  persisting,  and  whether  there  was  such  a 
thing  as  so-called  latent  gonococcus. 

Dr.  Heiman,  in  some  concluding  remarks,  described 
how  he  applied  the  Gram  method. 


©orrjesponctjeuce, 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

MEDICAL  COUNCIL — PHARMACOPCEIA — IRISH  CONJOINT 
BOARD — IMMUNITy  AND  SNAKE-POISON — SOCIETIES' 
CLOSING  SESSION — THICKENED  MESENTERY  AS  A  TU- 
MOR  PYLEPHLEBITIS RENAL  GROWTH ROYAL  SO- 
CIETY. 

London,  June  14,  1895. 

Besides  the  subjects  I  have  already  noticed  the  Gen- 
eral Medical  Council  discussed  before  separating  the 
coming  Pharmacopoeia  and  the  alleged  defects  of  the 
Irish  Conjoint  Board.  As  to  the  Pharmacopoeia  the 
committee  thereupon  had  gathered  information  from 
medical  authorities,  the  Pharmaceutical  Society,  from 
India,  and  the  colonies.  Drs.  Brunton,  Eraser,  and 
Walter  Smith  had  been  requested  to  act  as  referees  as 
to  the  properties  of  certain  preparations,  and  help  had 
also  been  called  in  on  chemical  and  botanical  matters. 
Professor  Attfield's  ninth  report  was  received  and  or- 
dered to  be  printed,  and  some  conversation  took  place 
as  to  his  remuneration.  It  was  also  said  that  a  con- 
siderable sum  would  have  to  be  paid  to  the  Pharma- 
ceutical Society  for  its  assistance — a  statement  some- 
what surprising  to  those  who  remember  the  an.xiety 
once  displayed  by  that' Society  to  take  a  share  in  the 
work  and  the  off-hand  manner  in  which  its  kindly  offer 
was  rejected.  It  must  be  admitted  that  whatever  may 
be  the  e.xcellences  of  the  volume  it  is  likely  to  be  ex- 
cessively costly,  and  the  preparation  seems  to  be  con- 
ducted in  a  clumsy  manner.  The  College  of  Physi- 
cians used  to  give  us  a  convenient  Pharmacopoeia  in 
two  sizes  at  a  reasonable  price.  Now  the  Council  lav- 
ishes on  the  work  enormous  sums,  and  not  a  few  fail  to 
find  it  of  the  value  they  anticipated.  Committees  are 
no  doubt  useful,  but  when  they  have  to  engage  experts 
to  do  the  work  at  much  greater  cost  than  would  be  ex- 
pended in  other  cases  on  the  same  experts,  it  is  no 
wonder  people  are  asking  what  is  the  use  of  the  com- 
mittees ?  A  vote  of  ^3,000  was  taken  on  account  by 
the  Pharmacopoeia  Committee,  and  Dr.  Tirard  was 
engaged  to  act  as  secretary. 

With  regard  to  the  allegations  against  the  Irish  Con- 
joint Board  and  the  Dublin  Apothecaries'  Hall  there 
was  an  animated — not  to  say  ill-tempered — discussion. 
Sir  P.  Smyly  declared  that  the  Dublin  College  of  Phy- 
sicians had  boycotted  the  Hall,  and  defending  the  ex- 
pression said  there  were  three  kinds  of  boycotting — 
shooting  a  man  dead,  shooting  him  in  the  legs,  and 
preventing  him  from  obtaining  food.  All  three  meth- 
ods. Sir  Philip  declared,  had  been  employed  by  the 
College  of  Physicians  against  the  Conjoint  Board.  The 
jealousy  of  the  College  toward  the  Hall  has  no  doubt 
been  intense,  though  it  may  be  admitted  that  there 
have  been  shortcomings.  If  the  Hall  could  not  get 
members  of  the  Dublin  College  to  act  as  examiners  on 
account  of  this  jealousy,  what  was  to  hinder  members 
of  the  London  or  Edinburgh  College  being  appointed? 
There  are  plenty  of  men  who  would  be  ready  to  take  a 
trip  across  the  Irish  Channel  and  examine  the  candi- 
dates— men,  too,   in   whom   full  confidence  might  be 


placed  as  to  the  just  discharge  of  the  duty.  However, 
the  Conjoint  Board  will  cease  to  exist  very  soon,  its  term 
of  agreement  coming  to  an  end.  ^Vhat  the  Privy  Coun- 
cil is  to  say  to  an  expiring  Board  we  may  yet  see. 

The  subject  of  immunity  attracts  still  further  atten- 
tion. On  the  6th  inst.  Professor  Eraser  brought  before 
the  Edinburgh  Royal  Society  the  results  of  a  research 
he  had  carried  out  on  snake  poison.  From  his  investi- 
gations it  would  seem  not  unlikely  that  we  are  on  the 
eve  of  discovering  how  to  prevent,  and  possibly  cure, 
the  effects  of  a  venomous  snake-bite.  Dr.  Eraser  has 
succeeded  in  rendering  rabbits  immune  to  from  twenty 
to  fifty  times  a  lethal  dose  of  snake-poison.  His  pre- 
vious researches  on  strophanthus  gives  confidence  in 
his  care  and  exactitude,  and  great  hopes  are  entertained 
as  to  the  outcome  of  his  work. 

Our  societies  are  closing  their  doors  for  the  session. 
On  Tuesday  last  the  l\Iedico-Chirurgical  held  its  con- 
cluding meeting,  when  two  papers  were  read — one  on 
"  The  Development  of  Mammary  Functions  by  the  Skin 
of  Lying-in  Women,"  the  other  on  "  Intra-peritoneal 
Rupture  of  the  Bladder." 

At  the  concluding  meeting  for  the  session  of  the 
Clinical  Society,  Dr.  F.  Lucas  Benham  read  a  paper 
upon  a  "  Case  of  Thickened  and  Contracted  Mesentery 
simulating  Tumor  in  a  Case  of  Cirrhosis  of  the  Liver,"  in 
a  man,  aged  fifty-five,  with  a  history  of  former  excess  of 
alcohol  and  of  an  attack  of  jaundice  some  years  ago. 
He  had  a  large  amount  of  ascites  and  was  almost  in 
extremis  when  first  seen.  Paracentesis  was  performed 
to  give  relief,  and  it  did  so,  but  he  died  two  days  after. 
A  tumor  which  was  discovered  during  life  was  found 
at  the  autopsy  to  consist  of  the  enormously  shrunken 
mesentery,  shortened,  thickened,  and  loaded  with  fat, 
the  small  intestines  being  huddled  up  compactly  to- 
gether. The  omentum  was  thickened  and  condensed 
into  the  shape  of  a  sausage.  The  condition  was  evi- 
dently that  of  a  form  of  chronic  peritonitis. 

Mr.  Barker  and  Dr.  Hale  White  spoke  of  similar 
cases. 

Dr.  Sidney  Phillips  related  a  case  of  suppurative 
pylephlebitis  with  abscess  in  the  spleen  and  a  foreign 
body  in  the  mesenteric  vein,  in  a  man,  aged  fifty-two, 
who  had  had  rheumatic  fever  at  the  age  of  seventeen, 
had  suffered  from  asthma,  and  had  been  a  free  spirit- 
drinker.  The  cause  of  the  general  suppurative  pyle- 
phlebitis was  in  all  probability  two  bristles  found  at 
the  necropsy  in  the  inferior  mesenteric  vein  ;  they  had 
probably  been  swallowed  at  some  previous  date,  and 
must  have  passed,  probably  as  one  bristle,  through  the 
wall  of  the  intestine,  and  that  of  the  vein,  though  no 
trace  could  be  discovered  of  their  passage.  When  the 
spleen  became  purulent  it  was  so  much  softened  that  it 
gave  the  erroneous  impression  that  its  enlargement  had 
lessened. 

Dr.  Samuel  West  described  a  case  of  recovery  from 
tuberculous  meningitis  in  a  girl,  two  and  one-half  years 
of  age.  Two  children  of  the  same  family  were  taken 
ill  at  the  same  time  with  similar  symptoms.  One  died, 
and  the  autopsy  confirmed  the  diagnosis,  so  it  was  pre- 
sumed the  other  child  also  had  tubercular  meningitis, 
though  it  was  admitted  that  the  course  of  the  disease 
was  unusual  in  both  cases.  Scepticism  was  expressed 
by  one  or  two  speakers. 

Mr.  Battle  related  a  case  of  calculus  of  the  kidney 
associated  with  a  growth  in  the  renal  pelvis.  Nephrot- 
omy and,  five  months  later,  nephrectomy,  were  per- 
formed. At  the  first  operation  it  was  expected  that 
epithelioma  would  be  found,  but  there  was  only  a 
growth  of  the  non-malignant  kind,  and  so  it  was  re- 
moved by  scraping.  The  pathologist,  however,  re- 
ported squamous  epithelioma.  Subsequently  the  pa- 
tient returned  with  clinical  signs  of  innocent  growth, 
but  there  was  severe  hemorrhage  constantly,  and  the 
kidney  was  removed  (August,  1894).  He  is  now  in 
good  health.  From  examination  of  the  kidney  the 
pathologist  now  considers  the  case  simple  papilloma. 


MEDICAL   RECORD. 


[July  6,  1895 


The  night  before  last  the  Royal  Society  held  its 
soiree.  This  is  the  "  Ladies'  Night,"  and  the  exhibi- 
tion is  very  popular.  Many  of  the  exhibits  were  ex- 
ceedingly attractive,  but  perhaps  none  excited  more 
admiration  than  the  telephonic  communication  estab- 
lished for  the  occasion  with  Edinburgh,  Belfast,  and 
other  places.  A  song,  distinctly  heard,  from  the  North 
seemed  to  some  of  the  visitors  to  border  on  the  incred- 
ible or  the  supernatural. 


OUR    PARIS    LETTER. 

(From  our  Special  Correspondent) 

PATHOLOGY  OF  THE  TONSILS  AT  THE  ACADEMY  OF  MED- 
ICINE ;  TUBERCULOSIS  AND  FOREIGN  BODY  OF  ;  CAL- 
CULUS OF — SUPERNUMERARY  URETHRA  AND  BLAD- 
DER  INTERMITTENT     FEVER    OF    PARISIAN  ORICIN 

DISEASED  VEAL MONUMENT    TO  CHARCOT,  ETC. 

Paris,  June  8,  1805. 

The  attention  of  the  Academy  of  Medicine  seems  to  be 
just  now  called  to  the  pathology  of  the  tonsils.  Pro- 
fessor Dieulafoy  claimed  to  have  proven  that  the  tons-ils 
were  often  the  original  seat  of  tubercular  deposit. 
This  he  did  by  means  of  a  series  of  inoculations  of  hy- 
pertrophied  tonsils  taken  from  patients,  and  the  guinea- 
pigs  used  in  the  experiments  invariably  became  tuber- 
culous ;  he  added,  "  I  have  examined  the  question  in 
another  aspect  and  I  have  endeavored  to  demonstrate 
that  tuberculosis  can  have  a  descending  course,  that  is 
to  say,  start  from  the  tonsils  and  then  invade  the  gan- 
glia, the  lymphatic  system,  and  finally  the  lungs." 

Professor  Cornil  doubted  this,  the  more  so  as  no  his- 
tological examination  of  the  tissues  had  been  made — ■ 
this  Professor  Dieulafoy  had  considered  unnecessary, 
as  the  autopsy  of  the  animals  inoculated  showed  such 
characteristic  lesions.  Professor  Grancher  seemed  to 
decide  the  question  by  saying  that,  Professor  Dieula- 
foy had  tuberculized  guinea-pigs  by  inoculating  them 
with  fragments  of  hypertrophied  tonsils,  and  if  he  had 
not  proven  the  tuberculous  nature  of  the  hypertrophy, 
he  had  at  least  directed  the  attention  of  the  Academy 
of  Medicine  to  the  frequency  of  the  bacillus  in  the  ton- 
sils. The  same  was  true  of  other  mucous  membranes, 
such  as  the  intestinal  membranes,  which  the  bacillus 
of  Koch  may  traverse  without  lesion  at  all,  and  yet  go 
on  and  produce  general  lesions  in  the  ganglia. 

MM.  Combe  and  Dubourquet-Laborderie  presented 
a  calculus  of  the  tonsil  about  the  size  of  a  small 
nut.  They  dwelt  upon  the  formation  of  these  calculi, 
which  have  for  point  of  departure,  or  kernel,  a  foreign 
body  surrounded  by  mucous  deposit,  the  salts  of  lime 
and  magnesia,  etc.,  offering  an  analogy  with  rhinoliths. 
Such  calculi  occasion  sometimes  severe  accidents,  but 
often,  on  account  of  the  tolerance  of  the  tonsil,  they 
only  cause  a  slight  inflammation.  Repeated  and  per- 
sistent amygdalitis  is  almost  always  caused  by  their 
presence  in  the  crypts,  where  they  are  the  origin  of  in- 
flammation of  the  gland  and  abscesses.  The  therapeu- 
tical indication  is  antiphlogistic  (gargles  with  carbolic 
acid  as  a  base,  or  phenosalyl  and  saccharin).  That 
failing,  resort  must  be  had  to  surgical  treatment,  disci- 
sion,  completed  by  a  galvanocauterization  of  the  wound. 

.\s  we  know  that  the  tonsils  are  the  starting-point  of 
diphtheria,  and  as  the  physiology  of  these  organs  has 
never  been  made  clear,  it  does  seem  as  if  they  were 
only  there  as  a  causa  morbi.  At  the  same  sitting  Pro- 
fessor Pean  jiresented  a  young  girl  not  yet  menstru- 
ating, with  an  incontinence  of  urine  having  lasted  since 
her  birth,  which,  however,  was  not  congenital,  although 
it  appeared  to  be.  The  infirmity  persisting,  the  vulva 
was  examined,  and  a  sac-like  protuberance  discovered 
in  the  median  line  and  on  the  anterior  wall  of  the 
vagina,  beyond  the  intact  hymen.     The  diagnosis  of 


cystocele  was  made.  A  more  attentive  examination 
then  led  Professor  Pean  to  discover  the  true  nature  of 
the  case.  Introducing  his  index-finger  into  the  vagina 
and  pressing  the  tumor,  he  saw  the  urine  come  out, 
not  of  the  external  orifice  of  the  urethra,  but  out 
of  another  opening  in  the  median  line  3  mm.  below  the 
natural  one.  Passing  a  stylet  into  that  opening,  a  vesi- 
cal diverticulum  was  found  having  a  supernumerary 
urethra.  To  cure  this  infirmity  the  only  treatment  was 
to  open  the  supplementary  urethra  and  bladder,  and 
excise  them.  The  incision  showed  that  the  accessrry 
urethra  was  8  ctm.  long,  and  separated  by  a  thick  tis- 
sue from  the  normal  urethra.  The  pocket  communi- 
cated high  up  and  behind  with  the  bladder.  There 
was  no  orifice  of  ureter  in  the  pocket. 

Intermittent  fever  of  Parisian  origin  is  certainly  a 
rarity  here,  but  Dr.  Ducazal  admitted  recently  into  the 
hospital  a  soldier  suffering  with  malarial  fever,  who, 
never  having  had  a  paludal  attack  before,  had  con- 
tracted the  disease  at  the  Ecole  Militaire,  where  he 
was  in  garrison,  near  embankments  that  had  been  thrown 
up  on  the  first  works  of  the  Exposition  of  1,900.  He 
had  an  enormous  hypertrophy  of  the  spleen  that  had 
led  the  physicians  at  first  to  think  that  he  had  a  tuber- 
cular peritonitis  and  an  abdominal  abscess.  The 
writer  has  seen  many  such  cases  in  Paris,  both  in  the 
hospitals  and  in  private  practice,  but  never  one  of  Pa- 
risian origin — all  had  come  from  malarious  countries. 

It  seems  that  alimentary  hygiene  is  still  interesting 
the  committee  on  sanitation,  and  M.  Vallin  has  just 
read  a  paper  on  alimentary  poisoning  caused  by  veal. 
This  poisoning,  or  intoxication,  as  he  calls  it,  is  caused 
by  eating  veal  that  has  died  of  infectious  diarrhoea  or 
septico-pyasmia.  This  disease  should  be  noted  by 
veterinarians,  and  the  attention  of  the  authorities  di- 
rected to  the  matter. 

A  monument  is  soon  to  be  erected  to  the  illustrious 
Charcot  by  his  fellow-professors,  students,  friends,  and 
admirers  in  general  throughout  France,  and  it  now 
seems  the  world.  At  a  recent  meeting  of  the  committee 
under  the  presidency  of  Professor  Brouardel,  it  was 
found  that  there  were  actually  in  the  treasury,  includ- 
ing subscriptions,  40,000  francs.  It  is  noteworthy  that 
a  very  large  proportion  of  the  subscribers  are  foreign- 
ers. The  execution  of  the  work  is  to  be  given  to  M. 
Falguiere — a  personal  friend  of  Charcot. 


HOW    TO    GET    PRACTICE. 

To  THE  Editor  of  the  Medic.\l  Record. 

Sir  :  Referring  to  the  article,  "  An  Ingenious  Medical 
Man  "  in  the  Medical  Record,  June  isth,  and  credited 
to  the  Afi-t/ical  Press,  I  am  reminded  of  a  similar  de- 
vice, if  not  the  same  out  of  which  the  Frfss  article  has 
been  evolved,  attributed  to  a  physician  of  Montpelier, 
published  in  T/ic  Fenny  Magazine,  London  and  New 
Vork,  April  6,  1S33,  as  follows  ;  "  Dr.  F ,  a  phy- 
sician of  Montpelier,  was  in  the  habit  of  employing  a 
very  ingenious  artifice.  When  he  came  to  a  town  where 
he  was  not  known,  he  pretended  to  have  lost  his  dog,  and 
ordered  the  public  crier  to  offer,  with  beat  of  drum,  a 
reward  of  twenty- five  louis  to  whoever  should  bring  it 
to  him.  The  crier  took  care  to  mention  all  titles  and 
academic  honors  of  the  doctor,  as  well  as  his  place  of 
residence.  He  soon  became  the  talk  of  the  town.  "  Do 
you  know,"  says  one,"  that  a  famous  jihysician  has  come 
here,  a  very  clever  fellow  ;  he  must  be  very  rich,  for 
he  offers  twenty-five  louis  for  finding  his  dog."  The 
dog  was  not  found,  but  patients  were.  Also  in  the 
same  journal  the  following  :  "  New  Way  to  Get  Prac- 
tice." A  poor  physician,  with  plenty  of  knowledge 
and  no  practice,  imparted  his  troubles  to  one  of  his 
friends.  "  Listen  to  my  advice,"  says  the  other,  "and 
follow  it.  The  Cafe  de  la  R^gence  is  in  fashion  ;  I 
play  at  chess  there  every  day  at  two  o'clock,  when  the 


July  6,    1895] 


MEDICAL    RECORD. 


33 


crowd  is  thickest.  Come  there  too  ;  do  not  recognize 
me,  and  do  not  speak  a  word,  but  seem  in  a  reverie  ; 
take  your  coffee  and  always  give  the  waiter  the  money 
in  a  piece  of  rose-colored  paper  ;  leave  the  rest  to  me." 
The  physician  followed  his  advice,  and  his  oddity  was 
soon  remarked.  His  kind  friend  said  to  the  customers 
of  the  coffee-house  :  "  Gentlemen,  do  not  think  ill  of 
this  man  because  he  seems  an  oddity  ;  he  is  a  pro- 
found practitioner ;  I  have  known  him  these  fifteen 
years,  and  I  could  tell  you  of  some  wonderful  cures 
that  he  has  performed  ;  but  he  thinks  of  nothing  but 
his  books,  and  never  speaks  except  to  his  patients, 
which  has  prevented  me  from  becoming  intimate  with 
him  ;  but  if  ever  I  am  obliged  to  keep  my  bed,  he  is 
the  doctor  for  me."  The  friend  went  on  in  this  way, 
varying  the  style  of  his  panegyric  from  time  to  time, 
till  by  degrees  all  his  auditors  consulted  the  doctor 
with  the  rose-colored  paper. 

J.  T.  Howard,  M.D. 

Washington,  D.  C,  June  18,  1895. 


THE  TREATMENT  OF  CHOLERA. 


Sir  :  In  the  synopsis,  in  a  recent  issue  of  the  Medical 
Record,  of  a  paper  on  cholera,  read  by  Dr.  Elmer 
Lee  before  the  American  Medical  Association  at  Balti- 
more, he  is  made  to  say,  "  Calomel,  salol,  and  quinine 
have  all  proven  broken  reeds." 

If  Dr.  Lee  knows  of  instances  in  which  any  consid- 
erable number  of  cholera  patients,  treated  with  quinine 
by  the  mouth  in  doses  at  the  rate  of  about  ten  grains 
an  hour,  have  failed  to  show  the  best  results  yet 
continuously  obtained  by  any  treatment  known,  or  that 
may  be  hoped  of  any  treatment  yet  to  be  devised,  it  is 
most  certainly  a  duty  he  owes  to  the  profession  and  to 
humanity  that  he  should  make  the  same  known. 

As  I  have  shown  in  this  journal  and  elsewhere,  the 
quinine  treatment  was  killed  by  intravenous  and  hypo- 
dermatic injections  of  the  drug,  and  because  it  failed 
to  reach  the  germ  in  the  intestinal  tract  on  its  route  to 
the  kidneys  when  so  administered. 

Professor  Koch  virtually  places  it  highest  of  all  in 
its  control  of  growth  of  the  germ,  and  Dr.  Graham, 
who  learned  his  method  in  the  laboratory  of  that  great 
scientist,  demonstrated  that  in  strength  of  i  to  2,500 
to  I  to  1,000,  it  kills  the  germ  in  time  varying  from 
one-half  hour  to  ten  minutes. 

From  1831  onward,  in  every  epidemic  up  to  and  in- 
cluding that  of  1873  in  the  Mississippi  Valley,  wherever 
given,  in  powder  or  in  solution,  by  the  mouth,  in  doses 
approximating  the  above,  it  has  invariably  shown  the 
remarkable  power  in  controlling  the  disease  which  we 
would  expect  from  its  demonstrated  effect  upon  the 
germ,  and  for  partial  failures  the  best  reasons  have 
been  educed.  If  Antonio  Putrelli,  Venice,  1831,  re- 
duced the  mortality  to  but  thirty-three  per  cent.,  it  was 
because  he  gave  the  remedy  in  eight-grain  pills,  which, 
made  up  with  any  of  the  old  excipients,  would,  with 
the  rapid  peristalsis  of  cholera,  rattle  down  the  intes- 
tinal tract,  to  be  discharged  at  the  anus  like  a  stone 
from  a  catapult.  If  Dr.  Van  Meerdervoort  (who, 
Bayard  Taylor  says,  was  first  to  demonstrate  anatomy 
to  the  Japanese  doctors)  succeeded  in  reducing  the  or- 
dinary mortality  of  the  disease  in  Nagasaki  of  sixty  to 
sixty-five  per  cent,  to  but  29.22  per  cent.,  it  was  because 
of  the  large  number  of  cases  that  he  attended,  an  aver- 
age of  over  eight  hundred  yearly  in  "three  different  fear- 
ful epidemics  "  (Nagasaki,  1857-63),  scattered  variously 
about  the  city  ;  he  being  the  only  European  physician 
in  that  city  of  sixty  thousand  souls,  and  rarely  called 
until  the  disease  was  well  advanced. 

In  Europe  and  America  I  have  collected  the  records 
of  cases  to  the  number  of  six  hundred  and  seventy-nine 
of  what  was  undoubtedly  cholera  of  statistic  grade  of 


severity  with  a  loss  of  but  thirty-two  patients,  less 
than  4.8  per  cent,  mortality,  and  almost  exactly  one- 
tenth  that  of  the  Hamburg  epidemic,  according  to  Pro- 
fessor Rumpf,  director  of  hospitals  in  that  city.  More- 
over, I  deny  that  twelve  of  these  thirty-two  fatal  cases 
have  any  right  whatever  to  a  place  in  these  statistics,  as 
they  were  deaths  that  occurred  in  the  Tennessee  Peniten- 
tiary in  the  epidemic  of  1873,  after  they  ceased  treating 
the  disease  as  pernicious  intermittent  and  began  with 
the  polytherapy  of  cholera.  Until  then,  for  a  period  of 
twenty-six  days,  with  a  daily  average  of  fifty-seven 
patients  under  treatment,  in  an  epidemic  in  which 
7,356  cases  were  reported,  of  whom  3,800  died,  in  an 
outbreak  that  previously  to  commencement  of  the 
cjuinine  treatment  had  developed  a  mortality-rate  of 
sixty  per  cent.,  and  thereafter  caused  in  the  city  of 
Nashville,  Tenn.,  1,000  deaths,  upon  a  dietary  of  fresh 
vegetables  and  sauerkraut,  in  a  Southern  penitentiary, 
there  was  not  a  death. 

Quinine  a  broken  reed  !  Have  men  in  the  Ohio 
Valley  yet  to  demonstrate  their  capacity  for  ratiocina- 
tion along  straight  lines  ? 

That  there  may  be  other  good  treatment  which  will 
succeed  in  reducing  the  mortality  in  an  epidemic  of 
cholera  below  the  fifty  per  cent,  rate  is  most  sincerely 
to  be  hoped.  That  this  has  not  yet  been  done  is  ap- 
parent, and  experimentation  in  cholera  epidemics  is 
costly  in  human  life. 

That  any  treatment  contemplating  enteroclysis  as 
its  method  of  administration  will  give  the  best  results 
in  an  extensive  epidemic,  is  a  matter  of  grave  doubt,  to 
say  the  least.  Fairly  good  results  may  accrue  in  hos- 
pital practice  where  there  is  every  appliance  and  physi- 
cians who  have  the  requisite  skill  in  getting  the  tannic- 
acid  solution,  for  instance,  beyond  the  ileocecal  valve, 
as  tannic  acid  has  one  twenty-fifth  the  power  over  the 
germ  awarded  by  Koch  to  quinine.  Unfortunately,  the 
most  of  the  cholera  so  far  in  the  United  States  has 
been  in  the  Mississippi  Valley,  and  much  of  it  in  coun- 
try practice.  Where  a  physician  has  to  ride  ten  miles 
in  one  direction  to  see  some  of  his  patients,  and  then 
as  far  in  another  direction  to  see  the  rest,  I  doubt  the 
practicability  of  this  method. 

Outside  the  great  cities  of  our  Atlantic  seaboard  is 
a  stretch  of  American  territory,  of  which  San  Francisco 
is  yet  some  hundreds  of  miles  east  of  the  centre,  where, 
for  the  most  part,  such  means  of  administration  could 
not  be  relied  upon. 

As  to  the  hydropathic  treatment  proposed  by  Dr. 
Lee,  I  am  glad  to  furnish  a  case  in  point — that  of  a 
German,  thought  to  be  dying  of  cholera  when  it  pre- 
vailed in  this  city  in  1S52.  In  answer  to  a  supposed 
last  request  a  pitcher  of  water  was  furnished  him, 
which  he  drank,  then  another,  which  he  also  drank  and 
recovered,  to  become  afterward  one  of  the  principal 
manufacturers  of  the  State.  All  very  well,  but  for  the 
other  German,  who  under  like  conditions  had  his  last 
request  also  granted — ate,  drank,  and  recovered.  The 
last  fellow  had  a  plate  of  Limburger  and  a  bottle  of 
beer. 

There  are  few  things  more  likely  to  be  vomited  in 
disturbed  states  of  the  stomach  than  water,  unless  it  be 
warm  water.  As  to  soap  and  water,  theory  and  fact 
are  both  against  them,  as  the  germ  flourishes  best  in 
alkaline  fluids,  and,  moreover,  both  the  Ganges  and  the 
Elbe  consist  in  the  main  of  water. 

Erskine  B.  Fullerton,  M.D. 

CoLL'MBfS  O.,  June  19.  1895. 


Science  and  Christian  Science. — A  student  in  one  of 
the  colleges  for  women  in  a  New  England  town  recently 
informed  the  faculty  that  she  could  no  longer  attend 
the  lectures  on  hygiene,  as  the  theories  there  taught 
were  opposed  to  the  teachings  of  Christian  science. 


34 


MEDICAL    RECORD. 


[July  6,    1895 


THE    AMERICAN    HUMANE   ASSOCIATION'. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  My  attention  has  just  been  called  to  an  editorial 
in  your  issue  of  June  Sth,  wherein  a  similarity  of  names 
has  led  to  an  error  which  I  trust  you  will  afford  me  an 
opportunity  to  correct.  The  American  Humane  Asso- 
ciation, which  has  issued  circulars  requesting  the  opin- 
ions of  members  of  the  medical  profession  and  others 
regarding  vivisection,  has  nothing  whatever  to  do  with 
the  American  Humane  Education  Society  of  Boston, 
whose  efforts  in  certain  directions  you  have  made  the 
subject  of  criticism. 

May  I  add  that  the  results  of  the  census  of  opinions 
in  regard  to  experimentation  upon  living  animals  will 
hardly  justify  your  very  pessimistic  conclusions  ?  The 
inquiry  was  not  instituted  to  "  secure  evidence  "  of  any 
kind,  but  rather  some  careful  expressions  of  opinion 
from  those  qualified  to  give  them.  So  far  from  the  re- 
plies coming  mainly  from  "  those  who  have  taken  some 
fanatical  interest  in  the  subject,"  and  who  "give  their 
vote  for  antivivisection,"  answers  have  come  from  some 
of  the  leading  scientific  men  in  this  country  and  Europe, 
and  the  majority  thus  far  received  are  not  from  the 
class  you  designate.  To  physicians  and  surgeons  of 
the  highest  eminence  in  this  country  and  Europe,  the 
American  Humane  Association  is  indebted  not  merely 
for  signatures  to  some  one  of  its  statements,  but  for  let- 
ters carefully  defining  their  position  in  regard  to  the 
whole  question  of  restriction  or  non- restriction.  Cer- 
tainly no  American  physician  need  hesitate  to  have 
his  views  on  any  subject  contrasted  with  those  of  Sir 
John  Eric  Erichsen,  Sir  Joseph  Fayrer,  Dr.  Forbes 
Winslow,  and  Dr.  Robert  Braithwaite. 

Albert  Leffingwell,  M.D. 

Cambridgf,  Mass.,  June  20,  iSqs. 


twenty-two.  The  number  of  syphilitics,  185.  Socially 
the  married  are  to  the  single,  as  three  to  one  ;  to  the 
widowed,  as  twelve  to  one  ;  while  the  divorced  stand 
as  one  man. 

Louis  C.  Pettit,  M.D. 


SOME    STATISTICS    ON    PARESIS. 

To  THE  Editor  of  the  Medical  Record 

Sir  :  Your  editorial  of  June  ist,  giving  rural  district 
returns  as  to  the  number  of  cases  of  paresis,  and  its  fre- 
quency compared  with  that  of  former  years,  may  be 
supplemented  with  similar  returns  from  the  male  asy- 
lum at  Ward's  Island,  New  York  City. 

,The  occurrence,  or  rather  the  recognition,  of  paresis 
has  apparently  taken  place  rather  abruptly  during  the 
year  1873;  previous  to  this  time  "  ramoUissement,"' 
"peri-encephalitis,"  etc.,  obscure  and  bewilder  occa- 
sional accurate  diagnosis  so  as  to  make  statistics  unre- 
liable. For  the  past  twenty  years  there  seems  to  have 
been  an  almost  mechanical  uniformity  in  ratio  between 
paresis  and  all  other  forms  of  insanity. 

During  the  period  from  1875  to  1895  the  number  of 
cases  of  paresis  (diagnosed  at  death)  was  as  follows  : 

1875  '"  1880,  total  deaths,    658  ;  paretics,  215,  or  32  per  cent. 


I8S0  • 

1885,  " 

861  ; 

'■    314, 

'36 

I8-S' 

1890,  " 

r,i40  ; 

397. 

'  3+ 

1890  ■' 

1891,  " 

2i3  ; 

:8, 

■  32 

1X91  ' 

1892,  •' 

"    290 ; 

8-, 

'  30 

1892  " 

«S93.  " 

293 ; 

92, 

'  33 

'Sq.'> ' 

1894,  " 

■'    263  ; 

88, 

■  i3 

1894  ' 

1895.  " 

287  ; 

95- 

■33 

Thus  giving  out  of  a  total  of  4,025  deaths,  1,366 
cases  of  paresis,  or  about  thirty- three  per  cent,  of 
deaths  from  all  forms  of  insanity. 

So  much  for  the  dead  who  died  of  paresis,  and  these 
alone  rather  point  to  a  previous  non-recognition  than 
an  increased  frequency. 

Of  the  admissions,  the  past  five  years  show  the  same 
uniform  progress.  In  4,628  male  admissions,  there 
were  705  cases  of  paresis,  or  about  fifteen  per  cent. 
The  death  records  of  this  disease  reveal  a  remarkable 
range  in  duration,  the  maximum  being  thirty- five  years. 
The  oldest  person  at  death,  seventy-nine  ;  the  youngest. 


^edicat  gtcms. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  June  29,  1895. 


Tuberculosis 73 

Typhoid  fever 8 

Scarlet  fever 55 

Cerebro-spinal  meningitis 2 

Measles 251 

Diphtheria 243 


The  License  to  Practise  Medicine  in  the  State  of  New 
York. — The  Law  Now  in  Force. — We  present  our  read- 
ers with  the  full  text  of  the  Medical  Law  of  the  State 
of  New  York,  with  all  amendments  to  date  : 

Laius  of  New  York,  ^Sgj,  ch.  66i. — Previous  laws  re- 
lating to  practice  of  medicine  were  repealed  May  9, 
1893,  when  this  law  took  effect. 

§  140.  Qu.^LiFiCATioxs. — Xo  person  shall  practise 
medicine  after  September  i,  1891,  unless  previously 
registered  and  legally  authorized  or  unless  licensed  by 
the  regents  and  registered  as  required  by  this  article  : 
nor  shall  any  ])erson  practise  medicine  who  has  ever 
been  convicted  of  a  felony  by  any  court,  or  w^hose  au- 
thority to  practise  is  suspended  or  revoked  by  the  re- 
gents on  recommendation  of  a  State  board. 

§  141.  St.ate  Boards  of  Medical  Examiners. — 
There  shall  continue  to  be  three  separate  State  boards 
of  medical  examiners  of  seven  members  each,  each  of 
whom  shall  hold  office  for  three  years  from  August  ist 
of  the  year  in  which  appointed.  One  board  shall  rep- 
resent the  Medical  Society  of  the  State  of  New  York, 
one  the  Homoeopathic  Medical  Society  of  the  State  of 
New  York,  and  one  the  Eclectic  Medical  Society  of  the 
State  of  New  York.  Each  of  these  three  societies  shall 
at  each  annual  meeting  nominate  twice  the  number  of 
examiners  to  be  appointed  in  that  year  on  the  board 
representing  it.  The  names  of  such  nominees  shall 
be  annually  transmitted  under  seal  by  the  president 
and  secretary  prior  to  May  1st  to  the  regents,  who  shall, 
prior  to  .\ugust  ist,  appoint  from  such  lists  the  exau. 
iners  required  to  fill  any  vacancies  that  will  occur  fron 
expiration  of  term  on  August  ist.  Any  other  vacancy, 
however  occurring,  shall  likewise  be  filled  by  the  re- 
gents for  the  unexpired  terra.  Each  nominee  before 
appointment  shall  furnish  to  the  regents  proof  that  he 
has  received  the  degree  of  doctor  of  medicine  from 
some  registered  medical  school  and  that  he  has  legalh 
practised  medicine  in  this  State  for  at  least  five  year^ 
If  no  nominees  are  legally  before  them  from  a  sociei> 
the  regents  may  appoint  from  members  in  good  stand- 
ing of  such  society  without  restriction.  The  regents 
may  remove  any  examiner  for  misconduct,  incapacity, 
or  neglect  of  duty. 

§  142.  Certificate  of  Appointment  ;  Oath  : 
Powers. — Every  medical  examiner  shall  receive  a  cer 
tificate  of  appointment  from  the  regents,  and  before  bo- 
ginning  his  term  of  oftice  shall  file  with  the  Secretary 
of  State  the  constitutional  oath  of  office.  Each  boarti, 
or  any  committee  thereof,  may  take  testimony  and 
proofs  concerning  all  matters  within  its  jurisdiction. 
Each  hoard  ma>,  subject  to  the  regents'  approval, 
make  all  by-laws  and  rules  not  inconsistent  with  law 
needed  in  performing  its  duties  ;  but  no  by-law  or  rule 


July  6,    1895] 


MEDICAL    RECORD. 


by  which  more  than  a  majorityvote  is  required  for  any 
specified  action  by  the  board  shall  be  amended,  sus- 
pended, or  repealed  by  a  smaller  vote  than  that  re- 
quired for  action  thereunder. 

§  143.  Expenses. — From  the  fees  provided  l)y  this 
article  the  regents  may  pay  all  proper  expenses  in- 
curred by  its  provisions,  except  compensation  to  medi- 
cal examiners  ;  and  any  surplus  at  the  end  of  any  aca- 
demic year  shall  be  apportioned  among  the  three 
boards //v  rata  according  to  the  number  of  candidates 
whose  answer  papers  have  been  marked  by  each. 

§  144  Officers  ;  Meetings  :  Quorum  ;  Commit- 
tees.— Each  board  shall  annually  elect  from  its  mem- 
bers a  president  and  a  secretary  for  the  academic  year, 
and  shall  hold  one  or  more  meetings  each  year  pur- 
suant to  call  of  the  regents,  who  may  also  call  joint 
meetings  of  the  three  boards  or  of  their  officers.  At 
any  meeting  a  majority  shall  constitute  a  quorum  ;  but 
questions  prepared  by  the  boards  may  be  grouped  and 
edited,  or  answer  papers  of  candidates  may  be  exam- 
ined and  marked  by  committees  duly  authorized  by 
the  boards  and  by  the  regents. 

§  145.  Admission  to  Ex.\mination. — The  regents 
shall  admit  to  examination  any  candidate  who  pays  a 
fee  of  §25  and  submits  satisfactory  evidence,  verified 
by  oath  if  required,  that  he  :  i.  Is  more  than  twenty- 
one  vears  of  age  ;  2,  is  of  good  moral  character  ;  3,  has 
the  general  education  required  in  all  cases  after  Au- 
gust I,  1895,  preliminary  to  receiving  the  degree  of 
bachelor  or  doctor  of  medicine  in  this  State  ;  4,  has 
studied  medicine  not  less  than  three  full  years,  includ- 
ing three  satisfactory  courses,  in  three  different  aca- 
demic years,  in  a  medical  school  registered  as  main- 
taining at  the  time  a  satisfactory  standard  ;  5,  has 
either  received  the  degree  of  bachelor  or  doctor  of 
medicine  from  some  registered  medical  school,  or  a 
diploma  or  license  conferring  full  right  to  practise  med- 
icine in  some  foreign  country. 

The  degree  of  bachelor  or  doctor  of  medicine  shall 
not  be  conferred  in  this  State  before  the  candidate  has 
filed  with  the  institution  conferring  it  the  certificate  of 
the  regents  that  three  years  before  the  date  of  the  de- 
gree, or  before  or  during  his  first  year  of  medical  study 
in  this  State,  he  had  either  graduated  from  a  registered 
college  or  satisfactorily  completed  not  less  than  a  three 
years'  academic  course  in  a  registered  academy  or  high 
school ;  or  had  a  preliminary  education  considered  and 
accepted  by  the  regents  as  fully  equivalent  ;  or  had 
passed  regents'  examinations  in  arithmetic,  elementary 
English,  geography,  spelling,  United  States  history, 
English  composition,  and  physics.  Students  who  had 
matriculated  in  a  New  York  medical  school  before 
June  5,  1890,  shall  be  exempt  from  this  preliminary 
education  requirement,  provided  the  degree  be  con- 
ferred before  August  i,  1S95.  The  regents  may  in  their 
discretion  accept  as  the  equivalent  for  any  part  of  the 
third  and  fourth  requirement,  evidence  of  five  or  more 
years'  reputable  practice  of  medicine,  provided  that 
such  substitution  be  specified  in  the  license. 

§  146.  Questions. — Each  board  shall  submit  to  the 
regents,  as  required,  lists  of  suitable  questions  for  thor- 
ough examination  in  anatomy,  physiology,  and  hygiene, 
chemistry,  surgery,  obstetrics,  pathology  and  diagnosis, 
and  therapeutics  including  practice  and  materia  med- 
ica.  From  these  lists  the  regents  shall  prepare  ques- 
tion papers  for  all  these  subjects,  which  at  any  exam- 
ination shall  be  the  same  for  all  candidates,  except 
that  in  therapeutics,  practice,  and  materia  medica  all 
the  questions  submitted  to  any  candidate  shall  be 
chosen  from  those  prepared  by  the  board  selected  by 
that  candidate,  and  shall  be  in  harmony  with  the  ten- 
ets of  that  school  as  determined  by  its  State  board  of 
medical  examiners. 

§  147.  Examinations  and  Reports. — Examina- 
tions for  license  shall  be  given  in  at  least  four  conven- 
ient places  in  this  State,  and  at  least  four  times  annually, 
in  accordance  with  the  regents'  rules,  and  shall  be  ex- 


clusively in  writing  and  in  English.  Each  examination 
shall  be  conducted  by  a  regents'  examiner,  who  shall 
not  be  one  of  the  medical  examiners.  At  the  close  of 
each  examination  the  regents'  examiner  in  charge  shall 
deliver  the  questions  and  answer  papers  to  the  board 
selected  by  each  candidate,  or  to  its  duly  authorized 
committee,  and  such  board,  without  unnecessary  delay, 
shall  examine  and  mark  the  answers  and  transmit  to 
the  regents  an  official  report,  signed  by  its  president 
and  secretary,  stating  the  standing  of  each  candidate 
in  each  branch,  his  general  average,  and  whether  the 
board  recommends  that  a  license  be  granted.  Such 
report  shall  include  the  questions  and  answers  and 
shall  be  filed  in  the  public  records  of  the  University. 
If  a  candidate  fails  on  first  examination,  he  may,  after 
not  less  than  six  months'  further  study,  have  a  second 
examination  without  fee.  If  the  failure  is  from  illness 
or  other  cause  satisfactory  to  the  regents,  they  may 
waive  the  required  six  months'  study. 

§  148.  Licenses. — On  receiving  from  a  State  board 
an  official  report  that  an  applicant  has  successfully 
passed  the  examinations  and  is  recommended  for  li- 
cense, the  regents  shall  issue  to  him,  if  in  their  judg- 
ment he  is  duly  qualified  therefor,  a  license  to  practise 
medicine.  Every  license  shall  be  issued  by  the  Uni- 
versity under  seal  and  shall  be  signed  by  each  acting 
medical  examiner  of  the  board  selected  and  by  the  of- 
ficer of  the  University  who  approved  the  credential 
which  admitted  the  candidate  to  examination,  and 
shall  state  that  the  licensee  has  given  satisfactory  evi- 
dence of  fitness  as  to  age,  character,  preliminary  and 
medical  education,  and  all  other  matters  required  by 
law,  and  that  after  full  examination  he  has  been  found 
properly  qualified  to  practise.  Applicants  examined 
and  licensed  by  other  State  examining  boards  regis- 
tered by  the  regents  as  maintaining  standards  not 
lower  than  those  provided  by  this  article,  and  appli- 
cants who  matriculated  in  a  New  York  State  medical 
school  before  June  5,  1S90,  and  who  receive  the  de- 
gree M.D.  from  a  registered  medical  school  before  Au- 
gust I,  1895,  may  without  further  examination,  on  pay- 
ment of  $10  to  the  regents  and  on  submitting  such 
evidence  as  they  may  require,  receive  from  them  an 
indorsement  of  their  licenses  or  diplomas  conferring 
all  rights  and  privileges  of  a  regents'  license  issued 
after  examination. 

If  any  person,  whose  registration  is  not  legal  because 
of  some  error,  misunderstanding,  or  unintentional  omis- 
sion, shall  submit  satisfactory  proof  that  he  had  all  re- 
quirements prescribed  by  law  at  the  time  of  his  imper- 
fect registration  and  was  entitled  to  be  legally  registered, 
he  may,  on  unanimous  recommendation  of  a  State  board 
of  medical  examiners,  receive  from  the  regents  under 
seal  a  certificate  of  the  facts,  which  may  be  registered 
by  any  county  clerk  and  shall  make  valid  the  previous 
imperfect  registration. 

Before  any  license  is  issued  it  shall  be  numbered  and 
recorded  in  a  book  kept  in  the  regents'  office,  and  its 
number  shall  be  noted  in  the  license.  This  record 
shall  be  open  to  public  inspection,  and  in  all  legal  pro- 
ceedings shall  have  the  same  weight  as  evidence  that  is 
given  to  a  record  of  conveyance  of  land. 

§  149.  Registry. — Every  license  to  practise  medi- 
cine shall,  before  the  licensee  begins  practice  there- 
under, be  registered  in  a  book  kept  in  the  clerk's  office 
of  the  county  where  such  practice  is  to  be  carried  on, 
with  name,  residence,  place  and  date  of  birth,  and 
source,  number,  and  date  of  his  license  to  practise. 
Before  registering,  each  licensee  shall  file,  to  be  kept 
in  a  bound  volume  in  the  county  clerk's  office,  an  affi- 
davit of  the  above  facts,  and  also  that  he  is  the  person 
named  in  such  license,  and  had,  before  receiving  the 
same,  complied  with  all  requisites  as  to  attendance, 
terms,  and  amount  of  study  and  examinations  required 
by  law  and  the  rules  of  the  University  as  preliminary 
to  the  conferment  thereof  ;  that  no  money  was  paid  for 
such  license,  except  the  regular  fees  paid  by  all  appli- 


36 


MEDICAL    RECORD. 


[July  6,    li 


cants  therefor  ;  that  no  fraud,  misrepresentations,  or 
mistake  in  any  material  regard  was  employed  by  any- 
one or  occurred  in  order  that  such  license  should  be 
conferred.  Every  license,  or  if  lost,  a  copy  thereof 
legally  certified  so  as  to  be  admissible  as  evidence,  or 
a  duly  attested  transcript  of  the  record  of  its  confer- 
ment shall,  before  registering,  be  exhibited  to  the 
county  clerk,  who,  only  in  case  it  was  issued  or  in- 
dorsed as  a  license  under  seal  by  the  regents,  shall  in- 
dorse or  stamp  on  it  the  date  and  his  name,  preceded 
by  the   words  :  "  Registered   as  authority    to  practise 

medicine  in  the  clerk's  office  of  county."     The 

clerk  shall  thereupon  give  to  every  physician  so  regis- 
tered a  transcript  of  the  entries  in  the  register,  with  a 
certificate  under  seal  that  he  has  filed  the  prescribed 
affidavit.  The  licensee  shall  pay  to  the  county  clerk  a 
total  fee  of  $i  for  registration,  affidavit,  and  certificate. 

§  150.  Registry  in  .Another  Cou.n'tv. — A  prac- 
tising physician  having  registered  a  lawful  authority  to 
practise  medicine  in  one  county,  and  removing  such 
practice  or  part  thereof  to  another  county,  or  regularly 
engaging  in  practice  or  opening  an  office  in  another 
county,  shall  show,  or  send  by  registered  mail  to  the 
clerk  of  such  other  county,  his  certificate  of  registra- 
tion. If  such  certificate  clearly  shows  that  the  original 
registration  was  of  an  authority  issued  under  seal  by 
the  regents,  or  if  the  certificate  itself  is  indorsed  by  the 
regents  as  entitled  to  registration,  the  clerk  shall  there- 
upon register  the  applicant  in  the  latter  county,  on  re- 
ceipt of  a  fee  of  twenty-five  cents,  and  shall  stamp  or 
indorse  on  such  certificate  the  date  and  his  name  pre- 
ceded by  the  words  :  "  Registered  also  in  .  .  . 
county,"  and  return  the  certificate  to  the  applicant. 

§  151.  Certificate  Presumptive  Evidence  ;  Un- 
authorized Registration  and  License  Prohibit- 
ed.— Every  unrevoked  certificate  and  indorsement  of 
registry,  made  as  provided  in  this  article,  shall  be  pre- 
sumptive evidence  in  all  courts  and  places,  that  the 
person  named  therein  is  legally  registered.  Hereafter 
no  person  shall  register  any  authority  to  practise  medi- 
cine unless  it  has  been  issued  or  indorsed  as  a  license 
by  the  regents.  No  such  registration  shall  be  valid 
unless  the  authority  registered  constituted  at  the  time 
of  registration,  a  license  under  the  laws  of  the  State 
then  in  force.  No  diploma  or  license  conferred  on  a 
person  not  actually  in  attendance  at  the  lectures,  in- 
struction, and  examinations  of  the  school  conferring  the 
same,  or  not  possessed  at  the  time  of  its  conferment,  of 
the  recjuirements  then  demanded  of  medical  students 
in  this  State  as  a  condition  of  their  being  licensed  so  to 
jiractise,  and  no  registration  not  in  accordance  with 
this  article  shall  be  lawful  authority  to  practise  medi- 
cine, nor  shall  the  degree  of  doctor  of  medicine  be  con- 
ferred rai/sa  honoris  or  ail c nudum,  nor  if  previously  con- 
ferred shall  it  be  a  qualification  for  such  practice. 

S  152.  Construction  of  this  Article. — This 
article  shall  not  be  construed  to  affect  commissioned 
medical  officers  serving  in  the  United  States  army, 
navy,  or  marine  hospital  service,  while  so  commis- 
sioned ;  or  any  one  while  actually  serving  on  the  resi- 
dent medical  staff  of  any  legally  incorporated  hosjtital  ; 
or  any  legally  registered  dentist  exclusively  engaged  in 
jjractising  dentistry  ;  or  any  manufacturer  of  artificial 
eyes,  limbs,  or  orthopedic  instruments  or  trusses  in  fit- 
ting such  instruments  on  persons  in  need  thereof  ;  or 
any  lawfully  iiualified  physician  in  other  States  or 
counties  meeting  legally  registered  physicians  in  this 
State  in  consultation  ;  or  any  physician  residing  on  a 
border  of  a  neighboring  State  and  duly  authorized  un- 
der the  laws  thereof  to  practise  medicine  therein,  whose 
practice  extends  into  this  State,  and  who  does  not  <)|)on 
an  office  or  ajipoint  a  ])lace  to  meet  patients  or  receive 
calls  within  this  State  ;  or  any  physician  duly  regis- 
tered in  one  county  called  to  attend  isolatetl  cases  in 
another  county,  but  not  residing  or  habitually  jiractis- 
ing  therein.  This  article  shall  be  construed  to  rei)eal 
all  acts  or  parts  of  acts  authorizing  conferment  of  any 


degree  in  medicine,  causa  honoris  or  ad  eundum  or 
otherwise  than  on  students  duly  graduated  after  satis- 
factory completion  of  a  preliminary  and  medical  course 
not  less  than  that  required  by  this  article,  as  a  condi- 
tion of  license. 

§  153.  Penalties  and  their  Collection. — Every 
person  who  shall  ])ractise  medicine  within  this  State, 
without  lawful  registration  or  in  violation  of  any  pro- 
vision of  this  article,  shall  forfeit  to  the  county  where- 
in such  person  shall  so  practise  or  in  which  any  such 
violation  shall  be  committed,  $50  for  every  such  viola- 
tion and  for  every  day  of  such  unlawful  practice, 
and  any  incorporated  medical  society  of  the  State  or 
any  county  medical  society  of  such  county  entitled  to 
representation  in  a  State  society,  may  bring  an  action 
in  the  name  of  such  county  for  the  collection  of  such 
penalties,  and  the  expense  incurred  by  any  such  society 
in  such  prosecution,  including  necessary  counsel  fees, 
may  be  retained  by  such  society  out  of  the  penalties  so 
collected,  and  the  residue,  if  any,  shall  be  paid  into  the 
county  treasury.  Any  person  who  shall  practise  medi- 
cine under  a  false  or  assumed  name,  or  who  shall  false- 
ly personate  another  practitioner  of  a  like  or  different 
name,  shall  be  guilty  of  a  felony  ;  and  any  person  guilty 
of  violating  any  of  the  other  provisions  of  this  act,  not 
otherwise  specifically  punished  herein,  or  who  shall  buy. 
sell,  or  fraudulently  obtain  any  medical  diploma,  li- 
cense, record,  or  registration,  or  who  shall  aid  or  abet 
such  buying,  selling,  or  fraudulently  obtaining,  or  who 
shall  practise  medicine  under  cover  of  a  diploma  or 
license  illegally  obtained,  or  signed  or  issued  unlawful- 
ly or  under  fraudulent  representations,  or  mistake  of 
fact  in  material  regard,  or  who,  after  conviction  of  a 
felony,  shall  attempt  to  practise  medicine,  and  any  per- 
son who  shall  append  the  letters  M.  D.  to  his  or  her 
name,  or  shall  assume  or  advertise  the  title  of  doctor 
in  such  a  manner  as  to  convey  the  impression  that  he 
is  a  lawful  practitioner  of  medicine  or  any  of  its 
branches  without  having  legally  received  the  medical 
degree,  shall  be  guilty  of  a  misdemeanor,  and  on  con- 
viction thereof  shall  be  punished  by  a  fine  of  not  less 
than  $250,  or  imprisonment  for  six  months  for  the  first 
offence,  and  on  conviction  of  a  subsequent  offence,  by 
a  fine  of  not  less  than  $500,  or  imprisonment  for  not 
less  than  one  year,  or  by  both  fine  and  imprisonment. 


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^K\^\xm\  l^rttctes. 


SHALL     INSANE     CRIMINALS      BE     IMPRIS- 
ONED OR   PUT    TO   DEATH? 

By  J.   B.  ransom,  M.D., 

CLINTOV,  N.  V. 
PHYSICIAN-    TO    CL'NTON'    PRISON. 

Such  assassinations  as  those  of  Czar  Alexander  II., 
President  Garfield,  President  Carnot,  and  Mayor  Har- 
rison, and  the  many  attempts  at  wholesale  assassinations 
which  have  occurred  within  a  score  of  years,  together 
with  numerous  horrifying  cases  of  homicide — all  cor- 
relative with  the  evolution  of  the  modern  crank — have 
stirred  the  whole  social  fabric  to  a  deep  feeling  of  con- 
cern as  to  what  disposal  is  to  be  made  of  this  so-called 
"  crank  element  ;  "  and,  naturally  enough,  developed 
an  exasperated  public  sentiment,  sweeping  in  its  con- 
clusions, swift  to  condemn,  and  eager  to  execute. 

Inasmuch  as  medical  expert  testimony  has  figured  so 
largely  in  many  of  the  trials  of  these  culprits,  it  thus 
becomes  a  necessary  and  profitable  question  for  us  to 
consider  as  medical  men.  I  shall  not  attempt,  in  a 
paper  of  this  length,  to  go  minutely  into  the  relations 
which  criminal  life  and  criminal  acts  bear  to  brain  con- 
ditions, but  will  limit  myself  to  the  consideration  of 
medical  expert  testimony,  particularly  in  cases  of  homi- 
cide, where  insanity  is  made  the  plea  of  the  defence. 

Assuming  that  this  State,  like  all  civilized  countries 
of  the  earth,  recognizes  that  law  of  common  justice  and 
right — the  exemption  from,  or  mitigation  of,  the  pen- 
alty consequent  upon  the  commission  of  crime  by  the 
mentally  irresponsible — I  shall  base  all  my  conclusions 
upon  this  assumption,  and  upon  the  belief  that  society 
at  large  does  not  voice  the  inhuman  and  brutal  senti- 
ment which  we  hear  so  often  expressed,  that  the  un- 
fortunate creature 

"  Who,  by  the  hand  of  nature  marked," 

is  thus  made  the  helpless  victim  of  his  own  physical 
environment,  should  be  imprisoned  or  put  out  of  exist- 
ence with  no  reference  whatsoever  to  his  responsibil- 
ity. There  is  something  too  revolting,  too  barbarous, 
in  this  sentiment  of  prostituting  justice  to  so  repulsive 
an  end,  and  is  indefensible  from  any  medical  or  moral 
stand-point. 

I  shall,  then,  assume  that  when  an  individual  is  found 
to  be  mentally  irresponsible  under  the  law,  he  should 
not   be    treated    as   a    responsible    criminal  ;  in    other 
words,  that  such  an  irresponsible  being  should  not  be 
sent  to  either  a  prison  proper  or  be  subject  to  execu- 
tion. 
j      As  to  what  is  to  be  done  with  this  class  of  criminals 
j  is  not  within  the  sphere  of  this  paper,  but  could  well 
I  form  the  subject   of  an   ampler  one.      Incidentally  I 
i  should  say,  however,  that  the  conditions  are  suggestive 
of  restrictions  in  immigration,  and  the  establishing  of 
institutions  especially  designed  for  the  care  of  degener- 
ate criminals,  and  the  enactment  of  adequate  laws  per- 
mitting their  apprehension,  and,  if  necessary,  lifelong 
detention  in  such  institutions.     In  this  way  only  will 
their  menace  to  public   safety  be  abated.      Certainly 
there  is  little  deterrent  benefit  to  be  derived,  or  safety 


to  be  secured,  by  the  execution  of  the  irresponsible 
crank,  for  numbers  of  this  kind  will  aspire  to  fulfil  his 
mission  and  share  his  diabolical  glory — if  I  may  so 
express  it — even  at  the  risk  of  such  a  fate.  This  savors 
too  much  of  the  philosophy  of  "'  locking  the  barn-door 
after  the  horse  is  stolen."  Apprehension,  not  execu- 
tion, is  what  we  want,  and  is  best  calculated  to  miti- 
gate this  evil. 

From  a  considerable  experience  and  from  different 
sources  of  information  I  am  led  to  believe  that  our 
present  methods  of  apprehending  and  trying  criminals 
are  very  much  at  fault,  especially  with  reference  to 
their  mental  condition.  It  is  a  fact  that  our  prisons 
and  penitentiaries  have  a  large  number  of  individuals 
confined  therein  who  are  mentally  irresponsible,  and 
who  were  undoubtedly  so  at  the  time  of  the  commission 
of  their  crimes.  In  these  institutions  you  will  find  all 
grades  of  the  degenerate,  from  the  imbecile  up  to  the 
paranoiac,  and  whose  crimes  range  from  a  larceny  to 
homicide.  My  knowledge  of  those  doing  life-sentence 
for  homicide  has  convinced  me  that  many  are  of  un- 
sound mind,  and  I  have  committed  a  number  of  them 
to  the  Asylum  for  Insane  Criminals.  When  we  come 
to  the  death  penalty,  even  here — in  more  than  one 
case — it  has  been  my  unpleasant  experience  to  discover 
meningeal  adhesions  over  atrophic  and  diseased  brain 
areas.  I'am  making  no  plea  for  the  responsible  crim- 
inal, nor  for  the  abolition  of  capital  [ninishment.  I  am 
simply  stating  a  series  of  facts,  having  their  causation 
in  conditions  which  I  believe  to  be  largely  due  to  the 
inability  of  the  courts  to  decide  upon  the  responsibility 
of  the  accused  under  the  law,  and,  through  the  failure 
of  medical  expert  testimony — -as  at  present  introduced 
— to  determine  the  mental  status  of  criminals  under  in- 
dictment and  to  properly  differentiate  and  classify 
them.  In  cases  where  the  defence  does  not  make  men- 
tal incapacity  a  plea,  the  matter  is  left  wholly  to  the 
judge  to  decide,  and  he,  either  through  inability  to  pass 
upon  such  a  question,  or  indisposition  to  raise  the  ques- 
tion, too  often  leaves  it  to  the  prison  authorities  to  decide 
as  to  a  man's  mental  condition.  If,  on  the  other  hand, 
a  plea  for  the  defence  is  made  on  the  ground  of  insanity, 
then  the  whole  of  the  cuinbersome  and  unwieldy  ma- 
chinery of  medical  expert  testimony  is  set  in  motion, 
and  this  nightmare  of  confusion  is  precipitated  upon 
the  court. 

I  do  not  wish  it  to  be  understood  that  I  am  making 
a  wholesale  condemnation  of  medical  expert  testimony, 
nor  that  I  second  all  of  the  severe  animadversions 
made  by  judges  and  writers  on  medical  jurisprudence, 
many  of  which  are  rash  and  altogether  too  sweeping  in 
their  condemnation.  What  I  would  condemn  is  the 
manner  and  method  of  the  introduction  of  medical 
expert  testimony  and  the  helplessness  of  the  courts  in 
protecting  themselves  against  the  admission  of  a  sort  of 
"  so-called  "  medical  expert  testimony,  based  either 
upon  ignorance  and  prejudice,  or  prompted  by  venality 
and  the  love  of  notoriety. 

Ordroneaux  as  early  as  1874  said:  "In  fact,  the 
calling  of  experts  has  now  come  to  be  regarded  as  the 
signal  for  the  display  of  forensic  pyrotechnics,  beneath 
whose  smoke  and  lurid  glare  law,  common-sense,  and 
unalloyed  justice  are  swept  away  in  a  whirlwind  of 
muddy  metaphysics.  It  is  needless  to  say,  however, 
that  all  honest  men  look  upon  this  as  a  judicial  farce, 
and  a  degradation  of  the  ethics  of  jurisprudence." 


38 


MEDICAL   RECORD. 


[July   13.  1895 


All  experts  are  not  thus,  and  it  is  a  well-known  fact 
that  there  are  many  competent  and  sincerely  just  ones. 
Neither  are  we  unmindful  of  the  fact  that  there  are, 
and  always  must  be,  serious  difficulties  in  the  way  of 
conclusively  fixing  the  mental  status  of  an  accused  in- 
dividual. A  careful  study,  however,  of  the  last  cen- 
tury's criminal  trials,  goes  to  show  that  gross  injustice 
has  been  done  in  many  cases  ;  that  ignorance  and  prej- 
udice have  too  often  proved  too  much  for  intelligent 
facts  ;  that  in  many  of  these  trials  the  medical  expert 
testimony  has  been  an  exhibition  of  contradictions  and 
absurdities  which  could  only  be  accounted  for  on  the 
grounds  above  mentioned,  or  its  servile  submission  to 
public  clamor,  which,  carried  to  a  logical  and  more 
radical  sequence,  simply  means  Lynch  law.  In  certain 
forms  of  insanity  this  seems  to  have  been  especially 
true.  There  seems  also  to  have  been  an  almost  total 
want  of  recognition  by  the  courts  of  certain  mental 
defects,  constituting  a  most  dangerous  and  hopeless 
form  of  mental  disease,  to  which  I  shall  refer  further  on. 

To  better  illustrate  the  above  I  will  call  your  atten- 
tion to  two  cases,  which  on  account  of  their  recent 
date  and  wide-spread  publication,  are  still  fresh  in  your 
minds,  and  in  which  medical  expert  testimony  failed  to 
arrive  at  conclusions  based  upon  facts  : 

Case  I. — Patrick  Joseph  Eugene  Prendergast,  a 
newsboy,  aged  twenty-six,  who  shot  Mayor  Harrison, 
of  Chicago,  in  December,  1893,  and  for  the  history  of 
whose  case  I  am  greatly  indebted  to  Drs.  Bannister ' 
and  Brower,-  who  wrote  up  his  case  thoroughly.  The 
assassination  took  place  just  as  the  Mayor  had  success- 
fully closed  an  important  function  of  the  Columbian 
Exposition,  and  so  great  was  the  shock  that  it  was  al- 
most impossible,  even  for  months  afterward,  to  find  a 
person  who  could  dispassionately  discuss  the  mental 
state  of  this  murderer.  So  familiar  are  the  details  of 
this  crime  that  it  is  unnecessary  to  speak  of  them  here. 

"  The  case  was  clearly  one  for  medical  expert  testi- 
mony to  decide  upon,  and  the  State's  attorney  origi- 
nally called  six  physicians  to  investigate  the  mental  con- 
dition of  this  man.  Five  of  them  had  large  experience 
in  the  treatment  of  the  insane  ;  the  sixth  was  a  sur- 
geon of  considerable  local  reputation,  making  no  claim, 
however,  to  expert  knowledge  of  insanity.  The  five 
physicians  reached   the  cnnrhisinn  that  the  man  was 


,il<:rg:ist. 


insane.    The  surgeon  reached  the  opposite.    Neverthe- 
less the  public  was  treated  to  another  judicial  murder." 
Prendergast's  history  well  sustains  the  conclusion"of 

'  H.  M.  Bannister,  A.M.,  M.D  ,  late  Senior  Physician  UlinoisjKast- 
ern  Hospital  for  the  Insane. 

'  H.  Brower,  M.D.,one  of  the  experts  called  by  the  State's  attor- 
ney to  e.vamine  the  mental  status  of  Prendergast. 


the  five  physicians.  "  He  was  born  in  Ireland,  April 
18,  1868.  His  paternal  grandfather  died  insane  ;  his 
mother  had  repeated  attacks  of  hysterics  ;  his  father 
died  of  consumption.  When  four  years  old  Prender- 
gast received  a  severe  injury  to  the  head  by  falling 
from  a  bench,  and  was  unconscious  for  a  considerable 
length  of  time,  vomiting  almost  constantly  for  four 
weeks  afterward.  He  was  a  peculiar  child  ;  solitary  in 
his  habits  ;  irritable  ;  easily  excited  ;  had  a  poor  mem- 
ory ;  was  dull  and  backward  in  school.  At  puberty  he 
became  distrustful  and  antagonistic  to  his  parents.  At 
sixteen  years  of  age  he  left  his  home  on  account  of 
imaginary  persecutions.  At  eighteen  he  had  exagger- 
ated opinions  of  his  own  ability  ;  he  became  a  fanatic 
on  the  single-tax  notion  ;  professing  to  be  a  Roman 
Catholic  he  yet  criticised  the  Pope's  administration  of 
the  Church  ;  he  wrote  prayers  which  he  claimed  were 
efficacious  against  certain  calamities  ;  he  claimed  that 
his  prayers  and  electioneering  elected  Mayor  Harrison, 
and  that  therefore  he  should  receive  the  office  of  Cor- 
poration Counsel,  and,  that  once  appointed,  he  simply 
needed  the  authority  of  this  office  to  speedily  elevate 
the  tracks  of  the  railroads,  so  as  to  put  a  stop  to  the 
slaughter  of  life  at  the  present  railroad  crossings  in 
that  city.  When  the  position  was  filled  by  a  skilful 
lawyer,  he  called  repeatedly  upon  him,  and  demanded 
him  to  vacate  the  office,  to  which  he,  Prendergast,  was 
alone  entitled.  During  the  discussion  of  the  Silver 
Bill  in  Congress,  he  wrote  numerous  postal  cards 
to  Congressmen  instructing  them  how  to  vote,  and 
claimed  that  his  prayers,  and  not  their  votes,  passed 
the  measure." '  In  a  very  deliberate  manner  he  shot 
the  Mayor,  and  then  proceeded  as  rapidly  as  possible 
to  the  police  station  and  told  the  officials  there  that  he 
had  shot  Mayor  Harrison. 


^^^/(AA^^ 


You  will  readily  see  by  the  picture  of  this  man  thai 
there  appears  to  be  an  unreasonable  development  ol 
the  lower  jaw.     Upon  a  closer  examination,  however,  ^ 
there  is  found  an  arrest  of  develo)>ment   of  the  bones 
of  the  face  and  upper  jaw,  extending  from  the  upper 

'  Quotations  from  Dr.  Brewer's  paper  on  Prendergast. 


July   13,  1895] 


MEDICAL    RECORD. 


39 


border  of  the  orbit  down,  producing  concavity.     This 
arrest  of   development   carries   the   nose  and  face  in 


from  one-quarter  to  three-quarters  of  an  inch  from  its 
normal  position.  As  a  result  of  the  arrest  of  develop- 
ment of  the  upper  jaw,  certain  forms  of  irregularities  of 


^w. 


the  teeth  occur,  as  you  will  notice  on  Fig.  5.'  On  the 
photograph  you  will  further  notice  the  typical  degen- 
erate ear  of  Morel.    Other  structures  of  the  body,  such 


before  the  sixth  year,  and  were  due  to  defects  in  the 
cell-structure  of  the  brain  governing  then  utrition  of 
these  parts. 

Figs.  2,  3,  and  4,  show  the  outlines  of  the  skull. 
Like  the  facial  bones  they  are  very  remarkable.  You 
will  notice  that  the  antero-posterior  and  biparietal 
diameters  are  not  ver}'  much  of  a  departure  from  the 
normal  type.  The  bitemporal  diameter,  on  the  con- 
trary, is  most  unusually  so.  Such  a  remarkable  arrest 
of  development  of  the  frontal  region  of  the  skull,  as 
the  outlines  on  Figs.  2  and  3  show,  indicates  that  the 
higher  intellectual  faculties  and  consequent  self-con- 
trol are  ver\"  deficient.  These  same  figures  also  show 
the  unusually  large  development  of  the  lower  mental 
faculties.  Fig.  4  shows  a  marked  depression  on  the 
top  of  the  head.  I  chiefly  wish  to  call  your  attention 
to  the  small  intellectual  and  controlling  power  of  such 
a  developed  brain.  These  facts  go  clearly  to  show 
that  this  man  was  a  creature  of  impulses,  and  not  of 
reason.  In  other  words,  impulse  was  the  mastering 
element,  the  moving  force  of  his  nature,  and  he  knew 
or  could  know  no  law  of  volition.  Prendergast  evi- 
dently belonged  to  that  class  of  degenerates  called 
paranoiacs,  fitting  closely  the  descriptions  of  Gray, 
Regis,  and  Kirchhoff,'  who  attribute  to  them  self-ex- 
altation ;  systematized  progressive  delusions  ;  tenden- 
cies toward  political  homicides,  apparently  pre  - 
meditated,  well  calculated,  and  consistent  with  their 
delusions.  Such  persons  need  but  an  inspiration  to 
develop  delusional  impulses,  which  are  executed  with 
astonishing  rapidity,  decisiveness,  and  fiendish  cunning. 

This  man  labored  under  the  delusion  that  it  was  a 
divinely  imposed  duty  for  him  to  slay  the  Mayor,  and 
to  see  that  track-elevation  might  be  effected,  and  lives 
accordingly  saved.  This  was  emphasized  by  his  ea- 
gerness to  give  himself  up  to  the  officers  of  the  law,  and 
the  assertion  that  he  would  do  the  same  thing  over 
again,  believing  "  that  the  God  who  had  commissioned 
him  would  have  him  under  his  special  care."  It  seems 
convincing  enough  to  the  average  mind  that  this  man 
was  insane,  and  yet,  in  spite  of  this,  and  the  fact — as 
before  stated — that  five  medical  experts  out  of  six  tes- 
tified that  he  was  insane,  it  proved  to  be  insufficient  to 
protect  him  from  the  injustice  which  public  clamor 
visited  upon  him,  and  he  was  executed. 


as  hair,   skin,  and   lymphatic  glands,    were    abnormal. 
These  arrests  of  development  occurred  early  in  life, 

'  The    photographs    and    drawings   illustrating   this    case    are   all 
copied  from  Dr.  Brewer's  paper  on  Prendergast. 


Fig.  6.— Lizzie  Hallid 


Case  II. — Mrs.  Lizzie  Halliday,  the  Sullivan  County 
triple  murderess.  This  woman's  case  and  trial  are  of 
so  recent  date  that  it  will  be  unnecessary  to  enter  into 
details  with  reference  to  them.     She  was  born  in  Ire- 

'L.  C.  Gray,  M.D.,  New  York  City  ;  E.  Regis,  Jr.,  M.D.,  Chief  of 
Clinique  of  Mental  Diseases.  Faculty  of  Medicine,  Paris,  France  ;  T. 
Kirchhoff,  M.D. ,  Physician  to  Schleswig  Insane  .Asylum,  KieL 


40 


MEDICAL   RECORD. 


[July 


1895 


land,  under  the  name  of  McNally,  and  came  lo  this 
country  in  1867.  She  is  now  thirty-six  years  of  age; 
five  feet  and  two  inches  in  height.     Her  girlhood   was 


uneventful,  unless  that  she  was  of  a  more  than  usually 
irritable  temper  and  rather  capricious  (see  Fig.  8). 
The  cast,  as  illustrated  by  Figs.  9  and  10,  and  roughly 
made  by  myself,  together  with  Figs.  6,  7,  and  11,  give 
the    outlines    of    Mrs.    Hallidav's   skull."     It  is  mark- 


edly asymmetrical.  Her  head  is  high  and  some- 
what tapering,  as  will  be  seen  in  Figs.  6  and  7.  I 
wish  particularly  to  call  your  attention  to  Fig.  n, 
showing  the  circumference  of  the  head.  It  is  one  of 
most  unusual  shape,  inasmuch  as  the  right  side  seems 
to  have  been  forced  backward,  and  the  left  forward, 
thus  making  an  irregular  elliptic  curve.  The  peculiar 
prominence  in  the  left  frontal  region  and  the  excessive 
prominence  of  the  right  occipital  are  very  noticeable, 
and  attracted  my  attention  when  I  first  examined  her. 
There  is  a  marked  flattening  in  the  right  occipito-pa- 
rietal  region,  and  also  an  excessive  development  of  the 
right  side  over  that  of  the  left,  which  is  exactly  o[)po- 

'  The  cast  was  made  as  follows ;  The  hair  having  been  evenly  pasted 
down  (0  the  scalp,  rubber  tissue  was  carefully  fitted  over  the  liair,  and 
pressed  firmly  down.  A  diaphragm  w.as  theii  pi  iced  around  the  iie.ad 
at  a  level  witli  the  eyebrows  in  front,  .and  immediately  below  the  base 
of  the  cranium  posteriorly,  and  a  mould  m.ade  in  the  regular  wav.  Sub- 
sequent expert  palpation  demonstrated  its  correctness. 


site  to  the  normal  head.  The  excessive  development 
over  the  paracentral  lobe  is  also  very  noticeable.  In 
the  greater  fulness  of  the  right  side  there  is  a  similar- 
ity between  this  head  and  that  of  Frendergast. 


Fics.  9  and  lo. — Casts  of  Mrs   Halliday's  head. 

Regis  says  that  in  chronic  insanities,  contrary  to  the 
usual  rule,  the  right  hemisphere  of  the  brain  very  often 
weighs  mere  than  the  left.  My  observations  in  the  ex- 
amination of  several  thousand  criminals  have  led  me 
to  believe  that,  as  a  rule,  when  in  the  inherent  crim- 


inal the  right  side  of  the  cranium  (that  is.  the  right 
hemisphere  of  the  brain)  is  in  an  excessive  develop- 
ment over  the  left,  especially  where  there  is  a  marked 
fulness  over  the  jiaracentral  lobe,  the  possessor's  im- 
pulses lead  toward  homicide.  I  have  repeatedly  been 
able  to  place  my  hand  upon  this  part  of  the  head  of 
criminals  and  designate  their  crimes  to  be  either  assault 
or  homicide,  without  any  previous  knowledge  of  their 


July    13,  1895] 


MEDICAL   RECORD. 


41 


history  or  themselves.  ■  Both  Figs.  4  and  7  show  this 
excessive  development,  which  in  Lizzie  Halliday  (Fig. 
7)  is  more  marked. 

A  look  at  these  photographs  of  her,  which  were  taken 
while  she  was  under  confinement  in  Clinton  Prison, 
shows  :     Nose    coarse    and    disproportionately    large  ; 


bridge  flat  and  upturned  ;  malars  and  superciliary 
arches  prominent,  mouth  large,  lips  medium  thickness, 
teeth  fairly  regular,  etc.  Space  will  not  permit  me  to 
enter  into  a  description  of  this  woman's  history  and 
symptoms  from  girlhood  until  the  time  of  her  arrest, 
although  it  is  exceedingly  interesting.     It  is,  however. 


elaborately  described  by  Dr.  Blumer '  in  a  paper  read 
before  the  Kings  County  iMedical  Society  on  Septem- 
ber 18,  1894,  and  I  am  greatly  indebted  to  him  for 
many  valuable  suggestions  and  quotations  in  the  prep- 
aration of  this  paper.  I  will  therefore  content  myselt 
by  stating  that  careful  and  painstaking  research,  pre- 
vious to  the  time  of  the  commission  of  the  triple  mur- 
der, for  which  she  was  tried  and  sentenced,  has  shown 
that  she  had  always  been  erratic  and  peculiar  beyond 
comprehension  ;  that  she  had  married  six  times — in 
every  instance  moved  by  some  unexplainable  caprice — 
and  that  she  had  been  in  two  asylums  in  this  State. 
There  is  also  evidence  going  to  show  that  this  woman 
for  the  whole  period  from  the  time  of  the  commission 
of  the  triple  murder  until  her  trial  gave  unmistakable 
symptoms  of  insanity. 

She  was  received  at  Clinton  Prison  on  June  29,  189.], 
and  on  that  date  came  under  my  professional  care,  re- 
maining in  my  charge  until  July  23d,  same  year.  -\ 
careful  record  of  observations  was  made  daily  during 
that  time  by  myself  and  attendants. 

Chief  among  the  physical  symptoms  noted  were 
rapid  pulse,  averaging  over  100  ;  extreme  emaciation  ; 
refusal  of  food,  necessitating  forced  feeding  ;  diabetic 
symptoms  (quantitative  analysis  of  her  urine  on  July 
13th  showing  4.5  per  cent,  of  glucose)  ;  excessive  men- 
strual flow  ;  at  these  times  she  was  much  more  violent 
and  difficult  to  control  ;  a  complete  an.nesthesia  even  ot 
the  most  sensitive  areas  of  the  skin,  eyeballs,  and  nose 
(this  analgesic  condition  was  so  complete  that  flies 
crawling  over  her  face  were  never  brushed  away,  and 
that  tests  made  with   the  knife-point  and  the  applica- 

'  G.  A.  Blumer,  M  D. ,  Superintendent  of  the  State  Asylum  for  the 
Insane  at  Utica,  N.  Y. 


tion  of  the  lighted  fuse  failed  to  produce  the  slightest 
reflex,  or  the  cessation  for  an  instant  of  her  incoherent 
jargon)  ;  drooling  of  larger  quantities  of  glairy  mucus 
from  the  nose  and  mouth  ;  her  walk  was  shuffling,  irreg- 
ular, and  uncertain,  and  she  could  not  maintain  her 
equilibrium  with  her  eyes  closed. 

The  mental  symptoms  noted  were  :  Illusions  and 
hallucinations  of  sight  and  sound  ;  she  was  violent  and 
noisy  ;  her  habits  were  extremely  filthy  ;  she  exhibited 
obsessions  (or  irresistible  propensities),  such  as  the 
ejaculation  of  vile  language  without  provocation,  ago- 
nizing fears  of  crossing  a  river  when  taken  to  and  from 
her  cell,  constant  repetition  of  the  number  13,  etc. 

The  following  extract  from  Dr.  Blumer's  paper  illus- 
trates vividly  the  above  :  "  The  patient  was  crouching 
in  a  corner  of  her  cell  with  her  face  turned  to  the  wall, 
muttering  and  hallooing  incoherently.  When  brought 
into  the  corridor  she  offered  resistance,  crying,  '  Don't 
let  me  go  by  the  river.'  Her  ears  and  nostrils  were 
stuffed  with  bits  of  dress  material.  When  forcibly 
seated  in  a  chair  she  began  to  pick  at  her  clothing,  to 
spit,  to  stamp  on  the  floor,  and,  when  not  restrained, 
pounded  her  thighs  violently  with  her  fists.  She  paid 
no  attention  to  her  examiners,  and  could  not  be  in- 
duced to  answer  questions.  The  following  were  some 
of  her  incoherent  mutterings,  taken  down  at  the  time  : 
'  Manure.  Nicodemus.  Pitchforks.  Don't  you  stay 
here.  No  !  I  don't  want  you.  Yes  I  You  did.  You 
took  my  baby.  Thirteen  and  fourteen  o'clock.  Snow 
and  bullfrogs.  Take  the  little  dress  out  of  the  drawer, 
and  bring  my  little  Isabella.  Take  them  snakes  away. 
Nineteen  cords  charcoal.  Don't  throw  that  over  me. 
I  can't  eat  that  sawdust.  You  have  got  small-pox  in 
your  heels.  She  broke  a  spine  of  my  ribs.  You  have 
got  that  bear  sewed  up  in  me,'  "  etc. 

These  symptoms,  taken  in  connection  with  the  con- 
figuration of  her  head  unmistakably  place  her  with  that 
class  of  degenerates  described  by  the  French  alienists 
as  the  phrenastheniacs,  in  other  words,  a  creature  of  ir- 
resistible impulses,  feebleness  of  will,  yet  possessed  of 
a  degree  of  conscious  and  reasoning  power,  and  whose 
dominant  morbid  tendencies  are  to  private  murder. 

Mrs.  Halliday  was  such  a  being.  With  intelligence 
and  reason  sufficient  to  plan  and  execute,  but  without 
power  to  choose,  without  moral  feeling,  unknown  to  re- 
morse, she  only  needed  an  exciting  cause,  such  as  some 
disturbance  of  the  reproductive  organs,  to  set  in  mo- 
tion an  impulse,  which,  resisted  it  may  be  for  a  time, 
yet  gathering  in  intensity,  becomes  too  strong  for  voli- 
tion, the  demoniacal  impulse  is  freed  from  its  domina- 
tion, and  the  fiendish  act  is  perpetrated.' 

The  picture  is  complete,  and  even  if  the  symptoms 
alleged  to  have  been  feigned  by  the  experts  for  the 
prosecution,  were  so,  the  physical  symptoms  above 
enumerated  at  least  admit  of  no  intelligent  doubt  as  to 
her  insanity.  Notwithstanding  this,  and  the  fact  that 
two  expert  alienists,  Drs.  .\llison  and  Talcott,-  under 
whose  charge  she  had  been  when  in  asylum,  testified 
that  she  was  insane,  this  woman,  principally  upon  the 
testimony  of  one  so-called  expert,  was  sentenced  to  be 
executed,  and  had  it  not  been  for  the  executive,  who 
in  clemency  appointed  the  commission  that  declared 
her  insane,  another  name  would  have  been  added  to 
the  list  of  judicial  homicides.' 

We  have  seen  by  the  above  that  both  Prendergast 
and  Lizzie  Halliday  belonged  to  a  class  of  degenerate 
criminals,  and  were  both  suffering  from  what  may  be 
termed  conscious-impulsive  insanity,  and  that  both 
cases  were  decided  by  the  courts  through  the  agency 
of  certain  medical  expert  testimony,  adjusting  itself  to 
suit  the  demand  of  an  excited  and  clamorous  public, 

'  H.  E.  Allison,  M.D.,  Superintendent  of  the  State  Asylum  for  In- 
sane Criminals  at  Matteawan,  and  who  now  has  her  in  charge,  be- 
lieves that  her  crimes  have  been  committed  when  she  was  or  had 
recently  been  pregnant,  and  there  is  much  to  substantiate  this  view. 

'  S.  H.  Talcott,  M.D..  Superintendent  of  the  Middletown  Asylum. 

'  The  members  of  this  commission  were  Drs.  G.  A.  Blumer,  J.  M. 
Lee,  and  J.  D.  Spencer. 


42 


MEDICAL    RECORD. 


[July  13,  1895 


in  direct  opposition  to  what  we  have  seen  to  be  the 
facts.  In  ijoth  cases  the  error  seems  to  have  arisen 
from  a  common  misapprehension  by  the  courts  of  just 
what  mental  responsibility  means.  The  courts  have 
repeatedly  held  that  the  question  to  decide  as  touching 
a  man's  mental  responsibility  under  the  law,  is  his  abil- 
ity to  distinguish  between  right  and  wrong,  that  is,  to 
be  able  to  understand  his  moral  and  legal  responsi- 
bility. While  this  applies  to  certain  forms  of  insanity 
it  is  not  all  that  is  necessary  in  the  way  of  a  test,  nor 
does  it  cover  the  whole  ground,  for  it  will  be  readily 
seen  that  by  the  application  of  this  test  alone  to  the 
cases  above  cited  a  rank  injustice  was  done.  The 
question  to  decide  in  any  given  case  of  insanity  is  not 
alone  as  to  whether  the  mental  perceptions  admit  the 
knowledge  of  the  right  or  wrong,  for  which  a  person  is 
held  to  trial,  for  it  may  be  a  question  of  the  individ- 
ual's power  to  control  his  impulse,  a  question  of  vo- 
lition, not  of  a  nice  adjustment  of  moral  equities. 
Consciousness  must  not  be  confounded  with  control, 
because,  as  we  have  seen,  an  insane  person  may  be 
perfectly  conscious  of  his  acts,  conscious  of  his  respon- 
sibility to  the  law,  conscious  of  the  penalty,  conscious 
to  a  degree,  enabling  him  to  use  his  powers  of  cunning 
to  avoid  the  infliction  of  penalty,  and  yet  in  no  way 
more  responsible  for  the  act  than  would  be  the  man 
who,  hurled  from  the  top  of  some  high  building,  falls 
upon  a  passing  pedestrian  and  crushes  him  to  death. 

The  power  of  controlling  the  acts  is  more  or  less  the 
essential  factor  in  insanity  and  irresponsibility,  and 
more  so  than  is  the  knowledge  of  their  nature  and  con- 
sequences. Insanity  is  a  disease,  and  not  a  legal  ques- 
tion. We  should  not  allow  ourselves  to  be  misled  by 
the  shrewd  tactics  of  the  manipulators  of  the  law,  or 
be  influenced  by  the  popular  distrust  of  the  plea  of  in- 
sanity as  a  defence  for  crime,  in  common  parlance 
called  "  The  Insanity  Dodge." 

If  it  is  conceded  that  insanity  is  to  lessen  responsi- 
bility and  to  mitigate  punishment,  why  then  there  is  no 
half-way  ground  to  be  taken.  This  mantle  of  attenua- 
tion cannot  justly  cover  only  a  certain  type  of  the  men- 
tally deficient,  but  must  extend  itself  over  all  forms  and 
types,  the  inherently  deficient  and  the  degenerate  as  well 
as  the  demented  and  the  melancholic.  The  fact  that 
the  law  does  not  afford  protection  for  the  former  class, 
who  need  it  so  much  more  than  the  latter  against  an 
exasperated  public  sentiment,  is  due,  as  before  inti- 
mated, to  the  failure  of  medical  expert  testimony,  as  at 
present  introduced,  to  so  protect  them,  and  in  the  light 
of  these  cases  there  has  apparently  been  little,  if  any, 
advance  made  toward  a  more  reasonable  and  more 
definite  method  of  introducing  such  testimony. 

It  is  true  that  occasionally  a  step  in  the  right  direc- 
tion is  taken  in  eliminating  much  that  is  objectionable 
and  harmful  in  such  trials,  as  was  the  case  in  a  recent 
trial  which  took  place  in  the  District  of  Columbia.' 
But  to  my  knowledge  nothing  consistent  with  an 
improved  revision  of  the  whole  system  of  medical  expert 
testimony  has  been  undertaken.  The  question  at  once 
arises.  By  whom  shall  this  needed  reform  be  under- 
taken, and  to  whom  shall  we  look  for  a  first  movement 
in  the  right  direction  ?  If  we  listen  intently  we  may 
hear  the  indefinable  mutterings  of  an  arousing  public 
sentiment  in  this  regard,  and  I  firmly  believe  that  the 
first  indictment  lodged  by  that  most  exacting  of  tri- 
bunals, an  awakened  public  mind,  will  be  against  the 
medical  profession,  and  the  courts  will  join  hands  with 
them  in  a  mutual  flagellation.  The  courts  themselves 
have  a  way  of  avoiding  such  indictments  unknown  to 
us.  Aside  from  this  aspect  of  the  case  there  remains 
to  us  as  a  profession  the  much  more  important  neces- 
sity of  preserving  our  professional  dignity  and  inspir- 
ing confidence  in  our  integrity  and  ability.  The  tes- 
tifying of  medical  experts  to  diametrically  opjiosite 
views  in  a  given  case  is  not  a  spectacle  calculated  to 

'  See  Medic.\l  Record,  November  17,  1894. 


enhance  the  prestige  of  the  profession  from  any  point 
of  view,  or  likely  to  increase  the  confidence  of  a  criti- 
cal public  in  the  efficiency  of  our  art.  It  then  remains 
for  us  to  act  with  promptness  and  determination,  and 
unite  in  an  effort  toward  a  change  in  this  whole  method 
of  giving  medical  expert  testimony. 

My  own  belief  is  that  this  whole  system  should  be 
radically  changed,  and  the  right  to  give  medical  ex- 
pert testimony  in  any  court  in  this  State  should  be 
lodged  in  a  non-partisan  State  Board,  appointed  by  the 
Governor  and  subject  to  approval  by  the  Senate.  I 
will  not  presume  upon  your  time,  nor  upon  my  legal 
acquisitions,  to  more  than  roughly  outline  what  seems 
to  me  would  be  the  most  likely  to  meet  the  require- 
ments of  the  situation. 

This  Board  should  act  in  a  capacity  of  instructors 
and  advisory  to  the  courts.  It  should  consist  of  a  suf- 
ficient number  to  amply  provide  for  all  criminal  trials 
likely  to  take  place  at  any  time,  and  should  be  subject 
to  the  call  of  the  proper  courts.  The  members  of  this 
Board  should  be  chosen  from  the  ranks  of  our  most 
expert  alienists,  men  ripe  in  experience  and  judgment, 
and  having  an  ascertained  qualification.  The  func- 
tions and  powers  of  this  Board  to  be  to  examine  with 
reference  to  the  sanity  or  insanity  of  the  accused,  and 
shall  therefore  he  empowered  to  call  and  examine  any 
witness  they  may  deem  necessary,  be  they  professional 
or  lay.  They  shall  have  access  to  all  evidence  throw- 
ing any  light  upon  the  case,  and  it  shall  also  be  pro- 
vided that  both  prosecution  and  defence  shall,  by 
showing  reasonable  cause,  have  the  privilege  of  appeal- 
ing to  the  courts  for  the  calling  of  additional  members 
of  the  said  Board  to  also  examine  the  accused,  where 
the  decision  by  the  first  expert  called  seems  inconsistent. 
In  no  case  shall  any  physician,  not  a  member  of  this 
Board,  be  allowed  to  testify  as  an  expert  in  insanity 
cases  other  than  through  the  Board  itself,  and  in  open 
court  his  evidence  shall  be  restricted  to  his  knowledge 
of  the  facts  in  the  case.  This  Board  should  receive  its 
remuneration  from  the  State.  If  it  should  be  urged 
that  the  creation  of  a  special  Board  by  the  State  is  un- 
wise, there  seems  little  objection  to  the  designation  of 
such  a  Board  from  the  ranks  of  qualified  alienists  al- 
ready in  the  State  service. 

I  believe  that  it  is  only  through  some  such  method 
of  procedure  that  the  whole  system  of  giving  medical 
expert  testimony  can  be  purged  of  its  incompetency, 
venality,  sensationalism,  and  confusion,  and  that  a 
trained,  thoroughly  experienced,  and  efficient  class  of 
medical  experts  can  be  secured.  Thereby  the  ends  of 
true  justice  can  be  most  nearly  meted  out  by  the 
courts,  and  the  medical  profession,  even  here,  as  in 
other  branches  of  its  work,  sustain  the  high  position  it 
so  deservedly  holds  as  a  conservator  of  the  human 
weal. 

Mr.  President,  I  would  suggest  including  in  the  dis- 
cussion of  this  paper  the  advisability  of  the  appoint- 
ment of  a  committee  to  consider  and  report  upon  the 
most  feasible  plan  for  an  improvement  in  the  present 
method  of  introducing  medical  expert  testimony  in 
cases  where  insanity  is  made  the  plea  for  the  defence. 

Dannbmoka,  N.  v.,  February-,  1S95. 


Meat  Eating  in  England. — In  the  three  years,  iSSj 
to  1SS4,  the  consumption  of  meat  in  England  was  loS 
pounds  per  head  ;  and  in  the  three  years  1S91  to  1S93 
it  was  1 19  per  liead. 

Medical  Education  for  Women  in  Russia. — The  ap- 
plications for  admission  to  the  new  School  of  Medi- 
cine for  Women,  which  is  to  be  opened  in  St.  Peters- 
burg at  the  beginning  of  the  academic  year  1S95-96, 
are  already  so  numerous  that  the  Russian  Education 
Department  has  decided  that  female  medical  students 
shall  be  admitted  to  the  medical  faculties  of  all  the 
universities  of  the  empire. 


July   13,  1895] 


MEDICAL    RECORD. 


43 


THE  TREATMENT  OF  SUMMER  COMPLAINT. 
OR  CxASTRO  -  ENTERITIS  CATARRHALIS 
ACUTA,  INCLUDING  CHOLERA  INFANTUM 
IN  CHILDREN. 

By  LOUIS  FISCHER,  M.D., 


IKSTRUCTOR  : 


OF  CHILDREN  AT  THE  NEW  YORK  POST-GRADL'ATE 
.  SCHOOL  AND  HOSPITAL  ;  VISITING  PHYSICIAN  TO  THS  MESSIAH  HOllE 
FOR  CHILDREN  ;  ATTENDING  PHYSICIAN  TO  THE  CH11_DREN*S  DEPARTMENT  OF 
THE  GERUAN   POLYKXINIK. 

Three  years  ago  it  was  my  good  fortune  to  study  some 
typical  cases  of  diarrhoea  in  a  mild  and  aggravated  form, 
occurring  in  several  hundred  children,  in  both  hospital 
and  private  practice.  The  results  of  these  examinations 
were  embodied  in  a  paper  published  in  the  Post-Grad- 
uate  Journal,  No.  10,  1892.  It  was  found  that  two 
classes  of  cases  presented  themselves  for  treatment, 
usually  during  a  sudden  increase  in  temperature  of  the 
weather  ;  so  much  so,  that  I  was  led  to  believe,  with  a 
great  many  others,  that  there  is  a  probability  that  some 
specific  micro-organism  is  latent  until  actively  devel- 
oped by  the  sudden  rise  of  temperature.  The  morbid 
process  consists  in  this  class  of  cases,  chiefly  of  i, 
vomiting,  and  2,  diarrhoea  —  the  vomit  depending 
upon  the  nature  and  the  frequency  of  the  food  and 
the  general  predisposition  and  %'itality  of  the  patient 
affected  ;  the  diarrhcea,  consisting  likewise,  as  in  the 
case  of  the  vomit,  of  either  undigested  particles  of 
food,  greenish  stools,  which  give  a  distinct  reaction 
with  nitric  acid,  showing  the  presence  of  bile  in  the 
passage,  other  stools  containing  mucus,  cylindrical 
epithelium  and  round  cells,  and  coming  chiefly  from 
the  small  intestines.  We  note  that  normally  there 
is  no  bile  in  the  large  intestines,  consequently  all 
green  stools  emanate  from  the  small  intestines.  When 
the  mucus  is  not  thoroughly  mixed  with  the  fasces, 
when  the  fseces  are  wrapped  up  in  it,  or  mucus  covers 
the  faeces  after  evacuation,  we  conclude  that  the 
mucus  comes  from  the  colon,  and  we  have  colitis. 
Blood,  when  found  in  a  bright  color  in  stools,  comes 
from  the  lower  end  of  the  bowels,  and  the  rule  that 
Boas  in  Berlin  lays  down  is,  "  The  darker  the  blood  in 
stools,  the  higher  up  the  morbid  process  must  be 
looked  for,  whereas  the  lighter  the  color  of  the  blood, 
the  lower  the  region  of  the  morbid  or  pathological 
process,  hence  it  is  sa'"e  to  examine  the  anus  fo.r 
erosions  and  fissures  of  the  anus,  when  the  blood  is 
bright."  Duodenal  catarrh  can  be  diagnosticated  only 
when  it  is  complicated  with  jaundice  ;  it  never  gives 
rise  to  diarrhcea  alone.  Tenesmus  is  observed  only 
when  the  lower  portion  of  the  rectum  is  involved 
in  the  morbid  process. 

Predisposition  to  Diarrhoea. — Healthy  infants  have  a 
normal  tendency  to  loose  liquid  and  semi-liquid  evac- 
uations from  the  bowels  :  i.  Partly  from  the  condi- 
tion of  the  intestinal  tract.  2.  Partly  from  the  nature 
of  normal  food,  i.e.,  breast-milk.  Peristaltic  move- 
ments in  a  healthy  child  are  very  active.  Young 
blood  and  lympathic  vessels  are  quite  permeable,  and 
the  transformation  of  the  surface  cells  are  active 
and  rapid.  The  peripheral  nerves  are  superficial, 
more  so  than  in  adults,  whose  mucous  membrane  and 
submucous  tissue  have  undergone  thickening  by  both 
normal  development  and  morbid  processes.  Besides, 
the  action  of  the  sphincter  ani  is  not  very  powerful. 
Fasces  are  not  retained  in  the  colon  and  rectum,  and 
little  time  is  afforded  for  the  reabsorption  of  the  li<juid 
or  dissolved  fscal  contents.  The  frequency  of  acids 
(sometimes  normal)  in  the  small  intestine  gives  rise  to 
the  formation  of  alkaline  salts  with  purgative  properties. 
Free  acids  when  found  in  the  intestine  show  that,  i, 
the  quantity  of  food  is  too  large  ;  2,  the  quantity  of 
the  digestive  fluid  is  too  small,  causing  fermentation 
instead  of  normal  digestion. 

The  diastatic  effect  of  pancreatic  juice  is  limited  at 
an  early  age,  and  undigested  material  is  carried  off. 
Colostrum  secreted  after  birth  is  apt  to  give  diarrhoea. 


Milk  containing  too  much  fat  or  too  many  salts,  as  in 
anaemia,  is  liable  to  produce  the  same  effect.  Let  us, 
then,  consider  the  first  etiology  of  these  cases,  and  we 
find  :  I.  Food — improper  quantity  and  quality.  2.  Im- 
proper artificial  feeding.  Some  authors,  even  Jacobi, 
say  that  mother's  milk  may  cause  this  pathological  con- 
dition. Mothers  who  are  sick  or  convalescing,  or  sub- 
ject to  strong  emotions,  who  nurse  too  often,  who  suffer 
from  tuberculosis  or  syphilis,  pregnant  women,  some 
who  are  menstruating,  and  all  anaemic  women  secrete 
improper  milk,  hence  they  should  not  nurse  for  the  time 
being,  or  until  their  milk  is  of  normal  quality.  3.  In- 
fluence of  weather  on  digestion,  especially  the  excessive 
heat  of  the  summer.  4.  Improper  disinfection  of  the 
nipples  after  nursing,  and  consequent  decomposition 
or  formation  of  micro  organisms,  which  can  infect  the 
milk.  5.  Improper  disinfection  of  the  nipples  before 
nursing.  6.  Naso-pharyngeal  catarrh  a  distinct  causa- 
tive factor  in  gastric  catarth,  as  was  shown  in  a  paper 
read  by  me  in  the  Section  of  Pediatrics  at  the  New 
York  Academy  of  Medicine  in  June,  1891.  Published 
in  Medical  Record  on  June  13,  1891. 

It  is  not  my  intention  to  elaborate  on  the  anatomical 
changes  during  the  course  of  this  pathological  condi- 
tion nor  to  describe  the  well-known  post-mortem 
changes,  which  are  so  much  more  completely  described 
in  our  text-books  and  which  cannot  be  demonstrated 
on  paper,  but  rather  confine  myself  to  the  treatment 
intra  vitam. 

Mechanical. — The  treatment  which  has  been  most 
successful  in  my  hands,  and  which  is  the  result  of  per- 
sonal experience,  besides  advice  from  such  authorities 
as  Professor  Baginsky,  of  Berlin,  Dr.  Hugo  Neumann, 
also  of  Berlin,  and  a  great  many  others.  If  improper 
food  is  the  cause  of  a  disordered  stomach,  it  stands  to 
reason  that  the  first  point  of  the  treatment  should  be  to 
remove  that  offensive  food.  For  that  purpose  we  resort 
to  mechanical  treatment,  consisting  of  washing  the 
stomach  with  the  ordinar)-  normal  saline  solution. 
When  a  child  is  brought  in  with  a  histor)-  of  vomiting 
I  proceed  in  the  following  manner  :  I  introduce  a  No. 
10  flexible  catheter,  haWng  more  than  one  opening,  by 
pushing  it  gently  against  the  pharyngeal  wall,  continu- 
ing to  push  it  down  the  pharrax  into  the  oesophagus 
until  we  reach  the  stomach.  The  tube  is  never  anoint- 
ed with  oil,  because  there  is  normally  so  much  mucus 
present  that  we  have  nature's  own  lubrication.  That 
a  No.  10  tube  is  not  too  large  for  a  child  between  six 
months  and  one  year  of  age  can  be  proven  by  the  fact 
that  after  we  attach  a  long  rubber  tube,  ending  in  an 
ordinar)'  glass  irrigator,  or  ending  in  a  long  glass  fun- 
nel, the  child  frequently  has  plenty  of  room  to  vomit 
the  excess  of  water  while  the  tube  is  in  situ,  so  that 
the  calibre  of  the  tube  allows  ample  room  for  natures 
relief,  if  necessary.  Having  then  introduced  the  tube^ 
I  usually  allow  water  of  the  temperature  of  from  90° 
to  105°  F.  to  gradually  flow  into  the  stomach  until 
about  one  pint  has  entered.  In  using  a  funnel  we  can 
syphon  off  the  contents  of  the  stomach  by  lowering  the 
funnel  below  the  level  of  the  stomach.  Ha%-ing  emp- 
tied as  much  as  we  can,  I  raise  the  funnel  above  the 
child's  head  and  again  pour  a  pint  of  this  normal  saline 
solution  into  the  stomach,  and  this  process  can  be  re- 
peated until  the  syphoning  proves  the  stomach  fairly 
clean.     So  much  for  lavage. 

The  question.  How  often  shall  we  irrigate  the  stom- 
ach ?  depends  on  the  amount  of  fermentation  present, 
on  the  condition  of  the  child  following  this  lavage,  and 
also  on  the  effect  of  the  irrigation  on  the  vomiting 
which  existed  prior  to  this  mechanical  treatment.  It 
is,  however,  customar>'  to  repeat  this  washing  either 
the  next  or  two  days  following  the  first  lavage.  After 
cleansing  the  stomach  of  this  offensive  food,  we  pre- 
scribe rest,  and  insist  on  leaving  the  child  at  least  two 
hours  without  giving  food  of  any  kind.  I  do,  however, 
permit  a  small  quantity  of  an  alkaline  water,  either 
Seltzer  or   Yichv,  ApoUinaris  water,  or   plain  boiled 


44 


MEDICAL   RECORD. 


[July   13,  1895 


(sterilized)  water  to  be  given.  -Lime-water  may  also 
be  given  undiluted  ad libitutn.  It  has  been  found  by  a 
great  many  authors,  and  I  perfectly  agree  with  them, 
that  alcoholic  stimulants  are  decidedly  harmful  in  some 
cases,  whereas  they  are  beneficial  in  others.  I  do  not, 
however,  prescribe  alcohol  in  any  form  when  a  child  is 
brought  to  me  with  a  high  temperature,  in  a  very  acute 
inflammatory  state  of  the  mucous  membranes,  and 
where  an  acute  catarrhal  gastric  or  enteric  fever  exists. 
Having  then  prescribed  rest  for  the  stomach,  the  next 
thing  is  to  discontinue  milk  in  any  and  every  form. 
It  is  surprising  to  find  that  even  in  nursing  babies  we 
can  frequently  work  wonderful  changes  by  discontinu- 
ing the  nursing  for  one-half  a  day  or  one  day,  while 
cleansing  the  alimentary  tract.  Where  severe  diarrhoea 
exists,  I  first  try  to  locate  the  lesion  in  the  intestine  by 
examining  the  nature  and  frequency  of  the  stools,  and 
we  invariably  keep  a  record  of  the  number  of  stools 
passed  in  twenty-four  hours.  Where  there  is  a  lien- 
tery,  i.e.,  stools  containing  indigestible  particles  of 
foods,  we  note  that  the  lesion  comes  from  the  stomach. 
I  have  previously  referred  to  the  presence  of  blood, 
mucus,  and  bile  in  the  stools,  and  it  is  very  important 
to  judge  the  nature  of  these  stools  before  resorting  to 
treatment.  In  all  diarrhceas,  however,  it  is  advisable 
to  irrigate  the  rectum  and  colon,  by  placing  the  child 
on  its  left  side,  introducing  a  flexible  rubber  tube, 
using  plenty  of  oil  or  vaseline  for  lubrication,  having 
passed  the  sphincter  and  gently  pushed  the  tube  be- 
yond the  rectum  into  the  colon,  as  far  up  as  we  can. 
At  times  a  little  difficulty  is  encountered,  owing  to  the 
spasmodic  contraction  of  the  muscles,  of  the  internal 
and  external  sphincters,  but  if  a  little  patience  is  used 
no  difficulty  will  be  encountered,  and  the  tube  will 
glide  easily  into  the  colon.  The  method  of  irrigation 
of  the  bowels  is  the  same  we  use  in  irrigating  the  stom- 
ach, excepting  that  we  do  not  seek  to  syphon  off  the 
contents  of  the  bowel,  but  rather  to  allow  a  pint  or  a 
quart,  sometimes  even  two  quarts  of  warm  normal  saline 
solution  to  flush  the  bowel,  and  in  this  way  wash  away 
as  much  of  the  faeces  and  offending  debris  as  exist  at 
the  time  within  the  bowel.  I  have  frequently  resorted 
to  flushing  the  bowel  with  cold  water,  but  I  found  a 
much  greater  benefit  from  the  use  of  the  warm  saline 
solution,  of  a  temperature  of  about  100°  F.  I  have  also 
frequently  washed  the  bowel  with  a  solution  of  boracic 
acidy  but  have  never  seen  any  decided  benefit  caused 
by  it.  The  same  may  be  said  of  astringent  irrigations, 
such  as  a  very  weak  solution  of  nitrate  of  silver  and 
also  tannin.  I  have  also  injected  a  i  to  10,000  solution 
of  bichloride  of  mercury,  and  have  never  seen  any  bene- 
fit directly  attributable  to  any  of  these  remedies,  so 
that  I  have  come  to  use  plain  warm  salt  water  and 
cleanse  the  bowel  as  perfectly  as  possible.  The  fre- 
quency of  cleansing  depends  upon  the  improvement 
shown  in  a  given  case.  While  some  cases  required  irri- 
gation every  day  for  one  week,  others  would  be  so  greatly 
improved  after  one  rectal  washing  that  it  was  not  neces- 
sary to  resort  to  it  again.  In  all  cases,  however,  a  great 
deal  of  judgment  and  common-sense  will  do  more  than 
using  every  remedy  or  any  remedy  haphazard,  without 
giving  the  stomach  and  bowel  the  proper  rest,  espe- 
cially where  there  is  a  weakened  state  of  digestion.  In 
a  great  many  cases  I  believe  that  my  greatest  benefit 
was  derived  by  insisting  on  feeding  my  patients  less 
often  and  with  smaller  cpiantities  than  heretofore. 

Medication. — Having  mentioned  the  cleansing  of  the 
stomacli  and  bowels  by  nature's  own  remedies,  using 
salt  water,  we  try  next  to  aid  nature  by  administering 
internally  some  antiseptic  that  will  aid  in  neutralizing 
fermentative  and  septic  processes  that  we  cannot  reach 
either  by  mouth  or  rectum  in  the  manner  described. 
Of  all  the  drugs  that  seem  to  exert  a  good  effect  in  the 
course  of  treatment,  I  have  tried  calomel,  and  believe 
that  a  small  dose  of  the  same,  properly  administered 
will  act  as  an  intestinal  antiseptic.  Whether  it  is  the 
mercuric  chloride  or  not,  I  am  not  prepared  to  say,  but 


I  do  know  and  have  seen  very  beneficial  changes  by  the 
administration  of  one-half  to  one  grain  of  calomel  once 
or  twice  within  three  or  four  hours  following  the  method 
of  cleansing  the  stomach  and  bowel,  as  detailed.  Castor- 
oil,  in  teaspoonful  doses,  I  believe  to  be  a  very  valuable 
remedy,  especially  so  because  it  has  a  tendency  to  con- 
stipate after  it  has  had  its  eliminative  effect.  Bismuth 
is  the  sovereign  remedy.  \Vhile  I  have  used  bismuth 
in  the  form  of  subnitrate,  salicylate,  and  subcarbonate, 
I  give  great  preference  to  the  continued  use  of  the 
bismuth-betanaphthol.  Formerly  I  was  in  the  habit 
of  prescribing  naphthol  with  bismuth,  but  since  the  in- 
troduction of  the  bismuth-betanaphthol,  we  have  a  sub- 
stance which,  in  my  opinion,  is  the  most  valuable  rem- 
edy that  can  be  given  to  children.  This  latter  drug 
has  been  physiologically  examined  at  the  Imperial  In- 
stitute for  Experimental  Medicine  at  St.  Petersburg. 
According  to  Professor  Von  Nencki,  betanaphthol-bis- 
muth  agreed  well  with  patients  even  after  long-con- 
tinued use.  This  remedy  is  the  outcome  of  a  great 
many  other  non-toxic  products  from  the  laboratory  of 
Dr.  F.  ^'on  Heyden,  and  is  indicated  in  all  forms  of 
bacillary  diarrhoea,  in  choleraic  diarrhoea,  especially, 
however,  in  those  forms  of  acute  catarrhal  gastro-en- 
teritis,  as  we  are  in  the  habit  of  seeing  them  in  our  city 
to-day.  The  naphthol  combined  with  bismuth  not  only 
has  an  antiseptic  effect  within  the  intestines,  but  also 
has  the  astringent  property  of  the  bismuth.  Vomiting 
never  followed  the  administration  of  the  drug,  nor  was 
any  other  symptom  directly  attributable  to  the  drug 
which  would  contra-indicate  its  use. 

Only  recently  a  child,  nine  years  of  age,  suffering  from 
a  most  severe  form  of  typhoid  fever  with  very  offensive 
green  stools,  seemed  to  improve  very  much  during  the 
course  of  treatment  with  this  drug.  The  betanaphthol- 
bismuth  seems  to  exert  some  influence  on  the  offensive 
smell  usually  to  be  found  in  these  typhoid  and  bacil- 
lary diarrhoeas. 

While  it  is  not  proper  for  me  to  enter  into  the  phys- 
iological action  of  betanaphthol-bismuth,  I  entirely 
agree  with  Professor  Hueppe,'  who  lauds  this  new 
remedy  as  a  most  powerful  intestinal  antiseptic,  and 
recommends  it  as  a  specific  in  cholera.  Von  Nencki 
claims  that  this  drug  was  well  borne  by  patients 
and  continued  for  a  long  time.  He  further  claims 
that  the  drug,  when  introduced  into  the  stomach,  is 
partly  decomposed  into  naphthol  and  bismuth.  A 
large  part  of  it,  however,  passes  into  the  intestine, 
where  the  acid  reaction  and  the  presence  of  the  pan- 
creatic juice  complete  the  disassociation.  Naphtol  is 
but  partly  eliminated  with  the  urine  ;  the  residue 
passes  through  the  whole  alimentary  canal,  and  is 
finally  excreted  with  the  fajces.  The  bismuth  in  the 
human  subject  is  entirely  excreted  as  the  sulphide  with 
the  fsces  ;  in  the  dog  a  large  part  becomes  the  soluble 
chloride,  on  account  of  the  relatively  much  greater 
formation  of  muriatic  acid  in  that  quadruped.  In  no 
single  case  were  any  toxic  symptoms  observed,  though 
daily  doses  of  from  seventy-five  to  one  hundred  and 
fifty  grains  were  given.  In  our  country  Wilcox,  in  a 
paper,  "  The  Preparations  of  Bismuth,"  read  before  the 
New  Vork  Clinical  Society,  December  15,  1S94,  speaks 
very  highly  of  the  betanaphthol,  especially  so  in  all  fer- 
mentative bowel  complaints.  Dr.  Hugo  Engel,  of 
Philadelphia,  in  the  Xru<  York  Medical  Journal.,  March 
,50,  1895,  in  a  paper  entitled  "  The  Therapeutic  Effects 
of  Betanaphthol-bismuth,  "  also  speaks  very  highly  of 
the  value  of  this  drug.  He  says,  in  speaking  of  the 
betanaphthol-bismuth  :  "  I  have  found  it  so  reliable  and 
so  superior  in  intestinal  complaints  to  all  the  various 
bismuth  salts  previously  known,  that  I  have  determined 
to  publish  my  observations  for  the  benefit  of  the  pro- 
fession and  suffering  humanity." 

While  the  use  of  the  phenols  for  internal  medication 
seems  to  have  been  limited,  it  can  only  be  explained 

'  Berliner  klinische  Wochcnschrift,  1893.  No.  7. 


r 


July    13,    1S95] 


MEDICAL    RECORD. 


45 


on  the  ground  that  they  are  very  poisonous  in  their 
free  state.  Their  causticity  makes  them  injurious  to 
the  gastro-intestinal  mucous  membrane,  besides  they 
have  a  very  disagreeable  odor  and  are  repugnant  to 
the  taste,  but  in  combination  with  bismuth  the  noxious 
properties  of  the  phenols  appear  to  be  neutralized. 
Then  when  these  substances  are  introduced  into  the 
system  they  are  decomposed,  the  phenols  being  lib- 
erated exert  a  characteristic  antiseptic  effect,  while  the 
bismuth  o.xide  that  is  set  free  combines  with  and  fixes 
the  toxic  albumins  in  the  intestines. 

A  child,  one  year  old,  can  be  given  five  grains  beta- 
naphthol-bismuth  every  two,  three,  or  four  hours,  as  re- 
quired ;  a  child  half  a  year  old  one-half  the  dose. 
I  always  insist  on  giving  these  powders  with  a  little 
boiled  (sterilized)  water,  and  preferably  when  the 
stomach  is  quite  free  from  food.  If  there  is  a  great 
tendency  to  vomiting  and  the  child  does  vomit  the  first 
or  second  dose  given,  it  is  my  custom  to  immediately 
follow  the  vomit  by  administering  another  dose  of  the 
same  quantity.  I  believe  the  fear  of  giving  opium  is 
exaggerated.  It  is  one  of  the  most  indispensable  drugs 
in  the  treatment  of  diarrhoea  with  pain  that  we  have  to- 
day. Great  care  must  be  exercised,  however,  to  give  only 
the  required  dose.  I  have,  therefore,  frequently  com- 
bined Dover's  powder  with  the  bismuth  phenol,  some- 
times giving  one-tenth  to  one-third  of  a  grain  of  Dover's 
powder  with  each  dose  of  the  bismuth  ;  also  I  have  had 
very  good  results  from  the  administration  of  nitrate  of 
silver,  one-fiftieth  to  one-thirtieth  of  a  grain,  or  even 
more,  every  few  hours,  where  bleedings  from  dysen- 
teric stools  have  existed.  I  do  not  refer  to  bleeding 
caused  by  the  small  erosions  or  from  the  ordinary  tenes- 
mus caused  by  fissura;  ani,  which  can  be  controlled 
much  easier  by  local  treatment  than  by  administering 
drugs  per  os.  It  is  wise,  therefore,  to  carefully  ex- 
amine the  anus  in  all  these  cases,  where  children  ap- 
pear to  suffer  very  much  pain  from  these  erosions.  The 
painting  of  the  anus  with  a  six  per  cent,  solution  of  co- 
caine or  the  watery  solution  of  opium  will  give  great  re- 
lief. 

The  antipyretic  treatment  of  these  gastro-intestinal 
catarrhs  is  one  that  requires  great  judgment.  For 
example,  we  frequently  have,  as  in  acute  gastritis,  a 
sudden  elevation  of  temperature  to  105",  106°,  or  even 
107°  F.,  and  this  hyperpyrexia  can  be  best  controlled  by 
the  administration  of  a  bath  in  the  following  manner  : 
We  place  the  child  in  a  blanket  and  introduce  the 
whole  body  up  to  the  neck  and  shoulders  into  water,  at 
a  temperature  of  90°  F.  I  gradually  add  cold  water  to 
lower  the  temperature  of  the  water  until  it  reaches  70^ 
F.  In  summer,  where  ice  is  handy,  I  place  the  child 
into  warm  water  and  add  a  large  piece  of  ice  to  this 
warm  water,  and  in  this  manner  allow  the  temperature 
of  the  water  to  be  gradually  cooled,  until  the  bath 
thermometer  shows  a  temperature  of  about  70°.  The 
duration  of  the  bath  should  not  be  more  than  five 
minutes,  otherwise  it  will  be  followed  by  a  chill  which 
is  sometimes  prolonged.  The  frequency  of  the  ad- 
ministration of  these  antipyretic  measures  depends  on 
the  condition  of  the  child.  I  have  frequently  found 
that  the  temperature  of  105°  or  106°  F.  can  be  reduced 
by  one  bath  three  and  four  degrees  during  the  bath,  and 
that  the  temperature  of  the  body  still  sinks  one  and 
even  more  than  one  degree  after  the  patient  is  taken 
out  of  the  water.  The  antipyretic  effect  of  these  baths 
will  last  at  times  two  and  three  hours,  and  if  the  tem- 
perature again  rises  we  can  administer  a  bath  every 
few  hours,  as  we  see  fit.  It  is  hard  to  generalize  the 
treatment  of  summer  complaint,  because  we  have  t(j 
individualize  in  most  of  ourcases,  and  find  that  certain 
active  measures  are  very  well  borne  by  one  class  of 
cases  which  are  not  at  all  tolerated  by  others.  One 
point  is  important,  and  that  is  to  reduce  the  very  high 
temperatures  that  occur  in  the  course  of  summer  com- 
plaint, owing  to  the  great  risk  that  we  run  from  con- 
tinued elevation  of  temperature  in  causing  convulsions 


and  possibly  death.  In  the  management  of  cholera 
infantum  I  am  in  the  habit  of  placing  the  child  with  a 
very  high  temperature  at  once  into  the  bath  as  above 
described  to  reduce  the  elevation  of  the  temperature 
as  much  as  possible.  The  next  step  is  to  cleanse  the 
stomach  and  bowels  by  irrigation  as  above  described, 
so  as  to  free  the  stomach  from  all  fermentative  prod- 
ucts and  render  it  as  completely  sterile  from  poisonous 
bacteria  as  possible,  and  by  all  means  to  put  an  ice- 
bag  on  the  top  of  the  head.  While  we  know  that 
sun-stroke  in  the  adult  is  usually  most  dangerous  and 
fatal  in  alcoholic  subjects,  we  do  not  know  how  much 
good  or  harm  is  done  by  the  administration  of  alcohol 
in  the  course  of  a  severe  cholera  infantum.  A  large 
experience  of  these  se\ere  cases  as  we  see  them  in 
this  city,  where  a  child  is  brought  in  in  a  condition 
of  collap;e,  with  cold  extremities,  covered  with  large 
beads  of  co'.d  perspiration  ;  the  eyes  half  open,  the  pupils 
dilated,  thi  head  very  hot,  the  fontanelle  widely  open, 
usually  depressed,  with  rapid  pulsation  ;  liquid,  watery, 
sometimes  greenish,  sometimes  brownish  stools,  more 
often  accom])anied  by  vomiting  ;  a  tongue  that  is  brown 
or  red,  studded  with  white  spots,  dry,  more  often  pro- 
truding from  the  mouth  ;  the  eyes  sunken,  surrounded 
by  deep  black  rings  ;  little  or  no  urine  voided  ;  the  ab- 
domen at  times  very  tympanitic,  at  other  times  re- 
tracted ;  a  distinct  typhoid  appearance,  while  the  body 
has  a  cadaverous  smell — where  we  have  a  clinical  pict- 
ure of  extreme  exhaustion,  as  above  described,  the 
pulse  feeble,  at  times  intermitting,  in  some  cases  180 
per  minute,  in  others  possibly  60  pulsations,  and  where 
we  are  in  the  midst  of  an  extremely  hot  summer's  day 
with  the  temperature  of  the  air  between  95°  and  100° 
F.  in  the  shade,  the  first  duty  is  to  cool  the  surround- 
ings as  much  as  possible.  It  is  in  these  cases  that  so 
much  good  can  be  accomplished  by  a  sudden  change 
of  air  from  the  city  to  the  sea  on  excursions,  such  as,  for 
example,  are  given  with  such  wonderful  benefit  by  the 
St.  John's  Guild  and  other  sanitariums.  The  well- 
known  constipating  effect  of  the  sea  air  on  adults  is 
here,  I  believe,  beneficially  shown  and  proven  by 
the  fact  that  at  times  two  hundred  or  three  hundred 
children  that  have  suffered  from  a  continuous  diarrhoea 
lasting  a  few  days  or  more  will  by  one  small  sea-voyage, 
lasting  one  day  in  these  trips,  suddenly  have  the  diar- 
rhoea stopped,  which  will  continue  to  remain  so  until 
the  next  sudden  approach  of  hot  weather. 

Stimulation. — The  strongest  nerve  stimulant  is  musk. 
In  urgent  cases  I  have  given  i  to  2  grains  within  half 
an  hour  in  a  little  mucilage  of  gum  Arabic  until  6 
grains  ha\e  been  given.  Camphor,  ^  to  2  grains,  can 
be  rubbed  up  with  glycerine  ;  or  10  to  15  drops  of 
spirits  of  camphor  in  some  cases  seem  to  do  good  ;  in 
obstinate  cases,  however,  hypodermic  injections  of 
spirits  of  camphor  prove  serviceable.  While  it  is  very 
rare  to  use  alcohol  in  any  or  all  forms  of  gastro-intesti- 
nal catarrh,  I  have,  however,  injected  in  collapse  a  tea- 
spoonful  of  alcohol  in  a  pint  of  hot  water  through  a 
flexible  catheter  (No.  12)  into  the  bowels,  or  given  a 
few  drops  of  whiskey  in  rice  gruel  or  barley  gruel.  A 
word  more  about  calomel.  A  great  many  children 
vomit  after  the  administration  of  calomel,  so  that  it  is 
wise  not  to  overlook  this  point,  but  it  does  augment 
the  flow  of  bile  by  stimulating  the  bile-ducts  and  hence 
it  is  a  very  valuable  remedy.  The  tannate  of  quinine, 
which  has  been  so  highly  recommended,  I  have  used 
in  our  dispensaries  for  the  last  six  or  seven  years, 
and  have  invariably  resorted  to  other  drugs ;  it  is 
therefore  a  very  poor  drug  to  be  used  in  this  condi- 
tion. 

Diet. — Our  next  step  will  be  to  nourish  our  patient. 
If  our  patient  is  a  nursling  we  must  carefully  inquire 
into  the  quality  and  quantity  of  its  mother's  or  wet- 
nurse's  milk.  The  microscopic  examination  of  the  milk 
will  be  necessary,  besides  the  creamometer,  which  is 
recommended  by  Holt,  can  be  used  to  estimate  the 
quantity  of  fat  and  cream  in  the  milk.     It  is  wise  to  in- 


46 


MEDICAL    RECORD. 


[July 


quire  into  the  conditions  previously  mentioned  in  this 
paper — e.f;.,  tuberculosis,  pregnancy — when  the  lactation 
is  interfered  with,  and  if  we  find  such  conditions  exist- 
ing, then  we  must  resort  to  hand-feeding — properly 
sterilized  milk,  diluted  according  to  the  age  of  the  child. 
If  the  child  is  hand-fed  it  is  a  cardinal  rule  in  all  cases 
of  summer  complaint  with  vomiting  and  diarrhcEa  to 
discontinue  milk  and  to  give  the  child  barley-gruel,  or 
what  I  have'  found  equally  good,  rice-gruel.  If  the 
child  does  well  it  is  a  good  plan  to  change  the  food 
from  time  to  time,  and  to  give  one  day  corn-starch  or 
rice  and  the  next  day  barley.  The  white  of  an  egg  or 
the  yolk  of  an  egg  beaten  up  with  sterilized  water  can 
also  be  given  advantageously  during  the  course  of  a 
diarrhoea  ;  so  also  have  I  found  some  good  by  the  ad- 
ministration of  beef  blood,  made  by  broiling  fresh  steak 
and  expressing  the  juice  with  a  lemon-squeezer,  and 
administering  twenty-five  or  thirty  drops  at  a  time  to  a 
child  of  si.\  months  or  over,  two  or  three  times  a  day. 
If  vomiting  is  very  persistent  and  the  stomach  has  been 
thoroughly  cleansed  and  cannot  be  controlled  by  the 
measures  resorted  to  above,  I  frequently  discontinue 
all  feeding  per  mouth  for  twenty-four  hours,  giving  the 
stomach  absolute  rest,  and  then  resort  to 

Bectal  Alimentation. — For  this  purpose  I  use  pep- 
tonized milk  (thoroughly  peptonized)  or  the  yolk  of  egg 
with  starch-water,  or  beef  blood  as  described  above, 
with  starch-water,  or  barley-gruel,  using  between  two 
and  four  ounces  for  one  enema.  This  quantity  I  in- 
ject into  the  rectum  very  slowly  every  two,  three,  or 
four  hours.  It  is  always  necessary  in  rectal  alimenta- 
tion to  thoroughly  wash  the  lower  bowel  by  using  an 
enema  of  soap-water  or  glycerin  and  water  before  each 
feeding. 

Hygienic. — Having  attended,  then,  to  the  mechanical 
treatment,  medication,  and  looked  after  the  proper  diet 
of  our  case,  we  next  try  to  give  our  patient  as  much 
cool  air  as  possible.  I  have  previously  referred  to  the 
importance  of  taking  a  child  away  from  atmospheric 
influences,  which  most  likely  cause  this  pathological 
condition,  and  where  this  is  not  possible,  I  remove  the 
child  into  the  largest  and  coolest  room  of  the  house. 
Where  sea-air  is  not  obtainable,  it  is  wise  to  add  some 
sea-salt  to  our  water  in  administering  the  baths  previ- 
ously mentioned,  as  they  have  a  very  invigorating  ef- 
fect. .Occasional  sponging  with  equal  parts  of  alco- 
hol and  water  or  a  small  quantity  of  Florida-water 
brightens  the  children  and  seems  to  check  perspiration. 
Children  in  this  condition  should  be  bathed  daily,  and 
where  extreme  prostration  exists,  they  can  be  bathed 
twice  daily  with  salt  water,  followed  by  rest  and  placing 
a  small  rubber  bag  half  filled  with  cracked  ice  over  the 
top  of  the  head  or  immediately  over  the  pulsating  fon- 
tanelle  and  left  ///  situ  for  a  number  of  hours.  In  other 
cases  where  there  are  symptoms  of  cyanosis  with  cold 
extremities  and  great  jierspiration,  with  pallor  of  the 
skin,  a  hot  mustard  bath  is  indicated — about  a  handful 
of  pulvis  sinapis  nigrse  wrapped  in  some  linen  and  sus- 
pended in  water  of  about  ioo°  F.  Immerse  the  child's 
body  and  gradually  raise  the  temperature  of  the  bath 
by  adding  boiling  water  until  reaction  sets  in  ;  then 
wrap  the  child  in  warm  blankets.  In  extreme  stupor 
I  have  sometimes  given  to  advantage  a  few  drops 
of  the  aromatic  spirits  of  ammonia  with  a  little 
boiled  water,  especially  where  the  pulsations  were  very 
feeble. 

To  sum  up,  my  plan  of  treatment  for  a  given  case  of 
catarrh  of  the  gastro-intestinal  mucous  membrane,  re- 
sulting from  the  combined  effects  of  extreme  heat  and 
improper  feeding,  would  be:  i.  To  irrigate  the  stomach 
as  previously  detailed,  to  free  the  gastric  mucous  mem- 
brane as  much  as  possible  from  offending  decomposing 
food  and  consequent  fermentation.  2.  To  free  the 
bowel  in  the  same  manner  from  all  offending  fasces  pos- 
sible by  irrigating  with  lukewarm  water  and  flushing  the 
colon  and  rectum  till  the  contents  llow  away  clear. 
3.  Never  resort  to  antipyretics,  as  antipyrin  and  qui- 


nine or  other  similar  drugs,  in  reducing  the  temperature, 
but  invariably  resort  to  hydropathic  measures,  relying 
on  the  warm  bath,  gradually  cooled  from  90°  to  70°. 
Duration  of  bath  in  all  five  minutes,  to  be  repeated 
every  few  hours  if  necessary.  4.  Placing  an  ice-bag  on 
the  top  of  the  head,  following  the  bath,  and  placing  the 
patient  in  the  coolest  possible  room,  if  we  cannot  have 
the  child  immediately  removed  to  cool  sea-air.  5.  Un- 
less it  be  a  nursling,  I  invariably  proscribe  milk  ;  and  if  a 
nursling  then  discontinue  the  breast  at  least  one-half  day 
to  give  the  stomach  absolute  rest.  6.  I  administer  beta- 
naphtol-bismuth  in  doses  of  five  to  ten  grains  to  a  child 
of  one  year  every  two,  three,  or  four  hours,  depend- 
ing on  the  nature  of  the  case.  7.  If  vomiting  persists 
and  cannot  be  controlled  by  medication,  I  resort  to 
rectal  feeding,  and  administer  the  bismuth  in  a  small 
suppository,  also  per  rectum,  but  invariably  doubling 
the  dose  required  per  mouth.  8.  I  invariably  warn 
against  the  danger  of  administering  alcohol,  and  any 
wine  or  beer.  I  administer  alcohol,  if  at  all  required, 
myself,  per  rectum,  as  detailed  above.  9.  Cold  spong- 
ing to  check  the  perspiration  with  equal  parts  of  alco- 
hol or  water  or  using  bay  rum  is  very  refreshing  and 
grateful,  besides  doing  service  in  cooling  the  body.  10. 
Where  cyanosis  and  very  cold  extremities  exist,  we  have 
to  individualize  our  treatment  and  sometimes  resort  to 
hot  mustard  baths,  in  preference  to  previous  hygienic 
measures  detailed. 

It  is  important  to  remark  that  the  cause  of  all  or 
nearly  all  gastro-intestinal  disorders  originates  in  the 
stomach  by  and  through  not  only  the  food  given,  but  an 
improper  assimilation  of  the  same,  due  no  doubt  to  at- 
mospheric surroundings,  and  hence  a  complete  break- 
ing off  and  stopping  of  feeding  per  mouth  is  ver)- bene- 
ficial to  a  great  many  cases,  and  where,  therefore,  we 
have  extreme  vomiting,  which  cannot  be  controlled  by 
other  means,  the  importance  of  rectal  feeding  and  ab- 
solute rest  of  the  stomach  cannot  be  overlooked. 

187  Second  Avenue. 


A  CASE  OF  EXOPHTHALMIC  GOITRE,  WITH 
MONOCULAR  SYMPTOMS  AND  UNILAT- 
ERAL  THYROID    HYPERTROPHY.! 

By    PERCY  FRIDENBERG,    M.D., 


Since  Graves's  classical  observations  first  drew  attention 
to  the  symptomatic  combination  of  thyroid  hypertrophy, 
cardiac  palpitation,  and  "  Anremic  Protrusion  of  the 
Eyeballs,"  and  Basedow,  independently,  and  but  a  few 
years  later,  described  similar  symptoms  as  characteris- 
tic features  of  a  distinct  "  Exophthalmic  Disease  " 
(Glotzaugen  -  Cachexie)  no  completely  satisfactory 
theory  has  been  advanced  in  explanation  of  the  pathol- 
ogy and  etiology  of  the  interesting  affection,  which  as 
Graves's  or  Basedow's  disease,  represents  a  very  definite 
and  not  uncommon  clinical  entity. 

In  view  of  the  i)resent  state  of  our  knowledge  on  this 
subject  the  report  of  a  case  of  exophthalmic  goitre, 
with  the  unusual  features  of  limitation  of  ocular  symp- 
toms to  one  side,  and  unilateral  enlargement  of  the  op- 
posite lobe  of  the  thyroid  gland,  may  not  be  without 
interest. 

The  patient  in  whom  this  rare  variation  was  observed 
applied  for  treatment  on  November  3,  1S94,  at  the  New 
York  Eye  and  Ear  Infirmary,  and  was  referred  to  me 
for  an  examination  of  the  refraction  by  Dr.  Ciruening, 
to  whom  I  am  indebted  for  permission  to  report  the 
following  notes  ;  The  patient,  Mrs.  .\.  J ,  is  twenty- 
four  years  of  age.  Her  father  and  mother  are  living, 
and  in  perfect  health,  aged  respectively  fifty-four  and 
forty-eight  years  of  age.     Six  sisters  and  four  brothers, 

>  Read  before  the  Section  on  Ophthalmology  of  the  New  York 
Academy. 


July 


1895] 


MEDICAL    RECORD. 


47 


all  robust  and  well,  are  subject,  according  to  the  testi- 
mony of  the  patient,  to  nen-ous  excitement.  The  pa- 
tient herself  has  always  been  well,  but  since  childhood 
she  has  been  nervous  and  easily  frightened.  She  has 
been  married  four  years.  Three  years  ago  she  aborted 
at  the  fourth  month,  and  has  not  been  pregnant  since. 
From  the  time  of  her  marriage  she  has  been  almost 
constantly  worried  and  e.xcited  by  domestic  infelicity, 
and  about  si.\  months  ago  her  condition  was  aggravated 
by  a  particularly  unpleasant  occurrence,  the  precise 
nature  of  which  I  did  not  investigate.  Within  a  few 
weeks  the  patient  noticed  that  she  became  fatigued  on 
the  slightest  exertion,  particularly  after  walking  or 
climbing  stairs,  flushing  frequently  and  perspiring 
freely.  Her  nervous  excitability  increased  markedly, 
with  the  additional  symptom  of  palpitation  and  dyspn^xa, 
and  occasionally  the  sensation  of  throbbing  in  the  ves- 
sels of  the  neck. 

The  patient,  who  is  a  dressmaker,  found  that  her  eyes 
ached  and  that  vision  became  blurred  after  sewing  a  few 
minutes,  and  she  was  told  that  "  she  looked  strange,"  and 
that  "  one  eye  was  larger  than  the  other." 

My  attention  was  immediately  attracted  by  the  pe- 
culiar expression  of  the  left  side  of  the  patient's  face, 
due  principally  to  the  staring  appearance  of  the  eye. 
It  was  this  characteristic  feature  which  at  once  sug- 
gested a  diagnosis.  The  palpebral  fissure  on  this  side 
was  widened  by  a  marked  retraction  of  the  upper  lid, 
which  allowed  alnjost  two  millimetres  of  the  sclera  to 
appear  above  the  margin  of  the  cornea  when  the 
visual  axis  was  horizontal.  The  globe  was  distinctly 
prominent,  but  not  to  a  high  degree,  and  Graefe's 
s}Tnptom  was  readily  elicited.  The  condition  is  well 
shown  in  Fig.  i,  taken  about  three  weeks  later.  In- 
voluntar)'  winking  was  decidedly  infrequent,  but  not 
evidently  impaired.  The  vision  was  normal  in  botii 
ej'es  ;  the  refraction  emmetropic.  There  was  an  insuf- 
ficiency of  the  internal  recti  of  2°  and  5°  respectively  for 
distance  and  near  vision.  Ophthalmoscopic  examina- 
tion showed  venous  pulsation  on  the  disc  in  the  le:: 
eye,  but  arterial  pulsation  could  not  be  detected.  The 
right  eye  showed  no  abnormality ;  the  appearance  oi 
this  side  of  the  face  was  perfectly  natural.  There  was 
some  flushing  of  the  face,  more  marked  on  the  left  side. 
and  greatly  increased  by  even  slight  mental  excitement. 
The  thyroid  was  not  noticeably  enlarged,  but  on  palpa- 
tion an  increase  in  size  of  the  right  lobe,  and  of  the 
isthmus  was  made  out.  There  was  a  fine  tremor  of  the 
tongue  and  hands,  almost  fibrillary  in  character,  and 
much  like  that  observed  in  paralysis  agitans,  but  some- 
what slower  (5  to  6  to  the  second).  The  heart  was 
over-acting  and  tumultuous,  at  times  intermitting  :  the 
second  pulmonic  sound  accentuated.  JThere  was  no 
evidence  of  a  valvular  lesion,  but  the  area  of  cardiac 
dulness  was  increased  to  the  left,  and  the  apex-beat 
was  heaving  and  diffused  over  the  precordia.  There 
was  marked  capillary  pulsation  on  the  breast  and  neck. 
A  loud  venous  hum  was  heard  over  the  jugular  vein. 
and  a  blowing  murmur,  coincident  with  the  first  sound 
of  the  heart,  over  the  enlarged  right  lobe  of  the  thyroid. 
The  lungs  were  normal,  but  inspiration  was  superficial, 
and  at  times,  gasping  ;  the  thorax  appeared  somewhat 
flat.  There  was  marked  pulsation  of  the  carotids,  es- 
pecially on  the  left  side,  but  the  radial  pulse  was  quite 
small  and  compressible,  averaging  120  to  the  minute 
when  the  patient  was  at  rest.  Although  I  impressed 
upon  the  patient  the  importance  of  avoiding  all  exer- 
tion, physical  and  mental,  some  weeks  elapsed  before 
she  realized  the  necessity  of  systematic  treatment.  I 
advised  rest  in  bed  or  on  a  lounge  for  several  hours  in 
the  morning  and  afternoon,  general  regulation  of  diet. 
and  the  use  of  ice-bags  over  the  heart  and  neck  for 
excessive  palpitation.  Tincture  of  digitalis  in  doses  ot 
five  minims  three  times  a  day  was  prescribed,  with  a 
tonic  containing  iron,  strychnine,  and  quinine.  The 
heart-action  was  not  improved  by  the  digitalis,  which 
after  several  weeks  had  been  increased  to  ten  minims 


four  times  a  day,  and,  although  the  ice-bags  promptly 
relieved  the  palpitation,  the  patient  found  it  inconven- 
ient to  use  them  regularly.  The  digitalis  was  discon- 
tinued, and  tincture  of  strophanthus,  three  minims,  three 
times  a  day,  was  ordered,  with  fifteen  grains  of  sodium 
bromide  on  retiring  at  night. 

This  case  has  been  under  obsersation  for  six  months, 
and  the  condition  at  present  is  slightly  improved.  The 
heart-action  is  somewhat  less  rapid,  the  palpitation, 
subjectively,  much  diminished.  The  exophthalmos  is 
st'll  present,  although  not  in  the  same  degree  as  before, 
and  the  retraction  of  the  upper  lid  is  hardly  noticeable. 

The  improvement  in  the  patient's  expression  has 
been  noticed  by  her  friends,  and  this  has  had  a  bene- 
ficial effect  on  her  general  condition.  The  prospect  of 
ultimate  complete  recovery  seems  good. 

In  the  above  case  all  the  classical  sjTnptoms  of 
Graves's  disease  were  present,  together  with  a  number 
which,  though  not  of  prime  importance,  are  character- 
istic of  the  affection.  Of  these  I  may  mention  the 
tremor  (Marie),    restlessness  and  ner%^ous  excitement 


(Charcot),  insufficiently  of  the  intemi  (Mobius),  super- 
ficial respiration  (Bryson),  and  the  flushing  and  hyper- 
hidrosis  with  the  attending  diminution  in  resistance  to 
the  galvanic  current.  The  most  striking  feature  of  the 
case,  however,  is  undoubtedly  the  peculiar  limitation  of 
the  ocular  s)-mptoms  to  the  left  side,  combined  T\'ith  a 
'"crossed"  hypertrophy  of  the  right  lobe  of  the  thy- 
roid. Unilateral  sj-mptoms  in  Graves's  disease  are  so 
inexplicable  by  the  ordinary  theories  that  some  writers 
on  the  subject  ^  have  denied  the  possibility  of  such  a 
variation,  while  Berger  -  considers  the  presence  of  uni- 
lateral exophthalmos  sufficient  evidence  to  exclude  a 
diagnosis  of  this  affection.  There  is  no  doubt  that 
many  of  the  cases  published  as  Basedow's  or  Graves's 
disease,  especially  those  dating  from  the  earlier  years 
in  the  study  of  this  disease,  were  based  on  insufficient 
observation.  Affections  of  the  cer\-ical  sjTnpathetic 
with  atypical  symptoms,'^  complicated  cardiac  lesions,* 

'  Schoit:  Deutsche  Med.  Ztg.,  1889,  No.  32.     Marcus  :  Ibid.,  1893, 
No.  48. 
"  Bull,  de  Soc.  de  Chir. ,  1884.  p.  277. 
»  Chvostek :  Wiener  Med.  Presse,  1872,  p.  497. 
*  Schnitzler:  Wiener  Med.  Halle,  1864,  No.  24,  p.  245. 


48 


MEDICAL   RECORD. 


[July 


hysterical  manifestations  in  chlorotic  girls,  and,  in  a 
number  of  cases,  true  endemic  or  sporadic  goitre  with 
pressure  symptoms  on  one  side,'  were  all  thrown  into 
the  convenient  category  of  morbus  Gravesii.  A  large 
number  of  the  cases  compiled  by  Hirschberg  '^  in  his 
historical  and  critical  essay  are  found  on  reference  to 
the  original  articles  to  be  ordinary  bilateral  cases  ;  '  in 
others  there  was  a  difference,  more  or  less  marked,  in 
the  degree  of  protrusion  of  the  two  eyes,^  while  in  a 
third  series  there  was  only  temporary  limitation  of 
symptoms  to  one  side,  the  exophthalmos  appearing 
somewhat  later  in  one  eye  than  in  the  other.'  Exclud- 
ing the  doubtful  cases,  I  find  the  following  references 
to  the  condition  under  discussion  ; 

Demours,''  observed  in  a  young  girl,  eleven  years  of 
age,  a  prominence  of  the  left  eye  of  one  and  a  half 
lines,  which  had  persisted  for  three  years.  The  patient 
had  had  slight  thyroid  enlargement  since  birth.  Her 
mother  showed  a  disposition  to  thyroid  enlargement 
since  childhood,  and  after  her  first  confinement  de- 
veloped a  goitre,  which  steadily  increased  in  size. 

Desmarres,"  reported,  under  the  title  "  De  I'Exoph- 
thalmie  produit  par  I'hypertrophie  du  tissu  cellulo- 
adipeux  de  I'orbite,"  several  cases  of  Graves's  disease, 
in  one  of  which  he  observed  unilateral  exophthalmos 
of  a  slight  degree  in  the  right  eye  of  a  young  woman, 
aged  thirty,  who  suffered  from  nervousness,  palpitation, 
and  thyroid  hypertrophy.  There  was  retraction  of  the 
upper  lid  ;  the  sight  was  perfect  and  motility  normal. 
After  treatment  for  three  months  with  potassium 
Sodide  internally  and  unguentum  iodi  applied  locally, 
■the  condition  improved  noticeably.  In  his  general  re- 
Tuarks  on  this  subject  Desmarres  draws  a  graphic  pict- 
ure of  the  physiognomy  in  this  affection,  and  in  partic- 
ular calls  attention  to  a  symptom  which  Stellwag  is 
supposed  to  have  discovered  sixteen  years  after  Des- 
marres described  it  in  the  following  words  : 

"  Lorsqu'on  regarde  attentiveraent  un  malade  atteint 
de  cette  affection,  on  remarque,  comme  premier 
symptome,  que  la  paupiere  superieure  ne  s'abaisse  plus 
comme  dans  I'etat  physiologique  sur  la  partie  supe- 
rieure de  la  cornee,  lorsque  I'oeil  regarde  horizontale- 
rnent ;  au  contraire,  la  cornee  reste  decouverte  en  to- 
talite,  ce  qui  donne  a  la  physionomie  quelque  chose  de 
hagard  fort  desagreable  a  voir.  .\  un  degre  un  peu 
plus  avance  encore,  le  malade  a  les  yeux  d'un  homme 
en  f'ureur,  et  cela  etablit  un  contrast  choquant  avec  la 
tranquillite  du  reste  de  la  ])hysionomie."  The  rest  of 
this  interesting  monograph  is  devoted  to  the  differen- 
tial diagnosis  of  the  exophthalmos  in  Graves's  disease 
from  that  due  to  hydrophthalmos  (bouphthalmos),  orbi- 
tal cellulitis  or  emphysema,  distention  of  the  sinuses, 
orbital  tumors,  and  other  causes. 

Mackenzie  '^  saw  one  case.  His  patient,  a  delicate, 
anaemic  young  woman,  whose  sister  had  been  under 
treatment  for-  years  for  Graves's  disease,  suffered  from 
amenorrhoea  with  nervous  symptoms,  dyspepsia,  and 
constipation.  After  several  months  of  mental  worry 
and  severe  physical  exertion  during  the  summer,  the 
right  eye  began  to  protrude,  and  the  thyroid  became 
enlarged.  The  symptoms  were  much  improved  by  the 
administration  of  the  tincture  of  iodine  (dose  not 
stated),  with  local  application  of  iodide  of  potassium 
ointment  to  the  neck  and  temporal  region. 

Priiel '  noted  the  development  of  right  exophthalmos 
with  bilateral  thyroid  hypertrophy  during  convalescence 
from  acute  bronchitis  of  a  man,  aged  fifty,  who  suf- 
fered from  palpitation  and  other  signs  of  cardiac  dis- 

'  Bergcr  :  Bull,  de  Soc.  de  Chir.,  1884,  p  277. 

'  Die  Basedow'sche  Krankheit.      Wiener  Klinik.  1894. 

'  Rosenberg  ;  Berl.  klin.  Wochenschr  ,  xi6$.  ii ,  277.  Sichel  ■ 
Bui).  Gcncrale  de  ThJr.ipie,  vol.  .ixx..  iS5j.  Patchelt :  Lancet  iSy- 
P  827. 

•Emmert:  Graefe's  Arcliiv,  xvii. ,  i  ,  p  203. 

»  Jendrassik  :  .-^rchiv  f.  Psychiatric,  u.  Nervenlicilk.,  18S6.  xvii 

■"  Traite  des  Maladies  de  I'CEil,  Paris.  1818. 

'  Gazette  des  Hop  .  1853.  No.  1,  p   2. 

"  Treatise  of  Oiseases  of  the  Eye,  4th  ed.,  1854. 

*  Graefe's  .•\rv.-hiv,  iii. ,  2,  199. 


ease  since  his  twentieth  year.  After  a  long  time  the 
left  eye  also  became  prominent.  The  case  terminated 
fatally,  and  the  post  mortem  examination  revealed  ex- 
tensive atheromatous  changes  in  the  aorta,  with  evi- 
dence of  mitral  stenosis  and  insufficiency.  In  two  other 
cases  right  exophthalmos  was  observed  in  young  girls, 
nineteen  and  fifteen  years  old,  respectively,  who  were 
chlorotic.  In  one  case  palpitation  and  hyperhidrosis 
appeared  later  and  persisted  for  several  years.  In  the 
other  case  a  severe  emotional  disturbance  was  the  deter- 
mining cause.  The  exophthalmos  suddenly  became 
much  more  marked  about  five  years  later  after  a  severe 
attack  of  hgematemesis  and  brought  about  a  condition 
of  acute  anffimia.  Struma  now  appeared  for  the  first 
time. 

Chvostek '  reports  the  case  of  a  woman,  aged  fifty- 
five.  Her  mother  had  shown  marked  symptoms  of 
nervous  weakness  since  youth.  Her  father  had  had  a 
valvular  lesion,  and  a  sister  had  been  affected  with 
Graves'  disease  for  twenty-five  years.  The  patient  had 
passed  through  severe  mental  excitement  eight  years 
before,  and  soon  after  presented  symptoms  of  exoph- 
thalmic goitre  with  striking  unilateral  symptoms.  The 
right  eye  was  noticeably  prominent,  the  right  lobe  of 
the  thyroid  much  enlarged.  Hyperhidrosis,  flushing, 
and  emaciation,  all  limited  to  the  right  side,  appeared 
later,  and  the  general  condition  became  very  bad,  al- 
though the  patient  eventually  recovered  completely. 

A  most  remarkable  case  is  reported  by  Burney  Yeo.^ 
The  patient,  a  woman,  aged  thirty-five,  had  always  en- 
joyed good  health,  although  extremely  nervous,  until 
her  fourth  confinement.  Symptoms  of  puerperal  sep- 
sis then  set  in  which  lasted  for  three  weeks.  When  she 
got  well  the  patient's  friends  would  not  let  her  look  at 
herself  in  the  glass  because  she  "looked  so  wild." 
There  was  marked  exophthalmos  on  the  left  side,  but 
it  was  difficult  to  say  whether  the  right  eye  was,  or  was 
not,  at  that  time,  more  prominent  than  natural.  The 
right  lobe  of  the  thyroid  was  considerably  enlarged, 
but  there  was  little  increase,  if  any,  in  the  size  of  the 
left  lobe.  At  about  the  same  time  the  eyelashes  and 
the  hair  of  the  eyebrow  on  the  left  side  began  to  fall 
out.  The  general  symptoms  of  nervousness,  flush- 
ing, hyperhidrosis,  and  palpitation,  with  a  pulse  of  136, 
were  noted.  Both  the  goitre  and  the  exophthalmos 
were  markedly  unilateral,  but  on  opposite  sides.  After 
nearly  six  months  the  right  eye  began  to  protrude,  and 
the  falling  out  of  the  eyelashes  and  of  the  hair  of  the 
eyebrow  on  the  corresponding  side  was  noticed.  At 
the  same  time  the  opposite  lobe  of  the  thyroid,  which 
had  formerly  appeared  to  be  normal,  began  to  enlarge, 
and  soon  equalled  the  right  lobe  in  size.  Veo  cites  a 
second  case  of  right  unilateral  exophthalmos  which 
had  persisted  Tor  one  year  in  a  robust  and  healthy 
young  girl  of  twenty-three.  Palpitation  and  nervous 
symptoms  developed,  the  pulse  ranging  from  n6  to 
140,  but  there  was  no  goitre. 

Becker  '  reports  the  case  of  a  lady,  aged  twenty-eight, 
who  had  been  married  seven  years  and  was  the  mother 
of  a  strong,  healthy  boy.  A  second  pregnancy  had  not 
occurred,  as  dysmenorrhiua  with  nervous  symptoms 
had  followed  the  first  confinement,  and  had  eventually 
developed  into  hysteria.  Since  one  year  occasional 
protrusion  of  the  left  eye  had  been  noticed,  while  the 
right  appeared  perfectly  normal.  PaljMtation  was  com- 
plained of  at  times,  and  there  was  slight  enlargement 
of  the  thyroid.  On  examination  the  sight  was  found 
to  be  iierfect.  There  was  only  slight  exophthalmos 
with  pulsation  of  the  retinal  arteries  in  the  left  eye. 
There  was  no  prominence  or  other  morbid  symptom  in 
the  right  eye. 

.\badie'  describes  the  following  case:  A  young 
woman,  aged  twentv-eight.  who  had  been  troubled  for 


'  Wiener  Med.  Pressc,  187a.  p.  497. 
=  British  Medical  loiirn.il,  March  17,  1877. 
'  Klin.  Monatsbl.  f.  .Vugcnheilk.,  .vviii.,  1S80. 
*  L'Union  Midical.  1880.  No.  157.  p.  S59. 


July   13,  1895] 


MEDICAL    RECORD. 


49 


several  months  with  excessive  feebleness,  general 
malaise,  palpitation,  and  marked  nervousness,  had 
been  under  treatment,  without  relief,  for  anaemia,  a 
diagnosis  having  been  made  "by  exclusion,"  as  physi- 
cal examination  had  failed  to  reveal  any  organic  evi- 
dence of  disease.  Some  time  later  the  patient  noticed 
a  greater  prominence  than  usual  of  the  right  eye.  The 
characteristic  expression  of  the  eye,  due  to  retraction 
of  the  upper  lid,  immediately  drew  attention  to  the 
real  nature  of  the  case.  The  pulse  when  the  patient 
rested  was  96.  The  prominence  of  the  right  eye  was 
manifest.  There  was  a  slight  enlargement  of  the  thy- 
roid, affecting  the  isthmus  only.  The  left  eye  appeared 
perfectly  normal.  In  the  case  of  a  man,  aged  thirty- 
four,  who  had  suffered  with  palpitation  for  three  years, 
Maher'  found  enlargement  of  the  thyroid,  notably  on 
the  right  side,  and  exophthalmos  of  the  right  eye,  the 
cornea  being  two  and  a  half  to  three  millimetres  in  ad- 
vance of  the  left.  This  condition  had  been  noticed  by 
the  patient  for  one  year.  Graefe's  symptom  was  not 
present. 


In  this  country  no  case  of  unilateral  exophthalmic 
goitre  has  been  published,  and,  to  my  knowledge,  but 
one  has  been  observed.  I  am  indebted  to  Dr.  George 
W.  Jacoby,  of  this  city,  who  presented  the  case  at  the 
Monthly  Scientific  Meeting  of  German  Physicians,  in 
December,  1893,  for  the  following  details,  and  the  ac- 
companying photograph  (Fig.  2)  : 

Kate  P ,  thirty- three  years  of  age,  has  complained 

for  about  two  months  of  general  nervousness,  palpita- 
tion, and  sweating.  For  about  the  same  length  of  time 
she  has  noticed  a  peculiar  expression  of  the  right  eye 
and  slight  prominence.  On  examination,  Graele's 
S)Tuptom,  with  retraction  of  the  upper  lid  and  slight 
exophthalmos,  all  on  the  right  side,  were  noted.  The 
thyroid  seemed  to  be  somewhat  enlarged  ;  the  right 
lobe  distinctly  fuller  than  the  left.  Mobius's  symptom 
was  distinct,  but  there  was  no  loss  of  involuntary  wink- 
ing. The  right  cornea  was  perhaps  slightly  anajstheiic. 
In  addition  to  these  symptoms,  there  was  tremor,  and 
a  bronze  decoloration  of  the  skin. 

'  Lancet.  1886,  No.  i,  p.  1221. 


In  all  but  three  of  the  thirteen  cases  reported  the 
right  eye  was  affected.  Of  the  three  cases  involving 
the  left  eye,  but  one,  that  of  Burney  Yeo,  was  asso- 
ciated with  hypertrophy  of  the  contra-lateral  lobe  of 
the  thyroid,  and  in  this  case  both  lobes  eventually  be- 
came much  enlarged.  Ocular  and  thyroid  symptoms 
limited  to  the  right  side,  were  seen  in  Chvostek's  case 
only.  In  my  case  there  has  been,  so  far,  no  evidence 
of  an  extension  of  the  affection  to  the  right  side,  and 
the  general  improvement  in  the  patient's  condition 
leads  me  to  believe  that  the  present  "crossed  "  condi- 
tion will  eventually  recede  without  any  change  in  the 
peculiar  limitation  of  the  symptoms. 

60  West  Seventt-sixth  Stfeet. 


WHERE  SHALL  OUR  CONSUMPTIVE  PA- 
TIENTS BE  SENT  -  SOME  PRACTICAL 
POINTS  FROM  THE  WRITER'S  OWN  EX- 
PERIENCE. 

By   WILLIAM   B.  BERRY,  M.D., 

P-\SADEN-A.    C\L. 

Let  me  express  to  my  friends  of  the  Orange  Moun- 
tain Medical  Society  my  cordial  and  undiminished  re- 
gard. Your  society  held  and  still  holds  many  of  my 
best  professional  friends,  and  it  is  this  reason  which 
leads  me  to  present  to  you  some  of  the  results  of  seven 
years  of  observation  of  phthisis  in  different  climatic  re- 
sorts in  this  country.  These  years  have  made  vacant 
several  places  in  your  ranks — -vacancies  I  do  not  like 
to  contemplate.  The  dreary  distance  that  separates 
us  is  kind  for  once,  and  it  helps  me  to-night  to  picture 
all  the  chairs  filled  as  they  were  in  the  old  days.  Once 
when  I  lived  among  you  I  was  called  to  supersede  one 
of  your  honored  members,  who  was  impeached  by  pater- 
familias as  being  "too  scientific."  It  is  with  mingled 
feelings  that  I  recall  the  perfect  satisfaction  with  which 
my  ministrations  were  accepted  by  that  household 
through  many  years.  Though  the  quality  which  this 
infers  is  not  the  one  to  plead  before  you,  I  beg  you  to 
lend  your  ears  and  listen. 

The  writer's  problem  has  been,  as  you  know,  to  re- 
gain his  health  and  have  a  home  the  year  round  in  a 
ci\-ilized  community,  under  his  own  flag.  This  is  not 
presented  as  a  dissertation  on  "  climate  "  or  on  its  fac- 
tors and  their  method  of  action,  and  I  shall  purposely 
avoid  figures  and  statistics.  Often  an  accurate  estimate 
of  the  properties  of  an  air  may  be  made  by  avoiding 
for  a  time  our  instruments  and  gauging  it  by  the  amount 
of  comfort  it  brings.  There  are  good  climates  and 
health  resorts,  so  called,  in  this  country  ;  there  are  so 
many  that  no  one  of  them  can  properly  assume  airs  of 
exclusiveness.  Able,  honest,  painstaking  men  have  put 
these  places  on  record,  but  the  profession  has  been 
bothered  into  scepticism  by  the  genius  who  "  writes 
up  "  climate  from  the  car  window,  by  the  man  who 
directly  or  indirectly  has  it  for  sale,  by  the  sick  pessi- 
mist who  has  failed  in  his  search  for  health,  or  by  the 
healthy  pessimist  who  has  failed  in  speculation.  A 
hunt  for  a  perfect  climate  is  a  rainbow  chase.  Prob- 
ably there  is  no  spot  where  at  times  one  could  not 
reasonably  and  easily  imagine  himself  on  the  streets  of 
Orange  and  Montclair — in  nasty  weather  too. 

Your  correspondent  will  speak  briefly  of  Colorado, 
where  a  year  and  a  half  was  passed  ;  of  .\sheville  and 
its  vicinity,  where  more  than  a  year  was  spent,  and  of 
Southern  California,  where  in  various  places  he  has  re- 
sided for  three  and  a  half  years.  To  the  average  busy 
doctor  a  health  resort  presents  itself  as  an  unfamiliar 
medicine,  and  he  straightway  and  with  suspicion  ques- 
tions :  What  is  it  ?  How  does  it  taste  ?  What  is  it  good 
for? 

Colorado  is  a  type  of  a  land  of  high,  dry  air,  sun- 
shine, and  arid  soil.  That  elevation  and  atmospheric 
dryness  have  a  decided  influence  on  pulmonary  con- 


5° 


MEDICAL   RECORD. 


[July  13,  1895 


sumption  goes  for  the  saying.  It  is  safe  to  assert  that 
a  great  majority  of  non-laryngeal,  and  a  respectable 
minority  of  cases  with  laryngeal,  complications  should 
have  the  driest  air  comfortably  attainable.  This  not- 
withstanding the  fact  that  a  few  of- these  cases  do  well 
on  the  coast  or  at  sea,  or  even  in  a  damp  valley.  As 
for  altitude,  the  writer  is  each  year  firmer  in  his  con- 
victions that  it  is  the  most  powerful  climatic  (or  other) 
therapeutic  agent  we  have  for  the  arrest  and  cure  of 
this  disease,  but  it  is  a  two-edged  sword.  It  is,  in 
ignorant  hands,  a  most  dangerous  remedy,  and  even 
the  wisest  do  not  always  know  just  where  or  how  much 
to  give,  but  this  we  can  as  truly  say  of  atropia  or  digi- 
talis. Whether  an  altitude  of  three  thousand  or  four 
thousand  feet  gives  all  the  good  results  and  has  none 
of  the  evils  of  one  of  six  thousand  or  eight  thousand 
feet  is  a  question  for  further  observation  ;  but  I  should 
be  inclined  to  say  "  No  "  decidedly.  The  value  of  the 
climate  of  the  Rocky  Mountain  region  is  beyond  ques- 
tion, and  one  has  but  to  look  about  in  every  town  to 
see  those  who  came  there  very  ill  leading  active,  effi- 
cient lives. 

In  Colorado,  as  in  every  other  resort,  a  dreary  pict- 
ure may  be  drawn,  if  only  the  disagreeable  features 
are  spoken  of,  but  they  should  be  noticed  and  weighed 
or  disappointment  and  harm  may  occur.  If  the  climate- 
seeker  expects  to  find  a  spot  where  he  does  not  have  to 
use  vigilant  wit  against  the  vagaries  of  nature,  he  had 
better  stay  at  home.  Among  the  peculiarities,  to  use 
no  harsher  term,  of  Colorado  climate,  should  be  noted 
a  great  difference  between  day  and  night  temperature, 
as  exists,  I  believe,  in  all  high  altitudes,  and  also  holds 
in  Southern  California. 

Again,  as  elsewhere,  dryness  means  dust,  if  there  is 
any  soil  and  air  motion,  and  an  exaggerated  air  motion 
seems  to  be  inseparable  from  all  health  resorts  worthy 
the  name.  A  certain  amount  of  wind  is  wholesome, 
no  doubt,  but  Colorado  may  truly  be  said  to  have  more 
than  is  necessary  or  pleasant.  Dr.  Fisk,  of  Denver,  and 
Dr.  Solly,  of  Colorado  Springs,  have  made  analyses  of 
the  cases  of  phthisis  coming  under  their  care  during  a 
term  of  years,  and  show  improvement  in  sixty-six  and 
two-thirds  percent.  Their  deductions  are  beyond  ques- 
tion fair  accurate,  and  true  ;  still  it  would  be  safe  to  say 
that  of  the  indiscriminate  throng  of  consumptives  who 
press  out  to  that  country,  far  more  are  injured  or  re- 
ceive no  benefit  than  are  in  any  way  helped.  For  this 
two  comprehensive  reasons  may  be  given  :  i.  So  many 
unsuitable  cases  are  sent  ;  2,  so  many  do  not  at  once 
put  themselves  under  competent  local  medical  care. 

We  must  all  recognize  the  fact  that  the  most  skilful 
advice  cannot  be  always  right  in  its  choice  of  a  climate, 
and  that  in  each  instance  there  is  a  large  amount  of  ex- 
periment. Again,  we  must  remember  that  a  large  |)er- 
centage  of  these  cases  sooner  or  later  reach  a  fatal 
termination,  go  where  they  will  and  do  what  they  will. 
It  is  not  an  infrequent  thing  in  an  altitude  such  as 
Colorado  Springs  (six  thousand  feet)  to  see  developed 
a  train  of  nervous  disorders  demanding  a  retreat  to  a 
lower  level.  It  would  seem  to  be  true  in  a  measure, 
though  not  to  the  extent  formerly  supposed,  that  a 
"  cure  "  wrought  in  a  high  altitude  puts  the  subject  in 
jirison,  and  that  he  does  not  have  the  wider  range  of 
choice  of  one  who  regains  his  health  within  a  short  dis- 
tance of  the  sea-level.  Practically  the  difference  is  not 
great,  for  good  sense  requires  that  anyone  "  recover- 
ing "  from  phthisis  should  strive  to  remain  in  a  climate 
as  nearly  as  possible  identical  with  the  one  in  which 
the  cure  is  wrought. 

The  Asheville  region  is  one  of  great  beauty,  and  pre- 
sents the  advantages  of  a  varying  moderate  altitude. 
In  a  climatic  way  it  is  a  decided  improvement  on  the 
Atlantic  coast.  Its  proximity  to  the  Eastern  centres 
and  the  comfortable  character  of  a  great  part  of  tiie 
year  make  it  a  desirable  resort  for  those  who  do  not 
need,  or  cannot  reach,  or  should  not  attempt,  the  more 
decided  change   that  begins  only  at  the   eastern  edge 


of  the  Rocky  Mountain  plateau.  I  cannot  speak  of  any 
of  the  other  places  in  the  South,  for  I  have  no  direct 
acquaintance  with  them,  but  their  name  is  legion. 

Southern  California. — It  is  difficult  to  give  a  fair  im- 
pression of  a  climate  from  a  written  page.  The  feat 
has  never  been  accomplished.  It  bears  the  same  rela- 
tion to  the  real  thing  that  a  cook-book  does  to  a  din- 
ner. To  me,  all  things  considered.  Southern  California 
seems  to  present  more  of  the  essentials  of  health  and 
comfort  for  a  larger  proportion  of  invalids  than  any 
other  section  I  have  visited.  One  finds  that  as  a  class 
those  who  have  knocked  about  the  most  are  the  best 
satisfied  here.  No  one  who  has  not  lived  in  the  coun- 
try the  year  round  and  leisurely  visited  the  various  | 
places  can  have  any  just  idea  of  it.  It  should  always  M 
be  remembered  that  it  is  a  land  of  many  and  varied  B 
climates,  of  wide  range  of  heat  and  cold,  dryness  and 
moisture,  of  mountain  height,  sea-level,  and  below  the 
sea.  Going  a  score  of  miles  from  its  principal  town, 
one  is  at  the  sea  ;  an  equal  distance  in  another  direc- 
tion, six  thousand  feet  above  it.  Journeying  three  or 
four  hours  from  the  ocean  through  ever  increasing  dry- 
ness brings  one  to  the  great  dryness  of  the  desert,  at, 
above,  or  below  the  sea-level. 

At  first  the  great  stretches  of  bleak  treeless  shorn 
desolation  are  a  surprise,  if  not  a  shock,  to  those  who 
are  acquainted  only  with  the  lavish  hand  of  nature 
through  the  Eastern  summers.  Here,  through  most  of 
the  year,  nature  wears  colors  not  in  vogue  in  the  East, 
and  it  often  takes  a  little  time  to  get  used  to  her 
strange  gowns,  but  we  soon  learn  that  her  taste  is  un- 
erring. The  winter  rains  make  the  land  green  for  a 
short  time,  then  it  lapses  into  its  normal  browns  and 
gray-greens  for  many  months,  save  where  a  discouraged 
stream  crawls,  or  where  the  hand  of  man  leads  water 
to  orchard,  garden,  or  lawn.  If  one  may  speak  in  gen- 
eral terms  of  a  vast  area  in  which  there  are  varying 
conditions,  there  may  be  said  to  be  throughout  South- 
ern California  a  warm  midday  and  a  cold  night  half 
the  year,  a  hot  midday  and  a  cool  night  the  other 
half.  With  the  hot  sun,  a  cool  breeze  from  the  sea, 
save  in  the  early  fall,  when  it  dies  down.  The  hot 
weather  is  the  dry  weather,  and  comfortable  if  one 
can  order  his  employment.  In  most  locations  there 
are  a  dozen  days  a  year  of  dry,  parching,  disagreeable 
wind  from  the  desert.  During  the  winter  and  early  spring 
many  rainy  days  and  then  dry  skies  for  many  months. 
Dry,  warm  weather  means  dust  and  flies,  and  they  are 
here,  but  are  to  be  conquered  in  the  usual  way.  For 
three  months  in  the  late  spring  and  early  summer,  and 
as  an  occasional  thing  at  any  time  in  the  year,  there 
is  fog,  which  a  buoyant  optimism  calls  "  dry  "  though 
dripping  at  every  pore.  This  fog  increases  as  you  ap- 
proach the  sea  and  go  up  the  coast.  The  country  in 
the  interior,  away  from  the  cooling  influence  of  the  sea, 
may  be  depressingly  hot  in  summer  and  autumn.  The 
immediate  seashore  is  always  cool,  and  the  nights  are 
relatively  warmer  than  in  inland  places. 

The  only  difficulty  is  in  finding,  for  those  who  cannot 
stand  the  sea  nor  an  altitude  of  at  least  five  thousand  feet, 
aconvenient  place  to  retreat  from  the  heat  of  September 
and  October,  and  perhaps  that  of  August  and  Novem- 
ber. There  are  some  phases  of  consumption  that  do 
well  on  the  shore,  but  it  should  be  understood  that  to 
the  vast  majority  of  pulmonary  invalids  the  Southern 
California  ocean-side  is  not  friendly.  The  islands,  a 
score  or  more  of  miles  out  in  the  sea,  offer  a  satisfactory 
refuge  from  the  heat  for  some  who  cannot  brave  the 
air  of  the  main  coast.  Perhaps  the  cultivation  and 
irrigation  of  the  soil  is  in  certain  locations  a  disadvan- 
tage to  the  sensitive  throat.  If  it  is,  it  certainly  cuts 
very  little  figure  and  may  be  easily  avoided.  The 
most  wholesome  air  the  sick  one  breathes  is  no  doubt 
amid  absolute  isolation  and  desolation,  but  those  of  us 
who  have  experimented  are  willing  to  compromise  the 
matter  and  take  a  cook  and  some  cultivation  in  "ours." 

As  far  as  I  can  learn,  the  high  mountain  resorts  in 


July   13,    1895] 


MEDICAL    RECORD. 


51 


Southern  California  are  crude,  and  if  a  permanent 
residence  at  five  thousand  feet  or  over  is  contemplated, 
the  "  resorts "  in  the  Rocky  Mountain  region  offer 
better  advantages. 

If  our  cases  of  phthisis  are  to  seek  relief  by  change 
of  climate,  where  shall  they  go  ?  Were  one  to  make  a 
round  of  visits  in  any  one  of  our  distant  climatic  re- 
sorts, he  would  be  convinced  that  a  large  proportion  of 
the  invalids  should  have  remained  at  home.  Do  not 
let  me  be  understood  as  deprecating  the  climatic  treat- 
ment of  phthisis.  It  stands  first  of  all  curative  and 
palliative  agents,  but  taking  for  granted  that  the  doctor 
knows  something  about  the  different  locations,  there 
are  two  great  preliminaries  to  be  studied  before  advice 
to  go  any  distance  is  given. 

1.  The  Patient's  Eavironment  in  all  Its  Features. — 
His  bank  account,  his  habits,  his  friends  are  by  no  means 
the  least  important  items.  Frequently  it  is  as  essential 
to  know  the  nerve  and  quality  of  a  man's  wife  as  to 
examine  his  sputum,  if  he  is  to  fight  for  health  in  a 
strange  land.  To  send  anyone  away  from  a  good  home 
to  be  grudgingly  and  with  suspicion  taken  into  a 
boarding-house,  there  to  lie,  ill  and  homesick,  receiv- 
ing in  e.\change  for  what  he  has  resigned  a  little  drier 
air  and  a  little  more  sunshine,  is  to  place  a  very  con- 
siderable balance  on  the  wrong  side  of  the  ledger. 
This  what  is  every  day  happening  in  these  places. 

2.  The  Physical  Condition  of  the  Patient. — I  ha\e 
attempted  to  classify  the  common  forms  of  phthisis 
pulmonalis  and  to  make  a  choice  of  climate  for  each  : 
A,  Incipient  cases  ;  B,  those  with  considerable  con- 
solidation but  no  fever,  and  those  with  pleuritic  de- 
posits ;  C,  those  very  sick  ;  Z>,  emphysematous  cases  ; 
£,  laryngeal  cases  ;  J^,  cases  in  which  the  fibroid  proc- 
ess is  marked. 

If  an  apology  is  due  for  the  arbitrary  and  unscien- 
tific construction  of  these  divisions,  it  may  be  said  tliey 
thus  group  themselves  in  the  doctor's  office,  if  not  in 
the  laboratory. 

A.  Incipient  cases  at  their  earliest  discovery,  or  those 
without  physical  signs,  but  where  from  heredity  or  evi- 
dent depreciation  we  suspect  or  fear  the  advent  of 
phthisis.  We  may  also  include  here  the  cases  of  slight 
hemoptysis  without  recognizable  consolidation.  Often 
the  early  diagnosis  is  very  difficult,  if  not  impossible, 
for  the  disease  may  e.xist  before  the  chest  signs  appear, 
to  say  nothing  of  these  signs  being  present  before  we 
discover  them.  No  doubt  some  of  us  can  bring  to 
mind  instances  where  the  symptoms  of  fever  pallor 
and  emaciation  were  not  understood  until  cough  or 
even'  hajmoptysis  supervened.  Very  rarely,  however. 
does  the  disease  come  without  more  or  less  cough,  and 
if  there  is  sputum,  careful,  competent  microscopic  ex- 
amination is  a  guide,  though  not  an  infallible  one,  to 
diagnosis.  Still  less  is  it  an  infallible  guide  to  progno- 
sis. An  early  diagnosis  is  often  the  most  important 
factor  of  a  favorable  prognosis.  No  subsequent  skill 
can  atone  for  want  of  promptness  in  diagnosis.  An 
early  haemorrhage  is  apt  to  be  a  fortunate  thing,  for  it 
will  stop  a  man  and  cause  him  to  follow  advice  as 
nothing  else  will.  These  incipient  cases  frequently  do 
well  at  home,  if  the  regulation  of  food,  ventilation,  and 
exercise  is  looked  after  in  all  detail  ;  but  the  greater 
number  do  best  when  they  are  sent  to  some  very  mode- 
rate altitude  (not  over  two  thousand  five  hundred  feet), 
watched,  their  mode  of  life  carefully  controlled,  then 
worked  up  to  some  decided  altitude  (five  thousand  to 
seven  thousand  feet).  The  commencement  of  this 
progressive  climatic  treatment  may  be  in  the  Eastern 
mountain  ranges,  if  the  season  of  the  year  is  suitable. 

Southern  California,  in  its  varying  degrees  of  dry- 
ness, elevation,  and  warmth,  promises  well  for  these 
cases.  I  believe  many  of  this  class  of  cases  would  do 
well  to  advance  to  the  Rocky  Mountain  region  after  a 
few  months  passed  in  this  region.  One  can  experi- 
ment with  altitude  here  and  get  out  of  it  in  an  hour  if 
it  doesn't  work.     The  cases  of  early  haemoptysis  need 


no  special  separate  consideration.  The  same  manage- 
ment holds  good  for  them.  Altitude,  even  a  high  alti- 
tude, is  not  contra-indicated. 

B.  Those  with  considerable  consolidation  of  recent 
formation,  but  with  no  marked  disturbance  of  pulse 
and  temperature,  do  well  at  a  dry  level  of  two  thousand 
or  three  thousand  feet,  and  then,  when  tolerance  and 
quiescence  are  established,  a  higher  location  for  a 
while.  Again  Southern  California  presents  a  favorable 
place  for  many  of  these  cases  at  first  and  perhaps  in- 
definitely. It  appears  unwise  and  will  be  found  difficult 
to  send  one  who  is  doing  well  to  another  place,  but  at  the 
proper  juncture  a  visit  in  the  Colorado  country  is  fre- 
quently of  the  greatest  service.  In  a  convalescent  from 
pleuritis,  where  there  is  much  deposit  and  where  from 
family  history  or  other  causes  we  fear  tubercular  de- 
generation, most  happy  results  are  often  obtained  in  an 
altitude  of  five  thousand  to  eight  thousand  feet  ;  in  this 
and  all  other  instances,  providing  the  heart  is  healthy 
and  the  nervous  system  unimpaired. 

C.  Those  very  sick,  either  from  advanced  disease  or 
active  involvement  of  much  lung  tissue,  had  better  re- 
main at  home,  unless  great  wealth  puts  them  outside 
the  pale  of  ordinary  mortality. 

£>.  Emphysematous  Cases. — -The  best  climate  for  the 
emphysema  of  a  phthisical  lung  is  that  which  best 
suits  the  bronchitis  which  goes  with  it.  There  is  wide 
space  for  experiment.  These  people  do  not  often  do 
well  at  any  altitude,  and  should  not  be  sent  there  until 
a  low,  warm,  moderately  dry  location  has  been  tried 
and  has  failed.  Some  points  in  Southern  California 
answer  well,  and  so  should  many  places  in  the  South 
Atlantic  States. 

E.  Laryngeal  Cases,  i.e.,  those  in  which  the  symptoms 
and  signs  of  tubercular  ulceration  of  the  laryngeal 
structures  are  prominent  features.  I  do  not  refer  to 
the  early  laryngeal  irritation  which  often  marks  the 
inception  of  phthisis  and  which  frequently  disappears 
as  the  lung  lesion  advances.  Any  considerable  eleva- 
tion is  disastrous  to  true  laryngeal  cases,  though  once 
in  a  while  we  see  one  do  well  in  the  mountains.  A 
warm,  even,  not  too  dry  climate  suits  best,  though  the 
parched  desert  at  the  sea-level  meets  the  wants  of  a 
few.  Often  even  where  the  dampness  hurries  on  the 
destruction  of  lung,  the  relief  from  laryngeal  pain 
makes  it  desirable  to  live  at  the  sea.  No  place  offers 
more  than  Southern  California  for  this  class. 

E.  Cases  in  which  the  Eonnation  of  Eibroits  Tissue 
is  Marked. — Thorough  study,  nice  discrimination,  and 
some  experimenting  are  needed  in  adjusting  these 
cases  in  their  proper  places.  Do  not  send  them  to  an 
altitude  if  they  are  beyond  middle  life  or  if  there  is 
much  bronchial  irritation  or  if  their  hearts  are  dilated 
or  feeble.  If  none  of  the  above  conditions  exist,  they 
may  try  the  Colorado  or  Rocky  Mountain  country, 
using  great  discretion  and  restraint  in  bodily  exertion. 
The  wide  range  of  choice  found  in  this  country  ren- 
ders Southern  California  desirable  for  this  class. 

These  six  groups  will  include  almost  all  who  come 
into  our  hands. 

Certain  complications  must  modify  our  counsel. 
Elderly  people,  those  with  diseased  or  feeble  hearts, 
cases  of  nephritis  or  of  tubercular  ulceration  of  intes- 
tine, are  not  apt  to  do  well  at  any  elevation  over  three 
thousand  feet.  In  seeking  health  from  climate,  it  must 
be  ever  remembered  that  it  is  all  out  of  doors  and  must 
there  be  sought.  If  the  open  air  in  these  "  resorts  "  is 
good,  the  indoor  air,  from  faulty  construction  and  care- 
lessness, is  bad.  This  goes  far  to  explain  why  men  do 
better  than  women. 

As  to  the  treatment  of  phthisis  by  drugs,  there  is 
only  space  for  a  word.  During  a  prolonged  case,  al- 
most every  drug  may  be  reasonably  called  into  use, 
and  if  used  with  discretion,  do  good.  It  is  with  drugs, 
as  General  Sherman  is  rejiorted  to  have  said  about 
guns  :  "  It  isn't  the  kind  of  gun,  so  much  as  the  kind 
of  man  who  holds  it."     The  stomach  is  to  be  treated 


52 


MEDICAL    RECORD. 


[July 


1895 


with  the  utmost  consideration,  and  anything  that  for 
an  hour  interferes  with  its  functions  should  be  with- 
held, unless  there  is  imperative  need  for  the  relief  of 
some  particular  symptom.  That  "  two  bad  lungs  and 
a  good  stomach  are  better  than  one  bad  lung  and  a 
poor  stomach "  is  a  homely  expression  often  heard 
where  consumptives  gather. 

The  proper  management — I  do  not  call  it  treatment — 
of  phthisis  pulmonalis  is  embraced  in  these  words  : 
To  build  up  and  maintain  the  integrity  and  restrictive 
power  of  each  cell  in  the  body.  There  is  no  one  point 
more  important  or  so  commonly  overlooked  as  the  reg- 
ulation and  restriction  of  exercise.  The  treatment  by 
rest,  absolute  rest,  even  rest  in  bed,  in  the  early  his- 
tory of  the  febrile  cases,  far  outshadows  all  others  in 
importance.  At  first  this  seemed  to  me  especially 
necessary  in  the  Colorado  altitude,  but  subsequent  ob- 
servation would  indicate  that  it  is  equally  important  at 
all  levels.  If  one  cannot  be  sent  to  a  distant  climate, 
let  every  effort  be  made  to  get  all  the  good  out  of  the 
one  to  which  the  invalid  is  confined.  I  knew  a  man 
with  decided  lung  disease,  who  unsuccessfully  went  the 
rounds  of  all  the  places  and  went  back  to  end  his  days 
on  a  sunny  porch  in  Boston — and  got  well  there  ! 

As  to  the  Communicability  of  Phthisis. — Consump- 
tives as  a  class  like  to  tell  where  they  "  caught  it."  It 
is  definite,  positive,  and  in  a  way  puts  the  blame  on 
somebody  else  and  so  fills  a  long- felt  want.  How  many 
physicians  have  seen  an  authentic  case  where  a  per- 
fectly healthy  person  contracted  the  disease  from  an 
infected  one  ?  I  know  of  just  one  where  it  was  prob- 
ably so  ac(]uired,  and  that  is  the  only  one  of  scores 
where  the  claims  of  infection  had  been  set  up  where 
the  evidence  was  at  all  conclusive.  After  severe  strain, 
nervous  or  physical,  we  all  see  the  disease,  as  it  were, 
grafted  on  to  the  debilitated  organization.  Whether 
this  happens  oftener  when  a  consumptive  is  in  close 
attendance  than  when  absent  I  do  not  know. 

The  following  extract  from  a  letter  from  one  who 
has  had  ample  field  of  observation,  voices  the  opinion 
of  those  whose  special  knowledge  led  me  to  ask  them  : 
"As  regards  your  question  ('  Have  you  observed  con- 
sumption to  be  communicable  ? ')  I  am  most  emphatic 
on  this  point.  I  have  never  seen  a  case  where  I  have 
thought  that  there  was  a  reasonable  ground  for  assum- 
ing that  ])hthisis  pulmonalis  had  been  communicated 
from  an  infected  person  to  one  previously  healthy.  I 
have  seen  but  few  cases  where  there  could  be  a  sus- 
picion, and  inquiry  would  usually  develop  the  fact 
thas  there  had  been  excessive  strain,  nervous  or  physi- 
cal, e.^s^.,  from  nursing,  inducing  a  debility  and  low  re- 
sistance and  then  exposure  to  cold  or  something  of  the 
sort.  I  have  seen  many  a  case  where  a  consumptive 
husband  or  wife  lived  in  the  same  room  with  and  even 
slept  with  a  healthy  husband  or  wife  and  I  never  knew 
any  bad  results  in  the  way  of  inoculation  or  infection 
to  follow." 

This  does  not  go  to  disprove  that  the  feeble  are  in 
danger  from  the  tuberculous.  No  attempt  in  that  di- 
rection is  intended.  It  does  not  in  the  least  remove 
the  need  of  most  vigilant  cleanliness.  Every  atom  of 
tubercular  or  suspected  sputum  should  be  destroyed 
by  chemicals  or  fire,  but  it  enables  us  to  say  that  the 
nineteenth-century  consumptive  may  be  safely  treated 
less  like  a  leper  than  the  clamor  of  lay  science  at  pres- 
ent demands.  Some  of  us  are  cultivating  a  broad  re- 
ceptivity of  mind  on  the  subject  of  the  significance  of 
the  bacillus  tuberculosis.  We  may  be  a  little  slack  in 
our  allegiance  to  his  sovereignty,  but  we  all  pay  trib- 
ute. Even  the  chief  sceptic  would  prefer  not  to  have 
the  rods  in  his  sputum.  However  much  pulmonary 
tuberculosis  at  the  bedside  may  differ  from  that  in  the 
laboratory,  it  is  to  those  who  are  working  along  the 
trail  that  Koch  blazed  out,  that  our  eyes  are  turned  in 
hopeful  expectation. 

My  apologies  are  due  for  the  triteness  of  this  subject, 
but  triteness  in  matters  medical  is  sometimes  synony- 


mous with  importance.  It  is  a  great  subject,  and  there 
were  a  dozen  places  as  we  came  along,  where  we  might 
have  stopped  and  discussed  some  point  barely  noticed, 
but  it  cannot  be  done  at  one  sitting.  If  you  have  had 
to  listen  to  what  you  know  as  well  already  and  could 
have  said  better,  it  may  be  a  consolation  to  recollect 
that  it  is  a  risk  everyone  runs  who  goes  to  medical  so- 
cieties. 


'^voQV6S3  at  pXetlical  Science. 

Primary  Carcinoma   of  the  Duodenum. — Dr.   Pic  has 

made  a  comprehensive  study  of  this  subject,  as  a  result 
of  which  he  has  formulated  the  following  propositions: 
A.  Primary  cancer  of  the  duodenum,  in  the  great  ma- 
jority of  cases,  like  primary  cancer  of  the  intestine  in 
general,  has  an  annular  form.  On  this  account  it  is 
very  apt  to  produce  stenosis  of  the  digestive  tract.  £. 
The  symptoms  of  this  cancerous  stenosis  vary  accord- 
ing to  the  height  at  which  it  is  produced.  A  cancer 
above  the  ampulla  of  Vater  has  a  symptomatology 
almost  identical  with  that  of  cancer  of  the  pylorus.  A 
cancer  below  the  ampulla  presents,  besides  symptoms 
of  malignant  pyloric  ste'nosis,  signs  indicating  a  perma- 
nent reflex  of  the  bile  and  the  pancreatic  juice  into  the 
stomach.  A  cancer  round  the  ampulla  presents,  ac- 
cording to  the  case,  a  symptomatology  more  or  less  re- 
sembling the  one  or  the  other  of  the  first  two  forms  ; 
it  is  a  composite  form.  C.  Among  the  so-called  can- 
cers of  the  ampulla  of  Vater  we  may  place  :  i.  Cancers 
of  the  duodenum  in  which  the  ampulla  is  invaded  ; 
nothing  distinguishes  these  tumors  clinically  from  or- 
dinary duodenal  cancers ;  they  are  included  in  our 
third  form.  2.  Cancers  primary  in  the  head  of  the 
pancreas.  3.  There  exist  some  cancers  appearing  to 
be  developed  at  the  expense  of  the  ampulla,  and  pre- 
senting the  clinical  picture  of  icterus  from  retention — 
a  picture  comparable  to  that  of  cancer  of  the  head  of 
the  pancreas.  These  cancers  must  be  distinguished 
clinically  and  histologically  from  cancers  of  the  duo- 
denum strictly  speaking,  and  must  be  classed  with  pan- 
creatic cancer,  of  which  they  appear  to  constitute  aber- 
rant varieties.  4.  it.  In  most  of  the  cases  there  is  a 
contraction  at  the  site  of  the  tumor  and  a  dilatation 
toward  the  stomach  tending  to  involve  this  organ,  and 
frequently  accompanied  by  pyloric  insufficiency.  />. 
The  histological  examination  has  revealed  up  to  the 
present,  among  the  primary  tumors  of  the  duodenum, 
cancers  of  the  investing  epithelium  type  (cyliiidrical 
epithelioma),  of  the  glandular  type  (primary  epitheli- 
oma of  Brunner's  gland),  of  the  embryonic  -  tissue 
type  (sarcoma),  and  of  the  lymphatic  type  (lymphade- 
noma).  As  a  matter  of  fact,  there  are  forms  of  cells 
entering  into  the  constitution  of  the  duodenum  other 
than  tliose  found  in  these  forms  of  cancer.  5.  The 
difficulty  of  diagnosis  in  cancer  of  the  duodenum  varies 
according  to  the  situation  of  the  neoplasm  ;  while  the 
diagnosis  of  the  form  which  occurs  above  the  ampulla 
is  ordinarily  impossible,  that  of  the  two  other  forms  is 
sometimes  possible.  Sjieaking  in  a  general  way,  the 
chief  differentiation  is  to  be  made  between  duodenal 
cancer  and  stenosis  of  the  digestive  tube  of  supra-duo- 
denal or  infra-duodenal  origin,  and  between  duodenal 
stenoses  of  extrinsic  origin.  6  The  topographical  di- 
agnosis is  of  greatest  imjiortance  from  an  operative 
point  of  view,  which  will  differ  according  to  the  situa- 
tion of  the  neoi)lasm  in  the  duodenum.  When  the 
diagnosis  is  impossible  early  exjiloratory  laparotomy 
will  be  necessary,  and  in  most  cases  will  be  onlv  palli- 
ative.— Rn'ue  de  M^decine. 


Poison  Labels, —  In  Ohio  there  is  a  law  making  it 
obligatory  on  dealers  to  affix  the  label  "  Poison  "  on  all 
bottles  of  household  ammonia  sold. 


July   13.  1895] 


MEDICAL   RECORD. 


53 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Stcrgery. 


GEORGE    F.  SHR.\DY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  July  13,  1895. 


UNNECESSARY    NOISES. 

In  a  recent  issue  of  a  daily  paper  there  was  a  report  to 
the  effect  that  a  sneak  thief  who  successfully  raided  a 
boarding-house  escaped  detection  by  purposely  making 
as  much  noise  as  possible  in  order  that  he  might  be  mis- 
taken for  a  belated  lodger.  The  result  proved  that 
there  was  no  better  way  to  quiet  the  apprehension  of 
anything  unusual  than  the  creation  of  an  ordinary 
racket  and  the  well-known  receptive  resignation  to  its 
usual  disturbing  tendencies.  There  is  in  the  cir- 
cumstances all  the  necessary  proofs  that  not  alone  in 
lodging-houses  but  in  every  other  environment  of  our 
so-called  advanced  civilization  the  denizen  of  a  crowded 
city  has  become  so  inured  to  the  discipline  of  noise 
that  he  submits  to  it  as  a  necessary  evil. 

The  interesting  question  comes  up  in  this  connection 
as  to  the  distinction  between  necessary  and  unnecessary 
noises.  The  formed  can  be  made  tolerable  by  reason 
of  their  inevitability,  but  the  latter  are  always  exasper- 
ating by  their  easy  preventability  and  consequent 
uselessness.  When  we  stop  to  consider  what  noises 
can  be  dispensed  with  without  harming  anyone  but  the 
maker  of  them  we  open  up  an  astonishingly  wide  field 
of  inquiry.  From  the  snoring  bed-fellow  to  the  noisy 
neighbor  there  is  all  the  difference  between  the  awaken- 
ing elbow-punch  in  the  rib  and  the  remote  possibility 
of  a  floral  gift  for  a  waiting  coffin.  But  the  applica- 
tion of  such  or  similar  means  are  so  seldom  made 
in  this  cruel  world  of  chance  that  practically  the  real 
remedies  are  very  few.  Still  less  is  this  the  case  with 
noises  apparently  beyond  our  reach.  The  clamor  of 
traffic  is  in  some  respects  a  necessity  of  the  struggle  for 
living  and  gain.  The  useless  accessories  of  such  a 
situation  are  too  numerous  to  mention.  Take  for  in- 
stance the  numerous  street  cries  of  pedlers,  the  roar  of 
the  elevated  train,  the  clang  of  the  cable  car,  the  irri- 
tating factory  whistle,  the  intrusive  hand-organ,  and 
even  the  reverentially  suggestive  church-bell. 

Not  long  since  a  piano  fiend  in  an  adjoining  house 
rendered  miserable  the  dying  hours  of  an  honored 
judge  in  brazen  defiance  of  frequent  protests  from  his 
bereaved  family.  We  wonder  if  it  be  true,  as  the 
Swedenborgians  assert,  that  pianos  will  be  allowed  in 
heaven.  If  so,  it  may  be  possible  to  assume  that  they 
will  be  tuned  to  a  harmony  unknown  and  unrecogniz- 
able by  earthly  mortals.  In  any  event  the  only  hope 
will  be  that  the  practising  miss  with  her  dreary  and  ex- 


asperating finger  drill  may  not  die  before  she  is  well 
started  with  a  tune.  The  piano,  however,  has  done  more 
to  educate  humanity  into  a  forced  toleration  of  disagree- 
able noises  than  any  other  known  agent  in  the  prodigal 
inventions  of  the  nineteenth  century.  The  discipline  of 
forbearance  that  it  has  inculcated  in  the  human  breast 
has  so  overwhelmed  the  disposition  to  profanity  toward 
all  other  comparatively  trifling  inflictions  that  there  is  a 
grim  satisfaction  in  believing  that  this  instrument  has 
very  indirectly  and  quite  innocently  helped  to  develop 
a  high  grade  of  self-sacrificing  Christian  charity.  All 
of  these,  however,  come  under  the  heading  of  really  un- 
necessary and  apparently  preventable  noises.  Much 
more  pronounced  ones  that  are  evidently  without 
remedy  are  resignedly  and  philosophically  borne,  and 
the  very  uselessness  of  prevention  is  in  itself  a  solace  of 
tolerance.  The  man  who  can  sleep  peacefully  through 
a  rattling  thunder-storm  loses  all  somnolent  composure 
while  his  neighbor  is  filling  a  bath-tub,  or  noisily  tum- 
bling over  bedroom  furniture.  The  traveller  who  could 
composedly  sleep  in  the  berth  of  a  limited  express 
train  would  suffer  the  wicked  suggestiveness  of  infant 
mortality  while  listening  to  the  wakeful  cry  of  a  restless 
baby. 

Strange  to  say,  however,  all  these  disturbers  of  the 
peace,  with  much  show  of  injured  innocence,  are  ever 
ready  to  act  upon  the  defensive  in  what  they  consider 
their  rights  and  privileges.  The  struggle  of  the  brass 
band  to  maintain  its  boisterous  hold  on  the  street  curb 
is  still  fresh  in  the  mind  of  the  long-suffering  New 
Yorker.  Luckily  for  the  latter  the  stuttering  voice  of 
the  brazen  funnel  is  relegated  to  "innocuous  desuetude." 
Many  of  the  street  cries  have  been  abolished  after 
similar  struggles  in  the  cause  of  quiet-loving  persons. 
Let  us  hope  that  many  more  reforms  will  follow  in  their 
wake. 

It  is  unnecessary  to  allude  to  the  wide-spread  evil 
effects  of  noise  upon  the  public  health.  If  the  accu- 
mulated agony  of  irritability  could  find  a  common  voice 
it  would  dangerously  jar  the  equilibrium  of  the  public 
peace.  The  only  mercy  is  that  it  has  so  many  differ- 
ent vents  through  the  thousand  channels  of  individual 
protests  that  a  general  explosion  of  wrath  is  thereby 
averted.  Appeals  are  often  made  to  the  Health  Board 
for  the  suppression  of  such  noises  as  may  be  construed 
as  prejudicial  to  health.  Practically  all  unnecessary 
noises  are  such,  although  the  police  catalogue  places 
many  under  the  designation  of  disorderly  ones.  The 
difficulties  in  the  way  of  deciding  which  is  which  are  not 
few.  The  Health  Department,  with  all  its  arbitrary 
power,  cannot  seemingly  make  a  politic  distinction. 
This  was  shown  in  the  case  of  the  cruel  pianist  and  the 
dying  judge.  Perhaps  some  day  a  proper  test  case  may 
be  brought  for  adjudication,  but  hardly  until  some  en- 
terprising neurologist  can  locate  the  noise-centre  and 
conclusively  prove  the  direct  causes  of  its  premature 
exhaustion. 


Suicide  of  a  Medical  Man. — A  surgeon  lately  practis- 
ing in  Bristol,  England,  was  called  to  the  door  by  a 
ring,  but  instead  of  the  expected  patient,  found  a  col- 
lector for  over-due  rent.  This  so  discouraged  him 
that  he  killed  himself. 


54 


MEDICAL    RECORD. 


[July   13,  1895 


WHAT  SHALL   BE    DONE    WITH    ADVERTIS- 
ING   QUACKS? 

With  the  present  restrictions  upon  the  practice  of 
legitimate  medicine,  backed  by  the  stringent  examina- 
tions of  the  State  boards,  it  becomes  us  to  inquire  how 
much  the  real  and  harmful  quackery  is  prevented. 
Judging  from  the  blatant  advertisements  in  the  daily 
papers  it  would  certainly  appear  that  medical  rogues 
are  rather  on  the  increase  than  the  decrease.  There  is 
such  an  inconsistency  in  all  this,  such  a  disposition  to 
curtail  the  privileges  of  the  virtuous  at  one  end,  and 
such  marked  apathy  in  guarding  the  dangerous  prac- 
tices at  the  other,  that  it  almost  seems  as  if  the  good 
must  be  punished  for  the  sake  of  the  bad. 

The  Medical  Society  of  our  own  county  has  striven 
with  commendable  zeal  to  bring  punishment  on  the 
offenders  in  question,  but  as  yet  has  been  unable  to 
succeed.  By  virtue  of  old  diplomas  these  advertising 
scoundrels  are  apparently  protected  by  law — at  least 
the  County  Society,  so  watchful  of  small  offenders, 
cannot  reach  them  by  any  legal  process  known  to  the 
counsel  of  that  body.  It  is  no  secret  that  most,  if 
not  all,  of  these  advertisers  are  professed  abortionists, 
and  have  from  time  to  time  been  under  arrest  on  such 
charges.  They  constantly  escape  a  just  punishment, 
and  the  very  indictment  is  oftentimes  used  as  a  means 
of  wider  advertisement  of  their  nefarious  practices. 
No  newspaper,  however  respectable,  refuses  their  stand- 
ing advertisements,  and  even  the  religious  weeklies 
pander  to  them  under  the  hypocritical  guise  of  covert 
endorsement.  These  latter  journals,  particularly, 
trusted  with  the  responsibility  of  guarding  the  physical 
and  moral  safety  of  the  community,  allow  the  quacks 
boldly  to  announce  for  sale  quick  cures  for  "  gonor- 
rhoea," vegetable  tonics  for  "falling  of  the  womb," 
infallible  pills  for  "female  irregularities,"  and  patented 
belly-bands  for  "  seminal  weakness  and  the  decline  of 
manlrood."  Aside  from  the  positive  damage  which 
such  advertisements  may  occasion  by  false  pretences 
and  actual  bodily  harm,  we  are  forced  to  contemplate 
the  still  greater  injury  to  morals  of  the  rising  genera- 
tion by  a  free,  forced,  and  covert  education  along  these 
dangerous  lines.  While  all  this  is  going  on  in  the 
broad  light  of  day,  and  under  the  very  noses  of  our 
medico  political  reformers,  we  learn  that  a  respectable 
well-educated  physician  cannot  remove  his  practice 
from  one  county  to  another  in  this  or  other  States  with- 
out suitable  legal  license  and  registration.  It  is  true 
that  the  New  York  quacks  cannot  practise  anywhere 
else  than  in  the  county  they  reside,  nor  do  they,  for 
obvious  reasons,  care  to  do  so.  There  is  no  better 
place  in  which  to  ply  their  abominable  trade  than  in 
this  city.  Their  only  desire  is  to  be  left  alone.  It  has 
always  been  a  puzzle  how  professed  abortionists  can 
go  on,  apparently  for  all  time,  undisturbed,  when  any 
respectable  practitioner  dares  not  respond  to  a  purel\ 
professional  call  in  a  case  of  emergency,  the  result  of 
these  criminal  jiractices,  without  the  protection  of  an- 
other professional  man  as  a  witness  and  without  a  pre- 
liminary notification  of  the  fact  to  the  Coroner.  It 
would  seem  more  just  that  the  power  of  the  law  should 
be  on  the  side  of  the  righteous  rather  than  on  that  of 
the  evil-doer.     The  same  law  that  imposes  restrictions 


upon  qualified  men  should  protect  them  against  the 
outrageously  wicked  machinations  of  the  evil  ones. 
There  should  be  no  stretch  of  power  in  the  law  in  one 
direction  more  than  in  another.  If  any  law  can  be  so 
framed  as  to  restrain  the  privileges  of  the  well- qualified 
in  certain  directions  there  is  no  reason  why  similar 
means  could  not  be  used  to  prevent  the  quacks  from 
openly  defying  every  enactment  that  has  thus  far  been 
made.  We  respectfully  call  the  attention  of  our  medi- 
cal law-makers  to  this  matter,  and  more  especially 
would  commend  the  latter  to  the  consideration  of  the 
county  societies,  which  have  volunteered  to  guard  the 
higher  interests  of  medicine  and  to  guarantee  a  rid- 
dance of  reprehensible  practices. 


HOW   TO   BEGIN    PRACTICE. 

The  all-important  question  how  and  where  to  begin 
])ractice  is  one  that  every  young  medical  man  must  set- 
tle for  himself.  The  considerations  that  should  gov- 
ern him  are  as  much  of  a  strictly  personal  as  of  a  purely 
professional  character.  At  best  it  is  but  an  experiment, 
the  success  of  which  largely  depends  upon  such  con- 
ditions as  only  time  and  opportunity  can  properly  de- 
velop. Of  one  thing  he  must  convince  himself  at  the 
outset,  and  that  is,  inasmuch  as  the  profession  is  very 
much  overcrowded,  the  community  at  large  is  not  over 
eager  to  test  his  abilities,  or  anxious,  in  view  of  his  sup- 
posed eminent  fitness  for  his  work,  to  find  him  an  easy 
or  safe  living.  He  must  necessarily  create  a  place  for 
himself  and  with  a  reasonable  persistence  of  purpose 
develop  his  own  plant.  If  he  be  content  to  commence 
in  a  small  way  and  be  satisfied  with  slow  advancement 
he  is  likely  to  succeed  in  any  neighborhood,  whether  in 
the  country  or  city.  The  better  chances  are  those  in  a 
young  and  growing  locality,  neither  rich  nor  poor,  but 
rather  among  people  of  the  middle  class.  The  latter 
are  generally  prompt  in  the  payment  of  the  smaller  fees 
that  must  satisfy  the  younger  professional  man.  The 
very  poor  patronize  the  dispensaries  and  the  very  rich 
are  generally  already  well  provided  with  specialists  in 
every  branch  and  a  family  physician  besides.  There 
is  no  greater  mistake  for  a  young  medical  man  with 
limited  means  than  to  settle  in  an  expensive  and  fash- 
ionable neighborhood  in  the  expectation  of  gaining, 
thereby,  a  first-class  practice  in  the  beginning.  As  a 
rule,  the  rich  will  entirely  ignore  him  and  the  poor  will 
be  afraid  of  his  style  and  assumed  superiority  of  living. 
The  people  who  are  likely  to  employ  him  at  all  will  be 
satisfied  with  a  moderate  establishment  and  will  be 
proportionately  impressed  with  his  earnest  business 
spirit. 

The  choice  of  city  or  country  depends  largely  on 
the  personal  habits  and  tastes  of  the  individual.  Coun- 
try practice,  strange  as  it  may  appear,  demands  a  higher 
grade  of  general  jirofessional  attainments  at  the  start 
than  those  by  which  a  young  man  makes  an  ordinary 
success  in  the  city.  In  the  country  the  young  practi- 
tioner must  from  the  very  nature  of  his  business  be  a 
good  all-round  man,  prepared  for  any  ordinary  emer- 
gency in  medicine,  surgery,  or  obstetrics,  while  his  city 
brother,  surrounded  by  experts,  can  very  readily  divide 
extra  responsibilities.     The  former  is  a  marked  man 


July  13,  1895] 


MEDICAL   RECORD. 


55 


from  the  beginning,  is  generally  known  by  everj-one  in 
his  town,  and  must  necessarily  at  the  very  commence- 
ment of  his  career  set  the  pace  for  the  remainder  of  his 
life.  On  the  other  hand,  the  metropolitan  youngster,  as 
far  as  a  general  reputation  is  concerned,  is  pretty  sure, 
in  his  earlier  struggles  at  least,  to  be  lost  in  a  crowd. 
The  returns  for  work  in  the  country  are  generally  more 
prompt  than  in  the  city,  and  sooner  reach  their  abso- 
lute limit,  while  the  rewards  in  the  city  are  slower  and 
in  the  end  are  proportionately  expansive.  It  is  quite 
uniformly  agreed  that  general  practice  is  the  best  surety 
for  a  good  start  anywhere,  and  in  a  large  city  the  most 
thickly  populated  portions  are  to  be  preferred.  There 
is  something  in  the  cosmopolitan  character  of  such  dis- 
tricts that  takes  a  young  and  struggling  practitioner  on 
his  merits,  and  is  as  ready  to  shift  to  the  newcomer  as 
stick  to  the  old  timer.  It  is  excellent  training  ground 
until  enough  money  is  made  to  move  into  a  better 
neighborhood.  In  any  event,  wherever,  whenever,  or 
however  a  young  man  begins  it  is  well  to  bear  these 
cardinal  business  points  always  in  mind  :  stick,  watch. 
wait,  and  work. 


TOBACCO    AND    RELIGION. 

It  is  somewhat  startling  to  learn  that  peace  has  been 
in  a  measure  declared  between  tobacco  and  religion,  and 
the  former,  that  has  been  so  often  declared  to  be  the  ally 
of  the  e\al  one,  is  about  to  join  forces  with  Christianity 
in  its  laudable  effort  to  evangelize  the  world.  Not  very 
long  ago,  at  a  ministerial  conference,  it  was  voted  that 
no  minister  of  the  gospel  could  consistently  preach 
with  a  so-called  tobacco  breath,  as  it  was  impossible 
under  such  circumstances  to  maintain  that  odor  of 
sanctity  and  earnestness  of  persuasion  necessary  for  suc- 
cessful spiritual  ministrations.  We  believe  one  good 
brother  rather  forcibly  alluded  to  the  impossibility  of 
drinking  pure  water  from  a  foul  cup  or  mug.  Althougli 
no  originality  was  claimed  for  the  allusion,  it  had  the 
telling  effect  of  securing  the  passage  of  a  resolution  for- 
bidding the  parson  from  smoking  or  chewing  the  so- 
called  noxious  weed.  It  is  fair  to  say  that  the  cause  of 
the  smokers  and  chewers  was  not  lost  without  a  struggle. 
Many,  however,  knowing  the  impossibility  of  sincere 
and  effectual  repentance  of  the  habit,  sought  relief  in 
that  usual  mental  reservation  of  possible  wickedness  in 
private  as  contrasted  with  plausible  \irtue  in  public. 
In  fact  one  of  the  committee,  in  copying  the  resolutions 
in  a  side  room,  was  charged  with  actually  smoking 
while  so  engaged.  It  was  maintained  on  that  occasion 
that  no  man  with  a  quid  in  his  teeth  could  properly 
round  his  periods  or  decorously  control  labial  re- 
flexes with  a  mouthful  of  redundant  saliva.  Certainly 
no  man  caught  in  the  act  could  pose  as  a  shining  exam- 
ple of  ordinary  Christian  self-denial. 

Now,  however,  it  would  appear  that  the  tobacco  as- 
pect has  entirely  changed  front.  We  notice  a  report  to 
the  effect  that  in  one  of  the  London  churches  there  has 
been  established  what  is  called  a  smoking  service,  in 
w  hich  the  habit  is  not  only  tolerated,  but  actually  en- 
couraged by  an  extra  offer  of  free  tobacco.  This  inno- 
vation will  doubtless  act  as  a  powerful  temptation  to 
many  outsiders,  and  may,  we  trust,  tend  to  overcome 
any  scruples  as  to  waste  of  time  in  listening  to  prosy 


sermons,  while  at  the  same  time  the  smokers  themselves 
may  become  more  benevolently  receptive  to  those  bet- 
ter influences  that  associate  themselves  so  directly  with 
the  other  forms  of  church  service.  The  smoker,  with 
his  pipe  well  aglow,  is  generally  prepared  to  look  on 
the  reasonable  and  happy  side  of  any  question.  Many 
an  after-dinner  speaker  is  saved  from  well-merited  con- 
demnation for  prosiness  by  the  benevolent  tolerance 
of  a  crowd  of  smokers.  Tobacco,  under  the  circum- 
stances, tones  down  antagonism,  paralyzes  criticism,  and 
in\ntes  conviction.  Thus  the  tobacco  service  is  likely 
to  be  a  success  in  every  way,  pro%ided  the  tobacco  it- 
self is  of  good  quality  and  the  smoking  service  of 
satisfactory  length  to  the  old  stagers. 


^exus  at  tUc  Wittk. 

The  Late  Professor  Thomas  Henry  Huxley  was  a  grad- 
uate in  medicine,  having  received  the  degree  of  M.D. 
in  1845  from  the  University  of  London.  He  stood 
second  in  the  list  of  honors  for  anatomy  and  physiol- 
ogy. He  joined  the  medical  service  of  the  navy  in 
1846,  and  was  surgeon  to  The  Rattlesnake  during  its 
trip  to  Australia  and  New  Guinea.  Professor  Huxley 
left  the  naval  service  after  seven  years,  and  during  that 
time  he  studied  natural  history  much  more  than  he  did 
medicine.  His  earliest  ambition  was  to  be  a  mechan- 
ical engineer,  and  he  studied  medicine  rather  against 
his  will.  In  his  autobiography  he  says  :  "  I  am  now 
actually  horrified  to  think  how  little  I  ever  knew  or 
cared  about  medicine  as  the  art  of  healing.  The  only 
part  of  my  professional  course  which  really  and  deeply 
interested  me  was  physiology,  which  is  the  mechanical 
engineering  of  living  machines."  Professor  Huxley's 
only  work  having  a  special  interest  to  medical  men,  as 
such,  was  his  "Lessons  in  Elementary  Physiology," 
which  was  a  very  good  introductorj-  manual  when  first 
published,  now  thirty  years  ago. 

Dr.  Edward  E.  Palmer  died  in  Louisville  on  July  6th 
of  injuries  received  while  riding  on  a  bicycle.  He 
came  in  collision  with  another  wheelman.  Dr.  Palmer 
was  President  of  the  Genito-urinary  Section  of  the 
American  Medical  Association.  He  was  bom  in  Wood- 
stock, Vt.,  and  went  to  Louisville  forty-four  years  ago. 

Gratesetters'  Netirosis. — Dr.  E.  C.  Runge  describes, 
in  the  New  Albany  Herald,  the  case  of  a  man  who  suf- 
fered from  a  peculiar  forward  jerking  of  both  legs, 
which  was  most  apt  to  occur  after  he  had  been  sitting 
for  some  time,  but  which  also  took  place  when  he  was 
occupied  in  reading  or  playing  games,  and  even  when 
he  was  asleep.  For  twenty-four  years  the  man  had 
followed  the  business  of  setting  grates,  and  had  worked 
in  a  kneeling  posture,  frequently  for  ten  hours  at  a 
stretch.  Dr.  Runge  suggests  that  this  peculiar  spas- 
modic disorder,  which  was  associated  also  with  some 
neurasthenic  symptoms,  should  be  classed  among  the 
occupation  neuroses. 

Examinations  of  the  New  Jersey  State  Board. — At 
the  June  examinations  of  this  Board,  over  forty  per 
cent,  (eleven  out  of  twenty-six)  of  the  candidates  ex- 
amined for  license  to  practise  medicine  in  New  Jersey 


56 


MEDICAL    RECORD. 


[July  13,  1895 


were  rejected.     One  candidate  was  dropped  before  the 
examination  was  completed,  for  "  cribbing." 

American  Orthopedic  Association. — The  ninth  an- 
nual meeting  of  this  Association  will  be  held  at  Chica- 
go September  17,  18,  and  19,  1895,  under  the  presi- 
dency of  Dr.  John  Ridlon,  of  that  city.  An  interesting 
programme  is  promised. 

Prophylactic  Measures  Against  Tuberculosis. — At  a 
recent  meeting  of  the  Berlin  Medical  .Society,  Profess- 
or Cornet  read  a  paper  on  the  above  subject  (77/6' 
Lancet^.  He  had  already  suggested  that  the  tubercle 
bacillus  is  not  ubiquitous,  as  some  observers  suppose, 
and  is  present  only  where  phthisical  patients  have  ex- 
pectorated and  where  the  dried  sputum  has  afterward 
become  dispersed.  This  result  he  had  arrived  at  by 
very  extensive  examinations  of  the  wards  in  hospitals, 
and  the  rooms  in  barracks,  prisons,  and  monasteries, 
where  crowds  of  people  live  together  in  a  limited 
space  ;  the  dust  and  mud  of  the  street  were  also  care- 
fully examined  by  him.  In  rooms  where  spittoons  con- 
taining some  water  were  in  use  he  very  seldom  found 
the  bacillus,  even  if  the  phthisical  patients  lived  there. 
According  to  him  the  prophylactic  measures  are  very 
simple  :  a  large  number  of  spittoons  partially  filled 
with  water  should  be  provided  in  order  to  prevent 
people  from  spitting  on  the  floors,  and  handkerchiefs 
should  not  be  used  for  receiving  expectoration  ;  more- 
over, the  floors  of  houses  and  the  streets  ought  to  be 
sprinkled  with  water  as  often  as  possible.  Heredity 
had  less  influence  on  the  origin  of  tuberculosis  than 
was  generally  believed.  In  a  great  many  cases  where 
the  children  of  phthisical  parents  were  attacked  with 
the  disease,  the  communication  might  be  due,  not  to 
heredity,  but  to  mere  contagion.  The  number  of  those 
suffering  from  phthisis  is,  in  Professor  Cornet's  opinion, 
estimated  to  be  higher  than  the  results  of  necropsies 
warrant.  It  is  an  error  to  suppose  that  the  atmosphere 
is  filled  with  tubercle  bacilli  ;  they  are  dangerous  only 
where  the  necessary  precautions  are  neglected.  In  proof 
of  the  efficacy  of  hygiene  in  reducing  the  danger  of 
tuberculosis.  Professor  Cornet  mentioned  that  on  his 
advice  the  Government  had  taken  the  above-described 
measures  to  prevent  the  general  dispersion  of  sputum 
in  prisons  and  lunatic  asylums,  and  that  since  this  time 
the  mortality  had  fallen  considerably. 

A  Systematic  Study  of  the  Therapeutics  of  Leprosy. 
— The  Board  of  Health  of  the  Hawaiian  Islands  has 
lately  established  a  small  hospital  at  Kalihi,  in  the  out- 
skirts of  Honolulu,  and  has  begun  a  work  which  has  for 
its  purpose  the  solution  of  the  questions  :  "  Is  leprosy 
curable  ? "  and  "  What  are  the  best  means  for  its  relief 
and  eradication  from  the  human  system  ? "  Twelve 
patients  selected  from  the  leper  colony  at  Kalawao,  on 
the  Island  of  Molokai,  have  been  placed  under  treat- 
ment at  the  Kalihi  Hospital,  where  they  are  provided 
with  an  abundance  of  wholesome,  nutritious  food,  clean 
bedding  in  airy  rooms,  and  the  opportunity  for  outdoor 
e.xercise  and  recreation.  There  is  also  an  abundant 
supply  of  pure  water,  and  the  use  of  hot  and  medicated 
baths  will  be  an  important  feature  of  the  treatment. 
The  many  several  remedies  which  experience  has 
pointed  out  as  of  use  in  combating  this  formidable  dis- 
ease will  be  tested  in  the  treatment  of  the  patients,  and 


their  efficiency  carefully  noted.  Careful  notes  have 
been  taken  and  photographs  made  of  the  patients,  and 
the  histories  will  be  continued  during  the  different  stages 
of  the  treatment.  The  "  Committee  on  the  Treatment 
of  Leprosy,"  which  has  undertaken  this  investigation  is 
anxious  to-enlist  in  its  aid  the  interest  and  intelligent 
co-operation  of  all  members  of  the  medical  profession, 
and  invites  suggestions  as  to  both  means  and  methods 
from  all  who  are  interested  in  the  study  of  leprosy.  It 
is  purposed  to  publish,  when  the  proper  time  comes,  a 
bulletin  or  report  of  progress  regarding  the  work.  In 
the  meantime  the  Committee  would  be  glad  to  enlarge 
its  acquaintance  with  the  bibliography  of  leprosy,  and 
to  be  put  in  the  way  of  becoming  the  owner  of  various 
monographs  on  the  subject  as  they  are  published.  The 
secretary  of  the  Committee  is  Dr.  N.  B.  Emerson, 
Honolulu,  H.  I. 

The  Chautauqua  County  Medical  Society  held  its  an- 
nual meeting  for  1895  at  the  Thompson  House,  May- 
ville,  N.  Y.,  on  Tuesday,  July  9th.  After  the  meeting 
the  members  adjourned  to  the  Kent  House,  at  Lake- 
wood. 

The  Late  Dr.  Alexander  I.  Aronson At  a  meeting 

of  the  Eastern  Medical  Society  of  New  York,  held 
June  28th,  the  following  resolutions  were  adopted  : 

Whereas,  Our  friend  and  beloved  colleague.  Dr. 
Alexander  I.  Aronson,  who  was  so  highly  esteemed  by 
all  who  knew  him,  as  to  his  professional  ability,  repu- 
tation, and  honesty,  has  been  suddenly  called  away  to 
his  eternal  rest ;  and 

Whereas,  The  Society  has  lost  a  member  and  sin- 
cere friend,  whose  place  will  be  difficult  to  fill,  and  his 
family  loses  a  blessing  father  and  loving  husband  ; 

Therefore,  be  it  Resolved,  That  we  all  regret  the  sud- 
den loss  of  our  late  colleague,  and  that  we  all  mourn 
our  loss,  that  we  extend  to  the  family  our  heartfelt 
sympathy  and  sincere  regret  in  this  sad  hour  of  afflic- 
tion ;  and  it  is  further 

Resolved,  That  a  copy  of  these  resolutions  be  spread 
on   the   minutes  of  our  society,  and  a  copy  be  sent 
to  the  bereaved  family  of  our  deceased  colleague,  and 
that  they  be  published  in  the  medical  and  local  press 
H.  B.  Abler,  M.D.,  President. 
E.  K.  Browd,  M.D., 
M.  Caspe,  M.D., 
M.  D'Avidoff,  M.D., 
M.  Burstein,  M.D., 
S.  Brothers,  M.D., 

Committee  on  Resolutions. 
Sero-therapy  of  Sjrphilis.— Those  who  have  watched 
the  various  ingenious  attempts  to  treat  syphilis  by  the 
application  of  sero-therapy,  have  become  aware  that  it 
is  very  manifest  that  nothing  has  been  accomplished 
of  any  practical  value. 

Nocturnal  Enuresis. — Dr.  Stumpf  has  suggested  a 
simple  exiiedient  for  the  treatment  of  nocturnal  enure- 
sis. It  consists  simply  in  raising  the  hips  of  the  child, 
so  that  it  sleeps  with  them  elevated  at  an  angle  of  130° 
to  150°  with  the  horizontal  spine.  This  is  accom- 
plished by  placing  one  or  two  ordinary  pillows  under 
the  thighs.  The  theory  is  that  the  urine  is  kept  from 
getting  into  the  urethra,  when  the  sphincter  is  relaxed 
during  sleep. 


July   13,  1895] 


MEDICAL    RECORD. 


57 


AMERICAN    NEUROLOGICAL    ASSOCIATION. 

T'lcenfy-Jirst  Annual  Meeting,  Held  in  Boston,  June  i, 
6,  and  7,  l8gs. 

Dr.   Philip  Coombs  Knapp,  of  Boston,  President, 
IN  THE  Chair. 

First  Day,  Wednesday,  June  sth. 

President's  Address. — The  President  thanked  the  As- 
sociation for  the  honor  conferred  upon  him,  ex- 
tended to  them  a  welcome  to  Boston  on  the  occasion 
of  their  first  visit  to  the  city,  and  offered  them  greet- 
ings from  the  various  honorary  members  abroad. 

The  Association  was  organized  twenty  5'ears  ago, 
with  a  membership  of  thirty-five.  At  that  time  the 
idea  of  such  a  society  was  something  of  an  experiment, 
as  few  similar  societies  existed  in  the  world.  The  so- 
ciety, however,  had  been  successful,  had  increased  un- 
til there  were  now  eighty- five  members,  and  the  meet- 
ings had  alwaj  s  been  profitable  and  interesting.  It  was 
not  a  society  limited  exclusively  to  specialists,  as  all 
who  were  interested  in  the  diseases  of  the  nervous  sys- 
tem had  been  welcomed  to  its  ranks. 

The  scientific  work  done  by  the  members  of  the  so- 
ciety was  briefly  reviewed.  The  chief  work  done  in 
this  country,  with  reference  to  diseases  of  the  mind 
and  nervous  system,  had  been  done  by  members  of  this 
Association.  In  regard  to  investigations  in  the  anatomy 
and  physiology  of  the  nervous  system,  the  work  done 
in  this  country  was  still  below  that  done  abroad,  and 
endowments  for  such  research  were  considered  desir- 
able. The  work  done  in  the  study  of  disease  and  its 
manifestations,  and  in  the  treatment  of  nervous  dis- 
eases, had  been  much  greater.  American  neurologists 
had  done  very  much  to  advance  our  knowledge  of  the 
treatment  of  disease  of  the  nervous  system,  and  no  dis- 
covery in  the  last  twenty  years  had  been  of  as  much 
importance  as  that  of  the  rest  cure  by  one  of  the  mem- 
bers of  the  society.  Dr.  Weir  Mitchell,  of  Philadelphia. 
Some  of  the  needs  for  work  in  the  future  were  then 
pointed  out,  among  them  being  the  need  of  a  journal, 
tmder  the  control  of  the  society,  and  greater  recogni- 
tion in  our  large  hospitals,  and  a  greater  knowledge  of 
nervous  diseases  by  the  physician  in  general  practice. 
The  greatest  hope  for  the  future  in  the  treatment  of 
nervous  diseases  lay  in  prevention.  Many  of  the  most 
serious  affections  were  secondary  to  infectious  diseases, 
and  therefore,  with  the  greater  knowledge  in  the  pre- 
vention and  treatment  of  these  diseases  would  come  a 
diminution  in  the  amount  of  nervous  diseases  due  to 
them.  In  many  cases  where  people  acquire  nervous 
diseases  on  account  of  a  defective  nervous  organiza- 
tion, it  was  considered  advisable  to  put  such  people 
under  a  definite  prescribed  existence.  There  were 
many  conditions  of  life  which  did  no  harm  to  the 
healthy  man,  but  against  which  sucli  persons  should 
be  protected.  These  persons  should  also  be  protected 
from  the  mental  contamination  of  neurotic  and  degen- 
erate influences,  whether  in  morals,  religion,  art,  litera- 
ture, or  sociology. 

There  had  been  much  claim  of  a  vast  increase  in 
nervous  diseases  at  the  present  time,  but  it  did  not 
seem  probable  that  the  conditions  of  life  to- day  were 
more  exacting  than  those  of  life  in  the  past,  and,  with 
better  food,  more  rational  standards  of  living,  and 
greater  security  for  life  and  property,  it  seemed  not 
improbable  that  there  was  an  actual  diminution  in  the 
amount  of  nervous  disease. 

Hysterical  Amblyopia  and  Amaurosis. — Dr.  J.  Ar- 
thur Booth,  of  New  York,  reported  four  cases  of  this 
affecti  on  successfully  treated  by  hypnotism. 

Dr.   F.  X.   Dercum,  of  Philadelphia,  thought  it  of 


interest  to  note  that  perception  of  light  was  normal  in 
these  cases.  In  his  experience,  reversal  of  the  color 
field  is  not  common,  and  does  not  occur  as  often  as 
supposed. 

Dr.  Morton  Prince,  of  Boston,  asked  if  the  pa- 
tient's vision  was  tested  during  the  hypnotic  state.  In 
his  opinion,  the  theory  of  a  shutting  off  of  conscious- 
ness during  hypnosis  is  a  correct  one.  In  many  of 
these  cases,  binocular  vision  is  preserved,  as  proved  by 
prism  and  stereoscope. 

Dr.  G.  L.  Walton,  of  Boston,  said  that  experiments 
seem  to  point  that  these  cases  really  do  see.  The  tests, 
however,  do  not  prove  that  these  patients  are  not  simu- 
lating. 

Dr.  Booth,  in  closing  the  discussion,  replied  that 
all  of  his  cases  were  tested  for  binocular  vision,  but  it 
was  found  absent.  There  was  no  cause  for  simulation. 
Complete  Hysterical  Anaesthesia  in  the  Male. — Dr. 
Preston,  of  Baltimore,  read  a  paper  with  the  above 
title.  The  case  related  was  that  of  a  man  aged  thirty- 
one.  Family  and  personal  history  were  unimportant. 
The  man  was  a  moderate  drinker,  and  during  a  spree 
got  into  a  fight,  but  received  no  injuries  other  than 
some  slight  bruises.  A  day  or  two  after  admission  into 
the  hospital  he  developed  a  small  patch  of  anresthesia 
of  the  scalp.  A  few  days  later,  general  anresthesia  ap- 
peared. There  was  complete  loss  of  tactile  and  pain 
sense  as  well  as  temperature  sense.  Muscular  sense 
was  greatly  imi)aired,  but  not  entirely  lost.  Taste  and 
smell  were  lost,  and  hearing  impaired.  There  was 
great  constriction  of  the  visual  fields,  and  the  color 
fields  were  reversed.  Reflexes,  superficial  and  deep, 
were  normal,  as  was  the  electrical  reaction.  The  pa- 
tient gradually  improved  and  finally  recovered  under 
hypnotic  suggestion.  Total  anajsthesia  is  a  compara- 
tively rare  condition  if  the  cases  of  transient  loss  of 
sensation  be  omitted.  Stress  was  laid  upon  the  im- 
portance and  reliability  of  careful  examination  of  the 
visual  fields. 

Dr.  George  W.  Jacobv,  of  New  York,  thought  that 
cases  of  total  hysterical  anaesthesia  are  not  rare.  They 
are  most  frequently  found  in  cases  of  insanity.  He  re- 
ferred to  the  case  of  a  young  girl,  in  whom  he  endeav- 
ored to  determine  the  presence  of  ataxia,  but  it  was 
not  demonstrable.  In  the  patients  that  he  had  ob- 
served, there  were  also  painful  points  on  deep  jiressure. 

Dr.  Walton  considered  it  unsafe  to  depend  upon 
constancy  of  tests  as  establishing  genuineness  in  cases 
of  supposed  hysteria.  A  clever  simulant  may  pretend 
an  ansesthetic  boundary,  sufiiciently  constant  to  fall 
within  the  limits  of  genuine  variation. 

Dr.  William  M.  Leszynsky,  of  New  York,  said  tliat 
with  proper  precautions  during  the  examination,  and 
with  our  present  methods  of  investigation  faithfully 
and  persistently  carried  out,  it  was  impossible  for  the 
cleverest  patient,  even  an  accomplished  ophthalmolo- 
gist, to  successfully  simulate  defective  visual  fields. 

Dr.  J.  J.  Putnam,  of  Boston,  believed  that  persons 
in  apparent  health  are  hysterical  to  a  certain  degree. 
The  diagnosis  must  be  made  from  the  general  aspect 
of  the  case,  and  not  from  any  single  symptom. 

Dr.  W.  a.  Jones,  of  Minneapolis,  asked  if  there  was 
any  immobility  of  the  eyeball  in  Dr.  Preston's  case. 

Dr.  J.  Madison  Taylor,  of  Philadelphia,  asked  if 
there  was  any  difficulty  in  locomotion,  more  particu- 
larly under  excitement. 

Dr.  Preston  replied  that  there  was  neither  immo- 
bility of  the  eyeball  nor  difficulty  in  locomotion.  The 
muscular  sense  was  preserved  and  there  was  no  ataxia. 
He  had  observed  total  anesthesia  in  one  case  of  insan- 
ity. He  thought  we  were  too  likely  to  neglect  a  care- 
ful study  of  the  central  organism,  while  devoting  so 
much  time  to  the  periphery. 

Railway  Spine. — This  was  the  title  of  a  paper  by 
Dr.  F.  X.  Dercum,  of  Philadelphia.  He  reported 
two  cases  with  autopsy.  In  the  first  case  there  was 
excessive  sprain  of  the  muscles  of  the  back  and  of  the 


58 


MEDICAL    RECORD. 


[July   13,  1895 


trunk  generally,  with  marked  spasm  of  the  muscles, 
and  tremor,  together  with  increased  reflex  excitability 
of  the  muscles  and  tendons.  In  addition,  the  symp- 
ptoms  so  commonly  observed  in  traumatic  neurasthenia 
were  typical  ;  namely,  disturbed  sleep,  startling  dreams, 
sudden  awakening  with  fright,  excessive  sweating,  fre- 
quent micturition,  occipital  headache,  tinnitus  aurium, 
marked  general  weakness,  etc.  The  patient  died  from 
some  intercurrent  disease.  Careful  examination  of  the 
nervous  system  showed  no  demonstrable  lesion.  In 
the  second  case  there  was  severe  traumatic  left  bra- 
chial neuritis  and  left  brachial  monoplegia,  with  atrophy 
of  muscles  about  the  left  shoulder.  Severe  sprain  of 
muscles  of  back  ;  right  hemi-analgesia  extending  from 
the  foot  up  to  the  level  of  the  nipple  ;  right  hemi-ther- 
mo-anassthesia  extending  from  the  foot  up  to  the  level 
of  the  false  ribs.  The  man  was  exceedingly  weak  phys- 
ically, but  mentally  he  seemed  clear  and  accepted 
his  situation  in  a  philosophical  spirit.  He  died  sud- 
denly from  the  rupture  of  an  aortic  aneurism.  The 
post-mortem  examination  of  the  nervous  system  proved 
negative. 

Dr.  Joseph  Collins,  of  New  York,  said  that  although 
the  autopsy  and  subsequent  histological  investigation 
did  not  succeed  in  unravelling  the  mystery  of  the  real 
basis  of  the  traumatic  neuroses,  the  cases  are  instruct- 
ive because  of  the  negative  findings.  He  was  in  the 
fullest  accord  with  Dr.  Dercum,  as  to  the  futility  of  at- 
tempting to  demonstrate  the  organic  basis  of  these  dis- 
eases by  means  of  older  methods  of  investigation,  more 
particularly  by  any  such  as  require  hardening  in  Mul- 
ler's  fluid  for  their  preparation.  In  the  first  place,  this 
procedure  allows  no  cellular  stain  except  the  carmine, 
and  this  is  so  inferior  to  the  Nissl  stain  that  there  should 
be  no  reason  for  using  it  ;  and  in  the  second  place, 
even  if  it  were  a  good  one  the  changes  that  go  on  in  the 
structures  which  it  stains,  from  lying  for  several  months 
in  a  watery  fluid,  are  such  as  to  negative  any  con- 
clusions that  might  be  drawn  from  possible  find- 
ings. 

In  one  of  Dr.  Dercum's  cases,  the  ponto-bulbar  symp- 
toms were  so  pronounced — the  facial  twitchings,  the 
hemi-atrophy,  the  sensory  disturbance — that  it  was  ex- 
tremely likely  that  some  anatomical  change  was  at  the 
bottom  of  it.  It  seemed  to  him,  moreover,  that  the 
presence  of  the  large  aneurism,  which  in  all  probability 
was  of  traumatic  origin,  would  indicate  that  the  changes 
in  these  cases  are  primarily  vascular. 

Dr.  Charles  K.  Mills,  of  Philadelphia,  looked 
upon  these  negative  results  as  being  very  valuable.  The 
microscopical  examination  should,  however,  have  in- 
cluded the  dorsal  spinal  ganglia. 

Dr.  Prince  said  the  paper  contained  a  direct  proof 
of  the  theory  of  the  traumatic  neuroses.  These  pa- 
tients suffered  from  psychical  shock  and  physical  shock. 
He  agreed  with  Dr.  Collins  as  to  the  method  of  study 
of  nerve-tissues. 

Dr.  Edward  D.  Fisher,  of  New  York,  reported  two 
similar  cases  still  under  observation.  He  believed  there 
must  be  some  pathological  changes  to  account  for  the 
symptoms  in  many  of  these  cases. 

Dr.  Smith  Baker,  of  Utica,  expressed  the  opinion 
that  at  the  time  of  the  accident  there  is  a  psychical 
copy  formed  which  perpetuates  this  as  a  series  of  mim- 
icry. A  fixation  of  attention  results,  and  may  bring 
about  changes  in  the  higher  cortical  centres. 

Dr.  L.  C.  Gray,  of  New  York,  thought  that  the  nat- 
ure of  these  cases  is  still  very  puz/.ling.  The  term  hys- 
teria is  objectionable.  These  railway  cases  are,  how- 
ever, not  hysterical. 

Dr.  F.  F.  Miles,  of  Baltimore,  said  we  will  cease  to 
record  diseases  as  functional.  'Hie  protoplasm  of  the 
neuron  is  altered  in  its  activities  by  shock.  Protoplasm 
has  a  tenacious  memory  (as  we  see  when  we  have  once 
taught  it  to  make  antitoxins)  and  may  repeat  an  ab- 
normal process  until  it  is  fixed  by  material  chant^e. 
The  mystery  is  why  this  takes  place  in  some  cases  of 


shock  and  not  in  others,  and  why  this  memory  is  per- 
petuated in  the  cell. 

Dr.  DERCU.\f,  in  closing  the  discussion,  fully  realized 
the  im.perfect  method  adopted  in  preparing  the  speci- 
mens, but  this  was  due  to  unavoidable  circumstances 
in  connection  with  the  autopsy,  and  not  from  lack  of 
familiarity  with  the  newer  methods. 

Dr.  M.  Allen  Starr,  of  New  York,  then  gave  a 
lantern  exhibition  of  photo-micrographs  of  nervous 
histology,  Golgi  stains.  This  was  followed  by  a  lantern 
exhibition  of  the  medulla  oblongata  of  a  chimpanzee 
with  other  specimens,  by  Dr.  Edward  Wyllys  Taylor,  of 
Boston. 

Exhibition  of  the  Brain  of  a  Chimpanzee,  by  Dr. 
Thomas  Dwight,  of  Boston.  He  spoke  of  the  brain 
of  the  chimpanzee  "Jumbo,"  and  discussed  chiefly  the 
anterior  limb  of  the  fissure  of  Sylvius.  On  the  left 
this  was  distinct,  ending  in  a  bifurcation  beneath  a 
rudimentary  pars  triangularis.  On  the  right  it  was 
represented  by  a  minute  depression  not  connected  with 
the  fissure. 

Inhibition  in  the  Physiology  of  Respiration. — Dr. 
WiLLiA.M  Townsend  Porter,  of  Boston,  said  that  it  is 
known  that  transverse  division  of  the  spinal  cord  be- 
tween the  bulb  and  the  phrenic  nuclei  causes  fatal 
arrest  of  the  respiratory  movements  of  the  trunk.  If 
death  be  prevented  for  a  time  by  artificial  respiration, 
the  reflex  powers  of  the  cord  gradually  increase,  and 
in  the  course  of  a  few  hours  they  may  become  so  great 
that  pinching  the  paws,  blowing  on  the  skin,  suspend- 
ing the  artificial  respiration,  etc.,  may  cause  extended 
muscular  contractions,  including  contraction  of  the 
respiratory  muscles. 

It  is  claimed  that  these  contractions  of  the  respira- 
tory muscles  after  the  separation  of  the  cord  from  the 
bulb  are  proof  that  the  respiratory  impulse  for  muscles 
of  the  trunk  is  not  derived  from  respiratory  cells  in  the 
bulb,  but  originates  in  the  spinal  cord.  Against  this 
hypothesis  of  spinal  respiration  is  urged  the  fatal  arrest 
of  the  respiration  of  the  trunk  caused  by  separating  the 
bulb  from  the  chord.  It  is  replied  that  section  of  the 
chord  stimulates  inhibitory  fibres  in  the  chord,  and 
thus  suspends  the  action  of  the  spinal  respiratory  cells. 

The  doctrine  of  prolonged  inhibition  of  spinal  respi- 
ration is  easily  overthrown  by  the  following  experiment  : 
Hemi-section  of  the  cord  usually  arrests  the  contrac- 
tions of  the  diaphragm  on  the  side  of  the  hemi-section. 
This  arrest  is  not  an  inhibition,  for  the  diaphragm  on 
the  side  of  the  hemi-section  begins  at  once  to  contract 
when  the  opposite  phrenic  nerve  is  cut.  It  follows 
that  two  hemi-sections,  completely  separating  the  cord 
from  the  bulb,  do  not  inhibit  the  diaphragmatic  respi- 
ration on  their  respective  sides.  The  phrenic  cells 
often  send  out  no  respiratory  impulses  after  such  a  sec- 
tion, because  they  receive  none  from  the  bulb.  The 
phrenic  cells  cannot  themselves  originate  respiratory 
impulses.  Hence  the  respiratory  impulse  does  not  arise 
in  the  spinal  cord. 

The  Pulse  in  Insanity. — Dr.  Theo.  H.  Kellogg,  of 
New  York,  read  a  paper  with  the  above  title.  It  was 
based  on  the  study  of  2,172  cases  of  insanity,  and  gave 
tables  and  diagrams.  The  sphygmograms  taken  from 
among  his  patients  on  enamel  paper  had  been  trans- 
ferred by  photographic  process,  and  were  mounted  on 
photographic  cards. 

The  general  conclusions  arrived  at  were  :  that  there 
is,  in  established  cases  of  insanity,  considerable  in- 
crease in  the  average  frequency  of  the  pulse,  both 
among  men  and  women.  The  average  obtained  from 
the  2,172  tases  was  84. S  per  minute  in  the  women  and 
80.8  in  the  men.  giving  a  general  average  of  82. S  in  the 
total  number  of  patients  studied.  There  was  irregu- 
larity of  heart  action  in  five  per  cent.,  intermittence  in 
two  per  cent.,  heart  murmurs  and  heart  lesions  in  eight 
per  cent. 

The  various  forms  of  sphygmographic  tracings  found 
in  the  different  forms  of   insanitv  were  discussed  at 


July    13,  1895] 


MEDICAL    RECORD. 


59 


some  length.  The  general  result  of  the  sphygm-i- 
graphic  studies  was  that  abnormal  tracings  are  to  be 
found  at  some  stage  of  the  disease  in  the  vast  majority 
of  cases  of  insanity.  They  are  due  to  affections  of  the 
cortical  and  spinal  motor  and  vaso-motor  centres,  to 
various  lesions  of  the  sympathetic,  to  disorders  of  the 
pneumogastric,  to  peripheral  and  central  vascular 
changes,  to  degenerations  of  central  organs,  to  toxic 
agents  in  the  blood,  to  auto-intoxications,  to  cachectic 
and  diathetic  conditions,  to  cardiac  lesions,  and  to  a 
great  variety  of  intercurrent  causes.  No  one  sphygmo- 
gram  is  pathognomonic  of  any  particular  form  of  insan- 
ity, but  there  are  certain  general  types  of  tracing  which 
are  found  in  one  form  of  mental  disease  and  not  in 
another. 

Localization  of  Lesions  in  the  Pons. — Dr.  Ch.\rles 
K.  Mills,  of  Philadelphia,  read  a  paper  upon  this  sub- 
ject. He  first  presented  a  record  of  a  case  with  au- 
topsy and  drawings  of  microscopical  sections.  This 
patient  was  a  man,  fifty-three  years  old,  with  a  syphilitic 
history.  His  intra-cranial  symptoms  came  on  about 
eight  months  before  his  death,  the  first  being  paralysis 
of  the  left  abducens  nerve.  He  had  attacks  of  weak- 
ness and  dizziness.  He  showed  on  examination  pare- 
sis of  the  left  leg  and  arm,  paralysis  of  the  left  external 
rectus,  paresis  of  the  right  external  rectus  with  some 
restriction  of  ocular  movements  to  the  left.  The  pa- 
tient was  extremely  emotional,  tending  to  break  into 
laughing  and  crying  without  special  incentive.  No 
areas  of  anaesthesia  were  discovered.  The  knee-jerk 
was  exaggerated  on  the  left  side. 

Examination  of  the  pons  and  preoblongata  revealed 
a  lesion  beginning  about  fifteen  millimetres  caudad 
to  the  junction  of  the  pons  and  crus.  It  was  on 
the  left  side,  close  to  the  median  line,  and  almost 
entirely  in  the  dorsal  half  of  the  pons.  Sections 
through  the  lesions  showed  softened  and  degenerated 
tissue  on  both  sides  of  the  median  line,  much  more 
marked  on  the  left.  As  shown  by  microscopical  ex- 
amination, the  parts  involved  in  the  lesion  were  the 
right  mesal  fillet  and  pyramidal  tracts  to  a  slight  de- 
gree, and  the  root-fibres  of  the  abducens.  In  connec- 
tion with  this  case,  remarks  were  made  on  the  method 
of  localizing  small  gross  lesions  in  the  pons.  This 
method  was  founded  upon  a  number  of  cases,  most  of 
which  have  been  published.  He  divided  each  half  of 
the  pons  and  preoblongata  into  nine  segments,  three 
ventral,  three  dorsal,  and  three  intermediate  between 
the  ventral  and  dorsal.  Drawings  were  shown  which 
were  based  upon  actual  sections  of  specimens.  The 
parts  played  by  the  cranial  nerves,  by  the  superficial 
and  deep  transverse  fibres,  by  the  pyramidal  tract,  the 
fillet,  the  systems  of  root-fibres,  and  the  nuclei  of  the 
cranial  nerves  and  the  special  pontile  nuclei  in  this 
method  of  local  diagnosis  were  shown. 


Second  Day,  Wednesday,  June  6th. 

Hyperostosis  Cranii. — Dr.  James  J.  Putnam,  of 
Boston,  read  a  paper  with  this  title.  He  reported  four 
cases  of  this  rare  disease,  showing  two  of  the  patients, 
besides  photographs  and  specimens  illustrative  of  the 
other  cases  and  of  the  disease  in  question. 

The  first  part  of  the  paper  was  devoted  to  a  general 
discussion  of  the  pathological  questions,  and  the  state- 
ment of  the  views  expressed  by  Virchow,  Baumgarten, 
and  Starr. 

Hitherto  these  enlargements  of  the  cranium  have 
been  considered  as  of  an  inflammatory  origin,  but 
the  two  writers  last  mentioned  have  brought  forward 
some  reason  for  thinking  that  the  disease  may  be 
a  species  of  trophic  affection,  distantly  analogous  to 
myxoedema  and  acromegaly.  This  is  an  interesting 
hypothesis,  but  cannot  yet  be  accepted  as  proved.  The 
symptoms  of  the  disease  are  mainly  due  to  pressure  by 
bony  masses    on   the  cranial   contents,  especially  the 


nerves  and  vessels  which  perforate  the  skull.  There  is 
often  exophthalmus,  due  to  partial  obliteration  of  the 
orbit,  and  usually  some  signs  of  paralysis  or  irritation 
of  cranial  nerves.  Epileptic  attacks  occasionally  oc- 
cur, and  sometimes  very  early  in  the  disease.  Double 
optic  neuritis  and  other  signs  of  intra-cranial  pressure 
may  be  present,  and  there  is  almost  always  headache, 
due  to  the  interstitial  bony  changes.  The  head  is 
sometimes  enormously  enlarged,  and  when,  as  fre- 
quently happens,  the  bones  of  the  face  are  involved, 
peculiar  deformities  may  be  present,  such  as  suggested 
to  Virchow  the  name  "leontiasis  ossea."  Photographs 
of  a  specimen  in  Washington,  illustrating  this  form  of 
the  disease,  were  exhibited. 

Baumgarten  pointed  out  that  the  disease  generally 
began  in  youth,  and  in  one  of  the  reporter's  cases  the 
first  indications  were  noticed  when  the  patient  was  five 
years  old,  in  the  form  of  two  exostoses  near  the  vortex, 
which  afterward  assumed  a  great  size.  The  cranial 
bones  usually  become  very  dense,  as  from  an  inflam- 
matory change,  but  sometimes  the  diploe  is  rarefied. 
The  question  of  operation  suggests  itself  as  a  means  of 
reducing  intra-cranial  pressure  or  of  cutting  off  the 
blood-supply  to  the  bone.  In  this  connection  it  may 
be  noted  that  the  channels  of  the  meningeal  vessels  are 
sometimes  strongly  marked,  sometimes  nearly  oblit- 
erated. 

Dr.  Starr,  of  New  York,  said  that  these  cases  were 
more  advanced  and  more  extreme  than  those  he  had 
reported.  He  tried  thyroid  extract  in  one  of  his  cases 
without  benefit.  He  was  led  to  do  this  as  he  had  seen 
some  improvement  after  its  administration  in  a  patient 
with  acromegaly. 

Dr.  Morton  Prince  narrated  the  history  of  a  case 
under  his  observation  in  which  this  condition  of  the 
cranium  followed  a  traumatism  which  occurred  two 
years  before.  The  enlargement  was  not  general,  but 
was  mostly  confined  to  the  frontal  bone.  At  the  au- 
topsy the  orbital  plates  were  found  enormously  en- 
larged, and  the  anterior  portion  of  the  brain  had  under- 
gone extreme  compression. 

Dr.  G.  M.  Hammond,  of  New  York,  asked  if  struct- 
ural changes  existed  in  other  bones.  His  case  was  of 
syphilitic  origin,  and  there  were  nodosities  and  other 
enlargements  in  the  long  bones. 

Dr.  Putnam  concluded  that  when  syphilis  was  pres- 
ent these  cases  should  be  placed  in  a  different  class. 
There  is  a  tendency  to  bony  enlargements  in  these 
cases. 

Dr.  F.  T.  Miles,  of  Baltimore,  showed  the  brain  of 
a  child,  three  and  a  half  years  old.  It  was  from  an 
idiot  with  left  hemiplegia.  The  right  cerebral  hemi- 
sphere was  atrophied  to  a  great  degree  in  all  of  its 
lobes  and  convolutions,  and  the  right  crus  was  small. 
The  left  cerebellar  hemisphere  was  one-third  smaller 
than  the  right. 

Dr.  H.  L.  Worcester,  of  Danvers,  had  made  au- 
topsies in  three  cases  where  there  was  decided  asym- 
metry of  the  cerebral  hemisphere,  but  the  cerebellum 
presented  no  abnormity. 

Dr.  Charles  K.  Mills  had  reported,  some  years  ago, 
the  case  of  a  negro  murderer  where  there  was  atrophy 
of  one  cerebellar  hemisphere  with  opposite  cerebral 
atrophy.  It  is  rare  to  find  coincident  atrophy  of  oppo- 
site cerebellum. 

Dr.  Starr  said  that  this  condition  is  usually  con- 
genital and  is  often  found  in  idiots. 

Dr.  Edward  B.  Angell,  of  Rochester,  had  seen  a 
similar  condition  at  autopsy  in  a  patient,  thirty-three 
years  of  age,  in  whom  a  cyst  of  the  cerebrum  had  ex- 
isted since  childhood. 

Cortical  Localization  in  the  Light  of  Recent  Re- 
searches into  the  Minute  Anatomy  of  the  Cortex. — 
Dr.  Charles  K.  Mills  opened  a  discussion  on  this 
subject.  He  said  that  the  different  theories  as  to  the 
separate  cortical  localization  of  movements  and  of  cu- 
taneous and  muscular  sensation,  which  had   been  the 


6o 


MEDICAL   RECORD. 


[July  13,  1895 


subjects  of  so  much  controversy,  have  again  become 
prominent  in  the  light  of  the  researches  founded  upon 
the  methods  of  Golgi,  and  particularly  those  made  by 
Raymon  y  Cajal,  Van  Gehuchten,  Schafer,  Andriezen, 
and  others.  Those  who  contend  against  the  doctrine 
that  the  Rolandic  cortex  is  a  purely  motor  region  be- 
lieve that  they  have  received  additional  support  for 
their  views.  The  varying  hypotheses  with  reference  to 
the  functions  of  the  corte.x  were  reviewed.  He  held 
that,  as  shown  by  Forel  and  Nansen,  we  have  been  too 
long  handicapped  by  prevailing  ideas  of  cell  action, 
and  by  theories  of  the  parts  played  by  the  cell-bodies 
as  originating  centres.  Impulses  are  transmitted  and 
transferred  by  processes  as  well  as  by  cell-bodies,  and 
the  function  of  the  latter  is  chiefly  trophic.  The  new 
researches  and  theories  he  believed  did  not  compel 
abandonment  of  former  views  as  to  special  localizations, 
although  different  stand-points  had  been  taken.  Dis- 
regarding theory  entirely,  he  believed  that  the  sub- 
division of  the  cerebrum  into  physiological  lobes — 
higher  psychical,  motor,  sensory  (meaning  for  the  repre- 
sentation of  cutaneous  and  muscular  sensations),  vis- 
ual, auditory,  olfactory,  gustatory,  and  naming — re- 
mained for  the  practical  purposes  of  the  physician  and 
surgeon  the  best.  While  the  whole  of  the  cortex  in 
some  of  its  strata  may  be  regarded  as  a  sensory  ex- 
panse, if  Rolandic  portions  and  particularly  the  con- 
volutions cephalad  of  the  central  fissure  constitute  a 
region  which  is  related  to  specialized  movements  of 
various  parts  of  the  body.  One  calls  it  motor,  another 
kinesthetic,  another  sensorimotor,  and  another  execu- 
tive, but  for  the  purposes  of  the  physician  and  surgeon 
it  is  a  motor  sphere,  the  irritation  of  which  causes 
specialized  movements,  while  its  destruction  impairs  or 
abolishes  these  movements.  He  did  not  believe  with 
Andriezen  that  it  was  necessary  to  regard  the  ambigu- 
ous and  great  pyramidal  cells  of  this  region,  whose 
apical  processes  received  the  terminals  of  the  fillet 
radiations,  as  the  first  sensory  cells  of  the  cortex.  In- 
deed he  regarded  it  as  important  to  rid  ourselves  en- 
tirely of  the  idea  of  sensory  cells  and  motor  cells.  The 
cortex  contains  localized  areas.  To  abandon  sep- 
arate sensory  and  motor  localization  would,  he  be- 
lieved, necessitate  the  abandonment  of  visual,  auditory, 
gustatory,  and  other  subdivisions  of  the  cortex.  The 
cerebral  sensory  area — that  is,  the  area  of  representa- 
tion for  skin  and  muscle  sensations — both  cortical  and 
subcortical,  would  be,  from  his  point  of  view,  that 
part  of  the  cerebrum  where  the  fillet  radiations  in  their 
most  compact  forms  are  nearest  to  the  surface  of  the 
brain,  and  therefore  this  region  might  continue  to  be 
described  as  it  had  been  by  him,  as  in  the  postero-pa- 
rietal,  quadrate,  and  formicate  convolutions.  Destruc- 
tion of  this  region,  especially  if  bilateral,  caused  more 
or  less  impairment  of  sensation.  He  referred  to  cases 
reported  by  Savill,  Sharkey,  Starr,  McCosh,  and  him- 
self as  confirming  this  view.  In  the  cerebrum,  as  in 
the  spinal  cord,  were  fields  of  junction  between  so- 
called  cortical  areas,  and  lesions  of  these  fields  of  con- 
junction, or  at  the  terminations  of  the  sensory  jiro- 
jection  fibres,  might  give  rise  to  temporary  sensory 
phenomena  ;  but  persistent  sensory  disturbances  were 
found  only  when  the  lesions  involved  the  convolutions 
included  by  him  in  the  general  sensory  area. 

Dr.  Dana  said  the  author  had  not  referred  to  or 
tried  to  explain  the  facts  which  establish  the  propo- 
sition that  he  believes  regarding  this  subject.  He 
(Dana)  had  collected  a  number  of  other  cases  and 
added  some  of  his  own,  and  it  is  because  he  cannot  ex- 
plain the  clinical  facts  or  the  pathological  (acts  by  any 
other  hypothesis  than  by  supposing  that  the  motor  and 
sensory  functions  are  practically  united  that  he  still 
holds  to  that  view.  He  asked  Dr.  Mills  to  explain 
why,  when  one  cuts  away  a  section  of  the  mid-central, 
pre-central  convolution,  he  finds  tactile  anaesthesia  and 
muscular  anajsthesia  the  next  day,  with  paralysis,  on 
any  theory  except  that  these  two  functions  are  united 


in  that  spot.  These  cases  are  extremely  numerous  in 
the  literature  of  neurology.  If  one  carefully  shaves  off 
the  anterior  pre-central  convolution  in  the  middle  part, 
he  will  get  sensory  disturbances,  anaesthesias. 

Dr.  Mills  may  not  perhaps  be  aware  that  in  the  liv- 
ing subject  the  motor  cortex  has  been  directly  irritated 
also  in  front  of  the  fissure  of  Rolando  and  produced 
sensory  and  motor  disturbances.  If  a  man's  sensory 
functions  are  localized  and  the  cutaneous  sensations 
and  muscular  sensations  are  located  in  the  gyrus  fomi- 
catus,  he  did  not  understand  how  the  passage  of  the 
electric  current  should  cause  sensations  entirely  analo- 
gous in  the  arm  to  those  of  the  tactile  impression  made 
upon  the  skin  ;  in  fact,  the  whole  weight  of  clinical  evi- 
dence is  in  favor  of  that  view  ;  the  surgical  operations, 
the  tumors,  the  softenings,  all  are  facts  which  cannot  be 
explained  on  any  other  hypothesis,  so  far  as  he  knew, 
than  that  the  two  functions  are  essentially  identical 
anatomically. 

It  is  a  plausible  theory  that  the  visual  centres,  centre 
for  visual  sensation,  and  auditory  and  gustatory  sensa- 
tions, are  separate  from  the  motor  sensations,  and  they 
and  cutanous  and  muscular  sensations  would  naturally 
have  separate  centres,  but  it  does  not  at  all  hold 
against  any  actual  facts,  and  when  we  come  to  analyze 
it  it  is  not  so  necessary  or  plausible  after  all.  The 
visual  sensations  are  not  so  closely  related  to  motion 
as  are  the  cutaneous  and  muscular  sensations.  For 
the  performance  of  co-ordinated  movement  we  must 
have  a  very  close  anatomical  relationship  between  the 
muscular  and  cutaneous  sensations.  They  cannot 
afford  to  have  muscular  sense  impinge  on  the  gyrus 
fornicatus  and  have  associated  bundles  running  up  to 
the  central  convolution.  They  must  be  close  together 
anatomically  for  the  purposes  of  a  perfect  machine, 
otherwise  we  could  not  make  rapid  motions  ;  and  he 
believed  it  is  for  that  reason  that  nature  had  gradually 
shifted  the  sensory  receptive  cells  so  that  they  are  in 
approximately  close  relation  with  the  motor  cells. 

He  believed  that  perhaps  if  we  were  all  agreed  as  to 
exactly  what  is  meant  by  sensations,  and  exactly  what 
tests  we  use  for  making  sensations,  and  were  agreed 
about  the  terminology  of  our  discussions,  we  would 
not  perhaps  have  so  much  discussion  about  this  matter. 
He  agreed  with  Dr.  Mills  that  sensations  are  not  closely 
localized,  and  he  agreed  that  we  should  speak  of  sen- 
sory areas,  but  did  not  believe  we  have  sensory  areas 
separate  from  the  motor  ones  back  in  the  post-central 
and  parietal  lobes  or  in  the  gyrus  fornicatus.  He  does 
not  accept  Dr.  Starr's  view  that  the  sensory  centres  are 
back  of  the  fissure  of  Rolando,  for  from  the  evidence 
he  had  been  able  to  collect  there  is  just  as  much  proof 
that  the  pre-central  convolution  has  sensory  functions 
as  that  the  post-central  one  has. 

Dr.  Putnam  thought  Dr.  Dana's  closing  sentence 
must  be  accepted  as  absolutely  certain  that  the  convo- 
lution in  advance  of  the  fissure  of  Rolando,  which  we 
ordinarily  associate  with  the  localized  movements,  has 
as  much  to  do  with  sensation  as  convolutions  anywhere 
else.  In  support  of  that  fact  he  mentioned  one  case 
among  many  where  Dr.  Warren  excised  a  minute 
piece  of  the  cortex  of  a  young  man  with  epilepsy  be- 
ginning in  one  hand — a  piece  a  few  millimetres  in  di- 
ameter— with  the  result  of  producing  paresis  of  the 
hand,  paralysis  in  the  beginning,  and  also  a  disturbance 
of  the  sensibility  of  the  whole  hand.  It  seemed  to  him 
that  showed  in  some  way  the  function  of  sensibility  is 
closely  related  to  the  same  centres  with  the  function  of 
motion.  What  that  relationship  is,  is  a  matter  still 
calling  for  a  great  deal  of  study.  His  own  \  iew  of  the 
difficulty  is  that  we  are  still  decidedly  lacking  in  a  suffi- 
ciently adeiiuate  physiological  or  psychological  con- 
ception of  what  we  mean  by  these  various  terms.  The 
function  of  sensibility  must  be  very  widely  distributed. 
When  any  part  of  the  body  is  touched  or  any  motion 
takes  place  there,  it  calls  immediately  on  various  other 
functions  to   come  into  action.     The  motion   of  the- 


July   13,  1895] 


MEDICAL    RECORD. 


61 


eyes  must  follow  very  rapidly  on  a  sensation,  because 
the  individual  touched  must  immediately  know  from 
what  cause  the  touch  arises,  and  the  like  ;  so  that  close 
relationships  must  be  established,  and,  as  a  matter  of 
fact,  we  have  every  reason  to  think  they  are  established, 
with  all  sorts  of  cerebral  functions  of  various  kinds. 
When  we  apply  sensory  stimulus  we  are  applying  what 
may  perhaps  be  a  very  gross  molecular  disturbance  of 
a  nerve  to  the  part  touched,  and  then  it  impinges  on 
some  part  of  the  brain  primarily,  and  from  there  it 
must  spread  just  as  we  know  in  the  spinal  cord  a  sen- 
sation will  make  its  way  from  a  minute  portion  of  the 
substance  of  the  cord  that  is  left ;  so  in  the  case  of  the 
brain,  if  one  channel  is  cut  off  it  will  make  its  way  into 
a  dozen  other  channels.  An  enormous  tumor  was  re- 
moved, almost  as  large  as  an  orange,  which  lay  directly 
in  the  motor  tract,  and  in  the  course  of  the  operation 
Dr.  Richardson  put  his  finger  down  and  thought  he 
felt  the  falx  and  various  recognizable  bodies  at  the 
base  of  the  brain,  if  not  of  the  skull  at  any  rate  of  the 
brain  ;  in  short,  it  must  be  that  the  whole  of  the  motor 
area  was  removed  with  a  good  part  of  the  internal  cap- 
sule. Nevertheless  that  patient  still  has  a  very  consid- 
erable degree  of  sensation  left,  of  course  modified  ;  but 
in  the  first  place  contact  gives  rise  to  a  painful  distress- 
ing feeling,  contact  with  the  paralyzed  parts  :  in  the 
second  place  even  a  slight  rubbing  is  felt,  and  the 
localization  is  still  fairly  good.  Nevertheless  he  feels 
in  a  very  high  degree,  so  that  although  the  removal  of 
the  motor  convolution  has  affected  the  sensibility  of 
the  limb,  it  has  not  by  any  manner  of  means  destroyed 
it.  Nerves  will  stand  a  high  degree  of  injury,  suffi- 
cient to  entirely  destroy  their  motor  functions,  without 
interfering  materially  with  their  sensory  functions. 
The  same  thing  in  the  cord  :  a  minute  portion  of  it 
will  convey  centripetal  impressions  ;  we  have  in  our 
own  power  to  make  what  may  be  tremendously  power- 
ful as  compared  with  the  little  thrill  corresponding  to 
a  motor  impulse  originating  in  a  voluntar}'  act  ;  so  also 
in  the  brain,  we  know  it  takes  a  very  extraordinary  de- 
gree of  mutilation  of  the  brain  to  entirely  destroy  sen- 
sibility. 

Although  we  must  admit  that  the  function  of  sensi- 
bility is  closely  related  to  the  function  of  localized  mo- 
tion, we  must  admit  that  it  is  closely  related  to  a  great 
many  other  functions,  and  it  remains  to  be  seen 
whether,  as  in  the  case  of  the  relation  of  the  mus- 
cles of  articulation  to  the  function  of  speech,  there  is 
any  centre  which  is  highly  specialized.  He  had  in 
mind  several  cases  where  the  sensory  functions  have 
been  disturbed  in  connection  with  paresis  of  one  hand, 
where  he  seemed  to  be  able  to  detect  a  higher  degree 
of  loss  of  sensibility  or  impairment  of  sensibility  on  the 
side  of  the  ulnar  part  of  the  hand  than  on  the  median 
portion. 

Dr.  Starr  said  we  certainly  have  facts  that  Dr. 
Dana  has  stated  that  are  indisputable,  and  those  of  us 
who  are  constantly  seeing  cases  of  cerebral  surgery  and 
exsecting  cysts  and  portions  of  the  cortex  by  clots  that 
can  be  removed,  are  perfectly  positive  that  a  small 
limited  area  of  the  so-called  motor  zone  does  inevitably 
produce  in  almost  every  case  more  or  less  disturbance 
of  sensation.  He  said  he  was  completely  mistaken  in 
1890,  when  he  maintained  that  sensations  were  only  to 
be  referred  behind  the  fissure  of  Rolando.  He  be- 
lieved with  Dr.  Dana  completely  to-day,  that  there  are 
sensations  produced  by  small  lesions  anterior  to  the 
fissure  of  Rolando,  and  that  the  sensory  area  of  the 
body  corresponds  exactly  with  its  motor  area,  so  far 
as  we  can  determine  clinically.  He  thought  it  would 
be  a  mistake  to  draw  too  broad  a  conclusion  from 
these  facts. 

It  is  perfectly  evident  that  the  term  diffusion  of  sen- 
sibility is  a  capital  one,  and  our  present  anatomy  shows 
why  it  is  ;  it  is  because  these  sensory  fibres  terminate 
in  brush-like  expansions,  so  that  we  must  conceive  of 
a  sensory  fibre  as  virtually  terminating  in  a  long  region 


of  the  nervous  system,  in  fact,  almost  throughout  its 
entire  length.  Now,  suppose  that  with  the  continued 
passage  of  sensations  over  these  fibres  diffusing  them- 
selves in  general  directions,  habit  opens  the  way  in  one 
direction  rather  than  in  another,  that  a  sensation  com- 
ing in  might  be  diffused  from  the  arm  over  the  entire 
parietal  arm-centre  and  also  diffused  over  the  motor- 
centre  ;  but  inasmuch  as  we  guide  our  movements  by 
touch  habitually,  the  result  is  that  a  greater  passage  is 
opened  out  over  to  the  motor  zone.  Diffusion  of  the 
sensibility  in  various  areas  gives  an  explanation  for  the 
fact  that  a  few  cases  are  on  record  where  we  get  sensa- 
tions lost  alone,  and  the  vast  majority  of  cases  show 
that  sensation  and  motion  are  lost  together.  We  must 
abandon  the  idea  of  consciousness  and  conscious  per- 
ception, and  perhaps  to  some  extent  of  conscious  mo- 
tion, being  associated  with  particular  cells.  It  is  just 
as  reasonable  to  believe  it  is  associated  with  association 
fibre  action,  the  combined  activity  of  various  areas  of 
the  brain,  as  it  is  with  single  cells,  and  he  thought  we 
will  come  down  finally  to  the  fact  that  a  cell  is  to  be 
regarded  more  as  a  trophic  centre  than  as  a  motor  or 
sensory. 

Dr.  Dercum  said  that  the  stand  which  had  been  taken 
enables  us  to  explain  certain  other  phenomena  not 
alluded  to  here,  namely,  the  fact  that  the  cuneus 
atrophies  in  cases  of  blindness  last  for  many  years. 
Certain  it  is  that  we  have  no  right  to  conclude  from 
these  facts  that  the  cuneus  only  sees.  It  is  probable  it 
does  other  things.  The  various  centres  of  the  cortex, 
as  we  know  them  clinically  and  pathologically,  are  sim- 
ply highways  of  ingress  and  egress  to  the  general  cor- 
tex. It  gives  us  no  right  to  say  that  this  portion  of  the 
brain  may  do  this  special  thing,  and  that  portion  that 
special  thing.  But  general  biological  considerations  also 
would  negative  the  sharp  differentiation  of  cells  into 
special  functions.  Nerve  protoplasm  reacts  to  certain 
forces  ;  to  say  one  cell  would  react  to  one  mode  of  mo- 
tion and  another  to  another,  is  unphilosophical,  and  not 
borne  out  by  general  biological  considerations. 

Dr.  Richardson  said,  in  reference  to  the  tumor  Dr. 
Putnam  spoke  of,  that  so  far  as  he  knew  there  was  no 
destruction  of  the  motor  areas  except  by  pressure  of 
the  growth.  The  tumor  was  very  large.  It  took  up  a 
very  large  portion  of  the  left  hemisphere.  During  the 
operation  he  touched  the  falx  throughout  a  great  deal 
of  its  extent,  his  finger  passing  through  a  very  large 
opening  through  the  crista  galli  to  the  tentorium.  But, 
so  far  as  he  knew,  there  was  no  destruction  of  brain 
tissue  by  manipulation  during  the  operation.  The  man 
is  now  doing  very  well. 

Dr.  Collins  had  recently  had  a  case  of  cerebral  sur- 
gery in  which  the  development  of  sensory  and  motor 
defects  were  rather  peculiar.  The  young  man  had  his 
first  attack  of  Jacksonian  epilepsy  in  November,  and 
the  movements  were  contraction  of  the  finger  and 
thumb.  A\"hen  he  saw  him  in  March  he  had  had  three. 
In  conjunction  with  Dr.  Sachs,  Dr.  Gerster  operated 
on  the  patient  overthe  superficial  cortical  thumb-and- 
index-finger  centre.  As  the  patient  bore  the  anses- 
thetic  very  badly,  it  was  necessary  to  postpone  the 
operation  after  the  skull  had  been  opened,  that  is,  cut- 
ting into  the  cortex  was  deferred.  That  night  he  had 
an  extremely  severe  attack,  which  had  been  preceded  a 
short  time  by  a  very  high  temperature  and  loss  of  con- 
sciousness for  a  long  time.  The  following  morning  he 
had  paresis  of  the  right  upper  extremity  and  loss  of 
sensation,  that  is,  loss  of  tactile  sense,  loss  of  sense  of 
position,  and  loss  of  muscular  sense  in  the  right  hand. 
Three  or  four  days  afterward  the  dressings  were  opened 
and  a  good  deal  of  distention  was  found  from  effusion 
into  the  surrounding  cellular  tissue,  but  otherwise, 
where  the  operation  had  been  done,  it  seemed  very 
much  like  normal.  Then  a  large  part  of  the  cortex 
was  cut  out.  An  old  pachymeningitis  was  present,  and 
the  Nissl  stain  revealed  degeneration  of  the  cortical 
cell.     He  was  put  to  bed  and  his  hand  tested  for  sensi- 


62 


MEDICAL   RECORD. 


[July 


1895 


bility  that  evening.  The  disturbances  of  sensation  had 
all  disappeared.  These  observations  were  made  with 
extreme  care. 

Dr.  Axgell,  of  Rochester,  corroborated  Dr.  CoIHns 
because  he  had  a  similar  case.  He  made  the  predic- 
tion that  there  would  be  paralysis  for  five  or  six  days 
at  least,  and  to  his  surprise,  when  the  boy  recovered 
from  ether  two  or  three  hours  after  operation,  he  tested 
him  thoroughly  and  found  sensory  paralysis.  Within 
twenty-four  hours  there  was  absolutely  no  sensory 
paralysis  or  sensory  disturbance.  He  did  not  believe 
it  possible  to  make  an  impression  upon  any  centre  of 
the  brain  closely  related  to  another  centre,  without 
affecting  temporarily  that  sensory  centre.  Whether 
this  will  explain  the  reason  why  we  have  a  short  paraly- 
sis of  sensation  when  we  remove  the  motor  cortex  or 
not  is,  of  course,  beyond  our  power  yet  to  determine. 
It  may  be  by  cutting  into  the  cortex  that  we  affected 
the  rootlets  of  the  radicles  from  the  sensory  tract  which 
we  suppose  reach  over  and  produce  this  diffusion  of 
sensation  that  has  been  referred  to. 

Dr.  Prince,  of  Boston,  said  there  is  a  third  fact 
which  Dr.  Starr  had  left  out  of  consideration,  and  that 
is  the  fact  that,  in  many  cases  which  have  been  referred 
to  by  other  gentlemen,  there  has  been  no  loss  of  sensa- 
tion. These  must  be  exceptional  cases  that  must  be 
taken  into  consideration  in  order  to  find  a  law.  A 
great  many  could  be  mentioned.  He  referred  to  two 
which  he  thought  were  of  great  importance.  Many 
will  remember  the  case  of  Dr.  Hall  White,  published 
in  1893,  in  which  case  he  excised  a  certain  portion 
of  the  cortex  and  with  great  care  observed  the  effect 
on  sensation,  and  although  he  had  paralysis  there  was 
no  loss  of  sensation.  What  seems  to  be  a  most  crucial 
test  was  a  case  published  a  short  time  ago.  In  that 
case  he  first  scooped  out  a  piece  of  the  brain  equal  in 
size  to  half  an  orange,  leaving  a  hole  two  inches  in 
depth,  involving  a  very  large  portion  of  the  upper 
part  of  the  descending  convolutions,  caudate  lobule, 
and  some  part  of  the  parietal  convolution.  Before 
the  operation  there  was  hemi-anresthesia  with  paral- 
ysis ;  after  operation  there  was  absolutely  no  loss  of 
sensation  whatsoever,  tested  in  the  most  minute  way. 
A  case  like  that  is  a  crucial  case,  and  if  the  word  cen- 
tre has  any  meaning  whatsoever  it  must  mean  a  portion 
of  brain  the  function  of  which  is  destroyed  when  taken 
away.  These  cases  must  be  taken  into  consideration, 
and  show  that  a  large  portion  of  the  motor  cortex  can 
be  destroyed  without  loss  of  sensation.  Dr.  Dana  asks 
how  to  explain  these  other  cases.  That  is  another 
question.  He  did  not  know  how  to  explain  them.  It 
is  common  to  have  injury  of  the  corpus  striatum  with 
aphasia  and  sensory  disturbances,  and  beginning  with 
hemi-anopsia  ;  hemi-anopsia  is  common  with  lesions  of 
the  corpus  striatum,  and  yet  no  one  localizes  hemi-anop- 
sia in  the  corpus  striatum.  Aphasia  is  common  as  a  sec- 
ondary disturbance  with  lesions  in  different  parts,  and  yet 
we  know  where  aphasia  is  located.  _  We  therefore  must 
regard  them  in  some  way  as  secondary  disturbances. 
In  the  case  of  the  corpus  striatum  we  can  explain  it  by 
oedema,  local  congestion.  It  is  possible  it  may  be  ex- 
plained on  some  form  of  irritation  of  associated  fibres, 
the  effect  of  inhibition.  Whatever  the  explanation,  it 
seemed  to  him  we  must  distinguish  the  facts  and  the 
logical  deduction  of  those  facts  from  any  necessary  ex- 
planation. 

Dr.  Putnam,  of  Boston,  said  no  one  would  speak 
clinically  or  anatomically  of  the  sense  of  hearing  and 
comprehension  of  spoken  words  as  located  in  the  same 
part  of  the  brain,  but  we  know  these  two  functions  lean 
on  each  other  internally  so  closely,  that  not  only  we 
get  more  or  less  aphasia  from  disturbance  of  the  centre 
for  hearing,  but  we  also  get  to  a  less  degree  a  great 
deal,  as  is  also  the  case  with  sensory  phenomena,  of 
disturbance  of  centres,  of  comprehension  in  most  forms 
of  motor  aphasia.  In  short,  cerebral  functions  do  not 
exist  in  themselves,  they  exist  as  related  to  other  func- 


tions, and  you  cannot  destroy  one  without  more  or  less 
impairing  others,  although  it  may  be  only  for  a  brief 
time. 

The  President  added  that  the  whole  of  our  knowl- 
edge of  the  neuron  goes  to  show  the  very  pronounced 
dependence  of  the  motor  neuron  upon  the  sensory 
neuron.  In  the  primary  neurons  it  has  been  clearly 
proven  that  the  terminal  processes  of  the  axis  cylinder 
of  the  sensory  neuron  are  closely  connected  with  the 
apical  process  of  the  motor  neuron  in  the  cord. 

The  development  of  the  fibres  in  the  cortex,  in  the 
brain  itself,  shows  that  the  sensory  tract  passes  distinctly 
upward  toward  the  central  convolution,  the  parietal  re- 
gion, rather  than  downward  and  inward  toward  the 
gyrus  fornicatus  where  Ferrier  some  time  ago  located 
the  sensory  centres,  and  where  Dr.  Mills  still  has  a  lean- 
ing toward  placing  it.  In  other  words,  judging  from 
all  the  analogies  in  the  anatomy  of  the  brain,  the  higher 
sensory  neurons  must  either  pass  upward  directly  to  con- 
nect by  their  axis  cylinder  processes  with  the  cells  of 
the  body  motor  neuron,  or  there  must  be  association 
tracts  from  these  axis  cylinders  going  up  to  the  motor 
processes.  We  find  no  association  tract  passing  up 
from  the  gyrus  fornicatus  to  the  central  fissures,  and 
furthermore,  although  Dr.  Prince  has  just  brought  up 
the  negative  cases  of  lesion  of  the  central  convolution 
without  injury  to  sensation,  there  have  been  in  the  past 
a  very  large  number  of  so-called  negative  cases  about 
the  central  convolution  with  absolutely  no  motor  dis- 
turbances. Most  of  those  with  our  increasing  knowl- 
edge have  been  explained  away,  and  ten  negative  cases 
do  not  afford  as  much  evidence  as  one  positive  case. 
The  positive  cases  of  sensory  disturbances  following 
lesions  behind  and  in  front  of  the  fissure  of  Rolando 
are  increasing  in  number  and  become  very  conclusive. 
The  positive  cases  of  lesion  in  the  neighborhood  of  the 
gyrus  fornicatus  are  very  few  and  far  between. 

Dr.  Mills,  in  closing,  claimed  that  this  discussion 
confirmed  the  stand-points  he  had  always  taken.  It 
seemed  to  him  astounding  that  Dr.  Dana  and  others 
here  speak  of  the  cases  in  which  physiological  or  path- 
ological lesion  of  the  motor  cortex  as  exceptionally  pro- 
ducing alone  motor  symptoms.  Everyone  of  us  must 
admit  the  cases  referred  to  by  Dr.  Starr  and  Dr.  Dana, 
and  by  Dr.  Putnam  and  Dr.  Knapp's  case,  because  we 
know  they  have  been  well  studied  and  well  recorded  ; 
that  is,  cases  in  which  sensory  phenomena  of  some  sort 
have  accompanied  the  motor  phenomena  in  cases  of 
destructive  lesion  of  the  pre-Rolandic  cortex.  We  must 
admit,  too,  the  two  or  three  cases  in  which  certain  ex- 
periments upon  the  cortex  in  life  have  caused  peculiar 
temporary  disturbances  of  sensation  at  the  time.  The 
cases  are  as  a  hundred  to  one  as  the  cases  against  the 
view  that  were  collected  by  Brown-Sequard,  as  against 
the  doctrine  of  crossed  paralysis.  These  cases  of  sen- 
sory disturbance  from  strictly  limited  lesion  of  the  mo- 
tor cortex,  cases  in  which  the  symptoms  were  motor 
alone  instead  of  sensory,  are  as  one  hundred  to  one,  and 
we  do  not  think  it  longer  worth  while  to  collect  these 
cases.  He  said  positively  that  in  a  score  of  these  cases 
with  the  greatest  care  the  patients  have  been  examined 
in  life  and  the  lesions  located  in  death,  and  in  cases  of 
operation  the  greatest  care  had  been  taken  in  studying 
sensory  phenomena,  and  those  sensory  phenomena  had 
not  been  present.  He  mentioned  two  cases  of  his  own, 
one  in  which  Dr.  Hearn  cleanly  excised  a  portion  of  the 
cortex  and  a  portion  right  across  and  in  front  of  the 
Rolandic  fissure  ;  another  case  in  which  Dr.  Keene  did 
the  same  thing,  cleanly  excising  the  cortex,  and  in 
which  he  studied  with  the  greatest  care,  as  soon  as  it 
was  possible,  the  sensory  phenomena,  and  in  which  these 
were  not  present,  and  in  which  the  motor  phenomena 
persisted  day  after  day.  and  day  after  day  changes 
were  noted,  until  the  patient  was  largely  restored  as  re- 
gards motion  and  sensation  not  having  disappeared  at 
all.  He  did  not  think  it  worth  while,  therefore,  to  pit 
these  cases  which  Dr.   Dana  had,  with  great  skill  and 


July   13,  1895] 


MEDICAL    RECORD. 


labor,  collected  as  an  argument  of  great  value  against 
the  very  numerous  cases  which  teach  the  other  thing. 
However  he  must  acknowledge  the  other  cases.  Have 
we  no  explanation  for  these  cases  ?  The  explanations 
have  been  given  here,  some  of  them.  He  would  sug- 
gest three  or  four  explanations  for  these  cases  in  which 
destructive  lesions  cephalad  of  the  sensory  area  have 
given  rise  to  sensory  disturbance. 

One  explanation  which  may  seem  far  fetched  is  that 
these  cases  are  somewhat  of  the  nature  of  the  cases  in 
which  we  have  a  sensory  disturbance  in  hystero-trau- 
matisms.  Many  times  yesterday  in  the  discussion  they 
told  us  about  hemi-anaesthesias  and  about  segment- 
al anaesthesia  as  result  of  a  man  being  struck  on  the 
head,  or  leg,  or  trunk,  and  certainly  the  traumatism  in- 
flicted by  the  surgeon's  knife,  or  by  injury,  or  disease  in 
acute  cases,  or  by  operation  such  as  Dr.  Dana  refers  to, 
is  greater  than  that  which  we  have  in  these  other  cases. 
Another  explanation  is  that  which  he  suggested  in 
1888,  which  grows  out  of  these  later  researches  on  cor- 
tex anatomy.  Undoubtedly  every  area  of  the  cortex, 
visual,  auditory,  gustatory,  sensory,  etc.,  must  be  related 
and  anatomically  connected  with  the  motor  regions  of 
the  cortex.  Now  it  is  through  the  destruction  of  these 
terminals  of  the  fillet  radiations,  whether  they  be  con- 
tinuous with  the  apical  process  of  the  pyramidal  cells 
or  simply  constitute  a  field  of  conjunction,  we  have  a 
separation  between  the  motor  and  sensory  areas,  and  at 
least  temporary  disturbances  of  sensation  would  very 
likely  in  many  instances  result.  It  is  a  great  cortical 
sensory  expanse  in  this  sense,  but  there  is  one  region 
in  the  brain  in  which  these  fillet  radiations  are  placed 
between  the  cortex,  and  which  for  the  surgeon's  and 
physician's  purpose  should  be  regarded  as  the  sensory 
region.  It  is  next  to  the  motor  region,  and  between  the 
motor  and  great  sensory  region.  It  has  a  separation, 
and  one  which  I  believe  is  practical  for  our  purposes. 

The  remarks  made  by  Dr.  Starr  he  thought  were  on 
the  whole  confirmatory  of  what  he  had  stated.  It 
would  seem,  therefore,  that  the  weight  of  argument  and 
the  weight  of  the  evidence  advanced  here  is  still  in 
favor  of  the  localizations  to  which  he  had  always  clung, 
and  which  were  believed  in  by  Charcot,  Ferrier,  and 
others.  He  had  never  claimed  the  gyrus  fornicatus 
was  the  sole  region  of  common  sensibility  in  the  cortex 
of  the  brain.  His  own  position  always  has  been  that 
the  sensory  cortex  proper  includes  at  least  a  portion  of 
the  gyrus  fornicatus,  quadrate  lobule,  posterior  parietal 
convolutions,  and  the  arguments  he  advances  must 
stand  for  the  motor  region  and  not  for  a  part  of  it. 

Dr.  Dana  asked  if  Dr.  Mills  would  tell  us  specifi- 
cally whether  he  denies  that  the  central  convolutions 
have  any  sensory  function,  if  he  absolutely  excludes 
sensory  function  from  the  central  convolution. 

Dr.  Mills  replied  that  for  our  purposes  and  for  our 
practical  idea  of  a  centre  or  area,  he  believed  the  cen- 
tral convolution  or  convolution  cephalad  of  the  central 
fissure  had  no  sensory  function  ;  he  believed  the  pos- 
terior central  convolution  and  the  posterior  parietal  and 
the  region  he  had  named  perhaps  take  part  in  sensory 
phenomena,  that  is,  the  sensory  region  posterior  of  the 
central  fissure. 

Tumor  of  Cerebellum  with  Autopsy. — This  was  the 
title  of  a  paper  by  Dr.  E.  D.  Fisher,  of  New  York. 
The  interesting  feature  of  the  case  was  the  absence 
of  any  symptoms  that  could  be  directly  referred  to 
the  cerebellum.  There  was  no  inco-ordination,  nor 
any  staggering  in  the  gait.  The  pain  was  situated 
principally  over  the  right  orbit. 

The  only  well-defined  cranial  lesion  was  that  of  the 
eighth  nerve  on  the  right  side,  there  being  absolute 
deafness.  There  was  possibly  a  slight  involvement  of 
the  seventh  nerve  on  the  right  side,  and  the  patient 
said  she  had  complete  loss  of  smell.  The  general 
symptoms  of  a  cerebral  tumor,  i.e.,  headache,  convul- 
sion, and  optic  neuritis,  were  present.  A  lesion  at  the 
base  of  the  brain   was  suggested  by  the  cranial  nerve 


lesion,  with  involvement  of  the  cerebellum  ;  the  absence, 
however,  of  cerebellar  symptoms,  and  the  localization 
of  the  pain  so  definitely  over  the  right  orbit,  led  to  an 
exploratory  operation  in  that  situation.  The  tumor 
was  not  found  at  the  time,  but  there  was  a  complete  re- 
lief from  the  pain  and  the  convulsions  until  the  time 
of  death,  eleven  weeks  later,  which  was  caused  by  a 
septic  basilar  meningitis.  Autopsy  revealed  a  glioma 
involving  the  right  cerebellar  hemisphere.  The  opera- 
tion was  by  the  bone-flap  method  of  procedure. 

Cases  of  Brain  Tumor. — Dr.  Preston,  of  Baltimore, 
related  three  cases  of  tumor  of  the  brain  with  autopsy. 
The  first  case  was  that  of  a  boy  aged  thirteen.  For  a 
year  he  had  what  looked  like  ordinary  epileptic  attacks, 
which  were  very  much  lessened  by  the  bromides. 
Then  he  suddenly  developed  diplopia  with  someneuro- 
retinitis.  Vision  was  greatly  reduced,  and  there  was  at 
first  left  lateral  achromatopsia,  and  afterward  left 
hemi-anopsia.  Gradually  he  lost  entirely  both  sight 
and  hearing.  The  reflexes,  both  superficial  and  deep, 
were  lost.  He  complained  of  most  intense  headache, 
and  there  was  gradual  failure  of  mental  power.  The 
autopsy  revealed  a  large  tumor  involving  the  entire 
right  temporal  lobe  ;  the  occipital  lobe  was  softened 
and  broken  down,  but  the  cortical  portion  of  the  occi- 
pital lobe  was  not  involved.  The  tumor  was  a  sarcoma. 
The  second  case  was  interesting  from  the  fact  that  the 
tumor,  a  small  papilloma  not  larger  than  a  partridge 
egg,  buried  itself  in  the  right  superior  occipital  con- 
volution, producing  intense  headache,  with  double 
optic  neuritis.  The  third  case  showed  a  large  sarco- 
matous tumor  involving  the  temporal  lobe  all  except 
the  first  convolution,  the  greater  part  of  the  occipital 
lobe,  and  the  lateral  lobe  of  the  cerebellum.  The  symp- 
toms were  not  very  well  marked  except  headache  and 
mental  disturbance.  It  was  interesting  to  note  that 
the  first  temporal  convolution  was  not  involved,  though 
the  rest  of  the  lobe  was  virtually  destroyed,  and  in 
accordance  with  our  accepted  views  concerning  the 
auditory  centres,  there  was  deafness. 

Brain  Ttunor. — This  was  the  presentation  of  a  speci- 
men by  Dr.  G.  L.  Walton,  of  Boston.  The  main  in- 
terest was  the  question  whether  operation  might  have 
proved  successful.  The  patient  was  fifty-three  years 
of  age,  and  complained  of  frontal  headache  only  two 
months  before  his  death.  Attacks  of  vertigo,  loss  of 
speech,  and  several  general  convulsions  preceded  and 
followed.  Aphasia,  agraphia,  right  hemiplegia,  and 
right  hemi-anopsia  were  present.  Double  optic  neuri- 
tis and  loss  of  superficial  reflexes  on  the  right.  The 
tumor  occupied  the  angle  between  the  Rolandic  and 
Sylvian  fissures.  Extension  forward  under  the  healthy 
cortex  reached  beyond  the  transverse  frontal  sulcus. 
It  was  fairly  well  defined  but  with  no  distinct  capsule. 
The  centre  was  necrotic.  The  symptoms  suggested  so 
extensive  infiltration  that  operation  was  considered  to 
offer  small  hope,  but  the  extension  backward  was  not 
so  great  as  the  hemi-anopsia  would  indicate,  a  fact 
which,  together  with  recently  published  cases  of  re- 
moval of  large  infiltrating  gliomata,  would  lead,  per- 
haps, to  a  somewhat  more  hopeful  prognosis  in  an- 
other case  of  this  nature. 

The  three  preceding  papers  were  discussed  together. 

Dr.  Starr  referred  to  a  case  of  infiltrating  glioma 
in  the  arm  area  of  the  motor  zone.  Symptoms  devel- 
oped in  the  course  of  a  year.  Headache,  optic  neuri- 
tis, spasm  of  right  hand  and  arm.  Later  paresis  and 
loss  of  sensation.  Operation  by  curved  bone-flap. 
Glioma  very  extensive  and  very  vascular.  It  was  im- 
possible to  remove  it  safely.  Death  within  a  few  hours. 
He  mentioned  a  case  of  suspected  tumor  of  corpora 
quadrigemina.  A  flap  of  bone  was  removed  from  pari- 
etal region  and  attempt  to  puncture  ventricles  was  un- 
successful. No  reliet  of  pain.  He  concluded  that 
operation  under  such  conditions  was  useless.  He 
agreed  with  Dr.  Fisher  that  the  position  of  the  pain  is 
of  no  value  in  localization. 


64 


MEDICAL   RECORD. 


[July   E3,  1895 


Dr.  Daxa  said  that  the  use  of  the  chisel  upon  chil- 
dren and  infants  is  a  bad  method  of  operation.  He 
recommended  the  use  of  the  improved  revolving  elec- 
trical saw,  as  used  by  Dr.  Powell,  of  Xew  York. 

Dr.  George  W.  Jacoby,  of  Xew  York,  had  witnessed 
two  operations  upon  adults  in  which  the  electrical  saw 
was  used.  He  considered  the  method  objectionable, 
as  there  was  more  hemorrhage  and  a  wedging  of  the 
saw  interfered  with  the  operation.  He  spoke  favor- 
ably of  Quincke's  lumbar  puncture  for  relief  of  intra- 
cranial pressure. 

Dr.  Dercum  spoke  in  favor  of  a  perpendicular  burr 
worked  by  a  dental  engine. 

Dr.  Collins  had  seen  a  case  where  after  each  series 
of  blows  from  the  mallet  and  chisel  the  pulse  fell  from 
60  or  70  to  35  or  40. 

Dr.  G.  M.  Hammond  had  witnessed  one  operation 
with  the  electrical  saw  upon  an  adult,  and  many  upon 
children.  The  saw  as  now  used  has  a  greater  electro- 
motive force  to  operate  it  than  formerly,  and  this  ob- 
viates the  earlier  difficulties  as  mentioned  by  Dr.  Ja- 
coby. 

Dr.  Dercum  had  noticed  the  same  symptoms  fol- 
lowing the  use  of  the  chisel  as  described  by  Dr.  Col- 
lins. 

Injury  of  the  Angular  Gyrus  from  Fracture  of  the 
Skull. — This  was  a  report  of  a  case  by  Dr.  C.  Eugene 
RlGG;,  of  St,  Paul. 

Hereditary  Chorea  with  Autopsy.— This  was  the  title 
of  a  paper  by  Dr.  Charles  L.  Dana,  Xew  York. 

Dr.  Mills  looked  upon  the  case  as  very  important. 
It  suggested  the  true  explanation  of  a  large  class  of 
cases  (such  as  Friedreich's  ataxia,  hereditary  chorea, 
spastic  paralysis),  that  these  are  teratological. 

Insanity  and  Phthisis,  their  Transmutation,  Concur- 
rence, and  Coexistence.— Dr.  H.  A.  Tomlinson,  of 
St.  Peter,  read  a  paper  with  the  above  title.  He  con- 
sidered that  phthisis  and  insanity  are  equally  potent 
factors  in  the  production  of  brain  instability. 

The  preponderance  of  degeneration  among  those 
having  an  heredity  of  phthisis  is  significant,  as  indica- 
tive of  the  influence  of  phthisis  in  one  generation,  in 
determining  a  defective  nervous  system  in  the  next, 
and  his  tables  also  indicated  that  the  more  direct  the 
heredity,  the  greater  is  the  probability  of  transmuta- 
tion. 

Disease  processes  which  are  constitutional  or  dia- 
thetic attack  primarily  one  or  other  form  of  tissue, 
with  the  result  of  progressive  degeneration  and  disin- 
tegration if  the  tissue  be  epithelial.  However,  if  the 
connective  tissue  is  the  seat  of  a  disease  process  it 
either  increases  rapidly  in  amount,  and  remains  per- 
manently increased,  or  undergoes  liquefaction. 

The  most  common  form  of  degeneration  among  the 
insane  is  the  connective-tissue  type,  or  the  premature 
and  excessive  manifestation  of  the  changes  which  or- 
dinarily occur  in  senility. 

The  preponderance  of  imperfectly  developed  con- 
nective tissue  in  one  generation  implies  the  excessive 
development  of  functional  tissue  in  the  next,  thus  ac- 
counting for  the  transmutation  of  disease  tendency. 
These  changes  are  abundantly  illustrated  in  the  tuber- 
culous and  defective  children  of  neurotic  or  syphilitic 
parents. 


Third  Day,  Friday,  June  7,  1S95. 

The  Diagnosis  of  Pachymeningitis  Interna  Hemor- 
rhagica.—  Dr.  William  X.  Bullard,  of  Boston,  read 
this  paper.  He  considered  the  pathology  of  this  alfec- 
tion  as  yet  unsettled,  though  he  believed  the  weight  of 
evidence  to  be  in  favor  of  a  non-inflammatory  origin. 
Tliere  are  several  forms  of  subdural  hemorrhage,  but 
what  follows  applies  only  to  the  apparently  spontane- 
ous, non-traumatic  affection  occurring  in  adults.  The 
points  of  differential  diagnosis  between  this  condition 


and  other  forms  of  intra-cranial  hemorrhage  are  :  i. 
The  subdural  hemorrhage  is  peculiarly  common  in 
paralytic  dements  and  in  the  chronic  insane,  and  not 
rare  in  chronic  alcoholics.  2.  The  onset  is  often  more 
gradual  than  in  ordinary  intra-cranial  hemorrhage,  and 
the  irritative  stage  lasts  unusually  long.  3.  The  symp- 
toms of  irritation  are  prominent.  General  epileptiform 
convulsions  and  localized  convulsive  movements  are 
apt  to  occur.  4.  The  peculiar  rigidity  occurring  in  one 
limb  in  connection  with  symptoms  of  hemorrhage,  and 
where  no  affection  like  tubercular  meningitis  exists,  is 
very  significant.  The  treatment  in  this  condition  is 
removal  of  the  clot.  In  all  more  serious  cases  this 
should  be  done  as  soon  as  the  disease  is  recognized. 
The  author  reported  a  case  in  which  operation  was  per- 
formed and  the  clot  removed,  although  too  late  to  save 
the  life  of  the  patient. 

Dr.  To.mlinson  thought  the  term  pachymeningitis 
was  a  misnomer.  The  primary  condition  was  non- 
inflammatory. In  syphilitic  cases  there  are  no  signs  of 
active  inflammation,  but  changes  in  the  blood-vessels. 

Dr.  Fisher  believed  that  the  blood  comes  from 
newly  formed  vessels  which  have  resulted  from  inflam- 
mation, and  asked  what  the  special  indications  were 
for  operative  interference. 

Dr.  Bullard  answered  that  operation  was  indicated 
where  symptoms  of  pressure  existed.  The  question  as 
to  the  origin  of  the  disease  remains  sub judice. 

Tabes  and  Mtiltiple  Sclerosis. — Dr.  E.  W.  Taylor, 
of  Boston,  showed  a  patient  suffering  with  the  unusual 
complication  of  tabes  dorsalis  and  multiple  sclerosis. 
Probable  syphilitic  infection  twenty  years  ago.  The 
patient  first  noticed  a  tumor  of  the  hands  fourteen  years 
ago,  followed  by  pain  of  a  lancinating  character  in 
the  legs,  associated  with  general  muscular  weakness. 
Gradual  increase  of  these  symptoms,  with  occasional 
paresthesia  of  the  legs.  Girdle  sensation  and  difficulty 
in  micturition.  Loss  of  knee-jerk,  Argyle  Robertson 
pupil,  lancinating  pains,  disturbances  of  sensibility, 
making  the  diagnosis  of  tabes  dorsalis  unquestioned. 
In  addition,  slight  nystagmus,  spasm  of  posterior  thigh 
muscles,  muscular  weakness,  hesitating  speech,  and  ab- 
solutely characteristic  intention  tremor,  which  masks 
what  little  ataxia  he  has. 

Dr.  Prince  then  presented  microscopical  specimens 
from  a  case  of  cerebro- spinal  syphilis. 

Pathology  and  Morbid  Anatomy  of  Amyotrophic 
Lateral  Sclerosis. — This  was  the  report  of  two  cases 
with  autopsy  by  Dr.  Joseph  Collins,  of  Xew  York. 

After  referring  to  the  moderately  constant  clinical 
picture  of  amyotrophic  lateral  sclerosis,  and  the  vari- 
able pathological  conditions  on  which  they  have  been 
found  to  be  dependent,  he  referred  to  the  fact  that  the 
number  of  cases  in  the  literature  which  were  well  sub- 
stantiated by  autopsy  were  fewer  in  number  than  one 
might  be  inclined  to  think.  Reference  was  also  made 
to  the  different  views  held  by  the  followers  of  Charcot 
and  Erb  on  one  hand,  the  Gowers,  Leyden,  and  others 
as  to  whether  the  disease  is  primarily  of  the  pyramids 
with  a  secondary  involvement  of  the  anterior  horns,  or 
whether  it  is  but  a  variation  from  the  common  form  of 
progressive  muscular  atrophy.  The  first  case  was  a 
male,  thirty-three  years  of  age.  The  autopsy  showed 
atrophy  of  the  ganglionic  cells  throughout  the  cord  ; 
in  the  cervical  and  dorsal  regions,  evidences  of  exces- 
sive vascularity,  in  the  shape  of  large  thickened  blood- 
vessels, especially  in  the  gray  matter  and  spaces  from 
which  vessels  have  dropped.  In  the  cervical  cord, 
corresponding  to  the  place  of  apparent  softening  in 
the  recent  state,  was  found  great  disorganization  of 
the  ground  substance  of  the  anterior  horns.  In  the 
medulla,  degeneration  of  the  nucleus  throughout  the 
entire  extent  with  the  exception  of  the  extreme  caudad 
end.  Slight  degeneration  in  the  tenth  and  common 
vago-accessorio-glosso-pharyngeal  nucleus.  Xo  de- 
generation of  the  pyramids  of  the  medulla.  Root  of 
the  twelfth  nerve  small  and  delicate. 


July   13,  1895] 


MEDICAL   RECORD. 


65 


Case  II.  was  a  male,  forty-eight  years  of  age.  A 
piece  of  cord  from  the  cervical  region  placed  in  alco- 
hol and  cultures  made  from  it  revealed  the  presence  of 
the  tubercle  bacillus  in  considerable  numbers.  In  cer- 
vical region,  degeneration  in  the  crossed  and  direct 
pyramidal  tracts  with  almost  complete  destruction  of 
the  anterior  horns  could  be  made  out.  In  the  dc  rsal 
region  there  was  sclerosis  of  crossed  pyramidal  tracts, 
slight  sclerosis  of  ascending  cerebellar  tracts,  dififusedly 
distributed  dilated  blood  -  vessels,  some  with  very 
much  thickened  walls.  Extensive  atrophy  of  cells  of 
anterior  horns.  Same  degeneration  in  lumbar  and 
sacral  regions  as  in  dorsal,  but  in  lesser  degree.  In 
medulla  atrophic  changes  in  the  nucleus  of  the  twelfth 
nerve.     Hemorrhage  of  ancient  date  in  dorsal  region. 

The  findings  in  these  two  cases  were  then  analyzed 
and  commented  on  in  detail. 

Peroneal  Muscular  Atrophy  with  Autopsy.  —  Dr. 
WiLLi.\M  C.  Kr.\us5,  of  Buffalo,  read  the  history  of  a 
case  of  muscular  atrophy  in  a  man  seventy-eight  years 
of  age,  who  at  the  age  of  eighteen  began  to  notice  a 
weakness  of  the  leg  muscles.  This  weakness  was  ac- 
companied by  atrophy  in  the  peroneal  and  hamstring 
muscles  of  both  legs,  and  extended  to  the  muscles  of 
the  thigh,  the  left  thigh  being  much  more  affected  than 
the  right.  Double  club-foot  of  the  pes-varus  variety 
resulted  and  also  a  double  genu-valgum.  The  tendon 
reflexes  were  absent  on  the  left  side,  also  on  the  right 
with  exception  of  the  patellar  tendon.  Fibrillary  con- 
tractions and  sensory  disturbances  were  entirely  want- 
ing. There  was  present  a  lordosis  and  scoliosis  of  the 
lumbo-sacral  region.  The  muscles  of  the  upper  ex- 
tremities were  unaffected.  The  patient  gave  no  history 
of  any  infantile  disease,  no  poliomyelitis,  and  ascribes 
the  affection  as  the  result  of  an  accident.  Patient 
died  of  ursemia.  Microscopic  examination  of  the 
spinal  cord  revealed  atrophy  of  the  anterior  horns, 
especially  on  the  left  side,  extending  from  the  caudal 
part  of  the  thoracic  region  to  the  conus  medullaris. 
The  multipolar  cells  of  the  antero-lateral  group  are  vis- 
ibly affected,  resulting  in  their  disappearance,  atrophy, 
or  degeneration,  while  the  median  group  is  less  affect- 
ed ;  the  left  side  is  much  more  affected  than  the  right. 
The  white  matter  is  somewhat  sclerosed,  particularly 
in  the  antero-lateral  and  posterior  columns,  but  not 
more  than  the  age  of  the  patient  would  warrant. 

Dr.  Collins  remarked  that  unless  Dr.  Krauss  es- 
tablishes that  this  was  not  a  case  of  chronic  anterior 
poliomyelitis,  then  it  should  not  be  accepted  as  one  of 
the  peroneal  type  of  muscular  atrophy. 

Writers'  Cramp.— Dr.  J.  \V.  Putnam,  of  Buffalo,  re- 
ported a  case  of  writers'  cramp  in  a  telegrapher.  The 
man  had  previously  had  telegraphers'  paralysis  of  wrist, 
later  the  symptoms  increased  to  such  an  extent  that 
the  mere  suggestion  of  writing  or  thought  of  writing 
would  bring  on  the  spasm.  The  spasm,  in  addition  to 
the  arm  muscles,  involved  the  trapezius  and  sterno- 
cleido-mastoid  of  the  left  side.  The  result  was  that 
when  attempting  to  write  the  head  would  twist  around 
to  such  an  extent  that  he  was  unable  to  see  the  paiier. 
The  patient  was  treated  by  hypnotism  and  deep  mus- 
cular injections  of  atropine.  Result  after  two  months 
was  complete  recovery. 

Dr.  Riggs  had  seen  a  similar  case,  but  the  tra]>e- 
zius  was  not  involved.  Much  relief  was  obtained  by 
the  use  of  hyoscine  hydrobromate. 

Dr.  Leszynsky  asked  whether  the  favorable  result 
was  due  to  hypnotism  or  atropine. 

Dr.  Putna.m  replied  that  he  attributed  the  recovery 
to  suggestion  through  hypnotism. 

Dr.  Smith  Baker  said  that  he  had  come  to  con- 
sider the  associated  contractions  (those  of  the  shoulder, 
head,  etc.)  as  natural  outcomes  of  the  habitual  attitude 
assumed  by  everyone  whenever  they  intend  to  do  any 
particular  thing  whatever.  They  may  be  designated 
as  associated  intention  contractions.  The  origin  ot 
these   undoubtedly  dates  back  to  the   time  of  either 


learning  to  write,  or  of  some  position  incidentally  as- 
sumed for  comfort,  or  other  favoring  result.  The  cure 
of  them  may  come  about  through  any  means  whereby 
the  associations  are  broken  up.  Possibly  writers' 
cramp  itself  is  most  fre(juently  of  purely  psychical 
origin,  and  so  rest  or  hypnotism,  or  any  other  sufficient 
psychical  impression  kept  up  long  enough,  will  result 
in  recovery. 

Auto-mi'mesis. — This  was  the  title  of  a  paper  by  Dr. 
Smith  Baker,  of  Utica. 

He  defined  auto-mimesis  as  the  process  whereby  im- 
pressions from  the  outside  world,  or  conceptions  aris- 
ing in  the  mind,  are  first  set  as  copy-models,  and  then 
automatically  reproduced  more  or  less  indefinitely,  un- 
til results  detrimental  or  otherwise  are  attained.  As 
usually  considered,  imitation  means  the  reproduction 
of  features  found  in  other  individuals.  Auto-mimesis, 
or  self-mimicry,  means  the  serial  reproduction  of  char- 
acteristics dominant  at  some  particular  time  in  one's 
own  mind.  How  such  a  copy-model  first  comes  to  be 
set  and  subsequently  followed  is  often  a  mystery. 
But  a  pain,  or  shock,  or  word,  or  muscular  tension,  or 
unusual  idea,  or  any  incidental  experience,  undoubtedly 
affords  the  requisite  suggestion — imitative  impulse. 
This  is  often  seen  in  the  development  of  hysteria, 
neurasthenia,  melancholia,  insistent  ideation,  and  allied 
states  and  tendencies,  while  evidence  is  accumulating 
to  show  that  the  succeeding  auto-mimesis  series  is  a 
quite  natural  outcome  of  such  an  imitative  impression. 
Cases  illustrating  auto-mimetic  development  of  disease 
were  given,  and  the  conclusion  reached  that  possibly 
in  this  way  there  have  been  opened  up  points  of  view, 
both  as  to  etiology  and  therapy,  which  are  of  value  to 
neurologists. 

Dr.  Ralph  L.  Parsons,  of  Sing  Sing,  presented 
drawings  and  photographs  illustrative  of  a  new  system 
of  baths  inaugurated  at  his  institution. 

Obstetrical  Paralysis. — This  was  a  paper  by  Dr.  G. 
L.  Walton,  of  Boston.  He  said  Carter  assumes  a 
stretching  of  the  brachial  plexus  at  a  spot  above  the 
origin  of  the  supra-scapular  nerve.  This  does  not  ac- 
count for  the  escape  of  the  branch  to  the  pectoralis 
major,  which  passes  off  immediately  below.  The  same 
difficulty  presents  itself  in  Oppenheim's  theory  of  press- 
ure against  the  clavicle.  The  reader  suggested  that 
the  supra-scapular  is  probably  bruised  independently 
against  the  supra-scapular  notch  or  spine  of  the  scap- 
ula, while  the  plexus  below  is  bruised  against  the 
clavicle.  The  branch  to  the  pectoralis  major  escapes 
through  having  no  bony  point  of  fixation.  Probably 
rotation  of  the  face  away  from  the  shoulder,  which  is 
caught  at  the  brim  of  the  pelvis,  aids  the  stretching,  as 
well  as  the  drawing  away  of  the  head  already  described 
in  this  connection. 

Discussed  by  Drs.  Starr,  Leszynsky,  and  the  Presi- 
dent. 

The  following  papers  were  read  by  title  : 

"  Home  Treatment  of  Insanity,"  by  H.  M.  Bannister, 
M.D.,  of  Chicago  ;  "  The  Dual  Action  of  the  Brain," 
by  Samuel  B.  Lyon,  M.D.,  of  Bloomingdale  ;  "An 
Operative  Procedure  for  the  Relief  of  Basilar  Menin- 
gitis Limited  to  the  Posterior  Fossa,"  by  J.  T.  Eskridge, 
of  Denver ;  "  Fissural  Studies  of  the  Brain  of  Two 
Philosophers,"  by  Professor  Burt  G.  Wilder,  M.D.,  of 
Ithaca  ;  "  The  Association  of  Tabes  and  Paretic  De- 
mentia," by  Theodore  M.  Diller,  M.D.,  of  Pittsburg  ; 
"  Must  Acute  Paranoia  be  Admitted  into  our  Nomen- 
clature," by  AVilliam  Noyes,  M.D.,  of  Foxboro'  ;  "  The 
Conservative  Value  of  the  Play  Impulse,"  by  Irving  C. 
Rosse,  M.I).,  of  Washington  ;  "  Telegraphers'  Paraly- 
sis," by  James  Hendrie  Lloyd,  of  Philadelphia;  "Case 
of  Multiple  Neuritis  in  an  Infant,"  by  Graeme  M. 
Hammond,  M.I).,  of  New  York  ;  "Pseudo-neurasthe- 
nia," by  Morton  Prince,  M.D.,  of  Boston. 

Election  of  Members. — The  following  named  gentle- 
men were  elected  to  active  membership  :  Dr.  Hugh 
F.   Patrick,  of   Chicago  ;   Dr.  Edward   Wyllys   Taylor, 


66 


MEDICAL    RECORD. 


[July   13,  1895 


of  Boston  ;  Dr.  Leopold  Stieglitz,  of  New  York  ;  Dr. 
John  Jenks  Thomas,  of  Boston  ;  Dr.  H.  L.  Worcester, 
of  Danvers  ;  Dr.  B.  Onuf,  of  Brooklyn,  N.  Y. 

Honorary  Members.— Dr.  S.  Weir  Mitchell,  of  Phil- 
adelphia ;  Dr.  Camillo  Golgi ;  Dr.  L.  Edinger,  of 
Frankfort  ;  Dr.  Ramon  y  Cajal,  of  Barcelona  ;  Dr.  De- 
jerino,  of  Paris. 

Election  of  OflScers. — The  officers  elected  for  the  en- 
suing year  were  :  President,  Dr.  F.  X.  Dercum,  of  Phil- 
adelphia :  Vice-Presidents,  Dr.  George  J.  Preston,  of 
Baltimore,  and  Dr.  C.  E.  Riggs,  of  St.  Paul ;  Secretary 
and  Treasurer,  Dr.  G.  M.  Hammond,  of  New  York. 


sium,  five  times  a  week,  and  a  solution  of  ten  grains  of 
salicylic  acid  before  going  to  bed.  The  patient  re- 
covered quickly,  but  on  account  of  relapses  produced 
by  her  mode  of  living,  I  had  to  repeat  this  treatment 
several  times,  which  always  was  beneficial  to  her. 


PERMANGANATE  OF  POTASSIUM  IN  THE 
TREATMENT  OF  PULMONARY  TUBERCU- 
LOSIS. 

By  LOUIS  BARKAN,   M.D., 


In  1885  I  employed  this  drug  with  most  gratifying  suc- 
cess in  two  cases  of  "  butcher  poisoning."  In  both  cases 
a  quite  slight  cut  on  the  hand  had  produced  several 
great  swellings  along  the  hand,  fore  and  upper  arm,  and 
there  was  a  copious  discharge  of  pus.  Washing  the 
wounds  with  a  solution  of  permanganate  of  potassium 
and  covering  them  freely  with  iodoform  produced  little 
effect.  On  the  eighth  day  in  one  patient,  and  the  tenth 
day  in  the  other,  chills  occurred.  I  then  began  the  use 
of  potassium  permanganate,  giving  a  drinking-glass  of 
a  light  red  solution  three  times  a  day.  The  ne.\t  day 
there  was  a  very  considerable  change  for  the  better, 
shivering  had  ceased,  appetite  and  sleep  had  come  back, 
and  I  was  justified  in  considering  both  patients  out  of 
danger.  This  convinced  me  that  permanganate  of 
potassium  is  not  only  good  for  snake  but  for  "butcher 
poisoning  "  too.  I  hope  it  is  equally  good  for  poison- 
ing derived  from  dissections. 

In  March,  1S93,  I  took  I.  B ,  a  phthisical  boy  of 

sixteen  years,  to  Lakewood.  I  had  treated  him  for  two 
years.  The  boy  had  cavities  on  both  sides  and  was  so 
reduced  in  health  and  strength  that  in  order  to  come  to 
the  ferry  he  only  could  use  the  horse-cars,  being  unable 
to  cfimb  the  stairs  of  the  elevated  railroad  or  to  stand 
the  shaking  of  a  carriage.  In  Lakewood  we  stayed  at 
a  farm-house,  standing  by  itself  on  a  hill,  with  well- 
ventilated  rooms.  In  the  first  five  days  no  improve- 
ment could  be  observed.  The  patient  continued  feverish 
coughing,  weak,  rather  sleepless,  and  perspiring  at  ni^^htj 
the  usual  means  having  failed  to  help;  creosote  was 
given,  but  after  being  used  for  several  days  was  refused 
by  the  patient.  I  gave  him  then  a  drinking-glass  of  a 
light  red  solution  of  permanganate  of  potassium  half  an 
hour  before  breakfast,  and  a  solution  of  ten  grains  of 
salicylic  acid  before  going  to  bed  on  eight  succeeding 
days.  I  consider  the  latter  far  superior  to  quinine  in 
tuberculosis,  as  it  not  only  does  not  interfere  with  dio-es- 
tion,  but  rather  promotes  it. 

A  couple  of  days  later  the  patient  felt  much  better 
and  could  go  out  into  the  open  air  without  feeling  chilly. 
Eight  days  after  commencing  this  treatment  the  patient 
enjoyed  his  meals— ate  three  eggs  for  breakfast,  slept 
well,  did  not  sweat  any  more,  and  was  in  excellent 
spirits.  On  the  fourteenth  day  of  his  stay  in  Lakewood 
he  was  able  to  escort  me  to  the  depot  and  to  walk  back 
without  discomfort — a  distance  of  a  mile  and  a  half. 
The  i)ulmonary  cavities  were  then  almost  healed,  his 
appearance  and  face  looked  surprisingly  well. 

In  two  other  cases  of  less  grave  tuberculosis  I  ex- 
perienced the  same  good  effect  with  the  same  treatment. 
The  fourth  case  was  a  con;bination  of  inlluen/.a  with 
symptoms  of  tuberculosis.     .Vn  hour  and  a  half  after 

breakfast  the  patient,  C.  B ,  took  a  small  drinkin^T. 

glass  of  a  dark  red  solution  of  permanganate  of  potas- 


NEW  TREATMENT  FOR  FRACTURE  OF  THE 
PATELLA. 

By  T.  E.  SCHUMPERT,  M.D., 

SURGEON  TO   THE   CH.^RITY  HOSPITAL,   SHRE^XPORT,   LA. 

I  THINK  I  cannot  better  demonstrate  the  treatment 
which  I  am  about  to  recommend  than  to  cite  my  first 
case. 

Mary  B ,  aged   twenty-five,    negro,    farm-hand. 

Admitted  December  27,  1895.  Diagnosis  :  Fracture  of 
both  patella;.  This  patient  was  brought  into  the  hos- 
pital supported  by  a  man  under  each  arm,  unable  to 
walk  or  stand  without  assistance.  About  the  first  of 
May,  1894,  while  walking  with  a  child  in  her  arms,  she 
stumbled  and  fell  backward,  and  was  unable  to  again 
resume  the  erect  posture  until  aided.  The  physician 
who  was  called  in  dressed  a  fracture  of  the  left  pa- 
tella, by  what  method  I  am  not  aware,  but  the  patient 
was  permitted  to  walk  after  the  first  week,  with  one 
crutch  and  no  dressing  save  a  dry  roller  bandage  ap- 
plied about  the  knee.  This  crutch  she  continued  to 
use  until  December  24th,  when,  while  stepping  from 
the  door  to  the  ground,  a  distance  of  about  eighteen 
inches,  with  the  sound  limb  in  advance,  the  knee  gave 
way  and  she  had  a  second  fall.  Three  days  later  I 
saw  her  at  the  hospital,  with  a  recent  fracture  of  the 
right  knee  and  a  fracture  with  ligamentous  union  of  the 
left.  The  fragments  of  the  old  fracture  were  separated 
three  inches.  Having  procured  from  a  hardware-store 
two  slender  ordinary  screws,  one-half  inch  in  length, 
we  were  ready  to  proceed  with  the  operation.  I  first 
boiled  the  screws  a  half-hour,  and  then  placed  them  in 
pure  carbolic  acid  for  another  half  hour,  then  in  a 
carbolized  solution  with  the  instruments,  to  remain  un- 
til used. 

After  the  usual  preparation  on  the  previous  day,  with 
an  antiseptic  dressing  applied  about  the  leg,  on  the 
day  of  the  operation,  taking  every  antiseptic  precaution, 
I  selected  the  limb  with  the  old  fracture  to  employ  the 
treatment  which  I  am  about  to  detail,  deeming  this 
the  most  unfavorable  for  a  good  result.  The  leg  hav- 
ing been  flexed  on  the  thigh  to  a  little  less  than  right 
angles,  I  made  a  transverse  incision  through  the  skin 
between  the  fragments,  extending  from  the  outer  to  the 
inner  condyle.  I  then  dissected  back  the  integument, 
laying  bare  the  fragment  both  above  and  below,  as  well 
as  the  intervening  ligament.  The  ligament  was  next 
removed,  and  the  edges  of  the  bone  well  denuded. 
Then  with  a  drill  I  slightly  punctured  each  fragment 
about  its  middle,  and  with  an  ordinary  screw-driver  in- 
serted a  screw  in  each  fragment  until  within  one  turn 
of  its  full  length.  The  leg  was  now  extended,  and  after 
having  my  assistants  press  the  quadriceps  extensor  from 
above  downward  I  was  able  to  bring  the  fragments  of 
bone  into  apposition,  and  with  a  silver  wire  applied 
around  the  screws  by  the  figure-of-eight  method,  to  keep 
them  in  contact.  The  integument  was  next  brought 
over  and  sutured,  and  the  leg  dressed  by  full  extension 
with  a  suitable  splint  beneath  and  a  dry  roller  bandage 
applied  about  the  thigh  from  above  downward,  also  one 
applied  about  the  leg, with  a  third  figure-of-eight  bandage 
applied  tightly  about  the  knee,  the  latter  bandage  having 
been  disturbed  but  once  during  eight  weeks.  I  prefer 
the  figure-of-eight  to  the  all-round  method  of  applying 
the  wire,  because  it  prevents  to  any  very  great  extent  the 
ducking  of  the  heads  of  the  screws,  whicli  could  be  dis- 
tinctly felt  beneath  the  skin.  The  figure-of-eight  bandage 
depresses  the  ligamentum  patella  and  quadriceps  exten- 
sor tendon  and  brings  the  fragments  together  through- 


July   13,  1895] 


MEDICAL    RECORD. 


67 


out  its  entire  depth.  My  idea  was  to  inject  cocaine 
over  the  head  of  each  screw  after  the  fracture  had 
healed,  and  by  unscrewing  to  withdraw  them,  but  on 
attempting  this  I  found  that  they  were  encysted  and  it 
could  not  be  done.  I  think  in  my  ne.xt  case  I  shall  not 
insert  them  so  deeply.  The  result  secured  was  perfect, 
with  no  impairment  in  motion  of  the  joint.  The  fract- 
ure of  the  right  leg,  though  a  much  more  favorable  case, 
was  treated  by  another  method,  and  the  result  was  not 
nearly  so  good. 


ACCIDENTS  TO  THE  EYE  WHILE  CHOPPING 
WITH   A  HOE. 


By  \V.   L.  BULLARD,  M.D., 


Ix  the  South,  at  this  season  of  the  year,  when  the  farm- 
ers are  chopping  cotton,  and  especially  so  in  sections 
of  country  where  rocks  or  stone  are  found,  the  oph- 
thalmologist is  frequently  consulted  by  patients  who 
come,  exclaiming,  "  Doctor,  I  wish  that  you  would  ex- 
amine my  eye  :  I  think  that  I  have  a  chip  of  stone  in 
it."  The  experienced  eye  surgeon  knows  at  once  that 
the  foreign  body  is  a  piece  of  steel  from  the  hoe,  and 
its  sequel  depends  largely  upon  the  force  with  which 
the  eye  is  struck  and  the  length  of  time  intervening 
between  the  accident  and  the  time  of  the  consultation. 
A  resume  of  the  following  cases,  described  as  succinctly 
as  possible,  will  designate  such  to  be  true. 

Case   I. — Miss  A ,  aged   fourteen,  near   Griffin, 

Ga.,  was  referred  to  me  in  May,  1886.  She  came  with 
the  idea  that  "  a  piece  of  rock  had  struck  her  in  the 
eye  while  chopping  cotton."  Macroscopically,  a  piece 
of  steel  from  the  hoe  could  be  seen  piercing  the  iris, 
midway  between  the  pupillary'  zone  and  the  peripher)'. 
Its  track  could  be  seen  where  it  perforated  the  cornea. 
Accident  happened  two  days  before.  Eye  ver)'  sensi- 
tive to  light,  and  showed  evidence  of  no  little  inflam- 
matory action.  Adnsed  an  operation,  which  was  con- 
sented to.  Cornea,  after  cocainization,  incised,  and  with 
iris  forceps  the  foreign  body  grasped,  including  the 
iris,  drawn  out,  and  removed  as  in  simple  iridectomy, 
and  the  wound  treated  in  the  same  way,  with  perfect 
results. 

C.A.SE    II. — Mr.    E ,  aged   thirt)',    Howards,  Ga. 

Consulted  me  in  May,  1890,  complaining  as  above. 
The  steel,  which  was  about  the  size  of  a  pin-head, 
could  be  seen  resting  on  the  iris,  and  an  incision  was 
made  in  the  cornea  and  the  piece  removed  with  for- 
ceps, after  which  wound  treated  in  the  usual  way,  with 
perfect  results. 

C.A.SE  III. — Mr.   G ,  aged  thirty-five,  Hamilton, 

Ga.  Consulted  me  in  May,  1892,  with  the  same  tale 
of  woe  as  Cases  I.  and  II.  The  chip  of  steel  could  be 
seen  embedded  in  the  iris.  An  iridectomy  was  per- 
formed, together  with  the  extraction  of  the  foreign 
body.  Wound  treated  as  that  after  simple  iridectomy, 
with  perfect  result. 

Case  IV.— Mrs.  S ,  Dadeville,  Ala.     Referred  to 

me  in  May.  1S94,  by  Dr.  B .     The  bit  of  steel  could 

be  seen  embedded  in  the  iris  ;  iridectomy  performed, 
and  a  piece  of  steel  removed  ;  wound  dressed  as  usual, 
and  patient  sent  directly  home.     Wound  did  not  heal 

as  advised,  and  Dr.  B- ,  the  family  physician,  was 

consulted,  and  another  piece  of  steel  extracted  from  the 
corneal  wound  (this  information  furnished  by  the  pa- 
tient's husband),  which  healed  without  any  further 
trouble. 

Case  V. — Mr.  S ,  aged  fifty,  Talbotton,  Ga.   Was 

referred  to  me  in  June,  1894,  by  his  family  physician, 
a  few  days  after  the  accident.  Patient  thought  "  that 
a  piece  of  rock  had  hit  him  in  the  eye,  but  felt  sure 
that  he  had  gotten  it  out."  A  glance  at  the  eye  con- 
vinced me  that  irido-cyclitis  had  set  in,  and  I  advised 


enucleation,  after  which  the  ball  was  cut  open,  and  the 
piece  of  steel  found  in  the  vitreous. 

Case  VI. — Mr.  I ,  aged  nineteen,  Lee  County,  Ala. 

Was  brought  by  his  father  to  my  oflnce  six  days  ago, 
telling  me  that  "  his  boy  had  a  rock  in  his  eye."  The 
accident  occurred  three  days  pre%-iously,  and  the  pain 
was  most  excruciaring,  ■n'ith  constant  vomiting.  Pan- 
ophthalmitis had  made  considerable  headway,  and 
enucleation  was  advised,  and  at  once  performed,  which 
gave  immediate  relief.  The  chip  of  steel  was  found  in 
the  vitreous. 

Case  VII. — Mrs.  D ,  aged  forty-five.  Mountain 

Hill,  Ga.  Brought  to  my  office  three  days  ago  by  her 
husband,  who  informed  me  that  "  his  wife  while  chop- 
ping with  a  hoe  struck  a  rock,  and  a  piece  of  it  struck 

her  in  the  eye."     Directly  after  the  accident  Mrs.  D 

was  seen  by  the  family  physician,  who  advised  that  I 
should  see  the  case,  which  was  done  in  nine  hours  after 
the  accident.  The  piece  of  steel  could  be  seen  lying 
on  the  lens,  between  it  and  the  iris.  An  incision  was 
made  in  the  cornea,  as  in  iridectomy,  and  with  a  pair 
of  iris  forceps  the  offending  member  was  extracted,  to 
my  delight  and  the  patient's  joy,  on  the  first  attenipt. 
The  iris  prolapsed  but  was  replaced,  a  solution  of  pilo- 
carpine used,  and  at  this  writing — three  days  afterward 
— the  indications  are  good  for  a  perfect  recovery. 

I  could  add  other  cases,  but  these  are  enough  to  con- 
vince us  that  when  we  see  in  the  press — as  we  often- 
times do — "  That  Mr.  A or  Master  B has  lost 

an  eye  by  a  chip  of  stone,"  it  is  a  fragment  of  steel 
from  the  hoe  that  should  be  held  responsible  for  the 
damage. 

1408  Third  Avenue,  May  n.  1893. 


OPER-A.TION  FOR  GUNSHOT  WOUND  OF 
THE   ABDOMEN. 

By  JOSEPH  N.  STUDY,  M.D., 

CUIBRIDGE  aTTi%  IND. 

Ox  the  morning  of  October  25,  1894,  J.  W ,  aged 

sixt)--five,  American,  after  shooting  his  infant  child 
shot  himself,  the  weapon  used  being  a  22-calibre  re- 
peating pistol.  The  bullet  penetrated  his  abdomen 
one  inch  above,  and  one  and  one-half  inch  to  the 
left  of,  the  umbilicus.  Within  a  few  minutes  after  the 
injur)-,  his  s}Tnptoms  became  bad,  and  to  all  appear- 
ances severe  internal  hemorrhage  had  occurred.  After 
three  hours  it  was  thought  his  symptoms  had  slightly 
improved.  Twenty-five  hours  after  the  injury  permis- 
sion was  given  to  open  the  abdomen.  The  skin  oyer 
the  abdomen  was  well  cleansed,  and  the  man  being 
etherized  I  proceeded  to  do  abdominal  section,  assisted 
by  Dr.  Boyd,  of  this  place.  An  effort  was  made  to  do 
an  aseptic  operation.  A  median  incision  was  made,  at 
first  four  inches,  increased  to  six  inches,  the  upper 
point  of  the  incision  being  two  inches  above  the  en- 
trance of  the  bullet. 

The  abdominal  cavity  was  well  filled  with  blood  and 
traces  of  faeces  were  observed.  It  was  found  that  the 
bullet,  after  penetrating  the  walls  of  the  abdomen,  had 
pursued  a  course  downward  and  backward,  and  had 
done  little  injury  until  coming  in  contact  with  the  in- 
ferior mesenteric  vein,  wounding  this  vessel  causing 
the  hemorrhage.  The  bullet  next  penetrated  the 
descending  colon  immediately  above  the  sigmoid  fle.x- 
ure,  passing  through  the  intestine  antero-posteriorly, 
making  two  openings  from  which  some  faeces  were  seen 
to  pass. 

The  ball  was  not  found,  but  was  supposed  to  have 
embedded  itself  in  the  deep  muscles.  The  bleeding 
vessel  was  ligated  with  catgut,  the  two  openings  in  the 
intestine  closed  by  Lembert  sutures,  the  abdominal 
cavity  cleansed  carefully,  the  abdominal  incision  sut- 
ured,' and  drainage-tube'  inserted  at  lower  end  of  in- 


68 


MEDICAL   RECORD. 


[July   13,  1895 


The  operation  lasted  forty  minutes.  The  man  was 
placed  in  bed  with  warm  water  bottles  to  his  body  and 
extremities.  Hypodermic  injections  of  ether  were 
given,  and  strychnine,  one-sixtieth  grain,  every  half  hour 
till  four  doses  were  given,  then  every  one  to  two  hours. 
Death  occurred  seven  hours  after  the  operation. 

Two  points  were  well  shown  in  this  case.  One,  the 
man  would  most  certainly  have  died  without  the  oper- 
ation. The  other,  operations  for  such  injuries  should 
be  done  soon  after  their  occurrence. 


A  PEANUT  IMPACTED  IN  THE  LEFT  BRON- 
CHUS. 

Bv   \V.   MOSER,   M.D., 


OLOGIST  TO    Sr.    CATHA 


«LVN   THROAT    HOSPITAL. 


The  pod  of  the  arachis  hypogjea  contains  a  seed 
which,  as  we  all  know,  is  so  designed  by  nature  as  to  be 
readily  divided  into  two  halves. 

I  recently  performed  an  autopsy  at  St.  Catha- 
rine's Hospital  on  a  child  about  two  years  of  age,  in 
which  one-half  of  the  nut  was  found  impacted  in  the 
left  bronchus,  completely  occluding  the  opening  from 
the  trachea  at  the  point  of  bifurcation.  The  nut  was 
firmly  impacted  at  this  site,  and  excited  ulceration  of 
the  surrounding  tissue. 

The  common  result  of  foreign  bodies  which  enter 
the  trachea  is  that  they  are  arrested,  not  in  the  left 
bronchus  as  in  this  case,  but  in  the  right.  The  right 
bronchus  being  wider  and  more  horizontal  than  the 
left  probably  explains  this  tendency.  Goodall  states 
that  the  septum  is  a  little  to  the  left  of  the  median  line 
where  the  trachea  divides,  and  this,  too,  might  explain 
wliy  the  right  bronchus  is  more  frequently  the  seat  of 
foreign  bodies  than  the  left  (Bryant).  When  a  foreign 
body  becomes  impacted  in  the  larynx  death  is  caused 
by  spasm  of  the  glottis  or  by  cedema.  But  when  either 
bronchus  becomes  obstructed  by  some  foreign  body  the 
danger  lies  in  broncho-pneumonia.  This  may  come  on 
rapidly  or  slowly  and  may  affect  only  one  lung,  or,  as  in 
the  case  in  question,  both  lower  lobes  were  consolidated 
within  two  weeks.  Tracheotomy  must  be  performed 
early  in  these  cases,  as  the  secondary  pneumonia  ren- 
ders the  prognosis  bad. 

The  moral  to  be  drawn  from  this  case  is  that  in- 
fants should  not  be  fed  on  the  pistache  de  terre,  which 
is  light,  smooth,  and  slippery,  and  may  easily,  when 
the  glottis  is  open,  pass  into  either  bronchus.  Parents 
feeding  their  children  on  peanuts  at  the  circus  should 
not  let  the  child  laugh  too  heartily,  lest  the  accident 
occur. 

158  Ross  Street. 


Disinfection  of  Localities. — MM.  Laveran  and  Vail- 
lard  announce  that  from  their  experiments  they  believe 
the  best  method  of  disinfecting  the  walls  of 
habitations  consists  of  first  washing  the 
walls  with  soapsuds,  then  with  a  five  per 
cent,  carbolic-acid  solution  or  to  two  to 
one  thousand  of  sublimate,  acidulated.  In 
all  localities  which  are  exposed  to  frequent 
soiling — hospitals,  barracks,  schools,  hotel- 
rooms,  etc.,  the  walls  should  be  of  imper- 
meable material,  easy  to  clean  and  disin- 
fect. If  sprays  are  used  the  liiiuid  should 
be  made  to  stream  along  ihe  walls,  but  in  this  way  the 
disinfection  is  often  imperfect.  The  carbolic  solution 
is  preferable  to  the  sublimate,  it  seems. — Journal  of 
the  American  AleJiea/  Assoeiation. 

Bismarck's  Head  has  recently  been  measured  by  a 
sculptor.  It  is  212  mm.  in  length  and  170  mm.  in 
breadth,  or  8J-S  by  6-3  inches. 


^euT  Instviimeuts. 

A    CHLOROFORM-DROPPER. 
Bv  C.  HOLTZCLAW,  M.D., 

CHATTANOOGA,   TEN.V. 

Appreciating  the  efificacy  of  the  drop  method  in 
the  administration  of  chloroform,  and  the  impractica- 
bility of  all  other  chloroform  droppers  now  in  use,  I 
have  adopted  the  old  chemical  drop-bottle  for  this 
purpose.  It  is  a  ground-glass  stoppered 
bottle,  on  the  rim  or  flange  of  which 
a  lip  is  blown.  From  this  lip  there 
extends  downward  a  small  groove  on 
the  inside,  about  half  the  length  of  the 
neck.  On  the  opposite  side,  about  the 
middle  of  the  neck,  there  is  a  small  hole 
for  the  admission  of  air. 

In  the  ground- glass  stopper  there  are, 
on  opposite  sides,  two  grooves  extend- 
ing about  half  the  length  of  the  stopper. 
When  wanted  for  use,  the  stopper  is 
turned  so  that  its  grooves  come  in  ap- 
position with  the  air-hole  on  one  side, 
and  with  the  grooves  in  the  neck  on  the 
other.  This  adjustment  can  be  so  regu- 
lated as  to  permit  a  stream  to  flow,  or  only  a  drop 
every  two  or  three  seconds.  When  not  in  use,  the 
stopper  is  turned  half-way  around,  removing  the 
grooves  from  the  airhole  and  groove  in  the  neck,  thus 
completely  closing  these  apertures.  The  bottle  then 
can  be  carried  in  pocket  or  satchel,  without  danger  of 
leakage  or  evaporation.  It  is,  at  once,  a  supply  bottle 
and  dropper  combined. 

I  suggest  its  general  adoption  for  the  purpose,  as 
being  compact,  practical,  easily  manipulated,  and  not 
liable  to  get  out  of  order.  The  bottle  can  be  made  of 
any  size,  and  the  danger  of  breaking  can  be  obviated 
by  enclosing  in  a  corrugated,  drawn-metal  case. 


LIGATURE-CARRIER  FOR  THE  PEDICLE  OF 
ABDOMINAL    TUMORS. 

By  AUGUSTIN  H     GOELET,   M.D., 

NtW    YORK. 

The  accompanying  illustration  represents  a  ligature- 
carrier  for  the  pedicle  of  abdominal  tumors  which  was 
shown  at  a  meeting  of  the  New  York  Obstetrical  So- 
ciety, May  15,  1894.  It  possesses  some  advantages  over 
similar  instruments  now  in  use,  which  can  perhaps  be 
better  explained  by  comparison  with  the  well-known 
ligature-carrier  of  Dr.  Cleveland.  That  otherwise  very 
admirable  instrument  does  not  hold  the  ligature  firmly, 
consequently  the  latter  frequently  slips  out  of  its  grasp, 
necessitating  reinsertion.     The  instrument  shown  in  the 


illustration  has  a  projecting  shoulder  on  the  inner  sur- 
face of  each  blade,  near  the  point,  each  overlapping  the 
other  when  closed  (see  (/,  in  the  figure),  which  renders 
slipping  of  the  ligature  impossible.  In  addition  to  this 
improvement  the  handles  are  made  straight,  like  the 
handle  of  an  ordinary  needle-holder,  instead  of  a  scis- 
sors-handle. This  makes  it  possible  to  grasp  and  use 
the  instrument  more  quickly.     A  spring  separates  the 


July   13,  1895] 


MEDICAL    RECORD. 


69 


two  arms  and  at  the  same  time  the  blades,  when  the  grasp 
of  the  hand  upon  the  handle  is  relaxed.  The  blades 
are  joined  by  a  new  lock,  which  permits  them  to  be 
readily  separated  for  cleansing,  and  the  instrument  can 
be  made  perfectly  aseptic. 

In  using  the  instrument  grasp  it  firmly  in  the  right 
hand,  thus  closing  the  blades,  transfix  the  pedicle,  then 
relax  the  hand-pressure,  thus  separating  the  blades,  in- 
sert the  ligature  between  them,  compress  the  handle  and 
withdraw  the  instrument  and  ligature  through  the 
pedicle. 


A    NEW    NEEDLE. 
Bv  JAMES  SPENCER  BROWN,  M.D., 

AXrENDlNJ    SURGSO.N    TO   M  JUN'TAINSIDi:    HOSPITAL,  M  3NTCLAIB,    N.    J. 

While  not  desiring  to  add  to  the  now  too  numerous 
instruments  used  by  the  surgeon,  the  cut  below  repre- 
sents a  needle  which  has  been  used  by 
the  author  and  found  to  combine  many 
desirable  features,  when  rapidity  of  work 
and  thorough  asepsis  are  demanded.  I 
am  therefore  tempted  to  present  it  to  the 
jjrofession. 

The  method  of  its  use  is  as  follows  : 
The  needle  is  sterilized  with  the  other  in- 
struments about  to  be  used.  The  sur- 
geon then  takes  a  spool  of  either  sterilized 
catgut  or  silk,  as  desired,  removes  the  steel 
guy  from  the  handle,  and  runs  the  spool 
over  the  needle  down  to  the  handle,  re- 
places the  guy,  threads  the  needle  and 
places  it  in  alcohol  with  the  other  need- 
les, etc. 

The  operator  uses  it  as  any  Peasley 
needle,  but  instead  of  being  compelled  to 
thread  the  needle  each  time  he  needs  but 
to  take  hold  of  the  free  end  of  the  suture 
material  with  a  pair  of  catch  forceps  and 
draw  the  needle  back.  The  spool  unrolls 
and  a  suture  is  left  in  position.  The  sut- 
ure is  then  cut  the  desired  length  and  the 
needle  is  again  ready  for  the  next  suture. 
The  desirable  features  of  this  over  the 
ordinary  Peasley  needle  are  that  all  hand- 
ling of  the  suture  material  is  done  away 
with.  No  time  is  lost  in  threading  nu- 
merous needles — consequently  rapidity  of 
work. 

The   author  has  found  the   needle  of 

especial  advantage  in  plastic  work  and  in  placing  in 

position  the  many  skin  sutures  after  coeliotomy. 

I    desire    to    extend    my  thanks  to   Messrs.   George 

Tiemann  &  Co.,  of    New  York,  for  carrying  out  my 

ideas. 


perforating  through  the  septum  into  the  opposite  nasal 
space.  To  avoid  this,  septometers,  devised  upon  the 
principle  of  the  ordinary  calliper,  have  been  used,  the 
operator  relying  usually,  however,  upon  his  own  good 
judgment.  By  the  use  of  the  little  nasal  lamp,  an  il- 
lustration of  which  is  herewith  presented,  a  very 
graphic  picture  of  the  gross 
thickness  at  the  point  upon 
which  he  would  operate  is  af- 
forded. Briefly  speaking,  the 
lamp  is  contained  in  a  piece  of 
heavy  barometer  tube,  properly 
electrically  connected,  and  so 
constructed  as  to  be  easily  kept 
aseptic  in  the  true  surgical  sense 
of  the  term.  The  one  Messrs. 
Meyrowitz  have  constructed  for 
me  has  a  brilliancy  of  two-can- 
dle power,  and  is  easily  illumin- 
ated by  a  four-volt  storage  or 
primary  cell-battery.  Its  method 
of  use  is  as  follows  :  Having 
thoroughly  cleaned  and  anes- 
thetized the  nares,  the  operat- 
ing-room is  darkened  (or  an 
opaque  cloth  thrown  over  the 
head  of  both  operator  and  pa- 
tient). The  trans-illuminating 
lamp  is  now  introduced  as  far 
as  possible  into  the  nasal  fossa 
opposite  the  side  of  operation, 
and  the  electricity  switched 
til  rough  the  lamp.  Upon  ex- 
amining the  side  of  operation 
with  the  nasal  speculum,  the 
light  will  be  easily  projected 
through  the  normal  tissues,  and 

intercepted  at  the  points  of  abnormal  thickening,  the 
result  being  that  the  mind  grasps  through  the  eye  a 
vivid  and  sufficiently  lasting  impression  of  the  points 
where  dense  opacity  indicates  that  removal  may  be 
boldly  and  freely  attempted  without  fear  of  perfora- 
tion. 

Only  use  of  this  little  instrument  will  fully  convince 
the  operator  of  its  value. 


DIAGNOSTIC    TRANS-ILLUMINATION    OF 
THE    SEPTUM    NASI. 

By  J.   H.  MARTINDALE,   M.D., 


A  FEW  months  ago,  having  stumbled  upon  the  use  of 
the  incandescent  lamp  as  a  means  of  septo-nasal  trans- 
illumination, I  would  present  the  same  to  the  readers 
of  the  Medical  Record. 

As  all  nasal  specialists  know,  the  presence  of  an  en- 
chondroma  or  exostosis  of  the  septum  is  very  fre- 
quently associated  with  deflection  of  the  septum,  the 
point  of  concavity  on  the  one  side  being  often  exactly 
opposite  the  point  of  growth  upon  the  other  ;  hence 
the  possibility,  when  removing  by  saw  or  trephine,  of 


LABIAL    RETRACTOR. 
By  D.  a.  CURRIE,  M.D., 

ENGLEWUoD,    N.  J. 

During  operations  for  mending  the  perineum,  I  have 
been  so  much  inconvenienced  and  delayed  by  assistants 
allowing  the  speculum  and 
retractors  to  constantly  slip 
and  become  misplaced, 
that  the  above  instrument 
suggested  itself  to  my 
mind.  It  is  self-retaining 
and  of  three  different  sizes 
and  two  different  lengths. 
My  experience  with  it  has 
been  that  the  work  of  pre])- 
aration  goes  on  more  rap- 
idly with  its  use  than  with 
that  of  two  unskilled  as- 
sistants. 

Some  one  may  have  dis- 
covered the  device  prior 
to  this,  but  neither  Messrs. 
Tiemann  &  Co.  nor  myself 
have  seen  or  heard  of  it. 

Those    wishing    to    try 
one  will  find  the  narrow,  short  blade  the  more  gener- 
ally useful  for  perineal  operations. 


70 


MEDICAL    RECORD. 


[July   13,  1895 


NEW   CILIA   FORCEPS. 
By  frank   ALLPORT,  M.D., 


S,    MINN., 

;v    AND    OTOLOGV 


OF  MINNESOTA,   ETC. 


I  WISH  to  call  attention  to  a  pair  of  cilia  forceps,  de- 
vised in  1880  by  myself.  I  have  endeavored  to  use 
other  forceps,  but  have  always  returned  to  the  instru- 
ment referred  to,  of  which  a  cut   is  here  given,  much 


reduced  in  size.  They  are  strongly  made,  easy  to 
handle,  and  the  points  are  of  such  size  and  shape  as 
to  enable  the  operative  to  grasp  firmly  and  tenaciously 
the  smallest  hair.  They  are  manufactured  by  E.  B. 
Meyrowitz. 


OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

HOSPITAL    SUNDAY COLLEGE   OF    SURGEONS — NEW  BY- 
LAW  ELECTION MEDICAL     REPORT      TO     COUNTY 

COUNCIL PROGRESS  OF  BIOLOGY PROFESSOR  HUX- 
LEY  THE  LATE  SIR  G.  PORTER DR.  CASE SUR- 
GEON-MAJOR   CARTER. 

London,  June  21,  1895. 

This  week  opened  with  Hospital  Sunday,  when  collec- 
tions were  made  at  almost  all  the  Metropolitan  churches 
of  all  denominations.  The  returns  are  necessarily  in- 
complete, but  nearly  ;^is,ooo  is  already  reported  as 
the  result,  and  this  amount  is  about  ;^i,ooo  above  that 
received  in  the  same  time  last  year.  Perhaps,  there- 
fore, the  total  contributions  may  be  an  advance  over 
last  year.  Certainly,  the  hospitals  need  more  than 
ever,  and  it  is  high  time  London  roused  itself  to  its  du- 
ties in  this  matter.  It  is  to  be  hoped,  too,  that  the  dis- 
tribution of  the  fund  will  this  year  excite  fewer  heart- 
burnings and  that  the  dead  set  of  a  few  prejudiced  men 
against  specialism  will  not  repeat  the  injustice  that  has 
more 'than  once  been  done. 

The  College  of  Surgeons  has  obtained  the  necessary 
sanction  for  a  by-law  which  will  enable  the  Council  to 
remove  from  its  roll  the  name  of  any  Fellow  or  mem- 
ber adjudged,  after  due  inquiry,  to  have  been  guilty  of 
disgraceful  conduct  in  any  professional  respect.  This 
will  give  the  college  the  power  of  maintaining  a  con- 
trol over  erring  individuals  which  it  has  never  shown 
much  desire  to  exercise. 

There  are  five  vacant  seats  on  the  Council  to  be  filled 
up  on  July  5th.  All  the  candidates  are  prominent  sur- 
geons, and  the  election  excites  a  good  deal  of  interest 
among  the  Fellows  who  elect.  The  members  have  no 
part  nor  lot  in  this  as  in  other  college  matters. 

Mr.  Shirley  Murphy's  second  annual  report  to  the 
I>ondon  County  Council  has  appeared,  and  will  inter- 
est all  sanitarians.  It  differs  considerably  from  the 
Registrar-General's  Report,  applying,  as  it  does,  only 
to  the  County  of  London,  and  giving  an  account  of  the 
sanitary  work  of  the  Council,  as  well  as  the  vital  sta- 
tistics of  the  population.  Among  other  statistics  is  a 
London  life  table  compared  with  tables  jirepared  by 
other  health  offices,  and  "  it  is  interesting  to  note  tliat 
at  each  age  and  for  each  sex  the  expectation  of  life  in 
London  exceeds  that  in  Manchester  and  Glasgow,  but 
is  less  than  that  of  Brighton."  Some  very  important 
jioints  are  raised  in  reference  to  diphtheria  and  scarlet 
fever,  especially  one  as  to  the  infiuence  of  schools,  for  a 
considerable  fall  in  the  number  of  cases  coincides  with 
the  summer  holiday. 

Professor  Ray  Lankester,  in   lecturing  at  the   Royal 


Institution,  lately,  on  the  "  Progress  of  Biological 
Science,"  gave  some  account  of  the  rapid  development 
of  bacteriology.  He  did  not  accept  the  influenza  ba- 
cillus ;  but  among  diseases  undoubtedly  caused  by 
bacteria  he  named  anthrax,  phthisis,  leprosy,  and  glan- 
ders. He  held  that  Koch  has  proved  that  cholera  is 
due  to  a  spirillum  which  breaks  up  into  comma-shaped 
segments,  the  comma  -  bacillus.  Typhoid,  tetanus, 
diphtheria,  and  erysipelas  were  also  microbial  diseases. 
He  made  some  observations  as  to  water  which  have 
been  misinterpreted  by  the  public  press.  Typhoid  and 
cholera  microbes  he  found  would  live  in  very  pure 
water.  Typhoid  microbes  would  sur\'ive  and  multi- 
ply in  distilled  water  for  three  or  four  weeks,  but  in 
ordinary  river-water  it  soon  perished  from  the  poison 
of  ordinary  putrefactive  bacteria.  So  far,  river-water 
might  be  less  dangerous  than  very  pure  lake-water  in 
certain  circumstances.  Thames  water  of  course  teems 
with  organisms  which  destroy  typhoid  bacilli,  but  that 
is  not  a  reason  for  drinking  Thames  water,  though  it 
may  give  hope  that  typhoid  pollution  need  not  be  per- 
manent. The  mention  of  filtration  was  then  consid- 
ered. The  growth  of  those  bacteria  which  are  arrested 
in  the  sand  of  the  great  filter  beds  forms  a  sort  of  jelly 
which  not  only  prevents  the  passage  of  solid  particles 
through  the  sand  but  kills  the  germs  of  typhoid.  The 
filter  beds  of  well-conducted  water-works  are  therefore 
a  great  protection.  Not  so,  however,  with  the  do- 
mestic filter,  which  Professor  Lankester  pronounced 
more  dangerous  than  otherwise,  for  he  had  found  bac- 
teria-free water  after  passing  through  such  a  filter  had 
taken  up  200,000  to  the  cubic  centimetre.  Any  domes- 
tic filter  to  be  of  use  would  have,  he  said,  to  be  steri- 
lized every  twenty-four  hours.  This  would  certainly 
be  a  pleasant  occupation  for  the  ordinary  domestic  ser- 
vant, and  I  fancy  paterfamilias  will  neither  undertake 
to  look  after  his  filter  himself  nor  yet  trust  his  cook  to 
carry  out  the  necessary  proceeding.  The  lesson,  there- 
fore, would  seem  to  be  to  get  rid  of  our  filters  until 
something  more  efficient  than  the  packings  hitherto  in 
use  shall  be  discovered. 

The  action  of  different  bacteria  in  presence  of  each 
other  was  also  illustrated  by  the  lecturer. 

Professor  Huxley's  illness  has  for  some  weeks  given 
great  anxiety  to  his  friends  and  admirers.  Influenza 
was  followed  by  serious  pulmonary  mischief,  and  now, 
just  when  he  was  said  to  have  rallied  from  this  and  it 
was  hoped  he  would  enter  on  convalescence,  I  hear 
that  nephritis  has  appeared  and  his  condition  is  very 
grave. 

The  death  of  Sir  George  Porter  on  Sunday  last  re- 
moves a  conspicuous  name  from  the  roll  of  Dublin  sur- 
geons. He  was  the  son  of  W.  H.  Porter,  the  eminent 
professor  of  surgery,  whose  writings  on  "  Aneurism  " 
and  other  subjects  will  be  well  known  to  your  readers, 
and  well  has  he  sustained  his  father's  reputation.  He 
has  been  loaded  with  all  the  dignities  open  to  the  high- 
est professional  rank — has  been  president  of  his  col- 
lege, professor  in  the  LTniversity  of  Dublin,  senior  sur- 
geon to  his  hospital,  and  admittedly  at  the  head  of  the 
Dublin  school.  Besides  the  baronetcy  he  was  Deputy- 
Lieutenant  of  Wexford  and  served  as  high  sheriff  in 
1887.  Through  all  his  honorable  career  he  has  had 
the  esteem  and  confidence  of  his  brethren. 

Dr.  W.  P.  Case,  medical  othcer  of  Croydon  L^nion 
and  member  of  the  Town  Council,  died  on  the  nth 
instant. 

Surgeon-^L1jo^  Henry  John  Carter,  F.R.S.,  whose 
work  on  the  "Geology  of  India"  and  other  writings 
were  of  the  highest  standard,  died  last  month  at  his 
birthplace,  Budleigh  Salterton,  to  which  he  retired  in 
1862  after  a  brilliant  Indian  career.  At  that  time  the 
Royal  Asiatic  Society  voted  him  ^,100  and  later  he  re- 
ceived the  Royal  Medal  of  the  Royal  Society.  Other 
honors  from  various  societies  had  previously  been 
showered  upon  him.  He  was  in  his  eighty-second 
year. 


July   13,  1895] 


MEDICAL   RECORD. 


71 


THE    CATHOLIC   CHURCH   AND  ABORTION. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  cause  of  legitimate  medical  science  I 
wish  to  present  the  following  in  answer  to  the  article 
in  Medical  Record  of  February  2,  1895,  entitled 
"  The  Catholic  Church  and  Obstetrical  Science."  I 
will  first  briefly  set  forth  the  teachings  of  the  church's 
recognized  moralists,  supplemented  by  authoritative 
decrees. 

Abortion  is  the  ejection  from  the  maternal  womb  of 
the  immature  foetus,  and  may  result  from  either  natural 
or  artificial  causes.  Xow,  the  earliest  period  when  the 
immature  foetus  can  live  outside  the  mother's  womb 
varies  from  the  twenty-eighth  to  the  thirtieth  week  of 
gestation.  A  foetus  delivered  at  this  age  would,  it  is 
true,  be  weaker  than  the  mature  one,  but  if  the  moth- 
er's health  demands  it,  the  church  hinders  not  this  ac- 
celeration of  labor,  since  nothing  is  done  directly 
against  the  child's  life. 

The  second  principle  on  which  theologians  are 
agreed  is  that  it  is  licet  to  employ  remedies  which  have 
their  direct  effect  to  remove  the  disease  of  the  mother, 
although  it  is  foreseen  that  the  ejection  of  the  imma- 
ture foetus  will  follow.  For  instance,  if  blood-letting 
were  required  to  relieve  the  mother  from  some  malady, 
it  could  be  performed,  even  though  it  were  foreseen 
to  be  fatal  to  the  foetus.  The  reasons  here  are  evident, 
for  the  death  is  not  a  per  se  effect,  but  an  accidental 
consequence,  which  the  mother  is  not  bound  to  obvi- 
ate. A  still  more  difficult  phase  presents  itself  when  it 
is  seen  that  the  foetus  will  cause  the  death  of  the 
mother  before  it  arrives  at  a  period  when  a  hope  might 
be  entertained  of  its  life  if  delivered.  Here  opinions 
differ,  and  some  condemn  what  others  allow.  As  I  am 
unwilling  to  restrict 'the  liberty  of  the  medical  profes- 
sion within  any  narrower  limits  than  those  absolutely 
required,  I  will  follow  the  opinions  of  the  most  liberal 
exponents  of  the  faculties  allowed  by  the  church.  I 
find  that  the  Jesuit  Lehmkuhl  is  most  liberal  on  this 
point.  In  the  first  place  he  denies  that  any  mother  is 
rigorously  bound  to  undergo  the  Caesarean  operation, 
especially  where  conscientious  physicians  judge  that 
it  is  far  more  dangerous  than  accelerated  labor.  If, 
however,  the  danger  to  life  is  no  greater  from  the  Ce- 
sarean operation  than  from  the  abortion,  the  mother 
would  then  lose  her  right  to  select  the  latter  instead  of 
the  former,  as  there  would  be  no  motive  in  so  doing. 
But  if,  all  things  considered,  a  moral  certainty  points 
to  abortion  as  the  only  means  of  saving  the  mother's 
life,  Lehmkuhl  allowed  the  induction  of  artificial  labor, 
at  that  time  when  the  foetus  has  so  far  progressed  that 
it  actually  menaces  the  mother's  life,  even  though  it 
has  not  evolved  to  that  extent  that  it  could  live  in  the 
medium  outside  the  mother's  womb,  ^'on  Olfers  also 
allows  such  practice,  although  Dr.  Capellman  condemns 
it  without  reserve.  I  have  never  seen  any  theologian 
that  allowed  it  save  only  Lehmkuhl,  but,  as  his  book  has 
the  imprimatur  of  Rome,  no  one  will  do  wrong  in  follow- 
ing such  opinion  in  practice.  Of  course,  Lehmkuhl  for- 
bids in  such  case  any  direct  act  tending  to  take  the  lite 
of  the  foetus,  such  as  diminution  of  the  foetus,  perforation 
of  the  cranium,  etc.  That  which  he  would  permit  would 
be,  for  instance,  the  effusion  of  the  liquor  amnii,  which 
would  render  the  expulsion  of  the  foetus  a  necessary 
consequence,  though  it  would  not  per  se  invade  the 
life  of  the  foetus.  This  again  cannot  be  done  to  pre- 
vent an  anticipated  danger  to  the  mother,  but  can  only 
be  done  in  the  actual  existence  of  the  danger.  I  be- 
lieve this  then  to  be  a  probable  opinion,  and  a  physi- 
cian can  act  upon  it ;  but  it  certainly  is  the  most  liberal 
faculty  given  to  the  medical  profession  by  theolo- 
gians. 

In  relation  to  the  operation  known  as  craniotomia  or 
cephalotripsia,  all  the  theologians  of  the  church  are  as 
a  unit  that  it  is  never  allowed,  under  any  conditions, 
while  the  foetus  is  alive.     The   ethical  reasons  for  this 


prohibition  are  founded  in  the  canon  of  the  Almighty 
against  murder  of  the  innocent.  From  the  moment  of 
the  conception  of  that  foetus  it  is  a  human  person, 
having  rights  the  same  as  every  other  human  individual. 
To  take  its  life  by  any  direct  invasion  is  murder,  and 
no  good  results  can  ever  justify  a  thing  intrinsically 
wrong.  That  it  is  in  a  helpless  condition  and  can 
neither  plead  for  nor  defend  its  right  to  live  aggravates 
the  crime.  No  plea  that  the  infant  is  an  invader  of  the 
mother's  right  to  life  can  avail  here,  as  the  mother  her- 
self in  her  malformation  is  the  aggressor,  preventing  the 
infant's  right  to  be  born.  Let  us  illustrate  this  by  an 
example.  Two  men  are  on  a  desolate  island  with  no 
food.  Will  any  man  defend  that  one  has  a  right  to  kill 
the  other  to  save  his  own  life  ?  Or,  perhaps,  we  may 
find  a  more  apposite  example.  Two  men  are  enclosed 
in  a  room  with  a  limited  amount  of  oxygen.  If  both 
go  on  respiring,  they  will  both  die  before  help  comes  ; 
if  one  only  were  there  the  supply  would  last  till  libera- 
tion. One  of  them  is  asleep,  and  the  other  slays  him 
while  he  sleeps.  No  man  who  advocates  craniotomia 
can  reprobate  the  killing  of  the  sleeper.  All  doubt  is 
removed  by  the  authoritative  declarations  of  the  Con- 
gregation of  the  Holy  Office,  and  also  by  the  Council  of 
Baltimore,  which  was  approved  by  Rome.  The  Con- 
gregation, after  having  examined  the  book  in  defence 
of  craniotomia  written  by  Pennacchi,  professor  of  his- 
tory in  the  Propaganda,  decided  that  the  doctrine  could 
not  be  taught.  The  Baltimore  Council  says  :  "  Neither 
is  it  allowable  to  any  mother,  whatever  thing  may  befall, 
even  to  the  saving  of  her  life,  to  permit  the  death  of 
the  child  in  her  womb."  It  is  true  that  Catholic  writ- 
ers have  defended  craniotomia,  but  they  have  always 
been  condemned,  and  their  authority  is  thus  neutralized 
by  the  church's  condemnation. 

What  Lehmkuhl  says  about  leaving  the  physician  in 
good  faith,  he  distinctly  affirms  does  not  render  the 
operation  licet,  but  he  counsels  it  to  be  at  times  expe- 
dient when  it  is  foreseen  that  a  prohibitory  injunction 
from  the  priest  would  do  no  good.  If  I  foresee  that  an 
eminent  physician  is  set  upon  performing  the  diminution 
of  the  foetus,  it  is  left  to  my  prudence  to  try  to  stop  him 
or  not,  and  Lehmkuhl  counsels  them  to  leave  him  in 
good  faith  when  a  prohibition  is  foreseen  to  be  futile. 
But  this  is  far  from  approving  such  act  in  itself.  Again 
I  am  surprised  to  see  the  writer  of  the  aforesaid  article 
contuse  the  issue  set  forth  by  the  cardinals  at  Rome 
and  an  issue  dealt  with  antecedently  by  the  Grand  Poeni- 
tentiary  of  Rome.  The  decision  of  the  congregation 
of  cardinals  is  the  decision  of  the  Holy  Office  before 
mentioned,  and  was  that  the  defence  of  craniotomia 
could  not  be  taught.  This  decree  is  the  latest  on  the 
subject  from  Rome,  and  was  given  in  1SS4.  The  other 
decree  was  given  by  a  special  officer  at  Rome,  delegated 
to  confer  upon  cases  in  moral  and  answer  them,  and 
was  in  1872.  The  said  Grand  Poenitentiary  was  asked 
whether  craniotomia  could  ever  be  allowed  by  a  priest, 
and  he  made  answer  :  "  Consult  the  approved  authors, 
and  act  prudently."  Now,  in  the  first  place,  here  the 
authors  are  not,  as  the  writer  quoted  by  the  Medical 
Record  states,  authors  of  medical  works,  but  of  moral 
treatises,  as  the  word  author  in  ecclesiastical  language 
standing  alone  always  implies  a  theologian.  Again,  the 
response  simply  declined  to  define  the  issue  then,  which 
was  finally  settled  in  1884,  and  allowed  the  priest  only 
the  safe  opinions  which  were  then  found  in  good  theo- 
logians. The  clause,  "act  prudently,"  simply  warned 
him  that,  at  times,  it  were  better  to  allow  a  physician  to 
go  on  in  good  faith  in  the  execution  of  an  illicit  act 
than  to  interpose  a  futile  prohibition.  If  then  the  end 
cannot  justify  the  means,  which  is  a  basic  principle  of 
morality,  I  see  not  how  physicians  can  approve  a  prac- 
tice which  is  a  stigma  on  their  high  profession.  Crani- 
otomia is  especially  reprehensible  to-day  since  by  the 
employment  of  the  aseptic  mode  of  operation  eighty  per 
cent,  of  mothers  live  through  the  Cesarean  operation,  a 
percentage   not  equalled   by  those  saved  by  abortion. 


72 


MEDICAL    RECORD. 


[July  13,  1895 


The  number  of  infants  safely  delivered  by  the  section 
is  about  in  the  same  proportion,  hence  one  may  easily 
see  the  motives  in  favor  of  the  Caesarean  sectiom,  and 
yet  in  America  craniotomia  is  the  order  of  the  day, 
while  the  section  is  rarely  operated,  unless  when  the 
physician  is  forced  to  it  by  the  principle  of  the  mother. 
Physicians,  who  are  the  defenders  of  life,  should  culti- 
vate ambition  for  their  high  profession  which  the  com- 
mon feelings  of  humanity  could  approve. 

A.  E.  Breen,  D.D., 

Professor  of  Holy  Scripture  in  St.  Bernard's 
Seminary,  Rochester,  N'.   Y. 


ON  THE   PHYSIOLOGICAL  ACTION  OF  PERI- 
ODIC INDUCED  CURRENTS. 

To  THH  Editor  of  thh  Msdical  Rbcord. 

Sir  :  If  Dr.  Rockwell  did  not  intend  to  criticise  my 
claims,  it  is  by  no  means  clear  why  he  wrote  his  first 
letter  :  but  we  will  accept  his  assertion  to  this  effect. 

In  my  presentation  of  what  I  deemed  to  be  self-evi- 
dent facts  I  may  have  failed,  in  my  previous  communi- 
cation, to  convey  precisely  what  I  desired.  This  seems 
to  have  led  Dr.  Rockwell  into  some  misapprehension, 
but  when  more  fully  explained  I  think  he  will  agree 
with  me  that  further  discussion  is  unnecessary. 

I  maintain  that  the  manufacturer  referred  to  did  ask 
my  consent  to  wind  upon  one  secondary  helix  all  of  the 
various  sizes  and  lengths  of  wire  originally  suggested 
only  by  me,  and  that  it  was  perfectly  proper  for  him  to 
have  done  so,  since  I  had  a  right  to  say  what  should  be 
put  upon  the  market  under  the  name  of  "  The  Goelet 
Induction  Apparatus."  It  was  distinctly  understood 
that  I  should  test  the  apparatus  after  it  was  so  con- 
structed, and  that  I  would  give  it  my  indorsement  only 
if  it  was  found  to  be  as  satisfactory  as  when  the  differ- 
ent sizes  of  wire  are  wound  upon  different  helices. 
The  apparatus  was  sent  to  me  for  approval  and  after 
testing  it  carefully  I  gave  it  my  indorsement.  For  more 
than  a  year  previous  to  this  time  two  other  manufact- 
urers had  been  making  the  apparatus  with  four  inter- 
changeable coils.  In  a  letter  I  received  from  one  of 
these  manufacturers  shortly  after  my  paper  appeared 
suggesting  this  combination  of  coils  and  giving  the  dif- 
erent  -sizes  and  lengths  of  wire  required,  the  statement 
was  made  that  it  was  the  only  practical  suggestion  which 
had  been  published  up  to  that  time,  regarding  the 
construction  of  faradic  apparatus  and  the  needs  of  the 
profession. 

Dr.  Rockwell  is  mistaken  in  supposing  that  the 
manufacturer  referred  to  above  constructed  for  him 
previously  a  continuous  coil  of  nearly  two  thousand 
yards,  made  up  of  the  same  sizes  and  lengths  of  wire 
mentioned  by  me.  In  fact  no  such  apparatus  with 
these  sizes  and  lengths  of  wire  or  anything  like  it  had 
ever  been  manufactured  or  described  at  the  time  I 
made  the  suggestion  at  the  first  meeting  of  the  Ameri- 
can Electro-Therapeutic  Association  in  1891.  If  Dr. 
Rockwell  thinks  he  described  such  coils  in  his  article 
in  the  Meuic.vl  Record  on  February  14,  1891,  he  is 
mistaken,  and  anyone  interested  can  see  his  mistake  by 
carefully  perusing  that  article.  The  coils  there  de- 
scribed were  continuous  with  the  primary,  and  no  sizes 
nor  lengths  of  the  wire  were  mentioned. 

It  is  neither  my  disposition  nor  desire  to  point  out 
any  marked  inconsistency  in  a  colleague's  communica- 
tion. Dr.  Rockwell's  may  have  been  written  in  haste. 
But  I  feel  obliged  to  call  his  attention  to  the  fact  that 
he  begins  by  disputing  my  rights  and  ends  by  suggest- 
ing that  he  and  I  have  had  quite  different  things  in 
mind.  A.  H.  Goelet,  M.D. 


A  Chinese  Maxim  says  that  when  doctors  go  afoot 
and  men  of  letters  drive  in  their  own  carriages,  the 
empire  is  well  governed. 


pietlicaX  gtems. 

Contagious  Diseases — 'Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  July  6,  1895. 


Tuberculosis 129  74 

Typhoid  fever 9  1 

Scarlet  fever 38  6 

Cerebro-spinal  meningitis o  7 

Measles 198  '        24 

Diphtheria 185  42 

Fencing  from  a  Hygienic  Stand-point. — According  to 
Lecomte  fencing  is  a  hygienic  exercise  of  the  first  rank 
and  even  a  curative  means  for  certain  deformities. 
This  exercise  should  be  practised  in  a  well-ventilated 
room,  under  the  direction  of  a  tnaitre  (Tarmes,  who  in- 
sists on  the  correct  execution  of  the  movements  and 
unrestrained  postures.  It  is  indispensable  to  use  the 
left  hand  also,  in  order  to  develop  the  two  sides  of  the 
body  equally.  Lender  the  influence  of  this  exercise  the 
muscles  develop,  the  joints  and  spinal  column  are  sup- 
pled, the  respiratory,  circulatory,  and  digestive  func- 
tions are  rendered  active  ;  nutrition  and  the  nutritive 
changes  are  stimulated  at  the  same  time  as  the  cuta- 
neous functions.  Fencing  has  given  excellent  results 
in  hysteria,  chorea,  migraine,  hypochondria,  insomnia, 
obesity,  gout,  rheumatism,  constipation,  and  chlorosis. 
It  assures  recovery  from  scoliosis  and  from  stiff  joints 
following  immobilization,  and  corrects  certain  cachectic 
deviations  of  the  lower  limbs. — Journal  of  the  Ameri- 
can Medical  Association. 

The  Use  and  Abuse  of  Antip3rretics. — At  a  recent 
meeting  of  the  West  London  Medico-chirurgical  So- 
ciety, a  report  of  which  appears  in  the  Lancet  for  May 
nth.  Dr.  William  Hunter  read  a  paper  in  which  he 
pointed  out  that  the  extent  to  which  antipyretic  agents 
were  used  and  their  manner  of  employment  were  great- 
ly influenced  by  our  views  of  fever.  After  considering 
the  analgetic  properties  of  the  more  recently  intro- 
duced antipyretics  derived  from  coal-tar  products,  such 
as  antipyrine,  phenacetine,  and  acetanilide,  he  said  that 
the  control  of  the  nervous  system  was  one  of  the  prin- 
cipal points  in  the  treatment  of  fever.  The  proper  ob- 
ject of  using  such  drugs  was  not  to  abolish  fever  by  a 
summary  process,  but  rather  to  bring  the  febrile  proc- 
ess within  reasonable  limits.  The  administration  of 
these  remedies,  he  said,  should  always  be  cautious, 
more  particularly  in  the  case  of  acetanilide,  the  usual 
dose  of  which,  as  given  in  books  (from  three  to  ten 
grains),  was  much  too  large  ;  it  should  be  from  one  to 
three  grains.  Dr.  Banning  remarked  that  no  antipy- 
retic equalled  the  use  of  cold  sponging  and  wet  packs, 
either  in  efficiency  or  in  safety.  Dr.  Eccles  believed 
that  the  direct  action  of  antipyrine  could  be  attributed 
to  its  reducing  qualities,  removing  oxygen  from  the 
protoplasm  of  the  nerve-cells,  and  thus  diminishing 
activity  and  producing  analgesia.  Dr.  Atkinson  said 
that  he  had  not  found  any  benefit  follow  the  use  of 
antipyretics,  and  thought  that,  as  the  temperature  al- 
ways fell  before  death,  high  temperature  by  itself  would 
not  kill  a  patient.  Mr.  Mc.Vdam  Eccles  referred  to 
surgical  cases  where  high  temperature  was  due  to  nerve- 
influence,  especially  in  cases  of  head  injury  followed 
by  high  fever  without  sepsis,  and  to  the  so-called  cath- 
eter fever.  He  said  that  after  injuries  of  the  head  the 
temperature  was  often  different  on  the  two  sides. — iVVw 
York  Medical  Journal. 

Epidemics  of  Typhoid  Fever  have  lately  been  traced 
in  Calcutta  and  Bombay  to  the  use  of  watercress  which 
grew  in  soil  polluted  by  sewerage. 


Medical   Record 

A  Weekly  journal  of  Medicine  and  Surgery 


Vol.  48,  No.  3. 
Whole  No.  1289. 


New  York,  July  20,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©tigitial  %,x\xt\zs. 


COMPARATIVELY    PAINLESS    MASTOID    DIS- 
EASE.' 

By  AI-BERT  H.  BUCK,  M.D., 


CLINICAL  PROFESSOR  OF 
CIANS  AND  SLTIGEONS, 
NEW  YORK  EVS  AND  EAB 


NEW  YORK    CITY. 

DISEASES  OF  THE  EAR  IN 
:EW  YORK  ;  CONSULTING  t 
INFIRMARY,  AND  THE  PRESE 


PHE  COLLEGE  OF  PHVSI- 
L-RAL  SURGEON  TO  THE 
HOSPITAL. 


Of  all  the  symptoms  which  characterize  both  the  acute 
and  the  chronic  forms  of  disease  of  the  mastoid  proc- 
ess, that  of  pain  is,  I  believe,  the  most  constant. 
Hypersemia  and  oedema  of  the  skin  behind  the  ear, 
and  tenderness  on  pressure  over  this  region,  are  often 
lacking.  Elevation  of  the  body  temperature  is  as 
often  absent  as  it  is  present,  and  that,  too,  even  in  the 
cases  which  are  characterized  by  the  presence  of  pus 
in  the  mastoid  cells.  The  existence  of  a  perforation 
in  the  membrana  tympani,  and  the  escape  of  a  more  or 
less  purulent  discharge  from  the  middle  ear  through 
this  perforation,  may  also  exceptionally  be  absent  from 
the  list  of  symptoms  belonging  to  a  case  of  mastoid 
disease.  And,  finally,  we  may  even  fail  to  find  that 
prolapsed  condition  of  the  upper  cutaneous  wall  of  the 
inner  half  of  the  external  auditory  canal  which  fur- 
nishes so  trustworthy  an  indication  of  the  inflamma- 
tion going  on  in  the  adjacent  bone.  But  in  the  vast 
majority  of  cases  pain  has  not  only  been  an  unfailing 
symptom  throughout  a  period  of  at  least  several  days, 
but  has  usually  constituted  the  most  striking  feature  of 
the  disease.  In  this  statement  I  believe  that  I  correctly 
reflect  the  experience  of  all  those  who  have  had  much 
to  do  with  the  various  forms  of  mastoid  disease.  Dur- 
ing the  early  months  of  the  present  year,  however,  I 
have  encountered  a  few  cases  in  which  the  symptom  of 
pain  has  occupied  such  a  markedly  subordinate  posi- 
tion that  I  have  thought  it  might  serve  a  useful  pur- 
pose if  I  should  report  them. 

There  are  four  of  these  cases,  all  of  them  of  an  acute 
character  and  all  of  them  characterized  by  pain  at  the 
onset — that  is,  at  the  time  when,  presumably,  the  in- 
flammation was  still  comfined  more  or  less  strictly  to 
the  tympanic  ca\'ity.  .\fter  this  initial  period,  which 
lasted  from  a  few  hours  to  two  or  three  days,  there  was 
either  no  pain  at  all  (as  in  Cases  II.  and  III.),  or  the 
pain  was  of  such  a  migratory  character  and  so  little 
pronounced  (Case  I.),  as  scarcely  to  attract  the  attend- 
ing physician's  attention  to  the  ear  as  its  starting-point  ; 
or,  finally  (Case  IV.),  this  symptom  only  developed 
when  some  special  exciting  cause — like  violent  physi- 
cal exercise — was  brought  into  play  as  a  means  of 
calling  it  forth. 

I  have  endeavored  to  formulate  some  sort  of  an  hy- 
pothesis which  might  explain  with  some  degree  of 
plausibility  this  coexistence  of  serious  inflammatory  dis- 
ease in  the  substance  of  the  greater  part  of  the  mastoid 
process  with  little  or  no  pain  in  the  affected  region,  but 
I  have  not  succeeded  in  finding  an  entirely  satisfactory 
explanation.  There  are  doubtless  several  varieties  of 
micro-organisms  which  are  competent  to  cause,  and 
actually  do  cause,  such  mastoid  disturbances  as  were 

'  Paper  read  before  the  American  Otological  Society  at  its  annual 
jneeting  July  i6,  1895. 


found  to  exist  in  these  four  cases  ;  and  it  is  a  permissi- 
ble inference  that  the  toxins  produced  by  these  differ- 
ent varieties  of  organisms  differ  in  their  composition  and 
in  the  effects  which  they  produce  upon  the  tissues  that 
come  in  contact  with  these  juices.  I  would  therefore 
venture  to  suggest  the  possibility  that  among  the  various 
living  organisms  which,  in  suitably  constructed  mastoid 
processes,  produce  serious  inflammation  and  ultimately 
destruction  of  the  tissues  involved,  there  may  be  one 
or  more  species  which  create  toxins  possessing  a 
decidedly  anaesthetizing  power  over  sentient  nerve 
fibrils.  As  a  proof  of  the  reasonableness  of  such  a 
belief,  I  need  only  to  point  to  the  painlessness  of 
tubercular  inflammations  of  the  middle  ear. 

But  the  etiological  aspects  of  these  cases  are,  it  seems 
to  me,  of  far  less  importance  than  their  practical  bear- 
ings, which  may  be  briefly  summed  up  as  follows  :  First, 
serious  disease  of  the  mastoid  process  may  coexist  with 
an  insignificant  amount  of  pain  in  the  affected  region  ; 
and,  second,  of  all  the  physical  evidences  of  disease  in 
this  part  of  the  temporal  bone  the  one  that  is  most 
rarely  lacking  is  a  prolapsed  condition  of  the  skin 
lining  the  upper  and  posterior  wall  of  the  external 
auditory  canal  in  close  proximity  to  the  membrana 
tympani.  (At  a  more  advanced  stage  of  the  disease,  or 
under  more  favorable  anatomical  relations,  this  prolapse 
may  extend  throughout  the  entire  length  of  the  canal.) 

C.\SE  I. — Female,  fifteen  years  of  age,  and  appar- 
ently in  robust  health.  About  January  4,  1S95,  she, 
along  with  several  members  of  the  family,  was  taken  ill 
with  what  seemed  to  be  the  grippe.  Verj'  soon  after- 
ward she  complained  of  pain  in  the  ear  and  at  various 
points  on  the  right  side  of  her  head.  These  pains 
were  supposed  to  be  of  a  purely  neuralgic  character, 
as  they  finally  centred  themselves  in  the  region  of  the 
right  cheek.  Her  temperature  at  this  time  was  found 
to  be  104°  F.  In  the  course  of  a  day  or  two  she 
seemed  to  have  recovered  her  usual  health  and  was 
permitted  to  return  to  school. 

On  January  loth  the  pains  in  the  ear  and  on  the 
right  side  of  the  head  returned,  but  were  not  specially 
severe  and  soon  passed  away  entirely.  She  felt  con- 
siderable general  malaise,  however,  and  her  tempera- 
ture was  found  to  be  decidedly  above  the  normal 
(104°  to  105°  F.).  As  the  pain  was  referred  sometimes 
to  one  side  of  the  head  and  sometimes  to  the  other, 
and  as  other  members  of  the  family  were  ill  at  the 
same  time  with  what  seemed  to  be  the  grippe,  it  was 
believed  that  the  elevation  of  the  temperature  was  at- 
tributable wholly  to  the  action  of  the  grippe  poison, 
and  that  the  pain  was  of  a  simple  neuralgic  character 
and  not  dependent  upon  any  local  inflammatory 
action.  Nevertheless,  the  attending  physician  examined 
the  ears  and  found  a  little  congestion  of  the  right 
membrana  tympani  ;  but  it  did  not  seem  to  him  that  it 
was  sufficient  to  explain  either  the  elevation  of  tem- 
perature or  the  pains  occasionally  experienced  by  the 
patient.  At  no  time  after  January  loth  did  she  ex- 
perience a?iy  pain  in  the  right  ear. 

On  the  morning  of  the  13th  she  had  a  decided  chill 
and  the  temperature  rose  to  105°  F.  It  was  then 
thought  that  the  ear  trouble  might  be  more  serious 
than  was  at  first  supposed,  and  I  was  accordingly 
asked  to  see  the  patient.  On  examination  I  found  the 
posterior  superior  quadrant  of  the  right  membrana 
tympani  and  the  immediately  adjacent  soft  parts  red, 


74 


MEDICAL   RECORD. 


[July   20,  1895 


swollen,  and  tensely  convex.  On  expressing  my  sur- 
prise that  she  was  not  in  suffering  on  account  of  this 
localized  inflammation,  the  patient  reiterated  the  state- 
ment that  she  had  no  pain  in  the  ear,  but  simply  felt 
the  beating  of  her  pulse  in  that  locality.  A  free  in- 
cision was  made  (without  the  aid  of  an  anaesthetic)  and 
a  drop  of  pinkish  pus  (quite  thick)  was  evacuated. 
For  several  hours  afterward  the  ear  was  frequently 
douched  with  hot  water,  and  hot  flaxseed  meal  poul- 
tices were  kept  applied  the  greater  part  of  the  time. 
Calomel  was  also  administered  every  hour  in  one-tenth- 
grain  doses. 

On  the  14th  I  found  that  she  had  vomited  twice 
during  the  night  and  that  her  temperature  had  not 
gone  below  104.5°  F-  No  perceptible  discharge  from 
the  ear  had  vet  shown  itself. 

On  the  15'th  I  found  that  she  had  again  vomited 
during  the  night,  that  her  temperature  remained  high, 
that  she  had  experienced  no  pain  in  the  ear,  and  that 
despite  the  douching  and  frequent  poulticing  no  dis- 
charge whatever  had  made  its  appearance.  An  exam- 
ination revealed  the  fact  that  my  incision  had  com- 
pletely healed,  and  that  the  posterior  and  upper  part  of 
the  drum  membrane  still  formed  with  the  adjacent 
soft  parts  a  protruding  red  mass  of  skin  of  a  some- 
what parched  aspect.  Slight  tenderness  on  pressure 
over  the  central  part  of  the  mastoid  process  was  also 
found  to  have  developed  since  the  previous  visit.  I 
accordingly  advised  that  the  mastoid  process  be  opened 
without  further  delay,  and  this  operation  was  performed 
on  the  same  day.  The  conditions  found  were  the 
following  :  The  antrum  filled  with  pus  and  granulation 
tissue ;  the  bone  in  the  immediate  vicinity  of  this 
cavity  perceptibly  softened  ;  everywhere  else  through- 
out the  mastoid  process  a  high  degree  of  hyperemia 
and  abundant  granulation  tissue  in  the  pneumatic 
cells. 

On  the  morning  of  January  i6th,  the  day  after  the 
operation,  her  temperature  was  found  to  be  normal  and 
it  remained  so  from  that  time  forward.  Her  pulse-rate 
also  fell  to  90,  and  in  the  course  of  another  day  or 
two  it  fell  to  72,  and  remained  at  about  that  rate  after- 
ward. Before  the  operation  the  pulse-rate  had  varied 
from  104  to  108. 

The  external  wound  closed  on  January  28th. 
Case  II. — Child,  six  years  old,  in  good  general 
health.  I  was  called  to  see  the  case,  for  the  first  time, 
on  Ivlay  17,  1895.  The  parents  stated  that  six  days 
previously  their  daughter  had  complained  of  pain  in 
the  left  ear,  and  that  soon  afterward  a  discharge  from 
this  ear  was  noticed,  but  that  it  had  lasted  only  about 
one  day  ;  and  that  from  that  time  to  the  day  on  which 
I  saw  her,  there  had  been  no  further  complaint  of  pain 
in  the  ear.  The  temperature,  however,  had  varied 
from  102°  to  105.2°  F.  On  examination,  I  found  the 
left  niembrana  tympani  red  and  markedly  bulging. 
There  was  no  redness  or  tenderness  of  the  skin  behind 
the  auricle  of  the  affected  ear.  An  anaesthetic  was 
administered,  and  I  made  a  long  crescent-shaped  in- 
cision in  the  left  drum  membrane,  giving  vent  to  a 
little  pinkish  pus.  Frequent  douching  w-ith  hot  boric- 
acid  solution  was  prescribed.  A  rather  scanty  discharge 
continued  during  the  next  twenty-four  hours  and  then 
ceased  entirely. 

May  23d. — There  has  been  no  further  discharge 
from  the  left  ear  since  the  i8th,  but  on  the  afternoon 
of  the  2ist  I  found  a  drop  or  two  of  yellowish  pus  at 
the  inner  end  of  the  external  auditory  canal.  From 
day  to  day,  however,  I  have  noted  a  slowly  increasing 
prolapse,  downward  and  forward,  of  the  skin  lining 
the  upper  and  posterior  portion  of  the  osseous  external 
auditory  canal ;  this  condition  being  first  noticeable  in 
the  vicinity  of  the  membrana  tympani.  The  child  has 
made  no  complaint,  at  any  time,  of  pain  in  the  ear,  and 
she  has  acted  as  if  she  were  entirely  free  from  any 
such  distress.  Furthermore,  the  membrana  tympani 
has  steadily  grown  paler  and  more  natural  in  appear- 


ance, and  every  attempt  to  elicit  any  sign  of  distress, 
when  I  pressed  firmly  upon  different  parts  of  the  left 
mastoid  process,  has  failed.  Day  after  day,  however, 
and  despite  the  fact  that  she  has  taken  daily,  for  three 
or  four  days  in  succession,  from  twelve  to  fifteen  grains 
of  quinine,  the  body  temperature  has  risen  every  after- 
noon to  104°  and  even  105°  F. 

May  24th. — Still  no  complaint  of  pain,  and  no  evi- 
dence of  any  distress.  But  the  temperature  continues 
to  rise  to  104°  or  105°  F.,  and  early  this  morning  the 
child  vomited.  There  is  also  now  a  little  tenderness 
over  the  central  part  of  the  mastoid  process,  and  the 
prolapsed  condition  of  the  cutaneous  wall  of  the  canal 
continues,  although  it  is  perhaps  less  marked  than  it 
has  been.  Operation  advised  and  performed  during 
the  afternoon  of  the  same  day.  When  the  outer  sur- 
face of  the  mastoid  bone  was  laid  bare,  the  peculiar 
shaven-beard  appearance  commonly  observed  in  the 
stage  just  preceding  that  of  actual  necrosis  was  recog- 
nized over  a  central  area  about  as  large  as  a  three-cent 
silver  bit.  This  corresponded  to  the  only  spot  where 
tenderness  on  pressure  had  been  elicited  at  the  last 
moment.  A  high  degree  of  venous  hyperemia  (the 
blood  was  unusually  dark)  and  the  filling  up  of  many 
of  the  pneumatic  cells  and  the  antrum  with  granulation 
tissue  were  the  only  lesions  noted-  Pus  was  not  found 
at  any  point ;  but  if  any  of  the  cells  had  contained  pus 
the  copiousness  of  the  bleeding  would  not  have  per- 
mitted us  to  recognize  its  presence. 

The  subsequent  progress  of  the  wound  was  every  way 
satisfactory.  Healing  took  place  without  the  forma- 
tion of  more  than  a  few  drops  of  pus.  The  skin  be- 
hind the  wound  remained  perfectly  normal  in  appear- 
ance. The  child  made  no  complaint  of  pain  in  the 
ear,  and  ate  and  slept  quite  well.  But  every  afternoon 
her  temperature  rose  to  a  high  level — rarely  under 
104°,  and  on  one  occasion  as  high  as  107°  F.  The 
administration  of  quinine  was  again  resorted  to,  and  it 
was  found  to  exert  a  limited  influence  upon  the  tem- 
perature. The  doses  were  increased  until  the  child 
finally  took  twenty-seven  grains  in  the  course  of  twenty- 
four  hours.  This  brought  on  vomiting,  and  it  was 
then  decided  (June  loth)  to  remove  the  child  from 
her  residence,  in  the  upper  part  of  the  city,  to  the 
country.  Since  that  time  I  have  heard  no  further  news 
of  the  child's  condition. 

Case  III. —  v^nild,  about  six  years  old.  General 
health  always  good.  Mild  attack  of  scarlet  fever  early 
in  April,  while  absent  from  home.  Child  complained 
of  pain  in  the  right  ear  for  two  or  three  days,  a  dis- 
charge then  made  its  appearance,  and  from  that  time 
onward  she  made  no  further  complaint  of  pain.  She 
ate  and  slept  well,  and  played  with  her  toys  as  if  she 
felt  perfectly  free  from  pain.  The  discharge  was  at  no 
time  abundant,  but  it  gradually  diminished  in  quantity 
until,  at  the  time  when  the  preceding  statement  of  the 
case  was  made  to  me  by  the  child's  father  (May  7, 
1895),  it  had  very  nearly  ceased.  As  the  family  ex- 
pected to  sail  for  Europe  on  May  2  2d,  and  as  the  child 
could  not  conveniently  be  brought  from  the  country 
before  the  20th,  the  father  wished  to  know  whether  he 
might  safely  postpone  bringing  her  to  see  me  until  that 
date.  I  replied  that  I  believed,  from  his  account  of 
the  case,  that  he  might  safely  allow  the  child  to  remain 
in  the  country  until  the  time  mentioned. 

On  May  20th  the  child  was  brought  to  New  York, 
and  I  examined  the  affected  ear.  The  external  audi- 
tory canal  was  of  normal  size  and  appearance  and 
contained  a  little  stringy  mucus  which  escaped  through 
a  very  small  perforation  in  the  centre  of  the  membrana 
tympani,  which  was  entirely  free  from  hypersemia,  but 
showed  a  little  fulness  in  the  vicinity  of  Shrapnell's 
membrane,  chiefly  posteriorly.  Usually  I  attach  great 
importance  to  this  condition,  but  as  the  child  had  ex- 
perienced no  pain  in  the  ear  for  several  weeks  past,  as 
there  was  neither  redness  nor  tenderness  of  the  mastoid 
integuments,  and  as  the  discharge  appeared  to  be  of  a 


July   20,  1895] 


MEDICAL   RECORD. 


75 


purely  mucoid  character  and  very  scanty,  I  made  up 
my  mind  that  no  serious  significance  should,  in  this 
particular  case,  be  attached  to  the  slight  prolapse  of 
the  skin  at  that  part  of  the  external  auditory  canal 
which  corresponds  to  the  floor  of  the  mastoid  antrum. 
I  therefore  dismissed  the  case  as  one  which  needed  no 
further  active  treatment  until  the  family  should  reach 
London  and  could  obtain  the  services  of  some  physician 
competent  to  thoroughly  remove  a  fairly  large  mass  of 
hypertrophied  adenoid  tissue  which  I  had  discovered 
in  the  vault  of  the  pharynx. 

The  following  morning  (May  21st)  the  child  com- 
plained of  pain  in  the  right  ear,  and  soon  afterward  the 
nurse  discovered  that  the  skin  behind  the  ear  was  red 
and  swollen.  Her  temperature  was  taken  and  was 
found  to  have  reached  103°  F. 

On  the  following  day — that  on  which  she  was  to 
have  sailed  for  Europe — I  operated  and  found  that  pus 
was  escaping  outward  through  a  very  fine  opening  in 
the  cortical  portion  of  the  mastoid  process.  The  bone 
substance  in  the  immediate  \icinit)'  of  this  small  open- 
ing appeared  to  be  dead.  Pus,  abundant  granulation 
tissue,  and  softened  bone  structure  were  found  through- 
out the  greater  part  of  the  mastoid  process.  The  ac- 
tivity of  the  bleeding  and  the  abundance  of  granula- 
tion tissue  found  at  this  depth  made  it  impossible  for 
us  to  determine  whether  the  antrum  contained  any  pus 
or  not.  A  considerable  area  of  softened  bone  was  re- 
moved from  the  region  situated  directly  above  and  be- 
hind this  cavity. 

On  the  eighth  day  following  the  operation  the  out- 
side wound  had  entirely  healed.  A  slight  mucoid 
discharge,  however,  still  continued  from  the  external 
auditory  canal  ;  but  this  ceased  entirely  on  the  fourth 
or  fifth  day  after  the  removal  (by  my  associate.  Dr. 
Robert  Lewis,  on  June  3d)  of  quite  a  large  adenoid 
growth  from  the  vault  of  the  phar)Tix.  A  decided  im- 
provement in  the  hearing  also  became  noticeable  at 
the  same  time. 

Case  IV. — Male,  sixteen  years  old,  in  good  general 
health.  About  April  15,  1895,  he  experienced  a  sharp 
pain  in  the  right  ear.  Dry  heat  was  applied  and  he 
obtained  relief  in  the  course  of  a  few  hours.  During 
the  following  four  weeks  he  occasionally,  for  brief 
periods  of  an  hour  or  two,  experienced  a  little  pain  be- 
hind the  same  ear.  There  was  no  discharge  at  any 
time  from  the  external  auditory  canal,  and  his  general 
health  seemed  to  be  comparatively  little  affected  by 
the  condition  of  the  ear.  He  made  the  impression 
upon  his  parents  of  being  more  nervous  and  irritable 
than  usual,  and  his  general  appearance  and  manner 
led  them  to  believe  that  he  was  perhaps  overworked. 
Nevertheless,  all  through  this  period,  he  indulged 
freely  in  athletic  sports. 

On  May  14th  he  had  a  second  brief  attack  of 
severe  pain  which  he  referred  to  the  region  behind 
the  right  ear.  Movements  of  the  head  aggravated  the 
pain. 

On  May  15th  I  saw  the  patient  for  the  first  time. 
The  hearing  power  of  the  right  ear  was  then  noticeably 
diminished.  There  was  some  drooping  of  the  upper 
and  posterior  cutaneous  wall  of  the  external  auditory 
canal  throughout  its  entire  length.  The  soft  part  be- 
hind Shrapnell's  membrane  was  also  somewhat  more 
prominent  than  natural,  and  the  membrana  tympani  it- 
self presented  a  dull  and  soaked  appearance,  but  with- 
out any  bulging  of  the  membrane  outward.  There  was 
no  redness  or  swelling  of  the  mastoid  integuments,  but 
there  was  some  tenderness  when  I  pressed  firmly  upon 
these  parts. 

Systematic  poulticing  and  rest  in  bed  were  ad\"ised. 
On  May  2 2d  I  saw  the  patient  again.  The  parents  re- 
ported that  under  the  treatment  suggested  the  pain  and 
tenderaess  on  pressure  had  rapidly  disappeared,  the 
temperature  had  returned  to  the  normal  height,  and  the 
boy  had  seemingly  obtained  complete  relief  from  his 
ear  trouble.     On  examination  I  found  that  the  droop- 


ing of  the  upper  wall  of  the  inner  half  of  the  canal  had 
greatly  diminished,  but  had  not  entirely  disappeared, 
nor  had  the  slightly  prolapsed  portion  of  skin  near 
Shrapnell's  membrane,  posteriorly,  returned  to  its  nor- 
mal situation.  Aside  from  these  two  points  there  was 
absolutely  nothing  to  indicate  that  the  mastoid  process 
was  not  in  a  condition  of  perfect  health.  Here  again 
I  felt  disposed  to  look  upon  these  slight  departures 
from  the  normal  condirion  as  simply  indications  that 
the  mastoid  process  had  not  entirely  recovered  from 
its  recent  inflammation,  but  that  the  remaining  osteitis 
wa&  insignificant  in  degree  and  extent.  I  accordingly 
advised  the  patient  to  go  about  again  as  usual,  but  to 
avoid  athletic  sports  until  he  felt  sure,  by  actual  ex- 
periment, that  his  ear  was  once  more  able  to  bear  the 
unusual  strain. 

On  May  23d,  still  feeling  quite  well,  he  indulged 
during  the  forenoon  in  a  single  game  of  tennis,  and 
walked  a  short  distance.  Early  in  the  afternoon  ihe 
pain  in  the  mastoid  region  had  returned,  his  tempera- 
ture rose  to  over  102°  F.,  and  the  skin  behind  the  ear 
once  more  became  red,  swollen,  and  tender.  Prompt 
and  continued  poulticing,  with  rest  in  bed,  soon  re- 
lieved the  pain,  swelling,  and  tenderness  behind  the 
ear,  and  restored  the  body  temperature  to  a  little 
over  98°  F. 

On  the  25th  I  found  him  free  from  all  pain,  with  a 
normal  temperature,  with  no  redness  or  swelling  of  the 
mastoid  integuments,  and  with  only  a  little  tenderness 
on  firm  pressure  over  the  central  and  lower  part  of  the 
mastoid  process.  The  history  of  the  case,  however, 
showed  so  plainly  that  a  focus  of  disease  must  still  be 
lingering  on  within  this  porrion  of  the  temporal  bone 
that  I  urged  the  ad\-isability  of  an  immediate  opera- 
tion. My  advice  was  accepted  and  the  operation 
was  performed  during  the  afternoon  of  the  same 
day. 

After  the  surface  of  the  bone  had  been  laid  bare,  and 
the  mastoid  hook  guide  had  been  put  in  position,  I 
applied  the  chisel  at  the  usual  spot,  just  behind  and  a 
little  above  the  knob  of  the  hook- — that  is,  just  behind 
and  a  little  above  the  cur\'ing  posterior  and  upper 
margin  of  the  entrance  to  the  osseous  external  auditory 
canal — and  removed  a  single  chip  of  bone  substance 
about  one  millimetre  in  thickness.  Immediately  under- 
neath this  thin  piece  of  bone  lay  what  seemed  to  me  to 
be  slightly  bluish  granulation  tissue.  Explorarion  with 
the  probe,  however,  revealed  the  fact  that  it  was  the 
outer  wall  of  the  lateral  sinus,  which  in  this  case  occu- 
pied a  position  not  only  unusually  far  forward,  but  also 
much  nearer  the  surface  of  the  skull  than  I  remember 
ever  to  have  seen  it  before.  On  further  removal  of  the 
bone  in  a  downward  direction  it  was  found  that  the 
central  and  lower  part  of  the  mastoid  process  was  con- 
verted into  quite  a  large  abscess  cavity,  into  which  the 
curving  portion  of  the  lateral  sinus  projected  to  the 
extent  of  two-thirds  or  more  of  its  circumference.  All 
this  exposed  surface  of  the  vein  was  covered  with  small 
elevations  of  granulation  tissue,  but  the  vessel  was 
thoroughly  elastic,  and  it  was  e\'ident  that  the  blood 
was  still  flowing  through  it  in  a  natural  manner.  By 
cautious  chiselling  and  spooning  with  a  Volkmann's 
spoon  directly  behind  the  vertical  portion  of  the  lateral 
sinus,  I  succeeded  in  reaching  the  antrum.  No  rec- 
ognizable pus  was  found  here,  but  abundant  granula- 
tion tissue  was  removed  both  from  this  cavity  and  from 
the  adjacent  pneumatic  spaces. 

The  further  history  of  the  case  presents  no  features 
of  special  interest.  The  wound  healed  naturally  and 
promptly  and  no  drawbacks  of  any  kind  occurred  dur- 
ing the  patient's  convalescence.* 

'  It  seems  to  me  that  no  case  could  illustrate  more  forcibly  than  this 
does  the  danger  which  attends  the  employment  of  the  drill  as  a  means 
of  establishing  a  drainage  channel  between  the  mastoid  antrum  and 
the  outer  world.  Having  been  in  former  years  a  strong  advocate  of 
the  use  of  this  instrument,  I  leel  as  if  now  it  were  peculiarly  incumbent 
upon  me  to  lose  no  good  oi^portunity  of  warning  against  its  employ- 
ment. 


MEDICAL   RECORD. 


[July  20,  1895 


A  NEW  METHOD  OF  TREATING  ADHERENT 
RETROPOSED  UTERI. 


By   WILLIAM    R.    PRYOR,  M.D., 


PROFESSOR 


GVNECOLOGV 


Surgical  procedures,  and  mechanical  as  well,  which 
seek  to  correct  retropositions  of  the  uterus,  may  be 
classed  under  two  divisions  :  they  correct  the  displace- 
ment either  by  maintaining  the  cervix  high  up  or  by 
drawing  the  corpus  uteri  forward.  This  classification 
applies  to  the  adherent  as  well  as  movable  forms  of 
retrodisplacement,  only  in  the  former  the  adhesions 
must  first  be  broken  up.  The  organ  may  be  released 
either  by  working  from  the  vagina,  as  by  Sims's  and 
Schultze's  methods,  or  by  abdominal  section.  Those 
who  have  performed  coeliotomy  for  adherent  retropo- 
sition  find,  as  a  rule,  lesions  of  the  uterus  and  adnexa 
greater  than  were  revealed  by  the  most  careful  exam- 
ination, and  have  generally  abandoned  the  forcible 
blind  separation  of  the  adherent  organ  by  the  vagina. 
So  then,  to-day,  most  cases  are  subjected  to  abdominal 
section  and  hysterorrhaphy.  The  possibilities  and 
limitations  of  this  operation  are  now  well  defined. 

Suffice  it  to  say  that  the  operation  is  an  eminently 
successful  one,  and  there  are  but  two  objections  to  it : 
it  converts  a  pelvic  organ  into  an  abdominal  one,  with 
fixation  of  the  corpus  uteri,  and  necessitates  section  of 
the  abdominal  wall. 

In  the  effort  to  find  some  substitute  for  this  too  se- 
vere procedure,  1  made  a  careful  study  of  my  opera- 
tions upon  the  adnexa  through  the  posterior  cul-de-sac, 
and  became  convinced  that  the  proper  method  of 
treating  these  cases  of  adherent  retroposed  uteri  was 
to  be  applied  through  the  vagina. 

Preparation  of  the  Patient. — For  two  days  before  the 
operation  the  patient's  vagina  should  be  kept  packed 
with  iodoform  gauze,  soaked  in  •j^Vff  HgCl,,  for  the 
purpose  of  loosening  the  superficial  epithelium  and 
straightening  the  rugs  of  the  vagina.  Three  days  be- 
fore the  operation  a  calomel  purge  is  given,  and  the 
night  before  two  or  three  compound  rhubarb  pills.  No 
enemata  are  given,  as  on  the  eve  of  the  operation  the 
patient  is  nervous,  and  much  of  the  enema  is  retained 
to  be  rejected  during  the  operation  over  the  field  of 
work.  The  abdomen  and  genitals  are  covered  by  a 
wetjysol  dressing,  one-half  to  one  per  cent.,  for  twelve 
hours.  The  patient  is  shaved  on  the  operating-table. 
Where  there  is  marked  intestinal  torpor,  strychnia  may 
be  given  in  small  doses,  grain  j'j,  t.i.d.,  for  three  days 
before  the  operation. 

Operation. — The  patient  having  been  shaved  and  the 
vagina  scrubbed,  she  is  placed  in  the  lithotomy  posture. 
The  instruments  used  are  Pean's  retractors  and  traction 
forceps,  and  Luer's  forceps,  in  addition  to  those  used 
for  curettage.  Strong  scissors,  curved  on  the  flat,  are 
also  needed.  The  uterus  is  thoroughly  curetted.  If 
there  be  hypertrophy  of  the  cervix,  Schroeder's  ampu- 
tation is  also  done.  Pean's  traction  forceps  grasp  the 
cervix  and  pull  it  down.  When  this  is  done,  the  point 
at  which  to  enter  the  cul-de-sac  is  not  easy  of  selection  ; 
but  when  the  cervix  is  pushed  up,  a  crescentic  fold  will 
appear  behind  it,  as  an  index  of  where  the  vagina 
is  reflected  from  the  cervix.  Just  in  front  of  this 
fold  the  mucous  membrane  is  incised  with  the  scis- 
sors in  the  form  of  a  crescent,  the  ends  of  the  curved 
incision  stopping  short  of  the  lateral  median  line.  Still 
making  firm  traction  with  the  forceps,  the  fingers  of  the 
left  hand  peel  back  the  vagina,  the  operator  keeping  his 
finger-tips  pressed  firmly  against  the  posterior  wall  of 
the  cervix.  The  anatomical  fact  must  be  here  borne  in 
mind  that  in  some  women  the  cul-de-sac  is  behind  the 
entire  vagina,  while  in  others  the  peritoneum  is  reflected 
to  the  bowel  from  the  uterus  at  the  level  of  the  internal 
OS.  Having  separated  the  vagina  as  far  up  as  the  in- 
ternal OS,  if  the  fingers  have  not  already  entered  the 
peritoneal  cavity,  they  are  withdrawn  and  the  opening 


Fig.  I.— tt,  Utenis  :  K,  \-agina :  R,  rec- 
tum ;  X,  wad  of  gaure.  The  cul-de-sac 
has  been  opened,  the  utenis  replaced, 
and  the  wad  of  gauze  placed  in  the  in- 
cision. The  \-agina  is  distended  with 
^auze  which  is  not  shown,  but  the  direc- 
tion of  effort  of  the  vagina]  gauze  is  in- 
dicated by  the  arrow. 


wiped  dr}-.  A  pouching  will  be  noticed  above,  and  is 
formed  by  the  peritoneum.  We  open  the  ca\ity  with 
one  snip  of  the  scissors,  applied  not  against  this  pouch, 
but  where  it  is  attached  to  the  uterus.  One  finger  is 
inserted  for  exploration,  and  to  break  up  adhesions. 
Should  there  not  be  suffi- 
cient room  for  this,  the 
two  index-fingers  are  in- 
troduced and  laterally 
separated.  This  will 
open  the  peritoneum  as 
wide  as  the  lateral  inci- 
sion in  the  mucosa.  Plen- 
ty of  room  is  now  ob- 
tained for  working  with 
two  fingers.  When  all 
adhesions  are  broken  up, 
a  large  iodoformized  pad, 
to  which  is  attached  a 
string,  is  introduced  into 
the  pelvis,  and  the  patient 
thrown  into  Trendelen- 
burg's position.  She  is 
still  on  the  back  with 
legs  flexed  on  abdomen. 
AVhile  she  is  in  Trendelen- 
burg's position,  the  intes- 
tines are  made  to  enter  the  abdominal  ca\dty,  and  an- 
other large  pad,  similar  to  the  first  one,  is  introduced. 
The  table  is  now  lowered  to  the  horizontal.  The  Pean 
retractor  is  inserted  into  the  pelvis  with  its  upper  end 
against  the  gauze,  and  the  uterus  is  pushed  up  behind 
the  symphysis  by  using  the  Pean  trowel.  In  this  way 
we  look  directly  into  the  pelvis.  The  adnexa  can  be  in- 
spected and  drawn  into  the  vagina.  If  they  require  at- 
tention, it  may  be  given  them,  or  one  may  be  removed. 
In  other  words,  a  part  of  that  work  which  we  apply  to 
the  adnexa  through  the  abdomen  can  be  applied  through 
the  vagina,  provided  we  employ  the  Trendelenburg 
position,  so  that  we  can  see  what  we  are  doing,  and  not 
have  the  intestines  prolapsing  into  the  vagina.  Satisfied 
that  the  uterus  is  free,  I  now  pack  the  organ  with  iodo- 
form gauze.  A  wad  of  iodoform  gauze  with  string  and 
large  enough  to  fill  the  opening  in  the  peritoneum  is 
now  prepared  and  held  in  readiness.  The  posterior  re- 
tractor is  drawn  down,  so  that  the  edge  of  the  vaginal 
incision  may  be  seen  and  grasped  with  forceps.  The 
two  or  more  pads  in  the  pelvis  are  now  withdrawn  and 
the  wad  of  gauze  inserted  into  the  opening  just  within 
the  cut  edges.  The  uterus  and  gauze  are  anteverted  en 
masse  by  Brandt's  method,  great  care  being  exercised 
lest  we  displace  the  wad  of  gauze.  If  the  gauze  be  not 
in  the  incision,  the  cul-de-sac  will  not  be  drained,  and 
no  lymph  will  form  posterior  to  the  cervix.  If  the 
gauze  be  pushed  up  too  far  behind  the  cervix,  it  will 
reach  the  tubal  ends,  and  they  will  become  implicated 
in  the  lymph  eitusion.  .-K  good  deal  of  manual  dex- 
terity is  required  to  replace  the  uterus  and  leave  the 
gauze  wad  in  just  the  proper  position  behind  the  cer- 
vix. Gauze  is  now  packed  in  the  vagina  in  such  a  way 
as  to  keep  the  cervix  forced  high  in  the  pelvis.  To  ac- 
complish this  the  space  occupied  by  the  bladder  must 
be  encroached  upon,  so  as  to  have  one  pillar  of  gauze 
from  the  cervix  to  the  symphysis.  This  necessitates 
filling  the  vagina  pretty  snugly. 

After-treatment. — Catheter  every  three  hours  for  a 
day,  after  which  the  patient  can  take  care  of  the  blad- 
der herself,  usually.  After  the  first  day  the  catheter 
may  be  used  every  four  to  six  hours,  not  more  than 
four  ounces  of  urine  being  allowed  to  accumulate  at 
one  time,  unless  the  patient  can  empty  the  bladder 
when  that  quantity  of  urine  accumulates.  The  bowels 
are  to  be  moved  in  forty-eight  hours,  earlier  if  there 
has  been  pus  in- the  uterus  or  pelvis.  I  use  half  an 
ounce  of  Rubinat  water,  with  an  equal  quantity  of  the 
seltzer,  until  ten  doses  are  taken  or  the  bowels  move. 
Enemata  are   not   allowed.      After   the   bowels   have 


July   20,  1895] 


MEDICAL   RECORD. 


// 


moved,  the  patient  may  be  permitted  any  light  diet — 
toast,  eggs,  gruel,  scraped  beef,  etc.  The  lower  pieces 
of  gauze  in  the  vagina  may  be  changed  on  the  third 
day,  as  they  are  probably  soiled  by  urine.  If  there  has 
been  much  pus  in  the  uterus,  the  uterine  packing  is 
withdrawn  at  this  time.  At  any  rate,  it  is  to  come  out 
when  the  vaginal  gauze  is  removed,  and  is  not  to  be 
renewed.  But  care  must  be  taken  that  the  vaginal 
gauze  be  renewed  as  carefully  and  as  snugly  as  the  first 
was  applied.  The  wad  of  gauze  in  the  cul-de-sac  is 
not  disturbed  for  from  seven  to  ten  days.  This  is  pos- 
sible with  one  kind  of  gauze  only.^  In  removing  this 
wad  of  gauze  Sims's  position  is  preferable.  The  wad 
should  be  removed  with  great  gentleness,  and  the  cer- 
vix should  be  supported  and  not  allowed  to  descend. 
A  wad,  smaller  but  similar  to  the  first,  is  introduced 
into  the  opening  and  the  vagina  again  filled  with  gauze. 
The  patient  is  allowed  out  of  bed  on  the  tenth  day.  A 
week  after  the  first  dressing  another  is  made,  and  five 
days  later  this  is  changed.  Two,  or  at  most  three, 
dressings  to  the  cul-de-sac  are  made,  but  the  vagina  is 
kept  packed  to  support  the  uterus  for  a  month.  I  usu- 
ally select  two  days  after  the  menstruation  to  operate, 
thus  gaining  abundance  of  time  for  after-treatment. 
After  the  cul-de-sac  has  closed,  vaginal  dressings  of 
tampons  soaked  in  ichthyol,  ten  per  cent.,  and  boro- 
glyceride,  ninety  per  cent.,  are  used  if  the  uterus  be 
enlarged. 

What  the  Operation  Accomplishes. — The  adhesions 
are  severed  and  the  possibly  occluded  tubes  opened. 
The  organ  is  lightened  by  curettage  and  cer\'ix  opera- 
tion, one  or  both.  At  the  same  time,  the  cervix  is 
maintained  in  such  an  elevated  position  that  the  intra- 
abdominal pressure  must  be  behind  the  corpus,  thus 
throwing  the  organ  well  forward.  By  a  slender  band 
of  false  membrane,  produced  by  hysterorrhaphy,  we 
correct  retroversion.  My  operation  does  the  same 
thing  by  a  dense  mass  of  lymph  about  the  utero-sacral 
ligaments.  My  operation  leaves  the  corpus  uteri  free, 
does  not  invade  the  bladder  space,  and  merely  corrects 
errors  in  the  relations  between  the  pelvic  viscera.  All 
other  operations  substitute  some  other,  perhaps  less 
serious,  malposition  for  the  adherent  retroversion  or 
flexion. 

I  first  applied  this  operation  six  months  ago,  and 
have  used  it  seven  times.  All  cases  had  one  or  both 
adnexa  occluded.  One  had  a  small  cystoma  associ- 
ated, measuring  two  inches  in  diameter,  and  but  one 
(the  last)  presented  pus  in  one  tube.  All  operations 
were  made  in  multipara  except  one.  The  exception 
was  a  case  of  gonorrhoeic  infection. 

Two  have  been  examined  by  Dr.  Jacobs,  of  Brus- 
sels, and  Dr.  Etheridge,  of  Chicago.  Two  have  been 
repeatedly  seen  and  examined  by  the  gentlemen  of  the 
Polyclinic.  The  last  operation  is  too  recent  to  report 
the  result,  except  that  she  has  nicely  recovered."  In 
every  case  the  uterus  maintains  an  anteverted  position. 
The  operation  is  offered  as  a  substitute  for  all  other 
procedures  applied  to  these  cases.  It  is  not  a  blind 
piece  of  work,  but  every  step  is  under  the  eyes'  guid- 
ance. It  but  retraces  the  steps  along  which  the  deform- 
ity occurred  —  descent,  retroposition,  infection  —  and 
corrects  each.  Plastic  work  upon  perineum  and  vagina 
is  not  to  be  overlooked,  but  must  be  applied  as  in  all 
other  conditions  demanding  it. 


Artificial  Fever  for  Insanity. — An  alienist  in  Vienna 
has  been  treating  insanity  by  inducing  fever  through 
the  injection  of  tuberculin.  With  each  rise  of  tem- 
perature there  is  an  improvement  in  the  mental  condi- 
tion, and  this  improvement  gradually,  through  constant 
repetition,  becomes  permanent. 

•  New  York  Medical  Journal,  May  18,  1895. 

■  This  lady  has  been  seen  and  examined  by  her  physician  since  the 
operation.  It  is  now  five  weeks  since  the  operation,  and  she  is  up, 
without  vaginal  support,  and  the  uterus  in  perfect  position. 


THE  TREATMENT  OF  FIBRO  -  MYOMATOUS 
UTERI  REQUIRING  HYSTERECTOMY  BY 
A  COMBINED  VAGINO-ABDOMINAL  METH- 
OD OF  ENUCLEATION  WITH  INDIVIDUAL 
LIGATION  OF   BLEEDING  VESSELS  ONLY. 

By  J.   COPLIN  STINSON,   M.D.,  CM., 

H.«IILTOy,    OST.\aiO. 
U\TE  HOUSE  SrRGEON",    SEW  YORK   POST-GR.\DtJ.\TK    HOSPrTAX.. 

Technique  of  the  Operation. — The  patient  is  prepared 
as  for  any  vagino-abdominal  operation.  After  anaes- 
thesia is  complete,  the  patient  is  placed  in  the  lithot- 
omy position,  and  the  perineum  is  retracted  by  Ede- 
bohl's  retractor  ;  lateral  retractors  are  frequently  also 
of  great  assistance.  The  first  step  consists  in  an  ex- 
ploratory incision  into  Douglas's  sac  to  establish  or  con- 
firm the  diagnosis  ;  next  is  circumcision  of  the  cervix, 
made  as  near  as  practicable  to  the  lower  end  of  the 
cervix  ;  hemorrhage  from  the  vaginal  arteries  is  thus 
reduced  to  the  minimum  ;  posteriorly  the  incision  is 
continuous  with  that  into  Douglas's  sac.  The  incision 
is  carried  through  mucous  into' submucous  tissue ;  now 
the  cer^'i-x  is  seized  with  vulsella  and  drawn  down  well 
into  the  vagina  and  then  separated  from  its  surround- 
ings by  blunt  dissection,  aided  at  times  by  snips  with 
the  scissors.  The  forceps  drag  down  the  cervix,  draw- 
ing the  tissues  adjacent  to  this  organ  taut,  while  the 
scissors  di%'ide  them  as  close  as  possible  to  it.  Now 
dissect  off  the  bladder  by  keeping  close  to  the  anterior 
surface  of  the  uterus  —  if  it  is  possible  to  go  high 
enough,  open  the  anterior  peritoneal  pouch,  or  it  may 
be  opened  from  above  later.  By  keeping  close  to  the 
uterus  with  blunt  dissection  aided  at  times  by  snips 
from  the  scissors,  you  separate  the  broad  ligaments  on 
each  side  as  high  as  you  can.  In  carrying  on  the 
above  dissection,  if  any  vessel  should  spurt  seize  it  at 
once  with  the  forceps  and  ligate  with  a  transfixion  catgut 
ligature.  The  object  in  freeing  the  cervix  and  lower 
portion  of  the  uterus  from  below  is  to  simplify  the 
further  steps  of  the  operation  from  above. 

Next  the  abdominal  incision  is  made  to  expose  the 
fundus,  tubes,  ovaries,  and  fibro-myomatous  masses. 
By  blunt  dissection,  aided  at  times  by  snips  with  the 
scissors,  you  ablate  the  tubes  and  ovaries  by  carrying 
your  dissection  as  close  as  possible  to  these  structures. 
Bleeding  vessels  are  ligated  with  fine  catgut.  Next 
continue  the  dissection  close  to  the  uterus,  till  the  broad 
ligaments  are  separated  on  both  sides  down  to  the  line 
of  separation  from  below.  Now,  if  the  bladder  has  not 
been  separated  from  below,  you  may  partly  distend 
this  organ  with  a  weak  boracic  solution  ;  then,  about 
one-half  an  inch  above  its  attachment  to  the  uterus,  an 
incision  is  made  and  the  remainder  of  the  bladder  sep- 
arated. 

Two  principles  are  involved  in  the  satisfactory  per- 
formance of  the  combined  vagino-abdominal  enuclea- 
tion of  a  fibro-myomatous  uterus.  The  first  is  to  dis- 
sect as  close  as  possible  to  the  uterus,  tubes,  and 
ovaries.  Bleeding  is  thus  reduced  to  the  minimum. 
By  this  means  you  divide  only  arterioles  or  capillaries, 
the  oozing  from  which  stops  almost  at  once.  The  sec- 
ond is  to  keep  your  immediate  dissection  well  in  \-iew, 
and  if  any  arterj'  be  divided  to  catch  it  at  once  with 
forceps  and  ligate  with  a  transfixion  catgut  ligature. 
Enucleation  with  simple  ligation  of  the  bleeding  vessel 
was,  as  a  routine  practice,  first  done  by  Pratt,  of  Chi- 
cago, to  whom  great  credit  is  due,  and  the  method 
justly  bears  his  name. 

After  separation  of  the  bladder  from  the  anterior 
surface  of  the  uterus  with  a  few  snips  of  the  scissors, 
uterus,  the  fibro-myomata,  tubes,  and  ovaries  are  lifted 
out  of  the  pelvis.  '  Now  the  peritoneum  of  the  pelvic 
floor  is  closed  with  a  running  catgut  suture,  but  if  there 
are  indications  for  drainage,  then  the  floor  is  partially 
closed  and  the  deep  pelvis  is  lightly  packed  with  gauze, 
the  ends  of  which  are  brought  down  into  the  vagina. 


78 


MEDICAL   RECORD. 


[July  20,  1895 


Next  the  abdominal  wall  is  closed  in  separate  layers 
with  chromatized  catgut  or  tendon  suture,  and  the 
dressing  is  applied.  Strips  of  gauze  are  placed  in  the 
raw  space  between  the  vagina  and  closed  or  partly 
closed  peritoneum,  and  finally  more  of  the  same  gauze 
is  placed  in  the  vagina.  A  gauze  pad  is  placed  over 
the  vulva.  The  after-treatment  is  simple.  Twelve  hours 
after  operation  the  patient  is  given  sips  of  milk  and  Vichy 
if  there  is  no  vomiting,  and  in  a  few  days  is  placed  on 
regular  diet.  The  urine  is  drawn  till  the  fourth  day, 
when  the  gauze  is  removed  from  the  vagina.  After 
that  the  patient  empties  her  bladder,  and  receives  a 
vaginal  douche  of  sterilized  water  or  i  to  3,000  subli- 
mate solution  after  each  urination.  After  the  removal 
of  the  gauze  a  small  strip  is  introduced  ;  this  is  changed 
in  three  days.  Twenty-four  hours  after  the  operation 
the  patient  receives  an  enema  of  Rochelle  salts,  |  iv.  ; 
olive  oil,  §  ij.  ;  glycerine,  §jss.  ;  enema,  Ojss.  If  this 
does  not  thoroughly  empty  the  bowels  of  flatus  and 
produce  a  free  movement,  then  salines  are  administered 
by  the  mouth.  Usually,  however,  the  enema  is  suffi- 
cient. 

The  abdominal  wound  is  usually  dressed  on  the  sev- 
enth day,  unless  there  is  some  reason  for  interference. 
By  the  end  of  three  weeks  the  patient  is,  as  a  rule,  able 
to  leave  her  bed.  The  vagino-abdominal  method  of 
enucleation  is  commended  in  all  cases  where  hysterec- 
tomy is  necessary  for  the  removal  of  fibro-myomata, 
except  in  those  cases  where  the  tumors  do  not  crowd 
into  the  pelvis  but  pull  the  cervix  and  vagina  toward 
the  upper  pelvic  cavity,  so  that  the  portio  vaginalis  can 
hardly  be  reached  by  the  examining  finger;  here  the 
whole  work  of  enucleation  must  be  done  through  the 
abdominal  incision.  The  vagino-abdominal  method 
of  enucleation  is  to  be  preferred  to  all  other  methods 
of  hysterectomy — as  it  is  the  safest  and  simplest ;  there 
is  no  danger  from  hemorrhage  nor  from  sloughing,  as 
there  is  no  constricting  of  tissues  by  ligatures  or  clamps. 
There  is  no  offensive  septic  vaginal  discharge  due  to 
sloughing  of  the  stumps  in  the  vagina.  There  is  no 
danger  of  tying  the  ureters,  and  the  chances  of  injury  to 
the  bladder  are  very  slight ;  shock  is  not  so  often  noted, 
and  the  danger  of  sepsis  is  reduced  to  the  minimum. 

148  Jambs  Strebt. 


ANTIPHTHISIN.' 
By  CHARLES  DENISON,  A.M.,   M.D., 

What  I  know  about  antiphthisin  I  have  learned  since 
the  middle  of  last  December  ;  and  I  have  to  thank  Dr. 
Edwin  Klebs,  the  author  of  it,  and  Dr.  Karl  von  Ruck, 
of  Asheville,  N.  C,  for  many  courtesies  received  which 
enable  me  to  make  a  pretty  fair  showing  for  the  rem- 
edy. Yet  I  cannot  consider  the  remedy  as  absolutely 
perfect,  nor  the  techni(jue  of  its  administration  as  un- 
questionably determined.  One  ought  to  have  a  longer 
time  of  observation,  and  a  larger  series  of  cases  from 
which  to  draw  conclusions,  before  presenting  a  conclu- 
sive report.  Therefore  please  consider  this  as  pre- 
liminary to  a  finished  report. 

Antiphthisin  is  very  much  like  tuberculocidin 
(Klebs),  though  differently  prepared.  Instead  of  being 
rnade  from  tuberculin,  it  is  made  directly  from  the  ten- 
times-concentrated  culture  fluid  of  tubercle  bacilli,  the 
toxic  principles  which  tuberculin  contains  being  sup- 
posedly excluded.  It  is  thus  claimed  to  represent  the 
soz-albumin — the  probable  germicidal  property  in  tu- 
berculin— as  much  as  exists  in  an  etpial  quantity  of 
tuberculin  ;  and  its  special  value  depends  upon'  the 
fact  that  a  larger  dosage  is  allowable  without  the  injuri- 
ous toxic  effects  to  be  expected  from  large  doses  of 
tuberculin. 
;^  According  to    Professor  Klebs    "  the    separation  of 

'  Report  on  Professor  Klebs's  New  Tuberculin  Derivative  and  Some 
01  the  Cases  Treated. 


tuberculin  (representing  the  tubercle  bacillus,  culture 
fluids,  and  ripe  cultures)  into  its  distinct  constituents 
gives  : 

"A.  A  tox-albttmin,  precipitated  by  sodic  iodide  of 
bismuth. 

"  Physiological  effects- — fever,  malaise,  headache,  gen- 
eral aching,  nausea,  diarrhoea,  lung  congestion,  cough. 

"  Therapeutic  effects  in  small  doses  —  stimulant  to 
tubercular  tissue. 

"  B.     Alkaloids,  soluble  in  alcohol. 

^^Physiological  effects — depression  of  heart  and  circu- 
lation, diminished  arterial  pressure,  capillary  thrombo- 
sis, hemorrhagic  effusions  in  parenchymatous  organs. 

"  C.     A  soz-albumin  (antiphthisin). 

"  Physiological  effects — none  in  doses  up  to  10  c.c.  ; 
destroys  tubercle  bacilli  in  the  test-glasses. 

"  Therapeutic  effects  in  animal  experiments — confers 
a  slight  degree  of  immunity  to  tubercular  infection. 
Causes  resorption  of  tubercular  tissue  and  conversion 
of  such  to  the  form  of  tissue  from  which  it  proliferated. 
Obtains  the  complete  cure  of  '  guinea-pig  tuberculosis  ' 
in  the  human  subject.  Tubercle  bacilli  degenerate 
and  disappear,  tubercular  infiltrations  are  resorbed, 
and  the  consolidations  clear  up.  Fever  is  diminished 
or  disappears  owing  to  destruction  of  bacilli  and  re- 
sorption of  tubercular  tissue.  Secondary  fever  may 
occur,  however,  from  its  effects  upon  tubercular 
lesions. 

"Z>.  An  albuminoid  substance,  obtained  from  the 
bodies  of  the  tubercle  bacilli. 

"  Physiological  effects  in  animals — confers  immunity 
to  a  much  greater  degree  than  does  raw  tuberculin. 

Therapeutic  effects — not  fully  determined  and  now 
the  subject  of  experiment.  In  the  healthy  human  be- 
ing, harmless  in  doses  up  to  3  c.c.  Not  yet  tried  in 
tuberculosis." 

This,  to  my  mind,  is  the  most  lucid  description  yet 
given  of  the  ingredients  of  tuberculin  or  the  combined 
substances  from  which  it  is  made.  And  the  separation 
of  the  "soz-albumin,"  if  accomplished  as  Professor 
Klebs  claims,  entitles  him  to  great  credit  ;  for  many 
of  my  own  cases  seem  to  furnish  a  verification  of 
his  statement  that  the  major  part  of  the  germicidal 
influence  of  tuberculin  resides  in  this  soz-albumin 
or  antii)hthisin. 

When,  last  December,  I  was  asked  to  give  the  rem- 
edy a  thorough  trial,  I  was  requested  by  Professor 
Klebs  "  that  you  will  not  try  the  remedy  except  in  cases 
of  pure  tuberculosis,  and  exclude  from  the  treatment, 
for  the  present,  cases  of  mixed  infection,  and  septic 
cases,  and  of  course  all  such  as  have  amyloid  or  are  so 
far  reduced  physically  that  they  necessarily  must  die  of 
the  complications  or  exhaustion  already  present." 

In  regard  to  such  exclusion  I  must  explain  that  it  is 
very  hard  to  make  it  work.  For  instance,  there  are  very 
few  cases  which  come  to  a  health  resort  like  Colorado 
in  whom  there  is  not  some  "  mixed  infection."  There- 
fore, as  my  object  has  been  to  help  my  ])atients  more 
than  to  prove  the  uniform  efficacy  of  the  remedy,  I 
have  followed  my  natural  inclination  to  give  some  al- 
most hopeless  invalids  a  chance.  I  conceive  that  the 
best  test  of  a  remedy  is  not  that  it  will  work  well  (as  is 
claimed  for  all  so-called  cures,  climatic  or  otherwise) 
in  incipient  non-febrile  cases,  or  as  usually  erroneously 
stated,  "in  the  first  stages  ;  "  but  the  proper  test  is  that 
it  has  some  specific  effect  upon  the  disease  as  we  most 
often  find  it  ;  and  that  is  after  there  has  been  more  or 
less  breaking  down  of  lung  tissue.  Climate,  with  right 
living,  can  take  care  of  those  other  cases,  but  we  need 
a  remedy  which  without  injury  to  a  far-gone  consump- 
tive will  give  him,  on  the  lines  of  more  or  less  pemia- 
nent  immunity  to  tuberculosis,  the  benefit  of  his  ten  to 
thirty  per  cent,  chance  of  arresting  his  disease,  if  in  fact 
that  slim  chance  is  his.  .1  believe  that  somewhere, 
within  the  range  of  the  remedies  here  discussed,  that 
boon  resides,  if  we  can  only  get  at  it ;  and  antiphthisin 
seems  to  be  the  nearest  approach  to  it  yet  proposed. 


July  20,  1895] 


MEDICAL    RECORD. 


79 


It  may  here  be  asked,  How  about  "  the  anti-tubercle 
serum  "  treatment  lately  introduced  by  Dr.  Paul  Paquin, 
of  St.  Louis  ?  I  have  not  investigated  that  method 
sufficiently  to  indorse  it  as  proven,  but  I  was  present 
at  the  late  meeting  of  the  American  Medical  Associa- 
tion when  Dr.  Paquin  presented  three  patients  treated 
with  his  horse  serum,  and  after  the  reading  of  his  paper 
I  invited  him,  as  well  as  Dr.  von  Ruck,  to  my  hotel, 
where  for  about  two  hours  we  e.xamined  these  cases 
and  their  histories.  Dr.  von  Ruck  was  inclined  to  be- 
lieve the  good  effects  noted  were  due  to  a  transmitted 
"tuberculin  effect,"  but  I  could  make  nothing  satisfac- 
tory out  of  them  because  there  was  nothing  correspond- 
ing with  my  own  usual  examination  with  which  to  make 
comparison.  The  origtnal  examinations  and  histories 
had  been  made  by  different  interns  in  the  hospital,  and 
essential  points  were  not  noted  and  classified.  For  in- 
stance, there  had  been  no  attempt  even  to  determine 
the  daily  fevettange  and  its  change  under  trealment. 
However,  admitting  a  favorable  condition  of  arrest, 
perhaps,  there  wa^  no  positive  cure  in  any  of  these 
cases,  for  both  Dr.  von  Ruck  and  I  found  infiltrations 
in  all,  and  the  evidence  of  softening  (in  progress  or  re- 
cent) in  one.  How  much  of  the  good  effect  was  to  be 
attributed  to  the  horse  serum  alone,  and  how  much  to 
the  supposed  immunizing  of  it,  was  impossible  to  tell. 

Last  year  I  experimented  myself  somewhat  with  dog 
serum,  the  healthy  puppy  having  been  thoroughly 
treated  previously  with  tuberculin,  but  I  could  get  no 
certain  good  effect  in  addition  to  that  of  the  tuberculin 
thus  transmitted  through  the  dog's  blood.  Afterward 
I  inferred  from  evidence  in  Sternberg's  "  Bacteriology  " 
that  such  an  experiment  as  I  had  tried  must  give  an 
uncertain  result,  for  toxic  germs  sent  through  the  cir- 
culation of  an  animal  are  variously  affected  according 
to  that  animal's  resistance  or  other  conditions.  In  fact 
we  learn  from  the  same  authority  that  attenuated  cult- 
ures of  some  germs  may  be  re-established  as  to  viru- 
lency  by  this  procedure.  Probably  the  immunity  ef- 
fect is  an  antitoxin  influence  created  in  the  blood  of 
the  living  subject  operated  upon. 

As  to  the  use  of  the  serum  from  dogs  previously 
treated  with  tuberculin  or  the  culture  fluids  of  tubercle 
bacilli,  I  have  lately  learned  that  these  experiments 
have  also  been  tried  in  Germany  and  no  decided  results 
were  obtained.  This  is  one  of  the  interesting  phases 
of  this  important  subject  which  we  have  to  acknowledge 
is  still  in  a  formative,  undetermined  stage. 

To  return  to  the  consideration  of  antiphthisin,  let 
us  discuss  its  action  in  connection  with  the  study  of  two 
or  three  cases  selected  from  the  twenty-three  I  have 
thus  far  had  under  treatment. 

Case  I.,  November  12,  1894. — C.  R ,  college  stu- 
dent, aged  twenty.-two,  from  Terre  Haute,  Ind.;  height, 
6  feet  ;  no  inherited  predisposition  to  tuberculosis, 
though  not  of  strong  constitution  ;  was  in  college  the 
years  1890  and  1891,  but  had  to  leave  because  of  poor 
health.  A  year  ago  was  treated  for  catarrh.  Last  sum- 
mer and  spring  had  a  cough  and  yellow  expectoration. 
Six  weeks  ago  had  pains  in  left  chest,  though  not  sick  in 
bed.  Yellow  expectoration  for  a  month  ;  less  now.  Tu- 
bercle bacilli  were  found  in  his  sputum  a  month  ago. 
Arrived  in  Colorado  three  days  ago,  and  felt  some  slight 
chest  pains  at  this  altitude.  Weight  in  health,  165 
pounds  ;  now  155  pounds.  General  condition  fair  ; 
pulse,  96  ;  respiration,  20  ;  temperature,  normal  ;  s])i- 
rometrical  record,  150  cubic  inches,  three-fourths  ol 
what  it  ought  to  be  ;  manometer  record,  65  mm.;  chest 
expansion,  33  and  34^  inches  ;  right  side  about  three- 
fourths  and  left  one-fourth  inch,  measured  separately. 

Physical  Examination. — Dulness  at  both  apices,  front 
and  rear,  chiefly  left,  with  a  dilatation  of  left  main 
bronchus  and  broncho  -  vesicular  respiration  around 
this  ;  also  some  of  same  sound  and  exaggerated  whis- 
per inner  part  of  right  mammary  region.  Dulness  de- 
cided and  pleuritic  friction  base  of  left,  especially  rear. 
Diagnosis. — Broncho-fibro-tuberculosis  with  pleurisy. 


Treatment. — A  blood  alterative  (syrup  of  hydriodic 
acid),  the  "  inhaler  and  exhaler,"  and  he  will  go  to 
McCoy's,  over  in  the  mountains. 

April  3,  1895. — Been  at  McCoy's.  Caught  cold  and 
was  ill  for  two  weeks  last  of  February,  with  pleurisy, 
etc.  Then  picked  up  ;  weight  now,  166  pi^^unds. 
Looks  better  ;  coughs  and  raises  very  little.  l)ysp- 
noea  less.  Spirometrical  record,  155  cubic  inches, 
and  manometer,  85  mm.  Pulse,  92  ;  respiration,  22, 
and  temperature,  ()<)}i°  F.,  3  p.m.  Expansion,  33  and 
7,6%  inches,  a  decided  gain  on  both  sides.  But  there 
is  a  shrunken  sjiot  below  the  left  clavicle  and  almost 
"  cracked  metal  "  there  ;  the  broncho-vesicular  respira- 
tion before  noted  remains.  The  lower  left  lobe  has 
opened  up  somewhat,  but  there  are  mucous  rales  in 
infra  -  scapular  region,  increased  on  coughing,  and 
twenty  bacilli  to  the  field  are  found.  He  has  been 
climbing  hills  and  taking  good  care  of  himself,  yet  the 
lung  is  simply  opened  up  and  tuberculosis  is  not  elim- 
inated. Recommend  additional  treatment  by  anti- 
phthisin. This  was  commenced  in  about  a  week,  and 
the  following  is  the  record  : 

April  23d. — Reached  nearly  three  cubic  centimetres 
antiphthisin  to-day  by  the  rectal  method  ;  no  great 
reactions.  Physical  signs  are  better.  Bacilli  only  four 
to  field  after  treatment  of  nine  days. 

May  3d. — Reached  over  four  cubic  centimetres  anti- 
phthisin ;  no  bacilli  to  field  now.  Semblance  of  cav- 
ity under  left  clavfcle  much  less,  lung  is  clearer,  and 
the  mucous  rales  on  coughing  are  heard  lower  down  in 
the  regr  of  left  lung-  Weight,  162  pounds  ;  looks  welt; 
can  play  tennis  two  hours  a  day. 

May  24th. — At  longer  intervals  worked  up  to  over 
five  cubic  centimetres  antiphthisin  for  the  last  dose 
to-day.  Has  continiied  to  improve,  and  now  there  is 
no  expectoration  whatever.  Looks  and  feels  better. 
Pulse,  72  ;  respiration,  18,  and  temperature  normal. 
Spirometrical  record,  160  cubic  inches  ;  manometer, 
85  mm.  Physical  examination  shows  decided  improve- 
ment. Positively  no  "  cracked  metal  "  left  apex,  front. 
Lung  has  cleared  up  nicely,  and  the  mucous  rales  on 
coughing  at  base  of  left  are  not  so  marked,  and  the  pa- 
tient is  here  to  verify  by  his  good  appearance  his  im- 
proved condition. 

If  we  had  wished  for  a  test  case  for  the  trial  of  anti- 
phthisin, we  could  not  have  done  better,  I  judge,  than 
to  have  chosen  this  gentleman,  who  if  he  had  any 
"  mixed  infections  "  had  eliminated  the  same  in  the 
mountains,  and  who  evidently  had  no  concealed  tuber- 
cular degenerations  in  out-of-the-way  lung  spaces,  un- 
doubtedly the  bane  of  many  doubtful  or  poorly  under- 
stood cases.  The  specific  could  only  reach  the  source 
of  tuberculosis  in  living  tissues,  and  that,  we  must  re- 
member, is  as  far  as  it  should  be  expected  to  reach. 
There  being  nothing  further  to  be  eliminated,  and  an 
excellent  vital  resistance  to  aid  this  process,  the  good 
result  is  easily  explained,  especially  to  one  who  has 
other  evidences  of  the  germicidal  influence  of  anti- 
phthisin. We  do  not  now  know  how  much  of  immu- 
nity accompanies  this  germicidal  effect,  or  how  it  is  as- 
sociated with  it,  but  it  is  reasonable  to  believe  that 
there  is  something  of  this  nature  in  antiphthisin, 
which,  according  to  my  experience,  is  a  decided  prop- 
erty in  crude  tuberculin. 

I  have  chosen  the  foregoing  case  to  show  how 
nicely  the  new  remedy  works  in  pure  tuberculosis,  even 
admitting  the  great  aid  of  the  climate  and  exercise. 

I  choose  the  next  case  to  show  that  a  like,  though 
not  as  great,  care  is  needed  in  the  administration  of 
this  soz-albumin  as  in  giving  the  crude  tuberculin  con- 
sidered as  a  tox-albumin  ;  in  other  words,  to  show  not 
only  that  every  patient  should  be  individualized,  but 
that  the  effects  of  these  remedial  agents  vary  in  differ- 
ent individuals,  and  that  the  amount  of  organic  matter, 
even  though  it  is  weighed  and  definite,  admitted  to  be 
in  antiphthisin,  is  enough  to  give  decided  systemic  and 
febrile   reactions  in  certain  cases.     This  is  contrary  to 


8o 


MEDICAL    RECORD. 


[July  20,  1895 


the  announcement  of  the  new  remedy,  but  this  only 
militates  against  its  use  in  treatment  to  the  extent  that 
it  is  not  yet  a  means  to  be  universally  given  out  to 
everyone  who  takes  a  notion  to  try  it.  Without  the 
precautions  the  inventor  of  it  is  taking  in  this  regard 
there  is  danger  enough  that,  through  ignorant  and  ill- 
advised*Tlse,  much  of  the  odium  which  befell  tuberculin 
would  attach  itself  to  antiphthisin  also. 

Case    IL,  February    21,    1895. — Mr.   A.  C.  G , 

aged  forty  ;  from  Palmyra,  N.  Y.  In  the  commission 
business;  married  ;  height,  5  feet  11^  inches;  no  in- 
heritance. Previous  to  present  sickness  health  good, 
though  he  is  of  a  very  nervous  temperament  and  has 
been  much  worried  about  business.  Have  never  seen 
anyone  so  alarmed  and  discouraged  because  bacilli 
were  found  in  his  sputum,  as  has  been  done  by  Dr. 
Lobinger  in  this  case  before  he  consulted  me. 

The  history  is  that  in  June,  1894,  he  received  some 
hurt  in  his  chest,  followed  by  a  cough  during  July, 
which  became  worse  in  August,  and  by  the  end  of 
August  he  was  expectorating  yellow  matter  and  having 
some  night*sweats.  In  November  he  caught  cold,  and 
this  was  followed  by  profuse  expectoration,  though  he 
was  not  at  any  time  sick  in  bed.  Took  considerable 
whiskey  and  milk  and  did  not  lose  weight.  Weight 
now  155  pounds.  Arrived  in  Colorado,  January  7, 
1895,  not  much  appreciating  the  altitude.  Sputum 
straw-colored,  less  than  a  drachm  a  day.  Pulse,  88  ; 
respiration,  16;  temperature,  normal  (a.m.);  spiromet- 
rical  record,  220  cubic  inches  ;  manometer,  50  mm.  ; 
expansion,  32}^  and  35^  inches ;  left  ^  inch  less 
than  right  side. 

Physical  Examination.  —  Dulness  at  both  apices, 
especially  in  left  infra-clavicular  region,  below  which 
and  in  left  mammary  region  there  is  a  broncho-vesicu- 
lar respiration  and  some  "  cog-wheel  "  breathing.  This 
place  under  left  clavicle  proved  to  be  a  concealed 
tubercular  infiltration  spot,  which  cleared  out  and  be- 
came a  small  dry  cavity  under  the  treatment  which 
followed. 

February  26,  1895. — Commenced  the  treatment  by 
antiphthisin  hypodermically.  By  the  time  I  had  in- 
creased to  I  c.c.  there  was  the  distinct  reaction  sound, 
similar  to  the  healing  sound  from  tuberculin,  in  the 
left  infra-clavicular  region,  following  less  marked  re- 
action sounds  in  response  to  smaller  doses  below  and  to 
the'right  of  this  spot,  also  in  the  axillary  and  interscap- 
ular regions.  There  were  also  temperature  rises  and 
general  reaction  results  in  response  to  1%,  iji,  and  to 
the  2  c.c.  doses,  till  finally  his  extreme  susceptibility 
was  overcome  by  the  tolerance  created  to  the  remedy. 
This  was,  during  the  last  of  the  treatment,  much 
aided  by  recourse  to  the  rectal  method  of  administra- 
tion.    The  record  of  this  case  goes  on  to  state  : 

May  3d. — The  left  lung  has  much  cleared  up.  The 
small  cavity  is  clear  and  seems  to  have  moved  up  un- 
derneath the  clavicle  and  the  cog-wheel  respiration 
below  has  disappeared.  Have  had  to  progress  very 
cautiously  with  the  treatment. 

May  1 8th. — Has  reached  3  c.c.  antiphthisin.  Weight 
now  155  pounds  and  he  looks  and  w  much  better.  The 
breath  sounds  are  good  and  dry — a  few  bronchial  (?) 
rales  in  left  interspinatus  region  on  coughing  ;  not  con- 
stant, however.  The  cavity  in  top  of  lung  has  shrunken 
to  a  smaller  spot  underneath  the  centre  of  the  clavicle, 
and  the  breathing  is  nearly  normal  over  the  rest  of  this 
lung. 

After  this  the  improved  condition  continued  till  the 
last  of  May,  when  the  patient  was  (temporarily)  dis- 
charged to  go  East  and  bring  his  family  out  to  Colorado 
to  reside.  The  bacilli,  which  had  been  one  to  four  to 
the  field  in  March,  became  "  involuted,"  as  is  usual  under 
this  treatment,  in  April  and  not  easily  found  ;  and  in 
four  microscopical  examinations  made  after  April  25th 
up  to  May  25th  none  were  found. 

I  believe  this  case  is  in  a  much  better  condition  than 
that  of  mere  "  arrest."     There  is  certainly  an  assurance 


of  health  in  the  cleared-up  condition  of  his  lung,  the 
improved  state  of  his  feelings  and  general  health,  which 
bespeak  a  degree  of  immunity  which  it  is  hoped  will 
last  him  for  some  time. 

The  unusual  local  febrile  and  systemic  reactions  to 
antiphthisin  shown  in  this  case  are  to  be  attributed  to 
the  fact,  perhaps,  that  the  concealed  condition  of  the 
tubercular  spot  in  the  top  of  the  left  lung  kept  up  a 
toxic  state  of  his  blood  which,  in  one  of  his  extreme 
nervous  state,  made  him  specially  susceptible  to  the 
antitoxin  effect  produced  by  the  organic  substance  the 
antiphthisin  undoubtedly  contained.  The  same  effects, 
though  much  less  in  degree,  have  been  variously  met 
with  in  other  cases,  when  the  treatment  was  pushed  too 
rapidly,  yet  no  bad  effects  have  resulted  therefrom.'  It 
only  goes  to  show  that  when  this  remedy  is  made  per- 
fect, and  the  technique  of  its  administration  determined, 
we  will  have  a  specific  well  calculated  to  combat  tuber- 
culosis pure  and  simple.  The  basis  for  this  belief 
rests  upon  conclusions  stated  by  Dr.  von  Ruck  as  fol- 
lows : 

"  The  etiological  treatment  of  diseases  caused  by 
pathogenic  micro-organisms  has  for  its  foundation  the 
fact  that  specific  disease  germs  produce  substances 
within  the  infected  living  organisms,  and  also  in  their 
own  culture  fluids,  which  are  inimical  to  their  own  life 
conditions,  and  that  infectious  diseases  thus  become 
self-limited  and  cultures  die  out  before  the  nutrient 
substances  are  exhausted,  on  account  of  the  poisoning 
and  destruction  of  the  disease  germs  themselves  by 
their  own  secretions  or  vegetation  products."  It  is 
claimed  that  this  specific  is  present  in  antiphthisin,  and 
that  this  is  proved  by  the  self-limitation  of  the  living 
cultures  and  by  "  the  destruction  of  the  virulency  of  the 
tubercle  bacillus  by  treating  it  with  antiphthisin  out- 
side of  the  living  organism." 

Experimentally  the  germicidal  and  healing  effect  of 
antiphthisin  seems  to  have  been  shown  in  most  of  the 
cases  I  have  had  under  its  influence  ;  i.e.,  in  the  les- 
sening of  the  number  of  germs  to  the  field  found  and 
their  degenerative  or  incomplete  forms  thrown  off  when 
good-sized  doses  were  reached,  as  well  as  in  the  clear- 
ing up  of  consolidated  or  infiltrated  tubercular  lung 
tissue. 

Therefore,  while  I  cannot  support  the  claim  that  anti- 
phthisin is  wholly  without  reaction  effects,  and  we  do 
not  yet  feel  quite  sure  of  its  exact  constituents  and 
their  constancy  ;  while  I  must  differ  with  Dr.  von  Ruck 
in  my  impression  that  some  toxins  rather  than  "no 
toxins  "  remain,  and  while  I  think  Professor  Klebs  is 
in  error  in  placing  the  dose  the  same  per  rectum  as 
when  given  hypodermically,  when  it  should  be  much 
less  by  the  latter  method,  yet  I  am  glad  to  recognize 
this  great  advance  in  specific  medication.  This  work  is 
certainly  in  the  right  direction,  and  a  possibility  is 
thereby  afforded  us  of  hastening  recovery-  through  the 
proper  method — the  increase  of  natural  resistance  to 
tuberculosis,  and  thus  hope  is  possible  for  some  other- 
wise incurable  cases. 

As  to  this  question  of  toxins,  it  has  seemed  to  me 
that  nature  may  have  some  selective  power  in  absorb- 
ing some  and  not  other  ingredients  of  the  remedy  when 
given  by  the  rectal  method,  and  hence  that  method  is 
to  be  preferred  in  very  susceptible  peisons  highly 
charged  with  the  tubercular  virus.  In  this  belief  Pro- 
fessor Klebs  seems  to  agree,  for  he  writes  me,  "  We 
know  through  the  labors  of  Brieger  that  the  resorption 
of  toxins  is  much  slower  than  of  the  other  albumoses." 

It  has  seemed  to  me  that  there  is  a  stimulating  effect 
due  to  antiphthisin,  and  that  produces  an  increased 
leucocytosis.  It  has  lately  occurred  to  me  that  a  limit 
to  the  good  which  antiphthisin  may  accomplish  in  a 
given  case  might  perhaps  be  assumed  to  have  been 
temporarily  reached  when  that  wonderful  process   is 

'"  >  Professor  Klebs  wishes  me  to  add  that  "  the  fever  results  from  the 
liberation  of  toxins  within  the  organism,  by  the  ficgencraiion  of  the 
tubercle  h.icilli,  and  tlio  resorption  of  the  tubercular  tissue." 


July   20,    1895] 


MEDICAL   RECORD. 


iDund  to  be  overtaxed  or  to  have  been  arrested,  as 
shown  by  the  paucity  of  leucocytes,  and  those  swollen 
or  granular,  when  demonstrated  by  microscopic  exam- 
ination with  high-power  lenses.  If  this  supposition  is 
correct,  it  may  be  a  greater  success  still  is  in  store  for 
lis  by  combining  or  alternating  with  the  use  of  anti- 
phthisin  or  a  similar  tubercular  product  somethincr 
else  to  be  found  which  will  foster  or  increase  this  fas- 
cinating leucocytosis.  A  case  lately  investigated  has 
impressed  this  expectation  upon  my  own  mind. 

I  would  have  liked  to  have  shown  the  helpful  and 
encouraging  results  of  antiphthisin  used  in  some  of 
the  advanced  third  or  excavation  cases  I  have  been 
working  with,  but  the  time  limits  for  this  paper  have 
already  been  reached,  and  I  must  content  myself  with 
the  general  statement  that  under  this  new  treatment  a 
certain  degree  of  immunity  and  prolongation  of  life  is 
possible,  to  be  added  to  that  which  this  climate  here 
offers  to  a  properly  selected  proportion  of  even  these 
fated  invalids. 


THE   PSYCHOLOGY  OF  NEURASTHENIA. 
By  W.  A-  McCLAIN,  M.D., 


If  we  look  into  a  medical  lexicon  we  find  this  term  de- 
fined as  "  an  exhaustion  or  deficiency  of  nervous  force." 
But  this  very  illy  defines  that  mysterious  group  of  symp- 
toms and  physical  manifestations  which  go  to  make  up 
the  sum  total  of  all  we  know  of  that  hydra-headed  mon- 
ster, neurasthenia. 

It  is  evident  to  all  neurologists  who  have  given  this 
subject  any  careful  thought  that  the  etiology  and 
pathology  of  this  disease  must  remain  to  a  great  extent 
shrouded  in  mystery,  and  very  little  has  been  added  to 
our  knowledge  in  this  direction  during  the  past  few 
years. 

The  utmost  extent  of  our  investigations  in  this  di- 
rection can  only  lead  us  at  last  to  that  misty  borderland 
of  mind  and  matter.  For  when  we  speak  of  the  exhaus- 
tion of  nervous  force  we  are  at  once  carried  back  to  the 
fountain-head  of  all  animal  life,  the  nerve-cells. 

What  is  meant  by  nervous  force  ?  What  must  be  dis- 
eased to  produce  an  exhaustion  of  this  force  ? 

Is  it  possible  that  a  degeneration  of  cell  life  in  nerve 
or  ganglion  is  the  cause  of  this  exhaustion  ?  If  this 
were  true,  then  this  force  must  be  generated  in  these 
structures.  But  science  has  failed  to  show  that  it  is 
produced  here. 

There  is  evidently  something  out  and  beyond  these 
tangible  structures — an  unseen  shadowy  hand  that  starts 
this  force  on  its  journey  down  the  highway  of  the 
nerves.  And  so  we  find  that  the  study  of  the  phenom- 
ena of  this  disease  leads  us  into  the  realm  of  mind,  and 
it  has  therefore  a  psychological  side  vastly  more  inter- 
esting to  us  than  the  physiological. 

Neurasthenia  must  be  studied  along  the  same  lines 
as  other  diseased  conditions  of  the  mind. 

However,  I  am  not  prepared  to  say  that  in  all  ])hases 
of  this  disease  the  mind  as  a  whole  is  diseased,  but  that 
the  same  agencies  which  produce  the  one  are  also  active 
in  producing  the  other. 

The  differentiation  between  this  neurosis  and  certain 
conditions  of  the  nervous  system  found  to  exist  in  hys- 
teria is  at  times  a  difficult  task.  The  literature  of  the 
subject  so  far  has  not  drawn  a  distinct  line  of  demarca- 
tion. And  the  two  diseases,  or  conditions,  are  very  fre- 
quently taken  the  one  for  the  other. 

There  is  no  disease,  however,  which  paralyzes  so 
much  utility,  and  which  imposes  upon  the  sufferer  such 
an  amount  of  aches  and  pains,  real  or  imaginary,  as  is 
experienced  by  the  neurasthenic.  He  has  the  discom- 
fort of  knowing  also  that  his  best  friends  have  no  sym- 
pathy for  his  condition,  and  often  speak  lightly  of  his 
manifold  complainings. 


This  necessarily  operates  against  the  condition,  and 
often  the  patient  is  led  to  suppress  his  feelings  and 
brood  over  them  till  at  last  the  mind — which  is  never 
stronger  than  its  weakest  part — becomes  unbalanced 
and  the  patient  sinks  into  a  condition  of  melancholia, 
and  suicide  often  closes  the  scene. 

Dr.  Brinton,  in  his  article  on  nervous  diseases  in  the 
lower  races  of  mankind,  observes  that  neurasthenia  is 
more  prevalent  among  those  of  lower  stages  of  culture. 
But  this  position  is  hardly  tenable  and  cannot  be  sus- 
tained by  facts  gained  by  careful  observation,  and  I  am 
compelled,  after  a  thorough  survey  of  the  field  of  litera- 
ture on  this  subject,  coupled  with  an  extensive  observa- 
tion among  the  uneducated  in  our  own  country,  to  ac- 
cept the  opposite  theory,  and  the  one  advanced  by  Dr. 
A.  D.  Rockwell  in  his  article  on  this  subject  in  the 
Nno  York  Medical  Journal  oi  1S93.  In  fact,  among  all 
the  cases  of  this  disease  which  I  have  observed  and 
noted  during  the  past  seven  years  in  hospital  and  dis- 
pensary, and  among  the  lower  classes  in  general,  but  few- 
typical  cases  of  neurasthenia  were  ever  found.  But  to 
the  contrary,  among  the  rich  and  well-to-do,  and  espe- 
cially among  professional  men  and  those  who  belong 
to  the  higher  walks  of  life,  this  disease  is  more  often 
found  in  its  most  typical  form. 

Dr.  Brinton,  as  quoted  by  Dr.  Rockwell,  states  that 
civilization,  so  far  from  increasing  this  malady,  is  one  of 
the  most  efficient  agents  in  reducing  it  in  frequency 
and  severity,  especially  when  freed  from  "  competitive 
anxieties." 

It  seems  well  that  he  added  this  latter  phrase,  for  it 
certainly  follows,  from  what  we  do  know  of  the  pathol- 
ogy of  this  disease,  that  these  very  "  competitive  anxie- 
ties "  which  are  so  intensified  in  this  country — this 
worry  of  business  and  professional  life — civilization 
only  fosters  and  deepens.  Perhaps  no  other  country  on 
the  face  of  the  globe  to-day  is  in  such  a  state  of  busi- 
ness ebullition — such  push  and  excitement  bordering  on 
frenzy  to  outstrip  all  competition — as  is  observed  in 
the  United  States.  And  to  this  state  of  excitement  and 
brain  fag  and  nervous  strain,  more  than  to  all  other  con- 
ditions combined,  is  due  the  prevalence  of  neurasthenia 
in  this  country.  The  younger  generations  in  most  of 
the  older  countries — Germany,  for  instance — are  con- 
tent to  follow  in  the  footsteps  of  their  fathers,  and  their 
work  has  a  tendency  to  partake  something  of  the  quiet- 
ude of  their  old  hills  and  streams. 

We  seldom  or  never  hear  of  English  or  German  ner- 
vousness as  the  same  term  is  applied  to  this  country, 
for  in  this  connection  it  carries  with  it  a  meaning  of 
peculiar  significance.  It  has  also  been  observed  that 
this  condition  is  not  found  among  the  inhabitants  of 
the  colder  latitudes.  Neither  is  it  so  prevalent  in  the 
torrid  zone,  but  only  in  that  region  known  as  the  tem- 
perate zone,  where  the  climate  is  ever  changing,  and 
the  atmosphere  is  filled  with  ozone  sufficient  to  pro- 
duce a  general  buoyancy  to  the  spirits.  Just  what  this 
peculiar  electrical  condition  has  to  do  with  the  disease 
we  are  not  yet  prepared  to  say.  But  it  is  evident  that 
this  surplus  energy,  whatever  may  be  its  source,  consti- 
tutes the  disease  proper,  and  not  therefore  a  lack  of 
nerve  force  as  the  books  define  it. 

To  use  a  patient's  own  words  who  was  a  sufferer 
from  this  disease,  "  I  felt  all  the  while  as  though  some 
shock  would  cause  me  to  explode."  Is  this  a  condi- 
tion of  exhaustion  of  nervous  energy  ?  Not  at  all,  but 
rather  a  weakening  of  the  lines  that  carry  this  force — 
a  broken  wire,  an  interrupted  current,  a  multiplicity  of 
currents  meeting  and  crossing,  the  weaker  ones  being 
attracted  by  the  stronger  ones  and  conducted  into 
unaccustomed  channels,  and  the  impression  often 
wholly  lost. 

And  this  accounts  for  the  inability  of  the  neuras- 
thenic to  engage  in  any  line  of  continued  thought.  He 
loses  the  subject  and  wanders,  or  the  current  of 
thought  ceases  to  flow  and  the  stream  is  lost  in  the 
sand. 


82 


MEDICAL   RECORD. 


[July   20,  1895 


To  understand  this  more  fully  we  have  only  to  study 
closely  the  minute  anatomy  of  the  brain  and  its  psy- 
chological functions. 

That  the  feelings  are  closely  connected  with  physi- 
cal manifestations  is  patent  and  undeniable.  But 
thought  is  at  times  so  quiet,  so  far  removed  from  bod- 
ily demonstration,  that  we  might  suppose  it  conducted 
in  a  region  of  pure  spirit — merely  imparting  its  conclu- 
sions through  a  material  intervention.  Unfortunately 
for  this  supposition,  the  fact  is  now  generally  admitted 
that  thought  exhausts  the  nervous  substance  as  surely 
as  walking  e.xhausts  the  muscles. 

Our  physical  framework  is  involved  with  thought  no 
less  decidedly  than  with  feeling.  To  all  varieties  of 
human  feeling  there  correspond  varieties  of  diffusion 
in  the  brain,  as  there  correspond  varieties  in  external 
manifestation. 

The  outward  signs  are  only  a  small  part  of  the  wave 
of  effects  upon  muscle's  and  viscera.  Many  movements 
receive  only  an  incipient  stimulus,  too  weak  for  pro- 
ducing action.  The  impulse  in  many  instances  may 
be  sufficiently  strong  in  the  start,  but  the  counter-im- 
pulse which  the  wave  meets  on  its  journey  may  be  suf- 
ficient to  suppress  it,  or  to  render  the  thought  as  to 
effect  of  no  purpose. 

But  these  diffused  waves  of  nervous  energy  are  in- 
separable adjuncts  of  feeling. 

The  powers  of  the  nervous  system  are  various,  and 
even  mutually  opposed.  Intellectual  feebleness,  decay 
of  memory,  and  incapability  of  thought  are  not  painful 
in  themselves.  But  there  is  probably  a  distinct  power 
of  the  nervous  system  connected  with  the  pleasurable 
tone  of  the  mind,  which  may  not  fail  when  intellect 
fails,  or  may  fail  while  the  intellect  is  yet  vigorous — a 
function  very  unequally  manifested  in  different  indi- 
viduals. 

The  mental  effect  of  diminished  power  in  various 
organic  functions  is  ultimately  realized  by  some  fail- 
ure in  the  brain  itself.  Could  we  suppose  the  brain  to 
maintain  all  its  functions,  derangements  might  occur  in 
other  organs  without  depressing  the  mind,  but,  strictly 
speaking,  this  is  'an  impossible  occurrence.  There  is 
sometimes  an  approach  to  this  situation,  namely,  when 
the  blood,  such  as  it  is,  flows  in  excess  to  the  brain, 
supporting  its  powers  at  the  expense  of  all  other  inter- 
ests, an  arrangement  that  cannot  be  permanent.  In 
such  a  contingency  there  is  an  extraordinary  exaltation 
of  mental  function,  including  a  hilarious  and  even  ec- 
static enjoyment.  It  is  the  state  that  narcotics  may 
produce  for  a  brief  moment  in  a  constitution  partially 
wrecked,  and  it  occasionally  occurs  in  the  closing  hours 
of  life. 

The  neurasthenic  state  is  not  infrequently  produced 
by  causes  whicli  may  be  easily  discerned  and  by  treat- 
ment removed.  Many  of  the  disturbances  of  the  di- 
gestive function,  anaemia,  uterine  displacements,  tape- 
worm, all  are  known  to  have  produced  manifestations 
of  this  disease  ;  yet  with  the  removal  of  the  cause  the 
symptoms  disappeared. 

But  with  grave  neurasthenia  we  have  another  picture 
presented,  with  no  objective  point  to  be  found,  no 
tangible  ground  in  view.  We  seek  in  vain,  in  the  words 
of  Shakespeare,  "  for  the  cause  of  this  effect,  or  rather 
say  the  cause  of  this  defect,  for  this  effect  defective 
comes  by  cause." 

The  therapeutics  of  this  disease,  contrary  to  most 
diseased  conditions,  is  far  in  advance  of  the  etiology 
and  pathology.  It  is  amenable  to  treatment,  and  in 
most  cases  is  a  self-limited  disease. 

Therefore  the  treatment  resolves  itself  into  an  effort 
to  treat  the  individual  and  not  the  disease  ;  salt-water 
baths,  a  change  of  climate  and  of  environment,  and 
a  calming  of  the  surging  waves  of  thought  which  dash 
down  the  interrupted  channels  of  their  being.  Restrict, 
as  far  as  possible,  all  impressions  made  upon  the  mind 
from  without,  for  while  we  go  the  round  of  the  mental 
circle  of  sensation,  emotion,  and  thought,  there  is  an 


unbroken  physical  circle  of  effects.  It  would  be  in- 
compatible with  all  we  know  of  cerebral  action  to  sup- 
pose that  the  physical  chain  ends  abruptly  in  a  physical 
void,  occupied  by  an  immaterial  substance,  which  im- 
material substance,  after  working  alone,  imparts  its  re- 
sults to  the  outer  edge  of  the  physical  break,  and  de- 
termines the  active  response — two  shores  of  the  material, 
with  an  intervening  ocean  of  the  immaterial.  There  is, 
in  fact,  no  rupture  of  nervous  continuity. 

And  by  thus  studying  the  relation  of  mind  and  body 
we  may  yet  arrive  at  the  true  pathology  of  this  disease. 
When  we  can  know  and  understand  the  origin  of  a 
thought,  and  the  molecular  change  of  gray  matter  in 
the  brain  consequent  upon  that  thought,  then,  and  not 
till  then,  may  the  pathology  of  neurasthenia  be  written. 

Coming  now  to  the  medicinal  treatment  of  this  dis- 
order, we  have  the  whole  pharmacopoeia  of  tonics  and 
sedatives  to  selecffrom,  but  each  case  must  be  treated 
upon  its  individual  conditions — supporting  treatment 
consisting  in  good  feeding  ;  tonics,  such  as  iron,  quinia, 
and  strychnia  ;  occasional  warm  baths  with  massage  ; 
stimulants  cautiously  used,  and  possibly  tonic  doses  of 
opium. 

Usually,  we  may  infer  that  the  pathological  condi- 
tion is  most  likely  to  be  one  of  defective  nutrition  from 
antemia  and  exhaustion. 

Where  there  are  decided  evidences  of  vaso-motor 
spasm  of  the  cerebral  vessels,  as  shown  by  pallor,  cold- 
ness of  head  and  extremities,  tinnitus,  vertigo,  etc.,  the 
inhalation  of  nitrite  of  amyl  is  generally  recommended 
with  good  results.  If  a  more  continued  effect  is  de- 
sired, nitro-glycerine  internally,  one-drop  doses  of  a  one 
per  cent,  solution,  is  employed  and  cautiously  increased. 

These  drugs  seem  to  have  a  double  beneficial  action 
in  these  cases,  dilating  the  peripheral  blood-vessels 
and  strengthening  and  freeing  the  heart's  action,  which 
is  embarrassed  by  under-innervation  or  over-inhibi- 
tion. 

Alcohol  and  opium  are  the  other  two  remedies  gen- 
erally recommended.  I  have  seen  some  temporary 
good  results  from  a  single  large  dose  of  alcohol,  but  I 
am  not  prepared  to  recommend  it.  Its  continued  use 
is  open  to  serious  objection,  and  the  same  may  be  said 
of  opium.  I  have  never  seen  the  opium  habit  created 
by  the  medical  use  of  this  drug  in  these  cases,  but  I 
can  readily  see  how  this  might  occur. 

Alcohol  as  a  vaso-dilator,  in  the  stricter  sense  of  the 
term,  has  but  a  limited  field  of  usefulness.  With  opium 
the  case  is  somewhat  different.  It  possibly  has,  in 
many  instances,  a  favorable  action  on  the  blood-vessels 
of  the  brain,  relieving  the  vaso-motor  spasm  and  aiding 
in  bringing  about  a  more  normal  condition  of  the  nu- 
trition of  nerve  elements.  In  these  conditions  small 
doses  seem  best,  from  two  to  six  drops  of  the  deodo- 
rized tincture  three  hours  apart  being  sufficient,  and  its 
results  cautiously  watched. 

Naturally  following  the  medical  treatment  of  the  dis- 
turbance of  the  cerebral  circulation  comes  that  of  the 
management  of  the  excessive  motor  excitement  and  ir- 
ritability, one  of  the  most  prominent  symptoms  of  this 
disease. 

This  involves  the  whole  question  as  to  the  use  of 
sedatives  in  mental  disorders,  in  regard  to  which  a 
wide  difference  of  opinion  exists  among  authorities,  and 
certainly  a  very  wide  range  of  variation  in  practice. 

The  fact  that  motor  activity  is  not  injurious,  but  pos- 
itively beneficial  and  ccHupensatory,  does  not  destroy 
the  other  fact,  that  in  many  cases  it  is  so  excessive  as 
to  wear  out  the  patient  unless  checked  ;  and  the  only 
way  this  can  be  done  successfully  is  by  the  use  of  seda- 
tives. And  possibly  the  safest  of  all  these  are  the 
bromides  of  potassium  and  soda.  They  seldom  do 
harm  when  projierly  diluted,  and  they  are  excellent 
adjuvants  to  other  and  more  powerful  quieting  agents. 

Clouston  recommends  the  use  of  the  bromides  with 
cannabis  indica  as  the  best  general  sedative,  while  oth- 
ers claim  that  Squibb's  fluid  extract  of  conium  and  hy- 


July   20,  1895] 


MEDICAL    RECORD. 


oscyamus  with  ten   to  fifteen   grains  of  chloral  is  the 
best  all-round  sedative  for  these  conditions. 

But  the  tonic  treatment  must  not  be  lost  sight  of  for 
a  moment.  Maltine,  cod-liver  oil,  the  peptones,  acid 
phosphates,  all  have  a  decidedly  beneficial  action  on 
this  disease,  and  on  most  mental  disorders.  The  farad- 
ic  or  galvanic  current  is  of  doubtful  utility.  But  the 
Weir  Mitchell  treatment  and  abundance  of  fresh  air 
and  sunshine,  promise  more  relief  to  these  most  miser- 
able of  all  human  sufferers — the  neurasthenic. 


ARE  WE  LIKELY  TO  HAVE  ANY  MORE 
EPIDEMICS  OF  ASIATIC  CHOLERA  IN 
NEW   YORK? 

By   F.  a.    BURRALL,_  M.D., 


During  the  last  few  years  much  anxiety  has  been  felt 
lest  cholera,  which  was  then  a  wide-spread  epidemic  in 
Europe,  should  cross  the  sea  and  again  visit  this  coun- 
try. The  painful  memories  of  former  visitations  are 
not  yet  effaced,  and  it  was  with  a  sense  of  relief  that 
summers  were  seen  to  pass  and  cool  autumns  arrive, 
without  the  advent  of  the  Asiatic  scourge. 

It  is  reasonable  to  suppose  that  until  sanitary  regu- 
lations are  better  enforced  and  ignorance  is  less  preva- 
lent in  some  portions  of  Russia  and  the  East  such  men- 
acings  of  cholera  will  be  likely  to  recur. 

The  question  arises,  How  far  should  they  be  a  source 
of  anxiety  to  this  outpost  of  our  country,  which  has 
often  been  a  distributer  of  this  pestilence  ?  Have  any 
advances  been  secured  in  the  knowledge  of  cholera 
during  later  years  which  render  it  more  manageable 
than  formerly  and  less  an  object  of  dread  ?  The  study 
of  this  question  is  connected  with  the  history  of  the 
Asiatic  scourge. 

The  literature  of  the  subject  is  so  extensive  and 
complete  that  the  materials  for  such  a  study  are  very 
ample.  Its  peculiar  features  have  attracted  the  care- 
ful scrutiny  of  the  keenest  and  most  patient  medical 
observers,  and  page  after  page  bears  witness  to  the  un- 
tiring efforts  which  have  been  made  to  solve  the  riddle 
of  this  erratic  and  mysterious  pestilence.  In  looking 
through  the  literature  of  cholera  we  can  clearly  follow 
the  forward  and  backward  footsteps  of  the  trail  which 
have  at  least  arrived  at  definite  opinions.  These  views, 
based  on  the  most  laborious  studies  and  scientific  in- 
vestigations, explain  why  cholera  has  been  so  difficult 
to  control  and  so  destructive  to  human  life.  For  a 
long  time  the  views  concerning  its  origin  and  nature 
were  indefinite  and  conflicting.  Now  vague,  now  fan- 
ciful in  the  highest  degree, 

"  Such  stuff  as  dreams  are  made  of," 

this  did  not  interfere  with  the  tenacity  of  those  who 
held  them,  and  the  result  was  to  render  any  unanimity 
of  action  which  looked  toward  preventive  measures 
weak  and  futile.  Such  unanimity  was  absolutely  nec- 
essary for  practical  results. 

For  a  long  time  the  question  of  the  communicability 
of  the  disease  was  completely  unsettled.  Those  who 
studied  the  pestilence  and  even  treated  it  in  epidemics 
were  widely  at  variance  concerning  this  point.  It  is 
difficult  for  those  of  us  who  have  watched  the  rise  and 
establishment  of  the  modern  ideas  concerning  cholera 
to  understand  how  men  could  have  failed  to  see  the 
bearing  of  facts  which  now  lie  so  open  and  clear  to  the 
view.  Yet,  as  in  other  matters,  the  strength  of  precon- 
ceived opinions  is  often  so  strong  that  facts  are  forced 
as  far  as  possible  to  fit  these  opinions,  and  the  plain, 
obvious  truth  is  overlooked.  Such  views  as  these  of 
Jameson,  who  wrote  in  1855,  are  an  instance  of  the 
ideas  of  very  many  at  that  period.     He  writes  : 

"  Everything,  we  think,  conspires  to  disprove  the  be- 


lief that  the  cholera  poison  came  from  the  East,  trav- 
ersed parts  of  Europe,  and  then  arrived  in  this  country 
and  now  fills  a  considerable  part  of  this  continent. 
Since  we  have  no  control  over  this  specific  matter,  it  is 
not  very  material  whether  we  can  or  not  ascertain  its 
source,  but  we  think,  with  Sydenham,  that  its  primary 
cause  emanates  from  the  earth.  In  briefly  summing  up 
the  character  of  cholera,  we  view  it  as  an  epidemic  and 
of  course  dependent  upon  some  atmospherical  contam- 
ination for  its  predisponent  cause,  mostly  confined  to 
neighborhoods  of  moderate  extent,  but  sometimes,  sim- 
ultaneously or  in  near  succession,  in  different  places ; 
it  is  most  clearly  non-contagious,  non-migratory." 

Still  another  writer  gives  it  as  his  opinion  that  "  I 
wish  it  to  be  distinctly  understood  that  I  have  seen 
nothing  in  its  progress  that  has  led  me  to  conclude 
that  contagion  is  instrumental  in  its  diffusion.  One  or 
tvfo  prima  fade  ca.ses  of  infection  have  presented  them- 
selves, but  a  little  scrutiny  has  shown  me  their  fal- 
lacy." 

As  to  the  cause  of  cholera,. all  kinds  of  ideas  were 
advanced.  One  writer  is  of  opinion  that  the  disease 
depends  upon  a  "  subtle  entity,"  which  spreads  by  the 
agency  of  some  modification  of  electricity,  like  ozone. 
He  writes  : 

"  What  other  agent  is  there  to  which  we  could 
ascribe  the  appearance  of  cholera  in  its  course  ?  It  is 
true,  electricity  has  the  quality  of  ubiquity,  but  this 
does  not  interfere  with  its  change  of  place,  as  may  be 
seen  in  the  operation  of  the  telegraph.  All  the  known 
laws  of  electricity,  in  all  its  modifications,  serve  to  give 
it  fitness  for  the  agency  of  spreading  a  subtle  entity, 
like  the  entity  which  gives  rise  to  cholera." 

In  1866,  among  other  views  which  were  brought 
forward  to  explain  the  cause  of  cholera,  it  was  reported 
by  "  Malakoff,"  who  was  then  the  Paris  correspondent 
of  the  A^eia  York  Times,  that  "  a  distinguished  lady  of 
title  had  made  a  communication  to  the  French  Acad- 
emy of  Sciences,  that  she  had  discovered  the  cause  of 
cholera  in  a  microscopic  insect  which  she  calls  the 
winged  leech  and  which  she  says  is  developed  in 
marshes  and  filthy  localities.  The  details  she  gives  in 
relation  to  the  animalcule  and  its  connection  with 
cholera  are  so  minute  that  the  Academy,  which  com- 
menced by  laughing  at  the  first  paragraph  of  the  re- 
port, finished  by  deciding  to  investigate  the  matter." 

It  was  hunting  in  the  fog  to  seek  for  prevention, 
while  the  nature  of  the  disease  was  so  imperfectly 
understood  and  its  communicability  denied.  Far- 
fetched explanations  were  advanced  for  the  strange 
conduct  of  what  seemed  to  be  a  capricious  pest,  and 
the  opposing  views  held  by  those  who  had  had  the 
best  opportunities  for  studying  the  disease  led  physi- 
cians and  the  public  to  regard  the  new  theories  with 
scant  favor. 

The  belief  in  the  communicability  of  cholera  had 
been  making  slow  headway  for  years.  The  admission 
of  negative  evidence  was  a  great  impediment  to  its 
progress.  But  those  who  thought  cholera  communi- 
cable held  that  the  testimony  of  the  five  witnesses 
who  saw  the  culprit  steal  the  axe  was  not  at  all  weak- 
ened by  that  of  the  twenty  who  swore  that  they  did 
not  see  the  theft.  There  were  so  many  instances 
where  the  arrival  of  cholera  patier.ts  at  villages  or  in 
families  in  which  there  was  no  cholera,  was  speedily 
followed  by  an  outbreak  of  the  disease,  that  these  accu- 
mulating facts  bore  convincing  evidence  in  favor  of 
communicability.  Why,  as  was  the  case,  should  cholera 
appear  in  an  uninfected  island  of  the  ocean,  soon  after 
the  advent  of  a  vessel  with  cholera  on  board,  unless  it 
had  been  brought  there  by  that  vessel  ?  One  such  in- 
stance of  portability  would  be  insuflficient  as  a  ground 
for  belief,  but  the  facts  flowed  in  in  increasing  num- 
bers, and  from  1867  to  1870  the  doctrine  of  the  com- 
municability of  cholera  had  gained  a  hold  sufficiently 
strong  to  form  a  basis  for  definite  sanitary  action. 
The  settling  of  this  point  in  tlie  minds  of  the  majority 


84 


MEDICAL    RECORD. 


[July  20,    1895 


was  the  most  important  step  in  advance  which  had 
been  made  for  years.  In  this  light  was  explained  the 
strange  circumstance,  which  had  seemed  inexplicable, 
that  this  pestilence  had  attacked  ships  in  midocean  as 
if  borne  from  distant  lands  or  dropped  from  the  clouds, 
by  attributing  it  to  an  infection  caused  by  the  opening 
of  trunks  and  airing  of  infected  clothing  by  passengers 
from  infected  districts.  It  may  be  incidentally  men- 
tioned that  cholera  has  been  said  to  be  unaffected  by 
cold,  and  to  spread  even  in  spite  of  the  rigors  of  a 
Russian  winter.  A  satisfactory  explanation  of  this 
fact  seems  to  be  that  the  houses  of  the  poorer  Russians 
are  closely  sealed  to  keep  out  the  intense  cold.  The 
interior  is  hot  and  filthy,  and  thus  the  cholera  plant  is 
fostered  and  carried  from  house  to  house,  although  it 
would  die  in  the  temperature  of  the  external  air.  At 
present  it  is  established  that  great  cold  is  unfavorable 
to  the  spread  of  this  disease,  but  at  one  time,  before 
the  communicability  of  cholera  was  admitted,  the 
spread  of  a  winter  epidemic  was  regarded  as  another 
bizarrerie  of  this  inscrutable  plague. 

Communicability  having  been  admitted,  or  in  other 
words  the  transfer  of  the  disease  as  a  special  poison  by 
human  agency,  then  the  question  of  prevention  as- 
sumed a  more  definite  and  practical  form.  Prevention 
was  all  the  more  important,  since  the  treatment  of  the 
fully  developed  malady  was  and  still  is  extremely  un- 
satisfactory. The  mortality  remained  about  the  same, 
notwithstanding  that  one  treatment  after  another  was 
recommended,  as  new  epidemics  came  and  went.  A 
certain  number  of  the  sick  recovered  under  almost 
any  treatment.  Methods  of  cure  which  seemed  ef- 
fective in  one  epidemic  proved  valueless  in  another, 
and  in  estimating  the  effect  of  remedies  it  was  neces- 
sary to  take  into  account  the  period  of  the  epidemic  in 
which  they  had  been  tried,  since  the  mortality  in  the 
early  part  of  the  epidemic  was  found  to  be  naturally 
much  larger  than  in  the  later  portions.  On  the  other 
hand  the  treatment  of  the  premonitory  symptoms  of 
cholera  had  been  found  quite  efficacious,  and  general 
cleanliness  had  limited  to  a  certain  degree  the  large 
mortality. 

As  confidence  became  developed  in  the  efficacy  of 
preventive  methods,  these  methods  were  more  carefully 
studied  and  improved.  Isolation,  cleanliness,  the  use 
of  pure  water,  and  house-to-house  visitations  were 
found  to  be  of  use,  because  definitely  directed  against 
a  special  poison,  which  displayed  prominent  character- 
istics, although  its  essential  nature  was  still  unknown. 
The  great  mistake  which  had  been  made,  of  concealing 
or  denying  first  cases  of  the  disease  for  fear  of  creating 
a  panic,  seemed  but  natural  when  no  satisfactory 
method  of  treating  them  was  known.  While  the  cases 
were  being  discussed,  the  disease  spread,  and  as  in 
one  of  the  Parisian  epidemics,  where  the  pestilence 
broke  out  in  vast  proportions,  this  was  not  a  primary 
wave,  but  the  sudden  development  from  cases  which 
had  been  present  in  the  city  for  a  month. 

Confidence  in  the  power  of  prevention  has  also  led 
to  another  and  most  important  step  which  is  strongly 
in  contrast  with  previous  custom.  Doubtful  cases  are 
treated  with  all  the  sanitary  discipline  of  genuine 
cholera,  and  efforts  are  made  to  bring  to  the  light  all 
such,  in  order  that  a  possible  lurking  evil  may  be 
"  stamped  out  "  before  it  has  made  headway. 

The  discovery  of  the  cholera  germ  by  Koch  has  thus 
far  been  of  less  practical  value  than  of  interest  from  a 
scientific  point  of  view.  This  statement  is  for  the  pres- 
ent time :  If  anti-cholera  inoculation  should  i)rove 
successful  it  will  be  the  great  preventive  method,  but 
this  treatment  is  still  sub jiidice.  At  all  events,  the  dis- 
covery of  the  bacillus  was  a  most  important  link  in  the 
history  of  the  disease  and  most  essential  to  its  com- 
pleteness. Still  what  had  already  been  acquired  was 
directly  in  the  line  of  what  would  be  indicated  by  that 
discovery.  It  has  often  been  the  case  that  medical 
treatment  has   been  in  advance  of  that  more   exact 


scientific  knowledge  which  comes  later  to  justify  the 
treatment  and  explain  its  results. 

One  fundamental  consideration  which  precedes  all 
others  when  we  regard  our  liability  to  an  introduction 
of  cholera  is  our  separation  from  European  ports  by 
the  ocean.  It  is  only  from  those  ports  that  we  have 
ever  received  it.  The  shortest  voyage  across  the 
sea  is  longer  than  the  ordinary  time  which  elapses 
between  infection  and  the  appearance  of  choleraic 
symptoms.  The  question  is  not  fully  settled,  but  it 
must  be  admitted  that  the  usual  period  of  incubation 
is  within  four  or  five  days.  A  maximum  period  has 
been  placed  at  twenty-one  days,  but  if  we  consider  the 
very  great  infrequency  of  cases  upon  which  this  esti- 
mate is  based,  we  must  admit  the  possibility,  at  least, 
that  the  infection  came  from  soiled  clothing  or  fomites, 
to  the  poisonous  action  of  which  the  patient  had  been 
exposed  during  the  latter  portion  of  the  twenty-one 
days. 

We  may  now  ask  what  legacy  have  the  years  given 
us  after  all  the  suffering  and  experience  and  study 
which  have  accompanied  the  successive  epidemics  of 
cholera? 

It  cannot  be  claimed  that  our  knowledge  of  chol- 
era is  complete.  In  some  directions  we  have  only  a 
"  working  hypothesis,"  but  the  knowledge  acquired  is 
sufficient  to  form  a  good  basis  for  preventive  treatment. 

We  may  regard  it  as  a  standard  opinion  at  present 
that  Asiatic  cholera  is  a  disease  produced  by  the  fer- 
mentative results  connected  with  the  presence  of  the 
cholera  bacillus.  The  existence  and  growth  of  the  ba- 
cillus are  favored  by  certain  conditions,  while  interfered 
with,  even  to  annihilation,  by  others.  Intense  cold 
checks  its  growth,  man)'  chemical  agents  destroy  it, 
cleanliness  retards  its  advance.  Experiments' made  to 
ascertain  whether  the  soil  in  itself  has  any  action  favor- 
able or  injurious  to  the  comma  bacillus  of  Asiatic 
cholera,  apart  from  the  moisture  which  these  soils  con- 
tain, are  of  much  interest.  The  earth  experimented 
with  was  white  crystal  sand,  yellow  sand,  garden  earth, 
and  peat,  and  these  earths  were  sterilized  by  moist 
heat.  Under  these  circumstances  the  bacilli  in  these 
different  soils  died  between  the  third  and  fourth  day. 
In  a  moist  soil,  where  there  was  no  excess  of  moisture, 
it  was  found  that  the  bacillus  in  the  white  cr}'Stal  sand 
was  alive  on  the  seventh  day,  in  moist  yellow  sand  on 
the  thirty-third,  and  in  moist  garden  earth  also  on  the 
thirty-third  day.  Peat  was  unfavorable  to  its  %-itality, 
since  in  that  soil  the  bacilli  were  dead  in  from  invari- 
ably twenty-four  to  twenty-six  hours,  independently  of 
the  amount  of  moisture  present.  Whether  the  acid 
present  in  peat  is  inimical  to  the  bacillus  is  not  stated. 
Some  acids,  such  as  sulphuric,  have  been  supposed  to 
act  as  antidotes  to  the  poison  of  cholera.  It  has  long 
been  held  by  Pettenkofer  that  the  epidemics  of  cholera 
depend  for  their  prevalence  on  the  varying  quantity  of 
water  in  the  soil,  and  in  India  certain  places,  like  Mul- 
tan,  in  the  Punjaub,  are  considered  as  out  of  the  cholera 
area,  and  cholera  is  "  always  present  in  damp  Bengal." 
So  that  the  drift  of  evidence  indicates  that  moist  soils 
favor  and  dry  soils  impede  the  spread  of  this  pesti- 
lence. 

Cholera  is  not  regarded  as  contagious  in  the  exact 
sense  of  the  word,  but  the  germ  taken  within  the  body, 
as  by  food  or  water,  originates  the  disease,  and  this  is 
spread  by  the  fermented  waste  of  the  body. 

The  usual  period  of  incubation  is  placed  at  from 
three  to  four  days.  The  occurrence  of  those  longer 
periods  which  are  given  as  elapsing  between  exposure 
and  the  appearance  of  symptoms  may  be  explained  by 
attributing  them  to  infected  clothing  or  other  fomites. 

As  a  rule,  epidemics  in  this  country  begin  by  a  single 
case,  or  two  or  three  in  near  succession.  The  premoni- 
tory symptoms  of  cholera  are,  as  a  rule,  easily  controlled. 
A  quarantine  may  be  so  conducted  as  to  aid  very  de- 

'  London  Letter  to  the  New  York  Mbdicai.  Record,  June  23, 
1895- 


July  20,  1895] 


MEDICAL   RECORD. 


85 


cidedl)'  in  prevention  without  greatly  embarrassing  the 
demands  of  commerce. 

What,  then,  do  these  premises  indicate  with  reference 
to  systematic  effort  in  keeping  cholera  out  of  this  con- 
tinent, and  especially  New  York  ?  In  the  first  place, 
such  an  examination  and  preliminary  quarantine  as 
was  practised  on  immigrants  sailing  to  America  from 
Amsterdam  or  Rotterdam  during  recent  cholera  epi- 
demics was  a  defensive  blow  nearest  the  seat  of  the 
evil,  and  a  five  days'  quarantine,  with  airing  or  disinfec- 
tion of  clothing,  would  be  a  great  advance  on  former 
methods. 

A  second  quarantine  on  this  side  of  the  water,  in  the 
event  of  suspicious  cases  arriving  on  board  of  a  vessel, 
is  an  additional  defence.  If  thorough  disinfection  of 
personal  clothing  and  baggage  is  practised,  and  all  ex- 
posed localities  are  carefully  cleansed,  so  that  if  the 
disease  enter  it  may  find  no  soil  to  nourish  it,  it  does 
not  seem  necessar)'  to  require  a  detention  longer  than 
ten  days,  including  the  passage,  for  healthy  vessels  from 
infected  ports  or  which  contain  passengers  from  in- 
fected districts,  or  for  infected  vessels  of  more  than 
ten  days  after  the  end  of  the  last  case  of  cholera  or 
acute  intestinal  disturbance. 

The  thorough  cleaning  of  seaport  towns,  and  a  sup- 
ply of  pure  drinking-water. 

The  co-operation  of  the  community  with  the  author- 
ities in  reporting  all  suspicious  cases.  No  one  can  be 
"  frightened  into  cholera  "  if  the  specific  disease  does 
not  exist,  and  the  best  method  of  averting  it  is,  with 
confidence  in  our  present  preventive  agencies,  to  search 
out  and  destroy  the  earliest  sparks  of  the  fire  before  it 
goes  beyond  our  control. 

The  sanitary  treatment  of  all  doubtful  cases  as  if  they 
were  genuine,  with  the  same  aids  of  isolation  and  dis- 
infection as  are  used  at  present  so  successfully  in  our 
epidemics  of  scarlet  fever,  diphtheria,  measles,  and 
small-pox. 

In  this  article  are  contrasted  the  former  views  con- 
cerning the  nature  of  Asiatic  cholera  with  our  present 
standard  opinions  and  the  views  concerning  preventive 
treatment.  A  comparison  of  the  earlier  with  late  views 
shows  us  how  high  the  tide  has  risen.  The  results  of 
preventive  efforts  made  within  a  few  years  in  this  city 
are  full  of  encouragement.  We  cannot  tell  how  many 
more  threatenings  of  cholera  we  may  have,  but  it  does 
not  seem  probable  that  this  city  will  ever  again  be 
forced  to  lament  the  visitation  of  a  cholera  epidemic. 
It  would  seem  as  if  nothing  but  a  relaxation  of  our 
present  vigilance  could  account  for  such  an  unhappy 
event. 

What  this  means  in  the  establishment  of  that  calm 
confidence  which  soothes  and  upholds  the  nervous  sys- 
tem of  a  community,  as  opposed  to  the  effects  caused 
by  the  dread  of  a  coming  horror,  what  of  sorrow  and 
misery  would  be  averted,  what  of  business  complica- 
tions and  loss  of  treasure  would  be  avoided,  it  is  im- 
piossible  to  thoroughly  comprehend  in  all  painful  de- 
tail. 


The  Dtike  of  Cambridge  seems  to  be  a  cad.  He  is 
commander-in-chief  of  the  British  army  and  is  about  as 
well  qualified  for  the  position  he  holds  as  was  the  ruler 
of  the  Queen's  Navee  ;  yet  he  had  the  impudence  to  re- 
fer to  Surgeon-Major  Robertson,  who  distinguished 
himself  for  heroism  at  Chitral,  as  "  that  brave  civilian," 
not  recognizing  a  surgeon  as  an  army  officer.  Surgeon- 
Major  Robertson  is  to  be  congratulated  in  not  being 
recognized  as  a  comrade  of  the  absurd  Duke  of  Cam- 
bridge. 

The  Horse  is  in  Luck,  for  just  at  the  time  that  his 
occupation  as  a  drawer  is  in  danger  of  being  lost  in 
competition  with  electricity  and  the  bicycle,  the  anti- 
toxin treatment  has  created  a  demand  for  him  as  a  pur- 
veyor of  serum. 


FRIEDREICH'S    ATAXIA,   WITH   CASES.^ 
By   SIDNEY  I.    SMALL,   M.D., 

SAGINAW,  MICH. 

In  reporting  these  cases  of  this  comparatively  rare  dis- 
ease I  do  not  expect  to  add  anything  original  to  its  lit- 
erature, but  I  am  encouraged  to  believe  that  a  history 
of  the  cases  which  have  been  under  my  observation 
for  a  considerable  time,  illustrated  by  the  presence  of 
the  individuals  themselves,  will  be  of  sufficient  interest 
to  claim  a  small  share  of  the  Society's  time. 

I  trust  it  will  not  be  deemed  a  reflection  on  the  dig- 
nity and  erudition  of  this  Society  that,  before  taking  up 
the  personal  histories,  I  recite  briefly  the  history  and 
general  course  of  the  disease,  as  a  reminder  for  those 
who  have  had  no  special  reason  for  its  recent  study, 
and  an  aid  to  the  appreciation  of  the  symptoms  as  they 
appear  in  the  different  stages. 

The  disease  was  first  noticed  in  1S61,  by  Professor 
Friedreich,  of  Heidelberg,  who  at  that  time  reported  six 
cases.  In  1866  but  14  new  cases  had  been  reported. 
In  1872,  the  number  had  increased  to  47,  and  at  the 
present  time  is  something  over  200.  The  only  case 
which  has  been  reported  in  this  State  was  described  by 
one  of  our  own  members.  Dr.  Inglis,  in  a  paper  read 
before  this  Society  in  1891. 

For  a  definition  of  the  affection  I  shall  quote  from 
the  excellent  monograph  of  Dr.  J.  P.  Crozer  Griffith, 
as  giving  briefly,  and  yet  clearly,  the  results  of  study 
up  to  the  present  time: 

"  Friedreich's  ataxia  is  a  chronic  systemic  inflamma- 
tory degeneration  of  the  spinal  cord,  developing  usu- 
ally in  infancy  or  childhood,  and  occurring  in  cases  in 
which  there  has  probably  been  an  arrest  of  develop- 
ment of  the  cord  during  foetal  life,  this  being  the  re- 
sult of  some  hereditary  predisposition.  It  is  situated 
chiefly  in  the  posterior  columns,  the  lateral  pyramidal 
tracts,  the  direct  cerebellar  tracts,  and  the  columns  of 
Clarke,  though  other  parts  of  the  white  and  gray  mat- 
ter are  very  commonly  somewhat  affected,  and  the 
sclerosis  extends  slightly  into  the  medulla.  The  affec- 
tion is  characterized  clinically  by  a  disturbance  of  the 
co-ordinarion  of  the  bodily  movements,  developing 
gradually,  advancing  from  below  upward,  and  finally 
invohdng  the  organs  of  speech.  Curvature  of  the  spine, 
talipes,  vertigo,  and  nystagmus  are  frequent.  The 
patellar  reflex  is  nearly  always  abolished.  Paralysis 
and  sensory  disturbances  are  not  uncommon  in  ad- 
vanced cases.  Trophic,  vaso-motor,  and  visceral  af- 
fecrions  are  unusual,  and  any  involvement  of  the  intel- 
lect is  probably  accidental." 

It  is  probable  that  all  sufferers  from  the  disease  in- 
herit from  some  of  their  ancestors,  near  or  remote,  a 
tendency  to  degenerative  processes,  yet  to  call  it  hered- 
itary we  must  regard  the  term  in  its  broadest  sense. 
While  cases  are  recorded  of  undoubted  direct  or  sim- 
ilar inheritance,  in  the  large  majority  it  will  be  found 
that  the  ancestors  suffered  from  some  other  form  of 
nervous  disease  ;  and  a  certain  number  appear  in 
which  no  sign  of  heredity  has  been  discovered. 

But  few  well-marked  cases  have  shown  the  first  symp- 
toms after  the  age  of  twenty  years.  In  127  cases  tabu- 
lated by  Griffith,  the  first  symptoms  were  noticed  in  39 
before  the  age  of  six  years  ;  in  45  at  from  six  to  ten 
years;  in  20  at  from  eleven  to  fifteen  years;  in  18  at 
from  sixteen  to  twenty  years  ;  and  in  5  at  from  twenty 
to  twenty-five  years.  Not  infrequently  the  first  mani- 
festations of  the  disease  have  been  preceded  by  some 
acute  affection,  usually  infectious. 

Clinically,  Friedreich's  ataxia  resembles  tabes  dor- 
salis  and  disseminated  sclerosis.  In  our  diagnosis  we 
have  to  bear  in  mind  the  early  development  of  Fried- 
reich's disease,  its  slow  but  steady  progress,  its  ten- 
dency to  occur  in  several  members  of  the  same  family, 
the  peculiar  oscillating,  staggering  gait,  the  usual  ab- 
sence of  the  patellar  reflex,  the  deformity  of  the  feet, 

>  Read  before  the  Michigan  State  Medical  Society,  June  7,  1895. 


86 


MEDICAL   RECORD. 


[July  20,  1895 


the  slow,  thick  speech,  scoliosis,  and  nystagmus  ;  the 
absence  of  pain,  cerebral  disturbances,  and  genito-uri- 
nary  troubles.  Tabes  dorsalis  is  a  disease  of  adult  life, 
with  pain  as  an  early  and  common  symptom,  seldom 
affecting  more  than  one  in  a  family  ;  lesions  of  the 
optic  nerve  are  early  and  frequent  symptoms,  without 
curvature  of  the  spine,  or  inco- ordinations  of  speech, 
and  very  seldom  nystagmus. 

Disseminated  sclerosis  rarely  appears  before  the  age 
of  twenty.  The  onset  is  sudden,  and  bit  one  case  in  a 
family  affected.  There  is  exaggeration  of  tendon  re- 
flexes, spastic  paraplegia,  cerebral  disturbances,  with 
vertigo,  headache,  and  epileptiform  and  apoplectiform 
attacks.  The  general  pathological  changes  are  well 
described  in  the  definition  quoted  at  the  beginning. 

Three  of  the  cases  which  form  the  subject  of  this 
paper  have  been,  for  a  number  of  years,  inmates  of  St. 
Mary's  Hospital,  in  Saginaw.  The  fourth  is  living  in 
Essexville,  in  which  town  all  the  children  were  born. 

In  my  study  of  the  family  history  I  find  nothing  of 
importance  on  the  paternal  side.  The  father  was  a 
native  of  Holland,  and  came  to  this  country  at  the  age 
of  twenty-five.  He  was  a  large,  strong  man,  and  healthy 
until  a  few  years  before  his  death,  which  occurred  at 
the  age  of  sixty-one,  of  gastric  cancer.  His  father  and 
mother  died  in  Holland  at  the  age  of  fifty-eight  and 
fifty-two,  respectively.  One  brother  is  living  in  this 
State  at  an  advanced  age. 

The  mother  of  the  patients,  French,  a  native  of  Can- 
ada, died  at  thirty-eight  years  of  age  from  blood-poi- 
soning, the  result  of  vaccination.  Maternal  grand- 
father living  at  eighty-five  ;  maternal  grandmother  died 
at  seventy-three.  A  sister  aged  twenty-eight  is  in  good 
health,  and  a  brother  aged  sixteen  is  apparently  well, 
though  inclined  to  stammer,  especially  if  at  all  ex- 
cited, and  the  patellar  reflex  is  absent  or  doubtful. 

From  a  maternal  aunt  I  obtain  the  following  per- 
sonal history  :  She  is  forty-six  years  of  age,  and  has 
been  married  twenty-three  years.  Three  months  after 
marriage,  being  then  pregnant,  she  took  cold,  and  had 
"inflammation  of  the  lungs"  which  lasted  several 
months,  and  for  one  year  after  recovering  from  this 
illness  she  was  unable  to  walk,  and  had  no  sensation 
in  her  legs  ;  then  she  learned  to  walk  as  a  child  learns. 
Three  years  afterward,  in  her  third  pregnancy,  she  suf- 
fered an  attack  similar  to  the  former,  and  was  again 
unable, to  walk  for  a  period  of  a  year  and  a  half,  since 
which  time  she  has  been  well  ;  so  she  says,  but  when 
the  marked  kyphosis  of  the  dorsal  region  developed  I 
was  unable  to  elicit  ;  probably  at  the  time  of  her  first 
illness.  She  has  had  nine  children,  seven  of  whom  are 
living.  The  first-born  died  at  two  and  a  half  years  of 
age,  never  having  been  healthy,  though  I  was  unable 
to  learn  the  immediate  cause  of  death.  The  other 
died  of  diphtheria.  The  remaining  children  are  well, 
mentally  and  physically.  A  cousin  of  the  parents  on 
the  mother's  side  has  a  daughter  eight  years  of  age, 
who  has  since  the  age  of  eight  months  had  convulsions, 
and  is  still  an  infant  in  all  but  years.  Three  other 
children,  of  the  ages  of  four,  six,  and  fourteen,  are  in 
good  condition,  physically  and  mentally.  It  may  be 
worthy  of  note  that  the  parents  are  slightly  related — 
their  grandmothers  being  half-sisters. 

In  another  branch  of  the  family  is  a  girl,  eleven  years 
of  age,  a  distant  cousin  of  the  patients,  who  had  hemi- 
plegia in  infancy,  and  still  remains  weak  in  body  and 
mind.  Eight  other  children,  whose  ages  range  from 
eight  to  twenty-two  years,  are  in  good  health. 

The  following  personal  histories  are  obtained  from 
the  patients  themselves  and  their  friends  : 

Case  I. — Mary  V ,  aged    twenty-six.     She    was 

in  good  health  up  to  thirteen  years  of  age,  when  there 
appeared  an  unsteadiness  in  her  gait — a  wavering,  un- 
certain manner  of  walking,  with  frequent  falls.  The 
patient  says  there  was  an  uneasy  sensation  in  the  back, 
and  later  in  the  knees  and  ankles,  though  it  never 
amounted  to  absolute  pain.     She  also  remembers  that 


she  was  unable  to  stand  upon  a  chair,  or  anything 
raised  even  but  a  little  distance  above  the  ground,  and 
this  she  noticed  some  time- — four  or  five  years — before 
the  trouble  in  walking  appeared.  At  the  age  of  nine- 
teen, the  difficulty  in  walking  had  so  far  increased  that 
she  was  compelled  to  use  crutches,  and  after  about  four 
months  was  no  longer  able  to  walk  even  with  this  sup- 
port. Menstruation  began  at  eighteen,  and  has  been 
normal. 

Present  Condition. — The  patient  sits  during  the  day 
in  an  arm-chair  in  a  somewhat  stooping  or  rather 
slouching  position.  There  is  some  scoliosis  in  the  dor- 
sal region.  She  is  unable  to  walk  or  stand,  and  gets 
about  by  drawing  herself  along  the  floor  by  the  hands. 
With  difficulty  she  can  get  from  the  floor  to  a  chair. 
She  can  extend  and  flex  the  leg  upon  the  thigh,  but 
cannot  flex  the  thigh  upon  the  trunk.  The  feet  are  in 
the  condition  of  talipes  equinus,  with  a  tendency  to 
dorsal  flexion  of  the  great  toe.  Patellar  reflex  is  ab- 
sent or  doubtful.  There  is  no  more  atrophy  of  the 
muscles  than  would  naturally  follow  disuse.  The  mus- 
cles of  the  arms  and  hands  are  fairly  strong,  but  show- 
ing marked  inco-ordination.  An  attempt  to  bring  the 
forefingers  together,  or  to  touch  the  tip  of  the  nose  or 
the  ear  is  seldom  successful.  When  the  limbs  have  re- 
mained for  some  time  at  rest  the  patient  is  unable  to 
tell  their  position  except  by  sight. 

In  grasping  an  object  the  hand  and  fingers  are  held 
in  a  claw-like  way,  and  often  carried  beyond  and  about 
the  object  before  seizing  it.  The  functions  of  the 
bladder  and  rectum  are  normal.  The  speech  is  thick, 
as  though  some  object  were  held  in  the  mouth,  and 
the  words  are  pronounced  in  a  slow  and  somewhat 
jerky  manner.  Though  generally  of  a  quiet  and  seri- 
ous habit,  the  patient  is  subject  to  fits  of  immoderate 
and  uncontrollable  laughter  on  slight  provocation. 
There  is  no  impairment  of  intellect  or  memory. 

Case  II. — Joseph  V ,  aged  twenty-five.     Ataxic 

symptoms  first  noticed  at  the  age  of  thirteen,  but  he 
was  able  to  go  about  and  work  until  the  age  of  eigh- 
teen, when  he  had  what  seems  to  have  been  an  attack 
of  typhoid  fever,  lasting  seven  weeks,  and  after  recov- 
ery he  could  v/alk  only  with  the  aid  of  crutches,  and 
this  aid  soon  became  insufficient,  and  walking  impossi- 
ble. 

Present  Condition. — He  is  unable  to  walk  or  stand, 
and  with  great  difficulty  gets  from  the  floor  to  a  chair  ; 
and  yet  he  goes  down  several  flights  of  stairs,  out  of 
doors,  and  about  the  lawn,  sliding  down  the  stairs,  and 
returning  very  slowly  by  seizing  the  balusters  with  his 
hands  and  drawing  himself  up  a  step  at  a  time.  His 
method  of  locomotion  is  the  same  as  that  of  his  sister, 
drawing  himself  by  the  hands. 

There  is  scoliosis  in  the  dorsal  region.  He  can  ex- 
tend and  flex  the  legs,  and  flex  the  thigh  upon  the 
trunk.  The  same  condition  of  talipes  and  dorsal  flex- 
ion of  the  great  toe  is  present,  as  in  his  sister.  The 
patellar  reflex  is  absent  ;  the  plantar  reflex  well  marked. 
There  is  no  apparent  lack  of  strength  in  the  muscles  of 
the  arm  and  hand,  but  the  inco-ordination  is  much 
greater  than  in  the  case  of  his  sister  ;  and  there  is  the 
same  inability  to  locate  the  position  of  the  limbs  when 
at  rest.  There  is  no  affection  of  the  visceral  or  uri- 
nary organs.  There  is  a  slight  oscillation  of  the  head, 
which  is  increased  by  conversation  or  excitement.  The 
speech  is  slow  and  even  more  unsteady  than  in  the 
previous  case. 

Memory  and  intellect  unimpaired. 

Case    HI. — John    Y ,    aged    twenty-four.      The 

first  symptoms  appeared  at  the  age  of  thirteen,  gradu- 
ally increasing,  and  at  the  age  of  twenty-one  he  gave 
up  walking  altogether,  after  a  few  months'  use  of 
crutches.  No  illness  preceded  and  no  pain  accom- 
panied the  ataxia.  One  bit  of  information  which  he 
gives  concerning  his  childhood  tells  of  inco-ordination 
in  the  arms  at  an  earlier  relative  date  than  is  usually 
given.     He  could  not  drive  a  nail  or  use  a  hammer  at 


July   20,  1895] 


MEDICAL    RECORD. 


87 


all  successfully,  but  always  hit  something  different  from 
that  at  which  he  aimed. 

Present  Condition. — Much  the  same  as  his  brother, 
except  in  degree,  the  symptoms  being  slightly  less 
marked,  as  might  be  expected  from  the  difference  in 
duration  ;  and  both  patellar  and  plantar  reflexes  are 
present. 

C.A.SE    IV. — Julia   V ,  aged    twenty-two,  was  in 

good  health  previous  to  the  first  appearance  of  the  dif- 
ficulty in  walking,  at  the  age  of  fourteen.  Never  had 
any  pain — not  even  a  headache,  and  even  now,  when 
sitting  in  a  chair,  feels  as  though  she  could  get  up  and 
walk  as  well  as  anyone.  Menstruation  began  at  eigh- 
teen, and  has  been  normal. 

Present  Condition. — She  has  a  healthy  appearance 
and  intelligent  expression.  She  walks  only  by  the  aid 
of  a  chair,  but  is  constantly  engaged  in  work  about  the 
house,  and  happiest  when  she  is  busy.  The  ataxia  is 
greater  in  the  right  leg.  In  both  feet,  but  more  marked 
in  the  right,  is  a  condition  of  talipes,  or  rather  an  ap- 
pearance of  exaggeration  in  the  arch  of  the  foot  at  the 
expense  of  its  length.  This  is  more  noticeable  than  in 
any  of  the  others.  The  patellar  reflex  is  absent,  plan- 
tar reflex  normal. 

A  point  which  I  have  noticed  in  all  of  these  cases  is 
a  tendency  to  hyper-extension  of  the  thumbs. 

In  no  one  of  them  has  there  been  pain,  anjesthesia, 
or  girdle  sensation,  and  nystagmus  has  not  appeared  as 
a  prominent  symptom. 

An  examination  of  the  eyes  in  Cases  I.,  II.,  and  III., 
by  Dr.  D.  B.  Cornell,  discovers  some  atrophy  of  the 
optic  nerve.  Accommodation,  pupillary  reflex,  and 
color  sense  are  normal. 


gtagtress  of  pXctTical  Science. 

Combinations  of  Morbid  Conditions  of  the  Chest. — 
Dr.  F.  T.  Roberts,  in  his  Lettsomian  Lectures  on  this 
subject,  easily  makes  good  his  contention  that  such 
combinations  are  very  common  and  that  their  impor- 
tance and  significance  are  inadequately  recognized. 
The  error  of  fixing  the  attention  upon  one  morbid  state 
or  one  prominent  clinical  symptom  is  very  general,  and 
to  immature  minds  and  unskilled  observers  is  practi- 
cally irresistible  ;  but  we  all  need  occasional  reminders 
that  there  are  no  hard-and-fast  lines  in  nature,  and 
that  the  elaborate  classifications  and  hard-and-fast  dis- 
tinctions so  usual  in  text-books,  though  often  practi- 
cally useful,  give  an  erroneous  impression  of  a  fixity 
and  precision  which  as  a  matter  of  fact  do  not  exist. 
( The  Lancet^  Disease  is  not  mathematical  or  me- 
chanical. It  is  fluid,  mobile,  easily  passing  from  one 
transition  to  another,  incapable  of  precise  definition, 
obeying  general  laws  and  definite  principles,  but  not  to 
be  confined  within  the  limits  of  rigid  rules  or  unvary- 
ing formulae.  Specialism  in  medicine  is  always  open 
to  the  reproach  that  disease  refuses  to  recognize  the 
limits  of  the  specialist's  domain.  Dr.  Roberts  wishes 
to  utter  "  an  emphatic  protest  against  the  absurd  de- 
velopment of  specialism  in  relation  to  this  region — i.e., 
the  chest — which  at  the  present  day  is  working  so  much 
mischief  ;  "  and  he  gives  it  as  his  opinion  that  '  the 
practice  of  dealing  with  each  thoracic  organ  as  if  it 
were  entirely  separate  and  distinct,  or,  still  more,  of 
making  a  specialty  of  different  complaints,  is  both 
dangerous  and  absurd."  It  is  evident,  we  think,  that 
any  attempt  to  study  pulmonary  disease  apart  from 
morbid  conditions  of  the  heart  must  be  doomed  to 
failure  ;  and  to  this  extent,  at  all  events,  we  entirely 
concur  in  Dr.  Roberts's  caveat  against  excessive  special- 
ism. But  we  must  beware  of  running  from  one  extreme 
to  another.  Dr.  Roberts  discusses  a  group  of  cases 
characterized  by  a  combination  of  conditions  difficult 
to  define,  but  of  great  practical  importance.     "  In  these 


cases  the  superficial  structures  are  more  or  less  wasted, 
it  may  be  considerably  :  the  chest-walls  are  obviously 
rigid  ;  localized  pleuritic  adhesions  can  be  made  out, 
it  may  be  in  several  spots  ;  there  are  no  gross  lesions 
to  be  detected  in  the  lungs,  but  these  organs  are  evi- 
dently wanting  in  normal  elasticity  and  tending  toward 
degeneration,  perhaps  also  exhibiting  limited  areas  of 
emphysema,  or  there  is  a  suspicion  of  a  fibrotic  change 
here  or  there  ;  sometimes  there  are  indications  of  com- 
mencing atheroma  of  the  aorta,  or  the  heart  is  feeble 
in  its  action  and  is  probably  of  actually  small  size." 
Everyone  is  familiar  with  these  cases  which,  as  the 
lecturer  says,  do  not  belong  to  the  chronic  emphysema- 
tous or  phthisical  groups,  and  are  often,  for  want  of  a 
better  title,  simply  labelled  cases  of  "  weak  chest." 
The  important  practical  point  about  such  cases  is  that 
they  do  well  by  using  suitable  precautions  and  having 
an  occasional  change  of  climate  ;  but  that  even  a 
slight  bronchial  attack  is  a  serious  matter  for  them  and 
that  they  die  really  from  pneumonia  or  other  grave 
acute  affection.  The  prognosis  and  treatment  of  such 
cases  require  to  be  regulated  by  a  due  recognition  of 
the  fact  that  s)'mptoms  trivial  in  themselves  acquire  a 
serious  gravity  when  viewed  in  relation  to  this  peculiar 
type  of  patient.  Dr.  Roberts  protests  against  the  crude 
and  superficial  way  in  which  many  of  the  laity  talk  of 
phthisis,  as  if  the  mere  recognition  of  the  bacillus  ex- 
plained everything.  He  points  out  the  absolute  neces- 
sity of  recognizing  the  numerous  grave  organic  changes 
wrought  by  the  disease,  such  as  consolidations,  tuber- 
culous, inflammatory,  caseous,  or  mixed  ;  miliary  tu- 
bercles, diffused  or  in  groups ;  softening  of  these 
structures  ;  cavities,  reparative  changes,  the  formation 
of  fibroid  tissue,  bronchial  inflammation,  compensatory 
emphysema,  and  the  like.  Cases  of  chronic  pneu- 
monia, in  whatever  way  arising,  "  in  time  assume  a 
decidedly  complex  character.  The  fibroid  change  is 
limited  in  most  cases  mainly  or  entirely  to  one  lung,  or 
a  portion  of  it,  which  is  thus  hardened  and  contracted, 
the  involved  structures  being  rendered  quite  useless  ; 
it  is  often  accompanied  with  the  remains  of  phthisical 
cavities,  and  still  more  frequently  with  dilated  bronchi, 
while  unaffected  areas  of  the  same  lung,  as  well  as  the 
opposite  one,  become  the  seat  of  compensatory  disten- 
tion, which  may  ultimately  terminate  in  true  emphy- 
sema. .  .  .  There  is  an  exceptional  class  of  chronic 
pneumonic  cases  which  may  prove  very  puzzling.  In 
these  one  lung  is  absolutely  solid,  either  throughout  or 
over  a  large  extent,  but  instead  of  being  contracted  it 
is  more  or  less  enlarged.  The  opposite  lung  becomes 
greatly  distended,  and  also  in  some  instances  the  seat 
of  dry  bronchial  catarrh  ;  so  that  the  general  aspect  of 
the  patient,  as  well  as  the  prominent  symptoms,  may  re- 
semble closely  at  first  sight  those  of  an  extreme  case  of 
emphysema  and  bronchitis,  with  an  asthmatic  ten- 
dency." Asthma  and  angina  pectoris  afford  Dr.  Rob- 
erts good  instances  of  the  necessity  of  a  comprehensive 
view  of  chest  ailments.  In  a  large  majority  of  cases 
asthma  "  supervenes  upon  distinct  and  obvious  morbid 
changes  associated  with  the  chest,  which  tend  to  be- 
come more  and  more  pronounced  as  the  case  pro- 
gresses. The  cases  in  which  asthma  occurs  are  usually 
more  or  less  of  the  emphysematous  and  bronchitic 
type  ;  but  rigidity  of  the  chest-walls,  adhesion  of  the 
upper  part  of  the  lung,  and  other  factors,  are  often  of 
much  importance  in  these  cases  in  relation  to  asthmatic 
attacks."  Angina  pectoris  "  usually  complicates  more 
or  less  definite  morbid  conditions  of  an  organic  nat- 
ure. .  .  .  Those  which  are  most  likely  to  be  over- 
looked are  atheroma  or  calcification  of  the  aorta  and 
coronary  arteries,  and  cardiac  degeneration  not  of  a 
pronounced  character.  "  Dr.  Roberts  is  eniphatic  on 
the  importance  of  recognizing  what  may  fairly  be  ex- 
pected from  treatment  and  what  it  is  folly  to  attempt ; 
on  the  necessity  of  wisely  adapting  our  measures  to 
acute  conditions  supervening  on  chronic  ;  on  the  need 
of  grappling  promptly  with  grave  conditions  readily 


MEDICAL   RECORD. 


[July  20,  1895 


amenable  to  treatment — e.g.,  effusions  into  serous  cavi- 
ties ;  on  the  value  of  rest  and  the  simpler  drugs  ;  on 
the  impolicy  of  fussy  therapeutics  and  routine  sympto- 
matic treatment ;  and  on  the  wisdom  of  being  on  our 
guard  in  relation  to  new  ''cures  "  and  vaunted  specifics. 
The  Importance  of  Menstruation  in  Determining 
Mental  Irresponsibility. — In  regard  to  the  mental  irre- 
sponsibility of  women  during  the  menstrual  period, 
Krafft-Ebing  reaches  the  following  conclusions  :  i.  It 
is  useful  to  consider  the  mental  soundness  of  women 
during  menstruation  from  a  medico-legal  point  of 
view.  2.  It  is  advisable,  where  a  woman  is  held  on  a 
criminal  charge,  to  ascertain  whether  the  commission 
of  the  act  coincided  with  the  menstrual  period  ;  and 
by  period  is  meant  not  only  the  days  when  there  is 
actual  flowing,  but  those  before  and  after  as  well.  3. 
It  is  best  to  advise  examination  of  the  mental  condi- 
tion when  such  coincidence  is  established.  This  is  in- 
dispensable when  there  is  a  personal  history  of  neuro- 
pathic defect,  of  mental  disturbance  at  the  time  of  pre- 
vious menstrual  periods,  or  when  the  nature  of  the  act 
reveals  any  striking  features.  4.  When  the  menstrual 
process  exerts  a  powerful  influence  on  the  mental  life 
of  the  subject,  the  accused  should  be  given  the  benefit 
of  extenuating  circumstances  in  the  infliction  of  the 
penalty,  even  although  there  be  no  proof  of  menstrual 
insanity.  5.  When  the  offence  or  crime  has,  in  a  per- 
son whose  mind  is  impaired,  occurred  during  the  men- 
strual period,  she  must  be  declared  irresponsible,  for 
there  is  every  reason  to  believe  the  act  due  to  emo- 
tional impulse.  6.  But  individuals,  who  by  reason  of 
menstrual  insanity  would  benefit  by  acquittal  on  this 
ground,  should  be  considered  as  dangerous  in  the  ex- 
treme and  subjected  during  the  times  of  the  menses  to 
close  surveillance.  It  is  best  to  confine  them  in  an 
asylum  for  the  insane,  where  they  will  be  comfortably 
cared  for  and  often  cured  of  this  menstrual  instability 
of  mind. — New  York  Medical  Times. 

Etiology  of  So-called  Continuous  Fever. — According 
to  Dr.  Chassiotis,  the  two  sources  of  infection  which 
have  been  found  to  cause  the  phenomena  of  so-called 
continued  fever — viz.,  typhoid  and  plasmodia  of 
malaria — have  not  been  found  in  some  cases.  Numer- 
ous observers  have  thought  to  explain  the  origin,  in 
the  absence  of  these,  on  various  hypotheses,  none  of 
which  are  satisfactory.  Chassiotis  had  the  opportunity 
of  examining  and  following  many  cases,  clinically,  and 
subsequently  pathologically  upon  the  autopsy  table. 
Peyer's  patches  and  the  mesenteric  glands  were  care- 
fully examined  for  typhoid  bacilli  without  success  ; 
likewise  resulted  the  search  for  malaria  plasmodia. 
Certain  features  of  these  cases  were  found  to  exist  in 
common  with  those  found  in  malaria,  typhoid  fever,  scar- 
let fever,  diphtheria,  and  other  miasmatic  affections,  i. 
In  various  organs,  especially  the  spleen,  liver,  and  kid- 
neys, were  found  many  embryonal  or  round  cells.  2. 
A  dilatation  of  the  blood-vessels.  Then  many  gran- 
ules of  pigment  as  in  malaria,  and  due  to  destruction  of 
red  blood-cells.  As  regards  the  round  cells  three 
varieties  were  observed  :  i.  Large  cells  with  an  abun- 
dance of  nuclear  chromatin.  2.  Smaller  cells  with  an 
abundance  of  nuclear  chromatin  3.  Smaller  cells  with 
scanty  nuclear  chromatin.  The  examination  of  the  blood 
revealed  the  most  interesting  features  of  Chassiotis's 
observations.  He  discovered  numerous  diplococci,  of 
oval  or  rounded  form  and  varying  in  size.  In  the  be- 
ginning of  the  attack  they  are  very  small,  but  increase 
in  size  as  the  affection  progresses,  attaining  a  length  of 
0.16 /i.  to  2 /i.  The  forms  are  most  perfect  during  the 
exacerbations  of  the  fever ;  they  show  evidences  of  de- 
generation during  the  remissions  of  apyrexia.  One  of 
the  most  characteristic  evidences  of  degeneration  is  the 
failure  of  the  diplococci  to  stain  well  or  uniformly. 
They  are  possessed  of  a  slow  motility  in  the  blood 
plasma,  when  placed  in  a  moist  chamber.  As  they  ap- 
proach the  edge  of  a  red  blood-cell,  they  show  a  trem- 


ulous motion.  Within  the  white  blood-cells  one  or 
more  diplococci  may  be  visible.  They  may  lie  at  the 
periphery  of  the  cells  or  completely  fill  them.  If  the 
temperature  be  very  high  and  there  is  coincident  weak- 
ness and  emaciation  preceding  death,  there  will  be 
marked  poikilocytosis  and  diminution  in  the  numbers 
of  red  blood-cells.  In  this  condition  each  half  of  the 
diplococcus  is  semilunar  in  shape,  with  distinct  space 
between  the  two,  and  appearance  as  though  the  whole 
were  surrounded  by  a  clear  gelatinous  caspule. — Pacific 
Medical  Journal. 

Fetid  Endometritis  of  Old  'Women.— According  to  the 
Paris  correspondent  of  The  Lancet  endometritis  occur- 
ring in  women  after  the  establishment  of  the  menopause 
is  doubtless  due  in  some  instances  to  the  reawakening 
of  an  old  infectious  process  or  to  a  necrobiosis  accom- 
panying the  elimination  of  a  moderate-sized  fibroma  ; 
but  these  causes  cannot  explain  other  cases.  Thus, 
Fritsch,  and,  later,  Patru,  ascribe  its  occurrence  to  a 
destruction  of  the  endometrium.  In  some  of  these  suf- 
ferers the  symptoms  recall  those  of  cancer  of  the  uterus 
— vaginal  irritation,  periodic  flow  of  pus,  emaciation, 
and  straw-colored  complexion.  The  importance  of  a 
correct  diagnosis  in  such  cases  has  impelled  Dr.  Mau- 
range  to  publish  three  observations  of  the  disease,  for 
a  description  of  which  classical  works  on  gynecology 
may  be  vainly  thumbed.  The  first  case  was  that  of  a 
woman,  aged  fifty-five,  in  whom  menstruation  had  ceased 
at  fifty.  For  the  past  few  months  she  had  lost  flesh, 
the  features  were  drawn,  and  the  complexion  yellowish. 
She  complained  of  abdominal  pains,  with  a  constant 
discharge  of  a  horribly  fetid,  thick  liquid — so  great  was 
the  stench  that  her  femme  de  c/iambre  covAA  not  bear  to 
remain  near  her.  An  examination  by  Drs.  Picque  and 
Josias,  surgeon  and  physician  respectively  to  the  Paris 
Hospital,  led  to  the  diagnosis  of  cancer,  despite  the 
smallness  and  mobility  of  the  uterus  and  the  absence  of 
lesions  of  the  os.  Hysterectomy  was  proposed  and  ac- 
cepted, but  fortunately  for  the  patient  the  os  was  first 
dilated  with  laminaria,  the  removal  of  which  gave  exit 
to  a  flow  of  pus,  floating  in  which  were  fragments  of 
mucous  membrane.  Examination  of  one  of  the  frag- 
ments failing  to  confirm  the  diagnosis  of  malignant  dis- 
ease, the  uterus  was  thoroughly  scraped,  with  the  result 
that  recovery  ensued  in  a  month.  Two  years  later  her 
appetite  had  returned,  the  complexion  was  normal,  and 
all  pains  had  ceased.  The  other  two  cases  cited  were 
similar  to  the  first.  It  would  appear  that  the  disease 
occurs  in  women  from  five  to  fourteen  years  after  the 
onset  of  the  climacteric,  that  it  attacks  women  who  have 
had  children  as  well  as  those  who  have  never  been 
pregnant,  and  that  pathological  antecedents  have  no 
appreciable  influence  on  its  occurrence.  The  symptoms 
are  as  detailed  above,  and,  in  addition,  the  sound  enters 
for  a  distance  of  from  seven  to  eight  centimetres  ;  its 
introduction  is  painful  and  its  removal  induces  a  copi- 
ous flow  of  blood-stained  pus  whose  fetidity  surpasses 
even  that  of  cancerous  ichor.  Only  histological  exami- 
nation of  debris  collected  by  curettage  can  enable  us  to 
distinguish  between  this  disease  and  cancer.  In  only 
one  instance  has  this  examination  been  made  (by  Dr. 
Maurange).  The  lesions  discovered  were  those  of 
chronic  catarrhal  endometritis — viz.,  glandular  hyper- 
trophy, leucocytal  infiltration,  and  areolar  hyperplasia. 
Microscopically  the  uterine  mucous  membrane  is 
swollen,  hardly  ever  ulcerated,  and  is  easily  detached 
with  the  curette.  The  prognosis  is  favorable  if  the  fol- 
lowing treatment  be  carried  out  :  Dilatation  of  the  os 
and  thorough  scraping  of  the  uterine  lining,  followed  by 
Uimponnement  of  the  uterine  cavity  with  iodoform  gauze. 


Danger  in  Frozen  Milk. — The  Lancet  is  justly  alarmed 
at  the  growing  trade  in  frozen  milk  from  Holland  and 
Sweden,  where  there  is  no  guarantee  as  to  its  freedom 
from  contamination. 


July  20,  1895] 


MEDICAL   RECORD. 


89 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  July  20,  1895. 


A    STUDY    OF    TWINS. 

The  subject  of  plural  births  in  the  human  animal 
is  one  that  has  always  attracted  the  attention  of  the 
curious,  whether  regarded  from  the  anatomical  or  from 
the  developmental  point  of  view.  A  recent  noteworthy 
contribution  to  the  literature  of  twins  is  a  comparison 
of  the  statistics  furnished  by  the  lying-in  hospitals  of 
the  Scandinavian  countries,  and  a  study  of  a  large  num- 
ber of  personal  observations,  published  by  Dr.  Drejer, 
in  Christiania.*  The  author  has  had  abundant  oppor- 
tunity, as  physician  to  the  large  lying-in  hospital  of 
Christiania,  for  studying  his  subject,  and  although  he 
presents  little  that  is  new  yet  his  contribution  is  valu- 
able, as  is  every  study  based  upon  facts. 

Multiple  births  occur  on  the  average  in  1.17  percent, 
of  all  cases,  but  this  percentage  varies  within  pretty 
wide  limits  in  different  races  ;  among  Europeans  it 
appears  to  be  highest  in  Slavonic  peoples  and  lowest 
in  the  Latin  races.  The  number  of  twin  pregnancies 
is  greater,  both  relatively  and  actually,  among  those 
living  in  the  country  than  in  city  dwellers,  and  among 
the  latter  the  proportion  seems  curiously  to  vary  in- 
versely as  the  size  of  the  town. 

There  is  a  certain  relation  between  human  fecundity 
in  general  and  the  frequency  of  twin  births,  but  there 
are  also  notable  differences.  Thus,  a  woman  is  at  the 
period  of  maximum  fecundity  at  the  beginning  of  her 
sexual  life,  during  the  early  years  of  her  marriage, 
and  while  the  husband  is  still  young,  but  twin  concep- 
tions are  more  common  in  later  sexual  life,  in  women 
who  have  married  late,  and  in  cases  in  which  the  hus- 
band is  considerably  older  than  the  wife. 

The  origin  of  the  twins,  whether  from  one  ovum  or 
two,  was  determined  by  Dr.  Drejer  from  an  examina- 
tion of  the  membranes,  a  single  placenta  indicating  a 
uni-ovular  origin.  In  the  cases  studied  by  the  author 
the  ratio  of  uni-ovular  to  bi-ovular  twins  was  as  1:3.7. 
a  much  larger  proportion  of  uni-ovular  twins  than  other 
investigators  have  found.  In  ninety-six  cases,  the  pla- 
centas were  weighed  and  were  found  to  be  as  heavy 
relatively  as  in  single  pregnancies.  The  umbilical  cord 
was,  as  a  rule,  shorter  than  in  normal  pregnancies,  and 
its  insertion  was  frequently  marginal. 

The  diagnosis  of  twins  is  impossible  before  the  end 
of  the  sixth  month,  and  is  at  all  times  very  difficult 

'  Om  Tvillinger,  af  P.  Drejer,  Praktiserende  Laege.  Kristiania 
Det  Steenske  Bogtrykkeri,  1895. 


until  labor  has  actually  begun.  In  only  48.8  per  cent, 
of  twin  pregnancies  were  the  children  carried  to  full  term. 
The  birth  of  the  first  child  is  apt  to  be  tedious,  owing 
to  the  fact  that  the  uterus  works  at  a  disadvantage 
through  the  body  of  the  other  child,  but  the  birth  of 
the  second  child  is  easy  and  rapid  because  of  the  very 
effectual  dilatation  of  the  parts.  The  presentation  in 
Dr.  Drejer's  cases  was  usually  occipital,  though  less  fre- 
quently so  than  in  normal  childbirth  ;  breech  presenta- 
tions were  common,  especially  of  the  second  child.  In 
.  one  of  the  author's  cases  the  placenta  of  the  first  child 
was  expelled  before  the  second  child  was  born,  but  in 
all  the  other  cases  the  two  children  were  born  first  and 
then  the  placentas,  these  usually  together.  The  ques- 
tion as  to  how  long  the  accoucheur  should  wait  after 
the  birth  of  the  first  child  before  taking  measures  to 
hasten  the  expulsion  of  the  second  is  one  that  has  given 
rise  to  more  or  less  discussion.  In  the  Maternity  at 
Christiania,  Professor  Schoenberg  has  established  the 
rule  to  wait  a  full  hour  after  the  birth  of  the  first  child, 
and  it  is  found  that  the  accouchement  is  spontaneously 
completed  within  that  period  in  eighty  per  cent,  of  the 
cases. 

Among  twins  the  number  of  boys  is  greater  than  that 
of  girls,  although  the  disproportion  is  not  so  great  as 
in  normal  pregnancies  ;  some  observers  have  even  as- 
serted that  girls  are  in  excess.  The  two  children  are 
more  apt  both  to  be  girls  than  to  be  of  opposite  sexes. 

Of  the  twin  births  occurring  in  the  author's  practice, 
13.22  per  cent,  of  the  children  were  still-born,  and  1 1.98 
of  those  born  alive  died  within  two  weeks,  a  mortality 
much  in  excess  of  that  following  single  births.  The 
prognosis  for  the  mother  is  somewhat  less  favorable 
than  in  uniparous  accouchements — the  increased  mor- 
tality in  the  cases  studied  being  due  to  the  complica- 
rions  of  pregnancy  and  child-birth,  and  especially  to 
eclampsia.  The  danger  of  infection  is  perhaps  a  little 
greater  than  in  the  case  of  single  birth,  but  in  none  of 
the  author's  cases  did  death  occur  from  puerperal  sep- 
ticaemia. 

ACROMEGALY   AND    GIGANTISM. 

About  a  year  ago  an  article  appeared  in  the  Journal 
of  Nervous  and  Mental  Diseases,  by  Dr.  C.  L.  Dana,  in 
which  he  described  the  brain  of  a  person  who  was  of 
gigantic  stature,  and  who  had  acromegaly.  The  idea 
was  suggested  that  gigantism  was  a  disease  allied  to 
acromegaly,  and  that  both  were  dependent  upon 
disease  or  perverted  functioning  of  the  pituitary 
gland.  A  number  of  cases  of  giants  with  acromegaly 
were  cited  in  evidence. 

It  seems  that  this  theory  was  not  propounded  first  by 
Dr.  Dana,  for  in  a  recent  article  by  Dr.  Robert  Massa- 
longo,  of  the  University  of  Padua,  the  claim  is  made 
that  he  published  a  theory  of  gigantism  and  acromegaly 
as  long  ago  as  1892. 

At  the  International  Congress  held  in  Rome  last 
year.  Professor  Tamberini  also  published  an  article 
upon  acromegaly,  in  which  he  asserted  the  same  views, 
and  cited  a  number  of  cases  in  which  examination  of 
the  skeleton  of  giants  showed  that  they  were  really 
cases  of  acromegaly. 

Dr.  Massalongo  believes  that  the  pituitary  gland  is 


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[July  20,  1895 


excessively  active  in  its  functioning  in  all  cases  of  real 
gigantism  ;  that  after  this  condition  has  reached  its 
climax,  however,  the  gland  begins  to  undergo  retro- 
grade changes,  and  coincidentally  with  this,  the  indi- 
vidual himself  begins  to  show  evidences  of  physical  and 
mental  decay.  In  the  cases  of  acromegaly,  he  believes 
that  the  process  is  less  complete,  and  that,  in  fact, 
acromegaly  is  only  an  abortive  type  of  gigantism,  both 
conditions  being  dependent  upon  this  same  underlying 
pathological  change.  A  number  of  new  giants  are 
brought  forward  in  support  of  this  view. 

Other  authors,  who  take  a  more  sceptical  view  regard- 
ing the  importance  of  the  pituitary  gland  in  its  relation 
to  excessive  growth,  state  that  while  it  is  true  that  the 
majority  of  giants  are  cases  of  acromegaly,  yet  this  is 
due  simply  to  the  fact  that  gigantism  furnishes  a  fruit- 
ful soil  for  the  disease  acromegaly  to  grow  upon.  In 
other  words,  giants  are  more  disposed  to  acromegaly 
than  ordinary  individuals,  hence  the  excessive  propor- 
tion of  such  among  them. 

The  subject  is  certainly  an  interesting  one,  although 
somewhat  academic,  so  far  as  the  ordinary  practitioner 
of  medicine  is  concerned. 


OSTEOPATHY. 

Life  in  the  United  States  of  America  is  made  much 
more  interesting,  if  not  more  safe,  by  reason  of  the 
various  medical  and  surgical  vagaries  that  crop  out 
over  the  land.  We  venture  to  say  that  in  no  other 
country  could  such  interesting  phenomena  as  Chris- 
tian science,  "  Perkinism,"  vegetarianism,  Thomp- 
sonianism;  mental  healing,  and  a  number  of  other 
interesting  forms  of  pathological  activity,  develop.  No 
sooner  is  one  thoroughly  exploited,  than  it  begins  to 
spread  around  the  country  ;  then,  after  a  few  years  of 
picturesque  and  uneven  existence,  it  dies  out.  Among 
the  latest  of  the  medico-surgical  cults,  is  what  is  known 
in  the  West  as  "  Osteopathy."  It  seems  that  at  Kirks- 
ville,  Mo.,  there  is  or  was  an  institution  known  as  the 
"  Medical  School  of  Osteopathy."  This  school  turns 
out  a  class  of  practitioners  who  call  themselves  "  osteo- 
paths," and  they  have  made  themselves  quite  popular 
in  certain  sections  of  the  great  Southwest.  The  per- 
son who  is  at  the  bottom  of  "  osteopathy,"  possesses 
not  only  skill  in  developing  a  medical  art,  but  also  in 
manipulating  politicians.  He  succeeded  in  getting  a 
bill  through  both  houses  of  the  Illinois  Legislature, 
amending  the  Medical  Practice  Act  of  that  State. 
The  amendment  was  in  the  form  of  a  law,  which  stated 
that  nothing  "  in  this  Act  shall  be  considered  to  pro- 
hibit services  in  a  case  of  emergency,  or  the  adminis- 
tration of  family  remedies,  or  the  practice  of  osteo- 
pathy." The  bill  was  vetoed  by  the  governor,  who  gave 
the  assurance,  however,  that  any  one  confining  his 
treatment  to  physical  manipulation  would  not  be  prose- 
cuted, thereby  giving  the  "osteopaths"  a  quasi  stand- 
ing before  the  law. 

We  learn  from  the  Medical  Fortnightly  that  osteo- 
pathy has  become  so  popular  in  Missouri  as  to  call  for 
scientific  investigation  of  its  merits,  and  Dr.  Steele,  of 
St.  Louis,  took  the  trouble  to  make  such  an  investiga- 
tion.    He  reports  that  the  theory  of  the  new  school  is 


this  :  There  are  two  kinds  of  diseases,  one  coming  from 
the  displaced  bones  of  the  extremities,  causing  deformi- 
ties, pain,  etc.;  the  other  from  dislocation  of  some  of 
the  vertebrae,  giving  rise  to  diseases  of  the  trunk.  The 
same  treatment,  however,  cures  all  cases,  and  this  treat- 
ment consists  in  acts  of  manipulation,  with  perhaps  an 
element  of  "  suggestion."  He  says  that  the  method 
certainly  effects  cures  in  cases  of  chronic  rheumatism 
and  sprains,  in  old  dislocations,  and  in  hysterical  and 
neurasthenic  pains.  In  other  words,  osteopathy  is 
practically  a  form  of  massage. 


BATHING    AND    DISEASE   OF   THE    EAR. 

Now  that  the  summer  season  is  at  hand  it  may  be  well 
to  remind  our  readers  of  some  of  the  aural  mishaps 
which  occur  to  those  who  indulge  in  bathing,  particu- 
larly in  sea  bathing,  where  there  is  a  good  deal  of  con- 
cussion from  the  surf.  A  correspondent  of  the  Lancet, 
Dr.  A.  H.  Cheatle,  says  that  the  common  accidents  to 
the  ear  are  acute  inflammation  of  the  middle  ear,  dif- 
fuse inflammation  of  the  external  ear,  the  lighting  up 
of  an  acute  condition  in  a  chronic  suppurating  otitis 
media,  simple  deafness  due  to  swelling  of  aceruminous 
plug.  Besides  this  there  are  occasionally  troubles  from 
diving,  such  as  concussion  of  the  labyrinth  and  rupture 
of  the  membrana  tympani.  In  order  to  avoid  these  acci- 
dents. Dr.  Cheatle  says  that  persons  suffering  from  mid- 
dle-ear discharge  should  never  bathe  at  all,  and  that 
those  who  have  had  middle-ear  discharge  and  whose 
membranes  have  healed  should  never  bathe  without 
some  efficient  means  for  preventing  the  water  from  en- 
tering the  ears,  such  as  firm  plugs  of  cotton-wool  with 
an  oil-skin  cap  fitting  tightly  over  them.  Water  remain- 
ing in  a  healthy  ear  should  be  let  out  as  soon  as  possible. 
Acute  otitis  seems  to  be  occasionally  caused  by  w-ater 
which  has  entered  the  naso-pharynx,  hence  the  nose 
should  be  protected.  Some  advise  that  everyone  who 
bathes  should  introduce  a  plug  of  cotton  in  the  ear. 


^cxus  of  ttie  'B^eefe. 

The  Medico-legal  Society.  —  The  Medico-legal  So- 
ciety of  this  city,  which  makes  a  specialty  of  holding 
congresses,  has  decided  to  hold  another  one  in  1895. 
The  meeting  will  be  held  in  or  near  this  city,  Septem- 
ber 4th,  5th,  and  6th,  and  the  science  of  medical  juris- 
prudence will  be  discussed  under  nine  different  head- 
ings, ranging  all  the  way  from  bacteriology  to  chemistry 
and  crime. 

The  Case  of  Secretary  Gresham. — In  the  journal  of 
the  American  MeJical  Association  for  June  26th,  Dr. 
W.  W.  Johnston,  of  Washington,  gives  in  great  detail 
the  clinical  history  of  the  last  illness  of  the  late  Secre- 
tary of  State.  Mr.  Gresham  was  taken  ill  April  30th, 
with  an  acute  pleurisy  with  effusion.  The  disease  ran 
about  the  ordinary  course,  and  at  the  end  of  three 
weeks  he  was  apparently  convalescent.  Suddenly, 
without  much  warning,  an  attack  of  pneumonia  de- 
veloped, from  which  the  patient  died  on  the  third  day. 


July  20,  1895] 


MEDICAL   RECORD. 


91 


The  Secretary  was  evidently  carefully  watched  and 
skilfully  treated.  We  scarcely  see  the  necessity,  how- 
ever, of  publishing  the  minute  details  of  such  an  illness, 
including  the  amount  of  buttermilk  drank,  the  number 
of  stools,  etc.;  but  the  record,  as  a  whole,  is  an  interest- 
ing account  of  the  untimely  and  fatal  illness  of  the  la- 
mented Secretary. 

The  Third  International  Congrress  of  Physiologists 

will  be  held  in  Berne,  Switzerland,  on  September  9  to 
13,  1895,  under  the  presidency  of  Professor  Kronecker, 
Director  of  the  Physiological  Institute  of  the  Univer- 
sity of  Berne.  The  official  languages  of  the  Congress 
will  be  French,  German,  and  English.  The  cost  of 
membership  is  ten  francs.  Titles  of  communications 
may  be  sent  to  Frederic  S.  Lee,  Secretary  of  the 
American  Physiological  Society,  Columbia  College, 
New  York  City. 

The  Late  Dr.  John  M.  Byron.— At  a  meeting  of  the 
Medical  Board  of  Columbus  Hospital,  held  July  8, 
1895,  the  following  action  was  taken,  relative  to  the 
death  of  Dr.  John  M.  Byron,  late  Visiting  Physician 
and  Pathologist  to  the  Hospital. 

1.  That  we  deeply  regret  the  loss  of  Dr.  John  M. 
Byron,  Visiting  Physician  and  Pathologist  to  Columbus 
Hospital,  and  that  we  desire  to  place  in  the  records  of 
the  hospital  the  following  sentiments,  as  an  expression 
of  our  regard  for,  and  appreciation  of,  our  late  associ- 
ate. 

2.  That  in  his  death  the  science  of  bacteriology  has 
lost  a  student  whose  intelligent  devotion  to  investiga- 
tion would  have  placed  him  among  the  most  illustrious 
workers  of  that  branch  of  medicine. 

3.  That  his  successful  career,  prematurely  cut  short 
by  an  infection  derived,  as  he  believed,  from  his  daily 
laboratory  work,  has  furnished  another  example  of  that 
true  self-sacrifice,  so  characteristic  of  medical  men  in 
their  devotion  to  duty. 

4.  That  we  deeply  sympathize  with  his  family  in 
their  bereavement,  and  it  is  hereby  ordered  that  the 
foregoing  record  be  transmitted  to  them,  and  sent  to 
the  local  medical  journals  for  publication. 

Stephen  Smith,  M.D., 

President  of  the  Medical  Board. 
Charles  H.  Lewis,  M.D.,  Secretary. 

Dr.  F.  T.  Roberts  has  been  appointed  professor  of 
medicine  to  succeed  Dr.  Charlton  Bastian,  at  the  Uni- 
versity College,  London. 

Rabies  in  England. — Rabies  is  said  to  be  increasing 
in  England.  In  the  first  five  months  of  the  year  1892 
there  were  only  11  cases  reported.  During  the  same 
period  of  the  following  year  there  were  37  cases,  while 
in  the  first  half  of  1894  the  number  of  cases  reported 
was  80  ;  and  this  year  it  is  373. 

The  Southern  Medical  Record  has  changed  hands, 
and  is  now  under  the  management  of  Dr.  Bernard 
Wolf,  of  Atlanta,  Ga. 

The  Medical  Society  ofVirginia  will  meet  in  Wythe- 
ville,  on  September  3d.  The  President  is  Dr.  Robert 
J.  Preston,  of  Marion.  The  Virginia  Society  now  num- 
bers   860   members,  and  it    is  hoped  that  the  coming 


meeting  will  result  in  increasing  the  membership  to 
1,000. 

Laboratory  Diphtheria.— Dr.  Ruffer,  the  Director  of 
the  British  Institute  of  Preventive  Medicine,  whose  re- 
searches in  regard  to  the  antitoxin  treatment  of  diph- 
theria are  so  well  known,  recently  contracted  a  severe 
attack  of  the  disease  in  the  course  of  his  investigations. 
Immediately  on  the  nature  of  his  complaint  being  as- 
certained he  was  treated  by  antitoxic  serum,  and,  we 
are  glad  to  learn,  with  most  satisfactory  results,  as  at 
last  reports  he  was  making  very  good  progress  toward 
recovery. 

The  Force  of  the  Human  Jaw. — Dr.  J.  V.  Black,  a 
dentist,  of  Jacksonville,  Fla.,  has  made  some  experi- 
ments as  to  the  force  exerted  by  the  human  jaw  in 
chewing  food.  He  says  that  the  amount  of  pressure 
recorded  in  a  single  bite,  varies  from  thirty  to  two 
hundred  and  seventy  pounds.  This  maximum  record, 
it  is  interesting  to  note,  was  made  by  a  physician. 
The  crushing  force  necessary  to  masticate  ordinary 
beefsteak.  Dr.  Black  says,  is  only  forty  to  forty-five 
pounds,  but  the  doctor  has  probably  never  lived  in  a 
boarding-house.  He  says  that  usually  a  good  deal 
more  force  is  applied  than  is  necessary,  viz.,  from  sixty 
to  eighty  pounds,  and  he  laments  somewhat  this  waste 
of  energy. 

Ipecac  in  the  Insomnia  of  Alcoholism. — Some  years 
ago  ipecac  was  greatly  advocated  as  a  hypnotic  in  in- 
somnia due  to  alcoholism.  Recently  Dr.  Waugh  has 
discovered  that  twenty  minims  of  the  fluid  extract  of 
ipecac  caused  sleep  in  a  patient  when  large  doses  of 
sulphonal  had  failed. 

An  Economist. — "  If  you  insist  on  knowing  the  truth, 
madam,"  said  the  doctor,  "  your  husband  will  not  live 
twenty-four  hours  longer."  "  Good  gracious  !  "  ejacu- 
lated the  broken-hearted  but  economical  wife,  "and 
yet  you  have  sent  in  medicine  enough  for  five  days." — 
Flieg.  Blatter. 

Cholera  is  reported  to  be  alarmingly  prevalent  in 
Prussian  Silesia. 

The  Ontario  Medical  Council The  Council  of  the 

College  of  Physicians  and  Surgeons  of  Ontario  met  on 
June  nth  at  the  Council  Building,  Toronto,  and  was 
in  session  two  weeks.  The  following-named  members 
were  elected  officers  for  the  current  year  :  President, 
William  T.  Harris,  M.D.,  Brantford  ;  Vice-President, 
A.  F.  Rogers,  M.D.,  Ottawa;  Registrar,  R.  A.  Pyne, 
M.D.,  Toronto  ;  Treasurer,  W.  T.  Aikins,  M.D.,  To- 
ronto ;  Solicitor,  B.  B.  Osier,  Q.  C,  Toronto. 

The  Hyams  Case. — A  great  deal  of  professional  in- 
terest has  been  aroused  in  Canada  by  what  is  known  as 
the  Hyams  Case.  According  to  the  Canadian  Practi- 
tioner, life  insurance  men,  elevator  experts,  surgeons, 
and  medical  jurists  have  all  taken  part  in  it.  A  young 
man  named  Wells  was  found  dead  at  the  foot  of  an  ele- 
vator shaft,  and  an  examination  apparently  showed 
that  the  head  alone  had  been  injured.  No  special  ex- 
amination was  made  at  the  time  the  body  was  found, 
and  two  years  passed  before  suspicions  of  foul  play 
were  strong  enough  to  call  for  further  investigation. 
The  body  was  then   exhumed   and   examined  with  as 


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MEDICAL    RECORD. 


[July  20,  1895 


much  minuteness  as  possible  under  the  circumstances. 
The  head  alone  was  damaged,  but  the  injuries  to  it 
were  of  such  a  character  as  to  completely  destroy  its 
continuity,  for  fractures  were  found  involving,  not  only 
the  vault,  but  the  base,  the  face,  and  even  the  lower 
jaw.  The  photographs  published  by  the  Practitioner 
showed  that  the  skull  was  apparently  almost  commi- 
nuted by  the  force  of  the  blow  or  fall,  or  both.  The 
ground  taken  by  the  prosecution  was  that  more  than 
one  blow  was  necessary  to  cause  all  the  injuries  found. 
A  large  number  of  experts  were  summoned  on  each 
side,  and  the  case  was  brought,  according  to  our  con- 
temporary, to  "  an  unsatisfactory  termination,"  but 
what  that  termination  is  we  are  not  informed.  The 
weight  of  the  medical  evidence  seems  to  have  been 
that  more  than  one  blow  was  necessary  in  order  to  pro- 
duce the  effects  upon  the  skull. 

The  Absorption   of  Salicylic  Acid Drs.  Lenoissier 

and  Lanois  have  made  some  experiments  upon  the 
method  of  absorption  of  salicylic  acid.  They  found 
that  the  application  of  salicylic  acid  in  solution  upon 
the  skin  led  to  its  absorption  in  small  amount.  They 
made  some  experiments  upon  the  method  by  which 
this  was  absorbed.  When  dissolved  in  alcohol,  and 
placed  upon  the  arm  and  then  covered  with  a  bandage, 
it  was  found  that  the  acid  was  not  absorbed  if  the  skin 
was  kept  cool.  If,  on  the  other  hand,  it  was  kept  warm 
by  external  applications,  salicylic  acid  was  soon  found 
in  the  urine.  They  concluded,  therefore,  that  the 
salicylic  acid  is  volatilized  and  absorbed  in  that  way. 
The  fact  that  this  drug  has  a  considerable  efficacy 
when  applied  externally  in  rheumatism  is  well  known, 
and  the  explanation  of  the  method  of  absorption  seems 
to  be  satisfactorily  determined. 

New  York  and  Paris  Saloons.— While  New  York  is 
trying  to  get  its  saloons  open,  Paris  is  trying  to  get 
some  of  hers  shut.  New  York  has  about  9,000  saloons. 
Paris  had,  in  1890,  29,583  wine-shops.  Eminent  physi- 
cians, such  as  Laquean  and  Lancereaux,  consider  that 
the  abuse  of  alcohol  is  increasing  the  amount  of 
phthisis  in  Paris.  In  1893  there  were  10,681  deaths 
from  this  disease,  about  two-thirds  being  in  men.  In 
New  York  the  total  deaths  from  this  disease  were,  in  i  S93, 
only  2,128.  It  is  evident  that  phthisis,  like  the  wine- 
shops, is  two  or  three  times  more  prevalent  in  Paris. 

Shall  Insane  Criminals  be  Imprisoned  or  Put  to 
Death  1 — In  the  communication  with  this  title  appear- 
ing in  the  issue  of  July  13th,  the  address  of  the  author, 
Dr.  J.  B.  Ransom,  should  be  Dannemora  instead  of 
Clinton.  On  pages  40  and  41,  where  figure  6  is  men- 
tioned in  the  text,  it  should  read  figure  13,  and  figure 
7  should  read  figure  12. 

Imprisonment  of  a  Physician  for  Negligent  Prescrip- 
tion.—A  young  physician  in  Berlin  has  been  recently 
condemned  to  a  month's  imprisonment  for  homicide 
through  negligence  (fahrlassiger  Todlung).  He  had  a 
woman  under  treatment  suffering  from  obstinate  tri- 
geminus neuralgia.  She  came  to  him  on  May  22d  to 
ask  for  a  prescription  for  a  narcotic,  as  she  had  suf- 
fered from  sleeplessness  for  a  long  time.  Knowing 
that  she  did  not  react  well  to  narcotics,  he  prescribed 
6   grammes   (i>^    drachm)   of   chloral   hydrate.      He 


signed  the  prescription  :  "  To  be  taken  in  two  portions 
before  going  to  bed."  The  apothecary  also  wrote  the 
same  directions.  The  woman  told  her  friends  that  ac- 
cording to  the  doctor's  orders  she  was  to  take  half  be- 
fore going  to  bed,  and  the  remainder  after  getting  into 
bed.  After  taking  the  first  half  she  seemed  drunk, 
she  became  lively,  laughed,  and  gesticulated  ;  she  then 
received  the  second  half  and  never  woke  again.  The 
autopsy  resulted  in  the  verdict  of  death  by  intoxica- 
tion with  chloral  hydrate.  The  chemical  investigation 
showed  that  not  more  than  six  grammes  had  been 
taken.  The  Pharmacopoeia  prescribes  three  grammes 
as  the  maximum  dose.  The  prescription,  however,  or- 
dered six  grammes,  to  be  taken  in  two  portions,  the 
one  shortly  after  the  other.  The  accused  stated  that 
he  had  repeatedly  impressed  on  the  patient  that  she 
should  take  half  at  once,  and  if  she  did  not  then  sleep 
she  should  take  a  teaspoonful  more  after  an  interval  of 
five  hours  ;  the  remainder  she  should  take  the  follow- 
ing morning.  The  statements  of  all  the  friends  of  the 
deceased  were  opposed  to  this,  however.  The  court, 
after  the  interrogation  of  two  experts,  awarded  a 
month's  imprisonment,  as  it  held  it  to  be  proved  that 
the  fatal  result  was  solely  attributable  to  the  ambigu- 
ous directions,  and  that  the  physician,  in  exceeding  the 
maximum  dose,  was  in  duty  bound  to  exercise  the 
greater  caution. — Medical  Press. 

Piano  Playing  and  Neuroses.  —  A  corresponding 
member  of  the  Paris  Academy  of  Medicine  has  sent  to 
that  learned  body  a  memoir  in  which  he  maintains  that 
the  numerous  cases  of  chlorosis,  neuroses,  and  neuras- 
thenia obsersed  among  young  girls  is  due  to  learning 
to  play  on  the  piano  and  the  hours  devoted  to  practis- 
ing. He  has  drawn  up  careful  statistics  from  which  he 
concludes  that,  among  six  thousand  pupils  obliged  be- 
fore attaining  the  age  of  twelve  to  learn  to  play  the 
piano,  nearly  twelve  per  cent,  suffer  from  nervous 
troubles.  The  author  does  not  attempt  to  draw  up 
statistics  of  the  victims  among  persons  who  have  to 
listen  to  their  performances. — British  Medical  Journal. 

Dr.  George  F.  Shrady  has  been  appointed  attending 
surgeon  to  Columbus  Hospital. 

Obituary  Notes. — Dr.  C.  M.  Fields,  died  on  July 
12th  at  Plainfield,  N.  J.,  from  an  overdose  of  morphine 
and  cocaine.  He  was  found  in  his  apartments  in  an 
unconscious  condition.  He  was  compelled  to  cease 
practice  several  years  ago,  and  since  that  time  he  has 
travelled  extensively  in  foreign  countries.  He  was  bom 
in  Bound  Brook,  and  was  forty-five  years  old. — Dr. 
JuDSON  C.  Nelson,  of  Truxton.  Cortland  County, 
N.  Y.,  died  July  nth,  of  angina  pectoris,  in  his  seventy- 
second  year.  He  was  a  graduate  of  Geneva  College  in 
1848,  and  began  practice  at  once  in  Truxton.  He 
went  out  as  surgeon  of  the  Seventy-sixth  New  York 
Volunteers.  After  the  war  he  returned  to  Truxton, 
where  he  had  an  extensive  practice,  both  family  and 
consultation.  He  was  a  gentleman  of  fine  appearance, 
although  his  health  had  been  much  impaired  by  his 
army  life.  He  was  a  Democrat  and  served  two  terms 
in  the  Assembly.  He  had  also  filled  other  offices  in 
the  county.  He  leaves  a  wife,  a  son,  and  a  married 
daughter. 


July  20,  1895] 


MEDICAL    RECORD. 


§lewiex»s  and  polices. 

Ectopic  Pregnancy  :  Its  Etiology,  Classification,  Embry- 
ology, Diagnosis,  and  Treatment.  Bv  J.  Clarence  Web- 
ster, B.A.,  M.D.,  F.R.C.P.  Ed.,  Assistant  to  the  Pro- 
fessor of  Midwifery  and  Diseases  of  Women  and  Children 
in  the  University  of  Edinburgh.  With  Eighty  Illustra- 
tions of  Naked  Eye  and  Microscopic  Appearances.  Pp. 
340.     New  York  :  Macmillan  &  Co.     1895. 

The  work  is  most  comprehensive,  scientific,  and  scholarly. 
It  will  prove  a  great  acquisition  to  the  knowledge  of  the  pro- 
fession on  this  much-disputed  subject.  The  points  which 
render  it  of  special  value  are  its  intelligent  review  of  the 
previous  literature,  a  broad  discussion  of  the  theories  as  to 
the  causation  of  ectopic  pregnancy,  and  an  exposition  of 
existing  conditions,  which  have  a  greater  value  than  anv 
hitherto  advanced,  owing  to  the  fact  that  it  is  supported  by 
the  evidence  given  by  frozen  sections  prepared  by  Dr.  Berrv 
Hart  and  the  author.  These,  with  the  careful  microscopic 
studies,  give  a  practical  value  to  the  work  which  cannot  fail 
to  make  it  appreciated. 

In  his  chapter  on  treatment  he  says  that  the  tendency  of 
the  present  time  is  toward  the  non-employment  of  electrici- 
ty. He  doubts  that  without  puncture  of  the  sac  sufficiently 
strong  currents  can  be  employed  to  prove  efficacious.  He 
favors  abdominal  incision  rather  than  the  vaginal  rnethnds 
of  reaching  the  tumor  in  surgical  procedure. 

Medical  Gynecology.  A  Treatise  on  the  Diseases  of 
Women  from  the  Stand-point  of  a  Physician.  Bv  Alex- 
ander J.  C.  Skene,  M.D.,  Professor 'in  the  Long  Island 
College,  Brooklyn,  formerly  Professor  in  the  New  York 
Post-Graduate  Medical  School,  etc.  With  Illustrations. 
Pp.  529.     New  York :   D.  Appleton  &  Co.     1895. 

Dr.  Skene  writes  this  book  to  advocate  conservative  meas- 
ures in  gynecology,  and  to  accentuate  the  importance  of 
medical  treatment,  and  its  success,  rather  than  the  surgical 
and  radical  measures,  to  which  gynecologists  are  tempted 
to  resort  in  their  haste  to  obtain  speedy  and  brilliant  re- 
sults. The  intention  is  a  laudable  one,  and  the  long  experi- 
ence of  Dr.  Skene  in  the  practice  of  the  diseases  of  women 
has  not  failed  to  yield  results  that  are  of  use  and  profit  to 
the  profession,  as  embodied  in  this  work.  In  his  discussion 
of  the  general  conditions  of  woman  in  her  mental  and  phvs- 
ical  education,  her  heredity  and  environment,  it  is  evident 
that  the  writer  is  not  thoroughly  acquainted  with  "  the  new 
woman."  The  reader  will  find  of  especial  value  his  chap- 
ters on  pelvic  inflammations  and  the  diseases  of  the  urinary 
organs.  His  wide  experience  in  Kings  County  Insane  Asy- 
lum is  the  basis  upon  which  he  gives  the  result  of  his  ex- 
perience. He  agrees  with  the  few  gynecologists  that  have 
had  to  do  with  these  unfortunate  women,  that  systematic 
gynecological  treatment  is  impossible  for  them,  and  that 
the  only  results  are  those  which  can  be  obtained  from  treat- 
ment given  under  the  influence  of  an  anesthetic.  He  finds 
nitrous  oxide  gas  the  most  useful  and  easily  administered 
anaesthetic  for  this  purpose. 

The  Evolution  of  the  Diseases  of  Women.  Bv  W. 
Balls  -  Headley,  M.A.,  M.D.,  F.R.C.P.  Pp. '375. 
London  :  Smith,  Elder  &  Co.     1894. 

The  author,  who  is  the  Lecturer  on  Obstetrics  and  Diseases 
of  Women  at  the  University  of  Melbourne,  gives  us  the 
rather  unusual  view  of  gynecology,  that  of  the  Australian. 
The  writer  is  determined  to  make  good  the  promise  of  his 
title,  and  one  could  almost  believe  that  he  had  taken  the 
word  evolution  and  its  adjective  evolutionary  as  a  trade- 
mark, by  which  all  his  chapters  were  to  be  kno\vn.  His 
definition  of  subinvolution  illustrates  what  is  meant.  "  Sub- 
involution," he  says,  "is  an  evolutionary  state  in  which  the 
various  structures  hypertrophied  by  pregnancy  and  stretched 
by  parturition  have  failed  to  return  to  their  normal  retracted 
state,"  etc.  Under  the  discussion  of  every  disease  there  is 
a  paragraph  entitled  "  Progressive  Evolutionary  Disease." 
This  continual  reiteration  is  not  always  apropos,  and  mars 
the  effect  of  the  work.  He  has  given  introductory  chapters 
on  sexual  relations  and  modern  marriages,  lamenting  the 
lateness  of  marriages,  and  the  decrease  of  offspring.  He 
exaggerates,  judging  from  an  American  standpoint,  the 
difficulties  of  childbirth,  when  he  says,  "  One  out  of  nine  in 
hospitals  and  a  larger  percentage  among  the  upper  classes 
cannot  produce  her  child  without  the  aid  of  forceps,  and 
many  more  not  without  lacerations,  misplacements,  and 
evolving  disease."     In  inflammatory  diseases  of  the  uterus 


and  displacements  in  \-irgins  he  gives  great  prominence  as 
an  etiological  factor  to  unsatisfied  sexual  desire.  Instead  of 
being  a  usual  cause,  it  is  very  rare,  judging  from  American 
stand-point  and  observation. 

The  book  is  written  clearly,  concisely,  and  comprehen- 
sively. The  chapters  on  the  various  diseases  present  clear 
pictures  to  the  student.  The  illustrations  are  most  excel- 
lent, from  their  simplicity  and  the  clearness  with  which 
they  demonstrate  the  points  which  are  to  be  shown.  The 
chapter  on  treatmentis  much  too  general  to  be  of  very  much 
use,  though  it  enforces  several  salient  points,  such  as  dila- 
tation, drainage,  and  curettement,  which  one  little  accus- 
tomed to  gynecology  might  in  his  attention  to  applications 
to  medicines  not  yield  the  considerations  due. 

Diseases  of  the  Ear.  A  Text-book  for  Practitioners  and 
Students  of  Medicine.  Pp.  645.  Bv  Edward  Brad- 
ford Dench,  Ph.B.,  M.D.  New  York :  D.  Appleton 
&  Co.     1894. 

The  author  is  to  be  commended  for  the  great  amount  of  labor 
performed  in  the  compilation  of  this  book.  It  contains  the 
matter  usually  embraced  in  works  on  the  ear;  170  pages 
are  thus  devoted  to  the  anatomy,  physiology,  and  examina- 
tion of  the  organ,  and  464  pages  to  its  diseases  and  their 
treatment.  That  most  important  feature  of  aural  surgery, 
namely,  the  surgery  of  the  conducting  apparatus,  is  consid- 
ered pretty  fully  in  50  pages.  It  would  have  been  a  courte- 
ous attention  to  the  authors'  colleagues  in  this  countr)-.  whose 
successful  labors  in  this  field  opened  to  him  the  way  for  such 
work,  had  he  made  some  acknowledgment  of  his  indebted- 
ness to  their  efforts.  The  attempt  so  extensively  to  illus- 
trate operations  on  the  middle  ear  by  means  of  pictures 
never  has  been  attempted  before,  so  far  as  we  remember  at 
least,  in  any  work  on  the  ear,  and  if  one  may  venture  to 
predict  from  the  impression  these  produce  on  the  mind,  the 
effort  will  not  be  repeated.  Nor  are  the  lithographic  views 
of  the  drum-head,  as  shown  in  Plates  V.  and  VI.,  and  in- 
tended to  represent  various  diseased  conditions  of  the  mem- 
brane, of  any  greater  value.  The  publishers  seem  to  have 
spared  no  expense  in  illustrating  the  book,  and  some  of  the 
illustrations  are  useful,  but  we  can  see  no  advantage  to  be 
gained  by  inserting  in  a  modern  work  on  the  ear  pictures  of 
the  valueless  catheters  of  Pomeroy  and  Noyes. 

Practitioners  and  students  of  medicine  are  in  need  of  a 
precise  and  practical  work  on  the  ear,  but  this  big  book  is 
too  verbose  with  theoretical  and  obsolete  matter,  which  has 
been  accepted  by  the  author  in  lieu  of  personal  knowledge, 
to  meet  this  want. 

Immunity,  Protective  Inoculations  in  Infectious 
Diseases  and  Serum-therapv.  By  George  M. 
Sternberg,  M.D.,  LL.D.,  Surgeon-General  United 
States  Army  ;  Ex-President  American  Public  Health  As- 
sociation ;  Honorary  Member  of  the  Epidermological  So- 
ciety of  London,  of  the  Royal  Academy  of  Medicine  of 
Rome,  of  the  Academy  of  Medicine  of  Rio  Janeiro,  of 
the  Societe  Frangaise  d'Hygiene,  etc.  New  York  :  Will- 
iam Wood  &  Co.     1895. 

The  author  divides  his  monograph  into  two  parts,  the  first 
dealing  with  immunity,  natural  and  acquired,  in  animals 
and  man,  the  second  treating  of  protective  innoculation  and 
serum-therapy.  He  takes  the  ground  that  pathogenic  bac- 
teria are  common  to  the  human  economy  during  health,  but 
are  kept  in  abeyance  by  the  vis  medicatrix  naturel — in  other 
words,  that  blood-serum  is  an  antitoxin.  As  early  as  1881, 
three  years  prior  to  Metschnikoff,  Dr.  Sternberg  affirms  that 
he  was  the  first  to  claim  that  leucocytes  were  bactericidal, 
that  immunity  is  acquired  through  acclimation,  inoculation 
by  attenuated  viruses,  and  an  attack  of  any  one  of  the  specific 
diseases.  In  part  second  a  chapter  is  devoted  to  an  elab- 
orate and  practically  interesting  consideration  of  each  of  the 
infectious  diseases  as  occurring  in  animal  and  man.  An 
elaborate  bibliography  is  annexed.  In  the  chapter  on  pneu- 
monia the  author  claims  priority  over  Fraenkel  in  the  discov- 
ery of  the  "micrococcus  pneumoniae  crouposae."  To  the 
general  practitioner  this  work  is  of  inestimable  value,  inas- 
much as  it  treats  in  a  thoroughly  scientific  manner  all  the 
important  questions  bearingupon  the  subject  of  serum-thera- 
py. It  gives  a  description  of  the  latest  methods  employed 
in  the  pursuit  of  this  very  interesting  and  promising  study. 
The  facts  presented  are  founded  on  a  long  series  of  experi- 
ments and  studies  by  the  author,  extending  over  a  number 
of  years  under  most  favorable  circumstances  and  with  un- 
usual facilities.  To  anyone  who  studies  this  book  carefully 
it  will  appear  self-evident  that  serum-therapy  has  opened  up 
a  large  and  useful  field  to  the  student  of  therapeusis.     Cer- 


94 


MEDICAL   RECORD. 


[July   20,  1895 


tainly  no  one  has  a  better  right  than  the  author  to  say  thus 
much  from  the  stand-point  of  an  acknowledged  authority  on 
the  subject  of  which  his  admirable  work  so  interestingly  and 
instructively  treats. 

Gout  and  its  Cure.    By  J.  Compton  Burn'ett,  ^\.D. 

Philadelphia  :  Boericke  &  Tafel.  1895. 
This  is  a  well-written  and  readable  little  treatise  on  the 
therapeutic  management  of  gout  from  the  stand-point  of  a 
homoeopathic  practitioner,  for  whom  urtica  urens  takes  tlie 
place  of  the  orthodox  colchicum.  The  author  is  an  ardent 
disciple  of  Hahnemann,  but  his  book  is  none  the  less  inter- 
esting, and  it  contains  numerous  little  hints  that  may  profit- 
ably be  followed  even  by  those  who  have  no  faith  in  the 
mother  tincture  of  nettle.  It  is  even  possible  that  urtica 
urens  will  do  as  inuch  for  gout  as  colchicum — which  is  not 
very  high  praise  for  either  remedy. 

Manuel  de  Diagnostic  Chirurgical.    Par  Slmon  Du- 
PLAY,  Professeur  de  Clinique  Chirurgicale  k  la  Faculte  de 
Medecine  de  Paris.  E.  Rochard,  Chirurgien  des   Hopi- 
taux,  et  A.  De.MOULIN,  Chef  de  Clinique  Chirurgicale  de 
la  Faculty.     Premier   Fascicule.      Paris  :  Octave    Doin. 
1S95. 
This  manual  of  surgical  diagnosis  is  a  resume  of  the  course 
of  instruction  given  by  Professor  Duplay  and  his  assistants 
at  the  School  of  Medicine  in  Paris.     This  first  volume  con- 
tains general  directions  on  the  examination  of  the  patient 
and  the  methods  of  clinical  exploration,  and  the  diagnosis 
of  diseases  of  the  head,  face,  neck,  and  spinal  column.     It 
is  a  very  practical  little  work  which  cannot  but  be  of  assist- 
ance to  any  student  or  young  practitioner  of  surgery.     A  few 
well-e.xecuted  illustrations,  printed  when  necessary  in  colors, 
add  to  the  usefulness  of  the  manual.     The  concluding  vol- 
ume is  promised  for  the  end  of  this  year.     ^ 

The  Year-book  of  Treatment  for  1895.  A~Cntica'l 
Review  for  Practitioners  of  Medicine  and  Surgery.  Phila- 
delphia :  Lea  Brothers  &  Co.  1895. 
This  excellent  annual  has  become  such  a  standard  work  and 
such  a  favorite  that  there  is  little  to  say  each  year  but  to 
repeat  the  praise  of  the  year  before.  The  present  volume  is 
fully  up  to  the  standard  of  its  predecessors,  and  with  it  in 
his  library  the  physician  would  have  no  e.xcuse  for  not  keep- 
ing abreast  of  the  times  in  the  therapeutic  art. 

Fifteenth  Report  of  the  State  Board  of  Health  of 

Wisconsin.  1S93-1S94.  Madison  :  1895. 
This  volume  contains  the  usual  matter  contained  in  re- 
ports of  boards  of  health,  but  possesses  an  added  interest 
Isecause  of  the  small-pox  which  the  board  had  to  fight  in  the 
city  of  Milwaukee,  and  of  the  rioting  excited  by  its  efibrts  to 
isolate  the  patients.  The  incident  is  well  described  in  th» 
report. 

Annual  Reports  of  the  Managers  and  Officers  of 
THE  State  Hospitals  of  New  Jersey  for  the  Year 
Ending  October  31, 1894.  Trenton:  1894, 
This  volume  contains  reports  of  the  liospitals  at  Trenton 
and  Morris  Plains.  Several  interesting  cases  are  related  in 
the  report  of  Dr.  Evans,  the  Medical  Director  of  the  Morris 
Plains  Hospital. 

Transactions  of  the  Sixteenth  Annual  Meetino  of 

the  American  Laryngological  Society,  Held  in  the 

City  of  Washington,  D.  C,  May  30,  31,  and  June  i,  1S94. 

New  York  :   D.  Appleton  &  Company.      1S95. 

The  meeting   of  the  American  Laryngological  Society  in 

Washington  a  year  ago   must  have  been  one  of  more  than 

average  interest,  if  we   can  judge  from  the  contents  of  the 

volume  before  us. 

TR.vrT.\T0  de  P.\tologia  e  Terapia  Chirurgica  Gen- 
ERALE  E   Speciale.    Dal  Profcssoie   Francesco  Du- 
rante, Direttore  dellaClinica  Chirurgica della  R.  Univer- 
sity di  Roma.    VoL  I.     Parts  I.  and  IL,  Roma  :  Society 
Editrice  Dante  Alighieri.     1895. 
This  work,  written  by  the  foremost  Italian  surgeon,  Pro- 
fessor Durante,   of  Rome,  promises  to  be  a  most  valuable 
addition  to  surgical  literature.     The  present  fascicule  con- 
tain seven  chapters — on   inflammation  and  its  results,  sur- 
gical fevers,  traumatisms,  the  healing  of  wounds,  the  com- 
plications of  wounds,  and  tumors.     The  autlior  treats  these 
general  subjects  in  a  way  to  hold  the  interest  of  the  reader 
while  at  the  same  time  instructing  him,  and  in  this  liis  work 
is  facilitated  in   no  small   measure  l)y  some  seventy   well- 
made  illustrations. 


Pathology  and  Treatment  of  Diseases  of  the  Skin, 
for  Practitioners  and  Students.  By  Moriz  K.a.- 
POSI,  Professor  of  Dermatology  and  Syphilis,  and  Chief 
of  the  Clinic  and  Division  for  Skin  Diseases  in  the  Vienna 
University.  With  Eighty-four  Illustrations.  Translation 
of  the  last  German  Edition  under  the  Supervision  of 
James  C.  Johnston,  M.D.  New  York  :  William  Wood  & 
Co.     1895. 

Fortunately  we  are  not  called  upon  to  speak  of  another 
text-book  to  be  added  to  the  rather  formidable  list  of  those 
devoted  to  skin  diseases  which  have  appeared  within  a  com- 
paratively brief  period.  It  is  in  this  instance  a  translation 
which  claims  attention.  Kaposi's  work  is  weU  worthy  of 
reproduction  for  the  benefit  of  those  whose  knowledge  of 
German  does  not  permit  the  full  enjoyment  of  the  original 
text.  The  reproduction  as  it  comes  to  us  shows  unmistaka- 
ble evidence  of  having  been  worthily  done. 

Not  every  student  has  the  advantage  of  a  course  of  study 
in  Vienna,  and  the  great  majority  of  practitioners  are  de- 
barred from  even  reading  the  works  of  distinguished  foreign 
teachers  in  the  original.  We  therefore  welcome  such  a 
publication,  which  affords  the  English-speaking  physician 
an  opportunity  to  become  familiar  with  the  prevailing  views 
and  practices  of  the  Vienna  school  of  dermatology.  In  the 
preface  to  this  American  edition,  written  by  George  Henry 
Fox,  a  just  tribute  is  paid  to  the  author's  attainments  and 
ability. 

An  occasional  word  or  turning  of  a  sentence  may  remind 
one  that  the  text  was  originally  German,  but  as  a  whole  the 
translation  shows  great  care  and  accuracy,  while  at  the 
same  time  the  English  has  been  made  as  fluent  as  a  strict 
following  of  the  text  would  permit.  On  page  336  the  omis- 
sion of  a  period  in  the  formula  for  Unna's  ointment  might 
cause  one  to  read  ten  grammes  of  corrosive  sublimate  where 
one  gramme  is  the  quantity  intended,  but  as  the  author 
states  that  he  has  never  seen  any  benefit  from  this  applica- 
tion in  lichen  planus,  perhaps  it  would  not  be  considered  a 
serious  error. 

We  may  note  in  passing  that  the  author  still  maintains 
the  identity  of  Besnier's  pityriasis  rubra  pilaris  with  his 
lichen  ruber  acuminatus :  that  he  admits  the  adjective 
"contagiosum,"  as  justified  in  the  designation  of  the  epi- 
thelial moUuscum,  while  leaving  it  as  an  open  question 
whether  the  gregarins  are  the  carriers  of  infection.  "  Alo- 
pecia areata,"  he  says,  "  we  arc  forced  to  assume,  is  due  to 
trophic  disturbance  of  entirely  unknown  origin."  The 
many  experimental  investigations  of  recent  times  and  the 
changes  of  views  based  upon  new  discoveries  have  not  op- 
erated to  cause  as  great  alterations  in  the  text  of  this  last 
edition  as  one  might  be  led  to  expect.  Still,  enough  will 
be  found  to  interest  those  most  familiar  with  earlier  edi- 
tions. There  is  one  full-page  colored  plate,  but  th*',  as  well 
as  the  other  eighty  odd  illustrations,  is  of  histological  sub- 
jects. The  impression  is  made  of  a  serious,  conscientious 
WO..V  upon  which  student  and  practitioner  can  alike  rely. 


Salicylic  Acid  Externally  in  Rheumatism. — Dr.  Kin 

nicutt  reported  at  a  meeting  of  the  Practitioners'  So- 
ciety upon  the  use  of  salicylic  acid  by  inunction  in 
cases  of  acute  articular  rheumatism.  The  formula  used 
by  him  was  that  of  Bourget,  viz.,  salicylic  acid  ten 
parts,  lanolin  ten  parts,  lard  one  hundred  parts.  Two 
drachms  of  the  pomade  were  rubbed  into  several  areas 
on  the  trunk  and  extremities,  every  four  hours,  the 
total  daily  inunctions  representing  sixty  grains  of  sali- 
cylic acid.  The  absorption  was  very  rapid,  requiring 
no  more  than  ten  minutes  for  the  single  inunction, 
and  it  was  unattended  with  any  irritation  of  the  skin. 
No  covering  was  employed.  The  inunction  of  two 
drachms  of  the  pomade,  representing  ten  grains  of  the 
acid,  permitted  the  discovery  of  the  latter  in  the  urine, 
at  the  end  of  four  hours.  It  had  proved  to  be  an  effi- 
cient method  of  introducing  salicylic  acid  into  the 
economy,  and  of  the  treatment  of  acute  articular  rheu- 
matism. It  possessed  the  advantage  of  not  producing 
disturbances  of  digestion. 

The  Plague  has  made  its  appearance  in  Foo  Chow, 
China.  There  is  no  pretence  of  sanitation  in  that  city, 
so  the  epidemic  will  probably  continue  until  the  soil 
has  been  exhausted. 


July   20,  1895] 


MEDICAL    RECORD. 


95 


I 


Jiociettj  ^epovts, 

AMERICAN"     LARYNGOLOGICAL    ASSOCIA- 
TION. 

Snenteenth  Annual  Congress,  Held  at  Rochester,  N.  Y., 
Juiii  i~,  iS,  and  ig,  jSqj. 

First  Day — Moxda\— June   17,   1895. 

President's  Address. — The  President,  Dr.  John  O. 
Roe,  of  Rochester,  delivered  the  opening  address  wel- 
coming the  members  of  the  Association  to  the  Flower 
City.  He  believed  that  these  annual  meetings  were 
productive  not  only  of  scientific,  but  also  of  social  good. 
Old  friendships  were  cemented  and  new  ones  formed. 
In  the  friendly  intercourse  of  such  gatherings,  much 
could  be  learned  which  could  not  be  incorporated  into 
formal  papers. 

Regarding  the  laryngological  progress  of  recent 
months,  he  would  call  attention  especially  to  the  value 
of  antitoxin  in  diphtheria,  and  to  the  great  progress 
made  in  the  treatment  of  tubercular  d'sease  of  the 
upper  air-passages,  by  Krause,  Her)ng,  and  their  fol- 
lowers. 

The  President  then  read  a  paper  on  "  The  Relation 
of  Damp  Air  to  Diseases  of  the  Upper  Air-passages 
with  Especial  Reference  to  the  Lake  Region." 

No  one  region  is  good  climatically  for  all  diseases, 
nor  can  it  promote  the  %-itality  of  all  the  bodily  organs. 
Conditions  good  for  respirator}'  difficulties  are  apt  to 
prove  the  opposite  for  biliary  troubles,  and  vice  versa. 
This  may  result  from  either  the  effect  of  the  atmos- 
phere on  the  organs  directly,  or  from  its  effects  on  the 
habits  of  the  individual. 

The  climate  of  the  Lake  region  seems  to  exert  an  in- 
jurious effect  on  the  nose,  throat,  and  lungs,  whereas 
in  this  locality  biliary  disorders  are  not  common.  It 
is  humid  and  characterized  by  sudden  variations  of 
temperature,  with  a  low  mean  annual  temperature. 
Any  climate  depends  partly  on  the  nature  and  degree 
of  cultivation  of  the  soil,  on  the  elevation  of  tempera- 
ture, and  the  position  of  a  given  localitj'  with  reference 
to  the  sea-level.  In  the  Lake  region,  the  soil  is  in 
places  light  and  sandy,  and  in  other  places  heavy  and 
underlaid  with  clay.  This  sub-soil  condition  largely 
determines  the  amount  of  moisture  in  the  atmosphere. 
Hence  the  importance  of  thorough  drainage  to  render 
any  given  locality  healthy.  The  sandy  soil  is  naturally 
drained,  so  to  speak,  but  the  heavy  soil  requires  the 
aid  of  sanitary  science.  The  Lake  region  is  highly 
cultivated  and  this  also  tends  to  lessen  the  amount  of 
atmospheric  watery  vapor,  and  the  acti\-ity  of  the  cir- 
culation varies  according  to  the  latter. 

The  chain  of  great  lakes  sends  down  over  the  region 
under  consideration  large  volumes  of  cold  air,  and 
there  are  consequently  frequent  and  rapid  changes  of 
temperature.  Early  warm  days  of  spring  are  suc- 
ceeded by  chilling  blasts  from  the  north.  The  amount 
■  of  cloudiness  is  considerable,  averaging  six  and  one- 
tenth  days  out  of  ten,  according  to  the  records  of  the 
past  twenty- five  years.  There  is  an  average  rainfall 
of  27.8  inches. 

The  damp-air  currents  check  the  insensible  perspi- 
ration and  thus  affect  the  body  unfavorably.  The 
mucous  membranes,  and  especially  the  nasal  mucosa, 
bear  the  brunt  of  this  onslaught.  Endosmosis  and  the 
alterated  elimination  both  lead  to  turgescence,  hy- 
peraemia,  and  hypemutrition,  and  from  the  naturally 
abundant  blood-supply  of  the  nose,  this  organ  is  espe- 
cially exposed  to  deleterious  influences. 

A  pernicious  American  habit  is  that  of  sleeping  with 
open  windows.  A  temperature  is  withstood  during 
the  night,  when  bodily  resistance  is  low,  which  could 
not  possibly  be  borne  with  comfort  during  the  day. 
Hence  the  frequent   colds   referred  to   exposure  the 


day  before,  but  which  are  in  reality  due  to  night  air, 
and  thus  naso-pharjTigeal  catarrh  has  come  to  be 
known  as  the  "  American  "  disease. 

The  relation  of  damp  air  to  phthisis  was  pointed 
out  by  Bowditch  over  thirty  years  ago,  and  though  we 
then  knew  nothing  about  the  tubercle  bacillus,  the  cor- 
rectness of  his  views  is  now  generally  admitted  ;  for  the 
damp  air  and  damp  soils  undoubtedly  prepare  the  tis- 
sues for  bacillar}-  invasion.  We  should  most  carefully 
drain  our  lands  and  houses,  and  thoroughly  ventilate 
our  rooms,  as  prophylactic  measures. 

Desiccated  Thyroids  in  Goitre. — Dr.  E.  Fletcher 
Ingals,  of  Chicago,  read  a  paper  with  this  title.  Dur- 
ing the  last  fifteen  years  he  has  treated  eighty-seven 
cases  of  bronchocele  and  exophthalmic  goitre.  Formerly 
he  gave  potass,  iodid.,  grs.  v.-x.,  thrice  daily.  If  the 
patients  were  not  distinctly  improved  in  two  or  three 
weeks,  he  gave  iodine  tincture,  gtts.  v.-xv.,  three  or 
four  times  daily,  administered  in  capsule  and  followed 
by  a  large  goblet  of  water,  beginning  with  the  minimum 
dose  and  increasing  one  drop  daily  ;  or  he  would  inject 
a  three  to  five  per  cent,  solution  of  carbolic  acid  in 
water  and  glycerine — using  from  twenty  to  fifty  minims 
at  one  injection,  and  injecting  once  a  week. 

During  the  past  three  or  four  years  he  has  used 
thyroid  preparations  of  various  kinds,  and  in  his  last 
six  cases  desiccated  thyroids.  Six  grains  of  this  prep- 
aration represent  one  entire  gland.  Dr.  Ingals  then 
gave  outline  clinical  histories  of  his  last  six  cases.  AU, 
with  one  exception,  are  still  under  treatment.  Several 
of  them  had  previously  been  subjected  to  the  old  style 
of  treatment.  He  had  obtained  reports  from  other 
physicians  who  had  used  the  desiccated  thyroids,  and 
was  able  to  report  on  50  cases  in  all.  Taylor's  series 
of  25  cases  showed  improvement  in  all  but  7.  The 
neck  was  uniformly  diminished  in  size.  As  unpleasant 
features  of  the  treatment,  headache  was  reported  in  thirty 
percent.,  dizziness  in  thirty-seven  per  cent.,  and  in- 
creased rapidity  of  pulse  in  twenty-five  per  cent.  Out  of 
the  50  cases  the  size  of  the  neck  was  reduced  in  38.  In 
addition  to  the  foregoing  unpleasant  symptoms,  were  to 
be  noted  trembling,  weakness,  backache,  nausea,  loss  of 
weight,  and  in  one  case  uterine  contractions  which  could 
be  directly  traced  to  the  effects  of  the  remedy.  He 
would,  from  his  study  of  the  question,  draw  the  follow- 
ing conclusions  :  i.  Thyroid  products  exert  a  power- 
ful effect  on  the  nervous  and  circulatory  apparatus,  as 
evidenced  by  head  pains,  rapid  pulse,  and  fluctuarions 
in  weight.  2.  These  s\Tnptoms  may  arise  from  a  daily 
dosage  of  from  one  and  a  half  to  two  thyroids.  3. 
From  cases  observed  it  is  not  irrational  to  suppose  that 
incautious  dosage  might  produce  fatal  results.  4. 
The  desiccated  preparations  are  the  preferable  mode 
of  administration.  5.  Internal  administration  offers 
as  good  results  as  hypodermatic  use.  6.  The  dosage 
should  commence  with  two  grains  thrice  daily,  and 
run  up  to  four  or  eight  if  necessary.  7.  The  effects 
are  not  constant  in  different  patients,  nor  are  they 
the  same  at  all  times  in  the  same  individual.  Some  of 
these  may  be  due  to  incidental  digestive  disorders. 
8.  The  remedy  is  of  value  in  myxoedema.  9.  In  ex- 
ophthalmic goitre,  the  gland  is  reduced  in  size,  but 
in  enlargement  (not  of  the  exopththalmic  type),  rapid- 
ity of  cardiac  action  may  be  aggravated,  instead  of 
benefited.  10.  Cystic  glands  do  not  seem  to  be  bene- 
fited. II.  There  is  no  evidence  that  thyroid  therapy 
has  any  place  in  diseases  other  than  the  foregoing. 

The  discussion  was  opened  by  Dr.  E.  L.  Shcrly, 
of  Detroit.  He  had  used  the  ordinary  extract  of 
thyroid  in  some  twenty  cases,  with  disappointing  re- 
sults. He  related  the  case  of  a  boy  from  whose  neck 
the  entire  gland  had  been  removed  some  years  ago, 
with  the  result  that  it  seemed  to  diminish  the  boy's 
physical  growth,  and  three  or  four  years  later  he  had 
developed  a  mental  apathy  and  a  peculiar  piping  voice. 
The  movement  of  the  cords  and  arytenoids  appeared 
normal,  except  that  the  normal  phonatory  tension  0£ 


96 


MEDICAL    RECORD. 


[July   20,    1895 


the  former  was  markedly  deficient.  For  the  past  two 
years  the  boy  had  been  on  thyroid  extract  (previous 
subdermic  administration  having  proved  useless),  with 
the  result  that  the  tension  of  the  cords  was  much 
better.  He  thought  that  laryngologists  should  protest 
against  the  whole  removal  of  the  gland  for  any  purpose 
whatever.  Experiments  have  shown  that  the  retention 
of  a  very  small  portion  will  prevent  the  untoward  re- 
sults which  follow  its  entire  extirpation. 

Dr.  W.  E.  Casselberry,  of  Chicago,  had  used  the 
remedy  in  one  case  of  exophthalmic  goitre,  giving  a 
preparation  of  fresh  gland  twice  a  week.  His  patient 
was  improved,  but  not  well.  He  called  attention  to  a 
recent  article  by  Paul  Bruns,  of  Tubingen,  who  had 
shown  from  a  series  of  cases  that  the  younger  the 
patient  was,  the  more  likely  was  he  to  be  benefited. 
Thus  all  his  cases  in  the  first  decade  of  life  were 
cured  ;  of  those  in  the  second  decade  seventy-five 
per  cent,  recovered;  then  the  recoveries  rapidly  dimin- 
ished as  the  age  increased,  and  of  the  cases  over  forty 
years,  scarcely  any  got  well.  Bechere  had  produced 
a  fatal  result  in  a  monkey  in  ten  days  under  thyroid 
feeding,  sudden  death  resulting  from  heart  failure. 

Dr.  Ingals,  in  closing  the  discussion,  stated  that  in 
view  of  the  possible  causative  agency  of  infected  water 
in  causing  goitre  in  certain  districts,  all  patients  should 
be  made  to  drink  distilled  or  otherwise  purified  water. 

Electrolysis  by  a  Current  Controller  for  the  Reduc- 
tion of  Spurs  of  the  Nasal  Septum. — This  was  the  title 
of  the  next  paper,  read  by  Dr.  W.  E.  Casselberry,  of 
Chicago.  Electrolysis  is  not  a  universal  substitute  for 
other  procedures,  as  it  has  well-defined  limitations.  A 
review  of  the  literature  shows  that  extravagant  claims 
have  been  made  for  it,  some  of  which  are  illogical  in 
argument  and  unsupported  in  clinical  experience.  Dr. 
Casselberry  then  described  a  Mcintosh  current  control- 
ler which  he  uses  in  connection  with  the  Edison  cur- 
rent. The  ideal  electrolytic  current  is  one  of  moder- 
ately high  tension  (voltage)  and  of  comparatively  low 
current  strength  (amperage).  He  follows  the  so-called 
bi-polar  method  and  uses  needles  of  irido-platinum. 

The  histories  of  ten  cases  were  next  given.  These  can 
be  divided  into  three  types  : 

1.  Spurs  strictly  cartilaginous.  Here  electrolysis  will 
remove  the  offending  mass,  but  one  must  be  careful  not 
to  carry  the  process  too  far,  else  perforation  may  result. 
Frqm  15  to  40  milliamperes,  and  seances  of  from  six  to 
eight  minutes  are  sufficient  to  dentalize  cartilage. 

2.  Spurs  partly  bony  and  partly  cartilaginous.  Here 
electrolysis  is  beneficial  directly  proportional  to  the  car- 
tilaginous percentage  of  the  mass  to  be  removed.  Only 
the  cartilage  disappears  ;  the  bone  does  not. 

3.  Spurs  wholly  of  bone.  Here  electrolysis  is  use- 
less. 

The  author  concluded  as  follows  : 

1.  Spurs  of  the  first  type  can  be  removed  by  electrol- 
ysis. There  is  no  danger  of  hemorrhage,  but  even  here 
it  is  not  a  universal  substitute  for  surgical  treatment. 

2.  Spurs  of  the  second  type  are  removable  only  in 
part. 

3.  Spurs  of  the  third  type  cannot  be  removed,  as  no 
needles  will  penetrate  the  bone. 

4.  Deviations  cannot  be  remedied  by  this  method. 

Dr.  J.  E.  Newcomb,  of  New  York,  opened  the  dis- 
cussion, narrating  his  own  experiences  with  this  method, 
and  taking  strong  issue  with  the  continental  authori- 
ties who  claimed  that  it  was  useful  in  bony  spurs  or  de- 
flections of  the  septum. 

Dr.  W.  H.  Daly,  of  Pittsburg,  would  condemn  the 
method  as  antiquated,  as  a  waste  of  time,  and  as  involv- 
ing the  use  of  that  most  unreliable  of  all  apparatus — an 
ampere  meter.  What  we  really  did  was  to  cauterize, 
rather  than  to  electrolyze.  He  preferred  the  usual  sur- 
gical procedures,  particularly  the  trephine  driven  by  the 
De  Vilbiss  motor.  Moreover,  Dr.  Casselberry 's  current 
controller  could  not  be  used  with  alternating  currents. 

Dr.  E.  p.  Shurly  thought  that  to  use  electrolysis 


for  these  spurs  was  analogous  to  trying  to  amputate  a 
thigh  by  lunar  caustic. 

Dr.  Jonathan  Wright,  of  Brooklyn,  thought  there 
was  a  legitimate  field  for  electrolysis  in  cases  of  phthi- 
sis and  other  debilitated  states,  where  we  did  not  wish 
to  risk  hemorrhage  and  shock.  These  patients  were 
in  a  delicate  position  and  it  was  easy  to  send  them 
down  hill. 

Dr.  Ingals  said  it  was  possible  to  remove  soft  an- 
terior spurs  with  the  fine  cautery  tip  heated  to  white- 
ness. 

Dr.  John  H.  Loumar,  of  Cleveland,  believed  that 
the  most  reliable  continental  authorities  were  against 
electrolysis. 

Dr.  S.  Hartwell  Chapman,  of  New  Haven,  thought 
Dr.  Casselberry's  apparatus  faulty  in  that  it  did  not 
sufficiently  reduce  the  initial  current  strength. 

Dr.  a.  B.  Thrasher,  of  Cincinnati,  inquired  whether 
the  bipolar  method  was  less  painful  than  the  mono- 
polar. 

Dr.  Casselberry  replied  that  it  was.  He  admitted 
the  validity  of  Dr.  Chapman's  objection  to  his  appara- 
tus, and  hoped  to  remedy  it  in  the  future. 

Is  Acute  Tonsillitis  in  any  Way  Dependent  on  the 
Rheumatic  State? — Paper  by  Dr.  George  B.  Hope, 
of  New  York.  (Read  by  Letter.)  He  believes  that 
the  very  generally  accepted  theory  of  tonsillitis  attrib- 
uting it  to  an  underlying  rheumatic  or  gouty  diathesis, 
is  not  substantiated  by  the  results  of  clinical  experi- 
ence, and  considers  the  theory  as  largely  the  result  of 
the  natural  disposition  to  fall  into  line  with  time-hon- 
ored statements  which  continue  to  pass  current  and 
are  not  subjected  to  careful  analysis. 

The  point  is  taken,  that  patients  subject  to  tonsillitis 
do  not  commonly  afford  a  history  of  rheumatism,  either 
proximate  or  remote,  and  that,  on  the  other  hand,  rheu- 
matic individuals  rarely  suffer  from  tonsillar  inflamma- 
tions. It  is  a  striking  fact  that  the  tonsil  is,  in  later  life, 
less  and  less  disposed  to  acute  attacks,  while  rheumatic 
tendencies  become  more  and  more  manifest  with  ad- 
vancing years.  On  pathological  grounds,  rheumatism 
should  attack  a  sero-fibrous  rather  than  a  muco-fibrous 
or  lymphatic  structure  such  as  the  tonsil.  Carrying 
the  argument  still  further,  it  is  claimed  that  peri-tonsil- 
lar  suppuration  is  clearly  of  an  infectious  nature,  and 
is  frequently  a  sequel  of  intra-nasal  operations. 

The  conclusion  deduced  from  the  foregoing  propo- 
sitions, is  that  the  favorite  anti-rheumatic  treatment, 
as  guaiac  or  the  salicylates,  addressed  to  the  causation 
is  either  erroneous  in  practice  or  acts  independently 
and  by  a  method  not  clearly  understood.  Such  reme- 
dies are  not  to  be  regarded  as  scientific,  and  must  be 
adjusted  to  the  varying  conditions  of  each  individual 
case.  Moreover  it  is  not  proven  that  they  either  abort 
or  mitigate  the  cause  of  the  disease.  After  the  read- 
ing of  papers,  there  was  the  following  presentation,  of 
apparatus  and  instruments  :  Dr.  J.  \V.  Gleitsmann,  of 
New  York,  a  nasal  conchotome.  Dr.  J.  W.  Farlow,  of 
Boston — picture  of  Ferdinand  I.  of  Germany,  who  died 
in  1524,  and  is  supposed  from  the  peculiar  physiognomy 
to  have  had  adenoids  in  the  naso-pharyngeal  vault. 
Dr.  Morris  J.  Asch,  of  New  York,  a  modification  of 
Cradle's  post- nasal  forceps,  also  Bors's  dilating  intuba- 
tion apparatus  for  laryngeal  stenosis,  and  a  mouth  gag. 
Dr.  A.  Coolidge,  Jr.,  of  Boston,  a  cartilage  knife  and  a 
dilator  for  syphilitic  adhesions  of  the  soft  palate  to  the 
post-pharyngeal  wall.  Dr.  J.  C.  Mulhall,  of  St.  Louis, 
a  current  controller  for  applying  the  alternating  cur- 
rent to  the  conditions  of  galvano-cautery  work. 


Second  Day,  Tuesday,  June  18,  1895. 

Lipomata  of  the  Larynx.— Dr.  J.  W.  Farlow,  of 
Boston,  related  the  clinical  histories  of  two  cases  of 
lipoma  and  showed  specimens  and  illustrative  diagrams. 
The  first  one  was  a  growth  of  the  inside  of  the  right 
cheek  occurring  in  a  boy  two  years  old.     It  appeared 


July   20,  1895] 


MEDICAL   RECORD. 


97 


I 


of  a  reddish  lobulated  appearance,  was  soft,  smooth, 
and  not  ulcerated,  looking  in  fact  like  a  portion  of  the 
parotid  and  attached  just  anterior  to  the  mouth  of 
Steno's  duct.  Removal  with  cold  wire  snare,  no  hemor- 
rhage. The  lipoma  of  the  larynx  occurred  in  a  male, 
aged  sixty-six,  in  good  health  till  fifteen  years  previous, 
when  he  noticed  a  growth  coming  from  somewhere  in 
the  throat  and  projecting  out  between  the  teeth.  A 
piece  two  inches  long  was  removed  by  scissors.  In 
March,  1893,  it  had  again  grown  and  was  so  long  that 
the  patient  had  to  hold  a  small  piece  of  cloth  about  it 
to  keep  it  from  getting  between  the  teeth.  It  seemed 
to  run  down  into  the  larynx  and  to  cause  suffocative 
attacks,  from  getting  nipped  between  the  cords  and  run- 
ning down  into  the  trachea.  A  cold  wire  snare  and 
long  curved  scissors  removed  another  piece.  Patient 
was  then  lost  sight  of,  but  again  returned  with  a  recur- 
rence of  the  growth  and  the  old  symptoms.  The  en- 
tire mass  was  then  removed  with  the  galvano-cautery 
snare,  and  its  attachment  found  to  be  above  the  right 
arytenoid.  Report  of  pathologist,  "sub-mucous  lipoma." 
No  recurrence  in  three  months. 

Some  Remarks  on  Removal  of  the  Tonsils. — This  was 
the  title  of  Dr.  Farlow's  second  paper.  He  discussed 
the  question  solely  from  the  point  of  the  choice  of  the 
method  of  operating.  He  first  breaks  up  adhesions  be- 
tween the  tonsils  and  the  faucial  pillars.  If  adenoids 
are  to  be  removed  at  the  same  time,  he  anesthetizes 
the  patient  and  first  removes  the  faucial  tonsils  by  a 
special  variety  of  wire  6craseur,  which  he  exhibited,  and 
then  removes  the  adenoids.  This  answers  well  for 
large  tonsils  in  large  mouths,  but  the  condition  is  fre- 
quently seen  in  children  with  small  mouths  and  narro'.v 
jaws.  The  tonsil  is  the  more  easily  encircled  by  the 
wire  loop  (No.  5  or  7  steel  piano  wire),  by  being 
pressed  in  from  the  outside.  This  method  is  also  ap- 
plicable in  adults,  and  the  speed  of  tightening  the  loop 
depends  on  the  consistency  of  the  tissue  to  be  removed. 
Ice  can  be  used  after  operation,  and  cocaine  applica- 
tions before  sections  of  the  tissue  removed  have  shown 
that  everything  has  been  taken  out  even  down  to  the 
sheath  of  the  tonsil. 

Dr.  Farlow  also  showed  the  tonsil  punch  of  Ruault, 
of  Paris,  and  the  conchotome  of  Hartmann,  both  of 
which  had  been  of  service  in  removing  the  tonsil  piece- 
meal. There  was  no  hemorrhage  to  speak  of  with  any 
of  the  foregoing  instruments.  The  punches  were  use- 
ful for  the  removal  of  the  tonsillar  masses  high  up  be- 
tween the  pillars,  and  knives  suitably  shaped  could  be 
used  to  open  up  fragments  of  tissue  to  be  removed  by 
the  punch.  He  had  tried  galvano-cautery,  but  had 
found  it  very  tedious. 

Dr.  F.  H.  Bosworth,  of  New  York,  said  that  if  we 
cut  into  any  lymphoid  tissue,  bleeding  was  possible,  but 
it  was  rare  in  children.  The  large  adherent  masses  be- 
tween the  faucial  pillars  must  be  dug  out  in  some  way, 
but  the  large  projecting  tonsils  could  be  guillotined. 
No  one  instrument  would  answer  for  every  case. 

Dr.  Ingals  had  found  bleeding  more  common  in 
children  whose  tonsils  were  not  large  at  the  time  of 
operation,  but  in  whom  removal  seemed  indicated. 
Cocaine  did  not  aneesthetize,  and  it  promoted  bleed- 
ing. 

Dr.  Carl  Seiler,  of  Philadelphia,  thought  that  the 
Matthieu  fork  instrument  was  faulty  as  generally  con- 
structed, in  that  the  long  diameter  of  the  fenestrum  was 
vertical  instead  of  horizontal  as  it  should  be. 

Dr.  Daly  thought  that  more  bad  surgery  had  been 
done  on  the  tonsils  than  on  any  other  part  of  the  body. 
Mackenzie's  instrument  doesn't  but  half  finish  the  task  ; 
we  must  trim  with  knife  or  forceps.  He  had  had  four 
or  five  alarming  hemorrhages. 

Dr.  Casselberry  would  assert  most  emphatically 
that  children,  as  well  as  adults,  may  bleed,  and  he  never 
operated  without  having  the  galvano-cautery  close  at 
hand.  In  fibrous  tonsils  he  preferred  the  hot  snare. 
It  was  difficult  to  separate  adhesions,  but  if  he  could  get 


the  muscular  pillars  free  he  did  not  hesitate  to  sacri- 
fice a  little  mucous  membrane  if  necessary. 

Dr.  Shurly  had  had  two  hemorrhages  in  children. 
We  must  estimate  the  nature  of  the  tonsil  and  the 
amount  to  be  removed,  and  must  be  prepared  for  an 
abnormal  distribution  of  vessels.  In  igni-puncture  he 
does  not  insert  the  cautery  tip  in  the  crypts,  but  diago- 
nally between  them.  He  aims  to  cut  across  the  lymph- 
spaces  and  set  up  a  new  inflammation  in  place  of  the 
old  chronic  proliferating  process.  He  would  differ 
from  Dr.  Seiler  as  to  the  greatest  diameter  of  the  ton- 
sils being  horizontal.     He  believes  it  to  be  vertical. 

Melancholia  Cured  by  Intra-nasal  Operation. — Case 
reported  by  Dr.  Bosworth,  of  New  York.  Patient 
was  a  male,  aged  forty-two  years,  who  became  melan- 
choly, sleepless,  and  unfitted  for  business  ;  complain- 
ing of  a  bursting  pain  between  the  ej-es  and  a  feeling  as 
if  the  eyeballs  were  too  large  for  their  sockets.  He  fell 
into  the  hands  of  various  physicians,  and  went  through 
the  following  ordeal  in  the  hope  that  each  procedure 
would  cure  him  :  Operation  for  varicocele,  wearing  of 
eyeglasses,  operation  for  stricture,  castration,  circum- 
cision, ligation  of  internal  pudic  artery,  operation  for 
hemorrhoids,  cautery  to  spine,  setori  in  neck,  tenotomy 
of  eye  muscles,  enucleation  of  one  eye.  He  finally 
came  into  Dr.  Bosworth's  hands.  He  found  almost 
complete  right  nasal  occlusion  from  septal  deviation, 
and  an  enlarged  left  middle  turbinated  with  myxoma- 
tous degeneration  and  evidences  of  ethinoiditis.  The 
removal  of  all  obstructions  from  the  nostrils  speedily 
restored  the  patient  to  health. 

A  Case  of  Suppurative  Ethmoid  Disease,  Followed  by 
Invasion  of  the  Sphenoidal  Sinus,  Abscess  of  the  Brain, 
and  Death. — Dr.  Bosworth  also  related  a  case  of  the 
above  nature.  Patient,  male,  aged  thirty-three,  had 
ethmoid  disease  with  usual  symptoms  for  some  years. 
He  then  had  sudden  headache,  left  facial  neuralgia, 
but  no  fever,  the  latter  symptoms  lasting  four  days. 
General  condition  good.  Pus  was  seen  running  down 
between  the  left  middle  turbinated  and  the  septum. 
These  last  symptoms  were  held  to  indicate  extension  of 
the  suppuration  to  the  sphenoidal  sinus.  The  use  of 
the  gouge  and  burr  afforded  but  temporary  relief,  and 
very  speedily  he  had  a  rigor  fever  (106''),  semi-coma, 
paralysis  of  left  face  and  arm,  and  died  in  twenty-four 
hours.  No  autopsy  was  held,  but  it  was  believed  that 
death  was  caused  by  abscess  at  the  base  of  the  brain. 
Dr.  Bosworth  desired  to  say  that  ethmoid  disease,  though 
generally  considered  not  fatal,  might  indirectly  become 
so  by  serving  as  a  focus  of  infection  for  the  sphenoid. 
He  believed  that  the  so-called  cases  of  sphenoidal  dis- 
ease are  probably  not  truly  so,  but  are  rather  ethmoidal 
than  sphenoidal.  He  had  seen  a  hundred  and  fifty 
cases  of  ethmoidal  disease,  but  only  two  of  independent 
sphenoid  disease. 

A  Further  Contribution  to  the  Study  of  Suppurative 
Disease  of  the  Accessory  Sinuses,  with  Reports  of  Cases. 
— A  paper  with  this  title  was  read  by  Dr.  J.  H.  Bryan, 
of  Washington,  D.C. 

Case  I.  Abscess  of  Right  Maxillary  Sinus,  from 
Dental  Caries. — Patient,  male,  aged  thirty-nine.  Symp- 
toms, nasal  discharge,  more  on  right  side,  neuralgia, 
some  emaciation,  mental  incapacity,  and  gastric  dis- 
turbance. On  examination  some  tenderness  over  canine 
fossa,  slight  inferior  turbinated  hypertrophy,  and  foul 
pus  discharged  by  forcible  blowing  ;  caries  of  first  and 
second  right  upper  molars.  Removal  of  one  molar 
disclosed  a  needle  sticking  in  its  root.  Patient  recol- 
lected that  he  had  picked  the  tooth  eight  years  before 
with  a  needle,  and  that  the  latter  had  broken  off. 
Sinus  washed  out  with  hydrogen  peroxide,  and  boric- 
acid  solution  thrown  in,  and  in  the  course  of  three 
weeks  pus  had  ceased  to  flow,  and  alveolar  opening 
was  allowed  to  close. 

Case  II.  Suppurating  Ethmoiditis  Terminating  in 
Caries  of  Anterior  Ethmoidal  Cells. — Patient,  male, 
aged  sixty-eight.     For  ten   years  neuralgia  over  inner 


MEDICAL   RECORD. 


[July   20,  1895 


angle  ;  left  orbit  always  more  acid  by  a  coryza.  Yellow- 
ish secretion  from  left  nostril.  No  orbital  swelling  or 
visual  disturbance  ;  left  middle  turbinated  bone  en- 
larged and  pus  flowing  down  from  below  and  above  it  ; 
probe  easily  detected  caries  of  anterior  ethmoid  cells, 
though  the  swollen  mucosa  prevented  inspection.  All 
diseased  bone  was  curetted  away  under  cocaine  ;  relief 
of  all  symptoms. 

Case  III.  Abscess  of  Left  Frontal  Sinus,  Resulting 
Nasal  Polypi  and  Hypertrophic  Rhinitis. — Patient,  male, 
aged  fifty,  with  left  nasal  discharge  for  some  years, 
left  frontal  headache,  obstruction  to  left  nostril  in 
breathing,  and  much  impairment  of  the  general  health, 
skin  over  left  frontal  sinus  was  somewhat  swollen  and 
red,  with  pain  on  pressure.  Right  inferior  turbinated 
body  hypertrophied  ;  left  nasal  chamber  blocked  by 
numerous  polypi,  with  adhesion  between  left  inferior 
turbinated  and  septum.  Polypi  removed,  adhesion 
broken  away,  and  turbinated  hypertrophies  reduced. 
This  sufficed  to  drain  the  frontal  sinus,  owing  to  the 
unusual  size  of  the  fronto-nasal  duct ;  result,  great  re- 
lief, but  not  at  time  of  writing  entirely  cured. 

Case  IV.  Abscess  of  the  Frontal,  Ethmoidal,  and  Max- 
illary Sinuses,  with  Caries  of  Frontc-ethmoidal  Cells. — 
Patient,  female,  aged  forty-eight,  subject  to  frequent  ca- 
tarrhs, and  for  past  seven  months  left  nasal  discharge  : 
teeth  sound,  but  those  on  left  upper  jaw  project  farther 
than  their  opposites  ;  severe  headaches  and  left  facial 
neuralgias  ;  left  side  face  congested,  with  supra-  and 
infra-orbital  swellings,  pain  on  pressure  over  these  re- 
gions and  also  over  canine  fossa  :  right  inferior  turbi- 
nated slightly  enlarged,  but  on  left  side  both  inferior  and 
middle  turbinated  bodies  were  congested  and  swollen, 
and  the  nose  filled  with  pus,  which  flowed  freely  ante- 
riorly and  posteriorly. 

Translumination  showed  opacities  over  left  frontal 
and  on  axillary  sinuses.  Visual  field  was  narrowed  for 
red  and  green.  Trephining  was  done  through  its  al- 
veolar process  after  e.\traction  of  the  first  molar  tooth. 
Gelatinous  mucus  escaped  ;  boric-acid  irrigation  and 
later  daily  washings  with  hydrogen  pero.xide  ;  all  these 
procedures  gave  but  partial  relief,  and  it  was  found  nec- 
essary to  open  the  frontal  sinus,  from  which  dark-green 
and  fetid  pus  was  removed.  Healing  occurred  in 
about  a  month  and  the  patient  was  about  to  be  dis- 
charged, when  the  purulent  flow  with  attendant  symp- 
toms reappeared.  Sinus  was  again  opened  thoroughly, 
curetted,  and  packed  with  iodoform  gauze.  Later  it 
was  discovered  that  communication  existed  between 
the  frontal  and  maxillary  sinuses.  Still  later  diseased 
bone  was  detected  about  the  anterior  ethmoid  cells. 
After  curetting  the  latter  a  cure  finally  resulted  after 
ten  months'  treatment. 

According  to  Dr.  Bryan,  not  only  is  grippe  a  fre- 
quent mark  for  these  sinus  diseases,  but  they  are  far 
from  being  uncommon  in  simple  rhinitis. 

After  enumerating  the  causes  of  frontal  and  eth- 
moidal disease,  the  writer  discussed  the  question  of 
diagnosis  of  the  latter  affections.  As  symptoms  of 
ethmoid  disease  we  may  have  pain  pressure,  exophthal- 
mus,  usual  disturbances,  and  a  softening  of  the  bone  at 
the  inner  angle  of  the  orbit.  Probing  through  the  nose 
will  in  the  majority  of  cases  detect  carious  bone. 

In  frontal  disease,  the  severity  of  symptoms  depends 
largely  on  whether  the  frontal  nasal  duct  is  opened  or 
closed  ;  pain  is  early  and  severe  ;  tenderness  on  press- 
ure is  frequent,  with  occasional  supra-orbital  redness 
and  swelling  and  purulent  discharge  in  the  nostril  ;  but 
if  the  fronto-nasal  duct  is  closed,  the  evidences  of  local 
pressure  in  the  neighborhood  of  the  sinus  become  very 
great.  Orbital  or  even  intra-cranial  abscess  may  re- 
sult unless  early  relief  is  atTorded. 

As  to  the  treatment  of  the  ethmoidal  cases,  we  should 
remove  the  cap  of  the  middle  turbinated  with  ,1  snare 
or  burr,  and  then  continue  the  opening  of  the  individual 
cells  with  some  easily  controlled  instrument,  for  we  are 
working  in  a  dangerous  region.     "  Free  drainage  "  is 


the  goal  of  all  our  efforts.  If  the  frontal-ethmoidai 
cells  are  involved  we  should  proceed  as  in  frontal  dis- 
ease. The  nose  should  be  freed  of  anything  which  seems 
to  clog  up  the  fronto-nasal  duct.  Incision  may  be  made 
just  below  the  supra- orbital  ridge  in  the  usual  manner, 
and  great  care  be  used  in  determining  whether  the  two 
frontal  sinuses  communicate  with  each  other.  If  the 
duct  is  closed  or  the  fronto-ethmoidal  cells  are  impli- 
cated in  the  suppurative  process,  the  little  finger  should 
be  crowded  into  the  nostril  of  the  affected  side,  and  on 
this  as  a  guide,  a  curved  trocar  should  be  thrust 
through  the  opening  in  the  sinus  into  the  nose. 

The  two  foregoing  papers  elicited  a  lively  discus- 
sion. Dr.  Wright  gave  his  experience  with  a  very  ob- 
stinate case  of  antral  disease.  It  was  often  difficult  to 
find  out  just  where  the  pus  came  from.  He  cautioned 
against  too  early  operation. 

Dr.  Ingals  had  seen  three  cases  of  sphenoidal  dis- 
ease. He  preferred  to  open  into  the  sinus  on  its  inferior 
rather  than  its  anterior  aspect. 

Dr.  Gleitsmann"  preferred  to  enter  the  sphenoidal 
sinus  with  Schaeffer"s  probe  passed  in  the  usual  way. 
In  one  case  he  had  had  profuse  secondary  hemorrhage. 
He  passed  the  probe  four  and  a  half  inches  up  and 
back  just  along  the  edge  of  the  middle  turbinated,  one- 
eighth  of  an  inch  above  its  lower  border.  In  chronic 
cases  the  anterior  sinus  wall  is  not  very  hard,  and  can 
be  easily  broken  through  with  the  probe. 

Dr.  Shurlv  was  surprised  to  notice  that  none  of  the 
speakers  had  alluded  to  disturbances  of  smell  in  these 
cases.  He  had  seen  many  cases  of  nasal  discharge 
which  he  referred  to  a  neuritis  of  the  olfactor}'  bulb, 
secondary  to  organic  brain  disease,  but  had  not  re- 
garded them  as  ethmoid  cases. 

Dr.  Daly  would  sever  the  nose  along  the  ala  on 
one  side  and  lay  it  over  on  the  face  before  attacking 
the  sphenoidal  sinus. 

Dr.  Mulhall  thought  the  brain  cavity  was  better 
guarded  from  injury  in  the  sphenoidal  than  in  the  eth- 
moidal region.  Sphenoidal  disease  apart  from  ethmoid 
was  rare.  Griinwald's  monograph  was  incomparably 
the  best  book  on  the  subject. 

An  exciting  discussion  followed  as  to  the  linear  dis- 
tance into  the  sphenoidal  sinus.  Various  opinions  were 
given,  but  no  one  was  able  from  personal  experience  to 
lay  down  decisive  data.  Griinwald's  measurements  are 
the  correct  ones. 

A  Consideration  of  Some  of  the  More  Important 
Principles.  — Dr.  W.  K.  Simpson,  of  New  York,  said 
that  the  history  of  advance  in  any  specialty  was  the 
history  of  its  surgery.  The  more  we  could  apply  gen- 
eral surgical  principles  to  morbid  conditions,  the  greater 
would  be  our  success.  Con-;ervaiive  surgery  may  be 
defined  as  "  knowing  when  not  to  interfere."  But  in- 
tra-nasal  surgery  has  gone  too  far  ■-■nd  the  pendulum  is 
now  returning  to  a  median  position.  Mistakes  have 
been  made,  but  they  should  be  our  landmarks  and  thus 
prevent  a  repetition  of  our  errors. 

The  writer  called  special  attention,  however,  to  the 
treatment  of  obstructive  or  hypertrophic  rhinitis  by  re- 
ducing measures.  The  nose  has  a  natural  protective 
office  toward  the  rest  of  the  body,  and  there  is  in  its 
pathology  a  pre-surgical  or  preoperative  period.  Dur- 
ing this,  we  should  do  as  much  as  possible  in  a  thera- 
peutic way  with  climate,  diet,  clothing,  environment. 
Where  we  have  conditions  of  hypertrophy  and  atrophy 
with  a  tendency  of  the  latter  to  spread,  we  should  be 
especially  chary  in  our  surgical  interference,  or  we  may 
hasten  the  atrophic  changes  :  remembering  also  that 
perfectly  symmetrical  nasal  interiors  are  rarely  encoun- 
tered. 

Our  choice  of  means  should  eliminate  as  much  as 
possible  shock,  leave  a  smooth,  hard  mucosa,  destroy  as 
little  membrane  as  is  consistent  with  the  attainment 
of  the  desired  result,  be  attended  with  a  minimum  of 
hemorrhage,  and  of  danger  of  infection,  and  finally 
leave  a  normal  secreting  surface.     Of  just  as  much  im- 


July  20,  1895] 


MEDICAL    RECORD. 


99 


portance  is  the  post-operative  care  of  these  cases,  in 
which  a  rigid  antiseptic  routine  should  be  carried  out. 
Nasal  surgeons  are  apt  to  get  careless  in  their  minor 
work  as  to  antisepsis.  Special  care  should  be  taken  to 
clean  the  thumb  and  forefinger  of  the  left  hand,  as  with 
these  the  commonly  employed  cotton  carrier  is  rolled. 
Xasal  asepsis  is  probably  impossible,  as  the  nose  is  not 
a  closed  cavity,  but  we  should  approximate  thereto  as 
closely  as  possible.  Many  of  the  so-called  "  heavy 
colds,"  "  grippe "  attacks  after  nasal  operations,  are 
nothing  but  mild  sepsis. 

Dr.  Mulh.\ll  thought  that  danger  of  septic  trouble 
was  greatly  lessened  if  we  used  the  galvano-cautery 
(when  applicable)  at  a  white  heat,  and  never  allowed  it 
to  cool  in  situ.  He  used  cocaine  four  per  cent,  over  the 
entire  nostril  and  ten  per  cent,  over  the  operative  site. 
The  smarting  produced  by  the  radiated  heat  was  im- 
mediately relieved  by  a  saturated  solution  of  bicarbon- 
ate of  soda. 

Dr.  Wright  said  that  while  formerly  he  had  no 
trouble  with  noses  after  the  cauterj',  he  found  he  did 
not  remove  much  tissue.  A  more  thorough  cauteriza- 
tive  plan  had,  however,  given  some  annoying  sequelse. 
Trichloracetic  acid  had  been  suggested  as  a  suitable 
application  after  the  operation. 

Ludwig's  Angina  was  the  title  of  the  following 
paper,  by  Dr.  J.  E.  Newcomb,  of  New  York.  The 
writer  traced  the  historj'  of  this  affection  as  it  has  been 
referred  to  in  the  medical  literature  of  the  past  sixty 
years.  The  name  itself  is  objectionable  on  the  ground 
that  pathological  processes  should  be  known,  not  by 
the  name  of  any  person,  but  by  their  distinguishing 
characteristics.  Moreover  it  is  probable  that  Heim, 
thirteen  years  before  Ludwig,  had  already  noticed  this 
peculiar  condition.  The  modern  conception  of  the 
affection  is  to  regard  it  as  a  diffuse  phlegmonous  in- 
flammation of  the  floor  of  the  mouth  and  of  the  inter- 
muscular and  sub-cutaneous  cellular  tissue  of  the  sub- 
maxillary region,  which  may  resolve  or  may  end  in 
gangrene  or  abscess.  Many  writers  confine  the  field 
of  its  occurrence  to  the  sub-maxillary  region,  but  this  is 
not  in  accord  with  the  earlier  views.  It  is  quite  evi- 
dent also  that  all  authorities  have  not  had  exactly  the 
same  thing  in  mind  when  using  this  title. 

It  has  always  been  a  matter  of  dispute  whether  the 
disease  should  be  regarded  as  a  morbid  entity  deserv- 
ing a  special  name  and  special  consideration,  or  not. 
Ludwig  gave  as  the  characteristic  local  features  the  fol- 
lowing :  I,  A  peculiar  wooden-like  induration  of  the 
connective  tissue  which  would  not  receive  impres- 
sions ;  2,  a  uniform  spread  of  this  induration  in  such  a 
way  that  it  is  always  sharply  bordered  by  a  zone  of 
entirely  unatfected  cellular  tissue:  3,  a  hard  swellii;; 
under  the  tongue  with  a  bolster-like  swelling  around 
the  interior  of  the  lower  jaw  of  a  deep-red  or  bluish- 
red  color. 

Out  of  the  various  confusing  statements  given,  it 
would  seem  that  the  true  view  is  to  regard  the  malady 
as  an  intensely  infectious  phlegmon,  occurring  under 
peculiar  conditions.  It  is,  in  fact,  one  form  of  septic 
sore  throat.  Etiologically  we  are  in  doubt,  for  the  bac- 
teriology is  very  meagre  thus  far,  and  only  the  ordinary 
germs  of  suppuration  have  been  found,  though  the  sug- 
gestion of  actinomycosis  has  been  made.  In  the  fatal 
cases  there  is  a  uniform  record  of  general  disintegra- 
tion of  the  cervical  cellular  tissue  and  muscular  sub- 
stance. Large  sloughs  have  been  found  mixed  with  an 
ichorous  fluid  or  offensive  pus.  In  several  instances 
the  pus  has  burrowed  down  along  the  planes  of  cellu- 
lar tissue  to  the  sternum,  mediastinum,  and  even  peri- 
cardium. 

The  nature  of  the  infection  is  a  very  indefinite  one 
in  many  instances.  All  lesions  of  the  teeth,  glands  of 
the  mouth,  herpetic  ulcerations  of  the  lips,  eruptions  of 
the  wisdom  teeth,  and  tonsillitis  act  as  predisposing 
causes,  for  they  favor  the  entrance  of  the  virulent 
germs  into  the  lymphatics,  and  the  conveyance  thereby 


into  the  cellular  tissues.  Cold  as  an  exciting  cause 
signifies  verj-  little,  for  what  is  called  "  cold  "  is  often 
an  indeterminable  infection. 

In  all  these  cases  the  pus  originates  in  the  triangular 
pyramidal  space  the  apex  of  which  (situated  below) 
corresponds  to  the  point  where  the  mylo-hyoid  muscle 
borders  the  genio-glossus  and  the  base  of  which  (situ- 
ated above)  stretches  along  under  the  tongue.  Its 
external  wall,  which  is  oblique,  is  formed  by  the  inter- 
nal face  of  the  inferior  maxilla  and  the  mylo-hyoid 
muscle :  the  internal  wall  (vertical)  by  the  genio- 
glossus  and  hyglossus.  L^ndoubtedly  the  sub-lingual 
gland  often  first  becomes  affected  and  the  sub-maxil- 
lary later.  The  germs  determining  the  sub-lingual 
phlegmasia  may  penetrate  the  sheath  of  the  sub-maxil- 
lary gland  also,  or  the  sub-lingual  pus  may  disassociate 
the  fibres  of  the  mylo-hyoid  muscle  and  thus  invade 
the  sub-maxillarj'  region. 

The  local  symptoms  are  those  of  a  phlegmon,  and  the 
constitutional  may  assume  either  a  sthenic  or  asthenic 
type  of  an  infectious  fever.  Special  importance  is 
attached  to  the  presence  at  the  inner  aspect  of  the 
dental  arcade  of  a  pad-like  or  button-like  area  of  hard- 
ness. 

A  differential  diagnosis  must  be  made  from  osteo- 
myelitis of  the  jaw,  simple  sub-maxillary-  adeno- 
phlegmon, and  that  rare  condition  known  as  Fleisch- 
man's  hygroma. 

About  100  cases  are  on  record  under  the  title  of 
Ludwig's  disease,  but  in  only  58  are  the  particulars 
given  with  sufficient  fulness  to  serve  for  analysis.  Of 
these,  44  were  males,  9  females,  and  5  infants  (sex  not 
stated).  The  oldest  patient  was  sixty-six  years  of  age, 
and  the  youngest  three  months.  Forty  per  cent,  oc- 
curred between  the  years  of  twenty  and  thirty.  Of  the 
58,  recovery  is  noted  in  33  and  death  in  25.  In  9  only 
were  bacteriological  findings  recorded,  viz.,  streptococci 
pyogenes,  4  ;  staphylococcus  pyogenes  aureus  and  albus, 
each  I,  and  cocci  of  erysipelas.  2.  In  one  the  microbe 
was  a  little  longer  and  narrower  than  the  B.  coli  com- 
munis, but  clearly  distinguishable  from  the  latter  by 
culture  reaction. 

Treatment  is  summed  up  in  early  incision,  subse- 
quent rigid  antisepsis,  and  general  supportive  measures. 

Very  recently  Semon,  of  London,  has  advanced  the 
view  that  this  malady,  along  with  erysipelas  of  the 
pharynx,  acute  oedematous  laryngitis,  oedema  of  the 
larynx,  and  phlegmonous  phars'ngitis,  are  all  practically 
one  and  the  same  thing,  viz.,  septic  inflammation  of  the 
throat,  differing  only  in  severity  and  localization,  and 
having  the  same  etiology.  His  general  statement  is 
that  this  theory  constitutes  a  simple  clinical  applica- 
tion of  bacteriological  principles  to  a  certain  group  of 
Sf]itic  inflammations. 

The  paper  was  discussed  by  Drs.  Daly  and  Ash, 
both  of  whom  related  cases  thought  to  be  of  this  nat- 
ure. Dr.  Swain  thought  that  peri-tonsillar  inflamma- 
tion at  the  base  of  the  tongue  might  produce  the  same 
type  of  symptoms. 

Tuberculosis  of  the  Upper  Air-passages. — The  ses- 
sion ended  with  a  discussion  on  this  topic  opened  by  Dr. 
Jonathan  Wright,  of  Brooklyn,  who  spoke  of  etiol- 
ogy. Recent  bacteriological  progress  has  led  us  to 
modify  very  largely  the  literal  interpretation  of  Koch's 
postulates  regarding  the  relations  of  germs  to  disease. 
We  now  know  that  bacteria  can  get  through  epithelium 
and  in  some  instances  they  seem  to  be  destroyed  by 
phagocytosis.  It  is  believed  possible  that  the  IjTii- 
phoid  tissue  at  the  base  of  the  tongue  may  become  in- 
oculated by  tubercular  material  taken  in  as  food.  It 
is  conjectural,  however,  as  to  whether  the  bacilli  found 
here  are  really  in  the  tissues  or  in  the  superficial  papil- 
lae. We  can  inject  tuberculous  material  into  animals 
and  kill  them,  but  the  Pravaz  syringe  does  not  exactly 
meet  the  requirements  of  clinical  medicine.  We  all 
get  a  dosage  of  tubercle  bacilli  sooner  or  later,  and  one 
in  every  seven  falls.     Autopsies  reveal  in  one  out  of 


MEDICAL   RECORD. 


[July  20,  1895 


every  two  or  three  evidences  of  arrested  tuberculosis. 
The  mortality  is  due  not  so  much  to  the  bacillus  as  to 
the  bad  general  environment  under  which  men  live. 
Physicians  as  a  class  are  not  particularly  liable  to  tu- 
bercular disease,  though  exposed  most  constantly  there- 
to. Children  fed  on  the  milk  of  Alderney  cows  suffer 
especially. 

The  scanty  anastomosis  between  the  external  and  in- 
ternal lymphatics  about  the  neck  explains  perhaps  why 
so  many  escape,  but  in  the  nose  the  abundant  com- 
munication of  the  lymph-channels  with  those  of  the 
sub-arachnoid  space  may  account  for  the  frequency  in 
children  of  tubercular  meningitis.  The  protection  of 
the  larynx  is  also  very  remarkable.  We  have  aban- 
doned Louis's  theory  of  corrosive  sputa,  but  many  pa- 
tients are  either  not  examined,  or  the  tubercular  de- 
posit escapes  observation,  or  the  tubercular  ulcers  are 
seen  only  when  the  patient  is  in  extremis.  Out  of 
25  cases  examined,  Dr.  Wright  found  nasal  or  throat 
tuberculosis  in  only  4.  As  we  clinically  see  the  disease, 
the  pyogenic  cocci  may  first  make  a  breach  in  the  epi- 
thelium through  which  the  bacillus  enters.  The  latter 
cannot  produce  an  abscess.  It  is  doubtful  whether  it 
can  penetrate  glandular  epithelium  or  not. 

Sections  of  the  laryngeal  mucosa  in  recently  born 
children  show  that  it  has  a  w-avy  outline,  especially  in 
the  inter-arytenoid  space.  Under  vocal  strain  this  wavy 
columnar  epithelium  stretches,  and  so  exercises  a  pro- 
tective influence  over  the  deeper  laryngeal  structures. 
Nasal  tuberculosis  in  phthisis  generally  comes  toward 
the  end  of  the  disease,  as  does  that  of  the  pharynx, 
though  the  latter  is  possible  in  the  earlier  stages  of 
acute  miliary  tuberculosis. 

Dr.  C.  C.  Rice,  of  New  York,  was  expected  to  speak 
on  diagnosis,  but  was  not  present.  The  following  is 
an  abstract  of  his  paper  : 

Tuberculosis  of  the  Ifares  is  Rare. — Willigk  found 
only  one  case  in  476  autopsies.  It  may  occur  either  as 
an  ulceration  on  the  nasal  septum  and  floor,  and  re- 
sembling tubercular  ulcerations  in  general,  or  as  small 
papillary  growths  attached  to  the  turbinated  tissues. 
Nasal  tuberculosis  is  frequently  overlooked,  since  it 
may  co-exist  with  septal  specific  disease,  and  because 
the  small  growths  frequently  removed  are  not  exam- 
ined. In  any  case  of  chronic  ulceration  in  a  patient 
with  pulmonary  disease,  we  should  be  suspicious  if  the 
nasaj  condition  resists  the  effect  of  the  iodide. 

Tuberculosis  of  the  Pharynx  and  Larynx. — In  Wil- 
ligk "s  1,307  autopsies,  the  latter  was  involved  237  times 
and  the  pharynx  only  once.  Rice  believes  that  tuber- 
culosis of  the  fauces  is  usually  associated  with  an  acute 
general  tuberculosis  rather  than  the  customary  chronic 
lung  process.  Occasionally  miliary  nodules  may  ap- 
jiear  in  the  soft  palate  before  it  undergoes  ulceration, 
but  probably  all  organs  are  affected  at  the  same  time. 

Tuberculosis  of  the  Larynx. — The  writer  further  be- 
lieves that  eighty  per  cent,  of  all  cases  of  laryngeal 
phthisis  can  be  easily  diagnosed,  but  that  great  care 
needs  to  be  exercised  in  the  remaining  twenty  per  cent. 
Of  this  latter  proportion,  perhaps  one-half  cannot  be 
definitely  diagnosed  without  the  aid  of  the  iodide  and 
the  microscope.  In  ordinary  cases  nothing  can  be 
more  typical  than  the  semi-cedematous,  semi-inflamma- 
tory swelling  of  the  tubercular  infiltrations,  and  the 
superficial  "  moth-eaten  "  ulcer  which  follows  with  its 
gray  surface.  Such  lesions  are  usually  symmetrical 
and  upon  a  very  aniemic  surface. 

In  the  laryngeal  appearances  in  incipient  tuberculo- 
sis, we  find  localized  anremias  of  the  hard  and  soft  pal- 
ate in  an  otlierwise  healthy  pharynx,  and,  with  this,  en- 
larged cai>illaries  merging  from:  he  different  portions 
of  the  palate  toward  the  uvula.  In  addition,  we  liave 
elevation  of  the  papillary  layer  in  the  inter-arytenoid 
commissure  and  feeble  action  of  the  internal  laryngeal 
adductors.  Recurring  papilloma  on  the  vocal  band  is 
to  be  regarded  as  a  suspicious  circumstance.  Rice  be- 
lieves that  there  is  often  an  intimate  relation  between 


them  and  tubercular  laryngitis.  Suspicious  also  is 
localized  congestion  of  the  arytenoid  cartilages  or  the 
slightest  appearance  of  bogginess. 

There  are  also  irregular  cases.  We  frequently  have 
the  co-existence  of  syphilitic  and  tubercular  ulcerations, 
and  specific  disease  in  the  larynx  with  tubercle  in  the 
lungs. 

One  or  two  cases  were  cited  presenting  that  patho- 
logical condition  common  enough  to  syphilis,  but  very 
rarely  seen  in  tuberculosis,  viz.,  adhesive  inflammation 
at  the  anterior  ends  of  the  vocal  bands.  Also  cases 
illustrating  three  forms  of  growths  seen  at  times  in  the 
tubercular  throats  :  i.  The  granular  hyperplasias  which 
are  the  ordinary  granulation  tissue  ;  2,  the  wart-Uke 
excrescences  frequently  seen  in  the  inter-arytenoid 
commissure,  and  which  are  closely  allied  to  the 
laryngeal  papillomata;  and,  3,  the  small  round  tuber- 
cular tumors  appearing  beneath  unbroken  mucous 
membrane,  microscopically  found  to  consist  of  a  tuber- 
cular structure  usually  containing  tubercle  bacilli. 

Dr.  E.  L.  Shurly,  of  Detroit,  spoke  on  "  treat- 
ment," and  enumerated  various  remedies  which  have 
been  used  in  the  disease.  He  believes  we  may  have  a 
phthisis  without  tuberculosis,  and  is  inclined  to  doubt 
whether  the  post-mortem  table  reveals  evidences  of 
previous  bacillary  invasion  as  often  as  is  claimed. 
The  best  local  remedies  he  has  found  have  been 
chlorine  gas,  solutions  of  sodium  formate,  and  iodo- 
form. As  a  specific  internal,  plain  iodine  with  chloride 
of  gold  and  sodium  have  accomplished  good  results. 
He  would  pay  great  attention  to  diet,  and  in  painful 
swallowing  would  use  gavage.  He  made  the  point 
that  vegetable  food  should  be  combined  with  the  meat 
extracts  in  these  cases.  In  the  laryngeal  cases  alcohol 
was  apt  to  be  too  irritating.  We  should  not  take 
away  all  hope  from  our  patients,  and  when  they  get  so 
low  we  should  use  morphine  enough  to  keep  them  com- 
fortable. Tracheotomy,  scarifying,  and  curetting  he 
did  not  believe  in. 

Surgical  Treatment  of  Laryngeal  Tuberculosis. — 
This  subdivision  of  the  general  topic  was  discussed  by 
Dr.  J.  W.  Gleitsmann,  of  New  York.  He  confined 
his  remarks  to  curettement  with  the  single  or  double 
instrument.  Surgical  treatment  is,  broadly  speaking, 
either  endo-  or  extra-laryngeal.  Under  the  former  are 
included  incision  with  knife  or  properly  curved  scis- 
sors, curettement,  sub-mucous  injections,  electrolysis, 
and  the  galvano-cautery  ;  under  the  latter  laryngotomy 
and  excision  of  diseased  parts,  extirpation  of  the 
larynx,  and  tracheotomy  ;  altogether  eight  subdivisions. 

A  rt'sumc'  w-as  given  of  the  historical  aspects  of  the 
subject.  Dr.  Gleitsmann  has  found  recorded  eight 
total  and  seven  partial  extirpations  of  the  larynx  for 
tubercular  disease.  In  four  of  the  former  category, 
diagnosis  was  made  before  operation,  two  were  done 
on  account  of  lupus,  and  two  had  been  diagnosed  as 
carcinoma.  In  the  latter  class,  five  operations  were 
done  for  tuberculosis,  one  for  lupus,  and  one  for  sup- 
posed carcinoma. 

As  to  curettement,  it  is  steadily  gaining  in  favor. 
Only  six  out  of  seventy  publications  consulted  are  in- 
different or  do  oppose  it.  ^Ve  cannot  hope  that  it  will 
exert  a  favorable  influence  on  the  almost  always  pres- 
ent pulmonary  complication,  but  we  are  justified  in. 
speaking  of  a  cure  of  the  larynx  where,  in  spite  of  the 
continuance  of  the  pulmonary  disease,  the  laryngeal 
symptoms  have  subsided  ;  when  the  larynx  bears  a  nor- 
mal aspect,  and  furthermore,  when  there  is  no  trace  of 
the  local  disease  found  at  post-mortem  examination — 
conditions  which  are  established  beyond  a  doubt  and 
which  are  on  record  in  literature.  Relapses  may  occur, 
for  curettement  cannot  of  course  remove  the  diathesis 
nor  can  any  other  plan  of  treatment. 

Two  writers  claim  to  have  observed  outbreak  and 
hastening  of  the  pulmonary  process  after  operation,  but 
this  is  probably  a  coincidence  and  does  not  prove  any 
causative  relation.     Other   objections   are   danger  of 


July   20,  1895] 


MEDICAL    RECORD. 


lOI 


hemorrhage,  pain,  and  difficulty  of  operating.  Bleeding 
can  be  arrested  by  a  styptic  solution  of  lactic  acid  and 
liquor  ferri  chloridi  ;  pain  can  be  almost  entirely 
avoided  by  the  repeated  applications  of  strong  solu- 
tions of  cocaine,  and  the  remedy  may  be  injected  di- 
rectly into  the  tissues.  Difficulty  in  operating  can 
never  be  considered  a  valid  objection  against  any  legit- 
imate surgical  procedure. 

Curettement  should  be  regarded  as  analogous  to  exci- 
sion by  the  surgeon  of  a  tuberculous  joint.  It  removes 
a  diseased  area,  a  focus  of  infection  which  is  a  constant 
drain  upon  an  already  debilitated  system.  It  is  in 
properly  selected  cases  more  effective,  quicker,  and  bet- 
ter in  result  than  any  other  procedure.  Besides,  the 
infiltration  of  the  arj'tenoid  region,  which  is  the  great 
cause  of  dysphagia,  can  often  be  removed  at  one  sitting 
by  the  double  curette.  Healing  is  prompt  and  cica- 
trization rapid.  Moreover,  the  suffering  of  patients 
due  to  abundant  nerve  proliferation,  justifies  arj^tenoi- 
dectomy.  Even  in  active  pulmonary  disease  with  hec- 
tic, diminution  of  dysphagia  means  more  nourishment 
taken  and  a  consequent  improvement  in  the  geileral 
condition.  Additional  advantages  gained  are  improve- 
ment in  voice,  cough,  and  respiration. 

Indications  for  curettement  are  : 

1.  Primary  tubercular  disease  without  lung  compli- 
cation. 

2.  Cases  with  concomitant  lung  disease,  either  incipi- 
ent or  which  has  stopped  short  of  softening  or  hectic. 

3.  Especially  circumscribed  ulcerations  and  infiltra- 
tions. 

4.  Dense  hard  swelling  of  the  arytenoid  region,  ven- 
tricular band,  posterior  wall,  tuberculous  tumors,  and 
affections  of  the  epiglottis. 

5.  In  advanced  lung  disease  with  distressing  dys- 
phagia from  arytenoid  infiltration. 

Contra-indications  are  : 

1.  Advanced  pulmonary  disease  and  hectic. 

2.  Disseminated  tubercular  disease  of  the  larynx 
leaving  little  or  no  area  of  healthy  tissue. 

3.  Extensive  infiltration  producing  stenosis.  Here 
tracheotomy  is  indicated. 

As  to  technique.  Heryng's  single  curettes  are  best 
suited  for  cleaning  and  scraping  of  ulcerations  : 
Krause's  double  curettes  and  Herj'ng's  rotary  curettes 
for  excision  of  tubercular  infiltration.  Sub-glottic  le- 
sions can  be  operated  upon  with  Scheinmann's  forceps, 
and  an  attempt  may  be  made  to  reach  the  ventricles  of 
the  larj-nx  with  laterally  bent  forceps.  Absolute  quiet 
is  necessary  after  operation,  and  until  cicatrization  is 
complete  daily  applications  should  be  made  of  lactic 
acid  and  pyoktannin  (one  or  two  per  cent.).  Cicatriza- 
tion occurs  in  from  seven  to  twenty-eight  days.  Ul- 
cerations which  are  well  defined  do  better  than  if  shal- 
low and  extended.  Dense  infiltrations  (which  are  gen- 
erally localized)  do  better  than  oedematous  conditions. 

After  giving  the  statistics  of  Heryng,  Gougenheim, 
and  Krause,  with  their  four  hundred  and  fifty-five 
cases.  Dr.  Gleitsmann  narrated  his  personal  experience 
with  the  double  curette  in  twelve,  all  with  lung  com- 
plication ;  two  operations  were  for  infiltration  of  the 
posterior  wall  alone,  one  for  such  with  affection  of  the 
ventricular  band  combined  ;  four  were  arytenoidecto- 
mies,  three  arjtenoidectomies  and  excision  of  the  ven- 
tricular band,  and  two  of  the  latter  alone.  Arytenoi- 
dectomy  was  necessary  a  second  time  with  two  patients 
on  account  of  recurring  infiltration.  One  patient  died 
from  heart  failure  and  another  from  advanced  lung 
disease.  Four  are  without  recurrence  of  laryngeal 
disease  from  six  to  ten  months.  Of  these,  one  had  an 
affection  of  the  posterior  wall,  another  of  ventricular 
bands,  and  two  of  the  arytenoid  region. 


Third  D.a.v,  Wednesday,  June  19,  1S95. 

Tuherculosis  of  the  Upper  Air-passages. — This  dis- 
cussion was  continued. 


Dr.  T.  Morris  Murr.w.  of  Washington,  D.  C,  had 
used  lactic  acid  in  seven  or  eight  cases  of  larj-ngeal 
and  phar\-ngeal  ulcers,  and  had  seen  good  results  in 
three.  One  case  was  curetted  two  weeks  before  the 
patient's  death.  The  uvula  was  also  infiltrated  in  this 
case.  The  ulcer  had  healed  and  the  patient's  last  days 
had  been  rendered  much  more  comfortable.  One  case 
had  remained  healed  now  for  five  years. 

Dr.  Ikgals  thought  that  of  one  thousand  cases 
operated  on  and  one  thousand  cases  treated  topically, 
the  latter  series  would  show  more  cures  than  the  for- 
mer. He  had  had  four  recoveries  from  laryngeal  and 
pharyngeal  ulcerations  by  simply  rubbing  in  lactic  acid 
without  previous  scraping.  In  the  deeper  cases  we 
should  doubtless  curette.  It  was  of  doubtful  propriety 
to  cut  away  large  masses  of  tissue.  The  trichloride  of 
iodine  (gr.  j.  to  ij.  to  water  ?  j.)  had  served  him  well. 
He  did  not  like  to  use  cocaine  here  on  account  of  its 
depressing  effects  upon  the  nervous  system.  The 
patient  is  not  so  able  to  bear  pain  afterward.  His 
favorite  mixture  is  one  of  carbolic  and  tannic  acids 
with  morphine.  It  smarts  at  first,  but  there  is  no 
pain  afterward. 

Dr.  Daly  had  seen  some  larj"ngeal  cases  recover 
under  diet,  inhalations,  and  especially  iodoform,  with 
which  he  saturates  the  patient.  He  has  never  curetted, 
thinking  it  useless  so  to  do.  He  had  used  creosote 
in  large  doses. 

Dr.  Wright,  in  closing  the  discussion,  said  that  he 
was  ver}'  sceptical  as  to  the  treatment  of  laryngeal 
tuberculosis.  Ulcers  will  occasionally  heal  under  curet- 
tement and  lactic  acid.  We  have  been  looking  too 
much  at  one  single  etiological  factor,  whereas  there  are 
many.  Laryngeal  tuberculosis  may  give  no  symptom 
whatever  even  when  the  erosive  process  has  gone  way 
down  to  the  cartilage.  The  cases  reported  cured  have 
been  limited  to  the  first  stage  of  the  disease. 

Very  few  cases  out  of  the  whole  number  are  suitable 
for  Krause's  and  Heryng's  methods. 

Dr.  Shurly  had  tried  Dr.  Ingals's  sedative  formula, 
but  had  great  difficulty  in  making  a  good  mixture  of 
the  three  ingredients,  and  used  them  separately.  -A.s 
to  creosote,  he  felt  disappointed  in  it,  but  thought  it  a 
good,  mild,  and  disinfecting  agent.  Has  had  no  ex- 
perience with  the  curette.  It  seemed  absurd  to  ex- 
pect recover}'  by  scraping  a  few  ulcers  while  there  were 
ulcerated  patches  on  invisible  areas. 

Necrosis  of  the  Middle  Turbinate. —  Paper  by  Dr. 
A.  B.  Thrasher,  of  Cincinnati.  \Vh\\e  in  acute  rhin- 
itis the  lower  turbinate  is  more  frequently  affected,  yet 
disease  of  the  middle  is  more  significant,  in  that  the 
pressure  on  the  adjacent  walls  is  great  and  the  mouths 
of  all  the  adjacent  sinuses  are  easily  closed,  thus  caus- 
ing a  mechanical  retention  of  the  normal  secretions, 
which  quickly  became  purulent. 

Ethmoiditis  is  comparatively  a  frequent  disease,  but 
necrosis  of  the  middle  turbinate  is  certainly  rare. 
Zuckerkandl  declares  he  has  never  seen  it.  AVoakes 
asserts  that  necrosis  is  present  as  a  rule  wherever  there 
is  ethmoiditis,  but  the  pathologist's  report  of  his  pub- 
lished cases  gives  only  two  cases  of  true  necrosis  out 
of  twenty  alleged  to  be  such. 

Dr.  Thrasher  sees  no  reason  why  prolonged  disease 
of  the  middle  bone  should  not  eventuate  in  necrosis,  as 
the  local  anatomical  conditions  all  would  appear  to 
favor  such  a  result.  Given  a  case  of  ethmoiditis  and  a 
polyp  springing  from  under  the  middle  turbinated,  the 
conditions  are  certainly  fairly  ripe  for  developing  ne- 
crosis of  the  latter  structure.  On  the  other  hand,  it  is 
possible  that  a  polyp  may  spring  from  a  membrane 
bathed  in  the  secretions  from  a  purulent  ethmoiditis. 
It  is  quite  analogous  to  the  condition  of  aural  polypi 
from  purulent  otitis  media.  Cysts  of  the  bone  do  not 
necessarily  lead  to  necrosis. 

Dr.  Thrasher  gave  the  two  following  clinical  his- 
tories : 

Case  I. — Woman  with  severe  pain  in  left  side  of  nose. 


MEDICAL   RECORD. 


[July   20,  1895 


radiating  over  entire  left  face  and  head,  constant 
though  with  regular  and  intense  exacerbations  ;  left 
side  nose  slightly  swollen.  Creamy  discharge  flowed 
from  beneath  left  middle  turbinated  bone  with  an 
offensive  odor,  but  not  that  of  necrosed  bone  ;  an- 
terior extremity  of  left  middle  turbinate  swollen  and 
pressing  on  septum  and  lower  turbinate.  Patient  had 
severe  influenza  one  year  before. 

Treatment. — Removal  by  cold  snare  of  projecting 
mass,  about  one  inch  long  by  one-third  inch  in  vertical, 
and  one-quarter  inch  in  lateral  diameter  ;  mucosa  was 
tightly  drawn  over  bone,  and  one-third  of  outer  por- 
tion of  latter  was  dead.  Adjacent  ethmoid  cells  were 
curetted.     No  recurrence  in  four  years. 

Case  II. — Male,  aged  twenty-six.  Neuralgia  right 
supra-  and  infra-orbital  nerves  for  two  years,  unrelieved 
by  medical  treatment ;  right  middle  turbinated  pre- 
senting as  a  large  rounded  mass  pushing  out  outer 
wall  of  nose  and  filling  middle  meatus ;  little  dis- 
charge. 

Treatment. — Cold  snare  broke  down  tissue  (in  an  en- 
deavor to  remove  en  masse),  leaving  a  large  open  cavity 
within  their  walls.  A  part  of  bony  tissue  removed  bore 
evidence  of  being  dead.  No  connection  could  be  made 
out;  between  opened  cyst  and  ethmoid  cells. 

The  general  symptoms  of  the  condition  are  :  i.  Pain, 
referred  to  supra-  or  infra-orbital  regions,  orbit  itself 
(ethmoid  involvement),  or  ear  ;  2,  discharge  often  offen- 
sive ;  3,  nasal  obstruction  and  anosmia,  but  frequently, 
even  in  severe  disease  of  the  middle  turbinate,  the 
breathing  is  unobstructed  ;  4,  obstruction  of  natural 
sinus  openings  with  attendant  symptoms  ;  5,  external 
nasal  deformity  and  displacement  (in  ethmoid  cases)  of 
globe  of  the  eye  ;  6,  various  reflex  disturbances. 

Treatment. — In  cases  of  middle  turbinate  inflamma- 
tion, if  mild  and  recent,  use  alkaline  sprays,  cocaine, 
scarification,  or  deep  incision  ;  if  the  case  is  of  long 
standing  and  osteitis  or  necrotic  bones  are  suspected, 
prompt  removal  of  the  offending  tissue  is  advocated. 
This  may  be  done  by  cold  snare,  drill,  trephine,  or 
saw-tooth  scissors.  Cauterization  here  is  contra-indi- 
cated owing  to  the  proximity  of  the  brain. 

Dr.  Thrasher  also  reported  a  case  of  congenital  osse- 
ous stenosis  of  the  naris.  Patient,  male  infant,  eigh- 
teen months  of  age  ;  in  good  condition  but  with  mouth 
breathing  and  muco-purulent  flow  from  right  naris. 
Adenoids  were  found  in  the  vault  and  removed,  but  a 
probe  passed  through  the  nostril  detected  a  thin 
partition  of  bone  just  at  the  posterior  naris.  This 
thin  scale,  thicker  toward  the  septum  and  thinning  out 
toward  the  external  wall,  was  seemingly  united  to  the 
latter  at  the  posterior  extremity  of  the  lower  turbinate, 
but  was  not  attached  to  the  turbinate,  as  could  be  de- 
tected by  the  finger  in  the  naso-pharynx. 

Dr.  S.  W.  Langmaid,  of  Boston,  had  seen  three  cases 
of  congenital  closure  of  the  nares.  He  thought  that  the 
temporary  continuance  of  mouth-breathing  after  opera- 
tion was  due  to  the  incapacity  of  the  nose  for  immedi- 
ate functional  activity  until  it  had  been  trained,  so  to 
speak. 

Dr.  Ingals  had  never  seen  any  congenital  cases. 
He  thought  that  in  many  cases  of  adenoids  there  was  a 
partial  closure  of  the  posterior  nares  which  was  over- 
looked. He  always  probes  both  nostrils  before  the 
patient  comes  out  from  under  the  anesthetic,  to  see  if 
thev  are  pervious. 

dysts  of  the  Naso-  and  Oro-pharynx  and  Fibroma  Pa- 
pillare,  or  True  Papilloma  of  the  Nasal  Septum. —  Dr. 
Jonathan  Wright,  of  Brooklyn,  described  cases  of 
this  nature  and  presented  illustrative  drawings.  Naso- 
pharyngeal cysts  are  very  rare,  and  sinuses  of  the  naso- 
pharyngeal mucosa  are  not  very  common,  though  Torn- 
waldt  has  asserted  the  contrary.  The  so-called 
pharyngeal  "  crusa  "  and  the  cysts  are  formed  by  the 
agglutination  of  the  folds  and  projections  of  the  mem- 
brane found  in  infancy.  Hence  results  a  closed  cavity 
leading  to  discharge  of,  or  retention  of,  thick  mucus, 


which  dilates  the  walled-in  space  to  the  proportions  of 
a  cyst. 

The  epithelium  in  the  naso-pharynx  is  columnar,  but 
shades  off  below  into  the  squamous,  and  in  many  cases 
of  hypertrophied  lymphoid  growths  in  the  vault  this  cov- 
ering is  in  part  or  wholly  of  squamous  cells,  evidently 
the  result  ol  irritation  from  secretions  or  rubbing  sur- 
faces. The  cyst  reported  in  the  present  paper  is 
probably  an  inclusion  cyst.  In  a  transverse  section 
through  folds  of  the  mucous  membrane  in  the  naso- 
pharynx of  a  still-born  child,  it  is  possible  to  see  oblong 
spaces  either  just  where  the  lymphoid  tissue  borders  on 
the  connective  tissue,  or  just  within  the  lymph  tissue 
itself,  or  just  within  the  connective  tissue.  These  spaces 
are  lined  with  a  single  endothelial  layer.  These  are 
probably  lymph-spaces  and  from  them  cysts  can  prob- 
ably originate. 

The  nasal  papilloma  was  removed  from  the  septum 
of  a  Roumanian  woman,  aged  twenty-eight,  with  a  his- 
tory of  nasal  obstruction  for  seven  years.  Just  inside 
the  left  nostril  was  a  soft,  vascular,  pedunculated  mass 
freely  movable.  The  cold  snare  removed  it  with  only 
moderate  hemorrhage.  The  site  of  attachment  was 
the'upper  part  of  the  cartilaginous  septum  about  2  ctm. 
from  the  columna.  This  spot  corresponded  with  a  region 
subjected  to  the  attrition  of  the  upper  edge  of  the  tri- 
angular cartilage,  forming  the  ridge  known  as  X\\t  plica 
vestibuli,  and  which  in  this  case  rubbed  against  the  sefN 
tum  when  the  lower  edge  of  the  triangular  cartilage 
was  rolled  out  by  muscular  action  in  the  dilatation 
of  the  ala  nasi  during  inspiration.  The  base  was 
cauterized  and  there  has  been  no  recurrence  (nine 
months). 

Microscopical  examination  showed  the  neoplasm  to 
be  a  true  fibroma  papillare. 

Dr.  Newcomb  had  recently  removed  with  the  cold 
snare  without  hemorrhage  a  naso-pharyngeal  cyst  from 
a  young  man  of  about  twenty.  There  was  still  left  a 
mass  in  situ,  and  he  presumed  he  had  a  multilocular 
condition  to  deal  with. 

Dr.  Langmaid  had  recently  removed  a  naso-pharyn- 
geal cyst  by  avulsion,  the  attachments  of  the  growth 
being  such  that  the  wire  loop  could  not  be  made  to  en- 
circle it.  No  hemorrhage  resulted.  In  cases  of  re- 
currence of  such  growths,  it  was  possible  that  we  left  a 
portion  of  the  cyst  wall  behind. 

Relation  of  Vasomotor  Distnrbances  to  Diseases  of 
the  Upper  Air-tract. — This  question  was  discussed  by 
Dr.  W.  H.  Dalv,  of  Pittsburg,  who  reiterated  his  well- 
known  teachings  on  this  subject.  He  called  attention  also 
to  a  variety  of  disturbance  first  described  by  Glascow, 
where  the  mucosa  is  pallid  and  yet  leaks  serum.  As  to  his 
own  success  in  relieving  asthma  and  hay-fever  by  intra- 
nasal treatment,  he  would  simply  say  that  his  own  sta- 
tistics showed  a  cure  in  sixty-three  per  cent,  of  catarrh 
and  hay-fever  cases,  and  in  forty  percent,  of  spasmodic 
asthma.  He  would  conclude  :  i.  That  abnormal  dis- 
turbances of  vasomotor  origin  may  be  primary  or  sec- 
ondary. 2.  That  both  may  be  co-active  and  progres- 
sive. 3.  That  the  surest  and  quickest  relief  is  afforded 
by  those  cases  where  surgical  interference  finds  its 
proper  election. 

Dk.  Mulhall  remarked  that  as  to  vasomotor  disturb- 
ance, there  was  the  pallid  variety  and  the  turgescent, 
just  as  some  people  get  white  in  the  face  when  angry 
and  others  red.  The  mode  of  life  was  a  frequent  factor 
in  such  cases,  rather  than  any  essential  intra-nasal  con- 
dition. Diet  and  exercise  would  do  much  to  relieve 
them.  He  advocated  daily  frictions  with  cold  water, 
mild  galvanism,  a  daily  dosage  of  atropia.  one  to  twenty 
grains,  given  in  the  morning  on  an  empty  stomach,  with 
one  drop  of  Fowler's  solution  after  meals. 

Dr.  SiMPSO.v  was  inclined  to  lay  less  stress  than 
formerly  on  the  reflex  disturbance  theory,  as  he  had 
seen  so  many  cases  in  which  a  thorough  examination 
of  the  entire  body  had  revealed  causes  of  disturbance 
supposed  at  first  to  originate  in  the  nose.     He  believed 


July   20,    1895] 


MEDICAL    RECORD. 


103 


that  it  would  be  found  in  most  instances  the  cause  was 
near  the  seat  of  the  disease  we  had  to  treat. 

The  Cigarette  Habit. — This  was  the  title  of  the  clos- 
ing paper,  read  by  Dr.  J.  C.  Mulh.\ll,  of  St.  Louis. 
The  chewer,  smoker,  and  snu£f-taker  all  e.xperience  a 
different  variety  of  satisfaction.  The  cigarette  smoker 
soon  learns  to  inhale  the  smoke,  an  unusual  habit  with 
either  cigar  or  pipe  smokers.  The  smoke  does  not 
penetrate  farther  than  the  first  diWsion  of  the  bronchi. 
It  does  not  reach  the  lungs  proper.  It  enters  into  the 
tidal  but  not  the  residual  air.  A  cigarette  milder  than 
the  one  habitually  used  does  not  give  the  usual  satis- 
factory feeling  to  the  larjngeal  and  tracheal  interior, 
nor  also  does  one  stronger  than  usual.  The  effect 
of  inhalation  is  really  a  pleasurable  sensation  produced 
upon  the  laryngeal  and  tracheal  filaments  of  the  pneu- 
mogastric  nerve,  a  sort  of  nicotine  satisfaction.  The 
absorption  of  material  from  smoke  varies,  of  course,  ac- 
cording to  amount  of  surface,  and  it  has  been  estimated 
that  in  inhalers  there  is  three  times  as  much  absorptive 
surface  as  in  non-inhalers.  Three  cigarettes  are  about 
equal  in  tobacco  strength  to  one  cigar,  but  it  is  the  fre- 
quency with  which  cigarettes  are  smoked  which  has  led 
to  the  characterization  of  the  habit  as  "deadly." 
Moreover,  the  circulative  effect  of  frequent  cigarettes  is 
analogous  to  that  of  a  given  amount  of  drug  adminis- 
tered in  divided  doses. 

The  e\'ils  of  cigarette  smoking  are  local  and  consti- 
tutional. The  latter  are  the  same  as  from  the  use  of 
tobacco  in  any  form — always  nicotinism — and  on  the 
young  these  evils  are  great.  Cigarettes  are  so  cheap 
that  they  may  be  said  to  teach  the  use  of  tobacco.  The 
first  cigarette  never  nauseates  as  does  the  first  cigar,  and 
hence  the  deterring  effect  of  the  latter  is  wanting. 

.A.S  to  local  effect,  cigarettes  may  aggravate  pre-exist- 
ing trouble,  but  Dr.  Mulhall  does  not  believe  that  there 
is  evidence  to  prove  that  they  originate  any  throat  dis- 
ease worthy  of  the  name.  There  may  be  a  mild  hyperae- 
mia  of  the  mucosa,  or  even  a  trifling  catarrh,  with  pearly 
viscid  secretion  ejected  by  a  single  slight  cough  in  the 
form  of  pellets.  A  few  rales  wholly  bronchial  are  oc- 
casionally heard.  The  murderer  Maxwell,  confined  in 
a  St.  Louis  jail,  inhaled  forty  cigarettes  daily,  and 
though  he  was  a  complete  physical  wreck,  he  had  no 
throat  alterations,  as  was  proven  by  an  e.xamination  of 
the  parts  made  after  death.  Mario,  the  great  singer, 
was  an  inveterate  inhaler. 

Dr.  Ingals,  in  discussing  the  paper,  said  that  he 
could  not  assent  to  the  doctrine  of  the  local  harmless- 
ness  of  tobacco.  He  has  seen  pronounced  tracheal 
cough  result  from  its  use. 

Dr.  Carl  Seiler  stated  that  the  habit  of  spitring 
while  smoking  did  more  local  harm  than  the  smoke  it- 
self, because  the  constant  loss  of  saliva  led  to  an  ab- 
normal dryness  of  the  pharynx. 

Dr.  Lang-Maid  thought  that  one  great  injurj'  of  to- 
bacco upon  the  young  was  in  its  destrucrion  of  the 
power  of  consecutive  thought,  by  reason  of  its  insidious 
narcotism.  As  to  pipe-smoking,  it  was  not  so  harmless 
as  generally  believed,  because  the  mouth  was  kept  hot 
by  the  heat  of  the  stem  and  the  relatively  large  raas;;  of 
fire  in  the  bowl. 

During  the  session  of  the  Congress  the  following  papers 
were  read  by  ritle  : 

■■  Foreign  Bodies  in  the  CEsophagus,"  by  Dr.  Harrison 
-■\llen,  of  Philadelphia.  "  The  Influence  of  Chronic 
Diseases  of  the  Throat  Upon  Certain  Defects  of 
Speech,"  by  Dr.  D.  Brj-son  Delavan,  of  New  York. 
"  Cyst  of  the  Maxillary  Sinus,"  by  Dr.  Charles  H. 
Knight,  of  New  York.  "  Pemphigus  of  the  Pharynx 
and  Larj'nx,"  by  Dr.  M.  R.  Brown,  of  Chicago.  "  Com- 
pensatorj-  Arytenoid  Movement,"  by  Dr.  William  Por- 
ter, of  St.  Louis.  "  A  Study  in  Diphtheria,"  by  Dr.  S. 
Hartwell  Chapman,  of  New  Haven. 

At  an  executive  session  the  following  gentlemen  were 
admitted  to  active  fellowship  : 

T.  E.  Boylan,    M.D.,    Cincinnati,   Thesis,    "  Herpes 


Chronica  Pharyngis  ;  "  F.  E.  Hopkins,  M.D.,  New  York, 
"  CEdema  of  the  Larynx  and  Report  of  a  Case." 
Thomas  Hubbard,  M.D.,  Toledo,  "  Treatment  of  Acute 
Lar)-ngkis."  J.  E.  H.  Nichols,  M.D.,  "  Intra-nasal 
Causes  of  Headache." 

The  next  meeting  wiU  be  at  Pittsburg,  Pa.,  the  time 
to  be  selected  by  the  Council.  The  following  officers 
were  elected  for  the  ensuing  year  :  President,  Dr.  W. 
H.  Daly,  Pittsburg.  First  Vice-President,  Dr.  Jona- 
than Wright,  Brooklyn.  Second  Vice-President,  Dr.  A. 
W.  de  Roaldes,  New  Orleans.  Secretary  and  Treas- 
urer, Dr.  H.  L.  Swain,  New  Haven.  Librarian,  Dr.  J. 
H.  Bryan,  Washington. 


MEDICAL   SOCIETY   OF   NEW   JERSEY. 

One  Hundred  and  Twenty-ninth  Annual  Meeting,  held 
at  Cape  May,  June  2j  and  26,  iSQj. 

0.  H.  Sproul,  M.D.,  Presidext,  ik  the  Chair. 

The  Health  of  New  Jersey. — Dr.  H.  W.  Elmer, 
chairman  of  the  standing  committee,  read  a  summarv- 
of  reports  from  physicians  throughout  the  State  regard- 
ing the  health  of  their  localities.  Typhoid  fever  had 
been  more  common  than  usual.  Antitoxin  for  diph- 
theria had  been  slow  of  adoption.  Three  cases  of 
hydrophobia  were  reported.  Variola,  which  had 
threatened  an  outbreak,  had  been  suppressed.  The 
consensus  of  opinion  was  in  favor  of  sterilized  water 
for  wounds  instead  of  antiseptic  solutions. 

Prevention  of  Blindness  tiirough  Legislative  Enact- 
ment.— Dr.  W.  B.  Johnson,  chairman  of  the  commit- 
tee on  this  subject,  read  the  report,  by  which  it  appeared 
that  they  had  succeeded  in  getting  a  bill  passed  by  the 
State  Legislature  which  differed  in  one  or  two  impor- 
tant points  from  the  one  first  passed  in  New  York  and 
subsequently  by  several  other  States.  He  quoted  a 
paper  by  Dr.  May  showing,  apparently,  no  decrease  in 
blindness  from  ophthalmia  neonatorum  in  New  York 
since  the  passage  of  Howe's  bill  in  1892.  The  inten- 
tions of  the  bill  were  not  carried  out.  The  following 
is  a  copy  of  the  New  Jersey  bill,  the  new  features  being 
in  italics  : 

1.  Be  it  enacted  by  the  Senate  and  General  Assem- 
bly of  the  State  of  New  Jersey,  That  should  one  or 
both  eyes  of  an  infant  become  inflamed,  swollen,  or 
reddened,  or  show  any  unnatural  discharge  at  any  time 
within  two  weeks  after  its  birth,  and  no  legally-qualified 
prattitiorur  of  medicine  be  in  attendance  upon  the  infant 
at  the  time,  it  shall  be  the  duty  of  the  midwife,  nurse, 
attendant,  or  relative  ha\-ing  charge  of  such  infant  to 
report  the  fact  in  writing,  within  si.x  hours,  to  the  local 
board  of  health  of  the  city,  township,  or  other  munici- 
pality in  which  the  parents  of  the  infant  reside. 

2.  And  be  it  enacted.  That  the  said  local  board  of 
health  shall  direct  the  parents  or  person  having  charge 
of  such  infant  suffering  from  such  inflammation,  swell- 
ing, redness,  or  unnatural  discharge  of  the  eyes,  toimme- 
6\zXt\\  place  it  in  charge  of  a  legally-qualified  practitioner 
of  medicine,  or  in  charge  of  the  physician  of  the  city, 
township,  or  other  municipality  if  unable  to  pay  for 
medical  sers  ices. 

3.  And  be  it  enacted.  That  every  local  board  of  health 
in  the  State  of  New  Jersey  shall  furnish  a  copy  of  this 
act  to  every  legally-qualified  practitioner  of  medicine, 
and  to  each  person  who  is  known  to  act  as  a  midwife 
or  nurse,  in  the  city,  township,  or  other  municipality  for 
which  such  board  of  health  is  appointed  ;  and  the  Sec- 
retary of  State  shall  cause  a  sufficient  number  of  copies 
of  this  act  to  be  printed,  and  to  supply  the  same  to  such 
officers  for  distribution. 

4.  And  be  it  enacted,  That  any  failure  to  comply  with 
the  provisions  of  this  act  shall  be  punished  by  a  fine 
not  to  exceed  two  hundred  dollars,  or  imprisonment 
not  to  exceed  six  months,   or  both,   upon  convicrion 


I04 


MEDICAL   RECORD. 


[July   20,  1895 


under  prosecution  proceedings  to  be  brought   by  any- 
local  board  of  health. 

5.  And  be  it  enacted.  That  this  act  shall  take  effect 
and  be  in  force  on  the  first  day  of  May,  one  thousand 
eight  hundred  and  ninety-five. 

Dr.  Charles  Kipp  thought  the  Society  was  to  be 
congratulated  on  the  passage  of  this  bill.  But  some- 
thing should  be  done  to  prevent  the  occurrence  of 
purulent  conjunctivitis,  and  to  lead  to  more  general 
knowledge  of  the  best  means  of  treating  it  among 
physicians,  and  he  moved  that  a  committee  be  ap- 
pointed to  inquire  into  the  best  methods  for  the  pre- 
vention of  purulent  conjunctivitis  of  the  new-born  in 
use  in  hospitals,  and  to  recommend  that  which  they 
regard  as  best  adapted  for  private  practice.  The  mo- 
tion was  adopted. 

New  Jersey  on  Bovine  Tuberculosis. — Dr.  J.  W. 
Stickler,  chairman  of  the  committee  on  bovine  tuber- 
culosis, stated  that  he  and  Dr.  A.  V.  M.  Baldwin,  mem- 
bers of  the  committee,  had  again  gone  before  the  com- 
mittee of  the  Legislature  and  advocated  the  passage  of 
a  bill  providing  for  the  inspection  of  herds  of  cattle 
throughout  the  State,  and  the  destruction  of  such  as 
might  be  found  tuberculous.  It  was  objected  to  on 
account  of  its  mandator)-  character,  and  the  fact  that  a 
veterinarian  was  to  be  inspector.  Of  course,  without 
such  provisions  the  law  would  be  worthless,  as  the 
present  one  was  proving  itself  to  be.  On  motion  the 
committee  was  continued. 

Relation  of  Physician  and  Pharmacist. — Dr.  H.  L. 
CoiT,  chairman  of  the  committee  on  this  subject,  read 
the  report.  The  following  ethical  rules  had  been 
formulated  :  Ethical  rules  for  the  guidance  of  physi- 
cians and  pharmacists  in  their  relations  with  one  an- 
other, proposed  to  be  adopted  conjointly  by  the  Medi- 
cal Society  of  New  jFersey  and  the  New  Jersey 
Pharmaceutical  Association. 

Propositions  :  i.  Ethical  principles,  or  standards  of 
right  conduct,  exist,  irrespective  of  their  formulation 
or  codification.  2.  Ethical  rules  are  calculated  to  ele- 
vate standards  of  moral  conduct  and  to  foster  a  spirit 
of  harmony  between  professional  men.  3.  A  code  of 
ethics  is  designed  not  only  for  the  restraint  of  those 
who  are  actuated  by  unworthy  motives,  but  for  the 
guidance  of  those  also  who  seek  to  be  governed  in  their 
actions  by  high  and  true  principles. 

Th§  Duties  of  the  Physician  to  the  Pharmacist.— i. 
The  physician  has  no  moral  right  to  discriminate  in 
favor  of  one  pharmacist  to  the  detriment  of  another, 
except  for  dishonesty,  incompetency,  or  unscientific 
methods  of  work.  2.  The  physician  is  never  justified 
in  receiving  from  a  pharmacist  gratuities  in  return  for 
patronage  ;  in  depositing  secret  formula  with  an  in- 
dividual phannacist,  or  by  word  or  deed  to  jeopardize 
his  professional  reputation.  3.  The  physician  may 
sometimes  find  it  an  advantage  to  the  patient  to  dis- 
pense the  medicine,  yet  in  the  main  it  must  be  re- 
garded as  a  subterfuge,  and  a  hindrance  to  all  interests 
involved.  The  physician  should,  if  practicable,  avail 
himself  of  the  superior  technical  skill  of  a  trained 
pharmacist  in  the  preparation  and  dispensing  of  medi- 
cines. 

The  Duties  of  the  Pharmacist  to  the  Physician. 4. 

The  pharmacist  who  recommends  drugs  or  medicines 
for  specific  remedial  purposes,  either  directly  or  through 
the  avenues  of  advertisement,  thereby  exceeds  the 
limits  of  his  profession,  and  commits  an  act  unworthv 
of  his  calling.  5.  The  pharmacist  who  consents  to 
diagnose  disease  or  prescribe  f^r  patients,  except  where 
emergencies  arise,  without  the  projier  medical  train- 
ing, assumes  responsibilities  for  which  he  is  not 
qualified,  and  justly  incurs  the  disapproval  of  phvsi- 
cians.  6.  The  phannacist  transgresses  his  true  province 
when,  for  commercial  purposes,  he  issues  to  physicians 
printed  matter  setting  forth  the  therapeutic  indications 
for  the  use  of  drugs  or  medicinal  preparations.  The 
constituents  of  the  drug  or  compound,  together  with 


its  chemical  and  physical  properties,   should    be    suf- 
ficient guarantee  of  its  utility. 

The  Duties  of  the  Physician  and  Phannacist  to  the 
Public. — 7.  The  combined  efforts  of  the  physician  and 
pharmacist  are  required  to  protect  the  public  from  the 
nostrum  maker,  pseudo-scientific  pharmacist,  the  sec- 
tarian physician,  and  drug-vender,  and  the  two  should 
be  in  continual  alliance  to  demand  the  extermination 
of  these  commercial  and  mercenary  institutions.  8. 
The  physician  and  pharmacist  should,  as  far  as  pos- 
sible, limit  the  multiplication  and  manufacture  of 
proprietary  compounds.  It  must  be  regarded  as  rep- 
rehensible to  encourage  the  use  of  these  remedies  to 
the  exclusion  of  those  which  are  official  in  the  phar- 
macopoeias. It  is  also  their  plain  duty  to  discourage 
the  use  and  sale  of  all  medicines  which  lead  to  baneful 
drug  habits.  9.  The  best  interests  of  the  patient  are 
undoubtedly  conserved  by  the  custom  of  physicians  of 
practising  rational  therapeutics,  to  the  exclusion  of 
those  methods  which  tend  to  the  use  of  many  remedies, 
or  those  of  unknown  composition  ;  and  the  supreme 
effort  of  the  dispensing  pharmacist  should  be  to  com- 
plete the  circle  of  therapeutics  by  supplying  eligible 
and  trustworthy  preparations. 

Dr.  Coit  stated  that  this  proposed  code  had  met 
with  warm  approval  by  the  State  Pharmaceutical  Asso- 
ciation, but  action  had  been  deferred  until  the  State 
Medical  Society  could  be  heard  from.  Upon  motion, 
action  and  discussion  were  postponed  until  the  next 
annual  meeting.  Printed  copies  were  ordered  dis- 
tributed among  the  district  societies  for  consideration. 

Diseases  of  Pregnancy  and  Parturition. — The  Presi- 
dent, Dr.  O.  H.  Sproul,  stated  that  he  had  not  been 
able  to  complete  the  address  which  he  had  intended  to 
deliver  on  this  occasion,  so  at  the  last  moment  had  pre- 
pared a  short  paper  containing  a  few  personal  obser- 
vations on  the  diseases  of  pregnancy  and  parturition,  for 
the  crudeness  of  which  he  presented  his  apology. 

Referring  to  the  vomiting  of  pregnancy,  out  of  over 
two  thousand  cases  of  pregnancy  which  he  had  at- 
tended there  was  uncontrollable  vomiting  in  but  one. 
This  patient  became  maniacal  and  died.  He  would 
now  resort  earlier  to  abortion  in  a  similar  case. 

Pruritus  affecting  the  genitals,  in  his  experience, 
usually  resulted  from  vaginitis,  and  was  relieved  by 
douche  of  boracic-acid  solution  and  subsequent  appli- 
cation of  nitrate  of  silver,  twenty  grains  to  the  ounce. 
Qidema  of  the  pudenda  and  extremities  was  usually 
relieved  by  salines.  Dr.  Sproul  performed  immediate 
perineorrhaphy,  but  left  the  surgical  treatment  of  lacer- 
ations of  the  cervix,  should  necessity  for  this  arise, 
until  later.  During  thirty  years'  practice  he  had  had 
but  two  cases  of  puerperal  fever.  It  was  a  rare  dis- 
ease in  rural  communities.  He  had  never  been  the 
agent  for  conveying  erysipelas  or  other  infectious  dis- 
ease. Perhaps  this  was  because  the  precautions  which 
had  been  inculcated  by  his  teachers  had  led  him  to 
adopt  more  than  usual  cleanliness.  In  the  manage- 
ment of  phlegmasia  dolens,  he  had  usually  been  suc- 
cessful with  the  flannel  roller  bandage  and  slightly  ele- 
vating the  limb.  In  hemorrhoids,  if  medicinal  and  pal- 
liative measures  did  not  give  relief,  he  resorted  to 
surgical  treatment  by  ligation.  Chloroform  anaesthesia 
to  the  extent  of  complete  insensibility  was  seldom 
necessary  in  labor,  and  should  therefore  be  avoided. 

Some  Original  Investigations  Showing  the  Antagon- 
ism Between  Morphine  and  Cocaine. — Dr.  J.  \V.  Stick- 
ler, of  Orange,  read  a  paper,  which  will  be  published 
in  full  later,  showing  that  the  best  antidote  for  morphine 
poisoning  is  cocaine,  and  vice  versa.  His  attention  had 
first  been  called  to  the  antagonism  between  the  two 
drugs  by  a  patient  taking  about  eighteen  grains  of  co- 
caine in  solution,  and  being  nervous  and  unable  to 
sleep  afterward,  took  about  half  an  ounce  of  laudanum, 
which  in  one  hour  relieved  the  nervousness  and  in- 
duced sleep.  The  patient  attended  to  his  business 
next  day.     Later  one  of  his  laboratory  assistants  gave 


July  20,  1895] 


MEDICAL    RECORD. 


105 


to  a  patient  who  had  taken  nearly  three  ounces  of 
laudanum,  three-fourths  of  a  grain  of  cocaine  in  di- 
vided doses,  and  within  two  hours  he  was  perfectly 
normal.  His  experiments  on  dogs  and  pigeons,  and 
also  on  two  men,  showed  strikingly  the  antagonistic  ef- 
fects of  cocaine  and  morphine,  and  in  comparison  with 
aconite  and  permanganate  of  potassium,  he  thought 
cocaine  was  a  far  superior  antidote  for  morphine  pois- 
oning. In  opium  poisoning  he  would  first  give  an 
emetic,  then  one-fourth  grain  cocaine  hypodermatically, 
repeating  it  twice  at  twent)'  minutes  interval  if  neces- 
sary. 

Comparative  Advantages  of  Water,  Hot  or  Cold,  ver- 
sus Germicidal  Solutions,  in  Modem  Surgery. — Dr.  W. 
B.  JoHNSOX  opened  the  discussion  upon  this  subject, 
which  had  been  presented  at  the  last  annual  meeting. 
He  pointed  out  the  marked  advance  which  the  Listerian 
system  had  made  possible,  but  stated  that  lately  the  use 
of  chemical  agents  had  come  to  be  so  far  restricted  that 
water  was  relied  upon  as  the  chief  factor,  or  even  the 
exclusive  one,  in  the  preparation  of  instruments  and 
cleansing  the  field  of  operation.  The  approach  to  the 
perfect  aseptic  technique  now  attained  was  undoubtedly 
due  to  perfect  ablution.  The  time  was  not  far  distant 
when  all  chemical  agents  for  the  destruction  of  bac- 
teria would  be  excluded  from  use  in  the  vicinity  of  the 
wound  —  asepsis,  not  antisepsis,  being  the  desidera- 
tum, when  complete  mechanical  cleansing  with  steril- 
ized water  would  render  the  use  of  germicidal  solutions 
unnecessar}-. 

Dr.  Mordecai  Price,  of  Philadelphia,  said  he 
thought  chemical  germicides  would  in  the  very  near 
future  be  consigned  to  oblivion.  He  was  not  afraid  of 
bacteria.  They  found  in  his  work  a  hotel  without  a 
table.  Leaving  no  food  for  them,  his  boarders  left. 
There  was  no  question  in  his  mind  that  bacteria  were 
not  the  cause  of  disease,  but  that  disease  was  the  cause 
of  bacteria.  Fortunately  he  had  come  into  surgery  af- 
ter Bautock  and  Tait  had  demonstrated  that  chemical 
germicides  were  useless — were  worse  than  useless — for 
they  complicated  the  disease  of  which  one  was  tr}ang 
to  relieve  the  patient.      Dr.  Price  relied  on  cleanliness. 

Dr.  Bartox,  of  Philadelphia,  employed  chemical 
antiseptics  whenever  he  had  to  operate  where  he  could 
not  avail  himself  of  the  services  of  his  own  trained  as- 
sistants, on  whose  aseptic  methods  he  could  place  per- 
fect reliance. 

Dk.  Ill  would  agree  with  Dr.  Price,  that  no  antisep- 
tic should  be  put  into  the  abdominal  cavity,  but  he 
could  see  no  reason  why  one  should  not  sterilize  the 
field  of  operation  as  well  as  the  hands  and  instruments. 

Dr.  CH.A.RLES  Kipp  said  that  antisepsis  had  made  it 
possible  to  operate  with  safety  upon  a  cataract  within 
an  hour  after  one  had  treated  a  case  of  gonorrhoeal  in- 
flammation of  the  eye. 

The  views  expressed  by  Drs.  Gross,  Keyser,  of  Phila- 
delphia, and  Benjamin,  were  in  accord  with  those  who 
used  antiseptics  in  addition  to  cleanliness. 

Papers  on  the  relations  between  physicians  and 
pharmacists  were  read  by  Delegates  AV.  C.  Alpen  and 
H.  P.  Reynolds,  from  the  State  Pharmaceutical  Associ- 
ation. 

Oar  State  Medical  Society,  Its  Past  Success,  and  Sug- 
gestions Concerning  Its  Future  Usefulness. — Dr.  D.  C. 
ExGLisH,  third  vice-president,  took  this  subject  for  his 
address.  As  showing  the  past  usefulness  of  the  Society, 
he  mentioned  the  fact  that  it  had  in  effect  originated 
the  State  Board  of  Health,  the  State  Asylum  for  the 
Insane  at  Trenton,  and  that  at  Morris  Plains,  the  Xew 
Jersey  Pharmaceutical  Association,  etc.  Among  the 
officers  of  the  Society  who  had  been  instrumental  in  its 
success  were  :  Steven  Wicks,  William  Pierson,  who  had 
acted  as  secretary  for  twenty-nine  successive  years, 
Ezra  M.  Hunt,  and  H.  R.  Baldwin.  Two  of  the  oldest 
and  most  valuable  members  were  Pennington  and 
Rogers.  The  society  was  the  oldest  in  the  States,  hav- 
ing  been  organized  in   1776,  with  thirteen  members. 


The  first  president  was  a  minister  of  the  gospel,  as  well  as 
a  practising  physician.  Dr.  English's  address  contained 
certain  suggestions  which  were  referred  to  a  com- 
mittee of  five  to  report  with  regard  to  their  adoption  in 
the  by-laws  at  the  next  annual  meeting. 

Tetany. — Dr.  Louis  Faugeres  Bishop,  of  Morris 
County,  reported  a  case  of  tetany,  a  rare  disease,  fewer 
than  one  hundred  cases  having  been  reported  in  this 
countr)'.  His  patient  still  occasionally  had  the  attacks 
of  clonic  spasms  which  extended  from  the  arm,  but  was 
improving. 

Election  of  Oflacers.— The  following  officers  were 
elected  :  President,  A\'illiam  Elmer ;  First  Vice-Presi- 
dent, T.  J.  Smith  ;  Second  Vice-President,  D.  C.  English  ; 
Third  Vice-President,  C.  R.  Fisher  ;  Corresponding  Sec- 
retary, E.  L.  B.  Godfrey  ;  Recording  Secretary,  William 
Pierson ;  Treasurer,  Archibald  Mercer.  The  next 
meeting  will  be  held  at  Asbury  Park,  the  fourth  Tues- 
day in  Tune,  1896. 


%zm  Insttrttments. 


A   NEW   MASTOID   RETRACTOR. 
By  MAX  THORNIER,  A.M.,  M.D.. 

CIKaNH.\TI,   O. 

PROFESSOR  OF  CLINICAL  LARYNGOLOGY  AND  OTOLOGY,  CINCIN*NAT1  COLLEGE  OF 
UEDICIN-E  AND  SURGERY  (SIEDICAL  DEPARTMENT  OF  THE  CINCINNATI  L*NIVES- 
Srrv)  ;  LARVNGOLOGIST  ANU  AURIST  TO  THE  C1NC1NN.\TI  HOSPITAL,  ETC 

Durixg  a  mastoid  operation  the  field  of  operation 
must  be  kept  thoroughly  clear  by  ha^ang  the  margins 
of  the  wound  well  drawn  apart.  After  making  the  in- 
cision parallel  to  the  insertion  of  the  auricle,  and  stop- 
ping the  hemorrhage,  the  bone  is  denuded  by  pushing 
the  parts  backward  and  forward  with  a  raspatory.  The 
margins  of  the  wound  are  then  kept  separated  during 
the  whole  operation  by  strong  three-  or  four-pronged 
retractors,  held  by  the  hands  of  assistants.  This  is, 
however,  not  only  very  riresome  during  protracted  op- 
erations, but  the  hands,  and  especially  the  one  holding 
the  posterior  retractor,  are  frequently  in  the  way  of  the 
surgeon.  To  overcome  this  difficulty  several  de\'ices 
have  been  invented,  as,  for  instance,  the  self-retaining 
retractors  of  Barth,  Zarniko,  AUport, 
and  Bishop.  All  of  these  are  con- 
structed on  the  principle  of  two  re- 
tracting hooks,  united  at  the  lower 
extremities  by  cross-bars,  or  by 
screws  ;  by  which  they  are  also  sep- 
arated and  kept  so  during  the  opera- 
tion. For  some  time  I  have  been 
using  a  little  device  that  is  so  ex- 
ceedingly simple  and  has  given  such 
universal  satisfacUon,  to  me  and  a 
number  of  colleagues,  that  I  think 
it  wiU  readily  recommend  itself  for 
this  and  similar  operations. 

The  instrument  consists  of  a  fiat 
S-shaped  piece  of  steel,  about  one  inch  and  three- 
fourths  long,  and  five-eighths  of  an  inch  broad.  One 
of  the  extremities  is  shaped  into  a  three-  or  four- 
pronged  hook,  while  the  other  extremity  forms  a  blunt, 
broad  retractor,  bent  in  the  opposite  direction.  This 
instrument  is  used  in  the  following  manner  : 

When  the  bone  is  well  denuded  and  the  periosteum 
pushed  aside,  the  prongs  of  one  retractor  are  well 
hooked  below  the  periosteum  of  the  posterior  margin  of 
the  wound,  and  the  prongs  of  the  other  retractor  below 
the  parts  of  the  anterior  margin  {i.e.,  the  detached 
auricle).  Then  a  long  strip  of  sterilized  gauze,  about 
an  inch  and  a  half  broad,  and  preferably  doubled, 
to  render  it  stronger,  is  folded  in  its  middle  over 
the  blunt  end  of  the  anterior  hook,  drawn  across  the 
forehead  and  around  the  head  of  the  patient,  and  fas- 
tened tightly  over  the  blunt  hook  of  the  posterior  re- 


/ 


io6 


MEDICAL    RECORD. 


[July  20,  1895 


tractor.  Instead  of  the  strip  of  gauze  one  may  also 
use  a  long  rubber  ring,  as  was  suggested  to  me  by  Dr. 
Vail,  of  this  city,  to  whom  I  am  also  indebted  for  the 
sketch  from  which  the  cut  has  been  made.  Sometimes 
the  amount  of  tissue  which  is  to  be  held  back  by  the 
anterior  retractor  is  so  enormous,  comprising  the  auri- 


"■'i-?:/*' 


cle  and  more  or  less  infiltrated  tissues  deep  down  into 
the  external  auditory  canal,  that  the  usual  anterior 
hook,  as  shown  in  the  cut,  cannot  sufficiently  grasp  it, 
to  embrace  it  well,  as  it  were.  For  such  cases,  and 
their  number  is  not  small,  I  have  had  constructed,  at 
the  suggestion  of  Professor  S.  C.  Ayres,  a  special  ante- 
rior hook  in  which  the  pronged  end  is  about  one  inch 
distant  from  the  flat  shaft.  With  this  hook,  especially 
if  we  have  one  somewhat  (about  one-fourth  to  three- 
eighths  of  an  inch)  broader,  and  having  four  instead  of 
three  prongs,  we  can  safely  hold  back  the  auricle  with 
any  amount  of  infiltrated  tissue. 

This  is  the  manner  of  procedure  in  which  the  antrum 
only  is  to  be  opened.  In  such  operations,  however,  in 
which  the  upper  and  posterior  walls  of  the  auditory 
canal  are  to  be  removed,  one  may  either  apply  both 
hooks,  in  the  above-described  manner,  or  one  may,  as 
I  would  prefer  in  some  cases,  use  only  the  posterior 
hook,  after  having  drawn  the  strip  of  gauze  around  the 
detached  auricle  between  the  wall  of  the  os- 
seous and  the  cutaneous  canal,  and  then  back 
through  the  auditory  canal  proper,  as  has 
been  recommended  by  Holmes.'  The  strip 
of  gauze  is  then  tied  around  the  forehead 
and  over  the  blunt  hook  of  the  posterior  re- 
tractor in  the  above-described  manner.  Lit- 
tle changes  in  the  application  of  the  hooks 
will  suggest  themselves,  of  course,  to  the 
surgeon  ;  sometimes,  for  instance,  the  rela- 
tive position  of  the  hooks  will  demand  that 
the  strip  of  gauze  be  carried  across  the  up- 
per lip,  just  below  the  nose,  instead  of  across  the 
forehead. 

The  advantages  of  this  method  are  obvious.  The 
margins  of  the  wound  are  kept  immovably  separated,  as 
the  gauze  can  be  fastened  tightly  or  loosely.  It  can 
be  removed  or  changed  in  an  instant.  One,  and  some- 
times two,  hands  of  an  assistant  are  positively  spared, 
and  one  may  do  with  one  assistant  less.  Neither 
hands  of  assistant  nor  cross-bars  of  instrument  are  in 
the  way  of  the  operator.  This  appliance  does  not  get 
tired  nor  relaxed,  as  the  hands  of  assistants  sometimes 
do  in  protracted  operations.  The  relative  position  of 
the  hooks  can  be  readily  changed  to  suit  the  con- 
venience of  the  surgeon.  The  posterior  hook  may  also 
serve    to  hold  down  the  flexible  probe,   which  is   in- 


troduced into  the  attic  from  the  posterior  funnel- 
shaped  opening,  after  the  antrum  has  been  opened. 
The  hooks  are  readily  rendered  aseptic,  and  the  gauze 
is,  of  course,  sterilized  before  the  operation.  Those 
who  prefer  a  blunt  retractor  instead  of  a  pronged  or 
sharp  one,  may  simply  reverse  the  instrument.  The 
slender  S-shaped  curve  renders  it  easily  adapted  to  the 
irregular  surfaces  with  which  we  have  to  deal.  And, 
finally,  the  instrument  can  be  used  for  any  other 
surgical  operations,  and  is  cheap  on  account  of  its 
simple  construction. 


c:'.;;: 


I'  Archivesjof  Otology,  1893, [p,  344.] 


^ao 


RECIPROCITY    IN    REGISTRATION. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  On  July  9th  the  State  Board  of  Registration  in 
Medicine  of  Maine  met  and  organized  ;  this  makes 
about  ten  States  which  require  an  examination  before 
a  person  is  allowed  to  practise  medicine,  regardless  of 
diplomas,  and  several  States  are  contemplating  the 
enactment  of  similar  laws.  But  nothing  can  be  done 
until  the  whole  of  the  medical  profession  in  a  State  is 
aroused,  sinking  at  least  for  the  time  their  petty  quar- 
rels and  jealousies,  and  act  as  a  unit. 

To  hasten  the  goal,  let  me  propose  a  measure  that  at 
once  would  place  practitioners  of  all  other  States  at  a 
disadvantage  and  thus  almost  force  them  to  the  adop- 
tion of  similar  laws.  Let  the  State  Boards  of  Massa- 
chusetts, Maine,  Minnesota,  Mississippi,  New  Jersey, 
New  York,  North  Carolina,  North  Dakota,  Texas 
(Vermont  and  Virginia  when  they  create  a  regular 
State  Board),  and  Washington,  or  a  committee  repre- 
senting them,  draw  up  a  section  to  be  added  to  their 
law,  something  like  this  :  "  And  said  Board  may  give 
a  certificate  of  registration  to  any  person,  who  has  pre- 
viously been  registered  in  another  State  where,  in  the 
judgment  of  the  Board,  the  standard  of  such  registra- 
tion is  equal  to  the  requirements  in  this  State,  upon 
the  presentation  of  satisfactory  proof  and  payment  of 
the  usual  fees,  etc." 

You  will  notice,  sir,  that  I  would  make  it  perfectly 
voluntary  upon  the  board  to  do  so  or  not  by  the  use  of 
the  word  "  may,"  and  yet  it  would  undoubtedly  answer 
every  purpose. 

I  object  to  the  methods  of  such  States  as  Alabama, 
California,  Connecticut,  District  of  Columbia,  Mary- 
land, New  Hampshire,  Vermont,  Virginia,  and  Wiscon- 
sin, where  the  examination,  which  is  not  always  required, 
is  conducted  by  the  various  medical  societies,  or  to 
Arkansas,  Florida,  Oklahoma,  and  a  few  others  where 
there  is  a  board  for  every  section  of  the  State.  There 
should  be  one  central  body,  appointed  by  the  governor, 
where  the  different  medical  sects  that  are  worthy  of 
recognition  should  be  represented.  Examinations 
should  be  practical  and  to  the  point — not  like  the  ex- 
aminers in  pharmacy  in  one  of  the  New  England  States, 
who  try  to  elevate  their  profession  by  "  sticking  "  the 
greatest  amount  of  candidates  by  theoretical  supposi- 
tions, and  who  have  only  succeeded  in  creating  a  new 
class  of  frauds,  crammed  with  just  such  questions  and 
answers,  who  for  a  consideration  will  go  and  be  ex- 
amined in  almost  anybody's  name. 

The  standard  should  be  uniform  throughout  all  the 
States,  a  matter  which  a  committee  could  easily  ar- 
range, and  then,  when  once  registered,  a  practitioner 
would  be  so  forever. 

The  convenience  resulting  from  such  a  law  would 
undoubtedly  swing  all  the  other  States  into  line,  and 
then  the  formation  of  a  National  Board  of  Medical  Ex- 
aminers would  be  in  order,  whose  certificate  would  be 
good  everywhere.  Country  Doctor. 

East  EuDiNCiTON,  Mb.,  July    1895. 


July   20,  1895] 


MEDICAL   RECORD. 


107 


THE    PRESENT    STATUS  OF   ANTITOXIN  I\ 
LONDON. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Having  just  returned  from  a  trip  to  England,  and 
thinking  the  readers  of  the  Medical  Record,  like  my- 
self, would  be  interested  to  learn  the  latest  English 
results  concerning  the  antitoxin  method  in  treatment 
of  diphtheria,  is  my  excuse  for  sending  you  these  few- 
lines. 

Knowing  that  in  London  there  were  several  hospi- 
tals devoted  exclusively  to  the  care  and  treatment  of 
infectious  diseases,  I  took  occasion  to  visit  one  of  the 
largest,  viz.,  the  London  Northwestern  Fever  Hospi- 
tal, on  purpose  to  find  out  for  myself,  from  the  physi- 
cians in  charge,  the  results  of  their  experience  with  this 
so-called  cure  for  diphtheria. 

I  was  very  cordially  received  by  the  resident  physi- 
cian, and  after  stating  the  object  of  my  visit,  he  kindly 
consented  to  furnish  me  all  the  information  he  had  at 
his  command,  and  at  the  same  time  invited  me  to  ac- 
company him  through  the  various  wards  of  the  insti- 
tution, which  I  did.  The  hospital  itself  is  composed 
of  several  detached  frame  buildings,  each  of  which 
accommodates  from  twenty-four  to  fifty  patients,  the 
aggregate  capacity  of  the  institution  being  four  hun- 
dred beds.  These  frame  buildings  are  now  being  rap- 
idly displaced  by  more  capacious  modern  brick  and 
stone  structures,  so  that  the  hospital  is  now  undergoing 
extensive  alterations.  Each  building  was  neat  and 
clean,  and  furnished  with  comfortable  beds,  which 
were  occupied  with  patients,  for  the  most  part  children, 
suffering  from  either  diphtheria  or  scarlet  fever  in  their 
various  stages. 

"  This,"  said  the  doctor,  "is  one  of  seven  hospitals  in 
London  devoted  exclusively  to  the  treatment  of  infec- 
tious diseases."  "  How  many  cases  of  diphtheria  have 
you  here  at  the  present  time  ?  "  I  asked.  "  About  two 
hundred,"  he  said.  "  Have  you  used  the  antitoxin  in 
your  treatment  of  them  ?"  "Yes,  we  have  been  using 
it  here  since  the  first  of  the  year."  "  What  has  been 
the  result  of  your  experience  with  it  ?  "  "  It  has  proven 
an  unfortunate  failure."  "  How  do  your  results  com- 
pare with  the  other  similar  institutions  ?  "  "  We  are 
all  agreed,  with  but  one  exception,  and  he  is  rapidly 
withdrawing  his  former  premature  statements  in  regard 
to  its  efficacy."  "Do  you  confirm  your  diagnosis  by 
making  cultures.?"  "Yes,  in  every  case."  At  this 
juncture  a  porter  informed  the  doctor  that  a  new  case 
of  diphtheria  had  just  arrived.  "  Come,"  said  he,"  and 
I  will  show  you  how  we  receive  patients  at  this  hospi- 
tal, and  how  we  make  our  cultures."  An  opportunity 
was  here  afforded  which  I  was  very  glad  to  take  ad- 
vantage of.  ■'  Do  you  often  have  mistakes  in  diag- 
nosis ?  "  I  asked.  "  Yes,"  said  the  doctor,  "  we  often 
get  cases  of  tonsillitis  for  diphtheria,  and  measles  for 
scarlet  fever."  "  In  cases  of  doubt,  how  do  you  avoid 
contamination  ?  "  "  We  have  a  receiving  ward  in  which 
doubtful  cases  are  kept  isolated  while  yet  under  obser- 
vation, until  we  are  satisfied."  "What  is  your  rate  of 
mortality  ?  "  "  Twenty-seven  per  cent.,  which  includes 
all  cases  ;  this  could  be  reduced  to  twenty,  if  only  the 
acute  cases  are  considered."  "  Has  this  been  increased 
or  diminished  since  you  have  used  the  antitoxin  ? " 
"  No,"  said  he,  "  it  has  remained  the  same.  Indeed,  I 
believe  that  the  antitoxin  is  harmful  to  the  patients, 
because  it  produces  a  rash,  which  again  increases  the 
fever  and  renders  the  patients  much  more  ill  than  they 
usually  were  before  we  used  the  remedy."  "  Are  you 
still  using  it  ? "  "  Yes,  we  do  not  wish  to  discard  it 
until  we  have  given  it  a  sufficient  trial  to  satisfy  the 
most  sanguine  mind,  but  for  myself,  I  am  now  ready 
to  brand  it  as  a  complete  failure."  "  How  is  it  regarded 
in  the  States  ? "  he  inquired.  I  replied  that  it  was  still 
in  the  scales  being  weighed,  and  that  many  had  formed 
the  same  conclusions  as  himself,  while  others  thought 
it  was  the  only  cure  for  diphtheria. 


Before  taking  my  leave  I  was  invited  to  partake  of 
the  inevitable  cup  of  tea,  which  is  so  common  a  part 
of  English  social  life,  and  thus  ended  what  I  considered 
a  very  profitable  afternoon's  outing  in  London. 
J.   PUNTON,  M.D., 
Professor  of  A'ervous  and  Mental  Diseases,  Uni- 
versity Medical  College,  Kansas  City,  Mo. 


^ctXical  Stems. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  July  13,  1895. 

Cases.     I    Deaths. 


Tuberculosis 166  112 

Typhoid  fever i8  3 

Scarlet  fever 50  4 

Cerebro-spinal  meningitis 2  5 

Measles 210  I        29 

Diphtheria ig6  19 

Professor  Cesare  Lombroso  was-  born  in  1846,  in 
Venice,  of  Hebrew  parents.  After  being  graduated  in 
medicine  he  became  interested  in  diseases  of  the  mind, 
and  especially  in  criminal  anthropology,  of  which  sci- 
ence he  has  been  called,  though  not  in  strict  justice, 
the  founder.  He  is  now  Professor  of  Medical  Juris- 
prudence in  the  University  of  Turin. 

The  Regents  of  the  State  University  have  voted  to 
confer  the  university  degree,  M.D.,  only  after  one  year's 
post-graduate  study  subsequent  to  receiving  the  degree 
of  bachelor  or  doctor  of  medicine  from  some  registered 
medical  school,  and  only  on  candidates  who  have  spent 
not  less  than  four  years'  total  study  in  accredited  medi- 
cal schools. 

The  State  Medical  Library.— Chancellor  Upson,  of 
the  regents,  has  appointed  Drs.  Charles  E.  Jones,  S.  B. 
Ward,  and  Willis  G.  Tucker,  of  Albany,  as  an  advisory 
medical  library  council  for  1896,  to  recommend  books  to 
be  bought  and  to  confer  with  the  director  of  the  library 
in  any  matters  connected  with  the  new  State  medical 
library,  which  may  be  submitted  to  them. 

Charing  Cross  Hospital,  in  London,  is  in  financial 
straits.  It  is  proposed  to  remove  the  hospital  to  Cam- 
berwell,  south  of  the  river,  and  to  sell  the  valuable  site 
on  which  it  now  stands. 

The  New  York  State  Medical  Law. — In  a  recent 
issue  we  published  the  full  text  of  the  codified  medical 
laws  of  the  State  of  New  York  as  they  existed  before 
the  session  of  the  last  Legislature.  In  order  to  empha- 
size the  changes  made  by  this  latter  body  (and  these 
are  the  only  changes,  notwithstanding  misleading  items 
published  in  some  medical  journals),  we  herewith  ap- 
pend the  amendments.  Section  145  has  been  amended 
by  Chap.  636  of  the  Laws  of  1895,  which  became  a  law 
upon  May  13,  1895.  The  amendment  relates  to  the 
preliminary  education  requirement.  The  second  para- 
graph of  this  section  now  reads  as  follows,  the  amended 
portion  being  in  italics  ; 

"  The  degree  of  bachelor  or  doctor  of  medicine  shall 
not  be  conferred  in  this  State  before  the  candidate  has 
filed  with  the  institution  conferring  it  the  certificate  of 
the  regents  that  three  years  before  the  date  of  the  de- 
gree he  has  either  graduated  from  a  registered  college 
or  satisfactorily  completed  a  full  course  in  a  registered 
academy  or  high  school ;  or  had  a  preliminary  education 
considered  atid  accepted  by  the  regents  as  fully  equivalent ; 
or  had  passed  regents'  examinations  representing  for  de- 
grees conferred  in  l8g8  one  year  of  academic  work,  for 
degrees  conferred  in  iSgg  two  years  of  academic  work. 


io8 


MEDICAL    RECORD. 


[July  20,  1895 


and  for  degrees  conferred  in  igoo  a  full  high  sclwol 
course.  Students  who  had  matriculated  in  a  New  York 
medical  school  before  June  5,  1890,  shall  be  exempt 
from  this  preliminary  education  requirement,  provided 
the  degree  be  conferred  before  August  i,  1895.  The 
regents  may,  in  their  discretion,  accept  as  the  equiva- 
lent for  any  part  of  the  third  and  fourth  requirement 
evidence  of  five  or  more  years'  reputable  practice,  pro- 
vided that  such  substitution  be  specified  in  the  license." 

Section  153,  under  which  illegal  practitioners  are  pro- 
ceeded against,  has  been  amended  by  Chap.  398  of  the 
laws  of  1895,  and  this  amendment  is  of  a  most  compre- 
hensive character.  By  restoring  the  provisions  of  the 
former  act  of  1887  which  gave  the  fines  to  the  Medical 
Societies,  it  renders  the  systematic  prosecution  of  of- 
fenders again  feasible.  This  section  now  reads  as  fol- 
lows : 

"  §  ^53-  -Penalties  and  their  collection. — Any  person 
who,  not  being  then  lawfully  authorized  to  practise 
medicine  within  this  State  and  so  registered  according 
to  law,  shall  practise  medicine  within  this  State  with- 
out lawful  registration  or  in  violation  of  any  provision 
of  this  article  ;  and  any  person  who  shall  buy,  sell,  or 
fraudulently  obtain  any  medical  diploma,  license,  rec- 
ord, or  registration,  or  who  shall  aid  or  abet  such  buy- 
ing, selling,  or  fraudulently  obtaining,  or  who  shall 
practise  medicine  under  cover  of  any  medical  diploma, 
license,  record,  or  registration  illegally  obtained,  or 
signed,  or  issued  unlawfully  or  under  fraudulent  repre- 
sentations or  mistake  of  fact  in  a  material  regard,  or 
who,  after  conviction  of  a  felony,  shall  attempt  to  prac- 
tise medicine,  or  shall  so  practise,  and  any  person  who 
shall  append  the  letters  M.D.  to  his  or  her  name,  or 
shall  assume  or  advertise  the  title  of  doctor  (or  any  title 
which  shall  show  or  tend  to  show  that  the  person  as- 
suming or  advertising  the  same  is  a  practitioner  of  any 
of  the  branches  of  medicine)  in  such  a  manner  as  to 
convey  the  impression  that  he  or  she  is  a  legal  practi- 
tioner of  medicine,  or  of  any  of  its  branches,  without 
having  legally  received  the  medical  degree,  or  without 
ha\ang  received  a  license  which  constituted  at  the  time 
an  authority  to  practise  medicine  under  the  laws  of  this 
State  then  in  force,  shall  be  guilty  of  a  misdemeanor, 
and  on  conviction  thereof  shall  be  punished  by  a  fine 
of  not  more  than  $250,  or  imprisonment  for  six  months 
for  the  first  offence,  and  on  conviction  of  any  subse- 
quen^t  offence,  by  a  fine  of  not  more  than  §500  or  impris- 
onment for  not  less  than  one  year,  or  by  both  fine  and 
imprisonment.  Any  person  who  shall  practise  medi- 
cine under  a  false  or  assumed  name,  or  who  shall  falsely 
personate  another  practitioner  of  a  like  or  different 
name,  shall  be  guilty  of  a  felony.  When  any  prosecu- 
tion under  this  article  is  made  on  the  complaint  of  any 
incorporated  medical  society  of  the  State,  or  any  county 
medical  society  of  such  county  entitled  to  representa- 
tion in  a  State  society,  the  fines  when  collected  shall  be 
paid  to  the  society  making  the  complaint,  and  any  ex- 
cess of  the  amount  of  fines  so  paid  over  the  expense 
incurred  by  the  said  society  in  enforcing  the  medical 
laws  of  this  State,  shall  be  paid  at  the  end  of  the  year 
to  the  county  treasurer." 

Complete  copies  of  the  amended  law  can  be  obtained 
by  addressing  the  Regents'  Office,  Albany,  N.  Y.,  or  on 
application  to  the  Secretary  of  the  State  Board  of  Medi- 
cal Examiners,  78  West  Eighty-second  Street,  New 
York  City. 

The  Mutilation-market  and  the  Business  of  Mendi- 
cancy.— Austro-Hungary  is  acquiring  an  evil  pre-emi- 
nence in  the  manufacture  of  deformity  and  iusu.^ 
natures.  Some  eighteen  months  ago  we  commented 
on  the  discovery  made  by  the  Croatian  police  of  a 
regular  mutilation-den,  where  boys  and  girls  of  tender 
years  were  distorted  or  maimed  to  supply  the  mendi- 
cancy-market— and  where,  by  fracture  or  by  continu- 
ous pressure  between  boards  tightened  by  screws,  the 
legs  and  arms  and  spinal  columns  of  these  poor  little 


victims  were  made  to  assume  monstrous  shapes — where 
even  the  eyes  were  gouged  out  and  artificial  sores  cre- 
ated— all  to  provide  the  traffickers  in  str^t-begging 
with  "  objects  "  wherewith  to  solicit  the  alms  of  the 
benevolent.  {The  Lancet.)  The  arrest  and  punishment 
of  these  purveyors  of  deformity  seem,  however,  to 
have  put  no  effective  stop  to  the  practice,  for  we  read 
in  a  Hungarian  journal  that  at  Prague  a  man,  Pros- 
chaska  by  name,  was  taken  into  custody  charged  with 
selling  to  the  firm  of  Ritter  &  Munster,  of  Holstein,  a 
number  of  children  who,  by  means  of  specially  con- 
trived alimentations,  had  had  their  growth  arrested  for 
exposure  as  "  Liliputians "  in  itinerant  exhibitions. 
For  every  child  so  stunted  and  maltreated  the  sum  of 
300  florins  was  paid.  We.  further  read  that  not  only 
were  the  authors  of  the  "  Liliputianizing "  system 
brought  to  justice,  but  also  the  unnatural  parents  who 
consented  to  its  being  applied  to  their  offspring,  and 
who  received  money  for  doing  so.  This  is,  of  course, 
quite  commendable  on  the  part  of  the  law  ;  but  we 
fear  its  heaviest  punishment  will  have  small  deterrent 
force  so  long  as  the  public  does  not  co-operate  in  sup- 
pressing the  "business  of  mendicancy."  Indiscrimi- 
nate alms-giving  lies  at  the  root  of  the  whole  evil. 
Rather  than  take  the  trouble  to  ascertain  where  relief 
can  most  worthily  and  effectively  be  bestowed,  the  so- 
called  "  benevolent "  man  will  lavish  his  small  change 
on  every  beggar  who  crosses  his  path,  thereby  creating 
half-a-dozen  similar  beggars  for  every  one  he  subsi- 
dizes, and  depriving  the  really  well-organized  charities 
of  the  funds  of  which  they  are  sorely  in  need.  One  of 
the  most  large-hearted  economists  of  his  generation, 
Archbishop  Whalely,  congratulated  himself  at  the  close 
of  his  life  that  he  never  gave  a  penny  to  a  beggar,  but 
that  the  money  withheld  from  such  objects  had  been 
profitably  bestowed  on  the  institutions,  medical  and 
other,  where  succor  was  vouchsafed  only  to  the  deserv- 
ing. If  the  public  acted  with  equal  wisdom  and  stiff- 
ened its  back  against  the  professional  mendicant,  while  J 
relaxing  its  purse-strings  in  support  of  well-accredited  I 
charities,  an  end  would  speedily  be  made  of  the  "  busi-  ■ 
ness  of  beggary,"  with  all  its  concomitants  of  "  mutila- 
lation-dens  "  and  "  Liliputian  farms,"  and  liisus  nat- 
ura  manufactured  and  supplied  to  order.  We  hope 
the  subject  will  be  adequately  discussed  at  the  Inter- 
national Congress  for  the  Protection  of  Infancy,  which 
will  meet  next  July  at  Bordeaux. 

Onychophagia. — M.  Bertillon,  whose  anthropometric 
system  of  identifying  criminals  has  made  his  name  so 
well  known  in  connection  with  the  outward  and  %'isible 
signs  of  inward  abnormality,  now  tells  us  that  biting 
the  nails — or,  to  give  it  its  scientific  name,  "onycho- 
phagia " — is  a  sign  of  degeneracy.     It  is  an  uncleanly 
habit  which,  in  some  people,  takes  the  place  of  that 
"  whittling  "  in  which  some  New  Englanders  find  relief 
for  their  superfluous  energies.     Long  ago  Dr.  O.  W. 
Holmes,  in  his  "  Autocrat  "  pointed  out  that  punning 
might  be  an  early  symptom  of  insanity,  and  in  that        _ 
opinion  we  are  inclined  to  agree  with  him,  at  least  if       ■ 
the  vice  is  habitual  and  suggestive  of  irresistible  im-       J 
pulse  ;  but  it  is  hard  that  one  should  be  convicted  of 
degeneracy  on  the  strength   of    ragged    nails.     What 
about  other  unconscious  or  semi-unconscious  acts  ?    Is        _ 
a  well-known  reformer  to  be  called  degenerate  because       ■ 
he  constantly  chews  tobacco  (when  he  is  not  drink-       ^ 
ing  tea)  ?  or  the  great  masses  of  humanity  who  indulge 
in  chewing-gum  ?     It  is  dangerous  to  have  a  trick  of 
any  kind  in  these  days  when  the  disciples  of  Lombroso 
are  among  us  "  takin'  notes,"  or  when  rubbing  the 
nose  or  cracking  the  fingers  may.  to  the  seeing  eye,  be 
as  fraught  with  mystic  meaning  as  our  Police  Com- 
missioners' midnight  ventures. 

Chloroform  in  Typhoid.— Dr.  Quill,  of  the  British 
Medical  Staff  in  India,  has  treated  a  large  number  of 
cases  of  typhoid  fever  with  chloroform  and  carbolic 
acid  internally,  and  claims  to  have  had  excellent  results. 


Medical   Record 

A  JVeekly  journal  of  Medicine  and  Surgery 


Vol.  48,  No.  4. 
Whole  No.  1290. 


New  York,  July  27,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©figinal  ^xXxzlzs. 


PREGNANCY  ASSOCIATED  WITH  DIABETES.' 
By  EDWARD  L.   PARTRIDGE,  M.D., 


In  a  consideration  of  the  subject  of  this  paper,  it  will 
be  impossible  to  do  more  than  present  the  experience 
of  a  few  observers  of  the  association  of  the  two  condi- 
tions of  diabetes  and  pregnancy.  But  little  has  been 
■written  on  the  subject,  and  the  opinions  of  the  writers 
have  been  reached  on  comparatively  little  experience. 
The  presentation  of  the  subject  by  those  who  have 
written  has  been  forcible,  however,  and  there  exists,  in 
the  minds  of  those  who  are  acquainted  with  the  sub- 
ject through  this  literature,  an  impression  that  very 
great  danger  attends  the  association  of  glucose  in  the 
urine  and  pregnancy.  On  more  than  one  occasion  the 
question  has  been  anxiously  raised  as  to  the  course  to 
be  pursued  when  these  conditions  coexist,  and  a  brief 
review  of  our  knowledge  on  the  subject  maybe  proper 
and  interesting,  even  if  devoid  of  much  result  of  a 
practical  nature.  •  By  result  of  a  practical  character, 
I  refer  to  the  formulation  of  rules  of  guidance  in 
reaching  prognosis,  and  decision  as  to  the  proper  treat- 
ment, especially  in  regard  to  the  interruption  of  the 
pregnancy.  That  we  would  welcome  conclusions  which 
we  could  feel  to  be  well-founded,  we  clearly  realize. 
Have  deductions  of  this  nature  been  reached  ? 

Glucose  in  the  urine  of  a  pregnant  woman  may  ap- 
pear for  a  single  examination,  or  be  occasionally  pres- 
ent and,  to  a  slight  degree,  constituting  a  glycosuria 
within  the  limit  of  what  may  be  physiological.  We 
may  meet  with  pregnancy  occurring  in  a  woman  who 
has  the  disease  diabetes,  or  diabetes  may  develop  dur- 
ing pregnancy,  continuing  thereafter ;  or,  finally,  we 
meet  with  instances  in  which  diabetes  develops  during 
pregnancy,  lasting  through  a  considerable  part,  or  the 
whole  of  gestation,  and  disappearing  to  recur  in  suc- 
ceeding pregnancies,  the  instances  of  the  latter  class 
constituting  what  might  be  called,  perhaps,  "  puerperal 
diabetes." 

Glycosuria  during  gestation  has  attracted  the  atten- 
tion of  all  who  have  occasion  to  make  urinary  analyses 
of  pregnant  women.  By  glycosuria  we  understand  the 
amount  of  glucose  to  be  small,  and  the  condition  need 
never  be  confounded  with  diabetes.  Inasmuch  as  uri- 
nary examinations  do  not  reciuire  frequent  repetition 
1  u ring  pregnancy,  and  as  the  majority  of  practitioners  do 

L  look  for  glucose,  and  furthermore,  as  glycosuria  may 

iiibit  itself  on  occasional  days,  or  in  certain  parts  of 
the  day  only,  it  is  probable  that  this  modification  of  the 
blood  and  urine  may  be  much  more  frequent  than  it  is 
reported  to  be.  It  is  in  the  latter  months  of  pregnancy 
that  it  is  most  commonly  observed,  and  it  is  then  that 
the  more  profound  disturbances  of  the  economy, 
through  the  influence  of  pregnancy,  are  present.  One 
theory  of  the  production  of  glycosuria  relates  to  the 
activity  of  the  mammary  glands  at  this  time,  with  a 
disposition  to  the  production  of  milk  sugar,  which  by 
its  presence  in  the  blood,  or  resor[)tion,  makes  its  ap- 
pearance in  the  urine. 
'  Read  at  a  meeting  of  the  Practitioners'  Society  of  New  York,  May 


However  this  may  be,  it  is  true  that  mth  the  activity 
of  the  mammary  glands  attending  the  establishment  of 
lactation  after  childbirth,  glycosuria  is  quite  common. 
By  the  early  investigations  of  Blot,  later  by  Tarnier, 
and  at  the  Simpson  Memorial  Hospital,  physiological 
glycosuria  has  been  shown  to  be  very  common.  Ber- 
beroff  notes  that  of  twenty-five  women  just  confined, 
thirteen  exhibited  gl3Cosuria.  The  theory  of  relation 
between  glycosuria  and  breast  activity  has  had  adher- 
ents so  devoted,  that  the  proposition  has  been  offered 
to  include,  in  the  critical  examination  of  women  for 
wet-nurses,  the  investigation  of  the  urine,  and  to  regard 
the  presence  of  sugar  as  a  favorable  indication. 

Passing  from  this  part  of  our  subject  to  a  considera- 
tion of  diabetes  as  a  disease,  in  its  relation  to  preg- 
nancy, we  find  in  the  important  paper  by  Mathews 
Duncan  much  of  serious  import.  He  classes  diabetes 
with  nephritis  and  scarlatina,  and  ascribes  to  it — as  we 
would  to  the  others — especial  malignity  when  associ- 
ated with  pregnancy,  parturiency,  or  the  lying-in  pe- 
riod. He  remarks  "  that  cases  of  the  kind  are  not  suf- 
ficiently numerous  to  justify  any  statistical  argument 
based  on  the  number  of  the  occurrences." 

Fry  takes  a  very  grave  view  of  the  dangers  of  the 
complication,  and  in  his  review  of  Duncan's  cases,  it 
appears  to  me,  has  with  some  effort  made  them  fit  his 
theories.  He  would  never  permit  a  woman  with  dia- 
betes to  marry,  and  questions  the  propriety  of  marriage 
where  there  is  a  "  strong  hereditary  predisposition  to 
diabetes."  Regarding  obstetrical  treatment  by  induction 
of  labor,  he  says  that  there  may  be  mild  cases  of  dia- 
betes, when  there  is  reason  to  think  that  pregnancy 
will  terminate  naturally,  in  which  interference  is  not 
justifiable,  yet  adds  that  "  the  difficult  point  to  decide 
is  not  as  to  the  advisability  of  inducing  premature  la- 
bor, but  as  to  when  it  shall  be  done." 

Barnes  believes  that  induction  of  labor  would  be  of 
doubtful  value  in  these  cases  feeling  that  by  the  time 
indications  for  its  adoption  are  reached,  a  perilous 
situation  will  have  rapidly  supervened,  and  results 
would  not  be  modified  by  such  a  course.  We  can  see 
that  the  explanation  of  the  record  of  so  few  cases  lies 
in  part  in  the  fact  that  general  statistics  show  women  to 
be  less  disposed  to  diabetes  in  the  early,  or  child-bear- 
ing, period  of  life  than  men  ;  and  furthermore,  when 
attacked  between  the  ages  of  twenty  and  twenty-five, 
they  are  often  subjects  of  amenorrhoea,  or  the  general 
health  is  so  deteriorated  that  marriage  and  pregnancy 
are  less  liable  to  occur. 

Diabetes,  in  its  unfavorable  aspect  during  pregnancy 
or  the  lying-in  state,  presents  certain  cases  of  sudden 
death  in  coma  or  collapse.  It  has  been  thought  also 
that,  following  a  safe  delivery,  there  is  more  rapid  prog- 
ress of  the  disease  when  it  has  been  known  to  have  ex- 
isted during  pregnancy.  Duncan  finds  one  case,  how- 
ever, which  shows  that  diabetes  may  not  return  in- 
pregnancy  occurring  after  its  cure.  A  fatal  case  re- 
ported by  Fry,  in  1891,  occurred  in  the  second  preg- 
nancy of  the  parient,  diabetes  developing  at  the  fifth 
month.  Death  of  the  foetus  at  the  seventh  month  was 
followed  by  premature  labor  and  the  death  of  the 
mother  on  the  fifth  day.  Minot,  in  1S88,  reports  a 
case  of  a  woman  of  twenty  known  to  have  had  diabetes 
for  more  thafl  six  months,  who  when  about  four  and  a 
half  months  advanced  in  pregnancy  became  suddenly 
comatose,  and  died  in  thirty-six  hours.     She  was   of 


no 


MEDICAL    RECORD. 


[July  27,   1.^95 


"  nervous  temperament  ;  one  grandfather  died  of  spinal 
disease  and  diabetes.  Her  father  died  of  tubercle  of 
the  spinal  cord." 

A  case  seen  by  me  in  the  practice  of  Dr.  Thomas  T. 
Gaunt  has  the  following  history  :  Aged  twenty,  first 
pregnancy.  At  three  months  urine  was  normal.  Sec- 
ond examination,  at  four  months,  showed  one  per  cent, 
of  glucose.  Symptoms  which  were  noted  from  this  time 
to  the  end  of  fifth  month — when  the  case  was  seen  by  me 
— were  sore  mouth,  salivation,  vomiting,  and  indigestion, 
loss  of  flesh,  and  prostration.  She  had  been  in  bed  sev- 
eral weeks,  during  which  she  had  been  on  strict  diet,not- 
withstanding  which  sugar  had  steadily  increased  to  two 
and  a  half  per  cent.  She  w^as  passing  ninety  to  one 
hundred  ounces  of  urine.  She  continued  anjemic,  had 
insomnia,  and  became  extremely  nervous,  vomiting 
several  times  a  day.  There  was  present  a  trace  of 
albumin,  but  no  casts.  At  six  months  sugar  reached 
highest  point,  viz.,  three  per  cent.,  a  trace  of  albumin 
continuing,  and  her  general  condition  being  not  essen- 
tially changed.  On  a  somewhat  more  liberal  diet, 
which  her  general  condition  demanded,  sugar  did  not 
increase,  and  she  improved  a  little,  being  up  and  about. 
At  seventh  month  she  had  improved  so  that  she  could 
walk  about  and  go  out  of  doors,  sugar  decreasing,  until 
at  eighth  month  there  was  a  trace  only,  urine  being 
normal  in  amount.  She  left  the  city,  and  about  this 
time  had  more  marked  albuminuria,  with  diminished 
urea  and  hyaline  and  granular  casts.  The  further  his- 
tory, as  reported,  was  continuance  of  trace  of  sugar, 
albuminuria  which  did  not  call  for  induced  labor,  con- 
finement at  term  with  child  which  lives,  having  been 
nursed  by  mother.  One  month  after  confinement, 
now  two  years  ago,  and  thereafter,  sugar  was  not  pres- 
ent in  the  urine.  From  my  investigation  of  current 
medical  literature,  I  do  not  find  other  cases  of  diabetes 
and  pregnane)'  reported.  Such  histories  are  likely  to 
appear  as  notes  of  isolated  cases,  and  a  very  full  search 
might  disclose  more,  but  my  impression  is  that  these 
would  be  few  in  number. 

It  is  probable  that  fatal  cases  would  be  reported 
most  commonly,  possessing,  as  they  would,  the  most 
striking  features.  It  is  easy  to  believe  that  many  cases, 
not  fatal,  might  fail  to  attract  attention,  for  in  those 
reported  by  Duncan  it  happened,  more  than  once,  that 
the  puzzling  and  alarming  conditions  of  coma  and  col- 
lapse led  to  the  investigation  which  disclosed  the  true 
state  of  affairs.  When  called  to  the  case  seen  by  me 
in  consultation,  I  advised  against  induction  of  labor, 
feeling  that  this  step,  which  would  have  sacrificed  a 
life,  was  not  justified  upon  any  opinion  founded  on 
what  I  regarded  as  an  incomplete  literature  of  the  sub- 
ject, and  because  it  appeared  to  me  that  the  patient 
was  reduced  in  health  by  other  influences  than  dia- 
betes. Her  salivation  and  continued  reflex  digestive 
disturbances  were  sufficient  to  account  for  ansemia,  loss 
of  flesh,  and  acceleration  of  pulse. 

While  all  urinary  examinations  during  pregnancy 
should  include  tests  for  glucose — and  but  little  addi- 
tional labor  attends  this — special  and  repeated  exami- 
nations should  be  made  on  the  appearance  of  an  un- 
favorable general  condition  of  the  patient.  Highly 
suggestive  symptoms  would  be  thirst,  dry  mouth,  suc- 
cession of  boils,  polyuria,  and  so  characteristic  are  these 
that,  when  present,  their  cause,  if  diabetes,  would  rare- 
ly escape  notice.  The  class  of  cases  most  treacherous 
would  be  thai  in  which  obscure  indications  of  ill-health 
were  present,  as  loss  of  flesh,  circulatory  and  digestive 
disturbances,  respiratory  effort,  or  debility.  .\n  easy 
and  too  frequent  explanation  for  such  deteriorated 
health  during  pregnancy,  often  as  satisfactory  and  con- 
vincing to  physician  as  to  patient,  is  in  the  condition 
of  pregnancy  itself,  which  is  generally  looked  upon  as 
capable  of  producing  every  variety  of  deviation  from 
the  health  standard.  Herein  lies  a  snare  to  be  avoided 
by  careful  urinary  investigation. 

We  have  in  all  a  collection  of  25  cases  of  pregnancy 


associated  with  diabetes,  22  collected  by  Duncan 
(these  reported  by  eleven  different  observers),  i  by 
Fry,  I  by  Minot,  and  i  by  the  writer,  which  are  open 
to  examination.  These  histories  are  fragmentary  in 
some  instances  ;  therefore,  while  exact  figures  cannot  be 
given  as  deductions,  yet  the  accuracy  of  certain  gen- 
eral statements  may  be  asserted.  The  total  number  of 
twenty-five  is  about  equally  made  up  by  the  two  classes, 
viz.,  women  already  having  diabetes  who  became  preg- 
nant, and  those  acquiring  diabetes  during  pregnancy. 
Among  the  cases  of  diabetes  developing  in  the  course 
of  pregnancy,  recovery  took  place  in  about  three- 
fourths,  with,  however,  an  exhibition  of  a  tendency  to 
recurrence  in  subsequent  pregnancy. 

In  the  class  in  which  pregnancy  occurred  in  women 
already  subjects  of  diabetes,  safety  through  delivery 
and  the  lying-in  period  was  apparent  in  about  two- 
thirds  of  the  cases.  In  most  of  this  class  ultimate  his- 
tory is  not  known,  but  for  months  at  least,  and  in  most 
instances  for  years,  these  women  lived,  and  the  condi- 
tion of  diabetes  is  not  shown  to  have  been  influenced 
in  either  way  through  the  intervention  of  pregnancy 
and  parturition.  It  should  be  borne  in  mind  that  age 
has  an  important  bearing  upon  prognosis  in  diabetes, 
and  that  between  twenty-five  and  forty-five  we  en- 
counter the  greater  number  of  severe  cases,  and  those 
most  prone  to  grave  results.  This  is  also  the  child- 
bearing  period.  All  of  the  twenty-five  cases  reported 
occurred  between  the  ages  of  twenty  and  thirty-eight, 
and  all  but  three  were  in  multiparae.  Fatal  coma  or 
collapse  in  diabetes  has  been  observed  to  follow  un- 
usual bodily  or  mental  exertion.  Labor,  certainly,  is 
a  severe  tax  on  the  physical  system,  a  great  strain  to 
the  nervous  organization,  and  we  can  understand  why 
the  fatal  complication,  from  which  death  may  occur, 
should  arise.  Yet  life  presents  many  other  adverse  and 
trying  situations  beside  parturition,  and  that  these,  un- 
associated  with  child-bearing,  give  us  recognized  deaths 
from  collapse  in  those  with  diabetes  is  well  known.  Is 
it  not  pertinent  to  ask  whether  deaths  associated  with 
pregnancy  can  be  said  to  arise  altogether  because  of 
pregnancy  ?  Again,  in  the  event  of  death  a  j'ear  or 
more  after  delivery,  can  we  properly  say  that  a  given 
patient  would  have  lived   longer  without  child-bear- 

Death  of  the  foetus  is  noticed  in  about  one-half  of  the 
cases.  Premature  delivery  is  observed  in  a  large  pro- 
portion of  the  reported  cases,  but  it  is  the  presence  of 
the  dead  foetus  which  causes  labor  before  term  rather 
than  the  direct  influence  of  diabetes.  Hydramnios  and 
excessive  foetal  development  are  not  rare,  and  even 
sugar  in  the  liquor  amnii  has  been  noted.  This  seems 
to  indicate  that  the  products  of  gestation  appropriate 
part  of  the  water  and  of  the  sugar,  despite  the  fact  that 
marked  elimination  of  both  on  the  part  of  the  mother 
is  taking  place. 

In  the  instances  of  diabetes  acquired  during  preg- 
nancy, glucose  in  a  marked  degree  was  discovered 
"  early  in  pregnancy  "  in  three  cases  ;  "  before  middle 
of  pregnancy"  in  one;  "at  four  months"  in  one; 
"at  four  and  one-half  months"  in  two;  "at  five 
months  "  in  two  :  "  at  eight  months  "  in  two  ;  "  at  par- 
turition "  in  one  ;  showing  that  diabetes  as  a  disease 
existed  before  tlie  middle  of  pregnancy  most  commonly, 
and  in  three  cases  only  the  discovery  was  made  after 
the  fifth  month.  The  histories  of  these  three  subjects 
do  not  show,  however,  that  previous  tests  for  glucose 
had  been  made. 

In  the  twenty-five  confinements  there  were  six  deaths 
in  coma  or  collapse,  closely  related  to  labor  as  to  time. 
One  of  these  deaths  took  place  in  a  woman  who  had 
diabetes  before  gestation,  while  five  were  in  patients 
who  acquired  the  disease  during  pregnancy.  The  fatal 
result  occurred  in  one  case  at  five  and  one-half  months  ; 
in  one  at  six  months  ;  in  one  at  six  and  one-half  months  ; 
in  two  at  seven  months  ;  and  in  one  at  nine  months. 

It  is  evident  that  diabetes,  as  a  grave  affection,  usu- 


July   27,  1895] 


MEDICAL    RECORD. 


ally  demands  consideration  before  viability  of  the 
child,  and  the  importance  of  tests  for  glucose  in  the 
early  months  of  pregnancy  is  emphasized. 

Coming  now  to  a  brief  regard  of  the  question  of  the 
propriety  of  artificial  interruption  of  pregnane}'  when 
associated  with  diabetes,  in  the  light  of  present  knowl- 
edge we  cannot  see  our  way  clearly,  certainly  not  to 
the  sacrifice  of  infant  life  in  ever)-  instance  coming  un- 
der our  notice.  Duncan,  a  pioneer  in  the  study  of  the 
subject,  decided  that  he  "  could  not  lay  down  any 
special  rules  of  treatment."  In  instances,  compara- 
tively few,  when  the  question  of  treatment  arises  after 
foetal  viability,  we  may  safely  say  that,  by  getting  the 
patient  into  the  best  possible  condition  through  diet 
and  perhaps  drugs,  by  which  sjTnptoms  pertaining  to 
the  nervous  system  are  quieted,  induction  of  labor 
should  be  adopted.  The  advantage  of  this  procedure 
(excited  consideration  of  the  subject  by  the  patient  not 
having  been  permitted  previously)  lies  in  the  shorter 
time  required  than  when  spontaneous  labor  is  allowed, 
and  in  the  judicious  use  of  chloral  or  other  anod\Tie 
in  the  early  part  of  labor,  and  chloroform  and  instru- 
mental aid  early  in  the  second  stage.  It  has  been  noted, 
however,  that  such  selected  cases  have  been  rare — and 
in  but  one  known  instance  has  induction  of  labor  been 
resorted  to,  in  which  case  the  patient  was  in  a  dying 
condition  at  the  time  of  the  operation. 

Inasmuch  as  instances  of  the  appearance  of  diabetes 
early  in  pregnancy,  before  the  viable  age  of  the  foetus, 
are  more  common  than  those  of  late  appearance,  the 
question  of  production  of  abortion  is  one  which  has  to 
be  met,  and  proves  to  be  a  complex  one.  We  have  no 
experience  with  this  form  of  treatment  to  aid  us  in  set- 
tling it,  and  it  would  seem  that  the  knowledge  of,  and 
experience  with,  the  disease  diabetes  can  contribute 
to  an  a  priori  opinion  as  much  as,  if  not  more  than,  an 
obstetrical  consideration  of  the  subject.  The  most 
profitable  line  of  study  might  be,  perhaps,  that  which 
will  determine  what  history  and  existing  symptoms  of 
diabetes  afford  a  serious  presentment  of  the  disease, 
one  which  apart  from  pregnancy  would  constitute  a 
grave  case,  such  an  one  as  would  demand  interference 
if  associated  with  pregnancy.  May  it  not  be  true  that 
family  history  and  temperament,  particularly  the  latter, 
are  matters  of  importance  ?  The  ner^'ous  organization 
is  that  which  most  keenly  feels  and  is  influenced  by 
physical  or  mental  strain  such  as  may  aj;tend  pregnancy 
and  parturition.  Do  duration  of  disease,  amount  of 
glucose  considering  both  percentage  and  quantity  of 
urine,  afford  indications  for  interruption  of  pregnancy  ? 
In  a  case  of  long  history,  with  attacks  of  threatened 
coma,  or  collapse,  the  indication  would  seem  most 
plain.  Absence  of  knee-jerk,  and  pains  and  disability 
of  lower  extremities  indicaring  neuritis  or  spinal  cord 
irritation,  furunculosis,  and  emaciation,  when  other 
causes  than  diabetes  can  be  excluded,  must  each  be 
given  defined  position  in  relation  to  gra\"ity  of  dia- 
betes. 

Unless  we  have  a  group  of  symptoms  which  betoken 
a  ver)-  critical  situation,  we  may  help  settle  our  ques- 
tion— while  at  the  same  time  we  benefit  our  patient — 
by  resorring  to  dieteric  and  other  treatment,  from  which 
we  rarely  fail  to  obtain  some  improvement,  before 
more  radical  procedure.  We  have  to  admit  that  the 
least  nervous  excitement  and  strain,  and  less  physical 
disturbance,  would  attend  interruption  of  pregnancy  in 
the  early  months. 

Thus  we  seem  compelled  to  the  conclusion  that  each 
case  must  be  considered  by  itself,  as  to  its  exigencies, 
as  we  have  no  special  rules  of  guidance. 

The  value  of  infant  life  and  the  right  to  its  sacrifice 
must  be  a  part  of  such  a  question  as  this,  and  here  we 
ever  meet  with  much  variance  of  opinion.  The  social 
economist,  the  physician  studying  this  subject  in  the 
abstract,  the  physician  in  close  relation  to  his  patient, 
and  the  la^-man  closely  related  to  the  patient,  has  each 
his  own  point  of  view. 


EXPERIMENTAL    PSYCHOLOCA'. 
By  E.  B.  TITCHENER,  A.M.,  Ph.D.,  F.Z.S., 


.AS5ISTA^■T  FROFESSOR  OF  P 
LABORATORY  .\T  CORNELL 
FOLOGICAL  SOCIETY'  OF 
ASSOOATION. 


iYCHOLOGV  AND  DIRECTOR  OF  THE  P3%'CHOLOGIC\L 
CNIVERSIT^-,  ITHACA,  N.  V.  ;  MEMBER  OF  THE  KEL- 
LOXDON,    .\ND    OF  THE    .\MERIC-\N     PSYCHOLOGICAL 


In  the  list  of  the  instructors  at  any  of  the  principal 
American  universities  will  be  found  some  name  with 
the  title  "  Professor  of  Experimental  Psychology,"  or 
"  Director  of  the  Psychological  Laboratory."  Those 
are  curious  titles.  Fifty  years  ago  they  would  have 
been  as  unintelligible  and  impossible  as  the  titles  "  Pro- 
fessor of  Experimental  Logic  "  or  "  Director  of  the 
Theological  Laboratory  "  would  be  to-day.  The  nine- 
teenth century  has  seen  the  doing  of  many  wonderful 
things  :  but  surely  nothing  is  quite  so  strange  or  won- 
derful as  this — the  construction  of  laboratories  in 
which  the  material  experimented  on  is  the  human 
mind. 

For  it  is  mind  that  the  psychologist  is  busied  with. 
P.iycholog}'  is  the  science  of  mind.  Ever\one  knows 
what  mind  means  ;  or,  at  least,  everj-one  uses  the  word 
quite  commonly  in  conversarion.  People  say  :  "  I  can- 
not make  up  my  mind."  It  is  that  which  they  cannot 
make  up  that  the  psychologist  experiments  upon.  Or 
they  say  :  "  I  have  half  a  mind  to  do  it."  Or  again,  if 
they  are  in  doubt  about  something,  and  ask  a  friend 
for  advice,  they  may  be  told  :  "  Look  into  j-our  own 
mind,  and  do  what  it  tells  you."  And  we  are  accus- 
tomed to  characterize  a  person  as  strong-minded  or 
weak-minded,  as  possessing  a  logical  mind,  or  a  quick 
mind,  or  an  acute  mind,  and  so  on.  Mind,  in  all  these 
senses,  is  the  subject  of  the  psychologist's  study. 

But  that,  of  course,  is  mind  in  the  rough.  One  can- 
not begin  to  work  upon  mind,  in  that  sense,  without 
further  preparation.  Let  me  give  an  illustration.  . 
Physics  deals  with  the  properties  of  matter — of  the 
bodies  of  the  world  outside  us.  And  the  physical  lab- 
oratory is  fitted  up  in  a  way  that  enables  the  student 
to  experiment  upon  natural  bodies — liquids  and  solids 
and  gases.  But  when  he  enters  a  physical  laboratorj- 
he  does  not  find  there  a  collection  of  natural  bodies. 
He  finds  a  number  of  special  instruments — inclined 
planes,  and  pulleys,  and  wedges,  and  pumps,  and  so 
forth.  It  is  by  their  aid  that  he  is  introduced  to  the 
study  of  natural  bodies  ;  and  his  study  would  not  be 
scientific  if  he  dispensed  with  them.  So  with  physiol- 
ogy. In  the  physiological  laboratory  he  is  taught  to 
examine  the  functions  of  the  various  animal  organs  : 
the  uses  of  the  heart,  and  the  muscles,  and  the  nerves. 
But  when  he  enters  the  laboratory',  he  does  not  find  a 
flock  of  sheep  waiting  to  be  worked  upon.  He  finds, 
again,  a  collection  of  special,  technical  instruments  ; 
and  he  works  with  a  single  bit  of  muscle,  or  a  single 
strand  of  nerve,  by  the  aid  of  those  instruments.  Just 
the  same  rules  obtain  in  psychology.  When  the  stu- 
dent comes  into  the  laboratofy,  he  is  not  set  to  work 
upon  mind  as  a  whole  ;  but  at  some  particular  little 
bit  of  mind,  some  special  mental  process.  That  is  the 
technical  phrase. 

But  how  does  one  get  to  these  "  bits  "  of  mind  ? 
How  is  this  cutting-up,  which  seems  to  be  a  necessary 
preliminary  to  scientific  work  upon  mental  phenomena, 
accomplished  ?  Why,  that  is  not  so  very  difficult. 
One  only  has  to  go  to  language,  and  ask  it  for  help, 
and  the  thing  is  done.  Language  is  fossil  mind.  AVhen 
we  talk,  we  do  so  in  order  to  give  expression  to  some- 
thing that  is  in  our  mind.  Words  are  symbols,  stand- 
ing for  different  bits  of  mind  ;  and  we  have  only  to  go 
and  quarry  among  these  sj-mbols  to  dig  out  any  num- 
ber of  separate  fragments,  which  we  can  then  set  to 
work  upon  in  the  laboratory.  Language  distinguishes 
one  set  of  mental  states  as  emotions.  Such  are  anger, 
fear,  hope.  It  distinguishes  others  as  feelings  :  pleas- 
ures and  pains.  It  distinguishes  others  as  sensations  : 
such  would  be  blue,  hot,  sweet,  heavy.     It  distinguishes 


MEDICAL   RECORD. 


[July   27,   ib95 


others  as  desires,  thoughts,  instincts,  ideas,  and  so  on. 
So  that  mind,  with  which  we  started  out  as  a  whole,  is 
split  up  by  an  appeal  to  language  into  a  large  number 
of  separate  mental  states  or  mental  processes.  To  the 
psychologist,  mind  is  simply  the  sum  total  of  all  those 
mental  states  that  language  has  marked  off — thoughts, 
feelings,  desires,  perceptions,  wishes,  moods,  sentiments, 
and  all  the  rest.  Those  states  constitute  the  material 
of  his  investigation. 

Now,  it  is  a  rule  of  scientific  inquirj'  to  begin  with 
the  simple,  and  not  go  on  to  deal  with  the  compound  till 
we  have  learned  all  that  we  can  learn  of  that.  Begin 
with  the  easy,  and  then  later  proceed  to  the  difficult. 
That  is  done  in  chemistry  ;  we  begin  with  the  elements 
— oxygen,  and  hydrogen,  and  the  like.  It  is  done  in 
biology  ;  we  start  out  with  the  most  rudimentary  ani- 
mals— those  that  consist  of  onl}'  a  single  cell — and 
gradually  take  more  difficult  forms  of  life,  till  we  come 
last  of  all  to  the  most  complex  form  that  there  is — ^man. 
Psychology  must  follow  the  same  rule.  AVe  must  begin 
with  very  simple  states  of  mind,  and  travel  by  slow  de- 
grees from  them  to  the  more  complex  and  difficult. 
And  a  little  reflection  shows  us  that  the  most  simple 
mental  states  that  we  experience  are  our  sensations. 
The  emotion  of  anger  is  plainly  complex  :  it  contains 
the  idea  of  the  person  who  has  made  one  angry  ;  the 
idea  of  the  act  of  his,  at  which  one  is  angry  ;  the 
idea  of  what  his  action  should  have  been,  of  what  he 
ought  to  have  done,  if  one  was  not  to  be  angry  ;  it  con- 
tains a  sense  of  personal  injury  ;  there  is  an  uncom- 
fortable feeling  in  it,  a  feeling  of  discomfort  and  un- 
easiness :  and  there  is  contained  in  it,  also,  the  wish  to 
be  oneself  again,  to  be  rid  of  one's  uncomfortableness. 
We  cannot  possibly,  then,  begin  to  study  mind  by  way 
of  emotion.  An  idea,  again,  is  a  compound  state.  My 
idea  of  a  house  contains  many  sensations  of  color; 
many  perceptions  of  form  and  outline  ;  as  well  as  a 
feeling  of  approval  or  disapproval  of  its  beauty  or  ugli- 
ness. But  the  sensation  is  something  different.  We 
cannot  split  that  up  into  other  states.  The  sensation 
of  blue  :  what  can  be  simpler  than  that  ?  Blueness 
cannot  be  resolved  into  so  many  ideas  and  feelings  ;  it 
is  just  itself,  and  we  cannot  go  behind  it.  So  the  sen- 
sation of  sweet.  You  cannot  say  that  it  is  composed 
of  any  other  states  ;  it  is  not  a  mixed  state  of  mind,  it 
is  an  ultimate  and  irreducible  experience.  So  the  sen- 
sation of  heaviness,  of  pressure  on  the  skin  ;  or  the 
fragrance  of  a  rose,  the  sensation  of  smell  ;  they  are 
last  things  of  mind,  states  at  which  inquiry  stops  short, 
beyond  which  analysis  cannot  go. 

It  will  now  not  be  surprising  if  I  say  that,  when  the 
student  goes  to  work  in  a  psychological  laboratory,  the 
first  thing  that  he  is  set  to  study  is  sensation.  He  is 
put  through  a  drill-course  in  sensation,  before  he  is  al- 
lowed to  take  in  hand  the  higher  mental  states,  like 
emotion  or  memory  or  attention.  At  the  same  time, 
there  may  be  some  hesitation  in  accepting  the  state- 
ment that  sensation  is  a^atter  for  the  psychologist  to 
investigate.  Does  not  the  study  of  sensation,  it  may  be 
asked,  belong  by  rights  to  the  physiologist  ?  Do  we 
not  find  discussions  of  sensation  in  every  physiological 
text-book  ?  Cannot  psychology  accept  the  resuhs  of 
physiological  research,  instead  of  starting  fresh  on  her 
own  account  ?  Those  are  all  fair  questions.  But  I 
think  that  1  can  show  by  a  very  simple  illustration  that 
there  is  work  for  the  psychologist  here,  and  that  he  is 
not  trespassing  on  the  physiologist's  domain  when  he 
undertakes  it. 

For  us  to  experience  a  sensation  of  any  kind,  it  is 
necessary  that  a  particular  bodily  organ  be  thrown  into 
activity.  We  can  only  see,  if  our  eye  is  in  activity  : 
we  can  only  hear,  when  our  ear  is  active  :  we  can  onlv 
taste  if  some  sort  of  impression  from  outside  affects  the 
tongue.  Now,  these  organs  of  sense  are  machines  or 
instruments,  just  like  the  physical  machines  and  instru- 
ments that  we  have  around  us  to  assist  us  in  our 
ordinary  employments.     Suppose  we  compare  the  ear 


for  instance,  to  such  an  instrument,  we  will  say  a  piano. 
A  piano  is  a  single  instrument,  but  it  is  made  up  of  a 
large  number  of  separate  parts.  There  are  so  many 
pieces  of  ivorj'  of  a  certain  shape  ;  so  many  pieces  of 
wood  of  a  certain  shape  ;  so  many  pieces  of  wire  of 
certain  lengths  and  thicknesses  ;  so  many  pieces  of  felt 
of  certain  forms  and  thicknesses.  One  way,  then,  of 
describing  the  piano  would  be  to  enumerate  all  these 
various  parts,  giving  exact  details  as  to  blemishes  or 
excellences.  It  would  be  a  long  and  wearisome  way  ; 
but  it  is  a  distinctly  possible  way.  But  now  all  these 
parts  of  the  piano,  which  we  will  suppose  to  have  been 
described,  are,  in  the  instrument  itself,  grouped  to- 
gether, held  together  in  systems,  by  hinges  and  levers 
and  screws.  One  system  would  consist  of  the  ^-string, 
with  the  felt-headed  hammer  that  strikes  it,  the  lever 
connecting  the  hammer  with  the  ivory  note,  this  note 
c  on  the  keyboard  itself,  and  the  part  of  the  damper 
that  works  upon  the  ^-string.  There  are  som.e  eighty- 
five  of  these  systems  in  the  instrument.  Plainly,  an- 
other way  of  describing  the  piano  would  be  to  give  an 
account  of  one  of  these  systems  ;  to  say  that  it  consists 
of  a  number  of  pieces  put  together  for  a  particular 
purpose,  and  to  state  what  this  purpose  is.  Instead  of 
giving  details  as  to  the  defects  or  excellences  of  the 
various  bits  of  wood  or  metal  or  ivory,  the  describer 
would  state  the  defects  of  the  system,  or  its  advantages, 
with  reference  to  the  work  which  it  had  to  do.  He 
would  say  that  the  systems  in  the  bass  did  not  work, 
because  the  wires  were  badly  strung  ;  that  particular 
notes  could  not  be  sounded,  because  the  hinges  were 
jammed,  and  so  on.  This  description  would  be  differ- 
ent altogether  from  the  first  one,  but  it  would  be  a  good 
description  from  a  certain  point  of  view.  And  now, 
lastly,  a  third  description  might  be  given  in  terms  of 
the  tones  which  can  be  got  from  the  piano.  One 
might  say  that  it  was  mellow  in  tone,  or  that  its  tone 
was  metallic  ;  one  might  say  that  the  bass  chords  were 
richer  than  the  treble  ;  or,  going  into  details,  one  might 
calculate  out  how  many  tonal  combinations  it  was  capa- 
ble of  producing,  or  ask  how  its  tone  differs  from  the 
tone  of  the  organ  or  the  trumpet,  which  are  also  musi- 
cal instruments.  -Apply  all  that  to  the  ear.  The  same 
three  stand-points  are  possible.  The  man  who  enu- 
merates and  describes  all  the  separate  parts  of  the  ear  is 
the  anatomist.  The  man  who  describes  the  ear  in  re- 
gard to  its  purpose  or  function  is  the  physiologist.  He 
will  tell  us  what  all  the  anatomical  portions  of  the  ear 
are  for,  and  whether  they  are  well  or  ill  adapted  to 
their  purpose  ;  he  will  tell  us  how  the  ear  works,  when 
a  vibration  of  the  air  outside  of  it  throws  it  into  activ- 
ity. The  man  who  pays  attention  to  the  sensations  of 
hearing,  who  asks  how  many  different  tones  the  ear 
can  appreciate,  how  all  these  various  tonal  sensations 
combine  in  the  mind  when  they  are  given  together, 
what  it  is  that  marks  oft'  in  the  mind  the  note  of  a 
trumpet  from  the  note  of  a  clarionette,  how  it  is  that 
some  tonal  sensations  and  combinations  of  them  are 
pleasant,  and  some  unpleasant — that  man  is  the  psychol- 
ogist. The  anatomist  finds  that  there  are  enough 
pieces  in  the  ear  to  allow  of  the  construction  of  sys- 
tems for  11,000  tones.  The  physiologist  finds  that 
there  are  11,000  working  systems  for  tones,  if  the  ear 
is  normal.  The  psychologist  finds  that  we  can  have 
11,000  distinct  sensations  of  hearing.  But  music  uses 
less  than  100  of  those  11,000.  There  is  a  further  prob- 
lem for  the  psychologist.  Why  is  it  that  music  does 
not  employ  more  tones  ?  W  liy,  of  all  the  possible  tones, 
does  she  employ  just  these  that  arc  given  by  the  vari- 
ous musical  instruments,  and  not  anmher  set  of  tones 
altogether  ?  These  questions  can  only  be  answered  by 
an  examination  of  the  mutual  relations  existing  between 
tonal  sensations  in  the  mind.  In  a  word,  "after  the 
spheres  of  anatomy  and  physiology  ha\  e  been  travelled 
through  and  left  behind,  there  is  another  domain  be- 
fore us,  demanding  exploration,  the  territory  of  psy- 
chology. 


July 


)] 


MEDICAL   RECORD. 


That,  I  hope,  is  a  satisfactory  answer  to  the  objection 
that  1  imagined  to  be  made  just  now,  the  objection  that 
the  study  of  sensation  belongs  to  physiology,  and  not  to 
psychology.  It  is  plain  that  the  student  can  be  put 
through  the  drill-course  that  I  mentioned  in  a  psycho- 
logical laboratory,  and  be  kept  strictly  within  the  bounds 
of  psychological  investigation.  And  now,  enough  hav- 
ing been  said  by  way  of  introduction,  I  can  go  on  to  tell 
something  of  what  a  psychological  laboratory  actually 
looks  like,  and  of  the  problems  that  are  worked  at 
there. 

If  I  were  showing  a  visitor  my  own  laboratory  I 
should  take  him  first  of  all  into  the  acoustic-room.  In 
that  room  he  would  find  all  manner  of  sound-,  or  rather 
tone-,  producing  instruments.  He  would  find  organ- 
pipes  ;  tiny  whistles,  carefull)'  constructed  to  tell  how 
many  vibrations  in  the  second  the  air-wave  that  strikes 
the  ear  is  making  ;  he  would  find  a  piano  ;  strings,  and 
bows  to  sound  them  with  ;  he  would  find  chests  con- 
taining metal  tongues  of  different  lengths,  which  can 
be  set  vibrating  by  a  draught  of  air ;  blocks  of  wood 
which  give  different  notes  when  one  strikes  them  ;  steel 
rods  which  give  deep  bass  tones  when  one  sets  them 
swinging  ;  and  above  all  he  would  find  tuning-forks  : 
tuning-forks  on  resonance  bo.xes,  that  boom  all  through 
the  room  when  they  are  struck,  and  little  hand  tuning- 
forks,  that  will  give  the  full  chromatic  scale,  but  are  so 
faint  that  they  must  be  held  close  up  to  the  ear  to  get  the 
tone  ;  tuning-forks  whose  tones  are  thousands  of  vibra- 
tions in  the  second  apart  from  one  another,  and  series 
of  forks  whose  tones  differ  from  each  other  only  by  a 
fraction  of  a  vibration  ;  tuning-forks  that  are  as  tall 
as  he  is  himself,  and  tuning-forks  whose  prongs  are  so 
short  that  they  are  hardly  anything  more  than  little 
knobs  of  metal  side  by  side  at  the  top  of  the  handle. 
All  these  instruments  we  employ  to  answer  the  ques- 
tions which  I  spoke  of  a  moment  ago  :  the  range  of 
hearing  sensations  (anything  between  the  rates  of  i6 
and  of  50,000  vibrations  in  the  second  can  be  heard  ); 
the  capacity  of  the  ear  to  discriminate  between  very 
similar  tones;  the  manner  in  which  simultaneous  tones 
blend  and  combine  in  the  mind  to  form  single  ideas  ; 
the  laws  of  the  musical  scale  ;  the  mental  process  by 
which  we  hear  an  organ  tone  as  different  from  the  tone 
of  a  flute,  and  so  on.  .\11  that  would  form  a  part  of 
the  student's  drill-course  in  sensation.  Then  I  should 
take  my  visitor  into  the  optical-room.  There  is  a  quite 
similar  collection  of  instruments.  We  have  instruments 
for  determining  of  how  many  sensations  of  light  and 
color  the  eye  is  capable  ;  there  are  about  40,000  of 
them.  Others  show  how  visual  sensations  are  modified 
by  the  presence  of  other  sensations  in  the  mind  ;  these 
are  the  phenomena  of  color-harmony  and  color-con- 
trast. Others  show  how  the  form  and  size  of  visual 
sensations  are  affected  by  the  various  possible  eye- 
movements.  Others  again  measure  the  eye's  jiower  of 
discriminating  between  sizes  and  forms  that  are  very 
nearly  alike.  Others  demonstrate  how  long  the  sensa- 
tion lasts,  and  what  its  nature  is,  after  the  physical 
stimulus  has  ceased  to  work.  Yet  others  show  us  how 
the  sensations  from  the  two  eyes  blend  together  har- 
moniously to  give  us  a  single  perception,  and  so  on. 
All  these  instruments  and  their  uses  have  to  be  learned 
by  the  student  of  psychology.  Then  in  another  room 
we  have  apparatus  for  the  investigation  of  the  other 
senses.  Thus  for  the  sense  of  touch  there  is  an  instru- 
ment that  carries  a  point  over  the  skin  at  a  constant 
rapidity,  and  in  a  constant  direction.  The  point  is 
moved  up-hill  and  down-dale,  over  the  surface  of  the 
skin,  at  a  perfectly  even  rate  ;  and  the  place  that  you 
have  worked  over  to-day  you  can  work  over  again  to- 
morrow, without  deviating  by  a  hair's  breadth  from  the 
old  path.  Then  there  are  other  instruments  for  giving 
simultaneous  impressions  of  equal  heaviness,  on  the 
skin.  By  their  aid  one  can  discover  how  good  the  skin 
is  at  estimating  distances  in  space.  You  put  down  two 
points,  an  inch  apart,  with  equal  pressure  :  and  after  a 


moment's  interval  two  different  points,  which  are  one 
and  an  eighth  inch  apart,  and  you  ask  whether  the 
skin  feels  that  one  of  the  distances  is  longer  than  the 
other,  or  if  it  is  incapable  of  discrimination  of  such  a 
small  difference.  Then  again  there  are  delicately 
graduated  series  of  weights,  by  the  help  of  which  we 
can  tell  how  fine  the  discrimination  of  our  muscles  and 
tendons  is,  they  being  the  organs  involved,  of  course, 
when  weights  are  lifted.  .\nd  there  are  plenty-  of 
others.  Lastly,  we  have  apparatus  for  the  examination 
of  smell  and  taste  and  the  temperature  sense,  although 
these  are  not  by  any  means  so  elaborate  or  so  perfect 
as  those  that  I  have  mentioned  hitherto.  All  of  them 
must  be  mastered  and  tested  by  the  student. 

The  first  thing,  then,  that  t'ne  beginner  in  experiment- 
al psychology  has  to  do,  is  to  get  a  thorough  knowl- 
edge of  the  sensations,  and  of  the  laws  which  govern 
their  appearance,  and  the  mode  of  their  combination  in 
mind.  There  is  another  branch  of  training  which  is 
not  quite  so  elementary,  but  equally  imj)ortant.  That 
is,  training  in  what  are  called  reaction-experiments.  I 
must  say  a  few  words  about  them. 

The  typical  reaction-experiment  is  very  simple.  The 
experimentee  sits,  we  will  say,  in  a  dark  room.  Sud- 
denly, a  light  flashes  out  from  the  darkness.  As  soon 
as  the  observer  has  seen  the  light,  he  makes  some  move- 
ment ;  the  movement  is  his  response  to  the  light,  and 
has  been  agreed  upon  beforehand  between  himself  and 
the  experimenter.  That  is  all — the  execution  of  a  defi- 
nite movement,  in  answer  to  a  definite  sense-impres- 
sion. But  the  way  in  which  the  experiment  is  con- 
trolled makes  it  valuable. 

The  instruments  are  always  so  arranged  that  the  time 
elapsing  between  the  giving  of  the  impression  and  the 
performance  of  the  movement  in  response  to  it  can  be 
measured.  At  the  moment  that  the  impression  is  given 
an  electric  clock  is  set  going  ;  and  at  the  moment  that 
the  movement  is  made  the  clock  is  stopped.  The  ap- 
paratus that  gives  the  flash  closes  an  electric  circuit  ; 
the  movement  that  answers  to  it  breaks  the  connection 
of  an  electric  key.  The  clock  goes  just  for  the  few 
hundredths  of  a  second  between  closing  and  breaking. 
Thousands — tens  of  thousands — of  these  time-records 
have  been  taken,  and  we  now  know  within  a  few  thou- 
sandths of  a  second  exactly  how  long  it  ought  to  take 
a  man  to  execute  a  movement  in  answer  to  a  flash  of 
light,  a  sharp  snapping  sound,  or  the  prick  of  an  elec- 
tric current  sent  into  his  skin. 

The  time  values  are  important  in  themselves  to  one 
who  knows  how  to  interpret  them.  But  for  the  begin- 
ner in  psychological  work  they  are  of  more  importance 
in  another  direction,  both  in  themselves  and  for  what 
they  tell  his  instructor  about  him.  For  instance,  if  a 
man's  reaction-time  is  too  slow,  and  remains  too  slow  in 
spite  of  practice,  it  is  of  no  use  to  go  any  further  with  him 
in  experiments  upon  the  will  or  the  attention  ;  and  so  if 
the  times  are  consistently  too  short,  or  if  they  are  persist- 
ently irregular.  Again,  the  instructor  knows  that  the 
length  of  the  reaction-time  will  differ,  according  as  the 
subject  directs  his  attention  principally  to  the  sense-im- 
pression or  to  the  movement  he  is  to  carry  out  in  re- 
sponse to  it.  He  will  therefore  say  :  "  In  this  set  of 
experiments,  attend  as  closely  as  you  can  to  the  flash, 
and  never  mind  the  movement."  And  at  another  time  : 
"  Attend  to  the  movement,  and  do  not  trouble  so  much 
about  the  flash."  If  the  experimentee  is  a  person  accus- 
tomed to  control  and  examine  his  mind,  if  he  is  the  stuff 
that  psychologists  are  made  of,  he  will  be  able  to  direct 
his  attention  as  he  is  told  ;  and  the  instructor  can  read 
off  from  the  electric  clock  that  the  attention  is  going 
in  this  direction  in  this  experiment,  and  in  that  direction 
in  that.  In  this  way  he  can  sift  out  the  attentive  stu- 
dents from  the  scatter-brained,  almost  at  a  glance  ; 
and  that  is  no  small  advantage.  On  the  other  side,  the 
student  is  benefited  by  reaction-experiments  in  a  way 
in  which  he  cannot  be  by  experiments  on  sensation — 
he  has  to  learn  to  control  his  mind  very  accurately,  to 


114 


MEDICAL    RECORD. 


[July  27,  1895 


keep  a  tight  rein  over  his  attention,  to  concentrate 
himself  and  not  follow  up  a  distraction,  to  watch  closely 
that  he  fulfil  exactly  the  conditions  of  the  experiment. 
No  small  advantage  this  to  the  student.  For  the  reac- 
tion is  the  type  of  all  action.  In  every-day  life  one 
has  an  idea  and  acts  on  it.  In  the  laboratory  one  has 
a  simple  sensation  and  acts  in  a  definite  way  upon  that. 
The  one  case  is  exact,  the  other  inexact  ;  that  is  all 
the  difference.  To  act  resolutely,  unhesitatingly,  with- 
out flurry  or  precipitation,  that  is  what  is  learnt  from 
reaction-experiments.  And  that  is  the  second  part  of 
psychological  drill-work. 

It  is  obvious,  now,  what  the  contents  of  another  room 
in  the  laboratory  will  be.  There  will  be  instruments 
which  give  a  sense-impression,  at  the  same  time  that 
they  close  an  electric  circuit.  We  have  a  large  pendu- 
lum which  sends  a  flash  of  light  in  this  way  ;  a  set  of 
electric  hammers  for  giving  sharp,  short  taps  of  sound  ; 
and  instruments  for  sending  a  momentary  electric  cur- 
rent into  the  skin.  Then  we  have  all  kinds  of  appa- 
ratus to  regulate  the  movement  made  in  answer  to  the 
impression  ;  the  reactor  may  answer  by  just  lifting  his 
finger  off  an  ordinary  telegraph  key,  or  by  opening  out 
his  thumb  and  finger,  or  by  opening  his  lips,  or  by 
speaking  a  word  into  a  funnel.  And,  thirdly,  there  are 
the  electric  clocks  themselves,  with  instruments  to  test 
their  accuracy,  and  other  instruments  to  test  the  accu- 
racy of  those  testing  instruments.  All  this  has  to  be 
understood  theoretically,  and  handled  practically,  by 
the  student  who  comes  to  work  in  the  laboratorj'. 

Those  are  the  two  sides  of  elementary  laboratory 
work.  The  sensation-drill  teaches  the  beginner  what 
it  is  necessary  for  him  to  know  about  the  element- 
ary processes  of  the  mind,  the  very  simplest  bits  of 
mind  that  we  can  reach  ;  and  at  the  same  time  gives 
him  practice  in  handling  instruments  of  precision. 
The  reaction-drill  teaches  him  to  get  control  of  his 
mind,  to  make  it  do  just  what  he  wants  it  to  do  at  the 
moment  ;  it  makes  him  steady  and  patient  and  relia- 
ble. When  the  student  has  got  as  far  as  this,  he  may 
be  allowed  to  begin  experimental  psychology. 

For  so  far  we  have  hardly  crossed  the  threshold  into 
the  science  proper.  One  would  hardly  say  that  the 
student  who  had  worked  through  an  elementary  arith- 
metic had  "  begun  mathematics  ;  "  you  do  not  really 
begin  mathematics  till  you  get  to  somewhere  about  the 
calculus.  And  it  is  the  same  here.  The  student  of 
whom  we  have  been  talking  has  now  obtained  a  base 
of  operations,  from  which  to  attack  experimental  psy- 
chology ;  but  nothing  more.  We  will  suppose  that  he 
wishes  to  continue.     What  will  he  have  to  do  ? 

Well  !  in  general  terms  it  is  easy  to  answer  that 
question;  His  work  will  be  the  experimental  examina- 
tion of  the  more  complex  mental  states.  He  may  take 
up  any  kind  of  problem  that  he  likes  :  his  material  may 
be  ideas,  and  their  laws  ;  or  feelings,  and  theirs  ;  or 
memory  ;  or  imagination  ;  or  attention  ;  or  what  not. 
What  department  of  inquiry  he  chooses  will  depend 
upon  his  particular  tastes,  and  on  what  has  interested 
him  in  the  course  of  his  reading  and  drill-work.  There 
are  a  certain  number  of  classical  experiments  upon 
these  higher  mental  processes  which  it  is  the  instruct- 
or's duty  to  see  that  he  repeats  and  understands  ;  but, 
apart  from  them,  lie  will  be  allowed  to  choose  for  him- 
self what  side  of  mind  he  devotes  himself  to  especially. 
It  may  be  thought  that  it  is  a  little  early  for  this  free- 
dom of  choice,  the  drill-course  being  only  just  con- 
cluded. But  this  must  be  remembered  :  If  our  particu- 
lar student  is  to  get  others  to  serve  as  his  experimental 
subjects  he  must  pay  them  back  in  kind,  by  letting 
them  experiment  on  him.  And  as  he  will  himself  re- 
quire some  half-dozen  assistants  in  his  own  work,  he 
will  devote  half-a-dozen  hours  a  week  of  his  own  time 
to  other  investigations.  So  that  there  is  no  fear  of  his 
becoming  prematurely  one-sided. 

What  are  these  special  problems  like  ?  We  will  take 
he  subjects  that  I  named  just  now.     First  of  all,  ideas. 


One  may  work  experimentally  upon  the  problems  of 
the  association  of  ideas,  as  it  is  called.  If  I  were  to 
write  up  the  word  "pin  "  before  a  class  upon  a  black- 
board, and  to  ask  my  audience  to  read  that  word,  and 
then  to  write  down  the  first  word  that  came  up  in  their 
minds  after  they  had  read  it,  three-fourths  of  the 
women  would  write  down  "  cushion,"  and  three-fourths 
of  the  men  "needle."  Those  words  are  very  fre- 
quently connected  or  "  associated  "  in  their  minds. 
Now,  there  are  several  laws  or  rules  of  this  association 
of  ideas,  and  they  can  only  be  got  at  by  experiment. 
Secondly,  I  mentioned  feelings.  It  is  a  matter  of  ordi- 
nary experience  that  we  find  certain  impressions  pleas- 
ant, and  certain  others  unpleasant.  We  can  make  that 
fact  the  material  of  experiment.  We  can  take  a  long 
series  of  colors,  for  instance,  and  expose  them  one  by 
one,  asking  the  experimentee  to  select  those  which  are 
pleasant  and  those  which  are  unpleasant.  Or  we  can 
take  a  series  of  forms — rectangles,  or  ovals,  or  crosses 
— and  expose  them  to  the  observer,  and  let  him  choose 
out  the  proportions  that  he  finds  most  pleasing  in  them. 
In  this  way  we  shall  discover  whether  there  is  one  uni- 
versal law — whether  all  of  us  like  the  same  forms  and 
colors,  and  dislike  the  same,  or  whether  there  are  dif- 
ferences between  one  individual  and  another.  That 
is  what  is  called  the  serial  method  of  experimenting 
upon  the  feelings.  Another  method,  which  is  only  just 
now  beginning  to  be  developed,  is  termed  the  expressive 
method.  You  present  objects  to  the  observer,  or  you 
place  him  in  certain  conditions,  and  you  register  the 
phenomena  of  expression,  which  indicate  whether  he 
is  pleased  or  displeased  with  things.  Thirdly,  I  sj'oke 
of  memory.  We  can  make  a  person  learn  by  heart  a 
series  of  words,  or  of  meaningless  syllables,  and  call 
upon  him  to  repeat  them  at  some  future  time.  The 
memorizing  must  be  done  by  a  definite  number  of  repe- 
titions ;  and  the  time  of  recall  must  be  definitely  fixed. 
Then  we  can  tell  what  the  laws  of  memory  and  forget- 
fulness  are  ;  what  kind  of  words  we  remember  best, 
and  what  kind  worst ;  and  by  varying  our  experiments, 
we  can  find  out  why  these  laws  hold.  As  regards  im- 
agination. We  can  place  the  observer  in  a  dark  room, 
and  tell  him  that  at  a  particular  place  upon  the  black 
surface  before  him  he  will  presently  see  a  faint  light. 
AVe  ask  him  to  state  when  he  sees  the  light,  and  to 
describe  its  form  and  color.  Many  a  student,  sitting 
in  this  way  in  the  dark  chamber,  has  seen  lights  which 
did  not  exist  outside  of  his  own  imagination.  And 
these  phenomena,  curious  as  they  are,  have  their  laws, 
like  all  the  rest.  Then,  lastly,  as  to  attention.  We 
can  inquire  how  many  ideas  the  mind  can  attend  to  at 
one  time  ;  or  how  long  it  can  attend  without  relaxation 
to  a  single  idea  ;  or  what  is  the  difference  between  the 
idea  to  which  we  attend,  and  the  idea  to  which  we  are 
inattentive  ;  and  what  happens  to  an  idea  when  we  dis- 
tract the  attention  from  it ;  and  so  forth. 

All  these  problems  require  special  apparatus ;  and 
all  this  apparatus  will  be  found  in  a  well-equipped 
psychological  laboratory.  We  have  particular  instru- 
ments to  study  memory,  under  all  its  aspects  ;  and 
particular  instruments  to  study  the  attention.  As  for 
imagination  :  not  only  have  we  at  Cornell  an  ordinary 
dark  chamber,  like  the  dark  chambers  that  the  photog- 
raphers use,  but  within  that  we  have  built  another 
smaller  chamber,  the  darkness  of  which  is  such  as  may 
be  felt.  Until  one  has  been  in  a  chamber  like  it,  one 
does  not  know  what  real  darkness  is  ;  and  when  one 
does  go  in,  one  does  not  wonder  that  the  unfortunate 
observer  placed  there  should  see  in  his  mind's  eye  very 
strange  things  indeed. 

That  is  the  kind  of  work  that  the  experimental  psy- 
chologist is  engaged  upon.  But  as  the  concrete  is  al- 
ways more  interesting  than  the  general,  I  will  end  by 
saying  a  word  or  two  about  the  three  principal  pieces 
of  work  that  we  have  done  or  are  doing  at  Cornell. 
The  first  is  this  :  We  all  know  that  the  skin  appreciates 
space  :  and  we  know  that  the  eye  appreciates  space 


July   27,  1895] 


MEDICAL   RECORD. 


115 


Now,  the  two  organs  do  not  agree.  Think  how  large 
the  cavity  of  a  hollow  tooth  feels  to  the  tongue,  and 
how  small  it  looks.  Think  how  large  a  blemish  on  the 
face  feels  to  the  finger,  and  how  small  it  looks.  There 
is  a  problem.  In  cases  where  both  organs  are  involved 
in  a  space-judgment,  how  are  the  two  verdicts  of  size 
reconciled  ?  We  hope  that  we  have  solved  that  prob- 
lem ;  at  least,  in  part.  The  second  is  this  :  When  we 
are  reading  the  page  of  a  book,  we  overlook  misprints. 
If  a  letter  is  wrong,  we  still  read  it  as  right.  Within 
what  limits  is  this  right  reading  of  a  wrong  group  of 
letters  possible  ?  Do  we  pay  most  attention  to  the 
shape  of  a  word,  neglecting  the  letters  ?  Or  do  we 
look  most  at  the  first  syllable,  and  overlook  the  rest  ? 
That  is  another  problem  at  which  we  are  working  ; 
and  we  have  good  hope  of  settling  the  questions  in- 
volved. And  the  third  is  this  :  If  we  are  doing  any- 
thing under  difficulties,  if  we  are  forcing  our  minds 
upon  it  in  face  of  distractions,  we  oftentimes  do  it  bet- 
ter than  we  should  had  we  been  altogether  comfortable 
and  undisturbed  during  its  performance.  At  the  same 
time,  if  the  distraction  becomes  powerful  enough,  we 
do  the  thing  worse  than  we  should  have  done,  had  we 
been  undisturbed.  Where  are  we  to  draw  the  line  ? 
What  is  the  limit  of  favorable  distraction  ?  There 
again  we  are  working,  and  working  in  good  hope  of  an 
answer. 

I  hope  now  that  I  have  made  clear  in  what  sense  it 
is  possible  to  experiment  upon  mind.  Strange  as  the 
statement  seemed  when  we  first  made  it,  it  turns  out  to 
be  perfectly  rational  and  intelligible.  The  wonder  is, 
as  the  wonder  always  is  when  a  discovery  is  made,  that 
this  discovery  of  the  applicabilit)'  of  the  experimental 
method  to  the  problems  of  psychology  was  not  made 
till  the  middle  of  the  present  century.  However,  the 
psychologists  try  to  make  up  for  the  youth  of  their  sci- 
ence by  the  enthusiasm  with  which  they  pursue  their 
investigations.  And  that  students  find  the  subject  in- 
teresting is  vouched  for  by  the  fact  that,  within  tlie  last 
few  years  all  the  universities  of  note  have  found  it  nec- 
essary to  establish  "  professorships  of  experimental  psy- 
chology "  and  "  psychological  laboratories." 


MEDICAL  TERMINOLOGY— ITS  ETYMOLOGY 
AND  ERRORS.' 

By  p.  J.  McCOURT,  M.D., 

NEW   YORK. 

Mr.  President  .a.n"d  Fellows  of  the  Academy  :  Of 
late,  much  has  been  said  before  this  Academy,  and 
much  has  been  written  in  our  journals,  advocating  the 
adoption  of  a  common  international  language  for  the 
interchange  of  professional  thought.  However  desir- 
able such  an  acquisition  may  be,  the  difficulties  in  the 
way  are  so  great  that  we  cannot  hope  for  its  attainment 
during  the  present  or  even  the  coming  generation. 
English  will  be  long  debarred  as  a  common  profes- 
sional language,  by  reason  of  international  jealousy. 
Greek,  then,  which  is  the  basis  of  our  nomenclature, 
and  also  the  mother  of  modern  tongues,  remains  the 
only  valid  language  for  such  purpose.  But  an  avail- 
able knowledge  of  Greek  will  demand  at  least  two 
years'  persistent  study  ;  and  there  are  many  useful 
men  in  the  profession,  as  well  as  many  others  about  to 
enter  it,  who  could  never  attain  that  knowledge. 
When,  however,  the  effort  has  been  made  with  appar- 
ent success,  the  student  who  was  taught  "  Greek  "  in 
the  universities  of  English-speaking  countries  will  find, 
upon  visiting  Greece,  or  on  coming  in  contact  with 
scholars  from  other  countries  who  have  learned  the 
language  correctly,  that  he  can  neither  understand  nor 
be  understood — that  he  will  not  know  the  pronuncia- 
tion of  one  word  in  twenty.     In  view  of  these  and 

'  Read  before  the  New  York  Academy  of  Medicine,  June  6,  i8c)5. 


Other  obstacles,  it  seems  a  waste  of  time,  for  the  pres- 
ent at  least,  to  discuss  a  project  so  purely  Utopian. 

It  should  not  be  inferred  from  these  premises  that  a 
knowledge  of  such  Greek  as  we  can  learn  in  our  own 
country  is  valueless.  On  the  contrary,  it  is  not  only 
valuable  but  indispensable.  Our  terminology  is  de- 
rived primarily  from  the  Greek  and  secondarily  from 
the  Latin.  Whatever  be  the  inconvenience  of  this  bur- 
den, the  rule  has  been  firmly  established,  and  we  can- 
not now  alter  it.  It  follows  that  at  least  a  slight  knowl- 
edge of  these  languages  is  necessary  to  a  comprehension 
of  the  words  we  use.  The  intelligence  and  dignity  of 
the  profession  render  this  demand  imperative.  When 
a  new  word  is  required  to  express  a  new  principle  or 
to  modify  an  old  one,  we  take  two  or  more  Greek 
words  from  which  to  construct  it.  The  word  thus 
formed  will  not  give  a  clear  perception  of  its  meaning, 
save  its  etymology  be  figured  clearly  and  picturesquely 
in  the  mind  of  him  who  employs  it.  Ruskin  long  ago 
entered  a  sound  and  eloquent  plea  for  picturesque 
reading.  But  many  of  our  terms  which  have  gained  a 
firm  hold  were  formed  in  this  manner  by  men  who 
were  lamentably  ignorant  of  the  Greek  and  Latin  lan- 
guages ;  and  as  a  consequence  the  Latinized  Greek  is 
often  grossly  perverted  and.  corrupted.  The  ancient 
Greeks,  who  had  not  the  light  of  modern  anatomy, 
physiology,  and  pathology  to  guide  them,  gave  errone- 
ous names  to  many  parts,  functions,  and  diseases  ;  and 
these  errors  have  been  perpetuated  with  but  slight  at- 
tempt at  correction  on  the  part  of  the  moderns.  The 
same  people,  especially  the  Athenians,  availed  them- 
selves fully  of  the  elastic  powers  of  the  beautiful  Greek 
to  bestow  ludicrous  and  fanciful  names  upon  persons 
and  things  around  them  ;  and  our  language  of  to-day 
is  affected  by  the  abuse  of  this  privilege.  Misnomers 
must  have  been  coeval  with  the  dawn  of  our  science, 
if  not  antecedent  to  it,  since  the  appellation  of  "  horse- 
driver  "  was  applied  to  one  of  the  most  gifted  of  an- 
cient philosophers — a  descendant  of  ^Esculapius,  the 
son  of  Heraclides,  the  student  of  Herodicus,  and  the 
"  Father  of  Medicine  " — Hippocrates,  from  Jiippos,  a 
horse,  and  chrateo,  to  govern. 

Other  difficulties,  also,  arise  in  the  way  of  attaining 
perfection  in  our  terminology.  Aside  from  our  yet  im- 
perfect knowledge  of  morbid  anatomy,  from  the  diffi- 
culty of  translating  idioms  and  of  finding  two  or  three 
words  in  which  to  describe  the  characteristic  features 
of  a  disease,  language  itself  is  imperfect  and  often  fails. 
Even  the  verb  "  to  be,"  by  which  we  declare  our  exist- 
ence, is  an  imperfect  verb  in  nearly  every  language 
having  a  grammatical  construction.  I  have  compared 
that  verb  in  twenty-six  languages,  and  in  all  of  these 
the  verb  was  found  to  be  imperfect. 

If,  therefore,  it  be  impracticable  at  this  time  to  adopt 
a  universal  medical  language,  it  is  both  practicable  and 
highly  essential  to  correct  and  improve  that  which  we 
now  use  ;  and  in  doing  this  we  must,  in  order  to  be 
understood,  follow,  to  some  extent,  the  erroneous  pro- 
nunciation taught  us.  The  ignoble  defects  of  our  ter- 
minology must  be  manifest  to  all  who  have  given  the 
subject  any  consideration  whatsoever.  Men  of  no 
other  calling  use  such  irrational  and  equivocative 
words  when  treating  of  their  subjects.  It  is  humiliat- 
ing to  reflect  that  the  cowboys  on  the  plains  employ  a 
more  intelligent  vocabulary  for  their  vocation  than  we 
do  for  ours — one  in  which  men  are  expected  to  clothe 
the  highest  order  of  human  thought. 

The  name  of  a  disease  must  be  defective  if  it  does 
not  clearly  indicate  the  pathological  change,  or  the 
part  affected,  or  both  ;  or,  failing  these,  the  character- 
istic effects  of  the  morbid  process — and  a  vast  majority 
of  those  in  use  fail  to  do  any  of  these.  Nor  does  the 
evil  end  here  ;  for  a  large  number  of  terms  delude  the 
student  by  indicating  conditions  which  do  not  exist, 
even  in  a  remote  degree.  While  not  a  purist  in  words, 
or  in  anything  else,  I  wish  to  recall  to  your  memory  a 
few  among  the  more  conspicuous  misnomers  in  almost 


Ii6 


MEDICAL   RECORD. 


[July  27,  1895 


constant  use,  and  to  show,  by  analysis  of  these,  the  ur- 
gent necessity  of  reconstructing  our  terminology. 

Acetabulum,  Latin  acctiim,  vinegar,  the  vinegar-cup 
of  the  ancients,  is  a  silly  misnomer  for  the  cotyloid 
cavity,  from  kotyle^  a  small  cup,  and  eidos,  a  form  or 
resemblance. 

Ague  may  be  from  the  French,  meaning  sharp,  but 
far  more  likely  arises  from  the  Gothic  root  agis,  to 
tremble. 

Allopathy,  allopathist,  from  alios,  other,  and  pathos, 
affection  or  disease,  are  terms  attached,  in  derision,  to 
the  rational  practice  and  practitioners  of  the  regular 
profession,  to  signify  that  we  cannot  cure  a  disease 
without  establishing  another  disease  in  its  place — -which 
we  all  know  to  be  an  untruth.  We  should  never  hear 
the  terms  applied  without  at  least  correction. 

Alopecia,  from  alopcx,  a  fox,  instead  of  calvities,  Lat- 
in calvus,  bald. 

Anasarca,  from  ana,  through,  and  sarx,  the  flesh  ; 
ascites,  askites,  from  askos,  a  leather  sack ;  oedema, 
from  oidema,  a  swelling,  are  all  equally  childish. 

Angina,  cynanche,  from  kyon,  a  dog,  and  aticho,  to 
strangle,  is  shown  by  Pliny  ("Nat.  Historia,"  viii.,  51) 
to  have  been  applied  to  sore  throat  in  both  dogs  and 
swine.  Galen  applied  the  term  to  laryngitis,  while 
Euripides  and  Heraclides  (Meineke's  "Com.  Frag- 
manta  ")  before  him  had  described  the  disease  as  tod 
anchones pelas  :  " 'tis  nigh  as  bad  as  hanging."  These 
generic  terms  are  now  happily  being  superseded  by 
others  of  more  definite  meaning. 

Aphtha,  from  apto,  to  kindle,  to  set  on  fire — not  to 
inflame,  as  rendered  by  Dunglison  in  his  Medical  Dic- 
tionary. 

Apoplexy,  apoplesso,  from  apo,  away,  from,  or  by 
means  of,  IlwA  plesso,  to  strike,  does  not  tellof  hemo'r- 
rhage  on  the  brain  or  elsewhere.  £— ? 

Artery,  from  acr,  air  or  spirit,  and  tereo,  to  preserve 
or  keep,  defines  a  vessel  in  which  air  is  the  last  thing 
contained. 

Asphyxia,  from  a,  privative  or  negative,  and  sphyxis, 
the  pulse,  describes  syncope,  but  not  strangulation, 
suffocation,  or  suspended  respiration,  the  projier  term 
for  which  is  apnoea,  from  a,  privative,  and  p»ei\  to 
breathe. 

Atheroma,  from  atlicra,  groats  or  meal,  also  gruel, 
and 

AtYesia,  from  a,  jirivative — and  treo,  to  bore,  unbored 
— both  give  false  ideas  of  the  pathological  conditions 
they  are  meant  to  define. 

Autopsy,  from  auto,  one's  self,  and  opsis,  the  act  of 
seeing,  does  not  necessarily  imply,  as  many  suppose  it 
does,  self-dissection.  Autopsy  may,  without  much 
strain,  signify  "seeing  or  examining  for  one's  self;" 
but  examination  of  the  cadaver  is  properly  expressed 
by  the  term  necropsy,  from  iiekros,  a  corpse,  and  opsii. 
from  the  future,  opsomai,  of  the  verb  orao,  to  behold — 
not  from  optomai,  as  given  in  all  our  medical  diction- 
aries. 

The  cajjrice  of  naming  a  disease  after  the  author 
who  has  first  or  early  described  it  is  either  egotistical 
or  idiotic — egotistical  when  applied  or  sanctioned  by 
the  author,  and  idiotic  when  adopted  by  others.  Such 
names  give  no  hint  of  the  lesion  implied,  and  can  serve 
only  to  confuse  our  students.  As  results  of  this  folly 
we  have  .A.ddison's  disease,  Bright's  disease,  Graves's 
disease,  Hodgkin's  disease,  MtJniere's  disease.  Scriv- 
ener's palsy,  etc. 

Beriberi  has  been  deemed  a  term  of  obscure  etymol- 
ogy, and  is  usually  rendered  from  the  Singhalese,  to 
imply  weakness,  intensified  by  repetition.  The  verb 
heri  (Aryan  root  bei-)  is  pure  Hindustani,  the  Braj  Bha- 
sha  dialect  of  the  Hindi,  which  in  turn  is  one  of  the 
seven  branches  of  the  Aryan  tongue  still  spoken  in  In- 

'  Following  the  course  adopted  when  touching  upon  this  subject  in 
18S0,  I  h;ive  placed  the  Greek  words,  like  those  of  other  languages 
quote  I,  in  italics.  The  terminal  o  in  the  Greek  words  given  is  usually 
long  {omtffa'). 


dia.  Beri  means,  in  both  the  ancient  and  modern  lan- 
guage of  the  Hindus,  to  be  fettered  or  shackled. 

Bougie,  French,  is  no  longer  a  "  wax  candle." 

Bronchocele,  from  bronchos,  the  windpipe,  and  kele, 
a.  protrusion  or  tumor.  Goitre,  possibly  from  the  Swiss 
gutter,  ])robably  from  the  Latin  guttur,  both  meaning 
throat  and  equally  incorrect. 

Bubo  comes  from  hubon,  the  groin,  and  yet  is  applied 
to  certain  swellings  in  the  axillary  and  parotid  regions. 

Cachexia,  from  kakos,  bad  or  evil,  and  htxis,  a  habit ; 
diathesis,  from  diatithcmi.  to  arrange  or  dispose  ;  dys- 
crasia,  from  dys,  bad,  and  krasis,  a  tempering,  or  tem- 
perament :  are  not  all  these  misleading,  incorrect,  and 
vague  ? 

"  Caesarean  section  "  has  served  to  perpetuate  an  his- 
toric fable,  since  Julius  Caesar  was  not  cut  out  through 
the  abdominal  parietes.  The  myth  had  its  origin  in 
mistaken  etymology  :  to  infants  thus  born  Pliny  and 
others  before  him  applied  the  term  ccesones,  Latin,  from 
cessutn,  to  cut. 

Catalepsy,  from  kata,  intensive,  and  lambano,  to 
seize,  or  to  pounce  upon,  gives  not  the  slightest  clew 
to  this  condition. 

Cataract,  from  kataraktes,  to  rush  down  (like  a  water- 
fall), might  oftener  be  applied  to  fluxes  than  to  an  ab- 
normal lens  condition. 

Chemists,  it  has  been  complained,  are  constantly 
changing  their  language  ;  but  that  language  is  now 
more  accurate  than  that  of  any  other  branch  of  medi- 
cine. It  still  retains  a  number  of  absurdities,  however, 
which  ought  to  be  eliminated.  Alcohol,  Arabic,  from 
al,  definite  article  the,  and  kahal,  a  fine,  subtle  pow- 
der. Alkali,  Arabic,  from  al,  the,  and  kali,  ash  (of 
plants  rich  in  soda) ;  but  kali  is  applied  to  potassium. 
From  this  source  we  also  derive  the  Arabic-Greek  hy- 
brid, alkaloid  :  literally,  "like  an  alkali,"  which  the  al- 
kaloids are  not.  Cobalt,  German,  kobold,  a  gnome  or 
demon.  Carbolic  acid  would  be  better  described  as  an 
alcohol.  Oxygen  is  not  the  "  acid-generator  "  which  its 
name  implies  ;  many  acids  contain  no  oxygen,  while  all 
contain  hydrogen.  Ozone,  from  ozo,  a  stench.  Sul- 
phuric ether — properly  ethylic  ether,  C,H,„0 — con- 
tains no  sulphur,  etc. 

Chlorosis,  from  chloros  (the  Greek  name  of  the  ele- 
ment chlorine),  green,  is  no  less  senseless  than  anaemia, 
from  a,  privative,  and  haima,  blood,  bloodless. 

Cirrhosis,  from  kirrhos,  reddish-yellow. 

Consumption,  marasmus,  phthisis,  and  tabes  each 
mean  to  waste  away,  or  to  consume. 

Dengue,  Spanish,  a  short  veil. 

Diabetes,  from  dia,  through,  and  baino,  to  go. 

Diphtheria,  from  diphtliera,  skin,  leather,  or  mem- 
brane :  at  best,  a  "  disease  of  the  membranes  "  (formed 
like  the  term  pneumonia). 

Dysentery,  from  dys,  difficulty,  and  cnteron,  a  bowel, 
instead  of  colitis,  from  kolon,  the  colon,  and  suffix  itis, 
denoting  inflammation  of  the  part  designated  by  the 
primati\-e. 

Embolism,  from  (•///,  in,  and  ballo,  to  throw  ;  some- 
thing or  anything  thrown  in. 

Epilepsy,  from  epilambano,  to  seize  upon,  is  quite  as 
silly  a.'?,  petit  ///<?/ and  grand  mal  of  the  French. 

Kpistaxis,  from  epistazo,  to  distil  up. 

Erysi])elas,  from  erytliros,  red,  and  pela,  skin.  This 
important  term  is  not  derived  in  part  from  erusos,  as 
Dunglison  renders  it,  since  there  is  no  such  word  in  the 
Greek  language,  ancient  or  modern. 

In  that  class  of  diseases  which  we  may,  with  some 
freedom,  term  eruptive,  there  is  among  their  names 
scarce  one  that  has  reason  in  its  etymology  or  suggest- 
iveness  in  its  root.  Acne  may  be  a  corru]>tion  of  ak- 
mai,  pimples  on  the  face  at  puberty ;  or,  better,  men- 
strual dermatosis  of  the  face  ;  but  Dunglison  follows 
Cassias  in  ascribing  it  to  akuii;  vigor — a  very  unfortu- 
nate condition,  it  must  be  inferred.  Cancer,  Latin 
cancer,  a  crab.  Carcinoma,  karkinos,  a  crab.  Scirrhus, 
skirrhos,  hard.     Ecthyma,   ektliyo.  to   break  out.     Ec- 


July   27,  1895] 


MEDICAL   RECORD. 


117 


zema,  ekzeo,  to  boil  out.  Exanthema,  exaiithco,  to 
blossom  out.  Herpes,  herpo,  to  creep.  Impetigo,  Latin 
impcto,  to  invade  or  attack.  Lepra,  lepras,  a  scaly  skin. 
Lichen,  leicheu,  moss.  Psoriasis,  psora,  the  itch,  but 
applied  to  scaly  tetter — in  Europe,  to  the  lepra  of  the 
Greeks.  Rupia,  rhypos,  dirt,  filth.  Scabies,  Latin,  scaho, 
to  scratch.  Sycosis,  sykoomai,  to  become  like  figs. 
Variola,  Latin  varius,  spotted,  etc.  What  are  all  these 
to  a  careful  reader  but  misleading  hints  to  the  diseases 
they  are  meant  to  depict  ? 

Gangrene,  from  i^raino,  to  gnaw.  Necrosis,  from 
nekroo,  to  deaden,  to  kill,  is  fairly  accurate  ;  and  there 
is  nothing  in  the  latter  term  to  restrict  its  application 
to  bone  tissue. 

Gonorrhoea,  from  •f:;oiic,  semen,  and  rhco,  to  flow,  is 
one  of  the  most  palpable  misnomers  we  still  tolerate. 
A  better  term  would  be  blennorrhagia,  from  hlcnna, 
mucus  or  slime,  and  rhfgnumi,  to  burst  forth  ;  .or, 
more  strictly  accurate,  blennorrhoea,  from  blenna  and 
rheo.  Baptorrhoea,-  from  baptos,  infected,  and  rheo, 
would  be  also  admissible. 

Gout,  Latin,  from  gutta,  a  drop  ;  podagra,  from 
fiddos,  a  foot,  and  agra,  a  seizure,  are  terms  whose 
'   rivations  are  laughable,  quaint,  and  wrong. 

Gynecology,  from  gyne,  gynaikos,  a  woman,  and 
logos,  the  doctrine  of.  You  will  remember  that  in  the 
Greek  and  Latin  languages  o  is  masculine  and  a  is 
feminine.  Here  we  have  a  term  jjurely  masculine  to 
designate  a  condition  purely  feminine.  The  correct 
term  should  be  gynecalogy.  Much  akin  to  this  para- 
do.x,  but  still  more  egregious,  is  the  term  "  Mariolatry," 
coined  by  a  bigot  of  divinity  to  imply  worship  of  the 
Virgin — which  no  church  teaches. 

Hernia,  from  eriios,  hernos,  a  branch  or  offshoot,  is 
certainly  misleading. 

Hydrophobia,  from  hydor,  water,  and  phobos,  dread 
or  fear,  so  named  from  one  of  its  occasional  symptoms, 
instead  of  the  condition,  which  is  that  of  rabies,  Latin 
rahio,  to  be  mad  or  to  rage.  But  the  correct  term  is 
lyssa,  from  lyssa,  rage,  madness  ;  also  the  worm  under 
the  tongue  of  dogs,  believed  to  produce  madness  (Pliny, 
xxix,  32). 

Hypnotism,  from  hypnos,  sleep. 

Hypochondriasis,  from  hypo,  under,  and  chondros,  a 
cartilage,  gives,  vaguely,  a  locality  where  is  an  organ 
which  may  be,  at  times,  the  cause  of  the  condition  an- 
nounced in  the  misnomer. 

Hysteria,  from  hystera,  the  womb,  should  have  imme- 
diately been  discarded  for  a  more  rational  term  when 
well-marked  cases  were  first  observed  in  the  male. 
Vet,  in  view  of  this  familiar  fact,  Dr.  Barnes  has  pro- 
posed a  name  nearly  as  vague  as  the  old  one — 
"  odphoria,"  from  oon,  ovum,  and  phero,  to  bear — 
based  upon  the  hypothesis  that  the  ovaries  and  not  the 
uterus  are  the  seat  of  this  neurosis. 

Hybrid  terms,  each  formed  from  two  languages,  were 
justly  denounced  by  the  ancient  Greeks  as  liybris,  law- 
less, violence,  wantonness.  This  mode  of  word-build- 
ing, at  once  constructive  and  destructive,  is  a  vice 
which  even  ignorance  cannot  excuse.  As  examples  of 
these  hybrid  terms  we  have  albuminuria,  from  Latin 
I  Hill  s,  white,   and   Greek  ouron,  urine.     Fibroid,   from 

uin  fibra,  fibre,  and  Greek  cidos,  appearance  or   re- 

uiblance.  Terminology,  from  Latin  terminus,  a 
crui,  and  Greek,  logos,  a  discourse  or  treatise.  Tu- 
berculosis, from  Latin  tubercidum,  tubercle,  and  Greek 
•sis,  denoting  formative  process,  etc.     We  might  with 

c(|ual  propriety  say  throatitis  as  vaginitis. 

Idiocy,  from  idiotai,  private  citizens,  not  office- 
.ic^ilders. 

Influenza,  Italian,  influence  (of  the  stars). 

Laparotomy,    from    lapara,    the   loins,   and    tome,    a 

iting   or   incision;    properly,  incision    for   nephrec- 

"uy,  and   not    abdominal    section,  the    correct  term 

'  which  is  coeliotomy,  from  koilia,  the  abdomen, 
i  tome. 

Laryngismus,  from  laryngizo,  to  shout  loud  or  often. 


The  secondary  meaning  of  spasm  sometimes  attached 
to  this  suffix  cannot  redeem  the  error. 

Lithotomy,  from  lithos,  a  stone,  and  temno,  to  cut. 
.\s  Campbell  naively  points  out,  it  is  the  bladder,  not 
the  stone,  that  is  cut  ;  and  he  suggests  the  correct  term, 
litho-cystotomy. 

Lymph,  Latin  lympha  (from  Greek  lymphe),  clear 
water. 

Malaria,  Italian,  from  7nala,  bad,  and  aria,  aii, 
illustrates  how  a  number  of  diseases  have  been  named 
from  their  causes  instead  of  their  effects. 

Malignant,  Latin  ?/taliis.  bad  or  evil,  is  but  little 
worse  than  its  equivalent,  xirulent,  Latin  virus,  a 
poison,  which,  in  turn,  is  derived  from  Sanskrit  veshas, 
a  filthy  poison. 

Mania,  from  mainomai,  to  rage — akin  to  men,  the 
moon,  and  equivalent  to  the  Latin  Itinaticus,  from 
luna,  the  moon — are  examples  of  ancient  superstitions 
to  which  we  still  cling. 

Melancholia,  from  melas,  melanos,  black,  and  chole, 
bile,  is  not  remarkable  for  lucidity. 

Myopia,  from  myo,  to  shut,  and  ops,  the  eye. 

Neurasthenia,  from  neuron,  a  nerve,  and  asthenia, 
absence  of  strength — although  the  nerves  would  seem 
to  have  acquired,  or  at  least  transmitted,  all  the  strength 
and  activity  of  the  body. 

Nymphomania  (see  gynecology),  from  nymphe,  a 
maiden,  and  mania,  should  give  place  to  andromania, 
from  aner,  a  man,  and  mania,  Nymphe  cannot  be 
translated  by  the  word  clitoris,  as  Dunglison  has  done, 
and  nowhere  in  history  has  the  noun  been  so  used. 

Pancreas,  Uom  pan,  all,  and  kreas,  flesh,  might  have 
been  applied  with  some  excuse  to  the  misnamed  pros- 
tate (from  pro,  before,  and  isteini,  to  stand),  which 
contains  but  little  if  any  adenoid  tissue. 

Paralysis,  from  para,  beside,  and  lysis,  from  lyo,  to 
loosen. 

Paresis,  irom  pariemi,  to  relax,  or  to  misdirect. 

Phlegmasia  dolens,  from  phlego,  to  burn,  or  phleg- 
mazo,  to  inflame,  and  Latin  doleo,  to  be  in  pain  ;  either 
but  poorly  describes  what  ought  to  be  called  obstruc- 
tive phlebitis. 

Phrenitis,  from  phren,  the  mind  (properly,  the  mid- 
riff or  diaphragm,  also  the  heart,  but  never  denotes 
the  brain),  and  itis.  Encephalitis,  from  en,  in,  kephale, 
the  head,  and  itis,  has  been  more  generally  sanc- 
tioned ;  but  meningo  -  cerebritis  is  less  faulty  than 
either. 

To  treat  of  the  "physiological"  action  of  drugs 
upon  the  body,  instead  of  their  pathological,  patho- 
genetic, or  toxicological  action,  is  an  abuse  of  lan- 
guage. 

Pneumonia,  from  pneumon,  the  lungs,  and  terminal 
ia,  denoting  a  morbid  condition  of  the  organ  named  : 
a  "disease  of  the  lungs,"  should  be  replaced  by  pneu- 
monitis, or  even  pulmonitis. 

Polypus,  {xom  polys,  many  ?a\Apous,  foot. 

Quarantine,  Italian,  from  quaranta,  forty  (days  of 
exclusion). 

Ranula,  Latin  dim.  of  rana,  a  frog. 

Rheumatism,  from  rheuma,  a  flux,  catarrh,  or  diar- 
rhoea, merely  im[)lies  an  indefinite  morbid  humor  in 
the  body,  but  gives  no  intimation  of  change  in  muscu- 
lar, articular,  or  synovial  tissues. 

Scorbutus,  Teutonic,  from  schaar,  torn,  and  buuk, 
the  abdomen. 

Scrofula,  Latin  scrofa,  a  sow  with  many  young ; 
correct  only  by  inference  that  the  disease  is  common 
to  swine  and  to  those  who  eat  of  their  flesh. 

Surgeon,  surgery,  from  cheir,  the  hand,  and  ergon, 
work  or  exploit  —  although  the  essence  of  the  '  ex- 
ploit "  is  brain-work. 

Syncope,  from  syn,  intensive,  and  kopto,  to  cut,  to 
cut  short. 

Syphilis  ;  "  etymology  unknown  "  or  "  uncertain  "  is 
the  comment  of  most  lexicographers.  That  given  by 
Blancardus — syn,   together,   and  phileo,   to   love — was 


ii8 


MEDICAL   RECORD. 


[July  27,  1895 


for  some  time  accepted  by  many.  But  there  is  little 
room  to  doubt  that  its  true  derivation  is  from  svs,  a 
swine,  and  phileo,  as  given  by  the  poet-doctor  Fran- 
castoro  in  his  medical  poem,  "  Syphilidis  sive  Morbi 
Gallici,"  libri  tres,  Verona,  1530,  one  of  whose  charac- 
ters, a  swineherd,  contracted  the  disease.  But  neither 
term  describes  the  lesion. 

Tetanus,  from  teino,  to  stretch  ;  so  named,  doubtless, 
because  the  condition  is  just  the  opposite,  that  of  mus- 
cular contraction.  Trismus,  from  trizo,  to  grate  or 
gnash  the  teeth,  is  equally  faulty. 

Tic  douloureux,  French,  painful  twitching. 

Nowhere  does  greater  chaos  reign  than  among  the 
names  of  fevers  ;  but  we  shall  only  consider  that  of 
typhoid,  from  typlios,  stupor,  and  eidos,  a  form  or  re- 
semblance;  literally,  "like  typhus,"  which  it  is  not. 
Enteric  fever,  from  eiiteron,  an  intestine,  is  equally 
inappropriate.  The  term  suggested  by  Murchison, 
pythogenic  icv^x—pyt/wgcns,  from  pyt/io,  putrid,  and 
gennao,  to  generate,  "born  of  putridity" — while  not 
correct,  is  the  best  yet  offered. 

Zymotic,  from  zyme,  leaven,  or  from  zymosis,  a  fer- 
ment. Both  forms  are,  like  many  of  the  others  given, 
so  ambiguous  as  to  call  for  no  criticism. 

Let  us  now  compare  the  foregoing  jargon  with  terms 
which  are  technically  correct,  which  clearly  describe  the 
lesion  implied,  and  the  contrast  will  be  worthy  of  note. 

Endocarditis,  from  endon,  within,  kardia,  the  heart, 
and  itis,  denoting  inflammation. 

Hsmatemesis,  from  haima,  blood,  and  emeo,  to  vomit. 

Hydropneumothorax,  from  /lydor,  water, /««/;//«,  air, 
and  thorax,  the  chest. 

Retroflexion,  Latin,  from  retro,  backward,  and  /lecto, 
to  bend. 

Is  it  not  possible  to  render  the  whole,  or  nearly  the 
whole  of  our  terminology  as  accurate,  beautiful,  and 
explicit  as  this  ?  It  would  seem  that  the  time  has  ar- 
rived when  such  advance  can  be  made,  and  that  the 
profession  is  ready  to  accept  it.  Scholars  and  men  of 
science  should  no  longer  be  forced  by  ancient  rule  or 
modern  error  to  speak  in  childish  prattle,  nor  to  per- 
plex themselves  and  those  who  are  to  follow  them  by 
the  use  of  terms  which  falsify  their  meaning.  The 
reconstructive  process,  however,  cannot  be  intrusted  to 
the  compilers  of  medical  dictionaries.  It  is  not  the 
lexicographer  who  makes  a  language,  but  the  scholars 
who  ^peak  and  write  it.  Hence  the  reformative  effort, 
to  achieve  success,  must  be  collective  and  made  in 
unison,  and  not  merely  individual.  If  this  Academy, 
as  the  leader  of  professional  thought  on  this  continent, 
will  take  the  initiative,  its  action  will  be  readily  sec- 
onded by  medical  journals  and  college  professors ; 
and  soon  our  terms  will  be  made  to  reveal  ideas  which 
they  now  conceal,  pervert,  or  obscure. 

From  this  mongrel  tree  of  philological  blunders  I 
have  plucked  but  a  few  of  the  withered  leaves.  I 
could  wish  that  the  office  had  found  one  who  was  also 
competent  to  do  the  pruning.  That  jiortion  of  the 
work  will  need  for  its  execution  the  united  efforts  of 
expert  pathologists  and  Greek  scholars — and  I  claim 
no  place  among  either. 

=33  West  Tvventv-third  Street. 


Russian  University  Students. — Russia  has  only  14,- 
619  university  students,  with  a  population  of  120,000,- 
000,  according  to  the  Riisskaya  Sc/ikola,  or  120  to  a 
million,  while  Germany,  with  50,000,000  inhabitants, 
has  25,000  students.  Moscow  is  the  largest  university, 
with  3,967  students  ;  St.  Petersburg  comes  next  with 
2,675.  T'^c  1,176  at  Warsaw  are  almost  exclusively 
Poles,  and  the  1,555  at  Dorpat,  Germans. 

Chloroform  vs.  Ether. — Professor  Gurlt,  of  Berlin, 
has  found  that  in  31,803  cases  of  chloroform  narcosis, 
23  deaths  occurred,  and  in  15,712  cases  of  ether  nar- 
cosi.s,  5  deaths. 


THERAPEUTIC  PROGRESS— A  SLOWER  PACE 
NECESSARY. 

By  R.  ELLIS,  M.D., 


It  is  necessary  for  the  medical  profession  to  observe 
how  much  medical  "  hash  " — of  a  poor  quality,  too — is 
continually  being  served  to  the  medical  public  ;  hash 
of  so  conglomerate  and  miserable  a  mixture  as  to  sicken 
any  normal  digestive  process.  The  journals  in  which 
the  hash  is  served  are  the  best  published,  edited  by 
the  best,  and  read  by  the  most ;  yet  the  pages  are  full  of 
medical  food  of  so  poor  a  quality  as  to  absolutely  pre- 
vent any  medical  growth. 

One  contributor  writes,  "  Away  with  ergot,"  and  sums 
up  his  conception  of  its  therapeusis  by  stating  it  should 
never  be  used.  Can  it  be  possible,  after  so  many  years 
of  ergot  use,  that  we  do  not  all  agree  as  to  its  thera- 
peutical applications  ? 

Another  writer  discusses  the  "  eliminative  treatment 
of  typhoid  fever,"  while  another,  after  so  many  have 
buried  and  forgotten  the  "cabinet,"  writes  favorably 
on  "  the  cabinet  treatinent  after  six  years  of  experience." 

Why,  in  the  name  of  .^sculapius,  can  we  not  agree 
as  to  the  therapeutical  indications  for  the  cabinet  ? 
Why  will  ninety-nine  sell  their  cabinets  for  a  song,  be- 
lieving them  to  be  of  no  value,  whereas  the  hundredth, 
after  "  six  years  of  experience,"  speaks  highly  of  it  ? 
Can  we  not  advance  in  a  better  and  more  scientific  way 
than  this  ?  Can  we  not  agree,  all  of  us,  once  and  for- 
ever, as  to  the  therapeutical  value  of  this  cabinet,  and 
then  go  on  to  another  subject,  rather  than  be  forced 
every  few  years  to  return  to  an  incompletely  explored 
field  abandoned  for  a  new  fad  ?  Did  the  ninety-nine 
fail  to  secure  benefit  through  faulty  technique  ?  Then 
let  the  hundredth  man  explain  his  technique  to  the 
others  until  we  all  agree  that  in  such  and  such  cases 
such  results  follow  from  cabinet  treatment — -then  we 
are  ready  for  the  next  step  forward. 

Another  writes  of  prescribing  large  quantities  of 
water  in  typhoid  fever,  even  to  six  quarts  a  day.  Well, 
that's  an  idea  !  You  say  you  have  tried  it.  On  how 
many  cases  ?  If  on  a  goodly  number,  so  that  you  have 
the  right  to  take  up  our  time  (which  you  do  by  presenting 
the  subject  to  us  in  the  magazine  we  read),  let  us  take 
this  subject  and  stick  to  it  until  we  settle  the  point,  and 
then  let  no  one  ten  years  from  now  startle  the  profes- 
sion by  writing  a  new  article  on  "  Treatment  of  Typhoid 
by  Giving  Six  Quarts  of  Water  Daily."  Let  him  begin 
his  investigations  from  the  point  where  we  ended,  not 
take  up  our  time  by  carrying  us  over  an  old  abandoned 
road. 

Of  recent  writers  in  reference  to  the  treatment  of 
peritonitis,  some  favor  salines,  others  the  Clark  method, 
while  still  others  say  "  first  salines,  then  opium."  Well, 
now  that  this  important  question  is  open  for  discussion, 
let  us  keep  it  open  until  we  are  ready  to  shut  it,  and 
then  let  us  keep  it  shut.  Can  we  not  do  this  in  ten 
years,  or  twenty,  or  even  a  hundred  wars,  after  ob- 
serving and  recording  thousands  of  cases  ?  Can  we 
not  then,  after  so  much  study  and  observation,  sum- 
marize the  treatment  so  scientifically  as  to  prevent  any- 
one from  going  back  again  to  the  very  beginning  ? 

AVe  have  used  ergot  for  hundreds  of  years,  and  we 
have  been  led  to  believe  that  we  knew  how  and  when 
to  use  it ;  but  x\ff\\  we  are  going  back  again,  and  soon 
many  will  proudly  say,  "  I  never  give  ergot,"  then 
new  discussions  will  arise,  and  twenty  years  from  now 
we  shall  have  an  ergot  era.  Can  we  not  once  and  for 
all  give  the  therapeutical  indications  for  ergot  and  then 
stick  to  ihem  ?  If  not,  then  let  us  agree  to  this  statement, 
"  At  present  the  profession  has  not  yet  definitely  estab- 
lished the  therapeutical  indications  for  ergot,"  and  let 
the  question  remain  open  until  we  can  and  do  agree. 

I  notice  another  writer  advises  against  vaginal  ex- 
aminations in  labor,  and  that  several  have  followed  in 


July   27,  1895] 


MEDICAL    RECORD. 


119 


his  footsteps.  Well,  that  is  strange,  indeed  I  Can  we 
not  all  agree  that  a  vaginal  examination  is  necessarj', 
and  that  palpation  is  not  all  that  is  necessarj'  ?  It  would 
seem  so,  but  here  and  there  one  catches  the  disease 
and  the  result  is  a  series  of  articles  against  any  vaginal 
examination.  If  these  writers  really  mean  what  they 
say,  then  let  us  throw  open  the  question  until  we  can 
agree,  and  then  let  the  question  remain  closed  unless 
someone  has  something  of  value  to  offer — some  sug- 
gestion proved  and  of  real  value. 

Again,  another  v»-rites  on  determining  the  sex  of  a 
child  before  birth,  and  soon  a  volume  is  produced  ex- 
plaining how  parents  may  show  nature  how  to  produce 
a  male  or  female  child  at  the  pleasure  of  the  parents. 

Stuff  and  nonsense  I  Have  we  not  lived  long  enough 
and  developed  the  science  of  medicine  far  enough  to 
know  that  no  one  can  decide  or  make  sex  ?  Yet  how 
many  articles  have  been  written  on  this  subject,  everj-- 
one  of  them  carrying  us  back  again  over  the  ground 
thoroughly  travelled.  WTiat  sane  man  can  but  believe 
that  the  ovaries  contain  male  and  female  ova,  and  that 
no  foolish  action  like  a  sitz-bath  or  an  exce^  of  ma- 
ternal passion,  etc.,  can  possibly  exert  any  influence  on 
sex  ?  Can  we  not  agree  on  this  question  ?  Well,  then 
let  us  look  into  it  and  settle  it  once  and  forever,  and 
then  let  us  not  open  the  subject  again  because  Dr. 
Curious  knows  of  a  case  where  a  woman  stood  on  her 
head  before  intercourse,  and  as  a  direct  result  of  this  all 
of  her  thirteen  children  are  boys.  Open  the  question  to 
such  an  observer,  and  as  sure  as  fate  all  over  the  medical 
field  others  will  relate  their  experience,  and  soon  a  book 
will  appear — probably  a  "  tome  "  entitled  "  The  Ma- 
ternal and  Paternal  Conduct  before  a  Male  or  Female 
Conception."  Now  a  writer,  pleased  with  hypodermatic 
medication,  states  candidly  :  "  The  time  is  at  hand  when 
direct  circulator}-  therapeutics — the  transfusion  or  in- 
jection of  accurately  dosed  assimilable  or  aseptic  reme- 
dies— will  be  deemed  alone  worthy  of  the  attention  of 
practical  physicians,  whose  aim  is  to  prevent  and  cure 
disease  without  doing  injur)'."  Is  the  time  at  hand  ? 
All  but  the  writer  agree  it  is  not ;  then  why  did  the 
writer  say  it  was  when  he  himself  knew  it  was  not  ? 
What  right  has  he  to  waste  our  time  by  presenting  to  us 
any  such  nonsense  ?  Why  did  the  editor  of  this  pub- 
lication accept  any  such  article  when  he  knew  it  sim- 
ply filled  space  ?  Better  leave  blank  pages  than  fill  them 
with  medical  nonsense. 

In  the  treatment  of  typhoid  fever  various  writers  have 
recently  favored  large  quantities  of  water,  the  dieting 
plan,  the  expectant  plan,  the  starvation  plan,  the  bath- 
ing plan,  etc.  Can  we  not  some  time,  some  way,  reach 
definite  conclusions  in  reference  to  the  treatment  of 
typhoid  fever,  and  then  stick  to  them  ?  Why  should 
writers  present  methods  of  treatment  tried  on  a  few 
cases,  when  we  all  know  there  are  a  million  things  that 
may  be  tried  ?  AVe  do  not  care  to  read  what  has  been 
tried  in  a  few  cases  so  much  as  to  read  about  some  one 
sensible  plan  tried  in  many  cases. 

If  the  Brand  bath  treatment  shows  a  mortality  of  .07 
per  cent,  out  of  19,000  cases,  is  that  not  enough  ?  Does 
this  large  number  not  furnish  sufficient  proof  to  make 
us  all  agree  to  this  method.  If  not,  let  us  keep  to  this 
;uestion  until  we  do  agree — let  us  not  drop  the  subject 

r  a  few  years  and  then  review  the  whole  matter  again 
irom  the  very  beginning  with  fresh  details,  only  to  drop 
it  for  a  new  fad  and  then  take  it  up  again. 

Can  we  not  agree  that  starvation  treatment,  in 
typhoid  fever,  is  very  highly  injurious  and  fatal?  No? 
Then  let  the  writer  of  this  article  and  others  who  invest 
in  his  stock  starve  their  patients  until  we  can  agree,  and 
then  let  us  agree  all  the  time.  At  present  we  all  agree 
that  no  medicine  cures  typhoid  fever,  and  that  therefore 
■ve  are  limited  to  expectant  therapeutics ;  from  this 
-tand-point  if  we  launch  out  at  all,  let  us  follow  one  path 
o  the  end  ;  if  19,000  cases  under  the  Brand  bath  treat- 
•nent  prove  nothing,  let  us  keep  on  the  journey  till  we 
iave,  if  necessar)-,  nineteen  million  cases  to  prove  the 


value  of  this  treatment.  From  this  vantage-point,  i: 
anjrthing  new  develop,  let  us  follow  it  out  until  we 
reach  the  end,  but  pray  let  us  begin  with  the  nineteen 
million  cases  and  not  from  the  beginning  again.  Sad 
it  is  to  see  us  drift  out  a  few  feet  on  the  stan-ation 
journey  and  then  return  ;  drift  out  on  the  specific 
treatment  by  calomel,  carbolic  acid,  and  iodine,  and 
then  return  ;  drift  out  at  the  summons  of  anyone  and 
again  return.  Pray  let  us  follow  eacA  path  until  we 
reach  the  end  or  are  forced  to  return  in  confusion  ;  and 
then  let  us,  as  a  profession,  remember  the  long  journey 
and  profit  by  our  experience.  If  anyone  has  an  "  idea  " 
let  it  start  from  the  end  of  a  pre\dous  journey  (if  there 
was  one)  and  not,  we  pray  you  again,  from  the  very 
beginning. 

Another  writer  says  in  a  recent  journal :  "  I  can  say 
that  a  careful  trial  of  forced  feeding  in  certain  cases  of 
scarlet  fever,  diphtheria,  typhoid  fever,  etc.,  will  con- 
vince anyone  of  its  very  great  value."  Here  is  another 
"  idea  :  "  we  believe  in  a  simple  nourishing  diet  in  all 
acute  diseases,  but  now  we  have  something  new.  On 
what  grotinds  does  this  writer  favor  forced  feeding  ? 
Has  he  reasonable  ground  for  taking  our  time  as  he 
presents  to  us  his  new  idea — yes  ?  Then  let  us  stick  to 
this  suggestion  until  we  have  pressed  out  all  the  meat, 
and  then  let  us  keep  it  fresh  before  us.  We  hope  the 
writer  will  not  retrace  his  steps  and  then  "  spring  it  on 
us  again,"  but  that  he  willnow  tell  us  just  what  "certain 
cases  "  are  greatly  benefited  by  forced  feeding,  -\gain, 
in  the  same  journal  a  writer  states  that  "  mycodermic 
medication  by  means  of  hypodermic  injections  of  yeast 
fungus  which  continues  to  live  in  the  tissues  and  de- 
stroys pathogenic  bacteria  by  phagocytosis,  are  of  very 
great  value.  Among  a  large  number  of  tubercular  pa- 
tients ninet}'  per  cent,  were  cured  in  the  earlier  stages  ; 
sixty-five  per  cent,  of  phthisis  in  the  second  degree. 
This  result  was  reached  in  five  thousand  cases."  Is  this 
statement  true  ?  then  we  who  believe  there  is  no  specific 
for  phthisis  and  follow  our  belief  by  prescribing  onlj^ 
fresh  air  and  good  food,  are  criminally  neghgent  in  not 
using  the  yeast  fungus  which  cures  from  ninety  to 
sixty-five  per  cent.  But  again  I  say,  is  this  statement 
true  ?  We  aU  believe  it  is  terribly  false,  but  we  don't 
know  it  to  be  so.  If  it  has  been  tried  in  over  five  thou- 
sand cases  with  such  flattering  success,  I  am  sure  it  is 
our  dutj'  to  immediately  take  up  this  new  treatment  and 
stick  to  it  until  we  know  "  where  we  are  at." 

We  must  acknowledge  that  each  writer  loads  his  gun 
with  a  new  idea,  hurriedly  fires  it,  and  then,  without 
stopping  to  examine  the  effects  of  his  first  random  shot, 
hastily  loads  and  fires  again  some  new  idea.  Can  we  not 
boast  of  better  soldiers  than  these — after  a  medical 
warfare  for  centuries  ?  can  we  not  show  better  marks- 
men ?  must  we  always  fire  at  random  and  keep  on  firing 
without  any  plan  or  result  ? 

In  the  next  journal  I  read  that  "  immunized  serum 
has  a  true  vaccinal  action  in  tuberculosis — in  three 
hundred  cases  at  least  a  temporary  cure  was  secured." 
This  is  the  second  random  shot  following  the  yeast 
"  fungus  shot.  Pray  shall  we  not,  after  such  an  effort, 
give  the  command  "  cease  firing,"  and  begin  to  study 
die  effect  of  these  shots,  firmly  ordering  that  whoever 
fires  another  one  shall  himself  be  actually  shot? 

Another  journal  advertises  ''animal  e.xtracts"  from 
"  cerebrine  "  to  "  ovarine  " — everj-where  these  snap 
shots  are  being  tried,  and  successfully  so,  judging  by 
the  statements  of  some  writers.  One  writes  that  he 
gave  a  highly  intelligent  sterile  lady  five  minims  daily 
of  ovarine,  and  that  the  menses  were  "  established  "  in 
three  weeks.  He  also  cheerfully  states  he  will  continue 
the  ovarine  until  the  lady  is  pregnant,  making  me  think 
of  the  young  son  of  a  friend  who,  receiving  the  prom- 
ise of  a  watch,  replied  by  letter  that  he  was  "  extreme- 
ly delighted  with  the  watch  which  was  to  be  given  to 
him."  Kindly  allow  me  here  to  fire  a  shot :  I  hereby 
bring  to  the  notice  of  the  profession  the  following  ani- 
mal extracts — mucine,  gelatine,  chondrine,  elastine,  and 


I20 


(MEDICAL    RECORD. 


[July  27,  1895 


keratine.  We  all  know  what  they  can  be  used  for — 
mucine,  for  the  catarrhal  diathesis  ;  gelatine,  for  bone 
weakness ;  chondrine,  for  cartilaginous  irritations  ; 
elastine,  for  that  "  tired  feeling  ;  "  and  keratine,  for 
loss  of  hair,  thin  splitting  nails,  etc. 

Stuff  and  nonsense  !  Let  us  acknowledge  that  in 
charging  the  enemy  with  animal  extracts  we  have  made 
an  over-zealous  charge  and  fired  too  many  random 
shots.  Let  us  go  back  again,  load  up  fresh,  all  of  us, 
with,  say,  thyroid  extract  or  some  extract,  and  then  let 
us  keep  firing  the  same  gun  and  the  same  ammunition 
until  we  know  again  "where  we  are  at." 

At  the  last  medical  congress  in  Vienna  six  methods 
for  treating  pyothorax  were  presented,  namely,  expect- 
ant, aspiration,  aspiration  and  injection,  permanent  as- 
piration, simple  incision,  and  resection  of  one  or  more 
ribs  ;  opinions  were  divided  as  to  the  best  treatment  in 
the  majority  of  cases — that  is  what  we  wish — the  ques- 
tion remains  open.  Many  favor  free  incision,  more 
favor  resection — possibly  in  years  to  come  we  may 
agree,  but  we  are  meanwhile  studying  and  heaping  up 
evidence  and  still  clinging  to  these  same  forms  of  treat- 
ment, because  they  are  mechanical  and  '"  there  is  no- 
where else  to  go." 

In.  therapeuses  it  would  be  well  if  we  wort  t  .us  m.e- 
chanically  forced  to  limit  ourselves  to  few  'casures 
well  tried  before  taking  up  new  fads  ;  humanity  would 
not  suffer  if  we  should  do  so — it  would  gain. 

Still  another  writes  "  that  a  hypodermic  injection  of 
morphia  one-fourth  grain,  one-half  hour  before  giving 
chloroform,  always  maintains  the  heart  and  respiration." 
Always?  My  last  journal  gives  a  case  of  a  death  un- 
der just  this  condition  ;  therefore  the  writer  will  kindly 
remember  one  exception  to  his  "  always." 

In  the  treatment  of  gonorrhoea  I  read  of  one  who  rec- 
ommends nitrate  of  silver,  gr.  ij.  to  gr.  Ix.  to  the  ounce, 
applied  carefully,  care  being  taken  that  the  bladder  is 
full  of  urine  ;  another  in  the  next  issue  of  the  journal 
ad\ases  injections  of  from  one  grain  to  one-eighth  per 
ounce,  and  says  even  very  weak  solutions  are  liable  to 
be  followed  by  a  violent  reaction.  This  is  interesting  ; 
the  discussion  is  an  open  one — let  it  be  so  until  we  can 
agree. 

In  diphtheria,  we  have  a  new  fad — "  antitoxin  " — let 
us  all  notice  carefully  just  how  much  time  and  study  we 
are  to  give  this  new  treatment.  We  may  have  a  remedy 
of  great  value — we  hope  we  have — but  let  us  cling  to 
the  new  fad  until  we  have  squeezed  it  dry,  if  there  is 
juice  in  it.  I  myself  believe  we  shall  be  eagerly  fol- 
lowing a  new  "idea"  in  a  very  few  months,  possibly 
weeks. 

Recently  a  monograph,  "new  and  important,"  in 
reference  to  the  bacteria  of  peritonitis,  has  been  pub- 
lished. After  a  long  statement  of  the  different  bacteria, 
the  pamphlet  sums  up  by  saying  :  "  The  number  of  bac- 
teria found  in  a  single  case  varied  from  one  to  nine  ;  a 
feature  of  special  interest  is  the  study  of  thirty  rej^re- 
sentations  of  the  bacillus  coli  communis  with  reference 
to  their  various  cultural  peculiarities,  number  of  loco- 
motor organs,  and  other  characteristics  ;  the  result 
shows  scarcely  any  two  of  them  are  alike,  and  we  find 
these  thirty  representations  divided  into  twenty  varie- 
ties. Other  important  and  non-pathogenic  bacilli  were 
discovered  resembling  the  Klebs-Loeffler  bacilli,  but 
another  observer  states  he  believes  there  are  as  many 
pseudo-diphtheria  bacilli  as  there  are  observers." 

"  No  conclusion  as  to  prognosis  can  be  drawn  from  a 
bacteriological  examination,  yet  where  no  bacteria  can 
be  demonstrated  it  would  seem  that  the  result  is  in  gen- 
eral more  favorable  than  in  those  where  bacteria  are 
present."  In  other  words,  summing  up  this  "  new  and 
important "  pamphlet  from  a  bacteriological  stand- 
point, in  peritonitis  we  may  find  bacilli  and  then  again 
we  may  not.  Such  pamphlets  should  not  be  published  ; 
they  accomplish  nothing  but  to  weary  and  disgust  their 
readers  ;  just  as  if  Mr.  Stanley  in  his  last  book  should 
force  us  to  read  a  long-drawn-out  account  of  the  weight 


of  each  stone  he  passed,  the  height  of  every  tree,  the 
number  of  branches  to  every  tree,  the  exact  number  of 
mosquitoes  seen,  etc.  We  do  not  care  about  such  tri- 
fling details,  we  are  hungry  for  facts,  and  Mr.  .Stanley 
gives  us  facts  and  leaves  out  foolish  and  useless  de- 
tails. Again,  in  the  same  journal  I  read  of  a  report  of 
two  cases  where,  after  sodium,  calomel,  and  quinine 
failed  in  a  treatment  of  five  days,  antikamnia  and  salol 
were  tried,  resulting  in  convalescence  in  twelve  days. 
From  these  two  cases  the  author  reaches  the  astonish- 
ing conclusion  that  "salol,  as  an  internal  antiseptic, 
combined  with  the  antipyretic  ([ualities  of  antikamnia, 
promise  all  that  can  be  desired  in  the  treatment  of  low 
and  continued  fevers  with  bowel  complications."  All 
that  can  be  desired  !  What  a  statement  after  an  ex- 
perience with  two  cases  !  Just  how  much  does  such  a 
statement  weigh,  and  how  much  does  it  influence  a 
careful  reader  ?  May  I  not  state  truthfully  that  such 
statements  insult  careful  readers  who  deny  themselves 
pleasure  to  gain  time  to  extract  meat  out  of  medical 
journals. 

Hello  !  here's  a  new  treatment  for  pneumonia  !  The 
intra-cellular  injection  of  serum  taken  from  a  conva- 
lescing pneumonic  case.  Serum  ?  All  right,  but  let  it 
be  serum,  until  we  know  "  where  we  are  at  "  with  serum. 
Some  praise  its  use,  others  assert  its  influence  is  abso- 
lutely nil,  among  these  being  a  hospital  physician,  who 
says,  "  In  the  few  cases  I  have  seen  treated  the  results 
were  «// under  serum  treatment  ;  "  wisely,  then,  does  he 
advocate  "  quinine  and  antikamnia,"  and  criticise  the 
use  of  large  doses  of  digitalis.  These  statements  of  this 
young  interne  weigh  nothing  and  accomplish  nothing, 
save  to  provoke  us  for  the  time  lost  in  wading  through 
such  useless  stuff. 

Is  it  possible  that,  after  years  devoted  to  the  study  of 
pneumonia,  the  profession  runs  away  to  the  new  sug- 
gestion "  serum  "'  ?  What  right  did  the  serum  advocate 
have  to  present  his  newly-born  babe  to  us  before  it  had 
its  clothes  on  ?  Why  must  we  be  bored  and  tortured 
by  so  many  "  schemes  "  and  "  ideas,"  when  we  all  know 
absolutely  that  we  cannot  carefully  study  so  many  at 
one  time  ?  Why  not  stick  to  the  old  way  until  someone 
proves  conclusively  that  he  has  a  new  and  tested  thera- 
peutical measure  ?  ^Vhile  writing  these  very  words,  a 
leading  journal  which  the  mail  has  just  brought  me 
introduces  me  to  another  new  "idea."  A  physician 
noting  that  earth-worms  digest  mud  believes  they  must 
possess  the  property  of  dissolving  urinary  deposits  ;  he 
therefore  (without  any  personal  investigation)  advises 
us  to  select  ten  or  twelve  worms  which  have  digested 
all  the  mud  they  can,  boil  for  one-half  hour  in  one- 
half  a  pint  of  water,  and  give  this  soup  to  the  patient  in 
one  dose.  His  closing  suggestion  is,  "  If  this  soup  is 
found  to  be  useful,  well-known  chemists  in  Europe  and 
America  would  prepare  an  extract,"  for  which  he  pro- 
poses the  term  "  Extractum  lumbrici  terrestris."  Hor- 
rible and  preposterous  nonsense  I  This  is  not  putting 
the  cart  before  the  horse,  but  attempting  to  hitch  up 
when  there  is  neither  horse  nor  cart,  yet  this  writer 
signs  himself  unblushingly,  L.R.C.P.&S.Edin. 

Now  kindly  allow  me  to  present  a  brilliant  idea. 
Since  tape-worms  absorb  intestinal  secretions  which  are 
of  value  in  digestion,  I  propose  for  intestinal  indiges- 
tion "  Tape-worm  soup."  If  this  is  found  to  be  of  value 
I  would  name  the  extract  "  Extractum  tsenix  solii  " 
and  hereby  claim  whatever  credit  may  arise  from  this 
brilliant  discoverj\ 

Pray,  can  we  not  work  in  a  more  scientific  way  ? 
Should  we  not  do  so  ?  Must  we  not  do  so  if  we  expect 
to  make  any  real  advance  ? 

We  can  prepare  medicine  from  every  imaginable 
thing,  from  everything  conccivaMe  outside  of  the  body 
to  everything  conciivable  inside  of  the  body,  and  ap- 
ply these  innumerable  remedies  for  every  conceivable 
disease.  We  know  this  to  be  true,  and  therefore  we 
should  give  little  credit  to  anyone  for  proposing  serum 
in  pneumonia  ;  "  liver  extract  "  for  the  diseases  of  the 


July  27,  1895] 


MEDICAL    RECORD. 


liver  :  "  spleen  extract  "  for  the  spleen  ;  typhoid  serum 
for  typhoid  fever,  etc.,  to  an  infinite  variety  of  sugges- 
tions. 

Anyone  can  make  suggestions,  mi/Hom  of  them  if 
desirable  ;  but  we  don't  need  "suggestions,"  we  sadly 
need  facts ;  we  are  nauseated  with  many  "  newly 
hatched,  unfledged  ideas  ;  "  we  are  starving  for  tested 
and  proved  therapeutical  facts. 


THE  USE  OF  THE  DIFFERENTIAL  STETH- 
OSCOPE IN  THE  STUDY  OF  CARDIAC 
MURMURS.' 

By  ANDREW  H.  SMITH,  M.D., 


Although  usually  the  auditory  impressions  made  upon 
the  two  organs  of  hearing  are  blended  together  and  are 
perceived  by  the  sensorium  as  one,  it  is  possible,  by  a 
little  training,  to  acquire  the  power  of  separating  them, 
compelling  the  sensorium,  as  it  were,  to  take  separate 
cognizance  of  the  perceptions  received  through  one  ear, 
as  distinguished  from  those  received  through  the  other. 
To  do  this,  however,  the  sound  waves  must  reach 
the  drum  membranes  through  different  and  distinct 
channels.  This  is  effected  bv 
the  differential  stethoscope, 
which,  in  its  simplest  form,  dif- 
fers from  the  ordinary  binaural 
instrument  simply  in  having  two 
thoracic  extremities  instead  of 
one,  each  connected  with  its 
respective  ear-piece.  This  ar- 
rangement enables  us  to  hear 
separately  two  sounds  produced 
at  the  same  time  in  two  local- 
ities more  or  less  distant  from 
each  other. 

An  analogous  effect  is  pro- 
duced when  a  piece  of  card- 
board is  placed  edgewise  be- 
tween the  eyes.  In  this  case 
the  visual  field  for  near  objects 
is  divided,  and  though  the  ad- 
vantage of  binocular  vision  is 
lost,  it  is  possible  with  a  little 
effort  to  take  cognizance  of  two 
distinct  visual  impressions  at 
the  same  time. 

The  field  in  which  this  stetho- 
scope is  useful  is  a  restricted 
one,  but  within  that  field  it  may 
render  essential  service.  Its  aid 
as  a  differential  instrument  is 
important  in  determining  the 
time,  rather  than  the  quality,  of  sounds  heard  in  differ- 
ent cardiac  localities.  We  have  no  practical  diflnculty 
in  appreciating  even  a  slight  dissimilarity  in  sounds 
which  are  separated  by  short  intervals.  We  can,  there- 
fore, with  the  ordinary  stethoscope  change  the  instru- 
ment from  one  part  of  the  cardiac  area  to  another,  and 
compare  satisfactorily  the  quality  of  the  sounds  we  hear. 
Under  normal  conditions  the  difference  in  character 
between  the  first  and  second  sounds  of  the  heart  is 
enough  in  itself  to  distinguish  them  from  each  other, 
independently  of  the  element  of  time.  But  cases  occur 
not  infrequently  in  which  neither  the  character  nor 
the  time  of  the  heart-sounds  is  available  for  this  dis- 
tinction. In  these  cases  the  quality  of  one  or  both  of 
the  sounds  is  masked  by  the  presence  of  a  murmur,  or 
so  modified  by  conditions  of  vascular  tension  as  to  be 
unrecognizable,  while  at  the  same  time  the  intervals 
embraced  in   the  cardiac  cycle,  instead  of   being  un- 

'  Read  at  the  meeting  of  the  Association  of  American  Physicians, 
May  30,  1895. 


equal,  have  the  same  duration.  This  latter  condition 
occurs  whenever  the  heart's  action  is  greatly  acceler- 
ated, as  the  increase  in  frequency  is  chiefly  at  the  ex- 
pense of  the  longer  interval.  At  the  same  time,  with 
such  a  rapid  action,  it  is  impossible  to  tell  which  of 
the  alternate  sounds  corresponds  with  the  apex  beat  or 
the  carotid  pulse. 

Under  these  conditions  it  is  manifest  that,  if  we  find 
a  murmur  at  the  apex,  and  by  shifting  the  stethoscope 
we  find  another  at  the  base,  we  shall  be  utterly  unable 
to  tell  whether  the  two  occur  simultaneously  or  succes- 
sively. And  yet  the  entire  question  of  how  the  signs 
shall  be  interpreted  hinges  upon  this  point.  Supposing 
a  lesion  at  each  orifice,  then  if  the  murmurs  are  syn- 
chronous, one  must  be  direct  and  the  other  regurgitant. 
If,  on  the  other  hand,  they  are  alternate,  then  both  must 
be  direct  or  both  regurgitant. 

Now,  whatever  help  it  would  be  to  us  in  the  solution 
of  the  problem  to  know  whether  the  two  murmurs  are 
produced  at  the  same  time,  or  first  one  and  then  the 
other,  that  amount  of  help  we  can  get  from  the  differ- 
ential stethoscope.  If  we  place  one  extremity  over 
the  apex  and  the  other  over  the  aortic  area,  we  shall 
know  at  once  what  is  going  on  in  each  locality  with 
each  period  of  systole  and  diastole.  If  we  hear  a  mur- 
mur with  each  ear  at  the  same  time,  we  shall  know  that 
the  two  murmurs  are  produced  by  the  same  act  of  the 
heart.  If  we  hear  a  murmur  alternately  with  the  right 
and  the  left  ear,  we  shall  know  that  one  occurs  with 
systole  and  the  other  with  diastole. 

I  have  seen  lately  two  cases  of  combined  mitral  in- 
sufficiency and  aortic  stenosis  in  which  the  differential 
stethoscope  showed  that  the  murmur  at  the  apex  pre- 
ceded that  at  the  base  by  a  very  appreciable  interval. 
The  systole,  therefore,  was  well  under  way  before  the 
blood  began  to  flow  through  the  aortic  orifice.  This  is 
easily  understood  when  we  consider  that  the  ventricle 
must  contract  sufficiently  to  occasion  a  pressure  within 
it  in  excess  of  that  in  the  aorta,  before  the  blood  will 
move  in  the  direction  of  the  latter.  The  leakage 
through  the  mitral  orifice  opposes  this  result  and  delays 
the  moment  at  which  the  intra-ventricular  tension 
reaches  and  exceeds  the  pressure  upon  the  semilunar 
valves.  During  this  interval  of  delay  we  have  the 
murmur  of  regurgitation,  but  not  the  stenotic  murmur. 
As  the  delay  is  proportioned  to  the  amount  of  blood 
flowing  back  into  the  auricle,  the  interval  between  the 
murmurs  is  an  accurate  measure  of  the  incompetency 
of  the  mitral  valve. 

Reduplication  of  one  or  other  of  the  cardiac  sounds 
is  of  frequent  occurrence,  and  has  been  explained  in  a 
variety  of  ways.  A  favorite  theory  has  been  that  it  was 
due  to  a  want  of  synchronism  in  the  action  of  the  ven- 
tricles. This  point  could  be  determined  by  simultane- 
ous auscultation  of  the  tricuspid  and  mitral,  or  of  the 
pulmonary  and  aortic  areas. 

Within  the  past  week  I  saw  a  case  which  the  day  be- 
fore had  presented  well-marked  reduplication  of  the 
second  sound  as  observed  by  the  physician  in  charge. 
This  was  no  longer  present,  but  the  differential  steth- 
oscope showed  a  marked  lagging  in  the  contraction  of 
the  left  ventricle  as  compared  with  the  right.  At  the 
same  time,  the  aortic  second  sound  was  sensibly  later 
than  the  pulmonarj'.  .\n  exaggeration  of  this  condi- 
tion would  have  constituted  reduplication. 

The  successful  use  of  the  differential  stethoscope 
requires  a  fairly  acute  and  well-trained  ear,  with  no 
difference  in  the  hearing-power  between  one  ear  and 
the  other.  Some  practice  in  this  special  form  of  aus- 
cultation may  be  necessary  to  acquire  the  power  of  giv- 
ing separate  yet  simultaneous  attention  to  the  impres- 
sions which  each  ear  receives. 

Among  Educated  Germans  no  less  than  sixty-seven 
per  cent.,  so  the  statistics  say,  have  imperfect  or  defec- 
tive eyesight. 


MEDICAL   RECORD. 


[July  27,  1895 


REPORT   OF   CASES    IN   BRAIN    SURGERY. 
By   DOUGLAS   C.    RAMSEY,   M.D.. 


STATE  MEDICAL   SOCIETIES. 

Case  I. — A.  O ,  aged  twenty-five.   Residence,  Mount 

Vernon.  April  7,  1891,  was  grinding  a  moulder's  knife 
on  an  emery  wheel  making  over  two  thousand  revolu- 
tions per  minute,  when  the  wheel  burst,  striking  him  in 
the  left  frontal  region  and  causing  an  extensive  lacera- 
tion of  the  soft  parts,  a  compound  comminuted  fracture 
of  frontal  bone,  and  tearing  away  brain  tissue  the  size 
of  my  thumb.  I  was  called  to  see  him  at  once  ;  found 
him  at  a  planing-mill,  where  he  received  the  injury.  He 
was  propped  up  in  a  chair,  having  recovered  conscious- 
ness. I  placed  a  clean  towel  over  the  wound,  ordered 
him  carried  to  his  boarding-house,  four  squares  distant. 

Assisted  by  Dr.  J.  W.  Powell,  I  then  proceeded  to 
treat  the  injury  antiseptically,  cleansing  the  hands  and 
injured  parts  with  a  hot  bichloride  solution,  sensibility 
being  sufficiently  stunted  to  dispense  with  an  anaes- 
thetic. I  removed  detached  brain  matter  the  size  of 
my  thumb,  twenty-five  spicula  of  bone,  some  driven 
into  the  brain  over  an  inch  ;  elevated  some  depressed 
bone  ;  removed  comminuted  portions  of  supra-orbital 
arch  ;  one-half  of  same,  an  area  of  about  two  and  one- 
fourth  by  one  and  one-half  inch  of  bone,  was  re- 
moved. The  very  considerable  hemorrhage  was  con- 
trolled by  pressure  and  packing.  I  then  closed  the 
soft  parts  with  catgut,  sublimate  gauze,  and  cotton, 
with  sublimate  gauze  bandage  over  all,  leaving  dura 
open — so  much  being  destroyed  it  was  impossible  to 
close  gap  in  same — and  leaving  catgut  bundle  for  drain- 
age at  lower  angle  of  wound.  The  brain  pulsated  at 
site  of  wound.  AVound  healed  by  first  intention.  Drains 
were  removed,  one  at  a  time,  until  last  were  removed 
on  the  sixth  day,  and  wound  closed  complete  by  tenth 
day  without  any  rise  in  temperature.  Patient  was  out 
on  the  street  thirteenth  da)\  There  was  loss  of  sight 
in  eye^  on  side  affected.  Aside  from  this  a  perfect  re- 
covery ensued.  He  is  now  a  carpenter  and  contractor 
in  active  service. 

Case   II.— R.   C ,  aged  thirty-four.     Residence, 

Mount  Vernon.  Presented  himself,  August,  rSgs,  with 
the  following  history  :  Was  injured  fourteen  months 
previously  by  being  struck  on  head  with  a  brick,  which 
produced  unconsciousness  and  was  followed  by  epilep- 
tic seizures.  He  was  trephined  by  his  attending  sur- 
geon, some  depressed  bone  elevated,  and  a  small  portion 
of  brick  removed,  with  improvement  for  two  weeks' 
time.  Epileptic  convulsions  then  returned,  occurring 
several  times  weekly  and  frequently  several  times  daily. 
When  I  saw  him  he  had  distinct  tremor  of  left  arm. 

August,  1893,  assisted  by  Dr.  Dixon  and  others,  I 
trephined  (button  of  bone  removed  being  one-fourth 
inch  thick,  probably  due  to  inflammatory  changes)  on 
right  side  of  head  at  site  of  injury,  and  with  rongeur 
removed  all  bone  which  could  not  be  elevated  into 
proper  position,  removing  bone  to  extent  of  about  two 
by  one  and  one-half  inches.  Wound  united  in  five  days 
without  suppuration  or  any  rise  in  temperature.  Dress- 
ing used  :  Catgut  sutures  in  scalp,  dusted  line  of  sutures 
with  iodoform  and  bichloride  gauze,  and  sublimate 
cotton  with  sublimate  gauze  bandage  over  all.  No 
drainage.  Has  never  had  any  return  of  epileptic 
seizures,  and  is  in  robust  health. 

Case   III. — H.    F ,  aged   nineteen.     Residence, 

Poor  Infirmary.  When  seen  pre.sented  the  following 
history  :  Four  years  before  was  injured  in  head  by  a 

'  Read  before  Indiana  State  Medical  Society,  June  7,  1893. 


falling  tree.  One  year  after  that  was  re-injured  by 
being  hit  on  head  with  a  club.  Had  epileptic  seizures 
from  time  of  first  injury,  several  a  week,  and  sometimes 
two  or  three  daily.  Was  trephined  by  a  surgeon  in 
Missouri  shortly  after  last  injury  was  received,  without 
benefit.  Site  of  this  operation,  left  side  of  the  head. 
Had  distinct  tremors  of  left  arm. 

September,  1894. — Assisted  by  Dr.  S.  H.  Pearse,  I 
made  a  crescent-shaped  incision  on  right  side  of  head 
and  trephined  near  site  of  injury.  Found  a  very  large 
area  of  depressed  bone,  which  was  with  difficulty  ele- 
vated into  position.  Then  removed  some  depressed 
spicula  with  forceps.  Operation  was  done  antisepti- 
cally, all  oozing  checked  by  pressure  and  flaps  stitched 
with  catgut.  Dusted  line  of  sutures  with  iodoform  and 
bichloride  gauze,  dressing  with  sublimate  cotton  and 
sublimate  gauze  bandage  over  all.  No  drainage. 
Thirty  hours  after  temperature  rose  to  103 J^"  F.,  with 
intense  headache.  Gave  5  grains  antikamnia  and  }( 
grain  morphine.  Temperature  fell  to  normal  within 
two  hours  and  never  rose  above  same  again.  Wound 
healing  by  first  intention  in  five  days.  No  return  of 
convulsions  for  three  weeks,  at  and  since  which  time 
he  has  had  from  time  to  time  hard  epileptic  seizures. 
I  do  not  believe  this  patient  has  been  benefited  by  the 
operation,  for  the  reason,  perhaps,  that  there  was  at 
time  of  receipt  of  wound  irremediable  injury  to  the 
brain  substance. 

Deductions. — Case  I.  is  illustrative  of  how  little  per- 
manent disability  for  performance  of  manual  labor  may 
result  after  serious  injury  and  considerable  loss  of 
brain  matter. 

Case  II.  shows  the  good  results  that  trephining  will 
sometimes  accomplish  when  performed  for  traumatic 
epilepsy. 

Case  III.  indicates  how  little  relief  is  sometimes  ob- 
tained in  trephining  for  traumatic  epilepsy. 


IRRIGATIONS    IN   ACUTE    GONORRHCEA. 
By  W.  a.  DAVISON,  M.D., 

FORT  BENTON,   MONT. 

In  an  extract  from  a  lecture  in  the  Medical  Record  of 
June  1, 1895,  Dr.  Rantier  says  :  "  When  the  gonorrhoea 
is  in  the  acute  stage  I  would  advise  not  to  interfere. 
Tell  the  patient  to  wear  a  suspensory  bandage,  to  take 
an  alkaline  bath  every  three  days,  and  in  about  ten 
days  afterward  to  come  back,  and  then  you  will  cure 
him."  This  might  do  in  great  medical  centres  in 
France,  and  possibly  even  in  the  medical  metropolis  of 
the  United  States,  but  the  medical  man  in  this  section 
who  prescribed  such  a  course  in  the  treatment  of  his 
cases  of  acute  gonorrhoea  would  most  assuredly  treat 
very  few  cases  of  this  disease.  My  plan  is  to  treat  gon- 
orrhoea at  any  stage.  Why  not  ?  If  we  will  adapt  our 
remedies  to  the  stage,  physical  condition,  and  individ- 
ual peculiarity  of  patient,  I  fail  to  see  why  we  should 
leave  nature  to  struggle  single-handed  with  her  adver- 
sary until  she  had  well-nigh  conquered.  We  do  not 
hold  our  hands  in  the  acute  stage  of  inflammatory  affec- 
tions of  other  organs,  and  why  this  ?  I  think  the  hot- 
water  irrigations  equall)'  adapted  to  the  acute  stage.  I 
begin  them  the  very  first  day  the  case  presents  itself, 
and  know  of  no  treatment  better  than  the  action  of  hot 
water.  I  use  a  good-sized  fountain  syringe  well  filled 
with  hot  borated  water — well  filled,  for  thus  the  heat  is 
retained  during  the  entire  time  necessary  to  make  a 
proper  application.  To  the  pipe  attach  a  glass  tube, 
and  over  the  end  of  this  for  two  inches  draw  a  soft 
rubber  catheter  ;  .inoint  well  with  carbolized  vaseline 
or  oleate  of  cocaine,  if  the  parts  are  very  much  irritated, 
or  better  only  sensitive  ;  and  here  one  may  easily  over- 
estimate the  amount  of  hyperjesthesia,  for  one  may  often 
pass  this  catheter,  causing  very  little  pain.     Introduce 


July  27,  1895] 


MEDICAL   RECORD. 


the  catheter  carefully  one  inch,  turn  on  the  hot  borated 
solution,  and  after  you  are  satisfied  all  is  clean  as  far  as 
you  have  gone,  very  gently  and  gradually  push  your 
catheter  into  the  deeper  urethra,  and  even  into  the  blad- 
der, if  one's  judgment  deems  it  advisable,  allowing,  all 
this  time,  the  water  to  flow  out  all  around  your  catheter. 
The  object  is  to  thoroughly  cleanse  the  urethra  as  you 
enter.  Your  fountain  should  not  be  elevated  more  tlian 
two  feet  above  the  patient.  These  irrigations  should 
be  repeated  at  least  daily,  and  at  least  a  quart  of  the 
hot  solution  consumed ;  often  two  quarts  is  better. 
Follow  these  irrigations  after  two  hours'  time  with  some 
soothing  mucilaginous  sedative  injection  of  not  more 
than  half  a  drachm  thrown  gently  in,  and  repeat  each  six 
hours  in  the  acute  stage  ;  but  in  the  subacute  or  chronic 
I  like  the  morphia  and  zinc  better  than  anything  I  have 
yet  tried. 

5  ■    Morphia  sulph J  iv. 

Zinc   acetate gf-  j- 

Aqua 3  iv.  ad  vj. 

I  have  pursued  this  plan  of  treatment  for  several 
years,  and  with  commendable  success.  The  patient 
will  pass  out  of  his  physician's  hands  with  a  grateful 
heart  and  free  from  stricture. 


A   CASE    OF   ACUTE    LARYNGITIS. 
By  M.  E.  HUGHES,  M.D., 


It  was  only  on  noticing  an  account  of  Dr.  Charles  S. 
Dickinson's  case  of  the  above  complaint,  as  related  in 
the  Record  of  June  ist,  that  I  decided  on  narrating  the 
experience  I  was  then  having  with  a  similar  case. 

June  3d,  I  met,  socially,  Mrs.  R.  B ,  aged  twenty- 
nine  years.  She  complained  of  a  cold  contracted  two 
days  before.  The  symptoms  at  that  time  were  a  dry 
cough  and  some  hoarseness  of  the  voice,  which  latter, 
she  stated,  had  been  first  noticed  that  morning  on  aris- 
ing. She  also  stated  that,  from  her  knowledge  of  the 
course  of  previous  attacks,  she  believed  the  hoarseness 
would  become  more  and  more  pronounced  quite  rapidly. 
Generally,  she  felt  about  as  usual. 

About  two  hours  later,  on  taking  my  leave,  she  said 
that  she  experienced  some  difficulty  in  breathing,  and 
that  she  believed  that  this  too  would  increase  rapidly 
in  severity.  It  was  now  evident  that  her  prediction  re- 
garding the  hoarseness  was  quite  true.  This  was  about 
five  o'clock  in  the  afternoon  (5  p.m.)  I  left  her,  say- 
ing that  I  would  return  later  and  endeavor  to  relieve 
her. 

At  9.30  P.M.,  on  my  return,  I  found  her  sitting  on  the 
edge  of  a  couch,  her  hands  down  by  her  sides  and 
pressing  firmly  against  the  couch,  body  bent  slightly 
forward,  eyes  bulging,  face  wearing  a  pinched,  anxious 
expression  as  if  in  fear  of  some  great  danger  against 
which  she  was  utterly  powerless,  and  suffering  from 
great  dyspnoea.     There  was  no  cyanosis. 

I  was  told  that  at  times,  since  I  had  left  her  in  the 
afternoon,  she  had  suffered  from  exacerbations  of  this 
dyspnoea  which  an  attack  of  coughing  would  relieve 
somewhat,  but  not  so  decidedly  as  when  the  coughing 
was  followed  by  the  expectoration  of  a  thick,  mucous- 
like  substance.  Pulse  very  rapid.  Temperature  in 
axilla  100°  F. 

I  at  once  sprayed  the  throat  well  with  a  four  per  cent, 
solution  of  cocaine,  cautioningheragainst  swallowing  the 
least  particle,  if  possible.  In  spraying  I  endeavored  to 
force  as  much  as  possible  into  the  larynx.  In  ten  min- 
utes there  was  a  very  noticeable  relief  from  the  dysp- 
ncea,  in  thirty  minutes  the  breathing  was  perfectly 
normal,  not  the  slightest  evidence  of  distress,  and  the 
face  had  assumed  its  wonted  expression. 


I  then  ordered  lUj.  of  the  tinctura  aconiti  radicis 
every  hour. 

She  retired  at  11.30  p.m.  and  slept  nearly  the  whole 
night.  The  spray  was  not  again  used,  nor  was  there 
any  occasion  for  it. 

The  next  day  the  only  evidences  of  any  past  trouble 
were  a  very  slight,  scarcely  noticeable  hoarseness,  and 
an  occasional  cough,  neither  of  which  existed  when  I 
called  twenty-four  hours  later. 

The  only  objections  to  the  use  of  cocaine  in  such 
cases  of  which  I  am  aware  are,  first,  the  possibility  of 
the  patient  sv,-allowing  a  poisonous  dose,  or  second,  if 
the  spray  were  left  in  the  hands  of  a  person  not  capa- 
ble of  using  it  intelligently,  or  at  sucli  times  only,  and 
in  such  quantities  only,  as  are  necessary,  the  possibility 
of  the  absorption  of  such  quantity  as  might  work  badly 
with  a  patient  such  as  mine,  for  instance,  a  nervous, 
sensitive  lady,  very  susceptible  to  drugs  of  all  kinds, 
and  poor  in  health  at  her  best. 


INCUBATION  PERIOD  OF  CHICKEN-POX 
DELAYED  BY  MEASLES.  AND  PAROTITIS 
FOLLOWING   CHICKEN-POX. 

By   HOBART   CHEESMAN,    M.U., 

NEW   YORK. 

In  reading  the  case  of  mumps  versus  measles,  by 
Dr.  Beverly  Robinson,  in  the  Medical  Record  of 
June  8,  1895, 1  was  reminded  of  a  case  which  occurred 
in  my  own  family  several  years  ago,  in  which  the  period 
of  incubation  of  chicken-pox  v/as  protracted  by  an  ex- 
posure and  attack  of  measles  taking  place  between  the 
time  of  exposure  and  that  of  the  attack  in  the  former 
disease.  An  elder  sister,  about  ten  years  of  age,  while 
attending  school,  was  attacked  by  chicken-pox.  A 
younger  sister,  about  six  years  of  age,  not  attending 
school,  and  at  home,  was  exposed  daily  to  the  chicken- 
pox  during  the  time  the  elder  sister  was  down  with  it. 
While  the  latter  was  convalescing  she  was  attacked 
with  measles,  which  she  must  have  also  contracted 
while  at  school,  before  the  chicken-pox  broke  out. 
The  younger  sister  was  exposed  to  the  measles  also, 
while  the  elder  was  sick  with  it.  About  twelve  or 
fourteen  days  subsequent  to  the  breaking  out  of  the 
measles  in  the  elder,  the  younger  sister  was  attacked 
with  measles.  This  was  eighteen  or  twenty  days  after 
she  had  been  first  exposed  to  chicken-pox.  The 
measles  proved  quite  a  sharp  attack,  but  ran  the  usual 
course.  About  the  time  the  last  trace  of  the  eruption 
was  disappearing,  an  eruption  of  chicken-pox  came 
out.  This  appearance  was  from  twenty-seven  to  thirty 
days  subsequent  to  the  beginning  of  the  attack  of 
chicken-pox  in  the  elder  sister,  when  the  younger  was 
first  exposed  to  it,  a  longer  time  than  the  longest  period 
of  incubation  of  this  disease  mentioned  in  text-books. 

Another  case,  but  of  a  different  nature,  and  which 
happened  recently  in  my  practice,  may  be  of  interest 
because  of  its  rarity.  There  are  three  boys  in  the  fam- 
ily in  which  the  case  occurred,  aged  respectively  thir- 
teen, nine,  and  five  years.  The  first  and  second  attend 
school,  the  younger  stays  at  home.  While  attending 
school,  the  second  boy  was  attacked  with  chicken-pox. 
About  nine  or  ten  days  thereafter,  the  youngest  boy 
came  down  with  it,  as  did  also  the  eldest  a  few  days 
later.  The  disease  ran  in  each  case  the  ordinary 
course.  About  a  week  after  the  attack  began  in  the 
youngest  boy  and  after  he  had  nearly  recovered,  an  in- 
flammation in  the  left  parotid  gland  developed,  which 
resembled  every  way  a  mild  case  of  mumps.  The 
shape  and  site  of  the  swelling  were  exactly  the  same, 
there  was  moderate  tenderness,  and  the  skin  over  it  was 
perceptibly  reddened.  The  pulse-rate  was  increased, 
and  the  temperature  went  up  to  100°  F.  for  about 
thirty-six  hours.     A  few  drops  of  lemon-juice  and  water 


124 


MEDICAL    RECORD. 


[July  27,  1895 


put  in  the  mouth  of  the  patient  caused  him  to  wince 
and  clap  his  hand  over  the  swollen  gland.  The  swell- 
ing subsided  in  three  or  four  days.  The  second  boy 
was  in  the  same  room  all  this  time  with  this  patient, 
but  did  not  contract  mumps,  neither  did  the  eldest, 
who  was  also  exposed.  The  latter,  so  far  as  I  could 
learn,  had  never  had  mumps,  although  he  possibly  had 
it  before  I  knew  him  ;  but  the  second  boy  I  know  has 
never  had  the  disease,  for  I  have  attended  him  since 
his  birth  ;  and  besides,  there  had  been  no  possibility 
of  exposure  to  mumps  for  at  least  three  weeks  previous 
to  the  development  of  the  parotitis.  Although  this  is 
a  sequel,  mentioned  as  not  very  infrequent,  to  the  ex- 
anthematous  diseases  in  children,  I  do  not  find  it  re- 
ferred to  in  this  relation  in  connection  particularly 
with  varicella,  nor  have  I  ever  seen  it  before  in  connec- 
tion with  this  particular  disease,  nor  has  anyone  whom 
I  have  questioned  regarding  the  matter.  Presumably, 
therefore,  it  is  a  somewhat  rare  condition. 

328  West  Fifty-seventh  Street. 


EPISTAXIS. 


By  JOHN  B.    RICHARDSON,    M.D., 

LOUISVILLE,    KV. 

I  PRESUME  no  apology  is  necessary  for  reporting  an 
extreme  case  of  the  above  nature,  with  treatment  em- 
ployed. 

May  2,  1895,  was  hurriedly  summoned  to  attend 
Miss  F ,  aged  thirty-eight  years,  suffering  with  vio- 
lent nose-bleeding.  Nearly  four  years  since,  waited  upon 
this  same  patient,  when  it  required  ten  days  or  more  to 
entirely  relieve  her,  so  profuse  and  troublesome  was 
the  hemorrhage. 

She  came  of  a  family  of  "  bleeders, "  her  mother, 
maternal  uncle,  and  her  brother  having  on  several  oc- 
casions had  bleedings  from  the  nose  difficult  to  con- 
trol. Nothing  specific  in  family  history  discoverable, 
upon  critical  questioning,  along  that  line. 

Cleansing  the  nasal  cavity  as  quickly  as  possible,  I 
applied  a  small  piece  of  absorbent  cotton,  which  had 
well  rubbed  into  its  meshes  finely  pulverized  alum,  to 
the  bleeding  point,  using  firm  pressure  for  several  min- 
utes, hoping  thereby  to  efi'ect  the  formation  of  a  clot, 
and  thus  check  the  bleeding.  This  was  accomplished, 
but  only  lasted  for  a  few  hours.  Two  days  elapsed, 
when  a  message  reached  me  she  was  bleeding  to  death. 
I  found  her  pulseless  at  the  wrist,  with  sighing  respira- 
tions, and  a  stream  of  blood  (arterial)  running  from  her 
left  nostril  and  down  pharynx,  being  swallowed,  and  a 
moment  afterward  she  fainted.  Upon  returning  to 
consciousness,  she  vomited  many  ounces  of  blood. 

Employing  reflected  light,  the  nasal  cavity  was 
cleared  of  blood-clots  and  flowing  blood  ;  the  eroded 
and  broken  wall  of  the  vessel  was  found  to  be  located 
at  the  junction  of  the  floor  of  the  right  nares  and  sep- 
tum of  the  nose,  three-fourths  of  an  inch  posterior  to 
its  external  orifice. 

Preparing  a  piece  of  absorbent  cotton  which,  when 
well  compressed,  would  be  somewhat  larger  than  would 
be  received  by  the  posterior  nasal  orifice.  I  secured  to 
its  centre  a  double  asepticized  waxed  cord,  also  a  sec- 
ond single  cord  for  the  subsequent  removal.  I  placed 
this  posterior  plug  in  position  by  means  of  Bellocq's 
cannula.  I  then  moistened  a  small  piece  of  absorbent 
cotton  with  the  iron  solution  and  passed  it  in  the  clasp 
of  an  ordinary  pair  of  nasal  forceps  to  the  ruptured  side 
of  the  bleeding  vessel,  and  retained  it  there  for  some  min- 
utes— upon  this  procedure  I  wish  to  lay  stress— placins 
other  small  compressed  pledgets  upon  the  first  one  ap- 
plied (after  the  manner,  when  properly  done,  we  proceed 
in  tamponing  the  vaginal  canal  in  cases  of  uterine  hem- 
orrhage), finally  introducing  the  larger  anterior  plus. 
pressing  it  compactly  and  well  filling  the  anterior  por- 
tion of  the  nasal  cavity  with  it,  and  securing  in  position 


by  tying  over  it  in  single-bow  knot  the  double  cord 
passing  out  of  nostril  from  posterior  plug. 

Prior  to  using  small  pieces  (as  last  described),  I  was 
troubled,  at  the  end  of  twelve  or  fifteen  hours  after 
each  replugging,  with  slight  recurring  bleedings  caused 
doubtless  by  failure  in  clot-forming  at  the  immediate 
point  of  hemorrhage  :  these  recurring  bleedings,  slight 
at  first,  continued  and  increased  until  it  became  neces- 
sary to  remove  both  anterior  and  posterior  plugs  and 
apply  others. 

General  treatment  consisted  of  hypodermic  injections 
of  ergotole  pro  re  nata  ;  cooling  and  acid  drinks  ;  nu- 
tritious fluid  food  in  small  quantities  at  short  intervals  : 
with  perfect  quietude  of  body  and  mind  ;  for  my  pa- 
tient was  almost  exsanguinated. 

Twelve  hours  later  oozing  of  blood  began  from  the 
left  nostril,  the  blood  finding  its  way  between  the  pos- 
terior plug  and  nasal  septum,  thence  into  the  left  nasal 
cavity  and  out  of  the  left  nostril ;  also  downward  through 
the  pharynx,  large  quantities  of  which  were  swallowed. 
This  increased  very  rapidly  several  times  during  the 
following  week,  necessitating  replugging.  These  hem- 
orrhages seemed  to  come  in  regular  cycles  of  from 
twelve  to  fifteen  hours'  intervals,  the  blood-pressure 
requisite  to  produce  them  seemingly  requiring  that 
length  of  time  to  be  re-established.  These  oft-repeat- 
ed rebellious  hemorrhages,  notwithstanding  the  most 
careful,  deliberate,  and  painstaking  manner  in  which 
both  anterior  and  posterior  plugs  were  applied,  recalled 
to  mind  a  formula  I  had  administered  in  many  cases 
of  intractable  hsemoptyses  and  metrorrhagia:,  the  modus 
operandi  of  whose  action  I  have  never  perfectly  under- 
stood, and  yet  know  it  to  be  very  effective.  This  I 
prescribed,  and  after  its  employment  in  conjunction 
with  "plugging"  there  was  no  further  hemorrhage. 
The  formula  is  as  follows  : 

5.        Hydrarg.  bichlorid gr.  j. 

Acid,  muriat.  dil 3  ij. 

Tr.  cannabis  ind "  ij. 

F.  E.  ergota: 3  '')• 

Syp.  simp 3J. 

Inf.  quassia 3  vijss. 

M.     Ft.  and  soL     Sig.  :  Tablespoonful  in  water  t.i.d. 

Before  concluding  I  desire  to  mention  a  practical 
point,  ^■iz.  :  Prior  to  the  final  removal  of  the  posterior 
plug  from  its  position,  secure  a  second  double  (fresh) 
cord  to  the  one  attached  to  the  posterior  nasal  plug 
(from  which  it  passes  through  the  nasal  cavity,  out 
through  the  anterior  orifice)  ;  as  the  old  one  is  re- 
moved let  the  new  double  cord  trail  after  it,  thereby 
placing  it  in  the  position  for  immediate  use  should  oc- 
casion again  arise  for  further  plugging,  thus  obviating 
the  need  for  a  second  introduction  of  Bellocq's  can- 
nula ;  which  latter  cannot  be  accomplished  without 
attendant  danger  of  disturbing  the  "temporary  clot." 
More  than  six  weeks  have  now  elapsed  since  the  re- 
moval of  what  I  term  the  "guard-cord,"  and  patient 
has  had  no  evidence  of  a  return  of  her  bleeding,  and 
has  almost  regained  perfect  health  and  strength. 


Foreign  Medical  Students  in  France. — French  medi- 
cal students  have  been  crying  out  against  "  the  inva- 
sion of  foreign  students,"  and  the  Pro^ris  Medical,  one 
of  the  most  sensible  and  fair-minded  medical  journals 
of  Pans,  has  undertaken  to  show  that  there  is  nothing 
to  fear  from  that  source.  In  1894.  for  example,  out  of 
249  hospital  internes,  only  14  were  foreigners.  "  In 
face  of  the  efforts  made  by  other  countries  to  attract 
the  largest  number  possible  of  foreign  students,  the 
complaints  and  recrimination  in  France  on  the  subject 
are  astonishing,"  says  the  editor.  Dr.  Bourneville. 
"  Indeed,  to  accord  the  right  to  students  of  all  nation- 
alities to  study  in  the  French  universities  on  the  same 
terms  as  Frenchmen,  and  to  take  part  in  comjietitive 
examinations,  will  do  more  good  than  any  number  of 
military  expeditions." 


July   27,  1895] 


MEDICAL    RECORD. 


125 


Medical   Record: 

A  Weekly  yo2iriial  of  Medicine  and  Stcrgcry. 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor. 


Pl'BI.ISHERS 

WM.   WOOD  &  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  July  27,  1895. 


TONSILLAR    TUBERCULOSIS. 

Although  the  functions  of  that  collection  of  lymphoid 
tissue  encircling  the  oro-pharynx,  and  called  at  differ- 
ent points  the  pharyngeal,  faucial,  or  lingual  tonsils,  are 
still  in  dispute,  it  is  well  known  that  it  is  a  site  of  in- 
fection from  various  pathogenic  germs.  The  different 
catarrhal  affections  to  which  it  is  subject  impair  the 
integrity  of  its  epithelial  investment,  and  though  phago- 
cytosis may  occur  at  these  points  to  some  extent,  the 
resistant  force  is  frequently  overcome  by  the  invasion 
from  without.  Of  recent  years  much  attention  has 
been  paid  to  the  question  as  to  whether  the  various 
tonsillar  areas  are  not  the  channels  through  which  the 
tubercle  bacillus  may  gain  entrance  to  the  system. 
Where  this  has  seemed  to  occur,  it  is  believed  that 
some  one  of  the  microbes  of  suppuration  has  carried 
the  outpost,  and  opened  up  a  way  of  entrance  for  the 
bacillus  itself. 

Tuberculosis  of  the  pharynx  and  naso-pharynx  may 
appear  in  the  course  of  an  acute  or  chronic  pulmonary 
tuberculosis  with  characteristic  local  lesions  and  symp- 
toms. Dieulafoy  has  recently  called  attention '  to  an- 
other form  of  the  localized  affection,  which  he  believes 
to  be  very  common.  It  presents  neither  granulations 
nor  ulcerations,  and  it  is  not,  as  a  rule,  at  all  painful. 
Functional  troubles  may  arise  at  times,  but  they  are  so 
slight  as  not  to  suggest  the  real  cause  ;  but  the  condi- 
tion should  be  recognized,  as  it  may  be  the  starting- 
point  of  a  general  systemic  infection. 

This  latent  tuberculosis  has  its  favorite  seat  in  the 
adenoid  (more  properly  lymphoid)  tissue  of  the  naso- 
pharynx. It  manifests  itself  most  obviously  as  a  mere 
enlargement  of  this  tissue,  without  at  first  sight  any 
peculiar  characteristics.  This  form  Dieulafoy  styles 
"latent  "  tuberculosis  of  the  tonsils,  fo  put  it  in  an- 
other way,  he  believes  that  if  tonsils  removed  from 
either  the  pharynx,  fauces,  or  tongue  are  submitted  to 
careful  examination,  they  will  be  found  to  contain  tu- 
bercular foci  far  more  commonly  than  has  generally 
been  supposed.  In  fact,  out  of  61  examinations  of  sup- 
posed simple  hypertrophic  tonsillar  tissue,  he  found 
the  bacillus  in  8  cases.  Out  of  35  cases  of  naso-pharyn- 
geal  adenoids,  the  bacillus  was  present  in  7.  In  the 
first  group,  bits  of  tissue  were  introduced  under  the 
skin  of  guinea-pigs,  and  all  succumbed  :  six  with  local 
tubercular  nodule  and  general  tuberculosis ;  2  without 
'  Bulletin  de  I'.^cademie  de  Medecine,  No.  17,  1895. 


local  deposit,  but  with  pulmonary  lesions  ;  49  without 
any  appreciable  lesion  or  without  an  autopsy  having 
been  made  ;  and  4  with  the  lesions  of  septicjemia.  In 
the  second  group  3  died  with  nodule  and  general  tu- 
berculosis ;  4  with  tuberculosis  without  nodule  ;  3  with 
septicaemia  ;  and  25  without  apparent  lesions. 

The  patients  from  whom  the  tonsillar  tissue  was  re- 
moved were  nearly  all  children  under  ten  years.  None 
of  them  presented  any  of  the  local  or  general  evidences 
of  tubercular  infection.  Dieulafoy  supposes  that  they 
all  possessed  what,  for  lack  of  a  more  exact  term,  we 
call  the  tubercular  "  predisposition,"  and  that  this  lym- 
phatic soil  was  first  inoculated  by  some  of  the  bacilli 
which  are  found  at  times  in  probably  every  healthy 
nose.  Again,  the  experiments  of  Chauveau,  Orth, 
Baumgarten,  and  Cadeac  conclusively  prove  that  the 
swallowing  of  material  containing  tubercle  bacilli  can 
infect  both  the  faucial  and  pharyngeal  tonsils.  Dieu- 
lafoy does  not  believe  that  the  penetration  of  the  bacil- 
lus into  the  tissue  requires  a  preceding  erosion  or 
wound.  This  statement,  however,  cannot  be  supported 
in  the  light  of  our  most  recent  knowledge,  as  herein- 
before suggested. 

The  inoculation  of  the  lymphoid  tissue  by  the  ba- 
cillus is  followed  by  a  functional  super  activity — a 
multiplication  of  lymphoid  cells  which  gives  to  the 
tonsillar  masses  a  considerable  volume.  This  is  the 
first  step  of  the  process.  Later,  after  months  or  years, 
the  phagocytic  action  fortunately  predominates  in  many 
instances,  and  fibrosis  ensues.  The  tissue  lessens  in  vol- 
ume, and  here,  as  in  many  cases  of  tuberculosis,  a  cure 
or  cessation  of  the  process  is  accomplished  without  any 
systemic  infection.  In  other  cases  this  happy  result 
does  not  follow,  and  the  second  stage  is  manifested  in 
the  appearance  of  submaxillary  and  cervical  glandular 
enlargements.  The  lymphatic  channels  are  probably 
the  route  through  which  the  infection  travels.  The 
course  of  this  extension  is  always  anatomically  down- 
ward. The  ganglionic  tuberculosis  may  be  arrested, 
but  the  danger  is  that  the  advance-guard  of  the  enemy 
will  sooner  or  later  appear  before  the  pulmonary  out- 
posts. Even  here  all  is  not  lost,  for  the  pulmonary 
structure  can  defend  itself  to  a  certain  extent,  and  it 
responds,  according  to  Dieulafoy's  \iew,  to  the  bacil- 
lary  attack  by  hemorrhage,  which  he  terms  one  of  de- 
fense {he'moptysie  de  defense). 

The  foregoing  views  in  general  are  not  essentially 
new.  Over  a  year  ago  Lermoyez  reported  two  cases  in 
which  the  removal  of  adenoid  vegetation  seemed  to  be 
the  signal  for  a  general  tubercular  invasion.  In  the 
second  case,  that  of  a  child  of  six  years,  a  second 
operation  was  necessary,  and  the  tissue  then  removed 
was  examined  and  bacilli  found. 

A  therapeutic  suggestion  in  these  cases  is  afforded 
by  the  experience  of  Fyffe,'  who  injected  the  sputum  of 
a  tuberculous  patient  into  guinea-pigs.  The  more  cre- 
osote the  patient  took,  the  less  virulent  the  sputa  seemed 
to  become.  Finally  creosote  was  injected  into  the  ani- 
mals before  they  were  inoculated  with  bacilli,  and  it 
seemed  to  greatly  hinder  the  progress  of  the  disease. 
In  cases  of  tubercular  adenoid  disease  it  might  be  that, 
if  creosote  were  given  early,  it  would  greatly  lessen  the 
probability  of  the  affection  going  beyond  the  first  stage. 
'  Lancet,  September  22,  1894. 


126 


MEDICAL   RECORD. 


[July   27,  1895 


DEATH  IN  THE  AURAL  TYMPANUM. 

Every  now  and  then  the  publicity  given  to  the  death  of 
some  prominent  person  from  inflammation  of  the  drum 
of  the  ear  calls  attention  to  the  subject.  Much  val- 
uable time  is  often  lost  in  the  futile  efforts  made  for  its 
relief  at  the  beginning,  not  to  mention  any  bad  effects 
of  meddlesome  treatment  afterward.  Cases  of  this 
kind  are  by  no  means  rare,  and  it  may  be  said  of  most 
of  them  that  recovery  would  not  have  been  impossible 
but  for  their  neglect  or  unwise  treatment. 

The  danger  in  these  cases  lies  either  in  the  extension 
of  the  morbid  process  arising  in  the  tympanum  to  the 
adjacent  cavities  of  the  mastoid,  with  which  a  free  com- 
munication exists,  or  to  intracranial  regions  by  means 
of  communicating  vessels.  Most  suppurating  middle- 
ear  affections  will  get  well  spontaneously  if  the  simple 
rules  of  surgical  drainage  be  observed.  But,  as  Dr. 
Sexton  remarked  before  the  Practitioners'  Society,  in 
commenting  on  a  paper  on  sinus  empyema  by  Dr. 
.\bbe,  and  reported  elsewhere  in  the  present  issue  of 
the  Medical  Record,  it  is  generally  found,  in  these 
and  other  fatal  cases  of  ear  disease,  that  we  have  to  deal 
with  a  run-down  subject,  and  that  the  patient  has  been 
over-zealously  treated  and  without  the  observance  of 
ordinary  aseptic  precautions.  Thus  a  mild  case  of 
otitis  media,  by  the  unskilful  use  of  an  unclean  knife 
carrying  infection  into  the  drum  and  setting  up  pro- 
fuse suppuration  there,  or  by  infection  from  syringing 
the  ear  with  foul  water,  may  speedily  be  converted  into 
a  grave  one.  Or,  the  pernicious  practice  of  inflating  the 
drum  in  such  cases  with  the  air-bag  may  convey  septic 
secretions  from  the  naso-pharynx  to  the  ear,  and  also 
distribute  the  morbid  contents  of  the  drum  to  various 
regions  of  the  pneumatic  system  of  the  middle  ear. 

The  profession  once  had  a  precept,  "  Let  the  ear 
alone,"  which  has  been,  wisely  or  unwisely,  abandoned 
for  the  sometimes  excessive  meddlesomeness  of  enthu- 
siastic aurists.  Indeed,  it  may  well  be  questioned  if  the 
former  method  was  not  attended  with  less  evil  than  the 
latter. 


who  are  so  much  overpaid,  under  the  special  direction 
of  the  State  Lunacy  Commission.  This  commission, 
the  report  adds,  has  done  a  great  deal  of  good  in  the 
way  of  saving  money  for  the  State  ;  and  the  legislative 
committee,  on  the  whole'  seems  to  be  very  much 
pleased. 

We  have,  at  other  times,  expressed  our  views  upon 
this  subject.  There  can  be  no  doubt  about  the  fact 
that  the  commission  has  done  excellent  work  ;  but 
from  a  medical  stand-point  it  seems  as  though  they 
cared  very  little  about  securing  more  efficient  work,  or 
promoting  scientific  work  in  any  way.  The  main  ob- 
ject of  the  commission  seems  to  have  been  to  reduce  the 
expenses  and  to  get  all  the  State  hospitals  in  a  very 
useful,  machine-like  condition. 


BLOOD    PLATELETS    IN    FUNCTIONAL  NER- 
VOUS   DISEASES. 

It  seems  impossible  for  persons,  even  the  most  seriously 
minded,  to  undertake  the  study  of  the  blood  without 
discovering  something  new  and  extraordinary,  which  no 
one  has  seen  before  and  which  few  others  are  ever  per- 
suaded to  see.  The  history  of  the  anatomy  and  pathology 
of  the  blood  is  a  history  of  all  kinds  of  now  exploded  dis- 
coveries and  theories,  from  the  fourth  corpuscle  to  the 
yeast  germs.  We  note  that  a  St.  Louis  physician.  Dr. 
Bremer,  has  also  been  investigating  the  state  of  the 
blood  in  several  hundred  cases  of  neurasthenia.  The 
result  of  his  investigations,  of  course,  has  been  to  dis- 
cover certain  changes  by  which  he  is  able  to  diagnos- 
ticate cases  of  neurasthenia  from  a  blood  examination 
alone.  Dr.  Bremer's  diagnostic  sign  is,  we  believe,  the 
enormous  production  of  blood  ''  platelets."  Naturally 
it  is  Dr.  Bremer's  view  that  neurasthenia  is  not  only  a 
nervous  affection,  but  also  a  disease  of  the  blood. 
Curiously  enough.  Dr.  Bremer  finds  that,  despite  this 
pathology,  bromides,  which  are  blood-destroyers,  are 
the  best  things  for  neurasthenia,  the  salutary  effects,  he 
thinks,  being  perhaps  due  to  the  production  of  sleep. 


THE   STATE    LUNACY   COMMISSION. 

The  State  Lunacy  Commission  is  having  its  innings  in 
its  controversy  with  the  medical  superintendents  of  this 
State.  In  a  recent  report  of  the  committee  of  the 
State  Legislature  on  the  work  of  the  State  Lunacy  Com- 
mission, and  upon  the  general  condition  of  the  State 
Asylums  for  the  Insane,  a  large  part  of  the  contents  is 
devoted  to  showing  that  the  salaries  of  the  superintend- 
ents of  the  State  hospitals  are  too  large,  and  that  the 
gentlemen  who  receive  these  salaries  live  a  joyous  and 
sybaritic  life,  rollirg  about  in  carriages  at  the  expense  of 
the  State,  living  in  houses  whose  annual  rental  is  worth 
$2,000,  and  altogether  wasting  the  money  of  the  State  in 
a  manner  which  is  most  shocking.  We  find  it  also  stated 
in  the  report  that  the  function  of  the  manager  of  the 
State  hospital  is  not  a  very  important  one,  and  that  it 
should  be  made,  if  anything,  still  more  restricted,  until  the 
work  done  by  these  managers  becomes  more  and  more 
perfunctory.  The  result  thus  aimed  at  will  be  to  place 
the  asylums  in  the  direct  control  of  the  superintendents, 


Half  a  Million  for  a  Brooklyn  Dispensary. — The 
memory  of  the  late  Henry  D.  Polhemus  is  to  be  per- 
petuated by  the  erection  of  a  dispensary  building  in 
connection  with  the  Long  Island  College  Hospital  in 
Brooklyn.  It  will  be  the  gift  of  Mr.  Polhemus's 
widow,  who  has  purchased  three  city  lots  for  the  pur- 
pose. The  building  will  be  five  stories  high,  and  will 
be  known  as  the  Polhemus  Memorial  Dispensary.  The 
estimated  cost  of  the  structure,  with  its  furnishings,  is 
$250,000,  and  in  addition  to  this  Mrs.  Polhemus  will 
present  the  dispensary  with  an  endowment  fund  of 
$250,000  for  its  maintenance.— /iV/'/w//  .]fi;/ii-tt/,iriJ  Si/r- 
gical  Journal. 

A  Gentleman  who  has  Lately  Become  an  Inebriate 

asks  in  Tin-  Laiiiit  for  a  home.      He  is  eighty  years  of 
age  and  has  an  income  of  ^"60  a  year. 

Baroness  Possauer,  of  Vienna,  has  presented  a 
petition  to  the  .Vustrian  Government,  praying  that 
women,  if  properly  qualified,  be  allowed  to  practise 
medicine  and  surgery  in  that  country. 


July   2;,  1895] 


MEDICAL    RECORD. 


127 


^etjjs  of  tUt  W^ezJx. 

The  Bicycle  and  Medical  Practice. — The  use  of  the 
bicycle  has  expanded  and  developed  from  a  salutary 
athletic  exercise  into  a  great  social  obsession.  It  has 
seized  upon  every  class  of  society,  both  sexes,  all  ages, 
and  every  condition  of  life.  It  is  taken  up  by  the  well 
because  it  makes  them  feel  better,  by  the  invalid  because 
it  makes  them  feel  well,  by  tired  people  because  it 
rests  them,  and  by  the  rested  because  it  makes  them 
feel  tired.  The  fat  ride  to  get  thin  and  the  thin 
to  get  fat.  It  has  displaced  the  horse,  and  in  women 
has,  in  a  measure,  replaced  the  uterus.  It  has  made 
the  simple  and  ancient  custom  of  walking  most 
unpopular  ;  it  has  cut  down  the  function  of  the 
steam-car,  and  competes  successfully  with  the  sub- 
urban trolley.  The  doctors  have  taken  it  up  and 
expressed  their  approval  of  it,  and  we  are  far  from 
saying  a  word  in  opposition.  The  bicycle  has  come  to 
stay,  though  not  with  quite  the  omnipresent  activity 
which  it  now  enjoys.  Already  we  notice  grave  and 
reverend  seigniors  in  our  profession  riding  along  the 
cobble-stones  in  their  golf  suits  instead  of  lying  com- 
fortably back  in  their  victorias.  Time  that  used  to  be 
spent  in  serious  scientific  pursuits  at  the  hospital,  in 
the  laboratory,  and  at  the  desk  is  now  shortened  in 
order  to  enjoy  a  ride  up  the  Boulevard.  The  bicycle 
has  cut  down  the  scientific  activity  of  the  New  York 
profession  at  least  fifty  per  cent,  already. —  The  Post- 
Graduate. 

Dr.  John  T.  Nagle,  Register  of  Vital  Statistics  of 
the  New  York  City  Board  of  Health,  has  been  retired 
upon  his  own  application.  Dr.  Nagle  was  appointed  a 
health  inspector  in  1869,  and  has  been  a  most  efficient 
officer  of  the  department.  He  is  succeeded  by  Dr. 
Roger  S.  Tracy,  himself  a  member  of  the  Health  De- 
partment for  more  than  a  quarter   of  a  century. 

Professor  Johann  Mikulicz,  of  Breslau,  has  been 
called  to  the  University  of  Bonn,  to  take  the  chair  of 
surgery  formerly  held  by  Professor  Trendelenburg. 

Dr.  Charles  C.  Hendricks,  of  Hoboken,  has  been  ap- 
pointed Health  Inspector  of  Hudson  County,  N.  J  ,  to 
succeed  the  late  Dr.  Saltonstall. 

The  U.  S.  Custom-House  in  New  York  is  reported  to 
be  in  a  very  dangerous  sanitary  condition,  with  leaking 
drain-pipes  and  defective  ventilation.  The  building  is 
also  reported  to  be  structurally  unsafe,  and  in  danger 
of  collapsing.  The  Treasury  Department  has  been 
repeatedly  notified  of  these  defects  in  the  Custom-house, 
but  nothing  has  yet  been  done  to  protect  the  lives  and 
health  of  the  government  clerks. 

A  Righteous  Verdict  in  a  Libel  Suit. — Drs.  A.  F,. 
Davis  and  B.  F.  Parrish,  of  this  city,  secured  verdicts 
on  July  15th  against  the  National  Police  Gazette,  each 
for  $25,000,  for  a  libel  published  two  and  a  half  years 
ago.  This  was  the  same  libel  for  which  the  plaintiffs 
secured  verdicts  of  $2,500  against  the  Sun  Publishing 
Company,  about  two  months  ago.  We  renew  our  con- 
gratulations to  Drs.  Davis  and  Parrish,  who  have  so 
effectively  punished  their  slanderers. 


The  Late  Dr.  Stephen  E.  Fuller. — At  a  meeting  of 
the  Kings  County  (N.  Y.)  Medical  Association,  held 
June  II,  1895,  the  following  resolution  was  adopted  : 

Whereas,  Dr.  Stephen  Edward  Fuller,  an  old  and 
highly  esteemed  member  of  this  Association,  has  been 
removed  from  our  membership  by  death  ; 

Resolved,  That  this  Association,  while  bowing  to  the 
inevitable  and  mourning  its  own  great  loss,  tender  to 
the  widow  and  family  our  sincere  sympathy  and  heart- 
felt condolence  in  their  affliction. 

George  A.  Ostr.\nder,  M.D., 
Thomas  M.  Rochester,  M.D., 

Committee. 

Obituary  Notes. — Dr.  James  Caleb  Jackson,  who 
nearly  forty  years  ago  founded  the  Jackson  Sanitarium 
at  Dansville,  N.  Y.,  died  at  his  home  in  that  town  re- 
cently, in  his  eighty-fifth  year.  Dr.  Jackson  was  an 
active  co-worker  with  Lloyd  Garrison  and  other  anti- 
slavery  agitators,  and  edited  several  newspapers  at  dif- 
ferent times  in  support  of  his  political  beliefs. — Dr.  A. 
H.  BuRBANK,  of  Yarmouth,  Me.,  died  on  June  27th. 
He  had  practised  in  Yarmouth  for  nearly  fifty  years. 

The  Czarewich  has  Consumption. — It  is  announced 
that  Dr.  Leyden,  of  Berlin,  and  Professor  Nothnagel,  of 
Vienna,  have  been  called  to  see  what  can  be  done  for 
the  Czarewich,  who  is  said  to  be  suffering  from  phthisis 
in  an  advanced  stage. 

Professor  Ludwig  Traube k  memorial  bust  of  the 

celebrated    physiologist    Traube    has    recently    been 
erected  in  Berlin. 

The  Value  of  a  Good  Name. — The  Berliner  klinische 
Wochenschrift  says  that  if  Dr.  A.  Jacobi's  name  were 
not  attached,  one  would  not  believe  in  the  statement 
that  he  had  had  a  patient  with  a  temperature  of  65°  C. 
Such  a  case  was  reported,  however,  by  Professor  Ja- 
cobi  at  a  meeting  of  the  Association  of  American  Phy- 
sicians this  year.  In  the  discussion  Professor  Welch 
reported  another  case  of  77°  C,  or  171°  F.  Professor 
Welch  has  also  a  good  name,  but  it  would  not  stand 
many  more  degrees  centigrade. 

A  Hospital  for  the  Colored  Race. — A  new  hospital 
organization  has  been  incorporated  in  this  city  under 
the  name  of  the  McDonough  Memorial  Hospital  Asso- 
ciation. The  new  hospital  will  be  managed  mainly  by 
colored  persons.  It  will  be  on  the  west  side  in  New 
York,  at  some  point  between  Twenty-third  and  Seventy- 
second  Streets,  within  some  district  largely  populated 
by  colored  people.  A  site  is  now  being  looked  for, 
and  the  work  of  erecting  a  suitable  building  will  be 
begun  as  soon  as  one  is  selected.  It  is  expected  to 
maintain  the  hospital  by  voluntary  contributions,  and 
already  assurances  of  substantial  contributions  have  been 
made — one  wealthy  friend  of  one  of  the  incorporators 
having  promised  to  fit  up  the  dispensary  department 
of  the  new  hospital  and  another  the  department  of  sur- 
gery. 

Dr.  Frederick  W.  Smith,  of  Syracuse,  has  been  ap- 
pointed by  Governor  Morton  to  succeed  Dr.  Florence 
O.  Donohue  as  a  member  of  the  State  Board  of  Health. 

Dr.  Thomas  S.  Hagan,  assistant  physician  at  Hart's 
Island,  was  found  dead    in  his  room  on   Wednesday 


128 


MEDICAL   RECORD. 


[July  27,  1895 


morning,  with  his  throat  cut.  There  were  deep  gashes 
in  his  throat  and  on  his  left  wrist  and  a  number  of 
slighter  wounds  and  contusions  on  other  parts  of  his 
body.  No  knife  was  found  in  his  room,  and  it  is 
thought  one  of  the  lunatics  on  the  island  may  have 
committed  the  fatal  assault. 

Dr.  John  B.  Murphy,  of  Chicago,  was  tendered  a  re- 
ception at  the  residence  of  Dr.  Thomas  H.  Manley,  of 
this  city,  on  Friday  evening  of  last  week.  He  sailed 
for  Europe  the  following  morning. 

Buffalo  Bill  and  the  Sick  Children.— During  the  late 
visit  of  Buffalo  Bill  and  his  "  show  "  to  this  city  the 
grounds  upon  which  the  show  was  held  were  very  near 
the  Children's  Hospital.  The  music  of  the  cowboy 
band,  the  sound  of  the  gun-shots  in  the  attack  on  the 
settler's  cabin,  etc.,  attracted  the  children's  attention, 
and  when  they  were  told  that  the  noises  were  made  by 
Indians  their  grief  at  their  confinement  increased  in 
proportion  to  their  desire  to  see  a  real  live  Indian. 
One  of  them  asked  the  visiting  surgeon  if  there  was 
no  way  in  which  this  could  be  brought  about,  and  the 
surgeon  suggested  that  he  write  a  letter  to  Buffalo  Bill 
and  ask  him.     The  boy  wrote  the  following  letter  : 

"  De.^r  Mr.  Buffalo  Bill  :  We  are  a  lot  of  little 
children  lying  on  our  backs  in  the  hospital  and  we 
cannot  move.  We  want  to  see  an  Indian  very  much. 
We  have  nroer  seen  one  in  our  lives  and  cannot  get  out. 
Will  you  please  send  us  one,  so  that  we  can  see  him  ? " 

Buffalo  Bill  was  evidently  touched  by  this  appeal, 
for  presently  six  Indian  braves,  a  squaw,  and  a  papoose 
visited  the  hospital  and  walked  about  the  wards  in  full 
regalia,  greatly  to  the  delight  of  the  children.  The 
Indians  were  about  to  execute  a  war-dance  for  the 
children  in  one  of  the  wards,  when  the  chief  demurred 
on  account  of  the  waxed  floor,  which  he  thought  was 
too  slippery  for  a  proper  performance  of  the  ceremonv. 
— Boston  Medical  and  Surgical  Journal. 

True. — That  very  progressive  medical  journal,  the 
-Medical  Record,  of  New  York  City,  is  about  to  in- 
crease still  further  its  facilities  by  adding  to  the  num- 
ber of  its  pages.  Dr.  Shrady  and  his  staff  have  suc- 
ceeded in  bringing  up  the  small  journal  which  was 
started  many  years  ago  to  be  the  leading  medical  journal 
of  the  wox\A.— Maryland  Medical  Journal. 

Prejudice  and  Exaggeration.— About  a  month  ago 
our  New  York  correspondent  related  particulars  of 
two  cases  of  diphtheria,  which  terminated  fatally  after 
the  use  of  antitoxin.  Most  of  our  readers  must  have 
felt  that  the  cases,  as  given,  were  not  conclusive  in 
respect  to  the  allegation  that  the  injections  were 
responsible  for  the  result,  in  spite  of  the  statement 
of  the  physician  administering  them,  who  is  reported 
to  have  said  that  some  mistake  must  have  been  made 
in  the  preparation  or  bottling  of  the  remedy.  Indeed, 
m  one  of  these  cases  it  is  clear  that  the  patient  was 
obviously  dying  from  diphtheria  itself  when  resort  was 
had  to  antitoxin.  The  record  has,  however,  been 
seized  upon  by  Mr.  Ernest  Bell,  who  has  disseminated 
It  broadcast  in  a  letter  which  has  been  inserted  in  a 
large  number  of  provincial  papers,  and  this  writer  has 
the  effrontery  to  say  that  "similar  fatalities  "  are  being 


heard  of  "  from  all  sides."  We  venture  to  affirm  that 
there  is  no  justification  at  all  for  such  a  sweeping 
assertion,  but,  on  the  contrary,  that  already  there  is 
abundant  proof  that  this  remedy  has  had  a  surprising 
influence  in  diminishing  the  mortality  from  diphtheria. 
The  attempt  to  excite  prejudice  by  such  exaggerated 
statements  cannot  be  too  strongly  reprobated,  and  we 
can  only  express  astonishment  that  they  should  have 
been  accepted  without  demur  by  those  who  are  respon- 
sible for  the  guidance  of  public  opinion. —  The  Lancet. 

Cholera  in  Japan. — It  has  been  reported  that  cholera  ■ 
was  raging  in  many  parts  of  Japan,  but  advices  received 
by  the  Marine  Hospital  Service  show  that  these  re- 
ports were  exaggerated.  There  were  but  fifteen  cases 
at  Osaka  and  Hiogo  up  to  June  15th,  and  none  at  all 
at  Nagasaki  and  Yokohama. 

YeUow  Fever  in  Brazil. — The  captain  of  a  vessel 
recently  arrived  from  Santos  says  that  when  he  left  that 
city  yellow  fever  was  raging.  According  to  his  possibly 
somewhat  overdrawn  description,  men  were  dropping 
dead  in  the  streets,  dying  by  scores  in  the  city  and  on 
the  vessels  in  port.  Some  of  the  vessels  had  their 
flags  at  half-mast  day  after  day  for  weeks,  as  man  after 
man  of  their  crews  succumbed  to  the  scourge.  The 
death-boat  was  rowed  about  the  harbor  day  and  night, 
from  vessel  to  vessel,  collecting  the  dead  and  taking 
the  bodies  ashore  for  burial.  Some  of  the  vessels  had 
only  one  or  two  men  left  of  their  entire  crew,  and  many 
of  them  were  unable  to  get  away  owing  to  lack  of  men. 
As  we  have  before  suggested.  Dr.  Domingo  Freire  has 
here  an  opportunity  to  demonstrate  the  worth  of  his 
preventive  inoculations  of  yellow  fever  that,  believing 
as  he  does  in  their  efficacy,  it  seems  little  short  of  mad- 
ness to  neglect. 

Erythropsia  (Red  Sight)  of  Ten  Minutes'  Duration. — 
Dr.  Hilbert,  of  Gensberg  {Memorabilien),  reports  the 
case  of  a  woman  sixty-three  years  of  age,  quite  neuras- 
thenic, who  became  exceedingly  alarmed  by  the  an- 
nouncement of  some  unpleasant  news.  She  suddenly 
saw  everything  red,  and  objects  continued  to  have  uni- 
formly the  color  of  blood  for  at  least  ten  minutes.  The 
symptom  then  gradually  disappeared.  A  few  other 
cases  of  erythropsia  or  red  sight  have  been  reported  by 
Borel  and  others.  The  symptom  is  a  very  curious  one. 
and  when  complete  is  due,  it  is  believed  by  Hilbert,  to 
a  central  disturbance. 

Leprosy  is  Increasing  in  Iceland  in  an  alarming  man- 
ner, according  to  the  Jesuit  missionary.  Father  Sveins- 
son.  Last  year  a  Danish  physician,  sent  by  the  gov- 
ernment, examined  one-third  of  the  island  and  found 
one  hundred  and  forty-one  lepers. 

On  the  Occasion  of  Prince  Bismarck's  Birthday  the 
German  Emperor  conferred  the  title  of  "  Medical 
Privy  Councillor  "  on  the  statesman's  physician.  Dr. 
Schweninger,  of  Berlin. 

■Wholesale  Ice-cream  Poisoning. — In  Odessa  recently 
over  two  hundred  persons  were  poisoned  from  eating 
ice-cream.  Seven  of  the  number  died.  The  authori- 
ties suspected  that  the  poisoning  was  intentional  and 
made  numerous  arrests,  but  could  not  substantiate  the 
charges  brought,  and  finally  let  the  matter  drop,  and 
attributed  the  disaster  to  tyrotoxicon. 


July  27,  1895J 


MEDICAL   RECORD. 


129 


lleuieiuB  and  fltoticcs. 

The  Physicians'  German  Vade-mecum.  A  Manual  for 
Medical  Practitioriers  for  Use  in  the  Treatment  of  German 
Patients.  By  Richard  S.  Rosenthal.  \'o1s.  I.  and  11. 
Chicago  :  The  Rosenthal  Publishing  Co. 

The  popularity  of  this  work  is  shown  by  the  fact  of  its  hav- 
ing attained  its  eleventh  edition.  It  is  particularly  adapted 
to  those  medical  men  who  have  but  a  superficial  knowledge 
of  conversational  German  and  a  very  limited  acquaintance 
with  medical  technicalities  in  German.  To  one  whollv  un- 
acquainted with  the  language  the  book  is  of  little  value  ;  in 
f  \ct,  would  be  dangerous  to  use,  for  mistakes  might  happen 
which  would  be  very  misleading  to  the  physician. 

FON'CTIONNEMENT      DE     LA     MaISON   D'ACCOUCHEMENTS 

Baudelocque.  Clinique  de  la  Faculte  dirigee  par  le 
PrOFESSEUR  Adolphe  PiNARD.  Pp.  100.  Paris:  G. 
Steinheil.     1895. 

Professor  Pinard,  since  1882,  when  he  first  was  connected 
with  the  Maternity  de  Lariboisiere,  and  afterward  with 
the  Clinique  Baudelocque,  has  published  each  year  the  re- 
sults of  his  service.  Each  year  he  says  he  has  proven  a 
constant  diminution  of  deaths  of  the  mothers  and  the  chil- 
dren. Of  the  two  thousand  one  hundred  and  thirty-seven 
women  at  the  Clinique  Baudelocque  in  1S94.  the  total  mor- 
tality numbered  only  seven.  He  attributes  his  success  not 
so  much  to  the  methods  employed  as  to  the  fact  that  he 
does  not  change  his  interns,  his  assistants,  or  his  nurses. 
The  tables  and  classifications  of  the  more  than  two  thousand 
cases  will  prove  of  great  interest  to  the  obstetricians,  and 
are  models  of  accurate  and  careful  scientific  investigation. 

The  Diseases  of  Personality.  By  Professor  Th. 
RiBOT.  Pp.  163.  Chicago:  The  Open  Court  Publishing 
Co.     1895. 

The  second  revised  edition  of  the  authorized  translation  of 
Professor  Ribot's  interesting  psychological  study  in  diseases 
of  the  personality  will  find  great  favor  with  American  readers. 
The  work  was  first  published  in  1884,  at  which  time  the 
ideas  of  the  physical  basis  of  the  mind  had  not  been  so 
widely  accepted  as  at  present. 

In  the  preface  to  the  last  French  edition  in  1891, 
after  remarking  on  the  wide  study  of  the  subject  of  dis- 
orders and  alterations  of  the  personality  which  has  taken 
place  since  he  first  wrote,  he  comments  on  the  experi- 
mentations made  with  hypnotism,  styling  them  provoked 
alterations  of  the  personality  ;  the  others  are  spontaneous 
alterations.  Wliile  recognizing  the  value  of  investigation  of 
the  provoked  and  artificial  disorders,  he  believes  that  the 
spontaneous  alterations  still  remain  the  most  solid  data  for 
the  study  of  morbid  manifestations  of  personality. 

Those  who  have  not  already  read  the  book  in  the  original 
will  find  a  most  excellent  translation  of  this  valuable  and  in- 
structive psychological  work. 

The  Diseases  and  Deformities  of  the  FoiTus.  An 
Attempt  Toward  a  Svsteni  of  Anti-Natal  Patholoi;v.  Bv 
J.  W.  Ballantyne,  M.D.,  F.R.C.P.E.,  F.R.S.E.i  Lect- 
urer on  Midwifery  and  Gynecology,  etc..  School  of  Medi- 
cine, Edinburgh.     With  plates.     Vol.  II. 

Congenital  Diseases  of  the  Subcutaneous  Tissue 
and  Skin.    Pp.  264.    Edinburgh  :  Oliver  &  Boyd.    1895. 

It  is  two  and  a  half  years  since  the  first  volume  of  this 
series  was  published.  The  delay  has  been  occasioned  by 
tb.e  researches  necessary  to  the  obscure  subject.     The  pres- 

t  work  is  an  elaborate  description  of  scleroma  neo- 
itorum,  subcutaneous  abscess,  ichthyosis,  and  other  con- 
genital cutaneous  affections. 

These  volumes,  with  the  others  which  are  to  follow,  will 
fill  a  place  in  medical  literature  which  has  not  yet  been 
worthily  occupied. 

On  Some  Symptoms  which  Simulate  Disease  of  thk 
Pelvic  Organs  in  Women  :  and  their  Treat.ment 
BY  Allo-Piesto-Myo-Kinetics  CMassage),  and  k\ 
Auto-Piesto- Myo- Kinetics  (Self -movements  01 
Muscles  UNDERPRESSURE).  By  A.  Rabagliati,  M.A.. 
F.R.C.S.  Ed.,  Honorary  Gynecologist,  Late  Senior  Hon- 
orarv  Surgeon  Bradford  Infirmary.  Pp.  95.  New  York  : 
William  Wood  &  Co.  1895. 
The  profession  will  take  great  interest  in  Dr.  Rabagliati's 
brochure,  as  it  deals  with  a  class  of  cases  which  is  the  most 


puzzling  to  physicians,  and  which  tax  their  ingenuity  to  the 
uttermost— neurasthenic  women.  The  writer  thinks  that  too 
much  stress  has  been  given  to  the  nervous  origin  of  these 
troubles,  called  neurasthenia  ;  that  while  in  some  instances 
the  nervous  system  is  involved,  in  many  the  primary  seat  is 
in  the  muscles  and  muscle  sheaths,  and  that  also  the  nerve 
sheaths  and  the  periosteum  or  bone  sheaths,  the  joints,  true 
and  false,  are  also  affected  in  these  cases,  which  are  proba- 
bly of  rheumatic  character.  He  says  that  many  times  dis- 
ease of  the  uterus  and  its  appendages  have  been  simulated 
by  this  trouble,  even  to  such  an  extent  as  to  have  occasioned 
the  removal  of  ovaries. 

He  regulates  the  diet  of  these  patients  and  initiates  them 
into  a  series  of  self-massage,  the  modus  operandi  of  which  is 
well  illustrated  by  a  series  of  beautiful  photographs. 

A  Treatise  on  the  Nervous  Diseases  of  Children 
for  Physici.ans  and  Students.  By  B.  Sachs,  M.D., 
Professor  of  Mental  and  Nervous  Diseases  in  the  New- 
York  Polyclinic,  etc.  New  York  j  William  Wood  &  Co., 
Publishers. 

The  advent  of  a  book  such  as  the  one  before  us  shows  the 
tendency  toward  specialism  of  medical  science  at  the  end  of 
the  nineteenth  century.  Within  a  generation  ago,  a  text- 
book, or  a  volume  devoted  exclusively  to  nervous  diseases, 
would  have  been  a  novelty,  but  to-day  the  requirements  of 
the  times  are  such  that  excursions  into  the  realms  of  science 
must  be  done  so  well  and  thoroughly  that  it  is  beyond  the 
capabilities  of  individual  man  to  do  them  satisfactorily 
without  a  division  of  labor.  That  such  division  of  labor  is 
advantageous  can  be  readily  seen  by  an  examination  of  the 
present  treatise,  which  fulfils  in  a  most  satisfactory  way  the 
promptings  that  led  to  the  writing  of  the  book,  which  the 
author  states  in  the  preface  to  have  been  the  making  of  a 
treatise  "which  would  give  both  the  physician  and  the  stu- 
dent fuller  information  regarding  these  diseases  than  is  to  be 
obtained  from  text-books  on  pediatrics." 

The  book  is  contained  in  an  introduction  and  two  parts. 
The  first  fifty  pages  are  devoted  to  a  consideration  of  the 
modes  and  m.ethods  of  examination  which  will  lead  most 
reliably  to  a  diagnosis.  By  the  judicious  use  of  tables  and 
illustrations,  the  author  has  succeeded  in  presenting  a  really 
massive  amount  of  information,  and  that  of  the  most  useful 
kind,  in  this  chapter,  which,  especially  to  the  student  and 
to  one  unfamiliar  with  the  intricacies  of  neurology,  must  be 
of  paramount  importance. 

Part  I.  is  devoted  to  the  general  nervous  diseases  and 
Part  II.  to  the  organic  diseases  of  the  nervous  system.  The 
author  has  departed  from  the  usual  custom  by  presenting 
first  the  functional  disorders  ;  and  we  are  told  in  the  preface 
that  he  did  so  advisedly,  not  alone  because  they  are  of  the 
greatest  practical  importance  and  constitute  fully  one-half 
of  the  nervous  diseases  observed  during  early  years,  but  that 
several  of  these  disorders,  such  as  convulsions,  epilepsy, 
and  hysteria,  have  an  important  bearing  on  the  life  of  the 
child  and  are  so  closely  related  to  many  organic  nervous  dis- 
eases of  the  nervous  system  that  it  seemed  absolutely  neces- 
sary to  explain  these  functional  troubles  before  proceeding 
to  a  discussion  of  structural  disease.  This  arrangement  will 
probably  commend  itself  to  the  practitioner.  It  is  of  the 
utmost  importance  to  keep  in  mind  the  intimate  relationship 
between  convulsions  in  children  and  epilepsy,  and  when  they 
are  presented  sequentially,  as  they  are  in  this  book,  the  mo- 
mentousness  of  this  matter  is  impressed  upon  the  reader. 
The  chapters  in  Part  1.  that  call  for  special  commendation 
are  those  devoted  to  epilepsy,  hysteria,  and  migraine.  The 
pathology  of  epilepsy,  both  inferential  and  determined  ;  the 
clinical  manifestations  of  the  disease  ;  that  extremely  im- 
portant matter,  the  management  of  patients  afflicted  with 
epilepsy,  are  put  down  in  a  masterly  and  convincing  man- 
ner, and  after  reading  it  one  feels  that  both  the  faddist  and 
the  nihilist  in  the  treatment  of  epilepsy  have  had  their 
claims  weighed  and  not  allowed. 

In  his  conception  of  hysteria  the  author  is  inclined  to 
take  the  most  advanced  and  substantiated  view  of  it,  which 
places  it  more  properly  among  the  mental  than  the  purely 
nervous  disorders,  using  the  latter  term  in  its  colloquial  and 
evcry-day  sense.  We  are  sure  that  his  positive  statement, 
that  hysteria  is  a  rare  disease,  in  this  country,  at  least,  not 
only  in  the  adult  but  extremely  so  in  children,  will  be  con- 
curred in  by  everyone  who  has  seen  much  of  nervous  dis- 
eases, and  it  should  go  a  long  way  toward  throttling  the 
impulse  which  prompts  some  to  label  every  nervous  mani- 
festation which  they  do  not  understand  as  "  hysterical  "  and 
therefore  to  be  sneered  at. 

The  chapters  devoted  to  chorea  and  the  choreiform  dis- 
eases, as  well  as  those  treating  of  tetanus  and  tetany,  are 


i^o 


MEDICAL   RECORD. 


[July  27,  1895 


characterized  by  the  elimination  of  antiquated  theories,  by 
the  absence  of  padding  and  the  presentation  of  facts  in  a 
scientific  and  readable  form.  The  concluding  chapter  of 
Part  I.  is  devoted  to  the  vasomotor  and  tropho  neuroses, 
under  which  terms  the  author  describes  for  sake  of  conven- 
ience, exophthalmic  goitre,  Raynaud's  disease,  myxoedema, 
angio-neurotic  oedema,  facial  hemiatrophy,  etc. 

In  Part  II.  the  diseases  of  the  peripheral  nerves  are  first 
considered,  and  especially  interesting  is  the  chapter  on 
multiple  neuritis,  a  condition  which,  with  the  exception  of 
the  polyneuritis  occurring  after  diphtheria,  has  been  con- 
sidered to  be  extremely  rare  in  children,  but  which  the 
author  believes  to  be  more  often  mistaken  for  anterior 
poliomyelitis  than  has  been  heretofore  recognized. 

The  diseases  of  the  spinal  cord  are  introduced  by  a  brief 
up-to-date  consideration  of  the  anatomy,  physiology,  and 
pathology  of  this  part  of  the  body,  which  is  illustrated  by  a 
helpful  colored  plate  taken  from  Flatau's  recent  work. 

The  chapters  here  which  we  would  especially  commend 
are  those  devoted  to  the  hereditary  or  family  diseases  of  the 
spinal  cord  and  to  the  progressive  muscular  atrophies.  Our 
conception  of  both  of  these  types  of  disease  is,  at  the  pres- 
ent time,  going  through  a  very  important  evolutionary  stage, 
and  although  it  may  even  yet  seem  to  the  mind  of  the 
uninitiated  and  the  casual  observer  that  the  facts  concerning 
these  two  conditions  are  in  a  very  chaotic  state,  his  mind 
will  be  relieved  of  such  erroneous  ideas  by  the  perusal  of 
these  chapters.  They  show  a  grasp  of  the  conception  of 
these  diseases,  a  practical  familiarity  with  them  as  they 
come  before  the  physician,  and  a  knowledge  of  the  literature 
of  the  subjects  which  does  credit  to  the  author,  and  which 
will  well  repay  the  student's  careful  study. 

The  part  of  the  book  devoted  to  diseases  of  the  brain 
is  built  on  the  same  plan  as  the  part  which  treats  of  the 
spinal  cord.  The  illustrations  and  diagrams  to  illustrate 
these  chapters  have  been  judiciously  selected  and  carefully 
executed.  Meningitis  and  epidemic  cerebro-spinal  men- 
ingitis are  considered  from  a  modern  pathological  point  of 
view.  We  are  sorry  the  author  did  not  present  7nore 
exhaustively  the  subject  of  encephalitis,,  for  it  is  hazarding 
a  very  safe  prophecy  to  say  that  there  is  more  of  encephalitis 
Simon  pure,  and  in  combination,  than  books  have  taugbf  us 
heretofore. 

The  infantile  cerebral  palsies,  a  subject  to  which  Sachs 
has  made  some  of  the  most  important  contributions  in  the 
literature,  are  particularly  instructive.  The  same  may  be 
said  of  that  extremely  important  subject,  abscess  of  the 
brain  and  thrombosis  of  the  intracranial  sinuses,  a  subject 
on  which  we  cannot  have  too  much  light  or  the  reflexionlof 
personal  experience. 

The  closing  chapters  are  taken  up  with  a  discussion  of  the 
common  forms  of  diseases  of  the  mind  as  seen  in  childhood, 
and  Jhe  subject  of  idiocy  and  imbecility.  An  appendix  of  a 
few  pages  contains  special  reference  to  such  measures  as  the 
rest  cure,  hydrotherapy,  etc.,  and  will,  no  doubt,  be  found 
useful  by  those  who  would  know  the  detail  of  application  of 
these  procedures. 

The  mechanical  part  of  the  volume,  particularly  the  print- 
ing and  the  illustrations,  leaves  nothing  to  be  desired. 
•  In  conclusion,  it  may  be  said  that,  as  a  text-book  of  the 
nervous  diseases  of  children,  the  book  before  us  compares 
favorably  vith  those  which  have  already  become,  or  are  fast 
becoming,  .lassies — Dana,  Cowers,  Oppenheim,  Marie — and 
is  a  credit  alike  to  the  author,  to  pediatrics,  and  neurology. 

The  Spirit  of  Cookery.  A^  Popular  Treatise  on  the 
History,  Science,  Practice,  and  Ethical  and  Medical 
Import  of  Culinary  Art,  with  a  Dictionary  of  Culinary 
Terms.  By  J.  L.  W.  Thudichum,  M.D.,  F.R.C.P., 
London.  London  and  New  York  :  Frederick  Warne  & 
Co.     1895.' 

This  treatise  contains  a  system"of  general  rules  on  the  prm- 
ciples  of  cookery,  and  enables  the  mastering  of  the  most  im- 
portant culinary  operations.  The  medical  profession  will  find 
in  this  work  many  materials  to  assist  them  in  dietetic  dis- 
quisitions, and  in  the  synthesis  of  meals  to  give  into  the 
hands  of  patients  or  their  providers. 

Indigestion.     An   Introduction  to  ttic  Study  of  the  Dis- 
eases of  the  Stomach.     By  George  Herscheli.    M.D. 
London.     Second  Edition.     New  York  :  G.  P.  Putnam's 
Sons.     London  :  Bailliere,  Tindall  &  Cox.     1895. 
This  book  is  an  excellent  guide  for  the  study  of  diseases  of 
the  stomach.     The  author  has  succeeded  in  beint;  concise 
clear,  and  practical.     The  treatment  of  hyperchlorhvdria  is 
described  on  page  208  as  follows  ; 


"  Everything  that  can  irritate  the  coats  of  the  stomach  must 
be  interdicted.  The  diet  must  consist  mainly  of  nitrogenous 
food,  both  because  it  is  easiest  digested,  and  also  for  the 
reason  that  it  possesses  the  advantage  of  entering  into  com- 
bination with  HCl,  and  thus  alleviating  the  pain  by  diminish- 
ing the  quantity  of  free  acid  in  the  stomach.  Any  kind  of 
meat  may  be  taken,  even  such  as  possesses  the  reputation 
of  being  difficult  of  digestion  ;  but  it  must  in  all  cases  be 
plainly  cooked,  either  roast,  boiled,  or  grilled.  Eggs  and 
milk  should  form  an  important  part  of  the  dietary,  as  they  are 
rich  in  albumin,  and  are  thus  very  effective  in  masking  pain. 
Indeed,  patients  usually  find  this  out  for  themselves,  and 
are  in  the  habit  of  taking  a  bealen-up  egg  or  a  glass  of  milk 
two  or  three  hours  after  a  meal  to  dull  their  pain.  The 
eggs  must  be  very  lightly  boiled  and  the  milk  sipped  very 
slowl)'.  The  reason  why  the  milk  must  be  taken  in  sips  is 
in  order  that  it  may  be  curdled  in  fine  flakes,  and  not  in  a 
solid  lump.  This  would  certainly  happen  if  a  glassful  were 
taken  at  a  gulp.  In  these  patients  the  milk-curdling  fer- 
ment is  always  in  excess,  and  consequently  the  curdling  of 
the  milk  is  very  energetic.  This  fact  will  possibly  explain 
the  assertion  of  many  sufferers  from  hyperchlorhydria,  '  that 
they  cannot  take  milk,  as  it  always  disagrees  and  makes 
them  bilious.'  I  find  that  patients  usually  describe  an  at- 
tack of  acute  dyspepsia  as  '  biliousness.'  Therefore,  when 
we  are  told  positively  by  a  patient  that  milk  docs  not  agree, 
we  must  not  attach  too  much  weight  to  the  statement  and 
exclude  it  from  the  dietary  until  we  have  tested  the  effect  of 
taking  it  in  sips.  Another  point  of  great  importance  is  to 
regulate  the  amount  of  salt  taken.  The  quantity  used  in 
cooking  and  taken  with  the  food  must  be  reduced  to  a 
minimum,  for  the  obvious  reason  that  from  it  is  derived, 
eventually,  a  large  proportion  of  the  acid  of  the  gastric 
Juice.  All  substances,  such  as  pickles,  spices,  and  strong 
sauces,  that  excite  the  secretion  of  gastric  juice,  must 
be  absolutely  avoided.  As  the  absorption  in  the  stomach 
is  normal,  and  since  there  is,  as  a  rule,  no  dilatation,  the  pa- 
tient need  not  be  restricted  in  his  drink,  and  may  take  milk 
and  water  ad  lib.  Moreover,  we  must  bear  in  mind  that  a 
certain  amount  of  fluid  is  of  a  distinct  advantage,  both  be- 
cause by  diluting  the  hyperacid  gastric  juice,  it  will  help  to 
diminish  pain,  and  also  because  it  will  favor  the  process 
of  peptonization,  which  is  retarded  if  the  stomach  contents 
are  concentrated  beyond  a  certain  point.  Instead  of  milk, 
a  little  red  or  white  claret  may  be  added  to  the  water,  or 
kumyss  may  be  taken  if  relished  by  the  patient.  All  strong 
wines,  spirits,  liqueurs,  tea,  and  coffee  are  to  be  absolutely 
avoided.  As  the  object  of  treatment  is  to  secure  as  much 
functional  rest  for  the  stomach  as  possible,  only  three  meals 
a  day  should  be  taken,  and  nothing  whatever  between 
them,  however  much  the  patient  may  be  tempted  to  do  so 
to  relieve  his  pain." 

CONSIDliR.VTIONS  SUR  LES  RlTPTURES  DE  L'UtERUS  ET  DU 

Vagin  Pend.ant  l'Accouchement.  Extrait  du  M^- 
moire  presente  au  Concours  de  Medecine  en  Chef  au  Ser- 
vice de  Gynecologic  par  le  Docteur  C.  I.  Andronesco, 
Medecin  .Adjoint  a  la  Matcrnite  de  Bucharest  (Roumaine). 
Imprimerie  de  I'Independcnce  Roumaine.     1895. 

Thirty-kive  cases  of  this  fortunately  rare  occurrence  have 
been  brought  together  by  the  writer.  He  emphasizes  the 
difficulty  of  determining  whether  the  peritoneum,  which  is 
incredibly  tough  and  unyielding  in  such  cases,  has  been 
torn  through  in  the  escape  of  the  child  into  the  abdominal 
cavity.  Where  such  is  the  case  laparotomy  is  by  far  the  best 
method  of  treatment.  Laparotomy  is  indicated  also  where 
there  is  hemorrhage  which  cannot  be  controlled.  In  cases 
where  the  parts  arc  irregularly  torn  and  the  rupture  so  ex- 
tensive as  to  render  the  repair  of  the  uterus  impossible, 
Porro's  operation  should  be  resorted  to. 

UNTERSUCHIINGEN  UBER  die  ReSPIR.\TION  UNO  ClRCUL.\- 
TION,  bei  Aenderung  des  Druckes  und  des  Sauerstoff- 
gehaltes  der  Luft.  Von  Dk.  .A.  Loewy.  Berlin  :  Verlag 
von  August  Hirschwald.  1S95. 
This  monograph  contains  an  extensive  experimental  study 
on  the  conditions  of  respiration  under  different  atmospheric 
pressure.  .Most  of  the  experiments  have  been  done  in  the 
pneumatic  cabinet  of  the  Jewish  Hospital  in  Berlin.  If  the 
atmospheric  pressure  was  gradually  decreased  (not  sud- 
denly) it  could  be  done  so  until  it  was  reduced  to  half  the 
figure  without  any  bad  eflects  to  the  person  breathing 
therein.  There  appeared  only  at  times  subjective  com- 
plaints of  a  nervous  nature,  slight  dizziness,  tired  feeling, 
and  uncontrollable  sleepy  sensation.  But  even  these  symp- 
toms could  be  relieved  by  exercise.  The  author  comes  to 
many  valuable  conclusions,  of  which  a  very  important  one 


July  27,   1895] 


MEDICAL    RECORD. 


is  that  the  respiratory  exchange  of  gas  in  the  lungs  is  in  a 
,  high  degree  independent  from  the  composition  of  the  in- 
[      haled  air. 

I  Bader-Almanach.  Mittheilungen  der  Bader,  Luftkurorte 
und  Heilanstalten  in  Deutschland,  Oesterreich,  der 
Schweiz  und  den  angrenzenden  Gebieten,  fiir  Aerzte  und 
Heilbediirftige.  Sechste  Ausgabe,  mit  Karte  der  Bader, 
Kurorte  und  Heilanstalten.  Berlin  :  Druck  und  Verlag 
von  Rudolf  Mosse. 

This  book  contains  a  complete  description  of  the  numerous 
watering-places  of  Europe.  It  states  the  curative  effect  of 
the  various  waters  and  bathing  establishments.  It  also 
'  gives  the  names  of  the  resident  physicians  and  the  prices 
of  the  hotels. 


J«0cietui  Reports. 

THE     PRACTITIONERS'    SOCIETY     OF    NEW 
YORK. 

Stated  Meeting,  May  j,  i8gj. 

Samuel  Sexton,  M.D.,  President,  pro  tem. 

Large  Chancre  of  Lip  ;  Disappearance  under  Mercurial 
Treatment. — Dr.  Robert  Abbe  first  presented  a  pa- 
tient illustrating  recovery  from  sinus  pyasmia,  the  his- 
tory of  which  was  read  later,  and  then  presented  the 
woman  shown  at  the  meeting  of  February  ist,  with  a 
large  chancre  of  the  lip  as  seen  in  the  photograph. 
The  tumor  had  disappeared  almost  entirely  under  mer- 
curial inunctions  continued  for  three  months,  a  drachm 
being  used  twice  a  day,  while  an  eighth  of  a  grain  of 
biniodide  of  mercury  was  given  internally  three  times 
a  day.  There  had  Ijeen  no  ptyalism,  and  the  patient 
was  in  'good  health.  Her  husband,  to  whom  she  had 
been  married  six  weeks  before  Dr.  Abbe  saw  her,  had 
mucous  patches  on  his  lips.  She  had  been  under 
treatment  three  weeks  for  supposed  cancer  by  another 
physician,  who  leeched  and  lanced  it,  and  then  sent 
her  to  the  Cancer  Hospital  to  have  the  tumor  re- 
moved. At  that  time  there  was  a  macular  rash  on  the 
body.  The  interest  of  the  case  related  to  the  very 
large  size  of  the  chancre,  rather  than  to  its  situation, 
which  was  somewhat  rare. 

Phthisis  Following  Chancre. — Dr.  W.  H.  Draper 
recalled  a  case  of  chancre  of  the  lip  which  he  had  seen 
a  good  many  years  ago.  Had  caused  it  to  disappear  un- 
der mercurial  treatment,  but  the  patient  developed 
disease  of  the  lungs  with  all  the  physical  signs  of  tuber- 
culosis, and  died  within  two  years.  One  author  had 
stated  that  pulmonary  phthisis  was  a  frequent  conse- 
quence of  syphilis. 

Dr.  Sexton  recalled  a  case  of  chancre  of  the  lip 
caused  by  a  friend  of  the  family  taking  the  child  up 
and  kissing  it.  He  asked  a  question  which  he  said  was 
not  exactly  pertinent  to  the  subject,  namely,  whether 
any  of  the  members  had  observed  communication  of 
gonorrhoea  to  the  rectum. 

Dr.  Peabody  replied  that  Dr.  Cutter  had  had  a  case 
of  gonorrhoea  in  the  mouth  at  the  New  York  Dispen- 
sary, and  he  supposed  that  under  favorable  conditions 
any  mucous  membrane  might  become  infected. 

Dr.  Abbe  believed  that  gonorrhoea  of  the  rectum 
was  one  of  the  things  mentioned  in  the  text-books  as 
occasionally  met  with.  Personally  he  had  never  seen 
a  case. 

Pregnancy  Associated  with  Diabetes. — Dr.  E.  L. 
Partridge  read  a  paper  on  this  subject.    (See  p.  109.) 

Nervous  Excitement  and  Diabetes. — Dr.  Beverley 
Robinson  said  he  had  nothing  to  contribute  bearing 
directly  upon  the  subject  of  pregnancy  associated  with 
diabetes.  He  might  mention  one  or  two  facts  which 
had  an  indirect  relation.  For  instance,  the  influence 
of  the  nervous  system  upon  the  amount  of  sugar  in  the 
urine  in  diabetic  patients  was  manifest  in  the  case  of  a 


man  under  his  care  who,  when  involved  in  business 
cares  in  the  city,  had  about  four  per  cent,  of  sugar  in 
his  urine,  and  none  at  all  when  in  the  countrj'  amusing 
himself  on  his  farm.  Regarding  the  condition  of  the 
blood  of  persons  dying  of  diabetes,  in  one  case  in  which 
he  had  had  it  examined  its  appearance  was  that  of  a 
soup,  and  it  was  extremely  acid.  He  did  not  mention 
this  as  something  new,  for  it  was  not,  but  simply  as  a 
personal  experience.  He  thought  he  had  warded  off 
comatose  symptoms  in  certain  cases  of  diabetes  by  ad- 
ministering alkalies  freely. 

Too  Much  Dieting  ? — The  other  point  to  which  Dr. 
Robinson  would  call  attention  was  the  need,  in  his 
opinion,  of  allowing  diabetic  patients  a  more  liberal 
diet  than  seemed  to  be  taught  in  the  books.  He  even 
regarded  farinaceous  food  as  less  pernicious  than  was 
generally  believed.  Of  course  it  was  known  to  increase 
the  amount  of  sugar  in  the  urine,  but  whether  it  injured 
the  patient  was  a  different  thing.  He  would  like  to 
hear  an  opinion  expressed  upon  that  question. 

A  Substitute  for  Sugar. — Dr.  Peabody  said,  in  reply 
to  Dr.  Robinson's  query,  that  he  had  noticed  that  pa- 
tients who  had  been  doing  badly  on  a  rigid  diet  fre- 
quently improved  in  a  decided  manner  when  given 
some  latitude  in  diet.  He  thought  each  case  had  to  be 
judged  of  by  itself  with  reference  to  diet  and  general 
treatment.  He  had  had  some  experience  with  the 
article  sold  under  the  name  diabetin.  It  was  sweet, 
and  was  a  sugar  in  its  physiological  effects,  increasing 
the  nutrition,  but  it  did  not  act  like  sugar  in  increasing 
the  amount  of  sugar  in  the  blood  or  urine  in  patients 
with  diabetes.  In  other  words,  it  supplied  the  patient 
■with  a  form  of  sugar  which  he  was  able  to  digest  and 
assimilate.  It  was  obtained  from  the  vegetable  king- 
dom. 

Diabetes  May  or  May  Not  be  a  Serious  Complication 
of  Pregnancy. — Dr.  W.  H.  Draper  had  had  but 
one  personal  experience  with  diabetes  in  pregnancy, 
and  he  could  only  say  that  in  that  instance  no  disastrous 
consequences  followed  ;  the  woman  passed  through 
normal  labor  at  term.  He  thought,  however,  that  the 
question  of  treatment  presented,  as  Dr.  Partridge  had 
stated,  many  difficultes.  It  seemed  to  him  that  dia- 
betes might  be  a  very  serious  complication  of  preg- 
nancy, and  it  might  not.  To  determine  the  ques- 
tion would  be  more  difficult  than  might  at  first  sight 
appear.  Sugar  sometimes  appeared  in  the  urine,  and 
was  called  diabetes,  but  more  properly  should  be 
called  glycosuria,  simply  from  over-indulgence  in  the 
carbo-hydrates.  He  thought  the  personal  history  of 
the  patient,  and  the  family  history,  would  be  important 
factors  in  determining  the  question  whether  this  or  a 
more  serious  form  of  diabetes  existed.  Sugar  appear- 
ing in  the  urine  of  a  pregnant  woman  in  whose  family 
there  had  been  diabetes  should  excite  apprehension. 

Primipara  More  Liable  to  Nervous  Influences. — Dr. 
Andrew  H.  Smith  inquired  of  the  reader  of  the  paper 
what  proportion  of  the  cases  had  occurred  in  primi- 
para or  multipara,  and  in  married  or  unmarried  women 

Dr.  Partridge  replied  that  the  impression  which 
he  had  received  in  reading  the  histories  of  the  cases 
was  that  all  had  occurred  in  married  women.  It  had 
not  been  stated  just  what  number  of  Duncan's  cases 
had  occurred  in  women  who  had  pre\'iously  borne  chil- 
dren, but  he  thought  at  least  two-thirds  were  multi- 
para. 

Dr.  Smith  said  the  point  which  he  had  in  mind  was 
whether  mental  influences  had  had  anything  to  do  with 
the  association  of  diabetes  and  pregnancy  in  these 
cases.  All  knew  that  diabetes  sometimes  arose  from 
great  mental  shock.  Also,  that  protracted  mental 
strain  sometimes  produced  an  effect  similar  to  sudden 
mental  shock.  An  unmarried  woman,  finding  herself 
pregnant,  would,  of  course,  have  distress  of  mind,  and 
a  primipara  of  nervous  temperament  would  experience 
greater  anxiety  than  a  multipara  of  stolid  habit.  He 
believed  that  a  considerable  degree  of  glycosuria  of 


MEDICAL   RECORD. 


[July  27,  1895 


transient  character  occurred  much  more  frequently 
than  was  generally  supposed.  Owing  to  the  fact  that 
the  sugar  appeared  in  the  urine  for  a  while  and  then 
disappeared,  it  was  likely  to  be  overlooked  unless  ex- 
aminations were  made  regularly  for  a  considerable  pe- 
riod. 

Codeia  in  Diabetes.— Dr.  Robinson  said  he  sup- 
posed most  of  us  had  little  faith  in  the  drug  treatment 
of  diabetes,  yet  as  he  had  used  codeia,  or  codeine,  to  a 
considerable  extent,  after  it  had  been  recommended  in 
a  paper  by  a  member  of  the  Society  some  years  ago,  he 
would  like  to  know  what  might  have  been  the  experi- 
ence of  others  with  it.  There  was  no  question  in  his 
mind  but  what  it  diminished  the  quantity  of  sugar  in 
the  urine,  and  could  be  given  in  considerable  doses  for 
some  time  without  apparently  affecting  the  patient  un- 
favorably. He  had  thought  that,  possibly,  it  had  done 
the  patient  a  good  deal  of  good,  but  the  final  end  of 
grave  cases  was  always  the  same. 

Dr.  Draper  replied  that  for  many  years  he  had 
been  in  the  habit  of  treating  grave  cases  of  diabetes 
with  opium,  in  one  form  or  another,  and  of  late  years 
with  codeine.  He  remembered  a  case  at  Roosevelt 
Hospital  in  which  he  had  given  large  doses  of  codeine, 
as  much  as  twelve  grains  a  day,  with  manifest  benefit. 
He  did  not  think  it  was  necessary  in  the  milder  form 
of  the  disease,  and  did  not  use  it.  But  where  diabetes 
did  not  yield  to  dietetic  treatment  and  to  alkalies,  he 
thought  there  was  no  remedy  equal  to  opium.  The 
disease  prevailed  to  a  considerable  extent  in  India, 
and  it  had  been  the  practice  of  the  people  there  for 
many  years  to  use  opium  in  its  treatment.  The  drug 
had  one  advantage — namely,  that  it  enabled  these 
patients  to  do  work  which  they  were  unable  to  do 
without  it  on  account  of  exhaustion. 

Dr.  Andrew  H.  S.mith  asked  Dr.  Draper  if  there 
was  any  other  drug  which  would  replace  opium,  and 
being  asked  for  an  example,  suggested  small  doses  of 
antipyrine. 

Dr.  Draper  said  he  thought  that  this  and  similar 
derivatives  of  coal-tar  were  beneficial  in  diabetes  to  a 
certain  extent,  but  especially  in  the  mild  form.  He  had 
not  obtained  much  benefit  from  them  in  the  grave  form. 

Dr.  Smith  said  he  had  entertained  the  theory  that 
possibly  the  circulation  of  sugar  in  the  blood  acted  as 
a  direct  irritant  upon  the  diabetic  centre  in  the  fourth 
ventricle,  and  that  treatment  calculated  to  lessen  the 
irritability  of  this  centre,  or  to  diminish  the  amount  of 
sugar  in  the  blood,  would  tend  to  break  the  vicious 
circle.  The  more  sugar  in  the  urine,  the  more  irrita- 
tion; the  more  irritation,  the  more  sugar. 

Dr.  Draper.  Do  you  think  these  agents  tend  to 
diminish  the  influence  of  the  diabetic  centre  in  the 
production  of  diabetes  ? 

Dr.  Smith.     It  seems  so  to  me. 

Sinus  Pysmia  and  Jugular  Thrombosis. — Dr.  Rob- 
ert Abbe  made  some  introductory  remarks,  and  then 
read  the  histories  of  four  cases  of  sinus  pysemia,  one 
being  that  of  the  patient  whom  he  had  already  pre- 
sented, and  who  had  recovered  from  sinus  pyaemia 
after  irrigation  of  the  jugular  vein  and  lateral  sinus. 

Sinus  pyremia,  he  said,  is  a  very  grave  complication 
of  certain  conditions,  being  especially  liable  to  occur 
in  inflammations  of  the  middle  ear.  This  fact  and 
the  value  of  surgical  treatment  by  the  Ballance  opera- 
tion should  be  more  widely  appreciated  among  general 
practitioners.  Whenever,  in  the  course  of  middle-ear 
suppuration,  the  pus  has  reached  the  lateral  sinus,  a 
form  of  pyajmia  is  set  up  of  such  gravity  that  it  has 
always  been  regarded  as  a  fatal  malady.  The  sinus 
becomes  thrombosed  with  a  septic  plug,  which  sjireads 
down  into  the  jugular  vein,  breaks  down,  and  the  i)urulent 
matter  is  carried  onward  into  the  circulation.  The 
patient  experiences  violent  chills,  septic  foci  form  in 
the  lungs  or  other  parts  of  the  body,  and  death  takes 
place  from  some  one  of  the  phases  of  sepsis.  Now 
Ballance  has  shown  that  many  of  these  cases  can  be 


cured  ;  for,  while  not  a  great  many  have  been  reported, 
yet  there  have  been  a  sufficient  number  to  prove  the 
great  value  of  operative  interference. 

The  essential  features  of  the  operation  consist  in 
ligating  the  jugular  in  the  neck  below  the  infective 
thrombus,  so  as  to  prevent  the  passage  of  any  of  the 
purulent  material  entering  the  circulation,  then  open- 
ing the  lateral  sinus  and  jugular  above  so  as  to  give 
exit  to  the  foul,  infective  matter.  Now  it  has  been 
found  that,  as  soon  as  the  jugular  has  been  tied, 
the  chills  cease.  The  patient,  who  had  been  having 
two  or  three  violent  rigors  a  day,  has  remained  free, 
and  the  natural  inference  has  been  that  the  chills  were 
due  to  the  entrance  of  septic  matter  from  the  jugular 
vein  into  the  general  circulation. 

Since  reading  Ballance's  paper  in  1891  I  have  had  a 
good  many  cases  of  abscess  of  the  mastoid  which  I  have 
trephined  and  cured  in  that  manner.  Of  cases  involv- 
ing the  lateral  sinus  and  jugular,  with  thrombosis  of  these 
vessels,  I  have  had  four.  In  one  of  them  I  did  not  do 
the  Ballance  operation  in  its  complete  form — that  is, 
I  did  not  tie  the  jugular,  but  I  uncovered  the  lateral 
sinus,  introduced  the  needle,  and  drawing  off  only  clear 
blood,  I  treated  the  case  simply  as  one  of  mastoid  ab- 
scess. But  the  man  continued  to  do  badly,  and  died 
on  the  seventh  day  of  septic  pneumonia.  I  have  always 
regretted  not  having  done  the  complete  Ballance  oper- 
ation in  this  case,  for  it  is  probable  that  the  septic 
thrombus  was  in  the  upper  part  of  the  jugular,  and  not 
in  the  lateral  sinus  itself,  and  had  I  tied  the  jugular  be- 
low and  opened  it  above  to  let  out  the  septic  material 
the  patient  might  have  recovered. 

Dr.  Abbe  then  read  the  histories  of  his  other  cases. 

Case  I.     Sinus  Pyemia  a?id  Jugular  Thrombosis ; 

Ballaiue's    Operation  ;    Recovery. — Miss    G ,    aged 

thirty-two,  trained  nurse.  The  patient  was  in  perfect 
health  until  two  weeks  before  the  operation ;  she  then 
had  an  acute  purulent  nasal  discharge  and  consulted 
Dr.  O.  B.  Douglas,  who  thought  she  had  ethmoidal 
necrosis,  as  she  had  one-sided  frontal  headache  with 
purulent  discharge.  This  lasted  ten  days  and  was  im- 
proved, though  an  earache  had  been  progressing  mean- 
while with  continued  headache. 

On  Saturday,  .A.pril  6th,  perforation  of  the  drum  with 
discharge  of  pus  from  the  left  ear,  occurred  spontane- 
ously. A  few  hours  later  a  violent  chill  took  place, 
with  a  temperature  of  105°  F.  She  was  then  seen  in 
consultation  by  Drs.  Douglas,  Nicoll,  Pomeroy,  and 
McNutt.  The  mastoid  area  showed  no  pain,  tender- 
ness, redness,  or  oedema.  Her  temperature  ranged 
from  104°  to  105°  F.  for  three  days.  With  recurrence 
of  chills,  delirium  set  in,  and  headache  continued. 
Hebetude  increased  into  semi-coma. 

On  Tuesday,  April  9th,  Dr.  Andrew  H.  Smith  was 
consulted  and  advised  surgical  interference,  and  I  was 
asked  to  take  charge  of  her.  When  seen  she  was  in 
semi-coma  and  could  scarcely  be  roused  to  any  re- 
sponse. Respiration  shallow  ;  pulse  thready,  120  ;  tem- 
perature, 105°  F.  The  mastoid  still  showed  no  external 
change,  nor  was  it  tender  on  pressure.  No  oedema  ex- 
tended backward  from  it  under  the  occipital  line,  as  has 
been  spoken  of.  .Along  the  jugular  vein,  however,  from 
the  tip  of  the  mastoid  down  the  front  of  the  sterno- 
mastoid  muscle  two-thirds  of  the  distance  to  the  ster- 
num, pressure  gave  the  jiatient  sharp  pain  and  roused 
her  somewhat  from  her  hebetude.  This  evidence  of 
jugular  pain  had  been  found  wanting  in  the  morning. 
.\  little  tumefaction  along  the  upper  part  of  the  same 
area  was  now  noticeable. 

Diagnosis. — Sinus  pya?mia  and  jugular  thrombosis  : 
immediate  operation.  .Assisted  by  Drs.  .A.  L.  Fisk. 
and  J.  E.  Nicoll.  The  first  incision  to  ligate  the  jugu- 
lar about  its  middle,  encountered  several  enlarged 
lymphatics  adherent  to  the  jugular  and  fixed  to  it  by 
extensive  periphlebitis.  The  vein  was  not  readily  rec- 
ognized, owing  to  its  half-flaccid  and  thickened  walls. 
A   hypodermic   removed   from  it  a   little  dirty  septic 


July    27,  1895] 


MEDICAL    RECORD. 


riaid.  Xo  further  attempt  to  deal  with  it  until  the 
sound  vein  should  be  ligated  below. 

Another  incision  was  made  low  down  in  front  of  the 
tendon  of  the  muscle — and  the  common  jugular  readily 
tied  between  two  ligatures  and  cut  across.  The  mas- 
toid process  was  now  freely  trephined  and  no  suppura- 
tion found.  The  bone  was  unusually  hard,  and  its 
cells  contained  only  gray  granulation  tissue.  No  foul 
bone  odor  was  present.  The  lateral  sinus  was  carefully 
uncovered  for  an  inch  and  a  quarter.  It  seemed  full 
and  had  a  transmitted  pulsation,  but  its  coats  were  thick 
and  inflamed.  Again  the  hypodermic  withdrew  from 
it  dirty  septic  fluid  instead  of  dark  blood.  It  was 
therefore  incised  its  full  length,  and  the  upper  jugu- 
lar vein  was  now  also  incised  for  an  inch  and  a  half, 
and  free  irrigation  from  one  to  the  other  with  subli- 
mate solution  I  to  1,000,  and  then  with  salt  solution, 
was  done.  The  jugular  was  split  down  to  the  clotted 
lymph  plug  just  above  the  facial  vein  entrance.  The 
upper  limit  of  the  thrombosed  sinus  was  just  at  the 
margin  of  the  trephine  opening,  and  a  probe  pressed 
through  it  let  out  a  gush  of  fresh  blood,  which  was  at 
once  checked  with  iodoform  gauze.  All  the  wounds 
were  then  plugged  with  iodoform  gauze. 

The  patient  rallied  well.  Temperature  fell  to  99°  F. 
within  two  hours  ;  pulse  to  go.  The  mind  was  clear 
by  the  following  morning.  No  further  chills  or  bad 
symptoms  occurred.  Some  difficulty  in  deglutition 
s"howed  itself  next  day  owing  to  the  pain  about  the 
tonsillar  region,  but  with  stomach-tube  feeding  for 
two  days  she  was  soon  free  from  pain. 

Daily  irrigation  of  the  jugular  and  sinus  with  bi- 
chloride and  peroxide  of  hydrogen,  followed  by  iodo- 
form gauze  packing,  resulted  in  rapid  improvement. 
The  vein  walls  of  the  lateral  sinus  and  jugular  sloughed 
away,  owing  to  the  intensity  of  the  septic  process  in 
which  they  had  been  involved,  and  the  space  was  filled 
with  granulation. 

The  patient  sat  up  on  the  eighteenth  day,  and  was 
shown  at  this  Society  on  the  twenty-fifth  day  after 
operation. 

C.4SE  II. — Sinus  Pymviia  and  Jugtilar  Thrombosis  ; 
Ballance's  Operation  ;  Death.  —  Young  woman,  aged 
twenty.  Operation,  February  9,  1893,  in  the  New  York 
Eye  and  Ear  Infirmary.     Suppurative  otitis,  one  year.' 

Two  weeks  since  had  symptoms  of  mastoid  abscess. 
Trephined  two  days  ago  by  Dr.  John  L.  Adams,  very 
small  quantity  of  pus  from  eburnated  bone,  no  bene- 
fit. Subsequent  chill  ;  temperature,  io2j4°  F.  ;  head 
symptoms.  Studied  by  Drs.  Bull,  Gruening,  Starr, 
and  Vought. 

Diagnosis. — Cerebral  abscess  of  temporo-sphenoidal 
lobe  ;  advised  operation.  Symptoms  :  pupils  even  ;  re- 
tina, choked  disk  ;  mental  lethargy  ;  pulse  slow  ;  no  ex- 
ternal swelling  ;  headache  ;  no  tenderness  on  percus- 
sion. I  suspected  thrombosis,  but  accepted  diagnosis  of 
Dr.  Starr  and  Dr.  Vought,  who  had  been  watching  the 
case,  and  trephined  by  their  invitation.  Dr.  Gruen- 
ing also  thought  the  rapid  fluctuations  of  temperature 
and  early  choked  disk  indicated  sinus  thrombosis. 
Used  a  one  inch  trephine,  one  and  one-fourth  inch  back, 
and  one  and  a  half  inch  above  meatus  ;  enlarged  this 
backward  to  avoid  large  dural  veins  ;  opened  the  dura 
by  three-fourths  inch  crescent,  and  punctured  the  api)ar- 
rently  normal  brain  in  every  direction  without  discov- 
ering pus.  Sutured  the  dura  and  closed  wound. 
Then  turned  to  the  mastoid  and  exposed  the  lateral 
sinus  after  hard  chiselling.  The  sinus  presented  thick 
walls,  lightly  pulsating  and  dusky.  Hypodermic  needle 
drew  a  half  drachm  of  fetid  plum-colored  blood.  I 
then  at  once  cut  in  the  middle  of  the  neck  for  the  jug- 
ular, and  tied  it  at  the  entrance  of  the  facial,  which  I 
also  tied  ;  I  then  cut  open  the  jugular,  and  free  venous 
blood  came  slowly  from  the  cut  end,  showing  that  the 
petrosal  vein  had  not  yet  been  plugged.     The  vein  was 

'  Case  reported  in  detail  by  Dr.  Adams  in  the  Archives  of  Otology, 
vol.  ,xxii. ,  Xo.  2,  1893. 


therefore  again  tied.  The  lateral  sinus  was  split  open 
and  curetted  out.  It  was  filled  with  putrid  clot,  very 
foul  smelling.  The  upper  limit  of  the  clot  was  at  the 
back  of  the  trephine  opening,  where  a  probe  let  out 
clean  blood.  Iodoform  tamponade  of  the  lateral  sinus 
and  jugular  wounds  completed  the  operation,  which 
had  taken  about  two  hours. 

The  temperature  fell  from  103°  F.  to  normal  in  a  few 
hours,  and  for  four  days  fluctuated  between  normal 
and  100°.  On  the  fifth  day  she  had  great  pain  in  her 
head,  became  comatose,  rapidly  failed,  and  died,  with 
rapid  accession  of  temperature,  107°  F. 

Autopsy  showed  a  limited  purulent  meningitis  cov- 
ering the  right  half  of  the  cerebellum — near  the  end  of 
the  diseased  lateral  sinus,  where  an  opening  had  per- 
forated from  the  mastoid  cells  and  communicated  also 
with  the  lateral  sinus. 

Case  III.  Sinus  Pyamia  with  Jugular  Thrombosis 
— Ballance's   Operation — Septic   Pneumonia — Death  on 

the  Fifth  Day. — J.  C ,  aged  forty-three,  on  March 

23,  1S91,  was  taken  with  the  ordinary  symptoms  of 
grippe,  rested  a  few  days,  and  resumed  work,  but  was 
taken  on  returning  home  the  first  day  with  violent  ear- 
ache. Abscess  broke  through  the  drum  and  gave  re- 
lief, but  repeated  gathering  and  discharge  took  him 
to  an  aurist.  Dr.  Huntington  Richards  enlarged  the 
drum  opening  and  later  trephined  the  mastoid.  Tem- 
porary relief  followed.  After  a  week  or  two  of  dimin- 
ishing discharge,  a  violent  chill  occurred,  accompanied 
by  fever  and  followed  by  sweating.  These  were  re- 
peated daily  for  four  days,  when  he  was  referred  to  me 
for  further  surgical  procedure.  Other  bad  symptoms 
had  come  also,  malaise,  nausea,  vomiting,  loss  of  appe- 
tite. 

He  was  admitted  to  St.  Luke's  Hospital,  May  27, 
1891,  with  a  temperature  io2|°  F.  The  mastoid  wound 
was  discharging  a  little  pus.  Slight  swelling  and  great 
tenderness  existed  along  the  front  of  the  sterno-mastoid 
muscle  from  the  skull  half  way  to  the  sternum.  Slight 
oedema  also  existed  behind  the  jaw  and  somewhat  in 
the  temporal  fossa.  His  urine  showed  fifteen  per  cent, 
of  albumin  and  casts. 

Operation. — May  28th.  The  mastoid  process  was 
gnawed  away  and  the  lateral  sinus  uncovered.  Aspi- 
ration of  it  by  a  hypodermic  needle  drew  a  little  puru- 
lent fluid.  The  sinus  wall  was  hard  and  showed  throm- 
bosis. The  jugular  vein  was  then  opened  in  the 
middle  of  the  neck,  at  the  junction  of  the  facial  vein, 
where  both  were  found  to  be  sound.  These  were 
ligated,  and  the  jugular  cut  across  above  the  ligature. 
A  few  drops  of  blood  escaped.  The  end  of  the  vein 
was  then  stitched  to  the  wound.  -■V  probe  passed  up- 
ward pressed  against  a  slight  barrier,  which  yielded, 
and  two  drachms  of  pus  flowed  from  the  vein.  Irriga- 
tion from  the  lateral  sinus  now  ran  freely  through  the 
jugular,  which  had  failed  prior  to  the  probe  breaking 
up  the  thrombosed  clot.  Sublimate  irrigation  was  then 
practised  upward  and  downward,  and  the  neck  wound 
closed  below  the  jugular,  which  opened  on  the  neck. 
Iodoform  gauze  packing  in  the  sinus  completed  the 
operation. 

The  patient  had  no  further  chills  after  the  operation, 
but  he  did  not  do  as  well  as  I  had  hoped.  Continued 
evidence  of  his  profound  poisoning  showed  in  his  ir- 
regular fever,  in  the  sloughy  septic  look  of  the  wound, 
in  his  bad-pulmonary  condition,  and  continuance  of 
his  septic  pneumonia.  He  died  five  days  after,  with 
temperature  ranging  from  103°  to  105°  F. 

Case  IV.  Mastoid Pycemia — Jugular  Thrombosis  (?) 
— Mastoid  Trephined— Lateral  Sinus  P.xplored— Jugu- 
lar net  Tied— Death  from   Septic   Pneumonia. — F.  A. 

W ,    aged    thirty-seven,  formerly   a   healthy   man, 

came  under  my  care  with  grave  septic  condition  from 
suppurative  otitis.  Urine  showed  albumin  four  per 
cent,  and  casts.  I  at  once  trephined  the  mastoid  and 
removed  stinking  pus  and  foul  necrosed  bone  from  the 
attic  and  middle  ear,  with  caseous  matter.     The  lateral 


134 


MEDICAL    RECORD. 


[July  27,  1895 


sinus  was  fully  uncovered,  and  though  it  looked  suspi- 
ciously inflamed,  pure  blood,  free  from  pus  corpuscles, 
was  drawn  from  it  by  hypodermic  needle.  It  was 
therefore  not  laid  open,  nor  did  it  seem  justified  to 
ligate  the  jugular.     Wounds  irrigated  and  packed. 

In  the  evening  chest  pains  increased,  and  precordial 
friction  sounds,  with  right  apex  consolidation,  showed 
themseh-es.  Respiration,  40  ;  temperature,  103°  F.  Pa- 
tient had  occasional  chills. 

On  the  third  day  after  a  very  hard  chill  occurred, 
with  increased  evidence  of  pleuro-pneumonia,  and  a 
small  amount  of  fluid  was  aspirated  from  the  chest. 
The  lung  symptoms  increased  and  he  died  on  the  sev- 
enth day  after  operation. 

My  impression  has  always  been  that  if  I  had  ligated 
his  jugular  vein,  I  would  have  given  him  abetter  chance 
to  recover,  by  cutting  off  infection  from  what  I  now  be- 
lieve to  have  been  a  high  jugular  thrombosis  without 
consolidation  of  the  mastoid  portion  of  the  lateral  sinus. 

Dr.  Robixsox  thought  a  good  deal  of  emphasis 
should  be  placed  upon  the  fact,  as  illustrated  by  the 
cases  reported  by  Dr.  Abbe  and  others,  that  there 
might  be  suppuration  in  the  jugular  and  lateral  sinus 
when  the  symptoms  over  the  mastoid  indicated  noth- 
ing. Only  the  other  day  he  had  felt  the  anxiety  which 
physicians  were  constantly  experiencing  lest  in  cases  of 
middle-ear  disease  mastoid  complication  should  arise. 
In  this  particular  case  he  had  been  debating  whether 
to  call  an  otologist  or  a  general  surgeon,  for  it  was  not 
certain  but  what  either  mastoid  trouble  or  pus  in  the 
lateral  sinus  might  be  present,  but  fortunately  the  case 
cleared  up  without  any  form  of  operative  interference. 

Dr.  Ch.\rles  S.  Bull  thought  the  cases  were  not 
rare  in  which  sinus  thrombosis  occurred  from  suppura- 
tion of  the  middle  ear,  and  without  the  presence  of 
mastoid  symptoms.  He  recalled  two  cases  which  he 
had  seen  in  consultation  during  the  winter  of  1S93-94. 
They  were  cases  of  acute  suppurative  ear  trouble,  and 
in  one  all  the  symptoms  of  sinus  thrombosis  which  Dr. 
Abbe  had  described  were  present,  while  there  were  no 
external  signs  of  mastoid  trouble.  An  operation  was 
done,  the  mastoid  was  found  entirely  free  from  pus. 
There  was  sinus  thrombosis,  but  unfortunately  menin- 
gitis had  already  developed  prior  to  the  operation  and 
caused  the  patient's  death.  Nearly  similar  symptoms 
were  present  in  the  second  case.  There  were  no  exter- 
nal symptoms  of  mastoid  trouble.  He  advised  an  op- 
eration for  sinus  thrombosis,  but  the  parents  would  not 
permit  it  and  the  child  died.  Autopsy  proved  the  ex- 
istence of  thrombosis  of  the  lateral  sinus  and  jugular 
vein.  There  had  been,  he  repeated,  no  external  evi- 
dence of  mastoid  trouble  in  these  two  instances.  He 
believed  siich  cases  were  not  uncommon. 

Dr.  Robinson  inquired  whether  under  such  condi- 
tions it  was  desirable  to  make  an  incision  simply  down 
to  the  periosteum  over  the  mastoid  ?  Would  it  prove 
of  any  benefit  to  the  patient  ?  would  the  appearance  of 
the  periosteum  reveal  anything  of  the  condition  be- 
neath ?  or,  if  surgeons  would  recommend  any  interfer- 
ence whatever,  would  it  rather  be  a  complete  opera- 
tion ? 

Dr.  C.  S.  Bull  replied  that  in  his  opinion  one 
should  go  down  to  the  abscess,  and  if  none  were  found, 
open  the  lateral  sinus. 

Dr.  W.  H.  Draper  mentioned  a  case  of  suppurative 
otitis  media  in  a  child  seen  this  winter  in  which  there 
was  singular  absence  of  pain,  but  very  high  tempera- 
ture. The  drum  membrane  showed  some  congestion, 
but  not  much  tension,  and  Dr.  Buck  hesitated  to  open 
it,  but  did  open  it  and  there  was  a  very  slight  discharge. 
The  temperature  continued  high,  105°  F.,  which  Dr. 
Draper  regarded  as  an  important  symptom  in  these 
cases.  There  was  no  oedema  over  the  mastoid,  and 
scarcely  any  tenderness.  Dr.  Buck  operated  and  found 
in  the  antrum  a  noticeable  amount  of  pus.  The  child 
did  perfectly  well. 

He  had  seen  a  case  like  Dr.  Abbe's  at  the  New  York 


Hospital  the  past  winter.  There  was  no  marked  ten- 
derness over  the  mastoid,  but  extreme  tenderness  along 
the  course  of  the  jugular  vein,  and  some  swelling.  He 
had  the  woman  transferred  to  the  surgical  ward,  but 
the  surgeons  did  not  operate  and  the  patient  died  with 
brain  symptoms.  He  had  noticed  in  a  recent  number 
of  TJie  Lancet  two  cases  in  which  Milliken,  of  Man- 
chester, had  done  Ballance's  operation  successfully,  one 
case  being  acute  otitis,  the  other  chronic. 

Dr.  a.  H.  Smith  said  he  had  been  very  much  inter- 
ested in  the  last  case  reported  by  Dr.  Abbe,  as  it  was 
the  one  which  Dr.  McNutt  had  consulted  him  about 
and  they  had  sent  to  Dr.  Abbe  to  operate.  He  had 
been  impressed  with  the  history  as  it  had  been  related 
to  him  by  Dr.  McNutt — recurring  chills,  sweating,  ex- 
cessive pain,  symptoms  of  brain  implication — and  told 
her  that  it  was  probably  a  case  of  thrombosis  of  the 
jugular.  He  saw  the  patient  two  or  three  hours  later, 
and  noticed  at  once  the  swelling  along  the  line  of  the 
jugular  vein — longitudinal,  cylindrical,  excessively  ten- 
der. Being  told  that  it  had  not  been  present  that 
morning,  he  inferred  that  it  had  taken  place  during  the 
day,  and  suggested  that  Dr.  Abbe  be  requested  to  come 
at  once,  prepared  to  operate.  He  had  been  very  much 
gratified  at  the  result.  He  believed  that  had  the  oper- 
ation been  deferred  until  next  morning  it  would  have 
been  too  late  to  save  life,  as  the  thrombus  was  rapidly 
extending  downward,  and  would  soon  have  reached  a 
point  below  which  it  would  have  been  impossible  to 
secure  the  vein. 

Dr.  Smith  referred  to  the  danger,  in  moving  these 
patients,  of  causing  the  septic  material  in  the  vein  to 
break  down  and  enter  the  general  circulation,  and  said 
he  had  cautioned  the  nurses  not  to  move  this  patient 
until  Dr.  Abbe  arrived. 

Meddling  With  the  Ear. — Dr.  Sexton  wished  to 
give  a  warning  to  practitioners  not  to  treat  cases  of 
acute  catarrhal  trouble  of  the  ear  so  rudely  as  was 
often  done,  judging  by  his  personal  observation.  It 
was  very  difficult,  it  was  true,  to  desist  from  doing 
something  when  called  to  these  cases,  but  the  patient 
would  be  better  off  with  no  interference  whatever  than 
with  that  which  was  out  of  place.  The  doctor  was 
likely,  for  instance,  to  inflate  the  ear  with  the  politzer 
bag  and  drive  the  purulent  matter,  if  any  were  present, 
in  every  direction.  Violent  and  unnecessarj'  syringing 
would  convert  a  simple  case  into  a  grave  one.  To  use 
an  unclean  knife  to  evacuate  purulent  or  sero-purulent 
matter  might  set  up  a  much  more  virulent  condition. 

Dr.  Abbe,  in  closing  the  discussion,  said  :  A  point 
of  interest  in  the  case  of  the  nurse  is  the  fact,  as  it 
seems  to  me,  that  it  was  the  direct  result  of  grippe. 
One  other  case  seemed  also  to  have  been  the  result  of 
grippe  occurring  in  1S91.  How  many  more  of  the 
cases  seen  by  different  men  have  resulted  from  that,  I 
am  unable  to  say.  The  fact  that  Dr.  Nichols  and  Dr. 
Pomeroy  had  examined  this  patient  on  the  morning  of 
operation  for  mastoid  disease  and  found  no  swelling, 
either  over  the  mastoid  or  along  the  jugular  vein, 
opens  up  the  interesting  question,  how  rapidly  peri- 
vascular inflammation  and  extension  of  thrombus  may 
take  place.  For  in  this  case  the  thrombus  at  night 
was  found  to  have  extended  well  down  in  the  jugular. 
Aside  from  the  testimony  of  such  able  men  as  Drs. 
Nichols  and  Pomeroy,  I  would  have  inferred  in  dissect- 
ing the  parts  that  the  inflammation  had  been  present 
at  least  three  days.  The  case  shows  how  constantly 
symptoms  of  sinus  thrombosis  should  be  watched  for 
during  an  attack  of  supposed  mastoid  disease.  Chills 
are  most  important  as  pointing  to  sinus  thrombosis. 
In  a  case  of  simple  ear  trouble  you  may  have  a  tem- 
perature of  105°  F.,  without  meningitis  and  without 
sinus  thrombosis — simply  with  confinement  of  pus. 
You  do  not  take  a  succession  of  chills.  If  there  is  a 
succession  of  chills,  sweating,  high  temperature,  I  be- 
lieve the  evidence  of  pysemia  is  absolute,  and  that  the 
pyaemia  must  be  the  result  of  a  septic  process  in  which 


July  27,  1895] 


MEDICAL    RECORD. 


the  large  venous  channels  are  suddenly  and  repeatedly 
invaded. 

One  can  produce  a  temperature  of  105°  F.  wthin  two 
minutes  after  injecting  two  grains  of  mixed  toxins  of 
erysipelas.  So  I  think  a  succession  of  chills  in  these 
cases  means  only  one  thing,  namel)',  pyaemia  through 
the  venous  channels.  Take  this  in  connection  with 
tenderness  along  the  jugular  and  you  may  discard,  as 
necessary  to  }-our  diagnosis,  tenderness  over  the  mas- 
toid, as  this  is  sometimes  absent.  Chill  and  tenderness 
together,  I  believe,  call  for  operation,  else  it  means 
death. 

Regarding  Dr.  Smith's  remark  as  to  moving  these 
patients,  Ballance  warns  against  moving  them  until  the 
jugular  has  been  tied  below  so  that  none  of  the  throm- 
bus may  be  driven  into  the  general  circulation.  In  one 
of  Ballance's  most  brilliant  cases,  he  first  tied  the  jugu- 
lar, then  transferred  the  patient  and  operated.  It  has 
been  shown  that  the  poison  does  not  work  backward 
from  the  sinus,  but  infects  the  patient  by  passing  down 
the  jugular. 

Replying  to  an  interrogatory  by  Dr.  Peabody,  Dr. 
Abbe  said  the  operation  was  an  easy  one  when  you 
knew  how  to  do  it. 

Case  of  Small  Anem-ism  Obliterating  Left  Bronclius 
by  Pressure,  and  causing'  Consolidation  of  Left  Lung, 
with  Symptoms  and  Physical  Signs  of  Empyema. — Dr. 
Peaeouv  showed  specimens  from  a  man  whose  symp- 
toms and  physical  signs  were  those  of  empyema,  and 
whose  lesion  was  a  small  aneurism  obliterating  left 
bronchus  by  pressure,  and  causing  hemorrhage  into 
the  air-vesicles  and  interstitial  pneumonia  throughout 
the  lung.  The  aneurism,  which  was  about  the  size  of 
an  English  walnut,  was  on  the  descending  thoracic 
aorta  and  compressed  the  left  primary  bronchus  just 
below  its  origin.  It  has  ruptured  and  filled  the  bronchi 
below  with  blood,  but  no  blood  reached  bronchus 
above  or  trachea.  Sections  of  the  lung  under  the 
microscope  showed  the  air-vesicles  filled  with  blood, 
and  their  walls  greatly  thickened  throughout  and  filled 
with  young  cells.  The  lung  was  much  tougher  and 
firmer  than  in  ordinary  lobar  pneumonia,  but  in  other 
respects  resembled  that  condition  to  the  naked  eye. 

Dr.  Peabody  pointed  out  the  impossibility  of  making 
an  accurate  diagnosis  under  these  circumstances,  the 
close  resemblance  of  the  case  to  one  of  empyema,  both 
in  its  history  and  in  its  physical  signs,  and  also  the 
light  that  it  shed  upon  the  causation  of  bronchial 
breathing.  This  sign  was  absent,  in  spite  of  the  con- 
solidation of  the  lung,  and  its  absence  was  explained 
by  the  occlusion  of  the  bronchus,  which  prevented  the 
transmission  of  the  respirator)'  sounds  from  the  trachea. 

The  history  of  the  case  was  as  follows:  J.  B , 

aged  fifty;  Ireland;  widower;  harnessmaker,  was  ad- 
mitted to  the  New  York  Hospital,  March  15,  1S95. 
His  father  died  of  hasty  consumption.  Last  winter 
he  had  pneumonia.  He  is  of  temperate  habits.  Says 
that  since  his  pneumonia  last  winter,  he  has  not  been 
perfectly  well ;  denies  syphilis  ;  he  has  taken  cold 
easily,  and  for  a  long  time  has  had  a  dry,  hacking 
cough,  but  has  been  strong  enough  to  keep  about  his 
work.  Two  weeks  ago  he  contracted  cold,  and  since 
then  has  been  coughing  badly.  He  has  been  short  of 
breath,  and  has  had  pain  in  right  side  of  chest.  He 
has  been  sweating  much  at  night  for  the  past  three 
nights.  There  has  been  no  loss  of  flesh,  nor  have 
there  been,  any  gastric  or  intestinal  symptoms.  His 
appetite  is  good  ;  his  bowels  are  constipated.  His 
chief  complaint  is  the  cough. 

On  admission,  his  temperature  and  respiration  were 
normal  ;  his  pulse  92.  With  the  exception  of  numer- 
ous rales  at  both  apices,  crepitant,  sonorous,  and 
:bilant,  a  physical  examination  was  absolutely  negative 
1  result,  both  as  to  chest  and  abdomen.  His  tongue 
was  moist  and  slightly  coated  ;  his  general  condition 
was  good.  His  urine  contained  a  small  anjount  of 
albumin,  but  was  otherwise  negative.     His  cough  con- 


tinued very  distressing,  and  after  nine  days  he  com- 
plained of  pain  in  the  back,  chiefly  on  the  left  side  ; 
and  on  this  day  it  was  discovered  that  all  over  the  left 
chest  posteriorly  there  were  dulness  and  absence  of 
vocal  and  respiratory  sounds.  This  led  to  the  sus- 
picion of  fluid  ;  and  an  exploratory  puncture  withdrew 
a  minute  quantity  of  whitish,  thick  fluid,  which  was 
proved  by  microscopic  examination  to  be  made  up  of 
pus.  His  temperature  rose  gradually  to  102°  F.,  and 
from  this  date  until  his  death  was  usually  somewhat 
above  the  normal,  and  occasionally  as  high  as  103°  F. 
His  pain  over  the  left  chest  continued  ;  his  cough  was 
not  improved  by  treatment  ;  his  appetite  failed,  and 
he  gradually  sank  and  died  exhausted  on  April  4th,  at 
7.40  A.M.,  a  little  less  than  two  weeks  after  the  develop- 
ment of  the  first  thoracic  signs. 

Case  of  Thrombosis  of  Basilar  Artery  due  to  Arterio- 
sclerosis.— Dr.  Peabody  also  showed  a  case  of  throm- 
bosis of  the  basilar  artery  with  softening  of  pons  and 
arterio-sclerosis  with  peri-arteritis  in  a  woman  thirty 
)'ears  of  age. 

The  basilar  and  other  arteries  of  the  brain,  particu- 
larly the  small  arteries,  showed  the  lesions  clearly. 
There  was  quiescent  old  tubercular  infiltration  of  one 
apex,  but  no  other  lesion  of  chest  or  abdomen.  A  his- 
tory of  syphilis  could  not  be  obtained. 

Dr.  Peabody  had  seen  and  published  two  other  cases 
of  thrombosis  of  basilar  artery  due  to  arterio-sclerosis. 
The  patient  was  a  German  woman,  thirty  years  of  age, 
married,  the  mother  of  several  living  children,  the 
youngest  being  an  infant  six  months  old,  who  is  since 
dead. 

She  was  comatose  on  her  admission  to  the  hospital 
on  April  i,  1S95.  From  her  friends  it  was  learned  that 
she  had  always  been  a  healthy  woman  prior  to  her  pres- 
ent illness.  One  week  before  her  admission  she  had 
complained  of  numbness  and  tingling  in  the  right  arm 
with  distinct  impairment  of  its  power.  Two  hours  be- 
fore her  admission  to  the  hospital  coma  suddenl)'  de- 
veloped.    S)'philis  is  denied. 

Her  husband  stated  that  she  had  been  under  a  strain 
of  much  care  and  worry  about  her  child. 

Physical  examination  revealed  rigidity  and  partial 
loss  of  power  in  right  upper  and  lower  extremities,  loss 
of  power  and  sensation  in  right  side  of  face,  dilatation 
of  right  pupil.  Heart  sounds  were  feeble,  but  there 
were  no  murmurs.  Urine  was  normal.  After  four 
days  her  temperature  rose  to  101°  F.  It  remained  with- 
out much  change  for  several  days,  and  then  steadily 
rose  to  106°  F.  on  April  6th.  when  she  died. 

Dr.  Kinnicutt  presented  the  photographs  of  a  case 
of  general  lympho-sarcoma.  The  case  had  been  under 
his  observation  in  the  wards  of  the  Presbyterian  Hos- 
pital, and  an  autopsy  had  been  obtained.  The  first 
symptoms  had  appeared  two  years  before  the  patient's 
death,  and  the  glands  had  been  attacked  in  the  classi- 
cal order — first  the  cervical  on  one  side,  then  the  axil- 
lary and  inguinal  groups  on  the  same  side  successively  ; 
a  year  later  the  cervical  glands  of  the  opposite  side 
had  been  attacked,  followed  by  the  involvement  of  the 
axillary  and  inguinal. 

On  admission  to  the  hospital,  the  superficial  glands 
throughout  the  body  were  enlarged,  the  anterior  and 
posterior  cervical  groups  enormously  so,  and  there 
were  the  physical  signs  of  implication  of  the  glands  in 
the  anterior  mediastinum  and  of  the  bronchial  group. 
A  large  mass  could  also  be  palpated  in  the  umbilical 
region,  which,  it  was  believed,  represented  the  retro- 
peritoneal glands.  The  liver  and  spleen  were  also  en- 
larged, the  edge  of  the  latter  being  palpable  three 
inches  below  the  costal  arch. 

The  differential  diagnosis  between  a  lymphatic  leu- 
ccemia  and  a  general  lymphadenoma  was  determined 
in  favor  of  the  latter  by  a  study  of  the  blood,  which 
showed  the  absence  of  an  excess  of  lymphocytes  :  a 
moderate  leucocytosis  was  present. 

The  autopsy  by  Dr.  Thacher  confirmed  the  correct- 


ir.6 


MEDICAL   RECORD. 


[July  27,  i{ 


ness  of  the  physical  signs  noted  during  life.  Aside 
from  the  involvement  of  the  superficial  glands  through- 
out the  body,  a  large  mass  filled  the  anterior  medias- 
tinum, the  bronchial  glands  of  both  lungs  were  greatly 
enlarged,  and  the  retro-peritoneal  group  formed  a  large 
tumor  made  of  numerous  nodes  welded  together.  The 
spleen  was  greatly  enlarged,  weighing  forty- two  ounces, 
and  its  normal  tissue  was  replaced  almost  wholly  by 
lym])h  nodes,  several  measuring  three  and  a  half  inches 
in  diameter. 

In  the  lungs,  several  nodules  were  present  near  the 
periphery,  in  addition  to  the  masses  about  the  roots. 
Just  beneath  the  pericardium  in  the  heart  muscle  two 
small  nodules  also  were  found.  Sections  of  the  heart, 
liver,  and  kidney  tissues  showed  areas  of  invasion 
of  lymphoid  tissue.  Sections  of  the  various  nodules 
showed  a  very  similar  structure,  essentially  a  round- 
celled  sarcoma.  There  were,  however,  "  many  large 
cells,  irregularly  distributed,  round  or  angular,  some 
with  many  nuclei."  "  The  nodules  appeared  to  the 
naked  ej  e  to  be  sharply  outlined,  but  on  microscop- 
ical examination  were  found  to  have  no  capsule  or 
sharp  demarcation  from  the  surrounding  structures, 
and  tissues  of  invaded  organs  were  sometimes  found 
within  the  tumors." 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  June  6,  iSgj. 

Joseph  D.  Bry.ant,  M.D.,  President,  in  the  Ch.air. 

Medical  Terminology ;  its  Etymology  and  Errors.— Dr. 

P.  J.  McCouRT  read  the  paper  (see  p.  115). 

Dr.  Charles  A.  Leale  opened  the  discussion.  The 
subject  of  medical  terminology,  its  etymology,  and  er- 
rors, he  said,  oft'ered  to  the  mind  material  for  appar- 
ently unlimited  work.  Scientific  men  of  all  national- 
ities had  at  various  times  endeavored  to  solve  the 
problem.  At  the  International  Congress  the  learned 
men  of 'the  profession,  speaking  in  a  great  variety  of 
languages,  had  utterly  failed  to  convey  their  ideas  to 
one  another.  Nothing  caused  a  deeper  sense  of  indi- 
vidual humiliation  than  for  a  scientific  man  to  sit  and 
listen  to  the  observations  of  another  in  his  own  profes- 
sion without  being  able  in  any  way  to  comprehend  his 
meaning. 

There  was  a  great  difficulty  in  the  way  of  ever  at- 
taining a  universal  language,  namely,  the  great  variety 
of  nations,  of  climate,  soil,  and  surroundings.  Experi- 
ence had  shown  that  where  a  people  having  a  compar- 
atively pure  language  had  been  transplanted  to  a  place 
where  the  surroundings  were  entirely  different  and 
complete  isolation  prevented  communication,  the  lan- 
guage formerly  spoken  underwent  a  change,  which  in 
three  or  four  generations  became  in  large  measure  in- 
comprehensible to  the  people  of  the  mother  country. 
The  people  of  the  different  provinces  of  one  great 
country  often  failed  to  understand  one  another.  °  An 
e.xample  was  seen  in  China,  where  the  troojjs  from  dif- 
ferent provinces  could  not  understand  even  ordinary 
military  orders  when  brought  under  one  command. 
Dialects  prevailed  among  the  two  hundred  and  forty 
thousand  American  Indians  so  that  one  tribe  could  not 
understand  another.  The  language  of  signs,  gestures 
looks,  came  more  nearly  to  being  universal'  than  any 
other  among  uncultured  people. 

With  regard  to  the  best  international  language  for 
the  interchange  of  professional  thought,  he  still  be- 
lieved that  English  would  year  by  year  gain  the  as- 
cendency, simjjly  because  of  its  becoming  more  widely 
diffused  and  being  the  means  by  which  wealth  could 
be  more  readily  acquired.  International  jealousy,  un- 
der the  pressure  of  overwhelming  power,  faded  as  a 
mist  before  us.  Might  made  right  in  dealing  with  bar- 
barian peo])le. 

The  spelling  and  pronunciation  of  words  in  the  same 


language  varied  in  different  localities.  One  could  often 
tell  from  which  college  a  man  came  by  his  pronuncia- 
tion of  such  words  as  bronchitis,  cerebritis,  etc.  There 
were  still  other  difficulties  in  the  way  of  a  jjerfect  ter- 
minology, which  it  seemed  impossible  to  overcome  at 
present.  If  it  were  based  on  the  pathology  of  to-day, 
our  knowledge  to-morrow  might  make  it  absolutely  in- 
accurate. Moreover,  morbid  anatomy  might  manifest 
itself  in  different  ways  under  different  surroundings. 
He  could  not  agree  with  the  essayist  in  the  statement 
that  it  was  humiliating  that  the  cowboys  of  the  plains 
could  use  language  which  more  accurately  conveyed 
their  impressions  than  ours  did  for  us.  Descending  to 
the  lower  orders,  one  found  the  lion,  the  dog,  the  bird, 
giving  utterance  to  sounds  which  fully  conveyed  their 
intended  meaning.  It  was  even  supposed  that  in  in- 
animate nature  there  were  harmonies  which  defied  the 
understanding  of  man.  Chemical  terms  were  supposed 
to  be  much  more  accurate  than  those  in  use  in  other 
branches  of  medicine.  We  were  supposed  in  chemis- 
try to  be  dealing  with  exact  known  quantities,  yet  it 
was  only  a  few  months  since  a  new  element  had  been 
discovered  in  our  atmosphere.  Thus  it  would  be  seen 
that  there  was  no  end  to  knowledge,  and  that  being  the 
case,  the  necessity  would  always  exist  for  changing  our 
et\mology  or  terms  to  make  that  advancing  kno.vledge 
comprehensible. 

Dr.  Leale  thought  the  suggestions  made  by  Dr.  Mc- 
Court  were  well  worthy  the  consideration  of  the  Acad- 
emy. 

Dr.  Daniel  Lewis  spoke  next.  He  said  he  would 
fully  confess  at  the  outset  his  inability  to  properly  dis- 
cuss a  paper  of  this  character.  The  first  impression 
which  he  had  received  while  listening  to  it  was  the 
great  care,  labor,  and  energy  which  Dr.  McCourt  had 
expended  in  its  preparation.  The  importance  of  the 
question  he  could  not,  of  course,  question. 

It  seemed  to  Dr.  Lewis  that  it  would  be  impossible 
to  adopt  a  terminology  to-day  which  would  apply  next 
year  in  all  cases.  Some  palpable  defects  could  be  rem- 
edied, which  remedies  would  be  permanent,  but  in  the 
field  of  nervous  diseases,  of  skin  diseases — in  fact,  of 
all  the  departments  of  medicine— the  new  pathology 
which  developed  from  year  to  year,  the  diversity  of 
opinion  among  pathologists  themselves,  would  make  it 
almost  impossible,  it  would  seem,  to  adopt  any  method 
of  treating  this  subject  which  would  relieve  it  of  the 
many  absurdities  made  apparent  by  the  reader  of  the 
paper.  Yet  he  would  like  to  see  Dr.  McCourt  con- 
tinue his  studies  in  that  direction.  But,  after  all,  when 
one  went  right  back  to  the  principle  of  the  thing,  it 
would  be  recognized  that  if  language  e.xpressed  an  idea 
which  we  understood,  it  was  as  good  language  as  we 
needed.  If  he  knew  what  was  meant  by  the  term  can- 
cer, for  example  ;  if  he  got  a  clear  understanding  of 
the  idea  which  the  speaker  intended  to  convey,  that 
language  was  just  as  effective,  just  as  useful,  just  as  in- 
structive to  him  as  it  would  be  if  it  were  strictly,  in  its 
primary  etymology,  scientific  or  accurate.  If  we  should 
carry  out  the  line  of  investigation  started  by  Dr.  Mc- 
Court this  evening  and  apply  it  in  other  directions,  we 
would  find  our  language  in  all  departments  filled  with 
terms,  words,  expressions,  which  had  their  origin — we 
had  not  studied  to  find  where,  but  doubtless  in  some 
term  quite  as  irrelevant  as  cancer  or  other  medical 
words  whose  etymology  had  been  criticised  in  the 
pa])er. 

Objects  to  Naming  Diseases  after  Symptoms. — Dr. 
W.  H.  Tho.mson  appreciated  both  the  learning  and  the 
motives  of  the  author.  Yet  the  question  was  hardly 
one  which  we  could  discuss  verbally — the  question  of 
reconstructing  our  medical  terminology  so  that  we  could 
get  rid  of  the  faulty  ideas  and  delusions  of  former  gen- 
erations. Medical  terminology  resembled  very  much 
some  rocks  in  geology,  having  been  formed  drop  by 
drop  and  preserving  many  fossils.  But  was  it  neces- 
sary to  change  or  discard  tliese  terms  because  the  ideas 


July  27,  1895] 


MEDICAL   RECORD. 


which  they  were  once  intended  to  convey  had  become 
fossil  ?  We  had  not  discarded  the  term  calico  notwith- 
standing the  fact  that  calico  was  now  manufactured 
elsewhere  than  in  Calicut,  yet  everybody  knew  exactly 
what  the  word  meant.  Dr.  Thomson  did  not  see  any 
practical  gain  in  changing  medical  terminology  in  the 
sense  of  the  purist.  We  would  all  get  at  loggerheads  if 
we  attempted  it. 

Then  should  we  attempt  to  establish  a  terminology 
for  newer  names  based  on  pathology  ?  Here  we  were 
met  at  once  by  difficulties  already  alluded  to  by  Dr. 
Leale  and  Dr.  Lewis.  We  could  not  get  our  pathology 
to  stay  good  :  we  had  not  the  pathological  facts.  But 
were  we  entirely  helpless?  He  thought  we  could  have 
some  principles  to  go  by.  One,  in  his  opinion,  should 
be  to  eliminate  from  our  terminology  all  names  of  dis- 
eases based  on  symptoms.  They  were  always  mislead- 
ing. An  example  was  given  in  locomotor  ataxia,  for 
in  this  particular  instance  the  patient  had  all  the  evid- 
ences of  that  disease  except  ataxic  gait.  Then  there 
was  exophthalmic  goitre.  He  could  not  recall  the  num- 
ber of  cases  in  which  he  had  seen  this  disease  when 
there  was  neither  exophthalmus  nor  goitre. 

We  ought  to  adopt  the  term  infectious  for  all  diseases 
dependent  upon  the  entrance  of  a  micro-organism  into 
the  body.  But  he  had  known  the  most  dreadful 
cruelty  practised  upon  unfortunate  patients  with  pul- 
monary tuberculosis  from  the  spread  of  the  idea,  first 
coming  from  the  medical  authorities,  that  tuberculosis 
was  a  contagious  disease.  It  ought  to  be  settled  in  one 
paragraph  as  to  what  constituted  the  difference  between 
an  infectious  disease  which  was  communicable,  and  one 
which  was  non-communicable.  Another  fault  which 
might  be  corrected  was  that  of  having  a  number  of 
terms  for  one  disease. 

But  Dr.  Thomson  would  not  disturb  names  whose 
signification  was  perfectly  distinct  and  universally  re- 
ceived simply  because  of  their  mistaken  etymology  or 
derivation.  The  reason  was  that,  like  in  disturbing 
anything  which  had  become  settled  by  usage,  we  would 
probably  introduce  more  confusion  than  would  be  off- 
set by  the  advantages.  But  where  terms  unquestion- 
ably led  to  mistakes  in  our  understanding  of  disease 
they  should  be  carefully  revised,  and  he  saw  no  better 
way  than  for  the  Academy  to  accept  the  responsibility 
and  appoint  a  committee  which  might  act  with  similar 
committees  in  other  countries  as  well  as  in  our  own. 
There  was  one  in  England  which  was  doing  some  good 
work,  although  it  was  going  slowly,  as  was  characteristic 
of  English  conservatism. 

Then  there  should  also  be  some  court  of  adjudication 
for  new  terms,  so  that  they  might  be  given  some  defi- 
nite signification.  This  need  was  especially  felt  in  neu- 
rological work.  The  term  neuron,  which  was  only 
three  years  of  age,  being  under  discussion  before  the 
New  York  Neurological  Society,  was  found  already  to 
have  six  different  meanings,  or  five  other  than  the 
meaning  attributed  to  it  originally  by  Waldeyer. 

Dr.  Achilles  Rose  mentioned  as  one  instance  in 
which  he  thought  it  was  proper  to  name  a  disease  after 
the  prominent  symi)tom,  the  one  recently  christened 
"achylia  gastrica  "  by  Dr.  Einhorn,  for  in  this  disease 
there  was  deficiency  of  the  juices  of  the  stomach,  the 
cause  of  which  could  not  always  be  discovered.  Dr. 
Rose  also  thought  that  a  great  many  errors  could  be 
avoided  in  using  the  Greek  for  medical  terminology,  if 
one  would  acquire  a  knowledge  of  the  living  (Ireek. 
There  must  be  mistakes  where  one  went  alone  by  the 
dictionary.  For  instance,  a  great  many  disputes  had 
arisen  over  the  spelling  of  the  word  "  polyclinic."  Yet 
one  with  a  speaking  knowledge  of  Greek  could  not 
make  the  mistake  of  spelling  it  with  an  "i  "  instead  of 
"y." 

Dr.  McCourt  closed  the  discussion.  He  had  en- 
deavored to  be  critical,  not  hypercritical.  He  had  not 
attacked  any  term  which  he  thought  it  appropriate  to 
retain.     He.  thought  long  usage  was  no  excuse  for  per- 


petuating wrong  terms.  Many  of  the  terms  now  in  use 
could  not  be  employed  in  court  without  explaining 
them  or  doing  violence  to  our  conscience.  Regarding 
pronunciation,  this  was  a  delicate  and  difficult  feature 
to  deal  with,  especially  in  connection  with  Latin.  The 
Italians  came  nearest  to  giving  the  correct  pronuncia- 
tion of  this  language.  With  Greek  it  was  easier,  as  it 
was  a  living  language.  But  our  college  professors  pre- 
sumed to  give  the  Greeks  themselves  points  in  the  pro- 
nunciation of  their  own  language.  They  ought  to  be 
better  informed  or  more  considerate. 

Dr.  McCourt  said  he  was  very  glad  Dr.  Thomson 
had  pointed  out  the  advantage  of  referring  new  terms 
to  a  committee  which  should  pass  upon  their  propriety 
and  exact  meaning  before  they  came  to  be  generally 
adopted,  thus  avoiding  new  errors. 

The  President  stated  that  the  Academy  and  its  sec- 
tions now  adjourned  until  October  ;  that  the  library 
would  open  only  during  the  day  from  June  isth  to 
August,  and  that  during  August  it  would  be  closed  for 
refurbishing. 


p;ciu  Itistrttmeuts. 


A  SELF- RETAINING    NASAL   SPECULU.AI. 
By  W.    W.    dees,    M.D., 

NEW   YOSK. 

The  accompanying  illustration  represents  a  self-re- 
taining nasal  speculum  which,  in  some  cases,  I  have 
found  a,lmost  indispensable.  The  speculum  proper  is 
of  the  ordinary  spring  variety,  controlled  by  a  set- 
screw.     At  the  back  of  the  spring  is  brazed  or  welded 


a  slotted  nib,  hinged  to  a  bar  which  in  turn  runs  to  a 
ball-and-socket  joint,  fastened  to  the  head-piece  of  an 
ordinary  forehead  mirror.  The  hinge-joint  permits 
the  speculum  to  be  used  on  either  side.  The  bar  can 
be  regulated  to  any  length.  The  ball-and-socket 
joint  allows  any  necessary  lateral  motion.  It  is  fast- 
ened to  the  patient's  head  by  a  band,  and  is  easily 
adjusted  to  any  case.  The  instrument  was  made  by 
Messrs.  Lincoln  &:  Luchesi,  New  York. 

352  West  Twenty-second  Street. 


Getting  Eeady  for  Cholera. — When  cholera  prevailed 
in  France  two  summers  ago,  the  health  authorities  sent 
word  to  the  mayor  of  a  village  in  the  threatened 
district  to  prepare  for  the  disease.  After  a  while  he 
reported  that  he  was  ready,  and  upon  inquiry  being 
made  as  to  what  precautions  had  been  taken,  it  was 
learned  that  a  sufficient  number  of  graves  had  been 
dug  in  the  cemetery  to  bury  every  man,  woman,  and 
child  in  the  village. 

The  BuUetin  General  de  Therapeutique,  which  vas 
for  twenty-three  years  edited  by  the  late  Dr.  Dujardin- 
Beaumetz,  is  now  under  the  editorial  management  of 
Dr.  G.  Bardet.  The  journal  was  founded  by  Dr. 
Miquel  in  1831. 


MEDICAL    RECORD. 


[July  27,   1895 


A    XEW 


SELF-RETAINING 
TRACTOR. 


PERINEAL     RE- 


By  D.    tod   GILLIAM,    M.D., 


COLUMBUS,   0. 


This  retractor  is  for  the  dorsal  position.  It  consists 
of  two  parts  :  the  retractor  proper,  and  the  holder. 
The  retractor  has  a  short  blade  and  a  short  handle. 
The  handle  is  notched  on  its  outer  aspect,  and  has  a 
ring  at  the  extremity.     The   holder  has  a  large   ring 


A  UTERINE  VOLSELLUM  FOR  USE  IN  VAG- 
INAL HYSTERECTOMY. 

By  homer  I.   OSTRO.VI,    M.D., 

NEW    VOKK. 

During  the  past  six  months,  I  have  performed  forty-three 
vaginal  hysterectomies.  Some  of  these  were  done  for 
the  removal  of  the  diseased  uterus,  others  for  uterine 
fibroids,  still  others  for  suppurating  tubes  and  ovaries.  ■ 


at  its  upper  extremity  to  embrace  the  hump  at  the 
lower  end  of  the  sacrum.  Below  this  is  a  saddle 
which  conforms  to  the  curve  of  the  coccyx.  At  the 
lo'.ver  end  of  the  holder  is  a  device  for  coupling  to  the 
retractor.  It  consists  of  a  rectangular  slot  which  opens 
on  the  left  side.  Near  the  upper  end  of  this  slot,  and 
running  transversely  across  the  same,  is  a  steel  pin 
which  fits  into  the  notches  on  the  handle.  A  thumb- 
screw at  the  extremity  of  the  holder,  which  regulates 
the  inclination  of  the  blade,  completes  the  mechanism. 
The  accompanying  cut  will  give  a  better  idea  of  the  in- 
strument than  is  possible  by  a  verbal  description.  It 
must  be  understood  at  the  outset  that  it  is  not  a 
speculum,  as  it  will  not,  as  a  rule,  expose  the  cervix 
unless  the  anterior  vaginal  wall  be  lifted  up,  or  the 
cervix  pulled  down.  A  retractor  should  have  a  short 
blade,  that  the  parts  may  be  drawn  down  within  easy 
reach.  It  should  not  have  broad  flanges  at  the  vulvar 
extremity,  as  this  interferes  with  the  free  use  of  fingers 
and  instruments.  The  experienced  operator  will  at 
once  see  the  advantages  of  this  arrangement,  while  the 
beginner  is  apt  to  be  disappointed  because  he  cannot 
at  once  see  the  cervix,  or  because  the  vulva,  in  a 
measure,  closes  in  and  obscures  the  view.  In  propor- 
tion as  a  retractor  is  made  with  long  blades  or  broad 
flanges,  it  is  spoiled  for  operative  purposes. 

Directions  :  Have  patient  on  her  back  with  buttocks 
projecting  a  little  beyond  the  end  of  the  table,  push 
the  holder  up  under  the  sacrum  until  the  saddle  is 
arrested  by  the  coccyx  ;  the  weight  of  the  body  anchors 
it  firmly.  Introduce  the  retractor  as  you  would  any 
other,  noting  the  position  of  the  cervix.  With  one 
or  two  fingers  of  the  left  hand  on  the  blade  of  the 
retractor,  and  the  thumb  under  the  end  of  the  holder, 
approximate  them  by  pressure.  The  index-finger  of 
the  right  hand  in  the  handle  ring  now  guides  it  into  the 
slot  and  applies  the  teeth  to  the  pin.  By  increased 
pressure  of  thumb  and  finger,  the  desired  degree  of 
retraction  is  obtained  and  held  by  the  notch  and  pin. 
The  inclination  of  the  blade  is  changed  at  will  by  the 
thumb-screw.  The  cervix  or  other  parts  are  now 
caught  by  a  bullet  forceps  and  drawn  down  toward  or 
outside  the  vulva.  The  instrument  is  simple,  efficient, 
and  inexpensive,  and  takes  up  but  little  more  room 
than  the  ordinary  bivalve  speculum. 


A  Natural  Feet  Society.— Some  English  ladies,  re- 
sidents in  China,  have  started  a  society  to  put  a  stop 
to  the  practice  of  binding  the  feet  of  young  girls. 
Chinamen,  who  resent  the  impertinence,  ask  the  mem- 
bers of  the  new  society  to  join  them  in  the  formation  of 
a  NaturaF  Waist  Society,  to  put  an  end  to  tight-lacing. 


The  operation  has  been  greatly  facilitated  by  the  use 
of  a  volsellum  which  Messrs.  Stohlmann,  Pfarre  & 
Co.  have  made  at  my  suggestion.  The  cross-bar  of 
the  instrument  permits  any  necessary  degree  of  trac- 
tion, and  the  broad  flat  handles,  which  rest  in  the 
palm  of  the  operator's  hand,  make  complete  rotation 
of  the  uterus  possible  during  its  separation  from  the 
vagina,  broad  ligaments,  and  peritoneum.  A  further 
advantage  is  found  in  the  shape  of  the  teeth,  which 
when  fixed,  close  the  os  uteri,  thus  shutting  off  a  fre- 
quent source  of  infection. 

42  West  Forty-eighth  Street. 


A    TRACHEAL    TUBE  -  GUIDE,     OR     EMER- 
GENCY  TRACHEAL   WOUND   DILATOR. 

By  FR.\XK  LEMOYNE  HUPP,  A.M.,  M.D., 

ATTENDI.VG  SU(«GEO.>I  TO  THE  CITY   HOSPITAL,   WHEELING,   W.   VA. 

Anything  which  might  lead  to  a  complication  of  the 
simple  methods  of  opening  the  trachea,  or  any  multi- 
plication of  the  already  too  numerous  instruments  for 
this  emergency  procedure,  is  to  be  condemned.  Yet 
Dr.  Lewis  S.  Pilcher  *  more  than  thirteen  years  ago  ob- 
served that  the  surgery  of  the  trachea,  in  many  in- 
stances, would  be  made  more  certain,  more  facile,  and 
more  productive  of  good  results,  if  the  special  condi- 
tions which  it  presents  were  more  carefully  studied 
and  met. 

One  of  the  most  distressing  experiences  we,  as  physi- 
cians, are  called  upon  to  meet,  and  an  experience  which 
comes  with  almost  startling  frequency,  is  that  of  a  child 
afflicted  with  laryngeal  diphtheria. 

During  the  past  year  I  have  had  occasion  to  open 
the  trachea  six  times  for  the  relief  of  the  stenosis  com- 
ing with  this  dreaded  disease,  and  in  nearly  every  in- 
stance I  have  recognized  the  need  of  an  instrument 
which  could  be  so  quickly  and  efficiently  introduced 
into  the  windpipe,  that  relief  would  be  immediate  and 
that  the  cannula  could  be  safely  and  accurately  placed. 

If  the  first  sign  of  danger  has  been  appreciated  and 
an  early  interference  has  been  brought  to  bear  in  the 
case,  all  will  go  well  and  relief  will  be  certain.  But, 
on  the  other  hand,  if  the  tracheotomy  has  been  de- 
layed or  the  medical  attendant  has  not  seen  the  case 
until  it  is  in  articulo  mortis,  then  whatever  is  done 
must  be  done  expeditiously,  or  life  will  be  extinct. 

It  is  particularly  for  this  latter  class  of  cases  that  I 
wish  to  call  the  attention  of  the  medical  profession  to 
an  instrument  which  may  be  used  where  the  little 
sufferer  is  in  immediate  danger  of  suffocation,  and 
where  the  introduction  of  a  cannula  is  of  supreme  im- 
portance. 

The  tube-guide  is  fashioned  like  a  miniature  Sims 
speculum,  as  may  be  seen  by  the  engraving,  terminat- 

'  Care  of  the  Trachea  after  its  Incision  for  ihe  Relief  of  Croup, 
Mbdical  Rrcord.  p.  342,  1882. 


July  27,  1895] 


MEDICAL   RECORD. 


139 


ing  in  a  probe  point,  grooved  on  its  convex  side  like 

the  speculum,  but  having  the   two  sides   converging 

toward  the  probe  point,     ^^'hen  the  tracheal  rings  have 

been  quickly  di\"ided  and  difficulty  is  encountered  in 

lacing  the  cannula,  the  probe-pointed  guide  may  be 

uickly  and  accurately  carried  down  along  the  finger 

nd  gently  forced  through  the  severed  rings,  and  trac- 

ion  made  in  a  direction  toward  the  sternum. 

If  there  be  no  cannula  at  hand,  and  no  other  cutting 
instrument  but  a  penknife,  with  the  aid  of  this  instru- 
ment a  child  can  be  kept  alive  almost  indefinitely  until 
the  tube  arrives,  there  being  no  interference  to  the  in- 
gress of  air. 

The    tube-guide    will   also   facilitate   the   cleansing 

process  and  the  removal  of  membrane,  and  care  in  this 

direction,   so  urgently  insisted   upon  by  Dr.  Pilcher,"' 

as  certainly  had  much  to  do  with  diminishing  the  per- 

entage  mortality  after  opening  the  trachea. 

The  instrument  is  made  by  George  Tiemann  &  Co., 
nd  is  so  constructed,  and  of  such  a  size  that  it  may 
ue  carried  in   the  vest-pocket.     I  have  had  a  three- 
pronged  retractor  placed  at  the  other  end  of  the  guide 
for  convenience  instead  of  a  simple  handle. 


Let  me  briefly  relate  two  failures  which  might  have 
een  averted  had  an  instrument  of  this  kind  been  at 
md  : 

Case  I. — W.  M ,  aged  two,  larj-ngeal  diphtheria 

:t  thirt\'-six  hour's  standing — stenosis  almost  absolute. 
With  the  assistance  of  Dr.  R.  M.  Baird  a  tracheotomy 
was  performed  ;  just  as  the  rings  were  divided  the  child 
:-iit  breathing.  Retractors  and  tenacula  were  used  to 
-old  open  the  severed  rings,  yet  when  the  cannula  was 
placed,  ever}-  effort  was  made  to  resuscitate  the  patient, 
but  all  to  no  avail. 

C.\SE  11. — K.  R .  aged  four,  diphtheriric  croup, 

suffocaring  dyspnoea.  Younger  child  in  same  room 
with  tube  in  neck.  Assisted  by  Dr.  James  Schwinn, 
the  trachea  was  speedily  opened — an  instrumental  ef- 
tort  was  made  to  separate  the  rings  and  to  introduce 
the  cannula  ;  but  the  edges  of  the  wound  in  the  trachea 
were  so  inverted  and  the  child  so  tar  gone,  that  life 
was  extinct  before  the  cannula  was  placed. 

61    PjURrEEVTH   StREEtT 


The  Hygiene  of  the  Futnre.— The  great  problems  in 
medicine  to-day  are  hygienic,  not  therapeuric,  though 
therapeutics  seems  to  be  getting  the  better  of  diph- 
theria. The  most  desirable  thing  in  the  affairs  of  man 
i=.  first,  the  making  of  people  healthy,  and,  second,  the 
making  of  them  happy.  The  dyspeptic  Puritanism 
which  whines  over  the  necessity  of  suffering  as  a  means 
of  grace  can  have  no  place  in  a  superstition-free  and 
scientifically  enlightened  philosophy.  AVTiat  we  want, 
and  what  hygiene  is  yet  to  give  us,  are  comfortable 
homes  for  all  mankind,  aseptic  alike  of  the  germs  of 
zj-motic  disease  and  of  the  taints  of  the  common  vices, 
where  noble  and  healthful  men,  noble  because  they 
are  strong  and  healthful,  and  sweet  and  beautiful  and 
healthful  women,  beautiful  and  sweet  because  they  are 
healthful,  shall  rear  their  little  families  of  disease- 
unblighted  children,  happy  because  healthful,  and 
giving  promise  of  future  attainment  in  the  good,  the 
beautiful,  and  the  true — promises  which  shall  not 
'  e  broken  because  hygienic  medicine  has  made  the 
keeping  of  such  promises  possible. — Professor  H.  A. 
CoTTELL,  University  of  Louisville. 


CorrespotxcTcwce. 

OUR   LONDON    LETTER. 

(From  our  Special  Corresponden:.) 

DEATH  OF  PROFESSOR  HUXLEY — THE  PRINCE  AND 
PRINCESS  OF  WALES  AT  HOSPITALS — KNIGHTHOODS 
FOR   THE   PROFESSION. 

LoKBON,  July  5,  1895. 

Huxley  is  dead.  Many  of  your  readers  may  have 
expected  this  from  what  I  have  written  as  to  his  illness. 
As  he  prefixed  an  autobiographical  sketch  to  the  recent 
edition  of  his  works,  many  of  the  interesting  events 
of  his  life  will  also  be  known  to,  and  recalled  by,  your 
readers  at  this  juncture.  Though  he  actually  practised 
the  profession  for  a  short  time,  it  is  as  a  scientific 
worker,  and  especially  as  a  biologist,  that  he  achieved 
the  great  position  he  held  so  long,  and  which  makes  his 
death  seem  to  leave  so  great  a  blank  in  the  scienrific 
world.  His  influence  with  the  public  was  largely  due 
to  his  great  ability  as  an  expositor  of  science.  His  lit- 
erary taste  and  skill  induced  many  to  approach  prob- 
lems they  would  have  shirked  under  the  guidance  of 
many  able  men.  His  oratorical  gifts,  too,  were  of  a 
high  order  and  very  attractive  to  cultured  minds.  He 
has  himself  stated  that  his  writings  cost  him  hard  work, 
that  he  thought  nothing  of  writing  a  sentence  three  or 
four  times  before  commitring  it  to  the  press,  and  so  he 
cannot  be  said  to  have  been  a  bom  writer  or  speaker, 
but  like  so  many  more  conquered  success  by  industrj-. 
Yet  his  finished  and  charming  st)-le,  as  well  as  his  labor 
in  producing  it,  must  be  considered  as  proving  that  he 
was  endowed  with  excellent  literary  taste  and  critical 
acumen.  He  would  doubtless  have  succeeded  in  any 
walk  of  life  demanding  intellect  and  industr}",  as  those 
who  know  how  manfully  he  worked  his  way  to  his 
great  position  along  the  rugged  road  of  science  will  be 
the  first  to  acknowledge.  The  profession  was  proud  of 
him  as  one  of  its  members,  and  he  wielded  great  influ- 
ence in  maintaining  and  promoting  scientific  culture 
in  our  ranks — the  more  so,  perhaps,  that  the  biolog- 
ical sciences  claimed  so  large  a  share  of  his  atten- 
tion. 

In  1883  he  became  President  of  the  Royal  Society. 
In  1S92  he  was  made  a  privy  councillor,  a  distinction 
conve}nng  the  title  Right  Honorable,  which  is,  I  think, 
unique  as  a  recognition  of  scientific  services,  being 
chiefly  earned  in  political  strife.  University  degrees 
and  Academy  fellowships  had,  of  course,  been  pre\Ti- 
ously  showered  upon  him  from  all  quarters. 

Theological  problems  seem  to  have  had  a  strange 
attraction  for  him  and  led  him  into  warm  controversy. 
In  this  he  displayed  his  courage  whoever  might  be  his 
opponent,  and  did  not  hesitate,  as  will  be  remembered, 
to  close  with  so  redoubtable  a  master  of  logomachy  as 
Mr.  Gladstone  himself.  Possessed  of  tenacity  of  pur- 
pose amounting  almost  to  obstinacy,  he  had  to  be 
driven  from  any  position  he  had  taken  up  before  he 
would  relinquish  it,  thus  illustrating  the  quality  on 
which  the  English  have  been  rallied,  of  not  knowing 
when  they  are  beaten.  He  originated  the  term  "  ag- 
nostic," thinking  it  the  antithesis  of  the  Gnostics  of  the 
Church,  who  professed  to  know  so  much.  Attempting 
to  apply  scientific  methods  to  the  Bible  in  all  its  parts 
was  sure  to  be  unpopular,  and  some  of  the  controversy 
he  thus  kindled  was  perhaps  as  useless  as  it  was  bitter. 
Moral  or  religious  problems  cannot  be  solved  by  me- 
chanics or  mathematics.  In  the  new  number  of  the 
Westminster  Review,  which,  by  a  coincidence,  appeared 
as  the  professor  lay  dead  in  his  house  at  Eastbourne, 
there  is  an  article  by  a  writer  who  proclaims  himself 
an  agnostic  and  devoted  disciple,  which  nevertheless 
consists  of  a  statement  of  difficulties  in  understanding 
the  views  of  the  great  agnostic.  This  seems  at  least  to 
show  that  Hu.xley's  clear  style   and  direct  argument 


I40 


MEDICAL    RECORD. 


[July   27,    1895 


failed  sometimes  to  make  his  philosophical  opinions 
comprehensible  to  some  of  his  ardent  admirers. 

Huxley's  friends  were  a  multitude,  and  they  are  vy- 
ing with  each  other  in  extolling  his  constancy,  simplici- 
ty, modesty,  love  of  truth,  and  other  virtues  ;  while  the 
medical  friends  who  attended  him  through  his  last  ill- 
ness were  charmed  with  his  patience,  cheerfulness,  and 
consideration  for  them.  He  died  on  Saturday,  and 
yesterday  his  remains  were  committed  to  the  grave 
at  the  Finchley  Cemetery,  where  two  of  his  children 
are  buried.  At  Charing  Cross  Hospital,  where  he  was 
a  student,  there  is  already  a  movement  to  raise  a  me- 
morial to  him  in  a  form  to  benefit  the  school. 

The  Prince  of  AVales  and  the  Crown  Prince  of  Den- 
mark went  to  St.  Bartholomew's  Hospital  on  the  occa- 
sion of  the  consecration  of  a  new  Masonic  lodge, 
named  after  Rahere,  the  founder  of  the  hospital.  The 
Prince  of  Wales  is  Grand  Master  of  the  English  Masons, 
and  the  Prince  of  Denmark  of  the  Danish  Masons. 
The  Rahere  lodge  will  be  another  strong  link  between 
doctors  and  Freemasons. 

The  Prince  of  Wales  displays  a  good  deal  of  interest 
in  medical  institutions.  Quite  lately  H.  R.  H.  helped 
the  bazaar  for  St.  Mary's  Hospital,  and  next  Monday 
he  is  to  lay  the  foundation-stone  of  the  new  build- 
ings of  the  Royal  Medical  Benevolent  College,  and  is 
to  open  the  new  buildings  of  the  Royal  Free  Hospital 
on  the  22d — on  this  occasion  being  accompanied  by  the 
Princess.  He  has  accepted  the  office  of  Chancellor  of 
the  University  of  Wales. 

Three  knighthoods  have  fallen  to  the  profession. 
Edinburgh  has  one  in  the  person  of  her  distinguished 
Medical  Officer  of  Health  and  Professor  of  Medical 
jurisprudence — Dr.  (henceforth  Sir  H.  D.)  Littlejohn. 
Dublin  has  two  :  very  proper,  no  doubt,  from  a  fallen 
Home  Rule  government,  but  both  are  worthy  recipi- 
ents, viz.,  Mr.  Thornley  Stoker  and  Dr.  Christopher 
Nixon. 

OUR   PARIS    LETTER. 

MEETINGS  OF  THE  ACADEMY  OF  MEDICINE — HOSPITALS 
MEDICAL  SOCIETY — SURGICAL  SOCIETY — BIOLOGICAL 
SOCIETY. 

Paris,  July  6.  1895. 

The  last  meetings  of  the  four  leading  medical  societies 
of  FFance  are  fraught  with  interest  to  the  general  prac- 
titioner as  well  as  the  specialist.  At  the  ".Academy  of 
Medicine  a  discussion  on  the  prophylaxis  of  diph- 
theria was  introduced  by  Professor  Dieulafoy,  who 
demonstrated  that  a  clinical  examination  alone  was  in- 
sufficient to  make  a  positive  diagnosis  between  herpet- 
ic and  diphtheritic  angina  ;  such  an  examination  was 
likewise  incapable  of  giving  us  information  regarding 
the  duration  of  bacillary  virulence.  One  means  only 
permits  us  to  separate  surely  and  unerringly  diphthe- 
ritic angina  from  others.  One  means  only  permits  us 
to  know  whether  the  bacilli  persist  in  a  state  of  viru- 
lence in  the  mouths  of  patients.  That  means  is  the 
bacteriological  examination. 

M.  Cadet  de  Gassicourt  requested  the  Academy  to 
formulate  a  petition  to  establish  in  Paris  laboratories 
directed  by  trained  specialists,  and  to  which  physicians 
could  send  for  examination  fragments  of  false  mem- 
branes and  mucosities  taken  from  individuals  sus- 
pected of  having  diphtheria  or  convalescing  from  that 
disease. 

M.  Rochard  pointed  out  the  danger  to  the  public 
health  caused  by  alcohols  called  superior,  and  by  the 
essences  with  which  liqueurs,  as  dispensed  in  cafes, 
are  made.  The  consumption  of  alcohol  has  doubled 
in  France  during  the  last  few  years.  At  the  same  time 
the  average  of  crime  lias  increased  with  alarming 
rapidity.  It  was  proposed,  in  order  to  counteract  this, 
to  limit  the  number  of  shops,  to  demand  a  good  moraj 
character  of  wine  -  sellers,  to  increase  the  duties  on 
alcohol,  and  to  prosecute  vigorously  frauds  of  all  kinds. 


The  question  of  the  influence  of  alcohol  in  the  pro- 
duction of  phthisis  was  next  discussed,  and  it  is  note- 
worthy that  at  Rouen  and  Havre,  where  the  quantity- 
of  alcohol  consumed  per  capita  annually  is  14  litres, 
there  are  402  and  522  deaths  from  phthisis  in  100,000 
inhabitants ;  while  at  Toulouse,  where  the  quantity 
used  is  2  litres  a  head,  there  are  only  290  deaths. 

M.  Bordaz  read  a  paper  on  the  use  of  permanganate 
of  lime  as  an  excellent  non-caustic  antiseptic.  It  is, 
however,  doubtful  if  it  is  better  than  the  permanganate 
of  potash,  which  possesses  also  microbicide  properties. 

At  the  Societe  Medicale  des  Hopitaux  M.  Gallard 
reported  a  case  of  acute  thyroiditis,  terminating  in 
resolution.  The  patient  was  a  woman  of  forty,  ner- 
vous, thin,  and  physiologically  miserable,  having  tume- 
faction of  the  thyroid  body  consecutive  to  the  grippe. 
There  was  great  pain  in  the  right  cervical  region  and 
difficulty  of  swallowing,  accompanied  by  fever  and  an 
enlargement  of  the  base  of  the  neck.  On  a  level  with 
the  right  lobe  of  the  thyroid  body,  there  was  a  tumor 
about  the  size  of  a  hen's  egg,  redness,  and  pain  ;  on  the 
left  side  the  tumefaction  was  less  accentuated.  Bella- 
donna ointment  was  applied  to  the  swelling,  with  anti- 
pyrine  and  purgatives  internally,  beginning  on  March 
23d.  On  the  26th,  amelioration,  less  pain,  less  diffi- 
culty in  swallowing  ;  pulse,  96,  temperature,  38.5°  C. 
On  the  27th,  pulse,  100,  temperature,  37.5°  C.  ;  the 
right  lobe  of  the  thyroid  body  is  reduced  to  the  size  of 
a  horse  chestnut.  On  the  29th,  restitutio  ad  integrum, 
no  fever,  no  trace  of  thyroid  swelling.  There  were, 
however,  several  attacks  of  palpitation  and  tachycardia 
subsequently,  the  heart  beating  from  128  to  140  per 
minute. 

M.  Legendre  reported  the  case  of  a  child  suffering 
from  generalized  eczema  complicated  with  obstinate 
gastro-intestinal  trouble.  The  patient  was  five  yejrs 
of  age  ;  the  eczema,  which  at  first  seemed  to  j-ield  to 
good  hygienic  measures,  began  after  a  i&^  weeks  to 
spread  rapidly,  and  soon  extended  over  the  entire  in- 
tegument ;  the  child  lost  flesh  and  diarrhoea  set  in.  All 
the  antidiarrhcea  treatments  were  tried  without  suc- 
cess, including  hypodermic  injections  of  physiological 
serum.  The  child  continued  to  waste  steadily.  The 
first  nurse,  an  alcoholic  with  acne,  had  been  discharged  ; 
the  second  got  off  with  an  abscess  of  the  mammary 
gland  ;  the  third  with  an  erythema  of  the  breast.  Vir- 
ulent stomatitis  now  made  its  appearance,  the  tempera- 
ture rose  suddenly  to  40°  and  even  41°  C,  and  the  child 
died  without  cardiac  or  pulmonary  complications  of 
what  M.  Legendre  calls  bucco-intestinal  septicjemia. 

At  the  last  meeting  of  the  Surgical  Society  M.  Ric^he- 
lot  continued  the  discussion  of  a  new  method  of  vagino- 
abdominal hysterectomy. 

At  the  last  meeting  of  the  Biological  Society,  Pro- 
fessor Hanot  reported  a  case  of  acute  miliary  tubercu- 
losis in  a  man  sixty-one  years  of  age.  The  tubercle, 
unique,  rounded,  firm  in  consistency,  about  the  size  of 
the  head  of  an  ordinary  pin,  and  projecting  slightly 
into  the  lumen  of  the  vessel,  was  situated  in  the  supe- 
rior portion  of  the  pectoral  aorta.  The  cuts  showed  an 
absence  of  blood-vessels,  the  presence  here  and  there 
of  the  bacillus  of  Koch,  and  a  few  giant  cells,  the  cen- 
tre being  in  a  state  of  caperification  :  all  of  which  attest 
rapid  formation  ;  the  rest  of  the  aorta  was  free  from 
lesion,  as  regards  the  internal  and  middle  tunicas  ;  on 
the  external  tunic  was  a  small  inflammatory  nodule  of 
no  particular  pathological  importance.  It  is  well 
known  that  the  tubercular  bacillus  enters  the  circula- 
tion in  two  ways,  generally  :  by  the  lymphatics  and  by 
the  veins  ;  the  entrance  by  the  arteries  is  probably  much 
more  frequent  than  is  known  ;  in  fact,  Koch,  Mugge, 
and  Cornil  have  each  reported  cases  of  tubercular  de- 
posit in  the  vessels  of  the  bronchial  ganglia,  the  in- 
ternal tunic  of  the  pulmonary  artery,  and  the  menin- 
geal arteries,  respectively. 

M.  Langlois  had  studied  with  M.  Atanazio,  the  ac- 
tion of  the  salts  of  cadmium  on  cold-blooded  animals. 


July   27,  1895] 


MEDICAL   RECORD. 


141 


In  injecting  into  a  frog  seventy  centigrammes  of  the 
sulphate  of  cadmium  by  kilogramme  of  weight  of  the 
animal,  they  caused  a  state  of  stupor  in  which  the  ex- 
citability of  the  nerves  remained  intact.  They  con- 
cluded from  their  experiments  that  cadmium  acts  upon 
the  ganglionary  system  of  the  heart. 

M.  Lapicque  affirmed  that  he  had  found  an  iron  hy- 
drate mostly  of  colloid  form  in  the  liver  of  a  diabetic 
patient,  and  M.  D'Arsonval  related  a  number  of  ex- 
periments proving  that  ozone  has  no  antiseptic  power. 


A  NEW  INTRODUCTOR  AND  EXTRACTOR 
FOR  INTUB.\TIN(r  THE  LARYNX. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  describing  my  "  New  Introductor  and  Ex- 
tractor for  Intubating  the  Larynx,"  in  the  issue  of 
June  15th  of  your  journal,  I  did  not  at  the  time  con- 
sider it  necessary  to  mention  that  the  instrument  had 
been  ordered  in  February.  The  extractor  and  tube 
with  wire  rim  attachment  were  ready  for  use  in  the  be- 
ginning of  March.  The  publication  of  the  instrument 
was  delayed  because  the  introductor  had  to  be  altered 
many  times  before  reaching  its  present  state  of  perfec- 
tion. I  hope  you  will,  in  justice  to  me,  give  these  few 
lines  space  in  your  valuable  publication. 

Yours  respectfully, 
D.wiD  C.  Lewinthal,   M.D. 


CRANIOTOMY   AND    THE   LAW. 

To  THE  Editor  of  the  Medical  Record 

Sir  :  The  article  on  "  The  Catholic  Church  and  Obstet- 
rical Science,"  Medical  Record,  June  22d,  is  inter- 
esting from  the  fact  that  it  defines  in  full  the  attitude 
of  a  powerful  religious  organization  on  a  question  of 
public  policy.  Professor  Sabetti's  able  article  places 
the  four  ecclesiastical  decisions  on  the  question  of  the 
justification  of  craniotomy  in  the  best  possible  form 
from  the  stand-point  of  the  body  he  represents.  "  The 
admission  therein  contained,  that  craniotomy  is  one  of 
those  surgical  operations  which  are  and  must  be  called 
directe  occisiva;,  truly  murderous,  precludes  every  other 
abstract  and  otherwise  possible  interpretation  of  the 
tuto  doceii  non posse,  except  the  practical  one,  i.e.,  that 
craniotomy  is  unlawful,  morally  unlawful  always,  and 
intrinsically  unlawful.  .  .  .  And  to  speak  of  '  sci- 
ence '  and  '  necessity  '  that  we  may  connive  at  such  a 
crime  is,  to  say  the  least,  ridiculous.  Science  is  ad- 
vanced only  by  truth,  and  necessity,  however  great,  can- 
not be  admitted  as  an  e.xcuse  for  crime." 

These  conclusions  of  Professor  Sabetti  are  theologi- 
cal. They  are  significant  in  this  :  that  good  theology 
may  be  bad  public  policy,  and  also  that  ecclesiastical 
deliberations  are  not  always  in  harmony  with  .Anglo- 
Saxon  law. 

The  question  is  a  legal  one  per  se,  against  which  any 
conflicting  view  is  untenable.  The  subdivisions  under 
which  the  common  law  takes  consideration  of  craniot- 
omy are  ansn'ers,  in  themselves,  to  the  conclusions 
quoted  above,  under  the  unfortunate  necessity  which 
demands  the  operation. 

The  standing  in  law  of  an  unborn  child  is  definite, 
his  civil  rights  are  on  an  equality  with  those  guar- 
anteed him  after  birth.  He  inherits  ;  may  take  under 
marriage  settlement,  or  specifically  under  a  gen- 
eral devise  as  a  child,  and  may  obtain  injunction  to 

I  stay  waste.  He  is  a  citizen  under  common  law,  his 
destruction  by  craniotomy  is  therefore  homicide  at 
common  law  after  quickening.     The  law  provides  spe- 

I        cific  defence  for  justifiable  homicide,  a  part  of  which, 

j       leading  up  to  the  special  form  we  are  discussing,  is 

'        classified  as  follows  : 


Repulsion  of  felonious  assault,  zim  vi  repel/ere  licet,  a 
cardinal  principle  of  Roman  law. 

Prevention  of  felony,  in  which  a  bona-fide  belief  that 
a  felony  is  in  process  of  commission,  justifies  the  homi- 
cide of  the  felon. 

The  execution  of  malefactors  by  an  executioner, 
under  the  law,  in  furtherance  of  public  justice. 

Superior  duty.  It  has  been  observed  that  there  are 
cases  in  which  a  surgeon,  when  called  upon  to  deter- 
mine whether  a  critical  operation  is  to  be  performed, 
may  undertake  such  operation,  though  the  prospects  of 
success  are  slight,  if  the  alternative  is  certain,  miser- 
able death  in  the  natural  progress  of  the  disease. 

The  law  of  necessity.  The  same  law  which  lies  at 
the  basis  of  jurisprudence  in  this  respect  justifies  the 
sacrifice  of  the  life  of  one  person,  when  actually  neces- 
sary for  the  preservation  of  the  life  of  another,  when 
the  two  are  reduced  to  such  extremities  that  one  or  the 
other  must  die.  This  is  the  necessitas  non  habet  legiim. 
It  is,  however,  strictly  limited  under  the  law  ;  canon 
jurists  hold  that  the  right  can  only  be  exercised  in  ex- 
tremity and  in  subordination  to  general  rules  of  duty,  to 
which  such  a  necessity  as  the  one  under  discussion 
must  be  subordinate. 

The  plain  reading  of  the  general  law  is  :  "  It  is  a 
defence  that  the  destruction  of  the  child's  life  was 
necessary  to  save  that  of  the  mother."  The  Ohio 
statute,  declaratory  of  the  common  law,  was  enacted  in 
protection  of  physicians  who  are  confronted  with  this 
dire  necessity.  It  provides  that  craniotomy  may  be 
performed  when  necessary  to  save  the  life  of  the 
mother  ;  hence,  when  the  question  is  between  an  unborn 
infant's  life  and  that  of  the  mother,  the  mother's  is  to 
be  preferred. 

This  doctrine  of  the  common  law  is  carried  intact 
into  other  contingencies  of  life,  i.e.,  as  between  a  sailor 
and  a  passenger  ;  supposing  there  are  more  than  enough 
sailors  for  navigation,  the  passenger  must  be  preferred. 
Upon  the  authority  of  Lord  Bacon,  it  has  always  been 
held  in  law  and  in  fact  that,  when  two  shipwrecked 
persons  get  on  the  same  plank,  and  one  of  them  find- 
ing it  not  able  to  save  them  thrusts  the  other  from  it, 
whereby  he  is  drowned,  it  is  justifiable  homicide. 

These  citations  on  justifiable  homicide  are  a  part  of 
the  criminal  law  of  the  United  States,  e.xcept  where 
modified  by  legislation.  To  this  authority  of  law  for 
the  operation  of  craniotomy  sound  principles  of  public 
policy,  too  universal  almost  to  need  mention  here,  would 
dictate  that  ;  a  physician,  from  his  general  experience 
in  obstetrics,  and  from  his  special  knowledge  in  a  par- 
ticular case,  aided  by  the  counsel  of  one  or  two  other 
reputable  physicians  to  whom  he  has  communicated  all 
he  knows  about  the  case,  and  who,  from  an  examination 
of  the  patient  and  in  full  possession  of  all  the  facts, 
give  a  concurrent  opinion,  that  in  order  to  save  the  life 
of  the  mother  the  life  of  the  child  must  be  sacrificed, 
the  soundest  principles  of  public  policy  demand  that 
the  mother  shall  be  saved.  The  physician  has  but  one 
proposition  before  him  :  to  save  one  life  at  the  expense 
of  the  other.  He  is  morally  inadeqateand  intrinsically 
unworthy  if  he  fails  to  do  so,  when  there  is  no  other 
recourse.  The  duty  he  owes  to  society  at  large  in  sav- 
ing the  mature  and  useful  life  of  the  mother  as  against 
the  life  of  the  child,  which  in  its  useful  relations  to  the 
social  body  is  yet  immature,  is  above  and  beyond  ad- 
verse legislation.  He  is  justified  under  the  plain  read- 
ing of  the  law  ;  under  the  law  of  necessity,  and  under 
the  law  of  superior  duty,  all  of  which  have  their  founda- 
tion in  the  overwhelming  sentiment  in  the  human  fam- 
ily, that  the  operation  is  intrinsically  and  fundament- 
ally right.  .\s  to  the  moral  lawfulness  of  .this  vexed 
question,  it  is  one  which  in  the  nature  of  the  case  can- 
not be  settled  by  an  ecclesiastical  body,  however  great 
its  services  to  humanity  may  be  or  may  have  been  ;  it  is 
a  question  beyond  its  jurisdiction  and  may  be  submit- 
ted in  the  following  broad  application  ;  Two  wrongs  do 
not  make  a  right,  one  comes  nearer  it. 


142 


MEDICAL    RECORD. 


[July  27,  1895 


The  letter  of  the  common  law  and  the  universal  pro- 
tection man  gives  to  the  life  of  his  mother  leave  the 
physician  no  room  to  escape  the  operation  when  the 
unfortunate  necessit)'  confronts  him,  i.e.,  when  sym- 
physeotomy cannot  give  the  necessary  outlet,  and  the 
physical  condition  of  the  mother  prevents  Caesarean 
section.  It  is  intrinsically  lawful  by  this  principle  : 
every  condition  in  life  is  dependent  on  the  possession 
and  preservation  of  life.  On  this  point  theological  law 
ought  not  to  be  at  variance  with  the  sina  qua  Jion  in 
common  law. 

William  A.  Galloway,  B.Sc,  M.D. 

Xekia,  O.,  July  I.  1S55. 


BICYCLING   FOR  WOMEN. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  One  is  loath  to  offer  an  objection  to  anything 
which  attracts  women  to  physical  exercise,  yet  one 
should  not  be  blind  to  the  dangers  attending  it.  Much 
has  been  written  upon  the  subject  of  bicycling  for  both 
sexes  ;  but  in  the  case  of  women,  after  the  opinions  of 
some  old  fogies  on  its  propriety  have  been  aired  and 
rejected,  the  main  discussion  has  been  upon  the  toilet. 
Garments  of  the  bifurcated  plan  have  been  much  in 
evidence,  as  they  concerned  the  style  as  well  as  the 
comfort  of  the  cycler. 

In  all  the  discussions,  the  physical  effects  of  the 
wheel  have  held  a  minor  place.  Some  have  experi- 
enced a  gain  in  weight,  others  have  lost,  and  many 
victims  of  obscure  "  nervous  "  conditions  have  reported 
themselves  improved  by  the  moderate  use  of  the  wheel. 

It  is  yet  too  early  to  judge  of  the  benefits  or  injuries 
due  to  cycling,  but  positive  danger  should  be  clearly  in- 
dicated and  removed.  One  danger  is  the  saddle,  which 
is  physically  and  morally  injurious  to  women.  Every- 
one is  familiar  with  the  general  form  of  the  ordinary 
saddle,  and  knows  how  entirely  inadequate  is  the  sup- 
port given  to  the  body,  which  needs  a  surface  at  least 
wide  enough  to  receive  the  tuberosities.  Otherwise 
the  support  is  thrown  upon  the  soft  parts  never  intended 
for  that  purpose,  while  the  arms  and  legs  transmit  a 
portion  of  the  weight. 

The  saddle  of  a  bicycle  has  been  compared  to  a 
saddle  for  a  horse.  A  woman  in  a  saddle  astride  a 
horse  has  proper  support  for  her  body  and  offends 
neither  modesty  nor  common-sense  though  she  shock 
conventionality.  But  on  a  bicycle  with  the  present 
form  of  saddle,  while  conventional,  she  offends  her 
physical  nature.  For  the  saddle  presses  upon  the  soft 
tissues  which  form  the  pelvic  floor,  finding  its  first  bony 
rest  at  the  pubic  arch  and  the  coccyx,  compressing  the 
soft  parts  which  cover  them.  This  means  that  these 
sensitive  tissues  are  subjected  to  a  pressure  the  evil 
results  of  which  cannot  yet  be  estimated.  Moreover, 
the  impingement  and  vibration  of  the  saddle  can  and 
do  act  as  a  sexual  excitant.  It  would  seem  better  for 
the  medical  profession  to  face  this  fact  than  to  leave  it 
a  food  for  the  evil-minded  or  a  subject  of  jokes.  That 
it  is  a  fact  may  be  verified  by  a  little  observation.  To 
this,  however,  two  difficulties  present  themselves.  One 
is  that  the  psychical  sexuality  of  women  is  an  unknown 
quantity  even  to  medical  men,  because  of  the  disincli- 
nation of  women  to  analyze  or  discuss  their  sexual 
feelings.  The  other  difficulty  is  the  indelicacy  of  in- 
terrogating women  on  such  a  subject,  besides  the  risk 
of  sometimes  inducing  a  dangerous  consciousness. 
Moreover,  it  would  scarcely  be  expected  that  women 
who  keej)  up  the  practice  would  be  inclined  to  make 
such  an  admission. 

The  form  of  the  saddle  is  probably  one  reason  why 
women  ride  more  gracefully  than  men,  for  the  jiosition 
of  a  "  scorcher "  would  be  decidedly  painful,  if  not 
impossible,  for  a  woman. 


In  these  days  it  is  at  least  in  order  to  look  for  signs 
of  degeneration  or  sexual  perversion,  and  the  bicycle 
may  prove  a  sign.  Yet  it  is  far  from  the  intention  of 
the  writer  to  intimate  that  the  large  number  of  women 
cyclers  are  in  either  condition.  The  only  object  of 
this  paper  is  to  point  out  a  danger  which  a  proper  sad- 
dle would  remove  from  a  most  healthful  form  of  exer- 
cise for  women. 

Theresa  Banx.\n,  M.D. 

503  W.\RREN-  St.,  Svracuse,  N.  Y. 


BICYCLING   FOR   HAY   FEVER. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  For  the  past  sixteen  years  I  have  had  annually 
an  attack  of  hay  fever,  beginning  about  the  20th  to  the 
27th  of  May,  and  lasting  until  about  July  15th.  In  all 
this  time  there  has  been  scarcely  any  variation  in  the 
severity  of  the  attacks,  the  symptoms  being  violent  par- 
oxysms of  sneezing  with  intense  itching  of  the  roof  of 
the  mouth,  extending  well  into  the  throat,  and  inflam- 
mation of  the  eyes,  causing  severe  pain  and  itching. 
Occasionally  some  cough,  but  never  any  asthma.  I 
have  tried,  during  these  years,  all  kinds  of  treatment 
with  no  good  results,  the  only  thing  giving  me  any 
relief  being  a  stay  at  Fire  Island,  and  then  only  when 
the  wind  blew  from  the  sea.  Going  into  the  countrj-, 
or  a  walk  through  Central  Park  even,  would  bring  on 
paro.xysms  of  sneezing  and  all  the  other  symptoms. 

In  March  last  I  learned  to  ride  the  bicycle,  and  be- 
coming very  fond  of  the  sport,  began  in  April  riding 
about  ten  miles  a  day,  until  in  May  I  was  able  to  in- 
dulge in  long  country  rides  of  twenty  to  forty  miles.  I 
noticed  that  the  wheeling  was  improving  my  general 
health,  although  this  has  always  been  good.  I  was 
looking  forward  to  my  annual  attack  of  hay  fever  this 
year  with  more  than  usual  regret,  for  I  fully  expected 
that  I  would  have  to  abandon  my  wheeling  during  this 
particular  period.  I  determined,  however,  to  keep  it 
up  as  long  as  possible,  and  I  noticed  after  my  attack 
had  begun  that  I  never  sneezed  while  pedalling.  I  rode 
through  Central  Park  every  day  with  no  bad  results,  but 
I  was  still  afraid  to  attempt  rides  into  the  countr\'. 
One  extremely  hot  Sunday  I  was  feeling  particularly 
miserable,  and  woke  up  in  the  morning  sneezing. 
Much  against  my  judgment,  I  was  induced  to  accom- 
pany some  friends  on  a  ride  around  Staten  Island,  feel- 
■  ing  morally  certain  when  I  started  that  I  should  have  to 
return  as  soon  as  I  reached  the  country.  There  was 
no  sea-air  that  day,  the  wind,  what  little  there  was  of 
it,  being  from  the  southwest,  and  the  most  aggravating 
to  my  condition.  There  were  also  lots  of  dust,  but 
through  it  all  I  rode  without  a  single  sneeze,  until  we 
stopped  at  a  roadside  inn  to  rest.  Just  as  soon  as  I  got 
off  my  wheel  all  the  symptoms  of  my  hay  fever  mani- 
fested themselves  in  a  most  marked  manner.  I  suffered 
intensely  for  quite  awhile,  until  I  mounted  my  wheel 
again,  when  immediately  every  symptom  disappeared. 
This  same  experience  was  repeated  three  times  during 
that  particular  ride.  So  marked  indeed  was  the  differ- 
ence in  my  condition  when  wheeling  and  not  doing  so, 
that  I  kept  on  experimenting  and  observing  all  during 
the  period  that  I  am  troubled  with  the  disease,  and 
every  subsequent  ride  confirmed  the  results  herein 
noted. 

It  has  been  evident  to  me  that  wheeling  has  abso- 
lutely controlled  all  the  symptoms  of  my  attack,  such  as 
the  sneezing  and  itching  in  the  mouth  and  eyes.  It 
has  done  so  when  exposed  to  all  the  exciting  causes, 
such  as  dust,  foliage,  heat,  and  sunlight.  It  is  a  fact, 
too,  that  just  as  soon  as  I  was  oft'  my  wheel  all  the 
symptoms  returned,  and  I  suffered  as  I  have  done  in 
previous  years,  that  is,  when  exposed  to  the  exciting 
causes.     I  should  sav,  moreover,  that  mv  condition  in 


July 


5] 


MEDICAL    RECORD. 


143 


the  city  was  also  much  improved,  and  that  I  did  no: 
suffer  nearly  as  much  as  in  former  years,  for  which  I 
thoroughly  believe  bicycle  riding  is  responsible. 
Very  truly  yours, 

An  Old  Hay-fever  Sufferer. 

New  York,  July  17.  xSgs. 


pXetlical  gtcms. 

Contagious  Diseases — "Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  July  20,  1895. 

Cases.        Deaths. 


Tuberculosis 58  79 

Tjrphoid  fever 21  10 

Scarlet  fever 36  3 

Cerebro-spinaJ  meningitis 4  4 

Measles 190  17 

Diphtheria 194  27 

Accidents  and  Ambulance  Organization  in  Berlin. — 
In  Berlin  the  ambulance  organization  has  been,  till  re- 
cently, very  deficient.  If,  for  instance,  a  person  is  run 
over  in  the  street  by  a  carriage  the  proceedings  are  as 
follows  :  At  first  a  great  many  people  assemble  round 
the  victim  to  give  their  opinion  of  the  matter.  Then 
several  run  to  the  houses  of  the  surgeons  in  the  neigh- 
borhood, who  probably  are  not  at  home.  Finally,  a 
policeman,  with  the  assistance  of  some  of  the  more 
intelligent  of  the  crowd,  place  the  injured  man  in  an 
ordinary  four-wheeler,  and  take  him  to  a  hospital. 
Very  often  this  want  of  ambulance  organization  has  led 
to  serious  results,  numerous  examples  of  which  I  could 
narrate.  For  night  accidents,  it  is  true,  there  are  the 
Sanitats-Wachen  dressing-rooms  in  several  quarters  of 
the  town,  where  from  10  p.m.  to  6  a.m.  a  medical  man 
and  an  assistant  are  on  duty.  These  are  maintained 
by  the  contributions  of  the  inhabitants  of  the  quarter, 
and  their  medical  officers  have  to  attend  casualties  in 
the  waiting-room  or  to  go  into  the  houses  if  their  help 
is  wanted.  Their  necessity  has  been  often  disputed  by 
the  profession,  for  in  the  night  medical  men  are  usually 
at  home  and  can  be  found  without  difficulty.  Besides, 
very  often  people  go  to  the  Sanitats-Wachen  who  have 
not  met  with  an  accident,  but  have  some  other  com- 
plaint for  which  they  hope  to  be  treated  free  of  charge. 
As  in  the  night  all  the  manufactories  are  closed,  the 
sufferers  from  really  grave  accidents  derive  no  advan- 
tage from  these  waiting-rooms,  and  the  habitues  are 
principally  rowdies  who  have  been  wounded  in  night 
rows.  Notwithstanding  all  this,  the  Sanitats-Wachen 
have  existed  nearly  twenty  years,  and  now  get  an  annual 
subvention  from  the  town  council  of  forty  thousand 
marks.  They  are  rather  insufficiently  furnished  with 
litters,  and  have  no  ambulance  carriages  ;  but  not  even 
the  great  general  hospitals  possess  ambulance  carriages. 
The  only  ambulance  carriages  that  exist  belong  to  private 
undertakers,  who  also  transport  sick  people,  and  are  in 
emergency  cases  difficult  to  obtain.  During  the  past  year 
a  great  improvement  has  been  made  in  this  matter  by  a 
private  society.  This  society  has  established  at  differ- 
ent points  of  the  town  Unfall-Stationen  (accident  sta- 
tions). There  are  four  principal  stations  and  eight 
branch  stations.  At  the  principal  stations  there  are 
newly  constructed  horse  ambulances  which  are  ready 
to  start  immediately  in  case  of  alarm  ;  the  principal 
stations  are  connected  with  accident  wards  of  thirty  or 
forty  beds,  where  the  injured  can  be  attended  till  they 
recover.  The  branch  stations  consist  of  a  dressing- 
room  with  the  necessary  instruments  and  dressing  ma- 
terials, and  a  room  with  one  or  two  beds  where  the 
wounded  can  rest  some  time.  At  all  the  stations  sur- 
geons and  assistants  are  on  duty  day  and  night.     They 


have  telephonic  communication,  so  that  in  cases  of  ac- 
cidents the  ambulances  and  surgeons  can  easily  be 
called.  The  new  organization  has  already  been  found 
to  be  of  the  greatest  practical  use. —  The  Lancet. 

The  Study  of  Heredity.— In  his  address  before  the 
Abernethian  Society,  Sir  James  Paget  drew  attention 
to  the  great  gaps  which  exist  in  our  knowledge  of  the 
laws  of  heredity.  Some  of  the  broad  facts  of  heredity 
are  familiar  enough,  and  are,  indeed,  too  palpable  to 
be  overlooked  even  by  careless  observers.  That  gout, 
cancer,  rheumatism,  tuberculosis,  and  insanity,  to  take 
a  few  examples  out  of  many,  are  often  inherited  is  a 
well-recognized  and  certain  fact,  but,  says  Sir  James 
Paget,  "  it  has  never  been  studied  carefully  what  may 
be  the  result  when  one  parent  has  one  transmissible 
disease  and  another  has  another  ;  what  comes  if  one 
parent  is  a  member  of  a  cancerous  family  and  another 
a  member  of  a  tuberculous  family.  Do  these  two  dis- 
eases in  any  respect  disturb  one  another  ?  Are  they 
mutually  exclusive,  or  do  they  mingle  together  ?  AVe 
know  that  acute  tuberculosis  and  acute  cancer  never 
make  rapid  progress  together  ;  they  seem  in  so  far  as 
that  to  be  antagonistic.  But  what  comes  of  it  when 
they  are  mingled  together  by  inheritance  ?  Of  that,  I 
think,  we  certainly  know  nothing."  This  is  only  a 
specimen  of  numerous  questions  which  might  be  put  in 
connection  with  the  subject  of  heredit)",  but  are  for  the 
present  without  any  certain  answer.  Is  heredity  more 
usually  through  the  male  or  the  female  ?  If  a  son  or 
daughter  strongly  resembles  the  male  or  female  par- 
ent, will  he  or  she  be  likely  to  develop  the  diseases  oc- 
curring in  the  corresponding  stock  ?  Why  does  dis- 
ease sometimes  "  skip  a  generation  "  only  to  reappear 
with  increased  virulence  ?  Why  does  the  epilepsy  of 
the  parent  become  insanity  in  the  child,  or  vice  versa  ? 
How  comes  it  that  the  female  transmits  the  tendency 
to  hsemophilia,  but  is  herself  exempt,  while  the  male 
who  suffers  does  not  usually  propagate  the  disease  ? 
We  might  multiply  these  queries  a  hundredfold,  but 
they  are  sufficient  to  show  how  much  darkness  still  en- 
velopes so  patent  and  all-important  a  fact  as  the  inheri- 
tance of  disease. 

Some  of  the  laws  of  heredity  are  approximately 
known,  although  often  their  raison  d'etre  is  inexplicable 
— as,  for  example,  the  law  that  disease  often  skips  a 
whole  generation  and  reappears  in  the  generation  that 
follows.  This  fact  has  long  been  observed  and  is  known 
as  "the  law  of  atavism."  It  seems  to  involve  the  as- 
sumption that  an  individual  apparently  quite  healthy 
may  contain  in  his  organism  the  seeds  of  disease — e.g., 
tuberculosis  or  cancer — and  transmit  the  tendency  to 
such  diseases  to  his  offspring,  although  he  has  never 
presented  any  symptom  of  them  himself.  This  may  be 
so,  but  if  such  a  theory  be  correct  it  intensifies  our  con- 
ception of  the  myster)'  of  pathological  processes.  If  it 
could  be  shown  in  such  cases  that  the  "  latent  "  seeds 
of  disease  (we  are  compelled  to  use  figurative  language 
in  this  connection  for  want  of  better)  remain  latent 
until  certain  favoring  conditions  combine  to  bring  them 
to  maturity,  the  mystery  would  be  materially  lessened, 
but  in  many  cases  we  have  no  evidence  that  such  is 
really  the  true  explanation.  It  may,  however,  be  re- 
garded as  often  a  probable  hypothesis. 

The  commingling  of  different  and  possibly  conflict- 
ing pathological  strains  presents,  as  Sir  James  Paget 
points  out,  a  curious  and  almost  wholly  neglected  field 
of  inquiry.  The  whole  subject  of  the  influence  upon 
each  other  of  different  morbid  processes  is  a  very  ob- 
scure one,  and  many  theories  on  the  subject  once  con- 
fidently advocated  have  had  to  yield  to  the  hard  logic 
of  facts.  It  was  once  thought  that  valvular  disease  of 
the  heart  was  almost  a  safeguard  against  pulmonary 
tuberculosis.  It  is  now  known  that  the  conjunction  of 
the  two  diseases,  though  uncommon,  is  not  excessively 
rare.  So  careful  an  observer  and  so  acute  a  reasoner 
as  Walshe  lent  the  weight  of  his  authority  to  the  old 


144 


MEDICAL   RECORD. 


[July  27,  1895 


idea  that  habitual  exposure  to  the  poison  of  malaria 
was  an  efficient  protection  against  phthisis.  This  no- 
tion is  almost  certainly  erroneous.  It  was  long  re- 
garded as  doubtful  whether  two  of  the  specific  fevers 
could  coe.xist.  Most  observers  have  seen  cases  which 
have  inclined  them  to  an  affirmative  opinion,  but  the 
sources  of  fallacy  are  many,  and  at  all  events  such  a 
conjunction  is  extremely  rare.  As  to  the  influence 
upon  the  offspring  of  two  conflicting  pathological 
strains,  we  must  be  content  to  confess,  as  Sir  James 
Paget  affirms,  that  "we  certainly  know  nothing."  But 
the  subject  is  not  inscrutable,  and  only  needs  careful 
and  minute  observation  in  order  that  some  light  may 
be  cast  upon  it.  The  relations  of  hereditary  cancer 
and  tuberculosis,  or  gout  and  syphilis,  might  be  worked 
out  if  sufficient  attention  were  drawn  to  the  matter. 

A  great  deal  of  work  still  remains  to  be  done  in  con- 
nection with  the  heredity  of  phthisis.  It  is  generally 
asserted  that  from  thirty  to  forty  per  cent,  of  the  cases 
arising  in  practice  occur  in  infected  families,  but  it  is 
striking  how  various  are  the  figures  given  by  different 
observers.  Owing  to  the  great  frequency  of  the  dis- 
ease and  the  probability  of  infection,  it  is  evident  that 
many  cases  of  apparent  inheritance  might  be  otherwise 
explained.  It  would  be  a  great  gain  to  practical  medi- 
cine if  we  had  decisive  evidence  as  to  the  influence  of 
heredity  upon  phthisis  on  the  one  hand  and  the  fre- 
quency of  infection  on  the  other.  We  are  still  without 
any  quite  satisfactory  theory  to  harmonize  the  appar- 
ently certain  facts  that  pulmonary  tuberculosis  is  due 
to  a  specific  bacillus  and  that  it  is  frequently  trans- 
mitted by  inheritance.  Some  French  observers  pub- 
lished a  few  years  ago  evidence  tending  to  show  that 
the  actual  bacillus  of  tubercle  was  conveyed  to  the  off- 
spring through  the  ovum,  but  this  view  has  not  been 
generally  accepted.  Many  believe  it  to  be  more  proba- 
ble that  the  parent  transmits  simply  a  constitutional 
delicacy  or  some  peculiarity  of  the  pulmonary  tissue 
which  renders  the  individual  more  liable  to  become 
the  subject  of  bacillary  infection  ;  but  it  cannot  be 
said  that  we  have  any  certain  information  on  the  sub- 
ject. 

Problems  of  heredity  should  appeal  more  especially 
to  the  cultured  and  philosophic  of  the  large  body  of 
general  practitioners.  Hospital  work  and  consult- 
ing practice  certainly  afford  an  imperfect  field  for  the 
elucidation  of  these  interesting  and  important  problem?.' 
The  hospital  or  consulting  physician  seldom  sees  the 
beginnings  of  disease,  and  he  has  very  rarely  the  op- 
portunity of  observing  the  disease  record  of  an  entire 
family.  The  general  practitioner  has  such  opportuni- 
ties, and  it  would  be  much  to  the  advantage  of  our  art 
if  those  opportunities  were  thoroughly  utilized. —  The 
Lancet. 

Twin  Tubal  Pregnancy:  Retention  of  Foetus  for 
Fifteen  Years. — According  to  the  Paris  correspondent 
of  The  Lancet,  M.  Folet,  of  Lille,  has  communicated 
to  the  Academy  of  Medicine  details  of  the  above  ex- 
traordinary case.  His  patient  is  a  woman  now  aged 
forty-nine,  who,  having  jjreviously  given  birth  to  four 
children  at  full  term,  became,  sixteen  years  ago,  again 
pregnant.  When  the  pregnancy  had  reached  the  ninth 
or  the  tenth  month  symptoms  simulating  labor  occurred,^' 
blood  and  membranes  being  expelled,  and  the  hemor- 
rhage persisting  for  six  weeks.  This  strange  occur- 
rence led  to  the  belief  that  no  pregnancy  had  really 
existed.  The  abdomen  remained,  however,  volumi- 
nous, but  for  fifteen  years  nothing  further  happened  to" 
disturb  her  until  a  year  ago,  when  repeated  attacks  of 
peritonitis  determined  her  admission  into  the  Saint-" 
Sauveur  Hospital,  Lille,  where  laparotomy  was  decided 
upon.  The  operation  was  lahoriotis  on  account  of  the 
presence  of  numerous  adhesions  of  the  fa^tal  sac  to  the 
intestines.  The  sac  was,  nevertheless,  excised  almost 
entire,  the  too  adherent  fundus  only  being  left  in  situ 
and  stitched  en  collerette  to  the  lower  part  of  the  abdom- 


inal incision.  Recovery  was  complete  in  six  weeks, 
no  accident  having  occurred  to  retard  it.  The  sac  con- 
tained two  foetuses — one  which  had  at  its  death  at- 
tained the  age  of  two  or  three  months,  and  the  other 
which  had  reached  the  full  term  of  nine  months — a 
phenomenon  which  is  so  extremely  rare  in  tubal  gesta- 
tion that  only  six  or  seven  examples  are  recorded.  The 
foetus  exhibited  at  the  Academy  by  M.  Folet  was  not  a 
lithopaedion.  Its  tissues  were  supple,  non-calcified, 
but  were,  nevertheless,  as  dense  as  cooked  bacon. 
With  the  exception  of  certain  alterations  undergone, 
the  tissues  had  retained  their  structure,  recognizable  by 
the  naked  eye  and  under  the  microscope. 


NEW   BOOKS   RECEIVED. 

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BuRDETT's  Hospital  and  Charities  Annual,  1895.  By 
Henry  C.  Burdett.  8to,  834  pages.  Published  by  the  Scienti5c 
Press,  London. 

A  Treatise  on  the  Nervous  Diseases  of  Children.  For 
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Formllaire  des  Sp^cialites  Pharmaceutiques.  By  le 
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The  Filtration  of  Public  W.\TER-snppLiES.  By  Allen  Ha- 
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THE  DOMINANT  INFLUENCE  IN  THE  MED- 
ICAL PROGRESS  OF  THE  NINETEENTH 
CENTURY. 

By  JOHN  SLADE  ELY,  M.D., 

PROFESSOR  OF  PATHOLOGY  IN  THE  WOMAN'S  MBDICAL  COLLEGE  OF  THE  NEW 
%'ORK  INFIRMARY  ;  ASSISTANT  IN  PATHOLOGY  IN  THE  COLLEGE  OF  PHYSICIANS 
AND  SURGEONS  ;   PATHOLOGIST  TO   BELLE\'UE  HOSPITAL, 

To  anyone  who  gives  thoughtful  consideration  to  the 
history  of  the  nineteenth  century,  it  must  be  evident 
that  in  it  we  have  the  final  triumph  of  scientific  realism 
over  speculative  philosoph)'.  Whatever  the  field  to 
which  we  direct  our  attention,  we  cannot  but  be  im- 
pressed with  the  influence  upon  its  progress  of  the  ap- 
plication to  it  of  scientific  principles.  The  many  con- 
veniences of  living  which  this  process  has  introduced 
have  clearly  demonstrated  the  practical  usefulness  of 
the  study  of  science,  and  what,  a  hundred  years  ago, 
was  regarded  as  theoretical,  delusive,  and  of  but  insig- 
nificant benefit  to  mankind,  has  come  to  occupy  a  posi- 
tion of  acknowledged  usefulness  among  all  classes  of 
the  community.  Science  is  supplanting  literature  and 
metaphysics  in  the  curricula  of  our  universities,  and 
scientific  schools  are  undergoing  an  almost  unprece- 
dented development  to  meet  the  demands  for  education 
in  those  departments  of  knowledge  which  have  been 
found  of  such  utility. 

When  we  search  out  the  influence  which  has  disclosed 
the  scientific  principles  from  which  all  these  practical 
deductions  have  been  made,  we  find  it  to  have  been  pre- 
eminently the  application  of  the  inductive  method  of 
reasoning  to  the  study  of  the  problems  of  science. 
Though  employed  by  Copernicus  and  a  few  of  his  asso- 
ciates in  arriving  at  their  magnificent  generalizations, 
the  general  applicability  of  the  inductive  method  to  all 
departments  of  scientific  investigation,  and  its  inestima- 
ble value,  were  first  appreciated  by  Bacon,  at  the  begin- 
ning of  the  seventeenth  century.  Under  the  influence 
of  his  teaching  physical  and  astronomical  science  at- 
tained a  wonderful  development,  culminating  in  the 
Newtonian  principle  of  universal  gravitation.  During 
the  greater  part  of  the  eighteenth  century,  however,  so- 
ciety was  dominated  by  an  idealistic  tendency,  which 
pervaded  all  classes  of  the  community,  undervalued  the 
benefit  to  be  derived  from  the  inductive  method,  and 
materially  impeded  the  progress  of  scientific  discovery. 
Fortunately,  in  the  general  upheaval  incident  to  the 
French  Revolution,  a  return  took  place  to  the  inductive 
method,  and  in  it  we  find  the  controlling  influence  in 
the  scientific  advancement  of  the  nineteenth  centur)'. 

Since  the  inductive  method  has  been  thus  potent  in 
the  development  of  general  science,  and  since,  as  we 
shall  presently  see,  the  progress  of  medicine  during  this 
century  is  directly  traceable  to  the  application  of  that 
method  to  the  study  of  disease,  we  may  be  permitted  to 
pause  for  a  moment  to  consider  its  essential  character- 
istics. 

Inductive  reasoning,  as  the  term  implies,  is  the  infer- 
ence of  general  laws  from  a  consideration  of  the  phe- 
nomena which  are  governed  by  those  laws,  and  which 
are  susceptible  of  observation  and  study.  Thus,  in 
physiology,  the  discovery  of  the  circulation  of  the  blood 


was  the  induction  of  a  great  natural  law  as  the  result 
of  study  of  the  structure  of  the  heart  and  blood-ves- 
sels, and  of  many  of  the  phenomena  of  the  circulation 
which  were  open  to  observation  and  experimental  in- 
vestigation. It  will  be  noted  that  two  distinct  proc- 
esses are  essential  to  the  inductive  method,  the  obser- 
vation of  phenomena  and  the  accumulation  of  facts 
relative  to  them,  and  the  reasoning  from  these  accumu- 
lated facts  up  to  the  general  law  by  which  they  are 
governed.  Fact  accumulation  and  generalization,  then, 
are  the  essentials  of  the  inductive  method. 

When,  now,  we  turn  from  these  more  general  consid- 
erations to  an  analysis  of  the  progress  of  medicine  dur 
ing  this  century,  we  cannot  but  be  impressed  with  the 
fact  that  this  century  marks  the  general  adoption  of  the 
inductive  method  in  the  study  of  disease,  the  fundamen- 
tal consideration  in  medical  science.  The  necessity  of 
the  application  to  pathology  of  the  method  of  investi- 
gation which  had  been  so  prolific  of  results  in  the  nat- 
ural sciences  was  indeed  impressed  upon  the  minds  of 
John  Hunter,  in  England,  and  of  Alorgagni,  in  Italy,  as 
early  as  the  middle  of  the  eighteenth  century,  and  both 
these  observers  collected  a  multitude  of  facts  relative 
to  the  various  phenomena  of  disease.  But  so  out  of 
touch  were  they  with  the  idealism  of  the  age  in  which 
they  lived  that  neither  of  them  attracted  a  large  follow- 
ing, and  it  is  to  the  French  school  of  the  beginning  of 
this  century  that  we  must  attribute  the  chief  agency  in 
the  introduction  of  the  inductive  method  into  medi- 
cine. 

The  magnitude  of  the  change  which  has  been  thereby 
brought  about  can  only  be  appreciated  after  a  glance 
at  the  state  of  medicine  at  the  end  of  the  last  century. 
At  this  time  we  find  medicine  dominated  by  all  man- 
ner of  absurd  philosophical  notions  as  to  the  nature  of 
disease,  and  as  to  the  methods  which  should  be  em- 
ployed to  combat  it.  The  natural  result  of  this  was 
the  elaboration  of  innumerable  systems  or  schools  of 
medicine,  each  presenting  its  own  metaphysical  con- 
ception of  the  phenomena  of  disease.  No  clearer  evi- 
dence of  their  lack  of  any  broad  foundation  in  fact 
could  be  desired  than  the  great  diversity  of  the  hypoth- 
eses which  were  made  the  bases  of  these  systems  by 
their  inventors.  The  fundamental  doctrine  of  one  of 
the  most  widely  diffused  of  these  systems  was  that 
health  depended  upon  a  proper  neutralization  of  all 
the  acids  and  alkalies  of  the  body.  Let  acid  or  alkali 
preponderate,  disease  resulted.  Diseases  were  then 
classified  in  two  groups,  according  as  they  were  due  to 
excess  of  alkali  or  acid,  each  group  being  in  turn 
treated  by  its  appropriate  acid  or  alkali.  According  to 
another  of  these  systems,  diseases  depended  upon  ex- 
cess or  diminution  of  the  vital  energy  ;  they  were 
therefore  sthenic  or  asthenic.  For  the  cure  of  the  one 
the  vitality  of  the  patient  must  be  depressed  ;  for  the 
cure  of  the  other  it  must  be  stimulated.  Homoeopathy, 
the  wildest  extravaganza  of  them  all,  is  the  only  one  of 
these  systems  which  can  in  any  sense  be  said  to  have 
survived  to  our  day.  It  is  from  such  a  state  of  chaos 
that  the  nineteenth  century  has  elevated  medicine  to  a 
worthy  position  beside  the  exacter  sciences. 

I  have  already  said  that  the  one  great  factor  in  the 
accomplishment  of  this  change  has  been  the  appli- 
cation of  the  exacter  methods  of  scientific  research 
to  the  study  of  the  phenomena  of  disease.  Whatever 
the  department  of  medicine  we  consider,  we  find  the 


146 


MEDICAL   RECORD. 


[August  3,  1895 


same  persistent  effort  of  its  devotees  to  observe  every 
minutest  detail  of  the  diseases  with  which  they  deal,  in 
the  hope  of  gaining  some  knowledge  of  the  nature  of 
the  perverted  processes  which  underlie  them.  The 
work  of  this  century  has,  then,  been  the  study  of 
pathology,  for  this  is  the  science  of  disease.  And  as 
we  look  back  at  it  we  are  impressed  with  the  fact  that, 
with  the  single  exception  of  the  introduction  of  anaes- 
thesia by  ether,  every  material  improvement  in  medi- 
cal practice  has  been  distinctly  traceable  to  this  study. 
The  investigation  and  elucidation  of  the  structure  and 
functions  of  the  various  tissues  and  organs  of  the  body 
in  health  have,  indeed,  prepared  the  way  for  the  proper 
interpretation  of  the  changes  of  structure  and  function 
incident  to  disease,  and  without  such  study  much  that 
has  been  accomplished  by  pathology  would  have  been 
impossible  ;  but  it  is  only  indirectly  and  through  the 
medium  of  pathology  that  these  departments  of  biology 
have  influenced  medical  practice,  and  we  must  there- 
fore consider  their  influence  as  subordinate  to  that  of 
the  study  of  disease  itself.  It  is,  accordingly,  to  the  de- 
velopment of  pathology  that  we  must  look  if  we  would 
correctly  estimate  the  influences  which  have  brought 
about  the  medical  progress  of  our  time. 

It  has  been  said  that  it  is  to  the  French  school  of  the 
early  years  of  this  century  that  the  chief  agency  in  the 
introduction  of  the  inductive  method  into  medicine  is 
to  be  attributed.  The  central  figure  in  this  school  is 
easily  Franfois  Xavier  Bichat,  who,  though  dying  at 
the  early  age  of  thirty-one,  has  been  pronounced  by 
Buckle  "  the  most  profound  thinker  and  the  most  con- 
summate observer  by  whom  the  organization  of  the 
animal  frame  has  yet  been  studied."'  His  devotion  was 
pre-eminently  to  the  study  of  human  anatomy  and  phys- 
iology, his  object  being  so  to  investigate  the  organiza- 
tion of  man  as  to  rise,  if  possible,  to  some  knowledge 
concerning  the  nature  and  origin  of  life.  It  was  soon 
evident  to  him  that,  before  any  conception  of  the  proc- 
esses underlying  life  could  be  arrived  at,  it  was  imper- 
atively necessary  that  there  be  an  exhaustive  acquaint- 
ance with  the  structures  of  which  living  beings  are 
composed.  Cuvier  had,  indeed,  pointed  out  the  im- 
mense aid  to  classification  to  be  derived  from  study  of 
the  internal  organs  of  animals,  but  Bichat  went  much 
further  and  insisted  upon  a  study  of  the  tissues  com- 
posing those  organs.  It  is  herein  that  his  greatest  ser- 
vice to  natural  science  and  to  medicine  lies.  From 
Biohat's  time  to  our  own  the  study  of  the  tissues  of 
plants  and  animals  has  absorbed  the  attention  of  all 
biologists. 

The  immediate  corollary  from  this  great  generaliza- 
tion of  Bichat,  of  inestimable  importance  to  medicine, 
was  that  no  true  conception  of  disease  was  possible 
without  the  most  minute  study  of  the  changes  in  the 
tissues  which  were  a  part  of  the  disease.  "  You  may 
observe  diseases  of  the  heart,  lungs,  abdominal  viscera, 
etc.,"  he  says,  "night  and  morning  by  the  sick-bed  for 
twenty  years,  yet  the  whole  furnishes  merely  a  jumble 
of  phenomena,  which  unite  into  nothing  complete. 
But  if  you  open  only  a  few  bodies  you  will  see  the  ob- 
scurity speedily  give  way,  a  result  never  accomplished 
by  simple  observation  if  we  do  not  know  the  seat  of  the 
disease."  He  furthermore  established  the  fact  of  the 
tendency  of  similar  tissues  to  similar  forms  of  disease. 
"As  every  tissue  has  everywhere  a  similar  disposition, 
since,  wherever  it  may  be,  it  possesses  the  same  struct- 
ure, the  same  properties,  etc.,  so  it  is  clear  that  its  dis- 
eases must  be  everywhere  the  same.  Whether  the  se- 
rous tissue  belongs  to  the  brain  as  the  arachnoid,  to  the 
lungs  as  the  pleura,  to  the  heart  as  the  pericardium,  to 
the  abdominal  viscera  as  the  peritoneum,  it  takes  on 
inflammation  everywhere  in  the  same  way  ;  everywhere 
dropsies  occur  in  the  same  way,"  etc.  Bichat  was  thus 
the  creator  of  general  pathological  anatomy,  and  the 
untiring  nature  of  his  researches  may  be  inferred  from 
the  fact  that  in  a  single  winter  he  examined  more  than 
six  hundred  bodies.     He  was  also  the  first  to  claim  for 


medicine  the  distinction  of  an  exact  science.  "Medi- 
cine," he  says,  "  will  have  the  right  to  be  associated 
with  the  exact  sciences,  at  least  as  regards  the  diag- 
nosis of  diseases,  as  soon  as  we  shall  everywhere  have 
united  with  the  most  thorough  and  rigorous  observation 
the  investigation  of  those  changes  which  our  organs 
suffer."  Thus  Bichat,  at  the  ver\'  threshold  of  our  cen- 
tury, insisted  upon  the  application  of  the  methods  of 
the  natural  sciences  to  the  study  of  disease.  If  medi- 
cine has  to-day  any  just  claim  to  a  recognized  position 
among  the  sciences,  it  is  because  of  its  development 
along  the  lines  thus  indicated. 

While  Bichat  was  thus  pointing  the  way  for  the  ac- 
quisition of  a  true  conception  of  the  nature  of  disease, 
the  first  of  the  means  of  physical  examination  which 
so  materially  aided  in  the  clinical  study  of  disease  was 
being  investigated  by  Corvisart.  In  1761,  Auenbrug- 
ger,  a  Viennese  physician,  had  published  in  a  small 
volume  a  description  of  a  "  new  invention  "  for  detect- 
ing the  hidden  diseases  of  the  chest  by  means  of  per- 
cussion. Though  based  upon  most  careful  and  accu- 
rate observations  of  the  sounds  emitted  from  the  chest 
when  gently  tapped  with  the  fingers,  both  in  health  and 
under  various  conditions  of  disease,  and  though  re- 
ceived with  favor  by  Stoll  and  a  few  others  of  his  as- 
sociates, the  method  passed  into  disuse  and  the  little 
book  was  forgotten  until  unearthed  by  Corvisart,  about 
1790.  During  the  following  twenty  years  Corvisart 
carefully  tested  the  accuracy  of  Auenbrugger's  obser- 
vations, verifying  them  by  post-mortem  examinations 
as  Auenbrugger  had  also  done.  In  1S08,  convinced 
of  the  value  of  percussion  as  a  diagnostic  sign,  Cor- 
visart made  public  a  French  translation  of  Auenbrug- 
ger's book,  adding  in  the  form  of  notes  many  observa- 
tions of  his  own.  Percussion  almost  immediately 
became  a  recognized  aid  in  diagnosis  among  the 
French  physicians  of  the  time,  being  alluded  to  by 
Bayle  as  early  as  1810,  in  his  celebrated  work  on  pul- 
monary consumption.  It  was  but  a  step  further  to 
auscultation,  which  by  1819  had  been  elaborately  tested 
by  Laennec  whose  great  work  placed  it  thenceforth 
among  the  indispensable  aids  to  diagnosis. 

Thus  grew  up  in  Paris  the  great  French  school  of 
pathological  anatomy  and  physical  diagnosis,  which 
was  the  guiding  star  of  medicine  for  nearly  half  a  cen- 
tury. In  the  development  of  physical  diagnosis  the 
necessity  of  verifying  by  post-mortem  examinations 
the  conclusions  arrived  at  from  the  study  of  physical 
signs  infused  a  practical  interest  in  pathological  anat- 
omy which  had  been  unknown  so  long  as  the  solution 
of  merely  theoretical  problems  was  all  that  was  looked 
for  from  its  study. 

And,  similarly,  the  proof  of  the  accuracy  of  the  in- 
formation to  be  gained  from  physical  signs,  which  was 
imparted  by  pathological  anatomy,  served  greatly  to 
increase  confidence  in  the  new  methods  of  clinical  ex- 
amination, and  to  encourage  otlier  efforts  to  adapt  phys- 
ical and  chemical  principles  to  the  needs  of  diagnosis. 
In  this  way  medicine  advanced  during  the  first  half  of 
the  century,  the  chief  aim  of  its  devotees  being  to  ob- 
tain, by  careful  observation  of  the  changes  in  structure 
and  perversions  of  function  incident  to  disease,  some 
conception  of  its  nature  which  should  be  of  practical 
value  in  its  detection  and  cure. 

When,  now,  we  turn  to  the  past  forty  years  and  ana- 
lyze the  influences  which  have  shaped  the  progress  of 
pathology  during  that  time,  we  are  at  once  impressed 
with  the  pre-eminence  of  two  great  generalizations — the 
"  cellular  pathology  "  of  Virchow  and  the  conception 
of  the  causal  relationship  of  micro-organisms  to  the  in- 
fectious diseases. 

The  underlying  principle  of  the  cellular  pathology, 
"omfiis  ccUtihr  e  cellula"  was  a  scientific  induction  of 
the  most  brilliant  nature,  based  upon  a  critical  study 
of  the  cell  in  its  relations  to  the  various  tissues.  So 
clear  was  the  demonstration,  and  so  masterly  the  man- 
ner of  its  presentation,  as  to  have  found  for  it  an  almost 


August  3,  1895] 


MEDICAL   RECORD. 


147 


immediate  acceptance,  and  from  the  delivery  of  Vir- 
chow's  lectures  elucidating  it,  in  1858.  until  the  present 
time,  the  cell  has  been  regarded  as  the  ultimate  living 
factor  in  the  production  of  the  tissues  of  all  living  be- 
ings. The  attention  of  those  engaged  in  the  investiga- 
tion of  the  changes  in  the  tissues  resulting  from  disease 
was  consequently  at  once  concentrated  upon  the  cell, 
and  new  light  was  thrown  upon  many  obscure  subjects 
in  pathological  anatomy,  notably  upon  tumors  and 
upon  inflammation. 

It  will  be  noted  that  the  cellular  pathology  is  in  real- 
ity but  an  extension  of  the  principle  enunciated  by 
Bichat.  The  study  of  the  tissues  is  still  paramount, 
but  in  the  production  and  development  of  the  tissues 
the  cell  is  the  controlling  influence.  Nevertheless,  to 
the  stimulus  imparted  to  histological  study  by  Virchow 
we  must  attribute,  in  a  very  large  degree,  that  painstak- 
ing investigation  of  minute  structural  details  which  has 
characterized  the  study  of  pathological  anatomy  in 
Germany  during  the  past  forty  years,  and  which,  com- 
bined with  the  careful  clinical  observation  inaugurated 
there  by  Krukenberg  and  Schonlein,  has  placed  that 
country  in  the  front  rank  of  the  nations  as  regards  the 
medicine  of  to-day. 

When,  finally,  we  consider  the  last  great  generaliza- 
tion of  the  nineteenth  century,  the  conception  of  the 
causal  relationship  of  micro-organisms  to  the  infectious 
diseases,  we  are  impressed  with  the  fact  that  here,  too, 
we  have  to  do  with  the  induction  of  a  great  scientific 
principle  from  a  mass  of  more  or  less  isolated  facts. 
Though  suggested  as  long  ago  as  1762,  the  idea  of  a 
contagii/m  vivum  of  disease  has  met  with  general  accept- 
ance only  after  long  and  careful  study.  It  is  unneces- 
sary for  my  purpose  to  review  the  gradual  development 
of  the  proof  which  is  now  so  convincing,  nor  can  we 
stop  to  consider  the  many  ingenious  devices  which 
have  been  invented  from  time  to  time  during  the  prog- 
ress of  the  science  of  bacteriology,  and  which  have 
made  possible  the  critical  study  of  the  minute  organ- 
isms with  which  it  is  concerned.  The  points  which  I 
would  particularly  emphasize  in  this  connection  are, 
that  the  conception  of  the  bacterial  origin  of  the  infec- 
tious diseases  is  the  outcome  of  the  same  careful  scien- 
tific investigation  which  led  up  to  the  generalizations 
of  Bichat  and  Virchow,  and  that  while  these  latter, 
though  profoundly  influential  in  developing  diagnosis 
to  a  high  degree  of  accuracy,  had  but  an  indirect  in- 
fluence upon  therapeutics,  the  new  conception  of  infec- 
tious disease  makes  possible  its  prevention  and  bids 
fair  to  revolutionize  its  treatment.  Already  we  are  in 
possession  of  many  valuable  facts  as  to  the  mode  of  en- 
trance of  infectious  germs  into  the  body  ;  as  to  the  man- 
ner in  which  they  are  cast  off  by  those  afflicted  with 
infectious  diseases  ;  as  to  their  existence  during  the  in- 
terval of  their  escape  from  one  individual  and  their  en- 
trance into  another  ;  as  to  their  vulnerability  to  light, 
heat,  chemical  agents,  drying,  etc. — all  of  which  demon- 
strate the  feasibility  of  simple  prophylactic  measures 
whose  general  adoption  could  not  but  be  followed  by 
a  very  material  decrease  in  the  prevalence  of  these  dis- 
eases. And,  at  the  same  time,  the  study  of  the  poisons 
elaborated  by  the  bacteria,  of  their  influence  in  the 
production  of  the  symptoms  of  infectious  diseases,  and 
of  their  relation  to  the  induction  of  an  artificial  im- 
munity from  them,  seems  destined  to  profoundly  mod- 
ify the  manner  of  our  treatment  of  those  diseases. 
This  last  is  still  in  the  developmental  stage,  but  it  would 
seem  not  improbable  that  the  next  decade  may  witness 
an  evolution  in  medicine  in  this  respect  of  the  very 
greatest  practical  importance. 

If,  in  this  brief  review  of  the  influences  which  have 
directed  the  course  of  medical  progress  during  this 
century,  I  have  omitted  to  mention  a  host  of  material 
advances  which  are  everywhere  apparent  in  all  depart- 
ments of  medicine,  it  is  because  I  believe  them  all  to 
have  had  but  a  subordinate  and  insignificant  influence 
in  moulding  medical  thought  in  comparison  to  those 


great  generalizations  to  which  I  have  referred.  From 
one  or  other  of  these  every  advance  in  every  depart- 
ment of  medicine  has  been  deduced  or  has  received  its 
final  shape.  It  is  interesting  to  note  that  in  this  de- 
velopment all  the  fundamental  problems  with  which 
pathology  deals  have  made  marked  progress  toward 
solution.  Our  knowledge  of  the  structural  changes  in- 
duced by  disease  has  received  much  light  from  the 
study  of  pathological  anatomy  and  histology  ;  our 
knowledge  of  perversions  of  function,  or  symptoms,  of 
disease  has  been  greatly  increased  by  the  study  of 
pathological  anatomy,  physical  diagnosis,  and  bacte- 
riology ;  and  our  conception  of  the  causation  of  dis- 
ease has  been  completely  revolutionized  by  the  discov- 
ery of  the  etiological  relationship  of  micro-organisms 
to  the  infectious  diseases.  These,  then,  have  been  the 
immediate  agencies  in  the  accomplishment  of  the  noble 
progress  of  medicine  during  our  time.  Upon  them  all 
others  are  more  or  less  dependent.  But  it  should  be 
clearly  held  in  mind  that  these  great  principles  are  all 
in  turn  the  outcome  of  the  application  to  medical  study 
of  the  critical  methods  of  observation  and  thought 
which  are  so  essentially  a  part  of  the  inductive  method. 

I  am  particularly  desirous  that  this  crystallization  of 
medicine  about  pathology  should  be  justly  appreciated 
during  this  century,  for  the  reason  that  until  recently 
there  has  been  a  tendency,  particularly  in  this  country, 
to  undervalue  the  labors  of  the  pathologist  as  of  little 
importance  to  practical  medicine  and  of  distinctly  less 
usefulness  to  humanity  than  the  more  direct  services 
of  the  practitioner  ;  and  this  feeling  has  operated  to 
deter  many,  whose  training  and  circumstances  emi- 
nently fitted  them  to  do  so,  from  undertaking  a  life- 
work  which  appeared  to  be  almost  wholly  theoretical 
in  scope.  The  fallacy  of  this  position  must  be  evident. 
A  very  important  branch  of  pathology,  as  has  been 
said,  is  devoted  to  the  study  of  the  perversions  of 
function  incident  to  disease,  and  this  is  of  necessity 
the  work  of  the  practising  physician,  for  from  no  one 
else  can  this  department  of  pathology  receive  advance- 
ment. But  the  pathological  anatomist  and  bacteriol- 
ogist in  their  laboratories,  in  contributing  to  the  prog- 
ress of  pathology  have  at  the  same  time  assisted  in 
shaping  the  course  of  medical  practice,  and  have  thus 
indirectly,  but  yet  powerfully,  contributed  to  the  amel- 
ioration of  human  suffering.  It  is  not  too  much  to  say 
that,  without  the  facts  regarding  the  nature  of  disease 
which  the  study  of  pathology  during  this  century  has 
contributed,  the  medicine  of  to-day  would  be  but 
slightly  removed  from  the  idealism  which  prevailed  at 
the  end  of  the  eighteenth  century.  But  in  another 
and  eyen  more  immediately  practical  way  pathology  is 
coming  to  be  of  assistance  to  practical  medicine.  In 
the  development  of  every  science  the  solution  of  many 
purely  theoretical  problems  must  precede  the  practical 
application  of  the  principles  involved.  Thus  every 
science  becomes  divided,  sooner  or  later,  into  two  de- 
partments :  the  pure  science,  occupied  with  the  solu- 
tion of  all  the  theoretical  problems  of  the  science,  and 
the  applied  science,  engaged  in  the  application  of  the 
principles  developed  in  the  study  of  the  pure  science 
to  the  needs  of  civilization. 

The  career  of  pathology  as  an  a])plied  science  can 
hardly  be  said  to  have  more  than  begun.  As  a  part  of 
the  general  under-estimation  of  pathology  in  this  coun- 
try, but  little  provision  has  been  made  for  it  by  our 
hospitals,  the  ground,  par  excellence,  for  its  develop- 
ment as  an  applied  science.  Until  our  hospitals  shall 
duly  appreciate  the  value  of  pathological  examinations 
in  the  diagnosis,  prognosis,  and  treatment  of  disease, 
and  shall  supply  means  for  the  development  of  pathol- 
ogy as  an  applied  science  in  a  measure  commensurate 
with  those  which  have  made  possible  its  splendid  prog- 
ress in  its  more  theoretical  department,  practical  medi- 
cine must  forego  a  very  large  part  of  the  aid  which 
pathology  so  freely  offers.  The  responsibility  of  the 
physician  to  make  use  of  every  means  known  to  medi- 


148 


MEDICAL    RECORD. 


[August  3,   1895 


cal  science  and  art  in  the  treatment  of  his  patient  has 
always  been  keenly  appreciated.  His  failure  to  do  so 
is  even  regarded  as  an  offence.  But  the  similar  re- 
sponsibility of  the  hospital  would  appear  to  have  been 
often  overlooked  in  the  matter  of  affording  its  patients 
the  advantage  of  such  examinations  as  the  pathologist 
alone  can  make.  What  was  said  by  Professor  Osier  of 
our  medical  schools,  about  three  years  ago,  applies  with 
force  to  our  hospitals  to-day  :  "  Thoroughly  equipped 
laboratories  in  charge  of  men  thoroughly  equipped  as 
teachers  and  investigators  is  the  most  pressing  want 
to-day  in  the  medical  schools  of  this  country."  That 
this  great  need  of  adequate  provision  for  pathology  in 
our  hospitals,  so  long  and  urgently  felt  by  their  medi- 
cal boards,  is  beginning  to  be  appreciated  by  their 
trustees,  is  evident  from  the  careful  consideration  which 
has  been  bestowed  upon  the  construction  and  organi- 
zation of  the  pathological  departments  of  a  number  of 
our  newer  institutions  of  that  sort,  and  from  the  liber- 
ality which  has  been  displayed  in  a  few  instances  in 
the  endowment  of  such  laboratories.  It  is  greatly  to 
be  hoped  that  the  next  few  years  may  witness  a  much 
further  development  in  this  particular  direction. 

In  a  science  so  rapidly  advancing  as  is  medicine  to- 
day, it  is  impossible  to  predict  with  certainty  what  even 
a  year  may  bring  forth,  but  that  it  will  continue  to  ad- 
vance so  long  as  it  is  dominated  by  the  methods  of  ob- 
servation and  thought  which  have  induced  its  splendid 
progress  during  this  century,  there  can  be  no  doubt. 
In  the  past,  a  period  of  epoch-making  generalization 
has  often  been  succeeded  by  a  time  of  assimilation, 
during  which  the  progress  of  civilization  has  been 
greatly  aided  by  many  practical  applications  of  the 
laws  induced  to  the  needs  of  the  community  as  a  whole. 
It  may  be  that  we  shall  witness  in  the  medicine  of  the 
near  future  a  period  of  similar  application  of  the  great 
principles  disclosed  during  the  nineteenth  century. 
There  is  certainly  very  much  to  be  accomplished  in 
this  direction,  and  there  is  need  in  its  accomplishment 
for  careful  scientific  work  on  the  part  of  every  devotee 
of  medicine,  whatever  the  field  of  his  activity. 

It  is  to  be  feared  that  the  responsibility  of  the  phy- 
sician to  his  science  is  too  often  forgotten  ;  his  ability 
to  aid  in  its  progress  too  modestly  under-estimated.  It 
is  true  that  it  is  given  to  but  few  to  make  the  great 
generalizations  of  a  science.  Theirs  are  the  names 
which  win  the  greatest  fame.  But  the  labors  of  the 
many  who  amass  the  facts  from  which  generalization 
takes  place  and  without  which  it  is  impossible,  and 
who  apply  the  principles  induced  to  the  needs  of  hu- 
manity and  of  civilization,  are  also  worthy  of  the  very 
highest  gratitude  of  mankind.  I  would  therefore  urge 
upon  everyone  whose  life  is  devoted  to  medicine  his 
responsibility  to  contribute  to  the  advancement  of  his 
science,  and  I  would  suggest  that  the  methods  of  care- 
ful scientific  research  which  have  yielded  so  much  in 
the  past  are  those  which  give  the  greatest  promise  for 
the  future.  Every  fact,  however  apparently  insignifi- 
cant, which  is  added  to  medical  knowledge  is  of  materi- 
al assistance  in  the  advancement  of  the  noblest  science 
which  has  yet  engaged  the  mind  of  man. 


Concerning  Spelling  Delormation. — It  is  very  grati- 
fying to  note  that  reformers  in  orthography  have  not 
yet  undermined  the  history  of  language  and  stamped 
their  obtrusive  methods  of  spelling  on  every  printed 
page.  The  simplification  of  construction  and  spelling 
of  a  language  may  be  an  inducement  for  foreigners  to 
learn  that  language  and  give  it  a  better  chance  to  be- 
come the  international  means  of  communication,  but 
anyone  who  has  studied  the  life  and  growth  of  lan- 
guage and  has  a  love  for  philology  (is  it  filolojy  ?)  may 
give  thanks  daily  that  phonetic  spelling  and  the  drop- 
ping of  silent  letters  has  not  yet  been  sanctioned  by 
the  best  writers. — Maryland  Medical  Journal. 


NOTES  ON  THE  NATURE  AND  TREATMENT 
OF  CHOREA,  BASED  ON  SEVENTY-FIVE 
CASES    IN    PRIVATE    PRACTICE.^ 

By  a.  D.   ROCKWELL,  A.M.,  M.D., 

NEW   YORK. 

If  any  apology  is  necessary  for  presenting  for  your 
consideration  a  subject  so  hackneyed  as  chorea,  the 
nature  of  which  so  many  able  and  careful  observers 
have  attempted  to  solve,  and  about  which  discussion 
and  theory  have  been  worn  threadbare,  it  is  :  First,  that 
any  disease,  the  source  of  so  much  anxiety  and  dis- 
tress as  chorea,  cannot  be  discussed  too  frequently  ; 
second,  that  my  experience  has  been  somewhat  large, 
and  gleaned  entirely  in  private  and  not  in  hospital 
practice,  upon  which  nearly  all  considerations  in  regard 
to  this  subject  are  based  ;  and  third,  if  I  cannot  offer 
anything  new  in  regard  to  medicinal  or  hygienic  meth- 
ods of  treatment,  I  am  in  a  position  to  speak  with  some 
authority  and  confidence  upon  the  methods  and  results 
of  electrical  treatment,  a  subject  even  yet,  in  its  relation 
to  this  disease,  too  little  understood  by  the  profession 
in  general,  and  almost  altogether  ignored  by  both 
teachers  and  writers  on  nervous  diseases.  I  have  long 
desired  to  give  the  impressions  of  many  years'  experi- 
ence in  observing  the  course  of  chorea  and  treating  its 
symptoms,  and  the  invitation  that  I  present  before  the 
Neurological  Section  something  pertaining  both  to  neu- 
rology and  electro-therapeutics  affords  me  the  oppor- 
tunity that  I  have  often  thought  to  take. 

Chorea  has  by  common  consent  been  put  in  that  class 
of  diseases  which  presents  no  constant  detectable  change 
in  any  of  the  structures  of  the  body,  and  is  therefore 
termed  functional  in  character.  It  is,  however,  more 
than  doubtful  whether  a  functional  disturbance,  how- 
ever slight  and  evanescent,  can  exist  without  corre- 
sponding disturbance  in  the  nutrition  of  the  nerve  ele- 
ments. Microscopical  changes  have,  it  is  true,  been 
occasionally  found,  but  not  with  sufficient  frequency 
to  enable  us  to  rely  on  morbid  anatomy  to  account  for 
the  disease,  and  the  nutritive  changes  that  in  all  proba- 
bility do  take  place  are  too  subtle  for  detection  and 
may,  perhaps,  ever  remain  conjectural.  Age  and  sex 
in  their  relation  to  chorea  tell  us  far  more  of  its  nature 
than  all  methods  of  post-mortem  examination. 

The  fact  that  it  is  almost  entirely  confined  to  early 
childhood  and  youth,  and  occurs  with  far  greater  fre- 
quency in  girls  than  in  boys,  in  the  emotional  period 
of  life  and  mostly  in  the  emotional  sex,  renders  it  prob- 
able that  the  disease  is,  in  the  vast  majority  of  in- 
stances, purely  functional,  dependent  upon  disturb- 
ances or  shock  to  the  motor  centres  of  the  brain.  To 
illustrate  :  I  once  had  under  my  professional  care  a 
young  girl  suffering  from  what  appeared  to  be  a  slight 
neuritis  of  the  radial  nerve.  On  one  occasion  she  was 
suddenly  asked  a  question  in  regard  to  certain  facts 
which  she  desired  to  conceal.  In  her  efforts  to  dis- 
guise any  appearance  of  surprise,  her  facial  muscles  im- 
mediately passed  beyond  her  mental  control,  and  for  a 
few  moments  the  localized  movements  exactly  simu- 
lated the  familiar  examples  of  facial  chorea.  It  was 
an  excellent  example  of  temporary  chorea,  having  its 
source  in  a  temporary  disturbance  in  the  cerebral  con- 
volutions. 

Neurasthenia  is  a  functional  disease,  and  it  may  be 
either  acute  and  temporary,  or  chronic  and  permanent. 
Just  as  the  fatigue  and  irritability  of  mind  and  body 
that  accompany  profound  and  concentrated  mental 
and  physical  effort  are  dissipated  by  rest  and  sleep,  so 
the  familiar  examples  of  lost  muscular  control  follow- 
ing sudden  emotional  influences  disappear  on  the  sub- 
sidence of  the  cause.  In  both  cases  we  have  to  do 
with  facts  of  cellular  nutrition  ;  in  the  one  case  with 
temporary  exhaustion,  in  the  other  with  temporary  irri- 

'  Read  before  the  Neurological  Section  of  the  American  Medical 
.Association,  May  8,  1894. 


August  3,  1895] 


MEDICAL   RECORD. 


149 


tation.  Intensify  and  prolong  the  processes  of  cell  ex- 
haustion and  cell  irritability,  and  we  get  in  the  one  case 
true  neurasthenia  and  in  the  other  true  chorea.  Another 
reason  for  rejecting  structural  change  as  the  causative 
factor  of  chorea  lies  in  the  fact  that,  so  far  as  we  have 
knowledge,  there  exists  no  structural  change  of  the  ner- 
vous and  muscular  system  that  will  in  itself  produce 
chorea.  Embolism,  to  which  it  has  been  ascribed,  pro- 
duces, so  far  as  we  know,  symptoms  of  a  far  different 
character.  It  is  associated  with  head  pain,  vertigo,  and 
nausea^at  least  at  its  outset — hemiplegia  of  varying  de- 
grees of  severity,  and,  when  right-sided,  with  aphasia  to- 
gether with  other  disturbances  of  speech.  Then  it  must 
be  remembered  how  serious  are  its  sequelas,  how  apt  it 
is  to  recur,  and  to  what  extent  nutrition  is  impaired. 
The  occasional  presence  of  embolic  particles  found  in 
fatal  cases  of  chorea  hardly  offers  sufficient  basis  for 
such  a  theory.  But  that  chorea  must  be  regarded  as  a 
disease  of  the  central  nervous  system,  either  primary, 
or  secondary  to  peripheral  irritation,  can  hardly  be 
questioned.  As  all  movement  as  well  as  all  thought 
has  its  origin  in  the  brain,  it  is  inconceivable  that  dis- 
ordered muscular  movement  such  as  characterizes 
chorea  can  depend  upon  peripheral  influences  alone. 
In  deference  to  our  inability  to  point  out  objective 
pathological  changes,  we  sometimes  speak  of  the  psy- 
chical origin  of  chorea,  yet  in  the  last  analysis  we  fall 
back  on  disturbance  of  the  motor  cortex. 

In  a  large  proportion  of  choreic  cases,  especially 
among  the  poor,  anaemia  exists,  and  in  another  large 
proportion  of  cases  fright  is  the  exciting  cause.  Some 
time  ago  a  child  was  brought  to  me,  suffering  from 
"  nervousness  "  and  extreme  anaemia.  I  prescribed  what 
seemed  to  be  necessary  and  for  a  time  saw  no  more  of 
her.  While  engaged  on  this  article,  the  mother  again 
returned  with  the  child,  suffering  now  from  an  acute 
and  violent  attack  of  chorea,  the  exciting  cause  of 
which  was  fright.  These  two  elements  of  causation, 
fright  acting  upon  a  nervous  system  weakened  and  ir- 
ritable through  its  vitiated  blood-supply,  seem  to  me  to 
give  great  strength  to  the  theory  of  malnutrition  of 
the  cortical  ganglion  cells,  as  the  seat  and  efficient 
cause  of  chorea.  The  analogy  existing  between  cer- 
tain nervous  diseases  that  are  attended  by  no  definite 
and  positive  vaso- motor  changes  is  interesting  and 
suggestive.  Influences,  the  same  in  kind  that  result  in 
diabetes  when  acting  on  the  nervous  system  of  a  man, 
result  in  hysteria  when  acting  on  the  emotional  nature 
of  a  woman,  or  in  chorea  when  it  is  the  tender  and  sus- 
ceptible nature  of  a  child. 

Conflicting  as  are  the  opinions  relating  to  the  pathol- 
ogy and  the  treatment  of  chorea,  there  are  certain  facts 
in  regard  to  the  disease  upon  which  all  experience 
agrees.  Like  Basedow's  disease,  whose  pathology  is  as 
doubtful  as  that  of  chorea,  it  occurs  far  more  fre- 
quently in  the  female  than  in  the  male.  In  my  own 
experience  its  exciting  cause,  in  the  majority  of  cases, 
can  be  traced  directly  to  fright  or  other  emotional 
causes,  and  in  this  it  again  bears  some  resemblance  to 
Basedow's  disease. 

With  increasing  years  the  disease  rapidly  decreases 
in  frequency,  but  becomes  far  more  intractable,  and 
even  dangerous  to  life. 

Notwithstanding  my  belief,  based  upon  these  seventy- 
five  closely  observed  cases,  that  the  majority  are  in  their 
essential  nature  central — although  neither  organic  nor 
structural  in  the  ordinary  acceptation  of  these  terms — 
yet  a  few  have  seemed  to  me  to  depend  upon  reflex  in- 
fluences, both  as  exciting  and  continuing  causes.  Pe- 
ripheral sensory  irritants,  such  as  a  redundant  prepuce 
with  collection  of  smegma,  intestinal  worms,  and  ocular 
defects,  have  all  within  my  own  experience  been  the 
undoubted  cause  of  chorea.  In  the  case  of  a  redun- 
dant prepuce,  an  operation  performed  by  Dr.  Charles 
McBurney,  at  my  request,  resulted  in  the  prompt  re- 
covery of  a  case  where  the  symptoms  had  been  persist- 
ent for  several  months.     In  a   second   case,  where    I 


finally  suspected  worms  to  be  the  cause  of  persistent 
choreic  symptoms  in  a  boy  aged  eight,  a  dose  of  san- 
tonine  resulted  in  the  expulsion  of  no  less  than  ten  of 
the  common  round  worms  and  all  of  considerable  size. 
This  patient  also  promptly  recovered.  In  a  third — a 
case  of  ocular  defect — an  operation  by  Dr.  George 
Stevens  resulted  in  too  prompt  an  alleviation  of  the 
symptoms  to  allow  of  any  doubt  as  to  its  direct  efficacy. 
But  reflex  influences  are  altogether  exceptional,  accord- 
ing to  my  experience,  in  the  production  of  chorea. 

Where  the  causes  above  enumerated  exist  once  in 
connection  with  choreic  symptoms,  they  occur  a  thou- 
sand times  without  any  such  connection.  It  is  the 
pseudo-choreas,  the  various  habit  spasms,  that  seem  to 
be  most  benefited  by  correcting  the  anomalies  of  the 
ocular  muscles  and  errors  of  refraction,  and  not  the  or- 
dinary true  chorea  of  childhood. 

Notwithstanding  all  the  investigations  of  and  the 
statistics  offered  by  those  who  have  written  upon  this 
subject,  I  have  been  unable  to  satisfy  myself  that  be- 
tween rheumatism  or  endocarditis  and  chorea  there  ex- 
ists any  constantly  direct  relation  as  cause  and  effect. 
The  frequency  with  which  a  soft  systolic  murmur  is 
found  associated  with  chorea  must  be  admitted,  and 
also  the  results  of  post-mortems  showing  endocarditis 
and  the  presence  of  vegetations  on  the  cardiac  valves  ; 
but  these  relations  have  been  analyzed  with  sufficient 
thoroughness  to  leave  little  doubt  but  that  they  are 
mostly  accidental,  even  if  in  certain  statistical  tables 
they  are  found  with  suggestive  frequency.  In  epilepsy, 
in  anaemia,  in  the  muscular  relaxation  associated  with 
certain  neurasthenic  cases,  we  not  infrequently  detect 
a  cardiac  murmur,  the  same  apparently  as  the  ordinary 
choreic  murmur.  While  these  murmurs  may  be,  and 
probably  are  due,  in  many  if  not  most  cases,  to  mitral 
regurgitation,  yet  they  speedily  disappear  with  no  per- 
manent structural  harm.  The  temporary  defective  ac- 
tion of  the  mitral  valve  is  believed  to  be  due  to  altered 
nutrition  or  innervation.  Certainly  the  functional  de- 
rangement of  the  action  of  the  valvular  apparatus  is 
sufficiently  evidenced  by  the  readiness  with  which  the 
murmur  disappears  as  the  disease  improves. 

If  rheumatism  is  the  efficient  cause  of  chorea  through 
the  action  of  its  sequel,  endocarditis,  then  it  is  hardly 
necessary  to  say  that  the  endocarditis  should  precede 
the  chorea.  On  the  contrary,  it  precedes  it  only  in  a 
very  small  proportion  of  cases  when  they  are  associated, 
and  in  a  large  number  of  cases  no  evidence  of  endocar- 
ditis can  be  found.  As  a  reflex  cause  endocarditis  may 
occasionally  be  responsible  for  chorea,  as  are  defects 
of  the  eye,  or  intestinal  worms,  or  redundant  prepuce  ; 
but  like  these  irritants,  it  may  and  does  exist  a  thousand 
times  without  any  relation  to  it  whatever.  Most  of  the 
cases  that  have  come  under  my  observation  have  been 
carefully  examined  for  evidences  of  heart  disease,  and 
in  more  than  one-half  of  them  there  could  be  found  no 
murmur  of  any  kind,  and  in  only  a  very  small  propor- 
tion was  there  any  history  of  aches  or  pains  that  could 
possibly  be  attributed  to  rheumatism. 

One  of  the  strongest  arguments  against  the  rheumatic 
origin  of  chorea  is  the  fact  that,  as  related  to  boys, 
girls  suffer  from  chorea  in  the  ratio  of  three  to  one, 
while  rheumatism  affects  boys  far  more  frequently  than 
girls.  Of  the  fifteen  among  my  own  cases  of  chorea 
that  gave  a  history  of  rheumatism,  ten  were  boys  and 
only  five  girls.  These  observations  are  very  much  in 
accord  with  those  of  Meyer,^  who,  out  of  121  cases, 
found  that  only  nine  per  cent,  had  rheumatism,  thir- 
teen per  cent,  heart  symptoms,  and  two  per  cent,  the 
two  combined  ;  and  with  those  of  Leroux,-  who,  out  of 
80  cases  of  chorea,  found  only  5  clear  cases  of  rheuma- 
tism and  14  with  heart  complications.  Of  these  last, 
5  were  mitral  lesions,  and  9  simple  anaemic  and  extra- 
cardiac  souflles. 

Much  stress  is  often  laid  upon  the  degree  of  disturb- 

'  Berliner  klinische  Wochenschrift,  July  4.  1890. 

'  Revue  Mensuelle  des  Maladies  de  I'Enfance,  Paris,  June,  1890 


I50 


MEDICAL    RECORD. 


[August  3,  1895 


ance  of  the  mental  function  in  chorea.  My  observa- 
tion of  the  disease,  as  it  occurs  in  children  who  are  well 
cared  for  both  as  to  mind  and  body,  is  that  there  is 
seldom  any  mental  defect.  Sometimes  a  young  child 
will  seem  dull  without  really  being  so,  and  the  parents 
and  friends  of  the  unfortunate  little  patient  will  act 
along  this  false  hypothesis,  to  the  child's  detriment. 
In  chorea  the  muscular  movements  are  not  in  harmony 
with  the  will.  The  child,  knowing  herself  unable  to 
give  correct  expression  to  thought  and  desire,  manifests, 
in  the  presence  of  strangers  especially,  a  distrust  and 
timidity  not  in  accord  with  an  acute  mental  state,  while 
the  operation  and  condition  of  the  mind,  as  registered 
in  the  facial  expression,  are  observed  and  misinterpreted 
because  of  the  constant  facial  deformity.  The  imper- 
fect muscular  co-ordination  occasionally  extends  to  the 
vocal  apparatus,  rendering  the  speech  somewhat  indis- 
tinct and  jerky.  In  other  cases  the  patient  talks  very 
well  when  once  started.  At  first  the  lips  may  be  seen 
to  move,  but  it  is  several  -seconds  before  there  is  any 
articulate  sound.  One  of  the  brightest  children  I  ever 
knew  had  this  symptom,  and  for  a  time  was  credited 
with  being  below  the  normal  level  mentally.  There  is 
a  class  of  choreic  cases  very  commonly  met  with  where 
the  inco-ordination  of  movement  is  ordinarily  slight, 
but  when  conscious  of  observation  the  muscular  dis- 
turbance becomes  exaggerated.  There  is  another  class 
where  a  contrary  condition  exists.  The  movements 
are  greatest  when  the  patient  is  at  play  and  uncon- 
scious of  observation,  but  by  an  effort  of  will  the  child 
can  control  these  movements. 

It  is  among  patients  of  the  first  class  that  mental 
defects  are  most  often  thought  to  exist  ;  these  cases 
are,  however,  far  less  apt  to  be  dull  than  those  of  the 
second  class,  and  recover  with  greater  rapidity.  I  do 
not  find  that  ordinary  chorea  is  distinctly  or  directly 
hereditary,  but,  among  the  better  class  at  least,  it  will 
be  found  that  in  an  unusually  large  number  of  cases 
the  cliild  inherits  a  neurotic  tendency. 

This  neuropathic  heredity  is  said  to  be  in  the  pro- 
portion of  about  one-sixth,  but  in  my  own  experience 
it  is  very  much  greater.  The  theory  advanced  by 
Garrod  that  the  rheumatic  poison  occasions  a  tem- 
porary overgrowth  of  connective  tissue  in  the  nerve- 
centres,  resulting  in  chorea,  has  little  to  recommend  it; 
but  the  infectious  theory,  about  which  so  much  has 
latefy  been  said,  has  points  of  strength  both  from  an 
anatomical  and  a  bacteriological  stand-point,  since 
there  is  found  in  the  nervous  system  a  special  bacillus 
pathogenic  for  microbes.  Bacteriological  and  experi- 
mental researches  have  been  made  by  Pianese'  in 
fifteen  acute  cases  of  chorea.  In  three  of  these  cases 
a  bacillus  was  isolated  from  the  blood,  and  inoculation 
caused  the  appearance  of  the  disease  in  dogs.  In  the 
opinion  of  this  author,  the  theory  of  the  infectious 
origin  of  chorea  is  far  more  satisfactory  and  complete 
than  all  other  theories.  Triboulet^  has  reported  three 
cases  of  secondary  infection  by  the  staphylococcus  in 
chorea,  and  gives  it  as  his  opinion  that  in  four-fifths  of 
the  cases  infection  could  be  traced  as  the  causative 
factor  of  the  nervous  trouble.' 

But,  however  suggestive  the  various  theories  and 
investigations  as  to  the  nature  of  chorea,  nothing  is 
more  certain  than  that  no  constant  pathological  change 
is  associated  with  it,  and  we  must  fall  back  upon  the 
theory  of  its  neurotic  functional  origin.  Its  almost 
invariable  benign  nature  and  tendency  to  recover  is 
the  strongest  evidence  that  it  can  depend  upon  no 
serious  or  persistent  pathological  change. 

As  regards  the  therapeutics  of  chorea,  there  is  much 
to  be  said,  both  from  the  stand-point  of  those  who  be- 
lieve in  the  necessity  and  efticacy  of  therapeutic  meas- 
ures, and  from  that  of  others  who  look  upon  it  as  prac- 

'  Riforma  Medica,  Naples,  July  20,  1894. 

^  Revue  Mensuelle  des  Maladies  de  I'Enfance,  Paris,  December. 
1891. 
'  These  de  la  Faculte  de  Paris. 


tically  a  self -limited  disease,  which  recovers  as  readily 
without  as  with  treatment.  Self-limited  it  is  not  in 
the  sense  that  we  speak  of  the  self-limitation  of  scarlet 
fever  or  measles. 

We  cannot  abort  or  very  much,  if  at  all,  cut  short 
the  course  of  these  diseases,  but  that  measures  can  be 
adopted  for  the  relief  of  associated  symptoms,  or  the 
arrest  of  complications,  is  admitted.  We  can,  how- 
ever, not  only  very  markedly  alleviate  the  severity  of 
choreic  disturbances  in  aggravated  cases,  but  can  do 
what  cannot  be  done  in  the  so-called  self-limited  dis- 
eases, shorten  the  duration  of  the  disease.  In  regard 
to  certain  hygienic  and  sanitary  methods  of  dealing 
with  chorea,  there  is  very  little  diversity  of  opinion. 
It  is  agreed  that  rest  is  a  most  important  factor  in 
most  cases,  and  in  those  more  serious  the  rest  should 
be  complete  and  continuous. 

In  the  less  severe  cases,  moderate  exercise  in  the 
open  air  is  allowable  and  beneficial,  but  in  no  case 
should  a  child  with  chorea  be  allowed  to  engage  in 
rough-and-tumble  sports.  Sleep,  and  much  of  it,  is 
essential,  and  when  it  is  greatly  disturbed  we  are 
justified  in  aiding  it  by  hypnotic  measures.  The  food 
should  be  nourishing,  but  simple.  If  the  appetite  be 
poor,  it  is  allowable,  and  even  desirable,  to  tempt  it  by 
daintly  prepared  food  of  judicious  selection,  but  to 
attempt  to  stimulate  appetite  by  artificial  means  is 
even  more  unjustifiable  in  the  case  of  a  child  than 
in  that  of  an  adult.  Far  more  harm  than  good  is  done 
by  forcing  food  when  nature  cries  out  against  it. 

To  enumerate  all  the  remedies  that  have  from  time 
to  time  been  advocated  almost  as  specifics  in  the  treat- 
ment of  this  disease  would  only  serve  to  indicate  the 
limited  data  of  experience  upon  which  opinions  are 
based. 

Few  of  them  have  stood  the  test  of  time  and  trial, 
and  the  general  opinion  is  that  medicinal  treatment  is 
extremely  unsatisfactory.  By  this  I  do  not  mean  to  say 
that,  in  individual  cases,  we  may  not  be  reasonably  sure 
of  the  efficacy  of  certain  remedies  in  alleviating  symp- 
toms and  shortening  the  duration  of  the  disease. 
There  are  indeed  well-authenticated  cases  of  long  dura- 
tion that  have  persistently  resisted  various  accredited 
methods  of  treatment,  and  finally  recovered  promptly 
upon  the  adoption  of  some  other  old  or  some  new  and 
untried  remedy. 

A  notable  illustration  of  this  is  related  in  Reynolds's 
"System  of  Medicine,"  where  a  distressing  choreic  afifec- 
tion  of  the  muscles  of  the  neck  had  existed  for  nine 
years,  defying  all  measures  for  its  relief.  Hypodermic 
injections  of  arsenic  were  attempted  with  almost  imme- 
diate relief  and  final  recovery.  But  I  would  say  that 
there  is  no  consensus  of  opinion  as  to  which  of  the 
many  drugs  used  is  the  most  effective. 

Arsenic  has  undoubtedly  the  preference,  but  proves 
too  often  absolutely  inert.  There  can  be  no  question, 
for  exam])le,  of  the  authenticity  of  the  case  just  alluded 
to,  and  encouraged  by  the  success  in  that  instance,  I 
thought  to  duplicate  it  in  an  obstinate  case  somewhat 
similar  in  character,  by  the  same  method  of  treatment, 
but  without  the  slightest  result.  Now,  although  I  have 
from  time  to  time  tested  nearly  all  the  well-recognized 
remedies  in  the  treatment  of  chorea,  yet  there  is  but 
one  remedy  that  I  have  used  with  more  or  less  persist- 
ency in  almost  every  case,  and  that  is  electricity.  1  am 
not  so  credulous  as  to  suppose  it  to  be  curative,  or  even 
markedly  beneficial,  in  every  case.  Occasionally,  on 
the  contrary,  it  has  seemed  to  be  positively  contra-indi- 
cated, although  long  experience  inclines  me  to  believe 
that  this  seeming  susceptibility  to  the  current  is  due 
more  to  a  failure  to  correctly  ditTerentiate  in  the  selec- 
tion of  the  kind  of  electricity  and  injudicious  methods 
of  application  than  to  any  adverse  idiosyncrasy  present. 

In  the  light  of  my  own  personal  experience  in  the 
treatment  of  chorea,  the  opinion  expressed,  more  than  a 
quarter  of  a  century  ago,  by  a  distinguished  j^hysician  is 
of  much  interest.     "  Electricity,"  he  says,  "  is  another 


I 


August  3,  1895] 


MEDICAL    RECORD. 


151 


agent  which  requires  a  passing  mention  in  this  place, 
though  all  that  can  be  said  respecting  it  is,  that  as  yet 
there  appears  to  be  little  or  no  reason  for  placing  any 
confidence  in  it  as  a  means  of  treatment.  Whether  this 
will  always  be  the  case — whether  there  are  not  modes 
of  using  electricity  which  will  have  the  effect  of  quiet- 
ing choreic  and  analogous  movements,  remains  to  be  seen. 
I  suspect  that  there  are  such  modes,  and  that  they  will 
be  beneficial,  but  I  have  not  yet  the  facts  to  justify  the 
expression  of  a  belief  on  the  subject."  '  Electricity 
benefits  chorea  on  the  same  principle  that  it  benefits 
neurasthenia  or  hysteria  and  many  other  functional  ner- 
vous diseases,  because  of  that  indirect  improvement  in 
nervous  force  which  is  a  part  and  a  result  of  the  gen- 
eral improvement  in  nutrition.  While  electricity  is 
neither  life  nor  nerve-force,  it  aids  in  sustaining  both 
life  and  nerve-force,  as  do  light  and  heat  ;  not  by  direct 
transformation,  but  indirectly  through  its  influence  over 
nutrition. 

This  influence  over  nutrition,  together  with  musculo- 
sedative  effects,  are  brought  about  in  greater  or  less  de- 
gree by  various  methods  of  electrization,  by  general 
faradization,  especially  with  the  high-tension  coil,  cen- 
tral galvanization,  static  electrification,  and  even  by 
peripheral  galvanization.  To  obtain  temporary  muscu- 
lo-sedative  effects,  there  is  no  method  that  equals  the 
depolarizing  method  of  central  and  peripheral  galvan- 
ization, by  which  is  meant  the  elimination  of  either  one 
or  the  other  pole.  In  this  way  the  neutral  point  is 
thrown  outside  the  body,  and  the  part  or  parts  brought 
under  the  influence  of  either  the  negative  or  positive 
pole  alone,  as  desired.  Static  electricity  (positive)  is 
also  sometimes  useful  in  chorea  in  calming  nervous 
excitement,  and  as  an  aid  to  nutrition. 

But  the  two  methods  that  I  have  found,  on  the  whole, 
to  be  the  most  effective  in  the  treatment  of  chorea,  are 
central  galvanization  and  general  faradization.  These 
two  methods  properly  differentiated  and  used,  either 
alone  or  in  alternation  according  to  the  indications  in 
each  individual  case,  are  capable  of  doing  much  not 
only  in  alleviating  the  violence  of  the  choreic  move- 
ments, but  in  shortening  the  duration  of  the  disease. 

A  somewhat  useful  point  in  the  way  of  differential 
indication  for  the  use  of  the  two  currents  and  the  two 
methods  of  application,  which  has  been  forced  upon  me 
by  repeated  observation,  is  the  following  :  For  children 
of  full  habit  and  in  that  excellent  condition  of  general 
health  which  we  not  infrequently  see  among  the  victims 
of  chorea,  the  galvanic  current  is  to  be  preferred.  For 
those,  on  the  contrary,  who  are  weak  and  anaemic,  with 
impaired  nutrition,  the  faradic  current  is  far  more 
grateful,  and  is  followed  by  better  results  both  immedi- 
ate and  permanent. 


TWO    CASES    OF    TREPHINING    FOR    TRAU- 
MATIC   EPILEPSY,  WITH   REMARKS. 

By  LEONARD   FREEMAN,   B.S.,   M.D., 

DENVER,  COL. 


Case  I. — The  first  case  was  that  of  a  well-developed 
white  man,  twenty-seven  years  of  age,  who  entered  the 
surgical  service  at  the  Cincinnati  Hospital,  of  which  I 
had  charge  at  the  time,  on  August  3,  1893.  About 
ten  years  previous  he  received  a  load  of  duck-shot 
full  in  the  face,  at  short  range.  The  sight  of  both  eyes 
was  destroyed,  and  a  number  of  shot  lodged  about  the 
face  and  head,  where  they  could  be  felt  beneath  the 
skin.  The  skull  was  perforated  in  the  centre  of  the 
forehead.  Some  necrosed  bone  was  subsequently  re- 
moved from  this  point,  leaving  a  depressed  and  puck- 
ered cicatrix  the  size  of  the  end  of  a  finger. 

Nine  days  after  the  injury,  according  to  the  patient, 
paralysis  of  the  entire  left  side  of  the  body  suddenly 
'  On  Chorea,  by  C.  B.  Radcliffe,  M.D.,  F.R.C.P.     1868. 


set  in,  while  he  was  standing  and  voiding  his  urine. 
Seven  days  after  the  injury  an  attack  of  epilepsy  oc- 
curred. At  first  the  convulsions  took  place  but  once  a 
month,  but  gradually  became  more  numerous,  until, 
when  he  entered  the  hospital,  he  sometimes  had  as 
many  as  five  a  day. 

The  convulsions  were  general,  beginning,  according 
to  the  nurse  and  the  interne,  in  the  right  arm.  The  pa- 
tient became  unconscious,  frothed  at  the  mouth,  and  at 
times  bit  his  tongue,  the  right  elbow  and  knee  becom- 
ing firmly  flexed.  Cj'anosis  and  stertorous  breathing 
supervened,  followed  by  considerable  malaise  and 
nausea. 

The  patient's  intellect  was  cloudy  and  heavy,  so  that 
he  expressed  himself  laboriously.  He  was  at  times 
somewhat  delirious.  Much  pain  was  often  experienced 
over  the  back  and  top  of  the  head.  The  left  side  of 
the  body  was  paretic,  the  hand  and  arm  being  almost 
useless,  although  the  left  leg  could  be  used  sufficiently 
well  to  enable  the  patient  to  shuffle  about  the  ward. 
According  to  himself  and  his  friends,  most  of  the  above 
symptoms  had  been  steadily  increasing. 

Dr.  F.  Kebler  and  Dr.  Joseph  Eichberg  were  called 
in  consultation,  and  an  operation  decided  upon.  Ow- 
ing to  the  fact  that  the  convulsions,  as  observed,  seemed 
to  begin  on  the  right  side,  although  paresis  was  confined 
to  the  left,  it  was  deemed  better  to  trephine  the  left 
side  of  the  skull  first,  and  then,  if  necessary,  make  a 
second  opening  on  the  right. 

The  operation  was  made  on  August  21,  1893,  chloro- 
form being  used  as  an  anesthetic.  The  centre  of  the 
fissure  of  Rolando  was  indicated  by  marking  the  bone 
with  a  drill,  and  a  large  horseshoe  flap  turned  down. 
The  skull  was  found  to  be  so  enormously  thick  that  it 
could  not  be  penetrated  with  the  inch-and-a-half  tre- 
phine at  first  employed,  and  a  smaller  and  deeper  in- 
strument had  to  be  substituted.  After  separating  the 
dura,  which  was  firmly  adherent,  the  opening  was  eii- 
larged  with  the  rongeur  forceps.  On  making  a  semi- 
circular incision  in  the  dura,  the  brain,  which  was  normal 
in  appearance,  bulged  strongly  forward.  A  grooved 
director  was  inserted  about  one  and  one-half  inch  into 
the  cerebral  tissue  in  all  directions  without  detecting 
anything  abnormal.  The  dura  was  then  sutured,  the 
button  of  bone  replaced,  and  the  wound  in  the  scalp 
united. 

The  patient  being  in  excellent  condition,  it  was  de- 
cided to  at  once  explore  the  opposite  hemisphere.  Ac- 
cordingly an  opening  was  made  over  the  centre  of  the 
right  Rolandic  fissure.  A  smaller  trephine  and  the 
rongeur  forceps  were  employed,  and  the  thickened  bone 
removed  with  comparatively  little  difficulty.  The 
membranes  were  again  found  markedly  adherent,  and 
the  apparently  normal  brain  tissue  bulged  more  strongly 
than  before.  On  probing,  nothing  was  found  until  the 
instrument  was  directed  toward  the  base  of  the  skull. 
Here,  from  one  to  one  and  one-half  inch  from  the 
surface,  was  encountered  a  decidedly  resisting  mass, 
having  apparently  a  definite  outline.  The  grooved  di- 
rector was  pressed  steadily  into  this  mass  until  it  pene- 
trated and  dropped  into  a  distinct  cavity,  from  which 
there  flowed  out,  alongside  the  instrument,  a  quantity 
of  clear  fluid.  After  tying  and  dividing  a  large  menin- 
geal vein  which  was  in  the  way,  the  opening  was  en- 
larged by  inserting  a  pair  of  haemostatic  forceps,  and 
spreading  the  blades  as  the  forceps  were  withdrawn. 
Several  ounces  of  clear  fluid  escaped,  and  the  bulging 
of  the  brain  subsided,  leaving  a  depression  on  its  sur- 
face. A  small  drainage-tube  was  inserted  and  brought 
out  through  a  hole  in  the  flap,  the  button  replaced,  and 
the  wound  closed. 

It  was  decided  by  those  present  that  the  cavity 
which  had  been  discovered  and  drained  was  either  a 
serous  cyst  or  a  cystically  enlarged  right  ventricle.  It 
is  certain  that  the  left  ventricle  was  not  enlarged,  this 
possibility  having  been  excluded  by  thorough  explora- 
tion.    That  the  cavity  was  not  merely  a  normal  ven- 


152 


MEDICAL   RECORD. 


[August  3,  1895 


tricle  was  shown  by  its  situation,  its  size,  and  its  firm 
wall.  The  probability  is  that  the  cavity  was  a  cyst  fol- 
lowing a  hemorrhage,  due  to  the  penetration  of  the 
brain  by  one  or  more  shot. 

The  patient  left  the  operating-table  in  excellent  con- 
dition, his  temperature  being  99°  F.  and  pulse  good. 
During  the  following  night  he  uttered  occasional  loud 
cries,  and  became  so  restless  that  shackles  had  to  be 
used.  His  temperature  mounted  to  101°  F.,  but  fell 
to  normal  by  morning.  The  next  night  the  shackles 
were  again  employed  and  the  cries  were  repeated.  On 
August  24th,  the  dressings,  which  were  saturated  with 
serous  fluid  tinged  with  blood,  were  renewed.  On 
August  26th,  the  drainage-tube  was  removed,  the  dis- 
charge, which  had  been  steadily  decreasing,  having 
almost  ceased.  The  patient's  condition  gradually 
improved  until  it  became  better  than  before  the  oper- 
ation. His  mind  grew  clearer,  and  his  headaches  less 
frequent,  until  the  latter  finally  disappeared.  There 
was  no  improvement,  however,  in  the  paresis.  During 
September  15th  and  i6th,  five  convulsions  occurred, 
beginning  in  the  left  arm  and  extending  to  the  rest  of 
the  body.  He  had  no  further  trouble  of  this  kind, 
however,  while  in  the  hospital,  and  was  discharged  on 
September  28,  1893. 

The  patient  was  seen  again  about  nine  months  after 
the  operation.  For  five  or  six  months  he  had  remained 
free  from  headache.  At  the  end  of  that  time  he  began 
to  be  annoyed  by  pain  near  the  bregma,  not  so  severe, 
however,  as  formerly.  This  continued  at  intervals  for 
two  or  three  months  and  then  ceased,  no  headaches  hav- 
ing occurred  during  the  last  three  weeks.  His  intellect 
was  found  much  clearer — he  spoke  quite  easily  and 
quickly,  and  seemed  to  have  the  ordinary  intelligence 
of  his  class.  He  had  had  occasional  epileptic  attacks, 
but  they  had  not  been  so  numerous  as  before,  and  not 
nearly  so  severe.  The  paresis  of  the  left  side  had  im- 
proved, but  the  hand  still  remained  useless.  Altogether, 
the  man's  condition  was  much  better  than  before  the 
operation.  Six  months  later  the  patient  was  again 
heard  from,  and  his  condition  found  to  be  about  the 
same,  perhaps,  as  before  he  was  operated  upon,  all 
benefit  which  he  had  derived  from  surgical  interfer- 
ence, which  was  at  first  quite  marked,  having  disap- 
peared. 

Case  II. — A  healthy,  well-developed  white  man,  be- 
tween twenty  and  twenty-five  years  of  age,  was  struck 
by  a  limb  of  a  falling  tree,  and  suffered  a  compound 
fracture  of  the  skull.  Fourteen  months  after  the  in- 
jury, on  March  12,  1894,  he  was  admitted  to  Christ's 
Hospital  in  Cincinnati.  A  puckered  scar  indicated 
the  seat  of  the  fracture.  The  depression,  which  was 
considerable,  was  about  an  inch  in  length  by  two- 
thirds  of  an  inch  in  width,  and  lay  along  the  right 
parietal  ridge  Justin  front  of  a  perpendicular  line  pass- 
ing through  the  external  auditory  meatus. 

Since  the  accident  epilepsy  had  set  in.  The  fits  had 
neither  been  numerous  nor  close  together,  but  had  in- 
creased in  severity.  One  occurred  in  September,  one 
in  December,  and  one  in  February.  They  were  ac- 
companied with  loss  of  consciousness,  and  lasted  about 
half  an  hour.  They  were  preceded  by  contracture  of 
the  fingers  of  the  left  hand  and  a  "sick  feeling." 
Headaches  had  been  frequent  and  annoying,  and  mem- 
ory had  suffered  considerably.  The  entire  left  side  of 
the  body  was  somewhat  weaker  than  the  right,  al- 
though the  patient  could  handle  himself  fairly  well. 
This  weakness  had  been  preceded  by  twitchings  of 
the  muscles,  and  then  complete,  but  temporary,  paraly- 
sis. The  left  side  of  the  face  was  almost  entirely 
paralyzed,  so  that  the  corner  of  the  mouth  could  not 
be  drawn  back,  and  the  tongue  was  much  deflected. 

An  operation  was  made  on  March  14,  1894,  chloro- 
form being  used  as  an  an;usthetic.  The  fracture  was 
exposed  by  a  large  horseshoe  flap,  and  a  button  of  bone 
removed  with  an  inch  trephine  ;  after  which  the  ron- 
geur forceps  were  freely  employed.      The  depressed 


bone  was  much  thickened,  roughened  on  its  under  sur- 
face, and  adherent  to  the  dura.  When  the  dura  was 
opened  by  a  semicircular  incision,  beneath  and  ad- 
herent to  it  was  found  a  yellowish,  puckered  mass,  the 
size  of  the  last  joint  of  the  thumb,  merging  into  the 
surrounding  substance  of  the  brain.  This  proved  to 
be  partly  fibrous  tissue,  and  mostly  remnants  of  an  old 
blood-clot.  There  was  no  cyst.  The  cicatrix  and  a 
small  portion  of  adherent  membranes  were  carefully 
dissected  out  with  scissors,  leaving  a  ca\"ity  in  which 
one  could  place  lengthwise  the  last  joint  of  the  thumb. 
Hemorrhage  was  slight.  In  closing  the  wound,  the 
dura  could  not  be  completely  reunited,  an  opening 
the  size  of  a  finger-nail  remaining.  A  drainage-tube 
was  brought  out  through  a  special  incision  in  the  flap. 
The  bone  which  had  been  removed  was  not  replaced. 
Recovery  from  the  operation  was  uneventful. 

Owing  to  a  free  discharge  of  bloody  cerebro-spin'al 
fluid  from  the  wound,  necessitating  renewal  of  the 
dressings,  the  drainage-tube  was  not  removed  until  the 
fourth  day.  As  the  edges  of  the  wound  seemed  united, 
the  stitches  were  also  taken  out.  This  proved  to  be  a 
mistake,  as  one  end  of  the  incision  gaped  considerably, 
requiring  the  re-insertion  of  one  or  two  sutures.  On 
the  third  day  after  the  operation,  a  slight  convul- 
sion occurred,  but  was  not  followed  by  others.  The 
headache  disappeared  at  once  and  did  not  return; 
while  the  patient's  memory  gradually  improved,  until 
he  considered  it  as  good  as  before  he  was  injured. 
The  facial  paralysis  disappeared  quite  rapidly,  so  that 
in  a  week  it  was  much  better  ;  and  when  the  patient 
was  discharged  on  April  14,  1894,  only  a  trace  re- 
mained ;  he  could  whistle  easily.  The  weakness  of 
the  left  side  had  also  markedly  improved  ;  the  muscles, 
the  patient  says,  had  grown  larger  and  firmer.  The 
tongue  had  lost  its  deflection.  Constipation  had  given 
place  to  regularity  of  the  bowels.  In  July,  1894,  his 
condition  remained  unchanged.  On  February  26, 
1895,  nearly  a  year  after  the  operation,  the  patient  was 
again  heard  from.  He  had  had  no  convulsions  since 
July  8,  1894,  the  paralysis  of  the  face  had  still  further 
improved,  while  the  hemiparesis  had  all  but  disap- 
peared. The  headaches  had  ceased,  and  memory  was 
as  good  as  it  had  ever  been.  Sutticient  time  has  not 
elapsed  to  justify  an  ultimate  prognosis,  but  so  far 
the  man's  condition  is  decidedly  improved. 

When  operative  surgery  of  the  brain  is  viewed  as  a 
whole,  it  impresses  itself  upon  the  observer  that  the 
most  important  point  is  surgical  cleanliness.  The  brain 
will  bear  an  astonishing  amount  of  rough  handling 
without  serious  consequences,  providing  that  inflam- 
mation does  not  occur  ;  and  inflammation,  as  has  been 
thoroughly  established,  is  due  to  infection  with  micro- 
organisms. We  may  probe  the  brain  in  various  di- 
rections, remove  large  portions  of  it,  tap  its  ventricles, 
compress  it,  bruise  it — in  fact,  there  is  no  reason  why 
we  should  not  even  sandpaper  it,  if  it  were  desirable — 
without  danger  to  life,  providing  only  that  we  keep  it 
clean.  Consider  the  amount  of  bruising  and  laceration 
that  may  result  from  depressed  fractures  and  bullet- 
wounds,  and  yet  the  patients  often  get  well.  The  or- 
gan can  even  recover  itself  with  facility  after  the  re- 
moval of  a  blood-clot  which  has  compressed  an 
entire  hemisjihere.  But  if  infection  once  take  place, 
especially  infection  of  the  meninges,  the  patient's 
chances  are  poor  indeed.  Hence,  as  far  as  operative 
technique  is  concerned,  nothing  is  so  important  as  the 
prevention  of  infection.  Whether  we  chisel  out  bone- 
flaps  or  employ  the  trejihine  ;  whether  we  replace  the 
bone  or  leave  the  opening  free  ;  whether  we  divide  the 
dura  in  a  cross  or  in  a  semicircle  ;  whether  we  explore 
in  this  direction  or  in  that,  or  use  one  instrument  or 
another — these  are  all  minor  considerations  compared 
with  the  vital  question  of  the  prevention  of  inflamma- 
tion. We  should  take  care  to  do  our  patient  no  harm, 
even  if  we  do  him  little  good. 

The  subject  is  of  such  importance  that  one  is  justi- 


August  3,  1895] 


MEDICAL  RECORD. 


153 


fied  in  saying,  I  think,  that,  except  in  cases  of  absolute 
and  immediate  necessity,  no  one  should  open  the  skull 
and  particularly  the  dura,  without  being  thoroughly 
familiar  with  all  the  details  of  surgical  cleanliness,  and 
without  being  prepared  to  carry  them  out  with  exact- 
ness. 

The  patient's  head  should  be  completely  shaved  and 
sterilized  several  days,  if  possible,  before  the  operation, 
and  protected  by  a  sterilized  cap  or  bandage.  If  a 
beard  is  present  it  should  be  removed,  at  least  on  the 
cheeks.  If  the  seat  of  the  proposed  operation  is  on  the 
anterior  portion  of  the  cranium  the  eyebrows  should 
be  shaved.  It  is  verj'  difficult  to  sterdize  the  beard 
and  eyebrows,  and  in  operating  they  may  easily  be 
touched  by  the  operator's  hands  or  instruments,  and 
thus  cause  infection. 

The  head  should  be  thoroughly  scrubbed  with  warm 
soapsuds  and  a  good  brush,  carefully  cleaning  out  any 
old  puckered  scar  which  may  be  present.  Such  scars 
are  dangerous,  as  they  occupy  the  exact  field  of  opera- 
tion. Then  vigorous  scrubbing  and  douching  with 
alcohol  or  ether,  by  means  of  a  bunch  of  sterilized 
gauze.  This  is  to  remove  any  remaining  oily  substance 
which  might  interfere  with  the  action  of  the  antiseptic. 
Then  follows  another  good  scrubbing  with  a  solution 
of  bichloride  of  mercury  of  a  strength  of  i  to  1,000,  or 
better  i  to  500.  These  several  scrubbings  must  be 
more  than  mere  formal  wettings  of  the  skin — they 
must  represent  an  intelligent  endeavor  to  remove  and 
kiU  the  micro-organisms  which  have  not  only  adhered 
to  the  scalp,  but  have  worked  themselves  in  among  the 
superficial  epithelial  cells  and  into  various  minute  de- 
pressions. One  should  bear  in  mind  that  the  skin  comes 
in  constant  contact  with  the  wound-secretions,  so  that 
germs  have  ample  time  to  multiply  and  produce  mis- 
chief. I  believe  that  infection  comes  as  often  from 
the  imperfectly  cleansed  skin  of  the  patient  as  it  does 
from  instruments  or  even  from  the  hands  of  the  opera- 
tor. After  sterilization,  the  scalp  should  be  covered 
with  a  layer  of  gauze  or  cotton  wet  in  i  to  1,000  bi- 
chloride-solution— and  protected  by  a  dry  dressing.  A 
wet  towel,  which  is  so  often  used,  does  not  form  a  satis- 
factor)'  dressing  because  it  cannot  be  so  perfectly 
fitted  to  the  head. 

A  few  hours  before  the  operation,  the  scalp  should 
again  be  sterilized  ;  and  not  only  the  scalp,  but  the 
ears,  neck,  sides  of  the  face,  and  forehead,  and  the  face 
itself  carefully  washed.  It  is  of  no  small  importance 
to  clean  the  ears  without  and  within.  Sometimes  an 
ear  must  be  included  in  the  dressings ;  and,  at  least, 
they  are  apt  to  come  in  contact  with  hands,  instru- 
ments, or  sutures.  If  the  ears,  face,  and  eyebrows  have 
not,  for  any  reason,  been  properly  attended  to,  danger 
may  be  avoided  by  catching  a  sterilized  cloth  about 
the  head  with  a  rubber  band,  and  permitting  the  cloth 
to  fall  downward  over  the  neck,  ears,  and  face  as  far 
as  the  nose.  If  this  band  is  heavy  enough  and  tight 
enough,  it  will  also  control  hemorrhage  from  the  arte- 
ries of  the  scalp.  There  is  generally  considerable  ooz- 
ing of  blood  and  cerebro-spinal  fluid  after  an  opera- 
tion upon  the  brain,  especially  if  the  patient  should 
vomit  following  the  anaasthetic;  hence  it  is  best  in  most 
cases  to  use  a  drainage-tube  ;  which  should  not  be 
brought  out  through  the  incision,  but  through  a  spe- 
cial opening  in  the  flap.  The  tube  can  be  removed  in 
a  day  or  so. 

The  dressing  of  the  wound  is  of  importance.  It  has 
been  sufficiently  demonstrated  that  dryness  is  a  prime 
factor  in  the  prevention  of  germ-growth.  The  dress- 
ings should  not  only  be  perfectly  dry  in  themselves, 
but  should  be  so  arranged  as  to  facilitate  rapid  evapo- 
ration of  the  moisture  which  they  absorb.  They  should 
cover  as  much  surface  as  possible  ;  and  be  of  consid- 
erable thickness,  to  guard  against  the  ready  soaking 
through  of  fluids  from  the  wound.  The  best  dressing, 
I  think,  is  arranged  in  this  way  :  First,  a  large  quan- 
tity of  gauze,  which  should  not  be  neatly  and  com- 


pactly folded,  as  is  often  done,  but  loosely  fluffed  up. 
Gauze  absorbs  more  evenly  when  used  in  this  way,  and 
permits  of  more  rapid  evaporation.  Over  this  is  placed 
a  moderately  thick  layer  of  steriHzed  cotton.  It  should 
be  remembered  that  cotton  is  not  used  so  much  for  ab- 
sorptive purposes  as  for  protection  from  germs,  and 
hence  it  should  cover  in  all  the  gauze,  and  come  every- 
where in  contact  with  the  surrounding  skin.  The  com- 
parative absorptive  powers  of  cotton  and  gauze  may 
frequently  be  noticed  :  fluids  soak  more  or  less  directly 
through  cotton,  while  they  spread  throughout  a  mass 
of  gauze  before  appearing  on  its  surface. 

Some  advise  covering  in  the  entire  dressing  with  a 
sheet  of  rubber  dam  (see  the  "  American  Text-book  of 
Surgery  ").  This  is  not  wise,  as  it  checks  evaporation 
and  keeps  the  dressing  moist.  For  the  same  reason  it 
is  better  not  to  use  a  starch-bandage,  or  even  a  com- 
mon muslin  roller,  for  the  final  covering,  but  a  band- 
age of  simple  gauze. 

If  the  discharge  soak  through,  or  appear  at  the  edges 
of  the  dressing,  a  new  dressing  must  be  applied  at  once, 
as  micro-organisms  rapidly  grow  into  the  moist  mate- 
rial. When  the  dressing  becomes  stained  through  it  is 
a  mistake  to  cover  it  up  with  more  cotton.  The  danger 
is  not  removed,  but  only  concealed  ;  for  we  can  rest 
assured  that  infection  has  occurred  as  soon  as  the 
staining  manifests  itself. 

It  is  practically  immaterial  whether  one  uses  plain 
gauze,  iodoform  gauze,  or  that  impregnated  with  vari- 
ous antiseptics ;  only  it  must  be  dry  and  surgically 
clean.  Plain  and  freshly  sterilized  gauze  is,  I  think, 
the  most  reliable  and  satisfactorv".  Where  a  steam 
sterilizer  cannot  be  obtained,  gauze  and  cotton  may  be 
easily  prepared  by  placing  them,  very  loosely  packed, 
in  a  pan  in  the  oven  of  an  ordinary  cooking-stove. 
When  the  cotton  begins  to  brown  on  the  surface,  the 
material  is  sterilized. 

Time  will  not  permit  me  to  dwell  upon  the  care  with 
which  hands,  instruments,  sutures,  etc.,  must  be  ren- 
dered free  from  infecting  micro-organisms,  nor  upon 
the  precautions  which  must  be  employed  to  preserve 
perfect  cleanliness  after  it  has  once  been  obtained. 
These  are  all  points,  however,  which  must  be  thor- 
oughly mastered  before  operative  work  upon  the  brain 
should  be  attempted. 

1327  Stout  Street. 


URETHROSCOPY  IX  CHRONIC  URETHRITIS.* 
By  FERD.    C.    valentine,  M.D., 


GENITO-UBJNARY  SURGEON   WEST  SIDE  GERM.\K 


SARY,   ETC. 


It  would  be  absurd  to  hold  that  all  cases  of  chronic 
urethritis  must  necessarily  be  treated  by  the  specialist. 
The  majority  can  be  successfully  managed  by  the  gen- 
eral practitioner,  who,  however,  as  a  rule,  cannot  de- 
vote the  time  necessary  for  that  careful  individualiza- 
tion which  each  case  requires.  Furthermore,  the  gen- 
eral practitioner  can  hardly  be  expected  to  provide 
himself  with  cumbersome  and  expensive  apparatus  and 
instruments,  for  which  he  has  but  occasional  use. 

The  many  pathological  elements  upon  which  chronic 
urethritis  may  depend,  need  not  now  be  discussed. 
This  paper's  object  will  be  subserved  in  mentioning  the 
conditions  found  by  urethral  endoscopy,  without  which 
no  chronic  urethritis  can  be  intelligently  treated. 
Time  was  when  every  chronic  urethritis  was  deemed 
dependent  upon  a  stricture.  The  urethra  was  un- 
mercifully slashed  ;  true  enough,  with  good  effect  in 
many  cases,  but  it  needed  the  superior  skill  of  an  Otis 
to  have  genuine  cicatricial  warrant  for  such  procedure. 

The  three  casts  of  normal  urethra;  I  have  the  pleas- 
ure of  showing,  evince  the  fact  that  nature  never  in- 
tended  the   urethra   to  be   a  tube   of   equal   calibre 

»  Read  before  the  Harlem  Medical  .Association,  June  S.  1^3- 


154 


MEDICAL   RECORD. 


[August  3,  1895 


throughout  its  entire  length.  On  the  contrary,  there 
are  so  many  variations  that  it  is  absolutely  impossible 
to  even  suggest  an  average  diameter  for  any  one  case. 
But  this  is  not  very  important  for  the  present  consid- 
eration, save  in  the  sense  that  to  judge  intelligently  of 
what  we  find  in  the  urethra,  we  must  know  that  at  al- 
most every  hair's-breadth  its  calibre  differs  materially. 

We  know  to-day  that  chronic  urethritis  does  not  at 
all  necessarily  depend  upon  stricture ;  nor  need  it 
manifest  itself  m  goutte-tnilitaire,  or  even  slight  agglu- 
tination of  the  lips  of  the  meatus.  Indeed,  a  chron- 
ic urethritis  can  exist  with  no  further  manifestation 
than  clap-filaments,  whose  presence  should  be  a  warn- 
ing to  many  men.  To  others  these  "  Tripper-faden  " 
are  a  source  of  grief,  with  all  the  usual  mental  con- 
comitants of  sexual  diseases.  Early  this  year,  in  a 
paper  on  "  Gonorrhceal  Hypochondriasis,"  read  be- 
fore the  Berlin  Anglo-American  Medical  Society,  1 
went  so  far  as  to  claim  for  chronic  gonorrhoea  the  pos- 
sible ability  to  evoke  insanity,  and  suggested  the  ad- 
visability of  unexplained  suicides  being  examined  for 
the  presence  of  inflammatory  foci  or  gonococci  long 
retained  within  urethral  crypts,  glands,  or  follicles. 
Subsequent  investigation,  study,  and  thought  have  con- 
vinced me  that  the  possibility  is  not  so  remote  as  might 
at  first  appear.  Aside,  then,  of  local  effects  and  readi- 
ness for  contagion,  chronic  urethritis  merits  consider- 
ation for  its  direct  influence  upon  the  patient's  sen- 
sorium  commune. 

The  need,  therefore,  of  most  thorough  searching  of 
the  urethra  for  a  diseased  condition  is  too  evident  for 
discussion.  Tactile  exploration,  so  useful  when  grosser 
constrictions  are  the  cause,  is  necessarily  limited  in  its 
revelations.  Considering  that  most  diseased  processes 
take  place  beneath  the  mucous  membrane,  they  are 
entirely  obscured  from  what  the  sound  can  communi- 
cate to  even  the  most  sensitive  touch.  This  fact,  that 
the  vast  majority  of  pathological  processes  in  the 
urethra  are  situated  beneath  the  mucosa,  has  been  used 
as  an  argument  against  urethroscopy.  It  has  been  held 
that  their  submucous  location  necessarily  excludes  them 
from  visual  detection.  Were  this  invariably  true,  we 
would  have  to  depend  exclusively  upon  the  sound  for 
diagnostic  purposes.  How  often  it  can  yield  unsatis- 
factory results  need  not  be  recited.  Our  other  alter- 
native, then,  without  urethroscopy,  would  be  to  treat 
chronic  urethritis  empirically.  This,  to  paraphrase  an 
old  adage,  would  be  to  literally  "  thrust  into  a  urethra 
of  which  we  know  nothing,  remedies  of  whose  effect 
we  consequently  can  know  less." 

In  a  measure,  the  unavailability  of  urethroscopy  holds 
good  when  reflected  or  projected  light  is  used.  It  is  in 
this  that  I  differ  from  my  friend,  W.  K.  Otis,  whose 
most  ingenious  aero-urethroscope  offers  everything  that 
can  be  desired  in  that  class  of  instruments.  But  the  in- 
strument which  I  shall  have  the  privilege  of  demon- 
strating on  the  patients  whom  I  brought  here  for  that 
purpose,  carries  the  light  into  the  urethra,  to  each  and 
every  point  it  may  be  desirable  to  examine.  This,  the 
Nitze-Oberlander  urethroscope,  not  only  satisfies  the 
physical  demand  for  visual  acuity  by  the  greatest  in- 
tensity of  illumination,  but  it  also  renders  much  of  the 
lower  part  of  the  urethra  translucent.  Thus  it  can  aid 
the  experienced  eye  in  at  least  locating  a  covered  dis- 
eased process. 

This  by  no  means  implies  that  every  chronic  urethri- 
tis depends  upon  a  submucous  diseased  spot,  which 
need  but  be  cauterized,  incised,  or  excised  to  cure  the 
infection.  On  the  contrary,  there  are  many  other 
conditions  which  the  urethroscope  exposes  to  sight. 
These  require  as  much  study  as  do  the  pathological 
changes  which  are  found  in  other  parts  of  the  body. 
Thus  we  may  have  variations  in  the  color  of  the  mucous 
membrane,  loss  of  normal  striation,  increase  or  diminu- 
tion of  the  normal  urethral  folds,  gaping  glands,  and 
numerous  other  conditions.  All  of  these  and  combina- 
tions of  them  indicate  various  etiological  factors.     Ep- 


ithelial denudations,  ulcers,  circumscribed  or  general 
diseased  conditions  of  a  catarrhal  or  specific  character, 
neoplasms,  etc.,  are  discoverable  only  by  means  of  the 
urethroscope. 

Oberlander,  if  he  deserved  no  other  credit,  merits 
immortalization  for  his  industrious  studies  of  the 
urethra  and  devising  methods  of  treatment  for  chronic 
urethritis.  Incidentally,  it  may  be  mentioned  here  that 
he  was  the  first  to  diagnose  carcinoma  of  the  urethra 
by  means  of  the  endoscope. 

Oberlander  found  an  active  coadjutor  in  KoUmann, 
who  did,  and  is  doing,  much  original  work  in  urethro- 
scopy. At  some  future  time  I  hope  to  show  photo- 
graphs taken  by  him  of  the  urethra.  These  demonstrate 
that  chronic  urethritis,  which  is  only  a  generic  term,  is 
of  sufficiently  varying  origin  to  merit  all  that  Ober- 
lander, Kollmann,  and  others  have  written  on  the  sub- 
ject. 

In  this  connection  it  must  not  be  forgotten  that  the 
urethroscope  often  proves  useful  in  finding  the  hidden 
lumen  of  severe  strictures — another  condition  pro- 
vocative of  chronic  urethritis. 

It  is  certainly  true  that  the  mere  presence  of  the  ure- 
throscopic  tube  can  produce  apparent  antemias  or  hy- 
perasmias.  To  the  inexperienced  eye  they  may  convey 
pathological  changes  where  none  exist.  But  study  and 
practice  do  away  with  this  source  of  error.  They  also 
teach  the  selection  of  the  proper  calibre  of  tube  for 
each  urethra,  and  so  holding  it  that  the  examined  parts 
are  rendered  neither  paler  nor  darker  than  in  reality 
they  are. 

We  are  met,  then,  by  three  self-evident  propositions: 
I,  Chronic  urethritis  is  a  generic  term,  covering  many 
diseases ;  2,  most  of  these  diseases  cannot  be  dis- 
covered by  intra-urethral  touch  or  by  external  mani-. 
festations  ;  3,  they  can  be  located,  studied,  and  treated 
only  through  the  urethroscope. 

A  discussion  of  the  various  kinds  of  urethroscopes 
would  lead  beyond  the  purposes  of  this  paper.  In  one, 
presented  by  me  to  the  American  Medical  Association 
on  May  7,  1895,  'hey  were  described.  Careful  ex- 
amination of  all  causes  me  to  advocate  the  Nitze- 
Oberliinder  urethroscope,  whose  intensity  of  direct 
illumination  compensates  fully  for  whatever  may  at 
first  appear  cumbersome  in  the  apparatus. 

The  one  I  have  the  privilege  of  showing  now,  and 
which  I  will  demonstrate  in  use  on  the  patients  here 
for  the  purpose,  is  naturally  not  of  the  dimensions 
which  I  would  advise  the  general  practitioner  to  ac- 
quire. The  smaller  forms  amply  suffice  for  all  general 
purposes.  They  consist  essentially  of  a  small  accumu- 
lator, connected  through  a  simple  rheostat  with  wires 
which  conduct  to  the  light-carrier.  This  light-carrier 
has  a  tube  which  carries  water  to  it,  and  another  which 
carries  water  from  it.  By  means  of  this  flow,  the  un- 
covered wire,  made  incandescent,  is  kept  cold,  no 
matter  how  long  it  rests  in  the  urethra.  This  apparatus, 
in  its  -simpler  or  more  complex  forms,  is  made  by 
Heynemann,  of  Leipzig.  The  form  I  use  is  one  in- 
tended for  specialists. 

I  abstain  from  recording  a  more  detailed  description 
of  the  instrument,  as  it  is  soon  to  be  published  in  an 
article,  in  English,  on  Urethroscopy,  by  Wossidlo,  of 
Berlin.  For  tlie  same  reason  I  do  not  now  mention 
anything  of  the  technique  of  urethroscopy;  further- 
more, it  will  be  evident  to  those  to  whom  I  have  the 
pleasure  of  showing  the  very  few  and  simple  manipula- 
tions required. 

The  appearance  of  the  urethra  varies  in  accord  with 
the  region  examined,  as  well  as  with  the  pathological 
conditions  that  may  prevail.  Oberlander,  Kollmann, 
Posner,  Griinfeld,  Burckhardt,  have  described  these  in 
their  works,  whose  study  cannot  be  too  highly  recom- 
mended. 

As  vastly  different  as  are  the  pathological  conditions 
which  cause  and  sustain  chronic  urethritis,  so  varying 
must  necessarily  the  treatment  be.     Shall  we  inject. 


August  3,   1895] 


MEDICAL   RECORD. 


155 


irrigate,  or  cauterize  ;  shall  we  incise  strictures  or  dis- 
eased glands  ;  shall  we  perform  a  species  of  massage  of 
the  entire  urethra  by  Oberlander's  or  Kollmann's 
modified  Otis  dilators;  shall  we  instill  ^^ith  the  Guyon 
or  Ultzmann  syringes;  shall  we  use  Gschirrhakl's 
brush  or  Wintemitz's  psychrophor;  shall  we  dilate 
with  sounds,  or  shall  we  leave  the  urethra  alone  and 
obtain  relief  by  constitutional  treatment  ? 

These  questions  can  be  answered  only  after  that 
close  individualization,  which  nothing  but  the  urethro- 
scope can  give.  It  would  be  folly  to  assert  that,  no 
cases  have  recovered  without  urethroscopy.  In  some, 
accident  has  given  success  to  crass  empiricism;  but 
these  could  have  been  intelligently  treated  and  more 
quickly  cured,  if  they  had  been  properly  examined.  It 
is,  therefore,  eWdent  that  no  attempt  should  ever  be 
made  to  treat  chronic  urethritis  until  the  practitioner 
has  ascertained  what  the  diseased  condition  is  and 
where  it  is  located.  Nothing  except  urethroscopy  will 
furnish  these  absolute  essentials. 

242  West  Forty-third  Street. 


INSOLATION  OR  THERMOPLEGIA  :    A  CLIN- 
ICAL  STUDY. 

By  F.  W.  ANTONINUS  FABRICIUS,  M.D., 

EX-HOUSE  PHYS1CL\N   OP  BELLEVX*E   HOSPITAL,  NEW  YORK   CITY. 

Insolation  or  thermoplegia  comprises  various  explo- 
sive phenomena  originating  in  the  central  nervous  sys- 
tem as  the  result  of  prolonged  exposure  to  a  high  tem- 
perature and  an  accumulation  of  toxic  products  in  the 
blood.  Violent  muscular  exercise  and  severe  mental 
strain  are  noted  predisposing  factors. 

Clinically,  three  distinct  varieties  are  recognized, 
each  form  demanding  special  treatment  modified  in 
accordance  with  the  intensity  of  the  attack  and  the 
condition  of  the  individual. 

I.  Anaemic  Form. — This  type,  better  known  under 
the  name  of  heat  exhaustion,  generally  affects  debili- 
tated subjects  with  a  high-strung  nervous  system  and 
low  resisting  power.  The  onset  is  the  least  sudden  of 
the  three  classes  of  cases,  presenting  a  prodromal  stage 
of  variable  duration.  The  symptoms  are  characteristic 
of  cardiac  syncope,  mental  depression,  dizziness,  head- 
ache, great  prostration,  and  at  times  nausea  and  yom- 
iting  ;  the  patient  sinks  to  the  ground  utterly  ex- 
hausted. Consciousness  may  be  preserved  for  some 
time  or  not  lost  at  all  ;  usually,  however,  syncope  su- 
pervenes, rapidly  deepening  into  coma.  Countenance 
is  pale,  eyes  are  half  closed,  pupils  widely  dilated,  and 
the  muscles  completely  relaxed.  The  skin  is  cool  and 
clammy,  the  pulse  accelerated  and  feeble,  later  on 
irregular,  respirations  are  sighing  and  increased  in  fre- 
quency. Superficial  reflexes  are  for  the  time  abolished, 
deep  continue  unaffected.  The  temperature  is  below 
the  normal,  ranging  from  97°  to  95°  F.  per  rectum. 
Death  may  result  immediately  from  cardiac  paralysis, 
I  or  later  on  from  asthenia  ;  in  one  instance  an  epilepti- 
form convulsion  terminated  the  scene. 

Treatment. — In  mild  cases  with  transient  syncope 
rest  alone  is  indicated  ;  the  severer  forms  of  collapse, 
however,  call  for  immediate  stimulation  to  support  the 
exhausted  heart.  Remove  patient  to  a  cool,  shady 
place,  with  the  head  lower  than  the  knees  and  inject 
subcutaneously  twenty  minims  of  aromatic  spirits  of 
ammonia,  to  be  followed  by 

B .    Strychn.  sulph gf-  "sV 

Atropin.  sulph gr.  yjrij 

Glonoin gr.  ^ 

M.  f.  hypo.     S.:  one  dose. 

If  the  heart  responds  put  patient  to  bed  and  apply  a 
hot  pack,  with  hot-water  bottles  to  the  feet  and  a  cold 
cloth  around  the  head.  It  is  not  advisable  to  allow 
patient  to  remain  in  the  pack  over  half  an  hour,  for  the 


temperature  might  suddenly  jump  to  the  other  extreme, 
rendering  the  prognosis  very  unfavorable.  Sponging 
the  body  with  hot  water  containing  one-third  of  alco- 
hol is  a  very  successful  method  of  administering  warmth 
and  stimulating  capillar)'  circulation.  Should  the  tem- 
perature fail  to  rise,  a  quart  of  a  one  per  cent,  solution 
of  sodium  chloride  at  a  temperature  of  105°  F.  may  be 
injected  per  rectum.  Owing  to  the  irritable  condition 
of  the  gastric  mucous  membrane  alimentation  is  to  be 
carried  on  by  nutritive  enemata. 

2.  Congestive  Form. — -In  the  second  or  congestive 
variety  the  onset  is  more  precipitate  and  the  prodromal 
stage  of  shorter  duration.  The  individual  is  suddenly 
seized  with  violent  throbbing  pains  in  the  head  and 
back  of  the  neck,  vertigo,  tinnitus  aurium,  and  marked 
muscular  weakness,  dropping  senseless  to  the  ground. 
The  face  is  flushed,  conjunctivae  are  injected,  pupils  di- 
lated ;  pulse  is  accelerated  and  of  rather  high  tension  ; 
respirarions  are  quite  deep  and  rapid.  Skin  is  con- 
gested, usually  moist.  The  temperature  is  elevated, 
rarely,  though,  over  103°  to  104°  F.  In  favorable 
cases  this  stage  of  coma  subsides  in  two  to  three  hours, 
leaving  the  patient  with  often  v-iolent  neuralgic  pains 
and  headaches,  slowly  regaining  his  former  state  of 
health,  but  sometimes  continuing  mentally  enfeebled. 

Treatment. — Applications  of  cold,  if  the  temperature 
is  103°  F.  or  over,  in  the  form  of  sponge  bath  or  wet 
pack.  A  ver>'  serviceable  apparatus  for  the  adminis- 
tration of  cold  baths,  particularly  in  hospital  and  fever 
practice,  has  been  deWsed  by  Dr.  H.  M.  Biggs,  of  Belle- 
vue  Hospital,  and  has  since  been  adopted  by  the  New 
York  Board  of  Health.  It  combines  all  the  advan- 
tages of  the  plunge  bath  with  a  minimum  disturbance 
to  the  parient,  who  is  simply  turned  from  side  to  side 
in  his  bed  while  the  apparatus  is  adjusted. 

Free  catharsis  should  be  encouraged  as  much  as  pos- 
sible, either  by  enemata  of  glycerine  and  ox-gall,  each 
§  j.,  or  gr.  }i  of  elaterin  given  by  mouth.  Venesection 
may  be  of  ser\-ice  in  some  cases,  especially  if  the  pa- 
tient is  robust  and  full-blooded  ;  this  may  aid  in  pre- 
venting pulmonary  complications,  which  are  very  liable 
to  occur  in  this  t}T3e  of  the  disease.  If,  on  the  con- 
trary, the  heart-power  fails,  then  active  stimulation 
must  be  resorted  to.  In  the  after-treatment  phenace- 
rin,  bromide,  and  chloral  will  be  found  of  service  in 
relieving  headache  and  insomnia. 

3.  ^Vhile  the  preceding  forms  are  met  with  at  all 
times  during  the  year,  the  third  or  apoplectic  tj'pe 
is  rarely,  if  ever,  seen  except  during  midsummer  with 
high  external  heat  and  great  accumulation  of  moisture. 
Persons  living  in  unhealthy  districts,  and  those  under- 
going violent  exertions,  such  as  stokers  on  tropical 
steamers,  workers  in  gas-houses,  soldiers  on  forced 
marches,  etc.,  easily  succumb  to  this  disease. 

The  onset  is  invariably  abrupt,  the  patient  falling  to 
the  ground  as  if  struck  by  lightning.  Consciousness  is 
lost  almost  immediately ;  countenance  is  deeply  con- 
gested, almost  cyanotic  ;  the  veins  of  the  forehead  are 
engorged,  and  stand  out  prominently  ;  the  features 
are  entirely  relaxed  and  devoid  of  expression ;  eyes 
are  wide  open  and  fixed  ;  pupils  show  marked  contrac- 
tion :  skin  is  drv'  and  burning  hot  to  the  touch  and 
appears  mottled  in  places  ;  the  pulse  is  accelerated, 
full,  and  bounding  ;  arteries  pulsating  forcibly  against 
the  examining  finger ;  respirations  are  increased  in 
frequency  and  quite  deep  ;  temperature  ranges  from 
106°  to  110°  F.,  or  even  higher,  in  one  case  rectal  tem- 
perature was  found  to  be  iio.S°  F.  Coma  is  verj'  pro- 
found ;  muscles  are  completely  relaxed ;  cutaneous 
reflexes  lost ;  deep  reflexes  increased.  We  find  paralysis 
of  the  sphincters,  involuntary  passages  of  urine  and 
faeces,  the  latter  usually  of  a  light  yellow  color,  a  diar- 
rhoeic  consistency,  and  a  peculiar  sickening  odor. 
Vomiting  early  in  the  attack  was  observed  only  infre- 
quently. 

This  type  is  most  fatal ;  death  resulting  from  apnoea. 
The  coma  lasts  anywhere  from  three  to  twelve  hours. 


1=16 


MEDICAL    RECORD. 


[August  3,  1895 


In  one  instance,  seen  in  1892,  patient  remained  coma- 
tose for  sixty-two  hours  and  recovered  eventually. 
The  chief  source  of  danger  is  found  in  the  hyper- 
pyrexia ;  if  not  speedily  checked  acute  cerebral  oedema 
and  dangerous  meningeal  congestion  will  soon  place 
the  patient  in  a  critical  state.  In  severe  cases  grave 
symptoms,  indicative  of  rapidly  progressing  changes  in 
the  gray  matter,  become  apparent ;  just  what  these 
changes  are  has  not  been  definitely  settled.  Owing  to 
the  high  temperature  the  elementary  constituents  of 
the  blood  must  undergo  important  transformations, 
and  so  will  all  the  other  tissues  in  immediate  contact 
with  it.  The  soft,  yielding,  nervous  centres  suffer  most. 
Following  the  sudden  rise  in  temperature,  and  the 
highly  increased  blood-pressure,  along  with  certain 
hsemic  changes,  degenerative  processes  take  place  in 
the  vessels,  favoring  a  transudation  of  the  serum  into 
the  parenchyma  of  the  nerve-tissues  and  their  lymph 
spaces,  offering  an  obstruction  to  the  return  flow  of 
blood,  resulting  in  venous  hyperaemia.  The  ganglion 
cells  themselves  probably  undergo  changes  in  addition 
to  the  above-mentioned  transient  nutritive  disturb- 
ances ;  there  possibly  occurs  a  partial  or  complete 
coagulation  of  the  protoplasm  in  the  cells,  with  a  sec- 
ondary disintegration  of  the  myeline  in  the  nerve-fibres, 
induced  by  the  intense  degree  of  thermic  energy.  If 
these  pathological  changes  advance  beyond  a  certain 
point,  death  must  inevitably  result,  for  regeneration  of 
the  nerve  elements  does  not  occur  ;  this  may  explain 
certain  sequelas  during  the  convalescent  stage,  partic- 
ularly mental  derangements,  as  dementia  and  imbecil- 
ity, which  presuppose  a  destructive  process  in  the 
brain. 

Usually  the  patient's  condition  changes  after  two  to 
four  hours  ;  either  consciousness  partially  returns  and 
he  recovers,  or — and  this  is  more  frequent — the  symp- 
toms increase  in  severity,  nearing  a  fatal  termination. 
Facial  paralysis  develops,  interfering  with  respiration, 
during  which  act  lips  are  sucked  in  and  puffed  out, 
breathing  becomes  labored  and  stertorous,  pulse  gradu- 
ally loses  in  volume  and  tension,  and  gains  in  rapidity. 
In  the  course  of  eight  to  ten  hours  rigidity  of  the  back 
of  the  neck  and  contractures  of  arms  and  legs  appear, 
indicating  spinal  involvement ;  these  cases  were  in- 
variably fatal.  The  temperature  oscillates  between 
106°  to  109°  F.,  influenced  largely  by  hydrotherapeutic 
measures.  It  may  remain  continually  high  or  remit 
three,  even  five,  degrees,  to  rise  again  in  two  to  three 
hours  ;  a  decided  elevation  just  before  dissolution  is 
common.  The  urine  contains  a  variable  amount  of 
albumin,  resulting  either  from  a  pre-existing  nephritis, 
or  an  acute  parenchymatous  degeneration  of  the  kid- 
neys ;  in  one  case  haemoglobinuria  was  present.  In 
three  cases  seen  in  1893,  at  Havana,  Cuba,  punctiform 
hemorrhages  appeared  in  the  conjunctiva,  in  the  sub- 
cutaneous tissues  of  the  eyelids,  abdomen,  and  feet. 

Death  occurring  early  results  from  cardiac  paralysis 
or  apnoea  ;  after  two  to  three  days  from  cerebral  oedema 
or  secondary  meningitis  ;  later  on  from  parenchymatous 
inflammations.  Uncomplicated  recoveries  are  said  to 
be  infrequent,  insanity  constituting  a  common  and 
dreaded  sequel. 

Treatment. — Everything  depends  on  the  speed  by 
which  the  high  temperature  is  brought  under  control. 
Loosen  the  clothing  and  remove  the  patient  to  a  cool, 
shady  place,  where  there  is  free  access  of  air  ;  strip 
him  of  all  clothing  and  apply  cold  in  some  form.  A 
most  efficient  method  is  found  in  the  garden-hose, 
douching  the  body  thoroughly  all  over  for  twenty  to 
thirty  minutes  till  a  decided  impression  is  made  on  the 
temperature,  which  usually  falls  then  to  105°  or  104° 
F.  The  stream  of  water  strikes  the  body  with  con- 
siderable force,  e.xerting  a  great  deal  of  friction,  thereby 
stimulating  to  a  high  degree  the  cutaneous  capillary 
circulation  and  exposing  in  this  manner  more  blood  to 
the  cooling  influence  of  water.  A  hypodermic  injec- 
tion should  now  be  given  of — IJ..  Tinct.  strophanth. 


TTlx.  ;  tinct.  aeon,  rad.,  Tllij.;  glonoin,  gr.  •^.  Mix,  and 
repeat  in  two  hours. 

The  douche  may  be  employed  again,  if  temperature 
calls  for  it,  in  one  to  two  hours,  but  it  is  preferable  to 
substitute  the  plunge-bath  containing  large  pieces  of 
ice.  While  one  attendant  supports  head,  two  others 
should  rapidly  and  thoroughly  massage  the  whole  body 
to  bring  the  blood  from  the  overheated  organs  to  the 
surface.  An  ice- cap  is  to  be  applied  to  the  head,  or 
better,  a  piece  of  ice  rubbed  over  it  and  neck.  The 
temperature  is  to  be  recorded  every  ten  minutes,  with 
the  pulse  and  respirations.  Shock  need  not  be  dreaded 
if  above  directions  are  carried  out  conscientiously, 
particularly  in  regard  to  friction,  which  constitutes  an 
important  vascular  stimulant.  When  the  temperature 
approaches  103°  F.,  a  sudden  change  takes  place,  the 
patient  becomes  very  restless  and  makes  unsuccessful 
efforts  to  get  up,  he  puffs  and  groans,  respirations  are 
accelerated,  while  the  pulse  drops  from  190-200  down 
to  150-140  without  losing  in  tension.  The  skin  as- 
sumes a  healthy  red  hue,  the  pupils  suddenly  dilate,  and 
explosive  vomiting  of  enormous  quantities  of  a  greenish- 
brown  fluid  occurs,  sometimes  projected  over  six  feet 
from  the  body  ;  it  was  found  to  be  unusually  rich  in  urea, 
with  an  admixture  of  altered  red  blood-cells,  the  reaction 
was  acid.  Sensibility  may  now  return,  but  this  is  infre 
quent ;  the  before-mentioned  phenomena  are  purely 
reflex.  As  soon  as  thermometer  indicates  a  fall  below 
io3.5°-io2°  F.,  patient  is  to  be  removed  from  tub  and 
placed  on  a  bed,  covered  with  a  rubber  blanket,  and  is 
then  enveloped  in  a  cold,  wet  sheet,  moistened  occa- 
sionally with  ice-water.  Should,  notwithstanding  this, 
the  temperature  rise  again,  the  plunge-bath  may  be  re- 
peated, or  the  bed-bath  substituted.  Enemata  of  cold 
water,  temperature  of  50°  F.,  combined  with  gastric 
lavage,  exert  a  powerful  stimulating  influence.  The 
water  should  be  allowed  to  run  in  and  out  slowly,  and 
its  gain  in  temperature  noted. 

If  the  individual  is  free  from  organic  disease  and 
strong,  phlebotomy  must  be  performed.  It  aids  in 
reducing  temperature,  overcomes  meningeal  conges- 
tion, and  by  lessening  arterial  tension  may  abort  an 
impending  cerebral  oedema,  diminishing  the  liabilities 
to  serious  complications.  Fourteen  ounces  of  blood 
may  be  removed  with  perfect  safety  ;  in  one  case  a 
corresponding  amount  of  Billroth's  solution,  at  a  tem- 
perature of  58°  F.,  was  allowed  to  escape  under  low 
pressure  through  a  hypodermic  needle  into  circulation 
through  the  same  opening  in  the  vein,  effecting  a  drop 
of  two  and  a  half  degrees  in  the  rectal  temperature. 
Subcutaneous  injections  of  carbamide  of  quinine,  anti- 
pyrine,  and  salicylic  acid  were  found  useful  in  those 
cases  when  prolonged  application  of  cold  did  not 
materially  reduce  the  temperature — antipyrine  in  five- 
grain  doses  is  most  reliable.  The  judicious  adminis- 
tration of  tincture  of  aconit.  rad.,  Illss,  every  twenty 
minutes,  is  followed  by  the  happiest  results  in  relieving 
the  dry,  hot  skin,  acting  as  a  mild  diaphoretic  and 
nervo-vascular  sedative  ;  it  should  be  discontinued, 
when  a  marked  impression  has  been  made  on  the 
pulse.  Active  diaphoresis  may  be  induced  by  pilocar- 
pine administered  subcutaneously  ;  by  mouth,  gtt.  iij.  of 
ol.  tiglii  are  to  be  given  to  thoroughly  cleanse  intesti- 
nal tract.  Hypodermic  injections  of  fifteen-grain  doses 
of  magnes.  sulphat.  failed  to  effect  evacuation  of  the 
bowels.  Venesection  may  be  repeated  in  apoplectic 
persons,  but  it  is  wiser  to  substitute  any  of  the  above- 
mentioned  vascular  sedatives.  A  fly-blister  to  the  back 
of  the  neck  is  sometimes  useful.  In  all  cases  where 
temperature  ranges  above  107°  F.  the  hair  should  Jdc 
cut  close  to  the  scalp  and  an  ice-cap  applied  ;  or  still 
better,  tie  a  large  abdominal  ice-coil  to  the  head  and 
let  ice-water  circulate  through  it  constantly.  Fibril- 
larly  twitchings  of  the  muscles  and  severe  convulsions 
invariably  predict  a  fatal  issue  close  at  hand.  Amyl 
nitrite  to  nostrils,  or  glonoin  hypodermically,  with  inha- 
lations of  chloroform,  may  diminish  their  intensity,  but 


August  3,  1895] 


MEDICAL    RECORD. 


157 


not  remove  the  underlying  condition.  Morphine  has 
been  used,  but  is  contraindicated  from  the  marked 
meningeal  hyperaemia  it  induces.  Chloral  and  bro- 
mides are  useless  during  the  convulsion,  but  they  mav, 
given  per  rectum  at  the  proper  time,  abort  it.  Chloral, 
fifteen  grains,  pot.  brom.,  forty  grains,  administered 
per  enema,  when  the  fibrillary  twitching  commences, 
may  be  successful. 

When  patient  regains  consciousness  temperature  usu- 
ally falls  below  normal,  but  alcoholic  stimulants  are 
rarely  called  for  ;  on  the  contrary,  they  do  harm  bv  pre- 
cipitating or  augmenting  meningitis.  After  one  to 
two  days  a  febrile  reaction — a  rise  to  102°  to  103°  F. — 
is  seen  and  may  indicate  meningeal  involvement.  Gen- 
erally, however,  it  is  of  no  vital  importance.  Should. 
however,  meningitis  set  in,  the  prognosis  is  rendered 
very  grave  ;  it  is  therefore  advisable  to  continue  the 
use  of  the  ice-cap  or  coil,  and  administer  a  cerebral 
sedative,  such  as  bromides,  ten  grains  t.i.d.  The  diet 
should  be  very  light  and  cold,  milk  with  Vichy,  seltzer, 
or  lime-water,  iced  lemonade,  and  a  little  claret  well  di- 
luted. If  the  stomach  rebels,  rectal  alimentation  is 
called  for.  The  severe  throbbing  headache  and  ach- 
ing pains  are  best  combated  by  counter-irritation  and 
the  coal-tar  preparations.  The  bowels  must  be  kept 
open  by  the  free  use  of  alkaline  waters  saturated  with 
salts  of  magnesium  and  sodium.  The  room  should  be 
kept  dark,  but  well  aerated,  and  all  active  movements 
interdicted.  The  stage  of  convalescence  is  slow  and 
tedious,  and  marked  by  the  appearance  of  sequelse  of 
more  or  less  significance.  The  brain  is  the  last  in  re- 
covering its  former  functional  actiWty,  if  it  does  at  all. 
and  it  is  the  duty  of  the  physician  to  familiarize  the 
patient's  friends  with  the  possibility  of  a  permanent 
mental  derangement  at  an  earlier  or  later  period.  At 
best  the  individual  will  always  be  delicate  and  greatly 
susceptible  to  the  influence  of  heat,  and  therefore  he 
should  be  ad\ised  to  live  in  a  temperate,  even  climate. 


NEW  LAWS  OF  INTEREST    TO    PHYSICIANS. 
By  FREDERIC  G.  MATHER, 


The  recent  Legislature  passed  a  number  of  laws  and 
amendments  of  interest  to  the  medical  profession. 
Among  the  most  important  amendments  were  those  to 
the  Public  Health  Law  as  follows  :  Providing  that  the 
State  Board  of  Health  appoint  two  of  its  members  as  a 
committee,  whose  particular  duties  shall  be  to  carry 
out  the  provisions  of  the  Public  Health  Law  relating  to 
tuberculosis  in  cattle,  and  such  members  so  appointed 
shall  be  entitled  to  receive  a  salary  of  $250  per  month 
and  any  necessar}'  expenses,  and  they  shall  hold  office 
for  one  year  ;  such  committee  shall  keep  a  complete 
record  of  all  the  work  done,  and  submit  monthly  reports 
thereof  to  the  State  Board  of  Health.  Providing  that  (in 
Section  145),  the  degree  of  bachelor  or  doctor  of  medi- 
cine shall  not  be  conferred  in  this  State  before  the  can- 
didate has  filed  with  the  institution  conferring  it  the  cer- 
tificate of  the  regents,  that  three  years  before  the  date 
of  the  degree  he  has  either  graduated  from  a  registered 
college  or  satisfactorily  completed  a  full  course  in  a 
registered  academy  or  high  school,  or  had  a  preliminary 
education  considered  and  accepted  by  the  regents  as 
fully  equivalent,  or  had  passed  regents'  examinations, 
representing  for  degrees  conferred  in  1898,  one  year  of 
academic  work,  for  degrees  conferred  in  1899,  two 
years  of  academic  work,  and  for  degrees  conferred  in 
1900,  a  full  high-school  course.  Dropping  out  (Section 
153)  the  prohibition  of  using  any  title  whatever  which 
shall  show  or  tend  to  show  that  the  person  so  assum- 
ing or  advertising  the  same  is  a  practitioner  of  any  of 
the  branches  of  medicine,  but  still  retaining  the  pro- 
hibition of  the  unauthorized  use  of  M.D.   Revising  Arti- 


cle 9.  by  vesting  the  power  of  granting  licenses  to  prac- 
tise denristrj-  in  a  State  Board  of  Dental  Examiners  and 
assimilating  in  that  regard  the  licensing  of  dentists  to 
the  licensing  of  physicians,  and  also  providing  punish- 
ments for  \-iolation  of  the  provisions  of  the  law.  Revis- 
ing Article  10  by  making  more  strict  examinations  for 
licenses  to  practise  veterinary  medicine  and  surger)*. 
Section  184,  requiring  that  every  licensee  of  the  State 
Board  of  Pharmacy  who  desires  to  continue  the  prac- 
tise of  his  profession  shall  annually,  within  thirty  days 
from  the  first  day  of  November,  pay  to  the  secretary 
of  said  board  a  fee  of  $1,  for  which  he  shall  receive  a 
renewal  of  his  license,  which  renewal  shall  be  displayed 
with  his  license. 

The  following  amendments  to  the  Public  Health  Law 
did  not  pass  :  Section  207,  allowing  medical  colleges 
or  schools  to  use  unclaimed  cadavers  from  almshouses  ; 
same  Section,  pro\-iding  as  to  cadavers,  that  it  shall 
apply  only  to  the  counties  of  Onondaga,  Oswego,  Madi- 
son, Cortland,  and  to  Auburn  State  Prison.  These 
bills  also  did  not  pass  :  Providing  that,  in  addition  to 
the  powers  now  conferred  by  law  upon  the  State  Board 
of  Health,  the  board  is  empowered,  and  it  shall  be  its 
duty  upon  receiWng  a  fee  therefor  of  $5°,  to  cause  an 
examination  and  analysis  to  be  made,  by  a  practical 
chemist,  of  any  drug,  medicine,  or  mixture  of  drugs, 
herbs,  or  medicines,  commonly  known  as  patent  or  pro- 
prietarj'  medicines,  and  shall  ascertain  and  determine 
whether  the  use  of  the  same  may  or  may  not  endanger 
the  public  health,  and  it  shall  not  be  lawful  for  any 
person  or  corporation  to  sell,  or  offer  for  sale,  any 
drug,  medicine,  or  mixture  not  prescribed  by  a  regular 
physician,  unless  the  same  shall  have  been  so  examined 
and  approved  and  certified  in  writing  as  not  dangerous 
to  the  public  health  by  the  State  Board  of  Health. 
Amending  the  State  Board  of  Pharmacy  Law  of  1884  so 
that  any  person  who  had  three  years'  experience  in  the 
practice  of  pharmacy  pre%'ious  to  Januan.-  i,  1884,  shall 
be  entitled  to  be  licensed  as  a  pharmacist,  and  if  the 
State  Board  of  Pharmacy  shall  refuse  to  grant  such 
license,  upon  application  duly  made  by  such  person  to 
the  secretary  of  said  board,  and  the  payment  of  the 
license  fee  required  by  law.  such  person  may,  on  fifteen 
days'  notice  to  the  secretary  of  such  board,  apply  to 
the  Supreme  Court,  at  a  special  term,  in  the  district  in 
which  such  applicant  resides,  for  an  order  directing 
such  board  to  issue  such  license.  Abolishing  the  office  of 
coroner,  in  accordance  with  the  re\'ised  Constitution, 
and  providing  for  the  performance  of  the  duties  now 
performed  by  coroners.  Amending  the  coroners'  law 
of  1875,  so  that  the  board  of  supervisors  shall,  at  its 
next  annual  meeting,  and  from  time  to  time  thereafter, 
fix  the  compensation  of  the  coroners  in  Erie  County  at 
§2,500  per  year  for  all  services  done  and  performed  by 
them,  except  when  acting  as  or  in  the  place  of  the 
sheriff  of  said  county,  and  which  compensation  shall 
not,  in  the  case  of  a  coroner  residing  in  the  city  of 
Buffalo,  at  the  time  of  his  election,  and  during  the  term 
of  office,  exceed  the  sum  of  $3,000,  and  not  exceeding 
two  in  number,  and  of  any  coroner  not  residing  in  the 
city  of  Buffalo,  at  the  time  of  his  election,  shall  not  ex- 
ceed the  sum  of  S500  per  annum,  which  compensation 
shall  not  be  increased  during  the  term  of  office  of  such 
coroner,  and  shall  be  in  lieu  of  all  fees  or  mileage  for 
such  sen-ices.  Amending  the  county  law  so  that  no  per- 
son shall  hereafter  be  eligible  to  the  office  of  coroner 
who  is  not  an  attorney  and  counsellor-at-law,  but  the 
holding  of  such  office  shall  not  act  to  prohibit  him  from 
practising  at  any  court,  except  in  relation  to  any  case 
which  may  have  been  before  him  as  a  coroner.  Amend- 
ing Section  390  of  the  Penal  Code  so  as  to  make  guilty 
of  a  misdemeanor  any  person  who,  in  various  ways,  pol- 
lutes any  public  water-supply.  Authorizing  the  Super- 
intendent of  State  Prisons  to  use  in  the  several  prisons 
of  the  State  the  double-chloride- of-gold  treatment  for 
the  cure  of  liquor,  opium,  morphine,  cocaine,  and  to- 
bacco diseases,  and  to  negotiate  for  and  purchase  such 


158 


MEDICAL   RECORD. 


[August  3,  1895 


medicines  prepared  under  recognized  double-chloride- 
of-gold  formulas  as  in  his  judgment  he  may  deem  ad- 
visable for  the  purpose  of  administering  such  treatment, 
and  in  carrj'ing  out  the  provisions  of  this  the  superin- 
tendent may  cause  one  or  more  of  the  prison  physi- 
cians to  be  instructed  in  the  administering  of  the  rem- 
edies prescribed,  and  the  treatment  of  the  diseases 
enumerated.  Repealing  the  law  of  1893  relative  to  the 
vaccination  of  school  children. 

The  Code  of  Civil  Procedure  was  amended  so  as  to 
exempt  from  jury  duty,  the  same  as  a  physician,  a  duly 
registered  veterinary  surgeon  actually  engaged  in  his 
profession  as  a  means  of  livelihood.  The  sum  of 
$100,000  was  appropriated  for  the  purpose  of  con- 
structing and  equipping  suitable  buildings  for  the  State 
Veterinary  College  at  Cornell  University,  but  no  part 
of  such  moneys  shall  be  expended  until  plans  and 
specifications  for  the  construction  and  equipment  of 
such  buildings  and  the  location  thereof  shall  have  been 
approved  by  the  Commissioner  of  Agriculture,  nor  until 
the  Comptroller  shall  have  certified  that,  in  his  judg- 
ment, the  expenses  of  the  completion  and  equipment 
of  such  buildings,  in  accordance  with  such  plans  and 
specifications,  will  not  exceed  the  amount  of  such  ap- 
propriation, and  such  buildings  and  equipment  shall 
be  the  property  of  the  State. 

A  law  was  passed  regulating  and  restraining  the 
practice  of  midwifery  in  Niagara  County  by  others 
than  legally  authorized  physicians.  The  county  judge 
of  that  county  is  authorized  to  appoint  a  board  of  ex- 
aminers in  midwifery,  to  consist  of  five  members,  who 
shall  have  been  licensed  to  practise  physics  and  surgery 
in  this  State,  and  thereafter  as  often  as  any  vacancy 
shall  occur  in  said  board,  said  county  judge  shall,  by  a 
like  order,  fill  such  vacancy.  This  board  is  to  issue 
certificates,  and  anyone  practising  without  a  certificate 
on  conviction  thereof  shall  be  fined  not  less  than  $50, 
nor  more  than  §100,  and  shall  forfeit  any  certificate 
granted  under  the  act.  A  similar  law  was  passed  for 
Rochester,  allowing  the  mayor  to  appoint  a  board  of 
three  examiners  ;  but  an  amendment  to  the  law  for  Erie 
County  failed,  providing  that  on  and  after  July  i,  1895, 
the  county  judge  of  Erie  County  shall  appoint  a  board 
of  examiners  in  midwifery,  to  consist  of  nine  instead  of 
five  members,  who  shall  have  been  licensed  to  practise 
physics  and  surgery  in  this  State,  and  who  shall  have 
been  in  active  practice  for  at  least  two  years  ;  three  of 
said  members  shall  be  designated  by  said  county  judge 
to  hold  office  for  one  year  ;  three  of  said  members  to 
hold  office  for  two  years,  and  three  of  said  members  to 
hold  office  for  three  years.  Annually  thereafter  the 
said  county  judge  shall  designate  three  physicians  to 
hold  office  as  members  of  said  board  for  a  term  of  three 
years. 

The  new  Membership  Corporations  Law,  from  the 
Statutory  Revision  Commission,  provides  that  five  or 
more  persons  may  become  a  corporation  for  the  pur- 
pose of  erecting,  establishing,  or  maintaining  a  hospi- 
tal, infirmary,  or  home  for  invalids,  aged  or  indigent 
persons,  by  making,  acknowledging,  and  filling  a  certif- 
icate, stating  the  particular  object  for  which  the  cor- 
poration is  to  be  formed  ;  the  name  of  the  proposed 
corporation  ;  the  town,  village,  or  city  in  which  its 
principal  office  is  to  be  located  ;  the  number  of  direc- 
tors, not  less  than  three  nor  more  than  thirty ;  the 
names  and  places  of  residence  of  the  persons  to  be 
its  directors  until  its  first  annual  meeting,  and  the  time 
for  holding  its  annual  meetings.  Such  certificate  may 
also  specify  the  qualification  of  members  of  the  cor- 
poration with  respect  to  their  adherence  or  non-adher- 
ence to  a  particular  school  or  theory  of  medical  or  sur- 
gical treatment,  and  the  systems  of  medical  practice 
or  treatment  to  be  used  or  applied  in  such  hosi)ital, 
infirmary,  dispensary,  or  home.  Such  certificate  sliall 
not  be  filed  without  the  written  approval,  indorsed 
thereupon  or  annexed  thereto,  of  the  State  Board  of 
Charities,  and  of  a  justice  of  the  supreme  court  of  the 


district  in  which  the  principal  office  or  place  of  busi- 
ness of  such  corporation  shall  be  located.  On  filing 
such  certificate,  in  pursuance  of  law,  the  signers  there- 
of, their  associates  and  successors,  shall  be  a  corpora- 
tion, in  accordance  with  the  provisions  of  such  certi- 
ficate. 

A  new  law  "  to  protect  human  life  "  provides  that  all 
hospital  buildings  used  for  general  hospital  purposes, 
or  hospitals  or  asylums  for  the  insane,  or  any  hospital 
buildings  that  are  more  than  two  stories  high,  shall 
have  properly  constructed  iron  stairways  on  the  out- 
side thereof,  with  suitable  doorways  leading  thereto 
from  each  story  above  the  first,  for  use  in  case  of  fire. 
It  shall  be  the  duty  of  the  trustees,  managers,  owners, 
or  proprietors  of  such  hospitals  or  asylums  to  cause 
such  stairways  to  be  constructed  and  maintained.  If 
the  trustees  or  owners  of  any  hospital,  except  those 
owned  and  maintained  by  a  city,  a  county,  or  the  State; 
shall  fail  to  provide  such  stairways  before  the  first  day  of 
October,  1896,  then  the  local  authorities  shall  proceed 
to  erect  such  stairways,  and  the  cost  thereof  may  be  re- 
covered by  an  action  at  law  from  the  property  of  said 
hospital.  The  district  attorney  of  each  county  is 
charged  with  the  execution  of  this  statute,  except  in  the 
case  of  hospitals  erected  or  maintained  by  the  State, 
city,  or  by  a  county.  This  law  is  to  take  effect  on  the 
first  day  of  October,  1895.  The  provisions  do  not  ap- 
ply to  any  institution  in  the  city  and  county  of  New 
York,  or  the  county  of  Kings,  which  the  fire  marshal 
of  said  city  or  county  shall  certify  in  writing  to  be  fire- 
proof to  an  extent  which  will  not  require  the  appliances 
and  fixtures  provided  for.  In  every  other  county  such 
certificate  shall  be  made  by  the  district  attorney  of 
the  county.  The  certificate  exempting  institutions  in 
any  county  from  the  operations  of  this  law  shall  be 
filed  during  the  month  of  January  in  each  year. 

A  charter  was  granted  to  St.  Joseph's  Hospital,  in 
Syracuse  ;  and  the  charter  of  Kingston  was  amended  so 
that  $2,500  can  be  appropriated  yearly  to  the  King- 
ston City  Hospital.  The  name  of  the  Bedford  Dis- 
pensary, in  Brooklyn,  was  changed  to  the  Bedford  Dis- 
pensary and  Hospital.  The  charter  of  the  BrookljTi 
Eye  and  Ear  Hospital  was  amended  so  that  the  direc- 
tors shall  be  not  less  than  eleven  nor  more  than  nine- 
teen. In  Oswego  a  charter  was  given  to  the  "  Doctor 
Mary  V.  Lee  Fund  to  Aid  Worthy  Students."  The 
board  of  trustees  of  the  Clifton  Springs  Sanitarium 
Company  was  authorized  to  issue  bonds  not  to  exceed 
$100,000,  and  mortgage  the  trust  property  to  raise 
money  to  pay  the  cost  of  completing  the  new  sanitarium 
building.  Authority  was  given  to  the  Board  of  Com- 
missioners of  the  Washington  Park,  Albany,  to  convey 
or  lease  a  plot  of  ground  for  the  purpose,  and  to  be 
used  for  the  erection  thereon,  of  the  Bender  Hygienic 
Laboratory,  and  the  laboratorj'  has  been  incorporated. 
A  charter  was  given  to  the  Pedic  Society  of  the  State 
of  New  York. 

In  New  York  City  the  Consolidation  Act  was  amended 
so  as  to  provide  for  the  making  and  use  of  diphtheria 
antitoxin  and  other  antitoxins,  and  to  establish  a  fund 
in  relation  thereto.  A  charter  was  granted  to  the  Hos- 
pital for  Scarlet  Fever  and  Diphtheria  Patients,  with 
Louisa  F.  Minturn,  F.  Augustus  Schermerhom,  Paul 
Tuckerman,  James  J.  Higginson,  Frederic  De  P.  Fos- 
ter, John  Winters  Brannan,  M.D.,  Cleveland  Dodge, 
T.  Mitchell  Prudden,  M.D.,  Alvah  H.  Doty,  M.D.,  and 
George  F.  Crane,  as  the  incorporators.  Another  new 
law  provides  that  overseers  of  the  poor  or  other  officers 
having  charge  of  the  dispensation  of  public  charity  in 
the  several  counties  of  this  State  shall  hereafter  send  to 
the  Pasteur  Institute,  in  the  city  of  New  York,  all  per- 
sons duly  certified  by  regular  physicians  to  have  been 
bitten  by  rabid  animals  or  otherwise  put  in  danger  of  in- 
fection with  rabies.  The  transportation  of  such  persons, 
with  necessary  attendant  or  attendants,  to  and  from  the 
city  of  New  York,  shall  be  a  charge  upon  the  counties 
in  which  they  reside.     The  sustenance,  nursing,  and 


August  3,  1895] 


MEDICAL   RECORD. 


159 


preventive  treatment  of  such  persons,  for  the  time  ad- 
judged necessary,  shall  be  provided  by  the  Pasteur  In- 
stitute. The  sum  of  $6,000  was  appropriated  to  the 
Pasteur  Institute  as  a  full  equivalent  for  the  services 
named  in  the  law  and  conditions  imposed  thereby. 
The  Pasteur  Institute  shall  be  at  all  times  open  to  the 
inspection  of  the  Governor  and  of  the  State  Board  of 
Health,  or  of  the  accredited  representative  of  either, 
and  shall  annually,  on  or  before  the  fifteenth  of  Januarv 
of  each  year  make  its  report  to  the  Legislature. 

Other  amendments  to  the  Consolidation  Act  were 
these  :  Allowing  annual  appropriations  of  $12,000  and 
$30,000,  respectively,  to  the  Society  of  the  Lying-in- 
Hospital  and  to  the  New  York  Post-Graduate  Medical 
School  and  Hospital  ;  allowing  to  the  New  York  Poly- 
clinic Medical  School  and  Hospital,  for  board,  nursing, 
and  medical  or  surgical  aid  and  attendance,  $1  per 
day  for  each  needy  and  charity  patient  who  occupies  a 
bed  in  said  hospital,  and  who  receives  such  care,  sup- 
port, and  maintenance,  such  payments  not  to  exceed  in 
the  aggregrate  $30,000  per  annum  ;  relative  to  coro- 
ners ;  exempting  from  taxation  the  property  of  the 
Northeastern  Dispensary.  Other  laws  were  as  follows  : 
Amending  the  charter  of  St.  John's  Guild  so  that  it  may 
hold  property,  provided  that  the  annual  net  income  of 
the  property,  real  and  personal,  of  the  corporation  shall 
not  exceed  the  amount  authorized  to  be  received  and 
held  by  hospital  corporations  under  the  laws  of  the 
State  ;  changing  the  corporate  name  of  the  New  York 
Orthopedic  Dispensary  to  the  New  York  Orthopedic 
Dispensary  and  Hospital  ;  extending  permanently  the 
charter  of  the  College  of  Pharmacy  of  the  City  of 
New  York,  with  Samuel  W.  Fairchild,  Charles  F. 
Chandler,  George  Masse)-,  John  R.  Caswell,  J.  Niven 
Hegeman,  Horatio  N.  Eraser,  as  incorporators,  and 
allowing  it  to  hold  propeity  not  to  exceed  $1,000,000  ; 
exempting  dispensaries  from  the  payment  of  water  as- 
sessments ;  authorizing  and  directing  the  Commission- 
ers of  the  Sinking  Fund  of  the  City  of  New  York,  when- 
ever required  so  to  do  by  the  Board  of  Estimate  and 
Apportionment,  to  designate  and  set  apart  so  much  of 
GouverneurSlip  as  will  be  requisite  for  the  construction 
thereon  of  a  building,  the  entire  cost,  expense,  and 
equipment  of  which  shall  not  exceed  $200,000,  for  the 
purpose  of  providing  suitable  accommodations  for  a 
reception  hospital  for  patients  injured  or  taken  sud- 
denly ill  in  the  lower  east  side  of  the  city.  The  Gover- 
nor refused  to  sign  a  charter  for  the  Metropolitan  Post- 
Graduate  School  of  Medicine,  with  Timothy  Field 
Allen,  William  Tod  Helmuth,  Arkell  R.  McMichael, 
Malcolm  Leal,  Charles  Deady,  Henry  M.  Dearborn, 
Wilfred  George  Fralick,  James  H.  Schley,  William  H. 
Bishop,  John  W.  Dowling,  George  T.  Stewart,  and 
Joseph  M.  Deuel,  as  the  incorporators. 

120  Lancaster  Street,  j 


A  Family  Birthday.-  -Dr.  W.  A.  Chamberlin,  writ- 
ing in  the  Northwestern  Lancet,  relates  a  curious  coin- 
cidence in  the  dates  of  birth  of  three  children  of  one 
family.  The  eldest  child  was  born  on  April  3,  1882, 
the  second  on  April  3,  1887,  and  the  youngest  on  April 
3,  1889,  and  all  within  three  hours  of  3  p.m. 

A  Penny-in-the-slot  Doctor. — The  English  papers 
describe  a  new  machine,  figured  in  the  likeness  of  a  man, 
which  is  provided  with  slots  corresponding  to  various 
parts  of  the  body.  If  one  has  a  headache  he  has  only 
to  insert  a  coin  into  the  slot  in  the  head,  and  the  ma- 
chine, after  due  consideration,  hands  out  a  prescription 
for  the  evil  in  question.  The  machines  do  not  make  up 
medicine,  but  the  address  of  the  nearest  druggist  is 
given.  It  only  remains  for  some  enterprising  philan- 
thropist to  supply  London  with  these  machines, 
says  The  Lancet,  and  the  relief  to  the  overcrowded 
out-patient  department  of  our  hospitals  would  be 
marked. 


Perforation   of  the   Diaphragm   in    Gastric    Ulcer. 

L.  Pick,  in  reporting  a  new  case,  gives  an  analysis  of 
all  cases  published  in  which  ulcer  of  the  stomach 
caused  perforation  of  the  diaphragm  {American  Jour- 
nal of  the  Medical  Sciences).  In  all,  twenty-eight  cases 
were  discovered  ;  but  the  author  thinks  that  other 
cases,  proved  by  autopsies,  have  been  observed,  and 
also  that  in  certain  cases  of  so-called  idiopathic  sup- 
purative pleurisy  or  pericarditis  gastric  ulcer  was  the 
cause.  (In  regard  to  this,  however,  Biach  has  shown 
that  in  nine  hundred  and  eighteen  cases  of  pyopneumo- 
thorax only  two  were  due  to  ulcer  of  the  stomach.) 
According  to  Pick,  perforation  of  a  gastric  ulcer  into 
the  thoracic  cavity  is  twice  as  frequent  as  adhesion  to 
and  perforation  of  the  anterior  abdominal  wall.  The 
commonest  outlet  is  in  the  pleura  or  lung,  and  affected 
the  left  pleura  nine  times,  the  left  pleura  and  lung 
seven  times,  and  the  right  pleura  once.  In  the  latter 
case  the  perforation  was  consecutive  to  subphrenic 
abscess.  The  pericardium  was  affected  alone  in  six 
cases,  and  the  pericardium  and  heart  in  four.  In  one 
case  the  mediastinum  was  affected,  and  in  the  author's 
case  the  anterior  thoracic  wall,  with  the  formation  of  a 
tumor  in  that  part.  In  twenty  cases  the  perforation 
was  direct,  and  in  eight  indirect,  or  following  subphren- 
ic suppuration.  In  this  conclusion  the  author  differs 
from  Brinton,  who  studied  a  smaller  number  of  cases. 
Pick's  analysis  shows  that  the  rare  ulcers  of  the  fundus 
are  much  more  likely  to  rupture  into  the  thorax  than 
those  of  all  other  parts  of  the  stomach,  but  that  the 
occurrence  of  thoracic  complication  depends  largely 
on  the  existence  of  old  adhesions  and  alterations  in  the 
position  of  the  thoracic  organs.  The  exciting  cause  of 
the  perforation  in  most  cases  is  mechanical,  either  by 
distention  from  food  or  gas,  vomiting,  straining  at 
stool,  etc.  Death  is  usually  due  to  complications, 
rarely  to  shock.  Perforation  of  the  heart  does  not 
cause  instant  death,  patients  having  lived  as  long  as 
three  or  four  days  after  hemorrhage  began. 

The  Pathology  of  Paraplegia  in  Vertebral  Caries, 
with  the  Indications  for  Operation. — According  to  Dr.  * 
Thorburn  {British  Aledical  Journal),  paraplegia 
may  be  produced  in  one  or  other  of  the  following 
ways  :  i.  Mere  kyphosis  is  not  usually  competent  to 
produce  paraplegia.  2.  Sudden  paraplegia  may  result 
in  rare  instances  from  fracture  of  carious  vertebrae. 
The  frequency  of  this  occurrence  is,  according  to 
Kraske,  about  two  per  cent,  of  the  total  number  of 
paraplegias  caused  by  vertebral  caries.  3.  Still  more 
infrequent  causes  are  the  bursting  of  an  abscess  into 
the  spinal  canal,  hemorrhage  into  the  canal,  and  dis- 
placement of  bony  sequestra  which  press  upon  the 
cord.  4.  The  most  usual  cause  of  paraplegia  is  press- 
ure by  granulation-tissue.  5.  In  a  few  cases  true 
tuberculous  periarteritis  is  found  within  the  cord,  gen- 
erally in  association  with  tuberculous  lepto-meningitis. 
In  regard  to  the  prognosis,  the  author  says  that  his 
own  experience  is,  that  nearly  all  cases  will  recover  if 
fixed  in  the  recumbent  position  for  a  sufficiently  long 
time,  but  the  time  required  may  be  very  prolonged. 
Cases  in  which  the  pafajtlegia  is  due  to  intra-medullary 
tuberculous  periarteritis  can  hardly  be  expected  to  get 
well,  and  those  in  which  pressure  has  arisen  from 
fracture  of  the  carious  bones  are  not  likely  to  improve 
to  any  great  extent.  Equally  unfavorable  are  some  of 
the  other  rare  varieties  of  paraplegia.  The  following 
indications  for  operation  are  given  :  1.  A  steady  in- 
crease in  symptoms  in  spite  of  favorable  conditions  and 
treatment.  2.  The  presence  of  symptoms  which  di- 
rectly threaten  life.  3.  The  persistence  of  symptoms 
in  spite  of  complete  rest  is  the  indication  which  has 
been  most  commonly  adopted.     4.  In  posterior  caries 


i6o 


MEDICAL   RECORD. 


[August  3,  1895 


(caries  of  the  arches)  operation  is  clearly  indicated,  as 
here  we  can  readily  both  treat  the  paraplegia  and  re- 
move the  whole  of  the  tuberculous  tissue.  5.  The  ex- 
istence of  severe  pain  if  the  patient  is  being  exhausted 
thereby.  6.  Children,  as  a  rule,  yield  better  results 
than  do  adults. 

Contra-indications  :  The  presence  of  active  tubercu- 
lous changes  in  other  organs.  Macewen  holds  that  we 
should  not  operate  in  the  presence  of  pyrexia.  The 
exception  to  this  would  be  if  the  cause  of  the  pyrexia 
could  be  removed  by  operation.  General  meningitis 
will  probably  prove  fatal  whether  an  operation  be  per- 
formed or  not.  Cases  of  fracture  of  carious  vertebrae 
are  manifestly  unsuitable  for  laminectomy,  and  most 
paraplegias  of  sudden  onset  will  fall  into  this  category. 

Idiopathic  Rupture  of  the  Heart. — Dr.  Collins  {Lan- 
cet) has  reported  the  case  of  a  man,  fifty-three  years 
old,  who  had  lived  a  temperate  life,  and  had  been 
troubled  only  by  dyspepsia  and  a  weak  heart.  There 
was  no  history  of  rheumatism  or  rheumatic  fever. 
The  man's  father  had  died  suddenly  of  heart  disease. 
After  feeling  out  of  sorts  for  a  time,  the  man  experi- 
enced severe  pain  in  the  precordium  and  felt  too  ill  to 
leave  his  bed.  He  gradually  became  worse  and  sick 
after  food.  Speech  became  thick,  the  mouth  was 
drawn  to  the  right,  and  the  right  eye  was  partially 
closed.  The  left  arm  became  paralyzed,  then  the  right 
leg.  The  tongue  deviated  to  the  right  on  protrusion. 
The  sphincters  were  unaffected.  The  heart-sounds 
were  faint  and  without  added  sounds.  The  man  was 
moved  to  a  water-bed,  his  body  and  head  being  kept 
horizontal,  and  great  care  being  taken  to  avoid  sudden 
movement.  Later,  when  his  pelvis  was  raised  to  allow 
the  introduction  of  a  bed-pan,  almost  instantaneous 
death  ensued.  Upon  post-mortem  examination,  pro- 
longed and  careful  search  failed  to  reveal  any  micro- 
scopic change  in  the  brain,  its  vessels,  or  the  meninges. 
On  opening  the  pericardium  it  was  found  to  be  filled 
with  blood-clot,  and  on  washing  this  away  a  laceration 
about  one  and  a  half  inch  in  length  was  found  in 
the  left  ventricle  ;  the  aperture  was  closed  by  a  recent 
clot.  The  cavities  of  the  heart  were  dilated,  the  walls 
thin  and  in  an  advanced  stage  of  fatty  degeneration. 
There  was  no  valvular  disease.  The  aorta  and  its  main 
'  branches  were  atheromatous.  Both  lungs  contained 
calcifying  tubercle  ;  the  abdomen  was  loaded  with  fat  ; 
the  spleen  was  soft ;  the  kidneys  were  engorged,  but 
otherwise  healthy. 

Confusion  between  Distended  Gall-bladder  and  Mov- 
able Kidney. — Dr.  Morris  points  out  that,  though  oq 
first  thought  there  is  not  much  resemblance  between 
these  two  affections,  the  one  is  often  confounded  with 
the  other  {British  Medical  Joiirfial).  The  fact  that 
both  affections  are  much  more  common  in  women  is 
noted,  and  the  fact  that  the  right  kidney  is  much 
more  movable  than  the  left  increases  the  chances  of 
error.  The  symptoms  common  to  both  are  pointed 
out.  Both  may  present  as  a  tumor  in  the  right  hypo- 
chondriac and  umbilical  regions,  and  the  physical  char- 
acteristics of  the  tumor  from  either  cause  may  be  sim- 
ilar. The  tumor  may  be  movable,  and  in  either  case 
the  percussion-note  overlying  it  may  be  resonant  or 
dull.  Both  diseases  may  cause  dyspeptic  symptoms 
or  give  rise  to  colic.  Either  may  cause  jaundice,  gas- 
tric intestinal  catarrh,  or  even  peritonitis.  In  neither 
case  is  the  condition  of  the  urine  a  reliable  guide. 
The  conditions  of  the  gall-bladder  which  tend  to  ren- 
der the  confusion  more  probable,  are  elongation  with 
a  reniform  outline,  mobility,  or  downward  displace- 
ment of  the  liver,  with  a  retroflexed  gall-bladder  under 
the  viscus,  causing  the  displaced  bladder  to  feel  like  a 
loin  rather  than  an  abdominal  tumor.  A  tilting  of  the 
kidney  from  l>ehind  forward,  bringing  its  anterior  end 
just  under  the  abdominal  parietes,  or  adhesion  of  the 
kidney  to  the  right  lobe  of  the  liver,  might  cause  the 
kidney  to  resemble  gall-bladder.     To  distinguish  be- 


tween the  two  conditions  it  must  be  remembered  that 
a  distended  gall-bladder,  as  well  as  the  kidney,  is  a 
frequent  cause  of  movable  abdominal  tumor.  The 
range  of  motion  in  the  gall-bladder  is,  however,  always 
in  the  arc  of  a  circle,  the  centre  of  which  is  a  point 
beneath  the  right  lobe  of  the  liver.  The  history  of  a 
distinct  attack  of  jaundice  is  an  important  factor  in 
diagnosis.  A  distended  gall-bladder  can  generally  be 
felt,  whereas  a  movable  kidney  often  cannot.  The' 
gall-bladder,  if  distended  with  stones,  is  much  harder 
than  the  kidney.  Variance  in  size  of  the  tumors  is  of 
no  importance,  unless  with  the  variance  in  size  there  is 
the  history  of  the  passage  of  large  quantities  of  urine. 
An  attempt  should  always  be  made  in  these  cases  to 
pass  the  hand  behind  the  tumor  and  palpate  the  kid- 
ney. 

The  Employment  of  the  Membrane  of  a  Hen's  Egg  in 
Grafting,— Dr.  Amat  gives  an  account  of  the  case  of  a 
young  boy  w-hom  he  had  treated  for  a  large  burn 
caused  by  boiling  water  in  the  dorso-lateral  region  of 
the  right  foot.  Repair  was  slow,  and  the  author  ad- 
vised Reverdin's  and  Thiersch's  method  of  skin  graft- 
ing, but  the  family  was  very  much  opposed  to  it.  M. 
Amat  then  thought  it  would  be  well  to  employ  the  ex- 
ceedingly vascular  internal  layer  of  the  membrane  of  a 
hen's  egg.  He  made  the  attempt  and  obtained  suc- 
cessful results.  In  1S8S  and  in  1893,  he  had  the  same 
success  in  the  treatment  of  burns  on  the  arm,  the  back, 
the  feet,  and  the  leg.  In  summing  up  his  observations 
and  those  of  others,  M.  Amat  found  that  good  results 
had  been  obtained  in  nine  cases  and  failure  in  seventy- 
four  cases,  as  regarded  the  anaplastic  value  of  the 
membrane  of  the  shell.  These  favorable  results,  says 
the  writer,  may  be  attributed  to  the  "action  of  vicin- 
ity "  of  the  graft  on  the  evolution  of  the  embryonic 
tissue,  and  not  to  its  nature.  There  are  therapeutic 
indications  for  its  employment,  especially  in  children, 
women,  and  nervous  persons.  The  technique  of  this 
operation  is  as  follows  :  i.  The  membrane  should  be 
taken  from  a  very  fresh  egg,  as  physiological  observa- 
tion has  shown  that  the  latent  life  of  this  membrane  is 
then  more  active.  2.  Grafting  must  not  be  done  until 
the  dressings  have  suppressed  the  suppuration  and  pro- 
voked a  healthy  growth.  Previously  to  the  transplan- 
tation, contact  with  the  air  must  be  avoided  by  a  thick 
dressing  of  gauze  saturated  with  a  carbolic-acid  solu- 
tion. 3.  Take  a  very  fresh  egg,  break  it  in  the  centre, 
empty  it  of  the  contents,  and  seize  the  membrane  with 
a  mouse-tooth  forceps  at  the  large  end  of  the  egg — 
that  is,  the  internal  layer  of  the  membrane  of  the 
shell.  4.  This  layer  is  cut  into  strips  about  four 
or  five  millimetres  in  width  and  of  the  same  length. 
These  are  applied  on  the  wound  with  the  point  of  a 
pair  of  scissors,  and  laid  on  their  albuminous  surface. 
5.  They  are  applied  at  a  distance  of  from  twelve  to  fif- 
teen millimetres,  and  are  covered  with  a  small  square  of 
tin  foil  and  then  by  a  dressing  of  gauze  saturated  with 
a  solution  of  carbolic  acid.  This  heteroplastic  pro- 
cedure, says  the  writer,  is  worthy  of  attention,  especial- 
ly from  practitioners  who  do  not  always  have  at  hand 
the  proi)er  material  for  "  inter-human  "  or  "  inter-zoo- 
human  "  heteroplasty.  From  this  point  of  view  it  is 
interesting  to  make  a  trial  of  this  procedure  in  rural 
practice. — Xcw  York  Medical  Journal. 


The  Four-years'  Course.— Word  comes  to  us  that 
the  rapid  lengthening  of  the  two  years  to  three  and 
now  four  courses  of  lectures  as  a  requirement  for  grad- 
uation is  producing  hard  times  in  some  medical  col- 
leges, and  will  be  the  cause  of  a  diminution  in  the 
number  of  existing  schools  of  medicine.  In  some 
quarters  this  is  a  seeming  hardship,  but,  after  all,  the 
process  is  one  highly  beneficial  to  the  medical  profes- 
sion.—  The  Lancet-  Clinic. 


August  3,  1895]  MEDICAL 

Medical   Record: 

A  Weekly  Journal  of  Medicijie  and  Surgery. 


RECORD. 


161 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 

WM.  WOOD  &.  CO.,  43,  45.  &  47  East  Tenth   Street 


New  York,  August  3,  1895. 


A    NEW   THEORY    OF    SLEEP. 

Since  the  discoveries  made  by  Golgi,  Cajal,  Retzius, 
and  others  of  the  peculiar  anatomical  characteristics  of 
the  nerve-cells  a  number  of  new  theories  regarding 
brain-function  and  brain-action  have  been  in  the  field. 
The  nerve-cell,  as  it  is  now  understood,  consists  of  a 
very  large  number  of  long  branched  processes,  which 
are  called  the  protoplasmic  processes,  and  a  single 
axis  cylinder  which  extends  out,  becoming  eventually 
the  nerve-fibre  and  giving  off  fine  lateral  branches.  It 
has  also  been  shown  that  each  nerve-cell  in  the  brain 
is  in  contiguity  with  some  other  nerve-cell,  or  rather 
with  the  terminals  of  the  axis-cylinder  process  of  that 
cell,  but  that  no  actual  union  takes  place  between  the 
processes  from  the  one  cell  and  fibre  process  of  the 
other.  When  one  set  of  nerve-cells,  for  example,  are 
thrown  into  activity,  impulses  are  sent  out  along  the 
axis  cylinders  and  their  terminal  end-brushes,  and 
these  affect  by  contact  the  protoplasmic  processes  of 
other  cells.  Cajal  and  others  look  upon  the  axis  cylin- 
der and  nerve-fibre  as  conveying  impulses  out  from  the 
nerve-cell  or  body,  while  the  protoplasmic  processes  re- 
ceive impulses  brought  to  them  and  carry  them  to  the 
cell-body.  These  latter,  therefore,  are  sometimes  called 
cellulipetal,  while  the  axis-cylinder  process  is  called 
cellulifugal.  We  are  speaking,  of  course,  now  of  the  re- 
lations of  the  different  groups  of  cells  in  different  parts 
of  the  brain,  rather  than  of  the  relations  of  these  cells 
to  the  spinal  cord  and  parts  below.  Some  time  ago 
Professor  Duval  proposed  the  theory  of  sleep  based 
upon  the  peculiar  relations  of  the  brain-cells  and  fibres. 
According  to  this  theory  the  nerve-cells  in  repose  re- 
tracted their  processes,  which,  as  he  thought,  were 
really  pseudopods.  The  cell  processes  being  thus  re- 
tracted, the  contiguity  of  the  cell  with  other  cells  was 
less  perfect,  hence  their  functions  became  lowered, 
consciousness  was  lost,  and  sleep  ensued.  Kolliker  ob- 
jected to  this  view,  on  the  ground  that  amoeboid  move- 
ments are  never  observed  in  nerve-cells,  at  least  of  the 
higher  animals  ;  Duval  having  contended  that  he  had 
seen  such  movements  in  the  lower  orders  of  animals. 
Cajal,  siding  with  Kolliker,  states  that  no  matter  what 
way  you  kill  an  animal — by  shock,  strangulation,  or  an- 
aesthesia— the  nerve-cells  never  differ  in  aspect,  and 
one  never  can  discover  any  amoeboid  movements  among 
them,  even  when  they  are  placed  freshly  in  the  field  of 
the  microscope.    Cajal  has,  however,  suggested  another 


theory  of  sleep  which  he  believes  more  rational  and 
more  in  accordance  with  facts.  While  nerve-cells  do 
not  have  amceboid  movements,  there  are,  scattered 
richly  throughout  the  brain-tissues,  other  cells  known 
as  neuroglia  cells.  These  are  cells  with  very  numerous 
fine  processes,  and  they  form  in  a  large  measure  the 
supporting  framework  of  the  brain-tissue,  sending  their 
fine  processes  in  among  the  nerve-cells  and  blood-ves- 
sels. Now  Cajal's  theory  is  that  these  neuroglia  cells 
during  repose  extend  or  relax  their  fine  hair-like  proc- 
esses. As  the  result  of  this  the  perfect  contact  be- 
tween the  processes  of  the  nerve-cells  and  the  end- 
brushes  from  the  axis  cylinders  that  surround  them  is 
interfered  with,  hence  the  brain  function  is  slowed  up 
and  sleep  ensues.  During  activity  these  neuroglia  cells 
retract  their  numberless  fine  processes,  the  contact  be- 
tween the  nerve-cells  becomes  perfect  again,  and  mental 
functions  are  resumed.  The  practical  facts  upon  which 
Cajal  bases  this  ingenious  theory  are  that  the  neuroglia 
cells  are  found  to  be  in  different  states.  In  some  their 
processes  are  retracted  and  shrivelled  and  in  others  they 
are  extended.  There  is  unquestionably  an  amoeboid 
movement,  therefore,  in  this  class  of  cells.  Further- 
more, it  is  in  accordance,  he  says,  with  physiological 
facts  that  a  cell  would  retract  its  processes  during  activ- 
ity and  relax  them  during  repose.  The  physical  basis 
of  sleep,  therefore,  according  to  this  view,  would  be  the 
bristling  up  of  the  hair-like  processes  of  the  neuroglia 
cells,  a  squeezing  of  them  in  between  the  machinery 
by  which  the  nerve  impulses  pass,  and  a  sort  of  a  clog- 
ging of  the  psychical  mechanism. 

Such  theories  are  of  course  as  yet  only  theories,  and 
may  be  regarded  by  practical  minds  with  great  con- 
tempt. Still,  there  is  sometimes  an  advantage  in  scien- 
tific hypotheses,  even  if  they  furnish  only  an  intellect- 
ual exercise  to  the  student. 


SURGERY    OF    THE    URETERS    AT     JOHNS 
HOPKINS    HOSPITAL. 

In  a  recent  issue  of  the  Bulletin  of  the  Jolins  Hopkins 
Hospital  is  an  interesting  account  of  the  brilliant  in- 
vestigation and  successful  surgery  of  Dr.  Howard  A. 
Kelley,  which  reflects  credit  upon  the  whole  American 
medical  profession.  It  is  now  several  years  since  Dr. 
Kelley  demonstrated  the  possibility  of  catheterization 
of  the  ureters,  the  benefits  of  which  are  shown  in  the 
diagnosis  of  obscure  kidney  trouble,  as  well  as  that  of 
a  positive  differentiation  of  a  diseased  kidney  from 
the  sound  one  by  the  collecting  of  urine  from  each 
separate  kidney.  He  cured  a  case  of  gonorrhoeal  pye- 
litis and  pyo-ureter  by  irrigation.  The  treatment  of 
this  case,  as  reported  in  the  Bulletin,  is  most  ingenious 
and  satisfactory.  In  it  he  demonstrates  the  following 
novel  and  important  points  : 

1.  Stricture  of  the  lower  extremity  of  the  ureter  can 
be  diagnosed  without  any  operation,  by  using  the  cys- 
toscope,  the  bladder  being  dilated  with  air  by  posture. 

2.  Stricture  of  the  ureter  can  be  improved  by  grad- 
ual dilatation  by  a  series  of  hollow  bougies  (catheters) 
and  without  a  kolpo-ureterotomy. 

3.  A  stricture  through  which  a  No.  5  (5  mm.  diam.) 
bougie  is  passed  every  day  for  several  weeks  will  still 


l62 


MEDICAL    RECORD. 


[August  3,  1895 


hold   back  the  urine  if  the  walls  of  the  ureter  above 
have  lost  their  contractility. 

4.  Pyo-ureter  and  hydro-ureter  can  be  diagnosed  by 
drawing  off  in  a  few  minutes  such  a  quantity  of  fluid 
as  it  is  manifestly  impossible  for  the  kidney  to  secrete 
in  that  amount  of  time. 

5.  Pyo-ureter  and  pyelitis  can  be  cured  by  washing 
out  the  ureter  and  pelvis  without  any  preliminary  cut- 
ting operation  to  disclose  the  ureteral  orifice  (as  in 
the  kolpo-uretero-cystotomy  of  Bozeman). 

6.  Variations  in  pressure  in  the  column  of  fluid  in  a 
distended  ureter  can  be  demonstrated  by  a  manometer 
attached  to  the  ureteral  catheter. 

7.  In  this  way  the  course  of  the  ureter  can  be 
mapped  out. 

He  also  reports  a  very  interesting  case  of  uretero- 
cystotomy,  performed  several  weeks  after  a  vaginal 
hysterectomy  and  a  sigmoid-proctostomy,  making  an 
anastomosis  of  the  lumen  of  the  sigmoid  flexure  through 
the  lateral  wall  of  the  rectum  at  the  pelvic  floor  with- 
out using  a  suture.  There  is  much  daring  surgery  in 
these  days,  much  surgical  ingenuity,  but  the  question 
is  how  large  a  proportion  of  it  will  stand  the  test  of 
time,  or  find  its  justification  ten  years  from  now.  Vet 
cases  such  as  these  are  triumphs  of  skill  in  which  we 
can  all  rejoice. 


absurd  position  was  taken  many  years  ago  by  the  astute 
politicians  of  New  Vork,  and  we  have  not  yet  been  able 
to  rid  our  legislators  of  the  delusion. 


CHICAGO'S  DEPARTMENT  OF  HEALTH  AND 
THE    DOCTORS. 

The  Doctors'  Club,  of  Chicago,  held  a  meeting  on 
June  28th,  at  which  time  the  subject  of  the  Board  of 
Health  and  the  Commissionership  was  brought  up. 
The  opinion  of  all  the  gentlemen  present  seemed  to  be 
very  unanimous  and  very  emphatic  to  the  effect  that 
the  Mayor  of  Chicago  had  broken  his  pledges  and 
treated  the  medical  profession  with  great  injustice  by 
his  removal  of  Dr.  Reynolds,  the  former  able  and  suc- 
cessful Health  Commissioner.  Some  very  forcible  and 
eloquent  speeches  were  made  by  a  number  of  members 
present.  The  Chicago  Medical  Recorder  sums  up  the 
situation  as  follows  :  "  An  important  medical  position 
has  been  lost  to  the  profession.  The  Health  Depart- 
ment, so  successfully  managed  by  medical  men  in  most 
European  and  x'X.merican  cities,  has  now  at  its  head  a 
ward  politician,  a  place-hunter,  who  had  been  dropped 
by  his  constituents,  and  regarding  whom  no  suspicion 
of  ability  in  or  knowledge  of  sanitary  science  had  been 
even  remotely  entertained.  The  semi-respectable  de- 
partment has  been  dragged,  therefore,  in  the  slime  of 
City  Hall  politics." 

The  only  voice  for  the  other  side  was  that  of  Dr. 
John  B.  Hamilton,  who  sided  with  the  Mayor,  offering 
the  excuse  that,  as  an  ofificial  of  the  Marine  Hospital 
Service,  he  was  obliged  to  render  any  sanitary  service 
to  the  city  that  the  Mayor  called  for.  The  Cliicago 
profession  seems  to  have  been  practically  unanimous  in 
urging  the  reappointment  of  Dr.  Reynolds,  and  it  is 
naturally  extremely  indignant  over  the  way  in  which  he 
has  been  treated.  We  trust  that  the  profession  of  the 
city  will  steadily  oppose  the  general  acceptance  of  the 
idea  that  doctors  cannot  possibly  be  good  business 
men,  and  therefore  should  not  be  appointed  to  posi- 
tions calling  for   business  capacity.      This   extremely 


THE    MEDICAL    EXAMINERS    OF    NEW   JER- 
SEY. 

The  fourth  annual  report  of  the  State  Board  of  Exarr- 
iners  of  New  Jersey  has  been  published,  and  shows 
that  the  License  Board  has  accomplished  a  great  deal 
of  good  work  during  its  brief  existence.  During  this 
time  they  have  examined  5  24  candidates  and  have  grant- 
ed 417  licenses.  In  other  words,  about  twenty  per  cent, 
of  those  who  have  applied  for  a  license  have  failed. 
The  Board  has  succeeded  in  repealing  the  charter  of  a 
bogus  medical  college  that  flourished  for  a  time  in 
Jersey  City.  It  has  secured  the  passage  of  a  law 
regulating  the  practice  of  midwifer)',  and  this  has  been 
in  successful  operation  for  two  years.  It  has  en- 
forced the  registration  law,  and  has  secured  the  pas- 
sage of  a  new  medical  law,  which  became  operative 
July  4,  1894,  and  which  the  Board  states  is  the  best 
State  medical  law  in  this  country  to-day.  The  law 
which  receives  this  high  praise  seems,  on  the  whole,  to 
justify  it.  It  requires  that  all  applicants  for  license  in 
medicine  shall  be  twenty-one  years  of  age,  shall  have 
their  moral  character  well  certified  to,  shall  be  grad- 
uates from  a  credited  college,  or  have  studied  at  least 
three  years  in  a  high  school  or  academy,  and  shall  have 
received  a  diploma  conferring  the  degree  of  Doctor  of 
Medicine  from  some  legally  incorporated  medical  col- 
lege, one  which  is  in  good  standing  in  the  opinion  of 
the  Board.  The  applicant  must  also  have  studied 
medicine  four  years  and  taken  three  courses  of  lectures. 
If,  however,  he  has  spent  one  year  in  a  hospital,  that 
counts  as  a  year  in  the  study  of  medicine. 


ANTIVENENE. 


The  latest  application  of  the  serum  therapy  is  in  the 
use  of  the  blood-serum  of  animals  that  have  been  im- 
munized against  snake-bites.  Dr.  Thomas  R.  Fraser,  of 
Edinburgh,  publishes  an  article  in  the  British  Medi- 
cal Journal  ctl  June  15th  on  this  subject.  Taking  the 
venom  of  the  cobra  of  India  and  of  the  rattlesnake 
{crotaliis  horridits)  of  America,  he  injected  these  in 
gradually  increasing  doses  into  rabbits,  cats,  and  kit- 
tens, until  they  were  able  to  take  injections  of  ten, 
twenty,  or  even  fifty  times  the  ordinary  lethal  doses. 
Having  made  certain  that  these  animals  were  relatively 
immune  against  the  poison,  he  took  their  blood-serum 
and  used  it  in  protective  inoculations  upon  other  animals. 
He  established  that  the  blood-serum,  or,  as  he  calls  it, 
"antivenene  "  of  animals  protected  against  large  lethal 
doses  of  venom  is  able  perfectly  to  prevent  lethal  doses 
of  the  venom  of  the  most  poisonous  of  serpents  from 
producing  death.  The  application  of  his  method  to 
man  has  not  yet  been  made,  but  Dr.  Fraser  looks  for- 
ward to  its  being  utilized  in  India,  where  the  annual 
deaths  from  sn.ake-bites  amount  to  twenty  thousand. 


Dr.  Behring  has  received  the  Cross  of  an  officer  of 
the  Legion  of  Honor  of  France. 


August  3,  1895] 


MEDICAL    RECORD. 


16: 


gleixrs  of  tTxe  B^ecfe. 

Proposed  International  Surgical  Congress. — At  the 
German  Surgical  Congress  recently  held  in  Berlin,  Pro- 
fessor Gussenbauer  announced  that  a  proposal  had 
been  received  from  some  American  surgeons,  that  an 
international  surgical  congress  should  be  organized, 
which  should  meet  every  five  years  at  different  places. 
The  German  Congress  appeared  to  be  favorably  in- 
clined to  the  proposal. 

Dr.  'William  Chapman  Jarvis,  of  this  city,  died  on 
July  30th  at  the  residence  of  his  brother,  Assistant- 
Surgeon  N.  S.  Jarvis,  U.  S.  A.,  at  Willet's  Point,  Long 
Island.  Dr.  Jarvis  was  a  son  of  the  late  Dr.  N.  S.  Jar- 
vis, a  surgeon  in  the  army.  He  was  a  graduate  of  the 
Medical  Department  of  the  University  of  Mar)'land  in 
1876,  but  had  always  practised  his  profession  in  New 
York.  He  was  Professor  of  Diseases  of  the  Throat  in 
the  University  of  the  City  of  New  York,  and  was  a 
member  of  many  local  societies  and  a  fellow  of  the 
American  Laryngological  Association.  Dr.  Jarvis  was 
a  conscientious  student  and  a  careful  writer,  and  had 
made  many  notable  contributions  to  lar)Tigological 
literature  ;  he  had  also  enriched  the  armamentarium 
of  that  branch  with  several  useful  instruments  of  his 
own  invention. 

A  Substitute  for  Execution  by  Electricity. — An  Ohio 
physician  proposes  that  the  death  penalty  be  carried 
out  by  filling  the  room  in  which  the  condemned  man 
is  sleeping  with  carbonic-acid  gas. 

Syphilis  in  Russia. — Syphilis  prevails  to  an  excessive 
degree  throughout  the  Russian  empire,  over  a  million 
patients  having  been  under  treatment  for  this  disease 
in  the  hospitals  of  the  country'  during  the  year  1890. 
As  was  shown  by  Dr.  Bulkley  in  the  interesting  collec- 
tion of  cases  published  in  his  "  Syphilis  Insontium," 
this  wide  prevalence  of  syphilis  in  Russia  is  not  due  so 
much  to  unusual  licentiousness  as  to  the  careless  and 
uncleanly  habits  of  the  people.  A  soldier  returning  to 
his  home  with  syphilis  contracted  during  his  service 
in  the  army,  will  often  infect  his  own  family,  and  even 
the  entire  village,  through  the  common  use  of  table 
utensils,  towels,  and  pipes.  The  necessity  of  energetic 
measures  to  prevent  the  further  spread  of  this  dis- 
ease has  so  impressed  itself  upon  the  Russian  authori- 
ties, that  the  subject  will  be  given  an  important  place 
among  the  discussions  at  the  International  Congress, 
which  will  meet  at  Moscow  next  summer. 

An  International  Language  Society. — A  correspond- 
ent of  a  London  contemporary  suggests  that  those  who 
desire  to  see  the  general  use  of  some  one  language  for 
contributions  to  medical  literature  would  probably 
advance  their  object  in  a  practical  way  by  forming 
themselves  into  an  international  society,  somewhat 
upon  the  model  of  the  New  Sydenham  Society,  the 
object  of  which  shall  be  the  publication  of  translations 
of  important  medical  papers  and  monographs  in  the 
selected  language.  It  would  be  somewhat  in  the  nature 
of  putting  the  cart  before  the  horse  to  found  a  society 


for  the  propagation  of  a    language    before    deciding 
upon  the  language. 

"  Talks  with  the  Doctor." — Under  this  title,  one  of  the 
daily  papers  gives  daily  counsel  to  the  individuals  who 
apply  for  prescriptions.  One  correspondent  asks  direc- 
tions for  taking  bromide  for  a  nervous  headache,  and 
is  told  to  take  from  fifteen  to  thirty  grains  every  two  or 
three  hours.  The  advice  to  take  as  much  as  thirty 
grains  of  bromide  every  three  hours  without  any  further 
qualifications  is  certainly  dangerous,  and  the  prescrip- 
tion is  another  illustration  of  how  impossible  it  is  to 
prescribe  safely  and  effectively  through  the  columns  of 
a  daily  paper.  "  Counter-prescribing  "  by  druggists, 
we  think,  on  the  whole,  would  be  a  little  safer. 

Dr.  Max  Simon  Nordau,  the  eminent  degenerate,  is 
about  to  follow  the  example  of  some  others  of  his  class 
and  enter  general  literature.  He  is  reported  to  be  now 
at  work  on  a  novel,  and  to  have  given  out  that  when 
that  is  finished  he  will  write  a  play.  He  has  been  earn- 
ing money  with  his  pen,  we  are  told,  since  he  was  four- 
teen years  of  age,  and  he  is  still  on  the  bright  side  of 
fifty. 

Cholera  in  Japan. — Notwithstanding  recent  semi- 
official denials,  cholera  appears  to  be  more  than  usu- 
ally prevalent  in  Japan  this  summer.  Advices  from 
Tokio,  of  July  12th,  say  that  there  is  every  premoni- 
tion of  a  serious  epidemic.  The  disease  has  appeared 
among  the  troops  at  Pescadores,  Port  Arthur,  and  Chin 
Chow,  its  germs  having  been  carried  by  returning  sol- 
diers. There  are  fourteen  centres  of  infection  from 
which  reports  of  fresh  cases  reach  the  authorities  daily. 
The  government  is  making  strenuous  efforts  to  check 
the  epidemic.  Since  the  outbreak  of  the  disease  up  to 
the  end  of  July,  there  were  9,000  cases  of  the  disease 
and  5,000  deaths.  The  cholera  is  raging  also  in  sev- 
eral cities  of  Corea. 

Assault  on  a  Physician.  —  Dr.  George  Drury,  of 
Brooklyn,  was  called  by  telephone  last  Saturday  to 
visit  a  person  said  to  be  at  the  point  of  death.  He 
went  to  the  place  indicated,  a  house  that  had  been  for 
some  time  unoccupied,  and  was  conducted  by  a  man 
who  opened  the  door  to  the  upper  floor.  Here  he  was 
set  upon  by  his  conductor  and  another  man,  beaten 
and  gagged,  and  robbed  of  his  money,  watch,  and  jew- 
elry. The  watch  and  jewelry  have  been  recovered  in 
a  pawn-shop  in  this  city,  and  the  authorities  hope  to 
apprehend  the  criminals.  Another  Brooklyn  physician 
was  called  recently  by  telephone  on  an  errand  similar 
to  that  which  led  Dr.  Drury  into  the  trap.  When  he 
arrived  at  the  house  a  woman  answered  the  bell  and 
said  that  no  one  was  sick  there.  Just  as  he  was  about 
to  leave,  a  man  came  to  the  door  and  said  that  the  sick 
person  was  upstairs.  The  doctor's  suspicions  were 
aroused,  however,  and  he  refused  to  go  inside. 

The  Water-Supply  of  London  is  at  the  mercy  of  pri- 
vate companies  that  are  unable  to  furnish  all  the  water 
needed  and  that  are  allowed  to  charge  full  price  to  the 
consumers  whether  they  give  a  constant  supply  or  not. 
\t  present  the  meagre  supply  of  water  in  the  eastern 
part  of  London  is  causing  increased  suffering  to  the  in- 
habitants of  that  section.  The  streets  are  filled  with 
women  offering  threepence  or  more  for  a  bucket  of 


164 


MEDICAL   RECORD. 


[August  3,  1895 


water,  but  they  are  unable  to  get  it  even  at  that  [jrice, 
for  the  very  good  reason  that  there  is  none.  The 
death-rate  in  East  London  has  been  doubled  since  the 
companies  began  turning  off  the  flow  of  water  except 
for  about  two  hours  in  the  twenty-four. 

An  International  Congress  of  Applied  Chemistry  will 
be  held  in  Paris  next  year.  A  preliminary  programme 
of  the  sections  has  been  drawn  up  for  consideration. 
They  are  to  be  ten  in  number,  and  will  cover  the  entire 
field  of  industrial  chemistry. 

Testimonial  to  Sir  Joseph  Lister. — Sir  Joseph  Lister 
was  presented  on  July  30th  with  his  portrait,  painted 
by  Mr.  J.  H.  Lorimer.  The  presentation  was  made  at 
a  meeting  held  at  King's  College  Hospital  by  Sir  John 
E.  Erichsen,  President  of  University  College. 

Yellow  Fever  in  Havana. — The  medical  inspector 
of  the  United  States  Marine  Hospital  Service  at  Ha- 
vana states  that  in  the  week  ended  July  25th  there 
were  seventy  new  cases  of  yellow  fever  in  that  city  and 
twenty-three  deaths. 

Dr.  George  B.  Fowler  has  been  appointed  by  Gov- 
ernor Morton  to  the  State  Board  of  Health  as  the 
Commissioner  representing  the  city  of  New  York. 

The  Grand  Duke  George,  Tsarewitch  of  Russia,  is 

suffering  from  pulmonary  tuberculosis  in  an  advanced 
stage.  He  proposes  to  spend  the  coming  winter  in  Al- 
giers. 

The  School  of  Medicine  for  Women  in  St.  Petersburg 
is  now,  thanks  to  private  liberality,  on  a  firm  founda- 
tion financially  and  will  soon  be  ready  for  work.  The 
curriculum,  which  is  to  extend  over  five  years,  will  be 
the  same  as  that  of  the  medical  faculty  in  the  univer- 
sity, and  will  be  open  to  single  women  over  twenty-one 
years  of  age.  Single  women  of  younger  age  and  mar- 
ried women  must  be  supplied  with  a  written  permission 
from  their  parents  and  husbands  respectively.  All  stu- 
dents must  know  a  certain  amount  of  Greek  and  Latin. 
A  clause  provides  that  a  woman  holding  the  school's 
diploma  will  not  be  eligible  as  director  of  a  general 
hospital. 

The  Proportion  of  Multiple  Births, — In  a  paper  read 
before  the  New  York  State  Medical  Society  some  years 
ago  Dr.  James  Y.  Kendall  reported  875  cases  of  child- 
birth occurring  in  his  own  practice,  among  which  were 
17  cases  of  twins,  or  1.7 1  per  cent.  This  is  much 
higher  than  the  average,  as  stated  by  Dr.  Drejer,  which 
we  noted  recently  as  being  1.17  per  cent. 

The  British  Medical  Association,  which  met  this 
week,  promised  to  be  one  of  considerable  interest  in 
the  matter  of  ethical  debates.  Among  other  questions 
proposed  for  discussion  were  "  Intra-professional  Eti- 
quette," "  Advertising,"  "  L^nqualified  Assistants," 
"  Gratuitous  and  Cheap  Contract  Practice,"  and  "  Hos- 
pitals and  Dispensaries."  Mr.  Lawson  Tait  promised 
to  introdiice  another  cause  for  acrimonious  dispute  in 
the  shape  of  a  resolution  denouncing  the  jiroposed 
Midwives'  Registration  Bill. 

The  Attractiveness  of  New  York. — The  editor  of  an 
esteemed  St.  Louis  contemporary  ajiologizes  to  his  read- 
ers for  a  delay  in  the  issue  of  the  journal,  alleging  the 


wholly  valid  excuse  that  he  was  detained  in  New  York. 
Another  esteemed  contemporary,  the  Medical  and  Sur- 
gical Reporter,  after  existing  for  forty-two  years  in 
Philadelphia,  has  come  to  live  in  New  York  amid  con- 
genial surroundings,  where  medical  thought  is  active. 
We  welcome  the  Reporter  to  the  medical  centre  and 
wish  it  many  years  and  a  constantly  increasing  circle 
of  readers. 

The  Memory  of  the  Late  Dr.  Dujardin-Beaumetz  has 
recently  been  honored  by  the  erection  of  a  bust  in  the 
garden  of  the  Hopital  Cochin,  in  Paris. 

Obituary  Notes. — Dr.  Walter  A.  Morton  died  at 
his  home  in  Brooklyn  on  July  2 2d.  He  was  thirty-six 
years  of  age,  and  was  a  graduate  of  the  Dartmouth 
Medical  School  in  1890. — Dr.  Benjamin  S.  Mackie, 
aged  fifty,  a  surgeon  in  the  United  States  Navy,  with 
the  relative  rank  of  Lieutenant-Commander,  was  found 
dead  on  July  25th  in  the  library  of  his  residence,  in 
Philadelphia,  with  a  bullet-hole  through  his  head.  He 
had  committed  suicide.  Dr.  Mackie  entered  the  navy 
in  1869.  His  last  service  was  aboard  the  cruiser  Chi- 
cago. He  had  been  on  waiting  orders  for  several 
months. — Dr.  Richard  Reasoner,  of  Morrisonville, 
111.,  was  shot  and  killed,  on  July  24th,  by  a  man  whose 
wife  had  been  under  his  professional  care.  The  woman 
had  become  insane,  and  her  husband  believed  it  was  in 
consequence  of  the  doctor's  treatment,  and  had  threat- 
ened several  times  to  take  his  life. 

Texas  Fever  in  the  Southern  States. — A  telegram 
from  Louisville  states  that  a  proclamation  has  been  is- 
sued by  the  Kentucky  State  Board  of  Health  quarantin- 
ing against  cattle  from  Virginia,  North  and  South  Caro- 
lina, Mississippi,  Indian  Territory,  Alabama,  Texas, 
Louisiana,  Arkansas,  Georgia,  and  Florida,  giving  as  a 
reason  for  this  action  that  Texas  fever  has  been  intro- 
duced into  these  States  recently  and  a  number  of  cattle 
have  died  of  it.  The  quarantine  is  to  be  maintained 
during  all  the  year  except  December,  January,  and 
February. 

Cholera  and  Quarantine. — The  English  journals  have 
taken  very  much  to  heart  the  charge  made  by  M.  Henri 
Monod,  at  a  meeting  of  the  Comite  Consultatif  d'Hy- 
giene  of  France,  that  England  is  to  blame,  by  her  re- 
fusal to  ratify  the  Paris  Convention,  for  the  occurrence 
of  cholera  this  year  in  Mecca.  They,  of  course,  repel 
the  charge,  but  seem  to  be  rather  hard  pushed  at  times 
to  do  so  convincingly.  The  Lancetss.y&  that  M.  Monod 
should  remember  that  if  France  would  only  give  up 
her  quarantine  notions  in  the  Red  Sea,  the  way  of  Eng- 
land to  do  that  which  is  right  would  be  much  clearer. 
"  It  is  quarantine  in  the  Red  Sea  that  endangers  the 
lives  of  Indian  pilgrims  and  constitutes  the  main,  if  not 
the  sole,  danger  of  cholera  reaching  Mecca  by  way  of 
the  sea.  If  our  pilgrims  were  only  allowed,  when  cer- 
tified after  a  long  voyage  to  be  free  from  cholera,  to 
sail  on  to  Jeddah  the  danger  of  cholera  travelling  by 
the  sea  route  would  practically  be  at  an  end."  We 
have  often  seen  it  stated  in  the  interests  of  commerce 
that  quarantine  was  ineffectual  as  a  means  of  staying 
the  advance  of  cholera  and  other  pestilences,  but  that 
effective  quarantine  not  only  fails  to  stay  the  progress 
but  even  favors  the  advance  of  epidemic  disease  is  a 
rather  strong  assertion. 


August  3,  1895] 


MEDICAL    RECORD. 


165 


s-ocictij  ^\cpovts. 


THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  February  ij,  i8gj. 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Aneurism  of  the  Arch  of  the  Aorta  was  presented  by 
Dr.  E.  Hodenpvl.  The  aneurism  was  so  large  that  it 
caused  extreme  pain,  and  the  patient,  a  German,  thirty 
years  of  age,  killed  himself  to  be  rid  of  the  pain.  He 
had  complained  for  a  considerable  time  of  pains  in  the 
chest.  He  committed  suicide  by  shooting  himself 
twice  in  the  left  breast.  Both  bullets  pierced  the  pleu- 
ral cavity,  but  did  not  injure  the  lung.  He  was  per- 
fectly conscious  for  some  hours  after  the  shooting. 
At  the  autopsy,  besides  the  conditions  brought  about 
by  the  shooting,  there  were  extensive  hemorrhages  into 
the  pleural  and  abdominal  cavities  ;  the  heart  lay  high 
in  the  chest,  and  immediately  below  it  was  a  large  mass 
which  was  close  to  the  vertebral  column,  and  pressed 
toward  the  median  line  by  a  large  quantity  of  blood  in 
the  pleural  cavity.  This  mass  was  removed  in  con- 
junction with  the  heart,  and  then  it  was  found  that  the 
mass  occupied  the  lower  lobe  of  the  lung  on  the  left 
side,  and  was  very  hard.  An  aneurism  was  found  at 
the  beginning  of  the  arch  of  the  aorta,  and  at  the  be- 
ginning of  the  thoracic  aorta  was  a  large,  sacculated 
aneurism  containing  a  considerable  amount  of  lami- 
nated fibrin.  The  aneurism  had  pressed  posteriorly, 
but  chiefly  laterally,  and  had  replaced  almost  com- 
pletely the  lower  lobe  of  the  lung.  Some  of  the  verte- 
brae had  been  eroded. 

Abscess  of  the  Liver. — Dr.  Hodenpvl  then  presented 
two  specimens  of  the  above.  The  first  specimen  was 
removed  from  a  man,  fift)'-two  years  of  age,  who  had 
suffered  from  irregular  chills  and  fever  for  five  or  six 
weeks  previous  to  his  admission  to  the  hospital.  He 
was  in  a  semi-comatose  condition  at  the  time  of  ad- 
mission, and  all  that  could  be  gathered  from  his  state- 
ments was  that  he  had  had  a  cough  with  muco-puru- 
lent  expectoration  for  two  weeks,  and  also  pain  in  the 
epigastrium  and  right  hypochondrium.  There  was  no 
history  of  his  having  had  diarrhoea  at  any  time.  His 
temperature  was  normal,  the  pulse  130  and  weak.  A 
needle  was  inserted  in  the  eighth  interspace  posteriorly 
in  two  places,  but  only  dark  blood  was  withdrawn. 
There  was  tenderness  over  the  region  of  the  liver,  and 
slight  dulness  over  an  area  about  three  inches  in  di- 
ameter. The  aspirating  needle  was  also  inserted  in 
the  median  line,  but  no  pus  was  obtained.  At  the  au- 
topsy the  liver  was  found  to  have  been  converted  into 
a  series  of  inter-communicating  cavities.  No  amoebre 
were  found. 

The  second  specimen  was  removed  from  a  man, 
twenty-five  years  of  age,  who  had  had  irregular  attacks 
of  dysentery  at  frequent  intervals  ever  since  early 
childhood.  For  the  last  two  months  the  dysentery 
had  been  uncontrollable,  there  having  been  daily  up- 
ward of  twenty  movements  containing  blood  and  mu- 
cus. There  had  been  no  elevation  of  temperature 
during  his  stay  in  the  hospital.  At  the  autopsy  a  well- 
marked  ulcerative  colitis  was  found,  and  an  enormous 
abscess  of  the  right  lobe  of  the  liver.  There  was  a 
marked  compensatory  hypertrophy  of  the  left  lobe  of 
the  liver. 

Hypertrophy  of  the  Prostate  and  Castration. — Dr. 
Hodenpyl  then  exhibited  two  specimens  of  hypertro- 
phy of  the  prostate.  One  of  them  showed  the  effect 
of  castration.  The  first  specimen  had  been  removed 
from  an  old  man  who  had  suffered  intensely  from  ob- 
struction of  the  bladder,  due  to  an  enormous  hyper- 
trophy of  the  prostate.     Castration  was  performed,  and 


this  resulted  in  a  shrinkage  of  the  prostate,  and  a  res- 
toration of  the  power  of  voluntary  urination.  Perfora- 
tion of  the  bladder  had  occurred  behind  and  a  little 
above  the  prostate,  and  as  a  result,  a  general  suppu- 
rative peritonitis.  The  second  specimen  showed  an 
enormous  prostate  gland.  It  had  been  removed  from 
the  body  of  a  man,  sixty-two  years  of  age,  who  had 
died  of  some  intercurrent  disease.  There  had  not 
been  any  marked  difficulty  in  urination.  In  the  fresh 
state  the  prostate  measured  four  inches  across  as  the 
bladder  was  opened.  The  bladder  was  capable  of 
containing  only  between  one  and  two  ounces  of  urine. 

Dr.  J.  W.  Brannan  said  that  the  patient  from  whom 
the  first  specimen  of  abscess  of  the  liver  had  been  re- 
moved, had  been  under  his  care  at  the  St.  Francis's  Hos- 
pital for  about  a  week.  -  The  chief  symptoms  had  been 
pain  in  the  region  of  the  liver,  and  moderate  tenderness. 
There  had  been  an  enlargement  of  the  liver,  so  that  it 
could  be  mapped  out  by  percussion  for  two  and  a  half 
inches  below  the  costal  margin,  and  there  had  been 
dulness  posteriorly  up  to  about  the  eighth  rib.  There 
had  also  been  very  marked  diarrhoea.  The  exploratory 
punctures  had  been  made  chiefly  with  reference  to  the 
lung,  but  one  puncture  had  been  made  with  a  \dew  of 
determining  the  existence  of  any  collection  of  fluid  in 
the  liver.  Nothing  but  dark  blood  had  been  obtained. 
The  case  had  taught  him  the  advisability  of  repeating 
the  punctures  if  at  first  no  pus  were  obtained.  Judg- 
ing from  his  experience  in  one  case  of  amoebic  dysen- 
tery, he  would  have  expected  to  find  the  amoebae  in  the 
intestines  chiefly  ;  hence,  it  was  unfortunate  that  no 
examination  of  the  intestines  had  been  made. 

The  case  of  abscess  of  the  liver  reported  by  Dr. 
Edebohls,  in  which  relief  had  been  repeatedly  given  by 
operation,  had  also  been  under  his  care,  and  he  had 
studied  it  very  carefully.  It  was  a  case  of  amoebic 
dysentery.  At  the  first  operation,  the  liver  had  only 
been  attached  to  the  abdominal  wall,  but  after  firm  ad- 
hesions had  formed,  the  liver  had  been  punctured  and 
drained. 

The  autopsy  in  that  case  had  shown  a  complete  ab- 
sorption of  the  adhesions  that  had  formed  at  the  first 
operation  between  the  capsule  of  the  liver  and  the  ab- 
dominal wall.  The  liver  was  of  normal  size,  and  yet 
a  large  part  of  the  liver  tissue  had  been  destroyed. 
Microscopical  examination  had  shown  extensive  dilata- 
tion of  the  blood-vessels  with  cirrhosis  of  the  liver,  and 
also  that  there  had  been  an  extensive  reproduction  of 
the  liver  tissue. 

Cardiac  Hypertrophy,  Endocarditis  of  Mitral  Valve, 
and  Free  Chordae  Tendinae. — Dr.  F.  Ferguson  presented 
specimens  from  a  case  of  the  above.  They  had  been 
removed  from  a  man,  forty-four  years  of  age,  who  had 
been  admitted  to  the  hospital  service  of  Dr.  W.  G. 
Thompson,  on  September  20,  1894.  There  was  no 
family  history  bearing  on  his  condition  ;  his  habits  were 
regular,  and  there  was  no  history  of  rheumatism. 
Some  six  months  prior  to  his  admission,  he  caught  cold, 
and  since  that  time  he  had  complained  of  dyspnoea. 
He  had  suffered  recently  from  constipation  and  haem- 
orrhoids. He  had  been  unable  to  sleep  on  account  of 
pain  over  the  liver  and  region  of  the  heart.  On  admis- 
sion his  abdomen  was  swollen,  and  he  complained 
chiefly  of  shortness  of  breath.  His  temperature  was 
97.8°  F.  ;  respirations,  32  :  and  pulse,  108.  On  physical 
examination,  there  were  signs  of  consolidation  and  of 
fluid  at  the  base  of  the  left  lung.  The  cardiac  apex 
was  at  the  sixth  intercostal  space,  four  and  a  half  inches 
to  the  left  of  the  median  line.  There  was  a  loud,  blow- 
ing, systolic  murmur  over  the  cardiac  area,  with  point 
of  intensity  over  the  apex,  and  heard  distinctly  over  the 
left  chest  posteriorly.  This  murmur  obscured  the  first 
sound  of  the  heart.  The  cardiac  action  was  slow,  regu- 
lar, and  of  fair  force,  but  the  pulse  was  irregular  and 
intermittent.  There  was  distention  of  the  veins  of  the 
neck.  The  area  of  liver  dulness  was  normal ;  splenic 
area  was  not  determined.     The  abdomen  was  distended 


i66 


MEDICAL    RECORD. 


[August  3,  1895 


and  tympanitic  over  the  central  area,  but  dull  along  the 
flanks ;  and  on  percussion  there  was  the  characteristic 
fluid  wave.  The  tongue  was  deep  red,  and  slightly  fis- 
sured. He  was  slightly  anaemic,  but  fairly  well  nour- 
ished, and  his  general  condition  appeared  fair  ;  but 
there  was  well-marked  oedema  at  the  ankles  and  on  the 
legs.  His  dyspnoea  became  aggravated,  and  on  Octo- 
ber I  St  his  right  pleural  cavity  was  aspirated  and  si.xty- 
four  ounces  of  clear  serum  withdrawn.  During  the 
month  of  October  he  was  troubled  with  incessant 
cough,  insomnia,  and  restlessness,  and  was  at  times 
delirious.  His  urine  was  alkaline.  It  had  a  specific 
gravity  of  1.020,  and  contained  varying  quantities  of  al- 
bumin, from  a  trace  at  the  date  of  his  admission  to 
twenty-five  per  cent,  by  volume  on  November  ist.  He 
also  suffered  from  coldness  of  Jiis  extremities,  and  the 
face  was  cyanotic.  All  his  symptoms  varied  from  time 
to  time — now  fairly  rational,  and  again,  delirious  ;  but 
there  was  a  general  and  progressive  decline,  and  he 
died  on  November  23,  1894.  There  was  only  a  trace 
of  albumin  in  his  urine  at  the  time  of  his  death.  His 
treatment  had  consisted  in  the  use  of  fluid  diet,  tonics, 
stimulants,  and  diuretics. 

At  the  autopsy  there  was  found  emaciation  of  the 
body,  but  no  oedema.  There  was  marked  anaemia. 
The  peritoneal  cavity  contained  500  c.c.  of  straw-col- 
ored serum.  In  the  right  pleural  cavity  were  800 
c.c.  of  blood-stained  serum,  but  the  left  pleural  cavity 
contained  no  fluid.  The  pericardium  was  normal. 
The  heart  was  large,  weighing  seventeen  and  a  half 
ounces.  Its  cavities  were  moderately  dilated  ;  the  wall 
of  the  left  ventricle  was  moderately  hypertrophied,  and 
that  of  the  right  ventricle  considerably  thickened. 
The  muscular  tissue  was  of  a  dark-red  color.  The 
aortic,  tricuspid,  and  pulmonary  valves  were  normal. 
The  mitral  valve  was  slightly  reduced  in  capacity, 
with  thickening  of  the  anterior  segment.  Five  of  the 
chordae  tendinae  were  free,  being  detached  close  to  their 
fleshy  columns,  without  any  evidence  of  their  previous 
attachment  on  the  surface  of  the  endocardium.  All  the 
organs  gave  evidence  of  prolonged  hypersemia.  The 
bladder  was  enormously  distended,  containing  700  c.c. 
of  cloudy  urine.  Its  walls  were  thickened.  There  was 
a  diverticulum  of  the  posterior  wall,  with  an  estimated 
capacity  of  30  c.c.  This  communicated  with  the  blad- 
der by  an  opening  i  ctm.  in  diameter.  The  prostate 
was  'enlarged,  especially  the  right  lobe,  which  en- 
croached upon  the  urethra,  and  must  have  caused  con- 
siderable obstruction  to  the  outflow  of  urine. 

Mitral  and  Aortic  Stenosis. — Dr.  Ferguson  also  pre- 
sented another  heart.  It  had  been  removed  from  a 
man,  thirty-one  years  of  age,  a  glass-worker  by  occupa- 
tion. He  had  been  admitted  to  the  service  of  Dr.  W. 
H.  Draper  at  the  New  York  Hospital  on  January  28, 
1895,  suffering  from  dyspnoea.  He  stated  that  he 
had  had  several  attacks  of  heart  failure,  and  had  been 
subject  to  cardiac  disease  for  years.  He  died  shortly 
after  his  admission  to  the  hospital.  At  the  autopsy, 
inspection  showed  the  body  to  be  well  nourished, 
and  free  from  oedema.  There  were  300  c.c.  of  blood- 
stained serum  in  the  right  pleural  cavity.  The  same 
quantity  of  similar  fluid  was  found  in  the  left  pleural 
cavity.  The  heart  was  slightly  increased  in  size,  the 
wall  of  the  right  ventricle  being  enormously  hypertro- 
phied, and  the  ventricle  moderately  dilated.  The 
valves  in  the  right  ventricle  were  normal.  The  left 
ventricle  was  slightly  dilated,  but  its  wall  was  normal 
in  thickness.  Two  of  the  aortic  cusps  were  blended 
together  over  a  distance  of  i  ctm.,  and  all  the  cusps 
were  thickened  and  retracted.  There  was  thickening 
and  retraction  of  the  segments  of  the  mitral  valve.  It 
admitted  a  probe  only  i  ctm.  in  diameter.  There  was 
great  dilatation  of  the  left  auricle,  with  thickening  of 
its  wall.  There  were  intense  congestion  and  oedema 
of  the  lungs.  The  liver  was  nutmeg  in  appearance. 
All  the  other  organs  presented  the  appearances  associ- 
ated with  prolonged  passive  hyperemia. 


Epithelioma  of  the  (Esophagus. — Dr.  Ferguson  pre- 
sented still  another  specimen.  It  had  been  taken  from 
a  man,  forty-four  years  of  age,  who  had  been  admitted 
to  the  service  of  Dr.  Frank  P.  Murray  on  January  17, 
1895.  During  last  July,  while  employed  in  beating 
carpets,  he  experienced  considerable  trouble  with  his 
throat.  Two  months  later,  he  noticed  difficulty  in  de- 
glutition, and  regurgitation  of  food  through  the  nasal 
passages.  During  the  three  months  prior  to  his  admis- 
sion he  had  not  been  able  to  swallow  solid  food.  Since 
the  beginning  of  his  sickness,  his  voice  during  wet 
weather  had  had  a  nasal  quality.  He  had  recently  suf- 
fered greatly  from  dyspnoea  and  dysphagia,  and  had 
lost  flesh  and  strength.  There  was  no  family  history 
bearing  on  his  case,  and  he  had  always  enjoyed  good 
health  up  to  the  commencement  of  his  present  illness. 
On  examination,  a  tumor  was  found  in  the  larynx, 
principally  on  the  left  side.  It  was  firm  and  nodular, 
and  adherent,  but  not  tender  on  pressure.  There  were 
enlarged  cervical  glands.  The  cachexia  was  marked. 
Owing  to  his  extreme  dyspnoea,  he  was  submitted  to 
tracheotomy,  from  which  he  reacted  favorably,  and 
with  a  considerable  improvement  in  respiration.  The 
operation  was  performed  on  January  19th.  Four  days 
later,  there  was  distinct  redness  and  swelling  on  the 
left  side  of  the  wound,  and  this  was  followed  by  greater 
difficulty  in  deglutition.  Three  days  after  this,  there 
was  a  fluctuating  area  to  the  left  of  the  tracheotomy 
wound,  which,  when  incised,  gave  vent  to  a  half-drachm 
of  pus.  Since  the  latter  part  of  January,  he  had  been 
fed  by  nutritive  enemata,  being  unable  to  take  any 
nourishment  by  the  mouth.  He  rapidly  declined,  there 
being  slight  fever,  but  no  pain.  He  died  on  February 
6th.  The  autopsy  showed  a  lobulated  tumor,  which 
completely  filled  the  upper  part  of  the  oesophagus  and 
lower  part  of  the  pharynx.  It  measured  13  ctm.  ver- 
tically, and  4  ctm.  antero-posteriorly.  Its  greatest 
transverse  measurement  was  5  ctm.  It  projected  into 
the  rima  glottis  and  the  space  behind  the  epiglottis, 
apparently  completely  filling  them.  The  left  aryteno- 
epiglottidean  fold  was  displaced  inward  by  the  pressure 
produced  by  the  development  of  the  tumor.  The  base 
of  attachment  was  the  posterior  wall  of  the  pharynx, 
and  the  posterior  and  lateral  wall  of  the  oesophagus, 
down  to  the  lower  border  of  the  cricoid  cartilage. 
Below  this  level  it  extended  downward,  and  was  at- 
tached to  the  anterior  wall  of  the  oesophagus.  The 
entire  area  of  attachment  was  10  ctm.  in  the  vertical 
direction,  and  about  7  ctm.  laterally.  There  was  a  very 
narrow  opening  along  the  right  side  of  the  oesophagus, 
through  which  a  small  probe  could  be  passed.  There 
was  also  a  narrow,  irregular  channel  in  the  interior  of 
the  tumor.  The  oesophagus  was  normal  below  the 
tumor.  The  posterior  wall  of  the  trachea,  just  below 
the  larynx  for  a  distance  of  5  ctm.,  bulged  forward  from 
the  encroachment  of  the  tumor.  The  tracheotomy 
opening  was  situated  in  the  median  line,  10  ctm.  above 
the  bifurcation,  and  just  below  the  bulging  of  the 
tracheal  wall  already  mentioned.  There  was  extreme 
emaciation  of  the  body.  An  old  tubercular  lesion  was 
found  in  both  apices,  but  chiefly  in  the  right  lung.  J 
There  was  also  a  small  tubercular  nodule  in  the  liver.  I 
There  was  chronic  diffuse  nephritis.  Microscopical  " 
examination  showed  the  structure  of  the  tumor  to  be 
that  of  an  epithelioma.  On  the  surface  it  presented 
in  places  the  appearances  common  in  ordinary  papillo- 
mata. 

The  President  said  he  was  extremely  interested  in 
the  specimen  showing  free  chord*  tendins.  Their 
free  ends  were  perfectly  round,  club-shaped,  and  fi- 
brous, and  there  was  not  the  slightest  appearance  of  a 
recent  endocarditis.  It  was  rather  hard  to  explain  how 
they  had  become  free.  The  question  arose  here  as  to 
whether,  with  a  simple  rheumatic  endocarditis,  there 
might  not  be  a  weakening  and  rupture  of  some  of  the 
chordae  tendinae.  The  murmur  in  this  case  was  said  to 
have  been  unusually  loud  and  widely  diffused,  and  en- 


August  3,  1895] 


MEDICAL   RECORD. 


167 


tirely  different  in  character  from  other  cardiac  mur- 
murs. Although  careful  search  was  made,  no  points 
had  been  discovered  to  indicate  where  the  chordae  ten- 
dinae  had  been  attached. 

Dr.  J.  W.  Braxnan  said  that  it  was  usually  stated 
in  the  text-books  that  if  one  were  in  doubt  as  to 
whether  an  apex  murmur  was  due  to  stenosis  or  regur- 
gitation, the  size  of  the  heart  would  decide  the  matter  ; 
in  other  words,  if  the  left  ventricle  were  small  and  the 
disease  had  existed  some  time,  the  existence  of  stenosis 
was  pretty  certain,  whereas  if  there  were  regurgitation 
present  there  would  also  be  hypertrophy.  He  would 
like  to  know  whether  pathological  studies  confirmed 
this  statement. 

Dr.  Fergusox  replied  that  the  left  ventricle  would 
be  abnormally  small,  commensurate  with  the  stenosis. 
This  would  be  so  even  if  moderate  regurgitation  were 
present,  the  wall  becoming  thin  and  the  cavity  reduced 
in  size. 

Dr.  Braxnan  said  he  had  found  it  difficult  to  be- 
lieve that  the  statement  to  which  he  had  just  referred 
was  strictly  correct,  because  after  the  enlargement  of  the 
right  side  of  the  heart,  it  would  seem  as  if  in  time  the 
left  ventricle  would  also  become  at  least  dilated  in 
order  to  keep  up  the  circulation. 

Dr.  H.  p.  Loo.mis  called  attention  to  the  fact  that  in 
the  specimen  presented  the  adherence  of  the  cusps 
must  have  interfered  with  the  circulation  in  the  coro- 
nary arteries. 

The  President  said,  regarding  the  point  raised  by 
Dr.  Brannan,  that  as  pure  and  simple  mitral  stenosis 
rarely  occurred,  the  value  of  such  a  method  of  clinical 
differentiation  was  not  very  great. 

Primary  Cancer  of  the  Ltmg. — Dr.  H.  P.  Loomis 
presented  the  specimen.  It  had  been  removed  from  a 
man  sixty  years  of  age.  It  was  situated  at  the  lower 
and  posterior  border  of  the  lower  lobe  of  the  left  lung, 
and  measured  in  its  vertical  diameter  two  inches,  antero- 
posteriorly  one  and  three-fourths  inches,  and  laterally 
two  inches.  It  was  irregular  in  shape,  and  distinctly 
lobulated.  The  lobules  were  more  or  less  completely 
surrounded  by  a  fibrous  capsule.  The  tumor  was  firm, 
and  of  an  opaque,  whitish-yellow  color.  A  large  branch 
of  the  pulmonary  arterj',  which  was  still  open,  ran 
through  the  centre  of  the  mass  from  above  downward. 
The  pulmonary  tissue  surrounding  the  tumor  presented 
the  characteristic  appearances  of  white  pneumonia.  The 
bronchial  tubes  throughout  the  consolidated  portion 
showed  the  endences  of  a  bronchitis.  The  lung  over 
the  tumor  was  firmly  adherent  to  the  chest  wall,  and  a 
slight  quantity  of  serous  fluid  was  found  at  the  iDottom 
of  the  left  pleural  cavity.  The  right  lung  was  perfectly 
normal,  with  the  exception  of  hypostatic  congestion  of 
the  lower  lobe,  and  some  old  pleuritic  adhesions.  The 
kidneys  presented  the  characteristic  appearances  of  a 
chronic  diffuse  parenchymatous  nephritis.  The  heart 
was  hypertrophied,  and  the  aorta  showed  the  evidences 
of  extensive  atheromatous  changes.  With  these  excep- 
tions, all  the  other  organs  were  normal.  A  most  thor- 
ough and  complete  examination  was  made  of  every 
organ  and  tissue  of  the  body  to  ascertain  if  there  were 
any  evidences  of  cancerous  development  in  other  parts. 
This  examination  included  the  mouth,  larynx,  oesopha- 
gus, digestive  tract,  bladder,  mediastinal  tissues,  brain, 
and  the  bronchial  and  retro-peritoneal  glands.  No 
abnormal  growth  was  found  anywhere  except  in  the 
left  lung.  Microscopical  examination  of  sections  taken 
from  different  portions  of  the  neoplasm  showed  it  to 
be  a  medullary  cancer  (carcinoma  molle).  The  new- 
growth  seemed  to  spring  from  the  epithelium  of  the 
mucous  membrane  of  the  bronchi.  In  some  places  an 
apparently  pre-existing  alveolar  structure,  as  if  the  can- 
cer-cells had  filled  the  air-cells,  could  be  made  out. 
No  pulmonarj'  lesion  was  diagnosed  during  life.  The 
man  had  been  an  inmate  of  the  almshouse  on  Black- 
well's  Island  for  a  long  time,  and  had  died,  as  far  as 
could  be  ascertained,  rather  suddenly. 


Primary  cancer  of  the  lungs,  the  speaker  said,  was 
one  of  the  rarest  pathological  lesions  found.  In  twenty- 
seven  cases  obtained  from  the  literature  of  this  country 
and  Europe,  and  analyzed  by  Reinhard,  only  one  lung 
was  involved  in  nearly  all  of  the  cases,  eighteen  times 
in  the  right,  and  nine  times  in  the  left  lung. 

Aneurism  of  the  Aorta  with  Multiple  Thrombi  was 
presented  by  Dr.  George  P.  Biggs.  The  specimens 
had  been  removed  from  a  woman,  thirty-four  years  of 
age,  who  had  complained  of  dyspnoea  and  slight  oedema 
of  the  lower  extremities  for  a  number  of  months. 
Shortly  before  admission  the  dyspnoea  increased,  and 
was  associated  with  cardiac  palpitation  and  dimness  of 
\'ision.  The  temperature  was  102.2°  F.;  the  respira- 
tions, 28  ;  and  the  pulse,  96.  Physical  examination 
showed  only  congesrion  of  both  lungs  posteriorly.  The 
cardiac  area  was  considerably  enlarged,  and  the  apex 
beat  was  in  the  sixth  space,  four  inches  to  the  left  of 
the  median  line.  There  was  a  blowing  systolic  mur- 
mur, and  the  action  of  the  heart  was  tumultuous. 
The  abdomen  was  large,  and  appeared  to  contain  some 
fluid.  The  urine  had  a  specific  gravity  of  1.024,  ^nd 
contained  five  per  cent,  of  albumin.  Dyspnoea  was 
the  chief  symptom.  The  temperature  remained  ele- 
vated, the  pulse  became  more  feeble,  and  she  died  on 
the  fourth  day  after  admission.  At  the  autopsy,  the 
adipose  tissue  of  the  abdominal  wall  was  found  to  be 
5  ctm.  in  thickness.  There  was  slight  general  oedema. 
The  peritoneum  contained  400  c.c.  of  verj'  bloody 
fluid.  The  small  intestines  presented  a  number  of 
dark,  reddish-brown  areas,  the  color  extending  into 
the  neighboring  mesentery  for  a  short  distance,  and  in- 
volving portions  of  the  omentum,  and  in  one  place 
the  transverse  colon.  These  dark-red  areas  were  cov- 
ered with  a  thin  layer  of  fibrin,  and  the  intestinal  wall 
was  soft  and  easily  torn  on  manipulation.  In  the 
right  pleural  ca\'ity  were  200  c.c.  of  bloody  fluid.  The 
left  pleural  cavity  was  obliterated  by  old  adhesions. 
The  heart  was  greatly  enlarged,  weighing  twenty-two 
ounces.  The  cavities  were  generally  hypertrophied 
and  dUated.  The  muscular  substance  was  soft,  flabby, 
and  mottled  in  appearance,  due  to  extravasations  of 
blood.  The  valves  of  the  right  side  were  all  normal. 
The  aortic  cusps  were  slightly  thickened  and  retracted. 
The  interesring  feature  was  an  aneurism,  beginning  un- 
usually low  down  in  the  aorta — i.e.,  at  its  very  begin- 
ning— and  involving  the  anterior  wall,  and  pressing 
forward  against  the  pulmonar)-  artery.  The  aneurism 
measured  4^  ctm.  vertically,  5  ctm.  transversely,  and 
about  1^4  ctm.  in  depth.  The  left  coronary  artery 
arose  from  the  aneurism  itself.  The  left  lung  was 
poorly  aerated,  congested,  and  slightly  osdematous  ; 
the  right  lung  was  similarly  congested,  but  contained 
three  hemorrhagic  infarctions,  two  in  the  lower  lobe, 
and  one  in  the  upper  lobe,  the  largest  being  in  the 
base  and  measuring  5  ctm.  in  diameter.  In  the  ves- 
sels leading  to  these  infarctions  were  very  firm  ante- 
mortem  thrombi,  adherent  to  the  vessel  wall.  The 
spleen  was  moderately  large  and  soft,  and  in  it  were  a 
number  of  reddish  areas,  verj-  suggestive  of  obstructed 
circulation,  but  they  were  not  infarctions.  The  kid- 
neys were  quite  large,  and  showed  evidence  of  paren- 
chymatous and  slight  interstitial  change.  The  liver 
showed  chronic  congestion,  .\long  the  greater  curva- 
ture of  the  stomach  a  number  of  small  vessels  in  the 
submucous  coat  were  vex)'  prominent,  owing  to  thrombi 
in  them.  In  the  intestines  the  fecal  matter  was  abun- 
dant and  very  bloody.  The  reddish-brown  areas  of 
peritoneum  showed  on  examination  that  the  wall  was 
hemorrhagic  throughout,  and  the  mesenteric  veins 
from  these  parts  were  the  seat  of  multiple  thrombi. 
The  arteries  were  perfectly  free.  No  thrombi  were 
found  in  the  other  vessels. 

A  Pectiliar  Ulcer  of  the  Duodenum. — Dr.  Biggs  also 
presented  a  specimen  which  had  been  taken  from  a 
sailor,  forty-five  years  of  age,  who  had  entered  the 
Hudson   Street    Hospital   complaining   of    abdominal 


i68 


MEDICAL    RECORD. 


[August  3,   1895 


pain  which  had  existed  for  two  01  three  days.  The 
pain  had  begun  in  the  umbilical  and  epigastric  regions, 
so  that  at  first  he  had  been  supposed  to  have  appendi- 
citis. Under  this  supposition  an  operation  was  per- 
formed, and  the  appendix  found  inflamed  upon  its  sur- 
face, as  was  also  the  entire  surface  of  the  peritoneum. 
Nothing  was  found  in  the  appendix.  The  man  died 
on  the  second  day  after  the  operation.  No  cause  had 
been  found  for  the  peritonitis.  The  autopsy  showed 
the  stump  of  the  appendix  in  good  condition,  with  ad- 
hesions formed  over  it.  The  peritonitis  was  quite  in- 
tense. Further  search  showed  the  lower  end  of  the 
duodenum  to  be  dark  and  almost  gangrenous.  On  its 
superior  wall  was  a  very  peculiar  destruction  of  tissue. 
The  mucous  membrane  was  destroyed  over  a  triangu- 
lar area,  about  one  centimetre  across.  The  edges  were 
sharply  defined,  and  the  base  of  the  ulcer  was  formed 
of  sloughy  tissue,  deeply  stained  with  bile.  Between 
the  pancreas  and  the  ulcer  the  tissues  were  found  to 
be  extensively  infiltrated  with  pus,  and  the  peritoneum 
in  this  neighborhood  was  thickly  covered  with  fibrin. 
The  site  of  the  ulcer  was  really  at  the  extra-peritoneal 
portion  of  the  duodenum,  but  the  inflammation  had  ex- 
tended to  the  peritoneum,  and  caused  the  general  peri- 
tonitis. Duodenal  ulcers  were  generally  in  the  first 
portion  of  the  duodenum,  and  were  like  the  round, 
punched-out  ulcers  found  in  the  stomach.  It  had 
been  suggested  that  the  slough  might  have  been  due  to 
a  thrombosis  of  the  veins,  but  no  such  condition  could 
be  found. 

Dr.  Hodenpyl  said  that  about  three  years  ago  he 
had  presented  to  the  Society  an  aneurism  in  the  same 
situation  and  of  about  the  same  size,  but  in  his  case 
there  had  been  an  opening  into  the  pulmonary  artery. 

The  Society  then  went  into  executive  session. 


Stated  Meeting,  February  2j,  iSg^. 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Multiple  Aneurisms  of  the  Abdominal  Aorta  and  Iliac 
Arteries,  with  Old  and  Recent  Ruptures,  and  Absence 
of  Left  Common  Iliac. — Dr.  T.  Mitchell  Prudden 
presented  specimens  from  the  above.  He  was  indebted 
for  the  specimens  to  Dr.  Clement  Cleveland,  in  whose 
care. the  patient  had  been.  The  patient,  a  man  of 
middle  age,  died  after  an  acute  illness  with  symptoms 
of  hemorrhage  into  or  behind  the  abdominal  cavity. 
The  body  was  well  formed  and  nourished,  and  at  the 
autopsy  about  half  a  litre  of  bloody  fluid  was  found  in 
the  abdominal  cavity.  The  diaphragm  was  pressed 
upward.  The  heart  was  pale,  and  with  the  exception 
of  a  slight  fatty  degeneration  of  the  aorta  above  the 
valves,  and  a  very  slight  thickening  of  the  edges  of  the 
mitral  valve,  the  heart  was  normal.  In  the  left  lung 
there  was  evidence  of  slight  bronchitis.  In  the  upper 
and  lower  lobes  of  the  right  lung  there  was  limited 
oedema.  In  both  lungs  there  was  considerable  em- 
physema at  the  edges.  The  spleen  was  slightly  en- 
larged and  soft.  The  liver  was  normal  in  size,  but  pale 
and  flabby.  The  pancreas  was  normal.  The  right 
kidney  was  pale,  and  contained  several  small  cysts  ; 
otherwise  in  the  gross  examination  the  kidneys  were 
apparently  normal.  On  removing  the  intestines,  which 
were  pushed  strongly  forward,  a  large,  dark  -  red, 
ovoidal  mass,  about  twenty-five  centimetres  long  and 
fifteen  centimetres  thick,  was  found  bulging  forward 
on  either  side  of  the  spinal  column.  This  was  clotted 
blood  infiltrating  the  post-peritoneal  fat  and  connec- 
tive tissue.  Blood,  fluid  and  clotted,  was  found  to 
have  densely  infiltrated  the  mesentery  nearly  to  its  in- 
testinal border,  the  lesser  omentum,  and  the  entire 
extra-peritoneal  connective  tissue  posteriorly  and  later- 
ally. The  aorta  was  normal  down  to  a  point  about 
four  centimetres  below  the  origin  of  the  renal  arteries. 
Here  the  lumen  was  slightly  narrowed  by  a  thin  pro- 


jecting portion  of  its  wall.  Between  this  point  and  the 
point  of  bifurcation,  the  aorta  was  distended  in  the 
form  of  an  ovoidal  aneurism,  9  ctni.  long  and  6  ctm.  in 
its  widest  diameter.  The  right  common  iliac  artery 
opened  from  this  aortic  aneurism  with  its  normal 
diameter,  but  immediately  widened  to  a  cylindrical 
sac,  about  four  centimetres  in  diameter.  At  the 
lower  end  of  this  sac  the  external  and  internal  iliacs 
passed  off  with  about  their  normal  dimensions.  The 
left  common  iliac  artery  was  absent,  the  external  and 
internal  iliacs  arising  together  from  the  lower  end  of 
the  aortic  aneurism.  The  left  external  iliac  maintained 
for  about  two  centimetres  from  its  origin  its  normal 
diameter,  then  widened  into  a  fusiform  dilatation, 
about  four  centimetres  long  and  2.5  ctm.  wide  at  the 
middle.  The  left  external  iliac  had  its  normal  diame- 
ter for  about  one  centimetre  from  its  origin  in  the  aorta. 
Here  it  presented  an  abrupt  anterior  aneurismal  pouch, 
about  five  centimetres  long  and  four  centimetres  wide. 
Below  this  the  vessel  maintained  a  diameter  of  about  2.5 
ctm.,  varying  somewhat  on  account  of  shallow,  irregu- 
lar sacculations.  From  the  lower  end  of  this  dilated 
vessel,  its  anterior  and  posterior  branches  arose  with 
normal  diameters.  The  entire  wall  of  the  lower  por- 
tion of  the  aorta  and  the  iliacs,  from  the  upper  end  of 
the  abdominal  aneurism  as  far  down  as  the  level  of  the 
origin  of  the  internal  iliac  branches,  was  the  seat  of 
chronic  arteritis  and  endarteritis.  The  walls  were 
thinned  in  places,  in  others  thickened  and  roughened. 
They  were  the  seat  of  fatty  degeneration  and  atheroma, 
and  in  a  few  spots  were  calcified.  Old  and  dense,  and 
closely  adherent  parietal  clots,  were  present  in  various 
places.  The  most  voluminous  of  these  was  in  the 
cylindrical  dilatation  of  the  right  common  iliac,  and  in 
the  sacculated  enlargement  of  the  left  internal  iliac. 
On  the  inner  side  of  the  dilated,  right  common  iliac, 
was  an  old  depressed  scar,  about  four  centimetres  long, 
and  at  this  point  the  inner  layers  of  the  vessel  had  rupt- 
ured at  some  earlier  period,  and  had  drawn  apart  at 
the  middle  to  a  distance  of  about  seven  centimetres. 
This  earlier  rupture  had  healed  by  the  formation  of  a 
dense  layer  of  fibrous  tissue  in  connection  with  the  ad- 
ventitia.  On  the  left  side  of  the  aortic  aneurism,  and 
running  obliquely  upward  and  forward,  was  a  fresh,  gap- 
ing complete  rupture  of  the  wall  of  the  aneurism,  about 
seven  centimetres  long,  through  which  the  blood  had 
found  its  way  into  the  surrounding  tissue. 

The  special  points  of  interest  in  this  case  were  :  i, 
the  malformation  of  the  iliac  ;  2,  the  multiple  aneu- 
risms in  a  limited  region  ;  3,.  the  extensive  interstitial, 
post-peritoneal  hemorrhage  from  the  ruptured  vessel ; 
and  4,  the  marks  of  an  extensive  earlier  rupture  of  the 
iliac,  which  had  spontaneously  healed. 

An  Enormous  Goitre  in  a  White  Mouse  was  pre- 
sented by  Dr.  K.  Hodenpvl.  The  mouse  had  been 
obtained  from  a  dealer  in  these  animals.  The  growth 
was  about  one-fourth  the  size  of  the  mouse.  A  section 
of  the  growth  was  exhibited  under  the  microscope,  and 
this  showed  it  to  be  a  typical  goitre. 

Stricture  of  the  (Esophagus  with  Epithelioma. — Dr. 
Hodenpyl  then  presented  a  specimen  of  the  above. 
The  stricture  had  been  almost  complete,  and  the  course 
of  the  disease  unusually  rapid,  being  less  than  three 
months.  The  specimen  had  been  removed  from  a  man, 
about  forty-five  years  of  age,  who  had  complained 
about  three  months  before  death  of  beginning  dyspha- 
gia. This  increased  until  at  the  time  of  his  admission 
to  the  hospital  he  was  unable  to  swallow  either  liquids 
or  solids.  He  died  of  exhaustion.  The  epithelioma 
was  found  about  eleven  inches  from  the  teeth.  There 
were  no  other  complicating  lesions  in  the  body. 

Multiple  New-growths  of  the  Lung,  Mediastinal,  and 
Mesenteric  Glands,  Liver,  and  Stomach. — Dr.  Hodenpyl 
also  presented  the  specimens.  They  had  been  taken 
from  a  man,  forty-three  years  of  age,  a  fireman  by  oc- 
cupation. While  on  active  duty  in  the  Fire  Department 
of   New  York  City   last   May,   he   slipped,  and  while 


Ausrust 


5] 


MEDICAL    RECORD. 


169 


prostrate,  was  struck  on  the  left  shoulder  with  some 
heavy  body.  He  soon  began  to  suffer  from  lancinat- 
ing pains  in  the  left  chest.  Shortly  after  the  accident 
he  expectorated  a  little  blood.  A  physician  who  ex- 
amined him  at  the  time  of  the  accident,  said  that  no 
bones  had  been  broken.  Last  July,  quite  a  large 
amount  of  bloody  fluid  was  withdrawn  from  the  left 
chest.  At  the  German  Hospital,  he  was  subsequently 
aspirated  five  times,  and  bloody  fluid  withdrawn  each 
time.  Last  December,  he  entered  St.  Francis  Hospi- 
tal. At  this  time  his  temperature  was  98.4°,  the  pulse 
120,  weak  and  intermittent,  and  the  respirations  22, 
costal  and  labored,  and  the  movement  of  the  left  side 
of  the  chest  was  slower.  Physical  examination  showed 
dulness  on  percussion  over  the  left  side  anteriorly, 
from  the  clavicle  to  the  margins  of  the  ribs,  extending 
to  the  right  edge  of  the  sternum  and  into  the  axilla. 
Posteriorly  on  the  left  side  there  was  absolute  dulness 
from  the  supra-spinous  fossa  down  over  the  scapula, 
and  from  the  lower  angle  of  the  scapula  to  the  base 
there  was  absolute  flatness.  In  the  inter-scapular  re- 
gion were  exaggerated  vocal  resonance  and  fremitus. 
At  the  base  of  the  left  lung  there  was  an  almost  entire 
absence  of  resonance  and  fremitus.  The  heart  sounds 
were  weak,  and  the  apex  beat  was  very  indistinct.  The 
patient  was  aspirated,  and  about  one  quart  of  blood- 
stained serum  obtained.  The  dyspnoea  was  not  at  all 
relieved  by  the  aspiration  :  the  pulse  became  weak  and 
verj'  irregular,  and  he  complained  of  a  sense  of  op- 
pression in  the  chest.  There  were  also  dysphagia, 
choking,  and  regurgitation  of  fluids.  After  a  few  days 
the  left  arm  became  swollen  and  verj'  painful,  and 
pitted  deeply  on  pressure.  Along  with  this  there  was 
some  swelling  of  the  abdomen  and  scrotum,  and  signs 
of  fluid  in  the  abdominal  cavity.  He  gradually  be- 
came weaker  and  drowsy,  and  for  a  few  days  before 
death  was  semi-comatose.     He  died  on    January  18, 

At  the  autopsy,  a  considerable  quantity  of  slightly 
bloody  fluid  was  found  in  the  abdominal  cavity,  but 
there  was  no  evidence  of  peritonitis.  The  pericardial 
sac  contained  about  one  quart  of  bloody  fluid.  The 
left  pleural  cavity  was  distended  with  clear  serum. 
There  were  no  adhesions  over  the  right  lung,  which  was 
emphysematous.  There  was  fresh  fibrin  on  the  peri- 
cardium. The  left  lung  had  been  nearly  converted 
into  a  mass  of  new-growth,  and  the  mediastinal  glands 
were  enormously  enlarged,  causing  great  compression 
of  the  trachea  and  oesophagus.  At  the  root  of  the 
neck,  just  above  the  heart,  was  a  large  mass,  about  two 
pounds  in  weight,  which  also  encircled  the  large  ves- 
sels at  the  neck.  One  of  the  ribs  showed  a  healed 
fracture  with  much  callus.  The  liver  was  large,  and 
contained  many  nodules  of  new-growth.  The  spleen 
was  enlarged  and  soft.  Around  the  cardiac  orifice  of 
the  stomach  were  numerous  enlarged  glands  containing 
new-growth.  The  stomach  was  contracted,  and  in  its 
wall  was  a  deeply  ulcerated  nodule  the  size  of  a  walnut. 
This  nodule  projected  'directly  into  the  cavity  of  the 
stomach.  At  the  beginning  of  the  duodenum  was  a 
marked  contraction  of  the  lumen  of  the  gut.  The 
bladder  was  normal.  The  heart  was  carefully  exam- 
ined for  an  old  rupture,  but  none  was  found. 

Sections  of  the  growths  were  exhibited  under  the 
microscope.  That  from  the  lung  seemed  to  be  a  typi- 
cal carcinoma.  It  had  a  well-marked  alveolar  struct- 
ure, the  alveoli  being  filled  up  apparently  with  epithe- 
lial cells.  The  speaker  said  he  had  not  been  able  to 
discover  connective  tissue  between  these  cells.  On  the 
other  hand,  in  the  liver  and  the  involved  mesenteric 
lymph  nodes  the  alveolar  structure  was  still  preserved, 
but  the  cells  were  quite  spindle-shaped,  and  here  and 
there  there  was  apparently  a  little  fibrilla  of  connective 
tissue  between  the  cells.  He  was  therefore  still  in  some 
doubt  as  to  whether  this  was  a  case  of  primary  carci- 
noma of  the  lung,  or  a  sarcoma  of  the  mediastinal 
glands,  with  secondary  involvement  of  the  lung,  liver. 


and  mesenteric  glands.  So  far  as  could  be  ascertained, 
the  man  had  been  in  perfect  health  up  to  the  time  of 
receiving  the  injury.  This  gave  the  case  unusual  in- 
terest. 

Dr.  Prudden  said  that,  from  the  description  given 
by  Dr.  Hodenpyl,  it  would  seem  proper  to  make  a 
diagnosis  of  both  carcinoma  and  sarcoma. 

Dr.  F.  Ferguson  asked  if  it  were  common  to  see 
sarcoma  of  the  liver  so  generalized.  He  would  not  lay 
much  stress  upon  the  size  and  shape  of  the  cells  in 
such  a  rapidl)'  growing  tumor. 

Dr.  Hodenpyl  rephed  that  he  did  not  wish  to  be 
understood  as  saying  that  he  laid  great  stress  on  the 
shape  of  the  cells. 

Congenital  Absence  of  the  Right  Kidney  ;  Displace- 
ment of  the  Left  Kidney. — Dr.  Alexander  Lambert 
presented  a  rather  rare  congenital  formation,  which 
had  been  found  in  a  man  fifty  years  of  age,  who  had 
been  admitted  to  the  hospital  with  intense  dyspnoea 
and  a  subnormal  temperature.  Physical  examinarion 
showed  very  rough  breathing  in  the  left  lung,  and  h)"- 
pertrophy  of  the  left  side  of  the  heart.  He  died  within 
forty-eight  hour;.  The  autopsy  revealed  an  entire  ab- 
sence of  the  rigl---';  kidney  and  ureter.  There  was  a 
supra-renal  capsule  on  the  left  side,  but  no  kidney  or 
ureter  in,  the  normal  locarion.  A  small  kidney  was 
found  in  the  hollow  of  the  sacrum.  The  rectum  turned 
at  the  brim  of  the  pelvis,  passed  over  the  promontory 
of  the  sacrum,  and  out  on  the  right  side.  The  kid- 
ney was  quite  small,  being  8  ctm.  long,  6  ctm.  broad, 
and  two  or  three  centimetres  thick.  It  weighed  72 
grammes.  No  markings  could  be  detected.  There 
was  one  large,  thick  ureter.  The  vessels  did  not  orig- 
inate from  the  aorta.  The  urine  had  had  no  casts, 
and  there  was  but  very  little  albumin.  The  specific 
gravity  had  been  quite  low.  It  was  remarkable  that 
he  could  live  so  long  with  such  a  small  quantity  of 
kidney  tissue. 

The  speaker  said  that  there  had  been  previously  re- 
ported to  this  Society  three  cases  of  absence  of  one 
kidney,  but  with  the  other  kidney  of  normal  size,  or 
larger  than  normal.  The  left  kidney,  as  was  usual,  was 
the  one  displaced  in  this  case.  Usually  the  left  was 
the  one  more  commonly  absent,  although  not  so  in  the 
case  just  reported.  That  there  was  a  congenital  ab- 
sence of  the  right  kidney  seemed  clear,  because  there 
was  but  one  urethral  opening  into  the  bladder,  and  no 
vessels  from  the  aorta  on  that  side.  Sections  of  the 
kidney  had  been  made  and  examined  by  Dr.  Ewing, 
who  had  found  the  kidney  to  be  made  up  almost  en- 
tirely of  connective  tissue. 

Dr.  J.\mes  Ewing  asked  if  the  extreme  length  of 
the  ureter  did  not  point  to  the  fact  that  the  kidney  had 
originally  been  in  its  normal  position. 

Dr.  Lambert  replied  that,  as  the  ureter  was  only 
six  and  a  half  inches  long,  he  did  not  think  this  theory 
was  tenable. 

The  President  said  he  had  found  a  very  similar 
specimen  in  the  museum  of  the  New  York  Hospital. 
In  this  the  bladder  was  not  attached,  but  the  small 
kidney  was  misshapen,  and  the  aorta  showed  a  very 
short  renal  artery,  beginning  just  above  the  bifurcation 
of  the  aorta.  The  historj'  of  the  case  was  not  with  the 
specimen. 

Endothelioma  of  the  Pia  Mater. — Dr.  H.  S.  Stearns 
presented  an  endothelioma  of  the  pia  mater.  It  was 
located  directly  in  the  median  line,  about  half-way  be- 
tween the  fissure  of  Rolando  and  the  anterior  edge  of 
the  brain.  It  was  5  ctm.  in  diameter,  about  i}i  ctm. 
thick,  and  circular  in  shape.  It  had  been  taken  from 
a  woman,  sixty- five  years  of  age,  from  whom  he  had 
removed  a  carcinomatous  breast  on  February  8th. 
She  had  had  no  cerebral  symptoms.  Ten  days  after 
the  operation  she  developed  pneumonia,  and  died 
shortly  afterward.  The  growth  in  the  brain  was  an 
endothelioma,  and  that  in  the  breast  a  typical  car- 
cinoma. 


ryo 


MEDICAL    RECORD. 


[August  3.  1895 


Acute  Infectious  Disease  with  Intestinal  Lesions. — 
Dr.  James  Ewing  presented  these  specimens.  The 
patient  was  a  plumber,  seventeen  years  of  age,  who  was 
admitted  to  the  Roosevelt  Hospital  on  Februarj'  7, 
1S95.  He  had  a  family  history  of  phthisis.  The  pres- 
ent illness  had  begun  on  February  rst  with  general 
pains,  moderate  fever,  and  considerable  prostration. 
On  the  second  day  there  was  abdominal  pain,  which 
was  at  first  diffused,  and  he  had  three  diarrhoeal  move- 
ments and  repeated  vomiting.  On  the  third  day  he 
developed  a  petechial  eruption,  most  marked  on  the 
limbs.  Following  an  enema  he  had  a  large,  dark  stool, 
and  the  next  day,  after  a  purge,  a  stool  containing 
mucus  and  blood.  Up  to  this  time  the  case  had  been 
considered  one  of  appendicitis.  On  February  12th  the 
abdominal  pain  became  much  worse,  and  on  the  follow- 
ing day  a  new  crop  of  petechial  spots  appeared  on  the 
exposed  parts  of  the  upper  limbs.  At  the  time  of  his 
admission  to  the  hospital,  the  urine  had  a  specific  grav- 
ity of  1.028,  was  acid  in  reaction,  and  was  free  from  al- 
bumin. On  February  i6th  its  specific  gra\'ity  was 
1. 013,  the  reaction  was  neutral,  and  there  was  a  small 
quantity  of  albumin  present.  On  February  i8th  the 
specific  gravity  was  i.or5,  and  the  urine  contained  thirty 
per  cent,  of  albumin.  On  February  20th  the  specific 
gravity  was- 1.022,  there  was  sixty  per  cent,  of  albumin, 
and  some  hyaline  and  epithelial  casts.  On  February  23d 
there  was  sixty-five  percent,  of  albumin,  and  a  speci- 
fic gravity  of  1.025.  His  temperature  rose  to  104.6°, 
the  pulse  to  150,  and  the  respirations  to  42,  and  it  was 
evident  that  there  was  a  double  pneumonia  and  a  be- 
ginning peritonitis.  On  the  next  day  the  specific  grav- 
ity of  the  urine  was  1.017,  and  it  contained  seventy  per 
cent,  of  albumin  and  five  per  cent,  of  sugar,  with  some 
waxy  casts.     He  died  on  February  27,  i?>g<,. 

The  history,  then,  was  that  of  an  acute  infectious 
disease  of  mild  onset,  with  symptoms  of  moderately 
acute  enteritis,  associated  with  a  petechial  eruption, 
occurring  in  two  distinct  crops.  Death  was  due  to  the 
pneumonia  and  the  peritonitis.  The  autopsy  showed 
pneumonia  in  both  lower  lobes,  and  a  general  purulent 
peritonitis.  Throughout  the  ileum,  and  in  other  parts 
of  the  small  intestine,  were  numerous  petechial  spots, 
and  a  considerable  number  ofpunched-out  ulcers  with- 
out much  inflammation  in  their  vicinity.  The  bases  of 
some  of  these  ulcers  were  quite  thin,  but  the  exact 
point  of  perforation  was  not  found.  Peyer's  patches 
were  apparently  normal,  and  the  mesenteric  glands 
were  considerably  enlarged. 

The  clinical  course  of  the  case,  the  speaker  said,  was 
very  similar  to  that  of  two  cases  occurring  in  Roose- 
velt Hospital  within  the  past  two  years,  and  these  latter 
had  been  recorded  as  examples  of  intestinal  mycosis. 

Dr.  Prudden  said  he  thought  that  one  contribution 
which  experimental  pathology  had  made  to  gross 
pathology  was,  that  it  was  not  necessary  to  have  a  per- 
foration of  the  intestine  in  such  cases  as  these  in  order 
to  account  for  peritonitis,  for  it  had  been  conclusively 
demonstrated  that  bacteria  could  pass  through  the  wall 
of  the  intestine  when  this  was  in  a  necrotic  condition. 

Hypertrophy  of  the  Heart  with  Fibrous  Thickening 
of  the  Abdominal  Aorta. — Dr.  F.  Ferguson  presented 
specimens  from  a  case  of  hypertrophy  of  the  heart. 
For  five  weeks  previous  to  the  admission  to  hospital, 
the  patient  had  suffered  from  shortness  of  breath, 
swelling  of  the  feet,  cardiac  palpitation,  and  pains  radi- 
ating from  back  around  to  the  abdomen.  On  admis- 
sion, the  temperature  was  normal,  respirations  28,  and 
pulse  So.  He  did  not  improve  under  the  usual  treat- 
ment of  cardiac  debility,  and  he  died  rather  suddenly. 
The  autopsy  revealed  marked  hypertrophy  and  enor- 
mous dilatation  of  the  left  ventricle  ;  moderate  hyper- 
trophy and  normal  valves  on  the  right  side.  The 
mitral  valve  was  slightly  narrowed.  The  cusps  of  the 
aortic  valve  were  very  greatly  thickened  and  retracted. 
There  was  also  a  pronounced  pericarditis.  Areas  of 
atheroma  were  scattered  throughout  the  aorta,  but  par- 


ticularly in  the  abdominal  portion.  Here  there  was  a 
fibrous  thickening,  possibly  due  to  the  enormous  hyper- 
trophy of  the  heart.  The  liver  was  of  the  nutmeg  type  ; 
the  lungs  were  the  seat  of  the  usual  cardiac  pneumonia  ; 
and  the  kidneys  showed  chronic  passive  hyperaemia. 

Anenrism  of  the  Superior  Pancreatico-duodenalis, 
with  Perforation  into  the  Common  Bile-duct. — Speci- 
mens of  this  case  were  presented  by  Dr.  Ferguson. 
Only  brief  notes  were  given,  as  it  was  to  be  published 
in  detail.  The  patient  was  a  man  of  forty-two,  and 
various  diagnoses  had  been  made,  e.g.,  pernicious  anae- 
mia, duodenal  ulcer,  carcinoma,  and  biliary  calculi.  A 
clot  was  found  extending  from  the  orifice  of  the  com- 
mon bile-duct  into  the  ramifications  of  the  bile-duct, 
and  into  the  liver  and  gall-bladder. 

The  President  said  that  Dr.  H.  M.  Biggs  had  pre- 
sented a  somewhat  similar  case  to  the  Society,  in  which 
there  had  been  a  well-defined  aneurism  at  about  the 
same  site.  His  patient  had  died  from  very  profuse 
hemorrhages  from  the  mouth  and  rectum,  lasting  about 
three  days.  It  had  been  remarked  by  one  of  those 
present  at  the  time  of  the  presentation  of  this  specimen, 
that  a  German  writer  had  reported  four  or  five  exactly 
similar  cases. 

Epithelioma  Following  Skin-grafting. — Dr.  E.  K. 
Dunham  presented  a  specimen  of  epithelioma  with  the 
following  history  :  A  woman,  fifty-three  years  of  age, 
had  abraded  the  right  tibial  crest.  The  ulcer  had 
healed  in  about  one  year,  lea\-ing  an  adherent  cicatrix. 
In  1872,  the  cicatrix  broke  down,  and  an  ulcer  formed 
which  never  healed.  On  March  9,  1894,  the  foul  ulcer 
was  thoroughly  scrapedi  and  in  May  the  ulcer,  which 
was  granulating,  was  grafted  with  skin.  In  June,  1894, 
she  was  discharged  ''  cured,"  all  of  the  grafts  having 
taken  except  one  small  spot.  In  February,  1895,  she 
was  re-admitted,  the  ulcer  having  re-opened.  At  this 
time  it  was  covered  with  unhealthy  granulations.  A 
portion  of  the  ulcer  was  excised  for  examination.  The 
specimen  presented  an  admixture  of  spiculae  of  bone 
and  epithelium,  some  in  nests  and  some  containing 
pearl  bodies.  The  speaker  said  he  would  like  to  know 
whether  this  condition  had  anything  to  do  directly  with 
the  skin-grafting. 

Dr.  Ferguson  said  he  thought  it  fairly  common  for 
such  epithelial  tumors  to  follow  injuries,  quite  a  num- 
ber of  years  after  the  injuries.  Chronic  ulcers  on  the 
front  of  the  leg  he  knew  became  epitheliomatous  in 
many  individuals.  He  felt  that  this  statement  could  be 
verified  by  the  records  of  any  of  our  hospitals. 

The  Societv  then  went  into  executive  session. 


Stated  Meeting,  March  ij,  rSgj. 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Primary  Tuberculosis  of  the  Kidneys.  —  Dr.  H.  P. 
Loo.Mis  presented  specimens  from  a  man  twenty  years 
of  age  who  had  been  admitted  to  the  hospital  two 
weeks  ago.  He  had  been  perfectly  healthy  up  to  four 
months  ago,  at  which  time  he  had  had  an  attack  of 
gonorrhoea.  Two  weeks  later  his  present  illness  had 
begun,  with  daily  chills  unaccompanied  by  sweating. 
He  steadily  lost  flesh  and  strength  up  to  the  time  of 
his  coming  to  the  hospital.  On  admission  his  temper- 
ature ranged  between  102°  and  103"  F.  His  blood 
was  examined  for  the  plasmodium  of  malaria,  but  it 
was  not  found.  Urination  was  quite  frequent.  The 
urine  had  a  specific  gravity  of  i.ooS,  was  straw-col- 
ored, acid,  and  contained  albumin  and  hyaline  casts. 
He  complained  of  pain  in  the  lower  portion  of  the 
abdomen,  and  also  on  micturition.  The  case  was  at 
first  supposed  to  be  one  of  pyelitis,  secondary  to  a 
gonorrhoea  and  inflammation  of  the  bladder.  After 
this  the  urine  was  examined  for  tubercle  bacilli,  and 
as  these  bacilli  were  found,  the  diagnosis  was  made  of 
tuberculosis.     No  evidence  of  tuberculosis  was  found 


August  3,  1895] 


MEDICAL    RECORD. 


171 


in  the  chest.  Three  or  four  days  before  his  death  his 
temperature  rose  quite  rapidly.  The  autopsy  was  made 
under  great  difficulties.  The  lungs  were  found  to  be 
studded  in  every  portion  with  exceedingly  minute  mil- 
iary tubercles.  The  liver  and  spleen  were  also  studded 
with  these  tubercles  in  a  similar  manner.  The  heart 
was  normal.  The  right  ureter  was  very  much  dilated 
with  fluid  like  urine.  The  kidney  on  that  side  was  the 
seat  of  a  chronic  tubercular  process.  The  process  had 
been  very  much  more  extensive  in  the  left  kidney,  so 
that  this  organ  was  almost  completely  destroyed,  and 
the  remains  of  the  organ  were  filled  with  cheesy  mat- 
ter, which  also  contained  the  tubercle  bacilli.  There 
was  no  tubercular  process  in  the  testicles  and  the  pros- 
tate. The  tubercular  process  in  the  bladder  seemed 
to  be  secondar)'  to  that  in  the  upper  portion  of  the 
genito-urinary  tract.  The  case,  therefore,  was  one  of 
primary  tuberculosis  of  the  kidneys.  The  speaker  said 
he  could  not  tell  where  the  infection  had  gained  en- 
trance to  the  system,  nor  could  he  say  whether  the 
attack  of  gonorrhoea  had  had  anything  to  do  with  this 
tuberculosis.  It  had  been  claimed  that  the  bacilli 
sometimes  gained  access  to  the  bronchial  glands,  and 
from  there  passed  to  the  blood,  and  so  on  until  the 
pelvis  of  the  kidney  was  reached. 

Double  Suppurating  Epididymitis ;  Ulcers  of  tie 
Stomach  ;  Calcareous  Plate  in  the  Diaphragm. — Dr. 
George  P.  Biggs  presented  specimens  from  a  man 
who  had  been  admitted  to  the  Hudson  Street  Hospital 
on  Februar)'  loth,  complaining  of  general  abdominal 
pain,  more  particularly  on  the  right  side.  No  venereal 
history  could  be  obtained.  His  temperature  was  found 
to  be  103.8°,  and  a  few  hours  later  it  was  105.4°  F.  Dur- 
ing this  time  it  was  not  noticed  that  the  oedema  of  the 
scrotum  was  rapidly  developed,  and  that  this  was  lo- 
calized chiefly  in  the  neighborhood  of  the  epididymis. 
On  the  second  day  he  developed  violent  delirium,  with 
great  abdominal  tenderness  and  distention.  He  was 
an  alcoholic  subject.  Thinking  the  case  to  be  one  of 
appendicitis  an  exploratory  incision  was  made,  but  the 
vermiform  appendix  was  found  to  be  perfectly  normal. 
His  temperature  continued  elevated,  reaching  as  high 
as  107°  F.,  and  he  died  the  second  day  after  the  opera- 
tion, or  six  days  after  the  beginning  of  the  trouble. 
Just  before  death  he  vomited  a  considerable  quantity 
of  thick,  bloody-looking  fluid.  At  the  autopsy  a  re- 
cent general  peritonitis  was  found,  the  cause  of  which 
could  not  be  discovered  at  first.  The  intestinal  tract 
throughout  was  normal.  There  was,  however,  a  good 
deal  of  swelling  in  each  iliac  region,  and  on  incision 
into  those  swellings  considerable  pus  was  found  to 
have  infiltrated  the  tissues  in  this  region.  On  the  right 
side  the  pus  had  infiltrated  the  fatty  capsule  of  the  kid- 
ney and  had  extended  down  along  the  spine  and  along 
the  inguinal  ring  and  cord  to  the  epididymis.  On  the 
left  side  the  infiltration  of  pus  was  less  extensive,  ex- 
tending up  to  the  promontory  of  the  sacrum  and  along 
the  cord  to  the  epididymis.  These  two  collections  of 
pus  did  not  communicate  with  each  other,  the  tissues 
in  front  of  the  spine  being  perfectly  normal.  From 
double  involvement  of  the  epididymis,  and  the  retro- 
peritoneal suppuration  and  peritonitis,  it  was  evident 
that  the  original  source  of  the  trouble  had  been  a  double 
epididymitis  of  a  very  virulent  character.  The  genito- 
urinary tract  was  examined  throughout  and  found  per- 
fectly normal,  and  the  testicles  proper  were  also  perfectly 
normal.  The  fresh  pus  showed  large  numbers  of  strep- 
tococci, and  cultures  made  from  these  collections  of  pus 
showed  pure  cultures  on  one  side.  It  had  been  noted  at 
the  time  of  his  admission  to  the  hospital  that  both  parotid 
glands  were  slightly  enlarged  and  tender,  but  no  spe- 
cial importance  had  been  attached  to  this  at  the  time. 
The  stomach  showed  two  or  three  quite  superficial  ul- 
cers along  the  greater  curvature  of  the  stomach,  near 
the  pylorus,  and  on  two  or  three  of  these  was  clotted 
blood,  indicating  the  source  of  the  bloody  vomiting 
occurring  just  before  death.     There  was  a  calcareous 


plate  in  the  diaphragm,  which  measured  three  inches 
in  length,  two  inches  in  width,  and  one-quarter  of  an 
inch  in  thickness. 

Gunshot  Wound  of  the  Heart  and  Lungs.— Dr.  Biggs 
also  presented  specimens  that  had  been  removed  from 
a  man  of  thirty-five  years  of  age,  who  had  been  admit- 
ted to  the  same  hospital.  He  had  shot  himself,  the 
bullet  entering  half  an  inch  below,  and  a  little  to  the 
inner  side  of,  the  left  nipple.  He  was  suffering  from 
severe  shock  at  the  time  of  his  admission.  Signs  of 
fluid  and  air  in  his  left  pleural  cavity  were  apparent, 
although  no  distinct  pericardial  involvement  was  made 
out.  He  lived  three  days.  At  the  autopsy  the  course 
of  the  bullet  was  traced  with  difficulty,  owing  to  the 
points  through  which  it  had  passed  having  been  cov- 
ered over  with  fibrin.  The  left  pleural  cavity  con- 
tained a  moderate  amount  of  air  and  at  least  1,500  c.c. 
of  dark  bloody  fluid.  The  surface  of  the  lung  was 
covered  everj'where  with  a  thin  layer  of  fibrin.  The 
pericardial  sac  was  distended  with  fibro-purulent  exu- 
dation. The  bullet  had  gone  through  the  lower  portion 
of  the  upper  lobe  of  the  lung,  had  then  passed  into 
the  pericardial  sac,  and  had  traversed  the  wall  of  the 
left  ventricle  for  a  distance  of  about  four  centimetres. 
The  bullet  had  entered  at  the  anterior  aspect  of  the 
left  ventricle,  about  midway  between  the  base  and  apex. 
The  bullet,  after  traversing  a  distance  of  about  four 
centimetres,  emerged,  entered  the  pericardium,  and 
again  passed  through  the  lower  lobe  of  the  lung,  finally 
lodging  between  the  ninth  and  tenth  ribs.  The  bullet 
did  not  enter  the  cavity  of  the  heart  at  all.  On  the 
inner  surface,  opposite  the  track  of  the  bullet,  was 
found  a  firm  ante-mortem  thrombus,  about  two  centi- 
metres in  length  and  one  centimetre  in  breadth  at  its 
thickest  part.  This  was  due  to  the  fact  that  the  vessels 
had  been  sufficiently  injured  to  cause  softening  through 
the  entire  thickness  of  the  wall,  and  so  give  rise  to 
endocarditis  and  thrombosis.  From  this  thrombus  an 
embolus  had  broken  off,  and  had  lodged  in  the 
branches  of  the  splenic  artery,  producing  large  red  in- 
farction, which  occupied  almost  the  entire  spleen.  The 
splenic  vein  was  also  completely  thrombosed. 

H3rpertrophy  and  Dilatation  of  the  Heart,  with  Tri- 
cuspid Regurgitation  and  Mitral  Stenosis. — Dr.  Biggs 
also  presented  specimens  that  had  been  taken  from  a 
boy,  eighteen  years  of  age,  who  stated  that  for  two 
years  previously  he  had  been  jaundiced,  and  had  suf- 
fered considerabl}'  from  shortness  of  breath.  On  ad- 
mission his  pulse  was  weak,  irregular,  and  rapid,  and 
had  a  distinct  pulsation.  There  was  also  marked  pul- 
sation of  the  veins  of  the  neck,  and  he  was  cyanosed. 
Examination  of  the  heart  showed  a  greatly  accentuated 
second  sound,  heard  more  over  the  right  side  of  the 
heart,  and  systolic.  The  diagnosis  was  made  of  tri- 
cuspid regurgitation  and  mitral  stenosis.  This  diagno- 
sis was  completely  confirmed  at  autopsy.  The  mitral 
orifice  was  found  to  be  very  greatly  narrowed.  The 
tricuspid  orifice  was  very  large,  so  that  almost  four  fin- 
gers could  be  passed  into  the  orifice.  The  points  of 
interest  were  the  great  thinness  of  the  left  ventricle  and 
marked  hypertrophy  of  the  right  ventricle.  The  kid- 
neys only  showed  the  effects  of  chronic  congestion. 


Stated  Meeting,  April  10,  iSg^. 
George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Tumors  from  the  Choroid  Plexus  of  a  Horse. — Dr.  J. 

H.  HuDDLESTOx  presented  several  specimens  from  the 
lower  animals.  The  first  specimen  was  the  brain  of  a 
horse,  with  two  tumors  originating  in  the  choroid  plex- 
uses. One  tumor  was  as  large  as  a  large  English  wal- 
nut, and  the  other  about  three  times  as  large.  So  far 
as  could  be  learned,  the  horse  had  presented  no  symp- 
toms until  the  evening  of  his  death,  when  he  had  ap- 
parently had  a  spasm.     Sections  of  the  tumor  were 


172 


MEDICAL   RECORD. 


[August  3,  1895 


exhibited  under  the  microscope.  Their  structure  in- 
dicated the  growths  to  be  fibro-sarcomata. 

Actinomycosis. — The  second  specimen  was  the  lower 
jaw  of  a  cow.  It  had  been  removed  from  an  animal 
suffering  from  actinomycosis,  or  the  disease  known 
among  meat  inspectors  as  "  lumpy-jaw."  The  fungus, 
the  speaker  said,  was  prone  to  lodge  in  the  mouth,  usu- 
ally in  the  lower  jaw,  where  it  works  into  the  perios- 
teum, and  finally  produces  a  raref)'ing  osteitis. 

Bats  from  a  Horse's  Stomach. — The  next  specimens 
were  bots  taken  from  a  horse's  stomach.  The  bots,  or 
larvae  of  a  kind  of  flv,  are  very  commonly  found  in 
greater  or  less  number  in  the  horse's  stomach.  They 
are  about  half  an  inch  long,  and  after  being  swallowed 
by  the  horse,  attach  themselves  to  the  mucous  mem- 
brane of  the  stomach,  and  live  there  for  ten  months  or 
more,  and  then  pass  out  with  the  excreta.  They  are 
not  generally  supposed  to  produce  any  symptoms,  al- 
though cases  have  been  recorded  where  they  have 
caused  perforation  of  the  stomach  and  death  from 
hemorrhage. 

Fseudo-tiibercks  in  a  Sheep's  Lung. — A  specimen  was 
then  shown  of  the  lung  of  a  sheep,  containing  bodies 
which  resembled  tubercles  rather  closely.  They  were 
not  tubercles,  however,  but  the  embryos  of  a  parasite 
which  had  entered  the  animal  through  the  bronchi. 

The  Ticks  of  Texan  Fever. — Dr.  Huddleston  said 
that  the  disease  known  as  "  Texan  fever  "  was  caused 
by  a  micro-organism  living  within  the  red  blood-cor- 
puscles. It  was  usually  found  in  pairs,  but  was  some- 
times found  outside  of  the  blood  -  corpuscle.  This 
parasite  gave  rise  to  haemoglobinuria,  and  death  in  a 
large  proportion  of  cases.  The  method  by  which  the 
disease  was  disseminated  had  only  been  quite  recently 
discovered  by  the  United  States  Bureau  of  Animal  In- 
dustry. It  had  been  found  that  these  "  ticks  "  took  up 
some  of  the  blood  from  infected  animals  and  trans- 
ferred it  to  other  animals. 

•  Intussusception  in  a  Dog. — The  last  specimen  had 
been  taken  from  a  Siberian  "  trick  dog,"  who,  after 
having  nearly  recovered  from  the  distemper,  had  been 
taken  ill  with  a  form  of  dysentery.  After  a  few  days 
a  tumor  had  been  felt  in  the  left  side  of  the  abdomen, 
and  then  an  intussusception  with  perforation  had  been 
discovered.  It  was  said  that  intussusception  was  not 
infrequent  in  dogs. 

Dr.  Reginald  H.  Savre  said  that  the  horse  some- 
times exhibited  lumps  on  the  body,  something  like  an 
urticarial  eruption  in  the  human  subject,  which  were 
supposed  to  be  due  to  bots.  This  was  frequently  as- 
sociated with  disturbed  digestion,  and  the  animals  were 
with  difficulty  restored  to  good  condition.  Bots  were 
frequently  passed  in  large  numbers  after  the  use  of 
brisk  purgatives  on  such  animals,  showing  that  the 
diagnosis  of  bots  was  probably  correct.  If,  therefore, 
as  had  been  said,  bots  were  almost  invariably  found  iii 
the  stomachs  of  horses,  why  was  it  that  they  only  ex- 
ceptionally gave  rise  to  symptoms  ? 

The  President  said  that  as  the  number  of  these 
bots  varied  very  greatly,  they  being  sometimes  so  nu- 
merous as  to  almost  coat  the  interior  of  the  stomach, 
it  was  not  improbable  that  the  presence  of  symptoms 
would  be  determined  by  the  number  of  these  bots  in 
the  stomach. 

Dr.  Huddleston  said  that  as  there  were  several 
varieties  of  bots,  this  might  also  explain  the  occasional 
occurrence  of  these  symptoms. 

Foreign  Body  in  the  Vermiform  Appendix.— Dr. 
Warren  Coleman  presented  a  vermiform  a])pendix 
containing  a  foreign  body.  It  had  been  removed  from 
a  man,  sixty-seven  years  of  age,  who  had  died  from 
broncho-pneumonia  complicating  chronic  diffuse  ne- 
phritis. On  opening  the  abdominal  cavity  the  tip  of 
the  vermiform  appendix  was  found  lying  on  the  sacral 
promontory  uncovered  by  intestine,  and  the  end  of  the 
appendix  was  decidedly  enlarged.  The  appendix  it- 
self measured  four  inches  in  diameter  and  about  one- 


fourth  of  an  inch  in  its  transverse  diameter.  The  for- 
eign body  was  found  to  be  a  fragment  of  bone,  one 
end  of  which  was  rounded,  and  from  the  other  end  of 
which  projected  three  sharp  points,  any  one  of  which 
would  seem  to  be  sharp  enough  to  perforate  the  wall 
during  a  sharp  contraction.  This  piece  of  bone  meas- 
ured five-eighths  of  an  inch  in  its  long  diameter  and 
one-quarter  of  an  inch  in  its  broadest  transverse  diam- 
eter. It  had  entered  the  appendix  blunt  end  foremost, 
and  had  travelled  up  as  far  as  it  could  go.  There  had 
not  been  found  the  slightest  evidence  of  inflammation 
outside  of  the  appendix,  or  within  it,  except  possibly 
a  slight  thickening  of  its  wall.  The  foreign  body  was 
entirely  surrounded  by  mucus,  and  the  lumen  of  the  ap- 
pendix was  entirely  filled  with  it.  The  appendix  itself 
had  a  mesentery  which  extended  nearly  half  of  its 
length.  The  appendix  had  not  been  bound  down  at  all. 

The  speaker  said  that  it  would  have  been  extremely 
interesting  if  the  complete  history  of  this  case  could 
have  been  obtained.  Reasoning  from  analogous  cases, 
involving  the  bile  ducts  and  ureters,  it  would  seem  that 
at  some  time  previously  this  man  must  have  had  a 
sharp  and  more  or  less  protracted  attack  of  colic. 
Appearances  would  seem  to  indicate  that  the  foreign 
body  had  been  in  the  appendix  for  a  considerable 
length  of  time,  for  there  was  a  pigmentation  of  the 
bone  which  would  have  hardly  existed  at  the  time  it 
was  swallowed.  Dr.  Coleman  said  that  he  had  never 
seen  a  case  of  foreign  body  in  the  appendix  before,  al- 
though he  had  made  it  a  rule  to  carefully  examine  the 
appendix  at  every  post-mortem.  No  faecal  impaction 
had  been  found  in  this  case. 

The  President  said  he  was  reminded  of  a  specimen 
recently  shown  by  Dr.  McBurney,  who  had  never  seen 
any  such  foreign  body  in  the  appendix  previous  to  that 
time.  It  had  been  found  during  an  operation  for  some 
other  abdominal  condition.  Two  small  bodies  had 
been  felt  in  the  appendix,  which  had  been  accordingly 
removed.  Two  perfectly  fresh  and  well-preserved 
grape-seeds  were  found  in  the  appendix.  They  had 
not  been  at  all  digested  and  there  was  no  evidence  of 
inflammation.  He  had  personally  seen  only  one  case 
in  which  there  had  been  a  grape-seed. 

Dr.  John  H.  Hinton  said  that  in  the  old  days  of 
the  Pathological  Society,  when  Dr.  Finnell  used  to 
bring  specimens  to  the  society,  he  had  presented  sev- 
eral specimens  from  cases  of  appendicitis,  where  beans 
had  been  found  in  the  appendix. 

Dr.  S.  T.  Armstrong  said  that  these  two  cases  were 
of  interest  as  showing  that  something  more  than  an  ex- 
traneous substance  in  the  appendix  was  necessary  to 
produce  appendicitis.  The  number  of  these  cases  was 
becoming  sufficiently  great  to  indicate  that  our  knowl- 
edge of  the  pathology  of  appendicitis  must  be  revised. 

Pulmonary  Tnberctilosis  with  Cavity  in  a  Child. — 
Dr.  Robert  S.  Adams  presented  a  tuberculous  lung 
removed  from  a  child  one  and  a  half  years  of  age. 
The  child  had  been  ailing  since  last  November  and  had 
been  known  as  "  the  child  with  a  bottle  lung,"  because 
of  flatness  over  the  lower  part  of  the  left  lung  posteri- 
orly, and  a  breathing  sound  at  this  part  almost  precisely 
like  that  produced  by  blowing  across  the  mouth  of  a 
bottle.  The  walls  of  the  pulmonary  cavity  were  very 
ragged.  A  "smear"  taken  from  the  lung  showed  tu- 
bercle bacilli.  The  upper  part  of  the  lung  had  been 
apparently  but  very  little  affected.  The  speaker  said 
that  tuberculosis  was  very  frequent  in  the  latter  part  of 
the  first  and  second  years  of  life,  but  it  was  not  com- 
mon to  hnd  very  large  cavities  in  sin.iU  children. 

Enlarged  Spleen ;  Lobar  Pneumonia ;  Pericarditis. — 
Dr.  Donald  M.  Barstow  presented  a  spleen  taken 
from  a  patient  who  had  been  brought  into  the  Hudson 
Street  Hospital  on  April  2d.  with  a  temperature  of 
102.4°  F.  and  a  very  rapid  and  feeble  pulse.  He  was 
somewhat  delirious,  and  there  was  marked  jaundice  of 
the  skin  and  conjunctiva.  The  delirium  and  tempera- 
ture increased,  and  he  died  early  in  the  morning  of 


August  3,  1895] 


MEDICAL   RECORD. 


17: 


April  4th.  The  history  had  been  obtained  only  through 
an  interpreter.  The  man  had  not  been  working  for 
eight  days,  as  he  had  been  suffering  from  pain  in  the 
chest,  not  very  definitely  localized,  and  from  pretty 
well-marked  dyspncea.  The  autopsy  was  made  a  few 
hours  after  death.  It  disclosed  a  lobar  pneumonia  of 
the  right  lung,  the  lung  being  entirely  consolidated. 
The  pericardium  contained  twelve  ounces  of  rather 
thin  pus.  The  heart  was  normal  and  the  valves  com- 
petent. Both  chambers  were  filled  with  blood-clot. 
The  tissue  was  rather  dark  and  granular.  The  liver 
was  apparently  normal.  The  spleen  measured  eleven 
inches  in  length,  eight  inches  in  width,  and  three  or 
four  inches  in  thickness,  and  weighed  seven  pounds 
eleven  ounces.  The  kidney  showed  the  degeneration 
which  accompanies  lobar  pneumonia.  There  were  no 
other  lesions.  The  cause  of  the  enlargement  of  the 
spleen  was  rather  interesting.  The  spleen  pulp  was 
rather  soft.  There  was  no  sign  of  acute  inflammation 
externally.  The  gall-ducts  were  pervious,  and  there 
was  no  obstruction  to  the  portal  vein  ;  hence,  a  con- 
gested spleen  could  be  excluded.  There  was  nothing 
in  the  spleen  or  in  the  blood  from  the  splenic  vein  to 
suggest  leucocythKmia.  The  man  was  an  Italian,  but 
whether  or  not  he  had  been  long  in  this  country  or  had 
recently  come  from  a  malarial  district,  could  not  be 
determined.  In  favor  of  the  theory  that  there  had 
been  an  acute  inflammation  was  the  fact  that  the  man 
was  profoundly  septic,  and  had  a  high  temperature, 
and  his  jaundice  was  evidently  due  to  some  poisoning 
of  the  blood.  Zeigler  says  that  in  acute  disease  the 
spleen  may  be  enlarged,  even  to  four  times  its  normal 
volume.  The  stomach  and  peritoneum  were  normal. 
The  intestines  were  not  opened.  It  was  possible, 
although  not  probable,  that  there  were  typhoid  ulcers 
in  the  small  intestine. 

The  President  said  he  could  recall  at  least  three 
instances  in  which  he  had  found  very  large  spleens  in 
adult  Italians,  evidently  the  result  of  chronic  disease, 
as  there  were  no  evidences  of  disease  of  the  blood  or 
lymphatic  glands.  Although  in  these  cases  the  spleen 
had  not  been  particularly  pigmented,  he  had  felt  that 
the  splenic  enlargement  had  been  due  to  malarial  in- 
fection. 

Myelitis  and  Rupture  of  the  Bladder. — Dr.  Henry 
Power  exhibited  some  photo-micrographs,  taken  with 
high  and  low  powers,  and  also  some  slides  under  the 
microscope  from  a  case  of  myelitis,  complicated  by 
rupture  of  the  bladder.  Death  had  occurred  from  the 
shock  of  the  rupture.  The  history  of  the  case  was  very 
meagre.  There  was  a  chronic  myelitis,  distributed 
principallj'  through  the  dorsal  and  lower  cervical 
regions.  The  interesting  part  was  the  condition  of  the 
veins  and  arteries.  The  former  were  almost  normal, 
whereas  the  media  and  adventitia  of  the  veins  contained 
a  large  quantity  of  round  cells — whether  leucocytes  or 
new  connective-tissue  cells  could  not  be  determined. 
Gowers  and  Zeigler  gave  a  general  description  of  such 
a  condition,  without  distinguishing  between  the  veins 
and  arteries. 


A  Remedy  for  Tape-worm. — Dr.  J.  H.  Newington, 
writing  to  The  Lancet,  says  that  many  years  ago  he  was 
giving  a  patient  a  mixture  as  follows  :  Hydriodate  of 
potass.,  gr.  xxxvj.  ;  iodine,  gr.  xij.  ;  water,  5j. — ten 
drops  three  times  a  day  in  water.  The  patient  unex- 
pectedly passed  a  tape-worm  eleven  yards  long,  dead, 
of  which  there  were  no  previous  symptoms.  He  has 
since  given  the  same  medicine  successfully  in  two  or 
three  cases.  The  last  patient  came  to  him  about  three 
years  since  and  stated  that  he  had  suffered  from  ta])e- 
worm  for  two  years  and  was  constantly  passing  pieces 
of  the  parasite,  but  could  not  get  rid  of  it.  Dr.  New- 
ington gave  him  the  same  medicine,  and  after  a  short 
time  he  passed  a  mass  of  tape-worm,  dead,  and  there  has 
been  no  return. 


©Ituical  gepartmcut. 

A  DELUSION  OF  STIFFENED  EXTREMITIES 
TREATED    BY   SUSPENSION. 

By  EDGAR  J.  SPRATLING,  M.D., 

FISHKILL-ON-HUDSON,  N.   Y. 

In  1S80,  a  patient  was  admitted  to  the  Middletown 
State  Hospital,  adjudged  insane  by  the  court  upon  a 
charge  of  assault  of  the  first  degree.  He  was  then  in 
a  state  of  profound  depression,  being  at  all  times  morose 
and  taciturn.  Until  18S5  he  worked  about  the  place, 
making  himself  more  or  less  u.seful,  as  patients  can  do, 
then  came  some  trivial  misunderstanding  with  the  of- 
ficials, according  to  his  own  statement,  concerning  a 
persistent  pain  in  the  lower  vertebrze.  From  patient's 
account  and  the  position  afterward  assumed  and  fixedly 
maintained,  this  pain  was  most  likely  coxalgia.  Upon 
this  he  went  to  bed,  where  he  remained  constantly,  re- 
fusing to  make  any  explanation  of  his  symptoms,  or  in 
any  way  seek  or  accept  the  medical  and  other  aid  offered 
him  by  the  officials.  He  states  that  the  pain  was  con- 
stant for  months  after  taking  to  his  bed,  until  in  fact  the 
habit  of  walking  was  entirely  lost,  after  that  no  effort 
was  made  to  walk,  but  he  would  lie  quiescent  till  dis- 
turbed by  some  patient  or  other  person,  whom  he  would 
then  assault  most  maliciously.  Those  in  authority 
were  always  to  him  especial  objects  of  attack  and  vitu- 
peration ;  he  seeming  instinctively  to  dislike  any  ex- 
ercise of  authority,  thinking  that  his  own  peculiar  pre- 
rogative. 

The  delusion  of  not  being  able  to  walk  was  now 
firmly  fixed  with  him.  He  refused  to  even  make  an 
effort ;  always  asserting  that  he  could  neither  place  his 
feet  in  juxtaposition,  nor  stand  erect.  He  was  equally 
positive  that  he  could  not  in  any  way  make  use  of  his 
hip-  or  knee-joints. 

After  being  a  never-ending  source  of  annoyance  to 
the  officials  his  transfer  to  the  Matteawan  State  Hos- 
pital was  secured.  He  was  admitted  here  on  a  stretcher, 
in  fairly  good  general  health,  in  a  bright  mental  condi- 
tion. This  was  in  1892.  He  remained  continuously 
in  bed,  going  out  once  each  day  to  the  water-closet, 
dragging  himself  on  the  floor,  or  crawling  by  the  aid 
of  chairs  and  tables.  Various  efforts  were  made  to  get 
him  to  sit  in  an  upright  position  in  a  chair,  but  he 
would  persist  in  maintaining  the  rigid  straight  position, 
thereby  slipping  out  on  the  floor.  These  efforts  or 
persuasions  to  make  him  try  to  walk  met  with  no 
encouragement.  He  would  in  no  way  co-operate  with 
the  physician,  even  becoming  angered  with  any  sug- 
gestion of  regular  treatment.  This  lasted  till  the  spring 
of  1895,  making  actual  time  spent  in  bed  over  eight 
years. 

On  March  26th,  after  electricity  and  massage  had 
been  tried  to  a  limited  extent  with  no  indication  of 
possible  ultimate  good,  it  was  decided  to  try  suspen- 
sion by  a  Sayre's  apparatus.  The  first  trial  lasted 
twelve  minutes.  The  time  he  remained  suspended  was 
increased  five  minutes  each  day,  and  after  each  time 
he  was  required  to  remain  standing  from  twenty  to 
thirty  minutes  in  the  middle  of  the  ward  hall,  where  he 
could  grasp  no  object  by  which  to  steady  himself.  Of 
course  the  patient  considered  all  this,  at  least  so  he 
expressed  it,  as  malignant  persecution,  and  protested 
most  vigorously  both  by  mouth  and  by  sheer  strength, 
fighting  tooth  and  nail. 

After  two  weeks  of  this  treatment  daily  it  was  dis- 
continued as  being  no  longer  indicated,  he  being  then 
willing  to  exercise  in  walking  a  given  length  of  time 
each  day.  He  was  never  allowed  a  crutch  or  walking 
cane. 

On  April  22d,  he  went  to  the  table,  up  and  down 
steps,  for  dinner,  the  first  time  in  over  eight  years.  He 
now  goes  regularly  to  his  meals,  is  friendly  and  good- 


174 


MEDICAL   RECORD. 


[August  3,  1895 


natured,  saying  that  the  treatment  was  a  benefit  to  him. 
He  helps  with  the  ward  work,  and  is  in  every  way  a 
changed  man,  standing  and  walking  erect  and  firm, 
rarely  or  never  indicating  any  inconvenience. 

Was  it  the  forcible  overcoming  of  his  delusion,  or  was 
it  the  actual  surgical  benefit  that  did  the  ultimate  good  ? 

There  were  two  physicians,  Dr.  R.  B.  Lamb  and  the 
writer,  employed  in  the  suspensions,  one  appearing  as 
the  aggressor,  the  other  as  the  moderator  as  it  were. 
To  the  latter  he  would  confide  his  sensations  in  the 
hope  of  getting  his  interference.  In  this  way  we  could 
regulate  the  management  of  the  whole  treatment  to  the 
best  good.  This  dual  method  is,  I  think,  very  often 
useful  in  the  management  of  any  fixed  delusion,  giving, 
as  it  usually  does,  the  physicians  a  decided  advantage. 

Matteawan  State  Hospital. 


parently  paradoxical  rule  :  "  In  retention  from  any 
cause,  compare  the  meatus  with  your  catheters.  When 
you  have  determined  upon  the  size  which  promises  to 
pass,  make  your  first  endeavors  with  two  sizes  larger." 

Posner'says  in  this  connection:  "In  the  vast  ma- 
jority of  instances,  the  careful  introduction  of  soft, 
elastic  instruments  will  accomplish  the  desired  end. 
At  all  events  these  instruments  are  recommendable  to 
those  who  have  not  acquired  considerable  skill  and 
practice.     At  least  no  injury  can  be  done  by  them." 

While  the  case  above  sketched  contains  nothing 
new,  I  feel  convinced  that  other  genito-urinary  special- 
ists will  agree  with  me  in  urging  upon  general  practi- 
tioners that  the  greatest  possible  safety  lies  in  always 
using  the  largest  possible  catheter. 

342  West  FoRTy-THiRD  Street. 


THE    LARGEST    CATHETER,    ALWAYS. 
By  FEKD.  C.  valentine,    M.D., 

NEW  YORK. 
GENITO-URINAKY  SURGEON,   WEST  SIDE  GERAIAN  DISPENSARY,   ETC. 

It  seems  surpassingly  remarkable,  in  view  of  all  that  is 
written  on  catheterization  of  the  urethra,  that  so  many 
otherwise  exceedingly  well-informed,  skilful  general 
practitioners  will  persist  in  endeavoring  to  pass  small 
catheters.  A  case  brilliantly  illustrating  this  error  was 
brought  to  my  attention  May  2 2d  of  this  year. 

A.  B ,  aged    sixty,  a  hale,  well-preserved    man, 

visiting  friends  in  Newark,  on  Sunday,  May  19th, 
found  no  convenience  for  urination,  and  never  having 
had  any  difficulty  before,  reserved  emptying  his  bald- 
der  until  he  would  reach  his  home  in  New  York.  On 
arriving  there  some  hours  later,  he  discovered  that  all 
efforts  at  extruding  urine  proved  abso- 
lutely futile.  From  Sunday  night  to 
Wednesday,  several  physicians  had  en- 
deavored to  relieve  him  with  small  in- 
struments. They  succeeded  only  in 
giving  the  patient  much  pain  and  draw- 
ing considerable  blood,  whose  quantity 
doubtless  was  much  exaggerated  in  the 
family's  statements. 

On  Wednesday  evening  Dr.  Ludwig 
Kohn  was  called  and,  finding  the  pa- 
tient in  the  condition  to  be  expected 
after  passing  no  urine  for  three  and 
one-half  days,  demanded  a  consulta- 
tion. Dr.  Henry  Roth  came  for  me. 
His  history  and  description  of  the  case 
caused  me  to  go  with  him  prepared  for 
supra-pubic  puncture  at  least. 

On  arrival  at  10.30  p.m.  I  found  the 
patient  exactly  as  described  by  Drs.  Kohn  and  Roth,  the 
salient  points  being  a  very  much  distended  bladder, 
whose  fundus  reached  apparently  to  the  umbilicus,  a 
prostate  hypertrophied  to  about  the  size  of  a  large  fist, 
with  a  well-defined  middle  lobe,  and  a  roomy  urethra 
with  no  less  than  half  a  dozen  lacerations  in  its  mem- 
branous part.  Before  proceeding  to  more  serious  opera- 
tive measures,  we  naturally  determined  to  essay  the  pas- 
sage of  a  catheter.  The  meatus  appeared  as  if  it  would 
comfortably  admit  a  10  American.  On  taking  a  Tie- 
mann's  12,  velvet-eyed,  soft  catheter,  the  comparative 
ease  with  which  it  passed  into  the  bladder  would  be  sur- 
prising to  those  not  accustomed  to  such  experiences. 

Dr.  Kohn,  who  continued  treating  the  case,  informs 
me  that  he  had  no  difficulty  in  increasing  the  size  of 
the  catheters  used  by  one  number  daily,  having  reached 
No.  15  on  Saturday,  May  25th,  and  that  the  patient 
is  in  exceedingly  good  condition.  Manifestly,  if  a  large 
catheter  had  at  once  been  used,  much  suffering  would 
have  been  spared  this  man. 

It  is  a  rule  with  me  to  urge  upon  those  who  favor 
me  by  attendance^upon  my  clinics  the  following  ap- 


^jewj  ^nstvxxmtnts. 

THE  OPEN-AIR  TREATMENT  OF  HIP-JOINT 
AND    SPINAL    DISEASE. 

By  W.  W.  BREMNER,  M.D.,  ', 

TORONTO,   CANADA. 
LATE     ASSISTANT    SURGEON,    HOSPITAL     FOR     RUPTURED^  AND 


It  is  now  almost  universally  admitted  that  hip-joint 
and  Pott's  disease  are  of  a  tubercular  nature,  and  that 
in  many  cases  of  these  diseases,  at  some  period  or  other 
in  their  course,  recumbency  becomes  a  necessity  in  the 
treatment.  Now,  it  is  not  proposed  for  an  instant  here 
to  lay  down  any  rules  as  to  what  cases  need  recumbency, 
but  it  is  desired  to  lay  before  the  profession  a  simple 
method  by  which   recumbency,  with  any  advantage  it 


may  have,  can  be  obtained  without  the  counter-balanc- 
ing evils  which  attend  it  when  used  in  the  general 
way  by  confining  a  patient  to  bed. 

A  light  carriage  with  wicker-work  sides,  rubber  tires, 
and  well-tempered  springs  is  made  of  a  length  suitable 
for  the  patient,  allowing  for  at  least  three  years'  growth, 
and  it  is  surprising  how  a  child  will  grow  on  such  a 
carriage  in  the  fresh  air  and  sunlight.  A  frame  of 
hard-wood,  of  a  length  suitable  for  the  weight  of  the 
patient,  is  then  made  ;  good  ash  (three-quarters  by  two 
and  a  half)  is  strong  enough  for  a  child  under  five  years 
of  age  ;  this  frame  should  fit  snugly  inside  the  wicker- 
work  of  the  carriage  and  be  covered  with  strong  can- 
vas laced  beneath  to  keep  it  tight.  The  canvas  can  be 
made  in  three  sections,  one  narrow  in  the  middle  for 
removal  when  the  l)ed-pan  is  required  ;  a  better  plan, 
however,  is  to  use  stiff  brown  paper  for  the  motions 
and  a  bottle  or  small  flat  dish  for  the  urine,  according 
to  sex.  An  apron,  reaching  from  the  axilla  to  the 
pubes,  is  sewed  on  either  side  of  the  canvas  and  fitted 

'Therapie  der  H.-»rnkr»nkheiten,  publishe.1  April,  1805,  in  Berlin. 


August  3,   1895] 


MEDICAL    RECORD. 


175 


with  buckles  to  keep  the  patient  in  position  ;  in  addi- 
tion, it  is  well  to  have  leather  straps  to  hold  down  the 
shoulders  ;  the  most  simple  way  is  to  tack  them  on  the 
sides  of  the  frame  and  let  them  cross  the  chest  diag- 
onally at  the  top  of  the  sternum. 

The  frame  can  be  lifted  in  and  out  of  the  carriage 
as  desired,  but  in  practice  it  will  be  found  very  con- 
venient to  keep  the  patient  in  the  carriage  day  and 
night.  In  warm  weather  a  light,  soft  quilt  under  the 
patient  or  a  narrow  pillow  is  all  that  is  required.  In 
cold  weather  a  small,  soft  mattress  or  a  couple  of  pil- 
lows should  be  placed  between  the  frame  and  the  car- 
riage to  keep  out  the  cold. 

In  spinal  disease  pads  of  felt  should  be  stitched  on 
the  canvas  on  either  side  the  kyphosis,  to  prevent  undue 
pressure  on  the  spinous  processes.  In  general,  it  is 
best  to  fit  the  patient  with  a  suitable  brace  as  well  as 
the  carriage. 

In  all  cases  of  hip  joint  disease,  and  in  those  of 
Pott's  disease  where  there  is  psoas  contraction,  means 
are  provided  for  counter-extension  by  a  light  but  stiff 
steel  bar  bent  across  the  frame  just  above  the  pubes, 
and  removable  at  pleasure  by  unscrewing  two  bolts  to 

which  perineal 
bands  are  attach- 
ed by  means  of 
buckles.  (See 
Fig.  2,  which  re- 
presents a  child 
seven  years  of  age 
with  very  severe 
hip-joint  disease, 
in  the  upright  po- 
sition, which  may 
be  given  at  pleas- 
ure and  which  is 
very  convenient 
when  taking 
food.)  Fig.  I 
shows  the  same 
child  in  the  hori- 
zontal  position. 
In  both  figures  the 
uprights  with 
cross-bar  at  the 
bottom  of  the 
frame  are  clearly 
shown.  These 
permit  of  e.xten- 
sion  being  made 
in  the  angle  of  de- 
formity, which  is 
most  necessary  in 
order  to  avoid 
:_,'reat  pain.  The 
child  shown  in  fig- 
ures, when  treat- 
ment was  commenced,  had  about  thirty-five  degrees  of 
flexion  and  twenty  degrees  of  adduction.  In  six  weeks, 
with  only  eight  pounds  of  weight,  the  limb  was  straight. 
The  bar  can  be  lowered  one-half  inch  every  day  for  a 
few  days,  and  the  splint  on  which  the  limb 
lies  abducted  a  little  at  about  the  same  inter- 
vals. Light  boards  are  fitted  on  either  side 
of  the  carriage  to  prevent  the  clothes  falling 
out.  During  the  day  counter-extension  is 
made  by  the  perineal  straps,  at  night  the  pressure  on 
the  perineum  can  be  relieved  by  elevating  the  foot  of 
the  carriage. 

This  metliod  has  been  tried  for  over  a  year  in  sev- 
eral cases  of  acute  hip-joint  disease,  with  most  satisfac- 
tory results  in  every  way,  especially  in  regard  to  the 
general  health.  As  far  as  I  can  find  out  from  the  lit- 
erature at  my  command,  the  method  is  new.  It  is  ap- 
plicable to  both  private  and  dispensary  patients,  as  no 
difficulty  is  found  in  getting  most  of  the  dispensary  pa- 
tients to  pay  a  small  monthly  rent  for  such  a  carriage. 


and  even  in  hospitals  it  might  be  used  with  advantage 
where  there  is  an  open-air  balcony  or  veranda  on  to 
which  the  carriages  could  be  wheeled. 

These  carriages   are  very  inexpensive   and   can  be 
made  by  any  bassinet  manufacturer. 

39  Bloor  Street,  East  Toronto. 


A  NEAV  ADENOID  FORCEPS. 
By   WILLIAM   P.    BRANDEGEE,    M.D., 


With  some  hesitation,  because  of  the  long  and  varied 
list  of  instruments  which  have  already  been  devised 


for  the  removal  of  adenoid  growth  in  the  vault  of  the 
pharynx  and  the  posterior  pharyngeal  wall,  I  present 
this  adenoid  forceps. 

This'  instrument  was  designed,  however,  to  eradi- 
cate certain  defects  in  construction  which  make  an 
adenoid  forceps  inefficient  for  operative  purposes.  The 
instrument  is  an  evulsion  and  cutting  forceps,  strongly 
built  and  smooth  on  all  surfaces  that  are  brought  in 
contact  with  mucous  membrane.  The  cutting  blades 
meet  in  the  median  line  but  do  not  cross,  work  later- 
ally, and  cut  not  only  on  the  superior  but  also  on  the 
posterior  surfaces. 

As  the  blades  do  not  cross,  a  space  is  left  for  the 
uvula  so  that  it  cannot  be  damaged  in  the  course  of 
the  operation.  The  instrument  can  readily  be  taken 
apart  and  rendered  aseptic.  This  forceps  is  introduced 
closed  and  only  opened  when  the  vault  of  the  pharynx 
is  reached.  My  thanks  are  due  Mr.  E.  B.  Meyrowitz 
for  the  workmanship  and  skill  displayed  in  the  con- 
struction of  the  instrument. 

36  West  Thirtv-thikd  Street, 


A  PHIMOSIS   CASE. 
By  R.  W.  KNOX,  M.D., 


Messrs.  Tiemann  &  Co.  have  made  for  me  a  phimo- 
sis forceps  and  also  a  prepuce-retractor.  These  in- 
struments they  have  included  in  a  small  aseptic  case 
containing  scissors,  hypodermic  syringe.  Grove  director, 
narrow-bladed  bistoury,  and  four  small  bottles  for  car- 
rying needles,  cocaine  tablets,  and  two  small  sizes  of 
silk  ligatures.  The  phimosis  forceps  has  been  previ- 
ously described.  The  retractor  gives  great  assistance 
in  applying  the  forceps  accurately,  and  without  the 
aid  of  an  assistant.     It  has  spring  blades  with  double 


tenaculum  points,  which  are  concealed  when  the 
instrument  is  closed.  The  cut  gives  a  better  idea 
of  its  mechanism  than  is  possible  by  a  description. 
I  operate  as  follows  :  The  patient  is  placed  on  a  table, 
and  the  parts  made  as  aseptic  as  possible  with  soap  and 
water.  A  rubber  band  is  placed  at  the  root  of  the 
penis,  encircling  that  organ  in  order  to  prevent  hem- 
orrhage during  the  operation,  and  also  to  confine  the 
action  of  the  cocaine.  I  find  about  ten  minims  of  a 
four  per  cent,  solution  of  cocaine  injected  in  different 
points  of  the  skin  sufficient  to  produce  complete  an- 


176 


MEDICAL    RECORD. 


[August  3,  1895 


aesthesia  of  the  parts  to  be  incised.  The  retractor  is 
now  introduced  a  short  distance  within  the  foreskin, 
the  blades  allowed  to  spring  apart  by  releasing  the 
slide  catch,  and  gentle  traction  made.  The  forceps  is 
now  applied  and  tightened  at  the  most  desirable  jjoint. 
The  bistoury  then  removes  the  engaged  prepuce  with 


a  single  stroke.  If  the  mucous  membrane  is  not  suffi- 
ciently removed  with  the  skin,  the  excess  can  be  quick- 
ly cut  away  with  the  scissors.  The  foreskin  can  be  re- 
moved much  more  quickly  and  accurately  in  this  way 
than  is  possible  by  the  use  of  knife  and  scissors  alone. 
The  case  has  the  advantage  that  everything  necessary 
for  the  operation  is  always  at  hand  and  can  be  readily 
carried  in  the  pocket. 


OUR   LONDON   LETTER. 

(From  Our  Special  Correspondent.) 

THE  PRINCE  AT  EPSOM  COLLEGE — THE  COLLEGE  OF 
SURGEONS  ELECTIONS — THE  MUSEUM — POLICE  SUR- 
GEONS— CAMBRIDGE  SUMMER  SCHOOL — CHLOROFORM 
FATALITIES — APPOINTMENT    OF    QUEEN's    SURGEON, 

ETC. DR.  RUFFER. 

London,  July  13,  1895. 

Epsom  was  adorned  in  holiday  attire  to  receive  the 
Prince  and  Princess  of  Wales  on  Monday  afternoon, 
and  the  inhabitants  indulged  to  the  utmost  their  dem- 
onstrations of  loyalty.  The  Prince  laid  in  a  workman- 
like manner  the  foundation-stone  of  the  lower  school 
which  is  to  be  added  to  the  Royal  Medical  Benevolent 
College,  mentioned  that  he  remembered  accompanying 
his  father,  more  than  forty  years  ago,  to  open  the  col- 
lege, and  expressed  the  hope  that  the  new  buildings 
rnay  add  in  every  way  to  the  usefulness  of  the  institu- 
tion. The  royal  party  inspected  the  college  before 
leaving,  amid  renewed  demonstrations  of  loyalty.  The 
school  has  maintained  a  good  position  and  grows  in  fa- 
vor. Last  year  an  act  of  Parliament  was  obtained  un- 
der which  the  Council  can  open  it  to  all  classes — ^the 
special  privileges  of  medical  men's  sons  being  reserved. 
It  is  thought  that  this  will  be  better  for  the  boys  than 
restricting  it  to  one  class,  the  admission  of  representa- 
tives of  other  professions  tending  to  widen  the  sympa- 
thies and  enlarge  the  ideas.  I  wish  it  were  possible  for 
the  fees  to  be  further  reduced  in  the  case  of  medical 
men  or  their  widows,  who,  though  their  sons  are  eligible 
for  the  foundation,  still  find  education  expensive. 

The  elections  to  the  Council  of  the  Royal  College  of 
Surgeons  had  unusual  interest,  as  this  was  the  first  oc- 
casion on  which  voting  papers  were  distributed  to  all 
the  fellows.  Of  these  621  used  their  papers,  and  60 
voted  in  person.  Thus  upward  of  400  fellows  did 
not  vote.  In  view  of  the  fuss  that  has  been  made  about 
the  privilege  of  the  fellowship,  this  is  not  a  result  to  boast 
of.  Perhaps  the  non-voters  would  willingly  see  the  en- 
franchisement of  the  members.  Surely  these  last,  as 
qualified  surgeons,  might  be  entrusted  with  a  vote  for 
councillors,  and  perhaps  for  the  president.  There  is  con- 
siderable discontent  at  the  canvassing  carried  on  at 
this  election,  but  what  is  to  be  expected  in  a  small,  ex- 
clusive constituency  ?  Still  the  majority  are  shocked 
at    the    unblushing    electioneering    tactics    in    a  body 


boasting  of  its  high  tone  and  academical  distinction  by 
examination.  Outsiders  say  F.R.C.S.,  Exam.,  is  not  a 
synonyme  for  a  gentleman  nor  an  academical  distinc- 
tion either,  as  the  term  is  usually  understood. 

After  the  election  there  was  a  display  of  the  many 
interesting  specimens  which  have  been  added  to  the 
museum  during  the  past  year. 

It  seems  likely  that  recognized  police  surgeons  will 
be  appointed  to  examine  prisoners  arrested  on  certain 
charges.  The  matter  was  pressed  on  the  Home  Secre- 
tary early  in  the  year,  and  before  resigning  Mr.  As- 
quith  issued  a  circular  letter  to  certain  authorities, 
pointing  out  the  advantages  of  such  appointments. 
Skilled  evidence  is  certainly  important  in  many  cases 
and  should  be  obtained  at  the  earliest  moment.  Closely 
connected  with  this  subject  is  a  strange  fact  that  came 
to  light  at  an  inquest  lately  on  the  body  of  a  woman 
found  in  a  canal.  A  policeman  deposed  that  he  found 
indications  of  death  from  drowning,  that  he  had  the 
body  taken  to  the  woman's  house,  where  he  had  all  her 
clothes  removed,  and  looked  for  bruises  or  signs  of  vio- 
lence. Surely  this  policeman  went  beyond  his  duties, 
and  should  have  been  sharply  taken  to  task,  instead  of 
permitted  to  give  evidence  which  it  is  a  medical  man's 
place  to  give. 

The  summer  school  at  Cambridge  for  qualified  men 
has  afforded  a  pleasant  week's  outing  with  scientific  les- 
sons to  eighty  members,  who  have  been  regaled  with 
lectures,  demonstrations,  and  exhibitions,  and  pro\nded 
with  quarters  and  good  fare  at  moderate  charges.  The 
idea  seems  to  have  "caught  on,"  and  will,  perhaps, 
prove  profitable  to  both  professors  and  students. 

Death  from  chloroform  seems  at  times  to  come  from 
recklessness.  A  young  surgeon  inhaled  it  to  assuage 
the  pain  of  sciatica,  and  seems  to  have  fallen  forward 
when  insensible  and  so  taken  a  fatal  dose.  Another 
man  is  said  to  have  regularly  taken  chloroform  for 
months  past.  At  length,  as  might  have  been  expected, 
he  paid  the  penalty  of  his  rashness  with  his  life. 
Though  not  a  doctor,  he  seems  to  have  had  no  diffi- 
culty in  obtaining  a  constant  supply  of  the  anaesthetic. 

A  sad  case,  apparently  of  abortion,  has  been  the  sub- 
ject of  judicial  inquiry  and  much  medical  conversation. 
A  graduate  whose  name  had  been  removed  from  the 
Register  had  been  consulted,  and  a  registered  man  saw 
the  patient  and  gave  a  certificate  of  death.  He  will 
probably  have  to  appear  before  the  Medical  Council, 
for,  surely,  "  covering  "  a  man  who  has  been  removed 
from  the  Register  is  as  bad  as  doing  so  for  one  who  has 
never  been  on  it.  Unless  further  protection  be  ob- 
tained for  those  who  are  registered,  there  will  surely 
be  further  abuses. 

Sir  r.  Smyly  has  been  gazetted  Surgeon  to  the 
Queen  in  Ireland,  in  succession  of  the  late  Sir  George 
Porter.  The  friends  and  admirers  of  Sir  G.  Porter 
propose  to  raise  a  permanent  memorial  of  his  services 
to  the  public  and  the  profession.  Mr.  Lentaigne,  of 
the  Mater  Misericordiee  Hospital,  has  been  elected  to 
succeed  him  in  the  Council  of  the  Dublin  College  of 
Surgeons. 

Dr.  Ruffer,  in  his  investigations  on  antitoxin,  un- 
fortunately inoculated  himself  with  diphtheria.  He  was 
treated  with  serum,  and  has  happily  recovered  after  a 
severe  illness.  This  is  another  illustration  of  the  dan- 
gers incurred  in  the  course  of  bacteriological  re- 
searches. 


The  Cost  of  Influenza. — At  a  meeting  of  one  of  the 
large  ICnglish  in.surance  companies  it  was  shown  that 
more  than  six  hundred  thousand  dollars  had  been  paid 
out  for  deaths  due  to  influenza. — Maryland  Medical 
Journal. 

A  French  Medical  Authority  asserts  that  death 
caused  by  a  fall  from  a  great  height  is  absolutely  pain- 
less. The  mind  acts  very  rapidly  for  a  time,  then  un- 
consciousness ensues. 


August  3,  1895] 


MEDICAL    RECORD. 


177 


ON  THE  PHYSIOLOGICAL  ACTIOX  OF  PERI- 
ODIC INDUCED  CURRENTS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  If  Dr.  Goelet  had  been  content  to  simply  reiter- 
ate his  altogether  untenable  statement  that  his  permis- 
sion was  asked  for  the  privilege  of  winding  on  a  single 
spool  certain  lengths  and  thicknesses  of  wire,  I  should 
have  been  content  to  allow  him  the  last  word  of  the 
discussion  ;  but  as  he  not  only  denies  my  priority  in 
essentials,  but  indulges  in  specific  contradiction,  I  beg 
to  be  allowed  in  proof  of  my  claim  to  offer  the  follow- 
ing letter  : 

"  Dr.  a.  D.  Rockwell.  • 

"  Dear  Sir  :  In  reply  to  yours  of  July  15th  I  would 
say  that  as  far  back  as  1884  we  constructed  for  you  a 
coil  far  exceeding  in  length  our  ordinary  coils,  to  illus- 
trate your  paper  '  On  the  Induction  Coil  ;  its  Varieties 
and  the  Differential  Indications  for  their  Use,'  and  in 
1889  still  another,  of  five  thousand  feet,  made  up  of  coils 
varying  in  lengths,  and  almost  identical  in  the  different 
sizes  of  wire  to  that  of  the  apparatus  under  discussion. 
"  Very  respectfully, 

"  T.  F.  Livingstone, 
for  the  Kidder  Mfg.  Co." 

It  was  on  experience  with  these  coils  that  I  based 
my  article  on  the  '"  Different  Physiologic  and  Thera- 
peutic Properties  of  the  Induced  Current  of  Electrici- 
ty "  (Medical  Record,  February  14,  1891). 

Dr.  Goelet  seems  to  think  that  the  important  thing 
is  some  exact  number  of  yards  in  each  individual  coil, 
and  because  he  suggested  a  few  different  numbers, 
requiring  only  a  knowledge  of  figures,  has  the  assur- 
ance to  designate  as  the  "  Goelet  Coil "  a  coil  the  es- 
sential features  of  which  were  well  understood  and  had 
been  thoroughly  described  before  Dr.  Goelet  had  be- 
gun to  interest  himself  in  electro-therapeutics. 

A.  D.  Rockwell,  M.D. 

July  17,  1895. 


SOME    ASPECTS    OF    THE    NEW    WOMAN 
FROM   A   MEDICAL   STAND-POINT. 

To  the  Editor  of  the  Medical  Record 

Sir  :  "  The  new  woman  "  is  at  present  merely  the  butt 
of  the  humorist,  but  I  am  inclined  to  think  that  to  the 
medical  profession  she  presents  an  interesting  study. 
For  many  years  female  dress  has  been  a  bete  noir  to  the 
doctors,  and  yet,  despite  all  that  has  been  written  and 
said  on  the  subject,  woman,  lovely  woman,  has  had  her 
way,  and  if  there  is  to  be  a  change  it  will  be  brought 
about  in  her  own  way  and  by  herself.  Concerning 
tight-lacing  I  shall  say  nothing,  for  so  much  has  been 
said  and  written  on  the  subject  that  it  has  become 
nauseous,  and  the  evil  is  self-evident.  But  there  is  an- 
other evil  connected  with  woman's  present  style  of 
dress  which  has  been  pretty  well  ignored.  I  allude  to 
the  skirt.  I  allow  that  it  is  graceful  and  capable  of  a 
great  amount  of  ornamentation,  but  it  is  unhygienic  in 
every  sense. 

How  often  when  the  icy  blasts  of  winter  have  been 
blowing  with  hurricane  force  have  we  seen  female  pe- 
destrians clutching  at  their  skirts  to  prevent  them  from 
being  blown  over  their  heads,  and  how  often  have  we 
seen  those  same  skirts  inflated,  not  like  a  balloon  with 
hot  but  with  cold  air.  In  fact,  they  are  too  often 
mere  traps  for  collecting  cold  air.  The  pelvic  organs 
are  well  supplied  with  blood-vessels,  and  it  must  follow 
that  when  the  parts  are  suddenly  chilled  the  blood- 
supply  is  temporarily  impaired.  "To  say  such  a  thing 
is  not  harmful  is,  of  course,  absurd. 

What  is  true  of  the  full-grown  woman  is  doubly  true 
of  her  younger  sister  with   shorter  skirts.     Now  sup- 


pose the  latest  fad,  bloomers,  becomes  the  general  dress 
of  woman,  all  this  will  be  done  away  with.  The  pelvic 
organs  will  be  well  protected  from  rapid  changes  of 
temperature.  There  will  not  be  alternating  congestion 
and  anaemia.  There  will  be  a  general  tone  given  to 
the  pelvis  which  modern  dress  prohibits. 

Now  as  to  the  much-discussed  question,  bicycle 
riding  for  women.  I  doubt  whether  it  is  the  best  way 
of  taking  exercise,  but  I  do  think  that  it  may  be,  indi- 
rectly, of  incalculable  benefit  to  the  female  race.  It  is 
undoubtedly  a  most  fascinating  pastime,  and  on  that 
account  many  a  woman  will  be  out  riding,  taking  in 
fresh  air,  exercising  her  whole  muscular  system,  when, 
did  she  not  have  her  wheel,  she  would  be  sitting  in  the 
house  reading  some  novel  or  engaging  in  some  seden- 
tary occupation.  Why  is  it  that  at  least  seventy-five 
per  cent,  of  our  patients  are  women  ?  Has  a  curse  been 
laid  on  the  se.x  which  condemns  them  to  a  greater  share 
of  ailments.  It  looks  so,  and  laymen  will  say  that 
childbirth  is  the  cause,  but  it  is  nothing  of  the  sort. 
Do  mares,  cows,  etc.,  fall  ill  oftener  than  the  males  of 
the  same  species  ?  No.  Why  ?  Because  their  hygienic 
surroundings  and  habits  of  life  are  the  same.  Child- 
birth is  a  physiological  act,  and  directly  it  impairs  health 
it  becomes  pathological.  We  know  that  the  higher  we 
go  in  the  scale  of  so-called  civilization  the  more  neu- 
rotic the  individual,  and  as  society  demands  that  its 
female  members  should  do  no  work,  so  there  follows  a 
life  of  indolence  with  lack  of  muscular  development. 
The  new  woman  is  changing  all  this.  She  is  engaging 
in  out-door  exercise  in  very  many  different  ways,  and 
to  enjoy  this  exercise  she  has  had  to  change  her  style 
of  dress. 

Neurasthenia  is  alarmingly  prevalent  among  our 
women,  and,  for  my  part,  I  believe  it  is  due  as  much  to 
lack  of  protection  to  the  pelvic  organs  from  climatic 
change  as  to  anything  else,  and  the  next  cause  on  the 
list  is  lack  of  proper,  healthy  exercise.  A  woman  will 
sit  in  the  house  all  day  and  at  nine  o'clock  at  night  go 
out  to  a  dance.  She  will  waltz  until  she  is  in  a  perspi- 
ration all  over.  She  will  be  very  solicitous  about  her 
shoulders,  but  will  forget  that  the  cool  air  will  pene- 
trate to  the  pelvis,  so  she  throws  a  shawl  over  her 
shoulders  and  goes  out  into  the  night  air  to  get  cool. 
She  does  get  cool,  especially  the  pelvic  organs.  The 
next  day  ovarian  pain  sets  in,  perhaps  a  cellulitis  de- 
velops. She  has  a  headache  ;  the  doctor  comes  and 
says,  "  You  have  caught  cold,"  but  no  word  of  advice 
about  avoiding  cold  to  the  pelvis.  Neurasthenia  super- 
venes. A  young  woman  stands  in  a  store  all  day  ;  at 
night  she  is  tired  ;  she  cannot  find  enjoyment  in  walk- 
ing. To  hire  a  horse  is  beyond  her  means,  so  she  sits 
down  and  reads  ;  in  a  short  time  she  becomes  hysteri- 
cal and  neurotic. 

All  this  can  be  remedied  by  following  the  lead  of  the 
new  woman  in  her  rational  dress  and  exercise.  Of 
course,  moderation  must  be  exercised  in  all  things. 

I  am  inclined  to  think  that  the  medical  profession 
may  do  much  in  advising,  or  rather,  approving,  such 
measures,  but  I  suppose  that  where  woman  is  con- 
cerned we  must  fold  our  hands  and  say,  Che  sard  sard. 
W.  H.  F.  Miller,  M.D. 

Clifton  Forge,  Va. 


Signing  One's  Own  Death  Certificate. — In  an  Italian 
town  the  death  took  place  of  the  communal  medical 
officer,  one  of  whose  duties  consisted  in  visiting  the 
dead  in  the  public  institutions,  and  in  writing  death 
certificates.  Among  his  papers  was  found  his  own 
death  certificate,  with  the  disease  from  which  he 
suffered  duly  recorded,  the  certificate  being  complete 
in  all  particulars  save  the  insertion  of  the  date  of  his 
death.  When,  therefore,  the  new  medical  officer  ap- 
peared on  the  scene,  all  that  was  deemed  to  be  neces- 
sary was  to  fill  in  the  date,  and  the  certificate  was  then 
regarded  as  valid. — Medical  Press. 


178 


MEDICAL   RECORD. 


[August  3,  1895 


MODERN    GREEK    AS    AN   INTERNATIONAL 
MEDICAL   LANGUAGE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  British  Medical  Journal  for  May  i8th,  the 
fact  is  noted  that  Dr.  Galabin's  "Guide  to  the  Diseases 
of  Women  "  has  been  translated  into  Greek  by  Dr. 
Luke  G.  Nipellos,  of  Athens.  In  view  of  the  fact  that 
this  language  is  urged  as  the  international  language  of 
medicine,  it  is  interesting  to  see  some  of  the  difficulties 
of  transliteration.  For  instance  2i)8ca/x  for  Sydenham, 
AayKav  for  Duncan  ;  Sir  John  Williams  and  Hodge  are 
left  in  Roman  characters.  Many  words,  as  enucleation, 
decidua,  prolapsus,  gutta-percha  are  placed  in  brackets, 
after  the  Greek  rendering,  so  the  reader  will  be  sure  of 
what  is  meant.  Some  names  of  drugs,  such  as  carba- 
mide of  quinine  are  untranslatable.  Now,  sir,  if  a  mod- 
ern Greek  in  his  own  study,  with  no  limitations  as  to 
time,  with  access  to  dictionaries,  vocabularies,  and  the 
like,  makes  such  poor  work  of  translation,  what  can  we 
expect  of  American  or  English  physicians  who  would 
have  to  speak  extemporaneously,  as  in  discussing  pa- 
pers ? 


Chicago,  III. 


Yours  truly, 

George  W.  Smith,  M.D. 


[A  modern  Greek  in  his  own  study  is  not  necessarily 
a  master  of  the  difficult  art  of  translation,  and  the  ca- 
pabilities of  the  language  should  not  be  judged  by  the 
result  of  his  efforts.  Moreover  the  necessity  of  trans- 
ferring bodily  some  foreign  words  is  no  more  of  an  ar- 
gument against  the  employment  of  Greek  than  is  the 
common  use  of  many  English  medical  terms  by  French 
writers  an  argument  against  the  adoption  of  French  as 
the  universal  language. — Ed.] 


THE    CONDUCT   OF    THE    PHYSICIAN    IN    A 
CASE   OF   CRIMINAL   ABORTION. 

To  THE  Editor  op  the  Medical  Record. 

Sir  :  In  Mr.  Robert  C.  Taylor's  reply  to  the  Medical 
Society  of  the  County  of  New  York,  in  regard  to  the 
status  of  the  physician  when  called  to  cases  of  abor- 
tion, I  read  the  following  :  "  If  he  receives  a  call  to 
attend  an  urgent  case  he  cannot  decline  it,  even  though 
it  be  suspicious." 

Is  this  law  peculiar  to  the  State  of  New  York  ?  It 
certainly  differs  from  what  I  have  seen  heretofore.  I 
was  taught  that  a  physician  had  a  right  absolutely  to 
refuse  any  or  all  cases.  That  the  fact  of  his  being  a 
physician  did  not  compel  him  to  assume  undesirable 
calls.  But  if  a  call  should  be  answered  to  attend  an 
obstetric  case,  or  an  urgent  case,  he  must  remain  and 
see  the  :asr  through,  or  see  that  some  other  physician 
was  in  attendance  before  leaving  the  case. 

When  a  physician  answers  a  call  he  enters  into  a 
contract  with  the  patient — a  preferred  contract  to  give 
his  reasonable  attention,  such  attention  as  the  case  re- 
quires. It  goes  without  saying  that  someone  must  at- 
tend these  cases  of  criminal  abortion,  but  it  seems  to 
me  to  be  unjust  that  respectable  physicians  should  be 
obliged  to  entangle  themselves  in  these  cases. 

Mr.  Taylor  says  :  "  The  duty  of  the  physician  in 
these  cases  relates  to  himself,"  i.e.,  self-protection. 

Now,  how  many  physicians  have  taken  the  trouble  to 
inform  themselves  in  regard  to  the  law  in  relation  to 
the  procuring  of  abortion  ?  I  think  the  statute  reads 
about  the  same  in  the  several  States,  viz.  :  "  Any  ])erson 
who  administers  a  drug,  or  performs  an  operation  upon 
a  woman,  whether  she  be  ])regnant  or  not,  for  the  pur- 
pose of  procuring  an  abortion,  unless  such  be  advised 
by  two  physicians  in  order  to  save  the  life  of  mother  or 
child,  or  both,  is  guilty  of  felony."  In  some  States  the 
clause  "quick  with  child  "  is  inserted. 

A  physician  who  assumes  sole  charge  of  one  of  these 
cases  is  very  imprudent.     The  question  arises,  how  am 


I  to  know  that  the  case  is  due  to  a  criminal  operation, 
or  to  accidental  or  so-called  natural  causes  ? 

In  nine  cases  out  of  ten,  if  the  woman  knows  she  is 
about  to  die,  she  will  tell  all  she  knows  about  the  case, 
and  the  attending  physician  should  get  a  dying  declara- 
tion. Be  sure  that  she  knows  she  is  going  to  die,  and 
what  she  says  will  be  accepted  by  the  court  without 
question.  It  is  the  cases  which  die  that  cause  trouble 
for  the  attending  physician. 

I  suppose  professional  abortionists  will  ply  their  vo- 
cation as  long  as  society  demands  that  they  exist.  The 
daily  and  weekly  papers  insert  their  advertisements, 
and  every  school-boy  and  girl  knows  what  they  mean. 

If  this  abominable  business  is  allowed  to  be  carried 
on,  and  is  winked  at  by  the  public  and  officers  of  the 
law,  let  the  public  suffer,  and  not  the  representatives  of 
a  respectable  profession,  who  are  in  many  cases  literal 
representatives  of  the  Good  Samaritan,  giving  time  and 
money  to  alleviate  the  sufferings  of  humanity. 

That  they  should  be  obliged  to  suffer  for  the  crimes 
of  those  who  are  aided  and  abetted  by  society  is  a 
blot  upon  what  is  called  a  Christian  civilization. 

William  H.  Russell,  M.D. 

Ipswich,  Mass. 


THE   COUNTRY   PRACTITIONER. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Most  of  our  medical  journals  are  filled  with  arti- 
cles by  our  city  brethren  of  the  profession,  and  the 
country  practitioner  does  not  seem  to  be  heard  from 
to  any  great  extent. 

The  surgeon,  the  laboratory  physician,  the  college 
professor,  hospital  doctor,  and  the  specialists  are  the 
ones  who  generally  give  in  their  experiences  through 
the  columns  of  our  journals,  and  while  the  articles  are 
excellent  in  their  way,  some  of  them  are  not  much 
help  to  us  country  practitioners  in  our  work,  embrac- 
ing as  it  does  everything  in  medicine  from  colds  to 
small-pox  and  paresis,  and  everything  in  surgery  from 
ingrowing  toe-nails  to  laparotomy.  Long  reports  of 
hip-joint  operations  or  rare  cases  of  skin  diseases,  and 
laboratory  experiments  to  settle  tweedledum  or  twee- 
dledee  of  certain  bacilli,  are  nice  in  their  way  and  very 
interesting  reading,  of  course,  but  it  does  not  always 
seem  to  suit  our  case.  It  may  be  that  we  will  have  to 
do  one  hip-joint  amputation  in  a  lifetime,  but  the 
chances  are  that  we  will  not,  and  if  there  are  only  a 
very  few  cases  of  the  rare  skin  disease  on  record,  it  is 
hardly  probable  that  we  will  make  a  living  by  our 
knowledge  of  that  particular  disease,  however  inter- 
esting it  may  be  ;  and  we  do  not  see  that  it  makes  a 
great  deal  of  difference  in  the  welfare  of  that  case  of 
pneumonia  whether  the  bacilli  which  produce  it  thrive 
best  on  gelatine  or  common  boarding-house  hash.  Of 
course,  these  things  must  be  known  and  studied. 
They  make  excellent  dessert  in  our  reading  course, 
but  they  are  not  the  substantial  fare  that  helps  us 
most  as  individual  country  doctors,  with  our  many 
shades  and  phases  of  diseases  of  the  more  common 
type.  We  have  no  specialist  at  our  elbow,  nobody  to 
send  our  patient  to  if  he  develops  disease  not  exactly 
in  our  line,  but  must  know  everything  ourselves  and 
do  everything  ourselves.  If  we  must  know  everything 
we  cannot  hope  to  know  all  of  everything,  so  we  have 
only  time  for  facts  about  things  of  use  to  us  in  our 
work.  The  deeper  questions  of  pathology,  bacteriol- 
ogy, special  operations,  and  new  theories,  we  leave  to 
our  city  brethren  ;  and  wliile  we  are  always  thankful 
for  their  labors,  we  cannot  help  but  sometimes  wish 
that  they  would  not  be  continually  startling  us  with 
new  discoveries  before  they  are  discovered,  and  new 
inventions  before  they  are  invented. 

We  of  the  rural  districts  are  expected  by  our  pa- 
tients to  do  a  great  many  things.  We  are  expected  to 
pull  a  tooth  for  twenty-five  cents,  and  do  it  better  than 


August  3,  1895] 


MEDICAL    RECORD. 


179 


a  dentist  ;  "  stop  "  typhoid  fever  at  once  ;  to  make  lines 
that  erysipelas  dares  not  cross  ;  to  cure  heart  disease, 
foretell  the  weather,  and  know  what  is  good  for  bots 
in  horses.  We  are  expected  to  know  what  makes  the 
baby  cry  without  seeing  it,  and  to  send  medicine  by 
John  for  female  trouble  ;  to  cure  rheumatism  with 
liniment  and  "  piles  "  with  "  salve  ;  "  to  "  break  the 
measles  out,"  and  dry  the  consumptive  cough  up. 

Needless  to  say  we  do  not  do  all  this,  but  no  amount 
of  explanation  will  always  make  it  clear  that  it  was  not 
our  duty  to  do  it. 

If  we  had  a  diploma  from  the  best  medical  school  in 
the  world,  and  had  carried  off  the  honors  of  our  class, 
and  were  not  gray-headed,  we  would  very  likely  be 
pitied  because  we  had  not  had  as  much  experience  as 
the  old  doctor  in  the  neighboring  town,  who  had  been 
a  nurse  in  the  army  for  six  months  and  had  practised 
for  twenty  years,  never  having  seen  the  inside  of  a 
medical  college. 

We  can't  telephone  for  an  instrument  and  get  it  in  a 
few  minutes  in  an  emergency  case,  but  must  operate 
with  what  we  have,  or  make  something  to  answer  the 
purpose  ;  yet  in  spite  of  all  these  things  we  manage  to 
overcome  the  difficulties  and  get  along  fairly  well,  and 
some  of  the  brightest  names  on  the  roll  of  honor  of 
our  profession  are  some  of  these  same  country  prac- 
titioners, men  who  have  conferred  lasting  benefit  on 
their  fellow-men.  Still  it  is  often  noticed  that  the 
wreath  of  honor  is  often  held  from  their  living  brow 
and  afterward  placed  on  their  grass-grown  graves. 
The  picture,  too,  has  sometimes  a  pleasant  side,  painted 
with  brighter  colors;  but  whether  his  life  be  bright  or 
dark,  grave  or  gay,  all  honor,  say  we,  to  the  patient, 
toiling,  enduring  servant  of  the  sick  and  suffering — the 
country  practitioner. 

Clement  C.  Collins,  M.D. 

ROACHDALE,   InD. 


RECIPROCITY   IN    REGISTRATION. 

^To  THE  Editor  op  the  Medical  Record. 

Sir  :  In  the  issue  of  July  20th  "  A  Country  Doctor  " 
says  :  "  I  object  to  the  methods  of  such  States  as  Ala- 
bama, California,  District  of  Columbia,  Maryland,  New 
Hampshire,  Vermont,  Virginia,  and  Wisconsin,  where 
the  examination,  which  is  not  always  required,  is  con- 
ducted by  the  various  medical  societies." 

As  far  as  regards  Virginia,  both  of  these  statements 
are  incorrect  :  the  examination  by  the  State  Board  is 
always  required,  and  the  said  examination  is  not  con- 
ducted by  the  "  various  medical  societies." 

In  justice  to  the  Virginia  Board  the  following  facts 
should  be  stated  :  Virginia  has  had  in  operation  an 
Examining  Board  since  1888.  Said  Board  consists  of 
three  from  each  congressional  district,  two  from  State 
at  large,  and  five  homoeopaths.  These  are  appointed 
by  the  Governor  of  the  State  from  a  list  of  names 
placed  before  him  by  the  Medical  Society  of  Virginia, 
as  being  reputable  physicians  and  learned  in  their  pro- 
fession. The  homoeopathic  members  are  chosen  at 
the  option  of  the  Governor.  Boards  serve  four  years 
and  have  examined,  up  to  date,  887  ;  licensed,  626  ; 
rejected  and  withdrawn,  261  ;  percentage  of  those  suc- 
cessful, 0.705. 

The  "  Country  Doctor  "  is  right  in  having  put  for- 
ward the  "  Reciprocity  in  Registration,"  but  it  would 
seem  rather  extreme  for  a  member  of  the  profession  in 
a  State  having  a  State  Board  of  Registration  only  since 
July  9,  1895,  to  be  offering  uninstructed  criticisms  upon 
the  methods  of  other  States  having  Examining  Boards 
in  operation  for  many  years,  and  with  a  percentage  of 
rejections  of  thirty  as  a  sample  of  the  thoroughness  of 
the  test. 

In  conclusion,  the  writer  may  remark  that  he  passed 
said  examination  in  Virginia  in  1892,  and  regards  it  as 


rigid,  but  fair.  We  are  glad  that  Maine  is  setting  her 
standard  high,  but  "  reciprocal  registration  "  is  a  great 
way  off  as  yet. 

Virginia  Country  Doctor. 

Woodstock,  Va.,  July  24,  1SJ5. 


^cxlical  gtems. 

Ccntagious  Diseases— Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  July  27,  1895. 


Cases.        Deaths. 


Tuberculosis !  48 

Typhoid  fever 13 

Scarlet  fever I  45 

Cerebro-spinal  meningitis 2 

Measles ]  170 

Diphtheria 174 


119 
7 
S 
5 


Vicarious  Menstruation  through  the  Lungs  and  its 
Relation  to  Tuberculosis,  with  Remarks  on  the  Treat- 
ment of  Pulmonary  Hemorrhage. — Dr.  Kober  describes 
the  case  of  a  girl  of  nineteen  years  with  a  tuberculous 
family  history,  who  had  severe  hemorrhage  from  the 
lungs  at  the  menstrual  period,  without  previous  signs  of 
pulmonary  disease.  The  menses  proper  lasted  only  a 
few  hours,  but  the  pulmonary  bleeding  continued  for 
three  days  with  great  severity.  The  bleeding  then  sub- 
sided, after  nausea  and  vomiting  had  come  on,  and  these 
latter  symptoms  lasted  some  days  longer.  During  this 
time  signs  of  pneumonia  appeared  in  both  bases,  with 
mild  general  symptoms.  In  about  ten  days  the  patient 
seemed  perfectly  well.  At  the  next  period  a  similar  set 
of  phenomena  appeared,  but  recovery  was  not  complete. 
The  patient  was  treated  for  tuberculosis,  although  bacilli 
could  at  no  time  be  found.  Efforts  were  made  at  the 
same  time  to  bring  on  uterine  hemorrhage  at  the  next 
menstrual  period,  but  in  vain,  and  a  third  time  pulmonary 
hemorrhage  appeared,  the  amount  of  blood  being  less 
than  at  the  former  periods.  Vomiting,  fever,  and  a 
fresh  pneumonic  attack  followed.  The  cough  remained, 
diarrhoea  appeared,  loss  of  flesh  and  strength,  with  night- 
sweats  and  high  temperature,  varied  the  picture,  and  in 
four  months  from  the  first  hemorrhage  the  patient  died. 
Tubercle  bacilli  could  not  be  found  up  to  the  last. 
Kober  thinks  the  patient  had  tuberculosis  at  the  time 
of  the  first  hemorrhage,  and  that  this  was  the  cause  of 
the  vicarious  menstruation,  the  lung  forming  a  locus 
minoris  resistcntia  which  suifers  in  the  high  arterial  ten- 
sion of  menstruation.  An  interesting  fact  is  that  no 
remedy  seemed  to  check  the  hemorrhage,  but  that  each 
of  the  three  attacks  was  cut  short  by  nausea  and  vomit- 
ing. This  recalls  the  treatment  of  Graves  and  Trous- 
seau, the  former  using  ipecac  in  nauseating,  the  latter 
in  emetic  doses.  Kober  proposes  a  combination,  first 
causing  vomiting,  and  then  keepinjj  up  nausea  by  small 
doses  of  the  remedy.  The  cause  of  the  natural  cure 
Kober  does  not  explain,  but  suggests  irritation  of  the 
vomiting-centre  by  lack  of  oxygen  from  loss  of  blood, 
or  in  a  reflex  way  by  the  blood  in  the  alveoli. —  The 
American  Journal  of  the  Medical  Sciences. 

The  Pulse  in  Insanity.— Abnormal  sphygmographic 
tracings  are  to  be  found  at  some  stage  of  the  disease  in 
the  vast  majority  of  cases  of  insanity.  They  are  due  to 
affections  of  the  cortical  and  spinal  motor  and  vaso- 
motor centres,  to  various  lesions  of  the  sympathetic, 
to  disorders  of  the  pneumogastric,  to  peripheral  and 
central  vascular  changes,  to  degenerations  of  central 
organs,  to  toxic  agents  in  the  blood,  to  auto-intoxica- 
tions, to  cachectic  and  diathetic  conditions,  to  cardiac 


i8o 


MEDICAL  RECORD. 


[August  3,  1895 


lesions,  and  to  a  great  variety  of  intercurrent  causes. 
These  abnormal  pulse-tracings  vary  much  in  different 
kinds  of  insanity  and  in  different  individuals  suffering 
from  the  same  form  of  mental  disorder,  and  they  are 
best  classified  according  to  the  actual  physical  status  of 
the  patient  and  the  etiology  and  stage  of  the  mental 
disorder.  No  one  sphygmogram  is  pathognomic  of  any 
particular  form  of  insanity,  but  there  are  certain  gen- 
eral types  of  tracings  which  are  found  in  one  form  of 
mental  disease  and  not  in  another.  Sphygmographic 
studies,  to  be  of  special  value,  should  be  continued  in 
the  same  patients  throughout  an  attack  of  mental  dis- 
order, and  tracings  finally  obtained  in  convalescence 
should  be  preserved  for  comparison.  Unfortunately, 
studies  with  the  sphygmograph  are  laborious  and  time- 
consuming,  but  they  are  of  such  diagnostic  and  prog- 
nostic value  in  mental  disorders  that  they  have  already 
become  an  indispensable  part  of  alienistic  science. — 
Theo.  H.  Kellogg,  M.D.,  Medical  Superintendent  of 
Willard  State  Hospital. 

Myxoedema   Treated  with  Thyroid  Extract. — At  a 

meeting  some  months  since  of  the  Practitioners'  So- 
ciety of  New  York,  Dr.  Kinnicutt  exhibited  photo- 
graphs and  reported  the  condition  of  a  myxosdematous 
patient,  fourteen  months  after  the  beginning  of  treat- 
ment with  thyroid  extract.  It  had  been  found  neces- 
sary to  continue  the  treatment,  and  during  the  past 
eight  months  about  twelve  minims  of  a  glycerine  ex- 
tract, representing  less  than  a  quarter  in  weight  of  the 
average  single  lobe  of  a  sheep's  gland,  had  been  given 
every  four  days.  The  duration  of  the  illness  before 
the  beginning  of  treatment  had  been  twelve  years,  and 
the  patient,  on  admission  to  the  hospital,  had  exhibited 
the  stage  of  advanced  degeneration.  There  was  marked 
general  muscular  paresis,  the  patient  had  been  bed- 
ridden for  a  year,  and  there  was  distinct  impairment 
of  mental  vigor.  The  great  improvement  after  five 
months  of  treatment  had  been  reported  previously. 
With  the  continuance  of  treatment  the  health  of  the 
patient  at  the  present  date  was  excellent.  The  muscu- 
lar power  and  mental  condition  were  apparently  nor- 
mal, the  patient  was  cheerful  and  able  to  attend  to  her 
simple  daily  duties.  The  hair  on  the  scalp,  from  hav- 
ing been  entirely  lost,  had  continued  to  grow  and  at 
the  present  time  was  very  abundant  and  reached  to 
the  shoulder.  The  probabilities  seemed  to  be  that  it 
would  be  necessary  to  continue  the  treatment  indefi- 
nitely, but  that  under  these  conditions  good  health 
would  be  maintained. 

Electricity  and  Cats. — Our  lay  contemporary,  the 
New  York  Press,  has  apparently  joined  the  ranks  of 
those  papers  which  seriously  propose  to  bring  home  to 
the  minds  of  plain  people  the  more  important  discover- 
ies of  modern  medicine.  The  propriety  of  thus  en- 
croaching upon  the  proper  territory  of  medical  journal- 
ism is  open  to  grave  question.  The  public  is  so  apt  to 
draw  wrong  conclusions  from  even  the  most  simplified 
presentation  of  erudite  propositions,  that  the  danger- 
point  may  be  reached  before  suspicion  has  fairly  been 
wakened.  The  electrical  properties  of  cats  are  know- 
ingly referred  to  in  the  Press.  Evidently  the  writer 
was  inspired  by  a  profound  respect  for  an  article  pub- 
lished recently  in  the  British  Medical  Journal.  The 
Press  has  this  to  say  on  the  subject  :  In  England  the 
cat  has  just  received  her  scientific  vindication  as  a  factor 
that  makes  for  good  in  modern  civilization.  They  have 
a  National  Cat  Club  in  Great  Britain,  and  at  the  recent 
annual  meeting  of  this  august  body  the  secretary  an- 
nounced to  an  admiring  audience  of  feline  fanciers  that 
cats,  and  more  particularly  old  cats,  were  "intense." 
In  family  circles  it  has  been  known  for  some  time  that 
persons  of  recognized  "  intensity "  were  occasionally 
called  "old  cats."  But  a  suspicion  of  slight  oppro- 
brium has  generally  been  associated  with  this  use  of  the 
term.     The    purely   scientific   correlation   of   intensity 


and  cats  is  undeniably  English,  and  likely  to  remain  so 
for  the  present. 

The  "  intensity  "  of  cats,  even  of  ordinary  old  toms, 
can  be  demonstrated  by  gently  rubbing  their  backs  in 
cold  dry  weather,  and,  preferably,  in  the  dark.  It  will 
then  easily  appear  that  the  animal  is  "  full  of  electric- 
ity." It  is  therefore  proposed  to  employ  old  cats  as 
convenient  storage  batteries  for  electrical  accumulation. 
It  has  already  been  accurately  computed  that  a  really 
intense  cat,  when  properly  charged,  will  give  off  enough 
electric  sparks  to  shatter  three  ordinary  attacks  of  hys- 
terics. People  subject  to  this  distressing  form  of  ner- 
vous disorder  can  now  be  seen  in  London  accompanied 
by  their  intense  cats.  A  stock  company  (limited)  has 
also  been  organized,  and  is  now  in  a  position  to  supply 
certified  felines  of  unimpeachable  pedigree  and  requi- 
site intensity  for  all  functions  where  hysterics  are  apt  to 
go  off  unexpectedly.  Emotional  first-nighters,  girls 
who  habitually  get  engaged  and  disengaged,  aesthetic 
tea  frequenters,  Paderewski  worshippers,  grass  widows, 
office  seekers,  and  all  individuals  whose  nervous  sys- 
tems require  occasional  fortification,  now  never  vent- 
ure out  in  London  without  a  duly  tested  intense  cat 
within  easy  reach.  For  children's  parties  and  charita- 
ble enterprises  kittens  have  been  found  strong  enough. 
It  is  further  proposed  to  use  the  "living  feline  galvan- 
ism "  for  curative  purposes  in  cases  where  formerly  the 
more  complex  and  expensive  system  of  hypnotic  sug- 
gestion was  in  vogue.  The  British  Medical  Journal,  in 
commenting  on  these  interesting  and  epoch-making  re- 
searches, says  :  "  Apart  from  questions  of  electro-physi- 
ology, it  is  instructive  to  learn  that  the  presence  of 
white  in  the  color  of  a  cat,  unless  the  animal  be  whole 
colored,  is  a  sign  of  weakness.  It  is  also  interesting  to 
know  that  the  National  Cat  Club  encourages  the  pro- 
duction of  whole-colored  cats  and  would  in  every  in- 
stance have  been  successful  in  this,  had  it  not  been  for 
the  disappointing  obstinacy  of  the  tortoise-shell  '  tom,' 
who,  it  appears,  resolutely  declines  to  become  a  cat  of 
another  color."  On  the  whole,  the  cat  seems  as  full  of 
promising  utility  as  of  intensity.  We  congratulate  the 
British  National  Cat  Club  on  the  eminent  success  of 
their  feline  labors.  We  await  with  bated  breath  the 
advent  of  "  intense  "  cats  in  our  country.  Perhaps 
there  are  some  here  now.     Who  knows  ! 

An  Original  Doctor. — There  is  a  quaint  and  original 
doctor  located  on  one  of  the  islands  on  Puget  Sound. 
He  advertises  in  posters  and  placards  printed  in  a  home 
outfit.  In  one  of  his  announcements  he  says  :  "  Legs 
and  arms  sawed  off  while  you  wate  without  pane. 
Childbirth  and  tumors  a  specialty.  No  odds  asked  in 
measles,  hooping  cough,  mumps  or  diarrear.  Bald  head, 
bunions,  corns,  warts,  cancer  and  ingrowing  tow  nales 
treated  scientifically.  Coleck,  cramps,  costiveness,  and 
worms  nailed  on  sight.  Wringworms,  pole  evil,  shin- 
gles, moles,  and  cross  eye  cured  in  one  treatment  or  no 
pay.  Private  diseases  of  man,  woman  or  beast  eradi- 
cated. P.  S.  Terms,  Cash  invariably  in  advance. 
No  cure,  no  pay.  P.  S.  (Take  Notis.)  No  coroner 
never  yet  sot  on  the  remanes  of  my  customers,  and 
enny  one  hiring  me  doan't  haf  to  be  good  layin'  up 
money  to  buy  a  gravessone.     Come  won,  come  awl. 

This  man  is  said  to  do  a  good  business,  although  you 
would  not  expect  it,  and  his  patients  say  he  cures  dis- 
eases, and  does  it  thoroughly  and  quickly." 

Railway  Sanitation. — Railroad  companies  are  not 
allowed  to  carry  the  dead  of  infectious  diseases  e.\cept 
under  certain  conditions  ;  why  should  they  carry  the 
living  without  any  ?  It  is  the  duty  of  national,  provin- 
cial, and  State  sanitary  associatioiis  to  educate  the  peo- 
ple in  matters  of  this  kind.  When  educated,  the 
people  will  demand  protection,  and  when  the  people 
demand  what  is  right  and  reasonable,  corporations, 
which  are  said  to  have  no  souls,  generally  find  it  con- 
venient and  advisable  to  comply. — National  Board  of 
Health  Magazine. 


August   lo,  1895] 


MEDICAL   RECORD. 


191 


UMBILICAL    HEMORRHAGE    IN    NEWLY 
BORN   INFANTS.' 

By   CHARLES   E.   NAMMACK,   M.D., 

VISITING    PHYSICIAN   TO    GOIVEKNEUR   HOSPITAL,    NEW   YORK. 

It  is  doubtful  whether  any  disease  having  a  correspond- 
ingly high  mortality-rate  has  received  so  little  attention 
as  spontaneous  bleeding  from  the  navel  in  neonati. 
The  infrequency  of  reported  cases  may  account  for 
this,  as  the  issue  is  generally  fatal,  and  cases  with  a 
fatal  termination  do  not  find  their  way  into  print  with 
the  same  facility  as  do  successful  cases.  It  is  prob- 
able that  the  death  certificates  of  the  fatal  cases  are 
filled  out  as  haemophilia  ;  but  the  disease  under  con- 
sideration differs  from  haemophilia  in  that  it  affects 
subjects  much  earlier  in  life  than  does  the  hemorrhagic 
diathesis,  which  seldom  shows  itself  before  the  end  of 
the  first  year.  The  blood  in  hsemophilia  is  usually 
coagulable,  and  not  so  in  the  disease  here  spoken  of.'- 

Spontaneous  umbilical  hemorrhage  is  also  a  disease 
of  a  self-limited  character,  cases  either  going  on  to 
death  or  recovery  within  a  few  days,^  whereas  bleeders 
are  apt  to  have  a  succession  of  hemorrhages  from  dif- 
ferent points  and  extending  over  a  longer  period  of 
time.  Bovee"*  has  collected  all  the  cases  in  literature, 
from  1635  to  189I;  to  the  number  of  five  hundred  and 
eighteen,  and  his  article  shows  exhaustive  study  and 
research.  He  writes  that  the  most  prolific  causes  are 
hereditary  diseases,  such  as  syphilis  and  dyscrasife, 
either  local  or  constitutional.  Van  Cott '  thinks  that 
there  is  overwhelming  clinical  evidence  that  jaundice 
exerts  a  profound  influence  toward  producing  the 
hemorrhagic  condition,  and  says  that  of  general  causes 
syphilis  should  stand  first  and  tuberculosis  next,  while 
of  special  conditions,  absorption  of  sepsis  at  navel 
takes  first  rank. 

The  frequency  of  the  disease  in  hospital  practice, 
and  its  definite  self-limited  character,  suggest  its  in- 
fectious nature,  yet  the  records  of  eighty-one  autopsies 
show  nothing,  in  the  majority  of  cases,  except  the 
hemorrhages  and  the  resulting  anaemia.* 

C.  F.  Craig  '  says  that  the  causes  are  :  i,  A  faulty 
condition  of  the  blood  ;  and  2,  a  pathologic  condition 
of  the  vessel-wall,  or  a  combination  of  both  conditions. 
He  quotes  Sir  J.  Y.  Simpson's  opinion  that  syphilis 
causes  thickening  and  infiltration,  loss  of  contractility, 
and,  therefore,  a  patulous  condition  of  the  vessel-walls.' 

Albert  Seppel '  records  an  interesting  case  in  which 
the  cord  fell  on  the  seventh  day,  and  hemorrhage,  be- 
ginning on  the  eleventh  day,  proved  fatal.  Autopsy 
showed  the  right  umbilical  artery  to  be  firmly  closed, 
while  through  the  left  a  fairly  thick  sound  passed 
easily.  Microscopical  examination  failed  to  disclose 
the  reason  for  this  disparity,  as  both  vessels  contained 
thrombi  in  various  stages  of  organization,  the  throm- 
bus in  the  right  artery  filling  out  entirely  the  lumen  of 
the  vessel,  while  that  in  the  left  artery  left  a  space  be- 
tween the  arterial  walls.  Bacteriological  examination 
showed  only  the  ordinary  post-mortem  microbes,  no 
specific  agent  being  found. 

Klebs  and  Eppinger  '"  have  described  a  micrococcus 
found  in  this  malady,  which  they  called  monas  hsmor- 
rhagicum. 

Dr.  Lefour  "  gives  the  history  of  a  family  of  five  chil- 
dren.    The  first  two  died  from  umbilical  hemorrhage 

'  Re.id  before  the  Section  in  Obstetrics,  New  York  Academy  of 
Medicine,  .^pril  25,  1895. 

=  Bovee ;  Journal  of  the  American  Medical  Association,  April  18, 
1891.  p.  542. 

»  Townsend  :  Archives  of  Pediatrics,  1894,  pp.  55i)-565. 

*  Journal  of  the  .^merican  Medical  Association,  April  18.  1891. 
=  Brooklyn  Medical  Journal,  1888. 

«  Townsend  :  Archives  of  Pediatrics,  1894. 

'  Medical  News,  Philadelphia,  1894.  vol.  l.w.,  p.  569. 

*  Vide  J.  Lewis  Smith  :  Seventh  edition,  i8go,  p.  130. 
"  Centralblatt  f.  Gynecologic,  1892,  pp.  470-473. 

"  Ziegler's  Te.xt-book  on  Pathology,  William  Wood  &  Co.,  i337 
P-  303- 
"  Gazette  des  Hopitau.f  de  Toulouse,  1893,  p.  217. 


The  cord  of  the  second  was  examined  microscopically, 
and  endarteritis  was  found.  The  third  and  fourth 
children  were  raised  without  accident.  The  fifth  child 
was  born  at  term,  and  the  cord  tied  with  a  caoutchouc 
thread.  On  the  fourth  day  hemorrhage  occurred  and 
was  controlled  by  ligature  en  masse. 

Dr.  P.  Lugeal '  reports  five  cases,  which  do  not  throw 
any  light  on  either  the  etiology  or  the  pathology  of  the 
condition. 

Helen  F.  Warner -publishes  three  cases,  of  which  two 
recovered. 

J.  Taylor  ^  narrates  three  cases  in  the  same  family, 
the  first  two  of  which  were  fatal.  The  third  recovered 
under  the  local  use  of  a  solution  of  one  ounce  tannin  in 
one  ounce  rectified  spirits.  Taylor  thinks  it  would  be 
worth  while  to  give  chloride  of  calcium  by  the  mouth 
in  these  cases.  This  therapeutic  possibility  has  been 
recently  spoken  of  by  W.  Oilman  Thompson.''  The 
symptomatology  of  this  disease  is  typically  illustrated 
by  the  narration  of  the  following  case  : 

Sarah  L ,  aged  four  days,  was  sent  to  Gouverneur 

Hospital,  March  i,  1895,  with  the  following  history  : 
She  is  the  sixth  child.  The  other  five  were  still-born 
prematurely  on  account  of  syphilis  in  the  mother. 
During  the  sixth  pregnancy  the  mother  received  con- 
stantly anti-syphilitic  treatment,  and  was  delivered  at 
term  by  a  midwife,  without  any  difficulty,  of  an  appar- 
ently healthy  child.  On  the  third  day  jaundice  devel- 
oped, and  on  the  fourth  day  the  cord  became  detached 
spontaneously.  Shortly  after,  hemorrhage  from  the 
navel  began  and  was  checked  by  styptic  cotton  and  a 
bandage.  It  soon  recurred,  and  the  child  was  taken  to 
a  dispensary,  where  a  plaster  bandage  was  applied. 
This  checked  the  bleeding  for  a  brief  time  only,  and  on 
its  reappearance  the  baby  was  brought  to  the  hospital. 
On  admission  she  was  markedly  jaundiced  and  pro- 
foundly ansemic.  The  bleeding  resisted  attempts  at 
compression,  and  the  visiting  surgeon.  Dr.  Henry  M. 
Silver,  applied  a  purse-string  suture  which  checked  the 
oozing  for  several  hours.  It  came  on  again,  however, 
and  the  child  died  on  the  sixth  day  after  birth,  and 
twenty-four  hours  after  admission  to  the  hospital. 

Regarding  the  pathology  of  the  affection  it  will  be 
seen  that  there  is  a  decided  lack  of  unanimity  on  the 
part  of  writers,  and  it  is  probable  that  widely  different 
pathological  causes  may  give  rise  to  the  condition. 
The  "  American  Text-book  of  the  Diseases  of  Chil- 
dren," p.  86,  says  that  "  in  cases  where  syphilis,  hae- 
mophilia, septic  infection,  and  acute  fatty  degeneration 
with  ha;moglobinuria,  are  present,  hemorrhage  may  oc- 
cur when  the  cord  separates,  or  even  before  that  time." 

Hagmophilia,  as  a  causative  factor,  may  be  excluded 
for  the  reasons  already  given.  Septic  infection  may 
reasonably  be  expected  to  present  a  different  clinical 
history  from  that  which  obtains  in  typical  cases  of 
spontaneous  umbilical  hemorrhage.  Acute  fatty  de- 
generation has  been  made  the  subject  of  careful  study 
by  Dr.  Mary  Putnam- Jacobi,^  and  Partridge''  seems  in- 
clined to  accept  this  condition  as  the  essential  cause. 
In  the  hope  of  adding  something  to  our  knowledge  of 
the  pathology  of  the  affection,  the  coroner's  consent  to 
the  removal  of  some  of  the  organs  in  the  writer's  case 
was  obtained,  and  Dr.  F.  Ferguson,  pathologist  to  the 
New  York  Hospital,  kindly  undertook  their  examina- 
tion and  has  furnished  the  following  report  : 

The  material  consists  of  the  heart,  lungs,  liver,  kid- 
neys, stomach,  and  portion  of  intestines.  Also  the  in- 
tegument surrounding  the  umbilicus  with  the  umbilical 
vessels  attached.  The  heart  and  blood-vessels  appear 
normal.  There  are  a  few  hemorrhages  in  the  lungs  and 
liver.  Otherwise  all  the  organs  appear  normal.  There 
is  an  opening  at  the  site  of  the  umbilicus,  dark  in  color, 

'  Journal  de  Mi'd.  de  Bordeau.v,  1891,  p.  181. 

'  Annals  of  Gynecology  and  Pediatrics,  June,  1891. 

''  Bristol  Medico-Chirurgical  Journal,  1893. 

*  Medic.m,  Record,  April  13,  1895,  p.  451. 

'  American  Journal  of  Obstetrics,  1878,  p.  499. 

"  Medicat,  Recorp,  August  23,  1890, 


192 


MEDICAL    RECORD. 


[August  lo,  1895 


and  I  ctm.  in  diameter.     A  probe,  ^2  ctm.  in  diameter, 
passes  freely  through  the  opening  up  to  the  liver. 

Microscopical  examination  was  as  follows  ;  Trans- 
verse sections  of  the  cord  at  different  levels  show  the  um- 
bilical arteries  contracted  and  apparently  normal.  The 
cord  is  extensively  infiltrated  with  small  round  cells 
which  form  areas  of  considerable  extent  and  are  very 
rich  in  vascular  supply.  Those  small  vessels  vary 
greatly  in  the  thickness  of  their  walls  and  all  of  them 
are  intensely  hyperasmic.  Many  of  them  are  sur- 
rounded by  hemorrhages  which  are  of  considerable 
extent.  The  hemorrhages  are  seen  to  be  more  abun- 
dant and  extensive  as  the  sections  approach  the  union 
of  the  cord  with  the  integument.  In  some  of  the  sec- 
tions only  a  few  vessels  are  observed,  but  the  hemor- 
rhages into  the  tissues  are  most  extensive.  None  of 
the  sections  made  shows  the  vessels  to  be  the  seat  of 
thrombi.  The  wall  of  the  umbilical  vein  is  not  well 
defined,  and  the  vessel  is  surrounded  by  small  round 
cells  which  are  closely  packed  together.  The  hemor- 
rhages in  the  cord  are  the  result  of  defective  small  ves- 
sels, and  the  larger  hemorrhages  come  from  the  umbil- 
ical arteries,  neither  of  which  is  found  occluded. 
Examinations  of  the  vessels  of  other  organs  reveal  no 
lesion,  but  there  are  hemorrhages  of  minute  sizes  in  the 
spleen  and  kidneys.  The  cells  of  the  liver  refuse  very 
generally  the  ha^matoxyline  stain,  and  vast  numbers 
of  streptococci  are  found  in  the  liver,  spleen,  and  kid- 
neys. These  are  seen  between  and  within  the  tubules 
in  the  kidneys,  and  in  the  liver  within  the  vessels,  on 
the  surface  of  the  cells,  and  in  the  stroma. 
I^From  the  pathologist's  report  it  would  seem  that  the 
essential  cause  of  the  hemorrhages  in  this  case  was  a 
degeneration  of  the  walls  of  the  vessels,  and  from  the 
clinical  history  the  conclusion  is  inevitable  that  syphilis 
caused  the  degeneration. 

J.  Collins  Warren '  adopts  the  opinion  that  the  um- 
bilical arteries  are  closed  by  a  growth  which  takes  place 
from  the  intima,  by  which  the  calibre  of  the  vessel  is 
narrowed,  and  that  new  walls  are  thus  formed  within 
the  old,  the  complete  closure  of  the  vessel  depending 
upon  a  proliferation  of  endothelial  cells  rather  than 
upon  a  thrombus.  Further  on  he  states  (p.  136)  that 
Thoma's  assumption  that  a  portion  of  the  newly  found 
tissue  is  of  a  muscular  character  is  fully  confirmed. 


Tight  Lacing  and  Gall-stones.— Professor  Marchand, 
of  Marburg,  has  again  called  attention  to  the  fact  that 
gall-stones  and  tight  lacing  are  frequent  coincidents. 
The  furrow  caused  by  lacing  runs  directly  across  the 
right  lobe  of  the  liver,  causing  a  tendency  to  atrophy 
of  the  gall-bladder.  When  tight  lacing  has  been  ex- 
treme, an  artificial  fissure  is  formed  in  the  liver,  giving 
rise  to  what  is  termed  the  "lacing  lobe,"  which  carries 
with  it  the  gall  bladder.  Stagnation  of  the  bile  is  well 
known  to  be  one  of  the  most  important  causes  of  the 
formation  of  gall-stones.  A  change  in  the  composition 
of  the  bile,  from  catarrh  resulting  from  congestion  of 
the  mucous  membrane  and  the  thickening  of  the  bile 
due  to  failure  of  the  gall-bladder  to  completely  evacu- 
ate itself,  gives  rise  to  the  formation  of  small  masses 
which  serve  as  nuclei  for  calculi  ;  hence,  anything  which 
obstructs  the  free  outflow  of  bile  through  the  cystic 
duct  must  favor  the  formation  of  gall-stones.  Mar- 
chand is  also  of  the  opinion  that  many  cases  of  cancer 
of  the  liver  should  be  attributed  to  tight  lacing.  It  is 
only  a  few  years  since  a  German  surgeon  was  obliged 
to  open  an  abdomen  to  remove  a  "  lacing  lobe  "  of  the 
liver,  which  had  been  so  completely  separated  from  the 
rest  of  the  organ  as  to  cause  its  death,  rendering  its  re- 
moval necessary. — Modern  MeJiciiu. 

In  1781  Ramdohr  first  successfully  united  the  human 
bowel  by  suture,  after  complete  division. 

'  The  Healing  of  .\rteries  after  Ligature.  Wni.  Wood  &  Co  .  1886 
p.  129. 


A  CLINICAL  .STUDY  OF  CASES  OF  PERSIST- 
ENT ABSENCE  OF  THE  GASTRIC  SECRE- 
TORY  FUNCTION.' 

By  D.  D.  STEWART,  M.D., 

rHILAOELFHIA,    P\. 


LECTURER   ON    MSDICIN 


ItCAL  COLLEGE. 


Gratitude  is  due  to  Leube  for  the  introduction  of 
modern  methods  of  research  that  have  made  a  diagno- 
sis of  atrophy  of  the  gastric  tubules  possible,  and  to 
Tavorski,  whose  method  of  stimulating  the  indolent 
secretory  follicles  in  cases  of  fictitious  atrophy  has  al- 
lowed of  the  certain  diagnosis  of  arrested  secretory 
function,  although  it  does  not  at  once  permit  the  path- 
ological diagnosis,  that  of  atroph)'.  This  last  and  the 
separation  of  curable  cases  of  neurosal  inhibition  from 
those  of  true  atrophy  can  be  made  clinically  with  great 
positiveness  after  a  time.  This  separation  is  arrived  at 
by  the  long  and  steady  duration  of  the  secretory  loss 
and  total  lack  of  response  to  treatment  to  provoke  re- 
turn, in  face  of  complete  restoration  to  function  of  the 
coincident  disturbed  motility — the  actual  cause  of  most 
of  the  symptoms,  direct  and  remote,  of  the  affection. 
The  separation  from  latent  gastric  carcinoma,  especially 
from  the  infiltrating  form,  is  made  by  the  absence  of 
cachexia,  of  wasting,  by  the  duration  of  the  case,  and 
if  atony  prevail,  as  is  common,  by  the  presence  of 
marked  and  persistent  lactic-acid  production.  In  gas- 
tric carcinoma,  save  in  its  terminal  stage,  as  also  in 
chronic  gastritis,  although  free  HCl  is  absent,  and  the 
gastric  secretion  after  a  trial-meal  shows  no  digestive 
activity,  a  fair  amount  of  pepsin  and  rennin  may  be 
readily  extracted  from  the  tubules  by  Javorski's  meth- 
od, unlike  what  is  the  case  in  primary  atrophy  of  the 
tubules.  These  ferments  have  existed  in  the  formative 
or  potential  stage  as  proenzymes,  and  needed  but  the 
stimulating  influence  of  HCl,  under  certain  favorable 
conditions,  for  their  conversion  into  active  digestants 
easily  recognizable.  In  these  cases  of  carcinoma,  and 
in  cases  of  chronic  gastritis  where  there  is  doubt  as  to 
diagnosis,  it  is  shown  that  the  amount  of  acidity,  the 
presence  of  indications  of  bound  HCl,  and  of  certain 
fermentative  changes  in  the  filtrate,  greatly  assist  in 
diagnosis  from  atrophy,  as  do  also  the  appearance  in 
the  wash-water  of  shreds  of  mucous  membrane  and  al- 
ways of  epithelial  cells  ;  these,  and  in  cancer  sometimes 
cell-nests  or  small  pieces  of  the  growth,  assist  in  the 
exclusion  of  atrophy  of  the  gastric  tubules,  especially 
as  a  primary  affection.  The  acidity  of  the  removed 
contents  in  cases  of  primary  arrest  of  gastric  secretion 
is  always  very  low,  and  consists,  save  in  exceptional 
instances,  only  of  that  of  the  food  eaten,  as  I  have 
shown  by  experiment. 

The  cases  here  described  are  of  especial  interest, 
occurring  as  they  do  as  an  idiopathic  affection,  unlike 
many  cases  described  by  Reichmann,  Javorski,  and 
many  others,  in  which  there  was  often  antecedent  his- 
tory of  chronic  gastritis  or  the  presence  of  carcinoma. 

I  have  followed  these  cases  for  several  years  ;  two 
for  nearly  three  years  ;  the  other  for  over  four  years. 
One,  the  most  instructive,  first  came  under  observation 
with  symptoms  of  chronic  arthritis,  due  to  the  deposit 
of  urates  in  the  joints,  as  was  shown  by  the  presence 
of  certain  symptoms  and  a  careful  study  of  the  urine 
over  a  long  period.  She  was  an  invalid — chair-ridden. 
Gastric  symptoms  were  practically  absent.  Symptoms 
of  renal  fibrosis  were  evident,  and  were  regarded  as  in 
the  early  stage.  Marked  atony  of  the  stomach  existed, 
and,  as  in  all  the  cases  I  describe,  total  and  continuous 
absence  of  secretion  of  gastric  juice — of  HCl,  of  pep- 
sin, and  of  the  milk-curdling  ferment. 

The  second  case  presented  herself  for  treatment  with 
symptoms  of  grave  anaemia,  which  had  recurred  in  at- 


'  Abstract  of  a  p.iper  \ 
adelphia,  April,  1S95. 


;ad  before  the  College  of  Physicians  of  Phil- 


August  lo,  1895] 


MEDICAL   RECORD. 


193 


tacks  of  months  in  duration  for  several  years.  With 
these  symptoms  were  those  indicative  of  the  condition 
described  by  our  President  as  cardiac  asthenia.  Gas- 
tric symptoms  were  in  the  background.  Neither  of 
these  cases  showed  the  slightest  indication  of  a  neuro- 
sis. One  is  in  middle  life  ;  the  second  is  thirty-five 
years  of  age.  The  third  case,  also  a  woman,  thirty- 
three  years  of  age,  is  a  typical  neurotic.  In  this  case 
more  doubt  has  all  along  existed  as  to  the  condition 
underlying  the  absent  secretory  function.  I  feel  that 
I  may  now  say  concerning  it  that,  although  its  origin 
may  be  regarded  as  neurosal,  its  long  and  steady  con- 
tinuance over  an  obser\-ed  period  of  four  years  is  very 
suggestive  of  atrophy  of  the  tubules. 

In  the  first  two  of  the  cases  a  complete  removal  of 
all  symptoms  occurred  under  treatment  directed  to  re- 
establishing secretion,  in  all  probability  through  it 
equally  influencing  the  impaired  motility.  The  treat- 
ment consisted  chiefly  in  the  use  of  the  hot  stomach 
douche,  intra-gastric  electricity,  and  of  large  doses  of 
HCl.  In  the  other  cases  the  douches  and  intra-gastric 
electricity  could  not  be  employed.  In  the  second  the 
free  use  of  HCl  and  intestinal  disinfectants  seemed 
mainly  the  cause  of  the  improvement.  Both  of  these 
two  cases  have  been  in  perfect  health  for  over  a  year, 
have  gained  largely  in  weight  (both  weigh  more  now 
than  ever  before),  and  eat  and  digest  without  discom- 
fort, like  ordinary  normal  individuals,  although  no  se- 
cretion of  gastric  juice  ever  occurs.  Digestion,  of 
course,  goes  on  in  the  bowels  by  the  aid  of  the  pancre- 
atic secretion.  It  is  here  pointed  out  that  the  conduct 
of  these  and  similar  cases  clearly  establishes  the  truth  of 
Bernard's  belief  that  the  stomach,  even  under  the  most 
favorable  conditions,  can  be  regarded  as  little  more 
than  a  reservoir  for  food  and  as  a  conduit  to  the  duo- 
denum, where  perfect  digestion  occurs.  They  certainly 
prove  that  the  secretory  function  is  secondary  in  im- 
portance to  that  of  motility.  Recent  experiments  of 
Kuhne  and  Chittenden  have  shown  that  even  under 
the  most  favorable  circumstances  true  peptonization 
occurs  only  to  a  limited  extent  in  the  stomach,  and 
that  gastric  digestion  is  but  a  preliminary  stage  to  more 
perfect  intestinal  proteolysis.  But  on  account  of  the 
almost  certain  likelihood  in  the  great  majority  of  cases 
of  absent  gastric  secretion,  as  in  other  affections  of  the 
stomach  characterized  by  mere  diminution  of  the  same, 
of  coincident  involvement  of  motility,  thus  originating 
atony  and  its  train  of  ills,  loss  of  secretory  function 
must  be  viewed  with  great  gravity.  Hence  Meyer 
believes  that  these  cases,  whether  secondary  or  idio- 
pathic, rarely  last  more  than  a  few  months  to  two  or 
three  years. 

The  third  of  my  cases  is  a  chlorotic  woman,  in  whom 
a  decided  neurotic  element  has  rendered  her  less  sus- 
ceptible to  general  improvement.  She  had  had  epi- 
leptoid  seizures  for  several  years  before  she  came  un- 
der observation.  She  would  submit  to  the  tube  only 
for  diagnostic  purposes,  and  even  then  with  reluctance, 
its  employment  often  causing  an  hysteroidal  seizure. 
The  douche  and  the  use  of  intra-gastric  electricity  could 
not  be  employed  for  these  reasons.  Her  nutrition  is 
now  always  fair,  and  at  times  very  good.  Gastric  symp- 
toms of  the  sort  described  by  Boas  and  others  did  not 
occur  at  all  in  Case  I.  and  were  slight  in  Case  II. 
Case  III.  had  the  characteristic  vomiting  and  pain  after 
meals.  These  were  removed  by  the  free  employment 
of  HCl,  and  do  not  recur  on  its  continuance.  She  has 
voluntarily  continued  it  quite  steadily  in  large  doses  for 
four  years. 

In  none  of  the  three  is  there  gastrectasia,  a  symptom 
regarded  as  common  by  Meyer  and  others. 

In  the  first  and  second  cases  the  origin  of  the  secre- 
tory loss  is  most  obscure  ;  in  the  third  a  neurotic  ele- 
ment is  so  prominent  that  it  may  be  regarded  as  the 
source  of  the  disorder.  In  the  others  none  exists.  In 
origin  all  of  these  cases  may  have  been  those  of  neu- 
rosal   suppression    of    secretion  —  inhibition    arising 


through  some  long-continued  reflex  irritation  not  no^\' 
evident.     Whatever  the  primary  determining  cause  may 
have  been,  the  long  duration  of  the  affection,  with  per- 
fect restoration  of  motility,  in  the  face,  in  two,  of  com- 
plete, and  thus  far  permanent   restoration  to  health, 
renders  the  continued  absence  of  gastric  secretion  of 
great  significance  and  grave  omen.     For  because  of  the 
functions  of  secretion  and  motility  being,  as  they  are, 
so  intimately  connected   by   innervation    through  the 
vagus  and  sympathetic,  it  is  reasonable  to  suppose  that 
complete  restoration  of  impaired  nerve  functioning  in 
one,  as  in  restored  motility,  would,  after  so  long  a  time 
in  which  restoration  has  continued,  lead  to  at  least  par- 
tial return  of  secretory  power.     This  should  especially 
be  were  the  trouble  merely  functional,  when  treatment 
as  successful  in  restoring  secretion  in  other  gastric  af- 
fections has  here  been  long  tried  resultlessly.     These 
cases  in  origin  may  have  been,  through  causes  not  ap- 
parent in  at  least  two,  those  of  neurosal  suppression  of 
secretion,  and  have  arisen  through  long-continued  re- 
flected disturbance   in  gastric  innervation,    impairing 
jointly  motility  and  secretion.     I  regard  in  this  particu- 
lar a  suggestion  of  Stockton's  as  especially  worthy  of 
attention.     He  asks  if  we  may  not  have  to  do  here  with 
an  affection  which  at  the  start  is  functional  merely,  but 
the  long-continued  inhibition  of  glands  is  succeeded  by 
atrophy.     This  had  been  my  own  thought,  although  I 
am  unable  to  accept  his  evident  preference  for  e3'e-strain 
as  the  source  of  reflected  irritation.     In  every  case  ob- 
served by  him,  curiously,  a  ver)'  similar  condition  of 
high  refractive  error  existed  in  all — unsymmetrical  as- 
tigmatism of   high    degree,    varying   from   i   to    5    D. 
There  also  was  noted,  in  all,  irregular  ametropia,  myopia 
in  one  eye,  hyperopia  in  the  other,  with  a  lack  of  cor- 
respondence in  the  axes  of  astigmatism.     It  is  interest- 
ing  that  the  one  case  (the  neurotic)   in  which  such 
errors  would  be  more  operative  has  practically  no  eye- 
strain.    Apart  from  a  low  hyperopia  the  eyes  were  quite 
normal.     In  Case  I.  some  refractive  error  existed,  but 
not  of  the  pronounced  character  noted  in  Stockton's 
cases.     She  is  a  woman  of  strong  will  and  sound  ner- 
vous organization,   one  little  likely  to  be  affected  by 
such  a  reflected  condition  as  is  present.     In  Case  II. 
less  refractive  error  was  found    than  in  Case  I. — too 
slight  error,  according  to  Dr.  Gould,  to  cause  any  serious 
reflex.     Inquiry  of  Dr.  Einhorn  as  to  the  condition  of 
refraction  in  his  four  cases  elicited  the  response  that  no 
refractive  trouble  was  found  to  exist  in  two  of  the  four 
A  third  is  crossed-eye.     No  examination  had  yet  been 
made  in  the  fourth  at  the  date  of  Dr.  Einhorn's  letter. 
As  concerns  therapy,  it  is  practically  useless,  after 
long  trial  to  hope  to  restore  secretory  activity,  although, 
since  the  same  remedies  are  applicable  to  maintain  the 
motor  function,  they  may  be  resorted  to  for  periods  of 
a  few  weeks  or  months  from  time  to  time.     The  reme- 
dies most  useful  are  those  influencing  motility,  obviat- 
ing stagnation,  and  maintaining  good  motor  power  when 
re-established.     The  chief  of  these  remedies,  incom- 
parably superior  to  all  others,  is  the  intra-gastric  use  of 
electricity,  contrasted  with  which  drugs,  such  as  strych- 
nine, are  as  nothing.     As  the  use  of  HCl,  which  favors 
secretorj'  return,  seems  also  to  influence  the  impaired 
motility,  it  may  also  be  employed.     HCl  is  more  espe- 
cially indicated  when  the  case  first  comes  under  obser- 
vation and  doubt  exists  as  to  the  pathological  condition 
underlying  the  absent  secretory  function.     It  should 
then  be  used  for  months  at  a  time.     It  must  be  em- 
ployed in  rather  large  doses,  such  as  from  4  to  8  c.c. 
( 3  j.  to  3  ij.)  of  the  dilute  acid,  and  for  best  effect  as  a 
secretory  stimulant  should  be  given  before  meals.     I 
give  it  in  this  amount  in  decinormal  solution  (0.364  per 
cent,  absolute  HCl),  preferably  introducing  it  through 
a  soft  stomach-tube,  which   the  patient  enters  to  the 
first  part  of  the  oesophagus.    Even  in  one  unaccustomed 
to  the  tube  and  prejudiced  to  its  employment,  so  littL- 
discomfort  after  a  trial  or  two  is  experienced  by  its 
introduction  only  thus  far,  especially  if  cocaine  is  first 


/" 


194 


MEDICAL   RECORD. 


[August  lo,  1895 


used  for  a  few  times,  that  it  is  in  nearly  all  cases  will- 
ingly resorted  to.  Thus  is  avoided  the  disagreeable 
taste  and  the  effects  upon  the  teeth  of  the  large  volume 
of  acid  necessary  in  these  cases. 

Artificial  digestants  are  rarely  required  in  these  cases. 
AVhat  is  essential  is  attention  to  the  motor  function.  If 
for  any  reason  digestion  is  regarded  as  imperfect  in  the 
bowel,  through  coincident  failure  of  pancreative  secre- 
tion, certain  digestive  agents  are  of  use  for  a  time. 
Should  failure  of  a  good  digestive  secretion  on  the  part  of 
the  pancreas  be  permanent,  nothing  then  can,  of  course, 
hope  to  avail  for  more  than  a  short  time.  The  admin- 
istration of  HCl  or  of  HCl  and  pepsin  as  digestants, 
for  obvious  reasons,  fully  considered,  are  utterly  unphys- 
iological.  HCl  alone  can,  of  course,  be  of  no  utility, 
unlike  the  case  in  gastric  catarrh  or  in  simple  nervous 
depression  of  secretion.  Secretion  of  pepsin  cannot  be 
hoped  to  be  stimulated  by  it  from  glands  long  the  seat 
of  atrophy.  With  pepsin  it  is  also  inutile,  as  sufficient 
cannot  conveniently  be  constantly  taken  to  completely 
saturate  the  albuminoids  and  salts  of  the  food  after  a 
moderately  large  meal.  To  support  this  may  be  cited 
the  interesting  experiments  of  Blum  (recently  quoted 
by  Chittenden  in  his  Cartwright  lectures),  who  shows 
that  with  a  daily  consumption  of  100  grammes  of  pro- 
teid,  a  fair  average,  there  would  be  required  no  less  that 
4^  litres  of  0.2  per  cent,  of  HCl  daily,  and  even  this 
would  not  suffice  to  give  free  acid.  The  only  physio- 
logical digestant  in  these  cases  is  a  pancreatic  prepara- 
tion, or  one  of  the  vegetable  digestants,  papain  or  pine- 
apple juice. 

THE     CURATIVE     VALUE    OF     THE    ANTI- 
TOXIN.' 

By  I.  P.  KLINGENSMITH,  M.D.,  F.S.Sc, 


SURGEON  PENNSYLVANIA  RAILROAD;  EX-PRESIDENT  WESTMORELAND  COUNTY 
(pa.)  medical  society;  member  and  ex-president  INDIANA  COL"NTY 
(pa.)  MEDICAL  SOCIETY  ;  MEMBER  MEDICAL  SOCIETY  OF  THE  STATE  OF 
PENNSYLVANIA;  OF  THE  AMERICAN  MEDICAL  ASSOCIATION;  OF  THE  BRITISH 
MEDICAL  ASSOCIATION  ;  OF  THE  NATIONAL  ASSOCIATION  OP  RAILWAY  SUR- 
GEONS ;  OF  THE  PITTSBURG  OBSTETRICAL  SOCIETY  ;  FELLOW  OF  THE  .MEDICO- 
LEGAL SOCIETY  OF  NEW  YORK;  CORRESPONDING  .MEMBER  NEW  YORK  ACAD- 
EMY OF  ANTHROPOLOGY  ;  FELLOW  OF  THE  SOCIETY  OF  SCIENCE,  LETTERS, 
AND   ART  OF   LONDON,    ETC. 

During  the  past  century  innumerable  agents  have 
been  emploj'ed  in  the  treatment  of  infectious  diseases 
with  varying  degrees  of  success.  When  the  micro- 
organismal  nature  of  the  infectious  diseases  was  estab- 
lished the  antiseptics  were  brought  into  use.  Their 
action  outside  the  body,  however,  is  no  criterion  of 
their  action  when  introduced  into  the  body,  as  experi- 
ence has  clearly  shown  that  it  is  useless  to  aim  at  dis- 
infection within  the  body.  Through  bacteriological 
research  the  situation  has  changed,  and  we  have  every 
reason  to  believe  that  for  the  various  specific  diseases 
specific  remedies  may  be  found.  Science  has  at  last 
triumphed  and  given  to  the  world  the  long  sought  for 
specific  for  diphtheria  in  the  antitoxin  serum.  Beh- 
ring,  of  Berlin,  began  his  experiments  with  this  new 
therapeutic  agent  in  1S90,  and  in  August,  1S91,  read  a 
paper  at  London  before  the  Seventh  International 
Congress  of  Hygiene  and  Demography,  in  which  he  de- 
tailed his  methods  and  results.  Roux,  of  Paris,  after 
pursuing  a  series  of  experiments  in  the  treatment  of 
diphtheria  by  the  antitoxin  serum,  since  1891,  and 
thereby  having  obtained  a  sufficient  number  of  facts  to 
enable  him  to  judge  the  method  properly,  read  a  "  Con- 
tribution to  the  Study  of  Serum  Therapy  in  Diphtheria  " 
before  the  Eighth  International  Congress  of  Hygiene 
and  Demography,  held  at  Buda-Pesth  in  September, 
1894.  In  this  paper  M.  Roux  sets  forth  that  his  re- 
sults fully  confirm  in  all  essential  points  those  that  have 
been  published  by  Behringand  his  collaborators. 
The  Technique, — As  this  method  of  treating  diph- 

'  Read    before    the  Indiana  County  (Pa.)  Medical   Society] May 
I J.  1895- 


theria  is  about  to  become  general,  I  will  briefly  refer  to 
the  technique  of  the  operation.  Of  primar)' importance 
is  the  selection  of  a  reliable  preparation  of  the  serum. 
Having  had  personal  experience  in  the  administration 
of  both  American  and  German  solutions,  the  results 
obtained  justify  me  in  giving  the  preference  to  the 
former.  The  home  product  has  in  my  hands  proven 
itself  to  be  of  greater  efficiency,  and  can  be  obtained  in 
a  much  fresher  state.  Antitoxin  serum  being  adminis- 
tered hypodermically,  it  is  therefore  necessary  to  use  a 
suitable  syringe.  As  the  required  dose  should  be  ad- 
ministered at  one  injection,  the  ordinary  hypodermic 
syringe,  on  account  of  its  limited  capacity  and  the  small 
calibre  of  its  needles,  will  not  answer  the  purpose.  My 
first  experience  was  with  a  Pasteur  syringe.  This  I 
found  unsatisfactory  on  account  of  its  having  leather 
fittings,  which  make  it  almost  impossible  to  sterilize  and 
render  aseptic,  and  frequently  dry  out  in  such  a  man- 
ner as  to  make  the  syringe  useless.  The  syringe  now 
used  by  me  was  devised  by  Dr.  Louis  Fischer,  of  the 
New  York  Post-Graduate  Medical  School,  and  is  made 
by  George  Ermold,  No.  312  East  22d  Street,  New 
York.  It  consists  of  a  glass  barrel  like  any  ordinary 
aspirating  syringe,  with  asbestos  fittings,  and  has  a  ca- 
pacity of  15  c.c.  The  calibre  of  the  needles  is  large, 
owing  to  the  thick  consistency  of  the  serum.  This 
syringe  is  entirely  aseptic  and  can  be  sterilized  with- 
out being  taken  apart,  and  its  asbestos  packing  can  be 
properly  regulated  by  screwing  the  ring  handle  to 
tighten  or  loosen  the  packing.  The  technique  of  in- 
jection is  simple.  It  should  be  borne  in  mind  that  the 
serum  being  aseptic,  the  entire  operation  must  be  con- 
ducted under  the  strictest  antiseptic  precautions,  just 
the  same  as  though  we  were  performing  any  important 
surgical  operation.  I  now  properly  sterilize  the  syringe 
by  boiling  and  using  o.i  per  cent,  solution  of  lysol. 
On  account  of  it  being  necessary  to  inject  so  large  an 
amount  of  the  serum,  the  locality  selected  should  be 
one  over  which  the  skin  is  quite  free.  The  region  pre- 
ferred by  me  being  in  the  intra-scapular  space.  The 
serum  should  be  injected  slowly,  the  puncture  sealed 
with  cotton  and  five  per  cent,  iodoforniized  collodion. 
The  injections  are  almost  painless  and  massage  is  un- 
necessary, as  the  swelling  caused  by  the  fluid  disap- 
pears quickly.  The  following  six  cases  of  diphtheria 
came  under  my  observation,  during  the  past  winter 
and  spring.  These  were  treated  by  antitoxin,  and  the 
results  were  so  uniformly  favorable  that  I  feel  it  my 
duty  to  report  them,  thus  adding  my  small  tribute  to 
one  of  the  greatest  discoveries  of  the  nineteenth  cen- 
tury. 

Case  I. — Child,  female,  aged  5  ;  occurred  in  the  prac- 
tice of  Dr.  A.  T.  Rutledge,  of  Blairsville,  and  was  seen 
by  me  in  consultation,  January  26,  1895.  For  ^^^  ^P" 
pended  notes  on  the  cases  given  below  I  hereby  ac- 
knowledge my  indebtedness  to  the  attending  physician. 
First  visit,  January  24,  1895,  when  I  found  a  well-de- 
fined case  of  diphtheria  on  fifth  day  of  disease  ;  tem- 
perature, 102°  F.;  pulse,  120  ;  the  tonsils  and  uvula 
being  covered  with  diphtheritic  membrane,  submaxil- 
lary glands  enlarged  and  tender,  characteristic  odor 
well  marked,  child  sulTering  from  prostration  and  very 
dull  and  listless.  At  once  informed  the  family  that 
their  child  was  suffering  from  diphtheria.  Prescribed 
the  usual  remedies  until  2  p.m.  January  26th,  when  the 
case  was  seen  in  consultation  by  Dr.  I.  P.  Klingen- 
smith.  As  at  that  time  the  general  septic  condition  of 
the  patient  was  so  manifest,  we  looked  upon  the  case 
not  only  as  hopeless  for  recovery,  but  questioned  the 
propriety  of  administering  the  antitoxin,  not  desiring 
to  bring  the  remedy  into  disrepute  in  the  event  of  fail- 
ure. But  notwithstanding  this  unfavorable  outlook,  we 
administered  15  c.c.  Gibier's  antitoxin.  This  was  fol- 
lowed,at  6  A.M.  on  the  27th,  with  10  c.c;  February  sth, 
10  CO.;  February  Sth,  10  c.c;  and  on  February  12th, 
5  c.c.  On  making  my  visit  at  6  o'clock  on  the  morn- 
ing of  the  27th,  sixteen  hours  after  the  administration 


August   lo,  1895] 


MEDICAL    RECORD. 


195 


of  the  first  dose  of  antitoxin,  I  found  marked  improve- 
ment of  the  patient,  general  and  local  symptoms  were 
more  favorable,  temperature  lower  and  pulse  stront^er. 
The  child  passed  through  a  gradual  and  uneventful 
convalescence  to  a  complete  recovery. 

Case    II. — lola  T ,    aged   two    years  and  nine 

months.  Saw  this  case  March  8,  1895.  This  patient 
presented  all  the  clinical  manifestations  of  the  malignant 
type  of  diphtheria.  Pulse,  140  ;  temperature,  103°  F. 
My  supply  of  antitoxin  at  the  time  being  limited  to  3.5 
c.c.  Gibier's  antitoxin,  at  11  p.m.  administered  the  same. 

March  9th,  9  a.m.:  Pulse,  130;  temperature,  102,5° 
F.  No  improvement,  except  that  the  small  dose  of 
antitoxin  administered  the  previous  night  stayed  the 
further  progress  of  the  disease. 

March  9th,  7  p.m.:  Pulse,  135  ;  temperature,  102.5° 
F.  Administered  4  ■  c.c.  Behring's  serum  \o.  3. 
March  loth,  10  a.m.:  Pulse,  130  ;  temperature,  101°  F. 
Administered  4  c.c.  Behring's  serum  No.  3.  March 
loth,  5  P.M.:  Pulse,  135  ;  temperature,  100.5°  ^-  March 
nth,  10  a.m.:  Pulse,  100;  temperature,  99°  F.  After 
the  administration  of  the  second  dose  the  child  made 
a  rapid  recovery. 

Case     III. — Ida    M ,    aged    twenty-one.     Was 

called  to  see  this  patient  at  10  p.m.,  March  9th  :  Pulse, 
140;  temperature,  103°  F.;  general  constitutional  dis- 
turbance. Diphtheria  suspected  in  consequence  of 
having  been  exposed  in  a  case  which  resulted  fatallv. 

March  loth,  12  M.:  Disease  well  developed,  tonsils 
covered  with  e.xudation,  submaxillary  enlargement,  and 
characteristic  odor  of  diphtheria.  March  loth,  3.30 
P.M.:  Pulse,  140  ;  temperature,  103°  F.;  15  c.c.  Gib- 
ier's antitoxin.  March  loth,  9  p.m.:  Pulse,  140;  tem- 
perature, 103.5°  F.  March  nth,  9  a.m.  :  Pulse,  no; 
temperature,  101.8°  F.;  10  c.c.  Gibier's  antitoxin. 
March  nth,  4  p.m.:  Pulse,  100;  temperature,  102°  F. 
March  12th,  9  a.m.:  Pulse,  96  ;  temperature,  99°  F. 
March  12th,  4.45  p.m.:  Pulse,  98  ;  temperature,  99°  F. 
March  13th,  10.15  a.m.:  Pulse  84  ;  temperature  99°  F. 
March  13th,  4.10  p.m.:  Pulse,  90  ;  temperature  98°  F. 
March  14th,  9.50  a.m.:  Pulse,  98  ;  temperature,  98.5° 
F.  March  14th,  5.20  p.m.:  Pulse,  90  ;  temperature, 
98.5°  F. 

Two  days  later  found  no  further  visits  indicated,  as 
patient  was  practically  convalescent.  On  March  loth 
administered  immunizing  dose,  3  c.c.  Gibier's  antitoxin, 
to  each  of  five  other  members  of  that  family,  none  of 
whom  contracted  the  disease. 

Case  IV. — Female,  aged  twenty-seven.  This  case 
first  came  under  my  observation  March  8th,  and  from 
the  history  given,  elicited  the  information  that  she  had 
been  sick  since  February  15th,  when  an  attack  of 
tonsillitis  resulting  in  suppuration  was  followed  by 
laryngitis,  which  by  February  26th  had  rendered  her 
unable  to  speak  beyond  a  whisper. 

When  I  first  saw  this  case  on  the  evening  of  March  Sth, 
she  was  suffering  from  subacute  laryngitis,  and  unable 
to  speak  except  in  aspirates,  very  rapid  pulse,  and 
patient  suffering  from  prostration  to  an  extreme  degree. 
Upon  inspection,  found  redness  of  the  fauces,  with 
■slight  submaxillary  tenderness. 

March  9th  :  Small  patch  of  exudation  on  right 
tonsil,  submaxillary  glands  enlarged  and  more  tender. 
March  loth,  4.45  p.m.:  Pulse,  130  ;  temperature,  99.5° 
F.  Exudation  on  both  tonsils,  submaxillary  glands 
more  tender. 

March  loth,  4.45  p.m.:  Pulse,  130  ;  temperature,  99.5° 
F.  Exudation  on  both  tonsils,  submaxillary  glands 
more  tender  and  much  enlarged.  Administered  15  c.c. 
Gibier's  antitoxin.  March  nth,  10  a.m.:  Pulse,  no; 
temperature,  ioo°  F.  Administered  4  c.c.  Behring's 
serum  No.  2.  March  nth,  5  p.m.;  Pulse,  120;  tem- 
perature, 101.5°  F'  March  12th,  10  a.m.:  Pulse,  120  ; 
temperature,  102°  F.  Administered  8  c.c.  Behring's 
serum  No.  2;  March  12th,  5  p.m.:  Pulse,  no;  tem- 
perature, ioi°  F.  March  13th,  10.30  a.m.:  Pulse,  no; 
temperature,  99.5°  F.     March  13th,  4.30  p.m.:  Pulse, 


no;  temperature,  99.5°  F.  Some  diphtheritic  exuda- 
tion still  existing,  I  administered  a  final  dose  of  r5  c.c. 
Gibier's  antitoxin.  From  this  on  the  convalescence 
was  uneventful,  resulting  in  complete  recovery. 

Case   V. — Jennie    VV' ,    aged   nineteen.      March 

i2th,  4.30  P.M.:  On  third  day  of  the  disease,  pulse,  120; 
temperature,  104°  F.;  both  tonsils  completely  covered 
with  heavy  diphtheritic  exudation,  very  extensive  sub- 
maxillary enlargement,  and,  in  fact,  presenting  all  the 
clinical  manifestations  of  a  case  of  diphtheria  of  a  very 
grave  type.  In  the  presence  of  Dr.  L.  S.  Clagett,  of 
Blairsville,  administered  15  c.c.  Gibier's  antitoxin. 
March  13th,  11. 15  a.m:  Pulse,  90;  temperature,  99.5° 
F.  Diminution  of  submaxillary  enlargement,  no  further 
extension  of  exudate,  and  improvement  of  general  con- 
dition of  patient.  Administered  10  c.c.  Gibier's  anti- 
toxin. March  14th,  9.30  A.M.:  Pulse,  78;  temperature, 
98°  F.  March  15th,  9.20  A.M.:  Pulse,  78;  temperature, 
98°  F.  March  i6th,  9.40  a.m.:  Pulse,  72;  tempera- 
ture, 98.5°  F.  Throat  free  from  membrane,  very  rapid 
convalescence  to  complete  recovery. 

Case   VI. — Earl   R ,   aged  six.     March  i8th,  3 

p.m.:  Saw  this  case  in  consultation  with  Dr.  E.  W. 
Blackburn,  of  Latrobe,  Pa.  Both  tonsils  were  covered 
with  a  thick  exudate  with  an  offensive  odor.  Disease 
had  progressed  for  three  days.  Pulse,  100;  tempera- 
ture, 99°  F.  Administered  15  c.c.  Gibier's  antitoxin. 
6  p.m.:  Pulse,  loS;  temperature,  100.5°  F.  March  19th, 
8.30  A.M.:  Pulse,  90;  temperature,  99.5°  F.  6.30  p..m.: 
Pulse,  100;  temperature,  100°  F.  General  improve- 
ment. Administered  10  c.c.  Gibier's  antitoxin.  March 
20th,  10  A.M.:  Pulse,  84;  temperature,  99°  F.  6  p..m.: 
Pulse,  96;  temperature,  99.5°  F.  March  21st,  9  a.m.: 
Pulse,  88;  temperature,  99°  F.  6  p.m.:  Pulse,  84;  tem- 
perature, 98°  F. 

Throat  entirely  free  from  membrane,  pulse  and 
temperature  remaining  normal,  child  made  rapid  re- 
covery. For  the  above  notes  my  thanks  are  due  to 
the  attending  physician. 

In  Cases  I.  and  II.  no  local  treatment  was  carried 
out ;  in  the  other  cases  Seder's  solution,  or  a  solution 
of  peroxide  of  hydrogen,  was  used  to  assist  in  removing 
the  membranes  as  they  became  detached.  Stimulants 
should  be  used  freely  in  all  cases.  In  a  family  in  which 
a  case  of  diphtheria  occurs,  the  other  members  should 
be  at  once  immunized.  It  is  needless  to  say  that  these 
cases  are  not  selected  mainly  for  publication,  but  are 
such  as  presented  themselves  consecutively  in  practice. 
It  should  be  here  remarked  that  the  infection  propaga- 
ting the  disease  in  Cases  II.,  III.,  IV.,  and  V.,  eman- 
ated from  the  same  source,  viz.,  from  the  case  of  a 
child  who  died  in  the  family  where  Cases  II.  and  III. 
followed.  From  my  experience  in  the  management  of 
the  above  six  cases,  I  feel  perfectly  free  to  say  that 
antitoxin  is  a  safe  remedy,  and  therefore  in  any  case 
presenting  the  clinical  manifestations  of  the  disease  I 
would  be  willing  to  err  by  giving  too  much  rather  than 
too  little  of  the  serum.  In  the  months  of  September, 
October,  and  November,  1891,  during  the  prevalence 
of  the  disease  at  Blairsville  at  that  time,  I  treated  thir- 
teen cases,  with  eight  deaths  and  five  recoveries,  mak- 
ing a  mortality  of  about  sixty-two  per  cent.  These 
cases  were  treated  by  the  most  approved  methods  then 
known  to  the  medical  profession. 

These  eight  cases,  which  in  1891  resulted  fatally, 
presented  no  greater  degree  of  malignancy  than  Cases 
I.,  II.,  III.,  and  v.,  that  were  recently  treated  with 
antitoxin  and  progressed  to  rapid  and  complete  recov- 
ery. At  the  Congress  of  Internal  Medicine  recently 
held  at  Munich,  Huebner  communicated  new  statistics 
regarding  the  effects  of  the  antitoxin  treatment  of 
diphtheria.  In  a  total  of  three  thousand  cases  col- 
lected from  different  parts  of  the  world,  the  mortality 
was  twenty  per  cent.  Baginsky  reported  that  at  the 
Kaiserin  Hospital  the  mortality,  which  used  to  range 
about  forty  per  cent.,  has  been  reduced  to  thirteen  per 
cent.     Ranke,    of   Munich,  found   that   under   serum 


/ 


196 


MEDICAL    RECORD. 


[August   10,  1895 


therapy  the  mortality-rate  fell  from  forty-two  per  cent. 
to  18.6  per  cent.  Statistics  of  the  Paris  hospitals  show 
that  the  death-rate  of  diphtheria  has  decreased  from 
sixty  per  cent,  to  twelve  per  cent.  In  the  face  of  this 
record  of  the  wonderful  decrease  in  the  mortalit)'-rate 
of  this  dreaded  disease,  it  seems  to  require  no  pro- 
phetic power  to  foresee  that  we  are  on  the  threshold 
of  discoveries  in  medicine  such  as  will  eclipse  all  that 
have  preceded  them. 


gr00tess  of  '^sdxc^l  Mcicncc. 

A  Modification  of  the  Invagination  Method  of  Operat- 
ing for  the  Eadical  Ctire  of  Hernia. — At  a  recent  meet- 
ing of  the  Philadelphia  Academy  of  Surgery,  Dr.  John 
H.  Packard  detailed  a  method  of  operating  for  the  radi- 
cal cure  of  hernia,  which  consists  essentially  in  the  in- 
vagination of  the  isolated  sac  i^Medical  A'ews).  The 
hernia  is  exposed  by  a  curved  incision  describing  a 
semicircular  flap  of  ample  size.  In  this  manner  the 
cicatrix  is  carried  away  from  the  seat  of  trouble,  which 
is  afterward  covered  in  by  sound  skin.  The  sac  is  laid 
bare  and  isolated  from  the  external  ring  down  to  its 
tip.  Sometimes  it  is  better  to  empty  it  during  this 
process,  which  may  often  be  accomplished  by  tearing 
with  the  fingers.  It  is  well  to  begin  the  isolation  at  the 
ring  and  to  proceed  downward.  In  order  to  secure 
control  of  the  empty  sac  a  silk  thread  is  now  passed 
through  its  wall  at  either  side  ;  the  two  ends  of  each  are 
left  long  and  caught  in  haemostatic  forceps.  With  the 
forefinger  of  the  left  hand  the  tip  of  the  sac  is  inverted 
and  pushed  up  as  far  as  the  internal  ring,  or  as  near  it 
as  possible.  Next,  a  slightly  curved  needle,  with  an 
eye  near  the  point,  and  armed  with  a  thoroughly  ster- 
ilized silk  thread,  is  passed  up  along  the  finger  as  a 
guide,  to  be  pushed  out  at  one  side  of  the  tip  through 
the  tendon  of  the  externar  oblique  muscle.  One  end 
of  the  thread  being  caught,  the  needle  is  withdrawn 
slightly,  and  again  pushed  through  the  tendon  at  the 
other  side  of  the  tip.  The  other  end  of  the  silk  thread 
is  now  detached  from  the  needle,  which  is  wholly  with- 
drawn, and  the  two  ends  left  slack  are  caught  together 
in  a  haemostatic  forceps.  Now,  by  means  of  the  two 
lateral  threads,  and  by  grasping  in  the  fingers,  the  doub- 
led sac  is  drawn  down  carefully,  and  with  a  small  curved 
needle  a  fine  silk  suture  is  passed  through  it  from  side 
to  side,  from  below  upward  as  far  as  possible,  and  then 
from  above  downward,  so  that  its  two  ends,  when  drawn 
tight,  will  crumple  up  the  sac  into  a  solid  mass.  These 
ends  are  tied  and  cut  off  short.  The  lateral  threads 
are  now  removed,  and  the  other  silk  thread  is  drawn  up 
tight,  pulling  the  plug  formed  of  the  sac  into  place  at 
the  internal  ring  ;  its  two  ends  are  tied  on  the  outer  sur- 
face of  the  tendon  of  the  external  oblique  and  cut  off 
short.  The  skin-flap  is  laid  over  in  place  again,  tlie 
wound  closed  by  sutures,  and  the  ordinary  antiseptic 
dressings  applied.  The  patient  is  kept  in  bed  until  the 
wound  is  completely  healed. 

The  Blood  in  Chronic  Cyanosis. — In  studying  the 
blood  of  eight  cases  of  chronic  cyanosis  from  congeni- 
tal heart-disease.  Dr.  Vacquez  found  marked  changes. 
In  all  cases  the  number  of  red  corpuscles  per  cubic 
millimetre  was  increased,  the  increase  being  in  direct 
ratio  to  the  intensity  of  the  cyanosis.  Besides  the  in- 
crease in  the  number  of  the  red  corpuscles,  an  increase 
in  size  was  also  noted,  though  not  until  the  cyanosis 
had  become  quite  marked  ;  in  fact,  in  the  earlier  years 
of  cyanosis  the  increase  in  number  was  only  relative. 
In  individuals  of  from  twelve  to  twenty  years  of  age 
blood-counts  of  from  5,600,000  to  6,300,000  were 
found,  the  diameter  of  the  corpuscles  varying  from  7.9/11 
to  12/x.  Vacquez  does  not  think  that  the  increase  in 
number  of  the  corpuscles  was  parallel  to  the  increase  in 
diameter,  but  thinks  that  both  are  due  to  the  same 


cause.  At  the  same  time  with  the  increase  in  size  and 
number  of  the  corpuscles,  there  is  an  increase  in  the 
amount  of  haemoglobin  in  each  individual  corpuscle,  so 
that  the  haimoglobin  does  not  show  its  normal  relation 
to  the  number  of  corpuscles.  The  question  as  to 
whether  the  increase  in  size  of  the  corpuscle  or  the  inr 
crease  in  hemoglobin  is  the  primary  process  cannot 
well  be  answered.  The  process  has  been  explained  on 
the  grounds  that  in  cyanosis  the  supply  of  oxygen  car- 
ried to  the  tissues  is  insufficient,  and  that  the  corpuscu- 
lar new-formation  is  compensatory.  Gibson,  in  The 
Lancet,  reports  a  case  of  a  boy,  aged  eight  years,  whose 
red  blood-corpuscles  were  8,470,000  per  c.c,  and  the 
haemoglobin  one  hundred  and  ten  per  cent.  He  refers 
to  other  instances  in  which  this  increase  in  the  blood- 
corpuscles  has  been  noted,  and  suggests  the  following 
interesting  explanation  :  "  In  venous  stasis  the  corpus- 
cles are  insufficiently  oxygenated  ;  they  cannot  perform 
such  an  active  part  as  oxygen-carriers,  and  they  can- 
not )'ield  too  much  oxygen  to  the  tissues.  It  must 
further  be  remembered  that  in  cyanosis  there  is  less 
metabolism  in  the  tissues,  and  therefore  less  waste  pro- 
duced. In  a  word,  the  functions  of  the  corpuscles  being 
lessened,  the  tear  and  wear  which  they  undergo  are  re- 
duced and  the  duration  of  their  individual  existence  in- 
creased. The  number  of  the  corpuscles  must  in  this  way 
be  proportionately  augmented,  and  this  must  lead  to  the 
numerical  increase  as  well  as  to  the  high  percentage  of 
haemoglobin,  until  a  balance  is  struck  between  the  pro- 
duction and  the  destruction  of  the  blood-corpuscles. — 
The  American  Journal  of  the  Medical  Sciences. 

Nncleated  Red  Corpuscles  in  the  Blood. — Zenoni  says 
that  Bizzozero,  Rieder,  and  others  have  noticed  the 
appearance  of  nucleated  red  corpuscles  in  the  blood 
after  considerable  or  repeated  hemorrhage.  These 
corpuscles  were  usually  noticed  some  days  only  after 
the  occurrence  of  the  hemorrhage,  but  Zenoni,  in  con- 
sequence of  his  experiments,  places  their  appearance 
much  earlier  i^The  British  Medical  Journal^.  His  ex- 
periments were  made  on  dogs,  guinea-pigs,  and  rabbits, 
in  whose  blood  he  had  previously  satisfied  himself  that 
there  were  no  circulating  nucleated  red  blood  corpus- 
cles. He  chose  a  dog  weighing  6.700  kilog.,  and  in 
ten  repeated  operations  withdrew  from  it  a  total  of 
1,830  c.c.  of  its  blood  ;  then,  after  defibrinating  the 
blood,  he  reinjected  it  into  the  circulation,  and  in  an 
hour  and  a  half  after  the  operation  noticed  the  appear- 
ance of  nucleated  red  corpuscles  in  the  circulating 
blood  on  examining  a  specimen  under  the  microscope. 
In  two  other  dogs  similarly  treated  the  appearances  of 
these  corpuscles  in  the  circulating  blood  took  place  five 
hours  and  a  half  and  seven  hours  and  a  half  after  the 
operation.  In  another  dog,  two  rabbits,  and  four  guin- 
ea-pigs, in  whom  a  moderate  amount  of  blood  was  with- 
drawn at  a  single  operation,  the  appearance  of  nucle- 
ated red  corpuscles  occurred  between  eighteen  and 
forty-eight  hours  after  the  operation.  Zenoni  thinks 
that  the  rapid  appearance  of  these  corpuscles  is  due  to 
the  mechanical  effect  produced  by  the  withdrawal  of 
blood,  for  after  repeated  bleedings  they  appear  too 
soon  for  their  reappearance  to  be  due  to  a  haematopo- 
ietic reaction  ;  moreover,  eight  or  nine  days  afterward 
they  are  no  longer  noticed,  exactly  when  the  haemato- 
poietic reaction  is  at  its  maximum.  He  further  thinks 
that  after  loss  of  blood  these  corpuscles  are  mechani- 
cally drawn  into  the  circulation  from  their  normal  site, 
the  bone  marrow  ;  that  a  certain  number  of  them  get 
stopped  in  the  spleen,  proliferate  there,  and  give  to  the 
spleen  that  fcetal  hcematopoietic  function  which  has 
been  ascribed  to  it  by  Bizzozero  as  taking  place  after 
hemorrhages. 


A  Medical  Witness  in  a  Taconia  court,  being  asked 
whether  medicine  w.is  an  art  or  a  science,  replied  with 
a  sigh  that  it  was  neither  one  nor  the  other,  but  as  yet 
merely  an  experiment. 


August  lo,  1895] 


MEDICAL   RECORD. 


197 


Medical   Record: 

A  Weekly  Joiirnal  of  Ahelicine  a?id  Surgery. 


GEORGE    F.   SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth  Street 


New  York,  August  10,  1895. 


THE  C.\USE  AND   TREATMENT   OF    FLATU- 
LENCE. 

In  an  article  in  the  Practitioner  for  July,  1895.  Dr. 
Stephen  McKenzie  gives  a  very  interesting  and  practi- 
cal discussion  on  the  subject  of  the  treatment  of  flatu- 
lence. There  are,  he  says,  probably  few  diseases 
which,  without  being  of  a  serious  nature,  give  rise  to 
such  discomfort  as  flatulence.  The  usual  story  is  that 
soon  after  a  meal,  or,  perhaps,  quite  independent  of 
the  partaking  of  food,  there  is  a  feeling  of  fulness  at 
the  epigastrium.  The  patient  loosens  the  waist-band, 
and  all  constricting  garments  ;  there  is  a  painful  sense 
of  oppression,  a  difficulty  in  breathing,  perhaps  palpi- 
tation of  the  heart,  and,  not  infrequently,  flushing  of 
the  face,  with  cold  hands  and  feet.  An  actual  vertigo 
may  occur,  and,  if  the  patient  is  of  a  ner\-ous  tempera- 
ment, he  or  she  may  become  almost  hysterical,  or,  at 
least,  go  into  a  state  of  profound  nervous  depression 
and  alarm.  After  a  time  the  cardia  rela.xes,  some  gas 
escapes,  and  rapid  relief  occurs. 

Dr.  McKenzie  discusses  the  causes  of  this  flatulence. 
A  certain  amount  of  air,  he  says,  is  swallowed  in  the 
process  of  mastication  and  deglutition  ;  but  he  does 
not  consider  that  this  swallowed  air  ever  produces  any 
of  the  phenomena  associated  with  flatulence.  The 
second  and  the  common  cause  to  which  flatulence  is 
attributed  is  fermentation  occurring  in  the  food  in  the 
stomach.  Dr.  McKenzie  does  not  believe,  however, 
that  the  gas  of  flatulence  is  the  result  of  food  fermenta- 
tion. He  cites  the  experiments  of  Sir  William  Roberts, 
who  shows  that  fermentative  processes  are  too  slow  for 
the  rapid  development  of  flatulence  in  dyspepsia,  and 
shows  further  that  the  gas  which  results  from  fermenta- 
tion can  only  develop  when  food  is  retained  in  the  stom- 
ach for  from  twenty-four  to  forty-eight  hours.  The  use 
of  anti-zymotics,  which  is  so  popular  for  fermentative 
dyspepsia,  and  which  undoubtedly  has  a  beneficial 
effect,  cannot  act  by  stopping  the  fermentation  of  food. 
since,  as  Dr.  McGuire  has  shown,  the  amount  of  creo- 
sote and  other  antiseptics  given  is  quite  insufficient  to 
stop  putrefactive  changes.  The  fermentation  theor)- 
of  flatulent  dyspepsia  must,  therefore,  be  dismissed. 

Sir  William  Roberts  has  shown  that  a  certain  amount 
of  flatulence  may  occur  in  acid  dyspepsia,  through  the 
action  of  an  acid  mucus  upon  an  alkaline  saliva,  swal- 
lowed with  the  food  ;  but  this  is  certainly  a  rare  and 
minor  factor  in  the  production  of  gas.     The  regurgita- 


tion of  carbonic-acid  gas  from  the  duodenum  may  some- 
times occur  and  cause  a  flatulent  distention  of  the 
stomach,  but  this  is  also  a  rare  phenomenon,  and  only 
occurs  when  the  gastric  juice  is  hyper-acid. 

Dr.  McKenzie,  therefore,  after  discussing  all  other 
theories,  and  dismissing  them  as  incomplete,  comes  to 
the  conclusion  that  flatulent  dyspepsia  is  due  to  a  lack 
of  gastric  tonicity.  In  other  words,  the  walls  of  the 
stomach,  being  weak  and  flabby  and  lacking  in  tone, 
suddenly  dilate,  and  the  volume  of  gas,  which  was 
before  somewhat  compressed,  expands  and  fills  out 
the  enlarged  viscus.  Dr.  McKenzie  states  that  the 
gas  does  not  increase  in  quantity  in  the  stomach,  but 
only  in  volume.  These  two  things,  quantity  and  vol- 
ume, which  are  identical  in  the  case  of  solid  bodies, 
are  not  so  with  gases.  The  sudden  development  of 
flatulent  distention  of  the  stomach,  its  also  rather  sud- 
den disappearance,  its  occurrence  in  hysterical  indivi- 
duals, the  prevalence  of  flatulent  dyspepsia  in  persons 
of  a  weak  nervous  condition,  and  the  relief  obtained 
by  treatment  directed  to  nerve  tonicity,  are  all  facts 
that  support  Dr.  McKenzie's  theory.  Associated  with 
this  gastric  atony  and,  perhaps,  dilatation,  there  is 
often  a  slight  catarrhal  condition  of  the  stomach, 
which  lessens  the  power  of  normal  gastric  digestion, 
and  helps,  also,  to  weaken  the  walls  of  the  stomach. 

The  chief  thing  in  attempting  to  treat  flatulent  dys- 
pepsia is  to  use  remedies  which  will  increase  the 
nervous  vigor,  and,  hence,  according  to  Dr.  McKenzie, 
tonics,  especially  nerve  tonics,  are  of  the  greatest  im- 
portance. Nux  vomica  and  strjxhnine  are  placed  at 
the  head  of  the  list.  We  believe,  from  statistics  col- 
lected regarding  the  frequency  of  different  drugs 
prescribed  in  the  British  Isles,  that  this  drug  leads  all 
others,  and  we  have  a  suspicion  that  the  Englishman 
has,  after  all,  about  as  much  nervous  dyspepsia  as  the 
American. 

When  there  is  some  gastritis  associated  with  this 
flatulent  dyspepsia,  and  when  the  tongue  is  coated.  Dr. 
McKenzie  gives  a  prescription  containing  bicarbonate 
of  soda,  strychnine,  spirit  of  chloroform  —  which  is 
another  inevitable  ingredient  of  British  prescriptions — 
all  dissolved  in  a  bitter  infusion  of  calumba  or  gentian. 
He  gives  two  ounces  of  this  bitter  mixture  three  times 
a  day,  between  meals.  The  English  habit  of  giving 
large  draughts  is  one  which  physicians  in  this  country 
have  not  adopted,  and  we  doubt  if  it  is  necessar)'. 

If  there  is  a  good  deal  of  pain  in  the  stomach,  as  well 
as  flatulence,  bismuth  is  added  to  the  mixture,  and  a 
pill  containing  carbolic  acid,  valerianate  of  zinc,  and 
aloine  is  given.  The  compound  asafcetida  pill  and  the 
extract  of  belladonna  are  sometimes  useful. 

In  enteralgia,  when  the  pain  is  located  lower  than 
the  stomach,  Indian  hemp  often  answers  better  than 
any  other  remedy,  given  in  doses  of  one-third  of  a 
grain.  For  the  violent  spasmodic  attacks,  which  these 
sufferers  often  have,  associated  with  distention  of  the 
stomach  and  intestines,  a  mixture  is  given  composed 
of  equal  parts  of  spirit  of  cajuput,  aromatic  spirit  of 
ammonia,  and  spirit  of  chlorofonn  ;  a  teaspoonful  of 
this  in  a  wine-glass  of  water  is  given  every  half  or 
quarter  of  an  hour. 

Dr.  McKenzie  does  not  believe  in  the  use  of  char- 
coal in  flatulence,  nor  dogs  he  place  great  stress  upon 


^ 


MEDICAL   RECORD. 


[August  lo,  1895 


the  value  of  bismuth.  The  gist  of  the  paper  is,  he 
says,  to  urge  the  importance  of  tonics  and  anti- 
spasmodics, as  the  rational  and  effective  treatment  of 
flatulence  by  improving  the  muscular  tone  of  the  stom- 
ach. 


EXPERT    TESTIMONY  AS  VIEWED    IN    ILLI- 
NOIS. 

Illinois  is  still  very  far  from  being  completely  civil- 
ized.    Circuit  Court  Judge    Creighton,  of   Sangamon 
County,  has  recently  been  unburdening  his  mind  on 
the  subject  of  expert  testimony  and  allied  topics,  and 
the  burden  drops  off  with  a  gentle  splash  that  recalls 
the  fall  of  the  buffalo  chip,  in  days  when  that  animal 
roamed    over   the   judge's  prairies.     Speaking   of  ex- 
perts, he  says  that  "of  course  the  court  has  no  power 
to  compel  an  expert  to  make  an  examination  or  pre- 
pare himself  to  testify  without  payment,  but  he  thinks 
that  an  expert  can  be  made  to  testify,  provided  he 
is   not  obliged  to  make   special  preparation."     From 
which    it   seems   that    the   judge   thinks    the   chemist 
or  surgeon  or  physician  can  go  and  testify  upon  any 
case,  if  he  chooses,  without  preparation.     The  learned 
judge  furthermore  says  that  physicians  in  Illinois  are 
"favored   children  of  the  State."     "A  department  of 
the  State  Government,"  he  says,  "is  maintained  very 
largely  for  their  benefit,  and  they  are  so  protected  by 
the  laws  of  the  State  and  by  public  opinion  and  confi- 
dence that   in  five  minutes'  time  a    doctor  may  earn 
more  than  an  ordinary  laborer  could  in  a  day  !  "     If 
our   Illinois  confreres  are   really  earning  $2.00  every 
five  minutes,  we  trust  that  the  fact  will  not  be  made 
known,  for  all  other  regions  of  the  country  will  imme- 
diately lose  their  medical  citizens.     The  argument  that 
the  doctor  is  so  favored  by  the  State  that  he  can  earn 
§2.00  in  five  minutes  is  worthy  of  a  giant  mind,   and 
deserves  to  go  down  in  the  history  of  medical  jurispru- 
dence emblazoned  in  letters  of  gold,  or  wafted  through 
the  etnpyrean  by  the  swiftest  and  most  characteristic 
cyclonic   whirlwind  that  the    prairies   of   Illinois  can 
generate.     The  theory  that   the   State  of  Illinois  has 
a  department  of  its  government — -viz.,  the  Health  De- 
partment— largely  for  the  benefit  of  the  medical  pro- 
fession is  also  extremely  unique  and  could  hardly  have 
come  from  any  mind  but  one  highly  trained  in  Sangam- 
on County.     To  the  common-sense  of  mankind  it  has 
heretofore  seemed  that  the  creation  of  the  Health  De- 
partment was,  if  anything,  prejudicial  to  the  medical 
profession,  since  it  cuts  down  mortality  and  prevents 
sickness  and  epidemics,  by  all   of  which  the  medical 
man  is  supposed  to,  and  does,  gain  his  livelihood.    Medi- 
cal literature  is  at  least  enriched  by  the  marvellous  brain 
of  Judge  Creighton,  which  thus,  in  one  single  effort,  is 
able  to  overturn  common  knowledge  and  place  before 
the  eyes  of  the  astonished  world  more  facts  in  medical 
jurisprudence  than  were  ever  dreamed  of  by  any  phi- 
losopher from  Descartes  to  B.  O.  Flower. 


Dr.  Lusk's  Text-book  on  Midwifery  is  to  be  trans- 
lated into  Arabic  for  the  use  of  students  in  the  Gov- 
ernment Medical  School  and  in  the  School  for  Mid- 
wives  at  Cairo. 


THE  WORLD'S  MEDICAL  CENTRE. 

The  history  of  our  schools  of  learning  within  the  pres- 
ent century  shows  with  what  comparative  rapidity  the 
centres  of  great  medical  activity  shift  themselves,  and 
it  also  shows  that  there  is  no  longer  any  special  great 
single  fountain-head  of  medical  learning,  such  as  used 
to  exist  fifty  or  a  hundred  years  ago.  LTndoubtedly,  in 
the  early  half  of  this  century,  Paris  was  conceded  to 
be  the  great  medical  centre.  The  activity  and  prestige 
of  this  school,  however,  waned  very  rapidly,  and  for 
many  years  it  has  possessed  few  attractions,  at  least 
for  American  students,  the  foreign  student  population 
of  Paris  being  largely  Latin  and  Russian.  After  Paris, 
Vienna  for  a  long  time  was  supreme  as  a  medical 
centre.  Of  late  years  this  place  has  to  some  extent  de- 
clined in  relative  popularity.  Now,  perhaps,  medical 
students  find  as  much  at  Berlin  as  at  any  other  sin- 
gle educational  centre.  We  notice  recently  a  claim 
put  forth  for  Edinburgh  as  the  foremost  place  for 
medical  undergraduates.  Edinburgh,  we  are  told,  has 
more  than  three  thousand  medical  students,  and  claims 
to  be  as  great  a  place  for  medical  education  as  it  ever 
was  in  its  palmiest  days.  Of  all  the  great  cities  of  the 
world,  London  alone  has  failed  to  make  itself  felt  as 
an  educational  centre  for  medical  students.  This  is 
due,  we  presume,  to  the  number  of  schools  and  to  the 
absence  of  a  great  central  educational  institution. 
London  is,  however,  awakening  to  the  fact  that  it 
should  utilize  its  vast  clinical  facilities  more  efficiently 
than  it  has  done  in  the  past. 


DRUMMING  FOR  DOCTORS  AT  HOT  SPRINGS.        \ 

Probably  nothing  has  placed  the  Hot  Springs  of 
Arkansas  and  its  medical  attendants  in  more  thorough 
disrepute  than  the  practice  of  drumming  up  visitors  on 
behalf  of  the  different  hotels  and  doctors.  Nothing  so 
absolutely  repugnant  to  the  self-respect  of  all  reputable 
medical  men  could  possibly  be  undertaken,  and  we 
have  no  doubt  that  hundreds  and  even  thousands  of 
physicians  throughout  the  country  have  deliberately 
warned  people  against  the  Hot  Springs,  on  account  of 
their  distrust  of  the  physicians  who  are  in  attendance 
there.  We  are  very  glad  to  record  the  fact,  therefore, 
that  some  systematic  efforts  are  being  made  to  stop 
this  practice  of  "  doctor-drumming."  At  a  meeting  of 
the  Hot  Springs  Medical  Society,  held  recently,  resolu-  , 
tions  were  passed  condemning  the  practice,  and  the  I 
Hot  Springs  Medical  Journal  states  that  "  a  feeling  * 
against  this  nefarious  business  is  becoming  general." 
The  Mayor  of  the  city,  even,  seems  determined  to  help 
the  good  cause.  The  city  council  has  licensed  the 
business  of  drumming  for  hotels  and  doctors,  and  it 
requires  now  that  the  drummer  shall  wear  a  badge 
stating  his  occupation,  the  object  being  to  put  the  in- 
tended victim  on  his  guard. 

We  learn    that   at   one   time  doctor-drumming   was 
stopped   through  the  distribution  of  circulars   on  the      J| 
railroads,  warning  visitors  to  look  out  for  the  friendly      ^ 
young  man  who  solicited  their  patronage.     This,  how- 
ever, while  effective,  was  found  by  the  city  cour>cil  to 
be  too  much  against  the  interests  of  important  persons 


August   lo,  1895] 


MEDICAL    RECORD. 


199 


in  the  city,  and  they  stopped  the  practice.  It  is  hoped 
that  by  making  the  doctor-drummers  wear  their  badge, 
the  business  will  be  lessened  if  not  stopped.  A  more 
efficient  way,  it  seems  to  us,  would  be  to  place  the  ban 
of  absolute  disreputability  on  all  physicians  who  send 
out  drummers. 


%nii5  of  tlic  ^aieek- 

Award  of  the  Hodgkins  Prizes.— The  authorities  of 
the  Smithsonian  Institution  have  awarded  the  Hodg- 
kins prizes  as  follows  ;  First  prize  of  $10,000  to  Lord 
Rayleigh  and  Professor  Ramsey,  of  London,  for  their 
discovery  of  argon  as  a  constituent  element  of  the  at- 
mosphere. Third  prize,  $1,000,  to  Henry  de  Varigny, 
of  Paris,  for  the  best  popular  essay  on  the  properties  of 
the  atmosphere,  entitled  "  L'Air  et  la  Vie."  The  sec- 
ond prize  of  $5,000,  was  not  awarded,  none  of  the 
contestants  having  fulfilled  the  conditions.  There 
were  218  papers  submitted  from  all  parts  of  the  world > 
a  number  of  which  received  honorable  mention,  coupled 
in  three  instances  with  a  silver  medal  and  in  six  with  a 
bronze  medal. 

The  Cholera  is  still  epidemic  in  many  parts  of  Rust 
sia,  although  St.  Petersburg  and  the  northern  cities  are 
officially  declared  to  be  free  from  it.  The  provinces  of 
Bessarabia,  Podolia,  Kiev,  and  Kherson  are  infected, 
many  towns  in  Podolia  especially  suffering  severely. 
In  Podolsk  recently,  the  inhabitants  took  fright  as 
usual  at  the  measures  taken  to  protect  them  and  re- 
sisted the  erection  of  temporary  hospitals  for  the  ac- 
commodation of  the  sufferers  from  the  disease,  and 
began  rioting  so  fiercely  that  it  was  found  necessary  to 
call  out  a  body  of  troops  to  quell  the  disturbance. 

Yellow  Fever  is  actively  helping  the  insurgent  cause 
in  Cuba.  A  recent  despatch  states  that  more  than  half 
of  the  Spanish  troops  stationed  at  Vera  Cruz  have  died 
of  the  disease,  and  many  new  cases  are  occurring  daily. 
Among  the  dead  was  the  surgeon  of  the  regiment. 

Dr.  William  A.  Betts.  of  Red  Bank,  N.  J.,  died  on 
August  4th,  aged  sixty-one.  He  was  graduated  from 
the  College  of  Physicians  and  Surgeons  of  New  York 
in  1861. 

A  Congregation  Struck  by  Lightning. — During  a 
storm  on  Sunday  last,  a  Methodist  church  at  Quaker- 
town,  N.  J.,  was  struck  by  lightning  and  over  twenty 
persons  in  the  congregation  were  injured  more  or  less 
seriously,  and  many  of  them  are  still  suffering  from 
shock.  Two  among  the  number  are  not  expected  to 
recover. 

The  Health  of  Paris. — Reports  were  circulated  re- 
cently on  the  Continent  that  a  mysterious  and  fatal 
epidemic  existed  in  Paris.  This  the  sanitary  authori- 
ties of  the  city  emphatically  deny,  affirming  that  the 
general  health  of  the  city  is  excellent,  that  the  number 
of  cases  of  typhoid  is  smaller  than  usual,  the  mortality 
from  diphtheria  is  almost  nil,  and  that  no  disease  exists 
in  an  epidemic  form. 

Dr.  Elias  Rodriguez,  Professor  of  Therapeutics  and 
Forensic  Medicine  in  the  LTniversity  of  Caracas,  Vene- 
zuela, died  in  that  city  a  few  weeks  ago. 


Professor  KLknlicz,  of  Breslau,  who  was  invited  to 
succeed  Professor  Trendelenburg  in  the  Chair  of  Sur- 
gery, having  declined  the  call,  the  post  has  been 
offered  to  Dr.  Schede,  director  of  the  Surgical  Side  of 
the  Eppendorf  General  Hospital,  Hamburg. 

American  Editions  of  Foreign  Journals. — The  An- 
nales  I  Octilistique  has  commenced  its  fifty-eighth  year 
with  an  edition  in  the  English  language,  published  in 
New  York  under  the  editorial  charge  of  Dr.  George  T. 
Stevens.  Commencing  with  the  May  number,  an  Amer- 
ican edition  of  the  British  Gyncecological  Journal,  the 
organ  of  the  British  Gynaecological  Society,  was  under- 
taken by  Hirschfeld  Brothers,  of  this  city. 

The  Montreal  Medical  Journal  for  July  comes  to  us 
in  new  and  enlarged  form  and  with  an  increased  edi- 
torial staff.  We  congratulate  our  esteemed  contempo- 
rary on  its  improved  appearance,  which  is  indicative  of 
a  well-deserved  success. 

The  Report  of  the  Pasteur  Institute  in  Paris  states 
that  1,387  patients  were  treated  there  during  1894,  7 
of  whom  died.  This  is  261  less  than  in  1893.  Two 
hundred  and  twenty-six  of  the  patients  were  foreigners, 
128  coming  from  England  and  only  i  from  Russia. 

New  Orleans  is  to  have  a  new  system  of  sewerage, 
which  it  will  take  several  years  to  complete  and  which 
will  cost  over  $8,000,000. 

Vital  Statistics  of  Michigan. — According  to  the 
State  report  for  1893,  just  issued,  there  were  registered 
in  Michigan  during  that  year  19,197  marriages,  47,722 
births,  and  21,982  deaths.  Of  the  deaths  returned, 
2,154  were  due  to  consumption  ;  1,218  to  diphtheria 
and  croup  ;  689  to  typhoid  fever  ;  360  to  scarlet  fever. 
There  were  644  deaths  from  cancer,  555  from  influenza, 
and  T,385  from  pneumonia. 

Cholera  in  Japan. — In  Osaka  and  Hiogo,  Japan,  in 
the  week  ended  July  6th  there  were  104  new  cases  of 
cholera,  with  79  deaths. 

The  American  Pharmaceutical  Association  will  hold 
its  annual  meeting  in  Denver  during  the  last  week  in 
August.  The  Brown  Palace  Hotel  will  be  the  head- 
quarters of  the  Association.  It  is  expected  that  over 
one  thousand  members  will  be  present. 

Dr.  S.  Weir  Mitchell  received  the  degree  of  LL.D. 
from  the  University  of  Edinburgh  on  August  ist.  In 
the  university  oration  he  was  described  as  "  the  chief 
ornament  to  medical  science  in  the  New  World." 

The  Report  of  the  New  York  State  Board  of  Phar- 
macy for  the  year  ending  June  21st  shows  that  238 
certificates  were  issued  during  the  year,  408  candidates 
were  examined,  and  207  were  licensed  to  practise. 
Ninety-nine  candidates  were  re-examined.  There 
were  33  complaints  against  alleged  violators  of  the 
Pharmacy  law  during  the  year,  and  6  convictions. 

A  Cholera  Antitoxin  has  been  discovered  by  Dr. 
Kanson,  one  of  Beh ring's  assistants.  It  is  claimed  that 
experiments  upon  animals  have  proved  its  immunizing 
and  curative  properties,  but  it  has  not  yet  been  tried  in 
the  human  subject. 

The  Italian  Congress  of  Internal  Medicine  will  be 
held  in  Rome  in  October  of  the  present  year. 


MEDICAL   RECORD. 


[August   lo,  1895 


Macao,  in  China,  which  escaped  the  plague  last  year 
when  it  was  prevalent  in  Canton  and  Hong  Kong,  has 
this  year  been  most  severely  affected.  The  disease 
first  appeared  therein  February  and  has  been  epidemic 
ever  since.  Its  neighbors,  Canton  and  Hong  Kong, 
on  the  other  hand,  have  suffered  but  little  this  year. 

Dr.  Daniel  Lewis,  of  this  city,  has  been  appointed 
President  of  the  State  Board  of  Health. 

The  Memory  of  Professor  Ludwig  Traube  has  been 
honored  by  the  placing  of  his  bust  in  the  garden  of  the 
Charite  Hospital  in  Berlin.  Professor  Traube  died  in 
1876. 

The  Royal  College  of  Surgeons.— Mr.  Christopher 
Heath  has  been  re-elected  President  of  the  Royal  Col- 
lege of  Surgeons,  England.  Mr.  Reginald  Harrison 
and  Mr.  Pickering  Pick  have  been  appointed  Vice- 
Presidents. 

The  California  State  Medical  Society  has  repri- 
manded one  of  its  members  for  telling  a  prospective 
patient  that  he  had  succeeded  in  curing  some  cases  of 

consumption. 

Increase  of  Lunacy  in  England. — According  to  the 
report  of  the  British  Commissioners  in  Lunacy,  re- 
cently issued,  the  total  number  of  lunatics,  idiots,  and 
persons  of  unsound  mind  was,  on  January  i,  1895, 
94,081,  an  increase  of  2,014  over  the  number  for  the 
previous  year.  The  increase  was  confined  almost 
wholly  to  the  pauper  class,  and  is  due,  apparently,  to 
the  more  general  reception  in  asylums  of  cases  of  sim- 
ple mental  decay,  resulting  from  e.xtreme  old  age. 

Laparotomy  in  a  Man  Aged  Eighty-five. — Drs.  J. 
Greig  Smith  and  C.  E.  S.  Flemming  report,  in  the 
British  Medical  Journal,  the  case  of  a  man,  eighty-five 
years  of  age,  suffering  from  volvulus  of  the  sigmoid 
flexure.  There  had  been  complete  obstruction  of  the 
bowels  for  a  week,  and  there  was  also  a  small  um- 
bilical hernia.  Coeliotomy  was  performed,  intestinal 
drainage  instituted  and  maintained  for  three  days,  and 
the  wound  then  closed.  The  man  made  a  perfect  re- 
covery. 

The  Charcot  Monument  Fund  now  amounts  to  over 
40,000  francs,  nearly  half  of  which  sum  has  been  con- 
tributed by  foreigners. 

Women  at  the  Door  of  the  Royal  College  of  Sur- 
geans. — At  the  last  meeting  of  the  Council  of  the 
Royal  College  of  Surgeons,  England,  a  petition  was 
presented  from  the  London  School  of  Medicine  for 
Women  praying  that  women  medical  students  might  be 
admitted  to  the  examinations  for  the  diplomas  of  the 
college.  The  matter  was  referred  to  a  committee  of 
the  Council  for  consideration  and  report.  The  move- 
ment to  admit  women  to  the  Royal  College  of  Sur- 
geons, and  to  that  of  Physicians  as  well,  is  strongly  sup- 
ported by  influential  members  of  the  profession  in 
London,  and  more  or  less  pressure  has  been  brought 
to  bear  upon  members  of  the  Council  of  the  College  of 
Surgeons  to  grant  the  petition. 

A  Large  Brain.— Dr.  G.  C.  Grant  reports  in  The 
Lancet  of  July  20th  a  case  of  a  man,  forty- three  years 
of  age,  who  had  suffered  from  epilepsy  for  seven  years 


and  died  from  congestion  of  the  lungs  following  a  suc- 
cession of  fits.  The  circumference  of  the  head  above 
the  eyebrows  was  25^  inches.  Clear  of  all  membranes 
the  brain  weighed  67  ounces  ;  the  convolutions  were 
plump  and  well  formed,  and  no  pathological  changes 
were  discoverable  except  enlargement  of  both  choroid 
plexuses  and  a  partial  ossification  of  the  left  one. 

Anthrax  in  New  Jersey. — In  consequence  of  a  re- 
port that  anthrax  was  prevalent  in  certain  parts  of  New 
Jersey,  a  State  Milk  Inspector  was  sent  to  investigate. 
He  states  that  seventy-two  cattle  have  died  in  Cumber- 
land County  from  that  disease,  and  that  many  others 
are  sick  and  will  probably  die.  The  report  has  had 
the  effect  of  preventing  the  shipping  of  milk  to  Phila- 
delphia from  the  infected  locality. 

King  Christian  of  Denmark  is  seriously  ill  with  ca- 
tarrhal cystitis,  and  it  is  feared,  by  reason  of  his  ad- 
vanced age,  that  he  cannot  recover. 

Miss  Eleonora  Duse.  the  Italian  actress,  is  reported 
to  be  suffering  from  melancholia,  and  her  condition  is 
such  as  to  cause  her  friends  and  admirers  much  un- 
easiness. 

The  Temperance  Movement  in  France. — For  some 
time  past  French  medical  writers  have  been  urging  the 
necessity  for  a  resolute  stand  being  made  against  the 
ravages  of  alcoholism.  Many  of  the  leading  medical 
journals  have  inveighed  in  the  strongest  language 
against  the  heavy  mortality  from  alcohol,  compared 
to  which  that  from  cholera  is  declared  to  be  absolute- 
ly benign.  In  little  less  than  half  a  century,  since 
1850,  the  consumption  of  alcohol  has  quadrupled  in 
France,  averaging  in  1894  four  litres  per  head.  Dr. 
Legrain,  Physician  to  the  Insane  Asylums  in  the  De- 
partment of  the  Seine,  has  made  an  extended  study  of 
alcoholic  heredity,  from  which  he  formulates  the  fol- 
lowing conclusions  :  i.  Double  parental  alcoholism 
creates  an  irresistible  tendency  to  drinking  in  the  chil- 
dren. 2.  Parental  absinthism  seems  to  transmit  epi- 
lepsy directly  to  the  offspring.  3.  The  parental  combi- 
nation of  absinthe  drinking  and  epilepsy  is  a  common 
cause  of  epilepsy  in  the  children.  Dr.  Moreau  de  Tours 
says  that  even  children,  in  certain  parts  of  France,  drink 
large  quantities  of  brandy  on  holidays.  Dr.  Roubino- 
vitch,  of  St.  Anne's  Asylum,  has  begun  to  lecture  on 
drunkenness  and  alcoholism  to  teachers  and  pupils  in 
the  schools  of  his  neighborhood,  and  many  other 
medical  men  have  engaged  in  the  new  crusade  against 
intemperance.  A  French  Temperance  Society  has  been 
recently  formed,  the  members  of  which  do  not  pledge 
themselves  to  teetotalism,  but  simply  to  abstinence 
from  spirits  and  strict  moderation  in  wines,  malt 
liquors,  and  cider. 

The  Commission  on  Leprosy  in  India  has  concluded 
its  work.  The  Commissioners  have  arrived  at  the  con- 
clusion that  the  alarm  at  the  spread  of  leprosy  in  India 
is  groundless,  for  they  find  that  the  number  of  cases  of 
the  disease  has  decreased.  Many  interesting  facts  and 
statistics  have  been  brought  to  light  during  the  holding 
of  the  Commission. 

An  Electrotherapeutic  Service,  under  the  direction 
of  Dr.  Plicque,  has  been  established  at  the  Lariboisiere 
Hospital  in  Paris. 


August  lo,  1895] 


MEDICAL   RECORD. 


201 


Demon  Possession.  Being  an  Inductive  Study  of  the  Phe- 
nomenon of  our  Times.  By  Rev.  John.  L.  Nevius,  D.D., 
{for  forty  years  a  missionary  to  the  Chinese).  With  an 
introduction  by  Rev.  F.  F.  Ellinwood,  D.D.  With  an 
Index  Bibliographical,  Biblical,  Pathological,  and  General. 
Small  8vo,  pp.  482.  Chicago,  New  York,  and  Toronto  : 
Fleming  H.  Revell  Co. 

This  is  a  curious  book,  and  one  written  with  such  sincerity 
of  purpose  and  painstaking  attempt  at  accuracy  that  we 
feel  somewhat  disarmed  in  an  attempt  to  criticise  it.  .An 
author  who  at  this  period  of  our  civilization  sits  down  delib- 
erately to  establish  a  thesis  that  dem.oniac  possession  exists, 
certainly  awakens  our  wonder.  The  idea  that  human 
beings  are  at  times  possessed  by  spirits,  evil  or  good,  has 
certainly  never  been  held  by  even  the  average  theologian  of 
late  years,  much  less  by  men  who  have  studied  the  question 
medically.  The  medical  view  of  those  cases  in  which  people 
are  supposed  ti3  be  demoniacally  possessed  is  that  they  are 
suffering  from  epilepsy,  hysteria,  or  insanity.  This  interpre- 
tation is  abundantly  supported  by  facts  and  is  sufficient  to 
explain  the  phenomena ;  sufficient,  at  least,  for  most  minds. 
Dr.  Nevius,  however,  thinks  that  in  certain  parts  of  China 
demon  possession  exists,  and  in  proof  of  this  he  collects  a 
large  number  of  stories  of  various  people  who  were,  as  the 
people  believe,  possessed  of  spirits.  The  theory  of  demon 
possession  is  ingeniously  supported  by  quotations  from  the 
works  of  medical  authors  and  psychologists  and  by  the 
teachings  of  Scripture.  There  is  also  appended  a  chapter 
upon  the  facts  and  literature  of  the  occult.  In  fact,  the 
book  contains  a  great  deal  that  is  curious  and  interesting  to 
all  persons  interested  in  psychology,  particularly  patholog- 
ical psychology,  and  it  will  have  its  use  even  for  those  who 
do  not  and  cannot  at  all  believe  in  the  theory  that  the  author 
tries  to  maintain. 

The  Pathology  of  the  Mind.  A  Study  of  its  Distem- 
pers, Deformities,  and  Disorders.  By  Henry  Maudsly, 
M.D.  8vo,  pp.  571.  London  and  New  York  :  Macmil- 
lan  &  Co.     1895. 

This  book,  according  to  the  author's  statement,  while  re- 
taining the  old  name  is  virtually  a  new  work.  Much  old 
matter  has  been  left  out,  fresh  matter  added,  and  the  work 
has  been  quite  recast  and  the  text  entirely  rewritten.  While 
we  have  no  doubt  that  Dr.  Maudsly  has  done  all  this,  and 
while  we  confess  freely  that  the  book  is  a  brilliant  academic 
discussion  of  insanity,  we  must  admit  to  being  personally 
much  disappointed  in  it.  Dr.  Maudsly  writes  from  his  study 
for  the  benefit  of  literary  men  and  philosophers,  and  he 
moves  in  an  atmosphere  somewhat  superior  to  that  occupied 
by  the  every-day  alienist.  We  are  sure  that  a  study  of  such 
a  treatise  is  useful  as  an  intellectual  exercise  for  those  who 
are  preparing  to  take  up  the  special  study  of  insanity,  but 
for  those  who  are  practising  this  branch  of  medicine  it  really 
has  mainly  a  philosophic  and  literary  value.  We  would  add 
that  we  do  not  think  that  any  man,  however  experienced  or 
eminent,  can  write  a  treatise  on  insanity  in  the  present  day 
and  not  give  some  account  of  the  work  and  views  of  others 
than  himself.  One  would  think  from  Dr.  Maudsly's  book 
that  there  really  was  no  other  writer  on  insanity  or  practi- 
tioner in  that  branch  of  medicine.  To  be  sure  in  his  chapter 
on  morbid  anatomy,  which,  by  the  way,  is  very  inadequate, 
there  is  some  brief  acknowledgment  of  the  work  done  by 
Bevan  Lewis  and  Wigglesworth,  and  we  here  also  find  a  ref- 
erence to  Meyncrt  and  Esquirol,  but  there  is  still  more  about 
Othello  and  Desdemona,  and  the  longest  quotation  of  all  is 
from  Li's  Penshs  of  Pascal.  Altogether,  we  must  repeat 
that  Dr.  Maudsly's  book  is  distinctly  disappointing,  espe- 
cially after  having  read  his  announcement  in  the  preface. 
The  book,  however,  perhaps  ought  not  to  be  judged  by  or- 
dinary standards.  It  is  rea'ly  a  discussion  of  the  philosophy 
of  the  subject,  with  some  finely  written  clinical  pictures,  but 
it  is  not  a  practical  text-book.  Viewing  it  from  this  stand- 
point it  deserves  great  praise  for  the  analytical  insight  and 
literary  form  displayed  by  the  distinguished  author. 

Hypnotism.  How  it  is  Done  ;  its  Uses  and  Dangers.  By 
James  M.  Cocke,  M.D.  Svo,  pp.  373.  Boston  :  Arena 
Publishing  Company.      1894. 

It  is  difficult  to  see,  with  the  excellent  works  on  hypnotism 
already  published  by  Tuckey,  Moll,  and  Bemheim,  the  need 
of  another  book  upon  this  subject.  However,  Dr.  Cocke 
asserts   that  he    has  had  great   experience    in  hypnotizing 


Americans,  and  has  some  special  knowledge  of  hypnotism 
as  it  affects  his  countrymen.  We  have  looked  through  his 
book,  however,  in  hopes  of  discovering  some  new  light  upon 
the  subject  or  some  new  results  from  hypnotism  as  a  thera- 
peutic agent,  and  we  find  nothing  that  really  satisfies  our 
expectations.  The  work  is  a  fairly  good  presentation  of  the 
general  subject  of  hypnotism,  and  the  author's  views  seem 
to  be  on  the  whole  not  extravagant.  His  experience  in  the 
use  of  hypnotism  with  dipsomaniacs  is  given  with  some  de- 
tail, and  the  fact  that  the  results  were  so  slight  gives  us  a 
good  impression  of  Dr.  Cocke's  candor  in  confessing  to  the 
inefficacy  of  the  method  in  treating  this  class  of  cases  at 
least. 

The  Elements  of  Pathological  Histology.  By  Dr. 
Anton  Weichselbaum.  Translated  by  W.  R.  Dawson, 
M.D.  (Dublin.)  W^ith  eight  Plates  and  a  large  number 
of  Illustrations  in  the  Text,  some  of  which  are  colored. 
Large  Svo,  pp.  456.  London  and  New  York  :  Longmans, 
Green  &  Co.  1894. 
This  book  is  a  translation  by  a  well-known  English  pathol- 
ogist of  the  work  of  Professor  Weichselbaum.  The  German 
author  is  well  known  to  our  readers  and  his  reputation  is 
sufficient  to  assure  us  of  a  sound  and  useful  book.  Dr.  Daw- 
son has  added  a  few  things  in  his  translation,  namely,  a  note 
on  the  gum  freezing  method,  and  a  brief  account  of  Bevan 
Lewis's  method  of  staining  nerve-cells.  The  general  pur- 
pose of  the  author  is  to  provide  the  beginner  in  the  study  of 
pathological  histology  with  a  guide  for  the  work  that  he  is 
preparing  to  take  up.  The  various  chapters  treat,  therefore, 
first,  of  methods  of  investigation,  which  are  given  in  detail 
and  include  bacteriological  methods.  The  next  part  is  de- 
voted to  general  pathological  histology  and  includes  various 
forms  of  degeneration,  progressive  tissue  changes,  inflam- 
mation, and  infective  granulation-tissue  tumors.  Subsequent 
chapters  include  tumors  and  parasites.  The  third  and  last 
part  of  the  book  is  devoted  to  special  pathological  histology, 
and  this  is  the  part  in  which  the  medical  practitioner  who 
has  already  equipped  himself  for  the  study  of  pathology  will 
feel  himself  most  interested.  The  work  is  not  bulky,  it 
presents  the  subjects  in  a  thorough  manner,  and  it  should 
form  a  very  useful  addition  to  the  physician's  library.  The 
tvpographical  work  is  excellent,  though  some  of  the  wood- 
cuts have  an  ancient  and^familiar  air. 

The  Extra  Pharmacopcf.ia.     By  William   Martin- 
dale,  F.C.S.,  late  examiner  of  the  Pharmaceutical  So- 
ciety, and  late  Teacher  of  Pharmacy  and  Demonstrator 
of  ^Iateria  Medica  at  University  College.     Medical  Refer- 
ences and  a  Therapeutic  Index  of  Diseases  and  Symptoms. 
By  W.  WVNN  Westcott,  M.B.  Lond..  Coroner  for  North- 
East  London.     Eighth  edition.     London  :   H.   K.  Lewis. 
1895. 
The  striking  feature  of  this  new  edition  is  the  incorporation 
of  chapters  on  antitoxins,  serums,  lymphs,  extracts  of  ani- 
mal glands  and  tissues.     Many  newer  drugs,  and  especially 
those  of  synthetic  origin,  have  received  attention,  while  the 
preparations  recently  added  to  the  French  Codex  and  Ger- 
man Pharmacopceia,  have  been  included  in  the  additions. 
Our  previous  good  opinion  of  the  work  remains  unchanged, 
and  the  druggist  as  well  as  the  practitioner  will  find  it  useful. 

DiAGNOSTIK    UND   THERAPIE   DER    MAGENKRANKHEITEN, 

nach  dem  heutigen  Stand  der  Wissenschaft  Bearbeitet. 
Von  Dr.  1.  Boas,  Specialarzt  fiir  Magen  und  Darm 
Krankheiten  in  Berlin.  II.  Theil.  Specielle  Diagnostik 
und  Therapie  der  Magenkrankheiten,  mit  8  Holzschnit- 
ten,  Zweite  ganzlich  unigearbeitetc  Auflage.  Leipzig  : 
V'erlag  von  Georg  Thiemc.     1895. 

The  second  edition  of  this  book  has  been  entirely  rewritten. 
It  was  only  a  few  months  after  the  appearance  of  the  first 
edition  that  the  author  was  compelled  to  enlarge  the  pres- 
ent one,  and  owing  to  the  new  theories  and  points  of  experi- 
ence gained  in  the  meantime,  he  has  been  compelled  to 
change  many  former  chapters.  The  author  starts  by  divid- 
ing Chapter  I.  into:  I.  Gastritis  Simplex.  2.  Gastritis  In- 
fectiosa.  3.  Gastritis  Phlegmonosa.  4.  Gastritis  Toxica. 
A  new  chapter  entitled  Gastritis  Acida  has  here  been  added. 
In  the  chapter  on  gastric  neuroses  we  find  a  new  clinical 
picture  which  the  author  designates  as  "  Die  Schmerzhafte 
Magenleere,"  "  Painful  condition  of  an  empty  stomach." 
We  find  that  he  has  united  the  former  chapters  entitled 
"  Atonie  "  and  "  Ectasie,"  and  made  one  chapter  which 
he  calls  "  Mechanical  Insufficiency,"  in  which,  however, 
he  still  insists  that  the  aftections  are  distinctly  different. 
There  are  also  numerous  additions  to  the  pathology  and 
therapeutics  of  the  gastric  affections. 


MEDICAL    RECORD. 


[August  lo,  1895 


While  the  work  as  a  whole  is  full  of  practical  points  per- 
taining to  the  methods,  both  chemical  and  clinical,  of  exam- 
ining all  gastric  disorders,  still,  too  much  stress  cannot  be 
laid  on  the  importance  of  carefully  diagnosticating  cancer. 
And  this  is  really  the  stronghold  of  the  whole  book.  Boas's 
views  have  been  accepted  and  he  is  looked  upon  as  an  au- 
thority in  this  affection.  His  papers  in  Deutsche  mcd.  Wochen- 
schrift,  1892,  No.  17,  and  in  Milne liener  med.  IVochenschrift. 
1893,  No.  43,  on  the  presence  of  lactic  acid  as  a  diagnostic 
factor  in  carcinoma  are  still  authoritative  the  world  over.  On 
page  177  of  this  volume  he  again  reiterates  his  views,  and 
believes  that  the  presence  of  lactic  acid  can  be  looked  upon 
as  a  positive  proof  of  the  existence  of  cancer.  The  alde- 
hyde test  of  Boas  can  only  be  here  referred  to.  .-Xt  any  rate 
Boas  has  found  that  he  can  frequently  diagnose  by  chemical 
examination  of  stomach  contents  the  presence  of  a  cancer 
long  before  a  tumor  can  be  palpated.  We  congratulate  the 
author  on  the  successful  outcome  of  the  present  volume  and 
trust  that  it  will  vindicate  the  claims  of  a  conscientious  stu- 
dent and  accomplished  clinician,  and  hope  the  book  will  be 
as  carefully  studied  as  it  really  deserves. 

CHIRURGIE  DE  L'URfeTHRE,  DE  LA  VESSIE,  DE  LA  PROS- 
TATE (indications — Manuel  Operatoire).  Par  V.  Rochet, 
Chirurgien  de  I'Antiquaille,  Professeur  Agreg^  kla  Faculte 
de  Lyon.     Paris:   G.  Steinheil.     1895. 

The  object  of  this  small  volume  is  to  point  out  the  indica- 
tions for  operation  in  genito-urinary  diseases,  and  then  to 
point  out  the  most  approved  manner  of  operating. 

While  not  at  all  intended  for  the  specialist  in  these  dis- 
eases, even  the  skilled  surgeon  might  here  and  there  find 
something  to  his  advantage. 

Illustrations  of  a  schematic  order  are  freely  scattered 
through  the  text.  In  one  the  figures  referred  to  in  the 
description  have  no  corresponding  figures  on  the  plate,  a 
fault,  wluch,  as  the  reviewer  knows,  is  often  to  be  laid  at 
the  door  of  the  publisher  rather  than  at  that  of  the  editor. 
Just  enough  regional  anatomy  is  given  to  refresh  the  oper- 
ator's memory  and  make  the  steps  clear.  It  is  an  interest- 
ing little  work,  especially  as  showing  the  methods  most  in 
vogue  in  France  for  bladder,  urethral,  and  prostatic  opera- 
tions. 

Diseases  of  Children  and  their  Homceopathic 
Treatment.  By  Robert N.  Tooker,  M.D.  Chicago  : 
Gross  &  Delbridge.     1895. 

The  author  states  that  this  volume  of  over  eight  hundred 
pages  is  the  outcome  of  thirty  years  of  practical  medical 
work.  It  treats  of  all  branches  of  pediatrics  and  contains 
many  useful  hints. 

All  modern  authors  have  been  consulted  and  due  credit 
given,  so  that  the  book  presents  a  combination  of  the  views 
of  both  medical  schools  and  seems  to  have  aimed  at  giving 
the'best  advice,  forgetting  the  homoeopathic  title  of  the  work. 

Laboratory  Guide  for  the  Bacteriologist.  By 
Langdon  Frothingham,  M.D.  Philadelphia  :  W.  B. 
Saunders.     1896. 

This  neat  little  book  is  merely  intended  as  a  guide  for 
practical  work  in  the  laboratory.  It  has  fulfilled  its  mission 
and  is  full  of  practical  points  and  directions  for  rapid  diffu- 
sion of  knowledge  otherwise  hard  to  obtain. 

La  MliTHODE  Brown-S^quard  :  Traits  d'Historique,  La 
Therapeutique  des  Tissus,  Compendium  de  Medications. 
Par  le  DoCTEUR  M.  Bra,  ouvrage  precede  de  lettres  et 
prefaces  de  MM.  les  Professeurs  Constantin  Paul, 
Mendel  Ewald,  Bruns,  Emminghaus,  et  Bvrom 
Bramwell.  Large  Svo,  624  pages.  Paris  :  J.  Roths- 
child.    1895. 

Just  as  we  are  being  told  that  the  method  of  Brown-S^quard 
is  an  entire  failure  and  was  but  the  offspring  of  a  restless 
senility,  we  receive  a  treatise  of  nearly  seven  hundred  pages 
devoted  to  the  therapeutics  of  the  tissues.  The  book,  of 
course,  includes  much  more  than  the  method  suggested  by 
the  late  Dr.  Brown-Sequard,  for  in  it  we  have  full  directions 
for  the  preparation  and  use  of  the  thyroid  gland,  the  me- 
dulla of  bones,  the  pancreatic  gland,  and  the  super-renal 
capsule.  The  book  is  preceded  by  letters  from  men  of  emi- 
nence, who  have  confined  their  commendations  of  histo- 
therapy  mainly  to  the  use  of  the  thyroid  gland,  or  to  expres- 
sions of  general  approval  of  the  purpose  of  the  work.  The 
book  begins  with  a  history  of  the  method,  then  a  chapter 
upon  the  technique  of  the  preparation  of  organic  liquids  in 
general,  dosage  and  methods  of  use,  and  we  then  have  sepa- 
rate chapters  devoted  to  the  use  of  the  orchitic  extract,  the 


ovarian  and  cerebral  extracts,  then  a  long  chapter  upon  the 
use  of  the  extracts  of  the  heart,  pancreas,  liver,  supra-renal 
capsule,  muscle,  kidneys,  lungs,  spleen,  medulla  of  bones, 
and  of  the  lymphatic  glands.  The  book  is  valuable  because 
it  classifies  and  presents  a  systematic  review  of  all  that  is 
known  of  an  important  branch  of  therapeutics,  rather  than 
because  it  shows  any  remarkable  discrimination  with  regard 
to  the  results  obtained  by  the  use  of  this  method. 

M.  Bra  says  that  the  book  was  not  originally  intended  for 
publication,  the  substance  of  it  being  written  for  the  Ar- 
chives, which  the  late  Dr.  Brown-Sequard  edited.  The 
death  of  his  distinguished  master,  however,  led  M.  Bra  to 
think  that  he  could  best  promote  the  interests  of  science 
and  honor  the  memory  of  his  friend  by  collecting  and  plac- 
ing in  book  forin  the  observations  and  experiments  which 
have  been  made  upon  the  subject  of  the  therapeutics  of  the 
tissues. 
Traite  Clinique  et  Therapeutique  d'Apr^s  l'En- 

SEIGNEMENT  DE  LA  SaLPETRIJiRE.  Par  le  DOCTELR 
GilLES  DE  LA  TOURETTE  ;  preface  de  M.  le  PROFESSEUR 
J.  M.  Charcot.  Seconde  Partie,  Hysterie  Paroxystique, 
avec  63  figures  dans  le  texte.  2vols.,€vo.  Paris:  E. 
Plon,  Nourrit  et  Cie.  1895. 
This  book  is  a  continuation  of  Dr.  Tourette's  elaborate 
work  upon  hysteria.  The  first  volume  was  termed  inter- 
paroxysmal  hysteria  ;  the  second  part  is  devoted  to  par- 
oxysmal hysteria.  The  work  begins  with  a  description 
of  hysterical  convulsions,  and  naturally  the  author  follows 
very  closely  the  description  of  the  different  phases  of  hys- 
teria, as  studied  and  photographed  at  La  Salpetriere.  We 
find  the  same  old  pictures  which  have  served  French  and 
other  neurologists  now  for  fifteen  or  twenty  years,  but 
which,  we  must  say,  do  not  accurately  represent  anything 
that  is  seen  on  this  side  of  the  Atlantic.  The  subsequent 
chapters  are  devoted  to  rhythmical  chorea,  convulsive  tic, 
myoclonus,  electric  chorea,  catalepsy,  mania,  somnambu- 
•lism,  hypnotism,  etc.  In  the  second  volume  the  writer 
takes  up  the  subject  of  paralyses  and  contractures,  and  then 
the  subject  of  the  visceral  manifestations  of  hysteria.  The 
book,  as  a  whole,  is  a  very  complete  treatise  upon  hysteria 
in  all  of  its  aspects.  The  author  announces  that  it  is  a 
treatise  on  hysteria  "  according  to  the  teaching  at  Sal- 
petriere," and  this  is  to  a  large  extent  the  case.  The  book, 
we  believe,  would  have  been  a  better  one  if  the  author  had 
seen  hysteria  in  other  countries,  and  had  not  written  it 
from  so  strictly  a  Salpetriere  and  French  stand-point,  but  if 
the  reader  bears  this  provincial  characteristic  in  mind,  he 
will  find  the  book  not  misleading  and,  as  a  rule,  most  use- 
ful to  him. 

Cystite  et  Infection  Urinaire.  Par  le  Dr.  Max  Mel- 
CHiOR,  Chef  de  Clinique,  Ancien  Chef  de  Laboratoire  k 
I'Hopital  Frederic  de  Copenhague.  Translation  from  the 
Danish-French  Edition,  revised  and  annotated  by  Dr. 
NoiiL  Halle,  Chef  de  Laboratoire  k  rH6pital  Necker. 
Paris  :  G.  Steinheil.  1895. 
This  French  edition  of  Dr.  Melchior's  important  work  has  a 
preface  by  Professor  F.  Guyon,  who  thinks  highly  of  the  work 
done  by  the  Danish  investigator.  .^  historical  resume  cover- 
ing the  features  of  the  question  of  urinary  infection  is  fol- 
lowed by  a  chapter  on  the  technique  employed  by  the 
author  in  collecting  and  analyzing  the  urine,  the  steps  of 
which  are  characterized  by  the  most  painstaking  asepsis  and 
attention  to  detail.  Chapter  111.  is  devoted  to  clinical  obser- 
vations and  bacteriological  investigations.  The  etiology 
and  pathogeny  of  cystitis  are  treated  in  a  most  interesting 
manner.  He  shows  that  ammoniacal  changes,  instead  of  being 
the  primary  and  necessary  condition  for  the  development  of 
cystitis,  .are  only  a  contingent  phenomenon,  often  secondary, 
and  due  to  the  action  of  several  varieties  of  microbes.  The 
therapeutics  and  prophylaxis  of  vesical  infection,  based  on 
clear  scientific  premises,  have  an  import.ance  which  claims 
attention,  and  still  it  is  interesting  to  note  how  often  the 
conclusions  agree  with  those  reached  from  purely  clinical 
study.  The  translator  has,  with  the  author's  sanction,  in- 
corporated a  number  of  notes  based  upon  his  own  laboratory 
work  in  the  same  direction. 

Petit  Compendium  Medical.  Quintessence  de  Patho- 
logic, Therapeutique,  et  Medecine  I'suelle.  Par  le  DOC- 
TEUR Antonin  Bossu,  Medecin  Honor.aire'de  I'lnfirmerie 
Marie-Thercse.  Third  edition,  revised  and  enlarged. 
Paris:  Ancienne  Hbrairie  Germer  Bailliereet  Cie.  Felix 
Alcan.  1S95. 
When  we  read  that  this  is  an  enlarged  edition  we  wonder 
what  the  earlier  ones  were,'for  it  is  the  smallest  volume  that 


August  lo,  1895] 


MEDICAL    RECORD. 


one  could  well  think  of  as  a  medical  work.  It  does  not  con- 
tain much  to  interest  the  American  student  unless  it  be  used 
as  an  aid  in  acquiring  French  medical  terms.  The  arrange- 
ment is  alphabetical,  but  the  word  you  seek  is  usually  the 
one  which  has  been  left  out. 

Atlas  of  the  Diseases  of  the  Skin.  In  a  Series  of  Illus- 
trations from  Original  Drawings  with  Descriptive  Letter- 
press. By  H.  Radcliffe  Crocker,  M.D.,  F.R.C.P., 
Physician,  Skin  Department,  University  College  Hospital, 
London  ;  formerly  Physician  to  the  East  London  Hos- 
pital for  Children  ;  Examiner  in  Medicine,  Apothecaries' 
Hall,  London.  Fasciculus  IX.  Edinburgh  and  London  : 
Young  J.  Pentland.    New  York  :  Macmillan  &  Co. 

We  have  already  noticed  the  preceding  eight  fasciculi  of 
this  important  work.  The  ninth  begins  the  second  half  of 
the  series.  The  plates  comprise  lithographs  of  Hydroa 
Herpetiforme,  Pityriasis  Rubra,  both  of  which  deserve  special 
mention  ;  Ichthyosis  Hystrix  and  Tylosis,  well  illustrated  in 
six  figures  ;  Psoriasis  Punctata,  Ichthyosis  Congenita,  and 
Lupus  Erythematosus.  The  last-named  plate  has  three  fig- 
ures, showing  the  affection  as  it  involves  the  scalp,  the  face, 
and  the  nose.  In  some  instances  it  is  fortunate  that  the  de- 
scriptive text  contains  a  history  of  the  case  portrayed,  since 
there  are  occasional  departures  from  the  type  which  would 
without  this  not  be  so  clear  or  instructive.  Dermatologists 
will  be  much  more  interested  in  this  production  than  general 
practitioners,  and  indeed  few  could  aftbrd  the  outlay.  There 
will,  as  inferred,  be  sixteen  parts  at  six  dollars  each.  It  has 
the  merit  of  being  strictly  original,  for  the  most  part  per- 
sonal to  the  author,  and  the  execution  has  been  accom- 
plished with  all  the  modern  improvements  in  the  art  of  plate- 
making. 

The  Deformities  of  the  Humax  Foot.  With  their 
Treatment.  By  W.  J.  Walsha.M,  M.B.,  CM.  Aberd., 
F.R.C.S.  Eng.,  Senior  Assistant-Surgeon,  Surgeon  in 
Charge  of  the  Orthopedic  Department,  and  Lecturer  in 
Anatomy,  St.  Bartholomew's  Hospital ;  and  William 
Kent  Hughes,  M.B.  Lond.,  M.B.  Melb.,  M.R.S.C.  fc:ng., 
L.R.C.P.  Lond.  ;  Orthopedic  Surgeon,  St.  Vincent's  Hos- 
pital ;  Assistant-Surgeon,  Children's  Hospital,  Melbourne  ; 
Surgical  Tutor,  Trinitv  College,  Melbourne.  New  York: 
William  Wood  &  Co. '   1S95. 

The  writers  of  this  work  have  done  a  service  to  their  fellows 
in  giving  them  within  the  covers  of  a  single  volume  all  that 
they  can  possibly  need  or  want  to  know  in  respect  to  de- 
formities of  the  foot.  The  only  fault  is  that  the  writers  have 
perhaps  been  too  thorough  in  their  review  of  orthopedic  prac- 
tice, and  have  given  the  perplexed  physician  the  choice  of 
so  many  methods  and  forms  of  appliances  that  he  is  left  in 
almost  as  much  doubt  as  before.  However,  the  writers  al- 
ways state  their  preference  and  practice  in  the  case  of  the 
deformity  in  question,  and  the  reader  will  not  go  far  astray 
if  he  follow  them.  The  work  is  excellently  gotten  up,  with 
numerous  original  and  well-executed  illustrations  of  casts 
and  dissections  of  deformities,  and  of  instruments.  The 
book  is  one  that  will  serve  as  a  work  of  reference  for  the 
general  practitioner  as  well  as  a  reliable  and  complete  text- 
book for  the  orthopedic  student  and  specialist. 

A  System  of  Surgery.  By  American  Authors.  Edited 
by  Frederic  S.  Dennis,  M.D.,  Professor  of  the  Princi- 
ples and  Practice  of  Surgery,  Bellevue  Hospital  Medical 
College,  New  York  ;  President  of  the  American  Surgical 
Association,  etc.,  assisted  by  John  S.  Billings,  M.D., 
LL.D.,  D.C.L.,  Deputy  Surgeon-General,  U.  S.  A.  Vols. 
I.  and  II.     Philadelphia  :  Lea  Brothers  &  Co.     1895. 

This  system  of  surgery  edited  by  Professor  Dennis  is  in- 
tended to  represent  American  surgery  pure  and  simple,  and 
numbers  among  its  contributors  a  goodly  share  of  repre- 
sentative men.  It  is  to  be  completed  in  four  volumes.  Al- 
though not  professedly  a  pioneer  in  the  matter  of  strictly 
American  authorship  in  its  own  branch  it  promises  to  cover 
the  field  very  effectually  and  elaborately.  The  present  vol- 
umes contain  the  History  and  Literature  of  Surgery,  by  Dr. 
Billings ;  Surgical  Pathology,  including  Inflammation  and 
the  Repair  of  Wounds,  by  Dr.  William  T.  Councilman  ; 
General  Bacteriology  of  Surgical  Infections,  by  Dr.  William 
H.  Welch  ;  Symptoms,  Diagnosis,  and  Treatment  of  Inflam- 
mation, Abscess,  Ulcer,  Gangrene,  by  Dr.  Charles  B.  Nan- 
crede  ;  Septicaemia,  Pyasmia,  and  Poisoned  Wounds,  by  Dr. 
W.  H.  Carmalt ;  Traumatic  Fever,  Erysipelas,  and  Tetanus, 
by  Dr.  J.  Collins  Warren  ;  Rabies  and  Hydrophobia,  by  Dr. 
Herman  M.  Biggs  ;  Gun-shot  Wounds,  by  Dr.  P.  S.  Conner  ; 
Fractures  and  Dislocations,  by   Dr.    Frederic  S.   Dennis  ; 


Anaesthesia,  by  Dr.  Horatio  C.  Wood  ;  The  Technique  of 
Antiseptic  and  Aseptic  Surgery,  by  Dr.  Arpad  G.  Gerster ; 
Operative  Surgery,  by  Dr.  Stephen  Smith  ;  Minor  Surgery, 
by  Dr.  Henry  R.  Wharton  ;  Plastic  Surgery,  by  Dr.  George 
R.  Fowler  ;  Military  Surgery  and  the  Care  of  the  Wounded 
on  the  Battle-field,  by  Dr.  William  H.  Forwood  ;  Diseases 
of  the  Bones,  by  Dr.  Nicholas  Senn  ;  Orthopaedic  Surgery, 
by  Dr.  Virgil  P.  Gibney ;  Aneurism,  by  Dr.  Lewis  A. 
Stimson  ;  Surgery  of  the  Arteries  and  Veins  (exclusive  of 
Aneurism),  by  Dr.  Frederic  S-  Dennis ;  Surgery  of  the 
Lymphatic  System,  by  Dr.  Frederic  H.  Gerrish  ;  Diseases 
and  Injuries  of  the  Head,  by  Dr.  Roswell  Park  ;  Surgery  of 
the  Spine,  by  Dr.  W.  N.  Keen  ;  and  Surgery  of  the  Nerves, 
by  Dr.  John  B.  Roberts. 

It  will  be  seen  that  the  subjects  are  reasonably  well  se- 
lected to  give  variety  and  interest  to  the  publication,  and 
are  unquestionably  representative  and  distributive.  Some 
of  the  authors  have  succeeded  admirably  in  their  man- 
agement of  subjects,  while  others  have  evidently  found  it 
impossible  to  compass  many  of  the  important  points  within 
the  required  scope.  There  is  this  to  be  said  in  qualification, 
that  all  the  writers  are  experienced  men,  and  it  is  fair  to 
assume  that  the  best  has  been  done  to  fulfil  the  laudably 
ambitious  endeavors  of  the  talented  editor.  The  article  by 
Dr.  Billings  is  a  masterpiece  of  thoroughness,  but  is  much 
too  long  for  a  work  of  this  size.  The  articles  on  surgical 
pathology,  bacteriology,  septicsemia,  and  traumatic  fever 
are  models  of  their  kind  and  amply  fulfil  the  expectations 
of  their  readers.  The  same  may  be  said  of  those  on  anti- 
septic and  operative  surgery,  and  on  fractures  and  dislo- 
cations. The  indexes  are  by  no  means  as  complete  as  they 
ought  to  be  in  a  work  of  this  kind.  The  work  is  profusely 
illustrated,  is  fairly  printed,  but  very  slovenly  bound. 

Abstract  of  Sanitary  Reports.  Vol.  IX.  Washing- 
ton, D.  C.     1S95. 

Volume  IX.  of  this  interesting  and  instructive  series  is  of 
unusually  large  size,  and  contains  much  valuable  material 
for  the  student  of  public  health.  The  supervising  surgeon- 
general  of  the  Marine  Hospital  is  to  be  congratulated  on  the 
success  of  his  endeavors  to  so  admirably  systematize  the 
work  of  his  bureau. 

The  History  of  Prostitution,  its  Extent,  Causes, 
AND  Effects  Throughout  the  World.  By  Will- 
iam W.  Sanger,  M.D.,  late  Resident  Physician  Black- 
well's  Island,  N.  Y.,  etc.  8vo,  pp.  709.  New  York: 
American  Medical  Press. 

This  work,  first  published  over  thirty  years  ago,  again  makes 
its  appearance  with  additions  and  comments  from  the  well- 
known  syphilographers,  Drs.  R.  W.  Taylor,  Prince  A.  Mor- 
row, and  F.  R.  Sturgis.  The  elaborate  study  of  the  subject 
by  the  original  author  gave  it  long  since  a  leading  position 
as  a  thoroughly  scientific  contribution  to  a  much  tabooed 
topic.  The  chaste  and  discretionary  methods  of  presenta- 
tion prove  how  much  science  can  make  pure  everything  it 
touches.  As  the  title  indicates,  the  work  treats  of  prosti- 
tution from  the  earliest  times  to  the  present  in  every  coun- 
try. To  the  student  of  sociology  the  data  are  of  more  than 
ordinary  interest,  as  proving  how  even  general  and  varied 
effects  depend  upon  common  and  well-recognized  causes. 
The  question  of  control  of  prostitution  by  legal  enactments 
is  very  fully  discussed,  and  all  its  different  aspects  are  quite 
impartially  considered,  not  only  in  reference  to  its  bearing 
on  social  questions,  but  what  is  equally  important,  to  the 
possibility  of  control  of  sexual  disease-. 

Treatment  of  Fractures  by  Massage  and  Mobiliz.\- 
tion  (Movement).  By  Dr.  Just  Lucas-Champion- 
NlfeRE,  Surgeon  to  Hospital  Beaujou,  Member  of  Acad- 
emy of  Medicine,  President  of  the  Surgical  Society  of 
Paris.     Paris:    Rueff  &  Co.     1895. 

This  work  is  a  distinct  innovation  regarding  the  generally 
accepted  treatment  of  fractures  by  rest  and  immobility. 
The  author  believes  that  massage  in  given  quantity  and 
quality  should  be  the  essential  feature  in  the  treatment  of 
all  cases  of  fracture,  and  more  particularly  in  those  involv- 
ing the  joints.  His  arguments  in  favor  of  his  method  are 
ingenious,  and  in  some  respects  are  quite  plausible,  especi- 
ally such  as  refer  to  the  maintenance  of  stimulated  circula- 
tion as  an  important  element  of  repair.  His  remarks  on 
the  necessity  of  maintaining  mobility  in  joint  fractures  com- 
mend themselves  to  the  good  judgment  of  surgeons,  and  al- 
together the  work  is  a  very  suggestive  one,  and  from  such  a 


204 


MEDICAL   RECORD. 


[August  lo,  1895 


stand-point  is  well  worthy  of  perusal.  The  very  novelty  of 
the  ideas  advanced  will  doubtless  attract  much  attention  to 
this  work.  As  might  be  expected  the  author  does  not  favor 
splints  save  in  exceptional  instances,  but  prefers  well-ad- 
justed bandages,  after  massage  has,  according  to  him,  done 
its  perfect  work. 

The  Filtration  of  Public  Water-supplies.  By  Al- 
len Hazen,  late  Chemist  in  Charge  of  the  Lawrence 
Experiment  Station  of  the  Massachusetts  State  Board  of 
Health.  8vo,  pp.  197.  New  York  :  John  Wiley  &  Sons. 
.S95. 

The  author  has  presented  a  very  thorough  work  on  the  sub- 
ject in  question,  dealing  with  all  the  different  varieties  of  fil- 
tration, and  oft'ers  some  very  conclusive  arguments  in  favor 
of  its  adoption  in  all  the  usual  methods  of  water-supply. 
The  work  also  contains  a  very  instructive  appendix  giving 
the  German  official  regulation  in  regard  to  filtration. 

Transactions  of  the  Southern  Surgical  and  Gyne- 
cological Association.  Vol.  VII.  8vo,  pp.  336.  Pub- 
lished by  the  Association.     1895. 

This  volume  contains  a  very  good  variety  of  practical  sub- 
jects bearing  upon  surgical  and  gjnecological  matters  and 
will  take  a  worthy  place  with  its  predecessors. 

Vital  Statistics  of  Boston  and  Philadelphia  for 
Six  Years  Ending  May  31,  1890.  By  John  S.  Bil- 
lings, M.D.,  Deputy  Surgeon  -  General  United  States 
Army,  Expert  Special  Agent.  4to,  pp.  266.  Washing- 
ton, D.  C,  Government  Printing  Office.     1895. 

This  is  a  very  elaborate  and  instructive  report  of  the  vital 
statistics  of  the  cities  named,  and  contains  their  divisions  in 
sanitary  districts,  indicating  the  prevalent  diseases  of  the 
same  as  shown  by  maps  in  different  colors.  Compiled  as 
they  are  from  the  health-board  reports  they  are  as  reliable 
as  they  can  be  made,  and  present  statistical  information 
which  is  of  the  greatest  value  to  the  statistician  and  hygien- 
ist. 

Buried  Alive.  An  Examination  into  the  Occult  Causes 
of  Apparent  Death,  Trance,  and  Catalepsy.  By  Franz 
Hartmann,  M.D.     1S95. 

This  work  treats  in  a  very  serious  mood  the  possibility  of 
being  buried  alive,  relates  some  probable  instances  of  such 
a  calamity,  and  insists  upon  the  value  of  putrefaction  as  a 
test  of  actual  death. 


©liuical  giepartmeut. 

A  CASE  OF  PRIMARY  POST-PARTUM  HEM- 
ORRHAGE —  PUERPERAL  SEPTICEMIA 
AND  DEATH. 

By  W.  D.   HUMPHREY.  A.M.,  M.D.. 

VIRGINIA,    ILL. 

In  the  April  number  of  the  American  Journal  of  Ob- 
stetrics a  case  of  "  Secondary  Post-partum  Hemor- 
rhage— Septicremia  and  Death,"  was  reported  by  Dr. 
E.  L.  Tompkins,  of  Washington,  D.C.  I  desire  to  re- 
port a  case  of  "  Primary  Post-partum  Hemorrhage — 
Puerperal  Septicemia  and  Death."  In  the  former 
case  the  hemorrhage  was  due  to  disturbance  of  the 
nervous  system,  mental  grief.  In  the  latter,  the  hem- 
orrhage is  of  an  entirely  different  origin. 

I  was  summoned  by  a  messenger  on  Sunday  morn- 
ing, February  17th,  to  the  residence  of  Mrs.  C.  F. 
C ,  who  resided  three  miles  in  the  country.  I  ar- 
rived about  seven  thirty,  and  found  her  engaged  in  the 
second  stage  of  labor,  with  the  third  child.  I  barely 
had  time  to  get  my  coat  off  and  thoroughly  disinfect 
my  hands  when  the  labor  was  abruptly  terminated.  I 
handed  the  child  to  the  attendant,  and  was  preparing 
to  extract  the  placenta,  when  I  felt  another  head  pre- 
senting. In  a  few  minutes  the  second  child  was  born, 
and  in  a  short  time  the  large  placentx  were  expelled, 
but  the  uterus  failed  to  retract.  In  less  time  than  it 
takes  to  tell  it,  a  violent  hemorrhage  occurred.  The 
flood-gates  seemed  to  have  been  thrown  wide  open,  for 


the  blood  gushed  out  in  a  perfect  torrent.  An  immense 
amount  of  blood  was  lost.  It  soaked  through  two  or 
three  thicknesses  of  an  old  quilt,  a  mattress,  and  formed 
a  large  pool  on  the  floor.  The  patient  was  rendered 
pulseless  and  collapse  seemed  imminent.  I  had  the 
head  lowered,  placed  hot  irons  to  the  extremities, 
administered  ergot  by  the  mouth,  and  injected  hypo- 
dermatically  whiskey  and  digitalis.  I  introduced 
one  hand  into  the  vagina,  and  with  the  other  grasped 
the  uterus  through  the  abdominal  wall.  Under 
the  above  methods  the  uterus  soon  contracted  and 
hemorrhage  was  under  control.  Whiskey  in  a  little 
hot  water  was  given  occasionally.  The  pulse  soon  be- 
gan to  improve  in  force,  and  by  noon  the  patient  had 
rallied  from  her  perilous  condition.  I  saw  the  case  in 
the  afternoon  about  four  o'clock.  She  was  able  to  talk 
and  laugh  some.  Pulse  still  improving.  Temperature, 
normal.  I  ordered  a  saline  laxative  to  be  given  in  the 
morning,  which  moved  the  bowels  freely.  I  called 
again  on  Monday  morning  and  found  her  feeling  quite 
well.  Temperature,  normal.  Uterus,  well  contracted. 
She  complained  of  nothing,  except  occasionally  of 
after-pains.  After  gi\'ing  the  necessary  instructions 
I  left,  expecting  that  all  would  be  well  ;  but  such  was 
not  the  case.  She  was  taken  with  a  chill  on  Monday 
night  about  nine  o'clock.  I  was  not  sent  for  until 
Tuesday  morning.  The  temperature  then  was  104°  F.  ; 
respiration,  40  ;  pulse,  120.  She  complained  of  intense 
pain  over  uterus.  There  was  some  slight  tenderness, 
but  the  abdomen  was  not  tympanitic.  The  skin  was 
hot  and  dry  ;  the  tongue  was  dry  and  covered  with 
thick  brown  coat,  and  the  thirst  was  intense.  The 
lochial  discharge  was  scanty  and  quite  offensive.  I  re- 
mained all  day  Wednesday.  The  temperature  was 
105°  F.  ;  pulse,  140  ;  respiration,  40.  The  intense 
thirst  continued.  The  face  was  pinched  and  bore  an 
anxious  expression,  and  was  occasionally  bathed  in  pro- 
fuse perspiration.  It  now  began  to  assume  a  livid  hue. 
Great  irritability  of  the  stomach  began  and  continued 
with  unabated  frequency.  She  vomited  a  large  quan- 
tity of  black,  grumous  matter,  which  proved  to  be  disin- 
tegrated blood,  indicating  an  extensive  capillary  hem- 
orrhage from  the  walls  of  the  stomach.  She  continued 
to  grow  worse,  and  died  comatose  at  nine  o'clock  Wed- 
nesday, about  seventy-two  hours  after  the  confinement. 

It  is  hardly  necessary  to  go  into  details  in  regard  to 
the  treatment  of  the  case.  Strict  antisepsis  was  carried 
out.  Treatment  was  local  and  constitutional.  A  three 
per  cent,  solution  of  carbolic  acid  and  creolin  was  em- 
ployed for  irrigating.  Alcohol  and  quinine  were  ad- 
ministered internally,  and  they,  together  with  cold 
sponging,  proved  most  useful  in  reduction  of  tem- 
perature. By  cold  sponging  the  temperature  was  re- 
duced from  105°  to  102°  F.,  but  it  returned  again  to 
the  old  mark  in  two  hours. 

The  important  point  to  call  attention  to  is  the  cause 
of  hemorrhage.  While  inertia  of  the  uterus  is  probably 
the  most  frequent  cause,  there  are  others  of  equal  im- 
portance. Inertia  is  most  often  manifested  after  a 
rapid  or  an  exceedingly  long  labor  ;  or  it  may  be  due 
to  great  distention  of  the  uterus,  as  in  twins,  polyhy- 
dramnois,  etc.  Although  due  to  the  above  factors,  it 
is  frequently  associated  with  certain  pathological  con- 
ditions. In  this  case  I  do  not  think  that  the  inertia 
was  due  entirely  to  the  rapid  labor  and  extreme  disten- 
tion of  the  uterus,  but  to  a  deranged  condition  of  the 
blood.  The  primary  cause  was,  no  doubt,  of  constitu- 
tional origin  ;  and  if  the  full  history  of  the  case  could 
have  been  elicited  the  exact  condition  might  have 
been  known,  but  it  was  probably  splenic  an?emia  or 
some  allied  condition.  The  puerperal  septicemia 
which  followed  had  no  connection  whatever  with  the 
hemorrhage.  They  are  separate  and  distinct  condi- 
tions, and  the  former  was  not  a  sequence  of  the  latter. 
I  am  unable  to  account  for  the  origin  of  the  septicae- 
mia which  destroyed  this  woman's  life.  I  know  that  this 
awful  disease,  this  terror  of  the  puerperium,  is  due  to  the 


August  lo,   1S95] 


MEDICAL   RECORD. 


205 


introduction  of  septic  bacteria  into  the  genital  tract. 
Puerperal  septicEeraia  is  heterogenetic  and  contagious. 
The  doctrine  of  autogenesis  has  been  exploded.  The 
poison  must  come  from  without,  and  in  this  case  either 
the  attendants  or  physician  were  to  blame.  I  am  able 
to  exonerate  myself,  from  the  fact  that  I  was  not  at- 
tending on  any  contagious  disease  at  the  time,  and  had 
employed  antiseptic  precautions.  The  husband  of  the 
patient,  being  exceedingly  penurious,  refused  to  employ 
a  nurse  until  it  was  too  late.  She  was,  therefore,  at- 
tended by  persons  who  had  no  experience  whatever  in 
the  management  of  such  cases,  and  did  not  receive  the 
proper  care  and  attention  which  she  ought  to  have 
had. 


hemiplegia,  involving  even  the  muscles  of  deglutition 
to  such  a  degree  that  it  was  necessary  to  feed  her  per 
rectum  for  five  days.  She  died  thirty-two  days  after 
operation,  and  yet  from  a  cause  in  no  way  connected 
with  the  operation,  as  she  had  been  the  \'ictim  of  right 
hemiplegia  (in  a  less  degree)  seven  and  nine  years  ago  ; 
i.e.,  this  was  the  third  attack. 


DOUBLE    OVARIOTOMY   IN   A   WOMAN  SEV- 
ENTY-ONE YEARS   OF  AGE— RECOVERY. 

By  F.  F.  L.\WREXCE,  M.D., 

COLUUBUS,  O. 

The  following  case  presents  some  features  not  fre- 
quently encountered  by  the  abdominal  surgeon,  viz., 
the  extreme  age  of  the  patient,  the  size  of  the  tumor, 
the  fusion  of  the  cystic  and  solid  growths,  each  ha\ing 
separate  pedicles,  the  cyst  from  left,  and  solid  from 
right  side  ;  and,  finally,  the  complete  recovery  of  the 
patient. 

Mrs.  B ,  aged  seventy-one,  first  noticed  a  tumor 

two  and  a  half  years  ago.  The  growth  was  very  rapid. 
In  April,  1894,  she  was  tapped  and  thirty-eight  pounds 
of  fluid  removed.  The  sac  refilled  rapidly,  and  was 
again  tapped  in  November,  when  fiftj'-eight  pounds 
were  removed.  The  tumor  rapidly  refilled,  and  in 
Januar)',  1895,  she  was  again  tapped,  but  owing  to  the 
occurrence  of  shock  only  thirty-four  pounds  of  fluid 
were  withdrawn.  After  the  second  and  third  tappings 
there  was  some  peritonitis.  After  the  third  tapping  a 
large  solid  mass  was  discovered  in  right  side. 

The  operation  was  performed  on  February  i6th. 
There  were  extensive  adhesions  to  the  parietes,  intes- 
tine, omentum,  diaphragm,  and  bladder.  While  I  was 
breaking  loose  the  broad  band  of  adhesion  to  the  dia- 
phragm respiration  stopped.  Aside  from  this,  the 
operation  was  without  incident.  On  turning  out  the 
tumor  it  was  discovered  to  have  two  distinct  pedicles. 
That  from  the  left  side  being  long  and  broad,  and  in  it 
the  left  Fallopian  tube  could  be  noted.  That  from  the 
right  side  to  the  solid  portion  of  the  tumor  was  broad 
and  short,  and  contained  the  right  Fallopian  tube. 
Both  pedicles  were  tied  off ;  the  numerous  adhesions 
were  tied  and  the  wound  closed,  a  drainage-tube  being 
inserted  in  the  lower  angle.  The  patient  was  put  to 
bed  forty-three  minutes  after  the  beginning  of  the  ad- 
ministration of  chloroform.  Shock  was  quite  severe. 
The  drainage-tube  was  removed  at  3  a.m.  on  February 
17th.  The  progress  from  that  on  was  uneventful. 
The  patient  sat  up  in  bed  on  the  fourteenth  day,  and 
in  the  chair  on  the  sixteenth  day. 

The  weight  of  the  tumor  was  eight}'-four  pounds. 
The  cyst  is  a  simple  multilocular  one.  The  solid  por- 
tion is  not  simply  adherent  to  the  cyst,  but  there  is 
absolute  fusion. 

Another  feature  of  the  case  worthy  of  note  is,  that  in 
1887  the  woman  had  right  hemiplegia,  which  did  not 
entirely  disappear  for  two  years.  Up  to  the  present 
date,  March  Sth,  there  has  been  absolutely  no  indica- 
tion of  any  trouble  of  any  kind.  The  highest  pulse 
has  been  88,  and  the  highest  temperature  99.2°  F.  So 
that  I  presume  it  is  fair  to  call  it  a  complete  surgical 
recovery.  Today  the  patient  is  sitting  up  and  feeling 
"  better  than  for  years." 

103  XoKTH  Fourth  Street. 

P.S. — After  the  patient  was  convalescent — in  fact, 
after  she  had  been  sitting  up  for  ten  days  or  more — she 
had  an  apoplectic  seizure,  resulting  in  complete  right 


VAGINAL    HYSTERECTOMY    FOR   CARCINO- 
MA  OF  THE  NECK  OF  UTERUS. 

Bt  .\.   ERNEST  McMAHOX.  .M.D., 

SL\SSHA1  L,    TEX. 

Aboxjt  five  weeks  since  I  was  called  upon  to  operate 
upon  a  patient  of  Drs.  Blalock,  of  Woodlawn,  Tex.,  and 
Baldwin,  of  Ferns,  Tex.,  for  carcinoma  of  the  neck  of 
the  uterus.  Hemorrhages  had  been  very  severe,  but  as 
yet  no  fixation  had  taken  place,  so  I  decided  to  perform 
vaginal  hysterectomy.  The  patient  was  a  white  woman, 
very  anaemic,  and  forty-three  years  of  age. 

After  preparing  patient  and  anaesthetizing  her.  Dr. 
Baldwin  administering  the  chloroform,  I  proceeded  to 
operate,  and  removed  the  uterus  by  the  method  de- 
scribed by  Dr.  Garceau,  in  the  American  Jcurnal  of 
Obstetrics,  March,  1895. 

The  patient  has  made  a  complete  and  uninterrupted 
recovery — at  no  time  did  the  temperature  go  above 
99°  F.,  and  she  is  now  enjoying  good  health  and  walk- 
ing about. 

The  operation  of  vaginal  hysterectomy  I  consider  a 
good  one  whenever  it  can  be  carried  out,  and  all  that 
is  necessary  is  a  thorough  knowledge  of  the  anatomy  of 
the  parts  and  a  careful  operator. 


Socictij  Reports. 

NEW   YORK   ACADEMY   OF   MEDICINE. 

SECTION  OX  GEXER.\L  MEDICINE. 

Tuesday  Evening,  May  2J,  iSQj. 

Louis  Faugeres  Bishop,  M.D.,  Chairjian,  pro  tem. 

Further  Report  of  Aehylia  Gastrica. — Dr.  Max  Ein- 
HORX  read  the  paper  (see  p.  5).  In  discussing  the  sub- 
ject Dr.  Fektox  B.  Turck  said  that  the  paper  was  a 
most  excellent  one,  and  he  had  no  criricism  to  offer  upon 
it,  yet  he  wished  to  say  that  he  saw  no  reason  for  the  name 
aehylia  gastrica.  That  which  was  called  aehylia  was  a 
symptom  and  must  be  due  to  some  pathological  cause, 
and  he  thought  the  name  was  hardly  justifiable  as  being 
applied  to  a  s>'mptom.  The  glandular  elements  of  the 
stomach  seemed  to  suspend  their  functions  for  a  time, 
but  the  motor  elements  remained  active.  The  same 
nerves  controlled  both  these  functions,  and  paralysis 
would  cause  the  paralysis  of  both,  but  as  the  motor 
function  was  not  affected  it  could  not  be  considered  a 
paralysis  with  atrophy  of  the  glands.  Dr.  Stewart,  of 
Philadelphia,  had  found  cases  in  which  there  was  a  re- 
turn of  glandular  activity  after  suspension  for  a  period 
of  nine  years,  so  it  seemed  possible  that  in  some  cases 
there  might  be  partial  atrophy  of  the  glandular  elements. 
This  partial  atrophy  might  be  due  to  anaemia,  or  to  a 
lack  of  nutrition,  for  the  glands  must  receive  a  proper 
amount  of  blood,  and  if  this,  for  any  reason,  was  insuffi- 
cient, the  secretions  would  be  suspended,  but  would 
appear  with  the  return  of  the  proper  blood-supply. 
This  was  illustrated  in  shock,  where  there  was  an  arrest 
and  then  a  return  of  the  blood-supply.  He  had  known 
of  cases  in  which  the  glandular  secretions  had  been  re- 
stored by  the  use  of  hot  water  and  massage,  and  one  case 
in  which,  after  an  absence  for  three  years,  hydrochloric 


206 


MEDICAL   RECORD. 


[August  lo,  i< 


acid  was  obtained  by  irritation  of  the  mucous  mem- 
brane for  fifteen  minutes  with  the  gyrometer. 

The  cases  which  the  writer  had  mentioned  in  his 
paper  were  especially  interesting  as  showing  that  the 
mucous  membrane  was  not  necessarily  affected.  An 
analogy  of  this  condition  was  found  in  a  number  of  or- 
gans of  the  body,  as  in  the  kidney  where  there  was  a 
suspension  of  function  without  atrophy  of  the  glandular 
structure.  He  had  obtained  from  the  stomach  in  which 
glandular  activity  had  ceased  shreds  of  mucous  mem- 
brane, and  found  on  examination  that  the  glands  were 
not  atrophied. 

Dr.  Louis  F.  Bishop  thought  the  author  of  the  pa- 
per deserved  much  credit  for  the  work  which  he  had 
done  upon  the  subject.  It  took  a  great  deal  of  time 
and  care  in  carrying  out  the  investigations.  The  work 
of  applying  the  different  tests,  and  the  extreme  care 
that  was  necessary  to  avoid  error,  made  the  task  very 
arduous. 

In  closing  the  discussion  Dr.  Eixhorn  said  he 
thought  he  was  justified  in  giving  the  name  achylia,  as 
it  was  possible  for  patients  to  get  along  very  well  with- 
out the  gastric  juice  if  the  intestines  had  adapted  them- 
selves to  that  condition.  Moreover,  he  did  not  see  any 
reason  for  not  giving  the  name  when  the  whole  line  of 
treatment  depended  upon  this  condition  found  in  the 
stomach.  In  some  cases  there  was  atrophy  of  the 
glands  and  in  some  not,  and  if,  after  a  time,  there  was 
a  return  of  gastric  juice,  it  must  be  concluded  that 
there  was  some  other  reason  for  the  previous  condition 
than  the  atrophy  of  the  glands. 

The  Flechsig  Method  in  the  Treatment  of  Insane  Ep- 
ileptics.— Dr.  L.  Pierce  Cl.-vrk:  read  the  paper  on  the 
above  subject.  He  said  that  the  treatment  and  tlie  eti- 
ology were  so  closely  related  that  he  would  have  to 
mention  them  together.  It  was  his  opinion  that  trauma, 
as  an  etiological  factor,  had  been  over-estimated,  for 
friends  of  tlie  unfortunate  patient  would  easily  remem- 
ber some  fall  or  slight  injury  that  had  been  received  at 
sometime,  and  thus  would  the  conclusion  be  reached 
that  trauma  was  the  cause.  Heredity  was  undoubtedly 
the  most  important  factor  in  the  etiology  of  epilepsy, 
and  he  believed  that  it  was  the  cause  in  more  than  fifty 
per  cent,  of  the  cases.  There  was  no  doubt  that  in 
many  families  it  was  Xature's  law  of  the  survival  of  the 
fittest,  for  these  persons  were  not  fit  to  propagate  the 
species,  and  so  Nature  placed  her  seal  upon  one  as  a 
criniinal,  another  as  a  consumptive,  etc.,  but  as  the  phy- 
sician could  not  judge,  he  had  to  do  the  best  he  could 
to  relieve  the  condition  as  it  was  found. 

It  could  be  reasonably  hoped  that  the  researches  that 
were  being  made  as  to  changes  in  the  nervous  system 
and  the  degeneration  of  the  nerve-cells  would  throw 
more  light  upon  this  subject  of  epilepsy.  There  were 
patients  who  contracted  epilepsy,  though  living  under 
good  conditions  and  at  that  age  when  least  expected, 
i.e.,  fifty  to  sixty  years,  and  others  seemed  to  get  well 
of  themselves. 

The  bromide  treatment  had  held  its  sway,  and,  though 
good,  yet  in  most  cases,  and  especially  in  cases  of  epi- 
leptic insanity,  it  only  held  back  the  attacks  for  a  time, 
and  finally  there  was  a  breaking  over.  It  was  seldom 
given,  therefore,  with  the  idea  of  effecting  a  cure,  but 
by  helping  to  restrain  the  fits  it  made  matters  easier  for 
the  keei)ers. 

In  order  to  give  the  Flechsig  method  of  treating 
epilepsy  a  trial,  the  writer  had  used  it  on  ten  patients 
in  the  Connecticut  Insane  Asylum.  The  first  patient 
had  a  history  of  hereditary  epilepsy,  and  fifteen  years 
ago  had  begun  to  have  epileptic  fits,  and  at  jiresent 
has  about  the  intelligence  of  an  eight-year-old  child. 
The  bromide  treatment  had  restrained  the  attacks 
for  awhile,  but  they  had  broken  over  the  restraint. 
She  was  put  on  the  opium-bromide  treatment,  and 
though  the  attacks  were  less  fretjuent  for  i  time,  they 
returned,  but  she  was  more  easily  managed. 

In  the  second  patient  the  attacks  were  rendered  less 


frequent,  but  the  stupor  was  increased  and  the  dementia 
hastened.  The  third  patient  gave  the  peculiar  historj' 
of  contracting  acute  Bright's  disease  during  the  opium 
treatment.  It  was  generally  agreed  that  the  bromides 
act  upon  the  epithelium  of  the  kidney,  and  it  was 
probable  that  in  this  case  the  opium  had  just  begun  to 
have  an  effect,  and  the  bromide  caused  the  albumin. 
The  opium  affected  the  fourth  patient  very  badly  and 
the  gastric  disturbances  were  severe. 

The  fifth  case  was  a  woman,  forty- seven  years  of 
age,  with  a  history  of  hereditary  epilepsy.  She  had 
the  first  fit  on  her  twelfth  birthday  and  since  then 
at  various  times.  The  bromide  treatment  affected 
her  badly  at  all  times  and  the  opium  had  no  influence 
for  good.  The  treatment  increased  her  stupor.  The 
sixth  case  received  no  benefit  from  the  opium  treat- 
ment. When  the  seventh  case  was  put  upon  it  the 
patient  said  he  felt  better,  but  the  number  of  fits  was 
increased.  He  improved  on  the  bromide  treatment, 
but  was  the  only  one  that  did.  The  eighth  case  was 
very  much  reduced  in  strength  by  the  bromide  neces- 
sary to  have  an  effect,  and  opium  rapidly  increased 
the  dementia.  The  ninth  patient  enjoyed  the  drowsi- 
ness produced  by  the  opium,  which  increased  the 
stupor  and  dementia.  The  tenth  patient  suffered 
from  aura  rising  from  the  epigastrium  to  the  third 
rib,  and  an  accumulation  of  saliva,  so  that  when  speak- 
ing it  sounded  like  a  blubbering  through  water.  This 
case  was  somewhat  uncommon  in  the  fact  that  the 
expulsion  of  saliva  often  took  the  place  of  the  fit. 
The  patient  improved  for  a  time  under  the  Flechsig 
treatment,  but  within  seven  months  the  power  of  con- 
trol had  ceased. 

It  seemed  proper  to  conclude,  therefore,  that  there 
was  no  fixed  law  by  which  we  could  prescribe,  and  we 
were  forced  to  the  conclusion  that  the  Flechsig  treat- 
ment was  little  better  than  the  bromide  treatment. 

Though  epilepsy  was  a  mental  degeneration,  the 
body  was  generally  healthy.  Muscular  exertion  had 
a  tendency  to  sustain  the  bodily  health.  The  question 
was  important  whether  the  restraining  of  cell  explosion 
gradually  diminished  the  tendency  to  explode,  or 
whether  it  was  but  a  damming  back  for  a  time,  to  be 
followed  with  a  severer  outbreak  with  its  consequent 
effects.  It  seemed  proper  to  conclude,  at  least,  that 
the  use  of  the  opium  treatment  was  of  little  value. 

In  discussing  the  preceding  paper.  Dr.  Frederick 
Peterson  stated  that  he  had  tried  the  Flechsig  method 
of  treating  epilepsy  with  opium  and  bromides  in  a 
large  number  of  cases  since  the  publication  of  the  new 
treatment  by  its  author.  In  cases  which  resisted 
ordinary  metliods,  in  the  obstinate  chronic  cases  with 
frequent  attacks  where  nothing  seemed  to  avail,  it  often 
produced  very  beneficial  results.  It  is  a  means  which 
should  only  be  resorted  to,  he  believed,  in  this  par- 
ticular class  of  epileptics.  Certain  cases  which  he  had 
observed  had  presented  some  of  the  mental  symptoms 
characteristic  to  the  disease,  and  in  these  the  opium- 
bromide  treatment  had  on  several  occasions  proved 
surprisingly  useful.  In  some  private  patients  he  had 
employed  codeine  in  the  place  of  opium  with  success. 
He  had  less  fear  of  inducing  the  opium  habit  when 
codeine  was  used,  though  with  due  caution  opium 
could  be  given  without  any  particular  danger. 

Dr.  Joseph  Collins  said  he  thought  trauma  was  a 
very  important  factor  in  the  etiology  of  epilepsy,  and 
cited  a  case  of  a  boy  that  had  been  treated  for  hysteria, 
but  an  operation  demonstrated  Jacksonian  epilepsy 
from  trauma.  He  thought  the  plan  of  treatment  of 
the  patients  referred  to  in  the  paper  was  not  carried 
out  as  Flechsig"s  method  required,  for  the  opium  treat- 
ment had  not  been  continued  long  enough,  and  the 
amount  of  bromide  following  was  not  enough.  It  was 
his  opinion  that  in  opium  the  practitioner  would  find  a 
drug  that  would  be  of  great  benefit  in  the  treatment  of 
epilepsy.  In  cases  of  long  standing,  where  the  bro- 
mides would  not  have  an  influence,  the  desired  effect 


August   lo,  1895] 


MEDICAL    RECORD. 


could  be  produced  by  the  use  of  opium.  He  remem- 
bered a  patient  who  was  brought  to  the  clinic  last  fall 
by  a  policeman,  and  whose  mother  said  that  he  was 
generally  out  of  his  right  mind  for  two  or  three  days, 
and  then  would  get  better  for  a  few  days.  He  was 
put  on  the  opium  treatment,  and-was  now  able  to  earn 
his  living,  was  much  improved  mentally,  and  had  had 
only  three  or  four  attacks. 

As  to  the  statement  that  the  effect  of  the  opium 
would  be  lost  in  eight  or  twelve  months,  he  would  like 
to  ask  what  would  be  the  objection  to  repeating  the 
treatment.  Had  anyone  seen  the  opium  habit  formed 
by  it,  or  the  health  injured  ?  He  thought  not.  As 
there  was  a  close  relation  between  the  epileptic  fits,  the 
dementia,  and  the  cell  degeneration,  he  did  not  think  it 
was  fair  to  take  those  who  were  so  near  dementia  to 
test  the  effectiveness  of  the  treatment.  If  it  was  ex- 
pected to  control  the  cells,  it  was  important  that  the 
cells  be  not  so  degenerated  that  they  could  not  be  af- 
fected. Flechsig  had  kept  his  patients  under  observa- 
tion for  five  years,  they  had  observed  theirs  for  one 
year,  and  he  did  not  think  we  ought  to  accept  as  con- 
clusive the  author's  cases  which  had  been  observed  for 
only  two  months.  He  thought  the  Flechsig  method 
was  an  important  measure  in  the  treatment  of  epilepsy. 

Dr.  T.  H.  Manlev  said  he  thought  trauma  in  pro- 
ducing epilepsy  was  of  minor  importance.  He  had 
treated  cases  by  trephining  and  had  seen  others  do  the 
same,  and  had  never  seen  one  in  which  perfect  recovery 
took  place. 

In  closing  the  discussion  Dr.  Clark  said  Dr.  Collins 
had  had  a  more  favorable  lot  of  patients  to  treat  than 
his  own.  The  reason  why  he  did  not  continue  the 
opium  treatment  longer  was  that  he  had  to  stop  it  or 
lose  his  patients'  lives.  He  thought  that  dementia  was 
much  more  rapid  in  those  cases  of  hereditary  epilepsy. 

At  the  close  of  the  meeting  Dr.  Fenton  B.  Turck, 
of  Chicago,  presented  several  instruments  which  could 
be  used  in  the  diagnosis  and  treatment  of  gastric  dis- 
turbances. The  gyrometer  was  valuable  in  determining 
the  size  of  the  stomach,  the  resistance  of  its  walls,  in 
washing  it  out,  and  for  stimulating  its  walls  by  a  kind  of 
massage.  He  also  presented  and  described  an  instru- 
ment for  the  introduction  of  oil  of  cloves  and  cinnamon 
into  the  stomach  in  the  form  of  spray,  so  there  would 
be  no  irritation  of  the  mucous  membrane,  yet  the  walls 
of  the  stomach  would  be  thoroughly  disinfected.  This 
instrument  was  made  with  double  tubes  so  that  air 
which  might  be  pumped  into  the  stomach  during  the 
treatment  could  escape  and  nausea  be  thus  obviated. 

The  next  instrument  presented  was  for  determining 
the  muscular  power  of  the  stomach,  and  consisted  of  a 
dilatable  rubber  bag  that  communicated  with  an  ap- 
paratus which  recorded  the  slightest  variation  in  press- 
ure. When  the  rubber  bag  had  been  introduced  into 
the  stomach  it  was  inflated  and  the  power  of  the  muscu- 
lar contraction  of  the  stomach  was  recorded.  It  was 
hoped  that  by  extended  investigation  there  could  be 
determined  a  gastric  unit  which  would  be  valuable  in 
diagnosing  atonic  conditions  of  the  stomach.  He  also 
presented  an  instrument  for  diagnosis  of  stricture  or  ob- 
struction of  the  oesophagus.  With  this  the  examiner 
could  judge  as  to  the  consistency  of  the  obstruction  or 
the  extent  of  stricture  by  the  resistance  communicated 
to  the  hand.  It  was  also  easy  to  tell  when  the  bulb  of 
the  instrument  had  passed  into  the  stomach. 


SECTION   ON  OBSTETRICS  AND  GYNECOLOGY. 

Stated  Meeting,  April  2j,  iSgs- 

Hexry  C.  Coe,  M.D.,  Chairman. 

Fatal  Case    of   Umbilical   Hemorrhage   in  a    Newly 

Born  Child. — Dr.  Charles  E.  Nammack  reported  the 

case.     (See  p.  191.) 

XTterus  Containing  Fully  Developed  Foetus  Removed 
Post  Mortem. — Dr.  S.  Marx  presented  a  uterus,  with  a 


fully  developed  foetus  and  membranes,  removed  post 
mortem  from  the  body  of  a  woman  who  had  died  dur- 
ing labor  from  some  obscure  pulmonary  trouble. 

Dr.  Garrigues  remarked  that  such  specimens  were 
rare,  and  this  one  had  been  very  nicely  preserved. 

United  Twins.— Dr.  Teinberg  presented  photo- 
graphs of  female  twins  united  at  the  coccyx  by  a  band 
two  and  a  half  inches  long,  and  five  inches  in  circum- 
ference. They  were  born  on  April  rsth,  and  were 
reported  in  the  daily  papers  as  another  instance  of  Si- 
amese twins.  The  labor  had  been  very  puzzling,  and 
the  union  of  the  twins  was  not  recognized  until  the 
birth  of  the  second  one.  They  weighed  about  nine 
pounds,  and  were  doing  well.  They  were  joined  from 
the  top  of  the  sacrum  to  the  tip  of  the  coccyx,  and 
the  two  coccyxes  were  undoubtedly  amalgamated. 
There  was  only  one  anus,  but  the  rectum  was  believed 
to  bifurcate  above.  The  external  genitals  were  placed 
farther  back  than  normal.  All  organs  were  believed 
to  be  separate,  excepting  the  common  anus.  There 
was  a  normal  placenta  of  one  childbirth.  The  com- 
mon cord  bifurcated  about  an  inch  from  the  placenta, 
one  branch  going  to  each  child.  The  question  of  sep- 
arating the  twins  would  come  up  later.  The  speaker 
was  disposed  to  think  it  could  be  done  successfully  by 
a  plastic  operation. 

Multiple  Fibroids  of  the  Uterus  Removed  by  Abdomi- 
nal Section. — Dr.  Paul  F.  Munde  presented  a  uterus 
containing  multiple  fibroids  which  he  had  removed 
about  six  weeks  ago  by  abdominal  section  from  a  single 
woman,  thirty-two  years  of  age.  As  he  had  stated  on 
former  occasions,  he  was  not  disposed  to  remove  the 
uterus  for  fibroids  unless  the  symptoms  gave  plain  in- 
dication, and  in  the  present  instance  two  years  had 
passed  between  the  time  when  he  had  first  seen  the  pa- 
tient and  the  operation.  He  liad  left  a  little  of  the  cer- 
vix in  order  not  to  destroy  the  vaginal  roof. 

Fibroid  Removed  Through  Vagina. — Dr.  Munde  also 
presented  a  fibroid  tumor  of  the  cervix  uteri,  in  a  vir- 
gin of  forty-one  years,  removed  with  some  difficulty 
through  the  narrow  vagina  after  cutting  into  the  cap- 
sule of  the  tumor,  inserting  forceps,  and  spreading  the 
blades  in  order  to  obtain  a  firmer  hold.  The  perineum 
and  vagina  were  torn.  The  rents  were  sewed  up  and 
the  patient  made  a  good  recovery.  The  tumor  weighed 
two  pounds.  In  a  former  similar  case  the  tumor  had 
weighed  three  pounds.  Dr.  Munde  said  he  had  sev- 
eral times  been  called  upon  to  remove  fibroids  which 
had  become  vaginal  in  elderly  virgins,  oftener  than  in 
women  who  had  borne  children. 

Dr.  H.  L.  Collyer  was  reminded  of  a  case  which 
he  had  seen  in  Connecticut,  one  of  fibroid  tumor  of 
the  uterus  filling  the  vagina,  which  had  been  mistaken 
by  the  local  physician  for  inversion  of  the  uterus.  The 
woman  has  borne  many  children.  The  perineum  was 
torn  to  the  third  degree  ;  the  tumor  filled  the  pelvis  so 
completely  that  he  found  extraction  impossible  until  he 
had  made  a  V-shaped  incision,  cutting  out  the  larger 
central  portion. 

Twin  Pregnancy  with  Blighted  Foetus,  Illustrated 
with  a  Case. — Dr.  Grace  Peckham-Murrav  read  the 
pajier.     (See  p.  711,  vol.  47.) 

The  Chairman,  Dr.  Coe,  said  that  a  few  months  ago 
he  had  shown  a  second  foetus,  acephalic,  poorly  de- 
veloped, which  lived  but  a  few  hours.  He  supposed  it 
would  be  classed  under  the  head  of  blighted  foetus, 
blighted  from  overgrowth  of  the  other  foetus,  which  was 
fully  developed. 

Triplet  Pregnancy  with  Blighted  Foetus. — Dr.  E.  A. 
Tucker  showed  photographs  of  a  case  at  the  Sloane 
Maternity,  triplets,  two  of  which  were  born  alive,  the 
third  mummified  and  flattened.  The  author  of  the  paper 
had  mentioned  the  fact  that  in  many  cases  it  was  diffi- 
cult to  determine  the  cause  of  death,  but  in  this  in- 
stance it  could  be  shown  that  the  foetus  had  caused  its 
own  death  by  twisting  the  cord  and  shutting  off  the  cir- 
culation.    There  had  been  plenty  of  room  for  its  devel- 


208 


MEDICAL    RECORD. 


[August  lo,  1895 


opment,  as  there  was  hydramnios.  The  two  living  babes 
were  small,  but  had  plenty  of  vitality.  There  were  three 
distinct  placenta  and  sacs.  The  third  had  undergone 
so-called  fatty  degeneration,  which  he  believ-ed  had  fol- 
lowed, not  preceded,  the  death  of  the  child.  All  three 
children  were  females.  The  mother  was  thirty  years 
old.     It  was  her  fourth  pregnancy. 

Caesarean  Section  Versus  Symphyseotomy,  with  Re- 
port of  Cases.— Dr.  Edward  P.  Davis,  of  Philadel- 
phia, read  a  paper  on  this  subject.  The  case  of  sym- 
physeotomy was  in  a  slightly  built  negress,  who  had 
registered  before  her  confinement  at  the  hospital  dis- 
pensary, but  who  was  not  taken  to  the  hospital  until  a 
number  of  hours  after  the  commencement  of  labor  and 
efforts  had  been  made  to  engage  the  head  by  posture 
and  by  forceps.  The  external  pelvic  measurements 
were  :  Anterior  superior  spines,  22  ctm.  ;  iliac  crests, 
23.5  ctm.  ;  trochanters,  27.5  ctm.  ;  e.xternal  conjugate, 
19  ctm.  The  patient  was  a  primipara,  aged  twenty- 
seven.  Finally  her  husband  consented  to  her  being 
taken  to  the  hospital  in  a  carriage,  where  symphyseot- 
omy was  performed.  On  opening  the  symphysis  the 
pubic  bones  separated  an  inch  and  a  half  and  the  child's 
head  immediately  descended  to  the  pelvic  floor.  Ex- 
traction was  made  with  Simpson's  forceps ;  the  child 
was  asphyxiated,  but  was  resuscitated.  The  cranial 
ditmeters  were  large:  Biparietal,  11  ;  bitemporal,  9  ; 
occipito-mental,  14  ctm.  The  uterus  was  packed  with 
iodoform  gauze,  the  symphyseotomy  wound  was  also 
tamponed  with  iodoform  gauze  and  closed,  except  that 
the  last  suture  was  left  untied.  The  vaginal  wall  had 
sustained  injury  by  the  head.  A  band  of  adhesive 
plaster  was  drawn  around  the  trochanters.  For  eigh- 
teen hours  the  patient  passed  no  urine  and  the  nurse 
made  unsuccessful  attempts  to  introduce  the  catheter, 
after  which  catheterization  was  performed  successfully 
by  a  medical  assistant,  and  the  following  night  the  pa- 
tient urinated  spontaneously.  She  died  on  the  third 
day  following  delivery.  The  child  survived.  It  was 
thought  infection  had  taken  place  through  the  vaginal 
injury,  which  was  due  to  the  unusual  breadth  of  the 
child's  head,  n  ctm.,  instead  of  9  ctm.,  which  was  the 
ordinary  breadth,  and  also  to  the  inelasticity  of  the 
vagina  and  vulva.  Then,  too,  the  patient's  powers  of 
resistance  to  germ  infection  had  been  diminished.  The 
case  showed  that  the  obstetrician,  before  choosing  sym- 
physeotomy, should  study  carefully  the  elasticity  of  the 
vagina  and  vulva  as  well  as  the  pelvic  and  cranial  di- 
mensions. 

The  case  of  Caesarean  section  was  also  in  a  negress, 
aged  eighteen  ;  strong  family  history  of  tuberculosis  ; 
poorly  developed  ;  height,  four  feet,  eight  inches;  illegit- 
imate pregnancy.  Pelvic  measurements  :  Iliac  spines, 
23  ctm. ;  iliac  crests,  24 ctm.;  external  conjugate,  17  ctm.; 
true  conjugate,  7.75  ctm.  Right  and  left  diagonal  un- 
equal. After  careful  pelvic  measurement  and  attempt 
to  determine  the  size  of  the  child's  head,  it  was  decided 
best  to  induci  labor,  as  the  pregnancy  was  near  full  term. 
After  the  patient  had  been  in  labor  twenty-seven  hours, 
following  the  introduction  of  a  bougie.  Dr.  Hirst  agreed 
with  Dr.  Davis  thit  it  was  best  to  perform  Cesarean 
section  and  make  it  impossible  for  the  patient  to  become 
pregnant  again.  Consequently  the  abdomen  was  opened, 
the  child  extracted  from  the  uterus,  and  the  uterus  re- 
moved. The  patient  made  a  good  recovery,  and  was 
now  nursing  her  own  child  and  also  helping  to  nurse 
another.  The  child's  head  measured  :  Biparietal  diam- 
eter, S.4  ctm.  ;  occipitofrontal,  11.25  ctm.  The  child's 
weight  was  four  pounds  and  fifteen  ounces.  It  was 
evident  from  the  measurements  that  the  method  of  de- 
livery was  based  on  relative  indications.  The  indica- 
tion for  coeliotomy  in  his  judgment  rested  not  merely 
upon  the  sm.ill  size  of  the  mother's  jielvis,  but  also 
upon  her  illy  developed  birth  canal  and  her  failure  to 
make  the  child  engage  by  spontaneous  effort.  Had 
the  Saenger  operation  been  done,  leaving  the  uterus, 
the  patient  would  have  been  exposed  again  to  illegiti- 


mate pregnancy.  Only  a  year  and  a  half  ago  a  woman 
had  been  submitted  to  the  Saenger  operation  in  Phila- 
delphia, and  was  now  suffering  the  disappointment  of  a 
second  pregnancy. 

Regarding  the  permanent  results  of  symphyseotomy, 
Dr.  Davis  had  delivered  two  other  women  by  this 
method,  in  neither  of  whom  could  any  abnormality 
now  be  discovered  in  the  pelvis. 

In  conclusion.  Dr.  Davis  said  his  experience  in  five 
symphyseotomies  had  led  him  to  believe  that  the  oper- 
ation was  a  child-saving  one,  as  in  these  cases  the  chil- 
dren had  been  saved  where  otherwise  no  alternative 
remained  but  craniotomy  or  delivery  through  the  ab- 
domen. One  of  the  cases  was  taken  from  a  tenement- 
house  while  the  patient  was  suffering  from  pneumonia, 
and  she  survived  the  operation  two  days.  The  cases 
reported  this  evening  led  him  to  believe  that  symphy- 
seotomy was  most  successful  in  women  not  weakened 
by  prolonged  labor,  in  whom  there  was  slight  contrac- 
tion of  the  pelvis,  no  great  disproportion  between  the 
pelvis  and  head,  and  in  women  in  whom  the  vagina 
and  vulva  were  well  developed  and  distensible.  The 
Saenger  operation  was  indicated  where  there  was 
marked  disproportion  between  the  head  and  pelvis,  as 
shown  by  failure  of  the  head  to  engage,  where  the 
vagina  was  poorly  developed,  and  in  married  women 
who  were  willing  to  run  the  risk  of  a  future  pregnancy. 
Where,  as  in  his  case,  the  patient  had  a  poor  constitu- 
tion and  was  liable  again  to  pregnancy,  he  would  advise 
cceliotomy  followed  by  hysterectomy. 

The  Chairman,  Dr.  Coe,  mentioned  as  among  the 
chief  points  for  discussion  in  connection  with  Dr. 
Davis's  paper,  i,  an  elective  operation  depended  not 
so  muc'n  upon  the  mere  presence  of  pelvic  deformity 
as  upon  disproportion  between  the  head  and  pelvis  ;  2, 
supra- vaginal  hysterectomy  as  oposed  to  the  Saenger 
operation  ;  3,  the  uldmate  results  of  symphyseotomy, 
which  he  was  sorry  to  say  had  not  been  so  good  in  this 
city  as  in  some  others;  4,  that  symphyseotomy  ought 
to  be  an  elective  operation,  and  was  most  apt  to  be 
successful  where  there  was  not  too  great  disproportion 
between  the  head  and  soft  parts. 

Five  Cases  of  Symphyseotomy. — Dr.  J.  Clifton  Ed- 
gar thought  the  discussion  was  a  little  premature  in 
its  bearing  upon  the  relative  value  of  symphyseotomy 
and  coeliotomy.  He  believed  that  about  seventy- 
four  cases  of  symphyseotomy  had  been  reported  in  this 
country,  with  a  maternal  mortality  of  twelve  or  four- 
teen per  cent.  The  mortality  from  the  Saenger  opera- 
tion was  known  to  range  anywhere  from  one  per  cent, 
up  to  forty.  Undoubtedly  if  cases  of  late  operation 
were  ruled  out  the  mortality  from  symphyseotomy 
could  be  reduced  almost  to  nothing,  as  it  had  been 
done  in  the  Saenger  operation.  Some  time  ago,  Dr. 
Reynolds,  of  Boston,  had  gone  over  the  statistics  of 
the  world  with  regard  to  the  Saenger  operation,  and 
had  collected  thirty-nine  cases  in  which  the  operation 
was  done  within  twenty-four  hours  after  the  orset  of 
labor,  no  previous  attempts  at  delivery,  no  complica- 
tions except  bony  obstruction,  and  all  these  patients 
had  recovered.  The  Oi)erations  were  done  by  thirty 
different  operators.  Under  the  same  circumstances 
equally  good  results  should  follow  symphyseotomy. 

Symphyseotomy  was  not  in  any  sense  a  simple  opera- 
tion. In  the  majority  of  cases,  too,  it  was  attended 
with  subsequent  complications,  but  of  these  we  had 
heard  little  from  Europe,  although,  no  doubt,  they  oc- 
curred there  as  elsewhere.  It  had  been  claimed  that 
there  would  not  be  danger  of  injury  to  the  vagina  and 
bladder  unless  the  pubic  separation  were  extended  to 
four  inclies.  But  it  had  been  shown  in  Italy  that  the 
vagina  began  to  be  stretched  at  7  ctm.,  and  there  was 
dangerous  stretching  at  10  ctm. 

In  reviewing  his  five  cases,  Dr.  Edgar  said  that  in 
none  did  the  jiubic  separation  approach  four  inches  ; 
in  one  there  was  marked  hemorrhage  from  the  vessels 
of  the  clitoris  ;  in  one  there  was  vaginal  laceration  and 


August  lo,   1895] 


MEDICAL   RECORD. 


209 


the  woman  still  had  a  sinus,  although  she  was  in  good 
condition.  The  permanent  results  were  good,  for  in 
two  of  his  patients,  obser\-ed  a  year  or  two  after  the  op- 
eration, no  evidence  existed  of  injury  to  the  pelvis.  It 
had  been  shown  in  Italy  that  the  periosteum  on  the 
front  of  the  pubic  bone  would  stand  stretching  7  or  8 
ctm.,  and  if  this  were  not  cut  through  with  the  knife  solid 
union  would  take  place  more  quickly.  Necrosis  of  the 
bone  did  not  mean  that  the  woman  was  doomed  to  be 
a  cripple,  for  in  one  of  his  cases  suppuration  and  necro- 
sis took  place,  and  although  the  convalescence  was  pro- 
tracted over  five  months,  yet  the  woman  was  now  able 
to  do  laborious  work. 

Dr.  Edgar  had  found  attempts  to  estimate  the  size  of 
the  child's  head  by  pushing  it  down  into  the  mother's 
peh-is  rather  unsatisfactory.  Faraheuf  had  invented  a 
kind  of  forceps  for  measuring  the  child's  head. 

All  of  Dr.  Edgar's  cases  of  symphyseotomy  had  been 
in  tenements.  In  one  the  conjugate  before  s)Tnphy- 
seotomy  measured  3.25  inches;  in  the  ne.xt  labor  the 
woman  was  delivered  by  version. 

Dr.  W.  T.  Lusk  could  report  two  cases  of  sjmiphy- 
seotomy.  The  first  patient  had  been  submitted  to  vari- 
ous efforts  at  delivery  before  admittance  to  the  hos- 
pital and  was  in  a  dying  condition.  Symphyseotomy 
was  done  to  save  the  child.  The  mother  died  after 
seventeen  hours,  and  the  child  also  died  after  eleven 
hours,  having  had  its  jaw  broken  before  he  saw  the 
patient. 

Dr.  Lusk  had  had  a  second  case  quite  recently,  in  a 
patient  aged  nineteen,  in  the  Infant  Asylum.  The  esti- 
mated antero-posterior  diameter  was  3  or  3.25  inches,  the 
transverse  very  narrow.  The  woman  had  been  in  labor 
nineteen  hours,  the  cervix  was  pretty  well  dilated,  the 
head  was  still  above  the  brim.  The  conditions  for  op- 
eration at  the  hospital  were  not  very  good.  During 
the  operation  he  rem.embered  many  times  a  statement 
of  Pinard,  that  no  man  should  undertake  S}Tnphyseo- 
tomy  without  having  a  chain-saw  at  hand,  and  he  re- 
gretted that  he  had  none  in  this  instance,  since  for  a 
part  of  the  distance  the  symphysis  presented  bony 
union,  and  it  took  him  thirty  minutes  to  effect  division 
when  under  ordinary  circumstances  it  should  have  re- 
quired not  more  than  three  minutes.  The  rest  of  the 
operation  was  simple,  and  was  performed  after  the 
manner  which  he  had  lately  seen  practised  by  Pinard 
in  Paris.  Performed  in  this  way,  very  little  blood,  not 
more  than  twenty  drops,  need  be  lost.  In  his  case  the 
pubic  bones  were  not  separated  more  than  6  ctm.,  by 
measure  with  the  instrument  used  in  Paris.  The  child 
was  extracted  with  forceps,  without  any  injury  to  the 
soft  parts.  An  attempt  was  made  to  sew  up  the 
fibrous  tissue  in  order  to  hold  the  symphysis  together, 
as  suggested  by  Faraheuf.  The  patient  died  seven 
days  after  the  operation,  with  all  the  symptoms  of  sep- 
tic peritonitis.  The  autopsy  showed  that  the  symphy- 
sis was  zigzag,  partly  bony,  and  that  a  saw  would  have 
quickly  divided  it.  The  sutures  had  not  held  and  there 
was  considerable  separation.  The  uterus,  tubes,  and 
ovaries  were  healthy.  There  was  peritonitis,  and  the 
intestines  were  glued  together.  Dr.  Lusk  said  he 
would  not  think  of  undertaking  sjinphyseotomy  in  a 
tenement  or  under  conditions  which  did  not  offer  the 
best  opportunities  for  antisepsis.  The  trouble  in  this 
case  had  arisen  from  the  fact  that  separation  of  the 
pubes  had  stripped  off  the  periosteum  to  quite  a  dis- 
tance, the  tissue  had  necrosed  and  led  to  infection. 

Dr.  Lusk  was  not  sure  but  what  under  similar  cir- 
cumstances he  would  on  another  occasion  choose  Ce- 
sarean section.  On  going  over  the  statistics  of  sym- 
physeotomy he  had  found  that  the  great  successes  had 
been  confined  to  comparatively  few  men,  who  had  op- 
erated under  favorable  conditions. 

Symphyseotomy  Has  a  Limited  Field. — Dr.  Ch.\rles 
Jewett  thought  symphyseotomy  would  hold  a  prom- 
inent place  in  obstetrical  surgery,  but  the  fact  became 
very  obvious  as  experience  increased  that  its  field  was 


a  narrow  one.  In  equally  competent  hands  Csesarean 
section  and  symphyseotomy  had  given  about  the  same 
success.  SjTnphyseotomy  labored  under  two  marked 
disadvantages.  In  the  first  place,  its  use  was  deter- 
mined by  little  more  than  half  an  inch  variation  in  the 
diameter  of  the  pelvis.  If  a  mistake  were  made  in  its 
indication  it  might  be  fatal  to  the  child  and  prove 
dangerous  to  the  mother,  whereas  if  one  chose  Cassa- 
rean  section  the  chances  for  both  mother  and  child 
would  be  good.  The  other  disadvantage  under  which 
symphyseotomy  labored  was  the  great  difficulty  in  the 
after-care,  whereas  in  Caesarean  section  this  was  ver}' 
simple.  If  sepsis  already  existed,  especially  in  the 
uterus,  symphyseotomy  was  preferable  to  simple  Caesa- 
rean  section,  but  the  latter  operation  followed  by  re- 
moval of  the  uterus  gave  the  mother  as  good  a  chance 
as  symphyseotomy. 

Named  for  the  Wrong  Men. — Dr.  H.  J.  Garrigues 
said  he  h.id  had  an  equal  experience  with  Csesarean 
section  and  with  symphyseotom}',  having  done  both 
operations  twice.  One  of  the  patients  submitted  to 
Caesarean  section  died,  all  the  others  lived.  The  first 
case  of  Caesarean  section  was  of  some  historical  inter- 
est, since  it  was  the  first  one  performed  according  to 
the  so-called  Saenger  method  after  Leopold's  two  cases, 
while  Saenger  himself  was  eighth  in  the  list  of  operators 
by  this  method.  The  only  original  idea  of  Saenger 
connected  with  Cesarean  section  was  to  cut  out  a 
piece  of  the  muscular  tissue  of  the  womb  and  then 
fold  in  the  peritoneum,  a  thing  which  was  speedily 
given  up.  In  this  country,  too,  we  heard  of  the  Tren- 
delenburg position,  while  in  Germany  they  did  not  so 
name  it,  for  the  position  had  been  used  by  Baden- 
hauer  in  iSSi,  and  probably  earlier  by  Billroth. 
Trendelenburg  had  only  popularized  it. 

A\Tiere  symphyseotomy  was  applicable,  Dr.  Gar- 
rigues decidedly  preferred  it  to  Caesarean  section.  It 
was  safer.  He  had  operated  once  in  a  dirty  house, 
but  he  would  never  do  it  again  if  it  were  possible  to 
convey  the  patient  to  a  hospital.  He  might  say  that  in 
his  second  case  the  pubic  separation  by  actual  meas- 
urement was  five  inches,  yet  no  damage  was  done. 
This  great  amount  of  separation  had  taken  place  while 
the  patient  was  under  the  care  of  assistants  who  knew 
little  about  symphyseotomy.  He  was  resuscitating  the 
asphyxiated  child  in  an  adjoining  room.  As  to  statis- 
tics in  Germany,  they  performed  Cesarean  section  if 
the  case  were  known  to  be  aseptic  ;  otherwise  they 
took  their  chances  with  symphyseotomy,  which,  of 
course,  made  a  worse  showing  for  the  latter. 

Two  Cases  of  Symphyseotomy. — Dr.  Edw.\rd  A. 
Ayres  had  had  two  cases  of  symphyseotomy  which  he 
had  not  yet  reported,  one  last  autumn,  the  other  on 
Monday  preceding  the  meeting.  The  conjugate  in  the 
first  case  measured  T,}i  inches.  The  child  died  before 
it  could  be  extracted,  hence  craniotomy  was  performed. 
The  pubic  bones  separated  three-fourths  of  an  inch. 
The  mother  made  a  perfect  recovery.  In  the  last  case 
the  conjugate  measured  sH  inches,  the  separation  was 
a  little  over  two  inches,  the  child  weighed  nearly  ten 
pounds,  but  its  heart  had  ceased  to  beat  before  it  was 
brought  into  the  world.  The  mother  was  fleshy,  and 
much  difficulty  was  experienced  in  bringing-the  pubic 
bones  together  again.  She  was  now  doing  well.  Dr. 
Ayers  spoke  verj'  highly  of  the  bed  used  in  the  Poly- 
clinic Hospital  in  these  cases.  A  wire  mattress  bed,  a 
wooden  frame  on  top  with  canvas  stretched  across  it, 
a  hole  in  the  canvas  at  the  buttock,  rope  and  pulley  to 
lift  the  wooden  frame.  One  strong  argument  in  favor 
of  Caesarean  section  was  the  much  smaller  foetal  mor- 
tality. He  did  not  think  the  fcetal  death-rate  follow- 
ing symphyseotomy  would  be  greatly  reduced  below 
twenty-six  per  cent.  Regarding  the  method  of  extract- 
ing the  child.  Dr.  Ayers  said  that  internal  version  had 
never  been  a  favorite  procedure  with  him,  and  in  s)!!!- 
physeotomy  it  would  increase  the  foetal  death-rate. 

Dr.  G.  \y.  Jarm.\x  remarked  that  these  women  did 


MEDICAL   RECORD. 


[August  lo,  1895 


not  always  fall  into  the  hands  of  men  of  much  operative 
experience,  nor  were  hospitals  always  accessible,  and 
he  would  ask  Dr.  Davis  which,  in  his  opinion,  was  the 
safer  procedure  for  men  of  limited  experience,  Caesa- 
rean  section  or  symphyseotomy. 

Six  Cases  of  Symphyseotomy. — Dr.  Coe  thought 
stress  should  be  laid  on  the  point  made  by  Dr.  Ayers, 
namely,  that  symphyseotomy  was  intended  as  a  life- 
saving  operation  for  the  child,  and  when  it  failed  in 
this  it  failed  of  its  purpose,  for  a  dead  child  could  be 
extracted  through  a  pelvis  of  such  dimensions  by  crani- 
otomy. They  had  had  six  cases  of  symphyseotomy  at 
the  Maternity  Hospital  within  a  comparatively  short 
period  of  time.  One  of  the  children  died.  In  this 
case  the  cervix  was  well  dilated.  The  child  was  not 
large.  Dr.  Coe  had  expected  an  easy  delivery  after 
symphyseotomy,  and  was  surprised  at  the  difficulty 
of  getting  the  head  through.  Version  had  been  per- 
formed. There  was  no  doubt  but  what  the  mother 
could  have  been  saved  as  well  by  Caesarean  section  as 
by  symphyseotomy,  and  the  child  would  not  have  died. 
In  cases  of  elective  Caesarean  section  the  child  had  been 
extracted  with  ease,  and  the  mother  had  made  a  smooth 
recovery.  Against  symphyseotomy  was  the  difficulty 
of  determining  the  size  of  the  child's  head.  He  had  had 
one  case  of  at  least  half  an  inch  separation  of  the  pubes 
six  months  after  symphyseotomy,  and  the  patient  walked 
with  a  waddling  motion.  There  were  probably  other 
similar  cases  which  had  not  been  reported.  Such  a  re- 
sult in  some  families  would  prove  a  very  serious  affair. 

Dr.  Davis  closed  the  discussion.  Replying  to  Dr. 
Jarman's  question,  he  thought  that  under  the  circum- 
stances named  the  general  practitioner,  with  the  assist- 
ance of  a  single  cool-headed  medical  neighbor,  could 
do  Cassarean  section  more  safely  to  mother  and  child 
than  symphyseotomy. 


Stated  Meeting,  May  2j,  iSg^. 

Henry    C.   Coe,  M.D.,  Chairm.\x. 

Cephalopagus. — Dr.  Charles  E.  Nammack  pre' 
sented  a  double  foetal  monstrosity,  the  principal  and 
the  parasite  being  joined  at  the  head.  Abortion  had 
taken  place  about  the  fifth  month.  The  specimens  had 
been  preser\-ed  for  some  months  before  he  saw  them, 
so  that  they  were  useless  for  studying  the  blood-sup- 
ply. 

'Conservative  Vaginal  Gynecology. — Dr.  H.  N.  Vine- 
berg  presented  specimens  from  two  cases.  The  first 
patient  had  suffered  from  backache,  migraine,  profuse 
menstruation.  He  found  retroversion  of  the  uterus  in 
third  degree,  with  marked  prolapsus  of  both  tubes  and 
ovaries,  but  he  was  unable  to  make  out  distinct  disease 
until  he  had  made  an  incision  in  front  of  the  vagina. 
The  left  tube  was  thickened,  the  left  ovary  contained 
some  small  cysts,  which  he  punctured  and  returned  the 
organs  to  the  abdominal  cavity.  The  right  ovary  con- 
tained a  cyst  as  large  as  an  almond,  which  he  incised, 
whipped  over  the  defect  with  running  catgut,  returned 
the  organ,  and  fixed  the  uterus  to  the  anterior  abdominal 
wall.  The  girl  had  been  well  since,  and  expressed  herself 
as  feeling  like  a  different  person.  To  his  mind  the 
uterus  was  now  in  ideal  anteversion. 

In  the  second  case  the  patient  had  suffered  from  a 
good  many  symptoms  relating  to  retroversion  which  he 
had  corrected  in  a  similar  manner,  leaving  the  organ 
in  good  anteversion.  There  was  still  some  pain  from  a 
thickened  tube. 

Ectopic  Pregnancy.— The  Chairman,  Dr.  Coe,  pre- 
sented a  specimen  of  tubal  pregnancy,  and  stated  that 
the  case  impressed  the  danger  of  delay.  The  patient 
gave  a  history  of  having  skipped  one  period  and  thought 
she  was  pregnant.  The  night  before,  when  her  period 
was  due,  she  had  very  severe  abdominal  pain.  On  ex- 
amination, some  hours  later,  Dr.  Coe  found  a  small 
uterus,  but  an  enlarged  left  tube.     That  was  all,  and 


there  were  no  subjective  symptoms  at  this  time,  the 
pulse  and  temperature  being  normal.  He  made  the 
diagnosis  of  possible  ectopic  pregnancy,  and  requested 
to  be  notified  at  once  in  case  symptoms  arose.  Symp- 
toms did  arise  that  night,  but  they  failed  to  notify  him 
until  the  next  afternoon,  when  she  was  practically  mor- 
ibund. He  gave  an  absolutely  bad  prognosis,  but  op- 
erated, found  the  abdomen  full  of  blood,  and  death 
occurred  soon  afterward.  He  believed  that  if  he  had 
insisted  on  operating  when  he  first  saw  the  patient  her 
life  would  have  been  saved. 

Dr.  Nammack  thought  the  cause  of  delay  was  the 
teaching  of  the  books  that  the  hemorrhage  might  take 
place  into  the  broad  ligament,  instead  of  into  the  free 
cavity,  and  become  shut  off  and  cause  no  further 
trouble. 

Coeliotomy  for  Fibroids. — Dr.  Francis  Foerster 
presented  large  fibroids  from  three  cases,  removed  with 
the  uterus  through  the  abdomen.  The  first  tumor  and 
uterus  weighed  fifteen  pounds.  This  case  was  compli- 
cated by  pregnancy  at  the  seventh  month.  The  woman 
had  been  almost  exhausted  by  hemorrhages.  Scarcely 
any  blood  was  lost  during  the  operation.  She  recov- 
ered. The  second  specimen  was  a  large  myomatous 
tumor  of  the  uterus,  pus  tubes,  and  an  ovarian  cyst  the 
size  of  a  child's  head.  The  patient  had  suffered  since 
the  birth  of  her  child  eighteen  years  before.  She  was 
extremely  anaemic  and  shock  was  profound.  She  died 
on  the  third  day. 

The  tumor  and  uterus  in  the  third  case  weighed 
twenty  pounds.  This  patient  had  also  suffered  greatly 
in  general  health  from  hemorrhage,  etc.,  was  jaundiced, 
the  heart  beat  120  to  140.  Little  blood  was  lost,  but 
as  a  precaution  he  injected  three  hundred  grammes  of 
salt  solution.  She  was  doing  well  since  the  operation 
two  days  ago. 

The  Chairman  thought  it  was  remarkable  that  Dr. 
Foerster's  patient  with  large  fibroid  had  not  died  of 
shock.  The  success  of  the  operation  was  probably  due 
in  no  small  degree  to  beginning  with  stimulants  in  ad- 
vance of  it,  instead  of  waiting,  as  many  operators  did, 
until  shock  had  set  in. 

Pregnancy  and  Labor  Complicated  by  Cardiac  Dis- 
ease.— Dr.  Julius  Rosenberg  read  a  paper  on  this 
subject,  giving  the  histories  of  two  cases  seen  by  him- 
self, and  reviewing  some  of  the  meagre  literature  on  the 
subject.  He  thought  it  probable  that  the  reason  why 
the  subject  had  received  so  little  attention  was  the  fact 
that  mild  cases  of  cardiac  disease  complicating  preg- 
nancy were  probably  overlooked,  while  the  severe  ones 
ended  fatally  and  therefore  remained  hidden.  His  first 
case  was  in  a  German  woman,  aged  thirty-two,  in  labor 
with  her  first  child.  The  pains  had  continued  about 
fifty  hours  when  he  was  called.  The  os  was  fully  di- 
lated, but  the  pains  were  feeble,  and  no  progress  was 
being  made.  "There  was  a  distinct  systolic  murmur  at 
the  apex.  Forceps  were  applied  and  a  living  child  was 
extracted.  The  patient  was  doing  well  until  she  sud- 
denly became  cyanotic,  pulse  rapid  and  irregular,  and 
in  spite  of  every  means  to  restore  her  she  died  within 
three  hours. 

The  second  patient  consulted  him  when  she  was  six 
months  pregnant.  She  had  had  chorea  during  child- 
hood which  had  left  her  with  a  damaged  heart.  She 
had  atonic  dyspepsia,  eructation  of  gas,  presystolic 
murmur,  displacement  of  the  heart  to  the  left,  oedema, 
bronchitis.  He  had  often  thought  of  emptying  the 
uterus,  but  concluded  that  the  best  chance  was  given 
by  letting  pregnancy  go  to  term.  Evidences  of  venous 
obstruction  increased,  fluid  was  present  in  the  pleural 
cavities,  there  was  cyanosis.  Labor  came  on  some- 
what prematurely.  The  patient's  condition  becoming 
alarming,  he  used  forceps  in  order  to  terminate  labor. 
A  living  boy  was  extracted.  The  uterus  contracted 
and  the  placenta  was  expelled  within  twenty  minutes. 
The  heart  continued  to  act  poorly  for  a  time,  but  later 
imjiroved  somewhat.     Four  hours  after  labor  she  was 


August  lo,  1895] 


MEDICAL   RECORD. 


seized  with  a  convulsion.  The  heart  failed  and  she 
died. 

Experience  had  shown  that,  excluding  milder  cases 
of  cardiac  trouble  complicating  pregnancy,  a  large  per- 
centage of  the  cases  proved  fatal.  The  immense  risk 
which  women  with  cardiac  disease  ran  in  becoming 
pregnant  made  it  imperative  that  marriage  be  forbidden. 
If  one's  advice  were  not  followed,  every  means  should 
be  taken  to  put  the  patient  in  good  general  condition. 
The  question  whether  delivery  should  be  hastened  was 
a  grave  one.  Unfortunately  the  hope  had  proven  de- 
lusive of  saving  the  patient  by  inducing  labor  when  the 
cardiac  symptoms  were  marked. 

^'^In  order  to  allow  the  heart  to  accommodate  itself  to 
the  arterial  changes  after  labor,  delivery  of  the  placen- 
ta should  not  be  hastened.  During  the  lying-in  period 
the  heart  required  constant  watching.  Simple  diet 
and  proper  stimulation  formed  the  basis  of  treat- 
ment. 

Dr.  Coe  called  attention  to  the  fact  that  the  period 
of  greatest  danger  to  these  patients  was  for  a  short  pe- 
riod after  labor.  He  said  Dr.  Grandin  could  relate  a 
case  bearing  on  that  point. 

Dr.  Egbert  H.  Grandin  thought  the  author's  ex- 
perience was  unique  in  that  he  had  seen  two  cases  of 
bad  cardiac  diseases  complicating  pregnancy  within  a 
short  period  of  time,  but  it  was  not  unique  in  the  result. 
Few  of  us  saw  enough  cases  of  this  kind  to  dogmatize 
as  to  management.  The  woman  with  cardiac  disease 
might  go  through  her  first  pregnancy,  possibly  her  sec- 
ond, without  special  difficulty,  simply  because  the  car- 
diac lesion  was  compensated  by  hypertrophy.  It  was 
when  this  compensation  ceased  and  dilatation  began 
that  danger  arose. 

As  to  marriage,  if  the  heart  lesion  were  not  of  ag- 
gravated type  he  would  not  forbid  it,  for  the  reason 
that  the  large  majority  of  women  with  minor  cardiac 
lesions  did  marry,  bore  children,  and  suffered  no  ill 
consequence.  If  the  heart  disease  were  of  an  aggra- 
vated type,  marriage  should  be  forbidden.  As  to  treat- 
ment, he  would  advise  emptying  the  uterus  just  as  soon 
as  there  was  cardiac  dyspnoea,  particularly  if  there  were 
albumin  in  the  urine.  When  one  decided  to  empty  the 
uterus,  the  sooner  it  was  done  the  better.  In  spite  of 
the  fact  that  chloroform  was  regarded  as  dangerous  in 
cardiac  disease,  he  would  prefer  to  administer  this  an- 
aesthetic during  induction  of  labor. 

Dr.  Simon  Baruch  related  a  case,  seen  with  Dr. 
Dana  twelve  years  ago,  that  of  a  primipara  with  car- 
diac insufficiency,  in  whom  the  pains  were  ineffectual. 
While  they  were  debating  what  to  do,  the  nurse  came 
out  of  the  lying-in  chamber  and  said  the  patient  had 
suddenly  expired.  He  then  made  up  his  mind  that 
if  he  should  ever  see  a  pregnant  woman  with  advanced 
mitral  disease,  he  would  at  once  empty  the  uterus. 

Dr.  Simon  Marx  had  seen  about  six  cases  of  car- 
diac disease  complicating  pregnancy,  in  two  of  which 
his  experience  was  rather  sad,  although  the  ultimate 
result  had  been  favorable.  He  believed  the  large 
majority  of  pregnant  women  with  cardiac  disease  got 
along  without  trouble,  but  where  dilatation  took  place 
the  danger  was  great.  He  was  a  great  believer  in 
nitro-glycerine,  for  it  was  both  a  cardiac  stimulant  and 
vaso-motor  dilator,  and  did  not  irritate  the  kidneys 
like  strophanthus  and  digitalis.  One  of  his  patients,  a 
young  woman,  in  good  circumstances,  had  passed 
through  her  labor  well,  then  went  into  collapse  from 
heart  failure.  He  resorted  to  heroic  treatment,  inject- 
ing one  twenty-fifth  of  a  grain  of  nitro-glycerine  every 
hour  for  ten  hours,  and  also  a  high  rectal  enema  of  a 
quart  of  salt  solution  every  hour  for  ten  hours.  Not 
until  then  did  she  begin  to  recover.  He  attributed  the 
collapse  in  this  case  partly  to  ergot.  This  drug  was 
faulty  in  these  cases,  inasmuch  as  it  acted  as  a  vaso- 
motor constrictor,  not  as  a  dilator. 

Dr.  Mary  Putnam-Jacobi  queried  whether  car- 
diac thrombosis  was  not  the  cause  of  death  after  labor 


in  these  cases,  for  the  conditions  were  favorable  for 
this  accident. 

Dr.  Anna  M.  Galbraith  related  a  case  of  marked 
cardiac  insufficiency  in  which  the  woman  passed 
through  labor  successfully,  bearing  a  living  child. 

Dr.  R.  a.  Murray  said  the  only  cases  in  which 
he  had  found  trouble  were  those  of  mitral  disease 
with  systemic  symptoms  before  pregnancy  occurred. 
Pregnancy  usually  rendered  these  cases  worse,  both 
during  the  early  and  the  later  months.  CEdema  of  the 
feet  and  lungs  and  cardiac  dyspnoea  were  danger 
signals.  He  had  seldom  seen  these  symptoms  without 
a  fatal  issue  before  or  after  confinement.  There  was, 
however,  even  a  more  dangerous  form  of  heart  disease, 
viz.,  fatty  degeneration  without  valvular  lesion.  He 
had  seen  one  such  case,  in  a  very  large  woman,  who 
had  coma  and  vomiting  before  labor.  The  child  was 
delivered,  she  improved  somewhat,  but  died  without 
the  nurse  being  aware  of  it.  In  the  case  of  a  young 
woman  he  advised  against  marriage  on  account  of  a 
fatty  heart,  but  the  advice  was  not  followed.  Dr.  Lusk 
saw  her  during  pregnancy,  and  his  assistant  induced 
labor  at  the  fourth  month,  but  she  died.  Labor  should 
be  induced  early. 

Dr.  Rosenberg  did  not  know  why  labor  should  be 
induced  when  the  symptoms  of  cardiac  disease  were 
slight.  When  they  were  serious,  the  prognosis  was  bad 
under  anv  circumstances. 

A  Contribution  to  the  Nature,  Cause,  and  Treatment 
of  Suspended  Animation  in  the  New-born. — Dr.  J.  D. 
BissELL  read  this  paper.  The  first  case  of  suspended 
animation  in  which  he  had  tried  prolonged  suspension 
occurred  in  a  child  to  which  he  was  hastily  summoned 
at  the  New  York  Asylum  for  Lying-in  Women,  Sep- 
tember, 1893.  He  arrived  almost  immediately,  but 
found  the  child  to  all  appearances  dead.  Having  had 
some  experience  with  suspension  in  chloroform  as- 
phyxia, and  observing  that  a  spark  of  life  remained,  he 
had  the  child  suspended  by  the  feet.  Breathing  and 
heart  action  were  soon  partly  restored,  but  stopped  at 
intervals,  and  it  was  fully  twenty  minutes  before  a 
voluntary  movement  was  observed  of  the  head  or  arms. 
The  child  was  then  placed  in  the  horizonal  position, 
but  as  it  grew  weaker,  a  pillow  was  arranged  and  its 
head  was  allowed  to  hang  down.  It  was  six  hours 
before  complete  recovery  took  place.  At  the  end  of 
two  weeks  it  left  the  hospital  healthy.  The  cause  of 
the  trouble  was  unknown. 

Not  long  afterward  he  had  opportunity  to  try  this 
method  in  suspended  animation  in  the  new-born.  The 
foetal  heart  action  had  been  strong,  but  before  the  end 
of  labor  there  was  marked  loss  of  blood,  the  heart  ac- 
tion became  weak  or  ceased.  Extraction  was  hastily 
performed.  The  child  was  pale,  there  was  general  com- 
plete muscular  relaxation,  no  apparent  heart  or  respira- 
tory action.  The  inverted  position  had  to  be  per- 
sisted in  in  this  case  for  two  hours.  At  first  very  weak 
gasps  set  in  ;  after  the  first  hour  they  became  a  little 
deeper,  and  finally  regular.  The  child  was  feeble,  but 
showed  excellent  health  by  the  twenty-first  day. 

The  third  case  was  also  one  of  suspended  animation 
in  the  new-born,  the  first  gasp  occurring  three  minutes 
after  delivery,  being  followed  immediately  by  flow  of 
mucus  from  the  mouth.  The  next  fifteen  minutes  there 
were  five  or  six  short  breaths.  At  the  end  of  an  hour 
and  twenty  minutes  after  suspension  was  begun  the 
lungs  and  heart  were  found  acting  normally.  The 
peculiar  feature  of  this  case  was  the  succession  of  rapid 
breathing  for  fifteen  or  twenty  minutes,  and  intervals 
of  two  or  three  minutes  without  breathing. 

Dr.  Bissell  had  attended  four  other  cases  in  which 
there  was  suspended  animation  of  the  new-born,  and 
resuscitated  them  in  a  similar  manner.  As  soon  as  de- 
livery was  completed  the  child  was  held  up  by  the  feet, 
mucus  was  cleared  from  the  mouth  or  throat  by  a  cot- 
ton swab,  the  child  was  wrapped  in  a  warm  blanket, 
the  cord  was  severed  if  there  was  no  pulse  ;  the  child 


MEDICAL   RECORD. 


[August  lo,  1895 


was  taken  near  a  stove  and  the  inverted  position  was 
maintained  until  resuscitation  had  taken  place.  Of 
other  methods  the  best  were  those  of  Schultze  and 
Dew.  He  thought  there  was  some  danger  in  the  ma- 
nipulations of  Schultze's  method,  and  as  to  inflation  of 
the  lung,  death  was  apt  to  result  from  too  much  force, 
besides  air  was  likely  to  be  driven  into  the  stomach  as 
well  as  into  the  lungs.  Other  methods  were  men- 
tioned. 

Suspended  animation  in  the  new-born  might  be  due 
to  impairment  of  the  umbilical  circulation  from  press- 
ure upon  the  cord,  entanglement  of  the  cord  upon  itself 
or  around  the  child,  to  loss  of  blood,  or  to  shock  fol- 
lowing injuries.  It  might  be  of  apoplectic,  cyanotic,  or 
ansemic  form.  In  either  case  the  circulation  demanded 
primary  consideration,  and  it  was  through  improvement 
of  this  that  we  must  look  for  awakened  activity  of 
the  nerves  covering  respiration.  Life  could  be  sus- 
tained several  minutes  after  birth  without  respiration 
through  the  lungs,  provided  the  heart  action  were  kept 
up.  The  latter  might  be  too  feeble  to  be  recognized, 
constituting  suspended  animation,  not  actual  death,  in 
which  case  the  heart  would  be  enabled  to  work  with 
greatest  advantage  by  placing  the  child  in  the  inverted 
position.  Each  inspiration  increased  the  amount  of 
oxygen  in  the  system  until  the  function  of  respiration 
was  fully  established.  The  suspended  position  also 
favored  expulsion  of  mucus.  The  method  could  be 
used  in  combination  with  others,  but  Dr.  Bissell  had 
practised  it  alone  in  order  to  give  it  a  fair  test. 

The  paper  was  discussed  by  Drs.  Dew,  P.  A.  Harris, 
R.  A.  Murray,  Rosenberg,  Jarman,  Amende,  and  the 
discussion  was  closed  by  Dr.  Bissell. 


THE  ELECTRO-MAGNET  FOR  THE  REMOV- 
AL OF  FOREIGN  BODIES  FROM  THE  EYE. 

By  H.  G.  SHERMAN,   M.D., 

CLEVELAND,    O. 

No  persons  who  present  themselves  to  the  oculist  cause 
greater  an.xiety  than  those  giving  a  history  of  an  impac- 
tion of  a  foreign  body  in  the  tissues,  or  a  penetration 


and  a  lodgement  of  the  same  within  the  chambers  of 
the  eye.  It  nearly  always  happens  that  the  point  of 
entrance  and  lodgement  of  a  foreign  bodv  is  difficult 


to  make  out,  owing  to  hemorrhage  or  swelling.  Should 
a  foreign  body  be  lodged  in  the  tissues  of  the  eye  or 
its  chambers,  it  is  of  the  gravest  concern,  for  we  know 
with  almost  absolute  certainty  that  sooner  or  later  an 
irido-clycitis  or  irido-choroiditis  will  supervene  with 
probable  loss  of  the  eye  in  case  the  foreign  body  can- 
not be  safely  extracted.  We  know  also  of  the  almost 
certain  involvement  of  the  integrity  of  vision  of  the 
other  eye  sympathetically  in  case  of  violent  inflamma- 
tory reactions  occurring  in  the  injured  eye.  There- 
fore, any  means  which  will  aid  in  the  certain  diagnosis 
of  the  presence  of  a  foreign  body  within  the  eye  and 
assist  in  its  removal  will  be  heralded  with  satisfaction. 
The  great  majority  of  these  cases  lead  one  to  look  for 
iron  or  steel,  and  while  various  magnets  have  been  em- 
ployed with  varying  success  for  the  removal  of  these 
bodies  through  open  wounds,  I  am  not  aware  that  an 
electro-magnet  has  been  devised  capable,  when  properly 
energized,  of  detecting  with  absolute  certainty  very 
small  particles  of  iron  or  steel  which  may  be  imbedded 
deeply  within  the  eye  and  the  presence  of  which  can- 
not be  made  out  by  any  clinical  evidence.  The  writer 
has  enjoyed  great  satisfaction  in  the  use  of  an  electro- 
magnet made  for  him  by  Mr.  Adams,  of  the  General  Elec- 
tric Company,  Cleveland,  O.  The  magnet  is  made  of  soft 
Norway  iron,  of  the  single-bar  type,  of  a  size  and  shape 
as  indicated  by  the  photo-engraving.  It  was  energized 
by  the  current  from  the  electric  (incandescent)  light 
wires  in  my  office.  About  twelve  amperes  and  an  elec- 
tro-motive force  of  one  hundred  and  twelve  volts,  de- 
veloping a  resistance  force  of  about  one  hundred  and 
twenty-five  pounds  to  the  square  inch,  was  found  suffi- 
cient to  draw  small  particles  of  iron  and  steel  from 
masses  of  various  organic  substances  employed  for  ex- 
perimental purposes,  the  details  of  which  I  need  not 
enter  into.  The  fsllcwirig  cases  will  better  illustrate 
tne  value  of  this  magnet : 

Case  I. — Miss  Katie  W was  referred  to  me  by 

Dr.  Sabin,  of  Warren,  O.,  June  22,  1894.  The  history 
of  the  case  gave  evidence  that  six  weeks  previous  to 
the  consultation,  while  employed  by  the  N.  Y.  P.  &  O. 
Electric  Light  Co.,  she  was  struck  in  the  eye  by  a  for- 
eign body,  supposed  to  be  a  filament  of  bamboo  which 
she  was  grinding  at  the  time  of  the  accident.  Dr. 
Sabin,  whom  she  consulted,  observed  a  slight  cut  in  the 
conjunctiva  about  one  line  from  the  corner  and  the  su- 
perior margin  of  the  lower  inner  quadrant  of  the  eye- 
ball. At  that  time  the 
doctor  did  not  suspect 
the  presence  of  a  foreign 
body  in  the  eye,  the  vision 
being  normal,  although 
the  girl  complained  of 
constant  pain  and  a  great 
abhorrence  to  light,  with 
excessive  lachrymation. 
At  the  time  of  consulta- 
tion with  Dr.  Sabin  I 
found  those  same  symp- 
toms obtaining  ;  in  addi- 
tion a  marked  circum- 
corneal,  deep-seated 
injection  existed,  acute 
sensitiveness  over  region 
of  original  injury,  deter- 
mined by  probe  and  i)res- 
sure.  The  ophthalmo- 
scope revealed  hyperre- 
mic  conditions  of  tl'c  op- 
tic disk  ;  vision  was  lound 
to  be  normal.  An  inci- 
sion was  made  through 
the  conjuctiva  at  point 
of  injury  and  cicatrix 
found  in  sclera.  I  did  not  deem  it  advisable  to  make 
an  exploratory  incision  in  the  scleratory  tissues  without 
more  positive  evidence  of  the  presence  of  a  foreign 


August  lo,  1895] 


MEDICAL    RECORD. 


213 


body.  I  therefore  advised  that  atropia  be  employed 
to  keep  the  eye  at  rest,  and  that  the  eye  be  properly 
protected  from  the  light  ;  also  that  the  girl  be  kept 
under  strict  observation  and  await  developments. 
During  the  next  five  months  I  saw  the  girl  several 
times,  but  gained  no  additional  knowledge  in  regard 
to  the  causation  of  the  pain,  etc.,  which  had  been 
more  or  less  constant  since  the  time  of  injury.  Vari- 
ous analgesics  were  employed  without  avail.  In  No- 
vember I  learned  that  the  girl's  eye  might  have  been 
injured  by  a  small  particle  of  steel,  as  a  nick  was 
discovered  in  the  knife  of  the  machine  at  which  she 
was  working  at  the  time  of  injury.  Acting  on  this 
information  I  had  the  magnet  constructed.  On  No- 
vember 25th  the  girl's  eye  was  brought  near  the  magnet 
energized  as  above  described.  When  with- 
in twelve  inches  of  the  magnet  she  com- 
plained of  a  sharp  cutting  pain  in  the  eye. 
The  magnet  had  determined  with  absolute 
certainty  the  presence  of  iron  or  steel  with- 
in this  girl's  eye.  November  30th  Dr.  Sabin 
was  sent  for,  and  we  prepared  to  make  an 
incision  through  the  tunic  of  the  eye  and 
remove  the  foreign  body.  The  patient  re- 
fused to  allow  the  operation  to  be  made  ; 
no  argument  would  avail,  and,  recognizing  the  possi- 
bilities in  the  case,  I  refused  to  assume  further  respon- 
sibility. In  order,  however,  to  convince  Dr.  Sabin  of 
the  presence  of  a  foreign  body  within  the  eye  I  deter- 
mined to  again  apply  the  magnet.  Twelve  amperes  at 
an  electro-motive  force  of  one  hundred  and  twelve  volts 
was  employed,  and  the  eye  placed  in  direct  contact  with 
the  magnet  cone,  with  the  unexpected  result  of  with- 
drawing through  the  tissues  (sclera  and  conjunctiva)  of 
a  piece  of  steel  wire  2  mm.  in  length  and  -j\  mm.  in  di- 
ameter, two  lines  inferior  to  the  point  of  entrance. 
Considerable  hemorrhage  followed  the  exit  of  the  for- 
eign body.  Shortly  afterward  the  patient  returned  to 
Warren  with  vision  unimpaired,  with  no  untoward 
symptoms  whatsoever,  and  is  now  employed  at  her  old 
work. 

Case  II. — April  4,  1895,   Joe  D ,  boiler-maker, 

presented  himself  at  my  office  with  the  statement  that 
a  piece  of  steel  struck  him  in  the  eye.  The  chambers 
of  the  eye  were  filled  with  blood,  preventing  an  ophthal- 
moscopic examination.  A  wound  in  the  sclera  was 
found,  the  magnet  brought  into  action,  and  a  piece  of 
steel  9  mm.  in  length  and  3  mm.  in  diameter  was  re- 
moved through  the  wound  aperture.  I  was  obliged 
to  remove  the  eye  on  account  of  the  violent  inflam- 
matory reaction  which  came  on  a  few  days  later,  and 
found  on  examination  that  the  foreign  body  had 
lodged  in  the  tunic  of  the  eye  at  the  fundus  near  the 
optic  disk. 

Case  III. — The  latter  part  of  -\pril  Dr.  Perkins  came 

into  my  office  with  Robert  D ,  in  whose  cheek  a  piece 

of  steel  had  imbedded  itself  deeply  three  weeks  pre- 
vious. The  magnet  immediately  detected  the  point  of 
location  ;  an  incision  through  the  integument  was  made 
and  the  steel  instantly  clicked  against  the  magnet. 

Case  IV. — May  2d,  John  B was  brought  to  my 

office  with  a  bit  of  iron  impacted  in  the  iris  of  the  right 
eye,  having  penetrated  the  cornea.  A  corneo-scleral 
section  was  made  and  the  iron  withdrawn  by  the  mag- 
net, carrying  with  it  a  segment  of  iris  which  was  ex- 
cised. 

Many  cases  of  iron  chips  implanted  on  the  cornea 
have  been  removed  by  placing  the  eye  in  direct  con- 
tact with  the  magnet  cone.  Sufficient  has  been  noted, 
I  trust,  to  determine  the  value  of  this  form  of  a  magnet 
as  a  sure  means  of  diagnosis  where  the  presence  of  iron 
or  steel  is  suspected. 


AN    IMPROVED   UTERINE   DILATOR. 
By  J.  W.  LOXG,  M.D., 

KICHMOND.    VA. 

In  1890  I  published  an  account  of  a  uterine  dilator, 
which  instrument  possessed  several  points  of  advan- 
tage over  any  dilator  then  on  the  market.  Recently  I 
have  improved  this  dilator  in  a  number  of  particulars, 
and  feel  sure  that  a  trial  will  prove  it  to  be  a  superior 
instrument. 

It  is  made  in  two  sizes.  The  smaller  one  has  smooth 
small  blades,  so  that  it  is  readily  introduced  into  even 
a  "pin-hole  os."  The  ordinary  dilator  is  too  blunt  for 
such  cases  and  cannot  be  introduced  without  first  en- 


larging the  external  os  with  a  sound  or  "boring  "  into 
it  with  the  point  of  a  scissors.  The  blades  "  feather  " 
just  enough  to  keep  them  from  slipping  out,  while  the 
shoulder  gauges  the  depth  of  introduction.  The  joint 
is  fastened  by  a  thumb-screw,  which  is  easily  removed; 
this  is  only  necessary  when  the  instrument  is  to  be 
cleaned.  "The  female  blade  should  be  made  a  little 
stouter  just  opposite  the  thumb-screw  than  is  shown  in 
the  cut.  The  handles  are  curved  downward  and  back- 
ward, throwing  them  and  the  hand  holding  them  en- 
tirely out  of  the  way  of  inspection  and  manipulation 
while  the  dilator  is  in  situ.  A  spring  between  the 
handles  keeps  the  blades  closed. 

The  large-sized  dilator  has  corrugated  blades,  and 
the  handles  may  be  fitted  with  a  thumb-screw,  but  it  is 
questionable  whether  or  not  a  thumb-screw  is  desirable. 

This  instrument  is  manufactured  by  Messrs.  Bartlett, 
Garvens  &  Co. 


Hiccough  in  the  new-born  is  a  symptom  of  hereditary 
syphilis.  The  effects  of  specific  treatment  on  the  hic- 
cough are  marked. — Carini. 


THE    HORIZONTAL    POSITION    FOR   APPLY- 
ING PLASTER  CAST. 

By  T.  W.  SLOAN.  M.D.. 

SEATTLE,   WASH, 

This  apparatus  is  one  by  the  use  of  which  we  are  ena- 
bled to  properly  apply  a  plaster  jacket  for  supporting  the 
spinal  column  in  any  case  requiring  artificial  support. 
Never  was  there  a  saying  more  pregnant  with  truth  than 
that  necessity  is  the  mother  of  invention.  It  was  on 
account  of  the  difficulties  in  the  way  of  applying  a  cast 
in  the  upright  position,  and  the  unsatisfactory  results 
often  following  its  application  in  that  way,  that  led 
me  to  devise  a  method  which  is  more  simple,  more 
efficient,  and  at  the  same  time  one  which  gives  the  pa- 
tient the  greatest  degree  of  comfort  possible  while  the  • 
jacket  is  being  applied. 

This  apparatus  consists  of  a  frame  eight  feet  long 
and  six  feet  high.  A  hammock  made  of  canton  flannel, 
double  thickness,  from  nine  to  fifteen  inches  wide  ac- 
cording to  the  size  of  the  patient,  and  a  few  inches 
longer  than  the  patient  to  be  treated,  is  stretched  be- 
tween the  two  upright  pieces.  To  the  top  rail  of  the 
frame  is  suspended  a  pole  by  two  straps  with  buckles, 
so  that  the  pole  can  be  raised  or  lowered  at  will  by  the 
operator.  This  completes  the  description  of  the  ap- 
paratus. 

The  patient  should  be  divested  of  all  clothing  cover- 
ing the  trunk  save  a  closely  fitting  knit  shirt,  and  if  we 
are  dealing  with  Potts'  disease  a  pad  of  absorbent  cot- 
ton should  be  placed  on  either  side  of  the  processes  of 


214 


MEDICAL    RECORD. 


[August  lo,  1895 


the  diseased  vertebra  and  held  in  position  by  one  turn 
of  a  bandage  around  the  body,  after  which  the  patient 
is  placed  upon  the  hammock.  With  emaciated  patients 
I  prefer  enveloping  the  body  in  a  layer  of  absorbent 
cotton,  which  is  easiest  accomplished  by  laying  strips 
across  the  hammock  before  placing  the  patient  upon 
it.  The  end  of  a  roller  bandage  is  now  attached  to  the 
suspended  bar,  and  about  three  turns  of  the  bandage 
are  taken  around  the  body  and  up  over  the  bar,  leav- 
ing an  interspace  between  each  turn  of  the  bandage. 
The  turns  of  the  suspension  bandage  should  be  drawn 
sufficiently  tight  to  cause  the  hammock  to  fit  the  con- 
cavity of  the  back,  and  after  securing  the  bandage  to 
the  bar,  they  can  be  further  adjusted,  if  necessary,  by 
raising  or  lowering  the  bar. 

After  first  applying  a  dry  roller  bandage,  the  plaster 
bandages  are  applied  and  should  be  carried  from  the 
trochanters  to  the  axillary  spaces.  The  number  of  plas- 
ter bandages  necessary  is  from  four  to  ten  five-yard 
ones,  according  to  age  of  patient,  the  latter  number 
being  sufficient  for  an  ad   ':      T'   i      ! 


This  patient,  being  carefully 


ed  before  and  after,  showed  an 
being  made. 


place  a  pad  of  folded  towels  or  like  material  over  the 
stomach  and  one  over  the  chest,  under  the  shirt,  so 
that  they  can  be  easily  removed  after  the  cast  becomes 
set,  thus  allowing  the  patient  plenty  of  breathing-room 
and  room  for  digestive  purposes. 

When  the  cast  has  been  applied,  the  patient  is  left 
undisturbed  a  sufficient  length  of  time  for  it  to  harden, 
which  should  be  not  less  than  two  hours  in  any  event. 
After  it  has  become  sufficiently  firm  the  patient  is 
placed  upon  the  feet,  and  the  two  ends  of  the  ham- 
mock, with  the  suspension  strips,  are  cut  off  even  with 
the  cast.  It  will  sometimes  be  found  necessary  to 
trim  off  the  edge  of  the  cast  under  the  armpits  to  let 
the  shoulders  down  to  their  natural  position,  and  also 
to  trim  out  in  front  of  each  groin  sufficiently  to  allow 
the  thighs  to  be  flexed  at  right  angles  with  the  trunk. 

Since  !  first  called  the  attention  of  the  profession  to 
this  method  of  applying  a  plaster  jacket  by  an  article 
published  in  the  Medical  Ri^coru,  March  lo,  1894, 
and  by  sending  out  some  photographs  later  on  of  my  im- 
proved apparatus  to  some  of  the  leading  surgeons  of  the 
country,  I  have  received  a  number  of  letters  and  have 
been  very  much  gratified  on  account  of  the  interest  mani- 


fested. Some  suggestions  have  been  offered  as  to  im- 
provements that  I  might  make,  only  one  of  which  I  will 
mention,  and  that  is  of  adding  traction  for  the  purpose 
of  making  extension  upon  the  spinal  column,  while  the 
jacket  is  being  applied.  This  suggestion,  coming  from 
so  eminent  a  source  as  Dr.  Lewis  A.  Sayre,  should  not 
pass  unheeded,  for  he  says :  "  If  you  will  now  add  to 
it  traction  by  the  head  and  feet,  to  overcome  the  reflex 
muscular  rigidity  while  you  are  applying  the  plaster, 
you  will  make  the  thing  perfect."  Now,  I  take  the  po- 
sition, and  my  experience  in  the  use  of  this  apparatus 
confirms  me  in  the  opinion,  that  muscular  rigidity  is 
overcome  by  this  position  alone,  and  that  strong  ex- 
tension is  never  required  after  we  have  secured  mus- 
cular relaxation  by  a  comfortable  reclining  posture. 
The  steady,  firm  pressure  exercised  upon  the  muscles 
of  the  back  while  the  patient  is  being  suspended  in 
my  hammock  apparatus  will  control  muscular  spasm 
with  no  less  certainty  than  a  well-applied  bandage  con- 
trols muscular  spasm  in  a  leg  or  an  arm.  In  the  treat- 
iiKii  •"  Potts'  disease  I  have  found  that  no  extension 
whatever  is  required,  except  where 
there  is  lateral  displacement,  in 
which  case  gentle  traction  made 
upon  one  foot,  while  the  shoulders 
are  being  supported,  will  be  suffi- 
cient to  bring  the  vertebral  col- 
umn into  line.  To  extend  the 
spine  forcibly  while  we  have  at  the 
same  time  secured  muscular  relax- 
ation is  not  only  unnecessary,  but 
it  is  certainly  not  entirely  devoid 
of  danger.  I  have  carefully  meas- 
ured the  height  of  each  patient 
upon  whom  I  have  applied  the 
])taster  jacket,  no  extension  being 
made  at  the  time,  and  have  found 
an  increase  in  height,  after  appli- 
cation of  the  cast,  of  not  less  than 
three-fourths  of  an  inch,  showing 
conclusively  that  in  this  position 
we  have  muscular  relaxation, 
which  is  the  one  condition  abso- 
lutely necessary  for  securing  ex- 
tension of  the  spine. 

Permit  me  here  to  quote  the 
opinion  of  a  man  to  whom  we  are 
all  indebted,  perhaps  more  than 
to  any  other  man  living,  for  the 
wonderful  advancements  during 
recent  years  in  the  surgery  of  the 
abdominal  cavity  —  I  refer  to  Dr. 
Nicholas  Senn.  He  says  ;  "  I  thank 
you  for  the  photograph,  and  con- 
gratulate you  on  your  exceedingly  simple  and  efficient 
method  of  extension."  That  expresses,  in  one  short 
sentence,  just  what  it  is,  for  it  is  an  extension  apparatus 
exceedingly  simple  and  exceedingly  efficient.  To  my 
mind  this  method  is  in  every  way  superior  to  the  time- 
honored  one  of  suspension  in  the  upright  position, 
and  I  can  think  of  no  condition  calling  for  the  use  of  the 
Sayre  ajiparatus  which  is  not  fully  met  by  it. 

1.  The  patient  experiences  no  pain  in  consequence 
of  the  operation. 

2.  In  this  position  we  secure  muscular  relaxation, 
without  which  we  cannot  hope  to  achieve  the  best  re- 
sults. 

3.  This  position  is  most  desirable  for  securing  per- 
fect adaptation  of  the  cast  to  the  patient's  body. 

4.  Time  is  not  limited  as  in  the  upright  position, 
and  we  are  not  compelled  to  rush  through  with  an  ope- 
ration the  result  of  which  depends  upon  the  amount  of 
care  we  exercise. 

5.  In  this  position  we  secure  the  nearest  approach  to 
absolute  quiet,  with  regard  to  muscular  movements, 
both  voluntary  and  involuntary,  including  respiratory 
movements. 


1  height,  no  e-xtension 


August  lo,  1895] 


MEDICAL    RECORD. 


6.  Fatal  syncope  can  never  occur  in  this  position  in 
consequence  of  the  operation,  as  has  sometimes  hap- 
pened with  feeble  patients  while  being  suspended  in 
the  upright  position. 

7.  After  the  cast  has  been  completed  the  patient  can 
be  left  quiet  and  comfortable  in  position  a  sufficient 
length  of  time  for  it  to  harden — a  thing  not  possible  in 
the  upright  position. 


A    NEW   MYRINGOTOME. 
By  CORNELIUS  WILLIAMS,  M.D., 

ST.   PACL,   .MINN. 

The  best  instrument  for  myringotomy  I  believe  to  be 
a  small  curved  knife,  which  Mr.  Meyrowitz,  of  New 
York,  has  made  for  me  and  which  is  sufficiently  de- 
scribed by  the  illustration.  The  knife  is  a  slight  mod- 
ification of  a  capsulotome  which  I  have  used  for 
several  years.  The  advantage  of  the  curved  blade 
over  the  straight  in  capsulotomy,  after  extraction  of 
cataract,  is  that  it  cuts  more  readily,  and  in  the  sweep 
of  the  knife  it  makes  a  longer  hole  in  the  membrane. 
Another  advantage  is  that  it  will  cut  old  capsules 
which  are  only  pushed  along  and  torn  from  their  ciliary 
attachments  by  the  straight  blade.     The  myringotome 


/=== 


which  is  shown  in  the  cut  would  be  a  better  instrument 
if  the  handle  and  the  shank  were  not  quite  so  long,  and 
with  the  deflection  at  the  junction  of  the  handle' and 
the  shank  a  right  angle.  The  capsulotome  makes  a 
good  enough  myringotome,  and  is  a  capital  knife  for 
styes. 

LATIN   AS    SHE   IS   WROTE   AND   SPOKE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  have  read  with  great  interest  your  editorial  in 
the  issue  of  June  15th,  entitled  "The  Need  of  a  Latin 
Revival,"  as  well  as  the  many  articles  which  have  ap- 
peared in  the  Medical  Record  during  the  last  twenty 
years,  advocating  the  study  and  use,  by  physicians,  of 
the  Latin  and  Greek  languages. 

It  would  surely  be  of  great  advantage  to  the  medical 
profession  if  all  its  members,  both  in  this  country  and 
Europe,  could  write  and  speak  with  elegance  both 
Latin  and  Greek.  All  the  medical  literature  of  the 
world  could  then  be  printed  in  one  of  these  classic 
tongues,  and  all  of  it  would  then  be  accessible  to  all  of 
us.  Not  only  at  the  large  international  gatherings, 
where  now  a  Babel  of  tongues  is  the  most  pro'minent 
feature,  but  at  the  county  society,  in  the  rural  districts, 
the  musical  tones  of  those  languages,  which  have  never 
been  equalled  for  force,  variety  of  e.xpression,  and 
beauty,  would  replace  the  abominable  jargon  of  Ger- 
man, French,  Russian,  Spanish,  English,  and  "  United 
States." 

For  the  speedy  attainment  of  this  ideal  condition, 
let  us  all  devoutly  pray,  especially  those  of  us  who 
know  as  yet  not  a  single  word  of  Latin  or  Greek. 

In  the  meanrime — and,  as  Mark  Twain,  I  believe  it 
was,  remarked,  "  it  would  probably  be  a  tolerably  mean 
time  "  for  some  of  us  busy  old  fellows,  who  would  have 
the  duties  of  a  large  pracrice  to  perform  at  the  same 
time  that  we  were  learning  to  speak  and  read  and  write 
Latin  and  Greek — would  it  not  be  well  to  remember 
that  our  profession  is  a  practical  profession,  and  that 
most  of  us  are  engaged  in  the  practice  of  medicine  ; 


that  many  of  us  are  obliged  to  gain  a  livelihood  for 
ourselves  and  our  families  by  that  practice,  and  that 
life  is  short  and  full  of  duties  ? 

Before  we  commence  in  earnest  the  study  of  these 
languages,  so  necessary  to  the  busy  practitioner,  will 
you  have  the  kindness  to  inform  us,  through  the  col- 
umns of  the  Record,  what  has  been  printed  in  either 
of  them,  during  the  last  five  hundred  years,  that  it 
would  pay  the  physician  of  to-day  to  read,  if  it  were 
translated  into  his  mother-tongue  ? 

A  large  percentage  of  the  technical  terms  employed 
in  medicine  are  of  Latin  or  Greek  origin,  and  of  course 
all  prescriptions  are  written  in  Latin.  This  latter  state- 
ment applies  more  particularly  to  the  prescriptions  of 
those  physicians  who  are  graduates  of  machine-shops, 
and  whose  classical  learning  and  preliminary  educa- 
tion was  obtained  in  business  offices  and  in  markets, 
and  behind  the  counters  of  our  large  retail  establish- 
ments. 

It  is  truly  gratifying  to  see  the  ease  with  which  these 
gentlemen  can  express  themselves  in  an  unknown 
tongue  ;  how  they  can  rise  superior  to  the  limitations 
of  gender  and  case,  and  the  facility  with  which  the 
classic  and  the  vulgar  tongues  <!an  be  mixed,  in  the 
prescription,  to  the  great  advantage  of  both.  It  also 
has  a  particularly  good  effect  on  the  minds  of  the 
patient  and  his  friends  to  read  these  Latin  patois  pre- 
scriptions. It  inspires  a  proper  amount  of  awe  for  the 
great  wisdom  of  the  medical 
mind,  and    usually    prevents    the 

-,\;"^'^^T ^rr^    laity,  and  sometimes  other  physi- 

-- — "■''  ■'^''    ''  '       '"^    cians,  and  even  the  druggist,  from 
finding  out  what  medicine  it  is  in- 
tended shall  be  given. 

No  man  or  woman  who  has  not  seen  it  done  can 
imagine  what  a  simple  thing  it  is  for  a  physician  who 
has  never  seen  a  Latin  grammar  to  write  out  a  full 
Latin  prescription.  Ever)'  doctor  knows  that  the  Latin 
for  iron  h/erri/m  or  ferti  or  ferra — it  makes  little  dif- 
ference which — and  the  druggist  or  his  youngest  clerk 
knows,  as  soon  as  he  sees  either  of  these  words,  that 
iron  in  some  form  is  called  for,  and  he  immediately 
puts  it  up.  If  the  physician  writes  rheum  or  rhei  or 
rhea,  he  knows,  and  the  druggist  knows,  that  it  is  rhu- 
barb that  is  called  for,  and  not  the  celebrated  actress 
of  a  similar  name. 

Any  druggist  knows,  if  he  knows  anything,  and  most 
of  them  do,  that  aqua  or  aquam  or  aquce  means  water, 
and  that  either  of  these  terms  can  be  used  in  place  of 
either  one  of  the  others.  If  the  physician  does  not 
know  this  he  ought  to.  How  much  better  it  is  to  write 
at  the  bottom  of  a  prescription,  as  was  done  by  a  phy- 
sician on  a  prescription  which  I  saw  to-day,  *'  Cochlear 
parvum  omni  tertia  hora  sumendum"  than  it  is  to  write, 
in  the  language  which  most  of  us  are  compelled  to 
use  in  talking  to  ignorant  people,  "  Take  a  teaspoonful 
once  in  three  hours." 

It  has  been  asserted,  and  I  presume  it  is  true,  that 
not  over  five  per  cent,  of  the  prescription  clerks  in  this 
State  have  any  knowledge  of  Latin,  and  I  am  ac- 
quainted with  an  ignorant  physician  who  only  spent 
four  years  in  the  study  of  Latin,  who  makes  the  absurd 
claim  that  it  is  not  safe  or  scientific  for  physicians,  who 
have  no  knowledge  of  this  tongue,  to  write  in  it  pre- 
scriptions to  be  translated  and  compounded  by  drug- 
gists who  enjoy  the  advantage  of  even  less  learning. 
As  might  be  expected,  this  same  physician  has  indorsed 
the  absurd  notion  that  in  this  country  it  would  be  well 
if  all  prescriptions  were  written  in  plain  vulgar 
"  United  States."  Does  not  everyone  know  that  mis- 
takes do  not  occur  when  prescriptions,  containing  the 
names,  and  methods  of  preparation,  and  doses,  and  fre- 
quency of  repetition  of  doses  of  poisons,  are  written  in 
Latin  patois  ?  Was  not  this  the  language  of  religion 
and  science  for  many  centuries  ?  Does  it  not  resemble 
the  language  of  Virgil  and  Cicero  and  Horace  ?  How, 
then,  can  errors  occur  in  writing  or  translating  it,  in 


2l6 


MEDICAL   RECORD. 


[August  lo,  1895 


this  enlightened  age  ?  What  has  been  said  of  Latin 
applies  with  equal  truth  to  Greek  ;  they  are  the  lan- 
guages of  science  and  of  scholars,  and  come  perfectly 
natural  to  all  physicians,  either  to  speak,  read,  or  write, 
but  particularly  to  write.  How  much  better  it  would 
be  for  our  beloved  profession  in  the  future,  if  our 
young  men  and  maidens,  instead  of  fooling  away  their 
time  with  microscopes  and  culture-tubes,  and  bacilli 
and  bacteriological  and  laboratory  work,  would  return 
to  the  true  fountain  of  wisdom,  which  is  the  Latin  lan- 
guage. How  much  better  to  absorb  wisdom  from  these 
pure  sources  than  to  waste  time,  as  many  do,  in  the 
study  of  the  barbaric  language  of  the  stupid  Dutch- 
man, a  language  which  contains  little  that  is  better  than 
the  vaporings  of  Goethe  and  Schiller  or  the  pseudo- 
science  of  Virchow  and  Ziemssen.  Let  us  by  all  means 
have  a  "  Latin  revival,"  it  is  without  doubt  the  one 
thing  that  is  needed  in  this  age  to  make  our  profession 
truly  scientific. 

Yours  truly, 

H.  L.  Waldo,  M.D. 

Tkov,  N.  V. 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  August  3,  1895. 


Tuberculosis 143 

Typhoid  fever 

Scarlet  fever 26 

Cerebro-spinal  meningitis 2 

Measles ]  163 

Diphtheria ;  159 


Coleridge  on  Genius  and  Degeneration. — In  the  '"  Let- 
ters of  Samuel  Taylor  Coleridge,"  just  published  under 
the  editorship  of  his  grandson,  ivir.  Ernest  Hartley 
Coleridge,  the  poet  gives  a  curious  prolepsis  of  Lom- 
broso's  views  as  to  the  intimate  connection  between 
genius  and  disease.  The  author  of  "  The  Ancient 
Mariner  "  writes  :  "  It  is  a  theory  of  mine  that  virtue 
and  genius  are  diseases  of  the  hypochondriacal  and 
scrofulous  genera,  and  exist  in  a  peculiar  state  of  the 
nerves  and  diseased  digestion,  analogous  to  the  beau- 
tiful diseases  that  color  and  variegate  certain  trees. 
However,  I  add  by  way  of  comfort,  that  it  is  my  faith 
that  the  virtue  and  genius  produce  the  disease,  not  the 
disease  the  virtue,  etc.,  though  when  present  it  fosters 
them."  Coleridge,  as  is  well  known,  was  a  slave  of 
opium.  He  is  said  to  have  swallowed  two  quarts  of 
laudanum  in  a  week,  and  on  one  occasion  he  took  a 
whole  quart  in  twenty-four  hours.  He  struggled  hard 
for  deliverance,  and  wished  that  he  might  be  kejit  from 
the  possibility  of  indulgence  by  force  tnajeurc.  In  the 
following  passage  he  sketches  out  a  i)lan  for  the  '"  thera- 
jjculic  seclusion  "  of  narcomaniacs  :  "This  might  give 
occasion  for  the  suggestion  of  one  new  charitable  insti- 
tution, under  authority  of  a  legislative  Act,  namely,  a 
Maison  de  Sante  (what  do  the  French  call  it  ?)  for 
lunacy  and  idiocy  of  the  will,  in  which  with  the  full 
consent  of,  or  at  the  direct  instance  of,  the  patient  him- 
self, and  with  the  concurrence  of  his  friends,  such  a 
person  under  the  certificate  of  a  physician  might  be 
placed  under  medical  and  moral  coercion.  I  am  con- 
vinced that  London  would  furnish  a  hundred  volun- 
teers in  as  many  days  from  the  ginshops  who  would 
swallow  their  glass  of  poison  in  order  to  get  courage  to 
present  themselves  to  the  hosjiital  in  question  ;  and  a 
similar  institution  might  exist  for  a  higher  class  of  will 
maniacs  or  impotents.  Had  such  a  house  of  health  been 
in  e.\istence,  I  know  who  would  have  entered  himself 


as  a  patient  some  five  and  twenty  years  ago."  It  should 
not  be  forgotten  that  Coleridge  spent  the  last  eighteen 
years  of  his  life  under  the  roof  of  Mr.  James  Gillman, 
a  medical  practitioner  of  Highgate,  who  tended  him 
with  more  than  brotherly  care  (the  expression  is  Cole- 
ridge's own)  as  an  honored  and  cherished  guest,  not 
as  a  patient  in  the  ordinary  sense. — British  Medical 
Journal. 

Cure  of  Cancer. — -A  paper  of  exciting  interest  was 
read  by  M.  Richet  at  the  Academic  des  Sciences  on 
two  cases  of  cancer  cure  by  sero-therapy.  He  said 
that  sero-therapy  had  gained  its  laurels  in  the  treat- 
ment of  diphtheria  and  other  affections,  and  the  two 
cases  he  brought  under  the  notice  of  his  colleagues  at 
that  meeting  proved  not  only  that  this  method  can  be 
applied,  not  only  to  maladies  in  which  the  microbe  is 
known  to  be  virulent,  but  also  in  affections  like  cancer 
whose  microbian  origin  is  still  probleinatic.  His  ex- 
periments were  made  as  follows  :  On  February  9th,  M. 
Reclus  removed  an  osteo-sarcoma  of  the  leg.  This 
tumor  was  well  rubbed  up  in  a  mortar  with  a  little 
water.  The  liquid  was  filtered  through  linen  and  in- 
jected into  three  animals  (an  ass  and  two  dogs).  This 
injection  was  not  followed  by  any  reaction,  and  in 
five,  seven,  and  fifteen  days  afterward  the  blood  was 
drawn  and  the  serum  separated.  It  was  this  serum 
that  he  used  in  the  cases  in  question.  The  first  of 
these  was  that  of  a  woman  who  had  been  operated 
on  in  October  last  for  tumor  presenting  the  look  of  a 
fibro-sarcoma  of  the  size  of  an  orange  and  adherent  to 
the  sixth,  seventh,  and  eighth  ribs,  without,  however, 
interesting  the  tegument.  In  February  the  tumor  re- 
turned and  rapidly  assumed  the  size  of  a  small  orange. 
The  treatment  by  the  serum  was  commenced  on  March 
1 2th,  and  continued  during  forty  days,  at  the  dose  of 
three  syringes  a  day  practised  around  the  tumor.  From 
March  25th  the  tumor  commenced  to  diminish  in  size, 
and  to-day  only  a  small  indurated  nodule  is  found,  and 
the  general  condition  of  the  patient  has  improved  con- 
siderably. The  tumor,  which  was  certainly  of  a  can- 
cerous nature,  was  thus  cured  by  the  injections  of 
serum.  The  second  case  was  that  of  a  man,  aged 
forty-four,  who  entered  the  hospital  on  March  27th 
last  for  a  tumor  in  the  epigastric  region  of  the  size  of 
an  orange,  and  diagnosed  cancer  of  the  stomach.  Surgi- 
cal intervention  being  considered  impossible,  the  treat- 
ment by  sero-therapy  was  decided  on  and  commenced 
on  April  6th  by  a  first  injection  of  4  c.c.  (four  Pravaz 
syringes),  and  from  that  time  up  to  the  24th  of  the 
same  month  as  much  as  64  ctm.  cubes  were  injected.  A 
general  improvement  in  the  condition  of  the  patient 
promptly  followed  ;  the  weight  increased  by  seven 
pounds,  and  from  April  loth  the  tumor  began  to  dimin- 
ish in  volume,  and  at  the  time  of  speaking  it  can  be  no 
longer  defined  by  the  fingers.  In  this  second  case,  as 
in  the  first,  added  M.  Richet,  the  improvement  was 
rapid  and  incontestable,  and  as  regards  the  first  case 
at  least,  the  anti-cancerous  serum  did  really  cure  a 
case  of  cancer. — Medical  Press. 

Death  of  the  Oldest  German  Surgeon. —  Professor 
Franz  von  Ried,  the  oldest  of  German  surgeons,  died 
at  Jena  on  June  loth,  aged  eighty-five.  He  was  a  pu- 
pil of  Michael  Jaeger,  at  Erlangen,  and  lectured  in  his 
place  for  some  time.  In  1S46  he  was  appointed  Pro- 
fessor of  Surgery  in  the  University  of  Jena,  and  this 
appointment  he  held  till  1SS4,  when  he  retired.  His 
principal  work  was  "  Die  Resectionen  von  Knochen," 
(Nuremberg.  1S47),  which  in  its  day  was  a  leading  au- 
thority on  the  subject. 

Treatment  of  Fractured  Patella. — The  method  of 
Barker  is  to  encircle  the  patella  with  a  vertical,  antero- 
posterior silk  ligature,  which,  when  tied,  holds  the  frag- 
ments firmly  together.  The  operation  is  done  subcu- 
taneously,  and  the  ends  of  the  ligature  are  cut  short. 
— British  Medical  Journal. 


Medical   Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  48,  No.  7. 
Whole  No.  1293. 


New  York,  August  17,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


SUICIDE    IN    THE    UNITED    STATES. 
By  JAMES   WEIR,  Jr.,    M.D., 

OWENSBORO',    KV. 

This  paper  has  been  prepared  with  special  reference  to 
suicide  as  observed  in  the  United  States,  though  vol- 
untary death  as  found  throughout  the  entire  world  is, 
incidentally,  discussed  therein. 

Self-slaughter  is  of  rare  occurrence  among  savage 
races  of  people  ;  of  so  infrequent  occurrence,  in  fact, 
that  one  is  almost  tempted  to  say  that  it  is  unknown 
among  them.  This  would  be,  however,  a  statement 
not  authorized  by  facts,  for  savages  commit  suicide  on 
occasions  when  influenced  by  the  fear  of  starvation,  or 
through  the  dread  of  a  lingering,  painful  death,  or 
through  pride.  The  higher  psychical  emotions  are 
wanting  in  the  savage  ;  he  is  very  near,  indeed,  in  this 
respect,  to  his  pithecoid  ancestor,  hence  he  bears  the 
ills  of  life  with  all  the  equanimity  of  an  animal  in 
which  Eestheticized  and  idealized /Jir/wi' are  absent. 

The  semi-civilized  Chinaman  is,  on  occasions,  prone 
to  suicide  ;  and,  I  am  inclined  to  believe,  most  of  the 
voluntary  deaths  occurring  among  the  Chinese  are 
brought  about  through  pride.  AVe  know  that  when 
overcome  in  battle  entire  companies  of  these  people 
will  kill  themselves  rather  than  fall  into  the  hands  of 
their  enemies.  The  Chinese  are  a  proud,  arrogant,  and 
insular  nation.  They  consider  all  foreigners  as  being 
barbarians  and  savages,  and  despise  them  as  beings 
utterly  beneath  their  notice  ;  hence,  when  overcome  by 
them,  they  deliberately  slay  themselves  rather  than  suf- 
fer the  ignominy  of  being  slain  by  these  "contemptible 
and  despicable  outsiders."  The  incentive  may  be,  how- 
ever, the  fear  of  torture.  Again,  there  is  a  certain 
standard  of  virtue  that  obtains  among  these  people, 
which  makes  the  fear  of  rape  a  powerful  factor  in  en- 
gendering the  act  of  suicide  in  the  females  of  this  race. 
The  usages  of  war  among  Eastern  nations  has  author- 
ized, heretofore,  the  violation  of  all  captured  females  : 
hence,  large  numbers  of  young  girls  and  women  kill 
themselves  when  they  see  that  they  are  in  danger  of 
being  taken  by  the  enemy.  This  fact  was  especially 
noticed  during  the  late  war  between  Japan  and  China. 

The  factors  inciting  suicide  in  the  Chinese  and  kin- 
dred races  of  people  are  not  those  which  bring  about 
self-slaughter  in  those  races  that  are  highly  civilized  ; 
the  psychical  maieries  morbi  are  markedly  different. 

When  we  turn  to  the  civilized  races  of  the  world, 
statistics  show  the  curious  facts  that  certain  ethnic 
elements  enter  into  the  influences  predisposing  suicide  ; 
that  voluntary  death  is  largely  on  the  increase  ;  that  it 
follows  in  the  wake  of  civilization,  and  that  its  average 
is  much  higher  in  those  races  in  which  are  to  be  found 
the  greatest  amount  of  culture  and  erudition. 

A  close  study  of  suicide,  as  observed  in  European 
countries,  demonstrates  the  fact  that  those  nations 
which  have  their  origin  in  the  Indo-Germanic  root- 
stocks  are  the  most  prone  to  commit  voluntary  doatli. 
With  few  exceptions,  and  these  exceptions  can  be  read- 
ily accounted  for  by  reason  of  exceptional  surround- 
ings, the  great  centres  of  suicide,  in  which  the  number 


of  suicides  per  million  of  inhabitants  runs  very  high, 
are  to  be  found  in  Germanic  countries. 

A  glance  at  the  accompanying  table,  prepared  for  me 
by  Professor  Weidner,  of  Vienna,  for  this  paper,  will  at 
once  show  this. 

Table  I.,  -Showing  Average  of  Suicides  in  Various  States 
OF  Europe  for  a  Period  of  Five  Years.' 


Hanover 

Mecklenburg. , 
Wurtemberg. . 

Saxony    

Denmark 

Hamburg 

France 

Spain 

Russ'a 

England 

Italy 


263 
306 


General 
Average. 


^  I  am  inclined  to  believe  that  the  averages  in  this  table  are  too  low  by  two  or 
three.— J.  W.,  Jr. 

Hovelacque  demonstrates  that  the  averages  of  suicide 
are  decidedly  higher  in  Germanic  countries  than  else- 
where. The  following  table,  which  I  have  slightly 
modified  in  order  to  make  it  more  explicit,  appeared  in 
La  Linguistique,  in  1876  : 

Table  II.  Linguistic  Table  De.monstr.\ting  the  Prepon- 
derance OF  Suicide  in  Germanic  Races.  Adapted  from 
Hovelacque.  2 


Languages. 

Maximum 
Proportion. 

Minimum  of 
Suicides. 

Average  per 
MiUion. 

People   speaking  the  first    group  of  the 

Italian    languages    derived    from   the 

Latin   (Italians,     Spaniards.    Rouma- 

nians, Portuguese,  Corsicans) 

74 

13 

31S 

People   speaking  the    second    group   of 

Italian  languages,  with  an  infiltration 

of  Cclto-Germanic    elements    (French, 

People   speaking    Scandinavian,    or  the 

first     subdivision     of  the     Germanic 

branch  (Danes,  Swedes,  Norwegians). 

263 

74 

.27.8 

People   speaking   the  languages  derived 

from  the  Low  German  (Frisians,  Flem- 

ings, Prussians,  English,   Germans  of 

the  North) 

301 

35 

148.0 

People  speaking  languages  derived  from 

the    High    German    (Saxons,    Central 

Germans.  Bavarians,  Auslrians.  Styri- 

ans,  Corinthians,  German  Swiss,  etc.). 

303 

90 

16s 

People  speaking  the  Slavic  idioms  of  the 

cians,  Sloveni,  Croats,  Dalmatians)... 

98 

14 

40 

People  speaking  the  Slavic  idioms  of  the 

Western  branch  (Czechts,    Moravians, 

■58 

98 

{130) 

'  Modified  from  tables  used  by  Morselli  in  his  work  on  Suicide. 

The  Celtic  and  Celto-Latinic  races  are  remarkably 
free  from  the  desire  for  self-slaughter.  Especially  is 
this  true  of  the  former  in  Ireland,  where  the  average 
rate  of  suicide  is  only  about  fifteen  per  million  of  in- 
habitants, and  of  the  latter  in  Spain,  where  the  aver- 
age is  about  twenty  per  million.  From  data  gathered 
throughout  Europe  and  Great  Britain,  which  embrace 
a  period  of  time  extending  from  January  i,  1880,  to 
December  31,  1893,  I  have  constructed  a  table  which 
shows  the  general  averages  of  the  four  great  divisions 
of  European  peoples.     I  have  taken  great  care  to  con- 


2l8 


MEDICAL   RECORD. 


[August  17,   1895 


fine  my  investigations,  as  far  as  possible,  to  cases  of 
authentic  suicide,  and  the  following  table  is  based  on 
official  records  which  were  furnished  by  the  proper 
legal  officers  and  persons  in  authority  : 

Table   III  ,    Showing    Suicidal   Averages    of    the    Four 
Great  Divisions  of  European  Peoples. 


Germanic. 

Scandinavians 

Germans  of  the  North 

Germans  of  the  South 

Anglo-Saxon 

Flemings 

Celts  ;  Celto-Latins. 

Celts 

Celto-Latins 

Slavs. 

Slavs  of  the  North 

Slavs  of  the  South 

Ural-Altaic. 
Magyars 


Average  per 
Mill  on: 

General 
Average 

130 1 

T55 
170  1- 

1.6 

75  1 

52} 

III 

43 

3'i 

38 

40  j 

46 

Morselli  observes  in  his  works  on  suicide  that  self- 
slaughter  begins  in  the  northern  European  states  with 
a  rather  high  average,  which  increases  to  a  maximum 
in  the  middle  states,  and  decreases  thence  slowly  to  a 
minimum  in  the  southern  states.  A  study  of  the  tables 
already  presented  in  this  article  will  show  that  this  ob- 
servation is  true  in  every  respect,  although  I  did  not 
have  this  in  view  when  compiling  them.  The  general 
averages  of  the  first  table  presented  will  show  that 
there  was  an  increase  in  the  number  of  suicides  per 
million  in  nearly  all  of  the  states  cited  ;  if  the  data  had 
embraced  a  longer  period  of  time,  this  increase  would 
have  been  shown  clearly  and  emphatically  in  all  of  the 
States.  Wherever  records  have  been  kept  for  any  num- 
ber of  years  they  always  show  an  increase  of  suicide.  In 
Sweden,  where  records  of  the  disease  have  been  kept 
for  a  long  time,  statistics  show  that  there  has  been 
an  increase  per  million  of  3  or  4  for  every  decade. 
In  i860,  the  average  for  the  United  States  was  32; 
in  1893,  it  was  55  for  each  million  of  inhabitants  ; 
Ireland  has  crept  up  from  10  per  million  in  1841  to  15 
per  million  in  1S93.  The  average  in  England,  in  1886, 
was  70  (69  +  )  per  million  of  inhabitants;  in  1893  it 
was  76  per  million  ;  in  Switzerland,  in  1872,  it  was  196, 
in  1893  it  was  204  ;  in  Italy,  in  1SS6,  it  was  36,  in  1S93 
it  was  42  ;  in  Russia,  in  1886,  it  was  ^^,  in  1893  it  was 
40.  Two  groups  of  periods  of  five  years  each,  taken 
from  records  obtained  throughout  the  United  States, 
from  Maine  to  Texas,  and  from  New  York  to  Califor- 
nia, show  that  there  is  an  increase  in  suicide  in  every 
section  of  the  country.  I  do  not  propose  to  burden 
the  reader's  attention  with  heavy  loads  of  official 
figures,  therefore  will  make  one  group  answer  for  all  in 
establishing  the  fact.  The  following  table  was  fur- 
nished me  by  Dr.  L.  J.  Mitchell,  of  Chicago,  medical 
assistant  to  the  coroner  of  Cook  County,  111. 

Table  IV.,  Showing  Increase  in  Suicide  per  Million  In- 
habitants IN  Chicago  and  Cook  County. 


Years. 


1890 

i8i)i 

1892 

■893 

'S94 

Gen'l  Average  per  year 


Male. 

Female. 

173 

43 

aoo 

70 

aaS 

66 

aSa 

83 

260 

57 

228.4 

63.4 

Per  Million.':; 


This  table  shows  an  increase  of  12  per  million  of  in- 
habitants in  a  iieriod  of  five  years.  This  large  increase 
is  undoubtedly  due  to  the  influence  of  the  Centennial 
year  (1893),  when  the  high  average  of  182  per  million 
of  inhabitants  was  reached  ;  leaving  out  this  year,  an 
annual  increase  of  5  or  6  will  beobserved,  which  is, 


probably,  the  natural  ratio  of  increase  for  this  section 
of  the  country.  There  are  exceptional  influences  at 
work  in  Chicago  which  create  this  high  rate  of  increase, 
and  these  adjuvants  to  this  increased  average  (per  mill- 
ion of  inhabitants)  ol  suicide  will  be  discussed  else- 
where in  this  paper.  In  Central  Pennsylvania  and 
Southern  Ohio  the  average  rate  of  increase  is  about 
the  same.  In  Hamilton  County,  O.  (Cincinnati),  the 
number  of  suicides  in  1894  was  87,  an  annual  increase 
of  30  in  five  years  per  million  of  inhabitants,  while  in 
Central  Pennsylvania  the  increase  per  million  was  3.1. 

In  the  Northwestern  States  an  annual  increase  of 
four  per  million,  for  a  period  embraced  by  the  last  five 
years,  can  be  noticed.  The  general  average  of  annual 
increase  for  the  United  States  during  the  period  em- 
braced by  the  last  five  years  is  1.5,  consequently  there 
must  be  some  factor  at  work  which  engenders  the 
high  averages  in  the  localities  just  cited.  That  factor 
is,  undoubtedly,  the  Germanic  element  (Danes,  Swedes, 
Germans,  etc.),  which  has  been  injected  into  the  popu- 
lations of  those  sections  where  these  high  averages  of 
increase  prevail. 

The  preponderance  of  suicides  of  Germanic  ex- 
traction can  be  noticed,  locally,  throughout  the  entire 
United  States  ;  in  fact,  if  it  were  not  for  these  peoples, 
I  am  confident  that  the  general  average  for  the  United 
States  would  fall  far  below  its  present  mark.  In  a 
population  composed  equally  of  Germans  and  Ameri- 
cans the  rate  of  suicide  is  eighty-five  per  cent.  German, 
and  this  rate  does  not  var)'  throughout  the  entire 
United  States. 

Let  us  turn  aside  for  a  moment  and  discuss  the 
question  :  Why  does  suicide  preponderate  among  the 
Germanic  peoples  ?  I  do  not  propose  to  treat  this  sub- 
ject in  this  paper  with  the  fulness  and  detail  that  it 
really  deserves,  for  that  would  be  impossible  in  the 
short  space  of  a  magazine  article ;  therefore  I  will 
only  enter  into  it  incidentally.  The  coroner  of  Cook 
County,  111.  (Chicago),  in  his  last  report  writes  as  fol- 
lows :  "  The  fact  of  this  practice  among  the  German 
race  jn  a  measure  helps  to  bear  out  the  theory  ad- 
vanced by  some  members  of  the  medical  profession, 
that  the  continued  consumption  of  beer  and  ale  is 
more  conducive  to  low  spirits  than  is  that  of  whiskey, 
especially  when  the  fact  is  taken  into  consideration 
that  among  all  the  Irish  population  of  the  city  only  ten 
committed  suicide  during  the  past  twelve  months. 
The  Irishman,  it  is  safe  to  assume,  drinks  whiskey  in 
the  same  proportion  that  his  German  brother  con 
sumes  beer." 

The  idea  that  beer-drinking  is  the  cause  of  the  pre- 
ponderance of  suicide  among  Germanic  peoples  is  one 
that  is  popularly  accepted  throughout  the  United  States  : 
it  is,  however,  in  my  opinion,  erroneous  and  based  on 
faulty  logic.  The  logician  who  deduces  a  cause  from 
a  sequence  is  standing  on  a  precarious  foundation  ;  he 
bases  his  premises  on  an  assumption — a  weak  and 
superficial  basis  in  logicial  reasoning.  The  English 
race  (Anglo-Saxon)  is  a  branch  of  the  great  Germanic 
race  and  is  a  beer-drinking  (ale,  porter,  half-and-half, 
etc.)  people,  yet  the  average  rate  of  suicide  is,  com- 
paratively speaking,  not  at  all  high.  Alcohol  in  any 
form  is,  undoubtedly,  a  factor  in  producing  degenera- 
tion, and  suicide  is,  emphatically,  an  evidence  of  de- 
generation ;  lience,  I  am  inclined  to  believe  that,  if 
alcohol  were  the  exciting  cause,  whiskey-drinkers  would 
more  readily  succumb  to  suicidal  desire  than  beer- 
drinkers.  A  careful  analysis  of  pure  malted  liquors 
will  show  that  they  contain  no  ingredient  capable  of 
causing  cerebral  degeneration  save  alcohol.  It  is  true 
that  lupulin  is  toxic,  but  the  quantity  imbibed  in 
pure  beers  is  not  sufficient,  in  my  opinion,  to  occasion 
any  great  amount  of  degeneration.  The  cause  of  this 
preponderance  of  suicide  in  Germanic  peoples  is  not 
occasioned  by  any  indulgence  of  tlie  ap]ietite,  but  has 
its  origin  in  a  psychical  trait  inherent  in  the  race. 
As  far  back  as  history  goes,  both  written  and  legend- 


August  17,  1895] 


MEDICAL   RECORD, 


219 


ary,  the  Germanic  races  have  shown  a  strange  indiffer- 
ence to  death.  They  are  not  braver  than  many  other 
races,  yet  they  do  not  seem  to  value  life  as  highly  as 
do  the  Celts  and  Celto-Latins.  When  the  balance- 
wheel  of  psychos  loses  its  equipoise  through  degenera- 
tion, this  indifference  to  death  becomes  a  strong  desire 
for  death,  and  the  German  suicides  ;  this,  in  my  opin- 
ion, is  the  true  cause  of  the  high  suicidal  averages  of 
the  Germanic  races.  Let  us  return  now  to  the  averages 
of  increase  as  observed  in  the  United  States.  The 
condensation  of  populations  in  circumscribed  areas, 
viz.,  in  cities  and  large  towns,  is  a  potent  factor  in 
building  up  increased  averages  of  suicide.  This  we 
can  readily  observe  by  a  study  of  mortuary  statistics 
(suicide)  as  furnished  by  the  coroners'  reports  emanat- 
ing from  all  of  the  large  cities  and  towns  of  the  coun- 
try. Thus,  the  average  annual  rate  of  increase,  per 
million  of  inhabitants,  for  the  State  of  New  York  is 
about  1.2,  while  the  rate  of  increase  for  New  York 
City  is  at  least  4.0.  These  rates  are  calculated  from 
the  reports  of  the  last  ten  years,  and  mean  that 
every  five  years  adds  an  average  of  four  per  million 
of  inhabitants  to  the  annual  number  of  suicides  oc- 
curring in  New  York  City,  and  one  per  million  of 
inhabitants  to  the  number  occurring  in  the  State 
at  large.  In  Chicago,  as  I  have  shown  elsewhere,  the 
rate  of  increase,  per  period  of  five  years,  is  annually 
6.0  per  million  of  inhabitants.  This  large  increase  is 
undoubtedly  due  to  two  factors  :  the  first  is  the  phe- 
nomenal growth  in  population  of  Chicago  during  the 
last  five  years  ;  the  second  is  the  large  influx  of  Ger- 
manic peoples  within  her  borders.  Lansing,  Mich.,  with 
a  population  of  20,000,  has  an  average  of  3  suicides  an- 
nually ;  this  gives  a  rate  of  150  suicides  per  million  of 
inhabitants.  The  annual  increase  for  the  entire  State 
of  Michigan,  for  a  period  of  five  years,  is  between  3.0 
and  4.0  ;  and  it  is  the  same  inAVisconsin  and  Minnesota. 
These  high  averages  are  not  to  be  observed  in  any  of 
the  Eastern  States,  especially  in  those  States  of  the  sea- 
board. It  is  true  that  the  general  average  of  New  York 
State  is  rather  high  (98),  but  this  is  due  to  the  influ- 
ence of  condensation  of  population  in  Brooklyn,  New 
York  City,  and  other  large  towns  of  the  State.  The 
general  average  of  the  State  of  Pennsylvania  is  92  ;  this 
comparatively  high  average  is  undoubtedly  due  to  the 
Germanic  elements  which  enter  so  largely  into  its  popu- 
lation. In  Maine,  Yermont,  and  New  Hampshire  the 
general  average,  deduced  from  official  records,  is  about 
thirty-eight  per  million  of  inhabitants.  This  average 
gradually  decreases  in  the  States  forming  the  Atlantic 
seaboard,  with  the  exception  of  the  States  of  New 
York,  Pennsylvania,  Massachusetts,  Rhode  Island,  and 
New  Jersey  toward  the  south,  until  it  reaches  the  low 
average  of  30  per  million  of  inhabitants  in  Georgia  and 
Florida.  In  the  Southern,  Middle,  and  \Vestern  States 
the  averages  run  from  thirty  to  sixty,  being  higher  in 
the  Middle  and  Western  States  than  in  the  Southern. 
When  we  stop  and  consider  that  in  the  United  States 
alone  over  four  thousand  people  annually  commit  self- 
slaughter,  and  that  every  five  years  will  see  a  material 
increase  in  this  already  large  number,  we  stand  amazed. 
Yet  I  have  not  exaggerated  the  estimate  in  the  slight- 
est degree.  If  I  were  to  write  down  the  total  sum  of 
all  the  people  who  annually  make  way  with  them- 
selves, blank  amazement,  and  perhaps  absolute  in- 
credulity, would  fill  the  minds  of  nine-tenths  of  those 
who  read  this  article.  To  those  who  are  at  all  curious, 
this  problem — i.e.,  the  total  annual  number  of  suicides  in 
the  civilized  world — is  one  which  can  be  easily  solved. 
Table  III.  gives  the  general  averages  for  the  European 
nations,  including  Great  Britain  ;  to  these  add  the 
general  averages  for  the  United  States  (55),  Mexico, 
Central,  and  South  America  (38),  and  Australia  (65); 
divide  the  sum  of  these  numbers  by  the  number  of 
averages  and  this  will  give,  approximately,  the  general 
average,  per  million  of  inhabitants,  for  the  entire  civ- 
ilized population  of  the  world. 


In  the  L^nited  States  suicide  begins  at  a  very  early 
age.  During  the  past  ten  years  almost  a  thousand 
boys  and  girls  below  the  age  of  sixteen  years  have 
taken  their  own  lives.  In  New  York  alone,  from  1871 
to  the  year  1876,  thirty-four  boys  and  girls  committed 
suicide,  and  five  of  the  thirty-four  were  between  ten 
and  fifteen  years  old.  The  records  of  Philadelphia, 
barring  a  slight  increase  due  to  condensation  of  popu- 
lation, show  the  correct  proportion  of  child  suicides. 

Table  V.,  Showing  General  Averages  of  Suicide  in 
Philadelphia,  Pa. — Men,  Women,  and  Children — for  a 
Period  of  Ten  Years.' 


Years. 

Males. 

Females. 

Total. 

Boys. 

Girls. 

Total. 

1884 , 

72 

17 

89 

, 

1885 

62 

16 

78 

2 

1886 

76 

14 

90 

I 

1887 

72 

16 

88 

I 

2 

1888 

71 

23 

94 

2 

5 

1889 

87 

17 

104 

2 

3 

1890 

6a 

80 

2 

3 

'89- 

79 

29 

loS 

5 

1892 

S3 

19 

102 

3 

4 

1893 

18 

118 

General  av 

rage 

9S 

General  average , . . 

J 

'  Furnished  by  M.  V.  Ball,  Medical  Department,  Eastern  State  Penitentiary, 
Philadelphia,  Pa. 

In  this  county  (Daviess  County,  Ky.)  two  children 
have  committed  voluntary  death  in  the  past  fifteen 
years — one,  a  boy,  by  hanging  ;  the  other,  a  girl,  by 
poison.  When  I  take  into  consideration  the  extraordi- 
nary precocity  of  the  juvenile  portion  of  the  populations 
of  our  large  cities,  I  wonder  that  the  number  of  child 
suicides  is  not  much  larger.  Age  undoubtedly  acts  as  a 
factor  in  increasing  or  decreasing  the  number  of  those 
who  commit  self-slaughter,  certain  favorable  ages  pre- 
ponderating in  all  the  lists  of  suicides  in  my  possession. 
From  two  lists  of  voluntary  deaths,  of  a  thousand  each, 
taken  from  two  periods  of  five  years  each,  viz.,  1882-86 
and  1889-93,  ^i^^  from  sixteen  States,  I  have  constructed 
the  following  tables  : 

Table  VI.,  Showing  the  Influence  of  Age  on  Suicide. 


i88a-86. 

Male. 

Female. 

125 

364 

J 

2 

140 

Age  betivecn  20  and  30  years 

260 

Totals 

Soo 

soo 

1889-93. 
Age  under  10  years 

130 
362 

SOO 

It  will  be  at  once  observed  that  the  most  favorable 
age  for  self-slaughter  in  women  is  between  the  ages  of 
twenty  and  thirty  years,  and  that  in  men  the  favora- 
ble age  is  between  thirty  and  forty.  In  the  next  table 
of  1,000  suicides,  500  men  and  500  women,  the  mini- 
mum age  was  twenty  and  the  maximum  age  eighty 
years. 
Table  VII.,  Showing  the  Influence  of  Age  on  Suicide. 


1890-94. 

Male. 

Female. 

203 

'56 
19 

A       h  tw                   A         vear<i 

A        \                    0  an«^  CO  vears 

Age  jciwcen  4         ,5      .g^. 

60 

A       h  rw         \    ^    A         veirs 

A       h*»f            T    and  80  vears 

T  tal 

500 

It  will  be  observed  that  the  same  law  holds  good  in 
this  table  also  ;  the  favorable  age  for  woman  lies  be- 
tween twenty  and  thirty  years,  and  that  for  man  be- 


220 


MEDICAL    RECORD. 


[August  17,   1895 


tween  thirty  and  forty  years.  There  is  a  gradual  de- 
crease in  the  number  of  suicides  in  women  after  the 
age  of  thirty,  and  in  men  after  the  age  of  forty,  years. 

Certain  months  of  the  year  as  well  as  certain  hours 
of  the  day  appear  to  be  selected  more  frequently  by 
persons  committing  voluntary  death  than  others.  Thus, 
there  are  more  suicides  in  the  months  of  July, 
August,  and  September  than  in  other  months,  and 
more  people  commit  self-slaughter  between  the  hours 
of  II  A.M.  and  12  M.  than  at  any  other  hour  during  the 
day.  It  is  comparatively  easy  to  assign  a  physiological 
reason  for  the  preponderance  of  suicide  during  the 
above-mentioned  months,  for  it  is  a  well-established  fact 
that  the  hot,  sultry  weather  of  our  summers  acts  very 
deleteriously  on  our  nervous  systems.  It  is  not  so 
easy,  however,  to  assign  a  reason  for  the  preponder- 
ance of  suicide  between  the  hours  of  11  a.m.  and  12  m. 
That  this  is  a  fact,  however,  a  study  of  the  following 
table  will  clearly  demonstrate  : 

Table  VIII.,  Giving  Hour  of  Suicide  in  1,986  Cases. 


Hour. 

Cases. 

Hour. 

Cases. 

6  A.M 

95 
90 

108 

^36 
82 
101 
106 
75 
78 

6  P.M 

8     ■'    

68 

10      " 

65 

a 

" 

12  M    (noonl 

12  midnight 

I  P  M 

r,        " 

4     "       

3  ;;  

46 

_  .1 

86 

Total 

Total 

1,203 

783 

It  will  be  seen  also  by  this  table  that  the  suicides 
committed  during  the  day  largely  outnumber  those 
committed  during  the  night  ;  all  of  my  lists  declare 
this  to  be  a  fact. 

Baly  and  Boudin  make  the  extraordinary  statement 
that  the  negro  evinces  a  great  predilection  for  suicide. 
This  is  contrary  to  the  proposition  advanced  in  the 
first  part  of  this  paper,  i.e.,  that  suicide  is  of  infrequent 
occurrence  among  savages. 

I  am  not  aware  of  the  source  from  which  MM.  Baly 
and  Boudin  derive  their  information,  but,  be  it  what- 
ever it  may,  it  is  wholly  at  variance  with  the  statistics 
in  my  possession.  We  might  safely  assume  on  general 
principles,  even  if  there  were  no  records  in  existence, 
that  the  statement  of  these  gentlemen  is  erroneous  ; 
for  we  know  that  the  negro  in  the  United  States  is  de- 
scended from  ancestors  who,  two  hundred  years  ago, 
were  utter  savages,  and,  since  it  is  an  accepted  and 
well-established  law  that  suicide  follows  in  the  wake  of 
high  civilization  and  coincident  intellectuality,  it  is 
reasonable  to  assume  that  the  pure-blooded  negro  has 
not  reached  that  degree  of  psychical  development  which 
must  accrue  ere  the  desire  for  voluntary  death  is  en- 
gendered. The  pure-blooded  negro  is  remarkably  free 
from  those  forms  of  insanity  which  make  themselves 
evident  by  vagaries  of  the  higher  emotions  ;  in  point  of 
fact,  he  is  an  individual  who  does  not  possess  the  high 
psychical  development  of  the  civilized  white.  Says 
Romanes,  one  of  the  most  distinguished  psychologists 
in  the  world,  as  well  as  one  of  the  profoundest  think- 
ers :  "  The  psychology  of  uncivilized  man  shows,  in  a 
marked  degree,  a  kind  of  vts  inertice  as  regards  any 
higher  development.  Even  so  highly  a  developed 
type  of  mind  as  that  of  the  negro — submitted,  too,  as  it 
has  been  in  millions  of  individual  cases,  to  close  con- 
tact with  minds  of  the  most  progressive  type,  and  en- 
joying, as  it  has  in  many  thousands  of  individual  cases, 
all  the  advantages  of  liberal  education — has  never,  so  far 
as  I  can  ascertain,  executed  one  single  stroke  of  original 
work  in  any  single  department  of  intellectual  activity." 

When  we  turn  to  actual  evidence,  we  find  tiiat  these 
psychological  reasons  for  the  non-prevalence  of  suicide 
among  negroes  are  corroborated  in  every  respect. 

In  Georgia,  Alabama,  Louisiana,  \rississippi,  North 


Carolina,  South  Carolina,  Tennessee,  and  Virginia, 
where  the  negro  is  greatly  en  c'videucc,  the  average  rate 
of  suicide  for  the  pure-blooded  negro  is  only  one  in 
every  hundred  of  suicides.  This  average,  in  all  proba- 
bility, is  a  little  too  high,  but  owing  to  the  lack  of  detail 
in  the  vital  statistics  of  these  States,  it  is  a  conservative 
one,  and  as  near  the  actual  rate  as  possible  under  the 
circumstances.  The  half-breed  negro  is,  however,  al- 
most invariably  a  degenerate  individual,  having  inher- 
ited all  of  the  weak  physical  and  psychical  traits  of  his 
white  ancestor  ;  consequently  the  rate  of  suicides  for 
mulattoes,  quadroons,  and  octoroons  is,  comparatively 
speaking,  rather  high.  The  pure-blooded  negro,  like  any 
other  savage,  will  commit  suicide  on  occasions,  but  these 
occasions  are  rare,  indeed,  and  are  brought  about  by 
the  most  exceptional  circumstances. 

The  methods  by  which  or  through  which  people  in 
the  United  States  commonly  commit  suicide  are  hang- 
ing, shooting,  drowning,  poisoning,  producing  hemor- 
rhage, and  asphyxiation.  The  proportion  in  which 
these  methods  are  used  throughout  the  United  States 
is  shown,  approximately,  by  the  following  table  : 

Table  IX.,  Showi.ng  the  Method  Commo.nly  Used  to  Pro- 
cure VoLu.NTARV  Death  in  the  City  of  Milwaukee, 
Wis.:  Year  1804.' 


Method  Used. 


Males. 

Females. 

Hanging 

Shooting 

Drowning  .... 

Cutting  Arteries 
Cutting  Throat  . 
Illuminating  Gas 


Total. 


4 

3 

X. 

X. 

53 

46 

'  \ 

1  Furnished  by  Henry  Ott»  coroner,  Milwaukee  County. 

Suicide  by  inhaling  illuminating  gas  is  greatly  on  the 
increase  in  the  Eastern  and  Middle  States.  Says  Dr. 
Francis  Harris,  medical  examiner  for  Suffolk  County 
(Boston),  Mass.,  in  a  letter  to  me  :  "  I  should  add,  in 
regard  to  the  matter  of  methods,  that  suicide  by  illumi- 
nating gas  is  rapidly  increasing  in  this  State.  The 
ease  and  painlessness  of  the  method,  as  well  as  the  leav- 
ing the  cause  always  a  matter  of  doubt  as  between  ac- 
cident and  suicide,  have  made  this  method  popular." 

I  have  asserted  that  suicide  is  most  frequent  in  those 
nations  or  communities  where  erudition,  coincidently, 
civilization,  is  highest.  AVe  have  seen  that  this  is  a 
fact  in  the  countries  of  the  Old  World  ;  now  let  us  see 
if  this  fact  obtains  in  the  United  States. 

In  newly  settled  regions  of  this  country,  say,  in  the 
Western  States,  erudition  is  far  below  par,  and  civiliza- 
tion is  rude  and  unconventional.  In  these  States,  the 
average  rate  of  suicide,  per  million  of  inhabitants,  is  far 
below  that  of  the  much  older  Eastern  States.  For  pur- 
poses of  comparison,  I  will  take  the  States  of  Colorado 
and  Massachusetts.  During  the  last  thirteen  years,  there 
have  occurred  in  Colorado  (population,  300,000)  102 
suicides,  an  annual  average  of  284-  per  million  of  in- 
habitants. In  Massachusetts,  where  erudition  is  higher, 
probably,  than  in  any  other  State  of  the  Union,  and 
where  the  population  is  uninfluenced  to  any  extent  by 
Germanic  elements,  the  annual  rate,  per  million  of  in- 
habitants reaches  the  high  average  of  98-)-.  The  fol- 
lowing table  brings  out  this  fact  very  patently  : 

Xable  X.,  Showing  Number  of  Suicides  in  the  State  of 
Mass.\chusetts  for  the  Period  of  Time  Embraced  by 
THE  L.vsT  KiVE  Years,  1889-1893.^ 


„                 Estimated 
'"*'■•         Population. 

Male. 

Female,  i    Total      1       f "  MBUon 
1     '"'*'•    !       Inhabitants. 

1S89....'        =,I75,"53 
1890....;        2,238,943 
1891....!        a,3°3.536 
189J....          2,369.994 
1893....          2,438,363 

■  57 
156 
14« 

118 

4" 
40 

6a 

199        Approximation.  91 

t           "■      t 

273                  "         "S 
290                      "           119 

894 

1 

■  Furnished  by  Francis  A.  Harris,M.  D.,  Medical  Examiner,  SuAblk  County, 
Mass* 


August  17,  1895] 


MEDICAL   RECORD. 


221 


Of  course,  condensation  of  population  must  be  con- 
sidered as  one  of  the  factors  in  the  production  of  this 
high  average  (98  -f ),  yet,  even  when  we  allow  for  this, 
we  will  still  have  an  average  far  above  that  of  Colorado 
(28+). 


BLOOD   ABSORPTION    FROM    THE    PERITO- 
NEAL CAVITY. 

By  F.  H.   SOUTHGATE,  M.D., 

CINCINNATI,  O. 
ASSISTANT  TO  THE  CHAIR  OF  PHYSIOLOGY,   MEDICAL  COLLEGE   OF  OHIO. 

Almost  all  the  injections  of  blood  into  the  abdominal 
cavity  for  the  study  of  absorption  have  been  made 
solely  with  reference  to  the  ordinary  study  of  the  trans- 
fusion of  blood.  The  present  researches  deal  specifi- 
cally with  the  effects  of  this  transfusion  upon  the  blood, 
and  upon  the  circulation  of  the  animal.  Recklinghau- 
sen, after  the  intraperitoneal  injection  of  defibrinated 
blood,  perceived  an  active  filling  of  the  lymphatic  ves- 
sels on  the  pleural  surface  of  the  diaphragm  with  the 
same.  Ponfick,  on  introducing  defibrinated  blood  into 
the  abdominal  cavity,  found  that  its  absorption  is  ac- 
companied by  an  increase  in  the  number  of  blood-cor- 
puscles in  the  blood  of  the  rabbit  so  treated,  an  in- 
crease which  reaches  its  maximum  on  the  first  or 
second  day  after  the  transfusion.  Further  than  this  the 
above-referred-to  researches  need  not  be  taken  into 
account. 

The  following  experiments  were  made,  first,  to  ob- 
serve the  effect  of  blood  absorption  upon  the  animal 
and  to  determine  the  condition  of  the  reabsorbed 
blood  on  its  return  to  the  blood-vessels  ;  second,  to 
discover  the  effect  of  an  auto-transfusion  on  the  num- 
ber of  blood-corpuscles  in  the  blood.  The  experiments 
are  set  forth  in  the  following  order  :  I.  The  direct 
transfusion  of  blood  from  the  carotid  artery  of  another 
animal  of  the  same  species.  II.  The  simple  removal 
of  blood  from  the  carotid  artery.  III.  The  direct  auto- 
transfusion  of  blood  from  the  carotid  artery  to  the  peri- 
toneal cavity.  IV.  The  direct  transfusion  of  blood 
from  the  carotid  artery  of  another  animal  of  a  different 
species. 

For  the  last  experiment  the  blood  of  a  dog  was 
taken  ;  the  other  animals  were  all  rabbits  of  the  same 
species,  weighing  between  1,500  and  2,000  gm.  each. 
As  an  instrument  for  measuring  the  amount  of  blood 
transfused,  a  Ludwig's  Stromuhr  was  selected.  This 
instrument  was  connected  with  a  rubber  tube,  extend- 
ing from  the  carotid  cannula  of  the  one  animal  to  a 
small  glass  tube  inserted  in  a  minute  incision  in  the  ab- 
dominal wall  of  the  other. 

In  order  to  determine  whether  the  blood,  when  re- 
absorbed, returns  to  the  blood-vessels  without  having 
undergone  any  serious  impairment,  calculations  were 
made  of  the  number  of  red  corpuscles  in  the  blood  of 
the  animal  before  the  transfusion,  and  at  various  pe- 
riods of  time  thereafter.  A  count  was  also  made  of  the 
number  of  red  blood-corpuscles  in  the  blood  of  the 
rabbits  suffering  from  simple  hemorrhage,  and  of  those 
in  the  blood  of  the  rabbits  which  had  received  the  for- 
eign blood  (that  of  the  dog),  on  account  of  the  well- 
known  power  of  the  latter  to  produce  hcemoglobinuria 
when  injected  directly  into  the  vessels  of  a  rabbit. 

The  count  of  the  red  blood-corpuscles  was,  at  first, 
made  with  a  Zeiss-Thoma  apparatus,  but  owing  to  the 
number  of  observations  necessary  to  obtain  an  avail- 
able average,  and  the  time  requisite  for  this  purpose,  as 
well  as  that  consumed  in  the  other  operations  on  the 
animals,  this  method  was  found  to  be  inferior,  as  a 
means  of  comparison,  to  the  Blix-Hedin-Gartner  Hama- 
tokrit  method,  as  improved  by  Dr.  Cowl,  a  full  expla- 
nation of  which  will  be  found  as  an  addenda  to  this 
paper.  By  this  method  three  or  four  observations  were 
made  at  each  of  the  periods  above  mentioned,  both  be- 


fore and  at  stated  intervals  after  transfusion.  These 
observations  show  a  remarkable  uniformity,  far  exceed- 
ing that  to  be  obtained,  with  ordinary  care,  by  the 
counting  method  of  Zeiss.  The  extreme  variation  from 
the  average  in  each  set  of  observations  was,  in  no  in- 
stance, more  than  eight  per  cent,  of  the  number  of 
blood-corpuscles  indicated  by  that  average,  while  the 
average  variation  between  the  two  extreme  observations 
was  only  1.5  per  cent. 

The  specimens  of  blood  were  taken  from  the  sub- 
cutaneous abdominal  veins  in  preference  to  the  ear,  as 
the  results  were  more  regular,  and  the  rabbits  were  kept 
on  the  board  only  as  long  as  the  primary  operations 
lasted. 

I.  The  Transfusion  of  Blood  from  Another  Animal. 
— In  these  cases,  as  well  as  in  the  following  ones  of 
auto-transfusion,  three  hours  after  the  transfusion  found 
the  pleural  surfaces  of  the  diaphragm  (described  by 
Recklinghausen,  Ludwig,  and  others)  beautifully  in- 
jected and  oftentimes  distended  with  blood.  In  gen- 
eral these  lymphatic  vessels  ran  directly  across  the 
muscular  fibres,  instead  of  with  them  like  the  veins,  and 
coming  from  both  sides  of  the  sternum  they  united 
into  a  stem,  which,  running  forward,  evidently  emptied 
into  the  lymphatic  trunks  accompanying  the  mammary 
vessels.  Neither  upon  the  peritoneal  surface  of  the 
diaphragm  nor  in  the  abdominal  cavity  were  injected 
lymphatic  vessels  to  be  found. 

After  the  transfusion  the  rabbits  showed  the  follow- 
ing appearances  :  In  all  cases,  at  the  end  of  the  first 
hour,  there  was  distention  of  the  veins.  In  two  cases 
the  ears  and  mucous  membranes  assumed  a  bluish  color. 
One  case  developed  a  marked  protrusion  of  the  eye- 
balls. The  blood-pressure  was  observed  in  seven 
cases.  In  four  cases  it  rose,  in  three  there  was  a 
slight  fall.  At  the  end  of  first,  second,  and  third  hours 
after  the  transfusion,  observation  showed  that  the 
average  increases  in  the  number  of  corpuscles  in  the 
blood  stood  at  ten,  eleven,  and  four  per  cent,  respec- 
tively. 

In  three  of  the  cases  urine  was  not  passed  during 
the  research,  and  only  a  few  cubic  centimetres  were 
found  in  the  bladder  after  death.  In  one  case  16  c.c. 
were  passed  forty-five  minutes  after  the  transfusion  ;  in  a 
second  case  10  c.c.  were  passed  in  twenty  minutes 
thereafter.  In  none  of  these  cases  was  there  evidence 
of  haemoglobinuria.  In  another  case  42  c.c.  of  blood 
were  transfused  into  the  abdominal  cavity  of  a  rabbit 
weighing  2,000  gm.  The  blood  changes  pursued  the 
typical  course  described  above.  The  rabbit  was  kept 
under  observation  for  ninety-six  hours,  being  cared  for 
in  the  same  manner  as  before  the  observation,  and  it 
remained  perfectly  well. 

n.  Simple  Hemorrhage  from  the  Carotid  Artery. — In 
six  cases  of  simple  hemorrhage,  with  an  average  loss  of 
27  c.c.  of  blood,  there  was  an  average  reduction  of 
twenty-three  per  cent,  in  the  number  of  corpuscles  at 
the  end  of  one  hour  after  the  abstraction  of  the  blood, 
and  at  the  end  of  the  second  hour  this  average  had 
increased  to  31.5  per  cent,  of  the  original  number  of 
corpuscles. 

III.  The  Transfusion  of  Blood  from  the  Carotid  Artery 
into  the  Peritoneal  Cavity  of  the  Same  Animal. — The 
three  cases  of  auto-transfusion,  owing  to  their  progres- 
sive nature,  deserve  detailed  consideration.  Twenty- 
four,  and  30  c.c.  of  blood,  respectively,  were  ab- 
stracted from  the  three  carotids;  i,  2,  and  11  c.c.  of 
blood  lay  unabsorbed  on  the  section  in  the  peritoneal 
cavity  three  hours  after  the  operations.  In  each  case 
9  c.c,  which  remained  in  the  transfusion  apparatus, 
were  lost  to  the  animal.  This  shows  an  absorption 
into  the  peritoneal  cavity  of  14,  12,  and  11  c.c,  respec- 
tively. We  may  note  here  a  markedly  greater  reab- 
sorption  in  the  cases  of  lesser  hemorrhage.  Although 
a  difference  of  6  c.c.  between  the  amounts  of  hemor- 
rhage is  absolutely  small,  it  is  relatively  great  when 
superimposed  upon  a  loss  of  24  c.c  of  blood  taken 


MEDICAL   RECORD. 


[August  17,  1895 


from  rabbits  weighing  from  1,600  to  1,800  gm.,  and  in 
these  cases  this  difference  is  more  clearly  set  forth 
by  the  changes  in  the  number  of  blood-corpuscles  in 
the  blood  of  the  animals,  resulting  from  the  auto- 
transfusion.  Then,  too,  it  is  seldom  that  more  than  40 
c.c.  of  blood  can  be  drawn  from  the  carotid  artery  of 
an  animal  of  such  weight  without  causing  death. 

Professor  Gad  informs  me  that  he  is  convinced,  by 
former  researches  of  his  own  respecting  the  auto-trans- 
fusion of  a  small  amount  of  blood  (about  fifteen  cubic 
centimetres  in  the  medium-sized  rabbit),  that  a  perfect 
reabsorption  is  accomplished  within  three  hours,  at 
the  end  of  which  time  not  a  particle  of  waste  matter  is 
to  be  found  in  the  peritoneal  cavity,  and  there  is  no 
trace  of  the  distended  lymphatic  vessels  of  the  dia- 
phragm. 

According  to  Wegner,  if  a  large  amount  of  artificially 
warmed  serum  (not  more  than  12  per  cent,  of  the  weight 
of  the  body)  be  introduced  into  the  abdominal  cavity 
of  a  rabbit,  only  two-thirds,  or  still  less,  of  the  whole 
amount  will  be  found  in  the  peritoneal  cavity  of  the 
animal  an  hour  after  it  has  been  killed.  After  the 
transfusion  of  an  amount  of  the  same  fluid  (about  five 
per  cent,  of  the  weight  of  the  body)  into  the  abdominal 
cavity  of  a  dog,  only  one-fourth  was  reabsorbed. 

The  effect  of  the  loss  of  blood  after  the  auto-trans- 
fusion is  shown  in  the  diminution  of  the  number  of 
blood-corpuscles,  for  in  the  three  cases,  with  a  loss  of 
19  c.c.  and  a  reabsorption  of  11  c.c,  the  number 
of  blood-corpuscles  showed,  at  the  end  of  the  first 
hour,  a  diminution  of  27  per  cent.,  and  at  the  end  of 
the  second  hour  a  diminution  of  24  per  cent. 

Whereas,  in  the  first  case,  with  a  reabsorption  of  14 
c.c.  of  blood  and  a  loss  to  the  animal  of  10  c.c,  the 
number  of  blood-corpuscles  at  the  end  of  the  first  hour 
after  the  operation  had  not  diminished,  and  at  the  end 
of  two  hours  the  corpuscles  showed  a  diminution  of  5 
per  cent.;  in  the  second  case,  with  a  reabsorption  of  12 
c.c.  and  a  loss  of  12  c.c,  there  was,  at  the  end  of  the 
first  hour,  a  diminution  of  lo  per  cent.,  and  at  the  end 
of  the  second  hour  the  blood-corpuscles  had  increased 
to  the  original  number  ;  and  in  the  third  case,  with  a 
regain  of  11  c.c.  by  reabsorption  and  a  loss  of  19  c.c, 
there  was  at  the  end  of  the  first  hour  a  diminution  in 
the  number  of  corpuscles  amounting  to  27  per  cent., 
while  at  the  end  of  the  second  hour  the  amount  of 
diminution  had  decreased  to  24  per  cent.  For  ex- 
traneous reasons,  auto-transfusion  was  not  carried  out 
in  a  large  number  of  cases.  In  order  to  make  a  com- 
parison with  the  cases  of  simple  hemorrhage,  we  leave 
out  of  account  these  individual  differences,  which  evi- 
dently result  from  the  complicating  hemorrhage,  and 
take  an  average.  \Ve  find  that  whereas  in  simple  hem- 
orrhage, as  above  stated,  the  number  of  blood-corpus- 
cles is  reduced,  at  the  end  of  the  first  and  second  hours, 
23  and  31.5  per  cent,  respectively,  after  auto-trans- 
fusion, with  more  or  less  loss  of  blood  to  the  animal, 
the  reduction  at  the  end  of  the  same  periods  of  time  is 
but  13,5  and  12  percent,  respectively. 

IV.  The  Direct  Transfusion  of  Foreign  Blood. — In 
one  case  an  easy  estimate  of  the  destructive  effect  of 
foreign  blood,  especially  concerning  the  formation  of 
hccmoglobinuria,  was  made.  Twenty  cubic  centimetres 
of  blood  were  taken  directly  from  the  carotid  artery  of 
a  healthy  dog  and  injected  into  the  peritoneal  cavity 
of  a  sound  rabbit,  with  the  following  result  :  After  an 
hour  ha;moglobin;emia  was  discovered  in  the  plasma, 
by  means  of  the  guaiacum  test,  and  the  red  color  of 
the  blood,  together  with  the  absence  of  the  corpuscles, 
as  demonstrated  by  the  use  of  the  microscope,  proved 
the  presence  of  free  ha-moglobin  in  the  blood.  A  small 
amount  of  urine  was  found  in  the  bladder  two  hours 
after  the  transfusion.  This,  closely  resembling  the 
blood  in  color,  showed  itself  to  contain  haemoglobin, 
but  no  blood-corpuscles.  Urine  passed  during  the 
night  contained  no  hemoglobin.  The  animal  was  not 
allowed  food  after  the  operation  until  the  second  night. 


On  the  post-mortem  examination  a  mass  of  dark-red 
fluid  (about  a  cubic  centimetre)  was  found  on  the  peri- 
cardium, the  pleura,  and  the  peritoneum. 

From  the  foregoing  researches  the  following  points 
were  noted : 

1.  Direct  transfusion  of  arterial  blood  from  one  ani- 
mal to  the  peritoneal  cavity  of  another  animal  of  the 
same  species  causes  no  perceptible  injury  to  the  animal 
receiving  the  blood. 

2.  Homogeneous,  non-defibrinated  blood  is  quickly 
reabsorbed  from  the  peritoneal  cavity  and  this  ab- 
sorption takes  place  chiefly  through  the  diaphragmatic 
lymphatics,  and  these  lymphatics,  as  a  rule,  do  not 
communicate  with  the  thoracic  duct. 

3.  Homogeneous  blood  reabsorbed  from  the  abdom- 
inal cavity  does  not  produce  hemoglobinuria,  but 
seems  to  be  absorbed  and  to  circulate  as  normal  blood. 

4.  After  a  moderate  loss  of  blood  absorption  from 
the  abdominal  cavity  takes  place  quickly,  but  the 
greater  the  loss  of  blood  the  slower  the  absorption. 

5.  After  simple  hemorrhage  the  relative  quantity  of 
the  solid  elements  of  the  blood  is  diminished. 

6.  After  hemorrhage,  if  there  be  sufficient  compen- 
sation by  transfusion  into  the  peritoneal  cavity,  the 
general  circulation  changes  very  little  or  not  at  all. 

7.  Simple  intraperitoneal  transfusion  of  blood  en- 
riches the  blood  of  the  animal  receiving  it,  and  the 
increase  in  the  corpuscular  elements  reaches  its  ma.x- 
imum  within  three  hours. 

8.  Transfusion  of  foreign  or  heterogeneous  blood 
into  the  abdominal  cavities  of  rabbits  produces  haemo- 
globinuria  and  results  in  the  death  of  the  animals. 

For  the  incitation  to  the  above  researches,  as  well  as 
for  assistance  in  pursuing  the  same,  I  wish  to  express 
my  sincere  thanks  to  Professor  J.  Gad,  in  whose  labora- 
tory, by  his  courtesy,  they  were  carried  out.  I  am 
also  much  indebted  to  Dr.  W.  Y.  Cowl  for  his  advice 
and  friendly  assistance. 


IMPROVED  MEANS  FOR  THE  HEMATO- 
CRIT METHOD  OF  BLOOD  EXAMINA- 
TION.' 

By  W.  Y.  cowl,  M.D., 


The  simple  and  rapidly  executed  method  of  determin- 
ing in  a  minute  specimen  of  blood  the  relative  propor- 
tion of  corpuscles  to  plasma  by  means  of  centrifugal 
force,  which  was  devised  and  first  employed  by  Blix  in 
1885,  and  since  then  further  pursued  and  improved  by 
Hedin,  Daland,  and  Gaertner,  has  lately  been  con- 
demned by  Bleibtreu  and  also  by  Biernacki,  upon  the 
ground  of  comparative  determinations  with  two  other 
methods  for  ascertaining  the  amount  of  corpuscles  in 
larger  quantities  of  blood. 

That  of  the  former  investigator  is  of  a  chemical  char- 
acter and  consists  in  the  determination,  first,  of  the 
amount  of  combined  nitrogen  and  therefore  of  albumin 
in  the  supernatant  fluid  from  each  of  two  portions  of  the 
same  specimen  of  defibrinated  blood  some  hours  after 
dilution  with  a  physiological  salt  solution  (sodium 
chloride,  6  to  water  1,000)  to  a  different  known  degree 
in  the  case  of  each  portion,  and  thence,  by  calculation, 
the  amount  of  serum  and  consequently  of  corpuscles  in 
the  original  specimen. 

The  method  is  based  upon  a  long-known  and  well- 
established  procedure  devised  by  Hoppe-Seyler,  and 
consisting  in  determinations  of,  i,  the  amount  of  oxy- 
hcemoglobin  and  albumin  in  the  blood  as  a  whole  ;  2, 
the  amount  of  the  same  in  tlie  blood-corpuscles  alone  ; 
3,  the  amount  of  fibrin  ;  4,  the  amount  of  albuminous 
matter  in  the  serum,  and,  5,  by  calculation  from  these 

'  A  communication  with  demonstration  given  at  the  meeting  of  Ger- 
man naturalists  and  physici.ans.  Vienna.  September.  1894.  detailing 
researches  carried  out  at  the  Physiological  Institute  of  the  L'niversitv 
of  Berlin. 


i 


August   17,  1895] 


MEDICAL   RECORD. 


data,  the  amounts  of  serum,  of  plasma,  and  of  blood- 
corpuscles  in  the  original  specimen. 

Biernacki,  on  the  other  hand,  simply  measures  the 
compact  mass  of  corpuscles  after  complete  sedimenta- 
tion from  the  plasma  or  serum.  Both  of  these  methods 
require  a  considerable  quantity  of  blood,  which,  in  the 
case  of  the  first  described,  varies  inversely  with  the  du- 
ration of  the  sedimentation  requisite  for  yielding  suffi- 
cient serum  for  an  accurate  application  of  Kjeldahl's 
method  for  determining  the  amount  of  nitrogen  pres- 
ent. 

Bleibtreu's  procedure  has  been  criticised,  however, 
upon  the  ground  of  experiments  by  Hamburger  and  by 
Biernacki.  In  the  hands  of  the  latter,  nevertheless,  as 
in  Bleibtreu's  original  research,  it  has  yielded  more  con- 
stant results  than  the  hematocrit  method  as  hitherto 
employed. 

Biernacki's  method,  which  possesses  a  like  advantage, 
requires  two  to  three  days  of  sedimentation,  and  occa- 
sions a  shrinkage  of  the  red  blood-corpuscles,  which  he 
attributes  to  the  extrusion  of  plasma  previously  held 
dissolved  or  suspended  within  them. 

Both  of  the  described  methods,  however,  have  yielded 
figures  which  agree  more  or  less  closely  with  those  long 
since  obtained  by  Welcker  and  others  for  the  average 
relative  quantities  of  plasma  (sixty-four  per  cent.)  and 
of  erythrocytes  (thirty-six  per  cent.)  in  normal  blood 
after  defibrination,  by  means  of  calculations  from  aver- 
age microscopic  measurements  of  the  red  disks  and  from 
determinations  of  the  average  number  of  the  same  in  a 
certain  volume  of  blood. 

The  various  percentages  obtained  for  the  amount  of 
corpuscles  in  normal  blood  by  the  hgematocrit  method 
in  the  researches  hitherto  published  are,  on  the  other 
hand,  largely  in  excess  of  those  of  Welcker  as  well  as  of 
Bleibtreu  and  of  Biernacki.  Both  of  the  latter  experi- 
menters, furthermore,  on  direct  comparison  of  the  he- 
matocrit with  their  own  methods,  with  various  kinds  of 
blood,  find  that  the  percentages  in  a  series  of  different 
specimens  lie  not  only  widely  apart,  but  do  not  run  par- 
allel. These  facts  alone  lead  each  author  without  fur- 
ther ado  to  express  the  wish  that  the  hematocrit  method 
disappear  from  use. 

Such  a  summary  disposal  of  the  matter,  however, 
seems  to  us  quite  unjustified,  so  long  as  they  have  not 
found  the  source  of  apparent  error,  and  especially  so 
in  view  of  the  questionability  of  their  own  methods  on  the 
one  hand  and  the  great  and  evident  advantages  of  the 
haematocrit  method  of  blood  examination  on  the  other, 
namely,  the  simplicity  and  directness  of  the  process, 
the  minute  quantity  of  blood  required  for  examination, 
the  avoidance  of  calculation,  and  particularly  of  multi- 
plication, in  attaining  the  result,  and  the  brief  period  of 
time  re<|uisite  for  its  performance. 

The  need  of  a  method  possessing  such  advantages 
came  home  to  us  personally  at  the  beginning  of  a  series 
of  researches  on  the  Absorption  of  Blood  from  the  Peri- 
toneal Cavity,  undertaken  at  the  instance  of  Professor 
John  Gad,  under  my  supervision,  by  Dr.  F.  H.  South- 
gate,  of  Newport,  Ky.,  carried  out  at  the  Physio- 
logical Institute  of  the  Berlin  University  during  the 
past  semester.  In  this  investigation  observations  of 
changes  in  the  corpuscular  richness  of  the  blood  in  ani- 
mals before  and  after  operation  were  requisite  in  such 
number  as  to  practically  exclude  the  employment  of  any 
of  the  above-mentioned  methods  or  indeed  of  the  h^cma- 
tocytometer  of  Thoma  and  Zeiss. 

We  have  therefore  subjected  the  hematocrit  method 
to  a  critical  examination,  to  the  results  of  which  we  here 
call  attention.  Before  doing  so,  however,  we  would 
make  a  prime  distinction  between  the  different  methods 
of  blood  examination  already  mentioned  which  has  not 
been  noted  by  previous  investigators,  but  which  is  nec- 
essary owing  to  facts  that  point  to  a  changeability  of 
the  red  blood-corpuscle  in  volume  ;  namely,  as  found 
by  Biernacki,  it  shrinks  when  at  rest  in  its  own  plasma 
or  serum  ;  furthermore  by  Lackschewitz,  that  it  swells 


within  or  without  the  organism  when  the  plasma  is 
thinned,  even  with  physiological  salt  solution  ;  again,  as 
found  in  my  own  researches,  its  size  depends  within 
wide  limits  upon  the  concentration  and  chemical  char- 
acter of  the  solution  added  to  the  blood.  It  is  thus 
evident  that  those  methods  which,  like  Hoppe-Seyler's 
and  Bleibtreu's,  determine  the  amount  of  a  certain  in- 
herent substance  in  weight  must  be  kept  separate  from 
those  like  the  hematocrit  and  Biernacki's  method,  which 
determine  the  volume  of  the  corpuscles  as  a  whole. 
The  former,  supposing  them  to  be  intrinsically  worthy 
of  it,  are  to  be  given  the  preference  for  researches  in 
which  absolute  percentages  are  requisite,  while  the  lat- 
ter, by  reason  of  their  simplicity  or  rapidly  completed 
execution,  afford  a  means  for  many  equally  important 
scientific  investigations,  as  well  as  clinical  examinations, 
that  would  otherwise  be  impossible  ;  the  determinations 
in  these  latter  cases  being  relative  instead  of  absolute, 
but  a  priori  no  less  exact  ;  the  precision,  which  de- 
pends on  uniformity  of  procedure  in  making  the  deter- 
minations being  not  less  binding  in  the  one  case  than 
in  the  other. 

That  examinations  with  reference  to  either  the 
volume  or  weight  of  the  corpuscles  of  the  blood  as  a 
whole  cannot  be  entirely  exact  at  the  present  time 
may  furthermore  be  readily  maintained  by  reason  of 
the  hitherto  disregarded  volume  or  weight  of  the  fu- 
gitive corpuscles,  usually  denominated  blood-placques, 
which  have  been  long  since  demonstrated  by  Norris  to 
be  present  in  large  numbers  in  every  specimen  of  nor- 
mal blood,  although  disintegrating  to  a  large  extent  soon 
after  the  latter  is  shed. 

In  a  preliminary  examination  of  the  hematocrit 
method  as  hitherto  employed  we  have  found  that  a 
serious  source  of  error  lies,  in  point  of  fact,  in  the  sub- 
stance employed  to  prevent  coagulation — namely,  po- 
tassium dichromate,  either  as  contained  in  a  simple 
two  and  a  half  per  cent,  solution  of  the  salt  or  in 
Miller's  fluid,  potassium  dichromate,  i  ;  sodium  sul- 
phate, 2  ;  aqua,  100. 

Upon  microscopic  examination  of  a  number  of  speci- 
mens of  corpuscles  removed  by  centrifugal  force  from 
a  mixture  of  blood  with  either  of  these  solutions  we 
have  observed  a  granular  organic  sediment,  at  times  in 
patches,  enclosing  a  number  of  red  disks.  From  this 
it  is  apparent  that  the  bichromate  solution  may  vitiate 
the  result  by  a  precipitation  or  coagulation  of  solid 
matter  from  the  plasma,  thus  increasing  the  apparent 
amount  of  corpuscles  in  the  specimen  subjected  to  ex- 
amination. 

It  could  be  questioned,  in  the  cases  mentioned, 
whether  the  adventitious  sediment  might  not  be  re- 
ferred to  the  centrifugation  alone,  and  to  this  doubt  we 
were  led  by  observing  that  blood  freshly  drawn  with- 
out any  admixture  will  coagulate  throughout  within  a 
few  seconds,  when  subjected  to  strong  centrifugal 
force,  which  would  otherwise  remain  fluid  for  over 
four  minutes.  On  simply  mixing  blood  and  the  bi- 
chromate solution,  however,  the  same  either  takes  on  a 
uniform  opacity  of  greenish-black  hue  or  throws  down 
a  slowly  sinking  voluminous  organic  sediment,  accord- 
ing to  the  proportion  of  the  two  ingredients.  This  is 
true  of  admixtures  with  all  solutions  of  potassium  di- 
chromate of  a  strength  available  for  the  hematocrit 
process. 

Owing  to  the  well-known  destructive  action  on  the 
blood  of  potassium  salts  in  general,  in  contradistinc- 
tion to  those  of  sodium,  it  is  remarkable  that  the 
sodium  salt  has  not  been  proposed  nor  tested  for 
the  hematocrit  process.  We  have,  therefore,  made 
comparative  tests  of  potassium  and  sodium  dichromate 
in  simple  solution  of  various  strength,'  and  find  funda- 
mental differences  in  their  action  in  conformity  with 

'  Owing  to  the  presence  of  two  molecules  of  water  of  crystallization 
in  the  sodium  compound,  absent  in  that  of  potassium,  their  molecular 
weights  do  not  vary  more  than  one  and  four-tenths  per  cent. ,  hence  the 
strengths  of  the  solutions  are  almost  the  same,  whether  measured  by 
the  absolute  weight  or  the  chemical  equivalence  of  the  contained  salt 


224 


MEDICAL   RECORD. 


[August  17,  1895 


the  fact  just  mentioned,  ^^^lereas  solutions  of  the 
potassium  salt,  in  strengths  stronger  than  two  and  a 
half  per  cent.,  mi.xed  with  normal  blood,  occasioned 
such  a  precipitation  or  coagulation  as  to  yield  on  cen- 
trifugation  a  column  of  solid  matter,  equal  in  bulk  to 
the  entire  mass  of  blood,  those  of  the  sodium  salt,  even 
in  a  strength  of  five  per  cent.,  produced  no  such 
coagulation  in  the  plasma.  Furthermore,  whereas  a 
one  per  cent,  solution  of  potassium  bichromate  would 
dissolve  the  entire  mass  of  red  blood-corpuscles  in  the 
same  manner  as  distilled  water,  the  same  strength  of 
the  sodium  salt  would  not  destroy  them,  although  dis- 
solving out  hfemoglobin  in  some  measure. 

Again,  while  both  salts  in  weak  yet  somewhat 
stronger  solution  (potassium  bichromate,  1.5  and  2.0 
percent.;  sodium  bichromate,  i.oand  1.5  percent.)  oc- 
casion a  perceptible  precipitation  of  albumin  noticeable 
in  the  cloudiness  of  the  fluid  after  removal  of  corpuscles 
by  centrifugation,  the  amount  of  this  precipitation  is 
uniformly  greater  in  the  case  of  the  potassium  than  of 
the  sodium  dichromate,  as  the  following  percentages 
of  corpuscles  plus  precipitated  albumin  in  the  same 
blood  after  centrifugation  with  solutions  containing  i.o, 
1.5,  2.0,  and  2.5  per  cent,  respectively  of  each  salt  in- 
dicate, namely,  with  potassium  bichromate,  ninety-eight, 
eighty,  sixty-seven,  and  fifty-seven  per  cent.;  with  sodi- 
um bichromate,  sixty-seven,  sixty-three,  sixty-one,  and 
fifty-three  per  cent. 

The  larger  figures  are  certainly  in  part  due  to 
swelling  of  the  corpuscles,  which  may  be  observed 
under  the  microscope  ;  weak  solutions,  furthermore, 
do  not  prevent  coagulation,  which,  although  the  rapid 
removal  of  the  corpuscles  from  the  plasma  prevents 
clotting  in  the  mass  of  the  latter,  may  take  place  be- 
tween the  corpuscles  themselves  and  thus  hinder  com- 
plete compression. 

As  has  long  been  known,  the  solution  of  the  red 
disks  by  distilled  water,  above  referred  to,  may  be 
avoided  on  diluting  blood  by  employing  a  solution  of 
common  salt  in  a  strength  approaching  that  of  the 
blood  plasma  in  this  constituent  (7.3  per  1,000),  such 
as  is  commonly  known  as  physiological  salt  solution. 
When  blood,  however,  is  removed  from  the  blood- 
vessels, defibrinated  and  diluted  with  a  salt  solution  of 
exactly  this  strength,  and  then  allowed  to  deposit  its 
corpuscles,  it  will  soon  be  perceived,  in  most  cases,  by 
the  color  of  the  supernatant  serum,  that  hemoglobin 
has'  become  dissolved  in  the  solution.  This,  as  has 
likewise  long  been  known,  may  usually  be  prevented 
by  employing  somewhat  stronger  solutions  of  salt  and 
without  appreciably  influencing  the  corpuscles,  as  shown 
by  the  microscope. 

Furthermore,  an  addition  of  sodium  chloride  in  less 
amount  than  that  in  the  blood  (e.g.,  5  per  r,ooo)  to 
solutions  of  potassium  dichromate,  or  of  other  salts, 
which  when  weak  dissolve  the  red  disks,  or  in  stronger 
solution  occasion  their  swelling,  will  prevent  the  same 
to  a  greater  degree  than  the  addition  of  an  equal 
quantity  of  the  chief  salt  in  solution.  The  action  of 
the  chloride  of  sodium  is,  therefore,  specifically  con- 
servative. 

Since  the  first  publications  on  the  hematocrit  meth- 
od the  necessity  of  the  i)resence  of  soluble  salts  of 
calcium  for  the  occurrence  of  coagulation  of  the  blood, 
and  also  for  the  formation  of  fibrin,  has  become  gen- 
erally known,  and  it  has  been  found  that  these  proc- 
esses may  be  indefinitely  prevented  by  substances 
capable  of  precipitating  calcium,  such  as  oxalic  acid, 
or,  better,  a  soluble  oxalate  or  fluoride.  These  im- 
portant facts  we  owe  to  the  labors  of  Briicke,  Hammar- 
sten,  Pekelharing,  Latschenberger,  Arthus,  and  Pages. 

Latschenberger,  by  repeated  coagulations  from  serum, 
has  indeed  shown  that  after  other  salts  no  longer  ap- 
pear in  the  coagula,  calcium  is  still  present  in  quan- 
tity. From  this  and  other  facts,  it  is  now  considered 
that  fibrin  is  a  calcium  compound,  although  containing 
but  one-thousandth  part  of  this  substance. 


Arthus  and  Pages  have  furthermore  found  that  by 
the  addition  of  a  soluble  salt  of  oxalic  acid,  such,  for 
instance,  as  the  sodium  compound  in  the  proportion  of 
one  part  to  one  thousand  of  blood,  which  is  sufficient 
to  precipitate  all  calcium  in  the  latter,  coagulation  may 
be  completely  prevented  for  an  indefinite  period  ;  that 
it  will,  indeed,  be  stopped  if  already  begun,  and  can 
even  be  caused  to  disappear  if  not  too  far  advanced. 

Based  upon  the  facts  detailed  with  reference  to  the 
prevention  of  coagulation,  on  the  one  hand,  and  the 
prevention  of  the  escape  of  haemoglobin  from  the  ery- 
throsytes,  as  well  as  the  prevention  of  their  swelling, 
on  the  other,  we  have  made  and  tested  the  following 
solution  for  employment  in  the  haematocrit  method  : 
It  has  yielded  us  results  of  exceptional  uniformity,  and 
unlike  the  bichromate  solution,  produces  no  precipita- 
tion of  albumin.  Its  formula  is  sodii  oxalate,  2.0  ; 
sodii  chlorid.,  lo.o  ;  aquae  dest.,  1,000.0.  This  solu- 
tion, when  mixed  with  blood  and  allowed  to  stand  at 
rest,  permits  the  corpuscles  to  sink  with  unusual  rapid- 
ity, leaving  a  clear,  almost  colorless,  supernatant  fluid, 
composed  substantially  of  diluted  plasma,  while  the 
corpuscles  themselves  preserve  their  normal  micro- 
scopic characters. 

The  chief  improvement  in  the  haematocrit  method 
up  to  the  present  time  has  been  made  in  the  mechani- 
cal means  of  execution.  Daland's  employment  of  the 
Zeiss  haematocytometer  pipette  for  taking  the  specimen 
of  blood  increased  the  certainty  of  its  exact  measure- 
ment, while  Gaertner  reduced  or  removed  the  liability 
to  error  in  the  further  process  by  directly  transferring 
the  whole  of  the  specimen,  mixed  with  a  large  and 
unmeasured  quantity  of  the  bichromate  solution,  to  a 
tube  for  centrifugation,  having  a  funnel-shaped  res- 
ervoir for  the  same  at  the  centripetal  end.  This  tube, 
however,  has  been  found  in  practice  by  Friedheim  to 
leak  at  the  centrifugal  end,  owing  to  an  extraordinarily 
ill-devised  combination  of  rubber  cap  fitted  to  a  screw 
thread  cut,  or  rather  attempted  to  be  cut,  directly  on 
the  glass  tube. 

To  avoid  this  palpable  source  of  error  we  have  had 
constructed'  a  new  tube  of  simple  kind,  the  chief  char- 
acteristics of  which  are  a  closed  centrifugal  end,  a 
wider  bore,  and  a  single  graduation,  indicating  the 
total  quantity  of  blood  introduced.  The  closed  end 
prevents  all  possible  loss  of  corpuscles  during  the 
centrifugation,  the  wide  bore  permits  a  better  extrac- 
tion of  surrounding  fluid  from  the  same  when  already 
tolerably  compact  and  enables  a  better  subsequent 
removal  of  the  same,  while  the  single  graduation  allows 
of  the  employment  of  a  number  of  like  tubes  in  connec- 
tion with  a  finely  graduated  scale  fitted  to  receive  them. 

For  taking  and  at  once  thoroughly  mixing  the  speci- 
men of  blood  with  the  solution  we  have  employed  a 
tube  similar  to  the  Zeiss  pipette  for  his  leucocytometer, 
but  bearing  a  single  graduation  corresponding  to  that 
on  the  centrifugation  tubes.  For  drawing  blood  the 
sheathed  lancet  of  Laker,  which  often  accompanies 
von  Fieischl's  hxmometer,  has  yielded  us  satisfactory 
service,  especially  after  having  added  to  it  a  regulating 
screw-nut  on  the  knife-shaft  above  the  sheath.  By 
this  means  the  amount  of  projection  of  the  point,  and 
therefore  depth  of  puncture  upon  pushing  the  shaft 
forward  against  a  light  spiral  spring  within  the  sheath, 
may  be  finely  adjusted.  An  instantaneous  and  painless 
puncture  is  thus  provided  for,  after  which,  by  slight 
pressure  upon  the  integument  to  the  proximal  side  of 
the  same,  a  more  than  sufficient  drop  of  blood  may  and 
should  be  easily  caused  to  exude. 

Owing  to  the  painlessness  of  the  operation  the  end 
of  the  finger  may  be  taken  as  the  site  of  the  same  with 
the  natural  advantage  of  its  abundant  blood-supply. 
By  keeping  the  particular  point  of  surface  supporting 
the  exuded  drop  of  blood  horizontal,  the  latter  will  re- 
tain a  globular  form,  thereby  incurring  the  least  expos- 

'  By  Rohrbeck  &  Luhme,  Berlin,  Karl  Street,  24,  who  have  under- 
taken 10  manufacture  the  haematocrit  as  here  specified. 


Augiist  17,  1895] 


MEDICAL   RECORD. 


ure  to  air  and  integument,  which  also  facilitates  the 
obtainment  of  the  exact  quantity  of  blood  within  the 
measuring  pipette.  This  latter  measurement  is  natu- 
rally the  critical  part  of  the  entire  operation  and  re- 
quires a  certain  amount  of  dexterity. 

To  lessen  its  difficulty  as  well  as  duration,  we  have 
modified  the  Zeiss  pipette  so  as  to  diminish  the  sensi- 
tiveness of  movement  of  fluid  contained  within  its  cap- 
illary portion  by  introducing  a  glass  air-bulb  of  one  inch 
in  diameter  in  the  course  of  the  rubber  tubing  connect- 
ing the  pipette  and  the  mouth-piece  of  the  instrument, 
while  giving  this  connection  altogether  a  considerable 
length  for  greater  convenience  and  surety  of  action. 
By  these  means  fluid  in  the  capillary  portion  of  the 
pipette  may  be  easily  prevented  from  reaching  the 
bulbous  enlargement  of  the  same  before  exact  meas- 
urement, which  is  not  the  case  with  the  Zeiss  instru- 
ment. To  readily  secure  the  exact  quantity  of  blood 
slightly  more  than  required  must  be  first  drawn  into  the 
pipette,  when  by  stopping  its  extremity  and  mo\-ing  the 
end  of  the  pipette  at  right  angles  along  the  surface  of 
the  other  hand,  while  producing  slight  air-pressure  be- 
hind the  column  of  blood,  the  latter  will  gradually 
flow  out  until  the  upper  end  of  the  column  stands  pre- 
cisely at  the  mark.  The  specimen  is  then  to  be  drawn 
further  within  the  capillary,  and  immediately  followed 
by  about  half  of  the  clot-preventing  solution  into  the 
bulb  of  the  instrument,  mixed  with  the  same  by  means 
of  the  contained  bit  of  glass,  and  transferred  to  the 
centrifugation-tube  by  the  help  of  a  bristle,  the  other 
two  quarter  porrions  of  solution  requisite  to  succes- 
sively free  the  pipette  from  the  remains  of  the  previous 
mixtures  being  likewise  transferred.  By  the  employ- 
ment of  the  above  given  oxalate  solution,  a  special 
cleansing  of  the  tube  from  time  to  time,  as  with  con- 
centrated sulphuric  acid,  such  as  is  necessary  upon  use 
of  a  bichromate  solution,  is  unnecessary  when  the  con- 
tents of  the  tube  be  each  time  soon  removed. 

The  centrifugation  of  the  specimen  may  be  per- 
formed with  any  centrifugal  machine,  and  is  to  be  con- 
tinued either  until  the  column  of  corpuscles  ceases  to 
perceptibly  diminish  in  length,  or,  in  case  of  compara- 
tive observations  for  a  certain  fixed  period  of  time,  suffi- 
cient to  render  the  corpuscles  compact.  Wherever — as, 
for  instance,  in  a  case  of  anfemia — a  simple  compar- 
ison with  normal  blood  is  wished,  a  specimen  of  each 
may  be  simultaneously  centrifugated  and  measured  be- 
fore the  mass  of  corpuscles  is  completely  compact, 
without  impairment  of  exactitude.  Such  a  centrifuga- 
tion is  conveniently  effected  with  Gaertner's  or  Rohr- 
beck  &  Luhme's  simple  hand  machines.  In  case  of 
the  former  but  two  spinnings  of  the  same  are  requisite, 
with  the  latter  a  revolution  of  from  one  to  three  min- 
utes suffices.  For  retaining  a  level  surface  on  the  col- 
umn of  blood-corpuscles  for  precise  measurement,  the 
motion  should  be  slowly  brought  to  a  stop. 

With  normal  human  blood,  the  above  detailed  hasma- 
tocrit  method,  when  the  corpuscles  are  reduced  by 
centrifugation  to  the  utmost  compactness,  has  yielded 
us  percentages  of  corpuscle  substance  varj-ing  from 
thirty-six  to  forty-four  per  cent.  As  before  stated  this 
does  not  represent  the  volume  of  the  corpuscles  as  ex- 
isting in  circulating  blood,  where,  owing  to  the  vari- 
able absorption  of  water  from  the  plasma,  their  size  is 
inconstant,  but  the  amount  of  corpuscular  substance 
under  fixed  and  constant  conditions  effected  by  the 
oxalated  solution  of  salt.  This  amount  we  hold  to  be 
a  better  measure  of  the  quality  of  the  blood  with  refer- 
ence to  the  ingredient  which  forms  some  nine- tenths  of 
its  red  disks,  namely,  its  haemoglobin,  than  those  here- 
tofore yielded  by  the  haematocrit  method. 

Observations  by  F.  H.  Southgate  upon  the  blood  of 
the  rabbit  obtained  from  the  subcutaneous  veins  have 
shown  a  generally  greater  uniformity  than  that  above 
specified,  which  would  indicate  that  blood  from  the 
capillaries  is  subject  to  greater  variability  than  that  in 
larger  vessels. 


AXIS-ADJUSTMEXT  :  A  XEW  AXD  RATIOX- 
AL  METHOD  OF  DELIVERIXG  THE  PLA- 
CEXTA.i 

By  ^YILLIA^I  R.  NICHOLS,  M.D., 


The  paper  I  have  ventured  to  bring  before  your  notice 
to-day,  under  the  heading  of  "'  A  Xew  and  Rational 
Method  of  Delivering  the  Placenta,"  needs  an  apology 
for  its  title,  since  it  is  new  only  in  the  sense  that  no 
reference  to  its  principles  can  be  found  in  any  litera- 
ture at  hand  ;  but  it  is  not  presumed  that  many  of  you, 
who  are  experts  and  veterans  in  the  obstetric  art,  have 
failed  to  practise,  long  before  the  writer,  some  of  the 
procedures  appertaining  to  the  method  ;  on  the  con- 
trary, it  is  believed  that  as  your  experience  has  become 
riper  and  your  management  more  dexterous,  you,  too, 
have  departed  from  the  teaching  of  the  schools  and 
books,  and  have  arrived  at  a  practice  in  accord  with 
principles  I  now  attempt  to  establish.  If  these  prin- 
ciples be  intrinsically  true  and  universally  applicable, 
then  the  methods  in  vogue  must  be  incidentally  suc- 
cessful, and,  as  such,  irrational,  irrespective  of  the 
measure  of  success  they  apparently  give  ;  and  the  dis- 
cussion of  these  principles,  which  this  paper  is  sure  to 
evoke,  cannot  fail  to  be  of  interest  and  profit  ;  for  they 
vitally  concern  that  stage  of  labor  which  is  admitted  by 
all  to  be  the  most  important  and  the  most  fraught  with 
dangers  and  accidents  to  the  lying-in  woman. 

The  manner  of  delivering  the  placenta  has  been  de- 
scribed as  being  accomplished  by  one  of  four  methods, 
viz.:  The  Natural  method,  wherein  Nature  herself  is 
competent,  as  she  is  generally  with  the  child.  The 
method  of  Traction  on  the  Cord,  now  fairly  obsolete. 
The  method  of  Expression,  as  enunciated  and  taught 
by  Crede,  but  which  had  been  practised  long  before 
his  time  by  the  Dublin  school,  and  taught  even  in  our 
own  backwoods  Province  by  the  late  Dr.  Workman, 
when  professor  of  obstetrics  in  King's  College,  To- 
ronto. And,  lastly,  the  method  of  Manual  Extraction, 
the  last  resort  in  failure  of  the  former  methods. 

As  the  method  of  Crede  has  superseded  the  former 
methods,  and  is  accepted  without  question  as  the 
method  par  excellence,  it  is  to  it  we  wish  to  pay  our  re- 
spects, and  to  do  it  the  deference  of  quoting  its  tech- 
nique in  full  and  of  commenting  thereon.  "  Firm 
pressure  is  to  be  made  upon  the  uterus  downward  and 
backward  in  the  axis  of  the  pelvic  brim,  when  a  con- 
traction is  felt  to  begin."  At  the  outset,  it  is  ad- 
mitted that  much  success  has  attended  this  manipula- 
tion, but  the  same  may  be  said  of  any  particular 
procedure,  in  any  condition,  wherein  nature  co-oper- 
ates ;  in  other  words,  where  success  is  incidental  to 
the  method,  and  not  intrinsic  or  essential.  The  limits 
to  which  this  "  firm  pressure  "  and  these  forcible  ef- 
forts may  be  pushed  appear  to  be,  on  the  one  hand, 
the  amount  of  Niolence  the  woman  can  tolerate,  and, 
on  the  other,  the  manual  strength  of  her  intellectual 
attendant.  I  speak  of  what  I  have  seen,  and,  it  may 
be,  of  what  I  have  practised.  I  can  never  forget  the 
amount  of  violence  offered  to  a  uterus  and  abdomen 
(not  to  speak  of  tender  endothelium)  at  my  first  case 
of  labor  in  a  lying-in  hospital.  The  vivid  remem- 
brance of  that  occasion  must  bear  the  onus  of  inflict- 
ing this  paper  upon  you.  Cases  that  cannot  be  thus 
delivered  are  denominated  "  retained  placentas  ;  "  and 
such  retention  is  taught  to  be  due  to  either  hour-glass 
contraction  or  organic  growth  to  the  uterine  walls. 
As  I  have  been  unable  to  satisfy  myself  of  having  met 
more  than  two,  if  even  so  many,  cases  of  true  organic 
growth  of  the  placenta  to  the  uterus,  and  not  even  one 
instance  of  hour-glass  contraction  in  over  half  a  thou- 
sand accouchements,  I  am  obliged  to  consider  the  re- 
tention to  be  due  in  the  great  majority  of  cases  to 

'  \  paper  read  before  the  Waterloo  Medical  Association,  at  Berlin, 
Ontario. 


226 


MEDICAL   RECORD. 


[August   17,  i{ 


other  factors.  Tliat  cases  of  retention  are  fairly  fre- 
quent, we  are  led  to  believe  from  the  histories  of  pa- 
tients, whose  statement  that  the  after-birth  was  "  grown 
fast  "  is  by  no  means  uncommon. 

Meeting  occasionally  with  cases  of  natural  delivery, 
wherein  nature  is  competent  without  any  assistance 
from  art,  and,  at  other  times,  with  cases  of  "  retained 
placentae  "  under  conditions  apparently  as  favorable,  I 
felt  myself  mystified  when  attempting  to  furnish  an  ex- 
planation for  the  difference,  and  when  I  was  obliged 
to  submit  my  patient  to  the  risks  of  manual  extraction 
for  a  placenta  showing  no  trace  of  organic  growth  to 
the  uterine  walls,  or  any  other  condition  accounting 
for  such  retention,  I  was  far  from  feeling  comfortable 
and  satisfied. 

If  a  careful  palpation  of  uteri  at  this  stage  of  labor 
be  made,  it  will  be  found  that  they  possess  marked 
variations  in  form.  Some  are  markedly  irregular  and 
bossed,  while  others  are  fairly  uniform.  These  varia- 
tions, so  far  as  I  am  aware,  have  met  with  no  interpre- 
tation ;  they  are  significant,  however.  Reflecting  that 
the  structures  superimposing  the  placenta — viz.,  the 
abdominal  and  uterine  walls — are  uniform  in  thickness, 
I  was  forced  to  the  conclusion  that  the  variations  are 
due  to  the  position  of  the  contained  placenta,  but  in 
just  what  shape  the  placenta  was  I  could  for  a  long 
time  form  no  proper  idea.  An  observation  that  I  had 
previously  made,  long  before  I  could  attach  to  it  either 
diagnostic  import  or  indication  for  treatment,  has  a 
bearing  upon  this  point.  It  was  to  the  effect  that  when 
blindly  manipulating  the  uterus  a  la  Credd,  I  was  on  a 
number  of  occasions  almost  startled  by  a  sudden  slip- 
ping or  jerking  within  my  hand,  accompanied  by  a 
transformation  of  its  contents,  which  was  manifest  to 
the  patient  as  well,  though  not  painfully,  and  delivery 
generally  occurred  soon  after  without  further  solicita- 
tion. By  degrees  it  began  to  dawn  upon  me  that  this 
slipping  and  transformation  was  a  turning  or  version 
of  the  placenta  upon  its  axis,  similar  in  manner  to  the 
version  of  the  fostus  at  times.  Further  attention  to 
these  points  showed  that  a  certain  rough  relationship 
existed  between  the  form  (as  felt  through  the  abdom- 
inal walls)  and  the  ease  with  which  delivery  was  ac- 
complished. When  the  uterus  was  fairly  imiform  and 
free  from  bossing,  and  elongated  rather,  nature  was 
frequently  competent,  or  but  little  diiificulty  was  expe- 
rienced by  artificial  methods  ;  when  the  uterus  was 
markedly  bossed  and  irregular,  and  broadened  rather, 
more  placental  dystochia  was  present,  or  retained  pla- 
cent;i;  were  obtained. 

As  before  stated,  I  regarded  these  variations  in  shape 
to  be  due  to  the  position  of  the  contained  placenta — in 
other  words,  to  the  relation  of  the  placental  axis  to  that 
of  the  uterus. 

In  order  to  have  an  intelligent  conception  of  the  pla- 
centa, it  is  necessary  to  examine  one  that  has  been  de- 
livered. It  will  be  found  to  be  possessed  of  an  ellip- 
tical rather  than  a  circular  form,  but  it  is  not  by  virtue 
of  this  that  we  can  speak  of  its  having  an  axis,  though 
doubtless  this  may  occasionally  be  so.  There  will  be 
revealed,  also,  deej)  sulci  or  furrows  on  its  uterine  sur- 
face, which  surface,  before  the  birth  of  the  child,  pre- 
sents a  convexity  corresponding  to  the  concavity  of  a 
segment  of  the  uterus,  against  which  it  is  in  apposition. 
The  sudden  diminution  consequent  upon  the  exjiulsion 
of  the  child  but  completes  a  process  of  folding  the  pla- 
centa upon  itself,  already  initiated  by  its  previous 
convexity  and  sulci.  It  is  with  this  folded  placenta  we 
have  to  do — folded  it  maybe  seen  when  emerging  from 
the  ostium  vagin:\; — folded  it  may  be  felt  when  passing 
through  the  os  uteri,  and  folded  it  lies  within  the  cav- 
ity of  the  uterus.  It  matters  not  whether  it  is  folded 
equally  or  unequally — the  practical  consideration  be- 
ing that  a  more  definite  axis  has  been  thereby  given  it, 
which  passes,  roughly  speaking,  through  the'  points  of 
reduplication  of  itsedge-s,  these  points  corresponding  to 
the  poles  of  the  faHus.     Simply  its  relative  length  has 


been  increased.  We  will  now  define  the  axis  of  the 
uterus  to  be  in  that  diameter  which  passes  from  the 
centre  of  the  os  to  the  centre  of  the  fundus. 

If,  now,  within  the- cavity  of  the  uterus,  the  placental 
axis,  as  previously  defined,  corresponds  to  the  axis  of 
the  uterus  as  above  given,  we  will  have,  as  determined 
by  abdominal  palpation,  a  fairly  uniform,  somewhat 
globular  and  elongated  form.  This  form,  I  have  al- 
ready remarked,  obtains  wherein  nature  is  frequently 
competent,  and  wherein  the  least  dystochia  occurs — 
the  reason  is  obvious.  If,  on  the  contrary,  the  axes  do 
not  correspond,  we  have  more  or  less  irregularity  and 
bossing,  as  the  placental  axis  deviates  from  or  ap- 
proaches that  of  the  uterus  ;  the  greatest  deviation  re- 
sulting in  a  "  placental  cross-birth,"  a  condition  much 
more  frequently  met  with  than  foetal  cross-birth,  owing 
to  the  antecedent  disparity  in  size  of  container  and 
contents,  to  the  original  site  of  implantation  of  the  pla- 
centa, and  the  subsequent  contractions  of  the  uterus. 
In  the  condition  referred  to  as  placental  cross-birth, 
the  poles  of  the  placenta  do  not  present  at  the  os  and 
fundus,  but  at  two  opposite  points  midway  between 
these.  A  relatively  broad  surface  is  thus  in  apposition 
with  the  OS — too  broad  and  too  large  for  it  to  enter 
that  opening,  and  any  contractions  occurring  (which 
operate  below  the  lower  pole  as  well  as  above  it)  tend 
to  imprison,  rather  than  to  expel,  the  placenta,  until 
such  times  as  a  correspondence  of  axes  has  by  whatever 
means  occurred.  In  this  we  have  the  explanation  for 
the  cases  of  so-called  retained  placentae,  so  common 
without  trace  of  organic  connection.  This  correspond- 
ence of  axes  is  occasionally  brought  about  by  succes- 
sive contractions  indefinitely  prolonged,  but  it  is  evi- 
dently the  duty  of  the  physician  not  to  wait  for  the 
efforts  of  a  partially  exhausted  organ,  lest  further 
efforts  induce  complete  exhaustion  and  precipitate  in- 
ertia and  hemorrhage.  When  the  axes  correspond,  or 
have  been  adjusted^  a  pole  presents  at  the  os,  which 
uterine  contractions  now  cause  it  to  enter  and  readily 
dilate,  by  bringing  into  play  the  mechanical  principles 
of  the  wedge.  The  blow  or  power  being  represented 
by  the  contractions,  the  wedge  by  the  sloping  pole  of 
the  placenta,  and  the  resistance  by  the  moderately  con- 
tracted OS. 

My  limited  experience  in  this  undeveloped  field 
leads  me  to  believe  that  it  is  possible,  in  the  vast  ma- 
jority of  cases,  to  diagnose  the  condition  of  placental 
cross-birth,  and  in  cases  of  less  axial  obliquity  to  deter- 
mine whether  the  upper  pole  is  anterior  or  posterior, 
or  right  or  left  with  the  lower  pole  in  a  corresponding 
opposite  position.  Nor  is  the  acquiring  of  this  degree 
of  refinement  in  palpation  to  be  considered  a  feat  of 
any  comment,  when  slightly  enlarged  appendices  and 
tubes  are  daily  diagnosed  and  accurately  mapped  out, 
in  abdomens  liaving  nothing  of  the  tlaccidity  that  is 
jjresent  in  the  third  stage  of  labor.  Who  of  you  will 
affirm  it  to  be  impossible  to  locate  within  the  abdom- 
inal cavity  a  body  having  the  dimensions  of  a  folded 
placenta  ?  I  know,  gentlemen,  you  have  met  with  no 
difficulty  in  palpating  the  floating  kidney,  and  I  believe 
that  when  you  have  given  this  subject  your  serious  at- 
tention, you  will  diagnose  the  position  of  the  placenta 
much  more  rapidly  than  I  can  even  speak  of  it.  The 
projections  or  bosses  correspond  to,  and  are  caused  by, 
the  poles  of  the  placenta,  which  the  hand,  rapidly 
swept  over  the  fundus  uteri,  deejily  behind  it,  and  over 
its  lateral  and  front  walls,  readily  detects.  There  is 
also  a  resistance  at  the  poles,  entirely  different  from 
that  at  other  i)oints,  and  the  poles  located,  the  position 
is  determined.  Some  of  you  may  object  to  this,  and 
say  if  it  be  such  a  simple  affair  to  diagnose  the  cor- 
relations of  the  placenta,  why  is  it  we  do  not  apply  the 
same  method  to  determining  the  position  of  the  child. 
instead  of  resorting  to  vaginal  examination  ?  Whoever 
of  you  has  had  a  ftietal  cross-birth  and  has  taken  the 
trouble  and  care  to  examine  the  abdomen,  will  have 
been  struck  by  the  unusual  form — so  unusual,  that  in- 


August  17,  1895] 


MEDICAL    RECORD. 


227 


spection  surmised  the  condition  before  palpation  con- 
firmed it.  We  are  the  slaves  of  habit,  and  are  so  ac- 
customed to  rely  upon  the  vaginal  examination,  that  we 
have  thrown  over  and  lost  sight  of  the  really  valuable 
evidence  derivable  from  external  methods  of  examina- 
tion. The  fact  is,  that  in  one  of  the  largest  German 
obstetric  clinics  no  other  method  of  examination  than 
the  external  is  permitted  dn  labor. 

The  slipping  and  transformation  that  I  have  spoken 
of  as  occurring  when  blindly  manipulating  the  uterus, 
and  which  I  have  interpreted  as  a  version  of  the  placenta 
on  its  axis,  gave  me  hopes  that  it  would  be  possible  to 
perform  version  when  desired,  and  so  obviate  recourse 
to  the  dangers  of  manual  extraction  in  case  of  dystochia 
or  retention.  Now  that  we  have  an  intelligent  concep- 
tion of  the  placenta  (contained  or  retained),  and  can, 
in  the  vast  majority  of  cases,  approximately  determine 
its  axis,  its  version  or  adjustment  of  axis  presents  but 
little  difficulty. 

Before  attempting  this,  it  is  desirable  to  refer  to  the 
terms  we  shall  use,  viz.:  Placental  cross-birth,  placental 
obliquity,  placental  version  ;  the  latter  being  accom- 
plished by  three  methods,  viz.:  external,  internal,  and 
combined  or  bipolar. 

As  external  placental  version  is  the  method  upon 
which  reliance  is  placed,  we  will  speak  of  it  fully,  and 
state  that  it  is  much  more  readily  performed  than  foetal 
version,  though  much  in  a  similar  manner.  We  pre- 
sume the  hand  has  followed  down  the  uterus  after  the 
expiilsion  of  the  child,  has  maintained  its  contraction, 
and,  most  of  all,  has  determined  the  position  of  the 
placenta.  Now,  when  the  uterus  announces,  by  insti- 
tuting a  pain  or  contraction,  that  its  physiological  rest 
is  over,  which  has  given  time  for  blood  coagulation  to 
seal  the  mouths  of  the  uterine  sinuses,  a  period  of 
from  ten  to  twenty  minutes  after  delivery  of  the  child, 
we  wait  for  the  interval,  that  is  for  the  period  when  com- 
plete contraction  is  absent.  In  antero-posterior  obliq- 
uity, we  proceed  by  grasping  the  upper  hemisphere  of 
the  uterus  in  either  hand  more  convenient,  pressing  the 
fingers  well  down  upon  the  posterior  wall,  while  the 
thumb  searches  downward  over  the  anterior  surface. 
When  the  upper  pole  is  anterior,  the  thumb  pulls 
upward  and  backward  on  this  projection,  while  the 
fingers  press  downward  and  forward  on  the  lower  pole, 
but  without  any  pressure  whatsoever,  in  the  direction 
indicated  by  Crede.  Should  a  contraction  occur,  it 
will  be  found  expedient  to  desist  and  wait  for  another 
interval.  Suddenly  the  slipping,  the  transformation  is 
felt,  and  version  has  been  accomplished.  The  pole, 
the  point  of  reflection,  the  analogue  of  the  wedge, 
enters  the  os,  which  the  finger  may  now  make  out  with 
some  difficulty,  covered  as  it  may  be  with  membranes 
containing  clot  or  fluid.  When  the  upper  pole  is 
posterior,  the  manipulations  are  reversed.  In  obliq- 
uity, where  the  upper  pole  is  lateral,  right  or  left,  the 
version  appears  to  be  more  readily  brought  about  by 
the  two  hands  applied,  one  on  each  side  over  a  jjole, 
making  proper  pressure,  which  may  also  be  accom- 
plished by  one  hand.  Placental  cross-birth  is  managed 
in  an  exactly  similar  manner.  The  combined,  or  bipo- 
lar, method  of  version  appears  to  be  indicated  only  on 
the  rarest  occasions  when  the  external  has  failed  ;  while 
corrective  pressure  is  made  over  the  fundus  uteri  (as 
already  referred  to  in  the  external  method)  by  one 
hand  externally,  the  other  makes  moderate  traction 
upon  the  cord.  This  appears  to  be  a  perfectly  justifi- 
able and  harmless  procedure,  notwithstanding  authori- 
tative opinions  to  the  contrary  ;  and  an  interval  also  is 
the  proper  time  for  its  exhibition.  When  turning  is 
felt  to  have  occurred,  we  must  immediately  desist.  .\ 
battledore  implantation  of  the  cord  on  the  lower  pole, 
when  posterior  or  lateral,  suggests  its  propriety  and 
success  ;  but,  if  on  the  upper  pole,  when  anterior  espe- 
cially, it  would  have  the  tendency  to  diverge  the  axis 
and  increase  the  dystochia,  a  condition  actually  brought 
about  in  practice  at  times.     Internal  version  is  simply 


manual  extraction,  so  seldom  to  be  used  as  only  to  re- 
quire mentioning,  in  a  classification  of  methods,  as  a 
last  serious  resort  when  former  methods  have  failed, 
organic  growth  exists,  or  hemorrhage  necessitates. 

Now  that  the  axis  or  poles  have  been  adjusted, 
uterine  contractions,  reinforced  at  times  by  slight 
assistance,  are  sufficient  to  produce  expulsion,  if  all 
the  other  factors  are  favorable  ;  but  it  is  essential  that 
we  ascertain  this.  In  the  non-gravid  state  the  uterine 
axis  does  not  normally  correspond  with  the  axis  of  the 
vagina,  but  subtends  it  at  an  angle.  In  the  gravid 
state  this  anteversion,  if  I  may  term  it,  is  frequently 
exaggerated  by  the  weight  of  the  child  acting  on  a  lax 
abdominal  parietes,  and  also  by  the  downward  pressure 
of  the  diaphragm  during  the  last  powerful  pains  when 
the  child  is  emerging.  The  relatively  large  size  of  the 
fcetal  head,  or  breech,  has  the  effect  of  obliterating  this 
angle,  and  rendering  for  the  time  being  the  parturient 
canal  straight.  But  the  placenta,  unable  from  its  size 
to  effect  this,  has  its  point  of  apposition  on  the  sacrum — 
a  solid  body  which  opposes  its  progress — instead  of 
into  the  lumen  of  the  vagina,  its  destination.  It  is  evi- 
dently to  our  advantage  to  adjust  these  axes  as  well,  by 
lifting  the  fundus  uteri  and  deeply  depressing  it  into 
the  abdomen.  We  will  now  expect,  and  are  generally 
not  disappointed  in  finding,  the  next  or  succeeding 
pain  effect  delivery,  aided,  only  occasionally,  by  the 
slightest  amount  of  pressure  upon  the  upper  hemi- 
sphere of  the  uterus,  which  is  to  be  applied,  not  in  an 
interval,  as  was  the  version,  but  during  a  pain.  The 
pressure,  even  at  this  favorable  stage,  is  not  to  be 
made  according  to  Crede's  dictum,  "downward  and 
backward  in  the  axis  of  the  pelvic  brim,"  as  that  would 
move  placenta  and  uterus  en  masse,  without  liberat- 
ing the  former.  The  pressure  should  be  of  a  com- 
pressive nature,  as  it  is  by  virtue  of  the  resultant  of 
this  com]50und  force  that  the  placenta  is  propelled, 
while  the  womb  remains  behind  in  the  grasp  of  the 
hand. 

The  sudden  diminution  in  size  of  the  womb,  as 
elicited  by  the  hand,  announces  that  the  placenta  is 
expelled,  which  may  be  found  in  the  vagina,  protrud- 
ing therefrom,  or  lying  in  the  bed,  with  membranes 
born  or  unborn.  Instead  of  proceeding  to  deliver 
these  at  once,  we  wait  for  uterine  relaxation.  As  the 
factor  of  the  relation  of  the  placenta  to  other  bodies 
is  over,  and  a  soft,  almost  fluid  body  as  the  mem- 
branes, being  practically  without  an  axis,  we  might 
consider  we  had  nothing  more  to  do  than  to  twist 
them  into  a  rope.  Of  much  greater  consequence  is  it 
to  maintain  the  fundus  uteri  well  down  into  the 
abdomen  so  as  to  render  the  canal  as  straight  as 
possible,  for  the  os  has  closed  down  to  the  size  of  a 
silver  half-dollar,  and  intra-uterum,  the  membranes  are 
spread  out  over  its  lower  surface,  after  the  manner  of  a 
fan.  Considerable  adhesion  exists  between  these  moist 
surfaces,  which  requires  some  little  force  to  separate, 
and  this  force  is  applied  at  a  disadvantage,  when  act- 
ing at  angle.  Simply  hooking  the  fingers  under  the 
membranes  is  sufficient  in  the  majority  of  cases,  if 
uterine  adjustment  be  maintained  ;  but  twisting  them 
into  a  rope  is  a  valuable  device  for  preventing  tearing. 

We  are  now  in  a  position  to  understand  the  in- 
cidental success  of  the  Crede  method,  since  (a)  such 
blind  manipulations,  from  themselves,  occasionally 
produce  version  ;  (/')  uterine  contractions,  from  in- 
ternal stimulation,  produce  version  ;  {c)  uterine  con- 
tractions, from  external  stimulation,  directly  or  in- 
directly, through  the  hypogastric  sympathetic  plexus, 
produce  version.  Retentions  are  common,  which  can- 
not be  accounted  for  on  the  grounds  of  hour-glass 
contraction  or  organic  connection. 

This  is,  I  believe,  the  rational  method  of  delivering 
the  placenta,  and  I  hold  that  forcible  expression,  as  it 
is  now  largely  practised,  should  have  no  place  in  the 
methods  of  the  modern  physician  ;  since  the  obstacles, 
which  these  forcible  efforts  are  put  forth  to  surmount 


228 


MEDICAL    RECORD. 


[August  17,  1895 


are  more  surely,  more  readily,  and  more  painlessly  re- 
moved by  axis-adjustment. 


TUMOR  AND  LARGE  CYST  OF  THE  CERE- 
BELLUM, WITH  SYMPTOMS  EXTENDING 
OVER   SEVERAL   YEARS. 

By  J,  T.    ESKRIDGE,    M.D., 

DENVER,    COU 


COUNTY  AND  ST.   LUKE'S  HOSPITALS. 

Lucy  E ,  eleven  years  of  age,  white,  of  German 

parentage,  was  referred  to  me  by  Dr.  McNaught,  Feb- 
ruary 19,  1S95,  <^"  account  of  convulsive  seizures  ex- 
tending over  a  period  of  several  years,  attended  by 
almost  complete  blindness.  Family  history  was  nega- 
tive. The  child  at  birth  was  apparently  healthy,  but 
when  fourteen  months  old,  while  teething,  began  roll- 
ing the  head  from  side  to  side,  and  when  taken  in  the 
mother's  arms  the  head  would  be  retracted  and  turned 
from  side  to  side.  The  child  would  frequently  cry  as 
if  in  pain.  Several  days  after  these  symptoms  first 
manifested  themselves,  she  was  seized  with  a  convul- 
sion which  lasted  about  five  minutes,  during  which 
there  was  cyanosis  of  the  face,  frothing  from  the 
mouth,  the  eyes  were  fixed  and  the  pupils  dilated. 
One  leg  was  flexed  at  the  knee  and  thigh,  but  which 
the  mother  does  not  now  remember,  both  hands  were 
clinched,  and  she  thinks  the  arms  were  extended  and 
rigid.  About  this  time,  or  February,  1885,  a  thick, 
offensive  discharge  took  place  from  both  ears.  The 
otorrhoea  continued  for  two  or  three  months,  and  dur- 
ing most  of  this  time  the  child  was  restless  and  threw 
its  head  from  side  to  side.  From  June,  1885,  to  Janu- 
ary, 1888,  the  child  was  not  really  ill,  but  it  remained 
nervous  and  fretful.  At  the  latter  date  it  had  a  slight 
attack  of  mumps  and  afterward  remained  in  its  usual 
condition  until  May,  1889,  when  it  suffered  from  mea- 
sles, but  recovery  from  this  seemed  to  be  complete. 
In  April,  1891,  it  fell  from  a  wagon,  striking  the  fore- 
head, just  above  the  right  eye,  against  a  horse's  hoof. 
There  was  a  contused  wound  over  the  eye  which  con- 
tinued to  suppurate  for  about  two  weeks.  At  this  time 
complaint  was  made  of  pain  in  the  back  of  the  head. 
After  this  it  remained  in  apparently  good  health  until 
June,  1892,  when  it  became  very  nervous,  and  vomited 
repeatedly.  The  vomiting  was  always  attended  with 
pain  in  the  occipital  region.  These  symptoms  continued 
for  two  weeks,  when  it  had  its  second  convulsion,  last- 
ing about  thirty  minutes.  This  seizure  began  by  the 
child  crying  loudly,  "  Mamma,  mamma  !  "  the  head  was 
retracted,  and  rolled  from  side  to  side,  the  spine  was 
arched  backward,  and  the  arms  and  legs  were  extended 
and  rigid.  The  child  remained  perfectly  conscious 
throughout  the  seizure,  moaned  and  called  its  mother, 
and  gave  evidence  of  great  suffering.  Six  hours  later 
it  had  a  second  and  similar  attack.  The  convulsions 
occurred  two  or  three  times  every  day,  and  on  one  day 
there  were  fourteen,  each  seizure  lasting  from  thirty 
minutes  to  several  hours.  Her  condition  seemed  to  be 
uninfluenced  by  treatment,  and,  in  fact,  the  mother 
stated  that  the  bromides  seemed  to  increase  the  seizures. 
In  December,  1892,  an  abscess  formed  in  the  right 
groin,  which  was  opened  a  few  days  later,  giving  vent 
to  a  free  discharge  of  pus.  About  this  time  the" child 
became  almost  totally  blind,  remaining  so  for  three 
months,  the  convulsions  continuing  in  the  meantime. 
Early  in  1S93  she  partially  regained  her  vision,  but  the 
convulsive  seizures,  which  were  nearly  all  of  the  same 
character,  continued  until  August,  1893.  From  this 
date  until  December,  1S94,  she  was  free  from  convul- 
sions, but  she  remained  nervous  and  vision  was  very 
poor.  At  the  latter  date  the  convulsions  recurred 
again  and  were  attended   with  increased  pain  in  the 


back  of  the  head  and  frequent  vomiting.  She  remained 
in  this  condition  until  I  saw  her,  February  19,  1895, 
when  I  placed  her  in  St.  Luke's  Hospital,  under  a 
trained  nurse,  to  have  the  con\njlsive  seizures  watched. 

Examination  February  22,  1895. — She  walks  fairly 
well  backward  or  forward  and  with  eyes  open  or  closed. 
There  is  no  evidence  of  distinct  ataxia  in  the  legs,  arms, 
or  trunk  muscles.  The  knee-jerks  are  slight,  and 
ankle-clonus  is  absent.  Plantar  reflexes  and  tendo- 
Achillis  are  present.  Lower  abdominal,  scarcely  per- 
ceptible ;  epigastric,  about  normal.  Deep  reflexes  of 
the  arms  are  not  increased.  Dyn.  R.  22  ;  L.  20.  ^^Tlile 
the  child  is  not  strong  for  its  age,  there  is  no  distinct 
paresis  or  paralysis  of  any  group  of  muscles.  The 
tongue  is  protruded  in  the  median  line.  All  the  general 
sensory  phenomena  and  the  special  senses,  smell  and 
taste,  are  normal.  Hearing  watch,  K.  j/2  ;  L.  j4.  The 
tuning-fork  is  heard  better  in  the  left  ear.  There 
is  no  weakness  of  the  external  ocular  muscles.  She  is 
able  to  perceive  objects  with  the  right  eye,  but  vision 
is  not  sufiicient  to  enable  her  to  distinguish  one  face 
from  another.  In  the  left  eye  there  is  only  slight  light 
perception.  There  is  an  extreme  degree  of  atrophy  in 
both  optic  nerves.  The  retinae  are  unusually  vascular, 
and  present  a  red,  velvety  appearance. 

She  remained  in  the  hospital  seven  days,  and  during 
this  time  she  had,  on  an  average,  from  three  to  four 
seizures  every  day.  Her  temperature  on  admission 
and  for  a  few  days  subsequently  remained  about  nor- 
mal, or  from  a  half  to  one  degree  subnormal.  The 
pulse  varied  from  70  to  100,  the  respirations  from  18  to 
26.  During  the  last  days  of  her  stay  in  the  hospital 
the  temperature  was  about  one  degree  above  normal, 
pulse  varied  from  80  to  102,  the  respirations  most  of 
the  time  from  20  to  34.  Her  appetite  was  good,  she 
was  well  nourished,  and  when  not  suffering  from  pain 
was  bright  and  cheerful.  Her  bowels  were  obstinately 
constipated,  requiring  large  enemas  to  effect  a  move- 
ment, as  the  ordinary  purgatives  were  inefficient. 

The  numerous  seizures  that  were  observed  did  not 
vary  greatly  in  character,  and  a  description  of  one, 
with  a  few  additional  remarks,  will  suffice  for  all.  I 
witnessed  two  of  these  attacks.  While  I  was  talking 
with  her,  she  seemed  to  be  free  from  pain  and  was 
laughing,  when  suddenly  she  cried,  "  Oh,  mamma, 
mamma  I  "  her  face  flushed,  head  was  extremely  re- 
tracted, spine  arched  backward,  arms  extended  and 
rigid,  right  leg  flexed  at  the  knee  and  hip,  the  left 
straight,  and  all  the  muscles  of  the  body  seemed  to  be 
rigid.  The  hands  were  closed  tightly.  While  in  this 
condition,  and  apparently  suffering  intense  agony,  she 
was  entirely  conscious  and  would  answer  if  spoken  to  ; 
respiration,  pulse,  and  temperature  were  about  normal. 
Pupils  were  dilated  and  did  not  respond  to  light. 

"The  spastic  seizure  which  I  observed  lasted  only 
two  or  three  minutes,  when  the  muscles  began  to  re- 
lax. She  seemed  greatly  exhausted  and  moaned  for 
several  minutes  after  the  attack  was  over.  She  said 
that  she  was  entirely  conscious  throughout  the  spasm 
and  that  the  pain  was  very  great,  especially  in  the  back 
of  the  neck  and  head.  Several  of  the  attacks  observ-ed 
by  the  nurse  were  twenty  or  thirty  minutes  in  duration, 
and  during  some  of  them  she  would  become  almost 
frantic  with  the  pain.  On  one  occasion,  while  trying 
to  bite  her  own  hand,  she  begged  the  nurse  to  strike 
her  head,  punch  out  her  eyes,  as  the  pain  in  the  front 
of  the  head  was  so  intense.  The  prolonged  spells  ex- 
hausted her  greatly,  and  the  pain  in  the  back  of  the 
head  and  neck  following  them  would  frequently  con- 
tinue for  several  hours  or  until  she  would  have  another 
attack.  If  the  pain  did  not  continue  long  after  a 
seizure,  each  seizure  would  be  followed  bv  a  period  of 
moaning  and  restlessness,  which  would  often  end  in 
sleep. 

About  8  .\.M.,  Feburary  26.  rS95.  the  day  that  I  had 
promised  her  that  her  mother  might  take  her  home,  I 
saw  her  while  she  was  eating  her  breakfast,  consisting 


August  17,  1895] 


MEDICAL    RECORD. 


229 


of  eggs,  toast,  and  milk,  which  she  seemed  to  relish 
very  much.  She  was  entirely  free  from  pain,  said  she 
felt  well,  and  was  happy  at  the  thought  of  going  home 
that  day.  The  nurse  reported,  however,  that  she  had 
suffered  from  three  attacks  the  previous  night ;  that 
while  all  had  been  longer  in  duration  and  greater  in 
severity  than  those  which  she  had  previously  witnessed, 
each  seizure  seemed  to  be  worse  than  the  one  which 
preceded  it.  She  remained  in  about  the  condition  in 
which  I  saw  her  until  noon,  when  suddenly  she  began 
to  scream  at  the  top  of  her  voice,  "  Mamma,  mamma, 
mamma  I "  and  immediately  an  intense  rigidity  seized 
every  muscle,  and  the  head  was  retracted  to  an  ex- 
treme degree,  the  spine  was  arched  backward  so  that 
she  lay  on  her  abdomen  with  head  and  feet  in  the  air. 
The  chest  muscles  and  diaphragm  were  contracted, 
respiration  ceased  for  a  time,  and  the  face  became 
deeply  cyanosed.  Later,  respiration  became  irregular, 
slow,  and  Cheyne-Stokes  in  character,  and  the  pulse 
slow  and  full.  This  seizure  lasted  one  and  a  half 
minutes,  but  she  was  no  sooner  out  of  one  than  she 
was  seized  by  another  of  greater  duration  and  intensity 
than  the  first.  These  attacks  continued  in  rapid  suc- 
cession, each  one  growing  more  severe  until  the  fifth 
occurred  about  2  p.m.,  when  respiration  ceased.  The 
heart  continued  to  beat  for  several  minutes  while  arti- 
ficial respiration  was  kept  up.  When  she  died  the  face 
was  deeply  cyanotic. 

The  autopsy  was  made  three  and  a  half  hours  after 
death  by  Drs.  McNaught  and  Hopkins.  The  vessels 
and  membranes  of  the  brain  presented  a  normal  ap- 
pearance. The  cortex  and  white  substances  of  the 
brain  showed  nothing  pathologic.  The  lateral  ventri- 
cles were  distended  by  about  four  ounces  of  a  straw- 
colored,  watery  fluid.  The  left  hemisphere  of  the 
cerebellum  was  apparently  about  twice  as  large  as  the 
right.  The  increase  in  size  was  apparently  due  to 
fluid  in  the  posterior  portion  of  the  left  hemisphere, 
while  the  anterior  portion  seemed  to  be  nearly  normal, 
and  no  undue  pressure  appeared  to  be  exerted  on  the 
pons  or  medulla.  On  cutting  into  the  left  hemisphere 
of  the  cerebellum  a  tumor  was  found  about  three- 
fourths  of  an  inch  in  diameter  in  its  extreme  posterior 
tip.  The  growth  was  hard  in  one  portion,  while  in 
another  two  or  three  small-sized  cysts  containing  a 
gelatinous  fluid  were  found.  Connected  with  this 
growth  was  a  large  cyst  two  or  three  inches  in  diameter 
and  extending  from  near  the  posterior  portion  of  the 
cerebellum  to  within  one-half  or  three-fourths  of  an 
inch  of  its  anterior  portion,  containing  a  thin,  straw- 
colored,  watery  fluid,  with  here  and  there,  and  espe- 
cially lying  against  the  walls  of  the  cyst,  some  rather 
thick  gelatinous-like  substance.  The  cyst-wall  was 
quite  thick,  well  defined,  tough  and  apparently  fibrous 
in  character. 

Microscopic  Appearance.^ — "  The  tumor  consisted  of 
two  portions — one,  the  external,  hard  and  alrnost 
fibrous,  and  the  other  softer.  The  internal  portion 
was  toward  the  cyst.  At  the  sides  passing  into  the 
cerebellar  tissue  the  growth  was  infiltrating  in  char- 
acter. The  soft  portion  varied  somewhat  from  the 
mere  gliomatous  and  the  more  distinctly  sarcomatous 
structure.  In  parts  there  was  a  marked  proliferation 
both  of  the  endothelium  and  the  adventitia  of  the 
smaller  blood-vessels,  a  new  formation  of  capillaries, 
to  such  an  extent  as  to  give  the  appearance  of  an 
angioma.  Many  of  the  blood-vessels  were  widely  di- 
lated, and  there  had  been  hemorrhages  in  parts,  with 
breaking  down  of  tissue  and  the  formation  of  small 
cysts.  The  wall  of  the  large  cyst  was  distinctly 
fibrous  in  character." 

Simple  non-parasitic  cysts  of  the  brain  are  most  com- 
monly the  result  of  acute  destructive  lesions,  usually  of 
vascular  origin,  such  as  hemorrhage  or  arterial  occlu- 
sion ;  the  effused  blood  or  disintegrated  nerve  elements 

'  By  Dr.  H.  C.  Crouch. 


having  been  removed,  the  cavity  becomes  a  receptacle 
into  which  the  watery  portion  of  the  blood  finds  access. 
Such  cysts  are  often  irregular  in  their  outlines,  and  the 
wall  may  not  be  well  defined.  Distinct  cysts  of  a  regu- 
lar shape  and  with  firm  fibrous  walls  sometimes  form  in. 
connection  with  traumatic  injuries  of  the  membranes- — 
a  beautiful  example  of  which  I  have  recently  observed 
in  consultation  with  Dr.  McNaught.  It  occurred  from 
a  blow  received  on  the  head  nearly  thirty  years  before, 
and  gave  rise  to  headache,  mental  disturbance,  and 
epileptic  seizures,  which  were  relieved  on  removal  of 
the  cyst.  Tumor,  especially  the  glioma  or  sarcoma,  of 
the  brain  may  contain  several  small  cysts,  or  a  large 
cyst,  as  in  the  case  just  reported,  may  be  connected 
with  a  small  tumor.  Such  cysts  have  their  origin  most 
probably  in  the  results  of  changes  which  take  place  in 
the  growth,  and  after  they  attain  a  certain  size  they 
become  much  larger  than  the  tumor  from  the  disten- 
tion of  the  cyst-wall  by  means  of  the  watery  portion  of 
the  blood.  In  the  present  instance  careful  microscop- 
ical search  was  made  for  granular  and  broken-down 
pus  corpuscles,  as  trauma,  distant  suppuration,  and 
otorrhoea,  all  causes  of  abscess  of  the  brain,  had  been 
experienced  by  the  little  sufferer. 

The  diagnosis  was  a  most  difficult  and,  as  proved  by 
the  autopsy,  an  unattainable  problem — for  me,  at  least. 
The  histpry  of  the  seizures,  preserved  consciousness, 
talking,  throwing  the  arms  wildly  around  without  dis- 
tinct clonic  convulsive  movements,  and  opisthotonus, 
at  first  suggested  hysteria,  but  this  was  easily  excluded 
by  the  optic-nerve  atrophy  and  vascular  changes  in  the 
fundi.  If  these  had  not  been  sufficient  to  enable  me 
to  diagnosticate  an  organic  lesion,  the  attacks  that  I 
witnessed  would  have  been  ample  evidence  of  organic 
change.  They  were  typical  of  irritation  in  the  pos- 
terior cerebral  fossa,  especially  around  the  pons  and 
medulla.  The  posterior  neck  muscles  were  as  rigid  as 
cords,  .the  head  was  retracted,  the  spine  arched  back- 
ward, the  masseters  were  at  times  firmly  contracted,  so 
that  when  she  attempted  to  speak,  her  teeth,  which  she 
could  not  separate,  were  simply  uncovered  by  the  lips. 
The  arms,  rigidly  extended,  were  thrown  wildly  around 
with  shock-like  convulsive  movements. 

Three  morbid  processes  were  considered  in  the  diag- 
nosis, viz.  :  abscess,  tumor,  and  the  results  of  an  old 
basilar  meningitis.  The  history  of  the  bilateral  otor- 
rhoea, with  a  very  offensive  discharge,  occurring  about 
the  time  of  her  first  nervous  symptoms,  and  attended 
by  a  convulsion  ;  the  suppuration  in  the  right  groin, 
the  origin  of  which  could  not  be  determined,  as  there 
had  never  been  any  further  evidence  of  caries  of  the 
spine  ;  and  a  blow  to  the  head  received  just  previously 
to  the  convulsive  seizure  becoming  frequent,  from  an 
etiological  stand-point  were  about  as  strong  evidence 
in  favor  of  cerebral  suppuration  as  one  expects  to  find. 
The  subnormal  temperature  during  the  first  few  days 
of  my  observation  of  the  case  was  also  in  favor  of 
chronic  cerebral  abscess.  The  otorrhoea  had  ceased 
for  a  period  of  nearly  ten  years,  and  during  this  time 
the  child  had  never  complained  of  pain  in  the  ears.  It 
seemed  to  me  that  if  the  little  patient  was  suffering 
from  abscess  of  the  brain  the  probabilities  were  against 
the  ears  having  been  the  source  of  the  septic  poison, 
as  a  chronic  abscess  from  ear  infection  rarely  runs  a 
very  prolonged  course.  Headache  is  common  to  all 
of  the  pathological  processes  under  discussion.  The 
optic-nerve  atrophy  without  any  swelling  of  the  disks 
was  in  favor  of  old  meningitis  and  against  the  pressure 
of  a  growth  or  an  abscess.  I  felt  inclined  to  exclude 
chronic  suppuration,  but  I  admitted  to  the  physician, 
Dr.  McNaught,  wth  whom  I  saw  and  studied  the  case, 
that  I  had  not  sufficient  reasons  to  be  positive  in  my 
opinion. 

Between  meningitis  and  tumor  I  could  not  decide. 
One  of  these  morbid  processes  would  have  accounted 
for  some  of  the  symptoms,  while  certain  ones  were 
more  common  to  the  other.     The  almost  total  loss  of 


MEDICAL   RECORD. 


[August  17,  1895 


sight  with  optic-nerve  atrophy,  and  the  seizures  at- 
tended with  opisthotonus,  rigidity  of  the  masseters, 
tonic  extensor  spasms  of  the  extremities,  especially  the 
superior  ones,  and  shock-like  movements  of  the  arms  are 
found  in  meningitis  in  the  posterior  fossa  when  the  sur- 
face of  the  pons  is  irritated,  and  not  in  tumor  as  a  rule 
unless  meningitis  is  also  present.  So  far  the  symptoms 
and  the  theory  of  meningitis  harmonized,  but  I  was  at 
a  loss  to  account  for  the  other  cranial  nerves  than  the 
optic  escaping.  That  the  child  at  times  should  feel 
quite  well,  be  entirely  free  from  headache  or  any  dis- 
comfort, and  that  there  should  be  no  rigidity  of  the 
posterior  neck-muscles  except  during  the  paroxysms, 
seemed  to  me  inconsistent  with  an  old  meningeal  exu- 
date in  the  posterior  fossa.  A  tumor  in  the  cerebellum 
so  situated  as  to  produce  remittent  pressure  on  the 
pons,  with  distinct  paroxysms  of  increasing  pressure,  is 
common  to  the  experience  of  everyone  who  has  studied 
and  observed  cerebellar  growths,  but  for  the  pressure 
symptoms  to  be  apparently  completely  intermittent, 
and  to  return  with  as  much  regularity  as  epileptic  seiz- 
ures, and  to  consist  solely  of  epileptoid  phenomena 
without  mental  dulness  or  loss  of  consciousness,  was 
new  in  my  experience. 

I  confessed  my  inability  to  make  even  a  problem- 
atic diagnosis,  and  advised  the  mother  to  take  her 
child  home,  as  I  could  not  recommend  an  op^ation  for 
her  relief,  but  about  an  hour  before  the  time  the  mother 
had  set  to  leave  the  hospital  the  child  was  seized  with 
a  series  of  convulsions  which  proved  fatal  within  two 
hours. 

While  the  body  was  on  the  post-mortem  table  I  was 
asked  by  Drs.  McNaught  and  Hopkins,  before  they 
began  their  examination,  for  my  diagnosis.  I  said  that 
a  double  lesion,  a  tumor  in  one  hemisphere  of  the  cere- 
bellum, and  an  old  meningeal  exudate  would  explain 
all  the  symptoms  observed  during  life,  but  not  the  ab- 
sence of  others. 

In  the  light  of  the  autopsy  which  revealed  the  pres- 
ence of  a  large  cyst  and  a  small  tumor  in  the  posterior 
three-fourths  of  the  left  cerebellar  hemisphere,  are  the 
symptoms  explicable  ?  It  is  possible  that,  owing  to 
the  watery  contents  of  the  cyst,  the  pressure  exerted 
by  the  cyst,  after  it  became  chronic,  on  the  adjacent 
structures  was  not  as  great  as  results  from  a  more  solid 
and  unyielding  tumor,  so  that,  while  there  might  have 
been^a  papillitis  during  the  early  stage  of  the  growth, 
the  lessened  pressure  on  the  formation  of  the  cyst  and 
the  breaking  down  of  the  growth  allowed  this  to  sub- 
side with  the  resulting  atrophy  of  the  optic  nerves,  and 
time  had  permitted  all  intra-ocular  exudates  to  be  ab- 
sorbed. We  know  that  a  growth  in  the  cerebellum, 
from  its  effects  upon  the  circulation,  especially  in  the 
veins  of  Galen  and  adjacent  veins  and  sinuses,  disturbs 
the  function  of  the  pons  and  medulla,  usually  to  a  slight 
extent  continuously,  and  when  it  has  reached  sufficient 
size  to  exert  pressure  on  the  respiratory  and  neighbor- 
ing centres,  by  paroxysms,  threatening  life  by  increased 
pressure  wliich  probably  results  in  temporary  oedema 
of  the  parts. 

In  the  case  of  a  cyst  with  yielding  contents,  which 
may  vary  in  quantity  from  time  to  time,  the  pressure 
symptoms  probably  may  become  intermittent.  The 
peculiar  tetanic  spasms  were,  most  likely,  due  to  tem- 
porary irritation  of  the  pons  and  medulla. 
•  With  the  information  gained  from  the  clinical  and 
pathological  observations  of  this  case,  could  error  be 
prevented  in  the  diagnosis  of  a  somewhat  similar  one  ? 
If  a  large  cyst  of  the  cerebellum  is  attended  with  more 
varying  pressure-symptoms  than  a  tumor,  a  problematic 
diagnosis  might  be  ventured,  and  it  might  be  correct  or 
it  might  not.  The  only  unilateral  symptom  in  the  case 
was  the  tendency  of  the  right  arm  to  become  a  little 
more  rigid  than  the  left,  with,  at  times,  a  turning  of  the 
head  and  eyes  to  the  right,  but  this  was  inconstant  and 
of  no  localizing  value  in  determining  which  hemisphere 
of  the  cerebellum  was  affected.     Had  it  been  possible 


to  localize  accurately  the  lesions,  the  tumor,  in  all  proba- 
bility, could  have  been  removed,  the  contents  of  the 
cyst  evacuated,  and  the  life  of  the  patient  saved. 

A  careful  study  of  the  case  just  reported  demon- 
strates how  meagre  and  unsatisfactory  are  the  symp- 
toms of  an  extensive  lesion  in  one  lateral  hemisphere 
of  the  cerebellum,  and  that  ataxia  from  lesions  of  this 
portion  of  the  brain  probably  only  occur  when  they 
are  situated  so  as  to  exert  pressure  on  the  pons,  usu- 
ally through  the  medium  of  the  middle  lobe  of  the 
cerebellum. 


THE    NEURO-CHEMICAL    ASPECT    OF    DIA- 
BETES. 

By   C.    C.   THAYER,   M.D., 

CLIFTON    SPRINGS    N.  V. 

The  etiology  of  diabetes,  after  two  centuries  of  scien- 
tific investigation,  remains  unsettled,  and  if  compre- 
hended by  any,  multiplied  hypotheses  excludes  una- 
nimity. By  a  physician  familiar  with  diabetes  these 
diversified  opinions  are  charitably  considered,  for  while 
diabetes  proper  exhibits  some  uniform  and  diagnostic 
symptoms,  otherwise  it  appears  differently  in  different 
cases  and  acts  differently  under  the  same  treatment. 
The  neurotic,  the  dietetic,  the  traumatic,  and  the  toxic 
are  varieties  demanding  appropriate  consideration. 

Its  treatment,  hygienic  and  therapeutic,  is  also  un- 
settled, like  its  pathology.  A  restricted  diet  is  best  for 
some,  a  mixed  diet  for  others,  a  warm  climate  for  one, 
a  cold  climate  for  another.  Codeia  works  a  charm  in 
one  and  a  harm  in  another.  Bromide  of  arsenic,  re- 
ported by  Clemens,  antipyrin  by  Robin,  iodine  by 
Seagen,  ergot  by  Tyson,  and  alkalies  by  Miathe  and 
Dougherty,  have  received  more  or  less  praise,  and  when 
we  have  exhausted  materia  medica  we  can  recommend 
a  change  of  climate.  Experimentation  is  as  far  as  we 
have  advanced  in  the  treatment  of  diabetes,  and  as  far 
as  we  can  advance  till  its  etiology  is  understood.  The 
triangular  "diabetic  area"  is  too  limited,  and  irritation 
of  the  calamus  scriptorius  too  infrequent,  to  account  for 
the  origin  and  cause  of  this  complex  disease. 

Saccharine  urine  is  produced  by  a  variety  of  causes, 
and  without  diabetes.  Inordinate  eating,  drinking, 
worry  and  watching,  bullet  and  sabre  wounds  in  vari- 
ous parts  of  the  body,  have  produced  sugar  in  the  urine. 
Diabetes  cannot  be  scientifically  diagnosed  from  sugar 
in  the  urine  alone. 

Ruling  out  in  this  paper  all  cases  of  glycosuria  of 
dietetic,  traumatic,  and  toxic  origin,  allow  me  to  present 
in  brief  six  cases  which  fairly  represent  the  whole  num- 
ber treated,  with  experiments  and  conclusions. 

Uniformity  of  diabetes  symptoms  justifies  their  omis- 
sion and  description  here. 

Case  I. — Female,  aged  fifty-four,  naturally  strong, 
weight  130  pounds.  After  her  husband's  death  she 
was  worn  with  grief  and  rapidly  failed,  with  diabetes. 
Six  months  later  she  came  under  our  care,  then  weigh- 
ing 106  pounds,  passing  9  ounces  of  urine  and  2):^ 
ounces  sugar  in  twenty-four  hours.  She  was  put  on 
codeia,  J4  grain  three  times  per  day,  and  gradually  in- 
creased till  she  had  taken  iS  grains  daily,  when  it  was 
exchanged  for  arsenic.  When  she  was  taking  3  grains 
daily  she  passed  5  ounces  of  urine  with  i  '4  ounce  of 
sugar.  In  this,  as  in  other  cases,  have  noticed  that  the 
maximum  benefits  of  codeia  were  reached  at  its  first 
physiological  effects,  and  that  beyond  this  it  did  more 
harm  than  good.  When  taking  16  grains  for  twelve 
hours  the  specific  gravity  was  just  1000,  then  rose  to 
1024,  then  to  1036.  Refusing  food  and  medicine,  she 
died  three  weeks  after  with  diaceturia. 

Case  II. — Male,  aged  seventy-four  ;  nervous,  bilious 
temperament,  and  quite  feeble,  and  was  passing  7  ounces 
of  urine  and  2'^^  ounces  of  sugar  daily.  Put  him  on 
electric  salt  and  stimulating  baths,  with  massage  and 


August   17,    1895] 


MEDICAL   RECORD. 


231 


oil  rubs,  taraxacum,  gentian,  and  phosphoric  acid,  with 
alkalies,  citrate  and  bicarbonate  of  potassium,  and  bo- 
racic  acid,  while  we  crowded  him  with  a  mixed  diet. 
The  urine  becoming  nearly  normal,  he  prepared  to  go 
home.  Having  acorn  on  his  toe,  he  applied  some  pat- 
ent corn  cure,  which  resulted  in  gangrene  and  death. 

C.4SE  III. — Male,  aged  forty-seven  ;  bilious  tempera- 
ment, passing  7  ounces  of  urine  with  2^  ounces  of  sugar 
daily.  Put  him  on  a  forced  mixed  diet,  with  milk,  tar- 
axacum, gentian,  and  phosphoric  acid,  with  alkalies  and 
baths  as  in  Case  II.,  and  after  six  weeks  discharged  him 
cured. 

Case  IV.  —  Male,  aged  fifty-two.  Had  lost  48 
pounds  of  flesh  and  was  passing  10J2  ounces  of  urine 
and  4  ounces  of  sugar  daily.  Put  him  on  an  absolute 
skimmed-milk  diet,  four  quarts  daily  ;  bro-arsenic  and 
alkalies,  central  galvanism,  salt  rubs,  cold  sp.  douche, 
and  massage.  After  eight  weeks  was  discharged  cured, 
and  has  done  a  large  pastoral  work  for  ten  years  since. 

Case  V. — Female,  aged  forty-two  :  bilious  tempera- 
ment, and  had  malarial  fever  two  years  before  I  saw 
her.  She  was  passing  lo.ounces  of  urine  and  3  ounces 
of  sugar  daily.  Put  her  on  meat,  milk,  and  salads  and 
four  quarts  of  water,  baths,  wheat  phosphoric  alkalies, 
blue-mass,  ferri.-chl.  et  quinea.  She  gained  thirty-two 
pounds  and  returned  home  cured. 

Case  VI. — A  daughter  of  our  vice-consul  of  Aintab, 
Turkey,  aged  eighteen  ;  naturally  strong  and  ruddy. 
One  month  after  her  decline  I  first  saw  her,  when  her 
mother  told  me  "  she  was  passing  a  pail  of  water  daily." 
I  could  not  there  make  a  quantitative  test  of  the  sugar, 
but  it  was  heavy.  Feeling  impotent  to  care  for  the 
case,  I  sent  her  to  our  Beirut  Medical  College,  but  she 
was  soon  returned  with  an  unfavorable  diagnosis. 
Another  opportunity  for  experiment.  Put  her  on  an 
absolute  meat  and  salad  diet,  with  plenty  of  water,  but 
had  to  lock  her  in  a  room  with  barred  windows,  and 
her  cries  for  bread  were  pitiful  ;  but  so  long  as  the 
urine  seemed  to  improve,  the  parents  consented  to  the 
vigorous  treatment.  After  three  weeks  she  was  re- 
leased from  her  incarceration,  and  after  eight  weeks 
she  was  pronounced  cured  ;  and,  having  recovered 
from  her  great  emaciation,  she  was  taken  to  the 
Aintab  Female  Seminary  by  her  parents  and  "  pre- 
sented "  to  the  mission  as  a  thank-offering,  and  as  the 
first  acquisition  from  this  large  Armenian  family  for 
twelve  years. 

We  often  find  diabetes  associated  with  epilepsy, 
chorea,  lithajmia,  and  malarial  poisoning,  and  attention 
has  been  called  to  a  family  type,  a  neurotic  inheri- 
tance which  characterizes  a  certain  class  of  patients 
and  accounts  for  many  objective  symptoms  ;  but  amore 
numerous  class  exhibits  disturbances  of  nutrition,  and 
these  may  be  divided  into  the  obese  and  emaciated. 
In  the  obese,  hepatic,  glycogenic  abnormalities  may 
account  for  the  limited  amount  of  sugar,  but  in  the 
rapidly  emaciating,  the  entire  cell  structure  seems 
besieged  with  a  consumption  or  retrograde  meta- 
morphosis or  chemical  degeneration,  the  cause  of 
which  is  not  clear,  whether  chemical  or  neurotic,  irrita- 
tive or  paralytic.  To  me  the  combination  of  all  four 
is  possible,  feasible,  and  comprehensive  as  the  etio- 
logical basis  of  this  complex  condition,  giving  rise  to 
saccharine  diabetes,  and  late  physiologists  promote 
this  view  in  part. 

It  is  the  concensus  of  opinion  among  modern  physi- 
ologists that  the  carbohydrates  are  cell-builders  ;  that 
by  transformation  they  produce  sugar,  and  the  same 
group  of  sugar  as  we  find  in  saccharine  diabetes  ;  that 
glycogen,  prominent  among  the  carbohydrates,  is  widely 
and  generously  distributed  throughout  the  body,  in  the 
cells  of  the  liver,  muscles,  embryonic  tissue,  white  cor- 
puscles, etc.  ;  that  glycogen  leaves  the  liver  as  sugar, 
and  that  the  quantity  and  destination  of  the  glycogen 
depends  on  the  character  of  the  diet  and  a  certain 
nerve  stimulus.  Glycosuria,  however  limited,  is  never 
insignificant,  but  points  to  a  pathological  condition. 


If  there  is  deficiency  in  the  selective-cell  energy  to 
reconstruct  from  the  carbohydrates  of  the  blood- 
plasma,  then  we  have  a  disassimilation,  a  chemical 
metabolism  resulting  in  sugar  and  tissue  degeneration. 
If  there  is  an  abortion  of  the  plasma,  or  a  pathological 
condition  rendering  the  plasma  unsuitable  for  cell  con- 
struction, we  have  sugar  and  tissue  degeneration. 

In  short,  the  hypothesis  to  account  for  the  excess  of 
sugar  in  the  urine  is  a  pathological  condition,  a  catabol- 
ism,  or  retrograde  metamorphosis  of  the  cell  structure, 
or  the  cell  plasma.  And  the  hypothesis  to  account  for 
the  excess  of  urine  is  an  aggravating  presence  of  the 
sugar  and  a  perversion  of  the  secretory  nerves. 

In  Foster's  "  table  of  the  relation  of  the  secretion  of 
urine  to  arterial  pressure  "  he  says  :  "  The  division  of 
the  renal  nerves  produces  polyuria,  and  division  of  the 
renal  nerves  and  stimulation  of  the  spinal  cord  below 
the  medulla  produces  greater  polyuria."  We  have  seen 
paralysis  do  the  same. 

The  most  successful  treatment  also  has  been  along 
the  line  of  neuro-chemical  indications,  viz.,  nerve  res- 
toration and  cell  reconstruction.  Our  best  treatment 
has  been  an  absolute  diet,  either  of  milk,  three  quarts, 
or  two  quarts  with  six  or  more  raw  eggs  daily,  or  meat 
varied  in  form,  with  salads  and  three  to  four  quarts  of 
water  ;  electro-thermal  and  salt  baths ;  central  gal- 
vanism and  faradism  ;  cold  spinal  douche  from  the 
nozzle  attached  to  a  fountain  or  tank,  one  minute 
morning  and  evening ;  the  needle  bath  ;  oil  and  mas- 
sage ;  alkalies,  wheat  phosphates,  and  strychnine. 


LEONARD'S    METHOD    FOR    DETECTING 
CELL-MOTION. 

By  W.  MOSER,  M.D., 


PATHOLOGIST  TO   ST.   CATHARINE'S   HOSPIT 


BROOKLYN,   N. 


The  essentials  to  this  method  are  :   i.  Warm  stage  ;  2, 
photo-micrograph. 

It  has  long  since  been  demonstrated  that  if  the  white 
blood-corpuscle  be  kept  at  about  the  temperature  of 
the  living  body  on  a  warm  stage — an  essential  acces- 
sory to  the  microscope — it  will  exhibit  amoeboid  motion. 
And  since  the  discovery  of  the  plasmodium  malarise  by 
Laveran,  the  warm  stage  has  been  frequently  used  to 
detect  the  varied  movements  of  this  parasite.  But 
only  recently  has  it  come  into  practical  use  in  studying 
the  movements  of  the  protoplasm  of  the  red  blood- 
corpuscle,  as  well  as  the  varied  phases  of  karyokinesis 
and  karyolysis  affecting  its  contained  nucleus.  In- 
deed, when  we  compare  the  "  rosette-shape  "  exhibited 
in  karyokinesis  with  the  same  shape  exhibited  as  part 
and  parcel  of  the  life  history  of  the  plasmodium  malaria, 
the  resemblance  becomes  striking,  and  the  two  might 
be  confounded.  A  close  observation  of  the  cells,  or 
other  cells  in  the  field,  with  the  presence  or  absence  of 
pigment,  ought  to  render  a  discrimination  quite  easy. 
Leonard '  studied  the  amoeboid  motion  of  the  red 
blood-corpuscle  in  blood  taken  from  a  case  of  malaria. 
He  had  the  cell  in  the  field  half  an  hour,  and  re- 
produced by  means  of  the  photo-micrograph  the 
different  movements  which  had  taken  place  in  the 
cell.  In  the  same  manner  he  endeavors  to  show  that 
diapedesis  of  the  red  blood-corpuscle  is  dependent 
upon  an  inherent  movement  of  the  cell  itself.  The 
writer  is  convinced  that  this  method  is  an  ideal  one, 
and  that  the  observations  made,  and  the  care  employed 
in  their  execution,  reflect  great  credit  upon  its  origina- 
tor. 

158  Ross  Street.  

Trinitrine,  or  nitroglycerine,  has  been  recommended 
as  an  anti-neuralgic,  especially  in  cases  of  inveterate 
sciatica. 

'  A  New  Method  for  Detecting  Cell  Motion,  American  Journal  of 
the  Medical  Sciences,  June,  1895. 


MEDICAL   RECORD. 


[August  17,  1895 


Cardiac  Irregularity  in  Childhood.  —  Writing  on  this 
subject  Professor  Heubner  excludes  cases  of  arhyth- 
mia  due  to  tubercular  meningitis  and  to  pronounced 
cardiac  inflammation.  He  recognizes  eight  classes 
of  cardiac  irregularity  :  i.  The  simplest  case  is  that 
of  irregularity  after  poisoning.  An  instance  is  quoted 
of  a  child  who  had  eaten  stramonium-seeds  ;  on  the 
third  day  there  was  decided  irregularity  of  the  pulse, 
which  disappeared  on  convalescence.  Large  doses 
of  digitalis  and  of  opium  have  been  noticed  to  pro- 
duce the  same  effect.  2.  Closely  allied  are  cases 
of  disturbed  rhythm  from  digestive  troubles.  Re- 
cent investigations  suggest  in  many  severe  forms  of 
indigestion  the  circulation  of  some  poison  in  the 
blood  —  a  form  of  auto-intoxication.  He  gives  an 
example  in  a  child  of  six  years  suffering  from  gastric 
disorder,  who  began  to  show  cerebral  symptoms,  vom- 
iting, etc.  There  were  rise  of  temperature,  very  irregu- 
lar, intermitting  pulse,  retraction  of  the  head,  and 
drowsiness.  It  was  regarded  as  a  case  of  auto-intoxi- 
cation, and  this  was  confirmed  by  the  favorable  issue 
and  the  appearance  of  acetone  in  large  amounts  in  the 
urine.  Another  case  showed  a  slow,  unequal  heart- 
beat. 3.  Cardiac  irregularity  may  be  met  with  in  ab- 
dominal affections  where  no  grounds  exist  for  consider- 
ing it  due  to  poison.  A  case  of  appendicitis,  in  a  girl 
of  eight  years,  is  quoted  ;  decided  intermittency  of 
pulse  was  present,  and  also  on  a  second  occasion  after 
an  attack  of  indigestion.  4.  Arhythmia  in  the  course 
of  infectious  diseases  is  divided  by  Heubner  into  two 
groups — (a)  that  during  the  development  and  height 
of  the  disease  ;  (d)  that  observed  during  convalescence. 
The  first  group  is  much  the  rarer.  Many  observers 
mention  it  in  typhoid  fever,  but  Heubner  has  had  no 
experience  of  it.  The  second  group  is  well  recog- 
nized. In  diphtheria  it  is  often  present,  and  also  not 
infrequently  in  scarlet  fever,  of  which  several  instances 
are  quoted  ;  measles  and  croupous  pneumonia  fre- 
quently give  rise  to  it,  and  sometimes  it  has  been  ob- 
served by  the  author  late  in  typhoid  fever.  5.  In 
anajmic  and  nervous  children  irregularity  is  frequently 
noted,  and  is  apt  to  lead  to  a  false  diagnosis  :  in 
rachitic,  feeble  children,  from  two  to  four  j'ears  old, 
such  irregularity  is  too  readily  accepted  as  an  indica- 
tion of  the  imminence  of  tubercular  meningitis.  6. 
Intestinal  parasites  are  said  to  cause  irregularity  of 
pulse,  but  no  evidence  of  it  has  occurred  in  the  author's 
experience.  7.  Under  certain  physiological  conditions 
irregularity  may  be  observed,  as  in  emotional  states, 
sometimes  during  sleep,  and  occasionally  following  a 
warm  bath,  with  subsequent  cooling.  8.  Da  Costa  has 
described  a  disturbance  of  rhythm  which  appears  to  be 
the  only  element  of  disease,  the  child  seeming  otherwise 
well,  and  all  the  other  causes  being  satisfactorilv  ex- 
cluded. During  febrile  attacks  the  irregularity  disap- 
peared. Discussing  the  mechanism  of  irregularity 
under  these  various  conditions,  the  author  refers  to 
nerve-influence — a  disturbance  of  the  regulating  nerves 
of  the  heart.  This  is  the  explanation  accepted  for 
tubercular  meningitis,  increased  intracranial  pressure 
affecting  the  centres  in  the  medulla.  Irritation  of 
peripheral  ner\es,  such  as  the  splanchnic  depressor, 
disturbs  rhythm,  and  would  account  for  a  continuance 
of  such  a  symptom  with  nausea  and  vomiting.  When 
due  to  poisoning  the  explanation  is  more  difficult  ;  but 
it  is  probably  a  result  of  action  upon  the  nerve-centres 
or  the  cardiac  muscle.  The  cause  of  arhythmia  in 
ancemic,  rapidly  growing  children  is  involved  in  doubt, 
though  the  suggestion  of  a  relatively  small  arterial  sys- 
tem is  founded  on  experimental  evidence.  The  treat- 
ment of  cardiac  irregularity  in  children  requires  a 
careful  consideration  of  causes.  If  reflex,  the  irritant 
should  be  removed.     When  due  to  poison,  the  stomach 


and  intestines  should  be  emptied  and  a  plentiful  supply 
of  water  should  be  given  to  cleanse  out  the  system. 
The  idiopathic  form  requires  moderate  movement,  light 
gymnastics,  frequent  small  meals,  and  sea-baths. — 
Zeitschrift  fiir  Kliiiische  Medicin. 

The  Diagnosis  of  Intestinal  Baptnre. — Dr.  Bemdt 

discusses  the  question  of  intestinal  rupture  from  the 
diagnostic  point  of  view,  emphasizing  not  only  the 
difficulty  of  establishing  the  certainty  of  a  lesion  of  the 
gut  wall,  but  also  the  importance  of  so  doing  in  order 
to  enable  the  surgeon  to  undertake  an  early  laparotomy. 
The  effects  of  a  severe  contusion  are  very  similar  to 
those  produced  by  rupture,  but  the  author  points  out 
that  while  vomiting  is  present  in  both  cases,  its  nature 
varies  so  much  as  to  constitute  it  an  important  element 
in  diagnosis.  In  simple  cases  of  shock  the  vomiting 
is  reflex  in  character,  and,  although  repeated  two  or 
three  times,  is  never  very  serious.  On  the  other  hand, 
where  the  intestine  is  ruptured,  it  is  due  to  the  extrava- 
sation of  the  gaseous  and  fluid  contents  of  the  bowel 
into  the  peritoneal  cavity,  and  is  then  always  of  a  per-- 
sistent  and  intractable  character.  Sundry  recent  in- 
vestigations are  added  in  which  this  opinion  has  been 
strikingly  confirmed.  —  Deutsche  Zeitschrift  fiir  Chi- 
rurgie. 

The  Influence  of  Alcohol  on  Sexual  Perversions,  Epi- 
lepsy, and  other  Psychical  Anomalies. — Dr.  Forel  calls 
attention  to  the  fact  that  the  inordinate  use  of  alcoholic 
beverages  not  only  leads  to  the  development  of  the  or- 
dinary alcoholic  psychoses,  especially  delirium  tremens, 
but  it  also  plays  a  prominent  role  in  psycho-pathology 
in  two  different  ways  :  Firstly,  the  hereditary  patho- 
logical predisposition  of  certain  persons  is  such  that 
they  cannot  indulge  in  alcohol  moderately,  but  become 
dipsomaniacs  at  once,  if  they  do  not  abstain  all  their 
lives.  Secondly,  alcoholic  intoxication  either  stimu- 
lates or  develops  directly  any  latent  psycho-patholog- 
ical germs  that  might  otherwise  have  remained  latent. 
In  the  current  casuistic  of  sexual  perversions  the  prin- 
cipal factors  enumerated  are  congenital  and  acquired 
dispositions,  acquired  nervous  or  mental  disorders,  and, 
in  some  cases,  bad  habits.  There  is  no  mention  of 
alcohol  as  a  causative  factor.  Forel  observed  cases  in 
which  the  use — or  abuse — of  alcohol  was  a  most  prom- 
inent feature,  and  enumerates  divers  illustrative  his- 
tories. It  is  an  established  fact  that  epileptics  stand 
alcohol  very  badly,  and  when  intoxicated  are  especially 
dangerous.  There  is  also  an  alcoholic  epilepsy,  the 
subjects  having  fits  only  when  intoxicated.  Forel  also 
alludes  to  the  "  pathological "  intoxications,  followed 
by  amnesia,  and  concludes  that  nearly  every  psychosis 
is  aggravated  by  the  use  of  alcohol.  Other  psychoses 
which  are  either  caused  or  kept  up  by  alcohol  are,  for 
instance,  alcoholic  mania,  melancholia,  pseudo-paraly- 
sis, incurable  secondary  dementia,  acute  and  chronic  hal- 
lucinary  .folly,  etc.  Forel  observed  many  cases  cured 
by  abstinence,  and  considers  indulgence  one  of  the 
greatest  obstacles  in  the  radical  cure  of  morpho-mania. 
He  had  always  observed  that  the  excitement  of  the  in- 
sane in  asylums  was  always  greater  after  entertainments 
at  which  wine  or  beer  were  served.  At  Biirgholzli,  of 
which  Forel  is  director,  alcoholic  beverages  have  been 
substitued  by  milk  and  lemonade.  He  commends  fol- 
lowing the  example  of  the  London  asylums  and  that  of 
Krapelin,  in  Heidelberg,  by  prohibiting  the  use  of  al- 
coholics.— Journal  of  Xen\ius  and  Mental  Disease. 


Antipyrin  as  a  Haemostatic  and  Analgesic.  —  Dr. 
Roswell  Park  advocated  the  use  of  antipyrin  as  a 
hsemostatic  in  surgery.  It  checks  oozing,  and  is  unir- 
ritating  and  slightly  antisepric.  A  four  or  five  per 
cent,  solution  should  be  used.  If  sprayed  into  the 
nose  it  relieves  headache,  coryza,  etc.,  and  the  spray 
also  relieves  acute  pharyngitis. 


August  17,  1895] 


MEDICAL    RECORD 


233 


Medical   Record: 

A  Weekly  yoiirnal  of  JMedtcine  attd  Siirgery. 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 

WM.  WOOD  &  CO.,  43/45,  &.  47  East  Tenth  Street 


NcAW  York,  August  17,  1895. 


SEROTHERAPY  OF  TYPHOID  FEYER. 

We  have  several  times  referred  to  the  attempts  made 
by  various  investigators  to  obtain  a  curative  serum  for 
typhoid  fever,  attempts  which  have  thus  far  resulted  in 
nothing  tangible. 

Typhoid  fever  would  appear,  however,  to  offer  an 
in^-iting  field  for  the  experimental  use  of  antitoxin,  for 
we  find  in  it  the  conditions  necessary  for  the  success- 
ful application  of  a  remedy  of  this  sort.  In  the  first 
place,  the  cause  of  the  disease  is  known,  and  this  cause 
is  active  in  many  of  the  lower  animals  as  well  as  in 
man.  Moreover,  typhoid  fever  in  all  probability  be- 
longs to  that  group  of  infectious  diseases  which  are 
self-limited,  a  cure  being  brought  about  by  an  immuni- 
zation of  the  system  effected  by  the  action  of  the  patho- 
genic bacillus,  and  the  immunity  so  acquired  is  perma- 
nent, or  at  least  of  long  duration,  a  second  attack  of 
the  disease,  after  the  period  of  relapses  is  past,  being 
an  exceedingly  rare  occurrence.  Finally,  and  this  is  a 
matter  of  very  great  importance  in  successful  sero- 
therapy, a  patient  with  typhoid,  fever  usually  comes 
under  treatment  before  the  disease  is  at  its  height. 

The  most  recent  experiment  in  the  use  of  antitoxin 
in  the  treatment  of  typhoid  fever,  and  one  that  .=eems 
to  give  more  promise  of  success  than  the  others  in 
this  direction,  is  related  by  Drs.  F.  Klemperer  and 
Ernest  Levy  in  the  Berliner  klinische  Wochcnschrift 
of  July  15,  1895.  After  some  unsatisfactory  attempts 
to  produce  a  curative  milk  by  inoculating  goats,  the 
authors  set  about  obtaining  an  antitoxic  serum.  For 
the  furnisher  of  this  serum  they  selected  the  dog, 
which  is  naturally  rather  rebellious  to  the  action  of  the 
typhoid  poison.  The  first  experiments  upon  animals 
seemed  to  demonstrate  that  this  serum  would  make 
the  recipient  immune  to  the  action  of  the  typhoid  ba- 
•cillus,  and  would  even  abort  the  disease,  if  employed 
a  not  too  long  time  after  infection. 

Up  to  the  time  of  the  publication  of  their  report  the 
authors  had  used  the  serum  in  but  five  cases  of  typhoid 
fever  in  the  human  subject.  Each  patient  received  an 
injection  of  20  c.c.  for  three  successive  evenings,  or 
60  c.c.  in  all.  All  the  patients  were  in  the  first  week 
of  the  disease.  The  injections  were  well  borne  and  no 
unpleasant  results  in  the  way  of  skin  eruptions  or  al- 
buminuria were  observed.  The  morning  remission  m 
the  temperature-curve  began  as  a  rule  on  the  third  day 
after    the  first  injection,  and  complete  apyrexia  was 


noted  by  the  end  of  the  second  or  beginning  of  the 
third  week.  In  one  case  there  was  a  slight  relapse  a 
week  after  the  subsidence  of  the  fever. 

All  the  cases  treated,  as  far  as  could  be  judged  from 
the  s)Tnptoms  and  temperature-curve  during  the  first 
week  before  the  injections  were  given,  were  mild  ones 
and  might  have  followed  the  same  favorable  course 
without  treatment.  The  authors  recognize  this  possi- 
bility and  make  no  undue  claims  for  their  remedy. 
The  experiments,  they  hold,  proved  only  two  things  : 
first,  that  the  serum,  if  it  is  not  curative,  at  least  does 
no  harm,  and  secondly,  that  it  does  not  cut  the  disease 
short,  but  possibly  hastens  its  course  and  induces  im- 
munity somewhat  earlier  than  the  disease  itself  would 
if  left  untreated. 

The  results  are  not  such  as  to  inspire  the  hope  of 
finding  a  specific  for  typhoid  fever,  but  if  it  be  found, 
on  further  trial,  that  the  course  of  the  disease  can  be 
hastened  and  its  dangers  averted  by  serotheraphy  we 
shall  at  least  have  gained  something.  But  five  cases 
prove  nothing,  and  until  the  serum  has  been  employed 
extensively  and  in  cases  of  all  degrees  of  severity  it 
will  be  impossible  to  predicate  anything  as  to  its  real 
value. 


THE  BRITISH  MEDICAL  ASSOCIATION. 

The  meeting  of  the  British  Medical  Association,  a  spe- 
cial report  of  which  appears  in  this  issue,  was  eminently 
successful  as  regards  attendance,  over  one  thousand 
members  being  present  at  the  opening  session.  This, 
however,  was  no  more  than  was  to  have  been  expected 
from  the  fact  that  the  meeting  was  held  in  London, 
which  contains  in  itself  many  more  than  that  number 
of  medical  practitioners. 

The  orations  were  by  men  of  the  first  rank,  whose 
efforts  were  worthy  of  themselves  and  of  the  audience 
to  which  they  were  addressed.  In  his  presidential  ad- 
dress Sir  J.  Russell  Reynolds  referred  to  a  prophecy 
made  by  Dr.  Parkes,  the  then  President  of  the  As- 
sociation, at  the  previous  meeting  in  London,  in  1873. 
In  speaking  of  Bright's  recognition  of  the  significance 
of  albuminuria,  and  of  Laennec's  introduction  of  aus- 
cultation as  an  aid  to  the  diagnosis  of  thoracic  affec- 
tions, Dr.  Parkes  made  the  prediction  that  these  two 
discoveries  marked  an  advance  in  the  science  of  medi- 
cine which  it  was  very  improbable  would  be  equalled 
in  the  present  century. 

Sir  William  Broadbent  gave  an  almost  new  presenta- 
don  of  the  hackneyed  theme  of  the  progress  of  medicine. 
Among  other  points  dwelt  upon  was  that  the  distinction 
between  the  art  and  the  science  of  medicine  was  rapidly 
becoming  narrower,  and  that  the  art  which  was  once  the 
all  in  medical  practice  was  fast  giving  way  to  the  sci- 
ence, although  the  latter  might  be  said  to  be  still  in  its 
infancy.  He  made  the  contention  that  the  best  physiolo- 
gist makes  the  best  pathologist,  and  the  best  pathologist 
the  best  physician,  a  saying  that  will  pass  as  a  neat 
epigram,  and  one  that  is  perhaps  also  in  a  measure  true. 

Mr.  Jonathan  Hutchinson's  address  was  of  more 
than  usual  interest  by  reason  of  the  many  personal 
reminiscences  it  contained.  The  speaker  made  a 
strong  plea  for  specialism,  in  surgery  at  least,  and 
proved  his  consistency  by  the   statement  that  he  had 


234 


MEDICAL  RECORD 


[August  17,  1895 


given  up  ovariotomy,  litholapaxy,  and  some  other  op- 
erations as  soon  as  he  found  that  more  practised  men 
could  do  them  better  than  he  could. 

Dr.  Schafer's  address  was  mainly  concerned  with  the 
functions  of  the  internal  or  ductless  glands  of  the  body, 
functions  which  we  are  learning  to  regard  as  of  the 
highest  importance,  and  with  the  treatment  of  certain 
diseases  by  animal  extracts. 

There  were  a  number  of  questions  brought  before 
the  meeting  which  were  the  occasion  of  several  very 
acrimonious  discussions,  but  these  are  matters  purely 
of  local  importance,  and  are  of  interest  to  outsiders 
only  as  showing  that  codes  and  general  medical  coun- 
cils and  royal  colleges  and  medical  associations  are  all 
powerless  to  compel  obedience  from  the  members  of 
the  profession  when  these  members  do  not  want  to 
obey  and  are  numerous  enough  to  dare  say  that  they 
do  not. 


A  PHYSICAL  SIGN  OF  ADHERENT  PERICAR- 
DII!.\I. 

In  view  of  the  fact  that  adherent  pericardium  often 
has  an  untoward  influence  upon  the  course  of  valvular 
diseases,  any  sign  by  which  the  condition  can  be  rec- 
ognized is  worthy  of  serious  attention.  In  The  Lancet 
of  July  27,  1895,  Dr.  Walter  Broadbent  calls  attention 
to  one  which  he  has  observed  in  four  cases  under 
treatment  at  the  Brompton  Hospital  for  Consumptives. 
One  of  the  cases  was  of  aortic  disease  of  rheumatic 
origin,  and  the  others  of  mitral  insufficiency  with  steno- 
sis. In  three  cases  there  was  abundant  evidence  of 
adhesion  of  the  pericardium  to  the  chest-wall  as  well 
as  to  the  diaphragm,  but  in  one  the  heart  moved  freely 
under  the  ribs  and  the  lung  expanded  well  over  it.  The 
sign  consisted  in  a  visible  retraction,  synchronous  with 
the  cardiac  systole,  of  the  left  side  of  the  back  in  the  re- 
gion of  the  eleventh  and  twelfth  ribs,  and  in  three  of  the 
cases  there  was  also  systolic  retraction  of  less  degree  in 
the  same  region  on  the  right  side.  In  all  the  cases  there 
was  a  definite  history  of  pericarditis,  and  in  three  of 
them  there  were  other  conditions  strongly  suggesting 
an  adherent  pericardium.  "  The  only  means  of  caus- 
ing this  retraction  on  both  sides,"  Dr.  Broadbent  says, 
"  would  seem  to  be  the  diaphragm,  which  if  pulled 
upon  would  have  more  effect  on  the  floating  eleventh 
and  twelfth  ribs  than  on  the  other  more  fixed  ones.  In 
cases  of  large  heart  with  adherent  pericardium  there 
is  a  considerable  area  of  the  ventricles  closely  adhe- 
rent to  the  central  tendon  of  the  diaphragm,  and  the 
])owerful  contraction  of  the  hypertrophied  heart  must 
give  a  decided  tug  to  the  structure."  That  the  retrac- 
tion should  be  observed  more  often  on  the  left  side 
than  on  the  right  is  only  what  might  naturally  he  ex- 
pected from  the  fact  that  the  adhesions  are  chiefly  to 
the  left  of  the  middle  line  ;  the  liver  also,  which  is  often 
large  in  these  cases,  may,  the  writer  thinks,  restrain  the 
movement  on  the  right. 


Honors  for  Irish  Medical  Men. — Knighthood  has 
been  conferred  upon  Dr.  Thornley  Stoker,  the  Presi- 
dent of  the  Royal  College  of  Surgeons  in  Ireland,  and 
Dr.  Christopher  Nixon,  the  physician  in  ordinary  to 
the  viceregal  household. 


A    STATE    IN    THE   VACCINE    BUSINESS. 

The  State  of  Illinois  has  gone  into  the  business  of 
manufacturing  vaccine  for  the  benefit  of  its  citizens. 
It  has  appropriated  the  sum  of  $3,000  for  the  purpose 
of  establishing  a  laboratory  in  connection  with  the 
State  University,  and  under  the  supervision  of  the 
State  Board  of  Health.  The  product  of  this  vaccine 
laboratory  is  to  be  furnished  to  all  physicians  and 
health  officers  within  the  State  at  the  cost  of  propaga- 
tion. We  presume  that  the  example  of  the  State  of 
Illinois  will  soon  be  followed  by  other  States.  The  im- 
mediate result  of  such  a  policy  of  State  control  will, 
doubtlessly,  be  on  the  whole  beneficial ;  but  we  have 
often  expressed  the  opinion  that  the  relegation  to  State 
authority  of  so  many  duties  that  can  really  be  well  done 
by  private  individuals  will  have  eventually  a  perni- 
cious effect,  since  it  increases  the  power  of  the  govern- 
ment at  the  expense  of  the  individual  and  establishes 
gradually  a  bureaucracy  or  a  political  machine. 

Vaccine  has  been  supplied  in  great  abundance  of  the 
best  quality  and  at  a  reasonable  price  by  private  indi- 
viduals now  for  many  years,  and  it  cannot  be  said  that 
the  State  must  take  care  of  it  because  good  vaccine 
cannot  be  obtained  otherwise.  This  condition  of  things 
does  not  perhaps  prevail  in  Illinois. 


^et»8  of  ttie  'W^zt\, 

Asylum  Abuses  in  Germany.  —  The  private  lunatic 
asylum  of  Haus  Kannen,  near  Amelsburen,  in  West- 
phalia, belonging  to  the  Alexian  brotherhood,  received 
a  visit  on  July  3d  from  an  official  committee.  The  in- 
quiry lasted  two  days,  and  is  said  to  have  yielded  such 
remarkable  results  that  the  provincial  administration 
is  already  considering  the  advisability  of  either  buying 
the  asylum  or  building  a  new  one,  to  be  placed  under 
medical  supervision  and  lay  guardians.  Gross  defects 
were  disclosed  in  the  sanitary  arrangements.  An  asy- 
lum at  Mariaberg,  under  the  care  of  the  same  order  of 
monks,  was  investigated  some  time  ago,  with  the  result 
that  the  father  superior  and  certain  other  of  the  monks 
were  arrested  for  cruelty  to  the  lunatics  under  their 
charge. 

The  Vesicating  Constituent  of  Croton-oil. — In  a  com- 
munication made  to  the  Royal  Society,  Mr.  Wyndham 
R.  Dunstan  and  Miss  L.  E.  Boole,  Lecturer  on  Chem- 
istry in  the  London  School  of  Medicine  for  Women, 
record  the  results  of  an  experimental  inquiry  into  the 
nature  of  the  vesicating  constituent  of  croton-oil.  Ac- 
cording to  the  research  of  Buchheim,  and  more  recent- 
ly of  Robert  and  Hirscheydt,  the  vesicating  action  of 
croton-oil  is  due  to  an  acid  closely  allied  to  oleic  acid, 
which  has  been  given  the  name  of  crotonoleic  acid,  and 
which  is  now  prepared  for  medical  purposes  on  a  large 
scale  in  Germany.  The  process  consists,  broadly,  in 
the  formation  first  of  barium  crotonoleate,  and  the  sub- 
sec]uent  decomposition  of  this  with  dilute  sulphuric 
acid  and  extraction  of  the  liberated  crotonoleic  acid  as 
a  viscid  oil  with  ether.  By  a  process  of  fractional  pre- 
cipitation, using  lead  salts,  the  above  investigators  were 
able  to  separate  from  this  so-called  crotonoleic  acid  a 


I 


August  17,  1895] 


MEDICAL    RECORD. 


235 


large  proportion  of  inactive  oily  acids,  till  at  last  they 
were  successful  in  obtaining,  by  a  series  of  operations 
in  which  alcoholic  extraction  and  separation  by  means 
of  lead  oxide  were  made  use  of,  a  resinous  substance 
having  extraordinary  power  as  a  vesicant.  The  com- 
position of  this  resin  is  expressed  by  the  empirical 
formula,  CjjH.jO,.  All  attempts  to  crystallize  or  to 
obtain  orystalline  derivatives  failed.  It  is  a  hard,  pale- 
yellow,  brittle  resin,  nearly  insoluble  in  water,  light 
petroleum,  and  benzine,  but  readily  dissolved  in  alco- 
hol, ether,  and  chloroform.  In  regard  to  its  constitu- 
tion it  is  concluded  that  the  vesicating  constituent  of 
croton-oil  is  a  lactone  or  an  anhydride  of  complicated 
structure. —  The  Lancet. 

Definition  of  an  Habitual  Drunkard. — A  petition  has 
been  presented  to  the  English  House  of  Lords,  pray- 
ing that  any  person  who  has  been  twice  convicted  of 
drunkenness  within  two  years  shall  be  defined  to  be 
an  habitual  drunkard,  and  that  any  licensed  dealer 
serving  or  harboring  him  after  due  notice  shall  be  liable 
to  penalties  and  forfeiture  of  license.  In  South  Aus- 
tralia three  convictions  within  six  months  constitute  an 
inebriate  an  habitual  drunkard.  An  Inebriates  Bill, 
which  was  before  the  late  Parliament  but  failed  to  be 
acted  upon  before  the  dissolution,  proposed  three  con- 
victions within  twelve  months. 

Nephropexy  by  Tendon. — At  the  May  meeting  of  the 
Societe  Nationale  de  Medecin  de  Lyon,  M.  Poullet 
presented  the  case  of  a  woman  upon  whom  he  had  suc- 
cessfully performed  the  operation  of  nephropexy  by 
means  of  a  tendon  of  the  longissimus  dorsi  muscle,  the 
upper  end  of  which  was  detached  from  its  muscular 
belly,  and  passed  so  as  to  make  a  loop,  through  the 
posterior  part  of  the  capsule  of  the  kidney,  supporting 
the  organ  and  holding  it  in  place.  This  ingenious 
method  is  probably  the  first  one  devised  for  fixation  of 
an  abdominal  organ  by  what  may  be  called  a  living 
suture,  as  one  end  of  the  tendon  is  not  freed  from  its 
attachment.  The  operation  was  first  successfully  per- 
formed upon  a  dog,  and  later  on  the  human  subject. — 
Boston  Medical  and  Surgical  Journal. 

The  Carcinoma  Antitoxin. — There  has  arisen  quite 
an  acrimonious  dispute  in  Germany,  between  Em- 
merich and  SchoU  on  one  side  and  Bruns  and  Augerer 
on  the  other,  regarding  the  efficacy  of  the  cancer 
"  Heilserum "  described  by  the  first  named  in  the 
Deutsche  medicinische  Wochenschrift.  Bruns  was  quoted 
by  the  authors  as  vouching  for  the  efficacy  of  the  treat- 
ment, but  he  now  denies  this  and  states  that  in  no  in- 
stance was  a  curative  effect  remarked,  while  in  some 
cases  the  general  state  of  the  patient  was  very  unfavor- 
ably influenced.  Cardiac  trouble  and  elevation  of  tem- 
perature were  very  frequent,  due  without  doubt  to  a 
septic  condition  of  the  fluid.  To  this  suggestion  Em- 
merich answered  that  the  antitoxin  was  originally 
aseptic  and  must  have  been  spoiled  by  Bruns  or  his  as- 
sistants. Bruns  replied  that  the  fluid  was  examined 
immediately  after  its  arrival  in  the  bacteriological 
laboratory  of  the  university,  and  numerous  strepto- 
cocci were  found  in  it.  Augerer  stated  that  two  of  his 
cases  were  attacked  with  erysipelas  during  the  antitoxin 
treatment.     The  controversy  has  assumed  a  very  per- 


sonal character  and  the  columns  of  the  medical  papers 
are  filled  with  charges  and  countercharges,  assertions 
and  denials.  The  weight  of  testimony  seems  to  be  de- 
cidedly against  the  efficacy  of  the  carcinoma  antitoxin. 

Miss  Bogolubska,  of  Merchinsk,  a  mining  village  in 
East  Siberia,  is  a  lady  of  great  determination,  who  de- 
serves the  thanks  of  her  sisters  in  other  lands.  She 
was  one  of  a  number  of  Russian  women  who  had 
sought  in  foreign  countries  the  advantages  of  a  medical 
education,  denied  them  in  their  own  land.  After  ob- 
taining her  degree  from  the  University  of  Berne  she 
returned  to  her  native  village,  and,  not  being  allowed 
to  practise  medicine,  worked  for  eight  years  as  a  nurse. 
She  was  specially  allowed  by  the  authorities,  however, 
to  labor  among  the  peasants  who  were  stricken  down 
in  the  cholera  outbreak  of  1892.  This  year  she  re- 
turned to  St.  Petersburgh,  where  she  obtained  permis- 
sion from  the  Czar  to  take  a  Russian  degree,  which 
confers  the  right  of  practising  in  any  part  of  the  em- 
pire. This  privilege  is  now  to  be  extended  among  her 
countrywomen  generally,  and  the  Woman's  Medical 
School  in  St.  Petersburg,  which  was  closed  for  political 
reasons  in  1887,  is  soon  to  be  reopened. 

Small-pox  in  a  Negro  Colony. — An  attempt  was  re- 
cently made  to  colonize  a  body  of  negroes  from  the 
Southern  States  in  Mexico,  but  it  was  unsuccessful. 
Small-pox  broke  out  among  the  colonists,  and  those 
now  returning  to  this  country  are  detained  in  quaran- 
tine at  Eagle  Pass.  Nearly  four  hundred  are  detained 
there,  and  of  these  one  hundred  and  twenty  are  in  hos- 
pital suffering  from  small-pox.  The  number  of  deaths 
averages  five  a  day. 

International  Congress  of  Railway  and  Steamship 
Sanitation. — A  meeting  of  railway  and  steamship  sur- 
geons, and  of  all  interested  in  preserving  the  health  of 
travellers,  will  be  held  in  Amsterdam  on  Friday  and 
Saturday,  September  20th  and  21st.  The  official  lan- 
guages of  the  Congress  will  be  English,  French,  and 
German.  The  membership  fee  is  5  florins  ($2.50). 
Those  intending  to  take  part  in  the  meeting  should 
send  notice  without  delay  to  the  Secretary  of  the 
Committee  on  Organization,  Dr.  M.  W.  Pijnappel, 
Stadhouderskade  60,  Amsterdam,  Holland.  Dr.  H. 
Snellen  is  Chairman  of  the  Committee  on  Organization. 

Professor  Ewald  Hering,  of  the  University  of  Prague, 
has  been  appointed  Professor  of  Physiology  in  the 
University  of  Leipsic,  in  succession  to  the  late  Carl 
Ludwig. 

Minnesota  State  Medical  Society. — The  twenty  - 
seventh  annual  meeting  of  this  Society  was  held  at 
Duluth,  Minn.,  June  19th,  President  Justus  Ohage,  of 
St.  Paul,  in  the  chair.  The  officers  elected  for  the  en- 
suing year  were  as  follows  :  President,  Dr.  Frank  All- 
port,  of  Minneapolis ;  First  Vice-President,  Dr.  J.  H. 
Dorsey,  of  Glencoe  ;  Second  Vice-President,  Dr.  E.  G. 
Chilton,  of  Howard  Lake  ;  Third  Vice-President,  Dr. 
N.  Jones,  of  Gaylord  ;  Secretary,  Dr.  Ignatius  Don- 
nelly, of  St.  Paul  ;  Treasurer,  Dr.  R.  J.  Hill,  of  Min- 
neapolis. 

Canadian  Medical  Association. — The  twenty-eighth 
annual  meeting    of   this   Association  will  be  held    in 


236 


MEDICAL    RECORD. 


[August  17,  1895 


Convocation  Hall,  Queen's  University,  Kingston,  Au- 
gust 28th,  29th,  and  30th.  The  President  of  the  Asso- 
ciation is  Dr.  William  Bayard,  of  St.  John,  N.  B.  ;  the 
Secretary,  Dr.  F.  N.  G.  Starr,  of  Toronto. 

The  Medical  Society  of  Virginia  will  hold  its  twenty- 
sixth  annual  session  in  Wytheville,  on  Tuesday  and 
Wednesday,  September  3d  and  4th.  The  President  of 
the  Society  is  Dr.  R.  J.  Preston,  of  Marion  ;  the  Secre- 
tary, Dr.  Landon  B.  Edwards,  of  Richmond. 

The  American  Association  of  Obstetricians  and 
Gynecologists  will  hold  its  eighth  annual  meeting  at 
the  Auditorium  Hotel,  Chicago,  on  September  24th, 
25th,  and  26th.  President,  Dr.  J.  Henry  Carstens,  of 
Detroit  ;  Secretary,  Dr.  William  Warren  Potter,  of 
Buffalo.     An  interesting  programme  is  announced. 

Obituary  Notes.— Dr.  Baillon,  the  well-known  bot- 
anist, died  suddenly  in  Paris  on  July  iSth.  He  was 
sixty-seven  years  old,  and  for  twenty-eight  years  had 
held  the  Chair  of  Botany  and  Natural  History  in  the 
medical  school  of  the  University  of  Paris. — Dr.  Henry 
Causs,  aged  twenty-eight,  of  Phcenicia,  N.  Y.,  died  on 
August  nth,  in  Kingston,  after  a  long  and  painful  ill- 
ness. Dr.  Gauss  was  born  in  Utica.  He  graduated 
from  Dartmouth  College  in  1888. 

Medical  Members  of  Parliament. — The  new  British 
Parliament  contains  ten  members  who  belong  to  the 
medical  profession. 

State  Board  of  Medical  Examiners  of  New  Jersey. — 
At  the  last  annual  meeting  of  this  board,  held  at  Tren- 
ton, July  2 2d,  the  following  officers  were  elected  :  Presi- 
dent, Edwin  De  Baun,  M.D.,  of  Passaic,  N.  J.  ;  Secre- 
tary, William  Perry  Watson,  M.D.,  of  Jersey  City,  N.  J.  ; 
Treasurer,  K.  H.  Worthington,  M.D.,  of  Trenton,  N.  J. 

Free  Public  Baths  in  Cities.— The  author  of  the  act 
passed  by  the  Legislature  of  New  York  State,  making 
compulsory  the  erection  and  maintenance  of  public 
baths  in  the  large  cities  of  the  State,  was  Mr.  Goodwin 
Brown,  of  Albany. 

An  International  Congress  of  Otology  will  meet  in 
Florence  on  September  23d,  under  the  presidency  of 
Professor  Grazzi.  Among  the  subjects  announced  for 
discussion  are  "  Intracranial  Abscess  Resulting  from 
Purulent  Otitis,"  "The  Pathology  of  the  Labyrinth," 
"  The  General  Treatment  of  Ear  Disease,"  and  "  The 
Physiology  of  the  Middle  Ear."  The  Secretary  of  the 
Congress  is  Dr.  Bobone,  of  San  Remo. 

Prize  Essay  on  Hygiene.— The  French  Society  de 
M^decine  Publique  et  d'Hygi^ne  Professionnelle  offers 
three  prizes  for  the  best  mhnoire  on  "  Preventable 
Diseases,  and  the  Preventive  Measures  to  be  Taken." 
The  first  prize  is  1,200  fr.,  the  second  800  fr.,  and  the 
third  500  fr.  The  essay  is  not  to  exceed  from  twenty 
to  thirty  pages  of  500  words  each.  The  following 
points  must  be  treated  :  How  to  prevent  contagious 
diseases  during  the  illness  and  after  ;  private  sanitation 
of  patients  and  those  who  tend  and  treat  them  ;  house 
sanitation  and  disinfection  ;  and  general  sanitation 
during  illness. 

The  Milk-supply  of  London  is,  according  to  the  Die- 
tetic and  Hygienic  Gazette,  "dangerously  and  disgrace- 


fully adulterated  by  all  sorts  of  swindling  operations." 
The  condensed  milk  on  sale  in  that  city  is  not  much 
better,  as  we  learn  from  the  report  of  an  analysis  made 
for  the  British  Medical  Journal  that  fourteen  out  of 
seventeen  brands  examined  were  made  of  skimmed 
milk. 

A  School  of  Medical  Hydrology  has  been  opened  at 
Luchon,  in  France.  It  possesses  a  good  laboratory 
and  nine  professors  on  the  teaching  staff. 

Successful  Ligature  of  the  Innominate  Artery. — A 

man  was  recently  on  exhibition  in  London  whose  in- 
nominate artery  was  tied  by  Mr.  Coppinger,  at  the  Mater 
Misericordias  Hospital  in  Dublin,  in  January,  1893. 
The  operation  was  for  the  relief  of  aneurism  of  the 
subclavian  artery.  He  was  exhibited  shortly  after  the 
operation  in  Dublin,  and  later  at  Newcastle-on-Tyne. 
The  man  is  now  fifty-nine  years  of  age  and  is  in  ex- 
cellent health.  It  is  claimed  for  him  that  he  is  the 
only  living  example  as  yet  exhibited  in  Europe  of  cure 
of  subclavian  aneurism  by  innominate  ligature. 

The  Result  of  a  Libel  Suit  in  Australia. — Mr.  C.  B. 
Elliott,  Government  Medical  Officer  in  Geraldton,  West 
Australia,  sued  the  Victorian  Express  Newspaper  Com- 
pany for  libel.  The  libel  was  contained  in  the  form  of 
a  letter,  asserting  that  the  large  number  of  cripples  in 
Geraldton  was  owing  to  the  incompetence  and  neglect 
of  the  hospital  medical  officer,  Mr.  Elliott.  After  a 
trial  which  lasted  eight  days,  the  jury  awarded  Mr.  El- 
liott ..^500  and  costs,  the  editor  being  also  sentenced  to 
fourteen  days'  imprisonment  for  some  contempt  of 
court  occurring  during  the  trial. 

A  Bust  of  Carl  Vogt  is  to  be  placed  either  in  the  ves- 
tibule of  the  University  or  on  the  Promenade  des  Bas- 
tions at  Geneva.  The  original  intention  was  to  place 
it  in  the-  University  building,  but  the  citizens  of  Gen- 
eva claim  that  the  savant  belonged  to  the  entire  city, 
and  not  alone  to  the  University,  and  urge  that  his  bust 
be  placed  where  it  may  be  seen  by  all. 

The  William  F.  Jenks  Memorial  Prize  of  five  hun- 
dred dollars,  under  the  deed  of  trust  of  Mrs.  William 
F.  Jenks,  has  been  awarded  to  Dr.  A.  Brothers,  of  New 
York,  for  the  best  essay  on  "  Infant  Mortality  During 
Labor,  and  its  Prevention."  The  Prize  Committee  also 
reports  as  highly  meritorious  the  essay  on  the  same 
subject  bearing  the  motto,  "  Vade  Mecum."  The 
writers  of  the  unsuccessful  essays  can  have  them  re- 
turned to  any  address  they  may  name,  by  sending  it 
and  the  motto  which  distinguished  the  essay,  to  the 
Chairman  of  the  Prize  Committee,  Horace  Y.  Evans, 
M.D.,  College  of  Physicians,  Philadelphia. 

Yellow  Fever  at  ftuarantine. — A  passenger  from 
Havana,  who  arrived  on  the  steamship  Seneca  last 
Monday,  on  Wednesday  developed  symptoms  of  yellow 
fever  and  was  removed  to  the  Swinburne  Island  Hos- 
pital. The  passenger  was  one  of  twenty-four  who  were 
detained  at  Hoffman  Island  for  observation,  this  being 
the  routine  treatment  of  all  persons  coming  from  Cuban 
ports  at  this  time  of  year,  who  cannot  prove  that  they 
are  natives  of  Cuba,  or  that  they  have  been  rendered 
immune  to  the  disease  by  a  previous  attack. 


August  17,  1895] 


MEDICAL    RECORD. 


237 


^Icuieius  miA  Notices. 

Twentieth  Century  Practice.  An  International  En- 
cyclopasdia  of  Modern  Medical  Science.  By  Leadin^j 
Authorities  of  Europe  and  America.  Edited  by  Thomas 
L.  Stedman,  M.D.,  Xe-.v  York  City.  In  Twenty  Volumes. 
Volume  III.  Occupation  Diseases,  Drug  Habits,  and 
Poisons.    New  York  :  William  Wood  &  Company.     1S95. 

The  third  volume  of  this  excellent  work  has  appeared  with 
gratifying  promptness,  which  seems  to  indicate  that  the  pub- 
lishers' promise  to  bring  out  a  volume  every  three  month? 
will  be  adhered  to.  The  contents  are  of  a  somewhat  mis- 
cellaneous character.  The  two  longest  articles  are  that 
entitled,  "  Alcoholism  and  Drug  Haljits,"  by  Dr.  Norman 
Kerr,  of  London,  and  one  on  "  Diseases  of  Occupations," 
by  Dr.  James  Hendrie  Lloyd,  of  Philadelphia,  both  of  un- 
usual excellence.  Dr.  Kerr  has  departed  here  from  the 
plan  followed  in  his  well-known  treatise  on  "  Inebriety  or 
Narcomania,"  in  that  he  treats  separately  of  the  injurious 
effects  of  alcohol  and  various  drugs  upon  the  habitual  con- 
sumers of  them,  and  of  the  morbid  impulse  to  take  these 
narcotics  to  excess  for  the  sake  of  experiencing  the  effects 
which  they  produce.  The  subject  of  teetotalism  is  dealt 
with  in  a  very  temperate  way  ;  the  argument  is  stated  fairly 
and  the  author's  conclusions  are  formulated  quietly,  without 
entire  condemnation  of  those  who  may  not  agree  with  him  in 
all  points,  or  even  in  most  points.  The  article  by  Dr.  Lloyd, 
on  the  diseases  incidental  to  occupations,  is  perhaps  the 
best  work  on  the  subject  that  has  appeared  since  that  of  Dr. 
Tracy  in  Buck's  "  Hygiene  ;  "  it  is  even  more  practical  than 
the  latter,  which  does  not  pretend  to  do  more  than  treat  of 
occupation  diseases  from  the  standpoint  of  hygiene.  Dr. 
Lloyd  classifies  his  subject  according  to  causes,  grouping 
under  the  same  head  diseases  affecting  men  engaged  in  the 
most  diverse  occupations.  This  is,  however,  not  a  defect, 
but  the  reverse,  since  it  saves  much  needless  repetition,  and 
brings  more  prominently  into  view  the  relation  of  cause  and 
effect  in  the  maladies  under  consideration.  The  classifica- 
tion by  occupation  has  been  made  by  the  compiler  of  the 
index.  The  I.. tter,  by  the  way,  is  excellent.  Of  the  shorter 
articles,  that  on  poisoning,  by  Drs.  Beaumont  Small,  of 
Ottawa,  and  James  Stewart,  of  Montreal,  is  the  most  im- 
portant. All  the  most  commonly  met  poisons  are  here  dealt 
with  as  regards  their  source,  their  effects  in  small  and  large 
doses,  and  the  treatment  of  these  effects.  Dr.  George  F. 
Shrady,  of  New  York,  has  contributed  a  very  practical  and 
interesting  article  on  "Shock,"  and  Professor  Councilman. 
of  Boston,  a  short  but  satisfactory  one  on  "  Osteomalacia.'' 
A  curious  subject  is  that  of  "  Mountain  Sickness,"  upon 
which  Dr.  von  Liebig,  of  Munich,  has  written  very  enter- 
tainingly. The  question  is  one  that  has  merely  an  academic 
interest  for  those  living  east  of  the  Rocky  Alountains,  but 
the  practical  value  of  the  article  may  be  tested  by  some  of 
our  fellow-countrymen  living  on  the  Pacific  slope.  The  sub- 
ject of  "  Seasickness  "  is  handled  by  Dr.  Albert  L.  Gihon. 
of  the  United  States  Navy,  in  a  thoroughly  practical  man- 
ner, and  yet  in  such  an  interesting  way  that  it  holds  the 
reader,  and  almost  makes  him  long  to  cross  the  ocean  to  see 
whether  all  the  terrors  which  Dr.  Gihon  depicts  are  real  or 
only  the  products  of  the  imagination.  Certainly  the  author, 
with  his  long  experience  as  a  sea  rover,  speaks  as  few  can 
so  fully  of  personal  knowledge,  and  he  has  told  us  all  there 
is  to  tell  of  this  distressing  malady.  Dr.  Gihon  also  writes 
in  this  volume  on  "  Heat-stroke,"  a  most  seasonable  topic, 
and  on  "  Frost-bite,"  which  will  be  seasonable  in  its  turn. 

The  volume  is  handsomely  printed,  sparingly  but  well 
illustrated,  and  substantially  bound.  The  completed  work 
will  certainly  be  an  ornament  to  the  book-shelves  of  its  pos- 
sessor, as  well  as  a  mine  of  information  from  which  he  can 
draw  at  will. 

Affections  Chirurgicales  des  Membres.  Statistique 
et  Observations.  Par  le  Dr.  Polaillon,  Chirurgien  de 
I'Hotel-Dieu,  Professeur  Agrege  a  la  Faculte  dc  Medccine 
de  Paris,  etc.     Paris  :  Octave  Doin.     1895. 

This  compilation  of  statistics  and  observations  of  hospital 
surgery,  especially  as  it  concerns  operations  upon  the  ex- 
tremities, dating  from  1879,  when  the  author  began  a  service 
at  the  Pitie,  has  been  continued  at  the  Hntel-Dieu  up  to 
iSg3,  and  its  publication  held  back  till  now  to  assure  more 
definite  results.  The  record,  which  embraces  over  eight 
lumdred  octavo  pages,  gives  evidence  of  being  carefully  done, 
representing  a  vast  amount  of  labor,  and  will  be  correspond- 
ingly valuable  to  surgeons  and  all  interested  in  the  outcome 


of  surgical  procedures  and  the  relative  frequency  of  the  aftec- 
tions  treated.  Histories  of  many  interesting  cases  are  given 
in  detail. 

Text-book  of  Operative  Surgery.  By  Theodore 
KoCHER,  Professor  of  Surgery  and  Director  of  the  Sur- 
gical Clinic  in  the  University  of  Bern.  Translated  by 
Harold  J.  Stiles,  M.B.,  F.R.C.S.  Edin.,  Senior  Dem- 
onstrator of  Surgery,  and  Formerly  Demonstrator  of  Anat- 
omy in  the  University  of  Edinburgh  ;  Assistant  Surgeon, 
Royal  Edinburgh  Hospital  for  Sick  Children.  With  185 
Illustrations.     London:  Adam  and  Charles  Black.      1S95. 

This  is  a  translation  of  the  second  edition  of  Dr.  Kocher's 
excellent  treatise  on  operative  surgery,  which  has  already 
won  for  itself  recognition  as  the  standard  work  on  this  sub- 
ject. The  translation  has  been  well  done,  and  the  illustra- 
tions are  admirable. 

Twenty-seyenth  Annual  Report,  Relating  to  the 
Registry  and  Return  of  Births,  Marriages,  and 
Deaths  IN  Michigan  for  THE  Year  1893.  Bythe  Sec- 
retary of  State  of  the  State  of  Michigan.  Lansing  :  Rob- 
ert Smith  &  Co.     1895. 

This  report  contains  many  data  of  great  value  to  the  stu- 
dent of  vital  statistics.  Among  other  features  of  interest  are 
several  diagrams  and  a  colored  map,  showing  the  distribu- 
tion of  mortality  from  typhoid  fever  in  the  State  during  the 
past  five  years. 

Geschichte  der  JiJDiscHEN- Aerzte.  Ein  Beitrag  zur 
Geschichte  der  Medicin.  Von  Dr.  Richard  Landau. 
Berlin  :  S.  Karger.      1893. 

In  this  book  the  author  presents  an  account  of  the  part 
taken  by  the  Hebrews  of  all  ages  in  medicine — a  part  by  no 
means  insignificant,  especially  in  the  middle  ages,  when 
they  shared  with  the  Arabs  the  honor  of  keeping  alive  the 
faintly  glimmering  torch  of  medical  science,  and  when,  in  a 
period  of  prejudice  and  persecution,  they  were  called  to  be 
the  physicians  of  kings  and  popes.  The  work  is  a  valuable 
contribution  to  the  history  of  medicine  as  w'ell  as  to  that  of 
the  Jews. 

CEuvres  De  Leon  Le  Fort,  Professeur  de  Clinique  Chi- 
rurgicale  h  la  Faculte  de  Medecine  de  Paris,  \'ice-president 
de  I'Acaddmie  de  Medecine,  Chirurgien  de  I'Hotel-Dieu. 
Publi^es  par  le  Dr.  Felix  Lejars,  Professeur  Agrege  a 
la  Faculte  de  Medecine,  Chirurgien  des  Hopitaux.  Tome 
I".     Paris  :  Fdlix  Alcan.     1895. 

This  is  the  first  volume  of  the  three  which  are  to  comprise 
all  the  works  of  the  late  Dr.  Le  Fort.  The  writings  have  been 
collected  by  his  pupil  and  son-in  law.  Dr.  Lejars,  and  ar- 
ranged by  him  in  the  order  of  subjects.  We  find  here  vari- 
ous articles  on  Hospital  Hygiene,  Demography,  and  Public 
Hygiene.  L'nder  each  heading  the  articles  are  grouped 
chronologically.  In  an  interesting  article  on  Maternity  Hos- 
pitals, written  in  1866,  the  doctrine  of  the  contagiousness  of 
puerperal  fever  is  forcibly  demonstrated.  In  the  second 
part  we  find  the  note  of  alarm  on  the  decreasing  population 
of  France  sounded,  and  the  cause  of  the  decrease  referred 
in  great  measure  to  the  great  mortality  of  the  new-born. 
Other  articles  of  interest  are  on  Prostitution  and  Obligatory 
Vaccination.  The  second  volume  will  contain  the  author's 
writings  on  Medical  Education  and  Military  Surgery,  and  in 
the  third  will  be  collected  all  of  Dr.  Le  Fort's  contribu- 
tions to  the  literature  of  General  and  Special  Surgery.  The 
work  is  a  worthy  monument  to  the  author's  learning  and  in- 
dustry. 

Transactions  of  the  AiMerican  Association  of  Ob- 
stetricians and  Gynecologists,  Vol.  VII.,  for  1894. 
Philadelphia  :   N.  J.  Doran.     1895. 

This  volume,  uniform  with  its  predecessors,  contains  some 
admirable  papers  on  abdominal  and  uterine  surgery. 

The  Aseptic  Treatment  of  Wounds.  By  Dr.  C.  Schim- 
MELBUSCH,  Assistant  to  the  Royal  Surgical  Clinic  Uni- 
versity, Berlin,  etc.  Translated  by  Frank  J.  Thorn- 
BURY,  M.D.,  Lecturer  on  Bacteriology,  University  of  Buf- 
falo, N.  Y.     G.  P.  Putnam's  Sons.     1895. 

This  little  work  is  not  concerned  with  the  treatment  in  gen- 
eral of  wounds,  but  solely  with  those  measures  which  are 
necessary  to  maintain  asepsis.  The  methods  described  by 
Dr.  Schimmclbusch  arc  those  in  use  in  v.  Bcrgmann's  clinic, 
in  Berlin,  and  are  naturally  most  thorough,  and  doubtless  as 
efficacious  as  they  are  thorough.  The  book  is  one  that  will 
be  found  useful  by  the  surgeon,  at  least  the  young  one,  and 


238 


MEDICAL   RECORD. 


[August  17,  1895 


the  student  who  is  preparing  himself  to  be  one.  There  is  a 
bibliography  of  sixteen  pages,  which  does  not  detract  from 
the  work,  though  it  seems  to  be  a  rather  useless  appendix. 
Some  of  the  translator's  additions  are  judicious  and  add  to 
the  value  of  the  book. 

FORMULAIRE  DES  SPECIALITES  Pharmaceutiques,  Com- 
position, Indications  Therapeutiques,  Mode  d'Emploi  et 
Dosage,  a  I'Usage  des  Medecins.  Par  le  Dr.  M.  Gau- 
TIER,  Ancien  Interne  des  Hopitaux,  et  F.  Renault, 
Pharmacien  de  i"  Classe,  Laureat  de  I'ficole  de  Phar- 
macie.     Paris  :  J.  B.  Bailliere  et  Fils.     1895. 

This  is  a  little  book  that  will  be  found  very  useful  for  all 
who  have  occasion  to  read  French  medical  literature.  Such 
are  often  puzzled  by  the  names  of  special  pharmaceutical 
preparations,  which  are  usually  called  after  the  men  who 
first  prescribed  them  and  contain  in  their  names  no  sugges- 
tion of  their  composition.  This  compilation  gives  a  list  of 
all  these  special  preparations,  with  their  composition,  indi- 
cation for  use,  mode  of  administration,  and  dose. 

The  Tre.atment  of  Wounds,  Ulcers,  and  Abscesses. 
By  W.  Watson  Chevne,  M.B.  Ed.,  etc.  Philadelphia  : 
Lea  Brothers  &  Co.     1895. 

Professor  Cheyxe's  book  is  a  thoroughly  practical  one, 
and  is  of  especial  use  to  the  practitioner  who  does  not  pre- 
tend to  any  degree  of  expertness  in  detail  in  the  surgical 
treatm.ent  of  wounds  or  ulcers.  It  deals  in  a  very  intelligent 
manner  with  the  accepted  methods,  but  is  somewhat  ele- 
mentary for  the  experienced  surgeon. 

The  Barnjum  Bar-bell  Drill.  By  R.  Tait  McKex- 
zie,  B.A.,  M.D.,  Demonstrator  of  Anatomy  and  Instruc- 
tor in  Gymnastics,  McGill  University  ;  Late  House  Sur- 
geon, Montreal  General  Hospital.  Springfield,  Mass.  : 
Triangle  Publishing  Co. 

This  book,  with  alliterative  title,  is  a  guide  to  a  series  of 
twenty-four  exercises  with  the  bar-bell.  Each  of  these  exer- 
cises is  illustrated  with  sixteen  photographs  of  the  positions, 
and  accompanying  the  text,  and  consists  of  an  explanation 
of  the  movements  and  a  statement  of  what  muscles  are 
called  into  play.  A  bar-bell  is  like  a  dumb-bell,  with  a  bar 
several  feet  long  between  the  bells. 


©linical  gjepartmcut. 

A  CASE  OF  MULTIPLE  ABSCESSES  OF  THE 
EXTERNAL  AUDITORY  CANAL,  FOLLOWED 
BY   PERICHONDRITIS   AURICULAE. 

By  albert  POHLY,  M.D., 

MEW  YOUC. 

In  looking  over  the  literature  of  perichondritis  auricu- 
lae, I  find  that  this  disease  is  comparatively  rare,  and  I 
therefore  take  the  liberty  of  reporting  the  follomng 
case  : 

Miss  S.  AV ,  thirty-eight  years  of  age,  called  at 

my  office  on  August  30,  1894,  complaining  of  a  dull 
pain  in  the  ear.  She  had  been  of  previous  good  health, 
and  did  not  know  any  cause  for  her  present  complaint. 
Upon  examination  I  found  a  swelling  behind  the 
concha,  nearly  occluding  the  auditory  canal.  I  made 
the  diagnosis  of  abscess  and  treated  it  accordingly,  or- 
dering hot-water  syringing  and  flaxseed-meal  poultices. 
This  treatment  was  continued  for  two  weeks  without 
improvement,  and  I  therefore  suggested  a  consultation 
with  Dr.  W.  Freudenthal. 

Dr.  Freudenthal  saw  the  patient  with  me  on  Septem- 
ber 14th,  and  confirmed  my  diagnosis  ;  made  an  inci- 
sion, and  a  little  pus  and  blood  exuded.  He  ordered 
the  continuation  of  hot  fomentations. 

I  saw  patient  every  day  ;  her  pain  increased,  owing 
to  other  small  abscesses  making  their  appearance, 
which  were  promptly  opened,  and  the  ear  was  syringed 
with  a  hot  saturated  solution  of  boracic  acid.  This 
was  kept  up  for  three  weeks,  when  the  swelling  disap- 
peared, but  I  noticed  that  a  little  polypus  was  fonning 


at  the  same  place  which  the  abscess  had  pre\-iousIy  oc- 
cupied. 

I  again  consulted  with  Dr.  Freudenthal,  who  re- 
moved the  polypus,  partly  with  the  snare  and  partly 
with  the  electrocautery.  Soon  after  this  the  helix  be- 
gan to  swell,  which  was  the  beginning  of  a  perichon- 
dritis. The  swelling  now  extended  rapidly,  involving 
the  whole  external  ear  (pinna),  giving  the  appearance 
of  a  big  tumor.  Dr.  Freudenthal  now  advised  an  oper- 
ation, which  he  performed  in  St.  Mark's  Hospital  on 
November  7,  1894. 

Operation. — Two  incisions  were  made,  one  into  the 
antihelix,  about  the  middle  of  the  external  ear,  the 
part  of  the  greatest  swelling,  and  a  counter-incision 
in  front  of  the  tragus.  A  great  amount  of  thick, 
creamy  pus  was  discharged.  The  wound  was  then 
scraped,  drained  with  iodoform  gauze,  and  bandaged. 

The  patient  remained  in  the  hospital  two  weeks  after 
the  operation,  but  without  much  improvement,  the  pain 
being  so  severe  that  she  was  unable  to  sleep  without 
narcotics.  There  was  considerable  discharge,  with 
but  little  diminution  of  swelling.  After  two  w-eeks  pa- 
tient became  homesick,  left  the  hospital,  and  again 
came  to  me  for  treatment.  I  saw  her  daily  for  two 
weeks,  syringing  the  ear  with  a  carbolic  solution  and 
draining  with  iodoform  gauze  ;  then  saw  her  every 
other  day,  continuing  the  same  treatment.  During 
this  period  there  was  a  marked  improvement ;  the  pain 
had  left  entirely,  and  the  swelling  diminished  consid- 
erably, although  there  was  a  discharge  of  pus  and 
blood,  which  is  still  present  to-day  ;  she  also  now  com- 
plains of  an  intense  itching  in  the  ear.  A  photograph 
taken  recently  shows  the  existing  malformation,  which 
will  in  all  probability  remain. 

Dr.  Knapp,  of  this  city,  in  the  Archives  of  Otology, 
says  that  he  has  only  seen  three  patients  with  peri- 
chondritis auricula:,  and  he  describes  the  following 
case  in  detail  : 

Patient,  Henry  A ,  of  New  York,  sixteen  years 

of  age,  had  always  enjoyed  good  health.  On  August 
29,  1879,  he  presented  himself  to  me  at  the  Dispensary 
of  the  Ophthalmic  and  Aural  Institute,  complaining  of 
a  moderately  painful  swelling  in  his  right  ear,  which  he 
had  first  noticed  a  few  days  previously.  His  ear  had 
never  before  given  him  any  trouble,  and  he  could  not 
ascribe  the  present  difficulty  to  any  cause.  I  found 
the  external  portion  of  the  meatus  slightly  red  and  uni- 
formly swollen,  so  as  to  obliterate  its  calibre.  When 
the  auricle  was  drawn  back,  the  canal  was  opened  to  a 
certain  degree  ;  no  ulcer  or  discharge  was  discovered. 
and  the  hearing  was  good.  The  swelling  was  most 
pronounced  on  the  anterior  lower  part,  where  also 
fluctuation  was  discovered.  The  case  was  entered  as 
furuncle  of  the  external  meatus,  and  the  fluctuating 
part  was  opened,  evacuating,  however,  not  creamy  but 
watery  pus.  A  week  later  the  swelling  in  the  canal 
had  diminished,  but  the  lower  part  of  the  concha  was 
red,  swollen,  and  indistinctly  fluctuating.  After  three 
days  the  swelling  in  the  concha  had  increased,  showed 
distinct  fluctuation,  and  was  moderately  painful  on 
pressure.  It  was  opened,  and  again  watery  pus  es- 
caped. Four  days  later  the  swelling  filled  the  whole 
concha,  was  dark  red,  and  had  a  doughy  feel.  I 
opened  it  above  the  lobule,  which  was  unaffected, 
with  a  Beer's  knife,  and  let  out,  as  before,  a  viscid 
fluid  with  denser  yellowish  flakes.  A  probe  introduced 
through  the  opening  could  be  pushed  more  than  half 
an  inch  upward.  The  cartilage  felt  hard  and  uneven, 
the  perichondrium  was  detached  from  it,  and  could, 
together  with  the  skin,  be  easily  raised  by  the  probe. 
I  now  inserted  a  small  silver  drainage-tube,  which  was 
cleansed  and  re-introduced  twice  daily.  The  ear  was 
covered  with  picked  linen,  held  by  a  flannel  roller. 
There  was  moderate  discharge  of  thin,  flaky  pus  from 
the  wound.  The  swelling  crept  slowly  and  steadily 
over  the  whole  anterior  surface  of  the  auricle,  except- 
ing the  lobule.     In  some   places  it   was  diffuse  ;    in 


August  17,  1895] 


MEDICAL    RECORD. 


239 


others  nodular  and  fluctuating.  These  places  were  al- 
ways lanced,  and  the  same  thin  viscid  pus  came  out  as 
on  the  first  opening,  never  any  blood.  In  the  fourth 
or  fifth  week  the  helix  and  posterior  surface  of  the  au- 
ricle were  swollen,  but  did  not  fluctuate.  At  the  be- 
ginning of  the  sixth  week  the  swelling  began  to  sub- 
side, first  in  the  cartilaginous  portion  of  the  meatus, 
then  in  the  concha,  then  posterior  surface  which  had 
been  free  from  suppuration,  and  gradually  all  over  the 
auricle.  The  tragus  assumed  its  natural  size,  the  pre- 
auricular glands  disappeared  completely,  the  opening 
in  the  anterior  surface  of  the  auricle  ceased  discharg- 
ing and  closed,  the  auricle  shrunk  and  remained  irreg- 
ularly corrugated.  The  antihelix,  the  fossas  antihelicis 
and  scaphoidea,  and  the  greater  part  of  the  concha  had 
disappeared  and  were  replaced  by  hardish  nodules  and 
ridges.  The  helix  was  considerably  atrophied.  The 
whole  misshapen  auricle  was  pressed  against  the  skull, 
and  measured  scarcely  two-thirds  of  its  natural  size  ; 
only  the  lobule  escaped  the  deformity,  because  it  had 
never  participated  in  the  inflammation. 

Dr.  R.  Pooley,  of  this  city,  reports  the  following  case 
in  the  Transactions  of  the  JSIedical  Society  of  the  State 
of  New  York,  year   1S81.     September  24,  1877,  I  was 

consulted  by  Mrs.   G ,  a  young  married    woman, 

aged  twenty-one,  born  in  New  York  of  German  par- 
ents. She  had  always  enjoyed  good  health,  and  up  to 
the  time  when  the  ear  disease  began  had  nothing  to 
complain  of.  Three  weeks  before  seeking  my  advice 
she  had  severe  pain  and  itching  in  the  meatus  of  the 
right  ear.  She  said  that  ''  a  boil  broke  in  the  ear — • 
broke,  and  gave  exit  to  a  greenish-looking  core,"  after 
which  she  was  better  for  a  time  ;  but  as  the  ear  began 
to  trouble  her  again,  she  sought  advice.  No  history  of 
injury,  nor  had  she  any  reason  to  assign  for  the  present 
difficulty.  I  found  upon  the  anterior  lower  wall  of  the 
auditory  canal,  just  within  the  meatus,  a  conical  swell- 
ing which  showed  the  usual  appearance  of  an  otitis 
e.xterna  furunculosa.  It  was  very  sensitive  to  press- 
ure with  a  probe.  A  deep  incision  was  made  into  the 
centre  of  the  swelling  and  a  small  quantity  of  watery- 
looking  pus  let  out. 

October  2d.  The  circumscribed  swelling  of  the 
canal  had  subsided,  but  the  lower  part  of  the  concha 
was  red  and  swollen,  although  no  distinct  fluctuation 
could  be  made  out.  This  swelling  rapidly  increased 
and  became  painful,  not  only  when  pressed  upon,  but 
spontaneously.  There  was  now  an  ill-defined  sensation 
of  fluctuation  present.  In  a  few'days  the  swelling  had 
rapidly  increased  to  such  an  extent  as  to  fill  the  whole 
concha  and  obliterate  its  normal  concavity  ;  the  swell- 
ing was  of  a  dark-red  color  and  boggy  to  the  feel. 
An  incision  into  the  most  dependent  part  of  the  tumor 
was  made  and  a  thin  glairy-looking  fluid  mixed  with 
yellowish-white  shreds  was  evacuated.  No  blood  es- 
caped. The  cartilage  was  roughened,  hard,  and  its 
perichondrium,  which  was  readily  detached,  raised 
together  with  the  skin  on  the  probe.  A  tent  of  char- 
pie  was  inserted  into  the  wound  to  keep  it  open,  the 
ear  covered  with  absorbent  cotton,  and  a  flannel  roller 
applied,  so  as  to  exert  a  pretty  firm  pressure.  There 
was  a  thin  watery  discharge,  mixed  with  broken-down 
shreds.  Slow  extension  of  the  swelling  over  the  entire 
anterior  surface  of  the  auricle,  successively  the  concha, 
helix,  and  antihelix,  and  the  fossa  helicis — in  fact,  all 
the  anterior  surface  of  the  auricle,  except  the  lobule. 
The  character  of  the  swelling  was  uneven,  in  some 
places  diffuse,  in  others  nodular.  When  the  swelling 
had  reached  the  helix  it  began  to  encroach  upon  the 
posterior  part  of  the  auricle,  every  part  of  which,  ex- 
cept the  lobule,  became  diffusely  red,  very  much  thick- 
ened and  swollen,  painful  to  the  touch,  but  gave  no  sen- 
sation of  fluctuation.  Although  the  lobule  itself  did 
not  become  involved,  there  were  two  abscesses  formed 
below  it — one  in  front,  the  other  behind— which  were 
opened. 

The  acute  inflammatory  symptoms  lasted  for  about 


two  months,  during  all  of  which  time  the  patient  suf- 
fered a  great  deal  of  pain,  always  aggravated  at  night ; 
so  severe  was  the  character  of  the  pain  that  s.e  had  to 
be  kept  more  or  less  under  the  influence  of  narcotics. 
Treatment  consisted  in  making  incisions  into  the  parts 
of  the  swelling  that  fluctuated  :  counting  the  first  made 
in  the  auditory  canal,  and  the  two  below  the  lobule, 
eleven  in  all  were  made.  In  addition  to  keeping  the 
lower  incisions  always  open,  injections  of  a  weak  solu- 
tion of  carbolic  acid,  and  toward  the  last,  of  iodine, 
were  made.  A  compress  bandage,  the  pressure  of 
which  seemed  to  allay  the  pain,  was  kept  constantly 
applied.  She  was  given  quinine  and  generous  diet. 
Hearing  was  but  little  affected.  The  swelling  gradually 
disappeared.  The  case  was  under  treatment  until 
March  27,  1879  (a  year  and  a  half),  and  considerable 
deformity  resulted. 

Dr.  Kipp,  of  Newark,  reports  a  case  of  spurious 
othcematoma  of  both  ears  as  the  result  of  a  burn,  in  a 
boy,  aged  five,  showing  some  similarity  with  perichon- 
dritis auricula.  They  were  treated  by  daily  applica- 
tion of  tincture  of  iodine,  and  at  the  end  of  two 
months  had  regained  their  normal  size  and  shape. 
The  only  deformity  was  a  wrinkled  condition  of  the 
fossa  helicis. 

Dr.  Pomeroy,  in  his  book  on  Diagnosis  and  Treat- 
ment of  Diseases  of  the  Ear,  illustrates  the  following 

case  :  I.   S ,  aged  forty-two,   in   May,  1874,  had  a 

violent  pain  in  the  right  ear,  which  continued  for  eleven 
days  with  very  little  abatement,  when  the  membrane 
ruptured  and  the  ear  discharged  large  quantities  of 
thick  creamy  pus,  with  but  little  relief  to  the  pain. 
-\fter  one  month  a  polypus  made  its  appearance  in  the 
meatus  and  was  removed.  Subsequently  a  very  pain- 
ful circumscribed  swelling  of  the  meatus  was  incised, 
which  gave  great  relief. 

In  July  a  swelling  made  its  appearance  in  the  region 
of  the  concha,  rapidly  extended  to  the  whole  of  the 
auricle,  increasing  its  size  prodigiously.  On  Septem- 
ber ist  I  saw  the  patient  for  the  first  time,  and  found  a 
large  abscess  occupying  the  region  of  the  concha  and 
extending  upon  the  auricle  in  all  directions  so  as  to  in- 
volve about  half  of  its  superficial  area.  It  pointed  both 
in  front  and  behind,  causing  the  auricle  to  stand  out 
from  the  head  at  right  angles.  In  front  of  the  meatus, 
near  the  tragus,  was  a  circumscribed  swelling  with  a 
fistulous  opening  in  its  apex.  The  swelling  of  the  au- 
ricle was  somewhat  nodulated,  giving  it  the  appearance 
of  carcinoma.  Fluctuation  was  easily  detected  both  in 
front  and  behind,  as  the  walls  of  the  abscess  were  very 
thin.  An  incision,  made  posteriorly,  evacuated  about 
five  drachms  of  pus.  A  finger  passed  into  the  incision 
revealed  the  fact  that  the  cartilage  of  the  auricle,  in  the 
region  of  the  pus  cavity,  had  entirely  disappeared  in 
front  and  behind  ;  there  was  nothing  left  except  in- 
tegument and  connective  tissue.  Subsequent  to  this, 
small  abscesses  made  their  appearance  as  follows  : 
Three  were  incised  just  above  the  region  of  the  lobu- 
lus,  one  in  the  tragus,  and  two  on  the  upper  portion  of 
the  helix.  The  principal  pus  cavity  closed  in  three 
weeks  without  special  treatment.  Carbolic-acid  solu" 
tions  were  injected  at  first,  but  they  were  not  well 
borne  and  were  discontinued.  Syringing  out  the  cav- 
ity with  warm  water  daily  was  practised.  The  dis- 
charge from  the  abscess  in  the  helix  was  somewhat 
glairy  in  consistency.  The  duration  of  the  affection 
was  a  little  more  than  five  months.  There  was  no  in- 
sanity, present  or  past,  in  the  patient  or  his  family,  and 
no  history  of  previous  traumatism  was  elicited.  My 
opinion  of  the  nature  of  this  case,  which  coincided  with 
that  of  Dr.  Mathewson's,  who  previously  had  treated 
the  patient,  was  that  these  abscesses  depended  on  a 
perichondritis,  and  that  this  had  been  developed  from 
an  inflammation  of  the  tympanum,  which  had  passed 
outward  along  the  meatus  and  involved  the  auricle  by 
extension. 

Regarding  the  etiology  of  perichondritis,  Dr.  Pome- 


240 


MEDICAL   RECORD. 


[August  17,  1895 


roy  rnoiitions  injuries,  burns,  frost-bites,  and  furun- 
cular  i,,'^'>.-.iniation. 

Dr.  R.Dosa  says  that  any  inflammation  of  the  integu- 
ment, connective  tissue,  and  cartilage  of  the  auricle, 
leading  to  effusion  of  serum,  blood,  or  the  formation  of 
pus,  will  be  apt  to  cause  a  deformity  of  the  part,  and  he 
cites  the  following  case  : 

A  polypus  formed  from  the  prolonged  use  of  poul- 
tices, the  inflammation  extended  to  the  tissue  of  the 
auricle,  and  after  a  long  period  of  suffering,  during 
which  small  abscesses  were  formed,  which  were  evacu- 
ated after  pursuing  a  sinous  course  in  the  integument, 
the  auricle  obtained. 

The  photograph  shows  helix  noniial,  anti-helix  and 
concha  replaced  by  a  uniform  intumescence  ;  the  lobule 
also  is  greatly  swollen. 

Dr.  W.  Freudenthal  attributes  the  perichondritis  in 
my  own  patient  to  the  same  cause,  namely,  the  pro- 
longed use  of  hot  poultices,  and  I  am  of  the  same 
opinion. 


A    CASE    OF   PLACENTA    PR.EVIA. 
By  MYRON  E.  FISHER,  M.D., 


On  August  20,  1S94,  I  was  called  to  see  Mrs.  P , 

aged  thirty-eight,  and  found  the  following  condition  of 
affairs  :  She  had  had  a  severe  chill  two  or  three  hours 
before  my  arrival,  and  I  found  her  with  a  temperature 
of  103)4°  F.  ;  pulse,  100.  While  sitting  at  the  table  a 
short  time  before  my  arrival  she  experienced  a  sensa- 
tion as  of  the  bursting  of  the  amniotic  sac,  which  in- 
deed was  what  really  did  happen.  The  amount  of 
amniotic  fluid  was  rather  more  than  we  would  natu- 
rally expect  at  full  term. 

The  previous  history  of  the  case,  as  far  as  I  was  able 
to  learn,  was  as  follows  :  About  two  months  before, 
while  riding  quite  rapidly  in  a  carriage  over  very  rough 
roads,  she  suddenly  felt  a  gush  of  fluid  and  immedi- 
ately her  clothing  was  drenched  with  it.  From  that 
time  until  I  was  called  she  had  been  flowing  more  or 
less  freely  all  the  time,  but  was  about  the  house  do- 
ing her  work,  supposing  that  the  foetus  must  have  passed 
away.  At  the  time  of  my  arrival  to  see  her  I  found  the 
OS  dilated  to  about  the  size  of  a  nickel  five-cent  piece, 
an'd  there  was  considerable  hemorrhage.  This  contin- 
ued, and  at  a  second  examination,  made  two  hours  later, 
I  found  somewhat  more  dilatation  and  was  able  to  feel 
a  mass  which  I  thought  to  be  placenta.  At  the  same 
time  I  could  feel  the  cord  distinctly,  which  was  pulsat- 
ing. The  hemorrhage  continued  and  I  resorted  to  a 
vaginal  tampon.  This  arrested  it  temporarily,  but  it 
began  again.  I  called  Dr.  F.  Krehbiel  in  consultation, 
and  we  decided  that  the  foetus  must  be  removed,  which 
was  done  without  any  diflficulty,  when  the  womb  con- 
tracted down,  there  was  no  more  hemorrhage,  and 
the  woman  made  a  complete  recovery  without  the  oc- 
currence of  one  unpleasant  symptom. 
-  Now  there  are  two  questions  I  would  like  to  ask 
about  this  case,  viz.  :  i.  Was  the  condition  of  placenta 
prfevia  due  to  an  arrested  abortion  occurring  at  the 
time  of  the  carriage  ride  two  months  before  ?  2.  What 
was  the  cause  of  the  high  temperature  which  I  found 
upon  my  arrival  at  the  bedside  of  my  patient  ? 

By  the  way,  I  should  have  reported  that  this  was  the 
fifth  pregnancy,  all  of  the  others  having  gone  on  to  full 
term  with  normal  labors. 

The  foBtus  was  about  twenty-five  centimetres  (ten 
inches)  in  length. 


The  best  deep  anatomical  guide  to  the  subclavian  ar- 
tery is  the  lower  cord  of  the  brachial  plexus,  which  not 
only  lies  directly  over,  but  is  attached  to  the  sheath  of 
the  vessel. — Horwitz. 


Society  ^e^jorts. 


THE  BRITISH  MEDICAL  ASSOCIATION. 

Sixty-third  Annual  Meeting   held  in  London,  July  jo 
and  ji  and  August  i  and  2,  1895. 

(Specially  Reported  for  the  Medical  Record.) 

First  Day,  Tvesdav,  July  30TH. 

There  was  a  very  large  attendance  of  members,  larger 
perhaps  than  on  any  former  occasion,  and  the  Metro- 
politan Branch  put  forth  all  its  energies  to  entertain  its 
numerous  visitors  and  make  the  meeting  a  success. 

The  Council  met  in  camera  at  9.30,  but  the  first  public 
function  was  at  St.  Paul's  Cathedral,  where  the  Arch- 
bishop of  Canterbury  preached  a  sermon  to  the  mem- 
bers, taking  as  his  text  Rev.  xxii.  i  :  "  And  he  showed 
me  a  pure  river  of  water  of  life,  clear  as  crystal,  pro- 
ceeding out  of  the  throne  of  God  and  the  Lamb." 
The  Archbishop  said  there  was  but  one  source  of  life, 
and  that  was  life  itself.  There  was  only  one  law — life 
from  life,  living  from  living.  In  physical  appearance, 
the  cells  in  which  life  revealed  itself  were  as  like  one 
another  as  drops  of  water.  No  analysis  could  distin- 
guish them  or  show  what  their  development  would  be. 
The  river  of  life  might  be  tainted  \vith  disease,  but  that 
was  accidental,  not  essential  to  it.  The  accidental 
taint  might  be  everywhere,  even  in  the  water  which 
looks  clearest.  But  in  this  century,  he  understood, 
new  light  had  arisen,  and  the  fatal  germs  of  some  dis- 
eases could  be  followed  and  slain,  and  it  was  now  dis- 
cussed whether  immunity  might  not  be  obtained  from 
some  of  the  sufferings  to  which  the  flesh  is  heir.  If 
this  should  be  so  it  would,  the  Archbishop  proceeded 
to  show,  furnish  another  analogy  to  Christian  doctrine. 

In  directly  exhorting  members  the  preacher  dwelt  on 
the  necessity  of  reverence,  which  was  so  important  a 
characteristic  of  the  true  religio  medici.  Their  study, 
he  said,  was  not  life,  but  rather  the  effects  of  life,  and 
in  the  study  of  that  mystery  it  would  be  strange  to  for- 
get reverence. 

The  first  general  meeting  of  members  opened  at  2.30. 
and  occupied  most  of  the  afternoon.  Dr.  Long  Fox, 
the  retiring  President^  could  find  no  words  in  which  to 
express  his  appreciation  of  the  kind  reception  he  met 
with  from  the  large  and  influential  meeting,  but  should 
not  think  of  detaining  them.  Sir  W.  Kingston,  M.D., 
then  proposed  a  vote  of  thanks  to  the  retiring  Presi- 
dent, which  was  seconded  by  Dr.  Cousins  and  carried 
unanimously  amid  great  applause,  and  Dr.  Long  Fox 
was  elected  a  Vice-President  of  the  .Association  for  life, 
and  returned  thanks  in  a  few  words. 

Sir  J.  Russell  Reynolds,  the  new  President,  then 
took  the  chair,  and  moved  the  adoption  of  the  report, 
which  was  taken  as  read. 

The  President  referred  to  the  growth  and  satis- 
factory state  of  the  Association,  which  numbered  six- 
teen thousand  members  and  was  the  largest  and  strong- 
est association  of  medical  men  in  the  world.  He 
mentioned  that  on  the  occasion  of  the  first  anniversarv 
meeting  the  members  of  the  Association  were  under 
one  thousand  five  hundred,  but  a  few  years  afterward 
they  had  increased  to  five  thousand,  and  year  by  year 
it  augmented  in  numbers  and  vitality. 

The  President  then  referred  to  the  exhaustive  re- 
port of  the  -Association  on  the  workhouses  and  the 
poor  law  administration,  which  had  stimulated  the  au- 
thorities to  effect  some  much  -  needed  reforms,  and 
especially  to  more  consideration  for  the  ])Oor.  The 
medical  act  needed  reform,  but  on  public  grounds,  not 
from  a  merely  professional  point  of  view.  The  habit- 
ual inebriates  should  be  dealt  with  by  the  County 
Councils,  who  should  have  the  power  to  deal  with  them 


August  17,  1895] 


MEDICAL    RECORD. 


241 


with  a  view  to  their  reformation,  which  would  never  be 
brought  about  by  sending  them  to  prison,  as  was  done 
under  the  present  system. 

Dr.  Ward  Cousixs,  President  of  the  Council,  was 
of  the  opinion  that  special  deficiencies  required  special 
treatment,  and  referred  to  the  assistance  given  to  asso- 
ciates in  the  south  of  Ireland  which  had  enabled  them 
to  gain  a  victory  in  their  contention  with  the  authori- 
ties. The  Association  had  sustained  many  losses  dur- 
ing the  past  year,  and  some  eminent  names  had  been 
removed  by  death  from  the  list  of  members.  The 
medical  profession  had  its  successes  and  its  disappoint- 
ments, but  it  was  a  noble  one  and  worthy  of  the  best 
men  in  the  community. 

The  Treasurer,  Mr.  Butlin,  would  not  detain  them 
long.  The  assets  of  the  Association  in  excess  of  all  lia- 
bilities amounted  to  the  sum  of  ^60, coo,  and  they  were 
approaching  a  condition  of  prosperity,  but  the  profits 
for  the  year  were  ^4,000  or  ;^5,oco  less  than  for  the 
previous  twelve  months. 

Dr.  Douglas  complained  that  the  report  had  been 
issued  so  late  that  a  great  many  members  had  not  had  an 
opportunity  of  reading  it,  and  he  considered  that  they 
ought  not  to  be  asked  to  pass  what  they  really  know 
little  or  nothing  about.  If  they  were  told  that  this  was 
in  consequence  of  the  Council  ha\ing  met  but  recently, 
all  he  could  say  was  that  they  should  have  met  in  time 
to  issue  the  report  earlier,  so  that  the  members  might 
have  had  an  opportunity  of  considering  it  before  being 
asked  to  vote  on  it. 

Dr.  Campbell  spoke  about  the  registration  of  mid- 
wives  and  the  suppression  of  illegal  medical  and  surgi- 
cal practice.  He  had  noticed  with  surprise,  in  a  recent 
number  of  the  Journal,  an  advertisement  from  a  man 
whose  name  had  been  removed  from  the  Medical 
Register,  and  he  wished  to  ask  the  President  of  the 
Council  how  it  was  that  such  a  grave  mistake  had  been 
made. 

Dr.  Ward  Cousins  replied  that  the  Council  had 
nothing  to  do  with  the  advertisements. 

Dr.  Campbell  then  e.xpressed  an  opinion  that  the 
editor  should  be  held  responsible,  and  if  he  would  not, 
or  could  not,  then  some  one  else  should  be  appointed 
in  his  place  who  would  be  more  in  harmony  with  the 
bulk  of  the  associates. 

Reference  was  then  made  to  a  case  in  which  it  was 
contended  that  the  Association  should  have  rendered 
monetary  aid  to  a  member  of  the  Association,  to  which 
the  President  replied  that  the  Council  were  in  sym- 
pathy with  the  gentleman  in  question,  but  they  had  no 
power,  according  to  the  memorandum  of  association, 
to  divert  any  money  to  such  a  purpose. 

The  Treasurer  was  then  asked  a  question  as  to  the 
lease  of  the  Association's  premises  in  the  Strand,  which 
he  said  would  expire  in  ten  years.  In  reply  to  further 
questions,  it  was  stated  that  the  increase  under  the 
head  of  Editorial  Staff  was  distributed  in  payment  for 
further  clerical  assistance  to  meet  the  increasing  ex- 
pansion of  the  Journal,  as  well  as  for  the  payment  of 
contributors  on  all  sorts  of  subjects,  from  all  parts 
of  the  world.  The  exact  amount  of  salary  received  by 
the  editor  was  stated  to  be  ;^i, 150  per  annum  ;  when 
they  (the  Association)  were  poorer,  they  paid  their 
editor  less,  and  now  that  they  were  better  off,  they 
paid  him  more.  Other  items  of  expenditure  were 
referred  to  designing  and  executing  illustrations,  and 
to  increase  of  actual  material  used  in  the  production 
of  the  Journal,  and  the  demands  of  an  enlarged  and 
constantly  growing  circulation. 

An  elderly  member  then  spoke  at  some  length,  but 
his  remarks  were  quite  inaudible,  except  to  a  few  mem- 
bers in  his  immediate  vicinity. 

The  President  then  put  the  reception  and  adoption 
of  the  report,  and  this  was  carried,  with  a  few  dis- 
senting voices. 

An  interim  report  on  the  state  of  general  practi- 
tioners during  the  past  year  was  then  considered,  and 


the  question  of  the  proposed  registration  of  midwives 
was  awarded  a  great  deal  of  attention,  if  nothing  new 
was  advanced  in  opposition  to  the  scheme.  Some 
members  denied  that  the  proposal  was  a  retrograde 
one,  and  others  objected  to  it  on  the  score  that  it 
created,  or  would  create,  an  inferior  grade  of  practi- 
tioners of  medicine,  and  advocated  the  better  educa- 
tion and  training,  with  a  view  to  registration,  of  medical, 
surgical,  and  obstetrical  nurses.  The  care  of  the 
parturient  woman  should  not  be  delegated  to  any  inter- 
mediate class  of  practitioner.  The  Midwife  Registra- 
tion Bill  was  not  now  before  Parliament,  because  no 
Parliament  was  now  extant,  and  when  it  was  con- 
stituted, if  the  bill  should  come  before  it,  it  would 
have  to  be  introduced  de  novo  as  an  entirely  new  bill, 
and  the  necessary  amendments  might  be  made  in  it 
and  safeguards  be  added  as  required. 

Dr.  Ward  Cousixs  said  that  the  Council  had  no 
power  to  institute  proceedings  for  illegal  practice,  nor 
had  they  any  power  to  control  it  in  the  interest  of  the 
public.  The  authority  that  should  prosecute  in  such 
cases  was  the  General  Medical  Council.  The  CouncU 
of  the  Association  had  taken  high  legal  opinion,  and  it 
was  adverse  to  their  interfering  in  such  matters.  True, 
the  memorandum  of  association  might  be  altered,  but 
that  could  not  be  done  ■n'ithout  entirely  changing  their 
constitution,  which  had  for  its  object  the  promotion  of 
the  honor  and  interests  of  the  profession.  At  present 
they  had  no  power  to  prosecute  quacks,  nor  was  there 
any  unanimity  upon  the  question  of  their  moving  in 
that  direction,  and  until  there  was  there  was  no  pos- 
sibility of  an  alteration  being  made  in  the  memoran- 
dum. At  the  same  time,  when  he  advocated  caution  he 
did  not  at  all  mean  that  nothing  should  be  done,  and 
advised  the  objectors  to  join  some  of  the  "  medical  de- 
fence unions  "  which  were  in  existence,  and  get  more 
members  on  the  General  Medical  Council,  which  was 
now  made  up  of  what  might  be  termed  the  privileged 
class. 

Dr.  Rextoul  said  that  the  Journal  was  in  favor  of 
the  registration  of  midwives,  and  the  bulk  of  the  asso- 
ciates were  opposed  to  it. 

Mr.  Lawsox  T.\it  then  moved  an  amendment  to 
the  report  to  the  effect  that  the  members  of  the  British 
Medical  Association  condemn  the  formation  of  a  new 
and  inferior  grade  of  practitioners,  which  was  received 
with  great  applause  by  the  meeting.  He  complained  of 
the  nan possumus  attitude  of  their  Council.  An  improve- 
ment in  the  status  of  the  midwife  was  necessar)-,  but 
was  registration  the  right  way  to  eft'ect  it  ?  He  said  "  no," 
emphatically,  while  the  other  side  regarded  it  as  inevi- 
table by  the  pressure  of  public  opinion.  But  such  a  step 
would  be  retrograde,  downward  and  backward  ;  medi- 
cal ladies  especially  would  be  handicapped  by  it  ;  and 
if  a  number  of  qualified  females  were  registered  what 
was  to  prevent  unqualified  male  assistants  from  being 
registered,  too  ?  The  registered  midwife  would  have 
no  responsibility  and  be  under  no  control.  The  poor 
would  not  be  benefited  by  the  registration  of  midwives, 
but  would,  on  tlie  contrary,  have  a  grievous  wrong  in- 
flicted on  them,  by  being  handed  over  to  the  care  of 
any  woman  who  had  ever  been  present  at  a  birth  and 
considered  herself  thereby  quahfied  to  be  a  midwife. 
If  the  stigma  of  pauperism  was  removed  from  persons 
obtaining  obstetric  assistance  from  the  parochial  medi- 
ical  officer  much  good  would  be  done,  whereas  now 
men  were  politically  degraded  if  their  wives  were  con- 
fined in  the  workhouse. 

Dr.  Colin  Campbell  was  far  from  complaining  of 
their  old  friend  "  Sairy  Gamp."  He  had  experience  of 
her  for  more  than  twenty  years,  and  he  must  say  that 
he  had  no  knowledge  of  any  such  horrors  as  he  had 
heard  and  read  of  in  her  regard  ;  on  the  contrary-,  it  was 
the  new  Sairy  he  found  intolerable,  the  nurse-midwife 
who  had  been  trained  for  three  months  in  a  lying-in 
hospital  more  or  less  efficiently,  and  who  considered 
herself  "educated  "  and  on  a  par  with  (he  might  have 


242 


MEDICAL    RECORD. 


[August  17,  1895 


said  better  than)  the  medical  practitioner.  The  Ob- 
stetrical Society  of  London  had  been  giving  out 
diplomas  by  the  yard  to  such  persons.  He  had  never 
had  any  trouble  with  the  old  order  of  nurses — they 
knew  their  place — but  he  had  with  the  new,  which  did 
not.  What  did  their  Council  do  toward  opposing  the 
mischievous  Midwives  Registration  Bill  ?  Nothing. 
A  bill  that  placed  women  of  the  Sarah  Gamp  stamp  on 
a  level  with  us  was  derogatory  to  the  honor  of  the 
medical  profession.  He  then  read  an  advertisement 
from  an  "  Anglo-French  "  firm  that  practically  offered 
to  procure  abortion  and  to  provide  midwives,  and 
asked  if  such  persons  were  to  be  registered.  It  was  a 
false  philanthropy  to  attempt  to  pass  off  a  three-months 
midwife  as  a  person  capable  of  attending  on  the  poor, 
and  to  represent  her  as  quite  sufficient  for  them  was 
an  abomination.  More  deaths  took  place  after  than  dur- 
ing parturition.  What  we  want  are  thoroughly  trained 
nurses  and  not  Sairy  Gamps  registered  as  midwives. 

Dr.  Kemp  asked  was  it  philanthropy  that  actuated 
them  in  their  opposition  to  the  registration  of  midwives. 
(Cries  of  "  Yes  !  "  "  Yes  !  ")  were  they  to  ignore  the  mill- 
ions {sic)  of  women  who  gained  their  livelihood  by  acting 
as  midwives  (laughter)  ?  They  seemed  very  impatient  to 
come  to  a  wrong  conclusion  ;  therefore,  as  they  refused 
his  services  in  their  pangs  (laughter),  he  would  withdraw 
them,  and  he  then  sat  down  amid  roars  of  laughter 
from  all  parts  of  the  hall. 

Mr,  Victor  Horsley  did  not  pretend  to  any  spe- 
cial gynecological  knowledge,  but  he  thought  the  ques- 
tion of  the  registration  of  midwives  was  not  before  the 
Association,  though  that  of  the  registration  of  midwife- 
ry and  other  nurses  was,  and  the  rider  to  the  motion 
moved  by  Mr.  Lawson  Tait  had  no  bearing  on  the 
question. 

Dr.  Reid  in  a  very  excited  fashion  apologized  for 
the  midwives  whom  he  had  been  largely  instrumental 
in  educating  ;  it  was  a  question  of  ^  s.  d.  (Cries  of 
"  To  whom  ?  "  and  uproar,  amid  which  the  doctor  sat 
down.) 

Dr.  Havward  said  many  poor  women  could  not  af- 
ford to  pay  more  than  two  or  three  shillings  for  a  mid- 
wife, and  wanted  to  know  where  they  would  find  a  doc- 
tor for  that ;  such  a  matter  was  not  to  be  decided  by 
that  meeting.     (Uproar.) 

Sir  B.  Walter  Foster  had  not  intended  to  inter- 
vene in  the  discussion,  and  should  not  have  done  so  but 
for  the  attempt  of  the  last  speaker  to  throw  dust  in  the 
eyes  of  the  meeting.  He  (Sir  W.  Foster)  was  by  no 
means  opposed  to  improvement  in  the  education  and 
training  and  cleanliness  of  midwives,  and  if  it  was  in- 
sinuated that  they  were  opposed  to  that  the  statement 
was  a  false  one.  He  then  pointed  out  the  danger  to 
parturient  women  from  incompetent  midwives  and  ad- 
vocated well-trained  midwifery  nurses.  Registration 
would  open  the  door  to  the  formation  of  a  low-grade 
order  of  practitioners,  covering  the  whole  ground  and 
encroaching  on  the  domain  of  medicine.  The  diploma 
only  allowed  the  midwife  to  attend  a  natural  labor, 
but  the  Registration  Bill  eliminated  this  safeguard. 
He  heartily  supported  and  called  upon  them  all  to  vote 
for  the  rider  named  by  Mr.  Lawson  Tait. 

An  associate  considered  the  registration  of  midwives 
a  necessity  ;  no  new  order  of  practitioners  would  be  es- 
tablished. (Cries  of  "  Vote  I  "  "  Vote  !  ")  He  spoke  on 
behalf  of  the  women  who  wanted  to  be  attended  by 
women  and  not  by  men,  and  would  prefer  the  midwives 
should  have  some  training,  rather  than  none.  He  was 
sorry  to  see  a  great  Association  ranging  themselves  on 
the  side  of  selfishness,  ((rroans  and  hisses,  during 
which  the  doctor  resumed  his  seat.) 

.\nother  associate  did  not  stand  there  to  utter  a  word 
against  the  honor  of  the  medical  profession,  nor  to 
be  lectured  by  specialists.  (Ironical  cheers.)  They 
wanted  to  get  the  spurious  metal  hall-marked  ;  a  nurse 
acted  under  control  and  a  midwife  independentlv. 

Mr.  Wheelhouse  wished  as  one  of  the  Direct  Rep- 


resentatives in  the  General  Medical  Council  to  say  a 
few  words  to  the  meeting.  He  was  utterly  opposed  to 
the  notion  of  hall-marking  spurious  metal,  to  the  ad- 
mission of  ignorant  women  into  a  position  that  meant 
ruin  to  the  medical  profession.  No  one  could  tell  how 
a  labor  would  turn  out  until  it  was  over,  and  an  igno- 
rant woman  would  not  recognize  danger  if  it  arose. 

Mrs.  ScHARLiCH  related  her  Indian  experience,  and 
said  that  no  members  of  the  profession  felt  the  danger 
of  unqualified  practice  more  than  the  medical  women. 
It  was  a  mistake  to  suppose  that  they  (medical  women) 
were  prepared  to  accept  a  minimum  fee,  but  there  were 
exceptions,  and  people  liked  to  have  a  qualified  person 
when  they  could  have  one. 

Dr.  Murdoch  Cameron*  moved  and  Dr.  Havward 
seconded  an  amendment  to  the  effect  that  the  Associa- 
tion approved  of  the  system  of  registering  midwives, 
and  when  this  was  put  to  the  meeting  only  forty  hands 
were  held  up  for  it.    The  amendment  was  therefore  lost. 

Mr.  Lawson  Tait's  rider  was  then  put  and  carried 
almost  unanimously.  A  member  then  wished  to  put 
another  amendment,  but  was  ruled  out  of  order  by 
the  President  and  sat  down  very  reluctantly. 

Protection  of  the  Profession. — Dr.  Arthur  Wels- 
ford  moved,  and  Mr.  Bullar  seconded,  "  That  it  is  to 
the  interest  of  the  public  and  of  the  profession  that  the 
Council  of  the  Association  should  take  power  and  au- 
thority to  protect  both  the  individual  and  collective 
interests  of  the  profession,  and  that  the  Council  be  re- 
quested to  take  such  steps  as  may  be  necessary  to  en- 
able it  to  actively  undertake  these  duties." 

Both  mover  and  seconder  urged  immediate  attention 
to  this  important  subject,  the  seconder  declaring  it  as 
necessary  to  put  down  quackery  inside  the  profession  as 
it  obviously  is  outside.  Dr.  M.-vck.enzie,  representing 
the  Devon  and  Somerset  branch,  supported  the  resolu- 
tion, and  declared  that  so  strong  a  feeling  existed  on 
the  subject  that  unless  it  were  met  defections  from  the 
Association  must  be  expected. 

The  motion  was  agreed  to  and  some  further  notices 
were  adjourned,  and  the  meeting  closed  with  a  vote  of 
thanks  to  the  Chairman. 

Evening   Session. 

President's  Address. — The  evening  general  meeting, 
which  was  pleasantly  combined  with  a  conversazione, 
was  held  at  the  Imperial  Institute  at  South  Kensing- 
ton. The  members  and  guests  were  received  in  the 
beautiful  vestibule  by  the  President  and  other  mem- 
bers of  the  Executive  and  Reception  Committees. 
The  President's  address  was  afterward  delivered  in  the 
temporary  Great  Hall.  To  pass  to  this  barn-like 
wooden  structure  from  the  marble  staircase  of  the  ves- 
tibule, with  its  fine  proiJortions  and  noble  pillars  and 
roof,  was  to  suffer  a  disappointment  of  one's  esthetic 
expectations.  Unfortunately  the  address  hardly  com- 
pensated most  of  those  present  for  this  disillusionment, 
as,  owing  partly  to  the  bad  acoustic  properties  of  the 
shanty,  and  partly  to  the  noise  outside,  Sir  J.  Russell 
Reynolds  was  only  audible  to  those  in  his  very  imme- 
diate neighborhood  ;  so  much  so  that  when  the  tempting 
strains  of  the  Strauss  orchestra  were  wafted  in  through 
the  windows,  the  bulk  of  the  audience  gave  it  up  as  a 
bad  job  and  left  for  the  gardens  and  the  conversazione. 

Sir  Russell  Reynolds  said  that  it  was  twenty-two 
years  ago  that  the  ISritish  Medical  Association  last  met 
in  London.  At  that  time  Sir  William  Ferguson  was  its 
president,  .and  could  that  distinguished  surgeon  have 
fallen  asleep  after  that  meeting  and  awakened  only  this 
year,  he  would  have  had  difficulty  in  believing  the 
reality  of  what  he  saw.  Those  of  us  who  were  privi- 
leged to  know  him.  remembered  his  coolness  in 
emergencies,  his  oper.ative  dexterity,  and  his  skill  in 
meeting  the  most  unexpected  accidents.  Vet  to-day 
those  who  had  been  his  dressers  would  be  found  per- 
forming, as  a  matter  of  course,  operations  from  which 
even  he  would,  in  the  state  of  our  knowledge  twenty 


August  17,  1 895 J 


MEDICAL   RECORD. 


24- 


years  ago,  have  shrunk  aghast.  In  1873,  Alexander 
Parkes  delivered  the  address  in  medicine,  and  he,  too, 
would  be  surprised  could  he  witness  the  progress  made 
in  medicine,  and  especially  in  preventive  medicine. 

Of  great  advantage  to  the  profession  in  England  was 
the  establishment  of  the  conjoint  examination  by  the 
Royal  College  of  Physicians  and  Surgeons,  and  the 
erection  of  the  Examination  Hall,  where  now  so  much 
valuable  research  work  was  carried  on.  The  student 
of  to-day  is  a  far  more  earnest  and  hard-working  in- 
dividual than  his  predecessor  of  twenty- two  years  ago. 
At  that  time  there  was  no  lack  of  teaching,  but  even  the 
teachers  scarcely  believed  the  half  of  what  they  taught, 
and  did  not  fully  understand  it. 

The  speaker  referred  to  the  present  state  of  nosol- 
ogy, and  regretted  the  tendency  to  label  diseases  or 
groups  of  symptoms  with  the  names  of  their  discoverers 
or  those  who  first  published  descriptions  of  them,  as 
tending  to  divert  attention  from  their  true  relations. 
He  deprecated  equally  Mr.  Hutchinson's  proposal  to 
call  newly  described  disorders  by  the  names  of  the  pa- 
tients who  were  first  noticed  to  suffer  from  them. 

Of  late  years  microbiology  and  the  germ  theory  of 
disease  had  attracted  more  and  more  attention,  as  had 
the  functions  of  structures  such  as  the  thyroid,  the 
adrenals,  and  the  pituitary  body,  which  were  formerly 
unknown,  but  now  bid  fair  to  reveal  themselves. 

The  protective  and  curative  power  of  the  products 
of  disease  germs  was  also  a  new  discovery,  which  was 
of  increasing  importance  and  promised  great  benefits 
to  mankind.  He  feared  that  in  our  social  life  there 
was  a  loss  of  reverence,  "  that  angel  of  the  world,"  and 
that  much  which  now  passed  for  wit  or  cleverness  is 
only  an  offence  against  the  religious  opinions  of  others, 
or  the  long-recognized  standards  of  propriety.  He 
said  that  he  would  not  quote  the  hateful  phrase  which 
was  used  to  characterize  this  class  of  thoughts  and 
actions,  but  he  did  not  think  that  the  "  end  of  the  nine- 
teenth century "  had  much  to  do  with  it.  Children 
may  strip  themselves  as  high  as  they  please  to  paddle 
in  the  edge  of  the  ocean,  but  when  in  the  later  years 
they  roam,  as  society  now  sanctions,  on  the  shores  of 
the  ocean  of  Time,  the  results  might  be  disastrous  to 
themselves.  With  regard  to  the  attitude  of  the  profes- 
sion toward  the  religious  element  in  men's  nature, 
we  should  be  careful  to  do  and  say  nothing  that  could 
damage  what  was  a  very  real  solace  and  comfort  to 
many  in  suffering  and  trouble. 

After  a  vote  of  thanks  had  been  proposed,  seconded, 
and  carried  by  acclamation,  the  audience  adjourned  to 
the  garden,  the  appearance  of  which  was  most  inviting, 
lit  up  by  many  colored  lights  and  filled  with  brilliantly 
dressed  ladies  and  sombre-coated  men.  The  Strauss 
orchestra  and  a  military  band  enlivened  the  proceed- 
ings, and  the  refreshment  buffets  were  well  patronized. 
It  was  nearly  midnight  ere  the  last  visitors  left. 


Second  Day,  Wednesday,  July  31ST. 

The  morning  of  the  second  day  was  devoted  to  sec- 
tional work.  In  the  afternoon  the  second  general  meet- 
ing was  held,  when  the  address  in  medicine  was  deliv- 
ered, after  which  the  business  adjourned  from  the  former 
general  meeting  was  resumed. 

The  Address  in  Medicine  was  delivered  by  Sir  Will- 
iam Broadbent.  Before  the  address  was  begun  Dr. 
Ward  Cousins  made  the  announcement  that  no  place 
had  been  decided  upon  for  holding  the  meeting  next 
year,  nor  had  any  decision  been  come  to  with  regard  to 
the  President  elect,  but  he  hoped  by  the  next  quarterly 
meeting  to  be  able  to  announce  that  both  points  had 
been  settled. 

Sir  Russeil  Reynolds  then  introduced  the  lecturer 
(Sir  W.  Broadbent),  who  began  by  saying  that  a  very 
heavy  responsibility  had  been  placed  upon  him  by  the 
Council  and  Association  ;  they  had  also  given  him  a  rare 
opportunity  and  conferred  upon  him  a  very  great  hon- 


or. The  temptation  to  take  up  some  special  subject  as 
the  text  of  his  address  had  been  very  great,  but  he  had 
resisted  it,  and  decided  to  cons'der  the  growth  of  the 
art  and  science  of  medicine  from  early  times. 

The  art  of  medicine  had  always  preceded  the  science 
and  had  always  been  considerably  in  advance,  but 
science  was  established  upon  the  firmer  basis  of  skill  in 
the  recognition  of  disease,  and  until  science  threw  light 
upon  it  the  progress  of  the  medical  art  had  been  but 
slow. 

True  science  consisted  in  the  application  of  science 
to  the  facts  revealed  by  observation. 

The  identification  of  the  various  forms  of  disease 
was,  at  first,  scarcely  worthy  of  the  designation  of  diag- 
nosis, but  was  simply  the  attaching  of  a  name  to  a  series 
of  symptoms.  Remedies  for  various  diseases  were  due 
to  the  observation  of  the  instinct  that  impelled  many 
animals  to  have  recourse  to  various  substances  when 
suffering  from  disease,  and  experience  afforded  a  fur- 
ther corroboration  of  the  value  of  the  remedies  thus  in- 
dicated. 

Of  the  infancy  of  medicine  we  know  little  or  noth- 
ing, but  even  in  the  time  of  Homer  the  healing  art  was 
known,  and  the  Chinese  had  practised  medicine  from  a 
very  remote  period.  Hippocrates  was  the  first  of  the 
ancients  of  whose  theory  and  practice  of  the  art  of 
healing  we  have  the  best  knowledge  ;  bleeding  was 
practised  as  well  as  cupping,  and  the  valuable  proper- 
ties of  opium  were  also  known  to  him  as  well  as  the  use 
of  enemata,  suppositories,  and  fomentations.  Hippo- 
crates flourished  somewhere  about  400  i;.c.  ;  he  was  a 
contemporary  of  Socrates  ;  he  had  little  true  knowledge 
and  his  physiology  was  extremely  imperfect.  The  at- 
titude of  his  mind  was  directed  toward  the  relief  of  dis- 
ease as  thus  differentiated,  and  in  this  he  was  guided 
rather  by  observation  than  by  theory.  He  could  not, 
however,  entirely  escape  the  influence  of  the  latter,  but 
he  generalized  from  observed  facts.  His  idea  of  "  crit- 
ical days  "  in  the  progress  of  disease  was  derived  from 
the  natural  history  of  febrile  attacks,  and  that  of  "hu- 
mor "  from  the  discharges  in  such  complaints,  for  in- 
stance, as  coryza  ;  the  condition  of  the  stools  in  diar- 
rhoea also  served  to  confirm  the  latter  theory,  for  he 
noticed  that  a  certain  lapse  of  time  intervened  between 
the  commencement  and  end  of  an  attack,  and  he  was 
thus  enabled  to  predict  the  date  of  the  critical  day. 

Another  theory  was  that  four  humors  existed,  whose 
harmony  constituted  health,  and  their  discordance,  or 
the  preponderance  of  one  of  them  over  the  others,  con- 
stituted or  caused  disease.  His  careful  study  of  the 
cause  of  disease  has  made  him  a  model  for  the  physi- 
cians of  all  time.  The  dissection  of  the  human  body 
was  practised  in  the  time  of  Galen,  whose  views  dom- 
inated medical  art  for  a  period  of  fifteen  hundred 
years.  He  was  an  apt  follower  of  Hippocrates,  for  he 
made  observation  the  basis  of  his  practice,  though  his 
imagination  led  him  to  theorize  ;  but  his  observations 
were  directed  by  excellent  common  sense,  while  his 
knowledge  of  anatomy  was  very  superior  to  that  of 
his  master  Hippocrates.  He  recognized  the  difference 
between  sensory  and  motory  nerves  ;  his  physiology 
no  doubt  was  fanciful,  but,  nevertheless,  he  made  some 
noteworthy  discoveries — for  instance,  that  urine  was 
secreted  by  the  kidneys  and  was  conveyed  into  the 
bladder  by  the  ureters  ;  and  when  this  idea  was  ridiculed 
by  his  contemporaries,  he  proved  it  by  applying  liga- 
tures to  the  ureters  ;  he  came  very  near  to  the  dis- 
covery of  the  circulation  of  the  blood,  and  knew  that 
the  arteries  contained  this  vital  fluid,  though  he  also  be- 
lieved them  to  con\  ey  air  through  the  body.  He  wrote 
upward  of  one  hundred  treatises  on  matters  connected 
with  the  science  and  art  of  medicine.  That  on  the 
localization  of  disease  was  very  true  to  nature,  and  his 
description  of  various  symptoms  was  remarkably  cor- 
rect. For  example,  his  account  of  dysuria  affords  evi- 
dence of  his  robust  common-sense,  and  is  singularly 
accurate  :  A  child  had  suppression  of  urine  which  was 


244 


MEDICAL   RECORD. 


[August  17,  1895 


referred  to  the  lodgment  of  a  stone  at  the  neck  of  the 
bladder  ;  the  patient  was  to  be  placed  on  his  back  with 
the  pelvis  elevated  and  the  knees  flexed,  he  was  then 
to  be  shaken  smartly,  when  the  stone  would  slip  from 
its  position  and  urine  would  be  immediately  voided  ;  if 
not,  the  patient  was  to  be  shaken  again  more  vigorously 
than  before,  and  if  relief  was  not  then  obtained,  he  was 
to  have  a  catheter  passed,  in  order  to  dislodge  the  stone. 

Galen's  materia  medica  remained  in  vogue  for  a  long 
period,  one  of  the  principal  remedies  being  theriaca, 
which  consisted  of  a  variety  of  substances  of  which 
li(|uorice  was  one. 

Both  Hippocrates  and  Galen  rejected  the  doctrine  of 
the  empirics,  which  referred  all  disease  to  alternated 
relaxation  and  constriction.  The  followers  of  Mo- 
hamrned  found  the  writings  of  these  fathers  of  medi- 
cine in  the  library  of  Alexandria,  and  the  ideas  con- 
tained in  them  were  largely  adopted  by  the  Arabian 
physicians,  which  brought  them  once  more  into  promi- 
nence. 

The  small-pox,  which  was  brought  by  the  Saracens 
into  Europe,  was  thought  to  be  due  to  the  presence  of 
a  particular  ferment  in  the  blood. 

The  great  plague,  circa  1348,  and  the  sweating  sick- 
ness of  1485,  left  no  mark  on  the  therapeutics  of  the 
world,  but  when  syphilis  appeared,  in  1494,  guiacum 
was  held,  though  it  is  difficult  to  account  for  the  fact, 
to  be  a  certain  specific,  but  it  was  soon  superseded  by 
mercury,  fumigation  being  practised  then  with  the  latter 
drug  as  well  as  inunction. 

In  the  fourteenth  century  the  dissection  of  the  hu- 
man body  and  its  post-mortem  examination  were  both 
practised.  In  15 18  the  art  of  medicine  received  a 
prodigious  impetus,  by  the  labors  of  many  eminent 
physicians,  and  in  1628,  Harvey  made  his  great  dis- 
covery of  the  circulation  of  the  blood,  which  has  made 
an  epoch  in  biology,  but  his  knowledge  he  derived 
from  Fabricius(?). 

It  was  a  long  time  before  the  great  discovery  had 
much  practical  effect  on  the  medical  art  ;  indeed,  the 
first  conclusions  from  it  were  absurd,  if  not  positively 
mischievous. 

The  nerves  were  also  supposed  to  circulate  a  special 
fluid. 

Sydenham  and  his  contemporary  Boerhaave,  circa 
1680,  offer  an  interesting  comparison  with  Hippocrates 
and  Galen,  and  the  most  important  addition  to  the  ma- 
teria' medica  in  their  time  was  "bark,"  of  which  the 
great  English  physician  had  a  high  appreciation  ;  he 
also  advocated  the  employment  of  mercury  in  the  treat- 
ment of  many  diseases,  and  had  a  high  opinion  of  anti- 
mony. Nature,  he  thought,  was  engaged  in  the  expul- 
sion of  various  peccant  substances  from  the  system,  and 
the  wisest  physician  was  he  who  rendered  her  the  most 
effective  aid  in  her  laudable  efforts. 

It  is  more  difficult  to  know  when,  where,  and  how  to 
act  than  it  is  to  determine  what  is  to  be  done  ;  any  ap- 
prentice will  tell  you  in  a  moment  what  to  give  to  i^urge 
oi_  make  a  patient  vomit,  but  it  is  not  so  easy  to  deter- 
mine when  those  effects  are  to  be  produced.  Much  per- 
versity is  often  displayed  in  the  application  of  new  dis- 
coveries, but  we  have  now  reached  a  point  in  the 
progress  of  medicine  when  we  can  have  no  other  guide 
than  science. 

Physiology  as  a  science  depends  on  the  appreciation 
of  physical  and  chemical  laws  ;  Harvey's  discovery  was 
a  barren  one  until  the  recognition,  or  discovery,  by 
Lavoisier,  of  the  phenomenon  of  respiration,  by  which 
we  arrived  at  the  knowledge  of  blood  tension  ;  while 
the  microscope  gave  an  expansion  to  knowledge  that 
cannot  be  over-estimated. 

Lavoisier  discovered  the  role  played  by  oxygen  in 
combustion,  and  his  recognition  of  its  analogy  with  the 
function  of  respiration  was  both  a  revelation  and  a 
revolution,  and  it  was  chemistry  that  demonstrated  the 
relationship. 

Chemistry   interprets    the   relation  existing  between 


structure  and  structure  ;  every  vital  act  is  a  chemical 
act,  and  chemistry  is  the  link  between  pathology  and 
therapeutics. 

Morgagni  was  the  founder  of  pathology,  and  Hunter, 
\'irchow,  and  others  gave  it  new  developments.  Clini- 
cal observation  has  always  been  in  advance  of  physical 
diagnosis,  but  the  latter  has  been  much  advantaged  by 
percussion,  auscultation,  and  the  clinical  thermometer, 
which  constitute  epochs  in  its  development  ;  the  last  es- 
pecially has  revolutionized  therapeutics,  and  it  is  difficult 
to  imagine  now  how  anything  could  have  been  done 
without  its  assistance,  not  only  in  the  diagnosis  but  the 
treatment  of  pyrexia  ;  and  yet  its  introduction  is  of  very 
recent  date.  Our  knowledge,  too,  of  the  various  duct- 
less glands  of  the  body  and  their  functions,  has  been 
greatly  improved  of  late,  and  we  know  that  their  role  is 
to  supply  something  to,  not  to  withdraw  anything 
from,  the  system. 

The  discovery  of  the  part  played  by  micro-organ- 
isms in  disease  and  the  discoveries  of  Lister,  whose  in- 
finite capacity  to  take  pains  constitutes  genius,  as  well 
as  the  discoveries  of  Pasteur,  can  only  be  mentioned, 
but  thanks  to  their  labors  we  have  ascertained  the  im- 
portant function  of  bacteria  and  their  products  in  the 
causation  as  well  as  in  the  alleviation  and  cure  of  dis- 
ease. 

What  bearing  has  all  this  on  therapeutics  ?  The  best 
pathologist  is  the  best  physician. 

New  remedies  are  introduced  every  day,  chiefly  for 
the  benefit  of  those  who  do  not  know  how  to  properly 
use  the  old  ones.  The  physiological  action  of  a  drug 
is  inferred  from  its  chemical  constitution,  and  thera- 
peutics only  waits  for  an  answer  to  the  questions  she 
puts  to  chemistry  in  order  to  become  a  science. 

There  are  still  new  fields  to  be  conquered,  for  there 
is  much  in  connection  with  the  art  of  medicine  that  is 
far  from  being  fully  understood  ;  in  this  personal  ex- 
perience is  the  best  guide  and  finds  expression  in 
theory  ;  but  no  theory  is  of  universal  application,  al- 
though homoeopathy,  a  relic  of  old  times,  pretends  that 
the  contrary  is  the  case  ;  but  we  are  in  danger  of  being 
carried  away  by  fashion. 

There  is  no  universal  panacea,  though  there  are  small 
working  hypotheses,  gout,  for  instance,  to  one,  and 
something  else  to  another,  who  get  hold  of  one  idea, 
apply  it  to  everything,  and  stick  to  it  through  thick  and 
thin  :  what  we  really  meant  is  to  treat  the  patient  and 
not  the  disease. 

Reverting  to  the  prevention  of  tuberculosis,  Sir 
William  said  that  antiseptics  would  destroy  organisms 
when  present,  but  care  should  be  taken  that  in  lower- 
ing the  temperature  we  did  not  also  lower  the  patient. 
Nature,  he  thought,  was  no  bungler,  but  knew  her 
business,  and  no  doubt  had  an  object  in  raising  it. 

At  no  time  than  the  present  had  the  science  of 
medicine  and  its  professors  more  right  to  be  congratu- 
lated on  its  progress,  and  never  have  both  stood  higher 
in  the  estimation  of  the  world. 

Dr.  P.wv  then  proposed  a  vote  of  thanks  to  the  lect- 
urer, and  remarked  that  science  should  always  be  the 
foundation  of  art,  but  the  latter  anteceded  science  as  a 
rule,  but  they  were  getting  nearer  and  nearer  to  their 
proper  relative  positions.  The  address  to  which  they 
had  just  listened  could  only  proceed  from  a  mind  of  a 
high  order,  and  he  would  only  say  that  it  was  worthy 
of  the  man  who  had  given  it. 

Professor  Cvm.mixc.  seconded,  and  said  that  in  all 
times  the  leaders  of  medical  thought  were  not  only 
great  physicians  and  surgeons,  they  were  also  great 
men.  Far  from  being  too  conservative,  we  (medical 
men)  are  only  too  ready,  he  thought,  to  take  up  new 
ideas. 

Dr.  Paw  stood  up  to  put  the  proposed  vote  to  the 
meeting,  and  then  said,  no,  he  would  not  put  it  (great 
applause).     Vote  of  thanks  carried  with  acclamation. 

Dr.  Keating,  of  Toronto,  then  came  forward  to 
convey  the  cordial  greeting  of  the  medical  men  of  On- 


August  17,  1895] 


MEDICAL   RECORD. 


245 


tario  to  the  great  British  Medical  Association.  Xo 
body  of  men  in  Canada  was  more  loyal  than  they,  their 
medical  association  numbered  some  three  thousand 
members,  and  they  took  a  great  pride  in  the  associa- 
tions, in  which  they  were  determined  to  live  and  die. 

The  Midwives  Eegistration  ftnestion  Again. — Mr. 
Victor  Horsley  moved  the  adoption  of  the  report 
of  the  Parliamentar)-  Bills  Committee.  The  bill  for 
the  amendment  of  the  medical  acts  that  was  before 
the  last  parliament  was,  he  thought,  too  narrow,  and 
should  have  embraced  the  constitution  and  procedure 
of  the  General  Medical  Council ;  the  committee  had 
referred  the  matter  for  consideration  to  a  sub-commit- 
tee that  had  only  had  time  to  consider  one  point, 
namely,  the  Registration  of  Midwives,  and  the  sub- 
committee asked  to  be  reappointed  in  order  to  give 
full  consideration  to  the  whole  subject. 

The  report  was  received  and  adopted  unanimously. 

Dr.  Lovell  Drage  offered  an  alternative  to  the 
Registration  of  Midwives,  namely,  the  improved  educa- 
tion of  the  male  medical  student  in  obstetrics.  Puer- 
peral fever  was  supposed  to  be  carried  from  one  pa- 
tient to  another  by  ignorant  women,  but  the  greatest 
parturient  mortalit}'  was  referable  to  the  accidents  of 
childbirth  and  not  to  puerperal  fever.  No  one  should 
be  permitted  to  undertake  the  practice  of  midwifery 
who  had  not  pre\"iously  attended  a  large  number  of 
cases  of  parturition.  He  then  proposed  the  following 
"  rider "  to  the  report,  although  Dr.  AVard  Cousins 
thought  it  unnecessar)-  as  the  subject  was  under  the 
consideration  of  their  Council,  whereupon  Dr.  Drage 
retorted  that  surely  the  Council  should  not  object  to 
have  their  hands  strengthened. 

Rider  :  "  That  we  viev:  with  deep  concern  and  re- 
gret the  recommendation  of  the  General  Medical  Coun- 
cil to  the  medical  examining  bodies  that  they  should 
admit  students  to  their  final  examination  who  present 
a  certificate  that  they  have  '  conducted  personally ' 
only  three,  and  '  been  present  at '  only  nine  confine- 
ments ;  and  as  the  General  Medical  CouncQ  has  re- 
fused on  November,  1890,  to  alter  this  recommenda- 
tion, we  instruct  our  Council  to  petition  the  General 
Medical  Council  to  recommend  that  no  student  be  ad- 
mitted to  his  final  medical  examination  until  he  pre- 
sents a  certificate  showing  that  he  has  personally  con- 
ducted at  least  thirty  confinements  under  the  direct 
supervision  of  a  registered  medical  practitioner.  We 
also  instruct  the  Council  to  take  immediate  steps  to 
have  Section  20  of  the  Metropolitan  Poor  Act  of  1869 
repealed,  which  prevents  workhouse  infirmaries  from 
being  used  for  the  clinical  instruction  of  medical  stu- 
dents in  practical  midwifer)-,  while  pupil  midwives  are 
now  admitted  ;  and  also  to  petition  the  committees, 
medical  staffs,  and,  if  need  be,  the  subscribers  to  the 
City  of  London  Lying-in,  the  British  Lying-in,  and 
the  Clapham  Maternity,  to  withdraw  their  rule  which 
excludes  male  medical  students  from  clinical  instruc- 
tion at  these  hospitals,  seeing  that  these  are  now  used 
by  pupil  midwives." 

This  was  seconded  by  Dr.  Rextoul,  who  said  he 
must  again  refer  to  the  scandalous  fact  that  men  were 
turned  out  to  practise  midwifery  after  attending  three 
labors ! 

After  some  discussion  a  vote  was  then  taken  on  the 
report,  which  was  declared  carried.  The  rider  was  then 
put  to  the  meeting,  and  speaking  in  support  of  it.  Dr. 
Ritchie,  of  Manchester,  said  that  students  had  to  take 
their  instruction  in  midwifery  from  the  midwives,  and 
Dr.  Draper  added  that  the  latter  had  to  be  "  tipped." 

The  rider  was  then  carried  unanimously. 

Dr.  Rentoul  moved  another  rider  with  reference  to 
the  direct  representation  of  general  practitioners  on 
the  General  Medical  Council.  Sir  Walter  Foster 
and  Mr.  Wheelhouse  supported  the  proposition,  and 
the  former  said  that  he  had  done  his  best,  but  they  were 
five  to  twenty-five,  and  he  had  received  no  outward  sup- 
port from  the  profession,  although  during  the  last  three 


years  he  was  in  a  position,  as  a  member  of  the  late  gov- 
ernment, to  have  done  something  to  forward  their 
views. 

On  reference  being  again  made  to  the  instruction  of 
students  in  midwifery.  Dr.  Ward  Cousins  said  that 
the  Council  was  of  opinion  that  careful  personal  in- 
struction in  three  cases  was  better  than  attendance  on 
thirty  cases,  in  some  of  which,  at  least,  the  only  part 
taken  by  the  student  would  be  to  rest  his  hand  on  the 
bed-post  and  look  on.     (Laughter  and  cheers.) 

Dr.  Rentoul's  rider,  seconded  by  Dr.  H.Woods,  was 
then  put  and  carried  unanimously. 

Dr.  Normax  Kerr  then  moved  the  adoption  of  the 
report  of  the  Committee  on  Legislation  for  Inebriates, 
and  observed  that  inebriation  should  be  treated  as  a 
disease  and  not  as  a  crime.  Inebriate  houses  were  not 
prisons,  and  with  reference  to  the  infringement  of  per-  • 
sonal  liberty,  was  not  this  done  every  day  in  the  case  of 
lunatics  who  had  never  been  guilty  of  crime  ?  Seconded, 
and  adopted  unanimously. 

The  report  of  the  Therapeutics  Committee  was 
also  moved,  seconded,  and  adopted,  without  dissent. 

The  report  of  the  Medical  Charities  Committee  was 
moved  by  Dr.  Bridgewater,  seconded  by  Dr.  Browx, 
and  adopted  unanimously. 

The  report  of  the  Committee  for  the  Efficient  Con- 
trol of  Railway  Servants'  and  Mariners'  Ej'esight,  was 
moved,  seconded,  put  to  the  meeting,  and  adopted 
unanimously. 

The  report  of  the  Committee  on  the  Mental  and  Phys- 
ical Condition  of  Children,  to  the  Council  of  the  British 
Medical  Association,  was  moved  by  Dr.  Bridgewater, 
seconded,  and  adopted  unanimously. 

The  report  of  the  Anaesthetics  Committee  was  simi- 
larly moved  and  adopted,  which  ended  the  proceedings 
for  the  day. 

There  was  a  musical  promenade  in  the  afternoon  at  the 
Gardens  of  the  Royal  Botanic  Society,  followed  in  the 
evening  by  an  illuminate  fete  at  the  same  gardens. 
This  very  popular  entertainment  continued  unril  mid- 
night. The  Duke  and  the  Duchess  of  Teck  visited  the 
gardens.  On  the  lake  there  was  a  floating  windmill, 
the  body  constructed  of  bright  red  lamps  and  the  sails 
white,  and  a  verj'  effective  attraction  it  proved  to  be. 
In  the  large  tent  there  was  a  great  display  of  medicinal 
and  tropical  plants  geographically  arranged,  and  the 
bands  gave  great  delight  to  the  lovers  of  music. 


Third  Dav,  Thursday,  August  ist. 

The  Address  in  Surgery  was  delivered  by  Mr.  Jon- 
athan Hutchinson,  who  was  received  with  loud  and 
prolonged  applause.  He  paid  a  graceful  tribute  to  the 
memory  of  Mr.  Arthur  Durham,  whose  untimely  death 
threw  the  duty  of  delivering  this  address  at  somewhat 
short  notice  on  his  shoulders.  It  would  perhaps  be  of 
advantage  to  take  a  brief  retrospect  of  surgery,  without 
going  back  beyond  the  last  century,  but  he  could  not 
attempt  to  compete  with  Sir  William  Broadbent,  whose 
retrospect  of  medicine  must  be  fresh  in  their  minds. 

In  the  year  1750  Samuel  Sharpe  published  "A 
Criucal  Enquirj'  into  Surgery."  The  author  -was  a 
fellow  of  the  Royal  Society  and  a  surgeon  of  good 
position  in  his  day,  and  he  prepared  himself  for  his 
task  by  travel  and  inquirj'  on  the  Continent,  where  he 
observed  and  studied  foreign  surgery,  and  this  work 
indeed  was  the  result  of  a  visit  to  Paris.  It  was  re- 
ceived with  favor  and  translated  into  French,  German, 
and  Spanish,  and  may  be  taken  as  affording  a  fair 
criterion  of  the  state  of  surgerj'  at  that  time. 

Sharpe  thought  well  of  English  surgerj'.  It  is  to  be 
remembered  that  Pott  was  then  in  his  prime  and  John 
Hunter  still  young.  As  to  the  treatment  of  fractures, 
Sharpe  says  that  of  course  all  surgeons  were  agreed  as 
to  their  treatment.  In  reading  his  book  one  is  struck 
by  the  restriction  of  topics,  in  marked  contrast  to  the 
vast  field  covered  by  surgerj-  now.     He  remarked  of 


246 


MEDICAL    RECORD. 


[August  17,  1895 


one  operation  that  it  was  "  neither  dreadful  in  the 
doing  nor  melancholy  in  the  event,"  and  it  would 
seem  that  the  contrary  was  true  of  many  of  the  opera- 
tions then  in  vogue.  More  than  sixty  years  afterward 
a  French  surgeon  named  Roux  published  in  Paris  the 
results  of  his  observations  made  in  London.  These 
were  the  days  of  Astley  Cooper  and  Lawrence,  and 
John  Hunter  had  been  dead  for  twenty  years.  He 
noted  what  he  considered  the  extraordinary  fondness 
of  English  surgeons  for  anatomical  preparations.  He, 
held  the  opinion  that  England  was  the  only  rival  of 
France  in  surgery,  other  nations  being  beneath  notice. 
Russia  was  then  only  emerging  from  barbarism,  and 
the  surgery  of  the  United  States,  which  has  of  late 
years  so  largely  contributed,  and  bids  fair  to  more  and 
more  contribute,  to  our  knowledge,  was  scarcely  in 
existence.  He  noted  also  that  only  one  hospital  in 
London,  and  that  the  speaker  was  proud  to  say  was  the 
London  Hospital,  made  any  attempt  to  distinguish  be- 
tween medical  and  surgical  cases.  In  some  cases  he 
criticised  adversely  the  dexterity  of  the  surgeons,  and 
remarked  that  twenty  minutes  was  the  time  taken  to 
perform  a  circular  amputation,  an  operation  which 
the  Paris  surgeons  would  have  completed  in  a  quarter 
of  that  time.  He  thought  also  that  fractures  were 
treated  better  in  France  than  in  England.  Roux  was 
amazed  to  find  so  much  time,  labor,  and  money  ex- 
pended at  the  College  of  Surgeons  Museum  on  com- 
parative anatomy,  a  subject  that  he  thought  should  be 
treated  in  a  museum  of  natural  history.  What  would 
he  say  could  he  revisit  the  museum  now  and  find  our 
best  wall  space  given  to  collections  of  skulls  and  other 
non-surgical  specimens  ?  We  have  turned  what  should 
be  an  unrivalled  clinical  museum  into  a  Golgotha  of 
anthropology. 

In  the  year  1854  Mr.  (now  Sir)  Spencer  Wells  was 
editor  of  the  Medical  Times  and  Gazette,  and  the 
present  speaker  was  his  assistant.  Believing  that  con- 
temporary medical  literature  but  imperfectly  repre- 
sented the  real  results  of  operative  surgery  in  London, 
he  instituted  a  systematic  inquiry,  which  was  largely 
conducted  during  three  years — from  1S55  to  1858 — by 
Mr.  Hutchinson.  In  the  course  of  that  inquiry  he 
learned  much.  He  frequented  all  the  operating  theatres 
of  London,  and  was  in  confidential  communication 
with  many  surgeons.  In  some  cases  the  results  were 
surprising. 

Spencer  Wells  and  Hutchinson  thought  at  one  time 
that  ovariotomy  was  an  unjustifiable  operation.  They 
knew  of  fourteen  consecutive  cases,  all  fatal  ;  and  in- 
deed a  well-known  coroner  announced  his  intention  to 
hold  an  inquest  on  the  next  fatal  case  that  came  under 
his  notice.  The  results  of  lithotrity  also  were  most 
discouraging.  Cases  were  reported  cured,  but  they  were 
not  cured  ;  they  turned  up  again  and  again,  and  be- 
came perennial  patients.  The  published  reports  on 
the  operation  were  most  untrustworthy.  This  was  be- 
fore the  work  of  Bigelow  had  entirely  revolutionized 
the  treatment  of  stone,  but  when  litholapaxy  was  in- 
troduced he  recognized  the  fact  that  the  days  of  lithot- 
omy as  regards  most  cases  were  numbered.  He  had 
taken  up  the  operation  warmly,  but  finding  that  he 
could  not  get  the  amount  of  practice  needful  for  the 
education  of  his  hands,  after  one  fatal  case  he  refused 
again  to  operate  and  handed  over  those  cases  that  came 
to  him  to  specialists.  He  had  done  this  in  many  cases, 
including  two  of  his  own  colleagues.  For  many  years 
now  there  had  been  no  death  from  the  operation  as  it 
had  come  under  his  notice,  and  no  case  had  required  a 
second  operation.  It  might  well  be  said  that  relief  was 
"  cito  et  tutum."  It  was  in  the  hands  of  specialists 
that  this  great  success  occurred.  He  considered  his 
practice  of  lithotrity  through  the  hands  of  others  most 
successful,  and  was  proud  of  it. 

Spencer  Wells  did  his  first  ovariotomy  in  February, 
1858,  and  the  speaker  followed  with  one  in  May  of  the 
same  year.     Both  were  successful.     Baker  Brown,  who 


had  some  years  previously  had  successful  cases,  was 
present  at  both  operations.  At  that  time  the  treatment 
of  the  pedicle  was  a  burning  question.  The  extra  ab- 
dominal method  commended  itself  to  him,  and  for  its 
better  carrying  out  he  had  introduced  the  clamp,  with 
gratifying  results.  Spencer  Wells,  however,  ligatured 
the  pedicle  and  dropped  it  back,  leaving  the  long  ends 
of  the  ligature  hanging  out  of  the  wound.  The  latter's 
first  case  suppurated,  perhaps  owing  to  the  ends  of  the 
ligatures  in  the  wound.  Finding  that  his  cases  in  the 
wards  of  a  general  hospital,  where  sufficiently  strict  pre- 
cautions could  not  be  taken,  did  not  do  so  well  as  those 
under  Spencer  Wells,  he  gave  up  operating  and  sent  all 
cases  to  the  Samaritan  Hospital,  acting  on  the  princi- 
ple that  it  would  be  wrong  to  undertake  an  operation 
himself  that  he  thought  could  be  better  or  more  safely 
performed  by  another.  After  a  time  the  clamp,  which 
at  one  time  bade  fair  to  become  a  permanent  addition 
to  the  surgeon's  armamentarium,  was  discarded,  and  the 
pedicle  generally  dropped  back  into  the  abdomen. 
Tyler  Smith  was  one  of  those  who  made  this  method 
popular.  It  was  difficult  to  understand  why  a  proceed- 
ing that  is  so  successful  now  should  have  been  so  un- 
successful formerly.  Probably  the  increased  knowl- 
edge of  the  principles  of  antisepsis  and  asepsis  was  the 
cause. 

Specialism  in  eye  disease  had  proved  of  the  greatest 
benefit.  When  Roux  visited  London  he  remarked 
with  disapproval  on  the  special  ophthalmic  hospitals 
which  were  springing  up.  He  thought  them  likely  to 
injure  the  best  interests  of  the  profession  and  the  pub- 
lic. Years  afterward  when  the  speaker  visited  Paris  he 
saw  the  results  of  this  prejudice  in  the  wards  of  Roux's 
own  hospital,  where  in  case  after  case  of  cataract  ex- 
traction the  eye  was  lost  through  suppuration.  He  be- 
lieved that  if  the  statistics  of  ovariotomy  for  the  whole 
kingdom  could  be  collected  they  would  be  found  to  be 
far  less  favorable  than  the  statistics  of  specialists. 

Many  men,  such  as  Sir  H.  Thompson,  in  bladder  sur- 
gery, ^Iacewen,  in  brain  operations,  and  Mayo  Robson, 
in  the  surgery  of  the  gall-bladder,  while  unconnected 
with  any  special  institutions,  were  yet  specialists.  These 
were  instances  of  what  we  might  call  personal  special- 
ism, and  these  men  were  benefactors  of  the  public,  and 
a  striking  feature  of  their  practice  was  that  they  had 
an  influence  over  and  trained  others  in  those  special 
branches.  The  evils  of  specialism  were  known  to  all, 
but  charlatanism  was  not  confined  to  specialists  by  any 
means,  and  it  was  in  the  early  days  of  a  specialty  and 
before  it  was  well  established  that  charlatans  found 
their  opportunity. 

Suppose  that  at  the  present  day  a  journal  were  to 
follow  the  plan  of  Spencer  Wells  and  himself  in  1855, 
the  results  would  be  astonishing.  The  increase  in  the 
number  of  operations  both  in  public  and  in  private 
practice  was  enormous.  He  could  remember  the  in- 
stitution of  the  first  nursing  home  in  London,  and  a 
very  humble  beginning  it  was.  Now  there  were  streets 
where  every  other  house  was  a  nursing  home,  and  each 
equipped  with  a  staff  of  admirable  nurses,  who  seemed 
to  be  born  for  their  calling.  What  became  of  such 
women  before  the  modern  nurse  existed  he  knew  not, 
and  he  was  equally  at  a  loss  to  know  what  became  of 
these  nurses  nowadays,  for  none  of  them  ever  seemed 
even  to  approach  middle  age. 

The  use  of  annesihetics  had  enormously  increased. 
It  was  not  so  very  long  ago  that  one  practitioner  only 
was  enough  for  the  needs  of  all  London,  and  some  sur- 
prise was  expressed  that  he  should  find  enough  to  do. 
Mr.  Snow  was  succeeded  by  Mr.  Clover,  and  although 
his  monopoly  was  less  absolute,  still  for  a  long  time  he 
had  no  rival.  To-day  there  were  names  of  no  less  than 
six  official  anesthetists  on  the  list  of  the  staff  of  Guy's 
Hospital  alone.  And  there  was  a  society  of  anesthe- 
tists which  had  found  it  necessary  to  refuse  to  admit 
any  but  bona-jide  specialists.  He  would  here  refer  to 
the  wonderfully  complete  and  interesting  museum  of 


August  17,  1895] 


MEDICAL   RECORD. 


247 


anjesthetic  apparatus  exhibited  in  connection  with  this 
meeting. 

The  change  in  the  last  twenty  years  in  the  senti- 
ments of  the  public  toward  operations  was  a  very  strik- 
ing one.  Formerly  the  surgeon  had  to  persuade  the 
patient  to  consent.  Now  he  was  in  danger  of  being 
persuaded  to  operate,  against  his  better  judgment,  by 
the  importunities  of  the  patient.  It  was  recorded  that 
each  ancient  Greek  physician  used  to  be  accompanied 
in  his  visits  by  an  orator,  whose  business  it  was  to  per- 
suade the  patient  to  take  his  medicine.  Xo  such  per- 
suasion was  now  needed  with  the  improved  pharmacy 
of  to-day.  He  often  wondered,  if  the  physician  needed 
one  orator,  by  how  many  the  surgeon  had  to  be  sur- 
rounded in  order  to  be  allowed  to  operate  ? 

Surely  no  one  ought  now  to  die  of  cancer  of  the 
tongue.  The  awful  mortality  of  other  times  was  due  to 
the  neglect  of  attention  to  the  early  stages  of  the  dis- 
ease. A  symptom  which  used  to  be  relied  upon,  and 
taught  as  a  valuable  one  for  diagnosis,  was  that  of  en- 
largement of  the  glands.  This,  which  in  S)Tne's  time 
was  considered  as  an  indication  that  operation  was 
needed,  would  now  be  considered  as  rendering  opera- 
tive interference  almost  hopeless.  He  remembered  to 
have  seen  Syme  do  his  operation,  dividing  and  evert- 
ing the  halves  of  the  jaw,  with  his  customary  dexter- 
ity. The  operation  was,  indeed,  "  dreadful  in  the  do- 
ing and  melancholy  in  the  event."  He  thought  that 
surgeons  even  nowadays,  erred  in  not  plainly  telling 
patients  as  soon  as  they  suspected  it,  that  they  had  can- 
cer. It  would  be  found  that  they  would  submit  to 
early  operation.  There  were  surgeons  now  who  could 
boast  of  scores  of  cases  of  partial  or  complete  removal, 
with  little  or  no  fatality.  Formerly  the  horrors  of  long 
suppuration  and  many  painful  dressings  deterred  pa- 
tients from  submitting  early  to  removal  of  the  breast, 
although  the  operation  had  long  been  a  successful  one. 
Xo  one  would  now  wait  for  enlargement  of  the  glands  ; 
and  retraction  of  the  nipple,  formerly  mentioned  as  an 
important  diagnostic  sign,  would  now  be  considered  as 
evidence  that  interference  had  been  too  long  delayed. 
The  evidences  afforded  by  the  finger  of  the  trained 
observer  were  enough,  and  it  was  now  the  rule,  "  when 
in  doubt,  operate."  Patients  had  got  to  know  that 
operation  and  subsequent  recovery  were  almost  pain- 
less, and  submit  gladly  to  early  performance.  The 
statistics  of  the  operation  must  be  rewritten.  Recov- 
eries without  recurrence  were  not  uncommon. 

As  regards  the  training  of  surgeons — in  London  re- 
cently a  five  years'  curriculum  had  been  made  com- 
pulsory. Although  he  supported  with  his  vote  the 
measures  concerted  by  the  two  colleges  for  carrying 
this  into  effect,  he  was  not  a  warm  advocate  of  it.  It 
seemed  to  be  an  application  of  the  argument,  "  If  you 
keep  a  horse  long  enough  at  the  water  you  can  make 
him  drink."  We  might  exclude  poor  students  who 
could  not  afford  so  long  a  time,  and  by  a  five  years' 
curriculum  John  Hunter  might  have  been  shut  out. 
In  arbitrary  enactments  of  this  kind  he  had  little  faith. 
He  would,  however,  reform  the  methods  of  examina- 
tion. More  time  was  wanted  and  more  quiet  oppor- 
tunities for  the  candidate  to  do  his  best.  Many  a 
nervous  man  was  disconcerted  on  entering  the  exam- 
ination-room by  the  examiner  suddenly  thrusting  some 
specimen  at  him  with  the  challenge,  "  Tell  me  what 
that  is  ?  " 

It  was  a  mistake  to  suppose  that  medical  education 
ends  with  the  attainment  of  a  diploma.  There  were 
plenty  of  general  hospitals  that  invited  the  lad  from 
school  or  college  and  provided  for  his  professional 
education  until  he  was  qualified.  He  hoped  that  some 
day  some  general  hospital  would  reser\e  itself  for  the 
teaching  of  the  qualified  men.  Some  operations  should, 
he  thought,  be  avoided  altogether,  except  the  skilled 
diagnostician  and  the  skilled  manipulator  were  at 
hand. 

In  conclusion  Mr.  Hutchinson  said  that  the  object  of 


his  address  had  been  to  attempt  to  grasp  clearly  and 
without  prejudice  the  tendency  of  modern  surgery. 
We  must  always  remember  that  our  first  duty  was  to 
our  patient,  and  that  his  claims  were  even  greater  than 
those  of  science.  He  referred  to  the  tendency  of 
improvements  in  surgery  to  damage  the  pecuniary  in- 
terests of  the  profession.  The  public  ought  to  appre- 
ciate this. 

We  might  all  be  most  thankful  for  the  progress  made. 
A  hearty  vote  of  thanks  to  the  speaker  was  carried  by 
acclamation. 

The  Patrick  Stewart  Prize. — Sir  J.  Russell  Rey- 
nolds then  presented  the  Patrick  Stewart  Prize  to 
Brigade  Surgeon  Lieutenant-Colonel  Cunningham  {in 
absentia)  for  his  valuable  work  in  bacteriology,  espe- 
cially as  regards  the  comma  bacillus.  He  had  also 
made  important  observations  as  to  the  temperature  of 
the  soil,  and  its  bearing  or  the  prevalence  and  activity 
of  cholera.  His  works  adorned  the  scientific  literature 
of  India  and  this  country. 


Fourth  Day,  Friday,  August  2D. 

Address  in  Physiology.  —  Dr.  Edward  Albert 
Sch.Xfer  began  his  address  by  stating  that  he  had 
selected  a  definite  subject  upon  which  to  address  the 
meeting,  namely,  the  internal  glands,  which  were 
organs  that  secreted  something  from  the  blood,  which 
had  a  considerable  part  to  play  in  the  economy 
of  the  body.  The  external  secreting  glands  might 
also  be  called  internal,  for  while  they  excreted  they 
also  passed  secretions  into  the  lymph  or  blood,  but 
the  ductless  glands  had  only  an  internal  secretion, 
and  this  was  of  more  importance  than  the  exter- 
nal secretion  ;  in  the  case  of  the  pancreas  there  was 
an  excretory  duct,  and  yet  if  this  organ  was  removed 
from  an  animal,  that  animal  would  die.  But  if  it  was 
only  partially  removed,  the  creature  would  live.  Re- 
moval of  the  kidneys  was  quickly  followed  by  the  death 
of  the  animal  that  had  been  deprived  of  them,  and  if 
only  partially  destroyed,  the  animal  would  live.  They 
should,  therefore,  be  ranked  with  the  liver  and  pancreas 
as  internal  secreting  glands. 

The  internal  secretion  of  the  liver  was  of  two  kinds, 
one  of  which  was  useful,  and  the  other  not  so,  and  this 
was  also  the  case  with  the  kidneys  ;  but  the  salivary 
and  the  mammary  glands  could  be  removed  without 
any  ill  effect  ensuing.  The  pancreas  was  structurally 
different  from  the  other  glands,  for  it  contained  within 
it  portions  of  vascular  epithelium  scattered  through  its 
other  tissues,  and  its  sole  use  was  not  to  secrete  pan- 
creatic juice.  Twenty  per  cent,  of  diabetic  patients 
suffered  from  disease  of  the  pancreas.  In  1845  C.  Ber- 
nard removed  the  pancreas  from  an  animal  and  it  died 
a  short  time  afterward,  but  on  a  subsequent  occasion 
the  operation  was  performed  under  more  favorable 
conditions,  and  then  glycosuria  and  polyuria  appeared. 
The  animals  wasted  and  died  in  about  fifteen  days  after 
the  operation,  but  if  a  portion  of  the  gland  was  left 
there  was  no  diabetes  ;  if  a  part  of  another  pancreas 
was  grafted  into  the  skin  of  an  animal  and  its  own  pan- 
creas was  removed,  that  was  sufficient  to  prevent  the 
diabetes,  which  appeared  as  soon  as  the  graft  was  taken 
away. 

Paraffin  had  been  injected  into  the  pancreatic  ducts, 
which  it  destroyed.  Atrophy  of  the  organ  followed, 
but  no  diabetes,  for  the  islands  of  vascular  epithelium 
were  left  intact,  and  to  that  fact  the  non-appearance  of 
the  glycosuria  was  due.  The  injection  of  pancreatic 
juice  into  the  veins  prevented  the  diabetes,  but  the 
operation  was  a  dangerous  one  ;  raw  pancreas  admin- 
istered by  the  mouth  had  no  effect — had  no  influence. 

The  ductless  glands  had  no  external  secretion,  but 
nevertheless  were  secreting  organs,  for  removal  of  the 
thyroid  gland  resulted  in  speedy  wasting  and  death, 
as  when  that  gland  was  extirpated  for  the  cure  of  goitre 
the  operation  was  quickly  followed  by  myxoedema.    Mr. 


248 


MEDICAL  RECORD. 


[August  17,  1895 


Victor  Horsley  had  operated  on  monkeys  and  found 
that  they  lived  longer  afterward  than  dogs  did  ;  when 
the  operation  was  performed  on  birds  no  result  fol- 
lowed, and  herbivorous  animals  seemed  to  suffer  little 
or  no  inconvenience  from  the  removal  of  the  thyroid 
gland,  with  the  exception,  however,  of  the  rabbit. 

The  ill  effects  following  the  removal  of  the  thyroid 
might  be  pr-evented  by  the  administration  of  thyroid 
extract  either  subcutaneously  or  by  the  mouth,  and  a 
successful  graft  of  thyroid  effected  a  complete  cure  ;  in 
those  cases  where  death  ensued  the  subjects  were 
thought  to  die  from  auto-toxication,  the  thyroid  gland 
collecting  material  from  the  blood  and  converting  it 
into  a  useful  or  at  least  a  harmless  product. 

The  pituitary  body  is  a  gland  with  an  internal  secre- 
tion, and  its  destruction  is  followed  by  death  in  about 
a  fortnight,  generally  from  an  attack  of  dyspnoea  ;  when 
the  thyroid  gland  was  removed  the  pituitary  body  was 
found  to  enlarge,  but  disease  of  the  latter  was  not  fol- 
lowed by  myxoedema  but  by  acromegaly.  Injury  of  the 
pituitary  body  caused  a  rise  of  the  blood-pressure,  and  a 
contraction  of  the  blood-vessels.  When  the  suprarenal 
capsules  were  removed,  death  from  great  muscular 
weakness  quickly  followed,  but  there  was  no  deposition 
of  pigment,  which  took  place  when  they  w-ere  injured 
or  diseased. 

Extract  of  suprarenal  capsules  produced  no  effect 
when  injected  into  a  dog,  unless  the  dose  was  large. 
Rabbits  are  more  susceptible.  The  intravenous  injec- 
tion of  their  extract  showed  that  the  suprarenal  cap- 
sules yield  a  secretion  of  great  power  over  the  auricle, 
and  that  this  effect  was  not  due  to  nervous  irritation 
was  proved  by  its  having  the  same  effect  in  a  frog  from 
which  the  whole  of  the  brain  and  spinal  cord  had 
been  removed  ;  but  the  effect  soon  passes  oft',  though 
the  reason  for  its  doing  so  is  doubtful,  probably  the 
product,  whatever  it  may  be,  becomes  stored  up  in  the 
muscles.  A  very  minute  dose  will  produce  the  effect, 
a  dose  of  one-millionth  part  of  a  grain  will  suffice. 

Internal  secretions  are  produced  by  the  ductless 
glands  as  well  as  by  the  external  glands.  There  is  a 
vast  field  for  the  employment  of  these  extracts,  but 
much  connected  with  them  is  still  very  obscure,  and  in 
all  probability  they  are  destined  to  take  the  place  of 
vegetable  remedies. 

Professor  Bowdich  proposed  a  vote  of  thanks  to 
the  lecturer,  and  said  that  so  far  the  employment  in 
medicine  of  these  animal  extracts  had  not  found  much 
favor  with  the  profession  or  the  public,  for  they  re- 
called to  mind  the  barbarous  remedies  of  the  middle 
ages,  when  portions  of  animals  were  blended  with  veg- 
etable and  mineral  products  into  a  hodgepodge  that 
was  then  thought  to  be  a  cure  for  every  malady  under 
the  sun. 

Professor  Lauder  Brunton  was  happy  to  second 
the  vote  of  thanks,  and  thought  that  we  have  now  come 
to  the  parting  of  the  ways  between  the  old  and  new 
therapeutics. 

A  vote  of  thanks  was  then  put  by  the  President,  and 
carried  with  acclamation. 

Professor  Sch.\fer,  in  re])ly,  would  make  but  two 
remarks  ;  he  greatly  appreciated  the  high  honor  that 
was  conferred  on  him  when  the  Council  asked  him  to 
address  the  meeting,  and  also  because  of  his  election 
as  the  successor  in  giving  the  address  in  physiology  of 
two  such  distinguished  men  as  W.  Sharpey  and  B. 
Saunderson. 

The  Secretary  of  the  Association  then  read  a  resolu- 
tion condemning  the  action  of  the  Medical  Aid  Societv 
and  an  expression  of  opinion  that  no  one  who  accepted 
the  position  of  medical  officer  to  it  should  continue 
a  member  of  the  British  Medical  Association,  which 
ought  to  have  power  to  control  practice  of  that  kind. 

The  usual  votes  of  thanks  to  all  who  had  contributed 
in  various  ways  to  the  success  of  the  several  meetings, 
and  the  jileasure  and  comfort  of  the  associates,  were 
then  pas.sed    with  the    usual  unanimity  and  applause, 


some  amusement  being  caused  by  the  President's  allu- 
sion to  the  Colleges  of  Physicians  and  Surgeons,  whose 
favors  he  remarked  were  yet  to  be  bestowed. 


'^exo  %n3tvxxmcnt5. 

HOLDERS  TO  USE  WITH  THE  HAND  DYNA- 
MOMETER. 

By  ALFRED  J.  ANDREWS,  M.D., 

BROOKL\'K,  N.   V. 

I  h.we  used  these  holders  in  testing  several  hundred 
cases  during  the  past  few  months,  with  so  much  advan- 
tage and  satisfaction  that  I  feel  that  others,  engaged  in 
similar  work,  may  find  them  useful.  Until  I  had  them 
made  for  me  by  Messrs.  Tiemann  &  Co.  I  did  not  secure 
as  much  accuracy  as  I  desired  in  the  examination  of 
the  candidates  for  positions  in  the  civil  service  of 
Brooklyn,  and  had  no  means  of  accurately  measuring 
deficient  or  defective  groups  of  muscles  on  either  side 
of  the  body  in  other  cases. 

The  hand  dynamometer  is  placed  in  the  frame,  dial 
outward,  and  is  held  in  position  by  the  traction  on  the 
handles.  In  some  tests  both  handles  are  held  by  pa- 
tient, in  others  one  is  held  by  the  operator  and  the  other 
by  patient  (or  other  maybe  affixed  to  a  hook  in  floor  or 
wall),  or  in  the  "  push  "  holder  one  handle  of  it  may  be 
applied  against  any  portion  of  patient's  body,  while  the 
other  is  held  by  the  physician  ;  in  still  other  tests  it  is 
necessary  to  have  a  strap  with  a  hook,  as  in  testing  the 
muscles  of  the  neck  with  the  "  pull "  holder,  in  which 
case  it  is  also  necessary 
to  prevent  the  patient 
from  influencing  the  re- 
sult with  his  weight. 

I  have  found  these 
tests  useful  in  recording 
the  progress  in  tabetic 
patients,  in  saturnine 
poisoning  and  nerve  in- 
jury, and  have  used 
them  in  testing  the  fol- 
lowing groups  of  mus- 
cles with  "  holder  for 
pulling  :  "  Flexors  of 
arm,  of  forearm,  of  leg, 
of  foot,  and  of  head; 
also  the  abductors  of 
the  arm  (in  different  di- 
rections) and  of  thigh. 
The  extensor  groups,  as 
those  of  forearm,  of 
arm,  of  leg  (quadriceps 
extensor) — these  while  seated — of  head  and  of  foot 
(with  strap). 

The  "  holder  for  pushing  "  may  be  used  to  supple- 
ment some  of  the  above  tests  and  for  adductors  of  arm 
(pectorals,  etc.),  flexors  of  thigh,  adductors  of  thigh,  and 
of  arm  while  forearm  is  flexed,  elbow  at  side,  and 
holder  is  between  inner  side  of  patient's  arm  and  physi- 
cians' hand,  which  is  on  patient's  side,  and  may  also  be 
used  in  testing  power  of  muscles  which  r,iise  hand  from 
shoulder  straight  up  above  head  (part  of  trapezius,  del- 
toid, serratus  magnus,  triceps,  etc.). 

And  lastly  the  pulling  frame  may  be  used  for  testing 
the  accuracy  of  the  dynamometer  itself,  by  hanging  it 
from  a  hook  and  applying  carefully  a  known  weight. 


Insomnia. — If  the  patient  is  unable  to  obtain  sleep 
during  early  hours  of  night,  give  trional  :  if  patient 
readily  falls  to  sleep  upon  retiring,  but  awakens  too 
early,  give  sulfonal. 


August  17,  1895] 


MEDICAL    RECORD. 


249 


€ai:xtsvon&cncc, 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  women's  petition  to  THE  COLLEGE  OF  SURGEONS 
— UNIVERSITY  OF  DURHAM — GENERAL  ELECTION  AND 

MEDICINE HONORS    FOR     SURGEONS    AT     CHITRAL 

MEMORIAL  TO  HUXLEY — SMALL-POX  IN  THE  SALVA- 
TION ARMY  SHELTERS  —  CHELSEA  HOSPITAL — PTO- 
MAINE POISONING — A  MEDICAL  MOVE  AT  THE  GEN- 
ERAL   ELECTION SANITATION     AS     A     PARTY    CRY 

ANOTHER  HOSPITAL  PROPOSED  FOR  LONDON- — THE 
PRINCE  AND  PRINCESS  AT  THE  ROYAL  FREE  HOS- 
PITAL  THE  SUNDAY  FUND — THE  DROUGHT — A  FA- 
TAL PRACTICAL  JOKE BRITISH  MEDICAL  ASSOCIA- 
TION MEETING — BRITISH  MEDICAL  ASSOCIATION  — 
MEMORIAL  TO  HUXLEY ANOTHER  TO  MEYER — PRES- 
ENTATION TO  SIR  J.  LISTER — DEATH  OF  SIR  J.  TOMES 
— HEALTH  OF  LONDON — OUTBREAK  OF  SMALL-POX. 

LONDON,  July  19,  1895. 

The  school  of  Medicine  for  Women  has  taken  what 
some  think  a  bold  step  in  petitioning  the  Council  of  the 
College  of  Surgeons  to  admit  women  to  the  examina- 
tions. The  Council  has  never  been  considered  a  body 
likely  to  entertain  such  a  proposal,  it  has  always  dis- 
played conservative,  if  not  to  say,  obstructive,  instincts. 
I  hear,  however,  that  the  ladies  are  very  hopeful,  and  it 
is  whispered  in  some  quarters  that  influence  has  been 
brought  to  bear  on  individual  councillors  which  jus- 
tifies the  expectation  of  success.  There  are  council- 
lors who  are  known  to  have  supported  the  women's 
school,  and  it  is  hardly  likely  that  they  would  not  be 
willing  to  admit  its  pupils  to  any  examination.  Then 
there  is  the  pecuniary  aspect  of  the  question.  The 
Council  is  not  likely  to  be  indifferent  to  this.  The  fee 
for  membership  is  twenty  guineas.  If  other  authori- 
ties admit  women,  why  should  not  the  college  secure  its 
share  of  qualifying  fees.  The  college  is  the  authority 
most  generally  known,  its  members  being  the  most  nu- 
merous, and  if  its  doors  should  be  opened  to  women  no 
doubt  they  will  crowd  into  it.  The  popularity  of  the 
diploma  would  secure  a  large  proportion  of  the  female 
candidates.  How  far  the  present  members  might  ap- 
prove the  intrusion  of  further  rivals  is  another  ques- 
tion. But  they  will  have  no  voice  in  the  matter.  The 
Council  will  decide.  Having  decided,  it  may  mention 
the  matter  in  the  report  to  the  meeting  of  fellows  and 
members,  but  that  meeting  would  be  unable  to  reverse 
the  decision. 

In  connection  with  this  subject,  I  may  state  that  the 
University  of  Durham  has  obtained  a  supplementary 
charter  which  enables  it  to  confer  on  women  any  de- 
grees it  can  confer  on  men  (except  degrees  in  divinity). 
One  lady  has  already  received  a  degree  in  science,  and 
medicine,  arts,  literature,  and  music  will  no  doubt  soon 
have  women  graduates  in  their  several  faculties. 

We  are  in  the  midst  of  a  general  election,  so  politi- 
cal controversy  and  excitement  is  displacing  many 
medical  subjects.  This  excitement  is  very  injurious  to 
certain  weak  or  nervous  persons,  and  three  deaths  are 
already  reported  as  having  occurred  from  this  cause. 
A  medical  man  was  also  assaulted  in  Cork,  a  rare  cir- 
cumstance even  in  that  lively  locality,  for  even  turbu- 
lent Irishmen  generally  respect  the  doctors,  to  which- 
ever party  they  belong. 

That  coveted  distinction,  the  Victoria  Cross,  has  been 
conferred  on  Surgeon-Captain  Whitchurch  for  his  con- 
spicuous bravery  during  the  sortie  from  Chitral  Fort. 
Your  readers  will  no  doubt  remember  how  he  carried 
Captain  Baird  on  his  back  through  a  hail  of  bullets,  for 
!  the  story  has  been  told  by  all  the  newspapers.  Sur- 
geon-Major Robertson  has  been  promoted  to  a  knight 
commandership  of  the  Star  of  India,  and  further  hon- 
ors will  no  doubt  in  due  time  be  gazetted. 


There  are.  I  believe,  not  one  hundred  and  eighty 
Victoria  Crosses  living  in  all  arms,  and  the  bronze 
medal  and  red  ribbon  being  so  seldom  conferred,  ren- 
ders the  distinction  more  coveted  than  perhaps  any. 
Dr.  Whitchurch  makes  the  number  of  medical  men 
who  have  won  this  honor  up  to  fifteen  now  alive. 
This  is  certainly  a  splendid  proportion,  and  should  put 
to  shame  the  snobs  who  sneer  at  the  army  surgeons  as 
"  non-combatants." 

The  memorial  to  the  late  Professor  Huxley  at  Char- 
ing Cross  Hospital  is  to  take  the  form  of  a  scholarship 
and  medal,  and  if  funds  permit  an  annual  lecture  on 
recent  advances  in  science  and  their  bearing  on  medi- 
cine. It  is  not  improbable  that  a  memorial  of  a  wider, 
perhaps  national,  scope  may  also  be  raised.  In  the 
meantime  the  Charing  Cross  School  may  be  congratu- 
lated on  the  probable  success  of  her  attempt  to  hon- 
or her  distinguished  son. 

Several  more  small-pox  cases  have  been  traced  to  Sal- 
vation Army  shelters,  but  the  managers  of  that  organiza- 
tion still  resist  the  proposal  to  place  them  under  sanitary 
supervision.  One  medical  officer  of  health  went  to  in- 
spect a  shelter  in  his  district  with  a  couple  of  his  inspect- 
ors, but  they  were  refused  admission.  Dr.  Waldo,  the 
medical  officer  of  health,  obtained  a  j  ustice's  warrant,  but 
was  again  refused  until  he  threatened  to  bring  a  force 
of  police.  On  this  he  was  admitted  and  found  over- 
crowding of  the  grossest  character  along  with  utterly 
inadequate  ventilation.  The  vestry  has  ordered  an 
abatement  of  the  nuisance,  and  it  is  to  be  hoped  that 
a  firm  determination  to  subject  so  dangerous  a  plague 
spot  to  the  sanitary  authorities  will  be  maintained.  No 
one  wishes  to  interfere  with  the  charitable  work  of  the 
Salvation  Army,  but  it  is  monstrous  that  it  should  be 
permitted  to  sow  small-pox  in  the  community.  "  Gen- 
eral "  Booth  may  be  as  autocratic  as  he  likes  over  his 
willing  "  soldiers,"  but  he  must  submit  to  sanitary  laws, 
and  if  there  is  any  difficulty  as  to  the  process  of  com- 
pelling him  legislation  must  be  called  in.  To  set  up  a 
focus  of  infectious  disease  under  the  name  of  charity  is 
too  great  a  demand  on  the  tolerance  of  the  commu- 
nity. It  is  a  great  pity  that  the  promoters  of  many  a 
good  work  should  be  so  obstinately  blind  to  the  evil  of 
spreading  infectious  disease.  There  are  able  medical 
men  among  the  supporters  of  the  Salvation  Army,  and 
they  would  do  well  to  speak  plainly  to  the  autocratic 
rulers,  and  if  not  listened  to,  they  had  better  separate 
themselves  from  the  organization  and  let  the  public 
know  why. 

It  is  whispered  that  further  trouble  threatens  the 
Chelsea  Hospital  for  Women.  I  hear  that  the  chair- 
man has  asked  for  the  resignation  of  one  of  the  lately 
elected  staff  who  refuses  to  comply  with  the  request. 

A  sad  case  of  poisoning,  apparently  by  ptomaines, 
has  occurred  in  a  girls'  school  at  Limerick,  and  four 
deaths  have  already  occurred.  This,  too,  just  before 
the  commencement  of  the  holidays,  when  children  and 
parents  were  looking  forward  to  a  happy  meeting.  A 
custard  was  suspected,  and  the  cook  had  noticed  that 
one  of  the  eggs  was  discolored.  Either  that  or  the 
milk  seemed  to  be  the  source  of  poison.  Sir  C.  Cani- 
eron  has  investigated  the  matter  and  found  no  ordi- 
nary poison  in  the  viscera  of  two  of  the  patients.  He, 
however,  extracted  a  substance  that  gave  all  the  reac- 
tions of  ptomaines,  but  the  quantity  was  too  small  to 
permit  of  differentiating  this  from  other  ptomaines. 
It  is  most  unfortunate  that  none  of  the  custard  was 
preserved,  nor  of  the  vomit  of  the  patients,  as  no  doubt 
Sir  C.  Cameron  would  have  been  able  to  shed  still  more 
light  on  the  matter.  I  believe  this  is  the  first  instance 
in  which  a  ptomaine  has  been  extracted  from  the  vis- 
cera of  a  person  so  poisoned. 

London,  July  26,  1895. 

In  the  turmoil  of  the  general  election  the  doctors  of 
Bradford,  led  by  their  distinguished  Medical  Officer  of 
Health  (Whiteside  Hime),  have  scored  well  for  their 


250 


MEDICAL   RECORD. 


[August  17,  1895 


profession.  They  submitted  a  series  of  questions  to 
the  parliamentary  candidates  in  their  locality  as  to  the 
relations  between  the  state  and  medical  men.  The 
pith  of  their  queries  was  whether  it  was  right  for  the 
state  to  exact  forced  labor  from  one  class  of  citizens  ; 
and  considering  medical  men  acquire  their  knowledge 
without  one  farthing  of  aid  from  the  state,  and  are  not 
protected  in  practice  as  the  lawyers  are,  ought  they  to 
be  compelled  to  give  gratuitously  the  result  of  their  la- 
bors, whether  by  notifications,  certificates,  or  otherwise  ? 

The  liberal  candidates  made  only  vague  replies,  no 
doubt  remembering  that  their  leaders  when  in  power 
have  always  slighted  the  profession.  The  conservative 
and  labor  candidates  gave  straightforward  and  satisfac- 
tory replies.  The  result  is  an  object  lesson  to  poli- 
ticians as  well  as  doctors,  for  Bradford  returned  three 
unionists  to  parliament  ;  and  although  the  wave  of  pub- 
lic disgust  which  has  made  a  clean  sweep  of  the  sepa- 
ratists had  much  to  do  with  it,  the  influence  of  the 
profession  must  also  be  reckoned,  and  when  it  is  re- 
membered how  wide-spread  that  influence  must  be  if 
united,  perhaps  legislators  will  give  some  attention  to 
representations  as  to  the  rights  and  wrongs  of  so  impor- 
tant a  class  of  electors. 

Disraeli,  when  leading  the  victorious  part)',  raised 
the  cry  "  Saaiias,  sanitas,  omnia  sanitas."  If  now  this 
party,  which  has  come  in  almost  unpledged  except  to 
maintain  the  union  of  the  empire,  will  at  once  take  up 
the  great  sanitary  questions  on  which  the  welfare  of  the 
public  so  much  depends,  we  may  cry  in  the  same  way  : 
Magna  est  sanitas  et  piurvalebit. 

It  seems  we  are  to  have  another  general  hospital  in 
London.  The  cry  is  the  need  of  such  accommodation 
south  of  the  Thames.  No  doubt  that  district  is  com- 
paratively poor,  but  it  has  done  hitherto  without  the 
proposed  two  hundred  beds,  and  north  of  the  river 
there  is  a  sad  superabundance  of  hospitals.  It  was 
proposed  that  Charing  Cross  Hospital  should  sell  its 
enormously  valuable  site  and  remove  to  the  poorer  lo- 
cality, but  the  managers  repudiated  the  proposition. 
Yet  it  would  have  been  an  honorable  action  and  have 
benefited  north  and  south  alike.  Will  no  other  hos- 
pital take  the  hint  ?  Something  depends  on  the  tenure 
of  their  sites.  I  suppose  the  Westminster  does  not 
hold  on  sufficiently  favorable  terms,  or  one  could  well 
spare  it,  and  to  place  some  unprejudiced  gentlemen  of 
the  south  on  its  board  would  perhaps  neutralize  the  un- 
just treatment  it  has  too  frequently  measured  to  its 
staff.  If  this  new  hospital  is  to  be  established  it  would 
be  a  blessing  to  confine  it  to  in-patients,  and  so  prevent 
any  further  abuse  of  the  out-patient  department  of  hos- 
pitals. 

The  Prince  of  Wales,  with  his  wife  and  daughters, 
opened  the  new  buildings  at  the  Royal  Free  Hospital 
on  Monday  last,  referring  gracefully  in  his  speech  to 
the  interest  taken  in  the  charity  by  his  family.  The 
new  front  building,  which  has  cost  about  thirty  thou- 
sand pounds,  is  named  after  the  Princess  Alexandra, 
and  after  the  ceremony  Her  Royal  Highness  passed  a 
considerable  time  in  the  wards,  speaking  a  few  words  to 
the  patients  and  distributing  among  them  the  flowers 
of  the  bouquet  which  had  been  presented  to  her. 

It  is  expected  that  the  Hospital  Sunday  Fund  will 
this  year  amount  to  ^46,000,  and  the  Lord  Mayor  is 
appealing  to  the  public  to  make  it  up  to  ^^50,000. 

The  long  spell  of  fine  weather  has  threatened  some 
districts  with  a  water-famine.  Proceedings  have  been 
taken  against  one  of  the  London  companies  for  not 
supplying  the  amount  necessary  to  householders.  It  is 
strange  that  this  should  be  considered  less  urgent  than 
the  watering  of  the  streets.  In  some  rural  districts, 
also,  the  drought  has  caused  suffering  and  brought  into 
prominence  defects  which  the  sanitary  authorities  must 
remedy,  or  great  danger  will  be  incurred. 

A  sad  death  has  followed  a  stupid  practical  joke. 
The  joker  tickled  a  sleeping  man's  ear  with  a  wooden 
spill.     A  sudden  start,  a  splinter  penetrating  the  tym- 


panum, inflammation  spreading  to  the  brain,  inquest  I 
Such  was  the  course  of  events.  When  will  these  prac- 
tical jokers  cease  their  foolish  annoyances  ? 

The  British  Medical  Association  is  to  occupy  us  in 
London  next  week.  Some  ominous  grumblings  have 
been  heard  as  to  the  rejection  of  papers  in  some  sec- 
tions. Some  discontent  has  also  been  manifested  at 
the  pressure  put  on  leading  men  to  prevent  them  giving 
their  communications  to  other  journals.  The  editor 
has  inserted  a  black-letter  notice  that  applications  for 
copies  must  be  addressed  to  him.  All  in  editorial  or- 
der, but  I  remember  some  years  ago  he  managed  to 
comply  with  such  requests  when  it  was  too  late.  As  I 
don't  want  copies  I  can  express  the  hope  that  those 
who  do  may  succeed  in  getting  them.  Still  it  savors 
of  littleness  that  "  this  great  association,"  as  the  clique 
love  to  call  themselves,  should  try  to  dictate  to  authors 
who  make  the  meetings  attractive. 

There  is  likely  to  be  a  regular  scrimmage  over  the  mid- 
wives  question,  which  is  exciting  controversy  in  all  di- 
rections. A  meeting  has  been  called  for  the  night  be- 
fore the  association  meets,  and  notices  of  amendments 
to  the  proposals  of  the  Council  have  been  given.  So 
at  least  one  lively  general  meeting  is  possible. 

London,  August  3.  1895. 

The  British  Medical  Association  has  occupied  us  this 
week,  and  what  with  address  and  speeches,  most  of  us 
are  glad  it  is  nearly  over.  Then  dinners,  luncheons, 
and  similar  functions  have  surfeited  many,  and  the  rest 
of  us  have  devoted  ourselves  to  making  our  guests 
comfortable. 

The  President  opened  with  a  dinner  on  Mondaj-, 
when  he  was  still  Presiderht-elect.  The  same  evening 
there  was  a  meeting  of  the  opponents  of  the  Registra- 
tion of  Midwives,  outside  the  association,  and  against 
the  policy  which  the  Journal  clique  has  so  unjustifiably 
tried  to  push.  The  profusion  of  entertainments  will 
have  given  our  provincial  brethren  a  great  variety  of 
choice,  and  most  of  them  seem  to  have  been  well 
pleased  at  our  efforts  to  please  them.  There  were  al- 
most necessarily  some  shortcomings  and  omissions,  but 
they  will  doubtless  be  forgiven. 

To-day  is  to  be  devoted  to  excursions  and  entertain- 
ments as  usual,  and  yesterday  not  a  few  of  our  guests 
bid  us  farewell.  Some  of  us  will  follow  their  example 
to-night  and  leave  the  metropolis  for  a  holiday,  which 
unless  snatched  at  once  will  be  lost  altogether.  Mean- 
time your  own  reporters  have  sent  you  full  accounts  of 
each  day's  proceedings. 

Memorials  and  testimonials  have  been  much  to  the 
fore  during  the  week.  It  is  proposed  to  raise  a  national 
one  to  the  late  Professor  Huxley,  and  the  Royal  Society 
has  taken  the  necessary  steps  to  constitute  a  prelimi- 
nary committee.  No  definite  action  further  than  receiv- 
ing names  of  those  intending  to  subscribe  will  be  taken 
at  present,  but  after  the  holidays  the  adherents  to  the 
proposal  will  be  asked  to  elect  a  committee  to  replace 
the  temporary  one  and  to  carry  out  the  wishes  of  sub- 
scribers in  the  matter. 

A  memorial  is  being  got  up  to  Wilhelm  Meyer,  whose 
pioneer  work  on  adenoids  in  the  naso-pharynx  is  every- 
where recognized — so  a  committee  has  formed  itself  in 
London.  These  gentlemen  have  appealed  to  the  pub- 
lic in  a  letter  to  the  newspapers  about  the  thousands  of 
persons  "  saved  from  life-long  deafness,"  and  so  on.  I 
don't  admire  the  taste  of  the  letter,  deeply  as  I  would 
honor  Meyer,  but  as  the  presidents  of  the  two  Royal 
Colleges  have  signed  it,  I  have  no  opposition  to  offer. 

There  was  a  large  gathering  at  King's  College  Hos- 
pital on  Tuesday,  to  present  to  Sir  Joseph  Lister  a 
portrait  of  himself.  The  presentation  was  made  by  Sir 
J.  E.  Erichsen  in  very  felicitous  terms.  Among  otlier 
appropriate  remarks  Sir  John  said  a  new  era  had  come, 
old  methods  had  been  swept  away,  and  new  ones  taken 
their  place  in  the  daily  practice  of  surgery,  and  the 
great  change  was  undoubtedly  due  to  the   antiseptic 


August  17,  1895] 


MEDICAL    RECORD. 


251 


system,  and  that  boon  constituted  Sir  Joseph  Lister  one 
of  the  greatest  benefactors  of  mankind.  Antiseptic 
surgery  had  become  almost  painless,  mortality  from  op- 
erations almost  extinguished,  and  the  domain  of  sur- 
gery immensely  increased.  He  did  not  undervalue  an- 
aesthetics, but  it  was  a  fact  that  during  the  twenty  years 
between  the  introduction  of  ansesthetics  and  that  of  an- 
tiseptics, mortality  had  actually  increased.  Nor  did  he 
undervalue  sanitation,  but  it  would  be  easier  for  anti- 
septics to  dispense  with  hygiene  than  for  hygiene  to  dis- 
pense with  antiseptics.  All  this  they  owed  to  the  genius 
and  untiring  labor  of  the  great  surgeon  sitting  by  his 
side  and  to  him  alone.  The  discover)"  of  antiseptics 
was  no  haphazard  affair,  but  was  worked  out  labori- 
ously on  scientific  lines.  He  placed  Lister  beside  John 
Hunter.  What  one  did  for  the  end  of  the  eighteenth 
centurj',  the  other  did  for  the  end  of  the  nineteenth.  It 
was  fitting  that  the  first  testimonial  should  be  within 
the  walls  where  so  much  of  the  work  had  been  done, 
and  perhaps  not  unbecoming  that  he  himself,  who  had 
been  Sir  Joseph's  earliest  teacher  of  practical  surgery, 
should  have  been  asked  to  present  it  to  his  dear  friend 
and  former  pupil.  Though  they  once  stood  in  that 
position  it  had  long  been  reversed,  and  for  twenty  years 
past  he  had  been  content  to  sit  at  the  feet  of  his  former 
pupil. 

Sir  Joseph  Lister  said  he  felt  overwhelmed  by  Sir 
John  Erichsen's  kind  and  flattering  words,  and  the  great 
gathering  of  former  pupils  and  colleagues.  He  could 
not  deny  that  the  presence  of  so  many  old  friends  was  a 
great  gratification,  and  showed  his  work  had  not  been 
in  vain.  He  gave  an  account  of  his  work  in  Edinburgh, 
Glasgow,  and  London,  which  was  listened  to  with  pro- 
found attention. 

Sir  John  Tomes,  F.R.S.,  died  on  Monday  at  the  age 
of  eighty  years.  He  was  the  pioneer  of  teaching  mod- 
em dental  surger\%  his  lectures  at  the  Middlesex  Hos- 
pital, begun  fifty  years  ago,  at  once  stamping  him  as  an 
authority.  His  papers  presented  to  the  Royal  Society 
established  his  reputation  as  a  man  of  science,  and  his 
name  is  indissolubly  connected  with  important  points 
in  the  structure  of  the  teeth.  For  his  services  to  den- 
tal education  he  was  knighted  in  1886.  Three  years 
previously  he  and  his  friend,  the  late  Professor  Huxley, 
were  elected  to  the  Honorary  Fellowship  of  the  Royal 
College  of  Surgeons. 

Last  week  the  London  death-rate  fell  to  23,  as  against 
22.5  in  the  other  large  towns.  Measles  and  diphtheria 
showed  an  increased  mortality.  The  deaths  from 
diarrhoea  reach  397,  which  number  is  137  above  the 
corrected  average. 

Small-pox  too  has  increased  to  such  a  degree  at  the 
East  end  of  London  that  the  Local  Government  Board 
have  re-issued  their  1893  circular  urging  Poor  Law 
Guardians  to  take  precautions  against  the  spread  of 
the  disease  through  casual  wards  and  workhouses. 
There  is  no  doubt  the  danger  is  great  and  largely 
through  the  folly  of  anti-vaccinationists.  Just  where 
these  cranks  have  deluded  the  most  ignorant  of  the  pop- 
ulation into  repudiating  vaccinarion  small-pox  has 
made  its  appearance.  In  189 1  the  ofiScial  report  showed 
that  in  one  district  (Mile  End)  half  the  children  born 
were  not  accounted  for  in  the  vaccination  returns. 
There  has  probably  been  no  improvement  since,  and 
yet  the  local  authorities  are  recalcitrant.  Some  method 
of  compelling  them  to  discharge  their  duty  must  be 
found,  or  the  vaccination  acts  will  be  practically  re- 
pealed in  certain  districts  to  the  peril  of  others. 


RECIPPvOCITY    IN    REGISTRATION. 

To  THE  Editor  of  the  Medic.\i.  Record. 

Sir  :  Allow  me  to  make  a  few  remarks  in  regard  to 
reciprocit)-  in  registration. 

1.  AMiat  is  registration  for?  Is  it  understood  in  the 
same  light  as  the  registration  of  the  Chinaman,  that  so 
many  should  land  and  no  more,  or  was  it  meant  for 
some  higher  purpose,  viz.,  to  protect  the  public  from 
quacker>%  fraud,  etc.,  and  to  protect  the  dignity  of  the 
medical  profession,  to  elevate  its  standard,  etc.  ? 

I  contend  that  the  registration  law  was  intended  for 
the  latter.  Now  let  us  see  if  it  has  accomplished  its 
purpose.  Let  us  consider  what  is  reciprocity.  It 
means  acting  in  return,  i.e.,  if  New  Jersey  will  allow  a 
New  York  physician,  who  has  passed  a  satisfactory  ex- 
aminarion  after  four  years'  study  in  a  reputable  college, 
to  register,  then  New  Jersey  physicians  should  enjoy  the 
same  priv-ilege  when  thej'  come  to  New  York.  Does  the 
absence  of  this  reciprocity  not  mean  that  registration 
laws  were  made  for  pecuniary  reasons  ?  Does  the 
knowledge  and  the  science  of  the  physician  cease  at  the 
border  line  of  the  State  ? 

^Vhy  is  it  that  a  patent  medicine,  made  after  the 
formula  of  a  physician,  and  claimed  by  its  maker  to  be 
a  panacea  for  all  the  evils  that  flesh  is  heir  to,  is 
allowed  to  flourish  in  the  United  States,  although  the 
formula  is  taken  from  say  New  York,  and  the  same 
physician  who  wrote  the  formula  has  no  right  to  go  to 
New  Jersey  and  prescribe  it  ?  Is  there  any  reason  for 
this  discrimination  ?  Is  it  not  a  disgrace  to  the  profes- 
sion and  an  insult  to  ever)-  physician  ? 

Now  let  me  point  out  the  injustice  of  the  registration 
law  as  it  is  at  present.  1.  A  physician  linng  in  New 
York  takes  a  vacation  at  the  seashore  of  New  Jersey  ; 
he  meets  his  own  patients  there,  but  he  has  no  right  to 
prescribe  for  them,  for  he  is  supposed  to  have  forgotten 
all  crossing  the  Hudson. 

2.  A  physician  having  complied  with  all  the  require- 
ments of  the  law  in  New  York,  and  unable  to  make  a 
living  there  (as  it  is  often  the  case),  having  spent  aU 
the  money  he  had,  has  no  right  to  go  to  Jersey  or  any 
other  State  unless  he  passes  an  examination  and  pays  a 
fee.     Is  that  jusrice  ?     ^^'hat  is  the  remedy  ? 

I  -suggest  that  the  medical  press,  societies,  and  in- 
dividual members  should  agitate  the  question  of  a 
Secretary  of  Public  Health,  and  so  do  away  with  the 
red  tape  of  the  different  States.  One  law  for  all  physi- 
cians of  the  United  States.  The  standard  of  medical 
practice  should  be  high,  but  once  the  examination  is 
passed  the  candidate  should  be  allowed  to  follow  his 
profession  in  any  of  the  States.  Of  course  there  will 
still  be  the  necessity  of  registration,  but  the  permission 
to  register  will  not  rest  within  the  discretion  of  any 
State  Examining  Board.     Respectfullv, 

L.  ^V.  ZwisOH.v,  M.D. 

New  York,  August  3,  1895. 


Medical  Politicians  in  France. — In  the  French  Sen- 
ate thirty-seven  senators  are  medical  men,  one  senator 
is  a  druggist,  and  three  senators  are  veterinary  sur- 
geons. In  the  Chamber  of  Deputies,  fifty-eight  depu- 
ties are  medical  men,  five  are  druggists,  and  one  is  a 
veterinary  surgeon. 


Snicide  is  not  common  in  Russia,  the  rate  being  30 
to  1,000,000  inhabitants,  while  in  Saxony  it  is  311,  in 
France  210,  in  Prussia  133,  in  Austria  130,  in  Bavaria 
90,  in  England  66  ;  and  while  the  rate  has  increased 
by  thirty  or  forty  per  cent,  in  other  European  countries 
during  the  last  thirty  years,  in  Russia  it  has  remained 
stationary.  Professor  Sikorski,  of  the  University  of 
Kiew,  thinks  the  low  rate  is  due,  in  part,  to  the  patience 
and  long-suffering  of  the  Russian  under  even  the  worst 
treatment,  but  also  to  an  indecision  of  character  which 
fears  to  do  anything  from  which  it  cannot  retreat. 

It  should  be  mentioned,  in  the  interests  of  antiseptic 
purity  and  suffering  humanity,  that  a  good  stout  tooth- 
brush, plenty  of  water,  and  some  antiseptic  dentifrice, 
applied  morning  and  night,  afford  a  greater  safeguard 
against  many  diseases  than  many  people  are  aware. — 
Sims  Woodhead. 


252 


MEDICAL  RECORD. 


[August  17,  1895 


Ipedical  gtcms. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  August  10,  1895. 

Cases.    !   Deaths. 


Tuberculosis ;  53 

Typhoid  fever I  29 

Scarlet  fever 24 

Cerebro-spinal  meningitis o 

Measles 135 

Diphtheria !  188 


Sewage  Organisms  and  Disease. — In  his  reports  pre- 
sented to  the  London  County  Council  Mr.  J.  Parry 
Laws,  F.I.C.,  made  the  important  observation  that  the 
micro-organisms  contained  in  sewer  air  were  not  only 
less  in  number  than  the  micro-organisms  in  fresh  air 
in  the  vicinity  at  the  same  time,  but  that  they  were 
also  apparently  related  to  and  derived  from  those  of 
fresh  air  rather  than  sewage,  while  there  was  no  evi- 
dence forthcoming  that  sewage  was  able  to  give  off 
micro-organisms  to  the  air  in  contact  with  it.  Acting 
on  the  instructions  of  the  Main  Drainage  Committee 
of  the  Council  this  investigation  has  since  been  ex- 
tended by  Mr.  Laws,  with  the  assistance  of  Dr.  An- 
drewes,  to  a  study  of  the  organisms  existent  in  sewage. 
From  a  copy  of  the  valuable  report  which  has  recently 
been  issued,  and  which  contains  a  careful  series  of 
well-chosen  and  laborious  experiments.  The  Lancet 
gathers  the  following  :  The  most  striking  difference  in 
the  bacteriology  of  sewage  and  sewer  air  appears  to  be 
the  absence  of  moulds  from  the  latter,  while  in  the 
former  moulds  were  found  to  be  a  predominant  feat- 
ure. The  bacillus  coli  communis  was  found,  with  one 
exception,  in  each  sami)le  of  sewage  examined,  but 
neither  it  nor  its  allies  were  ever  found  in  sewer  air. 
The  bacteria  of  sewage  rapidly  liquefy  nutrient  gela- 
tine, while  organisms  possessing  this  property  were 
practically  absent  in  sewer  air.  This  evidence  would 
seem  to  be  conclusive  that  there  is  no  relationship. be- 
tween the  organisms  of  sewer  air  and  sewage,  and  the 
writers  are  thereby  led  to  think  that  some  of  the  ill- 
effdcts  which  have  been  erroneously  (?)  ascribed  to 
sewer  air  may  be  due  to  subsoil  air  derived  from  soil 
polluted  by  constant  infiltration  of  excremental  matter, 
but  suggest  that  it  is  not  until  the  outer  margin  of  the 
permeated  soil  has  become  dry  that  the  air  is  infected 
with  organisms.  In  a  search  for  the  typhoid  bacillus 
in  sewers,  where  it  might  be  expected  to  be  present  in 
large  proportion,  such  as  in  the  drains  of  the  Eastern 
Hospital  at  Homerton,  they  were  successful  in  demon- 
strating the  actual  presence  of  the  bacillus  typhosus  ; 
but  in  a  sample  taken  about  a  quarter  of  a  mile  away 
no  single  colony  developing  on  culture  could  be  re- 
ferred to  the  bacillus  of  typhoid  fever.  In  the  light  of 
this  and  other  results  it  is  concluded  that  sewage,  even 
in  the  absence  of  the  normal  micro-organisms  which  it 
contains,  is  clearly  an  unfavorable  medium  for  the 
growth  of  the  typhoid  germ,  whereas  the  colon  bacillus 
can  grow  and  multiply  freely  in  it.  It  might  be  antici- 
pated, it  is  pointed  out,  that  in  competition  with  other 
organisms,  able  to  grow  well  in  sewage,  the  typhoid 
bacillus  would  die  out  even  more  speedily.  These  ex- 
periments are  only  preliminary  and  are  necessarily  in- 
complete, but  they  give  a  distinct  indication  of  the 
probable  fate  of  typhoid  bacilli  which  gain  access  in  a 
living  condition  to  sewage,  while  it  seems  "clear  that 
sewage  does  not  form  a  medium  in  which  much,  if  any, 
growth  is  possible  for  them  under  natural  conditions, 
and  their  death  is  probably  only  a  matter  of  a  few 
days,  or  at  most  one  or  two  weeks."  Obviously,  this 
resistance  to  growth  may  be  overcome  by  attenuation, 


as  when  sewage  has  access  to  the  drinking  supply  or 
to  milk. 

It  would  appear,  then,  that  so  far  as  bacteriological 
analysis  goes  there  is  no  ground  for  believing  that 
sewer  air  plays  any  part  in  the  conveyance  of  typhoid 
fever ;  but  are  the  conditions  under  which  the  bacte- 
riological examinations  of  sewage  and  of  sewer  air  are 
made  such  as  to  give  us  absolute  assurance  on  these 
and  other  points?  In  spite  of  its  apparent  bacterio- 
logical innocuousness  no  one  entertains  the  least  doubt 
.that  sewer  air  is  a  constant  source  of  disease,  and  if 
this  is  not  to  be  referred  to  micro-organisms  to  what 
may  it  be  ascribed  ?  There  is  undoubtedly  a  poisonous 
agency  at  work  when  sewer  air  is  inhaled,  which, 
though  it  may  not  directly  act,  yet  so  prepares  the  soil 
that  the  system  is  unable  to  resist  the  invading  organ- 
ism when  it  comes.  In  some  well-known  experiments 
it  was  shown  that  when  rats,  among  other  animals, 
were  inoculated  with  a  weak  growth  of  typhoid  cult- 
ure, after  previously  being  exposed  to  sewer  emana- 
tions, they  nearly  all  succumbed.  On  the  other  hand, 
rats  treated  to  the  same  dose  of  typhoid  culture,  but 
exposed  to  fresh  air  after  inoculation,  showed  little 
sign  of  illness  and  eventually  recovered.  What,  then, 
is  this  poisonous  constituent  of  sewer  air  which  leaves 
the  system  defenceless  against  the  attacks  of  the  mi- 
crobes which  it  may  encounter  ?  An  investigation  on 
this  point  would  form,  we  suggest,  an  excellent  and 
fitting  sequel  to  the  above  valuable  contribution. 


NEW   BOOKS   RECEIVED. 

While  the  Medical  Record  is  pUaseJ  to  receive  all  new  publi- 
cations which  may  be  sent  to  it,  and  an  acknowledgment  mill  be 
promptly  made  of  their  receipt  under  this  headings  it  must  be  ■with 
the  distinct  understanding  that  its  necessities  are  siuh  that  it  cannot 
be  considered  under  obligation  to  notice  or  review  any  publication 
received  by  it  which  in  the  judgment  0/  its  editor  will  not  be  of  in- 
terest to  its  readers. 

Leprosy  :  In  its  Clinical  and  Pathological  Aspects.  By  Dr. 
G.  Armauer  Hansen  and  Dr.  Carl  Looft.  Svo,  163  pages.  Illus- 
trated. Price  los.  6d.  Published  by  John  Wright  &  Co.,  Bristol, 
England. 

System  of  Surgery.  By  Frederic  S.  Dennis,  M.D.,  assisted 
by  John  S.  Billings,  M.D.  Octavo,  926  pages.  Illustrated.  Vol. 
II.     Published  by  Lea  Brothers  &  Co.,  Philadelphia,  Pa. 

Transactions  of  the  New  York  State  Medical  Associa- 
tion FOR  the  Year  1894.  Yol.  XI.  Edited  by  E.  V>.  Ferguson, 
M.D.  Svo,  751  pages.  Illustrated.  Published  by  the  Associa- 
tion, New  York  City. 

Skiascopy,  and  its  Practical  Application  to  the  Study 
OF  Refraction.  By  Edwaid  Jackson,  M.D.  Svo,  109  pages. 
Illustrated.  Published  by  The  Edwards  &  Docker  Co.,  Phila- 
delphia, Pa. 

The  Cell  Outlines  of  General  .\natomy  and  Physiol- 
ogy. By  Dr.  Oscar  Hertwig.  Svo,  36S  pages.  Illustrated. 
Price,  $3.00.  New  York  publishers,  Macmillan  &Co. ,  New  York 
City. 

Twentieth  Century  Practice.  An  International  Encyclo- 
pedia of  Modern  Medical  Science  Edited  by  Thomas  L.  Stedman, 
M.D.,  New  York  City.  Vol.  III.,  Svo.  Published  by  William 
Wood  &  Company,  New  York  City. 

The  Americ.\n  .\cademy  of  Railway  Surgeons.  Edited 
by  R.  Harvey  Reed,  Columbus,  O.  Svo, ,  140  pages.  (Vol.  1). 
Published  by  the  .\nierican  Medical  Press.  1895. 

Braithwaite's  Retrospect  of  Medicine.  Vol.  CLI.,  Janu- 
ary to  June,  1S95.  Edited  by  James  Braithwaite,  M.D.,  London. 
Svo.,  412  pages.  Published  by  Simpkin,  Marshall,  Hamilton, 
Kent  &  Co.,  Ltd.,  Edinburgh.  Scotland. 

\  Manual  of  Electro-Therapeutics  for  Students  and 
General  Practitioners.  By  C.  T.  Hood,  >LD.  Svo.,  iSi 
pages.  Piice,  $2.  Published  by  Gross  &  Delbridge  Company, 
Chicago,  111. 

CEuvres  de  Leon  lk  Fort.  Publiees  par  le  Dr.  Felix  Le- 
jars.  Tome  i.  Svo.,  931  pages.  Published  by  Felix  Alcan, 
Paris,  France, 


Medical   Record 

A  Weekly  journal  of  Medicine  and  Surgery 


Vol.  48,  No.  8. 
Whole  No.  1294. 


New  York,  August  24,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


CEREBRAL   TUBERCULOSIS  IN  ADULTS. 
By  JOHN  C.  KING,  M.D., 


In  the  February  number  of  the  Southern  California 
Practitioner  appeared  a  useful  article  by  Professor 
Brainerd,  in  which  he  detailed  four  cases  of  cerebral 
tuberculosis.  In  each  case  the  diagnosis  was  verified 
post  mortem.  Dr.  Brainerd  expressed  the  opinion  that 
all  such  cases  are  fatal.  He  referred  to  the  recovery 
of  Dr.  Solly's  reported  case,  but  doubted  the  diagnosis. 
I  desire,  at  the  risk  of  having  my  diagnostic  ability 
questioned,  to  report  one  case — Case  IV.  of  this  series — 
of  absolute  recovery  from  cerebral  tuberculosis  in  an 
adult ;  also  several  cases  in  which  recovery  from  cere- 
bral conditions  occurred,  followed,  however,  by  death, 
after  some  months,  from  the  ravages  of  the  disease  in 
other  parts  of  the  body.  I  am  of  opinion  that  tuber- 
cular deposits  in  or  upon  the  brain  are  of  more  fre- 
quent occurrence  than  is  generally  supposed.  Perusal 
of  systematic  works  on  practice  would  lead  us  to  con- 
sider nervous  tissue  slightly,  if  at  all,  obno.xious  to 
tubercle.  This  statement  excepts,  of  course,  the  ordi- 
nary tubercular  meningitis  of  childhood.  During  the 
past  ten  years  I  have  observed  more  than  a  dozen  cases 
of  cerebral  tuberculosis  in  adults,  about  two  per  cent. 
of  all  cases  of  tuberculosis  under  my  care  during  that 
time.  Of  these  I  have  preserved  notes  of  eight  cases, 
one  doubtful,  which  I  will  present  in  this  paper.  For 
twelve  years  preceding  the  past  ten,  I  was  engaged  in 
general  practice — four  years  in  dispensary  service — yet 
during  that  time  never  recognized  a  single  case.  The 
symptoms  of  cerebral  involvement  are  so  prominent  that 
"  he  who  runs  may  read  ;  "  yet,  judging  the  first  twelve 
by  the  past  ten  years,  I  must  have  overlooked  many 
cases.  Possibly  others  fail  to  realize  the  import  of 
these  symptoms.  Dr.  Brainerd  quoted  some  interest- 
ing statistics  of  the  disease  in  children,  and  referred  to 
Osier,  Whittaker,  Gowers,  Dana,  and  others  who  have 
noticed  it  in  adults.  However,  the  paucity  of  the  in- 
formation to  be  obtained  upon  this  subject  from  text- 
books is  very  marked.  I  may  be  permitted  to  refer  to 
the  statements  of  a  few  authorities  :  Flint,  in  "  Prac- 
tice," 1868,  declares  that  "meningitis  occurs  as  a  rare 
concomitant  in  the  adult,"  and  that  it  "  accounts  for 
the  development  of  delirium  and  coma  in  certain  cases." 
Ruehle,  in  Ziemssen,  1875,  writes,  "Whenever  phthi- 
sical patients  present  decided  symptoms  of  cerebral 
disturbance,  it  is  safe  to  infer  an  extension  of  the  tu- 
berculous process  to  the  brain.  The  occurrence,  there- 
fore, of  a  fixed  headache,  sudden  delirium,  or  maniacal 
excitement,  may  be  regarded  as  very  ominous  symp- 
toms." J.  Hughes  Bennett,  in  "Reynolds's  System," 
1880,  refers  incidentally  to  the  fact  that,  in  the  young, 
tubercle  complications  in  the  brain  and  its  membranes 
may  sometimes  occur.  Bartholow,  in  "  Practice,"  1882, 
does  not  refer  to  cerebral  tuberculosis  as  a  complica- 
tion of  the  pulmonary  form.  Ingals,  in  "  Diseases  of 
the  Chest,"  etc.,  1892,  states  that  "in  the  later  stages 
of  the  disease,  cerebral  ansemia,  or  possibly  tubercular 
change  in  the  brain  itself,  or  the  sympathetic  effects  of 


imperfect  digestion,  affect  the  mental  condition,  causing 
irritability,  fretfulness,  cerebral  fatigue  upon  mental 
exertion,  and  finally,  in  some  cases,  hallucinations  or 
fixed  delirium."  Osier,  in  "Practice,"  1892,  refers  to 
various  forms  of  cerebral  tuberculosis  apart  from  tuber- 
cular meningitis.  He  instances  hemorrhagic  pachy- 
meningitis caused  by  tubercle,  aphasia  produced  by 
solitary  tubercle  of  the  fissure  of  Sylvius.  He  writes  of 
aphasia  and  hemiplegia  of  many  months'  duration  ex- 
isting as  tubercular  complications  of  consumption. 
Loomis,  in  "Practical  Medicine,"  1892,  states  that 
"  cerebral  symptoms  are  rarely  pronounced  in  any  stage 
of  phthisis."  Later,  discussing  tubercular  tumor  of 
the  brain,  he  writes  that  children  are  chiefly  affected.   - 

The  following  cases  were  not  examined  post  mortem, 
but,  except  Case  I.,  the  symptoms  of  each  were  evi- 
dently the  result  of  tubercular  deposit  in  or  upon  the 
brain  : 

Case   I. — G.    B ,   aged    twenty-seven,    male,    of 

Milwaukee,  brewer,  under  my  observation  during  a 
large  part  of  the  year  1885.  Had  pulmonary  tubercu- 
losis, but  was  doing  exceedingly  well,  so  that  I  could 
offer  him  much  encouragement.  His  domestic  and 
financial  affairs  were  in  excellent  shape.  The  day  pre- 
vious to  his  death  the  young  man  came  to  my  office 
complaining  of  headache  ;  otherwise  seeming  quite  well. 
He  was  cheerful,  but  his  conversation  was  somewhat 
erratic.  Early  next  morning  I  was  called  by  a  work- 
man, who  stated  he  had  looked  into  Mr.  B 's  window 

after  having  knocked  at  the  door,  and  believed  him 
dead.  I  took  witnesses,  went  to  the  house,  burst  open 
the  door,  and  found  him  dead.  There  was  a  bullet 
wound  in  his  temple,  the  revolver  lay  upon  the  floor 
beside  the  body.  Evidently  suicide,  and  so  determined 
by  the  coroner's  jury.  A  note  was  found  addressed  to 
his  brother  and  dated  the  night  of  the  tragedy.  This 
note  was  written  in  German,  and  the  contents  were  in- 
coherent. The  man's  life  had  been  insured,  with  the 
proviso  that  death  from  suicide,  except  as  a  result  of 
mental  disease,  would  invalidate  the  policy.  I  swore 
the  patient  was  irresponsible,  basing  my  opinion  upon 
a  diagnosis  of  acute  cerebral  tuberculosis.  The  in- 
surance company  paid  the  claim. 

The  history  I  have  presented  is  very  meagre.  I 
think,  however,  perusal  of  the  following  cases  will,  by 
analogy,  justify  the  diagnosis  : 

Case  II. — Charles  P.   D ,   aged   twenty-five,   of 

Black  River,  N.  Y.  First  examined  in  the  latter  part 
of  1885.  Died  May  3,  1886.  Diagnosis  :  Pulmonary 
tuberculosis.  During  the  last  week  of  his  life  Dr. 
Johnson,  of  San  Diego,  was  in  consultation.  The  pa- 
tient was  surrounded  by  all  the  comfort  and  care  that 

friends  and  money  could  procure.     Mr.  D had  a 

very  fair  family  history.  He  had  been  a  successful 
manufacturer,  had  created  and  managed  a  large  and 
profitable  business,  far  in  excess  of  his  physical  ability. 
He  gradually  undermined  his  health  and  remained  in 
control  of  his  affairs  long  after  symptoms  of  pronounced 
pulmonary  disease  became  manifest.  Finally  he  came 
to  Southern  California.  Having  been  referred  to  me, 
he  applied  for  examination.  I  informed  him  that 
nothing  could  be  done  for  him,  beyond  the  relief  of 
certain  distressing  symptoms.  This  young  man  pos- 
sessed a  very  serene,  well-balanced,  highly  cultivated 
mind.  He  governed  his  thoughts  and  actions  in  ac- 
cordance with  most  exemplary  principles.     His  case 


254 


MEDICAL   RECORD. 


[August  24,  1895 


progressed  without  notable  failure  or  improvement  for 
some  months.  Indeed,  he  gained  a  little  strength,  ate 
pretty  well,  and  spent  his  time  quite  comfortably  in  the 
open  air.  He  lived  in  an  elegantly  appointed  country 
hotel,  half  a  dozen  miles  from  my  office.  I  visited  the 
house  every  two  or  three  days,  but  never  detected  any 
intimation  of  impending  involvement  of  my  young 
friend's  brain.     About  the  middle  of  April  I  was  sent 

for  to  visit  D .     When  I  arrived  the  landlady  called 

me  aside  and  stated  that — she  was  distressed  to  say  it 

— Mr.  D had   been    intoxicated    for   twenty- four 

hours  or  more.  She  wished  me  "to  straighten  him 
up."  I  found  him  sitting  upon  the  veranda,  as  I  ap- 
proached he  failed  to  recognize  me.  I  spoke  and  ex- 
tended my  hand.  He  arose,  held  out  his  hand,  mum- 
bled something  and  at  once  staggered  back  into  his 
chair.  He  presented  every  appearance  of  acute  alco- 
holism :  face  congested,  half-silly,  half-stupid  ex- 
pression, eyes  bright  and  a  trifle  watery,  muscles  re- 
laxed so  that  he  half-reclined  in  his  chair.  To  all  ray 
questions  he  replied  "Yes,"  with  a  silly  sort  of  laugh. 
He  would  respond  to  suggestions,  would  sit,  stand, 
swallow,  etc.,  as  requested.  At  times  he  would  even 
reply,  for  a  moment,  to  some  question,  with  apparent 
correctness,  and  then,  perhaps  before  his  answer  was 
complete,  would  relapse  into  the  semi-conscious  state. 
At  no  time  would  he  acknowledge  pain,  nor  did  he,  at 
any  time,  complain  of  headache.  He  endeavored  to 
walk  and  to  undress  himself,  but  his  muscles  seemed 
too  limp.  He  seemed  to  lack  both  co-ordinating  and 
muscular  power.  The  good  landlady  attended  him 
the  more  devotedly  because  she  had  misjudged  his 
condition.  For  several  days  he  remained  in  about  the 
same  state.  The  excretory  functions  were  performed 
when  he  was  so  requested.  Food  and  medicine  were 
also  taken  when  suggested.  Finally  his  condition  be- 
came worse  ;  semi-coma  and  coma  successively  devel- 
oped. Catheterization  became  necessary.  There  was 
no  fever  ;  heart  and  kidneys  normal  ;  respiration  be- 
came slower  and  deeper  than  before ;  pupils  nor- 
mal ;  face  became  paler.  There  was  no  action  of 
the  voluntary  muscles  for  some  days,  yet  no  tendency 
toward  bed-sores.  This  condition  persisted  for  live  or 
six  days,  when  improvement  began.  In  twenty-four 
hours  the  patient  was,  apparently,  as  well  as  before  the 
attack,  except  for  profound  prostration.  During  my 
absence  from  the  house,  Mr.  D gave  explicit  di- 
rections regarding  his  business  affairs  and  the  disposal 
of  his  effects.  Some  hours  after,  he  quietly  died.  He 
remained  conscious  to  almost  the  end. 

Case  111. — ^Charles    M ,    aged    twenty-eight,    of 

Lamar,  Mo.  Mother,  two  brothers,  sister,  and  aunts 
had  consumption.  Martin  developed  the  well-known 
symptoms  of  the  disease,  and  was  advised  to  remove 
to  Southern  California.  After  arriving  here  his  history 
was  uneventful  ;  the  disease  pursued  its  ordinary 
course,  although  its  progress  was  slow.  The  patient 
was  a  laborer,  had  wife  and  children  to  support,  con- 
sequently could  not  care  for  himself  as  he  ought  to  have 
done.  After  watching  his  case  for  some  two  years,  I 
was  called  to  his  bedside  on  September  S,  1888.  I 
found  him  wildly  delirious.  The  combined  efforts 
of  several  men  were  required  to  restrain  him.  My  first 
thought  was  "  a  drunk,"  notwithstanding  I  knew  him 
to  be  a  total  abstainer.  Investigation  soon  convinced 
me  that  his  system  contained  no  alcohol.  His  wife 
stated  that  except  a  severe  headache,  he  seemed  in  his 
usual  health  until  he  began  to  "  act  crazy,"  when  she 
sent  for  me.  The  patient  exhibited  the  wildest  mania. 
He  struggled,  fought,  bit,  raved,  cursed  violently  and 
obscenely.  He  had  been  a  consistent  Christian.  No 
other  symptoms  could  be  elicited.  The  terror  and  dis- 
tress with  which  he  inspired  his  family  and  friends  al- 
lowed no  time  for  examination.  To  prevent  injury  to 
himself  and  others  I  had  him  strapped  to  a  comfortable 
cot,  then  administered  hypodermics  of  morphia  sulph.  ; 
two  quarter-grain  doses  were  required.     Three  or  four 


hours  sleep  followed.  When  he  awoke  he  was  calmer 
but  still  delirious,  and  at  intervals  required  restraint. 
During  the  ensuing  twenty-four  hours  the  mania  very 
gradually  disappeared  and  semi-stupor  supervened. 
The  patient  would  swallow  nourishment  placed  be- 
tween his  lips  ;  would  attempt  to  answ^er  questions,  but 
his  replies  were  absolutely  incoherent.  At  the  first  ob- 
servation his  temperature  was  104^2°  F.,  but  within 
forty- eight  hours  became  almost  normal  without  the 
administration  of  antipyretics.  Bowels  and  bladder 
were  incontinent  for  two  days.  No  involuntary  motor 
symi)toms  were  apparent.  The  stupid  stage  gradually 
disappeared  after  five  or  six  days.  As  he  regained 
consciousness  the  only  symptom  complained  of  was 
headache,  which  he  could  not  localize  and  which  gradu- 
ally ceased  as  he  grew  more  rational.  No  memory  of 
his  condition  remained.  The  case  was  void  of  furthei 
symptoms  ;  recovery  was  rapid.     The  lung  trouble  was 

in  abeyance  for  a  few  weeks.    M returned  to  work 

and  for  two  months  was  able  to  earn  full  wages.  In 
December  he  died  from  phthisis  pulmonalis,  without 
return  of  cerebral  symptoms. 

Case  IV. — First  examined  July  16,  1889.     Referred 

to  me  by  Professor  Ingals.     Mrs.  W ,  of  Chicago, 

aged  twenty-seven,  married  four  and  one-half  years  ; 
miscarriage  two  years  ago  at  three  months.  Now  has 
a  baby  three  months  old.  Always  delicate  but  never 
really  sick  until  two  years  ago.  When  about  eleven 
years  old  underwent  a  surgical  operation  upon  her 
foot,  for  what  was  termed  tuberculosis  of  one  of  the 
bones.  No  tubercular  taint  in  her  family.  Husband 
healthy.  Had,  at  one  time,  some  slight  uterine  trouble 
— readily  cured  by  local  treatment.  Following  mis- 
carriage had  cough  and  diarrhoea.  Tubercle  bacilli 
demonstrated  in  sputa  and  stools.  Emaciation  began 
at  about  the  eighth  month  of  last  pregnancy.  Slight 
haemoptysis  during  labor,  in  which  she  was  attended 
by  Professor  Jaggard,  who  performed  episiotomy  and 
a  primary  operation  for  laceration.  Has  never  recov- 
ered strength  since  birth  of  child.  Menses  recurred 
about  six  weeks  ago ;  at  present  quite  weak.  Post- 
nasal catarrh.  Throat  dry,  and  at  times  painful  ; 
hoarseness  ;  vocal  cords  relaxed.  Slight  arjtenoidal 
swelling.  Pretty  constant,  loose,  painless  cough  ;  at 
times  becoming  paroxysmal  and  accompanied  by  vom- 
iting. Expectoration  profuse,  thick,  greenish  yellow. 
Pulse,  120;  temperature,  102^^°  F.  ;  respiration.  19; 
expansion,  26  to  28.  Cavity  in  the  left  apex.  Sub- 
crepitant  rales  pretty  much  all  over  remaining  part  of 
left  lung.  On  right  side  dulness  around  and  below 
nipple,  with  loud,  moist  rales  all  over  front  and  back. 
Appetite  fairly  good.  No  gastric  pain.  Tongue  clean. 
Diarrhoea.  Stools  changeable,  profuse,  mushy.  Four 
to  twenty  per  day.  Normal  weight  124  pounds;  at 
present  97.     Profuse  night-sweats  from  time  to  time. 

To  transcribe  my  notes  of  this  case  would  be  tedious, 
as  the  patient  remained  under  my  constant  treatment  for 
two  years.  I  will  at  once  detail  (and  that  rapidly)  the 
cerebral  symptoms  that  ensued  after  some  months.  The 
first  point  noticed  was  headache.  The  whole  head  was 
involved,  but  the  severest  pain  was  occipital,  extending 
forward  toward  the  eyes.  This  pain  became  exceedingly 
intense.  The  lady  was  very  courageous,  but  was  many 
times  forced  to  cry  and  scream  on  account  of  the  violence 
of  the  pain.  It  resembled  the  pain  accompanying  tumor 

of   the   brain.     Owing   to    this  pain  Mrs.  W was 

obliged  to  take  to  her  bed,  thus  avoiding  light,  noise,  and 
motion.  Finally  mental  symptoms  began  to  develop. 
A  little  flightiness  became  noticeable.  Hallucinations 
developed,  such  as  visions  of  rats,  bugs,  etc.,  on  the 
wall  and  bed.  Gradually  torpor  of  mind  became  ap- 
parent, marked  by  slow  and  stupid  replies  to  questions. 
Twitching  of  muscles  appeared,  followed  after  a  few 
days  by  violent  convulsions.  No  paralytic  symptoms 
at  any  time.  As  the  motor  disturbance  subsided  the 
patient  became  calmer,  evidently  had  less  headache, 
but  failed  to  recognize  husband,  sister,  or  nurse.     She 


August  24,  1895] 


MEDICAL   RECORD. 


255 


imagined  herself  in  another  city,  in  short,  exhibited 
the  classical  symptoms  of  an  attack  of  insanity.  This 
latter  condition,  after  continuing  some  two  weeks  longer, 
finally  wore  away,  leaving  the  patient  apparently  none 
the  worse  for  her  experience,  beyond  the  natural  pros- 
tration. The  pulmonary  and  intestinal  symptoms  had 
already  improved  to  a  marked  degree  prior  to  the  ap- 
pearance of  the  headache.  During  the  attack  just  de- 
tailed this  improvement  steadily  continued  and  no  re- 
lapse followed.  At  no  time  during  the  attack  was 
fever  manifest.  Incontinence  of  urine  and  faeces  oc- 
curred a  few  times.  Liquid  food  was  administered 
daily.     Respiration  was  slow  and  regular. 

When  Mrs.  W— —  left  Banning,  some  eighteen 
months  subsequently,  she  was  in  excellent  condition. 
No  diarrhcea  ;  weight,  120  pounds  ;  very  little  cough  ; 
scarcely  any  e.xpectoration  ;  plenty  of  strength.  To  all 
appearance  a  strong,  hearty  woman.  The  cavity  had 
contracted  ;  except  for  a  few  rales  the  physical  signs 
had  disappeared.  A  letter  from  her  husband,  a  few 
months  ago,  assured  me  that  her  improvement  had 
continued,  and  that  she  was  enjoying  excellent  health. 
I  consider  this  case  remarkable.  I  have  had  other 
patients  who  suffered  from  combined  pulmonarj',  with 
cavities,  and  intestinal  tuberculosis  make  good  recov- 
eries. No  other  one,  however,  in  which  these  con- 
ditions existed,  plus  cerebral  tuberculosis,  has  made 
such  marked  improvement.  The  five  or  six  years  of 
continued  good  health  indicate  the  possibility  of  a  final 
cure.  This  patient  had  all  the  advantages  that  love, 
wealth,  and  intelligence  could  bring  to  bear  upon  her 
case. 

Case  V. — One  evening  about  10  p.m.  the  proprietor 
of  the  Bryant  House  called  me  to  examine  a  stranger. 
The  patient,  a  man  about  forty  years  of  age,  came  to  the 
hotel,  having  arrived  on  the  west-bound  overland  train. 
The  man  sat  on  a  chair  in  the  office  until  supper-time, 
about  four  hours.  As  he  paid  no  attention  to  the  an- 
nouncement of  the  meal,  Mr.  W asked  if  he  wished 

supper,  the  man  looked  at  him  but  made  no  reply.  Mr. 

W then  touched  him  on  the  shoulder  and  invited 

him  to  the  supper-room,  the  man  arose  without  speaking 

and  followed.    Mr.  W placed  him  at  the  table  and 

was  obliged  to  attend  to  other  business.  The  waitress 
could  not  induce  him  to  give  an  order.  She  supposed 
him  intoxicated  and  brought  him  a  meal  of  her  own 
selection.  The  man  ate,  then  remained  in  his  chair 
until  the  waitress  requested  him  to  leave,  at  the  same 
time  taking  hold  of  his  chair.  He  arose  and  left  the 
room  without  speaking.  He  returned  to  the  office  and 
took  a  chair.  Later,  Mr.  W asked  him  if  he  de- 
sired a  room — -no  answer.     Realizing  that  something 

was  wrong  Mr.  W sent  for  me.     An   examination 

made  it  evident  the  patient  was  suffering  from  pulmo- 
nary phthisis.  I  could  not  induce  him  to  speak,  or  to 
reply  by  a  sign.  He  had  a  stupid,  half-dazed,  half-in- 
quiring expression  ;  was  free  from  fever ;  contracted 
his  brows  as  if  his  head  pained  ;  presented  no  motor 
symptoms.  The  man  had  arrived  without  baggage  ;  had 
probably  left  it  on  the  train.  The  hotel  register  and  a 
pen  were  offered  him.  He  took  the  pen  and  wrote. 
The  result  was  an  unintelligible  scrawl.  There  was 
nothing  on  his  person  that  offered  a  clew  to  his  name 

or  residence.     Mr.  W ,  the  landlord,  kindly  cared 

for  the  patient  that  night  and  took  him  next  morning 
to  the  county  hospital  at  San  Bernardino.  Some 
months  after  I  endeavored  to  trace  the  case.  Mean- 
while politics  had  reorganized  the  hospital  staff  and 
my  inquiries  were  fruitless.  Beyond  question  this  case 
was  one  of  cerebral  tuberculosis. 

Case  VI. — First  examined  December  10,  1890.  Re- 
ferred to  me  by  Dr.  Amdt,  of  San  Diego.     William  H. 

B ,  of  Ypsilanti,  Mich.     Tall,  spare,  blonde,  aged 

thirty-three  ;  teacher.  Father,  aged  fifty-three  :  and 
mother,  aged  forty-three,  died  of  phthisis.  Health 
always  excellent  until  the  summer  of  1889,  when  he 
took  no  vacation,  worked  at  the  Agricultural  College  all 


summer  and  entered  upon  his  fall  work  worn  out.  In 
October  he  took  cold,  coughed,  fainted  in  class-room  ; 
had  some  throat  trouble  :  spat  blood  occasionally.  In 
July,  1890,  came  to  Southern  California.  First  went 
to  a  small  place  in  the  mountains  where  he  improved  ; 
but,  wishing  more  contact  with  civilization,  went  to  the 
coast,  where  he  soon  began  to  fail.  Passing  over  the 
record  of  symptoms,  which  was  but  ordinary,  I  copy 
from  my  book  the  following  data  :  Weight  reduced 
from  163  to  136^  pounds.  Pulse,  120  ;  temperature, 
102°  F.  ;  respiration,  24  ;  expansion,  31  to  33'2  inches. 
LarjTix  much  congested  ;  both  arytenoids  swollen  and 
infiltrated,  almost  obliterating  the  space  between.  The 
patient  complained  much  of  lar\Tigeal  pain,  but  there 
was  no  ulceration.  Right  side  of  chest  much  flattened. 
Extensive  cavity  in  right  lung.  The  posterior  portion 
of  this  lung  was  utilized  for  respiratory  purposes,  while 
the  lateral  portions  were  infiltrated.  On  the  left  side 
existed  marked  dulness  at  apex,  and  persistent  moist 
rales  audible  all  over  front  and  back.  Under  proper 
care  this  patient  gained  perceptibly  during  the  ensuing 
three  months.  Appetite  and  weight  increased,  cough 
and  expectoration  diminished,  fever  subsided,  strength 
improved,  physical  signs  were  modified.  However, 
about  midnight  of  March  21st,  I  was  called  to  his 
room  ;  the  noise  he  had  made  having  awakened  a 
neighbor.  I  found  him  in  a  peculiar  dazed  condition, 
sitting  half  clad  upon  the  bed.  The  heart  was  beating 
140  times  per  minute  :  temperature,normal  ;  respiration, 
14.  His  replies  to  questions  were  very  slow,  one  or 
two  minutes  intervening  between  question  and  reply. 
Some  of  his  answers  were  a  propos  and  apparently  ra- 
tional, others  bore  no  relation  to  the  question.  He 
would  laugh  in  a  silly  manner  and  say  he  did  not  know 
what  ailed  him.  -Pain  in  the  head,  which  he  could  not 
locate,  seemed  a  prominent  symptom.  He  seemed 
conscious  of  his  surroundings  and  of  his  condition,  but 
his  remarks  were  erratic  and  disconnected.  Next 
morning  he  came  to  my  office  in  his  usual  condition. 
He  wished  to  know  what  ailed  him  the  preceding  night, 
his  memory  of  the  events  being  clouded.  The  only 
symptom  remaining  was  a  dull,  diffused  headache. 
During  the  following  month  the  patient  was  very  de- 
spondent— contrar)'  to  his  habit — and  gradually  lost 
bodily  vigor.  Yet  the  pulmonary  s}'mptoms  improved. 
About  2  A.M.  on  April  i8th,  I  was  again  called,  to  find 
him  in  a  condition  precisely  similar  to  that  of  March 
2ist,  except  that  he  had  fever,  temperature  103^2°  F., 
and  his  mental  hebetude  was  more  profound.  He 
would  answer  questions  if  urged,  but  his  replies  were 
mal  a  propos.  The  silly  laugh,  the  vacant  stare,  the  stu- 
pidity were  peculiar.  He  had  entire  control  over  his 
voluntary  muscles.  There  was  no  muscular  twitching, 
but,  at  times,  considerable  restlessness.  He  would  eat, 
if  requested,  or  evacuate  bowels  and  bladder  ;  but  did 
not  seem  to  think  of  such  things  unless  suggested  to 
him.  The  fever  subsided  in  a  day  or  two,  but  the  men- 
tal state  remained.  He  looked  like  one  in  a  dream, 
yet  conscious  when  spoken  to,  or  like  a  somnambulist. 
These  symptoms  continued,  with  gradually  decreasing 
intensity,  for  two  weeks.  His  mind  became  entirely 
clear  and  no  trace  of  cerebral  disease  remained  after 

three  or  four  weeks.     Mr.  B returned  to  Michigan, 

where  he  consulted  Professor  Shurly,  to  whom  I  had 
referred  him.  I  am  ignorant  of  his  further  history  un- 
til his  death,  late  in  the  summer  of  1892.  I  think  he 
remained  under  the  care  of  his  brother,  a  prominent 
Michigan  physician. 

Case  VII.  —  First  examined  January  28,  1S93. 
Charles  W.  G. ,  of  Tacoma,  student,  aged  twenty- 
two.  Family  history  free  from  tuberculosis.  Good 
health  until  February  1892,  when  he  had  la  grippe. 
Was  ordered  to  Southern  California  and  sent  to  me. 
Present  symptoms :  Pain  in  larynx  after  talking. 
Cough,  worse  in  morning  and  after  exercise,  but  little 
at  night,  dr)'  or  loose,  painful  to  throat.  Expectora- 
tion scanty,  freest  in  the  morning,  white,  frothy,  or  yel- 


256 


MEDICAL    RECORD. 


[August  24,  1895 


low,  at  present  bloody.  Has  had  several  hemorrhages 
during  past  fortnight.  Some  chest  pain  at  bases  of 
lungs,  occasionally  higher  on  left  side.  Sleeps  on  back 
or  right  side.  Appetite  good,  but  cannot  use  milk  or 
fats.  No  flatulence,  no  abdominal  pain.  Gastric  con- 
dition good  just  now,  although  he  reports  history  of 
irritable  stomach  ever  since  illness  began.  Bowels 
regular  until  he  commenced  taking  tannic  and  gallic 
acids  to  relieve  haemoptysis.  Kidneys  normal,  no  vene- 
real ;  night-sweats  have  disappeared.  Strength  very 
limited.  Normal  weight,  135  pounds  ;  present  weight, 
119.  Extremities  cold.  Very  nervous.  Respiration, 
36;  pulse,  112,  and  weak;  temperature,  iooj4°  F. 
Hyperemia  of  nasal  mucosa,  deviation  of  septum, 
hypertrophy  of  middle  turbinated.  Pharynx  congested  ; 
follicular  disease  of  posterior  wall.  Laryngeal  mucosa 
red  and  swollen,  presenting  sodden  appearance.  Vocal 
bands  approximate  and  are  pearly.  Arytenoids  infil- 
trated, pyramidal.  Right  lung  normal  except  slight 
retraction  of  apex.  Left  lung  hepatized,  some  little  air 
entering  the  infra-axillary,  supra-scapular,  and  infra- 
clavicular regions.  No  cavities,  but  evidences  of  begin- 
ning softening.  The  pulmonary  condition  was  prob- 
ably the  result  of  an  unresolved  pneumonia — tubercular 
infection  having  taken  place  later. 

From  the  date  of  my  examination  the  patient  con- 
tinued to  improve  until  February  21st.     On  the  22d 

Mr.  G. sent  for  me.     He  complained  of  nausea, 

pain  in  epigastrium,  and  headache.  February  23d,  pa- 
tient reported  a  sleepless  night,  very  severe  frontal 
headache,  inability  to  retain  food,  heavily  coated 
tongue.  Absence  of  abdominal  tenderness,  fever,  etc., 
excluded  gastritis.  Indigestion  of  nervous  origin  seemed 
to  explain  the  symptoms.  The  patient's  mind  was  slug- 
gish, his  answers  slow  and  hesitating — a  condition  I  at- 
tributed to  pain,  loss  of  sleep,  and  lack  of  food.  On 
February  24th  the  temperature  was  normal  ;  pulse,  60, 
full  and  strong  ;  abdominal  pain  moderate  ;  no  food 
retained  ;  constipated  stool ;  headache  more  general 
and  severe  ;  pupils  dilated  ;  mental  state  unchanged  ; 
very  restless  ;  complained  of  transitory  numbness  of 
left  side.  The  possibility  of  tubercular  deposit  in  the 
'  brain  began  to  be  considered.  To  reproduce  the  daily 
record  would  be  tedious.  From  this  time  forward  the 
manifestations  of  cerebral  disease  became  more  marked. 
The  pulse  continued  slow — 54  to  68 — full  and  strong, 
until  a  few  hours  before  death,  when  it  became  rapid  and 
weak.  Abdominal  pain  and  nausea  gradually  subsided, 
so  that,  in  a  few  days  patient  could  take  any  easily  di- 
gested food.  Bowels  remained  constipated.  Headache 
continued  constant,  always  more  severe  in  frontal  re- 
gion. Mental  symptoms  became  more  prominent  by 
almost  imperceptible  degrees.  At  first  merely  slowness 
of  cerebration,  then  confusion  of  ideas  and  statements, 
finally  a  dull,  stupid  state,  gradually  increasing  into 
coma.  The  numbness  was  referred  to  one,  then  the 
other,  and  finally  both  sides — always  transitory.  To- 
ward the  end  pupils  became  contracted.  The  restless- 
ness developed  into  twitching  of  muscles,  more  marked 
on  the  left  side.  At  times  he  was  a  trifle  difficult  to 
control.  There  was  retention  of  urine  for  a  few  days, 
necessitating  use  of  catheter.  From  the  first  the  res- 
piration was  affected,  the  rate  having  fallen  from  over 
30  to  16  or  18.  The  immediate  cause  of  death  seemed 
to  have  been  inhibition  of  the  respiratory  functions. 
Death  occurred  March  5th,  the  thirteenth  day. 

Case  VHL — March  16,  1S95.  In  response  to  a 
telegram  I  arrived  at  Indio  at  2  a.m.,  and  found  my 
patient  unconscious.  The  gentleman's  sister  stated 
that  Mr.  John  A.  D ,  of  San  Francisco,  aged  twenty- 
seven,  had  suffered  more  or  less  for  three  years  from 
some  lung  aft'ection.  That  a  few  months  before  he  had 
experienced  an  acute  attack  which  confined  him  to  bed 
for  many  days.  Subsequently  his  physician  had  or- 
dered him  to  Indio,  where  he  arrived  two  weeks  prior 

to    my    visit.     Mr.   D had    apparently   improved, 

and  on  March  15th  was  unusually  bright  and  cheerful. 


He  ate  a  hearty  dinner,  but  in  a  couple  of  hours  felt 
some  nausea,  soon  followed  by  vomiting.  During  the 
afternoon  he  complained  of  headache.  After  taking 
some  light  refreshment  he  retired  to  bed  about  6  p.m., 
still  complaining  of  headache  and  languor.  About  9 
P.M.  the  sister,  who  occupied  an  adjoining  room,  heard 
moans,  and  upon  running  to  her  brother's  bed  found 

him   unconscious.      Miss   D spoke  of  his  cough, 

expectoration,  loss  of  weight,  fever,  occasional  night- 
sweats,  etc.,  but  could  not  give  exact  information  re- 
garding any  of  his  symptoms.  Evidently  it  was  a  case 
of  tuberculosis.  I  found  him  lying  on  the  right  side, 
the  right  arm  and  hand  were  cold,  perhaps  from  inter- 
ference with  the  circulation.  He  would  lie  quietly,  as 
if  asleep,  for  about  an  hour,  or  until  disturbed.  Then 
for  some  twenty  minutes  became  restless,  tossing  his 
left  arm,  flexing  and  extending  the  lower  extremities, 
moaning,  etc.  He  could  swallow  liquid  placed  on  his 
tongue.  The  pupils  were  widely  dilated.  Respiration, 
48.  Pulse  ranged  from  80,  at  2  a.m.,  to  140  just  before 
death  about  7  a.m.  Temperature  slightly  above  nor- 
mal.     The    symptoms   of    this    case    are    necessarily 

meagre,  as  Mr.  D never  regained  consciousness ; 

but  they  are  sufficient  to  determine  the  diagnosis. 

I  have  no  doubt  that  many  slight  degrees  of  tuber- 
cular deposit  in  the  brain  remain  latent — so  far  as 
symptoms  are  concerned — and  that  many  other  cases 
exhibit  so  few  indications  that  we  overlook  their  exist- 
ence. Perhaps  the  diagnosis  is  unimportant — so  little 
can  be  done  for  relief.  Nevertheless,  it  is  interesting 
to  reflect  upon  the  ubiquity  of  tubercle. 


HYSTERICAL  AMBLYOPIA  AND  AMAURO- 
SIS. REPORT  OF  FIVE  CASES  TREATED 
BY   HYPNOTISM.  1 

By  J.  ARTHUR  BOOTH,  M.D., 

CONSULTING   NEUROLOGIST  TO  THE    FRENCH  HOSPITAL,  NEW  YORi:  CITY. 

We  may  define  hysteria  to  consist  of  such  a  condi- 
tion of  the  general  nervous  system,  original  or  acquired, 
as  renders  it  capable  of  simulating  most  local  diseases  ; 
of  complicating  them  in  their  progress,  and  modifying 
them  in  their  usual  phenomena.  The  number  of  de- 
rangements and  diseases  which  hysteria  is  capable  of 
simulating  is  well  known  ;  but  defective  vision  is  one 
of  the  less  familiar  forms,  and  so  I  take  the  opportunity 
to  direct  your  attention  to  this  subject ;  at  the  same 
time  reporting  a  few  cases,  which  may  prove  of  some 
interest. 

This  special  form  of  functional  trouble,  not  due  to 
alcohol  or  tobacco,  is,  by  no  means,  a  common  one  ; 
this  is  especially  true  in  regard  to  the  cases  of  amau- 
rosis ;  those  of  amblyopia  and  narrowing  of  the  fields  of 
vision  being  more  frequently  met  with. 

The  onset  of  the  disturbance  is  usually  sudden,  and 
generally  follows  some  shock,  either  mental  or  physical. 
In  attempting  to  examine  the  eye  there  is  a  spasmodic 
contraction  of  the  orbicularis  muscle  which  is  increased 
on  exposure  to  a  bright  light,  at  the  same  time  causing 
a  sense  of  anxiety,  profuse  lachrymation,  and  a  spas- 
modic closure  of  the  lid  of  the  eye.  The  globe  itself 
does  not  present  anything  abnormal,  except  that  in  a  cer- 
tain number  of  cases  one  may  find  some  anaesthesia 
of  the  cornea.  (This  was  a  marked  symptom  in  one  of 
my  cases.  Case  IV.)  The  pupils  are  equal  and  react 
readily  and  normally.  The  media,  lens,  vessels,  and 
fundus  are  normal,  so  that  the  local  examination  does 
not  lead  to  any  knowledge  of  the  pathological  nature 
of  the  other  symptoms  which  one  learns  from  the  pa- 
tient. Question  the  patient,  and  she  complains  of  de- 
fective vision,  pain  either  ocular  or  supra-orbital,  and 
great  sensibility  to  light.     There  may  be  absolute  loss 

'  Read  before  tlio  American  Neurologic-il  Association,  Boston.  Juno 
S.  1895- 


August  24,  1895] 


MEDICAL   RECORD. 


257 


of  sight,  generally  in  one  eye,  or  only  amblyopia  and  a 
reduction  of  the  field  of  vision  to  a  small  area  around  the 
fixation  point.  Besides  the  above  we  find  the  local  and 
general  symptoms  of  hysteria,  viz.  :  a  circumscribed 
pain  over  the  brow,  a  globular  sensation  in  the  throat, 
excitability  and  irritability  of  the  nervous  system,  pal- 
pitation of  the  heart,  a  tendency  to  laugh  and  cry  with- 
out cause,  irregular,  painful,  or  absent  menstruation. 

The  following  cases  were  referred  to  me  by  Dr.  David 
Webster,  and  well  illustrate  the  above  objective  and 
subjective  symptoms. 

Case  I.     Amblyopia  and  Contraction  of  the  Fields  of 

Vision.   Vision  Restored  in  Twelve  Se'ances. — Kate  T , 

eighteen  years  of  age,  was  seen  for  the  first  time  on 
June  12,  1894,  when  the  following  history  was  ob- 
tained :  She  had  always  been  nervous,  but  otherwise  had 
had  no  trouble  until  the  appearance  of  menstruation, 
two  years  ago  ;  then,  during  the  first  year  she  suffered 
much  pain  each  month.  For  the  past  year  menstruation 
has  come  on  at  irregular  intervals,  and  has  now  been 
absent  for  two  months.  Within  the  last  six  months  the 
patient  has  become  very  depressed  and  emotional,  and 
she  has  also  had  two  convulsive  seizures  of  a  hysterical 

L.E 


eral  health  good  up  to  eighteen  months  ago  ;  then  after 
some  business  troubles  and  excesses,  he  became  de- 
pressed, nervous,  and  could  not  sleep.  Six  months  ago 
he  noticed  that  he  was  having  periods  of  temporary 
blindness,  these  only  lasting  for  a  second  or  two.  Three 
months  later  his  vision  became  blurred,  and  this  con- 
dition has  remained  up  to  the  present  time.  He  has 
never  had  any  diplopia.  Within  the  last  month  there 
has  been  more  or  less  frontal  and  occipital  headache, 
and  lately  he  has  become  very  emotional.  Sometimes 
he  gets  confused  and  cannot  remember  dates,  otherwise 
his  memory  is  good.  The  urine  has  been  examined 
several  times  and  always  found  to  be  normal.  At  one 
time  he  had  herpes  preputialis,  and  being  told  that  it 
was  due  to  a  syphilitic  infection,  thought  all  his  symp- 
toms were  caused  by  this  disease. 

Examination. — Stands  well  with  eyes  closed.  Knee- 
jerks  high  but  equal.  Grasp  of  hands  as  shown  by  the 
dynamometer  :  R.  44-40  ;  L.  40-39.  Tongue  straight  ; 
speech  normal.  Pupils  equal,  of  medium  size,  and  ac- 
tive. The  ocular  muscles  thoroughly  tested  with 
prisms,  do  not  show  any  degree  of  paresis.  The  optic 
nerves   and  retinal    vessels    appear   perfectly   normal. 

M.E. 


nature.  One  month  ago  a  brother  committed  suicide, 
and  it  was  shortly  after  this  that  she  first  noticed  fail- 
ure of  vision  ;  at  times  becoming  entirely  blind  ;  this 
latter  condition  only  lasting  a  few  seconds.  Examina- 
tion does  not  reveal  any  organic  lesion  of  the  nervous 
system.  Any  attempt  to  examine  the  eyes  causes  a 
spasmodic  closure  of  the  lids.  Both  pupils  are  mod- 
erately dilated  and  react  normally.  The  vision  of  the 
right  eye  is  \\,  and  of  the  left  eye  %%.  Both  fields 
of  vision  are  very  much  contracted,  as  is  shown  in 
Fig.  I. 

The  fundus,  media,  and  vessels  are  normal,  nothing 
being  found  to  account  for  the  condition  present.  Two 
attempts  to  hypnotize  the  patient  failed,  but  on  the 
third  trial  she  passed  into  a  deep  sleep,  and  suggestions 
referable  to  the  conditions  present  were  made.  After 
seven  seances,  the  fields  were  again  measured  and  a 
marked  improvement  was  found,  the  degree  being 
shown  in  Fig.  2. 

The  treatment  by  suggestion  was  continued  until 
August  15th,  when  the  patient  was  discharged  with 
perfectly  normal  fields  and  vision  fully  restored. 

C.\SE  II.  Amblyopia.  Contraction  of  the  Visual  Fields. 
Improvement  after  Six  Seances.  — -  March  29,  1895. 
Charles  T ,  aged  twenty-eight,  single  ;  clerk.     Gen- 


Both  visual  fields  are  very  much  contracted.  (See 
Fig.  3-) 

There  is  no  loss  of  color  perception.  The  left  side, 
including  the  cornea,  is  slightly  anaesthetic,  and  he  now 
states  that  he  occasionally  has  a  temporary  feeling  of 
weakness  in  the  leg  and  arm  of  this  side.  Examina- 
tion does  not  reveal  the  slightest  loss  of  power  :  all  the 
muscles  are  firm  and  react  normally  to  both  the  fara- 
dic  and  galvanic  currents.  He  was  hypnotized  with- 
out any  difficulty,  and  the  proper  suggestions  were  then 
made.  This  method  of  treatment  was  continued  for 
two  weeks,  resulting  in  a  complete  disappearance  of 
many  of  the  symptoms  complained  of.  The  visual 
fields  were  again  measured,  and  though  some  improve- 
ment was  shown,  still  there  remained  a  certain  amount 
of  contraction.     (Fig.  4.) 

On  April  12th  he  stated  he  had  been  having  more  or 
less  pain  in  his  abdomen  for  several  days,  and  that  this 
morning  he  had  passed  some  white  objects  at  stool. 
Upon  examining  these,  they  were  found  to  be  a  num- 
ber of  the  links  of  taenia  solium.  A  mixture  of  castor- 
oil  and  felix  mas  was  ordered,  with  directions  as  to  diet, 
etc.;  which  resulted  in  the  passing  of  two  worms,  many 
yards  in  length,  including  the  heads.  Three  days  later 
his  eye  symptoms  had  all  disappeared,  the  visual  fields 


258 


MEDICAL    RECORD. 


[August  24,  1895 


1 


were  entirely  normal,  and  have  remained  so  up  to  the 
present  time. 

Case  III.     Monocular  Blindness.    Cure  in  Five  Se- 
ances.—  Fannie    T ,    aged    thirty-eight,    married. 

Seen  November  23,  1892.     She  was  perfectly  well  un- 
til one  month  ago,  about  which  time  she  became  de- 

L.B. 


fore  it,  the  right  eye  being  covered.  Vision  in  the  right 
eye  normal.  Pupils  normal  in  size  and  active  :  no 
ocular  paresis.  On  exposing  the  eyes  to  a  bright  light 
there  is  a  certain  amount  of  photophobia.  The  oph- 
thalmoscope shows  nothing  abnormal  either  in  media, 
disk,  or  vessels.    With  the  exception  of  a  slight  amount 

M.E. 


pressed  ;  could  not  attend  to  her  household  duties  and 
had  a  number  of  crying  spells.  Three  weeks  later  pain 
appeared  in  the  left  eye,  accompanied  by  some  blurring 
of  vision,  which  gradually  increased,  and  now  for  the 
past  three  days  there  has  been  complete  blindness  in 
this  eye.  No  vomiting,  diplopia,  or  vertigo.  There  is 
no  history  of  rheumatism,  malaria,  or  any  serious  illness, 


of  anaesthesia  of  the  cornea,  there  were  no  other  sen- 
sory changes.  The  patient  was  easily  hypnotized,  and 
the  necessary  suggestions  having  been  made,  she  was 
awakened  after  sleeping  ten  minutes.  The  right  eye 
was  then  covered  and  the  left  again  tested.  Vision 
was  about  the  same,  but  she  volunteered  the  statement 
that  there  was  less  blur,  and  the  pain  had  disappeared. 


having  always  enjoyed  good  health  up  to  the  time  of 
tlie  present  trouble.  She  has  three  healthy  children 
and  has  had  no  miscarriages.  Careful  inquiry  does  not 
reveal  any  history  of  syphilitic  infection.  Bowels  and 
menses  are  regular. 

Examination. — There  is  a  complete  loss  of  vision  in 
the  left  eye  :  she  fails  to  recognize  any  object  held  be- 


November  25th. — No  change  ;  condition  the  same 
Vision  again  tested  as  before  and  with  the  same  results. 
She  complains  of  a  good  deal  of  pain  in  the  left  eye 
and  face.  I  hypnotize  her  and  suggest  that  she  will 
have  no  more  pain  ;  that  the  rest  will  do  her  good  and 
that  she  will  now  see.  In  fifteen  minutes  she  sits  up  on 
the  couch,  and  placing  one  hand  over  the  right  eye. 


\ 


August  24,  1895] 


MEDICAL    RECORD. 


259 


recognizes  a  clock  on  the  wall  twelve  feet  distant,  al- 
though she  is  unable  to  distinguish  the  hands  or  tell 
the  time.  A  bunch  of  keys,  a  knife,  and  a  silver  half- 
dollar  are  named  correctly  at  four  feet.  The  pain  is 
entirely  gone. 

December  7th. — Patient  reports  that  she  is  now  able 
to  see  much  better,  also  that  the  pain  has  been  absent 
since  the  last  seance.  She  sees  well  at  ten  feet,  but  be- 
yond this  ever\thing  looks  blurred.     Seance  repeated. 

December  9th. — Has  been  perfectly  well  :  no  pain. 
Vision  entirely  restored. 

C-\SE  I^".  Monocular  Blindness.  Cure  in  Xine  Se- 
ances.— On  September  12,  1894,  the  patient  was  re- 
ferred to  me  by  Dr.  Webster  with  the  following  note  : 
"  I  see  no  sufficient  ophthalmoscopic  reason  for  the 
loss  of  all  but  perception  of  light  of  this  young  wom- 
an's left  eye.  If  you  can  find  no  lesion  of  the  brain 
to  cause  the  blindness  perhaps  you  can  restore  the 
sight  by  hypnotism  as  you  did  before." 

Mary  C ,  aged   eighteen,  married.     The  patient 

is  an  Armenian  and  cannot  speak  a  word  of  English, 
but  her  physician  is  present  and  acting  as  interpreter, 
the  following  historj'  is  obtained  :   Has  been  married 


z,.i: 


ferred  to  Dr.  Webster,  through  whose  kindness  I  saw 
the  case  on  February  4,  1895.  Although  there  does 
not  seem  to  be  any  doubt  in  my  mind  as  to  the  trou- 
ble being  a  functional  one,  all  methods  of  treatment 
have  proved  inefifectual.  The  following  is  the  his- 
torj'  : 

Agnes  L ,  fourteen  years  of  age  ;   single.     She 

was  perfectly  well  up  to  one  year  and  a  half  ago  ; 
about  this  time  she  fell  on  the  ice,  striking  the  back  of 
her  head.  She  was  much  frightened  and  jarred,  but 
did  not  vomit  or  lose  consciousness.  Menses  appeared 
for  the  first  time  shortly  after  this,  but  have  never  been 
regular,  two  months  haNang  now  elapsed  since  the  last 
period.  Two  months  after  the  accident  above  referred 
to,  the  patient  commenced  to  have  headache,  chiefly 
frontal,  but  sometimes  in  occiput  and  back  of  neck. 
On  May  5,  1894,  she  came  under  the  care  of  Dr.  Boyn- 
ton,  at  the  Ophthalmic  Hospital,  for  dimness  of  vision. 
Examination  revealed  almost  total  loss  of  \-ision  in 
the  right  eye,  without  any  change  in  the  fundus,  ves- 
sels, and  disk  ;  all  being  found  normal,  ^\^lile  in  the 
hospital  she  had  two  epileptoid  attacks,  hysterical  in 
character,  and   she  also   had   frequent   crying  spells. 


WiP-MJZO. 


five  years  ;  two  children  and  no  miscarriages  ;  is  now 
nursing  an  infant  eight  months  old.  Was  fairly  well  up 
to  the  past  month  ;  during  this  time  she  has  become 
depressed,  emotional,  and  has  often  complained  of  a 
lump  rising  in  the  throat.  A  few  days  ago  she  had 
some  headpain,  and  with  its  appearance  she  noticed 
failure  of  vision  in  the  left  eye,  and  now  the  patient 
cannot  distinguish  any  object  at  any  distance  far  or 
near,  but  she  can  make  out  the  difference  between  light 
and  darkness.  She  is  poorly  nourished  and  anfemic. 
Mucous  membrane  of  lips,  gums,  and  conjunctiva;  pale. 
Both  pupils  moderately  dilated,  the  left  not  reacting  as 
actively  as  the  right.  Fundus  entirely  normal.  Failing 
to  find  any  evidence  of  organic  trouble,  the  diagnosis 
of  a  functional  amaurosis  was  made  and  I  decided  to 
try  suggestion  for  its  relief.  The  patient  not  being 
able  to  understand  English,  I  was  not  successful  in  the 
first  attempt  to  hypnotize  her  ;  but  through  the  aid  of 
Dr.  Aterian  I  learned  the  proper  Armenian  words 
necessary  for  the  purpose  and  was  successful  at  the 
third  seance  in  obtaining  a  deep  hypnotic  sleep.  Com- 
plete recovery  took  place  in  nine  seances. 

Case  V.  Monocular  Blindness.  Unimproied. — This 
patient  had  been  under  the  care  of  Drs.  Boynton  and 
Palmer  at  the  Ophthalmic  Hospital,  and  was  finally  re- 


Thorough  treatment  with  strychnia,  glonoin,  iron,  and 
the  valerianates  caused  no  improvement. 

Examination. — There  is  a  complete  loss  of  vision  in 
the  right  eye.  Left  eye  vision  is  ^u^^,  brought  up  to 
normal  with  proper  glass.  Field  much  contracted  in 
all  directions.  In  a  moderate  light,  both  pupils  dilated, 
the  right  being  a  little  the  larger.  Reflex  through  the 
right  retina  not  as  good  as  through  the  left.  When  one 
illuminates  the  left  retina,  the  right  pupil  does  not  remain 
contracted  as  long.  With  direct  illumination  the  reac- 
tion is  about  the  same.  There  is  a  marked  loss  of 
sensation  of  the  cornea  of  the  right  eye,  but  no  anaes- 
thesia of  face,  body,  or  extremities.  The  patient  recog- 
nizes colors  readily.  The  knee-jerks  are  exaggerated 
but  equal.  The  question  of  simulation  was  considered, 
but  repeated  tests  by  prisms  and  other  means  gave 
negative  results.  Treatment  by  means  of  drugs  having 
failed  to  change  the  conditions  present,  hypnotism  and 
metalo-therapy  were  tried,  but  both  failed  to  influence 
the  patient  in  any  way. 

Prognosis  and  Diagnosis. — From  the  facts  brought 
out  in  the  above  histories,  we  see  that  an  amblyopia,  or 
amaurosis  from  hysteria,  may  be  slight  in  form  and 
transitor)'  in  duration,  or  very  severe  :  sometimes  tardy 
in  its  progress  and  prolonged  in  its  existence.     If  the 


26o 


MEDICAL   RECORD. 


[August  24,  1895 


condition  should  persist  for  any  length  of  time  and  an 
alteration  of  nutrition  or  any  morbid  formative  pro- 
cess be  set  up  by  the  prolonged  functional  disturbance, 
then  it  is  probable  that  finally  the  condition  would 
change  into  an  amaurosis  from  inflammation  and  con- 
gestion. This  latter  condition,  I  now  believe,  is  taking 
place  in  Case  V.,  which  illustrates  well  this  type  of  the 
disease. 

The  diagnosis  is  based  on  two  points,  viz.  :  the  ab- 
sence of  any  demonstrable  changes  in  the  eye,  and  the 
lack  of  that  agreement  between  the  individual  symp- 
toms constituting  the  disturbance  of  vision  which  un- 
der other  circumstances  they  would  exhibit.  Persons 
whose  visual  fields  are  unusually  contracted  still  move 
with  perfect  security,  without  stumbling,  in  a  space 
which  is  not  well  known  to  them.  The  only  difficulty 
in  diagnosis  exists  in  those  cases  where  a  line  must  be 
drawn  between  true  simulation  and  a  hysterical  blind- 
ness, that  is,  one  having  an  actual  existence  in  the 
imagination.  It  is  not  that  they  will  not,  but  they  can- 
not will.  The  retina  receives  the  impression,  but 
through  some  fault  of  the  higher  cortical  centres,  per- 
haps by  inhibition,  the  patient  remains  unconscious  of 
it. 

Treatment. — Besides  the  measures  usually  recom- 
mended in  the  treatment  of  these  disorders — the  inter- 
nal administration  of  strychnia,  iron,  etc. — I  wish  to 
urge  the  trial  of  hypnotism,  and  I  do  not  do  this  from 
any  optimistic  point  of  view. 

A  great  many  of  us  are  prone  to  look  upon  this  en- 
tire subject  as  either  belonging  to  the  domain  of  quack- 
ery, or  believing  that  it  requires  some  special  power 
hesitate  to  take  advantage  of  this  method  of  treatment. 
The  time  has  now  passed  for  any  such  argument,  and 
any  physician  who  would  take  the  trouble  to  study  the 
subject  would  obtain  satisfactory  results  in  a  certain 
number  of  cases.  The  manner  of  procedure  in  pro- 
ducing hypnosis  is  given  in  detail  in  current  literature, 
so  that  it  does  not  seem  necessary  to  dwell  upon  this 
part  of  the  subject  here,  except  to  state  that  the  fi.xa- 
tion  method  is  the  one  generally  employed. 

From  the  results  obtained  in  the  cases  just  sub- 
mitted, the  following  conclusions  may  be  drawn,  viz.  : 

1.  \ye  possess  in  suggestive  therapeutics  an  important 
aid  in  the  treatment  of  certain  morbid  conditions,  but 
just  how  valuable  this  may  be,  cannot  be  estimated 
until  it  is  more  generally  used  and  the  results  reported. 

2.  The  results  of  this  method  of  treatment  are  sufficient 
to  stimulate  the  profession  to  further  use  of  it.  3. 
Instead  of  waiting  and  trying  other  methods  first,  thus 
allowing  the  disease  to  exist  for  a  certain  time,  I  would 
recommend  the  trial  by  hypnotism  in  the  first  place. 
Two  of  the  cases  already  reported  had  been  treated  by 
other  measures  for  some  time  without  success.  4.  The 
use  of  hypnotism  by  the  intelligent  physician,  in  the 
cure  of  certain  morbid  conditions,  does  not  produce 
any  bad  effects,  notwithstanding  reports  to  the  con- 
trary. 

GonorrhcEa  :  When  Cured?— A  patient  who  has  had 
gonorrhoea  and  is  about  to  marry  asks  his  physician 
whether  he  is  completely  freed  from  his  disease  and 
witliout  danger  of  contaminating  his  wife.  In  such 
cases  the  writer  instructs  his  patient  to  drink  a  quart 
and  a  half  of  beer,  after  which  he  injects  into  the  pa- 
tient's urethra  a  two  per  cent,  solution  of  sublimate. 
If  he  is  actually  cured,  no  reaction  follows  ;  if  the  con- 
trary is  true,  a  discharge  will  be  set  up  which  some- 
times does  not  a|)pear  for  forty-eight  hours.  —  Dr. 
Kraft,  of  Utrecht. 

Artificial  Feeding  of  Infants.— I  do  not  advise  using 
milk  diluted  with  plain  water  for  young  babies  under 
four  months  old.  Tiie  simplest  and  most  commonly 
used  diluent  is  barley-water,  which  is  almost  entirely 
innutritions,  its  action  being  purely  mechanical  in 
breaking  up  the  casein. — Griffith. 


INTRA-  OR  EXTRA-PERITONEAL  TREAT- 
MENT OF  THE  PEDICLE,  OR  TOTAL  HYS- 
TERECTOMY. 

By  MARY  A.  DIXON  JONES,  M.D., 

BROOKLYN,   N.    V. 

Ix  1 886  I  saw  Austria's  great  surgeon,  Billroth,  treat 
the  pedicle  of  a  uterine  myoma  intra-peritoneally. 
More  than  once  did  Billroth,  with  his  quick  and 
graceful  step,  lead  me  around  the  wards  of  his  hospital 
to  see  this  and  other  patients.  To  me  it  was  exceedingly 
interesting  to  see  the  kindly  and  almost  childlike  en- 
thusiasm of  his  great  mind,  then  in  all  its  manly  vigor. 
Operating,  doing  much  of  surgery,  only  makes  the  good 
man  more  loving,  more  kind,  and  more  tender.  The 
patient  from  whom  he  removed  the  uterine  myoma  and 
treated  the  pedicle  intra-peritoneally  did  well. 

In  Berlin  I  saw  Schroeder  treat  the  pedicle  of  a 
uterine  myoma  intra-peritoneally.  Again  and  again  I 
stood  in  the  operating-room  of  this  excellent  surgeon, 
and  was  always  given  by  him  the  most  eligible  position. 
This  great  man  also  invited  me  to  accompany  him 
through  the  wards  of  his  hospital.  The  pedicles  of  all 
cases  of  uterine  myoma  he  treated  intra-peritoneally. 
It  seemed  a  beautiful  procedure,  except  that  I  occa- 
sionally would  like  to  see  how  the  pedicle  was  doing. 

In  London  I  saw  Granville  Bantock  remove  a 
uterine  myoma,  and  he  treated  the  pedicle  extra- 
peritoneally.  That  first  day — the  first  operation  at 
which  I  was  present — there  was  a  crowd  to  see  the 
great  operator.  I  imagined  I  would  scarcely  be  able 
to  get  a  glimpse.  I  stood  far  on  the  outside.  Ban- 
tock came  in  his  quiet,  amiable  manner  ;  he  looked  at 
his  instruments,  saw  that  all  was  right,  then  with  a 
kindly  glance  of  his  mild,  penetrating  eye,  and  almost 
a  suppressed  smile,  he,  with  inimitable  grace,  said  : 
"  The  shortest  to  the  front."  This  gave  me  a  place 
opposite  and  near  to  the  first  assistant.  The  pedicle 
had  attached  to  it  a  number  of  little  fibroid  tumors. 
It  was  a  difficult  case  to  manage.  Bantock  concluded 
to  leave  some  attached.  Dr.  Dornan,  the  first  assist- 
ant, subsequently  gave  me  a  picture  of  this  mass  of 
tumors.  I  was  privileged  to  see  Bantock  in  many 
operations,  he  always  stood  at  a  distance  from  the 
table,  nowhere  and  at  no  time  touching  it,  but  with  a 
firm  position  he  directed  the  whole  strength  of  his 
body  to  the  thoughtful  manipulations  of  his  hands. 

In  the  Woman's  Hospital  of  New  York  I  saw  Dr. 
Charles  C.  Lee  remove  a  large  fibroid  tumor,  extra- 
peritoneal treatment  of  the  pedicle.  Dr.  Lee  also 
most  kindly  gave  me  opportunities  of  seeing  the  condi- 
tion of  the  pedicle  from  time  to  time.  The  patient 
did  well.  I  saw  Dr.  Wylie  remove  a  large  fibroid 
tumor  and  treat  the  pedicle  extra-peritoneally.  The 
operation  was  beautifully  performed  and  the  patient 
made  an  excellent  recovery. 

On  August  15,  1887,  a  poor  colored  woman  came  to 
see  me  at  the  dispensary,  complaining  of  much  pain 
and  distress  on  each  side  of  the  pelvis,  and  in  the 
region  of  the  bladder  and  rectum.  She  said  she  had 
had  a  constant  hemorrhage,  varying  in  quantity,  since 
the  third  of  the  preceding  May.  I  found  the  uterus 
enlarged  to  the  size  of  the  seventh  month  by  an  inter- 
mural  myoma,  the  lower  part  being  wedged  tightly 
down  in  a  small  contracted  pelvis.  Some  weeks  after, 
this  woman  called  again  at  the  dispensary,  she  was  still 
bleeding,  sometimes  profusely,  and  was  growing  weaker 
and  weaker.  We  feared  her  life  might  be  in  danger,  so 
we  admitted  her  into  the  Woman's  Hospital  of  Brook- 
lyn, then  located  at  725  Greene  Avenue.  She  was  in 
an  extremely  feeble  condition,  that  evening  having  re- 
])eated  chills.  After  a  hot  bath  and  fresh  clothing  she 
was  placed  in  bed,  with  a  jug  of  hot  water  to  her  thin, 
bloodless  feet.  Day  after  day  she  had  the  most  care- 
ful nursing,  the  best  nourishment,  and  constant  medical 
attendance.     In  some  respects  she  seemed  to  improve. 


August  24,   1895] 


MEDICAL   RECORD. 


261 


notwithstanding  the  bleeding  and  other  serious  symp- 
toms continued.  We  decided  to  remove  the  tumor, 
which,  after  the  usual  preparations,  and  with  the  assist- 
ance of  Dr.  C.  X.  D.  Tones,  I  did,  on  November  15, 
1887.  The  omentum  was  generally  adherent,  and 
especially  bound  firmly  in  the  region  of  the  uterine 
appendages.  After  liberating  it,  and  tying  the  broad 
ligaments,  with  one  hand  under  the  tumor,  and  the 
other  with  Tait"s  screw,  the  mass  was  lifted  from  the 
abdominal  cavity.  There  were  especially  grave  difficul- 
ties in  securing  the  uterine  pedicle,  it  was  very  short ; 
many  fibroids  were  shelled  out,  finally  it  was  transfixed 
with  pins  and  placed  in  the  lower  angle  of  the  abdom- 
inal incision.  The  womb  was  dressed  two  or  three 
times  each  day,  and  the  patient  was  apparently  doing 
well  ;  still  for  weeks  this  woman  lay  on  her  back,  as  if 
chained  by  some  great  weight.  Day  after  day,  as  I 
rode  around  to  see  other  patients,  my  thoughts  con- 
tinually recurred  to  this  poor  colored  woman  in  that 
bed  in  the  hospital.  I  knew  that  the  continued  drag- 
ging of  that  pedicle  was  to  her  a  continued  shock.  I 
knew  that  that  pedicle  was  placing  her  in  constant 
danger  ;  and  of  what  possible  utility  would  it  be ; 
what  advantage  was  there  in  retaining  that  dense  piece 
of  fibrous  tissue,  that  piece  of  cervix  which  in  most  in- 
stances is  diseased  ?  Why  not  remove  it  ?  To  me  the 
clear  sunlight  of  heaven  shone  into  that  poor  woman's 
abdomen.  I  could  see  that  useless  piece  of  hard  cervix 
festering  and  disturbing  adjoining  structures,  and  so 
out  of  place  amid  the  soft  peritoneal  tissues.  Con- 
tinually I  could  see  more  and  more  the  beauties  of  re- 
moving it.  .  Over  and  over  again,  I  mentally  went  over 
the  operation  of  removing  the  cervix,  saw  that  it  was 
feasible  and  safe,  and  would  be  so  much  better  for  the 
operation  and  for  the  patient  I  Why  was  it  ever  thought 
necessary  to  retain  it  ? 

In  both  methods  of  operation,  extra-peritoneal  or  in- 
tra-peritoneal,  it  is  the  stump  that  makes  the  difficulty  : 
it  is  the  source  of  most  of  the  danger,  and  statistical 
history  shows  that  the  great  mortality  of  this  operation 
is  due  almost  entirely  to  unfavorable  conditions  origi- 
nating in,  or  generated  around,  the  stump.  Emmet  re- 
ports a  case.  "  The  stump  was  almost  all  cut  away, 
leaving  only  enough  of  the  cervical  tissues  to  hold  the 
ligatures  from  slipping  off,  and  it  was  so  covered  as  to 
be  placed  outside  of  the  peritoneal  cavity  ;  yet  on  the 
fourteenth  day  the  patient  died  from  rupture  of  an  ab- 
scess." This  distinguished  operator  says  further  :  "  I 
have  removed  the  whole  or  portions  of  the  uterus  in 
five  instances,  and,  notwithstanding  the  greatest  care 
to  insure  a  favorable  result,  all  the  patients  died,  sooner 
or  later,  from  blood-poisoning  generated  about  the 
stump."  Shall  we  say  it  is  a  safe  method  when  it  is  so 
frequently  fatal  in  the  hands  of  our  best  operators  ?  It 
is  not  the  operation,  or  the  method  of  operation,  but 
it  is  the  danger  which  is  inherent  in  the  stump,  or  in 
this  method  of  procedure. 

On  November  23,  18S7,  when  I  was  privileged  to 
present  this  tumor  that  I  had  removed  on  November 
15th,  before  the  New  York  Pathological  Society,  I  stated 
that  I  believed  a  better  and  more  natural  procedure 
would  have  been,  after  opening  the  abdominal  walls — 
being  assured  of  the  condition  of  affairs,  and  liberat- 
ing any  adhesions  that  might  exist — then  to  have  sev- 
ered the  vaginal  connections,  as  in  colpo-hysterectomy, 
and  so  remove  the  entire  uterus.  Or,  if  the  body  of 
the  tumor  or  uterus  were  removed  through  abdominal 
incision,  then  to  remove  the  uterine  stump  per  vaginam, 
and,  after  "  la  toilette  du  peritoine,"  close  the  abdomi- 
nal walls  and  leave  the  vaginal  opening  as  the  best  and 
most  natural  mode  of  effecting  drainage.  I  also  gave 
the  following  reasons  for  favoring  this  procedure  :  r. 
It  would  shorten  the  operation  ;  2,  would  be  less  shock 
to  the  patient ;  3,  would  lessen  the  dangers  of  the  op- 
eration :  4,  the  patient  would  make  a  rapid  recovery. 

I  carried  this  method  out  Februarj'  16,  18S8,  for  a 
tumor  altogether  weighing  seventeen  pounds.    The  pa- 


tient came  to  my  office  January  17,  1888.  Forty  years 
of  age,  twice  married  and  no  children.  A  uterine  my- 
oma extended  from  the  cervix  to  within  an  inch  of  the 
ensiform  cartilage,  and  was  larger  than  the  uterus  at 
term.  Her  emaciated  body  seemed  only  a  framework 
to  support  the  growth  ;  she  wished  to  have  it  removed. 
I  told  her  of  the  dangers  of  the  operation,  yet  I  be- 
lieved it  was  the  only  way  to  give  her  any  relief. 

At  the  next  visit  she  informed  me  that  she  had  seen 
a  physician  whom  she  had  previously  consulted,  and 
he  had  told  her  that  if  she  had  the  operation  she  would 
die  on  the  table.  She  replied  to  him  that  she  had 
rather  die  than  remain  as  she  was.  I  again  assented  to, 
and  emphasized  the  dangers  of  the  operation.  She 
still  said  she  wished  to  have  the  tumor  removed.  She 
was  admitted  into  the  Woman's  Hospital  of  Brooklyn, 
February  5th.  Operation  performed  Februar)-  i6th. 
As  she  lay  on  the  operating- table  under  ether,  the  body 
seemed  a  mere  skeleton  :  the  monstrously  large  and 
nodulated  tumor  filled  the  whole  abdominal  cavity,  ex- 
tending up  to  and  under  the  ribs.  A  small  exploratory 
incision  was  made  first  midway  between  the  umbilicus 
and  down  to  the  pubes.  I  passed  my  hand  in  and 
around  to  free  adhesions,  then  by  the  help  of  Tait's 
screw,  with  the  left  hand  beneath,  the  mass  was  lifted 
out  of  the  abdominal  cavity.  The  right  cube  was 
greatly  enlarged,  presented  the  appearance  of  a  coiled- 
up  and  adherent  mass  of  intestine  ;  the  left  tube  w-as 
also  adherent,  its  fimbriated  extremity  closed,  and  the 
tube  filled  with  pus.  The  tumor  was  removed.  "  The 
pedicle  thus  secured  consisted  of  a  mass  of  tumors,  one 
of  them  three  inches  in  diameter,  all  closely  packed, 
reaching  to  the  cervix.  I  knew  that  to  make  a  pedicle 
of  the  mass  would  not  only  endanger  the  patient's  Ufe, 
but  render  the  operation  unfinished  and  imperfect,  so 
I  decided  at  once  to  proceed  as  in  vaginal  hysterectomy 
for  the  removal  of  this  portion."  1  separated  the  va- 
ginal attachments — the  size  of  the  mass  rendered  it 
necessary  to  remove  through  the  abdominal  incision. 
Drainage  was  secured  both  through  the  vagina  and  ab- 
dominal womb.  By  thus  removing  the  entire  uterus 
we  not  only  got  clear  of  the  stump,  but  of  the  great 
mass  of  loose  tissue  which  surrounded  it  and  which,  if 
it  had  remained,  would  doubtless  have  produced  the 
most  serious  consequences  ;  and  which  is  probably  an 
explanation  of  why  the  report  has  so  frequently  to  be 
made  of  death  on  the  ninth,  twelfth,  or  fourteenth  day 
from  abscess  near  the  stump.  I  do  not  see  how  in  this 
case,  with  every  precaution,  the  formation  of  an 
abscess  could  have  been  prevented  in  so  much  loose 
issue. 

It  was  marvellous  to  see  how  much  more  rapid  was 
the  convalescence  of  the  patient  than  it  would  have 
been  had  not  the  stump  been  removed.  Keith  says  : 
"  The  average  time  of  convalescence  in  the  extra-peri- 
toneal cases  was  forty-one  days  ;  of  the  intra-peritoneal 
method,  three  weeks."  This  patient  was  practically 
well  on  the  twelfth  or  fourteenth  day,  had  an  excellent 
appetite,  and  had  gained  in  flesh  and  strength.  No 
such  results  could  possibly  have  been  secured  if  the 
stump  had  been  left. 

If  the  pedicle  or  cervix  is  removed,  it  should  pre- 
ferably be  treated  extra- peritoneally,  though  one  of  our 
first  authorities,  Dr.  T.  A.  Emmet,'  said  :  "  If  myotomy 
was  to  have  a  future,  it  would  have  to  be  done  by 
covering  the  stump  with  the  peritoneum  and  dropping 
it  into  the  peritoneal  cavity."  Professor  T.  G.  Thomas ' 
said  :  "  He  had  removed  the  uterus  from  seventeen  pa- 
tients ;  nine  of  them  had  recovered  and  the  remainder 
had  died.  A  large  number  had  been  treated  by  the 
clamp,  and  they  had  done  remarkably  well.  A  smaller 
number  had  been  treated  by  simply  returning  the 
pedicle,  and  they  had  done  badly."  Dirner,  of  Buda- 
Pesth,  Hungary,  says  the  extra-peritoneal  method  pre- 
vents hemorrhage  and  sepsis  more  completely  than  the 

'  American  Journal  of  Obstetrics,  January  5,  1885,  p.  85. 
'  Ibii,  January,  1887. 


262 


MEDICAL    RECORD, 


[August  24,  1895 


other  method.  Greig  Smith '  says  :  "  The  dangers  of 
the  intra-peritoneal  treatment  are  nearly  twice  as  great  as 
the  extra-peritoneal."  As  I  said  in  an  article  pub- 
lished in  the  New  York  Medical  Journal,  August  25, 
1888  :  "  But,  even  when  the  stump  is  treated  extra- 
peritoneally,  there  are  many  dangers,  and  may  be  much 
trouble,  as  of  an  operation  performed  September,  1887, 
by  one  of  the  most  distinguished  living  gynecological 
surgeons  and  at  a  centre  of  gynecological  science,  the 
record  is  death  on  the  seventh  day  '  from  pus  cavity 
on  one  side  of  the  pedicle.'  We  may  seek  to  produce 
the  best  conditions,  but  there  are  still  foul  septic  dis- 
charges, and,  if  the  patient  recovers,  it  is  only  the 
question  of  escaping  the  many  dangerous  possibilities. 
At  best  the  stump  is  a  hard,  fibrous  mass,  extending 
from  the  vaginal  to  the  abdominal  walls,  and  pulling 
upon  both.  In  this  case  I  have  reported  the  traction 
upon  the  abdominal  walls  was  so  great  that  it  made  a 
considerable  sink  or  depression  in  the  surface,  and 
caused  such  pressure  from  the  pins  that,  notwithstand- 
ing every  care  and  all  possible  disinfection,  keeping 
constantly  fresh  gauze  under  the  pins,  yet  beneath  them 
the  skin  sloughed,  and  with  all  this  there  were  the 
threatening  dangers  of  sepsis,  abscess,  etc.,  from  the 
decaying  stump.  Is  a  course  of  procedure  the  wisest 
that  is  necessarily  accompanied  by,  or  may  encounter, 
such  grave  conditions  ?  What  is  the  good  of  preserv- 
ing the  stump  intra-peritoneally  or  extra-peritoneally  ? 
It  is  only  the  remnant  or  remains  of  a  sickly  womb,  and 
can  be  of  no  service  and  may  do  much  damage — how 
much,  who  can  tell  ? — not  only  at  the  time  of  the  opera- 
tion, but  in  the  subsequent  history  of  the  patient.  One 
case  is  reported  in  which  '  within  a  year  cancer  de- 
veloped in  the  remains  of  the  cervix  and  proved  fatal.'  " 

Dr.  Joseph  Price's  magnificent  results  have  done 
much  to  favor  the  extra-peritoneal  method,  still  sur- 
geons have  long  recognized  the  dangers  of  the  stump, 
whether  much  or  little  is  left,  or  whether  treated  intra- 
or  extra-peritoneally.  Professor  W.  M.  Polk,  at  the 
meeting  of  the  New  York  Obstetrical  Society,  June  15, 
1889,  said  :'-  "  Lea\ing  a  large  suppurating,  or  rather 
gangrenous,  stump  is  a  surgical  fault  threatening  the 
life  of  the  patient,  and  improved  means  should  be  de- 
vised whereby  it  can  be  got  rid  of."  He  adds  ;  "  I 
should  like  to  have  the  question  under  discussion 
broadened  so  as  to  take  in  the  views  of  the  members 
upon,  the  propriety  of  total  extirpation  of  the  uterus, 
after  ligation  of  the  uterine  artery.  I  believe  it  is  time 
to  look  about  for  means  of  getting  rid  of  the  slowly 
sloughing  stump,  which  is  constantly  a  source  of  danger 
in  addition  to  what  pertains  to  ordinary  laparotomies." 

Dr.  E.  \V.  Gushing,  of  Boston,  on  March  28,  1895, 
read  before  the  (gynecological  Section  of  the  New  York 
Academy  of  Medicine  a  paper  on  "  Histerectomy  and 
Total  Extirpation  of  the  Uterus  by  Abdominal  Sec- 
tion." He  gave  the  evolution  of  hysterectomy  in  this 
country,  quoting  from  the  Xe~d<  York  Medical  Journal 
of  August  25,  1888,  that  the  first  case  of  total  hysterec- 
tomy in  this  country  for  uterine  myoma  was  performed 
by  Dr.  Mary  A.  Dixon  Jones,  February  16,  1888.  Dr. 
Gushing  referred  to  the  various  improvements  in  this 
operation,  and  the  excellent  work  done  by  Drs.  L.  A. 
Stimson,  \\illiam  M.  Polk,  Joseph  Eastman,  B.  F. 
Baer,  and  others.  During  the  discussion  Dr.  Baldy,  of 
Philadelphia,  said  he  thought  "  it  would  be  better  to 
leave  a  small  portion  of  the  cervix."  Dr.  F.  Kru'^,  in 
a  short  address,  favored  the  idea  that  all  the  ceTvix 
should  be  removed.  Dr.  Krug  had  on  a  previous 
occasion  said  that  "  total  hysterectomy  is  an  ideal 
operation."  At  a  meeting  of  the  New  York  Obstetri- 
cal Society,  November  5,  1889,  when  Dr.  Boldt  pre- 
sented "  an  interstitial  uterine  fibroid,"  removed  by  my 
method  of  total  extirpation  of  the  uterus,  Dr.  I  )udley 
inquired  :  "  What  advantage  is  there  in  removing  all 
the  cervix  over  that  form  of  hysterectomy  which  leaves 

'  Opus,  second  edition,  1888. 

'American  Journal  of  Obstetrics,  1889,  p.  130. 


part  of  the  cervix  as  a  stump  ?  "  Dr.  Boldt  well  re- 
plied, "  By  leaving  a  portion  of  the  stump,  the  patient 
is  exposed  somewhat  to  sepsis,  which  can  be  avoided 
by  complete  hysterectomy." 

As  to  Goffe's  method,  I  said  in  a  paper  published  in 
the  Medical  Record,  September  6,  1890:  "Goffe's 
method,  as  reported  by  the  New  York  Obstetrical  Jour- 
nal, is,  as  he  describes  it,  '  taking  out  the  whole  of  the 
uterus  except  a  bit  of  the  cervix,  covering  this  over 
with  peritoneum.'  But  in  all  his  cases,  as  he  reports 
them,  the  temperature  went  up  the  fourth  or  fifth  day, 
which,  says  Dr.  Goffe,  '  means  suppuration  under  the 
flap,  with  danger  of  the  pus  bursting  into  the  peritoneal 
cavity  ; '  so  in  each  case  he  dilated  the  cervix,  drained, 
and  irrigated.  Of  one  he  said,  '  A  gentle  amount  of 
pressure  caused  the  exit  of  about  half  an  ounce  of  pus 
and  broken-down  tissue.'  The  same  procedures  are 
used  by  Dr.  A.  P.  Dudley.  '  He  dissects  out  the  uterus 
to  about  three-fourths  of  an  inch  of  the  cervix.'  The 
third  day  there  is  the  same  rise  of  temperature,  the 
same  process  of  dilating  for  discharge  of  pus.  Thus, 
invariabl)',  a  certain  amount  of  suppuration  seems  to 
accompany  this  method,  so,  with  '  a  bit  of  the  cen-ix 
left,'  there  cannot  be,  as  Dr.  Goffe  expresses  it,  '  all 
the  elements  of  safety.'  " 

Dr.  E.  W.  Cushing  dwelt  at  length  upon,  and  espe- 
cially commended.  Dr.  L.  A.  Stimson's  method  of  first 
tying  the  uterine  artery  ;  which  is  indeed  an  excellent 
way  of  controlling  hemorrhage  ;  but  Dr.  Polk,  at  a 
meeting  of  the  New  York  Obstetrical  Society,  Febru- 
ary 18,  1890,  said  that  ^  "the  searching  for  the  uter- 
ine artery  down  by  the  side  of  the  uterus,  and  ligating 
and  enucleating  separately,  was  according  to  the  plan 
of  Dr.  Stimson,  but  as  a  matter  of  fact  it  was  unnec- 
essary, for  one  could  ligate  en  masse  without  any  diffi- 
culty." He  said,  further,  "  Ligating  en  masse  shortens 
the  operation."  Dr.  Bantock  reported  in  the  British 
Gynecological  Journal  iox  1890,  page  75,  "the  \trj  first 
case  in  which  he  removed  a  fibroid  tumor  from  the 
uterus  he  secured  both  the  ovarian  and  uterine  arteries 
separately,  and  then  put  a  serre-noeud  around  the  body 
of  the  uterus,  and  it  was  extraordinary  how  much  bleed- 
ing he  got." 

At  the  same  meeting  Dr.  Polk  incidentally  remarked  : 
"  The  operation  introduced  into  this  country  by  Dr. 
L.  A.  Stimson,  of  removing  the  entire  uterus  including 
the  cervix."  Is  not  this  a  mistake  ?  Dr.  Stimson  says 
his  first  two  cases  were  reported  to  the  New  York  Sur- 
gical Society,  Januar)'  9,  1889,  published  in  the  Ne-w 
York  Medical  Journal  March  9,  1889.  My  first  case 
was  reported  to  the  New  York  Pathological  Society 
February  22,  1888,  and  published  in  the  Xc7v  York 
Medical  Journal  August  25,  and  September  i,  1888. 

Dr.  Mendes  De  Leon,  of  Amsterdam,  wrote  me  Oc- 
tober 20,  1SS8  :  "Only  yesterday  I  returned  from  a 
trip  to  Berlin.  Martin  told  me  he  had  performed  four 
hysterectomies,  with  vaginal  extirpation  of  the  pedicle. 
As  soon  as  he  will  reach  the  series  of  ten  he  intends  to 
publish  it.  Is  this  method  of  tying  the  pedicle  yours 
or  his  ?  I  am  very  anxious  to  know  more  about  this 
question.  Perhaps  you  may  find  time  to  let  me  know 
one  of  these  days." 

Professor  A.  Martin,  of  Berlin,  was  in  this  country 
only  two  months  before  I  presented  the  subject  to  the 
Pathological  Society.  In  several  of  his  addresses  while 
here  he  spoke  of  the  treatment  of  the  pedicle,  strongly 
favoring  the  intra-peritoneal  method  :  so  far  as  I  know 
he  did  not  mention  the  vaginal  extirpation  of  the 
stump,  nor  did  anyone  else  previous  to  my  publication 
in  November,  1S87. 

Dr.  Joseph  Eastman  said  in  the  Cincinnati  Lancet- 
Clinic,  December  S,  1S04:  "Dr.  Mary  Dixon  Jones, 
of  New  York,  was  the  first  in  America  to  take  out  the 
entire  cervix."  This,  so  far  as  I  know,  is  true  :  at  least  I 
had  never  heard  of  its  being  done,  nor  do  I  consider 

American  Journal  of  Obstetrics,  1890,  p.  -,33. 


August  24,  1895] 


MEDICAL    RECORD. 


26- 


the  method  in  any  way  an  imitation  of  Freund's  oper- 
ation. It  has  different  uses  and  a  different  object. 
Further,  I  think  a  cancerous  cervix  should  be  removed 
only  through  the  vagina  —  should  never  be  taken 
through  the  peritoneal  cavity.  One  reason  why  I,  in 
my  article  on  "  Colo-hysterectomy  for  Malignant  Dis- 
ease,"^ so  emphasized  delivering  the  uterus  by  an- 
terior version,  was  that  by  posterior  version,  the  usual 
method,  the  diseased  cervix  was  so  often,  uninten- 
tionally, thrown  into  the  peritoneal  cavity. 

While  it  is  admitted  that  I  was  the  first  one  in 
America  to  perform  total  hysterectomy  for  uterine 
myoma,  still  I  have  now  to  record  that  I  was  not  the 
first  person  who  did  this  operation.  I  have  found  out, 
only  a  short  time  since,  through  the  kindness  of  Dr. 
H.  G.  Garrigues,  that  there  were  four  cases  of  "  Total 
Extirpation  of  the  Uterus  for  Fibroid,"  performed  by 
Bardenheuer,  of  Cologne,  Germany,  and  these  cases 
were  reported  as  an  appendix  to  a  book  entitled 
"  Drainierung  der  Peritoneal  Hohle,"  Stuttgart,  iS8r. 
Perhaps  if  we  search  the  records  further  we  may  pos- 
sibly find  the  same  operation  was  done  by  an  ancient 
Egyptian  physician- for  some  poor  suffering  woman. 


AN    OPERATIVE     PROCEDURE     FOR    SPINA 
BIFIDA. 

By  H.  HOWITT,  M.D., 

GUELPH,  O.NT. 

Although  the  Ontario  Medical  Association  has  a 
large  membership-roll,  I  doubt  if  it  has  a  single  mem- 
ber who  has  seen  an  adult  with  an  undoubted  and  well- 
marked  spina  bifida.  On  the  other  hand,  according  to 
the  excellent  authority  of  Holmes,  the  congenital  mal- 
formation probably  occurs  more  frequently  than  any 
other  except  hare-lip.  The  inference  to  be  deduced 
requires  no  words  of  explanation  from  me. 

In  the  early  years  of  my  practice  I  attended  a  lady 
in  confinement  who  gave  birth  to  a  ^ngorous  and  ap- 
parently well-formed  male  child.  But  when  the  little 
one  was  having  his  first  introduction  to  the  delights  of 
soap  and  water,  the  nurse  noticed  an  enlargement  on 
the  back.  An  examination  revealed  a  smooth,  globular, 
cystic  tumor,  about  the  size  of  a  small  egg,  in  the  middle 
of  the  lumbar  region,  immediately  under  the  skin.  Its 
nature  was  known  to  me,  but  at  the  time,  in  regard  to 
its  serious  import  my  knowledge  was  wanting.  Partly 
from  want  of  information,  and  partly  to  allay  the  anx- 
iety of  the  mother,  it  was  my  misfortune  to  make  light 
of  the  trouble,  and  even  to  hold  out  hopes  for  a  cure. 
On  reaching  home  and  consulting  my  books  it  was 
plain  to  me  my  prognosis  was  somewhat  astray.  How- 
ever, something  had  to  be  done.  The  method  of  treat- 
ment strongly  advocated  by  Dr.  Morton  was  rejected, 
because  to  my  way  of  viewing  the  subject  no  one  could 
be  sure  that  the  irritation  set  up  by  the  injection  would 
limit  its  action  to  the  sac.  For  want  of  a  better  plan 
that  of  applying  pressure  was  adopted.  As  time  passed, 
in  spite  of  my  best  efforts  the  tumor  continued  to  grow 
in  size.  The  family  became  alarmed  and  changed  their 
medical  adviser.  This  was  done  again  and  again,  until 
one  more  heroic  than  those  who  had  preceded  him 
promised  a  cure  by  an  operation.  The  doctor  had 
evidently  Morton's  operation  in  view,  for  he  decided  to 
tap  the  sac  and  inject  a  preparation  containing  tincture 
of  iodine.  Possibly  from  want  of  practical  skill  and  an 
understanding  of  the  details,  the  operation  was  not  com- 
pleted. For,  on  passing  the  trocar,  considerable  iluid 
was  permitted  to  escape,  and  before  the  injection  was 
used  the  child  took  a  convulsion.  He  never  rallied,  in 
a  few  hours  a  coffin  was  purchased,  and  presently  a  ti"y 
grave  in  the  cemetery  forever  hid  from  the  world  all 

'  American  Journal  of  Obstetrics,  November,  1893. 


the  material  evidence  of  the  mistakes  that  had  been 
made  in  our  sincere  though  ineffectual  efforts  to  save 
the  little  one. 

The  case  made  considerable  impression  on  my  mind 
at  the  time  ;  besides,  being  stung  by  the  knowledge  of 
the  fact  that  my  erroneous  prognosis  had  resulted  in 
the  loss  of  the  family  in  my  then  limited  practice,  I  de- 
tennined  to  study  the  subject  as  carefully  as  my  abil- 
ity and  means  at  command  would  permit. 

The  following  paragraphs  contain,  in  reference  to 
treatment,  the  gist  of  the  conclusions  arrived  at  by  me  : 

1.  That  one  of  the  most  important  functions  of  the 
cerebro-spinal  fluid  is  to  regulate  the  tension  of  the 
great  nerve-centres,  and  hence  the  blood-supply  to 
them.  For  illustration  grasp  with  your  hand  a  spina 
bifida,  and  what  is  the  result  ?  At  first  the  child  be- 
comes restless  and  cries,  then  if  you  increase  the  press- 
ure, a  convulsion,  still  more,  coma  and  death.  On  the 
other  hand,  withdraw  the  fluid  from  the  sac  (provided 
there  is  free  communication  between  it  and  the  sub- 
arachnoid space)  and  you  have  equally  alarming  results. 

2.  The  spinal  membranes,  and  consequently  the  walls 
of  the  spina  bifida,  resemble  the  peritoneum  in  being 
apt  on  irritation  to  form  adhesions.  This  provision 
safely  allows  the  communication  between  the  sac  and 
cord  to  be  closed  by  a  suitable  ligature,  provided  suf- 
ficient care  is  taken  to  prevent  septic  germs  from  ob- 
taining admission. 

3.  Neither  the  size  of  the  tumor  nor  the  breadth  of 
its  skin  base  has  any  significance  in  regard  to  the  char- 
acter of  the  communication  between  the  sac  and  cord.  A 
large  sessile  spina  bifida  may  have  so  small  and  imperfect 
a  communication  that  the  tumor  may  be  drained  with- 
out materially  disturbing  the  tension  of  the  cord.  This 
fact  accounts  for  occasional  cures  by  tapping,  irritating 
injections,  and  other  equally  unscientific  modes  of  treat- 
ment. On  the  other  hand,  a  small  one  attached  by  a 
pedicle  may  have  such  free  connection  that  even  to  tap 
it  leads  to  disastrous  results.  It  is  quite  natural  to  sup- 
pose that  the  delicate  cyst  of  a  spinal  hernia,  when  it 
impinges  against  the  skin,  may  meet  sufficient  resistance 
to  cause  it  to  extend  laterally.  This  explains  why  a 
large  one  may  have  an  exceedingly  small  pedicle. 

4.  That  we  are  not  to  follow  the  advice  given  in  our 
text-books,  namely,  to  estimate  the  amount  of  bone  de- 
ficiency and  chances  of  nerve-tissue  being  implicated 
in  the  protrusion  by  the  size  and  outline  of  the  tumor, 
but  to  do  so  by  the  general  condition  of  the  infant,  and 
especially  the  extent  of  paralysis  in  the  parts  below. 
All  portions  of  the  cord  which  escape  into  the  sac,  and 
which  are  attached  to  and  follow  its  inner  wall,  are  per- 
manently destroyed  so  far  as  their  natural  function  is 
concerned.  In  other  words,  we  have  paralysis  in  the 
parts  supplied  by  them,  and  they  may  be  removed 
without  adding  one  iota  to  the  paresis. 

5.  Spina  bifida  is  frequently  accompanied  by  other 
congenital  deformities  such  as  talipes,  sphincter  pare- 
sis, hydrocephalus,  and  paraplegia.  The  last  named  is 
always,  and  hydrocephalus  generally,  incompatible  with 
viability.  Hence  quite  a  number  of  the  cases  are  from 
the  first  beyond  the  possibility  of  cure. 

6.  That  no  operation  will  successfully  stand  repeated 
trials  by  different  operators,  unless  in  its  performance 
a  provision  is  made  to  prevent  disturbance  of  the  ten- 
sion of  cord. 

7.  The  higher  the  tumor  is  placed  on  the  spine,  the 
more  delicate  are  the  walls  of  its  sac,  the  greater  the 
irritation  to  it  by  the  movements  of  the  child,  and  the 
more  difficult  it  is,  other  things  being  equal,  to  treat. 

Having  come  to  the  above  conclusions  the  treatment 
indicated  to  me  appeared  quite  clear  and  devoid  of  any 
serious  difficulty  ;  but  nearly  two  years  passed  before  I 
had  an  opportunity  to  give  it  a  practical  test. 

The  operation  that  I  advise  is  very  simple  and  is 
easily  performed.  The  only  instruments  absolutely 
necessary  besides  sutures  and  an  aseptic  silk  ligature  are 
a  needle  and    scissors,  one  blade  of  which  is  probe- 


264 


MEDICAL   RECORD. 


[August  24,  1895 


pointed.  But  it  is  better  to  have  also  a  scalpel  and 
two  haemostatic  forceps.  Nevertheless,  it  is  very  essen- 
tial that  the  operation  should  be  done  scrupulously  in 
accordance  with  every  detail  of  modern  clean  surgery  ; 
for  if  any  form  of  septic  infection  reaches  the  delicate 
structures  within  the  spinal  column  there  is  only  one 
result — failure. 

When  normal  skin  covers  the  whole  of  the  tumor,  we 
first  mentally  or  otherwise  map  the  outlines  of  skin- 
flaps  necessary  to  close  the  wound  left  by  removal  of 
it.  Then  having  carefully  perforated  the  skin,  the 
probe-pointed  blade  of  scissors  is  introduced  between 
it  and  the  membranes  of  sac  and  the  skin  divided. 
The  flaps  are  now  by  fingers  or  handle  of  scalpel  sepa- 
rated from  cyst  down  to  the  fascia  of  back.  Then  the 
tumor  is  by  same  means  parted  from  its  loose  attach- 
ment to  fascia  till  the  pedicle  is  exposed. 

A  prepared  silk  or  other  suitable  aseptic  ligature  is 
tied  as  deeply  as  possible  on  the  pedicle  and  all  external 
to  it  removed.  After  the  oozing  has  ceased  the  wound 
is  closed  and  dressed.  The  dressing  I  prefer  consists 
of  a  pad  of  iodoform  or  bichloride  gauze  next  the 
wound,  then  absorbent  cotton,  and  over  these  a  piece  of 
oiled  silk.  The  margins  of  the  latter  are  sealed  to  back 
with  collodion,  and  thus  the  urine  is  prevented  from 
reaching  the  part.  In  ordinary  cases  it  is  not  neces- 
sary to  change  the  dressing  until  the  wound  is  healed. 
But  when  an  unusually  large  spina  bifida  is  removed, 
the  puckers  of  the  irregular  flaps  and  the  amount  of 
oozing  may  demand  a  provision  for  drainage  during 
the  first  day  or  two. 

When  part  of  the  tumor  has  no  cutaneous  covering, 
the  line  of  primary  cut  for  making  flaps  should  run  in 
the  skin  at  least  a  quarter  of  an  inch  from  margin. 
There  is  always  sufficient  to  make  the  flaps. 

No  matter  how  smoothly  things  may  proceed  after 
the  operation,  the  child  should  be  kept  in  its  cot  and  as 
quiet  as  possible  for  two  or  three  weeks,  or  until  all 
local  irritation  has  entirely  passed  away.  A  limited 
amount  of  paralysis  in  the  parts  below  does  not  by  any 
means  contra-indicate  the  operation  ;  nor  does,  under 
similar  circumstances,  the  presence  of  nerve-tissue  in 
a  case  with  translucent  wall.  The  operation  in  these 
cases  neither  aids  nor  increases  the  paresis.  It  should 
never  be  performed  on  a  child  who  has  hydrocepha- 
lus, paraplegia,  or  other  necessarily  fatal  ailment. 

When  we  exclude  the  one  mentioned  in  the  begin- 
ning of  this  paper,  in  my  own  practice,  only  two  cases 
suitable  for  operative  interference  have  occurred  ;  both 
of  them  in  1S85.  I  have  had,  however,  several  reports 
of  cases  sent  to  me  by  my  medical  friends  who  pre- 
viously obtained  the  details  of  the  operation.  Unfort- 
unately on  account  of  want  of  care  on  my  part  one  or 
two  of  them  may  have  been  lost. 

Below  are  short  notes  of  the  cases  in  the  order  in 
which  they  took  place  : 

C.\SE  I. — B.  A ,  born  April  18,  1885.     At  birth  a 

plump,  vigorous,  and  in  other  respects  well-developed 
male  infant.  Tumor  situated  in  lumbar  region  and 
covered  with  normal  skin.  At  first  its  size  was  not 
larger  than  a  pigeon's  egg.  Slight  pressure  on  it  caused 
child  to  become  restless  and  cry.  By  end  of  week 
tumor  had  more  than  doubled  its  original  size.  I 
advised  operation,  but  at  first  parents  objected.  In 
three  weeks  the  size  increased  to  that  of  a  large  orange. 
By  this  time  the  infant  had  to  be  kept  lying  on  its  side, 
and  could  not  bear  any  form  of  clothing  on  part.  He 
now  seldom  took  the  breast,  lost  flesh,  and  became  very 
fretful. 

Operation,  May  13th.  —  It  was  easily  performed. 
Pedicle  where  ligature  was  applied  nearly  an  inch  in 
diameter.  The  recovery  was  satisfactory  in  every  re- 
spect. To-day  there  is  merely  a  slight  scar  over  the 
spine,  just  below  the  middle  of  lumbar  region,  to  indi- 
cate the  situation  where  the  spina  bifida  was  attached. 
My  patient,  who  is  now  over  ten  years  of  age,  is  a 
strong,  active,  and  intelligent  youth. 


Case  II. — C.  M ,  male,  aged  six,  was  examined 

by  me  at  my  office  in  August,  1885.  I  found  the  boy, 
considering  age,  well  nourished.  On  the  lower  part  of 
the  lumbar  region  he  had  a  tumor  fully  three- fourths 
the  size  of  his  head.  The  greatest  diameter  of  it  was 
at  the  base.  Its  summit  was  devoid  of  skin  and  semi- 
transparent.  Through  this  portion  could  be  plainly 
seen  a  thin  band  of  nerve-tissue,  half  an  inch  wide,  and 
several  smaller  fibres  on  each  side  of  it.  The  nerve- 
tissue  extended  from  above  to  the  edge  of  true  skin 
below,  where  it  was  hidden  from  view.  He  had  talipes 
equinus  of  right  foot,  some  atrophy  of  the  leg,  and  con- 
siderable vesical  sphincter  paralysis.  The  boy  made  a 
good  recovery.  He  is  to-day  an  active  and  intelligent 
young  man.  The  paresis  has  neither  been  improved 
nor  aggravated  by  the  operation. 

The  next  two  cases  are  from  the  practice  of  Dr.  A. 
Mackinnon,  of  Guelph,  and  are  given  verbatim  from 
report  kindly  furnished  by  him. 

Case  III.— Mrs.  F 's  child,  born  August  6,  1886. 

The  tumor  was  very  small  at  birth,  and  appeared  to 
spring  from  the  level  of  the  third  cervical  vertebra. 
Though  the  head  was  large  the  child  was  in  other  re- 
spects well  formed. 

October  ist. — The  tumor  had  grown  rapidly,  being 
now  about  the  size  of  a  hen's  egg.  The  larger  portion 
of  its  surface  was  bluish  in  color  and  the  skin  verj-  thin. 
Under  chloroform  the  tumor  was  removed  according  to 
the  method  suggested  by  Dr.  Howitt. 

October  isth. — Found  the  wound  perfectly  healed, 
but  it  was  now  obvious  that  the  child  had  hydrocepha- 
lus.    The  size  of  the  head  rapidly  increased. 

November  ist. — The  little  patient  died  this  morning 
from  convulsions. 

Case  IV. — G.  McM ,  aged  six.     At  birth  a  tumor 

about  an  inch  in  diameter  was  found  attached  to  the 
sacral  region.  It  now  (June,  1SS7)  measures  vertically 
over  the  tumor  fourteen  inches,  and  transversely  twelve 
inches.  It  is  freely  movable  and  is  covered  completely 
by  skin  of  normal  appearance.  Below,  it  presents  two 
appendages  ;  one  about  two  and  a  half  inches  long  and 
about  the  same  diameter  as  the  vermiform  appendix 
which  it  resembles  somewhat  ;  the  other  is  about  an 
inch  in  length  and  looks  very  like  a  rudimentar)'  penis, 
from  which  occasionally  oozes  a  drop  of  clear  watery 
fluid.  (See  figure.)  The  boy  is  of  good  size,  bright 
and  intelligent  in  appearance,  and  has  good  muscular 
development  in  all  his  parts.  He  has  always  had  incon- 
tinence of  urine,  and  only  a  very  imperfect  control  over 
his  bowels.  A  central  vertical  line  through  the  tumor 
would  correspond  to  the  median  line  of  the  body.  It 
appears  to  be  attached  to  the  lower  part  of  the  sacrum. 

June  16,  1S87. — The  same  operation  as  in  Case  III. 
was  performed.  By  very  careful  dissection  this  huge 
mass  was  found  to  have  a  pedicle  smaller  than  a  lead- 
pencil.  The  cleft  of  the  sacrum  was  very  small,  but 
higher  than  had  been  supposed  prior  to  the  operation. 

July  5th. — He  left  the  hospital,  the  operation  wound 
almost  healed.  He  remained  perfectly  well  and  went 
to  school  the  following  winter. 

March  3c,  18SS. — Suffered  for  ten  or  twelve  days 
with  symptoms  of  meningitis  which  ended  in  death, 
nine  months  after  operation.  The  doctor  has  given  me 
a  photograph  taken  before  operation  of  his  remarkable 
case. 

The  next  is  from  the  pr.-ictice  of  Dr.  William  Lovett, 
of  Ayr,  and  is  also  given  verbatim.  The  operation  was 
performed  by  him  on  May  i,  1S90. 

Case    V. — C ,  a   healthy  boy,  six  months  old. 

When  horn  a  slight  tumor  about  the  size  of  a  plum  was 
situated  at  the  level  of  the  lower  lumbar  vertebr.'e,  which 
gradually  increased  until  I  saw  it,  when  it  was  the  size 
of  a  large  orange,  or  perhaps  better  the  shape  of  a  lemon, 
one-half  covered  with  skin.  Having  operated  three 
times  by  Morton's  operation  without  success  I  wrote  to 
Dr.  Howitt  for  his  plan  of  operation,  which  to  me  ap- 
peared the  most  reasonable  and  scientific,     .\ssisted  by 


August  24,  1895] 


MEDICAL    RECORD. 


265 


Dr.  Burt  we  proceeded  to  operate,  using  antiseptic  pre- 
cautions, by  dissecting  off  as  much  of  the  skin  as  would 
make  a  full  flap  ;  but  as  the  skin  was  firmly  adherent 
to  the  tumor  from  the  irritation  produced  by  lying  on 
it,  we  wounded  it  three  times.  Each  time  I  immedi- 
ately caught  it  in  my  fingers  and  applied  a  pair  of  for- 
ceps ;  having  got  to  the  base  we  separated  the  pedicle 
from  the  surrounding  opening  in  the  vertebrae.  We 
then  tied  it  with  strong  aseptic  silk  and  cut  it  off,  clos- 


Splna  Hif  da      Ca<;e  l\    of  the  rep^jrt 

ing  up  the  flaps  and  sewing  with  gut.  I  then  applied  a 
pad  of  bichloride  gauze  over  the  wound,  and  upon  it  a 
large  piece  of  gutta-percha  tissue  sufficiently  large  to 
cover  it  well,  around  the  under  surface  of  the  margin 
of  rubber.  I  brushed  with  collodion,  which  made  a  firm 
attachment,  air-tight,  with  the  skin  so  that  it  was  per- 
fectly free  from  danger  of  the  urine  of  the  child  inter- 
fering with  the  operation.  I  left  this  for  five  days  : 
again  dressed  it.  The  case  continued  to  heal  without 
a  single  unfavorable  symptom  ;  the  opening,  which  was 
left,  by  the  undeveloped  laminae  has  been  gradually 
lessening.  I  feel  satisfied  that  had  it  not  been  for  the 
operation  that  ere  this  (seven  months  later)  the  child 
would  have  been  out  of  existence,  whereas  we  have 
it  perfect  in  every  respect. 

Case  VI.— (Reported  by  Dr.  Wardlaw,  of  Gait).  Date 

of   operation,    September,    1890.      Baby  S ,   aged 

three  days;  tumor  situated  over  lower  lumbar  vertebrLV 
(used  chloroform).  Washed  with  bichloride  solution 
(i  to  4,000).  Made  incision  through  skin  on  each  side 
up  as  far  on  tumor  as  possible.  Owing  to  thinness 
of  skin  could  only  get  about  one  and  a  half  inch. 
Then  made  incisions  around  each  side,  joining  side  in- 
cisions and  dissected  skin,  etc.,  down  to  base.  Ligatcd 
and  severed  pedicle  and  returned  stump.  Stitched  up 
flaps  and  dressed  antiseptically,  covered  up  with  satin 
tissue. 

Being  so  low  down,  had  some  difficulty  in  keeping 
urine,  etc.,  from  wound  (nurse  not  being  very  care- 
ful) ;  but  it  healed  all  right,  and  yesterday  I  heard  that 
the  child  was  doing  nicely,  and  its  back  all  right. 

Case  VII. — Report  taken  from   a  private  letter  re- 


ceived from  a  friend  at  a  distance.  It  lacks  particulars 
but  is  extremely  candid  : 

"  I  followed  the  instructions  given  me  by  you  in  the 
case  of  spina  bifida.  Had  mother  and  child  go  to  the 
hospital  here.  The  operation  turned  out  as  you  stated, 
except  that  the  pedicle  was  much  larger — would  almost 
admit  the  tip  of  my  little  finger.  The  sac  was  as  large 
as  a  small  orange,  and  its  walls  extremely  thin,  and 
they  were  ruptured,  but  a  ligature  prevented  the  sac 
from  being  emptied.  Child  rallied  and  did  remark- 
ably well  for  a  week.  And  now  comes  the  point  where 
I  have  wanted  to  kick  mj^self  ever  since.  The  child 
was  so  well  and  the  mother  so  anxious  to  get  home  that 
I  consented,  and  that  afternoon  and  evening  the  child 
was  on  exhibition  to  the  neighbors,  the  delighted 
mother  acting  as  show-woman.  It  wound  up  about 
midnight  with  convulsions,  and  death  the  next  day. 

"  Examination  of  the  wound  after  death  found  it 
perfectly  sweet  and  its  surface  adherent.  Cause  of 
death,  stupidity  of  surgeon  and  disobedience  of 
mother." 

Four  of  the  patients  are  alive  and  well  to-day.  The 
last  case  is  the  only  one,  in  my  opinion,  in  which  death 
should  be  attributed  to  the  operation,  and  even  in  it 
under  more  favorable  circumstances  the  result  prob- 
ably would  have  been  quite  different.  The  procedure, 
you  will  admit,  has  so  far  proved  highly  satisfactory. 

The  more  my  attention  is  drawn  to  the  subject,  the 
more  I  am  convinced  that  spina  bifida,  in  an  otherwise 
healthy  child,  will,  with  comparatively  little  risk,  yield 
to  the  treatment. 


A  MARKED  CASE  OF  EXOPHTHALMOS  DUE 
TO    IXTRA-ORBITAL   CYST. 

By   CHARLES  I.   PROBEN,    M.D., 


That  exophthalmos  of  such  a  marked  degree  as  de- 
picted in  the  cut  should  have  existed  for  seven  years, 
and  have  escaped  the  scalpel  of  the  eager  surgeon,  is 


Fig.  I.— Exophthalmos  Due  to  Intra-orbital  Cyst. 


about  as  remarkable  in  this  progressive  chirurgical 
decade  as  the  rarity  of  the  lesion  itself.  The  lesion, 
not  being  of  a  painful  character,  nor  in  any  way  inter- 
fering with  the  vocation  of  the  afflicted,  relief  was 
simply  sought  for  its  cosmetic  effect,  in  order  to  avoid 
the  conspicuousness  of  this  unique  condition.  The 
annoyance  the  patient  was  subjected  to,  owing  to  the 
hideous  appearance  of  the  deformity,  led  him  to  desire 


266 


MEDICAL    RECORD. 


[August  24,   1895 


an  operation,  which  would  otherwise  not  have  been 
considered.  The  hope  that  this  rare  condition  may  be 
of  interest  has  incited  me  to  record  the  history,  with  a 
few  remarks  relative  to  this  subject,  with  the  accom- 
panying illustrations,  for  which  I  am  indebted  to  Dr. 
Frederick  Roth.  The  perspective  (Fig.  2)  shows  ex- 
ceedingly well  the  hideous  appearance  produced  by 
the  dislocated  organ  lying  far  below  the  horizontal 
plane  of  the  other  eye,  which  is  in  its  normal  situ.  The 
profile  view  (Fig.  i),  in  which  the  lids  are  retracted, 
depicts  the  complete  exophthalmos,  exposing  the  entire 
eyeball.  The  lids  are  easily  retracted  without  any 
pain,  and  tend  to  contract  behind  the  dislocated  organ. 
This  very  marked  dislocation  was  commented  upon  by 
different  medical  men  as  a  rare  condition.  The  pa- 
tient's history  was  as  follows  :  A  strong,  healthy  Italian, 
of  vigorous  physique,  who  emigrated  from  his  native 
land  five  years  ago,  aged  twenty-six  ;  with  a  negative 
family  history,  the  parents  being  alive  and  healthy. 
No  history  of  tuberculosis,  syphilis,  tumor,  or  other 
infirmity  elicited.  All  the  patient  remembers  is  that 
he  never  had  had  any  of  the  exanthemata,  and  that 
he  only  suffered  from  repeated  attacks  of  gastric  dys- 
pepsia. A  special  inquiry  and  examination  fails  to 
reveal  any  evidences  of  syphilitic  infection.     Absence 


Fig.  I. 

of  history  pertaining  to  carcinoma  or  to  any  form  of 
local  traumatism.  General  health  excellent.  The  first 
clew  pertaining  to  the  recognition  of  the  exophthalmos 
dates  back  seven  years,  when  the  attention  of  the  pa- 
tient and  his  friends  was  attracted  by  a  mere  protrusion 
or  prominence  of  the  eyeball.  The  apparent  exoph- 
thalmos was,  no  doubt,  produced  by  a  neoplasm,  which 
must  have  existed  for  a  long  time  prior  to  its  produc- 
ing the  noticeable  deformity.  From  its  slow  growth 
and  freedom  of  symptoms  we  surmise  the  benign 
character.  The  time  of  its  existence  can  only  be  con- 
jectured, whether  years,  or  i)ossibly  of  congenital 
origin.  Taking  the  slowness  of  the  growth  into  con- 
sideration, during  the  last  seven  years,  from  the  time 
of  its  apparent  inception,  we  must  at  least  surmise  its 
existence,  prior  to  this  period,  from  five  to  ten  years. 
Its  insidiousness,  slow  growth,  freedom  from  pain,  and 
the  uncertainty  of  the  period  of  its  existence,  make  the 
etiological  factor  very  dubious.  The  deviation  of  the 
pathological  from  the  normal  condition  can  readily  be 
perceived  by  a  comparison  of  the  following  measure- 
ments : 

Oculiis  Dexter.  Oculus  Sinister. 

Centimetres.  Centimetres. 

From  meili.iii  line 3.4  4.4 

From  brow 1.9  3. 7 

Iiuerciliary  space {!  i 

From  inner  to  outer  canthus 3.7  4.4 

From  cornea  to  meatus  auditorium 7. 5  g 


From  the  above  we  ascertain  that  there  is  a  marked 
protrusion  of  the  eyeball  of  i'.-  ctm.,  with  a  disloca- 
tion downward,  2  ctm.,  and  outward,  i  ctm.  The 
globe,  as  far  as  can  be  ascertained,  is  normal  in  size  and 
of  normal  tension.  Absence  of  pulsation  and  bruit. 
Ophthalmoscopic  examination  negative,  visual  field  and 
size  of  pupil  normal.  Sight,  O.  D.,  |^  ;  O.  S.,  |§.  Re- 
action to  light  and  accommodation.  Humors  clear. 
Absence  of  pain,  excessive  tenderness  or  congestion  of 
the  cornea  or  sclera.  The  dislocated  organ  lies  upon 
the  orbital  edge  of  the  superior  maxillary  bone  re- 
stricted in  its  movements.  When  gathered  between 
the  fingers  after  retraction  of  the  eyelids  the  organ  is 
practically  outside  of  the  orbital  cavity.  The  tissues 
of  the  eyelids  have  gradually  hypertrophied  pari  passu 
with  the  descent  of  the  eyeball,  covering  it  completely. 
The  distance  between  the  eyebrow  and  the  ciliary  mar- 
gin has  been  much  increased,  not  due  to  tension  but  a 
real  hypertrophy.  The  weight  is  borne  by  the  lower 
lid  and  the  sagging  produces  a  semilunar  interciliary 
space  instead  of  a  normal  elliptical  one,  making  the  fis- 
sure appear  much  larger.  Puncta  lacrymali  situated 
much  lower  than  normal.  This  leaves  the  globe  not  as 
well  protected  as  it  should  be.  Motion  is  more  or  less 
limited,  especially  abduction,  adduction,  and  rotation  ; 
the  upward  motion  is  interfered  with  by  the  tumor  very 
perceptibly  and  is  checked  at  a  certain  stage.  The 
natural  habitat  of  the  globe  in  the  orbital  cavity  is  oc- 
cupied by  a  rounded,  fairly  well-defined,  soft,  fluctu- 
ating mass,  partly  discerned  through  the  lids,  regular  in 
outline,  partly  movable,  and  conspicuous  by  absence  of 
any  attachment  to  neighboring  walls  or  to  the  eye.  Its 
freedom  from  tenderness,  its  peculiar  fluctuating  feel, 
its  absence  of  pulsation,  or  non-attachment  to  other 
organs  indicates  a  cystic  growth.  Neighboring  glands 
are  normal.  The  nares,  naso-pharynx,  or  antrum  do 
not  reveal  any  pathological  conditions  which  may  guide 
us  as  to  its  origin.  .Absence  of  pressure  or  reflex  sjTnp- 
toms.  To  recapitulate  :  we  have  a  cyst  occupying  the 
greater  part  of  the  orbital  cavity,  free  from  adhesions 
to  its  walls,  the  lids,  the  eyeball,  or  its  nerve,  produc- 
ing by  its  slow  continuous  growth  a  marked  protrusion 
of  the  eyeball,  with  an  enlargement  of  the  extrinsic 
tissues  and  coverings,  and  what  is  of  most  interest  is 
the  normal  overgrowth  of  the  optic  nerve,  this  reveal- 
ing no  pathological  condition  at  its  endings  in  the  ret- 
ina. 

From  measurements  accurately  taken  we  must  as- 
sume that  an  elongation  of  the  optic  nerve  has  taken 
place  of  nearly  two  centimetres.  This  is  both  interest- 
ing and  instructive.  The  character  of  the  cyst,  whether 
containing  simple  cystic  fluid  or  echinococcus,  can  only 
be  determined  by  puncture  and  a  microscopical  exam- 
ination. Congenital  cysts  are  simple,  or  more  frequently 
dermoid,  and  are  produced  by  an  inclusion  of  the  epi- 
blastic  layer.  We  may  mistake  the  condition  for  solid 
tumors  springing  from  the  orbital  walls  as  exostoses, 
sarcoma,  carcinoma,  or  for  aneurisms,  pulsating  tu- 
mors, or  for  the  cystic  changes  occurring  in  tumors 
from  disintegration  and  softening. 

Cystic  growths  of  the  orbit  should  be  divided  into 
three  classes  : 

1.  Those  that  originate  in  either  the  orbital  tissue, 
periosteum,  or  from  the  sheath  of  the  optic  nerves. 
These  are  cysts  pure  and  simple. 

2.  Those  that  arise  in  some  adjacent  bony  cavity 
and  encroach  upon  and  invade  the  orbital  fossa  sec- 
ondarily. These  may  arise  from  the  frontal,  ethmoid, 
sphenoid,  and  maxillary  sinuses,  the  nares  and  the  naso- 
pharynx. 

3.  Pathological  disintegration  and  liquefaction  of 
the  contents  of  solid  tumors,  as  sarcoma  carcinoma, 
etc.,  which  may  resemble  cysts  in  some  respects  only. 

Each  have  their  distinct  history,  and  an  examination 
will  reveal  their  character  and  their  origin.  Cysts  of 
the  sheath  of  the  optic  nerve  are  rare  and  not  readily 
recognizable  when  small.    The  abstraction  of  nutritive 


August  24,  1895] 


MEDICAL    RECORD. 


267 


pabulum  and  the  interference  with  the  function  bv 
pressure  produces  in  it  a  pathological  descending  de- 
generation, which  leads  to  vascular  and  later  atrophic 
changes,  recognizable  in  the  retinal  field  by  the  oph- 
thalmoscope, and  decided  loss  of  vision. 

Those  c)Sts  that  arise  from  adjacent  cavities,  espe- 
cially the  frontal  sinuses,  are  usually  due  to  an  occlu- 
sion of  the  duct,  producing  an  accumulated  retention  of 
its  secreting  contents,  over-distending  its  bony  walls,  and 
so  encroaching  upon  the  orbital  cavity.  Direct  exten- 
sion of  septic  processes  to  the  cavities,  producing  em- 
pyaemas  or  specific  necrosis  with  growth  of  tumors,  may 
produce  tumors  simulating  cysts.  In  the  beginning 
the  diagnosis  is  impossible,  and  only  when  marked 
over-distention  of  the  walls  takes  place,  and  its  en- 
croachment on  the  orbital  fossa,  can  a  diagnosis  be 
positive.  Especially  is  this  true  of  growths  from  the 
ethmoid  and  sphenoidal  sinuses  and  the  maxillary  an- 
trum. It  is  readily  seen  the  vast  magnitude  the  tumors 
must  assume  before  producing  exophthalmos.  The  dis- 
placement of  the  globe  varies  according  to  the  direc- 
tion from  which  the  growth  comes  :  from  the  frontal  it 
is  down  and  outward.  It  is  interesting  to  note  that 
the  frontal  sinuses  are  not  developed  to  any  extent  in 
childhood,  and  any  distention  of  them  will  give  rise  to 
local  manifestations  recognizable,  while  those  arising 
from  the  deeper  fossa;  do  not.  An  examination  by  il- 
lumination, nasal  and  post-nasal,  and  digital  explora- 
tion should  not  be  neglected.  Interference  with  the 
respiratory  function  and  disturbance  of  speech  are 
significant.  If  antral  tumors  are  suspected,  transillu- 
minarion  in  a  dark  room  may  be  of  service.  If  we 
have  concluded  that  we  have  to  do  with  a  simple  cyst, 
it  should  be  determined  whether  it  has  attachments  to 
the  orbital  walls  or  the  optic  nerve,  for  this  materially 
influences  our  treatment.  Puncture  and  injection, 
drainage  and  excision,  form  the  procedures  for  its  re- 
lief. Ifwe  have  to  deal  with  a  cyst  attached  to  the  optic 
nerve,  one  is  verj-  reluctant  in  adopting  radical  means 
before  resorting  to  the  simpler  methods.  The  with- 
drawal of  the  fluid  and  injection  of  irritating  fluids 
form  the  simpler  means  of  treatment.  The  injection 
of  the  latter  may  produce  a  contiguous  inflammation 
of  the  optic  ner\-e.  The  choice  of  incision,  whether 
subconjunctival  or  supra-orbital,  depends  upon  the  size 
and  location  of  the  tumor.  No  cast-iron  rules  can  be 
laid  down.  If  the  tumor  arises  from  a  neighboring 
cavity  our  treatment  is  a  different  one,  and  the  attack 
must  be  centred  to  the  direct  origin.  Indiscreetness 
and  over-aggressiveness  may  result  in  the  loss  of  the 
most  delicate  organ,  and  judicious  action  can  only  be 
contemplated  after  a  most  careful  examination  of  the 
tumor,  its  origin  and  attachments,  if  any,  and,  above 
all.  excluding  any  pathological  factor  from  the  neigh- 
boring fossa.  The  patient  whose  history  is  recorded  is 
at  present  under  observation,  awaiting  a  trial  by  the 
more  simpler  methods  for  the  relief  of  his  condition. 


Cocaine  in  Chloroform  Narcosis. — Rosenberg,  at  a  re- 
cent meeting  of  the  Berlin  Medical  Society,  advised  the 
anaesthetizing  of  the  mucous  membrane  of  the  nose 
with  a  spray  of  cocaine  solution  before  the  administra- 
tion of  chloroform.  By  this  means  anesthesia  is  more 
readily  induced,  and  the  reflex  action  on  the  heart  is 
prevented.  Cocaine  is  an  antidote  to  chloroform,  and, 
therefore,  its  absorption  would  probably  lessen  the 
danger  of  the  latter. 

Senile  Heart. — Four  cardinal  rules  with  regard  to 
diet  :  i.  There  must  never  be  less  than  five  hours  be- 
tween each  meal.  2.  Xo  solid  food  is  ever  to  be  taken 
between  meals.  3.  All  those  with  weak  hearts  should 
have  their  principal  meal  in  the  middle  of  the  day.  4. 
All  those  \\'ith  weak  hearts  should  have  their  meals  as 
dr)'  as  possible. — B.\lfol"R. 


THE  CAUSE  AND  TREATMENT  OF  CORNEAL 
ULCERS. 

Bv   S.   LATIMER  PHILLIPS.   M.D., 

S.^VANN-\H,    G.\. 

The  cornea,  from  its  prominent  situation  at  the  fore- 
part of  the  eyeball,  naturally  becomes  the  frequent 
seat  of  accident  and  disease.  A  goodl)'  portion  of 
these  takes  some  form  of  ulceration,  and  it  behooves 
us  to  be  ready  to  recognize  the  cause,  to  remove  it,  if 
it  is  within  our  power,  and  to  institute  a  treatment  that 
will  arrest  the  progress  of  the  disease,  and  bring  it  to  as 
speedy  a  termination  as  possible. 

In  a  paper  of  the  scope  of  this  we  cannot  go  too 
much  into  detail,  so  I  shall  only  glance  in  a  rapid 
manner  at  some  of  the  more  important  causes,  which 
we  will  divide  into  constitutional  and  local. 

Constitntional  Causes. — Oftenrimes  we  see  this  con- 
dition of  corneal  ulceration  developing  in  people  pulled 
down  by  some  chronic  disease,  as  phthisis,  malarial 
fever,  etc.  I  know  of  a  case  of  a  man  here,  far  gone 
in  consumprion,  who  by  careful  attenrion  to  his  diet, 
etc.,  is  able  to  get  about  and  attend  to  his  business  ; 
but  as  soon  as  he  becomes  run  down  from  indigestion 
or  overwork,  the  left  cornea  begins  to  ulcerate.  He 
has  had  several  attacks  of  this  mass,  and,  as  a  sequel,  a 
large  central  leucoma  with  but  little  vision. 

Ulcers  of  the  cornea  are  much  more  frequent  in  the 
adult  and  aged  than  in  childhood  and  youth,  if  we  ex- 
cept that  very  common  affection  of  childhood,  phlyc- 
tenular keratitis.  Here  there  appears  to  be  a  pecul- 
iar dyscrasia,  or  scrofulous  condition,  with  enlarged 
glands,  eczema  of  lids,  catarrhal  conjuncrivitis,  and 
tendency  to  ulceration  at  angles  of  lids,  nose,  etc.  Of 
course  where  there  is  lowered  vitality  the  cornea,  like 
other  portions  of  the  body,  becomes  weakened,  and  the 
slightest  irritation  will  serve  as  a  starting-point  of  in- 
flammation, which  ma)'  progress  to  complete  destruc- 
tion of  the  part  unless  the  system  is  put  in  a  condition 
to  resist  the  disease.  We  find  in  old  people  sometimes 
ulceration  of  the  cornea  slowly  progressing,  with  no 
other  appreciable  cause  than  lowered  %-itality.  I  have 
seen  in  the  aged  ulceration  of  the  cornea  after  undue 
straining  of  the  eyes  from  reading,  writing,  sewing,  etc. 

Local  Causes. — Anything  acting  as  an  irritant  to 
the  cornea  will  serve  as  a  beginning  for  the  ulcer. 
Foreign  bodies  of  any  kind  resting  on  the  corneal  sur- 
face, as  pieces  of  wood,  metal,  etc.,  produce  abrasions, 
through  which  the  germs  gain  access  to  the  underlying 
tissue,  and  set  up  suppurative  processes. 

Some  of  the  severest  cases  of  corneal  suppuration  I 
have  met  with  have  been  those  where  the  cornea  was 
pierced  by  beards  of  grain,  with  sharp  serrated  edges. 
These  make  a  jagged,  irregular  wound  in  which  the 
germs  easily  obtain  a  resting-place  and  multiply.  I 
have  known  stubborn,  persistent  ulcers  easily  get  well 
after  the  removal  of  an  ingrowing  lash  ;  this  by  con- 
stant scratching  has  kept  up  the  disease.  Granulation 
of  the  lid,  too,  is  not  an  uncommon  cause  of  corneal 
ulcer.  In  a  very  serious  form  of  this  disease  we  are 
apt  to  see  more  or  less  complication.  A  diseased  con- 
dition of  the  nose  may  be  a  cause  also.  The  germs  of 
the  disease  passing  up  through  the  lachrjmal  canal.  I 
remember  several  years  ago  the  case  of  a  man  with 
ozena,  the  result  of  syphilis,  with  destruction  of  car- 
tilage, and  caries  of  the  bones  of  the  nose,  who  was 
under  my  care.  He  had  a  central  corneal  ulcer,  sequel 
to  a  burn  by  a  small  piece  of  hot  iron,  and  notwithstand- 
ing the  most  \-igorous  treatment  the  eye  was  totally 
destroyed.  Of  course  acute  and  chronic  catarrh  of  the 
conjunctiva  play  a  part  in  the  causation  of  corneal 
ulcers.  In  those  severe  forms  of  purulent  conjunc- 
tivitis we  meet  with  sometimes,  where  there  is  so  much 
swelling  of  the  conjunctiva  that  the  corneal  nourish- 
ment is  interfered  with,  the  ulceration  varies  from  a 
very  small  point  to  the  suppuration  of  the  whole  cornea 
and  its  consequent  complete  destruction. 


268 


MEDICAL   RECORD. 


[August  24,  1895 


Treatment. — This  I  should  divide  into  medical  and 
surgical,  and  the  adoption  of  one  or  the  other  depends 
upon  the  state  of  the  ulcer  when  we  find  it  ;  oftentimes 
we  have  to  employ  both.  Of  course  where  the  patient 
is  in  a  reduced  or  debilitated  condition,  tonics  must  be 
freely  prescribed,  the  hypophosphites,  iron,  strychnine, 
etc.  In  those  scrofulous  conditions  so  often  seen  in 
children  I  prefer  the  iodides  in  some  form.  I  usually 
employ  the  syr.  ferri  iodid.,  and  with  much  satisfaction, 
together  with  strict  rules  as  to  diet.  Cod-liver  oil  is 
called  for  at  times,  and  in  old  people  with  delicate 
stomachs  the  vin  Mariani  appears  to  be  a  most  helpful 
tonic. 

The  local  medical  treatment  consists  mostly  of  seda- 
tives in  acute  ulcers,  and  stimulants  in  the  indolent 
kinds.  Atropia  is  useful  in  all  ulcerations  of  the  cor- 
nea, save  where  the  ulcer  is  peripheral  and  there  is  per- 
foration or  danger  of  it.  Here  eserine  is  called  for,  but 
not  in  too  strong  a  solution  {ij4  to  1  grain  to  i  ounce 
of  water).  In  a  suppurating  condition  of  the  cornea 
hot  applications  should  always  be  used,  water  as  hot  as 
can  be  borne  to  bathe  the  eye  in,  or  what  I  have  found 
at  times  soothing,  a  decoction  of  poppy  head,  a  large 
towel  to  be  wrung  out  of  this  and  applied  over  the 
closed  lids,  to  be  repeated  at  intervals  of  every  few 
minutes  for  fifteen  or  twenty  minutes.  If  dry  heat  is 
desirable  there  is  nothing  more  useful  than  the  Japan- 
ese hot  bo.x.  The  box,  after  the  cartridge  has  been 
lighted,  can  be  wrapped  in  a  piece  of  soft  cloth  and 
laid  over  the  closed  eye.  If  we  find  these  remedies  to 
fail,  then  we  must  resort  to  surgery. 

The  one  great  means  which  we  have  at  hand,  and 
which  can  always  be  depended  upon,  is  the  actual  cau- 
tery, though  frequently  patients  object  to  its  use.  But 
if  they  should,  however,  we  have  another  means  which 
in  my  hands  has  been  most  satisfactory.  There  is  noth- 
ing in  it  that  appears  appalling,  nor  is  it  very  painful. 
The  treatment  I  refer  to  is  the  application,  on  a  probe, 
to  the  entire  ulcerating  surface,  of  pure  carbolic  acid.  I 
believe  the  late  Dr.  Williams,  of  Cincinnati,  was  the  orig- 
inator of  this  method.  Its  application  requires  care  and 
delicacy  of  manipulation,  for  over-doctoring  the  eye  with 
carbolic  acid  in  its  pure  state  would  bring  about  results 
most  direful.  I  take  a  small  probe,  wrap  a  thin  piece 
of  absorbent  cotton  tightly  around  the  end,  dip  it  into 
deliquescent  carbolic  acid,  press  out  any  surplus  when 
withdrawing  from  neck  of  bottle,  and  touch  gently  the 
ulcerated  surface.  Only  the  smallest  quantity  is  to  be 
used,  the  acid  flowing  freely  into  every  sulcus  and  fur- 
row, however  small,  and  thus  coming  into  direct  con- 
tact with  all  the  diseased  surface.  Wherever  the  acid 
comes  in  contact  with  unhealthy  tissue  a  thin  veil  of 
slough  forms,  which  is  soon  thrown  off,  leaving  the  ulcer 
in  a  healthy  condition,  so  that  in  a  little  time  it  is  filled 
up  with  new  tissue.  This  treatment  is  especially 
adapted  to  children  with  phlyctenular  ulcers,  for  with 
them  hardly  more  than  one  application  will  be  neces- 
sary, unless  the  ulcer  be  very  large.  It  can  be  made 
usually  without  an  an;\;sthetic.  The  head  of  the  child 
is  held  by  an  assistant  while  the  operator  holds  apart 
the  lids  and  steadies  the  eyeball  with  thumb  and  fore- 
finger of  left  hand,  rapidly  making  application  with 
right.  I  hardly  ever  use  cocaine,  save  in  a  very  small 
child,  as  the  burning  is  almost  nothing,  carbolic  acid 
being  a  well-known  obtundent  of  sensibility. 

There  is  nothing,  though,  in  my  opinion,  that  can 
fully  take  the  place  of  the  topical  application  of  the 
actual  cautery.  This  is  used  principally  in  the  pro- 
gressive variety  of  ulcer,  though  it  can  be  employed 
with  telling  effect  from  the  superficial  phlyctenular  ul- 
cer, through  all  grades,  to  the  deep,  largely  sloughing 
kind.  For  convenience  and  elegance  I  prefer  the  pla- 
tinum tips  made  for  the  purpose,  fitted  into  a  suitable 
handle  and  brought  to  a  bright  crimson  glow  by  an 
electric  battery.  Having  the  eye  cocainized,  or  the 
patient  under  the  influence  of  chloroform,  we  may  cau- 
terize as  much  as  we  deem  expedient,  and  we  rarely 


fail  to  derive  benefit  from  the  operation.  If  the  bat- 
tery is  not  at  hand  we  can  use  the  bulb-pointed  plati- 
num instrument  devised  by  Dr.  Gruning,  brought  to  a 
red  heat  in  an  alcohol  flame  ;  or  even  an  ordinary  stra- 
bismus hook  maybe  employed.  The  difficulty  in  using 
Griining's  instrument  without  chloroform  anaesthesia 
is  that  after  the  eye  is  fixed  in  position  for  operation 
the  patient  seeing  the  heated  instrument  approaching 
the  eye  has  hardly  enough  fortitude  to  hold  the  eye 
steady,  but  moves  it  away,  and  the  instrument  loses  its 
heat  before  the  eye  is  again  fixed.  Besides,  there  has 
to  be  an  assistant  to  hold  the  lamp  near  the  eye.  After 
cauterization  the  bandage  had  better  be  applied,  and 
the  regular  treatment  of  atropia,  etc.,  carried  out.  One 
application  of  the  cautery  will  usually  be  sufficient ;  but 
if  not,  it  can  be  repeated  at  intervals  of  three  or  four 
days.  The  greatest  care  must  be  observed  in  this  op- 
eration not  to  puncture  the  cornea.  Especially  is  this 
so  when  the  ulcer  is  deep-seated,  though  if  we  watch 
closely  what  we  are  doing  we  can  touch  thoroughly  the 
parts  desired  and  escape  emptying  the  anterior  cham- 
ber. 


groQtess  of  ^cttical  M>cUnce. 

Cardiac  Irregularity  and  Obesity. — According  to  Dr. 
Kisch,  of  Marienbad,  no  functional  disturbance  in  the 
organism  occasions  the  individual  so  much  anxiety  and 
apprehension  as  when  the  regular  action  of  the  heart 
gets  disturbed.  The  educated  man  is  so  accustomed 
from  infancy  upward  to  the  regular  work  of  his  heart, 
and  is  so  convinced  of  its  supreme  importance,  that  any 
disturbance  of  it  readily  arouses  in  him  the  fear  that 
the  heart  may  refuse  completely  its  office.  The  author 
has  seen  medical  men  who  had  observed  cardiac  irreg- 
ularity in  themselves  plunged  thereby  into  deep  mental 
depression.  There  is  no  reason  for  this.  The  author 
points  out  that  irregularity  may  awaken  apprehensions 
in  grave  disease  of  circulatory  or  respiratory  apparatus, 
while,  on  the  other  hand,  it  possesses  only  trifling  sig- 
nificance. The  author  discusses  the  cardiac  arhyth- 
mia  of  obese  persons.  Slight  irregularity  is  observed 
in  youthful  patients  with  slight  heart  trouble,  especially 
in  young  girls  who  exhibit  the  anemic  form  of  lipoma- 
tosis. Actual  irregularity,  in  which  regular  beats  and 
pulses  alternate,  is  seen  chiefly  in  fat  people  who  have 
already  passed  their  fiftieth  year,  and  in  whom  other 
symptoms  of  heart  trouble  are  present.  Complete  ir- 
regularity, in  which  pulse-waves  alternating  in  tension 
and  size  regularly  follow  one  another,  is  seen  in  cases 
of  obesity  with  marked  heart  weakness  in  which  there 
is  dyspnoea,  angina  pectoris,  pronounced  backward 
pressure  in  the  venous  system,  with  cedema  and  dropsy. 
Kisch  holds,  in  contradistinction  to  French  authors, 
that  simple  cardiac  intermittency  and  slight  irregularity 
are  not  unfavorable  as  regards  prognosis,  and  these 
cases  may  be  seen,  after  a  course  of  treatment  directed 
to  adiposity,  to  recover  their  pulse  regularity.  On  the 
other  hand,  he  regards  the  occurrence  of  complete  irreg- 
ularity, delirium  cordis,  as  a  sign  of  grave  disturbance 
of  the  heart  mechanism  which  can  never  be  completely 
removed,  and  is  sometimes  also  the  sign  of  suddenly 
occurring  death. — Berliner  klinisehe  Woehensehrift. 


Incoercible  Vomiting  of  Pregnancy. — .\pply  the  con- 
tinuous current,  placing  the  positive  pole  on  the  clavi- 
cle, between  the  two  branches  of  the  sterno-cleido- 
mastoid,  and  the  negative  pole  over  the  umbilicus. 
Use  a  current  of  ten  or  fifteen  milliamperes  for  from 
fifteen  to  thirty  minutes.  This  method  succeeded  in 
five  cases  in  which  vomiting  was  so  intense  as  to  ren- 
der provoked  abortion  almost  imperative. — Gazette  des 
H6pitaux. 


August  24,  1895]  MEDICAL 

Medical   Record.- 

A  Weekly  Journal  of  Medicine  and  Siirgery, 


RECORD. 


269 


GEORGE    F.  SHIL\DY,  A.M.,  M.D.,  Editor. 


Publishers 
WM,  WOOD  &  CO.,  43.  45,  &  47  East  Tenth  Street 


Ne\v  York,  August  24,  1895. 


THE    STUDY   OF   CANCER. 

One  of  the  most  interesting  problems  engaging  the 
attention  of  medical  thinkers  and  investigators  at  the 
present  day  has  to  do  with  the  true  nature  of  cancer. 
What  is  cancer?  Is  it  a  morbid  process  owing  its  ex- 
istence to  the  presence  of  a  micro-organism  in  the  tis- 
sues exciting  the  cells  to  an  over-activity  of  growth  ? 
If  so,  is  this  micro-parasite  of  the  nature  of  the  malar- 
ial organism,  inhabiting  certain  localities  and  being 
taken  into  the  human  body  in  the  water  or  in  the  in- 
spired air,  or  in  both  ?  Or  may  it  be  transmitted  like 
the  parasite  of  syphilis,  directly  from  the  sick  to  the 
well  ?  Is  the  cell  stimulation,  assuming  that  there 
is  a  Plasmodium  or  a  bacterium  of  cancer,  due  to 
direct  irritation  by  the  micro-organism,  or  is  it  due 
to  the  action  of  a  toxin  elaborated  by  this  parasite  ? 
Or  is  cancer  an  inherited  vice  of  cell  life  and  growth, 
and  as  presumably  independent  of  a  micro-organism 
as  is  clubfoot  ?  These  and  a  dozen  similar  questions 
have  been  asked  again  and  again  since  the  new  views 
of  the  nature  of  infectious  diseases  have  gained  accept- 
ance, and  while  they  remain  thus  far  unanswered,  it 
seems  not  extravagant  to  hope  that  the  day  is  not  far 
distant  when  a  solution  of  some,  at  least,  of  the  main 
points  of  the  problem  will  be  reached. 

It  is  not,  however,  by  experiment  alone  that  this 
question  will  be  settled,  for  much  can  be  accomplished 
by  intelligent  clinical  observation.  The  number  of 
those  investigating  the  subject  experimentally  is  large 
and  ever  increasing,  and  there  are  among  them  not  a 
few  well  fitted,  by  trained  habits  of  scientific  research 
and  by  freedom  from  preformed  opinion,  for  the  work 
they  have  undertaken.  But  they  can  be  assisted  greatly 
by  those  general  practitioners,  especially  country  prac- 
titioners, who  have  lived  and  worked  all  their  lives  in 
one  community,  and  who  know  the  medical  histories 
of  every  family  for  perhaps  three  or  four  generations. 

In  a  paper  read  before  the  Oxford  Branch  of  the 
British  Medical  Association,  Mr.  D'Arcy  Power,  to  one 
of  whose  interesting  experiments  in  relation  to  the  eti- 
ology of  cancer  we  referred  not  long  since,  speaks  of 
the  assistance  the  general  practitioner  may  give  those 
who  are  trying  to  work  out  the  problem  from  a  scien- 
tific standpoint.  In  the  first  place,  he  says,  the  influ- 
ence of  heredity  should  be  ascertained  in  every  case  of 
cancer,  the  inquiries  being  made  in  reference  to  the 
collateral  as  well  as  to  the  lineal  descent.     The  family 


diathesis  on  the  parents'  side  should  be  noted,  for  it  is 
still  undecided  how  far,  if  at  all,  the  various  manifesta- 
tions of  the  arthritic  diathesis  are  associated  with  can- 
cer. Then,  again,  there  is  the  question  of  the  soil  and 
water  in  any  locality  where  cancer  appears  to  prevail 
to  an  unusual  extent.  Reports  of  "  cancer  houses," 
that  is,  of  houses  several  successive  inmates  of  which, 
unrelated  to  each  other,  have  died  of  cancerous  dis- 
ease, are  interesting ;  they  may  possibly  also  become 
injtructive  when  a  sufficient  number  of  them,  giving 
details  of  soil  and  water-supply,  of  age,  occupation, 
and  antecedents  of  the  successive  occupants,  etc.,  have 
been  collected.  In  thus  collecting  data  general  prac- 
titioners may  aid  greatly  in  the  solution  of  the  perplex- 
ing, and  for  that  very  reason  most  interesting,  problem 
of  the  pathogenesis  of  cancer. 


SCIENCE  AND  THE   FRENCH  DRUGGIST. 

There  has  been  a  great  deal  of  vague  writing  on  the 
subject  of  phosphates,  hypophosphites,  and  the  various 
other  phosphorous  compounds.  A  very  general  im- 
pression exists  in  the  profession  that  these  preparations 
have  some  value  in  medicine,  but  we  are  not  aware 
that  there  yet  exist  substantially  established  clinical 
facts  which  demonstrate  that  phosphates  or  phosphites 
do  any  good  whatever.  What  is  a  common  belief  and 
common  practice,  in  the  medical  profession  of  to-day, 
has,  however,  probably  some  substantial  basis.  A 
distinct  "  boom  "  was  given  to  the  phosphorus  com- 
pounds by  the  introduction  of  the  hypophosphites, 
and  the  extreme  claims  made  for  these  preparations  at 
the  time  of  their  introduction  are  still  remembered  by 
many.  Physicians,  however,  have  very  largely  for- 
saken a  strict  adherence  to  the  phosphite  compounds 
and  prescribe  phosphates  and  phosphorus  solutions  in 
their  place  with  apparently  much  the  same  effect. 

A  year  ago  Dr.  Albert  Robin  read  a  preliminary 
communication  before  the  Paris  Academy  of  Medicine 
upon  the  therapeutic  use  of  the  glycerin-phosphates, 
which  up  to  that  time,  he  said,  had  never  been  useful 
as  medicinal  agents.  He  may  perhaps  have  been 
mistaken  on  this  point  ;  at  least  we  are  informed  that  a 
good  many  years  ago  there  was  sold  in  this  city  under 
the  name  of  "  protogon,"  a  phosphorous  compound, 
which  was  really  a  glycerin-phosphate.  This  protogon 
was  extolled  as  a  new  discovery  of  extraordinary  value 
in  nervous  and  wasting  diseases  of  all  kinds,  but  the  bot- 
tom fell  out  of  "  protogon,"  as  it  has  of  so  many  other 
secret  or  proprietary  remedies  which  are  not  advertised 
with  sufficient  persistence. 

M.  Robin  asserts  that  his  new  preparation  has  oc- 
cupied his  attention  for  the  past  six  years,  and  he 
believes  that  there  is  a  great  future  for  it,  because  he 
thinks  it  exercises  an  elective  action  upon  the  nervous 
system.  He  has  made  a  study  of  the  nutritive  con- 
ditions, particularly  in  neurasthenia,  and  he  believes 
that  in  this  disease,  among  other  things,  there  exists  an 
exaggerated  consumption  of  the  lecithin  of  the  nervous 
centres.  On  the  other  hand,  he  finds  that  the  ordinary 
medicinal  phosphates  supply  this  need  in  a  very  im- 
perfect way.  Dr.  Robin  gives,  in  the  Bulletin  G<fn/ral 
de  Tlu'rapeutique,  an  account  of  a  long  series  of  experi- 


270 


MEDICAL   RECORD. 


[August  24,  1895 


ments  which  he  has  made  upon  the  nutrition  as  influ- 
enced by  different  drugs,  and  particularly  by  the 
phosphates.  His  article  is  accompanied  with  many 
tables  which  have  a  most  scientific  appearance,  and 
give  evidence  of  a  very  great  amount  of  chemical  and 
physiological  work.  We  have  not  space  for  any  de- 
tailed description  of  the  experiments.  Dr.  Robin, 
however,  concludes  his  study  with  certain  propositions 
which  he  considers  have  been  demonstrated. 

These  are,  first,  that  the  glycerin-phosphates  given 
by  subcutaneous  injection  accelerate  the  metabolic 
changes  of  the  organism,  affecting  both  the  organic  and 
the  inorganic  substances,  but  particularly  the  latter. 
Though  accelerating  principally  disintegrating  changes, 
they  act  in  all  the  stages  of  physiological  metabolism. 
In  other  words,  they  favor  both  the  assimilation  of 
albuminous  matter,  and  its  cellular  integration  and  dis- 
integration. They  influence  but  little  the  formation  of 
uric  acid.  They  act  upon  the  sulphur  compounds  and 
increase  the  o.xidation  products.  The  result  is  that 
the  organs  rich  in  sulphur,  like  the  liver  particularly, 
become  the  seat  of  more  active  nutrition  under  the  in- 
fluence of  these  wonderful  glycerin-phosphates.  They 
have  no  marked  effect  upon  the  intestinal  fermenta- 
tions. They  increase  the  excretion  of  chloride  of 
sodium  ;  they  favor,  probably,  the  assimilation  by  the 
nervous  system  of  the  phosphates  of  the  food,  and  they 
moderate  the  waste  of  the  nervous  system,  acting  upon 
these  centres  as  a  protection  and  fixing  the  materials  of 
the  nervous  centres  more  firmly.  They  increase  the 
changes  in  the  calcium  compounds  and  the  other  salts 
that  go  to  form  bony  tissue,  without  influencing  the 
changes  in  the  phosphated  compounds. 

We  observe  that  all  these  remarkable  effects  upon 
the  nutrition  of  the  nervous  system  are  accompanied 
with  an  inset  advertisement  of  the  glycerin-phosphates 
of  Robin  as  prepared  by  certain  skilled  Parisian  drug- 
gists. In  other  words,  coincident  with  the  appearance 
of  Robin's  article,  is  a  very  conveniently  placed  an- 
nouncement of  where  you  can  get  the  effective  prepara- 
tion. We  confess  to  some  serious  doubts  about  the 
value  of  the  glycero-phosphates,  despite  the  elaborate 
chemical  tables  and  laborious  physiological  analyses  of 
M.  Robin.  If  he  has  got  a  good  thing,  it  is  a  pity  that 
he  has  united  the  commercial  and  scientific  aspect  of 
it  in  such  an  ingenious  fashion. 


A    MENACE    TO    I'HE   COUNTRVS    HEALTH. 

Every  summer  the  eastern  seaboard  of  this  country, 
from  New  Orleans  to  New  York,  is  threatened  with  an 
invasion  of  yellow  fever  by  vessels  hailing  from  Cuban 
ports,  especially  Havana  and  Santiago.  Our  only  de- 
fence against  this  invasion  lies  in  a  quarantine  service 
which  varies  in  efficiency  at  different  points,  and  which 
may  fail  at  any  time  in  one  of  a  dozen  ports  through  a 
single  error  in  judgment  of  the  executive  officer.  This 
is  a  very  weak  defence,  as  the  country  learns  to  its  cost 
every  few  years  ;  yet  as  long  as  Cuba  belongs  to  a  for- 
eign power,  and  that  one  which  ranks  low  in  the  scale 
of  practical  sanitation,  so  long  shall  we  be  menaced 
with  every  returning  summer.  The  only  way  to  escape 
the  danger  is  to  stamp  out  the  plague  in  its  home. 


There  is  no  more  reason  why  yellow  fever  should  be 
endemic  in  Cuba  than  in  Jamaica.  Kingston,  in  Ja- 
maica, was  once  a  pest-hole,  now  it  is  a  health-resort. 
Havana,  Santiago,  and  dozens  of  smaller  places  along 
the  Cuban  coast  could  be  made  as  healthy  as  Kingston 
if  the  Spanish  authorities  would  undertake  the  task. 
But  they  never  have,  and  they  never  will,  if  we  may 
judge  from  the  way  they  have  neglected  their  duty  in 
this  respect  in  the  past.  Sanitarians,  therefore,  can 
scarcely  help  sympathizing  with  the  revolutionists  who 
are  struggling  for  the  freedom  of  their  native  island. 
The  manifest  destiny  of  the  island  appears  to  be  to  enter 
the  federation  of  American  States,  and  this  result  will 
doubtless  be  hastened  by  the  success  of  the  revolution. 
When  once  it  is  a  part  of  this  country,  the  government 
will  see  to  it  that  this  breeding  ground  for  the  yellow 
scourge  is  cleaned  and  garnished,  and  one  more  victory 
will  be  won  for  the  cause  of  sanitation. 


Fatal  Quarrel  Between  Surgeons. — Two  surgeons  of 
Portland,  Ore.,  who  had  formerly  been  partners,  quar- 
relled over  an  operation  performed  by  one  of  them  at 
the  city  hospital,  and  shot  each  other  fatally. 

Yellow  Fever  still  prevails  extensively  in  Cuba,  and 
appears  to  be  steadily  increasing.  Most  of  the  victims 
are  the  unacclimated  soldiers  from  Spain  who  are  fight- 
ing the  revolutionists. 

The  Late  Professor  Huxley.  — It  is  proposed  to  es- 
tablish a  memorial  to  the  late  Professor  Huxley,  which 
shall  take  the  form  of  an  annual  lecture  and  science 
scholarship  and  medal,  at  the  Charing  Cross  Hospital 
Medical  School. 

Dr.  Salomon  Moos,  Professor  of  Otology  at  the  Uni- 
versity of  Heidelberg,  died  recently  at  his  home  in  that 
city.  He  was  born  at  Randegg,  in  Baden,  July  15, 
1S31. 

Dr.  Thomas  McKennan,  of  Washington,  Pa.,  died  at 
his  home  in  that  place  on  August  9th.  He  was  born 
in  1824. 

Surgeon-General  James  R.  Tryon,  of  the  navy,  has 
been  elected  a  member  of  the  Red  Cross  Society  of 
Venezuela.  He  has  also  been  awarded  the  bronze 
medal  of  that  society  in  recognition  of  the  services  he 
rendered  the  wounded  at  La  Guayra  during  the  revo- 
lution of  1892,  when  Dr.  Tryon  was  attached  to  the 
flagship  Chicago. 

Henry  Dunant,  the  founder  of  the  Geneva  Red 
Cross  Society,  is  now,  it  is  reported,  at  the  age  of  sixty- 
seven,  in  great  poverty  and  nearly  starving.  He  spent 
all  he  had  in  promoting  his  idea. 

Dr.  Charles  F.  J.  Lehlbach  died  at  his  home  in  New- 
ark, N.  J.,  on  .\ugust  14th.  He  was  born  in  Baden  in 
i8js,andcame  to  this  country  when  fourteen  years  of  age 
with  his  father,  the  Rev.  Frederick  Augustus  Lehlbach, 
who  took  charge  of  a  German  church  in  Newark.  Dr. 
Lehlbach  was  graduated  from  the  College  of  Physicians 
and  Surgeons  in  this  city  in  1856,  and  [Practised  in 
Newark  until  the  war.     He  enlisted  at  the  beginning 


August  24,  1895] 


MEDICAL    RECORD. 


271 


of  the  civil  war  and  served  until  its  close,  when  he  re- 
turned to  Newark  and  built  up  an  extensive  practice. 

In  Memory  of  Dr.  Danielssen. — A  memorial  tablet 
of  the  late  Dr.  Danielssen,  designed  by  Max  Klein,  of 
Berlin,  has  been  placed  on  the  front  of  the  Lunge- 
gaards-Hospital  at  Bergen. 

The  Continental  Anglo-American  Medical  Society 
held  its  annual  meeting  in  London  on  August  2d,  at 
the  Savoy  Hotel,  under  the  presidency  of  Sir  Richard 
Quain.  Five  new  members  were  elected,  and  the 
Secretar)-,  Dr.  Barnard,  of  Paris,  stated  that  the  total 
membership  in  the  Society  had  now  reached  ninety-six. 
After  the  meeting  those  present  sat  down  to  a  luncheon. 
After  the  toast  "  The  Queen  and  the  President  of  the 
United  States  "  had  been  drunk,  Sir  Richard  Quain  pro- 
posed "  Prosperity  to  the  Society,"  expatiating  on  the 
need  supplied  by  such  a  body.  Responding  to  the  toast 
of  '■  Our  Guests,"  Mr.  Ernest  Hart  expressed  his  pleas- 
ure at  having  an  opportunity  of  meeting  such  a  represen- 
tative gathering  of  British  and  Americans  practising  on 
the  Continent.  The  Society  was  one  which  had  a  very 
useful  future  before  it,  and  he  wished  it  a  career  of 
ever-growing  usefulness  and  prosperity.  The  address 
of  Dr.  Barnard,  the  Secretary  of  the  Society,  is  362, 
Rue  St.  Honore,  Paris.  The  next  meeting  will  be  held 
at  the  same  time  and  place  as  that  of  the  British  Medi- 
cal Association. 

British  Laryngological,  Ehinological,  and  Otological 
Association. — The  annual  summer  meeting  was  held  on 
July  25th  and  26th,  Dr.  W.  McNeill  Whistler,  President, 
in  the  chair.  A  discussion  on  the  Surgical  Treatment 
of  the  Accessory  Cavities  of  the  Nose,  was  opened  by 
Dr.  J.  N.  Mackenzie  (Baltimore),  who  dealt  with  Em- 
pyema of  the  Antrum  of  Highmore.  He  was  in  accord 
with  Freeman,  who  opened  below  the  nasal  duct,  but 
considered  that  the  opening  by  an  alveolus  was  required 
in  all  but  recent  cases.  Dr.  Luc  (Paris)  dealt  with  Dis- 
ease of  the  Frontal  Sinus.  His  method  of  operation 
consists  in  opening  wide  by  the  anterior  wall  of  the 
sinus,  and  establishing  a  free  communication  with  the 
nose  by  means  of  an  india-rubber  drain.  Dr.  Brj'son 
Delavan  (New  York)  confined  his  observations  to  Eth- 
moidal Disease  ;  and  Dr.  F.  H.  Bosworth  (New  York) 
said  his  favorite  method  of  gaining  access  to  the  cells 
after  removal  of  the  anterior  end  of  the  middle  turbinal, 
was  by  the  use  of  a  drill.  Dr.  W.  H.  Daly  (Pittsburg), 
Dr.  Roaldes  (New  Orleans),  Mr.  Mayo  Collier,  and  Dr. 
Dundas  Grant,  continued  the  discussion.  The  subject 
of  the  treatment  of  Laryngeal  Stenosis  was  opened  by 
Dr.  Sajous  (Paris),  who  dealt  with  the  stenotic  condi 
tions  of  the  infra-glottic  space.  A  paper  on  this  subject 
by  Professor  Massei  (Naples)  followed.  On  July  26th 
Dr.  Krause  (Berlin)  and  Dr.  Heryng  (Warsaw)  opened 
a  discussion  upon  the  Surgical  Treatment  of  Laryngeal 
Tuberculosis,  and  described  their  methods  of  treatment 
by  curettement  and  the  application  of  lactic  acid.  Dr. 
Gleitsmann  (New  York)  stated  that  he  had  adopted, 
with  certain  slight  modifications,  the  methods  origi- 
nated by  Heryng  and  Krause.  Dr.  Sims  Woodhead  in- 
troduced a  discussion  upon  the  Antitoxin  Treatment 
of  Diphtheria,  and  described  his  views  and  experiences 
as  gained  from  an  investigation  of  2,000  cases.  He 
supported  the  treatment  not  only  for  diphtheria,  but 


also  as  a  prophylacric  against  its  occurrence  in  those 
exposed  to  infection.  Mr.  L.  Browne,  Dr.  Macintyre, 
and  Dr.  Roaldes  closed  the  discussion.  The  Society 
dined  at  the  Langham  Hotel  on  Friday  night,  and  a 
very  successful  meeting  was  then  concluded. — British 
Medical  Journal. 

The  First  Chinese  Woman  Doctor. — An  item  is  going 
the  round  of  our  exchanges  concerning  a  Dr.  Hu  King 
Eng,  recently  graduated  in  Philadelphia,  who  is  said  to 
be  the  first  Chinese  woman  to  acquire  an  American 
medical  degree.  This  is  incorrect,  for  she  was  pre- 
ceded by  Dr.  Y.  May  King,  who  was  graduated  in  this 
city  several  years  ago,  and  has  since  been  in  practice 
in  Kobe,  Japan.  Recently  Dr.  King  married  Mr.  H. 
E?a  da  Silva,  and  went  with  her  husband  to  Honolulu, 
where  she  now  resides. 

The  Woman's  Medical  Journal,  not  to  be  outdone  by 
its  contemporaries,  has  begun  the  publication  of  por- 
traits and  biographical  sketches  of  the  women  of  the 
profession.  Concerning  the  first  portrait,  the  Journal 
says  that  it  "  shows  a  young  woman  with  a  strong  and 
bright  face,  a  face  that  shows  determination  to  succeed, 
and  to  succeed  because  success  means  not  only  much 
for  her,  but  because  it  helps  every  other  woman,  not 
only  the  woman  of  to-day,  but  the  vast  army  of  to- 
morrow, who  are  waiting  now,  learning  what  to  do  and 
when  and  where  they  may  serve  the  world  best."  To 
which  it  is  our  pleasing  duty  to  add  that  the  face  is  not 
only  strong  and  bright,  but  comely  as  well.  We  predict 
for  our  esteemed  contemporary  a  rapidly  increasing  cir- 
culation. 

To  Prevent  the  Spread  of  Cholera  from  Mecca. — Dr. 
Saleh  Soubhy,  in  a  recent  work  on  the  Mecca  pilgrim- 
age, offers  the  suggestion  that  as  cholera  reaches  Mecca 
from  the  south,  it  should  be  arranged  throughout  the 
Mohammedan  world  that  pilgrimages  to  Mecca  from 
the  north  and  from  the  south  should  take  place  only 
on  alternate  years,  so  that  the  two  sets  of  pilgrims 
should  never  touch  or  intermingle. 

The  American  Dermatological  Association. — The 
nineteenth  annual  meeting  of  this  Association  will  be 
held  at  the  Windsor  Hotel,  Montreal,  Canada,  Septem- 
ber 17,  t8,  and  19,  1895.  The  President  of  the  Associa- 
tion is  Dr.  S.  Sherwell,  of  Brooklyn  ;  Vice-President,  Dr. 
J.  A.  Fordyce,  of  New  York  ;  Secretary  and  Treasurer, 
Dr.  C.  W.  Allen,  of  640  Madison  Avenue,  New  York. 

A  PortugTiese  Medical  Congress  is  being  organized 
by  the  Sociedade  de  Sciencias  Medicas.  It  will  be 
held  in  Lisbon. 

Australian  Medical  Students. — The  total  number  of 
students  in  the  Medical  Faculty  of  the  University  of 
Sydney  during  1894  was  one  hundred  and  nineteen. 

Diphtheria  is  increasing  in  London,  but  the  mortality 
from  the  disease  is  decreasing. 

The  Jenner  Centenary  in  Russia. — In  commemora- 
tion of  the  centenary  of  vaccination,  the  Russian  Na- 
tional Health  Society  proposes  to  offer  four  prizes  for 
the  best  works  on  vaccination  ;  to  collect  and  publish 
materials  for  a  history  of  the  practice  of  vaccination  in 
Russia,  and  also  a  short  history  of  the  same  in  Western 
Europe  ;  to  publish  a  Russian  translation  of  Jenner's 


272 


MEDICAL  RECORD. 


[August  24,  1895 


works,  with  his  biography  and  portrait ;  to  organize  an 
exhibition  of  objects  connected  with  vaccination  ;  and 
finally,  to  hold  a  commemorative  meeting  on  May  14, 
1896. 

The  Kansas  City  Medical  Record  has  appropriated 
twelve  columns  in  its  August  issue  from  the  Medical 
Record  without  giving  any  credit  therefor.  We  are 
ashamed  of  our  namesake. 

The  City  of  London  and  the  British  Medical  Associa- 
tion.— It  was  thought  that  the  corporation  of  the  city 
of  London  would  extend  its  hospitalities  to  the  mem- 
bers of  the  British  Medical  Association  during  the  late 
meeting,  but  it  did  not.  It  entertained  the  son  of  the 
Ameer  of  Afghanistan,  but  said  it  would  cost  too  much 
to  feed  the  doctors.  Even  a  request  that  the  Associa- 
tion have  the  use  of  the  Guildhall  was  granted  only  on 
condition  that  the  Association  furnish  the  necessary 
expenses.     The  offer  was  declined  with  thanks. 

A  Parisian  Medical  Quarrel. — Drs.  Proust  and  Roux 
are  at  present  engaged  in  a  bitter  controversy  concern- 
ing the  merits  of  the  diphtheria  antitoxin.  A  child 
died  soon  after  receiving  an  injection  of  antitoxin,  and 
Dr.  Proust  said  that  the  death  was  due  to  the  remedy. 
No  autopsy  had  been  made  on  the  child,  and  Dr.  Roux 
naturally  declaimed  against  the  assumption  that  the 
antitoxin  was  to  blame.  The  controversy  has  grown 
so  acute  that  some  of  the  participants  even  forget  their 
patriotism  and  assert  that  the  antitoxin  treatment  is  a 
German  discovery  anyway,  and  Roux  simply  appropri- 
ated it  without  warrant  and  proclaimed  it  as  his  own. 

Noble  Tattooed  Men. — According  to  a  writer  in  the 
Lancet-Clinic,  the  Duke  of  York,  his  uncle,  the  Duke 
of  Saxe-Coburg-Gotha,  the  Grand  Duke  Alexis,  and 
many  of  the  English  nobility,  have  had  themselves 
tattooed  with  flags,  initials,  coats-of-arms,  and  other 
deshgns. 

French  Brandy. — Dr.  Laborde  recently  read  a  paper 
before  the  Academie  de  Medecine  of  Paris  on  the 
liquor  supplied  to  the  French  army  under  the  name  of 
cognac.  He  had  analyzed  the  stuff  used  for  making 
the  worst  spirit  into  the  best  cognac,  and  found  that  it 
consisted  of  castor-oil,  cocoanut-oil,  and  other  fatty  sub- 
stances treated  with  nitric  acid  and  labelled  "  Boucpiet 
de  Cognac."  "  Pure  Jamaica  rum,"  sold  by  an  English 
house,  proved,  on  analysis,  to  be  mucli  of  the  same 
quality. 

Pasteurized  Vichy  is  advertised  for  sale  in  a  Broad- 
way drug-store.  A  fortune  awaits  the  man  of  enter- 
prise who  will  provide  aseptic  oysters  next  month. 

Kiel  and  Rostock  are  the  only  German  universities 
which  have  no  psychiatric  clinic. 

The  Meeting  of  the  British  Medical  Association  was 
not  so  largely  attended  as  was  at  first  announced.  It 
was  thought  that  the  number  of  those  present  would 
reach  six  thousand,  but  the  official  record  shows  that 
the  attendance  was  under  three  thousand. 

London  Doctors  and  Advertising, — The  English 
medical  man  is  nothing  if  not  ethical,  and  few  things 
shock  him  so  much  as   the  way  in  which  he  imagines 


his  American  confreres  keep  themselves  before  the 
public.  The  Londoner  seems,  however,  to  have  made 
hay  while  the  sun  shone  during  the  week  of  the  British 
Medical  Association.  One  of  the  daily  papers  had  col- 
umns of  biographical  notes  on  the  metropolitan  physi- 
cians and  surgeons,  prominent  and  otherwise,  the  de- 
tails of  which  could  hardly  have  been  obtained  from 
any  but  the  subjects  themselves,  and  the  photographs 
of  the  same  individuals  were  exposed  for  sale  in  many 
of  the  shops  along  the  Strand,  in  company  with  those 
of  royal  personages,  actresses,  and  other  celebrities. 

Tri-State  Medical  Society. — The  seventh  annual 
meeting  of  this  Society  will  be  held  in  Chattanooga, 
Tuesday,  Wednesday,  and  Thursday,  October  8th,  9th, 
and  loth.     A  large  attendance  is  expected. 

The  Effect  of  Ovariotomy  upon  the  Voice. — The  well- 
known  effect  of  castration  in  young  males  in  heighten- 
ing the  pitch  of  the  voice  has  led  Dr.  E.  J.  Moure,  of 
Bordeaux,  to  investigate  the  effect  of  ovariotomy  upon 
the  voice.  His  observations  in  two  cases  of  ovariotomy 
in  young  women  showed  an  effect  exactly  the  opposite 
of  that  of  castration  in  men,  since  the  voice  became 
deeper  and  harsher,  and  the  patients  thought  they  were 
hoarse.  The  higher  notes  were  lost  and  the  voice  fell 
from  soprano  to  mezzo-soprano.  This  small  number 
of  observations  is  obviously  entirely  insufficient  to  es- 
tablish a  fact  ;  and  as  no  previous  cases  are  on  record 
of  the  production  of  any  changes  in  the  voice  by  ova- 
riotomy, the  observations  must  await  confirmation  from 
further  cases. — Boston  Medical  and  Surgical  Journal. 

The  Metric  System  in  England. — A  committee  of  the 
House  of  Commons  has  made  a  report,  which  will  be 
voted  upon  at  an  early  date,  in  favor  of  the  adoption 
of  the  metric  system  in  England.  It  would  have  its 
use  made  immediately  legal,  and  obligatory  after  an 
interval  of  two  years.  As  a  preparation  for  the  change 
it  would  make  the  metric  system  a  compulsory  part  of 
teaching  in  all  public  schools,  "  as  a  necessary  and 
integral  part  of  arithmetic." 

La  Technologic  Sanitaire  is  the  title  of  a  new  sani- 
tary journal  published  in  Louvain. 

The  Medical  Faculty  of  Harvard  University  has  voted 
to  authorize  approved  physicians  having  the  necessary 
facilities  and  desirous  of  teaching  its  medical  students, 
to  announce  their  courses  yearly  in  the  Medical  School. 

Treatment  of  Soft  Corns. — Mr.  Philip  Miall  writes  to 

the  British  Medical  Journal  that  a  concentrated  solu- 
tion of  tannin,  made  by  dissolving  an  ounce  of  per- 
fectly freshly  made  tannin  in  six  drachms  of  water  with 
the  aid  of  gentle  heat,  gives  immediate  relief  to  soft 
corns,  if  applied  once  or  twice  a  day  between  the  toes 
after  washing.  Tannin  in  powder  is  not  quite  so  ef- 
fectual. 

The  Lancet  as  a  Chromo. — An  enterprising  acci- 
dent insurance  concern  in  London  has  issued  circulars 
to  medical  men  in  England,  offering  a  subscription  to 
The  Lancet  in  conjunction  with  an  accident  policy.  Our 
esteemed  contemporary  assures  its  readers  that  it  cannot 
approve  of  this  scheme,  with  which  it  is  in  no  way 
connected,  and  of  which  it  was  wholly  unaware  until 
one  of  the  offensive  circulars  came  into  its  possession. 


August  24,   1895] 


MEDICAL    RECORD. 


273 


THE!  EFFECT    OF  REMOVAL    OF    THE   OV  \. 
RIES    UPON   THE    SEXUAL   APPETITE. 

By  A.  LAPTHORN   SMITH,  M.D., 

MONTREAL,  CANADA. 

Miss  X ,  twenty-five  years  of  age,  consulted  me 

this  morning  for  a  discharge,  which  on  examination 
proved  to  be  gonorrhoea.  She  gave  me  the  following 
history  ;  She  had  had  her  ovaries  and  tubes  removed 
about  seven  years  ago  by  another  surgeon,  on  account 
of  pain  and  enlargement  in  them.  I  saw  her  a  few 
mont'.s  afterward,  when  she  consulted  me  for  troubles 
of  the  artificial  menopause,  through  which,  however, 
she  passed  successfully.  1  then  lost  sight  of  her  until 
to-day,  when  she  told  me  that  her  menstruation  had 
gradually  left  her,  until  the  end  of  the  year,  when  it  dis- 
appeared entirely,  so  that  she  has  had  no  periods  during 
the  last  six  years.  She  went  to  Boston  three  years  ago 
and  returned  to  Montreal  last  month,  when  she  met  a 
former  male  acquaintance  and  had  intercourse  with 
him.  During  this  act  she  became  very  excited,  having 
an  orgasm,  and  straining  herself,  which  she  thinks  is 
the  cause  of  her  discharge.  On  further  inquiry  she 
assured  me  that  she  never  had  experienced  so  much 
sexual  pleasure  as  she  did  this  time,  and  in  her  opinion 
the  removal  of  the  ovaries  in  no  way  alters  the  feelings 
of  a  woman  toward  the  opposite  sex. 

This,  of  course,  is  not  the  general  belief,  and  I  there- 
fore think  it  well  to  report  this  case  as  one  among 
many  others  in  which  the  removal  of  the  ovaries  has  not 
been  followed  by  loss  of  sexual  desire,  but,  on  the  con- 
trary, by  a  marked  increase  of  it. 

250  Bishop  Street. 


A    CASE    OF    TETANUS    CURED    WITH    AX- 
TITOXIN.i 

By  C.    F.   TIMMERMAN,    M.D., 


About  ten  years  ago,  I  read  a  paper  on  tetanus  before 
this  Society,  and  at  that  time  I  devoted  considerable 
time  to  the  etiology  of  the  disease,  and  gave  the 
opinion  of  our  best  authorities  prevailing  at  that  time. 
Lockhart  Clark  expresses  the  opinion  that  tetanus 
depends,  first,  upon  an  excessively  excited  state  of 
the  nerve-tissue  of  the  cord,  induced  by  hypera;niia 
and  morbid  conditions  of  the  blood-vessels  and  ex- 
udation, and  disintegration  resulting  therefrom.  Sec- 
ond, that  the  spasms  are  the  result  of  the  persistent 
irritation  of  the  peripheral  nerves,  by  which  the  ex- 
alted excitability 'of  the  cord  is  aroused,  and  thus 
the  cause  which  at  first  induced  in  the  cord  its  mor- 
bid susceptibility  to  reflex  action  is  subsequently  the 
source  of  that  irritation  by  which  the  reflex  action 
is  excited.  Another  states  that  a  large  percentage  of 
cases  of  tetanus  is  caused  by  injuries  to  the  periph- 
eral nerves  due  to  compression.  To-day,  thanks  to 
some  of  the  observers,  as  Rosenbach,  Nicolaier,  and 
Kitasato,  the  specific  bacillus  has  been  discovered. 
Carle  and  Rattone,  in  1884,  furnished  the  first  proof  of 
the  communicability  of  the  disease  by  inoculation  of 
rabbits  with  pus  from  a  wound,  in  a  case  of  human  tet- 
anus. Nicolaier,  in  1885,  found  disseminated  in  all 
kinds  of  earthy  matter  bacilli  which,  introduced  subcu- 
taneously  into  mice,  guinea-pigs,  and  rabbits,  produced 
typical  trismus  and  tetanus  with  fatal  termination. 
Rosenbach,  in  1886,  demonstrated  the  tetanus  bacillus 
for  the  first  time  in  man.  Thus  was  established  the 
generic  relation  to  the  diseases  of  the  bacillus  of  Nic- 

'  Read  before  the  Montgomery  County  Society,  June  12,  189s. 


olaier.  The  poison  appears  to  be  in  the  ptomaines,  a 
specific  product  of  the  tetanus  bacillus.  Kitasato  ob- 
served that  the  filtrate,  perfectly  free  of  germs,  produced 
the  same  tetanic  effect.  Since  wounds  of  the  most 
trivial  nature  are  as  apt  to  be  followed  by  the  disease 
as  those  more  serious,  it  stands  us  in  hand  to  be  on 
our  guard  at  all  times. 

In  the  treatment  of  this  disease,  since  such  poor  re- 
sults have  been  attained  with  the  old  remedies,  I  think 
the  hope  of  successful  treatment  lies  in  the  use  of  anti- 
toxin. 

I  have  been  unfortunate  enough  to  have  had  three 
cases  of  tetanus. 

Case  I. — J.  R ,  a  Pole,  aged  thirty-four.     On  the 

evening  of  October  16,  1885,  he  was  injured  in  a  rail- 
road accident,  and  remained  near  the  track  all  night. 
Fourteen  hours  after  the  injury,  I  found  him  with  the 
foot  crushed,  two  scalp  wounds,  and  many  cuts  and 
bruises  on  the  face,  arms,  and  hands.  I  dressed  the 
wounds  and  he  received  the  best  attention,  the  wounds 
healing  very  kindly.  On  the  eighth  day  the  first  symp- 
toms of  tetanus  were  present.  He  died  on  October 
25th,  nine  days  after  the  accident. 

Case  II. — J.  S ,  a  Pole,  aged  twenty-six.     He 

was  injured  in  a  mill,  his  arm  being  terribly  lacerated 
from  the  middle  third  of  the  humerus  to  the  wrist,  with 
fracture  of  the  humerus  at  the  middle  third.  I  dressed 
the  wounds,  placing  the  entire  arm  in  a  metal  trough, 
using  hot-water  dressing  and  antiseptics.  I  can  truly 
say  I  never  saw  a  wound  improve  better  than  this  did, 
but  on  about  the  twelfth  day  that  sardonic  grin  caused 
wrinkles  on  my  own  countenance,  and  in  spite  of  all 
the  well-known  remedies,  and  the  assistance  of  the  hos- 
pital staff  and  nurses,  he  died  on  the  nineteenth  day. 
At  autopsy  I  found  a  sharp  fragment  of  the  broken  bone 
hnbedded  in  the  median  nerve.  I  was  then  about  sat- 
isfied that  this  was  the  principal  cause  of  the  trouble. 

Case  III. — William  W ,  an  Irishman,  aged  nine- 
teen, burned  by  his  clothes  catching  fire  from  a  lamp, 
on  the  evening  of  April  28,  1895.  The  entire  left  side 
from  the  sternum  to  the  spine,  and  from  near  the  spine 
of  the  ileum  to  the  base  of  the  neck,  and  the  entire  arm 
from  near  the  wrist  to  the  base  of  the  neck,  including 
the  axilla,  and  also  both  hands  and  fingers,  were 
burned  deeply,  in  some  places  to  the  bone.  When  I  ar- 
rived at  the  house,  about  2  a.m.,  I  found  what  is  com- 
monly known  as  a  potato  poultice  applied.  (The  en- 
tire wound  was  covered  with  scraped  raw  potatoes, 
fresh  from  the  cellar — a  most  excellent  habitation  for 
the  bacilli  of  tetanus.)  I  removed  as  best  I  could  all 
this  material  and  applied  Carron-oil  dressing.  I  again 
dressed  the  wound  the  next  morning,  removing  all  that 
remained  of  the  poultice,  considerable  of  the  burned 
skin  coming  with  it,  opening  the  blisters  and  pressing 
the  skin  down  gently.  All  went  well,  the  wound  act- 
ing very  kindly. 

Nothing  occurred  to  cause  alarm  until  May  15th, 
seventeen  days  after  the  accident,  when  the  man  com- 
plained of  some  stiffness  of  his  jaw,  which  he  said  he 
had  felt  for  two  or  three  days.  1  lost  no  time  in  writ- 
ing to  Dr.  Paul  Gibier,  of  the  Pasteur  Institute,  New 
York  City,  who  promptly  replied  and  advised  me  to  use 
antitoxin  immediately,  also  stating  tiiat  he  had  never 
cured  tetanus  in  a  human  being,  but  had  in  a  number 
of  horses.  At  the  same  time  I  did  all  I  could  to  relieve 
the  advancing  tetanic  symptoms.  I  gave  sulph.  physos- 
stigma  hypodermically,  grains,  i  to  loo,  twice  daily,  and 
by  mouth  every  three  hours.  Later  I  increased  it  to 
grains  i  to  50  each  dose,  and  I  gave  morphia  as  indi- 
cated, and  chloral  very  freely,  sometimes  30  grains,  re- 
peated every  two,  three,  or  four  hours.  The  spasms 
were  at  first  so  well  controlled  by  these  remedies  that 
it  was  not  until  Tuesday  morning.  May  21st,  three 
weeks  after  the  injury,  I  used  the  antitoxin.  There 
was  an  apparent  fixation  of  the  muscles  of  respiration, 
and  he  was  almost  unable  to  breathe  ;  nearly  all  the 
muscles  were  in  a  constant  state  of  spasm.     I  admin- 


2/4 


MEDICAL    RECORD. 


[August  24,  1895 


istered  anodynes  with  a  more  free  hand  and  with  the 
family's  consent.  The  patient  then  grew  so  much  worse 
I  availed  myself  of  the  only  remaining  chance,  and 
tried  this  remedy.  I  gave  the  first  injection  of  25  c.c. 
(about  6  drachms)  tetanus  antitoxin,  in  the  lateral  part 
of  the  abdomen  ;  the  serum  was  very  rapidly  absorbed, 
and  at  10  p.m.  I  gave  another  25  c.c.  The  following 
morning  I  gave  10  c.c,  and  intended  to  give  the  re- 
maining 15  c.c,  but  he  was  so  exhausted  I  waited  until 
the  next  morning.  I  wrote  to  Dr.  Gibier,  who  advised 
me,  as  the  treatment  was  begun  so  late,  to  give  him 
more  serum,  and  also  to  wash  the  wounds  with  Gram's 
solution  (iodine,  i  gm.  ;  iodide  of  potassium,  2  gm.  ; 
and  distilled  water,  300  gm.).  On  Monday  morn- 
ing. May  27th,  I  injected  10  c.c.  more  of  the  serum, 
and  in  the  evening  15  c.c,  when  the  spasms  were 
almost  subdued.  I  waited  for  more  symptoms  to  ap- 
pear to  use  the  other  bottle,  but  there  was  no  use 
for  it,  and  I  relied  only  on  chloral  afterward.  The 
present  condition  of  the  wound  is  most  excellent,  every- 
thing healing  very  rapidly,  and  patient  sitting  up  most 
of  the  time.  In  looking  over  recent  publications  I  find 
only  six  or  seven  cases  in  all  where  antitoxin  or  tetonine 
has  been  used  successfully  in  tetanus,  and  they  were  all 
by  foreigners,  and  I  believe  this  is  the  first  case  in 
America  where  antitoxin  has  saved  a  human  being. 


A  C.\SE  OF  ACUTE  ATROPHY  OF  THE  LIVER. 
By  W.  KIRKER  BEATTV,  M.D., 


INTERNE  EMERGENCV    HOS- 


AccoRDiNG  to  Bartholow  the  term  acute  yellow  atro- 
phy of  the  liver  means  "an  acute  affection  of  the  liver 
characterized  by  a  rapid  wasting  or  degeneration  of  the 
organ  accompanied  by  the  systemic  symptoms  belong- 
ing to  an  acute  acholia  or  chotemia."  According  to 
Murchison,  "acute  atrophy  of  the  liver  is  probably  but 
a  symptom  of  some  blood-poisoning.  The  liver  be- 
comes rapidly  atrophied  with  the  development  of  jaun- 
dice and  cerebral  symptoms,  what  remains  of  the  organ 
after  death  is  found  to  be  extremely  soft  and  yellow, 
with  no  appearance  of  lobules  and  with  the  secreting 
cells  in  a  great  measure  broken  up  into  granular  matter 
and  oil-globules." 

The  following  is  the  history  of  the  case  from  the  date 
of  entrance  to  the  hospital  to  death,  which  occurred 
three  days  later,  including  as  much  of  the  antecedent 
history  as  could  be  obtained. 

April  17,  1895,  I  admitted  to  the  wards  of  the  hospi- 
tal M.  B ,  aged  thirty-five,  white  ;  female  ;  Ameri- 
can by  birth.  Has  had  nine  children,  seven  of  whom 
are  living  and  healthy.  Last  confinement  had  occurred 
sixteen  months  previous.  .\  probable  one  or  two 
months'  pregnancy  existing.  Her  antecedent  history 
showed  her  to  have  been  a  strong,  healthy  woman,  with 
no  hereditary  predisposition,  though  her  mother  died 
of  a  disease  which  strongly  resembles  in  descrijition 
this  one.  Her  hygienic  surroundings  were  of  the  worst, 
poverty  with  its  squalor  and  privation  of  nourishing 
food.  The  husband,  a  painter,  kept  his  kit  and  paints 
in  an  outbuilding,  so  that  little  influence  could  be  at- 
tributed to  them. 

The  first  symptoms  of  the  present  illness  were  ob- 
served April  nth,  when  she  complained  of  slight  back- 
ache. The  following  morning  symptoms  of  acute 
gastro-duodenal  catarrh  presented  themselves,  pain  in 
the  epigastrium,  anorexia,  nausea,  vomiting,  bitter  taste 
in  the  mouth,  headache  (which  was  very  persistent),  and 
general  malaise.  Icterus  was  probably  existent  to  some 
degree,  but  was  not  noticed  by  the  husband,  who  being 
a  working  man  seldom  saw  his  wife  save  by  lamplight. 
April  13th,  all  symptoms  save  that  of  the  persistent  head- 


ache were  relieved,  and  on  the  next  day,  Sunday,  she 
felt  well  enough  to  be  up.  But  on  Monday  marked 
icterus  set  in  and  the  patient  rapidly  grew  worse,  until 
Wednesday  the  17th,  when  she  was  admitted  to  the 
hospital  in  the  following  condition  :  Temperature,  37.8° 
C.  (99°  F.)  ;  respiration,  52,  and  pulse,  150,  scarcely 
perceptible.  She  tossed  about  constantly  in  a  state  of 
active  delirium.  Her  skin  was  hot,  dry,  and  harsh,  per- 
spiration having  been  entirely  checked.  The  entire 
body  was  jaundiced,  the  color  being  more  intense  on 
the  upper  part.  Tongue  dry,  brown,  and  glazed 
smoothly :  teeth  encrusted  with  sordes  ;  lips  discol- 
ored from  capillary  hemorrhages.  The  mucous  mem- 
brane lining  the  nasal  passages  was  stained  with  dried 
blood  and  discolored  by  capillary  hemorrhages.  Shortly 
after  admission  she  vomited,  the  matters  ejected  con- 
taining mucus  and  blood.  There  was  an  involuntary 
passage  of  colorless,  watery,  and  foul  faeces.  On  cathe- 
terization eight  ounces  of  urine  were  obtained,  which 
when  examined  was  found  to  be  of  a  very  dark  golden 
brown  color,  specific  gravity  1.020,  acid  reaction,  a  large 
amount  of  albumin,  and  devoid  of  chlorides  and  phos- 
phates. Physical  examination  of  the  hepatic  region 
elicited  pain  on  pressure  ;  on  palpation  no  part  of  the 
liver  could  be  felt  although  carefully  sought  for  ;  on 
percussion  hepatic  dulness  extended  but  two  inches 
below  the  nipple,  below  the  hepatic  dulness  tympanites 
was  found.  Splenic  dulness  was  slightly  increased,  but 
the  intestines  were  so  distended  that  this  was  not  eas- 
ily deteniiined. 

The  history  subsequent  to  this  was  that  of  progres- 
sive decline  from  the  active  delirium  to  low  muttering 
delirium,  tremors,  subsultus  tendinum,  carphologia,  stu- 
por, coma,  and  death  due  to  exhaustion  of  all  the  vital 
forces.  Briefly  it  is  as  follows  :  By  8  p.m.  the  pulse  had 
gained  in  strength  and  diminished  in  rate,  being  140  ; 
respiration  had  decreased  to  40  ;  temperature  had 
risen  to  38.7°  C.  (101.6°  ¥.).  The  temperature  appar- 
ently rising  as  delirium  increased. 

April  1 8th. — During  the  night  the  noisy  delirium 
merged  into  a  condition  of  stupor  from  which  the 
patient  could  be  partially  aroused  by  shouting  in  her 
ear.  8  a.m.,  the  pulse  was  12S,  the  temperature  had 
risen  to  39.5°  C.  (103°  F.).  Skin  was  more  moist,  and 
the  icterus  of  a  darker  shade  about  the  head  and  upper 
part  of  the  trunk  ;  the  extremities  slightly  lighter. 
I  P.M.,  pulse  imperceptible  ;  respiration,  44  ;  tempera- 
ture, 37.2°  C.  (99°  F.).  8  P.M.,  pulse  again  perceptible, 
being  160  ;  respiration,  44  ;  temperature,  39.2°  C. 
(102.6°  F.).  Extremities  cold  and  moist.  11  p.m., 
a  hemorrhagic  discharge  from  the  uterus  occurred,  but 
nothing  definite  could  be  ascertained  on  examination  ; 
in  all  probability  it  was  a  one  or  two  months'  concep- 
tion. 

April  19th. — During  the  night  vomiting  occurred 
frequently,  the  vomitus  consisting  of  the  ingesta,  mu- 
cus, and  blood.  The  pulse-rate  and  strength  had  im- 
proved, being  120;  respiration  continuing  uniformly 
at  44-  . 

The  patient  was  rapidly  drifting  into  a  very  low 
typhoid  condition  :  she  was  constantly  sinking  down 
in  bed,  muttering,  hands  trembling,  and  ceaselessly 
picking  at  the  bedclothes,  etc.  Mouth  was  constantly 
open,  as  if  the  muscles  were  too  weak  to  close  it ; 
tongue  dry  and  glazed,  with  a  smooth  dark  brown  coat- 
ing ;  lips  more  discolored  from  capillary  hemorrhages  ; 
breath  heavy  and  foul.  Bowels  had  several  involun- 
tary movements  during  the  night,  the  stools  being 
light  in  color  and  of  large  ipiantity.  Pupils  very  much 
dilated  and  not  responding  to  bright  light  nor  to  pilo- 
carpine which  had  been  injected  several  times.  Color 
of  the  skin  seemed  to  be  of  a  lighter  shade.  Pulse, 
150;  respiration,  48;  temperature,  38.1°  C.  (100.6° 
F.).  At  I  P.M.  the  pulse  was  128  ;  respiration,  46  : 
temperature,  38.7°  C.  (ioi.6°  ¥.).  At  8  p.m.,  the  lower 
delirium  merged  into  coma  ;  mucous  rales  over  the  en- 
tire chest  were  heard. 


August  24,  1895] 


MEDICAL    RECORD. 


75 


April  20th. — During  the  night  the  coma  gradually 
deepened.  Pulse  weaker  though  slower,  being  106  ; 
respiration,  56;  temperature,  38.2°  C.  (100.6°)  F.  The 
bowels  ceased  to  move.  At  i  p.m.  the  respirations  in- 
creased to  65.     Died  comatose  at  5  p.iM. 

The  treatment  was  wholly  symptomatic  and  tenta- 
tive, as  the  patient  was  practically  moribund  when 
brought  in.  Efforts  were  made  to  produce  diaphoresis 
by  hot  packs,  fluid  extract  of  jaborandi  by  mouth,  and 
hypodermic  injections  of  muriate  of  pilocarpine,  but 
with  no  apparent  effect,  though  as  much  as  one- third  of 
a  grain  was  used.  To  keep  the  bowels  open  magne- 
sium sulphate  and  the  mild  chloride  of  mercury  were 
used.  Free  and  bold  stimulation  was  employed  through- 
out, most  reliance  being  placed  on  nitro-glycerine,  which 
was  given  by  hypodermatic  injection  hourly  in  y^^ 
grain  doses.  Strychnia  by  hypodermatic  injection 
was  used  every  four  hours  without  apparent  effect, 
so  was  discontinued.  Digitalin  J^  grain  was  also 
tried  with  no  result.  The  nourishment  for  the  first 
day  was  milk,  but  this  being  vomited  before  digestion 
could  be  effected,  I  substituted  bovinine  with  suc- 
cess. 

Autopsy.  —  An  autopsy  was  made  but  permission 
could  be  obtained  to  examine  the  abdominal  viscera 
only.  Body  well  nourished  and  muscular.  Deeply 
jaundiced  hue  of  the  entire  body  including  all  the  ab- 
dominal viscera.  No  scars  on  the  genitals  nor  in  the 
groins.  A  layer  of  fat,  one  inch  thick,  deeply  bile- 
tinged,  covered  the  abdomen.  Serous  covering  of  the 
intestines  greatly  congested.  Stomach  and  intestines 
much  distended  with  gas.  The  liver  was  hidden  by 
distended  intestines,  the  lower  edge  being  above  the 
margin  of  the  ribs  ;  about  two  inches  only  of  the  liver 
was  opposed  to  the  thoracic  wall.  The  organ,  on  ac- 
count of  its  friability,  was  detached  with  some  difficulty 
in  order  to  remove  it  intact.  The  volume  was  reduced 
at  least  one-third,  but  as  there  was  no  facility  at  hand 
for  weighing  we  could  not  make  a  more  accurate  es- 
timate. It  was  quite  friable  and  flabby,  the  surface 
somewhat  wrinkled  and  splotched  with  greenish-yellow 
patches.  On  section  a  dark  greenish  substance  oozed. 
Bile-ducts  were  patent,  but  the  gall-bladder  was  much 
diminished  in  size  and  capacity,  and  empty,  save  for 
a  small  amount  of  inspissated  mucus.  Spleen,  much 
enlarged,  very  soft  and  friable.  Dark  greenish  red  on 
section.  Kidneys,  jaundiced  and  somewhat  enlarged, 
rather  soft  and  flabby.  Much  fibrous  tissue  in  its 
substance.  Pancreas,  jaundiced,  very  much  indurated 
and  enlarged  ;  adherent  to  all  surrounding  tissues  ;  re- 
sistant on  section.  Appendix  vermifcrmis,  calibre  nar- 
row, admitting  only  small  probe.  Uterus,  slightly  en- 
larged. 

The  following  is  a  chronological  list  of  all  cases 
reported  in  America  : 


TWIN-BIRTH  — ONE      CHILD 
OTHER   LIVING. 


DEAD,  THE 


1871 
1871 
1873 
•873 
1878 


Reporter. 


A.  T.  Holmes 

J.  Homans 

W.  M.  Chamberlain 

I.  G.  Porter 

K.  W.  Chapin 

R.  Watts 

G.  T.  Thomas 

H.  Curtis 

A.  L.  Loomis 

S.  C.  Chew 

J.  H.  Musser 

J.  Bowen 

E.  T.  Marsh 

J.  X.  Ziteke 


Periodical  and  Place. 


Date.    Vol.,  Page.-*. 


Medical   Chronicle,   Montreal, 

Canada 1S56 

Amer.  Journal  of  the  Medical  I 

Sciences,  Philadelphia,  Pa..|  1868 
Medical  Record,  .New  York,  ' 

N.  V 1871-721 

Amer.  Journal  of  the  Medical  I  I 

Sciences,  Philadelphia.  Pa..'   1871 
Philadelphia    Medical  Times,  I 

Philadelphia,  Pa !  1873-74 

Recokd,  New  York, 


N.  Y. 

North  Carolina  Medical  Jour- 
nal, Wilmington,  N.  C 

Boston  Medical  and  Surgical 

Journal.  Boston,  Mass 

New  York    Medical    Journal, 

New  York,  N.  Y 

Record,  New  York, 


1873 
1878 


N.  v. 


Proceedings  uf  the  Philadelphia 
County  Medical  Societ>',  Pa. 

Archives    of     Medicine,    New 

York,  N.  Y 

Record,  New  York, 


1883     j  'x; 
1882-83'  V. 


■1-.  53-73- 

i.,  a65. 

:i.,  150-152- 

r.,  486. 

•1  233-238- 

cviii.,  615. 

MM.,  31-33- 

xiv.,  369. 


N.  Y. 


By   HENRY    HEIMAN,    M.D., 


ATTENDING 


Mrs.  S ,  aged  twenty-eight,  married   seven   years, 

had  two  living  children  and  three  abortions.  I  was 
called  to  see  her  on  March  31st,  and  found  her  in  labor 
pains.  On  vaginal  examination  I  was  surprised  to  make 
out,  instead  of  the  usual  presentation,  a  sharp  irregu- 
larly circular  edge  of  bone,  extending  backward  from 
which  the  examining  finger  could  map  out  a  soft,  pulpy 
mass.  After  a  few  sharp  pains  a  dead  foetus  was  de- 
livered. It  was  of  a  grayish  color,  skin  macerated  in 
different  spots  ;  the  upper  and  lower  extremities  were 
flattened,  probably  from  pressure  ;  the  cranial  bones 
easily  compressible  and  freely  movable  ;  cranial  cavity 
nearly  empty.  On  my  first  examination  I  did  not  find 
the  membranes  which  should  have  contained  the  dead 
foetus.  Three  hours  after  delivery  of  the  dead  foetus 
a  living  child  was  expelled.  There  was  no  history  of 
any  vaginal  discharge  at  any  time  during  pregnancy. 

Parvin  gives  the  following  varieties  of  dead  foetus  : 
"  I.  Liquefaction  generally  occurring  during  the  first 
or  second  month  of  pregnancy,  e.g.,  fleshy  mole.  2. 
Mummification  :  In  this  variety  the  foetus  appears  as 
though  it  had  been  preserved  in  alcohol.  3.  Macera- 
tion :  In  this  variety  the  foetus  appears  swollen,  its 
form  changed,  abdominal  cavity  often  distended,  bones, 
of  the  cranium  move  freely  upon  pressure,  the  epi- 
dermis comes  off  in  large  flakes  ;  odor  is  not  pleasant, 
but  not  like  putrefaction."  My  case  seems  to  corre- 
spond with  this  type,  the  fa;tus  having  lived  up  to  the 
fourth  month.  "  4.  Putrefaction,  caused  when  mem- 
branes rupture  and  accompanied  with  general  symp- 
toms of  putrefaction."  The  patient  made  an  uninter- 
rupted recovery,  and  the  living  child  is  doing  well. 

220  East  ii6th  Street. 

Else  of  the  Medical  Profession. — During  early  medi- 
aeval times  the  monasteries,  serving  as  centres  of  in- 
struction, gave  some  embodiment  to  the  medical  pro- 
fession, like  that  which  our  colleges  give.  In  Italy 
there  later  arose  institutions  for  educating  physicians, 
as  the  medical  school  of  Salerno,  in  1140.  In  France, 
before  the  end  of  the  thirteenth  century,  the  surgeons 
had  become  incorporated  into  a  distinct  college,  follow- 
ing, in  this  way,  the  incorporated  medical  Faculty  ;  and 
while  thus  integrating  themselves,  they  excluded  from 
their  class  the  barbers,  who,  forbidden  to  perform  op- 
erations, were  allowed  only  to  dress  wounds,  etc.  In 
our  own  country  there  have  been  successive  consolida- 
tions. The  barber-surgeons  of  London  were  incorpo- 
rated by  Edward  H'.,  and  in  the  fifteenth  century  the 
College  of  Physicians  was  founded,  and  "  received 
power  to  grant  licenses  to  jjractice  medicine — a  power 
which  had  previously  been  confined  to  the  bishops." 
Progress  in  definiteness  of  integration  was  shown  when, 
in  the  time  of  Charles  I.,  persons  were  forbidden  to  ex- 
ercise surgery  in  London  and  within  seven  miles,  until 
they  had  been  examined  by  the  company  of  barbers  and 
surgeons  ;  and  also,  when,  by  the  eighteenth  year  of 
George  II.,  excluding  the  barbers,  the  Royal  College  of 
Surgeons  was  formed.  At  the  same  time  there  have 
grown  up  medical  schools  in  various  places,  which  pre- 
pare students  for  examination  by  these  incorporated 
medical  bodies  ;  further  integrations  being  implied. 
Hospitals,  too,  scattered  throughout  the  kingdom,  have 
become  places  of  clinical  instruction,  some  united  to 
colleges  and  some  not.  Another  species  of  integration 
has  been  achieved  by  medical  journals,  weekly  and 
quarterly,  which  serve  to  bring  into  communication 
educational  institutions,  incorporated  bodies,  and  the 
whole  profession. — Herbert  Spencer,  in  2'Ac  Popular 
Science  Alontlily. 


276 


MEDICAL    RECORD. 


[August  24,  1895 


Jiocictu  ^cprorts. 


THE  BRITISH  MEDICAL  ASSOCIATION. 

Sixty -third  Annual  Meeting,  held  in  London,  July  30 
and 31  and  August  i  and  2,  1895. 

(Specially  Reported  for  the  Medical  Rhcord.) 

SECTION  IN  MEDICINE. 

First  Day,  Wednesday,  July  31ST. 

Discussion  on  Diphtheria. — This  discussion  embraced 
the  following  points  :  i,  Pathology  of  diphtheria  and 
its  sequels  ;  2,  symptoms  and  progress  ;  3,  statistics 
of  mortality  under  the  antitoxin  treatment  and  under 
other  treatment  ;  4,  effect  of  the  antitoxin  treatment 
upon  the  local  affection,  upon  the  general  condition, 
and  upon  the  sequelae  ;  5,  effects  that  may  arise  from 
the  antitoxin  treatment. 

Dr.  Sydney  H.  C.  Martin,  in  opening  the  discus- 
sion, said  that  although  the  idea  was  combated  for  a 
long  time  even  by  eminent  men  like  the  late  Dr.  Mur- 
chison,  it  is  now  definitely  established  that  there  exists 
a  number  of  micro-organisms  intimately  connected 
with  the  various  diseases,  and  that  each  disorder  has  its 
specific  organism,  which  may  sometimes  also  be  found 
elsewhere.  Pasteur  laid  the  foundation  of  the  theory 
when  he  discovered  that  micro-organisms  could  be  arti- 
ficially cultivated  outside  the  body,  and  that  when  these 
culture-products  were  inoculated  in  an  animal,  such  as 
a  rabbit  or  a  guinea-pig,  they  gave  rise  to  a  disease  of 
the  same  kind  as  the  one  from  which  the  original  germs 
had  been  derived.  Bacteriology  is  not  merely  an  ab- 
stract science  devoid  of  practical  application,  for  nu- 
merous experiments  have  proved  the  existence  and 
character  of  a  number  of  micro-organisms  and  deter- 
mined the  part  they  play  in  the  causation  and  progress 
of  disease,  and  within  the  last  few  years  it  has  been 
proven  that  it  is  possible  to  prevent  their  development. 
But  how  to  prevent  the  spread  of  disease  is  only  one  of 
the  discoveries  that  we  owe  to  the  science  of  bacteri- 
ology. It  has  been  demonstrated  that  inoculation  with 
a  cultivated  micro-organism  will  produce  a  milder  form 
of  a^  disorder.  The  attenuation  of  these  micro-organ- 
isms can  be  effected  by  causing  them  to  pass  through 
the  system  of  some  animal,  or  by  an  artificial  culture 
in  various  media. 

The  pernicious  effects  due  to  the  presence  of  a  micro- 
organism are  referable,  not  to  the  action  of  the  bacilli 
themselves,  but  to  the  poisonous  effects  of  the  prod- 
ucts to  which  they  give  rise.  Antitoxin  is  derived  di- 
rectly from  the  toxin  produced  by  the  bacillus,  whether 
in  or  outside  the  body,  and  is  separated  from  the  latter 
by  filtration. 

The  most  recent  method  of  treating  diphtheria  is  by 
inoculation  with  the  serum  of  a  horse  that  has  been 
previously  inoculated  with  diphtheritic  poison.  A 
large  number  of  remedies  had  been  from  time  to  time 
proposed  for  the  treatment  of  diphtheria,  but  without 
producing  much  effect  on  the  general  symptoms  of  the 
disease  ;  and  whenever  a  new  therapeutic  remedy  is 
introduced  it  is  necessary  to  study  it  carefully  and 
watch  it  with  the  utmost  attention.  The  emjiloyment 
of  antitoxin  in  the  treatment  of  di]ihtheria  is  based  on 
the  study  of  the  pathology  of  the  disease,  which  is  an 
inflammatory  condition  of  the  mucous  membrane  of 
the  mouth  and  air-passages  excited  by  a  special  bacillus 
which  gives  rise  to  nerve  ilegeneration.  It  is  not  the 
bacillus  that  induces  the  death  of  the  patient,  but  the 
degeneration  of  the  nerves,  the  chief  symptoms  being 
suppression  of  urine  and  a  fatty  degeneration  of  the 
muscular  fibres  of  the  heart.  A  single  dose  of  the 
poison  will  give  rise  to  the  disease,  and  the  fluidity  of 
the  blood  is  affected  if  this  dose  be  a  large  one,  but  it 


is  the  absorption  of  repeated  small  doses  of  the  poison 
during  the  course  of  the  disease  that  has  such  a  disas- 
trous effect. 

Two  rabbits  were  experimented  with.  In  one  a  dose 
of  unmixed  poison  was  injected,  and  in  the  other  a  mixt- 
ure of  poison  and  antitoxin.  On  examination  after 
death,  the  former  was  found  to  have  fatty  degeneration 
of  the  muscular  fibres  of  the  heart  and  nervous  degen- 
eration, but  the  second  rabbit  had  a  perfectly  sound 
heart  and  only  a  trace  of  nerve  degeneration.  Exper- 
iments have  proved  that  antitoxin  is  quite  innocuous, 
but  the  toxin  induces  paralysis  on  the  fourth  day  after 
its  introduction  into  the  system  of  the  animal. 

Cardiac  syncope  in  diphtheritic  disease  is  due  to  the 
fatty  degeneration  of  the  muscular  fibres  of  the  heart. 

In  reply  to  a  question  Dr.  Martin  stated  that  the 
normal  temperature  of  a  healthy  rabbit  was  103°  F., 
and  to  another  he  said  that  not  only  was  the  injection 
of  antitoxin  followed  by  no  inconvenience  to  the  ani- 
mal, but  that  the  latter  even  increased  rapidly  in  weight. 

Dr.  G.  Si.ms  Woodhead  stated  that  the  persistence 
of  the  local  exudation  indicated  a  severe  form  of  diph- 
theria, and  that  when  it  was  gelatinous  the  case  became 
a  very  grave  one  indeed.  The  symptoms  were  albu- 
minuria, sometimes  but  not  always  pyrexia  (occasion- 
ally there  was  no  elevation  of  temperature),  and  drow- 
siness ;  vomiting  was  of  frequent  occurrence,  as  was 
also  suppression  of  urine;  when- the  renal  secretion 
continued  to  pass  it  was  much  more  concentrated  than 
usual  ;  there  was  also  more  or  less  hemorrhage  from 
the  mucous  membrane,  and  dropsy.  If  convulsions 
supervened  they  were  the  immediate  precursors  of  death. 
Some  of  these  aggravations  of  diphtheria,  especially  the 
last,  have  been  attributed  to  the  use  of  antitoxin,  but, 
the  speaker  considered,  without  adequate  reason.  In 
some  cases  the  diphtheritic  bacillus  could  not  be  de- 
tected, and  in  such  cases  the  injection  of  the  antitoxin 
was  productive  of  no  effect. 

In  241  cases  of  diphtheria  105  were  treated  with  an- 
titoxin and  136  by  other  methods,  and  the  mortality  in 
the  latter  was  considerably  higher  than  in  the  former. 
Age  was  an  important  factor  and  the  older  patients 
were  found  to  do  better  without  the  antitoxin  ;  never- 
theless, a  general  consideration  of  all  the  facts  tends  to 
prove  that  the  antitoxin  treatment  of  diphtheria  is  one 
to  be  commended  and  followed. 

The  antitoxin  does  not  cause  any  diminution  of  the 
albumin  in  the  urine,  nor  does  it  influence  the  anuria  : 
but  in  cases  where  it  was  used  there  was  found  to  be  a 
larger  proportion  of  paralytic  complications  than  in 
those  cases  where  it  had  not  been  employed,  although  it 
must  not  be  too  hastily  concluded  that  the  paralysis  is 
the  actual  result  of  the  use  of  antitoxin.  Paralysis  is 
usual  after  severe  cases  and  infrequent  after  those  that 
are  of  a  milder  type,  and  many  of  the  former  would 
probably  have  succumbed  had  they  not  been  tided  over 
the  peril  by  the  antitoxin.  Where  antitoxin  was  used 
in  mild  cases,  no  paralysis  was  observed.  The  fact  is 
that  the  antitoxin  has  no  control  over  the  paralysis, 
which,  however,  is  never  permanent,  and  from  the  ef- 
fects of  which  no  deaths  have  been  recorded.  Anti- 
toxin, in  like  manner,  does  not  influence  glandular  en- 
largements or  broncho-pneumonia. 

In  all  cases  it  is  important  to  commence  using  the  anti- 
toxin as  early  as  possible,  but  there  is  no  benefit  to  be 
derived  from  other  concurrent  treatment.  In  compli- 
cated cases  not  much  can  be  hoped  for  from  its  em- 
ployment. About  the  worst  combination  of  diseases  is 
that  of  diphtheria  and  measles,  which  nearly  always 
ends  fatally  from  broncho-pneumonia. 

Diphtheria  varies  in  severity  in  different  years,  in 
some  being  of  a  much  more  serious  type  than  in  others, 
and  although  the  results  of  the  antitoxin  treatment 
have  been  less  favorable  in  the  former,  enough  encour- 
agement has  been  obtained  all  round  to  induce  the 
speaker  to  persevere  with  it. 

Dr.  Alexander  Johnston  mentioned  the  occur- 


( 


August  24,  1895] 


MEDICAL   RECORD. 


277 


rence  of  paralysis  of  the  soft  palate,  a  subnormal  tem- 
perature, diminution  of  urine,  and  vomiting  as  beint; 
of  frequent  occurrence  in  diphtheria,  and  said  that  the 
diagnosis  of  the  disease  was  established  by  bacteriolog- 
ical examination,  notwithstanding  the  fact  that  other 
micro-organisms  were  found  along  with  the  diphtheria 
bacillus.  He  had  used  antitoxin  in  some  cases  which 
turned  out  to  be  scarlet  fever,  and  they  were  uninflu- 
enced by  it  in  any  way.  In  the  Belvedere  Hospital, 
Glasgow,  the  highest  mortality  was  41.4  and  the  lowest 
28.63  PC  cent.  ;  he  tried  the  antitoxin  in  7  cases,  5  of 
whom  died,  and  the  other  2  derived  no  benefit. 

Dr.  von  Ranke  said  that  he  began  the  use  of  anti- 
toxin nine  months  ago,  but  he  only  treated  cases  of 
pure  diphtheria,  all  very  severe  cases,  the  mortality  being 
17.7  ;  28.4  per  cent,  of  his  cases  were  treated  by  incu- 
bation and  41. 1  by  tracheotomy.  In  only  three  cases 
did  he  have  to  retain  the  tube  longer  than  four  days  ; 
he  always  has  it  removed  every  day  for  a  little  while  to 
see  how  the  patients  get  on  without  it. 

In  his  cases  of  diphtheria  of  the  pharynx  only  two 
per  cent,  died,  and  they  succumbed  to  heart  failure  ; 
nineteen  per  cent,  had  septic  symptoms.  The  mortality 
varied  according  to  the  age  of  the  patients.  Under 
twelve  months  all  died  ;  between  one  and  two  years 
27.5  per  cent.  Before  he  began  the  use  of  the  serum 
treatment  the  average  mortality  was  forty-six  per  cent,, 
the  highest,  57.7  per  cent.  Since  he  had  used  the  se- 
rum it  was  17.7  per  cent.,  and  the  change  in  the  clinical 
course  of  the  disease  was  also  very  marked.  Before,  it 
was  progressive.  Laryngeal  stenosis  was  benefited  in  a 
special  manner.  Croup  cases  improved  in  the  most 
wonderful  way,  and  twelve  hours  after  admission  no 
operation  was  necessary  ;  if  the  little  patients  were  in- 
tubated the  tube  could  be  removed  much  earlier  than 
would  otherwise  have  been  possible  without  the  serum 
treatment.  If  antitoxin  was  not  a  specific  in  diphthe- 
ria, at  least  it  was  a  most  powerful  remedy. 

Dr.  Lennox  Browne  was  not  altogether  opposed  to 
serum  injections  in  diphtheria,  but  he  was  watching  the 
treatment  and  had  arrived  at  a  very  different  conclu- 
sion from  that  of  the  last  speaker.  He  thought  that 
the  importance  of  the  rise  and  fall  of  the  temperature 
has  been  overestimated.  Antitoxin  had  no  influence 
over  nephritis.  It  was  said  that  the  serum  was  only  of 
use  in  cases  of  uncomplicated  diphtheria,  but  others 
were  inclined  to  believe  it  was  beneficial  in  mixed  cases 
also.  Statistics,  he  thought,  should  not  be  too  much 
insisted  upon,  as  the  records  made  were  the  result  very 
frequently  of  only  a  small  number  of  observations. 
Antitoxin  and  classical  treatment  contrasted  showed 
much  the  same  result.  He  did  not  think  the  reviews  in 
the  British  Medical  Journal  had  been  fairly  set  forth. 
One  case  was  counted  twice  over,  and  one  was  stated 
to  have  been  treated  on  June  31st,  a  day  he  did  not  find 
on  the  calendar.  Improvement  under  good  hygienic 
conditions  was  certainly  to  be  taken  into  account. 

Dr.  Baginsky,  of  Berlin,  said  that  he  had  written  a 
book  about  this  method  of  treatment.  Before  the  in- 
troduction qf  the  serum  treatment  the  mortality  from 
diphtheria  had  been  appalling.  He  began  the  use  ot 
antitoxin  in  March,  1894,  prior  to  which  time  from 
forty-one  to  fifty-eight  per  cent,  died ;  now  the 
mortality  was  no  more  than  fifteen  per  cent,  and  in 
the  best  class  only  five  per  cent.  The  whole  charac- 
ter of  the  disease  had  been  changed.  True,  they 
had  still  some  cases  of  failure  of  the  heart,  but  only  in 
mixed  cases  that  had  come  late  under  observation  ; 
probably  had  they  been  seen  earlier  these  patients 
would  have  lived,  for  he  had  never  lost  one  from  car- 
diac complications  when  the  case  had  been  under 
his  care  from  the  commencement  of  the  complaint.  If 
some  patients  had  nephritis  it  was  not  a  recent  devel- 
opment. The  mortality  of  cases  with  laryngeal  steno- 
sis before  the  serum  was  introduced  was  sixty  per  cent., 
but  only  twenty-one  per  cent,  since.  He  thought  he 
had  some  little  excuse  for  his  enthusiam. 


Dr.  Sims  Woodhead  had  got  past  the  stage  of  en- 
thusiasm that  was  untempered  by  facts.  He  thought 
some  were  too  timid  in  their  use  of  the  antitoxin,  for 
the  best  results  were  obtained  from  the  largest  doses, 
which  were  employed  by  those  who  had  the  greatest 
amount  of  experience  with  the  serum.  He  was  not 
prepared  to  find  the  mortality  influenced  in  so  marked 
a  manner,  but  he  had  remarked  upon  the  alteration  in 
the  character  of  the  disease  that  had  been  mentioned. 

Dr.  H.  M.  Biggs,  of  New  York,  spoke  from  mem- 
ory only,  having  no  data  within  reach.  He  explained 
that  any  medical  man  in  New  York  can  obtain  a  supply 
of  antitoxin  free  of  charge  on  application  to  the  Board 
of  Health,  and  can  have  it  administered,  if  desired,  by 
a  medical  inspector.  The  mortality  had  been  very 
considerably  reduced  as  regards  both  private  and  hos- 
pital cases.  The  antitoxin  conferred  a  remarkable  im- 
munity. 

Diphtheria  broke  out  in  four  institutions  for  children 
in  New  York.  There  were  107  cases  in  all.  Then 
the  rest  of  the  children  were  inoculated  with  the  serum, 
and  after  that  only  three  more  cases  occurred.  The 
immunization,  however,  only  lasts  for  about  a  month, 
and  then  the  inoculation  has  to  be  performed  again  ; 
but  in  all  probability  a  few  successive  inoculations 
would  ultimately  confer  permanent  immunity.  He 
could  not  speak  too  highly  of  the  treatment  by  an- 
titoxin. No  bad  results  followed,  except  a  slight  and 
temporary  urticaria  in  a  few  instances,  and  a  trifling 
rise  of  temperature  for  four  or  five  hours. 

Dr.  Campbell  Hall  had  not  much  to  add  to  the 
discussion  ;  nevertheless  he  came  from  a  place  where 
diphtheria  was  endemic,  and  he  began  the  serum  treat- 
ment as  an  unbeliever,  but  was  surprised  with  the 
result.  In  not  a  single  instance  did  the  membrane 
spread  after  inoculation,  and  he  would  not  now  think 
of  treating  the  disease  in  any  other  way  than  with  anti- 
toxin. 

Operative  Treatment  of  Athetosis.  —  Dr.  C.  E. 
Beevor  then  read  a  paper,  the  joint  work  of  himself 
and  Mr.  Horsley,  "  On  the  Pathology  of  Severe  Athe- 
tosis." The  first  patient  operated  on  had  suftered 
from  an  incessant,  uncontrollable  movement  of  the  hand 
and  arm,  but  after  the  removal  of  a  portion  of  the 
cortes  cerebri  there  was  complete  paralysis  of  the 
affected  arm  lasting  for  a  year,  when  motion  began  to 
be  gradually  restored.  Then  the  man  "  had  a  bad 
turn  "  and  eventually  died,  having  been  relieved  by 
the  operation  for  a  period  of  a  year.  The  athetosis  in 
this  case  was  the  result  of  injury  through  a  fall  on  the 
head. 

In  the  second  case  the  athetosis  was  also  the  conse- 
quence of  an  injury,  and  the  relief  was  complete  for 
two  years,  when,  owing  to  hernia  cerebri  occurring 
through  the  necrosis  of  the  bone  graft,  meningitis  set 
in,  the  inflammation  became  general,  and  the  patient 
died. 

Before  trephining  in  these  cases  numerous  experi- 
ments had  been  made  on  monkeys  and  on  an  orang- 
outang. 

The  Thyroid  Treatment  of  Myxoedema.  —  Dr. 
George  R.  Murray,  of  Newcastle-on-Tyne,  read  a 
paper  entitled  "  Notes  on  the  Progress  and  Present 
Condition  of  the  First  Case  of  Myxoedema  Treated  by 
Thyroid  Extract." 

The  question  had  been  asked  if  this  was  a  complaint 
that  was  capable  of  being  cured,  to  which  he  would  re- 
ply that  it  was,  and  that  it  would  not  return  when  the 
remedy  had  been  discontinued.  Myxcedema  is  a  dis- 
ease of  the  thyroid  gland,  but  even  when  the  gland 
cannot  be  restored  the  jjatient  can  be  cured,  and  there 
will  be  no  return  of  the  disease  as  long  as  he  continues 
to  take  the  remedy  in  daily  doses  of  ten  grains  each. 

Dr.  Colin  Campbell  mentioned  a  case  in  which  a 
relapse  had  taken  place  and  all  the  symptoms  of  myx- 
cedema had  returned  after  a  shock  caused  by  a  railway 
accident  ;  but  the  patient  had  ceased  taking  the  extract 


278 


MEDICAL  RECORD. 


[August  24,  1895 


four  months  before,  as  she  considered  that  she  was  com- 
pletely cured. 

Dr.  Murr.av,  in  reply,  said  that  he  doubted  very 
much  whether  the  railway  accident  had  had  anything 
to  do  with  the  return  of  the  symptoms,  for  a  relapse 
might  be  expected  in  about  one  hundred  days  after  a 
patient  had  given  up  the  daily  dose  of  the  extract. 

Uranium  Nitrate  in  Diabetes  Mellitus. — Dr.  Sam- 
uel West  said  that  in  large  doses  this  salt  acted  as  an 
irritant  poison,  and  small  doses  interfered  with  the  di- 
gestion of  starch  and  albumin.  A  knowledge  of  this 
action  had  induced  a  homoeopathic  physician  to  try  the 
drug  on  a  patient  suffering  from  diabetes.  Dr.  West 
first  tried  it  on  some  out-patients  who  were  suffering 
from  that  disease,  and  they  informed  him  that  after 
taking  it  for  a  short  time  their  secretion  of  urine  was 
diminished  by  about  half.  The  uranium  nitrate  was 
then  administered  to  some  other  patients  more  favor- 
ably situated  than  the  first.  He  began  with  small  doses 
of  one  grain,  gradually  increased  to  twenty  grains  three 
times  a  day,  and  the  effect  was  m.ost  marked,  for  not 
only  was  the  output  of  urine  greatly  diminished,  but 
the  quantity  of  sugar  contained  in  it  was  also  corre- 
spondingly decreased,  the  excessive  discharge  of  both 
sugar  and  urine  returning  as  soon  as  the  drug  was 
stopped.     This  certainly  proved  its  restraining  power. 

Another  case  that  had  hitherto  been  treated  by  a 
strict  attention  to  diet  was  then  put  under  the  uranium 
nitrate  treatment,  with  the  effect  that  the  urine  was 
much  diminished  in  quantity,  but  as  the  drug  caused 
nausea  it  had  to  be  discontinued,  and  then  the  diabetic 
symptoms  at  once  returned.  It  was  now  cautiously  re- 
sumed, and  for  four  or  five  months  this  patient's  urine 
was  normal  in  quantity  and  absolutely  free  from  sugar. 
The  patient  then  had  an  attack  of  influenza,  when  the 
uranium  was  discontinued  and  the  patient  soon  re- 
lapsed into  her  former  condition. 

Several  other  cases  also  derived  great  benefit  from 
the  use  of  the  uranium  salt.  The  drug  does  not,  how- 
ever, cure  the  disease,  but  it  certainly  exerts  a  very 
marked  effect  upon  its  progress. 

When  the  minimum  secretion  of  sugar  has  been 
reached  the  dose  of  the  drug  may  be  gradually  lessened, 
even  down  to  one  grain  a  day,  without  a  return  of  the 
symptoms,  but  it  had  better  not  be  left  off  altogether. 

Dr.  Garrett  -  Anderson  wished  to  know  if  ura- 
niufn  nitrate  was  an  expensive  drug,  and  also  what 
effect  it  had  on  the  diabetes  of  children. 

Dr.  West  replied  that  he  did  not  know  the  exact 
cost  of  the  drug,  but  he  imagined  it  was  by  no  means 
an  expensive  one.     He  had  never  tried  it  on  a  child. 

Bronzed  Diabetes. — Dr.  Hanot  then  gave  a  short 
address  in  French,  entitled  "  Notes  sur  le  Diabete 
Bronz6."  He  began  by  apologizing  for  speaking  in 
French,  but  his  knowledge  of  the  English  tongue  was 
too  limited  for  him  to  venture  to  use  it.  The  essen- 
tial character  of  this  disease,  for  he  considered  that 
bronzed  diabetes  was  a  special  and  indejiendent  malady, 
was  the  deposition  of  pigment  not  only  in  the  liver,  but 
in  every  organ  of  the  body.  This  deposition  was  not 
an  effect  of  the  diabetes,  but  was  due  to  an  obscure 
common  cause  ;  it  differed  in  many  essential  points 
from  morbus  Addisonii,  especially  in  the  bronzed  or 
pigmented  condition  of  the  mouth  and  fauces.  It  was 
certainly  a  disease  siii generis,  and  terminated  rapidly 
in  the  death  of  the  patient.  He  had  seen  seventeen 
cases  of  bronzed  diabetes,  in  all  of  which  there  was  a 
large  concretion  of  sugar.  The  final  complication  was 
generally  pneumonia,  but  occasionally  the  patient  suc- 
cumbed to  mere  exhaustion  or  to  svncope. 

Direct  Intra-pulmonary  Medication.  —  Mr.  Colin 
Camphell  said  that  llie  lungs  were  possessed  of  great 
absorbent  power,  perliaps  as  much  as  the  intestinal 
tract  itself,  and  much  greater  than  that  of  the  latter  in 
many  diseased  conditions.  Therefore  he  considered 
that  direct  treatment  of  diseases  of  the  lungs  would  be 
found  to  have  a  great  future  before  it.     At  present  the 


only  mode  of  directly  medicating  the  lungs  was  by 
means  of  the  inhalation  of  vapors,  but  it  was  more  than 
doubtful  whether  the  latter  reached  the  ultimate  rami- 
fications of  the  bronchi,  and  if  creosote,  for  instance, 
could  be  introduced  directly  and  brought  into  imme- 
diate contact  with  the  pulmonary  tissue,  much  more 
good  might  be  expected  from  its  employment. 

The  complaints  most  amenable  to  treatment  by  this 
method  were  all  bronchial  affections,  asthma,  tubercu- 
losis, and  similar  morbid  conditions  of  the  lungs  ;  in 
chronic  bronchial  asthma  it  had  a  marked  beneficial 
effect. 

Considering  the  rationale  of  the  treatment,  it  might 
be  expected  to  do  good  in  cases  of  chronic  interstitial 
pneumonia,  but  the  result  was  somewhat  disappointing. 
In  hemorrhage  from  the  lungs,  however,  the  direct  in- 
jection of  a  mixture  of  glycerine  and  turpentine  was 
productive  of  benefit,  and  was  followed  by  no  bad  re- 
sults, or  even  by  inconvenience  ;  even  in  cases  where 
a  cure  is  impossible,  it  will  afford  great  relief.  He  had 
known  cases  of  hereditary  phthisis  presenting  large  cav- 
ernous abscesses  in  the  lungs  to  be  entirely  and  per- 
manently cured.  At  first  there  might  be  a  little  dif- 
ficulty in  practising  these  intra-pulmonary  injections, 
but  what  operation  was  not  attended  with  more  or  less 
difficulty  when  first  practised  ?  The  difficulty,  however, 
is  soon  overcome  and  the  operation  is  performed  as 
easily  as  the  passing  of  a  catheter  or  the  administra- 
tion of  an  enema. 

Dr.  Murray  bore  testimony  to  the  efficacy  of  the 
treatment  in  several  cases  of  pulmonary  affections,  but 
he  had  not  employed  it  in  tuberculosis. 

In  reply  to  a  question  Mr.  Colin  Campbell  said  that 
he  had  a  special  syringe  made  for  practising  these  injec- 
tions. It  was  longer  than  those  in  ordinary  use  and  had 
a  more  extended  curve.  He  used  turpentine  in  equal 
proportion  with  olive- oil,  and  in  the  interval  between 
the  acts  of  inspiration  and  expiration  he  injected  one 
hundred  minims  three  times  into  the  lung,  which  he 
had  found  was  as  much  as  was  required.  The  admin- 
istration was  productive  of  so  little  inconvenience  that 
no  patient  had  ever  objected  to  a  repetition  of  the  in- 
jection. He  found  that  a  mixture  of  olive-oil  and 
menthol  recommended  by  Sir  T.  Grainger  Stewart  did 
not  mix  with  the  sputum,  and  had  substituted  glycerine 
for  the  former,  which  mingled  freely  and  carried  the 
menthol  along  with  it,  rendering  the  act  of  expectora- 
tion easy  by  liquefying  the  viscid  sputum.  He  had 
never  found  that  dypncea  was  produced,  and  should 
not  think  it  would  be  twice  in  ten  thousand  cases.  Of 
course  it  required  practice  to  give  the  injection  in  the 
right  way,  but  a  little  experience  would  soon  enable 
this  to  be  done  with  complete  satisfaction  to  the  pa- 
tient. 


Second  Dav,  Thursday,  August  ist. 
Discussion  on  Acute  Lobar  Pneumonia. — After  some 
preliminary  remarks  by  the  President  of  the  Section 
(Dr.  Pavy),  Dr.  Douglas  Powell  opeped  the  dis- 
cussion by  observing  that  we  are  on  the  border-land  of 
a  new  method  of  treating  this  formidable  disease,  the 
death-rate  of  which  still  holds  its  own.  To  describe  the 
well-known  symptoms  of  pneumonia  would,  he  thought, 
be  a  waste  of  time,  while  its  etiology  has  exercised  the 
minds  of  physicians  from  all  time.  The  disease  bears 
no  proportion  to  the  inclemency  of  a  climate,  but  in 
the  temperate  zones  it  is  more  prevalent  during  seasons 
of  low  temperature,  the  months  of  January,  February, 
and  March  having  the  highest  proportions,  both  as  re- 
gards the  incidence  of  pneumonia  and  its  mortality. 
Among  other  conditions  favorable  to  the  development  1 
of  the  disease  are  personal  imprudence,  exposure  to  i 
atmospheric  effects  in  exposed  places,  insufficient  or  I 
inappropriate  clothing,  the  artificial  conditions  of  social  T 
life,  sudden  changes  of  temperature,  which  are  all  to  be  A 
taken  into  consideration  when  estimating  the  etiology       I 


August  24,  1895] 


MEDICAL   RECORD. 


279 


of  pneumonia.  It  has  been  said  that  he  is  a  con- 
temptible man  who  is  always  absorbed  in  the  contem- 
plation of  his  own  skin  ;  but  an  imprudent  man  who 
takes  no  notice  of  his  surroundings  is  not  much  more 
to  be  commended. 

With  regard  to  an  etiology  depending  solely  on  the 
entrance  of  a  micro-organism  into  the  system,  such  an 
assumption  would  certainly  have  a  tendency  to  give 
rise  to  carelessness  ;  we  always  have  organisms  with  us, 
and  they  will  do  us  no  harm  unless  we  furnish  them 
with  an  occasion  for  destructive  development. 

The  compensatory  powers  of  the  system  may  be  de- 
feated by  nervous  shock  and  imprudence,  for  nasal 
catarrh  is  unquestionably  due  to  a  surface  chill,  and  of 
all  the  ills  that  flesh  is  heir  to  it  is  decidedly  one  of 
the  most  contagious,  running  its  course  rapidly  through 
a  household  when  one  of  the  members  has  been  at- 
tacked. 

When  pneumonia  occurs  in  the  course  of  a  febrile 
disease,  it  does  not  arise  during  the  period  of  active 
pyrexia,  but  when  the  temperature  has  begun  to  de- 
cline. With  regard  to  pneumonia  being  caused  by  a 
special  organism,  the  disease  is  a  general  rather  than  a 
local  one,  and  its  manifestation  in  a  given  locality  is 
only  part  of  its  general  presence  in  the  system.  Rheu- 
matism is  not  favorable  to  the  development  of  pneu- 
monia. There  are  three  favorite  candidates  for  the 
honor  of  distributing  pneumonia  among  us  ;  the  coccus 
that  is  found  at  all  times  in  the  saliva  is  the  one  that 
occurs  most  freely  in  cases  of  this  disease  ;  but,  on  the 
other  hand,  it  is  also  found  to  exist  in  other  diseases  that 
are  not  quite  analogous  with  pneumonia. 

Osier  did  not  find  the  pneumo-micro-organism  con- 
stant, but  observed  others  in  different  cases,  and  the 
pneumococcus  exists  largely  in  healthy  saliva.  Im- 
paired vitality  is  an  exciting  cause  of  the  disease. 

Pythogenic  pneumonia  is  practically  the  same  affec- 
tion as  ordinary  pneumonia,  but  the  temperature  is 
more  fluctuating.  When  pneumonia  spreads  among 
the  members  of  a  household  the  probability  is  that  they 
contract  it  from  the  same  originating  cause,  and  not 
through  contagion.  How  far  this  cause  is  associated 
with  the  effects  of  sewer-gas  is  undetermined. 

With  regard  to  the  treatment,  the  speaker's  expe- 
rience justified  the  routine  employment  of  salines,  diet, 
rest  in  airy  room  with  a  medium  temperature  of  60°  F., 
but  he  preferred  the  dose  of  medicine  to  be  given  every 
six  rather  than  every  four  hours,  so  as  to  allow  more 
time  for  the  administration  of  nutriment,  and  of  more 
powerful  drugs  when  these  were  indicated  by  the  gen- 
eral symptoms.  Quinine  was  far  preferable  to  the  old 
method  of  blood-letting  and  antimony,  which  were 
powerful  depressants,  and  weakened  the  heart  at  the 
critical  moment  of  the  struggle.  Tincture  of  iron  was 
a  valuable  aid. 

Pyrexia  is  a  normal  condition  of  pneumonia  and  is 
present  in  most  cases  ;  it  is  inimical  to  the  develop- 
ment of  microbes,  and  in  interfering  with  it  too  much 
there  is  a  risk  of  their  increased  action.  But  if  the  tem- 
perature of  the  patient  rises  above  104°  F.,  it  had  bet- 
ter be  reduced.  The  cold  cradle  is  useful  for  this  pur- 
pose, as  are  the  antipyretics,  but  care  must  be  taken 
not  to  let  the  temperature  fall  below  the  normal. 

The  consideration  of  pain  in  pneumonia  is  a  most 
important  one.  Poultices,  hot  or  cold,  have  but  little 
effect  in  reducing  it,  but  the  use  of  ice-compresses  is  a 
vexed  question  at  present.  They  are  of  decided  advan- 
tage in  the  case  of  children  and  young  adults,  they  do 
no  harm,  and  as  a  rule  relieve  the  pain,  but  have  no 
effect  on  the  respiration,  and  on  the  whole  leeches  are 
more  reliable  than  ice  for  dispersing  pain.  Blisters  ot 
small  size,  followed  by  a  rapid  succession  of  hot  i)oul- 
tices,  are  often  useful,  but  the  employment  of  morphine 
is  of  less  decided  advantage,  as  it  certainly  checks  the 
secretions.  ^Vhen  there  is  a  tendency  to  cyanosis  the 
inhalation  of  oxygen  is  productive  of  much  benefit. 
Strychnine  and   caffeine  are    two  powerful   remedies, 


and  the  latter  is  the  less  dangerous,  requires  less  super- 
vision than  the  former,  but  is  less  potent.  It  should 
be  administered  subcutaneously,  for  the  stomach  can- 
not be  depended  upon  to  act,  and  when  the  patient  re- 
covers he  may  find  himself  confronted  w-ith  an  accu- 
mulation of  the  drug  in  poisonous  quantity.  Oxygen 
must  not  be  reserved  for  a  last  resource,  but  be  given 
as  a  cardiac  tonic  at  an  early  stage  to  supply  the  left 
cavity  of  the  heart  with  a  sufficiency  of  red  blood  and 
sweep  away  the  products  of  imperfect  combustion. 

Plethoric  people  are  often  carried  off  rapidly  by  an 
at..ack  of  pneumonia — overwhelmed  by  it,  so  to  speak — 
and  in  such  case  leeches  are  indicated.  On  the  fifth 
day  of  the  disease  acids  should  be  substituted  for  sa- 
lines. 

The  antitoxin  treatment  of  pneumonia  by  the  intro- 
duction into  the  veins  of  a  patient  of  blood  drawn 
from  a  convalescent  from  the  same  disorder  is  not  sat- 
isfactory for  several  reasons,  but  chiefly  owing  to  the 
difficulty  of  obtaining  what  is  wanted  at  the  right  mo- 
ment, and  the  operation,  moreover,  is  not  free  from 
danger. 

Dr.  Washbocrn  was  of  the  opinion  that  pneumonia 
was  due  to  a  coccus  and  to  that  alone.  The  inflam- 
mation had  a  tendency  to  spread,  but  was  susceptible 
of  being  localized.  The  micro-organisms  (pneumo- 
cocci)  spread  through  the  walls  of  the  alveoli.  Both 
lobular  and  lobar  pneumonia  were  due  to  a  coccus, 
though  its  demonstration  is  difficult,  for  it  dies  out  at 
a  later  stage  of  the  disease,  and  is  replaced  by  others. 

Different  animals  evince  a  differing  degree  of  sus- 
ceptibility to  the  action  of  the  pneumococcus  ;  thus 
mice  are  peculiarly  liable  to  its  action,  guinea-pigs 
less  so,  and  fowls  are  immune. 

The  pathological  changes  observed  are  due  to  the 
action  of  a  number  of  different  factors,  and  the  several 
micro-organisms  give  rise  to  modifications  of  the  in- 
flammatory process.  Several  varieties  of  the  pneumococ- 
cus have  been  described,  but  they  differ  in  appearance 
only.  The  pneumococcus  produces  fibrous  pneumo- 
nia. The  treatment  of  the  disease  by  the  injection  of 
the  blood  of  a  convalescent  is  not  difficult  in  the  case 
of  animals,  and  gives  strong  reason  to  believe  that  it 
will  prove  to  be  a  specific  for  pneumonia. 

Dr.  Acld,  of  Glasgow,  said  that  the  inflammation  of 
pneumonia  was  not  confined  to  the  lungs,  but  also 
spread  to  the  meninges  of  the  brain  ;  the  disease  itself 
(pneumonia)  was,  however,  a  genuine  inflammation  due 
to  the  pneumococcus  which  circulated  in  the  blood  and 
produced  or  gave  rise  to  a  bacterial  toxin.  Leucocy- 
tosis  diminished  with  the  fall  of  temperature,  and  the 
local  lesion  in  the  lung  was  often  a  means  of  checking 
the  general  developmentof  the  microorganism  by  pre- 
venting its  expansion  in  other  parts  of  the  system. 
He  agreed  with  Dr.  Douglas  Powell  that  pneumonia  is 
due  to  the  action  of  a  special  coccus.  Pleurisy,  though 
often  associated  with  pneumonia,  is  nevertheless  a  dis- 
tinct disease,  for  some  rabbits  he  had  inoculated  with 
pleuritic  serum  developed  pleurisy  but  not  pneumonia. 

The  toxic  crisis  might  be  determined  by  the  elabora- 
tion of  antitoxin,  but  this  was  no  sign  that  the  disease 
was  arrested  or  even  diminished. 

Dr.  Dreschfeld,  of  Manchester,  said  that  he  would 
be  practical  in  his  remarks.  The  pneumococcus  was 
the  cause  of  pneumonia,  and  low  vitality  favored  its 
development.  The  sputa  should  be  carefully  disin- 
fected. Wandering  pneumonia  was  similar  to  typhoid, 
the  sputa  were  not  sanguineous  and  the  bacilli  were  not 
to  be  mistaken  for  pneumococci,  but  were  more  like  the 
bacilli  of  influenza. 

Dr.  J.  E.  Pollock  would  rather  add  to  his  knowl- 
edge than  discuss  doubtful  points.  What  was  the 
meaning  of  ]jneumonia  ;  what  its  cause  and  treatment  ? 
A  micro-organism  had  been  detected  in  croupous  pneu- 
monia, but  it  was  also  found  in  other  diseases.  What 
was  to  be  inferred  from  that  ?  Again,  was  it  the  cause 
or  the  result  of  morbid  action  ?     Certainly  there  are 


28o 


MEDICAL    RECORD. 


[August  24,   1895 


many  cases  of  the  disease  in  which  it  is  impossible  to 
trace  the  action  of  a  microbe.  For  instance,  a  robust 
man  of  thirty-five,  who  had  always  been  healthy  and  tem- 
perate, without  the  least  tendency  to  the  disease,  drove 
seven  miles  in  an  open  trap  in  the  face  of  a  keen  east 
wind.  He  was  lightly  clad,  took  a  chill,  developed 
pneumonia,  and  in  spite  of  every  care  and  attention 
died  in  a  few  days.  Was  this  the  result  of  the  invasion 
of  his  system  by  a  microbe,  or  was  it  due  to  the  effects 
of  a  chill  ?  We  live  in  a  world  of  microbes.  The 
speaker  then  instanced  himself  as  having  been  a  resi- 
dent physician  in  a  hospital  for  phthisis  without  con- 
tracting the  complaint,  although  he  was  not  without  a 
hereditary  bias,  as  his  mother  had  died  from  that  com- 
plaint. Cause  and  effect  are  by  no  means  invariable. 
Can  phthisis  be  accounted  for  in  every  case  by  the  mi- 
crobe theory  ?  He  thought  not  ;  but  if  so  it  was  con- 
tagious and  our  consumptives  ought  to  be  labelled 
"dangerous."  Very  well,  but  do  not  forget  that 
theory  is  not  proof,  and  must  give  way  to  clinical  ex- 
perience ;  laboratary  knowledge  by  itself  must  be  looked 
upon  with  caution. 

Dr.  Foswell,  of  Birmingham,  considered  that  pneu- 
monia was  a  constitutional  disease  which  attacks  other 
parts  of  the  body  as  well  as  the  lungs,  and  sometimes 
the  inflammation  of  the  latter  organ  is  quite  a  minor 
part  of  the  complaint  ;  wherefrom  the  question  arose, 
should  it  always  receive  the  same  name  ?  In  fatal 
pleuro-pneumonia  there  was  always  suppuration,  but 
the  presence  or  absence  of  that  complication  depended 
on  the  tissues  involved.  It  is  advisable  to  take  the 
widest  view  of  every  case.  The  speaker  once  lost  a 
patient  who  had  enteritis  as  well  as  pneumonia  because 
he  took  cognizance  only  of  the  latter. 

Ice-packing  is  a  valuable  method  of  combating  the 
effects  of  pneumonia,  particularly  in  the  case  of  chil- 
dren ;  after  half  an  hour,  sleep  is  induced  and  pain  re- 
lieved, but  if  the  latter  has  not  disappeared  by  that 
time  then  a  blister,  or  preferably  a  couple  of  leeches, 
should  be  had  recourse  to.  Strychnine  is  valuable  in 
cases  with  cardiac  complications  and  should  be  admin- 
istered subcutaneously.  He  had  never  observed  any  bad 
effect  from  its  use. 

Dr.  Tyson,  of  Folkestone,  could  not  hope  to  say 
anything  new  about  pneumonia,  but  he  differed  on 
some  points  from  several  previous  speakers,  being  com- 
pelled so  to  do  by  his  own  clinical  experience.  The 
time  had  come,  he  thought,  when  the  word  pneumonia, 
as  significative  of  a  distinct  disease,  could  no  longer  be 
used  by  itself,  but  must  be  coupled  with  a  differentiat- 
ing adjective  ;  thus,  asthmatic  pneumonia,  inflamma- 
tory pneumonia,  alcoholic  pneumonia,  septic  pneu- 
monia, which  all  differed,  and  must  be  taken,  each  on 
its  merits.  Country  practitioners,  as  a  rule,  cannot 
undertake  the  study  of  bacteriology,  and  the  treatment 
useful  in  each  class  or  type  of  the  disease  is  not  the 
same,  so  that  the  laboratory  student  must  work  in  con- 
junction with  the  clinical  observer. 

Dr.  G.  W.  Balfour,  of  Edinburgh,  had  a  theory  of 
his  own.  No  disease  had  ever  been  so  diversely  treated 
as  pneumonia.  Blood-letting,  antimony,  phosphorus, 
alcohol,  etc.,  had  each  in  turn  been  lauded  as  a  pan- 
acea, and  it  was  just  the  same  to-day,  new  specifics 
for  the  cure  of  the  disease  were  being  announced  every 
week  in  the  medical  journals.  He  was  strongly  of  the 
opinion  that  treatment  has  little  or  no  effec't  on  the 
course  of  pneumonia,  in  which  there  is  a  tendency  to 
recovery,  and  tliat  the  part  of  the  physician  is  rather  to 
obviate  death  than  to  control  the  course  of  the  disease. 
Death,  when  it  occurs  during  the  progress  of  an  attack, 
is  always  due  to  cardiac  failure.  No  treatment  can 
nullify  exhaustion  or  prevent  disease,  but  we  must  not 
aggravate  either.  Two  grave  features  of  the  disease 
are  to  be  guarded  against,  rise  of  temperature  and 
consolidation  of  the  lung  tissue,  while  exudation  in  the 
pulmonary  centre  is  not  worse  than  it  is  anywhere  else, 
the  heart  takes  little  notice  of  the  apparent  obstacle.  A 


very  high  temperature  is  productive  of  exhaustion  and 
indicates  complications. 

The  more  powerful  antipyretics  each  possess  a 
danger  of  their  own,  but  digitalis  is  eminently  useful 
along  with  free  stimulation.  The  recumbent  position 
should  be  strictly  enforced,  and  the  digitalis  must  not 
be  pushed  too  far.  Too  much  trust  should  not  be  re- 
posed in  opium,  but  chloroform  is  possessed  of  valu- 
able remedial  power;  pain  is  vanquished,  cough  allayed, 
temperature  dropped  under  its  use,  but  it  must  be 
carefully  watched  and  its  administration  in  small  doses 
by  the  mouth,  in  some  convenient  emulsion,  is  prefer- 
able to  inhalation  ;  it  can  be  conveniently  replaced  by 
chloral,  which  is  at  once  an  antipyretic,  an  hypnotic, 
and  eminently  manageable. 

Dr.  Bau.mler,  of  Freiburg,  preferred  the  treatment 
of  pneumonia  by  the  cooling  method — cold-cradle,  ice- 
packing,  both  of  70°  F.,  all  of  which  assisted  nature  by 
causing  the  external  blood-vessels  to  contract  and  a 
flow  of  blood  to  pass  through  and  "  flush  "  the  internal 
organs  ;  but  a  patient  with  a  fatty  heart  requires  a  dif- 
ferent course  of  treatment.  The  kidneys,  especially, 
are  benefited,  for  the  cold  excites  their  action,  and 
without  it  the  urine  becomes  concentrated,  but  with 
the  cool  method  it  flows  freely  and  many  injurious  prod- 
ucts are  carried  out  of  the  system,  strength  is  saved, 
and  a  restless,  wakeful  brain  receives  rest  and  quiet. 
This  is  especially  noticeable  in  the  case  of  children. 
Where  there  have  been  convulsions,  these  disappear 
after  the  cold  bath,  owing  to  the  beneficial  effect  of 
the  latter  on  the  extremities  of  the  sensitive  nerves  in 
the  skin.  To  sum  up  the  matter,  the  general  effect  on 
the  whole  course  of  the  disease  is  great.  Treatment 
should  not  be  wholly  symptomatic,  as  could  be  easily 
proved,  but  the  speaker  had  not  had  time  to  prepare 
statistics.  He  had  used  antipyretic  medicaments,  but 
had  latterly  come  to  the  conclusion  that  cooling  meas- 
ures are  infinitely  preferable,  owing  to  their  direct  ac- 
tion on  the  circulation  and  the  various  organs.  So 
many  differing  causes  affect  the  progress  of  a  case  of 
pneumonia  that  it  is  not  always  possible  to  estimate 
the  issue,  and  much  depends  on  the  remnants  of  pre- 
vious disease  in  the  lung. 

Dr.  Clifford  Allbutt  agreed  with  Dr.  Pollock 
that  if  a  bacteriologist  said  that  a  certain  microbe  was 
the  cause  of  the  disease  he  should  be  put  down,  but  he 
doubted  that  anyone  had  ever  said  so.  He  thought 
the  disease  could  not  be  traced  to  chill  alone  or  to 
bacteria  alone.  Leucocytosis  was  a  marked  means  of 
differentiation  between  the  diff'erent  forms  of  pneu- 
monia. If  cold  water  depresses  the  enemies  more  than 
the  defenders  of  the  citadel  of  life,  well  and  good  ;  but 
to  the  speaker  it  seemed  to  cut  both  ways.  The  inha- 
lation of  oxygen  was  most  valuable.  He  had  seen  a  pa- 
tient kept  alive  by  it  for  six  weeks,  and  it  alone  had 
kept  off  cyanosis  and  death  as  long  as  it  was  possible 
for  anything  to  have  done  so.  Superinfection  was  due 
to  the  spreading  of  the  original  toxin,  and  in  such  cases 
the  ordinary  tincture  of  iron  was  of  great  benefit. 
Bleeding  produced  a  temporary  effect  in  acute  pneu- 
monia, but  only  a  temporary  one. 

Dr.  G.  a.  GiiisoN,  of  Edinburgh,  agreed  with  Dr. 
Clifford  Allbutt  as  to  leucocytosis  and  the  part  it  played 
during  the  progress  of  pneumonia,  and  thought  that 
Dr.  Pollock  misunderstood  the  question  of  bacteriol- 
ogy. How  was  it  that  the  clinician  never  found  out  by 
his  observations  at  the  beilside  that  cholera  was  propa- 
gated by  a  bacterium  that  lurks  in  water  ? 

Dr.  Sinclair  Coohill,  of  Ventnor,  thought  that 
croupous  pneumonia  was  the  gravest  type  of  the  dis- 
ease, and  preferred  laudanum  to  morphine  in  treating  it. 
Aconite  lowered  the  temperature,  and  sponging  with 
tepid  or  cold  water  was  also  beneficial,  especially  if  the 
former  was  mixed  with  a  large  proportion  of  eau-de- 
cologne. 

Dr.  Hawkins,  of  Reading,  considered  that  pneu- 
monia is  an  infectious   disease    that   deranged  many 


I 


August  24,  1895] 


MEDICAL    RECORD. 


physiological  functions,  of  which  one  result,  consolida- 
tion, might  persist  for  a  considerable  time.  Injury 
might  give  rise  to  pneumonia.  He  considered  strych- 
nine to  be  useful  in  the  treatment  of  the  disease. 

Dr.  Lees  thought  it  was  most  important  to  give  the 
patient  sleep  first  of  all,  but  by  means  that  would  not 
cause  subsequent  depression.  He  deprecated  venesec- 
tion, and  thought  with  regard  to  cooling  measures  that 
the  use  of  the  ice-bag  was  preferable  to  the  bath,  but 
reducing  the  temperature  of  the  patient  was  not  very 
important.  When  the  ice-bag  failed  to  give  relief  it  was 
owing  to  timidity  on  the  part  of  the  physician.  He  in- 
stanced as  a  parallel  case  the  all  but  instantaneous  re- 
lief in  acute  sciatica  from  the  use  of  the  ice-bag. 

The  microbic  origin  of  pneumonia  was  bar  to  the 
treatment  of  the  disease  by  the  ice-bag,  for  the  pneu- 
mococcus  had  been  shown  to  be  extremely  suscep- 
tible to  changes  of  environment.  In  the  case  of  chil- 
dren it  was  requisite  to  apply  bottles  of  hot  water  to 
the  feet  in  order  to  keep  up  the  temperature  of  the  ex- 
tremities and  of  the  abdomen  ;  but  if  there  was  the  least 
tendency  to  cyanosis  the  ice  should  be  at  once  discon- 
tinued. 

A  subnormal  temperature  was  not  opposed  to  the  ice- 
bag  treatment,  by  the  adoption  of  which,  the  speaker 
affirmed,  some  cases  under  his  care  were  much  bene- 
fited. 

Dr.  Pope,  of  Leicester,  was  of  the  opinion  that  the 
pneumonia  developed  during  the  course  of  an  attack  of 
typhoid  fever  was  distinctly  infectious,  and  recom- 
mended the  immediate  isolation  of  a  patient  showing 
symptoms  of  it  in  a  fever  ward,  otherwise  the  other  in- 
mates would  probably  all  become  affected.  He  had 
seen  much  benefit  result  from  the  admixture  of  spiritus 
astheris  nitrosi  with  the  usual  salines,  and  had  found  that 
sodium  nitrate  was  no  adequate  substitute  for  the  more 
volatile  preparations. 

Dr.  Shixgleton  Smith,  of  Clifton,  had  been  in- 
formed that  gigantic  doses  of  digitalis  had  been  fol- 
lowed by  the  most  beneficial  results  at  Bucharest,  and 
hoped  that  should  he  ever  contract  the  complaint  that 
Dr.  Powell  would  not  evince  any  timidity  in  prescrib- 
ing it. 

Dr.  Squire  objected  to  the  term  "croupous,"  being 
applied  to  the  pneumonia  of  children,  and  had  seen  as 
good  results  follow  the  ordinary  treatment  of  the  dis- 
ease as  were  said  to  come  from  the  use  of  the  ice-bag,  if 
not,  indeed,  better. 

Dr.  Douglas  Powell,  in  reply,  was  much  gratified 
by  the  discussion  that  had  taken  place  upon  his  paper, 
and  was  of  opinion  that  the  use  of  antitoxin  was  the 
line  that  must  ultimately  be  followed  in  the  treatment 
of  pneumonia.  Oxygen  was  undoubtedly  a  valuable 
cardiac  stimulant  in  grave  cases,  but  he  was  reluctant 
to  apply  blisters  to  a  child  ;  in  the  case  of  children 
slight  counter-irritation  was  preferable. 

Leucocytosis  was  one  of  Nature's  methods  for  getting 
rid  of  the  disease.  As  to  the  mode  of  treatment  in 
vogue  at  Bucharest,  where  such  excellent  results  were 
obtained  from  the  use  of  heroic  doses  of  digitalis,  he 
had  been  informed  by  Professor  Baiimler,  who  was 
sitting  beside  him  while  Dr.  Smith  spoke,  that  the  pa- 
tients were  all  strong,  vigorous  young  men,  soldiers,  in 
the  prime  of  life. 

He  did  not  attach  much  importance  to  the  use  of 
spirits  of  nitrous  ether  in  consequence  of  its  action  on 
the  skin,  but  it  certainly  was  of  benefit  in  promoting  the 
excretion  of  urine. 

Guaiacol  in  Tuberculosis. — Dr.  Sinclair  Coghill, 
of  Ventnor,  then  read  a  paper  on  "  The  Hypodermic 
Use  of  Guaiacol  in  Acute  Pulmonary  Tuberculosis." 
Guaiacol,  he  said,  was  obtained  by  distillation  from  creo- 
sote, and  was  administered  to  the  patient  by  inhalation. 
His  experience  with  the  drug  in  these  cases  was  most 
encouraging.  When  it  was  given  subcutaneously,  the 
buttock  was  the  most  favorable  region  for  the  injec- 
tion. 


Serotherapy  of  Tuberculosis. — Dr.  Maragliano,  of 
Genoa,  presented  a  paper,  which  was  read  by  the  Sec- 
retary, on  the  treatment  of  pulmonary  tuberculosis  by 
specific  serum. 

It  is  impossible  to  argue  from  an  effect  upon  one  ani- 
mal to  another.  When  the  tuberculin  has  been  inject- 
ed into  a  tuberculous  patient,  the  latter  experiences  a 
sensation  of  well-being  that  is  not  produced  by  any 
other  treatment  ;  by  degrees  the  characteristic  bacillus 
disappears  from  the  blood,  and  from  being  acute  the 
symptoms  become  slight,  but  there  is  no  instance  as 
yet  of  complete  recovery  from  the  disease.  Is  no  bene- 
fit derived  ?  Yes,  providing  the  treatment  is  prolonged 
sufficiently  ;  but  where  destructive  centres  exist  the  com- 
plaint will  break  out  again  and  again,  and  a  perfect 
cure  cannot  be  hoped  for.  Fever  has  an  unfortunate 
influence  on  the  result.  Haemoptysis  does  not  counter- 
indicate  the  employment  of  tuberculin,  and  any  part 
of  the  body  that  may  be  most  convenient  may  be  se- 
lected for  the  purpose  of  injecting  the  remedy,  as  no 
reaction  follows. 

Dr.  J.  E.  Squire  said  that  naturally  the  association 
of  the  disease  with  bacilli  had  given  rise  to  an  attempt 
to  destroy  the  latter  in  situ,  but  he  questioned  whether 
it  was  possible  to  do  so.  We  cannot  reach  the  microbes 
in  their  retreats,  and  if  we  could  we  could  not  introduce 
a  sufficient  quantity  of  the  antidote  without  endangering 
the  safety  of  their  host,  and  so  the  bacilli  will  be  only 
scotched,  not  killed.  Drugs  have  their  value  in  the 
treatment  of  phthisis  ;  they  prevent  secondary  infection 
by  destroying  the  bacilli  that  have  been  ejected  from 
the  system.  He  preferred  the  use  of  inhalations  to  the 
dosing  of  the  patient  by  the  mouth,  but  hygiene  was 
better  than  antiseptics,  while  good  food  and  good  fresh 
air  were  superior  to  every  other  remedial  agent  that  had 
been  or  could  be  devised.  The  strengthening  of  the 
tissues  might  be  lost  sight  of  in  a  vain  attempt  to  kill 
an  offending  bacillus.  If  inhalations  were  employed, 
they  must  be  used  freely,  as  half-measures  only  de- 
feated their  own  object. 


Third  Day,  Fridav,  August  2D. 

The  Causes  of  Acute  Rheumatism  and  its  Relation 
to  Other  Affections. — Dr.  W.  B.  Cheadle  said  that  he 
used  the  term  acute  rheumatism  in  a  strict  sense,  as 
implying  a  disease  in  which  were  manifested  pericardi- 
tis, endocarditis,  and  rheumatic  joints.  Endocarditis 
had  seldom  any  other  exciting  cause,  a  possible  excep- 
tion being  in  the  case  of  chorea,  which,  however,  was 
intimately  associated  with  a  history  of  rheumatism,  as 
were  also  its  pathological  associations,  so  that  where 
endocarditis  was  found  in  a  case  of  chorea,  the  latter 
was  rheumatic  in  its  origin.  Pericarditis  also  had  a 
rheumatic  origin  and  might  be  associated  with  endo- 
carditis in  the  same  subject,  but  might  occur  alone. 

Tonsillitis  was  a  disease  of  debility  often  associated 
with  the  rheumatic  diathesis  as  well  as  with  arthritis, 
and  the  erythemata  had  a  similar  connection,  so  had 
purpura.  The  erythema  might  occur  in  any  part  of 
the  rheumatic  series.  Fatal  chorea  resulted  from  ex- 
travasation of  blood,  and  in  cases  of  scarlet  fever  that 
ended  fatally  endocarditis  was  always  present,  showing 
the  close  relationship  of  this  disease  as  well  as  of  cho- 
rea to  acute  rheumatism. 

Chorea,  whether  alone  or  associated  with  endocardi- 
tis, might  be  followed  by  arthritis,  and  occurred  in 
families  in  which  rheumatism  was  ripe.  He  instanced 
the  case  of  a  patient  who  had  chorea  only,  like  her 
mother,  but  the  grandmother  had  suffered  from  rheu- 
matism. Statistics,  however,  were  imperfect  and  un- 
satisfactory, rheumatic  arthritis  in  children  being  often 
slight  and  evanescent. 

False  chorea,  affecting  the  face  but  not  the  limbs,  was 
more  common  in  boys  and  presented  a  good  deal  of 
analogy  with  stammering  ;  in  such  cases  there  were   no 


MEDICAL   RECORD. 


[August  24,  1895 


rheumatic  manifestations.  In  fifty  cases  of  chorea 
that  he  had  collected,  there  was  history  of  family  rheu- 
matism in  fifty-two  per  cent.,  and  including  erythema, 
sixty-five  per  cent.  Chorea  resembled  rheumatism  in 
its  liability  to  relapse  and  might  occur  in  any  part  of 
the  rheumatic  series,  and  in  the  majority  of  cases  there 
would  be  a  history  of  acute  rheumatism. 

In  rheumatism  complicating  scarlet  fever  there  might 
be  pericarditis  or  endocarditis,  or  both,  also  erythema 
nodosum,  articular  rheumatism,  pneumonia,  bronchitis, 
though  the  position  of  each  in  the  series  was  uncertain, 
and  such  was  the  Protean  character  of  rheumatism 
that  they  might  all  arise  separately  and  independently 
of  each  other.  In  a  case  of  bronchial  catarrh  where 
the  heart  was  affected  without  any  other  symptom  of 
rheumatism,  the  patient,  a  child,  developed  chorea  a 
few  months  afterward,  in  nine  months  more  acute  rheu- 
matism, and  in  a  year  both. 

The  rheumatism  of  childhood  differs  in  many  re- 
spects from  that  of  adult  life.  While  age  increased  the 
tendency  to  affections  of  the  joints,  it  had  a  contrary 
effect  upon  those  of  the  nervous  system.  Chorea  was 
an  affection  of  childhood  and  at  that  age  arthritis  was 
at  its  minimum,  but  with  the  progress  of  years  the  posi- 
tion was  reversed.  In  adults,  arthritis  was  the  most 
ordinary  complication,  but  in  childhood  the  tendency 
to  it  was  only  slight. 

Diversity  of  opinion  prevails  as  to  the  etiology  of  the 
disease.  Was  there  a  morbid  agent  ?  What  was  the  effect 
of  surroundings,  of  age,  of  sex,  of  constitutional  pro- 
clivity ?  An  external  factor  was  chill,  which  was  often 
invoked  without  reason  but  must  in  rheumatism  be 
allowed.  A  boy  fell  into  a  stream,  but  stood  about  in 
his  wet  clothes,  for  fear  of  incurring  reproof  or  punish- 
ment, until  they  became  dried  upon  him,  and  this  im- 
prudence on  his  part  was  quickly  followed  by  an  attack 
of  acute  rheumatism,  so  that  the  relation  of  cause  and 
effect  admits  here  of  little  doubt. 

Acute  rheumatism  is  a  disease  of  temperate  climates, 
in  which  chill  is  a  common  but  not  an  invariable  factor  ; 
seasonal  influences  are  important,  the  disease  prevail- 
ing more  in  winter  and  spring  than  in  summer  and  au- 
tumn. Acute  rheumatism,  however,  often  occurs  in 
dry  seasons  when  the  ground  is  hot,  but  this  is  by  no 
means  incompatible  with  the  theory  of  causation  by 
chill,  for  prolonged  bodily  exertion  in  hot  weather  not 
only  weakens  the  system,  but  is  not  infrequently  fol- 
lowed by  a  rapid  lowering  of  the  body  temperature — in 
a  word,  chill — and  where  there  exists  a  constitutional 
tendency  the  disease  is  very  apt,  under  such  circum- 
stances, to  develop  itself. 

Parents  of  the  better  class  know  all  about  their  chil- 
dren and  their  ailments,  but  there  is  usually  a  defective 
history  in  the  great  majority  of  the  cases  brought  to 
our  notice.  Where  there  is  a  double  inheritance,  that 
is,  where  there  is  a  rheumatic  tendency  in  both  par- 
ents, we  find  the  most  striking  instances  of  acute 
rheumatism.  A  girl  of  nine  had  a  severe  attack  of 
chorea  with  endocarditis  and  pericarditis,  and  subcu- 
taneous nodules,  and  she  ultimately  died  from  cardiac 
dilatation.  Her  family  history  was  charged  with  rheu- 
matism on  both  sides. 

The  most  potent  influences  are  chill,  bodily  fatigue, 
a  dry  season,  and  constitutional  proclivity.  Is  the  ma- 
teries  morbi  a  simple  chemical  product,  or  a  micro-or- 
ganism, or  an  irritation  of  nerve  extremities  by  chill  ? 
M"e  have  no  proof  that  endocarditis  and  pericarditis 
are  due  to  any  other  factors. 

Gout  and  rheumatic  arthritis  have  no  relationship  to 
each  other,  and  when  pericarditis  supervenes  in  the 
course  of  the  former  disease  it  is  referable  to  Bright's 
disease  and  not  to  rheumatic  toxemia. 

Lactic  acid  and  uric  acid  have  been  suggested  as  the 
toxic  agents  in  acute  rheumatism,  but  the  theorv  is  one 
that  is  difficult  of  acceptance,  for  we  have  no  evidence 
of  the  presence  of  either.  Clinical  observation  is  op- 
posed to  the  idea  of  any  relationship  between  gout  and 


acute  rheumatism  ;  the  diseases  occur  in  different 
classes  of  patients. 

The  theory  of  microbic  origin  has  analogy  in  its 
favor,  but  on  the  other  hand  acute  rheumatism  is  not 
communicable  from  one  person  to  another,  nor  is  it  ma- 
larial in  its  origin,  but  is  directly  excited  by  a  sudden 
chill  ;  one  attack  leads  on  to  another,  as  in  the  case  of 
influenza.  True,  family  proclivity  does  not  directly 
militate  against  the  microbic  theorj-  of  the  origin  of 
acute  rheumatism.  Cases  of  the  transmission  of  the 
disease  are  rare  and  by  no  means  indisputable.  No 
organism  peculiar  to  the  complaint  has  been  identified, 
nor  does  the  disease  spread  by  inoculation,  so  that  on 
the  whole  we  are  bound  to  maintain  an  open  mind  and 
admit  that  the  direct  cause  of  acute  rheumatism  has 
not  yet  been  detennined. 

Sir  Dyce  Dlckworth  had  been  much  impressed 
by  the  ability  and  lucidity  of  the  paper,  to  which  he  had 
listened  with  as  much  profit  as  pleasure,  and  he  was 
guilty  of  no  exaggeration  when  he  termed  it  a  master- 
piece. The  subject  of  rheumatism  was  one  that  had 
much  interest  for  him,  but  it  was  not  a  simple  subject. 
On  the  contrary,  he  might  say  that  there  were  many 
rheumatisms.  It  was  not  merely  a  disease  of  the  joints. 
There  must  be  predisposition  to  the  disease  which 
must  have  a  basis.  Low  vitality,  exhaustion,  chill, 
shock,  and  predisposition  made  an  individual  the  prey 
of  an  organism  that  had  a  power  of  generating  toxin. 
True,  no  organism  had  yet  been  identified,  but  its  ex- 
istence was  clearly  indicated  by  analogy,  and  a  low- 
temperature  favored  the  bacillary  invasion  :  there  was 
a  tendency  to  relapse,  new  germs  recurring  when  di- 
eted with  favored  pabula.  The  infective  theory  certainly 
failed  to  explain  all  the  phenomena.  The  theory  of 
nervous  causation  and  a  hereditary  diathesis  undoubt- 
edly assisted  the  work  of  the  infecting  agent ;  many  per- 
sons present  no  such  soil  and  never  develop  rheumatism, 
as  some  never  contract  tuberculosis,  so  that,  on  the 
whole,  we  must  come  round  to  the  infective  theorj'. 

Dr.  Archibald  Garrad  thought  that  rheumatic 
fever  was  a  systemic  disease,  and  not  merely  a  local 
one  confined  to  the  joints.  A  momentary  chill  could 
not  cause  such  an  accumulation  of  lactic  acid  as  to 
produce  the  disease,  although  it  had  been  said  by  Sir 
W.  Foster  that  a  diabetic  patient  had  developed  acute 
rheumatism  after  taking  large  doses  of  lactic  acid. 
The  local  manifestations  of  the  disease  are  such  as 
might  be  expected  to  occur  from  the  invasion  of  a  mi- 
cro-organism, but  the  erythemata  of  acute  rheumatism 
were  not  infective  in  the  ordinary  sense  of  the  term. 
The  disease  had  more  analogy  with  those  of  undoubted 
malarial  origin  ;  but  in  that  case  how  did  chorea  fit 
in  ?  It  bore  the  same  relation  to  rheumatism  that  pa- 
ralysis did  to  diphtheria.  The  specific  poisoning  might 
precede  motor  disturbance  without  other  changes  ; 
there  were  no  morbid  alterations  in  chorea,  and  in 
acute  rheumatism  the  temperature  presented  no  defi- 
nite curve,  although  when  it  affected  certain  serous 
membranes  there  was  more  disturbance,  though  endo- 
carditis frequently  produced  no  rise  in  the  tempera- 
ture. 

Dr.  Mantle  thought  the  etiology  of  acute  rheuma- 
tism was  decidedly  bacterial,  and  this  view  was  acquired 
from  observations  at  the  bedside  in  localities  which 
were  devoid  of  sanitation,  and  there  rheumatism  was 
endemic,  as  well  as  scarlet  fever  and  tonsillitis.  He 
had  seen  five  cases  of  scarlet  fever  in  young  people, 
and  only  for  the  rash  would  have  put  them  down  as 
acute  rheumatism.  Rheumatism  occurred  in  two-thirds 
of  all  scarlatinal  cases  as  part  of  the  disease,  and  not  as 
sequelre.  Endocarditis  was  common  in  scarlatina,  but 
sweating  was  not.  He  had  seen  two  cases  of  rheumatism 
and  two  of  scarlet  fever  in  the  same  house  at  the  same 
time,  which  proved,  he  thought,  the  concurrence  of  the 
two,  so-called,  diseases.  Erythema  nodosum  was 
seldom  accompanied  by  rheumatic  fever,  and  he  rather 
looked    upon   it   as   the   manifestation    of    a   distinct 


I 


August  24,  1895] 


MEDICAL   RECORD. 


disease  ;  it  was  occasionally  associated  with  scarlet 
fever. 

Tonsillitis  and  acute  rheumatism  had  a  subtle  con- 
nection, and  followed  as  well  as  preceded  an  epidemic 
of  scarlet  fever.  Rheumatism  was  rarely  infective,  but 
sometimes  it  appeared  to  be  transmitted  from  one  per- 
son to  another. 

He  had  searched  for  a  micro-organism  in  the  serum, 
and  always  found  a  coccus  in  it  as  well  as  in  the  blood, 
and  in  all  probability  this  was  the  cause  of  the  disease  ; 
the  toxin  might  be  lactic  acid  produced  by  the  action 
of  the  micro-organism  in  the  system. 

Dr.  Newsholme  objected  to  the  term  acute  rheu- 
matism being  applied  to  rheumatic  fever,  for  chronic 
rheumatism  is  not  entitled  to  be  called  a  distinct  dis- 
ease. Some  years  rheumatism  is  more  prevalent  than 
in  others,  and  the  epidemics  occur  at  more  or  less 
regular  intervals.  In  Norway,  all  cases  of  rheumatic 
fever  are  compulsorily  notified.  There  is,  however,  no 
evidence  to  show  that  one  person  has  ever  been  directly 
infected  by  another.  It  was  thought  that  the  greater 
or  lesser  abundance  of  the  rainfall  had  an  influence  on 
these  epidemics  of  acute  fever,  but  they  had  occurred 
when  the  fall  of  rain  was  deficient.  A  dry  subsoil  and 
a  high  temperature  favored  the  development  of  rheu- 
matic fever. 

Sir  T.  Grainger  Stewart  must  suspend  his  judg- 
ment for  the  present  with  regard  to  the  presence  of  a 
micro-organism  in  rheumatic  fever,  but  admitted  that 
the  trend  of  opinion  was  in  that  direction.  Various 
affections  were  included  in  the  term  rheumatic  fever, 
and  a  differentiation  of  the  different  forms  of  the  dis- 
ease had  become  a  necessity  for  the  elaboration  of  a 
satisfactory  plan  of  treatment.  Rheumatism  begins  by 
being  a  local  disease,  and  remains  so  for  days  before  it 
infects  the  system  generally.  It  originates  in  exposure 
to  cold,  the  patient  takes  no  notice,  and  after  awhile 
other  tissues  than  the  one  first  affected  are  attacked  ; 
but  if  the  local  manifestation  is  taken  in  hand  and 
proper  remedies  and  precautions  taken,  the  patient  es- 
capes ;  therefore,  take  warning  by  the  first  twinge  and 
you  will  be  rewarded. 

Dr.  Haxdford  referred  to  the  relation  of  endocar- 
ditis to  rheumatism  in  children.  He  would  not  accept 
the  theory  of  the  bacillary  origin  of  the  disease.  He 
had  seen  endocarditis  v^-here  there  was  no  affection  of 
the  joints,  but  the  endocarditis  may  progress  for  weeks 
after  all  outward  manifestations  of  the  disease  have 
subsided  ;  which,  he  thought,  was  not  reconcilable 
with  the  theory  of  bacillary  origin. 

Dr.  Haig  was  an  absolute  radical  in  the  matter  of 
the  etiology  of  rheumatic  fever,  and  must  plead  the 
excuse  of  audi  alteravi  partem  in  order  to  obtain  a 
hearing.  Rheumatism,  in  his  opinion,  was  due  to  the 
introduction  and  retention  of  uric  acid  which  was  not 
formed  in  the  body.  Test  the  urine  to  discover  uric 
acid,  not  the  blood  or  the  tissues,  and  form  a  right  con- 
clusion. Because  no  uric  acid  was  found  in  the  blood 
was  not  to  be  taken  as  a  disproof  of  his  theory  ;  for  if 
there  was  none,  the  reason  was  that  it  was  all  gathered 
into  the  joints  and  could  not  be  in  two  places  at  once. 
The  disease  is  due  to  this  accumulation  of  uric  acid  in 
the  joints  ;  if  it  was  in  the  blood  there  would  be  no 
rheumatism.  In  some  cases  salicylic  acid  has  no  elfect, 
but  that  is  because  the  blood  is  alkaline  and  has  no  re- 
lation to  rheumatic  fever. 

Diet  and  drugs  act  on  the  rheumatic  diathesis,  for 
meat  does  harm  by  introducing  uric  acid  and  its  salts 
into  the  body  ;  cold  and  moisture  favor  its  excretion 
from  the  blood  and  its  deposition  in  the  joints.  Iron  is 
objectionable,  for  the  urate  of  iron  is  insoluble. 

Dr.  Stephen  MacKexzie  agreed  with  Dr.  Cheadle 
that  in  the  adult  arthritis  is  the  chief  symptom  of  acute 
rheumatism,  which,  however,  is  not  merely  arthritis  but 
a  disseminated  disease.  The  name  rheumatic  fever  is 
not  satisfactory,  for  sometimes  no  fever  is  to  be  dem- 
onstrated.    The  general  tendency  of  the  disease  is  in 


favor  of  microbic  origin,  but  in  the  present  state  of  our 
knowledge  one  must  not  commit  oneself  to  it,  although 
the  absence  of  an  organism  is  not  a  proof  that  the 
theory  is  not  correct.  Rheumatism  may  begin  locally. 
Dr.  Haig  certainly  had  the  courage  of  his  opinion  and 
a  feeling  of  pity  for  all  who  did  not  agree  with  his 
view,  which  however  carried  no  conviction  to  the 
speaker,  for  it  is  unsupported  by  facts.  Its  propounder 
appears  to  confound  gout  with  rheumatism,  if  both  are 
due  to  uric  acid  retained  in  the  system.  He  remarked 
that  some  diseases  did  not  frequently  concur  in  the 
same  subject.  If  a  young  person  has  rheumatism,  a 
subsequent  attack  will  be  rheumatic  also  and  not  gout, 
and  vice  versa.  If  the  supposed  relationship  really  ex- 
isted, then  salicylic  acid  should  have  some  effect  in 
gout,  but  it  had  no  influence  at  all  upon  that  disease. 

Chorea  was  certainly  rheumatic  in  its  nature, 
whether  occurring  before,  after,  or  during  the  progress 
of  the  other  phenomena  of  the  disease.  The  embolic 
theory  of  its  origin,  which  at  one  time  had  a  strong  head 
on  the  profession,  was  now  never  heard  of  ;  chorea  is  a 
form  of  rheumatism,  as  well  as  polyarthritis  acuta,  endo- 
carditis, pericarditis,  and  tonsillitis.  Salicylic  acid  has 
no  effect  on  chorea,  erythema  nodosum,  or  purpura,  but 
the  difference  between  the  tissues  affected  accounts 
for  this.  In  conclusion  he  offered  the.  most  hearty 
thanks  for  his  paper  to  Dr.  Cheadle,  who  had  left 
nothing  for  anyone  else  to  say  upon  the  subject. 

Dr.  Lees  differed  with  Dr.  Cheadle  only  in  one 
point :  erythema  nodosum  had  no  connection  what- 
ever with  rheumatism,  but  was  as  distinct  as  scarlet 
fever  or  measles,  coming  and  going  in  the  same  person 
again  and  again,  and  never  causing  a  cardiac  murmur. 
No  person  w-ith  acute  rheumatism  ever  develops  ery- 
thema nodosum  ;  other  erythemata  ?  yes,  but  nodo- 
sum never,  or  but  occasionally,  and  at  long  intervals 
between  the  two  aft'ections. 

Chorea  is  essentially  rheumatic,  is  a  rheumatic  con- 
dition, and  fright  is  much  exaggerated  as  a  determin- 
ing cause  ;  a  rheumatic  child  is  as  liable  to  be  fright- 
ened as  any  other,  but  no  harm  results  if  there  is  no 
rheumatic  history. 

Chorea  is  the  first  indication  of  rheumatism,  and  the 
patient  will  be  found,  subsequently,  to  develop  the 
remaining  symptoms  of  the  disease. 

In  chorea  the  knee-jerk  is  normal,  or  exaggerated,  or 
absent ;  no  neurotic  theory  can  explain  this.  There 
is,  however,  evidence  of  a  blood-poison  acting  on  the 
spinal  cord  or  the  peripheral  nerves.  Occasionally 
there  is  a  rapid  dilatation  of  the  heart  in  rheumatic 
children,  which  is  due  to  inflammation.  If  there  is  an 
acid  poison  in  the  blood,  it  may  act  as  lactic  acid 
would,  or  if  not,  as  a  direct  toxin. 

The  rheumatic  state  is  produced  by  a  blood-poison, 
which  may  be  eliminated  in  the  tissues  by  a  micro- 
organism. He  had  examined  the  brain  and  cord  in  a 
case  that  had  a  fatal  termination,  but  the  evidence  was 
entirely  of  a  negative  character.  Rheumatism  is  often 
associated  with  tonsillitis  ;  diphtheria  is  due  to  a  mi- 
crobe poisoning  the  system  by  toxin  which  it  elaborates, 
and  the  rheumatic  microbe  may  similarly  poison  the 
fauces  and  give  rise  to  the  tonsillary  affection. 

In  some  cases  of  tetanus  the  local  lesion  is  slight, 
and  yet  the  system  is  affected  by  toxin  originating  from 
a  restricted  focus. 

Dr.  Longhurst  had  had  no  intention  of  taking  part 
in  the  discussion,  but  thought  there  was  too  great  a 
tendency  to  localize  the  disease,  of  which  he  believed 
it  quite  possible  that  the  origin  might  be  bacterial,  but 
so  far,  he  was  sorry  to  say,  none  of  the  speakers  had 
been  able  to  convert  him  to  their  view.  He  believed 
the  disease  to  be  of  constitutional  origin,  and  occur- 
ring in  families  prone  to  rheumatism.  Climate  has  a 
direct  influence,  for  we  do  not  find  the  disease  making 
Its  appearance  in  hot  and  dry  countries,  unless  in  sub- 
jects who  had  a  constitutional  tendency  to  it — for  ex- 
ample, in  India,  during  the  hot  weather  ;  but  when  the 


284 


MEDICAL    RECORD. 


[August  24,  1895 


rainy  season  set  in,  the  change  of  condition  of  the  at- 
mosphere developed  it.  In  the  mountains  it  was  com- 
mon enough.  That  it  was  due  to  something  in  the  soil 
set  free  by  the  rain  is  probable  ;  that  this  something  is 
a  microbe  is  possible  ;  but  statistics  are  misleading,  for 
they  do  not  take  the  state  of  the  atmosphere  into  con- 
sideration. AVhat  is  really  wanted  is  accurate  meteor- 
ological observation  of  the  disease. 

Dr.  Cheadle  then  replied  and  thanked  all  for  their 
kind  appreciation  ;  he  imagined  he  had  been  telling 
them  an  old  story,  and  was  grateful  for  the  gentle  crit- 
icism. Salicylic  acid  affects  the  temperature  as  it  af- 
fects the  joints  in  acute  rheumatism,  rather  than  neu- 
tralizes the  poison.  The  occurrence,  simultaneously, 
of  scarlet  fever  and  acute  rheumatism  in  the  same 
house  was  certainly  very  suggestive,  but  he  had  noth- 
ing more  to  say  upon  that  point.  The  terms  acute 
rheumatism  and  rheumatic  fever  were,  he  agreed,  both 
open  to  objection,  but  what  was  there  as  an  alterna- 
tive .''  The  remarkably  slow  progress  of  the  epidemic  in 
Norway  remained  unexplained.  The  cases  that  de- 
rived no  benefit  from  salicylic  acid  were  not  ordinary 
rheumatic  cases.  That  endocarditis  should  go  on  de- 
veloping when  other  symptoms  had  disappeared  did 
not  disprove  the  microbic  theory  of  the  origin  of  rheu- 
matic fever.  •  He  was  quite  incapable  of  dealing  with 
the  chemical  points  advanced  by  Dr.  Haig,  but  was  of 
the  opinion  that  erythema  nodosum  is  distinctly  of 
rheumatic  origin. 

Aortic  Valvular  Disease.— Dr.  Alexander  Morison 
read  a  short  paper  on  "  The  Treatment  of  Aortic  Val- 
vular Disease,"  and  laid  considerable  emphasis  on  the 
employment  of  digitalis  as  a  remedial  agent.  Several 
members  joined  briefly  in  the  discussion,  all  agreeing 
that  digitalis  still  holds  the  field. 

Rest  in  the  Treatment  of  Rheumatic  Endocarditis. — 
Dr.  R.  Caton  then  read  a  paper  on  the  arrest  of  en- 
docarditis in  acute  rheumatism  by  the  use  of  com- 
plete rest  in  bed,  in  the  recumbent  position  (which  was 
never  altered  even  for  the  purpose  of  evacuating  the 
bowels),  and  by  a  succession  of  small  blisters  over  the 
intercostal  nerves.  In  support  of  his  contention  he 
produced  statistics  of  cases  treated  by  him,  in  which 
the  affection  was  arrested  and  in  a  number  of  them 
had  entirely  disappeared. 

Dr.  Stephen  Mackenzie  thought  that  such  a  re- 
rnark^ble  paper  should  not  be  allowed  to  pass  unno- 
ticed, and  would  certainly  give  the  plan  a  trial  at  the 
first  favorable  opportunity. 

Rheumatism  and  Gout.— Dr.  E.  S.  Reynolds  read 
a  paper  on  the  diagnosis  between  chronic  rheumatism 
and  chronic  gout,  in  which  he  said  that  the  deformities 
of  the  hand  due  to  the  former  disease  were  symmetri- 
cal, and  those  to  the  latter  asymmetrical,  an  opinion 
that  was  unchallenged. 

Arsenical  Multiple  Neuritis.— Dr.  Alfred  Parsons 
reported  a  case  of  arsenical  multiple  neuritis  following 
the  application  of  a  cancer  cure,  illustrated  his  remarks 
by  e.xcellent  photographs  of  the  unhappy  victim  of  an 
amateur  quack,  and  was  confirmed  in  his  diagnosis  by 
another  associate  who  related  the  particulars  of  a  very 
similar  case. 


Excision  of  the  Breast.— In  my  own  practice  I  rarely 
ever  apply  any  ligature  whatever  in  excision  of  the 
breast  ;  four  or  five  deep  sutures  are  passed  entirely  un- 
der the  wound  cavity,  and,  before  closing  these,  the 
edges  are  brought  accurately  together  by  a  fine  continu- 
ous suture,  no  drainage-tube  being  used  ;  tlie  deep  sut- 
ures are  now  firmly  closed  over  lead  i)lates  and,  usually, 
bleeding  is  absolutely  stopped  ;  if  hemorrhage  still  con- 
tinues from  any  point,  an  additional  dee[)  suture  will 
usually  make  the  wound  absolutely  dry.  The  result  is 
that  there  is  practically  no  bloody  serum  discharged 
from  the  wound,  and  the  original  dressings  can  be  left 
undisturbed  for  many  days. — Ball. 


NEW    YORK   ACADEMY   OF    MEDICINE. 

SECTION   ON  GENERAL   SURGERY. 

Stated  Meeting,  May  ij,  iSgj. 

R.  Farquhar  Curtis,  M.D.,  Chairman. 

Thyroidectomy  for  Exophthalmic   Goitre. — Dr.  A.  J. 

McCosH  presented  a  girl,  twenty  years  of  age,  who  had 
been  healthy  until  three  years  ago,  when  symptoms  be- 
gan to  develop  leading  up  to  a  well-marked  case  of  ex- 
ophthalmic goitre.  \Yhen  he  first  saw  her,  three 
months  ago,  the  exophthalmia  was  well  marked,  the 
thyroid  was  large,  the  right  half  being  the  larger,  the 
voice  was  hoarse  and  husky,  the  heart-beat  was  150. 
She  suffered  from  palpitation  and  nervousness,  and  had 
become  very  weak  and  anaemic.  In  the  medical  wards 
she  was  treated  two  months  by  galvanism,  arsenic,  and 
thyroid  extract,  but  with  no  benefit  further  than  what 
came  from  rest.  She  was  then  transferred  to  the  sur- 
gical ward,  where  Dr.  McCosh  removed  the  right  half 
of  the  thyroid  gland.  The  operation  was  exceedingly 
bloody,  ligatures  alone  not  being  sufficient  to  control 
hemorrhage,  so  that  gauze  pressure  had  to  be  employed. 
For  two  weeks  after  the  operation  the  pulse  was  very 
rapid,  a  part  of  the  time  200,  but  the  protrusion  of  the 
eyes  diminished  noticeably  within  twelve  hours,  and  at 
present  there  was  little  exophthalmia.  The  left  half 
of  the  thyroid  which  was  not  removed  had  decreased 
to  half  its  former  size  ;  the  pulse  now  averaged  about 
115  or  less.  She  had  gained  much  in  weight,  and  was 
continuing  to  improve.  After  the  operation  the  num- 
ber of  red  blood-corpuscles  was  fifty  per  cent,  less  than 
before,  being  the  greatest  diminution  which  he  had 
ever  observed  after  a  bloody  operation. 

Dr.  McCosh  said  some  authors  claimed  that  thyroid- 
ectomy was  not  more  dangerous  for  exophthalmic  goi- 
tre than  for  simple  goitre,  but  this  was  not  his  opinion. 
He  believed  that  twenty  per  cent,  of  the  former  class  of 
cases  died  after  operation.  Not  all  of  the  deaths  were 
due  to  shock  or  sepsis,  but  to  a  condition  attended  by 
symptoms  pointing  to  thyroid  poisoning,  which  had  re- 
sulted from  the  manipulations  of  the  surgeon  and  open- 
ing up  of  vessels.  The  symptoms  were  like  those  pro- 
duced by  over-doses  of  thyroid  extract  given  for 
myxoedema — cardiac  and  respiratory  oppression,  great 
prostration,  sometimes  high  temperature,  perhaps  end- 
ing in  sudden  death.  Of  cases  which  survived  thy- 
roidectomy, about  seventy-five  per  cent,  were  cured,  of 
the  remaining  twenty-five  per  cent,  about  half  were 
slightly  benefited,  the  others  not  at  all. 

The  Chairman,  Dr.  Curtis,  said  he  had  performed 
thyroidectomy  in  three  cases,  and  one  patient  had  died, 
the  death  having  been  due,  it  was  thought  by  Dr.  Starr 
and  himself,  to  absorption  of  thyroid  material.  The 
patient  had  high  temperature,  became  comatose  ;  in 
the  intervals  of  coma  there  was  nervous  excitement ; 
the  urine  contained  albumin  ;  death  at  the  end  of  forty- 
eight  hours.  The  wound  was  absolutely  aseptic,  and 
there  had  been  no  infiammatory  reaction  to  account 
for  the  rise  of  temperature.  In  the  other  two  cases 
there  was  also  albumin  in  the  urine  and  rise  of  temper- 
ature after  the  o]ieration,  but  the  patients  recovered. 

Suture  of  Fractured  Patella. — Dr.  B.  B.  Callauhet 
presented  a  m;m  in  illustration  of  the  treatment  of  fract- 
ure of  the  patella  by  open  incision  and  suture,  a  method 
which  he  liked  as  well  as  any  and  had  practised  in  four 
cases.  As  there  was  large  swelling  of  the  knee  when 
the  patient  was  first  brought  to  the  hospital,  he  decided 
to  wait  a  week,  meanwhile  applying  pressure  to  assist 
absorption.  He  then  made  a  transverse  incision  over 
the  patella,  drilled  two  holes  in  the  upper  and  lower 
pieces,  which  were  of  eijual  size,  and  united  them  by 
two  silver-wire  sutures,  closed  the  wound  absolutely, 
without  drainage,  and  put  on  a  ])laster  splint.  The 
plaster  was  removed  on  the  eighteenth  day  ;  primary 
union  was  found  complete.     The  plaster  splint  was  re- 


i( 


August  24,  1895] 


MEDICAL    RECORD. 


285 


applied  and  kept  on  until  the  twenty-sixth  day,  when 
massage  was  begun,  followed  by  firm  cotton  bandage. 
The  patient  was  discharged,  practically  cured,  two 
weeks  later. 

Dr.  Gallaudet  had  been  satisfied  with  this  method 
of  treatment,  although  he  was  aware  that  some  pre- 
ferred silk  suture,  some  without  drilling  holes,  some  a 
longitudinal  incision,  some  conservative  methods  with- 
out opening  the  knee. 

Dr.  Lilienthal  said  conservative  treatment  was 
not  necessarily  slow  in  bringing  about  a  perfect  func- 
tional result.  He  had  recently  shown  a  patient  at  the 
Surgical  Society,  in  which  under  massage  treatment  the 
patient  was  able  to  be  out  of  bed  by  the  tenth  day,  and 
was  discharged  cured  by  the  fortieth  day.  The  func- 
tional result  was  perfect,  and  but  for  a  slight  transverse 
ridge  in  the  line  of  union,  one  could  not  tell  there  had 
been  a  fracture. 

Dr.  Dawbarn  thought  there  was  no  difference  of 
opinion  among  surgeons  that  the  method  of  treat- 
ing fracture  of  the  patella  described  by  Dr.  Gallaudet 
was  ideal  for  one  who  could  assure  perfect  asepsis,  but 
this  could  not  be  expected  of  general  practitioners,  and 
for  them  a  conservative  method  was  to  be  recom- 
mended, especially  inasmuch  as  it  was  likely  to  give 
close  fibrous  union  and  good  functional  result.  Should 
it  fail,  and  the  patient  at  the  end  of  a  few  months 
should  be  unable  to  advance  one  foot  before  the  other 
in  going  upstairs,  it  would  still  be  time  to  unite  the 
fractured  bone  by  incision  and  suture. 

Nephrotomy  for  Stone. — Dr.  H.  Lilienthal  pre- 
sented a  man  on  whom  he  had  performed  nephrotomy 
for  stone.  Eight  years  ago  he  had  had  stricture  of  the 
urethra  in  the  perineal  portion,  which  had  been  oper- 
ated upon  by  perineal  section.  Two  years  and  a  half 
ago  he  had  been  operated  upon  for  abscess  of  the  kid- 
ney, probably  pyonephrosis,  but  as  the  abscess  was 
very  large  and  had  perforated  the  diaphragm,  two  ribs 
were  resected  and  drainage  established  in  that  way. 
He  remained  well  two  years  and  a  half,  then  on  Feb- 
ruary 1 2th  of  the  present  year  entered  the  hospital 
with  high  fever,  chills,  great  emaciation,  pus  in  the 
urine,  pain  in  the  left  side  running  downward  and  for- 
ward. No  tumor  or  swelling  could  be  felt.  An  ex- 
ploratory incision  was  made  over  the  left  kidney,  very 
firm  adhesions  due  to  the  former  abscess  were  found. 
No  hard  body  could  be  felt  in  the  kidney  either  by  pal- 
pation or  with  the  needle,  no  pus  was  found  ;  an  inci- 
sion was  made  down  to  the  pelvis  of  the  organ,  but 
still  nothing  could  be  felt.  The  patient  was  returned 
to  bed,  the  high  fever  and  pains  continued,  and  he  was 
expected  to  die  ;  but  three  days  after  the  first  operation 
it  was  decided  to  explore  the  organ  again  without  giv- 
ing anesthesia,  thus  having  the  patient's  sensation  to 
guide  the  exploring  finger  to  the  exact  seat  of  pain. 
Nothing  could  be  felt  even  then,  but  on  introducing 
the  needle  he  fancied  it  produced  a  little  friction,  and 
cutting  down  on  this  spot  a  small  stone  was  found  and 
removed.  The  patient  then  went  on  to  recovery. 
Had  he  been  deprived  of  the  patient's  guidance 
through  his  sense  of  pain  to  the  exact  location  of  the 
stone,  as  he  must  have  been  had  he  given  an  anius- 
thetic,  the  stone  would  not  have  been  found  and  the 
patient  would  have  died. 

Resection  of  the  Buccal  Nerve  for  Neuralgia. — Dr. 
E.  Eliot,  Jr.,  presented  a  man  on  whom  he  had  re- 
sected about  an  inch  of  the  buccal  branch  of  the  fifth 
pair  on  the  left  side  of  the  face  for  the  relief  of  periodic 
pain  of  seven  years'  duration,  located  in  the  face  just 
over  the  bicuspid  teeth.  Zukerkendel's  operation  was 
performed  with  slight  modification.  The  parts  sup- 
plied by  this  branch  remained  absolutely  anaesthetic  a 
few  days.  Sensation  was  now  returning,  but  there  had 
been  no  pain.  It  was  not  improbable,  however,  that 
this  would  recur  in  the  course  of  time. 

Repair  After  Bone-flap  Operation  on  the  Skull. — Dr. 
George  Wuolsey  read  a  brief  paper,  describing  a  case 


in  which  a  bone- flap  was  removed  from  the  skull  for 
the  relief  of  convulsive  and  mental  symptoms.  The 
boy  had  had  convulsions,  and  when  he  regained  con- 
sciousness there  was  paralysis  of  the  right  side.  A 
year  later  he  could  walk  well,  but  had  little  use  of  the 
right  hand,  and  began  to  have  epileptic  seizures  which 
increased  the  next  five  years.  He  showed  more  re- 
ligious feeling  than  intelligence.  The  epileptiform 
seizures  were  sometimes  limited  to  the  left  side,  some- 
times were  general.  A  horseshoe  incision  was  made 
over  the  motor  region  on  the  left  side,  exposing  the 
dura,  about  two  inches  and  a  quarter  in  diameter.  The 
skull  in  this  region  was  an  inch  thick.  The  mem- 
branes were  not  adherent.  The  aspirating  needle  was 
introduced  and  brought  out  fluid  which  seemed  to  be 
cerebro-spinal,  from  the  lateral  ventricle  rather  than 
from  an  independent  cyst.  Dr.  Woolsey  then  closed 
the  wound,  suturing  the  dura,  the  pericranium,  and 
scalp  in  three  different  layers.  The  boy  lived  a  year 
and  eight  months,  and  was  improved  a  part  of  the 
time,  but  gradually  grew  worse  and  died.  Dr.  Fisher, 
who  had  referred  the  case  to  him,  viewed  the  autopsy 
and  stated  that  it  was  a  case  of  parencephaly,  the  skull 
in  the  motor  region  being  an  inch  in  thickness  ;  the  en- 
tire left  hemisphere  much  atrophied,  the  space  being 
taken  by  a  cyst  which  was  continuous  with  the  lateral 
ventricle  ;  the  nerve-tracts  below  had  also  undergone 
degeneration  ;  the  left  lobe  of  the  cerebellum  was  also 
smaller  than  its  fellow. 

The  points  of  interest  in  connection  with  the  case 
were  :  i,  By  bevelling  the  chisel  only  on  the  inner  sur- 
face the  blows  of  the  mallet  were  slanting,  and  caused 
less  concussion  of  the  brain  than  where  the  chisel  was 
ground  on  both  surfaces  ;  2,  a  number  of  temporary 
overlapping  sutures  through  the  scalp  en  masse  pre- 
vented hemorrhage  ;  3,  the  method  of  operating  was 
shown  to  be  applicable  even  where  the  skull  was  enor- 
mously thickened  ;  4,  that  the  inner  flap  might  heal 
promptly,  without  adhesions  to  parts  beneath,  with 
smooth  inner  surface  ;  5,  that  the  dura,  after  incision 
and  suture,  with  use  of  drainage  through  the  lateral 
ventricle  passing  through  the  suture  for  two  or  three 
days,  might  heal  without  adhesion  to  either  bone  or  pia. 

Dr.  Dawbarn  could  not  imagine  a  more  successful 
plan  for  the  prevention  of  hemorrhage  from  the  scalp 
wound  than  that  suggested  by  Dr.  Keen,  of  tying  a 
rubber  tube  around  the  head.  He  had  used  it  many 
times,  and  with  the  result  of  securing  an  absolutely  dry 
wound.  There  were  two  objections  to  chiselling  the 
bone,  namely,  danger  of  the  chisel  slipping,  and  of  pro- 
ducing concussion  of  the  brain.  He  thought  the  chain- 
saw,  operated  by  electricity  or  other  motor,  devised  by 
an  Ohio  doctor,  was  going  to  prove  very  useful  in  bone 
surgery. 

Dr.  E.  D.  Fisher  said  that,  before  Dr.  Woolsey 
operated,  he  thought  this  boy's  condition  was  probably 
due  to  an  inflammation  starting  at  the  time  of  the_  com- 
mencement of  the  fits,  but  after  the  operation  it  was 
shown  that  there  was  parencephaly,  and  this  had  prob- 
ably originated  in  intra-uterine  life  ;  since  in  paren- 
cephaly there  was  loss  of  brain  substance,  one  could 
not  expect  to  accomplish  much  by  an  operation.  He 
had  not  seen  concussion  from  the  use  of  the  chisel. 

Dr.  Woolsey  said  the  saws  which  he  had  seen  used 
had  not  operated  satisfactorily.  The  Esmarch  bandage 
around  the  head  had,  according  to  his  observation, 
been  more  in  the  way  than  it  had  [jroven  useful  in  con- 
trolling hemorrhage. 

The'Use  of  Torsion  Instead  of  Ligatures. — Dr.  Jdhn 
F.  Erdmann  read  a  brief  paper  on  this  subject,  basing 
it  upon  the  use  of  torsion  in  over  one  hundred  cases 
operated  upon  at  the  City  Hospital.  At  the  present 
day,  he  said,  we  want  primary  union,  and  knowing  how 
difficult  it  was  to  keep  ligatures  sterile,  he  resorted  to 
torsion  as  a  means  of  checking  hemorrhage,  for  by  its 
use  we  could  dispose  of  ligatures  which  acted  as  for- 
eign bodies,  which  were  apt  to  excite  irritation,  which 


286 


MEDICAL   RECORD. 


[August  24,  1895 


were  apt  not  to  be  thoroughly  aseptic  or  to  become  in- 
fected by  our  hands,  and  also  avoid  the  possibility  of 
hemorrhage  by  slipping  of  the  knot.  Disposing  of  these 
conditions,  primary  union  was  more  likely  to  attend 
our  efforts.  The  possibility  of  secondary  hemorrhage 
after  torsion  was  very  slight,  much  less,  he  thought, 
than  after  ligation.  A  hsematoma  had  occurred  in 
only  one  of  his  105  cases,  and  then  was  due  to  the 
patient  displacing  the  dressing.  Only  a  compress  was 
required  to  stop  the  bleeding. 

Torsion  was  limited  or  unlimited.  By  limited  torsion 
was  meant  twisting  of  the  vessel  below  a  point  at  which 
it  was  held  by  forceps,  while  by  unlimited  torsion  was 
meant  simply  twisting  the  end  of  the  vessel  without 
grasping  it  above.  From  four  to  eight  turns  were  made. 
Care  should  be  taken  to  grasp  the  vessel  so  as  to  include 
its  entire  lumen.  As  a  result  of  torsion  the  inner  and 
middle  coats  of  the  artery  were  ruptured  and  retraction 
took  place,  forming  a  valve-like  occlusion  against  the 
exit  of  blood.  Dr.  Erdmann  said  he  had  not  had  op- 
portunity to  apply  torsion  to  so  large  arteries  as  the 
femoral  and  brachial,  but  that  Thomas  Bryant  and 
others  used  it  on  the  femoral  as  well  as  on  smaller  ves- 
sels. 

The  Chairman,  Dr.  Curtis,  remarked  that  by  some 
the  fact  had  been  overlooked  that  by  torsion  one  could 
get  rid  of  ligature  material  in  the  wound.  This  was 
very  important  when  we  were  in  doubt  as  to  the  asep- 
tic condition  of  our  ligature  material.  He  had  seen 
torsion  applied  where  ligation  had  to  be  resorted  to 
afterward,  but  he  thought  the  fault  lay  in  the  operator, 
not  in  the  method. 

Dr.  Dawr.\rn  doubted  whether  there  was  a  surgeon 
in  New  York  who,  if  about  to  be  operated  upon,  would 
consent  to  torsion  being  applied  to  his  femoral  instead 
of  ligation.     Torsion  might  do  for  smaller  vessels. 

Unusual  Deformity  of  the  Coccyx. — Dr.  Royal 
Whitman  presented  a  small  boy  who  had  been  brought 
to  the  hospital  because  of  pain  on  sitting.  Examination 
showed  an  unusual  congenital  deformity  of  the  coccyx, 
the  bone  being  movable  and  projecting  backward,  the 
usual  direction  in  such  cases  being  forward. 


®0rtrjeBpondeucc. 


APPARENT  HYPERTHERMIA. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  Medical  Record  of  July  27,  1895,  page 
127,  in  a  paragraph  headed  "The  Value  of  a  Good 
Name,"  after  mentioning  the  comment  of  the  Berliner 
klinische  Woc/ieiischri/t,  that  if  Dr.  Jacobi's  name  was 
not  attached  one  would  not  believe  in  the  statement 
that  he  had  had  a  patient  with  a  temperature  of  65°  C, 
and  after  mentioning  the  statement  in  the  same  journal 
that  I  had  reported  another  case  of  77°  C,  or  171°  p., 
you  say  :  "  Professor  Welch  has  also  a  good  name,  but 
it  would  not  stand  many  more  degrees  centigrade." 

I  desire  to  lift  some  forty  degrees  centigrade  off  from 
this  burden  on  my  reputation.  I  am  not  responsible 
for  the  report  of  the  case  of  171°  F.  It  was  reported 
by  Dr.  Galbraith,  of  Omaha,  in  an  article  entitled  "  A 
Remarkable  Case,"  and  published  in  the  Journal  of  the 
American  Medical  Association,  March  31,  189 1.  In  the 
discussion  at  the  last  meeting  of  the  Association  of 
American  Physicians,  following  the  report  of  Dr.  Ja- 
cobi's case,  I  referred  to  Dr.  Galbraith's  case  as  an  even 
more  remarkable  one. 

The  chief  interest  to  me  in  the  latter  case  was  less 
the  extraordinary  height  of  the  temperature  than  the 
entire  good  faith  with  which  Dr.  ("Talbraith,  one  of  the 
most  experienced  and  best  known  surgeons  in  Omaha, 
reported  the  case,  and  the  ajiparent  thoroughness  of  the 
tests  to  which  he  subjected  the  patient.  When  called  to 
see  the  patient  in  consultation  he  at  first  declined,  but 


later  went  in  an  attitude  of  complete  scepticism  and  of 
confident  belief  in  some  mode  of  deception  practised  by 
the  patient.  He  described  one  test  which  he  made  in 
the  following  words  :  "  The  patient  was  placed  in  a 
chair,  all  clothing  removed,  and  a  careful  examination 
was  made  of  her  mouth  and  axillary  region,  every- 
possible  precaution  taken  in  order  to  prevent  any  de- 
ception, and  holding  the  end  of  the  thermometer  so 
that  it  could  not  be  tipped  in  any  way,  we  again  pro- 
ceeded to  take  her  temperature  ;  but,  gentlemen,  the  re- 
sult was  the  same,  the  thermometer  under  the  axilla 
registered  137°  F.,  while  that  under  the  tongue  regis- 
tered 131°  F."  His  personal  examination  made  a  com- 
plete convert  of  Dr.  Galbraith.  Especially  constructed 
and  carefully  tested  thermometers  were  used.  There 
were  no  symptoms  indicative  of  high  temperature. 

In  my  commerfts  upon  this  case  and  that  of  Dr.  Ja- 
cobi  at  the  meeting  of  the  Association,  I  used  the  fol- 
lowing words  (stenographer's  report)  :  "  So  far  as  one 
can  judge  from  the  description  of  Dr.  Galbraith's  case, 
and  the  same  is  true  of  Dr.  Jacobi's  case,  there  was  no 
apparent  mode  of  deception.  Still,  Dr.  Jacobi  must 
pardon  me,  if,  with  the  greatest  respect  for  his  skill  as 
an  observer,  I  express  complete  scepticism  as  to  the 
trustworthiness  of  these  observations.  I  do  not  under- 
take to  explain  in  what  way  deception  was  practised, 
but  there  is  no  doubt  in  my  mind  that  there  was  de- 
ception. Such  temperatures  as  those  recorded  in  Dr. 
Galbraith's  and  Dr.  Jacobi's  cases  are  far  above  the  tem- 
perature of  heat  rigor  of  mammalian  muscle,  and  are  de- 
structive of  the  life  of  animal  cells.  They  could  not 
be  present  even  in  the  integument  alone,  for  any  length 
of  time,  without  leaving  behind  manifest  lesions  where 
they  existed.  I  consider  them  to  be  physical  impossi- 
bilities under  the  conditions  described." 

When  I  made  the  preceding  remarks  I  was  not  aware 
that  Dr.  Galbraith's  case  had  already  been  thoroughly 
discredited  by  subsequent  developments.  A  physician, 
Dr.  Bridges,  who  happened  to  be  present  when  I  was 
speaking,  immediately  afterward  told  me  that  he  had 
been  an  interne  in  a  hospital  when  this  patient  was  de- 
tected in  attempts  at  malingering.  Those  who  are  in- 
terested in  the  remarkable  performances  of  this  versa- 
tile malingerer  will  find  them  narrated  in  articles  by 
Dr.  J.  E.  .Summers,  Jr.,  and  by  Dr.  C.  T.  Poe,  in  the 
Omaha  Clinic,  September,  1891,  and  February,  1892.  I 
have  seen  in  the  Army  Medical  Museum,  in  Wash- 
ington, specimens  of  the  bones  sent  to  Dr.  Billings,  of 
which  the  woman  passed  per  vaginam  over  one  thousand, 
and  which  were  supposed  to  come  from  a  macerated 
foetus  in  the  abdomen.  These  bones  were  pronounced 
to  be  bones  from  fowls,  probably  chickens,  and  other 
animals.  None  of  them  were  from  "  any  organism  de- 
veloped in  the  human  female."  I  am  not  aware  that 
the  precise  method  of  deception  practised  upon  Dr. 
Galbraith  has  been  explained,  but  Dr.  Poe  detected 
the  patient  once  in  the  old-fashioned  trick  of  heating 
the  thermometer  by  a  hot  bottle  in  the  bed.  It  may  be 
mentioned  that  the  woman  had  attended  a  course  of 
lectures  in  the  Woman's  Medical  College  of  Chicago. 
Yours  respectfully, 

William  H.  Welch,  M.D. 

Baltimore,  .-August  o,  1895. 


Prostatic  Disease. — About  the  earliest  s)Tnptom  is  an 

increased  frequency  of  urination,  especially  at  night. 
This  symptom  very  often  precedes  any  enlargement 
that  can  be  discovered  either  by  rectal  examination  or 
by  the  use  of  the  catheter. — Keex. 

Ligation  of  the  Stump-end. — I  can  see  no  sense  in 
ligating  the  stump-end  at  all,  if  it  is  going  to  be  in- 
verted, any  more  than  I  should  think  of  tying  a  string 
around  a  wound  in  a  gut  before  inve  rting  its  edges  and 
using  Lembert  sutures.  The  ana.ogy  is  perfect. — 
Dawearx. 


August  24,  1895] 


MEDICAL   RECORD. 


287 


THE  QUESTION  OF  AN  INTERNATIONAL 
LANGUAGE. 

To  THE  Editor  of  the  MEDieu.  Record. 

Sir  :  The  agitation  for  Greek  as  the  international  sci- 
entific language,  by  Dr.  Achilles  Rose,  has  found  many 
responses.  While  some  are  in  accord  with  his  views, 
all  agree  that  since  scientific  works  are  no  longer  writ- 
ten in  Latin,  a  means  of  common  intercommunication 
is  manifestly  needed. 

The  claims  of  the  opponents  to  Greek  are  too  evi- 
dent to  require  discussion.  Yet  it  may  not  be  amiss  to 
call  attention  to  the  letter  of  Dr.  George  W.  Smith,  of 
Chicago,  in  the  Medical  Record  of  August  3,  1S95, 
in  which  he  shows  some  of  the  difficulties  which  pre- 
sent in  translation  into  Greek.  But,  like  many  others, 
he  politely  omits  mention  of  the  impediment  to  the 
acquisition  of  Greek  in  its  written  and  printed  charac- 
ters. The  adjective  "  politely  "  is  here  used  advisedly, 
for  Dr.  Smith  premises  that  everyone  remembers  more 
than  the  "Alfred,  beat  her,  damn  her,  belt  her,"  which 
was  more  or  less  successfully  hammered  into  him. 
Truth  is  that  ver)'  few  physicians  of  over  twenty  years' 
practical  experience  can  spell  the  simplest  Greek  word. 
In  face  of  this  fact,  how  many  could  take  time  from 
their  necessary  daily  medical  studies  to  learn  Greek  ? 

Spanish,  on  the  other-hand,  offers  inter  alia  the  fol- 
lowing attractions  as  an  international  language  :  I.  To- 
day over  eighty  million  people  speak  Spanish.  Their 
scientific  publications  are  numerous,  and  many  among 
them  are  of  a  really  superior  character.  2.  Spanish  is 
written  and  printed  in  Latin  characters.  3.  The  Span- 
ish alphabet  is  unchangeable  ;  no  matter  how  a  letter 
is  placed,  its  pronunciation  does  not  vary.  4.  The 
language  is  so  euphonious  that  its  acquisition  is  a  di- 
version instead  of  a  task.  5.  Spanish  spelling  is  purely 
phonetic.  6.  The  learner  has  but  three  letters  to  ac- 
quire. 7.  The  grammar  is  exceptionally  free  from  ir- 
regularities. 

To  demonstrate  how  easy  of  acquisition  the  language 
is,  and  how  readily  it  lends  itself  to  scientific  expression, 
the  following  is  presented  without  translation,  in  confi- 
dence that  no  one  can  fail  to  understand  its  meaning  : 

"  La  gonorrea  es  una  enfermedad  contagiosa  que 
depende  de  un  microbio  especifico,  descubierto  por 
Neisser  y  titulado  gonococco.  Su  tratamientomoderno 
es  por  inyecciones  intra-vesicales  de  permanganato  de 
potasio." 

How  many,  if  the  above  were  presented  in  Greek, 
could  see  anything  in  it  but  several  lines  of  hieroglyphs  ? 
It  is  by  no  means  offered  as  an  example  of  classical  Span- 
ish, but  as  the  effort  of  a  mere  tyro,  who  without  more 
than  mediocre  intelligence  and  no  special  linguistic 
ability,  learned  enough  Spanish  in  six  weeks  to  no 
longer  require  an  interpreter. 

Ferd.  C.  Valentine.  M.D. 

24a  West  Forty-third  Street,  New  V^jek. 


To  THE  Editor  of  the  Medical  Record, 

Sir  :  Although  you  have  answered  Dr.  George  W . 
Smith's  letter  in  your  issue  for  August  3d,  "  Modern 
Greek  as  an  International  Medical  Language,"  I  beg 
leave  to  say  a  few  additional  words. 

The  living  Greek  is  a  highly  developed  language. 
Without  much  difficulty,  every  thought  expressed  in  a 
foreign  idiom  can  be  translated  into  living  Greek.  ^\  e 
need  only  read  the  daily  papers  published  in  Greek  at 
this  day  to  convince  ourselves  of  this  fact  ;  or  we  may 
take  for  illustration  some  of  the  innumerable  words 
which  from  all  languages  have  been  translated  into 
Greek.  Moreover,  the  best  contradiction  of  Dr.  Smith's 
reproach  is  the  Greek  medical  journal  'TaXT/i-os," 
which  is  almost  exclusively  composed  of  translations 
from  English,  German,  French,  and  Italian  medical 
literature. 


Germans  are  amused  or  annoyed,  according  to  indi- 
vidual disposition,  in  reading  notices  in  our  railroad 
depots,  saying  in  monstrous  German  that  smoking  is 
prohibited.  Judging  from  these  notices,  the  German 
language  must  be  miserably  poor  and  awkward,  not 
even  capable  of  translation  of  the  words  "  Smoking  in 
the  cars  is  forbidden." 

As  to  the  correspondent  who  wrote  upon  Latin  in  a 
recent  issue,  I  would  say  that  his  views  are  not  new, 
for  the  Principal  of  the  University  of  Louvain,  in  the 
"  Vicar  of  Wakefield,"  is  made  to  say:  "You  see  me, 
young  man  ;  I  never  learned  Greek,  and  I  don't  find  I 
ever  missed  it.  I  have  had  a  doctor's  cap  and  gown 
without  Greek  ;  I  have  io,coo  florins  a  year  without 
Greek  ;  I  eat  heartily  without  Greek  :  and  in  short,  as 
I  don't  know  Greek,  I  don't  believe  there  is  any  good 
in  it." 

Yours, 

A.  Rose,  M.D. 

336  East  Fifteenth  Street. 


To  the  Editor  of  the  Medical  Record. 

Sir  :  "  Latin  as  She  is  Wrote  and  Spoke"  is  the  head- 
line of  a  letter  from  Dr.  H.  L.  Waldo,  of  Troy,  N.  Y., 
in  your  issue  of  August  loth.  The  doctor  deals  with 
his  subject  in  a  comic,  serio-comic,  serious,  half-satiri- 
cal manner,  which  leaves  the  reader  somewhat  in  doubt 
as  to  his  early  classical  education. 

We  hope  we  do  not  flatter  that  early  training,  how- 
ever, when  we  take  it  for  granted  that  he  could  once 
read  Pindar,  quote  freely  from  Horace,  and  readily  un- 
ravel the  intricacies  of  ^^schylus  and  Sophocles,  but 
now,  like  most  of  us,  has  grown  a  bit  rusty.  Seeing  Ger- 
man freely  quoted,  medical  articles  displaying  great 
erudition  with  their  multitude  of  German  foot-note  ref- 
erences, his  heart  has  been  won  by  the  Teuton.  Over- 
whelmed with  the  mass  of  German  literature,  thrashing 
over  and  over  theories  in  a  spirit  of  mysticism,  he 
hurls  into  the  background  his  Virgil  and  his  Homer, 
and  frantically  calls  for  the  "  Vaporings  of  Goethe  and 
Schiller,  the  pseudo-science  of  Virchow  and  Ziems- 
sen." 

He  is  serious  when  he  requests  the  Medical  Rec- 
ord to  inform  him  what  has  been  printed,  in  either 
Greek  or  Latin,  during  the  past  five  hundred  years 
that  will  pay  the  physician  of  to-day  to  read,  if  it  were 
printed  in  his  mother-tongue.  -Again  he  lays  bare  his 
innermost  thoughts  on  the  subject  when  he  asks  us  to  re- 
member that  our  profession  is  a  practical  profession. 
This  practical  chain  of  reasoning  of  the  doctor  will  ap- 
peal to  many  of  your  readers.  No  time  for  dead  lan- 
guages. There  are  families  to  keep,  babies  to  feed.  No 
time  to  unravel  the  etymological  meaning  of  oculist,au- 
rist,  rhinologist,  dermatologist,  etc.  It  is  enough  for 
us  understandingly  to  call  these  .Esculapian  disciples 
eyemen,  earmen,  nosemen,  skinmen.  However,  the  ad- 
vanced medical  colleges  are  demanding  from  their  stu- 
dents some  classical  education,  and  it  is  fast  becoming 
not  easy  for  the  machine-shop  or  grocer  boy  to  obtain 
his  license.  The  standard  is  being  elevated.  It  may 
not  be  expected  from  "  we  busy  old  fellows,"  long  in  the 
harness,  to  take  any  time  from  the  babies  and  delve 
into  Greek  and  Latin  roots.  Those  of  us  who  have 
lived  without  knowing  when  and  where  to  use  ferrum 
o\  ferri.  rheum  or  r/ui,  may  remain  happy  if  we  do  not 
know  the  wealth  of  knowledge  pertaining  to  our  pro- 
fession buried  in  the  classics.  In  blissful  ignorance 
we  may  be  content  to  remain  Philistines  ;  content  to 
prescribe  eyewashes,  injections,  blisters,  and  pills,  prac- 
tising on  in  the  same  happy  frame  of  mind  with  that 
type  of  day-laborer  who  returns  at  night,  eats  his  din- 
ner, drinks  his  beer,  smokes  his  clay  pipe,  and  goes  to 
bed.  To  the  writer  of  the  article  it  may  be  parenthet- 
ically remarked,  that  the  physician  who  unintelligently 
^'Tii^s  ferram,  ferri,  ox  ferra,  aquam  or  aqua,  for  iron 


288 


MEDICAL    RECORD. 


[August  24,  1895 


and  water,  does  not  trifle  with  the  ending  any  more 
than  he  would  trifle  with  the  butt-end  of  a  mule. 
He  is  content  with  fer.  and  aq.  In  other  words  he 
adopts  the  trick  of  the  bad  speller,  when  in  doubt 
whether  to  use  i  or  e,  rounds  his  i,  dots  his  e,  and  plays 
it  double.  The  "  busy  old  fellow  "  is  a  great  abbrevia- 
tor,  and  who  can  know  the  depth  of  his  knowledge  of 
declensional  endings  ?  In  one  breath  the  doctor  gasps, 
"  What's  the  use  ?  "  while  in  the  next  he  says,  "  A  large 
percentage  of  the  technical  terms  employed  in  medicine 
are  of  Latin  or  Greek  origin."  This  leads  me  to  ask  if  he 
does  not  agree  with  the  editorial  view  expressed  in  the 
Medical  Record,  to  which  he  refers,  "  It  will  not  take 
a  great  deal  of  scholarship  to  correct  the  general  de- 
fects of  classical  learning,  and  as  Latin  has  become  at- 
tached to  medical  literature  and  nomenclature  beyond 
possibility  of  divulsion,  we  suggest  that  medical  stu- 
dents be  drilled  a  little  in  the  mother-tongue."  This 
will  apply  equally  to  Greek,  which  to  us  at  the  present 
time  appears  of  even  greater  value  than  Latin,  as  we 
watch  the  newly-coined  medical  words  appearing  from 
day  to  day,  rising,  as  Barnum  would  express  it.  Sphinx- 
like from  the  ashes  of  the  Attics. 

Yes,  Latin  and  Greek  are  with  us  to  stay.  The  new 
physician  is  fast  being  compelled  to  study  them  ;  the 
"busy  old  fellow,"  bearing  in  mind  that  Cato  learned 
Greek  at  eighty,  if  possessed  of  any  linguistic  bump  at 
all,  will  not  find  it  difficult  to  acquire  enough  to  make 
him  proud  to  have  lived  and  gotten  one  peep  into  the 
Promised  Land,  and  see  his  science  unfold  itself  be- 
fore him,  as  he  in  his  practical  moments  never  dared  to 
dream.  We  may  make  this  good  by  calling  attention 
to  the  fact  that  in  the  "  Beginners'  Greek  Book  "  by 
White  appear  three  hundred  words  in  the  first  twenty- 
five  lessons.  Among  these  three  hundred  words,  there 
are  about  one  hundred  we  use  constantly  ;  many  of 
them  well-known  medical  terms.     Here  are  a  few  : 

fiiKpos little,  small. 

K€<j>aK't] head  (micro-cephalus). 

(dvri girdle  (zona  or  shingles). 

a'T€v6s narrow. 

&y8punos man  (anthropology). 

\6yos discourse  (all  the  'ologies). 

'Ittttos horse  )  ,  ■ 

/  .  •  hiiipopotamus. 

ToTafxos river   \      j  ^   t^ 

<Trp€7rT(i! necklace. 

ircifo) save. 

Note  here  the  practical  turn  made  by  the  business 
sharp  in  tacking  to  the  last  the  Greek  word  for  tooth, 
and  giving  us  the  world-wide  advertised  dentifrice, 
Sozodont. 

I  need  not  continue  this,  but  repeat  that  nearly  one 
hundred  common  words  appear  in  the  three  hundred 
words  occurring  in  the  first  twenty-five  lessons  of  a 
"Beginners'  Greek  Book."  This  means  five  weeks,  one 
hour  daily  recitation,  for  the  school-boy. 

Does  it  not  suggest  the  saving  of  time  for  the  busy 
practitioner,  did  he,  along  with  his  knives  and  his  scis- 
sors, his  cumbersome  electrical  plant,  his  desk  over- 
crowded with  advertisements  of  headache  powders,  pos- 
sess a  small  Greek  and  Latin  armamentarium  ?  Does  he 
not  see  how  much  less  the  young  men  and  maidens  would 
fool  away  their  time  in  the  laboratories  with  culture- 
tubes,  etc.,  did  they  enter  tliose  laboratories  with  even 
a  limited  classical  education  ?  They  would  not  stag- 
ger under  words  like  streptococcus.  Their  Greek 
would  at  once  suggest  cocci  arranged  like  a  necklace, 
s/rcptos  being  the  Greek  for  the  latter. 

Medical  education  is  in  the  ascendancy,  and  Greek 
and  Latin  must  remain  invaluable  since,  from  the  stand- 
point of  brevity  alone,  they  will  remain  in  use  for  scien- 
tific names. 

This  wave,  starting  in  the  larger  medical  centres,  will 
surely  extend  to  the  surrounding  country,  and  in  time 
reach  the  suburban  towns  of  East  Chatham,  Chatham 
Four  Corners,  Lansingburg,  and  Troy. 

Geo.  R.  Elliott,  M.D. 

48  East  Twenty-.sixth  Strbet. 


PROSTATITIS. 

To  THE  Editor  of  the  Medicai.  Record. 

Sir  :  Since  my  letter  in  the  Medical  Record  ap- 
peared, many  private  letters  from  various  parts  of  our 
continent  have  been  sent  here,  asking  further  informa- 
tion in  regard  to  the  treatment  I  proposed.  The  one 
word  sterilization  of  the  testicle  is  in  my  experience  the 
embodiment  of  success  ;  the  moment  semen  ceases  to 
be  developed  and  spermatozoa  no  longer  manifest  them- 
selves, recovery  commences. 

Any  form  of  injection  that  will  accomplish  these 
ends  will,  in  my  opinion,  succeed  ;  the  body  of  the  tes- 
ticle should  alone  be  pierced  by  the  needle.  I  use  co- 
caine because  it  is  painless  ;  because  there  is  no  sore- 
ness afterward,  and  the  patient  is  not  incapacitated  for 
business  ;  but  I  presume  cold  water  would  serve  the 
same  purpose. 

I  use  suppositories  made  of  cocoa  butter  :  i  grain 
cocaine,  5  drops  extract  belladonna,  and  5  drops  ex- 
tract henbane — one  of  these  pressed  into  the  bowel 
every  other  night. 

Where  there  is  a  constant  desire  to  urinate  I  use  i 
ounce  of  hot  water  112°  to  120°  F.,  3  grains  cocaine, 
and  inject  slowly  into  the  bladder,  the  patient  lying  on 
his  back  in  a  horizontal  position. 

I  have  had  remarkable  success  with  this  treatment, 
and  am  of  opinion  that  castration  is  wholly  unwarranted. 

My  treatment  neither  affects  sexual  desire  nor  pre- 
vents the  act  of  coition.  It  does  wholly  prevent  repro- 
duction, and  would,  I  think,  be  a  good  plan  to  adopt 
with  noted  and  hereditary  criminals. 

Yours, 
S.  E.  McCuLLV,  M.D. 

Toronto,  Canada. 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  August  10,  1895. 

Cases.       Deaths. 


Tuberculosis 53 

Typhoid  fever 19 

Scarlet  fever 30 

Cerebro-spinal  meningitis i 

Measles 99 

Diphtheria 124 


Penalty  for  Circulating  False  Reports. — There  is  a 
law  in  Florida  which  provides  that  "  any  person  or  per- 
sons who  shall  falsely  or  maliciously  disseminate  or 
spread  rumors  or  reports  concerning  the  existence  of 
any  infectious  or  contagious  disease  shall  be  guilty  of 
a  misdemeanor,  and,  upon  conviction,  shall  be  pun- 
ished by  a  fine  in  a  sum  of  not  less  than  $100  nor 
more  than  $1,000,  or  be  imprisoned  in  the  county  jail 
for  not  less  than  three  nor  more  than  six  months." 

The  Cost  of  Typhoid  Fever.— Dr.  Munro,  an  English 
medical  health  officer,  has  recently  computed  the  cost 
of  an  epidemic  of  typhoid  fever  occurring  in  his  dis- 
trict of  Mid-Renfrewshire.  There  were  859  cases,  74 
of  which  were  fatal.  The  average  cost  of  hospital 
treatment  was  about  $45,  on  which  figure  Dr.  Munro 
puts  the  average  cost  of  treatment  of  home  and  hospital 
cases  at  $25.  He  estimates  the  total  amount  of  wages 
lost  to  the  patients  at  about  $16,000.  The  cost  of  fu- 
nerals is  estimated  at  $25  each,  and  the  value  of  a  hu- 
man life  a  little  less  than  $Soo  per  head.  The  total 
pecuniary  cost  of  the  epidemic  was  accordingly  al- 
most exactly  $125  for  each  case. 


I 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  48,  No.  9. 
Whole  No.  1295. 


New  York,  August  31,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginat  Articles. 


A  CURIOUS  CASE  OF  APPENDICITIS;  WITH 
A  DISCUSSION  OF  CERTAIN  POINTS  IN 
OPERATIVE    TECHNIQUE.' 

By  ROBERT  H.  M.  DAWBARN,  M.D., 

THE   NEW  VORK 


The  following  case  of  appendicitis  presents  an  un- 
usual number  of  points  of  interest  in  itself.  For  this 
reason,  and  because  it  will  serve  as  a  text  for  a  brief 
discussion  of  a  few  details  in  operative  technique,  it 
has  been  selected  as  the  subject  for  to-night's  paper. 

About  eleven   o'clock  on  the  night  of  January  i6. 

1895,  I  was  called  in  to  see  Theodore  Van  B ,  a 

child  eleven  years  of  age.  He  had  then  felt  moder- 
ate pains  all  day,  with  some  tenderness  in  the  appendic- 
ular region,  and  had  been  kept  in  bed  by  his  mother, 
although  seemingly  not  very  seriously  ill.  He  looked 
up  at  me  brightly  and  cheerfully  at  the  time  of  my 
call.  His  temperature  was  one  degree  above  normal : 
pulse,  120;  respiration,  26.  The  bowels  had  been 
moved  both  that  and  the  preceding  day,  by  a  saline. 
Some  anorexia  was  noted.  No  tumor  could  be  felt, 
but  a  slight  degree  of  rigidity  of  the  right  half  of  the 
abdominal  wall,  as  compared  with  the  left  half.  The 
right  thigh  was  drawn  up,  and  added  pain  in  the  abdo- 
men resulted  from  a  gentle  attempt  to  extend  this  limb. 

I  have  been  led  to  feel  that  when  the  symptoms  in- 
dicate appendicitis,  the  combination  of  a  rapid  pulse 
and  respiration,  going  with  a  temperature  normal,  or 
nearly  so,  points  to  the  necessity  for  prompt  operation. 
Here,  however,  as  the  child  seemed  so  bright  and 
cheerful,  showing  no  constitutional  evidences  of  septic 
absorption,  I  thought  I  might  safely  wait  from  the  time 
of  this  my  first  visit,  at  nearly  midnight,  until  morning. 
Before  leaving  the  house  orders  were  given  to  prepare  a 
room  for  the  purpose  ;  also  to  fill  a  wash-boiler  with 
normal  salt  solution  (heaped  teaspoonful  to  quart  of 
water)  and  boil  it,  prior  to  the  morning  visit. 

That  night  I  was  awakened  before  daybreak  with 
the  news  that  the  little  patient  had  just  been  seized 
with  a  severe  chill.  Reflecting  on  Dr.  Fowler's  re- 
mark—that in  three  hundred  cases  of  appendicitis  he 
had  only  seen  two  in  which  a  chill  ushered  in  the 
symptoms,  and  in  both  of  these  the  appendix  was 
found  gangrenous — I  anticipated  a  similar  condition 
here,  although  the  chill  did  not  absolutely  begin  the 
case.     And  this  assumption  proved  to  be  true. 

As  soon  as  assistants  could  be  gotten  together  we 
operated,  in  the  early  morning.  These  gentlemen  were 
Drs.  William  J.  Kress  and  Richard  A.  Barr.  Upon 
our  arrival  the  patient's  condition  was  deplorable,  and 
in  striking  contrast  to  that  of  the  midnight  visit.  The 
pulse  was  now  running  and  thready,  at  about  140  per 
minute  ;  respiration,  40  ;  temperature,  about  99°  F. 
The  tenderness  had  spread  over  the  whole  abdomen, 
though  still  worse  on  the  right.  The  little  fellow  was 
covered  with  a  cold  sweat,  and  his  face  showed  anxiety. 
; ,  The  prognosis  seemed  to  be  of  the  worst,  and  perhaps 

1  '  Read,  in  major  part,  at  a  meeting  of  the  New  York  Surgical  So- 

j       ciety,  held  April  10, 1893. 


haidly  justified  operating.  However,  the  parents  chose 
the  only  course  offering  the  least  hope,  and  we  went 
ahead  with  ether  antesthesia.  Upon  opening  the  abdo- 
men there  was  a  prompt  escape  of  fluid  faeces  mingled 
with  pus,  dark  and  very  malodorous.  This  seemed 
to  bathe  the  bowels  everywhere,  most  of  it  being  found 
in  the  pelvis.  The  estimated  amount  removed  in  cleans- 
ing was  from  four  to  six  ounces.  The  bowels  were 
distended,  dark  red  or  purple,  and  distinctly  inflamed. 
Upon  searching  for  the  appendix,  a  curious  and  beau- 
tiful instance  was  made  manifest  of  Nature's  attempts 
to  protect  herself  against  threatened  bowel-perforations. 
That  corner  of  the  great  omentum  which  lay  nearest 
had  wrapped  itself  completely  around  the  diseased  ap- 
pendix— just  as  a  woman  might  wrap  the  corner  of  her 
apron  around  a  sore  finger. 

From  beneath  this  attempted  protection  the  fluid 
faeces  could  be  seen  welling  up  ;  showing  that  the  ef- 
fort had  not  quite  succeeded.  The  omentum  in  this 
region  was  greatly  congested  and  stiffened,  and  was 
swollen  to  several  times  its  normal  thickness  in  a  child. 
Upon  unrolling  this  corner  of  the  great  apron,  the  ap- 
pendix lay  exposed,  gangrenous  for  its  distal  three- 
fourths,  and  perforated  at  two  or  three  points.  Where 
the  partly  healthy  joined  the  dead  portion  was  a  round 
distention  of  its  wall,  evidently  old,  and  covered  with 
smooth  peritoneum  ;  and  this  cavity  was  filled  with  a 
round  and  hard  body  the  size  of  a  large  pea.  This  sac- 
culation is  quite  clearly  shown  in  the  specimen  to-night, 
which  has  been  sewn  together  where  it  had  been  split 
lengthwise,  and  then  filled  with  plaster-of-Paris. 

Strangely  enough,  although  this  sac  in  the  wall  of  the 
appendix  is  evidently  of  old  standing,  yet  the  parents 
insist  that  no  tenderness  nor  pain  whatsoever  had  been 
complained  of  prior  to  the  day  before  the  operation. 
The  hard  body  resembled  a  stone  in  density,  not  yield- 
ing at  all  to  the  finger-nail.  Examination  later  on, 
however,  showed  it  to  be  scybalous.  The  appendix 
was  now  removed  by  a  technique  which  I  have  used 
almost  exclusively  for  several  years  past  and  will  dis- 
cuss later  on. 

Next,  the  wound  was  freely  enlarged  at  both  ends, 
until  seven  inches  in  length  ;  ana  then  every  foot  of 
the  bowels  capable  of  removal  was  quickly  withdrawn 
so  as  to  lie  upon  the  skin  of  the  abdomen.  Now,  the 
normal  salt  solution,  as  hot  as  the  hand  would  bear, 
was  poured  from  a  pitcher  upon  the  bowels,  which  were 
gently  moved  in  all  directions,  to  favor  thoroughness  of 
cleansing.  Pitcherful  after  pitcherful  was  used,  and 
then  the  empty  cavity  in  which  the  intestines  had  lain 
was  as  freely  flushed  the  inserted  hand  aiding  the  wash- 
ing continually,  the  fingers  searching  out  all  recesses, 
until  the  water  returned  absolutely  colorless.  Without 
exaggeration,  almost  an  entire  wash-boilerful  of  hot 
normal  salt  solution  was  used  in  this  way.  The  bowels 
were  replaced  with  some  difficulty,  as  they  were  dis- 
tended with  gas  when  first  exposed.  A  shorter  skin 
incision  would  have  rendered  their  return  almost  im- 
possible, save  by  a  most  serious  degree  of  rough  hand- 
ling. Next,  the  infected  and  swollen  portion  of  the 
omentum,  as  referred  to  heretofore,  was  ligated  in  sec- 
tions and  amputated.  In  this  way  about  one-third  of 
the  great  apron  was  sacrificed.  The  wound  was  now 
closed  as  to  its  ends  with  silkworm  gut  sutures,  and  all 
the  rest  of  it  packed  with  a  mass  of  sterile  gauze,  strips 
of  which   ran  like  the  spread   fingers  of  a  hand  in  as 


290 


MEDICAL    RECORD. 


[August  3  r,  1895 


many  different  directions  among  the  bowels,  and  par- 
ticularly into  the  pelvis. 

The  little  patient's  condition  at  this  time  was  such 
that  it  was  feared  he  would  die  on  the  table.  Hot  sa- 
line infusion,  intra-venous,  was  employed,  nearly  a 
quart  being  used  with  great  benefit  ;  also  whiskey  and 
hot  water  by  enema  and  strychnine  by  needle  ;  and 
finally  he  reacted  well. 

As  to  the  subsequent  history,  only  those  portions 
which  are  of  unusual  interest  will  be  recorded  here, 
and  these  as  briefly  as  may  be. 

First,  the  extreme  difficulty  of  moving  the  semi-par- 
alyzed bowels.  This  it  was  thought  best  to  attempt  on 
the  second  day.  Large  doses  of  salines  were  given  by 
mouth  hourly,  and,  later  on,  castor-oil  ;  stimulant  en- 
emata  of  soap,  of  glycerine,  with  salines,  with  ox- gall, 
with  turpentine,  were  used  at  intervals — and  all  without 
effect  for  a  long  time.  After  between  one  and  two 
days  of  effort,  success  was  achieved  in  this  direction. 

As  showing  the  extremely  ichorous  character  of  the 
fluids  which  came  in  contact  with  the  raw  surfaces  of 
the  incision  in  the  belly  wall  during  the  operation,  it 
is  to  be  noted  that  the  entire  thickness  of  the  wound, 
on  both  sides,  sloughed,  presenting  a  gray,  offensive 
surface  on  the  third  and  fourth  day,  and  compelling  the 
removal  of  the  few  sutures  at  the  ends.  In  the  treat- 
ment of  this  sloughing  surface  sterile  gauze  soaked  in 
oil  of  turpentine  was  freely  employed  and  changed 
daily,  the  skin  being  thickly  dusted  with  compound 
talcum  or  bismuth  subnitrate,  to  avoid  turpentine  blis- 
tering. This  treatment  was  not  much  complained  of, 
and  was  ideal  in  its  results.  Indeed,  in  foul  and 
sloughy  wounds,  everywhere,  the  writer  knows  of  no 
plan  of  equal  value  with  this,  which  he  first  saw  sug- 
gested many  years  ago  by  Dr.  Banks,  the  Liverpool 
surgeon. 

Since  then  he  has  found  that  from  time  immemorial 
it  has  been  standard  treatment  for  foul  wounds  among 
the  people  of  the  pine-woods  districts  of  this  country. 

On  January  2 2d,  six  days  after  the  operation,  there 
developed  with  rapidity  an  acute  and  severe  degree  of 
parotitis  on  the  child's  right,  causing  him  much  suffer- 
ing. At  this  time  the  sloughs  were  not  yet  gone  from 
the  wound,  and  the  temperature  was  100°  to  101°  F. 
Under  an  ice-bag  the  pain  and  swelling  diminished, 
and  two  days  later  had  in  some  measure  subsided, 
whtn  the  same  complication  supervened,  this  time  in- 
volving his  left  parotid  gland.  This  again  took  a  sim- 
ilar course  under  the  same  cold  treatment. 

I  had  feared  the  worst  when  this  sympton  developed. 
It  is,  I  believe,  generally  regarded  as  of  very  grave  prog- 
nosis ;  not  of  course  per  se,  but  as  indicating  a  condi- 
tion of  profound  sepsis.  It  will  be  remembered  that  a 
few  years  ago  one  of  the  surgeons  to  the  New  York 
Woman's  Hospital  published  an  article  pointing  out  its 
extreme  fatality. 

The  next  complication  presented  by  this  little  suf- 
ferer was  about  this  same  time  in  its  inception.  The 
temperature  after  the  double  jiarotitis  did  not  drop  to 
normal,  but  gradually  and  irregularly  rose,  covering 
about  a  week,  until  upon  February  4th  it  had  reached 
10334°.  During  this  week  he  had  several  slight  rigors 
with  sweating,  at  irregular  intervals  ;  and  his  strength 
fell  away  alarmingly,  in  spite  of  strychnine,  suniulants, 
and  concentrated  foods  used  freely.  t>uinine  had  no 
effect  upon  this  fever,  and  I  felt  certain  that  there 
must  be  concealed  somewhere  in  his  abdomen  a  pocket 
of  pus  which  was  poisoning  him.  l?ut  exactly  where 
I  could  not  determine,  either  by  subjective  or  objective 
means.  During  the  last  few  days  of  this  period  the 
wound  looked  quite  normal  and  was  covered,  including 
the  adherent  bowels  which  formed  its  bottom,  with 
healthy  granulation-tissue.  The  temperature  alone  pre- 
vented secondary  suturing,  or  other  means  of  closing 
this  great  ga[).  I  hoped  that  the  suspected  abscess 
might  point  and  break  in  this  direction  if  the  wound 
were  kept  open. 


L'pon  February  3d  it  was  determined  to  use  a  coarse 
aspirating  needle  in  various  directions  through  the 
thick  bed  of  granulations  at  the  bottom  of  the  wound. 
This  was  done,  but  no  pus  was  found.  It  was  thought 
that  the  little  patient  was  too  weak  to  bear  a  fresh  lap- 
arotomy, or  even  to  endure  the  rough  handling  involved 
in  tearing  apart  the  firmly  adherent  bowels  beneath  and 
about  the  wound. 

Upon  the  day  following  this  aspirating.  Dr.  A.  G. 
Gerster  was  called  in  consultation.  He  made  a  careful 
examination  and  confirmed  my  diagnosis  of  an  abscess- 
cavity  concealed  somewhere,  and  poisoning  our  patient ; 
but  could  not  localize  it ;  and  he,  too,  advised  against 
operation,  for  the  reasons  named. 

Within  a  few  hours  after  Dr.  Gerster's  visit,  the 
child  solved  this  mystery  for  himself,  by  discharging 
this  abscess  through  some  unknown  point  into  his 
bowel,  and  thence  per  anum.  This  movement  was 
large  and  fluid  and  dark,  and  was  so  peculiarly  atro- 
cious in  odor  as  to  be  almost  overpowering.  The  mother 
told  me  that,  in  spite  of  the  wintry  weather,  every  win- 
dow and  door  in  the  flat  had  to  be  opened  for  exit  of 
the  smell.  Within  an  hour  after  this  the  temperature 
had  dropped  nearly  two  degrees  ;  and  it  quickly  fell 
to  normal. 

A  few  days  later  the  fever  and  all  these  symptoms  of 
poisoning  again  returned,  but  to  a  lesser  degree.  -A. 
second  and  smaller  offensive  movement  ended  them, 
and  since  then  they  have  not  recurred,  nor  has  any- 
thing further  happened  to  interrupt  convalescence. 
Daily,  under  saline  laxatives,  the  bowels  were  mide  to 
move  freely  during  the  septic  periods  mentioned.  Each 
time,  a  soft  and  normal  movement  preceded  the  very 
foul  ones  by  a  few  hours,  so  that  the  latter  could  not 
have  been  due  to  constipation  with  retention  and  de- 
composition of  fasces. 

It  would  seem  quite  plain  that  in  this  case  an  ab- 
scess beginning  in  some  peritoneal  recess  such  as  the 
fossa  of  Treitz,  or  perchance  the  fossa  sub-sigmoidea, 
and  walled  in  by  matted  intestines,  had  at  length  soft- 
ened and  penetrated  a  contiguous  loop  of  bowel. 

The  patient  is  now  in  good  health  and  free  from 
pain.  His  wound  is  solidly  healed,  and  has  contracted 
one  and  a  half  inch  at  each  end  ;  it  is  now  measuring 
four  inches  along  the  scar. 

I.  First,  as  to  the  incision.  As  a  general  thing.  Dr. 
McBurney's  plan  of  splitting  the  abdominal  muscles  so 
that  the  split  external  oblique  makes  nearly  a  right 
angle  with  the  split  internal  oblique  and  transversalis, 
would  seem  a  distinct  gain,  and  for  the  reasons  which 
Dr.  McBurney  has  pointed  out.  But  in  a  case  such  as 
this,  and  indeed  in  any  case  where  one  has  reason  to 
expect  pus,  it  would  seem  wiser,  as  he  has  himself 
stated,  to  make  the  more  usual  cceliotomy  incision. 
The  McBurney  plan  compels  a  free  dissection  and 
fully  double  as  much  raw  surface  to  absorb  poison. 

II.  Regarding  the  recognition  of  peritoneum  as  dis- 
tinguished from  transversalis  fascia.  These  membranes 
cannot  always  be  distinguished  by  a  dilTering  appear- 
ance. I  have  often  seen  transversalis  fascia  that  did 
not  look  fibrillated  and  was  just  as  shining  as  the 
peritoneum.  Possibly  it  may  be  worth  while,  for  other? 
than  the  members  of  this  Society,  to  refer  to  a  valuable 
point  which  many  years  ago  I  obtained  from  Dr.  Mc- 
Burney, and  have  never  seen  in  print,  namely,  that 
after  cutting  the  deepest  muscle,  its  cut  edge  be  lifted 
and  its  deep  surface  examined.  If,  now,  that  surface 
be  found  bare,  then  the  transversalis  fascia  has  not  \ei 
been  cut.  But  if  that  under  surface  of  the  deepest 
muscle  be  found  covered  with  a  fascia,  however  thin, 
that  is  the  transversalis  fascia,  which  has  already  been 
cut,  and  then  the  next  membrane  attacked  will  of  course 
be  the  peritoneum. 

III.  In  common  with  certain  other  surgeons,  the  writer 
is  now  inclined  to  advocate  a  double  incision  in  every 
appendix  case  with  a  tumor. 

Through  the  first  and  very  short  incision,  at  or  near 


August  31,  1895] 


MEDICAL    RECORD. 


291 


the  middle  line,  the  forefinger  is  introduced  into  the 
peritoneal  cavity,  and  by  it  the  tumor  is  felt.  If  ad- 
hesions separate  the  general  peritoneal  cavity  from  the 
pus-cavity,  then  this  finger  serves  as  the  best  possible 
guide,  while  the  second  cut  is  being  made,  to  enable  us 
by  that  second  cut  to  enter  that  pus-cavity  without  at 
any  point  through  inadvertence  entering  and  con- 
taminating the  general  peritoneal  cavity. 

IV.  Suppose,  in  an  appendicitis  case  with  a  tumor, 
we  have  made  our  first  and  short  cut,  introduced  the 
finger,  and  have  found  it  capable  of  sweeping  all  over 
the  front  of  that  tumor  ;  that,  in  other  words,  there  is 
no  blocking  off  of  that  tumor  from  the  general  ]3eri- 
toneal  cavity,  at  least  at  the  front.  Shall  we  now, 
after  making  our  second  incision,  which  exposes  the 
tumor,  attack  it  at  this  sitting,  open,  wipe  out  the  pus, 
and  drain  ?  Or  shall  we  pack  gauze  around  the  periph- 
ery of  the  tumor  and  wait,  before  cutting  into  that 
pus,  a  day  or  so  for  the  rapid  adhesions  which  will  in 
that  time  make  a  protecting  barrier,  closing  out  abso- 
lutely the  general  peritoneal  cavity  ? 

As  Dr.  \Vyeth  has  so  strongly  advocated,  I  think  the 
latter  plan  by  far  the  preferable,  because  the  safer. 
But  on  page  159  of  his  recent  work  upon  appendicitis, 
Dr.  Fowler  takes  the  opposite  course,  and  opens  into 
the  pus  at  once. 

The  plan  in  two  stages  is  directly  in  line  with  the 
tehnique  which  has,  elsewhere  in  the  abdomen,  made 
a  wonderful  change  in  the  direction  of  lowered  mor- 
tality ;  as,  for  example,  doing  inguinal  colotomy  in 
two  steps  a  day  apart,  instead  of  one,  as  formerly.  Of 
course,  in  the  appendicitis  contingency  just  discussed, 
if  the  localized  abscess  were  tense,  threatening  to  burst, 
it  would  be  wise  to  aspirate,  to  avoid  this  occurrence, 
and  then  pack  gauze  about  as  aforesaid. 

V.  Regarding  the  position  to  be  assumed  by  the  pa- 
tient. The  writer  is  not  an  advocate  of  Trendelen- 
burg's posture  in  this  operation,  either  in  purulent  or 
non-purulent  cases. 

As  to  the  former  class.  Dr.  Fowler,  in  his  work  {]>. 
152  ft  seg.),  points  out  the  objection  (when  there  is  a 
tumor,  or  any  other  reason  for  assuming  that  septic 
fluid  will  be  encountered)  that  in  such  cases  the  Tren- 
delenburg position  "  has  the  disadvantage  of  favoring 
the  passage  of  the  pus  to  the  upper  portion  of  the  peri- 
toneal cavity  ;  and,  at  the  same  time,  of  preventing  the 
rapid  turning  of  the  patient  upon  his  right  side,  in 
order  to  obtain  the  assistance  of  gravity  in  preventing 
the  infection  of  the  peritoneal  cavity." 

As  to  the  latter  class — the  non-purulent  cases — I 
would  say  that  here  again  the  horizontal  dorsal  posi- 
tion is  the  best ;  for  another  reason,  namely,  that  it 
enables  one,  more  readily  than  by  the  Trendelenburg 
posture,  to  overcome  a  common  annoyance,  that  caused 
by  the  small  intestines  crowding  into  the  field  of  opera- 
tion and  persistently  hiding  the  deeper  appendi.x  in 
the  most  e.xasperating  way. 

In  such  a  case,  the  plan  I  suggested  here  several 
years  ago  gives  prompt  relief.  This  is  to  roll  the  pa- 
tient over,  so  that  the  right  side  is  uppermost.  Now, 
with  a  stout  retractor,  draw  the  belly-wall,  at  the  cut, 
forward,  i.e.,  away  from  the  spinal  column.  .Thereby 
a  capacious  pocket  or  pouch  is  formed,  into  which 
the  small  intestines  drop  by  gravity.  The  ciccum, 
having  no  mesentery,  cannot,  however,  follow  the 
small  intestines,  and  must  remain  uncovered  and 
where  it  is  desired,  namely,  directly  beneath  the  cut. 
This  little  device  alone  has  many  times  saved  precious 
minutes  of  peritoneal  exposure.  The  ciucum  being 
plainly  in  view,  the  appendix  is  now  found  by  follow- 
ing either  of  its  bands  down  to  its  ending. 

To  a  lesser  degree  the  Trendelenburg  position  also 
removes  the  intestines  from  the  operative  field  ;  but 
often  (and  especially  when  they  are  at  all  tympanitic) 
not  so  perfectly  as  in  the  plan  just  described,  because 
the  liver,  right  kidney,  and  hepatic  flexure  of  the  colon 
are  near  enough  to  the  wound  to  prevent  as  large  a  free 


space  being  formed  for  the  bowels  to  drop  into  as  will 
be  obtained  by  the  writer's  method. 

VI.  A  propos  of  the  curiously  dense,  scybalous  ball 
which  filled  the  sacculated  side  of  the  appendix,  as  al- 
luded to  in  the  case  recorded  here,  perhaps  it  will 
not  be  amiss  to  record  another  and  similar  instance, 
which  teaches  a  lesson. 

Last  week  the  writer  operated  upon  a  patient  of  Dr. 
H.  G.  Myers,  of  tliis  city  ;  another  little  patient  with 
gangrenous  appendix.  The  belly  was  full  of  pus 
mingled  with  fluid  faeces,  and  the  child  died  of  shock 
and  sepsis  a  few  hours  later.  The  curious  and  instruc- 
tive point  was  that  we  removed  from  the  appendix 
what  seemed  to  be  a  date-stone.  This  was  handed 
about  for  inspection,  and  no  one  questioned  its  nature. 
But  upon  being  washed,  later  on,  it  softened  and 
crumbled  into  faeces. 

I  have  seen  two  similar  cases  :  one  in  which  a  "  pea- 
nut," removed  by  another  doctor,  proved  to  be  scybal- 
ous, and  the  other  in  which  an  "  orange-pit,"  which  was 
shown  me  months  after  the  operation,  and  after  dozens 
of  people  had  accepted  its  nature  without  a  doubt  ex- 
pressed, under  the  finger-nail  finally  revealed  itself  as 
hardened  fajces. 

I  question  whether  a  large  percentage  of  supposed 
offending  fruit-seeds  may  not  be  of  this  character.  Dr. 
Fowler  and  other  writers  also  take  this  view. 

VII.  It  is  with  great  interest  that  the  writer  has  noted 
the  wide  difference  of  opinion  which  exists  regarding 
the  proper  treatment  of  the  appendix  in  ordinary  non- 
perforative  cases.  In  this  surgical  society  he  has  found 
by  casual  inquiry  three  or  four  plans  in  use  by  as  many 
different  members  with  whom  he  has  talked,  and  of 
course  referring  to  one  and  the  same  kind  of  appen- 
dices. This  fact  has  led  to  a  collection  of  different 
plans,  by  aid  of  the  library.  The  following  methods 
have  all  been  used  and  advised  by  different  writers, 
and  comprise  (save  for  minor  and  unimportant  details) 
all  the  plans  with  which  the  writer  is  acquainted  : 

1.  Division  flush  with  the  cfficum,  and  the  hole  so 
left  closed  with  one,  or  more  commonly  two,  rows  of 
Lembert  sutures. 

2.  Ligation  at  junction  with  caecum  ;  section  ;  disin- 
fection of  stump  by  dissecting  or  by  scraping  away  the 
infected  mucous  membrane.  And  finally,  attempted 
sterilizing  of  stump,  either  by  Paquelin  cautery,  or 
else  chemically,  as  by  fuming  nitric  acid,  or  rubbing 
with  a  bichloride  of  mercury  tablet,  or  apjilying  a  drop 
of  pure  carbolic  acid. 

3.  This  is  plan  No.  2,  plus  burial  of  the  stump  be- 
neath the  peritoneum  of  the  ca;cum.  This  may  be 
done  either  by  (a)  simply  one  or  two  rows  of  Lembert 
suturing,  hiding  the  stump  at  the  bottom  of  a  furrow, 
or  (b)  the  peritoneum  is  incised,  flaps  of  it  are  dissected 
up,  the  stump  (made  up  of  ligated  muscular  and  mu- 
cous coats  of  the  appendix)  tucked  beneath  these  flaps, 
which  are  then  sewn  together. 

4.  Division,  leaving  a  short  stump  of  appendix ; 
which  is  then  disinfected  by  being  cauterized  within — 
the  mucous  membrane  being  seared  by  a  slender  Pa- 
(juelin  point.  Next  the  stump  is  ligated,  thereby  bring- 
ing the  burned  surfaces  in  contact. 

5.  Same  as  method  4,  except  that  a  final  step  is  the 
closure  of  the  peritoneum  over  the  burned  and  ligated 
stump,  by  Lembert  sutures,  with  either  (a)  or  (b)  of 
method  3. 

6.  Same  as  method  5,  except  that  ligation  is  omitted. 
The  divided  appendix  has  its  stump  seared  within  ; 
and  then  the  said  very  short  stump  is  buried  beneath 
the  Cffical  peritoneum  by  one  or  two  rows  of  Lembert 
sutures. 

7.  Leaving  the  divided  appendix  stump  a  half-inch 
long  ;  sewing  its  mucous  coat  together  at  the  divided 
end  ;  then  sewing  the  ])eritoneal  coat  togedier  over 
this  ;  and  finally,  sometimes  sewing  the  stump  so  that 
its  end  is  brought  in  contact  with  adjacent  peritoneum, 
as  an  added  protection — either  that  of  tiie  ciecum,  or 


292 


MEDICAL   RECORD. 


[August  31,  1895 


perhaps  that  of  the  divided  mesentery  of  the  appen- 
dix. 

8.  Tying  and  dividing,  leaving  a  half-inch  stump. 
Disinfecting  this  as  heretofore  mentioned  (in  plan  2). 
Inverting  it  and  sewing  the  caecal  peritoneum  over  it 
by  Lembert  sutures. 

To  this  last  step — concealing  the  end  of  the  stump 
under  mesenteric  or  adjacent  omental  peritoneum — sev- 
eral writers  refer. 

9.  In  cases  greatly  softened  by  inflammation,  so  that 
stitches  cut  out  of  the  caecum,  or  a  ligature  would  cut 
through  the  appendicular  base,  we  may  apply  one  or 
more  small,  light  haemostatic  clamps  ;  diWde  distally  to 
these,  and  leave  them  in  place  a  day  or  two. 

10.  Inverting  the  entire  and  unopened  appendix  into 
the  caecum. 

11.  Doing  nothing  to  the  appendix,  if  this  organ  is 
found  so  placed,  or  so  bound  by  adhesions,  that  con- 
siderable violence  would  be  needed  in  order  to  free 
and  remove  it,  or  that  by  freeing  it  a  protecting  layer 
of  adhesions  against  peritoneal  infection  would  be 
opened  up. 

12.  The  plan  advocated  by  the  writer. 

This  last  I  have  employed  in  every  suitable  case  for 
several  years  past.  It  is  as  simple  as  it  is  effectual  and 
easy  of  accomplishment.  (It  has  recently  been  de- 
scribed by  a  writer  in  the  International  Journal  of  Sur- 
gery, together  with  a  study  of  these  eleven  other  meth- 
ods.) Regarding  the  question  of  its  novelty,  both  Dr. 
McBurney  and  Dr.  Fowler,  of  this  Society,  have  told  me 
that  it  is  new  to  them.  Dr.  Fowler  will  include  it  in 
the  new  edition  of  his  well-known  work  upon  appen- 
dicitis. A  recent  letter  from  this  gentleman,  showing 
his  estimate  of  the  device,  is  as  follows  : 

"  Dear  Dr.  D.\wbarn  :  In  reply  to  a  communication 
received  from  you  some  time  ago,  would  say  that  I  have 
attempted  your  procedure  in  six  cases,  since  you  so 
kindly  demonstrated  it  for  me  upon  the  cadaver,  at  the 
Polyclinic.  In  four  of  these  (two  of  which  were  recur- 
rent cases  operated  upon  between  attacks,  the  other 
two  being  early  acute  cases)  no  difficulty  was  experi- 
enced in  accomplishing  the  inversion.  In  a  fifth,  after 
attempting  to  invert  the  appendix  and  failing,  I  at  last 
succeeded,  after  shortening  the  appendix-stump  consid- 
erably, and  destroying  the  stenosis  at  its  base,  by  intro- 
ducing the  thermo-cautery,  and  "  boring  through,"  as 
it  were.  The  sixth  case  was  gangrenous  at  its  base 
(and  hence  not  applicable).  I  congratulate  you  upon 
this  clever  and  efficient  device  for  disposing  of  the 
stump  of  the  appendix.     I  am 

"  Yours  very  sincerely, 

"  George  R.  Fowler." 

Upon  May  29th  Dr.  Fowler  mentioned  to  me,  as  a 
posiscriptum,  four  additional  cases  in  which  he  has 
used  the  plan — all  easily  and  successfully.  He  spoke 
of  it  as  being  the  "  briefest  and  best." 

Dr.  Fowler's  assistant.  Dr.  H.  B.  Delatour,  Visiting 
Surgeon  at  the  Methodist  Episcopal  and  Norwegian 
Hospitals,  Brooklyn,  has  just  recently  written  a  note 
saying,  "  I  have  used  your  plan  in  three  cases  of  acute 
appendicitis,  and  in  two  cases  where  the  apjjcndix  was 
removed  during  operations  on  the  pelvic  organs.  It 
has  been  entirely  satisfactory,  and  is  the  best  I  know 
of.  It  has  certainly  shortened  the  duration  of  the  op- 
eration, too.  Even  in  the  acute  cases  with  adhesions, 
by  means  of  a  small,  curved  needle  the  purse-string 
suture,  which  precedes  the  inversion,  was  readily 
placed." 

Dr.  Edward  L.  Williamson  has  kindly  spent  a  part  of 
several  days  at  the  New  York  Academy  of  Medicine 
library,  looking  over  appendix  literature,  and  has  not 
found  this  plan  described.  .\nd  in  further  evidence  as 
to  priority,  I  beg  to  submit  the  two  letters  printed  at 
the  end  of  this  article.     The  steps  are  as  follows  : 

a.  A  continuous  Lembert  suture  of  silk  is  made  to 
surround  the  appendix,  running  like  a  purse-string  or 
gathering-string  in  the  superficial  layers  of  the  ccecum. 


one-fourth  inch  from  the  appendix.  This  suture  is  not 
yet  tightened,  though  the  first  half  of  a  surgeon's  knot 
is  made  ready. 

b.  The  appendix  is  divided,  leaving  a  stump  of  vari- 
able length,  but  never  shorter  than  a  half-inch. 

c.  This  stump  is  stretched  for  a  moment,  as  to  its 
calibre,  by  introducing  through  it  a  closed  pair  of 
mouse-tooth  forceps,  into  the  caecum,  and  then  gently 
opening  the  blades.  Thereby  any  stricture,  from  swell- 
ing or  plastic  deposit,  will  be  stretched  ;  and  the  next 
step  made  even  easier  than  otherwise. 

d.  The  stump  is  seized  at  the  extreme  of  its  free  end 
by  a  similar  fine-pointed  pair  of  mouse-tooth  forceps  ; 
and  the  stump  is  promptly  invaginated — turned  "  out- 
side in,"  as  a  glove-finger  might  be.  So  that  when 
completed  the  forceps  and  appendix-end  are  one-half 
inch  inside  the  caecum. 

e.  The  suture  is  tightened,  during  which  step  the 
forceps  are  withdrawn.  Sometimes  it  is  a  help  to  in- 
sert a  grooved  director  or  a  probe  between  the  open 
jaws  of  the  forceps,  prior  to  withdrawing  the  latter,  in 
order  to  prevent  the  appendix  drawing  itself  out  again 
with  them. 

In  this,  as  in  so  many  points  of  surgical  technique, 
attention  to  the  smallest  details  is  worth  while.  For 
instance,  as  the  appendix,  the  caecum,  and  the  sur- 
geon's fingers  are  all  wet  and  slipper}-,  time  will  be 
saved  by  holding  the  viscera,  during  invagination,  with 
dry  sterile  gauze. 

Again  :  During  the  stretching  of  the  canal  alluded 
to,  the  ccecum  must  be  pressed  between  thumb  and  fin- 
ger, near  the  appendicular  attachment.  Consequently, 
no  fecal  contents  can  jet  out  during  the  instant  of 
stretching. 

Of  course,  it  is  admitted  that  in  a  few  instances  the 
plan  above  advised  is  not  feasible.  For  example,  when 
the  appendix  is  gangrenous  from  end  to  end,  or  has 
entirely  sloughed  away.  More  often,  from  softening 
of  the  caecal  walls,  it  seems  wise  to  place  two  rows  of 
the  circular  purse-string  suture,  the  second  lying  a 
quarter  of  an  inch  outside  the  first. 

When  from  inflammatory  deposit  the  caecal  or  ap- 
pendical  walls  are  almost  as  rigid  as  a  pipe-stem,  it  is 
plain  that  invagination  might  not  be  feasible  nor  clos- 
ure by  a  purse- string  suture.  However,  a  moderate  de- 
gree of  stiffness  of  the  appendix  makes  the  inversion 
even  easier  than  otherwise,  by  keeping  the  lumen 
patulous. 

The  theoretical  objection  to  this  plan  has  been  sug- 
gested to  the  writer,  that  one  may  have  loss  of  time 
from  bleeding  of  the  divided  end,  which  is  not  sur- 
rounded with  the  customary  ligature.  This  objection 
is  without  basis  in  fact.  The  preliminary  ligation  and 
division  of  the  mesentery  of  the  appendix  cuts  off  its 
main  blood-supply.  Should  a  vessel  of  the  divided 
end  spurt,  I  have  found  nothing  to  be  easier  than  to 
control  it  instantly  by  torsion. 

For  the  above-detailed  technique  I  would  claim  that 
it  applies  to  this  region  the  rules  of  surgical  procedure 
used  elsewhere  by  all  surgeons  in  wounds  of  the  gut, 
namely,  to  invert  the  edges,  and  bring  peritoneal  sur- 
faces in  contact. 

What  would  be  thought  of  the  surgeon  who  should 
treat  a  wound  of  the  bowel  by  tying  a  string  around  it, 
leaving  infected  mucous  surfaces  tied  together  ?  And 
yet  is  not  this  just  what  many  operators  do  to-day 
when  they  ligate  the  appendix  at  its  base,  and  cut  off  ? 
Practically,  they  have  a  round  hole  into  a  gut,  with  a 
string  tied  about  it.  And  although  by  scraping  and 
cautery  or  caustics  they  try  to  sterilize  the  stump  be- 
yond the  ligature,  yet  the  fact  remains  that  the  ligature 
is  still  holding  two  infected  mucous  surfaces  in  contact 
which  will  not  and  cannot  be  made  to  grow  together. 
Fibrinous  exudate  over  the  stump  in  most  cases  hides 
and  protects  this  botch,  and  being  thick  prevents  a 
fistula.  But  there  are  occasional  cases  recorded  in 
which,  as  it  seems  to  the  writer,  a  subsequent  small 


August  SI,  1895] 


MEDICAL    RECORD. 


29: 


.  exit  of  fasces  at  the  wound  has  plainly  had  this  for  a 
'        primal  cause. 

If,  before  tying  the  stump,  the  mucous  membrane  be 
burned  away  by  inserting  into  the  lumen  a  delicate 
cautery  point — which  is  a  favorite  technique  of  some 
operators — then,  to  be  sure,  those  infected  mucous 
surfaces  no  longer  exist :  but  that  surgeon  is  now 
bringing  two  sloughs  in  contact.  And  sloughs  cannot 
surely  be  expected  to  grow  together,  being  dead  tis- 
sue. We  are  depending  again  upon  a  providential 
deposit  of  thick  fibrin  over  a  bad  job.  Of  course. 
Providence  generally  obliges  us ;  but  why  use  a  bad 
principle  when  a  good  one,  and  an  easier  and  safer,  is 
at  hand  ? 

In  criticism  of  the  plan  of  ligating  the  stump  (or  its 
mucous  tunic  only),  next  disinfecting  the  end  by  anv 
plan,  and  then  bringing  peritoneum  over  it,  by  sutur- 
ing, either  with  or  without  first  dissecting  back  a  cuff 
or  flaps  :  Here,  whether  a  fistula  results  or  not  de- 
pends on  whether  the  peritoneal  stitches  or  the  catgut 
ligature  on  the  buried  stump-end  give  way  first.  The 
conception  is  faulty,  because  again  you  have  foul  mu- 
cous surfaces  tied  together.  If,  too,  there  occur  a 
rapid  secretion  of  infective  fluid  in  this  hollow  stump, 
that  poison  lies  between  what  are  practically  two  liga- 
tures ;  and  may  burst  outwardly,  or  force  itself  between 
the  peritoneal  stitches,  before  the  catgut  on  the  stump 
is  absorbed. 

Whereas,  by  the  plan  the  writer  advocates,  drainage 
is  perfect  and  unopposed  into  the  cscum,  where  it 
ought  to  go,  and  the  long  inverted  stump  is  an  added 
safety  against  outward  leakage,  by  bringing  so  much 
more  of  peritoneum  in  contact. 

This  last  point  shows  the  objection  to  the  plan  of 
simply  amputating  close  to  the  caecum,  and  placing  one 
or  two  rows  of  Lembert  stitches  to  close  the  hole.  It 
is  surgical  and  correct  in  conception,  and  brings  the 
peritoneal  and  not  the  mucous  tunics  together.  But 
the  writer  contends  that  by  invaginating  a  half-inch  of 
the  appendix-stump,  when  this  can  be  done  (which  is 
almost  always),  there  is  just  that  distance  more  of  peri- 
toneal surface  brought  in  contact  as  a  safeguard  against 
leakage.  To  throw  this  safeguard  away  deliberately, 
by  cutting  the  stump  short  off  seems  to  the  writer  un- 
wise. Also,  the  necessity  for  two  rows  of  Lembert  sut- 
ures is  obviated  by  the  plan  advised  herein. 

Regarding  Dr.  Edebohl's  plan  of  inverting  the  en- 
tire and  unopened  appendix,  the  writer  can  see  no  suf- 
ficient advantage  in  doing  this  in  healthy  appendices, 
and  in  a  long  appendix  it  is  extremely  difficult.  In 
the  diseased  organ  it  will  generally  be  found  impossible 
of  accomplishment.  Severing  and  stretching  the  canal 
for  a  moment  by  the  plan  advocated  in  this  paper  are 
essential,  as  a  rule,  in  order  to  invert  a  stump  of  more 
than  merely  trivial  length,  because  of  the  plastic  and 
congestive  strictures  so  often  present. 

VIII.  Finally,  the  writer  would  say  that  he  attrib- 
utes the  little  patient's  recovery,  whose  case  has  been 
to-night  discussed,  mainly  to  the  thoroughness  with 
which  flushing  of  the  bowels  and  peritoneal  cavity  was 
performed. 

As  a  rule,  wiping  away  pus  or  blood  or  faeces  is 
doubtless  much  safer  than  irrigation,  provided  these 
fluids  be  localized.  But  if  diffused,  that  alters  the  case. 
And  if  we  must  irrigate,  it  is  certain  that  withdrawal  of 
the  bowels  outside,  so  far  as  adhesions  permit,  greatly 
aids  thorough  cleansing,  both  of  intestines  and  of  the 
various  peritoneal  pouches  and  recesses. 

In  a  paper  published  recently  (see  Medical  Record, 
March  30,  1895),  Dr.  McBumey  reports  a  series  of 
most  interesting  cases  of  this  kind,  treated  by  irri- 
gation with  salt  solution  and  packing,  just  as  this 
one  was.  But  if  Dr.  McBurney  withdrew  the  bowels 
in  any  cf  these  instances,  it  was  at  least  not  men- 
tioned. 

Of  course  it  is  plain  that  there  may  be  some  added 
shock  from  the  procedure,  but  as  absolute   thorough- 


ness alone  offers  the  least  hope  in  these  desperate  cases, 
the  withdrawal  seems  the  lesser  evil. 

105  WaST   SEVEN-n'-FOL-RTH    STREET.  JunC  25,  1895. 

'■  United  States  N.wal  Hospital, 
"  Pensacola,  Fl.\.,  April  24,  1895. 

"  My  Dear  Doctor  :  Your  note  of  April  21st  has 
just  reached  me  and  I  hasten  to  reply. 

"  In  regard  to  the  technique  as  to  the  treatment  of 
the  stump  after  operation  in  cases  of  appendicitis,  I 
have  not  only  a  distinct  recollection  of  the  plan  you 
suggested,  but  I  have  notes  made  at  the  time  of  your 
demonstrations.  It  is  four  years  since  I  first  saw  you 
demonstrate  the  plan,  April,  1891,  and  less  than  six 
weeks  since  I  saw  you  again  demonstrate  the  same 
method.  It  strikes  me  that  such  a  simple  method  as 
turning  '  outside-in  '  the  stump  of  the  appendix,  and 
tightening  a  previously  arranged  purse-string  suture, 
would  have  occurred  to  one  as  a  simple  and  radical 
method  of  treating  the  long  stump.  If  the  credit  of 
having  established  this  neat  procedure  is  due  to  you — 
and  to  establish  your  claim  you  needs  must  show  that 
you  demonstrated  it  in  iSgo  and  1891 — I  cheerfully 
state  that  in  April,  1891,  I  was  a  member  of  your 
Operative  Surgery  Class  in  the  Polyclinic,  and  again 
in  February  and  March,  1895  :  and  in  the  presence  of 
both  classes  you  showed  the  method  of  inverting  the 
long  stump  and  the  use  of  the  purse-string  suture  in 
the  cjecum  about  the  base  of  the  appendix.  You  ask 
me  to  describe  the  plan  you  showed  in  1 891,  as  I  re- 
member it.  In  my  notes,  I  find  that  there  were  four 
steps  in  the  procedure  before  tying  :  i.  A  continuous 
suture  of  silk  around  the  appendix  (Lembert"s  suture) 
in  the  superficial  layers  of  the  caecum  ;  tie  first  part  of 
surgeon's  knot,  but  do  not  tighten.  2.  Cut  the  appen- 
dix, lea\-ing  a  stump  at  least  one-half  inch  long.  3. 
Stretch  calibre  of  the  stump.  4.  Seize  and  invert  end 
of  stump  by  using  mouse-toothed  forceps.  Now  tighten 
the  purse-string  suture  while  withdrawing  the  forceps. 

"  I  trust  that  this  may  serve  the  purpose  for  which 
you  wish  it.  I  am  sure  that  Dr.  Arnold  and  Dr.  Brewer 
can  substantiate  what  I  state.  Dr.  Arnold  is  now  in 
China  on  the  Petrel. 

"  With  best  wishes,  I  am 
"  Cordially  yours, 

"  James  Shirley  Hope, 
Passed  Assistant  Surgeon,  U.  S.  Naiy. 

"To  Dr.  H.  M.  Dawbarn." 

•'  United  States  Steamship  Petrel, 
Asiatic  St.\tion,  May  24,  1895." 

"  I  wish  to  be  a  witness  that,  in  .A.pril,  1891,  I  took  a 
course  at  the  New  York  Polyclinic  in  Operative  Sur- 
gery under  Dr.  Robert  H.  M.  Dawbarn,  the  other 
members  of  this  class  being  Assistant  Surgeon  James 
F.  Keeney,  U.  S.  N.  (now  deceased),  Dr.  J.  S.  Hope, 
at  present  also  a  member  of  the  Xavy  Medical  Corps, 
and  Drs.  M.  M.  Brewer,  S.  B.  Jenkins,  and  J.  N.  Jack- 
son ;  that  during  said  course  Dr.  Dawbarn  demon- 
strated, as  the  usual  technique  with  him  in  treating 
cases  of  appendicitis,  the  operation  detailed  below  ; 
and  I  can  be  the  more  certain  of  the  steps  involved, 
because  I  performed  the  operation  in  question  upon 
the  cadaver  under  his  directions  and  made  up  my 
notes  of  it  from  memory  immediately  afterward. 

^^ Steps  of  Procedure. — i.  After  exposure  and  isola- 
tion of  the  appendix,  a  continuous  Lembert's  suture  of 
silk  is  applied  in  the  superficial  layers  of  the  cascum, 
so  as  to  surround  the  head  of  the  appendix  at  a  dis- 
tance from  its  insertion  of  about  one-fourth  of  an  inch. 
Then  the  first  turns  of  a  surgeon's  knot  are  made  ready 
to  be  tightened.  2.  The  appendix  is  to  be  removed  so 
as  to  leave  a  stump  of  a  length  of  one-half  an  inch,  if  its 
condition  will  admit  of  this.  3.  The  lumen  of  this  stump 
is  stretched  by  the  gentle  separation  of  the  blades  of  a 
pair  of  slender  forceps  inserted  through  it  into  the  cae- 
cum. 4.  The  stump,  thus  freed  from  plastic  adhesions 
or  other  contractures,  is  then  to  be  inverted  into  the 


294 


MEDICAL   RECORD. 


[August  31,  1895 


caecum  by  passing  the  cut  end  of  the  appendix-stump 
into  its  lumen  in  the  grasp  of  a  pair  of  slender-jawed, 
fine-toothed  forceps,  upon  which  the  purse-string  su- 
ture is  then  gently  drawn.  5.  After  the  withdrawal  of 
the  forceps,  this  suture  is  drawn  in  until  the  peritoneal 
surfaces  are  closely  opposed,  when  it  is  to  be  made 
fast. 

"\V.  F.  Arnold,  M.D., 
"  Passed  Assistant  Surgeon,  U.  S.  Naiy." 


REPORT    OF    INTUBATION    CASES.' 
Bv  FREDERIC  M.  WARNER,  M.D., 


The  increase  in  favor  of  the  operation  of  intubation 
over  tracheotomy  in  this  country  has  been  steady  and 
constant.  The  latter,  formidable  at  best  to  the  lay 
mind,  involving  the  abhorrent  cutting  of  the  tissues 
and  the  sight  of  blood,  has  in  the  majority  of  instances 
been  performed  under  the  greatest  disadvantages ; 
scarcely  ever  permitted  until  the  patient  has  been  be- 
yond chance  of  recovery.  Intubation,  on  the  other 
hand,  when  properly  explained  to  the  child's  guardians, 
never  meets  with  any  opposition,  except  from  the 
densely  ignorant,  and  it  may  be  done  as  early  in  the 
disease  as  the  operator  deems  necessary.  In  Europe, 
where  they  have  been  loath  to  believe  that  the  genius 
and  perseverance  of  O'Dwyer  have  succeeded  where 
Bouchut  failed  after  halting  on  the  brink  of  discovery, 
the  operation  is  handicapped  by  doubts  and  improperly 
made  instruments.  This  series  of  cases  that  I  am  go- 
ing to  relate  is  numerically  small,  only  twenty  in  num- 
ber, but  in  detail  full  of  interest  to  those  to  whom  this 
subject  appeals. 

They  were  all  desperate  cases,  in  my  opinion  and 
in  the  judgment  of  those  who  saw  them  with  me. 
They  would  have  each  and  all  terminated  fatally  with- 
out operation — even  if  the  calomel  sublimation  treat- 
ment, which  has  modified  the  prognosis  in  croup  to  a 
considerable  extent,  had  always  been  employed.  Many 
cases  have  recovered  under  this  treatment  which  for- 
merly would  have  only  survived  by  the  aid  of  operative 
interference :  but  again,  there  are  many  cases  which 
are  not  influenced  favorably  by  the  inhalation  of  va- 
porized calomel,  no  matter  how  early  in  the  disease  this 
agent  is  employed. 

C.A.SE  I. — H.  M ,  five  years  of  age,  male.  Mem- 
branous exudate  on  nasal  and  pharyngeal  mucous  sur- 
face and  in  larynx  ;  albumin  in  urine  ;  child  had  been 
sick  ten  da)s  ;  the  larynx  had  been  involved  about 
four  days.  There  was  marked  supra-  and  infra-sternal 
depression,  with  extreme  dyspnoea  and  lividity  of  sur- 
face. Upon  introduction  of  the  No.  3  to  4  tube  a  piece 
of  false  membrane  about  two  inches  in  length  was  ex- 
pelled, to  the  relief  of  all  the  distressing  symptoms. 
The  tube  remained  in  the  larynx  four  days,  when  it  was 
coughed  out,  and  the  child  made  an  uninterrupted  re- 
covery. 

Case  II. — H.  P ,  aged   twenty  months,    female. 

Extensive  membranous  deposit  upon  tonsils  and  in 
pharynx  and  in  larynx  ;  extreme  dyspnoea.  Child  had 
been  sick  eight  days,  but  the  laryngitis  had  been  pres- 
ent only  about  twenty-four  hours.  .  A  No.  i  tube  was 
introduced  about  9  .a.m.  and  the  child  did  well,  breath- 
ing easily  until  about  5  p.m.  of  the  same  day,  when  the 
temperature  commenced  to  go  up  rapidly,  coincident 
with  the  extension  of  membrane  into  the  lung,  and 
death  occurred  eighteen  hours  after  introduction  of  the 
tube,  which  was  removed  post  mortem,  lumen  clear. 

Case  111. — S ,  aged  five   years,  male,  had   been 

'  Read  before  Section  on  Pediatrics,  New  Yorli  .'\cademv  of  Medi- 
cine, May  9,  1895. 


sick  eight  days,  with  twenty-four  hours  of  laryngeal  com- 
plication. When  I  saw  the  child  there  was  consider- 
able membranous  deposit  in  the  pharynx,  together  with 
a  great  deal  of  oedema.  A  No.  3  to  4  tube  which  was 
introduced  was  coughed  out  at  the  end  of  twenty- four 
hours.  The  dyspncea  continuing,  the  same  tube  was 
reinserted  and  was  again  coughed  out  in  about  twelve 
hours.  Ten  hours  later,  the  breathing  becoming  very 
difficult,  I  introduced  a  No.  5  tube,  the  next  larger  size. 
Three  days  afterward  the  child  expelled  this  tube  and 
went  on  to  complete  recovery. 

Case    IV. — R ,    aged    three,   male.      The   child 

had  been  sick  about  twenty-four  hours.  Large  mem- 
branous deposits  on  tonsils  and  wall  of  pharynx,  as- 
sociated with  extreme  dyspncea.  A  No.  2  tube  was 
introduced  and  the  patient  did  well  for  four  days,  when 
the  membrane  commenced  to  extend  downward,  and 
in  twenty-four  hours  the  child  was  dead.  The  tube 
was  removed  post  mortem. 

Case  V. — B ,  aged  four,  female.  False  mem- 
brane on  tonsils  and  pharynx.  Child  had  been 
hoarse  about  two  days.  The  case  was  very  urgent,  the 
dyspnoea  being  extreme.  A  No.  3  to  4  tube  was  intro- 
duced with  immediate  relief,  and  the  case  progressed 
favorably.  At  the  end  of  six  days  the  tube  was 
coughed  out,  and  although  the  child  was  suffering  from 
the  toxic  effects  of  the  disease  the  laryngitis  had  appar- 
ently disappeared.  Four  days  afterward  the  patient 
again  became  croupy,  and  it  was  necessary  to  again  in- 
sert the  tube.  Three  days  afterward,  during  a  parox- 
ysm of  coughing,  the  tube  was  expelled,  but  I  was 
obliged  to  reinsert  it  in  about  two  hours  to  relieve  the 
difficulty  in  breathing.  The  child  died  about  twelve 
hours  afterward  of  blood-poisoning. 

This  is  one  of  the  most  interesting  cases  that  I  have 
seen,  showing,  as  it  does,  that  life  was  prolonged  about 
fourteen  days  by  the  employment  of  the  operation  of 
intubation. 

Case    VI. — T ,  aged    five,  female.      The   child 

had  been  sick  about  three  days,  dyspnoea  having 
been  present  twelve  hours  when  I  saw  it.  It  was  a 
desperate  case  ;  the  throat  was  swollen  and  a  mass  of 
false  membrane.  The  child  was  livid  and  apparently 
lifeless.  As  a  forlorn  hope,  not  that  I  expected  any 
result,  I  introduced  tube  No.  5  and  tried  artificial  res- 
piration, with  no  effect.  I  then  pulled  out  the  tube  by 
the  attached  thread,  and  a  little  membrane  and  muco- 
pus  came  with  it.  The  patient  began  then  to  respond  to 
the  efforts  at  artificial  respiration.  Some  whiskey  hy- 
podermically  helped  restore  the  heart's  action  and  the 
child  coughed  out  more  membrane  and  muco-pus,  and 
then  breathed  freely.  Ten  hpurs  afterward  I  found 
the  patient  cyanotic  and  almost  pulseless.  I  intro- 
duced tube  No.  5,  through  which  the  patient  expelled 
considerable  false  membrane.  Twelve  hours  afterward 
I  saw  the  child  breathing  easily  and  in  good  condition, 
except  that  the  heart's  action  was  feeble.  I  cautioned 
the  mother  particularly  to  keep  the  child  lying  in  bed 
and  not  allow  it  to  be  agitated  or  disturbed.  One  hour 
afterward  the  child  suddenly  sat  up  in  bed,  and  fell 
back  dead.  I  removed  the  tube  post  mortem  and 
found  tlie  lumen  clear. 

Case   VII. — D ,  aged  two,  male.     The   patient 

in  this  case  had  been  suffering  from  dyspnoea  for 
two  days.  Tliere  was  no  membrane  to  be  seen  in  the 
throat.  On  introduction  of  tube  No.  2  several  large 
pieces  of  membrane  were  forcibly  expelled,  and  the 
child  was  left  in  perfectly  comfortable  condition,  but 
died  sixteen  hours  afterward,  presumably  of  extension 
downward  of  the  false  membrane. 

Case    VIII. — M ,    aged    sixteen    months,    male. 

Six  weeks  previously  this  patient  had  an  attack  of 
measles,  and  since  that  time  there  had  been  more  or 
less  croupy  breathing.  Suddenly  one  morning  he  was 
seized  with  an  attack  of  dyspniva  wliich  became  very 
rapidly  more  intense.  A  No.  i  tube  was  introduced 
four  hours  afterward  with  considerable  relief,  but  the 


August  31,  1895] 


MEDICAL   RECORD, 


295 


child  died  sixteen  hours  later  of  extension  downward 
of  the  membrane. 

Case  IX.^L.  S ,  aged  five,  female.     This  patient 

had  been  suffering  from  a  croupy  cough  and  voice  about 
ten  days.  Upon  insertion  of  a  No.  3  to  4  tube  con- 
siderable muco-pus  and  false  membrane  were  expelled, 
and  about  fifteen  minutes  afterward,  during  an  attack 
of  coughing,  the  child  became  suddenly  livid  and  gasped 
for  air.  I  realized  that  the  tube  had  become  occluded 
with  detached  membrane,  and  as  in  those  days  I  used 
to  cut  off  the  thread  as  soon  as  the  tube  was  in  place, 
I  could  not  pull  it  out.  My  extractor  was  in  the  case 
on  the  other  side  of  the  room,  and  rapidity  of  action 
was  imperative.  The  child  was  sitting  on  the  lap  of 
the  nurse  directly  in  front  of  me.  With  the  fingers  of 
my  left  hand  I  forced  up  the  larynx  externally,  and  I 
saw  easily  the  tube  ride  up  back  of  the  epiglottis.  I 
seized  and  extracted  it  by  the  tips  of  two  fingers  of  the 
right  hand.  This  was  followed  by  the  expulsion  of 
false  membrane  and  muco-pus.  The  child  now  breathed 
with  freedom,  and  was  perfectly  comfortable.  The 
following  day  the  patient  again  became  very  cyanotic, 
and  the  tube  was  reintroduced.  Almost  immediately 
the  same  phenomena  of  occlusion  of  the  tube  occurred. 
The  thread  this  time  being  still  attached,  the  tube  was 
rapidly  withdrawn  ;  the  child  expelled  a  quantity  of 
false  membrane,  which  had  probably  been  loosened 
and  dislodged  by  the  introduction  of  the  tube.  It  was 
not  necessary  to  again  intubate,  and  the  child  made  a 
good  recovery.  In  this  case  calomel  vaporization  was 
employed. 

Case  X. — L ,  aged  four,  female.     This  was  a  very 

bad  case,  the  dyspnoea  had  existed  about  twenty-four 
hours,  with  a  great  deal  of  false  membrane  in  the  phar- 
ynx and  on  tonsils,  with  considerable  swelling  of  glands 
of  the  neck,  as  the  child  was  extremely  small  for  its 
age.  .\  No.  2  tube  was  introduced,  and  with  the  ex- 
pulsion of  false  membrane  great  relief  was  obtained, 
but  the  child  died  thirty-two  hours  afterward  from 
extension  downward.  Calomel  vaporization  was  em- 
ployed in  this  case. 

Case  XI. — C ,  aged  five,  female.  Extreme  dysp- 
noea. Disease  had  been  present  about  one  week  ; 
more  or  less  croup  during  this  period.  Upon  intro- 
duction of  No.  3  to  4  tube  the  child  coughed  up  a  great 
deal  of  muco-pus,  but  no  membrane,  and  became  im- 
mediately relieved.  Saw  the  child  again  thirteen  hours 
afterward,  sleeping  quietly  and  breathing  easily.  ^Vas 
summoned  two  hours  later  and  found  the  patient  mori- 
bund, dying  at  once.  An  autopsy  was  refused,  the 
parents  even  forbidding  me  to  remove  the  tube.  Cal- 
omel vaporization  was  used  in  this  case. 

Case  XII. —  h -,  aged  three  years  and  six  months, 

female.  Laryngeal  symptoms  had  been  present  twen- 
ty-four hours.  The  child  was  suffering  extremely 
when  a  No.  2  tube  was  introduced.  Relief  occurred 
at  once,  but  death  took  place  thirteen  hours  later  from 
extension  downward  of  the  membrane.  Calomel  vapori- 
zation was  employed  in  this  case. 

Case    XIII.  —  H ,   aged   seven    years    and    six 

months,  female.  This  was  a  case  of  diphtheria  follow- 
ing measles.  A  croupy  cough  had  been  present  about 
twenty-four  hours.  After  introduction  of  a  No.  5  to 
7  tube  considerable  muco-pus  and  a  small  amount  of 
membrane  were  expelled.  Child  died  three  days  after- 
ward from  extension  downward.  Calomel  vaporization 
was  employed  in  this  case. 

Case  XIV. — S ,  four  years  of  age,  female.     Croup 

had  persisted  for  twelve  hours  and  the  child  was  rapidly 
becoming  cyanotic.  Great  relief  was  obtained  upon 
introduction  of  No.  3  to  4  tube.  The  child  was  doing 
well,  when  it  coughed  up  the  tube  sixteen  hours  after- 
ward and  died  of  suffocation  before  I  could  reach  the 
house,  though  summoned  at  once. 

Case    XV.  —  G ,   aged    fifteen   months,  female. 

This  was  a  very  interesting  case,  but  hopeless  from  the 
first  on  account  of  a  capillary  bronchitis  complicating 


the  croup,  and  the  age  of  the  patient.  The  patient 
had  been  sick  at  least  a  week  when  it  was  seen  by  me. 
A  No.  2  tube  was  at  once  introduced,  but  did  not  give 
any  appreciable  relief,  and  the  child  died  three  hours 
later. 

Case  XVI. — B ,  aged  two  years  and  six  months, 

female.  The  child  had  been  suffering  from  diphtheria 
with  membranous  deposits  on  tonsils  and  pharynx  for 
six  days.  During  the  last  two  days  croupy  respiration 
was  present.  Great  relief  was  obtained  upon  the  in- 
troduction of  tube  No.  2.  Forty  hours  afterward 
the  patient  died  from  extension  of  the  membrane 
downward.  Calomel  sublimation  was  employed  in 
this  case  faithfully,  and  for  awhile  with  seeming  bene- 
fit. 

Case  XVII.^G.  G ,  aged  seven,  male.     This  boy 

had  been  suffering  from  diphtheria  ten  days,  the  last 
five  of  which  he  had  been  croupy,  which  condition  in- 
creased so  rapidly  on  the  tenth  day  that  when  I  saw 
him  he  was  suffering  intensely  from  lack  of  air,  and  was 
old  enough  to  appreciate  the  cause.  Introduction  of 
No.  5  to  7  tube  was  followed  by  instant  relief.  Fifteen 
hours  afterward,  during  an  attack  of  coughing,  the 
father  became  frightened,  thought  the  boy  was  choking, 
and  pulled  out  the  tube  by  means  of  the  thread  which 
was  left  attached.  The  patient  breathed  with  ease  for 
awhile,  but  twelve  hours  later  it  became  necessary  to 
reintroduce  the  tube.  It  remained  in  place  about  five 
minutes,  when  it  was  coughed  out,  and  I  introduced 
one  of  the  next  larger  size  ;  thereupon  the  child  gagged 
and  coughed,  expelling  the  tube  together  with  a  com- 
plete membranous  cast  of  the  trachea  and  the  bifurca- 
tion. After  this  the  child's  respirations  were  easy,  and 
I  left  it  without  a  tube.  Three  days  later  I  was  sum- 
moned hastily  and  found  the  child  as  before,  cyanotic 
and  greatly  distressed  for  lack  of  air.  I  reintroduced 
the  tube,  and  again  it  was  expelled  with  another  com- 
plete cast  of  the  trachea.  Then,  as  the  patient  seemed 
perfectly  comfortable  once  more,  we  left  him  without 
reintroducing  the  tube.  Calomel  vaporization  was 
begun  at  this  time  and  the  details  carried  out  faithfully, 
and  the  child  made  a  good  recovery. 

Case  XVIII. — \V ,  aged  five,  male.     This  patient 

was  seen  on  the  fourth  day  of  the  disease.  The  mem- 
brane had  already  invaded  the  lung,  and  a  No.  5  to 
7  tube  was  introduced  to  see  if  it  would  make  any 
difference  in  the  respiration.  There  was  but  slight 
appreciable  effect  and  the  child  died  within  an  hour. 

Case    XIX. — D ,  aged   eighteen   months,    male. 

Child  had  been  sick  four  or  five  days.  There  was 
membrane  on  the  tonsils  and  pharynx,  and  the  dyspnoea 
was  extreme.  Immediate  relief  was  obtained  upon  in- 
troduction of  a  No.  I  tube,  the  child  expelling  a  great 
deal  of  false  membrane  and  muco-pus.  Four  hours  after- 
ward the  child  coughed  out  the  tube,  and  it  was  not 
necessary  to  reintroduce  it.  The  patient  made  a  good 
recovery.  In  this  case  calomel  sublimation  was  em- 
ployed with  considerable  benefit. 

Case  No.  XX. — B.  W ,  aged  seven,  male.     This 

child  had  had  influenza,  followed  by  a  slightly  croupy 
cough  lasting  about  two  weeks,  the  last  four  days  of 
which  it  grew  steadily  worse.  The  ])arents  did  not  real- 
ize the  gravity  until  the  child's  condition  became  critical, 
when  I  was  called.  Upon  introduction  of  a  No.  5  to  7 
tube  a  small  piece  of  membrane  about  one  inch  in 
length  was  expelled,  together  with  considerable  muco- 
pus.  There  was  no  membrane  visible  on  the  tonsils 
or  in  the  pharynx  ;  there  was  no  elevation  of  temper- 
ature, and  the  child  was  apparently  not  sick  except 
that  there  was  the  mechanical  obstruction  to  respira- 
tion— which  the  tube  removed.  The  patient  wore 
the  tube  until  the  seventh  day,  when  it  was  removed, 
encrusted  with  calcareous  deposits — and  the  child  was 
well. 

In  conclusion,  of  the  twenty  cases  intubated  six  re- 
covered— thirty  per  cent.  Ten  cases  were  treaterd  with 
calomel  sublimation  in  addition — of  these  three  recov- 


296 


MEDICAL   RECORD. 


[August  31,  1895 


ered.  The  other  treatment  consisted  in  the  adminis- 
tration of  iron  bichloride  and  stimulants,  with  the 
local  application  of  peroxide  of  hydrogen. 

56  West  FiKrv-sixTH  Street. 


ADENOID     GROWTHS     OF     THE    NASO- 
PHARYNX.' 

By  T.  C.  EVANS,  M.D., 


In  the  animal  economy  we  find  a  system  or  series  of 
lymphoid  or  adenoid  masses,  situated  in  different  loca- 
tions along  the  alimentary  canal  and  the  respiratory 
tract,  varying  in  number  and  location  according  to 
the  habits  and  environments  of  the  different  species. 
These  lymphoid  masses  appear  to  be  modified  or  spe- 
cialized lymphatic  glands,  or  at  least  they  are  inti- 
mately connected  with  the  lymphatic  system.  In  man 
and  other  omnivorous  mammals  these  masses  of  lym- 
phoid tissue  form  a  circle,  or  more  properly  speaking, 
two  or  more  less  complete  circles,  one  surrounding  the 
naso-pharyngeal  portion  of  the  respiratory  tract,  the 
other  the  oro-pharyngeal  portion  of  the  alimentary  canal. 
These  circles  are  often  described  as  the  lymphoid  ring, 
and  embrace  the  faucial  tonsils,  the  pharyngeal  tonsil, 
the  glandular  bodies  at  the  base  of  the  tongue,  as  well 
as  many  smaller  masses.  Besides  the  lymphoid  ring, 
these  masses  are  also  found  in  the  lower  reaches  of  the 
alimentary  canal,  in  the  jejunum,  and  especially  the 
ileum — here  they  are  known  as  agminated  glands,  or 
"  Peyer's  patches."  The  e.xact  function  of  these  masses 
is  still  somewhat  obscure,  but  it  has  been  pretty  clearly 
demonstrated  that  they  possess  a  phagocytic  action,  the 
lymphocytes  which  make  their  way  in  and  out  these 
masses  have  the  power  of  taking  up  the  various  forms 
of  bacteria  and  destroying  them.  The  process  appears 
to  be  similar,  or  rather  supplemental,  to  the  general 
phagocytosis  exhibited  by  the  leucocytes  of  the  general 
circulation.  This  phagocytic  power  is  evidently  in- 
tended to  protect  the  animal  against  infection  by  in- 
gested or  inhaled  bacteria.  But  in  diseased  conditions 
of  these  masses,  instead  of  protecting  against  the  intro- 
duction of  bacteria,  they  become  channels  of  invasion. 
The  lymphocytes  still  possessing  the  power  of  migra- 
tion, and  of  enveloping  bacteria  and  carrying  them 
from  the  surface,  appear  to  have  lost  their  bactericidal 
power  ;  instead  of  doomed  prisoners  the  bacteria  be- 
come mutinous  parasites,  feeding  and  multiplying  on 
the  protoplasm  of  the  cells,  while  they  are  being  car- 
ried to  a  neighboring  lymphatic  gland. 

In  this  paper  I  wish  only  to  speak  of  the  abnormal 
condition  of  those  masses  of  lymphoid  tissue  situated 
in  that  part  of  the  respiratory  tract  known  and  de- 
scribed as  the  naso-pharynx — the  disease  commonly 
known  as  adenoid  growths  of  the  naso-pharynx.  Meyer, 
of  Copenhagen,  in  186S,  was  the  first  to  fully  describe 
this  condition.  Czrmak,  in  i860,  Volintini  aiid  l.owen- 
berg,  in  1S65,  all  seem  to  have  observed  the  phenome- 
non, but  for  some  reason  failed  to  appreciate  its  im- 
portance. So  Meyer  is  considered,  and  justly  so,  the 
discoverer  of  lymphoid  hypertrophies  in  the  naso- 
pharynx. 

The  disease  consists  of  an  hypertrophy  of  the  lym- 
phoid tissue  that  encircles  the  naso  pharyngeal  portion 
of  the  respiratory  tract,  blocking  up  the  space  and 
mechanically  interfering  with,  or  altogether  inhibiting, 
nasal  respiration.  This  hyi)ertroi)hy"usually  involves, 
to  a  greater  or  less  extent,  the  faucial  tonsils  and  other 
contiguous  lymphoid  masses.  Except  that  heredity 
seems  to  play  some  part  in  its  production,  and  that  it 
is  essentially  a  disease  of  childhood,  little  can  be  said  as 
to  its  etiology. 

'  Read  at  the  Kentucky  State  Medical  Society,  H.irrodsbur?,  Kv 
June  i6.  1895.  =1      .  ' 


The  diagnosis  is  easily  made  from  the  characteristic 
symptoms  which  have  been  so  fully  and  frequently  de- 
scribed. The  open  mouth,  the  elongated  face,  the  ex- 
pressionless countenance,  the  dead  or  nasal  voice,  the 
inability  to  articulate  certain  consonants,  the  viscid 
mucus,  the  disturbed  sleep,  with  its  sweats,  snoring,  and 
night-terrors,  the  chest  deformity,  deafness,  and  men- 
tal hebetude,  all  make  a  picture  that  can  hardly  be 
mistaken.  But  if  these  are  not  sufficient,  positive  evi- 
dence can  be  had  by  passing  the  index-finger  into  the 
naso-pharynx  and  making  a  thorough  survey  of  its  walls 
and  contents.  This  procedure  is  easily  accomplished  ; 
while  causing  considerable  pain  it  cannot  possibly  do 
any  harm.  In  older  children  some  information  can 
be  obtained  by  the  use  of  the  rhinoscope.  In  addi- 
tion to  the  impaired  hearing,  the  deformities  of  nasal, 
buccal,  and  thoracic  cavities,  which  are  among  the 
most  distressing  and  persistent  of  the  sequela,  and 
have  been  recognized  since  the  days  of  Meyer,  I 
wish,  also,  to  call  your  attention  to  another  danger 
from  diseased  lymphoid  tissue  that  has  until  quite  re- 
cently been  overlooked — that  of  a  channel  for  tuber- 
cular infection.  Though  diseased  lymphoid  masses 
have  long  been  recognized  as  fruitful  source  of  infec- 
tion in  diphtheria  and  the  exanthemata,  attention  was 
not  called  to  the  fact  that  they  played  an  important 
role  in  tubercular  infection  until  1894,  when  Dr.  Sims 
Woodhead  delivered  an  address  before  the  North  Lon- 
don Medico- Chirurgical  Society  on  "  The  Channels  of 
Infection  in  Tuberculosis,".'  in  which  he  forcibly  de- 
monstrated the  dangers  from  diseased  lymphoid  masses, 
especially  the  pharyngeal  tonsils.  In  speaking  of  the 
part  played  by  the  "  lymphoid  ring  "  he  said  :  "  It  is 
found  when  pigs  are  fed  on  tuberculous  material  held 
in  solution,  especially  if  the  solution  contains  fatty  or 
viscid  material,  that  in  a  very  large  proportion  of  cases 
these  animals  become  affected  with  tuberculosis  of  the 
gland  associated  with  the  tonsils."  Further  on  he 
says  :  "  So  far  as  can  be  made  out  from  a  careful  con- 
sideration of  the  results  reported  by  observers  who 
have  collected  statistics,  and  have  performed  feeding 
experiments,  and  from  my  own  observation  of  a  num- 
ber of  similar  experiments,  I  am  driven  to  the  con- 
clusion that  this  method  of  infection  of  the  glands  of 
the  neck  through  the  tonsils  must  be  of  comparatively 
frequent  occurrence,  especially  in  children  living  under 
unsanitary  conditions,  and  subjected  to  various  devi- 
talizing influences." 

After  describing  the  process  of  invasion  in  the  pig 
from  the  tonsil  to  the  glands  in  the  neck,  and  to  the 
thorax  by  the  mediastinal  and  post-sternal  lymphatics, 
and  by  the  intercostal  lymphatics,  until  the  glands  at 
the  root  of  the  lungs  become  infected,  he  says;  "Of 
course,  in  children  it  is  not  possible  to  demonstrate  this 
line  of  invasion  in  the  same  way  that  one  can  in  ex- 
perimental animals,  for  the  simple  reason  that  in  ex- 
perimental animals  the  disease  can  be  traced  from  the 
very  earliest  stages  to  the  time  at  which  marked  ex- 
ternal signs  of  tuberculous  glands  make  their  appear- 
ance ;  but  sufficient  can  be  made  out  by  anyone  who 
will  classify  the  results  of  a  large  number  of  post-mor- 
tem examinations  of  children,  when  the  conditions  of 
the  glands  of  the  various  parts  of  the  body  have  been 
noted,  to  convince  him  that  the  process  of  invasion  of 
the  tonsil,  or  at  any  rate  of  the  lymphoid  tissue  in  this 
region,  is  of  a  comparatively  frequent  occurrence ; 
much  more  frequent  than  even  those  who  have  exam- 
ined a  large  number  of  cases  of  tubercle  in  children 
are  at  first  inclined  to  suppose.  The  very  cells,  then, 
which  in  health  have  to  do  with  the  destruction  of  ba- 
cilli, and  with  protecting  the  organism  against  their  in- 
vasion, are  those  which  appear  to  be  responsible  for 
the  conveyance  of  tubercle  bacilli  from  the  outer  sur- 
face to  the  tissues  beneath." 

From  the  researches  and  experiments  of  Dr.  Wood- 

'  Lancet,  October  27,  iSgq. 


August  31,  1895] 


MEDICAL   RECORD. 


297 


head,  it  is  evident  that  a  considerable  number  01  the 
cases  of  pulmonary  tuberculosis,  especially  in  early  life, 
are  secondar)-  to  tuberculosis  of  the  bronchial  glands 
at  the  root  of  the  lungs,  and  that  in  many  cases  the 
channel  of  infection  is  through  the  pharj-ngeal  or  fau- 
cial  tonsils.  Besides  the  abnormal  condition  of  the  tis- 
sues themselves  in  hypertrophy  of  the  pharyngeal  ton- 
sils, we  have  constantly  present  a  surface  of  greater  or 
less  extent  denuded  of  its  epithelium,  as  is  shown  by 
the  small  quantities  of  blood  which  so  often  streaked 
the  viscid  secretion  from  the  naso-pharjiix. 

I  think  it  is  reasonable  to  conclude  that  the  enlarged 
cervical  and  bronchial  glands  which  so  constantly  ac- 
company l)-mphoid  hypertrophies,  are  due  to  tubercu- 
lar infection  through  this  channel ;  that  instead  of  be 
ing  a  part,  a  diathesis,  or  dyscrasia,  which  has  gener- 
ally been  described  as  h-mphatism  or  scrofula,  they  are 
most  likely  the  result  of  tubercular  infection  through 
the  diseased  lymphoid  masses,  either  of  the  phar)T3geal 
ring  or  of  the  Peyer's  patches. 

To  again  quote  from  the  article  of  Dr.  AVoodhead, 
he  says  :  "  I  am  sure  that  those  of  you  who  have  made 
any  considerable  number  of  post-mortem  examinations 
of  the  bodies  of  tuberculous  patients,  who  have  suc- 
cumbed at  various  periods  of  life,  will  agree  with  me 
in  this,  that  the  affection  of  the  lung  often  appears  to 
(although  the  ultimate  cause  of  death)  be  merely  a 
secondary  affection.  I  have  seen  case  after  case  in 
children,  and  in  animals  fed  on  tuberculous  material, 
the  lung  markedly  affected,  but  in  a  large  proportion 
of  these  cases  it  has  been  possible  to  trace  the  course 
of  invasion  back  from  a  caseous  or  old  calcareous  mes- 
enteric gland  through  the  chain  of  retro-peritoneal 
glands,  up  through  the  diaphragm  to  the  posterior  me- 
diastinal and  bronchial  glands,  and  so  on  to  the  lungs. 
I  have  not  seen  this  in  a  few  cases  only,  but  in  dozens 
of  children,  in  a  few  adults,  and  in  many  animals.  We 
also  have  an  example  of  a  secondary  affection  of  the 
lungs  following  tubercle  of  the  pharjTigeal  tonsillar 
structure,  through  the  glands  of  the  neck,  then  those 
in  the  thorax,  and  finally  to  the  lung  itself,  in  the  ex- 
amples that  have  already  been  given  of  infection  of  the 
pig  by  tuberculous  milk." 

In  going  into  detail  of  dangers  from  tuberculous  in- 
fection, somewhat  to  the  exclusion  of  other  symptoms 
and  sequelae  of  adenoid  growths,  I  do  not  wish  to  be 
understood  as  underestimating  their  importance,  but 
they  have  been  so  often  given  that  a  repetition  is  here 
unnecessary. 

The  treatment  of  adenoids  of  the  naso-pharjTix  is 
either  expectant  or  surgical.  The  probability  of  fa- 
vorably affecting  lymphoid  hypertrophies  by  the  use  of 
drugs,  either  topically  or  constitutionally,  is  so  remote 
as  to  scarcely  entitle  it  to  consideration.  The  expec- 
tant plan — the  "  outgrowing  "  process  which  the  par- 
ents so  confidently  count  on — has  at  least  this  advan- 
tage, that  the  hypertrophy  usually  diminishes  v.ith 
age,  and  sometimes  entirely  disappears  with  adolescence. 
The  cavity  of  the  naso-pharynx  is  proportionately 
larger,  so  that  the  respiratory  obstruction,  so  far  as  the 
naso-phar\-nx  is  concerned,  is  diminished,  or  altogether 
disappears.  On  the  other  hand,  the  deformities  due  to 
years  of  mouth-breathing  do  not  disappear  with  the 
"  outgrowing  "  of  the  obstruction.  The  high-arched 
palate,  the  contracted  nasal  chambers,  the  defomied 
alse,  with  their  small,  round  nostrils,  the  listless  facial 
expression,  due  in  part  to  the  deformity  and  in  part  to 
the  impaired  hearing,  have  by  this  time  become  so 
much  a  part  of  the  physical  make-up  that  neither  time 
nor  treatment  can  effectually  efface  them.  The  ex- 
pectant plan  is  at  best  long,  tedious,  and  uncertain,  en- 
tailing years  of  suspense  on  the  physician  and  parent, 
and  subjecting  the  patient  to  dangers  which,  when  once 
encountered,  cannot  be  corrected. 

In  speaking  of  the  removal  or  destruction  of  pha- 
ryngeal hypertrophies  by  surgical  means,  it  will  not  be 
necessary  to  review  the  many  operations  that  have  been 


devised,  and  the  almost  endless  list  of  instruments  and 
appliances  that  have  been  invented  for  this  purpose, 
most  of  which  have  for  various  reasons  been  aban- 
doned. Most  operators  now  confine  themselves  to  one 
of  the  following  methods,  ^-iz.:  ist.  Removal  by  the 
post-nasal  curette  :  the  most  efficient  instrument  is  what 
is  known  as  the  improved  Gottstein  curette  ;  with  this  it 
is  possible  to  completely  remove  the  hypertrophies  from 
the  dome  and  posterior  wall  of  the  pharj'nx  without  dan- 
ger to  the  Eustachian  tube  or  soft  palate.  It  is  the  only 
instrument  necessary  for  the  operation,  e.xcept  occasion- 
al'y,  in  intractable  children,  a  mouth-gag  will  be  of  ser- 
vice. 2d,  Removal  by  post-nasal  cutting  forceps  ;  all  the 
post-nasal  are  in  fact  modelled  after  the  old  post-nasal 
forceps  of  Lowenberg.  I  think  the  one  in  most  com- 
mon use  at  this  time  is  what  is  known  as  Gradle's  for- 
ceps, which  consists  of  triangular  fenestrated  blades, 
the  fenestrse  being  guarded  by  a  shield  to  prevent  the 
excised  tissue  from  falling  into  the  larynx.  The  only 
danger  in  the  cutting  forceps  is  to  the  soft  palate, 
which  can  be  held  forward  with  the  finger,  or  tied  out 
of  the  way. 

In  this  connection  I  wish  to  state  that  where,  for  any 
reason,  it  is  necessary  to  hold  the  palate  forward,  it  is 
best  to  at  once  pass  a  tape  or  soft  catheter  through  the 
nose  and  tie  the  palate  out  of  the  way.  Xone  of  the 
many  palate  retractors  have  in  my  hands  been  satisfac- 
tory. Instead  of  getting  a  view  of  the  post-nasal  space, 
I  have  usually  gotten  the  contents  of  the  stomach. 
Probably  the  chief  question  is  whether  or  not  general 
anaesthesia  is  required.  The  hemorrhage  after  the 
operation  is  quite  profuse  for  a  few  minutes,  making 
an  anno)-ing  and  troublesome  complication  in  the  use  of 
anaesthetics.  This  danger  can  be  lessened,  but  not  en- 
tirely obviated,  by  the  position  of  the  patient  during 
the  operation,  placing  the  head  lower  than  the  body  so 
that  the  blood  will  gravitate  away  from  the  larynx.  As 
a  rule  I  operate  without  an  anaesthetic.  Patients  who 
were  old  enough  to  talk  intelligently  have  often  told 
me  that  the  curetting  produces  no  more  pain  than  the 
preliminary  exploration  with  the  index-finger.  Cocaine 
seems  to  do  little  good  in  these  cases,  and  is  not  well 
borne  bj"  children. 

The  dangers  of  the  operation,  other  than  those  due 
to  the  administration  of  anaesthetics  under  adverse  con- 
ditions, are  almost  nil.  There  is  no  shock,  and  the 
subsequent  discomforts  are  rarely  sufficient  to  confine 
the  patient  to  bed.  The  galvano-cautery  is  only  ap- 
plicable in  a  small  per  cent,  of  the  cases.  It  is  indi- 
cated in  the  sessile  or  cushion-shaped  growths.  Such 
conditions  are  usually  found  during  youth.  In  these 
sessile  tumors  the  hypertrophy  is  of  the  connective 
tissue,  rather  than  the  stroma  of  the  phar}ngeal  tonsil. 
Destruction  by  the  cautery  is  generally  regarded  as  the 
most  conservative  operation,  but  is  the  most  difficult. 
The  use  of  the  galvano-cautery  presupposes  a  tractable 
patient  with  a  tolerant  pharjnx  ;  an  operator  sufficiently 
skilled  in  the  use  of  instruments  to  manipulate  the  rhi- 
noscopic  mirror  with  one  hand,  the  electrode  with 
the  other,  to  locate  and  limit  the  point  of  cauterization 
by  the  image  in  the  mirror.  No  one  should  be  reckless 
enough  to  introduce  a  cautery  electrode  into  the  naso- 
pharjnx  without  being  able  to  watch  and  guard  the 
process  from  start  to  finish.  Electrodes  are  used  both 
through  the  nose  and  behind  the  palate.  The  destruc- 
tion of  any  considerable  amount  of  tissue  by  the  gal- 
vano-cauter)-  is  tedious,  and  will  require  many  sittings. 


Eestoration  of  Joint  Functions  after  Fracture. — Mas- 
sage, soaking  in  hot  water,  frictions  with  liniments, 
electricity,  passive  motion,  and  attempts  at  voluntary 
movement  continued  for  months,  will  often  cause  great 
improvement  in  the  functional  usefulness  of  joints  sup- 
posed to  be  irretrievably  damaged  through  fracture. — 
Roberts. 


298 


MEDICAL   RECORD. 


[August  31,  1895 


THE   ABUSE   OF    MEDICAL   CHARITIES.' 
By  frank  van  FLEET,   M.D.. 


OPHTHALMIC   S 

URGE ON 

ANT  SURGED 

N  TO  M.\ 

EASES   OFTH 

E  EVe,  A 

HOSPITAL. 

•-GRADUATE  ' 


HOSPITALS  :  ASSIST- 
INSTRUCTOR  IN  DIS- 
-  SCHOOL  AND 


It  is  one  of  the  crying  outrages  of  the  times  that  the 
free  dispensaries  in  our  city,  and,  I  presume,  the  same 
may  be  said  of  all  cities,  treat,  gratuitously,  many  patients 
who  are  abundantly  able  to  pay  for  services  rendered, 
and  it  is  a  melancholy  fact  that  the  number  so  treated 
is  getting  larger  every  year. 

In  the  fourteen  years  that  it  has  been  my  fortune  to 
be  connected  with  the  different  hospitals  and  free  clinics 
devoted  to  the  treatment  of  diseases  of  the  eye  in  New 
York  City,  I  have  seen  this  evil  grow  until  now  it  has 
reached  such  proportions  that  it  seems  to  me  that  it 
may  form  a  theme  worthy  our  discussion  in  this  medi- 
cal body,  with  the  end  in  view  that,  in  a  multitude  of 
counsel  we  may  devise  some  scheme  whereby  its  evil 
tendencies  may  not  only  be  more  fully  appreciated,  but 
its  future  growth  curtailed. 

This  abuse  is  an  evil  which  we  cannot  continue  to 
observe  with  indifference,  for  not  only  does  it  take  away 
from  the  members  of  the  medical  profession  what  should 
be  a  legitimate  source  of  income,  and  deprive  the  wor- 
thy poor,  for  whom  these  free  institutions  are  intended, 
of  the  time  and  attention  necessary  for  their  proper 
treatment,  but  it  also  begets  in  the  unworthy  and  unde- 
serving recipients  habits  which  tend  to  degrade  them, 
the  influences  of  which  may  e.\tend  far  into  the  future, 
affecting  not  only  themselves  but  generations  yet  un- 
born. 

This  growing  tendency  to  get  something  for  nothing 
is  widespread,  and  has  a  deeper  hold  on  the  community 
at  large  than  we  are  willing  to  admit  ;  indeed,  I  believe 
it  would  be  difficult  to  convince  the  public  mind  of  its 
extent  unless  brought  face  to  face  with  the  facts.  It 
may  influence  the  skeptic,  and  cause  him  to  stop  and 
ponder,  when  I  say  that  in  the  Manhattan  Eye  and  Ear 
Hospital,  where  I  have  the  honor  to  serve,  out  o^  16,893 
patients  registered  in  all  departments  for  the  year  ending 
September  30,  1894,  771  were  refused  treatment  because 
of  their  ability  to  pay.  This  number,  which  is  over  4.5 
per  cent,  of  all  who  applied  for  treatment,  may  or  may 
not  fairly  represent  an  average  that  would  apply  to  all 
institutions  of  its  kind  in  our  city  ;  but,  while  we  are  as 
careful  as  we  can  be  to  sift  out  the  unworthy,  yet  it  is 
patent  to  all  observers  that  many  slip  in  who  could, 
with  justice,  be  excluded. 

While  not  desiring  to  enter  into  invidious  compari- 
sons, I  know  that  in  our  institution  we  treat  a  better 
class  of  patients  than  are  found  in  some  other  clinics, 
and  by  better  class  I  mean  that  we  have  more  native- 
born  Americans  in  the  classes  at  the  Manhattan — in  the 
year  above  quoted  sixty-one  per  cent,  of  our  patients 
were  native  born.  Vet  I  know  that  in  clinics  where 
the  applicants  are  largely  of  foreign  birth,  a  very  large 
number  are  able  to  pay  for  medical  services. 

The  subject  I  bring  for  discussion  is  not  a  trivial  one, 
but  one  involving  many  intricate  problems  for  its  jiroper 
solution  ;  I  ask  you,  therefore,  to  bear  with  me  [latiently 
while  I  array  before  you  some  of  the  thoughts  that  have 
occurred  to  me  while  turning  this  matter  over  and  over 
again  in  my  mind. 

In  the  first  place,  it  is  not  an  easy  question  to  decide 
who  is,  and  who  is  not,  able  to  pay  for  medical  advice, 
nor,  deciding  this,  is  it  possible  to  formulate  at  once  a 
system  whereby  we  can  correct  the  evil.  It  has  oc- 
curred to  me  that  in  order  to  arrive  at  a  projier  solu- 
tion of  the  subject,  it  will  be  well  to  consider  the 
matter  under  the  following  headings,  namely, 

'  Read  at  the  eleventh  annual  meeting  of  the  Filth  District  Branch 
of  the  New  York  State  Medical  Association,  held  in  Brooklyn.  N  Y 

May  28,  1895.  '    ' 


First.  Who  is,  and  who  is  not,  able  to  pay  for  medi- 
cal advice  ? 

Second.  What  is  the  effect  of  the  abuse  of  charities, 
medical  and  otherwise,  on  the  public  mind  ? 

Third.  Who  or  what  is  to  blame  for  this  abuse  ? 
Fourth.  What  remedy,  or  remedies,  shall  we  suggest 
to  correct  it  ? 

The  clinic  cards  of  most  institutions  contain  the 
statement  that  none  are  treated  except  those  who  are 
too  poor  to  pay  for  medical  advice.  Services  of  one 
kind  or  another  are  paid  for  in  various  ways  ;  the 
legal-tender,  known  as  money,  being  the  equivalent 
generally  employed  in  civilized  communities.  But 
money  is  not  the  only  medium  of  interchange  ;  the 
medium  may  be  anything  the  contracting  parties 
mutually  agree  upon.  The  physician  giving  a  part  of 
his  time  to  free  dispensaries  and  hospitals  does  so 
with  the  distinct  desire  and  understanding  that  in 
return  for  this  consideration  he  shall  receive  experi- 
ence, and,  going  into  an  institution  where  many  people 
are  treated,  and  where  he  receives  the  advice  and  aid 
of  able  superiors,  he  acquires  a  knowledge  and  prestige 
that  places  him  in  a  position  he  could  attain  in  no 
other  way.  His  superiors,  who  grow  old  and  gray  in 
the  service,  and  who  from  long  observation  become 
familiar  with  all  the  clinical  features  of  every  part  of 
their  specialties,  find,  perhaps,  their  only  reward  in 
having  at  their  command  material  for  teaching  medical 
students,  and  both  they  and  their  assistants  are  looked 
upon,  because  of  their  hospital  and  dispensary  connec- 
tions, as  authorities  in  their  special  lines. 

The  clinic  patient  gets  treatment,  and  in  return  gives 
himself  as  material  for  observation  and  medical  teach- 
ing ;  that  he  is  well  paid  for  this  offering  to  science  is 
attested  by  the  fact  that  he  is  saved  from  blindness, 
disease,  or  death,  and  no  liberties  are  taken  with  him, 
no  operations  or  experiments  are  performed  upon  him, 
without  his  consent  and  desire.  The  obligation  is  not, 
therefore,  all  on  one  side,  but  is  mutual. 

Physicians,  however,  much  as  they  would  like  to  give 
their  time  to  interesting  hospital  work,  much  as  they 
would  like  to  devote  themselves  to  relieving  the  suffer- 
ings of  afflicted  humanity,  for  much  of  the  work  done 
is  neither  instructive  nor  pleasing,  are  forced,  at  least 
most  of  them,  to  do  something  more  than  this.  The 
growing  demands  of  civilization  and  individual  ad- 
vancement necessitate  a  style  of  living  that  requires 
something  more  than  experience  in  scientific  matters. 
It  requires  the  possession  of  that  other  medium  of 
interchange,  money ;  an  article  man)'  medical  men, 
especially  the  younger,  do  not  possess  in  abundance. 

Now,  if  all  people  afflicted  with  sickness  or  defects 
applied  to  dispensaries  for  treatment,  it  would  neces- 
sitate that  the  attending  physicians  have  independent 
means.  The  management  of  these  institutions  have  ac- 
cordingly found  it  necessary  to  say  who  they  will,  or  who 
they  will  not,  treat,  and  have  decreed  that  only  those  too 
poor  to  pay  for  medical  attendance  shall  receive  treat- 
ment without  monetary  consideration.  The  question 
we  naturally  ask  is,  \Vhat  constitutes  being  too  poor  to 
pay  for  medical  attendance  ?  At  most  institutions  ap- 
plicants will  be  interrogated  something  after  this  man- 
ner :  What  is  your  name  ?  Where  were  you  born  ?  Are 
you  married  or  single  ?  What  is  your  business  ?  What  is 
your  income  ?  If  married.  How  many  children  have 
you  ?  From  the  answers  given  the  deductions  are  drawn, 
which  cannot  be  carefully  done  when,  in  the  space  of 
two  or  three  hours,  the  entry  clerk  sees  and  records 
from  sixty  to  a  hundred  patients.  The  final  question, 
which  may,  or  may  not,  be  asked,  is  :  Can  you  not 
afford  to  pay  a  physician  ?  Almost  invariably  the 
answer  comes.  No  !  We  have  frequently  found  that 
this  denial  is  a  deliberate  falsehood  ;  yet  in  many  in- 
stances people  who  are  more  able  to  pay  than  the 
physician  is  to  give  free  treatment,  truly  feel  that  they 
are  not.     Let  us  consider  a  few  instances. 

Mrs.   M ,  who  calls  on  her  physician  regularly, 


August  31,  1895] 


MEDICAL   RECORD. 


299 


and  at  the  end  of  the  year  settles  the  bill  at  the  rate  of 
five  or  ten  dollars  per  office  visit,  has  in  her  employ  a 
maid  who  has  headache,  or  something  of  the  kind,  re- 
quiring medical  advice.  The  maid  receives  a  monthly 
wage  of  twenty  dollars,  and,  of  course,  could  not  be 
expected  to  pay  for  two  or  three  consultations  all  she 

could  earn  in  a  month.     Mrs.  M contributes  yearly 

to  certain  dispensaries,  and  at  once  concludes  that  her 
servant  had  better  go  to  one  of  them  for  treatment. 
There  are  many  just  such  cases.  School  teachers, 
clerks,  and  a  long  list  of  workers  of  every  kind,  earn- 
ing good  salaries,  justly  feel  that  they  cannot  afford  to 
pay  big  fees  for  medical  ad\'ice.  But  these  medical 
men,  these  specialists,  do  not  invariably  get,  or  even 
charge,  big  fees.  Although  they  may  have  a  fee  which 
is,  say  ten  dollars,  they  are  willing  to  make  reductions, 
and  their  books  will  show,  at  the  end  of  the  year,  that 
if  it  were  not  for  the  patients  who  paid  small  fees,  say 
one  or  two  dollars,  the  might)^  specialist  would  have 
had  to  curtail  expenses. 

There  are  many  people  who  would  rather  pay  a 
small  fee  than  have  free  treatment,  if  they  knew  where 
to  go  ;  but  there  are  also  those  who  feel  that  after  living 
as  they  like  to  live,  dressing  as  they  like  to  dress,  and 
humoring  all  their  desires  and  vanities,  they  are  unable 
to  pay  for,  let  us  say,  having  their  eyes  examined,  espe- 
cially as  they  want  to  get  gold-rimmed  spectacles.  Now 
these  people  are  not  worthy  objects  of  charity,  and 
they  should  be  refused  treatment.  A  man  who  pos- 
sesses and  wears  a  diamond  scarf-pin  has  no  right  to 
present  himself  for  charity  treatment.  If  he  were  to 
pay  a  physician  for  treating  him  and  then  help  himself 
to  somebody's  diamond  pin  because  he  had  no  money 
left  to  pay  for  one,  he  would  be  designated  a  thief. 
But  because  he  pays  for  the  diamond  and  steals  the 
medical  advice  he  is  no  less  a  thief,  although  he  may 
not  violate  the  written  law. 

The  woman  who  works  for  her  living  and  dresses  in 
silk  and  wears  a  sealskin  cloak  has  no  right  to  come  to 
a  free  dispensary  for  treatment.  The  girl  or  boy, 
sixteen  or  seventeen  years  of  age,  attending  school  or 
college,  richly  dressed  and  wearing  gold  ornaments 
about  their  persons,  have  no  right  to  come  for  free 
treatment,  even  though  their  parents  may  be  hard- 
working mechanics.  The  attending  physician  justly 
feels  that  these  people  are  enjoying  profits  that  should 
accrue  to  the  doctor  and  his  family.  Consider  a  case 
like  this.  Two  well-dressed  elderly  men  present 
themselves,  having  come  from  out  of  town.  They  are 
brothers,  and  one  has  cataracts  that  are  ready  for 
operation.  The  attending  physician  asks  if  he  cannot 
afford  to  pay  ?  Well,  if  it  is  absolutely  necessary  he 
may  be  able  to  pay  something.  He  is  told  that  this 
institution  is  for  people  who  are  too  poor  to  pay  even  a 
small  fee,  and  he  is  referred  to  the  superintendent,  who 
will  furnish  him  with  a  list  of  the  doctors  connected 
with  that  dispensary,  any  of  whom  will  treat  him  at  re- 
duced rates  if  necessary.  The  men  depart,  and  shortly 
after  the  superintendent  comes  in  to  say  that  this  man  is 
a  veteran,  living  on  a  pension,  and  has  saved  a  little 
money,  but  cannot  afford  to  pay.  The  gentleman  who 
accompanies  him  is  his  brother  and  he  is  a  wealthy  man. 
Xow  consider  the  inconsistency  of  this.  Why  should  a 
rich  man  bring  his  poorer  brother  to  a  physician  and 
ask  charity  ?  Why  does  he  not  bestow  the  charity  in- 
stead of  asking  it  of  a  stranger  ?  Again,  a  physician 
sends  a  patient  with  a  note  asking  attention.  The  ap- 
pearance of  the  patient  indicates  a  comfortable  exist- 
ence, but,  in  answer  to  the  usual  question,  denies 
ability  to  pay.  Naturally  this  question  follows,  "  Do 
you  pay  your  family  physician  ? "  and  the  surprised 
answer  comes,  "  Certainly."  And  so  we  could  go  on 
indefinitely.  It  seems  to  me  that  if  we  could  eliminate 
from  our  clinics  those  who  are  able  to  pay  for  medical 
advice,  a  very  large  number  would  be  rejected. 

The  person  who  is  able  to  dress  elegantly  ought 
not  to  be  treated  free.     We  frequently  say  to  people. 


"  Really  your  dress  does  not  seem  in  keeping  with  your 
request  for  charity  ;  "  but  the  pat  answer  comes  that 
a  person  may  have  sufficient  pride  to  dress  well  and 
yet  not  have  much  money.  But  such  an  answer  should 
not  be  accepted.  A  person  who  is  able  to  dress  well 
has  no  business  to  ask  charity  ;  they  have  no  right  to 
rob  Peter  to  pay  Paul  ;  if  they  want  medical  advice 
they  should  be  compelled  to  pay  for  it  with  some  of 
the  money  they  would  spend  on  their  dress,  or  go  with- 
out it.  It  may  be  true  that  they  cannot  afford  both,  but 
the  physician  should  not  be  expected  to  make  up  the 
deficiency  ;  he  experiences  enough  of  that  deficiency 
often  in  his  own  family.  Nor  should  the  physician  in 
general  practice  be  allowed  to  send  a  patient  to  the 
dispensary  for  free  advice  when  he  gets  a  fee  for  his 
treatment.  If  the  patient  can  only  afford  one  fee,  that 
should  at  least  be  divided  with  the  consultant.  A 
common  example  is  this  : 

Mrs.  B ,  from  Greenpoint,  Long  Island,  presents 

herself  with  iritis,  for  which  Dr.  F ,  after  treating  her 

for  three  weeks,  sends  her  to  the  hospital  with  an  in- 
troduction written  on  his  card.    Mrs.  B is  married, 

and  has  two  grown  children,  who  are  self-supporting. 

Mrs.  B ■  herself  keeps  a  fancy  store.     When  asked  if 

she  cannot  afford  to  pay  an  oculist  she  says  she  cannot. 

When  asked  if  she  paid  Dr.  F for  his  treatment,  she 

says  she  did,  and  adds  further,  that  he  sent  her  to  us, 
and  he  has  been  very  kind  to  her.  It  certainly  re- 
quires less  effort  and  generosity  when  you  can  dispense 
charity  at  some  one  else's  expense. 

I  believe  that  an  adult,  unmarried,  and  in  robust 
general  health,  should  not  be  allowed  charity,  unless 
too  old  to  work.  There  must,  of  course,  be  exceptions, 
they  may  have  some  ailment  that  incapacitates  them. 
To  our  eye-clinics,  however,  people  come  who  have 
some  ocular  trouble  which  may  not  incapacitate  them, 
but  is  simply  an  inconvenience.  They  are  able-bodied 
mechanics,  policemen,  firemen,  clerks,  typewriters, 
bookkeepers,  etc.,  male  and  female,  unmarried,  with 
no  one  depending  on  them  for  a  living,  and  earning 
from  twelve  to  twenty-five  dollars  weekly,  and  up- 
ward ;  they  should  not  be  allowed  free  treatment  ; 
they  take  up  the  time  that  should  be  devoted  to  wor- 
thier people  ;  they  rob  the  doctor  of  his  just  fee,  but, 
worse  than  all,  they  degrade  themselves,  and  sow  in 
themselves  the  seeds  of  pauperism.  They  kill  that 
feeling  of  independence  and  honor  which  should  be, 
and  is,  innate  to  the  character  of  the  native-born  Amer- 
ican, without  which  we  cannot  be  good  citizens,  and 
they  lay  the  foundation  of  a  system  of  beggary  that 
shall  curse  and  degrade,  instead  of  blessing  and  elevat- 
ing, their  descendants. 

The  man  or  woman  whose  happiness,  comfort,  and 
continued  ability  to  earn  a  living  depends  on  their  eyes, 
should  be  willing  to  share  that  advantage  with  the  ocu- 
list— who  puts  them  in  a  condition  to  do  their  work, 
no  matter  how  small  that  consideration  may  be.  If  the 
man  or  woman  have,  depending  on  them  for  support, 
families,  aged  parents,  and  others,  who  would  be  de- 
prived of  necessaries  if  fees  had  to  be  paid  to  doctors, 
that  man  or  woman  has  a  right  to  ask  that  charity, 
which  we,  as  physicians,  are  willing  and  glad  to  be 
able  to  bestow.  But  if  we  are  asked  to  bestow  charity 
that  robust  and  able  people  may  have  lu.xuries  for 
themselves  and  their  families,  luxuries  we  may  not  be 
able  to  obtain  for  ourselves,  then  we  feel  that  we  have 
a  right  to  protest. 

The  effect  of  this  abuse  of  medical  charities  is,  as  I 
have  said  above,  degrading  to  the  public  mind,  and  its 
tendency  is  toward  the  increase  of  pauperism.  The 
cardinal  principle  of  American  institutions  is  indepen- 
dence ;  a  feeling  which  makes  a  man  spurn  with  scorn 
an  insinuation  that  he  should  be  an  object  of  charity. 
This  is  the  feeling  which  actuated  our  forefathers,  and 
made  them  feel  that  they  had  no  right  to  anything  they 
did  not  gain  by  toil  ;  to  accept  charity  was,  to  them, 
humiliating    indeed.      Increasing    population,  with   its 


300 


MEDICAL    RECORD. 


[August  3T,  1895 


necessary  increase  in  competition, has  gradually  brought 
about  a  feeling  that  one  is  justified  in  getting  all  he  can 
with  as  small  an  outlay  as  possible,  a  feeling  increased 
and  strengthened  year  by  year  by  the  influx  of  paupers 
from  Europe,  who,  after  years  of  frantic  struggle  with 
poverty  at  home,  have  been  forced  to  come  to  our  fair 
land  in  the  hope  of  better  things.  They  bring  with 
them  their  begging,  grasping  methods,  so  necessary  in 
their  own  lands  to  insure  them  a  living  at  all,  which, 
coming  in  contact  with  the  free  and  independent 
.\merican  spirit,  contaminates  it.  These  people  and 
their  children  are  the  ones  who  frequent  our  clinics. 
It  would  be  impossible  perhaps  to  eradicate  this  feeling 
from  the  immigrants  themselves,  that  they  are  justified 
in  getting  all  they  can  for  nothing,  but  it  would  be  well 
for  us,  as  a  people,  if  we  could  keep  it  from  taking  root 
in  their  children,  and  from  them  being  disseminated  to 
our  own. 

The  indiscriminate  distribution  of  charity,  therefore, 
tends  to  destroy  the  sense  of  honor  in  the  recipients, 
makes  them  unmindful  of  the  rights  of  others,  and  be- 
gets pauperism. 

Where  shall  we  place  the  blame  ?  It  is  difiicult  to 
say  who  is  able  to  pay  for  medical  services,  but  the  ef- 
fect of  too  much  charity  on  succeeding  generations  is 
easily  predicted.  When,  however,  we  come  to  the 
question  as  to  why  these  charities  are  abused,  we  are 
confronted  by  a  subject  of  such  magnitude  that  one  is 
at  a  loss  to  know  just  where  to  begin. 

No  one  person,  no  one  class  of  people,  can  be  said 
to  be  wholly  and  exclusively  to  blame.  The  people, 
meaning  the  public,  are  to  blame  in  a  measure,  the  in- 
stitutions and  tlieir  attending  physicians  and  surgeons 
partly,  and  outside  medical  men,  with  the  laity,  con- 
tribute their  share.  The  fact,  then,  is  that  we  are  all, 
in  a  measure,  responsible.  Many  people  go  to  dispen- 
saries for  special  treatment,  simply  because  they  do  not 
know  where  else  to  go  ;  they  have  no  idea  or  notion  of 
getting  advice  or  treatment  for  nothing,  but  they  have 
never  heard  of  any  particular  specialist  ;  they  ask  for 
one  at  the  dispensary  and  expect  to  pay.  Others  go 
because  they  think  they  have  a  perfect  right  to  do  so. 
They  think  the  city  pays  the  doctors  and  supports  the 
institutions,  and  that  these  places  are  for  their  benefit. 
They  put  ten  cents  or  a  penny  in  the  poor-box  and  feel 
that  they  are  charitable  indeed  ;  when  refused  treat- 
ment, because  they  are  not  worthy  objects  of  charity, 
they  become  indignant  and  threaten  all  sorts  of  ven- 
geance, such  as  complaining  to  the  mayor  or  some  other 
high  official. 

Others,  seeing  the  reckless  extravagance  of  some  of 
the  so-called  charitable  millionaires,  feel  that  they  may 
as  well  get  some  of  the  plums  going.  This  is  one  of 
the  unfortunate  results  of  civilization  and  progress  : 
the  money,  centring  in  the  hands  of  a  few  individuals, 
leaves  them  a  surplus  which  creates  a  corresponding 
deficiency  somewhere  else.  With  this  surplus  the  mul- 
timillionaire builds  hospitals  and  institutions  which  are 
often  of  doubtful  benefit  to  mankind.  That  they  are 
monuments  to  the  liberality  of  their  donors  is  true,  but 
that  they  benefit  the  race  I  am  not  so  sure,  ^^'e  have 
now  in  course  of  erection  in  our  city  a  hospital,  the 
construction  of  which  wil!  necessitate  the  needless  out- 
lay of  thousands  and  thousands  of  dollars  that  might 
be  put  to  better  uses.  There  are  a  number  of  institu- 
tions in  the  city  of  New  York  devoted  to  charity, 
where,  counting  the  running  expenses  together  with  the 
interest  on  the  money  invested  in  costly  buildings 
makes  the  per  capita  cost  of  caring  for  inmates  more 
than  it  would  cost  to  board  them  in  the  highest-priced 
hotels  in  town.     Surely  this  is  a  perversion  of  charity. 

There  are  far  too  many  hospitals  and  dispensaries, 
which  continue  to  grow  in  number,  not  because  there 
is  really  any  need  for  more,  but  because  one  or  more 
medical  men  want  personal  advertisement,  or  one  or 
more  millionaires  want  monuments  to  their  generosity. 

This  is  sad  but  true,  and  its  effect  on  the  public 


mind  is  not  good.  Doctors  themselves  are  to  blame 
for  some  of  the  abuse  of  medical  charities.  A  case 
came  to  my  notice  a  short  time  ago  where  a  patient 
was  sent  to  the  clinic  for  eye  trouble  by  a  prominent 
physician  in  town,  who  was  at  the  same  time  treating 
the  patient  in  his  office  and  being  paid  for  his  services. 
People  frequently  apply  for  treatment,  or  for  a  diagno- 
sis, so  that  the  family  physician  can  treat  them,  and 
state  that  they  are  sent  by  their  physicians  for  that 
purpose.  Now,  of  course,  this  is  a  condition,  despi- 
cable in  the  extreme. 

A  physician  in  general  practice  ought  to,  at  least,  be 
willing  to  divide  with  his  colleague,  and  yet  the  medi- 
cal men  who  abuse  these  charities  are  frequently  the 
ones  who  complain  most  bitterly  about  the  dispensa- 
ries interfering  with  their  practice. 

There  is  a  feeling,  or  an  idea,  very  prevalent,  that 
specialists  invariably  charge  and  get  enormous  fees. 
This  is,  of  course,  an  erroneous  idea  :  it  is  the  patients 
paying  small  fees  who  make  up  the  bulk  of  the  special- 
ist's clientele.  When  specialists  were  few  in  number  they 
may  have  received  larger  fees,  but,  as  every  town  and 
city  has  one  or  more  experts  in  special  lines,  and  as 
competition  becomes  greater,  the  size  of  fee  necessar- 
ily diminishes.  I  think  myself  that  the  day  of  large 
fees  is  past. 

There  was  a  time  when  a  few  men  had  a  monopoly 
of  intelligence  and  ability,  but  in  these  days  of  post- 
graduate instruction  it  would  be  impossible  to  pick 
out  one  man  who  stands  above  his  fellows  ;  true,  some 
are  superior  in  many  ways  to  others,  but  the  best  have 
so  many  peers  that  a  line  cannot  be  drawn.  One  man, 
or  a  few  men,  who  charge  large  fees,  cannot  compete 
with  many  men,  of  equal  ability,  who  charge  smaller 
fees.  It  is  said  of  one  man  in  our  city,  who,  when 
patients  present  themselves  who  cannot  afford  to  pay  a 
fee  of  ten  dollars,  informs  them  that  they  are  charity 
patients  and  refers  them  to  his  clinic.  This,  if  true, 
stamps  him  as  unjust,  not  only  to  his  fellow-practi- 
tioners, but  to  his  patients  as  well.  There  are  many 
physicians  who  would  gladly  treat  these  people  for 
smaller  sums,  and  people,  as  a  rule,  would  rather  pay  a 
small  fee  than  go  to  free  clinics.  One  thing  is  certain  ; 
the  men  who  have  the  largest  practices,  and  are  ac- 
cordingly the  best  known,  are  the  men  who  charge 
moderate  fees.  There  is  really  no  reason  why  a  spe- 
cialist should  get  a  larger  fee  than  the  general  practi- 
tioner ;  he  renders  no  greater  service.  It  is  true  he 
does  what  the  family  doctor  often  cannot  do  ;  but,  on 
the  other  hand,  the  family  doctor  does  what  the  spe- 
cialist cannot  do. 

We  find,  then,  three  classes  of  people  who  frequent 
hospitals  and  free  clinics. 

The  first  class,  composed  of  those  who  come,  either 
because  they  do  not  know  where  else  to  go,  or  else 
have  a  mistaken  idea  that  specialists  charge  such  enor- 
mous fees  that  it  would  be  impossible  for  them  to 
afford  private  treatment.  These  people  cease  to  be 
applicants  for  charity  when  given  the  proper  infor- 
mation. 

The  second  class,  constituting,  by  the  way,  a  goodly 
sized  proportion  of  all  who  come,  is  composed  of  peo- 
ple in  comfortable  circumstances  who  are  abundantly 
able  to  pay  for  medical  advice,  but  who  are  referred  to 
the  dispensary  by  their  family  physicians,  over  whose 
motives  we  will  draw  the  veil.  The  third  class  is  com- 
posed of  those  who  are  downright  frauds  ;  they  would 
pick  your  pocket,  if  they  had  a  good  chance,  even  while 
you  are  bestowing  charity.  They  are  the  people  who 
own  tenements,  and  who.  when  they  have  ailments, 
put  on  tattered  and  worn  clothing,  and  present  them- 
selves for  free  treatment.  They  are  a  bad  element  in 
society. 

There  is  a  fourth  class,  which  may  constitute  twenty- 
five  i)er  cent,  of  all  who  attend  ;  I  doubt  if  it  is  much 
more.  They  are  the  deserving  poor,  driven  to  ask 
charity  because  of  misfortunes  of  one  kind  or  another. 


August  3  [,  1895] 


MEDICAL    RECORD, 


and  for  whom  we  are  willing,  nay,  eager  to  do  all  we 
can.  It  is  the  gratitude  of  this  class  that  makes  char- 
ity sweet,  and  the  ingratitude  of  the  others  that  makes 
it  bitter.  We  come,  then,  to  the  consideration  of  the 
fourth  heading  of  my  discourse,  namely,  what  remedy 
or  remedies  shall  we  suggest  to  correct  this  evil  ? 

I  would  say  that  the  first  step  should  be  an  effort  to 
raise  the  moral  tone  of  society.  Teach  the  people,  first, 
that  it  is  more  blessed  to  give  than  to  receive  ;  second, 
that  to  accept  charity  under  a  misrepresentation  of 
facts  does  not  differ,  morally,  from  taking  that  which 
is  the  property  of  some  other  person  ;  and  third,  that 
these  thieving  actions  tend  not  only  to  belittle  them- 
selves, but  beget  habits  in  succeeding  generations 
which  will  dull  that  spirit  of  independence  that  should 
be  our  natural  heritage,  and,  leaving  them  degraded 
will  contribute  to  the  development  of  a  nation  of  piu- 
pers. 

These  strides  toward  that  millennium  when  people 
seeing  the  right  will  do  it,  must,  of  necessity  be  slow, 
and  in  the  interval  let  us  insist  that  patrons  of  chari- 
table institutions,  and  charitably  disposed  individuals 
generally,  shall  refer  to  free  clinics  for  free  treatment 
only  people  who  are  too  poor  to  pay  even  the  smallest 
fee  ;  that  physicians  coming  in  contact  with  people 
who  need  the  attention  of  specialists  shall  use  the  ut- 
most discrimination,  and  not  consider  as  fit  subjects 
for  charity  patients  who  pay  them  fees,  realizing  that 
if  patients  can  pay  their  family  physicians  they  ought 
also  to  pay  consulting  physicians.  Attendants,  medi- 
cal and  otherwise,  in  free  clinics  should  be  taught  that 
to  treat  people  for  nothing  who  are  apparently  able  to 
pay  for  medical  services  is  a  perversion  of  charity  and 
should,  under  no  circumstance,  be  countenanced. 

We  have  in  our  city  a  body,  called  the  Charity  Or- 
ganization Society,  that  will  investigate  privately, 
through  its  agents,  any  person  whose  name  is  given 
and  will  report  whether  they  are  fit  subjects  for  char- 
ity. This  Society,  which  does  a  noble  work,  will  report 
and  investigate  for  anyone,  whether  a  member  or  not  ; 
but  as  the  yearly  membership  fee  is  small,  it  seems  to 
me  that  it  would  be  a  good  thing  if  every  institution 
devoted  to  the  distribution  of  charity  would  become  a 
member,  and  thereby  give  financial  as  well  as  moral 
support  to  a  good  cause.  Failing  in  this,  I  would  sug- 
gest that  every  free  dispensary  and  hospital  employ  an 
agent  themselves,  whose  business  it  shall  be  to  investi- 
,,ite  doubtful  cases.  In  this  way  a  large  proportion,  if 
■  ot  all,  unworthy  applicants  could  be  weeded  out,  to 
the  end  that  not  only  would  the  noble  cause  of  charity 
be  elevated,  but  justice  would  be  done  to  the  worthy 
poor,  and  also  to  that  large  number  of  struggling  phy- 
sicians our  medical  colleges  delight  in  turning  out  year 
after  year. 


Corneal  Ulcer.— Dr.  A.  Llewellyn  Hall,  of  Fair 
Haven,  X.  V.,  writes :  Cases  of  intractable  corneal 
ulceration  which  have  long  resisted  the  usual  methods 
of  treatment  quickly  improve  under  the  use  of  glyce- 
rite  of  tannin  and  carbolic  acid  prepared  according  to 
the  following  formula  : 

B .   Acidi  carbolic! grs.  xv. 

Acidi  tannic! grs.  xxx. 

GlycerinL ;  j . 

M. 

Carefully  cleanse  the  eye  with  warm  sterilized  water 
strongly  impregnated  with  boric  acid,  introduce  a  few 
drops  of  weak  cocaine  solution  to  annul  pain,  and  after 
a  wait  of  five  minutes  freely  touch  the  ulcer  with  the 
glycerite  by  means  of  a  fine  camel's  hair  pencil.  Re- 
peat twice  or  thrice  daily  for  the  first  few  days  and 
then  gradually  discontinue  as  healing  progresses.  In 
conjunction  with  this  treatment  it  is  well  to  maintain 
the  usual  instillation  of  atropin.  Unpleasant  reaction 
never  occurs. 


PRIMARY  CARCINOMA  OF  THE  HEAD  OF 
THE  PAXCRE.\S.  WITH  HOUR-GLASS  CON- 
TRACTION OF  THE  STO.MACH,  SIMUL.AT- 
ING    DURING    LIFE    PYLORIC   STENOSIS.' 

By  D.  J.   MILTON  MILLER,  M.D., 


The  patient,  a  single  woman,  a  domestic,  aged  fifty- 
three,  first  came  under  observation  in  the  wards  of  the 
Episcopal  Hospital,  in  February,  1894.  At  that  time 
she  gave  a  history  of  three  months'  illness,  the  principal 
symptoms  of  which  were  epigastric  pain  and  occasional 
vomiting  ;  the  latter  usually  affording  relief,  and  con- 
sisting of  mucus  and  undigested  food,  and  once  of 
bright-red  blood.  The  outlines  of  the  stomach  were 
apparently  normal,  and  deep  pressure  in  the  epigas- 
trium elicited  pain,  but  there  was  no  tumor.  Giinz- 
burg's  test  revealed  the  presence  of  free  HCl,  but  not  in 
excessive  amount,  i.e.,  the  reaction,  though  well  de- 
fined, was  not  intensely  so.  She  had  always  been  an 
excessive  eater  and  a  large  drinker  of  tea,  but  never  of 
alcohol.  There  was  no  family  history  of  note.  Under 
rest  and  a  diet  of  peptonized  milk  she  rapidly  improved, 
and  within  three  months  was  discharged,  a  diagnosis  of 
chronic  catarrhal  gastritis  having  been  made. 

On  November  3,  1894,  she  was  readmitted  into  the 
Episcopal  Hospital.  It  was  then  noted  that  she  had 
lost  considerable  flesh  and  was  quite  ansemic.  She  re- 
ported marked  increase  in,  and  almost  constant,  pain 
and  frequent  vomiting — on  several  occasions  of  pure 
blood,  or  the  so-called  "  coffee  grounds"  material.  There 
was  no  tumor  discernible.  The  outlines  of  the  stomach, 
as  defined  by  auscultatory  percussion,  appeared  to  be 
normal,  and  remained  so  throughout  the  whole  history 
of  the  case.  Examination  of  the  gastric  contents  after 
Ewald's  test-meal  gave  a  faint  reaction  with  Giinz- 
burg's  solution.  The  contents  had  a  strongly  acid 
odor,  reacting  promptly  to  blue  litmus  paper.  By  the 
latter  part  of  December  a  small,  immovable,  ill-de- 
fined, and  very  tender  tumor  could  be  felt  in  the  epi- 
gastrium, two  inches  below  the  ensiform  cartilage. 
Shortly  after  admission  peptonized  milk  in  small  quan- 
tities was  ordered,  and  daily  lavage  was  practised.  To 
effect  this,  a  large  amount  of  water  was  used,  and  it  was 
noticed  that,  although  the  washings  were  done  in  the 
morning,  they  contained  quantities  of  food  given  the 
day  before.  This  occurred  even  when  no  food  or  milk 
had  been  taken  for  twelve  or  fourteen  hours.  About 
the  20th  of  January,  1895,  a  light  jaundice  was  noted. 
This  grew  more  intense,  and  was  accompanied  by  an 
increase  in  the  hepatic  dimensions,  and  by  the  develop- 
ment of  an  oval,  elastic,  and  semi-fluctuating  tumor  at 
the  tip  of  the  ninth  right  rib  ;  this  was  thought  to  be 
the  gall-bladder. 

Several  examinations  during  the  course  of  the  disease 
failed  to  give  constant  evidence  of  the  presence  of  free 
HCl.  This  was  probably  due,  as  the  sequel  will  show, 
to  the  failure  to  thoroughly  wash  out  the  stomach  on 
the  night  previous  to  the  administration  of  the  test- 
breakfast — a  precaution  that  should  never  be  omitted, 
if  we  desire  correct  results  in  chemical  examination  of 
the  gastric  contents.  The  salol-test  for  the  motor 
function  of  the  stomach  was  also  employed,  but  with 
unsatisfactor}'  results. 

■  During  the  latter  third  of  the  patient's  life  the  stools 
were  frequently,  but  unsuccessfully,  examined  for  evi- 
dences of  fat.  A  microscopic  examination,  however, 
was  not  made.  The  urine,  though  tested  on  several 
occasions,  contained  neither  sugar  nor  albumin. 

By  February  ijlh  the  epigastric  tumor  was  more  de- 
fined, and  still  very  painful  and  immovable.  Other- 
wise the  patient's  condition  continued  about  the  same. 
Sometimes  vomiting  daily  for  a  period,  and  then  a  week 
or  ten  days  elapsing  with   entire   freedom  from    this 

'  Read  before  the  Philadelphia  Pathological  Society,  May  8,  1895. 


302 


MEDICAL    RECORD 


[August  31,  1895 


symptom.  Pure  blood  was  never  vomited  while  under 
observation,  though  the  so-called  "  coffee  grounds" 
matter  was  ejected  on  several  occasions.  At  this  time 
Dr.  D.  D.  Stewart  kindly  saw  the  case,  and  consented 
to  undertake  an  examination  of  the  gastric  contents 
with  the  view  of  determining  the  absence  or  presence  of 
lactic  acid.  In  order  to  eliminate  all  sources  of  error, 
the  organ,  at  Dr.  Stewart's  suggestion,  was  thoroughly 
cleansed  prior  to  the  administration  of  Boas's  flour  soup. 
In  doing  this  forty-eight  quarts  of  water  were  used.  In 
the  withdrawn  contents,  Dr.  Stewart  found  a  total 
acidity  of  88  ;  .05  of  free  HCl ;  sharp  reaction  with  Giinz- 
burg's  test  ;  and  no  lactic  acid.  In  the  light  of  this  ex- 
amination a  probable  diagnosis  of  cicatricial  stenosis 
from  old  ulcers  was  made. 

From  the  25th  to  the  28th  of  February  the  patient 
was  fed  exclusively  on  meat  broths,  milk  being  entire- 
ly withheld  ;  on  the  latter  date  the  stomach  was  again 
thoroughly  washed  out  with  a  solution  of  soda  (sod. 
bicarb.,  3  ss.  ;  water,  Oij.).  It  took  but  eight  quarts  on 
this  occasion  to  cleanse  the  organ.  The  flour  soup  was 
then  introduced  through,  and  before  removing,  the  tube, 
allowed  to  remain  in  the  stomach  over  night,  and  with- 
drawn the  next  morning  by  aspiration.'  Dr.  Stewart's 
examination  of  this  was  as  follows  :  Contents  received, 
360  c.c.  ;  strong  odor  of  salol  (given  six  days  jire- 
viously)  ;  total  acidity,  70  ;  sharp  Giinzburg  ;  free  HCl, 
0.175  ;  combined  and  free  HCl  (Leo's  method), 
0.02225  !  r'o  lactic  acid  :  egg  disk  completely  dissolved 
in  three  and  a  half  hours. 

On  the  7th  of  March  tympanites  developed,  and 
there  were  signs  of  commencing  cardiac  failure. 
Various  measures  were  employed  to  relieve  the  ab- 
dominal distention,  but  with  indifferent  success.  The 
patient  gradually  grew  weaker  and  died  March  13th. 
It  should  be  added  that  no  enlargement  of  the  supra- 
clavicular and  inguinal  glands  was  at  any  time  pres- 
ent, and  that  the  temperature  ranged  between  98°  and 
99.5°  F.,  occasionally  reaching  100°  F. 

Autopsy. — Body  emaciated.  Skin  and  mucous  mem- 
branes deeply  tinged  with  bile.  Fleurse  adherent  at 
various  points.  Lungs  pale,  except  at  posterior  bases, 
where  there  is  hypostatic  congestion.  Slight  amount 
of  fluid  in  pericardium.  Heart  small,  muscle  jiale, 
valves  normal.  Stomach  and  intestines  strongly  dis- 
tended with  gas.  Stomach  occupies  an  almost  vertical 
position,  the  whole  of  the  organ  lying  to  the  left  of 
the  median  line,  the  lowest  extremity  on  a  level 
with  the  umbilicus.  The  pylorus  is  at  a  point  midway 
between  the  ensiform  cartilage  and  the  umbilicus.  On 
a  line  with  the  pvlorus,  and  involving  the  whole  cir- 
cumference of  the  stomach,  is  a  constricting  band, 
which  divides  the  organ  into  two  parts  :  the  lower, 
consisting  of  about  one-third  of  the  stomach,  is  thus 
separated  from  the  body  of  the  viscus  by  a  rather  nar- 
row opening.  The  diameter  of  the  stomach  is  lessened 
about  one-half  at  this  point.  The  portion  above  the 
constriction  is  of  about  normal  capacity,  while  that  be- 
low seems  dilated.  (Owing  to  rupture  of  the  walls  be- 
fore the  removal  of  the  stomach,  the  exact  capacity 
could  not  be  tested,  but  the  constricted  portion  evi- 
dently held  about  sixteen  fluid  ounces,  the  rest  of  the 
organ  about  two  pints.)  The  mucous  membrane  is 
softened  (post  mortem)  and  in  a  state  of  catarrhal 
gastritis  ;  but  there  is  no  evidence  of  cicatrization  at  the 
site  of  the  constriction  or  elsewhere.  The  pyloric  ori- 
fice is  little,  if  at  all,  narrowed,  as  it  admits  the  fore-, 
finger  with  ease.  Tlie  head  of  the  pancreas  is  the  seat 
of  a  hard  tumor,  about  the  size  of  a  hen's  egg,  which 
completely  surrounds  and  occludes  the  pancreatic  and 
common  bile-ducts.  As  a  result  the  body  of  the  pan- 
creas is  enlarged  and  softened,  its  duct  dilated  and 
filled  with  retained  secretion.  Behind  the  obstructed 
portion,  the  common  duct  is  dilated  and  filled  with 
dark   bile.     The    cystic   and   hepatic   ducts   are   also 

'  These  manipulations  were  carried  on  under  Dr.  Stewart's  direc- 
tions. 


dilated,  while  the  gall-bladder  is  enlarged  and  distend- 
ed with  fluid  bile.  The  liver  is  enlarged,  bile-tinged, 
the  ramification  of  the  hepatic  duct  filled  with  dark- 
greenish  fluid.  There  are  no  secondary  growths.  The 
condition  of  the  other  organs  is  unnoteworthy.  Dr. 
McFarland,  pathologist  to  the  Episcopal  Hospital,  ex- 
amined the  pancreatic  growth,  and  reported  it  to  be 
carcinoma. 

This  case  presents  many  points  of  interest.  In  the  first 
place,  it  emphasizes  the  value  and  the  necessity  of 
the  modern  methods  of  research  in  the  diagnosis  of 
obscure  affections  of  the  stomach  and  pyloric  zone. 
The  clinical  history  above  narrated  certainly  warranted 
the  diagnosis  of  malignant  stenosis  of  the  pylorus,  with 
secondary  involvement  of  the  li\er,  or,  at  least,  of  the 
glands  in  the  hepatic  fissure  ;  but  the  constant  presence 
of  free  HCl  (although  by  our  imperfect  methods  this  was 
often  absent),  and  above  all  the  absence  of  lactic  acid, 
enabled  us  to  exclude  gastric  cancer,  and  led  us  to  attri- 
bute the  symptoms  to  a  cicatricial  stenosis  of  the  pylo- 
rus, hypertrophic  in  character,  occluding  the  common 
duct,  with  possibly  a  concomitant  carcinoma  of  the  pan- 
creatic head.  The  autopsy  showed  the  latter  surmise 
to  be  true.  There  was  no  stenosis,  but  a  remarkable 
constriction  of  the  whole  circumference  of  the  stomach, 
forming  the  diverticulum  above  mentioned,  and  ac- 
counting for  the  signs  of  dilatation  during  life,  and  the 
difficulty  in  washing  out  the  organ,  the  food  collecting 
in  the  constricted  portion.  It  explained,  also,  why 
auscultatory  percussion  failed  to  reveal  the  true  dimen- 
sions of  the  organ,  the  stomach  note  being  lost  as  soon 
as  the  space  separating  the  two  portions  came  under 
the  percussing  finger.  This  contraction  was  evidently 
congenital,  as  there  was  not  the  slightest  evidence 
at  the  autopsy  of  cicatrices  at  the  site  of  the  constric- 
tion. Contractions  of  the  stomach  seem  to  be  rather 
rare  anomalies,  as  the  few  works  we  have  referred  to 
make  little  or  no  mention  of  them.  This  seems  to  be 
an  instance  of  exaggeration  of  the  antrum  pylori  (the 
lower  quarter  lying  in  front  of  the  pylorus),  which 
Ewald '  mentions  as  causing  the  stomach,  without  the 
action  of  cicatricial  contraction,  to  assume  the  shape  of 
an  hour-glass.  Another  interesting  feature  is  the  con- 
firmatory evidence  which  our  case  gives  of  Boas's  and 
D.  D.  Stewart's  -  work  on  the  value  of  the  presence 
of  lactic  acid  as  a  sign  of  carcinoma  of  the  stomach. 
The  gastric  catarrh  was  evidently  sympathetic  in  char- 
acter, and  the  weakening  and  dilatation  of  the  con- 
stricted portion  sequential  to  this.  Lentil  the  onset 
of  the  pancreatic  disease  the  diverticulum  must  have 
been  able  to  empty  itself,  as  there  were  no  symptoms 
before  that  time.  With  the  appearance  of  the  carci- 
noma, however,  and  the  consequent  gastritis,  the  motor 
power  of  the  stomach  was  impaired,  and  signs  of  dila- 
tation became  evident. 

As  to  the  pancreas,  a  comparatively  uncommon  con- 
dition is  presented  in  the  limitation  of  the  malignant 
growth  to  the  gland  alone.  In  only  12  out  of  127  cases 
of  pancreatic  cancer  collected  by  Segre,^  was  the  dis- 
ease confined  to  that  organ.  It  is  quite  possible  that 
the  pancreatic  disease  might  have  been  detected  with 
more  certainty  during  life,  had  closer  attention  been 
paid  to  the  presence  of  fat  in  the  stools  and  glycosuria  : 
but  owing  to  the  prominence  and  interesting  features 
of  the  gastric  symptoms,  the  stools  were  not  examined 
microscopically,  and  the  urine  was  tested  but  a  few 
times. 

Baboes. — Treatment  for  this  consists  in,  first,  thor- 
ough antiseptic  cleansing  of  operative  region,  followed 
by  puncture  and  complete  evacuation  of  the  pus.  Ten 
per  cent,  iodoform  vaseline  mixture,  liquefied  by  heat, 
is  then  injected  and  a  bichloride  dressing  applied. — 

FONTAN. 

'  Diseases  of  Stomach.  English  Translation,  p.  m.    New  York,  1892. 

'  Medical  News.  February  16.  1S95. 

'  Osier:  Practice  of  Medicine,  p.  ^6i.     New  York,  18 


August  31,  1895] 


MEDICAL    RECORD. 


^O.q 


GLIOMA— OPERATIdX,     CAUTERY,     RECOV 
ERY.- 

By  WILLIAM   CLARENCE  BOTELER,  M.D., 


This  disease,  variously  styled  gliosarcoma,  fungous 
hjematodes,  small-celled  sarcoma  of  the  retina,  by  dif- 
ferent pathologists,  was  first  described  by  Mr.  Wardrop 
during  the  early  part  of  the  present  centurj-,  and  al- 
though the  light  of  science  has  since  then  permeated 
e%ery  tissue-element  of  the  body,  from  1836  to  the 
present  time  authors  have  not  differed  greatly  as  to  the 
prognosis  and  treatment  of  this  affection.  In  1S46  Dr. 
Little  said  :  "  This  disease  is  a  constitutional  and  fatal 
one,  from  which  even  the  knife  of  the  surgeon  affords 
scarcely  a  probability  of  escape,  the  malady  having,  with 
few  exceptions,  reappeared  after  extirpation,  though 
the  operation  was  performed  in  the  incipient  stage  and 
under  circumstances  the  best  calculated  to  insure  suc- 
cess." Etiologically  and  histologically  the  earlier  au- 
thors of  America  did  not  attempt  to  describe  it  ;  but 
more  latterly  the  affection  has  been  by  some  considered 
as  arising  from  the  ''  optic  nerve,"  "  the  retina  and 
optic  nerv-e,"  or  "  the  retina  "  alone,  the  latter  being 
that  now  generally  accepted.  Dr.  T.  R.  Wolfe,  of  Glas- 
gow, Scotland,  in  his  text-book  of  1S82,  seems  to  local- 
ize the  disease  as  first  commencing  in  the  optic  nerve. 
Schmidt  Rimpler,  of  Marburg,  Prussia,  revised  by 
Roosa  in  his  text-book  of  1S89,  does  not  offer  any 
original  investigations  or  opinions  as  to  the  genesis  or 
histology  of  the  affection,  but  after  quoting  Virchow  as 
the  first  to  describe  it  as  glioma  of  the  retina  says  :  '"  It 
unquestionably  originates  in  the  internal  granular  layer 
of  the  litter."  Professor  Soelberg  Wells,  in  the  last 
edition  of  his  great  work,  revised  by  Dr.  Charles  Stead- 
man  Bull,  of  Xew  York,  ascribed  its  origin  to  the  inter- 
stitial connective  tissue  of  the  retina,  and  Dr.  Ernest 
Fuchs,  of  Vienna,  brooking  no  reasonable  doubts  on 
this  question,  classifies  the  condition  as  glioma  of  the 
retina,  and  depending  also  on  the  researches  of  Vir- 
chow, says  "  it  develops  mainly  from  the  inner  granu- 
lar layer  of  the  latter."  But  as  it  is  a  connective-tissue 
growth,  Iwanoft'  logically  concludes  "  that  it  may  origi- 
nate from  the  connective-tissue  elements  of  all  or  any 
of  the  layers  of  the  retina."  The  tumor  is  an  aggrega- 
tion of  roundish,  granular,  nucleated  cells,  with  little 
intercellular  substance. 

Histologically,  authors  have  agreed  that  it  is  identi- 
cal with  the  small  round-celled  sarcoma,  and  that  mi- 
croscopically there  was  no  difference  between  the  two. 
But  very  lately  Dr.  Ernest  Fuchs  claims  "  that  a  micro- 
scopic difference  does  exist  in  that  the  cell  of  the  glioma 
is  never  pigmented."  Clinically  all  authors  and  oph- 
thalmologists generally  agree  upon  the  usual  rapid  de- 
velopment of  the  growth,  its  tendency  to  invade  adja- 
cent structures,  to  the  "'  metastatic  development  of 
_  tumors  in  distant  organs,  on  its  usually  fatal  termina- 
tion despite  operative  measures  and  all  that  can  be 
done."  In  a  busy  ophthalmological  practice  of  seven- 
j  teen  years,  I  have  had  personally  but  four  of  these 
'  cases.  All  of  them  were  little  boys,  three  or  four  years 
of  age  ;  clinically  they  were  all  mainly  similar ;  exen- 
teration of  the  orbit  was  done  in  each  case  ;  three  died 
and  one  recovered  ;  two  of  the  cases  had  reached  the 
fourth  stage,  and  two,  including  the  one  recovery  I  have 
now  to  report,  were  in  the  third. 

Few  cases  of  the  disease  have  been  reported  where 
recovery  followed,  although  Professor  Panizza,  in  1846, 
referred  to  a  case  in  the  person  of  "  a  man  "  whom,  he 
averred,  he  had  known  to  get  well.  Dr.  Fuchs  says 
'■  while  the  disease  is  still  confined  to  the  eyeball  we 
may  hope  for  permanent  recovery,  but  when  it  has  per- 
forated the  eyeball,  rapid  recurrences  both  in  loco  and 

'  Read  before  the  Kansas  City  Medico  Chinirgical  Society  of  the 
College  of  Physicians  and  Surgeons,  January  15,  1895. 


in  the  neighboring  lymphatic  glands  seldom  fail  to  oc- 
cur." Professor  Soelberg  Wells  asserts,  "  the  prognosis 
is  always  extremely  grave  and  we  have  no  guarantee  at 
any  time  that  the  nerve  is  not  already  implicated  al- 
though the  tumor  may  be  still  very  small."  Professor 
Schmidt  Rimpler  agrees  mainly  with  Wells,  but  alleges 
that  "  recoveries  may  be  had  from  early  operation." 

The  disease  seems  to  be  unquestionably  one  of  child- 
hood, despite  some  questionable  cases  reported  in 
adults,  and  from  its  early  manifestations  in  many  cases 
it  is  not  unreasonable  to  suppose  that  it  may  have  its 
origin  in  early  foetal  life  and  in  traumatisms  inflicted 
in  the  progress  of  labor.  The  symptoms  as  a  rule  are 
as  follows  :  In  early  appearance  the  eyeball,  as  a 
whole,  is  quite  healthy  and  normal  ;  there  is  neither 
pain,  congestion,  nor  inflammation  ;  the  pupil  is  slightly 
dilated,  and  on  closer  inspection  a  yellow-whitish  re- 
flection is  seen  from  its  centre,  due  to  the  growth  of 
the  disease  and  the  detachment  of  the  retina  which  it 
pushes  forward.  .A.s  the  growth  increases,  the  tension 
of  the  eyeball  is  vastly  augmented,  its  size  is  exag- 
gerated, the  lens  becomes  opaque,  and  the  lens  and 
iris  are  pushed  fom-ard  against  the  inner  surface  of  the 
distended  and  overgrown  cornea.  At  this  stage  for  the 
first  time  the  patient  experiences  pain.  When  the  fun- 
gous-appearing tumor  has  filled  the  cavity  of  the  eye- 
ball, and  the  latter  is  more  hideous  and  larger  than 
the  eye  of  an  ox,  perforation  generally  takes  place.  At 
this  stage  the  tumor  sprouts  forth  from  its  enWron- 
ments  in  red  cauliflower  form,  and  being  unconfined, 
its  growth  is  exceedingly  rapid.  .\  sanious  liquid  ex- 
udes from  its  surface,  the  eyelids  are  greatly  swollen, 
the  tumor  bleeds  on  the  least  touch,  and  by  way  of 
metastasis  the  disease  invades  the  neighboring  lym- 
phatic glands,  the  internal  organs,  generally  the  liver, 
and  patients  die  in  from  a  few  months  to  several  years, 
either  by  exhaustion  or  an  extension  of  the  dreadful 
disease  to  the  brain.  Notwithstanding  the  clinical  his- 
tory just  given  of  this  disease  and  the  universally  un- 
favorable prognoses  quoted,  I  have  one  recovery  to 
report  from  my  only  four  cases. 

B.  T ,  aged  three  and  one-half  years,  was  brought 

to  me  from  Centralia,  Kan.,  in  January,  1893,  for  inves- 
tigation as  to  the  condition  of  one  of  his  eyes,  which  had 
been  noticed  from  birth  to  possess  "some  peculiarity." 
He  was  of  the  blond  type,  reasonably  well  nourished, 
but  his  general  development  showed  a  frail  constitu- 
tion. The  mother,  possessed  of  all  the  keen  intuitions 
of  intelligent  womanhood,  complained  "  that  from  in- 
attention by  a  physician  at  birth  or  during  delivery 
the  child's  eye  had  sustained  injury,  and  during  the 
first  hour  of  life  they  noticed  there  was  something 
wrong  with  it."  There  was  no  knowledge  of  scrofula 
or  cancer  in  the  families  of  either  the  father  or  mother, 
nor  of  any  injury  that  could  have  been  inflicted  at  play 
at  any  time.  These  parents  had  another  child,  a  boy, 
then  six  years  old,  with  good  eyes  and  average  health 
and  strength. 

This  peculiarity  had  been  noticed  many  times  from 
birth  by  the  mother,  who  frequently  wondered  at  the 
shining  of  the  ball  like  a  cat's  eye  in  a  darkened  room. 
When  the  case  came  to  me  for  examination  there  was 
no  inflammatory  s)-mptoms  and  the  history  given  by 
the  parents  showed  there  had  been  none  :  but  toward 
the  last  the  part  had  become  irritable  and  the  child 
complained  of  pain.  The  first  and  second  stages  of 
the  disease  having  passed  when  the  case  was  presented, 
the  third  stage  being  in  its  meridian  of  advancement, 
the  diagnosis  was  easy.  The  pronounced  enlargement 
of  the  eyeball  to  three  times  its  normal  dimensions, 
being  the  size  of  a  common  egg  ;  the  presence  of  the 
rectinal  excrescence,  and  the  yellow  characteristic  re- 
flex in  the  distended  pupil  of  the  hypertrophied  eye  ; 
the  high  tension  ;  the  exaggerated  size,  projecting  from 
the  orbit,  and  disturbed  relations  of  all  the  parts  of  the 
eyeball  :  the  presence  of  commencing  ulceration  at 
the  sclero- corneal  junction   where   the   overstretched 


304 


MEDICAL    RECORD. 


[August  j;[,   1895 


tunics  had  begun  retrograde  metamoriihosis,  showed  a 
most  typical  case  of  glioma  retina  of  the  third  stage. 

We  could  find  no  symptom  that  indicated  the  exten- 
sion of  the  disease  to  adjacent  parts  (the  fourth  stage), 
and  from  the  seeming  freedom  of  the  brain,  liver,  and 
lymphatics  from  metastatic  implication,  we  gave  the 
parents  a  ray  of  hope  that  a  thorough,  complete  re- 
moval of  the  contents  of  the  orbit  might  save  the  pa- 
tient's life  ;  the  slow  development  of  the  growth,  three 
and  one-half  years,  lending  courage  to  our  assertions. 
The  usual  fatal  termination  of  glioma,  the  steps  of  the 
operation,  the  necessity  of  chloroform,  the  liability  to 
regrowth  of  the  mass,  having  been  explained,  the  par- 
ents readily  consented  to  complete  amputation  of  the 
contents  of  the  orbit.  This  was  done,  as  stated  above, 
about  the  middle  of  January,  1893.  There  was  no 
particular  effort  made  at  simple  enucleation,  but  after 
dissecting  the  conjunctiva,  transversely  separating  and 
holding  it  aside  for  future  use,  the  entire  contents  of 
the  orbit  were  exenterated  or  dissected  away,  the  optic 
nerve  divided  by  pointed  scissors  at  the  apex  of  the 
orbital  cone  ;  then  the  same  thoroughly  cauterized  by 
an  applicator  carried  to  white  heat  with  a  spirit-lamp. 
The  orbit  was  packed  with  absorbent  cotton  saturated 
with  hydrg.  bichl.,  i  to  2,000  grains.  It  was  dressed 
antiseptically  in  the  same  manner  for  two  weeks,  when 
the  child  and  its  parents  returned  to  their  home.  At 
the  present  writing,  January  15,  1895,  almost  two  years 
from  the  time  of  the  removal  of  the  mass,  the  mother 
writes  me  as  follows  : 

"  Dear  Doctor  :  After  your  operation  in  January, 
1S93,  we  dressed  our  son's  eye  with  a  syringe  every 
other  day  until  the  following  May  ;  every  day  during 
the  summer  until  October.  Since  that  time  we  have 
dressed  it  only  with  the  idea  of  cleanliness,  and  have 
not  had  any  trouble  with  it.  The  remaining  eye  seems 
strong,  and  he  is  enjoying  very  good  health." 

Since  Professors  Fuchs,  Wells,  Wolfe,  Yirchow, 
Graefe,  etc.,  concede  "  the  children  generally  die  either 
from  exhaustion,  or  extension  of  the  disease  to  vital 
organs,  especially  the  brain,"  it  seems  reasonable  that, 
from  the  absolute  restoration  to  health  of  the  little 
child  above,  we  have  here  a  result  that  would  have 
been  unusual  in  the  experience  of  these  great  authori- 
ties, and  one  that  deserves  to  be  classed  with  the  very 
few  recoveries  from  this  disease  sparsely  referred  to  by 
the' great  masters  of  ophthalmology  of  the  world. 


^voQV&ss  Of  pXjecliraX  ^cii^wcc. 

Appendicitis. —  Dr.  :Murphy  believes  that  there  has 
been  no  controversy  in  the  history  of  medical  science 
in  which  the  struggle  has  been  so  intense  between  the 
surgeon  and  the  physician  as  that  concerning  appen- 
dicitis. Differences  of  opinion  in  regard  to  the  clinical 
course  and  propriety  of  operative  and  non-operative 
methods  have  been  almost  entirely  due  to  erroneous 
notions  of  the  pathological  conditions.  It  is  now 
settled  that  all,  except  two  per  cent.,  of  the  inflam- 
matory lesions  about  the  caput  coli  are  due  to  primary 
lesions  of  the  appendix.  Observation  shows  that  in 
the  acute  slage  the  pus  is  found  outside  tlie  appendix 
in  ninety-four  jjer  cent,  of  the  cases,  and  that  this  does 
not  necessarily  indicate  a  perforation  of  that  organ. 
Invasion  of  the  peritoneum  and  formation  of  a  peri- 
appendicular abscess  may  occur  with  an  internal  ulcera- 
tion of  the  appendix  without  iierforation.  Finall)',  the 
points  still  in  dispute  are  the  pathological  changes 'pro- 
duced by  perforation  into  the  peritoneal  cavity;  the 
likelihood  of  that  perforation,  and  also  perforation 
of  the  circumscribed  abscess  about  it  into  the  peri- 
toneal cavity  ;  the  immediate  and  remote  symiJtomatic 
and  physical  manifestations  of  the  latter,  and  the  ulti- 
mate result  of  such  rupture.  The  pathological  changes 
produced  depend   on  the   character   of   the   material 


admitted  into  the  peritoneal  cavity,  whether  it  is  pus 
or  bacilli  in  which  the  staphylococcus  predominates, 
whether  the  bacillus  coli  communis  exists  in  its  viru- 
lent or  inert  condition,  and  whether  the  parts,  in  which 
any  or  all  of  these  may  have  existed,  have  become  in- 
nocuous. It  also  depends  on  the  quantity  of  material 
admitted  at  one  time  into  the  peritoneal  cavity,  on  the 
condition  of  the  peritoneum  at  the  time  of  forma- 
tion of  the  pus.  Only  two  per  cent,  of  the  cases  of  ap- 
pendicitis are  found  to  contain  foreign  bodies,  and 
fecal  concretions  are  found  in  thirty-eight  per  cent. 
The  other  cases  are  :  i.  Simple  pus  infection,  produc- 
ing the  catarrhal  variety.  2.  Excessive  infection  by 
the  bacillus  coli  communis,  or  by  pyogenic  microbes, 
producing  gangrene  of  a  greater  or  lesser  portion  of 
the  appendix.  3.  Pressure  atrophy,  with  infection  of 
the  appendix  ((/)  by  fecal  concrement,  and  (i)  by 
foreign  bodies.  4.  Retention  accumulations  (ii)  from 
cicatricial  contractions,  stenosis,  and  obliteration,  and 
(fi)  from  occlusion  by  enteroliths  or  foreign  bodies. 
Perforation  was  found  in  seventy  per  cent,  of  the  re- 
ports of  autopsy  collected,  and  in  his  own  cases  it 
occurred  in  eighty-seven  per  cent.  We  have  no  sign, 
symptom,  or  combination  of  signs  or  symptoms,  that 
indicates  with  any  degree  of  certainty  suppurative 
peritonitis  in  the  early  stage.  The  rule  first,  last,  and 
always,  should  be,  operate  in  every  case  of  appendicitis, 
promising  or  unpromising,  at  the  earliest  possible  mo- 
ment..—J'/u'/aM/'/im  Medical  News. 

Heart  Disease  and  Menstruation. — Dr.  Gow  recently 
read  a  paper  before  the  Obstetrical  Society  of  London, 
with  a  record  of  50  cases  of  this  kind.  In  2S  the  flow 
was  unaltered  ;  in  17  the  flow  was  absent  or  scantier 
than  before  ;  in  5  the  flow  was  either  more  profuse  or 
recurred  more  frequently  than  before  ;  in  no  case  was 
there  good  evidence  that  heart  disease  gave  rise  to 
severe  menorrhagia.  It  would  seem  that  either  amen- 
orrhoea  or  scanty  menstruation  was  a  far  more  common 
accompaniment  of  heart  disease  than  menorrhagia.  A 
further  analysis  of  these  cases  seemed  to  point  to  the 
fact  that  heart  disease  led  to  relative  sterility,  and  also 
that  it  greatly  increased  the  tendency  to  premature  ex- 
pulsion of  the  ovum.  In  conclusion,  it  was  pointed 
out  that  a  large  number  of  women  suffering  from  val- 
vular disease  of  the  heart  pass  safely  through  the  period 
of  pregnancy  and  labor.  The  cases  were  further  an- 
alyzed as  follows:  i.  Mitral  stenosis  (22  cases).  In  9 
cases  menstruation  was  regular  and  the  amount  lost  un- 
altered, in  5  cases  menstruation  was  regular  but  more 
scanty,  in  4  cases  there  was  amenorrha'a,  and  in  4 
cases  menstruation  was  either  more  frequent  or  more 
profuse.  2.  Mitral  incompetence  (15  cases).  In  10 
cases  menstruation  was  unaltered,  in  4  cases  menstrua- 
tion was  more  scanty,  and  in  i  case  there  was  amenor- 
rhoea.  3.  Mitral  stenosis  and  incompetence  (7  cases). 
In  4  cases  menstruation  was  unaltered,  in  1  case  men- 
struation was  more  scanty,  in  i  case  there  was  amenor- 
rhoea,  and  in  i  case  there  was  slightly  increased  men- 
strual loss.  4.  Aortic  incompetence  and  obstruction 
(2  cases).  In  both  cases  menstruation  was  unaltered. 
5.  Aortic  and  mitral  incompetence  (3  cases).  In  all 
cases  menstruation  was  unaltered.  6.  Aortic  incompe- 
tence and  obstruction  and  mitral  incompetence  (i 
case).  Menstrual  loss  was  more  scanty  than  before. — 
The  Lancet. 

Inversion  of  the  Vermiform  Appendix. — i.  Inversion 
of  the  stump  of  the  appendix  should  be  substituted  for 
ligation  in  all  cases  of  acute  appendicitis  in  which  it 
can  be  ai>plied.  2.  In  chronic  appendicitis  either  the 
entire  appendix  or  its  stump  should  be  inverted,  pref- 
erence being  given  to  inversion  of  the  uncut  appendix 
whenever  practicable.  3.  In  all  cctliotomies  under- 
taken for  the  relief  of  conditions  other  than  appendi- 
citis, the  normal  appendix,  if  readily  and  safely  acces- 
sible, should  be  inverted  entire. — Edebohls. 


August  31,  1895] 


MEDICAL   RECORD. 


305 


Medical   Record: 

A  Weekly  yourfial  0/ Medicine  atid  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &.  47  East  Tenth  Street 


New  York,  August  31,  1895. 


THE    PHYSIOLOGICAL  ACTION  OF  THE  EX- 
TRACT OF   THE    SUPRA-RENAL  CAPSULE. 

Several  papers  on  this  subject  have  been  published  in 
the  Journal  of  Physiology.  Dr.  G.  Oliver  and  Profess- 
or Schafer  report  the  results  of  their  experiments  with 
the  e.xtracts  injected  into  the  cow,  sheep,  and  dog. 
They  found  that  when  the  substance  was  introduced 
into  the  vein  of  an  animal,  it  produced  a  rapid  contrac- 
tion of  the  arteries,  a  rise  in  blood-pressure,  and  a 
stimulation  of  the  vagus  nerve  which  was  very  pro- 
nounced Respiration  was  but  slightly  affected.  They 
found  that  the  extract  acted  about  the  same,  whether 
taken  from  the  calf,  sheep,  dog,  cat,  guinea- pig,  or 
man.  Further  investigations  along  the  same  lines  show 
that  the  introduction  of  these  extracts  into  the  system, 
while  producing  very  striking  effects,  never  led  to  a 
fatal  result.  It  was  also  found  that  the  active  part 
of  the  capsule  was  the  medulla,  while  solutions  of  the 
cortex  seemed  to  have  very  little  effect.  They  found 
also  that  the  extract  made  from  the  glands  taken  from 
cases  of  Addison's  disease  had  no  activity.  The 
authors  were  led  to  the  conclusion  that  the  extract 
was  not  influenced  by  hepatic  digestion  and  could  be 
taken  by  the  stomach.  On  the  whole,  the  results  of 
their  experiments  were  to  show  that  the  active  sub- 
stance in  this  gland  has  an  extremely  powerful  influ- 
ence upon  the  nerves  controlling  the  heart  and  circula- 
tory apparatus,  and  they  further  concluded  that  the 
gland  is  not  destructive  in  its  function,  but  rather  se- 
cretory, that  is  to  say,  that  it  does  not  select  effete 
matter  from  the  blood,  but  pours  some  substance  into 
the  blood  which  is  of  great  importance  to  the  economy. 

Dr.  Moore,  of  the  University  College,  has  contrib- 
uted an  elaborate  paper  on  the  chemical  nature  of  the 
active  substance  occurring  in  the  supra-renal  gland. 
He  finds  that  its  active  principle  is  soluble  in  water 
and  in  dilute  alcohol  ;  that  it  is  not  affected  by  acids, 
nor  injured  by  boiling  for  some  minutes,  but  is  de- 
stroyed by  alkalies  and  oxydizing  agents  ;  it  does  not 
reduce  Fehling's  solution,  and  it  is  not  volatile  ;  it 
dialyzes  freely  through  parchment  paper,  and  the  sub- 
stance so  obtained  is  free  from  proteids. 

M.  V.  Nabarro  also  contributes  an  article  on  the 
chemical  properties  of  the  supra-renal  extract,  but  the 
descriptions  are  too  technical  to  be  of  interest  to  the 
general  reader. 

It  seems  to  be  pretty  well  established  that  the  gl.ind 


does  contain  a  powerfully  active  poison,  which  has  cer- 
tain definite  chemical  properties,  and  which  is,  perhaps, 
one  of  the  nucleo-albumins. 


COUNTER  PRESCRIBING. 

Some  criticism  has  been  excited  by  the  action  of  the 
County  Medical  Society  in  bringing  suit  against  a 
druggist  of  this  city  for  violation  of  the  medical  prac- 
tice law.  The  Financial  Review  states  that  the  drug- 
gist in  question  was  a  man  in  good  standing  and  ex- 
perienced in  his  profession.  He  was  arrested  through 
the  instigation  of  the  County  Medical  Society  and 
brought  before  the  Tombs  Police  Court.  The  presi- 
ding magistrate  expressed  the  opinion  that  the  druggist 
had  the  right  to  do  what  he  had  done,  and  added  that 
if  he  had  known  the  circumstances  in  the  first  place, 
he  would  not  have  issued  the  warrant  for  the  arrest. 
The  Review  states  that  the  charge  against  him  was 
absurd,  and  was  "  evidently  the  result  of  that  profes- 
sional bitterness  which  so  many  physicians  feel  toward 
druggists  in  consequence  of  what  they  designate  as 
'counter  prescribing.'"  The  fact,  adds  the  Review, 
that  the  child  for  whom  the  medicine  was  prescribed 
by  the  druggist,  died,  proved  nothing,  since  patients  of 
physicians  sometimes  die  also. 

We  are  not,  we  confess,  familiar  with  all  the  facts  on 
each  side  of  this  question,  but  we  do  know  that  the 
general  attitude  of  the  County  Medical  Society  toward 
"  counter  prescribing  "  has  been  a  very  conservative 
one.  When  one  compares  the  enormous  amount  of 
counter  prescribing  by  druggists  of  this  city  with  the 
very  few  prosecutions,  it  would  be  apparent  to  every- 
one that  there  is  no  "  professional  bitterness  "  of  any 
moment,  in  this  city,  at  least.  The  habit  of  druggists 
of  prescribing  simple  remedies  for  simple  complaints 
is  well  enough,  and  is,  no  doubt,  of  service  to  the  poor. 
It  is  only  the  systematic  abuse  of  it  which  is  dangerous 
to  the  public  health  and  individual  lives,  and  it  is  upon 
this  ground,  as  well  as  upon  the  ground  that  it  inter- 
feres with  the  work  of  the  physician,  that  the  medical 
profession  protests  against  it. 


TRAUMATIC    PSYCHOSIS    IN    A    HORSE. 

Dr.  Charles  F£r6  gives  an  account  of  a  horse  with  a 
curious  nervous  disturbance,  which  seems  to  resemble 
in  many  respects  a  form  of  confusional  or  stuporous 
insanity  in  man.  The  condition,  he  says,  is  one  not  un- 
known to  veterinarians  and  is  described  by  them  as 
"  immobilite." 

The  animal  in  question  was  six  years  old,  vigorous, 
and  without  any  morbid  heredity,  and  perforce  of  regu- 
lar and  temperate  habits,  being  in  active  service  on  a 
truck.  One  day  there  was  an  accident  and  the  horse 
and  cart  were  thrown  down  a  bank,  a  distance  of  about 
eighteen  feet.  The  horse  was  apparently  in  no  way 
injured  and  for  several  days  continued  his  usual  work. 
Then  it  was  noticed  that  he  began  to  get  dull  and  apa- 
thetic, his  eyes  would  become  fixed,  he  paid  no  atten- 
tion to  his  surroundings,  and  did  not  recognize  or 
notice  those  who  were  accustomed  to  attend  him,  and 


3o6 


MEDICAL   RECORD. 


[August  31,  1895 


whom  he  had  previously  shown  that  he  remembered. 
This  apathy  increased,  and  he  would  sometimes  place 
his  head  on  the  edge  of  the  manger  and  so  remain  for 
hours  without  moving  or  noticing  his  food.  When  this 
was  pushed  into  his  mouth  he  would  often  let  it  fall 
out.  If  one  leg  were  taken  and  crossed  in  front  of  the 
the  other,  he  would  let  it  stay  there.  It  was  only  by 
the  greatest  exertion  that  he  could  be  hitched  to  his 
cart  and  forced  to  move.  While  going  along  the  road 
the  horse  sometimes  suddenly  fell  down,  to  the  great 
disconcertment  of  his  driver.  At  other  times,  after 
walking  slowly  and  apathetically  for  a  time,  he  would 
suddenly  break  into  a  furious  and  dangerous  burst  of 
speed.  After  such  outbursts  he  would  become  more 
"  immobile  "  than  ever.  His  condition  differed  on  dif- 
ferent days,  but  on  the  whole  he  grew  more  lethargic, 
emaciated,  and  cataleptic.  He  never  became  maniacal, 
and  did  not  kick  or  bite. 

The  outcome  is  not  distinctly  stated  by  Dr.  Fere, 
but  at  the  time  of  report  the  owner  had  decided  to 
send  him  to  a  butcher,  and  perhaps  the  finale  was 
sausages  and  steaks.  We  regret  that  no  autopsy  was 
made,  but  the  reporter  assures  us  that  in  other  and 
similar  cases  there  had  sometimes  been  found  a  dropsi- 
cal condition  of  the  brain,  while  at  other  times  no 
lesion  couldbe  discovered. 

Bouley  refers  to  this  condition  of  the  horse  under 
the  name  of  immohiliU\  and  Chaslin  describes  it  in  man 
as  "confusion  mentale  [irimitive." 

Perhaps  some  of  our  readers  have  had  personal  ex- 
periences with  "  immobility  "  in  the  horse,  though  the 
condition  known  as  Langsamkeit  or  nature  tardive  is 
more  common  in  the  domesticated  specimens  of  this 
country. 

NEW  EDITIONS    OF    MEDICAL  MEN. 

Dr.  Wu.liam  H.  Thomson  has  recently  suggested 
that  it  is  the  duty  of  the  physician  to  get  out  a  new 
edition  of  himself  at  certain  stated  periods.  This  is 
another  way  of  putting  the  fact  which  the  late  Sir  An- 
drew Clark  used  to  call  attention  to  :  That  a  man  was 
never  old  as  long  as  he  had  not  lost  his  receptivity,  his 
capacity  to  learn  and  to  adjust  himself  to  the  progress  of 
the  world.  The  figure  of  speech  adopted  by  Dr.  Thom- 
son, however,  is  a  very  suggestive  one,  and  we  have  no 
doubt  that  its  current  use  would  have  a  great  deal  of 
practical  value.  Dr.  Thomson  suggests  that  one  reason 
why  the  country  practitioner  falls  behind  is  that  he 
gets  into  certain  ruts  and  is  too  idle  or  too  busy  to  get 
himself  out  of  them.  It  is  the  country  practitioner,  he 
thinks,  that  especially  needs  a  new  edition  of  himself. 
Not  that  he  is  inherently  less  ambitious  or  more  indo- 
lent than  his  city  brother,  but  because  the  publishing 
ofiices  and  means  of  issuing  "  new  editions  "  are  mainly 
in  the  large  centres.  The  establishment  of  graduate 
schools  for  the  instruction  of  medical  men  has  enabled 
practitioners  to  use  the  facilities  that  modern  science 
brings  out  freshly  every  year,  and  we  fancy  in  the 
course  of  time  it  will  be  the  city  doctor  who  will  be 
behindhand  in  editing  himself,  for  he  is  generally  too 
thoroughly  confident  of  his  medical  equipment  to  think 
it  worth  while  to  take  a  course  of  instruction  from  his 
fellowman. 


%f)Xis  of  ttic  'SmccU. 

The  Society  of  Medical  Phonographers  held  its  first 
annual  meeting  in  London  on  July  30th.  Addresses 
were  made  by  the  President  and  founder,  Dr.  W.  R. 
Cowers,  Sir  Henry  Howorth,  Sir  William  Broadbent, 
and  Mr.  Thomson,  and  letters  were  read  from  General 
Sir  Charles  Wilson,  the  Bishop  of  Hereford,  and  Dr. 
Gladstone.  The  President  said  that  Dr.  Langdon,  of 
Cincinnati,  though  forty-five  years  of  age,  had,  in  a 
fortnight,  obtained  the  power  of  writing  a  shorthand 
letter  which  he  (Dr.  Gowers)  was  able  to  read  as 
swiftly  as  he  could  speak,  but  he  did  not  say  how  long 
it  took  Dr.  Langdon  to  write  the  letter. 

Cronica  de  Ciencias    Medicas    de   Filipinas   is  the 

title  of  a  new  journal  published   in   Manila  under  the 
editorial  direction  of  1  )r.  A.  Alfonso  Maseras. 

Anthrax  in  New  York  State. — The  State  Board  of 
Health  has  found  that  anthrax  prevails  among  cattle 
in  many  parts  of  New  York.  The  Board  has  been 
conducting  investigations  looking  to  the  discovery  and 
extermination  of  bovine  tuberculosis,  and  this  led  to  the 
discovery  of  the  rather  wide  prevalence  of  anthrax. 
The  Board  is  empowered  to  deal  summarily  only  with 
tuberculosis,  and  must  look  to  the  Legislature  for 
power  to  destroy  animals  infected  with  anthrax. 

The  Intercolonial  Medical  Congress  of  Australasia 

will  hold  its  opening  session  on  February  3d  next,  in- 
stead of  February  17th,  as  at  first  announced. 

A  Representative  of  the  University  Regents  in  New 
York  City.  — The  Regents  of  the  l^niversity  of  the 
State  of  New  York,  in  response  to  urgent  requests, 
have  decided  to  open  an  office  in  this  city  for  the  ac- 
commodation of  the  immense  amount  of  business  which 
comes  from  here.  The  office  will  be  at  10  East  Forty- 
second  Street,  and  will  be  open  after  September  10, 
189s,  during  the  school  week,  from  9  a.m.  to  4  p.m., 
and  7  to  9  P.M.  Business  hours  will  be  from  9  a.m. 
to  12  M.,  but  the  deputy,  Mr.  Aza  O.  Gallup,  will  see 
callers  at  olher  hours  if  they  cannot  come  between  9 
and  12.  The  representative  of  the  Regents  will  have 
all  publications,  blanks,  and  necessary  records  for  the 
accomn^dation  of  law,  medical,  dental,  and  veteri- 
nary students,  and  for  all  the  professional,  academic, 
and  higher  examinations  conducted  by  the  University. 

The  Weber-Parkes  Prize. — This  prize  was  founded 
by  Dr.  Hermann  Weber  in  memory  of  the  late  Dr.  E. 
A.  Parkes.  It  is  of  the  value  of  about  $750,  and  will 
be  awarded  triennially  to  the  author  of  the  best  essay 
upon  some  branch  of  the  subject  of  tuberculosis,  espe- 
cially with  reference  to  pulmonary  consumption  in 
man.  The  first  award  will  be  made  in  1897,  and  the 
adjudicators  have  selected  as  the  subject  for  the  essay 
"The  Means,  Prophylactic  or  Curative,  deemed  by  the 
Author  to  have  N'alue  in  the  Control  of  Tuberculosis, 
especial  Regard  being  had  to  their  Application  to  Hu- 
man Tuberculosis."  This  subject  was  selected  by  Dr. 
1.  E.  Pollock,  Dr.  Thome  Thome,  and  Professor  W. 
S.  Greenfield,  who  were  nominated  by  the  President  of 
the  Royal  College  of   Physicians  of  London,  and   the  j 


August  .31,  1895] 


MEDICAL  RECORD. 


307 


merits  of  the  competing  essays  will  be  determined  by 
the  same  men.  The  essay  must  be  based  on  original 
work  and  observations  (experimental  or  other)  of  the 
author,  and  must  include  a  detailed  exposition  of  the 
methods  employed  and  their  mode  of  application. 
The  competition  is  open  to  members  of  the  medical 
profession  in  all  countries.  The  essays  must  be  type- 
written and  in  English  ;  or  if  written  in  a  foreign  lan- 
guage must  be  accompanied  by  a  translation  into  Eng- 
lish. The  essays  must  be  delivered  to  the  Registrar  of 
the  Royal  College  of  Physicians  on  or  before  July  i, 
1897.  In  addition  to  the  money  prize  a  bronze  medal 
will  be  given  to  the  holder  of  the  prize,  and  a  second 
medal  to  the  essayist  who  comes  ne.xt  in  order  of  merit. 
Further  information  for  the  guidance  of  competitors 
may  be  obtained  by  addressing  the  Registrar  of  the 
college,  Dr.  Edward  I.iveing,  London,  England. 

The  Hospitals  of  New  York  State. — According  to  a 
law  passed  last  year  all  corporations  established  for  the 
purpose  of  giving  medical  and  surgical  relief  must  have 
their  certificates  of  incorporation  approved  by  the 
State  Board  of  Charities  before  they  can  obtain  the  de- 
sired powers  to  act.  The  necessity  of  making  intpii- 
ries  concerning  various  bodies  suggested  to  the  members 
of  the  Board  the  desirability  of  an  investigation  of  the 
existing  hospitals  in  the  State,  for  the  purpose  of  de- 
termining their  present  condition  and  efficiency,  how 
far  they  have  accomplished  the  purposes  for  which  they 
were  established,  and  what  communities  are  not  sup- 
plied with  hospital  facilities.  Dr.  Stephen  Smith, 
chairman  of  the  committee  appointed  to  conduct  this 
investigation,  has  visited  most  of  the  hospitals  of  the 
State  west  of  Albany.  As  one  result  of  this  investiga- 
tion it  has  been  found  that  some  of  the  best  conducted 
and  best  constructed  hosjjitals  are  in  the  smaller  towns, 
and  some  of  the  worst  are  in  the  larger  cities.  One  of 
the  most  common  faults  is  that  the  hospital  is  built  in 
order  to  secure  handsome  architectural  effects  without 
much  regard  for  the  prevailing  winds,  sunlight,  etc. 
It  is  suggested  that  there  be  created  in  the  office  of  the 
State  Board  of  Charities  a  bureau  of  information  on 
the  construction  and  management  of  hospitals.  If 
there  were  such  a  bureau,  where  the  plans  of  all  the 
latest  and  most  approved  hospitals  of  this  and  foreign 
countries  could  be  readily  consulted,  the  errors  of  the 
past  would  be  avoided,  and  improved  design*  would  be 
suggested  for  the  future  hospitals  of  this  State. 

Dr.  Emil  Yung  has  been  appointed  Professor  of 
Anatomy  at  the  University  of  Geneva,  to  succeed  the 
late  Professor  Carl  Vogt. 

Cholera  in  Japan. — It  is  reported  from  Japan  that  the 
number  of  cases  of  cholera  in  that  country  since  the 
beginning  of  the  present  epidemic  has  been  about 
25,000.  The  disease  has  been  of  more  than  average 
virulence  if  it  is  true,  as  stated,  that  the  deaths  exceed 
16,000,  or  sixty-four  per  cent,  of  those  attacked. 

The  British  Medical  Association  will  meet  next  year, 
it  is  believed,  in  Eastbourne,  the  medical  men  of  which 
place,  seconded  by  the  mayor  and  corporation,  having 
invited  the  .Association  to  come  there. 

Dr.  Schimmelbush,  whose  work  on  the  "  .\sei)tic 
Treatment  of  Wounds  "  was  recently  reviewed  in  these 


columns,  died  in  Berlin  on  August  2d,  aged  thirty- 
five.  He  was  assistant  to  Professor  von  Bergmann, 
in  the  Surgical  Clinic  of  the  University  of  Berlin,  and 
was  looked  upon  as  one  of  the  foremost  of  the  younger 
generation  of  German  surgeons. 

The  International  Medico-Legal  Congress  will  be 
held  in  the  United  States  court-rooms,  in  the  Post-office 
building,  in  this  city,  on  September  4th,  5th,  and  6th. 
The  chairman  of  the  Committee  of  Arrangements  is  the 
Hon.  Ra.stus  S.  Ransom,  and  the  secretary,  Clark  Bell, 
Esq.  Dr.  Forbes  Winslow,  of  London,  is  expected  to 
be  present  to  act  as  chairman  of  the  Section  on  Insan- 
ity and  Mental  Medicine. 

Dr.  W.  W.  Cable,  of  Pittsburg,  died  at  his  home  in 
that  city  on  August  27th,  aged  seventy-two. 

The   American  Electro-therapeutic   Association  will 

hold  its  fifth  annual  meeting  in  the  council-room  of 
the  College  of  Physicians  and  Surgeons  of  Ontario, 
Toronto,  Canada,  on  September  3,  4,  and  5,  1895. 
The  president  of  the  association  is  Dr.  A.  Lapthorne 
Smith,  of  Montreal  ;  secretary.  Dr.  Emil  Heuel,  of  New 
York. 

Dr.  Maragliano's  Impressions  of  the  British  Medical 
Association. — The  Rome  correspondent  of  The  Lancet 
quotes  an  interview  with  Professor  Maragliano,  of 
Genoa,  by  the  London  representative  of  //  Secolo,  to 
whom  he  expressed  his  high  admiration  of  the  sanitary 
institutions,  the  hospitals,  and  the  whole  hygienic  organi- 
zations of  the  British  capital.  He  was  surprised  at  the 
solidarity  prevailing  among  the  British  medical  men,  at 
their  well-disciplined  meetings,  at  the  practical  sense 
which  guides  them,  not  only  in  the  field  of  science,  but 
in  that  of  professional  interests.  The  admirable  or- 
ganization of  the  meeting  itself  elicited  his  special 
commendation,  its  hospitality  being  beyond  the  hopes 
even  of  the  exacting.  The  scientific  discussions  he 
found  impressed  with  the  gravity  proper  to  the  practi- 
cal genius  of  the  race,  and  while  he  missed  the  enthu- 
siastic outburst  of  his  southern  compatriots  he  re- 
marked the  great  attention  in  following  the  scientific 
discussions  and  communications. 

Punishment  for  Selling  Skim  Milk. — Complaint  was 
made  not  long  ago  that  persons  arrested  for  selling 
watered  milk  in  this  city  were  let  off  without  adequate 
punishment.  The  complaint  seems  to  have  been 
heeded,  for  two  milk-dealers  received  a  few  days  ago 
sentences  of  a  $50  fine  and  ten  days'  imprisonment,  in- 
stead of  the  $25  fine  usually  imposed  for  selling  watered 
and  skimmed  milk.  .V  few  such  sentences  as  these 
will  go  far  toward  preventing  the  sale  of  adulterated 
milk  in  New  York. 

A  Sociedade  de  Medicina  e  Cirurgia  da  Bahia  is  the 

name  of  a  society  founded  recently  in  Bahia,  Brazil. 
Dr.  Pacheco  Mendes  is  the  president,  and  Drs.  Braz 
do  Amaral  and  Cerqueira  Lima  are  the  secretaries  of 
the  society.  The  organization  publishes  a  monthly 
volume  of  transactions  under  the  direction  of  Dr. 
Juliano  Moreira. 

The  Index  Medicus  will  probably  be  revived,  at  least 
it  is  hoped  that  the  subscriptions  will  reach  the  requisite 


3o8 


MEDICAL   RECORD. 


[August  31,  1895 


two  hundred  before  December  ist  next.  In  addition 
to  the  subscriptions  received  by  the  publisher,  Dr.  Bill- 
ings had  received  forty -eight  up  to  August  23d. 
These  subscriptions  are  conditional  upon  the  obtaining 
of  two  hundred  before  December.  It  is  hoped  that 
when  the  physicians  return  from  their  summer  vaca- 
tion the  desired  number  will  quickly  be  obtained. 

Eighty-two  Physicians  from  the  United  States  and 
nine  from  Canada  were  registered  as  guests  and  visi- 
tors at  the  recent  meeting  of  the  British  Medical  Asso- 
ciation. 

Miss  McFee,  of  Montreal,  has  just  obtained  the  de- 
gree of  Doctor  oi  Philosophy  at  Zurich.  She  is  a 
graduate  of  McGill  University,  and  studied  Philosophy 
at  Cornell  and  under  Professor  Wundt  of  Leipzig. 

A  New  Explanation  of  the  Bicycle  Face. — A  writer 
in  the  Christian  Intelligencer  says  that  the  true  explana- 
tion of  the  bicycle  face  has  not  yet  been  given  by  the 
doctors,  who  have  themselves  "  fallen  in  with  the  un- 
belief and  recklessness  of  the  times  and  do  not  insist 
in  their  spoken  and  written  words  upon  the  need  of 
one  day  of  rest  in  every  seven."  This  explanation  is 
to  be  found  in  the  habit  of  wheeling  on  Sunday.  "  Is 
it  not  possible,"  the  Intelligencer  asks,  "  that  the  law  of 
the  Decalogue  is  binding  upon  bicyclists  as  well  as 
upon  other  people,  and  an  habitual  violation  of  the  law 
of  the  Sabbath  may  result  in  the  worn,  weary,  and  ex- 
hausted face  called  the  bicycle  face  ?  The  bicyclists 
are  doing  much  to  destroy  the  Sabbath,  and  at  the 
same  time  are  injuring  their  own  bodies  and  souls. 
The  bicycle  face,  indicating  extreme  weariness  and  ex- 
haustion, due  to  the  severe  strain  of  violent  exercise 
on  seven  days  of  the  week,  will  be  followed,  as  surely 
as  the  Decalogue  is  the  law  of  God,  with  moral  weari- 
ness and  exhaustion  in  the  wheelmen  and  in  those  in- 
lluenped  by  them."  On  the  other  hand,  a  French 
physician,  who  is  himself  a  wheelman,  maintains  that 
the  greatest  benefit  from  this  form  of  exercise  can  be 
obtained  only  by  cycling  every  day  regularly.  Those 
who  wheel  every  day  can  do  so  without  causing  exces- 
sive action  of  the  heart,  whereas  those  who  ride  only 
once  or  twice  a  week  do  so  at  their  peril,  the  unwonted 
exercise  causing  a  tumultuous  and  rapid  action  of  the 
heart  that  may  have  very  serious  consequences. 

Water-supply  of  Cleveland.— The  Ohio  State  Board 
of  Health  has  refused  the  petition  of  the  City  of  Cleve- 
land to  be  allowed  to  discharge  sewage  from  a  new  dis- 
trict into  Lake  Erie  near  the  intake  of  the  city  water- 
supply.  Mr.  Allen  Hazen,  of  Boston,  was  employed 
by  the  Board  as  consulting  engineer.  Investigation 
showed  that  the  water-supply  is  already  polluted,  and 
statistics  revealed  that  the  typhoid  death-rate  for  the 
past  seven  years  has  been  higher  in  Cleveland  than  in 
any  other  large  city  of  the  State.  Plans  for  extending 
the  intake  into  the  lake  are  under  consideration  ;  but 
Secretary  Probst  is  of  opinion  that,  while  this  may  af- 
ford a  temporary  remedy,  all  the  lake  cities  will  event- 
ually be  compelled  to  resort  to  filtration  for  the  purifi- 
cation of  their  water-supplies.  A  better  way  would 
seem  to  be  to  prevent  pollution  by  a  proper  disposal  of 
sewage. — Journal  of  the  American  Medical  Association. 


(Dbitwavrj. 

WILLIAM    C.    JARVIS,    M.D., 


NEW  VORJC. 


Dr.  William  C.  Jarvis  died  at  Willet's  Point,  N.  Y., 
July  3d.  He  was  born  in  1855  at  Fortress  Monroe,  Va., 
where  his  father,  the  late  Surgeon  N.  S.  Jarvis,  U.  S.  A., 
was  stationed  as  post  surgeon.  After  the  death  of  his 
father  in  1862,  Baltimore  became  his  home.  He  studied 
medicine  at  the  University  of  Maryland,  graduating  at 
the  age  of  twenty  years.  He  then  devoted  a  year  to 
the  study  of  chemistry  and  biology  at  the  Johns  Hop- 
kins University. 

In  1877,  considering  New  York  the  most  promising 
field  for  a  young  doctor,  though  almost  an  entire 
stranger  here,  he  commenced  practice  in  the  eastern 
section  of  the  city.  After  a  year  devoted  to  general 
medicine,  he  adopted  laryngology  as  a  specialty.  Dr. 
Jarvis's  success  as  a  laryngologist  was  not  surprising 
with  his  peculiar  inventive  powers.  Of  the  numerous 
instruments  contributed  by  him  to  nasal  and  throat 
surgery  may  be  mentioned,  inter  alia,  the  Jarvis  snare, 
in  which  the  value  of  piano- wire  for  cutting  purposes 
was  first  demonstrated,  and  by  means  of  which  morbid 
growths,  whose  removal  by  older  methods  necessitated 
painful  and  ghastly  operations  through  the  face,  are 
eradicated  easily  and  almost  painlessly.  The  many 
modifications  of  this  little  instrument  have  in  them- 
selves proven  how  valuable  was  the  principle.  The 
laryngeal  applicator,  intended  for  the  employment  of 
fused  crystals  of  chromic  acid,  in  accordance  with  apian 
conceived  by  himself,  the  ring  speculum,  and  the  oper- 
ating nasal  speculum  are  probably  the  best  known  of 
his  additions  to  the  armamentarium  of  the  laryngolo- 
gist. 

By  temperament  and  inheritance  an  indefatigable 
student.  Dr.  Jarvis  was  proficient  in  French  and  Ger- 
man, and  he  retained  also  his  knowledge  of  the  Latin  and 
Greek  classics.  In  his  many  contributions  to  medical 
literature  Dr.  Jarvis  labored  conscientiously  to  avoid 
a  spirit  of  exaggeration  and  to  submit  only  facts  which 
he  had  proven  by  extensive  personal  experience  of  real 
value.  Among  his  contributions  to  medical  literature 
are  several  chapters  on  the  throat  and  nose  in  well- 
known  text-books.  At  the  age  of  twenty-six  he  was 
invited  to  occupy  the  chair  of  laryngology  at  the  Uni- 
versity of  New  York.  He  was  at  that  time  barely  ac- 
quainted with  the  members  of  the  faculty  of  that  in- 
stitution and  was  told  by  the  late  Professor  Loomis 
that  he  had  been  selected  simply  and  only  because  he 
was  considered  the  man  (jualified  for  the  place.  That 
Dr.  Jarvis  was  a  rare  diagnostician,  operator,  and  thera- 
peutist it  is  needless  to  add. 

Nor  was  his  knowledge  of  medicine  cramped  by  the 
selection  of  a  specialty  ;  he  was  a  faithful  student  of 
general  medicine,  thoroughly  aware  of  its  value  in  the 
practice  of  a  special  branch. 

At  the  time  of  his  death  Dr.  Jarvis,  by  reason  of  ill 
health,  had  become  Kmsritus  Professor  of  Laryngology 
at  the  L^niversity  of  New  York,  and  consulting  phy- 
sician to  the  City  Hospital.  He  was  a  member  of  the 
American  Laryngological  .\ssociation,  a  fellow  of  the 
Academy  of  Medicine,  and  a  member  of  other  medical 
societies. 

The  most  interesting  feature  of  the  man,  however, 
was  his  personal  character.  His  was  a  type  of  the 
Christian,  which  all  men,  however  sceptical,  were  com- 
pelled to  admire.  He  was  a  true  philanthropist  ; 
though  fighting  with  all  his  energies  unworthy  appeals 
to  the  charitable,  he  gave  liberally,  and  worked  joyfully 
for  the  deserving  poor  and  alllicted.  Withal  a  modest, 
unpretentious  man,  a  true  friend,  of  a  generous,  open- 
hearted  loving  character,  the  medical  profession  and 
the  community  have  sustained  in  his  taking  away  a 
severe  loss. 


August  31,  1895] 


MEDICAL   RECORD. 


509 


©liuical  §epartment. 

ANENCEPHALOUS    MONSTERS. 
By  ALBERT  C.  BOWERMAN,   M.B., 


It  may  be  inferred  from  recent  reports  in  the  Medical 
Record  that  the  "  anencephalous  monster  "  continues 
the  invasion  of  the  present  race  with  a  regularity  here- 
tofore unsuspected  ;  but  from  the  brevity  of  its  in- 
dividual existence,  it  may  safely  be  conjectured  that  its 
advent  is  premature,  being  in  the  experimental  stage  of 
its  evolution,  for  its  short-lived  appearance  could 
scarcely  be  explained  on  the  ground  of  atavism.  Does 
the  frequency  of  its  repetition,  under  remote  and  dis- 
similar conditions  of  life,  suggest  the  possibility  of  a 
design  on  the  part  of  nature  to  meet  impending  neces- 
sities by  anatomical  reconstruction  ? 

The  absence  of  cerebral  development,  coupled  with 
a  good  physical  organization,  might  not  unreasonablv 
imply  that,  with  the  specialization  of  occupations,  our 
race  is  fast  becoming  an  aggregate  of  automata  to 
whom,  or  to  which,  a  cerebrum  will  be  superfluous 
and  possibly  a  source  of  inconvenience.  Nature  may 
be  congratulated  on  having  already  achieved  remark- 
able successes  in  this  direction  ;  and  on  the  grounds 
of  experimental  research  she  may  be  excused  for  her 
prodigal  waste  of  energy  in  the  perpetuation  of  useless 
survivals.  Viewed  from  the  stand-point  of  the  contem- 
poraries of  the  cave-bear,  the  present  race  may  not 
unreasonably  be  stigmatized  as  monstrous  ;  while  from 
our  own  point  of  view  the  evolving  cyclist  will  repre- 
sent a  readjustment  of  anatomical  parts  too  curious 
for  conception  ;  so  that  it  is,  at  least,  not  generous  to 
rashly  criticise  the  subject  of  our  pen-sketch  without 
first  being  made  acquainted  with  the  peculiar  sphere 
she  was  intended  to  fill.  That  there  was  a  miscalcula- 
tion in  the  time  and  an  error  in  judgment  in  the 
selection  of  a  place  for  her  debut,  is  conceivable  from 
the  rapidity  with  which  her  exit  followed  upon  the 
heels  of  her  unfortunate  advent ;  but  if  we  are  to  gain 
any  information  from  the  parental  environment,  we 
may  presume  that  her  sphere  was  at  least  semi-aquatic, 
as  her  birth  occurred  at  a  barren  sand-lot  on  the  bor- 
ders of  a  marsh.  However,  be  this  as  it  may,  on  the 
evening  of  November  2d  last,  I  was  called  to  attend 
the  wife  of  a  laborer,  said  to  be  in  the  eighth  month  of 
her  second  pregnancy,  and  suffering  for  some  hours 
with  labor-pain.  She  was  twenty-four  years  of  age, 
and  about  two  years  before  had  given  birth  to  a  living 
child,  normal  in  appearance,  which,  however,  died  at 
about  ten  months  of  some  cerebral  difficulty.'  For 
some  weeks  the  patient  had  suffered  from  the  weight 
and  distention  of  what  was  not  unreasonably  suspected 
to  be  a  multiple  pregnancy,  but  which  proved  ulti- 
mately to  be  an  excess  of  amniotic  fluid.  She  was 
restless  and  sleepless,  suffering  from  dyspnoea,  and 
the  common  "nagging"  pains  of  early  labor.  Ex- 
amination revealed  a  slightly  dilated  os  uteri.  Nothing 
more  unusual  occurred  until  December  7th  following, 
when  I  was  again  called.  I  found  her  much  exhausted 
from  hemorrhage,  having  been  delivered  some  hours 
previously  of  a  living  "  anencephalous  "  female  child, 
which  the  nurse  assured  me  had  lived  and  breathed  for 
nearly  an  hour.  The  body  and  limbs  were  fairly 
developed,  though  somewhat  disprojiortioned,  and  the 
weight  would  be  about  three  pounds.  The  limbs, 
especially  the  lower,  were  extremely  long,  giving  the 
body  a  shortened  and  truncated  appearance.  It  was, 
so  to  speak,  curtailed  at  the  head,  and  was  entirely 
without  even  the  suspicion  of  a  neck,  so  that  it  was  a 
reasonable  subject  for  electrocution.  The  prominence 
of  the  chin  occupied  the  sternal  notch  ;  and  the  ears, 
which    were    well    developed,    lay   behind    and   rather 


below  the  shoulder-joints  ;  the  face,  which  was  well 
formed,  though  not  exactly  interesting  in  the  usual 
sense,  was  directed  upward  ;  and  the  eyes,  exceedingly 
prominent  from  the  lack  of  frontal  bone,  were  disposed 
as  a  lookout  in  the  rear.  There  is  no  doubt  but  that 
an  eye  at  the  back  of  the  head  would  often  gather  un- 
suspected information,  but  when  it  is  furnished  at  the 
expense  of  the  usual  position,  the  advantages  and  dis- 
advantages are  counterbalanced.  Behind  and  between 
the  ears  was  a  fringe  of  dark  hair  on  either  side  of  the 
posterior  median  line  corresponding  to  the  occiput  ; 
but  the  cranium,  if  any,  was  open  in  the  latter  region, 
and  continuous  with  the  unclosed  spinal  canal  as  far 
down  as  the  lower  lumbar  vertebra.  Protruding  from 
the  upper  end  of  this  canal,  and  overlapped  by  the 
fringe  of  hair,  were  the  congested  lobes  of  the  cere- 
bellum, much  enlarged  and  exposed  across  the  dorsum 
almost  to  the  base  of  the  sacrum,  and  too  large  to  be 
admitted  into  the  limited  room  of  the  cranium.  The 
length  of  back,  from  occiput  to  sacrum,  could  not 
have  been  more  than  three  inches,  so  that  the  child 
had  the  appearance  of  a  crescent  with  the  hollow  at 
the  back. 


By  G.    R.    HIXMAN,    M.D., 


In  the  Medical  Record  for  April  20th  was  the  report 
of  a  case  of  anencephalous  monster  by  Dr.  R.  H.  Fill- 
more, of  Cookshire,  P.  Q.,  Canada.  And  again  another 
case  quite  similar  reported  by  Dr.  J.  E.  Tompkins,  of 
Fredericksburg,  Va.  The  following  case,  read  in  con- 
nection with  those  above  mentioned,  may  possibly  be  of 
interest  : 

On  the  evening  of  March  2,  1895,  at  8  o'clock,  Mr. 
T called  me  to  see  his  wife,  whom  I  found  suffer- 
ing pains  of  no  regularity  and  not  of  the  true  labor 
type.  Her  age  was  about  twenty  and  she  was  a  primi- 
para.  As  she  was  only  at  the  end  of  the  seventh  month 
of  her  pregnancy  I  endeavored  to  quiet  the  pains  by 
viburnum,  morphine  having  been  given  by  another 
physician  without  effect. 

I  remained  with  the  patient  till  midnight.  When  I 
left  she  had  been  sleeping  about  two  hours  and  her 
pains  were  completely  subdued.  Examination  had  re- 
vealed a  soft,  patulous  os,  but  there  had  been  no  hemor- 
rhage. 

At  6  A.M.  I  was  again  summoned  and  found  the 
woman  having  pains  quite  regularly  and  of  the  true 
labor  type.  I  therefore  concluded  that  my  attempts 
to  forestall  the  issue  were  impossible,  and  assuming  the 
expectant  attitude,  awaited  results.  Labor  progressed 
slowly  until  the  bag  of  waters  ruptured.  The  mem- 
branes were  extremely  tough,  and  I  delayed  rupturing 
them,  as  my  patient  was  very  nervous  and  the  bag  was 
acting  the  part  of  a  dilator.  After  the  bag  had  rupt- 
ured the  pains  became  more  powerful,  and  my  next 
examination  revealed  the  presence  of  something  un- 
usual. I  informed  the  father  that  we  had  something, 
but  what  it  was  I  could  not  tell.  The  sensations  felt  by 
me  on  examination  were  like  feeling  of  a  substance  hard 
as  a  stone  and  of  irregular  surface.  Labor  proceeded 
well  and  at  about  6  p.m.  on  the  same  day  a  monstrosity 
came  to  light,  dead.  The  mother  said  she  had  felt  no 
motion  for  two  or  three  days  previous.  The  weight  of 
the  foetus  was  about  five  pounds,  skin  tan  color  or 
brown,  large  bulging  eyes,  broad  flat  nose,  mouth  open, 
tongue  protruding,  os  frontis  flattened  and  receding ; 
diameter  of  head,  biparietal,  two  and  one-half  inches. 
On  examining  closely  I  found  no  sexual  organs  and  no 
anus  ;  but  there  was  a  black  substance  upon  the  right 
side  of  nates,  upon  removing  which  I  found  a  small 
opening  or  orifice,  evidently  the  bowel  outlet.  At  the 
base  of  its  skull  was  an  opening  large  enough  to  admit 
the  end  of  my  little  finger  ;  from  that  a  little  blood  was 
oozing. 


3IO 


MEDICAL   RECORD. 


[August  31,  1895 


The  above  case  is  entirely  unique  with  me.  The 
mother,  so  far  as  I  know,  is  well  and  healthy,  nothing 
that  can  be  attributed  to  her  in  any  way  bearing 
upon  the  etiology  of  this  monster.  Her  husband  is 
choreic,  has  head-jerk,  produced,  it  is  said,  as  the  result 
of  a  maternal  impression,  his  mother.  I  am  told,  hav- 
ing been  frightened  by  a  snake. 


By  JOHN   W.    S.    McCULLOUGH,    M.D., 


ALLISTON,   ONT. 


Mrs.    C ,   aged  thirty-two,  Il-para,   was   taken  in 

labor  at  seven  months.  She  is  a  very  stout  woman, 
five  feet  si.x  inches  in  height  and  weighing  210  pounds. 
I  saw  her  shortly  after  labor  began  and  found  the  cervix 
dilated  to  the  size  of  a  quarter-dollar.  The  edges  were 
sharp,  hard,  and  inelastic.  Gave  three  twenty-grain 
doses  of  chloral  hydrate  at  intervals  of  fifteen  minutes, 
and  had  the  satisfaction  of  soon  finding  the  cervix 
soften  very  materially.  The  presentation  was  difficult 
to  make  out,  but  I  was  convinced  from  the  bimanual 
examination  that  I  had  an  occipital  presentation  of 
some  kind.  The  pains  were  very  strong,  but  progress 
was  slow.  After  the  os  was  thoroughly  well  dilated  I 
felt  satisfied  that  I  had  a  dead  foetus.  I  ruptured  the 
membranes  and  delivery  was  soon  complete.  1  imme- 
diately expressed  the  placenta.  The  hemorrhage  was 
very  trifling. 

The  fojtus  measured  fifteen  inches.  The  nails  were 
developed,  as  also  were  the  eyelids  ;  the  eyes  were 
open.  There  was  a  hare-lip.  The  foetus  was  a  male, 
the  testicles  had  not  descended  ;  the  limbs  and  body  of 
the  child  were  perfect.  The  placenta  was  almost  en- 
tirely in  a  state  of  fatty  degeneration.  I  am  of  opinion 
that  the  condition  of  the  placenta  accounts  for  the 
non-development  of  the  fcetus. 

Cur.  Victoria  and  Ont-^rjo  Streets. 


Surgical  Swogestions. 

Indications  for  Induction  of  Abortion. — Absolute  In- 
dications:  I.  Uncontrollable  vomiting  of  pregnancy. 
2.  Incarceration  of  the  gravid  uterus.  3.  Obstruction 
of  the  pelvic  outlet  by  tumors  or  exudates.  4.  Pro- 
gressive and  pernicious  anaemia.     5.  Grave  chorea. 

Relative  Indications :  1.  Great  contractions  of  the 
pelvis  with  the  conjugata  vera  below  5  ctm.  2.  Pul- 
monary emphysema  with  signs  of  degeneration  of  the 
heart.  3.  Nephritis,  especially  with  eclampsia.  4. 
Chronic  heart  disease.  5.  Other  general  diseases  of 
the  mother  which  jeopardize  her  life  at  the  time  of  de- 
livery. 

A  conjugata  vera  of  6  ctm.  and  advanced  pulmo- 
nary tuberculosis  should  not  be  regarded  as  indications 
for  abortion.  It  is  not  just  to  sacrifice  a  future  life  for 
one  that  is  "certainly  lost."  — -Teike. 

Fistula  in  Ano. —  i.  Never  sever  the  sphincteis  at 
more  than  one  place  at  the  same  operation,  no  matter 
what  the  complications  may  be,  otherwise  incontinence 
is  sure  to  follow.  2.  Unless  all  the  channels  are  fol- 
lowed up  and  laid  open,  the  operation  will  fail  of  its 
purpose.  3.  Fistula  resulting  from  tubercular  abscess 
must  not  be  operated  upon  if  there  is  sufficient  tissue- 
destruction  of  lung  to  produce  hectic,  fever,  sweats, 
etc.,  unless  the  fistula  is  causing  severe  painful  spasms 
of  the  sphincters  ;  then  it  should  be  divided  at  any  stage. 
4.  .\fter  laying  the  fistula  tract  open  the  wound  must 
be  made  to  heal  from  the  bottom,  and  as  the  cutaneous 
or  mucous  side  of  the  wound  is  better  nourished  it  will 
throw  out  a  more  healthy  granulation,  that  tends  to 
bridge  over  and  close  the  slower  granular  surface  at 
the  bottom,  thus  leaving  a  fistula  remaining.     5.  When 


the  fistulous  tract  is  not  too  complicated  it  should  be 
dissected  out  entire,  and  the  wound  brought  together, 
beginning  at  the  bottom,  with  continuous  catgut  sutures 
and  approximating  the  surfaces  in  successive  layers 
until  the  whole  wound  is  closed.  — Bacox. 

Diagnosis  of  Rupture  of  the  Intestine  After  Contu- 
sion of  the  Abdomen. —  i.  The  absence  of  liver-dulness 
(Moritz).  2.  Frequent  and  uncontrollable  vomiting. 
3.  The  appearance  of  peritonitis,  if  lesions  of  the  kid- 
ney, bladder,  liver,  and  spleen  can  be  excluded.  4. 
Spontaneous  pain  in  the  abdomen  is  not  of  itself  of 
much  diagnostic  value. 

Regarding  the  advisability  of  operating  in  these  cases, 
the  author  says  :  1.  If  there  is  unmistakable  evidence 
of  rupture  of  the  intestine,  immediate  laparotomy  is  in- 
dicated. 2.  Exploratory  laparotomy  after  contusion 
of  the  abdomen  is  usually  to  be  avoided  ;  in  uncertain 
cases,  expectant  treatment  should  be  adopted  (Moty). 
3.  If  soon  after  the  injury  (twenty-four  to  thirty  hours) 
there  are  signs  of  sepsis,  operation  is  contra-indicated. 
A  low  temperature  with  marked  constitutional  symp- 
toms is  an  especially  unfavorable  condition.  4.  Ra- 
pidity and  delicacy  are  essential  in  operating  for  rup- 
ture of  the  intestine,  especially  if  peritonitis  is  present. 
Therefore,  a  long  abdominal  incision,  rapid,  systematic 
examination  of  the  intestine,  avoiding  rough  tearing  or 
handling  ;  if  possible  to  avoid  it,  do  not  resect  the  in- 
testine ;  employ  simple  Lembert  sutures,  or  at  most  a 
wedge-shaped  resection  of  the  injured  portion  of  in- 
testine, and  close  with  a  simple  running  suture  includ- 
ing the  muscular  and  serous  coats.  Flushing  the  ab- 
dominal cavity  with  antiseptic  liquids  is  to  be  avoided. 

— Berndt. 

Gonorrhoeal  Immunity. —  i.  Gonorrhoea  is  a  self- 
limited  disease,  recovery  following  after  a  varying 
length  of  time,  without  any  treatment  other  than 
ptisanes,  baths,  and  hygiene.  2.  Abortive  treatment 
does  not  succeed  rapidly  and  fully  until  the  period  of 
acute  inflammation  has  passed.  3.  A  patient,  either 
male  or  female,  apparently,  though  not  really  cured,  is 
capable  of  transmitting  a  subacute  gonorrhoea — that  is, 
the  colorless  drop  of  secretion  is  capable  of  inoculation 
if  it  contains  a  f  ew  gonococci.  The  author  consequent- 
ly believes  that  the  gonococcus  during  its  evolution 
modifies  its  culture  media,  i.e.,  the  urethral  mucous 
membrane.  It  continues  to  grow  there  but  becomes 
more  and  more  attenuated  and  latent,  until  it  finally 
disappears.  Unless  this  is  true,  a  gonorrhoea,  untreated, 
would  last  indefinitely,  the  cocci  multiplying  and  re-in- 
oculating themselves  in  the  infected  urethra  continuous- 
ly. It  is  at  the  time  when  the  virulence  begin  to  dimin- 
ish that  abortive  treatment  succeeds.  If,  on  the  other 
hand,  this  attenuated  gonococcus  comes  in  contact 
with  a  healthy  mucous  membrane  in  another  individual 
it  is  immediately  rejuvenated,. prospers,  and  produces 
acute  gonorrhceal  symptoms,  since  it  finds  there  a  suit- 
able culture  medium,  which  is  not  exhausted  with  that 
from  whence  it  came  and  where  it  was  about  to  die. 
The  objectors  to  this  theory  say  :  "  If  you  admit  that 
the  role  of  the  culture-medium  is  thus  superior  to  that 
of  the  microbe,  how  can  you  explain  acute  attacks  in 
men  having  gleet  ?  How  can  their  exhausted  mucous 
membrane  become  re-inoculated  ?  "  Guiard  believes 
this  re-infection  is  impossible  in  cases  where  the  gleety 
discharge  contains  cocci.  He,  however,  reserves  his 
opinion  regarding  this  form  of  relative  immunity  until 
further  facts  are  juocured. — Jamin   .\nd  Gl'i.\ru. 

Indications  for  Resection  of  Skull. — i.  —  We  are 
called  to  make  a  resection  in  com|>licated  fractures, 
when  it  is  feared  that  infective  matter  has  entered  the 
wound,  or  when  it  is  known  that  the  cranial  cavity  has 
been  penetrated  by  some  dirty  knife  or  instrument.  2. 
In  fractures  to  which  an  unclean  dressing  has  been  ap- 
plied. 3.  When  we  suspect  a  fracture  of  the  inner 
table  or  for  depressed  fractures.     4.  For  the  removal 


August  3  [,  1895] 


MEDICAL   RECORD. 


311 


of  foreign  bodies,  bullets,  knife-blades,  etc.  5.  For 
cerebral  hemorrhage,  with  signs  of  compression,  and 
for  the  ligation  of  the  middle  meningeal  artery.  6. 
For  fractures  which  have  subsequently  become  infect- 
ed through  carelessness  on  the  part  of  the  surgeon  or 
attendant.  7.  For  tumors  of  the  brain,  abscess  of  the 
brain,  epilepsy,  and  chorea,  when  due  to  ^trauma, 
syphilis,  and  tuberculosis. 

Anto-inoculation  of  Chancre.— In  the  first  case  the 
seat  of  the  chancre  was  inoculated  in  the  right  armpit  ; 
in  the  second,  the  chancre  was  on  the  inner  side  of  the 
eyelid,  which  the  patient  had  rubbed  continually,  a 
particle  of  iron  shaving  having  lodged  in  the  conjunc- 
tival cul  de  sac  ;  in  the  third,  it  occurred  in  the  folds 
of  the  prepuce. — Noli.v. 


^Ixerapcxttic  gtiuts. 

Pityriasis  Versicolor. — 

B .    Cold  cream SJ-i 

Unwashed  precipitated  sulphur I  j. 

Iodide  of  sulphur Z  i 

Red  oxide  of  mercury gi'.  15+ 

Rub  in  well  three  times  daily,  then  dust  with  a  powder  made  of 
talc  and  starch. 

—Mouviinent  TlUr.  et  Mc'J. 
Cholera  Infantum. — 

'S,.     Naphthaliui gr.  x-x.-Lsx. 

01.  bergamii gt.  i.— ij. 

M.  et  ft.  chart  No.  XII.  Sig. :  One  powder  every  two  or  tlnee 
hours. 

—Holt. 

IJ .    Tr.  opii  deod gtt.  xvi. 

Spt.  ammon.  aromat f  3  i. 

Bismuth,  subnit 3  ij. 

Syr.   simp f  J  iv. 

Mist,  cretce ...   f  J  iss. 

M.  Sig.:  Teaspoonful  every  two  or  three  hours  for  a  child  of  one 
year. 

— J.  Lewis  Smith. 
H3rperemesis. — 

R  .    Cocain.  chlorohydrat gr.  iss. 

Antipyrine gr.  xvi. 

Aquae  destil 3  iv. 

M.  Sig.:    J  i.  every  half  hour  until  relieved. 

— Li;t.\nt. 
Dysentery. — 

li.    Pulv.   ipecac,  co gr.  vi. 

Bismuth,  subcarb 5  '• 

Pulv.  aroniat gr.  vi. 

M.  et  ft.  chart  No.  XII.  Sig.:  One  powder  every  three  hours 
tor  children. 

— St.arr. 
Croup. — 

1}  .    Acid  laclici 3  iijss. 

Aquae  destil 3  x. 

M.  Sig.:  Apply  often  by  means  of  a  spray-producer  (to  diss.ilve 
false  membrane). 

MORELL    M.\CKEXZ1E. 

Alopecia  after  Acute  Diseases. — 

B.     Alcohol :  vi^s, 

Veratrine gr.  vi ■.^, 

Tinct.  benztiin git.  \\ . 

Salicylic  acid gr.  vi>>. 

M.    Sig.— Apply  locally. 

— Kaposi. 
To  Lubricate  Catheters. — 

B  .    Bichloride  mercury gr.  i. 

Glycerin , 

Water ...aa    3  ij 

Powdered  soap 3  iv. 

M. 

This  ointment  is  claimed  to  be  unirritating  to  the 
urethra,  and  to  possess  greater  lubricating  power  than 
•either  oil  or  glycerin. — Guvon. 


,^ocietij  Reports. 


THE    BRITISH    MEDICAL  ASSOCIATION. 

Sixty-third  Annual  Meeting,  held  in  London,  July  jo 
and  ji  and  August  i  and  2,  iSgj. 

(Specially  Reported  for  the  Medical  Record.) 

SECTION     OF     OBSTETRIC     MEDICINE     AND     GYNE- 
COLOGY. 

First  Dav,  Wedxesdav,  Jliv  31ST. 

Address  of  the  Chairman. — Sir  William  Priestlv  de- 
livered a  short  inaugural  address,  in  which  he  drew  at- 
tention to  the  enormous  advances  which  had  been  made 
in  midwifery  practice,  especially  those  due  to  the  appli- 
cation of  antiseptics  in  midwifery.  Whereas  in  a  lying- 
in  hospital  with  which  he  was  connected  the  mortality  was 
34  per  1,000  before  the  introduction  of  antiseptics,  since 
that  epoch  it  had  been  only  2.5  per  1,000.  And  in  addi- 
tion to  the  saving  of  life  there  was  a  much  lessened  mor- 
bidity during  the  puerperal  period.  Although  there  was 
so  great  an  improvement  in  lying-in  institutions,  yet  the 
mortality  in  private  practice  had  not  diminished  to  the 
same  extent,  therefore  the  discussion  which  had  been 
arranged  for  that  morning. 

Other  improvements  were  those  in  forceps,  and  es- 
pecially the  introduction  of  the  axis  traction  forceps, 
which  allowed  of  delivery  in  cases  in  which  it  was  pre- 
viously impossible. 

Modifications  also  in  craniotomy  instruments  had 
rendered  that  operation  easier  and  safer. 

But  the  greatest  advances  had  been  in  gynecology. 
He  could  recollect  the  time  when  tapping  was  the  only 
remedy  for  ovarian  tumors,  and  a  promise  of  five  years 
of  life  was  the  longest  that  could  be  given  to  a  patient 
with  such  a  tumor.  A  great  surgeon  of  that  day  had 
said  that  he  considered  the  man  who  attempted  the 
complete  removal  of  an  ovarian  tumor  guilty  of  man- 
slaughter. The  speaker  had  lived  long  enough  to  see 
several  different  systems  of  treatment,  enthusiastically 
advocated,  have  their  day  and  then  wane  away.  First 
there  was  the  craze  of  ulceration  of  the  os  as  a  cause  of 
most  of  the  ailments  of  women,  and  the  treatment  of 
these  ulcerations  by  caustic,  etc.;  then  clitoridectomy 
loomed  up  as  a  treatment,  but  was  soon  discredited  ; 
after  this  displacements  of  the  uterus  held  the  field,  and 
mechanical  treatment  ruled  the  day  ;  again  there  was 
an  epoch  of  enthusiasm  for  castration  as  a  cure  for 
many  neuroses  ;  erelong  it  was  discovered  that  the  op- 
eration was  followed  by  worse  nervous  symptoms  than 
those  for  the  relief  of  which  it  was  undertaken  ;  then 
rents  of  the  cervix  were  thought  to  be  the  cause  of 
symptoms  in  so  large  a  proportion  of  cases  that  one  gyne 
cologist  discovered  and  operated  on  three  hundred  torn 
cervices  out  of  nine  hundred  women  examined  by  him  ; 
lastly,  there  had  been  an  epidemic  of  the  operation  for 
the  removal  of  the  appendages.  Many  of  these  recom- 
mendations had  come  from  across  the  Atlantic.  No 
doubt  each  of  them  had  some  value,  but  the  tendency 
now  was  to  import  too  large  a  surgical  element  into  the 
treatment,  and  to  neglect  the  medical  side  of  gynecology. 
We  must  consider  the  welfare  of  our  patients  first  and 
the  science  of  surgery  second.  The  records  of  one 
thousand  operations  liad  no  intrinsic  value  unless  the 
operations  can  be  shown  to  have  been  necessary,  and 
he  especially  def)recated  the  efforts  to  make  long  lists 
of  operations.  He  would  entirely  discountenance  large 
operations  for  uterine  fibroids  which  were  not  producing 
symptoms  ;  also  the  operation  of  opening  the  abdomen 
for  the  treatment  of  displacements  of  the  uterus  ; 
considered  the  views  he  had  expressed  were  those  of 
real  as  against  spurious  progress,  and  he  was  willing  to 
receive  any  help  from  new  ideas  and  operations,  but 


312 


MEDICAL    RECORD. 


[August  31,  1895 


would  always  hear  in  mind  the  motto  :  Primo  non  no- 
cerc  (at  least  do  no  harm). 

Dr.  Priestly  deprecated  the  tendency  of  the  obstetric 
physician  to  invade  the  domain  of  surgery  and  thought 
that  sepsis  was  more  likely  to  be  acquired  in  the  work  of 
the  surgeon,  and  he  would  advise  obstetric  physicians 
to  keep  to  their  own  art.  He  would  in  general  hospitals 
appoint  a  surgeon  to  act  with  the  obstetric  physician, 
and  in  special  hospitals  would  have  physicians  to  con- 
sult with  the  surgeons,  but  each  man  should  take  his 
own  course. 

Dr.  Llsk,  of  New  York,  in  proposing  a  vote  of  thanks, 
said  that  he  thought  the  address  would  do  good  in 
America,  and  that  he  agreed  with  the  President's 
views. 

The  vote  of  thanks  was  seconded  by  Dr.  Martin, 
of  Berlin,  and  carried  with  acclamation. 

The  Aseptic  and  Antiseptic  Precautions  Necessary 
for  the  Prevention  of  Puerperal  Fever  in  Private  Prac- 
tice.— Dk.  (1.  EkxiST  Hf.km.w,  of  London,  opened 
the  discussion  on  this  question.  In  answer  to  the 
question.  What  is  puerperal  fever  ?  he  said  that  it  is 
a  fever  caused  by  the  inoculation  of  septic  organisms. 
Septic  organisms  are  not  the  same  as  saprophytes 
(which  in  our  climate  are  everywhere  present),  but 
may  in  suitable  soil  be  bred  from  saprophytes.  They 
only  thrive  in  special  soil,  and  they  can  and  ought  to 
be  destroyed.  Sterilization,  that  is  the  destruction  of 
all  micro-organisms,  is  impracticable  in  midwifery 
practice.  Puerperal  fever  may  be  prevented  by  keep- 
ing septic  germs  from  the  patient.  This  is  to  be  done 
by  asepsis,  that  is  cleanliness,  and  antisepsis,  that  is 
the  use  of  germicides.  The  germicide  which  is  the 
most  portable  and  most  trustworthy,  and  therefore  the 
best  for  midwifery  practice,  is  corrosive  sublimate. 
Carbolic  acid  is  inconvenient,  and  no  other  antiseptic 
has  been  shown  to  be  so  good  clinically  as  perchlo- 
ride.  'i'he  precautions  to  be  used  are  of  two  kinds  : 
I,  E.\ternal,  those  applied  to  the  surroundings  of  the 
patient ;  2,  internal,  those  applied  to  the  patient. 

The  external  antiseptic  precautions  comprise  the 
purification  of  each  attendant's  hands  by  washing  with 
soap  and  water,  using  a  nail-brush  and  soaking  in  a 
corrosive  sublimate  solution  i  to  1,000,  and  of  all  in- 
struments by  boiling  ;  scrupulous  cleanliness  in  the 
dress  of  nurse  and  medical  attendant ;  the  use  of  clean 
absorbent  material  instead  of  napkins  and  sponges. 
The  nurse's  dress  should  be  light  color,  with  washable 
apron  and  sleeves  to  turn  up,  attached  by  buttons. 
There  should  be  no  rings  on  the  fingers.  The  internal 
aseptic  and  antiseptic  precautions  comprise  restriction 
of  vaginal  e.xaminations  to  the  fewest  possible  ;  wash- 
ing of  the  genitals  ;  the  use  of  an  antiseptic  lubricant  ; 
vaginal  antiseptic  douches  during  labor,  after  delivery, 
and  throughout  the  lying-in.  The  only  one  of  these 
precautions  that  can  jjossibly  do  harm  to  the  patient  is 
the  use  of  antiseptic  vaginal  douches.  Experience  has 
shown  that  healthy  women  whose  labors  are  normal  do 
as  well  without  vaginal  douches  as  with  them,  though 
these  are  necessary  in  some  abnormal  cases. 

In  private  as  compared  with  hospital  practice  there 
is  less  danger  ;  therefore  vaginal  antiseptic  douches 
before  delivery  and  during  the  lying-in  maybe  omitted, 
e.xcept  in  cases  in  which  the  discharges  are  unhealthy. 
An  antiseptic  douche  immediately  after  labor  is  over 
should  be  given  by  the  medical  man  himself.  The 
nurse  receives  less  guidance  ;  she  is  not  guided  by 
rules  as  she  is  in  a  hospital.  But  such  guidance  is 
necessary.  The  medical  man  should  make  it  part  of 
his  duty  to  the  patient  to  instruct  her  nurse.  Some 
physicians  do  this  by  giving  the  nurse  a  printed  ])aper  of 
directions.  This  practice  is  reiommendcd  for  general 
adoption.  The  nurse  is  under  less  discipline.  She  is 
often  chosen  by  the  patient.  The  patient's  wish  is  her 
law,  for  her  success  depends  upon  her  pleasing  the  pa- 
tient. The  doctor  should  insist  that  the  nurse  obey 
him,  that  she  be  dismissed  if  she  neglect  his  rules,  and 


he  should  decline  to  be  responsible  for  the  case  unless 
the  nurse  is  engaged  with  this  understanding. 

Dr.  Stiari,  of  Brooklyn,  said  that  he  had  prepared 
a  paper,  but  would  not  read  it,  as  Dr.  Herman  had 
covered  the  same  ground.  He  would  emjihasize  the  fol- 
lowing points  :  First,  that  the  physician  himself  should 
be  thoroughly  imbued  with  the  principles  of  asepsis, 
and  secondly,  that  he  should  instruct  the  nurse  and 
make  certain  that  she  understands  his  instructions. 
The  patient  should  be  talked  to  and  instructed  as  to 
what  her  dangers  are.  The  physician  should  have 
clean  linen,  and  should  dispense  as  much  as  possible 
with  the  vaginal  examination,  using  the  abdominal  in- 
stead. 

Dr.  Llsk,  of  New  York,  would  first  wash  hands  in 
alcohol  and  then  in  corrosive  solution.  He  would  cut 
the  pubic  hair  and  sterilize  the  perineum  and  inner 
surfaces  of  the  thighs.  He  would  not  use  a  vaginal 
douche  after  a  simple  labor,  and  would  strongly  dis- 
countenance douching  before  labor,  as  nature  thorough- 
ly cleansed  the  vagina,  first  by  the  liquor  amnii,  and 
then  by  the  passage  of  the  f(£tal  head.  He  dwelt  on 
the  great  importance  of  clearing  away  all  clots  and 
tissue,  which  might  decompose.  He  would  place  some 
antiseptic  material  over  the  perineum  before  applying 
the  hand  to  guide  the  head  as  it  was  emerging  to  avoid 
soiling  the  hand  with  fecal  matter.  He  thought  it  im- 
portant to  wait  long  enough  for  the  placenta  to  be  de- 
tached ;  complete  separation  would  be  shown  by  the 
cessation  of  pulsation  in  the  cord.  There  was  no  ne- 
cessity to  twist  the  membranes  into  a  cord  as  advised 
by  some  ;  it  was  sufficient  to  allow  the  weight  of  the 
placenta  to  draw  away  the  membranes. 

Dr.  Smvly,  of  the  Rotunda  Hospital,  Dublin,  said 
that  it  was  not  always  necessary  on  the  first  visit  to 
make  a  vaginal  examination.  The  nurse  should  never 
be  allowed  to  make  a  vaginal  examination ;  and  he 
thought  the  douche  in  the  hands  of  a  nurse  was  dan- 
gerous. He  formerly  douched  each  patient  twice  a  day 
after  confinement,  but  had  now  given  up  that  plan  as 
dangerous. 

Dr.  Swavne,  of  Bristol,  drew  attention  to  the  fact 
that  among  the  poorer  classes  the  patients  may  infect 
themselves  with  their  finger-nails. 

Dr.  Plavfair,  of  London,  regretted  that  practition- 
ers were  not  so  imbued  with  antiseptic  principles  that 
such  a  discussion  should  have  been  considered  unnec- 
essary. He  had  found  it  impossible  to  get  nurses  to  use 
I  in  20  carbolic  solution  for  the  hands,  on  account  of  its 
unpleasant  roughening  eft'ect  on  the  skin  ;  but  per- 
chloride  had  not  this  disadvantage  to  the  same  extent. 
He  attached  most  importance  to  the  thorough  scrub- 
bing of  the  hands.  He  considered  that  douching  dur- 
ing lying-in  gave  so  much  comfort  to  the  patient  that 
he  would  not  say  it  should  not  be  used.  For  this 
purpose  Condy's  fluid  acted  well. 

Dr.  Bvkrs,  of  Belfast,  would  minimize  vaginal  ex- 
amination as  much  as  possible,  and  thought  it  was  a 
great  step  forward  to  substitute  abdominal  examination, 
by  which  he  considered  almost  everything  necessary 
could  be  ascertained.  In  making  a  vaginal  examina- 
tion particular  care  should  be  taken  to  avoid  contam- 
ination from  the  rectum,  and  he  thought  that  some 
so-called  autogenetic  cases  could  be  attributed  to  this 
cause.  For  two  years  he  used  a  douche  after  delivery 
in  each  case  ;  last  year  he  abandoned  the  practice  and 
had  found  no  difference  in  the  results.  After  the 
birth  of  the  child  he  follows  the  Rotunda  practice  of 
turning  the  woman  on  her  back  for  the  expression  of 
the  placenta,  as  by  so  doing  the  entrance  of  air  was 
avoided. 

Dr.  -More  Madden,  of  Dublin,  considered  it  im- 
portant to  get  the  woman  into  a  good  state  of  health 
by  tonics,  etc.,  before  delivery. 

Dr.  MiKDOCH  Cameron',  of  Glasgow,  thought  there 
were  two  forms  of  puerperal  fever — sapntmia  with 
fetid  lochia  and  septicaemia  with  suppression  of  lochia. 


August  3t,   1895] 


MEDICAL    RECORD. 


3^3 


For  the  first,  one  could  do  a  great  deal  ;  for  the  second, 
nothing. 

Dr.  Hek.niax,  in  closing  the  discussion,  said  that 
he  could  not  see  the  good  of  attempting  to  sterilize  the 
perineum  and  thighs,  since  complete  sterilization  was 
impossible.  Corrosive  sublimate  was  the  one  germi- 
cide which  had  stood  all  tests.  He  would  boil  all  in- 
struments, including  the  vaginal  tubes. 

Electrotherapy  as  a  Means  of  Diagnosis  in  Gynecol- 
ogy.— Dr.  G.  Apostoli,  of  Paris,  presented  a  com- 
munication with  this  title.  After  a  long  and  thorough 
trial  of  this  method  he  had  come  to  the  following 
general  conclusions  :  i.  The  faradic  current  of  tension 
(generated  by  the  coil  of  long  and  fine  wire)  applied  to 
the  uterine  cavity,  according  to  the  rules  established 
by  the  speaker  in  18S3,  relieves,  for  a  longer  or  shorter 
time,  all  ovarian  pain  of  nervous  or  hysterical  origin  ; 
but  it  is  powerless  or  nearly  so  in  cases  of  ovarian  pain 
caused  by  inflammatory  lesion  of  the  peri-uteriiTe  tissue 
or  of  the  appendages.  2.  The  same  faradic  current  is 
therefore  useful  in  diagnosis,  inasmuch  as  it  helps  us  to 
distinguish  the  nature  of  so-called  ovarian  pain  and  to 
determine  rapidly  the  differential  diagnosis  between 
hysterical  and  inflammatory  ovarian  pain.  Where  the 
two  kinds  of  pain  exist  in  the  same  patient  we  are 
helped  to  understand  their  nature  by  the  fact  that  the 
one  is  relieved  and  the  other  is  not.  3.  If,  then,  the 
curative  effect  of  the  faradic  current  clears  up  or  recti- 
fies a  doubtful  diagnosis,  it  protects  us  at  the  same 
time  from  undertaking  a  useless  operation.  On  the 
other  hand,  if  the  same  faradic  current  proves  ineffec- 
tive, the  lesion  being  inflammatory,  we  are  led  to  resort 
to  a  supplementary  galvanic  treatment  or  to  a  surgical 
operation  sooner  or  later.  4.  The  constant  galvanic 
current,  applied  to  the  uterine  cavity  in  doses  gradually 
increasing  from  50  to  120  milliamperes,  according  to 
the  rules  published  by  the  speaker  in  1S84,  and  bear- 
ing in  mind  the  individual  susceptibility  and  tolerance, 
will  be  almost  always  supported  without  much  pain 
during  the  seance,  and  without  febrile  reaction  after- 
ward, if  the  parts  adjacent  to  the  uterus  are  free  from 
inflammation.  Simple  cystic,  peri-uterine  tumors  which 
are  neither  inflamed  nor  suppurating  (such  as  ovarian 
cysts  and  hydro-salpin.x),  may  also  show  perfect  toler- 
ance of  the  galvanic  current.  The  galvanic  current  is 
also  sometimes  perfectly  supported  by  cases  in  which 
the  uterus  is  surrounded  by  old  inflammatory  products 
or  exudations  no  longer  pathogenic.  5.  There  are 
three  classes  of  cases  which  should  be  considered  as 
exceptions  to  the  preceding  rule,  for  they  bear  the 
galvanic  current  more  or  less  badly,  though  they  do 
not  necessarily  produce  much  febrile  reaction  after  the 
seance.  They  are  :  </.  Certain  forms  of  hysteria,  b. 
Fibro-cystic  tumors  of  the  uterus,  c.  Enteritis  with 
false  membrane.  It  is  generally  easy  to  diagnose  these 
cases  of  intolerance.  6.  All  acute  peri-uterine  inflam- 
mation (of  the  pelvic  cellular  tissues,  of  the  peritoneum, 
and  especially  of  the  appendages)  will  cause  the  gal- 
vanic current  to  be  badly  borne  when  it  passes  40  or 
50  milliamperes,  and  will  cause  intolerable  pain  and 
febrile  reaction  when  carried  beyond  this  intensity.  7. 
The  intolerance  for  the  galvanic  current  is  generally 
proportionate  to  the  extent  and  gravity  of  the  lesions 
referred  to  and  increases  with  the  intensity  of  the 
current  employed,  especially  when  it  passes  40  or  50 
milliamptres.  8.  All  inflammation  of  the  appendages 
which  is  curable  without  radical  operation  wall  bear 
the  galvanic  current  better  and  better,  and  there  will 
be  a  corresponding  improvement  of  the  prominent 
symptoms,  such  as  pain  and  hemorrhages.  The  intoler- 
ance noted  at  the  beginning  progressively  disappears. 
9.  All  grave  inflammatory  lesions  of  the  apjjendages, 
and  notably  all  suppurative  processes  which  are  incur- 
able by  conservative  means,  show  the  same  intolerance 
from  the  beginning  to  the  end  of  the  treatment  which 
was  noticed  at  first,  and  which  is  apt  to  increase  instead 
of  diminish  if  the  treatment  is  continued.     10.  Thus 


the  simple  study  of  the  tolerance  or  intolerance  of  the 
intra  uterine  galvanic  treatment,  and  especially  of  the 
post-operative  pain  and  fever  occurring  on  the  evening 
of  or  the  day  following  the  treatment,  enables  us  to 
make  the  diagnosis.  It  also,  in  four  or  five  seances, 
given  twice  weekly,  informs  us  of  the  condition  of  the 
appendages,  of  their  possible  inflammation  and  its  de- 
gree, and  in  this  way  it  lessens  the  number  of  laparot- 
omies and  exploratory  incisions.  11.  The  same  study 
of  the  so-called  galvanic  reactions  also  informs  us,' 
after  a  few  trials,  of  the  curability  of  these  inflammatory 
lesions  which  the  electric  current  has  demonstrated, 
and  in  consequence  of  this  it  tells  us  in  one  case  to 
abstain  from  operation  while  in  another  it  shows  an 
operation  to  be  urgent.  12.  Finally,  gynecological 
electro- therapeutics,  carefully,  methodically,  and  pa- 
tiently applied,  instead  of  being  opposed  to  the  marvel- 
lous progress  of  surgery,  comes  to  its  aid.  Indepen- 
dently, in  fact,  of  the  great  therapeutic  service  which  it 
renders  every  day,  electricity  assists  us  in  diagnosis  and 
thus  directly  serves  the  interests  of  surgery,  in  one  case 
showing  an  operation  to  be  useless  and  dangerous,  in 
another  that  its  necessity  is  urgent.  Many  laparot- 
omies, so-called  exploratory  incisions  and  mutilations 
practised  without  due  deliberation  for  the  relief  of  re- 
bellious ovarian  pain  or  for  lesions  of  the  appendages 
of  uncertain  nature,  should  be  delayed  until  all  the  re- 
sources of  faradic  sedation,  on  the  one  hand,  and  of  the 
intra-uterine  galvanic  effect,  on  the  other,  have  been 
tried.  Experience  has  abundantly  proved  these  cur- 
rents to  be  innocuous  if  gi\en  with  necessary  aseptic 
precautions. 

Dr.  Franklin  Martin,  of  Chicago,  had  worked  for 
ten  years  at  the  Woman's  Hospital,  using  both  electric- 
ity and  surgery,  and  so  was  not  biassed  either  way.  He 
found  it  a  fact  that  pain  was  produced  and  electricity 
was  not  well  borne  when  collections  of  pus  were  pres- 
ent. He  did  not  believe,  however,  that  it  should  be 
used  as  a  diagnostic  agent,  and  it  was  very  dangerous, 
and  should  not  be  used  when  pyosalpynx  was  sus- 
pected. 

Gonorrhoea  in  Women. — Dr.  More  Madden,  of 
Dublin,  read  a  paper  on  gonorrhoeal  infection  in  some 
of  its  gynecological  aspects.  He  thought  that  the  impor- 
tance of  gonorrhtea  was  not  yet  fully  recognized. 
Most  cases  in  married  women  were  due  to  a  recru- 
descence of  an  old  injection  in  the  husband.  He  did 
not  consider  that  the  presence  or  absence  of  the  gono- 
coccus  was  an  infallible  test,  as  other  cocci  almost  in- 
distinguishable were  found  in  the  vaginal  secretions, 
and  he  would  treat  all  suspicious  discharges  at  once  by 
the  free  employment  of  germicides. 

Dr.  Purslow,  of  Birmingham,  thought  that  every- 
one engaged  in  hospital  practice  must  agree  as  to  the 
great  importance  of  gonorrhrea  as  a  cause  of  disease  of 
the  uterus  and  appendages,  but  it  was  not  often  possi- 
ble to  follow  cases  through  from  the  onset  of  infection. 
He  had  had  two  cases  under  observation  for  two  years. 
Each  became  infected  with  undoubted  gonorrhoea 
when  pregnant  and  afterward  aborted.  They  were 
treated  with  injections  of  perchloride  of  mercury,  and 
up  to  the  present  there  was  no  disease  of  the  appen- 
dages. He  asked  whether  any  of  those  present  had  tried 
the  active  treatment  of  gonorrhoea  by  thorough  disin- 
fection of  the  vagina  under  anxsthesia. 

Dr  W.  Japp  Sinclair,  of  Manchester,  said  that  he 
considered  the  gonococcus  of  no  use  as  a  diagnostic 
sign.  He  considered  that  inflammation  of  Bartholin's 
glands  was  the  most  important  clinical  sign  of  acute 
gonorrhoea. 

Dr.  W.  S.  a.  Griffith,  of  London,  thought  there 
was  an  undoubted  gonorrhoeal  vaginitis,  and  that  the 
disease  was  not  always  confined,  as  some  held,  to  the 
urethra.  He  had  treated  cases  in  the  way  Dr.  Purslow 
had  mentioned.  He  placed  the  patient  in  the  lithotomy 
position,  used  a  speculum,  and  swabbed  out  the  vagina 
very  thoroughly,  then  dried  it  and  dusted  with  iodo- 


314 


MEDICAL   RECORD. 


[August  31,  1895 


form,  and  afterward  kept  the  surfaces  apart  by  a  sim- 
ple dressing,  which  latter  he  removed  in  twenty-four 
hours  and  followed  up  by  simple  douching. 

Surgical  Treatment  of  Puerperal  Fever. — Dr.  James 
MuRPHv,  of  Sunderland,  read  a  jjaper  on  this  subject. 
He  narrated  some  cases  in  which  he  had  curetted,  and 
others  in  which  he  had  performed  abdominal  section, 
and  urged  the  application  of  each  of  these  in  suitable 
conditions. 

Dr.  Leith  Napier,  of  London,  would  always  use 
gentle  curetting  before  doing  an  abdominal  section. 
His  experience  of  operating  in  suppurative  peritonitis 
had  not  been  so  satisfactory  as  that  of  Dr.  Murphy. 

Mr.  J.  W.  Taylor,  of  Birmingham,  had  found  oper- 
ation successful  when  there  were  limited  collections  of 
pus,  but  when  there  was  general  peritonitis  it  was  no 


Dr.  Lusk,  of  New  York,  thought  curetting  of  a  par- 
turient uterus  was  the  most  mischie\ous  practice  ever 
introduced  into  midwifery  practice. 

Dr.  Griffith,  of  London,  thought  few  cases  were 
suitable  for  curetting,  and  that  it  was  a  proceeding 
which  had  been  much  overdone.  It  was  a  dangerous 
operation,  and  he  had  known  very  severe  bleeding  fol- 
low from  the  opening  of  the  uteric  sinuses  by  the  cu- 
rette. He  thought  that  in  some  cases  the  finger  would 
remove  any  retained  matter  better  than  the  curette, 
and  that  then  washing  out  was  followed  by  good  re- 
sults. There  were  many  cases  of  puerperal  pyrexia  in 
which  no  sepsis  was  present. 


Second  Day,  Thursday,  August  ist. 

Anterior  Colpotomy. — Dr.  Martin,  of  Berlin,  read  a 
l)aper  with  this  title.  He  first  pointed  out  the  dis- 
agreeable results  which  followed  an  abdominal  section, 
especially  those  resulting  from  the  presence  of  the  scar. 
Of  late  years  there  had  been  a  great  advance  in  vag- 
inal surgery,  and  the  best  entrance  into  the  abdominal 
cavity  from  the  vagina  was  through  the  anterior  fornix  ; 
there  were  no  organs  and  no  vessels  in  the  way.  The 
bladder  can  be  separated  and  pushed  up  without 
danger  and  the  ureter  can  be  pushed  out  of  reach. 

Dcscriptuyn  of  the  Operation. — Patient  is  placed  in 
lithotomy  position  and  the  uterus  fi.xed  by  a  special 
pair  of  forceps  which  combines  both  a  probe  and  a 
vulsellum.  Another  pair  of  vulsella  is  fixed  into  the 
vaginal  wall  over  the  urethra  and  the  vaginal  wall  is 
raised  and  incised  vertically.  The  upper  portion  and 
bladder  is  pushed  up  with  the  finger  and  carried  out 
of  the  way  behind  the  symphysis.  The  peritoneal  fold 
between  bladder  and  uterus  is  then  seen  and  is  opened. 
There  is  very  small  loss  of  blood  during  this  part  of 
the  operation,  no  (jressure  forceps  or  ligature  being  re- 
quired until  the  peritoneal  cavity  is  opened.  After 
the  operation  the  uterus  and  adnexa  are  replaced  and 
catgut  sutures  passed  through  vaginal  wall,  perito- 
neum, uterine  tissue,  and  back  through  vaginal  wall 
again. 

This  operation  was  suitable  for  myomatous  tumors 
wherever  situated,  and  large  tumors  might  be  removed 
in  this  way  by  morcellement. 

Total  extirpation  of  the  uterus  could  be  performed, 
retroflexed  uteri  could  be  fixed,  and  ])eritoneal  adhe- 
sions could  be  broken  down.  In  procidentia  he  ex- 
cised part  of  the  vaginal  wall  and  fixed  the  uterus  to 
the  upper  part.  Cystic  ovarian  tumors  could  be 
brought  down  and  the  pedicle  seen  and  ligatured.  In 
diseases  of  the  tubes  the  operation  had  special  advan- 
tages, and  he  had  done  it  in  tubal  jjregnancy.  In 
cases  of  distended  tubes  the  tube  could  be  opened  and 
drained  and  the  opening  fixed  to  the  edges  of  the 
wound.  The  speaker  had  jjerformed  anterior  colpot- 
omy in  loy  cases  ;  all  had  recovered.  The  minority 
had  reipiired  the  use  of  the  catheter  after  operation  ;  in 
four  of  these  operations  he  had  done  total  extirpation 
of  the  uterus.     For  niyomata  he  would  prefer  abdom- 


inal section  when  the  tumor  was  larger  than  the  size  of 
two  fists. 

Vaginal  CcEliotomy.— Mr.  L  W.  Taylor,  of  Bir- 
mingham, read  a  paper  advocating  this  operation.  He 
drew  attention  to  the  advantages  of  the  utero-vesical 
pouch  for  the  operation.  The  uterus  may  be  ante- 
verted  and  both  it  and  the  appendages  inspected. 
Vaginal  fixation  of  the  uterus  in  this  operation  places 
it  in  a  more  satisfactory  position  than  that  by  any  other 
method.  In  doing  vaginal  hysterectomy  the  uterus 
was  anteverted  and  brought  out  and  forceps  applied  to 
the  broad  ligament  from  above  downward.  Doyen 
originated  this  method.  He  (Taylor)  made  a  trans- 
verse incision  in  anterior  fornix,  passed  a  provisional 
silk  suture  through  uterus  as  high  as  he  could  reach; 
if  vaginal  fixation  only  was  required,  he  passed  silk- 
worm gut  sutures  through  uterus  and  vaginal  wall. 
Apart  from  vaginal  hysterectomy  he  had  done  this 
operation  seven  times  and  he  was  satisfied  with  its 
value,  especially  for  retroflexion  incurable  by  other 
methods.  He  removed  the  sutures  which  he  used  for 
fixation  in  six  weeks  and  left  no  buried  ones.  The 
operation  was  more  difficult  than  abdominal  section, 
but  the  advantage  to  the  patient  was  decided,  and  re- 
covery was  more  sure  ;  then  there  was  no  visible  scar 
resulting  and  no  risk  of  hernia.  He  differed  from 
Martin  in  making  a  transverse  instead  of  a  longitudinal 
incision. 

Dr.  Donald,  of  Manchester,  read  a  paper  on  a 
case  of  vaginal  coeliotomy  for  tubal  pregnancy.  He 
opened  the  peritoneal  cavity  through  anterior  fornix. 

In  the  discussion  which  followed  on  these  three  pa- 
pers, Dr.  Cushino,  of  Boston,  said  that  in  these  opera- 
tions a  process  of  evolution  was  always  going  on.  He 
did  not  use  a  single  long  forceps,  as  he  was  afraid  that 
the  upper  part  of  the  broad  ligament  might  not  be  se- 
cured, and  he  preferred  to  put  on  two  or  three  smaller 
ones  on  each  side.  He  had  known  a  blade  of  the  long 
clamp  snap  twelve  hours  after  operation.  In  bringing 
down  the  uterus,  if  he  were  not  going  to  remove  it,  he 
would  avoid  as  much  as  possible  the  provisional  liga- 
ture and  the  vulsellum.  He  preferred  a  vertical  to  a 
transverse  vaginal  incision  because  there  was,  i,  less 
hemorrhage  ;  2,  more  room.  There  was  a  danger  of 
including  ureters  in  the  sutures  when  they  were  put  in 
transversely  and  too  freely;  he  thought  that  the  separa- 
tion of  adhesions  was  easier  than  when  abdominal 
section  was  done,  and  no  drainage-tube  was  required. 

Dr.  S.mvlv,  of  Dublin,  had  done  the  operation  about 
twenty  times,  and  he  considered  that  for  fixation  of 
the  uterus  it  had  great  advantages  over  abdominal 
section,  or  Alexander's  operation  ;  at  first  he  did  fixa- 
tion without  opening  the  peritoneum,  but  he  found  the 
displacement  recur  ;  he  now  opens  the  peritoneal  cav- 
ity ;  the  most  satisfactory  results  he  had  had  from  the 
operation  had  been  in  cases  of  prolapse. 

Dr.  Walten,  of  Manchester,  had  operated  on  two 
patients,  who  had  previously  been  operated  on  by  ab- 
dominal section,  and  the  luitients  expressed  apprecia- 
tion of  the  vaginal  method  as  compared  with  section. 
During  the  operation,  an  assistant  should  introduce  a 
finger  into  the  rectum  and  push  up  the  uterus. 

Dr.  Alfred  Smi  in,  of  Dublin,  asked.  How  would  a 
wound  of  intestine  caused  by  separating  adhesions  be 
treated  when  the  operation  was  performed  in  this  way  ? 

Dr.  Martin,  in  closing  the  discussion,  said  he  had 
never  met  a  wound  of  the  intestine  in  all  his  cases, 
though  lie  had  had  to  deal  with  severe  adhesions,  but 
his  custom  was  to  pull  the  organs  out  gradually  and 
see  the  adhesions  before  dealing  with  them.  If  the 
uterus  were  adherent  to  the  sacrum,  he  would  not  do 
coeliotomy.  He  would  open  the  anterior  in  preference 
to  the  posterior  fornix,  because  the  tubes  were  nearer 
and  the  uterus  could  be  more  easily  dealt  with  in  the 
former  incision.  He  had  found  cases  in  which  both 
tubes  needed  removal  were  a  minority  of  the  total 
cases  he  had  operated  on,  and  he  would  preserve  one 


August  31,  1895] 


MEDICAL    RECORD. 


315 


tube  and  the  uterus  whenever  possible.  Hydrosalpynx 
did  not  need  removal,  he  would  prefer  salpyngostomy. 
He  preferred  the  vertical  to  the  transverse  incision,  be- 
cause the  latter  was  liable  to  be  extended  by  tearing, 
and  the  ureters  might  be  injured.  He  used  catgut  for 
nearly  all  his  work  now,  and  seldom  used  silk  or  silk- 
wormgut. 

The  Management  of  Girls  at  the  Period  of  Puberty. — 
Dr.  Plavfair,  of  London,  read  a  paper  entitled,  "  Re- 
marks on  the  Education  and  Training  of  (lirls  at  and 
about  the  Period  of  Puberty."  Up  to  puberty  there 
was  no  necessity  to  treat  boys  and  girls  differently.  At 
puberty  well-defined  changes  occur  in  the  girl,  and  there 
was  an  especial  development  of  the  nervous  and  emo- 
tional system.  With  limitations  essential  to  sex,  he 
considered  that  the  advent  of  the  higher  education  of 
women  was  an  advantage.  The  fault  of  nearly  all 
who  managed  high  schools  was  that  they  ignored  the 
sexual  functions  of  the  girls,  and  that  they  contend 
that  there  was  no  real  difference  between  the  adoles- 
cent male  and  female.  If  that  were  so,  how  is  it  that 
we  see  so  many  cases  of  anaemia  in  the  adolescent  girl, 
and  the  disease  is  almost  unknown  in  boys  ?  One 
reason  is  that  in  boys'  schools  physical  sports  are 
compulsory,  while  that  is  not  so  in  girls'  schools,  and 
the  tendency  is  for  them  not  to  take  nearly  sufficient 
exercise.  Exercise  should  be  compulsory  in  girls' 
schools,  and  another  regulation  he  would  like  to  see 
would  be  one  to  interdict  corsets.  He  would  insist  on 
the  importance  of  at  once  stopping  all  school  work 
when  symptoms  of  illness  begin  to  show  themselves. 

Dr.  Scharlieb,  of  London,  would  also  make  phys- 
ical exercise  compulsory.  He  thought  that  too  many 
school-mistresses  were  absolutely  blind  to  physical 
symptoms. 

Dr,  Gray  thought  that  among  no  class  of  girls  was 
the  evil  of  overwork  and  insufficient  exercise  more 
pronounced  than  in  pupil  teachers. 

Puerperal  Eclampsia. — Dr.  Swavne,  of  Bristol,  read 
a  paper  on  the  "  Treatment  of  Eclampsia  Occurring 
during  Pregnancy  before  the  Commencement  of  Labor," 
in  which  he  said  that  he  placed  most  faith  in  venesec- 
tion as  a  remedial  agent. 

Dr.  Scharlieb  had  seen  many  cases  in  India,  and 
there  bleeding  was  not  advisable,  as  many  were 
ansmic.  Had  found  chloroform  give  best  results, 
putting  the  patient  under  it  for  each  examination,  and 
keeping  her  under  it  if  the  fits  were  frequent. 

Dr.  Smvly,  of  the  Rotunda  Hospital,  Dublin,  would 
not  induce  labor  in  these  cases.  Though  chloroform 
stopped  convulsions,  he  thought  it  increased  death- 
rate.  He  would  trust  to  morphia  given  hypodermic- 
ally.  He  had  observed  no  benefit  from  potassium 
bromide  and  thought  pilocarpine  dangerous. 

Dr.  W.  S.  a.  Griffith,  of  London,  would  induce 
labor  with  the  proviso  that  it  were  done  safely  and 
aseptically. 

Dr.  Barbour,  of  Edinburgh,  had  made  frozen  sec- 
tions with  a  view  to  determine  whether  pressure  of  the 
uterus  had  any  importance  as  a  cause  of  the  albu- 
minuria which  precedes  the  convulsions,  and  had  come 
to  the  conclusion  that,  whatever  the  cause,  it  was  not 
mechanical.     Advised  induction  of  labor. 


Third  Day,  Friday,  August  2d. 

The  Early  Diagnosis  of  Malignant  Disease  of  the 
Uterus,  and  the  Treatment  by  Partial  or  Total  Exci- 
sion.— Dr.  J.  KNowbLEY  Thornton  opened  the  dis- 
cussion on  this  subject,  saying  that  he  would  give  his 
own  practical  experience  and  views,  not  a  summary  of 
that  of  others.  He  appealed  to  those  in  general  prac- 
tice to  take  more  note  of  trivial  discharges,  and  depart- 
ures from  menstrual  health,  and  above  all  in  such  cases 
to  insist  on  an  internal  examination  ;  it  is  in  their  hands, 
and  not  in  those  of  the  consultants,  that  advance  in 
early  diagnosis  lies — if  there  is  only  suspicion  have  it  at 


once  either  confirmed  or  dispelled  by  consultation  with 
some  specialist  of  experience.  He  detailed  briefly  the 
most  reliable  symptoms  of  cancer,  but  deprecated  the 
removal  of  small  portions  for  microscopical  examina- 
tions, as  he  believed  that  interference  of  this  sort  often 
favored  the  growth  of  the  neoplasm.  He  advocated 
supra-vaginal  amputation  of  the  cervix  for  adenoma 
and  epithelial  cancer  of  the  vaginal  portion  ;  to  remove 
the  uterine  body  is  useless  in  most  of  these  cases.  The 
speaker  gave  a  brief  description  of  the  method  of  per- 
forming supra- vaginal  amputation  of  the  cervix  and 
vaginal  hysterectomy.  He  agreed  with  Williams  that 
certain  so-called  recurrences  were  really  fresh  outbreaks, 
in  a  specially  susceptible  organ,  and  their  bearing  on 
the  relative  value  of  the  two  operations.  As  regarded 
the  selection  of  cases  he  would  deprecate  operation  in 
hopeless  cases,  and  insisted  on  the  application  here  of 
the  sound  surgical  rule,  that  operations  for  malignant 
disease  should  only  be  performed  when  the  whole  dis- 
ease can  be  efficiently  and  entirely  removed.  He  de- 
fined cancer  as  a  growth  of  epithelial  cells  with  a  ten- 
dency to  invade  tissue,  and  to  break  down  and  die. 
As  to  the  after-treatment,  he  preferred  light  plugging 
with  iodoform  gauze,  leaving  the  plug  in  for  a  week 
unless  the  temperature  rises  or  discharge  becomes  of- 
fensive. After  recovery,  he  advised  careful  examina- 
tion every  three  weeks.  Complete  removal  of  the  uterus 
may  be  effected  by  either  vaginal  or  combined  vaginal 
and  abdominal  operation. 

The  speaker  would  only  do  the  latter  when  the  va- 
gina is  too  small  or  the  uterus  too  large  for  the  former 
operation  to  be  possible. 

In  cases  of  vaginal  extirpation  he  opened  the  peri- 
toneum at  front  and  back  by  pushing  up  a  pair  of 
Lister  sinus  forceps,  and  then  enlarged  the  opening. 
He  divided  the  broad  ligament  bit  by  bit,  tying  the  ves- 
sels as  they  appear  with  silk,  and  he  thought  that  in  this 
way  there  was  less  danger  of  injury  to  the  ureters  than 
when  the  clamp  was  used.  He  did  not  use  sutures  for 
the  peritoneal  edges,  and  plugged  lightly  with  gauze 
and  removed  it  and  used  free  douching  on  first  ap- 
pearance of  any  fetor  or  rise  of  temperature.  He 
would  not  operate  at  all  when  mobility  of  the  uterus 
was  in  any  way  impaired,  nor  when  the  vaginal  wall  was 
involved. 

Dr.  Martin,  of  Berlin,  could  not  depend  altogether 
on  symptoms,  and  would  only  place  absolute  reliance 
on  microscopic  examination.  He  had  found  that  even 
in  some  cases  in  which  the  growth  was  diagnosed  at  an 
early  stage,  and  removed  freely,  it  recurred,  and  did 
not  think  that  the  question  of  the  advisability  of  opera- 
tion on  every  case,  even  when  discovered  early,  was  yet 
settled.  He  did  not  believe  in  partial  excision  ;  no 
one  would  propose  partial  operation  in  cancer  of  the 
breast.  In  his  own  practice  he  had  found  that  in  all 
cases  in  which  he  had  done  supra-vaginal  amputation 
of  the  cervix  disease  recurred,  and  he  now  always  prac- 
tised total  extirpation.  He  did  not  operate  when  can- 
cer had  invaded  the  broad  ligaments  or  glands,  but  he 
did  not  consider  invasion  of  the  vaginal  wall  a  bar  to 
operation,  as  that  could  be  removed.  He  did  not  ap- 
prove of  some  operations  done  lately,  in  which  the  sa- 
crum was  resected  and  the  glands  as  well  as  the  uterus 
were  removed.  A  day  or  two  before  operation  he  re- 
moved any  sloughing  growth  with  the  hot  iron.  The 
primary  result  of  total  extirpation  was  assured,  with  a 
mortality  of  four  to  ten  per  cent.,  but  the  secondary 
results  were  doubtful. 

Dr.  Pozzi,  of  Paris,  said  that  total  extirpation  was 
the  best  operation,  and  was  the  one  always  practised  in 
France.  He  thought  that  high  amputation  of  the  cer- 
vix was  a  bad  operation,  for  in  doing  it  hiumostosis 
was  difficult,  and  in  women  not  past  the  climacteric 
there  was  a  possibility  of  stenosis  of  the  cervix  followed 
by  haemometra  occurring,  and  he  had  seen  three  such 
cases.  In  France  they  used  forceps.  When  the  uterus 
could  be  easily  drawn  down  the  operation  was  a  good 


;i6 


MEDICAL   RECORD, 


[August  31,  1895 


one,  but  when  it  could  not  it  was  a  difficult  and 
bad  one.  In  cases  unsuitable  for  radical  operation, 
curetting,  followed  by  the  free  use  of  the  hot  iron,  not 
the  Paquelin  cautery,  prolongs  life. 

Dr.  Lusk.,  of  New  York,  did  not  trust  microscopical 
diagnosis,  as  different  laboratories  gave  different  reports 
on  same  specimen.  In  the  treatment  of  incurable  cases 
he  found  good  results  from  scraping  and  packing  with 
chloride  of  zinc,   3  v.  to  ^  j. 

Dr.  W.  Japp  Sinclair,  of  Manchester,  thought  that 
the  greatest  difficulty  in  differential  diagnosis  of  early 
cancer  was  from  hyperplasia  of  cervix  associated  with 
laceration  and  erosion  of  retention  cysts.  He  did  not 
believe  in  microscopical  e.\aniination,  and  thought  that 
the  most  important  clinical  test  was  that  cancerous  tis- 
sue was  friable  and  would  break  down  under  a  sharp 
spoon,  while  the  other  would  not.  He  did  not  consider 
supra-vaginal  amputation  a  suitable  operation  in  women 
who  had  not  passed  the  menopause.  He  used  the  liga- 
ture and  did  not  pack  wound,  but  put  in  drainage- 
tube. 

Dr.  Pi.A'iFAiR,  of  London,  placed  no  reliance  on  mi- 
croscopical examination,  and  did  not  approve  of  partial 
extirpation. 

Mr.  Taylor,  of  Birmingham,  had  faith  in  the  mi- 
croscope. He  thought,  as  a  clinical  sign,  blood  on  the 
examining  finger  was  one  which  should  most  excite  sus- 
picion.    He  advocated  total  extirpation. 

Dr.  Smylv,  of  Dublin,  advocated  the  ligature.  He 
always  destroyed  the  cancer  with  the  cautery  before 
resorting  to  operation. 

Dr.  Spkxcer,  of  London,  advocated  amputation  of 
the  cervix.  He  believed  some  cases  in  which  cancer 
of  the  body  of  the  uterus  had  been  said  to  exist  were 
really  not  cancer.  He  considered  cancer  of  the  body 
an  exceedingly  rare  disease.  He  had  known  pregnancy 
to  occur  in  a  case  in  which  almost  complete  stenosis  of 
the  OS  followed  amputation  of  the  cervix.  Cesarean 
section  had  to  be  performed  in  that  case. 

Dr.  Thornton,  in  closing  the  discussion,  pointed 
out  that  the  analogy  with  the  breast  does  not  hold,  as 
the  cervix  and  body  of  the  uterus  are  different  in 
structure  ;  furthermore,  cancer  of  the  cervix  seldom 
tends  to  invade  the  body.  The  life-history  of  cases  of 
partial  extirpation  gave  the  best  ultimate  results. 

Position  of  the  Foetus  in  Utero. — Dr.  Murdoch 
Cameron,  of  C.lasgow,  read  a  paper  entitled,  "A  New 
Theory  as  to  the  Position  of  Foetus  in  Utero."  This 
was  based  on  observations  made  in  the  course  of  the 
operation  of  Cn^sarean  section,  on  the  relative  position 
of  the  dorsum  of  the  foetus  and  the  placenta  ;  these 
showed  that  the  placenta  and  dorsum  of  the  faHus 
wereon  opposite  sides  of  the  uterus,  thus  in  the  first 
cranial  position  the  placenta  would  be  on  the  right 
side  of  the  uterus  posteriorly.  Dr.  Cameron's  theory 
was  that  if  the  fnetus  should  be  so  placed  as  to  bring 
its  dorsum  and  the  placenta  in  apposition,  then  the 
pressure  to  which  the  placenta  was  subjected  caused 
partial  asphyxia  in  the  foetus,  and  the  latter  changed 
its  position  so  as  to  bring  it  into  the  relation  "de- 
scribed. 

The  Changes  in  the  Uterus  during  the  Third  Stage 
of  Labor.— Dr.  Fkeki.and  Barikur,  of  Edinburgh, 
read  a  paper  on  this  subject,  his  observations  being 
based  on  the  study  of  fro/en  sections.  They  showed 
that  the  placenta  did  not  separate  during  the  diminu- 
tion in  the  size  of  the  uterus  which  followed  the  birth 
of  the  child,  and  that  there  was  no  evidence  of  separa- 
tion even  when  the  uterus  contained  nothing  else  but 
the  placenta.  He  had  found  no  evidence  of  retro-pla- 
cental  hemorrhage.  Frozen  sections  at  the  end  of  the 
second  stage  showed  no  separation  of  the  placenta, 
contrary  to  the  usual  view.  At  the  commencement  of 
the  third  stage,  the  placenta  was  unseparated,  even 
though  the  area  of  its  site  had  been  reduced  to  one- 
fourth.  The  clinical  bearing  of  this  was  that  patients 
never  bleed  until  the  second  stage  is  over.     The  arrest 


of  hemorrhage  is  caused  by  a  complete  rearrangement 
of  muscular  fibres  ;  besides  shortening,  the  planes  of 
muscular  fibres  glide  on  one  another,  so  as  to  make  the 
path  of  the  blood-vessel  tortuous.  Shrinking  of  the 
site  is  not  the  chief  factor  in  producing  separation  of 
the  placenta.  One  factor,  no  doubt,  is  the  forcing  out 
of  the  placenta  by  uterine  contraction  in  the  same  way 
as  the  ffjetus  was  forced  out. 

The  Section  was  then  adjourned. 


NEW   YORK    PATHOLOGICAL   SOCIETY. 

Stated  Meeting,  April  24,   iSQj. 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Gall-bladder  Containing  a  Large  Calculus. — Dr.  Don- 
ald M.  Barstow"^  presented  a  specimen  that  had 
been  taken  from  a  very  obese  woman,  forty-eight  years 
of  age,  who  had  been  admitted  to  the  New  York  Hos- 
pital on  May  7th.  She  had  given  no  history  of  biliary 
colic.  She  was  anjemic  and  feeble,  and  suffered  con- 
siderably from  dyspnoea.  She  died  on  May  31st.  At 
the  autopsy  the  valves  of  the  heart  were  found  to  be 
competent.  There  was  slight  stenosis  of  the  mitral 
valve.  The  heart  muscle  showed  considerable  fatty 
infiltration.  The  pericardium  contained  about  one 
ounce  of  serous  fluid.  The  peritoneum  contained  a 
considerable  quantity  of  the  same  kind  of  fluid.  The 
kidneys  were  somewhat  enlarged  and  congested.  The 
liver  was  the  ordinary  "  nutmeg  liver."  The  gall- 
bladder contained  a  calculus  which  filled  up  the  entire 
fundus.  The  wall  of  the  bladder  was  somewhat  thick- 
ened, and  the  mucous  membrane  eroded.  There  was 
a  cicatrix  at  the  point  of  contact  with  the  calculus. 

Calcareous  Deposit  in  the  Pleura. — Dr.  Barstow  also 
presented  a  specimen  taken  from  a  man,  fifty  years  of 
age,  who  had  died  of  intense  acute  infectious  process, 
the  exact  nature  of  which  had  not  been  determined. 
The  plate  had  been  found  in  two  pieces,  situated  in 
the  right  pleural  cavity,  about  opposite  the  sixth  rib. 
On  palpation,  before  its  removal,  it  had  felt  not  un- 
like an  old  fracture  of  a  rib.  The  two  layers  of 
the  pleura  were  everywhere  adherent.  On  section  the 
mass  had  been  found  to  be  composed  of  calcareous 
matter,  held  together  by  connective  tissue.  Those 
masses  occurred  most  commonly  after  empyema,  the 
fluid  portions  being  absorbed,  and  the  remainder 
undergoing  calcification.  The  fact  that  these  masses 
were  more  commonly  found  situated  at  a  lower  level 
would  suggest  the  possibility  of  this  one  having  been 
formed  in  connection  with  an  encapsulated  empyema. 

Dr.  James  Ewing  said  that  he  had  quite  recently 
seen  a  case  of  empyema  that  liad  been  operated  upon, 
and  in  which  death  had  occurred  shortly  afterward 
from  other  causes.  At  the  autopsy  a  calcareous  plate 
had  been  found  in  the  pleural  cavity,  which  had  re- 
minded him  of  the  specimen  just  ]iresented.  It  was 
about  the  size  of  a  half-dollar,  calcified  in  the  centre, 
and  cartilaginous  at  its  periphery. 

Colloid  Carcinoma  of  the  Rectum. — Dr.  Charles  E. 
Bruce  i)resented  for  Dr.  Mc.-Vlpin  a  specimen  which 
had  been  removed  from  a  woman  in  St.  Vincent's 
Hospital.  She  had  given  a  history  of  chronic  con- 
stipation and  a  gradually  developing  cachexia.  The 
autopsy  showed  adhesions  to  the  bladder  above  the 
rectum,  and  perforation  through  the  adhesions  into 
the  bladder. 

A  Tubercular  Lung.— Dr.  Bruce  presented  a  lung 
removed  from  a  case  of  tuberculosis.  In  the  right 
apex  was  an  old  cavity  surrounded  by  fibrous  tissue. 
The  lung  was  filled  with  tubercles  and  areas  of  lobar 
pneumonia.  The  point  of  interest  was  a  nodule  in  the 
central  portion  of  the  lung,  the  nature  of  which  had 
not  yet  been  determined,  as  the  autopsy  had  been 
made   only  a  few  hours  before.     The  report  on  the 


August  31,    1895] 


MEDICAL    RECORD. 


3^7 


nature  of  this  growth  would  be  presented  at  some 
future  meeting. 

Multiple  Abscesses  of  the  Liver  and  Extensive  Tuber- 
culosis.— Dr.    Bruce    also    presented    S|)ecimens    from 

another  case  of  tuberculosis.     The  patient,  V.  L , 

twenty-six  years  of  age,  a  German,  had  had  good 
health  up  to  April,  1894,  at  which  time  a  severe  diar- 
rhoea developed.  He  went  to  the  German  Hospital, 
and  was  discharged  "cured"  from  there  on  June  6, 
1S94.  While  working  in  a  restaurant,  and  drinking 
very  freely  of  ice-water  during  the  midsummer,  he  was 
seized  with  severe  cramps  over  the  region  of  the  liver, 
and  extending  up  into  the  back.  The  first  attack  lasted 
two  hours,  and  after  this  he  usually  had  one  attack  in 
the  twenty-four  hours.  During  these  attacks  he  e.xpe- 
rienced  a  feeling  of  swelling  and  hardness  in  the  riglit 
side,  and  he  had  a  rapid  pulse  and  shortness  of  breath. 
When  admitted,  on  August  30,  1894,  examination 
showed  the  breathing  to  be  very  feeble  over  the  lower 
part  of  the  right  lung,  with  prolonged  and  high-pitched 
expiration.  The  liver  dulness  was  much  increased, 
and  there  was  very  great  tenderness.  There  was  also 
severe  pain  in  the  lower  border  of  the  ribs,  one  inch 
inside  of  the  right  mammary  line.  The  heart  action 
was  regular,  but  rapid.  The  lung  signs  were  not 
prominent.  The  case  at  this  time  had  been  supjjosed 
to  be  one  of  hepatic  colic.  Aspiration  of  the  li\er, 
done  at  the  suggestion  of  Dr.  (leorge  P.  Biggs,  had 
shosvn  no  pus.  Numerous  tubercle  bacilli  had  been 
found  in  the  sputum.  The  man  died  on  January  30, 
1895.  At  the  autopsy  there  was  found  a  marked 
abdominal  ascites.  The  right  lung  was  compressed 
and  the  pleural  cavity  was  filled  with  fluid.  Both  lungs 
showed  nodules,  cavities,  and  areas  of  consolidation. 
The  heart  was  normal.  The  spleen  was  firm  and 
contained  tubercular  nodules.  The  liver  was  very 
large,  and  was  filled  with  tubercular  nodules,  some 
of  which  had  undergone  degeneration  and  were 
filled  with  creamy  pus.  The  intestines  were  filled  with 
ulcers  and  small  tubercular  nodules.  The  mesenteric 
glands  were  enlarged  and  cheesy.  The  right  kid- 
ney contained  a  large  tubercular  nodule.  There  were 
gall-stones  in  the  common  duct.  Cultures  from  the 
liver  pus  showed  a  mixed  variety,  but  no  tubercle 
bacilli. 

The  President  said  that,  from  the  repeated  attacks 
of  severe  diarrhoea  with  pain  in  the  region  of  the  liver, 
he  had  been  led  to  consider  the  case  one  of  hepatic  ab- 
scess, and  he  had  therefore  suggested  aspiration  of  the 
liver.  Two  aspirations  had  been  made,  but  as  they  had 
failed  to  reveal  the  presence  of  pus,  he  had  begun  to 
doubt  the  correctness  of  his  first  diagnosis.  The  ab- 
scesses found  in  the  liver  must  have  been  of  the  ordi- 
nary infective  kind — at  any  rate,  he  had  never  seen  any 
such  tubercular  lesion  in  the  liver. 

New  Mounting  Medium.— Dr.  Henry  S.  Sie.^rns 
presented  two  slides  to  illustrate  the  effect  of  Dr.  I'iff- 
ard's  new  mounting  medium.  These  two  slides  had 
been  taken  from  the  same  block  of  tissue,  and  stained, 
washed,  dehydrated,  and  clarified  at  the  same  time,  and 
for  the  same  length  of  time,  in  each  solution.  The 
only  difference  was  that  one  had  been  mounted  in  tlie 
ordinary  mixture  of  Canada  balsam  and  xylol,  and  the 
other  mounted  in  the  new  material  perfected  by  Dr. 
Piffard.  It  seemed  to  him  that  these  slides  very  clearly 
demonstrated  the  great  value  of  this  new  medium. 
Owing  to  its  very  refractive  index,  minute  details  of 
structure  could  be  easily  detected  with  a  narrow-an^le 
objective,  which  could  only  be  discerned  with  difticuliy 
under  a  wide-angle  objective  if  the  object  had  been 
mounted  in  balsam.  This  new  medium  was  the  ordi- 
nary "sweet-gum  "  of  the  South,  extracted  with  xylol, 
and  the  xylol  afterward  driven  off  by  heat.  Two  parts 
of  this  sticky  gum  are  to  be  dissolved  in  one  part  of 
the  monobromide  of  naphthalin,  and  used  exactly  in 
the  same  way  as  the  ordinary  Canada  balsam.  The 
ordinary  storax  had  been  experimented  with,  and  had 


given  a  mounting  medium   with  a  refractive  index  of 
about  one  hundred  and  fifty-eight. 

The  speaker  said  that  he  had  found  this  new  medium 
so  superior  to  the  Canada  balsam  that  he  did  not  in- 
tend to  use  the  latter  hereafter  in  the  college.  The 
section  under  the  microscope  was  from  a  glioma  of  the 
brain.  He  had  not  been  able  to  demonstrate  the 
branching  cells  in  it  until  he  had  mounted  the  speci- 
men in  this  new  medium. 

Retro-pharyngeal  Abscess.  — Dr.  George  P.  Biggs 
presented  specimens  from  this  case.  The  patient,  a 
child,  eighteen  months  of  age,  had  been  a  coroner's 
case  in  which  the  diagnosis  had  been  made  of  diph- 
theria. At  the  autopsy,  however,  nothing  had  been 
found  except  slight  parenchymatous  change  in  the  or- 
gans, until  the  larynx  had  been  reached.  On  removing 
this  organ,  considerable  pus  had  escaped  from  the 
retro-pharyngeal  region,  and  examination  then  had 
shown  the  cavity  of  a  retro-pharyngeal  abscess,  about 
three  centimetres  in  diameter.  There  had  been  no  rupt- 
ure of  the  abscess  during  life.  The  mucous  membrane 
of  the  pharynx,  tonsils,  and  larynx  was  normal,  and 
there  was  no  evidence  of  diphtheria.  Death  had  been 
apparently  due  to  the  projection  forward  of  the  pharyn- 
geal abscess  and  the  consequent  occlusion  of  the  rima 
glottidis. 

Perforating  Duodenal  Ulcer. — Dr.  George  P.  Biggs 
then  presented  specimens  from  a  case  of  perforating 
duodenal  ulcer.  The  patient,  a  man  thirty-five  years  of 
age,  had  been  admitted  to  the  Hudson  Street  Hospital 
on  April  20th,  at  2  p.m.,  complaining  of  severe  abdomi- 
nal pain  and  diarrhcea  which  had  lasted  for  two  or  three 
days.  After  admission,  the  bowels  were  constipated, 
and  he  vomited  some  bloody-looking  fluid.  The  pain 
was  most  marked  in  the  lower  part  of  the  right  side  of 
the  abdomen.  The  abdomen  was  moderately  dis- 
tended, and  there  was  great  tenderness  over  the  whole 
right  side,  but  especially  in  the  right  iliac  region.  His 
temperature  was  100°  F.  On  the  day  after  admission 
the  abdominal  pain  was  more  diffused,  and  the  ab- 
domen was  not  much  swollen,  but  was  quite  rigid. 
The  bowels  moved  freely  after  an  enema.  (Dn  the  next 
day  the  pain  was  less  intense,  but  on  the  day  after 
this  his  condition  was  poor  ;  the  abdomen  was  dis- 
tended ;  there  was  fluid  in  the  right  side  of  the  ab- 
domen, and  the  pulse  was  rapid,  thready,  and  weak. 
An  exploratory  incision  was  made  for  the  purpose  of 
drainage,  as  it  was  supposed  that  there  was  an  appen- 
dicitis and  peritonitis.  The  appendix  was  found  per- 
fectly normal.  Five  or  six  ounces  of  turbid  serum 
were  removed  from  the  abdominal  cavity,  and  consid- 
erable lymph  found  over  the  intestines.  The  patient 
died  about  one  hour  later.  The  autopsy  showed  the 
small  intestine  greatly  distended  and  congested,  and 
the  peritonitis  seemed  to  be  most  intense  in  the  pelvis. 
There  were  some  large  hemorrhoids  with  superficial 
ulceration  of  the  mucous  membrane.  It  was  at  first 
thought  that  the  inflammation  might  have  extended 
from  here  to  the  peritoneum,  but  further  examination 
showed  this  not  to  be  the  case.  The  first  portion  of 
the  duodenum  was  adherent  to  the  under-surface  of 
the  right  lobe  of  the  liver,  near  the  gall-bladder. 
There  were  many  recent  adhesions,  and  on  separating 
these  carefully,  a  perforation  about  three  millimetres  in 
diameter  was  found  just  beyond  the  pyloric  ring,  in  the 
base  of  an  old  ovoid  ulceration.  This  ulcer  was  ^ 
ctm.  in  length,  and  ^2  ctm.  in  diameter,  and  its  long 
diameter  corresponded  with  the  long  axis  of  the  intes- 
tine. It  was  in  the  superior  wall  of  the  duodenum. 
Just  enough  adhesions  had  formed  around  it  to  pre- 
vent the  escape  of  gas.  Another  old  ulceration  was 
found  in  the  posterior  wall  of  the  duodenum.  The 
sjicaker  remarked  that  this  had  been  the  third  case  of 
perforating  duodenal  ulcer  at  that  hospital,  within  a 
few  months,  which  had  been  diagnosticated  as  appen- 
dicitis. In  all,  the  symptoms  had  been  localized  to  the 
appendix  region.     -Ml   three   cases  had  been  operated 


3i8 


MEDICAL  RECORD. 


[August  31,  1895 


upon  after  there  had  been  unmistakable  evidence  of 
peritonitis,  but  in  no  instance  had  there  been  any  re- 
lief of  the  symptoms. 


Stated  Meeting,  May  8,  iSgs- 
George  P.  Biggs,  M.D.,  President,  ix  the  Chair. 

A  Recurrent  Carcinoma  of  the  Breast. — Dr.  H.  J. 

BoLDT  presented  several  specimens.  The  first  one 
was  obtained  from  a  woman,  fifty  years  of  age.  The 
operation  had  been  done  by  taking  away  the  entire 
pectoral  structures  down  to  the  bone.  In  this  instance, 
he  had  been  obliged  to  remove  a  part  of  the  pectoral 
muscles  from  the  other  half  of  the  breast,  and  dissect 
out  all  the  glandular  structures  about  the  vessels,  re- 
moving all  in  one  piece.  This  method  of  operating 
would  have  been  adopted  at  first  had  it  not  been  that 
the  family  had  been  opposed  to  such  an  extensive  op- 
eration at  that  time. 

Pelvic  Abscesses ;  Vaginal  Operation. — The  second 
specimen  had  been  taken  from  one  of  a  series  of  thir- 
teen recent  cases  in  which  he  had  resorted  to  the  radi- 
cal vaginal  operation  for  suppurative  disease  of  the 
pelvic  organs.  In  this  particular  case  there  were  five 
abscesses.  The  specimen  showed  a  fairly  large  tu- 
mor which  had  involved  the  pelvic  cavity  and  had 
extended  half-way  up  to  the  umbilicus  on  the  right 
side.  Pus  had  been  removed  from  below  by  aspira- 
tion and  irrigation  ;  then  the  uterus  had  been  taken 
out,  and  the  abscess  sacs  removed  piecemeal.  The  op- 
eration was  indicated  in  all  those  cases  of  diffuse  pelvic 
suppuration  in  which  the  abdominal  operations  were 
not  appropriate,  and  in  which  the  pelvic  contents  were 
bound  down,  and  there  were  probably  many  intestinal 
adhesions. 

Tubal  Abortion,  with  Embryo. — The  next  specimen 
was  one  of  tubal  abortion,  with  embryo.  The  only 
symptoms  of  pregnancy  that  the  patient  had  presented 
had  been  that  she  had  not  menstruated  for  ten  weeks. 
There  had  been  no  dark  discharge  from  the  uterus. 
The  speaker  said  he  had  seen  her  last  night  in  consul- 
tation, with  the  object  of  determining  whether  or  not 
she  was  really  pregnant.  She  had  become  quite  rapid- 
ly anaemic  in  the  last  few  days,  but  there  had  been  no 
pain.  Examination  had  shown  the  uterus  to  be  decid- 
edly enlarged,  and  a  small  nodule  was  situated  behind 
the  organ.  Bimanual  examination  had  revealed  a 
characteristic  crackling  feel,  indicating  to  him  free 
fluid  in  the  peritoneal  cavity.  The  uterus  had  been 
freely  movable.  He  had  made  a  diagnosis  of  tubal 
gestation  with  rupture.  The  patient  had  requested 
that  the  operation  be  postponed  until  this  morning, 
and  on  his  arrival  at  the  hospital  at  that  time  he  had 
found  that  there  had  been  a  fresh  hemorrhage  and 
the  patient  was  in  a  state  of  collapse.  He  opened  the 
cul-de-sac  of  Douglas,  and  finding  the  bleeding  still 
active  the  abdomen  was  opened.  The  quantity  of 
blood  found  in  the  peritoneal  cavity  was  estimated  to 
be  between  2,500  and  3,000  gm.  An  infusion  of 
saline  solution  into  the  cellular  tissue  was  started  im- 
mediately after  the  anesthesia  had  been  begun,  and 
she  had  received  five  pints  of  this  solution.  She  had 
also  received  one  dose  of  yij  of  a  grain  of  strychnine 
hypodermatically.  It  was  too  early  yet  to  say  what 
would  be  the  outcome  of  the  case. 

Ruptured  Tubal  Pregnancy  with  Placenta  within 
the  Tube. — Dr.  Boldt  then  presented  this  specimen. 
It  had  been  taken  from  a  patient,  about  thirty  years  of 
age,  who  had  had  children  previously.  In  this  case 
there  had  been  the  usual  signs  of  pregnancy,  and  there 
had  been  a  progressive  intra-i)eritoneal  hemorrhage.  He 
had  operated  per  vaginam,  removing  the  tube,  and  leav- 
in^the  clamp  in  as  drainage,  in  addition  to  the  gauze. 

malignant  Deciduoma  (?).— The  next  specimen  was 
from  a  case  of  malignant  disease  complicated  with  pel- 
vic abscess.     The  patient  being  an  Italian  who  was  un- 


able to  speak  English,  no  history  had  been  obtained. 
From  its  general  appearance  he  thought  the  tumor  to 
be  one  of  malignant  deciduoma.  If  so,  it  was  a  rare 
specimen,  and  on  this  account  he  asked  that  it  be  re- 
ferred to  the  Committee  on  Microscopy  for  examination 
and  report.     This  was  done. 

Dr.  Willi.^m  Vissman  remarked  that  the  locality  of 
this  tumor  would  be  very  unusual  for  a  carcinoma,  and 
a  very  probable  one  for  a  malignant  deciduoma. 

Dr.  Boldt  then  presented  the  following  specimens  : 
Cancer  in  the  interior  of  the  cervical  canal ;  cancer  of 
the  vaginal  portion  ;  two  fibromata  of  the  uterus,  re- 
moved per  vaginam  :  four  or  five  specimens  of  hys- 
terectomy for  chronic  inflammatory  disease  without 
suppuration,  and  three  dermoid  cysts.  He  said  that 
he  felt  disposed  to  strongly  advocate  the  vaginal 
operation  because  the  patients  made  a  very  rapid  con- 
valescence, there  was  no  danger  of  ventral  hernia,  atid 
the  troublesome  neuralgic  pains  sometimes  felt  in  the 
abdominal  scar  were  avoided.  He  did  not  close  the 
peritoneal  cavity,  and  consequently  was  not  afraid  of 
infecting  that  cavity,  the  pus  draining  out  from  below. 

A  Method  of  Preserving  the  Epithelia  of  the  Gastro- 
intestinal Tract. — Dr.  Henry  Power  made  a  pre- 
liminary report  on  this  subject.  His  idea  had  been  to 
introduce  the  preservative  into  the  body,  instead  of  re- 
moving portions  from  the  body  and  placing  them  in 
the  preservative.  His  first  experiments  had  been 
directed  toward  introducing  the  preservative  into  the 
stomach  by  puncture,  but  this  method  had  presented 
so  many  difficulties  in  practice  that  he  had  abandoned 
it.  Two  rabbits  were  then  killed,  and  immediately 
injected  by  the  rectum  with  Miiller's  fluid,  using  1,500 
c.c.  of  the  fluid  and  a  pressure  of  about  four  feet. 
This  pressure  was  continued  for  twenty-four  hours. 
Examination  with  the  microscope  showed  that  this  ex- 
treme pressure  had  injured  the  tissues,  and  had  caused 
them  to  become  infiltrated  with  the  fluid.  The  next 
experiment  was  with  a  two  per-cent  solution  of  formalin, 
and  a  pressure  of  from  eight  to  twelve  inches,  only 
about  one  litre  of  fluid  being  introduced.  This  pro- 
duced very  little  subcutaneous  oedema,  and  the  con- 
nective-tissue cells  were  remarkably  well  preser%-ed.  In 
another  experiment,  a  dog  was  killed  with  chloroform 
and  about  one  and  a  half  litre  of  a  two  per-cent. 
formalin  solution  injected  into  the  peritoneal  cavity. 
By  this  method  the  large  intestine  was  well  preserved. 
Then  a  trial  was  made  with  a  five  per-cent.  solution  of 
formalin  injected  into  the  rectum  under  a  pressure  of 
eight  inches,  and  also  with  an  injection  into  the  peri- 
toneal cavity  under  a  pressure  of  two  feet.  In  the 
latter  experiment  on  a  large  dog  the  intestine  received 
about  two  litres  and  the  peritoneal  cavity  about  one 
litre.  After  twenty-four  hours  the  tissues  were  hard- 
ened in  graduated  alcohol,  and  on  microscopical  ex- 
amination it  was  found  that  they  had  been  very  satis- 
factorily preserved  and  without  distortion.  The  method 
is  very  simple,  and  involves  practically  no  marring  of 
the  body.  Only  a  minu'.e  needle  puncture  is  left  in 
the  abdomen.  Two  rubber  douche-bags,  a  cannula 
for  the  rectum,  and  a  large  hollow  needle  for  the  peri- 
toneal cavity  constitute  'the  requisite  apparatus.  The 
speaker  said  that  by  this  method  the  preservation  was 
more  perfect  than  he  had  ever  seen  before. 

Dr.  Viss.man  said  that  tsvo  or  three  years  ago  experi- 
ments had  been  made  on  both  the  lower  animals  and 
on  human  beings,  with  a  view  to  determining  the  best 
method  of  irrigating  the  intestine  in  cholera.  It  had 
been  found  that  the  whole  gut  could  be  irrigated  with 
a  pressure  of  about  four  feet.  It  had  not  been  found 
necessary  in  these  experiments  to  tie  in  the  cannula,  the 
use  of  a  large  flange  answering  the  same  purpose. 


Cholethiasis. — The  indications  for  surgical  interven- 
tion in  these  cases  are  to  be  measured  by  the  danger 
resulting  from  frequent  attacks  of  colic  and  prolonged 
existence  of  jaundice. — Gersvnv. 


August  31,  1895] 


MEDICAL    RECORD 


319 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondeat.) 

NOTES  ON  THE  MEETING  OF  THE  BRITISH  MEDICAL 
ASSOCIATION  IN  LONDON THE  PROCEEDINGS EN- 
TERTAINMENTS  MUSEUM PUFFERY,    ETC. 

London,  August  9,  1895. 

The  British  Medical  Association  has  been  and  gone. 
The  members  have  returned  to  their  homes  or  set  out 
on  their  annual  holidays.  London  has  assumed  its 
usual  appearance  at  this  season — that  is,  it  is  deserted 
by  many  of  our  leaders,  who  will  turn  up  again  late  in 
September,  though  the  dearth  of  doctors  is  by  no  means 
lamented  by  those  who  remain  behind. 

The  meeting  was  pronounced  a  successful  one,  and 
our  guests  were  generally  gratified  by  their  reception. 
Hospitality  was  displayed  in  great  variety,  and  some  of 
the  entertainments  were  exceedingly  successful,  but 
London  is  so  vast  a  place  that  not  a  few  took  the  op- 
portunity of  examining  and  enjopng  some  of  its  ordi- 
nary features,  and  others  who  knew  it  well  took  some  of 
the  more  distant  excursions.  Besides  those  I  have  re- 
corded, there  was  Dr.  Down's  garden  party  at  Hamp- 
ton, another  at  the  Children's  Hospital,  and  a  third  at 
St.  Thomas's  Hospital,  on  the  same  day,  thus  di\Tding 
the  mass  of  visitors.  Then,  in  the  evening  a  ladies' 
party  in  Regent  Street  Gallery,  a  reception  at  Hyde 
Park,  a  smoking  conversazione  at  the  Clinical  Museum, 
and  another  by  the  Masonic  Brotherhood  at  Portman 
Rooms.  The  same  evening  (Thursday),  the  annual 
dinner  was  celebrated  in  the  usual  way,  when  foreign 
guests  were  numerous,  and  complaints  about  the  din- 
ner general.  Saturday  was  the  chief  excursion  day. 
One  party  went  to  Claybury  and  Epping  Forest,  and 
had  luncheon  as  guests  of  the  County  Council  in  their 
asylum  ;  another  were  entertained,  at  Hazlemere.  by 
Mr.  Hutchinson  ;  another  by  Mr.  Smith,  M.P.,  at 
Marlow.  Excursions  were  also  ai ranged  to  Oxford, 
Reading,  Silchester,  Windsor  Castle,  and  Hampton 
Court.  Other  contingents  went  to  Hastings  and  East- 
bourne, and  it  is  reported  that  the  last  town  is  desirous 
that  the  Association  should  meet  there  next  year.  It 
would  be  a  popular  place.  Some  places  have  felt  dif- 
fident about  coming  immediately  after  the  great  me- 
tropolis, and  perhaps  it  would  only  be  fair  to  select  a 
rather  more  distant  place,  and  one  which  would  not 
pretend  to  vie  with  the  great  city,  but  would  give  us  a 
a  pleasant  country  outing.  But  much  must  depend  on 
the  invitations  that  may  be  given. 

Those  of  us  who  accepted  Dr.  Tuke's  invitation  (on 
Wednesday)  had  a  very  enjoyable  afternoon  in  the 
grounds  surrounding  the  beautiful  Florentine  villa, 
built  by  the  first  Earl  of  Burlington,  and  owned  now 
by  the  Duke  of  Devonshire.  The  splendid  old  cedars 
of  Lebanon  forming  the  avenue,  and  other  beautiful 
trees,  the  old-fashioned  Italian  garden,  with  its  busts 
and  pedestals,  and  the  charming  vistas  among  the  trees, 
make  the  space  of  about  forty  acres  perhaps  the  most 
beautiful  in  the  neighborhood  of  London.  Nor  must 
I  omit  the  yew  hedges  of  great  size  and  age  which  one 
visitor  called  rcw  nitjue,  and  I  did  not  pinch  him  for 
his  pun  I  The  weather  was  lovely  and  the  genial  host- 
ess and  host  could  not  but  be  gratified  with  the  de- 
light of  the  brilliant  company  that  had  assembled  on 
their  invitation. 

The  Gynecological  Society  gave  a  dinner,  and  the 
Brussels  graduates  met  to  discuss  their  grievance  over 
the  dinner-table.  The  museum  served  as  a  rendezvous, 
and  many  pleasant  greetings  might  be  there  overheard 
or  taken  part  in.  Naturally  the  venders  of  all  the 
wares  that  doctors  need  were  in  full  force.  The  manu- 
facturers could  not  omit  so  excellent  a  chance  of  ad- 


vertising their  productions.  The  journals,  under  the 
guise  of  reports,  give  amazing  testimonials  to  these 
traders.  I  do  not  propose  to  follow  the  example,  but 
merelv  say  that  as  a  whole  the  museum  was  a  pleasant 
lounge,  and  gave  the  opportunity  of  seeing  a  number 
of  useful  articles — both  new  and  old — and  comparing 
them.  Further  information  is  to  be  found  in  the  cata- 
logue and  the  journal,  and  will  be  forwarded  by  most 
of  the  dealers  on  application.  I  have  always  felt  an 
attraction  toward  the  annual  museum.  I  wonder  whether 
it  is  from  a  desire  to  examine  and  compare  the  articles 
on  show,  or  whether  it  is  because  the  exhibition  it- 
self is  a  sort  of  microcosm  of  "  this  great  Association," 
as  the  clique  continually  mouth  it.  On  the  one  hand, 
the  articles  exhibited  proclaim  their  uses  and  advertise 
their  producers.  On  the  other,  the  living,  breathing, 
talking  members  are  on  show,  and  together  form  one 
gigantic  advertisement.  And  all  the  year  round  the 
official  organ  of  the  Association  declaims  from  week  to 
week  on  the  iniquity  of  puffing,  and  is  itself  a  standing 
example  of  that  same  wickedness,  and  its  editor  about 
as  inconsistent  as  the  medical  defender  of  vaccination, 
who  lowered  his  flag  to  the  faddists  when  appealing  to 
them  as  a  candidate. 


THE    ETHICS    OF    CRANIOTOMY. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  have  been  somewha't  interested  in  the  discus- 
sion, "  The  Catholic  Church  and  Obstetric  Science," 
which  has  been  going  forward  in  the  pages  of  the 
Medical  Record  for  some  time  past.  I  must  say, 
however,  that  a  good  deal  of  the  interest  that  would 
otherwise  attach  to  a  consideration  of  the  general 
question  of  the  lawfulness  of  homicide  has  been  de- 
tracted from  by  the  fact  that  the  discussion  referred  to 
has  been  confined  merely  to  whether  or  not  the  Catholic 
Church  allows  the  practice  of  craniotomy. 

To  an  overwhelming  majority  of  your  readers  the 
Catholic  Church  does  not,  nor  does  any  church  for 
that  matter,  speak  with  authority.  I  cannot,  there- 
fore, think  it  otherwise  than  fruitless,  not  to  say  irrel- 
evant, that  the  discussion  should  be  continued  within 
the  hitherto  narrow  limits,  especially  since  such  an 
eminent  authority  as  Father  Sabetti  has  said  the  last 
word  in  behalf  of  the  church. 

Human  life  has  always  been  held  in  the  most  sacred 
estimation  among  civilized  nations,  hence  the  reason 
for  the  absorbing  interest  always  manifested  by  think- 
ing people  in  all  questions  relating  to  the  justification 
of  homicide. 

True  as  this  observation  is,  it  is  no  less  strange  that 
the  members  of  the  medical  profession,  of  all  persons 
the  most  concerned,  and  who  on  occasion  are  called  on 
to  exercise  the  power  of  life  and  death,  have  always 
displayed  a  disposition  to  shirk  the  ethics  of  this  sub- 
ject altogether,  or  when  compelled  to  notice  it,  to  do 
so  in  a  lame  and  hesitating  manner. 

Truly  may  it  be  said  that  the  position  of  the  phy- 
sician is  a  strangely  unique  one,  unique  in  a  manner 
that  applies  to  no  other  class  or  calling.  No  nobler 
avocation  indeed  is  there  than  his,  and  yet  none  so 
paradoxical. 

On  the  one  hand,  it  is  of  the  function  of  his  glorious 
calling  to  bestow  the  blessings  of  health,  ay,  to  re- 
store, in  a  sense,  the  very  life  to  poor  suffering  human 
beings  ;  while,  on  the  other  hand,  he  is  expected,  even 
commanded  under  pain  of  reprobation,  deliberately  to 
destroy  that  which  it  is  his  greatest  privilege  and  pre- 
rogative to  save. 

The  hangman  and  headsman,  it  would  seem,  belong 
to  a  rational  order  of  things,  for  they  are  but  agents  of 
the  State,  which  has  legitimate  power  over  life  and 
death.  They  are  free  of  responsibilty  in  the  premises, 
and   their   victims   are   criminals   who   justly   deserve 


320 


MEDICAL    RECORD. 


[August  31,    1895 


death  ;  while  the  physician  combines  in  himself  the 
offices  of  judge,  jury,  and  executioner  in  the  case  of 
the  innocent  and  defenceless.  Here,  indeed,  we  have 
the  very  hyperbole  of  paradox. 

Deprecating  as  I  do  the  treatment  of  this  question 
from  the  point  of  view  of  any  particular  creed,  since 
no  creed  admittedly  speaks  with  authority  to  the 
medical  profession,  it  is  with  considerable  satisfaction 
that  I  welcome  the  article  of  Dr.  William  A.  Galloway, 
"  Craniotomy  and  the  Law,"  which  appeared  in  your 
issue  of  July  27th. 

What  commends  his  article  specially  to  me  is  that  it 
aims  to  treat  this  grave  question  in  a  secular,  as  distin- 
guished from  a  sectarian,  manner.  There  ought,  there- 
fore, to  be  no  place  for  the  introduction  of  such 
digressing  issues  as  the  odium  anti-theologicum,  or  of 
special  pleading,  in  the  interest  of  any  particular  re- 
ligious system. 

Dr.  Galloway  bases  his  argument  for  the  lawfulness 
of  craniotomy  in  the  teachings  of  common  law,  contend- 
ing, at  least  implicitly,  that  it  is  unnecessary  to  seek 
farther  the  desired  justification.  However,  the  basis 
of  common  law,  though  broad,  is  certainly  not  broad 
enough  for  the  consideration  of  such  a  question  as  the 
present  one.  His  coolness  rises  to  sublime  heights,  in 
thus  assuming  infallibility  for  common  law,  ignoring 
the  very  important  fact  that  behind  it  there  is  another 
and  higher  law,  whose  imperative,  to  everyone  with  a 
conscience,  is  ultimate.  It  evidently  never  occurs  to 
him  that  some  time  could  be  profitably  spent  in  re- 
search, with  the  view  to  discovering  how  often  com- 
mon-law maxims  seen  to  be  at  variance  with  the 
principles  of  morality,  have  been  abrogated  by  statu- 
tory enactment. 

Now,  the  maxims  of  common  law  relating  to  craniot- 
omy, the  statutes  in  conformity  therewith,  as  well  as 
Dr.  Galloway's  arguments  (some  of  them  at  least),  rest 
on  a  basis  of  pure  unmitigated  expediency,  and  this  is 
certainly  in  direct  contravention  of  the  teachings  of  all 
schools  of  moral  science,  even  the  utilitarian. 

To  show  this,  I  quote  some  passages  from  his  article  : 
"  It  "  (the  Ohio  statute)  "  jarovides  that  craniotomy 
may  be  done  to  save  the  life  of  the  mother  ;  hence 
when  the  question  is  between  an  unborn  infant's  life  and 
that  of  the  mother,  the  mother's  is  to  be  preferred." 
Why  the  mother's  is  to  be  preferred,  he  tells  us  further 
on,'  where  he  says  :  "  The  duty  he  "  (the  physician) 
"  owes  to  society  at  large  in  saving  the  mature  and  use- 
ful life  of  the  mother  as  against  the  life  of  the  child, 
which  in  its  useful  relations  to  the  social  body  is  yet 
imiitatuie  "  (the  italics  are  mine),  "  is  above  and  beyond 
adverse  legislation." 

In  order  to  strengthen  his  position  by  showing  that 
the  case  of  the  foetus  in  utero,  in  this  emergency,  does 
not  stand  alone,  but  is  one  among  many  in  the  differ- 
ent contingencies  of  life,  he  introduces  what  he  thinks 
is  an  analogous  case.  He  says  :  "  Upon  the  authority 
of  Lord  Bacon  it  has  always  been  held  in  law  and  fact, 
when  two  shipwrecked  persons  get  on  the  same  jjlank, 
and  one  of  them  finding  it  unable  to  save  them,  thrusts 
the  other  from  it,  whereby  he  is  drowned,  it  is  justifi- 
able homicide."  That  the  governing  principle  here  is 
not  utility,  and  that  the  analogy  is  a  false  one,  will  be 
shown  further  on. 

But  why,  some  may  ask,  is  not  utility  a  sufficient 
justification  ?  That  it  is  not  only  not  sufficient,  but  in 
no  sense  a  justification  at  all,  can  best  be  shown  by 
stating  a  case  of  moiher  and  foetus,  essentially  like  the 
above,  but  with  the  normal  attribute  of  the  two  re- 
versed. Let  us  suppose  the  case  of  a  mother  who,  in- 
stead of  a  blessing,  has  been  a  scourge  to  society,  and 
that  an  individual,  it  might  be  the  father,  and  he  a 
great  and  good  ruler  without  an  heir,  stands  pledged 
to  insure  the  future  usefulness  of  the  child  to  society. 
Will  any  one  outside  a  lunatic  asylum  justify  in  this  case 
the  deliberate  and  direct  killing  of  the  mother  to  save  the 
child  ?     And  yet  if  utility  be  a  just  reason,  why  should 


it  not  be  done  ?  Why  should  the  mother  receive  any 
consideration  whatever? 

With  regard  to  the  precept  against  taking  human  life 
in  its  general  meaning,  there  is  no  difference  of  opin- 
ion between  Dr.  Galloway  and  myself. 

What  I  object  to,  however,  is  that  the  tone  of  his 
language  in  describing  the  exceptions  to  it  bears  the 
implication  that  not  to  moral,  but  to  human,  law  are  to 
be  traced  the  ultimate  sanctions  for  conduct  in  the  cir- 
cumstances under  consideration.  The  exceptions  he 
cites  are  reasonable  and  just,  and  in  strict  accord  with 
sound  morality.  He  gives  five  of  these,  four  of  which 
in  their  last  analysis  are  reducible  to  one — self-defence. 
The  fourth,  which  he  calls  superior  duty,  is  not  relevant 
here  and  need  not  therefore  be  considered. 

Here  Dr.  Galloway,  in  addition  to  utility,  puts  for- 
ward self-defence  as  a  justification,  and  in  this  I  am  at 
one  with  him.  He  falls  into  grave  error,  however,  in 
his  application  of  this  principle  when  he  considers  the 
foetus  the  aggressor.  That  the  mother  and  not  the 
foetus  is  the  aggressor,  I  think  can  be  plainly  shown. 

Let  us  see.  The  child's  presence  in  utero  is  due  to 
no  act  of  its  own,  but  to  the  conscious  and  deliberate 
act  of  the  father  and  mother.  Again,  the  assault  be- 
gins, continues,  and  ends  in  the  tissues  of  the  mother. 
There  is  no  controverting  the  fact  that  the  acts  of  the 
mother,  from  the  first  of  copulation,  which  is  voluntary, 
to  the  last  of  parturition,  which  is  consequentially  so, 
are  positive  and  active,  while  those  of  the  child  are 
merely  passive.  This  being  so,  how,  by  any  distortion 
of  thought  or  language,  can  the  child  be  considered  in 
that  condition  of  activity  connoted  by  the  word  ag- 
gressor ?  The  foetus  has  a  right  to  its  life  as  against 
the  mother,  not  on  any  mere  grounds  of  shifting  expe- 
diency, but  according  to  right,  reason,  and  morals,  and 
deliberately  and  directly  to  deprive  it  of  that  life  is  an 
unjustifiable  act  in  no  w-ay  distinguishable  from  a  like 
act  in  the  case  of  an  adult  and  called  by  a  name  that 
"  hath  not  a  pleasant  sound  i'  the  ear." 

At  this  point  I  will  make  good  the  assertion  that  the 
analogy  between  the  obstetric  case  and  that  of  the 
shipwrecked  persons  is  a  false  one.  Before  doing  so, 
however,  I  will  state  that  even  if  the  analogy  were  true 
it  is  by  no  means  on  the  principle  of  utility  that  he  who 
kills  the  other  is  warranted  in  doing  so.  His  right  is 
based  on  the  law  older  than  the  churches  and  than  all 
human  enactments,  yes,  even  older  than  Moses  and  the 
Decalogue,  that  is,  the  law  of  self-preservation.  For  it 
is  evident  that  if  utility  is  here  the  determining  element 
the  same  practice  should  hold  as  in  the  obstetric  case. 

Suppose,  for  instance,  that  of  the  two  persons  on  the 
plank,  one  was  known  to  be  a  highly  useful  member  of 
society  and  the  other  a  degraded  criminal,  why  should 
nf)t  the  latter  be  held  culpable  if  he  succeed  in  kill- 
ing the  former  ?  It  is  only  necessary  to  state  the  case 
to  lay  bare  its  absurdity. 

The  attempt  to  establish  an  analogy  between  this 
case  and  the  obstetric  one  is  unfortunate  in  this,  that 
in  the  latter  there  is  an  unjust  aggressor — the  mother — 
while  in  the  former  there  exists  the  strange  but  never- 
theless real  condition  of  two  persons,  each  of  whom  is 
both  an  aggressor  (though  not  an  unjust  one)  and  an 
aggressed,  and  justification  is  with  him  that  succeeds. 

I  stated  above  that  even  the  utilitarian  school  of 
moral  science  would  not  justify  the  taking  of  human 
life  for  merely  expedient  reasons,  and  this  assertion 
perhaps  needs  some  explanation  and  amplification. 
According  to  this  school  utility  is  only  made  use  of  to 
furnish  reasonable  sanctions  for  ultimate  moral  laws, 
and  is  in  no  way  to  be  applied  in  particular  and  con- 
crete cases.  The  case  of  the  shipwrecked  illustrates 
this  most  admirably.  The  teachings  of  this  school 
would  never  countenance  the  rule  that  the  less  must 
give  way  to  more  worthy.  If,  on  the  other  hand,  he 
turn  to  that  other  great  school  of  ethics,  known  as  the 
traditional  or  intentive,  the  advocate  of  craniotomy 
will  find  less  consolation  and  encouragement. 


I 


August  31,  1895] 


MEDICAL    RECORD. 


Thus  I  affirm,  it  is  plainly  seen  that  there  is  no  sys- 
tem of  moral  science  whose  teachings  can  be  appealed 
to  in  support  of  Dr.  Galloway's  contentions.  There  is 
nothing,  then,  for  him  to  do  but  either  to  accept  the 
behests  of  the  moral  law  as  we  now  understand  them 
or  to  found  a  new  school.  To  do  this  latter,  however, 
he  must  discover  some  principle  or  principles  of  ethics 
that  have  hitherto  eluded  the  profound  thinkers  of  the 
past,  for  most  surely  the  principles  he  advances,  if 
pushed  to  their  legitimate  logical  consequences,  will 
lead  to  moral  chaos. 

Thomas  J.  Kearxev,  M.D. 

New  York,  August  6,  1895. 


and  rest-producing  doses  of  bromides  had  been  very 
numerous,  were  reduced  in  number  to  physiologic 
quantities.  I  consider  the  bromides  as  one  of  the  reme- 
dies in  some  of  the  cases  of  neurasthenia.  This  can  be 
proven  by  the  examination  of  the  blood  made  before 
and  after  the  administration  of  the  drug.  I  positively 
know,  that  the  platelets  in  these  cases  diminish  in  num- 
bers, i.e.,  that  the  e.\cessive  decay  of  the  red  blood- 
corpuscles  is  arrested. 

Respectfully, 
LuDwiG  Bremer,  M.D. 

St.  Lol'is.  Mo. 


BLOOD    CHANGES    IN    NEURASTHENIA. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  issue  of  July  27th  you  refer  disparag- 
ingly to  my  remarks,  made  several  months  ago  before 
the  St.  Louis  Medical  Society,  about  certain  blood 
changes  which  I  discovered  in  typical  cases  of  neuras- 
thenia. You  have  no  very  e.xalted  opinion  of  blood 
examinations  in  general,  and  consider  them  unreliable. 
Permit  me  to  say,  that  I  fully  concur  with  you  so  far 
as  the  distrust  of  new  discoveries  or  alleged  discover- 
ies about  the  physiology  and  anatomy  of  the  blood  is 
concerned.  There  is  no  field  in  the  medical  sciences 
that  is  less  cultivated  than  haematology.  The  supersti- 
tions which  have  from  time  immemorial  supplanted 
exact  knowledge  about  the  morphologic  constituents 
of  the  blood,  still  flourish  with  unabated  vigor.  The 
anomalous  appearances  of  the  red  blood-corpuscles  and 
their  deviation  from  the  typical  cells,  the  want  of  in- 
formation about  the  character  and  prevenience  of  the 
uncolored  corpuscular  elements  of  the  blood — all  these 
defects  of  our  knowledge,  and  many  more,  too  numer- 
ous to  mention — have  given  rise  to  a  flood  of  hypotheses 
and  fantastic  theories,  which,  by  the  majority  of  the 
medical  profession,  are  believed  as  if  they  were  proven 
facts.  Thus  the  prevailing  teachings  concerning  co- 
agulation and  thrombus-formation  are  predicated  at 
all  the  medical  schools  as  solid  facts.  In  reality  they 
are  fundamentally  erroneous,  as  I  shall  try  to  demon- 
strate in  a  future  publication.  On  this  occasion  I  shall 
also  show  what  undreamt  of  morphologic  characters  of 
the  blood-elements  may  be  brought  out  by  improved 
staining  methods.  Permit  me  to  cite  as  one  of  the  re- 
sults of  these  methods,  already  published  by  me,  the 
infallible  anilin  color- reaction  of  diabetic  blood.  By 
this  method  it  is  possible  to  pick  out  a  diabetic  with 
absolute  certainty  from  any  number  of  healthy  persons, 
or  such  as  suffer  from  diseases  other  than  diabetes  or 
glycosuria. 

An  extensive  article  entitled  "  On  the  Blood  Changes 
in  Neurasthenia,  together  with  some  remarks  on  the 
Anatomy  of  the  Blood,"  will  soon  appear  in  the  Ameri- 
can Journal  of  the  Medical  Sciences.  I  think  that  the 
illustrations  accompanying  this  article  will  throw  some 
light  on  a  hitherto  unexplored  and  dark  subject. 

Finally,  permit  me  to  state  that  I  consider  the  belief 
which,  with  most  medical  men,  amounts  almost  to  an 
axiom,  that  the  bromides  act  as  destroyers  of  the  red 
blood-corpuscles,  is  one  of  the  superstitions  previously 
referred  to.  The  deleterious  action  of  these  drugs  on 
the  blood  has  never  been  demonstrated  by  experiment. 
That  excessive  or  long-continued  dosing  with  bromides 
will  produce  cachexia  and  anaemia  (so-called)  is  a  well- 
known  fact.  But  this  is  also  true  of  other  drugs,  when 
continued  too  long  or  administered  in  excessive  doses. 
Thus,  phosphorus,  arsenic,  and  even  iron  will  have  this 
effect  if  improperly  given.  Besides,  I  have  not  said 
that  the  bromides  were  the  remedy  for  neurasthenia  ; 
in  the  course  of  my  cursory  remarks  before  the  Society 
I  only  incidentally  mentioned  the  fact  that  the  plate- 
lets, which  previously  to  the  administration  of  sleep- 


STERILIZED    MILK   AND    FREE    LUNCH. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  This  is  the  microbian  era,  in  which  most  of  our 
fleshly  ills  are  causatively  referred  to  specific  bacteria, 
and  consequently  our  faculties  are  more  than  ever  ob- 
sers'ant  of  septic  possibilities,  not  only  within  the  clini- 
cal domain,  but  also  in  the  ordinary  careless  habits  of 
humanity.  The  presence  of  two  physicians  as  public 
and  unthinking  participators  in  the  unsanitary  practices 
of  the  rabble,  is  the  inspiring  motive  for  the  succeeding 
remarks.  One  of  our  guild  held  his  position  one  swel- 
tering day,  in  a  line  of  drinkers  leading  to  a  sterilized 
milk  station,  and  the  other  doctor  regaled  himself  at 
the  free-lunch  counter  of  a  public  house. 

The  disgusting  certainties  imparted  to  this  brand  of 
milk  by  reason  of  slovenly  handling  in  the  outfits  gen- 
erously provided  by  Mr.  Strauss,  of  New  York  City, 
will  claim  the  first  word,  after  which  will  be  noted  the 
potency  for  evil  presiding  over  the  free-lunch  board, 
so  temptingly  displayed  to  the  patron  of  the  saloon. 

With  the  philanthropic  intention  of  lessening  the 
death-rate  among  the  children  of  the  poor,  due  to  the 
use  of  polluted  milk,  and  with  the  further  purpose  of 
furnishing  a  healthy  thirst  assuager  to  the  public,  Mr. 
Strauss  is  maintaining  booths  or  depots  for  the  distribu- 
tion of  sterilized  milk,  at  or  below  cost,  to  all  comers. 
While  there  is  no  denying  the  good  thereby  done  to  the 
metropolitan  infants  when  the  sterilized  article  is  con- 
veyed home  in  clean,  closed  vessels,  there  is,  on  the 
other  hand,  not  a  particle  of  extra  safety  in  the  identi- 
cal commodity  sold  by  the  glass  at  the  same  stations. 

People  of  every  condition  apply  at  these  depots, 
from  well-attired,  cleanly  folk,  down  through  every  de- 
gree of  descent  to  unwashed  vagrants,  all  enjoyably 
disposing  of  the  supposed  hygienic  beverage,  while  the 
fastidious  spectator  dubiously  observes  the  untidy 
method  of  dispensing.  As  each  customer  drinks  his  al- 
lowance, the  attendant  receives  the  emptied  drinking- 
vessel,  dips  it  into  a  tub  of  water,  agitates  it  therein  a 
few  times,  and  places  it  upon  the  shelf  to  drain,  there 
to  await  the  salute  of  after-coming  lips.  The  first  glass 
of  milk  might  be  regarded  as  sterile,  but  such  a  claim 
could  not  be  conceded  to  those  following.  Each  suc- 
ceeding glass  that  is  immersed  in  the  rinsing  fluid,  adds 
its  portion  of  milk  dregs  together  with  whatever  con- 
tamination has  been  bequeathed  by  the  hand  and  mouth 
of  the  consumer.  It  requires  but  a  momentary  consid- 
eration to  demonstrate  upon  what  a  frail  reed  of  safety 
those  thirsty  throngs  rely  as  they  eagerly  jostle  for  the 
coveted  draught,  befouled  with  vileness  from  the  un- 
brushed  teeth  of  the  negligent,  the  filthy  mustache  of 
the  rhinitic,  and  the  lip  of  the  syphilitic.  The  refined 
nature  of  a  cleanly  person  revolts  at  the  menu  of  human 
dirtiness  thus  partaken  by  an  uncritical  contingent  of 
his  fellows,  beguiled  into  a  sense  of  comfortable  security 
by  the  claim  of  sterility,  a  pretension  that  would  be 
fairly  incontestable  if  running-water  cleansing  were  pro- 
vided. 

To  those  whose  tastes  seek  gratification  in  the  saloon, 
there  is  an  equally  great  risk  resident  in  the  gratuitous 
provender  awaiting  the  attention  of  every  visitor.  The 
alluring  picture  of  snowy  table-cloth,  gleaming  glass- 


MEDICAL   RECORD, 


[August  31,  1895 


ware,  rich  china,  and  varied  viands,  which  assails  the 
senses  and  magnetically  draws  its  ever-present  group  of 
nibblers,  is,  despite  its  charming  setting,  a  veritable 
"whited  sepulchre."  Cheese  of  every  age,  tint,  odor, 
and  grade  of  viability  handled  by  every  guest  ;  pickled 
oysters  speared  with  a  fork  that  finds  its  way  into  the 
mouth  of  every  user,  or,  often  more  primitively  fished 
out  by  unspeakable  fingers  ;  dishes  of  salt  into  which 
the  pungent  radish  is  dipped  between  the  bites  that 
precede  its  final  mastication  ;  platters  of  meat  wherein 
the  slices  are  sorted  over  by  the  uncertain  hands  of  boti 
vivants  ;  salads  in  every  variety  of  conglomeration,  ap- 
propriated in  all  the  conceivable  methods  naturally  be- 
fitting the  breeding  of  the  luncher  ;  the  dangling  towel 
bearing  the  imprint  of  soiled  fingers,  and  serving  as  a 
universal  napkin  ;  and  every  other  ingredient  of  the 
publican's  bill  of  fare  receives  its  quota  of  infection 
from  the  touch  of  unkempt,  tipsy,  and  diseased  patrons. 
Culture  have  been  made  from  material  derived  from 
the  sterilized  milk  depot  and  the  free-lunch  counter, 
and  an  inspection  of  the  abounding  malignant  organ- 
isms thus  generated  would  considerably  surprise  the 
uninitiated,  as  he  recognized  the  familiar  bacteria  of 
the  graver  forms  of  disease. 

In  office,  workshop,  bedside,  public  conveyance,  and 
in  every  attitude  of  life,  all  are  exposed  in  manifold 
ways,  and  the  danger,  though  appreciated  or  not,  is  in 
the  nature  of  things  unavoidable,  unless  we  isolate  our- 
selves from  social,  business,  and  charitable  relation- 
ship with  mankind.  In  the  case  of  those  ills  which 
might  be  escaped,  the  physician  should  ever  remember 
that  "  e.xample  is  better  than  precept  "  in  the  estimation 
of  the  world,  which  is  not  slow  to  discern  a  disregard 
for  professional  proprieties. 

S.\MCEL  J.  Johnson,  M.D. 


A    SHORTER   SC.\LE    FOR   THE    THERMOM- 
ETER. 

To  THE  Editor  of  thb  Medical  Record. 

Sir  :  Much  thought  and  scheming  has  been  expended 
upon  the  method  of  arranging  thermometers  in  cases 
for  the  convenience  of  carrying  and  handling,  and  the 
avoidance  of  loss  and  breakage.  Various  changes, 
also,  have  been  made  in  the  shape  of  the  column  to 
lessen  the  difficulty  of  rapidly  reading  the  scale  ;  an 
opaque  background  has  been  put  to  a  clear  cylinder, 
and  possibly  the  most  noticeable  improvement  is  the 
magnifying  thermometer. 

But  why  is  the  thermometer  encumbered  by  so  large 
a  range  of  degrees  ?  The  thermometer  now  in  my 
possession,  purchased  recently  and  one  of  the  standard 
makes,  is  marked  from  95°  to  115°  F.  Some  of  the 
thermometers  register  only  to  110°  F.  ;  the  latter 
gives  a  range  of  15°,  and  the  former  20°  F.  Is  the 
downward  reading  to  95°  F.  ever  needed  ?  and  how 
very  rarely  has  a  physician  occasion  to  use  the  scale 
above  107°  F.  It  is  likely  that  the  majority  of  general 
practitioners  never  are  brought  to  the  trying  ordeal  of 
watching  or  combating  a  temperature  rising  above  107° 
F. 

Supposing  this  to  be  the  case,  start  the  scale  at  98° 
F.,  and  stop  at  107°  F.,  and  there  are  only  nine  degrees 
to  be  recorded  on  the  thermometer,  commencing  at 
nearly  a  degree  below  normal,  and  including  the  point 
of  high  degree,  rarely  e.\ceeded.  Such  a  scale,  then, 
would  satisfy  the  demands  of  all  ordinary  cases  of  the 
busy  practitioner  ;  would  permit  of  the  degree  spaces 
being  much  larger  than  now  made  ;  would  materially 
simplify  the  reading  of  the  temperature,  which  needs 
often  to  be  done  hurriedly,  and  in  the  sick-room,  where 
the  light  is  insufficient  for  easily  seeing  the  small  mark- 
ings ;  and  would  especially  allow  of  the  divisions  of 
the  degrees  to  be  made  more  distinct  and  thereby 
facilitate  the  correct  reading  of  the  fractional  parts  of 


the  degrees,  and  afford  the  opportunity  of  a  far  more 
accurate  record  of  the  variations  of  the  temperature. 

Further,  if  the  scale  included  only  9°  F.,  and  the 
degree  spaces  were  of  the  same  size  as  now  ordinarily 
made,  it  would  permit  of  a  shorter  thermometer  that 
might  be  desirable  to  many.  It  might  be  short  enough 
to  be  worn  as  a  charm  on  a  watch  chain,  or  carried  in 
the  vest  pocket  as  a  penknife. 

The  thermometer,  with  the  degrees  thus  limited  and 
enlarged,  would  serve  the  doctor  or  the  nurse  in  almost 
all  cases,  and  with  an  easier  reading.  If  deemed  neces- 
sary, a  thermometer  indicating  from  95°  to  110°  F., 
could  be  kept  for  the  rare  cases  requiring  such  a  range. 

A  leading  manufacturer  informs  me  that  such  a 
thermometer,  with  the  degree  spaces  of  any  size  de- 
sired, can  be  made  with  accuracy,  and  be  much  more 
easily  read,  as  well  as  give  more  definiteness  to  the 
fractional  parts  of  the  degrees. 

Elm.-^r  C.  F.\hrnev,  M.D. 

Harrisburg,  Pa. 


THE    CAUSE    OF    FLATULENCE. 

To  THE  Kditor  of  the  Medical  Record. 

Sir  :  In  the  Medical  Record  of  August  loth,  con- 
siderable editorial  space  is  devoted  to  an  article  on 
Flatulence,  by  Dr.  Stephen  McKenzie.  It  is  stated 
that  the  gist  of  Dr.  McKenzie's  paper,  as  regards  the 
etiology  of  flatulence,  is,  that  "  the  walls  of  the  stomach 
being  weak  and  flabby  and  lacking  in  tone,  suddenly 
dilate,  and  the  volume  of  gas,  which  was  before  some- 
what compressed,  expands  and  fills  out  the  enlarged 
viscus.  Dr.  McKenzie  states  that  the  gas  does  not  in- 
crease in  quantity  in  the  stomach,  but  only  in  volume." 

The  above  statement  seems  to  be  incompatible  with 
certain  well-known  physical  laws,  as  well  as  with  known 
vital  principles  : 

First,  his  theory  supposes  a  certain  considerable 
amount  of  gas  constantly  present  in  the  stomach  ; 
granting  this,  what  must  be  the  condition  of  this  gas  as 
regards  its  elastic  tension  ?  Either  the  gas  must  be  com- 
pressed during  all  the  period  of  time  when  flatulence  is 
absent,  and  this  compression  must  be  maintained  by  a 
tonic  contraction  of  the  stomach  walls,  or  else  the  gas 
must  be  subject  to  the  normal  or  existing  atmospheric 
pressure,  in  which  latter  event  relaxation  of  the  muscu- 
lar walls  could  not  affect  its  volume.  To  make  our 
meaning  plain,  suppose  a  rubber  bag  of  a  capacity  of 
one  gallon,  have  two  quarts  of  gas  put  into  it  and  then 
be  closed  ;  the  bag  would  be  perfectly  relaxed,  and  yet 
the  volume  of  gas  would  remain  two  quarts  unless  the 
temperature  were  changed  or  the  outside  pressure  al- 
tered. If  the  bag  were  placed  under  the  receiver  of 
an  air-pump  and  the  air  exhausted,  then  the  elastic 
tension  of  the  enclosed  gas  would  come  into  jilay 
and  the  bag  might  be  filled  or  distended.  Now,  what 
must  be  the  conditions  surrounding  the  stomach  ? 
must  not  its  walls  be  constantly  subject  to  the  sur- 
rounding atmospheric  pressure  from  without  ?  Sup- 
pose there  be  a  change  in  the  contents  of  the  abdom- 
inal cavity,  would  not  this  be  instantly  compensated 
for  by  the  atmospheric  pressure  from  without  ?  Can 
we  conceive  of  a  partial  vacuum  in  the  cavity  when  it 
is  enclosed  by  soft  patts  in  contact  with  the  air?  or  can 
we  conceive  of  a  gaseous  distention  of  the  stomach, 
except  the  gas  be  generated  within  and  finding  no  es- 
cape, distends  the  organ,  and  with  it  also  the  abdom- 
inal walls  ? 

Under  the  assumption  of  Dr.  McKenzie,  the  volume 
of  gas  constantly  in  the  stomach  must,  as  we  has-e 
shown,  be  materially  compressed,  otherwise  it  could 
not  expand.  This  compression  must  be  maintained  by 
the  active  contraction  of  the  stomach  walls.  Is  it  con- 
ceivable that  a  we.ik  and  flabby  stomach  could  resist  any 
material  pressure  for  hours  at  a  time  ?  is  not  such  an 
assumption  at  variance  with  all  known  laws  of  rauscu- 


August  31,  1895] 


MEDICAL    RECORD. 


lar  contractility,  and  must  not  Dr.  McKenzie  seek  for 
some  other  explanation  than  an  expansion  of  volume  "' 
Would  it  not  be  more  rational  to  assume  that  a  weak 
and  dilated  stomach,  being  unable  to  completely  expel 
its  contents,  has  constantly  m  it  a  residuum  of  fermenta- 
tive material,  twenty  four  to  forty- eight  hours  old  if 
need  be,  and  which,  under  favorable  conditions,  sud- 
denly splits  up,  evolving  rapidly  large  amounts  of  gas  ? 
Louis  H.  Jones,  M.D., 
Professor  of  Chemistry,  Atlanta  Medical  College. 


%zvi  Instruments. 

AN    EASY    AXD    READY    METHOD    OF   CIR- 
CUMCISION. 

By  JOHN  W.    ROSS,  Surgeon,  U.  S.  Navy  (Retired,, 


f  OBSTETRICS 


SERV,  SEWANEE  MEDICAL  COLLHGE 


Retract  the  foreskin  ;  insert  the  glans  penis  up  to  the 
corona  into  the  open  mouth  of  a  glass  tube ;  draw  the 
foreskin  well  forward  over  the  end  of  the  tube  ;  tie  a 
strong,  small  silk  cord  very  tightly  around  the  foreskin 
immediately  in  front  of  the 
flange  of  the  tube  ;  amputate 
the  foreskin  one-eighth  of 
an  inch  in  front  of  the  con- 
stricting cord  by  a  circular 
sweep    of    the    knife ;    unite 


<  II 


dressing  ;  and  keep  the   patient  in  bed,  with  the  penis 
elevated,  for  from  twenty-four  to  forty-eight  hours. 

In  cases  of  phimosis  the  prepuce  should  be  divided 
dorsally  sufficiently  to  allow  its  easy  retraction  over  the 
corona.  The  fact  that  the  longitudinal  cut  edges  will 
not  coapt  along  the  tube  is  of  little  or  no  importance. 
The  slit  foreskin  should  be  spread  around  the  tube  as 
accurately  as  practicable,  and  the  operation  proceeded 
with  as  usual.  If  deemed  advisable,  the  little  notch  in 
the  prepuce  just  above  the  cord  may  be  closed  with  a 
suture  or  two,  involving  only  the  integument. 

I  have  generally  used  test-tubes,  as  they  are  almost 
invariably  at  hand,  of  sizes  suitable  for  infants  or 
adults.  But  pretty  much  anything  of  the  kind  will  do, 
such  asurinometer-tubes,  slender,  large  mouthed  bottles 
(neckless  ones  preferably),  which  are  to  be  found  in  all 
drug-stores.  For  adults,  the  tube  should  be  strong 
enough  not  to  be  easily  crushed,  and  its  mouth  should 
be  surmounted  by  a  rather  abrupt  rim,  free  from  cut- 
ting edges.  Should  the  flange  not  be  high  enough,  or 
rounded  enough,  it  may  easily  be  made  so  by  winding 
a  strong  wax  thread  tightly  around  and  around,  behind 
and  against  it.  I  have  made  an  excellent  apparatus  by 
thus  wrapping  with  a  thread  the  open  end  of  a  flange- 
less  urinometer-tube  until  a  suitable  ridge  was  built  up. 
The  lumen  should  correspond  with  the  diameter  of  the 
glans  about  one-eighth  of  an  inch  anterior  to  the  corona. 
It  has  been  found  better  not  to  remove  more  of  the 
foreskin  than  can  be  with  moderate  force  drawn  in 
front  of  the  flange  at  that  point. 

The  constricting  cord  should  be  about  the  size  of 
the  ordinary  silver  probe  of  the  pocket  cases.  In 
adults  it  should  be  drawn  very  tightly  indeed  around 
the  prepuce,  compressing  this  strongly  against  the  tube. 
I  draw  it  almost  as  tightly  as  I  can  with  the  fingers, 
and  have  never  known  it  to  do  the  slightest  harm  to 
the  tissues.  \Vhen  this  has  been  done,  I  have  never 
known  the  skin  to  slip  from  under  the  cord,  and  have 
never  been  troubled  with  hemorrhage,  either  during  or 
after  the  operation. 

It  is  generally  better  to  give  ether  to  children,  and 
to  inject  cocaine  in  front  of  the  constricting  cord  in 
adults.  The  advantages  of  this  method  are  its  blood- 
lessness,  its  simplicity  of  technique,  and  the  fact  that 
no  special  instrument  or  apparatus  is  required,  every- 
thing necessary  for  its  performance  upon  the  largest  or 
smallest  penis  being  found  in  the  physician's  house  or 
in  the  average  drug-store. 

The    above- described    method     of   circumcision    is 

virtually  the  same   in  principle  as  that  detailed  by  me 

in   the   Medical   Record   of  September  26,    1885,  a 

ring  of  hard  rubber  being  used  in  that 

operation  instead  of  the  tube.    It  proved 

'^'^  difficult  to    keep    the    ring   in    position 

.  under    the  foreskin.       The  tube,  how- 

SittcO  ever,  projecting  as  it  does  beyond  the 

foreskin,  is  under  complete  control. 

The    earlier    operation  and    "  Ross's     Circumcision 

Ring  "  are  described  and  figured  in  the  second  edition 

of  Stephen  Smith's  "  Operative  Surgery,"  page  712. 


Fic.  I. — Showing  a  Largish, 
SlrongTest-tulie  with  which  sev- 
eral acult  circumcisions  have 
been  done. 


FiG.  2. — Showing  Semi-diatrram- 
matically  the  Tube  in  iitu  bciwct-n 
the  Superjacent  Prepuce  and  the 
Subjacent  Glans  Penis,  and  dcn.im- 
strating  the  mor 
ures  of  the  Operation. 


the  mucous  and  cutaneous  edges  of  the  stump  of  the 
prepuce  by  eight  or  ten  fine  interrupted  sutures  ;  cut 
the  constricting  cord  ;  remove  the  tube  ;  cover  the  cut 
edges  well  with  powdered  iodoform  ;  encircle  the  an- 
terior half  of  the  penis  with  a  roller  bandage  of  iodo- 
form gauze,  allowing  the  meatus  to  project  slightly  for 
facility  of  urination  without  soiling  or  removal  of  the 


<!]. 


Intestiual  Anastomosis. — There  are  three  chief  points 
to  be  considered  in  effecting  an  astomosis,  or  in  sutur- 
ing a  wound  of  intestine  :  i.  That  adequately  broad 
and  sufficiently  wide  surfaces  of  healthy  intestine 
should  be  in  contact.  2.  That  though  it  is  advisable 
to  exclude  the  mucous  membrane  from  the  stitches, 
the  fibres  of  the  submucous  coat  must  always  be  in- 
cluded. 3.  That  the  operation  should  be  performed 
as  rapidly  as  possible. — Bidwell. 

Erysipelas. — 

B.      Ammon.  sulpho-ichlhyol, 

Spt.  Klher aa  I  part 

Collodi.  elastic! 2  parts. 

M. 

— Zelewskv. 


324 


MEDICAL    RECORD. 


[August  31,  1895 


ptedijcal  gtems. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  August  24,  1895. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 


Duplex  Personality. — Dr.  R.  Osgood  Mason,  in  a  re- 
cent paper  on  "  Duplex  Personality.  Its  Relations  to 
Hypnotism  and  also  to  Lucidity,"  makes  the  following 
points  :  First,  that  there  are  now  on  record  many  well- 
authenticated  cases  where,  from  a  condition  of  syncope 
brought  about  by  pain,  weakness,  or  long-continued  ill- 
ness, from  epileptiform  attacks,  loss  of  consciousness 
from  shock  or  other  physical  causes,  patients  have 
emerged  into  an  entirely  new  and  unusual  condition. 
In  this  new  condition  the  individual  thinks,  speaks, 
and  acts  in  a  manner  entirely  different  from  the  usual 
or  primary  personality.  Even  physical  conditions  are 
changed.  In  one  case,  from  a  condition  of  wretched 
bodily  health  accompanied  by  epileptiform  attacks,  in- 
dolence, and  melancholia,  the  patient  emerged  into  a 
state  of  excellent  health  accompanied  by  industry  and 
cheerfulness,  and  without  a  trace  of  epilepsy,  hysteria, 
or  melancholia  ;  in  fact  it  was  an  entirely  new  and  dif- 
ferent con.sciousness  and  personality.  During  this  sec- 
ond condition  the  primary  consciousness  is  entirely 
blotted  out,  and  the  time  so  occupied  is  a  blank.  The 
■second  consciousness  or  personality,  on  the  other  hand, 
knows  of  the  primary  self,  but  only  as  another  and  dis- 
tinct person,  having  no  special  relations  to  itself,  and 
with  whom  it  does  not  wish  to  be  confounded.  It  has 
■opinions,  sentiments,  memories,  a  personal  history,  in 
•fact  a  character  altogether  independent  and  often  en- 
tirely different  from  .the  primary  self,  but  sane,  consist- 
ent^ with  itself,  and  in  harmony  with  its  surroundings. 
This  second  personality  may  continue  for  a  few  min- 
utes or  hours,  and  may  alternate  frequently  with  the 
primary  self,  or  it  may  remain  months  and  even  years 
at  a  time,  and  so  become  the  dominant  personality,  al- 
ternating only  seldom  with  the  primary  self.  In  either 
case  all  the  occasions  when  this  second  self  is  [)resent 
are  linked  together  in  one  distinct  chain  of  memories, 
forming  a  personality  just  as  consciously  distinct  as  the 
primary  self.  On  close  examination  and  comparison  it 
is  found  that  this  second  personality  presents  very 
marked  analogies  to  the  condition  of  somnambulism  in 
ordinary  sleep.  Again,  it  is  found  to  be  identical  with 
the  condition  of  somnambulism  which  occurs  in  the 
hypnotic  state,  and  in  some  instances,  as  that  of  Ansel 
Bourn,  the  second  personality  has  repeatedly  been 
brought  into  activity  by  hyjmotism. 

Here,  then,  are  three  distinct  conditions  in  which  a 
second  consciousness  or  personality  is  brought  to  the 
surface  and  becomes  the  ruling  personality  to  the  ex- 
clusion of  the  primary  self,  namely,  loss  of  conscious- 
ness from  disease,  shock,  or  other  physical  causes,  or- 
dinary sleep,  and  the  hypnotic  trance.  Examining 
closely  the  i)ersonalities  apparent  in  these  conditions, 
and  especially  in  the  condition  of  ordinary  somnambu- 
lism and  that  of  the  hypnotic  trance,  we  find  certain 
supra-normal  faculties  present  in  these  new  or  second 
personalities  not  present  in  the  normal  or  primary  per- 
sonality, especially  the  faculty  of  supra-normal  vision. 
This  alleged  fact  is  not  generally  accepted,  because 
from  the  stand-point  of  the  ordinary  laws  of  optics  act- 


ing upon  physical  organs,  such  vision  is  of  course  im- 
possible. But  ft'ithin  the  past  ten  years  the  subject  has 
been  systematically  studied  as  never  before,  and  the 
evidence  of  such  vision  is  simply  overwhelming.  But 
it  is  the  subliminal  self,  and  not  the  primary  self,  which 
possesses  this  power.  This  supra-normal  vision  is  also 
sometimes  exercised  in  dreams  and  in  reverie. 

The  following  conclusions  are  drawn  :  i.  That  there 
does  exist  in  some  persons,  probably  in  all,  a  subliminal 
self  or  second  personality,  whose  action  is  not  strictly 
limited  by  the  physical  body,  and  which  possesses  per- 
ceptive powers  far  exceeding  those  of  the  primary  self. 
2.  That  lucidity  or  clairvoyance  is  an  attribute  of  the 
subliminal  self,  and  in  that  view  is  perfectly  reasonable 
and  is  a  proper  subject  of  investigation  by  scientific 
methods.  3.  That  hypnotism  is  a  means  of  experi- 
mentally bringing  this  subliminal  self  with  its  added 
perceptive  powers  into  action. 

Intestinal  Resection. — The  cicatrix  does  not  contract. 
In  intestinal  obstruction,  resection  with  end-to-end 
union  gives  better  results  than  lateral  approximation, 
and  should  always  be  performed  when  practicable. 
The  same  operation  should  always  be  done  in  gangre- 
nous hernia.  In  fecal  fistula  the  bowel  should  be  re- 
sected and  united  end  to  end.  Patients  should  receive 
liquid  nourishment  as  soon  as  the  effect  of  the  anaes- 
thetic passes  off.  The  bowels  should  be  made  to  move 
as  soon  as  possible  after  the  operation,  and  frequent 
evacuations  kept  up.  If  the  button  does  not  pass  in 
three  or  four  weeks,  the  rectum  should  be  examined, 
as  it  may  rest  just  inside  the  sphincter.  There  has 
been  one  case  reported  of  occlusion  of  the  button  by 
fecal  impaction  in  the  cylinder.  This  can  be  easily 
avoided  by  cathartics  immediately  after  the  operation. 
When  returning  to  the  abdomen,  the  intestines  should 
be  placed  in  parallel  lines,  especially  at  the  seat  of 
approximation,  to  prevent  sharp  curves  and  obstruc- 
tions. There  is  no  danger  of  obstruction  from  the 
button,  as  not  a  single  case  has  been  reported.  There 
is  no  danger  of  extension  of  pressure  atrophy  beyond 
the  line  of  pressure.  Primary  adhesions  may  be 
hastened  in  malignant  cases  by  abrading  the  peri- 
toneum with  a  needle.  In  ordinary  cases  this  is  un- 
necessary. A  supporting  suture  is  never  necessary  to 
secure  union,  and  should  only  be  used  to  relieve 
tension  when  the  viscera  approximated  are  forced  out 
of  position.  The  mucous  membrane  should  be  pushed 
down  in  the  cup  of  the  button  before  closing  it ;  if 
redundant,  it  should  be  trimmed  off  with  scissors.  It 
should  never  be  allowed  to  protrude  between  the  edges 
of  the  button  when  the  button  is  closed. — Murphy. 

Lacerated  Cervix.— i.  That  suturing  the  lacerated 
cervix  properly,  immediately  after  the  labor,  will  result 
in  primary  union  of  the  same  and  prevent  many  of  the 
evils  that  follow  in  the  wake  of  a  union  by  second  in- 
tention. 2.  That  the  fear  of  septicremia  attending  the 
manipulation  of  the  cervix,  and  the  introduction  of 
poisons,  which  will  induce  septicjemia  at  the  same 
time,  is  an  unfounded  one,  and  would  be  dissipated  by 
giving  such  work  a  proper  test.  3.  That  it  is  a  method 
of  procedure  more  justifiable  than  an  immediate  repair 
of  the  perineum,  which  the  profession  of  to-day  uni- 
versally advocates.  4.  That  the  securing  of  primary 
restoration  of  the  laceration  hastens  involution,  pre- 
vents subinvolution,  and  the  various  forms  of  displace- 
ment which  are  induced  by  it  in  such  an  overweighted 
organ.  5.  That  catgut  is  the  proper  suture,  and  per- 
fectly safe  and  reliable  when  carefully  prepared. — 
Dudley. 

Hypertrophied  Tonsil.— The  action  of  the  tensor  and 
levator  palati  muscles,  which  largely  control  the  air  sup- 
ply of  the  middle  ear,  is  interfered  with  by  the  pressure 
of  hypertrophied  tonsils,  thus  causing  impairment  of 
hearing. 


Medical   Record 

A  Weekly  jfournal  of  Medicine  and  Surgery 


Vol.  48,  No.  10. 
Whole  No.  1296. 


New  York,  September  7,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


PRACTICAL    URETHROSCOPY. 
By  H.   R.   WOSSIDLO,  M.D., 

BERLIN,   GERMANY. 

The  diagnosis  of  urethral  diseases,  strangely  enough, 
still  maintains  a  peculiar  and  distinct  position  in  medi- 
cal science.  While  in  all  the  other  specialties  inspec- 
tion of  the  organs  is  carried  as  far  as  possible,  there 
are  even  now  genito-urinary  specialists  who  consider 
urethroscopy  unnecessarj'.  Those  who  do  not  confess 
it  openly  prove  it  by  not  using  the  urethroscope. 

Would  it  not  be  most  grave  dereliction  to  neglect  the 
laryngoscope  in  a  throat  affection,  or  to  attempt  to 
treat  an  aural  disease  without  the  otoscope  ? 

It  is  an  equally  self-evident  proposition  that  we  can- 
not diagnose  urethral  affections  without  ocular  explo- 
ration. Naturally  this  is  inhibited  in  acute  urethritis, 
for  the  irritation  which  the  endoscope  would  then  pro- 
duce would  violate  one  of  the  most  fundamental  surgi- 
cal principles. 

The  diagnosis  of  chronic  gonorrhoea  is  generally 
based  upon  the  following  symptoms  :  Occasional  or 
constant  appearance  of  a  small  quantity  of  muco- 
purulent or  mucous  discharge,  especially  in  the  morn- 
ing ;  filaments  in  the  urine,  and  principally  on  the  pres- 
ence of  gonococci  in  the  secretion  or  in  the  filaments. 

Microscopical  e.xamination  of  the  discharge  for 
gonococci,  leucocytes,  etc.,  is,  beyond  cavil,  an  effec- 
tive means  of  diagnosis,  and  is  requisite  in  every  case  of 
chronic  gonorrhoea.  The  discovery  of  gonococci  in 
the  discharge  or  in  the  filaments  is  conclusive  for  the 
existence  of  gonorrhoea  and  for  its  infectious  nature. 
But  it  is  generally  acknowledged  that  the  presence  of 
gonococci  in  the  secretion  is  not  constant.  The  fila- 
ments or  the  discharge  may  be  examined  for  weeks  or 
months  without  finding  gonococci.  If  the  patient  be 
then  dismissed  as  cured,  a  most  painful  surprise  may 
follow  by  a  gynecologist  finding  gonorrhoeal  infection 
of  the  patient's  wife,  who  had  been  in  perfect  health 
until  her  husband  was  permitted  to  resume  sexual  re- 
lations with  her. 

The  appearance  of  filaments  in  the  urine  warrants 
the  conclusion  that  desquamation  and  inflammatory 
exudation  is  still  taking  place  ;  but  their  presence 
does  not  prove  that  the  discharge  is  still  infectious. 
Neisser,  of  Breslau,  to  confirm  the  diagnosis,  recom- 
mended artificial  irritation  of  the  urethra  by  injecting 
a  solution  of  nitrate  of  silver.  Very  often  gonococci 
wiU  again  be  found  in  the  muco-purulent  secretion  re- 
awakened by  these  injections.  But  in  many  instances 
no  gonococci  will  be  found,  despite  frequently  repeated 
irritating  injections.  And  even  then  the  patient  may 
not  be  cured. 

Men  oftentirpes  wiU  consult  physicians  on  the  propri- 
ety of  marriage.  Such  a  case  may  have  had  gonorrhoea 
some  years  before,  and  wishes  to  know  if  he  may  con- 
sider himself  perfectly  cured.  On  examination  neither 
secretion  nor  filaments  nor  gonococci  may  be  found, 
and  still  the  man  may  not  be  cured,  as  is  shown  by  a 
case  narrated  by  Oberlaender,  of  Dresden.' 

'  Ueber  die  praktische  Bedeutung  des  Gonococcus,  von  Dr.  F.  M. 
Oberlaender.     Berliner  Klinik,  1888,  Heft  5. 


A  physician,  who  had  his  last  attack  of  gonorrhoea  six 
years  previously,  called  on  Oberlaender  on  account  of 
a  bladder  weakness.  He  had  recovered  quickly  and 
apparently  entirely  from  his  previous  gonorrhoea.  He 
had  had  no  discharge  or  any  other  symptoms  for  five 
3-ears.  About  four  years  before  he  had  an  attack  of 
rheumatism,  followed  by  almost  annual  recurrences. 
He. was  married  about  three  years  ago.  His  wife 
aborted  in  the  fifth  month  of  pregnancy  ;  this  was  fol- 
lowed by  gonorrhoeal  endometritis.  Then  the  patient 
began  to  experience  vesical  weakness.  The  urethro- 
scope revealed  indisputable  chronic  urethritis.  Ap- 
propriate treatment  caused  the  urethritis  to  subside  ; 
the  rheumatic  attacks  ceased  and  the  bladder  symp- 
toms disappeared. 

I  may  add  here  a  case  of  my  own.  One  of  my  pa- 
tients consulted  me  not  long  ago  regarding  a  peculiar 
twisting  of  the  urinal  stream,  which  he  attributed  to  a 
possible  stricture.  Nine  years  before  he  had  gonor- 
rhoea, of  which  he  considered  himself  perfectly  cured, 
as  he  never  had  any  symptoms  thereof  since.  At  the 
time  of  the  consultation  the  possibility  of  a  fresh  infec- 
tion was  out  of  question. 

Superficial  examination  showed  no  discharge,  few 
filaments  only,  no  gonococci ;  a  large-sized  sound 
passed  the  urethra  easily.  The  urethroscope  showed 
some  infiltration  of  the  urethra  and  several  diseased 
glands.  I  succeeded  in  removing  a  little  secretion  from 
one  of  these  glands.  To  our  great  surprise  it  revealed 
gonococci. 

Such  cases  will  occasionally  occur.  In  view  of  such 
facts  alone,  even  entirely  by  themselves,  ay,  without 
resorting  to  analogies  of  any  kind,  must  a  specialist, 
and  especially  the  urologist,  not  be  required  to  employ 
all  available  diagnostic  means  ?  What  would  be  thought 
of  a  physician  if  he  limited  his  examination  of  a  case 
of  tuberculosis  to  what  bacteriology  of  the  sputum  re- 
vealed, without  inquiring  into  the  pathological  changes 
of  the  lungs  by  percussion  and  auscultation  ? 

If  we  further  remember  the  fearful  havoc  gonorrhoea 
exerts  in  women  as  well  as  in  men,  can  it  be  permis- 
sible to  neglect  even  one  means  of  confirming  the  diag- 
nosis ?  These  points  alone  demonstrate  beyond  all  and 
any  peradventure  that  urethroscopy  is  necessary  for 
the  diagnosis  of  chronic  gonorrhoea.  It  is  most  sadly 
surprising  that  this  proposition  is  not  universally  ac- 
cepted, at  least  not  in  deed. 

The  disregard  for  urethroscopy  may  be  due  to  de- 
fective methods  for  illuminating  the  urethral  canal 
which  have  been  used  until  now.  A  brief  historical 
sketch  will  illustrate  this  : 

The  first  attempt  to  inspect  the  urethral  canal  was 
made  by  Bozzini,  of  Frankfort,  at  the  beginning  of  this 
century.  He  constructed  an  apparatus  for  examina- 
tion of  the  "  canals  and  cavities  of  the  human  body,"  a 
part  of  which  was  designed  for  urethral  inspection. 
His  invention  fell  into  oblivion,  and  nothing  further  is 
recorded  of  attempts  at  urethroscopy  until  Segalas,  in 
1826,  constructed  a  new  instrument,  which  he  called 
"speculum  urethro-cystique."  About  the  same  time  a 
similar  apparatus  was  invented  by  an  American,  John 
Fisher,  and,  1840,  by  an  Endish  physician,  Avery. 
Ratier  (1843)  ^^^  Cazenave  (1848)  constructed  dia- 
phanoscopic  instruments. 

None  of  these  instruments,  however,  came  into  gen- 
eral use,  and  even  were  soon  forgotten.     It  was  left  to 


326 


MEDICAL    RECORD. 


[September   7,  1895 


Desormeaux  to  raise  endoscopy  to  a  scientific  basis,  so 
that  he  may  justly  be  called  the  father  of  endoscopy. 
In  1853  he  demonstrated  his  instrument  at  the  Acade- 
mic de  Medecine  de  Paris  ;  in  1865  he  jjublished  his 
work  "  De  I'Endoscope  et  ses  applications  au  diagnos- 
tic et  au  traitement  des  affections  de  I'urethre  et  de  la 
vessie."  Desormeaux's  instrument  was  modified  by 
Fiirstenheim,  Tarnowsky,  and  others.  All  these  en- 
doscopes proved  too  complicated  and  cumbersome, 
the  urethral  tube  and  the  lamp  being  affixed  in  one 
piece.  The  necessity  was  felt  to  separate  the  light 
from  the  tube  and  to  throw  the  light  iiito  the  urethral 
canal  by  means  of  a  reflector. 

Griinfeld.of  Vienna,  was  the  first  to  make  endoscopy 
popular  with  the  medical  profession.  His  book  on  en- 
doscopy of  the  urethra  and  bladder  is  the  first  standard 
work  published  on  this  subject.  He  first  used  a  petro- 
leum lamp  as  the  source  of  his  light,  which  he  threw 
into  the  urethra  with  the  usual  laryngoscopical  reflec- 
tor. He  devised  several  endoscopic  tubes,  of  various 
lengths,  some  of  them  open,  others  fenestrated  in  front 
or  at  the  end. 

Grunfeld's  simple  instrument  underwent  several  mo- 


chronischen  Trippers,"  and  in  1893  his  "  Lehrbuch  der 
Urethroskopie,"  which  is  a  standard  work  on  this  sub- 
ject. 

At  present  the  value  of  the  two  methods  is  the  sub- 
ject of  a  controversy  which  has  been  made  needlessly 
acrimonious,  based  perhaps  principally  upon  the  value 
of  each  instrument  in  its  inventor's  hands.  But  the 
conviction  must  remain  that  from  discussion,  however 
conducted,  truth  must  eventually  prevail.  This  is 
neither  the  time  nor  the  place  to  enter  into  the  merits 
of  the  dispute.  A  few  simple  facts,  however,  will  be 
mentioned  in  connection  with  the  instrument  I  use 
and  intend  to  describe  in  these  pages.  It  is  the 
Nitze-Oberlaender  urethroscope. 

The  endoscopic  tubes  are  made  of  silver,  which  pro- 
duces the  least  disturbing  reflexes,  is  most  durable  and 
useful.  The  tubes  we  use  have  a  calibre  of  23,  25,  27, 
29,  31  Fil.  Charriere.  Oberlaender,  and  Kollmann,  of 
Leipzig,  have  shown  the  advisability  of  employing  large- 
sized  urethral  tubes.  Their  use  quickly  convinces  one 
that  they  rest  quite  loosely  in  the  urethra. 

The  only  difficulty  in  introducing  large  tubes  may 
be  experienced  at  the  external  orifice  or  at  the  valve  of 


Fic.  I.— The  Original  Xitze  Urctliroscopc. 


!.— The  XiLze  Leiter  Urethroscope. 


Fig.  3. — Oberlaender's  Modilicatio: 


difications,  of  which  that  of  Klotz,  of  New  York,  mer- 
its special  mention. 

The  introduction  of  electric  light  for  diagnostic  pur- 
poses into  medical  practice  gave  birth  to  a  number  of 
new  inventions.  At  present  most  specialists  use  the 
electric  light  for  examining  the  urethra. 

We  may  divide  the  various  endoscopes  now  in  use 
into  two  classes  :  i,  Those  which  throw  electric  light 
into  the  urethra  by  means  of  reflectors  or  prisms  ;  and 
2,  those  which  directly  illuminate  the  urethra  by  di- 
rectly putting  the  light  into  it.  Of  the  former,  Leiter's, 
Lang's,  Otis's,  Casper's,  and  Antal's  urethroscopes  are 
the  best  known.  These  electro-endoscopes  consist  of 
a  short  tube  to  whose  ocular  end  the  illuminating  ap- 
paratus is  attached.  The  latter  is  a  mignon-lamp, 
whose  light  is  reflected  by  a  mirror  or  prism  into  the 
urethral  canal. 

Direct  illumination  of  the  urethra  was  invented  by 
Nitze,  in  1877.  It  was  left  to  Oberlaender,  of  Dresden, 
aided  by  this  urethroscope,  to  teach  the  differentiation 
of  anatomical  changes  in  chronic  gonorrhoea,  and  to 
make  a  new  departure  in  its  treatment. 

Besides  several  articles,  he  published  in  1S88  his 
book,   "  Beitr-ige   zur   Pathologic   und    Therapie    des 


Gu^rin,  which,  when  present,  is  situated  at  the  end  of 
the  fossa  navicularis.  In  the  cavernous  portion  and  at 
the  bulb  the  urethral  canal  is  naturally  wide,  and  can 
in  relatively  many  cases  easily  be  passed  by  tubes  of 
calibre  31  Charriere.  The  lining  membrane  of  the 
urethra  being  longitudinally  folded,  it  is  desirable  that 
these  folds  be  smoothed  out  during  examination.    And 


Fig.  4. — ^Thc  Nitze-Obcrlaondcr  Urethroscope,  modified  by  C.  G.  Hej-ncmann. 

this  requires  large-sized  tubes.  The  extra-urethral  rim 
of  the  tube  has  a  spur  to  which  the  light-carrier  can  be 
affixed. 

The  light-carrier  consists  of  two  wires  which  conduct  j 
the  electric  current  to  platinum  wire,  the  one  being  in- 
sulated, the  other  not.  They  rest  upon  a  tunnelled  bar, 
through  which  cold  water  circulates.     The  slender  and 


September  7,  1895] 


MEDICAL    RECORD. 


127 


delicate  handle  has  two  screws  for  con- 
necting the  wires  of  the  light-carrier  with 
the  conducting  wires  of  the  galvanic  bat- 
tery.      The    tunnel    for   the   circulating 
water   is    connected    by  an    india-rubber 
tube  with  an  irrigator,  which,  filled  with 
cold   water,   is  fixed  at  about   three  feet 
above  the  apparatus,  either  to  the  wall  of 
the  room  or  by  an  iron  bar  rising  from 
the  apparatus.       From  this  irrigator   the 
water  runs  through  the  rubber  tube  into 
the  tunnel  underneath  the  platinum  wire  : 
another  tube  conducts  the  water  from  the 
light-carrier  to  a  hard-rubber  or  tin  box 
into  which  it  finally  drips.     On  closing  the 
galvanic   current  the   platinum  wire   be- 
comes   incandescent, 
producing   a   strong 
electric    light.     The 
heat   of    this    glowing 
wire  is  cooled  by  the 
cold  water  circulating 
in  the  tunnels  beneath 
it.    The  light-producer 
may  either  be  an  ac- 
cumulator or  a   chro- 
mic -  acid   battery.      A 
rheostat   enables  us  to 
control  the  strength  of 
the  current. 

Under   the    super- 
vision   of    Dr.    Koll- 
mann,    of    Leipzig, 
Heynemann    modified 
Nitze's    original    ure- 
throscope, as  shown  by 
Figs-  I,  2,  3,  4,  5,  6,  7. 
These  alterations  have 
_^  made  the  urethroscope 
■*'  more    easily    manage- 
^  able  and  allow  an  easier 
employment   of    other 
instruments  through  it, 
such  as  probes, urethro- 
tomes, etc. 
For  the  easy  introduction  of  the  urethral  tube  it  is 
armed  with  an  obturator.     The  obturators  for  the  an- 


terior  urethra  are   straight,   those   for    the    posterior 
urethra  have   a  joint   by  which   they  can   be   made 


Fig.  5.  —  Oberlaendcr^s  Electro  -  urcthro 
scopic  Apparatus.  Chromic  Acid  Batterj- 
Cooling  Device,  and  Urethroscope. 


Fig.  7. — Combination  Apparatus  for  Urethroscopy,  Cystoscopy.  Constant  Cur- 
rent, and  Electrolysis,  constructed  by  C.  G.  Heynemann.  Leipzig.  One  of 
»k=o-  ;.-  ;„  —  ;_  ^^^  Genito-urinary  Department,  West  Side  German  Dis- 


these 
pensar}',  Ne 


York. 


to  assume  the  shape  of  the  Mercier  catheter  (Figs. 
8  and  9). 


tiG.  8. — Urethral  Tube  and  Obturator. 


Oberlaender  also  designed  a  dilating  tube  with  two 
blades  (Fig.   10).      For  the   purpose   of  probing   the 


Fig.  9. — Jointed  Obturator  for  Posterior  Ureliiroscopy. 

urethral  glands  an  endoscopic  sound  is  used  (Fig.  11). 
Another  instrument  is  a  capillary  aspirator  for  remov- 


FlG.  6. — Electro-urethroscopic  Apparatus  with  Accumulator. 


MEDICAL    RECORD. 


[September  7,  1895 


ing  such  thin  liquid  as  may  be  found  in  the  urethral 
canal  (Fig.  12).  For  the  purpose  of  removing  mucus 
or  pus  from  the  glands  a  spatula  has  been  constructed 

(Fig-  13)- 

Of  the  instruments  used  for  endoscopic  treatment 


which  are  inserted  into  the  light-carrier,  be  not  loose, 
but  rest  firmly  in  their  sockets.  Should  carelessness 
allow  such  a  condition  to  prevail,  the  light  will  flicker 
and  go  out.  The  same  disturbance  can  be  produced 
by  any  defect  in  the  battery  or  the  conducting  wires. 


Fig.  II.— KoUn 


i  Endoscopic  Sound. 


I  shall  mention  :  a.  The  endoscopic  knife  de- 
signed for  making  small  incisions  into  the 
glands  or  infiltrations  (Fig.  14).  d.  The  en- 
doscopic cannula  armed  with  a  syringe  for 
injections  into  the  urethral  glands  or  other  orifices 
(Fig.  15).     c.  An  urethral  forceps  for  the  removal  of 


Fig.  12. — Kollmann's  CapiUan-  Aspirator. 

foreign  bodies  and  for  the  treatment  of  urethral 
tumors  (Fig.  16).  d.  An  electrolytic  sound  for 
destroying  such  diseased  glands  as  will  not 
yield  to  other  treatment  (Fig.  17).  The  ap- 
plication of  electrolysis  in  these  cases  must  not 
be  confounded  with  the  operations  of  Foot,  of  Paris, 
Robert  Newmann,  of  New  York,  or  Lang,  of  Vienna,  for 


Fig.  13. — Kollmann's  Spatula. 


Stricture,     e.  An  instrument  designed  for  in- 
ternal urethrotomy,  permitting  the  perform- 
ance of  this  operation  under  the  guidance  of 
the  eye  (Figs.  18  and  19). 
All  these  instruments  can  be  used  through  the  en- 
doscopic tube,  while  the  electric  light  enables  us  to  su- 
pervise the  field  of  operation. 


Intra -urethral  Knife. 


The  urethroscope  and  the  endoscopic  instru-      «    v 
menjs  just  mentioned  are  made  by  C.  G.  Heyne-      \^ 
mann,  3  Erdmannstrasse,  Leipzig. 
^  4While  urethroscopy  is  simple  enough,  its  technique 
merits  somewhat  detailed  attention.     Before  introduc- 


ing the  tube  into  the  urethra,  every  part  of  the 
apparatus  should  be  tested,  to  be  assured  that  it  is 
in  working  order.     The  water  must  be  in  circula- 
tion through  the  soft-rubber  tubes  and   through  the 
light-carrier.     This  being  the  case,  the  rheostat  must 


Fig.  17. — Kollmann's  tlectrol>'tic  Soiuid. 

The  platinum  wire  may  occasionally  be  pressed 
down  upon  the  light-carrier  ;  this  will  prevent 
it  giving  a  good  light.  In  such  an  event  the 
defect  can  easily  be  remedied  by  raising  the 
wire  from  contact  with  a  bit  of  stiff  paper  drawn  be- 
neath the  wire  and  the  plate. 

The  whole  apparatus  being  in  perfect  order  and  the 
water  turned  on.  the  patient  is  ordered  to  emptj'  his 
bladder.  Any  urethral  discharge  that  may  be  present 
having  been  washed  away  with  a  syringe,  the  patient  is 
then  placed  on  the  examination  chair.  If  the  patient 
be  very  sensitive  it  will  be  advisable,  before  introducing 


-Obcrlaender's  Tube  for  Ii 


:thrctomy. 


the  urethral  tube,  to  inject  i  or  2  grammes  of  a  three 
per  cent,  or  five  per  cent,  solution  of  cocaine.  By 
closing  the  external  orifice  the  patient  retains  the  in- 
jected cocaine  in  the  urethra,  and  by  gentle  rubbing 
spreads  it  over  the  whole  urethra. 

When  it  is  intended  to  examine  the  posterior  urethra 
it  will  be  well  to  use  stronger  solutions  of  cocaine  with 
an  injector  for  this  part,  such  as  an  Ultzmann  syringe. 

Although  the  application  of  cocaine  to  the  urethra  is 
generally  borne  well,  it  still  requires  care.     I  generally 


_^ 


Fig.  iq. — Knives  for  Oberlaender^s  latia-urethrotoroy. 


use  a  three  percent,  or  five  per  cent,  solution,  and  inject 
as  little  as  possible.  Kollmann's  little  syringe  made  for 
this  purpose  will  be  found  very  useful.  In  the  majority 
of  cases  cocaine  is  not  needed,  but  in  private  practice  it 
will  be  better  to  use  it,  as  patients  appreciate  the  phy- 
sician's skill  more  if  an  otherwise  disagreeable  exami- 
nation be  made  painless. 

After  the  urethra  is  cocainized,  endoscopic  tube  No. 
23  may  be  introduced,  the  larger  sizes  being  reserved 
for  later  use.     I  lay  particular  stress  upon  this  point, 


16.— Dittel's  Inlra-urethral  Forceps,  modified  by  KoUmaim. 


be  turned  on  until  the  platinum  wire  becomes  sufficiently 
incandescent  to  give  a  good  white  light  and  no  further, 
lest  the  wire  be  burned  through.  Should  this  happen 
to  the  novice  the  rheostat  must  be  turned  back  to  re- 
duce the  galvanic  current.  Then  pressing  the  two 
ends  of  the  platinum  wire  together  with  a  pair  of  for- 
ceps, they  will  be  reunited  by  turning  on  the  rheostat 
sufficiently,  only  until  the  platinum  wire  becomes  of  a 
red  heat. 

Thorough  examination  of  the  urethra  naturally  de- 
pends upon  the  neat  adjustment  of  all  parts  of  the 
apparatus.  Of  these  the  platinum  wire,  whose  incan- 
descence furnishes  the  light,  requires    that   its   ends, 


because  by  commencing 
the    examination    with 
smaller  tubes  the  exist- 
ence of  folds  of  the  lin- 
ing   membrane    of    the 
urethra   can   be   ascer- 
tained.    In  using  a  large 
tube  at  once  these  folds 
may  be  stretched  and  ap- 
pear obliterated  during  the  examination.     An  error  in 
diagnosis  may  be  the  consequence,  as  will  be  shown 
later  on.    The  endoscopic  tubes  must  be  lubricated  with 
ten  per  cent,  or  twenty  per  cent,  boro-glycerine  before 


i 


September  7,  1895] 


MEDICAL    RECORD. 


329 


passing  them  into  the  urethra.  In  case  a  stricture  pre- 
vents the  introduction  of  the  tube,  it  is  better  to  with- 
draw the  instrument  instead  of  forcing  it  through  the 
stricture.  After  dilating  the  stricture  the  completion 
of  the  examination  will  be  easy.  If  the  meatus  is  too 
narrow  for  the  passage  or  the  tube,  the  defect  ma)'  be 
easily  corrected  by  some  dilatation  or  by  meatotomy, 
if  there  be  reason  at  all  to  make  an  endoscopy. 

After  the  endoscopic  tube  is  introduced  to  the  bulb, 
the  obturator  is  withdrawn.  All  superfluous  glyc- 
erine, or  mucus,  or  blood  has  to  be  removed  with 
cotton  wool  twisted  round  a  probe  or  similar  instru- 
ment. If  this  be  omitted  the  electric  light  will  be  dis- 
turbed by  steam,  or  the  mucus  or  blood  will  obscure 
the  view.  The  urethra  being  dried,  the  light-carrier 
is  put  into  the  tube  and  fixed  on  the  spur  by  the  screw 
provided  for  that  purpose.  When  the  mucous  mem- 
brane which  presents  at  the  end  of  the  tube  has  been 
carefuUy  examined,  the  tube,  with  the  light  fixed  as 
above  described,  must  be  slowly  drawn  out  of  the  ure- 
thra, care  being  taken  that  it  be  kept  in  the  urethral 
axis,  unless  a  special  part  requires  particular  examina- 
tion. 

While  at  a  cursory  first  glance  the  Nitze-Oberlaender 
apparatus  may  appear  cumbersome  and  complicated, 
a  few  moments'  impartial  examination  will  show  it  to 
be  exceedingly  simple.  The  expense  may,  too,  seem 
an  objection,  but  when  it  is  considered  that  200  marks 
(;^io — $50)  will  cover  an  outfit  applicable  to  all  pur- 
poses, and  that  spare-parts  are  very  cheap  and  rarely 
required,  this  feature  is  minimized.  But,  beyond  all, 
even  were  the  apparatus  and  its  management  difficult 
and  requisite  of  special  skill,  the  clear  aspect  it  gives 
of  diseased  regions  of  the  urethra  and  the  facility  it 
offers  for  their  direct  medical  and  surgical  treatment, 
would  outweigh  all  possible  objections. 

One  of  the  objections  that  have  been  made  against 
the  Nitze-Oberlaender  urethroscope  merits  brief  notice. 
It  is  that  the  introduction  of  uncovered  electric  light 
six  inches  into  the  urethra,  makes  the  tube  unbearably 
hot.  It  has  been  my  pleasure  to  demonstrate  the  ap- 
paratus to  very  many  medical  men  from  all  parts  of  the 
world  at  my  Polyclinic,  4  Breitestrasse,  Berlin.  They 
have  witnessed  the  light  resting  in  the  urethra  (without 
cocaine)  for  as  long  as  ten  minutes  and  over,  while  the 
patient  either  related  his  history  or  looked  on  indiffer- 
ently. Then,  without  turning  off  the  light,  I  have 
withdrawn  it  from  the  urethra  and  placed  the  tube 
with  the  light  upon  the  palmar  surface  of  the  wrist  of 
the  gentlemen  about  me.  with  but  one  result.  All  ex- 
pressed unfeigned  surprise  that  the  tube  with  its  con- 
tained light  conveyed  nothing  further  than  the  normal 
body  temperature.  But  even  were  a  material  rise  of  tem- 
perature the  result  (which  is  not  the  case  with  the  Xitze- 
Oberlaender),  it  would  more  than  compensate  ihe  in- 
terruptions in  the  examination  which  it  would  exact. 
It  must  be  manifest  to  even  a  moment's  thought  that 
distinctness  of  vision  is  in  direct  relation  to  illumina- 
tion. The  nearer  the  light  to  the  object  to  be  examined, 
the  clearer  the  object  must  appear.  The  Nitze-Ober- 
laender urethroscope  places  the  light  at,  almost  into, 
close  contact  with  any  part  of  the  urethra,  while  all  other 
urethroscopes  reflect  light  into  the  canal ;  the  source 
of  light  then  being  ten,  at  least  six,  inches  from  the  site 
to  be  examined.  All  other  arguments  against  the 
Nitze-Oberlaender  fall  of  their  own  weight,  and  there- 
fore require  no  discussion  here. 

The  diagnosis  of  pathological  changes  in  the  urethra 
premises  a  knowledge  of  its  normal  endoscopic  aspect. 
This  varies  individually  according  to  the  width  and 
length,  i.e.,  the  calibre  of  the  urethra,  and  according  to 
the  blood-supply  of  its  mucous  membrane.  Thus  a 
normally  ansemic  urethra  appears  pale  and  rosy  ;  a 
slightly  hyperaemic  urethra  looks  distinctly  red  :  while 
a  normally  hyperaemic  mucous  lining  is  of  a  purple 
color. 

In  considering  the  normal  color  of  the  mucous  mem- 


brane, it  must  be  borne  in  mind  that  it  is  subject  to 
modifications  by  the  pressure  of  the  endoscopic  tube  : 
this  artificial  appearance  must  be  distinguished  from 
pathological  changes  which  cause  similar  discoloration. 
The  application  of  cocaine  will  also  to  a  degree  affect 
the  color  of  the  mucous  membrane,  by  making  it  appear 
somewhat  anaemic.  It  will  not  be  found  difficidt  to 
learn  to  exclude  any  errors  on  these  scores. 

In  looking  through  the  urethroscope  the  first  thing 
seen  is  a  more  or  less  highly  colored  disk  of  mucous 
membrane.  This,  in  closing  in  over  the  objective  end 
of  the  tube,  forms  a  funnel  or  circle  of  mucous  mem- 
brane which  presents  for  careful  obser\'ation,  i,  a  rim  ; 
2,  a  central  figure  ;  3,  an  intervening  surface.  The  rim 
or  edge  of  the  funnel  generally  appears  more  or  less 
whitened  by  the  pressure  of  the  margins  of  the  open 
tube. 

The  central  figure  is  the  lumen  of  the  urethra.  Its 
shape  varies  in  the  different  parts  of  the  urethra,  ap- 
pearing as  a  semilunar  opening  in  the  bulbous  portion, 
as  a  dimple  in  the  pars  cavernosa,  and  round,  or  oval, 
or  T-shaped  in  the  glans.  A  number  of  longitudinal 
folds  radiate  from  the  centre  of  the  mucous  membrane  ; 
these  are  of  great  diagnostic  importance.  Their  thick- 
ness indicates  whether  they  are  infiltrated  and  the  de- 
gree of  such  infiltration.  Many  cases  present  longitu- 
dinal red  stripes  ;  they  indicate  a  non-infiltrated 
mucous  membrane.  Normal  mucous  lining  of  the 
urethra  shows  everywhere  an  equally  smooth  and  glist- 
ening surface  with  a  net-work  of  small  vessels. 

In  drawing  out  the  endoscopic  tube  the  openings  of 
the  urethral  glands  (Morgagnian  crypts)  present  as  red 
depressed  specks  or  small  slits  of  the  calibre  of  a 
pin's  head  along  the  roof,  the  surrounding  mucous 
membrane  being  normally  smooth  or  slightly  elevated. 
Very  prominent  or  gaping  glandular  openings,  sur- 
rounded by  a  deeply  colored  mucosa,  indicate  patho- 
logical conditions  which  will  be  considered  in  their 
proper  place.  The  number  of  these  crj-pts  varies,  under 
normal  conditions,  from  three  to  eight.  An  accumu- 
lation of  glandular  openings  in  groups  indicates  pat 
ological  changes. 

Endoscopy  of  the  posterior  urethra  is  very  rarely 
practised,  partly  because  it  sometimes  is  painful,  and 
partly  because  it  causes  some  hemorrhage.  These  not 
only  interfere  with  the  examination  and  are  out  of  pro- 
portion to  the  benefits  which  could  result  from  such 
examination.  Still,  when  necessary  it  is  easily  accom- 
plished by  introducing  the  endoscopic  tube  armed  with 
the  elbowed  obturator  till  it  enters  the  pars  membra- 
nosa.  In  lowering  the  outer  end  of  the  tube  below  the 
horizontal  it  is  gently  conducted  into  the  bladder. 
Withdrawal  of  the  obturator  will  naturally  be  accom- 
panied by  an  escape  of  urine  through  the  tube.  After 
gently  drawing  out  the  tube  until  no  more  urine  ap- 
pears, the  liquid  still  remaining  in  the  tube  is  carefully 
mopped  up.  Then,  on  inserting  the  light  the  coUiculus 
seminalis  appears  in  the  field  of  vision  as  a  round,  red- 
dish, pea-sized  body.  In  many  cases  the  openings  of 
the  prostatic  and  ejaculatory  ducts  can  be  seen.  The 
peripheral  continuation  of  the  caput  gallinaginis  pre- 
sents as  a  more  or  less  prominent  ridge  of  mucous 
mem'orane. 

In  studying  the  anatomical  changes  of  chronic  ure- 
thritis as  presented  by  the  urethroscope,  we  find  in  all 
stages  of  the  disease  two  pathological  processes  :  i.  Al- 
terations of  the  epithelial  layer  ;  2,  pathological  changes 
of  the  urethral  glands.  The  epithelial  layer  normally 
forms  a  smooth,  transparent  covering  of  the  mucous 
membrane,  having  a  distinct  uniform  lustre.  This 
lustre  will  be  increased  if  the  mucosa  be  congested  and 
swollen  ;  it  will  be  diminished  when  the  mucous  mem- 
brane is  infiltrated.  To  avoid  errors  it  is  necessary  to 
know  that  an  augmented  lustre  of  the  epithelial  stratum 
can  be  artificially  produced  by  some  liquid  left  on  the 
mucous  membrane,  such  as  glycerine,  cocaine,  or  mu- 
cus, or  urine. 


MEDICAL   RECORD, 


[September  7,  1895 


Increased  lustre  of  the  epithelial  layer  is  found  in 
all  cases  of  subacute  superficial  urethritis.  The  more 
infiltrated  the  mucous  membrane  becomes,  the  more 
faint  its  lustre  will  certainly  be  ;  the  same  holds  good 
in  epithelial  desquamation  with  or  without  infiltration. 
In  some  parts  the  epithelium  may  be  entirely  lost,  leav- 
ing patches  of  easily  bleeding  granulations  or  small 
ulcerations.  In  the  severer  forms  of  infiltration  of  the 
mucosa,  the  epithelial  layer  not  only  loses  its  smooth- 
ness and  lustre,  but  becomes  uneven  and  scaly ;  it 
turns  opaque  and  grayish  as  if  covered  by  a  veil. 
Sometimes  the  lining  membrane  is  covered  with  snowy 
white  adherent  patches,  varying  in  size  from  a  pin's 
head  to  several  centimetres  in  dimension.  On  account 
of  the  similarity  of  this  condition  with  psoriasis  muco- 
sre  oris,  Oberlaender  calls  it  psoriasis  mucosae  urethra- 
ls. 

The  pathological  changes  of  the  urethral  glands  are 
divided  into  two  classes,  according  to  their  structure 
and  situation.  If  glandular  orifices  are  visible  in  num- 
bers the  glands  manifestly  are  diseased.  Pari  passu 
with  the  severity  of  the  inflammation  of  the  whole  mu- 
cous membrane,  the  epithelial  layer  is  destroyed,  and 
thus  the  orifices  of  the  diseased  glands  exposed  as  little 
red  specks  mostly  arranged  in  groups. 

Oberlaender  also  diagnoses  sub- epithelial  glandular 
inflammation,  in  which  cases  the  orifices  remain  invis- 
ible. The  epithelial  layer  covering  their  outlets  has  a 
dull,  dry,  lack-lustre  appearance;  sometimes  desquama- 
tion takes  place. 

The  Morgagnian  crypts  are  visible  in  all  forms  of 
chronic  urethritis.  A  solitary  diseased  crypt  very 
rarely  appears  on  a  rosy,  otherwise  normal,  mucous 
membrane  ;  usually  several  crypts  are  found  affected  at 
the  same  time.  In  the  milder  degrees  of  inflammation 
their  orifices  appear  as  small  red  specks  with  swollen, 
puffy  walls.  Now  and  then  a  watery  or  milky  or  puru- 
lent discharge  oozes  from  them.  In  the  severer  forms 
of  gonorrhoeal  disease,  with  consequent  infiltration 
around  the  crypts,  their  orifices  gape  and  often  are  sur- 
rounded by  a  puffy  red,  prominent  wall,  distinctly 
marked  against  the  neighboring  tissue. 

The  orifices  of  the  crypts  are  seldom  closed  ;  the 
inflammation  assumes  a  follicular  character  and  remains 
in  this  condition  for  a  long  time.  Endoscopically  we 
then  see  a  small  reddish  prominence  in  the  mucosa 
witlj  a  little  dimple  in  its  centre,  while  the  lumen  is  in- 
visible. These  encapsuled  crypts  can  be  felt  by  the 
finger  as  small,  hard  nodules. 

To  be  able  to  understand  and  diagnose  pathological 
changes  of  the  urethral  mucosa  in  chronic  urethritis  by 
means  of  the  urethroscope,  it  is  of  imjjortance  to  re- 
member the  histological  process  in  chronic  gonorrhoea. 
All  chronic  gonorrhoeal  affections  of  the  urethra  are 
circumscribed  and  irregularly  bounded.  The  jirincipal 
seat  of  the  disease  is  in  the  pars  cavernosa  urethra,  or 
in  the  anterior  part,  the  bulb  being  ajiparently  less 
often  affected.  The  salient  histological  feature  in 
chronic  urethritis  is  cellular  infiltration  of  the  sub-epi- 
thelial connective  tissue,  with  a  tendency  to  fibrous 
transformation  thereof.  In  the  milder  forms  we  find 
the  sub-epithelial  tissue  impregnated  with  a  more  or 
less  dense  infiltration,  consisting  of  mononuclear  or  e])i- 
thelioid  cells  or  leucocytes,  which  either  remain  in  the 
upper  layers  of  the  sub-epithelial  tissue  or  extend 
to  a  greater  depth.  If  these  cellular  infiltrations 
cause  only  a  swelling  and  hypera^mia  of  the  mucous 
membrane,  with  no  tendency  to  transformation  into 
hyperplastic  connective  tissue,  the  condition  is  diag- 
nosed as  the  first  form  of  chronic  urethritis,  the  ure- 
thritis mucosa;  of  Oberlaender.  Gradually  the  cellular 
infiltration  around  the  Morgagnian  crypts  and  Littre's 
glands  becomes  condensed.  The  epithelium  of  the 
urethra  being  swollen  and  in  a  state  of  desquamation, 
now  changes  from  cylindrical  epithelium  into  pave- 
ment epithelium. 

The  second  form  of  chronic   urethritis  is  character- 


ized by  a  denser  and  deeper  cellular  infiltration,  con- 
taining not  only  leucocytes  but  also  numerous  young 
connective-tissue  cells.  Whenever  the  cellular  infiltra- 
tion has  gone  over  to  the  formation  of  new  fibrous  tis- 
sue, the  urethra  appears  to  be  embedded  into  a  rigid 
mass.  The  increasing  fibrous  tissue  finally  forms  a 
callous  cicatricial  girdle  around  the  lumen  of  the  ure- 
thra. We  call  this  second  form  of  chronic  urethritis 
areal  infiltration  (Herdinfiltrat).  Naturally  these  dif- 
ferent stages  of  sub-epithelial  infiltration  modify  the 
endoscopic  picture  of  the  mucous  membrane. 

In  the  first  stage,  when  only  cellular  infiltration  has 
taken  place,  we  find  an  increased  lustre  of  the  lining 
membrane.  In  cases  of  denser  cellular  infiltration  the 
lining  membrane  has  a  dull,  uneven  appearance.  The 
diseased  area  appears  redder  than  the  normal  mucous 
membrane,  which  becomes  swollen  and  puffy.  The 
longitudinal  folds  are  not  slender  as  in  the  normal  state, 
but  coarse  and  broad.  Instead  of  6  to  10  smaller  folds 
we  find  but  4  to  6  in  the  central  figure.  The  longitudi- 
nal stripes  have  entirely  disappeared.  The  Morgag- 
nian crypts  have  swollen,  inflamed  orifices  ;  occasion- 
ally secretion  oozes  from  them.  Littre's  glands  are  not 
visible.  When  they  appear  in  the  field  of  vision,  how- 
ever, the  disease  is  in  a  progressive  stage.  All  these 
changes  are  irregularly  circumscribed.  We  call  this 
stage  of  the  disease  urethritis  mucosse,  or  soft  infiltra- 
tion. 

Endoscopy  of  hard  infiltration  will  naturally  show 
very  various  forms  according  to  the  advance  of  trans- 
formation of  the  cellular  infiltration  into  fibrous  tissue. 
With  regard  to  the  affections  of  the  glands  we  subdi- 
vide the  hard  infiltrations  into  two  classes.  In  the 
first  the  glandular  hard  infiltrations,  the  orifices  of 
Littre's  glands  and  of  the  crypts  are  always  visible,  as 
they  are  more  or  less  inflamed.  The  second  variety  of 
hard  infiltrations,  the  so-called  dry  form,  shows  no  or 
but  few  glandular  orifices,  they  being  covered  by  a 
layer  of  epithelial  and  connective  tissue.  A  dry,  dull 
appearance  of  the  epithelium  is  characteristic  in  these 
cases. 

On  introducing  the  endoscopic  tube  in  a  case  of 
hard  infiltration  a  resistance  by  the  urethral  wall  is  felt. 
The  central  figure  appears  as  a  wide  gaping  funnel. 
The  longitudinal  folds  as  well  as  the  longitudinal 
stripes  have  disappeared.  The  lining  membrane  has  a 
more  or  less  grayish  color.  The  denser  the  fibrous  tis- 
sue has  become,  the  more  the  whole  urethra  will  have 
the  look  of  a  rigid  canal  ;  in  the  worst  form  it  shows 
white  cicatricial  tissue. 

If  Littre's  glands  are  visible  their  orifices  will  be 
seen  in  groups,  as  red  inflamed  spots  in  a  grayish  dis- 
colored mucous  membrane. 

The  Morgagnian  crypts  gape,  their  lumen  is  remark- 
ably distended,  often  surrounded  by  an  inflamed  wall, 
which  distinctly  shows  against  the  infiltrated,  discolored 
neighborhood. 

In  the  dry  form  of  the  hard  infiltrations  Littre's 
glands  are  invisible.  The  epithelium  has  a  particularly 
dry  and  dull  appearance,  desquamating  in  spots. 

A  careful  study  of  such  cases  will  reveal  the  differ- 
ence between  the  various  degrees  of  these  hard  infil- 
trations. Thus  we  can  diagnose  hard  infiltrations  of 
minor  intensity,  those  of  a  medium  degree,  and  hard 
infiltrations  of  the  severest  forms  going  over  into  cal- 
lous stricture.  In  comparing  such  cases  it  will  become 
clear  that  between  chronic  gonorrhoea  and  stricture 
only  a  gradual  and  not  a  distinct  difference  exists. 
Even  in  cases  of  stricture  we  are  able  to  ascertain  if  it 
depends  upon  a  glandular  or  a  dry  follicular  form  of 
urethritis. 

The  various  stages  of  restoration,  as  they  occur  in  the 
diseased  urethra  under  appropriate  treatment,  can  be 
followed  endoscopically.  If  a  chronic  urethritis  has 
been  perfectly  cured  the  urethra  will  have  the  follow- 
ing aspect :  the  epithelial  layer  will  grow  smooth  with 
normal  lustre,  normally  folded  mucous  membrane  with    i: 


September  7,  1895] 


MEDICAL   RECORD. 


a  normal  healthy  color  ;  the  crypts  and  glands  cease  to 
be  infiltrated,  but  they  may  still  be  visible  ;  and  exist- 
ing cicatrices  become  smooth  and  even. 

As  has  been  suggested  before,  urethroscopy  of  the 
posterior  urethra  should  not  be  employed  save  when 
required.  It  is  contra- indicated  in  all  cases  of  acute 
or  subacute  posterior  urethritis,  in  tuberculous  cases, 
and  in  hypertrophy  of  the  prostate.  In  sexual  neuroses 
or  in  chronic  posterior  urethritis  endoscopy  of  the  pos- 
terior urethra  will  often  be  found  useful. 

In  chronic  posterior  urethritis  we  also  distinguish 
between  soft  swellings  of  the  mucous  membrane  and 
hard  infiltrations,  the  former  being  the  rule  while  hard 
infiltrations  are  rare.  In  soft  infiltrations  the  mucous 
membrane  has  a  purple  or  cyanotic  color,  is  swollen 
and  of  an  increased  lustre  ;  especially  the  crest  of  the 
urethra  and  its  peripheral  continuation  show  these  path- 
ological changes  ;  the  parts  bleed  easily.  Hard  in- 
filtrations of  the  posterior  urethra  only  develop  after 
long  continual  swellings  of  the  mucosa,  which  then  ap- 
pears pale,  grayish,  dry,  and  lustreless.  The  caput  gal- 
linaginis  also  has  a  pale  yellowish  color,  a  dull  lustre, 
and  is  not  prominent  nor  wrinkled,  but  flat  and  smooth. 

Of  tumors  of  the  urethra  we  mostly  find  papillomata, 
now  and  then  fibrous  polypi,  and  very  rarely  carcino- 
mata.  Papillomata  and  fibrous  polypi  can  easily  be 
diagnosed  with  the  urethroscope.  The  removal  of  these 
growths  will  often  cure  an  otherwise  untractable  gleet. 
Oberlaender  was  the  first  to  diagnose  carcinoma  of  the 
urethra  by  means  of  the  urethroscope. 

The  diagnostic  value  of  urethroscopy  having  been 
demonstrated,  its  therapeutic  advantages  merit  consid- 
eration. As  previously  remarked,  there  is  every  reason 
for  demanding  an  exact  diagnosis  in  urethral  affections 
as  in  all  other  diseases.  Urethroscopy,  we  have  seen, 
enables  us  to  diagnose  the  various  forms  and  stages  of 
chronic  urethritis  ;  hence  it  is  but  logical  to  expect  the 
abandonment  of  the  routine  treatment  of  chronic 
gonorrhoea  by  injections  and  bougies,  and  that  the  case 
be  treated  according  to  differential  diagnosis,  which 
urethroscopy  makes  possible. 

Bearing  in  mind  that  the  principal  anatomical  and 
endoscopic  feature  of  chronic  urethritis  is  cellular  in- 
filtration of  the  mucosa,  with  a  tendency  to  transforma- 
tion into  fibrous  tissue,  it  must  be  obvious  that  the 
ordinary  urethral  injections  are  of  no  therapeutic  value. 
This  has  been  recognized  some  time  ago,  and  it  led  to 
the  application  of  the  bougie  or  metallic  sound  in  cases 
of  chronic  gonorrhcea.  These  instruments  are  intro- 
duced into  the  urethra  for  the  purpose  of  dilating  it 
and  of  causing  pressure  upon  the  infiltrated  mucosa,  in 
this  way  effecting  a  dissolution  or  melting  of  the  infil- 
trations. A  moment's  thought  will  show  the  impossi- 
bility of  attaining  this  aim  by  means  of  the  soft  elastic 
bougie,  especially  in  cases  of  hard  urethral  infiltrations. 

The  passing  of  metallic  sounds  of  various  calibre  in 
cases  of  chronic  urethritis  is  undoubtedly  more  rational 
than  the  application  of  the  soft  bougie.  The  heavy 
metallic  sound,  especially  if  large  calibres  are  used,  in 
many  cases  answers  the  purpose  of  stimulating  the  re- 
absorption  of  hard  infiltrations,  but  not  in  all.  In  very 
many  cases  a  narrow  meatus  will  prevent  the  introduc- 
tion of  a  larger  sound  than  perhaps  No.  24  or  26  Fil. 
Charriere,  or  even  a  much  smaller  calibre.  Such  a  size 
would  then  lie  quite  loosely  in  the  urethral  canal  with- 
out exerting  any  pressure  or  dilatation  whatever.  For 
this  reason  various  dilators  have  been  devised,  which 
are  easily  introduced  through  a  narrow  meatus  and 
allow  dilatation  of  tlie  urethra  to  any  degree  desired. 
The  best  dilators  are  those  of  Otis,  Planer,  and 
Oberlaender,  the  Oberlaender's  dilator  being  the  most 
useful.  While  all  the  dilators  have  two  blades,  Koll- 
mann  constructed  a  dilator  with  four  branches  for  the 
pars  anterior,  with  the  purpose  of  exerting  dilatation  of 
equal  force  in  all  directions. 

By  means  of  these  dilators  infiltrations  of  all  dimen- 
sions can  be  broken  down,  and  thus  the  normal  calibre 


of  the  urethra  restored.  But  it  is  evident  that  true 
callous  infiltrations  are  no  fit  objects  for  dilatation  ;  they 
must  be  treated  by  the  other  methods  which  enter  into 
the  therapeutics  of  this  form  of  urethroscopy.  If  the 
dilators  are  used  indiscriminately  without  previous  en- 
doscopic diagnosis  as  to  the  seat  of  the  infiltrations, 
dilatations  may  be  continued  for  months  and  months 
without  gaining  the  end  in  view.  Urethroscopy  has 
shown  that  infiltrations  are  always  circumscribed  and 
not  diffuse.  Cures  can  be  effected  only  by  directing 
dilatation  to  those  localized  infiltrated  places.  Is  it 
therefore  too  great  a  requirement  that  all  treatment 
should  be  based  upon  correct  endoscopic  diagnosis  ? 

The  Nit'ze-Oberlaender  urethroscope  not  only  guides 
treatment  by  dilatations  to  the  very  seat  of  infiltration, 
but  also  enables  the  physician  to  attack  localized  go- 
norrhceal  foci  through  the  urethroscopic  tube  under 
the  guidance  of  the  eye.  The  endoscopic  tubes  are 
sufficiently  wide  to  admit  the  introduction  of  other  in- 
struments besides  the  electric  light,  and  enable  the 
practitioner  to  employ  them  under  direct  illumination 
of  the  diseased  parts.  Infiltrated  glands  can  easily  be 
incised  with  a  knife  or  destroyed  with  an  electrolytic 
sound  ;  various  solutions  can  be  injected  into  the  glands 
or  any  openings  found  in  the  urethra.  Under  direct 
illumination  hard  infiltrations  also  can  be  incised,  and 
even  internal  urethrotomies  performed.  The  endoscopic 
tubes  will  also  allow  sufficient  room  for  the  removal  of 
urethral  polypi  by  means  of  the  snare  or  forceps.  All 
this  can  be  done,  and  must  be  done,  under  the  super- 
vision of  the  eye.  Whoever  will  test  the  applications 
of  these  instruments  through  the  endoscopic  tube  will 
find  no  difficulty  in  handling  them. 

It  is  beyond  my  hopes  that  this  little  effort  will  give 
the  urethroscope  a  place  among  the  general  practition- 
er's instruments  of  precision  and  treatment ;  an  abler 
pen  than  mine  would  be  required  for  such  a  desirable 
end.  But  it  is  my  hope  that  at  least  those"  specialists 
who  have  as  yet  not  used  the  instrumentarium  I  have 
herein  mentioned,  will  be  led  by  these  crude  lines  to 
investigate.  Their  work  then  will  serve  to  tear  urethral 
diseases  from  the  realm  of  that  crass  empiricism  which, 
sadly  enough,  has  too  long  enveloped  them.  If  my 
labor  brings  about  only  investigation,  my  ambition  will 
be  more  than  gratified. 

In  conclusion  I  desire  to  perform  a  most  pleasant 
duty.  It  is  to  thank  those  gentlemen  from  England, 
America,  and  the  British  Colonies  who  have  honored 
me  by  becoming  my  pupils,  for  the  incentive  they  gave 
me  to  condense  herein  the  salient  points  of  my  clinical 
lectures.  Thanks  also  are  due  to  my  friend  Ferdinand 
C.  Valentine,  M.D.,  of  New  York,  for  valuable  sugges- 
tions regarding  the  arrangement  of  this  little  article. 

May  30,  1893. 


Amputation  of  Omentum  in  Hernia. — i.  All  irreduci- 
ble hernias  should  be  operated  upon  unless  contra- 
indicated  by  age  or  condition  of  the  patient.  2.  All 
omentum  found  outside  the  abdomen,  or  that  will  pro- 
trude under  gentle  traction,  should  be  removed.  3. 
Multiple,  independent  ligatures  of  good-sized  silk, 
which  surround  the  vessels  alone,  or  small  pieces  of 
fatty  tissue,  are  believed  to  be  safer  than  other  methods. 
4.  The  use  of  some  film-forming  substance,  as  aristol, 
on  the  stump  is  believed  to  protect  in  a  measure  from 
subsequent  adhesions. — De  Garmo. 

Absorption  of  Ligatures. — In  four  hundred  experi- 
ments it  was  found  that,  in  from  one  to  two  years,  sev- 
enty per  cent,  of  catgut  ligature  had  become  absorbed  ; 
thirty-six  per  cent,  of  silk,  sixty-six  per  cent,  of  hemp 
or  flax,  and  twenty  per  cent,  of  horse-hair.  Order  of 
rapidity  ;  catgut,  hemp,  silk,  horse-hair. — Porta. 

Insomnia. — Asafcetida  is  a  valuable  remedy  in  the 
insomnia  occurring  in  the  aged. 


332 


MEDICAL   RECORD. 


[September  7,  1895 


ARE   WORK  AND  AVORRY  CAUSES  OF    NER- 
VOUS  AFFECTIONS? 

By  L.    HARRISON   METTLER,   A.M.,    M.D., 

CHICAGO,   ILL. 

Much  stress  is  laid  by  authors  upon  overwork  as  a 
cause  of  nervous  troubles.  On  the  other  hand,  Dr. 
Clifford  Allbutt  says,  in  a  recent  popular  essay,  that  as 
excitation  is  the  function  of  normal  nerve-cells  it  is 
hardly  conceivable  that  their  injury  should  be  brought 
about  by  simple  excitation.  It  is  not  to  be  denied  that 
neurasthenia  is  a  palpable  reality,  and  that  it  is  an  ac- 
companiment of  modern  civilization.  The  genuine 
neurasthenic,  with  his  restlessness,  insomnia,  absent- 
mindedness,  weakened  memory,  languid  expression, 
drawling  speech,  tired  gait,  lack  of  enthusiasm,  ten- 
dency toward  pessimism,  headache  and  other  aches, 
dyspepsia,  constipation,  and  general  malaise  is  too  vis- 
ibly among  us  to  deny  his  existence.  There  are  those 
who  declare  that  our  modern  civilization,  with  its  high- 
pressure  mode  of  life,  its  sharp  competition,  its  ex- 
hausting round  of  amusements,  its  rivalry  of  wealth, 
its  fads,  follies,  and  fashions,  its  sensationalism,  its 
superficiality  and  mental  boulimia,  its  self-indulgence, 
luxury,  and  unnatural  stimulation,  is  responsible  for  the 
increase  of  nervous  troubles.  They  say  we  must  retract 
and  put  ourselves  under  greater  restraint  ;  we  must  re- 
turn to  a  Spartan  simplicity,  and  we  must  live  a  less 
sensuous  life,  cultivating  more  and  more  the  homely 
pleasures  of  a  rustic  existence.  All  of  which  is  un- 
doubtedly true  and  has  been  preached  by  poet  and 
philosopher  from  Hesiod  to  Thoreau.  On  the  other 
hand,  there  are  not  wanting  advocates  of  a  still  greater 
stimulation  of  human  nerve-force.  They  believe  that 
man  is  capable  of  a  still  higher  civilization  and  that 
science  is_ going  to  give  him  possession  of  yet  greater 
power  over  nature.  In  the  attainment  of  this  desirable 
climax  they  hold  that  the  weaker  existences  must  neces- 
sarily be  eliminated,  simply  because  of  their  incapabil- 
ity to  keep  up  with  the  rapid  march  of  events. 

In  the  struggle  of  mind  over  matter  some  must  ob- 
viously be  led  astray  or  be  oppressed  by  the  unwonted 
glamour  of  the  new  conditions.  Many  nervous  sys- 
tems must  be  shattered  and  ruined  in  their  futile  effort 
to  accommodate  themselves  to  the  swift  change.  The 
wopks  of  genius,  the  creations  of  art,  the  discoveries  of 
science,  are  all  the  result  of  highly  stimulated  nerve- 
force.  Rousseau's  idea  of  the  normal  man  is  not  the 
right  idea,  for  if  man  is  to  remain  in  a  blissful  state  of 
barbarism,  civilization  and  his  high  destiny  would  be 
impossible.  Advancement  comes  only  from  competi- 
tion, and  competition  involves  an  ever-increasing  stimu- 
lation of  nerve-force.  Barbarous  races  dwindle  away 
and  ultimately  vani,sh  in  the  presence  of  civilized  man 
because  they  cannot  compete  with  his  superior  intelli- 
gence. If  they  attempt  to  compete,  they  are  quickly 
overwhelmed,  and  their  constitutions  are  undermined 
by  the  too  sudden  alteration  of  environment.  In 
somewhat  of  a  similar  way  we  are  approaching  a  higher 
state  of  civilization,  and  many  a  constitution  is  being 
broken  down  because  of  its  unprepared  condition  to 
meet  the  rapidly  changing  environment.  Neurasthenia 
is  to  a  large  extent  the  cry  of  the  weaker  nervous  sys- 
tems, that  they  are  being  left  in  the  rapid  advancement 
of  the  race.  They  are  struggling  hard  and  valiantly 
to  keep  up,  but  all  without  avail.  It  is  a  question,  then, 
whether  human  progress  shall  stop  and  turn  back  in 
their  behalf,  or  continue  onward  in  its  career  and  leave 
them  to  their  fate.  Must  electricity  and  steam  be 
abolished  that  the  nerves  of  neurasthenics  be  relieved  of 
the  harrowing  excitement  of  high  speed  ?  Must  grand 
opera,  great  commercial  enterprises,  and  magnificent 
feats  of  skill  and  genius  remain  unattempted  because 
a  certain  number  of  nervous  systems  are  incapable  of 
maintaining  their  healthy  equilibrium  in  the  presence 
of  such  vast  undertakings  ?     Most  assuredly  not,  an- 


swer the  advocates  of  the  higher  advancement  for  the 
human  race.  Let  nerve-force  be  even  more  stimu- 
lated, they  say  ;  let  man  continue  to  strive  after  his 
loftiest  mental  and  physical  ideals  ;  that  is  the  very 
purpose,  the  raisoti  aetre,  of  nervous  matter.  Civiliza- 
tion and  the  increased  stimulation  of  the  world's  nerve- 
force  proceed  pari  passu  ;  if  nerve-force  fails  it  must  be 
regenerated  in  some  other  way  than  by  the  checking  of 
competition  and  human  progress.  Thus  argue  the  two 
opposing  factions  in  regard  to  the  causes  and  amelio- 
ration of  the  neurasthenia  so  prevalent  at  the  present 
day.  Both  explanations  have  an  element  of  truth  in 
them  ;  but  neither,  it  seems  to  me,  has  yet  accounted 
for  the  great  excess  of  neurasthenia  that  exists  in  our 
midst,  and  daily  flocks  to  the  offices  of  our  noted  neu- 
rologists. 

As  I  do  not  purpose  to  consider  here  such  physical 
causes  of  neurasthenia  as  autoinfection,  toxaemia,  re- 
flexes, traumatisms,  etc.,  but  rather  the  psychic  causes 
and  causes  originating  in  vicious  habits,  I  will  at  once 
enter  in  medias  res  by  considering  for  a  moment  the 
modern  physiology  of  the  nervous  apparatus.  In  the 
most  recent  conception  of  the  cerebro-spinal  system  of 
nerves  impulses  originating  in  the  cerebral  cortex  are 
as  much  peripheral  as  those  starting  from  the  skin. 
The  direct  sensor5'-motor  centres  are  to  be  found  in 
the  spinal  cord  and  basal  ganglia.  The  cortex  is  a 
general  centre  for  the  representation  of  motor  and 
sensory  images.  Psychosis  is  a  sensorj'-motor  phe- 
nomenon and  mentalization  is  the  result  of  the  com- 
bined activities  of  the  cortical,  sensory,  and  motor 
areas.  Voluntary  action,  therefore,  is  as  much  a  reflex 
as  an  ordinary  involuntary  spinal  reflex.  Removal  of 
the  cerebral  hemispheres,  olfactory  ganglia,  optic  lobes, 
corpora  striata,  and  optic  thalami  results  in  a  loss  of  in- 
telligence, of  inhibitory  rationalit)',  but  the  animal  still 
executes  purposive  movements  which  are  somewhat  dif- 
ferent from  the  simple  reflex  acts  depending  upon  the 
spinal  cord.  In  1876  Hitzig  spoke  of  the  effects  of 
cortical  lesions  in  the  motor  area  as  "  the  expression  of 
an  abnormal  representative  action  ;  "  in  other  words,  as 
the  result  of  a  destruction  of  the  motor  images  belong- 
ing to  certain  voluntary  movements.  The  muscles  of 
the  animal  are  not  paralyzed,  but  the  animal  no  longer 
possesses  any  mental  images  as  ideal  representations  of 
the  movements  it  should  make  or  desires  to  make. 
The  condition,  roughly  illustrated,  is  probably  some- 
what like  that  of  the  nightmare,  in  which  the  victim  is 
more  or  less  conscious  of  his  surroundings  and  is  full 
of  a  desire  to  move,  but  is  nevertheless  incapable  of 
action  or  acts  only  automatically. 

Munk's  theory  is  popular  in  Germany  and  affirms 
that  the  activity  of  the  cortical  sensory-motor  areas 
results  in  '"  conceptions  of  movements  "  rather  than 
movements  themselves.  Franck  inclines  to  the  theory 
of  a  reflex  action  in  the  motor  areas.  Marique  adopts 
somewhat  this  reflex  theory  for  the  motor  cortex. 
Schiff's  theory  in  regard  to  the  cortex  is  that  of  a  pure 
reflex.  Many  authorities  among  British  and  conti- 
nental experimenters  could  be  cited  to  show  that  the 
cerebral  cortex  does  not  act  directly  upon  the  external 
sensory  musculir  apparatus  of  the  body.  Though 
there  is  considerable  obscurity  in  regard  to  the  real 
functions  of  the  basal  gangli\  and  in  regard  to  the 
mental  relations  among  themselves  of  the  sensory  and 
motor  areas  of  the  brain,  there  is  almost  a  unanimous 
opinion,  based  upon  the  closest  study,  that  the  gray  mat- 
ter of  the  cord  (and  possibly  of  the  basal  ganglia  as 
well)  is  the  direct  centre  from  whence  pass  the  motor 
impulses  to  the  muscles  and  sensory  impulses  to  the 
brain.  The  idea  of  a  certain  desired  movement  orig- 
inates somehow  in  the  cortex  ;  a  certain  set  of  cells  are 
started  into  activity  and  send  forth  an  impulse  to  the 
cells  in  the  anterior  horns  of  the  cord.  These  cornual 
cells  receive  the  impulse,  transform  it,  and  send  it  out 
to  the  appropriate  muscles  for  the  production  of  the 
required  movement.     In  the  same  way  the  prick  of  a 


September  7,    1S95] 


MEDICAL   RECORD. 


pin  is  felt  somewhere  on  the  surface  of  the  body  and 
the  sensory  impulse  is  transmitted  to  the  gray  matter 
of  the  cord.  Here  it  is  transformed  and  sent  up  to  the 
sensory  cells  of  the  cortex,  which  interpret  the  nature 
of  the  original  impulse.  In  both  instances  the  brain 
acts  more  as  the  interpreter  of  the  motor  and  sensor}- 
impulses.  In  either  case  the  brain  has  remained  rela- 
tively quiescent,  and  both  the  motor  and  sensory  im- 
pulses have  been  reflective  in  the  cord.  These  facts 
are  so  well  known  that  I  only  refer  to  them  in  the 
briefest  possible  manner.  The  reason  that  I  refer  to 
them  at  all  here  is  to  show  that  the  cerebro-spinal  sys- 
tem resembles  a  balance,  with  its  fulcrum  in  the  inter- 
mediary gray  matter  of  the  cord  and  its  two  armatures, 
the  cerebro-spinal  system  of  nerves  and  ner^-e-cells  on 
the  one  hand,  and  the  spino-musculo-cutaneous  system 
on  the  other.  The  former,  roughly  speaking,  is  psychi- 
cal in  character,  or  has  to  do  with  impulses  that  partake 
of  purely  mental  characteristics,  while  the  latter  is  more 
strictly  organic  in  character  and  is  somewhat  of  a  mere 
connecting  link  between  man's  ego  and  the  external 
world.  Of  course  there  are  many  details  not  entered 
upon  here,  and  this  conception  of  the  cerebro-spinal 
apparatus  is  only  presented  coarsely  for  the  purposes  of 
the  present  essay. 

Accepting,  then,  for  the  nonce,  this  twofold  concep- 
tion of  the  cerebro-spinal  system,  the  internal  or  men- 
tal or  psychic  on  the  one  hand,  and  the  external  or  or- 
ganic or  musculo-cutaneous  on  the  other,  I  wish  to 
show  that  a  want  of  proper  balance  between  the  two, 
rather  than  the  mere  overwork  of  the  entire  system,  is 
the  real  cause  of  much  of  the  modern  neurasthenia. 
And  if  I  can  succeed  in  doing  this,  not  the  least  of  the 
advantages  will  be  that  certain  suggestions  will  natu- 
rally present  themselves  to  the  mind  of  the  reader  for 
the  relief  of  the  trouble. 

It  is  an  old  saying  that  genius  and  talent  are  but 
synonyms  for  industry  and  an  unusual  capacity  for 
work.  Dr.  Clifford  Allbutt  has  said  that  in  his  exten- 
sive observation  he  has  rarely  seen  a  case  of  mental 
break-down  from  simple  overwork,  provided  the  indi- 
%'idual  originally  had  a  normal  nervous  system  free 
from  hereditary  taint.  In  almost  every  instance  of  in- 
sanity seen  by  him  attributed  to  prolonged  nervous 
strain  there  was  some  inherited  weakness,  bad  mode 
of  life,  or  other  cause  beside  the  mere  overwork. 
Clearly,  therefore,  the  work,  while  being  an  active 
cause,  should  not  be  regarded  as  the  sole  or  even  the 
important  cause.  Every  once  in  awhile,  however,  there 
are  genuine  cases  of  neurasthenia  in  whom  there  seems 
to  have  been  an  originally  strong  and  healthy  physique, 
but  in  whom  overwork  has  been,  so  far  as  we  can  see, 
the  real  and  only  cause  of  the  trouble.  In  such  cases 
I  have  almost  invariably  noticed  that  it  was  not  the 
overwork  alone  that  initiated  the  nervous  break  down, 
but  rather  the  monotony  of  that  work.  To  illustrate  : 
A  pianist  practises  upon  his  instrument  say  eight  hours 
a  day,  and  does  almost  absolutely  nothing  else  in  the 
way  of  a  physical  or  mental  offset  during  the  hours 
that  he  does  not  practise  ;  in  a  short  time  neurasthenia 
results.  On  the  other  hand,  another  pianist  of  appar- 
ently equal  physique  and  nerve-force  also  practises 
eight  hours  a  day  in  divided  intervals,  and  when  not 
practising  turns  all  his  energy  to  some  other  pursuit, 
mental  or  physical  ;  he  continues  for  years  and  never 
shows  the  least  indications  of  neurasthenia.  Xeurol- 
ogists  have  all  seen  such  examples,  and  they  are  well 
illustrated  in  the  lives  respectively  of  Schumann  and 
Mendelssohn. 

I  was  recently  told  by  a  distinguished  concert-singer, 
educated  for  many  years  abroad,  that  the  reason  a 
great  many  vocalists  never  get  beyond  the  amateur, 
though  they  may  have  marvellous  vocal  powers,  is  that 
they  practise  singing  aloud  too  long  a  time  at  once,  and 
so  completely  exhaust  their  voices  and  ner\-e-force. 
For  this  reason  many  of  the  continental  teachers  are 
telling  their  pupils  to  practise  their  singing  mentally, 


that  is,  to  hold  the  music  and  read  it  without  making  a 
sound  with  the  vocal  cords  except  occasionally.  I  see 
in  this  method  not  a  diminution  of  actual  work  done, 
but  a  decided  relief  in  its  monotonous  character. 

Many  artisans  use  their  hands  more  than  does  a  tele- 
graph operator,  but  the  latter  is  the  one  who  suffers 
from  the  cramp,  because  of  the  persistent  monotony  of 
his  work. 

The  introduction  of  machinery  and  the  specialization 
of  work,  chiefly  brought  about  in  the  great  factories,  has 
not  increased  but  rather  lessened  the  actual  work  done 
by  the  operatives.  Nevertheless  cramps,  neurasthenia, 
and  a  dozen  other  functional  ailments  attack  the  latter 
that  were  quite  unknown  to  the  hard-working  all-round 
mechanic  of  former  days.  The  great  majority  of  the 
modern  factory  employes  are  either  unable  or  unwill- 
ing, through  ignorance  or  weariness,  to  offset  the  mo- 
notonous strain  to  which  they  are  subjected  by  appro- 
priate mental  relaxation.  One  side  of  their  nervous 
apparatus  is  therefore  in  more  or  less  of  a  dormant 
state,  while  the  other  is  stimulated  or  exercised  to  an 
unusual  degree. 

Among  students,  scientists,  professional  men,  and 
brain-workers  generally,  the  same  condition  obtains  upon 
the  other  side  of  the  ner\-ous  apparatus.  With  them,  in- 
stead of  a  monotonous  series  of  external  impulses  pour- 
ing in  upon  the  reflex  centres  of  the  cord,  the  impulses 
are  sent  down,  in  the  representative  form  as  it  were, 
from  the  cortex  to  the  spinal  centres,  but  there  they 
end  without  their  appropriate  outlet  in  musculo-cuta- 
neous activity. 

The  romance  writer,  for  instance,  like  the  unfortu- 
nate Marie  Corelli,  who  leads  more  or  less  of  an  ardu- 
ous sedentary  life,  exercising  her  imagination  with  all 
sorts  of  real  and  unreal  visions,  stimulates  but  one  side 
of  her  nervous  make-up,  leaving  the  organic  side  more 
or  less  dormant  and  subject  to  unfulfilled  impulses. 
Every  form  of  prolonged  mental  strain,  without  a  com- 
plementary relaxation  in  some  form  of  physical  activ- 
ity, necessarily  disturbs  the  balance  between  the  psy- 
chic and  organic  sides  of  the  nervous  system.  It  is  this 
prolonged  breach  of  balance  rather  than  the  mere 
quantity  of  work  done  that  acts  disastrously  upon  the 
ner\e- centres.  For  this  reason  the  introduction  of 
athletics,  when  properly  graded,  into  university  life  has 
been  of  advantage  to  the  average  student.  Consider 
the  life  and  work  of  Oliver  Wendell  Holmes,  who  lived 
an  all-round  existence  full  of  out-door  pleasure  as  well 
as  of  mental  strain,  and  one  will  have  an  admirable  il- 
lustration of  a  well-balanced  nervous  system  tending 
toward  health,  optimism,  and  good  old  age.  I  was  once 
told  by  a  friend  that  one  evening  he  happened  to  be  in 
a  room  adjoining  one  occupied  by  Faderewski,  and  that 
out  of  mere  curiosity  he  took  the  trouble  to  note  that 
during  one  of  his  practising  periods  this  distinguished 
pianist  executed  a  particular  cadenza  without  a  mo- 
ment's cessation  something  like  seven  hundred  and  fifty 
times.  Is  it  any  wonder  this  artist  at  the  end  of  the 
season  suffered  an  attack  of  ner\-ous  prostration  I  The 
one-sided  monotony  of  such  an  exercise  would  disin- 
tegrate any  normal  nervous  matter. 

The  increased  responsibilities  necessarily  associated 
with  our  higher  civilization  and  keener  competition 
produce  an  excess  of  worry.  To  this  worry  has  been 
attributed  much  of  our  modern  neurasthenia,  and  justly 
so,  but  the  worry  which  is  usually  associated  with  neu- 
rasthenia is  the  result  rather  than  the  cause  of  that 
trouble.  It  is  the  expression  of  an  unbalanced  ner- 
vous system,  the  cry  of  the  nerves  and  nervous  ele- 
ments on  the  psychic  side  for  more  rest  or  more  exer- 
cise to  restore  the  normal  equilibrium  of  the  whole. 
There  is  a  form  of  worry,  however,  which  is  unavoid- 
able and  is  a  cause  rather  than  a  result  of  neurasthenia. 
It  is  the  accompaniment  of  a  highly  organized  nervous 
apparatus,  is  to  a  certain  extent  normal,  and  is  some- 
times otherwise  known  as  over-anxiety.  To  tell  a  man 
who  is  involved  in  a  vast  enterprise  not  to  worry  be- 


334 


MEDICAL   RECORD. 


[September  7,  1895 


cause  of  certain  changing  conditions  would  be  about 
as  sensible  as  to  try  and  persuade  a  miner  entrapped 
in  a  caved-in  shaft  to  keep  cool  and  not  get  nervous. 
Accidents  and  responsibilities  bring  fear  and  anxiety, 
and  these  in  turn  produce  worry.  Such  worry  is  in- 
voluntary and  reveals  an  over-excited  condition  of  the 
psychic  side  of  the  nervous  system.  It  can  be  borne 
for  a  time,  but  if  not  counteracted  by  some  complemen- 
tary exercise  of  the  other  side,  the  organic,  it  sooner 
or  later  results  in  a  disastrous  breach  of  balance  and 
neurasthenia.  It  isn't  the  worry,  or  even  the  excess  of 
it,  that  harms,  but  the  monotonous  continuation  of  it. 
The  occasional  manifestation  of  this  worry  is  in  fact  a 
wholesome  sign,  for  it  shows  a  commendably  sensitive 
nervous  organization.  The  orator,  for  instance,  who 
experiences  a  feeling  of  over-anxiety  before  he  appears 
in  the  presence  of  his  audience  is  likely  to  develop  into 
a  greater  speaker  as  he  goes  on  in  life  than  the  one 
who  is  so  stoically  indifferent  as  to  feel  no  nervousness 
at  all.  As  physical  pain  is  man's  greatest  protector  by 
teaching  him  to  be  more  guarded  in  the  future,  so 
mental  anxiety  up  to  a  certain  point  is  his  benefactor 
in  causing  him  to  avoid,  if  possible,  the  mistakes 
of  the  past.  Just  as  the  continuation  of  physical 
pain  ends  in  physical  breakdown,  so  the  continua- 
tion of  worry  terminates  in  the  ruin  of  the  nervous 
system. 

Work  and  worry,  I  therefore  take  it,  are  not  bane- 
ful in  themselves,  not  even  when  carried  to  excess,  but 
the  monotonous,  unbroken  continuation  of  the  excess 
is  exceedingly  injurious.  An  occasional  break  in 
the  equilibrium  of  so  delicately  a  balanced  organiza- 
tion as  the  human  cerebro-spinal  nervous  system  is  not 
only  necessary  but  often  extremely  commendable. 
Only  in  this  way  can  individual  and  racial  advance- 
ment be  accomplished.  But  too  long  maintenance  of 
the  rupture  of  equilibrium  terminates,  as  we  see  all 
about  us,  in  the  most  unfortunate  results  for  the  ner- 
vous system. 

The  corollary  of  all  this  is  almost  too  obvious  to 
need  repetition.  In  the  management  of  neurasthenia 
failures  are  notoriously  frequent,  and  very  largely,  I  be- 
lieve, because  the  trouble  is  not  viewed  from  the 
above  stand-point.  Absolute  rest  is  frequently  as  un- 
effective  in  restraining  an  overwrought  nervous  system 
as  the  whole  gamut  of  nervines,  stimulants,  baths,  mas- 
sage, 3,nd  electricity.  How  often  has  the  mistake  been 
made  of  sending  a  patient  broken  down  with  an  excess 
of  business  care  and  anxiety  away  to  some  lonely 
mountain  resort  ;  or  of  recommending  some  pampered 
daughter,  living  a  quiet  life  in  a  small  town,  into  the 
midst  of  the  unwonted  glare  and  whirl  of  some  fashion- 
able summer  resort  !  An  athlete  must  keep  up  his 
training,  but  it  must  be  regulated  ;  so  a  hard  student 
should  not  be  deprived  entirely  of  his  books,  but  his 
physical  relaxations  should  be  properly  intermingled 
with  his  studies.  Before  any  general  advice  is  given, 
before  any  medicine  is  prescribed,  the  daily  and  al- 
most hourly  habits  of  the  neurasthenic  should  be  in- 
quired into.  When  any  monotonous  habits  or  particu- 
lar nervous  strain,  mental  or  physical,  are  discovered, 
it  is  not  enough,  nay,  more,  it  is  generally  highly  in- 
jurious to  tell  the  patient  he  must  give  up  absolutely 
such  habits.  Most  patients  will  answer  that  that  is 
more  easily  said  than  done,  and  in  most  cases  it  is  so. 
On  the  other  hand,  the  medical  adviser  must  study  the 
nature  of  those  habits  and  employments  and  recom- 
mend others  that  counteract  or  complement  them  in 
some  way.  The  athlete  must  be  recommended  to  take 
up  some  line  of  mental  study,  and  the  scholar  must  be 
encouraged  to  adopt  some  regular  form  of  physical 
exercise.  The  monotony  rather  than  the  mere  amount 
of  their  respective  occupations  must  be  overcome. 
The  emotional  maiden  who  overindulges  her  imagina- 
tion with  novels  should  be  recommended  to  exercise  her 
reasoning  faculty  more  with  works  of  a  different  charac- 
ter.    If  she  is  visionary  and  given  to  dawdling  away  her 


time  in  day-dreams,  she  should  be  given  a  few  tasks  in 
household  drudgery  as  an  offset. 

Gardening  is  a  splendid  relaxation  for  a  banker.  A 
European  trip  with  the  faithful  keeping  of  a  diary  is  a 
capital  outing  for  the  girl  who  has  passed  a  butterfly 
existence  of  a  long  fashionable  winter.  Tennis,  boat- 
ing, and  all  sorts  of  athletic  sports  are  to  be  urged  for 
those  whose  occupations  are  sedentary  and  confining. 
On  the  other  hand,  those  whose  work  is  largely  me- 
chanical and  physical  should  be  persuaded  to  relax 
themselves  by  taking  up  a  course  of  reading,  or  the 
study  of  some  language,  art,  or  science.  Gardening 
would  be  a  poor  sort  of  relaxation  for  the  carpenter 
who  has  been  pushing  the  plane  all  day.  The  commer- 
cial traveller  would  smile  at  you  if  you  suggested  to 
him  that  he  needed  more  physical  exercise  ;  so  would 
the  shop-walker  or  the  letter-carrier  or  the  insurance 
solicitor.  It  is  a  good  thing  to  suggest  to  neurasthenics 
also  the  authors  and  books  they  should  read,  the  kind  of 
amusements  it  would  be  well  for  them  to  see,  the  class 
of  friends  that  they  should  cultivate.  In  fine,  no  de- 
tail is  unimportant  in  the  management  of  this  prevalent 
trouble  and  the  details  of  the  moral  treatment  are  un- 
doubtedly the  most  important.  It  must  always  be  re- 
membered that  a  neurasthenic's  nervous  system  is  in 
most  cases  not  so  much  overworked  or  underworked  as 
unbalanced.  Every  suggestion  made  by  the  medical 
attendant  must  have  in  view  the  restoration  of  this 
balance.  To  obtain  the  best  results  in  the  treatment 
of  neurasthenia  demands  therefore  a  thorough  compre- 
hension of  the  trouble  and  a  faithful  attention  to  the 
minutest  details  on  the  part  of  the  practitioner.  He 
must  be  a  man  quick-witted,  full  of  ready  ideas,  liber- 
ally educated,  somewhat  of  a  psychologist,  a  close  stu- 
dent of  human  nature,  conversant  with  the  people  and 
events  of  his  day,  sympathetic,  social,  and  positive  in 
character.  Such  a  physician  will  handle  cases  of  neu- 
rasthenia, all  other  things  being  equal,  better  than  one 
who  merely  prescribes  drugs  and  recommends  rest  and 
change. 

Coli"Mbl:s  Memori.al  Bl'Ilding. 


FCETAL   DYSTOCIA.' 

Illustr.ated  by  a  Case  of  Difficult  Delivery 
OF  Head,  Shoulders,  and  Adherent  Placenta, 
WITH  Remarks  on  the  Immediate  After-treat- 
ment OF  Postpartum  Hemorrhage. 

By  ERVIN  a.  ■tucker,  M.D., 

RESIDENT   PHYSICIAN,  SLOANE  MATERNITY  HOSPITAL,  NEW  YORK  CITY. 

So  many  members  of  this  Society  are  constantly  brought 
into  intimate  contact  with  obstetric  cases  involving 
complications  of  more  or  less  difficulty  that  no  apology 
seems  necessary  in  presenting  before  you  to-night  this 
paper  upon  a  special  subject.  The  case  about  to  be 
described  has  been  selected  not  only  because  it  is  in 
itself  an  extremely  interesting  and  unusual  case,  but 
because  it  will  offer  for  discussion  so  many  points  which 
are  of  direct  practical  value  to  us  all. 

This  i>atient  was  thirty-six  years  of  age;  pregnant 
for  the  eighth  time.  Her  first  three  children  were  born 
alive,  the  next  four  still.  All  the  children  had  been 
large — at  least  nine  pounds  in  weight.  There  was  much 
cedema  of  the  extremities  in  the  first  and  second  preg- 
nancies, less  in  the  third,  and  none  subsequently.  She 
was  extremely  desirous  of  having  another  living  child  ; 
but,  as  four  in  succession  had  been  born  dead,  she  was 
of  course  much  in  doubt  whether  this  could  be  accom- 
plished. Just  why  these  four  apparently  healthy  chil- 
dren were  stillborn  I  could  not  learn.  She  was  a  woman 
of  very  large  frame,  in  good  healtli  when  I  first  saw  her. 
Her  pelvis  was  symmetrical  and  unusually  large.     Her 

'  Read  before  the  West  End  Medical  Society,  June  i,  1895. 


September  7,  1895] 


MEDICAL    RECORD. 


last  menstruation  was  June  15th  to  20th,  and  she  was 
sure  that  she  felt  life  on  November  7th.  When  I  saw  her, 
November  2 2d,  the  fundus  was  at  the  proper  height  for 
a  five  months'  pregnancy,  and  therefore  corresponded 
exactl)'  with  the  dates  of  menstruation  and  quickening. 
On  January  19th  the  fundus  was  at  the  proper  height 
for  a  seven  months'  pregnancy,  the  child,  presenting 
by  the  breech,  was  freely  movable  in  the  liquor  amnii, 
which  was  rather  more  abundant  than  is  usual  at  seven 
months. 

Three  weeks  later  (February  7th)  this  patient  pre- 
sented quite  another  picture — the  liquor  amnii  had  in- 
creased enormously  in  quantity  so  that  the  fundus  was 
almost  at  the  ensiform,  and  the  position  of  the  foetus 
could  no  longer  be  made  out  by  palpation  ;  moderate 
dyspnoea  was  present  because  of  the  pressure  upon  dia- 
phragm, and  the  stomach  refused  to  retain  ordinary 
food.  Secretion  of  urine  was  scanty,  but  there  were 
never  any  evidences  of  nephritis.  I  told  the  patient 
that  it  would  be  necessary  to  induce  labor  before  long 
if  she  became  worse.  It  had  been  my  intention  from 
the  first  to  induce  labor  before  full  term,  in  order  to 
avoid  having  the  child  too  large  for  easy  delivery  and 
to  avoid  degeneration  of  the  placenta,  which  I  suspected 
might  have  been  the  cause  of  the  deaths  of  the  previ- 
ous children,  as  we  know  that  placental  degeneration 
often  occurs  in  multiparse  at  full  term,  if  the  children 
are  unusually  robust  and  grow  to  an  enormous  size. 

On  Februar)'  i6th  (nine  days  after  the  dyspnoea  had 
begun  to  be  distressing)  the  patient  was  brought  to  the 
hospital  in  a  desperately  bad  condition.  Her  pains 
had  begun  the  night  before  at  eight  o'clock  and  she 
was  completely  in  the  second  stage  when  admitted  at 
II  A.M.,  i.e.,  duration  of  first  stage  of  labor  had  been 
fifteen  hours.  Labor  had  evidently  come  on  because 
of  the  excessive  abdominal  pressure — fundus  was  at 
the  ensiform,  and  the  abdomen  extraordinarily  distend- 
ed and  so  tense  that  palpation  was  absolutely  impossi- 
ble. Dyspnoea  was  extreme,  pulse  rapid,  temperature 
high,  and  her  general  condition  very  poor  because  of 
the  exhaustion  from  lack  of  sleep  and  inability  to  re- 
tain any  food.  She  was  quickly  prepared  for  delivery. 
AVhen  the  membranes  were  ruptured,  at  11. 18  a.m.,  the 
position  of  the  child  was  found  to  be  L.  O.  P.,  the  head, 
of  large  size,  engaged  in  the  pelvic  brim.  It  was  no- 
ticed that  the  scalp  was  unusually  thick,  and  seemed 
oedematous  immediately  after  the  rupture  of  the  mem- 
branes, when  of  course  no  caput  succedaneum  had  had 
time  to  form.  Child  was  alive,  but  the  heart  could  not 
be  heard  because  of  the  hydramnios. 

The  mother's  condition  was  so  alarming  that  imme- 
diate delivery  was  clearly  indicated,  so  forceps  was 
applied  at  11.26  a.m.  to  sides  of  the  head.  The  wide 
separation  of  the  forceps  handles  showed  that  the  head 
must  be  very  large.  With  moderate  traction,  aided  by 
the  patient  bearing  down,  the  head  advanced  into  the 
pelvic  cavity  and  the  position  became  occiput  directly 
posterior.  The  forceps  now  began  to  Slip  badly,  when 
stronger  traction  was  used.  As  it  was  necessary,  for 
the  mother's  sake,  to  deliver  this  head  as  soon  as  pos- 
sible, the  handles  of  the  forceps  were  compressed  and 
an  increasingly  strong  traction  used,  but  the  forceps 
slipped  just  the  same.  As  the  head  was  now  com- 
pletely in  the  pelvic  cavity,  with  the  occiput  directly 
posterior,  an  attempt  was  made  to  rotate  the  occiput  to 
the  front,  but  this  resulted  only  in  the  forceps  going 
around  till  inverted,  while  the  head  remained  station- 
ary. Hoping  that  a  forceps  with  a  greater  divergence 
between  the  blades  might  secure  a  better  hold,  I  sub- 
stituted Simpson  forceps  for  the  McLane  forceps, 
which  had  been  used  up  to  this  time,  but  this  fe- 
nestrated instrument  slipped  with  every  traction,  even 
when  the  handles  were  held  tight  together.  Of  course, 
I  had  by  this  time  given  up  all  hope  of  saving  the 
child,  for  I  knew  that  the  skull  must  have  been  more 
or  less  fractured  when  the  forceps  slipped  while  the 
handles  were  compressed.     Auscultation  showed  that 


the  foetal  heart  was  still  beating,  but  was  very  irregular. 
The  forceps  was  removed  at  11.47  a.m.,  because  de- 
livery with  this  instrument  was  impossible,  and  further 
attempts  would  be  a  waste  of  time. 

Podalic  version  seemed  indicated  now,  as  forceps 
had  failed  and  craniotomy  of  the  living  child  was  not 
thought  best,  though  I  must  say,  in  thinking  the  case 
calmly  over  since,  that  craniotomy  was  really  indicated, 
if  we  consider  the  fact  that  the  skull  was  already  fract- 
ured so  that  the  child  could  not  possibly  live  long  even 
if  born  alive,  and  if  we  give  due  weight  to  the  advan- 
tages gained  from  not  administering  chloroform  to  a 
patient  whose  condition  was  already  very  bad,  and  not 
subjecting  her  to  the  shock  which  is  necessary  in  doing 
an  internal  version.  Another  thing  which  made  me  at 
that  time  decide  upon  version  was  the  knowledge  that 
the  patient  was  so  desirous  of  having  the  child  bom 
alive.  So  chloroform  was  given  to  the  surgical  degree, 
the  left  hand  was  slowly  passed  into  vagina  at  11.55 
A.M.,  pushing  the  head  up  and  off  to  the  left.  In  the 
relaxed  condition,  due  to  the  chloroform,  this  was  not 
at  all  difficult,  and  the  head  was  soon  resting  in  the 
left  iliac  fossa.  The  anterior  (right)  knee  was  at  once 
found  and  a  finger  hooked  into  its  flexure,  but  strong 
traction  failed  to  make  the  child  turn.  The  leg  was 
then  straightened  out  and  a  good  hold  obtained  upon 
the  foot,  but  the  strongest  possible  traction  upon  this 
right  foot,  with  upward  pressure  upon  the  head,  and 
downward  pressure  upon  the  breech,  failed  to  turn. 
Traction  was  made  upon  both  feet  with  the  same 
negative  result.  The  umbilical  cord  was  now  felt  of 
at  the  navel  and  found  to  be  pulseless,  so  the  child  was 
undoubtedly  dead  (12.16  p.m.).  Death  of  the  child 
probably  explains  why  the  attempts  at  version  failed, 
for  a  dead  body  lacks  that  resiliency  which  makes  ver- 
sion easy. 

Soon  after  the  hand  was  withdrawn  the  head  came 
down  into  the  pelvis  again.  The  blades  of  Tarnier's 
cephalotribe  were  then  inserted  laterally,  grasping  the 
head  (L.  O.  P.)  over  the  left  side  of  forehead  and  the 
right  side  of  occiput.  The  blades  were  screwed  so 
firmly  together  that  slipping  was  impossible.  Repeated 
tractions,  as  powerful  as  could  be  exerted,  with  ex- 
treme oscillation,  laterally  and  vertically,  caused  slow 
advance  till  the  head  was  born  at  12.24  p.m.  As 
the  head  was  being  extracted,  the  occiput  was  rotated 
to  the  front,  so  as  to  have  a  smaller  diameter  born. 
During  the  strong  traction  necessary  for  delivery  the 
head  burst  and  most  of  the  brain  escaped.  Then  it 
was  discovered  that  the  shoulders  were  too  large  to 
enter  the  pelvic  brim,  though  the  strongest  possible 
traction,  without  and  with  oscillation,  was  made  with 
the  cephalotribe  still  grasping  the  head. 

The  only  way  now  remaining  to  effect  delivery  was 
to  diminish  the  shoulder-bulk,  so  the  head  was  removed 
from  the  body  by  turning  it  around  completely,  thus 
wringing  it  off  of  the  neck  very  easily  and  quickly, 
lea\'ing  as  neat  a  stump  as  if  the  decapitation  had  been 
done  with  a  knife.  My  hand  was  then  inserted  and 
the  anterior  (right)  arm  brought  down.  Traction  upon 
this  arm  so  strong  that  the  shoulder  joint  began  to  sep- 
arate failed  to  cause  advance,  so  the  other  arm  was 
brought  down  and  traction  made  upon  it  till  it  also  be- 
gan to  tear  in  the  axilla.  By  this  time  the  shoulders 
had  come  down  to  the  pelvic  floor.  As  no  more  trac- 
tion could  be  made  upon  the  arms,  a  blunt  hook  was 
forced  between  the  ribs  near  the  spine.  By  very  strong 
traction  on  this  hook  the  body  was  finally  delivered, 
back  anterior,  at  12.46  p.m. 

The  patient  was  by  this  time  in  extremis.  The  ute- 
rus, containing  the  secundines,  was  unusually  large  and 
flabby.  A  little  blood  began  to  trickle  away  just  after 
delivery  of  the  child,  so  an  attempt  was  made  to  ex- 
press the  placenta  in  order  to  prevent  further  hemor- 
rhage. As  this  attempt  failed,  the  whole  hand  was  in- 
serted and  the  placenta  found  on  the  right  side  of  the 
uterus,  extending  up  well  over  the  fundus.     This  pla- 


MEDICAL    RECORD. 


[September  7,  1895 


centa  was  firmly  adherent  over  its  entire  maternal  sur- 
face and  had  to  be  dug  away  from  the  uterine  wall  with 
the  fingers  and  brought  out  by  the  handful.  This  was 
done  as  rapidly  as  possible — in  about  three  minutes. 
Hemorrhage  was  profuse  all  the  while.  As  soon  as  all 
the  placenta  had  been  extracted,  at  12.51  p.m.,  a  hot 
acetic-acid  uterine  douche  was  given,  causing  the  ute- 
rus to  contract  well  and  remain  contracted  so  that  there 
was  no  more  hemorrhage. 

Before  extraction  of  the  placenta  was  completed,  the 
patient  was  apparently  dying  ;  all  the  symptoms  due  to 
great  loss  of  blood  were  present.  Meanwhile  a  nurse 
had  been  giving  hypodermics  of  ether  and  of  brandy — 
at  least  a  dozen  of  a  half  drachm  each  were  given  as 
rapidly  as  possible,  but  the  pulse  remained  impercepti- 
ble at  the  wrist.  As  soon  as  the  uterus  was  emptied 
the  first  hot  saline  enema  was  given  and  the  patient 
soon  began  to  rally  slowly.  One-half  hour  later  the 
pulse  could  be  counted  (120),  and  it  slowed  gradually 
as  the  enemata  were  given.  The  great  value  of  hot  sa- 
line enemata  after  hemorrhage  cannot  be  over-esti- 
mated, and  their  value  was  especially  illustrated  in  this 
case.  The  first  enema,  consisting  of  two  pints  of  water 
at  116°  F.,  one  ounce  of  whiskey,  and  one  drachm  of 
salt,  was  given  at  i  p.m.,  and  followed  by  another  at 
1.30  and  another  at  2.45  and  another  at  3.45  p.m.,  then 
a  smaller  hot  enema  (one  pint  of  water,  one  ounce  of 
whiskey,  and  one  drachm  of  salt)  was  given  at  5.30  and 
again  at  10  p.m.  All  these  were  retained  except  the 
last,  which  was  partially  expelled.  As  soon  as  an 
enema  of  this  kind  ceases  to  be  retained,  I  take  it  as  a 
sign  that  the  vascular  system  has  obtained  all  the  fluid 
it  needs  to  replace  the  lost  blood.  In  this  case  there 
were  fully  nine  pints  of  saline  solution  retained  and  ab- 
sorbed before  the  pulse  became  full  and  strong,  thus 
showing  that  no  more  fluid  was  needed.  The  value  of 
the  heat  carried  in  with  the  enema  must  not  be  under- 
estimated. When  a  patient  is  in  deepest  collapse,  one 
hot  enema  will  do  more  good  than  several  warm  ones. 
The  salt  must  not  be  omitted,  if  we  wish  the  fluid  to  be 
quickly  absorbed.  A  drachm  of  salt  to  a  pint  of  water 
makes  a  formula  easy  to  remember  and  is  near  enough 
to  a  "  nonnal  salt  solution  "  for  all  practical  purposes. 
The  enema  also  gives  us  an  easy  means  for  introducing 
stimulants  when  the  stomach  refuses  everything,  and 
we  thus  avoid  the  inconvenience  of  hypodermic  stimu- 
latiop. 

I  run  the  risk  of  wearying  you  with  these  statements 
about  well-known  facts,  because  I  am  afraid  that  in  the 
eager  rush  for  new  remedies  and  new  specifics,  which 
is  so  characteristic  of  this  day  and  generation,  some 
of  us  have  forgotten,  or  may  forget,  the  standard 
value  of  these  simple  but  always  reliable  methods  of 
dealing  with  serious  conditions.  For  several  years 
now  I  have  used  hot  saline  enemata  containing  various 
stimulants  for  the  immediate  after-treatment  of  all  cases 
of  severe  hemorrhage  with  the  result  that  I  cannot  re- 
port even  one  fatal  case. 

During  the  night  following  delivery  the  patient  could 
retain  nothing  in  the  stomach.  She  vomited  repeatedly, 
and  retched  even  when  the  stomach  was  empty.  This 
troublesome  symptom  was  finally  relieved  by  giving 
small  doses  of  champagne  and  cracked  ice,  after  sev- 
eral other  gastric  sedatives  had  been  tried  in  vain.  In 
the  afternoon  (about  twenty-four  hours  post-partum) 
she  could  retain  milk  and  vichy.  From  this  time  on 
her  convalescence  was  rapid  and  constant,  without  an 
unfavorable  symptom  of  any  kind. 

The  chart  of  her  temperature,  pulse,  and  respiration 
showed  that  her  puerperium  was  uneventful,  except  for 
the  wonderful  fact  that  she  recovered.  She  had  no  after- 
pains,  as  she  had  had  in  all  previous  puerperia  except  the 
first.  She  had  no  headache,  which  is  so  common  after 
an  enormous  hemorrhage.  She  had  no  sepsis,  which  is 
so  apt  to  follow  exhausting  labors,  especially  if  there  is 
much  blood  lost,  or  if  operative  manipulations  are  pro- 
longed.    The  absence  of  the  headache  and   sepsis  and 


her  smooth  convalescence  were  undoubtedly  due  to 
the  generous  use  of  the  saline  enemata.  The  absence 
of  after-pains  was  due  to  the  thorough  emptying  of  the 
uterus.  The  lochia  were  nonnal  in  quantity  from  the 
first,  instead  of  being  scanty  as  is  the  rule  after  hemor- 
rhage, but  their  color  was  pale.  The  uterus  involuted 
perfectly.  At  her  own  request,  because  she  felt  so  well, 
she  was  allowed  up  in  a  chair  on  the  twelfth  day  and 
was  allowed  to  walk  a  little  on  the  seventeenth  day. 

With  your  permission  I  will  set  before  you  some 
rather  astonishing  figures  about  this  case.  Of  course 
you  are  at  liberty  not  to  believe  them,  but  I  assure 
you  that  they  are  true.  When  the  membranes  rupt- 
ured, nine  quarts  of  liquor  amnii  were  caught  in  pails  ; 
a  moderate  estimate  is  that  fully  one-half  as  much  more 
was  lost  then  and  during  deliver)-,  as  some  escaped 
with  every  pain,  and  much  more  came  away,  when  the 
attempt  at  version  was  made ;  therefore,  the  total 
quantity  of  liquor  amnii  was  at  least  twenty- seven  pints. 
The  child,  a  female,  though  of  only  about  eight  months' 
intra-uterine  development,  according  to  the  best  of  my 
knowledge  and  belief,  measured  56  ctm.  in  length  ;  the 
circumference  of  the  shoulders  was  43  ctm.;  of  the  ab- 
domen, 45  ctm.  ;  and  of  the  right  thigh,  19.5  ctm. 
The  head  and  body  weighed  9  pounds  6  ounces,  but 
all  of  the  blood  and  meconium  and  nearly  all  of  the 
brain  were  missing ;  these  would  certainly  weigh  2 
pounds  (probably  more)  in  such  a  large  child,  so  the 
total  weight  was  at  least  1 1  pounds  6  ounces.  A  ne- 
cropsy of  this  child  revealed  the  fact  that  the  peritoneal 
and  pleural  and  pericardial  cavities  were  full  of  brown- 
ish serum,  so  the  child  would  probablj'  not  have  sur- 
vived long,  even  if  it  had  been  born  uninjured.  Most 
of  the  blood  with  the  placental  debris  was  caught  in 
basins.  After  the  pieces  of  placenta  had  been  picked 
out,  the  blood  was  found  to  weigh  93  ounces  ;  a  very 
modest  estimate  of  the  blood  that  was  not  caught  is  12 
ounces  ;  so  the  total  blood  loss  was  105  ounces,  all 
of  which  hemorrhage  took  place  within  five  minutes. 
The  placenta  weighed  3  pounds  11  ounces.  If  we  add 
together  all  that  escaped  from  this  patient's  body  from 
the  time  when  the  membranes  ruptured  till  the  uterus 
was  empty,  a-e  find  a  sum  total  of  about  forty-eight  and 
one  half  pounds. 

In  the  operative  part  of  this  case  there  were  several 
practical  points  demonstrated  which,  it  seems  to  me, 
are  well  worth  considering.  One  lesson  of  special  im- 
portance is,  that  if  the  forceps  slips  when  properly  ap- 
plied, it  means  that  the  case  is  not  adapted  for  delivery 
with  forceps,  i.e.,  the  forceps  is  contra-indicated  and  its 
further  use  will  result  only  in  doing  harm.  Fenestrated 
forceps  blades  slip  just  as  badly  as  do  solid  blades,  if 
the  head  is  too  large,  i.e.,  any  forceps  will  slip,  if  it 
does  not  fit  the  head.  If  the  forceps  slips  while  strong 
traction  is  being  made,  the  child's  skull  will  surely  be 
fractured.  After  the  liquor  amnii  is  gone,  version  is 
always  difficult  and  usually  impossible,  if  the  child  is 
dead.  When  the  foetal  heart  cannot  be  heard,  feeling 
of  the  cord  at  the  navel  is  a  legitimate  way  of  finding 
out  whether  the  child  is  alive  or  dead,  if  this  infonna- 
tion  is  necessary  for  deciding  upon  further  treatment. 
If  the  child  must  be  born  head  first  and  forceps  can- 
not deliver,  the  cephalotribe  is  the  best  instrument  for 
obtaining  a  hold  of  the  head  firm  enough  to  accom- 
plish delivery.  Oscillation  will  cause  advance  when 
straight  traction  fails.  Pulling  down  one  or  both  arms 
after  decapitation  is  the  easiest  way  to  deliver  enor- 
mous shoulders  which  cannot  otherwise  be  made  to  en- 
ter the  pelvic  brim.  If  the  placenta  is  adherent  to  the 
uterine  wall,  its  removal  by  hand  is  the  only  quick  and 
safe  method. 


Abortion. — After  membranes  have  been  removed, 
the  uterine  cavity  should  be  swabbed  out  with  iodine 
it  being  an  excellent  antiseptic  and  hemostatic. — 
Parvin. 


September  7,    1895] 


MEDICAL   RECORD. 


DEAFNESS  FROM  INTRA-NASAL  DISEASE- 
By  JOHN  A.  THOMPSON,  M.D., 

CINCINNATI,  0. 

All  the  scientific  work  done  by  physicians  in  their 
own  field  of  labor  is  directed  toward  the  prevention  or 
relief  of  human  suffering.  Our  physiological  laborato- 
ries only  fulfil  the  purpose  of  their  creation  when  they 
investigate  and  teach  the  laws  of  normal  being  and 
show  us  how  to  avoid  a  disastrous  conflict  with  them. 
Pathological  investigations,  including  bacteriology,  are 
meant  to  teach  us  the  true  nature  of  disease,  that  we 
may  prevent  or  cure  the  abnormal  processes  revealed. 
We  seek  for  knowledge  only  that  we  may  apply  it  to 
the  individual  case.  As  the  object  of  all  this  study  is 
clinical,  suggestions  for  physiological  and  pathological 
research  must  largely  come  from  clinical  observation. 
The  experience  of  the  physician  in  his  daily  rounds 
among  the  sick  and  suffering  should  show  where  we 
are  lacking  in  knowledge.  The  practitiorer  should 
suggest  the  topics  that  the  investigator  may  work  out 
in  the  laboratory.  I  believe  it  a  duty,  where  a  physician 
encounters  cases  that  cannot  be  explained  by  known 
physiological  and  pathological  principles,  to  place  these 
cases  on  record,  hoping  that  some  acuter  mind  may 
supply  an  explanation  which  will  result  in  the  preven- 
tion or  cure  of  similar  conditions  in  other  patients. 

Diseases  of  the  ear  are  more  intractable  to  treatment 
than  those  we  encounter  in  any  other  department  of 
medicine.  Late  cases  of  chronic  catarrhal  otitis  media 
in  either  of  its  forms  are  regarded  by  experienced 
otologists  as  being  almost  hopeless  by  modern  methods 
of  treatment.  From  this  hopelessness  arises  the  con- 
stant suggestion  of  new  procedures  directed  to  the  ear 
itself,  in  the  hope  of  at  least  partially  restoring  the 
function  which  is  so  important  to  the  happiness  and 
success  in  life  of  the  individual.  A  few  observers, 
notably  Swinburne,  turning  from  the  attempt  to  cure 
the  already  established  condition,  have  sought  to  lessen 
the  number  of  hopelessly  deaf  by  seeking  the  cause 
and  method  of  prevention.  Swinburne  examined  the 
nose  and  throat  carefully  in  a  thousand  cases  which 
presented  themselves  at  the  Harlem  Eye,  Ear,  and 
Throat  Infirmary,  complaining  of  deafness.  Where 
deafness  results  from  disease  of  the  middle  ear,  his 
conclusions  are  that  in  ninety-five  per  cent,  of  all  cases 
the  primary  lesion  is  in  the  noseor  naso-pharynx.  Just 
how  disease  in  these  organs  produces  chronic  inflam- 
mation in  the  tympanic  cavity  has  been  a  question  of 
dispute.  Some  experienced  writers  claim  it  is  due  to 
the  direct  extension  of  inflammation  by  continuity  of 
tissue.  In  structure  the  tympanum  is  only  one  of  the 
accessory  sinuses  of  the  nose,  though  it  differs  entirely 
from  that  organ  in  function.  Others  have  thought  we 
could  trace  the  resultant  ear  disease,  secondary  to 
obstructive  lesions  in  the  upper  respiratory  tract,  to 
imperfect  aeration  of  the  middle  ear.  Still  other  au- 
thorities have  thought  that  the  interference  with  the 
circulation  in  the  internal  and  middle  ear  by  the  in- 
flammatory and  neoplastic  changes  in  the  nose  or 
naso-pharynx  was  the  cause  of  the  secondary  disease. 
While  the  battle  has  been  fierce  and  the  flow  of  ink 
free  in  this  wordy  war,  it  is  probable  that  all  are  right ; 
that  each  method  plays  a  part  in  the  production  of 
secondary  diseases  in  the  middle  ear. 

While  I  have  seen  many  cases  where  the  secondary 
deafness  could  be  accounted  for  and  the  cure  under- 
stood from  the  well-known  relations  of  nasal  and  aural 
diseases,  I  have  encountered  others  that  are  not  sus- 
ceptible of  explanation  by  any  of  the  known  facts  in 
rhinology  or  otology.  I  wish  to  report  three  of  these 
cases,  chosen  because  they  are  dissimilar  in  many  of 
their  features.  They  suggest  that  there  is  a  relation 
not  yet  understood  between  the  healthy  condition  of 
the  nose  and  naso-pharynx,  and  the  sense  of  hearing. 
In  all  of  these  cases  there  has  been  a  serious  and  irre- 


medial  impairment  of  the  organ  of  hearing,  yet  in  all 
the  ability  to  hear  has  been  greatly  increased  by  re- 
storing the  nose  and  throat  to  their  normal  condition. 

Mrs.  S ,  aged  thirty-one  years,  married  when  six- 
teen years  old,  has  suffered  from  diseases  of  the  gener- 
ative organs  since  the  birth  of  her  first  child.  She  is 
very  nervous,  weak,  and  ansemic.  She  suffered  from 
pains. in  the  chest,  headache,  cardiac  palpitation, 
rapid  pulse,  and  dyspepsia.  These  symptoms  could  not 
be  relieved  by  ordinary  constitutional  treatment.  She 
was  referred  to  me  by  her  physician,  Dr.  W.  H.  De- 
Witt,  for  the  treatment  of  the  upper  air-passages,  with 
the  hope  of  relieving  these  intractable  symptoms,  which 
he  believed  were  secondary  to  the  local  disorder. 

The  patient  had  marked  hypertrophic  rhinitis,  with  a 
deflected  and  thickened  septum.  The  thickening  was 
in  the  right  nostril.  There  was  also  marked  naso- 
pharyngeal catarrh.  The  right  ear  was  deaf  to  all  or- 
dinary tests.  She  could  not  hear  the  watch  on  contact. 
She  could  not  hear  the  conversational  voice.  She 
could  hear  loud  voices  only  as  an  indistinct  noise.  She 
gave  a  history  of  this  ear  as  follows  :  Seven  years  be- 
fore, while  suffering  greatly  from  her  uterine  trouble, 
the  ear  became  inflamed  and  was  intensely  painful  for 
several  days.  The  drum  was  finally  perforated  ;  the 
pain  diminished  with  the  free  discharge  of  pus  from  the 
ear.  She  had  had  occasional  attacks  of  acute  suppura- 
tion in  the  middle  ear  from  that  time.  Inspection  of 
the  ear  showed  a  cicatricial  drum  membrane  with  evi- 
dence of  old  perforations.  There  was  no  suppuration 
at  this  time.  The  ossicles  were  firmly  bound  together 
by  old  inflammatory  adhesions.  The  condition  re- 
vealed by  inspection  was  so  bad  that  no  attempt  was 
made  then  or  subsequently  to  improve  the  hearing  by 
treatment  of  the  ear.  The  hypertrophic  rhinitis  was 
treated  by  the  usual  method,  and  the  spur  on  the  sep- 
tum was  removed  March  13,  1894.  The  headache  and 
neuralgia  of  the  chest,  which  the  patient  had  supposed 
were  all  due  to  her  uterine  trouble,  were  entirely  re- 
lieved within  six  months  after  this  operation.  The 
rapid  pulse  and  cardiac  palpitation  yielded  to  the 
combined  effect  of  the  operation  and  heart  tonics  ad- 
ministered internally.  The  patient  began  to  improve 
in  health  and  strength  and  in  a  short  time  felt  better, 
weighed  more,  and  was  better  able  to  do  her  work  than 
she  had  been  for  years.  About  ten  months  after  the 
operation  she  discovered  that  hearing  had  returned  to 
the  supposed  incurably  deaf  right  ear.  A  careful  test 
of  this  organ  in  April,  1895,  shows  that  the  patient  is 
able  to  hear  the  conversational  voice  fairly  well,  and 
hears  the  watch,  which  was  not  heard  on  contact  be- 
fore the  operation,  two  inches  from  the  ear. 

F.  J.  H ,  aged  eighteen,  had  scarlatina  when  he 

was  thirteen  years  old.  The  scarlatina  was  compli- 
cated by  purulent  otitis  media  in  both  ears.  The 
drum  membrane  and  ossicles  of  the  right  ear  were  com- 
pletely destroyed.  In  the  left  ear  three-fourths  of  the 
drum  membrane  was  destroyed  and  the  ossicles  remain 
bound  together  by  cicatricial  adhesions.  With  every 
cold  the  patient  caught  there  would  be  suppuration 
from  one  or  both  ears.  I  saw  him  first  in  March,  1894. 
At  that  time  he  heard  a  conversational  voice  one  foot, 
could  not  hear  a  watch  on  contact,  and  could  not  hear 
a  whisper  at  all.  There  was  no  appreciable  difference 
in  the  hearing  powers  of  the  two  ears.  He  was  about 
to  lose  his  situation  as  clerk  because  of  his  inability  to 
carry  on  a  conversation  with  customers  in  the  store. 

Examination  of  the  nose  and  throat  showed  hyper- 
trophic rhinitis  and  a  large  spur  on  the  septum  in  the 
left  nostril.  There  was  a  complicating  naso-pharyn- 
geal  catarrh.  After  treating  the  acute  inflammation 
that  was  present  when  I  saw  him,  for  a  few  days,  I  re- 
moved the  spur  and  cauterized  the  hypertrophied  tur- 
binated bodies  so  as  to  give  him  free  breathing  room 
through  the  nose.  The  left  ear  was  suppurating  when 
I  first  saw  him,  but  this  suppuration  readily  yielded  to 
the  dry  treatment.     The  patient  was  under  treatment 


338 


MEDICAL    RECORD. 


[September  7,    1895 


six  weeks,  and  was  dismissed  with  the  ability  to  hear  a 
whisper  three  feet  and  to  distinguish  ordinary  conver- 
sation so  readily  that  he  still  retains  his  position  as 
clerk.  December  i,  1894,  he  caught  a  severe  cold, 
and  with  the  resultant  swelling  and  inflammation 
of  the  nose  and  throat  his  hearing  became  again  seri- 
ously impaired.  Ten  days  of  local  treatment  cured 
this  attack,  and  with  the  return  of  the  nose  to  the  nor- 
mal condition  the  hearing  distance  for  the  whispered 
voice  again  became  three  feet  for  either  ear. 

Mrs.  F.  L.  T ,  aged  thirty-five,  has  been  deaf  from 

childhood.  I  can  get  no  distinct  history  of  the  cause  of 
this  deafness.  She  had  repeated  attacks  of  acute  puru- 
lent otitis.  In  her  earlier  years  she  was  treated  by  a  num- 
ber of  good  otologists,  who  succeeded  in  checking  the 
suppuration,  but  did  not  prevent  the  total  loss  of  hearing 
power  in  the  right  ear.  She  had  been  constantly  under 
the  care  of  a  competent  man  for  three  years  before  I 
saw  her.  She  had  visited  him  once  or  twice  a  week  all 
this  time  to  have  the  left  ear  inflated  by  the  Politzer 
method.  This  inflation  gave  temporary  relief  from  the 
tinnitus  aurium  and  improved  the  hearing  temporarily. 
In  spite  of  this  treatment  the  deafness  was  progressive, 
and  at  the  end  of  the  three  years  she  was  worse  than  at 
the  beginning  of  this  period.  Examination  of  the  ears 
showed  the  right  ear  with  only  a  perception  of  loud 
sounds.  Inspection  of  the  drum  showed  only  a  mass 
of  cicatricial  tissue,  through  which  nothing  could  be 
seen  to  throw  any  light  on  the  condition  of  the  middle 
ear.  The  left  ear  showed  a  badly  retracted  drum 
membrane  with  cicatrices  where  old  perforations  had 
healed.  Loud  voice  heard  only  one  foot,  watch  not 
at  all,  in  left  ear.  Examination  of  the  nose  showed  a 
bad  hypertrophic  rhinitis,  and  in  the  right  nostril,  at 
the  junction  of  the  perpendicular  plate  of  the  ethmoid 
with  the  triangular  cartilage,  there  was  an  enchondroma 
with  a  broad  base  nearly  an  inch  in  diameter  and  so 
thick  that  it  completely  filled  the  upper  and  anterior 
portion  of  the  right  nostril.  As  all  known  methods  of 
direct  treatment  to  the  ear  had  failed  to  benefit  the 
deafness,  I  decided  to  remove  the  enchondroma  and  to 
restore  the  lumen  of  the  nostril  by  cauterization  of  the 
hypertrophied  tissue  in  the  turbinated  bodies.  The 
operation  was  made  under  chloroform  October  11, 
1894.  I  cut  the  nasal  branch  of  the  ophthalmic  artery 
in  the  first  incision  for  the  removal  of  the  tumor.  This 
complicated  very  much  an  operation,  always  difficult 
to  perform  on  account  of  the  free  bleeding  hiding  the 
field  of  operation.  I  removed  the  tumor  as  rapidly  as 
possible  and  packed  the  nose  with  cotton  saturated 
with  McKenzie's  styptic  solution.  Recovery  was  fur- 
ther complicated  by  an  attack  of  follicular  tonsillitis 
which  began  three  days  after  the  operation.  The  pa- 
tient was  already  weakened  from  loss  of  blood  and  from 
the  shock,  so  the  attack  of  tonsillitis  was  unusually  se- 
vere and  prolonged.  The  immediate  effect  upon  the 
hearing  was  of  course  disastrous.  As  soon  as  the  pa- 
tient was  able  to  resume  her  visits  to  the  oflSce,  the  hy- 
pertrophied tissue  in  the  turbinated  bodies  was  de- 
stroyed by  the  galvano-cautery  as  rapidly  as  this  could 
be  done  without  exciting  severe  inflammation.  The 
patient  remained  under  treatment  for  four  months  and 
was  dismissed  with  hearing  distance  for  the  watch,  left 
ear,  of  nine  inches.  She  hears  the  ordinary  conversa- 
tional voice  with  ease.  She  had  never  been  able  to 
hear  a  clock,  which  had  been  given  her  as  a  wedding 
present  eight  years  before,  until  after  this  operation. 
On  awakening  one  night  she  was  very  much  alarmed 
at  its  ticking,  though  she  was  lying  in  bed  across  the 
room  from  the  mantel  on  which  the  clock  stood.  Up 
to  the  present  the  improvement  has  continued,  and  I 
have  no  doubt  the  hearing  will  be  better  a  year  from 
now  than  it  is  to-day. 

These  three  cases  present  few  similar  features.  There 
was  in  all  marked  nasal  obstruction  from  hypertrophy 
of  the  normal  tissues  and  from  the  growth  of  abnormal 
structures.     The  condition  of  the  ears  in  all  was  such 


as  to  offer  no  hope  of  cure  by  treatment  of  the  ear  it- 
self. All  were  benefited  so  they  could  hear  ordinary 
conversation,  the  best  test  of  hearing  power,  by  treat- 
ment of  the  nose. 

In  the  first  case  reported  the  ear  was  never  treated, 
either  before  or  after  the  operation  on  the  nose,  yet  as 
a  result  of  this  operation  hearing  is  restored  to  an  ear 
which  to  all  appearances  was  hopelessly  deaf. 

In  the  third  case  the  patient  had  been  under  the 
constant  care  of  competent  men  from  childhood  to  ma- 
ture life.  In  spite  of  this  care  the  hearing  power  was 
entirely  lost  in  one  ear  and  so  far  diminished  in  the 
other  ear  that  common  conversation  could  not  be  heard. 
Yet  in  this  case  the  hearing  power  is  restored  to  the 
ear  by  restoring  the  norma!  lumen  of  the  nostrils.  Dur- 
ing the  time  she  was  my  patient  the  ear  received  no 
treatment.  It  might  be  said  the  result  in  these  cases 
was  due  to  the  fact  that  normal  respiration  and  aera- 
tion of  the  middle  ear  through  the  Eustachian  tube  was 
restored.  While  this  is  a  possible  explanation,  I  do 
not  believe  it  to  be  the  true  one.  In  the  third  case 
the  Eustachian  tube  had  been  kept  open  by  constant 
treatment,  yet  the  deafness  was  increasing.  The  tube 
remaining  open,  no  attention  was  paid  to  it  while  I  was 
treating  the  nose,  j-et  there  was  a  remarkable  gain  in 
hearing  power.  It  certainly  will  not  apply  to  the  sec- 
ond case,  where  in  one  ear  there  was  no  drum  mem- 
brane at  all  and  in  the  other  ear  only  a  remnant.  The 
recurrence  of  the  deafness  months  afterward  when  the 
nose  became  inflamed  and  swollen,  and  the  proniTit 
restoration  of  good  hearing  power  by  treatment  of  the 
nose,  is  an  additional  demonstration  of  the  controlling 
influence  that,  in  this  case  at  least,  the  nose  has  on  the 
power  of  hearing. 

While  I  do  not  pretend  to  explain  the  influence 
which  brought  about  the  deafness  or  the  cure  in  these 
cases,  there  is  a  practical  conclusion  to  be  drawn,  upon 
which  we  can  act,  even  if  we  do  not  understand  thor- 
oughly the  theory  or  the  principle  on  which  our  action 
is  based. 

This  deduction  is,  that  no  case  of  supposed  incurable 
deafness  is  really  so  unless  the  nose  and  naso  pharynx 
have  been  examined  and  treated,  if  necessary,  by  a 
competent  rhinologist. 


ALKALINE    INJECTIONS    FOR   THE   TREAT- 
MENT  OF  GONORRHCEA. 

By  PHILIP  JAISOHN,  M.D., 

PATHOLOGIST  TO  THE  GARnELD  MEMORIAL   HOSPITAL,  WASHINGTON,  D.    C. 

The  methods  of  treating  gonorrhcea  are  almost  as  nu- 
merous as  the  individuals  who  are  affected  with  this 
disease.  There  is  no  fixed  rule  governing  the  treat- 
ment of  this  common  malady.  For  instance,  the  so- 
called  "  specific  treatments  "  "  work  marvels  "  in  one 
case,  but  fail  in  another.  The  books  and  journals  are 
full  of  contributions  and  suggestions  under  the  head  of 
the  treatment  of  gonorrhoea,  according  to  the  individ- 
ual's experience  as  to  what  success  he  has  obtained  by  a 
certain  mode  of  treatment.  However,  all  these  various 
methods  have  one  common  object  in  view  ;  that  is,  to 
arrest  or  destroy  the  growth  of  the  germs  which  cause 
the  inflammation.  The  majority  of  cases  generally 
yield  under  these  treatments  in  a  more  or  less  satisfac- 
tory manner,  but  as  a  rule  the  moderately  severe  cases 
never  become  entirely  cured  in  less  than  four  weeks' 
time. 

It  is  needless  to  say  how  frequently  we  meet  with 
those  cases  that  have  been  supposed  to  be  cured,  which 
have  developed  into  gleet,  stricture,  inflammation  of 
the  adjacent  glands,  etc.  There  is  a  new  fact  which 
has  hitherto  been  unobserved,  and  which  I  think  will 
be  of  interest  to  the  medical  profession.  Before  going 
further,  it  is  necessary  to  understand  the  characteristics 


September  7,    1895] 


MEDICAL    RECORD. 


339 


of  the  germ  which  causes  gonorrhoea  (gonococcus),  in 
order  to  describe  the  new  fact  more  intelligently. 

The  gonococcus  was  discovered  by  Neisser  in  1S79, 
and  cultivated  by  Baume  in  1885.  It  is  constantly 
present  in  virulent  gonorrhceal  discharges  from  the  part 
in  the  interior  of  the  pus-cells,  or  attached  to  the  sur- 
face of  the  epithelial  cells.  Baume  succeeded  in  culti- 
vating it  only  in  the  blood-serum  ;  but  no  one  has  ever 
been  able  to  make  it  grow  in  the  ordinary  peptonized 
bouillon,  nutrient  gelatine,  or  agar-agar.  Recently, 
however,  it  has  been  successfully  cultivated  in  the  or- 
dinary media,  provided  the  media  are  rendered  acid  by 
adding  a  few  drops  of  hydrochloric  acid. 

As  a  rule,  bacteria  do  not  grow  well  in  acid  media, 
whether  they  be  of  pathogenic  or  innocuous  variety. 
Therefore  the  peculiarity  of  gonococcus  is  that  it  grows 
in  acid,  and  not  in  alkaline  media.  For  this  reason 
gonococci  flourish  in  the  mucous  membrane  of  the  ure- 
thra or  vagina,  which  are  acid  in  reaction  by  the  pas 
sage  of  urine  and  the  glandular  secretions.  Knowing 
the  fact  that  they  do  not  grow  in  alkaline  media  sug- 
gests to  us  the  idea  of  rendering  the  urethral  or  vaginal 
mucous  membrane  alkaline  in  the  treatment  of  gonor- 
rhoea. The  obvious  reason  is  to  make  the  part  as  un- 
favorable as  possible  for  gonococci  to  thrive  in.  I 
have  treated  si.\  cases  at  different  stages  of  the  disease, 
and  obtained  the  most  satisfactory  results  by  using  al- 
kaline antiseptic  injections.  At  the  same  time,  liberal 
doses  of  alkaline  diuretics  administered  internally  ; 
the  object  of  which  is  not  only  to  make  the  part  alkaline 
by  the  local  irrigations,  but  rendering  the  urine  alka- 
line also.  Of  course,  we  must  consider  also  the  man- 
agement of  staphylococcus,  which  is  always  associated 
with  gonococcus  to  produce  pus,  and  aggravates  inflam- 
mation in  this  form  of  urethritis.  There  is  nothing 
which  will  destroy  these  pyogenic  cocci  more  effectually 
than  the  solution  of  bichloride  of  mercury.  For  this 
purpose  I  use  the  mercurial  solution  at  the  strength  of 
one  to  ten  thousand,  making  this  solution  alkaline  by 
adding  liquor  potassii  at  the  proportion  of  one-half 
drachm  to  the  ounce. 

The  injections  should  be  given  at  least  every  four 
hours,  and  internally  the  following  mi.xture  is  given  ; 

9.    Sodii  bicarbonatis 3  j. 

Spts.  setheris  nitrosi f .  5  ss. 

Potassii  citratis §  ij. 

In{us.  lini  comp q.s.  O  j. 

M.  Sig.  :  Take  a  wineglassful  every  two  or  three  hours. 

My  experience  with  this  mode  of  treatment  is  limited, 
therefore  I  will  not  make  more  conclusive  remarks  in 
regard  to  its  efficacy,  but  my  faith  concerning  it  is 
great.  The  chief  merit  of  this  method  is  that  it  hastens 
the  recovery  much  quicker  than  any  other  procedure. 
In  my  own  experience,  four  out  of  six  cases  became  en- 
tirely cured  within  two  weeks  of  the  treatment,  although 
in  the  beginning  they  were  all  severe  types  of  gonor- 
rhoea. The  other  two  cases  were  of  long  standing,  and 
they  took  longer  to  gain  complete  recovery  ;  but  the 
gleety  discharge  diminished  considerably  after  two  or 
three  irrigations,  and  disappeared  altogether  within 
three  weeks. 


CoUca  Pictonum. — 

9 .    Magnesii  suJphat 5  j. 

Acid,  sulphuric  dil f  3  ]• 

Aquae ^ f  |  iv. 

M.  Sig. :  Give  one  tablespoonful  three  times  a  day,  preceded  by 
ten  grains  of  iodide  of  potash. 

— Brunton. 

Rhetunatism  in  Malta  continues  »o  be  treated,  in  se- 
vere cases,  by  bee  stings,  a  method  which  has  pre- 
served its  reputation  for  a  long  time.  The  antidote  is 
said  to  give  great  relief  to  sufferers,  though  on  first 
hearing  it  does  not  recommend  itself  so  well  to  the  un- 
initiated. 


GEOLOGY— A   MEDICAL   COLLATERAL. 
By  HARVEY  B.  BASHORE,  M.D., 

WEST  F.\1RVIEW,   PA. 

The  earth,  or  at  least  its  upper  layers,  is  beginning  to 
have  such  an  important  place  in  the  prevention  of  dis- 
eases and  epidemics,  that  a  study  of  geology  must 
become  of  more  or  less  value  to  the  physician  and  the 
sanitarian  ;  the  correct  understanding  of  drainage  and 
sewage  disposal,  of  water  and  food  supply,  depend 
considerably  on  a  definite  knowledge  of  the  earth's 
surface. 

It  is  not  long  since,  that  through  the  labors  of  Schloes- 
sing,  Miintz,  and  Warrington,  we  know  the  role  of  the 
nitrifying  organisms  in  filth  disposal  ;  summer  and 
winter,  nitrification  goes  on,  and  filth,  changed  into 
harmless  compounds  unfit  for  bacterial  development, 
furnishes  a  nutrient  for  growing  plants. 

The  study  of  wells,  their  quality,  quantity,  and  pollu- 
tion of  their  waters,  depends  notably  upon  the  rock  struct- 
ure. The  "  strike  "  and  the  "  dip  "  of  a  rock-bed  are  of 
vast  importance  in  studying  the  drainage  area  and  the 
water-supply.  The  "  dip  "  of  a  stratum  frequently  deter- 
mines whether  or  not  a  certain  well  is  infected,  and  the 
character  of  an  adjoining  clay-bed  may  determine 
whether  or  not  it  forms  an  impassable  barrier  to  a  leak- 
ing cesspool  or  drain.  The  outcrop  of  an  imperme- 
able stratum  will  determine  with  surprising  accuracy 
the  depth  to  be  drilled  for  a  well,  though  far  distant 
from  the  outcrop. 

In  artesian  well-supply  the  water-bearing  horizons 
are  of  the  utmost  importance,  and  geologists  are  now  at 
work  mapping  them  out  in  the  eastern  coastal  plain  ; 
by  this  means  much  useless  labor  has  been  saved, 
and  districts  which  formerly  drank  polluted  surface 
waters  are  now  supplied  with  the  pure  water  of  a  deep 
boring.  The  character  of  the  water  yielded  in  a  cer- 
tain place  always  depends  upon  the  character  of  the 
rock-bed  from  which  it  is  derived  ;  the  hard  and 
sparkling  water  of  a  limestone  region — with  its  sup- 
posed calculi-forming  properties — forms  a  marked  con- 
trast to  the  soft,  palatable  waters  of  a  slate  or  sand- 
stone region. 

The  location  of  certain  strata  may  directly  affect  the 
health  and  comfort  of  large  cities  and  wide-spread 
districts.  For  example,  the  Schuylkill,  polluted  by 
mine  drainage  and  sewage,  is  partially,  at  least,  purified 
by  limestone  strata  crossing  its  course  above  Philadel- 
phia ;  the  limestone  changing  the  proto-sulphate  of  the 
mine  drainage  into  oxide  and  sulphate  of  iron  ;  the 
oxide  precipitating  the  organic  matter  thereby  aids 
purification,  and  the  sulphate  is  changed  into  the  harm- 
less calcium  sulphate.  The  Susquehanna  is  likewise 
polluted,  but  the  great  limestone  belt  of  Pennsylvania 
crosses  the  Susquehanna  Valley  below  Harrisburg,  and 
hence  that  city  and  all  above  suffer  from  polluted 
water. 

The  structure  of  a  town  site  is  at  times  of  vast  im- 
portance to  the  health  of  the  dwellers  thereon  ;  Bethle- 
hem, Pa.,  suffered  from  an  epidemic  which  was  traced 
to  its  public  water-supply,  namely,  a  spring.  How  this 
became  infected  puzzled  the  physicians  for  some  time, 
but  at  last  the  difficulty  was  explained.  The  town  is 
built  on  Silurian  limestone,  which  almost  always  bears 
large  underground  streams  and  large  water-bearing 
cavities  ;  the  cesspools  of  the  town,  in  certain  places, 
pierced  the  water-bearing  strata  and  infected  the  spring 
far  away. 

But  it  is  in  the  last  stages  of  geological  history  that 
effects  were  produced  which  had,  perhaps,  the  most 
bearing  on  sanitary  topics.  The  location  of  cities  and 
highways,  the  drainage  of  large  areas,  the  changing  of 
old  river  courses,  depend  in  a  great  measure  on  pleis- 
tocene formations.  The  great  glacier  and  its  con- 
comitant phenomena,  wherever  they  acted,  literally 
changed  the  "  face  of  nature." 


340 


MEDICAL    RECORD. 


[September  7,   1895 


In  deep  and  narrow  valleys,  like  that  of  the  Susque- 
hanna, their  value  and  importance  is  more  apparent, 
perhaps,  than  elsewhere,  and  anyone  who  has  ever 
travelled  northern  regions  will  readily  see  how  vastly 
civilization  has  been  modified  by  the  great  glacier. 

If  pleistocene  floods  had  not  swept  through  our 
river  valleys  and  deposited  their  layers  of  clay  and 
gravel,'  many  cities  would  not  stand  where  they  do 
now,  nor  would  railroads  follow  these  natural  highways. 

Camille  P'lammarion  tells  us  in  his  "  Last  Days  of 
the  World  "  some  very  fascinating  facts  about  geologi- 
cal changes  in  the  ages  to  come  ;  how  the  very  life- 
history  and  all  nature  of  the  globe  is  changed,  simply 
by  the  increased  permeability  of  the  earth's  strata ; 
thereby,  of  course,  leading  to  a  diminution  of  water. 
While  M.  Flammarion's  deductions  are  perhaps  con- 
siderably exaggerated,  we  are,  nevertheless,  beginning 
to  learn  that  geology  is  not  all  theory,  but  that  it  has 
some  practical  bearing  on,  at  least,  part  of  the  world's 
life-history. 


groQtrcss  of  ptjctTicaX  ^cUnc^. 

The  Treatment  of  Dysmenorrlioea.  —  Dr.  Schwarze 
writes  upon  treatment  of  the  forms  of  dysmenorrhoea 
which  are  unassociated  with  inflammatory  disease  of 
the  uterus  at  its  appendages,  those  due  to  anatomical 
changes  and  congenital  malformation  of  the  uterus, 
therefore  that  associated  with  pathological  anteflexion, 
retroflexion  in  the  virgin  uterus,  and  the  different  forms 
of  congenital  deformity  of  the  uterus.  This  class  in- 
cludes stenosis  of  the  external  and  internal  os  and  all 
forms  of  dysmenorrhoea  in  which  no  anatomical  changes 
can  be  demonstrated.  He  believes  the  following  drugs 
are  of  use  :  the  preparations  of  iron,  antipyrin,  phena- 
cetin,  antifebrin,  exalgin,  and  sodium  salicylate.  In 
some  cases  it  may  be  necessary  to  administer  codeine 
and  opium,  the  dose  being  small.  In  young  girls  and 
women  of  apparent  good  health  the  Thure-Brandt's 
method  of  gymnastics  of  the  entire  body  is  frequently 
followed  by  marked  benefit.  It  should  particularly  be 
applied  for  a  week  preceding  each  menstrual  period. 
In  well-developed  and  apparently  healthy  virgins,  with 
severe  dysmenorrhoea,  the  writer  advises  ext.  viburnum 
prunifolium  fl.,  a  teaspoonful  three  times  daily,  for 
five  to  seven  days  before  and  during  the  menstrual 
period.  Usually  the  Thure-Brandt  gymnastics  and  the 
viburnum  prunifolium  treatment  are  combined.  Mas- 
sage of  the  uterus  does  good  in  those  cases  where  there 
is  an  undeveloped  or  infantile  uterus.  It  should  not 
be  employed  in  young  girls.  The  introduction  of  a 
sound  into  the  uterus  just  before  the  menstrual  period, 
removing  the  pathological  anteflexion  and  dilating  the 
canal,  is  often  followed  by  relief  of  symptoms.  Rapid 
dilatation  of  the  cervical  canal  a  day  before  the  period 
is  the  better  method.  Electricity  applied  to  the  uterus 
does  good  in  many  cases.  The  negative  pole,  an  alu- 
minium sound,  is  introduced  into  the  uterine  cavity, 
and  the  positive  pole,  a  large,  flat  electrode,  is  placed 
upon  the  abdomen.  A  faradic  current  of  from  fifty  to 
one  hundred  and  fifty  milliamp^res  is  employed.  Fi- 
nally, should  there  be  no  anatomical  lesion  and  the  men- 
strual period  so  very  painful  that  life  is  made  unhappy, 
oophorectomy  should  be  performed. —  U?iiversity  Medi- 
cal Magazine. 

The  Treatment  of  Vomiting.— A  French  physician 
recommends  the  following  formulas,  the  first  of  which, 
according  to  Steffen,  is  useful  in  the  vomiting  of  preg- 
nancy :  Distilled  water,  five  ounces  ;  tincture  of  iodine, 
twelve  drops.  A  tablespoonful  of  this  in  half  a  glass 
of  sweetened  water  is  to  be  taken  every  two  hours. 
The  same  author  recommends  the  addition  of  a  few 
milligrammes  of  morphine  hydrochloride  to  each  spoon- 

■  See  The  Story  of  the  Gravels,  by  the  author,  in  Lippincotfs 
Magazine  for  March. 


ful,  or  an  ounce  of  the  distilled  water  may  be  replaced 
by  an  ounce  of  cherry-laurel  water.  The  Centralblati 
fiir  die  gesammte  Therapie  recommends  the  two  follow- 
ing formulas:  i.  Chloroform,  nine  hundred  grains; 
tincture  of  iodine,  one  hundred  and  twelve  grains.  Five 
drops  of  this  are  to  be  taken  every  night  in  a  glass  of 
Seltzer  water.  2.  Distilled  water,  three  ounces  and  a 
quarter ;  cocaine  hydrochloride,  half  a  grain ;  anti- 
pyrine.  fifteen  grains.  A  teaspoonful  may  be  taken 
every  half  hour.  The  following  procedure,  says  the 
writer,  in  which  three  solutions  are  used,  has  often 
been  employed  successfully  :  i.  Alcohol,  one  hundred 
and  fifty  grains  ;  menthol,  eight  grains  ;  tincture  of  nux 
vomica,  thirty  grains.  2.  Tincture  of  iodine,  one  hun- 
dred and  fifty  grains.  3.  Saturated  chloroform  water, 
three  ounces.  Every  half  hour,  or  every  fifteen  minutes 
if  necessary,  the  patient  should  take  a  dessertspoonful 
of  the  chloroform  water,  which  may  be  diluted  with 
iced  Seltzer  water,  after  having  added  ten  drops  of  the 
first  solution  to  it.  If  this  is  not  sufficient,  two  drops 
of  the  tincture  of  iodine  may  be  added  to  each  spoonful. 
Finally,  if  it  is  necessary,  from  two  to  three  drops  of  a 
i-in  50  solution  of  morphine  or  cocaine  may  be  added 
to  these  formulas.  These  two  solutionsare  usually  em- 
ployed for  subcutaneous  injections.  It  is  well  to  sub- 
stitute occasionally  for  one  of  these  medicaments  from 
two  to  four  drops  of  the  ordinary  solution  of  antipyrine 
for  cutaneous  injections,  according  to  the  following 
formula  :  Antipyrine,  sevent5'-five  grains  ;  cocaine  hy- 
drochloride, two  grains  and  a  half ;  distilled  water,  a 
sufficient  quantity  to  make  ten  cubic  centimetres.  If 
these  different  medications  fail,  says  the  writer,  the 
physician  may  resort  to  the  following  therapeutic 
measure,  which  is  very  simple  and  has  been  success- 
fully empl-oyed  by  M.  Robin  in  serious  cases  :  Apply  a 
small  blister  to  the  pit  of  the  stomach,  also  administer 
a  small  suppository  containing  a  grain  and  a  half  of 
powdered  crude  opium  and  a  sufficient  quantity  of 
cacao  butter  once  or  twice  during  the  twenty-four 
hours.  The  vomiting  is  very  often  arrested,  even  if  it 
is  the  serious  vomiting  of  typhoid  fever.  Sometimes, 
also,  inhalations  of  oxygen  are  useful. — New  York 
Medical  Journal. 

Obliterative  Arteritis  in  a  Boy  Fourteen  Years  of  Age. 
— A  case  of  this  kind,  occurring  in  a  young  boy,  is  re- 
ported in  The  Lancet  by  Dr.  B.  W.  Bond.  K  boy,  four- 
teen years  of  age,  came  to  him  suffering  from  a  sharp 
attack  of  "  shingles,"  extending  around  the  left  side  of 
the  chest  and  back.  He  was  evidently  in  bad  health, 
and  on  taking  his  left  wrist  to  feel  his  pulse  the  doctor 
discovered  that  none  could  be  felt.  No  pulse  could 
be  felt  anywhere  in  the  left  upper  extremity  until  the 
subclavian  was  reached.  Here  the  beat  was  synchro- 
nous with  that  of  the  right  subclavian,  but  much  feebler. 
The  radial  and  brachial  arteries  could  be  felt  as  cord- 
like bodies.  On  questioning  the  boy,  he  said  that  be- 
yond occasionally  having  "  pins  and  needles  "  in  the 
left  arm  and  fingers,  he  had  felt  no  inconvenience 
whatever,  and,  in  fact,  he  was  unaware  of  the  condi- 
tion. He  usually  suffered  from  chilblains  during  the 
winter  months,  especially  on  the  feet.  The  collateral 
circulation  was  evidently  good,  for  beyond  a  slight 
blueness  of  the  fingers,  there  was  no  other  visible  sign 
of  deficient  nutrition.  The  temperature  of  the  fingers 
was  practically  the  same  on  both  sides,  and  there  was 
no  ansesthesia.  As  regards  cause,  there  was  no  sign  of 
cervical  rib  or  pressure  on  vessels,  the  heart-sounds 
were  normal,  and  no  specific  or  rheumatic  history 
could  be  obtained.  There  was  no  sign  of  congenita] 
syphilis  elsewhere.  The  pulse  in  the  right  radial  was 
normal,  and  no  undue  thickening  of  arterial  walls 
could  be  feU.  The  interest  of  the  case  lies  in  the 
early  age  of  the  patient.  Dr.  Bond  has  seen  a  similar 
condition  at  the  age  of  twenty-three  and  twenty-four 
years,  but  believes  it  to  be  rarely  seen  in  a  patient  as 
young  as  fourteen  years. 


September  7,  1895] 


MEDICAL    RECORD. 


34' 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.  SHR.A.DY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &,  CO.,  43,  45,  &.  47  East  Tenth  Street 


New  York,  September  7,  1895. 


THE    TREATMENT     OF    SPR.\INS     BY     MAS- 
SAGE. 

From  a  study  of  over  twelve  hundred  recent  cases  of 
various  kinds  and  degrees  of  sprain,  Drs.  Van  Arsdale 
and  Gallant  ( The  Medical  N'eics)  announce  the  follow- 
ing conclusions  : 

Massage  is  indicated  in  subcutaneous  hemorrhage, 
traumatic  joint  inflammations,  recent  or  of  long  stand- 
ing, and  other  late  forms  of  inflammation,  such  as  that 
from  rheumatism,  etc. 

Fractures  at  the  arkle  are  not  jeopardized  by  very 
early  massage,  but  whether  or  not  massage  later  on 
(during  the  first  week)  is  harmful,  all  are  not  agreed. 
Immediate  massage,  on  the  contrary  (if  need  be,  under 
anaesthesia),  permits  of  a  better  diagnosis,  and  in  cases 
with  great  swelling  hastens  the  union  of  fragments  by 
removing  the  blood  and  exudation  between  them.  If 
fracture  is  made  out,  the  massage  is  not  to  be  repeated. 
As  to  contra-indications,  massage  should  never  be  ap- 
plied in  bacterial  inflammations,  i.e.,  tuberculous,  gonor- 
rhoeal,  or  pyaemic  joints.  The  authors  believe  that 
massage  of  sprained  joints  will  :  i.  Prevent  swelling,  or 
rapidly  disperse  it  if  present.  2.  Prevent  pain,  or 
quickly  remove  it  when  due,  as  it  must  be,  to  tension. 
3.  Prevent  stiffness,  or  overcome  it  when  already  pres- 
ent from  disuse.  4.  Prevent  the  sense  of  weakness 
and  restore  the  part  to  its  original  vigor  and  strength. 
5.  Reduce  the  time  of  treatment  from  weeks  to  a  cor- 
responding number  of  days.  6.  Permit  the  immediate 
use  of  the  injured  member. 

When  it  is  remembered  that  the  treatment  of  sprains 
by  the  older  methods  is  often  far  from  satisfactory,  the 
good  results  obtained  by  massage  in  the  hands  of  ex- 
perts certainly  claim  attention.  The  general  practi- 
tioner will  do  well,  however,  before  entirely  discarding 
these  "older  methods,"  to  thoroughly  acquaint  himself 
with  what  joint  massage  really  means. 

Dr.  Van  Arsdale  has  described  at  some  length  his 
own  method  of  procedure,  and  we  cannot  do  better 
than  transcribe  his  words  : 

"  In  treating  a  sprained  ankle  by  massage  it  is  con- 
venient to  have  the  patient  lie  at  full  length  on  a  rather 
low  table  (from  eighteen  to  twenty-four  inches  high) 
upon  his  back  with  his  head  on  a  pillow,  or  upon  his 
abdomen,  with  the  flexors  of  the  leg  relaxed.  The 
limb  should  be  bared  to  well  above  the  knee,  and  no 
constricting  garments  should  be  permitted  to  interfere 


with  the  circulation  in  the  thigh.  Examination  of 
the  injured  joint  having  been  made,  the  circumference 
of  the  limb  and  the  extent  of  motility  noted,  the  entire 
foot  and  leg  are  next  moistened  with  chloroform-oil 
uniformly  applied  by  means  of  gentle  rubbing  over  the 
entire  surface.  The  gentle  touch  thus  first  brought  to 
bear  upon  the  parts  has  the  advantage  of  reassuring  the 
patient.  In  applying  the  emollient,  care  must  be  taken 
to  arrive  at  a  'happy  mean,'  as  too  little  will  result  in 
friction,  which  will  irritate  the  skin  and  increase  the 
discomfort  of  the  patient,  while  an  excess  causes  the 
hand  to  slip  over  the  surface,  and  results  in  an  unneces- 
sary waste  of  strength,  an  early  fatigue  on  the  part  of 
the  masseur,  without  accomplishing  the  desired  effect. 

"  Beginning  well  above  the  tender  or  swollen  por- 
tions of  the  limb,  gentle,  systematic,  upward  strokes 
are  carried  well  above  the  knee.  These  first  strokes 
are  made  with  the  pulp  of  the  fingers,  both  hands 
being  used  and  held  parallel  with  the  leg.  At  first 
the  sides  of  the  leg  are  attacked,  one  with  each  hand  ; 
but  soon  more  of  the  palmar  surface  of  the  fingers  is 
brought  into  contact  with  the  skin  of  the  patient  and 
gradually  surrounds  the  whole  circumference  of  the 
leg,  each  stroke  being  long  and  slow  (not  more  than 
thirty  to  the  minute).  As  the  force  of  the  pressure  is 
gradually  increased,  the  pulp  of  the  thumb  is  brought 
into  play,  and  the  right  hand  supersedes  the  other  in 
force  and  activity,  until  it  will  become  necessary  to 
grasp  the  lower  part  of  the  heel,  or  metatarsals,  and 
make  counter-traction  in  order  to  steady  the  limb  and 
permit  of  a  greater  development  of  force. 

"  When  the  leg,  by  a  change  of  color  from  blue  to 
white,  shows  evidence  of  depletion  of  venous  blood 
and  lymph,  the  strokes  may  begin  lower  down  and 
more  directly  over  the  seat  of  injury,  always  being 
carried  upward  with  the  pressure  exercised  by  the 
fingers — delicate  at  first,  but  with  ever-increasing  in- 
tensity, with  the  thumb  of  one  hand  only,  while  the 
other  hand  steadies  the  foot  in  the  most  convenient 
position.  The  tissues,  which  were  hard  and  resistant 
to  the  touch  at  first,  soon  become  softer  and  more 
elastic,  and  with  this  the  pain  at  first  experienced  by 
the  patient  grows  gradually  less  and  his  confidence  in 
the  operation  increases.  From  time  to  time,  when- 
ever the  superficial  veins  of  the  leg  that  were  first 
emptied  appear  engorged  or  swollen,  it  is  considered 
imperative  to  continue  the  strokes  upward  above  the 
knee,  and  repeat  the  massage  of  the  upper  leg  in  order 
to  evacuate  the  newly  imported  supply  of  blood  and 
lymph  well  into  the  vessels  of  the  thigh,  and,  as  it 
were,  'drive  the  fluids  home.'  In  like  manner  the  toes 
and  the  portions  below  the  place  of  injury  are  visited 
and  their  tissues  also  are  emptied  of  the  stagnant  fluids. 
The  region  around  the  ankle  is  now  considerably 
smaller,  paler,  and  softer  than  at  first,  and  the  thumb, 
keeping  up  the  upward  stroking  all  the  time,  and  mov- 
ing with  an  independent  action  against  the  fingers 
placed  opposite  to  it  on  the  limb,  busies  itself  finding 
out  the  special  points  around  the  joint  where  more 
marked  hardness  and  stiffness  may  be  felt,  and  in  div- 
ing down  between  the  bony  projections  and  tendon- 
sheaths,  while  it  glides  more  lightly  over  the  promi- 
nences and  ridges  of  bone.  The  well-trained  thumb  is 
very  quick  at  discovering  the  points  of  special  sore- 


342 


MEDICAL    RECORD- 


[Septcmbcr  7,  189: 


ness,  even  without  the  help  of  the  patient's  subjective 
sensations,  and  will  make  them  special  points  of  attack. 
When  fatigue  is  experienced,  the  hands  are  changed 
and  the  work  carried  on  with  the  left. 

"Toward  the  end  of  the  stance,  which  must  be  in 
dicated  by  the  patient's  sensations  and  condition,  the 
strokes  are  made  to  grow  gradually  more  gentle  again, 
and,  becoming  longer,  extend  from  the  foot  well  up  to 
the  knee,  more  closely  resembling  those  described  by 
some  authors  as  effleurage.  This  procedure  always 
gives  the  patient  a  sensation  of  pleasure  and  relief,  and 
when  the  seance  is  ended  he  should  be  entirely  free 
from  pain,  at  least  for  a  time.  If  he  is  not,  it  is  a  sign 
that  the  massage  has  not  been  properly  applied. 

"  Massage  the  limb  twice  daily,  morning  and  after- 
noon, for  half  an  hour  at  a  time.  After  massage  rest 
the  joint  for  half  an  hour,  and  then  permit  the  use  of 
the  limb  in  walking.  Elevation  of  the  leg  between 
seances  is  always  advisable.     Moist  warmth  is  useless." 


A    NEW   METHOD    OF    EXAMINING   THE 
RECTUM  AND  SIGMOID  FLEXURE. 

Dr.  Howard  A.  Kelly  announces  a  new  method  of  ex- 
amination and  treatment  of  diseases  of  the  rectum  and 
sigmoid  flexure.  This  method  he  has  been  using  for 
eleven  years,  but  has  not  perfected  it  until  within  the 
last  two  years.  The  details  of  his  procedure  are  given 
in  the  Annals  of  Surgery  for  April,  1895. 

The  steps  are  briefly  these  :  i.  Thorough  evacua- 
tion of  the  bowels. 

2.  The  patient  is  placed  in  a  knee-breast  posture, 
the  elbows  spread  out  at  the  sides,  while  the  thighs  are 
perpendicular. 

3.  A  cylindrical  speculum  or  proctoscope,  provided 
with  an  obturator,  is  then  introduced. 

The  buttocks  are  drawn  apart  and  the  blunt  end  of 
the  obturator  is  laid  on  the  anus,  which  is  also  coated 
with  vaseline.  The  direction  of  introduction  is  down- 
ward and  forward,  and  when  the  sphincter  is  well 
passed  up  under  the  sacral  promontory.  The  moment 
the  speculum  clears  the  sphincter  area,  the  obturator  is 
withdrawn,  then  air  rushes  in  and  distends  the  bowel. 
This  constitutes  the  fourth  step  in  the  procedure. 
Fifth,  and  last,  is  the  inspection  of  the  dilated  bowel 
by  light  reflected  from  a  head-mirror.  Anaesthesia  is 
usually  unnecessary,  since  the  specula  are  mostly  of 
small  calibre.  They  differ  in  length,  the  longest  being 
35  ctm.,  and  this  is  called  the  sigmoidscope. 

Dr.  Kelly  states  that  by  means  of  this  method  of  ex- 
amination, he  has  plainly  seen  and  sounded  a  stricture 
of  the  bowel  14  ctm.  (five  and  a  half  inches)  above  the 
anus.  He  has  also  recently  seen  a  polypus  not  more 
than  5  mm.  in  diameter,  10  ctm.  (four  inches)  above 
the  anus,  and  he  has  had  occasion  to  examine  cases 
diagnosed  and  treated  for  years  as  colitis,  in  which  he 
found  the  rectum  the  seat  of  a  chronic  inflammatory 
trouble,  limited  either  above  or  below  the  promontory 
by  a  perfectly  sound  mucosa. 


HIPPOPYRRHINE. 

A  VENERABLE  Correspondent  of  the  Gazette  des  Hopi- 
taux  makes  a  suggestion  regarding  the  use  of  the 
word  vaccine  and  vaccinate.  He  recognizes,  as  so 
many  others  have  done,  the  awkwardness  of  the 
term  as  applied  to  the  inoculation  of  animals  or 
men  for  the  prevention  of  diseases  other  than  small- 
pox. To  use  the  word  vaccinate  in  connection  with 
diphtheria,  rabies,  or  cholera,  is  manifestly  an  improper 
application  of  terms.  Still  we  need  something  that 
will  serve  as  an  equivalent.  In  the  case  of  the  anti- 
toxin injections  for  diphtheria,  Dr.  Badour,  the  writer 
in  question,  suggests  the  term,  hippopyrrhinate,  as  an 
equivalent  to  the  word  vaccinate.  The  word  is  a 
combination  of  tTnros,  horse,  and  Truppos,  red.  The 
last  word  has  for  its  French  equivalent  the  term  rouxt 
which  is  an  ingenious  compliment  to  Monsieur  Roux, 
the  pioneer  in  France  of  the  anti-diphtheritic  injection. 
Dr.  Badour  would  therefore  "  hippopyrrhinate  "  chil- 
dren suffering  from  diphtheria  rather  than  inoculate 
them  with  diphtheritic  antitoxin.  The  French  writer's 
idea  is  better  than  his  suggestion.  The  average  physi- 
cian would  be  more  embarrassed  in  attempting  to  use 
so  clumsy  a  term  than  he  would  by  the  operation  itself. 
There  is,  however,  a  distinct  need  for  some  general 
word  which  is  the  equivalent  of  vaccinate.  The  word 
immunize  has  been  adopted  largely,  and  fills  to  a  con- 
siderable extent  the  need,  but  when  a  person  has 
already  been  attacked  with  the  disease  such  word  is 
not  applicable.  We  shall  hope  that  some  of  the 
learned  members  of  our  profession,  who  are  fond  of 
word-making,  will  discover  a  term  that  will  hit  off  tlie 
case  aptly  and  euphoniously. 


A  Fatal  Name.— An  Italian  was  recently  killed  in 
this  city,  during  a  quarrel,  by  a  fellow-countryman 
bearing    the  deadly  name  of  Morphini. 


The   New   Mexico    Standard  for  Medical   Colleges. — 

At  a  recent  meeting  of  the  New  Mexico  Board  of  Health 
it  was  resolved  that  examination  will  be  required  from 
all  applicants  to  practise  medicine  in  the  territor\'  who 
shall  have  been  graduated  after  July  i,  1897,  from 
any  medical  college  not  requiring  preliminary  examina- 
tion of  its  matriculants,  or  equivalent  evidence  of  satis- 
factory general  education,  and,  for  graduation,  evi- 
dence of  four  years'  study  of  medicine  and  four  terms 
of  lectures  occurring  in  four  separate  years.  Mean- 
while the  present  standard  of  three  years'  study,  three 
terms  of  lectures  in  three  separate  years,  and  prelimi- 
nary examination  of  matriculants  will  be  maintained  for 
all  applicants  who  have  been  graduated  since  July  i, 
1S90. 

Hospitals  and  Horse-racing. — M.  I.ebaudy  has  sent 
to  the  French  Hospital  and  Dispensary  of  London  a 
donation  of  25,000  francs,  part  of  a  prize  won  by  a 
horse  which  he  had  entered  at  the  Auteuil  races. 

The  William  F.  Jenks  Memorial  Prize. — The  author 
of  the  essay  bearing  the  motto.  "  Vade  mecum,"  which 
was  designated  as  highly  meritorious  by  the  committee 
of  award  of  this  prize,  was  Dr.  William  RienhotT,  of 
Springfield,  Mo.  Tlie  essay  was  on  the  subject,  "In- 
fant Mortality  during  Labor,  and  its  Prevention." 


September  7,  1895] 


MEDICAL    RECORD. 


543 


The  American  Academy  of  Railway  Surgeons, — 
The  second  annual  meeting  of  this  society  will  be  held 
in  the  banquet  hall  of  the  Auditorium  Hotel,  Chicago, 
on  Wednesday,  Thursday,  and  Friday,  September  25, 
26,  and  27,  1895.  The  president  of  the  Academy  is  Dr. 
C.  K.  Cole,  of  Helena,  Mont.,  and  the  secretarj'  Dr. 
Webb  J.  Kelly,  of  Galion,  O. 

The  New  York  State  Medical  Licensing  Examina- 
tions,— During  the  academic  year  from  September,  1894, 
to  June,  1895,  inclusive,  the  total  number  of  candidates 
coming  up  for  examination  before  the  State  Licensing 
Board  was  677.  Of  this  number  507  were  successful, 
and  170,  or  25.1  per  cent.,  were  rejected.  Si.x  hundred 
and  six  of  these  candidates,  of  whom  161,  or  26.5  per 
cent,  were  rejected,  came  before  the  regular  board  ;  60, 
with  8  (13.3  per  cent.)  rejected,  came  before  the  ho- 
moeopathic board  ;  11,  with  i  (9.1  per  cent.)  rejected, 
came  before  the  eclectic  board.  Of  the  candidates  for 
the  year,  83  came  up  for  examination  in  September,  77 
in  November,  56  in  January,  66  in  April,  163  in  May, 
and  232  in  June. 

The  Cholera. — The  London  Times  reported  on 
August  29th  that  a  man  had  died  in  one  of  the  suburbs 
of  that  city,  after  a  sickness  which  lasted  sixtj'  hours, 
and  that  a  post-mortem  examination  indicated  that  his 
death  was  due  to  cholera.  The  Lancet,  however,  in- 
vestigated the  rumor  and  found  that  there  was  no 
proof  whatever  that  the  disease  was  Asiatic  cholera,  for 
a  careful  bacteriological  examination  failed  to  show  the 
presence  of  Koch's  spirilla.  The  reports  of  the  dis- 
ease in  the  East  are,  unfortunately,  better  founded.  A 
despatch  from  Shanghai  says  that  oflScial  reports  show 
that  there  were  forty  thousand  deaths  from  cholera  in 
Pekin  during  August.  Other  parts  of  China,  notably 
Nankin,  and  most  of  the  large  cities  of  Japan,  are  also 
suffering  severely  from  the  ravages  of  the  disease.  It 
is  reported  that  cholera  has  been  brought  to  Honolulu 
by  a  ship  which  touched  there  on  her  way  from  Hong 
Kong  to  San  Francisco.  The  same  ship,  upon  her  ar- 
rival at  the  latter  port,  reported  a  clean  bill  of  health. 
The  customs  officers  have  discovered,  however,  that 
during  the  ten  days  she  lay  there,  there  were  in  a  cubby 
hole  in  the  steerage  three  bodies  of  Chinamen  who  had 
died  of  cholera.  The  prevalence  of  cholera  in  Hono- 
lulu and  in  the  Orient  has  created  much  anxiety  on 
the  Pacific  coast.  The  Board  of  Health  of  Portland, 
Ore.,  is  already  adopting  stringent  quarantine  meas- 
ures, and  it  is  thought  that  at  no  time  have  the  cities 
in  that  part  of  the  countr)-  been  so  seriously  menaced 
as  now.  The  disease  has  also  been  carried  from  Japan- 
ese ports  to  Vladivostock,  in  Siberia. 

The  Huxley  Memorial. — According  to  a  report  in 
Scierue,  the  movement  begun  in  England  for  the  erec- 
tion of  a  suitable  memorial  to  Professor  Huxley  is  tak- 
ing form  rapidly.  A  suggestion  has  been  made  that  the 
monument  be  made  international,  and  it  is  expected 
that,  on  the  convening  of  the  British  committee,  in  Oc- 
tober, this  extension  of  the  plan  may  be  given  formal 
approval. 

A  Ship's  Crew  with  Beriberi. — The  captain  of  a 
steamship,  recently  arrived  here  from  Barbadoes,  re- 
ports that  when  he  left  that  port  there  was  an  Ameri- 


can bark  in  the  harbor  whose  captain  and  nearly  all  of 
the  crew  were  suffering  wth  beriberi.  The  bark  had 
sailed  from  Aleppy,  Madras,  on  May  i6th,  loaded  with 
general  merchandise  bound  for  New  York,  and  on  the 
voyage  nearly  all  of  the  crew  and  also  the  captain  were 
stricken  with  the  disease.  They  put  into  Barbadoes 
for  medical  assistance  and  fresh  provisions. 

An  Epidemic  of  the  Dancing  Sickness  broke  out  a  few 
weeks  ago  among  the  school-children  of  Rehlingen,  a 
\allage  in  Germany.  During  a  ^Holent  thunder-storm 
that  came  on  one  day  while  the  children  were  all  in 
school,  one  of  them,  a  girl  twelve  years  of  age,  was  sud- 
denly seized  with  a  general  tremor,  and  soon  after, 
jumping  from  her  seat,  began  to  dance  wildly  over  the 
floor.  Other  girls  immediately  began  to  imitate  her, 
and  before  long  there  were  over  thirty  of  the  girls, 
and  seven  or  eight  of  the  boys,  all  hysterically  dancing 
around  the  school-rooms.  This  was  kept  up  for  an 
hour  or  two,  and  was  repeated  the  following  day  at 
about  the  same  hour.  The  schools  were  then  closed 
for  three  weeks  in  order  to  get  the  children  into  a  nor- 
mal state. 

The  Pilgrimage  to  Lourdes  this  year  is  the  largest 
that  has  ever  taken  place.  From  fifteen  thousand  to 
twenty  thousand  ill  and  afflicted  were  received  there 
every  day.  A  great  many  reputed  miracles  have  been 
reported  ;  the  cases  are  examined  at  Lourdes  by  a 
board  of  physicians,  three  of  whom  are  English-speak- 
ing Protestants.  A  despatch  in  the  Sun  says  that  the 
reports  of  the  pilgrimage  were  "  in  some  features  most 
appalling.  The  Orleans  station  in  Paris  was  filled  day 
and  night  by  thousands  of  sufferers  enduring  indescrib- 
able agonies  in  the  effort  to  reach  the  healing  waters. 
Most  of  the  time  the  air  rang  with  shrieks  of  pain  as  the 
almost  dpng  pilgrims  were  loaded  or  unloaded  on  the 
cars,  which  were  packed  to  their  utmost  capacity.  The 
scene  one  afternoon,  when  a  special  train  from  Ger- 
many, laden  with  six  hundred  invalids,  many  of  them 
desperate  cases,  arrived  for  a  change  of  cars,  was  enough 
to  drive  mad  any  spectator  without  the  strongest  ner\'e." 
The  officials  of  the  Orleans  railway  state  that  the  re- 
turning trains  have  not  nearly  as  many  passengers  re- 
quiring assistance  as  the  departing  trains. 

Obituary  Notes, — Dr.  Edward  Scott,  of  this  city,  a 
graduate  of  the  College  of  Physicians  and  Surgeons, 
died  in  San  Diego,  on  August  29th,  of  phthisis.  He  was 
twenty- eight  years  of  age,  and  had  gone  to  the  Pacific 
coast  three  months  ago  in  the  hope  of  arresting  the  prog- 
ress of  the  disease. — Dr.  Thomas  Henderson  Chand- 
ler, Dean  of  the  Harvard  Dental  School,  died  in  Bos- 
ton, on  August  27th,  at  the  age  of  seventy-one  years. — 
Dr.  Henry  W.  Rand,  of  Brooklyn,  died  at  Sugar  Hill, 
N.  H.,  recently.  He  was  born  in  Nova  Scotia  in  185 1, 
and  was  graduated  from  the  Bellevue  Hospital  Medical 
College  in  1877.  He  was  Lecturer  on  the  Principles 
of  Surgery  at  the  Medical  School  of  the  Long  Island 
Hospital.     He  left  a  wife  and  two  children. 

Mortality  in  New  York  State. — According  to  the 
State  Board  of  Health  bulletin,  the  average  daily  mor- 
tality in  this  State  for  July  was  377,  as  against  293  for 
June.  The  average  daily  mortality  during  July  in  the 
past  ten  years  was  370.     More  than  one-quarter  of  the 


344 


MEDICAL    RECORD. 


[September  7,  1895 


deaths  from  all  causes  were  from  diarrhoeal  diseases, 
though  the  number  from  this  cause  was  below  the  average 
for  the  past  ten  years.  About  fifty  per  cent,  of  the  deaths 
from  all  causes  were  of  children  under  the  age  of  five 
years.  Diphtheria  caused  less  than  three  per  cent,  of 
the  deaths,  the  mortality  being  below  that  of  the  corre- 
sponding month  in  1894.  Whooping-cough  caused 
143  deaths,  measles  130,  and  scarlet  fever  but  32,  all  of 
them  being  in  the  maritime  and  Hudson  Valley  districts. 
There  were  no  deaths  from  small-pox,  and  no  cases  of 
this  disease  were  reported. 

Cremation  in  the  United  States. — In  a  report  made  to 
the  New  England  Cremation  Society,  it  is  stated  that 
seventeen  crematories  have  been  established  in  this 
country  during  the  past  ten  years.  The  number  of 
bodies  cremated  in  each  of  the  ten  years  was  as  follows  : 
In  1885,  36  ;  in  1886,  119  ;  in  1887,  125  ;  in  1888,  199  ; 
in  1889,  262  ;  in  1890,  362  ;  in  1891,  464  ;  in  1892,  576  ; 
in  1893,  677  ;  in  1894,  876. 

Public  Baths  in  New  York.— Mr.  W.  Tolman,  Secre- 
tary of  the  Committee  on  Public  Baths,  recently  re-  . 
ported  to  Mayor  Strong  that  plans  for  the  public  bath- 
houses had  been  prepared  and,  after  approval  by  the 
Health  Department,  adopted.  The  next  step  will  be 
the  selection  of  several  sites  for  the  bath-houses,  and 
then  the  securing  of  the  necessary  appropriation,  which 
it  is  hoped  can  be  done  in  time  to  have  one  or  more  of 
the  baths  in  operation  by  or  before  the  beginning  of 
next  summer. 

The  Mortality  in  European  Cities  during  1894. — The 

death-rate  of  Berlin  for  1894  was  17.2  in  a  thousand, 
that  of  London,  17.7  ;  Brussels  and  Hamburg,  18. i  ; 
Amsterdam,  18.3;  Copenhagen,  18.7;  Turin,  18.S  ; 
Rome,  19.6  ;  Glasgow,  20.0  ;  Paris,  20.2  ;  Manchester, 
20.4  ;  Vienna,  22.8  ;  Liverpool,  23.8  ;  Dublin,  24.7  ; 
St.  Petersburg,  31.4  ;  and  Moscow,  34.1. 

Mandelate  of  Antipyrin  is  a  newly  discovered  com- 
bination which  is  said  to  have  all  the  therapeutic  prop- 
erties of  antipyrin,  but  without  its  injurious  action 
upon  the  heart.  Mandelic  acid  is  obtained  by  the 
action  of  prussic  acid  and  hydrochloric  acid  ujjon  ben- 
zaldehyd. 

The  Pennsylvania  and  Maryland  Medical  Union  As- 
sociation held  its  eighteenth  annual  meeting  at  Co- 
lumbia, Pa.,  on  August  29th. 

Medical  Touts  at  Hot  Springs.^l'he  fight  on  the 
ropers  and  steerers  goes  merrily  on.  The  doctors, 
almost  to  a  man,  are  backing  the  authorities  with 
money  and  influence,  and  we  hope  before  long  to  be 
able  to  chronicle  the  fact  that  not  one  of  these  men  will 
be  left  in  our  fair  city. — Hot  Springs  Medical  Journal. 

Cimicifuga  in  Rheumatism.— Dr.  David  Hurd  {Mcdi- 
cal  Aj^e)  is  a  firm  believer  in  the  efficiency  of  cimicifuga 
as  a  remedy  for  rheumatism  of  all  kinds.  He  gives 
from  four  to  six  drops  (presumably  of  the  fluid  extract) 
four  times  a  day.  The  drug,  like  many  others  of  its 
kind,  possesses  irritant  properties  which,  in  large 
amounts,  produce  vomiting  and  purging  —  a  direct 
method  of  excretion  possessed  by  the  animal  organism. 
In  smaller  doses  it  enters  the  circulation,  and  tlien  it 
is  only  reasonable  to  suppose  that  the  various  excre- 


tory organs  are  stimulated  to  extra  activity  in  throwing 
the  offending  substance  out  of  the  system.  To  this  in- 
creased activity  of  the  emunctories  the  improvement  in 
rheumatic  affections  following  the  use  of  cimicifuga 
must  doubtless  be  attributed. — Pittsburg  Medical  Re- 
view. 

Etiology  of  General  Paralysis. — At  the  recent  French 
Congress  of  Alienists  and  Neurologists,  M.  Lagrange 
read  a  paper  on  "  The  Relation  of  Syphilis  to  General 
Paralysis  of  the  Insane."  Among  287  women  in  his 
hospital  service,  6  had  general  paralysis,  and  of  these 
only  I  was  syphilitic.  Of  250  men,  25  were  paralytic, 
but  only  2  syphilitic.  One  man,  forty  years  of  age, 
had  contracted  syphilis  after  he  had  had  distinct  symp- 
toms of  general  paresis  for  some  time. 

Oxygen  Treatment  of  Ulcers. — One  of  the  most  in- 
teresting demonstrations  of  the  meeting  was  that  by 
Dr.  Stoker,  of  Dublin.  It  consisted  in  the  application 
of  oxygen  gas  to  the  treatment  of  chronic  ulcers.  The 
treatment  consists  in  the  incarceration  of  the  affected 
part  in  a  chamber  charged  with  oxygen  during  several 
hours  of  each  day.  I  recall  one  illustrative  case  of  a 
large  annular  ulcer  of  the  leg,  which  had  defied  all 
sorts  of  treatment  in  the  London  hospitals  for  years, 
and  which  was  completely  cured  by  this  treatment  in 
two  months.  One  interesting  test  case  was  that  of  a 
woman  with  a  very  large  ulcer  on  each  leg,  each  prac- 
tically like  the  other.  The  one  was  being  subjected  to 
the  modern  bichloride  treatment,  the  other  to  the 
oxygen  treatment.  The  former  was  free  from  all  germ 
life,  none  being  demonstrated  by  culture  processes, 
while  the  latter  abounded  in  practically  all  of  the 
pathogenic  variety,  yet  the  latter  ulcer  was  healing  with 
twice  the  rapidity  of  the  former.  This  fact  would  in- 
dicate that  oxygen  is  not  a  germicide,  and  that  the 
presence  of  pathogenic  germs  in  an  ulcer  is  not 
inimical  to  the  process  of  repair.  The  paper,  when 
published,  will  attract  widespread  attention,  a  fact  for 
which  the  profession  is  in  no  sense  indebted  to  the 
Council  of  the  British  Medical  Association,  which  de- 
clined to  give  Dr.  Stoker  a  place  on  the  programme, 
but  who,  with  true  Irish  grit,  hired  his  own  hall. — Dr. 
Charles  A.  L.  Reed  in  the  Lancet-Clinic. 

One  of  the  Early  Woman  Doctors. — .\  veracious 
writer  in  the  Paris  Temps  tells  a  story  of  an  English 
army  surgeon,  named  Macleod,  "  a  grave,  skilful,  wise, 
and  reserved  practitioner."  His  comrades  sometimes 
rallied  him  on  his  sobriety  and  continence,  but  he  re- 
plied only  with  a  shrug  of  the  shoulders.  One  day,  in 
India,  a  lieutenant  of  his  mess  jokingly  said  that  he 
lived  like  a  young  lady.  Macleod  jumped  from  his 
chair  and  slapped  the  officer  in  the  face.  A  duel  fol- 
lowed, and  the  lieutenant  was  shot.  The  surgeon  then 
resigned  and  returned  to  England.  Upon  his  death, 
some  years  later,  it  was  found  that  the  surgeon  was  a 
woman,  and  among  her  papers  were  found  some  show- 
ing that  she  was  a  member  of  one  of  the  oldest  fami- 
lies in  Great  Britain. 

The  Trade  of  Medicine.— A  German  paper  gives  an 
account  of  a  danger  menacing  the  welfare  of  doctors 
which  has  lately  appeared  in  Munich  in  the  shape  of 
"  medical  corporations,"  advertised  to  furnish  treat- 
ment at  extremely  low  rates. 


September  7,  1895] 


MEDICAL   RECORD, 


345 


^etrietus  and  Notices. 


Manuel  de  S^rotherapie  Anti-diphtherique.  Par 
le  Dr.  M.  Funck,  Chef  des  Travaux  Bacteriologiques 
dc  rinstitut  Serotherapique  de  Bruxelles.  Preface  by 
Professor  Destree.     Brussels  :  H.  Tanertin.     1895. 

This  may  be  said  to  be  the  first  practical  work  of  the  kind 
on  the  methods  of  preparing  antitoxin,  the  action  of  the 
serum,  the  technique  of  injection,  etc.  Besides  this,  in  the 
one  hundred  and  sixty  pages  are  comprised  an  account  of 
the  evolution  of  serotherapy  and  the  general  results  from 
it  in  diphtheria  during  1894.  The  work  is  one  of  practical 
interest  at  the  present  time,  aud  deals  with  the  actual  re- 
sults of  laboratory  work  and  observation. 

The  Cell.  Outlines  of  General  Anatomv  and 
Physiology.  By  Dr.  Oscar  Hertwig,  Professor  E.x- 
traordinarius  of  Anatomy  and  Comparative  Anatomy  ; 
Director  of  the  II.  Anatomical  Institute  of  the  University 
of  Berlin.  Translated  by  M.  Campbell  and  edited  by 
Henry  Johnstone  Campbell,  M.D.,  Assistant  Physi- 
cian to  the  City  of  London  Hospital  for  the  Diseases  of 
the  Chest,  and  to  the  East  London  Hospital  for  Children. 
London  :  Swan  Sonnenschein  &  Co.  New  York  :  Mac- 
millan  &  Co.     1895. 

This  is  an  important  addition  to  the  literature  of  histoloi,'!- 
cal  anatomy  and  physiology,  and  we  are  glad  to  find  it 
translated  into  English  for  the  use  of  those  students  who  are 
unable  to  read  the  work  in  the  original.  The  translation  has 
been  well  done  in  the  main,  though  it  is  a  pity  that  the  editor 
has  apparently  never  heard  of  the  word  proton,  proposed. 
we  believe,  by  Wilder,  as  an  equivalent  of  the  German  An- 
lage.  Indeed,  both  author  and  editor  might  have  improved 
their  work  considerably  by  a  study  of  the  American  litera- 
ture of  the  cell. 

Transactions  of  the  New  York  State  Medical  As- 
sociation for  the  Year  1894.  Volume  XI.  Edited 
for  the  Association  by  E.  D.  FERGUSON,  M.D.,  of  Rens- 
selaer County,  N.  Y.     Published  by  the  Association. 

This  handsomely  printed  volume,  of  some  seven  hundred 
and  fifty  pages,  contains  a  number  of  interesting  papers  on 
a  great  variety  of  subjects. 

A  Summary  of  the  Vital  Statistics  of  the  New 
England  St.\tes  for  the  Year  1892.  Boston  :  Dam- 
rell  &  Upham. 
This  is  a  concise  statement  of  the  marriages,  divorces, 
births,  and  deaths  in  the  six  New  England  States  for  1892. 
It  has  been  compiled  under  the  direction  of  the  Secretaries 
of  the  Boards  of  Health  of  these  States,  and  is  an  important 
contribution  to  statistical  literature. 

Annual  Report  of  the  Supervising  Surgeon-Gen- 
eral OF  THE  Marine  Hospital  Service  of  the  Igni- 
ted States  for  the  Year  1S93.  In  Two  Volumes 
Washington  :  Government  Printing  Office.     1895. 

These  volumes  contain  the  usual  reports  of  the  Marine 
Hospital  surgeons  and  inspectors  on  duty  in  this  country 
and  abroad.  They  are  an  evidence  of  the  good  work  done 
by  the  officers  of  this  service  under  the  able  and  energetic 
direction  of  Dr.  Wyman.  In  looking  over  these  reports, 
however,  one  is  constantly  reminded  that  the  work  done 
belongs  in  no  sense  to  the  Treasury  Department,  but  should 
be  done  by  officers  of  a  National  Health  Department. 

Encyclopaedie  der  Therapie.  Herausgegeben  von  Os- 
car Liebreich,  Dr.  Med.  Geheimer  Medicinalrath,  o.ii. 
Professor  der  Heilmittellehre  an  der  Friedrich-Wil- 
helms-Universitiit,  unter  Mitwirkung  von  Martin  Mkn- 
DELSOHN,  Dr.  Med.,  Privatdocent  der  Inneren  Mcdicin 
an  der  Friedrich-Wilhelms-Universitat,  und  Ari'HUR 
WiJRZBURG,  Dr.  Med.  Kgl.  Sanitatsrath,  Bibliothekar 
im  Kaiserlichen  Gesundheitsamte.  Erster  Band,  erste 
Abtheilung.     Berlin  :  August  Hirschwald.     1895. 

This  is  the  first  part  of  the  first  volume  of  what  promises 
to  be  a  work  of  great  merit  and  utility.  It  is  not  strictly  an 
encyclopaedia  of  therapeutics,  for  a  number  of  subjects 
treated,  as,  for  example,  amyloid  degeneration,  are  as  yet 
beyond  the  reach  of  treatment.  It  is  perhaps  rather  an  en- 
cyclopaedic medical  dictionary  with  special  emphasis  upon 
the  therapeutic  titles.  Many  of  the  leading  clinicians  of 
Germany,  in  addition  to  those  specially  designated  as  ed- 


itors, are  contributors  to  the  work.  Among  the  more  im- 
portant subjects  dealt  with  in  this  part  are  :  Abscess,  Ab- 
sorption, Acids,  Alcohol,  Diseases  of  Old  Age  (Alterskrank- 
heiten)  Anaesthesia,  Antidotes,  Antimony,  Antiphlogosis, 
Antipyretics,  Antisepsis  and  Asepsis,  Arsenic,  Asthma, 
Medication  (Arzneianwcndungi,  and  Atropine.  One  of  the 
titles,  written  by  Ewald,  is  on  Achylia  Gastrica,  the  term 
proposed  by  Einhorn  for  a  condition  in  which  there  is  no 
secretion  of  the  gastric  juice.  This  and  many  other  articles 
show  that  the  work  is  fully  up  to  date.  The  completion  of 
the  work  is  promised  within  the  next  two  years. 

The  London  HoMfjEOP.\THic  Hospital  Reports.  Ed- 
ited by  George  Burford,  M.B.,  C.  Knox  Shaw,  and 
Byres  Moir,  M.D.  Vol.  IV.  London  :  Homoeopathic 
Hospital.     1894. 

This  volume  contains  a  number  of  papers  on  various  sub- 
jects by  the  leading  homoeopathic  practitioners  of  London. 

The  American  Academy  of  Railway  Surgeons.  Of- 
ficial Report  of  the  First  Meeting.  Edited  by  R.  Har- 
vey Reed,  M.D.  Chicago  :  American  Medical  Press 
Association.     1895. 

This  volume  of  transactions  contains  the  history  of  the 
Evolution  of  the  American  Academy  of  Railway  Surgeons  as 
well  as  the  report  of  its  first  meeting  in  Chicago,  in  Novem- 
ber, 1894. 

The  Retrospect  of  Medicine.  A  Half-yearly  Journal, 
Containing  a  Retrospective  View  of  Every  Discovery  and 
Practical  Improvement  in  the  Medical  Sciences.  Edited 
by  James  Braithwaite,  M.D.,  Obstetric  Physician  and 
Surgeon  to  the  Leeds  General  Infirmary,  etc  Vol.  CXI. 
London :  Simpkin.  Marshall,  Hamilton,  Kent  &  Co. 
1895. 

Braithwaite's  Retrospect  appears  with  its  accustomed 
regularity,  and  contains  the  usual  amount  of  abstracts  from 
periodical  literature.  This  excellent  work  holds  its  own 
well  in  competition  with  its  younger  rivals. 

Skiascopy  and  its  Practical  Application  to  the 
Study  of  Refraction.  By  Edward  Jackson.  A.M., 
M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Philadel- 
phia Polyclinic  and  College  for  Graduates  in  Medicine  ; 
Surgeon  to  Wills  Eye  Hospital,  etc.  With  twenty-six 
Illustrations.  Philadelphia  :  The  Edwards  &  Docker  Co. 
1895. 

The  object  of  this  book  is  to  urge  a  more  general  adoption 
of  skiascopy  in  the  examination  for  ametropia.  The  method 
is  one  which  is  but  little  employed  by  ophthalmologists,  but 
the  author  believes  that  this  neglect  is  the  examiner's  loss. 
The  description  of  the  test  is  clearly  expressed,  and  the 
author  writes  with  all  the  authority  and  the  enthusiasm  of 
an  expert.  Young  ophthalmologists  cannot  afford  to  gnore 
skiascopy,  and  they  can  nowhere  find  it  better  explained 
than  in  this  little  work. 

The  Eye  in  its  Rel.^tion  to  Health.  By  Chalmer 
Prentice,  M.D.    Chicago  :  A.  C.  McClurg  &  Co.    1895. 

The  author  of  this  curious  book  was  evidently  prepared  to 
encounter  adverse  criticism,  for  he  begins  with  the  defini- 
tion of  a  critic  and  recounts  his  necessary  qualifications. 
We  confess  we  have  been  unable  to  verify  the  facts  of  as- 
tounding cures  of  organic  diseases  by  the  fitting  of  glasses, 
as  recounted  by  the  author,  which  run  counter  to  ali  medi- 
cal experience  from  the  days  of  Hippocrates  up  to  that  of 
Prentice.  Among  the  cases  which  the  author  asserts  that 
he  has  cured  by  eye-glasses  are  many  of  pulmonary  tuber- 
culosis, diabetes  mellitus,  ovaritis,  "  female  weakness," 
Bright's  disease,  prostatitis,  insanity,  cirrhosis  of  the  liver, 
sterility,  rheumatism,  and  uric-acid  diathesis. 

O  Quarto  Centenario  da  Febre  Amarella.  Pelo  Dr. 
Carlos  Seidl,  Director  do  Hospital  de  S.  Sebastiao. 
Rio  de  Janeiro  :  Besnard  FrSres.     1895. 

This  is  a  brief  monograph  written  to  commemorate,  but 
not  to  celebrate,  the  quadri-centennial  of  the  first  appear- 
ance among  the  Europeans,  companions  of  Columbus,  of 
yellow  fever.     This  occurred  on  March  24,  1495. 

Chart  of  the  Sympathetic  Nervous  System.  By  By- 
ron Robinson,  M.D.  Chicago  :  E.  H.  Colgrove  &  Co. 
1895. 
This  is  a  drawing,  life-size,  of  the  sympathetic  nerve,  made 
from  dissections.  It  gives  one  a  very  clear  idea  of  jthis  im- 
portant part  of  the  nervous  system. 


346 


MEDICAL  RECORD. 


[September  7,  1895 


Oftalmologia  Clinica.  Por  el  Dr.  Enrique  Lopez. 
Segunda  Serie.  Habana  :  Imprenta  del  Avisador  Comer- 
cial.     1895. 

This  is  a  study  of  i,ooo  cases  of  affections  of  the  eye  con- 
ducted on  the  same  plan  as  an  analysis  of  a  former  series  of 
1,000  cases  published  by  Dr.  Lopez  five  years  ago.  This 
volume  is  illustrated  by  sixty-seven  wood-cuts.  The  work  is 
a  valuable  contribution  to  ophthalmological  literature. 

A  Complete  Case  Recorder  in  General  Medicine 
AND  Gynecology,  for  the  Use  of  Physicians,  Students, 
Dispensaries,  and  Hospitals.  By  S.  B.  LYON,  M.D. 
Chicago  :  A.  L.  Koursh  &  Co.     1895. 

These  blanks  are  intended  to  assist  the  student  in  hospital 
or  the  practising  physician  in  keeping  an  accurate  record 
of  his  cases.  They  seem  to  be  well  adapted  to  this  pur- 
pose. 

Studier  over  ^tiologien  og  Pathologien  af  Ileus. 
Af  Johan  Nicolaysen.  Kristiania :  Det  Steenske 
Bogtrykkeri.     1895. 

This  is  an  interesting  monograph,  illustrated  by  two  colored 
plates,  based  upon  a  careful  study  of  thirty  cases  of  ileus. 
Fourteen  were  due  to  internal  obstruction,  sixteen  to  strangu- 
lation of  the  gut  from  external  causes. 

Anuario  de  la  Clinica  Privada  del  Dr.  Fargas.  Bar- 
celona.    1895. 

This  is  a  report  of  the  gynecological  cases  occurring  in  the 
private  practice  of  Dr.  Fargas  during  the  course  of  a  year. 
The  subjects  treated  are  surgical  intervention  in  uterine  myo- 
mata,  torsion  of  the  pedicle  in  ovarian  tumor,  anssthesia, 
aseptic  methods  employed  by  the  author,  vaginal  applica- 
tions, and  a  description  of  an  operating-table. 

La  Medicacion  Antiti5rmica  en  los  Procesos  Fe- 
briles  Agudos.  Por  J.  Queralto,  Profesor  Auxiliar 
de  Ch'nicas  en  la  Facultad  de  Medicina  de  Barcelona,  etc. 
Barcelona:  Francisco  Martinez.     1895. 

This  excellent  monograph  on  antipyretic  medication  in  acute 
febrile  conditions  obtained  the  prize  of  the  Royal  Academy 
of  Medicine  and  Surgery  of  Barcelona,  in  1S92.  The  au- 
thor's conclusions  are,  in  general,  that  fever  calls  for  no 
treatment  other  than  that  directed  against  the  causal  condi- 
tion, except  when  it  rises  to  a  dangerous  height.  In  such 
case  the  antipyretic  that  is  of  the  most  value  is  the  cold  bath  ; 
alcohol  in  moderate  doses  is  also  very  beneficial. 


ClPIiuical  ^epuxtmcnt, 

CASES    OF   BRAIN   TUMOR.' 
By  GEORGE  J.   PRESTON,  M.D., 


Since  the  last  meeting  of  this  Society,  several  cases 
of  tumor  of  the  brain  have  come  under  my  notice, 
among  which  the  following  are  perhaps  worthy  of 
record  : 

Case    L — Samuel    F ,   colored,   aged    thirteen. 

Family  history  negative,  except  that  the  father  gives  a 
suspicious  history  of  syphilis.  The  boy's  personal  his- 
tory was  good  ;  he  has  had  the  usual  diseases  of  child- 
hood, but  has  been  fairly  healthy.  In  April,  1S93,  he 
had  a  convulsion,  which  was  attributed  to  undigested 
food.  A  few  weeks  after  this  he  had  another  convul- 
sive attack,  and  since  has  had  two  or  three  attacks  a 
week.  The  attacks  are  general,  attended  by  total  loss 
of  consciousness.  Just  before  the  attack  comes  on  he 
holds  his  arms  out  in  front  of  his  body.  When  first 
seen  at  the  dispensary  the  case  was  regarded  as  one  of 
idiopathic  epilepsy,  and  the  attacks  were  very  much 
lessened  in  frequency  by  the  bromides.  After  he  had 
been  some  months  under  treatment  he  suddenly  devel- 
oped diplopia.  An  examination  of  his  eyes,  kindly 
made   for  me   at   this   time  (March   14,  1894)  by  Dr. 


'  Read  before  the  Twenty-first  Annuar'Meeting",of,the  American 
Neurological  Association,  Boston,  June  sth. 


Harry  Friedenwald,  showed  paralysis  of  the  right  ex- 
ternal rectus  and  intense  neuro- retinitis  of  both  eyes, 
v.  — R.  E.  ^,  v.—  L.  E.,  reduced  to  counting  fingers 
at  4  to  5  feet.  There  was  also  left  lateral  achroma- 
topsia. At  the  next  examination,  a  week  later,  central 
vision  was  the  same  ;  but  there  was  now  left  lateral 
hemiopia,  complete  in  the  upper  half  of  the  field,  and 
partial  in  the  lower.  The  part  preserved  on  the  hemi- 
opic  side  was  still  further  reduced  by  March  i6th,  ten 
days  later.  The  boy  was  admitted  into  the  hospital 
June  16,  1894,  when  the  following  notes  were  made  : 
Organs  of  circulation,  digestion,  respiration  normal. 
Urine  shows  no  trace  of  albumin  or  sugar.  Great  loss 
of  strength  and  general  emaciation.  Is  barely  able  to 
stand,  and  cannot  walk  without  assistance.  There 
seems  to  be  some  tendency  to  fall  backward.  Both 
superficial  and  deep  reflexes  absent.  Complains  of  in- 
tense headache,  and  the  head  seems  very  sensitive  to  per- 
cussion. Tactile  and  pain  sense  greatly  impaired.  By 
this  time  the  paralysis  of  the  right  external  rectus  had 
entirely  disappeared.  Hearing  was.  greatly  impaired 
by  April  3d,  and  when  admitted  into  hospital  the  boy 
was  completely  blind  and  deaf.  The  optic  nerves  now 
showed  post-neuritic  atrophy.  The  boy's  strength 
gradually  failed,  and  death  took  place  on  July  22d. 

The  autopsy  revealed  a  tumor  measuring  something 
like  6  X  6  ctm.,  situated  in  the  right  temporosphenoidal 
lobe.  The  growth  apparently  started  from  the  inner 
surface  of  the  dura  mater,  and  the  bones  of  the  right 
middle  fossa  were  eroded  by  the  pressure.  The  whole 
of  the  right  temporo-sphenoidal  lobe  was  softened  and 
disintegrated,  and  the  softening  also  involved  the  right 
occipital  lobe.  The  right  cuneus  was  softened  in  its 
centre,  but  the  gray  matter  was  not  invaded.  The 
only  part  of  the  cortex  involved  was  the  temporal  lobe. 
The  ventricles  were  full  of  fluid.  Other  organs  normal. 
Microscopic  examination  of  the  tumor  showed  it  to  be 
a  sarcoma. 

Case  II. — Georgianna  C ,  colored,  aged  thirty- 
nine.  Family  history  negative,  except  that  a  brother 
had  epilepsy.  Personal  history  negative.  Examina- 
tion of  chest  showed  pulmonary  tuberculosis.  Heart 
normal.  No  albumin  or  sugar  in  urine.  Reflexes, 
superficial  and  deep,  normal.  Patient  states  that  she 
has  had  intense,  unintermittent  pain  in  the  head,  and 
locates  the  pain  about  the  junction  of  the  lamboid 
and  sagittal  sutures.  There  is  marked  tenderness  on 
percussion  at  this  point.  According  to  the  statements  K 
of  patient  this  pain  began  five  or  six  weeks  prior  to  en- 
tering the  hospital.  Mental  power  is  distinctly  im- 
paired ;  there  are  no  delusions,  but  she  answers  ques- 
tions in  a  vague,  uncertain  way,  and  her  talk  is  rambling. 
Patient  has  had  epileptiform  attacks  for  some  months 
past,  and  says  she  can  tell  when  the  attacks  are 
coming  on  by  certain  peculiar  feelings  in  her  arms, 
particularly  the  right.  Examination  of  the  eyes  shows 
double  optic  neuritis,  with  congestion  and  tortuous 
veins.     The  right  eye  has  many  retinal  hemorrhages. 

Death  occurred  from  pulmonary  tuberculosis,  and 
the  autopsy  revealed  a  circular,  firm  tumor,  fungoid  in 
appearance,  measuring  2  to  3  ctm.  in  diameter,  and  at- 
tached to  the  under  surface  of  the  dura.  The  tumor 
imbedded  itself  in  the  superior  occipital  convolutioaj 
of  the  right  side,  making  a  cavity  about  the  size  of  ; 
partridge  egg.  Microscopic  examination  of  the  tumor 
showed  it  to  be  a  papilloma.  The  ventricles  were  full 
of  fluid,  the  brain  otherwise  normal.  The  interest  of 
this  case  lies  in  the  marked  symptoms,  head  pain  and 
tenderness  on  percussion  and  optic  neuritis,  caused  by 
a  tumor  of  such  small  size  and  located  in  such  a  com- 
paratively unimportant  part  of  the  brain. 

Case  III. — Henry  J ,  colored,  aged  thirty-five, 

was  brought  into  the  hospital  in  a  convulsion.  Gave  a 
history  of  having  had  fits  before,  but  it  was  impossible 
to  fix  the  date  of  onset.  Organs  of  circulation,  respira- 
tion, and  digestion  were  normal.  Examination  of  the 
urine  showed  albumin  and  casts.     There  was  no  paraly- 


us 


September  7,  1895] 


MEDICAL   RECORD. 


347 


sis  of  motion  or  sensation,  and  the  reflexes,  superficial 
and  deep,  were  present.  Ophthalmic  examination 
showed  congestion  of  eye  ground,  but  the  condition 
of  the  patient  was  such  that  no  thorough  examination 
could  be  made.  After  a  few  days  the  patient's  general 
condition  improved  somewhat,  and  he  complained  of 
intense  headache,  unintermittent  in  character,  and  not 
confined  to  any  particular  part  of  the  head.  At  this 
time  a  peculiar  tremor  developed  ;  starting  in  the  left 
arm,  it  gradually  involved  the  shoulder  and  head  of 
the  same  side.  In  a  few  days  the  tremor  became 
general,  involving  the  whole  body,  and  a  rather  active 
delirium  set  in.  Patient  would  answer  questions,  but 
in  an  irrational  way ;  there  was  no  deafness.  He 
finally  became  maniacal,  and  had  to  be  tied  in  bed. 
For  a  few  days  his  delirium  took  a  religious  turn,  going 
to  heaven,  conversing  with  the  Lord,  etc.  He  then 
took  a  turn  at  swearing,  and  for  several  days  kept  this 
up  constantly.  The  patient  became  gradually  weaker, 
and  died  November  isth,  or  about  two  weeks  after  ad- 
mission to  the  hospital. 

The  autopsy  showed  a  tumor  growing  apparently 
from  the  dura,  involving  the  posterior  portion  of  the 
left  temporo-sphenoidal  lobe,  the  occipital  lobe  of  left 
side,  and  the  left  lateral  lobe  of  the  cerebellum.  The 
growth  destroyed  the  posterior  half  of  the  second  and 
third  convolutions  of  the  temporal  lobe,  but  did  not 
touch  the  first  convolution.  It  will  be  remembered 
that  theie  was  no  discoverable  impairment  of  hearing. 
The  occipital  lobe  was  also  involved,  most  of  the 
angular  and  supra-marginal  gyri  being  compressed. 
The  tumor  encroached  slightly  on  the  under  surface 
of  the  left  lateral  lobe  of  the  cerebellum.  It  is  to  be  re- 
gretted that  the  condition  of  the  patient  was  such  that  no 
accurate  examination  of  the  eyes  could  be  made.  The 
tumor  was  a  sarcoma.  The  liver  and  kidneys  were 
cirrhotic,  and  spleen  small  and  cirrhotic. 

Case  I.  was  the  only  one  in  which  operation  was  sug- 
gested, and  the  father  of  the  child  refused  permission. 
In  the  other  two  cases,  although  a  diagnosis  of  brain- 
tumor  was  made,  definite  localization  was  impossible. 


THE  COEXISTENCE  OF   ERUPTIVE  FEVERS. 
By  A.  A.  HIMOWICH,  M.Sc,  M.D., 

NEW  YORK. 
VISITING   PHYSICIAN,    BETH   ISRAEL   HOSPITAL. 

John  Hunter'  announced  his  doctrine  on  this  sub- 
ject in  the  following  language  : 

"  As  I  reckon  every  operation  in  the  body  an  action, 
whether  universal  or  partial,  it  appears  to  me  beyond  a 
doubt  that  no  two  actions  can  take  place  in  the  same 
constitution,  nor  in  the  same  part  at  one  and  the  same 
time  ;  the  operations  of  the  body  are  similar  in  this 
respect  to  actions  or  motions  in  common  matter. 

'  It  naturally  results  from  this  principle  that  no  two 
different  fevers  can  exist  in  the  same  constitution,  nor 
two  local  diseases  in  the  same  part,  at  the  same  time. 
.  .  .  In  two  eruptive  diseases,  when  both  are  neces- 
sarily the  consequence  of  fever,  and  when  both  natu- 
rally appear  after  the  fever,  nearly  at  the  same  distance 
of  time,  it  would  be  impossible  for  the  two  to  have 
their  respective  eruptions,  even  in  different  parts,  be- 
cause it  is  impossible  that  the  two  preceding  fevers 
should  be  coexistent." 

Charles  Murchison,^  commenting  on  Hunter's  views, 
very  justly  remarks  that  this  doctrine  is  at  variance 
with  clinical  experience.  At  present  there  are  very 
few  physicians  who  have  not  met  cases  in  which  the 
coexistence  of  two  fevers  was  plainly  manifest,  but 
the  coexistence  of  eruptive  fevers  is  indeed  of  rare  oc- 
currence.    We  very  often  meet  cases  of  scarlet  fever 

•  John  Hunter's  Works,  Palmer's  Edition,  vol.  iii.,  p.  4. 
2  Murchison  on  Fevers,  Second  Edition. 


and  diphtheria,  measles  and  diphtheria,  but  we  do 
not  often  meet  typhus  or  typhoid  fever  together  with 
scarlatina,  nor  scarlatina  together  with  measles.  Be- 
cause of  the  comparative  rarity  of  such  coexistences  I 
consider  the  following  cases  worthy  of  record  : 

Case  I. — S.  S ,  female,  about  three  years  of  age, 

was  taken  sick  with  an  unusually  high  fever.  As  no 
cause  could  be  found  to  account  for  the  high  tem- 
perature, I  deferred  diagnosis  until  further  develop- 
ment and  treated  this  symptom  by  frequently  sponging 
the  body  with  alcohol  and  water.  Two  days  later 
there  appeared  the  well-known  eruption  of  varicella, 
but  this  did  not  in  the  least  diminish  the  severity  of 
the  fever. 

As  I  had  never  before  seen  such  a  peculiar  case  of 
varicella,  I  watched  my  little  patient  with  extreme 
interest.  Next  day  my  attention  was  called  by  the 
mother  to  the  patient's  throat,  as  she  observed  some 
difficulty  in  swallowing.  The  throat  was  typical  of 
scarlet  fever ;  an  examination  of  the  body  revealed 
the  scarlet  eruption.  The  case  proved  to  be  a  very 
severe  scarlatina. 

There  were  two  more  girls  in  the  family.  One  older, 
who  had  already  suffered  from  this  disease,  and  one 
younger.  The  latter  was  not  isolated  at  the  beginning, 
and  when  the  true  nature  of  the  disease  was  ascertained 
I  considered  it  too  late  for  isolation. 

I  must  confess  that  there  was  also  the  desire  to  see 
how  her  younger  sister  would  be  affected.  The  result 
was  that  this  child  went  through  the  same  experience 
as  her  sister,  viz.,  high  temperature,  varicella,  and 
scarlet  fever.  Both  suffered  subsequently  from  ne- 
phritis, and  both  recovered. 

Case  II. — R.  S ,  female,  four  years  of  age,  was 

brought  to  my  office  for  treatment.  Her  mother  made 
the  diagnosis  of  varicella,  but  she  thought  the  child 
was  also  sick  otherwise.  The  diagnosis  was  correct, 
but  as  the  fever  was  higher  than  in  an  ordinary  case  of 
varicella,  and  the  general  appearance  bad,  I  ordered 
the  child  to  be  put  to  bed  and  fed  on  milk  alone. 
Next  day  I  found  the  typical  eruption  of  scarlatina  on 
the  child's  body  and  face  ;  the  throat  was  also  one  of 
scarlet  fev'er.  The  disease  in  this  case  ran  a  much 
milder  course  than  in  the  two  previous  cases. 

Case  III. — S.  K -,  female,  about  three  and  one-half 

years  of  age,  was  brought  to  my  office  for  general  dis- 
temper. The  mother  gave  me  the  following  history  :  The 
child  had  a  red  eruption  on  the  body  first,  then  on  the 
face  and  extremities  ;  but  no  other  symptoms  were  ob- 
served. At  night  she  would  have  some  fever,  which 
would  disappear  in  the  morning.  The  child  was  play- 
ing during  the  day  with  other  childeren  of  the  same 
tenement,  and  there  was  nothing  to  indicate  that 
medical  advice  was  necessary.  The  eruption  was  all 
gone,  but  the  child's  general  condition  became  very 
bad.  From  the  history,  it  seemed  evident  that  the 
patient  was  suffering  from  a  mild  attack  of  scarlet 
fever.  The  examination  strengthened  this  supposition. 
The  child's  body  was  in  the  desquamative  stage,  and 
there  was  albumin  in  the  urine.  On  further  question- 
ing I  learned  that  there  were  other  children  suffering 
from  scarlet  fever  in  the  same  house  about  the  same 
time  that  this  child  had  the  eruption.  The  child  had 
bronchitis,  not  of  a  severe  form  ;  surely  not  enough  to 
account  for  the  general  debility  and  malaise.  Con- 
sidering the  nephritis  mostly  responsible  for  the 
trouble,  I  began  to  treat  the  kidneys,  with  the  result 
that  the  amount  of  albumin  was  diminished  consider- 
ably. The  fever  increased  steadily,  and  with  increase 
of  fever  the  pulmonary  symptoms  became  worse.  This 
led  me  to  believe  that  the  fever  was  due  to  the  develop- 
ment of  a  broncho-pneumonia.  The  mother  noticed 
that  the  child's  eyelids  were  red  and  heavy,  and  there 
was  a  great  deal  of  sneezing  and  coryza.  The  same 
night  the  whole  face  and  body  were  covered  with  a 
red  eruption,  while  the  severity  of  the  fever  abated. 
When  I  saw  the  child  in  the  morning  I  was  struck  by 


548 


MEDICAL   RECORD. 


[September  7,  1895 


the  peculiarity  of  the  rash.  There  was  surely  measles, 
but  besides  measles  there  was  also  the  distinct  eruption 
of  scarlatina.  Both  eruptions  coexistent  in  the  same 
child  at  the  same  time  !  The  scarlatina  was  probably 
a  reinfection  from  the  previous  attack. 

Dr.  Francis  Iluber  also  saw  the  case  in  my  absence. 
When  1  was  informed  of  the  fact  I  saw  Dr.  Huber,  and 
he  told  me  that  he  could  plainly  distinguish  the  erup- 
tions of  both  measles  and  scarlatina. 

These  cases  show  that  eruptive  fevers  may  be  co- 
existent, not  only  varicella  and  scarlet  fever,  but  also 
measles  and  scarlatina.  This  coexistence  is  probably 
of  greater  frequency  than  is  generally  supposed,  but 
the  symptoms  of  one  fever  mask  the  other  so  that  it  is 
rarely  recognized  and  very  often  not  even  suspected. 

That  one  attack  of  scarlatina  does  not  always  im- 
munize the  individual  from  another  attack  of  the  same 
disease,  and  that  they  may  follow  each  other  in  rapid 
succession,  undisturbed  by  other  pathological  changes 
in  the  same  system,  is  clearly  shown  in  the  last  case 
here  reported. 

136  HsNRV  Street. 


TREATMENT  OF  TYPHOID  FEVER. 
By  WILLI.A.M   E.    PUTNAM,  M.D., 


I  BELIEVE  that  typhoid  fever,  like  diphtheria,  is  first  a 
local  trouble  and  then  becomes  systemic.  I  first  empty 
the  bowel  and  unload  the  portal  circulation,  using 
calomel  or  cascara  sagrada,  or  any  other  efficient  laxa- 
tive, so  that  the  bowel  is  well  emptied.  At  my  first 
visit  I  put  the  patient  in  possession  of  the  largest  and 
best  room  in  the  house: 

Usually  all  carpets,  rugs,  and  curtains  are  taken  up. 
During  the  last  two  years  I  have  not  used  aconite  or 
fever  remedy  of  any  kind  internally.  I  order  first 
a  soap-and-water  bath,  going  over  the  body  a  little  at  a 
time  and  covering  all  parts  not  under  the  brush.  Then 
I  have  the  nurse  give  an  alcoholic  rub.  This  is  always 
followed  by  a  fall  in  temperature  of  from  one  to  two 
degrees  and  one  or  two  hours'  sleep.  To  lower  a  fever 
of  104°  F.,  I  have  the  nurse  wet  the  whole  surface  of 
the  body  with  alcohol,  wait  five  minutes  and  go  over 
the  patient  again  ;  then  take  the  temperature  and,  if  not 
low, enough,  go  over  patient  once  more,  but  not  to  ex- 
ceed three  times,  with  the  alcohol.  Internally  I  used 
for  several  years  turpentine  in  emulsion,  after  an  ex- 
cellent article  I  read  in  the  Medical  Record.  Then 
I  used  salol  with  good  results.  For  the  last  two 
years,  I  have  used  sulphocarbolate  of  zinc  in  two- 
grain  tablets.  Dose,  four  grains  every  two  to  four 
hours.  I  have  lately  treated  about  twenty  cases  with 
sulphocarbolate  of  zinc,  depending  almost  entirely  on 
that  one  drug.  A  number  of  times,  when  the  tempera- 
ture would  jump  up  two  or  three  degrees,  1  have 
doubled  the  dose  of  my  sulphocarbolate  of  zinc,  and  it 
acted  on  the  typhoid  poison  in  the  canal  in  such  an  ef- 
fective manner  as  to  bring  the  fever  down  two  or  three 
degrees.  I  claim  in  all  cases  where  the  bowels  are 
open  that  four-grain  doses  of  sulphocarbolate  of  zinc 
will  lower  the  temperature.  In  private  practice,  when 
the  patient  eats  forbidden  fruit,  as  we  know  they  oft- 
times  do,  I  never  hesitate  to  go  after  it  and  chase  it 
down  through  the  canal  with  half  a  grain  of  mild  chlo- 
ride of  mercury  or  cascara  sagrada  tablets. 

Nitrate  of  strychnia,  grain  ^j,  every  four  hours  all 
the  way  through,  will  give  your  patient  comfort  and 
help  his  lungs  to  pump  more  good  air.  This  drug  is 
best  given  in  tablet  triturates. 

During  convalescence  I  give  the  old  standby— qui- 
nine, strychnia,  and  iron.  Since  1885  I  have  not  lost  one 
case  of  typhoid  where  1  was  called  during  the  first  ten 
days  of  the  disease,  and  1  have  had  as  high  as  twenty- 
three  cases  of  typhoid  under  treatment  at  the  same 
time. 


THE    BRITISH    MEDICAL  ASSOCIATION. 

Sixty-third  Annual  Meeting,  held  in  London,  July  jo 
and  ji,  and  Augtcst  I  and  2,  iSpj. 

(Specially  Reported  for  the  Medicai.  Rbcord.) 

SECTION  OF  SURGERY. 

First  Day,  Wednesday,  July  31ST. 

Address  of  the  Chairman. — Sir  William  MacCormac 
took  as  the  subject  of  his  address  "  Some  Points  of 
Interest  in  Connection  with  the  Surgery  of  War."  He 
said  that  a  study  of  the  effects  of  the  new  small-bore 
rifle-bullets  and  the  injuries  that  they  inflicted  was  one 
that  it  was  impossible  to  over-estimate.  It  was  to  be 
regretted  that  in  the  British  army  the  principal  medical 
officer  in  the  field  was  not  given  that  influence  in  the 
councils  of  the  general  commanding  which  was  his 
due.  The  disposal  of  the  enormous  number  of  wounded 
that  was  sure  to  collect  after  a  general  action  in  the 
future  was  a  question  that  would  have  to  be  reckoned 
with.  The  speaker  showed  specimens  obtained  in  the 
war  of  1870-71,  exhibiting  the  shattering  effect  on 
bones  of  the  large  bullets  then  in  use.  There  was  a 
strong  family  likeness  between  the  new  rifles  adopted 
by  all  the  European  powers.  The  bore  was,  upon  the 
average,  less  than  one-third  of  an  inch,  the  charge  of 
powder  varied  from  215  to  225  grains,  the  bullet  re- 
sembled a  lead-pencil,  and  its  length  was  about  four 
times  its  diameter.  It  described  twenty- five  revolu- 
tions in  a  second,  had  an  initial  velocity  of  two  thou- 
sand feet  per  second,  and  an  effective  range  of  about 
two  miles.  Hitherto  nine-tenths  of  the  wounded  in 
modern  war  were  injured  by  rifle-bullets.  Many  ex- 
periments had  been  conducted  with  a  view  to  ascertain 
the  nature  of  the  injuries  that  would  probably  be  met 
with  in  future  wars.  Leaden  vessels  and  pipes  filled 
with  jelly  had  been  fired  at,  at  short  ranges,  and  the  re- 
sults noted.  The  distortion  and  explosive  effects  were 
enormous.  Large  rents  were  made,  and  the  walls  of 
the  vessels  bulged  out  in  various  directions.  The 
explosive  effect  seemed  to  occur  after  the  bullet  had 
traversed  the  vessel ;  for  the  displaced  wall  could,  in 
many  cases,  be  pushed  back,  showing  the  cleanly  cut 
round  hole  of  exit. 

The  German  War  Ministry,  with  its  characteristic 
practical  foresight,  had  instituted  and  carried  out  a 
series  of  elaborate  experiments  in  order  that  German 
military  surgeons  might  be  prepared,  as  far  as  possible, 
for  the  nature  of  the  injuries  that  they  might  be  called 
upon  to  treat.  In  the  museum  in  Berlin  there  were 
now  upward  of  one  thousand  specimens,  the  result  of 
these  experiments.  Most  elaborate  precautions  were 
taken,  which  the  speaker  detailed,  so  that  the  bodies 
of  men  and  animals  fired  at  should  be,  as  far  as  pos- 
sible, under  the  conditions  in  which  they  would  be 
struck  in  real  warfare.  In  examining  the  wounds 
frozen  sections  were  made,  or  the  track  of  the  bullet 
injected  with  fusible  metal.  At  a  range  of  two  thou- 
sand yards  the  bullet  traversed  the  skull,  thorax,  or 
abdomen.  The  liver  was  the  organ  that  suffered  most 
damage,  being,  in  some  cases,  almost  pulped.  The  in- 
testines were  perforated  by  multiple  wounds,  from 
three  to  eight  in  number.  The  effects  of  a  bullet,  fired 
at  a  range  of  fifty  metres,  on  a  full  skull  were  appall- 
ing, its  walls  being  shattered  fearfully.  On  an  empty 
skull,  beyond  the  two  perforations,  little  damage  was 
inflicted.  Using  reduced  charges  at  a  short  range,  the 
effects  were  proportionately  less  severe.  When  the  shaft 
of  one  of  the  long  bones,  such  as  the  femur,  was  struck, 
great  damage  was  inflicted,  the  bone  being  shattered 
for  a  distance  of  five  or  six  inches.  When  the  cancel- 
lous  tissue  at   the   end  of  a   long   bone  was   struck. 


September  7,  1895] 


MEDICAL    RECORD. 


549 


much  less  damage  was  caused  beyond  the  perforation. 
The  conclusion  to  be  drawn  from  these  experiments 
on  the  long  bones,  and  from  the  specimens  exhibited, 
was  that  the  damage  done  was  very  great  up  to  ranges 
of  two  thousand  yards  or  even  more.  The  openings  of 
entrance  and  of  exit  were  both  small,  but  great  dam- 
age was  done  in  between,  as  in  the  case  of  an  ankle- 
joint,  which  was  quite  shattered.  The  new  bullet  was 
often  found  to  be  unchanged  in  appearance  even  after 
penetrating  cancellous  bone.  After  richochetting,  the 
bullet  was  extremely  dangerous,  as  its  hard  cover- 
ing was  liable  to  be  torn  and  the  sharp  edges  cut 
through  arteries  and  other  soft  parts.  In  4.5  per 
cent,  of  the  bullets  found  after  inflicting  a  wound, 
there  was  deformity  of  the  projectile.  As  regards  the 
danger  of  hemorrhage,  primary  bleeding  was  much 
more  likely  to  occur  in  wounds  from  the  new  bullet 
than  from  the  older,  while  secondary  hemorrhage 
would  be  less  frequent.  It  was  well  known  that  in  the 
field  wounds  of  the  large  arteries  are  generally  fatal, 
for  the  patient  dies  before  help  can  reach  him.  It 
was,  therefore,  greatly  to  Jthe  credit  of  the  Japanese 
that  in  the  late  war  with  China  they  saved  two  such 
cases,  one  of  wound  of  the  brachial  artery,  the  other  of 
the  femoral.  This  showed  how  closely  their  bearer 
companies  must  have  attended  on  the  troops  engaged. 

It  was  noteworthy  that  large  vessels  were  frequently 
only  partially  divided  by  the  new  bullet,  and  this,  to 
some  extent,  explained  the  greater  liability  to  primary 
hemorrhage. 

As  Volkmann  had  observed,  injuries  to  bones  caused 
by  gunshot  are  less  serious  and  heal  much  better  than 
injuries  of  the  like  extent  inflicted  by  other  forms  of 
violence.  The  experience  of  the  German-Russian 
surgeons  von  Bergmann  and  Reyher  in  Europe  and 
Asia  respectively,  during  the  Russo-Turkish  War,  was 
remarkable.  They  recorded  most  successful  results  of 
conservative  treatment  in  cases  of  wounds  of  the  knee- 
joint. 

In  future,  conservatism  must  be  the  rule  in  the  treat- 
ment of  gunshot  wounds  of  the  bones.  Direct  wounds 
of  the  lung  by  the  new  bullets  were  simple,  and  unless 
a  large  vessel  or  bronchus  were  wounded  almost  trivial. 
Splinters  of  bone  were  seldom  carried  in.  When,  how- 
ever, the  bullet  glanced  off  some  external  object,  the 
injuries  were  serious.  Otherwise  the  elastic  air-con- 
taining substance  of  the  lung  suffered  scarcely  any 
harm  beyond  the  small  track  of  the  bullet. 

Excluding  suicidal  cases,  the  mortality  in  lung 
wounds  recorded  was  only  12.5  per  cent.,  and  all  these 
cases  succumbed  to  injury  of  large  vessels  or  bronchi. 

Injuries  of  the  skull  are  very  serious.  In  1870-71 
ten  per  cent,  of  the  wounded  were  injured  in  the  skull, 
but  in  not  all  of  these  was  it  penetrated.  In  future, 
probably,  the  skull  would  be  seriously  fractured  or 
fissured  whenever  it  was  touched  by  a  bullet. 

Wounds  of  the  abdomen  will  probably  be  invariably 
fatal,  unless  an  early  laparotomy  can  be  performed. 
This  affords  the  only  hope  of  recovery,  but  it  is  prob- 
able that  in  the  field  in  the  confusion  and  strain  at- 
tending a  general  action,  with  hundreds  of  wounded 
needing  help,  the  surgeon  will  be  unable  to  afford  the 
time  and  care  needed  for  its  performance.  Skilled  as- 
sistance will  also  perhaps  be  scarce. 

It  is  to  be  expected  that  the  next  great  war  will  be 
far  more  destructive  to  life  than  former  wars  of  modern 
times,  but  the  recoveries  among  the  cases  treated  will 
probably  be  more  numerous.  Bullets  will  seldom 
lodge  in  the  body,  and  should  one  do  so,  it  should  be 
left  alone  and  not  searched  for.  The  probe  will  be 
less  used  and,  as  Fischer  has  said,  the  surgeon  at  the 
dressing  station  must  use  his  eye  more  than  his  hand. 

The  address  was  illustrated  by  numerous  lantern 
slides  and  preparations  lent  by  Professor  Hueter,  of 
Greifswald,  and  by  others. 

Rhinoplasty. — Surgeon-Major  Keegan  then  read 
a  paper  on  "  Rhinoplasty  in  India."     His  experience 


had  been  chiefly  among  young  and  healthy  patients, 
principally  women  who  had  been  mutilated  by  jealous 
husbands  or  others.  The  operation  which  he  usually 
practised  was  that  described  in  Treves's  "  Operative 
Surgery."  He  removed  a  flap  of  skin  from  the  nasal 
bones,  and  having  reversed  it  so  that  the  epidermal  sur- 
face was  inward,  used  it  as  a  lining  for  the  newly 
formed  nares  in  order  to  prevent  subsequent  contrac- 
tion. A  flap  brought  down  from  the  forehead  was 
used  to  cover  the  surface  thus  denuded  and  to  com- 
plete the  nose.  In  dividing  the  root  of  the  flap 
later  on,  he  was  careful  to  cut  a  wedge-shaped  piece 
out  of  it,  in  order  to  preserve  the  shape  of  the  bridge 
of  the  nose.  Lantern  photographs  of  several  women 
and  one  man,  showing  their  condition  before  and  after 
operation,  were  projected  on  the  screen.  The  results 
in  all  cases  appeared  to  be  excellent.  There  was  no 
discussion  on  this  paper. 

Fracture  of  tie  Femur. — Sir  William  Stokes,  of 
Dublin,  then  read  a  paper  on  the  "  Diagnosis  and 
Treatment  of  Fractures  of  the  Upper  Third  of  the 
Femur."  He  said  the  subject  was  perhaps  not  so  in- 
teresting as  the  more  modem  developments  of  surgery, 
such  as  operations  on  the  brain,  the  abdomen,  etc. 
It  was  good,  however,  to  look  back  from  time  to  time 
and  revalue  the  conclusions  that  had  been  arrived  at. 
Some  surgeons  thought  that  the  amount  of  attention 
that  was  devoted  to  the  diagnosis  of  certain  injuries 
in  and  about  the  joints  was  excessive.  He  could  not 
agree  with  this  view.  He  held  that  as  long  as  any- 
thing was  unknown,  no  amount  of  attention  was  exces- 
sive that  would  help  to  throw  light  upon  it.  At  present 
inquirers  into  this  subject  were  impeded  by  a  dense 
jungle  of  conflicting  symptoms.  He  contrasted  these, 
and  referred  to  the  fact  that  in  the  repair  of  some  cases 
of  injuries  of  the  upper  end  of  the  femur  there  was  exu- 
berant bone  formation,  in  others  there  was  none 
formed.  Sometimes  the  injury  preceded  a  fall,  in 
others  it  was  the  result  of  one.  In  dealing  with  fract- 
ures of  the  neck  and  of  the  thigh-bone,  the  fibro-syn- 
ovial  envelope  of  the  cervix  was  often  left  unconsid- 
ered. This  structure,  which  he  preferred  to  call 
Stanley's  ligament,  was  of  great  importance.  On  its 
integrity  the  result  of  fracture  of  the  cervix  largely  de- 
pended. 

The  fibro-synovial  covering  had  but  very  feeble  and 
osteogenetic  power.  Want  of  union  was  often  due  in 
old  persons  to  osteoporosis,  but  it  was  a  mistake  to 
suppose  that  the  angle  that  the  neck  of  the  femur 
made  with  the  shaft  was  altered  in  this  disease.  The 
specimen  before  them  showed  this  clearly,  as  Hum- 
phry had  already  pointed  out.  Fracture  was  not  due 
to  any  alteration  of  angle.  The  change  in  shape  of 
the  lower  jaw  in  old  persons  was  often  quoted  as  a 
parallel  case,  but  the  analogy  was  a  false  one.  The 
deformity  of  the  jaw  was  due  to  unopposed  muscular 
action,  the  teeth  having  been  lost  and  the  muscles  con- 
tinuing to  act  without  enough  resistance  to  balance 
them.  He  thought  that  the  old  classification  of  fract- 
ures of  the  neck  of  the  thigh-bone  into  intra-  and 
extra-capsular  was  clinically  good.  The  former  class 
he  would  divide  into  those  with  and  without  penetra- 
tion. Extra-capsular  he  would  divide  into  those  with 
and  without  impaction.  By  means  of  a  lantern-slide 
photograph  of  a  specimen  he  showed  that  the  angle 
of  the  cervix  might  be  increased  in  impacted  fracture. 
It  was  to  be  noted  that  very  tall  people  had  cervixes 
more  oblique  than  usual — for  instance,  the  thigh-bone 
of  Magrath,  the  Irish  giant,  which  he  showed. 

The  nearer  to  the  head  of  the  bone  the  fracture  was 
the  less  chance  there  was  of  union.  Eversion  of  the 
limb  was  due  to  rotation  of  the  shaft  of  the  bone  over 
a  hinge  situated  in  the  anterior  wall  of  the  neck  at  the 
point  of  fracture.  Inversion,  when  it  occurred,  was 
due  to  the  position  of  the  limb  at  the  time  of  accident. 
The  differential  diagnosis  of  these  fractures  was  most 
important   to  the  surgeon  and  to   the   patient.     The 


55° 


MEDICAL   RECORD. 


[September  7,  1895 


usual  treatment  adopted  only  tended  to  separate  the 
fragments.  As  to  routine  treatment  the  practice  of 
laying  the  limb  on  a  pillow  and  in  fact  doing  nothing 
should  be  entirely  abandoned.  He  referred  to  Senn's 
experiments.  The  good  results  obtained  by  the  use  of 
ivory  and  bone  nails  showed,  in  his  opinion,  that  the 
more  perfect  the  fixation  the  more  certain  the  union. 
It  was,  therefore,  most  unwise  to  attempt  to  disengage 
the  impacted  fragments.  The  outcome  of  Senn's  e.x- 
periments  was  the  splint  here  shown,  which  carried  a 
scre.v  pad  by  which  carefully  graduated  pressure  could 
be  brought  to  bear  in  order  to  keep  the  fragments  in 
apposition.  In  Erichsen's  "  Surgery  "  it  was  said  that  in 
an  impacted  extra-capsular  fracture  there  was  no  hope 
of  restoring  the  limb  to  its  normal  length  and  position, 
and  the  patient  must  be  left  lame  for  life.  Southam, 
of  Manchester,  however,  in  a  young  person,  had  broken 
down  the  impaction  and  got  a  good  result.  This  was 
only  a  single  case,  and  the  procedure  was  not  often  ap- 
plicable, and  not  at  all  in  old  persons.  Union  did 
sometimes  occur  in  intra-capsular  fracture,  but  in  these 
cases  he  believed  that  Stanley's  ligament  was  not  pene- 
trated. He  thought  that  Bryant's  double  splint  or  his 
own  screw  extension  splint  was  the  best  apparatus.  The 
latter  allowed  the  patient  to  sit  up  while  keeping  up 
moderate  extension.  This  was  a  very  great  advantage, 
especially  in  old  persons.  There  were  two  essentials 
in  a  good  splint  :  i.  It  should  allow  the  patient  to  sit 
up  ;  2,  the  extension  should  not  be  more  than  to  secure 
immobility. 

Conclusions  :  Alteration  of  the  axis  of  the  neck  does 
not  occur,  and  is  therefore  not  a  cause  of  fracture. 
Absorption  is  due  to  osteoporosis  preexisting,  and  in 
contusions  to  its  being  set  up.  Distinction  and  clas- 
sification are  of  importance.  Bony  union  is  possible 
in  all  situations.  The  nearer  the  fracture  to  the  head 
the  less  the  chance  of  union.  In  treatment,  fixation, 
rest,  and  moderate  extension  are  desiderata. 

In  the  discussion  that  followed  Sir  George  M.  Hum- 
phry said  that  there  was  not  much  left  to  add  to  what 
Sir  W.  Stokes  had  said.  He  would  state  it  as  an 
axiom  that  fracture  in  any  part  of  the  body  and  at  any 
age  will  almost  surely  unite  if  kept  at  rest  with  the 
fragments  in  apposition.  The  cervixes  of  the  femurs 
in  old  people  were  altered  by  senile  absorption  due  to 
diminished  power  of  resistance  to  the  absorptive  cells 
which  were  normally  present  in  the  cancelli.  The  up- 
per part  of  the  femur  was  peculiarly  dependent  for  its 
strength  on  the  cancellous  structure.  An  interesting 
point  was  that,  despite  these  senile  changes,  the  osteo- 
genetic  cells  in  the  bone  did  not  lose  their  powers. 
Non-union  was  rare  after  fracture  at  the  base  of  the 
neck.  Much  bone  was  generally  thrown  out  there,  and 
as  the  specimens  produced  showed,  it  was  often  super- 
abundant. Intra-capsular  fracture  was  commonest  at 
the  narrowest  part  of  the  neck  close  to  the  head.  Non- 
union in  such  cases  was  not  due  to  the  want  of  bone- 
forming  power  of  old  people,  or  to  deficiency  of  blood- 
supply.  All  parts  of  the  skeleton  had  blood- supply 
enough  for  their  repair.  Failure  to  unite  was  largely 
due  to  the  impossibility  of  overlapping  of  fragments  in 
this  situation.  It  was  an  established  fact  that  overlap- 
ping bones  almost  always  unite,  and  that  firmly.  Sec- 
ondly, it  was  due  to  the  fact  that  the  new  bone-forming 
cells  were  not  detained  by  the  soft  parts  in  the  neigh- 
borhood of  the  fracture,  but  were  set  free  in  the  cavity 
of  the  joint  capsule.  If  the  fragments  be  kept  in  apposi- 
tion they  will  surely  unite.  He  showed  a  specimen  in 
which  a  fracture  close  to  the  trochanter  had  united 
firmly,  although  the  patient  was  eighty  years  old.  A 
section  through  the  bone  showed  firm  union.  The  re- 
taining fibro-synovial  membrane  was  thicker  in  front, 
but  it  was  also  closer  to  the  bone  and  more  liable  to  be 
torn  than  at  the  back,  where  it  was  loose.  Whether 
torn  or  not,  however,  the  result  was  much  the  same. 
Contact  between  the  broken  surfaces  was  the  essential 
thing. 


Absorption  occurred  almost  exclusively  in  the  outer 
fragment,  between  the  site  of  fracture  and  the  trochan- 
ter, not  between  the  fracture  and  the  head  of  the  bone. 
This  process  might  be  very  rapid.  Almost  the  whole 
neck  of  the  femur  might  disappear  in  two  or  three 
weeks.  He  showed  a  specimen  illustrating  this  liability 
of  the  outer  fragment  to  absorption.  The  neck  had 
entirely  gone,  while  the  broken  surface  close  to  the 
head  was  unchanged  and  still  bore  a  projecting  spicula 
of  bone  that  (as  often  happened)  had  split  away  from 
the  under  side  of  the  neck.  This  absorption  was  due, 
he  said,  to  rubbing,  and  to  the  abundance  of  osteophage 
cells  and  weakness  of  resistance  to  them. 

Mr.  Bryant  agreed  with  Sir  W.  Stokes,  although  he 
thought  that  the  tabulation  of  these  fractures  into  the 
eleven  varieties  referred  to  was  not  of  much  clinical 
value.  Nor  did  he  think  that  the  distinction  between 
intra-  and  extracapsular  fracture  was  clinically  im- 
portant. The  really  important  question  was  whether 
the  fracture  was  impacted  or  not  impacted.  Most  of 
these  fractures  were  originally  impacted,  but  the  impac- 
tion was  destroj'ed  afterward,  either  by  the  active  or 
passive  movement  of  the  limb. 

He  agreed  that  the  cause  of  inversion  in  certain  cases 
was  the  position  that  the  foot  happened  to  be  in  at  the 
time  of  the  breaking.  Immobilization  and  moderate 
extension  were  the  ends  to  aim  at.  He  had  had  forty- 
two  consecutive  cases  of  the  average  age  of  seventy  : 
all  had  left  hospital  with  good  and  useful  limbs.  Bed- 
sores were  practically  unknown.  He  could  not  pretend 
to  say  whether  there  were  intra-  or  extra-capsular  fract- 
ures. Very  gentle  examinations  only  should  be  al- 
lowed, and  no  attempt  made  to  obtain  crepitus,  which 
was  not  needed  for  diagnosis. 

Southam's  case  was  a  striking  exception.  He  (Mr. 
Bryant)  had  had  one  patient,  aged  thirty,  in  whom 
there  was  inversion  of  the  limb  and  impaction  of  the 
fragments.  The  case  looks  like  one  of  dislocation. 
Considering  at  that  age  that  it  was  wrong  to  condemn 
the  patient  to  be  a  cripple  for  life,  he  loosened  the  im- 
paction under  an  anaesthetic  and  rotated  the  limb  out. 
The  result  was  very  good,  but  an  enormous  amount  of 
callus  was  thrown  out.  In  such  exceptional  cases  it 
was  justifiable  to  gently  break  down  the  impaction. 
The  do  nothing  treatment  was  unjustifiable. 

Dr.  Bennett,  of  Dublin,  said  that  he  would  take  a 
wider  field  than  the  previous  speakers  had  done.  He 
would  include  fractures  below  the  trochanters.  He  had 
twice  produced  intra-capsular  fracture  of  the  neck  in 
attempts  to  produce  dislocations  onto  the  dorsum  ilii, 
by  forcible  adduction  in  cadavers  of  seventy  to  eighty 
years  old. 

Mr.  Greig  Smith  thought  that  there  was  some  risk 
of  elevating  a  rare  variety  into  a  separate  species  and  of 
drawing  clinical  references  therefrom. 

An  important  division  was  that  into  fractures  caused 
by  indirect  vertical  violence  at  any  part  of  the  neck 
and  fractures  from  direct  transverse  violence  applied 
near  the  trochanter  major.  The  degree  and  direction 
of  obliquity  of  the  fracture  was  most  important  both  as 
regards  immediate  reduction  of  deformity  and  final 
result. 

It  was  to  be  remembered  that  only  part  of  the  head 
of  the  femur  bore  against  the  acetabulum  in  the  erect 
position  of  the  body,  and  the  obliquity  of  the  line  of 
fracture  and  eversion  of  the  limb  depended  on  this. 
Non-union  was  due  to  the  absence  of  a  nidus  for  the 
formation  of  new  bone.  We  were  too  apt  to  forget  the 
rdle  played  by  the  soft  parts,  and  more  especially  by 
fibrous  tissue  in  the  repair  of  fractures. 

He  asked  for  a  simple  classification  and  would  espe- 
cially classify  the  obliquity.  The  fracture  might  be 
oblique  downward  and  outward,  and  in  that  case 
there  would  be  no  shortening. 

Mr.  Mayo  Robson  said  that  in  his  opinion  an  elab- 
orate classification  was  only  possible  in  the  post-mor- 
tem room.     It  was  of  small  clinical  value.     The  pres- 


September  7,  1895] 


MEDICAL   RECORD. 


35J 


ence  or  absence  of  impaction  was  the  really  important 
thing.  He  believed  that  wherever  there  was  opposi- 
tion there  was  union.  He  would  disturb  the  parts  as 
little  as  possible,  and  apply  the  long  splint  with  ex- 
tension. If,  however,  recumbency  was  badly  borne, 
Thomas's  hip-splint  was  useful.  As  regards  Southam's 
case,  no  doubt  many  surgeons  had  had  such  cases 
where  breaking  down  the  impaction  in  young  persons 
was  advisable,  and  had  proved  useful.  In  such  it  was 
not  justifiable  to  let  things  alone.  An  important  point 
was  to  find  out  the  best  method  of  treating  these  diffi- 
cult injuries. 

Professor  Sinclair  thought  that  the  specimens 
showed  that  bony  union  was  commoner  than  was  gen- 
erally believed.  Intra-capsular  fracture  was  often 
caused  by  external  rotation,  in  which  case  the  perios- 
teum was  not  torn,  and  union  resulted.  When,  how- 
ever, the  fracture  was  caused  by  vertical  force,  the 
weight  of  the  body  continuing  to  act  after  the  bone  had 
given  way  tore  through  the  periosteum. 

Sir  W.  Hingston,  of  Montreal,  said  that  he  was 
surprised  to  hear  a  general  opinion  expressed  that  union 
was  common  and  shortening  rare.  The  experience  of 
surgeons  in  America  was  entirely  different.  Actions 
against  surgeons  for  malpraxis  in  the  treatment  of 
fractured  femur  were  so  common  that  it  had  been 
found  necessary  at  one  of  the  great  surgical  gatherings 
in  the  United  States  to  express  the  conviction  that 
some  amount  of  shortening  was  unavoidable.  He  was 
delighted  to  hear  that  in  this  metropolis  surgeons  were 
so  successful.  He  feared,  however,  that  general  prac- 
titioners in  the  country  would  still  have  to  screen  them- 
selves behind  the  American  pronunciamento  rather 
than  the  cheering  dictum  of  accomplished  London  sur- 
geons. 

Mr.  Gant  thought  that  shortening  was  almost  uni- 
versal. 

Dr.  Weekes,  of  the  United  States,  said  that  he  held 
the  classical  views  as  to  the  classification  and  causation 
of  these  fractures.  He  thought  that  Liston's  long 
splint  with  a  hip-piece  to  prevent  rotation,  or  else  a 
long  sand-bag,  was  the  best  thing  to  use. 

Mr.  Keetlev  said  that  in  young  people  he  would 
treat  fractures  of  the  upper  part  of  the  femur  just  like 
other  fractures.  He  described  a  case  of  fracture  of  the 
neck  of  the  femur  on  which  he  had  operated.  He  had 
found  the  head  ankylosed  to  the  ilium  and  to  the  mush- 
room-like end  of  the  neck  by  new  bone.  Removal  of  the 
i.ead  and  of  the  mushroom  like  growth  gave  a  good  result. 
>ir  William  Hingston's  delicate  sarcasm  was  perhaps 
justified.  It  was,  however,  so  kindly  put  that  while  we 
ajipreciated  it  we  were  not  hurt  by  it.  Still,  however, 
he  held  that  it  was  a  fact  that  in  London,  in  fractures 
of  the  femur,  those  of  the  neck  excepted,  shortening 
was  rare.  Indeed,  he  had  been  looking  for  the  last 
year  or  two  for  cases  of  shortening  in  which  to  use  his 
pins,  but  almost  without  success.  He  showed  the  pins 
that  he  used  for  such  cases  and  also  in  recent  oblique 
overlapping  fractures.  These  consisted  of  two  L- 
shaped  pieces  of  steel,  one  arm  of  each  of  which  was 
passed  through  a  hole  made  in  the  bone  with  a  brad- 
awl, beyond  the  fracture,  the  other  arms  being  lashed 
together  with  wire  while  the  bones  were  held  in  the  cor- 
rect position.  An  anfesthetic  was  of  course  necessary 
for  this  operation.  The  results  had  so  far  been  excel- 
lent. 

Sir  William  Stokes  then  closed  the  discussion.  He 
did  not  agree  with  Sir  George  Humphry  that  the 
blood-supply  to  the  bones  was  always  enough.  If  the 
ligamentum  teres  were  torn  through,  the  supply  to 
the  head  could  not  be  enough.  Several  speakers  had 
taken  exception  to  his  classification,  but  he  thought 
their  objections  were  not  well  founded.  We  must  go 
to  the  dead-house  for  our  pathology.  A  propos  of  Sir 
William  Hingston's  remarks  as  to  the  prevalence  of 
shortening  in  America,  they  were  too  sweeping.  Dr. 
Senn  had  stated  that   with  his  splint  he  got  results 


without  shortening.  He  thought  that  Keetley's  pins 
were  too  weak  and  flexible  for  their  purpose.  Wood's 
rather  similar  contrivance  appeared  to  him  to  be 
stronger  and  better. 

Floating  Kidney. — Mr.  Kendall  Franks,  of  Dub- 
lin, then  read  an  interesting  paper  on  the  "  Pathology 
and  Symptoms  of  Movable  Kidney,"  clearly  illustrated 
by  lantern  slides.  There  were  several  theories  current 
as  to  the  causation  of  this  condition.  Tight-lacing  and 
menstrual  congestion  were  said  to  cause  it.  Newman's 
theory  was  that  during  violent  muscular  efforts,  such 
as  occurred  in  parturition  or  in  lifting  heavy  weights, 
the  kidney  might  be  squeezed  between  the  psoas  and 
quadratus  lumborum  muscles  and  shot  out  of  its 
place,  just  as  a  bean  may  be  shot  forth  from  between 
the  finger  and  thumb.  Mr.  Franks  thought  that  he 
would  be  able  to  show  that  this  theory  would  not  hold 
water.  In  an  inquiry  into  this  subject  it  was  first  nec- 
essary to  find  out  what  kept  the  kidney  in  its  place  in 
health.  Dr.  Cunningham  and  he,  by  means  of  injec- 
tions of  Miiller's  fluid  and  of  spirit  several  times  re- 
peated, had  succeeded  in  hardening  the  kidney  in  situ, 
and  thus  fixing  the  form  which  it  held  in  the  unopened 
abdomen.  On  examining  the  anterior  surface  of  the 
kidney  thus  treated,  it  was  seen  that  this  was  not 
smooth  and  rounded,  but  that  it  presented  always  a 
transverse  ridge,  above  and  below  which  the  surface 
sloped  backward.  Viewed  in  profile  from  the  outer 
side  each  kidney  appeared  to  be  formed,  as  it  were,  of 
two  almost  right-angled  triangles  placed  base  to  base, 
so  that  its  posterior  surface  was  flat.  It  would  appear 
that  the  kidney,  by  the  pressure  of  other  organs,  the 
liver  above  on  the  right  side  and  the  spleen  on  the  left, 
was  wedged  into  position  by  two  forces  acting  in  a 
backward  direction.  On  the  posterior  surface  could 
be  seen  depressions  caused  by  the  twelfth  rib  and  the 
psoas  and  the  quadratus  lumborum  muscles.  Other 
forces  tending  to  prevent  its  movement  were  the  con- 
nective tissue  and  the  fatty  capsule.  This  last,  he 
beheved,  had  not  much  influence,  for  it  must  be  re- 
membered that  at  the  temperature  of  the  living  body 
the  fat  was  fluid.  He  believed  that  a  loss  of  balance 
in  the  abdomen  after  parturition  was  the  commonest 
cause  of  movable  kidney. 

It  was  well  known  that  the  intra-abdominal  pressure, 
which  was  previously  positive,  became  negative  on  de- 
livery and  remained  so  for  some  time  afterward.  Get- 
ting up  too  soon  from  child-bed  was  the  determining 
cause.  The  symptoms  differed  on  the  two  sides,  but 
dragging  pain  and  malaise  were  symptoms  common  to 
both.  On  the  right  side,  indigestion,  abdominal  pain, 
flatulence,  and  vomiting  were  complained  of.  No  va- 
riety of  food  or  regalation  of  diet  and  no  medical 
treatment  affected  these  gastric  crises  ;  the  symptoms, 
indeed,  strongly  resembled  those  of  stricture  of  the 
pylorus.  The  cause  of  these  symptoms  was  made  clear 
in  a  case  of  Mr.  Franks's  on  which  he  operated.  The 
kidney  was  found  in  the  right  iliac  fossa,  having  in  its 
descent  dragged  down  the  duodenum  by  means  of  an 
adhesion,  so  that  the  gut  was  kinked  and  almost  com- 
pletely occluded.  In  some  cases  the  adhesion  is  less 
tight  or  longer  and  there  is  no  kinking.  On  the  left 
side  the  symptoms  are  not  so  marked  or  special,  but 
occasionally  obstinate  and  intractable  constipation  oc- 
curs. On  operating  on  such  a  case  he  had  found  the 
kidney  enveloped  in  the  colon,  which  it  had  dragged 
down  and  which  had  fallen  over  the  front  of  it.  Fixa- 
tion of  the  kidney  by  suture  entirely  removed  this 
symptom,  and  the  bowels  afterward  acted  regularly  and 
without  trouble. 

Mr.  Bland  Sutton  said  that  jaundice  was  some- 
times a  symptom  of  movable  kidney  on  the  right  side. 
The  diagnosis  of  movable,  or  rather  of  floating,  kidney 
was  often  wrong,  and  on  opening  the  abdomen  it  was 
found  that  the  symptoms  were  due  to  other  conditions, 
the  kidney  being  normally  fixed  and  situated.  A  mov- 
able kidney  is  not  free  to  roam  about  the  abdomen   in 


352 


MEDICAL   RECORD. 


[September  7,  1895 


all  directions  ;  its  movements  are  limited  to  an  up- 
ward and  downward  direction,  and  it  slides  in  a  chan- 
nel like  a  mole's  "  run  "  behind  the  peritoneum. 


SECTION   OF   SURGERY. 

Second  Day,  Thursday,  August  ist. 

True  Ankylosis.— Mr.  Howard  Marsh  read  a  paper 
on  the  "  Pathology  and  Clinical  History  of  some  Rare 
Forms  of  Bony  Ankylosis."  He  described  certain  cases 
of  tubercular  joints  that  had  come  under  his  observa- 
tion, that  had  run  their  course  without  suppuration  and 
had  ended,  as  shown  on  subsequent  excision,  in  bony 
ankylosis.  The  bones  removed  from  an  elbow  were 
shown  to  the  meeting.  This  kind  of  plastic  inflamma- 
tion running  on  to  organization  of  inflammatory  prod- 
ucts without  suppuration,  occurred,  he  believed,  also 
in  the  spine.  He  showed  a  specimen  of  ankylosis  of 
the  atlas  and  axis  that  he  said  supported  this  view.  It 
was  a  question  whether  bony  ankylosis  might  not  occur 
in  Charcot's  disease.  He  thought  that  it  might  without 
suppuration,  and  quoted  a  case  of  Charcot's  where  the 
foot  was  affected.  In  this  foot  the  cuneiform  and  me- 
tatarsal bones  were  ankylosed.  The  two  skeletons  of 
feet  shown  had  been  lent  to  him  by  Professor  Hum- 
phry. In  these  there  was  bony  ankylosis  and  the  sur- 
faces of  the  bones  were  covered  with  vegetations  and 
bony  deposits,  the  joint  surfaces  being  little  affected. 
The  history  of  this  specimen  was  unknown.  It  was 
difficult  to  believe  that  the  changes  were  the  result  of 
pyaemia.  He  had  observed  a  case  of  injury  to  the  me- 
dian nerve  that  was  followed  by  stiffness  and  bony  an- 
kylosis of  a  finger  joint  without  suppuration. 

There  was  no  doubt  that  bony  ankylosis  followed 
sometimes  on  gonorrhoeal  rheumatism,  and  that  it  also 
occurred  in  the  spine  in  scoliosis.  He  had  seen  a  case 
in  which  throughout  the  lower  extremity  the  joints 
were  ankylosed  by  bone.  It  was  common  in  osteo- 
arthritis in  the  spine,  unlike  other  joints  in  that  dis- 
ease. The  joints  themselves  were  intact,  but  the 
ligamentous  tissues  were  ossified.  The  process  was 
sometimes  reparative,  as  when  it  occurred  in  acutely 
inflamed  pyaemic  joints  or  in  tubercular  joints,  and 
sometimes  degenerative,  as  in  Charcot's  disease  and  in 
gout,  and  in  the  feet  lent  by  Sir  George  Humphry,  and 
when  ligaments  were  ossified. 

Mr.  Targett  said  that  these  cases  of  ossification  of 
ligaments  much  resembled  myositis  ossificans.  In  one 
of  the  specimens  shown  to-day  the  ligaments  were 
clearly  defined  in  new  bone,  the  anterior  common  and 
costo- transverse  ligaments  being  quite  clear  and  dis- 
tinct. In  Charcot's  disease  there  was  atrophy  of  the 
bone  ;  if  this  were  not  present,  the  case  was  probably 
not  one  of  Charcot's  disease.  After  the  joint  inflam- 
mations of  puerperal  fever,  bony  ankylosis  was  often 
rapid  and  complete. 

Mr.  Bowlev  said  that  in  the  case  of  injury  of  the 
median  nerve  alluded  to,  many  fingers  were  ankylosed. 
The  changes  which  took  place  in  the  joints  after  nerve 
injuries  were  very  like  those  of  rheumatism,  but  bony 
ankylosis  was  not  common  and  ligaments  were  more 
liable  to  be  affected  than  were  joint  surfaces.  There 
were  changes  in  the  joints  in  many  nerve  diseases  be- 
sides tabes.  He  believed  that  some  day  certain  now 
little  understood  joint  lesions  would  be  recognized  as 
the  result  of  definite  nervous  lesions. 

Mr.  Bland  Sutton  said  that  similar  changes  oc- 
curred in  the  spines  of  horses.  He  did  not  believe  that 
the  atlas  and  axis  shown  could  be  tubercular,  because 
of  the  age  of  the  patient.  Tubercle  started  in  the 
junction  cartilages  before  ossification  was  complete. 
Further,  every  museum  contained  specimens  of  occip- 
ito-atlo-axoid  ankylosis.  These  specimens  had  usu- 
ally no  histor)',  but  were  found  in  cemeteries,  and  one 
he  had  seen  that  was  removed  from  an  Egyptian  mum- 
my.    Arbuthnot  Lane  had  said  that  this  condition  oc- 


curred in  costermongers,  and  was  the  result  of  carrying 
a  load  on  the  head.  It  had  occurred  to  the  speaker 
that  if  that  were  the  case,  a  similar  condition  should  be 
found  in  cattle  which  carried  the  yoke  on  their  horns, 
as  was  customary  in  some  places.  He  had  visited  the 
Veterinary  Museum  at  Alfort  and  had  found  several 
specimens  there.  He  could  confirm  Mr.  Marsh's  de- 
scription of  these  cases  where  the  anterior  common 
ligament  was  ossified.  Those  specimens  v»'ere  generally 
labelled  as  rheumatoid  arthritis.  The  condition  was  a 
very  common  one  in  the  horse.  There  were  numerous 
specimens  at  Alfort  and  in  the  museum  at  Camden 
Town.  In  men  no  symptom  beyond  stiffness  of  back 
and  stooping  were  complained  of  ;  but  in  horses  there 
was  great  danger,  if  they  were  cast  for  any  purpose,  that 
in  the  struggle  to  rise  again  the  spine  might  be  fract- 
ured and  palsy  ensue. 

Mr.  Ellis,  of  Gloucester,  pointed  out  that  the  great 
toe  affected  in  the  specimen  was  in  the  position  of  rest, 
that  of  valgus.  Those  joints  most  exposed  to  irrita- 
tion were  most  liable  to  ankylosis. 

Mr.  Howard  Marsh,  in  reply,  said  that,  as  to  the 
specimen  of  the  first  two  cervical  vertebras,  he  must 
absolutely  differ  from  Mr.  Sutton.  Tuberculous  dis- 
ease of  the  spine  might  occur  at  any  age.  He  in- 
stanced the  case  of  Dean  Buckland,  who  died  of  atlo- 
axoid  disease  at  the  age  of  eighty.  He  thought  that  if 
Mr.  Sutton  had  ankylosis  of  his  own  vertebrae  he 
would  not  speak  of  the  affection  as  trivial  and  causing 
no  trouble.  In  these  cases  the  patients  were  rendered 
helpless  and  unable  to  rise  from  the  horizontal  posi- 
tion. 

A  Hiding  Place  for  Vesical  Calculus. — Mr.  G.  Buck- 
STON  Browne  then  read  a  paper  in  which  he  called 
attention  to  a  hitherto  undescribed  locality  in  the  male 
urinary  bladder,  where  a  stone  may  lie  and  elude 
contact  with  any  instrument  passed  through  the  urethra. 
He  said  that  in  some  cases  where  a  stone  had  been 
suspected,  it  could  not  be  found  by  the  sound  per 
urethra,  yet  on  opening  the  bladder  above  the  pubes 
it  was  found.  In  other  cases  a  stone  had  been  dis- 
covered with  the  sound,  but  on  doing  a  perineal  lithot- 
omy it  could  not  be  found.  In  these  cases  the 
prostate  was  enlarged  inside  the  bladder,  generally 
backward,  forming  the  middle  lobe,  and  a  stone  might 
be  hidden  in  the  pouch  behind  this  which  he  had  be- 
fore described.  In  some  cases,  however,  there  were 
lateral  enlargements  of  the  intra-vesical  portion  of  the 
prostate,  and  a  stone  might  be  hidden  in  a  pocket  be- 
tween one  of  these  and  the  bladder  wall.  In  two  cases 
he  had  found,  on  opening  the  bladder  above  the  pubes, 
that  this  was  the  case.  In  the  first  case,  he  was  occa- 
sionally able  to  touch  the  stone  with  the  sound,  but 
never  could  seize  it  with  the  lithotrite.  After  several 
attempts  the  supra-pubic  operation  was  performed, 
and  the  stone  found  in  the  right  lateral  pouch  described. 
In  the  second  case  the  urethra  was  eleven  inches  long. 
Blood  followed  all  attempts  at  examination  or  catheter- 
ization. Under  an  anesthetic,  he  succeeded  in  finding 
a  stone.  The  bladder  was  distended  with  solution, 
which  was  retained  by  means  of  an  elastic  ligature  on 
the  penis  which  prevented  escape  of  fluid  at  the 
side  of  the  lithotrite.  In  this  way  he  was  enabled  to 
crush  the  stone.  A  few  months  afterward  symptoms 
of  stone  returned.  He  could  not  detect  a  stone  by 
any  means  at  his  disposal.  The  bladder  was,  how- 
ever, opened  above  the  pubes,  and  a  stone  found  in 
one  of  the  lateral  pouches.  "That  first  crushed  had 
probably  lain  on  top  of  it.  He  advocated  distension 
of  the  bladder  and  lithotrity  in  cases  where  supra-pubic 
lithotomy  was  too  severe  a  proceeding.  This  failing, 
he  would  try  to  dislodge  the  stone  by  suction  through 
the  evacuator,  to  which  an  aspirator  was  attached.  He 
found  that  Cadge,  of  Norwich,  whom  he  considered  1 
the  greatest  authority  on  stone,  had  alluded  to  this  | 
lateral  pouch  in  his  lectures,  some  years  ago,  at  the 
Roval  College  of  Surgeons. 


September  7,  1895] 


MEDICAL    RECORD. 


o3o 


Mr.  Mayo  Robsox  described  a  case  where  a  large, 
hitherto  undiscovered,  stone  was  found,  on  supra- 
pubic operation,  to  lie  in  a  pouch  in  front  of  the 
intra-vesical  lobe  of  the  prostate.  In  another  case 
several  stones  were  extracted  with  difficulty  from  a 
pouch  behind  the  prostate. 

Mr.  Buckstox  Browne  thought  Mr.  Robson's  first 
case  must  be  unique. 

Treatment  of  Neoplasms  of  the  Thyroid  Gland. — Mr. 
BuTLiN  then  opened  a  discussion  on  "  The  Surgical 
Treatment  of  Cysts,  Tumors,  and  Carcinoma  of  the 
Thyroid  Gland,  and  Accessory  Thyroids."  Malig- 
nant disease  of  the  thyroid  was  not  amenable  to  opera- 
tion. These  tumors  grew  very  rapidly  and  infiltrated 
neighboring  tissues  very  early.  Cysto-adenoma  was 
not  uncommon.  The  surgery  of  the  thyroid  had  ad- 
vanced very  rapidly  during  the  last  few  years.  This 
improvement  was  due  to  pathological  study.  Thanks 
to  this  it  was  now  known  that  cysts  were  very  common 
in  the  gland.  All  cysto-adenomas  were  innocent  tu- 
mors separable  and  encapsuled,  and  the  gland  was 
healthy,  as  in  the  case  of  similar  tumors  in  the  breast. 
Our  nomenclature  showed  a  slowness  to  appreciate  our 
newer  knowledge.  A  so-called  cystic  goitre  was  not  a 
goitre  at  all,  the  gland  itself  being  unaffected.  The 
operation  for  the  removal  of  these  cysts  was  simple. 
Drainage  was  needed  for  the  first  few  days,  owing  to 
the  presence  of  a  cavity.  Sosin's  operation  of  enuclea- 
tion was  applicable  to  all  partial  enlargements  of  the 
gland,  unless  it  dipped  down  behind  the  sternum.  He 
described  a  case  that  came  to  him  in  the  out-patient 
room  some  time  ago,  which  he  aspirated  ;  there  was 
considerable  bleeding,  and  oozing  occurred  whenever 
the  dressing  was  removed.  He  had  at  last  to  lay 
it  open  and  plug  the  cavity,  which  proved  to  be  a 
large  one.  Such  bleeding  was  due  to  vascular  growths 
on  the  wall  of  the  interior  of  the  cyst.  The  scar 
that  remained  was  an  objection  to  the  enucleation  op- 
eration. He  thought  that  the  method  of  injection 
advocated  by  Morell  Mackenzie,  and  described  in  de- 
tail in  the  "  Transactions  of  the  Clinical  Society,"  was 
often  most  successful.  He  strongly  recommended  that 
Mackenzie's  directions  should  be  adhered  to  in  using 
this  method.  Its  object  was  to  convert  the  cyst  into 
an  abscess  and  allow  the  matter  to  escape  through  a 
cannula  until  the  ca\dty  was  closed.  It  was  not  appli- 
cable to  hospital  cases,  on  account  of  the  time  it  occu- 
pied, but  for  the  well-to-do  who  thought  a  great  deal  of 
the  disfigurement  a  scar  produced,  it  had  a  great  deal  to 
recommend  it.  The  method  had  fallen  into  disuse,  but 
he  believed  that  the  difficulties  encountered  were  due 
to  want  of  care  in  selecting  cases.  For  instance,  it  has 
been  used  in  parenchymatous  enlargement  with  very 
bad  results.  Injection  into  the  cavity  of  a  cyst  was 
safe,  but  into  the  substance  of  the  gland  it  was  not  to 
be  thought  of.  Large  cysts  and  hemorrhagic  cysts 
should  not  be  injected,  nor  those  in  delicate  and  stru- 
mous persons,  nor  should  old-standing  cysts  with  thick 
walls.  A  moderate  amount  of  intra-cystic  growth  was 
not  a  contra-indication  to  injection. 

Dr.  AV.  W.  Keex,  of  Philadelphia,  said  that  thyroid 
disease  was  not  common  in  America,  and  therefore  his 
experience  was  not  great,  but  he  had  recently  visited 
Switzerland  and  had  observed  the  practice  of  Swiss 
surgeons  in  operating  on  the  gland.  No  antesthetics 
were  used  except  in  the  case  of  young  children  and 
very  nervous  women.  Five  out  of  six  of  the  cases  he 
saw  thus  operated  seemed  to  feel  very  little  pain,  and 
the  bleeding  was  much  less.  Kocher  used  a  transverse 
incision  curved  with  the  convexity  downward.  The 
scar  of  this  showed  less  than  a  median  vertical  one. 
To  minimize  scar  he  recommended  the  subcuticular 
•ture  recommended  by  Dr.  Halstead,  of  the  Johns 
ilopkins  Hospital.  He  thought  that  the  minute  atten- 
tion paid  to  the  arrest  of  hemorrhage  in  Switzerland 
deserved  to  be  imitated.  Scarcely  two  ounces  of  blood 
were  lost  in  an  operation.     Kocher's  actual  work  ex- 


actly corresponded  to  his  published  method  of  opera- 
tion in  all  its  details. 

Mr.  Charters  Svmoxds  said  that  he  had  had  forty- 
four  cases  without  a  fatal  result.  Twenty-nine  of  these 
were  cases  of  adenoma.  He  thought  that  certain  cases 
of  malignant  disease  in  an  early  stage  might  be  benefited 
by  operation.  In  advanced  cases  tracheotomy  was  often 
needed  as  a  palliative.  He  preferred  a  median  incis- 
ion to  the  oblique  lateral  incision.  If  the  cyst  on  ex- 
posure appeared  white,  it  might  be  fearlessly  excised. 
If,  however,  it  were  purple  it  was  probably  almost  solid 
from  intra-cystic  growth,  and  alarming  bleeding  might 
be  expected  at  first.  This,  however,  could  be  promptly 
stopped  by  everting  the  wall  of  the  cyst  and  seizing  the 
bleeding  vessel.  He  preferred  to  operate  under  an  an- 
aesthetic. He  had  never  encountered  serious  bleeding. 
He  kept  a  drain  in  for  only  twenty-four  hours.  He 
did  not  hesitate  to  remove  cysts  that  slipped  down  be- 
hind the  sternum.  He  thought  that  Mr.  Butlin's  se- 
lection of  cases  for  injection  was  a  good  one,  but  cysts 
without  solid  growth  were  very  rare.  The  cyst  wall 
was  very  thin  where  the  growth  was  situated,  and  might 
give  way  when  suppuration  occurred.  As  to  the  scar, 
he  made  a  small  incision  as  low  down  as  possible,  so 
that  it  could  easily  be  hidden.  A  very  small  wound 
would  suffice  if  the  cyst  were  punctured  and  emptied 
before  removal. 

Mr.  Mayo  Roeson  said  that  he  had  found  packing 
the  cyst  answer  well.  He  had  heard  of  accidents  after 
injection.  Since  he  had  read  Mr.  Symond's  paper  he 
had  always  removed  cysts.  He  had  no  experience  of 
the  accessory  thyroids.  In  his  experience,  cases  of  ma- 
lignant disease  were  too  far  advanced  when  seen  to  be 
amenable  to  operation.  In  these  cases  distressing  dysp- 
noea occurred,  and  it  was  difficult  to  relieve  it.  Trach- 
eotomy was  out  of  the  question  sometimes.  He  had 
found  great  relief  from  intubation.  He  had  had  dif- 
ficulty in  isolating  certain  cysts,  and  had  sometimes 
been  obliged  to  remove  half  the  gland  when  there  were 
many  cysts.  As  to  subcuticular  suture,  it  minimized 
the  scar.  He  did  not  think,  however,  that  Butlin's  ob- 
jection to  the  scar  was  of  great  weight.  Ether  was  not 
a  good  anesthetic.  It  increased  the  bleeding  and  dysp- 
noea. He  preferred  chloroform  or  A.  C.  E.  mixture. 
He  would  always  give  an  anesthetic,  even  if  it  were 
only  continued  till  the  skin  incision  were  made.  When 
in  an  operation  on  the  thyroid  tracheotomy  became  nec- 
essary as  a  temporary  measure,  it  was  a  good  plan  to 
suture  the  rings  together  at  the  end  of  the  operation 
and  close  the  wound,  leaving  the  sutures  buried. 

Mr.  Berry  had  never  seen  a  case  of  malignant  dis- 
ease amenable  to  operation.  The  layer  of  tissue  im- 
mediately over  the  capsule  of  a  cyst  or  tumor  was 
almost  always  microscopically  thyroid-gland  tissue, 
however  thin.  Enucleation  was  only  advisable  when 
there  was  a  single  well-defined  tumor.  If  the  tumors 
were  multiple  or  ill-defined  extirpation  was  better. 
The  more  nearly  the  tumor  approached  to  the  globular 
form,  the  more  likely  that  it  could  be  enucleated.  The 
more  pyriform  it  was,  the  less  likely  to  be  fit  for  enu- 
cleation. Smooth  regular-surfaced  tumors  may  gener- 
ally be  enucleated.  He  described  a  case  of  large  sub- 
sternal tumor  that  he  had  successfully  removed.  The 
tumor  scarcely  showed  above  the  sternum. 

Mr.  Keetley  had  operated  on  two  cases  of  malig- 
nant disease,  also  three  times  without  an  anresthetic. 
In  one  case  of  a  very  large  tumor  the  ansesthetic  was 
stopped  as  soon  as  the  skin  incisions  were  done.  He 
was  not  so  clever  as  the  abdominal  surgeons  who  would 
clear  you  out  a  pelvis  in  three  minutes  or  so,  and  this 
operation  occupied  three  hours.  The  patient  was  un- 
restrained throughout,  yet  did  not  interfere  with  his 
hands  or  struggle  in  any  way.  She  suffered  hardly 
any  pain  except  when,  owing  to  the  difficulty  of  rais- 
ing the  tumor  in  order  to  free  it  behind,  where  it  was 
adherent  to  the  trachea  and  larynx,  he  had  to  divide 
its  wall  and  scoop  out  the  contents  in  order  to  allow 


354 


MEDICAL  RECORD. 


[September  7,  1895 


it  to  collapse.  The  question  of  malignant  disease  was 
too  wide  a  one  to  go  into  here  thoroughly,  but  in  their 
early  stage  these  growths  must  be  entirely  encapsuled, 
and  could  we  but  diagnose  them  early  enough  they 
might  be  removed.  Attention  was  clearly  needed  to 
early  diagnosis.  The  increased  tendency  of  surgeons 
to  operate  on  the  thyroid  must  surely  lead  to  opera- 
tions on  early  malignant  tumors.  The  improvement  of 
late  years  in  our  treatment  of  the  thyroid  was  due  to 
pathological  knowledge  acquired  in  vivo  instead  of  post 
mortem.  He  did  not  approve  of  the  injection  treat- 
ment. He  thought  so  serious  a  thing  as  a  cyst  in  the 
neck  should  be  treated  through  an  adequate  open  in- 
cision. No  drain  should  be  necessary.  If  there  were 
a  collection  of  fluid  a  day  or  two  after  operation,  it  was 
easy  to  insert  a  probe  and  give  it  vent. 

Mr.  B.\rker  had  succeeded  in  removing  large  ma- 
lignant tumors  of  the  thyroid.  In  the  first  case  the 
growth  formed  the  largest  tumor  of  the  neck  that  he 
had  ever  seen.  More  than  one  surgical  authority  had 
advised  against  operation  five  years  before.  He  had 
to  make  an  incision  over  thirteen  inches  long  from  the 
mastoid  process  to  the  episternal  notch.  The  glands 
were  found  to  be  involved  and  were  removed,  so  that 
the  pleura  was  exposed  at  the  bottom  of  the  wound. 
The  patient  recovered.  Two  years  afterward  recur- 
rence occurred  in  a  gland  that  had  escaped  removal. 
This  was  excised,  and  the  patient  was  still  alive  six 
years  after  this  last  proceeding.  In  another  case  also 
he  had  successfully  removed  a  malignant  growth.  He 
thought  that  there  was  no  doubt  as  to  the  nature  of  the 
growth  in  either  case. 

Mr.  J0RD.A.N  Lloyd  said  that  he  thought  that  enu- 
cleation was  an  easy  proceeding,  until  he  encountered 
two  cases  of  quite  unenucleable  cysts  containing  solid 
growths.  In  many  cases  the  hemorrhage  was  trivial, 
but  it  might  be  alarming.  He  thought  that  Mr.  Bark- 
er's cases  were  something  very  different  to  the  cases  of 
malignant  disease  referred  to  by  Mr.  Butlin  and  other 
speakers.  The  long  duration  of  the  disease  in  Mr. 
Barker's  first  case  was  a  most  curious  and  interesting 
fact  in  the  history  of  the  thyroid.  That  a  patient  with 
an  undoubtedly  malignant  tumor  should  survive  to  be 
operated  on  five  or  six  years  after  she  had  been  pro- 
nounced too  far  gone  for  operation,  was  simply  astound- 
ing. He  shared  the  belief  of  other  speakers,  that  ma- 
lignant tumors  of  the  thyroid  in  the  present  state  of 
kno.vledge  were  not  fit  to  be  operated  on.  The  dan- 
gers of  the  injection  treatment  were  immense.  He 
thought  very  little  of  the  objections  to  open  incision 
on  account  of  the  scar.  A  transverse  incision  low 
down  in  the  neck  was  applicable  to  many  cases,  and  the 
scar  was  not  obvious. 

Mr.  Thelwall  Thom.\s  said  that  he  had  operated 
on  two  cases  of  accessory  thyroids.  In  one  lumps  were 
removed  from  behiniand  beneath  the  sterno-mastoid, 
and  below  the  angle  of  the  jaw.  The  microscopical 
appearances  were  those  of  thyroid-gland  tissue.  In 
the  second  case  there  was  a  tumor  above  the  clavicle 
in  the  posterior  triangle.  It  proved  to  consist  of  cystic 
thyroid  tissue,  the  gland  itself  being  normal.  It  was 
easily  removed.  Scars  were  due,  he  thought,  to  the 
line  of  incision  crossing  the  natural  folds  of  the  neck. 
What  soon  after  operation  seemed  to  be  a  linear,  almost 
invisible  scar,  became  broader  and  more  marked  if  the 
incision  were  across  the  folds,  but  if  it  were  parallel  it 
scarcely  showed. 

Mr.  R.  C.  Chicken  deprecated  the  use  of  iodine 
and  other  irritants  to  swellings  in  the  neck.  They  did 
no  good,  and  often  increased  the  difficulties  of  subse- 
quent operation.  The  only  case  of  trouble  from  bleed- 
ing that  he  had  had  was  due  to  the  use  of  that  most 
unreliable  and  most  treacherous  of  surgical  devices — 
the  Staffordshire  knot.  It  was  only  of  use  when  it  was 
wrongly  tied.  In  severe  dyspnoea  section  of  the  isth- 
mus was  most  serviceable. 

Mr.  Cathc.\rt  reminded  his  hearers  that  one  can- 


not draw  the  line  clearly  between  innocence  and  ma- 
lignancy. Hence  arose  the  divergent  views  of  Mr. 
Barker  and  other  speakers. 

Mr.  Butlix,  in  reply,  said  that  so  far  as  congratu- 
lating Swiss  surgeons  on  only  shedding  two  ounces  of 
blood,  he  should  be  ashamed  himself  of  such  hemor- 
rhage. Two  drachms  was  more  like  the  average  in  his 
cases.  One  objection  to  the  transverse  incision  was, 
that  where  the  scar  was  visible  it  suggested  the  last 
penalty  of  the  law,  and  might  lead  to  unpleasant  re- 
marks. He  always  avoided  puncture  of  the  cyst,  be- 
cause it  made  removal  more  difficult. 


Third  Day,  Friday,  August  2D. 

Intestinal  Anastomosis. — The  proceedings  began  with 
an  interesting  demonstration  on  the  cadaver  by  Dr. 
Murphy,  of  Chicago,  of  the  method  of  using  his  but- 
tons. It  is  impossible  here  to  describe  the  demonstra- 
tion, which  was  watched  with  great  interest  by  many 
surgeons.  Dr.  Murphy  pointed  out  that  perfect  coap- 
tation of  surfaces  was  necessary.  The  desiderata  were, 
I,  perfect  coaptation  of  surfaces  ;  2,  immediate  adhe- 
sion ;  3,  sufficient  calibre  after  separation  of  the  but- 
ton ;  4,  permanent  organization  of  the  uniting  material ; 
5,  avoidance  of  contraction  afterward  ;  6,  maintenance 
of  asepsis  ;  and  7,  speed  in  performance  of  operation. 
When  all  seven  were  attained  we  had  an  ideal  operation. 
By  his  method  edge-to-edge  union  was  obtained,  not 
lateral  approximation,  for  the  inverted  portions  are  cut 
off  by  pressure  atrophy.  Microscopic  examination 
after  union  showed  this  to  be  the  case.  He  claimed 
that  the  connective  tissue  was  only  temporary,  and  that 
it  was  ultimately  replaced  by  reproduction  of  muscular 
and  other  layers  of  gut,  so  that  in  the  end  there  was  no 
scar  and  no  contraction.  There  were  certain  points 
about  the  blood-supply  of  the  intestine  worthy  of  atten- 
tion. There  were  two  principal  sources,  one  the  radi- 
ating mesenteric  vessels,  the  other  a  collateral  or  par- 
allel supply.  It  was  found  by  experiment  that  the 
mesenteric  vessels  might  be  ligatured  for  a  space  of 
seven  inches  without  necrosis  following  ;  but,  on  the 
other  hand,  we  could  not  arrest  the  circulation  through 
the  lateral  vessel  along  the  bowel  for  more  than  half  an 
inch  without  producing  necrosis.  Some  failures  of 
union  were  due  to  neglect  of  this.  More  of  the  bowel 
should  be  removed  on  the  convex  border  than  on  the 
mesenteric,  and  care  must  be  taken  not  to  include  too 
much  of  the  gut  on  the  convex  side.  The  point  of  at- 
tachment of  the  mesentery  was  a  weak  point  in  using 
the  button  in  endtoend  approximation.  A  figure-of- 
eight  stitch  should  be  placed  across  this  place,  so  as  to 
draw  the  two  layers  of  peritoneum  closely  round  the 
bowel  and  button.  In  inserting  the  button,  the  female 
half  should  first  be  placed,  and  in  putting  in  the  male 
half  it  should  be  grasped  by  its  outer  flange.  It  was 
necessary  to  see  that  the  edge  of  the  mucosa  was  all 
within  the  grasp  of  the  button,  otherwise  one  might  get 
mucosa  applied  to  serosa,  with  resultant  non  union. 
On  opening  the  abdomen  it  was  easy  to  tell  in  which 
direction  the  upper  end  of  the  gut  lay.  If  the  hand 
were  run  along  the  mesentery  and  the  latter  were  found 
to  be  attached  to  the  right,  the  true  upper  end  of  the 
bowel  would  be  found  to  lie  below,  and  vice  versa. 
The  mesentery  should  be  ligatured  close  to  its  base, 
and  one  ligature  would  do  for  many  inches  of  gut. 
The  thread  should  never  be  pulled  tight  before  making 
the  knot,  otherwise  the  bowel  may  be  torn.  The 
halves  of  the  button  should  be  slowly  and  steadily 
pressed  together  until  the  "  click  "  was  heard.  Open- 
ings in  the  gut  should  be  two-thirds  the  size  of  the  but-  ^ 
ton.  For  resection  of  the  rectum  a  special  long,  cylin- 
dered  button  was  to  be  used. 

Cervical  Spinal  Surgery.— Mr.  Victor  Horslev 
read  a  paper  on  "  The  Results  of  Operative  Treatment 
of  Injury  or  Disease  of  the  Cervical  Vertebrae."  He 
had  performed  laminectomy  in  seven  cases  of  caries  andl 


September   7,  1895] 


MEDICAL    RECORD. 


fracture  of  the  spine  in  the  cervical  region  with  paraly- 
sis. He  had  had  one  death,  but  all  the  patients  recov- 
ered from  the  operation.  He  exhibited  three  patients 
to  the  Section. 

Case  I. — Caries  of  atlas  and  axis,  palsy  of  all  four 
limbs,  and  beginning  of  palsy  of  respiration.  Skin 
dusky  and  respirations  thirty-six  per  minute.  In  1888 
he  removed  the  arches  of  the  first  and  second  cervical 
vertebrae.  Six  days  after  the  operation  power  began 
to  return.  Wasting  of  the  interossei  of  the  hands  was 
very  marked,  as  in  all  these  cases.  It  was  still  notice- 
able, although  it  was  seven  years  since  the  operation. 

Case  II. — Caries  of  fifth  and  sixth  cerN-ical  vertebrae. 
Palsy  marked  but  not  complete.  Reflexes  exaggerated. 
Sensation  normal.     Recovered  after  laminectomy. 

Case  III. — Absolute  motor  palsy  of  lower  limbs  and 
of  right  upper  limb.  Anaesthesia  up  to  third  rib.  Re- 
flexes absent  on  right  side,  exaggerated  on  the  left. 
Removal  of  arches  of  third  to  seventh  cervical  verte- 
brae.    Began  to  recover  in  three  days. 

In  all  cases  he  had  noticed  rapid  recovery  after  the 
third  day  from  the  operation.  Ephemeral  recovery 
was  often  noticed.  This  might  be  explained  by  the 
occurrence  of  temporary  cedema. 

Case  IV. — Fracture  of  cervical  spine  from  a  fall  five 
months  before  the  operation.  Palsy  of  all  four  limbs. 
Slight  recovery.  Then  became  worse.  Angle  at  spines 
of  fifth  and  sixth  cervical  vertebrae.  Sensory  palsy 
was  severe.  There  was  even  analgesia  denoting  injury 
to  the  central  gray  matter.  Reflexes  were  exaggerated 
and  the  rectum  paralyzed.  Theie  was  contraction  of 
the  knees.  Quite  recovered  after  operation  and  re- 
moval of  fibrous  tissue  and  forcible  extension,  but  the 
interossei  were  still  rather  wasted. 

Case  V. — Fall  from  a  cart.  Walked  after  a  week. 
Bodies  of  fifth  and  sixth  cervical  vertebrae  fractured. 
Treated  at  various  hospitals  for  symptoms,  but  there 
was  no  deformity  in  line  of  spinous  processes.  Motor 
and  sensor)-  palsy,  and  some  analgesia  and  vesico-rectal 
paralysis.  Reflexes  exaggerated.  The  left  optic  disk 
was  swollen,  possibly  commencing  optic  neuritis.  Op- 
eration :  Removal  of  arches  of  fifth,  sixth,  and  seventh 
cervical  vertebrae.  The  body  of  the  sixth  was  found  to 
be  crushed  and  fragments  driven  back.  Forcible  ex- 
tension and  consequent  abolition  of  ridge.  Recovered 
by  the  twelfth  day.     Recovery  permanent. 

Case  VI. — Tossed  by  a  bull.  Fracture.  Gradual 
onset  of  palsy.  Lower  half  of  cord  involved.  Anaes- 
thesia of  post-axial  part  of  upper  limb  and  of  patches 
on  lower  limb.  Vesico-rectal  palsy.  Operation  sim- 
ilar to  Case  V.  No  ephemeral  improvement.  Palsy 
was  more  marked  after  operation  (due  to  oedema  ?). 
Recovery  slow  and  not  yet  quite  complete. 

C.\SE  VII.— Fall  from  a  car  on  to  the  forehead.  Got 
up  and  walked  two  hundred  yards.  Tried  to  walk  up- 
stairs, but  could  not.  Rapidly  became  paralyzed  in  all 
four  limbs.  Some  recovery  afterward  took  place. 
When  seen  by  j\Ir.  Horsley  had  spastic  rigidity  of 
limbs.  Had  some  voluntary  movement,  but  it  varied. 
Slight  deformity  of  spine.  Post-axial  anaesthesia  of 
upper  limbs.  Exaggerated  reflexes.  Laminectomy 
and  ephemeral  recovery.  Permanent  recovery  three 
weeks  after  the  operation.  Can  now  walk  a  mile  and 
is  still  improving.  This  patient  gave  up  his  support 
too  soon  and  spasm  began  to  reappear,  but  disappeared 
again  on  reapplication. 

Mr.  Horsley  referred  to  alarming  phenomena  which 
might  appear  after  laminectomy  in  the  cervical  region. 
In  some  cases  the  temperature  rose  to  104°  F.  and  the 
pulse  to  130.  He  let  out  the  cerebro-spinal  fluid  from 
the  wound  and  the  temperature  fell  at  once. 

The  President  said  that  the  patients  exhibited  were 
surgical  triumphs.  He  would  ask  for  information  as  to 
the  gradual  onset  of  sjinptoms  in  certain  of  the  cases, 
and  in  cases  where  the  palsy  was  immediate  he  would 
ask  how  we  were  to  tell  whether  the  damage  done  were 
or  were  not  irreparable. 


Sir  William  Stokes  asked  Mr.  Horsley  to  explain 
how  in  caries  removal  of  the  laminae  gave  perma- 
nent relief,  when  in  this  disease  the  bodies  alone  are  as 
a  rule  affected.  He  would  like  to  hear  something  as 
to  the  condition  of  the  bones  that  were  removed.  In 
cases  of  fracture  the  operation  was  unpopular  in 
Dublin.  How  was  permanent  extension  provided  for 
in  the  case  recorded  in  which  extension  was  found  pos- 
sible on  operation  ? 

Mr.  E.  Noble  Smith  said  that  in  cases  of  caries  it 
was  important  to  know  when  operation  was  necessary 
and  when  recovery  might  be  expected  without  it. 

Mr.  Keetley  has  had  two  cases  of  laminectom)', 
one  of  them  for  cervical  fracture  of  the  spine.  In  one 
the  fifth  cervical  vertebra  was  pressed  back  on  to  the 
fourth.  Paralysis  was  immediate.  He  removed  the 
lamina  of  the  fourth  cervical.  There  was  some  im- 
provement, but  on  the  fourth  day  the  patient  died.  -A.t 
the  necropsy  the  cord  was  found  to  be  clearly  divided 
although  the  dura  mater  was  intact.  In  the  second 
case,  of  a  boy  aged  eighteen,  there  was  long-standing 
complete  paraplegia  from  caries.  The  condition  was 
improved  by  gypsum  corset,  but  the  improvement  was 
transitory.  Laminectomy  over  the  projection  did  not 
seem  likely  to  do  good.  He  therefore  attacked  the 
bodies  through  the  pedicles  and  heads  of  the  ribs.  No 
abscess  was  found  and  the  bodies,  as  far  as  they  could 
be  examined,  were  sound.  The  patient  was  many 
months  in  hospital.  He  went  home  and  finally  re- 
covered, as  nearly  all  such  cases  do  if  left  alone.  Mr. 
Horsley's  experience  of  these  cases  was  greater  than 
that  of  anyone  present  except  Professor  McEwen  ;  but 
Mr.  Keetley  ventured  to  think  that  in  the  case  of  caries 
extension  would  have  done  as  well  without  the  pre- 
liminary laminectomy.  Cervical  laminectomy  was  a 
very  serious  operation,  more  so  in  surgery.  Imme- 
diately after  a  fracture  it  was  very  difficult  to  decide  as 
to  need  of  operation.  Examination  was  dangerous,  for 
the  slightest  movement  of  the  parts  might  prove  fatal. 
Laminectomy  was  almost  the  only  operation  in  which 
we  approached  the  disease  from  the  most  dangerous 
side  with  structures  of  the  greatest  importance  inter- 
vening. Why  not  operate  on  the  cervical  spine  from 
the  front  and  side  ? 

Mr.  Damer  Harrison  said  that  hyperextension  of 
the  neck  was  most  valuable  in  fracture.  He  thought 
that  some  of  Mr.  Horsley "s  cases  would  have  recovered 
with  this  treatment  alone.  It  was  impossible  to  tell 
what  amount  of  injury  was  inflicted  on  the  cord.  For 
instance,  in  one  case  he  had  known  palsy  come  on 
three  days  after  the  accident.  Laminectomy  failed 
to  relieve  the  symptoms.  The  dura  mater  was  not 
opened.  After  death,  the  outside  of  the  cord  showed  no 
sign  of  injury  to  the  naked  eye,  but  on  section  hemor- 
rhage in  the  gray  matter  was  found. 

Mr.  Luke  Freer  asked  for  more  information  as  to 
the  stage  of  the  disease  in  the  case  of  caries  recorded, 
and  the  duration  of  the  paralysis.  These  cases  almost 
always  recovered  in  time, 

Mr.  Mavo  Robsox  had  done  laminectomy  for 
caries,  and  found  three  vertebras  bathed  in  pus.  The 
same  patient  afterward  had  fracture  of  the  vertebra 
next  above.  The  result  was  a  very  partial  recovery. 
The  cord  was  found  to  be  half  divided.  Laminectomy 
did  no  good.  If  the  cord  were  injured  at  the  time  of 
accident,  he  did  not  believe  that  laminectomy  was  of 
any  use.  If  it  were  not  injured,  then  recovery  would 
occur  without  laminectomy. 

Mr.  V.  Horslev,  in  reply,  said  that  in  acute  cases, 
if  there  were  complete  motor  palsy  and  abolition  of 
deep  reflexes,  an  operation  was  not  justifiable.  In 
caries,  removal  of  the  granulation  tissue  on  the  dura 
mater  relieved  pressure.  He  advocated  elastic  exten- 
sion under  the  chin  and  mastoid  processes,  through 
steel  spring  supports  fixed  to  a  poroplastic  jacket.  In 
some  cases  operation  was  undertaken  to  save  life,  on 
account  of   urgent  dyspnoea,  etc.     When  paraplegia 


356 


MEDICAL   RECORD. 


[September  7,  1895 


was  due  to  abscess,  he  would  always  operate  and  drain 
the  abscess  if  necessary  through  the  pedicles.  Drain- 
age must  be  kept  up,  or  there  would  be  no  improve- 
ment from  the  palsy.  When  extension  has  been  tried 
for  some  months  without  marked  improvement,  he 
would  operate. 

Colectomy — Mr.  Mavo  Robson  read  a  paper  on  "  A 
Series  of  Cases  of  Colectomy."  He  said  that  four  out 
of  five  cases  recovered.  He  believed  that  the  use  of 
his  decalcified  bone  bobbin  was  a  great  improvement 
in  the  operation  of  cholecystectomy.  He  used  it  also 
in  acute  obstruction  and  for  lateral  anastomosis.  With 
the  bobbin  the  operation  could  be  done  as  quickly 
and  as  safely,  or  more  safely,  than  with  Murphy's  but- 
ton. In  some  cases,  it  was  a  good  plan  to  paint  a  thin 
coating  of  shellac  round  the  central  portion  of  the  bob- 
bin so  as  to  delay  dissolution.  There  had  been  thir- 
teen cases  in  the  Leeds  Infirmary,  under  five  different 
surgeons,  with  a  mortality  of  twenty-three  per  cent. 
He  thought  that  this  might  be  taken  as  the  real  rate  of 
mortality  in  this  operation. 

Mr.  Greig  Smith  said  that  he  believed  it  was  best 
to  bring  the  tumor  and  stricture  outside  the  wound 
and  fix  it  by  means  of  a  skewer  ;  incise  the  bowel  and 
drain  it  and  operate  on  the  stricture  later  on  when  the 
abdomen  was  again  flat  and  the  bowel  not  distended 
and  had  recovered  its  tone.  No  anaesthetic  was  needed 
for  the  second  stage  of  the  operation.  He  described 
three  cases  which  could  not  have  borne  resection  at 
time  of  preliminary  incision,  but  all  recovered  after  de- 
ferred resection  operation  without  a  bad  symptom. 
The  deferred  enterectomy  was  much  easier  with  the 
bowel  outside  the  abdomen.  In  one  case  of  acute  ob- 
struction with  a  small  malignant  stricture,  he  used 
Murphy's  button.  All  went  well  for  two  days.  The 
patient  then  died.  The  button  was  found  to  be  all 
right,  but  the  patient  was  not  fit  for  the  operation. 
Had  he  divided  the  operation  into  two  stages,  he  be- 
lieved that  the  patient  would  have  recovered. 

Dr.  W.  W.  Keen,  of  Philadelphia,  described  a  case 
of  failure  with  Murphy's  button.  He  could  not  get 
the  two  halves  to  close  on  one  another  with  any 
amount  of  force  that  he  dare  apply.  The  patient  died. 
The  gut  was  found  to  have  sloughed  over  the  upper 
half  of  the  button.  The  obstacle  to  approximation 
was  caused  by  the  catching  of  the  end  of  the  thread, 
shqwing  the  importance  of  attending  to  Murphy's 
direction  that  the  thread  should  be  cut  short  after 
tying. 

Mr.  Herbert  Allingham  had  had  eight  cases  of 
resection,  of  which  four  died.  All  were  combined  with 
obstruction.  He  had  determined  in  future  to  drain 
these  cases  first  as  recommended  by  Mr.  Grey  Smith. 
He  could  not,  however,  agree  with  that  surgeon  as  to 
the  painlessness  of  removal  of  the  stricture  gat.  He 
found  the  mesentery  very  sensitive,  and  that  there  was 
marked  shock  on  cutting.  He  much  preferred  Rob- 
son's  bobbin  to  Murphy's  button. 

Mr.  Harrison  Critps  heartily  indorsed  what  Mr. 
Grey  Smith  had  said  as  to  the  advantages  of  the  oper- 
ation in  two  stages.  He  thought  that  no  patient  with 
actual  obstruction  was  fit  for  resection.  As  to  Mur- 
])hy's  button,  he  thought  it  the  most  fatal  way  of  treat- 
ing obstruction.  It  was  used  in  four  cases  at  St. 
Bartholomew's  Hospital,  all  of  whom  died.  In  two  of 
these  the  button  had  nothing  to  do  with  the  result. 
Of  the  other  two,  one  died  on  the  eighth  d;iy.  The 
junction  was  complete.  The  button  had  passed  down 
tiie  bowel  for  six  inches  and  had  then  stuck  fast  and 
ulcerated  through,  causing  death  from  fecal  extrava- 
sation and  peritonitis.  In  the  other  case,  the  intestine 
had  sloughed  where  it  was  stretched  over  the  button. 
He  thought  highly  of  Mayo  Robson's  bobbin,  but  be- 
lieved that  the  finger  was  the  best  guide  in  suturing  ; 
there  was  no  need  to  hurry,  and  a  careful  and  accurate 
appro.ximation  and  suture  of  the  two  ends  could  be 
made. 


Dr.  Macewen  said  that  in  surgery  he  was  generally 
a  radical,  but  on  this  subject  he  was  a  conservative. 
He  had  relied  in  the  past  on  sutures  and  sutures  alone. 
He  would  not  say  that  he  would  never  use  the  button 
or  bobbin,  but  thought  that  further  experience  was  re- 
quired of  their  practical  value.  He  liked  the  operation 
in  two  stages,  but  there  were  cases  in  which  one  could 
not  get  the  tumor  outside  the  abdomen  as  Mr.  Grey 
Smith  advised.  He  spoke  of  cases  in  which  the  con- 
trol of  the  bowels  was  for  long  defective.  This  he  be- 
lieved to  be  due  to  removal  of  the  ileo-caecal  valve. 

Mr.  Mavo  Robson,  in  reply,  said  that  he  could  not 
agree  with  Mr.  Smith  that  the  tumor  could  generally 
be  easily  drawn  out  of  the  abdomen,  but  he  thought 
preliminary  drainage  very  valuable  when  practicable. 
In  enterectomy  and  pylorectomy  simple  suturing  did 
well,  but  the  bobbin  was  better.  Its  use  secured  con- 
tinuity of  the  bowel-wall  and  avoidance  of  contraction. 
The  important  point  was  that  the  ends  of  the  gut  were 
united  by  sutures  and  not  by  the  bobbin.  The  latter 
was  merely  a  guide  and  a  protection  to  the  sutures  for 
several  days.  Some  of  the  specimens  in  the  museum 
showed  how  Murphy's  button  might  score  the  intestine 
in  its  passage  down. 

Colotomy. — Mr.  Harrison  Cripps  read  a  paper 
on  "A  Complication  Occurring  in  Inguinal  Colotomy." 
The  mortality  in  nearly  every  case  was  due  to  delayed 
operation.  When  the  obstruction  was  complete  it  was 
difficult  to  get  at  the  bowel  and  it  would  bear  very  lit- 
tle handling.  It  was  difficult  to  stitch  it  to  the  skin 
without  going  into  the  muscular  coat.  In  some  cases 
there  was  difficulty  in  finding  the  bowel,  but  this  diffi- 
culty diminished  with  experience,  which  had  taught 
him  that  the  best  plan  was  to  feel  for  the  brim  of  the 
pelvis  when  the  rectum  would  be  found  and  traced  to 
its  sigmoid  flexure,  which  in  these  cases  lay  much 
nearer  the  middle  line  than  normal.  Absence  of  a 
mesentery  was  a  most  unfortunate  and  dangerous  com- 
plication. To  this  cause  he  owed  all  the  deaths  except 
one.  The  question  arose.  What  was  to  be  done  under 
these  circumstances  ?  Should  the  operation  be  given 
up  and  the  other  side  opened  ?  The  objection  to  this 
course  was  that  owing  to  the  fluidity  of  the  faeces  in 
the  ascending  colon,  the  management  of  the  artificial 
anus  was  far  more  difficult.  He  preferred  to  suture 
the  parietal  peritoneum  to  the  bowel.  No  attempt 
should  be  made  to  draw  the  skin  down  to  the  gut,  but 
the  peritoneum  should  be  separated  from  the  wall  of 
the  abdomen  as  far  as  necessary.  The  bowel  might  be 
opened  at  the  mesentery  and  the  cut  edges  sutured  to 
the  parietal  peritoneum  ;  but  in  this  way  the  wound 
was  apt  to  get  soiled.  This  might  be  avoided  by  rais- 
ing, as  it  were,  flaps  from  tlie  bowel,  consisting  of  peri- 
toneum and  muscular  coats,  and  suturing  these  to  the 
parietal  peritoneum.  The  mucosa  should  not  be  di- 
vided until  two  days  afterward.  The  bowel  was  only 
likely  to  tear  away  when  there  was  too  short  a  mesen- 
tery. It  was  an  excellent  rule  to  draw  out  plenty  of 
the  gut,  as  had  been  taught  by  Mr.  H.  W.  Allingham. 
A  free  opening  was  always  desirable,  and  in  many  cases 
a  spring  dilator  was  required. 

In  one  case,  after  colotomy,  a  rare  complication  oc- 
curred which  ended  fatally.  The  patient  did  well  and 
recovered  from  the  operation  and  was  about  to  leave 
the  hospital  when  he  had  a  sudden  attack  of  pain  in  the 
neighborhood  of  the  artificial  anus,  accompanied  by 
vomiting.  As  he  described  it,  "  Something  slipped  in 
his  inside,"  and  the  pain  and  vomiting  thereupon 
ceased.  As  he  seemed  quite  well,  he  was  allowed  to 
leave  the  hospital,  but  he  returned  ten  days  afterward 
in  a  dying  condition  with  the  same  symptoms  and  died 
soon  after  admission.  At  the  necropsy  it  was  found 
that  a  loop  of  small  intestine  had  slipped  between  the 
attachment  of  the  colon  and  the  wall  of  the  belly. , 
Prompt  abdominal  section  would  have  saved  him  had  \ 
the  meaning  of  the  symptoms  been  understood.  This 
case  would  be  a  warning  to  him  in  the  future. 


September  7,  1895] 


MEDICAL   RECORD. 


357 


Hernia  of  the  Sigmoid  Flexure. — Mr.  William  An- 
derson then  reported  three  cases  of  sackless  hernia 
of  the  sigmoid  flexure  through  the  left  inguinal 
canal,  with  anatomical  specimen.  He  said  that  this 
variety  of  hernia  arose  from  the  absence  of  a  mesentery, 
the  gut  being  covered  by  peritoneum  for  only  half  its 
circumference.  The  bowel  having  stretched  its  con- 
nections, slips  down  in  the  sub-peritoneal  tissue  and 
passes  easily  through  the  internal  abdominal  ring  which 
is  not  protected  by  parietal  peritoneum. 

Mr.  H.  Morris  had  made  an  attempt  to  form  a 
mesentery  in  a  similar  case.  Mr.  Anderson  thought  it 
was  advisable  when  operating  to  close  the  inguinal 
canal  as  completely  as  possible. 

Splenectomy. — Mr.  Spanton  then  reported  three 
cases  of  splenectomy  in  his  practice.  Two  of  these 
were  fatal,  one  had  recovered.  He  submitted  an  elab- 
orate table  giving  the  details  of  93  cases  of  this  opera- 
tion with  their  results.  Twenty-five  of  these  were 
described  as  leucocythsmic.  Of  these  only  i  recov- 
ered, and  this  was  classed  by  Mr.  Knowsley  Thornton 
under  hypertrophy.  This  gave  a  death-rate  of  ninety- 
six  per  cent.  Of  the  remaining  68  cases,  44  were  cases 
of  hypertrophy  ;  of  these  20  recovered  ;  12  were  cases 
of  wandering  spleen  ;  of  these  1 1  recovered.  Of  the 
remaining  12  cases,  all  recovered  except  i  (condi- 
tion not  stated)  ;  these  included  rotated,  sarcomatous, 
and  cystic  spleens.  The  death-rate  of  splenectomy 
(exclusive  of  leucocythaemia)  had  improved  from  eighty 
per  cent,  in  the  decade  1865-75  to  fifty-one;  eighty- 
five  per  cent,  in  1875-85,  and  to  19.35  P^^"  cent,  in 
1885-95. 

In  the  speaker's  first  case  (in  1883)  death  occurred 
from  hemorrhage  in  seven  hours.  The  spleen,  which 
was  hypertrophied,  weighed  8  pounds  3  ounces.  In  the 
second  case,  in  1891,  the  patient  died  from  shock  in 
eleven  hours  ;  the  spleen  weighed  $}4  pounds.  The 
patient  was  very  ansemic  and  the  case  very  unprom- 
ising. She  had  suffered  great  pain  and  distress,  and 
had  wished  for  operation.  In  the  third  case  he  trans- 
fixed and  doubly  ligatured  the  suspensory  ligament 
and  the  pedicle.  The  spleen  weighed  6  pounds  4 
ounces.  There  was  rise  of  temperature  and  pains,  re- 
ferred to  the  situation  of  the  pedicle,  for  some  time. 
The  operation  lasted  half  an  hour.  In  all  three  cases 
the  operation  was  undertaken  on  account  of  hyper- 
trophy. He  thought  that  in  future  splenectomy  should 
not  be  thought  of  in  leucocythaemia.  In  hypertrophy 
the  symptoms  were  so  severe  and  rendered  life  such  a 
burden  that  the  operation  was  quite  justifiable.  The 
mortality  had  diminished  very  much  of  late  years.  He 
thought  that  in  certain  cases  of  wandering  spleen  also 
operation  was  justifiable. 

Bladder  Drainage.— Mr.  Cathcart  then  exhibited 
and  explained  a  simple  apparatus  for  draining  the  blad- 
der in  cases  of  supra-pubic  lithotomy.  It  consisted  of 
an  ordinary  irrigator  or  douche  can,  the  rubber  tube 
from  which,  by  means  of  a  Y-shaped  junction-tube, 
was  made  to  bifurcate.  One  branch  rested  in  the 
bladder,  the  other  was  interrupted  by  an  S-shaped  tube 
of  glass,  from  which  it  ran  to  a  receptacle  on  the  floor. 
By  means  of  a  pinch-cock  on  the  rubber  tube  close  to 
the  reservoir  the  flow  of  water  from  the  latter  was  re- 
duced to  a  mere  dribble.  This  accumulated  in  the  S- 
tube,  and  thus  the  urine  in  the  bladder  was  drawn  off 
by  an  intermittent  syphon  action. 

Owing  to  the  want  of  time  the  remaining  papers  in 
the  programme  were  read  by  title,  and  this  terminated 
the  proceedings  of  the  section. 


Friars'  Balsam,  so  successfully  used  during  the 
Middle  Ages  in  the  treatment  of  wounds,  ulcers,  etc., 
doubtless  owes  its  virtues  to  the  antiseptic  action  of 
the  benzoic  acid  it  contained,  although  the  part  played 
by  germs  in  wound  repair  was  then  unknown. 


Bronchitis. — 

5.    Potassium  citrate ^  ss. 

Lemon  juice g  j. 

Syrup,  ipecac 3  ij. 

Aquae ad     3  iij. 

M.  S.  :  One-half  ounce  four  or  six  times  a  day  for  an  adult. 

— H.  C.  Wood. 
Sluggish  Liver  and  Indigestion. — 

3.    Acid,  nitro-hydrochlor.  dil Tll_x. 

Tinct.  podophyllin TTl.x. 

Succ.  taraxaci 3  j. 

Tinct.  iiucis  vom Tl^^x. 

Syrup,  zingiberis 3  ss. 

Aq.  menth.  pip ad  3  ss. 

S. — In  water  three  times  a  day. 

Hydrotherapy  in  Fevers. — Winternitz,  at  the  Interna- 
tional Congress  at  Rome  last  spring,  gave  the  results  of 
some  recent  investigations  of  thermic  effects  on  the 
composition  of  the  blood  in  health.  He  demonstrated 
that  all  applications  of  cold  to  the  entire  or  greater 
portion  of  the  surface  of  the  body,  when  proper  reac- 
tion was  secured,  led  to  three  remarkable  results,  viz., 
an  increase  in  the  number  of  leucocytes,  an  increase  in 
the  percentage  of  haemoglobin,  and  an  increase  in  the 
specific  gravity  of  the  blood.  Local  applications  of 
cold,  followed  by  reaction,  accomplished  the  same  re- 
;ults  in  the  local  blood-supply.  This  affords  us  now 
for  the  first  time  a  rational  instead  of  empirical  basis 
for  the  employment  of  cold  compresses  and  poultices. 

Gout  manifesting  itself  anywhere  but  in  a  joint  is 
to  be  considered  irregular  or  incomplete.  —  Duck- 
worth. 

Kraurosis  Vulvae. — Proceed  as  follows  :  a  ten  per 
cent,  ointment  of  cocaine  to  be  applied  and  bromides 
administered  internally  ;  at  the  end  of  a  week  the  af- 
fected parts  are  to  be  painted  with  tincture  of  iron 
twice  a  week  ;  under  this  treatment  the  burning  and 
smarting  soon  diminished  and  the  fissures  healed. 
Next  the  parts  were  smeared  with  Lassar's  salicylic 
paste,  and  finally  tampons  were  applied  soaked  in  aten 
per  cent,  solution  of  ichthyolresorcin.  In  two  months 
the  parts  assumed  a  natural  appearance,  and  recovery 
was  complete. — Bericke. 

Chancroid. — Actual  cautery  and  dress  antiseptically  : 

5.   Acidi  sulphurici, 

Pulv.  carbonis  ligni aa    3  ss. 

M.  Q.  s.  ft.  magma.  Sig.  :  Dry  the  sore  and  apply  thoroughly 
by  means  of  a  wooden  spatula.  Allow  artificial  escfiar  thus  formed 
to  separate  spontaneously,  using  no  dressing. 

— RiCORD. 

Catarrh  of  Gall-ducts. — 

If.    Animon.  iodid 3  j. 

Liq.  potass,  arsenitis f  3  ss. 

Tr.  calumbce f  3  ss. 

Aq.  destillat f  3  jss. 

M.  Sig.  :  Take  a  teaspoonful  three  times  a  day  before  meals. 

— Bartholow. 

Aconite  is  the  only  drug  which  in  poisonous  doses 
will  cause  numbness  of,  and  tickling  of,  the  first  of  the 
mucous  membranes  with  which  it  comes  in  contact, 
and  then  of  the  extremities. — Hare. 

Anaemia,  especially  when  accompanied  by  cardiac 
disturbances,  such  as  weakness  and  irregularity  of  the 
pulse  : 

IJ .    Iron  by  hydrogen, 

Powdered  camphor aa    3  jss. 

Extract  gentian gis.  cxxxv. 

Mucilage  gum  Arabic q.  s. 

Make  ninety  pills.      Dose  :  Two  or  three  thrice  daily. 

— Edlefsen. 

Nitro-glycerine  is  a  heart  sedative  and  not  a  stimu- 
lant.— Hare. 


358 


MEDICAL   RECORD. 


[September  7,  1895 


Chronic  Rheumatic  Arthritis. — Lord  Anson  paid 
_;!^3oo  for  the  privilege  of  publishing  the  following 
prescription  for  chronic  rheumatic  arthritis  : 

B.   Sulphur 5j. 

Cream  of  tartar |  j. 

Khubarb ;  iv. 

Gum  guiac 3  j. 

Make  one  powder  and  add  honey 3  xvj. 

Mix  well,  take  two  tablespoonfuls  in  a  tumbler  of  white  wine 
and  hot  water  on  going  to  bed,  and  repeating  the  dose  on  getting 
up  in  the  morning. 

— Louisville  Medical  Monthly. 

Acute  Coryza. — 

5 .    Cocain.  muriat gr.  vj. 

Bismuth,  subcarb 3  ss. 

Talc 3  jss. 

M.  Sig  :  Enough  to  cover  a  silver  five-cent  piece  insufflated  into 
each  nostril  every  two  hours. 

— S.ijous. 

3 .    Carbolic  acid pt.  j. 

Ammonia  water pt-  j. 

Alcohol pt-  ']■ 

Distilled  water pt.  iij. 

Mix.  Sig.  :  Gtt.  10  to  be  dropped  on  a  piece  of  blotting-paper 
and  inhaled  for  a  few  moments  every  hour. 

— Monit.  Therap. 

Nasal  and  Faucial  Catarrh. — 

5 .    Acid,  carbol.  liq ■Tn_xxx. 

Sodii  biborat, 

Sodii  bicarb fia  3  j. 

Glycerinas f  3  iijss. 

AquEe q.  s.  ad  f  §  iv. 

M.  Sig  :  To  be  used  as  a  spray. 

— DOBELL. 

Pruritus  Cutaneus. 

B  .    Acid,  carbolic! 3  j. 

Potassse  fusee 3  ss. 

Aq.  dest Oss. 

M. 

— Van  Hari.ingen. 
Marasmus. — 

5 .        Syrupi  ferri  iodidi 3  j. 

Synipi  acacias 3  \'ij. 

Aquae  foeniculi J  j. 

M.  S.  :  3j.  t.i.d. 

— DUPASQUIER. 

Acne  Eosacea. 

3 .        Sulphur  prsecip 3  j. 

Calaminje  prspar 3  'j. 

Zinci   oxidi 3  j. 

Glycerini 3  j. 

Aquje  destil ad  J  iv. 

M.  ft.  lotio. 

Sig.  :  The  lotion  to  be  shaken,  then  painted  on  with  a  camel's 
hair  brush  at  night. 

In  morning  face  is  washed  with  a  little  warm  water 
(no  soap)  and  powdered  over  with  following  : 

'Sf,       Acidi  borici pts.  x. 

Talci pts.  XV. 

M.  ft.  pulv. 

Sig.  :  To  be  applied  every  morning. 

— Jamieson. 

Strontium  Bromide  in  Epilepsy  is  less  prone  than 
potassium  salt  to  produce  acne  and  other  disagreeable 
symptoms,  but  it  has  less  control  over  the  epileptic 
convulsion.  — Wood. 

Acute  Bronchitis. — 

g.    Carbonate  of  ammonia. 

Salicylate  of  sodium fia    3  j. 

Camphorated  tincture  of  opium. 

Syrup  of  orange  flowers, 

Syrup  of  tolu afi   §  j. 

Water |  ij. 

F.  S.  A. — To  take  a  dessertspoonful  eveij'  three  hours. 

— Lewinthal. 

Tonsillitis. — If  obstinate,  sodium  salicylate  should 
not  be  overlooked,  as  some  rheumatic  element  is  pos- 
sible.— Gaillard. 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 

THE  THROAT  HOSPITAL  AGAIN — THE  SCHOOL  BOARD'S 
INSULT  TO  DOCTORS  —  METRIC  SYSTEM  FOR  THE 
PHARMACOPCEIA — THE    LATE    DR.    GOODFELLOW. 

London,  August  17,  1895. 

The  Throat  Hospital,  in  Golden  Square,  is  again  the 
scene  of  squabbling,  but  only  a  languid  interest  is  ex- 
cited by  the  struggles  of  those  who  seem  to  be  defeated. 
A  joint  letter  was  sent  to  the  newspapers  to  inform  the 
public,  that  the  three  persons  who  sign  it  "  have  now 
entirely  severed  our  connection  with  "  the  hospital. 
These  three  persons,  who  deem  themselves  of  sufficient 
importance  for  the  public  to  be  interested  in  their  pro- 
ceedings, are  :  1,  the  President — a  nobleman  and  an 
ornamental  official  who  probably  knows  little  about 
the  matter ;  2,  Mr.  R.  Courtenay  Welsh,  who  de- 
scribes himself  as  "  lately  a  member,  and  for  nearly 
twelve  years  chairman,  of  the  Committee  of  Manage- 
ment ; "  3,  Dr.  Greville  MacDonald,  who  describes 
himself  as  "lately  Dean  of  the  Medical  School,  and 
for  eight  years  physician."  Possibly  these  two  last 
are  surprised  that  they  have  not  found  either  the  pub- 
lic or  the  profession  at  all  curious  as  to  their  reasons. 
Far  be  it  from  me  to  add  to  their  chagrin,  but  on  the 
supposition  that  they  feel  aggrieved,  not  too  great  an 
assumption  in  face  of  their  letter,  and  on  the  further 
supposition  that  they  would  like  to  know  why  they  can 
obtain  so  little  notice,  I  suggest.  Nemesis.  Let  them 
remember  their  part  in  the  great  scandal  of  that  hospi- 
tal eight  years  ago.  At  that  time,  Mr.  Welsh  was 
chairman,  and  Dr.  MacDonald,  house  surgeon,  not 
long  previously  appointed.  Mr.  Welsh  is  not  a  medi- 
cal man,  but  is  said  to  be  a  "  limb  of  the  law."  His 
conduct  on  that  occasion  was  beneath  the  dignity  of 
any  pettifogging  practitioner.  He  it  was  who  got 
the  late  Dr.  R.  H.  Semple  to  resign  in  order  to  give  his 
day  to  Mackenzie's  nominee,  Mr.  Hovell.  When  the 
staff  protested  and  waited  on  the  committee,  Mr. 
Welsh  was  in  the  chair  and  pretended  that  no  rule  or 
custom  of  the  staff  could  be  recognized  unless  re- 
corded in  the  minutes  of  the  committee — which  of 
course  the  staff  never  saw.  He  it  was  who  occupied 
the  chair  when  the  staff  unanimously  resigned — no. 
not  unanimously,  Mr.  Hovell  remained — and  when 
within  half  an  hour,  the  committee  accepted  the  six 
resignations  and  appointed  three  persons  in  their 
places.  Of  these  three  Dr.  MacDonald  was  one. 
However  tempting  the  jump  from  house  surgeon  to 
full  physician,  he  could  not  be  ignorant  of  what  would 
be  thought  of  the  whole  transaction,  and  however  great 
may  have  been  his  satisfaction  at  displacing  others,  he 
ought  surely  to  be  aware  that  his  conduct  on  that  oc- 
casion scarcely  entitles  him  to  expect  sympathy  on 
this  Nemesis. 

The  London  School  Board  has  made  a  mistake  in 
throwing  doubt  on  medical  certificates,  as  to  the  ab- 
sence of  children  from  schools.  You  must  know  the 
Board  does  not  pay  for  such  certificates,  which  have 
been  given  up  to  now  out  of  kindness  to  protect  par- 
ents from  the  worry  of  unnecessary  proceedings.  The 
officials  have  now  got  the  Board  to  sanction  the  ap- 
pointment of  medical  inspectors  to  investigate  the 
bona  fide  character  of  the  certificates.  This  is  regarded  1 
as  an  insult,  and  at  some  hospitals  the  physicians  who  J 
had  hitherto  given  these  documents,  have  agreed  to 
sign  no  more  until  the  Board  rescinds  the  obnoxioud 
resolution  on  the  question.  If  the  Board  persists,  il 
will  soon  have  no  certificates  to  investigate.  Is  it  rea- 
sonable that  doctors  should  be  asked  to  give  certificates  1 


September  7,  1895] 


MEDICAL    RECORD. 


;59 


gratuitously,  and  when  they  consent  that  their  honesty 
should  be  impugned  ? 

It  seems  to  be  settled  now  that  in  the  coming  new 
Pharmacopoeia  the  metric  system  will  be  employed, 
but  that  concurrent  statements  will  be  given  in  the  old 
measures.  This  will  no  doubt  assist  the  change  which 
will  eventually  become  established. 

Dr.  Goodfellow.  formerly  physician  to  the  Middle- 
sex hospital,  died  lately  at  the  age  of  eighty-six.  He 
had  retired  from  practice  for  a  long  time.  In  his  day 
he  did  much  good  work,  and  enjoyed  the  respect  and 
esteem  of  the  profession. 


SIR    B.    W.    RICHARDSON    AND    SCIENTIFIC 
ACCURACY. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  There  is  much  uneasiness  in  the  minds  of  the 
laity  regarding  the  good  or  evil  that  may  co.me  ulti- 
mately from  bicycle  riding.  Dependent  as  they  are 
upon  statistics  from  scientific  men,  it  is  little  wonder 
that  they  are  confused  by  the  conflicting  statements 
from  what  are  supposed  to  be  reliable  sources.  The 
preponderance  of  reports  seems  to  be  in  favor  of  bicy- 
cling in  moderation — always  barring  racing  and  hard 
riding.  In  its  good  effect  bicycling  in  no  way  differs 
from  any  other  of  the  out-door  sports  or  exercises,  with 
the  additional  advantage  that  it  is  less  tiresome  and 
monotonous.  But  now  we  have  coming  forward  a  cer- 
tain class  of  supposedly  scientific  observers,  who  seem 
to  draw  all  their  conclusions  from  a  racing  stand-point, 
and  judge  and  condemn  the  bicycle  accordingly.  They 
have  not  the  fairness  to  state  the  simple  fact  that  all 
exercise  in  excess  is  injurious,  either  directly  or  in- 
directly, to  the  heart,  and  leave  the  lay  reader  to  be- 
lieve that  bicycling  alone  is  the  only  exercise  that  is 
really  a  "heart-destroyer." 

Sir  Benjamin  Ward  Richardson,  in  a  recent  article  in 
the  North  American  Revteic,  says  that  great  injury  is 
done  to  the  heart  by  the  bicycle.  He  makes  the  state- 
ment that  he  and  some  learned  doctor  had  made  the 
discovery  that  "  as  soon  as  brisk  cycling  is  commenced 
the  motions  of  the  heart  begin  to  increase."  This 
statement  is  about  as  original  as  to  say  that  as  soon  as 
the  sun  begins  to  rise  the  day  begins  to  break.  It 
leaves  the  impression  that  very  few  forms  of  exercise 
increase  the  heart's  action,  while  we  are  well  aware 
that  any  exercise  of  any  kind  will  produce  a  like  ef- 
fect. Sir  Benjamin  would  undoubtedly  be  one  to  ad- 
vise keeping  constantly  in  the  recumbent  position, 
simply  because  standing  increases  the  rapidity  of  the 
heart's  action. 

He  makes  the  statement  that  "  rowing  tells  mostly  on 
the  breathing  organs,"  presumably  meaning  the  lungs. 
We  should  all  certainly  enjoy  having  him  explain  just 
how  an  increase  of  activity  on  the  part  of  the  "  breath- 
ing organs  "  could  take  place  without  a  corresponding 
increase  in  the  heart's  action.  Increased  respiration 
certainly  means  increased  blood  -  supply,  which  is 
synonymous  with  saying  increased  heart's  action.  And 
it  would  perhaps  interest  him  in  a  scientific  way,  to 
reconcile  with  his  statement  the  fact  that  so  large  a 
percentage  of  professional  and  college  oarsmen  have 
been  afflicted  with  heart  disease. 

He  states  further  that  "  dumb-bell  exercise  tells 
mostly  on  the  muscles,  while  hill-climbing  and  pedes- 
trian feats  affect  the  nervous  system."  Also,  that  "  he 
has  known  the  beats  of  the  heart  to  rise  from  eighty  to 
two  hundred  per  minute  in  the  first  exercise  of  riding." 
This  statement  concerning  the  increased  heart-rate  is 
nothing  new  or  surprising  to  the  medical  profession, 
but  it  gives  much  cause  for  alarm  to  the  ordinary 
reader.  His  statements  concerning  dumb-bell  exer- 
cise and  hill-climbing,  however,  are  so  misleading  that 
they  would  be  either  explained  more  fully  or  omitted 


entirely  by  a  scientific  writer.  If  Sir  Benjamin  would 
take  an  ordinarily  strong  but  untrained  man,  having  a 
normal  pulse-rate  of  seventy-two  beats  per  minute,  and 
allow  him  to  exercise  simply  the  muscles  of  the  arms 
with  six-  or  eight-pound  dumb-bells  for  sixty  seconds, 
he  would  find  at  the  expiration  of  that  time  that  the 
pulse  had  increased  to  anywhere  from  one  hundred 
and  fifty  to  one  hundred  and  sixty  or  seventy  beats  per 
minute.  This  would  seem  to  disprove  his  statement 
or  implied  meaning  that  dumb-bells  affect  simply  the 
muscular  system,  and  also  show  that  cycling  is  not 
alone  in  its  action  upon  the  heart. 

He  should  also  recall  the  fact  that  in  all  contests 
where  strength  and  endurance  are  required  by  athletes 
the  training  to  increase  the  strength  and  tone  of  the 
heart  is  mostly  done  by  cross-country  pedestrian  and 
hill-climbing  expeditions.  But  despite  such  exercises 
the  nervous  systems  of  most  athletes  (which  must  suf- 
fer inordinately  according  to  Sir  Benjamin's  theory) 
are  usually  in  very  good  condition  after  such  long  runs 
and  climbs. 

While  articles  such  as  Sir  Benjamin's  and  others  of 
its  class  have  no  effect  upon  the  medical  profession 
and  scientific  thinkers,  still  they  are  written  for  popu- 
lar magazines,  and  in  that  manner  reach  a  class  of 
people  who  believe  the  statements  made  because  they 
are  supposed  to  give  at  least  a  truthful  impression,  even 
if  only  popularly  scientific.  One  can  only  think  of 
such  writers  that  they  are  either  thoroughly  unscientific, 
or  else  so  prejudiced  that  they  are  willing  to  sacrifice 
almost  anything  to  make  their  prejudices  seem  well 
founded.  From  the  article  quoted  above  one  might 
well  infer  that  the  writer  had  only  recently  discovered 
that  there  was  an  organ  in  the  body  called  the  heart, 
whose  fundamental  functions  were  as  yet  unknown. 
E.  H.  Williams,  M.D. 

Decorah*  Ia. 


^exti  %nstxumt\\Xs. 

A   NEW   PERCUSSION   HAMMER. 
By  JOHN  T.  GIBBONS,  M.D., 

ATTENDING    PHYSICIAN,   ST.    CATHARINE'S    HOSPITAL,    THE     CENTRAL     THROAT 
HOSPITAL,   AND  POLYCLINIC   DISPENSARIES,   BROOKLYN,   N.   Y. 

The  accompanying  design  of  a  percussion  haminer  may 
interest  your  readers,  especially  those  engaged  in  heart 
and  lung  work.  The  rubber  is  curved  so  that  a  broader 
surface  strikes  the  finger  than  in  the  hammers  we  have 


had  hitherto.  It  is  fastened  in  a  dome  which  is  sur- 
mounted by  a  ball,  which  gives  a  requisite  weight  to 
the  whole.  The  handle  (a  modification  of  Niemeyer's) 
is  screwed  into  the  ball. 

1297  BusHWicK  Avenue. 


Chloral  Hydrate  is  the  hypnotic  par  excellence  when 
pain  is  not  a  prominent  element  in  the  case.  I  find  it 
best  to  combine  it  with  ammonia  and  strychnine,  some 
ammonia  salt,  not  alkaline  ;  all  alkalies  are  sure  to 
bring  about  decomposition  of  chloral  hydrate,  thus 
making  it  utterly  valueless  as  a  medicament,  especially 
as  a  hypnotic.     Following  is  a  good  combination  : 

9.    Chloral  hydrate gr.  "x. 

Ammonia  bromide gr-  "x. 

n.  ext.  nux  vom g't-  x- 

Fl.  ext.  belladonna gtt.  ij. 

Mix.  Sig.  :  To  be  taken  at  once  and  repeated  in  an  hour  or  two 
if  needed. 

— Adolphus. 


36o 


MEDICAL   RECORD. 


[September  7,  18^5 


pCetlicaX  gtcius. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  August  31,  1895. 


128 

127 

34 

5 

26 

4 

S 

9 

84 

7 

124 

21 

Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 


Physiological  Action  of  Periodical  Induced  Currents. 
— Dr.  A.  H.  Goelet  writes,  enclosing  the  following 
letter  from  the  Kidder  Manufacturing  Company  : 

"  New  York,  August  20,  1895. 

"  Dr.  a.  H.  Goelet — Sir  :  In  answer  to  yours  of 
this  day,  would  state  your  permission  was  given  for 
winding  your  lengths  and  diameters  of  wire  first  on 
two  stationary  helices,  using  a  Xo.  21  wire  instead  of 
18  and  22  ;  arranging  it  so  as  to  give  the  same  results. 
And  later  your  permission  was  also  granted  to  ^\^nd 
these  upon  one  heli.x.  Manufacturers  always  extend 
this  courtesy  to  the  profession.  The  coil  made  for  Dr. 
Rockwell,  containing  5,000  feet,  was  made  up  of  Nos. 
16,  21,  32,  34,  36,  and  38  wires." 

Dr.  Goelet  adds  :  "  It  will  thus  be  seen  that  the  coil 
to  which  Dr.  Rockwell  lays  claim  is  very  different  from 
mine,  which  is  made  up  of  Nos.  21,  32,  and  36  wire,  hav- 
ing a  total  length  of  7,550  feet." 

A  Census  of  Centenarians  has  been  taken  in  France, 
and  the  results,  which  have  been  published,  show  that 
there  are  now  alive  in  that  country  two  hundred  and 
thirteen  persons  who  are  over  one  hundred  years  old. 
Of  these  one  hundred  and  forty-seven  are  women. 

A  Blood-thirsty  Profession. — Deputy  Surgeon- Gen- 
eral Thornton,  of  England,  is  dreadfully  frightened  to 
find  himself  in  the  company  of  ghouls.  In  a  long  let- 
ter in  the  Liverpool  Daily  Post  of  August  loth  he 
warps  the  public  of  "  a  serious  danger  which  is  impend- 
ing over  all  civilized  nations,  and  which,  year  by  year, 
grows  more  threatening.  I  refer,"  he  says,  "  to  the 
danger  of  human  vivisection,  which  is  a  direct  and  in- 
evitable consequence  of  the  rapid  and  sinister  growth 
of  the  vivisecting  spirit,  and  the  rage  for  experimental 
research,  not  only  in  the  medical  profession  but  also 
among  scientists  generally.  There  are  many  men  who, 
though  kind  and  humane  in  the  ordinary  relations  of 
life,  become  pitiless  and  remorseless  when  dominated 
by  the  vivisecting  spirit.  Their  minds  are  filled  with 
the  ardor  of  research,  the  hope  of  discovery,  and  the 
expectation  of  riches,  honors,  and  fame  as  the  reward 
of  their  labors.  Such  men  would  vivisect  human 
beings  as  readily  as  animals,  if  they  dared,  and  they 
are  only  prevented  from  doing  so  now  by  fear  of  the 
law  and  public  opinion."  When  the  Deputy  Surgeon- 
General  came  to,  he  was  probably  surprised  to  read 
what  he  had  written  the  night  before. 

Medical  Book-borrowers. — The  editor  of  the  Denver 
Mediiiil  Times  is  a  victim  of  designing  book-borrowers. 
He  says  he  has  lost  over  fifty  volumes  during  the  past 
year  by  the  failure  of  borrowers  to  return  his  books, 
and  he  now  calls  a  halt.  Denver  has  a  medical  de- 
partment in  the  High  School  Library,  and  he  warns  the 
pestiferous  borro*vers  to  go  there  and  leave  his  library 
alone.  We  extend  to  our  esteemed  contemporary  the 
assurance  of  our  profound  commiseration. 

Syphilis  and  the  Female  Genitals. — The  Vienna  cor- 
respondent of  the  Medical  Press  writes  that  Professor 


Xeumann,  in  his  paper  before  the  Gesellschaft,  reviewed 
the  history  of  this  dire  disease  as  recorded  by  litera- 
ture, and  then  criticised  the  physiological  effect  on 
conception,  pregnancy,  and  progeny.  His  deductions 
were  obtained  from  6.000  cases.  With  respect  to  the 
recent  exanthemata  on  the  mucous  membrane  of  the 
vagina,  the  moist  papule  was  the  characteristic  form  of 
syphilis.  Clinically,  this  is  hard  to  diagnose  when  con- 
fined to  the  cervix  uteri,  but  anatomically  it  cannot  be 
denied  a  place.  In  800  cases  of  primary  syphilis  he 
found  51  to  be  located  on  the  vaginal  portio  uteri,  and 
only  four  times  on  the  vagina  itself.  Indiwdual  diag- 
nosis is  often  very  difficult  in  multiparae,  although  these 
appear  to  be  the  most  easily  affected.  He  has  not  at- 
tempted to  determine  the  exact  proportion  the  prima- 
parae  stand  to  the  multiparae.  In  both  the  cicatrix  ere- 
long leads  on  to  atresia  and  menstrual  disturbances. 
The  morbid  products  of  syphilis,  such  as  gumma  and 
ulceration,  are  not  uncommon  to  the  female  genitals. 
The  gumma  is  most  frequently  met  with  at  the  "  in- 
troitus"  of  the  vagina,  or  anterior  third,  less  seldom 
on  the  posterior  or  middle  third.  He  recited  a  case 
where  the  gumma  of  the  vagina  resulted  in  a  fistula 
with  the  bowel.  He  showed  by  histological  specimens 
that  recurrences  frequently  occur  in  the  vagina.  The 
ovaries  and  tuba  have  also  been  assumed  as  the  site  of 
syphilis,  but  not  so  clearly  proved.  Syphilitic  affec- 
tions of  the  corpus  uteri  are  rare,  only  one  case  stand- 
ing on  record  as  such,  which  may  be  considered  as 
strange,  seeing  that  metritis  and  endometritis  with 
abortion  is  such  a  common  result  of  the  syphilitic 
poison  and  a  fruitful  source  of  sterility.  So  many  hy- 
potheses are  set  forth  concerning  the  etiology  that  only 
a  few  may  be  related  here.  The  older  opinions  as- 
sumed that  the  poison  was  conveyed  through  the  ovule 
or  spermatic  fluid.  The  syphilitic  changes  that  pro- 
duce endo-  and  myo-metrium  of  the  placenta,  causing 
death  of  the  ovum,  is  the  most  reasonable  source  of 
destruction.  We  cannot  always  find  from  a  macro- 
scopic examination  of  the  placenta  and  uterus  the  exact 
cause,  but  when  microscopically  examined  we  find 
endo-  and  peri-arteritis  of  the  foetal  and  utero-placental 
vessels,  as  well  as  thrombosis  with  narrowing  or  perfect 
occlusion  of  the  placental  and  femoral  vessels,  clearly 
demonstrating  the  cause  of  death.  Myometrium  is  an- 
other fruitful  cause.  By  the  intervening  syphilitic 
foetus  from  the  father  the  mother  can  scarcely  escape 
the  poison  at  parturition,  as  the  poison  can  be  easily 
.taken  up  from  the  small  lacerations.  We  know  of  no 
organ  in  the  body  where  the  syphilitic  fluid,  if  freely 
applied,  will  not  localize  itself  and  recur,  as  we  often 
meet  with  it  in  the  neighborhood  of  the  uterus  acting 
as  the  principal  source  in  habitual  abortion.  From 
this  point  of  view,  there  are  often  many  inexplicable 
cases  of  death  of  the  foetus,  either  before  or  after  birth, 
where  no  trace  of  syphilis  can  be  elicited  in  either 
father  or  mother,  yet  the  fruit  dies  of  this  enfeeble- 
ment.  On  the  other  hand,  it  not  infrequently  occurs 
in  pronounced  tertiary  syphilis,  where  mother  and 
father  are  both  syphilitic  and  the  progeny  free. 
Whether  the  cause  presides  in  the  red  blood  corpus- 
cles, a  diminution  of  haemoglobin,  or  a  toxine  principle 
pure  and  simple,  is  yet  to  be  exi)lained  by  future  in- 
vestigation. Another  hypothesis  of  oligcemia  or  perni- 
cious anaemia  of  the  fcEtus,  which  may  be  the  cause  of 
death,  cannot  be  denied. 

Medical  Politicians. — Lawyers  and  other  laymen  are 
not  keeping  up  with  the  doctors  in  the  political  proces- 
sion in  some  parts  of  France.  In  the  department  of 
Gers  all  the  members  of  the  General  Council  are  phy- 
sicians, and  no  non-medical  man  could  well  have  been 
chosen  at  the  last  election,  for  every  candidate  was  a 
doctor. 

Furuncles. — A  strong  solution  of  chloral  hydrate  in 
glycerine  and  water  frequently  applied,  it  is  said  will 
abort  furuncles. 


Medical   Record 

A  JVeekly  yoiirnal  of  Medicine  and  Surgery 


Vol.  48,  No.  II. 
'Whole  No.  1297. 


New  York,  September  14,  1895. 


$5.00  Per  Annum. 
Single  Copies,  xoc. 


©wgitial  Jtrticles. 

THIRD  REPORT  ON  ELIMINATIVE  AND 
ANTISEPTIC  TREATMENT  OF  TYPHOID 
FEVER. 

Bv   W.  B.  THISTLE,  M.D.,  L.R.C.P.  LoND. 

ASSISTANT  DEMONSTRATOR  OF  ANATOMY.  UNIVERSITV  OF  TORONTO  ;  LECTURFR 
ON  DISEASES  OF  CHILDRFN.  woman's  .MEDICAL  COLLEGE  ;  PHYSICIAN  TO 
VICTORIA    HOSPITAL  FOR  SICK   CHILDREN. 

Regarding  the  immense  amount  of  energy  and  effort 
expended  in  the  study  of  disease-producing  fungi  or 
bacteria,  it  would  be  but  mere  commonplace  to  say 
that  all  the  accumulated  knowledge,  the  result  of  such 
expenditure,  can  be  of  little  worth  apart  from  gratifica- 
tion of  scientific  curiosity,  until  it  can  be  brought  to 
bear  directly  upon  the  treatment  of  disease  due  to  these 
organisms,  .\ssuredly,  too,  the  more  accurate  and 
comprehensive  a  knowledge  of  bacteria  is  gained,  the 
more  clearly  outlined  become  the  indications  for  treat- 
ment. In  order  to  have  this  harmony  between  pathol- 
ogy and  treatment,  it  is  necessary,  in  the  first  instance, 
to  be  as  fully  informed  as  possible  concerning  the  in- 
vading micro-organism,  and  how  and  why  it  is  able  to 
bring  about  the  tissue  changes  and  clinical  symptoms 
peculiar  to  it ;  and,  in  the  second,  to  remember  and 
constantly  to  strive  to  apply  that  knowlege  when  the 
diseased  condition  appears. 

With  special  reference  to  typhoid  infection  it  oc- 
curred to  me,  some  three  years  ago,  that  the  treatment 
advised  in  current  lext-books,  and  that  almost  univer- 
sally taught,  did  not  follow  at  all  closely  as  a  logical 
sequence  on  what  had  been  ascertained  concerning  the 
nature  and  pathology  of  the  disease,  that  there  was  in 
fact  a  lack  of  harmony  between  pathology  and  treat- 
ment. Accordingly,  I  attempted  a  plan  of  treatment 
which  seemed  to  me  to  embody  the  application  of 
valuable  facts  relating  to  the  infective  germ,  and  the 
way  in  which  it  brought  about  d.sturbance  and  de- 
struction in  the  human  body.  Two  years  ago  I  pub- 
lished this  plan  of  treatment  in  the  Canadian  Practi- 
tiomr,  April,  1893,  under  the  title  of  "  Eliminative  and 
Antiseptic  Treatment  of  Typhoid,"  and  with  it  all  the 
cases  so  treated.  In  1894  a  second  paper  under  the 
same  heading  appeared  in  the  Medical  Record  of 
March  loth.  To  this  second  paper  I  appended  an 
analysis  of  forty  consecutive  cases  without  fatalit)',  and 
running  a  course  unusually  short  and  unusually  free 
from  distressing  symptoms,  and  from  what  have  been 
spoken  of  as  the  accidents  of  the  disease. 

I  now  beg  to  make  a  third  report,  and  in  doing  so  I 
shall  in  no  way  alter  the  original  title,  for  nothing  to 
my  mind  would  so  clearly  indicate  the  principles  of 
treatment  as  the  two  words  "  Eliminative  "  and  "  -An- 
tiseptic." I  shall,  also,  still  adhere  to  what  seemed  to 
me  on  the  former  occasions  the  correct  way  toapjiroach 
a  discussion  of  this  kind,  and  first  gather  together,  as 
completely  and  as  concisely  as  I  may,  what  has  up  to 
date  been  determined  by  bacteriologists  and  patholo- 
gists concerning  the  germ  itself,  and  also,  the  relation 
which  it  bears  to  the  lesions  and  symptoms  of  the  dis- 
ease. By  so  doing  it  becomes  easier  to  appreciate 
consistency  or  want  of  consistency  in  the  principles  of 
reatment  which  I  shall  have  to  bring  forward,  as  well 
s  in  those  which  are  generally  accepted  and  taught. 


It  is,  of  course,  past  question  that  enteric  fever  is  the 
result  of  bacterial  infection.  So  far,  all  are  agreed, 
but  when  it  comes  to  giving  credit  to  one  particular 
variety,  there  is  by  no  means  a  like  unanimity.  There 
are  those  who  attribute  everything  to  Eberth's  bacillus, 
while  there  are  many  observers  who  are  of  the  opinion 
that  other  bacilli,  as  well,  are  resjjonsible  for  part  at 
least  of  the  disturbance.  The  bacillus  coli  communis, 
particularly,  is  by  many  considered  to  produce  much 
of  the  toxaemia.  Others,  again,  urge  that  Eberth's  bacil- 
lus is  simply  a  modified  form  of  common  colon  bacil- 
lus. The  great  difficulty  in  distinguishing  Eberth's 
bacillus  from  the  bacillus  coli  communis,  perhaps,  ac- 
counts for  these  varied  views.  There  are,  however, 
many  apparently  sufficient  reasons  for  believing  that 
common  bacillus  of  the  intestine  is  responsible  for  a  por- 
tion of  the  disorder,  even  though  Eberth's  bacillus  be 
recognized  as  the  primary  and  chief  aggressor  in  the 
disease.  There  is  the  primary  fact,  with  reference  to 
bacillus  coli  communis,  that  it  is  capable  of  producing 
toxaemia  even  to  a  fatal  degree.  Treves,'  in  his  paper 
on  peritonitis,  describes  the  condition,  when  associated 
with  intestinal  disease  and  injury,  as  one  of  poisoning 
from  escape  of  these  bacteria  from  the  injured  or 
opened  intestine,  followed  by  rapid  spread  over  peri- 
toneal surface,  with  correspondingly  rapid  absorption 
of  the  toxic  substance  to  which  they  give  rise.  It  may, 
then,  be  taken  as  proven  that  the  bacillus  coli  com- 
munis is  poisonous.  Under  ordinary  circumstances 
the  quantity  absorbed  is  not  sufficiently  great  to  give 
rise  to  symptoms.  It  is  more  likely,  though,  that  im- 
munity from  this  constant  poison  is  due  to  the  func- 
tional activity  of  the  liver  in  in;ercepting  and  destroying 
these  harmful  substances."  Treves,^ also,  expresses  the 
opinion  that,  under  certain  circumstances,  the  common 
bacillus  of  the  intestine  becomes  more  virulent,  which 
is  quite  in  keeping  with  what  has  been  determined  in 
experimental  growths  of  other  forms  of  bacteria.  It  is 
maintained  by  others  that  this  increase  in  virulence  oc- 
curs when  it  is  a>sociated  with  Eberth's  bacillus. 
However,  looking  at  the  condition  which  prevails,  say 
in  the  first  week  of  typhoid,  it  becomes  evident  that 
many  forms  of  bacillus  are  to  be  found  throughout  the 
intestinal  canal.  Owing  to  lack  of  secretion,  food  ma- 
terials are  not  digested  and  absorbed,  but  the  mass  re- 
mains to  be  broken  up  by  the  ordinary  germs  of  putre- 
faction, absorption  of  toxic  i)roducts  of  course  taking 
place.  It  is  only  necessary  to  imagine  this  process  re- 
peated and  continued,  to  be  convinced  that  many  forms 
of  bacteria  are  present  in  addition  to  Eberth's  bacillus 
and  the  bacillus  coli  communis,  and  that  some  por- 
tion of  toxfemia  must  be  attributed  to  these  putrefactive 
or  unclassified  germs.  Given  Eberth's  bacillus  as  the 
primary  cause,  it  requires  no  argument  to  prove  that 
other  forms  must  play  a  part  in  the  production  of 
symptoms. 

We  have  only  to  recall  the  manner  in  which  bacteria 
bring  about  disturbance,  by  virtue  of  the  toxic  sub- 
stance which  they  produce,  to  perceive  clearly  that 
the  condition  in  typhoid  is  one  of  continuous  intoxica- 
tion. The  primary  and  chief  source  of  the  poison  is 
the  alimentary  canal,  although  it  should  not  be  for- 
gotten that  some  portion  of  toxaemia  must  be  attributed 

'  British  Medical  Journal,  January,  1894. 

-  Lauder  Brunton :  Disorders  of  Digestion. 

J  Treves  :  British  Medical  Journal,  January,  1894. 


362 


MEDICAL    RECORD. 


[September  14,  1895 


to  poison  elaborated  by  bacteria  which  have  been  car- 
ried from  the  intestine  and  deposited  in  the  various 
tissues  of  the  body,  notably  in  tissues  most  directly 
connected  with  the  alimentary  canal,  e.g.,  lymphatic 
nodes  of  intestine  and  mesentery. 

I  am  fond  of  comparing  the  prolonged  poisoning  of 
typhoid  to  the  commonest  intoxication  we  are  familiar 
with,  e.g.,  alcoholic.  Typho-toxin  and  alcohol  are 
each  the  result  of  bacterial  action,  under  certain  con- 
ditions. One  process  takes  place  within  the  body,  the 
other  without.  Each  poison  has  in  the  main  its  char- 
acteristic train  of  symptoms.  These  symptoms  are  the 
physiological  effects,  and  from  a  survey  of  these  signs 
we  can  estimate  approximately  the  degree  of  poisoning, 
ahvays  remembering  that,  as  with  alcoholic  poisoning 
so  with  the  toxaemia  of  typhoid,  individual  peculiarity 
may  play  a  part,  that  certain  conditions  may  increase 
susceptibility,  while  certain  other  conditions  may  have 
a  directly  contrary  effect.  It  must  be  remembered, 
too,  that  in  neither  case  are  we  always  dealing  with  the 
pure  drug.  With  alcoholic  poisoning  must  be  includ- 
ed frequently  poisonous  effects  arising  from  introduc- 
tion of  these  substances  usually  separated  and  removed. 
Making  allowance,  then,  for  these  conditions  and  pecu- 
liarities, it  remains  true  that,  just  as  we  judge  of  the  de- 
gree of  intoxication  from  the  appearance  and  actions 
of  the  drunken  man,  so  in  the  case  of  typhoid  we  can 
read  in  the  symptoms  the  amount  of  toxin  in  the  sys- 
tem. 

With  reference  to  the  local  effects  of  typhoid  poison 
we  are  not  able  to  estimate  so  accurately  their  degree. 
We  have,  however,  a  few  valuable  facts  concerning  the 
effects  of  typhoid  toxin  :  i.  That  it  will  irritate  tissue- 
cells  and  produce  swelling,  congestion,  and  infiltrations 
of  the  part.  2.  That,  if  it  becomes  concentrated  to  a 
sufficient  degree,  the  irritation  is  replaced  by  complete 
destruction  or  necrosis.  3.  That  necrosis  may  be 
brought  about,  not  so  much  as  a  result  of  concentra- 
tion of  poison,  but  owing  to  long  continuance  of  con- 
tact'  (Sims  Woodhead).  It  is  only  in  the  case  of  the 
grosser  destruction  of  tissue,  e.g.,  in  the  intestinal  lym- 
phatics, that  this  local  or  "caustic  "  effect  can  be  con- 
sidered quite  apart  from  those  derangements  of  func- 
tion which  depend  largely  upon  the  local  effect  widely 
distributed,  t'.^:,''..  rapid  tissue  waste  or  increased  rate  of 
molecular  death  from  wide-spread  irritation.  It  is, 
then,  safe  to  assume  the  local  effect  whenever  the  gen- 
eral symptoms  are  present.  To  state  it  concisely,  there 
is  in  typhoid  fever  infection  of  the  body  by  bacterial 
growth,  which  brings  about  a  condition  analogous  to 
fermentation,  with  the  production  of  a  chemical  sub- 
stance, "  typho-toxin,"  which  when  diffused  through 
the  body  gives  rise  to  general  symptoms,  and  where 
concentrated,  to  irritation  or  complete  destruction  of 
tissue. 

Facts  to  be  carefully  noted  are  :  i.  That  general 
symptoms  are  increased  or  diminished  according  to  the 
amount  of  poison  in  the  body,  or  dosage.  2.  That  the 
extent  or  degree  of  local  lesion  is  determined  by  the 
degree  of  concentration  of  the  poison  and  the  duration 
of  contact.-  Fenwick  and  Bokenliam  have  succeeded 
in  isolating  an  albumose  from  the  spleens  of  those  who 
had  died  in  the  third  week  of  typhoid  fever.  F^xperi- 
menting  with  this  substance  on  animals,  they  found 
that  if  it  be  injected  in  quantities  exceeding  0.02 
gramme  per  kilo  of  body-weight,  there  is  invariably 
elevation  of  temperature  and  anorexia.  The  more  the 
dose  is  increased  above  0.02  gramme  per  kilo,  within 
certain  limits,  the  higher  the  temperature.  If  injec- 
tions above  this  quantity  are  given  on  alternate  days, 
there  is  persistent  elevation  of  temperature  with  ano- 
rexia and  rapid  diminution  of  body-weight. 

Leaving  the  consideration  of  what  has  been  deter- 
mined concerning  the  poison  of  typhoid  and  its  action 
on   the  organism,  let  us  turn  to  consideration  of  the 

1  Woodhead :  Bacteria  and  Their  Products. 
^  British  Medical  Journal,  April  13.  1895,  p.  Soi. 


way  in  which  infection  takes  place,  and  how  the  fungi 
become  established  in  the  human  body.  Whether  we 
say  infection  is  due  to  Eberth's  bacteria  or  to  a  modi- 
fied colon  bacillus,  it  most  assuredly  comes  from  with- 
out. For  the  purpose  of  this  paper,  it  is  taken  in  with 
contaminated  water,  is  not  destroyed  in  the  stomach, 
and  takes  on  active  growth  in  the  small  intestine. 
Very  shortly  large  numbers  of  intestinal  lymphatic 
nodes  become  swollen  and  congested  as  the  result  of 
the  invasion  of  bacilli  which  have  come  from  the  intes- 
tinal contents.  Shortly,  the  mesenteric  glands  become 
affected  in  the  same  way,  and  after  a  time  bacilli  may 
be  found  in  clusters  in  many  parts  of  the  body.  In  a 
former  paper  I  ascribed  the  apparently  selective  ten- 
dency of  these  organisms  for  the  solitary  glands  as  due 
simply  to  the  anatomical  arrangement  by  which  each 
lymph-node  became  as  it  were  a  small  reservoir,  into 
which  bacteria  and  poison  were  conveyed  by  the  nu- 
merous lymph-ducts  which  drain  the  surrounding  area  of 
intestinal  surface. 

This  "hiving  "  or  concentration  makes  it  clear  why 
the  intestinal  lymph-nodes  almost  invariably  present  a 
marked  degree  of  local  change.  There  are  those  who 
maintain  that  now,  although  there  may  be  and  usually 
is  infection  of  lymphatic  glands  for  several  feet,  as 
well  as  of  other  tissues,  the  infective  micro-organisms 
are  no  longer  to  be  found  in  the  intestinal  contents. 
But  after  some  time,  about  the  eighth '  or  ninth  day 
and  during  the  remainder  of  the  attack,  they  may  be 
found  in  the  bowel  discharges. 

When  one  stops  to  consider  it,  this  seems  an  im- 
probable thing,  for  in  the  first  instance  the  contents  of 
the  intestine  must  have  been  favorable  for  growth  at 
the  time  the  intestinal  lymphatic  nodes  and  the  body 
generally  became  infected.  Then,  in  the  second,  it  is 
necessary,  in  order  to  have  simultaneous  invasion  of 
many  glands  scattered  over  several  feet  of  intestine,  to 
presuppose  that  the  bacilli  taken  in  with  the  glass  of 
impure  water  must  have  multiplied  to  some  consider- 
able extent.  Now,  how  comes  it  that  after  this  wide- 
spread infection  of  the  intestinal  glands  the  bacilli  are 
no  longer  able  to  flourish  in  the  intestinal  contents  ? 
They  most  assuredly  have  been  able  to  exist  and  flour- 
ish there,  and,  according  to  those  who  hold  the  view  I 
have  mentioned,  after  this  disappearance  they  return 
again  and  once  more  find  the  conditions  suitable. 
From  this  time,  as  early  as  the  eighth  or  ninth  day 
(Klein),  until  the  termination  of  the  disease,  they  con- 
tinue in  the  intestine. 

I  confess  that  this  theory  of  presence  in  the  intes- 
tinal contents,  followed  by  disappearance,  and  again  by 
reappearance,  is  hard  to  understand.  To  those  who  urge 
that  it  is  exceedingly  difficult  to  distinguish  Eberth"s 
specific  bacillus  from  certain  forms  of  common  colon 
bacilli ;  or  to  those  who  maintain  that  typhoid  is  due  to 
a  virulent  form  of  colon  bacilli,  this  difficulty  does  not 
present  itself.  According  to  them  the  specific  germs 
maybe  present  in  the  intestine  throughout  the  first  days 
of  the  active  disease,  as  well  as  during  the  period  coin- 
cident with  infection  of  the  intestinal  lymphatic  nodes, 
and  that  period  remaining  after  the  first  ten  days  or 
fortnight. 

Leaving  these  diverse  views,  and  taking  into  con- 
sideration the  facts  of  the  case  only  whether  it  is  de- 
cided to  have  a  specific  Eberth's  bacillus  or  modified 
colon  bacillus,  or  whatever  may  be  decided  as  to  name 
— it  becomes  clear  that  the  infective  germ  must  have 
been  present  in  the  lumen  of  the  intestine  in  order  to 
have  infected  the  intestinal  glands,  and  there  in  very 
considerable  quantity,  in  order  to  have  produced  infec- 
tion simultaneously  in  so  many  glands  scattered  over  so 
great  an  extent  cii  surface. 

It  is  also  beyond  a  doubt  that  the  specific  germ  is 
present  in  the  discharges  during  a  portion  of  the  period 
which  follows  infection  of  the  intestinal  glands,  because 

'Klein:  British  Medical  lournal,  October  13,  1894;  and  Hirsch- 
feld  :  British  Medical  Journal,  .^pril  ao,  1895.  p.  8i69. 


September  14,  1895] 


MEDICAL    RECORD. 


563 


whole  epidemics  have  been  traced  to  contamination 
from  active  cases.  Besides,  there  is  no  disagreement 
concerning  their  presence  during  the  later  period. 
Now,  what  reason  is  there  for  the  assumption  that  the 
intestinal  contents  possess  immunity  during  this  inter- 
vening period  ? 

Then,  are  we  to  assume  that  migration  of  bacilli 
from  the  intestinal  contents  to  the  intestinal  lymphatic 
glands  is  fully  completed  before  any  constitutional 
symptoms  arise  ?  Such  a  theory  is  manifestly  unreason- 
able, yet  unless  we  maintain  it  absolutely  we  must  ad- 
mit that  the  infectious  germs  which  give  rise  to  the 
disease  form  part  of  the  intestinal  contents  in  the  early 
stage  of  the  disease.  In  other  words,  the  process  of 
invasion  of  the  glands  is  coincident  with  the  earlier 
symptoms  of  toxjemia. 

When  all  are  agreed  that  it  is  impossible,  from  a  mor- 
phological stand-point  only,  to  distinguish  a  specific 
typhoid  germ  from  the  colon  bacilli  which  are  always 
present,  and  when  many  bacteriologists  maintain  that 
there  are  no  specific  germs  apart  from  the  modified 
colon  bacillus,  it  does  seem  unnecessary  to  assume  this 
period  of  absence,  leaving  out  of  consideration  alto- 
gether the  manifest  absurdity  which  I  have  just  shonn 
this  theory  to  involve. 

I  have  devoted  some  space  to  this  question,  because 
since  I  first  advocated  active  treatment  of  typhoid,  ob- 
jections have  been  raised  on  the  ground  that  in  the 
early  stage  of  the  disease  no  specific  bacteria  are  to  be 
found  in  the  intestine. 

Let  us,  now,  turn  to  the  question  of  treatment  of  the 
condition  arising  from  the  infective  process  briefly  de- 
scribed above,  and  in  so  doing  adopt  the  plan  indicated 
in  the  beginning  of  this  paper,  to  arrive  at  the  treat- 
ment by  applying  the  knowledge  possessed  of  the  in- 
fective germ,  and  all  relating  to  it.  It  can  scarcely  be 
said  that  this  has  been  the  plan  adopted  in  arriving  at 
the  treatment  of  the  past.  Until  recently  treatment 
was  nothing.  In  many  countries  "let  alone"  is  still 
the  vogue. 

In  my  first  paper  I  stated  that  I  believed  all  the  in- 
dications furnished  by  a  study  of  the  morbid  process 
were  met  by  the  adoption  of  a  plan  of  treatment  em- 
bracing three  distinct  heads  or  principles  :  Elimination, 
antisepsis,  and  dilution.  I  still  adhere  to  that  belief. 
Elimination  is  accomplished  by  free  and  continuous 
purgation,  as  well  as  by  the  flushing  action  of  large 
quantities  of  water  on  kidneys  and  bowels.  By  the 
use  of  purgative  medicines  the  infective  process  is  dis- 
turbed in  several  ways  :  i.  Bacilli  are  carried  out  of 
the  intestine  together  with  the  toxic  substances  pro- 
duced by  them.  2.  Poison  held  in  solution  by  the 
body  fluids  escapes  with  the  free  secretion  into  the  in- 
testine :  and  besides,  at  frequent  intervals  a  quantity 
of  what,  in  this  instance,  must  be  extremely  toxic  bile, 
is  swept  away  instead  of  continuing  in  the  circuit  from 
the  liver  to  the  intestine  and  back  again.  If  constantly 
relieved  in  this  way  the  liver  can  more  frequently  per- 
form its  role '  of  standing  guard  and  intercepting  toxic 
substances  which  would  otherwise  reach  the  general 
circulation.  3.  Infection  of  intestinal  glands  is  lim- 
ited, or,  in  other  words,  the  source  of  supply  from  which 
bacilli  and  poison  are  carried  from  the  intestine  is  cut 
off.  That  is,  just  as  you  can  and  do  limit  the  dose 
of  poison  received  by  the  system  generally,  so  do  you 
limit  the  local  dosage  and  consequent  injury  of  the 
intestinal  glands  by  the  same  means.  This  surely  re- 
quires no  argument,  it  is  evident,  if  only  one  stops  to 
recall  the  manner  in  which  infection  takes  place.  In 
the  one  case,  lessened  dose  means  milder  symptoms, 
and  in  the  other  the  smaller  the  local  dose  the  less 
severe  the  local  lesion. 

Concerning  toxin  already  absorbed  and  in  contact  with 
the  tissues,  held  in  solution  by  the  body  fluids,  some  por- 
tion of  it  must  be  removed  with  the  secretion  poured  into 

'  Bouchard :   Auto-intoxication  in  Disease. 


the  intestine,  when  stimulated  by  purgative  medicines. 
as  well  as  that  drained  off  through  the  kidne)  s.  There 
is  nothing  unusual  in  such  a  claim.  We  have  many 
examples  of  removal  of  poisonous  material  from  the 
body  by  similar  procedure. 

By  repeating  this  process  it  certainly  tends  to  pre- 
vent a  dangerous  accumulation  of  toxin  in  the  system, 
and  at  the  same  time  prevents,  or  tends  to  prevent, 
local  lesion  in  the  intestine  from  becoming  sufficiently 
great  to  destroy  a  vessel,  or  extend  entirely  through 
the  intestinal  wall.  It  must  not  be  forgotten  that  tis- 
sue resistance  is  increased  just  as  the  tissues  are  freed 
from  the  effect  of  the  poison.  Hence  the  tissue  cells 
are  in  this  way  rendered  more  capable  of  resisting  and 
destroying  the  bacilli  already  present  in  them.  It  is 
obvious,  too,  in  order  to  escape  harm,  the  earlier  elimi- 
nation is  brought  about  and  the  more  constantly  it  is 
secured,  the  better,  whether  with  reference  to  general 
symptoms  or  local  lesion.  In  many  instances,  I  be- 
lieve, brisk  purgation  in  the  early  stage  carries  out  so 
much  of  the  culture  and  relieves  the  tissue  to  so  great 
an  extent  that  the  remaining  bacilli  are  destroyed  by 
the  liberated  tissue  and  the  fever  is  aborted. 

When  this  is  not  accomplished,  or  when  the  case  is 
not  seen  early,  then  purgation  must  be  prompt  and 
energetic  enough  to  relieve  dangerous  conditions,  and 
continuous  enough  to  keep  the  dose  of  poison  below  a 
harmful  point,  if  possible,  until  such  time  as  immunity 
is  reached.  In  judging  of  the  amount  of  poison  pre- 
sent, attention  should  not  be  exclusively  directed  to 
one  or  two  symptoms,  but  the  entire  list  of  symptoms 
should  be  considered. 

Coming  now  to  the  second  feature  in  treatment, 
that  is,  attempting  to  destroy  micro-organisms  by  anti- 
septics, there  can  scarcely  be  doubt  about  the  pos- 
sibility of  doing  this  to  some  degree.  It  is  quite 
possible  to  completely  deodorize  the  contents  of  the 
intestine  by  means  of  salol  or  salicylate  of  bismuth, 
and,  no  doubt,  by  other  agents,  as  anyone  can  demon- 
strate. But  to  be  efficient,  antiseptics  should  be  used 
in  association  with  purgatives  for  the  following  reasons  : 

1.  Just  as  it  is  easier  to  approximately  sterilize  an 
abscess-cavity  after  first  having  emptied  it,  so  is  it  to 
derive  benefit  from  intestinal  antiseptics  if  the  intestine 
be  first  cleared  of  its  contents. 

2.  Intestinal  antiseptics,  while  lessening  the  produc- 
tion of  poison  by  destroying  bacilli,  yet  could  have  no 
possible  effect  on  the  poison  already  in  the  intestine, 
but  in  many  instances  might  themselves  add  to  the 
toxins  present. 

3.  Much  larger  quantities  of  antiseptics  can  be  used 
without  poisonous  symptoms  arising,  if,  at  the  same 
time,  elimination  by  the  bowels  is  continuously  main- 
tained. Any  benefit  derived  from  an  antiseptic  is  ob- 
tained at  once,  and  if  it  is  speedily  cleared  away  much 
which  would  otherwise  be  absorbed  escapes  with  the 
contents  of  the  bowels. 

The  remaining  factor  in  treatment  is  clearly  indi- 
cated, for  the  local  effect  of  the  poison  depends  upon 
its  degree  of  concentration,  as  well  as  upon  duration  of 
contact. 

Injection  of  large  quantities  of  fluid  is  a  necessary 
adjunct  to  elimination.  Fluid  drained  off,  continu- 
ously carrying  with  it  the  poisonous  material  it  con- 
tains, must  be  replaced.  If  this  were  not  done,  the 
tissues  would  suff'er  from  lack  of  fluid  and  the  toxin 
remaining  would  assume  a  more  concentr&ted,  and 
therefore  a  more  active,  form.  It  might  be  well,  at 
this  point,  to  consider  elimination  by  purgation  in  its 
relation  to  certain  accidents  of  the  disease,  i.e.,  hemor- 
rhage and  perforation.  I  do  not  propose  to  enter  into 
the  question  at  length,  but  shall  content  myself  by 
pointing  out  that,  if  it  is  true  that  the  local  lesion  is 
proportionate  to  the  local  dosage  and  duration  of  con- 
tact, and  if  it  is  true  that  the  toxin  and  bacilli,  which 
would  otherwise  reach  the  lymphatic  glands,  can  be 
carried  out  by  purgation,  then  it  must  be  that  elimina- 


5  64 


MEDICAL    RECORD. 


[September  14,   1895 


tion  by  purgation  tends  to  lessen  the  occurrence  of 
both  hemorrhage  and  perforation. 

In  the  late  cases  the  indications  are  the  same.  If  a  ves- 
sel is  already  necrosed,  hemorrhage  is  unavoidable  ;  if 
not  already  necrosed,  the  way  to  prevent  it  becoming  so 
is  by  removing  the  poison.  With  reference  to  this  point 
I  beg  to  refer  to  the  paper  in  the  Canadian  Practi- 
tioner of  April,  1893,  or  to  the  Medical  Record  of 
March  10,  1894,  where  I  have  discussed  this  question 
at  length.  I  still  maintain  the  same  conclusion,  that 
purgation  at  no  time  causes  perforation  or  hemorrhage, 
but  at  all  times  tends  to  prevent  its  occurrence.  Mis- 
conception regarding  this  matter  was  the  great  barrier 
which  interposed  whenever  an  attempt  was  made  to 
follow  in  treatment  the  indications  furnished  by  study 
of  the  morbid  process.  So  great  was  the  dread  of 
these  two  accidents  that  the  fact  that  the  great  major- 
ity of  fatalities  were  due,  not  to  hemorrhage  and  perfora- 
tion, but  to  toxemia,  was  lost  sight  of.  A  study  of  the 
cases  I  have  to  report  with  reference  to  this  point,  will, 
I  believe,  convince  the  most  sceptical  that  formerly  a 
misconception  did  exist. 

So  much  for  meeting  the  indications  furnished  by  con- 
sideration of  what  has  been  determined  concerning  mi- 
cro organisms  on  paper  or  in  theory.  How  does  it  work 
out  in  actual  practice  ?     Precisely  as  it  does  in  theory. 

I  have  to  report  172  cases  with  a  mortality  of  five,  or 
three  per  cent.  No  cases  were  excluded,  late  cases  are 
taken  as  well  as  early.  Forty- four  of  these  were  my  own 
patients.  Forty- one  cases  were  treated  at  the  Toronto 
General  Hospital,  to  a  considerable  extent  under  my  own 
direction,  and  in  every  instance  under  my  observation. 
The  remaining  87  cases  were  furnished  me  by  several 
medical  friends,  with  two  exceptions  resident  in  Toronto. 

I  have  excluded  none  from  my  list,  whether  coming 
under  eliminative  treatment  early  or  late,  provided  only 
that  the  treatment  had  been  fairly  carried  out  from 
that  time.  Concerning  the  cases  received  from  others, 
I  can  only  speak  in  general  terms.  All  these  cases 
were  reported  as  having  done  well,  with  two  exceptions, 
and  the  treatment  gave  results  such  as  I  have  indicated 
in  the  papers  published.  One  case  died  from  hemor- 
rhage and  one  from  pneumonia  during  early  conva- 
lescence. The  hemorrhage  case  had  been  ill  in  the 
country  while  nursing  a  case  of  typhoid;  returned  to 
the  city,  and  after  two  weeks'  illness  was  again  taken  to 
the  country.  A\'hen  seen  she  was  comatose,  had  tym- 
panites, and  temperature  of  104°  F.  Given  saline  in 
drachm  doses  every  four  hours,  and  shortly  the  tempera- 
ture fell,  tympanites  disappeared,  and  consciousness  re- 
turned. On  the  third  day,  at  12  a.m.,  she  had  a  slight 
hemorrhage  and  the  saline  was  discontinued.  Next 
day,  at  5  p.m.,  she  had  a  severe  hemorrhage  and  died 
at  once. 

The  case  of  pneumonia  occurred  in  an  alcoholic,  and 
in  my  opinion  it  is  doubtful  whether  he  ever  had 
tyjihoid.  However,  I  have  included  his  case  in  my 
list.  In  two  other  cases  hemorrhage  occurred,  but 
treatment  was  persevered  in  with  favorable  results. 

Coming  now  to  my  own  cases,  forty-four  in  number. 
I  had  one  death  from  pneumonia,  following  a  very 
severe  attack,  in  a  boy  nine  years  of  age.  In  tlii.s 
case,  too,  there  was  slight  hemorrhage,  which  I  thought 
might  come  from  the  rectal  veins,  as  it  was  small  and 
bright  in  color.  The  autopsy  showed  a  remarkable  con- 
dition of  the  intestine.  Although  death  took  place  in 
the  fjurtit  week,  two  minute  ulcers  only  were  found  in 
the  ileum,  but  the  intestinal  glands  tlirougliout  were 
swollen. 

The  forty-one  hospital  cases  gave  two  deaths.  One 
from  hemorrhage,  where  the  autopsy  siiowed  the  jircs- 
cnce  of  ulcers  from  the  ileum  as  far  down  as  the  sig- 
moid flexure.  She  had  been  in  the  hosjiital  eight  days 
when  death  occurred.  This  case  jnejcnted  symptoms 
ol  severe  infection,  high  temperature,  distention,  and  a 
dusky  expression.  She  did  well  until  the  hemorrhage 
occurred.    This  was  slight  at  first.  The  Durgatives  were 


discontinued  and  opium  given  until  termination  fatally 
from  extensive  hemorrhage. 

The  second  fatal  case  occurred  from  hemorrhage 
from  the  stomach  and  nose  with  general  purpura,  hem- 
orrhage in  every  part  of  the  body.  Autopsy  showed  a 
large  number  of  ulcers,  covered  with  black,  dry  sloughs. 
The  patient  died  on  the  fourth  day  in  hospital.  These 
five  cases  make  up  the  entire  list  of  fatalities.  Two 
died  from  pneumonia,  after  recovering  from  severe  at- 
tacks of  typhoid. 

The  two  fatal  hemorrhages  occurred  in  cases  com- 
ing under  observation,  certainly,  in  the  third  week  of 
active  illness.  Both  cases  gave  indications  of  profound 
and. dangerous  toxaemia,  which  disappeared  as  soon  as 
elimination  was  secured. 

Analysis  of  one  hundred  and  seventy-two  cases. 
Mortality  of  three  per  cent.  No  death  from  toxaemia. 
No  perforation.  Hemorrhage  in  eight  cases,  including 
the  two  fatal  cases.  My  own  single  case  of  hemorrhage 
was  so  slight  that  I  attributed  it  to  rectal  engorgement. 
In  all  the  cases  where  I  had  opportunity  of  observing, 
except  the  two  fatal  cases,  the  amount  lost  was  small. 

Tympanites  ne\er  developed  in  my  own  or  hospital 
cases  during  treatment,  and  where  present  at  first  in- 
variably disappeared  as  soon  as  elimination  was  freely 
secured.  Delirium  practically  unknown  after  the  first 
days,  and  I  cannot  recall  a  single  instance  where  it 
was  present  after  treatment  became  established. 

Out  of  sixty-four  charts  in  my  possession,  fifty-eight 
show  that  the  highest  temperature  reached  was  in  the 
first  three  days.  That  is,  the  temperature  inclined  to- 
ward normal  as  soon  as  elimination  was  secured.  In 
many  instances  the  chart  shows  decline  in  temperature 
as  regular  as  a  flight  of  stairs,  t-.^j,'-.,  charts  Nos.  1,2,  and  3. 


The  pulse,  contrary  to  opinion  often  expressed,  im- 
[iroves  with  the  general  symptoms,  and  it  is  no  un- 
common thing  to  have  a  pulse  between  seventy  and 
eighty,  strong  and  regular,  after  two  weeks  of  continu- 
ous purgation.     For  example,  average  movements  five 


September  14,  1895] 


MEDICAL    RECORD, 


565 


per  day  for  eleven  days,  pulse  eighty  ;  average  daily 
movements  four  for  eighteen  days,  pulse  seventy-ei^ht ; 
average  movements  per  day  five  for  twelve  days,  pulse 
sixty-eight. 


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beg  so  pitifully  to  be  allowed  to  escape  if  elimination 
is  promoted  in  some  other  way. 

In  short,  under  this  method  of  treatment  the  strik- 
ing feature  is  the  absence  or  speedy  disappearance,  in 
practically  every  case,  of  the  classical  group  of  s^-mp- 
toms,  delirium  or  coma,  tympanites,  subsultus,  and  the 
extremely  foul  condition  of  the  mouth  and  tongue. 
The  two  following  cases  are  examples  of  speedy  im- 
provement : 

Case  I. — Alice  G ,  aged  twenty-four,   under  Dr. 

J.  E.  Graham,  was  the  first  case  treated  in  this  way  in 
the  Toronto  General  Hospital,  Dr.  Graham  kindly  al- 
lowing me  to  supervise  the  treatment.  When  the  treat- 
ment began  she  had  already  been  seven  days  in  the 
hospital.  Had  been  given  no  purgative  medicine 
whatever.     She   was  dusky  and  drowsy,  had  decided 


Diarrhoea,  in  my  own  cases,  never  required  control- 
ling treatment.  The  difficulty  was  rather  the  other 
way.  In  many  instances  it  is  not  an  easy  matter  to 
secure  sufficiently  free  movement,  and  different  purga- 
tives and  expedients  must  be  resorted  to.  Sponging  as 
routine  treatment  twice  daily,  but  in  my  own  cases 
never  required  for  reduction  of  temperature.  Lately, 
many  who  are  warm  advocates  of  the  cold  bath  or 
Brant  treatment,  have  arrived  at  an  explanation  of  its 
action.  It  promotes  elimination  '  of  toxin  by  the  urine, 
increasing  the  toxidity  6f  the  urine  five  times.  Very 
good;  but  why  confine  elimination  to  the  kidneys? 
Bouchard  has  shown  that  in  health  the  bile  discharged 
into  the  intestine  contains  just  six  times  the  amount  of 
toxin  that  is  discharged  with  the  urine.  In  the  event 
of  unusually  toxic  processes  occurring  in  the  intestine 


tympanites  and  muscular  tremor.  There  was  a  well- 
marked  pericardial  friction  rub,  also  an  aortic  regurgi- 
tant and  mitral  systolic  murmur,  all  appearing  within 
a  few  days.  Treatment  began  on  the  17th,  and  free 
elimination  by  daily  doses   of  calomel   and   Rcchelle 


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it  is  fair  to  conclude  that  the  toxidity  of  the  bile  would 
be  very  greatly  increased.  If  increased  elimination  of 
toxin  is  the  great  desideratum,  one  need  not  look  far 
for  a  more  direct  method  than  that  of  immersing  the 
sick  man  many,  times  a  day  in  a  tub  or  a  bed  full  of 
cold  water.    Besides,  he  is  not  likely  to  cry  so  loudly  or 

'  Burr :  Chicago  Medical  Recorder,  October,  1894,  p.  229. 


salts  secured.  Improvement  every  day.  Tympanites 
completely  gone  on  the  20th,  and  on  the  24th  the 
temperature  became  normal  and  continued  so.  At 
the  same  time  a  perfectly  tvpical  rash  was  present 
(Chart  i). 

Case  II. — Also  a  patient  of  Dr.  J.  E.  Graham  in 
the  General  Hospital.  I  was  asked  to  see  him  in  the 
absence  of  Dr.  Graham.  He  had  been  ill  for  two  weeks 


566 


MEDICAL    RECORD. 


[September  14,    1895 


and  had  been  in  the  hospital  five  days.  Temperature, 
104.2°  F.,  when  seen  on  the  evening  of  the  fifth  day 
(Thursday).  At  the  time  of  my  visit  he  was  profoundly 
unconscious,  with  greatly  distended  abdomen,  stertorous 
and  rattling  breathing,  jaw  fallen,  tongue  dry,  tremulous 
and  spasmodic  conditions  of  muscles,  subsultus,  and 
picking  at  the  bedclothes.  In  fact  he  seemed  to  be  in 
extremis.  I  advised  magnesia  sulphate,  half  an  ounce 
at  once,  and  continued  in  drachm  dojes  every  hour,  and 
plenty  of  fluid.  In  addition,  in  order  to  hold  him  un- 
til toxsemia  should  lessen,  strychnine  and  whiskey  were 
given  at  intervals.  This  was  on  Thursday  evening,  the 
1 6th,  and  on  Saturday  morning  he  was  quite  conscious. 
Purgatives  were  continued  vigorously.  Condition  con- 
tinued to  improve,  and  ou  the  2 2d  the  temperature 
became  normal  ;  subsequently  it  rose  slightly,  and 
again  became  normal  on  the  27th,  to  continue  so. 

In  this  case  I  am  convinced  the  patient  would  have 
died  in  a  very  short  time  if  the  toxaemia  had  not  been 
quickly  lessened. 

Charts  2,  3,  and  4  are  quite  characteristic,  and  show 
the  number  of  bowel  movements  daily.  I  have  fre- 
quently been  asked  how  much  purgative  should  be  given 
in  a  day.  One  can  have  no  fixed  rule.  The  idea  is  to 
give  enough  to  secure  elimination,  and  the  amount 
required  is  a  matter  of  experiment  in  each  case. 
Usually  three  or  four  grains  of  calomel  in  divided 
half-grain  doses,  followed  by  a  saline  in  three  or  four 
hours,  will  result  in  free  elimination.  If  not,  com- 
pound cathartic  pill  No.  2,  followed  by  sulphate  of 
magnesia  or  other  saline,  or  else  sulphate  of  magnesia 
alone  in  repeated  doses.  At  any  rate  secure  elimination 
quickly,  it  matters  little  how  it  is  don;.  In  many  cases 
days  are  lost.  The  dose  ordered  to-day  fails  to  purge. 
Next  day  another  is  ordered,  still  without  result,  no  pro- 
vision having  been  made  in  the  event  of  the  medi- 
cine ordered  not  being  sutlicient.  In  this  way  several 
days  may  go  by,  and  while  the  patient  may  be  taking 
purgative  medicine  he  is  certainly  not  receiving  elimi- 
native  treatment.  Indeed,  I  have  known  this  condition 
of  things  to  exist  during  an  entire  illness.  Of  course, 
treatment  after  that  fashion  must  be  due  either  to 
carelessness,  or  failure  to  grasp  the  principle  in  elimi- 
native  treatment. 


THE  AUSTRALIAN,  OR  O'HARA,  OPERATION 
FOR  THE  RADICAL  CURE  OF  HERNI.A. 

By  THOMAS  H.  MANLEV,  M.D., 


In  the  spring  of  1894,  while  making  a  tour  through  the 
London  hospitals,  it  was  my  privilege  to  witness  many 
surgical  operations  that  I  never  before  had  seen,  and  a 
few  that  I  had  not  even  heard  of. 

The  great  attraction  which  British  surgery  had  for 
me  was  the  generally  humane  character  of  the  aims 
which  inspire  the  operator,  and  the  pronounced  conser- 
vatism which  one  sees  extended  to  all  cases,  with  few 
exceptions. 

It  was  my  purpose,  particularly,  to  determine,  as  far 
as  possible,  just  what  the  position  of  hernial  surgery 
was,  in  those  cases  of  non-strangulated  variety  ;  and  en- 
deavor, if  possible,  to  gather  some  information  of  the 
details  in  technique  of  operating  that  might  enable  us 
to  give  our  patient  a  better  assurance  of  permanence  of 
cure  after  operation  than  has  been  before  possible. 
Happily,  in  this  respect,  my  hopes  were  realized. 

One  afternoon,  while  in  attendance  on  a  clinic  held 
by  Mr.  Golding  Bird,  a  case  of  hernia  was  brought  in 
for  operation.  My  surprise  was  great  when  I  saw  him 
commence  and  go  through  an  operation,  of  which  I  had 
no  knowledge  before,  though  of  late  years  I  had  made 
a  searching  examination  into  all  available  literature  on 
hernial  operations,  the  ancient  as  well  as  the  modern. 
The  professor  described  the  various  steps  of  the  opera- 
tion, performed  it  with  great  skill  and  ease,  and  highly 


commended  it.  but  failed  to  mention  the  name  of  its 
originator  or  its  history. 

My  impression  of  the  operation  was  so  favorable  that, 
as  soon  after  my  return  home  as  a  case  of  reducible 
inguinal  hernia  came  under  my  care,  this  particular  op- 
eration was  employed,  and  since  the  latter  part  of  April, 
1894,  twenty- one  cases  have  been  so  treated  by  me,  and 
in  no  single  instance  has  there  been  a  relapse,  as  far  as 
I  can  learn.  I  have  since  learned  that  Henry  O'Hara, 
M.R.C.,  S.I.  senior  surgeon  to  the  Albert  Hospital, 
Melbourne,  Australia,  first  devised  it.  At  the  late  meet- 
ing of  the  National  Association  of  Railway  Surgeons,  at 
Chicago,  on  the  invitation  of  Professor  John  B.  Murphy, 
a  surgical  clinic  was  held  by  me  in  Cook  County  Hos- 
pital, on  which  occasion  I  was  enabled  to  perform  the 
O'Hara,  or  Australian,  operation  for  the  radical  cure  of 
reducible  hernia,  and  demonstrated  the  various  steps  of 
its  technique.  Its  simplicity  and  rationale  so  pleased 
those  who  saw  it  that  a  large  number  have  since  ur- 
gently requested  me  to  publish  a  description  of  the  op- 
eration, and  so  illustrate  it  that  they  might  the  better 
understand  it.  To  fulfil  this  purpose,  and,  besides, 
recommend  to  the  profession  what  has  impressed  me 
as  the  most  desirable,  safest,  and  most  durable  of  all 
surgical  cures  of  hernia,  these  few  notes  are  submitted. 

In  the  beginning  it  is  necessary  that  we  have  a  cor- 
rect understanding  of  the  precise  etiological  elements 
which  enter  into  a  hernia,  in  order  that  we  may  the  bet- 
ter appreciate  how  far  we  may  hope  to  deal  with  this 
infirmity  by  surgical  measures  ;  for  it  may  be  well  to 
confess  at  the  outset  that  there  are  several  tvpes  of  her- 
nia quite  beyond  our  power  to  cure. 

The  three  anatomical  elements  which  enter  into  the 
development  of  hernia  are  :  ist.  Parietal ;  2d,  visceral ; 
and  3d,  mesenteric.  Besides  these,  there  are  many 
other  determining  factors.  The  parietal  only  will  be 
considered  here,  and  only  so  far  as  may  be  necessarj-  to 
discuss  the  special  plan  under  consideration  ;  for  in 
that  class  of  cases  only  in  which  the  faulty  devel- 
opment of  structure  is  lodged  in  the  walls,  involving  the 
canals  of  emergence,  can  we  hope  for  or  promise  per- 
manent results. 

M.  Paul  Segond,  in  his  classical  work  on  hernia,' 
was  disposed  to  take  a  pessimistic  view  of  modern  sur- 
gical operations  for  hernia  ;  because  he  believed  there 
was  a  certain  mortality  attending  them.  Of  late,  how- 
ever, he  has  changed  his  opinion.  In  properly  selected 
reducible  hernis,  treated  skilfully  by  the  method  here 
described,  there  should  be  no  danger  to  life  at  all. 

The  technique  embraced  in  the  O'Hara  operation 
combines  some  of  the  principles  of  the  more  ancient 
methods  of  Gerdy,  Watzer,  and  Valette,  with  the  more 
modern  of  Reisel,  Macewen,  and  McBurney,  i.e.,  inva- 
gination with  obliteration  of  the  lumen  of  the  sac,  to 
which  is  superadded  the  more  modern  procedure  of  the 
open  incision. 

It  radically  differs  from  all  other  modern  operations 
inasmuch  as  it  leaves  the  abdominal  walls  intact,  the 
inguinal  canal  open,  and  the  sac  undisturbed  in  the 
scrotum.  This  is  wherein  its  great  strength  lies  :  for 
in  all  cases,  after  treatment  by  this  plan,  we  can  give 
our  patient  an  assurance  that,  if  we  should  fail  to  ac- 
complish a  permanent  cure,  we  still  do  not  leave  him  in 
a  state  much  worse  than  though  nothing  had  been  done, 
as  is  the  case  with  many  other  current  operations. 

As  will  be  seen,  the  ideal  cases  of  hernire  which  are 
the  most  appropriate  for  the  O'Hara  operation  are  the 
indirect  complete  inguinal  in  the  male,  although  with 
some  slight  modification  it  may  be  utilized  with  advan- 
tage in  the  femoral  or  inguinal  of  the  female. 

In  order  to  derive  the  most  satisfactory  results  with 
this  operation,  we  should  exercise  discretion  in  select- 
ing our  cases  ;  taking  due  care  to  exclude  those  which 
are  very  chronic,  or  have  undergone  extensive  struct- 
ural changes. 

Hernial  operations,    in  reducible   cases,  are  under- 

>  Traiteniem  Chirurg.  des  Hernies,  par  M.  Paul  Segond. 


September   14,  1895] 


MEDICAL   RECORD 


367 


taken  chiefly  for  three  reasons  :  i,  To  obliterate  a 
deformity-cosmetic  purpose  ;  2,  to  place  a  hernia  in 
such  a  position  that  it  may  be  more  safely  and  com- 
fortably supported  by  a  truss  ;  and,  3,  to  secure  a  defi- 
nite cure.  This  operation,  as  far  as  my  experience  goes, 
fulfils  the  two  latter  in  a  larger  measure  than  any 
other,  and  for  its  cosmeiic  results  is  equalled  by  none 
yet  undertaken  by  the  open  incision. 

The  Various  Types  of  Hernia  for  which  the  Austra- 
lian Method  is  Best  Adapted. — It  goes  without  saying 
that  there  are  various  ruptures  that  should  never  be 
operated  on  except  in  the  presence  of  impending,  or 
actual,  strangulation.  There  are  many  others  of  such 
varied  anatomical  elements  that  no  definite  lines  can  be 
followed  in  dealing  with -them  by  operative  methods  ; 
and  thus  it  is  that  with  the  scheme  here  described 
there  are  certain  types  in  which  we  must  deviate  from 
our  regular  course  after  an  operation  is  begun. 

Complete,  Indirect,  Inguinal  Hernia  in  the  Alale. — 
The  most  common  variety  of  hernia,  viz.,  the  complete, 
indirect,  inguinal,  is  that  most  suitable  for  the  O'Hara 
operation,  inasmuch  as  in  this  we  have  the  sac  well 
down  in  the  scrotum,  and  are  able  to  separate  the 
neck  or  stalk  as  it  emerges  through  the  external  ring. 

In  the  female,  when  the  viscera  make  their  way  out 
through,  or  by,  the  canal  of  Nuck  into  the  labium  majus, 
we  may  succeed  equally  well.  It  is  well  to  remember, 
however,  in  this,  which  is  an  unusual  form  of  hernia 
in  women,  that  the  extrusion  commonly  consists  of 
some  of  the  organs  of  generation,  and  that  the  in- 
guinal canal  with  the  female  is  very  short  and  rudi- 
mentary. 

Congenital  Inguinal  Hernia. — With  cases  of  congeni- 
tal inguinal  hernia,  as  there  is  an  absence  of  a  free, 
peritoneal  investment,  and  hence  no  sac,  we  may 
strip  the  fascia  propria  off  the  elements  of  the  cord, 
and  invaginate  it  in  such  a  manner  as  to  quite  com- 
pletely obturate  the  inner  ring. 

Bubonocele. — Bubonocele  consists  of  a  hernial  arrest 
within  the  inguinal  canal  between  the  rings  ;  or  the 
apex  of  the  sac  may  extend  a  short  distance  just  out- 
side the  external  ring.  In  gen  line  bubonoceles  the 
anterior  wall  of  the  inguinal  canal  must  be  opened, 
when  we  will  be  obliged  to  invaginate  the  peritoneal 
pouch  entire.  When  any  part  of  the  sac  protrudes 
through  the  external  ring,  we  may  easily  draw  it 
down  and  free  it  from  the  cord,  when  it  may  be  turned 
on  itself  and  sent  entire  through  the  internal  ring. 

Femoral  Hernia. — In  femoral  hernia  of  recent  devel- 
opment we  may  utilize  this  method  with  advantage  ; 
though  as  aJl  surgeons  well  know,  owing  to  the  inti- 
mate contact  of  the  fascia  propria  with  the  great  blood- 
trunks,  the  utmost  caution  must  be  observed  in  the 
process  of  isolation,  inversion,  and  anchoring  the  neck 
of  the  sac.  If  we  keep  close  to  the  inner  border  of 
the  falciform  process  and  send  our  carrying-needle 
through  the  conjoined  tendon,  or  Haselbach's  triangle, 
we  will  avoid  all  danger  of  vascular  damage. 

Age. — Seven  of  my  cases  were  in  children  under 
five.  In  all  this  class,  when  they  are  over  measles 
and  whooping-cough  and  have  ruptures  which  are 
incoercible,  the  earlier  they  are  treated  the  better. 
These  little  ones  suffer  but  very  slightly  from  the  oper- 
ation, and  can  be  scarcely  restrained  from  running 
about  after  the  first  few  days  succeeding  the  oper- 
ation. 

Period  of  Convalescence. — One  of  the  greatest  ad- 
vantages of  this  operation  is  the  very  brief  convales- 
cence. 

As  there  has  been  no  shock  to  the  system,  no  exten- 
sive division  of  tissues  with  large  breaches  in  the  soft 
parts  to  close  in,  there  is  no  pyrexia,  no  constitutional 
disturbance  ;  and  as  a  rule,  with  adults,  it  is  my  prac- 
tice not  to  confine  them  in  bed  beyond  nine  or  ten  days. 
Children  are  allowed  to  be  up  after  a  week,  but  aspica- 
bandage  is  worn  for  six  weeks  later,  when  all  supports 
are  cast  aside.     AVith  adults,  as  the  reparative  power  of 


the  tissue  is  not  so  active,  it  usually  requires  about  a 
fortnight  for  complete  union. 

Technique  of  Operation. — In  order  to  endeavor  to 
render  the  written  description  of  this  operation  more 
comprehensive,  I  have  had  struck  off  the  few  diagram- 
matic sketches  here  inserted,  although,  as  there  is  a  great 
diversity  in  the  pathological  changes  of  the  tissues  which 
we  encounter,  and  the  extent  in  the  alteration  and 
changed  relations  of  the  anatomical  structures,  no  de- 
scription by  pictorial  illustration,  however  perfect,  will 
convey  more  than  the  most  elementary  outlines  for  an 
operator. 

The  Extent  and  Site  of  the  Division  of  the  Tissues. — 
In  uncomplicated  cases  of  reducible,  indirect,  inguinal 
hernia,  we  commence  by  making  two  incisions.  The 
first,  or  inguinal  incision,  is  made  down  on  the  neck  of 
the  sac  as  it  emerges  through  the  external  ring.  A 
two  -  inch  incision  carried  downward  over  the  long 
axis  of  the  protrusion  in  the  direction  of  the  scrotum, 
or  labium,  according  to  sex,  will  give  us  ample  space 
to  reach  the  peritoneal  envelope,  completely  detach  it 
from  the  spermatic  cord,  lift  it  out  of  the  opening, 
draw  it  well  downward,  transfix,  ligate,  divide,  and  in- 
vaginate it. 

The  position  and  extent  of  this  incision  must  be 
modified  according  to  the  volume  and  site  of  the  her- 
nial descent. 

The  precise  and  exact  manipulation  of  this  incision, 
and  what  it  exposes,  constitutes  the  key  to  the  opera- 
tion. 

In  order  to  proceed  with  rapidity  and  safety  it  is  not 
only  necessary  that  we  are  familiar  with  the  normal 
elements  of  the  spermatic  cord,  but  we  must  also  fully 
understand  the  extensive  alteration  in  structure  which 
we  may  be  prepared  to  meet  in  the  generality  of  cases. 
In  fully  developed  scrotal  hernia  of  moderate  volume 
our  course  is  clear.  The  sac  is  adherent  to  the  con- 
nective tissues  of  the  scrotum,  the  infundibular  pro- 
cess of  the  cord  is  quite  free,  therefore  we  readily  ex- 
pose and  lift  the  neck  out  through  the  opening. 

It  will  be  remembered,  however,  that  in  some  varie- 
ties of  inguinal  hernia  the  sac  is  quite  free  and  elastic, 
following  closely  on  the  contained  viscera  in  reduc- 
tion ;  so  that  when  we  open  down  over  the  track,  which 
but  a  moment  before  it  occupied,  we  find  nothing 
except  the  spermatic  structures,  for  it  has  ascended  to 
the  internal  ring,  or  at  any  rate  it  is  within  the  canal, 


^  _  h  Com  pli- 

cated Hemia  on  the  Left.  "  i,  Di%*idcd  layers  of  coverings,  iliac  incision  ;  2,  free 
loops  ofligature :  3,  inguinal  incision:  4,  neck  of  sac;  s,  vas  deferens;  6,  sper- 
matic nerve  ;  7,  spermatic  artery  ;  8,  pampiniform  plexus  ;  9,  testis. 

out  of  sight.  In  others,  though  just  before  operation 
the  rupture  comes  down  well  into  the  scrotum  on  in- 
cision, after  reduction  we  will  find  in  some  cases 
that  the  sac  is  so  far  pulled  up  the  inguinal  canal  that 
only  its  tip  emerges  through  the  external  ring  (Fig.  i). 


368 


MEDICAL    RECORD. 


[September  14,  1895 


In  another,  not  uncommon,  fonn    we  will    find    no 
fascia  propria  of  the  cord. 

The  peritoneal  pouch  (Fig.  i)  comes  down  not  on  our 
side,  under  or  over  it,  but  directly  through  its  various 
strands,  which  cling  to  its  walls  with  such  ten- 
acity that  a  delicate  dissection  may  be  recessarj' 
to  free  them  before  the  sac  is  divided.     After 
we  have  reached  this  and  completely  insolated  it, 
our  next  step  will  be  to  be  positively  assured 
that  it  is  empty  of   the  viscera.     If  these   are 
adherent  to  the  internal  surface  we  should  open 
the  sac  and  liberate  them  before  division.     Now 
we  will   pass  the  index-finger  up  the  inguinal  j  ., — 
canal  and  free  the  spermatic  cord  from  the  neck  ~ 

of  the  sac  as  far  up  as  the  internal  ring.  While 
the  finger  is  in  the  canal  the  lip  is  gently  pressed 
against  the  internal  ring  until  this  is  somewhat 
dilated.  We  are  now  ready  to  make  the  second 
or  iliac  incision,  which  should  be  situated  lialf 
an  inch  posterior  and  above  the  upper  margin 
of  the  inner  aperture. 

This  incision  should  not  be  more  than  one 
inch  in  length  and  should  extend  down  to,  but 
not  through,  the  fascia  transversalis.  At  this 
site  we  escape  the  internal  epigastric  artery  and 
have  nothing  to  fear  from  hemorrhage.  The 
index-finger  is  kept  in  the  canal,  pressing  the  integu- 
ments outward  and  maintaining  a  support  while  we 
divide  the  tissues  directlv  on  it. 


After  all  hemorrhage  is  subdued  and  the  wounds  are 
rendered  thoroughly  aseptic,  we  close  in  both  inci- 
sions hermetically  with  continued  catgut  suture  and 
apply  the  usual  dressings. 


Fig.  2. — Showing  the  Raised  Neck  of  the  Sac.  through  the  In^inal  Incision,  i,  I 
2,  free  loops  of  ligature  :  3.  collapsed  neck  of  sack  ;  4.  atrophied  testis  and  distended  sac 
retracted  divided  sac. 


This  completes  the  first  Stage  of  the  operation.  We 
begin  the  second  by  withdrawing  the  index-finger  and 
raising  the  sac  on  a  tenaculum  (Fig.  2),  and  making 
tension  from  above  downward.  Then,  with  a  needle 
carrying  a  double-looped  suture,  the  neck  is  transfixed, 
and  its  lumen  closed  by  a  firm  square  knot,  when  ten- 
sion is  made  from  above  and  it  is  cut  through  with  the 
scissors.  The  distal  end  is  now  drawn  immediately 
downward  and  lost  from  sight  by  its  own  contraction, 
while  the  proximal  end  rises  by  contraction  up  the  in- 
guinal canal.  Now,  with  a  long  needle  perforated  near 
its  point  and  fixed  in  a  handle,  we  carry  each  loop  up 
separately  through  the  inguinal  canal,  the  internal  ring, 
and  out  through  the  iliac  incision  through  the  parietal 
peritoneum.  Each  of  these  loops  should  emerge  through 
the  fascia  transversalis  about  three  lines  apart.  In  per- 
forming this  part  of  the  operation  we  may  introduce  the 
needle  from  above  or  below  (Fig.  3). 

After  the  loops  are  both  well  drawn  out,  through 
above,  and  the  neck  of  the  sac  is  wedged  in  and  an- 
chored between  the  parietal  peritoneum  and  sheath  of 
the  transversalis  muscle,  they  are  firmly  knotted  and 
cut  off.     We  are  now  ready  for  the  third  and  last  stage. 


.  Free  loops  of  sutures  sent  up 
:merging  armed  needles. 

In  femoral  hernia  in  the  male  the  lower  incision  is 
made  external  to  the  scroto-femoral  fold  ;  the  upper, 
through  the  conjoined  tendon  extending  down  to  the 
peritoneal  reflexion,  below  the  course  of  the 
internal  epigastric  artery. 

As  this  species  of  hernia  seldom  attains  a 
considerable  volume,  we  will  not  be  obliged  to 
very  often  vary  the  position  or  direction  of 
the  incision  (Fig.  4).  Although  no  oppor- 
tunity has  yet  presented  itself  to  me  to  apply 
this  method  on  the  female,  still  it  is  my  con- 
viction that  it  will  prove  equally  efficient  with 
her. 

We  will  not,  in  this  type,  be  embarrassed  by 
the  presence  of  the  spermatic  cord,  as  in  the 
male  ;  and  therefore  it  should  be  performed 
with  greater  ease  and  rapidity,  without  the 
probabilities  of  relapse  (Fig.  6). 

The  case  illustrated  by  Fig.  7  was  a  boy, 
seven  years  of  age,  who  since  he  was  three 
years  old  had  a  rupture.  For  a  long  time  he 
could  wear  no  description  of  a  truss  with  com- 
fort, and  the  protrusion  was  steadily  increasing 
in  size,  .\lthough  the  hernia  came  well  down 
into  the  scrotum  after  reduction,  on  dissection 
:  it  was  found  that  the  sac  was  drawn  up  so  far 
"  into  the  inguinal  canal  that  only  its  conical  tip 
protruded  through  the  external  ring.    This  was 


KiG.  4. — showing  Relative  Position  of  Incisioas,  for  Inguinal  Hernia — Right 
Side,  Female.     Relative  Position  for  Incisions  in  remoral  Hernia,  on  Left  Side. 
Female,     i.  Incisions  for  inguinal  hernia,  in  female ;  incisions  for  femoral  her- 
;  for  femoral  hernia,  closed  :  3,  neck  of  sac.  drawn  up  and  lodged  ; 


September  14,  1895] 


MEDICAL    RECORD. 


569 


drawn  down, 
placed  lower 


transfixed,  and  ligated,  as  though  it  was 
down.     This  cut  is  to  show  the  site  of 


Fig.  5.— Parts  Ready  to  Close  In. 


the  incisions  on    the  living   subject,  and  was  photo- 
graphed the  ninth  day  after  operation. 

This  case  shown  in  Fig.  8  is  at  the  present  time  under 


Fig.  6. — Illustrating  Position  of  Incisions,  < 
male,  i,  Inguinal  incision  in  femoral  hernia 
nackof  sac. 


2,  vulvar 


.1  Hemia  in  the  Fe- 
ll with  e.vposed 


my  care,  having  been  operated  on  June  17  th,  and  was 
photographed  the  day  before.  It  is  included  here  in 
order  to  illustrate,  first,  an  incomplete,  indirect,  ingui- 


/ 

sition  and  direction  of   the   incisions  in  this  type  of 
hernial  infinnit)'. 

Fig.  9  is  a  photograph  from  a  young  man  who  came 
to  me  for  treatment  for  rupture.  The  mass  was  not  a 
hernia,  but  malignant  disease  of  the  testis,  spermatic 
cord,  and  the  retro-peritoneal  tissues,  compressing  the 
cava,  and  thus  producing  a  very  varicose  dilatation  of  all 


the  peripheral  veinous  channels.  The  disease  speedily 
ended  mortally,  and  was  proven  to  be  an  adeno-sarcoma. 

Conclusions. — From  the  rudimentary  description  of 
the  Australian  operation  and  the  diagrammatic  sketches 
here  inserted,  it  is  hoped  that  one  may  be  better  en- 
abled to  comprehend  the  principles  on  which  it  is 
founded.  None,  to  my  knowledge,  so  highly  com- 
mends itself,  for  the  many  reasons  here  set  forth. 

With  a  procedure  of  so  much  promise,  and  one  which 
has  stood  the  repeated  test  of  application  on  various 
types  of  inguinal  hernia,  without  relapse  in  a  single 
case  yet,  there  should  be  a  large  field  for  its  employ- 


nal  hemia,  with  some  of  the  anatomical  features  of  a 
cystocele  of  the  cord  ;  besides,  to  note  the  relative  po- 


ment.  With  time,  and  perhaps  some  minor  improve- 
ments in  detail,  there  should  be  still  better  reports 
from  it. 

In  order  to  realize  the  fullest  advantages  from  it, 
however,  caution  and  discrimination  must  be  exercised 
in  the  selection  of  cases.  In  operation,  rigorous  asep- 
sis is  the  foundation  of  success,  for  contamination  of 
the  tissues  will  lead  to  serious  sequelae  that  have  no 
legitimate  place  in  the  formal  operation. 

NoTB. — The  drawings  in  this  article  were  made  through  the  kind" 
ness  of  Dr.  A.  D.  Davidow. 

115  West  Forty-ninth  Strebt, 


370 


MEDICAL   RECORD. 


[September  14,  1895 


THREE  CASES  OF  ABDOMINAL  SECTION 
FOR  EXTRA-UTERINE  PREGNANCY,  PRE- 
SENTING UNUSUAL  FEATURES. 

By   EMORY  I.AXPHEAR,  M.D.,  Ph.D., 


FORMERLY  PROFA.<;S0R  OF  I 
CITY  .MEDICAL  COLLEGE  - 
OF  SURGERY  IN  THE  ST. 


ST.   LOUIS,  MO. 

ERATIVe  AND  CLI.N'ICAL  SUP.CERV  IN"  THE  KANSAS 
D  PROFESSOR  OP  THE  PRINXIPLES  AND  PRACTICE 
UIS  COLLEGE  OF  PHYSICIANS  AND   SURGEONS. 

Three  of  my  operations  for  extra-uterine  pregnancy 
have  presented  unusually  interesting  features  :  the 
first  on  account  of  the  long  time  which  elapsed  be- 
tween the  date  of  rupture  and  that  of  operation,  yet 
attended  with  satisfactory  results  ;  the  second  by  rea- 
son of  the  peculiar  difficulties  encountered  ;  the  third 
because  the  diagnosis  and  operation  were  made  prior 
to  rupture  of  the  tube. 

Laparotomy  for  Extra-uterine  Pregnancy  on  the 
Fifteenth   Day  after    Tubal  Rupture — Recovery. — On 

August  16,  1S92,  I  saw  Mrs.  Belle  W ,  at  her  home, 

four  miles  south  of  Hamilton,  Mo.,  in  consultation 
with  her  physician,  Dr.  Tinsley  Brown.  She  was 
forty-two  years  of  age,  the  mother  of  two  children 
aged  eighteen  and  fourteen  years.  She  was  pregnant 
a  third  time  in  1888,  but  miscarried  at  the  fourth 
rnonth,  and  never  fully  regained  her  health,  menstrua- 
tion being  profuse  and  retroversion  so  marked  and 
painful  as  to  require  frequent  local  treatment  by  gly- 
cerine tampons,  etc.  Her  last  menstruation  was  a  lit- 
tle before  June  ist,  after  which  there  were  some  of 
the  usual  symptoms  of  pregnancy.  August  2d  she 
was  seized  with  an  excruciating  pain  in  the  left  ovarian 
region  and  a  sharp  hemorrhage  occurred  from  the 
uterus.  This  bleeding  soon  ceased,  but  the  pain  con- 
tinued in  a  modified  degree.  She  became  very  weak, 
and  by  the  time  Dr.  Brown  reached  her  she  was  in 
profound  collapse  :  pulse  almost  imperceptible  ;  pa- 
tient nearly  unconscious,  and  the  abdomen  greatly  dis- 
tended :  the  usual  signs  of  internal  hemorrhage.  But 
under  stimulants  she  rallied,  and  at  the  time  of  mv  ex- 
amination she  was  in  fair  condition,  though  the  temper- 
ature was  101°  F.  The  diagnosis  of  ruptured  tubal 
pregnancy  was  positive. 

At  9  A.M.  next  morning,  with  the  assistance  of  Drs. 
Brown  and  Lindley,  of  Hamilton,  I  curetted  the  uterus, 
removing  decidual  membrane  and  decomposing  blood- 
clots — evidently  the  cause  of  the  elevation  of  tempera- 
ture— and  packed  the  uterus  with  gauze.  Then  I 
opened  the  abdomen  and  turned  out  a  gallon  and  a 
h.alf  of  fluid  and  clotted  blood  mixed  with  serum 
from  the  peritoneum,  in  which  was  found  the  foetus. 
The  torn  ovary  and  tube  were  removed  and  the  abdomen 
and  pelvis  thoroughly  irrigated  with  boiled  water  until 
no  more  clots  came  away,  as  much  of  the  fluid  sponged 
out  with  aseptic  gauze  as  could  be  removed  without 
too  much  irritation  of  viscera,  and  the  incision  closed 
without  drainage,  with  the  usual  dressings. 

Convalescence  was  prompt  and  satisfactory  in  every 
respect.  The  afternoon  temperature  was  100°  F.  (the 
morning  register  just  before  o])eration  being  102°  F.), 
and  sank  a  half  degree  daily  until  the  normal  was 
reached.  The  sutures  were  removed  on  the  tenth  day 
and  she  sat  up  on  the  fourteenth.  In  four  weeks  she 
began  to  do  her  own  housework,  and  has  since  that 
time  been  in  better  health  than  for  many  years  before 
the  operation. 

The  remarkable  features  of  this  case  are  the  rallying 
after  such  a  serious  hemorrhage,  the  long  period  that 
elapsed  between  the  accident  and  the  operation,  and 
the  speedy  recovery  under  such  circumstances. 

I  am  not  in  favor  of  irrigation  in  most  cases  of  ab- 
dominal section  ;  in  a  case  like  this,  where  blood-clots 
were  many  and  in  almost  every  part  of  the  abdomen, 
there  was  nothing  else  to  be  done  ;  but  the  abdomen 
having  been  fairly  well  cleaned  and  dried,  drainage 
could  have  but  added  to  the  danger. 


Ruptured  Tubal  Pregnancy  Complicated  by  (Edema- 
tous  Myoma  —  Laparotomy  and  Hysterectomy  under 

Difficulties — Death May  i,  1892,  I  was  called  to  see 

Sarah  B— ,  colored,  aged  about  thirty-eight,  who  had 
been  married  seven  years,  but  never  became  pregnant, 
so  she  supposed.  For  several  years  she  had  suffered  from 
a  uterine  tumor  of  large  size,  for  which  ergot  had  been 
taken  with  little  benefit.  She  last  menstruated  in  Janu- 
ary, 1892,  but  besides  the  cessation  of  menses  no  signs 
of  pregnancy  were  noticed,  so  the  ergot  was  continued 
vigorously. 

April  30th. — In  the  afternoon  labor  pains  began,  and 
becam.e  quite  severe  in  the  evening,  at  which  time  her 
physician.  Dr.  A.  L.  Hunt,  examined  her,  finding  no  dila- 
tation of  the  OS  and  no  discharge.  Morphine  was  given. 
At  6.  30  A..M.  the  patient  experienced  a  sudden,  sharp, 
cutting  pain  in  the  right  inguinal  region  and  became 
unconscious.  At  8  o'clock  she  was  seen  by  the  doctor, 
who  found  her  in  profound  collapse,  almost  pulseless, 
and  with  abdomen  distended  to  farthest  possible  limits. 
He  diagnosticated  ruptured  tubal  pregnancy,  but  re- 
garded the  patient  as  dying  ;  however,  he  gave  power- 
ful stimulants — brandy  in  as  large  quantities  as  possible, 
etc.  At  4  P.M.,  much  to  his  surprise,  he  found  the 
woman  still  alive,  and  so  suggested  operation.  The 
abdomen  was  now  filled  with  blood,  almost  to  the  point 
of  bursting,  it  seemed. 

At  5  P.M.,  assisted  by  Drs.  A.  H.  Cordier  and  J.  C. 
Maxson,  of  Kansas  City,  Dr.  Hunt  administering  the 
ether,  I  opened  the  abdomen.  The  operation  was 
performed  in  a  lonely  negro  cabin  of  two  rooms,  a 
hovel,  upon  a  door  from  an  outhouse  resting  upon  two 
boxes,  the  instruments  occupying  the  only  table.  One 
tin  wash-basin,  an  earthen  bowl  and  plate,  a  bucket,  a 
boiler  of  hot  water  and  a  quart  cup  constituted  the 
"  facilities  "  of  our  operating-room.  Fully  three  quarts 
of  blood  gushed  from  the  peritoneal  space.  A  four- 
months'  foetus  and  placenta  were  found  under  the  liver 
floating  in  blood  which  came  from  a  huge  rupture  in 
an  enlarged  tube.  As  the  clots  and  liquid  blood  were 
cleaned  out  it  became  evident  that  active  hemorrhage 
was  still  going  on  ;  so  the  tube  with  its  extensive  tear 
was  brought  into  the  wound  and  the  ovarian  artery 
found  bleeding  copiously.  It  was  very  much  enlarged, 
probably  because  the  whole  pelvis  and  lower  abdomen 
were  filled  by  a  large  solid  tumor  of  the  uterus.  The 
artery  having  been  tied,  we  next  attempted  to  remove 
the  injured  tube,  but  it  was  so  intimately  blended  with 
the  tumor,  and  the  tear  extended  so  deeply  into  the 
uterine  tissue,  that  this  was  found  impossible.  We  next 
tried  to  pull  the  tumor  forward  and  stitch  the  ruptured 
portion  into  the  lower  angle  of  the  abdominal  incision  ; 
but  the  tumor  was  so  friable  that  no  such  sutures  would 
hold — no  matter  how  deeply  they  were  passed  they 
would  at  once  cut  through,  just  as  if  the  tumor  were 
half  decomposed — so  this  plan  had  also  to  be  aban- 
doned. There  remained  nothing  to  do  except  to  re- 
move the  tumor.  But  here  a  new  difficulty  confronted 
us.  No  one  had  anticipated  the  necessity  of  a  hyste- 
rectomy, so  there  were  no  instruments  at  hand  save 
those  always  found  in  my  emergency  operating-case. 
Means  had  to  be  devised  as  we  progressed.  I  was  in 
favor  of  making  total  extirpation  as  probably  speedier 
and  safer  with  the  means  at  our  command  ;  but  Dr. 
Cordier  objected,  because,  i,  the  vagina  was  unpre- 
pared, and  therefore  frightfully  foul  ;  2,  the  large  size 
of  the  tumor  would  greatly  prolong  the  operation,  and 
no  rubber  constrictor  was  at  hand  to  control  hemorrhage 
if  we  cut  the  tumor  away  ;  and,  3,  under  the  circum- 
stances there  would  be  less  loss  of  blood  by  making  a 
pedicle  than  by  removal  of  the  entire  uterus.  We 
therefore  pulled  the  tumor  and  uterus  strongly  into  the 
opening,  ligated  and  severed  the  broad  ligament,  and  be- 
gan the  processor  stripping  downward  to  form  a  pedicle, 
Dr.  Cordier  working  in  front  while  I  attacked  the  poste- 
rior surface.  We  thus  quickly  formed  a  satisfactory  ped- . 
icle  and  introduced  our  "  hysterectomy  pins,"  these  con- 


September  14,  1895] 


MEDICAL  RECORD. 


!7i 


i 


sisting  of  the  blades  of  long  dressing-forceps  thrust 
through  the  tissues  at  right  angles  to  each  other.  An  ex- 
ceedingly strong  silk  cord  which  I  happened  to  possess 
was  thrown  around  the  pedicle  below  the  "pins,"  and 
with  all  our  strength  we  pulled  and  pulled,  and  then 
tied  ;  once  more  around  and  another  pulling  and  tying, 
and  we  cut  away  the  tumor.  Our  improvised  constrictor 
acted  as  well  as  the  most  perfect  serre-nceud  and  wire, 
not  a  bit  of  bleeding  following  ;  but  to  be  sure  of  h^'e- 
mostasis  we  pulled  the  two  flaps  of  peritoneum  which 
had  been  stripped  from  the  tumor  upward  over  the 
stump  and  stitched  it  over  and  over  with  catgut,  then 
fastened  the  stump  in  the  incision  in  the  usual  manner, 
irrigated  the  belly  thoroughly,  closed  the  cut,  and  ap- 
plied our  dressings.  Remarkable  as  it  may  seem,  the 
work  was  completed  in  forty-five  minutes.  No  blood 
was  lost  after  the  ovarian  artery  was  caught,  but  the 
previous  hemorrhage  was  so  great  that  in  spite  of  the 
most  vigorous  stimulation  she  never  rallied,  death  oc- 
curring within  an  hour  after  the  completion  of  our 
work. 

I  have  always  censured  myself  that  I  tried  to  oper- 
ate under  such  conditions.  Knowing  there  was  a  large 
uterine  tumor  present,  it  would  have  been  better,  I  am 
sure,  to  have  used  intravenous  injections  of  normal 
salt  solution,  and  ordered  brandy,  digitalis,  liquid  food, 
etc.,  waiting  a  few  hours  until  the  patient  rallied  from 
the  shock  and  until  careful  preparation  could  have 
been  made  for  hysterectomy  with  proper  instruments. 
It  is  doubtful  if  the  patient  could  have  bled  much 
more,  as  the  abdominal  walls  seemed  to  have  reached 
their  limits.  Yet  at  the  time  of  operation  I  felt  that 
the  patient's  only  chance  was  in  immediate  sectipn — -an 
opinion  with  which  Dr.  Cordier  coincided.  So  far  as 
the  operative  work  itself  is  concerned,  I  do  not  believe 
we  could  have  done  it  any  more  quickly  or  more  safely 
if  we  had  had  every  instrument  and  appliance  ordina- 
rily at  hand  for  abdominal  hysterectomy. 

Under  more  favorable  surroundings  this  patient 
would,  I  think,  have  been  better  off  by  total  extirpa- 
tion of  the  enlarged  and  useless  uterus. 

The  foetus  bore  evidences  of  being  at  the  fifteenth 
week  of  gestation.  The  membranes  were  not  rupt- 
ured. 

Tubal  Pregnancy — Diagnosis  before  Rupture — Ab- 
dominal Section — Cure. — Mrs.  Dora  G ,  twenty-four 

years  of  age,  was  brought  to  me  March  20,  1894,  by 
her  attending  physician,  Dr.  C.  Lengel,  of  Kansas  City, 
Mo.  She  was  married  at  sixteen,  and  had  a  miscar- 
riage at  third  month  at  seventeen  ;  no  trouble  followed. 
At  twenty-two  she  had  prolapsus  uteri,  cause  unknown, 
which  Dr.  Lengel  cured  by  local  measures,  non- opera- 
tive. Some  tubal  trouble  began  in  May,  1893 — pain, 
tenderness,  and  other  evidences  of  salpingitis,  with 
endometritis.  These  were  relieved  by  glycerine  tam- 
pons, application  of  iodine  to  the  cavity  of  the  uterus 
and  vault  of  the  vagina,  etc.  Menstruation  was  not  in- 
terrupted, but  continued  regularly  every  twenty-eight 
days  until  six  weeks  before  my  examination,  at  which 
time  the  usual  flow  did  not  appear,  nor  did  it  come  in 
another  twenty-eight  days.  Having  thus  missed  two  of 
her  periods,  and  feeling  the  usual  signs  of  pregnancy — 
nausea,  tenderness  of  the  breasts,  etc.,  she  naturally 
came  to  the  conclusion  that  she  was  enciente ;  but  she 
became  very  anxious  about  herself  on  account  of  a 
peculiar  sickening  pain  in  the  left  side  and  a  faintness 
from  time  to  time.  She  therefore  consulted  her  ])hy- 
sician.who  did  not  share  her  anxiety  until  March  iSth, 
when  a  uterine  hemorrhage  occurred,  not  exactly  like 
a  menstrual  discharge.  He  suspected  tubal  pregnancy 
and  so  called  me  into  the  case. 

Examination  showed  the  uterus  pushed  a  little  to 
the  right,  and  (I  thought)  some  enlargement  of  the 
left  tube  ;  a  bloody  discharge  from  the  uterus  ;  upon 
slightly  dilating  the  cervix  a  small  curette  was  easily 
introduced  and  brought  away  shreds  of  tissue  resem- 
bling the  decidua  vera.     There  being  such  evidences 


of  ectopic  pregnancy  I  had  the  patient  placed  in  St. 
Joseph's  Hospital,  where  I  operated  with  the  assistance 
of  Drs.  T.  B.  Thrush  and  J.  C.  Maxson.  The  left 
tube  was  found  the  seat  of  pregnancy,  neither  sac  nor 
tube  having  yet  ruptured  ;  it  was  readily  removed  with- 
out drainage,  and  convalescence  was  rapid. 

Now  why  did  I  make  the  diagnosis  of  tubal  preg- 
nancy and  operate  ?  Especially  why  did  I  have  the 
courage  to  operate  in  the  face  of  Lawson  Tait's  opinion 
that  diagnosis  before  rupture  is  almost  impossible  ?  In 
his  "  Lectures  on  Ectopic  Pregnancy,"  page  49,  Mr. 
Tait  says :  "  The  strangest  thing  to  me  is  that,  in  the 
enormous  experience  I  have  now  had  in  tubal  preg- 
nancy,^ I  have  never  but  once  been  called  upon  to 
make  an  examination  until  the  rupture  occurred,  and 
in  that  case  there  was  neither  history  nor  symptoms 
which  enabled  me  to  do  more  than  to  determine  that 
there  was  tubal  occlusion.  Under  these  circumstances 
I  think  I  may  be  excused  for  maintaining  a  somewhat 
sceptical  attitude  concerning  the  correctness  of  the 
diagnosis  of  those  gentlemen  who  speak  so  confidently 
of  making  a  certain  diagnosis  of  tubal  pregnancy  be- 
fore the  period  of  rupture.  The  great  bulk  of  the 
utterances  in  these  directions  may  stand  very  well  in 
'society  discussions,' but  they  will  not  stand  the  test  of 
'  bedside  experience.' " 

But  it  must  be  remembered  that  this  was  written  in 
1889,  and  at  a  time  when  the  advocates  of  puncture  of 
the  tube  and  destruction  of  the  foetus  by  electrolysis 
were  enthusiastic  in  pushing  their  theories,  and  were 
antagonizing  Mr.  Tait's  plan  of  treatment  by  coeli- 
otomy. 

In  five  years  there  were  great  advances  in  our 
knowledge  of  the  subject.  There  was  an  almost  uni- 
versal adoption  of  the  proposition  that  the  safety  of  the 
mother  lies  only  in  early  operation  ;  and  intelligent 
practitioners  everywhere  were  on  the  alert  for  such 
cases,  studying  carefully  every  case  of  pregnancy  in 
which  there  was  the  slightest  irregularity.  As  a  conse- 
quence of  this  increased  interest  and  closer  study  I 
knew  of  a  number  of  instances  in  which  a  diagnosis  had 
been  made  prior  to  rupture  '  and  the  correctness  of  the 
opinion  demonstrated  at  the  operation.  This  was  the 
first  point  that  influenced  me  in  favor  of  abdominal  sec- 
tion. 

The  second  point  in  favor  of  operation  was  that  the 
history  and  symptoms  pointed  almost  unmistakably  to 
tubal  pregnancy,  viz.,  the  woman  had  been  once  preg- 
nant ;  there  was  then  a  long  period  of  sterility,  with 
the  history  of  a  salpingitis — a  very  important  item  be- 
cause Tait  says  that  "  ectopic  gestation  is  alsvays  caused 
by  destruction  of  the  proper  epithelium  of  the  tube  by 
inflammation  "  (Lectures,  p.  5).  There  was  the  cessa- 
tion of  menstruation  and  symptoms  of  pregnancy  ;  the 
tube  on  one  side  was  enlarged  ;  there  was  no  foetus  in 
the  uterus,  which  was  bleeding,  but  there  were  evidences 
of  the  presence  of  the  decidua  vera — not  certain,  but 
reasonably  sure  ;  and  there  was  the  existence  of  the 
peculiar  pain  described  by  Joseph  Price  as  "  a  severe, 
paroxysmal  pain — a  sickening,  pelvic  pain  which  is 
neither  cramp-like  nor  colicky,  though  often  described 
by  these  terms."  ^ 

The  third  point  was,  there  was  unquestionably  some 
trouble  with  the  left  tube,  which  probably  demanded 
removal  ;  and  even  if  not,  there  was  practically  no 
danger  in  an  exploratory  operation  if  the  rules  of  per- 
fect asepsis  were  scrupulously  followed. 

A  noteworthy  feature  of  this  case  is  the  fact  that  the 
tenth  week  of  gestation  was  passed  without  the  least 
sign  of  probable  early  rupture  of  the  tube  or  of  the 
foetal  membranes. 

3312  Salisbury  Street. 

'  His  e-tperience  at  that  time  consisted  of  thirty-nine  operations 
with  two  deaths. — E.  L. 

»  Quite  a  number  of  these  cases  have  been  reported  in  Kansas  City 
and  St.  Louis  by  men  like  Crowell,  Cordier,  and  Summx 

»  Extra-uterine  Pregnancy,  p.  i6. 


572 


MEDICAL   RECORD. 


[September   14,  1895 


PAROVARIAN  CYST.  COMPLICATED  BY  THE 
PASSAGE  OF  RENAL  CALCULL  SIMULAT- 
ING AND  DIAGNOSED  AS  ECTOPIC  GES- 
TATION—OPERATION. 

By  KARL  W.  DOEGE,  M.D., 

MARSHFIHLO,  WIS. 

Axv  pathological  condition  simulating  a  trouble  of  as 
serious  a  nature  as  ectopic  gestation  should  command 
our  attention  immediately.  It  is  for  this  reason  that  I 
wish  to  report  the  following  case  : 

Mrs.  A.  H ,  aged  twenty-eight,  is  a  hard-working 

farmer  woman ;  mother  of  two  children,  the  oldest 
being  five  )'ears  of  age,  and  the  youngest  one.  Has 
menstruated  three  times  since  her  last  confinement, 
and  always  regularly,  the  flow  lasting  from  five  to  six 
days.  Her  last  menstrual  period,  which  occurred 
about  one  week  previous  to  the  commencement  of  her 
trouble,  did  not  last  as  long,  nor  was  the  flow  as  pro- 
fuse as  on  former  occasions.  While  feeling  in  perfect 
health,  and  after  having  assisted  at  harvesting  during 
the  da)',  she  was  suddenly  seized  with  severe  pain  dur- 
ing the  night,  wakening  her  from  her  sleep.  The  pain 
was  extremely  violent,  situated  in  the  right  side  and 
accompanied  by  profound  shock.  Seeing  her  about 
six  hours  from  the  commencement  of  her  trouble,  I 
found  her  covered  with  clammy  perspiration.  Hands 
.and  feet  were  cold.  She  was  shivering.  Expression 
of  face  pinched.  Pulse  92,  but  not  especially  weak, 
and  temperature  below  normal.  On  palpation  there 
was  great  sensitiveness  in  the  right  inguinal  and  hypo- 
gastric region.  The  vaginal  examination  was  not  satis- 
factory. On  account  of  the  extreme  tenderness,  only 
an  expression  of  abnormal  fulness  could  be  obtained. 
The  vault  of  the  vagina  to  the  left  of  the  cervix  con- 
tained a  number  of  enlarged  and  forcibly  pulsating 
arteries,  running  in  a  lateral  direction.  Patient  thinks 
herself  pregnant,  in  spite  of  having  menstruated  but  a 
week  ago.  No  urinary  symptoms  are  present.  With- 
out making  an  attempt  at  an  exact  diagnosis,  the 
rupture  of  a  blood-vessel  in  the  pelvis  was  thought 
probable,  and  treatment  applied  accordingly.  On  ac- 
count of  patient's  belief  of  pregnancy,  and  considering 
the  previous  slight  menstrual  variation,  the  enlarged 
and  tortuous  arteries  in  the  vault  of  the  vagina,  and 
fulness  of  the  latter,  the  diagnosis  of  ectopic  gestation 
was  held  in  reserve,  to  be  verified  or  disproved,  if  pos- 
sible, at  a  future  examination. 

The  passage  of  a  renal  calculus  was  thought  of,  but 
rejected,  there  being  no  urinary  symptoms  of  any  kind. 
Instructions,  however,  were  given  to  watch  the  urine 
for  the  next  two  or  three  days.  Under  rest,  cold,  and 
morphine,  the  pain  and  sensitiveness  gradually  sub- 
sided after  three  days,  the  patient  feeling  perfectly 
well.  No  calculi  were  discovered.  She  failed  to  ap- 
pear for  subsequent  examination. 

Next  month  she  menstruated  in  due  time,  but  again 
not  as  usual.  This  time  the  flow  was  prolonged,  not 
as  free,  and  interrupted  repeatedly.  No  membrane 
was  passed  and  no  discomfort  felt  while  flowing.  The 
day  following  the  ceasing  of  the  flux  she  again  was 
seized  by  an  attack  exactly  like  the  one  four  weeks 
ago.  The  shock  this  time  was  probably  not  as  severe 
as  before.  Under  similar  treatment  this  also  passed 
off  in  four  days,  but  recovery  did  not  appear  to  be  as 
complete  as  heretofore,  slight  jars  while  walking  caus- 
ing uneasiness  in  lower  part  of  abdomen. 

A  week  later  she  jiresented  herself  for  examination. 
On  palpation  a  fulness  and  sensitiveness  of  the  right 
inguinal  and  hypogastric  region  could  be  made  out. 
On  bimanual  examination  a  tense,  clearly  cystic  tumor 
was  felt,  located  almost  centrally.  It  seemed  to  be 
the  size  of  an  orange,  slightly  movable,  lying  close  to 
the  left  of  the  uterus,  very  sensitive  to  pressure,  and 
was  coursed  by  large  tortuous  arteries  at  its  lower  pres- 


entation.    The   uterus  was  slightly  enlarged   and  its 
fundus  pushed  well  into  the  right  inguinal  region. 

Considering  the  paroxysmal  and  tearing  nature  of 
the  pain,  the  presence  of  a  tumor,  the  tortuous  blood- 
vessels, the  enlarged  uterus,  and  the  slight  menstrual 
disturbances,  ectopic  gestation  was  thought  highly- 
probable  and  an  operation  urged. 

A  week  later  she  came  to  St.  Joseph's  Hospital,  and 
assisted  by  Drs.  Lathrop  and  Budge  I  opened  the  ab- 
domen, and  a  cyst  about  the  size  of  an  orange  was 
found.  It  was  coursed  by  numerous  blood-vessels. 
Its  walls  were  thin  and  transparent,  showing  dark 
and  bloody  contents.  It  proved  to  be  a  parovarian 
cyst.  While  trying  to  shell  it  out  from  its  serous  cov- 
ering it  broke.  A  smart  hemorrhage  followed,  which 
was  readily  controlled  by  clamping  its  base.  Three  or 
four  smaller  cysts  were  seen  and  removed  with  it.  The 
left  and  right  tubes  were  healthy.  The  cyst  wall  after 
excision  showed  a  dark  bloody  spot,  about  the  size 
of  a  twenty-five  cent  piece,  where  undoubtedly  a  rupt- 
ure of  a  blood-vessel  had  taken  place,  thus  accounting 
for  the  bloody  contents. 

The  findings  certainly  disproved  our  diagnosis  of 
ectopic  gestation.  On  the  other  hand,  they  did  not 
offer  a  quite  satisfactory  explanation  as  to  the  exact 
cause  of  her  two  previous  attacks.  Even  with  the  un- 
doubted fact  that  hemorrhage  had  taken  place  into  the 
cyst,  and  assuming  the  woman  to  be  of  a  highly  sensi- 
tive disposition,  it  was  not  probable  that  so  severe  a 
pain  and  signs  of  collapse  should  be  caused  by  a  slight 
intra-cystic  hemorrhage. 

The  woman  made  an  uninterrupted  recovery.  She 
was  to  leave  the  hospital  on  the  twenty-first  day.  The 
evening  before  her  expected  departure  she  expressed 
to  one  of  the  nurses  a  desire  to  stay  in  the  hospital  a 
little  longer,  her  home  environments  not  being  quite  as 
cheerful  as  could  be.  Two  hours  later  she  began  to 
complain  of  severe  and  darting  pains,  similar  to  those 
of  her  previous  attacks,  only  situated  a  little  higher, 
just  below  the  ribs.  There  was  again  the  same  collapse 
and  the  same  cold  perspiration,  though  not  as  severe  as 
formerl)'.  Morphine  quieted  her,  and  she  was  better 
the  next  morning.  No  urinary  symptoms,  except  a 
moderate  frequency  of  micturition  on  the  day  previous 
to  the  attack,  had  been  observed.  The  immediate 
result,  however,  was  that  she  stayed  in  the  hospital  a 
little  longer.  Since  that  day,  however,  I  regarded  her 
very  sceptically,  believing  her  hysterical  and  simulat- 
ing the  attacks.  After  one  week  she  left  the  hospital,] 
and  expressed  herself  as  feeling  well,  with  neither  paia] 
nor  tenderness. 

.\bout  three  weeks  later  her  husband  entered  my 
office  one  morning  and  presented  me,  at  the  request  of 
his  wife,  with  something  that  she  evacuated  from  her 
bladder  about  a  week  previous.  It  had  been  passed 
with  considerable  pain  and  much  straining.  I  beheld 
a  typical  vesicular  calculus,  not  quite  round,  a  little 
larger  than  a  lemon- seed.  It  was  white  in  color,  and 
from  its  surface  were  seen  protruding  three  smaller 
calculi,  evidently  renal  in  origin,  about  the  size  of  a 
hemp-seed  each,  and  yellowish  brown  in  appearance. 
This  little  stone  to  me  told  quite  a  story.  Whatever 
had  been  doubtful  and  mysterious  about  the  case  was 
certainly  now  as  clear  as  day.  We  had  a  case  of  paro- 
varian cyst  complicated  by  the  passage  of  renal  calculi. 

.A.S  regards  the  tardy  appearance  of  these  calculi  we 
have  two  possibilities  :  i.  The  calculi  of  the  first  two 
attacks  may  have  been  passed  unnoticed.  Those  of 
the  third  attack,  i.e..  after  the  operation,  there  being 
several  in  number,  were  retained  in  the  bladder,  be- 
cause the  woman  always  occupied  a  recumbent  post- 
ure and  used  a  bedpan  for  urinating.  Under  these | 
circumstances  the  calculi  would  not  be  very  apt  to 
pass,  gravitating  as  they  would  to  the  posterior  part  o^ 
the  bladder.  Here  they  came  in  contact  with  eac 
other,  and  were  finally  encrusted,  thus  forming  a  single 
vesicular  calculus,  which,  after  the  woman  had  left  her 


Sepiember   14,  1S95I 


MEDICAL    RECORD. 


bed,  began  to  cause  trouble  and  was  eventually  passed. 
2.  We  may  assume  the  existence  of  a  slight  ectasic 
condition  of  the  bladder.  The  calculus  of  each  of  the 
three  attacks  (there  being  three  renal  calculi  in  the 
specimen)  were  retained  in  a  little  pocket,  were  en- 
crusted, and  finally  evacuated  as  a  single  object. 

We  might  well  ask  ourselves  how  could  we  have  avoid- 
ed our  error  before  and  how  after  the  operation  ?  Be- 
fore the  operation,  there  being  a  complete  absence  of 
all  urinary  symptoms,  the  probabilit)-  certainly  pointed 
very  strongly  toward  ectopic  gestation.  After  the 
operation  the  discrepancy  between  the  small  cystic 
hemorrhage,  which  in  reality  caused  little  or  no  pain, 
and  the  previous  stormy  paroxysmal  attacks,  should 
have  put  us  on  our  guard,  thus  preventing  the  diag- 
nosis of  hysteria. 

To  be  just  to  myself  I  may  state  that  at  the  last  at- 
tack I  again  did  think  of  calculus,  yet  dropped  that 
possibility  for  the  more  convenient  hysteria,  the  latter 
certainly  offering  the  easiest  way  out  of  the  dilemma. 

I  have  reponed  the  above  case  because  in  mv 
opinion  these  coincidences  should  be  thought  of  in  ail 
such  cases  of  supposed  ectopic  gestation  where  the 
symptoms  do  not  make  an  exact  diagnosis  possible. 
Besides  their  practical  value,  theoretically,  such  dis- 
criminapons  are  highly  satisfactory  and  pleasing. 

/  


RHEUM-\TISM  AS  A  CAUSE  OF  APPENDI- 
CITIS :  POINTS  IN  ITS  MEDICAL  TREAT- 
MENT. 

By  BEVERLEY  ROBIXSOX.  M.D., 

KEW   YORK. 

The  etiology  of  appendicitis  in  many  instances  is  still 
very  obscure,  both  for  physicians  and  surgeons.  It  is 
therefore  satisfactory  to  become  convinced,  by  careful 
clinical  observation,  that  one  has  found  an  obvious  and 
frequent  cause  of  numerous  cases  of  a  disease  which  is 
frequently  fatal. 

To  my  mind  this  cause  is  rheumatism.  The  judg- 
ment I  now  hold  definitely  about  this  matter  is  not  an 
opinion  reached  rapidly  and  without  carefully  weighing 
the  observations  and  reports  of  others.  After  several 
years  of  close  inquiry  into  the  origin  of  those  cases  I 
have  met  with  or  read  about,  I  have  not  been  able  tci 
explain  apparently  inconsequent  facts  from  any  other 
stand-point.  I  do  not  remember  personally  to  have 
seen  an  attack  of  acute  articular  rheumatism  either  di- 
rectly precede  or  follow  evident  signs  of  appendicitis. 
and  to  be  connected  with  it  in  such  a  way  that  the  re 
lation  of  the  two  affections  was  clearly  defined.  Al- 
though this  statement  is  correct  of  my  own  experience. 
it  is  not  true  of  others.  And  already  more  than  one 
such  report  has  been  made.  AMien  it  comes  to  the 
milder,  and,  according  to  some,  perhaps  less  character- 
istic symptoms  of  rheumatism,  these  I  have  repeated!) 
observed  in  patients  who  have  had  one  or  more  attacks 
of  appendicitis.  Again,  I  have  seen  more  than  one  pa- 
tient who,  subsequent  to  attacks  of  appendicitis,  have 
had  decided  articular  manifestations,  and,  during  many 
years  of  this  rheumaric  localization,  the  appendical  re- 
gion has  remained  entirely  free  from  any  inflammatory 
disease. 

There  is  really  nothing  rational  to  urge  against  rheu- 
matism as  a  frequent  cause  of  appendicitis.  That  rheu- 
matic inflammation  should  attack  this  region  very  often 
is  only  what  we  should  expect,  if  we  consider  the  clcse 
relationship  of  the  appendix  with  the  peritoneum  :  and 
the  fact  that  this  serous  membrane,  like  the  pleura  or 
the  pericardium,  is  precisely  the  structure  for  which 
rheumatism,  when  it  leaves  the  joints,  has  a  special  pre- 
dilection. 

The  sudden  development  of  many  examples  of  acute 
appendicitis  does  not  in  any  degree  militate  against 


rheumatism  as  an  efficient  and  frequent  cause  of  it, 
since  the  sudden  and  rapid  development  of  acute 
rheumatic  inflammation  is  true  of  the  tonsils,  the 
ovaries,  the  uterine  appendages,  and  the  joints  them- 
selves. The  rapid  progress  toward  suppuration  is  no 
reason  to  rule  aside  my  explanation,  since  acute  quinsy 
Nvith  suppuration,  now  well  known  to  be  of  rheumatic 
origin — as  salpingitis  with  speedy  formation  of  an 
abscess  cavity  of  like  origin — is  no  uncommon  find- 
ing. 

No  doubt  in  many  cases  which  I  might  easily  re- 
port, exception  could  be  taken  by  the  reader  to  my 
diagnosis  of  the  rheumatic  cause  of  appendicitis,  in 
\'iew  of  possible  error  of  interpretation.  Here,  again, 
as  in  most  things  medical — panicularly  where  clinical 
manifestations  are  seemingly  doubtful  until  repeated 
experience  has  corroborated  proof — we  are  forced 
to  apply  the  touchstone  of  wise  therapeutic  inter- 
ference. In  this  connection  I  cannot  but  aflSrm  that 
treatment  with  salicin,  or  the  salicylates,  in  sufficient 
and  frequently  repeated  doses,  has,  in  my  experience, 
diminished  pain  and  inflammatory  manifestations  in 
the  appendical  region  more  frequently  than  any  other 
routine  method  of  treatment.  In  many  cases,  I  am 
now  thoroughly  convinced,  suppuration  has  by  this 
means  been  mainly  avoided.  Not  that  other  remedial 
measures  of  a  suitable  kind  should  not  be  instituted. 
Among  these  I  place  as  verj-  important  liquid,  or  low 
diet,  and  relative  rest.  In  very  acute  cases,  of  course, 
with  pronounced  fever  and  vomiting,  entire  rest  in  bed, 
and  liquid  diet  solely,  are  imperatively  required.  In 
these  instances,  moreover,  I  would  insist  in  the  begin- 
ning upon  the  local  application  of  poultices,  or  the  ice- 
coil,  or  ice-bag.  I  usually  prefer  repeated  poultices,  as 
I  believe  them  more  suitable  to  resolution  of  rheumatic 
inflammation.  -A.gain,  I  should  rely  upon  moderately 
large  laxative  enemata  to  free  up  constipated  bowels  in 
those  persons  who  have  very  marked  general  reaction. 
In  numerous  instances,  I  am  equally  satisfied,  where 
the  general  reaction  is  not  so  pronounced,  a  mercurial 
in  the  form  of  six  or  eight  grains  of  gray  powder,  or 
an  equal  dose  of  blue  mass,  serves  a  better  purpose. 
I  do  not  believe  it  increases  the  danger  to  the  parient, 
as  I  do  not  believe  it  increases  the  peristaltic  action  of 
the  bowels  to  any  appreciable  extent,  and  I  am  of  the 
opinion  that  it  promotes  the  flow  of  bile,  which,  in 
more  ways  than  one,  is  directly  useful.  Of  course, 
in  some  cases  where  pain  is  very  severe,  anodynes 
should  be  resorted  to,  and  in  extreme  instances  of  this 
kind  hypodermic  injections  of  morphine  are  our  final 
resort.  Yet  let  us  bear  in  mind  that  like  the  opera- 
tion itself,  unless  obviously  called  for,  it  is  bad  treat- 
ment— radically  bad — if  my  belief  in  regard  to  the 
causation  of  many  cases  of  appendicitis  be  correct  and 
sustained. 

I  cannot  but  think,  even  as  I  write,  of  an  opinion 
held  by  one  of  our  most  eminent  surgeons,  viz.,  that  in 
prescribing  a  drug  the  same  care  and  knowledge  should 
be  exercised  as  in  performing  a  severe  surgical  opera- 
tion. Evidently  the  thought  passing  through  the  mind 
of  this  great  exponent  of  his  side  of  the  question,  was 
the  distinct  conviction  of  the  untold  harm  accomplished 
by  ignorant  interference,  seemingly  trivial  in  character. 
Now,  morphine,  of  all  drugs,  is  the  one  that  locks  up 
most  rapidly  and  completely  our  secretory  functions. 
It  is  true  of  the  kidneys,  the  stomach,  the  bowels,  the 
liver,  the  respiratory  organs,  in  one  way  or  another. 
How,  then,  can  it  be  rational,  when  we  wish,  above 
all  things,  to  promote  and  further  rapid  secretion 
and  excretion,  to  employ,  in  very  active  manner  and 
doses,  the  drug  that  arrests  it  all  ?  Pain  is  present, 
is  the  answer,  and  pain  must  be  subdued.  Yes,  I 
reply,  but  make  the  attempt  first  of  all,  and  as  long  as 
you  should,  with  drugs  that  will  not  be  manifestly 
harmful.  Codeine,  in  frequent  and  sufficient  doses,  will 
often  advantageously  take  the  place  of  morphine.  It 
does  not  lock  up  secretions  to  anything  like  the  same  ce- 


174 


MEDICAL   RECORD. 


[September    14,  1895 


gree  ;  it  does  not  nauseate  or  constipate  much,  as  a  rule. 
It  does  mitigate,  and  sometimes  abolish,  pain.  It  allows 
time  to  be  utilized  so  as  to  use  the  proper  remedial 
drug — viz.,  salicylate  of  soda — and  thus  it  guards  the 
patient  not  infrequently  against  surgical  interference, 
which  is  the  ruling  spirit  of  the  hour.  I  do  not  wish 
to  be  considered  as  one  of  those  who  object  at  all  to 
laparotomy  in  appendical  inflammation,  when  surgical 
interference  is  called  for.  I  do  wish  at  this  time  to 
point  out  the  medical  way  in  which  much  that  is 
beneficial  may  result,  and  considerable  harm  may  be 
avoided. 

In  conclusion,  I  would  add  that  local  depletion  with 
leeches,  or  wet  cups,  over  the  painful  region,  in  pa- 
tients of  full  habit,  remains  at  present,  as  during  the 
past,  a  proper  and  judicious  abortive  treatment  of  ap- 


pendicitis. 


/ 


^^ 


THE  ACTION  OF    THE    DIPHTHERIA   ANTI- 
TOXIN   UPON    THE    KIDNEYS. 

By  WILLIAM  VISSMAN,  M.D., 

NEW  YORK  CITV. 

LECTURER  OS    P.\THOLOGY   AND    CLINICAL  MICROSCOPY    IN    THE    NEW  YORK  POLY- 
CLINIC. 

As  is  well  known,  the  mortality  from  diphtheria  is  ex- 
ceedingly variable,  ranging  from  about  twenty  to  sev- 
enty per  cent.,  according  to  locality  and  the  character 
of  the  epidemic.  From  time  to  time  new  remedies 
have  been  asserted  to  be  specifics,  only  to  lose  their 
"  specific  "  qualities  with  the  next  succeeding  epi- 
demic. 

We  were  rather  certain  as  to  the  etiology  of  the  dis- 
ease in  question,  until  some  of  the  opponents  of  diph- 
theria antitoxin  began  to  question  the  causative  re- 
lation of  the  Loeffler  bacillus.  At  all  events  the 
opponents  have  shown,  and  some  of  the  most  ardent 
bacteriologists  (Loeffler,  Fraenkel,  and  others)  agree, 
that  the  Loeffler  bacillus  is  not  found  in  every  case  of 
diphtheria  ;  furthermore,  that  it  is  found  in  the  throats 
of  healthy  individuals,  -•^gain,  we  must  admit  that, 
when  lower  animals  are  inoculated  with  ihis  organism, 
they  do  not  manifest  the  same  anatomical  lesions 
found  in  persons  suffering  with  true  diphtheria.  It  is 
true<  if  we  remove  the  epithelium  from  the  mucous 
membrane  of  the  vagina  of  a  guinea-pig,  and  then  in- 
fect the  denuded  surface  with  the  Loeffler  bacillus,  a 
pseudo-membrane  is  formed  ;  but  it  differs  from  tlie 
pseudo-membrane  formed  in  true  diphtheria  of  man 
in  that  it  remains  confined  to  the  seat  of  inoculation, 
while  in  man  it  spreads  rapidly.  However,  it  is  not 
our  aim  to  fully  discuss  the  etiology  of  diphtheria  in 
this  place. 

From  the  voluminous  literature  upon  the  treatment 
of  diphtheria  with  antitoxin,  we  find  that  the  views  of 
the  effect  of  the  serum  treatment  are  vastly  different. 
The  statistics  of  some  clinicians  show  excelient  results 
with  this  treatment,  while  others  show  little  or  no  bet- 
ter results  than  those  obtained  without  its  use.  Still 
others  report  most  excellent  results  from  the  employ- 
ment of  other  methods.  Some  of  these  results  are  as 
follows  :  Baginsky  used  antitoxin  in  303  cases,  with  40 
deaths  ;  and  in  230  cases  treated  with  other  remedies 
there  were  no  deaths.  Caiion  treated  44  cases  with 
antitoxin,  and  75  per  cent,  recovered  ;  of  66  cases 
treated  with  other  remedies,  70  per  cent,  recovered. 
Sonnenburg  employed  serum  in  95  cases,  with  79.4  per 
cent,  recoveries  ;  and  in  116  cases  treated  by  other 
methods  there  were  72.4  per  cent,  recoveries.  Gutt- 
mann  treated  Si  cases  with  ])ilocarpin,  and  all  recov- 
ered. Aufrecht  used  chlorate  of  potassium,  internally 
and  as  a  mouth  wash,  in  264  cases,  with  but  i  death. 
With  good  nourishment  and  cleansing  the  mouth,  K.ust 
treated  144  cases,  with  a  mortality  of  12. 

From  the  vast  difference  in  the  virulence  of  various 


epidemics,  it  is  plain  that  the  statistics  now  at  hand  are 
not  sufficient  to  warrant  any  definite  conclusion  as  to 
the  merits  of  antitoxin  in  the  treatment  of  diphtheria. 
Hence  we  must  consider  the  effects  in  individual  cases. 
But  here,  too,  we  find  competent  observers  reporting 
very  different  results.  Some  have  seen  the  disease 
vanish  as  if  by  magic  ;  others  have  seen  their-  cases  re- 
cover gradually  ;  and  others,  again,  have  seen  little  or 
no  effect,  or  an  ill  effect. 

Nearly  all  are  agreed  that  there  are  certain  disagree- 
able results  from  its  use  in  some  cases,  .\mong  these 
complications  are  erythema,  hemorrhages  in  the  skin, 
heart  weakness,  pain  in  the  joints  with  or  without 
swelling,  which  ma)'  last  for  several  days.  A  few  have 
observed  albuminuria  more  frequently,  others  less  fre- 
quently, while  still  others  consider  albuminuria  an  in- 
dication for  the  administration  of  more  antitoxin. 
Since  albuminuria  is  rather  a  frequent  complication  of 
diphtheria,  it  is  rather  difficult  to  determine  whether  it 
is  the  result  of  diphtheria  or  the  antitoxin. 

To  obtain  light  upon  the  effect  of  antitoxin  on  the 
kidneys,  diphtheria  antito.xin,  kindly  furnished  by  Dr. 
Paul  Gibier,  of  this  city,  was  injected  into  healthy  rab- 
bits. Upon  the  suggestion  of  Dr.  Gibier  an  effort  was 
made  to  collect  the  urine  from  the  animals  for  exam- 
ination previous  to  the  experiments.  This,  however, 
was  not  accomplished.  Consequently,  every  animal  was 
accompanied  by  a  control  animal.  The  animals  were 
divided  into  two  series,  the  first  series  into  two  groups 
of  six  animals  each.  The  animals  used  (rabbits) 
weighed  between  three  and  four  and  a  half  pounds. 
In  the  first  group  of  the  first  series  each  animal  re- 
ceived an  injection  of  i  c.c.  of  antitoxin.  In  the  sec- 
ond group,  each  animal  received  2  c.c.  In  the  second 
series  (three  animals)  each  received  i  c.c.  on  three  con- 
secutive days.  In  both  groups  of  the  first  series  an 
animal  was  killed  each  day,  until  the  groups  were  ex- 
hausted. In  the  second  series,  after  the  third  injection 
one  animal  was  killed  every  day  until  the  group  was 
destroyed.  As  the  character  of  the  lesions  was  the 
same  in  all  of  the  animals,  varying  in  intensity  with  the 
size  of  the  dose  administered,  it  will  not  be  necessary 
to  give  a  detailed  account  of  the  changes  observed  in 
each  animal.  .\t  the  site  of  injection  there  was  a  nod- 
ule which  extended  over  a  radius  of  about  an  inch  from 
the  point  where  the  needle  had  entered.  The  nodule 
was  slightly  painful  on  pressure,  but  the  general  condi- 
tion of  the  animals  was  good  so  far  as  could  be  ob- 
served. .\t  the  end  of  the  second  day  the  lump  began 
to  grow  smaller,  and  was  scarcely  perceptible  on  the 
animals  killed  on  the  seventh  day  after  the  injection. 

On  cutting  through  the  nodule  the  subcutaneous  tis- 
sue was  found  to  be  impregnated  with  a  straw-colored, 
serous  fluid,  containing  very  few  leucocytes.  Part  of 
this  fluid  was  used  for  inoculating  glycerine  agar  and 
gelatine,  but  at  the  end  of  three  days  no  growth  had 
appeared.  As  time  elapsed,  the  cudema  grew  less 
marked,  but  the  fluid  was  always  found  to  be  sterile. 

As  the  object  of  the  investigations  was  to  determine 
the  action  of  antitoxin  upon  the  kidneys,  little  attention 
was  paid  to  other  organs,  more  than  to  note  that  the 
spleen  and  liver  were  slightly  swollen  and  redder  than 
normal. 

The  kidneys  of  the  animals  killed  twenty- four  hours 
after  the  injections  were  very  firm,  and  of  a  dark-red 
color.  On  the  cut  surface  the  cortical  substance  was 
very  much  injected,  slightly  opaque,  and  a  little  more 
prominent  than  the  medullary  substance,  which  was 
pale  in  color. 

(^n  microscopic  examination  of  fresh  sections  in  0.6 
per  cent,  salt  solution,  the  Malpighian  bodies  and 
capillaries  of  the  cortex  were  found  to  be  distended 
with  blood.  The  epithelial  cells  of  the  tubules  were 
filled  with  refractive  granules  obscuring  the  nuclei, 
which  were  only  brought  to  view  by  the  addition  of 
dilute  acetic  acid.  There  were  no  casts  found  in  the 
tubules.     These  conditions  were  found  in  all  of  the 


September   14,  1S95] 


MEDICAL  RECORDc 


0/  o 


animals,  and,  as  the  time  after  the  administration  of 
the  antitoxin  increased,  the  injection  of  the  blood- 
vessels decreased  and  the  cloudy  swelling  became  more 
prominent. 

In  the  animals  of  the  second  series,  the  only  differ- 
ence discernible  was  that  the  injection  of  the  capil- 
laries was  more  pronounced,  and  that  there  were  a  few 
slight  hemorrhages  into  the  tubules.  Fatty  metamor- 
phosis of  the  epithelium  was  not  observed  in  a  single 
instance.  It  is  highly  probable  that,  had  these  sec- 
tions been  subjected  to  fi.xing  by  alcohol,  or  other  fix- 
ing agents,  the  cloudy  swelling  above  described  would 
have  been  overlooked. 

Since  the  doses  administered  to  the  rabbits  were 
about  equal,  or  a  trifle  less,  proportionately,  than  the 
doses  administered  to  children  in  cases  of  diphtheria, 
it  is  reasonable  to  suppose  that,  approximately,  the  same 
changes  are  brought  about  in  children  when  antitoxin 
is  administered.  Certainly,  this  is  assuming  that  a 
pound  of  rabbit  is  equivalent  to  a  pound  of  human 
subject  !  Yet,  this  is  no  greater  assumption  than  the 
first  use  of  the  remedy  was  based  upon. 

Strangely  enough,  the  facts  first  adduced  by  Behring, 
and  repeated  by  Roux,  Parks,  Biggs,  and  others,  have 
received  very  little  consideration.  These  observers, 
after  ascertaining  exactly  how  much  antitoxin  was  re- 
quired to  neutralize  a  certain  amount  of  toxin,  found 
that  if  a  definite  dose  of  toxin  was  introduced  with  a 
definite  dose  of  antitoxin,  the  animals  suffered  very 
little.  If  antitoxin  was  introduced  about  twelve  hours 
before  the  toxin,  the  animals  recovered.  But  if  the 
order  was  reversed,  i.e.,  the  toxin  given  twelve  hours 
before  the  antito.xin,  recovery  was  not  the  rule.  The 
animals  generally  succumbed  to  the  effects  of  the 
toxin.  These  experiments,  carried  out  by  the  above- 
named  authors,  indicate  that  antitoxin  has  a  certain 
antidotal  effect  when  administered  with,  or  very  shortly 
before,  the  toxin  ;  but  after  the  toxin  has  once  begun 
to  affect  the  organism,  the  antitoxin  has  but  slight,  if 
any,  power  of  neutralizing  its  ill  effects.  On  the  con- 
trary, the  experiments  forming  the  subject  of  this 
paper  would  indicate  that  the  antitoxin  has  a  harmful 
influence,  in  that  it  impairs  the  health  of  the  organism 
and  would,  consequently,  reduce  the  power  to  resist 
the  inroads  of  the  disease. 

As  for  the  immunizing  power,  experience  thus  far 
has  produced  very  little  encouragement.  To  begin 
with,  any  number  of  persons  have  had  diphtheria  with 
all  of  its  concomitant  dangers,  and  this,  too,  in  as  short 
a  time  as  twenty-four  hours  after  the  administration  of 
supposed  immunizing  dose  of  antitoxin.  Again,  all 
admit  that  its  immunizing  powers  are  of  but  a  transi- 
tory nature  ;  indeed,  it  is  of  so  short  duration  that,  in 
almost  all  cases,  it  ceases  long  before  the  diphtheria 
bacilli  disappear  from  the  fauces  or  lose  their  viru- 
lence. From  this  it  would  seem  that,  if  antitoxin  is 
injected  a  very  short  while  before  the  patient  begins  to 
manifest  diphtheria,  i.e.,  before  the  pseudo-membrane 
is  formed  and  before  the  real  effect  of  the  toxin  be- 
comes apparent,  the  patient  may  possibly  be  benefited  : 
but  since  a  large  number  of  individuals  have  Loetfler 
bacilli  in  their  fauces  without  suffering  any  embarrass- 
ment at  any  time,  it  is  impossible  to  determine  which 
of  these  persons  should  or  should  not  receive  the 
serum. 

Since  the  injection  of  serum  into  rabbits  produces  a 
cloudy  swelling  of  the  kidneys,  or  an  acute  nephritis, 
as  shown  above,  if  all  of  these  persons  having  viru- 
lent diphtheria  bacilli  in  their  fauces  were  treated  with 
antitoxin,  many  would  be  injured  for  an  uncertain 
benefit  to  a  very  few.  After  the  disease  has  made 
such  progress  that  it  can  be  diagnosed,  the  toxin  has 
produced  such  an  effect  upon  the  organism  that,  judg- 
ing from  the  experiments  of  Behring,  Biggs,  Parks,  and 
others,  little  benefit  is  to  be  expected  from  antitoxin. 
And  since  observing  the  results  of  experiments  just 
reported  on  rabbits,  it  is  highly  probable  that,  instead 


of  reducing  the  mortality  of  diphtheria,  antitoxin  has 
really  increased  the  death-rate. 

244  West  139TH  Street. 


A  CASE  OF  PERFORATIVE  APPEXDICITIS 
WITH  GENERAL  PURULENT  PERITONI- 
TIS—OPERATION— RECOVERY."^ 

By  FR.\>;K  D.  gray,  M.D., 


ATTENDING 


TO    CHRIST   HOSPITAL,    JERSEY    CITY,   N.  J. 


The  time  has  probably  passed  when  every  instance  of 
appendicitis  is  worthy  of  special  record,  but  certain 
interesting  and  somewhat  unusual  features  of  the  fol- 
lowing case  make  it,  I  think,  of  value  to  those  of  the 
profession  who  are  interested  in  the  subject : 

J.  E.  R ,  aged  twenty-nine,  colored,  Pulman  por- 
ter, applied  to  me  at  my  office  on  the  evening  of  April 
9,  1895,  for  relief  of  severe  abdominal  pain  located 
just  at  the  right  of  the  umbilicus.  He  had  suffered 
since  early  that  morning,  having  felt  perfectly  well  the 
day  before.  Being  in  Washington,  D.  C,  he  applied 
at  a  pharmacy  and  was  given  a  dose  of  castor-oil,  which 
had  no  effect  except  to  produce  emesis.  He  attended 
to  his  duties  on  the  trip  from  Washington  to  New 
York  that  day,  although  in  much  pain  and  having  sev- 
eral attacks  of  vomiting.  There  was  no  history  of 
previous  attacks  of  the  kind. 

Temperature  per  orem  was  noniial  and  pulse  80. 
There  was  no  tenderness  on  pressure  in  either  iliac 
region — in  fact,  the  patient  claimed  that  pressure  over 
the  seat  of  greatest  pain  relieved  instead  of  aggravat- 
ing it.  Constipation  had  existed  for  several  days  and 
a  hearty  meal  of  rather  indigestible  food  had  been 
eaten  the  previous  evening. 

In  view  of  this  history  I  diagnosed  intestinal  colic, 
consequent  on  an  acute  attack  of  indigestion  ;  admin- 
istered one- fourth  grain  of  morphine,  hypodermically, 
and  prescribed  an  active  cathartic  to  be  taken  on  re- 
tiring. I  saw  the  patient  next  morning  at  his  room 
and  found  him  but  little,  if  any,  relieved  ;  the  bowels 
had  not  moved — the  pain  still  was  persistent  and  of 
the  same  character  as  before,  with  absence  of  tender- 
ness ;  temperature  per  orem  still  normal,  and  pulse 
about  eighty.  With  the  idea  that  free  catharsis  would 
give  relief,  I  ordered  drachm  doses  of  magnesia  sul- 
phate, to  be  given  hourly  until  the  bowels  moved,  and 
hot  fomentations  applied  to  the  abdomen. 

At  8  o'clock  that  evening  I  received  an  urgent  call 
to  this  case  and  on  my  arrival  found  the  patient  in  a 
condition  of  partial  collapse,  bathed  in  cold  perspira- 
tion, pulse  rapid  and  thready,  temperature  102.3°  F. 
per  rectum,  and  suffering  excruciating  pain,  with  ex- 
quisite tenderness  over  the  whole  abdomen  and  con- 
siderable tympanites.  I  at  once  realized  that  I  now 
had  to  deal  with  a  case  of  intestinal  perforation  from 
some  cause,  most  likely  perforative  appendicitis,  and 
that  the  only  hope  for  my  patient  lay  in  an  immediate 
cceliotomy. 

The  surroundings  at  his  home  being  unfavorable  for 
such  an  operation,  I  had  him  transferred  at  once  to 
Christ  Hospital,  where  he  arrived  at  10.30  p.m.  and  at 
II  p.-M.  I  operated,  having  associated  with  me  Dr.  (i. 
K.  Dickinson,  of  the  surgical  staff.  Dr.  J.  M.  Rector, 
and  the  house  staff. 

Owing  to  the  uncertainty  as  to  the  exact  location  of 
the  lesion  and  the  great  probability  of  finding  general 
infection  of  the  peritoneum,  I  adopted  a  median  incis- 
ion (about  three  and  one-half  inches  in  length).  On 
opening  the  peritoneal  cavity  I  found  the  intestines 
deeply  congested,  dotted  with  numerous  small  patches 
of  adherent  lymph,  and  bathed  in  a  quantity  of  sero- 
purulent  fluid.  The  mesenteric  glands  were  already 
much  engorged,  in  fact  all  the  appearances  of  a  severe 

'  Read  before  the  Hudson  County  Medical  Society  June  4,  1895. 


376 


MEDICAL  RECORD. 


[September  14,  1895 


general  purulent  ])eritonilis  were  present.  1  found  the 
appendix  only  moderately  thickened,  with  but  slight 
adhesions  to  the  adjoining  intestine  and  none  to  the 
abdominal  wall.  It  was  perforated  and  contained  a 
concretion  closely  resembling  a  date-seed  in  general 
appearance.  In  spite  of  this  very  unpromising  state  of 
affairs  we  proceeded  with  as  much  care  as  if  we  had' 
every  reason  to  expect  recovery,  though  I  must  con- 
fess that  we  all  feared  it  to  be  a  routine  that  would  be 
of  little  use  to  our  patient.  The  appendix  was  ligated 
and  removed,  its  lumen  disinfected  with  ninety  per  cent, 
carbolic  acid  and  closed  with  Lembert  sutures,  the  in- 
testines were  thoroughly  washed  with  large  quantities 
of  warm  sterilized  water  poured  upon  them,  and  the 
abdominal  cavity  carefully  dried,  down  to  the  depths 
of  the  pelvis,  by  sterilized  sponges.  A  large  iodoform- 
gauze  drain  was  introduced,  without  a  tube,  well  down 
to  the  bottom  of  the  pelvis  and  brought  out  at  the 
lower  angle  of  the  incision.  A  large  portion  of  the  intes- 
tinal canal  had  escaped  from  the  abdominal  cavity  dur- 
ing the  operation  and  was  protected  by  warm  sterilized 
gauzes.  Owing  to  distention  of  the  bowels  this  was 
returned  with  considerable  difficulty  and  the  wound 
closed  with  silkworm  sutures.  The  patient  rallied 
well,  having  but  little  shock,  and  rested  well  through 
the  night,  with  no  vomiting.  No  nourishment  was  al- 
lowed until  5.30  P.M.,  when  he  took  and  retained  a 
half  ounce  of  peptonized  milk  every  hour. 

On  the  third  and  fourth  days  after  operation  there 
were  occasional  attacks  of  green  vomiting  accompanied 
by  hiccough,  which  gave  me  some  anxiety,  but  these 
symptoms  were  readily  controlled  by  hourly  doses  of 
calomel,  gr.  ^,  and  oxalate  of  cerjium,  gr.  i.  On 
the  occurrence  of  vomiting  an  attempt  was  made  to 
move  the  bowels  by  enema,  but  without  success.  On 
the  fifth  day,  however,  the  bowels  responded  to  hour- 
ly doses  of  magnes.  sulph.,  one  drachm,  followed 
by  an  enema  ;  after  this,  salts  or  an  enema  were  ad- 
ministered every  second  day  with  good  result.  For  the 
first  few  days  there  was  considerable  tympanites,  which 
gradually  subsided  after  the  introduction  of  a  rectal 
tube.  For  the  first  ten  days  the  patient  complained  ot' 
rather  severe  pain  and  tenderness  over  the  entire  ab- 
domen, which,  however,  was  controlled  by  an  occa 
sional  hypodermic  of  morphine — usually  one  dose 
(never  more  than  two)  of  one-fourth  grain  in  twenty- 
four  hours. 

Fdr  the  first  forty -eight  hours  the  gauze  drain 
brought  away  a  free  wateiy  discharge,  becoming  very 
scanty  by  the  fourth  day,  when  the  wick  was  removed 
and  replaced  by  a  shorter  one.  The  sutures  were  all 
removed  on  the  fourteenth  day,  patient  allowed  to  sit 
up  on  the  twentieth  day,  and  discharged  cured,  May 
6th,  twenty-six  days  after  operation. 

Follov\'ing  is  the  record  of  pulse  and  temperature  for 
first  six  days — all  lemperature  rectal  : 

1st  day  pulse  ranged  from  lOO  lo  120  ;  leniperaiurt-,    gy      lo  loo.S 

2d    '■        "         "          "       6S  "     98;  "                99.4"   loo.z 

3d    "        "         "           "       -2  "     8S ;  "              100      "   loi 

4tli   "       "         "           "       72   '■      8n  ;  '•                 gg.G  "    101.4 

5''i  "      "         "          "       72  "     80;  '■              100     "   100.2 

'"'»    "       ■■          "           '■        72   "     So  ;  ••                 97. 8  "     99.8 

After  the  sixth  day,  pulse  and  temperature  remained 
normal. 

The  points  of  special  interest  which  I  would  em- 
phasize in  this  case  are  :  First,  the  misleading  char 
acter  of  the  early  symptoms,  there  being  during  the 
first  twenty-four  hours  of  the  disease  absence  of  fever, 
if  we  could  b  lieve  the  record  of  temperature  taken 
under  the  tongue  (I  would  remark  here,  by  the  way, 
th.it  I  think  it  is  better  practice  to  take  the  rectal  tem- 
perature in  cases  of  suspected  appendicitis),  also  ab- 
sence of  that  characteristic  right  iliac  tenderness  which 
we  usually  consider  essential  to  a  diagnosis  of  appen- 
dicitis. On  the  contrary,  in  tliis  case  the  pain  was  ap- 
parently relieved  somewliat  bv  i^ressure. 


Another  point  worthy  of  notice  is  the  unusually 
rapid  progress  of  the  case.  Within  thirty-six  hours 
after  the  inception  of  pain  there  was  perforation  of 
the  appendix  and  general  septic  peritonitis. 

Again  note  the  rapidity  with  which  purulent  infec- 
tion of  the  peritoneum  took  place  after  perforation. 
The  patient  says  that  a  decided  change  in  the  charac- 
ter of  his  pain  occurred  about  7  p.m.,  it  becoming 
greatly  increased  in  intensity  and  accompanied  by  ten- 
derness, cold  perspiration,  great  prostration,  etc.  It  is 
reasonable  to  suppose  that  perforation  occurred  at  that 
time.  Upon  opening  the  peritoneal  cavity  four  hours 
later  we  found  a  large  quantity  of  sero-purulent  fluid 
with  beginning  lymph  exudates — in  fact,  all  the  condi- 
tions of  the  worst  form  of  general  peritonitis. 

Lastly,  and  to  my  mind  most  important  of  all,  is  the 
fact  that  so  desperate  a  case,  to  all  appearances,  should 
prove  so  amenable  to  prompt  and  thorough  surgical 
measures.  The  history  of  this  case  after  operation 
was  no  more  serious  than  many  an  uncomplicated  ap- 
pendicitis ;  in^eality,  beyond  a  few  attacks  of  vomiting 
and  hiccough  on  the  third  and  fourth  days  and  a 
moderate  degree  of  pain  for  the  first  week  or  ten  days, 
there  were  no  unfavorable  symptoms. 

So  far  as  a  single  instance  may  go,  it  shows  that  we 
need  not  despair  of  the  worst  cases  of  this  sort  so  long 
as  we  have  the  resources  of  prompt  surgical  interfer- 
ence, thorough  cleansing  of  peritoneal  surfaces,  and 
free  drainage. 


Cork  Splints  for  Deflections  of  the  Nasal  Septum. — 
Dr.  Berens  reports  excellent  results  from  the  use  of  a 
simple  device  for  a  splint  in  cases  of  fracture  or  opera- 
tion for  deflected  septum  nasi.  Plugs  of  cotton  or 
oakum  become  too  readily  foul,  while  the  various  sup- 
ports which  have  been  used  have  many  disadvantages, 
the  soft-rubber  tubing  being  too  yielding,  while  the 
hard  rubber  or  ivory  plugs  cause  too  much  pressure 
and  pain.  Berens  makes  his  splints  from  corks  in  the 
following  manner  :  A  selected  cork  (pint-bottle  size), 
in  average  length  one  and  a  quarter  inches,  in  breadth 
at  its  broad  end  three-quarters  of  an  inch,  at  its  nar- 
row end  one-quarter  of  an  inch  less,  is  whittled  to  the 
shape  of  an  almond  with  the  point  cut  off,  and  flat- 
tened on  the  side  that  is  to  lie  against  the  septum  ;  the 
opposite  side  near  its  lower  border  is  slightly  grooved 
for  the  reception  of  the  inferior  turbinated  body  A 
nasal  burr  or  trephine  is  now  used  to  hollow  the  splint, 
leaving  the  shell  one  and  a  sixteenth  to  one-eighth  of 
an  inch  thick.  A  rat-tail  file,  a  small-bladed  knife  or 
red-hot  metal  may  also  be  used  for  this  purpose.  Sand- 
paper is  used  to  smooth  both  the  inner  and  outer  sur- 
faces, and  the  whole  splint  is  then  coated  with  flexible 
collodion,  to  which  has  been  added  iodoform  in  the 
proportion  of  thirty  grains  to  the  fluid  ounce,  allowed 
to  dry  and  it  is  ready  for  use.  The  making  of  the 
splints  requires  no  especial  mechanical  skill,  and  they 
can  be  modified  with  ease  to  suit  the  peculiarities  of 
each  case.  The  special  advantages  of  these  splints, 
which  are  possessed  by  no  other  similar  device,  are  the 
quickness  and  ease  with  which  they  can  be  made  and 
shaped  to  fit  the  peculiarities  of  each  case  :  their  cheap- 
ness, lightness,  and  elasticity  combined  with  sufficient 
firmness  to  support  the  septum  ;  their  durability  and 
non-conduction  of  heat  and  cold  and  non-interference 
with  the  free  circulation  of  the  blood  ;  the  ease  with 
which  they  can  be  cleaned  //;  si/u  by  washing  out  with 
peroxide  of  hydrogen  and  boric-acid  solutions,  fol- 
lowed by  an  oily  spray,  as  benzoinol,  and  the  length  of 
time  they  can  be  worn  without  jjain,  discomfort,  or 
Fe\ere  ulceration. — Bos/on  Meaiial  aitii  Sitr^icjl  four- 
nal. 


September   14,   1895] 


MEDICAL    RECORD. 


377 


Medical   Record: 

A  Weekly  Jojirnal of  Medicitie  and  Stirgery, 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  September  14,  1895. 


THE      FUNDAMENTAL       DIFFERENCE 
TWEEN    PLANTS   AND    ANIMALS. 


be- 


As  our  knowledge  of  biology  has  progressed,  the  at- 
tempts to  distinguish  between  animal  and  plant  life 
have  become  more  and  more  difficult.  The  commonly 
accepted  distinction  was  based  upon  the  difference  be- 
tween the  synthetic  or  building-up  process  in  the  two 
biological  series.  The  plant  has  the  power  of  bringing 
free  nitrogen  into  combination  with  other  atoms,  while 
the  animal  does  not  have  this  power.  Dr.  Minot,  in  an 
article  published  in  Science  of  March  2 2d,  says,  that 
it  is  much  to  be  regretted  that  this  method  of  defining 
the  difference  between  animals  and  plants  has  been  so 
widely  accepted,  since  it  is  not  entirely  true,  and  there- 
fore leads  to  much  perplexity.  There  are  some  plants 
without  chlorophyll  that  cannot  bring  nitrogen  into 
combination,  and  there  are  some  animals  in  which  syn- 
thetic processes  occur.  Another  distinction  often 
drawn,  says  Dr.  Minot,  between  animals  and  plants,  is 
that  of  the  presence  in  the  former  of  internal  digestive 
organs,  but  this  distinction  also  does  not  hold  entirely 
true,  for  the  amceba  has  no  internal  digestive  organs  at 
all,  though  it  is  classed  as  an  animal.  Dr.  Minot  thinks 
that  we  can  best  define  the  two  primary  dinsions  of 
the  living  world  thus  :  Animals  are  organisms  which 
take  part  of  their  food  in  the  form  of  concrete  par- 
ticles which  are  lodged  in  the  cell  protoplasm  by  tlie 
activity  of  the  protoplasm  itself.  Plants  are  organisms 
which  obtain  all  their  food  in  either  the  liquid  or  gase- 
ous form  by  osmosis  or  diffusion.  The  writer  admits 
that  there  are  a  few  examples  which  somewhat  militate 
against  the  acceptation  of  this  distinction.  The  only 
class  which  he  distinctly  cites  as  an  exception,  how- 
ever, is  the  myxocy:es,  and  these,  he  suggests,  form  a 
link  between  animal  and  plant  life.  The  tape  worm,  he 
admits,  might  be  considered  an  example  of  an  animal 
that  lives  by  osmosis,  but  this  animal  may  perhaps  also 
take  part  of  its  food  by  the  absorption  of  the  concrete 
particles. 

An  animal,  then,  according  to  Dr.  Miuot,  is  an  or- 
ganism which  takes  its  food  in  a  solid  form  ;  a  plant, 
one  which  takes  it  in  a  liquid  or  gaseous  form. 
The  animal  lives  through  the  vital  activity  of  its  proto- 
plasm, stretching  out  its  substance  and  enveloping  the 
particles  of  food.  Only  in  this  way,  by  getting  the 
concrete  substance  into  its  meshes,  is  the  animal  able  to 
live.    The  plant,  however,  lives  by  osmosis  or  diffusion 


alone.  Of  course  the  animal  also  absorbs  liquids  and 
gases  by  this  same  process,  and  therefore  includes  in 
its  \-ital  functions  some  of  those  which  are  peculiar  to 
the  plant. 

Dr.  Minot  elaborates  his  view  of  the  essential  char- 
acteristic of  the  animal  in  an  ingenious  way,  showing 
that,  owing  to  the  fact  that  animal  life  depends  upon 
the  activity  of  its  protoplasm,  the  animal  is  therefore 
compelled  to  exert  itself.  Its  protoplasm  is  obliged  to 
be  kept  in  a  state  of  activity,  and  hence  the  gradual 
development  of  the  cells  of  the  body  into  organs  which 
help  the  animal  in  its  pursuit  of  food  and  in  the  propa- 
gation of  its  species.  In  other  words,  it  is  harder  to 
live  on  solid  food  than  on  a  gaseous  diet,  since  the 
former  requires  an  active  and  positive  effort  on  the 
part  of  the  organism. 


RAILWAY    HOSPITALS    FOR   THE    EAST. 

The  International  Medico-Legal  Congress  which  met 
recently  in  this  city  was  not  productive  of  very  great 
results,  yet  there  were  some  rather  interesting  papers 
read. 

Dr.  George  Chaffee,  of  Brooklyn,  presented  a  com- 
munication entitled  "  Is  the  Railway  Hospital  System  an 
Economy  ?"  and  he  made  a  very  strong  and  interesting 
plea  in  behalf  of  the  extension  of  the  railway  hospital 
system  to  the  lines  in  the  East.  Dr.  Chaflfee  states  that 
the  hospital  system,  which  is  already  so  popular  in  the 
South  and  West,  is  now  being  seriously  considered  by 
the  officials  of  some  of  the  leading  Eastern  roads.  He 
himself  has  been  directing  his  efforts  toward  securing 
the  adoption  of  this  system  in  the  East.  Dr.  Chaffee 
asserts  that  the  hospital  system  is  economical,  practical, 
and  self-supporting,  and  he  presents  some  facts  and 
figures  to  bear  out  this  view. 

It  is  objected  that,  in  the  East,  such  a  system  is 
hardly  necessary,  since  all  our  large  and  even  small 
towns  are  now  well  equipped  with  good  hospitals  ;  but 
to  this  he  replies  that  the  system  by  which  railroads 
own  and  control  hospitals  is  one  which  secures  the 
immediate  ser\'ices  of  specially  trained  surgeons  for  the 
benefit  of  those  injured  in  the  employ  of  the  railroads. 
The  employees  practically  own  and  control  the  hos- 
pitals, and  support  them  by  small  assessments  which 
are  paid  pro  rata  by  every  individual  in  the  employ  of 
the  company.  The  system,  he  believes,  tends  to  lessen 
the  amount  of  litigation  connected  with  railroads,  and 
also  prevents  many  of  the  disastrous  effects  of  railroad 
injuries.  Particularizing  the  system  still  more,  Dr. 
Chaffee  makes  these  three  statements  : 

1.  "  It  does  not  cost  the  corporation  one  cent;  the 
system  is  established  and  maintained  by  light  monthly 
assessments  upon  the  employees — from  the  President 
down. 

2.  "  It  favors  compromise  and  prevents  much  litiga- 
tion, a  saving  of  thousand  of  dollars  annually. 

3.  "  Not  only  employees,  but  injured  patrons  as  well, 
are  cared  for  in  the  railway  hospital  without  cost  to 
the  corporation,  and  are  thus  kept  in  the  family  circle 
instead  of  being  placed— as  is  the  case  in  many  in- 
stances— directly  in  the  hands  of  the  enemy  at  their 
homes." 


378 


MEDICAL   RECORD. 


[September   14,  1895 


^Ve  have  presented  the  claims  made  in  behalf  of  the 
railway  hos[)ital  system,  and  we  find  no  record  of  any 
discussion  in  which  such  a  system  is  opposed.  It  would 
be  well,  however,  before  the  medical  employees  of  the 
railroads  of  the  East  give  their  approval  to  such  a 
system,  to  consider  both  sides  of  the  question.  .Mrcady 
we  have  great  complaints  about  the  evils  of  the  con- 
tract doctor  system,  and  Western  journals  contain  a 
great  deal  of  acrimonious  discussion  as  to  the  rights 
of  private  practitioners  and  the  encroachment  upon 
them  by  the  servants  of  the  corporations.  The  estab- 
lishment of  the  railway  hospital  system  means  an 
additional  step  in  the  syndicating  of  medical  service. 
It  means  that  a  large  number  of  medical  men  will  be- 
come employees  and  practically  clerks  of  great  corpo 
rations.  It  means  that  such  a  class  of  men  will  lose, 
to  a  large  e.\tent,  independence  of  spirit,  and  that  the 
kind  of  work  that  they  do  will  be  classed  more  and 
more,  not  as  professional  services,  but  as  a  species  of 
skilled  workmanship,  like  that  of  a  high-class  mechanic. 
We  do  not  say  that  all  these  disadvantages  will  out- 
weigh the  arguments  that  can  be  brought  forward  to 
sustain  the  otlier  side,  but  we  feel  sure  that  the  railway 
hospital  system  is  one  that  is  not  quite  so  free  from 
blemishes  as  the  enthusiasm  of  Dr.  Chaffee  would  make 
us  think. 


were  from  men,  96  were  from  women.  The  brains  in- 
cluded in  part  cases  of  general  paralysis,  and  in  part 
cases  of  insane  due  to  other  causes,  excluding,  how- 
ever, in  all  instances  the  brains  of  senile  dements. 

The  author  concludes  that  the  brain-weight  of  man 
is  greater  than  that  of  woman,  and  that  in  man  the 
brain  mantle  is  proportionately  larger.  In  women,  on 
the  other  hand,  the  cerebellum  and  brain-axis  are  pro- 
portionately larger  than  the  rest  of  the  brain.  In  gen- 
eral paralysis  he  finds  that  the  weight  of  the  brain  is 
decidedly  less  on  an  average  than  the  weight  of  a  nor- 
mal brain.  This  loss  of  weight  affects  especially  the 
mantle.  It  furthermore  affects  especially  the  frontal 
lobes  and,  still  further,  it  affects  the  left  cerebral  hemi- 
sphere more  than  the  right.  He  finds  also  that  in 
general  paralysis  there  is  a  greater  loss  of  brain-weight 
than  in  insanity  due  to  other  causes,  leaving  aside 
senile  dementia.  The  average  weight  of  the  brain  of 
the  insane  is  not,  in  fact,  very  much  less  than  that  of 
the  healthy  man,  leaving  out  of  consideration  the  forms 
of  insanity  just  referred  to.  The  diminution  of  the 
weight  of  the  brain  in  general  paralysis  shows  its  effect 
more  strikingly  in  the  brains  of  women  than  in  those  of 
men. 


THE  WEIGHT  OF  THE  BRAIN  IN  THE  SANE 
AND    INSANE. 

It  would  seem  to  be  a  rather  easy  thing  to  get  at  the 
facts  regarding  the  weight  of  the  human  brain  and  its 
significance.  This,  however,  has  not  proved  to  be  the 
case,  and  even  now,  despite  years  of  weighing  and 
careful  collecting  of  statistics,  observers  have  hardly 
yet  reached  a  certainty  upon  any  of  the  facts  connected 
with  the  volume  of  the  human  brain.  Consequently  a 
fresh  contribution  to  this  subject  by  Dr.  A.  Mercier  is 
interesting  and  welcome.  The  title  of  his  monograph 
is  "'  The  Diminution  of  the  Weight  of  the  Brain  in 
General  Paralysis."  The  author,  however,  gives  more 
in  his  article  than  would  be  inferred  from  its  title.  He, 
in  the  first  place,  collects  the  statistics  of  brain-weights 
that  have  been  furnished  by  other  observers  and  says 
that,  as  a  result  of  the  study  of  the  data  thus  collected, 
the  weight  of  the  brain  of  a  normal  European  adult  is 
1,375  grammes  for  a  man,  and  1,245  grammes  for  a 
woman.  He,  however,  adopts  as  the  safer  average  the 
figures  given  by  Weichselbaum  and  Pleger,  viz.,  1,353  for 
man  and  1,200  for  woman.  The  next  point  which  Dr. 
Mercier  takes  up  is  the  relative  weight  of  the  brain  as 
a  whole  to  that  of  the  brain  mantle.  By  this  is  meant 
the  brain  minus  the  cerebellum,  pons,  and  brain-axis 
these  parts  being  carefully  removed  by  a  method  spe- 
cially described  by  the  late  Professor  Meynart.  It  is 
found  that,  assuming  the  weight  of  the  male  brain  to  be 
1,353  grammes,  that  of  the  mantle  is  1,070.  This  is  for 
the  male  brain.  In  the  brain  of  an  average  woman 
weighing  1,200  grammes,  the  mantle  would  weigh  943 
grammes.  Using  these  figures  as  a  basis,  the  author 
proceeds  to  compare  the  statistics  of  brain- weights  in 
the  insane,  and  then  gives  the  result  of  his  own  investi- 
gation as  to  the  weight  of  brains  of  this  class.  Dr. 
Mercier's   figures  include   330  brains.     Of  these,   234 


A  LAYMAN'S  IDEA  OF  EUTHANASIA. 

Mr.  Albert  Bach,  a  lawyer  and  vice-president  of 
the  Medico-Legal  Society,  seems  to  have  definite  opin- 
ions as  to  the  right  of  a  man  to  take  his  own  or  an- 
other's life — opinions  which,  we  trust,  are  not  shared 
by  the  majority  of  his  fellow-members  of  the  Medico- 
Legal  Society.  At  the  recent  congress,  held  in  this 
city,  there  was  quite  a  discussion  upon  suicide,  in  the 
course  of  which  Mr.  Bach  ventured  the  assertion  that  a 
man  has  a  right  to  kill  himself  under  certain  circum- 
stances, just  as  a  physician  has  the  right  to  administer 
drugs  to  end  the  agony  of  a  patient.  He  held  that  a 
physician  has  the  moral  right  to  end  human  life  under 
these  circumstances.  Mr.  Bach  is,  of  course,  at  lib- 
erty to  hold  what  views  he  will  as  to  the  taking  of 
human  life,  so  long  as  he  does  not  attempt  to  carry 
them  out  in  practice  ;  but  he  unwisely  goes  further  and 
says,  not  only  that  physicians  may  end  life  in  order  to 
cut  short  suffering,  but  that  he  knows  they  do. 

That  physicians  give  drugs  to  ease  the  agony  of  a 
dying  jierson  is  true,  for  it  is  part  of  their  mission  to 
relieve  pain  and  to  rob  death  of  its  terrors,  as  far  as 
they  may,  when  they  cannot  avert  it.  But  to  argue 
from  this  that  the  physician  kills  his  patient  in  order 
to  relieve  his  sufferings,  betrays  a  curious  lack  of  rea- 
soning power  or  a  wilful  abuse  of  it.  To  promote  eu- 
thanasia is  the  right  and  the  duty  of  the  physician  ;  to 
take  the  life  of  a  dying  man  or  to  hasten  his  dissolu- 
tion by  the  administration  of  drugs  is  no  more  justifia- 
ble in  the  physician  than  would  be  the  ending  of  the 
patient's  life  by  the  stiletto  or  the  pistol,  or  than  poi- 
soning is  at  the  hands  of  some  expectant  heir  or 
avowed  enemy. 

If  Mr.  Bach  knoivs  of  any  specific  instances  of  the 
killing  of  patients  he  should  give  them,  but  he  has  no 
right  to  libel  an  entire  profession  and  to  misconstrue 
an  act  of  mercy  into  what  would  be  accounted  a  crime 
by  all  but  those  of  his  own  way  of  thinking. 


September  J4,  1895] 


MEDICAL    RECORD. 


379 


ST.  LOUIS  AND  FREE  DISPENSARIES. 

St.  Louis,  having  been  greatly  worried  by  the  number 
of  its  medical  colleges,  and  aftei  having  become  greatly 
embittered  through  the  strife  between  its  medical  so- 
cieties, is  having  an  interesting  set-to  between  two  of 
its  journalists.  Lest,  even  with  all  these  things,  life 
should  still  become  stale  and  monotonous,  the  Medical 
Rcvinv  has  begun  to  lament  the  excessive  number  of 
its  city  dispensaries.  The  newly  appointed  heahli 
commissioner  of  the  State,  Dr.  Starkloff,  is,  we  are 
told,  a  very  energetic  gentleman,  who  is  ambitious  to 
have  the  city  treat  more  people  for  nothing.  He  has 
consequently  established  four  new  city  dispensaries. 
When  these  four  new  dispensaries  are  added  to  tlie 
eleven  or  thirteen  medical  colleges,  and  the  private 
free  clinics  and  free  dispensaries  connected  with  the 
hospitals,  the  sum  total  is  alarming,  and  the  Medical 
Review  feels  justly  disposed  to  criticise  the  unnecessary 
zeal  of  the  new  health  commissioner. 


^eitjs  of  the  "SSIecfe. 

The  American  Public  Health  Association. — The  twen- 
ty-third annual  meeting  of  this  Association  will  be 
held  at  Denver,  Col.,  on  October  i,  2,  3,  and  4,  1895. 
The  headquarters  for  the  meeting  will  be  at  the 
Brown  Palace  Hotel.  The  officers  of  the  Association 
are  :  President,  Dr.  William  Bailey,  of  Louisville,  Ky.  ; 
First  Vice-President,  Dr.  Granville  P.  Conn,  of  Con- 
cord, N.  H. ;  Second  Vice-President,  Dr.  Gregorio  Men- 
dizabal,  of  Orizaba,  Vera  Cruz,  Mexico  ;  Secretary, 
Dr.  Irving  A.  Watson,  of  Concord,  N.  H. ;  Treasurer, 
Dr.  Henry  D.  Holton,  of  Brattleboro,  Vt.  The  fol- 
lowing subjects  have  been  proposed  for  discussion  : 
I,  "  The  Pollution  of  Water-supplies  ;  "  2,  "  The  Dis- 
posal of  Garbage  and  Refuse  ;  "  3,  "  Animal  Diseases 
and  Animal  Food  ;  "  4,  "  The  Nomenclature  of  Dis- 
eases and  Forms  of  Statistics  ;  "  5,  "  Protective  In- 
oculations in  Infectious  Diseases  ;  "  6,  "  National 
Health  Legislation  ;  "  7,  "  The  Cause  and  Prevention 
of  Diphtlieria  ;  "  8,  "  Causes  and  Prevention  of  Infant 
Mortality  ;  "  9,  "  The  Restriction  and  Prevention  of 
Tuberculosis  ;  "  10,  "  Car  Sanitation  ;  "  11,  "  The  Pre- 
vention of  the  Spread  of  Yellow  Fever  ;  "  12,  "  Steam- 
ship and  Steamboat  Sanitation  ;  "  13,  "  Transportation 
of  the  Dead  ;  "  14,  "  The  Disposal  of  the  Dead  ;  "  15, 
"  The  Abuse  of  Alcoholic  Drinks  from  a  Sanitary 
Standpoint."  This  Association  is  one  composed  of 
earnest  workers  in  the  cause  of  sanitation,  who  discuss 
much  that  might  be  of  service  to  the  community  ;  but 
its  usefulness  is  seriously  impaired  by  a  rule  which  for- 
bids members  to  publish,  in  whole  or  in  abstract,  any 
paper  read  before  the  Association  until  after  its  publica- 
tion in  the  official  transactions.  Very  few  people  other 
than  members  of  the  Association  see  its  volume  of  trans- 
actions, and  the  papers  are  therefore  buried  and  prac- 
tically useless. 

An  International  Congress  for  the  Study  of  Alcohol 
was  recently  held  at  Basle,  Switzerland.  Its  member- 
ship was  composed  very  largely  of  advocates  of  total 
abstinence,  and  all  its  conclusions  were  adverse  to  the 


use  of  alcoholic  beverages.     The  ne.xt  congress  will  be 
held  in  Brussels. 

A  Quarantine  Brutality. — A  man  suffering  from  small- 
pox was  recently  expelled  from  .\rkansas  and  refused 
aduiittance  into  Mississippi.  As  he  could  not  well  re- 
main in  or  on  the  Mississippi  River  until  the  disease 
ran  its  course,  he  attempted  to  evade  the  quarantine 
and  land  on  the  river  bank  in  the  latter  State,  but  was 
shot  and  killed  by  one  of  the  quarantine  officers. 

A  Pension  of  ^200  a  year  has  been  granted  to  the 
widow  of  the  late  Professor  Huxley. 

The  Morphine  Habit  in  China. — According  to  an 
English  contemporary  the  British  consuls  in  China  have 
repeatedly  drawn  attention  to  the  increasing  prevalence 
in  several  ports  of  the  pernicious  habit  of  injecting 
preparations  of  morphine,  practised  by  unqualified  per- 
sons among  the  natives.  This  custom  was  originally 
introduced  as  a  cure  for  opium  smoking,  but  it  is  a 
case  in  which  the  remedy  is  worse  than  the  disease. 
Those  who  sell  morphine  and  make  the  injections  pro- 
cure a  profit  of  from  two  hundred  to  four  hundred  per 
cent.  The  charge  for  smoking  an  injection  is  one  cent. 
One  of  the  victims  of  the  practice  said  :  "  It  is  much 
cheaper  than  opium  smoking,  and  I  get  the  same  satis- 
faction out  of  it.  I  know  of  ten  Chinese  doctors,  each 
of  whom  treats  fifty  to  one  hundred  men  daily  with  this 
medicine." 

The  Late  Dr.  Wollmann. — At  a  meeting  of  the 
Medical  Board  of  the  Beth  Israel  Hospital  held  August 
28,  1895,  the  following  resolutions  were  adopted  : 

Whereas,  Our  respected  colleague  and  colladorator 
in  the  charitable  work  of  the  Beth  Israel  Hospital,  Dr. 
Marcus  Wollmann,  has  been  removed  from  us  by 
death  ; 

Resolved,  That  we  deeply  feel  and  mourn  the  loss  of 
an  esteemed  friend  as  well  as  member  of  our  Board, 
whose  career  was  so  sadly  cut  short  during  the  best 
lieriod  of  his  life  ;  and  that  we  tender  to  his  sorrowing 
widow  and  family  our  sincere  sympathy  and  condo- 
lence in  their  affliction.     And  be  it  further 

Resolved,  That  a  copy  of  these  resolutions  be  spread 
on  the  minutes  of  this  Board,  and  that  a  coi)y  be  sent 
to  the  bereaved  family.  Also  that  copies  be  sent  to 
the  medical  press  for  publication. 

A.  E.  Isaacs,  M.D.,  President. 
D.  RoiiiNSON,  M.D.,  Secretary. 

Obituary  Notes. — Dr.  John  Sver  Bristowe  died  at 
Dixton  Vicarage,  Monmouth,  England,  on  August  20th, 
aged  sixty-eight.  He  had  been  out  of  health  for  some 
time,  but  the  precise  nature  of  his  illness  was  not 
clearly  understood.  Dr.  Bristowe  was  known  in  this 
country  chiefly  through  his  "  Treatise  on  the  Theory 
and  Practice  of  Medicine,"  published  in  1876.  In 
1888  he  published  a  work  on  "  Diseases  of  the  Nervous 
System."  He  was  also  a  frequent  contributor  of  ar- 
ticles on  various  subjects  to  periodical  literature. 
He  delivered  the  Lumleian  Lectures  in  1879,  on  the 
"  Pathological  Relation  of  Voice  and  Speech  ;  "  the 
Lettsomian  Lectures,  on  "  Syphilis  of  the  Nervous  Sys- 
tem ;  "  and  the  Croonian  Lectures,  on  "  Disease  and  its 
Medical  Treatment."     Dr.  Bristowe's  father  and  grand- 


38o 


MEDICAL    RECORD. 


[September   14,  1895 


father  were  physicians,  and  one  of  his  sons  is  a  practi- 
tioner and  another  a  student  of  medicine. — Dr.  Ernst 
Hoi'PeSk.\i,ek,  Professor  of  Physiological  and  Patho- 
logical Chemistry  at  the  Kaiser  Wilhelm  University  in 
Strassburg,  died  of  apoplexy  on  August  loth,  at  his 
summer  residence  on  the  Bodensee.  He  was  born  in 
1S25  in  Freiburg,  in  Thiiringen.  He  began  practice  in 
Berlin  in  1852,  was  then  privat  decent  at  Greifswald 
for  two  years,  when  he  returned  to  Berlin.  In  1861  he 
went  to  Tubingen  and  in  1872  to  Strassburg,  where  he 
remained  the  rest  of  his  life. — Dr.  Joannes  Ch.  Bam- 
BAS,  editor  of  Galcnos,  died  in  Athens  on  August  ist. 
He  was  born  in  1849,  and  after  being  graduated  from 
the  medical  department  of  the  National  University  at 
Athens,  spent  some  time  in  study  in  Paris,  Berlin,  and 
Vienna.  A  few  years  after  his  return  to  Athens  he 
was  appointed  Professor  of  Hygiene  in  the  National 
University. — Dr.  William  S.  Layman,  of  Schoharie, 
died  at  his  home  on  September  5th,  at  the  age  of  sixty- 
four  years.  He  was  a  graduate  of  the  Albany  Medical 
College  in  the  class  of  1857. 

The  Lectures  at  the  London  College  of  Physicians  for 

the  coming  year  will  be  delivered  as  follows  :  The 
Bradshaw  lecture  by  Dr.  Bradbury  ;  the  Lumleian  lect- 
ures by  Sir  Dyce  Duckworth  ;  the  Gulstonian  lecture 
by  Dr.  Mason  ;  and  the  Croonian  lecture  by  Dr. 
Oliver. 

The  Mississippi  Valley  Medical  Association,  at  its 

recent  meeting  in  Detroit,  elected  Dr.  H.  O.  Walker, 
of  that  city,  president  for  the  ensuing  year.  The  next 
meeting  of  the  Association  will  be  held  in  Minne- 
apolis. 

Wisconsin's  Cholera  Fund. — The  Legislature  of  Wis- 
consin lias  ajipropriated  $50,000  as  a  contingent  fund 
to  be  used  by  the  Health  Board,  if  necessary  at  any 
time  during  the  next  two  years,  to  prevent  the  intro- 
duction of  cholera. 

The  American  Social  Science  Association  held  its 
annual  meeting  at  Satatoga  during  the  first  week  in 
September.  In  the  Health  Department  papers  were 
read  by  the  chairman,  Dr.  Frederick  Peterson,  of  New 
York,  on  "  The  Craig  Colony  for  Epileptics  ;  "  by  Dr. 
L.  Duncan  Bulkley,  of  New  York,  on  "  A  Plea  for  the 
Legal  C'ontrol  of  Certain  Dangerous  Communicable 
Diseases  ;  "  and  by  Dr.  Grace  Peckham  Murray,  of  New 
York,  on  "  The  Relation  of  Education  to  the  Cerebral 
Development  of  the  Child."  Dr.  T.  W.  Cheesman,  of 
New  York,  delivered  an  address  on  "  The  Bacteria  : 
What  They  Are;  What  They  Do;  How  We  Study 
Them."  The  lecture  was  illustrated  with  stereopticon 
views. 

The  following  officers  were  elected  for  the  ensuing 
year  :  President,  F.  J.  Kingsbury,  of  Waterbury,  Conn.  ; 
First  Vice-President,  H.  L.  Wayland,  of  Philadelphia ; 
General  Secretary,  F.  B.  Sanborn,  of  Concord,  Mass.  ; 
Treasurer,  Anson  Phelps  Stokes,  of  New  York. 

The  National  Wholesale  Druggists'  Association  will 
hold  its  next  annual  meeting  in  Philadelphia. 

Cholera  i.s  reported  to  ha\c  broken  out  at  Brusa,  a 
town  in  Asiatic  Turkey,  about  sixty  miles  from  Con- 
stantinople, and  a  quarantine  cordon  has  been  drawn 


around  the  place  to  |)revent  the  spread  of  the  disease 
to  the  capital.  The  province  of  Podolia  in  Russia  has 
been  officially  declared  infected.  The  disease  prevails 
also  to  some  extent  in  Tangier.  \  correspondent  of 
the  Nffi'oe  Vremya,  of  St.  Petersburg,  sends  the  startling, 
but  doubtless  incorrect,  information  that  there  are  over 
twO  thousand  deaths  a  day  from  cholera  in  Pekin. 
Every  precaution  is  being  taken  to  prevent  the  intro- 
duction of  the  disease  into  the  Pacific  coast  ports  of 
this  country,  and  the  Treasury  Department  has  or- 
dered, upon  the  recommendation  of  the  Marine  Hos- 
l>ital  Service,  that  the  baggage  of  passengers  arriving 
at  any  port  on  the  Pacific  coast  from  China,  Japan,  or 
Hawaii  be  disinfected  before  being  landed.  A  despatch 
from  New  Zealand  says  that  there  is  no  cholera  at  Hon- 
oluhi,  the  report  of  an  outbreak  there  having  been 
started  by  the  death  of  some  Chinamen  after  eating 
some  poisonous  food. 

Clinical  Instruction  at  Bellevue  Hospital. — At  the 
request  of  the  Commissioners  of  Public  Charities  and 
Correction  the  members  of  the  Fourth  Division  of 
Bellevue  Hospital  have  decided  to  form  an  organization 
for  the  purpose  of  giving  instruction  to  graduates  and 
third-year  students.  The  medical  staff  of  the  Fourth 
Division  consists  of  Drs.  C.  L.  Dana,  George  B.  Fowler, 
and  Alexander  Lambert.  The  surgical  staff  consists 
of  Drs.  J.  W.  S.  Gouley,  Charles  Phelps,  and  W.  F. 
Fluhrer.  The  gynecologist  is  Dr.  W.  Gill  Wylie.  The 
clinics  will  begin  about  October  ist.  Each  course  of 
instruction  will  continiie  six  weeks,  and  at  least  five 
such  courses  will  be  given  during  the  year. 

The  American  Climatological  Association  will  hold  its     I 
next  annual  meeting  in  Lakewood,  N.  J.,  in  May,  1896.      ■ 
The   president   of   the  Association    is    Dr.    James    B. 
Walker,  and  the  secretary  Dr.  Guy  Hinsdale,  both  of 
Philadeli)hia. 

The  Idaho  State  Medical  Society  held  its  third  an- 
nual meeting  at  Boise  City  on  Monday,  Tuesday,  and 
Wednesday  of  this  week.  The  officers  for  this  meet- 
ing were  Dr.  I.  H.  Moore,  of  Pocatello,  President ; 
Dr.  E.  L.  Perrault,  of  Boise  City,  Vice-President ;  Dr. 
C.  L.  Sweet,  of  Boise  City,  Secretary  and  Treasurer. 

Suprarenal  Extract   in   Addison's  Disease. — Dr.  E. 

Lloyd  Jones  reports  in  the  British  Medical  Journal  of 
August  24,  1895,  a  case  of  Addison's  disease  treated  by 
extract  of  suprarenal  body.  The  case  was  that  of  a 
married  woman  who  had  been  complaining  of  frequent 
nausea  and  vomiting,  great  weakness,  and  discoloration 
of  the  skin.  The  first  symptoms  had  appeared  about 
two  years  before,  and  consisted  in  acute  pain  in  the 
back,  diarrhoea,  and  vomiting.  She  was  placed  upon 
suprarenal  extract,  and  in  five  days  was  reported  much 
better,  no  longer  suffering  with  nausea.  At  the  end  of 
three  months  Dr.  Jones  said  that  she  had  had  no 
vomiting  for  a  month,  she  could  eat  almost  any  food, 
the  excessive  pigmentation  had  quite  disappeared,  and 
she  a|>peared  to  be  practically  well. 

Vaccination  a  Preliminary  to   Marriage. — CouplesJ 
living  in  the  Scandinavian  Peninsula  who  desire  to  be 
married  must  produce  certificates  showing  that  thej 
have  been  successfully  vaccinated,  as  well  as  baptizec" 
before  the  ceremony  can  be  legally  performed. 


September  14,  1895] 


MEDICAL    RECORD. 


?8i 


CCUuical  gepartm^ut. 


creased.  At  the  end  of  the  seventeenth  da\-  he  was  able 
to  leave  the  ward  and  was  discharged  on  September 
29th  as  cured. 


CASE    OF   TRAUMATIC   TETANUS   WITH 
URETHRAL   SPASM. 


By  HUGO  E.  WANGELIN,  M.D., 


On  September  i,  1894,  Jacob  N — ■ — -,  aged  fifty-two, 
colored,  was  admitted  to  the  St.  Clair  County  Farm 
suffering  from  a  nail-thrust  in  the  right  foot.  About 
ten  days  before  admittance  he  stepped  on  a  rusty  wire- 
nail,  which  penetrated  his  heavy  shoe  sole  and  entered 
his  foot  about  two  inches  from  the  toe  and  three-quar- 
ters of  an  inch  from  the  medial  line  of  the  foot,  pene- 
trating to  a  depth  of  about  an  inch.  When  admitted 
to  the  farm  he  was  in  fairly  good  shape.  The  ne.xt  day, 
September  2d,  I  noticed  a  jerking  of  the  extensors  of 
the  foot  and  a  slight  stiffness  of  the  muscles  of  the 
jaw.  Before  night  these  symptoms  became  worse,  and 
by  the  following  day  had  extended  to  all  the  extensors 
of  the  body,  and  the  jaw  was  set  during  the  convulsions 
with  the  typical  ri'sus  sardotiicus.  The  spasms  after 
the  fourth  day  of  admittance  were  at  their  height. 
The  slightest  touch  or  breeze  blowing  over  him  was 
enough  to  bring  on  the  spasms,  which  recurred  spon- 
taneously every  five  to  eight  minutes.  His  whole  body 
was  as  stiff  as  a  log.  He  could  not  bend  his  arms  or 
his  legs.  This  condition  remained  several  days,  and 
as  he  was  unable  to  swallow  anything,  all  nourish- 
ment was  given  per  rectum.  At  one  time  death  was 
expected,  but  he  was  safely  bridged  over  by  big  in- 
jections of  whiskey. 

The  second  day  after  admission  he  was  troubled 
with  retention  of  urine,  and  I  attempted  to  use  the 
catheter  on  him.  After  the  metal  catheter  had  entered 
the  urethra  about  one-half  inch  it  was  obstructed  in  its 
passage,  and  no  amount  of  force  could  introduce  it  any 
further.  This  manipulation  caused  a  convulsion,  and 
when  the  spasm  passed  off,  the  catheter  slipped  into  the 
bladder  very  easily.  While  the  catheter  was  still  in  the 
bladder  a  spasm  occurred  and  so  powerfully  was  the 
catheter  held  that  it  could  not  be  withdrawn.  I  next 
attempted  to  introduce  the  soft  rubber  catheter  and 
met  with  the  same  results.  Waiting  till  the  opportunity 
offered,  I  introduced  it  very  easily.  While  this  catheter 
was  in  the  bladder  there  was  a  flow  of  urine.  The 
spasm  was  again  excited,  and  the  constriction  was  so 
great  as  to  stop  the  flow  of  urine.  This  procedure 
was  accompanied  with  little  or  no  pain,  and  in  fact  the 
only  pain  the  patient  complained  of  was  a  pressing  pain 
over  the  region  of  the  stomach.  The  catheterization 
was  made  every  day  for  a  week,  and  each  time  it  was  te- 
dious work,  but  as  the  case  progressed  it  became  easier. 
In  passing  the  catheter  I  could  detect  five  distinct 
points  where  the  instrument  would  not  pass  during  the 
spasm.  After  recovery  the  catheter  would  pass  easily, 
and  with  no  amount  of  search  could  I  find  any  point 
along  the  urethral  track  where  there  was  an  obstruction. 
Why  should  this  disease  act  so  on  the  urethra  and  not 
on  the  oesophagus,  through  which  a  feeding-tube  can  be 
passed  even  during  the  spasm  ? 

The  first  thing  done  in  the  treatment  of  this  case  was 
the  entire  excision  of  the  wound  made  by  the  nail  and 
a  large  crucial  incision  across  the  seat  of  injury.  Every 
two  hours  the  wound  was  washed  out  with  a  very  hot 
solution  of  I  to  1000  corrosive  sublimate  solution,  and 
then  packed  with  corrosive  gauze.  The  internal  reme- 
dies used  were  morphia  sulph.,  \  ;  bromide  potass., 
grain  xx  ;  chloral  hydrate,  grain  xx.  This  dose  was 
repeated  every  three  hours.  When  the  spasms  were 
great,  chloroform  was  used  ;  during  the  climax  nitro- 
glycerine and  whiskey,  hypodermically.  After  he  be- 
gan to  mend,  the  morphia  mixture  was  gradually  de- 


LOOSE   BODY    IN   THE    KNEE-JOINT. 
Bv  R.  P.  MYERS,  M.D., 


HONOLULU,   H. 


There  appeared  in  the  Medical  Record  of  March  9, 
1S95,  by  Dr.  Wingelin,  an  article  on  "  Loose  Bone  in 
the  Knee-joint."  The  similarity  of  the  case  reported 
by  him  to  one  occurring  in  my  practice  in  the  winter 
of  1 89 1,  in  Colorado,  U.  S.,  causes  me  to  make  the  fol- 
lowing report  : 

Mr.  C ,  a  gentleman  of  leisure,  having  lived  in 

London  some  nineteen  years,  self-indulgent  in  his  ap- 
petites, and  of  a  rheumatic  diathesis,  florid  and  inert  to 
a  degree,  occupied  all  of  his  time  in  reading.  He  told 
me  for  some  two  years  he  had  been  suffering  much 
pain  in  left  knee  when  in  motion  from  having  struck 
the  joint  ;  but  at  the  time  only  suffered  slight  discom- 
fort. On  examination,  found  no  redness,  heat,  pain  or 
swelling.  Upon  manipulation,  found  a  loose  body 
floating,  as  it  were,  on  outside  of  joint.  It  was  mov- 
able to  all  parts,  and  at  times  I  would  lose  it.  It 
would  slip  several  inches  above  the  patella  and  then  I 
could  not  find  it.  I  started  to  operate  once  and  lost 
it  ;  was  not  sorry,  for  I  found  he  could  not  take  chloro- 
form or  ether,  so  I  used  salt  and  ice.  Located  the  body, 
had  an  assistant  apply  the  "freezing,"  and  arranged  to 
operate,  when  lo  I  I  found  the  parts  frozen  hard  and 
of  some  whiteness.  My  chance  was  gone,  and  I  was 
annoyed  at  the  condition  of  the  frozen  point,  and  feared 
results.  Some  hours  passed  before  the  parts  regained 
their  normal  condition.  I  kept  him  in  bed  the  rest  of 
the  day,  and  the  following  he  got  up,  well  rid  of  his 
trouble.  From  that  day  to  the  day  of  his  death,  which 
occurred   some  months  after,  the  floating  body  could 

not  be  found.     Could  Mr.  C have  knocked  off  a 

piece  of  cartilage  when  he  struck  the  knee  ?  Through 
the  thin  skin  it  felt  smooth  and  almost  compressible. 
What  became  of  the  foreign  substance  ?  Did  the  freez- 
ing cause  its  absorption  ? 


PERIOSTITIS  AND  NECROSIS    OF  THE  RIBS 
FOLLOWING   TYPHOID    FEVER. 

By  a.   S.   GRIMM,  M.D., 

ST.    .M.^Ry'S,   W,   VA. 

I  WAS  called  to   see   Mr.  H October  4,  1892,  and 

found  him  suffering  from  typhoid  fever  of  a  pronounced 
although  not  an  unusually  severe  type.  There  was 
nothing  peculiar  about  the  case  until  about  the  end  of 
the  third  week,  when  he  complained  of  pain  over  the 
sixth  rib  at  the  junction  of  the  rib  proper  with  the  car- 
tilage. This  pain  continued,  and  in  a  few  days  a  red- 
ness with  some  tenderness  was  observed  over  the  seat 
of  the  trouble,  and  finally  a  swelling  was  distinctly  no- 
ticed. These  symptoms  were  still  present  after  he  was 
convalescent  and  able  to  go  around,  and  after  fluctua- 
tion appeared  (which  was  two  or  three  months  after  his 
recovery  from  fever)  I  lanced  the  tumor  and  it  dis- 
charged pus  rather  freely,  which  it  continued  to  do  for 
more  than  a  year  afterward.  After  trying  in  vain  to 
heal  the  cavity  by  injecting  disinfecting  and  absorbent 
washes,  I  advised  an  operation,  to  which  he  consented, 
and  which  I  performed  as  follows  : 

I  made  a  longitudinal  incision  over  the  seat  of  troub- 
le, and  the  rib  being  found  necrosed  it  was  excised.  It 
was  ascertained  that  the  fifth  and  seventh  ribs  were  also 
affected,  so  the  wound  was  enlarged,  and  all  necrosed 
tissues  were  removed  by  the  bone  scoop.  The  wound 
was  closed  and  dressed  with  gauze  and  was  not  dis- 
turbed   for  several  days,   when   it  was    dressed   again 


MEDICAL    RECORD. 


[September  14,  1895 


as  before.  This  was  repeated  several  times  until  the 
wound  healed  throughout  the  greater  part  of  its 
length  ;  but  it  continued  to  have  a  small  discharge  for 
a  considerable  time  after  the  operation,  which  I  believe 
came  from  the  under  side  of  the  sternum,  as  I  feared  to 
remove  so  much  of  it,  although  the  diseased  part  ap- 
peared to  be  all  removed. 

The  wound  finally  healed  entirely  and  the  patient  (a 
carpenter)  has  resumed  his  work,  and  is  now  an  able- 
bodied  man. 


CONTUSION  AND  LACERATION  OF  THE  AN- 
TERIOR VAGINAL   WALL  AND  URETHRA. 

By   FRANK    OVERTON,    A.M.,    M.D., 

PATCHOGUH,    N.    V. 
LATE    HOUSE    SURGEON,   CITV    HOSPITAL,    NSW    YORK. 

The  literature  concerning  traumatic  injuries  of  the 
vagina  and  urethra  of  external  origin  is  very  scanty. 
In  Keating  and  Coe's  "  Clinical  Gynecology,"  page  262, 
occurs  this  statement  :  "  The  vagina,  from  its  location, 
is  rarely  subject  to  injuries  from  e.xternal  violence. 
There  are  a  few  recorded  cases  in  which  women  have 
fallen  upon  stakes  that  have  deeply  penetrated  the  parts, 
but  such  cases  are  very  rare."  Hence  a  special  interest 
is  attached  to  a  report  of  the  following  case  involving 
lacerations  of  both  the  vagina  and  the  urethra,  with  acute 
distention  of  the  bladder,  ending  in  complete  recovery 
of  function. 

On   February   11,   1895,  Mrs.   L ,  a  short,  stout 

Italian,  weighing  one  hundred  and  seventy-five  pounds, 
aged  thirty-two,  married,  and  six  months  pregnant,  fell 
through  a  hatchway  in  the  ceiling,  striking  astride  alow 
bed-post.  When  seen  three  hours  later  the  sheets  were 
saturated  with  blood  and  she  was  still  bleeding  copi- 
ously and  suffering  considerable  pain,  but  there  were 
no  signs  of  shock. 

A  vaginal  examination  revealed  a  soft  fluctuating 
mass  bulging  the  anterior  vaginal  wall  and  extending 
upward  as  far  as  the  finger  could  reach.  The  cervix  could 
not  be  felt.  On  everting  the  labia;  a  transverse  tear 
in  the  anterior  vaginal  wall  was  noticed  for  the  first  time. 
This  tear  split  the  meatus  of  the  urethra,  and  extended 
on  each  side  as  far  as  the  posterior  limits  of  the  labise 
mioone.  The  urethra  and  the  anterior  vaginal  wall 
were  pushed  upward  and  backward,  entirely  denuding 
the  symphysis  and  an  inch  of  each  pubic  bone.  There 
were  no  external  marks  whatever.  A  speculum  and  de- 
pressor showed  the  cervix  exceedingly  high  up  and 
normal  in  appearance.  After  an  hour's  attempt  at  ca- 
theterization the  urethra  was  recognized  by  its  cord-like 
feel,  and  a  soft  catheter  was  finally  introduced  and  over 
a  quart  of  urine  drawn  with  immediate  disappear- 
ance of  the  tumor  in  the  anterior  vaginal  wall  and  de- 
scent of  the  cervix. 

With  only  the  assistance  of  half  a  dozen  excited 
female  friends  of  the  patient,  and  only  one  basin  of  a 
one-per-cent.  solution  of  lysol  for  the  instruments  and 
for  antisepsis,  the  vaginal  flap  was  sewed  in  place  by 
a  continuous  catgut  suture,  and  a  silkworm-gut  suture 
was  inserted  in  ihe  orifice  of  the  urethra,  the  end  of 
which  was  lacerated  beyond  recognition.  The  soft- 
rubber  catheter  was  left  in  the  urethra. 

On  the  next  day  swelling  and  ecchymosis  appeared 
in  both  labia;  and  buttocks,  which  soon  l)ecame  extreme 
and  threatened  gangrene.  Yet  it  almost  entirely  disaj)- 
peared  at  the  end  of  ten  days  without  special  treatment. 
The  woimd  was  irrigated  twice  a  day  with  a  one-per- 
cent, lysol  solution.  Union  occurred  by  first  intention 
without  rise  of  temperature. 

Some  cystitis  developed,  and  under  irrigations  of 
one-half-per-cent.  lysol  solutions  it  only  increased. 
The  catheter  was  expelled  on  the  sixth  day  during  an 
attack  of  tenesmus,  which,  however,  was  not  trouble- 
some during  convalescence.    The  cystitis  soon  subsided 


and  urine  was  passed  about  every  two  hours.  At  first 
its  flow  could  not  be  controlled,  but  the  intervals  be- 
tween urination  gradually  lengthened  until  within  a 
month  she  had  recovered  almost  full  control  of  the 
bladder. 

On  May  9,  1895,  she  was  delivered  of  a  fine  hoy 
weighing  seven  and  one-half  pounds.  The  scar  pro- 
lapsed out  the  way  of  pressure  against  the  pubic  bone, 
and  convalescence  was  normal. 

On  July  8th  an  examination  showed  only  slight  re- 
mains of  the  scar.  The  orifice  of  the  urethra  was  at 
the  bottom  of  a  slight  conical  depression  surrounded 
by  some  small  tabs.  There  were  no  signs  of  a  stricture 
of  the  urethra,  and  a  soft  catheter  drew  off  one-half  an 
ounce  of  urine  when  introduced  an  inch.  The  patient 
stated  that  she  arose  once  in  the  night  to  urinate,  and 
during  the  day  she  urinated  about  every  four  hours. 
She  could  control  the  desire  to  urinate  for  about  ten 
minutes.  The  only  remaining  symptom  of  the  fall  was 
tenderness  of  the  coccyx. 


ACUTE  TRAUMATIC  TETANUS— CHOPART'S 
OPERATION— DEATH. 

By  JOSEPH  N.   BARNEY,  Jr.,   M.D., 

WOODSTOCK,     VA. 

On    Thursday,    July    11,    1895,    Nettie    D ,  white, 

aged  twelve,  while  playing  about  the  kitchen,  pierced 
the  ball  of  the  right  foot  along  the  axis  of  first  metatar- 
sal bone  with  a  fragment  of  wood.  The  splinter  was 
three-fourths  of  an  inch  long  and  slender.  She  pulled  it 
out  and  continued  running  around  barefoot.  In  the 
evening  an  elder  sister  opened  a  very  small  abscess  at 
place  of  puncture,  allowing  a  single  drop  of  pus  to 
escape.  This  was  repeated  on  Friday  and  Saturday 
following.  At  no  time  was  more  than  a  single  drop  of 
pus  obtained,  and  there  was  almost  no  pain.  Sunday 
morning  the  patient  found,  upon  putting  on  the  right 
shoe,  that  the  ball  of  the  foot  was  rather  tender.  For 
that  reason  she  did  not  goto  Sunday-school,  but  played 
around  all  day.  At  dinner,  Sunday,  she  complained 
several  times  of  slight  difficulty  in  mastication.  Early 
upon  the  morning  of  Monday,  July  15th,  she  awoke 
with  a  feeling  of  stiffness  in  the  muscles  of  the  neck 
and  difficulty  in  opening  the  mouth  wide.  Upon  get- 
ting out  of  bed  to  go  to  another  room  she  could  only 
hold  the  head  far  back  with  comfort. 

I  was  summoned  at  4.30  .^.ji.,and  reached  the  patient. 
two  miles  away,  at  6.  I  found  a  very  stout,  well-devel- 
oped subject ;  pulse,  90  ;  temperature,  99°  F.  ;  respi- 
ration, 20.  No  pain ;  swallowing  good,  as  regards 
liquids.  Slight  convulsive  movements  of  the  masseters 
and  temi)orals  ;  no  opisthotonos.  The  wound  of  the 
foot  was  almost  imperceptible  and  was  only  slightly 
tender  upon  hard  pressure.  I  ordered  ten  grains  chloral 
hydrate  and  ten  grains  sodium  bromide  every  two 
hours,  which  was  taken  with  little  difficulty. 

At  5  P.M.  same  day  returned  with  my  partner.  Dr.  D. 
D.  Carter,  and  found  the  patient  had  been  subject  to 
tetanic  spasms  since  noon.  Swallowing  was  still  good. 
There  was  marked  opisthotonos.  The  spasms  were 
almost  continuous.  The  patient  was  jierfectly  rational 
and  comi)lained  of  no  pain,  except  a  "  tired  feeling  "  in 
the  back. 

.\t  6.30  P.M.,  assisted  by  Drs.  Carter,  Beyer,  and 
Ott,  Chopart's  operation  was  performed.  Some  time 
was  occupied  in  finding  and  ligating  the  plantar  artery. 
Time  of  the  operation  was  fifteen  minutes.  No  excep- 
tional appearance  of  foot  except  venous  stasis  and 
very  dark  blood.  Tiie  jiatient  rallied  well,  less  than 
one  ounce  of  chloroform  having  been  administered,  and 
never  knew  up  to  her  death  that  the  operation  had 
been  performed,  having  no  pain. 

The  tetanic  seizures  recommenced  about  8  p.m.,  and 
at  2  A.M.  Tuesday  morning,  when  I  returned,  were  al- 


September  14,  1895] 


MEDICAL    RECORD. 


most  continuous.  Chloroform  had  been  administered 
in  the  interim  to  the  extent  of  two  ounces.  Pulse, 
150  ;  temperature,  101°  F.  ;  respiration,  65.  Chloral 
was  increased  to  20  grains,  and  probably  five  minutes 
of  rest  was  secured.  The  condition  remained  un- 
changed until  7  .A..M.,  when  the  laryngeal  muscles  were 
tetanized  for  fully  sixty-nine  seconds.  Under  stimu- 
lation with  brandy  she  reacted,  and  shortly  after  the 
pulse  was  160  ;  temperature,  101°  F.  ;  respiration,  90. 
At  7.20  A.M.  she  called  for  water,  swallowing  with 
some  effort,  and  said  she  had  no  pain.  At  7.30  a.m.  a 
tonic  spasm  of  the  laryngeal  muscle  closed  the  scene, 
the  radial  artery  pulsating  for  one  and  a  half  minutes 
after  respiration  had  entirely  ceased,  and  after  the 
pulse  had  ceased  the  flexor  tendons  continued  to  quiver 
for  thirty  seconds.     No  post  mortem  was  obtained. 


CANCER  IN  HUSBAND  AND  WIFE. 
By  E.  H.  smith,  M.D., 

SANTA   CLARA,    CAL. 

Mrs.  P was   sixty-eight  years  of  age  when  I  first 

saw  her.  Stout  and  florid.  Had  always  lived  very 
plainly  and  temperately.  She  was  suffering  from  the  ef- 
fects of  a  previous  paralytic  stroke,  which,  I  have  no 
doubt,  was  due  to  an  embolus,  as  there  was  an  organic 
lesion  of  the  aortic  valves.  The  patient  was  suffering 
from  gastro-enteric  catarrh.  She  was  peculiar,  and  I 
could  get  no  history  from  her  except  by  piecemeal. 
Last  September,  nearly  a  year  and  a  half  after  first  see- 
ing her,  I  was  asked  to  examine  her  right  breast,  and 
found  a  very  large  carcinomatous  mass.  She  had  had 
three  abortions,  no  children  at  term,  and  had  never 
had  any  inflammatory  trouble  with  her  breasts.  Xo 
history  of  anything  specific.  This  breast  broke  down, 
sloughed,  and  ended  in  the  death  of  the  patient  in 
July. 

Mr.  E.  N.  P ,   husband  of  this  pa  lent,  has   tor 

years  complained  of  colic  pains  in  the  abdomen.  He  is 
by  occupation  a  farmer  ;  has  always  been  temperate  and 
has  lived  a  very  quiet  life.  Within  the  last  six  months 
he  has  developed  all  the  characteristic  signs  of  cancer 
of  the  stomach  with  secondary  infiltration  of  the  liver. 
He  has  pain  and  soreness  over  the  stomach  and  liver  ; 
vomits  blood  and  grumous-looking  material,  and  passes 
bloody  mucus  from  the  bowel.  The  liver  is  enlarged, 
extending  nearly  to  the  umbilicus,  nodular,  and  tender. 
The  patient  is  emaciated  and  very  weak  ;  cannot  live 
long.  The  man  is  an  Irish-American,  the  woman  was 
a  native  of  Ireland.  They  were  in  no  way  related. 
No  history  of  heredity  on  either  side  can  be  ob- 
tained. 


THE  ELECTRO-MAGNET   FOR  THE  REMOV- 
AL OF  IRON  PARTICLES  FROM  THE  EVE. 

By  S.  MITCHELL,  M.D., 

HORNELLSVILLE.    N.  V. 

Under  the  heading  "  Accidents  to  the  Eye  while 
Chopping  with  a  Hoe  "  Dr.  W.  L.  Bullard,  of  Colum- 
bus, Ga.,  reports  three  cases  where  pieces  of  steel  were 
extracted  from  the  anterior  chamber  of  the  eye  with 
iridectomy,  and  two  cases  without  iridectomy.  Also 
two  cases  where  the  foreign  body  (a  particle  of  steel 
in  both  cases)  was  found  in  the  vitreous  after  enuclea- 
tion. 

The  doctor  certainly  seems  to  have  met  with  good 
success  in  removing  fragments  of  steel  from  the  ante- 
rior chamber  by  means  of  forceps.  But  I  should  not 
feel  that  I  was  prepared  to  deal  with  these  cases  un- 
less an  electro-magnet  was  a  part  of  my  armamentari- 
um, and  by  its  use  perhaps  save  performing  an  iridec- 
tomy  as  well   as  removing  the  offender  with   greater 


ease.  In  those  cases  where  there  are  strong  probabil- 
ities that  a  piece  of  steel  or  iron  is  lodged  in  the  vit- 
reous chamber,  a  search  with  the  electro-magnet  is 
often  rewarded  by  the  removal  of  the  particle  and 
the  saving  of  the  globe.  And  although  there  may  re- 
main no  useful  vision,  it  is  much  better  than  an  artifi- 
cial eye,  and  the  prospects  that  it  will  become  a  danger- 
ous companion  are  very  slight. 

I  am  now  using  the  Edison  incandescent  light  circuit 
in  my  office,  and  by  means  of  a  converter,  manufact- 
ured by  a  mechanic  in  this  city,  I  am  able  to  use  it 
for  all  kinds  of  galvano-cautery  work.  To  this  con- 
verter I  attach  my  electro-magnet  and  find  that  it  has 
a  much  stronger  attractive  force  than  with  any  stor- 
age battery  that  I  have  ever  used. 

The  electro-magnet  is  the  most  useful  of  all  instru- 
ments where  particles  of  steel  or  iron  are  to  be  removed 
from  the  interior  of  the  globe. 


A   FAMILY    HISTORY    OF    HYDROCELE. 
By  R.    CADWALLADER,    M.D., 


RIVER  .MILLS,    CAL. 


It  is  so  rare  to  find  any  certain  cause  for  hydrocele  of 
the  tunica  vaginitis  testis  that  the  following  family  his- 
tory is  worthy  of  note  : 

On  February  11,  1895,  I  operated  on  a  double  hydro- 
cele in  a  young  man  aged  twenty-eight.  He  told  me 
that  his  elder  brother  had  been  treated  for  the  same 
trouble.  On  June  12,  1885,  I  operated  on  his  father 
for  the  same  thing,  limited  to  the  right  side,  and  from 
him  learned  the  family  history. 

His  father  suffered  from  it  for  years  prior  to  his 
death,  and  of  three  sons  in  the  second  generation  two 
had  the  trouble.  He  himself  only  became  afflicted 
about  the  time  of  his  discharge  from  the  army  in  1865. 
Of  his  six  sons,  two  died  at  nineteen  months  and  three 
years  and  six  months,  apparently  free.  The  third  son 
began  to  be  troubled  at  fifteen  years  of  age  ;  the 
fourth  son,  upon  whom  I  first  operated,  at  sixteen  years 
of  age.  The  fifth  son,  now  seventeen  years  of  a^e,  is 
apparently  free,  but  a  sixth  son,  who  died  in  infancy, 
showed  a  well-marked  tumor  before  his  decease.  Of 
the  six  sons  born  in  the  third  generation  two  infants 
and  one  adult  were  normal,  while  one  infant  and  two 
adults  suffered. 

In  both  cases  I  opened  and  excised  a  large  part  of 
the  greatly  thickened  and  redundant  sac.  My  experi- 
ence has  taught  me  not  to  temporize  with  injections  or 
tapping. 

In  cases  where  the  testicle  must  be  removed,  and 
after  all  castrations,  I  am  in  the  habit  of  passing  two 
or  three  heavy  gut  sutures,  using  a  full  curved  needle, 
from  above  downward,  taking  in  the  layers  of  fascia 
forming  the  canal  and  the  chord,  so  as  to  close  it  for 
all  time.  This  prevents  hernia  ever  taking  place  there 
and  controls  all  hemorrhage  from  that  point.  To  pre- 
vent non-union  from  the  vermicular  movements  of  the 
scrotum  I  find  continued  sutures  are  better  than  inter- 
rupted ones.  Torsion  is  quicker  and  better  than  liga- 
tion also  when  dissecting  out  the  hypertrophied  tunica. 


Creosote  in  Pulmonary  Tubercnlosis. — My  own  exjjer- 
iments,  as  also  those  of  Dr.  Albu,  at  the  Moabit  Hos- 
pital, in  Berlin,  and  of  others,  have  conclusively  shown 
that  the  remedy  has  no  influence  upon  the  disease,  and 
particularly  not  upon  the  growth  and  virulency  of  the 
specific  germ.  Apart  from  its  influence  upon  the 
bronchial  catarrh,  creosote  has  a  value  in  certain 
gastro  intestinal  derangements,  but  the  considerations 
for  its  preference  are  the  same  as  they  would  be  if  the 
])atient  were  not  tubercular  at  all. — Karl  von  Ruck. 

If  Patients  who  abort  regularly,  and  generally  be- 
fore the  fourth  month,  pass  the  fourth  month  success- 
fully tiiey  will  generally  go  to  term. — Parvin. 


384 


MEDICAL   RECORD. 


[September  14,  1895 


J>ocicti3  Reports. 


THE  CANADIAN    MEDICAL   ASSOCIATION. 

T'li'enty-eighth  Annual  Meeting,  held  in  Kingston,  Ont., 
August  2j,  28,  2Q,  and  JO,  iSpj. 

(Special  Report  for  the  Medical  Rhcord.) 

Diagnosis  and  Treatment  of  Eetro-displacements  of 
the  Uterus. — Dr.  A.  Lapthorn  Smith,  of  Montreal, 
read  a  paper  with  this  title.  It  should  be  remembered 
that  this  condition  occurred  in  single  as  well  as  married 
women  ;  and  the  condition  was  not  a  rare  one.  It  was 
more  common  in  women  who  had  miscarried.  It  oc- 
curred often  among  working-girls  from  overlifting,  the 
bowels  being  forced  between  the  anterior  surface  of  the 
uterus  and  the  abdominal  wall.  Another  cause  was  a 
fall  on  the  back.  The  uterus  might  or  might  not  be 
held  down  by  adhesions  ;  it  often  was  merely  locked 
down  by  the  prominence  of  the  sacrum.  The  sjinptoms 
sometimes  simulated  peritonitis,  the  patient  suffering 
acute  pain  in  the  pelvis  and  back  and  being  unable  to 
pass  water,  the  abdomen  being  distended  and  tender  ; 
all  of  which  would  be  relieved  by  replacement.  The 
doctor  then  pointed  out  that  the  round  ligaments  con- 
tained muscular  fibres,  and  he  drew  attention  to  their 
nerve-supply  and  functions.  During  muscular  efforts 
they  drew  the  uterus  forward  and  prevented  the  intes- 
tines from  descending  in  front  of  it.  In  women  run 
down  in  health  these  little  muscles  suffered  in  common 
with  the  general  muscular  system  and  allowed  too  much 
motility  of  the  organ,  thus  predisposing  to  the  displace- 
ment. Other  pathological  conditions  were  found  asso- 
ciated with  this  condition — engorgement  of  the  organ 
due  to  obstruction  of  the  venous  outflow  ;  adhesions, 
diseased  and  displaced  ovaries  and  tubes.  The 
patient  often  suffered  much  on  locomotion  and  the 
uterus  was  tender  and  painful.  Besides  miscarriages 
and  abnormal  labors  as  a  factor  in  the  causation,  the 
reader  of  the  paper  added  the  use  of  the  pad  and  binder 
after  labor.  The  diagnosis  was  usually  easy  in  emaci- 
ated women.  The  points  in  the  differential  diagno- 
sis were  alluded  to.  In  an  uncomplicated  case,  by 
placing  the  woman  in  the  knee-chest  position  and  intro- 
ducing a  Sims  speculum,  replacement  would  follow.  If 
the  fundus  was  locked  under  the  prominence  of  the 
sacrum,  the  anterior  lip  of  the  cervix  should  be  grasped 
and  drawn  downward  and  backward  ;  this  would  free 
it  if  there  were  no  adhesions.  In  cases  where  adhe- 
sions were  present  he  advised  the  application  of  Church- 
ill's tincture  of  iodine  to  the  vault  of  the  vagina  and 
tampons  of  boro-glycerine.  After  replacement,  the 
organ  may  be  held  in  place  by  a  soft-rubber  pessary 
with  a  special  spring.  This  should  be  cleansed  fre- 
quently. The  speaker  then  detailed  at  length  Alex- 
ander's operation  and  that  of  ventro-fixation  for  the 
maintenance  of  the  organ  in  the  correct  position,  the 
first  being  applicable  to  those  cases  where  the  uterus 
was  free,  the  second  to  those  where  adhesions  were 
present. 

Dr.  Edward  Farrell,  of  Halifax,  said  that  in 
operating  for  ventro- fixation  he  had  an  assistant  who 
held  the  uterus  up  with  a  sound  :  by  doing  this  a  small- 
er incision  would  do.  In  a  case  he  had  operated  on, 
four  days  after  the  operation  she  showed  signs  of  in- 
testinal obstruction.  The  patient  was  placed  in  the 
Trendelenburg  position  and  the  hips  shaken  strongly, 
when  a  severe  pain  announced  that  the  obstruction  had 
disappeared.  The  bowel  was  probably  pressed  between 
the  anterior  wall  of  the  uterus  and  the  abdominal  wall. 

Sir  William  Hixgston  said  that  in  these  cases  it 
was  not  often  necessary  to  resort  to  an  Alexander  oper- 
ation or  the  operation  of  ventro-fixaiion,  if  patience  were 


exercised.  He  favored  the  use  of  the  stem  pessary  ;  he 
preferred  the  ventro-fixation  to  the  Alexander  operation. 

Experimental  Cachexia  Strumipriva. — Dr.  Wesley 
Mills  read  a  paper  on  this  subject.  Before  presenting 
his  paper  he  showed  two  cats  from  which  he  had  re- 
moved the  thyroid  glands  and  a  dog  from  which  he 
had  removed  one-half  the  gland.  Although  the  opera- 
tion on  the  cats  had  been  done  at  the  same  time,  yet 
one  showed  more  advanced  symptoms  than  the  other, 
the  latter  exhibiting  the  most  resisting  power.  The 
cats  seemed  to  be  in  a  sort  of  stupor,  were  very 
much  emaciated,  although  they  had  been  operated 
on  but  forty-eight  hours  before  ;  one  of  them  refused 
food  ;  in  each  was  seen  a  tonic  spasm  when  it  at- 
tempted to  perform  any  muscular  exertion  ;  there  was 
considerable  dyspnoea,  considerable  facial  movement 
being  noticed  at  each  inspiration.  The  dog  had  not 
suffered  nearly  so  severely  and  was  recovering.  The 
doctor's  paper  dealt  with  the  various  theories  given  as 
to  the  function  of  the  thyroid  gland.  He  dwelt  on  the 
difficulty  of  ascertaining  just  the  exact  importance  any 
gland  was  in  its  effects  upon  the  blood,  on  account  of 
the  complex  composition  of  the  blood.  The  thyroid 
had  evidently  to  do  with  the  blood  formation  ;  that 
seemed  to  be  apparent  from  the  fact  that  the  blood  be- 
came poor  in  red  corpuscles  and  unduly  rich  in  white 
ones  after  the  removal  of  the  gland.  There  was  prob- 
ably a  great  change  in  the  plasma  as  well.  Recent 
investigations  had  shown  that  the  plasma  was  some- 
thing more  than  a  fluid  in  which  the  corpuscles  floated. 
It  had  been  suggested  that  the  pituitary  body,  on  ac- 
count of  its  similarity,  had  something  of  the  same 
function  as  the  thyroid  ;  but  it  was  a  mistake  to  sup- 
pose that,  because  they  were  anatomically  similar,  their 
functions  were  the  same.  The  speaker  pointed  out 
that  the  carnivora  were  most  affected  by  the  removal 
of  the  thyroid,  the  herbivora  less,  and  the  rodents 
not  affected  at  all.  Total  extirpations  in  man  were 
rare  ;  in  man  and  in  the  monkey  the  result  of  removal 
was  myxoedema. 

Presidential  Address. — Dr.  William  Bayard,  of  St. 
John,  N.  B.,  in  his  address  thanked  them  for  giving 
him  the  presidency.  The  physician's  profession,  he 
said,  was  one  of  the  highest,  and  instead  of  its  being 
named  last  in  the  learned  professions — diWnity,  law. 
medicine — it  should  come  second. 

When  a  hospital  was  a  State  institution,  the  doctors 
should  be  paid  the  same  as  other  officials.  Every 
properly  organized  hospital  board  should  have  one  or 
more  medical  men  on  it.  The  philanthropic  work  of 
the  profession  did  not  stop  with  the  free  work  it  did. 
It  was  estimated  that  sanitary  measures  in  England 
saved  the  lives  of  seventy  thousand  per  year. 

In  referring  to  the  "  cramming  "  system  in  schools, 
he  said  education  should  not  be  pressed  to  the  sacri- 
fice of  health.  He  recommended  an  investigation  into 
the  schools  where  "cramming"  of  scholars  was  car- 
ried on.  He  also  said  he  regarded  the  use  of  alcohol 
as  the  greatest  curse  of  the  age.  He  pointed  out  that 
the  medical  profession  had  no  representation  in  Par- 
liament, which  was  a  sad  lack  to  the  country  as  well  as 
to  the  profession. 

In  ending  a  most  interesting  address,  the  President 
recommended  the  establishment  of  an  institution  for 
inebriates,  to  be  supported  by  the  government,  as  it 
obtained  the  profit  from  the  traffic  which  caused  them. 

Sir  James  Grant  moved  the  adoption  of  the  ad- 
dress. He  said  that  it  the  medical  profession  gave 
their  service  to  the  charitable  institutions  gratuitously, 
those  who  were  able  to  pay  should  not  be  allowed  to 
get  free  doctors  at  the  hospitals.  The  government 
should  employ  someone  to  carry  on  the  science  of  bac- 
teriology for  the  i)rotection  of  the  public.  He  said  that 
the  idea  of  educating  the  public  up  to  an  university 
standard,  for  which  they  were  never  intended,  was 
wrong,  and  that  there  was  too  great  a  tendency  at  the 
present  age  for  young  farmers  to  work  into  the  city  and 


September   14,   1895] 


MEDICAL   RECORD. 


385 


fill  up  the  workshops  and  professions.  Sir  James  also 
claimed  that  the  abuse  of  alcohol  could  only  be  ban- 
ished by  education. 

Physical  Training-  and  Development  as  a  Thera- 
peutic Measure. — Dr.  B.  E.  McKenzie,  of  Toronto, 
read  a  paper  with  this  title.  He  drew  a  strong  distinc- 
tion between  "athletics,"  an  exercise  for  sport,  and 
"  g3'mnastics  "  combined  with  "  massage,"  being  an  ex- 
ercise not  only  for  the  development  of  muscular 
strength  and  proficiency  in  certain  lines,  but  for  the 
improvement  in,  and  often  obliteration  of,  serious  de- 
formities. He  spoke  mostly  with  regard  to  the  physi- 
cal training  of  women,  especially  those  who  suffered 
from  muscular  or  osseous  abnormalities.  He  claimed 
that  the  woman  of  modern  times  is  not  to  be  compared 
with  her  ancestor  of  ancient  times  in  the  matter  of 
physical  development,  and  that  want  practically  arose 
from  the  evils  of  modern  dress.  The  speaker  asserted 
that  by  careful  physical  training,  even  those  afflicted 
with  spinal  curvature  may  be  helped  materially,  and 
perhaps  entirely  cured.  He  strongly  advocated  a  sys- 
tem of  training  (by  classes,  if  possible).  The  patient 
was  to  be  placed  before  a  mirror,  and  those  muscles 
upon  which  the  deformities  depend  are  to  be  brought 
into  forced  action  according  to  a  graduated  system 
prescribed  by  the  trainer,  and  the  proper  position 
taken.  He  further  said  that  such  treatment  invaria- 
bly tended  to  aid  the  functions  of  all  the  vital  organs, 
to  improve  appetite,  mental  capacity,  and  all  the  physi- 
ological functions  of  the  body,  at  the  same  time  in- 
creasing the  chest  measure,  height,  and  weight. 

Dr.  McKenzie  then  gave  the  history  of  one  or  two 
cases  treated  by  gymnastics,  one  being  of  a  girl  of 
twenty-two  with  spinal  curvature  accompanied  with 
pain,  in  which  the  treatment  was  entirely  successful  ; 
and  another  of  a  boy  of  seven  years,  with  rota-lateral 
curvature,  accompanied  by  chorea.  Complete  control 
of  the  muscles  was  gained  in  less  than  a  week,  and  en- 
tire recovery  ensued.  He  quoted  Dr.  Crighton  Browne 
as  a  strong  advocate  of  physical  training  in  muscular 
abnormalities,  who  claims  that  the  system  is  also  of 
benefit  to  criminals  and  imbeciles.  The  speaker  con- 
cluded with  the  assertion  that  the  medical  profession 
did  not  pay  enough  attention  to  this  subject  ;  that 
modem  methods  of  living  render  it  imperative,  and 
that  the  treatment  must  be  used  in  connection  with 
current  approved  methods.  He  also  recommended 
that  physical  training  should  be  carried  on  in  all 
schools. 

Dr.  'Louis  A.  Sayre,  of  New  York,  said  that  the 
subject  of  physical  training  was  one  of  the  greatest  im- 
portance that  could  be  brought  before  the  profession. 
He  was  glad  to  see  that  it  was  receiving  more  recogni- 
tion than  formerly.  Physical  training  was  one  of  the 
principal  elements  in  the  sustenance  of  a  nation.  It  had 
a  marked  effect  on  the  mental  and  moral  force  of  a 
people.  A  good  mental  condition  was  dependent  on 
proper  nutrition  and  exercise.  The  training,  he  said, 
must  be  systematic.  He  then  spoke  of  the  causes  of 
lateral  curvature  and  commended  the  treatment  that 
Dr.  McKenzie  had  advocated — of  mental  and  physical 
training,  using  no  instruments,  no  machinery  of  any 
kind,  plaster  of  Paris  supports,  or  splints  of  any  sort.  A 
judicious  teacher  was  necessary  to  train  the  children 
in  these  exercises.  He  related  the  history  of  a  case 
that  had  come  under  his  attention,  in  which  the  patient, 
a  small  boy,  weak  and  frail  in  body,  was  mentally  an 
imbecile.  Under  the  treatment  the  progress,  both 
physical  and  mental,  was  exceedingly  gratifying.  By 
continuance  of  the  treatment  he  was  sure  that  the  boy 
would  make  a  useful  man. 

Dr.  Regin.\ld  H.  Sayre,  of  New  York,  said  that 
under  this  treatment  he  had  found  that  the  life  of  a 
child  was  changed  from  that  of  a  mere  animal  to  that 
of  a  rational  human  being.  To  those  who  had  not 
witnessed  the  results  of  the  treatment  it  would  be  a 
revelation.     He  spoke  more  particularly  of  the  effects 


of  training  in  certain  form  of  rickets.  To  properly 
treat  these  cases  it  was  absolutely  necessary  that  the 
physician  exercise  a  very  great  deal  of  patience  and 
perseverance.  This  system  of  treatment  had  suffered 
because  of  the  great  numbers  of  people  who  had  gone 
into  the  business  who  understood  little  or  nothing  about 
it.  The  effects  of  proper  treatment  were  particularly 
noticeable  on  the  muscular,  nervous,  and  circulatory 
systems.  In  certain  advanced  cases  where  the  bones 
were  deformed  so  that  walking  was  difficult,  he  advised 
the  use  of  supports  until  the  muscles,  unaided,  were 
strong  enough  to  support  the  patient.  He  then  referred 
to  the  necessity  of  improvement  in  school  in  regard  to 
exercises  and  gymnastics.  He  also  pointed  out  the 
danger  of  over-training,  as  was  seen  in  those  training 
for  athletic  contests. 

Dr.  Roddick,  of  Montreal,  gave  his  experience 
with  these  cases.  In  certain  cases  he  had  found  that, 
in  addition  to  the  training,  supports  were  needed, 
especially  in  the  intervals  between  the  exercises.  He 
had  secured  a  competent  instructress.  It  was  absolutely 
necessary  that  this  training  should  be  relegated  to 
someone  who  would  perform  the  duties  intelligently. 
He  could  speak  in  the  highest  terms  of  this  line  of 
treatment  in  these  spinal  cases.  He  said  that  in  the  less 
pronounced  cases  a  cure  could  certainly  be  promised. 
The  speaker  then  entered  into  a  classification  of  these 
cases,  and  dealt  with  the  appropriate  form  of  treatment 
for  each.  He  said  the  mistake  was  of  ten  made  of  de- 
veloping the  muscles  on  the  strong  side  overmuch  and 
thus  aggravating  the  mischief.  He  referred  to  recent 
observations  he  had  made  in  Egypt  in  regard  to  spinal 
deformity.  He  was  surprised  to  learn  that  they  had  no 
cases  of  this  sort  there.  He  believed  this  was  due  to 
the  fact  that  they  were  in  the  habit  of  having  the  girls 
carry  water-bottles  on  the  head  ;  in  this  way  the  muscles 
of  the  head  and  trunk  were  strengthened.  He  had  in- 
troduced this  principle  in  his  classes — of  having  those 
under  training  carry  weights  on  their  heads  as  a  part  of 
the  exercises  they  perform  for  the  correction  of  their 
deformity. 

Surgery  of  the  Brain. — Mr.  I.  H.  Cameron,  of  To- 
ronto, read  the  address  in  surgery,  taking  for  his  sub- 
ject "  The  Present  Status  of  Cerebral  Surgery."  He 
pointed  out  the  great  strides  that  had  been  made  in 
this  department  of  surgery  during  the  past  twenty 
years.  He  commented  particularly  on  the  work  of 
McKeowen.  The  speaker  dealt  first  with  the  matter 
of  fractures  and  their  surgical  treatment  ;  then  with 
the  question  of  hemorrhage,  meningeal  and  cerebral, 
and  its  treatment.  The  subject  of  tumors,  cysts,  and 
abscesses  was  then  taken  up.  Some  references  were 
then  made  to  the  application  of  surgery  to  diseased 
states  of  the  brain. 

Sarcoma  of  the  Medtdla. — Dr.  J.  E.  Graham,  of 
Toronto,  read  a  paper  giving  the  history  of  a  case  of 
sarcomatous  tumor  of  the  medulla  oblongata.  The 
patient,  a  man  fifty-two  years  of  age,  in  active  life,  con- 
tracted typhoid  fever,  and  subsequently  la  grippe,  about 
a  year  before  the  doctor  saw  him,  recovery  ensuing  in 
about  three  months.  Some  time  later,  on  returning 
home  earlier  than  usual,  he  fell  on  entering  the  house, 
bruising  his  head  over  the  occipital  protuberance. 
There  was  slight  nausea,  but  ultimate  recovery.  At  a 
later  date  the  patient  showed  symptoms  of  nervousness, 
irritability,  disturbed  sleep,  failing  eye- sight,  and  an  in- 
ability to  stand  alone.  The  sexual  functions  were  nor- 
mal. In  walking  he  turned  to  the  left  side.  His  thirst 
was  considerable  at  times.  Still  later  he  experienced 
numbness  of  left  side  of  face,  neck,  and  arm,  sudden 
vomiting,  hesitation  of  speech,  etc.  His  sense  of  touch 
was  normal,  as  was  also  his  pulse  and  temperature. 
There  was  no  muscular  atrophy.  He  complained  of 
headache  in  the  occipital  region  and  pain  in  the  thorax. 
The  treatment  consisted  in  the  administration  of  potas- 
sium iodide  and  artificial  foods.  Pneumonic  symptoms 
set  in  at  the  last,  with  a  rapid  consolidation  of  both 


386 


MEDICAL   RECORD. 


[September  14,  i! 


lungs,  the  temperature  rising  to  102°  F.  Death  ensued. 
On  post-mortem  examination  a  sarcomatous  tumor  was 
found  in  connection  with  the  restiform  body,  5  mm.  by 
15  mm.  in  size.  The  tumor  consisted  mostly  of  round 
cells,  with  a  few  spindle-shaped  ones  interspersed,  and 
was  plentifully  supplied  with  blood-vessels. 

Dr.  Graham  quoted  many  authorities  describing  some- 
what the  same  condition,  showing  that  the  case  in 
question  was  almost  unique.  He  also  showed  charts  of 
the  position  of  the  tumor. 

Removal  of  the  Membrana  Tympani  and  the  Ossicles. 
— This  was  the  title  of  a  paper  by  Dr.  F.  Buller,  of 
Montreal.  This  surgical  procedure  for  the  relief  of 
chronic  otitis  of  the  middle  ear,  he  said,  since  its  intro- 
duction in  1873,  had  been  brought  prominently  before 
the  profession.  It  had  proved  to  be  a  means  of  bene- 
fit in  the  obstinate  cases.  He  pointed  out  the  difficul- 
ties in  handling  these  cases,  particularly  when  the  bony 
structures  had  become  involved  in  the  inflammatory 
process.  The  essayist  referred  to  the  other  methods 
that  had  been  adopted  for  the  treatment  of  this  con- 
dition, particularly  to  that  of  clearing  out  the  tym- 
panum through  the  mastoid.  By  removal  through  the 
external  meatus,  the  method  was  comparatively  easy, 
and  the  patient  able  to  go  about  his  work  the  next  day. 
Even  when  the  discharge  recurred  there  was  a  much 
better  chance  for  drainage  than  before.  Antiseptic 
cleansing  measures  would  be  more  efficient.  Marked 
improvement  in  the  hearing  usually  followed  this  form 
of  treatment,  especially  where  there  was  no  labyrinthine 
complication.  The  thickened  tympanic  structures  had 
become  functionless  and  were  better  out  of  the  way. 
The  great  object  in  operating  was  to  free  the  patient 
from  a  constant  menace  to  life.  The  general  practi- 
tioner and  the  public  were  not  sufficiently  aware  of  the 
gravity  of  this  condition.  Meningitis  often  followed 
the  neglect  of  treatment,  and  the  patient  was  often  mis- 
takenly said  to  have  succumbed  from  typhoid  fever. 
The  doctor  then  gave  the  outlines  of  a  few  cases  show- 
ing the  beneficial  results  of  this  operation. 

Skin  Clinic. — A  skin  clinic  was  conducted  by  Drs. 
J.  E.  Graham,  of  Toronto,  A.  R.  Robinson  and  L. 
Duncan  Bulkley,  of  New  York.  The  first  patient 
was  a  woman  whose  hair  had  fallen  out  in  the  spring 
of  1890,  commencing  in  small  areas,  and  extending. 
She  had  consulted  a  physician  who  applied  croton 
oil  ;  she  was  bald  for  two  months.  The  hair  grew 
again"  for  three  months  and  she  had  quite  a  crop  ; 
but  it  fell  out  again.  Various  forms  of  treatment  had 
been  adopted,  but  without  avail.  During  the  last  year 
her  liead  was  hot  at  times  and  covered  with  perspira- 
tion. In  his  remarks,  the  speaker  said  that  all  the 
typical  signs  of  alopecia  areata  were  not  seen  in  this 
case.  The  diagnostic  points  he  then  cited.  It  ap- 
peared to  him  that  there  were  two  classes  of  cases — 
the  parasitic  and  the  non-parasitic  ;  for  he  had  known 
of  several  cases  occurring  in  one  household.  The 
]iathology  was  then  dealt  with.  As  to  treatment,  tonics 
internally  ;  and  crysophanic  acid  and  the  mercurial 
ointments  were  recommended  externally. 

Dr.  Robinson  ascertained  from  the  patient  that  the 
hair  had  begun  falling  out  in  a  small  spot,  increasing 
in  area  by  peripheral  extension  till  it  reached  a  diam- 
eter of  two  or  three  inches.  This  was  characteristic. 
Examining  the  scalp  with  the  naked  eye,  little  or  no 
change  could  be  seen.  He  leaned  to  the  parasitic  the- 
ory as  to  causation.  Examining  the  individual  hair 
microscopically,  it  would  be  seen  to  be  atrophied.  The 
skin  would  also  be  seen  to  contain  inflammatory  prod- 
ucts, to  be  seen  in  the  subpapillary  layer,  and  to  a 
limited  extent  in  the  epidermis.  If  a  large  number  of 
spots  was  seen,  it  was  an  indication  that  a  large  amount 
of  scalp  was  involved,  and  that  cure  would  not  be  ef- 
fected until  all  the  hair  had  fallen  out.  Keeping  in 
mind  the  causation,  he  believed  in  bringing  the  leuco- 
cytes into  play.  Applications  of  croton  oil,  fifty  per 
cent.,  would  give  a  good  migration. 


Dr.  Bulkley,  examining  the  head  with  a  lens,  said 
that  small  points  could  be  seen,  which  were  broken 
hairs  ;  these  were  to  be  seen  among  the  small  finer 
hairs  present.  He  considered  the  cause  to  be  tropho- 
neurotic. It  might  be  due  to  a  micro-organism,  but 
not  to  a  parasite  ;  for  the  patient  might  rub  her  head 
against  any  other  without  fear  of  communicating  the 
disease.  With  the  microscope  the  diagnosis  from  tinea 
tonsurans  could  be  easily  made  out.  Certain  forms  of 
seborrhoea  attacked  the  hair  similarly,  but  the  absence 
of  inflammation  excluded  that  diagnosis.  The  prog- 
nosis was  hopeful,  if  treatment  was  continued  long 
enough.  With  the  neurotic  theory  in  mind,  he  would 
give  nerve  tonics — phosphorus,  strychnia  internally.  In 
addition,  he  would  correct  errors  in  diet,  and  recom- 
mend foods  containing  fats  and  phosphorus  to  supply 
nutriment  to  the  hairs.  Externally  he  had  found  ap- 
plication of  a  saturated  carbolic  acid  solution  produce 
a  crop. 

A  clinic  on  psoriasis  and  eczema  seborrhceacum  was 
continued,  the  same  three  gentlemen  contributing. 

The  Cold  Bath  in  Typhoid  Fever.— Dr.  William  Os- 
LER,  of  Baltimore,  read  a  paper  on  "  Five  Years'  Expe- 
rience with  the  Cold  Bath  Treatment  of  Typhoid 
Fever."  He  quoted  statistics,  showing  the  death-rate 
to  be  6.3  per  cent,  under  this  form  of  treatment,  which 
was  considerably  less  than  that  obtained  from  any 
other  method  of  treatment.  Statistics  from  other  hos- 
pitals throughout  the  world  agreed  with  his.  The 
Brandt  system  he  confessed  he  had  not  followed  fully  : 
Markedly  asthenic  cases  ;  patients  with  very  high  tem- 
perature, rapid  pulse,  meteorism  ;  cases  in  which  se- 
vere complications,  such  as  hemorrhage,  perforation, 
pneumonia  were  present ;  cases  in  which  the  tempera- 
ture remained  under  i02j^°  F.;  and  mild  cases — all  of 
these  did  not  receive  the  cold  bath.  In  these — fifty- 
eight  cases — the  death-rate  was  10.2.  The  effects  of 
the  cold  bath  were  not  only  antipyretic,  but  beneficial 
to  the  system  in  many  ways.  The  dietary  consisted 
wholly  of  milk,  broths,  and  egg  albumin.  The  essayist 
then  referred  to  particular  cases,  pointing  out  any  spe- 
cial features  in  the  way  of  symptoms  or  complications. 
He  outlined,  in  reply  to  question,  the  way  in  which  the 
baths  were  given.  Many  cases  of  typhoid,  he  believed, 
died  from  over- medication — from  too  active  antipyretic 
treatment,  from  too  much  digitalis,  or  too  much  nitro- 
glycerine, or  too  many  doctors. 

Dr.  W.  S.  Muir,  of  Truro,  N.  S.,  said  that  in  Truro 
they  had  two  natural  water-courses  that  had  been 
closed  up  since  the  town  had  been  incorporated. 
But  during  the  fall  freshets  they  had  overflowed  for 
three  or  four  days.  They  rarely  had  spring  typhoid, 
but  in  August,  following  the  freshets,  they  always  had 
an  epidemic  of  typhoid.  In  every  case  that  had  oc- 
curred since  1S90  he  had  marked  on  a  map  the  houses 
in  which  the  cases  had  occurred.  It  was  curious  to 
note  the  line  which  the  typhoid  had  taken.  From  that 
time  up  till  August  of  this  year  he  had  had  159  cases, 
with  a  death-rate  of  8.1  per  cent.  In  only  one  single 
instance  could  he  trace  the  typhoid  to  the  water-sup- 
ply. The  private  practitioner  got  his  cases  earlier  than 
his  hospital  confrere,  and  thus  had  a  better  chance  to 
cope  with  the  disease.  He  strongly  condemned  the 
use  of  antipyretics.  In  his  experience  it  was  safer  to 
watch  the  pulse  than  the  temperature.  His  cases  with 
bad  pulses  died.  He  had  not  yet  seen  a  case  of  hemor- 
rhage of  the  bowels  die,  when  the  hemorrhage  came 
on  early  in  the  second  week.  Invariably  the  fatal 
hemorrhages  came  on  during  the  third  or  fourth  week. 

Operative  Treatment  of  Injuries  to  the  Head. — Dr. 
McCosH,  of  Xew  York,  read  a  paper  on  this  subject. 
The  paper  dealt  first  with  fractures  and  their  compli- 
cations, the  diagnosis,  and  appropriate  surgical  treat- 
ment. The  technique  of  the  operations  was  outlined 
and  some  interesting  cases  reported. 

Dr.  James  Sill,  of  Montreal,  spoke  of  the  necessity 
of   early  interference   in   those   cases  where  pressure 


September    14,  1895] 


MEDICAL   RECORD. 


S}Tnptoms  were  present.  To  open  the  cranium  was  a 
comparatively  safe  operation.  It  was  far  safer  to 
operate  than  not  to.  Strict  asepsis  was  of  the  utmost 
importance. 

Dr.  George  A.  Peters,  of  Toronto,  pointed  out  the 
necessity  of  enlarging  the  wound  in  cases  of  punctured 
fractures,  to  ascertain  whether  or  not  there  were  any 
spicules  of  bone  impinging  on  the  brain  substance.  If 
the  surgeon  kept  the  wound  aseptic  there  was  little 
danger  of  hernia  cerebri.  He  thought  it  wise  to  retain 
the  dura  mater  wherever  possible. 

Dr.  W.  W.  White,  of  St.  John,  N.  B.,  related  the 
history  of  several  cases  that  had  come  under  his  notice. 
The  first  was  an  operation  for  depressed  bone  in  a  coal- 
heaver  who  had  been  struck  with  a  piece  of  coal.  The 
doctor  used  a  chisel  and  mallet  in  operating.  Perfect 
recovery  ensued.  He  also  related  the  case  of  a  child 
that  had  received  a  fall  followed  by  paralysis  of  the 
right  side,  accompanied  with  loss  of  speech,  the  dumb- 
ness lasting  six  months.  Relief  followed  the  absorp- 
tion of  the  clot. 

Address  in  Medicine. — Dr.  Edward  Farrell,  of 
Halifax,  delivered  the  address  in  medicine.  The  ad- 
dress dealt  with  the  wonderful  advancement  that  had 
been  made  in  recent  years  in  the  various  departments 
of  medicine.  He  outlined  the  advances  that  had  been 
made  in  clinical  medicine  and  morbid  pathology,  as 
well  as  in  the  more  recent  study  of  bacteriolog)'.  He 
pointed  out  the  immense  saving  of  life  effected  by  the 
study  of  sanitary  science.  He  spoke  particularly  of 
the  names  of  men  eminent  in  medicine  who  had  worked 
all  their  lives  in  the  investigation  of  epidemic  diseases, 
and  through  whose  influences  these  scourges  of  the 
human  race  were  becoming  things  of  the  past.  He  held 
that  states  were  not  la^^sh  enough  with  grants  for  the 
furtherance  of  scientific  research,  particularly  those  of 
Eiiglish-speaking  peoples. 

New  Eemedies  in  Dermatology. — Dr.  L.  Duncax 
Bulklev,  of  New  York,  read  a  paper  on  the  newer 
remedies  in  skin  diseases.  Among  those  used  in  local 
treatment  he  referred  more  particularly  to  the  value  of 
resorciii,  ichthyol,  europhen,  aristol. 

Mechanical  Dysmenorrhoea. — Dr.  J.  Campbell,  of 
Seaforth,  read  a  paper  on  dysmenorrhoea,  accompanied 
by  anteversion  of  the  uterus  and  stenosis  of  the  os  in- 
ternum. He  outlined  the  treatment  as  being  tirst, 
rapid  dilatation  with  applications  to  the  endometrium, 
afterward  with  galvanism,  followed  by  laparotomy  with 
extirpation  of  both  tubes  and  ovaries  ;  a  complete  cure 
resulting.  The  ovaries  on  removal  showed  a  cystic 
condition  which  seemed  to  be  the  only  element  to  ac- 
count for  the  symptoms  of  the  dysmenorrhoea  which 
persisted  after  the  dilatation. 

Early  Treatment  of  Skin  Cancer. — Dr.  A.  R.  Robin- 
sox,  of  New  York,  read  a  paper  on  "  The  Importance 
of  Early  Treatment  in  Cutaneous  Cancer."  The  doc- 
tor pointed  out  and  illustrated  with  drawings  the  path- 
ological condition  present  in  the  varied  classes  of  epi- 
thelial growths,  and  showed  the  relation  the  progress 
of  the  clinical  symptoms  bore  to  the  pathological  con- 
dition, from  a  study  of  which  rational  treatment  could 
be  decided  upon.  Cancer  was,  he  contended,  at  first 
purely  a  local  disease  and  quite  amenable  to  cure  if  re- 
moved before  the  deeper  structures  were  involved.  In 
the  cure  of  these  cases  the  essayist  said  that  he  never 
used  the  knife.  He  condemned  strongly  the  usage  of 
applications  of  nitrate  of  silver  to  small  growths  of  a 
suspicious  character.  This  often  only  aggravated  the 
mischief. 

Thyroid  Feeding  in  Stupor. — Dr.  C.  K.  Clarke,  of 
Kingston,  read  a  paper  on  this  subject.  He  had  ob- 
served, as  had  been  done  before,  the  effects  of  acute 
disease  on  these  cases  of  stupor,  how  that  it  benefited 
them — in  some  cases  effecting  a  complete  cure.  In  the 
first  case  reported  the  patient  was  almost  a  hopeless 
dement.  Upon  the  administration  of  the  thyroid  e.x- 
tract  improvement  began,  which  gradually  progressed 


until  the  cure  seemed  to  be  next  to  complete  :  when 
suddenly  the  patient,  without  apparent  cause,  relapsed 
back  completely  into  his  former  condition.  In  several 
other  cases  which  the  doctor  reported  the  effects  were 
well  marked,  a  permanent  cure  resulting.  The  doses 
given  went  as  high  as  twenty  grains. 

Hip-joint  Disease. — Dr.  Lewis  A.  Savre,  of  New 
York,  then  gave  a  clinic  on  "  Hip  joint  Disease."  Two 
patients  were  shown.  Dr.  Sayre  showed  how  he  con- 
ducted the  examination  of  a  patient  suft'ering  from  this 
trouble.  The  patient  was  completely  stripped  from 
the  chest  downward,  and  two  tapes  were  applied  to  the 
front  of  the  body,  the  one  reaching  from  the  ensiform 
cartilage  to  the  pubis,  the  other  joining  the  anterior 
superior  spinous  processes.  These  had  to  be  kept  at 
right  angles.  It  was  found  that,  with  the  spine  held 
well  down  to  the  hard  table,  that  the  sound  leg  could 
be  tilted  and  turned  in  any  direction  without  tilting  the 
pelvis,  the  sick  limb  being  held  flexed  to  such  a  degree 
as  to  allow  the  back  to  be  kept  flat.  Upon  then  at- 
tempting to  straighten  the  leg  the  diseased  side  of  the 
pelvis  would  tilt  up.  It  was  shown  that  while  slight 
traction  was  made  in  the  line  in  which  the  limb  was, 
when  flexed  to  be  comfortable,  that  ease  was  at  once 
experienced.  This  indicated  the  line  of  treatment — 
to  fix  the  joint  so  that  the  leg  would  be  held  in  this 
position  and  to  make  slight  traction.  Then  to  grad- 
ually straighten  while  the  child  remained  on  his  back. 
At  the  end  of  two  or  three  weeks,  when  the  limb  was 
straight,  a  fixation  splint  could  be  applied  and  the 
child  allowed  to  get  out  into  the  open  air.  This  was 
the  method  to  pursue  if  suppuration  and  abscess  had 
not  set  in. 

Acute  Uraemia. — Dr.  McPhedrax  then  read  a  paper 
on  "  Acute  Ursmia,  Followed  by  Gangrenous  Abscess 
of  the  Lung."  The  patient,  a  man  aged  fifty-eight, 
had  for  some  time  been  failing  in  health,  the  manifes- 
tations of  the  decline  being  shown  by  vertigo,  fre- 
quency of  micturition,  constipation,  disagreeable  taste 
in  the  mouth,  hard  pulse,  etc.  He  had  a  convulsion, 
sudden  in  its  onset  and  severe  in  character.  It  was 
followed  by  prolonged  coma.  The  second  week  after 
it  was  noticed  that  his  breath  was  very  foul,  and  his 
sputum  showed  the  presence  of  elastic  fibres.  Albu- 
min was  present  in  large  quantity  in  the  urine.  Signs 
of  change  in  the  lung  were  noted  by  physical  examina- 
tion. There  were  recurring  attacks  of  hemorrhage, 
and  at  three  distinct  periods  the  breath  smelled  gan- 
grenous. Under  treatment  improvement  took  place, 
followed  by  recovery.  The  condition  of  the  lung  the 
reader  believed  to  be  due  to  degeneration  of  the  pul- 
monar}-  artery  primarily.  Beside  the  hygienic  treat- 
ment diuretin  was  administered  in  15-grain  doses  every 
four  hours. 

Ophthalmometry. — Dr.  R.  A.  Reeve  read  a  paper  in 
which  he  pointed  out  the  great  value  of  the  ophthal- 
mometer in  ascertaining  the  presence  of  astigmatism 
and  other  refractive  errors.  He  showed  the  superior- 
ity of  this  instrument  over  other  appliances  formerly 
used.  By  means  of  a  photograph  he  demonstrated  the 
parts  of  which  it  was  composed. 

Tumor  of  the  Brain. — Dr.  T.  \Yebster  of  i:;.-."'^*-- 
:reasea  glandular  secretion.  Leucocytes  attacked  the 
jonococci,  carried  them  to  the  surface,  where  they  were 
discharged,  and  repair  took  place  and  the  symptoms 
subsided.  Resolution  took  place  slowly  in  the  urethral 
glands,  which  continued  to  discharge  some  time  after 
the  inflammation  in  the  remainder  of  the  urethra  had 
subsided. 

Posterior  Urethritis. — Dr.  Guiteras  considered  this 
as  an  extension  of  the  disease  ;  some  thought  it  occurred 
in  eighty  per  cent,  of  the  cases,  and  he  thought  it  oc- 
curred at  least  that  often.  Often  it  was  not  severe 
enough  to  cause  s}Tnptonis  and  was  not  noticed.  The 
disease  did  not  travel  down  the  urethra  fast,  for  the 
mucous  membrane  was  less  vascular  and  almost  void  of 
glands  and  follicles.  The  patients  in  whom  marked 
symptoms  occurred  were  those  who  were  physically  be- 


3SS 


MEDICAL   RECORD, 


[September  14,  1895 


mucus,  and  blood.  About  three  weeks  after  labor 
came  on.  The  uterus  was  almost  entirely  filled  with  a 
spongy,  friable  placenta,  which  was  removed  piece-meal. 
Several  of  the  pores  contained  hydatids.  The  foetus 
was  dead  and  crushed  flat.  The  woman  made  a  good 
recovery. 

Hernia  of  the  Appendis.— Dr.  R.  W.  Garratt,  of 
Kingston,  related  the  history  of  a  case  of  hernia  of  the 
vermiform  appendix.  The  condition  occurred  in  a 
green-grocer  who  had  much  heavy  lifting.  After  a 
heavy  lift  he  had  taken  some  five  years  previous,  he  dis- 
covered that  there  was  a  tumor  in  the  left  inguinal 
region,  which  gave  him  considerable  pain.  He  under- 
went treatment  by  truss  for  some  time,  but  without  sat- 
isfaction. It  was  thought  to  be  omentum,  and  an  opera- 
tion was  finally  decided  upon.  Upon  cutting  down  on 
the  tumor  a  bubble  of  gas  was  noticed  issuing  from  it, 
followed  by  the  exudation  of  about  a  drachm  of  stinking 
pus.  The  appendix  was  drawn  down  and  removed. 
The  patient  made  an  e.xcellent  recovery. 

Nephrectomy. — Dr.  Ahern,  of  Quebec,  reported 
a  case  of  "  Transperitoneal  Nephrectomy."  The  oper- 
ation was  done  for  hydronephrosis.  The  trouble  began 
by  the  appearance  of  a  tumor  in  the  left  side,  which  after 
a  few  weeks  disappeared.  It  was  accompanied  by 
pain.  The  tumor  reformed.  The  history  of  the  case 
and  the  points  of  the  differential  diagnosis  were  pointed 
out.  A  distinguishing  point  in  the  diagnosis  was  the 
palpation  of  a  ribbon-like  band  over  the'surface  of  the 
tumor — the  descending  colon.  The  tumor  was  removed 
by  an  anterior  median  incision  ;  the  condition  was  found 
to  have  been  due  to  a  congenital  malformation  of  the 
ureter.  These  cases  usually  occurred  on  the  right  side. 
The  essayist  referred  to  the  treatment  of  these  cases  by 
aspiration  and  by  nephrectomy. 

Dr.  C.  R.  Dickinson,  of  Toronto,  read  a  paper  on 
"  Some  Indications  for  Electrolysis  in  Angioma  and 
Goitre."  He  pointed  out  that  by  treating  angioma 
by  this  method  the  chances  of  disfigurement  were 
much  less  than  by  other  measures.  Excision  was 
often  useless,  the  cautery  was  sometimes  disappoint- 
ing, and  scarifications,  applications,  and  injections  were 
not  free  from  danger.  Small,  superficial  angiomata 
called  for  the  negative  pole  and  mild  currents.  In 
the  cavernous  form  destruction  of  tissue  might  be  called 
for.  Histories  of  cases  were  given  showing  the  good 
results  following  this  form  of  treatment.  The  doctor 
also  spoke  of  its  application  to  goitre,  one  hundred  and 
twenty  cases  of  which  he  had  treated  with  gratifyin<r 
success.  '     * 

The  Canadian  Militia  Medical  Service. — A  paper  was 
presented  by  Dr.  W.  Topin,  of  Halifax,  on  changes 
which  he  proposed  in  the  Canadian  Militia  Medical 
Service,  the  substance  of  which  was  that,  in  the  speak- 
er's opinion,  instruction  in  military  surgery  should  be 
given  to  militia  medical  officers. '  He  also  held  that 
the  ambulance  system  should  be  reinforced  by  bearer 
companies,  where  it  was  possible,  on  the  basis  laid 
down  by  the  Deputy  Surgeon-General  to  render  first 
aid  to  the  wounded  and  assist  in  field  hospitals. 

h».t  „_ 


m  area  by  peripheral  extension  till  it  reached  a  diam" 
eter  of  two  or  three  inches.     This  was  characteristic. 
Examining  the  scalp  with   the  naked  eye,  little  or  no 
change  could  be  seen.     He  leaned  to  the  parasitic  the- 
ory as  to  causation.     Examining  the  individual  hair 
microscopically,  it  would  be  seen  to  be  atrophied.    The      ( 
skin  would  also  be  seen  to  contain  inflammatory  prod-      1 
iicts,  to  be  seen  in   the   subpapillary  layer,  and  to  a 
limited  extent  in  the  epidermis.     If  a  large  number  of      1 
spots  was  seen,  it  was  an  indication  that  a  large  amount 
of  scalp  was  involved,  and  that  cure  would  not  be  ef-      c 
fected  until  all  the  hair  had  fallen  out.     Keeping  in      u 
mind  the  causation,  he  believed  in  bringing  the  leuco-      a 
cytes  into  play.     Applications  of  croton  oil,  fifty  per 
cent.,  would  give  a  good  migration.  c 


NEW     YORK    COUNTY    MEDICAL     ASSOCIA- 
TION. 

Stated  Meeting,  June  17,   iSgj. 

Samuel  B.  W.  McLeod,  M.D.,  President,  in  the 
Chair. 

Repeated  Intestinal  Anastomosis  on  a  Dog. —  Dr. 
Thomas  H.  Manlev  presented  some  specimens  from 
a  dog  on  which,  at  intervals  of  about  two  weeks,  he 
had  performed  intestinal  anastomosis  four  different 
times,  with  complete  success. 

O'Hara's  Operation  for  Hernia. — Dr.  Manley  then 
presented  a  child  with  inguinal  hernia,  and  made  some 
remarks  upon  the  radical  treatment  of  this  affection  by 
the  O'Hara  or  Australian  method.     (See  p.  366.) 

State  Medicine :  The  Physician  as  a  Citizen. — Dr. 
Douglas  H.  Stewart  read  a  paper  with  this  title. 
He  thought  the  medical  profession  was  without  influ- 
ence in  public  affairs,  because,  unlike  the  legal  profes- 
sion, it  was  not  organized  to  act  politically.  About  the 
only  public  office  held  by  physicians  related  to  the 
Health  Board,  and  even  there  the  law  expressly  stated 
that  the  president  should  not  be  a  physician.  What 
would  the  legal  profession  say  of  a  law  which  forbade 
a  lawyer  being  a  judge  of  the  Supreme  Court  ?  We 
allowed  outsiders  to  do  our  thinking  for  us  in  pub- 
lic matters,  and  they  rather  despised  us  for  allowing 
them  to  do  it.  Our  lack  of  unity  made  us  the  mark 
of  caustic  sarcasm.  But  every  man  would  become  a 
giant  if  it  was  known  that  his  whole  profession  was  at 
his  back.  One  for  all,  and  all  for  one,  would  win 
recognition  and  respect  every  time  and  everywhere. 
Perhaps  our  most  powerful  disorganizers  were  the  hos- 
pitals and  dispensaries  outside  of  the  public  charity 
institutions.  They  made  an  annual  report  showing  a 
wonderful  number  of  patients  treated,  claimed  a  small  - 
death-rate  and  remarkable  results,  but  there  was  no 
mention  of  the  number  of  dying  patients  refused  ad- 
mittance or  transferred  to  Bellevue.  If  the  members  of 
the  medical  profession  would  decide  not  to  allow  their 
learning  and  time  to  be  taxed  without  adequate  re- 
presentation on  the  Board  of  Trustees,  the  medical 
charity  evil  would  soon  be  mitigated  and  the  lay 
trustee  would  cease  his  arrogance. 

Another  field  in  which  a  united  medical  profession 
could  do  something  to  reform  abuses,  related  to  the 
condition  of  the  streets.  London  and  Paris,  which 
had  a  much  larger  street  area  than  New  York,  were 
kept,  by  comparison,  immaculate.  Then  our  uneven 
pavements  were  being  constantly  dug  up  and  left  so 
for  days.  The  stones  were  put  back  loosely,  to  be 
sunk  immediately  far  below  the  surrounding  level. 
The  physician  was  more  interested  in  good  roads  than 
the  farmer  and  merchant,  as  he  could  not,  like  them, 
wait  for  fair  weather.  Here  railroad  magnates  still 
used  horses  which  distributed  manure  in  the  streets  ; 
they  added  salt  to  our  slush  ;  they  compelled  us  to 
hang  on  a  strap.  A  little  agitation  for  a  law,  "  No  seat, 
no  fare,"  would  remedy  the  latter  evil.  We  were  com- 
pelled to  support  the  insane  of  the  State  while  support- 
ing our  own.  In  our  public  schools  many  rooms  were 
without  seats,  and  our  children  had  to  sit  on  the  floor ; 
in  some  the  seats  were  too  small,  causing  crooked 
spines ;  in  some,  three  children  had  but  two  seats  be- 
tween them  ;  others  were  dark  and  alongside  the 
elevated  railroad  and  noisy  streets ;  one  school  for 
boys  was  made  use  of  for  girls,  and  as  the  urinals  were 
inconvenient,  the  ingenious  janitor  bored  holes  into 
the  floor  and  allowed  the  cellar  to  become  flooded. 
There  were  many  schools  without  sewer  connections. 

In  our  progressive  city  the  sick  were  prescribed  for 
■\y        x^^^^.^r^cnpT  doctor    who    never   saw  them.     Chir. 
S     the  lithotomy  posture,  the  vagina  openea  witn  an  aii- 
a     terior  and  posterior  retractor,  and  the  vagina  thorough- 
r,    ly  painted  with  nitrate  of  silver,  twenty  to  thirty  grains 
to  the  ounce.     The  vagina  was  packed  with  iodoform 


September  14,    1895] 


MEDICAL   RECORD. 


389 


pense  in  Cincinnati,  St.  Louis,  New  Orleans,  and 
various  other  cities,  and  found  to  give  off  such  a  hor- 
rible stink  for  many  blocks  around  that  it  had  to  be 
abandoned.  Here  they  had  put  up  a  temporary,  most 
defective  incineration  plant  on  trial,  and  had  con- 
demned it,  when  the  method  properly  carried  out  in 
other  cities  had  given  the  highest  degree  of  success. 
Other  cities  put  such  matters  into  the  hands  of  the 
Health  Board.  Physicians  were  so  far  from  being 
united  that  they  would  go  into  court,  at  the  instigation 
of  some  shyster  lawyer,  and  testify  against  one  another. 
Let  us  act  together.  Let  us  back  a  man  sometimes, 
beciuse  he  is  a  brother.  Carry  this  fact  in  mind,  that 
not  fifty-five  per  cent,  of  medical  ser\nce  in  this  cit)'  is 
paid  for.  Let  us  do  what  we  can  to  take  our  city  out 
from  under  the  hea\y  rule  of  Albany. 

The  paper  was  discussed  by  Drs  A.  B.  Deynard, 
Frank  Van  Fleet,  G.  D.  McGauran,  C.  B.  White. 
Brothers.  T.  H.  ^L\NLEV,  Nye,  and  the  discussion 
was  closed  by  the  author.  They  spoke  warmly  against 
the  abuses  mentioned,  as  well  as  others,  and  advocated 
greater  unity  in  the  profession,  and  participation  in 
public  affairs. 

Living  Greek :  The  Language  of  Physicians  and 
Scholars ;  a  Language  Easily  Acquired. — Dr.  Achilles 
Rose  read  the  paper.  Since  the  establishment  of  the 
American  school  at  Athens,  founded  in  1S92  by  the 
American  Archaeological  Institute,  supported  by  con- 
tributions from  eighteen  universities  in  the  United 
States,  there  had  been  a  diffusion  among  cultivated 
people  of  a  more  correct  notion  of  the  Greek  language. 
and  of  the  fact  that  it  was  a  living  language.  It  was 
generally  conceded  that  a  study  of  the  classical  lan- 
guages, and  of  the  Greek  especially,  was  a  powerful 
means  of  elevating  and  ennobling  the  mind  and  charac- 
ter, and  could  not  be  dispensed  with.  The  Greek  lan- 
guage was  practical  as  well  as  ideal.  It  was  easy  to 
learn  as  a  living  language,  but  it  was  necessary  to  re- 
form methods  of  teaching  it  in  the  colleges.  It  was  re- 
markable how  it  had  been  calumniated,  by  claiming 
that,  as  spoken  by  the  Greeks  to-day,  it  was  mixed  with 
various  other  languages.  As  a  matter  of  fact,  it  had 
been  preserved  remarkably  pure  from  ancient  times, 
and  for  this  we  were  much  indebted  to  the  Greek 
Church.  As  an  example  of  the  ease  with  which  Greek 
could  be  learned  as  a  li%-ing  language,.  Dr.  Rose  pre- 
sented his  little  daughter,  about  seven  years  of  age,  who 
recited  a  piece  and  sang  in  Greek.  She  also  spoke  a 
piece  in  French,  showing  that  durirg  childhood  the 
learning  of  languages  was  easy. 

Dr.  Fred.  C.  Valentine  thought  it  would  prove  far 
more  practical  to  make  Spanish  the  language  of  physi- 
cians and  scholars,  for  it  was  already  spoken  by  eighty 
millions  of  people,  was  beautiful,  its  orthography  was 
phonetic  with  few  exceptions,  and  one  could  learn  to 
speak  it  in  as  many  weeks  as  were  required  to  learn  the 
Greek  alphabet. 

The  President  had  come  to  the  conclusion  that 
the  preponderance  of  evidence  was  in  favor  of  Greek  as 
the  language  of  scholars,  for  it  was  a  language  of  very 
great  beauty,  of  very  great  flexibility,  and  one  possessing 
the  power  to  carry  ideas  to  others  as  perhaps  no  other 
language  could. 


Hospitals  for  Tuberculosis. — At  the  recent  meeting 
of  the  American  Climatological  Association  it  was 
noted  that,  "'  Since  tuberculosis  has  been  demonstrated 
to  be  a  communicable  disease,  it  has  become  doubly 
desirable  that  hospitals  for  the  reception  of  the  poor 
afflicted  with  the  disease  should  be  established,"  and 
the  Association  resolved  to  "  recommend  the  establish- 
ment of  such  hospitals  in  every  State,  not  only  for  thc 
relief  of  the  great  sutt'ering  attending  this  disease 
among  the  poor,  but  also  as  a  protection  of  the  com- 
munity against  its  spread." 


MEDICAL    SOCIETY    OF    THE     COUNTY   OF 
NEW   YORK. 

Stated  Meeting,  Monday  Evening,  May  i~,  iSgj. 

Egbert    H.    Gijaxdin.    M.D.,    President,    in    the 
Chair. 

Dr.  S.  Tvnberg  exhibited  the  case  of  pygopagus 
(joined  twins)  which  has  been  previously  described  in 
the  Medical  Record. 

Gonorrhcea  in  Man. — Dr.  R.\mon  Guiter.^s  read  a 
paper  on  this  subject.  He  said  gonorrhoea  was  de- 
rived from  ydros,  semen,  and  p«<u,  to  flow  ;  as  it  was 
for  a  long  time  considered  a  disease  of  the  secretory 
apparatus  resulting  in  a  flow  of  semen  from  the  ure- 
thra. The  more  proper  name  urethritis  appeared  to  be 
gaining  ground.  The  disease  had  been  prevalent  since 
the  earliest  days  of  medicine,  mentioned  by  Hippo- 
crates and  Celsus,  and  considered  contagious. 

About  the  last  of  the  fifteenth  centurj'  syphilis  be- 
came prevalent  in  Europe,  and  was  considered  related 
to  gonorrhcea  and  due  to  the  same  virus.  This  idea 
prevailed  until  the  Revolution,  when  John  Hunter 
claimed  they  were  two  distinct  diseases.  He  inocu- 
lated himself  with^^us  from  an  acute  urethritis,  but  the 
patient  had  an  unrecognized  syphilis  at  the  same  time. 
Hunter  contracted  it,  was  convinced  that  both  were  the 
same,  and  thus  the  true  relation  was  undiscovered  until 
Ricord's  investigations. 

Etiology. — Usually  due  to  coitus.  Rarely  to  indirect 
causes.  Two  varieties  were  spoken  of  which  he  would 
call  urethritis  and  pseudo-urethritis.  The  first  em- 
braced the  acute  running  clap  due  to  the  gonococcus 
of  Neisser,  the  latter  the  so-called  "  strains  "  and  slight 
ephemeral  discharges.  The  period  of  incubation  was 
one  to  fourteen  days,  and  the  discharge  was  generally 
noticed  about  the  third  day. 

Clinical  History. — Shortly  after  a  suspicious  coitus 
there  was  itching  sensation  about  the  meatus,  followed 
by  pain  during  micturition,  slight  moisture,  or  drop  of 
muco-pus  on  meatus,  which  was  somewhat  congested. 
These  symptoms  grew  more  severe  steadily  for  one  or 
two  weeks  and  gradually  subsided.  The  course  of  an 
acute  attack  was  from  four  to  five  weeks.  When  it 
passed  six  weeks  it  was  considered  chronic. 

Diagnosis. — The  microscope,  or  a  few  days'  time, 
would  distinjruish  between  urethritis  and  pseudo-ure- 
thritis. The  former  grew  rapidly  worse,  the  latter  rap- 
idly better.  The  former  was  more  difficult  to  distin- 
guish from  an  acute  exacerbation  of  an  old  condition, 
where  the  gonococcus  was  always  present.  The  his- 
tory of  the  cases  usually  assisted. 

The  chancroid  ulcer  and  chancre  might  be  confused 
with  urethritis.  The  former  could  be  recognized  by 
the  loss  of  tissue.  In  the  latter,  where  there  was  diffi- 
culty in  opening  the  meatus  to  see,  he  found  a  wire 
nasal  speculum  an  excellent  aid. 

Pathology. — The  gonococcus  made  its  way  to  the 
subepithelial  tissue  and  excited  an  inflammation,  there 
was  an  exfoliation  of  the  urethral  epithelium  and  in- 
creased glandular  secretion.  Leucocrtes  attacked  the 
gonococci,  carried  them  to  the  surface,  where  they  were 
discharged,  and  repair  took  place  and  the  s}"mptoms 
subsided.  Resolution  took  place  slowly  in  the  urethral 
glands,  which  continued  to  discharge  some  time  after 
the  inflammation  in  the  remainder  of  the  urethra  had 
subsided. 

Posterior  Urethritis, — Dr.  Guiteras  considered  this 
as  an  extension  of  the  disease  ;  some  thought  it  occurred 
in  eighty  per  cent,  of  the  cases,  and  he  thought  it  oc- 
curred at  least  that  often.  Often  it  was  not  severe 
enough  to  cause  s)Tnptoms  and  was  not  noticed.  The 
disease  did  not  travel  down  the  urethra  fast,  for  the 
mucous  membrane  was  less  vascular  and  almost  void  of 
glands  and  follicles.  The  patients  in  whom  marked 
symptoms  occurred  were  those  who  were  physically  be- 


390 


MEDICAL   RECORD. 


[September  14,  1895 


low  par.  It  might  occur  any  time  during  the  attack, 
but  usually  not  before  the  tenth  day,  and  most  gener- 
ally in  the  third  or  fourth  week.  The  patient  experi- 
enced discomfort  and  a  sense  of  weight  in  the  peri- 
neum, increased  frequency  of  urination,  and  in  severe 
cases  urinated  every  few  minutes  during  the  day  and 
often  at  night.  When  subacute  the  Ultzman  glass  was 
used  for  diagnosis. 

Chronic  Urethritis, — This  condition  was  considered 
to  exist  wjien  after  six  weeks  some  discharge  existed, 
but  so  slight  that  no  discharge  was  noticed  during  the 
day  and  only  slight  in  the  morning.  "  Tripper  faden  " 
were  usually  found,  and  this  was  generally  due  to  the 
presence  of  granular  patches,  ulcerations,  denudations, 
localized  hyperemia,  or  strictures  along  the  urethra. 

Experience  had  taught  him  the  majority  of  cases 
were  due  to  strictures  with  localized  congestion  pos- 
terior to  them.  The  strictures  were  due  to  localized 
inflammation  and  were  soft,  resilient,  or  hard.  There 
was  another  form,  the  congenital,  which  was  located 
near  the  meatus  and  was  very  unyielding. 

He  examined  the  patient  for  chronic  urethritis  as 
follows  :  the  meatus  for  a  discharge  which  would  point 
to  anterior  inflammation,  washed  out  the  anterior  ure- 
thra with  a  rubber  or  glass  tube,  then  let  the  patient 
pass  his  urine  in  two  glasses.  If  *he  first  glass  con- 
tained more  flakes  than  the  second,  he  concluded  there 
was  posterior  urethritis,  and  if  there  were  no  flakes  in 
either  it  was  evident  there  was  no  posterior  trouble. 
He  then  examined  the  urethra  with  the  acorn  bulb 
bougies  for  strictures,  and  then  endoscoped  the  ure- 
thra for  granular  patches,  localized  congestions,  denu- 
dations, or  ulcerations. 

Prognosis. — The  disease  usually  lasted  from  four  to 
six  weeks.  It  was  considered  cured  when  the  discharge 
ceased,  but  it  might  remain  localized  or  subacute  after 
this.  Some  authors  held  that  as  long  as  "  Tripper  faden  " 
were  found  the  disease  was  not  cured.  Dr.  Guiteras 
said  he  presumed  they  were  right,  but  he  thought  they 
would  disappear  if  the  patient  abstained  from  alcohol- 
ism and  venery  for  a  few  weeks.  The  occurrence  of 
posterior  urethritis,  complications,  or  strictures  made 
the  prognosis  difficult. 

Treatment. — Dr.  Guiteras  said  that  in  his  own  prac- 
tice the  treatment  depended  on,  i,  the  stage  of  inflam- 
mation in  which  the  patient  presented  himself  ;  2,  the 
presence  or  absence  of  posterior  urethritis  ;  3,  the  pres- 
ence or  absence  of  strictures. 

If  the  patient  had  an  acute  attack  in  the  first  stage 
with  great  tenderness,  he  delayed  active  treatment  for  a 
while  and  tried  to  make  him  comfortable.  He  gave 
him  a  diluent  ;  put  him  on  either  cubebs  in  teaspoonful 
doses  three  times  a  day,  or  santal  midi  ca])sules,  be- 
ginning with  one  and  running  up  to  four  three  times 
a  day.  He  regulated  the  bowels  with  Rochelle  salts, 
prescribed  two  hot  sitz-baths  a  day,  and  regulated  the 
diet. 

This  usually  took  away  the  congestion  in  three  days, 
enough  to  permit  of  hand  astringent  injections  or  hot 
irrigations.  He  then  began  with  irrigations  given  once 
a  day,  accompanied  by  mild  slightly  astringent  hand 
injection.  If  the  patient  were  in  a  hospital  he  used  ir- 
rigation twice  a  day  and  no  hand  injection.  For  irri- 
gation he  used  permanganate  of  jiotash  or  nitrate  of 
silver.  He  used  to  begin  with  permanganate  of  potash, 
and  used  silver  only  when  the  former  failed  ;  now  he 
reversed  it,  for  the  nitrate  of  silver  seemed  to  have  the 


and  then  to  take  a  few  deep  breaths.  To  his  internal 
treatment  he  added  ten  drops  of  belladonna  three  times 
a  da\'  to  overcome  the  tenesmus,  and  sandal-wood  oil 
to  modify  the  urine.  Of  the  latter  he  began  with  fifteen 
drops,  and  increased  five  drops  a  day  as  long  as  it  was 
well  borne.  If  irrigation  did  not  benefit  he  left  off  the 
general  treatment  of  the  urethra  and  gave  posterior  in- 
stillations of  nitrate  of  silver  every  other  day  by  means 
of  the  Ultzman  syringe,  beginning  with  one  grain  to 
the  ounce  solution  and  gradually  increasing. 

In  chronic  urethritis  he  examined  for  strictures  with 
a  bulbous  sound  and  endoscoped  the  urethra.  If  there 
were  yielding  strictures  he  dilated  them  by  the  Ober- 
lander  dilator  by  easy  stages,  and  afterward  passed  the 
Otis  curve  anointed  with  equal  parts  of  the  ointment  of 
the  red  oxide  of  mercury  and  vaseline.  If  the  stricture 
were  unyielding  he  advised  urethrotomy  by  the  Otis 
method. 

Dr.  Guiteras  said  that  in  closing  he  wished  to  call 
attention  to  the  fact  that  patients  would  complain  as 
much  of  a  one  to  one  thousand  solution  of  nitrate  of 
silver  by  the  irrigation  method  as  they  would  of  one 
in  fifty  solution  by  the  hand  method. 

The  Treatment  of  Gonorrhcea  in  Women. — Dr.  Will- 
iam R.  Prvor  read  the  paper  on  this  subject.  He 
said  that  throughout  the  entire  treatment  of  gonorrhoea 
in  women  one  principle  must  govern  the  physician  ;  the 
disease  must  be  locally  checked  and  extension  pre- 
vented, (ionorrhcta  produced  few  destructive  lesions 
when  it  affected  primarily  the  external  genitals,  but 
when  it  had  extended  to  the  pelvic  viscera  it  often  de- 
stroyed the  integrity  of  the  affected  organs  and  chronic 
invalidism  might  be  induced. 

Gonorrhoea!  Urethritis. — This  should  be  treated  from 
the  very  first.  Internally  he  administered  citrate  of 
potash  for  the  first  three  days  or  so,  to  alkalinize  the 
urine,  locally  he  applied  every  day  nitrate  of  silver, 
10  grains  to  i  ounce,  and  after  the  urethritis  had  some- 
what subsided  the  solution  might  be  reduced  to  5  grains 
to  I  ounce,  and  applied  less  often.  The  patient  should 
frequently  bathe  the  vulva  with  one-half  per  cent,  lysol 
solution  ;  but  no  douching  was  admissible. 

Gonorrhoeal  Cystitis. — Forty  to  sixty  grains  of  ben- 
zoate  of  soda  should  be  given  internally,  the  bladder 
should  be  washed  out  with  super-saturated  solution  of 
boracic  acid  at  least  twice  a  day,  the  bladder  being 
filled  and  emptied  several  times  at  each  sitting.  The 
viscus  should  then  be  left  full  of  the  solution.  The  ac- 
companying urethritis  should  be  treated  with  daily  ap- 
plication of  nitrate  of  silver,  5  grains  to  i  ounce.  In 
washing  out  the  bladder  a  single  catheter  should  be 
used. 

Gonorrhoea!  Ureteritis. — If  the  bladder  were  affected 
acutely  at  the  same  time,  benzoate  of  soda  only  should 
be  used,  but  if  the  bladder  were  not  very  sensitive  the 
ureter  might  be  washed  out  with  boracic-acid  solution. 
When  the  infection  attacked  the  urinary  system  it  could 
not  be  guarded  against  by  antiseptics,  but  the  urine 
had  to  be  rendered  antiseptic  and  increased  in  quan- 
tity by  the  use  of  large  auKHmts  of  Buffalo  Lithia  water. 

Gonorrhoea!  Vulvitis. — Nitrate  of  silver  should  be  ap- 
plied   to  e\ery  fold    of    the   vulva,   meatus    urinarius, 
clitoris,  and  nynipha;,  and  every  part  be  painted  with  a 
solution  of  twenty  grains  to  the  ounce  and  allowed  to 
dry.     The  vasiliia  •slir.nld    lie  n.ii;l-e<-1^  "•'''>    t>v«r,t<.  .N^r 
.^ i ,  ..I  aumc,  tnree  chiiaren  nad  but  two  seats  be- 
tween   them  ;    others    were    dark    and    alongside    the 
jlevated    railroad  and 


best  effect.  If  the  permanganate  were  used  he  began -'"=^^'^"  .ai.iuau  anu  noisy  streets;  one  school  lor 
with  one  in  five  thou.sand  and  increased  to  one  in  Two '°>''  was  made  use  ot  tor  g.rls.  and  as  the  ur.nals  were 
thousand,  and  if  nitrate  of  silver,  he  began  with  one  in  "convenient  the  ingenious  janitor  bored  holes  into 
eight  thousand  and  increased  to  one  in  two  thousand.  ,^;f  "^""^  ^"'^  ^'""^'^  the  cellar  to  become  flooded. 
The  irrigating  fluid  should  be  used  as  hot  as  could  be  ^  ^,^''^  ^'''-"'^  '"^'">'  .''^'^""'^  ""'^"."{  '"^^^'^^  connections 
borne.  In  posterior  urethritis  he  did  not  use  hand  in-  ^"  *^"'  progressive  city  the  sick  were  prescribed  for 
jections,  but  modified  his  method  of  irrigation  bv  in- ^^  a  newspaper  doctor  who  never  saw  them.  Our 
creasing  the  height  of  the  douche  jar  from  two  t^  five 'y^^'.  ^'^1"'"^ /^P'"^"'"^"'  '«"'<^'^  ""  '^.^  ^^!  °[ 
feet.  If  the  solution  did  not  overcome  the  "  cut-off  " '^,*'P*'"g  '^  V^^"" '?1  TT^^  ^°'  "!?  '^"•''"^^  °^ 
muscle  he  directed  the  patient  to  strain  as  if  to  urinate,  '^f"'*^'  ^  "'^"'"^  ''''^'^'^   ^""^  '^^^'^  *"^^  ^'  S'^^*  ^''- 


September  14,  1895] 


MEDICAL   RECORD. 


391 


gauze,  the  application  repeated  every  two  days  for 
three  treatments  when  the  gauze  alone  could  be  used. 

Gonorrhoeal  Endocervicitis, — Dr.  Pryor  said  this  was 
about  five  times  as  frequent  as  vaginitis  and  too  much 
neglected.  The  mucous  membrane  of  the  cervix  should 
be  touched  with  a  strong  tincture  of  iodine,  repeated 
every  day,  and  the  vagina  packed  with  iodoform  gauze. 
Care  should  be  taken  not  to  pass  the  internal  os,  and 
as  the  cervix  was  lined  with  true  mucous  membrane  it 
would  take  quite  a  little  while  to  cure  the  patient.  As 
there  was  no  possible  way  to  place  a  dam  between  the 
infected  locality  and  the  more  important  structures 
above,  the  only  hope  was  to  successfully  treat  the  af- 
fection by  such  means  as  were  efficiently  germicidal 
and  still  do  the  least  amount  of  damage  to  the  tissue 
cells,  upon  whose  resistance  to  pathological  influences 
depended  protection  against  complications. 

Gonorrhoeal  Endometritis. — Immediate  operation  was 
necessary.  If  the  cervix  was  not  dilated,  dilate  it  up 
to  one-half  inch,  and  if  this  was  not  possible,  incise  it. 
Dilate  the  uterine  canal,  wash  with  boric  acid  solution, 
using  a  large  Jirtsch-Bozeman  catheter.  The  cervix 
was  then  swabbed  with  five  per  cent,  carbolic  solution, 
and  the  uterus  thoroughly  curetted.  All  debris  was 
then  washed  out  with  the  irrigating  catheter,  but  no 
bichloride,  carbolic,  or  other  strong  antiseptic  should  be 
used,  for  they  would  produce  sloughing  and  a  nidus 
for  any  gonococci  which  might  remain.  He  did  not 
paint  the  endometrium  with  iodine  or  carbolic  acid. 
He  then  packed  the  uterus  with  iodoform  gauze,  also 
the  vagina,  and  the  first  dressing  was  made  in  five  days. 
He  based  his  technique  upon  the  belief  that  the  endo- 
metrium was  a  lymphoid  structure,  and  any  agent 
strong  enough  to  prove  germicidal  would  destroy  the 
living  body  cells. 

Dr.  Pryor  did  not  favor  palliative  treatment  of 
gonorrhoeal  endometritis.  He  believed  no  case  of 
gonorrhoea  was  cured  as  long  as  the  gonococcus  was 
found,  and  it  was  the  physician's  duty  to  impress  upon 
the  patient  the  importance  of  persistent  treatment  at 
his  hands.*  He  believed  the  prevalence  of  gonorrhoea 
was  due  more  to  the  uncured  form  in  women  than  to 
the  gleet  of  men.  Gonorrhoeal  salpingitis  in  the  acute 
form  was  treated  in  the  same  manner  as  gonorrhrsa! 
endometritis,  but  in  the  chronic  form  nothing  but  ex- 
tirpation of  the  tubes  would  effect  a  cure. 

When  to  Begin  and  when  to  Stop  Treatment, — Dr. 
Herman  Goldexberg  opened  the  discussion.  He 
said  there  were  two  questions  :  first,  when  should  treat- 
ment be  begun,  and  second,  when  should  it  end.  It 
seemed  natural  to  attack  the  gonococcus  so  as  to  kill 
it.  It  entered  the  tissue  before  the  third  day,  so  he 
did  not  see  how  nitrate  of  silver  could  cure  unless  used 
within  a  few  hours.  He  had  found  only  one  case  that 
yielded  to  the  primary  treatment,  and  he  believed  most 
of  the  cases  cured  thus  were  exacerbations.  Perman- 
ganate of  potassium  had  proved  the  most  satisfactory 
to  him.  Posterior  urethritis  had  been  considered  a 
complication,  but  now  it  was  admitted  to  be  an  exten- 
sion, and  in  thirty  per  cent,  of  the  cases  there  was  a 
I)Osterior  urethritis  by  the  twelfth  day.  There  were 
cases  that  could  not  be  cured,  but  fortunately  they 
were  few.  Neisser  depended  upon  a  microscopic  ex- 
amination, but  he  thought  in  cases  where  matrimony 
.}^'ft^^^RJ'',t?'JlP^^'^'^  ''^^  condition  of  the  prostate  should 

Hospitals  for  Tuberculosis, — At  the  recent  meeting 
of  the  American  Climatological  Association  it  was 
noted  that,  ''  Since  tuberculosis  has  been  demonstrated 
to  be  a  communicable  disease,  it  has  become  doubly 
desirable  that  hospitals  for  the  reception  of  the  poor 
afflicted  with  the  disease  should  be  established,"  and 
'  the  Association  resolved  to  "  recommend  the  estnH'-'-'- 
xuLcx  au.vU,»i.- -i'liiiauiig  urugs — such  as  salts  of  ar- 
senic, copper,  zinc,  and  iron — should  usually  be  given 
directly  after  food,  except  where  local  conditions  re- 
quire their  administration  in  small  doses  before  food. 


catarrhal  one,  but  a  severe  form.  The  urethra  might 
recover  after  one  attack,  but  after  more  it  never  recov- 
ered. The  whole  question  of  chronic  urethritis  was 
summed  up  in  the  one  word  ulcer.  This  might  be 
microscopic,  but  situated  along  the  narrow  sinus  it 
would  exist  for  a  long  time.  By  the  thickening  of  the 
tissue  strictures  were  formed,  but  they  were  rare  and 
seldom  found  at  autopsy.  The  ulcer  would  stop  the 
sound  and  the  patient  was  told  that  he  had  an  ulcer. 
Nitrate  of  silver  was  used,  for  it  excited  a  slight  in- 
flammation which  brought  the  cells  to  the  surface  and 
the  ulcer  was  reached.  He  thought  it  was  the  excep- 
tion where  posterior  urethritis  was  not  found. 

A  New  Culture  Medium  for  the  Gonococcus. — Dr. 
Fred  C.  Valentine  thought  the  first  author  erred  in 
thinking  the  name  urethritis  was  becoming  more  used 
than  gonorrhoea,  and  he  feared  the  latter  name  would 
be  continued.  It  was  strange  that  Dr.  Guiteras  would 
use  a  wire  nasal  speculum  when  he  could  use  Ober- 
lander's  urethroscope.  Dr.  Guiteras  had  mentioned 
six  weeks  as  a  normal  time,  but  Janet,  of  Paris,  allowed 
two  days,  and  his  own  cases  lasted  five  days.  He 
thought  Janet's  theory,  that  the  permanganate  of  po- 
tassium injection  caused  an  anaemia  and  prevented  a 
good  culture  medium  for  the  gonococcus,  was  the  right 
one.  Dr.  Valentine  said  he  had  found  a  good  culture 
medium  for  the  gonococcus  in  sandal  oil.  There  was 
one  thing  which  could  be  positively  stated,  no  man 
should  be  allowed  to  marry  who  could  infect  the 
woman.  By  treating  the  urethra  with  nitrate  of  silver 
and  examining  the  exudate,  it  could  be  determined 
whether  the  gonococcus  was  present  or  not. 

Dr.  J.  P.  McGowAN   said  that  at  their  clinic  they 
used  warm  solution  of  permanganate  of  potassium  and 
gradually  increased  the  solution.     The  bladder  might 
be  filled  with  the  solution.     The  patient  was  often  re- 
lieved in  a  few  hours  and  should  be  treated  two  days, 
which  a  rest  is  grateful.     The  usual  exodus  has  taken 
place  and   London  is  said  to  be  empty,  but  there  are 
plenty  of  doctors  for  all  the  requirements  of  the  public, 
although   so  many  are   taking   their  holidays.     Every 
one  of  the  staff  of  reporters  who  worked  so  assiduous- 
ly for  the  Medical  Record  at  the  meeting  disappeared 

especially  if  used  strong. 

Infection  in  the  Puerperal  State. — Dr.  H.  N.  Vine- 
berg  said  he  was  sorry  the  writer  of  the  paper  did  not 
mention  infection  during  the  puerperal  period.  There 
was  no  doubt  that  cases  occurred,  and  he  had  seen  two 
such.  He  thought  that  as  long  as  a  gonorrhoeal  affec- 
tion was  limited  to  the  cervix,  it  should  be  treated 
in  a  way  that  it  would  not  be  extended,  for  the  disease 
would  not  go  beyond  the  internal  os  by  itself.  The 
reason  the  disease  advanced  rapidly  sometimes  was  be- 
cause some  other  disease  was  present,  or  the  treatment 
extended  it  instead  of  stopping  it.  He  approved  of 
the  excision  of  Bartholoni's  glands  when  they  were  in- 
fected, but  it  was  not  as  easy  an  operation  as  might  be 
thought. 

Dr.  Her.man  L.  Collier  said  the  patients  came 
to  the  physician  at  different  stages  of  the  disease, 
and  he  had  to  treat  them  according  to  the  stage.  It 
was  possible  to  cure  ten  per  cent,  of  the  cases  in  the 
acute  form  in  two  weeks.  To  render  relief,  at  first 
cooling  lotions  were  advisable,  as  opium  wash,  etc. 
For  the  second  stage,  nitrate  of  silver  was  satisfactory. 
He  coated  the  vagina  with  a  solution  of  nitrate  of  sil- 
ver and  the  outside  with  a  ten-grain  solution.  This 
might  be  done  every  day  or  every  other  day.  Douch- 
ing every  four  hours  with  ammonia  solution  or  some 
other  was  important.  When  the  disease  extended  to 
the  endometrium  it  was  generally  the  result  of  careless- 
ness. 

Dr.  Ramon  Guiteras  said,  in  closing,  that  the 
reason  he  used  the  wire  nasal  speculum  was  that  he 
could  examine  thoroughly  and  easily  the  anterior  half- 
inch  of  the  urethra,  and  that  was  all  he  wanted  when 


592 


MEDICAL   RECORD. 


[September   14,  1895 


he  used  it.  There  was  a  difference  of  opinion  as  to  the 
length  of  the  disease.  Dr.  Finger  had  said  six  weeks. 
He  thought  ten  grains  of  nitrate  of  silver  to  the  ounce 
was  too  much. 


^Ticrapcxttic  gluts. 

Salicylates  in  Rheumatism.— The  salicylate  acid  mus' 
be  obtained  from  the  vegetable  kingdom  ;  it  mus' 
be  given  without  an  alkali  or  a  base  ;  from  forty  to 
eighty  grains  should  be  given  daily  for  ten  days  ;  the 
patient's  diet  should  consist  of  milk  and  farinaceous 
food  for  at  least  a  week  ;  the  bowels  should  be  freely 
opened  daily. — L.\th.\m. 

Dyspepsia.— In  every  case  of  persistent  dyspepsia, 
careful  examination  of  urine  should  be  made. — Loomis. 

Constipation  in  Infants.  — 

B .    Sodii  bicarb t  j. 

Tr.  nucis  vomicse T^.^j- 

Tr.  card,  comp., 

Syr.  simp aa  f  3  ij. 

Aq.  chloroform  (Br.  P) f  3  ss. 

Aquae f  j  ij- 

M.  Sig.:  Teaspoonful  everj'  six  hours. 

— Eustace  S.mith. 
Bronchitis. — 

E.    Phenol  salicylate, 

Terpin  hydrate aa   3  j- 

Codein  sulphate gr.  ij. 

M. :  Make  twenty  capsules  or  pills.     One  every  four  hours. 

— SOLIS-COHEN. 

During'  Lactation  menstruation  is  absent  as  a  rule, 
but  ovulation  may  occur.  It  is  not  very  common  for 
women  to  conceive  while  nursing,  but  if  they  do,  lacta- 

were  found  the  disease  was  not  cured.  Dr.  Guiteras 
said  he  presumed  they  were  right,  but  he  thought  they 
would  disappear  if  the  patient  abstained  from  alcohol- 
ism and  venery  for  a  few  weeks.  The  occurrence  of 
posterior  urethritis,  complications,  or  strictures  made 
the  prognosis  difficult. 

Cholera  Morbus. — 

^.     Acid,  sulph.  aromat., 

Ex.  haematoxylon aa  f  3  ij. 

'        Spt.  chloroform f  3  ss. 

Syr.  zingiberis q.  s.  ad.   f  3  iij. 

M.     Sig.:  Teaspoonful  every  two  hours. 

— Hare. 

Acne. — Use  superfatted  menthol -eucalyptol  soap 
when  skin  is  inflamed. — Mackenzie. 

Neuralgia  of  Dental  Origin.— Give  five  drops  of  the 
tincture  of  gelsemium  three  times  a  day,  and  increase 
to  ten  drops  three  times  a  day,  till  the  patient  sees 
double,  and  then  stop  the  administration  of  the  drug. — 
Da  CnsTA. 

Stomatitis. — In  the  herpetic  form  use  : 

B .   Distilled  water. 

Glycerin 55  f  3  iiss. 

Iodine, 

Iodide  of  potassium Sfi  gr.  vj. 

M.    Sig.:  Apply  to  lesions. 

— Marfan. 
For  Eczema  of  the  Face.— Carefully  remove  all  the 
crusts.     Avoid  water.     Keep    the    following  ointment 
constantly  applied   to  the   lesions  by  means  of  a  soft 
linen  mask. 

B.    Ung.  Picis 3i. 

Lng.  Diach 3  ij. 

Ung.  Zinci  ox 3  ij. 

Mix.     Sig.:  For  external  use. 

Treatment  of  Cardiac  Disease. — In  strychnine  we 
have  an  ideal  cardiac  stimulant,  which  not  only  acts 
upon  the  circulation,  but  as  well  upon  respiration,  di- 


gestion, and  assimilation.  It  is  especially  indicated  in 
the  weak  heart  of  pneumonia  and  febrile  processes, 
given  hypodennatically  in  ^V  to  iV  grain  doses,  re- 
peated until  some  sign  of  the  drug  is  manifested.  It  is 
also  useful  to  relieve  the  alarming  symptoms  which  oc- 
cur in  surgical  anaesthesia,  in  the  cardiac  weakness 
often  associated  with  neurasthenia,  and  in  that  due  to 
depressed  nerve- force.  Strophanthus  is  of  great  value 
as  a  cardiac  sedative  in  that  form  of  tachycardia  so 
common  in  exophthalmic  goitre.  These  two  drugs  will 
retain  their  supremacy  because  of  their  influence  over 
the  vital  centres  in  the  medulla,  to  which  the  various 
systems  of  the  body  look  for  support  and  encourage- 
ment.— Kr.4U.~s. 

Hepatic  and  Nephritic  Colic. — 

B .    Valerianate  of  amyl, 

Sulphuric  ether aa  gtt.  iij. 

M.    For  one  capsule.     Let  twenty  such  capsules  be  made. 
Sig. :  Two  capsules  every  half  hour  until  six  have  been  taken. 

— Za  Medecine  Moderne. 
Asthma. — 

B  -    Ammon.  iodidi 3  ij- 

Ext.  grindelia  rob f  3  ss. 

Tr.  lobeliae, 

Tr.  belladonna, 

Syrup  pruni  virg .  aa    3  j- 

Aq.  dest. 
M.  Sig.  :  Teaspoonful  three  times  a  day. 

Leucocytes  in  Diphtheria. — i.  The  leucocytosis  of 
diphtheria  is  materially  different  from  that  of  the  other 
infectious  diseases  which  have  been  investigated  in 
that  particular.  2.  Hyper-leucocytosis  is  in  diphtheria 
a  distinctly  unfavorable  sign,  and,  consequently,  valu- 
able indications  as  to  the  progress  of  a  case  and  the  ef- 
ficiency of  any  particular  plan  of  treatment  may  often 
be  gained  from  examination  of  the  blood.  3.  The 
diphtheria  bacilli  which  find  their  way  into  the  body 
are  destroyed  by  the  phagocytic  action  of  the  leuco- 
cytes. 4.  The  majority  of  the  diphtheria  bacilli  con- 
.cerned  in  the  production  of  the  lesion  of  diphtheria 
.are  cast  off  in  the  false  membrane;  only  a*\'ery  small 
number  are  disposed  of  by  phagocytosis.  5.  The  ac- 
tion of  the  poison  of  diphtheria  in  inducing  necrosis  of 
cells  tends  to  lessen  the  power  of  the  leucocytes  to  act 
as  phagocytes.  6.  The  action  of  antitoxic  serum  is  to 
make  all  the  cells  of  the  body  more  resistant  to  the  de- 
structive action  of  the  diphtheritic  poison. — Gabrits- 

CHEW5KV. 

Asthma. — At  the  moment  of  the  attack,  spray  rapidly 
the  back  of  the  patient  with  chloride  of  methyl,  from 
above  downward  and  from  below  upward.  The  attack 
will  cease  in  a  few  moments  ;  if  not,  spray  lightly  the 
upper  part  of  the  chest.  If  the  skin  be  delicate,  as  in 
women,  cover  the  parts  with  a  bit  of  fine  gauze  and 
make  the  strength  of  the  spray  proportionate  to  the 
strength  of  the  patient  and  the  violence  of  the  attack. 
— Tsakiris. 

Chronic  Constipation. — 

B.    Strych.  sulph gr.  i. 

Ext.  bellad gr.  v. 

Pulv.  ipecac gr.  x. 

Ext.  calocynth  co gr.  xv. 

Pulv.  rhei gr.  xv. 

M.  div.  in  capsulae  No.  XXX. 
Sie.  :  Take  one  after  meals.  „„   „„„.„   w- 

^  ,       ..  „.„..  i.au  uui  two  seats  be- 

^een   them ;    others   were   dark    and    alongside   the 
evated    railroad  and    noisy    streets ;  one    school    for 
)ys  was  made  use  of  for  girls,  and  as  the  urinals  were 
convenient,  the    ingenious   janitor  bored    holes  into 
e   floor  and   allowed   the   cellar  to  become  flooded, 
here  were  many  schools  without  sewer  connections. 
In  our  progressive  city  the  sick  were  prescribed  for 
>»-jvuu!naner  doctor    who   never   saw  them.     Our 
the  lithotomv  posture,  the  vagina  openea  witii  an  an- 
terior and  posterior  retractor,  and  the  vagina  thorough- 
ly painted  with  nitrate  of  silver,  twenty  to  thirty  grains 
10  the  ounce.     The  vagina  was  packed  with  iodoform 


September  14,  1895] 


MEDICAL  RECORa 


393 


tion  from  the  pressure  of  absolute  want.  It  was  a 
period  of  suspension  of  industr)-,  strikes,  lockouts,  and 
labor  insurrections,  when  the  condition  of  the  mass  of 
the  people  was  productive  of  the  causes  of  suicide.  I 
have  examined  a  resume  of  incentives  to  suicide,  as 
shown  by  the  coroner's  inquests  in  Cook  Cnnnt.-  c— 
■  \.\^^^,^^-> ^,jii^\L.\x;i.  0.110.  uysentery. — 

8-     Cupri  salphat., 

Morphise  siUphat aa  gr.  i. 

Quinise  sulphat gr.  xxiv. 

M.     ft.  pil.  No.  XII. 

^ig.  :   One  pill  three  times  a  day. 

Squibb's  Cholera  Mixture.^ 

5.     Tinct.  opii. 

Tinct.  capsici, 

Spts.  camphora: aa  !i.    31. 

Chloroformi fl.    'z,\\\. 

Alcoholis q.  s.  ad  fl.    ?  v. 

M.   Dj5e. — Twenty  to  forty  minims. 

Flatulent   Colic— 

B .     Tinct.  nucis  vomica? 3  i. 

Acidi  nitro  muriatici  dil X  li- 

Spiritus  chloroformi I  L 

Infus.  gentianss ad    3  vi. 

Dose. — Tablespoonful  three  times  daily  after  meals. 

Perttissis. — 

B .      Spts.  chloroform I  ss. 

Ammon.  bromidi S  j- 

Syr.  simplicis q.  s.  ft.    3  ii. 

M.   Sig.  :  Teaspoonful  ever)'  two,  three,  or  four  hours. 

— Stidh.\m. 

Tic  Doulotireux.  —  Treatment  consists  in  making 
subcutaneous  injections  of  the  following  solution  into 
the  affected  side  of  the  face  :  Distilled  water,  10 
grammes  (2!^  fluidrachms)  ;  antipyrin,  4  grammes  (i 
drachm)  ;  hydrochlorate  of  cocaine,  0.03  gramme  (J- 
grain).  The  face  sometimes  became  much  swollen, 
but  soon  resumed  its  normal  appearance. — Gr.\xdcle- 

MEXT. 

Diarrhoea  in  Infants. — For  diarrhoea  in  infants  from 
one  to  two  years  of  age,  the  following  is  useful : — 

B .     Acid,  carbolici gr.  ij. 

Bismuth  subnit 5  j. 

Syrup  acacise 3  ss. 

Aq.  menth.  pip ad    3  ij. 

TT^.  fl.  mist.  :  A  half  teaspoonful  every  two  to  four  hours. 

Not  to  be  Given  During  Pregnancy. — The  chief  reme- 
dies which  are  dangerous  to  the  pregnant  woman  are 
salicylate  of  soda  and  ergot.  Purgatives — castor  oil, 
mineral  salts,  and  especially  aloes — should  be  avoided. 
Quinine  in  too  large  doses  must  also  be  omitted  ;  when 
given  at  all  it  should  be  guarded  by  combination  with 

opium. — HUGENMN. 


Centenarians  in  France. — A  census  of  centenarians 
recently  taken  in  France  gives  213  persons  of  one  hun- 
dred years  or  over,  147  of  them  women  and  66  men. 
The  oldest  was  a  woman  who  had  just  died  at  one 
hundred  and  fifty,  in  a  \-illage  of  the  department  of 
Haute  Garonne.  Nearly  all  the  centenarians  belonged 
to  the  lowest  ranks  in  life. 

Hospitals  for  Tuberculosis. — At  the  recent  meeting 
•ne   American    Climatological    .Association    it   was 
jd  that,  "'Since  tuberculosis  has  been  demonstrated 
:o   lie  a  communicable  disease,  it  has  become  doubly 
desirable  that  hospitals  for  the  reception  of  the  poor 
afflicted  with  the  disease  should  be  established,"  and 
the  Association  resolved  to  "  recommend  the  establish- 
j  ment  of  such  hospitals  in  every  State,  not  only  for  the 
relief    of   the    great    suffering   attending    this    disease 
among  the  poor,  but  also  as  a  protection  of  the  com- 
munity against  its  spread." 


C0xrr«sponacncc. 

OUR   LONDON    LETTER. 

(From  oar  Special  CorrespoDdenc) 

E.^STEOURXE     POSTPONES     HER   INVIT.A.TIOX THE     AN- 
NUAL EXODUS DR.  S.A.MBON's  COLLECTION  OF    MEDI- 

C.\L  ANTIQUITIES — MR.  VICTOR  HORSLEY'S  QUESTION 

AT    THE    MEDICAL    .A.S50CI.A.TION OFFICIAL    ANSWER 

3ALV.A.TI0N     SHELTERS SM.A.LL  -  POX VACCINA- 
TION   ACTS. 

LONDON,    .-VugUSE  24,    1895. 

It  seems  that  the  British  Medical  Association  is  not  to 
visit  Eastbourne  ne.xt  year  after  all.  The  reason  re- 
ported is  that  the  local  profession  is  hardly  prepared 
to  support  the  proposal  of  the  mayor,  but  will  probably 
be  desirous  of  doing  so  two  or  three  years  hence. 
This  may  be  a  disappointment  to  some  of  our  northern 
friends,  but  Londoners  are  mostly  acquainted  with  the 
attractions  of  Eastbourne.  I  confess  to  a  little  sur- 
prise that  the  local  doctors  should  not  have  been  eager 
to  seize  the  opportunity  of  what  is,  after  all,  a  capital 
advertisement  of  their  pleasant  health-resort.  Perhaps 
they  are  deterred  by  the  expenses  that  have  been  in- 
curred in  the  London  \-isit,  for  unfortunately  the  ex- 
cursions on  this  occasion  have  been  costly,  no  doubt, 
because  the  metropolis  has  plenty  of  attractions  within 
itself,  and  proxincial  ^-isito^s  did  not  care  to  take 
country  trips.  Some  other  town  will,  no  doubt,  after 
a  while  offer  an  invitation. 

Those  of  us  who  are  left  in  town  feel  a  relief  that 
the  meeting  is  over,  not  but  what  it  has  been  a  great 
pleasure  to  have  our  houses  filled  with  our  country 
friends,  but  the  hospitality  involves  an  amount  of 
fatigue  and  anxiety  to  make  our  guests  happy,  after 
which  a  rest  is  grateful.  The  usual  exodus  has  taken 
place  and  London  is  said  to  be  empty,  but  there  are 
plenty  of  doctors  for  all  the  requirements  of  the  public, 
although  so  many  are  taking  their  holidays.  Every 
one  of  the  staff  of  reporters  who  worked  so  assiduous- 
ly for  the  Medical  Record  at  the  meeting  disappeared 
immediately  afterward,  and  some  of  them  copied  their 
reports  in  the  country. 

Among  the  most  interesting  events  of  the  meeting 
was  the  exhibition  of  medical  antiquities  collected  by 
Dr.  Sambon,  of  Rome,  which  the  members  were  in- 
vited to  inspect  by  Messrs.  Oppenheimer,  who  certain- 
ly deser\-ed  thanks  for  so  instructive  and  interesting  an 
exhibition.  Dr.  Sambon's  collection  includes  a  great 
number  of  ancient  instruments  such  as  probes,  direc 
tors,  tenacula,  lancets,  clamps,  specula  of  various  kinds, 
and  other  instruments,  most  ol  them  in  bronze,  and  ar- 
tistically ornamented  and  finished  in  a  manner  worthy 
of  a  moderi>  instrument  maker.  Then  there  were  a 
number  of  donaria  in  terra-cotta — such  as  were  pre- 
sented to  the  gods  and  preser\-ed  in  the  temples  in 
commemoration  of  cures.  Everyone  with  a  taste  for 
antiquities  must  appreciate  such  a  collection. 

A  good  deal  of  amusement  has  been  excited  by  Mr. 
Victor  Horsley's  attempt  to  obtain  from  the  Council  a 
simple  answer,  yes  or  no,  to  the  question  :  whether  that 
body  or,  as  some  say,  "  the  ruling  clique,"  will  carr>-  out 
the  directions  of  the  general  meetings  ?  The  official 
anssver  given  him  was  "  that  the  Council  had  always 
acted  on  the  principle  that  resolutions  of  the  annual 
meeting  were  an  instruction  to  carrj-  out  the  policy  in- 
dicated, unless  in  contravention  of  the  memorandum 
of  association."  I  am  surprised  that  any  gentleman 
should  undertake  to  make  such  an  assertion,  consider- 
ing the  many  times  such  resolutions  have  been  treated 
with  contempt  ;  for  example,  when  the  Brighton  meet- 
ing expressed  a  determination  to  take  no  part  in  the 
election  of  a  representative  on  the  General  Medical 
Council,  the  clique  adjourned  to  an  hotel  and  resolved 
to  support  one  of  themselves  as  a  candidate,  and  used 


394 


MEDICAL    RECORD, 


[September  14,  1895 


all  the  power  of  the  Association  to  carry  tlieir  deter- 
mination. Again,  notwithstanding  the  condemnation 
of  the  Notification  Acts  at  the  Worcester  meeting,  they 
have  ever  since  been  supported  by  the  Journal.  We 
shall  see  whether  the  Journal  will  now  cease  to  push 
the  registration  of  midwives,  now  that  the  last  meeting 
has  distinctly  condemned  that  policy.  It  is  unfortu- 
nately too  true  that  the  Association  is  no  more  than  a 
limited  liability  company  for  publishing  a  cheap  jour- 
nal, and  that  at  enormous  cost,  to  the  great  advantage 
no  doubt  of  its  well-paid  editor,  whose  travels  in  vari- 
ous lands  may  stimulate  the  formation  of  new  branches, 
but  can  scarcely  be  remunerative  to  the  Ass  iciation  or 
promote  the  interests  of  the  British  members.  Great 
hopes  were  entertained  that  when  ten  thousand  mem- 
bers had  been  attained,  reforms  would  be  supported 
and  legislators  would  listen.  Now  that  so  much  larger 
proportions  have  been  attained  the  profession  still 
speaks  in  vain.  Can  it  be  that  an  ex-minister  was 
right  when  some  years  ago  he  remarked,  "  that  if  doc- 
tors wished  their  wishes  attended  to  they  should  choose 
a  different  representative  to  express  them  ?  " 

The  medical  officer  of  health  for  St.  George's,  South- 
wark,  has  summoned  the  officer  in  charge  of  the  Black- 
friars  Shelter  of  the  Salvation  Army,  for  creating  a 
nuisance  injurious  to  the  public  health.  This  is  the 
shelter  which  proved  the  focus  for  small-pox,  and  now 
it  appears  that  on  inspection  more  than  double  the 
number  of  persons  w-ere  admitted  than  ought  to  occupy 
the  space  at  command.  It  is  high  time  the  Salvation 
Army  and  other  so-called  philanthropic  bodies  should 
be  called  to  account  for  their  neglect  of  sanitation  and 
the  danger  they  ignore  of  disseminating  infectious  dis- 
eases. Why  should  not  a  man  who  communicates  dis- 
ease to  his  neighbor  be  held  liable  in  damages  ?  Em- 
ployers have  to  pay  their  workmen  for  accidents  which 
might  have  been  prevented,  and  a  disease  is  often  worse 
than  an  accident.  Small-pox  continues  to  spread  in 
the  East  End.  This  is  the  result  of  the  neglect  of  vac- 
cination, which  has  been  deliberately  evaded  with  the 
connivance  of  boards  of  guardians.  It  is  suggested 
that  the  administration  of  the  Acts  should  no  longer  be 
entrusted  to  these  Boards,  but  to  a  central  authority, 
say — the  Local  Government  Board. 


RELIGION,     DISTURBED      INDUSTRY, 
SUICIDE. 


AND 


Sir:  In  the  admirable  compilation  on  "Suicide  in 
the  United  States,"  which  appeared  in  the  Medical 
Record  of  August  17th,  I  think  Dr.  Weir  has  over- 
looked two  prime  factors  controlling  the  proportion  of 
suicides  among  different  peoples,  and  at  different 
places,  namely,  religion  and  disturbed  industrial  con- 
ditions. The  first  factor  is  negative  or  prohibitive  in 
operation.  It  receives  not  the  remotest  reference  in 
the  article  named.  The  second  might  be  inferred,  by 
the  student  of  economics,  from  the  author's  reference 
to  "condensation  of  population,"  which,  of  course,  in- 
volves keener  struggle  for  existence  leading  to  the  de- 
spair of  the  weaker  and  unfortunate.  That  the  latter 
is  a  force  paramount  in  the  production  of  the  increased 
suicide-rate  of  recent  years,  is  abundantly  demonstrated 
by  the  author's  own  figures  and,  taken  in  connection 
with  the  influence  of  the  Church  of  Rome  and  ciiurches 
of  similar  tenets  regarding  suicide,  sufficiently  explains 
certain  variations  of  the  suicide-rate  without  the  neces- 
sity of  any  abstruse  theory  of  inherent  national  psy- 
choses, or  at  least  gives  a  tangible  foundation  for  a 
working  theory. 

First,  taking  into  account  the  prohibitive  character 
of  the  Roman  Catholic  teachings,  we  find  that  they  ex- 
plain the  comparatively  smaller  proportion  of  suicides 
among  the  Celts  and  Celto-Latin  peojtles,  as  compared 


gestion,  and  assimilation.  It  is  especially  indicated  in 
the  weak  heart  of  pneumonia  and  febrile  processes, 
given  hypodermaticaljy  in  ^V  to  iV  grain  doses,  re- 
peated until  some  sign  of  the  drug  is  manifested.  It  is 
also  useful  to  relieve  the  alarming  symptoms  which  oc- 
and  c'efiiJi!i';iV/}='Lj\rwesthesia,  in  the  cardiac  weakness 
devotees  from  the  cradle  up.  This  prohibit'ive  tactor 
does  not  obtain  in  the  case  of  the  (iermanic  peoples,  a 
race  of  independents  in  religion,  each  individual  of 
which  is  making  a  race  for  his  own  salvation  unhindered 
by  the  restrictive  mandates  of  a  strong  body  of  ecclesi- 
astics, who,  to  a  great  extent,  would  otherwise  control 
his  destiny  as  the  acknowledged  mouth-pieces  of  Al- 
mighty God.  True,  the  Protestant  tenets  are  adverse 
likewise  to  suicide,  but  in  general  religious  observances 
among  the  Protestants  are  not  as  strictly  enforced  as 
among  the  Roman  Catholics.  That  the  belief  in  the 
restrictive  and  prohibitive  character  of  implicit  religious 
conviction  is  well  founded,  is  also  shown  by  application 
of  the  principle  to  the  Slavic  races.  The  latter  are 
dominated  by  the  Greek  Church,  whose  tenets  regard- 
ing suicide  are  of  the  same  strongly  interdicting  char- 
acter as  the  Roman  Catholic  Church.  In  fact  the 
proof  is  the  stronger,  for  the  proportional  ratio  of  Slav 
to  Germanic  suicides  is  3  to  i,  while,  as  between  the 
Celts  and  Celto- Latins  and  the  Germanics,  the  ratio  is 
but  2^2  to  I  (in  approximate  figures).  The  more  ab- 
ject and  unquestioning  observance  of  religious  injunc- 
tions among  the  Slavs  accounts  for  this  difference. 
The  same  observation  holds  good  as  between  the  Celts 
and  Celto-Latins,  suicides  among  the  latter  occurring 
with  about  twice  the  frequency  (65  to  32  being  the 
ratio)  as  among  the  former.  The  more  materialistic 
tincturing  of  beliefs  and  consequent  looser  religious 
observances  among  the  Celto-Latins,  gives  the  coinci- 
dence of  more  frequent  suicides.  Enumeration  of  Dr. 
Weir's  figures  for  the  United  States,  Latin  America, 
and  Australia  is  but  another  proof  of  the  prohibitive 
influence  of  rigorous  religious  training.  In  the  toler- 
ant, free-thinking  LTnited  States,  tempered  by  a  gener- 
ous mixture  of  Roman  Catholicism,  the  suicide-rate 
is  55  to  the  million  of  inhabitants.  In  Rome-dom- 
inated Latin  America,  including  Mexico,  Central  and 
South  America,  the  rate  sinks  to  38,  while  in  Prot- 
estant Australia  the  rate  jumps  to  65.  Regarding 
Mexico  I  can  speak  from  personal  observation,  and 
from  talks  with  native  physicians  who  have  given 
this  subject  time  and  attention.  The  unity  of  obser- 
vation here  is  that  suicide  among  confessing  or  ortho- 
dox Catholic  is  exceedingly  rare,  and  that  the  rate 
for  Mexico  is  swelled  from  backsliders  in  the  church 
and  from  the  colonies  of  foreigners  without  the  influ- 
ence of  the  dominant  church. 

So  much  for  the  prohibitive  character  of  religious 
teachings.  There  is  no  doubt  that  firm  religious  con- 
victions are  a  vast  sustaining  power  to  those  tempted 
to  self-destruction,  and  as  such  deserve  due  attention 
and  study. 

As  for  the  factor  of  disturbed  industrial  conditions. 
1  introduce  them  to  stem  the  tide  of  Dr.  Weir's  seem- 
ing pessimism.  He  apparently  concludes  that  the 
ratio  of  death  by  suicide  is  yearly  increasing,  with  a 
prospect  of  continuing  so  unqualifiedly.  Verily  such 
might  easily  be  the  conclusion  from  a  cursory  examina- 
tion of  the  author's  figures,  without  giving  contempo- 
rary history  causative  credit.  Taking  the  Chicago  fig- 
ures in  hand,  as  supplied  by  Dr.  Louis  J  Mitchel. 
coroner's  physician  of  Cook  County,  111.,  the  ratio 
from  1S90  to  1894,  inclusive,  does  show  an  annual  in- 
crease in  the  suicide- rate,  with  an  excessive  rate  in 
1893.  This  latter  year  was  the  Columbian  Fair  year, 
when  the  floating  population  of  the  city  was  vastly  in- 
creased, and  it  is  probable  that  a  proper  estimate  was 
not  made  of  this  absolute  increase  in  population.  Be- 
sides this,  it  must  be  remembered  that  the  stress  of 
hard  times,  wliich  during  this  period  gradually  grew 
greater  and  greater,  drove  many  people  to  self-destruc- 


September  14,  1895] 


MEDICAL   RECORD, 


395 


tion  from  the  pressure  of  nbsohite  want.  It  was  a 
period  of  suspension  of  industry,  strikes,  lockouts,  and 
labor  insurrections,  when  the  condition  of  the  mass  of 
the  people  was  productive  of  the  causes  of  suicide.  I 
have  examined  a  resume  of  incentives  to  suicide,  as 
shown  by  the  coroner's  inquests  in  Cook  County  for 
this  period,  and  it  shows  a  progressive  increase  among 
suicides  due  to  poverty  and  want. 

Dr.  Weir's  figures  regarding  the  suicide-rate  per  mill- 
ion in  the  State  of  Massachusetts  curiously  bear  me 
out  here.  Massachusetts  is  a  manufacturing  State,  and 
during  the  prosperous  years  1889, 1S90,  and  1891,  when 
its  factories  were  in  full  blast  under  the  protective  tariff 
stimulus,  the  rate  sank  from  91  to  81  per  million. 
With  1892  came  the  suspension  of  factory  work  in 
Massachusetts,  and  with  this  suspension  want  and  suf- 
fering among  the  people,  and  a  consequent  suicide- 
rate  of  115,  which  under  a  continuance  of  industrial 
paralysis  rose  in  1893  to  119.  What  I  hold  is,  that  in 
view  of  disturbed  industrial  conditions,  Dr.  Weir's  con- 
clusions that  an  absolute  and  continuous  increase  in 
the  suicide-rate  is  to  be  expected,  are  insufficiently 
borne  out  by  the  facts.  They  prove  nothing  more  than 
that,  with  conditions  favoring  the  development  of  want 
and  misery  among  the  people  and  thus  fostering  the 
incentives  to  suicide,  proportionately  more  people,  act- 
ing under  the  increased  pressure,  will  succumb  to  the 
temptation  of  self-destruction.  The  conclusions  re- 
garding the  world's  suicide-rate  in  general  are  open  to 
the  same  criticism,  because  his  comparisons  are  all 
drawn  between  past  years  of  comparative  prosperity 
and  the  rate  for  the  year  1893,  when  industrial  stagna- 
tion and  distress  were  general  ;  the  period  of  financial, 
labor,  and  trade  upheavals  when,  I  repeat,  the  incen- 
tives to  suicide  were  vastly  greater  than  at  most  any 
other  period  of  recent  history. 

Respectfully, 

C.  L.  Bennett,  M.D.. 

Surgeon  to  La  Gran  Fundkion  Central  Mexicana. 
Aguas  Calientes,  Mexico,  August  26,  1895. 


THE    ETHICS    OF   CRANIOTOMY. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  It  is  possible  that  you  are  becoming  wearied  with 
the  subject,  but  the  last  letter  by  Dr.  Kearney  has 
placed  the  discussion  of  craniotomy  on  a  broader  basis 
than  it  had  heretofore  had.  The  conclusion,  however, 
is  so  very  lame  and  unsatisfactory,  that  I  cannot  for- 
bear asking  leave  to  present  one  view  of  the  question 
that  has  not  yet  been  mentioned.  I  suppose  Dr.  Gal- 
loway well  able  to  fight  his  own  battles,  and  I  wish  to 
refer  only  to  the  last  paragraph  of  Dr.  Kearney's  article 
in  the  Medic-\l  Record  of  August  31,  1S95  : 

"  Thus  I  affirm,  it  is  plainly  seen  that  there  is  no  sys- 
tem of  moral  science  v»fhose  teachings  can  be  appealed 
to  in  support  of  Dr.  Galloway's  contentions.  There  is 
nothing,  then,  for  him  to  do  but  either  to  accept  the 
behests  of  the  moral  law  as  we  now  understand  them 
or  to  found  a  new  school.  To  do  this  latter,  however, 
he  must  discover  some  principle  or  principles  of  ethics 
that  have  hitherto  eluded  the  profound  thinkers  of 
the  past,  for  most  surely  the  principles  he  advances,  if 
jnished  to  their  legitimate  logical  consequences,  will 
lead  to  moral  chaos." 

Procuring  the  death  of  the  fo.-tus  to  save  the  life  of 
the  mother  is,  I  am  sure,  to  be  defended  on  ethical 
grounds.  The  principles  of  ethics  applicable  to  the 
case  have  already  been  enunciated  and  are  now  gen- 
erally received  by  thinking  men.  The  only  difficulty 
is  that  these  principles  have  not  been  yet  distinctly 
enough  applied  to  the  case  in  hand. 

We  may  safely  assume,  I  believe,  that  the  theory  of 
evolution  is  the  best  working  hypothesis  in  every 
branch  of  natural  science.     We  are  learning,  through 


Herbert  Spencer  and  all  late  writers  on  ethics  and  poli- 
tics, that  the  same  principle  will  best  explain  the  facts. 
History  is  being  rewritten  from  an  evolutionary  stand- 
point. Under  the  teaching  of  the  school  of  Lombroso. 
even  the  criminal  code  is  changing  to  harmonize 
with  the  same  great  principle. 

The  theory  of  gradual  development,  Darwinism,  for 
a  popular  name,  has  proved  to  be  the  most  (ar-reach- 
ing,  stimulating,  and  helpful  principle  ever  enunciated. 
Now  that  we  have  had  the  last  word  on  the  subject  of 
craniotomy  from  the  church,  and  from  precedent  in 
jurisprudence  with  their  conflicting  decisions,  and  a  re- 
duction to  a  "moral  chaos,"  why  not  ask  what  the 
principle  of  development,  which  has  helped  us  out  of 
so  many  quagmires,  will  do  for  us. 

Let  us  admit  two  projj'ositions — that  man  has  de- 
veloped from  the  lower  forms  of  animal  life,  and  that 
the  development  of  the  individual  corresponds  to  the 
development  of  the  race  up  to  that  point.  If  these 
principles  are  denied,  I  have  not  the  space  or  ability  to 
go  through  the  voluminous  proof  that  seems  to  me  con- 
vincing. 

If  these  are  admitted,  it  seems  to  me  it  must  neces- 
sarily follow  that,  while  the  human  embryo  is  from  the 
first  alive,  it  is  not  a  human  being  until  it  has  de- 
veloped and  differentiated  to  such  a  point  as  corresponds 
to  that  point  at  the  birth  of  the  race  where  the  animal 
became  a  man.  I  am  sure  I  do  not  know  just  w  hen  that 
occurred  in  the  past,  and  I  do  not  know  at  what  point 
it  takes  place  in  the  individual.  I  am  sure,  however, 
it  is  a  good  ways  this  side  the  act  of  copulation,  that 
it  is  this  side  the  fourth  week  when  it  is  impossible  to 
distinguish  the  human  foetus  from  that  of  a  cat.  In 
inquiring  for  that  distinctive  feature  which  distin- 
guishes the  man  from  the  animal,  I  find  none  but  men- 
tality. If  we  wait  for  distinctive  mentality  to  appear 
in  the  development  of  the  individual,  it  would  be  some 
time  after  birth. 

I  am  well  aware  that  the  idea  arouses  antagonism 
and  inflammatory  denunciation  in  some  minds.  That 
it  will  prove  to  be  the  true  one,  however,  depends  only 
on  the  truth  of  the  general  theory  of  development. 
That  it  is  already  held  by  some  is  shown  by  this  .sen- 
tence from  a  recent  article  by  Lombroso  ( The  Forum, 
September,  1895,  p.  42).  The  original  referred  to  I 
have  not  yet  been  able  to  obtain.  "  Balestrini  made  a 
wonderful  study  of  infanticide  and  abortion,  and  de- 
monstrated that  in  the  case  of  abortion,  especially, 
what  is  killed  is  not  a  man,  but  a  being  inferior  in  the 
zoological  world." 

F.  W.   HiGGiNS,  M.D. 

Cortland,  N.  V. 

Silly  Old  Folks.— One  of  the  daily  papers  recently 
])ablished  an  account  of  a  boat-race  rowed  at  Deal, 
England,  between  four  four-oared  crews  of  boatmen  over 
sixty  years  of  age.  The  winning  oarsmen  averaged 
seventy  years,  while  their  coxswain  was  eighty-five. 
At  the  same  time  appeared  an  item  concerning  two 
women  in  Maine,  one  sixty- nine  and  the  other  eighty 
years  of  age,  who  held  the  championship  of  their  town 
for  rope-skipping.  It  is  a  pity  these  hale  old  people 
have  not  as  much  wisdom  as  they  have  physical  strength, 
to  prevent  them  from  abusing  the  latter. 

The  Term  ••  Uricacidemia  "  recently  was  stigmatized 
in  these  columns  as  a  fearful  mongrel  never  employed 
by  educated  writers.  This  assertion,  however,  is  not 
altogether  true,  it  seems.  For  in  a  late  number  of  the 
British  Medical  Journal  the  eminent  Dr.  Haig  employs, 
unreservedly,  this  wonderful  combination  of  two  Eng- 
lish words  and  a  Greek  suffix.  Hereafter  no  one  will 
be  surprised  to  see  crop  up  in  medical  literature  such 
vocabulary  beauties  as  whitebloodcorpuscleemia,  grape- 
sugaruria,  eggwhiteuria,  gallstoniasis,  stomachguttitis, 
etc.  Verily,  the  English  language  has  lost  nothing  of 
the  flexibility  and  adaptability  of  vigorous  youth. — 
Western  Druggist. 


596 


vIEDICAL   RECORD. 


[September  14,  1895 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  September  7,  1895. 


Tuberculosis 95 

Tjrphoid  fever 3' 

Scarlet  fever 21 

Cerebro-spiaal  meningitis 2 

Measles . . . .' 63 

Dipht)j<ria I37 


The  Ear  in  the  Exanthemata. — Among  the  prevent- 
able diseases,  which  have  so  often  been  allowed  to  gain 
ground  through  neglect  at  their  first  onset,  may  be 
counted  otitis  inedia  suppurativa  following  the  exan- 
themata. The  aural  surgeon  meets  such  cases  every 
day.  and  more  often  ihan  not  they  have  been  neglected 
by  parents  because  they  believed  in  the  absurd  and 
ignorant  fallacy,  that  the  patient  '"  would  grow  out  of 
it."  Xow,  thanks  to  the  improvi-ment  in  the  education 
of  the  general  public,  we  may  hope  that  these  cases 
will  become  less  in  number,  and  that  some  of  the  more, 
alarming  complications  of  exanihematous  otitis  media 
may  be  met  with  less  often.  Quoting  recent  stitistics, 
it  may  be  said  that  out  of  501  cases  of  middle-ear  dis- 
ease in  children,  131  originated  during  an  attack  of 
measles,  63  during  scarlet  fever,  147  owed  their  origin 
to  catarrh,  and  10 1  to  teething  ;  so  that  it  will  be  seen 
that  some  two  fifths  arise  in  measles  and  scarlet  fever. 
Xow.  without  go  ng  deeply  into  symptomatology,  it  is 
only  necessary  to  point  out  how  these  diseases  give  rise 
to  pharyngeal  troubles,  causing  blocking  of  the  Eus- 
tachian tubes,  and  the  accumulation  of  secretion  in  the 
tvmpanum.  Since  the  Eustachian  tubes  drain  better  m 
the  upright  than  the  recumbent  position,  the  child  suf- 
fering from  measles  or  scarlet  fever  is  placed  at  a 
further  disadvantage,  as  pointed  out  by  Walker  Do wnie, 
who  consequently  insists  upon  the  frequent  and  strong 
use  of  the  jjocket-handkerchief  to  keep  the  nose  and 
naso  pharynx  free  from  the  very  beginning  ot  the  ill- 
ness, when  there  are  catarrhal  symptoms.  If  the  child 
is  tL)0  young,  politzerization  can  always  take  the  place 
.)f  the  handkerchief.  The  pent-up  secretion  in  the 
tympanum  gives  rise  to  considerable  pain,  and  if  this 
be  not  relieved  by  the  means  just  mentioned,  the  risks 
of  future  oiorrhcea  can  be  best  avoided  by  paracentesis 
of  the  membrana  tympani.  If  done  at  the  lower  and 
posterior  part  of  the  membrane,  with  a  shouldered 
myringotome  under  proper  focal  illumination,  the 
child's  head  being  securely  held,  this  little  operation  is 
perfectly  safe  and  simple,  and  the  wound  readily  heals. 
If  the  patient  be  the  subject  of  adenoids,  these  must 
be  left  until  recovery  from  the  e.xanthem.  It  cannot 
be  too  deeply  and  strongly  impressed  upon  the  public 
that  it  is  during  the  primary  febrile  disease  that  the  ear 
requires  care,  and  that  a  discharge  from  that  organ 
during  measles,  scarlet  fever,  or  small-pox,  means  cul- 
pable neglect  and  carelessness.  Inquiries  as  to  the 
ear  should  be  made  at  every  visit,  and  an  occasional 
examination  with  a  speculum  insisted  upon.  Further, 
when  earache  is  complained  of,  it  is  by  the  simple  and 
scientific  methods  mentioned  above  that  relief  must  be 
afforded,  and  the  ear  (^perhaps  also  the  life)  s.ived,  and 
not  by  the  palliative  means  of  blisters  or  leeclies. —  Tlu 
Medical  Times. 

The  Royal  College  of  Physicians.— In  the  tenth  year 
of  the  reign  of  Henry  VIII..  on  September  ^,  15 18, 
"John  Chambre.  Thomas  Linacre,  Ferdinand  de  Vic- 
toria, Medicorum  Nostrorum.  Nicholas  Holsack,  John 
Francis,  Robert  Vaxley  "  were  granted  letters  patent 


giving  them  the  privilege  of  admitting  men  to  practise 
medicine  in  London  and  seven  miles  around.  This 
was  the  original  foundation  of  the  present  Royal  Col- 
lege of  Physicians  of  London.  The  first  letters  patent 
having  apparently  been  inadequate  for  the  purposes 
intended,  in  the  fourteenth  year  of  Henr)'  VIII.  a  stat- 
ute was  passed  enacting  that  no  person  save  a  graduate 
of  Oxford  or  Cambridge  should  practise  in  England, 
unless  he  had  a  license  from  the  President  of  the  Col- 
lege of  Phjsicians  aforesaid,  and  from  three  of  the 
"  Elects,"  who  were  chosen  from  among  the  Fellows. 

Medical  Students  in  Italy. — There  were  19,048  med- 
ical students  registered  in  Italy  in  1894-95.  The  num- 
ber of  universities  is  twenty- one,  and  the  number  of 
students  registered  at  the  various  universities  varies 
from  3,697  at  Naples  to  87  at  Milan.  The  percentage 
of  medical  students  to  the  population  is  about  61  ]ier 
100,000  inhabitants.  In  France  it  is  57  per  100,000. 
and  in  Germany  63  per  100,000.  In  Italy,  university 
education  is  chiefly  supported  by  the  State,  the  stu- 
dents paying  only  a  yearly  tax  of  200  or  300  francs. 
•According  to  the  la':est  statistics,  after  subtracting  the 
tax  paid  by  the  students,  each  student  costs  annuall\ 
to  the  State  a  sum  which  varies  from  a  minimum  o! 
215  francs  at  the  University  of  Naples  to  a  maximum 
of  1,408  francs  a:  the  University  ot  Siena.  It  appears 
from  the  returns  that  the  larger  the  number  of  students 
at  a  university,  the  smaller  the  annual  expenses  for 
their  education. 

Acne  Rosacea. — F"reeze  the  part  with  a  rhigolene 
spray  or  cth)  1  chloride,  and  freely  scarify  with  a  five- 
bladed  knife.  This  treatment  gives  prompt  relief. — 
Caxtrell. 


NEW   BOOKS   RECEIVED. 


"  ^While  the  Mkiucal  Record  is  pleased  to  reeeive  all  new  publt- 
cations  -uhich  may  be  sent  to  it,  and  an  ,uknewledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  -with 
the  distinct  under stan-ling  tliat  its  necessities  are  such  that  it  cannot 
be  considered  under  obligation  to  notice  or  review  any  publication 
received  by  it  which  in  the  judgment  0/  its  editor  will  not  be  of  in- 
terest to  its  readers. 

ExEKCisK  .\ND  Food  fok  Pulmo.s'.\rv  Invalids.  By  Dr. 
Charles  Denison.  i2mo,  71  pages.  Illustrated.  Price  35  cents. 
Published  by  The  Chain  &  Hardy  Co..  Denver,  Col. 

The  Diseases  of  the  Liver  :  Jaundice   G.\llsto.sks.  E.s- 

LARGEMENT,  TUMOKS.  -\ND  CaXCER  :  AND  THEIR  TREATMENT. 
By  T.  Compton  Burnett.  M.D.  lamo.  244  pages.  Illustrated. 
Price,  ll.oo.     Published  by  Boerickc  &  T.Tffel,  Philadelphia. 

Induk.\T1VE  MEDLls-flNO-PERlCARDiTlS.  By  Thomas  Harris, 
M.D.  8vo,  67  pages.  Illustrated.'  Published  by  Smith,  Elder  & 
Co.,  London. 

Transactions  of  the  Medical  Society  of  the  State  of 
Pennsylvania,  Held  at  CH.uiBERSBURG.  Forty-fifth  An- 
nual Session.  i8<)S-  Vol.  26.  Svo.  504  pages.  Published  by 
the  Society.  The  Edwards  and  Docker  Co.,  Philadelphia.  Pa., 
Printers. 

Praciical  DiETErics.  With  Special  Reference  to  Diet  in 
DlSE.\SE.  By  W.  Oilman  Thompson,  M.  D.  Svo,  801  pages.  Il- 
lustrated.    Published  by  D.  .\ppIeton  &  Co.,  New  York  City. 

The  Theory  and  Practice  of  Cou.nter  irrit.ktion.  By  H. 
Cameron  Gillies,  M.D.  Svo,  236  pages.  Price,  6d.  Publishers, 
Macmillan  &  Co..  New  York  City. 

Transactions  of  the  Medical  Society  of  the  St.^te  of 
Califi>kni.\.  Session  of  1895.  Svo,  452  pages.  W.  A.  Wood- 
ward &  Co.,  Printers,  San  Francisco,  Cal. 

Modern  Medicine  .AND  IIomo;op.\thy.  Two  .\ddresses  by 
John  J*r  Roberts,  M.D.  i6mo.  69  pages.  Price,  75  cents. 
PuliHShed  by  The  Edwards  &  Docker  Co..  Philadelphia,  Pa. 

The  Pocket  Materia  Medica  and  THERAPEirrics.     By  C 
Henri  Lei'nard.     Second  Edition.     Revised  and  Enlaiged.      i6in< 
387  P->ses.     Price.  $1.00.     Published  by  the  Illuslraled  Medi 
Journal  Co.,  Detroit,  Mich. 

Le  Phthisique,  et  Son  Traitement  IIygibniqub.  Par 
Dr.  E.P.  Leon-Petit.  i6mo.  303  pages.  Illustrated.  Prices 
4fr.  and  3fr.  Published  by  .-Vucienne  Librairie  Geniier,  Baill 
et  Cie  ,  Felix  .\lcan,  Editeur,  Paiis,  France. 


I 

lere     r 


Medical   Record 

A  IVeekly  journal  of  Medicine  and  Surgery 


Vol.  48,  No.  12. 
Whole  No.  1298. 


New  York,  September  21,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©vxgtnaX  |^rt^c^es. 


PREVENTION    OF    UTERINE    DISEASE    DUE 
TO    CHILD-BEARING.i 

By  W.  gill  WVLIE,  M.D., 


Most  of  my  work  as  a  physician  and  surgeon  has  been 
devoted  to  effecting  cures  of  diseases  as  we  find  them 
in  women  after  child-bearing,  but  the  first  ten  years  of 
my  practice  was  that  of  a  general  practitioner,  and  I 
still  take  a  limited  but  sufficient  number  of  selected 
cases  of  obstetrics,  to  make  the  matter  one  of  great  in- 
terest and  more  or  less  of  a  study.  During  the  past 
fifteen  years,  which  I  have  devoted  mainly  to  the  de- 
velopment and  improvement  of  the  art  of  gynecological 
surgery,  there  has  been  a  great  advance  in  this  work, 
30  much  so  that  in  our  annual  meetings  papers  on  any 
other  subject  than  surgical  gynecology  are  rare.  Be- 
sides, it  seems  to  me  that  we  have  reached  the  point 
where  we  should  at  least  attempt  to  divert  some  of  the 
immense  interest  and  almost  general  devotion  mani- 
fested not  only  by  men  especially  trained  in  gynecol- 
ogy, but  by  the  profession  at  large,  to  what  may  well 
be  termed  fashionable  surgical  gynecology,  to  that 
higher  plane  of  our  work  as  physicians,  namely,  to  the 
prevention  of  disease.  To-day,  as  physicians  and  ar- 
tists in  surgery,  we  can  readily  relieve,  and  in  almost  all 
cases  cure,  the  special  diseases  of  women  promptly  and 
accurately  with  very  little  risk  to  life,  and  we  can  well 
afford  to  turn  our  attention  and  direct  our  efforts  to 
the  prevention  of  such  diseases.  Fifteen  years  ago 
many  important  diseases  of  women  were  improperly 
treated,  and  the  practice  of  the  art  of  gynecological 
surger)-  was  of  very  doubtful  practical  value  to  our  pa- 
tients ;  but  to-day  there  are  hundreds  of  accomplished 
artists  in  our  ranks  who  can  and  do  effect  cures  of 
these  diseases,  and  there  are  many  thousands  more  of 
the  profession  who,  if  they  keep  up  the  interest  and 
their  readiness  to  operate,  should  become  expert  or 
kill  many  women.  How  much  better  it  would  be  if  we 
could  succeed  in  getting  up  an  almost  universal  inter- 
est, and  one  might  say  fashion,  in  our  profession  to 
prevent  many,  yes,  mobt,  of  these  cases  ?  How  much 
greater  and  more  real  our  help  toward  the  health  and 
happiness  of  womankind  would  be  ? 

Suppose  one  had  the  power  to  direct  the  immense 
amount  of  energy,  interest,  and  work  now  so  intensely 
and  enthusiastically  devoted  by  not  only  all  specialists 
in  gynecology,  but  one  might  say  nearly  all  of  the  pro- 
fession who  think  themselves  capable  and  are  so  will- 
ing and  an.xious  to  sew  up  lacerations,  remove  ovaries, 
and  do  hysterectomies,  etc.,  to  the  prevention  of  dis- 
eases of  women,  what  an  amount  of  good  to  mankind 
and  especially  to  women  would  result  ?  The  work 
might  not  be  so  e.xciting,  nor  so  brilliant,  nor  immedi- 
ate in  tangible  results,  but  much  greater  in  the  highest 
sense  of  the  word.  We  will  endeavor  to  enumerate 
some  of  the  plain  and  practical  fields  of  work  in  which 
much  of  this  great  force  might  be  made  really  useful. 

As  physicians  we  can  do  much  by  urging  on  parents 

'  Read  at  Baltimore,  May  29,  1895,  before  the  American  Gynecolog- 
ical Society. 


to  keep  girls  in  good  health,  especially  during  the  time 
that  the  generative  organs  are  undergoing  rapid  devel- 
opment, say  from  ten  to  seventeen  years  of  age.  The 
generative  organs  are  not  essential  to  the  life  of  the  in- 
dividual and  are  the  last  of  the  organs  to  develop  ; 
therefore  they  are  the  first  to  suffer  if  the  forces  essen- 
tial to  full  development  are  used  up  too  closely  by  ex- 
cessive work,  deficient  food,  or  want  of  fresh  air  and 
exercise,  especially  if  the  work  or  the  life  uses  up  or 
expends  this  force  in  mental  or  emotional  excesses. 
In  fact,  it  seems  absolutely  essential  to  the  full  devel- 
opment of  the  generative  organs  of  a  woman  for  her  to 
have  a  surplus  of  force  over  and  above  what  is  needed 
for  the  uses  and  development  of  the  other  organs  of  the 
woman. 

Imperfect  development  of  the  generative  organs  re- 
sults usually  in  a  small  flexed  uterus,  with  catarrhal 
erosions  and  chronic  endometritis,  causing  leucorrhoea, 
dysmenorrhoea,  and,  later,  in  sterility  or  lacerations  of 
the  cervix,  subinvolutions,  displacements,  etc. 

It  is  the  duty  of  physicians  to  impress  upon  newly 
married  women  the  necessity  of  keeping  in  good  gen- 
eral health  during  pregnancy.  By  keeping  the  bowels 
regular  and  taking  some  special  food  such  as  would  be 
easily  digested,  and  other  means  to  keep  the  general 
health  good,  both  the  mother  and  child  can  be  made 
to  reach  the  full  term  in  good  physical  condition. 

By  actual  experience  I  have  proved  that  by  careful 
feeding  and  attention  to  the  general  health  during 
pregnancy,  and  induction  of  premature  labor  when  in- 
dicated, it  is  practical  to  avoid  craniotomy  or  Caesarean 
operation  in  most  cases  of  deformity,  and  even  where 
the  uterus  is  imperfectly  developed,  or  the  os  eroded 
by  disease  of  the  follicles  and  glands  of  the  mucous 
membrane,  by  inducing  labor  from  one  to  three  weeks 
before  full  term  we  can  not  only  avoid  difficult  labor 
and  laceration  of  the  imperfectly  developed  or  diseased 
cer\-ix  uteri,  but  the  forceps  become,  except  in  rare  in- 
stances, unnecessary.  If  the  pelvis  is  below  the  aver- 
age si^e,  or  if  there  is  any  deformity  ;  if  the  husband's 
head  is  excessively  large  and  the  woman  small  ;  or  if 
there  is  imperfect  development  or  chronic  disease  of 
the  cervix,  I  do  not  hesitate  to  induce  labor  before 
full  tenn,  especially  in  primipara.  If  the  first  labor  is 
after  the  woman  is  thirty  years  old  or  more,  it  is  best 
to  induce  labor  a  week  or  ten  days  before  full  term. 
About  the  end  of  the  seventh  month  or  before  the  end 
of  the  eighth  month  I  invariably  examine,  to  determine 
the  condition  of  the  parts  and  the  position  of  the  head. 
As  a  rule  one  can  easily  perform  external  version  if  he 
finds  the  head  not  presenting  in  a  normal  position. 

I  do  not  advise  induction  of  labor  without  a  good 
reason,  but  I  know  that  it  can  be  done  by  an  expert  who 
understands  and  practices  cleanliness  and  the  use  of 
antiseptics  with  practically  no  more  danger  to  either 
child  or  mother  than  labor  at  full  term.  Not  only  is 
the  labor  when  properly  induced  shorter  and  easier  on 
account  of  the  relatively  smaller  child  and  softer  and 
therefore  more  malleable  head,  but  as  the  time  of  labor 
is  positively  known,  everything  is  in  readiness,  and  both 
the  nurse  and  doctor  are  present  without  fail,  and 
cleanliness  is  carried  out  with  more  accuracy,  and  ac- 
cidents from  hemorrhage,  etc.,  more  certainly  avoided. 
The  method  of  inducing  labor  which  I  have  found  to 
be  practically  the  best  in  my  hands  is  an  old  one.  Ob- 
servini^  all  rules  of  cleanliness,  I   use  the  tincture  of 


MEDICAL   RECORD. 


[September  21,  1895 


green  soap  to  wash  not  only  the  patient,  but  the  hands 
of  nurse  and  doctor,  supplemented  by  a  solution  of 
hydrarg.  bichloride  i  to  3,000.  If  the  vagina  is  small, 
or  if  the  induction  is  more  than  a  week  before  full 
term,  I  move  the  patient's  bowels  well,  and  by  the  use 
of  a  clean  and  new  rubber  colporteur  I  distend  and 
soften  the  vagina  for  several  hours  or  a  day  before  in- 
ducing labor.  I  then  take  an  old-fashioned  gum  cathe- 
ter, a  new  one,  wash  and  disinfect  it,  partly  fill  it  with 
iodoform,  and  start  the  introduction  with  a  properly 
curved  stylet  so  as  to  be  able  to  pass  the  catheter  up 
anteriorly  to  the  presenting  head.  After  giving  it  a 
fair  start  the  stylet  is  withdrawn  and  the  catheter  care- 
fully passed  up  till  it  is  all  well  up  in  the  uterus,  lying 
between  the  membranes  and  the  anterior  wall  of  the 
uterus,  with  from  one  to  three  inches  of  the  lower  end 
in  the  vagina.  The  catheter  is  introduced  at  bedtime, 
and  usually  two  ounces  of  castor-oil  is  given  by  mouth. 
One  must,  if  possible,  avoid  rupturing  the  membranes 
when  introducing  the  catheter.  With  rare  exception 
labor  pains  will  begin  the  next  morning,  and  when  labor 
is  fairly  started  the  catheter  is  withdrawn.  I  have  tried 
the  glycerine  injections  and  other  methods,  but  prefer 
the  one  given  above.  Glycerine  injected  in  the  preg- 
nant uterus,  when  it  remains  will  induce  labor,  but  it 
often  causes  alarming  pain  in  the  head  and  intense  op- 
pressive sensations  about  the  chest ;  besides,  the  labor 
is  induced  too  rapidly  and  the  tissue  may  not  have  had 
time  to  soften  and  properly  dilate. 

Prevention  of  sepsis  after  labor  or  abortions  is  now 
so  well  understood  that  it  is  only  necessary  to  urge 
the  simple  but  efficient  means  used  in  almost  all  of  our 
lying-in  hospitals  and  used  in  private  practice  by  many 
of  the  profession.  In  1870,  twenty-five  years  ago, 
when  I  began  practice  as  an  intern  in  Bellevue  Hos- 
pital, the  death-rate  in  the  lying-in  wards  from  puer- 
peral fever  was  every  year  from  five  to  twenty- five  per 
cent,  of  all  women  delivered.  To-day  many  hundreds 
of  consecutive  cases  are  delivered  in  our  best  lying-in 
hospitals  without  a  death  from  sepsis.  In  the  spring 
of  1S72,  when  it  was  my  turn  to  take  charge  of  the 
lying-in  wards  then  in  Bellevue  Hospital,  I  had  become 
a  convert  to  the  germ  theory  of  disease  and  had  been 
fully  imbued  with  a  faith  in  antiseptics  by  my  old  pre- 
ceptor, the  late  Dr.  James  R.  Wood.  By  throwing 
away  all  sponges  and  old  oil-cloths,  and  personally  at- 
tending each  case  in  all  its  details  of  cleanliness,  and 
trea^ting  each  case  with  all  the  care  that  I  would  be- 
stow upon  a  wound,  I  delivered  all  of  my  forty-one 
cases  without  a  death  from  sepsis.  In  July,  1872,  I 
had  the  advantage  of  seeing  the  great  Lister  at  work  in 
Edinburgh,  and  brought  home  with  me  to  New  York  his 
methods  and  appliances  for  treating  and  dressing  wounds, 
making  practical  application  of  his  teaching  from  that 
day  to  this  on  all  women  that  I  have  ever  attended, 
after  either  a  labor  or  abortion.  So  far  I  have  never 
yet  had  a  death  from  any  cause,  after  either  labor  or 
abortion,  which  I  have  attended,  and  only  one  had  sep- 
sis which  endangered  the  life  of  the  patient.  To  day 
I  find  that  there  are  many  of  my  colleagues  in  the  pro- 
fession under  forty-five  who  have  had  for  many  con- 
secutive years  the  same  good  fortune.'  Thirteen  years 
ago,  in  a  paper  read  before  the  New  York  County  Medi- 
cal Society  and  i)ublished  in  the  Medical  Record,  I 
gave  an  account  of  my  meihod  of  preventing  and  treat- 
ing sepsis  after  labor  and  abortions.  To-day  I  use  the 
same  methods  somewhat  simplified.  I  will  now  briefly 
relate  the  means  I  now  carry  out  in  every  case. 

Prevention  of  Sepsis  after  Labor  or  Abortion. — Be- 
fore agreeing  to  take  a  case  it  must  be  stipulated  that 
I  am  to  have  full  charge  of  the  case  in  every  sense  of 
the  word  The  nurse  must  be  one  of  my  own  training, 
or  at  least  selected  by  me.     Before  labor  is  expected 

'  I  must  confess  that  all  of  my  cases,  except  in  the  very  first  few  years 
of  n\y  practice,  were  among  the  best  class  of  well-to-do  women,  able 
to  pay  for  the  best  nursing  and  to  compensate  nie  for  the  closest  atten- 
tion. 


the  nurse  must  be  in  the  house  with  all  medicines,  in- 
struments, etc.,  likely  to  be  needed,  on  hand.  The 
room  to  be  used  is  cleared  of  all  stuffy  furniture  and 
hangings  and  given  a  thorough  cleaning  ;  a  sheet  or 
two  is  tacked  over  the  carpet  where  the  new  cheap  and 
strong  cot  which  is  to  be  used  to  deliver  on  is  placed  ; 
all  towels,  bedclothing  and  linen  is  to  be  especially 
laundered,  so  as  to  be  practically  sterilized,  and  kept  in 
readiness.  On  or  before  the  first  indications  of  labor 
beginning  the  patient  is  given  a  complete  bath  if  there 
is  time,  or,  at  any  rate,  the  vulva  and  vagina  are  well 
scrubbed  and  washed  with  tincture  of  green  in  place 
of  ordinary  soap,  and  the  parts  washed  off  with  i  to 
3,000  solution  of  hydrarg.  bichloride.  The  nurse  must 
have  on  a  clean  wash  dress,  and  I  put  on  a  surgical 
gown  ;  my  hands  and  the  nurse's  are  always  washed 
with  tincture  of  green  soap  and  dipped  in  a  solution  of 
bichloride  each  time  before  examining  the  patient. 
During  and  after  labor  a  solution  of  bichloride,  i  to 
3,000  or  4,000,  is  used  to  wash  off  the  vulva.  If  there  is 
time  the  bowels  are  well  moved  by  castor-oil,  and  al- 
ways the  rectum  emptied  by  enemata  ;  all  instruments 
used  have  been  sterilized  by  boiling,  and  put  in  a  so- 
lution of  I  to  40  carbolic  acid  before  being  used.  Any 
hemorrhage  is  checked  by  emptying  the  uterus  of  pla- 
centa or  clots,  and,  if  necessary,  by  ligation  of  the  cir- 
cular artery  when  the  cervix  is  torn  or  by  sewing  up 
the  perineum  when  torn.  Any  tearing  of  consequence 
to  the  perineum  is  sewed  up.  After  labor,  except  in 
cases  complicated  by  severe  hemorrhage  or  lacerations 
requiring  sewing,  the  patient  is  made  to  sit  up  to  pass 
water  or  have  the  bowels  move.  For  a  full  week  the 
antiseptic  napkins  or  absorbent  pads  are  kept  over  the 
vulva  and  changed  every  few  hours  as  required  by  the 
discharge,  and  after  each  time  the  bowels  move  or  the 
patient  passes  water  the  vulva  is  washed  off  by  means 
of  a  David  syringe  and  solution  of  i  to  3,000  of  bichlo- 
ride of  mercury.  This  is  kept  up  faithfully  for  seven 
days  after  labor.  On  the  sixth  or  seventh  day  the  pa- 
tient sits  up  out  of  bed.  On  the  tenth  day  the  patient 
is  carefully  examined  as  to  the  condition  of  the  parts, 
the  character  of  discharge,  and  position  and  condition 
of  the  uterus,  and  to  decide  if  any  local  treatment  is 
needed  to  insure  normal  involution  and  prevention  of 
subinvolution  of  the  uterus,  relaxation  of  the  ligaments, 
and  displacements  of  the  uterus.  No  vaginal  douches 
are  given  after  labor  unless  instruments  have  been  used 
to  deliver,  or  hands  have  been  introduced  into  the 
uterus,  or  there  is  a  rise  of  temperature  or  an  odor  to 
the  discharge. 

I  will  not  discuss  the  questions  as  to  the  methods  of 
delivering  the  child  in  abnormal  labor,  for  the  art  of 
delivering  the  child  and  membranes  is  well  understood 
and  better  taught  by  those  who  have  devoted  more 
time  to,  and  have  had  much  more  experience  in,  the  art 
of  obstetrics. 

Treatment  of  Acute  Sepsis  Occurring  after  Labor  and 
Abortions  to  Prevent  its  Extension  or  from  Causing 
Permanent  Injury.— In  the  paper  already  referred  to  I 
gave  fully  my  views  and  methods  on  the  local  treat- 
ment of  sepsis  after  labor  and  abortions,  and  would  be 
content  here  merely  to  state  the  method,  but  I  am  satis- 
fied that  what  may  be  called  the  fashionable  methods 
now  being  resorted  to  and  so  ably  advocated  by  some 
of  my  colleagues  has  a  very  radical  defect  when  apjilied 
to  any  but  fresh  and  rather  superficial  septic  uterine 
infection.  I  mean  curettage  and  gauze  packing,  as  it 
is  called.  Of  course  in  all  cases  where  it  is  possible  the 
uterus  should  be  emptied,  but  there  is  an  erroneous 
belief  and  teaching  now  very  prevalent,  namely,  that 
sepsis  is  caused  by  retained  placenta,  and  all  that  is 
needed  to  cure  is  to  curette  it  out  and  pack  the  uterus 
with  iodoform  gauze.  It  is  true  that  retained  placental 
tissue  and  clots  make  a  very  favorable  nidus  and  food 
for  septic  germs,  and  undoubted;)'  make  sepsis  more 
liable  to  increase  when  it  is  present,  and  lessen  the 
chance  of  the  normal  tissues  defending  themselves,  and 


September  2t,  1895] 


MEDICAL   RECORD, 


599 


thus  make  sepsis  more  dangerous,  but  uninfected  pla- 
cental tissue  will  not  cause  sepsis.  Of  course  it  should 
be  removed,  and  it  is  very  important  to  remove  or  give 
free  drainage  to  all  effete  tissue,  when  once  the  septic 
germs  become  active,  if  we  are  to  treat  the  case  success- 
fully ;  but  sepsis  will,  as  we  well  know,  start  up  and 
kill  when  there  is  no  such  thing  as  a  placenta  about. 
My  belief  is  that  septic  germs  must  have  some  effete 
material,  or  at  least  defective  organic  matter,  to  develop 
and  thrive  in  and  cause  the  kind  of  sepsis  which  first 
infects  a  puerperal  woman  ;  but  the  presence  alone  of 
such  material  will  not  cause  sepsis. 

Now,  as  to  the  use  of  gauze  as  a  drain  in  ordinary 
cavities  where  the  secretions  or  excretions  are  thin  and 
watery.  Loosely  packed  gauze  drains  well,  but  the  uterus 
in  the  condition  is  different.  It  has  in  it  many  glands 
and  follicles  which  secrete  or  e.xcrete,  especially  when 
irritated  or  inflamed,  a  thick  gummy  material,  which 
after  a  few  hours  soon  chokes  drainage  through  gauze, 
and  what  escapes  passes  around  and  in  spite  of,  and  not 
through,  the  gauze.  Besides  the  uterus  is  a  contractile 
organ  with  a  very  powerful  sphincter  guarding  its 
mouth,  and  as  soon  as  contractions  begin  this  constricts 
the  gauze  and  obstructs  drainage.  I  admit  that  in  all 
cases  the  uterus  should  be  carefully  emptied,  but  I  pre- 
fer the  combined  method  of  the  hand  or  fingers  and 
forceps  where  this  is  practicable.  After  removing  with 
forceps  all  large  pieces,  I  very  carefully  run  a  large- 
sized  curette  over  the  surface  to  bring  away  small  ad- 
herent pieces  ;  but  soon  after  labor  and  abortions,  es- 
pecially when  rendered  soft  and  patulous  from  sepsis, 
it  is  an  easy  matter  to  push  a  smallish  curette  entirely 
through  the  uterus,  and  it  is  not  an  infrequent  occur- 
rence. Again  I  admit  that  soon  after  the  first  chill  and 
rise  of  temperature  from  puerperal  sepsis  inmost  cases, 
if  one  empties  well  the  uterus  of  all  clots  and  retained 
placenta,  and  all  material  favorable  to  the  rapid  devel- 
opment of  sepsis,  that  one  good  antiseptic  washing  out 
and  loose  packing  with  gauze  will  check  the  sepsis,  and 
in  many  cases  effect  a  cure  ;  but,  where  there  is  failure 
to  effect  a  complete  emptying  of  all,  or  almost  all,  of  the 
effete  material,  or  at  least  that  part  of  it  already  infected 
by  sepsis,  curetting  and  the  preceding  method  of 
gauze-packing  will  not  effect  a  cure  even  when  supple- 
mented by  one  washing  out,  and  when  it  fails  and  the 
gauze  is  left  in  over  twelve  or  twenty-four  hours  it  in- 
creases the  danger  to  life  by  tending  to  keep  the  septic 
material  in  the  uterus,  and  where  there  is  a  close  pack- 
ing with  gauze  it  tends  to  force  the  sepsis  into  the  si- 
nuses, veins,  or  Fallopian  tubes  :  that,  in  cases  of  sepsis 
which  have  existed  for  several  days,  the  curettage  and 
gauze-packing  is  much  more  likely  to  fail  to  effect  a 
cure,  for  the  sepsis  has  had  time  to  penetrate  deeper 
into  the  uterine  tissues.  Of  course  when  the  septic 
material  has  entered  the  peritoneum  or  is  located  in  the 
veins  or  lymphatics  outside  of  the  uterus  no  local  treat- 
ment of  the  uterus  can  effect  a  complete  cure.  We  will 
assume  that  the  septic  material,  the  centre  and  source 
of  the  infected  matter,  is  still  within  the  uterus  and  has 
not  yet  infested  the  peritoneum  nor  the  lymphatics  and 
veins  outside  of  the  uterus.  For  experience  teaches 
us  that  for  many  hours,  and  often  two,  three,  and  four 
days  or  more,  in  most  cases  the  septic  centre  which 
causes  the  symptoms  is  still  confined  to  the  uterus.  In 
all  cases,  unless  we  can  clearly  detect  local  sepsis  within 
the  peritoneum,  the  lymphatics,  veins,  or  some  tissue 
outside  of  the  uterus,  we  must  at  once  act  on  the  as- 
sumption that  it  is  still  confined  to  the  uterus  until  we 
have  tested  the  matter  by  actual  emptying  and  local 
[  treatment  of  the  uterine  cavity.  Xow,  I  believe  that 
i !  the  method  which  I  proposed,  practised  fifteen  years 
ago,  has  proved  by  experience  and  direct  comparison 
to  be  more  reliable  than  the  method  now  known  as 
that  by  curettage  and  gauze-packing.  Being  called  to 
see  a  case  of  puerperal  fever,  it  will  not  do  to  examine, 
and  finding  a  laceration  of  the  perineum  or  cervix,  to 
.       assume  that  a  small,  open  wound,  except  in  rare  forms 


of  septic  poison,  such  as  true  diphtheria,  can  cause  the 
symptoms  of  a  severe  or  dangerous  puerperal  sepsis. 
After  washing  out  the  vagina  and  cleaning  off  and 
cauterizing  with  pure  carbolic  acid  any  torn  or  lacer- 
ated tissue  a  few  times,  unless  there  is  rapid  and  con- 
tinued improvement  I  soon  begin  by  washing  out  the 
uterus,  which  will  as  a  rule  be  found  patulous  and  read- 
ily dilatable  in  septic  cases,  with  a  solution  of  i  to  40 
of  Calvert's  No.  i  carbolic-acid  solution.  Beginning 
cautiously  and  carefully,  I  give  the  whole  cavity  a  soak- 
ing wash  of  two  quarts  or  more,  then  with  my  hand, 
fingers,  and  forceps  where  it  is  practicable,  I  empty  the 
uterus  of  all  clots  and  effete  material.  If  it  is  an  old 
case,  I  first  dilate  the  os  well  with  steel  dilators,  but 
never  with  tents  of  any  kind,  and  after  running  a  large- 
sized  curette  over  the  surface  to  get  off  all  small  ad- 
herent tissues  I  swab  out  well  the  whole  cavity  with 
pure  carbolic  acid  rendered  soluble  with  a  little  glyc- 
erine and  water  and  immediately  follow  this  up  by 
washing  out  the  uterus  with  a  hot  solution  of  carbolic 
acid.  I  to  60,  injecting  a  quart  or  more.  If  the  uterus 
is  large  and  very  patulous  I  may  use  a  large-sized 
Chamberlain's  glass  tube,  but  in  all  other  cases,  and 
after  the  first  washing  or  two,  I  invariably  use  a  large- 
sized  No.  12  or  14  old  style  stiff-gum  catheter.  I  intro- 
duce t"ne  catheter  well  up  to  the  fundus,  with  a  stylet  in 
it.  Then  I  fill  the  catheter  with  water  after  removing 
the  stylet,  and  connect  it  with  an  ordinary  Davidson's 
syringe.  Beginning  my  injection  very  slowly  and  gradu- 
ally turning  the  catheter  about  in  the  uterus,  I  pump 
the  water  with  full  force  as  soon  as  it  begins  to  run  out 
of  the  vagina  freely.  I  aim  to  completely  flood  the 
whole  canty  and  use  not  less  than  from  one  to  two 
quarts  of  i  to  60  solution  of  Calvert's  No.  i  carbolic 
acid.  Immediately  after  the  first  washing  out  in  acute 
or  severe  cases  the  patient  will  have  as  a  rule  a  chill 
and  rapid  rise  of  temperature,  which  is  undoubtedly  due 
to  increased  abortion  from  the  fresh  wounds  to  the 
mucous  membranes  by  the  instruments  used.^ 

The  reason  I  use  the  catheter  is  that  it  can  be 
readily  adapted  to  any  size  or  position  of  the  uterus, 
which  often  hardens  up  and  flexes  sharply  as  soon  as  the 
sepsis  is  checked,  though  poison  may  not  yet  be  com- 
pletely eliminated  and  is  liable  to  develop  again  and 
renew  itself  in  full  force.  Glass  tubes  often  fail  to 
reach  the  fundus  after  a  few  washings.  Double  recur- 
rent and  other  theoretical  contrivances  often  fail  to  do 
more  than  wash  out  a  small  section  of  the  cavity  by 
running  in  at  one  eye  and  out  at  the  other,  and  those  fine 
contrivances  which  aim  to  forcibly  distend  the  uterus 
or  vagina  before  emptying  the  fluid  are  very  liable  to 
force  the  septic  material  through  the  Fallopian  tubes 
into  the  peritoneum.  It  takes  an  expert  to  reach  the 
fundus  and  wash  out  efficiently  as  the  uterus  begins  tc 
contract,  for  failure  to  wash  out  or  kill  all  germs  means 
a  relapse. 

To  empty  the  uterus  and  wash  it  out  is  very  impor- 
tant, but  unless  the  first  washing  is  followed  up  by  an- 
other washing  in  about  one  hour  after  the  first  is  fin- 
ished, especially  if  an  interval  of  three  or  more  hours  is 
allowed  to  intervene,  the  treatment  will  utterly  fail  in 
many  cases  ;  in  fact,  in  almost  all  except  in  very  fresh 
and  simple  cases  of  septic  infection.  In  from  three  to 
eight  hours  the  germs  left  have  found  effete  material 
to  develop  on,  excretions  and  mucus  cover  the  sur- 
face, and  almost  all  of  the  original  local  sepsis  has  been 
reproduced.  Thus  it  is  essential  to  wash  every  hour, 
until  the  escaping  fluid  is  practically  clear  of  all,  espe- 
cially all  dark-colored,  material  and  the  temperature  has 
fallen  to  or  nearly  normal.  As  the  water  returns 
clearer  and  clearer  the  temperature  sinks  gradually,  and, 
as  a  rule,  after  five  or  six  washings  the  temperature  is 
near  the  normal  mark  and  will  remain  so.  If  the  tem- 
perature does  not  materially  fall  after  five  or  six  wash- 
ings, then  the  fever  is  kept  up  by  other  sources  of  sep- 

>  This  rapid  rise  of  temperature  has  caused  many  a  beginner  to 
give  up  washing  out  the  uterus,  prejudicing  him  against  the  method. 


400 


MEDICAL    RECORD. 


[September  21,    1895 


tic  infection,  and  we  must  find  them  and  when  practical 
must  operate  to  get  rid  of  the  sepsis. 

I  have  tried  different  antiseptic  solutions  in  washing 
out  the  uterus  and  prefer  i  to  60  to  i  to  100  solution 
of  Calvert's  No.  i  carbolic  acid.  It  is  safe,  does  not 
constringe  the  parts,  and  soaks  into  the  tissues  and  soft- 
ens them.  It  is  possible  that  the  carbolic  acid  enters 
the  circulation  and  acts  favorably,  but  it  is  its  local  ac- 
tion that  I  rely  upon.  If  more  than  six  hourly  wash- 
ings are  required  to  control  the  sepsis  I  use  alternately 
a  solution  of  boracic  acid.  If  one  will  watch  the  urine 
there  is  no  danger  of  carbolic-acid  poisoning,  for  the 
urine  becomes  smoky  and  plainly  indicates  that  the 
carbolic-acid  injections  should  be  stopped  or  at  least 
lessened.  In  old  indolent  sloughing  cases  I  use  per- 
oxide of  hydrogen  or  iodoform,  and  usually  insert  a 
large  hard-rubber  inter-uterine  drainage-tube.  Bichlo- 
ride of  mercury  cannot  be  used  safely  except  in  weak 
solution,  I  to  5,000,  and  not  too  often  ;  besides,  it  con- 
stringes  the  tissues  and  interferes  with  free  drainage 
and  insertion  of  the  tube. 

A  Simple  Method  to  Insure  Normal  Involution  After 
Labor  or  Abortion,  and  Prevent  Chronic  Endometritis, 
Relaxation  of  Ligaments,  and  Displacements. — Many 
years  ago  I  discovered  if  boro-glyceride  (not  glyce- 
rite  or  a  simple  mixture  of  boracic  acid  and  glycerine) 
was  combined  with  pure  glycerine  in  solution  ten  to 
twenty  per  cent.,  that  we  could  saturate  cotton  pled- 
gets with  it  and  apply  in  the  vagina  with  the  best  pos- 
sible results,  that  there  would  be  no  ferment  of  the 
glycerine  and  secretion  to  cause  irritation,  etc.,  and  that 
it  would  excite  an  immense  amount  of  secretion  from  the 
uterine  and  vaginal  glands  when  left  in  for  twenty-four 
hours.  I  advocate  the  use  of  these  pledgets  twice 
or  three  times  a  week  in  the  vagina  in  all  cases  where 
I  wish  to  improve  the  pelvic  circulation  and  thus  re- 
duce the  size  of  the  uterus  and  relieve  the  over-con- 
gested tissues  in  all  parts  of  the  pelvis.  I  have  had  espe- 
cially good  results  in  all  cases  of  subinvolution  after 
curetting  and  draining  the  uterine  cavity ;  that  it  was 
much  more  rapid  and  certain  than  the  prevailing  plan 
then  in  use  and  now  so  much  practised,  of  rest  in  bed, 
hot  vaginal  douches,  etc.  Besides,  by  making  the  loll 
of  absorbent  cotton  firm  and  i|^  to  2^2  inches  long 
and  from  i  to  1^4  in  diameter,  that  a  sagging  and  re- 
troverted  uterus  could  be  readily  held  up  in  a  more  nat- 
ural and  better  manner  than  by  a  hard  pessary.  The 
active  circulation  caused  by  the  boro-glyceride  and  glyc- 
erine mixture  contracted  the  vaginal  tissues  so  that  the 
cotton  pledgets  remained  in  place,  and  this  contracted 
and  firm  condition  of  the  tissues  would  continue  for  a 
day  or  so  in  most  cases,  thus  enabling  the  patient  to  go 
about  without  trouble  for  twenty-four  to  forty-eight 
hours  after  removal  of  the  cotton  and  give  time  to 
cleanse  away  the  coagulated  mucus,  etc.,  from  the  va- 
gina. 

For  full  fifteen  years  I  have  practised  and  taught 
the  use  of  this  simple  treatment  in  all  cases  after  abor- 
tions, especially  when  there  was  any  kind  of  inflamma- 
tion or  hardening  of  the  uterus  complicating  the  abor- 
tion, and  in  all  cases  after  labor  where  one  desires  to 
insure  a  return  of  the  uterus  to  its  normal  size  and  po- 
sition in  the  pelvis.  In  many  cases  among  ilie  well-to- 
do  class,  in  our  cities  at  least,  there  is  a  marked  ten- 
dency for  women  to  have  more  or  less  trouble  after 
labor.  The  general  health  is  not  good  or  the  uterus 
is  not  well  developed,  and  the  cervix  is  torn,  and  on  ac- 
count of  the  relaxed  and  bad  general  health  or  disease 
of  the  cervix,  it  fails  to  heal  and  subinvolution,  chronic 
endjmetritis,  and  displacements  follow. 

Many  years  ago  I  also  discovered  that  many  cases 
of  melancholia  and  extreme  nervousness  and  sterility 
are  due  to  chronic  subinvolution  or  enlargement  of  the 
uterus,  and  that  when  we  cured  the  subinvolution  or 
the  local  disease  or  condition  the  melancholia  in  many 
cases  would  disappear  as  i-  by  magic.  Some  of  these 
cases  were  classed  as  insa  le  and  were  considered  in- 


curable, but  were  entirely  relieved  of  all  actual  symp- 
toms by  reducing  the  uterus  to  its  normal  size  and  cur- 
ing of  any  existing  local  disease.  I  do  not  mean  to 
say  that  melancholia  or  tendency  to  disturbed  mental 
balance  is  eradicated,  but  that  enlargement  of  the 
uterus  and  associated  local  disease  will  in  some  women, 
not  all,  cause  or  excite  melancholia,  and  that  a  cure  of 
the  local  disease  will  cure  the  abnormal  mental  disturb- 
ance called  melancholia.  This  experience  led  me  to 
use  the  boro-glyceride  cotton  pledgets  to  prevent  sub- 
involution, especially  in  very  nervous  women  who  had 
had  melancholia  or  other  forms  of  mental  disturbance 
before  pregnancy.  About  the  tenth  day  after  labor 
I  examine  the  women  locally.  If  the  uterus  is  large 
and  crowded  down  in  the  pelvis,  or  if  the  secretions 
are  still  bloody  or  abnormal,  or  if  I  have  any  good  rea- 
sons from  previous  knowledge  of  the  case  to  believe 
that  relaxation,  subinvolution,  displacements,  etc.,  are 
liable  to  follow,  I  put  the  patient  in  Sim's  position  on 
her  left  side,  push  the  uterus  well  up  out  of  the  pelvis, 
and  apply  a  suitable  sized  and  soft,  but  firm  enough  to 
keep  in  shape,  boro-glyceride  cotton  pledget  in  the 
vagina.  It  is  so  placed  under  the  cer\-ix  uteri,  so  that 
the  uterus  cannot  sink  down  in  the  pelvis  nor  fall 
backward.  This  is  left  in  place  twenty-four  hours, 
then  removed  by  the  linen  string  tied  to  the  proximal 
end.  A  vaginal  douche  of  solution  boracic  acid  is 
given.  Two  days  later  the  same  treatment  is  applied 
and  repeated  twice  a  week  till  the  uterus  is  normal  in 
size  and  position,  which  usually  takes  six  weeks.  At 
the  end  of  two  months  after  labor  if  there  is  any  lacera- 
tion of  the  cervix  complicated  by  follicular  disease  the 
diseased  tissue  is  cut  away  and  the  cers'ix  sewed  up  or 
amputated  and  the  canal  of  the  cer\-ix  is  always  left 
lined  with  a  healthy  mucous  membrane.  When  ampu- 
tation is  done,  the  flaps  to  line  the  canal  are  made  from 
the  anterior  and  posterior  parts  of  the  cer\-ix.  If  the  1 
perineum  is  torn,  especially  the  inner  portion  that  sup-  ! 
ports  the  lower  end  of  the  rectum,  it  is  sewed  up  also.         ' 

By  the  simple  application  of  the  boro-glyceride  the 
patient  is  able  to  get  out  at  the  end  of  two  weeks  with-         ■ 
out  injury  and  dismissed  perfectly  cured  at  the  end  of         ( 
six  or  eight  weeks. 

For  many  years  past  I  have  followed  up  some  of  my 
old  cases  of  retroversion  and  flexion  where  I  had 
sewed  up  or  amputated  the  diseased  tissue  of  the  cer- 
vix and  restored  the  perineum,  still  the  uterus  would 
prolapse  and  retrovert  unless  artificially  supported. 
When  such  a  case  can  be  got  sufficiently  well  to  become 
pregnant,  it  is  necessary  in  most  cases  to  keep  the 
uterus  from  retroverting  and  flexing  till  after  the  third 
month  so  as  to  prevent  abortion.  This  can  safely  be 
done  by  the  regular  application  of  the  boro-glyceride 
cotton  twice  a  week  or  a  properly  fitted  Smith  hard- 
rubber  pessary. 

After  labor,  the  regular  use  twice  a  week  of  the 
boro-glyceride  cotton  pledgets,  in  such  a  case,  for  six 
weeks  will,  as  a  rule,  result  in  a  complete  cure  of  all 
the  local  trouble. 


Smoking. — The  use  of  tobacco  does  not  decline, 
despite  the  warnings  of  hygienists  and  moralists.  Ac- 
cording to  a  tobacco  trade  journal,  there  is  a  steady 
increase  in  the  number  of  cigars  and  cigarettes  smoked 
in  this  country,  and  notably  in  the  consumption  of 
cigarettes.  During  the  fiscal  year  just  closed  there 
were  sold  in  the  United  States  3,333.845,560  cigarettes, 
and  4,130,440.370  cigars.  The  increase  in  the  con- 
sumption of  cigars  over  the  previous  year  was  68,522,938. 

An  Attack  on  the  Parasitic  Theory  of  Malaria. — Dr. 
Lawrie.  of  Hyderabad,  says  that  there  are  no  parasites 
in  the  blood  in  malaria,  and  that  Laver.m  and  the  Ital- 
ian investigators  have  mistaken  the  nuclei  ot  the  white 
cells  in  the  blood  for  plasmodia. 


September  21,  1S95] 


MEDICAL    RECORD. 


401 


A  CASE  OF  DOUBLE  FORMATION  OF  THE 
FACE  WITH  CRAXIO-RHACHI-SCHISIS  IN- 
VOLVING THE  WHOLE  VERTEBRAL  COL- 
UMN. 

Ry   B.   OXLT  (ONUFROWICZ  ,   M.D., 

BRO-  KL^'N,   S.    V, 

In  giving  the  history  of  the  above  case  I  must  confine 
m\'self  to  a  report  of  the  important  and  interesting 
points  still  remaining  in  memory,  as  I  had  the  misfort- 
une to  lose  the  notes  which  I  took  concerning  it. 

Mrs.  X ,  the  mother  of  the  hemicephalus  in  ques- 
tion, had  previously  borne  well-developed  twins  which 
reached  about  the  age  of  two  years  (?)  and  died,  both 
on  the   same  day,   from    an  intestinal   disease.     Mrs. 

X 's  mother  was  one  of  twins.     A  sister  of   Mrs. 

X 's  father  had  borne  twins. 

As  I  have  mentioned,  Mrs.  X was  delivered  of 

twins  once,  then  she  had  an  abortion  at  an  early  period 
of  gestation  (probably  about  three  months),  and,  so  far 
as  I  remember,  her  third  confinement  was  with  the 
hemicephalus.  The  birth  of  the  latter  took  place  some- 
what more  than  a  month  before  the  regular  term.  It 
may  be  interesting  to  note  some  details  of  the  confine- 
ment. 

At  the  beginning  of  labor  examination  revealed  an 
enormous  quantity  of  amniotic  fluid.  No  heart-sounds 
were  to  be  heard  in  spite  of  thorough  auscultation. 
The  position  of  the  foetus  could  not  be  made  out  with 
any  degree  of  certainty.  On  introducing  two  fingers 
into  the  uterus  one  could  feel  a  hard  and  sharp  promi- 
nence protruding  during  the  uterine  contractions,  and 
receding  after  relaxation  of  the  latter.  Examination 
post  partum  proved  this  protruding  part  to  be  a  sort  of 
promontory  (Fig.  2),  forming  the  transition  between 
the  uncovered  base  of  the  skull  and  the  vertebral  col- 
umn. Twelve  hours  after  this  first  examination  the 
described  part  was  still  floating  quite  loosely  over  the 
entrance  of  the  pehis  ;  the  water  had  not  yet  broken. 
As  the  external  orifice  of  the  uterus  was  sufficientlv 
wide  to  admit  the  passage  of  the  foetus  I  deemed  it  ex- 
pedient to  relieve  the  patient's  acute  sufferings  by 
manual  extraction  of  the  foetus.  The  membranes  were 
broken,  which  caused  a  torrent  of  fluid  to  break  forth, 
a  foot  was  seized,  and  the  foetus  extracted.  It  was 
then  put  into  a  two  and  a  half  per  cent,  watery  solu- 
tion of  carbolic  acid,  which  has  the  advantage  of  pre- 
serving the  color  and  gross  anatomical  structures,  espe- 
cially the  skin,  and  of  not  causing  any  shrinkage.  On 
the  other  hand,  it  has  the  disadvantage  of  spoiling  the 
specimen  for  microscopical  examination,  at  least  of  cer- 
tain tissues — for  instance,  nervous  tissue. 


Fig.  I  is  a  photograph  which  gives  a  front  view  of 
the  foetus.  It  demonstrates  a  nearly  perfect  double 
formation  of  the  face  :  four  eyes,  two  noses,  two 
mouths,  two  chins,  but  only  one  ear  for  each  face. 
The  two  mouths  are  separated  by  means  of  a  skin- 
bridge  which  continues  backward  as  a  probably  carti- 


laginous septum  reaching  nearly  but  not  quite  to  the 
posterior  wall  of  the  pharynx,  so  as  to  leave  a  com- 
munication between  the  pharynx  corresponding  to  the 
right  and  that  corresponding  to  the  left  face.  Each 
mouth  presents  a  well-developed  tongue,  a  hard  palate, 
and  a  distinct  horseshoe  shaped  outline  or  impression 
of  the  superior  and  inferior  alveolary  processes.  It 
seems  also  as  if  there  was  one  soft  palate  common  to 
both  faces  ;  at  least  a  structure  like  anterior  and  pos- 
terior pillars  is  seen  on  the  external  side  of  each  of  the 
communicating  pharynges.  Attempts  to  find  out  wheth- 
er the  oesophagus  was  single  or  double  were  not  suc- 
cessful. The  sound  did  not  pass  beyond  the  pharynx 
or  it  came  out  at  an  opening  in  the  base  of  the  skull, 
which  will  be  mentioned  later. 

Chins. — -The  two  chins  are  separated  by  a  slight 
vertical  ridge  formed  by  an  elevation  of  the  skin.  Two 
separate  lower  jaws  are  distinctly  felt ;  the  medial 
branch  of  each  can  be  followed  by  palpation  some  dis- 
tance backward.  Each  jaw  can  be  moved  upward  and 
downward  separately — that  is,  independently  from  the 
other — which  proves  that  they  are  not  united  further 
backward. 

Ears. — There  is  one  ear  corresponding  to  each  face 
situated  on  the  lateral  sides  of  the  head,  in  normal  po- 
sition with  relation  to  the  latter.  The  right  one  looks 
much  like  the  cropped  ear  of  a  dog,  the  left  one,  aside 
from  having  an  abnormally  large  tragus,  is  well  devel- 
oped. 

Strictly  speaking,  there  is  no  formation  that  could 
be  called  a  neck.  The  head,  with  the  two  faces,  sits 
directly  on  the  body,  the  ears  rest  upon  the  shoulders 
so  that  the  tip  of  the  left  ear  is  turned  outward  and 
upward  from  the  pressure  of  the  left  shoulder.  In 
front  the  skin,  instead  of  receding  backward  to  display 
the  inferior  surface  of  the  chins,  passes  straight  from 
the  anterior  surface  of  the  latter  into  the  skin  of  the 
chest.  It  is  thus  difficult  to  state  with  certainty 
whether  any  formation  corresponding  to  the  larynx 
exists.  No  such  formation  can  be  made  out  by  in- 
spection or  by  palpation.  Further  down  there  is  no 
double  formation,  at  least  not  outwardly  ;  two  arms, 
one  body,  two  legs. 

Arms. — Perfectly  well  developed,  including  nails,  fin- 
gers, hands,  forearms,  arms;  shoulder-blades,  and  clavi- 
cles. The  latter,  however,  seem  to  terminate  loosely 
with  what  should  be  their  sternal  end,  instead  of  artic- 
ulating with  the  sternum. 

Chest. — No  sternum,  at  least  no  osseous  sternum,  is 
present.  All  ribs  can  be  felt  ending  free  anteriorly, 
thus  leaving  an  anterior  gap  in  the  skeleton  of  the 
chest  which  widens  in  a  downward  direction,  measuring 
about  one  and  one-fourth  inch  in  width  at  the  level 
of  the  first  ribs  and  about  two  inches  at  a  level  at 
which  the  processus  xiphoides  would  be  situated  under 
normal  circumstances. 

Pelvis. — The  left  and  right  half  of  the  pelvis  are 
loosely  connected  ;  they  can  be  freely  moved  from 
and  against  each  other  on  the  longitudinal  axis  of  the 
body. 

Lower  Extremities. — I  cannot  state  whether  the  ab- 
normity of  shape  is  due  to  misformation  or  to  distor- 
tion caused  by  the  manipulations  of  extraction  of  the 
fatus.  I  am  inclined  to  think  that  originally  the  lower 
limbs  were  not  deformed. 

Genitals. — Well- developed  scrotum  and  penis.  Testi- 
cles in  normal  position. 

Posterior  Aspect. — Fig.  2  is  a  photograph  giving  a 
view  of  the  back  and  of  the  base  of  the  skull.  The 
photograph  shows  that  the  skull  and  vertebral  column 
have  remained  unclosed.  There  is  rhachi-schisis  of  the 
whole  vertebral  column,  involving  also  the  os  sacrum. 
The  edge  {vide  Fig.  2,  No.  9)  of  the  large  gap  in  the  me- 
dian line  is  formed  by  the  processus  spinosi  of  the  verte- 
bra;, which,  having  remained  ununited,  have  a  transversal 
position  ;  that  is,  the  position  which  under  normal  cir- 
cumstances is  occupied  by  the  processus  transversi.    To 


402 


MEDICAL   RECORD. 


[September  21,  1895 


demonstrate  this  condition  clearly  the  periosteum  was 
removed  from  the  left  side  of  the  cervical  portion  of 
the  spine,  thus  displaying  the  bodies  of  the  vertebrae 


-y*.*  y ' 


F:g.  2. — I.  Opening  coinmunicaliiig  with  ihc  pharynx  ;  2.  anterior  cluiuiil  proc- 
esses of  left  sphenoid  bone  :  3,  rudunent  of  temporal  bone  :  4,  internal  auditor^' 
meatus  :  5,  foramen  lacerum  posterius  ;  6,  occipital  part  of  left  occipital  bone  :  7. 
anterior  condyloid  foramen;  8.  posterior  condyloid  foramen;  g,  spinous  proc- 
esses: ID,  c!tuda  equina ;   11,  spinal  dura  mater :   12,  promontory.^ 

and  the  processus  spinosi.  Fig.  3  gives  a  view  of  one 
cervical  vertebra,  showing  the  processus  spinosi  directed 
transversely,  while  the  processus  transversi  occupy  a 
dorso-ventrad  position.' 


ventral 


■proc    transvers 
iroc  obi 


auus 
■proc.  spiitts 


The  large  gap  mentioned  is  covered  by  a  membrane 
which  cephalad  passes  into  the  dura  mater  cerebri  and 
must  therefore  be  considered  as  the  dura  mater  spina- 
lis. At  the  caudal  end  and  also  in  the  upper  part  of 
the  back  this  membrane  passes  directly  into  the  meso- 
dermal layer  of  the  adjoining  skin  ;  in  other  regions 
this  connection  is  torn.  At  the  caudal  end  fibre 
bundles  are  seen  eradiating  from  the  dura  mater  in  a 
laterocaudal  direction  and  entering  under  the  perios- 
teum of  the  vertebraa.  The  arrangement  of  these 
bundles  is  quite  analogous  to  that  of  the  cauda  equina. 
Similar  bundles  are  seen  all  along  the  vertebral  column; 
only  the  more  cephalad  they  are  situated  the  more 
horizontal  is  their  course.  This  arrangement  of  the 
said  bundles  and  their  soft  consistency  makes  it  certain 
that  they  are  rudiments  of  root  bundles  of  spinal 
nerves.  Histologically  this  could  not  be  decided,  as 
the  preservation  with  carbolic  acid  solution  made  the 
nerves  unfit  for  microscopical  examination.  I  have 
used  the  expression  "  rudiments  "  because  the  bundles 

■  I  take  opportunity  to  mention  here  that  I  shall  bv  preference 
avail  myself  of  the  expressions  "  cephalad  "  and  "  caudad,  "  or  "  proxi- 
mal and  distal."  and  of  the  terms  "  ventrad  dorsad"  to  designate 
the  relative  position  of  the  parts  instead  of  using  the  terms  "  anterior, 
superior,  posterior,  inferior,"  which  are  easily  misinterpreted. 


are  much  thinner  than,  comparing  them  with  the 
calibre  of  normal  spinal  roots,  one  would  expect  them 
to  be.  Of  the  spinal  cord  nothing  is  present ;  prob- 
ably it  was  destroyed  a  long  time  before  the  birth  of 
the  foetus,  which  would  explain  the  rudimentary  ap- 
pearance of  the  spinal  nerve-roots. 

Skull. — As  before  mentioned,  the  base  of  the  skull 
was  found  uncovered.  This  was  at  least  the  case  with 
the  petrous  portions  of  the  temporal  bones  and  the 
parts  situated  caudad  of  them.  The  parts  cephalad  of 
the  petrous  bones  were  covered  with  rudiments  of  front- 
al, parietal,  and  temporal  bones.  These  were  in  close 
contact  with  the  underlying  bones  of  the  base  of  the 
skull,  so  that  only  a  narrow  slit  corresponded  to  what 
normally  would  hold  the  frontal,  parietal,  and  temporal 
lobes  of  the  brain. 

Dura  mater  present  but  defective,  torn  (prob- 
ably, at  least  partly,  by  the  manipulations  connected 
with  the  extraction  of  the  foetus)  so  that  one  cannot 
make  out  by  its  shape  whether  it  held  two  separate 
brains  or  only  one.  Rather  large  pieces  of  brain  were 
found  in  the  dura,  but  so  crushed  that  shape  and  struct- 
ure were  lost. 

To  get  a  view  of  the  bony  structure  the  periost  was 
removed  from  the  base  of  the  skull.  The  first  thing 
that  strikes  one's  attention  is  a  kind  of  promontory, 
situated  at  the  distal  end  of  the  base  of  the  skull  form- 
ing a  direct  transition  from  the  latter  to  the  vertebral 
column  (Fig.  2,  No.  12).  This  promontory  bears  a  rather 
close  resemblance  to  a  sacral  bone.  Like  the  latter  it 
is  curved,  both  longitudinally  and  transversely,  the  con- 
vexity of  the  curve  being  directed  dorsad.  Its  proxi- 
mal end  is  rather  wide  in  a  transverse  direction  ;  cau- 
dad it  somewhat  increases  in  width,  being  widest  at 
about  the  middle  of  its  longitudinal  extent,  from  which 
point  it  becomes  narrower  and  terminates  with  a  nar- 
row median  ridge  at  the  distal  end.  The  median  part 
of  the  promontory  is  occupied  by  a  torus  which  passes 
through  its  entire  length.  In  a  transverse  direction 
this  torus  has  semicircular  shape,  in  longitudinal  (ce- 
phalo  caudad)  it  looks  conus-like,  the  base  of  the 
conus  being  situated  at  the  proximal  end  :  only,  as  I 
mentioned  before,  this  conus  shows  a  strong  longitudi- 
nal curve,  the  convexity  of  which  is  directed  dorsad. 
On  each  side  of  the  torus  there  is  a  longitudinal  row  of 
four  foramina.  These  are  separated  from  each  other 
by  transverse  ridges.  Most  of  the  latter  have  preserved 
a  distinct  individuality,  as  at  their  lateral  ends  they  are 
separated  from  each  other  by  a  thin  cartilaginous  layer 
or  joined  by  osseous  suture.  In  two  of  them  the  lat- 
eral ends  are  melted  into  one  coherent  mass  of  bone. 

All  parts  mentioned  so  far  show  complete  ossifica- 
tion, the  lateral  border  of  the  promontory,  however, 
is  formed  by  cartilage.  At  the  proximal  end  the  torus 
has  a  wart-like  process  (Fig.  2,  IV)  ;  ventrad  from  this 
there  is  a  round  opening  of  about  ij4  mm.  in  diameter. 
A  small  sound  passed  through  this  opening  comes  out 
at  the  most  distal  of  the  foramina  of  the  left  side. 
Since  some  force  has  to  be  used,  however,  to  pass  the 
sound  it  remains  doubtful  whether  this  communication 
is  a  natural  canal  or  an  artefact.  In  passing  the  sound 
slowly  through  this  canal  the  inner  (ventral)  surface  of 
the  torus  can  be  distinctly  felt  as  presenting  several 
transverse  elevations  alternating  with  transverse  de- 
pressions. The  ventral  wall  of  the  canal  seems  to  be 
formed  of  cartilaginous  tissue.  Distally  this  tissue 
seems  to  pass  directly  into  the  body  of  the  first  cervi- 
cal vertebra,  which  (viz.,  the  body)  is  still  perfectly  car- 
tilaginous on  its  dorsal  surface. 

Of  the  lateral  and  proximal  connections  of  the  prom- 
ontory 1  shall  speak  later. 

There  is  no  doubt  from  the  structure  of  this  prom- 
ontory that  it  is  a  vertebral  formation  composed 
probably  of  four  vertebrre.  It  remains  to  explain  the 
significance  of  its  various  parts.  One  explanation 
would  be  that  the  vertebral  canal  has  remained  open, 
in  which  case  the  longitudinal  torus  would  correspond 


September  21,   1895] 


MEDICAL    RECORD. 


403 


to  the  bodies  of  vertebrae,  while  the  transverse  ridges — 
analogous  to  the  condition  of  the  other  vertebrae — would 
represent  the  processus  spinosi  directed  transversely, 
instead  of  dorso-ventrad  as  they  should  be  under  nor- 
mal circumstances. 

The  second  explanation  would  be  that  the  vertebral 
canal  is  closed,  that  accordingly  the  longitudinal  torus 
represents  processus  spinosi  grown  together  to  one  solid 
mass  of  bone,  while  the  transverse  ridges  between  the 
foramina  correspond  to  processus  transversi,  the  bodies 
of  the  vertebrae  being  formed  by  the  cartilaginous 
tissue  situated  ventrad  from  the  longitudinal  canal 
mentioned. 

The  following  points  speak  in  favor  of  the  second 
explanation  : 

1.  The  bodies  of  the  vertebrae  of  the  cerncal  part  of 
the  column  (probably  also  those  of  the  other  vertebra;, 
but  these  were  not  examined  in  order  not  to  spoil  the 
specimen)  are  still  cartilaginous,  while  the  longitudi- 
nal torus  of  the  promontory  is  perfectly  ossified.  This 
fact  makes  it  very  improbable  that  the  torus  should  cor- 
respond to  a  row  of  bodies  of  vertebnie.  On  the  other 
side — analogous  to  the  bodies  of  the  cervical  vertebrae 
— the  tissue  ventrad  from  the  longitudinal  canal  of  the 

roraontory  is  cartilaginous. 

2.  The  processes  of  the  cervical  vertebrae  are  ossi- 
ned,  as  is  also  the  longitudinal  torus.  The  hypothesis 
that  the  torus  represents  processus  spinosi  grown  to- 
gether to  one  mass  of  bone  receives  still  more  support 
by  this  fact. 

3.  If  the  longitudinal  torus  is  actually  composed  of 
a  series  of  processus  spinosi  a  canal  corresponding  to 
the  vertebral  canal  must  exist  ventrad  from  the  torus. 
Such  a  canal  is,  indeed,  present,  but  as  I  mentioned 
before  the  possibility  of  its  being  an  artefact  cannot  be 
positively  excluded. 

Although  the  facts  mentioned  make  the  second  ex- 
planation very  probable,  I  cannot  arrive  at  a  definite 
conclusion  on  the  point.  I  feel  satisfied,  however,  that 
the  structure  which  I  have  called  promontory  is  a  for- 
mation composed  of  several,  probably  four,  vertebr;e. 
From  the  description  given  the  peculiar  similarity 
which  this  formation  bears  to  a  sacral  bone  becomes 
apparent. 

I  first  thought  that  the  structure  in  question  might  be 
the  modified  upper  part  of  the  cervical  portion  of  the 
spine,  but  found  proof  that  this  is  not  the  case.  After 
finding  out  which  vertebra  corresponded  to  the  first 
rib,  and  which  consequently  must  be  the  first  dorsal 
vertebra,  I  counted  upward,  with  the  result  that  there 
were  seven  processus  spinosi  (cervical)  between  the  for- 
mation designated  as  promontory  and  the  first  dorsal 
vertebra.  This  proves  the  promontory  to  be  a  verte- 
bral formation /cr  se. 

Proximally  from  the  described  vertebral  formation, 
and  directly  connected  with  the  proximal  part  of  its 
lateral  borders,  we  find  on  each  side  a  bone  of  more  or 
less  rectangular  shape.  The  longitudinal  axis  of  this 
rectangle  is  directed  from  backward  inward  to  forward 
sideward.  It  (the  rectangular)  is  divided  by  an  osse 
ous  suture  into  an  anterior  (A)  and  posterior  (£)  part 
(Fig.  2,  A  and  £).  Between  the  rectangular  bone  of 
the  right  and  that  of  the  left  side  we  find  a  hole  which 
has  the  shape  of  an  equicrural  acute-angled  triangle, 
the  crura  of  the  latter  being  formed  by  the  rectangular 
bones  {A  -f  £)  of  each  side,  while  the  base  is  situ- 
ated cephalad.  The  said  triangular  hole  opens  di- 
rectly into  the  common  pharynx.  Originally  it  was 
covered  by  a  thick  layer  of  periosteum,  which  I  had  re- 
moved in  order  to  get  a  view  of  the  osseous  structure 
of  the  base  of  the  skull,  and  which  contained  an  osse- 
ous nucleus. 

The  lateral  borders  of  the  bones  A  and  B  of  both 
sides  are  connected  by  cartilage  with  the  petrous  and 
occipital  bones. 

Occipital  Bones. — They  are  represented  in  two  halves, 
one  corresponding  to  the  right,  the  other  to  the  left 


face.  These  halves  are  separated  from  each  other  by 
the  promontory  described,  and  by  the  bones  £,  un- 
less we  consider  these  to  torm  part  of  the  occipital 
bones.  Each  half  shows  a  well-developed  condyloid 
portion  and  a  rudimentary  occipital  part.  If  a  basilar 
portion  exists,  we  must  consider  it  as  represented  by 
the  bone  £  plus  the  partly  ossified  periosteum  which 
covered  the  triangular  hole  mentioned  above.  This 
hole,  it  will  be  remembered,  opens  into  the  pharynx, 
and  the  fact  that  under  normal  circumstances  the  basi- 
lar portion  of  the  occipital  bone  forms  the  roof  of  the 
pharynx  speaks  in  favor  of  said  supposition. 

The  occipital  portion  of  the  occipital  bone  is  repre- 
sented on  each  side  by  a  small  bone  situated  laterally 
from  the  condyloid  portion,  connected  with  the  latter 
by  a  strip  of  cartilage,  while  cephalad  it  joins  with 
the  petrous  portion  of  the  temporal  bone.  Its  pos- 
terior border  in  line  v%-ith  that  of  the  condyloid 
portion  forms  a  curve,  the  convexity  of  which  is 
directed  caudad.  The  condyloid  portion  is  well-de- 
veloped ;  it  has  a  well-marked  condyloid  process — 
which  of  course  cannot  be  seen  in  the  photograph,  but 
is  found  on  lifting  the  bone — and  both  an  anterior  and 
posterior  condyloid  foramen.  The  foramen  occipitale 
magnum  does  not  exist,  as  the  parts  situated  caudad 
from  the  foramen  condyloideum  posterius,  which  under 
normal  conditions  close  the  circle  forming  the  foramen 
occipitale  magnum,  are  absent. 

Petrous  Portions  of  the  Temporal  Bones. — There  are 
two  petrous  bones,  one  corresponding  to  the  right,  the 
other  to  the  left  face.  Posteriorly  they  are  connected 
with  the  left  and  right  half  occipital  bone  respectively  ; 
medially  each  joins  the  bone  A  of  its  side  ;  cephalad 
they  connect  with  the  sphenoid  bones.  Both  petrous 
bones  have  a  peculiar  shape,  due  evidently  to  incom- 
plete ossification.  Aside  from  the  meatus  auditorius 
internuswe  find  laterally,  and  somewhat  cephalad  from 
the  same,  a  rather  large,  funnel-like  foramen  or  fos- 
sa, which  can  be  traced  only  a  short  distance  inward 
and  seems  to  end  blindly.  In  position  it  corresponds 
to  the  region  where  we  would  expect  the  space  between 
the  three  semicircular  canals,  and  the  most  plausible 
explanation  is  that  ossification  has  not  progressed  suffi- 
ciently to  fill  up  this  space  with  bone.  We  further  find 
distinctly  marked  the  aqu^ductus  vestibuli  and  coch- 
leae, the  Fallopian  canals,  and  the  foramina  laterum 
medium  and  posterius. 

Sphenoid  Bones. — The  bones  described  so  far  were 
single.  There  were  two  petrous  portions  of  temporal 
bones,  and  two  half  occipital  bones,  just  as  in  a  normal 
skull.  With  the  sphenoid  bones  the  duplication  be- 
gins. We  see  two  sphenoid  bones,  each  composed  of  a 
body  and  two  greater  wings  ;  the  lesser  wings  are  ab- 
sent. The  two  sphenoid  bones  meet  in  the  median 
line  of  the  skull  by  connection  of  the  medially  situated 
greater  wings  of  each.  This  connection  is  marked  by 
osseous  suture  in  the  distal  part,  by  a  vertical  crista  in 
the  proximal  part.  Quite  near  this  crista,  one  to  each 
side  of  it,  there  are  two  foramina,  which  in  shape  and 
position  correspond  to  the  foramina  rotunda.  A  short 
distance  caudad  from  these  there  is  another  pair  of 
foramina  which,  although  small,  must  be  considered  as 
the  foramina  ovalia  from  their  position.  These  two 
foramina  (ovalia)  are  joined  by  a  rather  deep  groove 
which,  crossing  the  median  line  of  the  skull  at  a  right 
angle,  passes  from  one  foramen  to  the  other.  The  dis- 
tal border  of  the  joined  medial  greater  wings  of  both 
sphenoid  bones  forms  the  proximal  border  of  the  trigo- 
nal space  which  opens  into  the  common  pharynx.  Two 
small  incisions  of  this  border  may  perhaps  represent 
the  rudiments  of  foramina  spinosa. 

It  is  seen  from  the  above  description  that  the  ex- 
treme corner  of  the  medial  ala  magna  of  each  sphenoid 
bone  is  absent.  With  the  lateral  greater  wings  this  is 
not  the  case  ;  they  are  complete  and  of  approximately 
normal  shape.  The  foramina  rotunda  and  ovalia  are 
well  marked  ;  the  foramina  spinosa  cannot  be  identified 


404 


MEDICAL    RECORD. 


[September  21,  1895 


with  any  degree  of  certainty.  The  body  of  each  sphe- 
noid bone  is  rather  well  developed,  but  without  the 
posterior  clinoid  processes.  The  olivary  process  has 
an  olive  shape,  only  its  longitudinal  diameter  is  di- 
rected sagittally  (cephalocaudad)  instead  of  transverse- 
ly, as  it  ought  to  be.  The  processus  clinoidei  anteriores 
appear  like  rings  attached  to  the  body.  The  openings  of 
these  rings  correspond  to  the  optic  foramina.  No 
smaller  wingi  are  present,  for  which  reason  the  sphenoid 
(orbital)  fissures,  instead  of  forming  actual  (narrow)  fis- 
sures, appear  as  large,  irregularly  circular  openings. 

I  have  mentioned  already  that  the  frontal,  jmrietal, 
and  temporal  bones  are  but  rudimentarily  developed. 
I  must  state,  however,  that  of  the  two  frontal  bones 
only  the  posterior  part  is  absent  ;  the  anterior  part,  in- 
cluding the  orbital  plate,  is  normally  developed  ;  there 
are  four  well-developed  orbitas. 

In  summing  up  we  find  the  following  conditions  to  be 
present  : 

1.  Duplicity  of  the  face  and  anterior  part  of  the 
head.  The  duplication  begins  proximally  from  the  pe- 
trous portions  of  the  temporal  bones,  including  thus  the 
sphenoid,  frontal,  nasal,  supra-maxillary,  and  infra- 
maxillary  bones.  Two  pharynges  are  present,  which 
communicate  with  each  other. 

2.  Cranio-rhachi-schisis  involving  the  entire  verte- 
bral column. 

3.  Interposition  of  a  peculiar  os  sacrum-like  verte- 
bral formation  and  of  two  longitudinal  bones  (each  of 
these  again  divided  into  an  anterior  and  posterior 
part)  between  the  occipital  and  petrous  bones  of  each 
side.  In  proximo-distal  direction  these  intercalary  for- 
mations form  the  transition  between  the  base  of  the 
skull  and  the  vertebral  column. 

4.  Absence  of  the  sternum  (at  least  of  an  osseous 
sternum). 

According  to  the  classification  and  nomenclature 
adopted  by  Ziegler '  and  Marchand "  the  monster  de- 
scribed belongs  to  the  group  of  diprosopi.  It  must  be 
designated  as  a  diprosopus  diotus,  tetrophthalmus,  di- 
stomus,  with  cranio-rhachi-schisis  involving  the  entire 
vertebral  column. 


THE  THERAPEUTIC  VALUE  OF  WATER  IN 
THE  TREATMENT  OF  SOME  NERVOUS 
AND  MENTAL  CONDITIONS. 

By  HORACE  PHILLIPS,  M.D., 


SrSTANr    PHVSICIA 


FOR   THE   INS\ 


One  of  the  earliest  references  to  the  strengthening  effect 
of  the  bath  seems  to  have  been  made  by  Homer,  when 
Ulysses  visited  the  king  of  the  Phjeacians  ( Alcinous)  and 
was  conducted  to  a  bath,  that  he  might  regain  renewed 
strength  after  his  journey.  The  heroes  of  tlie  Olympic 
games  were  accustomed  to  take  cold  baths  in  order 
that  they  might  be  better  able  to  contest  for  the  honors 
of  the  field.  Plato  prescribed  the  bath  as  a  means  of 
preserving  the  health  and  preventing  disease.  Hip- 
pocrates, in  his  treatise  on  "  Air,  Water,  and  Locality," 
divides  the  causes  of  disease  into  climate  and  diet,  and 
practised  bleeding,  cupping,  cauterization,  auscultation, 
and  bathing.  Asclepiades,  of  Bithynia,  who  appears  to 
have  been  a  man  of  rather  limited  science  and  skill, 
forsook  the  general  methods  of  tiie  practice  of  medi- 
cine in  his  day,  and  relied  entirely  in  the  treatment  of 
his  cases  upon  the  therapeutic  action  of  the  bath,  ex- 
ercise, and  regulated  diet.  Later,  Galen,  during  the 
second  century,  seems  to  have  recognized  the  pos- 
sibilities  of   water   in   the  treatment   of   disease,   and 

'  Lehrbuch  der  allgemeinen  pathologisehen  Anatomie  und  Patho- 
genese.     7th  edition,  page  423.    Jena.     1802. 

•  Realencyclopuedie  der  gesammtcn  Heilkunde,  vol.  13.  under  the 

heading  Missbildungcn. 


incorporated  it  as  one  of  the  recognized  methods  of 
treatment. 

The  public  baths  at  Pompeii,  though  that  of  a 
provincial  town,  and  inferior  in  size  to  those  at  the 
capital,  occupied  a  piece  of  ground  embracing  an  area 
of  ten  thousand  square  feet,  and  consisted  of  ten  dis- 
tinct establishments,  the  smaller  of  which  is  believed 
to  have  been  devoted  exclusively  to  women.  In  the 
larger  was  a  court,  bounded  on  two  sides  by  a  portico, 
which  was  used  as  a  waiting-room  for  those  seeking 
admission  to  the  thermas.  From  this  space  a  com- 
municating passage  admitted  to  a  smaller  room,  where 
the  clothes  of  the  bather  were  left  (apodyterium)  ; 
from  this  a  door  led  to  an  apartment  in  which  was  the 
frigidarium,  or  cold  bath.  A  pool  in  the  centre  of 
this  apartment  was  of  white  marble,  circular  in  shape, 
twelve  feet  in  diameter  and  three  feet  in  width,  the 
water  being  conducted  into  the  side  of  the  pool  by  a 
bronze  sprout,  and  in  the  bottom  an  outlet,  which 
served  to  empty  the  bath. 

From  the  frigidarium  a  door  opened  into  a  smaller 
room,  which  was  warmed  by  a  large  portable  fireplace, 
and  here  those  who  wished  to  use  the  warm  bath  were 
anointed  and  rubbed  by  attendants  previous  to  enter- 
ing the  caldarium.  The  floor  of  the  caldarium  was 
placed  on  small  pillars  so  that  the  heat  from  the  fur- 
naces had  free  admission  beneath  it.  At  one  end  of 
this  room  was  placed  the  hot  bath,  which  consisted  of 
a  shallow  cistern  15x4X2  feet  in  depth.  Inside  the 
batii,  and  along  the  rim,  was  a  seat  upon  which  the 
bathers  might  sit;  the  warm  water  was  furnished  from 
caldrons  communicating  with  the  bath  by  pipes.  At 
the  far  end  of  the  room  was  a  huge  vase,  from  the 
centre  of  which  projected  a  spout,  throwing  a  stream 
of  cold  water,  which  was  designed  to  fall  upon  the 
head  and  shoulders  of  the  bather  previous  to  his  quit- 
ting the  heated  atmosphere  of  the  caldarium. 

The  great  thermoe  constructed  by  the  Emperor  of 
Rome  were  very  elaborate  and  expensive,  but  con- 
structed on  the  same  general  plan  as  that  just  de- 
scribed. Those  of  Caracalla  were  perhaps  most 
famous,  being  fifteen  hundred  feet  long  by  twelve 
hundred  and  fifty  feet  broad,  and  having,  in  addition 
to  the  usual  apartments,  large  open  spaces  for  exer- 
cise and  covered  courts  which  might  be  used  for  the 
same  purpose  during  inclement  weather. 

The  use  of  the  cold  or  hot  bath  was  regulated  by 
the  direction  of  a  physician  or  the  inclination  of  the 
bather.  Previous  to  bathing  it  was  customary  for 
gentle  exercise  to  be  taken  ;  then  the  bather  passed, 
after  denuding  in  the  tepidarium,  to  the  caldarium, 
and  after  waiting  for  a  short  time,  immersed  himself 
gradually  in  the  hot  water,  or  had  it  simply  poured 
over  his  head  and  shoulders.  Then  he  had  a  douche 
of  cold  water,  and  left  this  apartment  to  pass  into  the 
frigidarium,  where  he  took  a  cold  plunge.  He  was 
then  scraped  with  strigils  (small  curved  instruments), 
dried  by  being  rubbed  with  linen  cloths,  and  finally 
anointed  ;  then,  after  resting  in  the  adjoining  room,  he 
was  ready  to  undertake  the  duties  of  the  day. 

When  only  one  bath  was  desired,  it  was  taken  shortly 
before  the  principal  meal,  although  under  the  direc- 
tion   of   a    physician,  or   when    suffering   from    slight 
bodily    disorders,  it    was   not  uncommon    for  four  or  _ 
six   baths    to  be   taken  during  tlie   day.     Commodus  ■ 
is  said  to  have  indulged  in  as  many  as  seven  baths  ■ 
a  day. 

The  Turks  and  Arabs  had,  after  the  decline  of 
Roman  civilization,  more  particularly  cherished  the 
custom  of  bathing  than  other  nations  ;  and  by  the  laws 
of  Mohammed,  as  laid  down  in  the  Koran,  all  true  be- 
lievers were  obliged  to  recite  five  prayers  daily,  and 
either  to  bathe  or  to  wash  their  hands,  feet,  and  face 
before  each  prayer. 

Long  after  the  fall  of  the  Roman  Empire  the  bath 
was  retained,  as  is  witnessed  by  the  splendid  remains 
which  exist  in  K.ircelona  and  Granada,  and  which  were 


I 


September  21,    1895] 


MEDICAL    RECORD, 


405 


constructed  and  used  by  the  Moors  previous  to  their 
conquest  by  the  Spaniards. 

During  the  period  of  the  Dark  Ages  the  knowledge 
and  curative  action  of  the  bath  was  prescribed  and  prac- 
tised by  such  peoples  as  the  Arabs,  Indians,  Japanese, 
and  Moors,  and  through  the  agency  of  these  last  was 
the  bath  introduced  to  European  nations  during  the 
revival  of  learning. 

During  the  sixteenth  and  seventeenth  centuries  water 
seems  to  have  again  attained  some  recognition  as  a 
remedial  agent,  for  we  read  of  Ambroise  Pare  prescrib- 
ing it  in  the  treatment  of  various  disorders  which  ap- 
peared among  the  troops  of  Henry  III.  During  the 
latter  portion  of  the  eighteenth  century  and  first  half 
of  the  present  century,  the  bath  had  been  used  and 
abused  in  many  cases,  especially  in  the  treatment  of  in- 
sanity ;  for  we  read  that  it  had  been  proposed  to  drive 
delirious  ideas  from  the  minds  of  the  insane  by  this 
method,  and  ofttimes  they  w-ere  brought  to  the  verge 
of  dissolution  by  prolonged  submersion.  Another 
favorite  method  was  the  cold  douche,  where  the  pa- 
tient was  subjected  to  extremes  of  temperature,  often 
resulting  in  pronounced  rigors  or  loss  of  consciousness. 
Such  radical  treatment  was,  however,  soon  recognized 
as  questionable  and  was  succeeded,  after  a  careful  study 
of  the  influence  of  heated  water  upon  the  human  or- 
ganism, by  the  more  modern  and  scientific  administra- 
tion of  the  bath. 

It  is  essential  in  studying  the  action  of  the  bath  upon 
the  system  that  we  study  that  force  which  the  water, 
or  whatever  media  we  use,  conveys  to  the  human 
economy,  namely,  heat  in  its  different  varieties  and 
intensities.  The  well-known  fact  that  water  requires 
more  heat  to  warm  it,  and  gives  out  more  units  of  heat 
in  cooling  over  a  given  range  of  temperature,  makes  it 
invaluable  in  bathing. 

Heat  when  applied  to  the  surface  of  the  body  in  this 
manner,  as  stated  by  Dr.  Parke  (98°  to  112°  F.),  is  said 
to  produce  at  first  an  inconvenient  and  then  a  painful 
sensation,  due  to  the  determination  of  the  blood  to  the 
surface,  which  soon  becomes  swollen  and  reddened,  the 
face  turgid,  eyes  injected,  action  of  the  heart  increased, 
and  full  and  frequent  pulse,  with  a  sensation  of  dizzi- 
ness and  vertigo  ;  the  carotid  arteries  in  particular 
beat  with  violence,  the  breathing  is  oppressed,  and 
there  is  a  painful  sensation  of  weight  about  the  head. 
Soon  parts  of  the  body  not  covered  by  water  break  out 
in  a  profuse  perspiration,  which  only  partially  relieves 
the  discomfort  of  the  patient.  On  leaving  the  bath  the 
excitement  does  not  subside  ;  the  pulse  continues  to 
beat  with  force  and  frequency,  the  extremities  remain 
swollen,  the  patient  perspires  profusely,  and  the  secre- 
tion of  urine  is  diminished.  There  is  now  a  sense  of 
muscular  fatigue,  and  the  whole  system  is  relaxed  and 
weakened.  Physiologically  we  seem  to  have  a  partial 
paralysis  of  the  vaso-motor  system,  with  a  consequent 
dilatation  of  the  whole  capillary  system,  an  increased 
pulse,  which  becomes  less  tense  and  more  rapid,  due  to 
a  fall  of  blood-pressure  from  withdrawal  of  blood  from 
the  deeper  structures,  a  general  condition  of  passive 
hyperemia,  with  a  decided  increased  activity  of  the 
skin  ;  the  urine  is  found  to  be  scanty  and  containing  a 
lessened  amount  of  urea.  The  temperature  of  the 
body  will  be  found  to  have  increased  while  the  patient 
is  in  the  bath,  but  on  withdrawal  the  temperature 
rapidly  falls,  due  to  the  increased  area  of  blood  exposed 
in  the  congested  vessels. 

The  degree  of  heat  at  which  coagulation  of  the 
blood  in  the  arteries  is  said  to  occur  is  42y%°  C,  which 
temperature,  if  not  fatal,  produces  fatty  infiltration  and 
degeneration  of  the  liver,  heart,  kidneys,  and  muscles. 
To  man  100  to  132°  C.  in  air  proves  dangerous  and 
ofttimes  fatal,  and  a  temperature  several  degrees  lower 
would  probably  have  the  same  effect  in  water. 

The  degree  of  heat,  as  furnished  by  the  hot  bath, 
which  would  be  fruitful  of  therapeutic  action  would,  in 
view  of  the  influences  which  we  learn  that  it  produces 


upon  the  body,  range  between  98°  F.  and  128°  F.  It 
needs  no  demonstration  to  state  that  a  greater  degree 
of  dry  heat  will  be  tolerated  by  the  system  than  that 
conveyed  by  water.  The  Japanese  have  been  for  ages 
accustomed  to  bathing  in  water  heated  to  a  temperature 
of  128°  F.,  and  to  remain  in  such  a  bath  for  a  period 
of  from  three  to  five  minutes,  the  parboiling  process 
which  they  thus  undergo  seeming  to  cause  no  appar- 
ent injury,  and  being  stated  to  have  a  beneficial  effect 
upon  persons  suffering  from  rheumatism  and  various 
skin  diseases. 

Let  us  next  consider  what  are  the  effects  produced 
by  a  less  degree  of  heat  upon  the  system  w-hen  applied 
to  it  by  means  of  the  bath,  as  that  produced  by  the 
cold  or  cool  bath  (32°  to  70°  F).  Dr.  Forbes  has  de- 
scribed the  sensation  produced  by  such  a  bath  to  be  as 
follows  : 

"  On  plunging  into  the  cold  water  the  bather  ex- 
periences a  sensation  of  shock,  varying  in  intensity 
with  the  temperature  of  the  water,  which  may  amount 
to  a  rigor,  with  a  sudden  catching  of  the  breath,  draw- 
ing up  of  the  limbs  and  arms,  caused  by  the  sudden 
contact  of  the  cold  fluid  with  the  surface  of  the 
trunk  and  face.  In  some  persons  this  spasmodic  anhe- 
lation  is  so  great  as  to  entirely  prevent  speech.  The 
surface  appears  contracted  and  shrunken,  the  super- 
ficial veins  become  smaller  and  disappear,  the  hue  of 
the  skin  assumes  a  bluish  tinge,  and  after  a  short  time, 
which  depends  partly  upon  the  coldness  of  the  water 
and  partly  upon  the  constitutional  vigor  of  the  bather, 
reaction  takes  place,  the  chilliness  and  rigor  disap- 
pear and  are  succeeded  by  a  sensation  of  warmth 
which  diffuses  itself  over  the  whole  surface.  The  res- 
pirations become  tranquil,  and  there  is  a  general  feel- 
ing of  lightness  and  vigor.  After  a  variable  period, 
the  bather  again  begins  to  suffer  from  the  cold  ;  trem- 
bling and  rigor  supervene,  the  movements  become  im- 
paired and  feeble,  the  pulse  smaller  and  less  frequent, 
the  respirations  are  oppressed,  and  the  whole  body  is 
languid  and  pulseless.  If  he  leave  the  water  before  the 
occurrence  of  the  second  period  of  rigor,  there  is  a  re- 
newal of  reaction  ;  a  glow  pervades  the  surface  ;  the 
color  returns  and  is  heightened  ;  the  pulse  is  stronger 
and  fuller  than  previous  to  the  submersion,  and  there 
is  a  general  feeling  of  buoyancy  and  vigor." 

The  physiological  eft'ects  upon  the  vascular  and  ner- 
vous system  produced  by  the  application  of  cold  are, 
first,  a  stimulation  of  the  vasomotor  system  and  exal- 
tation of  the  spinal  reflexes,  with  a  contraction  of  the 
terminal  blood-vessels,  slowing  of  the  current  of  blood,  a 
diminution  of  the  number  of  corpuscles,  and  a  gradual 
paling  of  the  tissues.  The  corpuscles  become  less  trans- 
parent, and  finally  their  movement  ceases,  the  vessels 
becoming  blocked.  Dilatation  then  ensues,  due  to  a 
partial  paralysis  of  the  vaso-motor  system,  with  an  ac- 
cumulation of  blood  in  the  terminal  vessels  causing  a 
cyanotic  condition  of  the  surface.  This  condition  may 
reach  the  deeper-seated  vessels,  but  after  a  time  causes 
an  increased  resistance  which  may  be  demonstrated  by 
the  sphygmograph. 

The  pulse,  under  the  influence  of  cold,  falls  quite 
perceptibly,  due  no  doubt  to  the  stimulation  of  the  in- 
hibitory cardiac  nerve,  associated  with  a  decided  fall  in 
the  blood-pressure.  The  respirations  are  lessened  in 
frequency  and  become  more  slow,  the  secretion  of 
urine  is  scanty,  and  the  liver  and  deeper  structures  be- 
come congested.  The  hyper;emia  which  is  noticed  in 
the  cyanotic  condition  does  not  cause  exudation.  The 
temperature  of  the  surface  will  be  found  to  have  fallen 
in  proportion  to  the  degree  of  cold  and  the  time  in 
which  it  is  applied.  The  loss  of  heat  following  a 
continued  application  of  cold  causes  a  decrease  of 
temperature  chiefly  by  conduction,  notwithstanding 
that  at  the  same  time  there  is  an  increased  production 
of  heat  in  the  body  ;  but  the  peripheral  circulation 
being  slow-ed,  not  so  great  a  supply  of  blood  is  exposed 
to  its  influence,  and  an  internal  temperature  will  show 


4o6 


MEDICAL   RECORD. 


[September  21,  1S95 


but  slight  decrease  of  heat.  Following  this  retardation 
of  the  peripheral  circulation,  there  is  a  paralysis  of  the 
sensory  nerve-filaments :  the  pulmonary  circulation 
becomes  impeded,  diminished  oxidation  of  the  blood 
occurs,  and  the  vital  centres  become  affected,  produc- 
ing loss  of  muscular  power  and  sleep,  deepening  into 
coma. 

What  has  been  stated  by  Liebemieister  as  "  the 
primary  after-effect '"  occurs  shortly  after  the  body 
has  been  in  contact  with  a  cold  media.  The  surface 
which  has  been  blanched  and  reduced  in  temperature 
now  becomes  pink,  and  in  withdrawal  from  contact  with 
cold,  assisted  by  friction,  assumes  a  red  and  glowing 
appearance.  The  current  of  blood  in  the  capillaries  is 
accelerated  :  the  blood-pressure  rises ;  the  pulse  be- 
comes fuller  and  stronger,  showing  an  increased  action 
of  the  heart  ;  the  respirations  are  now  deep  and  full, 
and  the  spinal  reflexes  become  less  excited.  The  sen- 
sory nerve-filaments  resume  their  activity,  the  skin 
becomes  reactive  and  moist,  the  bodil)'  temperature 
increased,  and  we  have  all  the  conditions  of  a  healthy 
reaction  established.  The  time  at  which  reaction 
takes  place  is  variable,  usually  being  more  prompt 
when  exercise  is  conjoined  with  bathing,  when  a  lower 
temperature  can  be  borne  than  under  other  circum- 
stances. 

M.  Roustan  has  stated  that  after  a  plunge  in  the 
Seine  at  a  temperature  of  43°  F.  he  was  unable  to 
remain  longer  than  six  minutes,  and  reaction  did  not 
take  place  until  that  same  night,  after  many  hours  of 
great  discomfort,  together  with  feeling  of  pain  and 
weight  in  his  head. 

The  deductions  to  be  drawn  from  the  effects  just 
considered  of  cold  baths  upon  the  system  would  seem 
to  be  that  low  temperatures  are  better  borne  and  the 
reaction  more  prompt  when  exercise,  either  by  massage 
or  muscular  exertion,  is  practiced,  but  not  being  car- 
ried to  the  point  of  fatigue,  for  Dr.  Patreizi  has  found 
that  under  the  influence  of  cold  the  work  of  a  muscle 
rapidly  diminishes,  being  reduced  as  much  as  one- 
fourth  of  its  normal  capacity,  the  same  being  true  of 
high  temperatures,  where  he  found  that  the  blood  in 
superheated  muscles  is  no  longer  capable  of  histological 
exchange,  and  the  toxic  products  act  more  energeti- 
cally upon  the  muscle  at  such  temperatures.  No  influ- 
ences should  be  exerted  which  tend  to  demand  of  the 
system  an  increased  local  supply  of  blood,  either  phys- 
iologically or  otherwise ;  hence  no  food  should  be 
taken  before  a  bath.  The  same  holds  true  of  the  use 
of  alcohol  or  any  stimulating  substance  previous  to 
bathing.  As  the  first  effects  of  the  cold  bath  tend  to 
depress  the  vital  powers,  shock  the  nervous  system, 
and  decrease  the  bodily  temperature,  these  conditions 
tend  to  call  for  extra  exertion  upon  the  heart,  which 
has  already  been  active  in  supplying  a  previous  local 
demand. 

In  persons  of  tender  years,  as  well  as  those  advanced 
in  life,  cold  bathing  should  be  interdicted,  also  in  cases 
in  which  organic  disease  of  any  vascular  or  excretive 
organs  exist,  as  here  reaction  is  slow  and  ofttimes  im- 
perfect. The  warm  bath  (70°  to  95°  F.)  embraces 
most  of  the  beneficial  effects  which  are  derived  from 
that  of  the  cold  bath  with  but  few  of  its  dangers,  and 
lacks  the  debilitating  and  congesting  effects  which  fol- 
low the  use  of  high  temperatures.  In  the  warm  bath 
we  have  a  gentle  stimulation  of  the  peripheral  circula- 
tion, no  nervous  shock,  no  alteration  in  the  blood- 
pressure,  an  increased  action  of  the  skin  and  kidneys, 
with  but  little  change  in  bodily  temperature,  and  an 
action  which  will  relieve  a  congestion  of  deeper  struct- 
ures by  opening  up  new  channels  to  a  blocked  circu- 
lation, with  no  cause  for  alteration  in  the  functions 
of  the  vital  organs. 

Coming  to  consider  the  therapeutical  action  which 
the  bath  may  have  in  that  group  of  nervous  and  men- 
tal diseases  which  is  characterized  principally  by 
marked  changes  in  the  circulatory  system,  one  which 


would  seem  to  be  susceptible  to  benefit  from  the  action 
of  water  is  neurasthenia.  This  may  be  termed  a  con- 
dition where  lack  of  tone,  increased  excitability,  and  a 
tendency  to  rapid  fatigue,  especially  of  the  muscular 
system,  are  the  chief  characteristics.  We  would  seem 
to  have  conditions  which  might  be  benefited  by  the 
bath,  the  loss  of  tone,  brought  about  by  imperfect 
nutrition  in  which  the  whole  nervous  system  has  suf- 
fered, and  the  vaso-motor  system  is  prostrated  and  has 
become  fatigued,  which  is  demonstrated  by  the  ten- 
dency to  blush.  This  Beard  has  counted  among  the 
most  characteristic  symptoms  of  neurasthenia.  In 
addition,  the  oedema  of  hands  and  feet,  with  rapid  and 
transient  changes  of  temperature  in  various  parts  of  the 
body,  hemorrhoidal  and  capillary  aneurisms,  bear  wit- 
ness to  the  general  impaired  condition  of  the  vascular 
system. 

Owing  to  the  impaired  physical  condition  of  such 
patients,  although  cold  baths  would  seem  to  be  indi- 
cated, yet  from  the  shock  which  would  be  consequent 
upon  their  administration,  and  failure  under  such  con- 
ditions for  reaction  to  be  promptly  established,  they 
are  contra-indicated.  Tuke  has  stated  that  actually 
hot  or  cold  baths  should  not  be  used  in  the  treatment 
of  this  condition,  but  that  moderately  cold  baths  exert 
a  beneficial  action  ;  also  the  vapor  bath  is  beneficial  in 
many  cases.  Massage  should  not  be  neglected  in  this 
connection,  as  the  mechanical  effect  thus  produced  is 
a  valuable  adjunct  to  the  therapeutic  action  of  the  batii. 
Ross  states  that  he  has  found  the  thermal  lime-baths 
useful  in  the  treatment  of  neurasthenia,  and  does  not 
recommend  the  use  of  cold  baths. 

In  melancholia,  where  alteration  in  the  general  nutri- 
tion takes  first  rank  as  a  physical  symptom,  we  have  as 
evidence  of  disordered  circulation  opaque  and  muddy 
skin,  with  impaired  growth  of  its  appendages,  dr)- 
furred  tongue,  constipated  bov.-els,  a  slow  and  soft 
pulse,  and  lowered  bodily  temperature,  and  in  many 
cases  oedema  and  cyanosis  of  extremities.  Here  the 
bath,  by  stimulating  the  peripheral  circulation,  estab- 
lishing the  normal  action  of  the  skin,  and  increasing 
the  bodily  temperature,  either  by  reaction  or  direct 
heat,  shows  itself  to  be  a  valuable  agent. 

The  warm  bath  is  most  generally  applicable  in  mel- 
ancholia where  impairment  of  the  functions  of  the  skin 
and  excretory  organs  are  involved,  while  those  cases 
exhibiting  nervous  excitability,  with  hypochondriacal 
notions,  normal  excretory  organs,  and  pulse  more 
rapid  than  usual,  are  most  benefited  by  the  cold  bath 
or  sponging. 

Brierre  de  Boismont  recommends  the  continued  use 
of  the  warm  bath  with  cold  affusions  to  the  head  in 
melancholia,  and  states  that  he  knows  of  no  remedy 
which  compares  with  prolonged  baths  and  continued 
irrigation  in  the  treatment  of  such  cases.  Clouston 
speaks  highly  of  the  Turkish  bath  in  the  treatment  of 
melancholia,  and  when  the  hyper-action  of  the  brain 
seemed  to  exercise  an  inhibitor)-  influence  on  the  car- 
diac nerve-innervation.  causing  small  pulse,  lowered 
arterial  tone,  and  impeded  capillary  circulation,  marked 
benefit  was  experienced. 

In  mania  Bevan  Lewis  has  noted  disordered  circu- 
lation as  one  of  the  bodily  symptoms,  in  some  instances 
showing  itself  by  injection  of  the  peripheral  vessels  of 
head  and  neck,  and  again  by  marked  pallor  of  the  face, 
associated  with  a  small  and  frequent  pulse  and  heart- 
sounds  which  are  often  mufiled.  Albutt  has  pointed 
to  the  anxmic  condition  of  the  optic  disks  (alternating 
with  marked  vascular  suffusion,  doubtless  caused  by 
spasm  of  the  retinal  vessels)  as  an  important  S)Tnptom 
in  this  disease.  The  headaches,  sense  of  weight,  and 
insomnia  are  ofttimes  associated  with  an  increased  tem- 
perature, ranging  to  100°  F.  In  addition  to  these 
symptoms  there  is  a  furred  tongue,  either  lost  or  per- 
verted appetite,  constipated  bowels,  a  sluggish  con- 
dition of  the  glandular  system,  and  in  some  cases  furun- 
cles and  whitlow  are  present  in  the  acute  form  of  mania. 


September  21,  1895] 


MEDICAL   RECORD. 


407 


I 


Dr.  Savage,  referring  to  the  pulse-tracings  which  he 
has  conducted,  states  :  "  They  bear  a  strong  resem- 
blance to  those  found  in  fever  and  acute  diseases,  but 
in  maniacal  tracings  the  rate  is  less  and  the  heart  more 
forcible."  The  skin,  the  urine,  and  general  nutrition 
are  also  disordered,  and  add  their  quota  to  complete  the 
clinical  picture  of  the  physical  symptoms  in  this  disease. 

Acute  delirious  mania  differs  from  the  less  severe 
form  of  the  disease  in  that  each  symptom  is  intensi- 
fied and  is  associated  with  a  marked  hyperpyre.xia. 
complete  insomnia,  arrested  nutrition,  scanty  urine. 
a  dry  brown  tongue,  and  general  condition  of  exhaus- 
tion, which  is  well  expressed  by  the  form  typhomania. 
The  adaptation  of  the  bath  as  a  factor  in  the  treatment 
of  mania  must  be  modified  to  the  exigencies  of  each 
case,  and  it  is  imperative  that  when  such  alterations  of 
the  \-ital  functions  exist  as  diseases  of  this  character 
produce,  radical  and  heroic  measures  should  be  avoided. 
It  has  been  said  that  "  some  patients  are  mad  from  an 
excess  of  blood,  others  from  a  deficiency  of  blood."  a 
statement  which  gives  us  a  hint  as  to  the  dangers  which 
we  must  combat  in  the  treatment  of  this  disease. 

Clouston  states  that  he  has  seen  prolonged  warm 
baths  (99°  F.)  do  good  in  many  cases,  and  in  some  act 
like  a  charm.  His  usual  plan  of  treatment  was  "  to 
immerse  the  patient  in  the  heated  water  and  apply 
cold  affusions  to  the  head,  the  eflfect  of  this  com- 
bined bath  being  to  fill  the  capillaries  all  through  the 
body  and  withdraw  blood  from  the  brain,  to  depress 
the  heart's  action,  to  soothe  nervous  irritation,  and  to 
produce  sleep." 

The  more  rapid  capillary  dilatation  and  consequent 
displacement  of  large  volumes  of  blood  from  congested 
centres  would  seem  to  be  more  readily  effected  by 
baths  of  a  higher  temperature,  but  the  determination 
of  quantities  of  blood  to  the  surface  by  this  means  has 
been  found  to  be  associated  with  results  which  are 
alarming,  and  at  times  deplorable  accidents  have  fol- 
lowed this  method  of  treatment.  The  shower-bath  of 
a  moderate  temperature  has  been  found  useful,  but 
here  it  should  be  remembered  that  sufficient  physical 
strength  must  exist  in  order  that  reaction  may  be  es- 
tablished, else  the  results  may  be  harmful. 

In  the  acute  stages  of  general  paralysis  cold  baths 
have  been  strongly  urged  by  Voisin,  particularly  dur- 
ing periods  of  excitement  with  increased  temperature. 
The  baths  were  given  at  60°  F.  for  a  period  of  ten 
minutes,  the  patient  being  well  wrapped  in  warm  blan- 
kets for  an  hour  afterward,  until  the  pale  face,  blue 
lips,  etc.,  gave  place  to  signs  of  complete  reaction.  It 
is  claimed  that  the  cold  bath  in  such  cases  improves 
the  general  state,  lowers  the  temperature,  diminishes 
the  tendency  to  bed-sores,  and  increases  the  mental 
reflexes,  particularly  if  a  stuporous  or  depressed  con- 
dition exists.  The  warm  baths  are  also  recommended 
in  chronic  mania,  dementia  and  epilepsy,  where  they 
seem  to  have  a  tonic  action  by  building  up  and  im- 
proving the  general  tone  of  the  system,  and  rendering 
the  patient  thereby  less  liable  to  succumb  to  inter- 
current acute  affections  to  which  he  might  otherwise 
fall  a  ready  victim. 

Although  the  therapeutic  action  of  the  bath  has  been 
recognized  for  centuries,  yet  its  application  outside  of 
sanitariums  and  so-called  water-cure  establishments 
has  not  become  the  factor  in  the  treatment  of  disease 
which  its  importance  and  promise  would  warrant. 
There  seems,  however,  by  the  general  interest  which 
this  subject  has  recently  awakened,  and  as  evinced  by 
the  equipment  of  hospitals  and  other  institutions  for 
the  treatment  of  chronic  diseases  with  appliances  for 
the  proper  administration  of  the  bath,  that  careful  and 
searching  inquiry  and  experimentation  will  be  made 
by  competent  scientific  observers.  And  this  remedial 
agent  will  erelong  take  its  proper  rank  among  the 
more  important  methods  of  treatment  of  chronic  dis- 
ease, which  have  hitherto  been  regarded  as  beyond  the 
reach  of  medical  science. 


\  REPORT  OF  A  CASE  IXVOLVIXG  THE 
QUESTION"  OF  THE  DIAGNOSIS  AND  OF 
THE  PROPER  TREATMENT  OF  APPEN- 
DICITIS IN  PREGNANT  WOMEN. 

By  J.  W.  THOMASOX,  M.D., 

m^NTSVILLE,  TSX. 

A  CASE  occurring  in  my  practice  recently  was  so  in- 
teresting, not  only  from  a  general  clinical  standpoint, 
but  particularly  in  its  bearings  upon  the  diagnosis  and 
treatment  of  appendicitis  in  pregnant  women,  and  upon 
the  possibility  of  the  confusion  of  that  grave  disorder 
with  other  pathological  conditions,  that  I  feel  I  may  be 
excused  for  reporting  it. 

On  the  afternoon  of  April  3,  1S95,  a  gentleman  called 
at  my  office  for  a  prescription  for  his  wife,  who,  he 
said,  was  feeling  a  little  indisposed,  had  some  pain 
and  uneasiness  in  her  right  side,  and  was  constipated. 
He  stated  further  that  she  had  had  no  fever,  and  had 
been  well  until  this  time.  Knowing  the  lady  in  ques- 
tion to  be  a  stout,  healthy  young  woman,  I  judged 
from  his  description  of  her  symptoms  that  she  could 
not  be  very  sick,  and  so  suggested  a  teaspoonful  of 
compound  licorice  powder  and  a  sinapism,  to  be  fol- 
lowed by  hot  applications  until  pain  should  be  relieved. 
I  was  called  to  see  the  patient  at  nine  o'clock  next 
morning  (April  4th).  She  was  a  woman  about 
twenty  years  of  age,  and  just  entering  upon  the  ninth 
month  of  her  first  pregnancy.  She  stated  that  she  had 
taken  the  purgative,  but  had  vomited  once  or  twice 
during  the  night,  and  it  had  not  moved  the  bowels  : 
that  the  hot  applications  had  failed  to  relieve  the  pain 
which  v.-as  located  in  the  lower  right  side  of  the  ab- 
domen, and  was  constant.  Upon  examination,  I  found 
her  temperature  to  be  104.4°  F.,  and  pulse  132  beats 
to  the  minute.  There  was  no  tumor  or  swelling  dis- 
coverable in  the  right  iliac  region,  palpation  of  which, 
however,  was  unsatisfactory,  by  reason  of  the  abdominal 
distention  due  to  the  advanced  stage  of  pregnancy  :  but 
the  pain  was  constant,  and  most  intense  over  the  region 
of  the  appendix.  Vaginal  examination  was  negative  : 
the  child's  head  was  so  large  and  so  low  in  the  pelvis. 
that  I  could  make  out  nothing  further  than  the  fact 
that  there  was  no  special  tenderness  anjTvhere  on  the 
right  side  of  the  pelvic  vault.  The  patient  stated  that 
the  course  of  her  pregnancy  had  been  uneventful,  and 
her  health,  until  now,  excellent ;  that  she  had  taken  a 
walk  on  the  day  before,  and  had  felt  this  pain  come  on 
rather  suddenly  as  she  was  walking,  and  that  she  had 
not  been  free  from  it  since.  She  could  not  say  when 
the  fever  came  on,  as  she  had  had  no  well-marked 
chill.  The  foetus  was  alive  and  active.  There  was 
nothing  unusual  about  its  heart-sounds  or  about  the 
placental  bruit.  No  special  tenderness  of  uterine 
walls,  save  near  seat  of  pain  in  the  right  iliac  region. 
No  evidence  of  special  trouble  about  kidneys  or 
bladder.     What  then  was  the  diagnosis  ? 

Dr.  J.  B.  Murphy,  in  an  article  published  in  the 
Journal  of  the  American  Medical  Association,  of  March 
23,  1895,  states  that  the  symptoms  by  which  we  may 
diagnosticate  "  appendicitis  "  with  almost  positive  cer- 
tainty are  (to  use  his  own  language)  :  "  i,  A  sudden 
pain  in  the  abdomen  ;  2,  shortly  followed  by  nausea 
and  perhaps  vomiting  ;  3,  local  tenderness  over  the 
side  of  the  appendix,  and  most  frequently  in  the  right 
iliac  region  ;  4,  elevation  of  temperature." 

I  had  read  this  article,  and  had  had  some  experi- 
ence, both  surgical  and  medical,  with  appendicitis.  I 
thought  I  could  exclude  everything  else  in  this  case. 
and  so  made  my  diagnosis  accordingly.  Many  cases 
of  appendicitis  will  recover  by  natural  processes,  and 
may  be  influenced  favorably  by  medical  treatment 
only.  My  own  professional  experience  has  convinced 
me  of  this  fact,  and  that  such  is  a  common  experi- 
ence is  one  reason  why  surgical  treatment  is  so  often 
postponed  longer  than  it  should  be.     Then,  too,  de- 


4o8 


MEDICAL   RECORD. 


[September  21,  1895 


lay  in  these  cases  does  not  always  prove  fatal.  A 
case  reported  by  Dr.  P.  F.  Mund^,  in  the  Medical 
Record  of  December  i,  1894,  and  now  famous  in 
medical  literature,  was  of  a  woman,  eight  months  preg- 
nant, who  was  attacked  with  pain  in  right  iliac  region, 
fever,  vomiting,  and  other  symptoms  of  appendicitis, 
which  were  followed  a  week  later  by  miscarriage  and 
delivery  of  a  dead  foetus.  The  appendicial  abscess 
was  only  diagnosed  on  the  day  after  the  delivery, 
operation  performed  about  six  days  later,  and  the 
woman  made  a  good  recovery. 

On  the  other  hand,  operations  for  appendicitis  in 
pregnant  women,  where  such  operations  have  been  re- 
ported, seem  not  to  have  been  followed  by  such  re- 
sults as  would  justify  a  practitioner  in  proceeding 
without  hesitation  to  adopt  surgical  measures,  to  the 
exclusion  of  all  other  treatment. 

In  an  article  entitled  "  Gestation  Complicated  by 
Appendicial  Abscess,"  by  Dr.  L.  L.  McArthur,  of 
Chicago,  published  in  the  February,  1895,  number  of 
the  American  Journal  of  Obstetrics,  the  author  reports 
two  cases  of  appendicial  abscess  in  pregnant  women  : 
Case  I.  was  a  woman  aged  thirty-one  years,  multipara, 
pregnant  four  and  one-half  months.  Operation  was 
performed  on  the  third  day  of  attack,  abortion  fol- 
lowed next  morning,  and  death  of  the  patient  occurred 
on  the  second  day  after  operation.  Case  II.  was  a 
woman  aged  thirty-four,  tripara,  five  months  pregnant, 
who  had  been  sick  three  weeks  before  she  was  taken 
to  the  hospital,  when  diagnosis  of  appendicitis  was 
made  and  operation  performed  a  day  later.  Mis- 
carriage occurred  two  days  afterward  and  death  on  the 
fifth  day  after  operation. 

To  illustrate  the  difficulty  of  absolutely  accurate 
diagnosis  in  some  of  these  cases,  Dr.  McArthur  reports 
another  case,  where  a  woman  aged  twenty-three,  after 
a  long  railroad  journey  and  a  week  of  "malaise,"  de- 
veloped suddenly  a  temperature  of  105°  F.,  with 
vomiting  and  general  abdominal  pain  which,  after  the 
second  day,  was  most  intense  in  the  right  iliac  region. 
Several  surgeons  concurred  in  his  diagnosis  of  appen- 
dicitis, and  advised  exploratory  incision,  which  being 
made,  threw  no  light  on  the  cause  of  the  symptoms, 
but  exposed  to  view  a  normal  condition  of  the  appen- 
dix and  abdominal  organs  generally.  The  patient 
aborted  next  day,  giving  birth  to  a  macerated  foetus, 
and  ,the  author  concludes  that  the  symptoms  were  due 
to  the  irritation  set  up  by  the  presence  of  this  dead 
body  in  the  uterus.  This  woman  recovered,  but  was 
not  a  case  of  appendicitis. 

In  the  discussion  elicited  by  the  reading  of  this 
paper  before  the  Chicago  Gynecological  Society,  no 
definite  plan  was  agreed  upon  as  the  proper  course 
to  pursue  in  the  management  of  these  cases.  It  was 
brought  out  that  the  troublesome  feature  in  dealing 
with  them,  was  the  fact  that  the  pregnant  womb  gener- 
ally forms  one  wall  of  the  appendicial  abscess.  The 
disturbance  to  the  uterus  incident  to  opening,  cleans- 
ing, and  draining  the  abscess,  is  almost  sure  to  cause  it 
to  evacuate  its  contents,  and  in  so  doing,  it  draws  away 
from  the  new  relations  it  has  formed,  tearing  the  ad- 
hesions which  walled  off  the  abscess,  and  permitting 
the  escape  of  septic  matter  into  the  general  peritoneal 
cavity.  In  view  of  these  dangers,  a  member  present 
suggested  that  the  best  mode  of  procedure  in  these 
cases,  when  operation  seemed  imperative,  would  be 
first  to  induce  a  rapid  abortion,  then  to  open,  cleanse, 
and  drain  the  abscess,  and  thus  leave  no  opi)ortunity 
for  furtlier  peritoneal  infection  by  assumption  of  new 
relations  by  that  wall  of  the  abscess  formed  by  the 
uterus. 

With  these  conditions  before  me  I  concluded  to 
risk  delay  in  my  case  and  to  await  development  for  a 
while.  Accordingly  I  prescribed  for  my  jiatient  one 
grain  of  calomel  every  three  hours  until  six  grains 
should  have  been  taken,  two  and  one-half  grains  of 
Dover's  powder  with  every  other  dose  of  calomel,  and 


one  minim  of  tincture  of  aconite  every  hour  until  some 
reduction  of  temperature  should  be  accomplished. 
At  4.45  p.^f.,  temperature  was  102°  F. ;  pulse,  142.  Pa- 
tient still  complained  of  constant  pain  in  iliac  region  and 
now  also  in  lumbar  region,  and  pain  intense  on  pressure 
over  appendix.  Aconite  was  discontinued  and  warm 
water  enemata  ordered  ;  one  now,  one  in  three  hours, 
and  a  tablespoonful  of  sulphate  of  magnesium  to  be 
taken  at  6  a.m.  to-morrow.  It  is  of  interest  to  note 
that  a  specimen  of  urine  examined  contained  about  one- 
sixth,  by  bulk,  of  albumin. 

April  5th,  9  A.M. — Temperature,  99°  F.;  pulse,  112. 
Enema  last  night  moved  bowels  and  gave  some  relief 
to  pain.  Medicines  have  acted  several  times.  Pain 
still  severe  in  iliac  region.  4.30  p.m. — Temperature, 
102°  F. ;  pulse,  124.  Bowels  and  bladder  inclined  to 
be  irritable  ;  considerable  pain  in  right  iliac  region  in- 
tensified by  pressure  over  region  of  appendix.  No 
nausea  or  vomiting.  P  itient  has  taken  small  quantities 
of  water  and  chicken  broth  during  the  day.  I  gave 
hypodermatic  injection  of  morphine  sulphate,  \  grain, 
and  atropine  sulphate,  grain  yj^  ;  ordered  hot  applica- 
tions continued  and  thirty  drops  of  laudanum  by  enema 
if  necessary  to  relieve  pain  during  the  night. 

April  6th,  9  a.m. — Temperature,  99^^  F.;  pulse,  120. 
Some  irritability  of  the  bladder  during  the  night  was 
relieved  by  the  use  of  the  laudanum  enema,  one  time. 
Pain  not  so  severe  this  morning,  but  still  marked  in  the 
usual  place.  Hot  applications  continued  ;  no  other 
treatment.    4  p.m. — Temperature,  ioof°  F.;  pulse,  120. 

April  7th,  9  .\M. — Temperature,  99°  F.;  pulse,  iiS. 
Had  a  fairly  good  night,  though  suffered  some  pain  and 
used  laudanum  enema  once  during  the  night.  Pain 
still  rather  severe  over  appendix.  4  p.m. — Temperature, 
ioof°  F.;  pulse,  118.     No  special  change  in  symptoms. 

April  8th,  1.30  a.m. — Was  called  up  at  this  hour  and 
told  that  patient  was  restless  and  perspiring  profusely. 
.\lmost  sure  that  the  dreaded  rupture  had  occurred  and 
that  surgical  measures  could  be  postponed  no  longer. 
I  found,  upon  my  arrival  at  her  bedside,  my  patient's 
general  condition  not  at  all  unfavorable.  Temperature 
had  fallen  to  96°  F.;  pulse,  to  90.  I  am  inclined  to 
think  that  this  was  the  crisis  in  this  case.  A  dose  of 
mixed  bromides  was  the  only  sedative  given  and  pa- 
tient's temperature  at  9  .a.m.  next  morning  (April  8th) 
was  97f°  F.;  pulse,  100.  Still  some  pain,  but  only 
elicited  by  pressure  over  region  of  appendix. 

April  8th,  4.30  p.m. — Temperature,  98°  F.  ;  patient 
cheerful  and  comfortable.  The  further  progress  of 
this  case  was  without  incident  of  importance.  After 
April  loth,  I  discontinued  my  visits,  temperature  re- 
maining normal,  and  there  being  but  slight  tenderness 
on  pressure  over  appendix.  Impressed  with  the  grav- 
ity of  the  symptoms  in  the  beginning,  however,  I  felt 
that  my  patient  would  not  be  entirely  safe  until  her 
confinement  should  have  tr.ken  place. 

The  sequel  was  even  more  interesting  than  it  prom- 
ised to  be.  I  was  called  again  to  this  lady  at  7  a.m., 
April  30th  ;  found  her  in  labor  ;  presentation  L.  O.  A.  ; 
temperature  and  pulse  normal.  Labor  was  natural, 
though  severe  and  tedious,  and  delivery  of  a  large 
healthy  female  child  was  accomplished  at  about  5.30 
P.M.,  without  even  rupture  of  perineum.  Proceeding  to 
deliver  the  afterbirth  I  remarked  tlie  position  of  the 
uterus  which,  contracted  in  a  cylindrical  roll,  lay  ob- 
liquely across  the  abdomen,  seemingly  drawn  toward 
the  right  side.  Upon  expressing  the  placenta  with  one 
hand  and  receiving  it  with  the  other,  I  was  struck  with 
the  hard,  leathery  feeling  of  its  free  surface  and  border, 
and  the  [leculiar  gritty  sensation  imparted  by  the  part 
which  had  been  attached  to  the  uterine  wall,  and  noted 
too  that  that  attachment  seemed  to  have  been  to  the 
right  side  of  uterus.  Examining  the  placenta,  I  found 
its  peculiar  feeling  to  be  due  to  its  having  undergone 
calcareous  degeneration  ;  its  substance  feeling  like 
sand  -  paper  ;  so  thickly  were  the  limy  concretions 
dispersed  throughout  its  tissues.     The  free  surface  was 


September  21,  1895] 


MEDICAL   RECORD. 


409 


of  whitish  appearance,  showing  here  and  there  eleva- 
tions resembling  nodules  of  inflammatory  lymph,  while 
the  large  blood-vessels  and  their  tract  were  enveloped 
in  and  covered  with  this  yellowish  white  deposit  of 
plastic  material.  The  condition  suggested  was  that  of 
inflammation  of  the  placenta,  stepping  short  of  for- 
mation of  pus,  but  followed  by  calcareous  degenera- 
tion. 

Though  my  patient  had  had  a  temperature  higher 
than  that  to  which  Dr.  Munde  attributed  the  death  of 
the  foetus  in  his  case  quoted  above,  and  though  this 
rare  condition  of  the  placenta  is  said  to  be  one  cause 
of  the  death  of  the  fcetus  in  utero  (Leischman),  the 
child  in  this  instance  was  very  much  alive,  fat,  and 
weighed  eleven  pounds.  The  fact  that  my  patient's 
temperature  after  delivery  was  102°  F.,  caused  me 
some  little  uneasiness  ;  but  the  pain  in  the  right  side 
did  not  return,  the  fever  had  disappeared  by  ne.xt 
morning,  and  the  lying-in  period  was  uneventful.  An 
examination  a  few  weeks  ago  showed  a  verj*  slight  ten- 
derness in  right  iliac  region,  but  patient  is  up  and  seems 
in  perfect  health  at  this  time. 

I  am  not  altogether  satisfied  as  to  the  correct  diag- 
nosis of  this  case,  the  symptoms  of  which  may  have 
been  caused  by  any  one  of  at  least  three  pathological 
conditions.  They  may  have  been  due  to  appendicitis, 
and  were  certainly  the  symptoms  usually  considered 
pathognomonic  of  that  condition  ;  while  the  placental 
condition  may  have  been  the  result  of  gradually  pro- 
gressive calcareous  change,  extending  over  a  longer  pe- 
riod of  time  than  the  twenty-seven  days  which  inter- 
vened between  the  onset  of  this  attack  and  labor.  Or 
they  may  have  been  due  primarily  to  "  inflammation  of 
the  placenta,"  subsiding  before  pus  formation  and  fol- 
lowed by  the  calcareous  change,  and  not  to  appendi- 
citis at  all.  Dr.  McArthur's  third  case,  quoted  above, 
resembling  this  case  in  its  features  of  high  temperature, 
localized  pain,  and  other  sy.mptoms  of  appendicitis, 
renders  this-  second  idea  as  to  diagnosis  of  my  case 
plausible.  Or,  finally,  they  may  have  been  set  up  by 
an  appendicial  inflammation,  the  contiguous  right  wall 
of  the  uterus  forming  one  side  of  the  resulting  inflam- 
matory- focus,  and  an  extension  of  inflammation  through 
the  right  wall  of  the  uterus  may  have 
caused  the  changes  found  in  the  placenta, 
the  original  appendicial  inflammation  ter- 
minating either  by  resolution  or  by  dis- 
charge of  inflammatory  products  into  the 
intestinal  canal. 

The  prime  object  of  this  paper,  how- 
ever, is  to  solicit  an  expression  of  opinion 
as  to  the  proper  mode  of  dealing  with  ap- 
pendicitis complicating  pregnancy.  Wher- 
may  we  temporize  ?  When  must  we  oper 
ate  ?  It  seems  to  me  that  if  we  must  oper- 
ate upon  these  cases,  the  radical  plan  of 
first  inducing  abortion  and  then  opening 
the  abdominal  cavity,  is  a  rational  plan  ; 
but  it,  too,  must  necessarily  involve  grave 
risks  for  the  patient.  Where  the  womb 
forms  one  wall  of  the  appendicial  abscess,  ' 

and  who  can  tell  when  this  condition  ex-  ^' 

ists,  to  lid  it  of  its  contents  and  insure  its 
safe  contraction,  would  be  to  tear  it  from 
its  adhesions  about  the  appendix  and  to 
set  free  the  contents  of  the  abscess  in 
the  abdominal  cavity.  Some  time  must  elapse  be- 
tween the  induction  and  completion  of  the  abortion 
and  the  opening  of  the  abdominal  cavity.  The  possi- 
bility of  the  infection  of  the  general  peritoneal  cavity 
in  this  interval,  however  short  it  may  be,  is  a  danger- 
ous flaw  in  this  plan  of  treatment.  Operation  without 
first  causing  abortion  proved  fatal  in  the  two  cases  pub- 
lished. Delay  and  operation  after  labor  was  success- 
ful in  Professor  Munde's  case.  Delay  alone  is  some- 
times rewarded  by  the  recovery  of  the  patient. 

The  surgeon  with  large  experience   and  abundant 


facilities  may  risk  operation  in  these  cases  and  ^•iew 
the  results  with  equanimity,  feeling  that  he  has  per- 
formed his  duty  in  carrying  out  strict  surgical  princi- 
ples ;  but  the  practitioner  in  small  towns,  where  the 
welfare  of  every  patient  is  a  personal  matter  and 
fraught  with  anxiety  and  responsibilities  to  himself, 
must,  in  view  at  least  of  published  results  in  these 
cases,  hesitate  before  adopting  radical  measures  of 
treatment. 


PLASTIC   OPERATION    OX  THE    PENIS    AND 
SCROTUM. 

By   H.    C.    hall,    M.D., 

TFI.T  URIDE,    COU 

C.  E.  R ,  aged  thirty-two,  with  fine  physique  and 

seemingly  perfect  constitution,  no  objective  nor  subject- 
ive symptoms  of  past  or  present  venereal  trouble  ;  con- 
sulted me,  January  28th  last,  with  the  statement  that 
while  at  work  in  a  stamp  mill,  four  days  before,  the 
work  being  of  a  nature  requiring  great  force  to  be  ex- 
erted with  his  left  leg,  he  was  taken  with  slight  pain 
in  the  left  inguinal  region,  which  increased  gradually 
the  following  four  days,  when  he  was  compelled  to  quit 
work.  On  examination  I  found  a  number  of  enlarged 
and  inflamed  glands  in  that  region.  The  usual  methods 
for  the  relief  of  such  a  condition  were  employed,  but 
to  no  avail  whatever.  It  pursued  an  indolent  and 
gradually  advancing  course  until  March  ist,  when  there 
was  sufficient  evidence  of  suppuration  in  one  of  the 
glands  to  warrant  an  incision,  which  was  made  with  the 
result  of  evacuating  about  an  ounce  of  healthy-looking 
pus.  Strict  antisepsis  was  observed  at  time  of,  and  fol- 
lowing, the  incision.  The  patient  was  on  the  street 
within  two  or  three  days  thereafter,  and  continued  to 
go  about  until  March  13th,  when,  while  sitting  in  my 
office,  after  having  just  remarked  that  he  felt  fairly 
well,  he  was  seized  with  a  most  violent  chill,  lasting 
forty-five  minutes.  At  the  end  of  this  time  he  was 
greatly  prostrated,  and  vomited  profusely,  the  pulse  and 
temperature  rising  rapidly.  The  prostration  continued, 
and  at  noon  of  the  second  day  thereafter  he  directed 


my  attention  to  an  uneasiness,  as  he  termed  it,  of  the 
scrotum  and  penis.  Examination  revealed  a  begin- 
ning inflamm.ation  of  the  skin  and  subcutaneous  tissues 
of  those  parts.  By  the  evening  of  the  following  day 
they  had  attained  to  enormous  dimensions,  and  by  noon 
of  the  day  after  this,  lines  of  demarcation  were  forming. 
Temperature  above  104°  F.;  pulse  rapid  and  feeble, 
and  beginning  delirium.  The  parts  sloughed  away  and 
on  the  fourth  day  I  removed  all  the  sloughing  tissue,  as 
shown  in  Fig.  i. 

As  the  destruction  of  the  penis  cannot  be  well  seen, 


4IO 


MEDICAL    RECORD. 


[September  21,  1895 


I  will  state  that  two- thirds  of  its  entire  skin  and  subcu- 
taneous tissue  sloughed,  leaving  a  strip,  from  base  to 
apex,  amounting  to  one-third.  Improvement  in  the 
general  condition  set  in  from  the  date  of  removal  of 
the  slough.  During  the  following  three  weeks,  the 
testicles  were  kept  well  incased  in  oil-silk  and  absorb- 
ent cotton,  at  the  end  of  which  time  their  surfaces  pre- 
sented a  healthy  and  granular  appearance. 

On  April  nth,  in  the  presence,  and  with  the  valuable 
assistance,  of  Drs.  Brown,  Tosh,  Russell,  and  Litch- 
field, a  flap  of  three  and  one-half  inches  in  its  greatest 
width,  and  six  inches  in  length,  with  convexities  to  suit 
conditions,  was  dissected  from  the  inner  aspect  of  the 
right  thigh,  leaving  a  pedicle  one  and  three-quarters 
inch  in  width,  and  a  little  above  the  level  of  the  parts 
to  be  covered.  After  freshening  and  smoothing  the 
edges  of  the  remaining  portion  of  scrotum,  the  flap  was 
sutured  to  it,  except  a  space  of  one-third  of  an  inch  at 
the  furthest  extremity  of  flap,  which  granulated  incom- 
pletely. Direct  union  followed  in  the  entire  circumfer- 
ence. 

On  May  i8th,  five  weeks  from  date  of  operation,  the 
pedicle  was  severed  and  returned  to  its  place.  The  cut 
surface  of  the  flap  being  sutured  to  that  portion  of  the 
scrotum  beneath,  which  also  united  directly.  Four  Aveeks 
seemed  suflicient  to  complete  the  union  of  the  flap  be- 
fore severing  the  pedicle,  but  another  week  was  added 
to  insure  absolute  safety.  At  that  time  the  penis  was 
nearly  covered  in  its  entirety  with  new  skin. 

On  May  20th  the  patient  came  to  my  office  on 
crutches.  The  wound  on  the  thigh  progressed  rapidly 
and  well.  On  June  i6th,  when  the  photograph  repro- 
duced in  Fig.  2  was  taken,  there  was  a  space  only  one- 


half  inch  wide  unhealed,  and  this  was  closed  on    |uly 

I  St. 

The  patient  is  now  in  the  East,  and  writes  me  that  he 
is  feeling  quite  well,  and  experiences  little  or  no  incon- 
v.'nience  from  his  late  trouble. 


A  Diphtheria  Laboratory  in  Paris. — .\  municipal  lab- 
oratory for  bacteriology  has  been  established  in  the  old 
Lobau  barracks  in  Paris,  where  analyses  of  suspected 
cases  of  diphtheria  are  made  within  twenty- four^hours 
after  the  materials  have  been  handed  in. 


SYMPHYSEOTOMY. 
By  T.  E.  TAYLOR,   M.D., 


Since  the  recent  revival  of  the  almost  forgotten  op- 
eration of  symphyseotomy  a  few  years  ago,  the  cases 
reported  have  multiplied,  and  the  technique  has  been 
perfected,  until  we  are  rapidly  getting  into  a  position 
where  we  can  define  the  limits  within  which  it  is  justi- 
fiable. Until  this  is  done  every  operation  should  be 
reported,  as  the  larger  the  number  of  cases  recorded 
the  less  is  the  likelihood  of  error.  Having  recently 
had  a  patient  who  was  delivered  by  this  means,  I  take 
this  opportunity  to  report  the  case. 

Mrs.  G ,  aged   thirty-three,  German,  sent  for  me 

early  in  the  morning  of  March  6th.  I  saw  her  at  7  a.m., 
and  was  told  that  she  had  had  strong  pains  all  night, 
labor  having  set  in  at  2  p.m.  the  previous  day,  and  the 
membranes  having  ruptured  at  10  p.m.  I  was  also  told 
that  her  previous  labors  had  all  been  difficult,  all  of 
her  four  deliveries  having  been  by  craniotomy. 

Upon  making  an  examination  I  found  the  os  thor- 
oughly dilated,  the  vertex  presenting  in  the  first  posi- 
tion, and  the  head  so  firmly  crowded  down  into  the 
inlet  that  I  could  not  reach  the  promontory  of  the 
sacrum,  though  the  ease  with  which  I  could  reach  the 
upper  segments  of  the  sacrum  indicated  that  its  prom- 
ontory would  be  within  reach  were  the  head  out  of 
the  way.  Upon  taking  the  customary  external  meas- 
urements I  found  the  following  dimensions  :  Spines, 
10J2  inches  ;  crests,  9^3  inches  ;  extended  conjugate, 
6%  inches. 

Two  weeks  after  delivery  I  found  the  diagonal  con- 
jugate to  measure  three  and  one-fourth  inches,  giving 
me  an  estimated  true  conjugate  of  two  and  five-eighths 
inches. 

Although  satisfied  from  the  measurements  of  the 
pelvis  that  there  was  no  possibility  of  a  head  approach- 
ing the  normal  in  size  passing  through  it,  this  conclu- 
sion also  being  confirmed  by  the  history  of  successive 
craniotomies,  yet  as  the  surroundings  were  most  un- 
favorable for  any  operation,  and  as  the  patient  was 
very  averse  to  going  to  a  hospital,  or  indeed  to  under- 
going any  operation  at  all,  I  put  on  the  forceps  to  give 
her  the  benefit  of  any  chance  that  the  head  might  be 
small  and  compressible  enough  to  pass  through  the 
contracted  inlet.  The  forceps  were  applied  without 
difficulty,  but  strong  traction  applied  with  remission 
for  half  an  hour  failed  to  produce  any  effect.  It 
seemed  evident,  therefore,  that  an  operation  was  in- 
evitable, and  she  was  persuaded  to  go  to  St.  Luke's 
Hospital  for  this  purpose.  Dr.  Parkhill  being  called  to 
my  assistance.  Dr.  Parkhill  agreed  with  me  that  sym- 
physeotomy was  the  preferable  operation,  though  the 
conditions  were  not  what  we  should  have  liked,  as  the 
woman  had  been  in  labor  already  twenty-four  hours, 
and  ten  hours  had  elapsed  since  the  membranes  had 
ruptured,  she  being  during  this  time  in  the  care  of  a 
most  ignorant  and  dirty  midwife,  who  had  made  fre- 
quent examinations.  I  confess,  too,  that  the  prelimi- 
nary application  of  the  forceps,  though  authorised  and 
even  insisted  upon  by  some,  was  hopeless  and  ill-ad- 
vised, and  had  an  unfavorable  bearing  on  the  progno- 
sis. It  must  be  remembered,  however,  that  at  this  time 
I  had  not  been  able  to  measure  the  diagonal  conjugate, 
and  consequently  could  not  know  how  great  the  con- 
traction was,  estimates  founded  upon  the  external  con- 
jugate being  very  unreliable. 

At  the  hospital  the  abdomen,  thighs,  and  vulva  were 
shaved  and  thorouglily  disinfected  as  for  any  opera 
tion,  and  the  vagina  was  also  thoroughly  disinfected. 
Dr.  Parkhill  operated  by  the  open  method,  dividing 
the  symphysis  from  before  backward  with  a  bistoury. 
.\s  so  often  happens,  the  symphysis  was  not  in  the  me- 
dian line  but  a  little  to  the  left.  Upon  dividing  the 
symphysis  the  pubic  bones  separated  about  an  inch  and 


September  21,  1895] 


MEDICAL   RECORD. 


411 


a  half,  the  separation  as  the  head  passed  through  the 
inlet  reaching  two  and  one-half  inches.  The  labor  was 
at  once  completed  by  the  application  of  the  forceps, 
only  moderate  traction  being  necessary.  The  child 
was  asphyxiated,  but  it  was  soon  resuscitated.  The 
patient  recovered  without  noteworthy  incident,  leaving 
the  hospital  on  the  ninth  day,  and  within  three  weeks 
resuming  her  household  duties  and  the  care  of  the 
baby.  There  is  no  perceptible  movement  of  the  pubic 
bones,  and  her  gait  is  as  secure  as  formerly. 

This  result  was  very  gratifying  in  comparison  with 
the  bloody  record  of  four  successive  craniotomies. 
The  question  arises,  Was  it  the  best  possible  operation 
to  do  ?  At  our  meeting  last  year  a  successful  case  of 
Caesarean  section  was  reported,  and  to  some  it  may 
seem  that  the  latter  is  the  more  promising  operation. 
Looking  into  the  statistics  of  the  two  operations,  we 
find  that  the  results  in  both  depend  largely  on  the  pe- 
riod covered  and  the  operators  concerned.  If  we  go 
back  fifteen  or  twenty  years,  before  the  days  of  aseptic 
surgery,  and  when  the  indications  calling  for  them  were 
not  well  understood,  we  find  both  operations  alike  unsat- 
isfactory. To  resort  to  them  when  every  other  hope  has 
failed,  and  when  the  mother  is  already  exhausted  by  a 
long  and  fruitless  labor,  is  not  fair  to  these  operations, 
and  the  resulting  mortality  is  not  so  much  the  mortality 
of  the  operation  as  the  mortality  of  prolonged  labor. 
The  true  mortality  of  symphyseotomy,  as  of  Caasarean 
section,  must  be  computed  from  those  cases  alone 
where  the  measurements  have  been  carefully  taken, 
and  the  most  suitable  operation  undertaken  as  a  matter 
of  election,  not  as  a  last  resort,  and  where  every  pre- 
caution has  been  taken  to  avoid  sepsis.  Tried  by  this 
standard  the  earlier  cases,  down  to  1880,  must  be  re- 
jected as  a  whole  ;  and  of  the  cases  reported  since  that 
time,  while  the  field  of  the  operation  v\^as  ill  defined,  a 
large  part,  including  most  of  the  fatal  cases,  must  also 
be  thrown  out,  as  they  were  either  performed  after 
labor  had  continued  a  long  time,  or  the  conditions 
were  such  as  to  make  symphyseotomy  unsuitable,  or 
death  was  due  to  some  complication  unconnected  with 
the  operation  itself.  What  the  results  of  symphyseot- 
omy, thus  revised,  may  be  are  seen  by  the  statistics 
reported  by  Spinelli  in  the  Annates  de  Gynecologic  and 
translated  by  Dr.  E.  Gustav  Zincke  for  the  Ohio  ATciii- 
cal  /ournal  ior  A-px'i\,  1895,  where,  of  twenty- three  cases 
operated  on  by  Morrisani,  Novi,  and  others,  all  the 
mothers  recovered  and  only  one  child  died  twelve 
hours  after  the  operation.  Similarly  Grandin  and  Jar- 
man  state  that  of  the  four  deaths  occurring  in  thirty- 
one  cases  operated  upon  in  the  United  States  up  to 
March,  1894,  in  not  a  single  case  was  the  operation 
elective,  being  only  performed  after  the  patient  was 
already  greatly  exhausted  ;  while  of  the  nine  fiital 
deaths  eight  would  not  have  occurred  if  the  operation 
had  been  elective.  Even  the  best  statistics  of  Cesa- 
rean section  cannot  equal  these  results,  so  that  the  con- 
clusion seems  warranted  that  when  the  pelvic  contrac- 
tion is  not  below  the  limits  of  successful  symphyseotomy 
it  is  not  only  the  less  formidable  operation  to  the  pa- 
tient, but  it  is  really  less  hazardous.  Beyond  these 
limits  the  combination  of  induced  premature  labor  and 
symphyseotomy  is  feasible,  but  will  not  usually  give  as 
good  results  as  Csesarean  section. 

The  limits  within  which  symphyseotomy  is  feasible 
are  pretty  well  determined,  extending  from  the  limit 
of  a  safe  delivery  by  forceps  with  a  true  conjugate  of 
about  three  and  one- half  inches  down  to  a  conjugate 
of  two  and  one-half  inches.  It  is  unsafe  to  allow  the 
pubic  bones  to  separate  more  than  three  inches,  lest  the 
sacro-iliac  joints  be  injured,  which  gives  us  a  gain  of 
about  three-fifths  inch  in  the  true  conjugate  ;  but  as 
the  transverse  diameters  are  increased  much  more  than 
the  conjugate,  there  is  plenty  of  room  for  moulding  the 
head,  so  that  the  entire  gain  by  the  operation  is  etiual 
to  a  gain  of  one  inch  in  the  true  conjugate. 

As  to  embryotomy,  does  it  not  seem  that  it  is  time 


to  say  that  this  operation  is  not  justifiable  if  the  child 
is  living  ?  Granting  that  we  should  attach  more  im- 
portance to  the  safety  of  the  mother  than  of  the  child, 
when  we  have  an  operation  that  is  as  safe  for  the 
mother,  and  which  usually  saves  the  child,  how  can  we 
hesitate  as  to  our  duty  ?  Of  course,  the  patient  and 
friends  must  consent  to  the  operation,  and  they  may 
refuse  to  allow  symphyseotomy,  but  this  does  not  jus- 
tify us  in  destroying  the  child,  any  more  than  her  earlier 
preference  for  abortion  would  have  justified  us  in  re- 
sorting to  this  means  for  relief  of  the  nausea  of  preg- 
nancy, when  not  justified  by  the  necessities  of  the  case. 


A  CASE  OF  ECHINOCOCCUS  CYSTS  OF  THE 
LIVER,  PLEURA,  OMENTUM,  MESENTERY, 
PERITONEUM,  AND  BLADDER. 

By  HARLAN  M.  PAGE,  A.M.,   M.D., 

HlRANf,    O. 

I  w.\s  called,  September  3, 1894,  two  miles  into  the  coun- 
try, to  see  a  German  woman,  fifty-one  years  of  age,  the 
mother  of  two  children,  the  youngest  being  twenty- 
one.  She  had  always  worked  hard,  in  doors  and  out. 
She  had  a  moderate  appetite,  slept  well,  menstruated 
regularly,  and  was  not  constipated.  Two  days  before 
she  had  begun  to  have  pain  in  the  right  hypochondriac 
region,  and  the  dyspnoea,  from  which  she  had  suffered 
more  or  less  for  five  years,  had  increased.  Had  had 
slight  chills.  Seven  years  before  she  had  noticed  a 
small  lump  the  size  of  a  hen's  egg  in  the  right  hypo- 
chondrium,  which  had  gradually  increased  in  size.  She 
was  in  fair  flesh,  slightly  jaundiced,  with  a  very  anx- 
ious and  distressed  expression.  Temperature,  102°  F.; 
pulse,  1 20  and  feeble  ;  respirations,  30.  Tongue  slightly 
coated.  Examination  of  the  chest  elicited  increased 
vesicular  murmur  on  the  left  side.  .A.pex  beat  in  nor- 
mal position.  Dulness  on  percussion  on  the  right  side, 
with  no  increase  of  vocal  resonance.  Abdomen  gen- 
erally distended,  with  a  circumscribed  prominence  in 
the  right  hypochondrium.  Dulness  marked  from  the 
clavicle  on  the  right  side  to  a  line  drawn  between  the 
anterior  superior  spines  of  the  ilia,  extending  over  the 
median  line  in  the  abdominal  region.  Palpation  de- 
monstrated fluid  in  the  circumscribed  prominence,  and 
hard  nodular  masses  throughout  the  remainder  of  the 
area.  Examination  per  vaginam  showed  that  there  was 
no  connection  between  the  uterus  and  appendages  and 
the  mass  above,  although  Douglas's  cul-de-sac  was  full 
of  nodular  resisting  material.  I  could  not  arrive  at  any 
reasonable  diagnosis,  and  advised  the  patient's  going  to 
Cleveland  for  further  advice. 

At  the  end  of  four  weeks,  during  which  time  the  woman 
had  suffered  much  from  pain  and  dyspnoea,  I  was  again 
summoned.  I  found  all  the  previous  conditions  exag- 
gerated, and  in  addition  ascites  and  oedema  of  the 
ankles.  They  were  now  ready  to  follow  my  suggestion, 
and  accordingly  Dr.  T.  M.  Sabin,  of  Warren,  was 
called.  We  aspirated  the  circumscribed  tumor  above 
referred  to  for  purposes  of  diagnosis,  and  brought  to 
light  fetid  pus  which  we  evacuated  by  means  of  an  in- 
cision one  inch  in  length.  So  great  was  the  tension 
that  the  pus  spurted  at  least  three  feet  beyond  the  pa- 
tient's body.  We  obtained  in  all  about  five  quarts  of 
pus  and  straw-colored  fluid.  In  this  we  weie  surprised 
to  find  a  large  number  of  sacs  filled  with  a  yellowish 
fluid,  and  in  addition  a  large  opaque  one  which  had 
collapsed  as  a  result  of  the  incision.  As  this  did  not 
escape  last  we  were  convinced  that  the  container  of  all 
was  yet  within.  We  dressed  with  iodoform  gauze  and 
cotton,  and  left  our  patient  much  relieved  as  regards 
dyspnoea.  .\t  the  next  dressing  I  succeeded  in  getting 
out,  by  change  of  position,  fully  a  quart  of  bile-stained 
fluid  devoid  of  odor  ;  this  characterized  the  discharge 
to  the  end,  suggesting  the  deodorant  property  of  bile. 


412 


MEDICAL   RECORD 


[September  21,  1895 


During  the  five  days  immediately  succeeding  the  oper- 
ation the  temperature  remained  normal,  the  heart  ac- 
tion was  improved,  and  respirations  became  easy.  She 
took  considerable  nourishment  and  seemed  to  be  improv- 
ing in  every  way  until  the  sixth  day,  when  she  began 
coughing  severely,  nnd  died  on  the  seventh  day,  appar- 
ently from  exhaustion. 

I  was  compelled  to  make  the  post-mortem  examina- 
tion alone  and  on  limited  time,  hence  my  observations 
were  not  as  many  or  as  accurate  as  the  case  merited. 
I  found  the  pleural  sac  on  the  right  side  full  of  pus  and 
the  pus  full  of  sacs  such  as  escaped  from  the  incised 
tumor.  The  lung  did  not  seem  to  have  been  involved 
in  cystic  changes,  but  was  compressed  into  a  very  small 
compass  and  hepatized.  Much  of  the  liver  was  in- 
volved, some  of  the  cysts  having  undergone  purulent 
transformation  ;  others  not.  This  condition  was  also 
true  of  the  many  found  in  the  peritoneum,  omentum, 
and  mesentery.  The  intestines,  and  in  fact  all  the  ab- 
dominal viscera,  were  matted  together.  The  uterus  and 
appendages  were  demonstrably  uninvolved,  as  were 
also  the  kidneys.  In  making  my  incision  I  tapped  the 
bladder,  and  a  large  quantity  of  clear  fluid  escaped  as 
though  under  pressure  ;  following  this  came  six  or  eight 
small  opaque  sacs  about  the  size  of  marbles,  and  finally 
one  capable  of  holding  at  least  four  ounces  of  fluid. 
My  time  was  up,  and  I  reluctantly  withdrew  from  terri- 
tory which  certainly  had  many  more  interesting  things 
with  which  to  reward  more  careful  investigation.  I 
bore  away  with  me  several  of  the  omental  cysts  and 
those  from  the  bladder,  in  the  contents  of  which  I 
again  found  the  booklets  of  the  taenia  echinococcus,  or 
at  least  felt  sure  that  I  did  ;  and  my  faith  was  strength- 
ened by  Professor  A.  P.  Ohimacher,  of  Cleveland,  O., 
who  kindly  demonstrated  them.  Here  there  was  a 
clear  case  of  echinococcus  cysts  of  liver,  omentum, 
peritoneum,  mesentery,  pleura,  and  bladder.  As  to  the 
primary  seat  of  the  trouble  we  can  only  conjecture. 
As  to  the  source  of  infection,  it  was  undoubtedly  from 
dogs,  of  which  they  always  kept  several  about  the 
house,  and  with  whom  they  lived  on  very  intimate 
terms. 

The  case  would  seem  to  me  to  be  worthy  of  note  : 
I.  On  account  of  rarity,  Osier  having  been  able  to  col- 
lect only  eighty-five  cases  in  the  United  States  and 
Canada.    2.  In  the  very  wide  dissemination  of  the  cysts. 

3.  In  the  fact  that  the  patient  was  able  to  do  hard 
manual  labor  up  to  within  four  weeks  of  her  death. 

4.  The  phenomena  of  disappearance  of  odor  coinci- 
dently  with  the  appearance  of  bile  in  the  fluid  from 
the  sac  incised  ante-mortem.  5.  In  the  fact  that  the 
temperature  remained  normal  after  the  operation  until 
death. 

In  connection  with  these  last  two  the  question  has 
arisen  in  my  mind,  whether  absorption  of  bile  might 
not  counteract  the  effects  of  inflammatory  changes  so 
far  as  temperature  is  concerned. 


Risk  of  Operating  without  Consent. — An  action  in- 
volving a  claim  for  ^£"2,000  has  been  tried  in  Belgium, 
which  is  of  considerable  interest  to  surgeons.  It  ap- 
pears that  a  lady  who  suffered  from  uterine  hemorrhage 
was  recommended  by  a  consultant  who  was  called  in 
by  her  family  attendant  to  allow  the  uterus  to  be  curet- 
ted, to  which  she  and  her  husband  consented.  When 
the  operation  was  begun  it  was  discovered  that  there 
was  cancer  of  the  uterus,  and  the  operator  and  the 
family  practitioner  decided  then  and  there  to  remove 
the  whole  organ,  the  result  being  that  the  patient  died 
from  hemorrhage.  As  neither  the  patient  nor  the  hus- 
band was  consulted  about  the  hysterectomy,  it  was  held 
by  the  court  to  be  unjustifiable.  The  damages  were, 
however,  reduced  to  ;^2oo. —  The  Lancet. 

Supra-pubic  Cystotomy  was  first  performed  by  Franco, 
in  1561. 


grogtess  of  pXctlicaX  %zit\\tt. 


The  Treatment  of  Nervous  Disturbances  of  the  Heart 
Resulting  from  Influenza. — Dr.  Sansom  advises  as  a 
routine  practice  the  use  of  sulphocarbolate  of  sodium 
in  doses  of  twenty  to  thirty  grains,  every  two,  three,  or 
four  hours,  according  to  the  severity  of  the  case.  The 
diet  should  be  almost  entirely  liquid.  Alcoholic  stim- 
ulants should  be  administered  with  caution  ;  cham- 
pagne diluted  with  ApoUinaris,  or  brandy  in  dessert- 
spoonfuls every  three  or  four  hours  with  milk  and  soda- 
water.  When  the  temperature  rises  above  103°  F., 
quinine  is  the  best  antipyretic.  Phenacetin  or  anti- 
pyrin  gives  comfort,  but  their  action  must  be  watched, 
as  they  sometimes  increase  the  already  profuse  per- 
spirations. Pains  are  best  controlled  by  phenacetin  or 
antipyrin,  unless  profuse  perspiration  or  signs  of  ner- 
vous prostration  are  contraindications.  In  profound 
adynamia  the  writer  knows  of  no  more  efficient  remedy 
than  musk  in  five-grain  doses.  The  hypodermic  injec- 
tion of  brandy,  ether,  or  strychnine  may  be  called  for. 
During  convalescence,  for  several  weeks,  the  sulpho- 
carbolate of  sodium  with  Fowler's  solution  is  to  be 
given  three  times  a  day  after  meals,  and  the  naso- 
pharynx repeatedly  sprayed  with  an  antiseptic  solution 
like  the  following  :  Camphor  and  menthol,  of  each 
twenty  grains  ;  pure  carbolic  acid,  one-half  drachm  ; 
parolein,  four  ounces.  The  signs  and  symptoms  re- 
ferred to  the  heart  resulting  from  influenza  in  the  au- 
thor's cases  were  thus  distributed  :  In  100  cases  :  pain 
referred  to  the  heart,  23  cases  ;  tachycardia,  37  cases  ; 
irregular  heart,  25  cases  ;  bradycardia,  5  cases  ;  or- 
ganic disease  of  the  heart,  10  cases  For  heart-pain 
after  influenza,  complete  rest,  morphine  hypodermically 
(one-fourth  to  one-third  grain)  with  diffusible  stimu- 
lants are  the  remedial  measures  recommended.  Once 
the  severity  is  mitigated,  five  grains  of  quinine  dis- 
solved in  hydrobromic  acid  is  preferable  to  morphia. 
For  more  continuous  treatment  of  the  early  painful 
phase,  sodium  bromide  (twenty  grains)  with  Fowler's 
solution  (three  minims)  three  times  a  day  after  food  is 
recommended.  In  some  cases  sodium  iodide  (five 
grains)  is  added  with  benefit.  When  pain  is  persistent, 
local  treatment  is  useful.  Mustard  poultices  sprinkled 
with  tinctures  of  opium,  belladonna,  and  aconite,  give 
relief  in  some  cases.  In  others  a  fomentation  of  lint 
soaked  in  a  hot  solution  of  sodium  salicylate  is  very 
eflicacious ;  or  an  ointment  containing  twenty  per 
cent,  of  salicylic  acid  and  ten  per  cent,  of  menthol  in 
a  fatty  basis  of  lanolin  and  lard,  may  be  rubbed  in 
over  the  painful  area.  In  more  chronic  cases  small 
blisters  prove  efficient.  In  tachycardia,  or  palpitation 
following  influenza,  the  writer  considers  digitalis  and 
analogous  cardiac  tonics  not  only  useless  but  danger- 
ous. The  mixture  of  sodium  bromide  with  small  doses 
of  arsenic,  as  suggested  for  the  treatment  of  the  car- 
diac pain,  is  perhaps  most  generally  useful.  For  the 
insomnia,  chloralamide  (twenty  to  twenty-five  grains) 
at  bedtime  is  regarded  as  the  most  useful  and  least 
harmful  hypnotic.  Opium,  the  author  thinks,  should 
be  avoided  or  reserved  for  emergencies.  For  continu- 
ous tachycardia,  a  galvanic  current  from  a  Schall's 
four-  or  six-celled  battery  is  recommended,  the  anode 
held  over  the  nape  of  the  neck  and  the  cathode  gently 
pressed  into  the  groove  of  the  neck  outside  the  lar\'nx. 
Abnormal  retardation  of  the  pulse-rate  may  be  relieved 
by  phenacetin  and  camphor,  with  local  warmth  and 
counter-irritation  of  the  ejiigastrium  and  abdomen. 
Permanent  bradycardia  is  serious.  Tincture  of  bella- 
donna (ten  minims  thrice  daily),  massage,  and  gradu- 
ated muscular  exercise  are  useful  ;  but  it  must  be  real- 
ized that  the  condition  of  very  slow  heart  is  one  of 
peril. —  The  Practitioner. 


September  21,  1895J 


MEDICAL   RECORD. 


4^3 


Medical   Record: 

A  Weekly  y our 7ial of  Medicitie  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


WM.  WOOD  St  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  September  21,  1895. 


CHLORAL. 

Chlor-A-l  is  usually  considered  to  be  essentially  a  hyp- 
notic and  sedative  drug.  It  has,  however,  quite  a 
number  of  other  uses.  In  this  city  it  has  long  been 
employed,  in  small  doses,  as  a  vaso-dilator,  two  or 
three  grains  being  given,  combined  perhaps  with  iodide 
of  potassium.  Associated  with  this  same  drug,  Dr. 
Pal  finds  it  of  service  in  bronchial  asthma,  and  the 
same  physician  has  found  it  effective  also,  in  doses  of 
10  to  20  grains,  in  checking  bleeding  from  the  lungs. 
On  the  same  principle,  that  is,  on  the  principle  of  its 
acting  as  a  relaxer  of  arterial  tension.  Dr.  Cherchevsky 
has  used  it  in  small  doses  daily  to  counteract  coldness 
of  the  feet  and  hands,  which  are  so  disagreeable  symp- 
toms in  some  cases  of  anaemia  and  neurasthenia.  Dr. 
Pal  has  also  recommended  chloral  hydrate  as  a  laxative 
in  various  forms  of  chronic  constipation,  principally 
those  of  neuropathic  patients.  The  dose  here,  how- 
ever, is  more  than  20  grains,  and,  as  the  Practitioner 
truly  says,  the  drug  must  be  a  dangerous  one  to  use  for 
such  a  purpose. 

M.  Spehn  recommends  chloral  very  highly  as  a  local 
application  for  boils.  He  directs  that  the  boil  be  kept 
covered  with  a  tampon  of  cotton  well  soaked  in  a  solu- 
tion of  chloral  hydrate,  glycerin,  and  water.  The 
strength  of  the  solution  is  about  two  drachms  to  the 
ounce. 

A  writer  in  the  Semaine  Medicale  recommends 
chloral  for  children  who  are  irritable  and  restless  when 
suffering  from  scarlet  fever.  .Vnother  use  of  chloral  is 
in  certain  forms  of  dyspepsia  in  which  there  is  a  sense 
of  distention  with  pain  in  the  neighborhood  of  the 
cardiac  end  of  the  stomach.  This  dyspepsia  usually 
occurs  in  neurotic  persons  and  may  be  termed  a  ner- 
vous type  of  the  disorder.  According  to  the  Thera- 
peutic Gazette,  a  little  chloral  hydrate  (one  or  two 
grains)  dissolved  in  peppermint  water  is  of  service 
here. 

Chloral  is  recommended  by  Playfair,  in  his  text- 
book, for  dilating  the  rigid  cervix,  during  the  early 
stages  of  labor. 

We  are  somewhat  loath  to  give  chloral  any  more 
prestige  than  it  already  has.  Still  we  should  add  that 
it  is  a  drug  which  has  been  shown  to  be  of  some  ser- 
vice in  epilepsy,  and  which  is  one  of  the  sheet-anchors 
in  acute  alcoholism  ;  but  it  is  also  a  drug  whose  con- 
tinued use,  even  in  rather  moderate  doses,  is  sure  to 


injure  the  patient  eventually.  Chloral  needs  always  to 
be  given  cautiously  at  first,  and  never  for  prolonged 
periods  of  time. 

BONE  SETTERS    AND    NATURAL    DOCTORS. 

We  hear  veiy  little  nowadays  about  natural  doctors.  The 
discoveries  in  the  line  of  bacteriology  and  the  improve- 
ments in  methods  of  physical  examination  and  surgical 
treatment  have  rather  thrown  this  interesting  class  into 
the  background.  There  was  a  time,  perhaps,  when  some 
of  these  born  artists  could  come  into  a  sick-room  and 
by  simply  looking  at  a  patient  make  a  diagnosis  which 
was  most  satisfactory  to  the  family  by  reason  of  the 
learned  terms  with  which  an  apparent  exact  knowledge 
was  clothed.  In  these  times,  however,  patients  prefer 
to  have  their  urine  examined  by  those  skilled  in  chem- 
ical knowledge  in  order  to  say  whether  they  have 
Bright's  disease,  and  they  prefer  to  have  the  heart  or 
lung  examined  with  instruments  of  precision  rather 
than  depend  on  the  guess-work  of  the  intuitive  practi- 
tioner. That  instinctive  knowledge  which  made  what 
used  to  be  called  the  natural  physician  was  in  the  main 
simply  a  knowledge  of  human  nature  combined  with  a 
good  deal  of  self-confidence  and  practical  sense.  These 
are  still  valuable  and  essential  parts  of  the  physician's 
equipment,  but  to  them  have  to  be  added  the  technical 
knowledge  which  enables  him  to  select  proper  antisep- 
tics in  his  surgical  operations  and  to  make  a  careful  ex- 
amination of  all  the  organs  of  the  body  which  can  be 
reached  by  instruments  of  precision. 

We  have  been  led  to  make  these  observations  by  the 
perusal  of  an  interesting  article  on  the  Sweet  family  of 
Narragansett,  which  recently  appeared  in  the  Medical 
Tribune  over  the  signature  of  Dr.  Alexander  Wilder. 
Many  of  the  physicians  of  the  present  day  have  heard 
of  the  Sweet  family  and  their  wonderful  bone-setting 
gifts.  Probably  some  of  our  older  physicians  have 
even  come  in  contact  with  them,  but  they  are  to  most 
of  us  little  more  than  a  tradition. 

The  original  member  of  the  family,  we  are  told,  was 
Captain  Banoni  Sweet,  who  had  been  a  captain  in  the 
British  service,  and  who  after  the  Revolutionar)-  War 
settled  in  Narragansett.  His  descendants  continued 
to  live  in  that  neighborhood  and  followed  various 
humble  occupations,  some  of  them  being  farmers, 
blacksmiths,  fishermen,  mechanics,  and  so  on.  Job 
Sweet,  one  of  the  descendants  made  his  great  hit  by 
relieving  Theodosia  Burr,  daughter  of  Aaron  Burr,  of 
a  so-called  dislocation  of  the  hip  which  had  baffled  the 
skill  of  the  New  York  and  Rhode  Island  surgeons  for 
a  long  time.  The  story  of  Dr.  Job's  trip  to  Boston, 
and  the  dramatic  way  in  which  he  disconcerted  the 
regular  faculty  by  his  marvellous  manipulations  of 
Theodosia's  hip  makes  very  interesting  reading,  but 
we  can  hardly  regard  it  as  historical  truth.  We  have 
some  suspicion  that  perhaps  Theodosia  had  what  in 
these  later  days  would  have  been  called  a  hysterical 
joint.  However,  Dr.  Job  got  his  reputation  and  his 
fee  and  went  home  to  return  to  his  ordinary  avoca- 
tions. 

Job  had  a  son,  by  the  name  of  Jonathan,  who  was 
equally  skilful,  apparently,  with  his  father,  and  there 
WIS  a  Dr.  Sweet,  of  Fall  River,  who  had  a  very  success- 


414 


MEDICAL   RECORD. 


[September  21,  1895 


fill  experience  with  the  Philadelphia  surgeons.  In  fact, 
the  history  of  the  bone-setting  Sweets,  as  told  by  Dr. 
Wilder,  does  not  reflect  the  greatest  credit  upon  the 
skill  of  the  eminent  surgeons  of  Boston,  Philadelphia, 
and  New  York. 

The  Sweets,  we  are  told,  abounded  in  liniments, 
tinctures,  embrocations,  and  salves,  prepared  by  them- 
selves from  the  plants,  roots,  and  bark  of  trees  growing 
in  New  England.  Their  usual  plan  of  operations  seems 
to  have  been  to  place  some  emollient  application  upon 
the  affected  joint  for  a  time,  and  then  by  a  deft  manip- 
ulation to  set  the  bone  back  in  its  place.  There  is 
no  doubt  that  they  did  possess  a  good  deal  of  skill 
in  this  kind  of  work.  After  all,  the  setting  of  a 
joint  is  not  a  very  complex  mechanical  problem,  and  a 
great  many  more  people  could  set  joints  than  do  so 


is  (juite  rigid  enough  so  far  as  the  points  criticised  by 
Mr.  Bach  are  concerned. 

The  trouble  with  him  and  with  lay  students  of  this 
subject  generally,  is  that  only  one  danger  is  seriously 
considered,  namely,  that  of  committing  a  sane  man  to 
an  insane  asylum.  The  much  greater  danger  of  allow- 
ing insane  people  with  homicidal,  suicidal,  and  crim- 
inal tendencies  to  go  about  at  large  is  quite  forgotten  ; 
and  the  result  is  that  we  have,  every  year,  a  certain 
considerable  proportion  of  homicides  committed  by 
lunatics  who  would,  no  doubt,  have  been  safely  placed 
away  in  lunatic  asylums,  if  it  were  not  for  this  fear  on 
the  part  of  the  public  that  a  sane  man  may  be  consid- 
ered insane. 

We  must  confess  that,  judging  from  the  expression 
of  the  opinion  by  alienists,  the  need  of  an  amendment 


now  if  they  possessed  the  confidence  of  the  patient  to  the  present  law,  in  order  to  protect  the  public,  does 

and  the  confidence  in  themselves  which   the    Sweets  not  really  exist.     There  are  certain  defects  in  the  law, 

had.    This  family  seems  to  have  inherited  a  belief  that  but  they  relate  rather  to  the  forms  and  details  of  the 

they  possessed  some  inborn  gift  by  which  they  could  commitment.     Any  plan  to  have  the  judge  himself  see 

see  into  the  joints,  and  by  which  they  were  enabled  to  the  lunatic  before  he  signs  the  paper  is  an  impossible 


picture  in  their  mind's  eye  in  each  case  the  exact  po- 
sition of  the  displaced  parts.  They  apparently  had  a 
certain  hallucination  at  the  time  of  the  operation,  and 
saw  in  their  minds,  at  least,  an  open,  dissected  joint 
before  their  eyes. 

The  occupation  of  the  bone-setter  is  pretty  nearly 
gone  by  reason  of  the  greater  intelligence  of  the 
people  and  the  greater  skill  of  the  regular  faculty. 
There  are  still  a  few  people  in  the  world  who  prefer  to 
be  treated  by  an  old  woman  or  a  bone-setter  when  they 
have  some  serious  ailment,  but  the  number  is  extremely 
small  and  will  probably  grow  smaller,  though  we  would 
not  venture  to  predict  that  either  folly  or  bone-setting 
will  ever  entirely  die  out. 


one,  for  many  lunatics  are  quite  unfit  to  be  brought 
into  the  presence  of  the  court  ;  and  so  far  as  the  ap- 
pointment of  a  commission  or  a  jury  is  concerned,  in 
order  to  determine  the  sanity  of  the  patient,  this  is  al- 
ready provided  for  by  the  present  law. 


THE    COMMITMENT    OF   THE    INSANE. 

Mr.  Albert  Bach,  a  lawyer  of  ability  and  standing, 
read  an  article  at  the  recent  Medico-Legal  Congress 
upon  the  subject  of  the  commitment  of  the  insane, 
which  has  attracted  the  notice  of  some  of  our  daily 
contemporaries.  Mr.  Bach,  who  is  Vice-President  of 
the  Medico-Legal  Society,  and  who  has,  no  doubt, 
made  much  study  of  the  question,  thinks  that  the  pres- 
ent method  of  committing  the  insane  is  not  perfect, 
and  that  the  imperfections  lie  in  its  not  being  safe 
enough  ;  or,  in  other  words,  not  provided  with  suffi- 
cient care  against  the  commitment  to  insane  asylums 
of  sane  persons. 

At  regular  intervals  for  many  years  individuals  have 
become  alarmed  over  the  possible  commitment  of  the 
sane  into  lunatic  asylums.  The  result  of  this  agitation 
has  been  to  secure  close  and  careful  restrictions  upon 
the  methods  of  commitment.  The  present  New  York 
law  is  one  which,  so  far  as  the  safeguards  which  Mr. 
Bach  is  alarmed  about  are  concerned,  does  not  much 
differ  from  that  which  has  existed  for  a  number  of 
years,  and  which  has  given  satisfaction  in  this  and 
many  other  States  where  similar  provisions  have  been 
applied.  The  practising  physician  and  alienist,  who 
are  familiar  with  the  workings  of  this  law,  find  that  it 


THE    DEAN    OF 


NORWICH 
BILLS. 


ON    DOCTORS' 


The  ancient  city  of  Norwich,  in  England,  is  a  pleasant 
place,  in  which  many  good  people  have  lived — eminent 
divines,  masterful  surgeons,  noted  linguists,  and  hand- 
some women — and  though  many  have  come  from  there 
to  the  gain  of  other  places,  there  are  still  not  a  few  re- 
maining.    Among  the  best  of  them  is  the  present  Dean 
of  Norwich,  who  combines  with  other  good  qualities  a 
just  appreciation  of  the  value  of  medical  services.     In 
his  sermon  at  the  Cathedral  on  Hospital  Sunday,  he 
delivered  a  eulogy  upon  the  physician  and  his  work  of 
charity  among  his  fellows.     This  is  perhaps  not  par- 
ticularly worthy  of  notice,  for  we  are  frequently  told 
on  public  occasions  how  good  we  are,  and  usually  must 
rest  satisfied  with  this  patronizing  approval  ;  but  the 
Dean  is  a  practical  man  and  one  who  believes  that  the 
laborer  is  worthy  of  his  hire,  and  he  told  his  people  in 
plain  words  that  they  must  pay  their  doctors  for  work 
done.     His  remarks  concerning  doctors'  bills,  says  the 
British  Medical  Journal,  should  be  widely  read,  for 
they  deserve  the  attention  of  many  whose  position  in 
the  world  is  undisputed,  who  stand    well  with  their 
neighbors,  and  are  looked  on  as  honest  men,  but  never- 
theless relegate  the  payment  of  their  doctors'  bills  to 
the  dim  and  distant  future.     The  Dean  is  reported  as 
having  said  :  "  Nor  can  I,  nor  shall  I,  be  silent  about 
the  wrongs  to  which  scores  of  medical  men  are  subject. 
I  refer  to  the  startling  contrast  there  is  between  the  in- 
exorable  demands  which   society    makes   on   medical 
men  and  the  elasticity  of  the  social  conscience  w-ith  re- 
spect to  their  remuneration.     I  have  known  cases  where 
men  are  summoned,  at  all  hours,  and  at  all  seasons  of 
the  year.     Their  Ijills  are  presented  with  timidity,  if 
not   anxiety,   and  they   are   received   sometimes  with 


September   21,  1895] 


MEDICAL   RECORD. 


415 


amazement,  sometimes  with  indignation,  and  some- 
times relegated  to  oblivion.  Nor  are  cases  unknown 
where  the  righteous  demand  for  work  done  is  met  by 
calling  in  another  practitioner,  he  in  turn  to  suffer  as 
his  brother  did  before  him.  I  cannot  permit  myself  to 
imagine  that  I  address  any  such  wrongdoer  here  to- 
day. But  if  I  do,  then,  in  my  Master's  name,  I  entreat 
you  to  remember  that  the  medical  men  of  this  nation 
are  the  highest  type  of  their  class  in  the  world  ;  they 
are  entrusted  with  the  secrets  of  domestic  life  ;  they 
have  all  our  liabilities,  with  the  special  liabilities  of 
their  order  ;  they  frequently  die  as  martyrs  to  science, 
to  suffering,  to  sympathy,  to  destitution.  .  .  .  Be- 
lieving this,  my  plea  is  that  every  unpaid  medical  bill 
be  discharged  generously,  gratefully,  cheerfully,  and 
that  whatever  account  must  be  deferred  in  payment, 
the  last  to  be  deferred  is  the  account  of  him  who  is  the 
human  agent  who  has  brought  us  into  the  world,  en- 
ables us  to  continue  our  work  in  life,  and  many  a  time 
lays  down  his  own  in  endeavoring  to  baffle  death." 


^cvos  of  tlxc  "e^celi. 

The  Health  of  the  Pope.— The  Rome  correspondent  of 
T/ie  Lancet  writes  that  the  out-of-door  life  the  Pope 
leads  in  the  beautiful  demense  between  the  Vatican 
Palace  and  the  Janiculan  has  told  favorably  on  his 
health,  which,  all  things  considered,  was  never  better 
than  to-day.  For  one  thing,  he  has  no  threatening  of 
those  fainting  fits  which,  in  the  spring  months  especi- 
ally and  during  the  exigencies  of  urgent  business,  were 
apt  to  overtake  him.  With  due  allowance  for  the  se- 
nile anemia  of  which  he  has  more  than  the  average 
octogenarian's  share,  this  result  is  of  very  good  omen. 
Dr.  Lapponi,  physician  to  His  Holiness,  in  reply  to  an 
interrogatory  addressed  to  him,  said  that  if  nothing  un- 
foreseen happens,  the  Holy  Father's  constitution  is  so 
sound  that  he  might  well  attain  his  hundredth  year. 

Dr.  Giacomo  Asiari,  of  Pesaro,  Italy,  attained  his 
hundredth  year  on  July  29th,  having  been  born  at  Forli 
on  that  day  in  1795.  He  received  his  medical  diploma 
from  the  University  of  Florence  in  1821.  In  June, 
1861,  he  retired  from  practice,  the  town  council  of 
Pesaro  voting  him  an  annual  pension  in  recognition  of 
his  professional  and  civic  virtues. 

Anthrax  is  reported  as  prevailing  in  epidemic  form 
among  the  dairy  cattle  near  St.  Louis. 

Cycles  for  Invalids  and  Doctors.— The  possible  uses  of 
the  cycle,  says  the  British  Medical  Journal,  have  not 
yet  been  dreamt  of.  The  cumbersome  Bath  chair  for 
invalids  is  giving  place  to  a  light  wicker  chair  mounted 
as  a  tricycle  driven  from  behind.  In  this  easy  little 
carriage  an  invalid  can  be  trundled  about  the  country 
lanes  at  the  rate  of  five  or  six  miles  an  hour,  enjoying 
the  breezes  and  the  sunshine  and  the  invigorating 
pleasure  of  change  of  scene  at  very  small  expense. 
Many  country  doctors  have  long  been  accustomed  to 
pay  their  visits  on  a  tricycle  ;  but  we  hear  now  of  a 
cycle  cab  used  by  a  metropolitan  doctor,  which  is 
driven  by  two  youths,  one  behind  and  the  other   in 


front.     By  this  method  fatigue  is  avoided  and  the  ex- 
penses of  the  stable  abolished. 

The  Heidelberg  Ophthalmological  Congress  has 
awarded  the  Graefe  Medal  to  Dr.  Theodor  Leber, 
Professor  of  Ophthalmology  in  the  University  of  Hei- 
delberg. 

The  German  Emperor  has  promised  a  subscription 
of  10,000  marks  (§2,500)  toward  the  cost  of  erection  of 
a  statue  to  Helmholtz  in  Berlin. 

Railroad  Liability  for  Medical  Services. — The  liabil- 
ity of  railroads  for  medical  services  to  victims  of  in- 
juries when  attended  by  physicians  not  in  railroad  em- 
ploy is  the  subject  of  very  contradictory  decisions  by 
the  courts.  The  recent  decision  of  the  Kansas  Supreme 
Court  in  the  case  of  Steelsmith  vs.  the  Union  Pacific 
Railroad  is  in  the  line  of  ordinary  rules  governing  con- 
tracts. Dr.  Steelsmith,  of  Abilene,  Kan.,  was  called  by 
the  station-master  to  attend  a  brakeman  fatally  injured 
in  the  discharge  of  his  duty,  the  local  surgeon  being 
away.  Payment  for  the  services  rendered  was  refused. 
Dr.  Steelsmith  then  brought  suit  in  the  Justice  Court, 
which  decided  in  his  favor.  The  company  appealed  to 
the  District  Court,  which  reversed  the  decision  of  the 
Justice  Court.  Dr.  Steelsmith  appealed  to  the  Kansas 
Supreme  Court,  which  reversed  the  decision  of  the  Dis- 
trict Court,  awarded  him  the  full  amount  and  assessed 
the  costs  on  the  railroad  company.  The  legal  principle 
governing  the  decision  is  equitable  and  has  long  been 
law,  yet  it  was  contemptuously  disregarded  by  the  Dis- 
trict Court. — Medical  Standard. 

Surgeons  are  said  to  be  much  in  favor  of  the  bicycle 
because  it  "  helps  their  specialty."  We  hear  of  one 
doctor  at  a  summer-resort  who  had  twenty  cases  of 
bicycle  accidents  in  four  weeks.  The  Scientific  Amer- 
ican gives  an  explanation  of  the  physics  of  bicycle  ac- 
cidents which  is  very  impressive.  The  ability,  it  says, 
of  a  bicycle  and  rider  in  rapid  motion  to  do  serious 
damage  in  a  collision  with  another  machine  or  with  a 
pedestrian  is  fully  appreciated  by  few  wheelmen.  A 
man  weighing  one  hundred  and  fifty  pounds  and  mov- 
ing at  the  rate  of  ten  feet  per  second  (which  is  only 
about  seven  miles  per  hour)  has  a  momentum  of  1,500 
pounds,  leaving  out  of  the  account  the  weight 
of  the  wheel.  This  is  sufificient  to  upset  any  pedestrian 
with  terrific  force.  A  collision  between  two  wheels, 
each  with  a  150-pound  rider,  spinning  at  the  moderate 
speed  of  seven  miles  per  hour,  would  result  in  a  smash- 
up,  with  a  force  of  3,000  pounds.  In  view  of  these 
facts,  it  is  no  wonder  that  bicycle  accidents  are  often 
very  serious.  The  tractive  force  required  to  propel  a 
bicycle  over  a  smooth  level  surface  is  estimated  at  o.oi 
of  the  load  ;  calling  the  load  150  pounds,  a  foice  of 
a  pound  and  a  half  would  be  required  to  move  the 
wheel  forward,  and  this  calls  for  a  pressure  on  the  ped- 
als of  six  pounds  and  three-quarters  on  a  wheel  geared 
in  the  usual  manner.  When,  however,  the  road  is 
rough,  or  on  an  up  grade,  the  case  is  different.  On  a 
grade  of  i  in  10,  for  example,  the  rider,  in  addition  to 
the  tractive  force,  actually  lifts  one-tenth  of  his  weight 
and  that  of  the  machine. 

The  Cholera. — -The  disease  is  supposed  to  have  been 
brought  to  the  Sandwich   Islands  from  China  in  the 


4i6 


MEDICAL    RECORD. 


[September  21,  1895 


steamship  Belgic,  which  arrived  on  August  9th,  with 
over  five  hundred  Chinese  immigrants,  some  already 
suffering  from  diarrhoea.  Up  to  August  24th  there 
had  been  six  cases.  After  that  there  were  none,  until 
the  30th,  when  nine  cases  were  reported,  one  a  seaman 
on  the  United  States  steamer  Bennington.  Up  to 
September  8th  there  were  fifty- eight  cases  with  forty- 
four  deaths,  all  the  cases  being  among  the  natives  and 
Chinese,  except  those  on  the  Bennington.  Seventeen 
of  these  cases,  with  nine  deaths,  had  occurred  since 
September  5th,  so  that  the  disease  appears  to  be  in- 
creasing. The  steamship  Rio  Janeiro,  which  arrived 
at  San  Francisco  on  September  i6th  from  China,  Japan, 
and  Hawaii,  brings  consular  certificates  showing  that 
the  disease  prevails  in  Yokohama,  Nagasaki,  and 
Honolulu  among  the  ports  at  which  she  touched.  At 
Tangier,  in  Morocco,  cholera  has  been  declared 
epidemic,  twelve  new  cases  having  been  reported  on 
September  i6th.  A  bacterioscopic  examination  by 
Spanish  medical  officers  shows  the  affection  to  be  gen- 
uine Asiatic  cholera. 

The  British  Association  for  the  Advancement  of  Sci- 
ence.— The  sixty-fifth  annual  meeting  of  this  associa- 
tion was  held  at  Ipswich,  on  September  nth,  12th,  and 
13th.  Sir  Douglas  Galton,  the  president,  while  deliv- 
ering the  annual  address,  which  was  of  unusual  length 
even  for  such  an  occasion,  fainted..  He  soon  recov- 
ered, but  was  unable  to  continue  the  address,  which 
was  finished  by  one  of  the  members.  Dr.  Percy 
Frankland  delivered  a  eulogy  on  "  Pasteur,  the  Chem- 
ist, Physicist,  and  Biologist."  The  next  meeting  of  the 
Association  will  be  held  in  Liverpool,  in  1896,  under 
the  presidency  of  Sir  Joseph  Lister.  It  was  voted  to 
hold  the  meeting  following  that,  namely  in  1897,  in 
Toronto. 

Professional  Dignity  in  Belgium. — A  dry  goods  es- 
tablishment in  Liege,  among  other  inducements  to  at- 
tract custom,  advertises  to  give  credit  for  all  purchases, 
to  insure  the  goods  bought  against  destruction  by  fire, 
and  to  supply  free  medical  service  to  the  purchaser  and 
his  family  for  a  length  of  time  proportional  to  the 
amount  of  the  purchase.  After  completing  his  pur- 
chase the  customer  receives  one  or  more  coupons,  ac- 
cording to  the  amount  of  his  expenditure,  each  one  en- 
titling him  to  a  visit  from  the  physician  whose  name 
and  address  are  there  printed.  With  cool  effrontery  l.c 
Scalpel  calls  this  a  pioc^iM  Amciicain,  as  if  Belgium 
were  not  a  by-word  for  quackery  among  the  nations  of 
the  earth. 

Dr.  Ellwood  Overstreet,  of  Petrona,  Ind.,  was  shot  a 
few  days  ago  by  a  patient  to  whom  he  was  about  to 
give  a  hypodermic  injection  of  morphine.  The  man, 
who  appears  to  have  been  maniacally  excited,  refused  to 
take  the  remedy  by  the  mouth  and  warned  the  physi- 
cian not  to  attempt  to  give  it  to  him  any  other  way. 

The  Metric  System.— in  the  forthcoming  edition  of 
the  British  Pharmacopoeia  the  metric  system  will  be  in- 
troduced side  by  side  with  the  old  weights  and  meas- 
ures. 

The  Index  Medicus.— Seventeen  additional  subscrip- 
tions were  received  by  Dr.  Billings  for  the  Index  M(<U- 
cits,  from  August  24th  to  September  7th. 


The  Chair  of  Pathology  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia  is  said  to  be  vacant. 

The  Police  and  the  Bicyclers. — Paris  journals  state 
that  the  Chief  of  Police  is  going  to  arrest  all  women 
promenading  the  streets,  who  are  wearing  the  divided 
skirt.  If  mounted  upon  a  bicycle  the  lady  is  safe,  but 
the  moment  she  gets  upon  the  pavement  she  is  liable  to 
arrest.  This  sensitiveness  of  the  French  mind  to  the 
attire  of  the  bicycle  lady  is  almost  pathological. 

The  Practice  of  Medicine  by  Dmggists. — The  French 
Court  has  confirmed  the  sentence  of  a  druggist  who 
was  fined  125  francs  for  practising  medicine  without  a 
license.  The  druggist  simply  prescribed  the  applica- 
tion of  compresses  of  a  two  per  cent,  solution  of  car- 
bolic acid.  Surely  our  druggists  live  under  a  much 
more  liberal  regime  than  those  of  Paris. 

The  Medical  Poet  of  Finland, — Dr.  Elias  Loennrot, 
a  country  pliysician  of  Finland,  has  been  called  the 
"  Christopher  Columbus  of  Finnish  poetry."  Dr. 
Loennrot  has  written  one  or  two  epic  poems,  celebrat- 
ing the  early  history  of  the  country. 

At  a  Recent  Annual  Meeting  of  the  Alumni  of  the 

Chicago  Medical  College,  the  graduates  presented  to 
the  college  three  life-sized  bronze  busts  :  oce  of  Dr. 
Hosmer  Allen  Johnson,  one  of  Dr.  William  Henry  By- 
ford,  and  the  third  of  Dr.  Joseph  S.  Jewell. 

Large  Bequests  to  Massachusetts  Institutions. — Un- 
der the  will  of  the  late  Thomas  O.  H.  P.  Burnham, 
who  was  for  many  years  a  dealer  in  second-hand  books, 
nearly  two-thirds  of  an  estate  of  §602,562  will  go  to 
charitable  and  educational  organizations.  The  Massa- 
chusetts General  Hospital  was  made  the  residuary 
legatee,  and  has  been  paid  $263,048.  Thte  Home  for 
Aged  Men,  and  Tuft's  College  will  receive  $10,000 
each  ;  Children's  Home,  Children's  Hospital,  Boston 
Asylum  and  Farm  School,  Washington  Home,  Massa- 
chusetts School  for  Feeble-minded  Children,  Perkins' 
Institute  for  the  Blind  and  Boston  Lying-in  Hospital, 
$5,000,  each  ;  Boston  Dispensary,  Asylum  for  Aged 
Females,  New  England  Hospital  for  AVomen  and  Chil- 
dren, and  Consumptives'  Home,  §2,000. 

The  Miscellaneous  Uses  of  Thyroid  Feeding. — Dr. 
Mosse,  of  Paris,  says  that  in  one  jiatient  who  had  en- 
tered his  hospital  for  simple  jaundice  and  who  also  had 
a  psoriasis  of  long  standing,  he  used  the  thyroid  gland 
after  the  usual  remedies  had  failed,  and  produced  a 
rapid  and  permanent  cure.  In  a  case  of  goitre  of  a 
young  girl,  the  thyroid  did  no  good.  Dr.  Thiberge, 
another  Paris  physician,  got  no  results  in  psoriasis  in 
three  cases,  and  got  very  little  permanent  help  in  eight 
others. 

Medical  Men  in  Parliament. — In  the  English  House 
of  Parliament  there  are.  altogether,  ten  medical  men. 
Of  these  seven  are  Irishmen,  representing  nothing, 
says  Tlie  Practitioner,  but  the  discontents  of  that  po- 
litical Mrs.  Cummidge  ;  two  are  Scotch  ;  and  one  only 
is  English.  In  fact,  practically  speaking,  says  our  con- 
temporary, the  medical  profession  has  only  two  repre- 
sentatives, Sir  Walter  Foster  and  Robert  Farquson. 
When,  we  would  ask,  is  an  Irish  doctor  not  a  doctor  ? 
The  answer  is  given  above. 


September  21,  1895] 


MEDICAL   RECORD, 


417 


INFECTIOUS    ENDOCARDITIS   OF    THE    TRI- 
CUSPID VALVE. 

Bv  HERBERT  UPHAM  WILLIAMS,  M.D., 

BUFFALO,  N.  Y. 

Edward  O'B entered  the  Erie  County  Hospital 

December  5,  1894.  Service  of  Dr.  Pryor.  Aged  fifty- 
six,  married,  Irish,  laborer,  family  history  good,  hard 
drinker,  and  hard  worker.  On  entering  he  had  cough, 
rusty  sputum,  cyanosis,  dyspncea.  Respiration,  50  ; 
pulse,  no  ;  temperature,  103°  F.  Examination  showed 
expansion  of  chest  diminished,  tactile  fremitus  in- 
creased universally,  sibilant  rales  heard  over  both  lungs, 
but  most  marked  over  upper  lobe  of  right,  increased  dul- 
ness  over  whole  chest,  but  most  marked  posteriorly. 
Diagnosis  of  lobar  pneumonia  of  right  lung  and  oedema 
of  the  lungs. 

December  15th. — Bronchial  breathing  heard  poste- 
riorly on  both  sides,  subcrepitant  rales  heard  over  up- 
per lobe  and  anterior  aspect  of  right  lung,  with  in- 
creased dulness  over  the  same  region.  About  this 
date  the  patient  began  to  vomit,  and  to  have  several 
chills  daily,  accompanied  by  high  rise  of  temperature, 
and  followed  by  sweating. 

December  26th. — The  chills  have  continued  one  or 
more  times  daily  ;  the  patient  is  said  to  have  as  many 
as  two  in  one  hour  ;  the  chills  have  been  accompanied 
by  rise  of  temperature  from  103°  to  105°  F.,  followed  by 
copious  sweating  and  fall  of  temperature.  The  patient 
has  continued  to  vomit  thin  greenish  material  ;  500 
c.c.  to  650  c.c.  of  urine  passed  in  twenty- four  hours, 
containing  21.5  gm.  of  urea,  abundant  albumin,  and 
epithelial  cells,  but  no  casts. 

December  28th. — Showed  no  abatement  of  the  fre- 
quency of  the  chills,  temperature  usually  reaching 
105°  F.  after  a  chill.  Throughout,  the  examination 
of  the  heart  was  unsatisfactory  on  account  of  the 
noisy  breathing  ;  therefore,  although  malignant  endo- 
carditis had  been  suspected,  no  confirmation  could  be 
obtained  from  physical  examination.  The  possibility 
of  a  central  abscess  of  the  lung  existing  was  also  con- 
sidered, and  for  diagnostic  purposes  exploration  was 
made  with  the  needle  on  both  sides,  opposite  the  angle 
of  the  scapula,  but  with  negative  results. 

The  patient  was  intelligent,  and  conscious  through 
the  entire  course  of  his  disease.  The  chills  continued 
without  interruption  until  the  day  of  his  death,  Janu- 
ary 7,  1895.  On  the  day  before  his  death  the  temper- 
ature reached  106°  F. 

Autopsy,  January  8th,  about  twenty-four  hours  after 
death.  Usual  post-mortem  discoloration  of  dependent 
parts  ;  rigor  mortis  firm  ;  subcutaneous  fat  abundant. 
Both  lungs  adherent  in  spots  over  all  surfaces,  but  not 
firmly  ;  left  lung  congested  posteriorly,  on  section  ex- 
uding bloody  froth  ;  upper  lobe  solid,  red,  outhnes  of 
lobules  well  marked,  exuding  bloody  and  purulent 
fluid  ;  right  lung  firm  throughout,  the  upper  lobe  being 
grayish  in  color,  mottled  with  black,  quantities  of  pus 
issuing  from  bronchial  tubes  ;  lower  and  middle  lobes 
less  completely  solidified,  and  containing  some  air,  very 
dark  red  color,  bronchial  tubes  exuding  pus,  firm 
thrombi  of  pink  color  found  in  several  of  the  smaller 
branches  of  the  pulmonary  vein  in  the  lower  lobe. 
Pericardial  cavity  contained  about  thirty  cubic  centi 
metres  of  serum  ;  position  of  heart  normal,  heart  large, 
flabby,  ventricles  empty.  Spleen  large,  soft  ;  pulp  gray- 
ish-red in  color.  Kidneys,  capsules  stripped  off  easily  ; 
on  section  general  appearance  pale,  cortex  grayish- 
white,  with  distinct  reddish  striations  ;  medulla  red- 
dish-pink ;  urinary  bladder  normal.  Liver  large,  very 
flabby,  light  reddish-brown,  centre  of  lobule  red,  outer 
part  gray,  cut  surface  greasy.     Mucous  membranes  of 


stomach,  small  intestine,  cajcum,  vermiform  appendix, 
and  large  intestine  all  normal.     Brain  not  examined. 

Diagnosis  :  Lobar-pneumonia  of  upper  lobe  left  lung 
and  entire  right  lung,  acute  splenitis,  parenchymatous 
degeneration  of  liver  and  kidneys. 

Most  interesting  was  the  heart.  Mitral  orifice  ad- 
mitted two  fingers,  mitral  valve  presenting  no  unusual 
appearances  except  a  small  reddish-brown  discolora- 
tion, not  elevated,  on  the  posterior  segment  ;  aortic 
valve  normal  ;  a  few  small  atheromatous  patches  in 
aorta  ;  muscle  of  ventricle  pale,  flabby,  greatest  thick- 
ness of  left,  13  mm.,  of  right,  5  mm.  ;  the  pulmonary 
artery  contained  a  yellowish  fibrinous  clot ;  pulmonary 
valve  normal.  Of  the  tricuspid  valve  the  left  segment 
was  much  thickened,  and  its  upper  surface  rough,  and 
covered  with  a  deposit  of  fibrin  from  the  free  margin 
to  within  10  or  15  mm.  of  the  attached  edge  ;  the  por- 
tion attached  appeared  normal  ;  the  anterior  segment 
exhibited  two  round  areas,  close  to  the  free  margin, 
each  about  five  millimetres  in  diameter,  each  the  seat 
of  thickening  and  accumulation  of  fibrin  ;  removal  of  the 
fibrin  on  these  spots  showed  the  tissues  of  the  valve  to 
be  eroded  ;  the  posterior  segment  appeared  normal. 

Both  coronary  arteries  and  their  branches  were  ex- 
amined without  finding  any  thrombosis,  embolism,  or 
other  abnormality. 

The  heart  was  placed  in  alcohol  about  an  hour  after 
its  removal  ;  after  hardening,  and  embedding  in  cel- 
loidin,  numerous  thin  sections  were  made.  The  left- 
hand  and  most  diseased  segment  of  the  tricuspid  valve 
examined  histologically  was  found  healthy  at  its  basal 
part,  becoming,  as  the  thickened  free  edge  was  ap- 
proached, the  seat  of  infiltration  with  small,  poly- 
nuclear,  round  cells  on  the  auricular  surface  in 
the  subendocardial  layer,  and  extending,  farther 
on,  through  all  the  tissues  of  the  valve.  The  auric- 
ular aspect  of  the  valve  was  then  found  converted 
into  a  thick  homogeneous,  hyaline  layer,  containing 
very  few  nuclei,  but  surrounded  by  the  small- cell  in- 
filtration above  mentioned,  whose  nuclei  appeared 
densely  packed  in  this  situation,  fading  away  gradually 
into  the  relatively  healthy  parts  of  the  valve,  often  ar- 
ranged in  strings.  The  nuclei  of  these  cells  frequently 
showed  fragmentation.  There  was  also  multiplication 
of  nuclei  close  to  the  ventricular  surface.  Masses  of 
fibrin  were  observed  attached  to  the  hyaline  necrotic 
tissue.  Near  the  margin  of  the  valve  the  increase  in 
thickness  became  very  great,  and  the  entire  substance 
of  the  valve  was  converted  into  homogeneous  hyaline 
material,  rarely  exhibiting  nuclei.  With  the  Weigert 
fibrin  stain  strings  and  irregular  masses  of  fibrin  were 
demonstrated  through  the  hyaline  valve  tissue  and  at- 
tached to  its  surface  ;  fields  could  be  seen  pervaded  by 
a  delicate  fibrin  net-work.  Bacteria  were  found  in  the 
hyaline  valve  tissue,  and  just  below  its  surface,  loosely 
or  in  clumps  in  what  appeared  to  be  lymph  spaces, 
within  the  masses  of  fibrin,  and  in  the  area  of  cell-in- 
filtration. They  were  most  abundant  in  the  first-named 
locality.  They  stained  with  watery  solutions  of  the 
aniline  dyes,  by  Gram's  method,  and  by  the  Weigert 
fibrin  stain,  best  by  the  last.  Morphologically  they 
varied  from  round,  through  oval  forms,  to  bacilli  with 
rounded  ends,  often  club-shaped  and  staining  unequally. 
The  oval  type  prevailed.  Much  irregularity  in  size 
was  noted.  The  smaller  cocci  measured  4^  to  6/x. ;  the 
larger  bacilli  attained  a  length  of  3/x.  Many  times  the 
cocci  and  oval  forms  were  observed  in  pairs.  No  cap- 
sule could  be  demonstrated. 

Similar  bacteria  were  found  in  sections  made  from 
one  of  the  small  round  ulcers  mentioned  as  occurring 
on  the  right-hand  segment  of  the  valve,  which  no  doubt 
was  infected  from  the  left-hand  segment.  Search 
through  sections  of  the  base  and  attachment  of  the 
valve  and  the  adjacent  muscle,  and  of  the  muscle  of 
both  ventricles,  and  of  the  coronary  artery  failed  to 
demonstrate  any  bacteria. 

The  muscle  cells  showed  their  transverse  striations 


4i8 


MEDICAL  RECORD. 


[September  21,  1895 


distinctly  ;  their  nuclei  stained  well  for  the  most  part, 
but  at  times  faintly  ;  the  pigment  granules  about  the 
nuclei  were  well  developed.  No  fat  could  be  seen  in 
the  muscle  cells,  which  in  any  case  would  not  have 
been  expected,  as  the  tissues  were  hardened  in  alcohol 
and  embedded  in  celloidin. 

The  clinical  history  indicated  that  the  pneumonia 
preceded  the  endocarditis.  During  more  than  four 
weeks  no  progress  was  made  toward  resolution  in  the 
solidified  lobes.  The  endocarditis  dated  very  likely 
from  the  chills,  which  commenced  ten  days  after  the 
patient  came  under  observation. 

The  case  was  studied  with  the  idea  that  infection 
might  have  proceeded  from  septic  emboli  carried  from 
the  lung  into  the  heart  by  way  of  the  coronary  artery. 
But  the  location  of  the  inflammatory  process  along  the 
margin  of  the  tricuspid  valve,  the  absence  of  embolism 
in  the  branches  of  the  coronary  artery,  the  failure  to 
find  bacteria  at  the  base  of  the  valve  or  in  capillaries  in 
other  parts  of  the  heart,  all  make  this  explanation  ap- 
pear improbable. 

It  is  extremely  to  be  regretted  that  the  circumstances 
of  the  autopsy  did  not  permit  of  the  use  of  culture 
methods  to  determine  the  nature  of  the  bacteria,  which 
were  beyond  a  doubt  the  cause  of  this  endocarditis. 
The  morphological  differences  noted  in  them  are  com- 
patible with  their  having  been  all  of  one  species  ;  but 
it  is  not  impossible  that  the  case  was  one  of  mixed  in- 
fection. The  source  of  infection  was  in  all  probability 
in  the  lungs. 

A  CASE  OF  SUCCESSFUL  TREATMENT  OF 
ENURESIS  NOCTURNA  BY  THE  TEST 
OPERATION. 

By  GUSTAVUS  BLECH,  M.D., 

DETROIT,    MICH. 

The  patient,  a  girl,  fourteen  years  of  age,  servant, 
suffered  quite  a  long  time  from  enuresis  nocturna. 
She  was  treated  by  different  physicians  with  drogues, 
massage,  electricity,  etc.,  without  any  improvement  of 
her  disagreeable  condition.  Patient  is  rather  stout  for 
her  age,  well  developed,  and  menstruated  regularly  for 
the  last  six  months.  Family  history  good  ;  no  similar 
case  on  record.  Inspection  reveals  nothing  abnormal, 
with  tlie  exception  that  she  cannot  retain  her  urine  for 
a  longer  period.  This  fact  led  me  to  believe  that  there 
existed  a  natural  relaxation  of  the  urethral  walls.  Hav- 
ing noticed  in  the  Frauenarzt  for  May,  1895,  a  descrip- 
tion of  a  new  operation  for  incontinentia  urinre  by  test, 
I  decided  to  undertake  it  in  this  case,  as  an  energetic 
measure  was  indicated,  the  girl  being  obliged  to  earn 
her  own  living,  and  unable  to  find  constant  employ- 
ment on  account  of  this  trouble. 

The  test  operation  consists  in  vertical  incisions  at 
both  sides  of  the  meatus  urinarius,  transforming  the 
vertical  wound  in  an  horizontal  by  passing  sutures 
through  the  upper  and  lower  end  of  the  incision,  and 
bringing  the  margins  into  exact  approximation.  A  few 
more  fine  stitches  close  the  figure-of-eight  opening.  By 
this  procedure  the  tissues  around  the  urethra  become 
thickened  on  both  sides,  and  the  traction  exercises  also 
pressure  upon  the  urethra.  The  resistance  of  the  canal 
is  increased  and  greater  force  is  necessary  to  expel  the 
urine.  The  operation  was  almost  painless  after  an  in- 
jection of  one-half  drachm  of  a  five  per  cent,  solution 
of  hydrochlorate  of  cocaine  in  each  side.  The  bleed- 
ing ceased  after  suturing.  No  catheter  was  used.  The 
parts  were  protected  against  irritation  from  the  urine 
by  application  of  borated  vaseline.  Healing  took  place 
per  primam  intentionem.  After  the  operation  the  pa- 
tient could  pass  her  urine  only  in  a  fine  stream,  but 
after  complete  healing  and  consequently  strengthening 
of  the  sphincter,  the  act  is  done  normally.  She  can 
retain  the  urine  over  night,  or  awakens  in' due  time  to 
avoid  incontinence. 


ANGIOMA   CAVERNOSUM    OF   THE   SPLEEN. 
By  M.  D.  HOGE,  Jr.,  M.D., 

PROFE?SOR  OF  HISTOI.OGV   .iND  FATHOLOGV   UNIVERSITY  COLLEGE  OF  MEDICINE. 
RICHMOND,    VA. 

Angiomata,  from  their  structure  and  formation,  are 
divided  into  capillary  and  cavernous  forms.  In  the 
former  there  is  a  distinct  formation  of  blood-vessels 
produced  by  the  excavation  of  solid  nucleated  proto- 
plasmic cells,  which  gradually  become  converted  into 
tubes.  These  tubes,  or  rudimentary  capillaries,  are 
always  connected  with  some  previously  existing  blood- 
vessels. Such  growths  form  the  simpler  kind  of  con- 
genital njevus  vasculosus.  These  nearly  always  occur 
in  the  skin,  sometimes  in  the  subcutaneous  tissue  or 
mucous  surfaces,  very  rarely  in  internal  organs. 

In  angioma  cavernosum  the  capillary  system  is  lost, 
and  the  blood  is  contained  in  a  number  of  freely  inter- 
communicating spaces  which  resemble  the  corpora 
cavernosa  of  the  penis.  These  occur  more  frecjuently 
in  the  subcutaneous  tissues,  in  the  orbit,  pharynx,  nose, 
and  internal  organs.  They  often  pulsate,  and  are  con- 
nected by  wide  openings  with  arteries  and  veins,  espe- 
cially the  latter.  The  liver  is  almost  always  the  loca- 
tion in  which  this  form  of  tumor  is  found,  and  it  is  on 
account  of  its  extreme  rarity  of  occurrence  in  the 
spleen  the  present  case  is  reported. 

Mrs.  ls\ — '■ — ,  aged  forty-five,  was  admitted  into  St. 
Luke's  Home,  May  2,  1895,  complaining  of  a  gradual 
loss  of  flesh  from  144  to  129  pounds,  and  lately  a  rather 
rapidly  growing  tumor  on  the  left  side.  She  had  been 
in  perfect  health  up  to  ten  years  ago,  when  she  suffered 
from  alternating  attacks  of  constipation  and  diarrhoea. 
She  is  the  mother  of  thirteen  children,  three  of  which 
were  stillborn.  Four  years  ago,  after  the  birth  of  her 
last  child,  she  noticed  the  swelling  on  the  left  side, 
which  caused  her  much  anxiety  on  account  of  its 
rapid  and  mysterious  growth  ;  it  was  never  actually 
painful,  but  constant  brooding  over  it  reduced  her 
much,  both  in  flesh  and  spirits.  She  has  never  had 
malaria,  and  has  been  singularly  exempt  from  all  kinds 
of  sickness. 

Dr.  Hunter  McGuire,  in  performing  the  operation, 
made  a  median  incision,  which  at  once  disclosed  a 
dark,  soft,  highly  vascular  tumor,  extending  well  down 
toward  the  left  ovary.  On  looking  for  the  attachment, 
it  could  be  followed  up  to  the  spleen  ;  it  was  at  once 
removed,  and  the  bleeding  stump  secured.  When  sent 
for  examination  it  was  found  to  be  kidney-shaped  and 
measured  eight  inches  long,  five  inches  wide,  and  an 
inch  and  a  half  thick.  Small  pieces  were  at  once  fixed 
in  formal  and  absolute  alcohol,  stained  in  various  ways 
and  mounted  in  balsam.  Under  the  microscope  the 
entire  spleenic  structure  had  disappeared,  and  in  its 
place  large  cavernous  openings  were  seen,  freely  com- 
municating with  each  other  and  around  the  outer  edge 
indications  of  a  more  or  less  distinct  fibrous  capsule. 

On  account  of  the  great  rarity  of  this  form  of  tumor 
invading  the  spleen,  and  the  perfect  and  uninterrupted 
recovery  of  the  patient,  the  case  has  been  reported. 

Pieces  of  tissue  were  sent  to  Dr.  James  E.  Reeves,  of 
Chattanooga,  Tenn.,  who  confirmed  the  diagnosis  of 
cavernous  angioma  of  the  spleen. 

A  letter  from  the  patient,  dated  August  3, 1895,  states 
that  she  is  now  in  perfect  health. 


A  Stroke  of  Genius. — There  is  a  woman  in  an  Ohio 
town  whose  ability  as  an  advertiser  demands  a  wider 
field  for  its  exercise.  She  is  an  "electric  physician," 
and  recently  appeared  before  the  local  Board  of  Health 
with  a  complaint  against  one  of  her  neighbors  who 
kept  several  cows.  She  was  so  full  of  electricity  and 
magnetism,  she  said,  that  she  drew  the  flies  in  swarms 
from  the  cows,  and  she  wanted  the  Board  to  abolish 
either  the  flies,  the  cows,  or  the  owner  of  the  latter,  as 
she  said  she  could  not  possibly  stand  it  any  longer. 


September  21,  1895] 


MEDICAL    RECORD. 


419 


Jiociettj  Reports. 

THE    BRITISH    MEDICAL    ASSOCIATION. 

Sixty-third  Annual  Meeting,  held  in  London,    July  jo 
and  ji,  and  August  i  and  2,  iSgj. 

(Specially  Reponed  for  the  Medical  Record.) 

SECTION  ON  PHARMACOLOGY  AND   THERAPEUTICS. 

First   Day.  Wedxesdav,  July  31ST. 

Anarcotine  in  Malarial  Fever. — Sir  William  Roberts 
took,  as  the  subject  of  his  presidential  address,  "  Anarco- 
tine, a  Neglected  Alkaloid  of  Opium."  During  his 
visit  in  India  as  a  member  of  the  Opium  Commission 
his  attention  had  been  called  to  the  employment  of 
this  alkaloid  in  the  treatment  of  malarial  fevers. 
Anarcotine  was  brought  into  prominent  notice  in  In- 
dia about  fifty  years  ago.  At  that  time  quinine  became 
very  scarce  and  dear,  and  the  Indian  medical  autho- 
rities had  to  cast  about  for  some  cheaper  and  more 
abundant  substitute.  Now,  opium  had  long  been  held 
in  high  repute  among  the  natives  of  India  as  a  remedy 
and  protective  against  malarial  fevers  ;  and  habitual 
opium-eaters  were  said  to  enjoy  a  remarkable  im- 
munity from  malarial  infection.  Attention  was  there- 
fore directed  to  anarcotine.  which  is  the  most  abundant 
alkaloid  of  Bengal  opium,  and  trials  were  made  of  its 
curative  power  in  malarial  fevers.  The  results  of  these 
trials  induced  the  Indian  authorities  to  institute  further 
experiments,  and  these  proving  favorable,  they  caused 
anarcotine  to  be  prepared  in  quantity  and  distributed 
to  the  medical  depots  throughout  British  India. 

In  1857-59  Dr.  Palmer  treated  at  Ghazipur  546  cases 
of  malarial  fever  with  anarcotine,  in  doses  ranging  from 
one  to  three  grains.  Of  these  541  were  cured  and  only 
5  died.  In  addition  to  these  546  officially  reported 
cases  he  treated  with  anarcotine  a  large  number  of 
other  cases  of  malarial  fever,  amounting  in  all  to  little 
short  of  1,000  cases.  Summing  up  his  general  ex- 
perience, he  states  that  in  seventy  per  cent,  the  fever 
was  arrested  at  the  second  paroxysm  after  the  medi- 
cine was  administered  ;  in  twenty  per  cent,  the  arrest 
was  equally  sure,  but  was  not  quite  so  quick  ;  and  in 
ten  per  cent,  the  medicine  did  not  appear  to  have  any 
curative  effect.  He  further  re'iiarks  that  there  are  cases 
where  anarcotine  is  decidedly  more  efficacious  than  qui- 
nine, namely,  where  there  is  an  intolerance  of  quinine, 
and  where  quinine  has  been  given  without  any  effect 
for  a  long  time. 

Dr.  Garden  succeeded  Dr.  Palmer  in  civil  charge 
of  the  Ghazipur  Station  in  1859  :  and  at  that  time  a 
severe  outbreak  of  intermittent  fever,  of  quotidian  and 
tertian  type,  had  to  be  dealt  with.  Taking  advantage 
of  the  opportunity  he  subjected  anarcotine  to  an  ex- 
tensive trial.  He  treated  altogether  684  cases,  and 
gives  details  of  194.  Of  these  194  cases  187  were 
rapidly  cured  by  anarcotine.  It  only  failed  in  7  cases, 
or  3.6  per  cent.  It,  moreover,  cured  some  cases  where 
quinine  had  failed.  The  doses  he  employed  ranged 
from  one  and  a  halt  to  three  grains.  Dr.  Palmer  and 
Dr.  Garden  perceived  a  distinction  between  quinine  and 
anarcotine,  and  recognized  that  there  were  cases  of 
malarial  fever  which  resisted  quirine  but  yielded  to 
anarcotine.  Both  observers  also  noted  that  in  a  cer- 
tain percentage  of  the  cases  anarcotine  proved  wholh' 
ineffective.  These  discrepancies  are  probably  to  be 
explained  by  the  facts  brought  to  light  in  recent  re- 
searches on  the  infective  organisms  of  paludal  fevers. 
It  has  been  shown  that  these  organisms  are  of  more 
than  one  kind,  and  that  each  kind  corresponds  to 
a  particular  type  of  malarial  fever.  There  seems  to 
be  valid  evidences  that  in  anarcotine  we  possess  a 
second  antiperiodic  of  great  power  analogous  to,  but 


not  identical  with,  quinine.  The  speaker  emphasized 
the  desirability  of  subjecting  anarcotine  to  a  fresh  ex- 
amination, with  a  view  of  ascertaining  its  value,  as 
compared  with  quinine,  in  the  different  types  of 
malarial  infection,  and  in  cases  v.-here  quinine  has 
proved  ineffective.  Anarcotine  was  originally  named 
■'  Narcotine  "  by  its  discoverer,  Derosne,  and  this  is 
the  name  by  which  it  is  still  generally  known.  This 
designation  is,  however.  whoUy  inappropriate  and  mis- 
leading, as.  when  pure,  it  is  quite  devoid  of  narcotic 
properties. 

A  Discussion  on  Serotherapy  was  opened  by  Dr.  E. 
Kleix  with  a  paper  upon  the  "  Nature  of  Antitoxin." 
One  of  the  oldest  deductions  that  have  been  made  as 
to  infectious  diseases  was  that  a  first  attack  confers  a 
certain  immunity  against  a  second.  Modern  pathology 
distinguishes,  as  acquired  immunity,  the  condition  of 
insusceptibility  after  a  first  attack  from  natural  insus- 
ceptibility observed  in  certain  individuals  or  in  certain 
species  of  animals  against  any  one  kind  of  infectious 
disorders. 

Natural  immunity  is  altogether  different  from  ac- 
quired immunity,  the  former  being  probably  dependent 
upon  some  peculiarity  of  cells  or  tissues  ;  the  latter  to 
the  presence  of  chemical  substances  in  the  blood,  which 
were  termed  anti-bodies.  The  methods  of  production 
of  antitoxin  by  injection  of  gradually  increasing  doses 
of  the  toxins  or  of  the  toxins  plus  living  bacilli  were  then 
briefly  described.  The  antitoxins  had  a  very  great 
power  of  neutralizing  the  toxins,  but  much  larger  doses 
had  to  be  employed  if  living  bacilli  were  present  in 
addition.  Hence  the  antitoxic  substance  and  the  sub- 
stance immunizing  against  the  living  bacilli  seemed  to 
be  distinct,  and,  in  fact,  it  could  be  shown  experiment- 
ally that  they  were  not  formed  simultaneously  or  to  the 
same  degree.  The  antitoxic  substance  was  perhaps  a 
ferment,  and  in  the  future  two  classes  of  animals  might 
be  kept,  one  class  immunized  against  the  toxins,  and 
furnishing  antitoxin  for  the  treatment  of  diphtheria, 
another  class  immunized  against  the  linng  bacilli,  and 
furnishing  a  serum  which  might  be  used  for  preventive 
inoculation.  Experimentally,  the  value  of  antitoxin 
was  as  firmly  established  as  that  of  any  known  drug. 

Dr.  J.  W.  Washbourn  said  that  the  discovery  of 
serum  therapeutics  marks  a  distinct  epoch  in  the  his- 
tory of  medicine.  During  recent  years  rapid  strides 
have  been  made  in  surgical  therapeutics  owing  to  the 
introduction  of  methods  of  treating  wounds  which  are 
based  upon  sound  scientific  principles.  In  medicine 
our  knowledge  of  the  etiology  and  pathology  of  disease 
has  been  greatly  enriched  during  recent  years  by  the 
study  of  physiology  and  bacteriology,  but  medical 
therapeutics,  with  the  exception  of  the  progress  due  to 
improved  methods  of  diagnosis,  has,  until  within  the 
last  year,  remained  almost  at  a  standstill. 

The  progress  of  bacterial  therapeutics  has  been 
slow,  and  it  received  a  set-back  in  the  failure  of  tuber- 
culin. But  that  failure  was  due  to  the  fact  that  the  ex- 
perimental proof  of  its  value  rested  upon  insufficient 
evidence.  The  application  of  the  treatment  to  the  hu- 
man subject  was  attempted  before  it  had  been  proved 
to  be  efficacious  in  the  case  of  animals.  The  principle 
of  serum  therapeutics  rests  upon  an  entirely  different 
basis.  Careful  and  accurate  experiments  have  shown 
that  the  blood-serum  of  highly  immunized  animals  pos- 
sesses remarkable  therapeutic  properties.  In  regard  to 
diphtheria  antitoxin,  the  remedy  had  been  thoroughly 
and  satisfactorily  tested  before  it  was  applied  to  the 
treatment  of  the  disease  in  man.  With  regard  to  tetan- 
us antitoxin,  the  results  seem  as  yet  to  be  somewhat 
disa  'pointing,  but  the  cases  treated  have  been  too  few 
to  warrant  any  definite  conclusions.  There  are  two 
methods  by  which  the  value  of  diphtheria  antitoxin  can 
be  giUged — the  clinical  and  the  statistical  ;  and  a  large 
number  of  cases  are  now  available  for  this.  In  regard 
to  the  statistical  method,  it  is  most  important  that  the 
age  of  the  patients  should  be  mentioned,  for  whereas 


420 


MEDICAL    RECORD. 


[September  21,   1895 


for  children  under  five  years  the  mortality  is  49  09  per 
cent.,  for  persons  over  fifteen  years  the  mortality  is 
only  4  6  per  cent.  The  varying  severity  of  different 
epidemics  is  also  a  factor  which  must  not  be  neglected. 
The  position  of  the  membrane,  whether  faucial  or  in- 
volving the  larynx,  is  another  important  factor.  Exclud- 
ing all  sources  of  fallacy,  we  now  have  records  of  over 
three  thousand  cases  treated  with  antitoxin,  and  statistics 
show  a  diminished  mortality,  in  some  instances  one- 
half  that  which  existed  in  pre-antitoxin  days.  This 
was  the  case  in  Paris,  where  at  the  same  time  at  the 
Trousseau  Hospital  under  the  old  treatment  the 
mortality  remained  up  to  the  average,  and  also  in 
Berlin,  where  there  was  a  great  diminution  of  mortal- 
ity when  the  antitoxin  was  used,  a  rise  when  the 
supply  of  the  remedy  failed,  followed  at  once  by  a 
decline  on  the  resumption  of  the  use  of  the  remedy. 
Statistics,  therefore,  definitely  prove  the  advantage  of 
the  antitoxin  treatment.  The  speaker  then  dwelt  in 
some  detail  upon  the  effects  of  the  remedy  as  mani- 
fested clinically.  The  exudation  clears  off  more  rapidly, 
obviating  in  many  cases  the  necessity  for  tracheotomy. 
The  temperature  when  high  is  lowered,  the  pulse  be- 
comes slower  and  more  regular.  No  deleterious  effects 
upon  the  kidneys  could  be  ascribed  to  the  remedy. 

As  to  the  effect  of  the  antitoxin  treatment  upon  the 
occurrence  of  paralysis  more  extended  observations  are 
requiied  before  we  can  arrive  at  a  conclusion.  In  this 
connection,  however,  we  must  not  forget  that  the  more 
severe  the  attack  of  diphtheria  the  more  likely  is  pa- 
ralysis to  supervene.  Many  fatal  cases  would  probably 
have  developed  paralysis  had  they  recovered.  Conse- 
quently when  the  mortality  is  lowered  by  treatment 
the  actual  number  of  cases  of  paralysis  may  increase 
through  this  cause  alone. 

When  the  false  membrane  has  been  invaded  by 
pyogenic  bacteria  the  action  of  the  antitoxin  may  be 
interfered  with.  Slight  complications,  such  as  rashes, 
pyrexia,  and  joint  pains,  sometimes  attend  the  use  of 
the  remedy,  but  these  are  of  a  transient  character  and 
retard  recovery  simply.  The  rashes  are  of  an  erythe- 
matous or  urticarial  nature,  and  the  joint  pains  proceed 
usually  from  the  structures  around  the  joint,  although 
actual  effusion  may  occur.  The  speaker  emphasized 
the  importance  of  antiseptic  precautions.  The  syringe 
should  be  one  that  can  be  boiled  easily.  The  dose 
should  vary  according  to  the  age  of  the  patient  and  the 
severity  of  the  disease.  As  regards  the  prophylactic 
use  of  the  serum,  the  protection  did  not  last  long,  and 
it  would  only  be  exceptionally  indicated.  In  conclu- 
sion, the  possibilities  of  serum  therapeutics  were  touched 
upon  as  applied  to  bacterial  diseases  such  as  erysipelas, 
pneumonia,  puerperal  fever,  and  the  like. 

Dr.  Charteris  spoke  of  the  cases  of  diphtheria  he 
had  seen  treated  with  antitoxin.  There  seemed  to  be 
no  doubt  about  its  efficacy  ;  the  membrane  ceased  to 
spread,  the  pulse  became  fuller  and  stronger,  and  the 
whole  aspect  of  the  i)atient  improved.  He  had  experi- 
mented with  the  various  makes  of  antitoxin  in  the  mar- 
ket and  had  observed  no  injurious  effects  from  any  of 
them. 

Dr.  R.  T.  Hewlett  confined  his  remarks  to  tetanus 
antitoxin.  He  first  gave  a  brief  outline  of  the  methods 
employed  by  Behring,  Roux  and  Vaillard,  and  himself, 
in  obtaining  tetanus  antitoxin.  He  pointed  out  that 
the  antitoxin  issued  by  Tizzoni  differed  from  the  others 
in  that  it  was  obtained  by  precipitation  of  the  serum 
by  means  of  alcohol  ;  in  the  other  cases  the  serum  was 
issued  either  in  the  usual  liquid  form,  or  was  reduced 
to  a  solid  by  being  dried  in  ractio  over  sulphuric  acid. 
All  these  antitoxins  possessed  a  very  high  immunizing 
power,  which  should  never  be  less  than  i  to  1,000,000. 
The  mortality  of  tetanus  under  the  old  methods  of 
treatment  was  about  seventy-five  per  cent.  The  speaker 
had  collected  statistics  of  61  cases  treated  with  anti- 
toxin, and  of  these  22,  or  thirty-six  per  cent.,  died.  It  is 
probable  that  these  figures  are  somewhat  too  favorable. 


but  after  making  all  allowances,  the  antitoxin  treatment 
of  tetanus  is  undoubtedly  an  advance. 
•  Dr.  Nestor  Tirard  referred  to  the  results  of  the 
antitoxin  treatment  of  diphtheria  at  the  Evelina  Hos- 
pital. The  pulse  gained  strength,  and  in  some  cases 
diminished  in  rate  ;  the  temperature  either  fell  or  re- 
mained the  same — in  no  case  did  it  rise  ;  the  nervous 
system  gained  in  tone,  and  the  membrane  speedily 
diminished  and  did  not  form  again.  With  regard  to 
ill-effects,  it  was  found  that  albumin  was  found  in  the 
urine  in  many  cases,  but  this  was  also  often  noticed 
before  the  antitoxin  had  been  used  at  all,  and  it  was 
unaccompanied  by  any  symptoms  referable  to  interfer- 
ence with  renal  function.  A  rash  had  been  noted  in 
three  cases  ;  it  was  always  of  the  nature  of  an  urticaria, 
and  gave  no  trouble.  Post-diphtheritic  paralysis  had 
not  been  observed.  While  it  was  possible  that  the 
greatly  diminished  death-rate  might  be  due  to  an  unu- 
sually favorable  epidemic,  yet  the  cases  treated  had  beeD 
very  severe  in  their  clinical  features. 

Dr.  W.  Gavton  was  not  much  in  favor  of  the  anti- 
toxin treatment  of  diphtheria.  The  reduction  in  the- 
death  rate  is  slight  (not  more  than  five  per  cent.),  and 
may  well  be  due  to  a  mild  character  of  the  disease  at 
the  present  time.  The  number  of  cases  complicated 
with  nephritis  is  much  greater,  and  paralysis  is  more 
common.  The  experience  of  himself  and  his  col- 
leagues at  the  Northwestern  Fever  Hospital  might 
be  summed  up  thus  ;  Those  cases  that  under  the  old 
treatment  would  probably  have  died  still  were  fatal 
under  the  new.  Those  which  might  get  better  recov- 
ered in  about  the  same  proportion,  while  the  mild 
cases  improved  no  more  rapidly — indeed  rather  the 
contrary,  considering  the  frequency  of  the  incidence  of 
rashes,  than  those  without  it. 

Dr.  Foord  Caiger  had  employed  antitoxin  in  two 
hundred  and  thirty  cases  of  diphtheria,  and  was  im- 
pressed with  the  value  of  the  remedy.  There  were 
fewer  cases  with  heart  failure,  but  more  of  paralysis — 
a  fact  that  could  readily  be  explained  by  the  greater 
number  of  severe  cases  that  recovered.  The  mem- 
brane, which  before  the  use  of  antitoxin  was  adherent,, 
on  an  average,  4.6  days,  now  fell  off  in  2.6  days.  Irt 
the  nasal  form  the  acrid  discharge  was  soon  checked 
and  the  patients  rendered  more  comfortable.  In  la- 
ryngeal cases  the  benefits  were  most  marked  ;  both  the 
membrane  and  swelling  soon  disappeared,  and  the 
number  of  cases  requiring  tracheotomy  was  reduced 
from  seventy  per  cent,  to  forty-three  per  cent.  The 
mortality  was  also  lessened,  and  in  cases  that  eventu- 
ally terminated  fatally  the  duration  of  life  was  extended 
— lengthened  an  average  of  very  nearly  three  days.  The 
speaker  gave  much  larger  doses  than  were  customary. 
He  began  with  50  c.c,  and  gave  sometimes  as  much  as 
180  c.c.  in  the  first  three  days.  He  believed  that  the 
results  were  much  better  if  large  doses  were  given. 

Dr.  Fraser  discussed  the  modes  of  testing  the 
strength  of  antitoxin,  and  said  he  considered  them 
faulty,  as  tending  to  convey  an  exaggerated  idea  of  the 
strength  of  the  remedy.  Instead  of  the  antitoxin  be- 
ing given  before  or  at  the  same  time  with  the  toxin, 
the  test  should  be  made  to  conform  more  nearly  to 
what  occurs  in  practice  by  administering  the  remedy 
some  time  after  the  toxin  has  been  taken. 

Mr.  Boricnha.m  said  that  the  bulk  of  the  fluid  to  be 
administered  was  a  serious  difficulty  in  private  prac- 
tice ;  cases  were  known  to  him  in  which  the  parents 
had  withdrawn  a  consent  previously  given  when  they 
saw  the  size  of  the  syringe  to  be  used.  He  thought  he 
had  overcome  this  objection  in  a  fairly  satisfactory 
manner.  By  a  process  of  drying,  combined  or  not 
with  previous  concentration  at  a  low  temperature  in 
vacuo,  he  had  succeeded  in  reducing  the  serum  to  a 
condition  of  thin  golden  scales  :  100  c.c.  yield  on  an 
average  between  10  and  11  gm.  of  dry  scales.  These 
are  readily  soluble  in  about  two  and  a  half  to  three 
times  their  weight  of  water,  and  the  activity  of  the 


September  21,  1895] 


MEDICAL    RECORD. 


421 


solution  thus  made  is  almost  identical  with  that  of  the 
original  serum.  He  had  heard  of  no  ill-efifects  follow- 
ing its  use  ;  it  keeps  perfectly,  and  may  be  used  with 
a  comparatively  small  syringe. 

Dr.  Klein,  in  closing  the  discussion,  spoke  approv- 
ingly of  the  use  of  dried  serum,  and  he  believed  it 
would  be  found  less  likely  to  produce  a  rash  than  the 
ordinary  form. 

Dr.  Washbourx  said  that  the  cises  upon  which  Dr. 
Gaynor  based  his  unfavorable  opinion  were  altogether 
too  few  to  have  any  particular  value  one  way  or  the 
other,  yet  what  little  they  did  show  was  in  favor  of  the 
neiv  remedy,  since  the  mortality'  had  been  reduced  five 
per  cent.  The  report  was  very  unsatisfactory,  in  that 
nothing  definite  was  said  as  to  the  dose  or  the  mode  of 
administration  of  the  antitoxin. 

Antivenene  in  Snake-poisoning. — Dr.  T.  R.  Frasek 
read  a  paper  upon  the  induction  of  artificial  immunity 
to  snake-bites.  It  has  long  been  suggested  that  the 
feats  of  snake-charmers  were  rendered  possible  through 
the  production  of  artificial  immunity.  If  this  be  the 
explanation,  the  protection  must  have  been  obtained, 
in  most  cases,  at  least,  by  the  introduction  of  the  venom 
into  the  stomach.  It  is  generally  asserted  that  snake- 
venom  is  innocuous  when  taken  into  the  stomach,  yet 
it  does  not  necessarily  follow  that  it  is  incapable  of 
producing  protection  when  swallowed.  To  test  this. 
Dr.  Fraser  experimented  upon  cats  and  white  rats,  and 
found  that  immunity  could  be  secured  by  the  stomach 
administration  of  the  venom.  The  blood-serum  of 
serpents,  as  shown  by  some  of  the  speaker's  experi- 
ments, also  contains  a  substance  which  possesses  anti- 
dotal properties  against  their  own  venom  as  well  as 
against  that  of  other  species.  This  antitoxic  substance 
he  called  antivenene.  The  antidotal  action  of  anti- 
venene seems  to  be  rather  of  the  nature  of  a  chemical 
reaction  than  of  a  physiological  antidote.  With  regard 
to  the  administration  of  antivenene,  several  successive 
doses  would  appear  to  be  more  effectual  than  one  large 
one.  It  should  be  injected  at  the  seat  of  the  bite,  be- 
fore the  ligature,  if  applied  round  the  limb,  had  been 
removed,  and  before  excision.  It  will  probably  be 
found  that  20  c.c.  is  sufficient  for  the  initial  dose. 
Dr.  Fraser  exhibited  two  preparations  of  antivenene, 
one  in  the  usual  liquid  form  of  remedies  used  in  sero- 
therapy, the  other  the  blood-serum  dried  in  vacuo  over 
sulphuric  acid.  The  dry  antivenene  is  readily  soluble 
in  water,  and  retains  unimpaired  the  original  antidotal 
power  of  the  liquid  preparation. 

Dr.  Stokvis,  of  Amsterdam,  said  that  he  was  much 
interested  in  the  possible  effects  of  the  epidermic  ap- 
plication of  antivenene.  He  stated  that  in  the  Dutch 
colonies  it  is  customary  for  the  snake-catchers  to  pre- 
pare themselves  before  starting  by  rubbing  all  over 
their  skin  a  powder  made  from  the  dried  heads  of 
snakes,  with  their  poison-glands.  As  a  result  of  this 
precaution  they  either  are  not  bitten,  or  they  are  ren- 
dered immune  against  the  effects  of  bites. 

Dr.  Fr.\ser  said  that  he  had  not  tried  epidermal 
application  of  antivenene,  but  as  immunity  could  be 
produced  by  absorption  through  the  epithelial  lining  of 
the  stomach  it  was  quite  possible  that  inunction  would 
act  similarly.     It  was  worthy  of  trial. 


Council,  was  desirous  of  learning  the  views  of  general 
practitioners  in  regard  to  the  changes  to  be  made  in 
the  next  re^asion. 

Drs.  Carter,  Stockman,  Fraser.  and  others  took 
part  in  the  discussion. 

Drs.  Harlev  and  Surveyor  then  presented  a  com- 
munication on  the  '■  Action  of  Beta-naphthol  and  Bis- 
muth Subnitrate  as  Intestinal  Antiseptics."  This  was 
followed  by  a  paper  by  Dr.  C.  D.  F.  Phillips  on  the 
'■  Pharmacological  Action  of  Berberine." 


Second  Day,  Thursday,  August  ist. 

Revision  of  the  Pharmacopoeia. — The  second  session 
of  this  Section  was  taken  up  almost  entirely  with  a  dis- 
cussion concerning  the  revision  of  the  British  Phar- 
macopoeia— what  articles  should  be  dropped,  what  new 
remedies  admitted,  whether  the  new  forms,  such  as 
tabloids,  granules,  etc.,  should  be  included  :  whether 
the  details  of  the  making  of  poultices  should  find  a 
place,  etc.  The  chair  during  the  discussion  was  oc- 
cupied by  Dr.  Lauder  Brunton. 

The  discussion  was  opened  by  Dr.  Leech,  of  Man- 
chester,  who,  as  a  member   of   the  General  Medical 


Third  Day,  Friday,  August  2D. 

Therapeutic  Uses  of  Mineral  Waters. — The  discus- 
sion was  opened  by  Dr.  Fortescue  Fox,  who  read  a 
paper  on  "  Strathpeffer."  These  are  sulphur  waters, 
and  if  continued  for  too  long  a  period  were  liable  to 
cause  anaemia.  They  are  contra-indicated  also  in 
acute  congestive  or  inflammatory  states  of  the  abdo- 
minal viscera,  in  tuberculosis,  acute  rheumatism,  albu- 
minuria, and  uncompensated  valvular  lesions.  They 
are  indicated  in  the  chronic  congestions  and  stases, 
commonly  occurring  in  people  of  sedentarj-  habits  in 
later  middle  life.  The  speaker  was  persuaded  that  the 
waters  were  the  main  factor  in  the  good  effects  of  treat- 
ment at  resorts  of  this  nature,  for  the  change  of  air, 
scene,  diet,  and  surroundings  were  wholly  insufficient  to 
account  for  the  great  benefit  received  in  so  many  cases 
of  chronic  disease. 

Dr.  S.  Hyde  read  a  paper  on  the  "'  Waters  of  Bux- 
ton." There  is  quite  a  variety  of  waters  found  at,  and 
near,  Buxton — saline,  sulphur,  and  ferruginous.  Sub- 
acute rheumatism  was  often  greatly  benefited,  although 
at  first  the  treatment  usually  caused  a  return  of  the 
acute  symptoms  ;  these  are  of  short  duration,  however, 
and  rapid  progress  toward  recovery  follows,  a  large 
number  of  patients  being  completely  cured.  In  acute 
gout  the  internal  use  of  the  waters  is  alone  indicated, 
but  in  chronic  gout  the  use  of  baths  in  addition  is  use- 
ful. In  rheumatoid  arthritis  the  combined  internal  and 
external  treatment,  together  with  massage,  gives  satis- 
factory results.  Massage  is  a  valuable  adjunct  in 
many  conditions,  but  electricity  is  not  particularly 
beneficial.  Other  diseases  benefited  by  the  waters  and 
methods  of  treatment  in  use  at  Buxton  are  lumbago, 
peripheral  neuritis,  and  various  skin  affections  depend- 
ent upon  gout. 

iratnral  Versus  Artificial  Waters. — The  speaker  then 
referred  to  the  fact,  which  was  one  of  common  observa- 
tion by  all  who  had  had  to  do  with  hydrotherapy,  that, 
however  closely  an  artificial  water,  prepared  syntheti- 
cally, resembled  a  natural  one,  it  was,  nevertheless, 
lacking  in  some  peculiar  propertj-  which  gave  the  char- 
acter to  the  natural  water  and  rendered  it,  therapeuti- 
cally, more  efficient.  He  was  at  one  with  the  previous 
speaker  in  holding  that  the  conditions  of  change  of 
life  and  surroundings  accompanying  treatment  at  a  spa 
were  not  sufficient  to  explain  the  benefits  received. 

Dr.  a.  S.  Myrtle  said  there  certainly  was  some 
property  in  natural  springs  which  was  lacking  in  arti- 
ficial waters,  however  closely  they  resembled  the  natu- 
ral. He  referred  briefly  to  the  properties  of  the  Har- 
rowgate  waters,  and  described  the  plan  of  treatment 
pursued  by  himself.  He  considered  that  strict  dieting 
was  unnecessary  while  undergoing  the  treatment  ;  pa- 
tients might  have  anything  in  reason,  food  and  drink, 
provided  it  did  not  disagree  and  was  taken  in  modera- 
tion. He  was  in  the  habit  of  recommending  for  break- 
fast "  anything  you  like,  b  it  not  too  much  of  it,"  and 
just  the  same  for  lunch  and  for  dinner.  The  sulphur 
waters  at  Harrogate  were  the  only  ones  used  externally, 
the  sulphuretted  hydrogen  contained  in  them  being 
sedative  in  nervous  conditions  and  in  affections  of  the 
gastric  and  bronchial  mucous  membranes.  The  other 
waters  were  stimulant,  diuretic,  and  tonic.  In  chronic 
diseases  of  the  heart  the  waters  were  very  useful,  but 
should  be  employed  with  great  care. 


422 


MEDICAL   RECORD. 


[September  21,  1895 


Mr.  W.  Tomlixs  read  a  paper  on  the  "  Brine  Baths 
of  Droitwich."  After  referring  to  the  large  amount  of 
saline  constituents  which  these  waters  contain,  the  cases 
suitable  for  the  treatment  were  discussed.  Attention 
was  also  drawn  to  the  attractiveness  of  the  scenery  and 
to  the  favorable  climatic  conditions  of  Droitwich. 

Dr.  Parsoxs  referred  to  the  value  of  the  spa  treat- 
ment in  diabetes  and  other  diseases. 

Dr.  Cuffe  and  others  also  took  part  in  the  discus- 
sion. 

Loretin. — Dr.  Herbert  Snow  read  a  paper  on  this 
organic  iodine  compound  discovered  by  Claus,  of  Frei- 
burg, which  is  possessed  of  aseptic  properties.  It  is  a 
yellow,  crystalline  powder,  but  slightly  soluble  in  water, 
and  forming  emulsions  with  ether,  oil,  and  collodion. 
It  forms  neutral  salts  with  alkalies,  which  are  freely 
soluble  in  water.  Loretin  is  odorless  and  non-poison- 
ous, and  is,  Dr.  Snow  said,  superior  in  germicidal 
power  to  some  of  the  preparations  now  in  favor  with 
surgeons.  It  is  also  a  good  deodorant,  destroying  the 
fcetor  of  sloughing  cancerous  sores.  Dusted  into  deep 
wounds  it  prevents  suppuration,  and  no  bad  symptoms 
had  been  observed  after  its  use.  Applied  to  the  skin 
or  to  a  granulating  sore  it  is  perfectly  unirritating. 

Guaiacol  by  H3fpoderniic  Injection. — Dr.  F.  R. 
AValters  read  a  paper  on  the  "  Subcutaneous  Use  of 
Guaiacol."  When  injected  under  the  skin  guaiacol 
is  found  to  be  very  irritating,  and  producing  sloughing, 
but  when  injected  into  the  muscular  tissue  the  irritat- 
ing properties  are  less  marked,  and  very  considerable 
doses  may  be  administered  without  causipg  constitu- 
tional disturbance. 

Yeast  Fungi  in  Tuberculosis. — Dr.  de  Backer,  of 
Paris,  read  a  paper  on  the  "  Treatment  of  Tuberculosis 
by  Living  Ferments."  Yeast  fungi  are  made  use  of  and 
are  injected  in  the  living  state  subcutaneously.  The 
speaker  believed  that  the  beneficial  therapeutic  action  of 
these  living  ferments,  an  action  which  he  had  now  been 
observing  for  a  considerable  time,  and  which  he  regarded 
as  little  less  than  marvellous,  was  to  be  explained  on 
the  theory  of  phagocytosis. 


SECTION  ON  PATHOLOGY. 

•     First  Day,  Wednesday,  July  31ST. 

The  Process  of  Repair.— Dr.  Sa.muel  Wilks,  Chairman 
of  the  Section,  took  this  as  the  subject  of  the  annual  ad- 
dress. All  about  us,  he  said,  change  is  ever  going  on  ; 
and  not  only  in  the  world  around  us,  but  also  in  the 
entire  universe,  as  far  as  we  can  learn  by  the  evidence 
furnished  by  the  telescope  and  the  spectroscope,  this 
same  endless  succession  of  growth  and  decay  goes  on. 
Just  as  the  body  grows  and  decays,  as  a  whole,  so  do 
its  several  parts.  We  may  see  the  two  processes  of 
production  and  destruction  going  on  in  the  tissues 
whenever  these  are  subjected  to  any  special  stimulus, 
such  as  injury  or  other  morbid  influence.  In  speaking 
of  any  unnatural  condition  in  the  body,  we  commonly 
employ  the  term  "  morbid,"  but  this  is  not  strictly 
correct,  for  only  a  portion  of  what  is  found  is  really 
pathological,  the  rest  being  the  result  of  a  true  physio- 
logical process.  When  employing  the  terms  "  morbid  " 
or  "  disease,"  we  do  not  recognize,  as  we  should,  the 
reparative  process  that  goes  hand  in  hand  with  the 
destructive  one.  With  regard  to  injuries,  we  seldom 
have  any  difficulty  in  recognizing  this  reparative  action, 
and  in  many  cases  of  internal  disease  also  we  can 
readily  distinguish  the  physiological  from  the  patho- 
logical. In  valvular  heart  disease,  for  example,  we 
know  that  the  hypertrophied  cavities  are  the  manifesta- 
tion of  a  conservative  process  ;  and,  in  like  manner, 
hypertrophy  of  other  hollow  viscera  is  the  attempt  of 
nature  to  overcome  obstruction,  and  is  truly  conserva- 
tive and  not  pathological.  There  are,  however,  other 
more  complex  states,  in  which  it  is  difiicult  to  dis- 
tinguish clearly  between  pathological  and  physiological 


changes.  It  is  possible  that  the  two  processes  are  more 
intimately  associated  than  we  have  hitherto  believed, 
and  that  a  mutual  relation  of  a  chemical  or  electrical 
nature  may  exist  between  them.  Thus  it  has  been 
shown  that  if  one  electrode  is  placed  upon  an  ulcer 
the  latter  will  heal  rapidly,  while  a  sore  is  being  pro- 
duced at  the  point  of  application  of  the  other  electrode. 
The  two  processes  are  also  seen  going  on  before  the 
eye  in  almost  any  ulcer,  for  along  with  the  destruction 
we  see,  during  the  process  of  granulation  and  secre- 
tion, that  new  material  is  being  formed.  One  reason 
why  this  double  process  is  so  often  overlooked  is, 
doubtless,  owing  to  the  fact  that  the  reparative  material 
is  not  equal  in  organization  and  similar  in  structure  to 
the  original  tissue  which  it  replaces.  The  complex 
parenchymatous  structures  are  not  renewed,  after  in- 
jur)', as  are  the  simpler  ones  of  bone  or  connective 
tissue  ;  we  do,  however,  occasionally  see  true  regenera- 
tion of  glandular  or  nerve  tissue.  Still  this  is  true 
repair,  even  if  imperfect  and  partial,  and  we  have  been 
wrong  in  calling  the  process  morbid,  instead  of  repara- 
tive. This  distinction  is  a  useful  one  in  the  matter  of 
prognosis  and  treatment,  as  well  as  of  a  purely  patho- 
logical interest.  The  speaker  illustrated  his  meaning 
by  several  examples.  As  regards  piUhisis,  he  said, 
nothing  was  more  common  than  an  error  in  prognosis, 
and  this  simply  because  there  has  been  a  confusion  in 
the  mind  of  the  profession  between  the  constructive 
and  destructive  changes  present  in  the  lungs.  In  fact, 
the  very  signs  which  are  the  strongest  evidence  of  a 
beginning  reparative  process  are  regarded  by  many  as 
the  unmistakable  signs  of  disease.  He  recognizes  the 
existence  of  a  cavity,  and  at  once  condemns  his  pa- 
tient, forgetting  that  the  physical  signs,  dull  tympanitic 
note,  pectoriloquy,  sinking  in  of  the  chest-walls,  and 
absence  of  vibration  all  point  to  the  presence  of  a 
cavity  with  hard  walls,  the  result  of  a  reparative  action 
following  the  destructive  process.  The  destroyed  por- 
tion has  been  walled  off  from  the  healthy  part  of  the 
lung  by  this  fibrous  barrier,  which  the  examiner  has 
looked  upon  as  a  sign  of  disease  rather  than  of  a  pro- 
tection against  further  spread  of  the  disease.  Unfort- 
unately, it  is  not  alone  the  tyro  who  make  this  deplor- 
able mistake,  for  the  speaker  had  often  had  occasion 
to  note  the  surprise  of  old  practitioners  on  seeing  their 
former  phthisical  patients  alive  after  they  had  con- 
demned them  to  speedy  death. 

This  case  of  phthisis  is,  perhaps,  the  commonest  ex- 
ample, where  the  constructive  and  destructive  proc- 
esses have  not  been  sufficiently  distinguished  ;  but 
the  same  may  be  seen  in  cirrhosis  of  the  liver.  This 
organ  may  be  observed  during  life  to  be  first  enlarged 
and  then  become  nodulated  and  shrunken  :  among 
other  signs  of  the  disease  which  the  text-books  de- 
scribe is  an  enlargement  of  the  veins  on  the  surface  of 
the  abdomen.  These  were  thought  at  one  time  to  be 
due  to  some  pressure  on  the  vena  cava,  but  this  is 
really  not  the  case,  and  the  appearance  is  now  shown 
to  be  due  to  an  enlargement  of  the  epigastric  vein  in 
connection  with  the  opening  up  of  the  old  umbilical 
vein,  which  often  becomes  as  large  as  a  goose-quill. 
Through  this  the  portal  blood  flows  and  finds  a  free  pas- 
sage into  the  vena  cava  and  systemic  circulation.  The 
patient  in  this  way  is  relieved  from  an  engorgement  of 
the  portal  system  and  from  the  consequent  dropsy.  This 
enlargement  of  the  veins  is,  therefore,  a  sign  of  a  repara- 
tive character.  And  probably  this  is  not  all,  for  when 
the  cirrhotic  organ  is  examined  carefully  and  micro- 
scopically we  find  that,  although  the  nodules  are  com- 
posed mainly  of  atrophied  hepatic  tissue,  there  has  also 
been  an  attempt  to  replace  it  by  a  new  formation  of  cells 
and  vessels.  New  blood-vessels  may  be  seen  and  appar- 
ently new  ducts,  as  well  as  cell  growth.  Now,  although 
these  new  elements  are  not  perfect  enough  to  take  on 
the  function  of  the  liver,  there  can  be  little  doubt  that 
they  do  relieve  the  circulation  in  a  disabled  organ. 

There  are  other  cases  in  which  the  two  processes  of 


September   21,  1S95] 


MEDICAL    RECORD. 


construction  and  destruction  are  even  more  closely  in- 
terwoven, so  that  it  is  often  impossible  to  distinguish 
between  them  and  to  assign  the  right  place  to  each. 
We  should  study  these  with  greater  care  and  more  in- 
telligently, for  the  discovery  of  the  several  influences 
exerted  in  the  production  of  each  is  a  matter  of  great 
practical  importance.  A  consideration  of  them  also 
shows  that  pathology  is  governed  by  the  same  laws  as 
those  which  exist  elsewhere  throughout  the  realm  of 
Nature,  and  it  therefore  must  take  its  place  on  an 
equivalent  tooting  with  the  other  sciences. 

The  Mosquito  as  the  Intermediate  Host  of  the  Mala- 
rial Parasite. — Dr.  Patrick  Manson  then  read  a 
paper  entitled  "  Some  Facts  in  the  Life-History  of  the 
Malaria  Parasite,"  in  which  he  advanced  the  theory 
that  the  micro-organism  was  conveyed  to  man  by 
means  of  the  mosquito.  He  began  by  describing  the 
forms  of  the  parasite  seen  in  the  blood  of  malarious 
patients,  and  showed  how  these  varied  in  their  appear- 
ances according  to  the  stage  of  the  disease  during 
which  they  were  obtained.  The  flagellate  forms,  he 
said,  are  only  developed  outside  the  body  and  never 
within  the  circulation.  In  their  earliest  stages  they 
are  merely  masses  of  pigmented  granular  protoplasm, 
which  can  be  seen  to  thrust  out  the  characteristic 
fligellK.  These  separate  themselves  later  from  the 
parent  cell  and  play  an  important  part  in  the  develop- 
ment of  the  micro-organism  after  they  have  escaped 
from  the  body.  The  intra-corpuscular  elements  are 
destined  to  carry  on  the  life  of  the  parasite  within  the 
body,  whereas  the  flagellate  forms  maintain  the  con- 
tinuity of  the  species  outside  the  body.  But  it  has 
been  asked,  how  the  flagellate  forms  escape  from  the 
circulation  ?  In  reply  to  this  the  speaker  referred  to  the 
researches  of  Surgeon-Major  Ross,  of  Secunderabad, 
which  suggested  the  probability  that  the  mosquito  was 
an  intermediate  host  of  the  parasite.  This  observer 
had  found  that  the  parasites  resisted  destruction  in  the 
stomach  of  the  mosquito,  and  he  had  also  observed 
that  they  occurred  much  more  frequently  in  the  flagel- 
late form  in  the  blood  of  this  insect  than  in  blood 
drawn  from  the  finger  of  a  patient  with  malaria.  The 
development  of  the  plasmodium  in  this  intermediate 
host  is  also  evidenced  by  the  fact  that  the  crescent 
forms  all  become  spheres.  Dr.  Manson  then  quoted 
an  instance  of  a  man  who  by  accident  had  swallowed 
the  contents  of  a  bottle  containing  malarious  mosqui- 
toes, and  who.  although  he  had  never  had  the  disease 
nor  had  been  exposed  to  it,  yet  developed  malaria  in 
eleven  days.  The  disease  is  apparently  not  communi- 
cated directly  to  man  by  the  insect,  but  it  is  probable 
that  the  parasites  are  added  to  water  or  soil  on  the 
death  of  the  mosquito,  and  by  that  means  are  carried 
into  the  human  body.  Malaria  is,  therefore,  to  be  re- 
garded as  one  of  the  water-borne  diseases. 

Dr.  Thin  objected  to  this  hypothesis  of  Dr.  Man- 
son,  adducing,  among  other  arguments,  the  fact  that 
in  Sierra  Leone  malarial  fever  is  exceedingly  prevalent, 
but  mosquitoes  are  few.  He  agreed,  however,  with  Dr. 
Manson,  if  it  be  admitted  that  these  insects  are  the 
intermediate  host,  that  drinking-water  probably  forms 
the  means  of  communication  to  man.  He  believed 
that  the  flagelhu  play  some  part  in  the  life-history  of 
the  organism,  though  he  was  not  yet  prepared  to  say 
what,  and  are  not,  as  asserted  by  Marchiafava.  due  to 
the  convulsive  movements  of  the  protoplasm  in  its 
death-struggles. 

In  reply  Dr.  Manson  said  that  the  parasite  must 
have  some  third  form  not  yet  discovered  in  which  it 
can  remain  latent  in  the  body  for  a  long  time,  until  the 
conditions  favorable  for  its  development  occur,  at 
which  time  the  patient  develops  an  attack  of  fever. 
While  he  recognized  the  fact  that  there  were  many  ob- 
jections to  his  theory,  yet  he  hoped,  with  the  more 
complete  investigation  of  what  was  as  yet  an  entirely 
new  field,  that  these  would  be  removed. 

Exophthalmic  Goitre. — Dr.  A.  Foxwell  reported  a 


case  of  acute  exophthalmos  which  had  recently  been 
under  his  care,  in  which  pronounced  changes  were  found 
post  mortem  in  the  brain.  These  changes  were  the 
following  :  i.  Chronic  inflammation  and  sclerosis  of 
the  pia,  covering  part  of  the  vermiform  process,  and  of 
that  covering  the  fourth  ventricle  and  also  of  the 
middle  commissure  of  the  third  ventricle.  2.  Acute 
softening  of  the  surface  of  both  thalami.  3.  Exces- 
sive vascularity  of  the  surface  of  the  brain  of  the  inter- 
nal capsule,  of  the  cerebellum,  and  of  the  medulla — in 
the  middle  of  the  medulla,  at  any  rate — leading  to  oc- 
casional hemorrhages.  4.  Sclerotic  changes,  involving 
portions  of  the  tegmen,  pyraniids,  and  the  nuclei  of  the 
fasciculus  gracilis  and  cuneatus,  and  of  the  tenth  pair 
of  nerves. 

Thyroidectomy. — Dr.  George  R.  Murray  then 
read  a  paper  upon  the  effects  of  removal  of  the  thyroid 
gland  in  the  lower  animals,  and  said  that  these  effects 
in  rabbits  were  strikingly  like  to  the  symptoms  of  myx- 
cedema  in  man.  He  showed  a  number  of  photographs 
illustrating  animals  operated  upon,  in  which  the  skin 
lesions,  the  swelling  of  the  neck,  the  apathetic  appear- 
ance, etc.,  were  well  shown.  These  symptoms,  he  held, 
were  very  similar  to  those  observed  in  the  human  sub- 
ject of  myxoedema. 

Syringomyelia. — Dr.  J.  H.  Targett  presented  a 
communication  on  "Syringomyelia  and  Joint  Disease," 
in  which  he  reported  a  number  of  cases  of  this  affec- 
tion that  had  been  under  his  care,  in  which  the  articu- 
lar lesions  were  observed  to  bear  a  striking  resem- 
blance to  those  met  within  the  arthropathies  of  locomo- 
tor ataxia.  He  likewise  dwelt  in  some  detail  on  the 
other  manifestations  of  the  disease,  namely,  muscular 
atrophy,  trophic  skin  affections,  the  curious  condition 
in  which  there  is  insensibility  to  pain  and  temperature 
changes,  while  the  ordinary  sensibility  of  the  skin  re- 
mains unimpaired. 

The  Nature  of  Cancer. — Dr.  Braithewaite  opened 
the  discussion  on  this  subject  with  a  paper  in  which  he 
contended  that  the  cause  of  the  disease  was  a  mould 
fungus  that  he  had  discovered  in  cancerous  tissues. 
This  fungus  was  present  in  the  soil  of  certain  districts 
and  was  carried  in  the  drinking-water,  so  that  cancer 
was  another  of  the  increasing  number  of  diseases  that 
have  been  found  to  be  carried  in  water. 

This  paper  was  discussed  at  some  length  by  Mr. 
D'Arcv  Power,  Dr.  Russell  Wells,  Dr.  Bous 
field,  and  Mr.  Shattock,  who  held  that  Dr.  Braithe- 
waite's  conclusions  were  based  upon  a  misconception  of 
the  forms  which  he  had  observed  in  the  microscopical 
examination  of  cancerous  tissue.  The  appearances  de- 
scribed by  the  reader  of  the  paper  were,  they  main- 
tained, due  to  changes  in  fat  cells  and  elastic  tissue 
produced  by  the  methods  used  in  the  preparation  of 
the  specimens,  and  they  held  that  the  so-called  spores 
were  in  reality  crystalline  substances  deposited  in  col- 
loid media. 

The  Chemistry  of  Carcinoma  and  Sarcoma. — Dr. 
Hewlet  1  read  a  paper  on  Ehrlich's  diazo-reaction 
in  cancer,  in  which  he  asserted  that  the  micro-chemical 
reactions  of  the  so-called  cancer  parasites  are  wholly 
unlike  those  of  the  coccidia,  with  which  they  are  usually 
associated. 

The  discussion  was  continued  by  Mr.  Blake,  who 
read  a  paper  on  the  "  Occurrence  of  Cancer  in  Chalk 
Valleys,"  and  by  Dr.  Herbert  Snow,  the  title  of 
whose  communication  was  the  "  Insidious  Marrow  In- 
fection of  Mammary  Carcinoma."  The  latter  reported 
several  cases  showing  the  danger  of  this  infection  being 
passed  over  unrecognized,  as  might  very  readily  hap- 
pen, by  reason  of  the  ill-defined  character  of  the  symp- 
toms. 

In  closing  the  discussion.  Dr.  Braithewaite  said  that 
the  arguments  of  his  opponents  failed  to  convince  him 
that  he  had  made  such  a  serious  error  as  they  seemed 
to  think.  Indeed,  the  cases  reported  by  one  of  those 
who  had  taken  part  in  the  discussion  bore  out  remark- 


424 


MEDICAL    RECORD. 


[September  21,  1895 


ably  his  theory  of  the  water-borne  nature  of  malignant 
disease. 


Secoxd  Day,  Thursday,  August  ist. 

Peripheral  Neuritis.— The  greater  part  of  the  session 
of  the  second  day  was  occupied  with  the  discussion  on 
the  pathology  of  this  affection. 

Dr.  Seymour  J.  Sharkey  said  that  the  symptoms 
of  peripheral  neuritis  have  long  been  known,  and  Graves 
suggested  that  they  had  their  origin  in  disease  of  the 
peripheral  nerves,  but  it  was  only  in  1864  that  Dumes- 
nil  showed  that  such  a  pathological  condition  existed 
in  the  disease.  As  usually  happens,  when  a  new  field 
like  this  is  opened  up,  a  large  number  of  conditions 
previously  not  understood  have  been  attributed  to  this 
cause,  and  we  shall  probably  have  to  strike  from  the 
list  many  diseases  at  present  referred  to  inflammation 
of  the  peripheral  nerves.  The  subject,  indeed,  is  still 
in  its  infancy,  and  there  are  many  things  yet  to  be 
learned.  It  is  a  question  whether  we  have  not  been 
trying  to  draw  too  sharp  a  line  between  the  periph- 
eral and  the  central  nervous  system  ;  whether  we 
have  not  been  too  anxious  to  limit  the  pathology  of 
many  of  these  diseases  to  the  nerves,  while  the  va- 
rious agents  which  produce  them  cause  alteration  in 
the  centres  as  well.  Alcohol,  lead,  the  poisons  of  acute 
specific  diseases,  and  many  others,  are  certainly  pro- 
ductive of  wide-spread  central  changes,  at  the  same  time 
that  they  specially  affect  the  peripheral  nerves.  An- 
other question  is  whether  the  condition  is  truly  one  of 
inflammation.  Are  we  justified  in  speaking  of  a  change 
in  nerves  as  inflammatory  in  the  absence  of  those  vas- 
cular phenomena  which  are  usually  looked  upon  as 
proof  of  inflammation  ?  The  pathological  condition 
found  post  mortem  is  often  segmentation  and  breaking 
up  of  the  medullary  sheath  and  nothing  more.  This  is 
called  '■  parenchymatous  neuritis."  In  other  cases 
nothing  at  all  is  found.  The  speaker  thought  it  would 
be  more  correct  to  speak  of  peripheral  nerve-intoxica- 
tion where  nothing  is  found  post  mortem,  of  peripheral 
nerve-degeneration  where  the  only  change  is  breaking 
up  of  the  white  sheath  of  Schwann,  and  of  peripheral 
neuritis  when  the  vascular  phenomena  of  inflammation 
are  present  as  well.  The  granular  degeneration  of 
muscles,  whether  fatty  or  albuminous,  and  that  of  many 
cells  in  the  body,  such  as  those  of  the  liver,  is  not  the 
result  of  inflammation  only.  Why,  then,  should  break- 
ing up  of  the  medullary  sheath  into  droplets  be  called 
neuritis?  It  may  or  may  not  be  true  that  we  cannot 
yet  separate  these  cases  clinically,  but  it  may  be  possi- 
ble to  do  so  some  day.  If  this  distinction  between 
nerve  degeneration  and  nerve-inflammation  were  made, 
many  cases,  such,  for  instance,  as  are  now  sometimes 
classified  as  "dyscrasic  peripheral  neuritis  "  would  re- 
ceive a  more  reasonable  explanation  as  cases  of  degen- 
eration. 

.■\gain,  it  is  possible  that  we  have  not  learned  to  ap- 
preciate the  significance  of  the  changes  in  nerve-sub- 
stance found  post  mortem.  Lesions  supposed  to  be 
those  of  parenchymatous  neuritis  have  been  found  after 
death  when  there  were  no  symptoms  pointing  to  that 
condition  during  life.  It  is  possible  that  ordinary  post- 
mortem changes  have  been  mistaken  for  pathological 
lesions.  In  multiple  neuritis  the  peripheral  ramifica- 
tion of  the  nerves  are  first  and  most  affected.  This 
may  be  because  they  are  more  exposed  to  the  action  of 
the  poison,  or  perhaps  less  able  to  resist  it  than  the 
more  central  portions.  Another  interesting  point,  the 
speaker  said,  is  that  certain  poisons  appear  to  have  a 
special  affinity  for  certain  nerves. 

In  alcoholic  neuritis  the  extensor  muscles  of  the 
limbs,  and  especially  of  the  legs,  almost  invariably  fall 
first  a  prey  to  the  poison  ;  in  lead-poisoning,  the  exten- 
sors of  the  fingers  and  wrists  ;  in  diphtheria,  the  mus- 
cles of  the  throat  and  internal  muscles  of  the  eye.  Still 
more  remarkable  is  it  that  the  selective  power  of  these 


toxic  agents  may  exert  itself  on  the  motor  filaments  or 
on  the  sensory  almost  exclusively.  In  lead-poisoning, 
for  instance,  sensory  alterations  are  hardly  complained 
of  at  all,  and  the  same  is  often  true  of  diphtheria, 
whereas  in  cases  of  alcoholic  neuritis  a  stage  of  the 
most  acute  sensory  disturbance  may  long  precede  the 
advent  of  paralysis.  Indeed,  there  is  some  ground  for 
supposing  that  even  the  trophic  and  vasomotor  nerves 
may  be  specially  picked  out  in  some  cases.  There  are 
grounds  for  supposing  that  the  remarkable  vascular 
and  trophic  changes  which  characterize  Raynaud's 
disease  are  the  result  of  a  special  affection  of  the  vas- 
cular and  trophic  nerve- filaments  or  the  centres  from 
which  they  radiate.  We  do  not  know  as  much  as  we 
might  about  the  so-called  reaction  of  degeneration. 
The  alterations  which  occur  are  very  variable,  some- 
times being  but  slight,  sometimes  profound.  In  the 
latter  case  they  indicate,  no  doubt,  a  very  marked  dis- 
organization of  nerve  and  muscle.  But  we  do  not 
know  what  the  slighter  changes  or  their  absence  may 
signify  as  regards  the  pathological  changes  in  the 
nerves. 

Now  that  it  has  been  shown  that  atrophic  paralysis 
may  result  from  disease  of  the  peripheral  nerves,  the 
question  arises  whether  we  have  any  means  at  our  dis- 
posal enabling  us  to  distinguish  betneen  anterior  cor- 
nual  disease  and  peripheral  nerve  disease.  Again,  cases 
of  paraplegia  due  to  an  extensive  affection  of  the  spinal 
cord,  in  which,  nevertheless,  there  is  no  alteration  in 
sensation,  are  not  uncommon,  and  similar  affections  of 
the  spinal  cord  and  its  surroundings  may  result  in  para- 
plegia with  pain  and  sensory  disturbances.  Dr.  Sharkey 
asked  how  such  diseases  of  the  spinal  cord  were  to  be 
distinguished  from  peripheral  neuritis.  This  has  gen- 
erally been  done  by  the  presence  of  an  affection  of  the 
sphincters  in  the  former  and  its  absence  in  the  latter. 
This,  however,  the  speaker  maintained,  is  not  a  safe 
criterion.  He  had  lately  had  a  case  of  painful  para- 
plegia under  his  care  in  which  the  sphincters  were  in- 
volved, and  in  which  nothing  was  discovered  at  the 
post-mortem  examination.  On  microscopic  investiga- 
tion of  the  nerves  proceeding  from  the  pelvis  an  in- 
tense neuritis  was  found.  Another  question  is  that  of 
the  cause  of  the  peripheral  neuritis  and  muscular  atro- 
phy which  occur  in  association  with  joint  disease. 
This  has  not  yet  received  a  satisfactory  explanation. 
Other  points  raised  by  the  speaker,  and  which  he  hoped 
would  some  day  receive  a  satisfactory  explanation,  were 
the  absence  of  knee-jerk  in  many  cases  of  diabetes,  the 
cause  of  Raynaud's  disease,  the  question  whether  pe- 
ripheral neuritis  ever  gives  rise  to  spasmodic  affections, 
the  possibility  that  many  so-called  functional  diseases 
of  the  viscera  are  the  result  of  temporary  inflammation 
or  degeneration  of  nerves  due  to  the  action  of  some 
■poison. 

Dr.  W.  M.  Ori)  spoke  of  the  coincidence  of  anaemia, 
ulcer  of  the  stomach,  and  valvular  heart  troubles.  He 
had  thought  that  possibly  the  presence  of  a  gastric  ulcer 
had  caused  nutritive  disturbances  in  the  heart,  or  per- 
haps the  two  conditions  were  due  to  a  common  cause 
— some  nerve-lesion.  The  circular  margin  of  ulcer  of 
the  stomach  offered  a  presumption  of  its  nervous 
origin. 

Post-mortem  Nerve-lesions. — Dr.  Russell  Wells 
read  a  p.iper  on  "  Post  -  mortem  Degeneration  of 
Nerves,"  in  which  he  described  the  results  of  a  study 
undertaken  by  himself  and  Dr.  \\'.  H.  Wilson.  In  pa- 
tients dying  from  various  diseases  quite  apart  from 
nerve-lesions,  the  appearance  of  the  medullary  portion, 
as  seen  under  the  microscope,  varied  according  to  the 
time  after  death  at  which  the  preparation  was  examined. 
The  earliest  changes  were  breaking  up  of  the  medullary 
sheath  and  variations  in  the  readiness  with  which  the 
nerve-fibres  stained  with  reagents ;  the  axis  cylinders  did 
not  take  part  in  these  changes.  The  loss  of  the  medulla 
gives  rise  to  appearances  which  render  the  nerves  indis- 
tinguishable under  the  microscope  from  nerves  taken 


September  21,    1895] 


MEDICAL   RECORD. 


425 


from  cases  of  neuritis.  Dr.  Wells  said,  however,  that 
he  had  not  seen  as  a  post-mortem  change  rupture  of 
the  axis  cylinder,  which  writers  on  neuritis  describe  as 
occurring  in  that  affection.  He  was  of  opinion  that 
the  changes  met  with  in  neuritis  are  not  always  due  to 
post-mortem  decomposition,  because  in  the  case  of  ani- 
mals in  which  neuritis  has  been  produced  artificially 
the  nerves  are  usually  examined  immediately  after  they 
are  killed,  and  yet  the  nerves  show  alterations  in 
structure. 

Dr.  Mott  thought  that  peripheral  neuritis  was  of 
interest  in  view  of  the  theory  of  Marie  that  it  is  due  to 
modifications  in  the  ganglion  cell  with  which  the  nerve 
is  in  anatomical  continuity.  That  in  diphtheria  changes 
occur  in  the  cells  of  the  anterior  horn  as  well  as  in  the 
nerves,  and  that  the  paralysis  was  in  some  instances 
permanent  and  associated  with  wasting,  was  in  favor  of 
this  view.  He  believed  that  the  reason  why  alterations 
in  structure  occurred  in  the  end  plates  of  motor  nerves 
in  peripheral  neuritis  was  their  remoteness  from  the 
seat  of  nutrition  in  the  ganglion  cell.  Fibrous  tissue 
met  with  around  the  nervous  tissue  in  various  cases  of 
nerve-degeneration  he  believed  to  be  secondary  to  that 
degeneration. 

Dr.  Ormi- rod  suggested  that,  as  Dr.  Hughlings  Jack- 
son had  shown  that  the  smaller  nerve-cells  were  more 
I'kely  to  be  affected  than  the  larger  by  poison,  it  was 
reasonable  to  assume  that  the  smaller  terminal  fibres 
were  more  readily  affected  than  the  larger  trunks. 

Sir  T.  Grainger  Stewart  thought  that  an  affection 
of  peripheral  nerves  was  the  only  eNplanation  of  the 
combination  of  the  motor,  sensory,  and  nutritive 
rhanges  met  with  in  this  disease  He  thought  the  fol- 
I'lwing  clinical  points  were  worthy  of  note  :  i.  The 
possibility  of  perfect  recovery  from  so  marked  a  lesion 
of  the  nerves ;  2,  an  affection  of  peripheral  nerves 
offers  a  ready  e.xplanation  of  the  transitory  parah  ses 
met  with  in  the  early  stages  of  locomotor  ataxy  :  3, 
the  capriciousness  of  neuritis  in  the  selection  of 
nerves  ;  4,  the  not  infrequent  deaths  in  this  disease 
due  to  the  involvement  of  vital  nerves.  He  said  that 
hypodermic  injections  of  strychnine,  as  soon  as  the 
first  acute  stage  was  passed  over,  were  much  more  effi- 
cacious than  the  administration  of  the  drug  by  the 
mouth. 

Dr.  Hamilton  questioned  the  correctness  of  the 
nomenclature  in  peripheral  neuritis,  for  he  believed 
the  appearances  were  entirely  due  to  degenerative 
changes,  and  not  to  inflammatory  processes  at  all. 

Dr.  Saundbv  was  of  the  opinion  that  in  many  cases 
the  changes  were  in  reality  due  to  inflammation  of  the 
nerves.  He  evidenced  in  support  of  this  view  the  ten- 
derness which  occurs  over  the  nerve-trunks  in  certain 
torms  of  neuritis,  as  well  as  tlie  swelling  which  accom 
panics  this  tenderness. 

Vaccinia  and  Small-pox. — Dr.  S.  Monckton  Cope- 
man  read  a  long  paper  in  which  he  gave  the  details  of 
a  successful  attempt  to  cultivate  the  micro-organism  of 
variola  and  to  inoculate  therewith  a  calf,  obtaining 
from  the  latter  a  lym]jh  with  which  a  successful  vac- 
cination was  performed.  He  had  discovered  a  }ear 
ago  the  presence  in  specially  stained  specimens  of  vac- 
cine lymph,  taken  before  full  maturity  of  the  vesicles, 
minute  bacilli,  often  in  cons  derable  numbers  and  in 
practically  pure  culture.  These  bacilli  cannot  be 
found  in  mature  lymph,  for  the  reason  probably  that 
they  have  given  place  to  spores.  After  several  at- 
tempts he  succeeded  in  cultivating  this  micro-organism 
in  the  hen's  egg.  He  began  by  first  cleansing  the  sur- 
face of  the  egg  with  corrosive  sublimate  solution  and 
afterward  with  alcohol,  and  then  breaking  a  small  hole 
in  the  shell  by  means  of  a  sterilized  needle  and  forceps. 
Through  the  opening  thus  made  he  mixed  the  yolk  and 
albumin  of  the  egg  by  means  of  a  platinum  needle,  and 
then  carried  out  the  inoculation  by  means  of  a  glass 
capillary  pijiette  which  had  recently  been  drawn  out 
in  the  blow-pipe  flame.     For  these  inoculations  he  em- 


ployed variolous  crusts  which  were  rubbed  up  in  a 
small  glass  mortar  with  a  minimal  quantity  of  sterilized 
normal  saline  solution.  After  the  inoculation  the  small 
hole  in  the  egg  was  closed  up,  and  the  eggs  were  placed 
on  beds  of  cotton-wool  and  kept  in  the  incubator  at  a 
temperature  of  37°  i'.  Here  they  were  left  for  varying 
periods  of  time,  a  month  being  the  period  which  was 
eventually  found  to  be  that  which  was  most  desirable. 
On  opening  an  egg  thus  treated  the  speaker  found  a 
creamy  material,  which  had  rejilaced  the  ordinary  egg 
contents.  This  material,  examined  under  the  micro- 
scope, appeared  to  be  a  pure  culture  of  one  organism 
only — viz.,  a  bacillus  which  morphologically  was  not  to 
be  distinguished  from  the  bacillus  previously  found  in 
early  vaccine  lymph. 

Attempts  to  grow  this  bacillus  in  various  subcultures 
were  invariably  unsuccessful,  but  inoculations  of  calves 
gave  positive  results.  With  the  lymph  obtained  from 
these  calves  children  were  vaccinated  and  the  opera- 
tion "  took  "  well.  The  experiments,  however,  were 
not  as  satisfactory  as  they  might  have  been,  for  it  was 
necessary  to  use  calves  at  a  vaccine  station  which  were 
at  the  same  time  vaccinated  in  some  other  part  with 
the  calf  lymph  employed  at  that  station.  Every  possi- 
ble precaution  was  taken  in  the  way  of  sterilizing  in- 
struments and  keeping  the  incisions  protected  as  far  as 
possible  against  accidental  inoculation  with  lymph  from 
some  part  of  the  same  or  other  calf  into  which  the  or- 
dinary animal  vaccine  material  had  been  inserted. 
Nevertheless,  it  is  possible  that,  in  spite  of  all  precau- 
tions, accidental  inoculation  with  ordinary  lymph  may 
have  occurred  ;  or  possibly  the  simultaneous  inocula- 
tion of  the  calves  with  egg  culture  and  with  ordinary 
vaccine  lymph  may  have  in  some  way  influenced  the 
manifestation  witnessed  on  the  areas  wherein  the  egg 
lymph  was  inserted. 

The  experiments  would,  however,  be  repeated  with 
all  these  possible  sources  of  error  eliminated.  Should 
these  prove  successful  it  is  not  too  much  to  believe  that 
we  may  eventually  be  able  to  elaborate  not  only  a  vac- 
cine but  an  antitoxin  for  treatment  of  a  person  actually 
suffering  from  the  disease,  as  we  now  treat  the  subjects 
of  diphtheria. 

Dr.  Haughton  thought  that  there  was  something 
more  than  mere  microbic  infection  in  the  production  of 
smallpox- — that  insanitary  conditions  were  of  nearly,  if 
not  quite,  equal  importance. 

Dr.  Dexham  had  noticed  that  the  vaccine  from  a 
calf  approaching  puberty  was  not  so  efficacious  as  that 
taken  from  a  younger  animal.  He  confirmed  a  statement 
which  had  been  made  by  the  reader  of  the  paper  that 
the  mixing  of  lymph  with  glycerine  and  storing  for 
some  time  led  to  the  total  destruction  in  it  of  saprophy- 
tic organisms. 

In  closing  the  discussion,  Dr.  Copeman,  referring  to 
vaccine  points,  said  that  they  are  bad,  and  that  if  used 
at  all  they  should  be  made  of  celluloid,  which  can  be 
sterilized,  rather  than  ivory,  which  cannot  be  so  satis- 
factorily sterilized  owing  to  the  interstices  in  it.  In 
answer  to  a  question,  he  stated  that  he  did  not  believe 
that  the  psorosperms  produced  in  the  rabbit's  cornea 
after  inoculation  had  anything  to  do  with  the  produc- 
tion of  small-pox,  and  he  said  that  they  had  never 
been  found  in  vaccine  lymph  itself. 

Pernicious  Anaemia.— Dr.  Hunter  then  read  a 
paper  on  this  affection  in  which  he  held  that  it  was  a 
disease  sui\^enens  and  not  related  to  the  forms  of  ane- 
mia associated  with  cancer  and  other  diseases.  His 
reasons  for  this  conclusion  were  that  there  are  not  the 
same  pathological  changes  in  the  blood  in  the  latter  as 
in  pernicious  anajmia,  and  that  the  extreme  degree  of 
blood  change  is  always  associated  with  marked  patho- 
logical changes  in  the  liver,  kidney,  and  spleen,  such  as 
are  not  found  in  traumatic  and  other  anremias.  Dr. 
Stockman  had  advanced  the  view  that  the  main  differ- 
ence between  pernicious  anaemia  and  other  forms  of 
anremia   lies  in  the    presence   of   hemorrhages   in   the 


426 


MEDICAL    RECORD. 


[September  21,  1895 


former  and  not  in  the  latter,  but  the  speaker  said  that 
he  had  failed  to  produce  pigment  deposits  in  the  liver 
by  injecting  large  quantities  of  blood  into  the  peritoneal 
cavity  of  rabbits,  and  further,  that  in  his  experience 
hemorrhages  in  pernicious  anaemia  were  very  rare  ex- 
cept into  the  retina  and  meninges. 

Dr.  Copeman  thought  that  urobilin  occurred  only 
in  those  cases  of  pernicious  anaemia  which  were  associ- 
ated with  high  temperature,  and  he  thought  that  there 
were  other  cases  in  which  just  as  profound  changes  oc- 
curred in  the  blood  without  the  deposition  of  pigment 
in  the  liver. 


Third  Day,  Friday,  August  2D. 

Lymphadenoma. — Dr.  W.  G.  Spencer  opened  the 
discussion  on  this  subject.  The  term,  he  said,  was  one 
applicable  to  all  neoplasms  composed  of  lymphadenoid 
tissue  resembling  in  structure  a  lymphatic  gland.  Un- 
til our  knowledge  of  these  growths  is  enlarged  it  is  bet- 
ter to  rest  satisfied  with  some  general  term  of  this  kind. 
In  a  study  of  the  etiology  of  the  affection  we  may  fol- 
low the  analogy  of  tuberculosis  and  distinguish  a  local 
disease,  lymphadenoma,  and  a  general  disease,  lympha- 
denomatous.  There  are  two  types  of  the  local  affec- 
tion. The  first  is  simple  lymphadenoma,  which  is  sim- 
ply an  overgrowth  of  lymphadenoid  tissue  excited  by 
some  cause  acting  continually  upon  this  tissue  from  the 
surface  of  the  skin  or  mucous  membrane.  In  malig- 
nant lymphadenoma  there  is  a  tendency  in  the  cells  to 
proliferate  without  the  incitation  of  the  continuous  local 
irritation.  The  connective-tissue  cells  of  the  septa  and 
capsule  also  participate  in  this  overgrowth.  Since  there 
is  no  source  of  irritation,  acting  from  without,  which  is 
sufficient  to  keep  up  the  continued  multiplication  of 
cells,  the  cause  must  be  looked  for  within  the  tumors 
themselves.  Then  there  is  the  general  affection,  lym- 
phadenomatosis,  in  which  lymphadenoid  tissue,  wher- 
ever existent,  is  attacked,  and  in  which  we  find  also  the 
general  symptoms  cachexia,  anemia,  hemorrhages,  ir- 
regular temperature  curve,  and  an  increased  proportion 
of  white  blood-cells.  Hodgkin's  disease,  lymphatic 
cachexia,  splenic  leucaemia,  and  various  other  names 
have  been  applied  to  this  disease,  but  they  are  confusing 
and  ought  to  be  dropped.  If  a  classification  be  at- 
tempted, it  is  better  to  adopt  one  based  upon  the  way 
by  which  the  virus,  if  there  be  one,  enters  the  system. 
Thus  we  find  cases  in  which  the  infection  apparently 
occurs  through  the  intestinal  tract,  others  in  which  the 
channel  is  the  lungs.  Much  experimental  work  is  being 
done  to  determine  whether  there  is  a  micro-organism 
acting  as  the  cause  of  the  disease,  but  there  are  still  the 
usual  contradictory  and  negative  results  inseparable 
from  the  early  stages  of  such  investigations. 

Mr.  J.  Jackson  (Clarke  said  that  in  his  opinion 
there  was  no  distinction  to  be  made  between  Hodg- 
kin's disease,  lymphosarcoma,  and  lymphadenoma. 
He  thought  lymphadenoma  frequently  went  on  to  true 
sarcoma.  In  cases  of  deep-seated  mediastinal  lyni])]!- 
adenoma,  a  diagnosis  was  often  made  possible  by  in- 
filtration of  the  skin.  He  had  found  lymphomatous 
growths  in  various  organs  in  leucaemia.  Lymphade- 
noma was  often  found  associated  with  osteoarthritis 
and  gout. 

Dr.  Murray  Leslie  related  a  number  of  cases 
showing  the  existence  of  a  close  relationship  between 
lymphadenoma  and  leucaemia  and  splenic  anaemia. 
The  number  of  leucocytes  and  ha;mocytes  depends  on 
tlie  relative  involvement  of  blood-destroying  struct- 
ures. Dr.  Leslie  believed  that  lymphadenoma  is  an  in- 
fectious disease,  and  offered  the  following  arguments 
in  favor  of  this  hypothesis  :  i.  Certain  cases  seem  to 
owe  their  origin  to  exposure  to  foul  air  ;  2,  micrococci 
and  other  organisms  have  been  found  in  tlie  affected 
structures  ;  3,  the  close  analogy  which  exists  between 
this  and  tuberculosis  and  other  microbic  diseases  ;  4, 


affection  of  the  cervical  glands  would  point  to  infec- 
tion by  the  mouth,  of  the  mediastinal  glands  by  the 
lungs,  and  of  thfe  mesenteric  glands  and  Peyer's 
patches  by  the  alimentary  canal  ;  5,  pyrexia  and  night 
sweats  are  present,  as  in  other  diseases  of  micro-para- 
sitic origin  ;  6,  the  beneficial  effects  of  arsenic  are 
probably  to  be  attributed  to  its  germicidal  action,  and 
are  comparable  with  the  action  of  mercury  in  syphilis. 
The  speaker  would  place  lymphadenoma  among  the 
granulomata,  along  with  syphilis,  tubercle,  and  leprosy. 

Dr.  G.  X.  Pitt  said  that  true  lymphadenoma  con- 
sists of  an  adenoid  overgrowth  limited  to  adenoid  tis- 
sue, which  never  fungates  or  infiltrates,  and  which  de- 
stroys only  by  pressure  on  vital  structures.  He  had 
seen  tubercle  and  lymphadenoma  associated,  and  he 
thought  the  difference  between  neoplasms  and  infec- 
tious granulomata  might  turn  out  to  be  less  than  at 
present  supposed.  When  there  is  leucocytosis  the 
spleen  is  more  frequently  enlarged,  though,  on  the 
other  hand,  a  temporary  and  variable  leucocytosis  may 
occur  apart  from  splenic  enlargement.  He  did  not 
agree  with  Dr.  Spencer,  who  had  said  that  if  improve- 
ment took  place  under  the  use  of  arsenic,  the  disease 
must  be  lymphadenoma,  for  he  had  seen  an  undoubted 
spindle-celled  sarcoma  melt  away  under  the  action  of 
this  drug. 

Dr.  Snow  said  there  were  three  distinct  affections 
characterized  by  enlargement  of  the  lymphatic  glands, 
viz.,  I,  Simple  lymphoma  ;  2,  Hodgkin's  disease,  a 
general  enlargement  of  glands  throughout  the  body, 
often  occurring  during  pregnancy  or  after  exposure  to 
cold  or  w-et,  accompanied  by  elevation  of  temperature, 
and  shown  under  the  microscope  to  be  a  cirrhosis  of  the 
gland  ;  3,  lymphosarcoma  or  lymphocarcinoma,  a  true 
cancer,  and  showing  all  the  features  of  a  malignant 
growth,  viz.,  cell  proliferation,  erosion  of  adjacent  tis- 
sues, and  progressively  fatal  tendency. 

In  closing  the  discussion  Dr.  Spencer  said  that 
lymphoma  should  be  applied  to  a  growth  of  lymphatic 
vessels,  lymphadenoma  to  one  of  the  lymphatic  glands. 
He  did  not  feel  at  all  certain  as  to  the  microbic  origin 
of  the  neoplasms.  As  to  leucremia,  that  was  a  symp- 
tom only  and  not  a  disease. 

The  Diazo-reaction.^DR.  Hewlett  then  presented 
a  communication  on  Ehrlich's  diazo-reaction  of  the 
urine  in  typhoid  fever.  The  same  reaction,  he  said,  is 
obtained  with  morphine  even  in  a  i  to  5,000  solution. 
This  was  the  only  foreign  substance,  however,  with 
which  he  had  been  able  to  obtain  a  reaction.  The  re- 
action can  be  obtained  as  early  as  the  sixth  day  in  cases 
of  typhoid  fever,  but  the  speaker  did  not  regard  the  test 
as  especially  reliable  or  as  one  of  positive  diagnostic 
value  ;  negatively,  however  (its  absence  showing  that 
the  affection  was  not  typhoid  fever),  he  regarded  it  as 
vgry  valuable. 

Microbes  in  the  Air. — Dr.  St.  Clair  Thomson 
reported  tlie  results  of  a  number  of  experiments  con- 
ducted in  collaboration  with  Dr.  Hewlett,  to  deter- 
mine the  fate  of  micro-organisms  in  the  respired  air. 
They  had  found  that  fewer  bacteria  were  inhaled 
through  the  nose  in  ordinary  breathing  than  was  com- 
monly supposed,  and  that  most  of  these  were  arrested 
at  the  entrance  to  the  nostrils.  Indeed,  the  mucous 
membrane  of  the  nose,  in  health,  w.is  truly  aseptic. 

Hypertrophic  Pulmonary  Osteoarthropathy. — Dr.  F. 
R.  Walters  reported  a  case  of  hypertrophic  pulmo- 
nary osteoarthropathy,  and  presented  the  patient  to  the 
Section.  He  thought  that  the  disease  was  the  result  of 
the  action  of  toxins  upon  the  tissues.  It  was  essentially 
different  from  acromegaly. 

A  paper  on  "  Psorospermosis "  was  then  read  by 
Drs.  Danett  and  Surveyor,  and  another  on  the  "  Growth 
of  the  Choleraic  Vibrio  and  other  Bacilli  in  Sunlight  " 
by  Dr.  Westbrook. 

After  a  vote  of  thanks  to  the  presiding  officer.  Dr. 
Wilks,  the  sessions  of  the  Section  were  brought  to  a 
close. 


September  21,  1895] 


MEDICAL    RECORD. 


427 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  ON  ORTHOPEDIC  SURGERY. 

Stated  Meeting,  May  17,  iSQj. 

L.  W.  Hubbard,  M.D.,  Chairman. 

Bending  of  the  Neck  of  the  Femnr. — Dr.  Royal 
^VHIT.MA^"  presented  a  boy,  about  eleven  years  of  age, 
v.-ith  bending  of  the  neck  of  one  femur,  causing  consid- 
erable adduction,  but  not  to  the  degree  which  he  had 
seen  in  some  other  cases.  The  deformity  was  a  rare 
one.  He  had  seen  only  six  cases.  There  was  limita- 
tion of  motion  in  all  directions,  and  some  pain  was 
present,  sometimes  very  severe.  These  cases  were  usu- 
ally mistaken  for  hip-disease  or  dislocation. 

Congenital  Dislocation  of  the  Shoulder ;  Replacement 
after  Trimming  the  Head  of  the  Humerus. — Dr.  A.  M. 
P.HELPS  presented  a  boy,  nine  years  old,  who  after  birth, 
the  labor  having  been  instrumental,  was  found  to  have 
dislocation  of  the  humerus  backward  under  the  spine 
of  the  scapula.  The  doctor  suggested  that  it  be  left 
until  the  child  got  older,  and  later  another  physician 
pronounced  it  a  case  of  paralysis.  Other  physicians 
and  surgeons  had  since  seen  the  boy  and  were  of  opin- 
ion that  an  operation  was  not  advisable.  After  con- 
sultation with  Drs.  Gibney  and  Morris,  Dr.  Phelps 
decided  to  operate.  Sixteen  days  ago  he  cut  down  on 
the  head  of  the  bone,  which  was  underneath  the  spine 
of  the  scapula,  liberated  it,  felt  of  the  glenoid  cavity, 
found  it  nearly  as  large  as  a  quarter  of  a  dollar,  con- 
sidered whether  to  enlarge  the  cavity  or  trim  the  head 
of  the  bone,  and  decided  to  do  the  latter,  for  the  reason 
that,  had  he  enlarged  the  cavity  it  would  still  have  been 
necessary  to  shorten  the  humerus  in  order  to  replace  it 
and  the  result  would  have  been,  in  bringing  the  two 
raw  surfaces  together,  anchylosis  of  the  joint.  The  case 
seemed  to  possess  some  unique  features,  differing,  of 
course,  from  old  dislocations  forward  under  the  acro- 
mian  or  backward  into  the  axilla,  and  also  in  the  man- 
ner of  adapting  the  articulating  surfaces  to  each  other. 

The  Treatment  of  Postural  Deformities  of  the  Trunk 
by  Means  of  Rapid  and  Thorough  Physical  Develop- 
ment.— This  was  the  title  of  the  paper  of  the  evening, 
by  Dr.  Jacob  Teschxer.  He  commenced  by  saying 
that  the  results  of  the  different  forms  of  treatment  of 
postural  deformities  have  been  generally  slow  and  un- 
satisfactory up  to  the  present  time.  He  claimed  that  a 
weakened  or  rudimentary  condition  of  certain  muscu- 
lar groups,  or  of  the  muscular  system  generally,  is  the 
most  important  etiological  factor  in  these  deformities. 
Development  of  the  full  strength  of  the  individual,  of  the 
entire  muscular  system,  and  thorough  muscular  educa- 
tion, are  the  desiderata  in  treatment.  The  amount  of 
benefit  derived  from  gymnastics  is  in  proportion  to  the 
v.ill,  strength,  and  development  which  are  necessary  to 
partially  or  completely  reduce  a  postural  deformity. 
Gymnasium  and  class  work  for  deformities  are  strongly 
objected  to.  So  are  all  supporting  or  immobilizing 
-ppliances,  because  they  interfere  with  perfect  muscu- 
.ar  freedom. 

The  important  points  to  be  observed  in  the  develop- 
ment of  strength  and  muscle,  and  in  muscular  educa- 
tion, are  correct  attitude,  ease,  grace,  and  rhythm  of 
lotion,  and  automatic  and  independent  and  full  action 
A  only  those  groups  of  muscles  which  are  called  into 
play  by  the  performance  of  each  separate  exercise,  and 
each  group  of  muscles  automatically  exercised  until  it  is 
thoroughly  tired.  No  muscle  can  be  properly  devel- 
oped unless  it  be  tired  by  frequent  and  uninterrupted 
automatic  contractions  and  relaxations. 

Taking  the  stand-point  that  :  i.  Lack  of  strength  and 
ack  of  muscular  development ;  2,  habitual  faulty  posi- 
•-ion  with  superimposed  weight  ;  and  3,  lack  of  co-ordi- 
nating power  or  lack  of  muscular  control,  are  the  more 
potent  etiological  factors  in  producing  deformities. 
He  corrects  deformities  by  reversing  these  conditions  : 


I,  By  developing  the  muscles  and  their  strength  ;  2, 
by  acquiring  an  habitually  corrected  position  with  super- 
imposed weight ;  and  3.  by  educating  all  the  muscles  to 
proper  co-ordination  and  complete  control. 

A  series  of  twenty-six  dumb-bell  exercises  were  de- 
monstrated by  a  nude  patient.  Heavy  work  with  dumb- 
bells weighing  from  five  to  forty  pounds  each,  and 
with  steel  bars  weighing  from  twenty-six  to  seventy- 
eight  pounds,  was  also  shown  by  different  patients.  An 
exact  record  is  kept  of  the  work  done  by  each  patient 
at  each  \"isit.  After  the  work  they  are  showered  with 
cold  water  and  rubbed  down  with  alcohol.  The 
heavier  the  weight  held  above  the  head,  the  more  the 
patient  must  exert  him-  or  herself  to  improve  the  atti- 
tude in  order  to  maintain  the  equilibrium  ;  hence  the 
greater  the  weight,  the  greater  the  correction  of  the 
deformity. 

Nine  cases  were  reported,  with  charts  and  photo- 
graphs, of  which  five  were  exhibited.  One  case  of 
deformity  of  the  stemo-costal  articulations  of  the  right 
side,  and  six  cases  of  mild  curvatures  and  round- 
shoulders  practically  cured,  and  two  cases  of  old  and 
firmly  fixed  scolioses  (one  from  infancy)  which  were 
greatly  improved.  All  the  patients  improved  in  gen- 
eral health.  Measurements  and  strength  tests  were 
made  according  to  the  Sargent  system  and  recorded 
upon  the  Sargent  charts.  The  chest  capacities,  chest 
depths,  girths,  breadths,  and  strength  tests  are  generally 
increased,  the  abdominal  depths  are  decreased,  and 
the  feet,  the  foundation  of  correct  posture,  are  im- 
proved, inasmuch  as  all  flat  feet  become  shorter,  and 
the  normal  feet  grow.  No  bad  effect  upon  the  hearts 
of  patients  could  be  detected,  and  their  general  im- 
provement, and  increase  in  weight,  should  prove  that 
they  are  not  overworked. 

Employs  Mechanics  and  Exercise. — Dr.  Bracket, 
of  Boston,  said  he  had  had  no  practical  experience 
with  the  particular  method  described  by  Dr.  Teschner. 
He  looked  upon  lateral  curvature  as  a  vice  of  growth. 
While  the  patient  had  assumed  an  abnormal  position, 
growth  went  on  and  made  the  faulty  position  perma- 
nent, unless  some  means  were  taken  to  correct  it.  The 
spine  being  more  flexible  on  one  side  than  the  other, 
tended  to  bend  toward  the  concavity  and  to  become 
rotated.  Although  during  active  physical  exercise  the 
spine  could  be  made  to  straighten  itself  in  a  measure, 
and  this  process  could  be  repeated,  yet  during  the  in- 
tervals there  vv-as  a  tendency  to  resume  the  abnormal 
position.  He  believed,  therefore,  in  mechanical  treat- 
ment, supplemented  by  physical  development.  By  ap- 
paratus one  could  correct  the  faulty  position  and  main- 
tain it  in  a  positive  way,  while  by  exercise  growth  could 
be  encouraged  in  the  corrected  position  and  overcome 
the  tendency  to  relapse.  A  careful  record  should  be 
kept  of  one's  cases  both  by  outline  and  by  photograph. 

The  Dangers  of  the  Proposed  Method. — Dr.  H.  A. 
Wilson,  of  Philadelphia,  thought  it  would  be  impossi- 
ble for  the  physician  to  give  personal  supervision  of 
this  work  and  treat  many  cases.  If  it  were  transferred 
to  a  masseur  or  gymnast,  it  would  lead  to  such  abuses 
as  were  seen  in  all  cities.  He  must  acknowledge  that 
he  had  felt  some  anxiety  when  he  witnessed  the  small 
patient  going  through  such  severe  labor,  and  the  dan- 
ger would  certainly  be  real  should  it  be  prescribed 
without  the  immediate  supervision  of  a  doctor.  GjTn- 
nastic  exercises  without  intelligent  supernsion  often 
led  to  asymmetrical  development  of  the  muscles  of  the 
body  and  to  deformity. 

Dr.  J.  Young  said  Dr.  Teschner's  plan  of  treatment 
of  these  cases  was  entirely  opposed  to  that  which  he 
was  in  the  habit  of  employing.  He  was  accustomed  to 
prescribing  the  Swedish  movement  cure,  which  implied 
a  moderate  exercise  of  the  desired  group  of  muscles, 
giving  time  also  for  compensatory  development  of  the 
muscles  of  the  heart  and  respiration.  He  had  found 
that  unless  development  of  the  muscles  under  the  con- 
trol of  the  will  was  brought  about  slowly,  there  would 


428 


MEDICAL   RECORD. 


[September  21,  1895 


not  be  sufficient  compensatory  development  of  the 
heart  and  respiratory  muscles.  The  treatment  by 
muscular  exercise,  therefore,  should  take  time.  The 
use  of  massage  was  important,  and  electricity  had  its 
place.  The  condition  of  rotation  was  one  which  like- 
wise deserved  special  attention. 

Dr.  R.  W.  Lovett,  of  Boston,  thought  the  greatest 
objection  to  the  treatment  described  in  the  paper  was 
that  the  e.xercise  was  of  the  two  sides  equally.  He  was 
of  opinion  that  special  attention  should  be  given  the 
weaker  muscles.  While  gymnastic  treatment  was  pow- 
erful for  good,  it  was  equally  powerful  for  evil.  The 
more  he  saw  of  gymnastic  treatment  in  lateral  curva- 
ture, the  more  he  became  impressed  with  the  necessity 
for  extreme  care.  Two  years  ago  he  had  first  put 
some  cases  under  the  Swedish  movement  cure,  the 
Lyng  system,  by  a  lady  who  had  had  special  opportu- 
nities, and  although  he  was  at  first  a  sceptic,  he  had 
since  become  convinced  that  the  method  was  a  valua- 
ble one.  The  weaker  muscles  were  picked  out  and  ex- 
ercised and  strengthened,  while  the  stronger  opponents 
were  isolated.  The  patients  came  twice  a  day.  Noth- 
ing but  a  cot  and  a  bar  were  necessary.  Milder  cases 
might  become  perfectly  straight  in  the  course  of  some 
months.  Forcible  correction  was  also  resorted  to  in 
other  than  the  mildest  cases.  He  felt  like  Dr.  Wilson, 
that  there  was  some  danger  connected  with  the  severe 
form  of  exercise  prescribed  by  Dr.  Teschner. 

Dr.  H.  LiLiEXTHAL  had  seen  some  of  Dr.  Tesch- 
ner's  work,  and  believed  that  it  would  accomplish  what 
had  been  claimed  for  it. 

Dr.  Regin.\ld  H.  Savre  thought  the  method  was 
liable  to  result  in  undue  muscle  strain.  The  direction 
given  the  patients  to  breathe  easily  and  regularly  dur- 
ing the  exercises,  could  not  be  followed  while  the  va- 
rious muscles  of  the  body  were  under  strain  :  it  was 
natural  under  such  conditions  to  hold  the  breath. 
Young  tissue,  as  well  as  old  friable  tissue,  was  liable  to 
overstrain  and  injury.  There  was  greater  danger  of 
harm  in  the  deformed  patients  than  in  persons  of  nor- 
mal form.  In  some  instances  there  was  practically  no 
muscle  to  work  upon,  and  it  was  necessary  to  give  the 
bones  proper  support  during  growth  in  order  to  avoid 
further  deformity. 

Dr.  Samuel  Ketch  thought  minor  deformities  could 
be  corrected  by  ordinary  means.  There  was  greater 
difficulty  in  rotary  lateral  curvature.  The  rotation  de- 
served particular  attention,  and  no  case  could  be  con- 
sidered cured  until  this  element  had  been  eliminated. 
Regarding  rapid  physical  development  by  muscular 
exercise,  he  might  say  that  during  the  past  year  he  had 
watched  persons  training  in  a  noted  gymnasium  of  the 
city,  and  had  observed  that  deformity  was  not  uncom- 
mon. One  of  tlie  teachers,  a  physician,  showed  lateral 
curvature  of  the  spine.  It  seemed  to  him  that  the 
heavy  exercise  put  upon  small  children  for  a  short  time 
would  result  deleteriously  in  the  future.  It  was  a  ques- 
tion whether  the  gain  which  had  been  made  in  the  cases 
reported  would  be  retained  without  some  support  or 
continuing  the  treatment.  He  thought  most  good 
would  come  from  increasing  the  lateral  flexibility  of 
the  spine  and  keeping  the  patient  in  as  good  position 
as  possible. 

Dr.  Teschner  closed  the  discussion.  Regarding 
apparatus,  he  had  tried  it  and  had  found  that  while  it 
had  some  effect  in  changing  the  contour  of  the  spine, 
it  was  less  in  correcting  the  seat  of  the  deformity  than 
in  jiroducing  deformity  where  none  had  existed  before. 
Some  of  the  gentlemen  had  spoken  of  dangers  con- 
nected with  the  physical  training  which  he"  had  de- 
scribed. On  the  other  hand,  he  could  point  to  danger 
from  the  use  of  mechanical  treatment,  and  mentioned 
an  instance  or  two  in  which  syncope  had  resulted  from 
the  pressure  upon  the  sternum,  etc. 

As  to  flexibility  of  the  spine,  he  claimed  that  the 
method  which  he  advocated  was  most  efficient  in  this 
direction.     One  could  not  wait  for  correction  by  the 


development  of  the  muscles  which  were  at  fault  when, 
as  sometimes  appeared  to  be  the  case,  they  were 
scarcely  present  even  in  the  rudimentary  state.  He 
saw  no  reason  for  slow  correction  of  the  deformity 
when  it  could  be  brought  about  rapidly.  It  was  a  mis- 
take to  suppose  that  the  voluntary  muscles  were  devel- 
oped without  proportional  growth  of  the  cardiac  and 
respiratory  muscles.  The  lung  capacity  had  been 
markedly  increased,  there  had  been  no  cardiac  symp- 
toms, and  beyond  doubt  the  heart  had  developed  in 
proportion  to  the  rest  of  the  muscular  system.  He  im- 
pressed the  fact  that  he  gave  each  case  his  personal 
attention,  besides  having  an  experienced  assistant. 


-jxxrjgxcal  ^Suggestions. 

Gastrectomy. — (i)  The  smallest  amount  (a  few  drops 
in  the  first  case)  of  anaesthetic  possible  should  be  used  : 
(2)  all  antiseptics  should  be  avoided  in  the  abdominal 
cavity  ;  (3)  the  extra-peritoneal  method  of  resection 
should  be  adopted,  the  posterior  part  of  the  ring  of 
sutures  is  surrounded  by  gauze,  and  the  situation  of 
the  ren:iaining  sutures  should  be  permanently  extra- 
peritoneal, the  anterior  wall  of  the  stomach  is  covered 
in  by  a  flap  of  skin  ;  (4)  the  patient  should  be  fed  early 
by  the  mouth. — Langenbuch. 

In  Prolapse  of  the  Rectum,  sometimes  much  relief  is 
obtained  by  injecting,  before  going  to  the  closet,  from 
I  vij.  to  3  viij.  of  warm  water,  and  afterward  an  ounce 
of  cold  water,  allowing  it  to  remain. — Keen. 

Treatment  of  Burns. — 

Aristol 5—10.0 

Olive-oU   20.0 

Vaseline. 

Lanoline ua  40.0 

—Haas. 
Gonorrhoea. — 

Perchloride  of  mercury i  part 

-\ntip>Tin 100  parts 

Disiilled  water 10,000  parts 

The  injection  should  be  used  four  times  a  day  and 
retained  as  long  as  possible.  The  addition  of  anti- 
pyrin  prevents  smarting. — Vatier. 

Chordae. — 

e.    Ex.  opii gr.  j. 

Caniphome gr.  x. 

01.  iheobrom q.  s. 

M.  et  ft.  Suppository  No.  I.  Sig.  :  Use  at  bedtime. 

— RlCORD. 

Gonorrhoea,  Second  Stage. — 

5 .    I  lydrarg.  chlor.  corros   gr.  * 

Acidi  carbolici 3  iss 

Zinci  sulpho-carbolate gr.  xxiv. 

Boro-glyceride  ( fifty  per  ceiiL  sol. ) f  1  "j- 

Aquoe  ros.^ q.  s.  a.  d.   f  J  viij. 

M.  Sig.:  Use  as  injection  after  urinating. 

— White. 

Women  affected  with  metritis  or  displacements  often 
suffer  with  dry  cough  without  any  disease  of  the  re- 
spiratory organs. — Pozzi. 

Incontinence  of  Urine. — 

8.    Sodii  lienzi:itis. 

Sodii  s.alicyl;\tis :v.s  gr.  xx. 

Fid.  exl.  belladonna: •. gtt.  ij. 

Aqua;  cinnamomi 3  iv. 

M.  Sig. :  A  teaspoonful  four  or  five  times  daily. 

— White. 
Tricophytosis. — 

Chrysarobin gui.  10  to  25 

Salicylic  acid gm.  5 

Ointment  of  styrax gm.  3 

Iclithyol gm.  5 

Simple  ointment gm.  5 

— Du  Castel. 


September  21,    1895] 


MEDICAL    RECORD. 


429 


Cold  Bathing  during  menstruation  is  a  beneficial 
■measure,  provided  women  accustom  themselves  to  it 
ty  bathing  everj-  day  for  at  least  eight  days  before  the 
period.  Houzel  holds  that  cold  salt-water  baths  facili- 
tate the  menstrual  flow,  increase  the  duration  of  geni- 
tal life,  and  increase  fecundity. — Dep-\sse. 

Salol  in    Non-parasitic   Sycosis Twenty   to   forty 

grains  to  the  ounce  of  petrolatum  were  employed. — 
Caxtrell. 

Fractures. — The  object  of  the  surgeon  in  treating 
fractures  about  the  joints  should  be  :  i.  To  allow  free 
circulation  in  the  limb.  2.  To  obtain  complete  rest 
for  the  injured  structures  until  they  assume  their  nor- 
mal condition.  3.  To  posture  so  that  the  callus  e.\u- 
•dation  shall  not  unduly  hamper  the  joint  movements. 

Apoplexy.  — Apoplexy  occurring  in  early  adult  life  is 
much  more  frequently  due  to  syphilis  than  embolism, 
and  syphilis  is  a  factor  in  a  third  of  all  apoplexies,  at 
least  in  large  cities.  Apoplexies  are  increasir  g  in  dispro 
portionate  frequency.  The  disease  does  not  especially 
affect  brain  workers  if  they  live  temperately,  but  rather 
■spares  them.  An  attack  is  sometimes  a  conservative 
agent,  calling  a  halt  to  excessive  activity  and  intemper 
ate  living,  and  actually  prolonging  life.  About  one- 
fourth  of  those  stricken  with  apoplexy  die  from  the 
attack  (hemorrhages  being  the  most  dangerous,  throm- 
boses, especially  syphilitic,  being  least  so).  The  aver- 
age duration  of  life  of  those  who  have  and  survive  one 
shock  is  over  five  years.  The  chances  of  a  second  at- 
tack before  the  fourth  year  are  always  considerable, 
yet  do  not  amount  to  fifty  per  cent,  and  are  inconsid- 
■erable  so  far  as  hemorrhages  are  concerned.  Throm- 
boses are  much  more  apt  to  recur  than  hemorrhages. — 

D.^NA. 

Acute  Typhlitis. — I  have  rarely  seen  a  case  of  acute 
typhlitis  in  which  the  large  bowel  was  not  full  of  old 
faeces,  and  I  have  still  more  rarely  seen  a  case  in  which 
the  colon  could  be  unloaded  in  which  recovery  did  not 
take  place.  So  true  is  this,  that  of  late  years  I  have 
nearly  always  regarded  the  emptying  of  the  colon  as 
ending  the  immediate  danger  to  life,  provided,  of 
course,  that  the  inflammation  has  not  proceeded  to  the 
point  where  an  abscess  has  formed  or  perforation  taken 
place. — Stoker. 

Bactericidal  Properties  in  the  Vaginal  Secretion  of 
Pregnancy.  — Not  only  is  the  vaginal  secretion  in  nor- 
mal pregnancy  free  from  pathological  germs,  but  it  has 
a  distinct  germicidal  power.  Experiments  were  made 
in  a  great  number  of  pregnant  women  by  introducing 
into  the  vagina  different  kinds  of  germs,  and  then  at 
stated  intervals  withdrawing  secretion  for  examination, 
and  it  was  found  that  the  secretion  was  equally  active 
whether  the  vagina  contained  the  "  normal  secretion  " 
or  the  so-called  pathological  secretion  described  by 
Doederlein.  In  these  experiments  the  streptococcus 
was  killed  first,  the  staphylococcus  and  the  pyocyaneus 
needing  almost  twice  as  much  time.  The  vagina  was 
found  clear  in  two  days  at  longest.  Syringing  the 
vagina  with  antiseptic  solutions  has  the  effect  of  re- 
ducing or  completely  destroying  its  germicidal  powers. 
Hence  prophylactic  syringing  should  be  given  up.  It 
does  no  good,  and  much  harm.  Even  in  pregnancy 
with  gonorrhoeal  infection  it  is  best  omitted.  Disinfec- 
tion of  the  internal  genital  passages  should  be  aban- 
doned as  part  of  the  routine  of  antiseptic  midwifery. — 
Kroenig. 

Corneal  Ulcer. — Aristol  is  recommended  in  powder 
form  for  indolent  corneal  ulcerations  with  suppurating 
base.  It  is  thickly  applied  with  a  brush  and  the  eye 
kept  closed  for  a  time.  A  five  per  cent,  ointment  is 
useful  in  ulcerative  blepharitis,  being  preferable  to  the 
yellow  precipitate  ointment  on  account  of  its  causing 
less  irritation.     This  ointment  has  given  good  results 


in  obstinate,  recurring  hordeola  when  rubbed  into  the 
edges  of  the  lids  at  night. — Heuse. 

Facial  Erysipelas. — 

5.    Ergotine gm.  1.30 

Liquid  e-Ktiact  of  ergot gm.  S 

Lanolin ,   gm.  15 

Fresh  lard gm.  45 

Nf.    For  externa!  use. 

— Lees. 

Novel  Treatment  of  Fracture. — Cat  down  on  every 
oblique  fracture  of  the  leg,  expose  the  fragments,  bring 
them  into  accurate  apposition,  drill  holes  and  fasten 
by  steel  screws.  There  is  immediate  relief  of  pain  by 
this  method,  absence  of  tension  and  discomfort  due  to 
extravasation  of  blood  into  the  tissues,  and  shortening 
of  the  period  of  treatment.  This  is  especially  to  be 
recommended  in  the  laboring  man,  to  whom  time  is 
money. — Arbuthnot  Lane. 

Rhythmic  Tractions  of  the  Tongue. — i.  Lingual  trac- 
tions should  be  moderate  to  produce  their  effect  ; 
tractions  too  forcible  cause  an  inhibition  of  the  respira- 
tory reflex.  2.  The  best  mode  of  practising  traction 
is  to  use  no  special  instrument,  but  to  seize  the  point 
of  the  tongue  with  a  bit  of  linen  between  the  fingers. 
3.  The  process  is  not  superior  to  other  methods,  es- 
pecially insufflation,  and  that  it  would  be  culpable  to 
employ  it  exclusively. — Pinard. 

Post-Partum  Hemorrhage. — Flooding  after  the  appli- 
cation of  the  forceps  must  always  be  expected,  since 
the  instrument  is  usually  employed  because  of  uterine 
inertia,  a  source  of  hemorrhage.  The  danger  comes 
when  the  placenta  is  expelled. — T.\rnier. 

Painful  Fissures  of  the  Nipples  have,  for  some  time 
past,  been  treated  by  the  application  of  cocaine,  either 
in  the  form  of  an  ointment  or  a  liniment.  It  has  been 
found,  however,  that  when  thus  employed,  the  secre 
tion  of  milk  is  diminished  and  the  erection  of  the  nip- 
ple prevented.  These  objections  have  led  Dr.  Joire, 
of  Lille,  to  use  cocaine  with  the  direct  object  of  check- 
ing the  secretion  of  milk  when  necessary.  He  recom- 
mends a  solution  of  one  grain  of  cocaine  in  ten  grains 
of  water  and  ten  grams  of  glycerine,  and  he  advises 
that  this  should  be  used  as  a  lotion  to  the  nipple  five 
or  six  times  a  day.  He  explains  the  arrest  of  secre- 
tion by  the  anjesthesia  of  the  nipple  which  results. — 
The  Lancet. 

Disinfection  of  Knives  for  Operation. — Boiling  in 
soda  solution  is  required  for  complete  asepsis  of  oper- 
ating knives.  The  latter  are  not  rendered  dull  by  the 
treatment,  but  are  doubtless  often  injured  by  contact 
of  the  blades  with  other  instruments  and  with  the  ves- 
sel. Small  narrow  tin  boxes  containing  racks  in  which 
the  knives  may  be  placed  with  edges  free  should  be 
used.  The  bottom  of  the  box  has  several  perforations. 
The  boxes  are  placed  in  a  vessel  of  water  and  boiled. 
Knives  should  afterwards  not  be  placed  in  carbolic 
solution,  which  dulls.  Care  is  not  required  to  have  an 
exact  I  per  cent,  solution  of  soda,  because  a  stronger 
solution  does  not  injure.  .A  chemically  pure  soda 
should  be  used.  If  powdered  an  even  tablespoonful ; 
if  crystallized  three  tablespoonfuls  to  the  pint  is  suffi- 
cient.— Ible. 

Silver  Sutures  in  Hernia  Wounds. — For  about  one  year 
I  have  sewed  all  of  my  hernia  wounds  with  silver  wire 
and  have  covered  them  with  silver  foil.  ^Vithout  ex- 
ception the  wounds  have  healed  absolutely /c'/-//-/>/ww. 
Not  a  single  stitch  abscess  has  been  observed  either 
during  or  subsequent  to  the  healing  of  the  wound. 
Such  absolutely  perfect  healing  of  the  hernia  wounds 
we  have  not  had  heretofore,  and  I  am  convinced  that 
the  use  of  silver  as  a  suture  material  has  contributed 
somewhat  to  this  result. — De  Gar.mo. 


43° 


MEDICAL   RECORD. 


[September  21,  1S.95 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE    LATE    DR.    BRISTOWE HEALTH    OF     LONDON DR. 

BRUNTON'S       promotion THE       COMMANDER-IN- 
CHIEF. 

LONDON,  August  31,   1895. 

The  death  of  Dr.  Bristowe  will  have  been  learned  with 
regret  on  your-side  of  the  Atlantic  as  well  as  ours,  for 
his  reputation  as  a  teacher  and  writer,  as  well  as  a 
sound  physician,  has  for  many  years  been  very  exten- 
sive, and  not  a  few  of  the  visitors  from  the  States  have 
obser\-ed  his  clinic  at  St.  Thomas's  Hospital.  Dr.  Bris- 
towe's  health  had  been  failing  for  two  or  three  years— 
indeed  he  had  scarcely  been  the  same  since  the  shock 
of  his  brother's  death,' in  1892.  soon  after  which  he  was 
struck  down  by  influenza.  This  left  a  legacy  of  ill 
health.  He  went  to  Monmouth  for  a  change,  and  there 
the  end  came  within  a  week  of  his  arrival,  heart-failure 
being  the  immediate  cause.  Dr.  Bristowe  was  the  son 
of  a  medical  man  and  was  born  in  1S27.  He  was  edu- 
cated at  King's  College  and  St.  Thomas's  Hospiral,  and 
graduated  at  the  L'niversity  of  London.  He  distin- 
guished himself  as  a  student,  and  his  subsequent  career 
was  always  onward.  He  received  many  honors  in  the 
profession  and  bore  them  with  becoming  modesty. 
His  "  Theory  and  Practice  of  Medicine  "  appeared  in 
1876  and  at  once  took  high  rank  as  a  text  book — a 
position  it  has  maintained  through  the  seven  editions 
that  have  been  called  for.  His  book  on  "Diseases  of 
the  Nervous  System,"  which  was  published  in  188S,  was 
a  collection  of  important  cases,  and  I  believe  only  fail- 
ing health  prevented  him  from  bringing  out  similar 
works  on  other  diseases.  He  was  president  of  the 
Neurological  Society,  and  had  occupied  the  same  office 
in  other  societies.  The  nervous  system  seems  to  have 
been  a  favorite  study  with  him,  and  his  opinion  on 
nerve  diseases  was  regarded  as  one  of  the  most  reliable 
to  be  obtained.  As  may  be  noticed  in  his  writings,  he 
was  reluctant  to  prescribe  drugs  unless  he  felt  there 
was  a  clear  indication  for  them.  Hence  in  some  quar- 
ters he  was  looked  upon  as  a  sceptic  in  therapeutics  ; 
and  yet  that  idea  scarcely  represents  his  attitude. 
Students  found  that  if  they  could  give  a  solid  reason 
why,  he  was  ready  to  approve  their  suggestions  ;  but  he 
was  opposed  to  the  routine  ordering  of  medicine,  and 
would  often  limit  his  prescription  to  a  bitter  infusion. 
His  clinical  teaching  was  of  the  very  highest  order,  and 
he  devoted  himself  to  it  with  a  zeal  and  patience  which 
was  greatly  appreciated.  Among  extra  professional  ac- 
complishments may  be  mentioned  painting,  and  it  is 
whispered  that  in  youth  he  had  thought  of  following 
art  as  a  calling.  He  was  also  somewhat  of  a  poet,  and 
published  a  volume  of  verses. 

Diphtheria  is  still  increasing.  Small-pox  remains 
without  any  marked  tendency  to  decrease.  A  sus- 
pected case  of  cholera  occurred  last  week,  but  bacterio- 
logical examination  showed  that  it  was  not  so. 

Dr.  Lauder  Brunton  has  at  last  got  his  advance,  and 
becomes  full  physician  to  St.  Bartholomew's  Hospital — ■ 
where  he  has  been  assistant  physician  for  over  twenty 
years.  Among  all  the  inequalities  that  occur,  the  long 
waiting  at  Bartholomew's  ought  to  be  remedied.  It 
was  at  this  hospital  that  the  late  Mr.  Wormald  was 
kept  in  a  subordinate  position  when  he  had  become 
President  of  the  College  of  Surgeons.  Verily  doctors 
do  give  their  gratuitous  services  freely  enough  for  the 
public  to  form  a  poor  estimate  of  their  value. 

The  Duke  of  Cambridge  is  really  to  give  up  the 
commandershipin-chief.  The  army  medical  staff  thus 
gets  rid  of  one  who  never  appreciated  its  services. 
Lord  Wolseley  is  to  succeed,  but  he  is  not  much  of  a 
friend  to  the  Medical  Department,  I  fear. 


ALKALINE    INJECTIONS   IN   GONORRHCEA. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Dr.  Philip  Jaisohn's  article  in  the  issue  of  your 
journal  for  September  7,  1895,  entitled  "Alkaline  In- 
jections for  the  Treatment  of  Gonorrhoea,"  I  have  read 
with  great  satisfaction. 

Ever  since  1882,  that  is,  since  I  read  a  certain  paper 
of  Kiichenmeister,  I  have  treated  the  first  stage  of  man- 
ifested gonorrhoea  by  means  of  injections  of  diluted 
lime-water  (i  to  4),  and  have  found  that  Kiichenmeis- 
ter was  quite  correct  in  saying  that  by  such  treatment 
we  are  enabled  to  do  away  with  those  well-known  pain- 
ful symptoms  of  the  acute  inflammation  of  the  urethra. 
Kuchenmeisler  claims  that  the  lime-water  acs  o-. 
the  infected  mucous  membrane  of  the  urethra  ever, 
more  promptly  than  on  diphtheritic  membranes  of  nose 
and  pharynx,  namely,  by  dissolving  the  superficial 
layer,  and  thus  remo\'ing  the  nutrient  soil  for  the  mi- 
crobes. 

The  theory  of  this  treatment  impressed  me  favor- 
ably, and  since  I  found  it  confirmed  by  practical  ex- 
perience I  often  spoke  to  specialists  on  genito  urinary 
diseases  about  it,  but  none  would  ever  pay  attention  tc 
my  remarks. 

I  ask  the  patients  to  repeat  those  injections  frequent- 
ly every  hour  in  the  beginning,  if  they  can  convenient- 
ly do  so.  and  continue  less  frequently  for  three  or  four 
days.  Precaution  is  to  be  taken  that  the  water  for  di- 
lution be  distilled,  and  that  the  solution  is  not  deterio- 
rated by  exposure  to  air. 

A.  Rose,  M.D. 

336  East  Fiftee.n-th  Street. 


'^cxo  lustruiuents. 

THE    STOMACH-DOUCHE    AND    ITS    USES. 
By  M.  gross,  M.D., 

NEW  YORK. 

While  in  ordinary  lavage  of  the  stomach  the  fluid  is 
carried  into  the  organ  by  its  own  weight,  this  is  ef- 
fected in  the  case  of  the  stomach-douche  by  simple 
elevation  of  the  reservoir  or  by  certain  pressure  ap- 
paratus. The  stomach-douche,  therefore,  is  intended 
to  irrigate  the  organ  with  fluid  under  great  pressure, 
so  as  to  exert  a  therapeutic  effect  upon  the  walls  o: 
the  stomach. 

The  first  favorable  effects  of  the  stomach-douche  in 
gastralgia  were  reported  by  Malbranc,*  from  Kuss- 
maul's  clinic,  and  since  then  favorable  results  from 
its  use  have  been  noted  also  by  Ewald.  Boas,  and 
others  in  various,  particularly  nervous,  affections  of  the 
stomach.  To  Rosenheim  '■  belongs  the  credit  of  hav- 
ing rehabilitated  the  stomach-douche,  and  he,  too,  was 
the  first  to  point  out  the  great  difference  between  a 
simple  lavage  and  an  irrigation  by  means  of  a  douche. 
Ordinary  lavage  is  performed  for  the  purpose  of 
cleansing  the  interior  of  the  stomach  of  the  remnants 
of  food  encumbering  its  walls  and  causing,  besides, 
various  functional  disturbances  by  their  decomposition. 
Equally  important  is  the  cleansing  of  the  stomach  of 
mucus,  which  adheres  more  or  less  firmly  to  the  wall 
and  tends  to  neutralize  any  existing  diminished  secre- 
tion of  hydrochloric  acid,  while  it  also  prevents  the' 
contact  of  food,  agitated  by  the  gastric  peristalsis,  with  I 
the  wall  of  the  organ,  thereby  diminishing  or  abolish- 
ing the  stimulation  necessary  to  the  secretion  of  hydro- 
chloric acid.  It  is  customary,  too.  to  perform  lavage 
in  order  to  strengthen  the  muscular  coat  by  the  stimu-i 
lation  of  the  gastric  wall,  or  to  increase  the  secretior 

'  Berl.  Klin.  Wochenschr. ,  1878,  p.  41. 
'  Therap.  Monatshefte,  August,  iSoi. 


September  21,  1895] 


MEDICAL    RECORD, 


431 


or  again,  in  other  cases,  to  inhibit  an  increased  secre- 
tion {e.g.,  in  continuous  acid  secretion)  by  the  intro- 
duction of  chemical  solutions.  But  is  it  possible  to  at- 
tain the  objects  here  enumerated  by  ordinary  lavage  of 
the  stomach  ? 

The  stream  of  liquid  introduced  within  the  stomach 
through  the  tubes  generally  used  strikes  merely  the 
portion  of  the  wall  adjoining  the  opening  of  the  tube 
with  a  slight  pressure.  Moreover,  the  accumulated 
fluid  can  but  unnecessarily  encumber  the  organ  ;  the 
agitation  of  the  fluid  within  the  stomach,  which  we  are 
able  to  effect  by  elevating  the  reservoir  and  then  rapid- 
ly lowering  the  tube,  is,  as  is  well  known,  not  alway> 
sufficient  to  thoroughly  cleanse  the  interior  of  the  or- 
gan ;  tough,  adhering  mucus  is  either  not  reached  by 
the  agitated  water  or  else  the  force  is  not  sufficient  to 
detach  it. 

All  this  proves  that  we  may  expect  perfect  results 
from  simple  lavage  of  the  stomach  only  in  exceptional 
cases  ;  but  it  is  different  when  the  fluid  introduced 
may  be  forced  over  all  portions  of  the  interior  surface 
of  the  stomach  by  corresponding  pressure.  This  is 
effected  by  the  stomach-douche  by  irrigation  of  the 
cavity  of  the  organ. 

Rosenheim  employs  for  gastric  irrigation  a  tube  de- 
vised by  him,  provided  with  numerous  small  openings 
in  its  lateral  wall  and  a  larger  opening  at  its  end  ;  the 
latter  opening  has  a  smaller  diameter  than  the  tube,  so 
that  the  efflux  should  be  rather  restricted  ;  the  ter 
minal  opening  serves  at  the  same  time  for  a  rapid  evacu- 
ation of  the  fluid  introduced.  But  this  tube,  too,  does 
not  come  up  to  our  expectations,  for  the  lateral  press 
ure,  being  diverted,  is  diminished  by  the  terminal 
opening  ;  besides,  it  is  impossible  to  prevent  overfilliug 
of  the  stomach,  in  which  case  the  tube  is  submerged 
and  the  effect  of  the  lateral  spray  is  thus  counteracted. 
It  is  only  an  empty  cavity  of  the  stomach,  which  can 
be  reached  from  every  direction,  that  can  be  thorougli- 
ly  cleansed  and  thus  rendered  more  accessible  for  other 
therapeutic  purposes. 

The  stomach-douche  devised  by  me  will  satisfy  all 


i 


the  above-mentioned  requirements.  The  description 
and  mode  of  application  of  the  apparatus  will  show  its 
advantages.  The  apparatus  consists  of  ( i )  two  graduated 
bottles  (A)  of  a  capacity  of  one  to  two  litres,  in  which 
the  fluid  to  be  employed  is  kept  under  constant  press- 
ure, easily  regulated  by  means  of  a  condenser  {B)  or  an 
ordinary  air-pump.  Two  reservoirs  are  supplied  to 
enable  the  physician,  if  necessary,  to  irrigate  the 
stomach  alternately  with  fluids  of  varying  temperature, 
or  perhaps  for  rinsing  after  the  use  of  a  chemical 
composition.  (2)  A  double  tube  (C)  ;  the  external 
one,  in  the  length  of  about  five  to  six  centimetres  per- 


forated in  all  directions  by  numerous  small  afflux  open- 
ings ;  while  the  internal  one  (Z*),  completely  isolated 
from  the  outer,  serves  merely  for  the  rapid,  instantane- 
ous afflux  of  the  fluid.  The  fluid  escaping  through  the 
inner  tube  is  received  into  a  graduated  vessel  {£)  in- 
tended for  the  control  of  the  quantity  of  fluid  returned. 
Should  the  inner  (return)  tube  be  obstructed  by  rem- 
nants of  food  or  mucus,  slight  expression  or  aspiration 
will  suffice  to  restore  the  flow. 

The  tube  is  introduce  d  as  follows  :  Commencing 
behind  at  the  eighth  or  ninth  dorsal  vertebra  (the 
region  of  the  cardiac  orifice)  the  tube  is  measured 
along  the  back  and  the  side  of  the  neck  as  far  as  the 
level  of  the  teeth  and  the  length  marked  by  a  sliding 
mouthpiece  (J^)  ;  the  tube  is  then  introduced  as  far  as 
indicated  by  the  slider,  and  by  blowing  through  the 
inner  tube  we  ascertain  whether  the  tube  has  just 
passed  the  cardiac  opening,  in  which  case  the  air  no 
longer  escapes  upward  through  that  opening.  When 
the  end  of  the  tube  has  passed  the  cardiac  opening  I 
first  blow  a  few  times  into  the  stomach  so  as  to  unfold 
it  as  much  as  possible  ;  then  I  advance  the  tube  about 
five  or  six  centimetres,  exactly  the  length  of  the  per- 
forated portion  of  the  outer  tube  ;  the  tube  must  de- 
pend free  into  the  cavity  of  the  stomach,  surveying 
the  field  of  operation,  as  it  were. 

The  advantages  are,  briefly  :  i.  Constant  pressure 
upon  the  fluid  introduced.  This  pressure  can  be  ex- 
actly regulated  and  interrupted  when  desired.  The 
flow  is  not  weakened  at  the  end  of  the  tube,  since  the 
latter  is  completely  closed  at  the  button.  2.  All  parts  of 
the  interior  of  the  stomach  are  reached.  3.  The  fluid 
introduced  is  immediately  removed  by  the  return  tube  : 
in  other  words,  the  fluid  which  reaches  the  stomach  in 
the  form  of  spray  always  finds  the  organ  empty  :  the 
stomach  is  not  encumbered  by  a  thick  stream  striking 
the  wall  ;  finally,  there  being  an  immediate  escape  of 
such  chemical  solutions  as  may  have  been  introduced, 
there  can  be  no  intoxication  by  their  passage  through 
the  pylorus  into  the  intestine. 

As  an  experiment,  I  may  take  one  of  my  patients 
affected  with  chronic  mucous  inflamma- 
tion of  the  gastric  mucosa,  introduce  the 
ordinary  tube  so  as  to  cleanse  the  stom- 
ach of  mucus,  etc.,  and  the  water,  even 
in  different  positions  of  the  patient, 
finally  escapes  perfectly  clear.  Then, 
introducing  my  douche,  I  am  still  able 
to  remove  additional  tough  mucus,  and 
this  I  have  repeatedly  verified. 

The  effect  of  the  stomach-douche  is 
mechanical,  chemical,  and  thermic.  The 
mechanical  effect  is  to  be  looked  upon 
as  a  stimulus  which  produces  a  condi- 
tion of  excitation  in  nerve  and  muscle  : 
by  the  force  of  the  stream— an  internal 
massage,  as  it  were — we  produce  a  direct 
and  reflex  stimulation  of  the  vaso-motor 
nerves  and  thereby  secondarily  improve 
the  circulation  ;  the  peristalsis  is  stimu- 
lated and  the  smooth  muscle  fibres  re- 
spond more  readily  to  tactile  irritation. 
The  agitation  of  the  peripheral-nerve 
termini  is  propagated  as  far  as  the  cen- 
tres and  transmitted  by  them  to  the 
a  more  intense  oxidation  of  the  blood 
within  the  muscle  fibres  is  effected  ;  sympathetic 
nerves  and  ganglia  are  directly  stimulated  ;  thus  secre- 
tion and  reflexes  are  produced  in  the  organic  muscu- 
lar fibres  and  functional  disturbances  are  overcome 
(Schreiber).  In  order  to  increase  the  stimulation  of 
the  muscular  fibres  I  often  employ  an  interrupted 
stream. 

Thermic  Effect. — By  using  warm  water  we  secure  the 
effect  of  a  local  bath  :  increased  irritation  of  the  sen- 
sory gastric  nerves  is  reduced,  reflex  spastic  contract- 
ures of  the  muscles  are  removed,  and  by  the  improved 


motor  fibres  : 


432 


MEDICAL   RECORD. 


[September  21,  1895 


circulation  the  vegetative  processes  in  the  wall  of  the 
stomach  are  favored.  I  intensify  the  thermic  effect 
by  the  alternate  production  of  warm  and  cold  water. 
The  stimulation  of  nerves  and  vessels  by  the  action  of 
cold  is  heightened  by  preceding  heat. 

Chemical  Effect. — ^Ialbranc  used  warm  carbonated 
water  (38°  C.)  and  siphon.  In  these  cases  the  car- 
bonic acid  acted  as  a  local  anodyne.  For  dissolving 
mucus  we  employ  artificial  Emser  salt  :  chloride  of 
sodium,  2  parts  ;  carbonate  of  sodium,  i  part.  For 
stimulating  the  secretion  of  hydrochloric  acid  we  may 
use,  not  rarely  with  good  results,  table  salt,  one  tea- 
spoonful  to  the  litre  of  water.  Infusions  of  hops  and 
quassia,  cinchona  bark,  condurango  bark,  stimulate 
the  muscles  and  motor  nerves  of  the  stomach,  as  well 
as  the  secretory  nerves  and  those  of  the  sensory  nerves 
which  transmit  the  sensation  of  hunger.  Solutions  of 
liquor  ferri  sesqui  chloridi  {}i  to  1,000)  have  been  used 
by  me  with  striking  results  in  anaemic  and  chlorotic 
patients.  Nitrate  of  silver  (ji  to  2,000)  was  first  used 
by  Reichmann  in  gastrorrhoea  for  the  purpose  of  reduc- 
ing the  secretion  of  hydrochloric  acid.  It  will  often 
relieve  the  symptoms  of  superacidity,  though  it  does 
not  cure  that  condition.  In  hypersesthesias  (the  sen- 
sations being  present  when  the  stomach  is  empty,  as 
opposed  to  gastric  ulcer,  in  which  the  pain  usually  de- 
pends upon  the  presence  of  food)  and  erosions  good 
symptomatic  results  have  likewise  been  obtained  with 
silver  nitrate.  The  same  may  be  said  of  hypersensi- 
bility  (increase  of  hydrochloric  acid  need  not  neces- 
sarily cause  symptoms).  In  gastrorrhcea  the  silver 
nitrate  produces,  aside  from  the  amelioration  of  symp- 
toms, a  diminution  of  the  hydrochloric  acid,  though 
not  in  every  case  (Rosenheim).  Chloroform  water 
(50  to  60  gm.  of  chloroform  are  agitated  with  one 
litre  of  water  ;  the  excess  of  chloroform  sinks  to  the 
bottom  of  the  vessel,  and  the  supernatant  water  is 
drawn  off  for  use),  too,  has  been  used  with  good  effect 
in  hypersensibility.  In  order  to  prevent  intoxication 
from  the  use  of  silver  nitrate  solution  or  chloroform 
water,  these  liquids  should  not  be  left  in  the  stomach 
for  more  than  one-half  to  one  minute,  and  the  organ 
should  then  be  washed  out  with  warm  water.  Anti- 
septic effects  are  produced  by  solutions  of  salicylic 
acid  (i  to  1,000). 

776  Madison  Avesue. 


Medical  gtciiis. 

Contag^ious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  September  14,  1895. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. 

Measles 

Diphtheria 


Birth  of  Child  without  Rupture  of  Membranes. — Dr. 

Forman  observed  tiiis  rare  occurrence  in  the  case  of  a 
woman  aged  twenty-two  years,  seven  months  advanced 
in  her  second  pregnancy  {2'/ie  British  Medical  Joiti- 
nal.)  She  was  suffering  from  pleuro-pneumonia,  the 
temperature  having  risen  to  103.6°  F.  A  few  minutes 
after  cupping-glasses  had  been  applied  to  the  bases  of 
the  lungs  the  patient  felt  a  desire  to  defecate  :  this  was 
followed  by  a  single  pain  which  expelled  the  entire 
ovum  with  a  little  blood.  There  was  no  further  escape 
of  blood.  Forman  arrived  a  few  minutes  later.  He 
found    between  the    patient's    thighs  a   big  cyst  with 


Cases. 

Deaths. 

95 

114 

31 

8 

1            20 

I 

4 

4 

I         60 

4 

151 

21 

transparent  walls.  The  mother  was  free  from  all  the 
evils  which  may  follow  precipitate  delivery  ;  the  uterus 
contracted  well.  The  wall  of  the  cyst  was  then  cut ; 
about  a  pint  of  amniotic  fluid  escaped.  A  female  child 
was  seen  ;  there  was  no  pulsation  of  the  cord,  but  after 
active  measures  the  infant  breathed  well  and  took  the 
breast.  It  weighed  3  pounds  6  ounces,  and  measured 
over  fourteen  inches  ;  the  placenta  weighed  a  little 
under  a  pound.  The  cord  was  very  gelatinous,  and 
measured  eighteen  and  one-half  inches  in  length.  Judg- 
ing from  the  position  in  which  the  ovum  lay — outside 
the  vulva^t  seemed  that  the  breech  had  presented, 
and  that  the  placenta  had  been  inserted  very  low  down 
without  being  pravia.  The  child  lived  only  sixteen 
hours,  and  the  mother  had  a  bad  attack  of  empyema. 
P'orman  quotes  a  considerable  number  of  cases  of 
membranes  unruptured  at  birth. 

The  Secretary  of  Agriculture  on  Eheumatism. — Ac- 
cording to  a  newspaper  interview  Secretary  Morton 
has  improved  upon  the  salicyl  treatment  of  rheumatism, 
since  he  has  discovered  a  means  of  prevention.  He 
suffered  with  the  disease,  he  said,  for  many  years. 
One  day,  twelve  years  ago,  someone  told  him  that 
rheumatism  generally  followed  kidney  trouble,  and 
that  this  disease  was  largely  due  to  the  starch  in  pota- 
toes. Thereupon  Mr.  Morton  stopped  eating  potatoes. 
He  has  eaten  none  in  twelve  years,  and  it  is  just  that 
long  since  he  has  had  a  rheumatic  twinge. 


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SOME  ORIGINAL  INVESTIGATIONS,  SHOW- 
ING THE  ANTAGONISM  BETWEEN  MOR- 
PHINE   AND    COCAINE.' 

By  JOSEPH  WILLIAM  STICKLER,   M.S.,   M.D., 

•  ■K.i.SGE,   N.  J. 

Some  time  ago  my  attention  was  called  to  the  apparent 
antidotal  effect  of  opium  in  a  case  of  cocaine  intoxica- 
tion. The  patient  in  question  had  taken  two  ounces 
of  a  four  per  cent,  solution  of  cocaine  in  about  two 
hours.  Being  unable  to  sleep  and  being  very  nervous 
after  having  taken  this  large  dose,  he  took  about  half 
an  ounce  of  laudanum,  which  in  the  course  of  one  hour 
relieved  the  nervousness  and  induced  sleep.  Except 
for  some  mental  hebetude  and  a  sense  of  muscular 
prostration,  the  ])atient  was  in  fair  condition  all  the 
next  day — in  good  enough  condition  to  attend  to  his 
business. 

It  seemed  to  me  that  such  a  result  could  only  be  ex- 
plained by  the  antidotal  effect  of  the  laudanum.  In 
order  to  determine  whether  my  supposition  was  true  I 
made  some  observations,  the  details  of  which,  and  the 
conclusions  deduced  therefrom,  I  respectfully  ask  you 
to  consider.  The  observations  were  made  on  forty 
pigeons,  two  dogs,  and  four  men,  and  in  this  work  I 
was  kindly  assisted  by  Drs.  William  D.  Arnold,  Walter 
Dodge,  and  H.  E    Matthews. 

First  Series. — Beginning  at  ii  .a.m.,  October  12,  1894, 
I  injected  pigeons  Nos.  i  and  2,  wiih  morphine,  grain 
one-quarter.  1 1  a.m.  :  Pupils  of  pigeon  No.  2  con- 
tracted, No.  I  unchanged.  Both  birds  a  little  dull  and 
unsteady.  11.13  a.m.:  Pupils  of  pigeon  No.  i  con 
traded.  1115  a.m.:  Pigeon  No.  i  very  unsteady. 
11.22  A.M.  :  Gave  pigeon  No.  i  second  dose  of  mor- 
phine, grain  one  quarter.  11.23  -^-M-  :  Gave  pigeon 
No.  2  second  dose  of  morphine,  grain  one-quarter. 
11.54  A..\!.  :  Both  birds  quiet.  Rather  drowsy,  but 
awake  and  susceptible  to  impressions.  12.07  ''•^'-  • 
Gave  No.  i  an  injection  of  one-half  grain  of  morphine, 
and  at  12.10  p.m.  gave  No.  2  one-half  grain  of  mor- 
phine ;  in  a  few  moments  both  pigeons  were  drowsy 
and  disinclined  to  move  when  ap]jroached.  2.29  p.m.  : 
Injected  into  abdominal  cavity  of  pigeon  No.  i  two 
grains  of  cocaine,  aqueous  solution.  2.35  p.m.  :  Mild 
convulsions.  Staggering  gait.  Head  and  neck  thrown 
back,  feet  extended  forward,  tail  and  wings  spread, 
pupils  dilated.  3.06  p.m.  :  General  condition  much 
improved,  makes  efforts  to  walk,  Ijut  is  unable  to  prop- 
erly CO  ordinate  the  muscles  of  locomotion.  Respira- 
tion 80  and  panting.  3.52  p.m.  :  Respiration  is  52. 
Stands  by  bracing  himself  with  wings  and  tail,  keeps 
his  bill  open  and  sometimes  makes  a  hissing  sound 
during  ihe  respiratory  act.  Moves  about  on  table  from 
time  to  time,  using  his  wings  as  supplementary  helps. 
5.45  p.m.  :  Died.  2.56  p..m.  :  Injected  pigeon  No.  2  with 
two  grains  of  cocaine.  The  injection  was  made  into 
the  abdominal  cavity.  It  flew  about  the  laboratory  as 
soon  as  released,  and  finally  alighted  upon  one  of  the 
doors,    where    it    rested    quietly.      2.58    p..m.  :    When 

'  Read  before  the  Medical  Society  of  New  Jersey  at  its  last  an- 
nual session  at  Cape  May,  June  25,  1895. 


alarmed,  lost  its  balance  and  flew  to  the  floor.  It 
could  not  stand.  Developed  convulsive  movements. 
Head  and  neck  drawn  back.  Bill  open  and  respira- 
tions very  rapid.  Wings  outspread,  legs  thrown  di- 
rectly back,  and  eyelids  in  constant  motion.  3  p.m.  : 
Head  drooping.  Respirations  still  rapid,  and  very 
shallow.  Constant  tremors.  3.02  p.m.  :  Gasping  for 
breath.  Breathing  less  rapidly.  Eyes  open  and  star- 
ing. Slight  convulsive  movements  of  neck.  3-02j4 
P.M.  ;  Died.  Morphine  contracted  pupils.  Cocaine 
dilated  them. 

Second  Series. — 1.36  p.m.  :  Injected  into  abdominal 
cavity  of  pigeon  No.  3  (no  morphine  having  pre- 
viously been  given)  two  grains  of  cocaine.  It  became 
unconscious  at  once,  and  was  placed  in  a  basket.  At 
2.20  P.M.,  when  I  returned  from  lunch,  he  was  dead. 
2.32  P.M.  :  Injected  into  abdominal  cavity  of  pigeon 
No.  4  (no  morphine  having  previously  been  given) 
two  grains  of  cocaine,  and  the  bird  was  dead  in  less 
than  sixty  seconds.  The  syringe  was  scarcely  emptied 
before  the  pigeon's  head  and  neck  were  thrown  back. 
Its  wings  outspread,  and  general  convulsive  movements 
developed,  one  or  two  gasps  accompanied  these  mani- 
festations, and  life  was  extinct.  Pupils  of  these  birds 
dilated. 

Third  Series. — 11.30  a..m.:  Injected  one  grain  of 
morphine  subcutaneously  into  a  dog  weighing  about 
six  pounds.  12.18  p.m.:  Dog  lying  down.  Head 
stretched  out  and  face  evincing  distress.  Nausea  and 
vomiting  a  few  moments  after  injection.  12.25  p.m.: 
[f  touched,  walks  away  from  the  place  where  he  was 
lying,  and  after  a  while  lies  down  again.  12.30  p.m.: 
Moves  about  voluntarily  but  has  a  staggering  gait,  and 
shows  great  weakness  in  his  hind  legs.  1.03  p.m.:  In- 
jected another  grain  of  morphine.  1.12  p.m  :  Rolled 
over  on  side  and  appeared  very  drowsy.  Would  get 
up  and  walk  away  when  approached.  3.29  p.m.:  Quite 
lively,  trots  across  the  room,  but  shows  weakness  in  his 
hind  legs.  Injected  one  grain  of  cocaine  into  abdom- 
inal cavity.  3.32  P.M.:  He  soon  began  to  run  about 
the  room,  elevating  each  front  foot  as  high  as  possible 
when  in  motion.  Salivation  constant  and  extreme. 
The  urine  flows  freely.  He  suddenly  fell  upon  right 
side,  crying  loudly.  He  next  had  convulsive  move- . 
ments.  3.34^/2  p.m.:  Tonic  convulsions.  The  front 
legs  held  out  in  front,  stiff  and  straight.  3.36  p.m.: 
Quiet,  and  legs  relaxed.     3.37  p..m.:  Dead. 

Dog  No.  2  weighed  about  thirteen  pounds.  Injected 
at  11.30  A..M.,  into  his  abdominal  cavity,  one  grain  of 
morphine.  He  soon  became  nauseated  and  then  vom- 
ited six  times,  after  this  he  became  quie'.  12.18  p.m.: 
Does  not  notice  what  is  going  on  in  the  laboratory,  or 
will  not  move  if  touched.  Panting.  12.29  p.m.:  In- 
jected one  grain  of  morphine.  12.58  p.m.:  Rolls  over 
on  his  side  but  regains  his  position.  1.35  p..m.:  In- 
jected two  grains  of  morphine.  2.48  p.m.:  Hind  legs 
paralyzed.  Very  quiet.  2.59  P.M.:  Injected  two  grains 
of  cocaine.  3.13  p.m.:  Injected  two  grains  of  cocaine. 
Almost  immediately  tongue  was  protruded  from  mouth. 
Profuse  and  constant  discharge  of  salixa,  and  urine  ran 
freely  and  steadily  for  some  time.  During  this  time  he 
lay  on  the  floor  with  his  legs  extended,  and  a  wild  ex- 
pression of  face.  Head  drawn  to  right  side.  3.30 
P..M.:  Salivation  still  more  decided.  3.48  P.M.:  Injected 
two  grains  of  cocaine.  3.55  p.. m.:  Head  rolls  from  side 
to  side.     3.56)2  P..M.:  rolls  over  on  side.     Head  drawn 


434 


MEDICAL    RECORD. 


[September  28,  1895 


back.  Front  legs  stretched  out.  Hind  legs  drawn  up. 
4.03  P.M.:  Tonic  convulsions.  4.10  p.m.:  Convulsions 
cease.  Looks  quite  natural,  tries  to  get  up  and  walk, 
but  cannot,  as  hind  legs  are  still  paralyzed.  Moves 
about  by  reaching  forward  with  liis  front  legs  and 
dragging  his  body.  Sometimes  moves  rapidly  in  a  cir- 
cle. 4.18  P.M.:  Had  another  convulsion,  but  not  a^  se- 
vere as  the  other.  4.20  P.M.:  Appears  brightly.  4.30 
P.M.:  Throws  body  on  hind  legs  and  then  revolves 
rapidly.  Sight  seems  impaired,  as  he  often  hits  his 
head  against  various  things  in  the  laboratory.  4.40 
P.M.:  Making  rapid  revolutions,  using  hind  legs  as  piv- 
otal points.  4.45  P.M.:  Seems  to  be  resting.  4.55  p.m.: 
Very  lively.  More  strength  in  hind  legs,  occasionally 
rises  on  them.  5  p.m.:  Salivation  and  urination  have 
ceased.  Seems  to  act  like  a  dog  scared  at  something, 
and  would  make  violent  efforts  to  get  away. 

After  5  o'clock  p.m.,  Dr.  Walter  Dodge  watched  this 
interesting  specimen  of  the  canine  species,  and  his  e.\- 
perience  with  him  was  a  somewhat  lively  one.  At 
times  he  would  remain  perfectly  quiet,  then  he  would 
make  a  few  trips  around  the  laboratory  at  a  rate  of 
speed  that  would  astonish  a  streak  of  chain  lightning. 
and  he  was  not  over-particular  what  he  "  took  in  "  on 
the  way.  On  one  of  his  rounds  he  put  his  head  into  a 
cuspidore,  and  with  that  as  a  htlmet,  he  whizzed 
around  the  laboratory  about  twenty  times.  Then  again 
he  got  tangled  up  with  t!ie  blackboard  frame,  and  with 
that  on  his  back,  he  went  around  the  laboratory  table 
at  the  rate  of  about  one  hundred  and  fifty  times  to  the 
minute.  The  doctor,  thinking  that  it  would  be  wise  to 
get  out  of  the  way  of  this  active  animal,  perched  him- 
self upon  a  high  stool  and  placed  three  or  four  chairs 
in  front  of  it  as  a  protection.  Thus  barricaded  he  felt 
comparatively  secure.  The  dog,  however,  ran  under 
the  chairs  and  got  under  the  stool  on  which  the  ob- 
server was  standing,  and  by  means  of  a  tremendous 
effort  upset  stool  and  doctor,  the  latter  coming  down 
on  the  dog.  a  result  he  evidently  was  not  looking  for, 
as  he  gave  a  howl  and  "  lit  out  "  at  a  rate  that  assured 
the  doctor  that,  whatever  paralysis  he  had  suffered  from 
a  comparatively  short  time  before,  had  entirely  disap- 
peared. Part  of  the  time  he  was  entertaining  Dr. 
Dodge  in  the  manner  stated  and  part  of  the  time  he 
was  quiet.  The  following  morning  he  was  perfectly 
normal,  except  that  he  looked  disgusted  with  every- 
thingithat  reminded  him  of  his  experiences  of  the  day 
before  ;  he  was  therefore  given  his  freedom. 

Fourth  Series. — Injected  into  abdominal  cavity  of 
pigeon  Xo.  5,  two  grains  of  morphine  at  10.35  a-M-. 
June  7,  1895.  10.40  A.M.:  Dull,  and  shows  some  lack 
of  co-ordinating  power  on  attempting  to  walk.  10.55 
.-v.M.:  Disposed  to  be  quiet,  but  can  fly  when  thrown 
into  the  air.  1 1.04  .'^.M.:  Injected  two  grains  of  cocaine 
into  abdominal  cavity.  11.06  a.m.:  Toppling  back- 
ward and  forward.  Bill  open  and  respiration  some- 
w^hat  quickened.  Wings  partly  spread,  i  i.i3'.>  a  .m.: 
On  side.  Tail  spread  and  wings  e.xtended.  11.37  a.m.: 
Dead. 

Injected  into  pigeon  No.  6  two  grains  of  morphine 
at  10.38  A.M.  10.42  a.m.:  Drooping.  Winking  rapidly 
and  totters  when  he  walks.  Pupils  contracted.  Res- 
piration slow.  10.55  A.M.:  Can  fly  well,  tieneral  con- 
dition good.  11.10  a.m.:  Injected  two  grains  of  cocaine 
into  abdominal  cavity.  11. i:;  a.m.:  Wings  outstretched. 
Legs  e.xtended  backward.  Bill  open.  Pupils  dilated. 
1 1. 1 7  A.M.:   Dead. 

Injected  into  pigeon  No.  7  two  grains  of  morphine 
at  10.45  A.M.  io.5o^'2  a.m.:  Drowsy  and  staggering. 
10.55  A^i-  Can  fly.  11.02  a.m.:  Tilted  forward  on 
chest,  but  can  walk  and  tly.  Pupils  contracted.  11.19 
A.M.:  Injected  two  grains  of  cocaine  into  abdominal 
cavity.  1 1.21  a.m.:  Fluttering  about.  1 1.23  a.m.:  Dead. 
Injected  into  pigeon  No.  8  two  grains  of  morphine 
at  10.47  -^  M-  IO-50  A.M.:  Drowsy  and  a  staggering 
gait.  Pupils  contracted.  10.55  .-^..m.:  When  thrown 
into  the  air,  can  fly  well.     11.02  a.m.:  Tilted  forward 


on  chest,  but  is  strong  enough  to  walk  and  fly.  11.19 
A.M.:  Injected  into  abdominal  cavity  two  grains  of  co- 
caine. 11.21  A.M.:  Convulsive  movements.  11.23  A.M.: 
Dead. 

Fifth   Series Injected    into   abdominal   cavity   of 

pigeon  No.  9  one  grain  of  morphine  at  10.15  a.m.,  June 

7,  1895.  Pigeon  almost  immediately  became  quiet,  but 
not  sleepy.  Pupils  contracted.  11.24  a.m.:  Injected 
one-half  grain  of  cocaine  into  abdominal  cavity.  11.26 
a.m.:  General  convulsive  movements.  Tail  and  wings 
spread.     ii.37'2  a.m.:  Dead. 

Injected  into  abdominal  cavity  of  pigeon  No.  10  one 
grain  of  morphine  at  10.56  a.m.  Pigeon  became  quiet 
in  a  few  moments,  but  was  easily  aroused.  Pupils  con- 
tracted. 11.26  a.m.:  Injected  one-half  grain  of  co- 
caine into  abdominal  cavity.  11.28  A.M.:  Head  thrown 
back,  wings  outstretched.  Pupils  dilated.  11.35  a.m.: 
Dead. 

Injected  into  pigeon  No.  11  one  grain  of  morphine 
at  10.57  •*•*••  11.29  -^^■•-  Injected  one-half  grain  of 
cocaine  into  abdominal  cavity.  11.35  a.m.:  Convul- 
sions. Injected  one-half  grain  of  morphine  into  ab- 
dominal cavity.  Bird  became  quiet  and  conscious. 
Breathed  easily  and  remained  quiet  until  12.11  p.m., 
when  it  died. 

Injected  into  abdominal  cavity  of  pigeon  No.  12  one 
grain  of  morphine  at  10.58  a.m.  Became  quiet  and 
sleepy  in  a  short  time.  Pupils  contracted.  11.31'j 
a.m.:  Injected  into  abdominal  cavity  one-half  grain  of 
cocaine.  The  pigeon  soon  began  to  totter,  but  re- 
mained upon  its  feet  until  11.40I2  -A..m.,  when  it  died. 

Sixth  Series. — Injected  into  abdominal  cavity  of 
pigeon  No.  13,  at  2.33  p.m.,  June  7,  1895,  one-half 
grain  of  atropine.  At  2.41  p.m.  injected  into  abdominal 
cavity  one-half  grain  of  cocaine.     Pigeon  lived. 

Injected  into  pigeon  No.  14  one-half  grain  of  atro- 
pine. Five  minutes  later  injected  one-half  grain  of 
cocaine.     Pigeon  died  in  fifty  seconds. 

Injected  into  abdominal  cavity  of  pigeon  No.  15  one- 
half  grain  of  atropine  at  2.46  p.m.  3.50  p.m.:  Injected 
one-half  grain  of  cocaine.  Pigeon  died  in  seven  min- 
utes. 

Injected  into  pigeon  No.  16  one-half  grain  of  atro- 
pine at  3.47  P.M.  Later  injected  one-half  grain  of 
cocaine.     Pigeon  died  in  sixty  seconds. 

Seventh  Series. — Injected  into  abdominal  cavity  of 
pigeon  No.  17  one-half  grain  of  atropine  at  12.32  p.m.. 
June  8,  1895.  12.09  P.M.:  Nauseated.  12.39  p.m.:  I"" 
jected  one  grain  of  cocaine  into  abdominal  cavity,  and 
pigeon  died  in  twenty  seconds. 

Injected  into  pigeon  No.  18  one-half  grain  of  atro- 
pine at  12.04  P.M.  12.09  P-^i-  Nauseated.  12.32  p..m.: 
Injected  into  abdominal  cavity  one  grain  of  cocaine. 
Pigeon  died  in  five  minutes. 

Injected  into  abdominal  cavity  of  pigeon  No.  19  one- 
half  grain  of  atropine  at  12.05  P-^'-  Nauseated  a  little 
later.  12.29  ''^'■'  Injected  into  abdominal  cavity  one 
grain  of  cocaine.     Pigeon  died  in  seventeen  seconds. 

Injected  into  abdominal  cavity  of  pigeon  No.  20  one- 
half  grain  of  atropine  at  12.07  P-^'-  Nauseated  a  few 
moments  later.  12.26  p.m.:  Injected  into  abdominal 
cavity  one  grain  of  cocaine.  Pigeon  died  in  fifteen  sec- 
onds. 

Eighth  Series. — Injected  into  abdominal  cavity  of 
pigeon   No.   21  one  grain  of  morphine  at  11  a.m.,  June 

8,  1895.  11. 28  A.M.:  Manifestly  stupid.  11.59  A.M.: 
Injected  three-quarters  of  a  grain  of  morphine.  Half 
an  hour  later  very  stupid.  Pupils  contracted.  1.14 
P.M.:  Injected  one  grain  of  cocaine  into  abdominal 
cavity.     1.23  p.m.:   Pigeon  dead. 

Injected  into  abdominal  cavity  of  pigeon  No.  22 
one  grain  of  morphine  at  11.22  A.M.  11. 28  a.m.:  Quite 
willing  to  sit  still.  11.56  a.m.:  Injected  one  grain  of 
morphine.  1.24  p.m.:  Injected  one  grain  of  cocaine 
into  abdominal  cavity.  1.27  p.m.:  Totters  about  when 
walking.  1.28  p.m.:  i General  convulsive  movements. 
2.05  P.M.:  Pigeon  dead. 


September  28,  1895] 


MEDICAL   RECORD. 


435 


Injected  into  abdominal  cavity  of  pigeon  \o.  2- 
one  grain  of  morphine  at  11.05  -^M-  11-28  a.m.:  Dis^ 
posed  to  be  quiet.  11.43  am-:  Injected  one  grain  of 
morphine.  The  second  dose  made  the  pigeon  very- 
quiet.  1. 18  P.M.:  Injected  into  abdominal  cavitv  one 
grain  of  cocaine.     1.22  p.m.:  Pigeon  dead. 

Injected  into  abdominal  cavity  of  pigeon  No.  24 
one  grain  of  morphine  at  11.07  a.m.  11.15  am' 
Rather  stupid  and  tottering.  Pupils  contracted! 
11.28  A.M.:  Very  quiet.  11.45  a.m.:  Injected  one 
gram  of  morphine.  12.48  p.m.:  Injected  into  abdom- 
inal cavity  one  grain  of  cocaine.  12.51  P.M.:  Totter- 
ing gait.  Pupils  dilated.  Quiet.  12.56  p.m.:  Marked 
convulsive  movements.     1.20  p.m.:  Pigeon  dead. 

Ninth  Series.— Injected  one-quarter  of  a  grain  of 
cocaine  into  abdominal  cavity  of  pigeon  No  j:;  at 
12.10  p.m.  12.12  P.M.:  Pupils  widely  dilated.  Tail 
spread.  Gait  tottering.  12.14  P-M.:  Fell  down 
Staggers  about.  12.15  pm.:  On  back.  Head  thrown 
back.  Bill  open.  Respiration  rapid  and  labored. 
1.22  p.m.:  Active  convulsions.  Eyes  closed.  Wings 
and  tail  spread.  Unable  to  stand  or  fly.  1.40  p.m.: 
Standing  and  apparently  recovering.  Can  use  wings. 
1.50  p.m.:  Suddenly  fell  forward.  Gasped  once  or 
twice,  and  then  died. 

Injected  into  abdominal  cavity  of  pigeon  No.  26 
one-quarter  grain  of  cocaine  at  12.15  !"•"•  12.18  p.m.- 
Unsteady.  12.23  P-M.:  Vomiting,  and  except  slight 
shiverings,  showed  no  effects  of  the  drug. 

Injected  into  pigeon  No.  27  one-quarter  grain  of 
cocaine  at  12.18  p.m.  12.27  P-M.:  Pigeon  on  back  with 
wings  extended.  Pupils  dilated.  12.29  P-'^I'  Pigeon 
dead.  " 

Injected  into  abdominal  cavity  of  pigeon  No.  28. 
one-quarter  grain  of  cocaine  at  12.21  p.m.  Paralyzed 
almost  immediately.  12.24  p.m.:  Completelv  pros- 
trated. Respiration  is  very  rapid  and  panting'  i^  ••; 
P.M.:  Dead.  is-       --o 

Tenth  Series.— Injected  into  abdominal  cavity  of 
pigeon  No.  29  one  grain  of  morphine  at  11.09  -^-M- 
11.28  A.M.:  Disposed  to  be  quiet.  11.39  a.m.;  In- 
jected one  grain  of  morphine  into  abdominal  cavity, 
12.41  P.M.  :  Injected  one-quarter  grain  of  cocaine  into 
abdominal  cavity.  12.43  P-M-  :  Convulsive  movements. 
12.48  P.M.:   Dead. 

Injected  into  abdominal  cavity  of  pigeon  No.  30, 
one  grain  of  morphine  at  11. 10  a.m.  11.2S  am.  ': 
Quiet,  but  easily  aroused.  11.35  a.m.:  Injected  one 
gram  of  morphine.  12  m.  :  Injected  one-quarter 
grain  of  cocaine.  1.30  p.m.  :  Gait  tottering.  1  .4  p  m  - 
Dead. 

Injected  into  abdominal  cavity  of  pigeon  No.  31 
one  grain  of  morphine  at  11.12  a.m.  11.16  a.m.: 
Vomited.  11.28  a.m.:  Resting  quietly.  11.47  a.m.: 
Injected  one  grain  of  morphine.  Bird  became  quiet  in 
a  few  moments.  12.43  P-M-:  Injected  into  abdominal 
cavity  one-quarter  grain  of  cocaine.  12.51  p.m.:  Gait 
tottering.  Bill  open.  Pupils  dilated.  1.40  p.m.:  Can 
fly  and  is  quite  natural  in  appearance.  This  pigeon 
made  a  good  recovery. 

Injected  into  pigeon  No.  32  one  grain  of  morphine 
at  11.13  a.m.  ir-28  a.m.:  Sitting  quietly  on  floor. 
Easily  disturbed.  11.52  a.m.:  Injected  one  grain  of 
morphine.  12.46  p.m.:  Injected  one-quarter  grain  of 
cocaine  into  abdominal  cavity.  12.51  p.m.:  Tottering 
gait,  and  pupils  dilated.  1.40  p.m.:  Pigeon  can  tly  and 
IS  rapidly  becoming  normal.     Made  a  good  recovery 

Eleventh  Series.— Injected  into  abdominal  cavity  of 
pigeon  No.  :i3  one- half  grain  of  cocaine.  Pigeon  died 
in  thirty  seconds. 

Injected  into  pigeon  No.  34  one-half  grain  of  co- 
caine.    Died  in  sixty  seconds. 

Injected  pigeon  No.  35  with  one-half  grain  of  co- 
caine.     Died  in  twenty  seconds. 

Injected  pigeon  No.  36  with  one-half  grain  of  co- 
caine, lived  three  minutes.  In  each  instance,  the  pupils 
were  dilated. 


Twelfth  Series.— Injected  pigeon  No.  37  with  two 
grains  of  cocaine  subcutaneously.  Died  in  sixty  se- 
conds. This  bird  stood  perfectly  still  a  few  moments 
after  injection,  then  suddenly  died.     Pupils  dilated. 

Injected  subcutaneously  pigeon  No.  38  with  two 
grains  of  cocaine  at  11  a.m.  In  a  very  short  time 
convulsions  developed.  I  then  injected  into  abdom- 
inal cavity  one  grain  of  morphine,  convulsions  ceased, 
bird  became  quiet,  and  died  at  12.14  p-M- 

Injected  into  abdominal  cavity  of  pigeon  No.  ^g 
one  grain  of  morphine  and  one  grain  of  cocaine.  Pi- 
geon died  in  two  minutes. 

Injected  into  pigeon  No.  40  one  grain  of  morphine 
and  one-half  grain  of  cocaine.  Pigeon  lived  one  min- 
ute. 

The  following  observations  were  made  in  the  pres- 
ence and  with  the  assistance  of  Drs.  George  Bayles. 
Thomas  P.  Fitch,  Mefford  Runyon,  and  H.  E.  Mat- 
thews. In  these  cases  I  gave  only  the  same  quantity 
of  morphine  and  cocaine  that  I  administered  in  pri- 
vate practice.  My  wish  was  to  demonstrate  to  others 
what  I  had  already  witnessed. 

Thirteenth   Series.— Mr.    E ,  aged    thirty-eight, 

lungs,  heart,  kidneys,  and  other  organs  in  good  con- 
dition. Skin  warm  and  dry.  Before  administration  of 
cocaine,  pulse  66.  Respirations,  24.  Temperature,  98^° 
F.  7.58  P.M.,  October  12,  1894:  Patient  took  one 
grain  of  cocaine  (in  aqueous  solution)  into  mouth  and 
held  it  there  five  minutes,  then  swallowed  it.  His 
pupils  began  to  dilate  four  minutes  later.  Pulse,  72  : 
respirations,  28.  Sialogogue  effect  pronounced  in  live 
minutes.  8.08  p. ji.:  Patient  felt  elated.  Hands  moist. 
8.12  P.M.  :  Pulse,  68  :  respiration,  20.  Pupils  quite 
widely  dilated.  8.14  p.m.  :  Mental  exhilaration  not 
quite  so  pronounced.  But  said  that  the  sense  of  mus- 
cular fatigue  he  had  when  he  came  to  the  laboratory 
had  all  disappeared,  and  he  felt  as  if  he  could  walk  to 
Newark  and  back.  S.21  p.m.  :  Pulse,  72  ;  respirations, 
20  ;  temperature,  (jSl°  F.  831  p.m.  :  Palms  of  hands 
moist,  otherwise  condition  the  same.  8.39  p.m.  :  Gave 
hypodermic  injection  of  morphine,  grain  one-quarter,  in 
forearm.  8,45  p.m.  :  Pulse,  80  ;  respirations,  20.  Feels 
a  little  heavy.  Pupils  very  slightly  contracted.  8.50 
P.M.  :  Pulse,  72  ;  respirations,  20.  Palms  still  moist. 
Did  not  complain  of  dry  throat  or  mouth.  Pupils 
somewhat  more  contracted  than  at  time  of  previous 
observation.  Feels  slight  muscular  fatigue.  No  nau- 
sea. 9.01  P.M.  :  Respirations,  20  ;  pulse,  78,  strong  and 
regular.  9.05  p.m.  :  Temperature,  98^°  F.  Not  at  all 
sleepy  or  inclined  to  lie  down  or  keep  quiet.  Rather 
talkative.  This  patient  went  to  his  home  about  one 
mile  distant,  and  had  a  comfortable  night,  except  that 
he  was  wakeful  until  three  or  four  o'clock  the  next 
morning. 

Mr.  E.  B ,  aged    twenty-one,  in    perfect    health. 

Prior  to  administration  of  cocaine,  pulse,  66  ;  respira- 
tions, 24  ;  temperature,  98^°  F.  Skin  warm  and  dry. 
7.58  P.M.  :  Took  one  grain  of  cocaine  in  aqueous  solu- 
tion into  his  mouth,  retained  it  there  five  minutes,  then 
swallowed  it.  8.01  p.m.  :  Pupils  dilated.  8.05  p.m.  : 
Pulse,  80,  regular  and  strong  ;  respirations,  28.  Pupils 
quite  widely  dilated.  Sialogogue  effect  pronounced. 
8.10  P.M.:  Pulse,  76;  respirations,  26;  pupils,  same. 
8.15  P..M.  :  Feels  elated  and  inclined  to  use  his  muscu- 
lar system.  8.21  p.m.  :  Tem])erature,  99^°  F.  8.30 
P.M.  :  Pulse,  74  ;  respiration,  22  ;  temperature,  99°  F. 
Pupils  a  little  less  dilated  than  before.  8.39  p.m.  :  Hy- 
podermic injection  of  morphine,  grain  one- quarter  into 
forearm.  8.45  P.M.:  Says  he  feels  comfortably,  "  just 
a  little  heavy,"  but  not  inclined  to  sleep  or  lie  down. 
8.52  P.M.  :  Pulse,  72  ;  respirations,  20.  Palms  still 
moist,  and  does  not  comjilain  of  dry  mouth  or  throat. 
9.05  P.M.  :  Temperature,  98!°  F.  Feels  perfectly  fresh 
and  wide  awake.  9.11  p.. m.  :  Pu])ils  normal.  No  nau- 
sea or  lieadache.  He  walked  about  one  mile  to  his 
home,  and  with  the  exception  of  some  wakefulness  had 
a  comfortable  night. 


436 


MEDICAL    RECORD. 


[September  28,    1895 


Fourteenth  Series. — Mr.  J.    B ,  aged    seventeen. 

In  perfect  health.  I'rior  to  hypodermic  injection  of 
morphine,  pulse,  80  ;  respirations,  18;  temperature,  975° 
F.  Skin  slightly  cool.  Face  warm.  Pupils  quite 
Videly  dilated.  7.43  p.m.  :  Administered  hypodermi- 
tally  in  forearm  one-fourth  grain  of  morphine.  7.49 
P.M.:  Pulse,  80,  full  and  strong.  7.52  p.m.:  A  slight 
dizziness,  and  in  five  minutes  later,  pulse  88.  8.09 
I'.M.  :  Pulse,  80  ;  respirations,  18.  8.14  i'.m.  :  Pulse, 
80.  Pupils  remarkably  contracted  and  patient  decid- 
edly sleepy.  Face  pale,  and  skin  cool  and  dry.  8.22 
P.M.:  Says,  legs  are  tired.  Pulse,  80,  and  thready  ;  res- 
pirations, 16.  Patient  manifestly  sleepy.  8.25  p.m.  : 
Gave  patient  one  grain  of  cocaine  by  mouth.  He  re- 
tained it  there  five  minutes  before  swallowing  it.  8.35 
P.M.  :  Pulse,  80  and  strong  ;  respirations,  18.  Pupils 
slowly  expanding.  8.38  p.m.  :  Feels  nauseated.  8.40 
P.M.  :  Still  feels  sleepy.  8.45  p.m.  :  Not  so  sleepy. 
Nausea  disappeared.  Walks  about.  8.48  p.m.  :  Pulse, 
68;  normal  in  character  ;  res'pirations,  18.  Pupils  di- 
lated. 8. 55  p.m.  :  Pulse.  72  ;  respirations,  20.  9  p.m.  : 
Vomited.  9.02  p.m.  :  Feels  brighter.  This  man  drove 
home,  a  distance  of  two  miles.  He  was  somewhat 
wakeful  during  the  night. 

Mr.   B ,  aged    fifty.     Except    for  a  slight   cold, 

was  well.  Prior  to  subcutaneous  injection  of  mor- 
phine, pulse,  90  ;  respirations,  20  ;  temperature,  99f°  F. 
Pupils  normal.  7.42  p.m.  :  Injected  into  forearm  one- 
fourth  grain  of  morphine.  7.50  p.  m.  :  Pulse,  84.  Other- 
wise no  change.  7.55  P.M.:  Pulse,  88.  8.  i'..\i.  :  Pulse, 
84,  fuller  and  stronger.  8.07  p..m.  Pulse,  72  :  respira- 
tions, 20.  8.12  P.M.:  Pulse,  So.  Pupils  remarkably 
contracted.  8.18  p.m.  :  Said  he  felt  muscular  weak- 
ness. Was  quite  drowsy.  Pulse,  66  ;  respiration,  22. 
8. 25  P.M.  :  Patient  took  into  his  mouth  one  grain  of 
cocaine,  held  it  there  live  minutes,  then  svvallowed  it. 
8.35  p.m.  :  Pulse,  72  and  stronger  ;  respirations,  22. 
Pupils  still  contracted.  Not  so  tired  or  sleepy.  8.40 
p.  .M. :  Pulse,  74  and  strong;  respirations,  18.  8. 45 
p.  M.  :  Feels  as  well  as  ever.  Pulse,  72  ;  respirations,  18. 
He  walked  some  distance  to  get  his  horse  and  wagon, 
and  then  drove  home. 

At  this  point  I  may  say,  that  the  above  results  are  in 
harmony  with  those  I  have  obtained  in  the  treatment 
of  patients  in  private  practice.  I  have  also  witnessed 
the  follpwing  effects  of  cocaine:  i.  Lengthening  of 
respiratory  act.  I'en  seconds  frequently  being  con- 
sumed before  the  process  was  completed.  2.  E.xpira- 
tion  was  sometimes  lengthened  to  such  an  extent  as  to 
occupy  ten  or  fifteen  seconds  of  time.  3.  The  entire 
muscular  system  energized  and  stimulated  so  that  the 
jiatient  could  walk  or  work  along  time  without  fatigue, 
however  tired  before  the  administration  of  the  drug, 
4.  Intellectual  faculties  revived  and  sustained  in  active 
operation  a  long  time.  5.  \\'akefulness  of  a  temporary 
character,  if  the  cocaine  were  given  in  small  doses  and 
for  a  brief  time.  Insomnia  of  a  more  or  less  perma- 
nent type  if  the  drug  were  continued  any  length  of 
time.  6.  Decided  impairment  of  appetite.  7.  Most 
marked  and  prompt  stimulation  of  sweat  glands,  sali- 
vary glands,  and  kidneys.  8.  Involuntary  llow  of  urine 
when  dose  is  excessive.  9.  Great  jirostration  following 
withdrawal  after  prolonged  or  excessive  use.  10.  First 
quickening,  then  slowing,  of  respiration.  11.  Pulse 
somewhat  quickened  and  strengthened. 

Remarks  and  Deductions.—  Ihe  following  remarks 
apply  only  to  pigeons  :  i.  They  are  extremely  suscep- 
tible to  cocaine.  One-halt  grain  will  almost  always 
kill  in  a  few  seconds.  One-quarter  of  a  grain  is  usu- 
ally fatal  in  a  few  moments.  2.  One  grain  or  more  of 
cocaine  is  always  fatal  in  a  few  seconds  or  minutes,  ;, 
Its  administration  is  always  followed  by  convulsive 
movements,  if  a  toxic  dose  be  given.  4.  It  invariably 
quickens  resi)iration  and  renders  it  gasping  and  shal- 
low, when  a  lethal  do.se  has  been  given.  5.  It  always 
dilates  the  pui)ils,and  makes  the  heart  beat' more  ri\\nd- 
ly  and  forcibly  if  a  medical  dose  be  administered.     6. 


It  causes  a  staggering  gait  when  given  in  excess.  7. 
When  a  non-toxic  dose  is  administered,  nausea  and 
vomiting  follow,  then  some  tremors  which  last  a  short 
time,  and  the  bird  appears  quite  natural.  8.  When  in- 
jected subcutaneously  its  characteristic  effect  is  some- 
what delayed,  but  it  finally  obtains.  9.  When  injected 
into  abdominal  cavity  it  acts  almost  instantly.  The 
difference  in  time  between  the  two  methods  is  only  a 
few  moments.  10.  The  average  time  pigeons  lived 
after  intra-abdominal  injections  of  two  grains  of  co- 
caine, one  grain  of  morphine  having  been  previously 
administered,  was  2y\  minutes.  11.  Average  time 
pigeons  lived  after  intra-abdominal  injections  of  two 
grains  of  cocaine,  two  grains  of  morphine  having  pre- 
viously been  given,  1 1  yV  minutes.  12.  Average  time 
pigeons  lived,  injected  with  one-half  grain  of  cocaine 
(intra-abdominal),  previously  treated  with  one  grain  of 
morphine,  was  fifteen  minutes  eight  seconds.  13.  Aver- 
age duration  of  life  of  pigeons  into  whose  abdominal 
cavities  one-half  grain  of  cocaine  has  been  injected, 
previously  treated  with  one-half  grain  of  atropine,  was 
two  minutes  eight  seconds.  14.  Average  time  pigeons 
lived  after  injection  of  one  grain  of  cocaine  into  ab- 
dominal cavity,  half-grain  of  atropine  having  previously 
been  given,  was  one  minute  thirty-eight  seconds.  15. 
Average  time  pigeons  lived  after  injection  of  one  grain 
of  cocaine  into  abdominal  cavity,  two  grains  of  mor- 
phine having  previously  been  given,  was  twenty-five 
minutes  six  seconds.  16,  Pigeons  treated  with  three- 
quarters  of  a  grain  of  morphine,  then  with  one  grain  of 
cocaine,  lived  nine  minutes,  17.  Pigeons  into  whose 
abdominal  cavities  one  quarter  of  a  grain  of  cocaine 
WIS  injected,  no  morphine  having  previously  been 
given,  lived  thirty  eight  minutes  thirty-two  seconds. 
iS,  Pigeons  treated  with  two  grains  of  morphine  (in- 
jected into  abdominal  ca\ity),  then  with  one-tjuarter  of 
a  grain  of  cocaine,  lived  on  an  average  of  fifty-five 
minutes  fifty-five  seconds.  19  Pigeons  into  whose 
abdominal  cavities  one-half  grain  of  cocaine  was  in- 
jected had  an  average  life  of  only  one  minute  two 
seconds.  20.  Two  grains  of  cocaine  injected  subcu- 
taneously, killed  in  sixty  seconds.  21.  One  grain  of 
morphine  and  one  grain  of  cocaine  injected  into  ab- 
dominal cavity  of  pigeon  caused  death  at  the  end  of 
two  minutes.  22.  Pige  jns  injected  with  two  grains  of 
cocaine  subcutaneously,  then  with  one  grain  of  mor- 
phine, lived  one  hour  and  five  minutes. 

I  wish  now  to  institute,  if  possible,  a  striking  com- 
parison of  results,  which  will  make  clear  the  point 
these  investigations  are  intended  to  prove. 

First,  in  relation  to  the  ]>igeons.  Taking  into  ac- 
count all  the  birds  treated.  Those  having  first  mor- 
[jhine,  then  a  lethal  dose  of  cocaine,  had  an  average  life 
(jf  forty-four  minutes  and  eight  seconds.  Those  hav- 
ing first  atropine,  then  a  lethal  dose  of  cocaine,  had  an 
average  life  of  one  minute  and  forty-two  seconds. 
Those  having  only  a  lethal  dose  of  cocaine  had  an 
average  life  of  one  minute  and  two  seconds. 

This  comparison  shows  conclusively,  so  far  as  pig- 
eons are  concerned,  that  mor])hine  and  cocaine  are 
manifestly  antagonistic  to  each  other.  It  further  shows 
that  atropine  furnishes  almost  no  protection  (probably 
none)  against  the  prompt  and  violent  action  of  co- 
caine. 

.\s  far  as  the  dogs  are  concerned,  it  would  seem 
that  while  two  grains  of  morphine  do  not  successfully 
antagonize  one  grain  of  cocaine,  four  grains  of  mor- 
phine will  serve  as  an  antidote  for  four  grains  of  co- 
caine. 

.\  comparison  of  results  furnished  by  the  investi- 
gations upon  the  man,  clearly  shows  the  mutual  an- 
tagonism between  the  two  drugs.  Morphine  con- 
tracted the  pupils.  Cocaine  dilated  them.  Morphine 
retarded  jiulse-rate  somewhat,  but  did  not  alter  its 
force  perceptibly.  Cocaine  accelerated  the  pulse  and 
strengthened  it.  Morphine  diminished  the  number  of 
respirations   to    the    minute.       Respirations    were    in- 


September  28,   1895] 


MEDICAL    RECORD. 


437 


creased  in  number  by  cocaine.  (When  any  consider- 
able quantity  of  cocaine  is  taken,  respirations  are  cut 
down  in  number  and  altered  in  character,  as  already 
indicated.)  The  morphine  produced  a  sense  of  mus- 
cular fatigue  and  drowsiness.  Cocaine  energized  and 
made  active  the  muscular  system  and  had  a  "  wak- 
ing-up  effect  "  upon  the  intellectual  faculties.  Mor- 
phine caused  dryness  of  threat,  mouth,  and  skin,  also 
impaired  functional  activity  of  kidneys.  Cocaine  in- 
creased the  moisture  of  the  throat,  mouth,  and  skin, 
and  increased  the  functional  activity  of  the  kidneys. 

Thus  it  is  seen  that  those  two  agents  are  opposed  to 
each  other  in  their  therapeutic  action  upon  man.  I 
have  given  to  patients  who  have  had  severe  pain,  one- 
fourth  grain  of  morphine  and  one-fourth  grain  of  co 
caine  hypodermically,  and  not  only  has  the  pain  been 
relieved,  but  there  has  been  no  drowsiness,  nausea,  or 
vomiting  to  interfere  with  attention  to  the  business  of 
the  day.  When  morphine  is  to  be  given  at  night  in" 
comparatively  small  doses,  it  is  beU  not  to  use  cocaine, 
as  it  is  likely  to  prevent  sleep,  so  decided  is  it  in  its 
effect  upon  the  brain. 

The  very  rapid  diffusibility  of  cocaine  has  been  made 
prominent  in  these  investigations.  When  given  hypo- 
dermically, a  constitutional  effect  of  the  most  decided 
character  was  produced  in  a  little  less  than  fifteen  sec- 
onds. Even  when  held  in  the  mouth  in  a  small 
quantity,  a  constitutional  effect  was  produced  in  two 
minutes  by  local  absorption.  In  this  short  time  there 
was  some  dilatation  of  the  pupils  and  a  beginning  sense 
of  muscular  and  mental  exhilaration.  Diaphoresis  was 
also  experienced. 

At  this  point  let  me  quote  a  case  which  is  an  addi- 
tional demonstration  of  the  value  of  cocaine  as  an  an- 
tidote for  opium. 

Dr.  H.  E.  Matthews,  my  associate  in  laboratory  work, 
was  called  to  treat  a  case  of  opium  poisoning.  Being 
interested  in  my  investigations,  he  concluded  to  use 
cocaine  as  an  antidote.  The  details  of  his  experience 
are  as  follows  : 

Mrs.  R ,  on  June  6,  1895,  about  6.45  p.m.,  dur- 
ing a  quarrel  with  her  husband,  took  a  three-ounce  bot- 
tle of  laudanum  which  was  nearly  full,  and  drank  all 
but  about  half  an  ounce  of  its  contents.  When  Dr. 
Matthews  saw  her,  twenty  minutes  later,  her  pupils  were 
contracted  and  she  was  greatly  excited  ;  so  greatly 
excited  that  he  considered  her  respirations,  16  to  the 
minute,  due  in  a  large  measure  to  the  nervous  distur- 
bance. Her  pulse  was  80.  He  gave  her  six  grains  of 
hydrarg.  sulph.  flava,  which  in  five  minutes  made  her 
vomit  a  clear  fluid  which  had  neither  the  color  nor  odor 
of  laudanum.  He  concluded,  therefore,  that  most  of 
the  poison  had  been  absorbed.  He  then  administered 
hypodermically  one-half  grain  of  cocaine.  At  7.40 
P.M.,  she  was  more  quiet  in  manner,  but  felt  more  vig- 
orous. He  then  gave  her  hypodermically  one-quarter 
grain  of  cocaine.  In  one  hour  she  was  perfectly  nor- 
mal and  in  her  general  condition,  her  pupils  being 
well  dilated. 

I  doubt  if  permanganate  of  potash  or  atropine  would 
have  given  as  good  a  showing  as  that. 

In  conclusion,  let  me  say  that  in  any  case  of  opium 
poisoning,  I  would  first  employ  an  emetic,  then  I  would 
give  hypodermically  one-fourth  to  one-half  grain  of 
cocaine  ;  wait  twenty  minutes,  and  if  no  decided  effect 
had  been  obtained  I  would  give  another  injection  of 
one-fourth  grain  ;  after  waiting  another  twenty  minutes 
I  would  repeat  the  dose  if  there  were  no  manifest  im- 
provements in  the  case.  I  think  three  separate  doses 
of  one-quarter  grain  each  at  intervals  of  twenty  min- 
utes, is  the  best  plan  to  follow,  on  account  of  the  very 
quick  diffusibility  of  the  drug  and  its  sustained  effect. 
During  this  time  I  would  administer  coffee  by  mouth 
or  rectum  as  a  supplementary  heart  stimulant,  and  in 
extreme  cases  employ  artificial  respiration. 

While  I  urge  this  method,  I  hope  with  becoming 
deference   to  the  opinion  of  others,  concerning  other 


plans  of  treatment,  I  urge  it  with  the  honest  conviction 
that  it  is  an  improvement  upon  the  atropine  and  per- 
manganate of  potash  methods. 


NUCLEIN  IS  NATURE'S  ANTITOXIN.  AND 
SOME  OF  THE  FUNDAMENTAL  PRINCI- 
PLES UNDERLYING  OUR  MODERN  THER- 
APY.' 

By  J.  MOUNT  BLEYER,  M.U,   F.R.A.M.S.  N.\ples. 


NEW   VORl- 

LARVNGOLOGIST  TO  THE  GERMAN  WEST-SIDE 
NATIONAL  ACADB.MY  OF  .MEDICINE;  MEMB 
GOLOGICAL  SOCIETY  OF  PARIS,  FR-ANCE  ;  N 
ELECTRO- THERAPEUTICS  ;  MEMBER  OF  TH 
MEMBER  PEDRO-ESCOHEDO,  MEXICO,  ETC. 


:  CLINIC  ;  .ME.MBER  OF  THE  .ME-VICAX 
£R  OF  THE  OTOLOGICAL  AND  LARYN- 
EMBER  OF  THE  FRENCH  SOCIETY  OF 
E  AMERICAN    MEDIC 


A  LITTLE  over  five  decades  have  just  crept  by  us  since 
the  great  Schwann  communicated  the  results  of  his 
discoveries  on  animal  tissues  to  the  French  Academy, 
which  became  the  foundation  to  a  budding  science 
upon  which  since  then  an  imposing  structure  has  been 
built. 

Closely  following  upon  Robert  Brown's  and  Schlei- 
den's  work,  Schwann  published,  in  1839,  his  famous  mi- 
croscopical researches,  and  came  to  the  conclusion 
that  all  possible  tissues  of  both  animals  and  plants  con- 
sisted of  cells,  or  of  materials  derived  from  cells,  it 
seemed  that  the  primary  units — molecules,  so  to  say, 
of  which  all  living  beings  are  built  up,  had  finally  been 
discovered.  A  small  piece  of  structureless,  granulated, 
jelly-like  substance — the  sarcode  in  animals  and  the 
protoplasm  in  plants — surrounded  or  not  by  a  thin  mem- 
brane, and  containing  a  nucleus,  this  was  the  primary 
unit,  giving  origin  to  all  the  most  complex  and  varied 
tissues. 

This  conception  gave  a  formidable  impulse  to  science 
and  to  scientific  philosophy  altogether,  the  more  so  as 
it  was  soon  followed  by  a  most  important  discovery 
which  established  the  close  resemblance  existing  be- 
tween the  subdivision  of  cells  and  the  phenomena  of 
sexual  reproduction  in  plants  and  animals.  Twenty- 
two  years  later,  another  still  more  important  step  was 
made  in  the  same  direction  when  Max  Schultz  pub- 
lished his  memoir  "  Das  Protoplasm,"  and  proved  that 
the  granular,  jelly-like  substance  of  the  cells  is  identi- 
cal in  both  the  animal  and  vegetable  kingdoms,  that  it 
is  the  very  seat  of  all  physiological  activity,  as  it  is  capa- 
ble of  movement,  of  nutrition,  of  growth,  of  reproduc- 
tion, and  even  of  sensibility,  or,  at  least,  of  irritabil- 
ity. Many  must  certainly  remember  the  effect  pro- 
duced by  the  broad  generalization  based  upon  Max 
Schultz's  ideas  by  Haeckel  in  Germany,  and  Mr.  Hux- 
ley in  his  well-known  lay  sermon,  "  The  Physical  Basis 
of  Life." 

However,  if  protoplasm  were  the  seat  of  physiologi- 
cal activity  ;  if  it  could  move,  grow,  reproduce  itself, 
and  display  irritability,  was  it  still  to  be  considered  as  a 
structureless,  granulated  jelly  or  slime  ?  It  was  a  world 
in  itself,  and  the  microscope  had  to  be  directed  toward 
the  further  study  of  this  world.  So  it  was,  by  Lionel 
Beale,  Schultz  himself,  Strasburger,  and  most  of  the 
famous  histologists.  Discovery  upon  discovery  was  the 
reward  of  this  work,  and  the  recent  researches  of  Stras- 
burger, Fleming,  Guignard,  and  Fol,  while  fully  con- 
firming the  broad  generalization  laid  at  the  foundation 
of  modern  biology,  revealed  a  wide  series  of  new  facts 
having  a  direct  bearing  upon  the  question  of  heredity 
which  is  so  much  debated  now  in  connection  with 
Weisraann's  views.* 

'  Read  before  the  American  Medical  .Association.  May  7,  8.  g,  and 
10,  1895.     Section.  Practice  of  Medicine. 

?  Strasburger :  Ueber  Kem-und  Zell-Theilung  in  Pflanzenreiche, 
Jena.  1888  ;  Guignar<l.  in  Bull.  Soc  Botanique  de  France,  1890,  tome 
xxxvi  .  and  Comptes  Kendus,  1891,  toiiie  c.\ii..  pp.  539,  1074,  and  1320; 
tome  cxiii.,  p.  917 ;  W.  Fleming,  in  Archiv  fiir  Mikrosk  Anatomie,  1891, 
Bd.  xxxvii..  p.  249,  and  Anatomischer  Anzeiger,  1891,  p.  78.  An  im- 
mense literature  lias  suddenly  grown  up  upon  this  subject ;  excellent 


438 


MEDICAL    RECORD. 


[September  28,  1895 


From  the  above-mentioned  researches  it  became  evi- 
dent that  protoplasm  itself  consists  at  least  of  two  dif- 
ferent substances — one  of  them  a  minute  net-work  of 
very  delicate  fibrils,  while  the  other,  an  apparently 
homogeneous  substance,  filling  up  the  interstices  be- 
tween the  net-work.  Then  it  was  observed  that  the  nu- 
cleus, which  makes  a  necessary  constituent  part  of  cells, 
has  a  still  more  complicated  structure  of  subdivision  of 
the  cells,  and  those  of  reproduction.  It  consists  of  a 
nuclear  plasm,  surrounded  by  a  very  thin  membrane  ; 
contains  very  often  a  still  smaller  nucleolus  ;  and  within 
the  nuclear  plasm  the  microscope  discovers  extremely 
thin  threads,  or  fibres,  consisting  in  their  turn  of  ex 
tremely  thin  minute  granules,  or  sporules — the  whole 
appearing  as  a  ball  of  thread  coiled  up  somewhat 
roughly.  The  albuminous  matter  of  which  these 
threads  consist  receive  the  name  of  "  Nuclein,"  and 
the  threads  themselves  were  named  chromatin  fibres, 
owing  to  their  affinity  for  coloring  matter.  The  trans- 
formation in  the  nucleus  which  has  just  been  described 
received  the  general  name  of  Karyokinesis,  or  nuclear 
movement.  (The  names,  as  seen,  are  simply  descrip- 
tive.) This  being  the  usual  aspect  of  the  nucleus,  a 
series  of  modifications  begin  within  it,  when  the  mo- 
ment arrives  for  a  cell  to  subdivide.  The  nucleolus 
disappears  ;  the  beaded  threads,  or  fibres,  shorten  and 
become  thicker.  They  assume  tlie  shape  of  minute 
hooks,  which  join  together  (by  the  tops  of  the  bend- 
ings)  in  one  point,  the  pole.  By  the  same  time  the 
membrane  of  the  nucleus  is  reabsorbed,  and  the  sur- 
rounding protoplasm  of  the  cell  penetrates  within  the 
nucleus,  thus  mixing  up  together  with  the  nuclear 
plasm.  Thereupon  a  most  important  change  follows. 
Each  of  the  thickened  nuclein  fibres,  or  threads,  splits 
in  its  length,  and  the  number  of  the  threads  being 
thus  doubled,  one- half  of  them  is  attracted  toward  a 
radiated  spindle-figure  in  one  part  of  the  cell,  while 
the  other  half  arranges  in  the  same  way  in  its  opposite 
part.  The  two  radiated  figures  thus  separate,  and  only 
then  (if  the  nucleus  subdivides  in  giving  origin  to  two 
new  cells)  a  membrane,  or  parts  of  a  membrane,  grow 
between  the  two.  After  the  separation,  the  fibres 
either  coalesce  with  their  ends  or  return  to  the  shape 
of  a  ball  of  thread. 

It  is  a  whole  world  undergoing  a  complete  cycle  of 
modifications.  And  yet  this  is  not  all.  It  appears 
from  Strasburger's  work  that  all  the  cells  are  not  quite 
alike,  buj:  that  the  number  of  nuclein  fibres  varies  from 
eight  to  sixteen  in  the  different  families  of  plants,  the 
individuality  of  the  types  thus  seemingly  depending 
upon  their  number  ;  while  Guignard  found  that  with 
several  plants  the  cells  which  will  be  destined,  after  the 
division  of  the  mother-cell,  to  become  the  reproductive 
organs,  will  always  have  but  one-half  of  the  normal 
number  of  fibres  (say  twelve),  while  those  which  are  des- 
tined to  become  the  vegetative  organs  will  have  the 
full  number — say  twenty-four.'  The  former  will 
acquire  the  full  number  of  fibres  only  after  fecunda- 
tion. Are,  then,  the  cells  differentiated  from  the  first 
movement  of  their  bi-jiartition  ?  And  what  part  does 
the  number  of  chromatine  fibres  play  in  that  differen- 
tiation ? 

Further  complications  are  discovered  through  the 
study  of  the  protoplasm  itself.  It  was  known  some 
time  ago  that  there  are,  in  the  animal  cells,  two  pecu- 
liar spots  surrounded  by  rays  of  sarcode,  which  were 
named  spheres  of  attraction,  or  directing  spheres,  or  cen- 
trosomata,  or  simply  "  centres."  The  same  minute 
centres  have  now  been  found  by  Strasburgerand  Guign- 
ard in  vegetable  cells  also,  and  it  appears  that  these 
bodies  essentially  belong  to  the  protoplasm — not  to  the 

'funtils  of  the  whole  question  have  been  given  in  linglish  up  to  i883 
")■  Professor  McKendrick.  in  Proceed.  Glasgow  Philos.  Society, 
il.  xi.v.  ;  and  to  the  end  of  1890  by  William  Turner  in  an  address, 
I'hc  Cell  Tlieory.  P.ist  and  Present,  delivered  in  October.  1890,  before 
ihc  Scottish  Microscopical  Society  (Nature,  vol.  xiv.,  p   2  et  seq. ). 

'  Report  upon  which  the  Prix  Bordin  was  awarded  to  Guignard,  in 
Comptes  Rendus,  December  21,  1891,  p.  917; 


nucleus — take  a  leading  part  in  the  phenomena  of  re- 
l)ioduction.  Professor  Fol,  who  carried  on  his  re- 
searches with  eggs  of  sea-urchins,  saw  that  when  the 
elements  of  the  male  cell  have  entered  the  female  cell, 
the  centre  of  the  former  separates  from  the  top  of  its 
nucleus  and  joins  the  centre  of  the  latter.  Both  lie 
close  to  one  another  ;  then  they  become  elongated  and 
take  positions  on  the  opposite  sides  of  the  nucleus, 
which  is  now  formed  by  both  coalesced  nuclei,  sur- 
rounded by  a  radiation  of  the  fibrils  of  protoplasm. 
Then  begins  what  Fol  terms  the  "  quadrille  of  the  cen- 
tres." Each  of  them  divides  into  two  half-centres,  and 
all  four  move,  so  that  each  half-centre  of  the  male  cell 
meets  and  coalesces  with  one  half-centre  of  the  female 
cell,  and  the  two  newly  formed  centres  become  the 
poles  of  attraction  for  the  spindles  of  the  nucleus.  The 
act  of  fecundation  is  thus  not  a  simple  coalescence  of 
two  nuclei,  originated  from  two  separate  individuals, 
as  was  first  supposed  ;  but  it  also  consists  of  the  union 
of  each  two  of  the  four  half  centres  originated  in  the 
protoplasm. 

The  interest  attached  to  these  minute  changes  is 
great,  on  account  of  their  influence  upon  the  theory 
of  heredity.  The  observations  of  Fol,  and  the  quite 
analogous  observation  of  Guignard  as  regards  plants, 
would  only  confirm  the  doubts  expressed  by  Sir  Will- 
iam Turner  in  his  address  before  the  Microscopical  So- 
ciety '  as  to  the  germ  plasm  being  so  isolated  from  the 
cells  of  the  body  generally  as  to  be  influenced  by  them 
and  to  be  unaffected  by  its  surroundings  ;  and  they 
would  give  further  weight  to  his  restrictions  upon 
^Veissmann's  theory  of  heredity.  However,  the  ques- 
tions at  issue  are  so  complicated  and  so  delicate  that 
further  research  is  necessary  before  positive  conclu- 
sions can  be  drawn. 

But  what  is  protoplasm  itself?  What  is  this  jelly- 
like matter  which  exhibits  all  phenomena  of  life  ?  Sci- 
ence has  not  yet  given  an  absolute  answer  to  this  great 
question.  On  the  one  side,  we  have  the  germs  of  an 
opinion,  shared  by  some  biologists  who  are  inclined  to 
see  in  protoplasm  an  aggregation  of  lower  organisms. 
Thus  R.  Altmann  -  and  I.  Strauss  ^  consider  that  the 
granulations  of  protoplasm  are  the  essential  and  funda- 
mental elements  of  the  organic  being.  As  to  the  cell, 
it  is  not,  in  Altmann's  opinion,  an  elementary  organism, 
but  a  colony  of  elementary  organisms  which  group  to- 
gether, according  to  certain  fixed  rules  of  colonization. 
They  constitute  the  protoplasm  as  we  1  as  the  nuclear 
plasm,  and  ihey  are  the  morphological  units  of  all  liv- 
ing matter.  These  granules,  he  maintains,  are  identi- 
cal with  microbes  ;  their  shape,  their  chemical  reaction, 
their  movements,  and  their  secretory  functions  are  sim- 
ilar ;  but  the  granules  of  the  protoplasm  differ  from 
bacteria  in  not  being  capable  of  a  sejiarate  existence. 
They  can  only  live  in  cells.  It  is  absolutely  impossible 
to  say,  at  the  present  time,  how  far  this  view  may  find 
indorsement  in  later  research,  though  it  must  be  men- 
tioned that  it  is  derived  from  elaborate  investigations 
into  the  cells  of  various  glands  and  their  secretions, 
and  that  it  finds  support  in  facts  accumulated  by  many 
well-known  anatomists.'  It  must  also  be  added  that 
some  biologists,  namely,  J.  C.  Vogt,'  go  a  step  further 
and  maintain  that  all  micro-organisms,  and  all  cells  of 
more  comi)licated  organisms  are  structures  of  a  fourth 
or  higher  order  ;  they  are  colonies  of  polyblasts,  which 
themselves  consist  of  monoblasts,  or  those  granules 
which  are  distinguished  in  the  protoplasm  and  the  nu- 
clear plasm.  But,  on  the  other  side,  we  also  have  the 
other   extreme   view,    supported    by  the    authority   of 

'  See  note  i. 

-  Die  F.lemciitar-organismen  und  ihre  Beziehungen  zu  den  Zellen. 
Leipzig.  1890,  with  21  plates. 

'■>  Stir  la  Morphologic  de  la  Cellule  bactericnne  in  Journal  de  Mi- 
crographie,  t.  xv. ,  October  25,  1891. 

'  The  author  names  Giamizzi,  Ranvier.  Renant,  and  partly  Henri 
M.artin. 

^  Das  Empfindings  prinzip  und  das  protoplasma  auf  Grund  eines 
einheitlichcn  Substanzbegriffes.  Leipzig.  1891.  Journal  of  the  Mi- 
croscopical Society,  February,  1892. 


September  28,  1895] 


MEDICAL    RECORD. 


439 


Professor  O.  Butschli,  who  sees  in  protoplasm  nothing 
but  a  foam,  quite  similar  to  the  foams  which  may  be 
artificially  produced,  and  who  maintains  that  all  phe- 
nomena observed  in  living  protoplasm  are  simply  phys- 
ical and  chemical  processes. 

The  great  question  as  to  what  protoplasm  is,  evi- 
dently will  not  be  solved  soon,  but  the  above-mentioned 
researches  will  give  an  idea  of  the  problems  which  at 
this  moment  absorb  the  attention  of  biologists.  One 
important  step  has  certainly  been  made,  the  compli- 
cated structure  of  protoplasm  has  been  recognized  and 
the  exploration  of  the  vital  processes  in  living  matter 
now  stands  on  a  firm  footing.' 

Having  in  the  foregoing  traced  and  given  the  most 
modern  views  underlying  the  principles  upon  which  our 
modern  therapy  is  founded  I  have  still  a  few  words  to 
say  regarding  my  own  views  on  ''nature's  antitoxin," 
which  most  evidently  exists  in  the  protoplasm,  and  is 
constantly  formed  in  the  living  body  by  the  leucocytes 
for  economical  and  protective  purposes.  This  sub- 
stance is  known  to  us  now  as  "'  nuclein." 

This  cellulized  substance,  nuclein,  takes  upon  itself 
the  task  of  performing  many  complex  functions  in  the 
physiological  economy,  and  one  of  the  most  important. 
besides  that  of  providing  the  tissues  with  its  entire  nu- 
triment, is  to  protect  its  tissues  from  being  invaded  by 
such  poisons  with  which  the  body  is  constantly  threat- 
ened. In  fact  nuclein  is  nature's  immunizer,  and  it  is 
also  the  most  important  matter  in  all  nature,  for  it  alone 
is  the  bearer  of  life.  With  slight  changes  it  forms  not 
only  the  bodies  of  all  plant  cells,  but  also  the  white  and 
yolk  of  the  egg,  flesh  and  blood,  the  substance  of  the 
brain  and  nerves,  milk  and  cheese,  the  skin  and  hair  of 
animals.  While  in  lifeless  nature  nearly  every  kind  of 
stone  has  a  different  chemical  constitution,  in  the  world 
of  life  one  and  the  same  fundamental  substance  forms 
the  basis  of  the  bodies  of  plants,  animals,  and  men. 

We  find  a  very  important  device  that  mother  nature 
has  provided  the  cell  with  a  hard  shell  in  case  or  war- 
fare with  bacteria  and  other  poisons  which  bodies  in 
their  momentary  lives  are  endangered  with.  This  soft 
protoplasm,  or  "  nuclein,"  as  we  learned  before,  would 
not  be  able  to  resist  the  presence  and  assault  of  strange 
bodies  ;  it  is  therefore  that  it  is  surrounded  with  a  hard 
shell  or  envelope,  which  it  prepares  as  a  dwelling  and 
for  its  protection  in  a  similar  manner  as  the  snail  forms 
its  shell  by  secreting  over  its  surface  a  matter  which 
soon  hardens  into  a  firm,  transparent  enclosure.  This 
shell,  known  as  cell-wall,  does  not  show  the  most  mi- 
nute opening,  but  incloses  the  protoplasm  perfectly 
tight.  We  might,  therefore,  liken  the  cell  to  an  egg,  in 
which  the  soft  living  contents  are  concealed  in  the  hard 
shell. 

But  in  nature  nothing  is  great  and  nothing  little,  and 
there  is  room,  even  in  the  smallest  of  nature's  cells,  for 
the  greatest  diversity  and  development  of  the  powers 
of  life,  etc.,  a  continuous  formation  and  transformation, 
origin  and  decay,  a  constant  change  of  matter  is  going 
on  in  every  cell  ;  reception  and  assimilation  of  food, 
inspiration  and  expiration  ;  certain  atoms  which  have 
become  of  no  use  for  purposes  of  life  are  cast  aside, 
others  are  taken  up  from  without  in  their  places  ;  as  on 
this  food  and  change  of  substance  depend  the  renova- 
tion of  the  cell  and  the  maintenance  of  its  life.  Evi- 
dently not  solid  substances  are  appropriated,  for  we 
know  that  the  cell  is  inclosed  in  a  perfectly  closed  en- 
velope, but  liquid  and  gaseous  foods  can  be  easily  ab- 
sorbed. Although  the  most  perfect  microscopes  have 
never  made  any  holes  visible  in  the  cell-envelope,  there 
is  not  the  slightest  doubt  that  this  envelope  is  porous. 
Therefore  we  may  understand  that,  when  a  cell  is 
placed  in  a  fluid,  the  envelope  absorbs  it  to  fulness, 
and  conveys  to  the  inner  protoplasmic  body  as  much 
as  it  requires  ;  and,  inversely,  certain  parts  of  the  cell- 

■  Professor  R.  Greef  s  exploration  of  the  motor  fibrils  of  the  amoeba 
rricola   (Biologisches  Centralblatf.  November,  1891,  pp.    590  and 

' .-'  niay  be  mentioned  as  :in  illustration  of  sucli  researches. 


juices,  which  the  living  protoplasmic  body  does  not  need 
for  itself,  are  transpired  through  the  pores  of  the  enve- 
lope and  become  applicable  to  the  use  of  other  cells  ; 
and  the  same  may  take  place  v.-ith  air  and  gases,  etc. 

From  the  many  experiments  the  evidence  gathered 
has  shown  conclusively  that  the  leucocyte  plays  the 
important  rj/e  in  the  physiological  life  of  the  beings — 
as  well  as  in  the  cell  in  the  vegetable  world.  That  the 
cell  is  the  manufacturer  of  an  immunizing  substance 
has  been  again  proven  by  the  most  recent  experiments 
of  Dr.  Pheiffer,  of  Berlin,  which  substantiates  those  of 
mine  and  others  before  him.  In  the  last  number  of 
Modern  Medicine  and  Bacteriological  Review  there  ap- 
pears an  article  of  exceptional  interest,  inasmuch  as  it 
contains  an  original  article  by  Professor  Metchnikoff, 
whose  theories  on  phagocytosis  are  so  well  known,  and 
goes  far  to  elucidate  the  idea  that  the  leucocyte  is 
the  manufacturer  of  nature's  antitoxin  and  thereby  the 
normal  physiological  immunizer. 

The  interest  in  this  article  by  Professor  Metchni- 
koff. "  The  Extra-cellular  Destruction  of  Bacteria  in  the 
Organism,"  lies  in  the  critical  comment  upon  some  of 
the  conclusions  deduced  by  Dr.  Pheiffer  from  his  ex- 
periments on  the  destruction  of  cholera  vibrios  in  the 
peritoneal  cavity  of  guinea-pigs.  Dr.  Pheiffer  observed 
this  destruction  of  cholera  vibrios  when  the  latter  were 
introduced  into  animals  previously  vaccinated  against 
this  germ,  and  also  in  the  case  of  unprotected  animals 
when  the  vibrios  were  injected  together  with  a  small 
quantity  of  serum  from  vaccinated  animals.  In  both 
cases  Dr.  Pheift'er  found  that  they  were  destroyed  out- 
side the  cells  in  the  peritoneal  fluid,  and  he  believes 
that  this  bacteria-killing  fluid  is  secreted  by  the  cellular 
elements  in  consequence  of  a  special  excitation  produced 
by  the  injection  of  cholera  vibrios,  and  that  the  im- 
munity acquired  by  guinea-pigs  is  independent  of  phago- 
cytosis. Professor  Metchnikoff,  however,  regards  this 
as  an  episode  in  the  battle  between  bacteria  and  pha- 
gocytes, and  maintains,  on  evidence  supported  by 
experiments,  that  the  leucocytes  secrete  this  bacteria- 
killing  fluid  while  undergoing  the  process  of  degenera- 
tion due  to  the  injection  of  Pheiffer's  mixture  of 
vibrios,  serum,  and  broth.  That,  although  unable  to 
engulf  the  vibrios,  they  are  able  still  to  destroy  them 
by  their  secretions  (nature's  antitoxin).  Metchnikoff 
points  out  that  if  before  introducing  the  vibrio  mixture 
a  few  cubic  centimetres  of  broth  be  injected  into  the 
peritoneal  cavity,  the  leucocytes  will  gather  together  in 
great  force  after  a  few  hours,  and  if  the  vibrio  mixture 
be  then  introduced  phagocytosis  does  take  place,  and 
the  cholera  bacteria  are  more  rapidly  destroyed  by  this 
process  of  intra- phagocytosis  than  by  the  extracellular 
destruction  produced  by  the  condition  of  Pheiffer's  ex- 
periments. I  must  myself  agree  with  some  of  the  views 
of  both  these  gentlemen.  For  the  last  two  years  this 
question  has  interested  me  so  much  that  I  under- 
took many  varied  scientific  and  clinical  experiments 
founded  on  the  foregoing  ones  just  cited.  I  must 
say  that  my  clinical  experience  has  also  given  me  proof 
sufficient  to  warrant  my  conclusions.  My  observations 
were  directed  toward  diphtherias  of  different  grades, 
cancers,  fevers,  and  phthisis,  with  different  prepa- 
rations of  the  nucleins — among  them  my  own  ' — made 
from  the  fish  eggs,  and  that  one  known  as  proto-nu- 
clein,  also  with  serums,  without  culture  and  in  the 
attenuated  form,  and  the  antitoxin  diphtheria.  Some 
of  my  observations  with  the  nucleins  in  diphtheria,  fol- 
licular tonsillitis,  and  pseudo-diphtheria  have  already 
been  reported  and  printed  in  several  of  the  leading 
American  and  foreign  journals.  These  clinical  truths 
as  reported  gave  me  further  stimulus  to  carry  on  the 
more  extensive  ones,  which  will  follow  this  present 
paper.  It  also  gives  me  great  pleasure  to  see  that  I 
foreshadowed  that  the  serums  alone,  and  without  the  at- 

*  The  egg  nucleins  are  manufactured  for  me  by  special  process,  and 
can  be  supplied  by  Mr.  Oscar  G.  Kalish,  chemist.  Twenty-third  Street 
and  Fourth  .Avenue,  Ne'.v  York  Citv. 


440 


MEDICAL    RECORD. 


[September  28,  1895 


tenuation.  have  the  power  of  exhibiting  their  strong 
bactericidal  powers.  My  own  researches  are  corrob 
orated  by  those  later  ones  of  Pheiffer  and  Metchnikoff. 

In  all  my  work  the  microscope  was  not  neglected,  as 
I  found  it  a  most  important  witness_  in  my  clinical 
cases  regarding  the  blood  counts  for  its  leucocytotic 
potency. 

The  efficacy  of  the  antito.xin  of  diphtheria,  and  those 
which  have  serum  as  their  base,  if  my  conclusions  be 
justifiable,  must  therefore  be  dependent  upon  the 
nuclein  in  the  serum,  and  thus  its  value  does  not  lie  in 
the  attenuation  of  the  serum,  but  in  the  nuclein  that 
the  serum  contains,  the  attenuation  being  only  an  extra 
dynamic  irritant  by  means  of  which  leucocytosis  is 
produced— so  giving  rise  to  an  increased  amount  of 
nuclein,  or  bacteria-killing  fluid,  as  shown  above.  This, 
and  this  alone,  can  explain  the  therapeutic  value  of 
antitoxins.  From  all  I  have  been  able  to  learn  from 
my  clinical  and  experimental  studies  and  from  the 
exhaustive  work  upon  kindred  subjects  by  those  gone 
before,  I  incline  to  the  belief  that  both  Pheiffer  and 
Metchnikoff  have  given  us  the  partial  solution  of  this 
most  valuable  and  interesting  problem  of  immunization 
and  protection  against  all  diseases  in  that  they  and 
myself  hold  that  the  immunity  is  brought  about  by  the 
bursting  of  the  leucocyte,  filled  with  its  ripe  or  cellu- 
lized  substance,  which  in  turn  is  given  by  the  circu- 
latory fluids  to  the  organs  whenever  and  wherever  it  is 
needed.  The  subject  is  far  too  recent  and  yet  in  its 
infancy,  but  it  is  upon  it  that  our  modern  therapy  must 
be  based. 

46:1  LsxmcTON  Avenue. 


SOME  OF  THE  CONDITIONS  REQUIRING 
SPECIAL  CARE  AFTER  ABDOMINAL  SEC- 
TION. 

By  RUFUS  B.  hall,  A.M.,  M.D., 

CINCINNATI,  0. 

PROFESSOR  CLINICAL  GVNF.CQLOGV  IN  MIAMI  MHDICAL  COLLEGE  ;  GYNECOLOGIST 
AT  PRESBVrERI  AN  HOSPITAL  :  FELLOW  OF  AMERICAN  ASSOCIATION  OF  OBSTET- 
RICIANS ANO  GYNECOLOGtSTS  ;    MEMBER    OF  SOL'THHR.N    SURGICAL  AND  GVNECO- 


The  mortality  after  abdominal  section  is  largely  de- 
pendent upon  the  thoroughness  with  which  the  patient 
is  prepared  for  the  operation,  and  the  readiness  with 
which'complications  are  met  after  the  operation  is  com- 
pleted. In  emergency  cases,  where  no  time  can  be  taken 
for  preliminary  treatment,  the  after  care  of  the  patient 
becomes  a  question  of  the  greatest  importance.  The 
after-care  of  the  ordinary  case  is  a  source  of  great 
anxiety  to  the  operator  until  the  danger  period  is  past, 
but  the  emergency  case  is  one  that  involves  greater  re- 
sponsibility and  anxiety. 

We  shall  not  speak  of  the  after  care  of  emergency 
cases,  but  of  the  after-care  of  the  ordinary  case.  That 
the  patient  may  have  the  best  chance  for  recovery  after 
a  section,  she  should  be  given  the  benefit  of  everything 
known  to  science  which  will  contribute  in  any  way  to 
her  comfort  and  welfare. 

I  shall  not  consider  in  detail  the  preparation  of  the 
patient  for  the  operation,  but  I  wish  to  emphasize  one 
or  two  important  points.  It  would  be  quite  impossible 
to  establish  any  fixed  rules  to  be  followed  in  all  cases, 
yet  we  might  say  that  all  cases  should  have  hot  baths 
daily  for  several  days  preceding  the  operation.  One 
of  the  most  annoying  conditions  to  overcome  is  consti- 
pation ;  it  is  almost  always  present.  Where  time  will  per- 
mit a  good  routine  to  observe  is  this  :  Five  to  eight 
grains  of  calomel  in  the  evening,  followed  by  sulphate  of 
magnesia  in  the  morning,  and  every  second  morning  for 
a  week  or  so,  by  a  saline  i)urge.  This,  in  conjunction 
with  full  doses  of  strychnia  given  three  or  four  times  a 
day,  and  proper  attention  to  a  diet  which  does  not  con- 
stipate, will  be  found  efficient.  Now  that  we  under- 
stand so  well  the  evil  effects  of  the  bacillus  coli  com- 


munis, we  can  better  appreciate  the  necessity  of  putting 
the  intestinal  tract  in  a  good  sanitary  condition.  In  ad- 
dition, the  preliminary  use  of  strychnia  puts  the  patient 
in  a  better  condition  to  secure  an  easy  and  prompt 
evacuation  of  the  bowels  following  the  operation. 

I  also  attach  much  importance  to  a  careful  examina- 
tion of  the  urine.  If  the  kidneys  are  found  defective 
in  the  performance  of  their  function,  the  condition  is 
corrected  as  far  as  possible  by  careful  medication, 
quantities  of  lithia  water,  and  hot  baths.  If  marked 
organic  disease  of  the  kidney  exists,  we  are  made  aware 
of  the  true  condition  before  the  operation  and  select 
the  anaesthetic  that  is  least  likely  to  be  harmful. 

The  patient  always  complains  of  severe  pain  directly 
after  regaining  consciousness,  but  if  she  is  prepared 
mentally  before  the  operation  for  this  condition,  and 
told  of  the  great  necessity  for  avoiding  morphine,  as  a 
rule  she  can  be  persuaded  to  bear  the  pain.  At  the 
end  of  eight  or  ten  hours,  if  she  has  not  been  given 
morphine,  she  rarely  complains  of  pain,  but  if  one  dose 
is  given,  its  use  will  have  to  be  continued  for  three  or 
four  days  at  frequent  intervals,  thus  complicating  the 
convalescence.  I  am  seldom  compelled  to  give  mor- 
phine after  an  operation  ;  in  fact,  I  have  given  it  to  but 
one  patient  in  two  and  one-half  years.  I  occasionally 
give  codeia,  which  does  not  relieve  the  pain  so  thor- 
oughly, but  gives  some  relief.  It  does  not  have  the  bad 
effect  of  morphine,  and  it  satisfies  the  nervous  patient's 
desire  that  something  be  done  to  relieve  the  pain. 

Another  condition  with  which  we  have  to  contend  is 
extreme  thirst.  Almost  the  first  thing  a  patient  asks 
for  is  a  drink  of  water,  but  it  must  not  be  given.  She 
must  have  absolutely  nothing  in  the  stomach  for  twelve 
to  fifteen  hours,  as  it  increases  the  tendency  to  vomit. 
Another  reason  for  refusing  water  is,  if  we  withhold  all 
fluids,  the  excess  of  fluid  in  the  peritoneal  cavity  will 
be  more  readily  absorbed.  After  twelve  or  fifteen 
hours,  if  there  is  no  vomiting,  give  a  teaspoonful  of  hot 
water,  as  hot  as  the  patient  can  stand.  It  quenches 
thirst  better  than  cold  and  has  a  tendency  to  prevent 
vomiting.  The  thorough  physic  from  the  salines,  plus  the 
section,  creates  a  great  thirst.  To  allay  this  and  supply 
the  body  with  water  I  give  an  enema  of  twelve  ounces 
of  a  saline  solution  within  an  hour  after  the  operation, 
repeating  it  every  four  or  five  hours  for  twenty-four  to 
thirty-six  hours.  The  patient  complains  compara- 
tively little  of  thirst  if  thus  treated. 

Ether  is  more  likely  to  cause  vomiting  as  the  pa- 
tient is  returning  to  consciousness.  As  vomiting  is  one 
of  the  complications  following  operations,  and  once 
started  is  difficult  to  control,  everything  likely  to  cause 
or  aggravate  it  should  be  avoided  as  far  as  possible.  It 
is  one  of  the  most  annoying  conditions  with  which  we 
have  to  deal,  and,  as  a  general  rule,  the  less  you  do  in 
the  way  of  medication  the  first  six  hours  after  the  oper- 
ation the  better  it  will  be  for  the  patient.  Put  abso- 
lutely nothing  into  the  stomach  ;  give  the  patient  noth- 
ing for  the  vomiting.  I  frequently  have  to  oppose  the 
views  of  the  family  attendant  in  these  cases.  He  wants 
to  give  the  standard  remedies  for  vomiting  and  insists 
upon  it.  I  have  found  it  to  be  a  fact  that  the  more  we 
put  into  the  stomach  the  first  six  hours,  the  longer  the 
patient  will  continue  to  vomit.  What  she  needs,  and 
the  best  treatment  for  this  condition,  is  to  withhold 
everything  from  the  stomach. 

If,  however,  the  patient  continues  to  vomit  for  ten 
or  twelve  hours  or  longer,  you  may  look  for  a  cause 
other  than  the  anesthetic,  probably  sepsis,  septic  peri- 
tonitis, or  both.  Patients  as  a  rule  do  not  vomit 
longer  than  six  to  eight  hours  after  an  operation,  when 
the  nausea  is  due  to  the  anxsthetic  alone.  If,  in  addi- 
tion to  the  vomiting,  the  jiatient  has  a  quick  pulse,  is 
restless,  or  the  abdomen  is  distended,  the  vomiting  re- 
quires our  closest  attention,  for  now  it  is  all  important 
that  it  be  stopped.  It  is  now  evident  that  it  is  not 
from  the  anajsthetic,  but  is  due  to  a  septic  condition, 
and  the  sooner  we  can  get  the  bowels  moved  the  better 


September  28,    1895] 


MEDICAL    RECORD. 


441 


for  our  patient.  In  fact,  the  vomiting  will  not  be  con- 
trolled until  the  bowels  are  thoroughly  evacuated. 
For  this  condition  I  use  a  fourth  to  one- half  grain  dose 
of  calomel  rubbed  up  with  a  little  sugar  of  milk,  placed 
dry  on  the  tongue  every  thirty  minutes.  If  the  vonnit- 
ing  occurs  oftener  than  every  thirty  minutes,  repeat 
the  dose  after  each  attack  of  vomiting.  This,  with  a 
small  mustard-plaster  over  the  stomach,  with  hypo- 
dermics of  strychnia  given  every  three  to  four  hours, 
is  continued  until  the  bowels  are  moved.  I  pursue  the 
same  course  of  treatment  for  the  gaseous  distention  of 
the  bowels.  From  six  to  eight  hours  after  commenc- 
ing the  calomel,  I  order  enemas  of  two  ounces  of  gly- 
cerine with  as  much  warm  water,  to  be  repeated  in  an 
hour.  If  this  does  no  good,  I  use  an  enema  composed 
of  two  quarts' of  warm  water,  an  ounce  of  turpentine, 
and  two  ounces  of  glycerine,  through  a  rectil  tube, 
passed  far  up  in  the  colon,  instructing  the  patient  to 
retain  it  as  long  as  possible.  Even  if  there  be  no 
mDvement,  the  patient  will  frequently  pass  great  quan- 
tities of  gas  with  the  injection  and  feel  much  relieved. 
If  the  bowels  move,  the  vomiting  is  at  an  end  at  once 
and  convalescence  established.  Suppose  we  have  done 
all  this  and  the  bowels  have  not  moved  ?  In  many  of 
these  cases  the  patient  has  stopped  vomiting  by  this 
time,  or  at  least  does  not  vomit  so  frequently.  I  then 
give  a  seidlitz  powder  every  half  hour  or  hour,  or  a  so- 
lution of  citrate  of  magnesia,  two  ounces  every  hour, 
or  sulphate  of  magnesia,  a  teaspoonful  every  hour,  and 
repeat  enemas  every  hour  or  two.  I  continue  the 
hypodermics  of  strychnia  in  full  doses.  I  persist  in 
this  line  of  treatment  until  the  bowels  are  thoroiighly 
moved. 

There  are  many  dangers  following  these  operations, 
but  those  most  frequently  met  with  are  shock,  the  in- 
fluence of  the  anaesthetic,  and  hemorrhage.  These 
may  be  partly  guarded  against  by  careful  preparation 
of  the  patient  and  thorough  work  by  the  operator,  yet 
they  cannot  be  entirely  obviated. 

As  a  prevention  from  shock,  two  ounces  o:  whiskey 
with  four  ounces  of  warm  water  should  be  given  per 
rectum  one  hour  before  the  anaesthetic  and  a  hvpo- 
dermic  of  one-twentieth  of  a  grain  of  strychnia  tnenty 
minutes  before.  If  the  patient  suffers  severely  from 
shock  during  or  following  the  operation,  she  should 
have  one  fortieth  of  a  grain  of  strychnia,  hypodermi- 
cally,  within  three-quarters  of  an  hour  after  the  first 
dose.  If  necessary,  I  would  continue  the  strychnia  in 
one-fortieth  grain  doses  every  two  hours,  until  four 
more  doses  have  been  given.  This  will  give  the  pa- 
tient's heart  strength  and  reduce  her  pulse.  She 
should  be  kept  as  quiet  as  possible,  surrounded  with 
blankets  and  jugs  of  hot  water,  and  the  surface  of  the 
body  not  exposed  to  the  atmosphere.  I  have  little 
confidence  in  whiskey,  given  either  per  rectum  or  hy- 
podermically,  while  the  patient  is  suffering  from  pro- 
found shock.  Our  main  reliance  must  be  upon  strych- 
nia, digitaline,  and  nitroglycerine.  I  frequently  combine 
one  or  both  of  these  remedies  with  strvchnia.  The 
nitroglycerine  is  a  good  remedy  for  temporary  effect. 
but  its  effects  only  last  a  few  minutes,  therefore  we 
must  rely  chiefly  upon  the  strychnia  and  digitaline. 

The  bad  influence  of  the  ansesthetic  upon  the  heart, 
kidneys,  and  the  lungs  is  recognized  by  evervone. 
The  risk  can  in  some  measure  be  anticipated  by 
proper  preparation  of  the  patient.  The  danger  of 
suppression  of  the  urine  is  less  in  sound  kidneys  than 
in  diseased  ones,  therefore  the  necessity  of  careful  e.\- 
amination  of  the  urine,  chemically  and  microscopi- 
cally, so  that  we  may  know  something  of  the  condition 
of  the  kidneys  before  the  operation.  Other  things  be- 
ing equal,  chloroform  is  safer  in  the  presence  of  renal 
disease  and  ether  in  cardiac  disease.  If  there  is  no 
contra-indication,  I  prefer  chloroform  as  the  routine 
anaesthetic.  I  have  found  the  detrimental  effects  of 
ether  by  diminishing  the  secretion  of  urine  so  univer- 
sal that  I  have  discarded  it  altogether  in  my  abdom- 


inal work,  e.xcept  in  a  few  rare  instances  of  heart  le- 
sion. In  such  cases  where  I  feel  that  the  danger  to 
the  heart  from  chloroform  overbalances  the  danger  to 
the  kidneys  from  ether,  I  use  the  latter. 

I  wish  to  emphasize  the  fact  that  a  man  experienced 
in  giving  anaesthetics  is  of  great  value,  and  his 
service  greatly  increases  the  patient's  chances  for  re- 
covery. One  who  will  give  his  undivided  attention  to 
the  administration  of  the  drug  ;  who  is  ever  watchful 
of  the  patient's  condition  ;  who  is  not  in  any  way  inter- 
ested or  absorbed  mentally  in  the  operation  :  one  who 
is  not  ambitious  to  become  an  operator  himself,  and  in 
his  desire  to  witness  the  details  of  the  operation  or 
some  unusual  condition  encountered,  neglects  his  re- 
sponsible duty,  is  to  be  desired,  and  in  all  large  cities 
the  services  of  such  a  man  can  be  secured.  My  anaes- 
thetizer.  Dr.  Colter,  uses  from  a  drachm  and  a  half  to 
three  drachms  of  chloroform,  keeping  the  patient  under 
surgical  anaesthesia  from  thirty  to  forty  minutes.  It  is 
very  rarely  that  he  uses  more  than  three  drachms.  By 
thus  minimizing  the  amount  of  the  anaesthetic  we  lessen 
the  danger  to  our  patient,  and  that  may  make  all  the 
difference  between  recovery  and  death  in  the  ultimate 
result.  Notwithstanding  careful  preparation  of  the  pa- 
tient for  days  preceding  the  operation,  where  examina- 
tion has  revealed  a  lesion  of  the  kidney,  and  in  a  few 
cases  where  no  such  lesion  could  be  detected,  suppres- 
sion of  the  urine  has  followed  the  operation.  In  some 
of  the  most  obstinate  cases  the  patient  has  secreted  six 
or  eight  ounces  of  urine  the  first  twenty  four  to  thirty 
hours,  and  then  there  was  entire  suppression  followed 
by  coma. 

The  following  two  cases  will  serve  as  illustratic  ns  of 
suppression  of  urine  following  operations,  both  in  the 
presence  and  absence  of  organic  disease  of  the  kidney: 

Case  I. —  Mrs.  S ,  aged  fifty-two,  operated  upon 

May  16,  1892,  under  chloroform  for  the  removal  of  a 
very  large  ovarian  cyst.  The  legs  and  feet  were  cede- 
matous  when  admitted  on  May  3d.  She  had  secreted 
but  a  few  ounces  of  urine  in  twenty-four  hours  for 
several  weeks  previous.  Large  quantities  of  albumin 
were  present  and  microscopical  examination  showed 
granular  casts.  The  day  of  admission  and  up  to  the 
following  morning  she  suffered  so  much  from  dyspnoea 
that  it  was  thought  best  to  tap  her.  Several  gallons  of 
fluid  were  drawn,  giving  temporary  relief,  and  more 
urine  was  secreted  for  the  next  fen-  days.  On  the 
morning  of  the  i6th  it  was  thought  best  to  make  the 
radical  operation,  notwithstanding  one-fifth  of  the  bulk 
of  the  urine  was  albumin.  The  first  eighteen  hours 
after  the  operation  the  patient  secreted  seven  or  eight 
ounces  of  urine  and  then  for  a  few  days  from  two  to 
six  ounces  daily.  In  spite  of  catharsis  by  salines,  and 
sweats,  the  kidneys  refused  to  act.  She  was  so  feeble 
that  I  feared  to  use  pilocarpine  and  resorted  to  corn- 
pack  sweats,  which  acted  nicely  and  relieved  the  coma 
for  eight  to  twelve  hours.  She  again  relapsed  into  her 
comatose  condition  and  the  sweating  process  was  re- 
peated at  intervals  of  ten  to  eighteen  hours.  We  ad- 
ministered digitaline  and  strychnia  hypodermically, 
and  gave  large  quantities  of  lithia  water.  Her  strength 
was  sustained  by  liberal  supplies  of  liquid  nourish- 
ment. On  the  fifth  day  the  function  of  the  kidneys  was 
resumed.  The  patient  made  a  good  recovery  and  went 
home  at  the  end  of  five  weeks  and  is  now  enjoying 
good  health. 

Case  II. — A  resident  of  Louisville,  twenty-eight 
years  of  age,  married  three  years,  was  visiting  friends  in 
this  city.  Since  her  marriage  she  had  had  a  number  of 
attacks  of  inflammation  in  the  abdomen.  The  present 
attack  commenced  as  her  previous  ones,  but  more 
severe.  In  the  fourth  week  of  her  present  illness  I  was 
called  to  see  her  in  consultation  with  her  physician.  Dr. 
Van  Meter,  of  this  city.  She  was  very  ill,  had  a  high 
temperature,  rapid  pulse,  chills,  sweats,  and  vomiting. 
She  had  a  tumor  in  the  pelvis  somewhat  larger  than  a 
cocoanut.     From  her  clinical  history  and  physical  ex 


442 


MEDICAL    RECORD. 


[September  28,  li 


amination  I  diagnosed  suppurating  tumor  in  the  pel- 
vis. She  was  admitted  to  the  hospital  on  November 
5,  1893,  and  a  section  was  made  on  the  morning  of  the 
sixth.  A  double  pyosalpin.x  and  two  suppurating 
ovaries,  holding  fully  a  pint  of  pus,  were  removed.  The 
anesthetic  was  chloroform.  She  rallied  nicely  and  se- 
creted eight  or  ten  ounces  of  urine  the  first  twenty- 
four  hours.  The  next  six  hours  she  became  drowsy. 
At  the  end  of  twelve  hours  she  was  catheterized  and 
less  than  an  ounce  of  urine  removed.  Notwithstand- 
ing the  fact  that  she  had  free  purgation  with  salines, 
profuse  sweating  from  pilocarpine  at  intervals  of  eight 
or  twelve  hours  for  the  following  five  days,  she  was  so 
thoroughly  comatose  that  she  was  unable  to  answer 
questions.  For  fully  twenty-four  hours  of  that  time 
she  could  not  be  aroused  at  all.  She  was  sustained  by 
hypodermic  injections  of  strychnia,  digitaline,  and  nitro- 
glycerine. Pilocarpine  had  such  a  weakening  effect  on 
her  heart  that  we  substituted  corn-packs.  This  acted 
nicely.  On  the  seventh  day  she  secreted  seven  ounces 
of  urine  and  the  eighth  day  twenty  ounces,  and  from 
that  time  the  kidneys  acted  nicely  without  any  stimula- 
tion. She  made  a  complete  recovery  and  was  discharged 
December  i6th,  and  is  now  enjoying  good  health. 
Only  a  trace  of  albumin  could  be  detected  in  the  urine 
at  any  time,  and  never  anything  abnormal  under  the 
microscope.  Knowing  as  we  do  that  suppression  of 
the  urine  is  one  of  the  most  fatal  complications  we  have 
following  these  operations,  the  happy  termination  of 
these  cases  is  a  matter  of  congratulation  and  an  argu- 
ment in  favor  of  the  treatment  adopted. 

One  of  the  conditions  to  be  dreaded,  especially  fol- 
lowing inflammatory  and  suppurating  diseases  in  the 
pelvis,  is  hemorrhage.  We  have  been  thorough  in  our 
operation  ;  liberated  all  the  organs  by  breaking  up  the 
adhesions.  We  have  quite  a  good  deal  of  hemorrhage 
during  the  operation,  and  the  collapse  necessarily  fol- 
lowing the  manipulations  and  loss  of  blood  ;  we  find 
the  patient  is  not  bleeding  more  than  a  general  oozing 
when  we  put  her  to  bed,  and  so  feel  perfectly  secure. 
As  she  rallies  we  find  the  hemorrhage  starts  up.  There 
is  bright-red  blood  welling  up  through  the  drainage- 
tube  and  soiling  the  dressing.  If  the  hemorrhage  is 
not  too  severe,  we  keep  the  drainage-tube  dry  by  re- 
peated pumping  as  often  as  every  ten  or  fifteen  minutes. 
If  the  hemorrhage  is  persistent  or  increases  in  quantity, 
making  a  profound  impression  on  the  patient,  reopen 
the  wound  and  secure  the  bleeding  point.  The  re- 
opening of  the  wound  is  a  serious  procedure,  but  under 
these  circumstances  there  is  nothing  else  left  to  do,  and 
if  this  is  to  be  successful  it  must  be  done  promptly.  If 
we  delay  until  the  patient  has  lost  a  greater  quantity  of 
bljod,  her  life  will  be  sacrificed.  It  is  now  a  question 
of  saving  the  patient  from  a  death  by  hemorrhage,  just 
as  if  you  had  a  hemorrhage  from  the  stump  of  an  ampu- 
tated limb  ;  not  so  quick,  but  quick  enough.  I  have 
little  doubt  that  many  patients  have  been  lost  from  this 
cause.  With  the  patient  in  the  Trendelenburg  position, 
it  is  not  a  difficult  matter  to  find  the  bleeding  jjoint  and 
secure  it.  It  may  be  that  the  ligature  has  slijjped  or 
cut  through  the  pedicle,  or  possibly  a  bleeding  point 
has  been  overlooked  during  the  operation  :  but  no 
difference  what  the  source  of  the  hemorrhage,  it  must 
be  controlled  or  the  patient  will  surely  die.  There  is 
nothing  in  this  work  that  tries  my  courage  as  a  hemor- 
rhage under  these  circumstances.  The  following  cases 
very  fairly  illustrate  accidents  of  this  kind  : 

Mrs.  M ,  of  Troy,  operated  upon  in  the  Woman's 

Hospital,  .\pril  i,  1891,  for  the  relief  of  a  chronic  in- 
flammation in  the  pelvis.  Adhesions  were  extensive 
and  firm  Both  appendages  were  removed.  The  pa- 
tient suffered  from  nausea  following  the  oi)eration. 
There  was  the  usual  amount  of  drainage  from  the 
drainage-tube  during  the  day.  The  patient  was  very 
unruly,  not  heeding  the  instructions  of  the  nurse  ;  she 
persisted  in  straining  desperately  at  each  act  of  vomit- 
ing, and  at  n.30  that  night  while  retching  felt  some- 


thing gi\e  way  in  the  alidomen  and  called  the  nurse's 
attention  to  it.  f  )n  inspecting  the  dressings,  they  were 
found  saturated  with  blood  and  blood  running  from 
the  drainage-tube.  I  was  notified  by  telephone  and  at 
once  repaired  to  the  hospital.  I  reached  the  patient 
within  an  hour  after  the  accident  and  found  her  semi- 
conscious, and  a  pulse  that  was  scarcely  perceptible. 
With  the  assistance  of  two  nurses,  without  removing 
the  patient  from  the  bed,  I  at  once  cut  the  stitches  in 
the  abdominal  wound  and  found  that  the  ovarian  artery- 
was  cut  through  by  the  ligature  and  the  pedicle  more 
than  half  cut  off.  This  was  seized  and  ligated  without 
difficulty,  the  abdomen  was  irrigated  and  closed,  and 
the  patient  had  no  furth'er  trouble  from  this  source. 
She  made  a  prompt  recovery.  I  have  no  hesitation  in 
saying  the  patient  would  have  died  within'  a  very  short 
time  without  surgical  interference. 

We  occasionally  see  large  varicose  veins  in  the  pedi- 
cle in  operation,  both  for  the  removal  of  ovarian  cyst 
and  fibroid  tumor  ;  these  are  a  source  of  post  operative 
hemorrhage  that  has  not  been  duly  recognized  by  the 
profession.  I  reported  a  case  of  this  kind  operated 
upon  in  October,  1892,  where  the  vein  ruptured  on  the 
proximal  side  of  the  ligature  the  second  day  following 
the  operation.     On  January  21,  1895.  I  removed  9.  large 

fibroid  tumor  from  Miss  W ,  Mt.    Vernon,  at  my 

private  hospital.  It  was  observed  there  were  very  large 
varicose  veins  on  one  side.  This  condition  was  com 
mented  upon  during  the  operation.  Everything  went 
well,  the  incision  was  closed.  While  applying  the  dress- 
ings we  noticed  blood  running  from  the  drainage-tube. 
I  immediately  cut  the  stitches,  reopened  the  abdomen 
and  found  a  pint  or  more  of  blood  in  the  pelvis  and  a 
rent  in  the  vein  on  the  distal  side.  The  vein  was  ligated 
separately.  The  patient  made  a  good  recovery.  If  the 
drainage-tube  had  not  been  placed  in  this  patient,  we 
would  have  had  no  means  of  knowing  of  the  hemor- 
rhage until  too  late  to  save  her  life.  The  shock  from 
the  loss  of  blood  would  have  been  misconstrued  as  the 
shock  of  the  operation.  Enough  has  been  said  to  em- 
phasize the  statement  made  before,  that  these  are  try- 
ing cases  which  do  not  admit  of  any  half-way  measures. 


MASTURBATION    IN    THE   ADULT. 
By  EDGAR  J.  SPRATLING,  M.D., 

MATTE.VWAN    ,^TATE    HOSPIT.M.,    PISHKILL-OS'-THE-HUDSON,   N.    V. 

M.vsTi  Rn.A HON  being  in  itself  a  habit  fraught  witii 
dangers  to  its  devotee  just  in  proportion  as  the  ner- 
vous stamina  of  the  individual  is  lacking,  one  would 
naturally  think  with  horror  of  its  octopus-like  grasp 
within  the  walls  of  every  institution  intended  for  the 
care  and  treatment  of  those  unable  mentalh-  or  morally 
to  stand  on  an  equality  with  his  free  fellow-man.  And 
well  may  those  in  whose  care  the  insane  are  placed  re- 
gard it  as  an  arch  enemy,  for  hand  in  hand  with  its 
boon  companion,  sodomy,  it  stalks  through  every  ward, 
entangling  its  victims  more  hopelessly  with  each  pass- 
ing night. 

In  women  the  road  to  its  cure  is  an  endless  and  mo- 
notonous journey,  for  nothing  short  of  ovariotomy  will 
be  found  to  deserve  even  the  term  palliative  ;  clitori- 
dectomy,  anatomically  and  physiologically,  could  be 
but  a  failure,  blistering  only  cruelty. 

Among  men  the  case  is  not  so  hopeless,  for  there 
anatomy  is  partly  in  the  operator's  favor.  Of  the 
treatments  we  might  speak  of  blistering  the  glans 
penis,  but  only  to  condemn  it  as  an  uncalled  -  for 
cruelty  ;  the  possible  beneficial  effect  is  so  transient. 
while  the  untoward  effect  is  often  so  lasting  upon  the 
patient  mentally  in  the  way  of  a  feeling  of  resentment, 
that  it  is  doubtful  if  one  could  ever  justify  such  a  pro- 
ceeding. 

The  various  kinds  of  apparatus  that  are  intended  to 


I 


i 


September  28,  1895] 


MEDICAL   RECORD. 


443 


prevent  the  mobility  of  the  foreskin,  are  one  and  all  to 
be  let  alone  as  unsatisfactory  and  unsuccessful,  if  not 
actually  mischievous,  by  concentrating  the  patient's  at- 
tention to  that  locality.  Preventing  the  opportunity  for 
the  practice  is  simply  out  of  the  question.  Castration  is 
not  to  be  considered  for  many  and  very  obvious  reasons. 
Complete  section  of  the  dorsal  nerves  of  the  penis 
(as  I  have  previously  advocated)  is  a  rational  proced- 
ure, but  rather  too  radical  for  constant  routine  prac- 
tice. The  cases  require  the  greatest  care  in  the  selec- 
tion for  this  operation,  and  even  then  with  all  due  care 
one  will  generally  have  to  encounter  the  most  strenu- 
ous objections  and  later  the  bitterest  reproach  and  con- 
demnation from  the  patients  and  from  their  relatives— 
though  the  object  sought  may  have  been  obtained. 

In  all  cases,  taken  as  they  come,  circumcision  is  un- 
doubtedly the  physician's  closest  friend  and  ally,  offer- 
ing as  It  does  a  certain  means  of  alleviation  and  pro- 
nounced benefit,  granting  as  it   does  immunitv   from 
after-reproach.     Those  cases  in  which  the  glans  pre- 
sents a  moist,  semi-oily  appearance,  with  papilla;  strik- 
ingly  developed   about    the    corona,    long    thickened 
foreskin,  pliant  and  giving,  large  and  often  tortuous 
dorsal  veins,  go  to  make  up  a  picture  that  is  exceed- 
ingly tempting  to   the  surgeon's  scissors.     The  whole 
operation,  when  the  scissors  and  continuous  suture  are 
used,  takes  only  from  four  to  six  minutes— and  time  is 
a  great  consideration,  especially  in  the  case  of  the  in- 
sane, even  though  local  anaesthetics  mav  be  used.     To 
obtain  the  best  results  one  must  cut  away  enough  skin 
and  mucous  membrane  to  rather  put  it  on  the  stretch 
when  erections  come  later.     There  must  be  no  play  in 
the  skin  after  the  wound  has  thoroughly  healed,  but  it 
must  fit  tightly  over  the  penis,  for  should  there  be  any 
play  the  patient   will  be  found  to   readily  resume  his 
practice,  not  begrudging  the  time  and  extra  energy  re- 
quired to  produce  the  orgasm.     It  is  true,  however, 
that  the  longer  it  takes  to  have  an  orgasm,  the  less 
frequently    it    will    be    attempted,    consequently    the 
greater  the  benefit  gained.     Tubes,  rings,  clamps,  and 
directors,  devised   as  aids  in  circumcision,  are   worse 
than  useless  on  account  of  the  time  involved  in  their 
manipulation,  and  also  because  they   necessitate   the 
use  of  a  knife  instead  of  scissors,  thus  inducing  more 
hemorrhage,  and  most  likely  necessitating  interrupted 
sutures  instead  of  the  continuous.     We  may  not  be 
sure  that  we   have  done  away   with  the  possibility  of 
masturbation,  but  we  may  feel  confident  that  we  have 
limited  it  to  within    the   danger  lines,    which    is  the 
primary  object  sought,  as  we  are  from  the  outset  striv- 
ing for  the  hygienic,  not  the  moral,  benefit — the  latter  is 
usually  too  far  from  our  reach  to  even  consider. 

The  younger  the  patient  operated  upon  the  more 
pronounced  the  benefit,  though  occasionally  we  find 
patients  who  were  circumcised  before  puberty  that  re- 
quire a  resection  of  the  skin,  as  it  has  grown  loose  and 
pliant  after  that  epoch.  Mental  depression  following 
circunicision  is  practically  unknown,  and  the  only  pa- 
tients in  whom  there  is  any  but  the  most  pronounced 
physical  gam,  are  those  above  fifty  years  old.  .•\nd  we 
might  note,  too,  that  after  that  age  masturbation  seems 
to  have  very  little  influence  on  the  health,  the  patient 
seemingly  having  passed  the  period  at  which  the  drain 
can  do  much  harm.  Many  of  the  boys  and  younger 
men  begin  to  show  marked  gain  in  weight  and  even  in 
mental  activity  within  ten  days  after  the  operation. 
Generally  the  patients  do  not  object  to  the  operation 
when  its  nature  and  object  are  fully  explained  to  them  ; 
indeed,  some  of  the  most  intelligent  insist  on  it  being 
done,  acknowledging  their  inability  to  free  themselves 
of  their  habit  voluntarily. 


Bequest  to  the  New  York  Post  Graduate  Medical 
School  and  Hospital.— The  New  York  Post-Graduate 
Medical  School  and  Hospital  has  received  a  gift  of 
$5,000  from  the  estate  of  the  late  Henry  M.  Cram. 


THE  VALUE  OF  PHENYLHYDR.\ZIN  -  HV- 
DROCHLORATE  IN  THE  DIAGNOSIS  OF 
DIABETES    MELLITUS. 

By  FRANCIS   A.   WINTER,  M.D., 

FORT    HA.\COCK,  TEX. 
ASSISTANT    SURGEON,    UNITED    STATES   ARMY. 

The  employment  of  phenylhydrazin  as  a  test  for  the 
detection  of  grape  sugar  has  been  a  subject  of  com- 
ment and  observation  since  its  first  employment  by 
Fischer,  of  Erlangen  ;  and  the  subsequent  endorse- 
ments by  Von  Jaksch  and  Utzmann  in  Europe,  and  of 
Bond  in  this  country,  have  contributed  a  measure  of 
prominence  to  the  salt  second  to  that  of  no  other 
agent.  Some  observers  have  been  most  laudatory  in 
their  opinions  of  its  worth,  and  would  make  it'  an 
agency  of  supreme  value.  My  interest  in  the  general 
subject  of  urinalysis,  and  the  recollection  of  a  signal 
disappointment  with  the  salt,  has  prompted  an  investi- 
gation of  the  matter,  and  while  the  inquiry  has  brought 
forth  no  results  of  significant  novelty,  it  has  yet  shown 
me  at  once  the  value  and  the  demerits  of  the  test  in 
the  final  adjudication  of  the  grave  and  momentous 
question  as  to  whether  a  given  urine  is,  or  is  not,  the 
index  of  diabetes  mellitus. 

It  has  been  my  endeavor,  in  a  research  extending 
over  some  months,  to  consider  the  agent  from  the 
stand-points  of— i,  delicacy  ;  2,  the  influence  of  sub- 
stances and  "  constituents  "  in  the  urine  (adventitious 
and  constant)  ;  3,  uniformity  of  response,  with  certain 
presence  of  glucose  ;  and  4,  its  comparative  value  as  a 
test.  I  have  made  the  observations  with  both  water 
and  urine  for  solvents,  and  have  taken  at  different  times 
such  drugs,  etc.,  as  would  probably  modify  my  own 
urinary  excretion.  In  some  instances  I  have  employed 
the  urine  of  physically  sound  soldiers  living  in  bar- 
racks. 

The  method  followed  in  the  work  has  been,  in  the 
main,  as  follows  :  A  space  of  three  centimetres  of  a 
test-tube  is  filled  with  the  salt ;  an  equal  quantity  of 
sodic  acetate  having  been  added,  the  tube  is  filled  half 
full  of  the  suspected  solution  and  then  shaken  to  dis- 
solve. The  liquid  is  slowly  raised  to  the  boiling-point 
and  kept  there  for  thirty  seconds,  when  the  tube  is  im- 
mersed in  cold  water  and  the  sediment  examined  in 
one  hour,  and  again  in  twenty  four  hours.  The  result, 
in  presence  of  glucose,  should  be  masses  of  brilliant! 
canary-yellow,  acicular  crystals,  taking  the  general' 
form  of  sheaves,  an  arrangement  similar  to  the  crystals 
of  tyrosine,  rarely  found  in  urine. 

This  technique  I  have  varied  in  many  ways,  hoping 
that  departures  from  a  standard  procedure  might  influ- 
ence the  result.  The  boiling  has  been  prolonged  for 
various  periods,  from  thirty  seconds  to  half  an  hour 
(in  the  extended  ebullition  the  solution  is  kept  at  orig- 
inal strength  by  immediate  condensation  and  return  to 
the  flask)  ;  solutions  have  been  cooled  gradually,  and 
the  sediments  examined  at  diffeient  times,  from  a  few 
minutes  to  a  week,  after  the  experiment.  It  may  safelv 
be  considered  that  these  variations  are  of  no  materia'l 
influence.  1  advert  to  this  because  of  the  varieties  of 
technique  advocated  by  different  authors. 

A  carefully  prepared  ten  per  cent,  solution  of  glucose 
in  urine  is  taken  and  diluted  as  one  requires,  through 
decimal  gradations,  to  one-tenth  per  cent.,  and  so  on. 
Each  dilution  is  treated  as  shown  above,  and  the  re- 
sults carefully  noted.  With  solutions  of  from  ten  per 
cent.to  one  and  one-half  per  cent,  strength,  the  reac- 
tion is  characteristic  and  constant.  There  is  a  brilliant 
yellow  precipitate,  showing  the  microscopic  characters 
noted  above.  These  crystals  are  most  abundant  in  the 
stronger  solutions  and  decrease  in  number  and  show 
alterations  of  definitive  character,  />ari  /lassu,  with  the 
attenuation  of  the  solution,  until  at  one  per  cent, 
strength  they  become  comparatively  rare,  with  a  patent 
change  in  morphology,  showing  in  many  instances  as 


MEDICAL    RECORD. 


444 

small  globular  bodies,  central  to  a  number  of  delicate, 
sharp  radii,  or  spicules,  resembling  somewhat  the  crys- 
tal of  ammonum  urate  ("  hedgehog").  The  preserva- 
tion of  a  crystalline  character  is  unequivocal,  though 
much  patience  is  often  demanded  in  finding  them.  Be- 
low one-half  per  cent.,  the  reaction  is  practically  nega- 
tive. Numerous  bodies  appear,  wanting  in  shape  and 
color  the  qualities  of  phenylglucosazone  (the  product). 
The  prevailing  type  is  a  round,  dark-brown  body,  shov.-- 
ing  no  crystalline  structure,  and  refracting  light  much 
as  does  a  fat  cell.  There  are  also  to  be  found  small 
polygonal  plates,  slightly  brown  at  the  periphery. 
Both  the  foregoing  structures  are  in  no  sense  charac- 
teristic or  recognizable  as  phenylglucosazone. 

The  reduction  is  little,  if  at  all,  influenced  by  other 
material  in  the  urine.  Excess  of  urea  and  uric  acid 
provoke  no  change  ;  the  urine  of  a  carbohydrate  diet 
(urea  23  to  27  gm.  in  twenty  four  hours)  reacts  abun- 
dantly ;  the  ingestion  of  benzoic  acid  and  subsequent 
elimination  of  hippuric  acid,  in  excess,  is  responsive 
when  glucose  is  present  (the  urine  of  herbivora  is  a 
suitable  vehicle)  ;  the  salicylates,  camphor,  turpentine, 
asparagin,  and  the  various  synthetic  antipyretics,  have 
no  influence;  a  urine  rendered  light  green  by  use  of 
phenol,  and  reacting  with  the  tri-nitro  phenic  colora- 
tion to  nitric  acid  is  suitable.  All  of  the  above  agents 
provoke  no  response  unless  glucose  be  added.  Subse- 
quent to  this  admixture  the  reaction  is  unimpeded. 
With  large  doses  of  chloral  the  urine  gave  a  precipitate 
of  small  reddish-brown  globular  bodies,  similar  to  those 
noted  above,  as  coming  from  very  weak  glucose  solu- 
tions. Glucose  added  to  this  urine  results  in  the  char- 
acteristic crystals,  accompanying  the  globular  bodies. 

As  to  the'uniformity  of  the  test's  response  (sugar  in 
quantity  being  present)  my  experimental  work  is  af- 
firmative. From  the  notes  of  a  case  occurring  in  civil 
practice  some  years  since,  1  think  its  unfailing  indica- 
tion of  sugar  to  be  assailable  as  a  general  proposition. 
The  urine  in  question  was  given  me  by  Dr.  Bryson,  of  St. 
Louis,  and  had  long  been  considered  sugared.  Just  at 
this  time  I  was  working  with  phenylhydrazin  and  had 
been  much  gratified  by  the  truly  spl.-ndid  results  of  its 
employment.  I  applied  the  test  to  the  urine  in  ques- 
tion, and  was  surprised  to  find  it  unresponsive.  .\11 
the  usual  reduction  tests  had  been  responsive,  and  un- 
der fer;nentation  the  urine  lost  in  specific  gravity  the 
approximate  equivalent  of  six  per  cent,  sugar.  During 
some  months  I  made  frequent  attempts  to  obtain  phe- 
nylglucosazone, but  always  unsuccessfully.  The  fer- 
mentation was  sedulously  used  for  control.  I  thought 
the  presence  of  sugar  unequivocally  shown,  and  regret 
that  the  polariscope  was  not  employed  to  emphasize 
the  fact.  Other  urines  examined  with  the  same  salt 
were  responsive,  as  were  aqueous  solutions  of  glucose. 

After  a  protracted  experience  with  the  test  1  have 
concluded  that  while  it  has  great  merits  it  is  certainly 
amenable  to  criticism.  For  delicacy  the  copper  (Feh- 
ling's)  test  has  proven,  in  my  experience,  its  superior. 
Fermentation  is  equally  delicate  and  significant.  Solu- 
tions of  one-half  per  cent,  strength  may  be  estimated, 
even  quantitatively  by  yeast,  while  the  faintest  response 
with  phenylhydrazin  is  difficult  of  establishment. 

In  the  instance  of  failure  noted  above  the  classical 
uncertainty  of  the  ordinary  reduction  tests  was  met 
by  fermentation,  and  Marshall's  glycosuric  acid  was 
excluded  by  the  same  agency. 

In  my  opinion  the  singularity  of  the  result  must  be 
attributed  to  one  of  those  occult  and  mysterious  prod- 
ucts of  excretion  which,  by  its  presence,  in  some  un- 
fathomable manner,  inhibits  the  reduction.  In  the 
light  of  contemporaneous  discoveries  and  identifica- 
tions this  view  seems  not  untenable,  and  while  my  own 
sedulous  efforts  have  failed  to  show  any  source  of 
modification,  1  can  easily  imagine  the  ultimate  defini- 
tion of  the  matter  in  the  hands  of  the  trained  physiol- 
ogist. 

Failure  in  this  instance  has  certainly  furnished  me 


[September  28,    1895 


with  a  timely  caution,  and  emphasized  the  conviction 
that,  aside  from  fermentation  and  the  polariscope,  we 
possess  no  single  test  absolutely  final  to  a  decision  of 
the  glycosuric  character  of  urines. 

My  experience  leads  me  to  think  that  phenylhydra- 
zin may  have  a  great  measure  of  value  in  inquiries  of 
this  kind,  but  I  cannot  esteem  it  a  siimmum  honum, 
and  should,  personally,  prefer  fermentation. 

Its  greatest  source  of  value  seems  to  me  to  lie  in  Us 
constancy  to  glucose  only,  for  if  phenylglucosazone 
appear,  one  may  safely  consider  glucose  present.  Quan- 
titatively I  have  found  the  test  of  no  value.  I  have 
endeavored  to  establish  a  satisfactory  scale  from  the 
number  of  crystals  appearing  in  the  field,  but  they  are 
inconstant  and  ununiform.  A  word  of  caution  re- 
specting the  salt  used  is  a  propos.  Merck's  preparation 
is  reliable,  while  others  I  have  found  unsatisfactory. 


DIAGNOSIS  AND  CHRONOLOGY  OF  ABOR- 
TIONS.' 

By   EDWARD   A.  AYERS,   M.D., 

PSOFBSSOR  OF  ..BSTETRICS  NEW  YORK  POLVCLINIC:  PHYSICIAN  IN  CHIEF  MOTHER'S 
AND   B\BIES'   HOSriTAL,   ETC. 

The  weak  spot  in  the  relations  of  our  profession  to  the 
management  of  abortions  is  our  want  of  accurate  knowl- 
edge of  the  anatomy  and  physiology  of  the  uterus,  de- 
cidua,  and  fcetal  m'embranes,  and  particularly  of  the 
chronology  of  the  membranes  in  the  first  three  months 
of  pregnancv.  Embryology  is  a  very  incomplete  sci- 
ence as  vet,'  and  a  most  difficult,  though  fascinating, 
department  of  biology.  .K  famous  writer  said  of  his  es- 
say, "  I  have  not  had  time  to  write  a  short  one."  Our 
authors  and  investigators  have  not  had  time  to  simplify 
embryology.  Virtuosity  is  impossible  in  the  pioneer. 
Space  has  not  been  given  to  the  various  parts  of  the 
subject  of  embryology  in  proportion  to  their  relative 
clinical  needs.  Thus  the  foetus  has  been  splendidly 
described,  --^nd  it  is  truly  a  beautiful  picture  to  ob- 
serve through  the  microscope's  widening  eye  the  solid 
field  of  uniformed  cells  line  and  deploy  until  the  form- 
ing outlines  of  liver,  lung,  or  spleen  appear.  To  wit- 
ness the  formation  of  a  calibre  out  of  a  lamination  of 
cells  is  a  profoundly  impressive  suggestor  that  "  there 
is  a  divinity  doth  shape  our  ends,"  and  that  thrills  the 
scientific  heart.  But  the  development  of  the  foetus  has 
little  part  in  our  proper  understanding  of  cases  where 
life  or  health  are  at  stake  from  an  interrupted  preg- 
nancy. Its  length,  weight,  and  limb  formation  largely 
comprise  the  important  points. 

In  the  study  of  the  foetal  membranes  and  decidua, 
our  text-books  develop  the  subject  by  following  sepa- 
rately a  single  tissue,  as  the  amnion  or  allantois,  from 
their  origin  to  their  formation,  leaving  the  mind  much 
confused  when  we  endeavor  to  comprehend  their  ad- 
vancement as  a  whole. 

For  the  handling  of  patients  in  abortion  we  need  to 
know  how  the  tissues  are  arranged  at  four  weeks,  six 
weeks,  eight  weeks,  ten  weeks,  and  three  months.  If 
we  have  this  knowledge,  the  uterus  becomes  as  glass, 
and  the  questions  of  treatment  are  answered  almost  as 
soon  as  asked.  The  complexities  of  embryology,  taken 
at  any  one  period,  are  sufficiently  difficult  of  compre- 
hension, when  we  consider  that  the  anatomical  arrange- 
ment of  theembrvo  and  its  membranes  changes  greatly 
from  week  to  week,  that  what  is  to  day  largely  decidua 
and  slightlv  ovum,is  in  a  few  days  mostly  ovum  and 
little  decidua  ;  or  this  fortnight  is  mostly  chorion  and  in 
the  next  placenta  ;  we  do  not  wonder  that  the  subject  has 
been  too  often  relegated  to  the  back  shelf  of  the  library. 
Our  society  discussions  generally  begin  and  end  with 
consideration  of  the  causes  and  treatment  of  abortions. 
Shall  we  complete  the  threatened  abortion,  shall  we  di- 
late the  cervix  or  use  a  tampon,  shall  we  empty  the 

I  h  paper  read  before  the  Brooklyn  Medical  Society. 


September  28,    1895] 


MEDICAL    RECORD. 


445 


uterus,  and  if  so,  with  a  curette,  or  placental  for- 
ceps, or  the  finger  ?  Shall  we  use  gauze  or  irriga- 
tion in  the  uterus,  or  both  ?  These  are  important 
questions,  but  they  have  received  a  vast  amount  of 
attention  compared  to  those  involving  a  fine  ability 
in  diagnosis. 

Will  you  pardon  my  endeavor  to  state  some  of  the 
salient  points  that  aim  to  strengthen  the  department  of 
diagnosis. 

The  diagnostic  tissues  of  pregnancy  are  :  Foetus,  am- 
nion, chorion,  and  decidua.  As  the  latter  has  been 
claimed  by  well-known  German  writers  not  to  be  pa- 
thognomonic of  pregnancy,  it  is  necessary  to  e.\plain  my 
position.  In  1889  I  published  a  very  carefully  pre- 
pared paper  on  "  The  Decidua  in  the  Diagnosis  of  Ex- 
tra-uterine Pregnancy."  In  that  paper  I  claimed  that 
if  decidual  cells  were  found  in  the  uterus,  a  pregnancy 
either  within  or  without,  that  is  an  extra-uterine,  ex- 
isted, or  had  recently  existed-  Olshausen,  Ruge,  and 
others  have  declared  against  this,  claiming  to  have 
found  these  embryonic  cells  in  membranous  dysmenor- 
rhoea.  My  special  point  in  that  paper  was  that  if  we 
obtained  by  exfoliation  or  curettement  decidual  cells 
from  the  uterine  cavity,  and  no  foetus  and  membranes 
were  present  in  the  cavity,  then  an  extra-uterine  preg- 
nancy existed. 

Without  going  into  the  discussion  here,  let  me  say 
that,  whether  I  shall  ultimately  be  proven  right  or 
wrong,  I  fully  believe  that  though  exceptions  to  the  rule 
that  decidual  cells  are  pathognomonic  of  pregnancy 
may  exist,  this  much  may  be  taken,  without  hesitation, 
as  a  safe  rule  :  That  endometrium,  which  is  conspicu- 
ously made  up  of  decidual  cells,  and  particularly  where 
such  membrane  is  soft  and  free  from  fibrous  tissue,  is 
the  decidua  of  pregnancy  only.  The  recognition  of  any 
of  these  four  diagnostic  tissues  is  always  desirable,  but 
not  always  easy,  owing  to  the  broken  form  in  which  we 
may  receive  them,  and  the  many  alterations  that  may 
take  place  in  their  structure. 

The  FcEtus. — There  is  no  dititiculty  in  recognizing  the 
embryo,  if  it  is  present.  It  may  be  absorbed  previous 
to  the  expulsion  of  the  ovum. 

The  Amnion. — There  is  no  tissue  liable  to  be  mis- 
taken for  the  amnion.  It  is  very  thin,  transparent,  and 
microscopically  found  to  be  free  from  blood-vessels. 
Its  surface  is  smooth  and  glistening. 

The  Chorion. — Normal  chorion  has  a  white,  sheep- 
skin-like base,  from  which  radiate  strav-colored  villi 
branching  into  two  to  five  single  offshoots.  These 
villi  are  to  be  differentiated  from  fibrous  shreds  only, 
and  are  therefore  easily  recognized.  They  have,  in- 
stead of  thread  like  free  ends,  club-like  tips,  which  are 
thick  enough  to  be  recognized  with  the  naked  eye.  In 
medico-legal  testimony  one  would  be  justified  in  de- 
claring the  presence  of  pregnancy  if  only  a  single  villus 
were  obtained  from  the  uterus.  The  villus  consists  of 
a  single  layer  of  flat  epithelium,  enclosing  an  afferent 
and  efferent  capillary,  suriounded  wiih  a  very  light 
connective  tissue.  The  one  abnormal  change  of  im- 
portance in  the  chorion  is  that  of  cystic  degeneration. 
The  metamorphosis  is  absolute,  and  the  well-known 
grape-like  mass  is  the  result.  Once  seen  or  once  felt, 
this  |)athological  tissue  can  never  be  mistaken.  It  is  a 
group  of  watery  cysts  of  sizes  ranging  from  a  pin-head 
to  a  large  grape,  attached  by  a  pedicle  to  an  opaque 
membrane  ;  and  may  only  fill  an  ounce  vial  or  a  wooden 
pail. 

The  Decidua. — This  is  much  the  most  difficult  preg- 
nancy tissue  to  recognize,  because  of  its  less  distinct 
and  individual  construction,  and  especially  its  great  va- 
riety of  pathological  appearances.  Normal  decidua, 
when  exfoliated  in  the  first  week  of  pregnancy,  has  'he 
general  form  of  the  cavity  of  the  uterus.  It  presents 
on  its  outer  surface  somewhat  the  rough  surface  of 
leather,  having  loose  fibres  from  having  been  torn  from 
its  base,  the  musculo-glandular  layer  of  the  uterus.  Its 
inner  surface  is  smooth,  and   like  the  outer  surface  of 


the  skin.  It  is  thrown  into  folds.  Of  course  the  ar- 
rangement of  the  three  decidua  will  depend  upoi; 
the  period  of  pregnancy.  The  three  conspicuous  formr 
the  decidua  present  are  :  The  intra- uterine  decidua  of 
an  extra-uterine  pregnancy,  in  which  we  find  a  thinner 
membrane  than  in  normal  intra-uterine  pregnancy,  cf 
uniform  thickness  throughout,  very  flexible,  and  hay- 
ing no  reflexa  inside.  Next  the  form  present  in  normai 
gestation,  in  which  we  find  it  as  described  above.  On 
cutting  open  such  a  decidua  we  find  the  reflexa  usually 
lying  pendent  from  the  upper  or  fundal  part,  not  filling 
the  cavity  of  the  vera,  thinner  than  the  latter,  and 
smooth  en  its  outer  part.  This  decidua  is  very  vascu- 
lar, and  therefore  red  to  the  shade  of  muscle,  but  not  of 
the  same  texture  to  the  eye.  It  is  about  two  millime- 
tres thick  in  the  first  month,  the  vera  and  reflexa  get- 
ting thinner  in  the  second  and  third  months.  The  third 
variety  of  decidua  is  such  as  we  see  in  its  most  exag- 
gerated form  in  the  uterine  mole.  Do  not  understand 
.me  to  say  that  a  mole  is  decidua,  as  the  amnion  is  a 
part  of  that  tumor.  But  the  mole  shows  the  highest 
degree  of  thickening  of  the  decidua,  and  is  really  a  form 
of  general  hyperplasia.  A  large  part  of  its  structure  is 
intermingled  blood-clot. 

Chxonolog'y. — I  wish  now  to  briefly  consider  the  most 
practical  [..base  of  the  subject,  namely,  the  arrangement 
of  the  membranes  at  certain  periods  of  pregnancy. 
The  advantage  of  an  accurate  knowledge  of  the  growth 
of  the  ovum  as  a  whole  lies  in  the  fact  that  where  we 
can  name  the  week  of  pregnancy,  having,  for  instance, 
secured  the  embryo  in  a  paitial  abortion,  we  can  de- 
cide far  more  scientifically  what  treatment  the  uterus 
requires  than  by  simply  resorting  to  a  curette.  I  will 
consider  the  behavior  of  these  tissues  in  abortions  at 
the  same  time. 

At  Four  U'tc-ks. — The  decidua  is  much  ihe  most  im- 
portant membrane  at  four  weeks'  gestation.  The  re- 
flexa is  fully  formed,  but  does  not  occupy  more  than 
three-fifths  of  the  uterine  cavity.  Consequently  on  intro- 
ducing the  finger  within  the  internal  os  it  would,  after 
having  passed  the  vera  at  ihat  point,  come  in  contact  with 
a  body  like  a  polyp  at  a  distance  of  a  little  over  one- 
eighth  of  an  inch.  The  ovum  is  about  the  size  of  a  large 
hazel-nut.  The  chorion  is  fully  formed  on  all  sides, 
with  the  exception  of  the  normal  bald  spot,  the  size  of 
a  well  dilated  pupil.  The  amnion,  on  opening  the 
chorion,  will  be  found  to  embrace  the  embryo,  but 
not  to  have  expanded  to  more  than  half  the  distance 
t)  the  chorionic  periphery.  The  embryo  will  be 
found  lymg  free  within  the  amnion,  and  about  the 
size  of  a  small  Lima  bean.  The  liiile  elevations  that 
are  to  form  the  extremities  appear  upon  the  embryo. 
The  latter  is  a  little  larger  than  a  good-sized  pea. 
The  characteristics  of  an  abortion  at  this  time  are  :  A 
hemorrhage  that  is  apt  to  be  classed  as  a  severe  men- 
struation, an  effort  of  nature  to  catch  up  after  having 
missed  one  period,  the  probable  escape  of  the  ovum  in 
blood-clots  unnoticed,  and  a  temporary  cessation  of 
hemorrhage,  with  its  recurrence  in  a  few  days,  and 
more  uterine  pains,  accompanied  with  the  expulsion  of 
the  decidua.  Or,  instead  of  decidual  expulsion  there 
is  a  gradual  disintegration  of  the  decidua  that  may 
leave  the  uterus  finally  clean,  involuted,  and  well,  or  the 
development  of  a  slow  endomettitis,  with  heavy  feel- 
ing, excessive  menstruations,  etc. 

While  it  is  best  to  interfere  wiih  the  curette  and  get 
the  uterus  clean  when  much  hemorrhage  or  excessive 
menstruation  result,  in  the  former  case  acting  at  once, 
and  in  the  latter  after  a  menstruation,  yet  so  many- 
women  fully  recover  unaided,  and  interference  carries 
risks,  it  is  best  to  use  sharp  discrimination  in  the  indi- 
vidual cases,  letting  most  of  them  alone. 

At  Six  H'eeki. —  The  decidua  is  still  prominent  and 
important.  The  vera  is  unchanged,  the  serotina  has 
grown  and  thickened,  the  reflexa  is  undergoingan  atro- 
phy that  began  in  the  fifth  week.  The  latter  is  nearer 
to  the  internal  os.     The  chorion  has  expanded  to  the 


446 


MEDICAL    RECORD. 


[September  28,  1895 


size  of  a  silver  half-dollar,  and  enjoys  a  luxuriant 
growth  of  villi.  The  amnion  is  nearer  the  periphery, 
but  is  still  separated  from  it.  The  embryo  has  doub- 
led in  size,  and  its  extremities  show  an  appreciable 
length.  The  characteristics  of  an  abortion  at  this 
period  I  will  consider  with  those  at  eight  weeks. 

A(  Eight  Weeks. — This  is  a  very  frequent  period  for 
the  occurrence  of  abortions.  It  is  the  menstrual  pe- 
riod that  would  have  been,  and  it  is  the  period  of 
marked  transition  from  chorionic  nutrition  to  placental. 
This  latter  metamorphosis  requires  that  the  villi  on 
three-fourths  of  the  chorionic  surface  shall  atrophy,  with 
a  corresponding  growth  at  the  placental  site.  In  tissues 
of  their  delicate  construction  the  readjustment  of  cell- 
pressures  is  readily  provocative  of  capillary  ruptures 
and  so  leading  to  abortion.  At  eight  weeks  the  cho- 
rion and  remnant  of  the  decidua  reflexa  fully  occupy 
the  cavity  of  the  uterus.  The  amnion  also  occupies 
the  entire  cavity  of  the  chorion.  The  foetus  measures 
3.5  ctm.  and  has  the  hands  and  feet  well  outlined. 
The  decidua,  having  grown  thinner,  is  less  apt  to  come 
away  complete,  particularly  as  the  chorion  is  more  apt 
to  rupture,  and  by  the  collapse  resulting  make  it  doubly 
difficult  for  the  uterus  to  separate  and  expel  the  mem- 
branes. If  the  chorion  escapes  from  the  uterus  with- 
out rupture,  it  generally  escapes  alone,  leaving  the  de- 
cidua behind.  This  decidua  should  be  removed  at 
once,  and  the  best  medium  for  its  removal  is  the  finger. 
A  sensitive  patient  will  require  an  anaesthetic.  The 
finger  inserted  within  the  cervix,  the  fundus  must  be 
pressed  down  until  the  finger  can  reach  the  fundus  and 
thoroughly  separate  all  the  membrane  before  withdraw- 
ing the  finger.  Where  the  cervix  is  tight  (it  is  seldom 
hard  if  there  is  still  tissue  within  that  should  come  out) 
the  curette  may  be  substituted  for  the  finger.  \\'hen 
the  chorion  ruptures  during  uterine  dilatation,  an  un- 
fortunate accident,  it  may  be  necessary  to  dilate  the 
cervix,  as  it  now  becomes  hard  for  the  uterus  to  force 
open  the  former. 

At  Ten  Jl'ceks. — The  foetus  and  partially  formed  pla- 
centa are  now  the  prominent  parts  in  the  uterus.  The 
temporary  villi  of  the  chorion  have  largely  disappeared, 
also  the  reflexa,  leaving  a  thin  layer  composed  ot  the 
amnion  and  chorion  to  be  felt,  should  the  finger  be  in- 
troduced within  the  cervix.  The  prominent  character- 
istics of  abortion  at  this  time  are  expulsion  of  the  fce- 
tus  and  umbilical  cord  alone  ;  their  expression  with  the 
amnion,  .which  may  or  may  not  be  unruptured  ;  the 
cord  having  separated  from  the  forming  placenta  at  its 
junction  with  the  latter.  The  placental  tissue  is  apt  to 
remain  in  the  uterus  for  a  varying  time  and  cause 
hemorrhage,  and  to  become  foul-smelling.  It  should 
be  removed  soon  after  the  expulsion  of  the  foetus.  We 
rarely  obtain  a  specimen  at  this  period  of  a  complete 
exfoliation  of  decidua,  and  all  the  other  membranes  and 
foetus,  on  account  of  the  ease  with  which  the  sac:  rupt- 
ures. 

At  Three  Months. — The  placental  form  is  now  well 
established,  and  the  uterine  contents  behave  much  as 
they  do  at  full  term,  with  these  differences,  that  the 
placenta  is  less  firmly  put  together,  and  is  more  firmly 
united  to  the  uterus.  There  is  danger,  therefore,  of 
masses  of  placenta  being  retained,  even  though  much 
may  be  expelled. 

I  have  time,  now,  for  only  a  brief  summary  of  the 
variations  in  the  treatment  of  abortions  that  are  de- 
manded at  different  weeks  of  pregnancy.  As  a  gen- 
eral proposition  ii  is  fair  to  say  that  whenever  an  abor- 
tion takes  place,  none  of  the  tissues  that  are  present 
only  in  pregnancy  should  be  left  in  the  uterus.  The 
uterus  certainly  objects  to  fa;tus,  amnion,  and  chorion, 
once  the  ovum  dies,  and  it  cannot  use  the  decidua 
either  in  repair  or  in  forming  new  endometrium.  It 
must  get  out  before  a  healthy  state  can  be  inaugurated. 
It  cannot  be  said  that  we  should  always  interlere  and 
remove  these  tissues,  for  though  nature  may  be  ineffi- 
cient, there  is  room  for  much  bungling  on  our  part. 


Our  individual  judgments  in  given  cases  must  de- 
cide. 

-At  four  weeks'  abortion  we  should,  as  a  rule,  keep 
down  hemorrhage  and  wait  on  nature.  If  called  upon 
to  interfere,  it  will  be  the  decidua  that  we  will  needs 
remove.  The  curette,  and  not  the  finger,  should  be 
used. 

At  six  and  eight  weeks  the  chorion  will  cause  the  most 
trouble.  Either  finger  or  curette  may  be  indicated  in 
cleansing  the  uterus.  A  strip  of  iodoform  gauze  should 
be  introduced  to  the  fundus  to  prevent  secondary  hem- 
orrhage, render  a  foul  cavity  pure,  to  stimulate  re- 
pair, and  favor  drainage. 

At  ten  and  twelve  weeks  the  foetus  comes  out  first, 
and  the  other  tissues  are  apt  to  need  artificial  removal. 
The  finger  is  to  be  preferred  to  any  instrument.  Gauze 
should  be  used  at  these  times.  Small,  repeated  doses 
of  ergot  are  desirable  for  twenty- four  hours. 

In  cystic  degeneration  of  the  chorion  the  cervix 
should  be  dilated  with  a  Barnes's  bag,  and  the  contents 
scraped  out  with  the  finger  or  hand.  Gauze  should  be 
introduced  immediately,  and  left  twenty-four  hours. 
Ergot  is  needed.  In  uterine  mole  the  uterus  should 
be  let  alone,  barring  the  need  of  checking  hemorrhage. 
A  mole  is  a  ven,'  solid  body  and  comes  away  whole, 
leaving  the  cavity  clean.  Having  devoted  this  paper 
to  the  diagnostics  of  abortions,  I  must  express  regret 
at  touching  upon  the  extensive  subject  of  treatment  in 
the  most  superficial  manner. 


CHANCRE   OF   THE   TONSIL,  WITH   REPORT 
OF    A    CASE.i 

By  henry  B.  HITZ,  M.D., 

UILWAUKEE,  WIS. 

Of  the  various  forms  of  syphilitic  infection  that  daily 
demand  the  attention  of  the  physician,  among  the 
rarest  is  found  chancre  of  the  tonsil.  Of  77  cases  of 
chancre  in  the  buccal  cavity  collected  by  Fournier,  but 
I  was  upon  the  tonsil. 

Diday  collected  671  cases  of  erratic  chancre,  but 
did  not  find  any  back  of  the  anterior  pillars.  This 
writer  reported  8  cases  in  the  year  1S61-62.  In  1891 
Szadek  reported  4,  and  Grauducheau  i.  Since  this 
time  several  cases  have  been  reported  in  the  journals, 
but  I  have  not  been  able  to  get  track  of  them.  Morell 
MacKenzie  saw  but  7  cases  in  his  long  and  varied  ex- 
perience. 

The  most  graphic  and  satisfactory  account  of  chan- 
cre of  the  tonsil  is  given  by  Donaldson,  in  the  Medical 
Xeius  of  August  15,  1SS5,  the  substance  of  which  is  to 
be  found  in  the  "  Reference  Handbook  of  the  Medical 
Sciences,"  and  a  resuiiu'  oi  which  I  give  as  follows  : 

This  disease  is  less  uncommon  than  is  generally  sup- 
posed, although  difficult  of  recognition,  owing  to  the 
absence  of  history,  and  the  atypical  appearance  of  the 
lesion.  It  occurs  most  frequently  in  women  for  obvi- 
ous reasons,  although  it  has  been  innocently  acquired 
by  kissing,  instruments,  etc.  Out  of  the  7  cases  seen 
by  MacKenzie,  6  were  females.  Owing  to  the  exposed 
condition  and  the  character  of  the  tonsillar  structure, 
the  explanation  of  its  appearance  in  this  locality  is 
plain,  the  large  tonsillar  crypts  affording  ample  oppor- 
tunity for  the  lodgement  and  ready  absorption  of  the 
virus. 

The  signs  of  infection  usually  begin  with  slight  red- 
ness and  swelling,  without  perceptible  induration,  fol- 
lowed later  by  pain  during  deglutition,  and  increased 
redness  ;  and  still  later  by  hypertrophy  and  superficial 
erosion,  having  an  indurated  base,  while  more  or  less 
glandular  enlargement  occurs  upon  the  affected  side. 
The  rapid  hypertrophy  and  general  tumefaction  is  in 

>  Read  before  the  meeting  of  the  Wisconsiu  State  Medical  Society, 
West  Superior,  June,  1895. 


September  28,  1895 J 


MEDICAL    RECORD. 


44  7 


itself  an  important  and  constant  sign.  Second  only 
to  this  is  the  superficial  erosion,  increasing  to  an 
actively  ulcerating  surface,  usually  covered  wth  a 
thick  grayish-white  pellicle  of  somewhat  granular  char- 
acter. 

The  glandular  enlargement  upon  the  affected  side  is 
constant  and  of  an  indolent  type,  but  never  goes  on  to 
suppuration.  The  difficulty  of  diagnosis  is  usually  due 
to  the  absence  of  history,  either  through  the  reticence 
or  ignorance  of  the  patient,  and  to  its  unusual  situation 
and  diversity  of  appearance.  It  must  be  differentiated 
from  malignant  disease,  especially  epithelioma,  tuber- 
culosis, secondary  and  tertiary  syphilis,  diphtheria,  and 
gangrenous  ulceration  of  the  tonsil. 

Morell  MacKenzie  suggests  that  if  an  ulcer  remains 
obstinately  on  the  tonsil,  in  spite  of  treatment  for  four 
or  five  weeks,  a  suspicion  of  its  syphilitic  nature  may 
be  indulged  in. 

Donaldson  suggests  that  if  a  lesion  upon  the  tonsil 
has  been  of  slow  unilateral  development,  with  pain  and 
glandular  enlargement  upon  the  affected  side,  without 
febrile  reaction,  and  is  superficial,  with  a  grayish-white 
pellicle  ;  if  the  patient  has  a  history  or  even  the  sus- 
picion of  syphilitic  exposure,  and  has  not  been  subject 
to  simple  tonsillitis  ;  if  the  sore  has  appeared  from  fif- 
teen days  to  three  weeks  after  exposure  ;  and  if  the 
whole  is  followed  in  due  time  by  a  secondary  outbreak, 
we  are  certainly  justified  in  diagnosing  chancre  of  the 
tonsil. 

Generally  unilateral,  the  duration  of  chancre  of  the 
tonsil  has  been  thought  to  be  shorter  than  the  same  le- 
sion elsewhere.  In  Donaldson's  case  the  secondary 
eruption  appeared  within  a  week  after  patient's  first 
visit,  and  before  the  sore  had  healed. 

Having  given  a  cursory  glance  at  the  history  of  this 
disease,  I  shall  now  ask  you  to  review  with  me  the  fol- 
lowing case,  which  came  to  my  notice  November  21, 
1894  : 

M.    R ,   male,    aged    twenty-eight  ;  weight,    180 

pounds  ;  family  and  personal  history  good,  e.xcept  for 
rheumatic  diatheses.  About  eight  years  ago  patient 
was  treated  for  chancroid,  and  subsequently  for  gonor- 
rhoea. Of  late  he  has  been  dissipated,  often  becom- 
ing intoxicated,  and  while  in  this  condition  visiting 
houses  of  prostitution.  About  five  weeks  prior  to  the 
above  date  and  several  weeks  after  last  having  inter- 
viewed a  prostitute,  he  noticed  on  arising  one  morning 
a  slight  soreness  of  the  throat,  which  became  progres- 
sively worse.  Upon  the  fourth  day,  the  pain  being  se- 
vere, he  consulted  his  ph)sician,  who  diagnosed  "  ton- 
sillitis," and  treated  him  accordingly  for  the  subsequent 
four  weeks.  At  the  end  of  this  period,  having  but 
slightly  improved,  he  consulted  Dr.  N.  Dodge,  who 
after  a  casual  glance  at  his  throat  referred  him  to 
me. 

Careful  examination  revealed  the  following  patho- 
logical condition  :  Upon  the  left  tonsil  was  a  large 
ovoid  ulcer,  about  the  size  of  a  dime,  the  surface  of 
which  was  covered  with  a  grayish-white  necrotic  coat. 
A  deep  sulcus  divided  this  surface  into  two  vertical 
parts,  while  a  small  quantity  of  sero-purulent  discharge 
exuded  therefrom.  Its  base  was  firm  and  indurated, 
and  its  lower  border  could  only  be  seen  by  forcibly  de- 
pressing the  tongue  ;  when  this  was  done  it  appeared 
elevated  above  the  surrounding  and  hypertrophied  ton- 
sil, the  whole  mass  of  which  approached  the  median 
line.  Owing  to  the  swelling,  the  pillars  were  forced 
asunder,  were  thickened  and  of  an  angry,  dark  red 
color,  having  upon  their  upper  margins  several  super- 
ficial ulcers,  evidently  from  contact  with  the  large  ul- 
cer during  deglutition.  Externally  there  was  swelling 
and  tenderness  under  the  corresponding  angle  of  jaw, 
and  notwithstanding  the  excess  of  adipose  in  this  case, 
the  submaxillary  and  left  cervical  glands  were  felt  to 
be  distinctly  enlarged.  Careful  examination  elsewhere 
failed  to  show  any  glandular  enlargement,  either  in  the 
post-  or   right-cervical,  supra  trochlear  or  inguinal   re- 


gions. Thorough  inspection  of  the  genitalia  devel- 
oped nothing  but  an  old  stellate  cicatrix  upon  corona. 
The  skin  upon  the  chest  appeared  "  blotchy,"  but  at- 
tracted attention  only  in  so  far  as  its  being  the  possible 
premonitor  of  a  secondary  eruption. 

Having  a  suspicion  of  the  probable  nature  of  the 
case,  careful  inquiry  into  the  patient's  habits  was  made, 
but  failed  to  elicit  any  other  information  than  that  of 
several  sexual  contacts  with  various  prostitutes  within 
the  preceding  three  months. 

Upon  this  visit  the  patient  was  given  a  placebo,  and 
told  to  return  in  two  days,  at  which  time  he  appeared 
with  a  light,  though  unmistakable  macular  eruption 
upon  his  chest  and  abdomen,  which  he  observed  with 
surprise  when  his  attention  was  called  to  it.  -^gain  the 
genitalia  were  carefully  examined,  with  the  same  result 
as  before,  except  that  two  bright  maculae  were  seen 
upon  the  dorsum  of  the  penis.  He  complained  of  hav- 
ing had  considerable  muscular  pain  since  his  previous 
visit,  with  general  malaise  and  restlessness.  Pain  dur- 
ing deglutition  was  less  pronounced,  and  there  was 
slight  though  marked  improvement  in  the  appearance 
of  the  throat. 

There  being  no  longer  doubt  as  to  the  diagnosis, 
mercury  was  administered  in  the  form  of  the  green 
iodide  in  rapidly  increasing  doses,  with  inunctions  at 
night,  and  patient  was  informed  of  his  condition. 

On  the  26th  he  again  appeared,  with  this  time  a  well- 
marked  maculo-papular  eruption  upon  his  chest,  ab- 
domen, and  limbs,  while  upon  the  face  and  neck  it  was 
just  beginning  to  appear.  The  improvement  of  the 
local  lesion  had  rapidly  progressed,  although  the  indu 
ration  still  persisted.  On  the  28th  abdominal  pains, 
diarrhoea,  and  other  symptoms  of  the  systemic  action  of 
the  mercury  appeared,  but  were  quelled  under  the  ad- 
ministration of  a  lead  and  opium  pill,  and  did  not 
again  appear  while  under  my  treatment. 

On  December  3d,  at  the  persuasion  of  a  friend,  the 
patient  visited  Dr.  A.  H.  Levings,  who  told  him  he  had 
syphilis,  but  said  nothing  about  the  seat  of  the  original 
lesion.  On  this  day  he  appeared  with  a  mild  acute 
laryngitis.  The  local  lesion  had  now  entirely  healed, 
but  there  was  little  diminution  of  the  induration.  The 
eruption  upon  the  body  had  almost  disappeared,  and 
could  be  but  faintly  seen  on  the  face,  while  upon  the 
forearms  and  hands  it  was  still  pronounced. 

On  December  6th  he  was  referred  back  to  Dr.  N. 
Dodge  for  systemic  treatment.  At  this  time  he  was 
receiving  one  and  a  half  grain  of  mercury  in  pill-form 
daily,  with  nightly  inunctions. 

During  the  temporary  absence  of  Dr.  Dodge,  on 
April  6,  1895,  the  patient  again  appeared  at  my  office 
with  large  ulcers  in  both  nasal  cavities,  mucous  patches 
in  the  buccal  cavity,  a  marked  superficial  glossitis,  alo- 
pecia, and  a  rupia  upon  the  scrotum. 

The  interest  in  this  case  centres  in  the  primary  sore, 
and  in  the  subsequent  rapid  appearance  of  the  second- 
ary symptoms.  Dismissing  with  a  word  its  syphilitic 
nature,  of  which  there  is  absolutely  no  doubt,  the  ques- 
tion arises  :  Was  the  tonsil  the  real  seat  of  primary  in- 
fection ? 

In  the  absence  of  all  signs  of  recent  venereal  disease, 
either  extra-  or  intra-urethral,  or  of  any  hypertrophy  ol 
the  inguinal  glands,  the  known  presence  of  a  large  in- 
dolent, indurated  ulcer  upon  the  tonsil,  resisting  local 
treatment  and  antedating  by  at  least  five  weeks  (and 
probably  longer,  as  pain  is  not  the  earliest  symptom)  the 
secondary  outbreak  :  the  history  of  prior  exposure  ; 
the  chain  of  enlarged  and  tender  lymph-glands  upon 
the  affected  side,  and  their  absence  in  other  regions, 
and  the  well  recognized  rapid  appearance  of  the  sec- 
ondary phenomena  when  the  primary  lesion  is  located 
here,  have  led  me  to  diagnose,  without  hesitation, 
this  case  as  one  of  chancre  of  the  tonsil,  a  diagnosis 
also  unhesitatingly  concurred  in  by  Dr.  J.  Steele 
Barnes,  who  saw  the  patient  with  me  upon  his  second 
visit. 


448 


MEDICAL   RECORD. 


[September  28,  1895 


gronitess  of  pXjetltcaTl  Jiciencc. 

Diagnostic  Ureterotomy.  —  Within  the  last  year  Ur. 
Kelly  has  performed  three  operations,  at  the  comple- 
tion of  which  he  feared  the  ureter  had  been  ligated,  as 
it  appeared  in  each  instance  to  be  enlarged  {Annals  of 
Si/rgtrj).  It  was  impossible  to  ascertain  certainly 
whether  this  accident  had  occurred  without  either 
taking  out  a  large  number  of  ligatures  which  had  been 
placed  in  the  ureteral  area  or  catheterizing  the  ureters. 
In  either  event  the  danger  would  have  been  much 
greater  to  the  patient  than  -the  operation  about  to  be 
described.  To  remove  all  of  the  ligatures  in  the 
ureteral  area  and  relegate  all  of  the  bleeding  vessels 
would  have  consumed  too  much  time,  and  the  cathe- 
terization of  the  ureters  would  have  been  still  more  im- 
practicable. For  these  reasons,  he  determined  to 
resort  to  ureterotomy  as  the  easiest  solution  of  his 
dilemma.  Accordingly  he  located  the  ureter  at  the 
pelvic  brim,  snipped  the  peritoneum  over  its  course, 
and  made  a  longitudinal  incision,  one-half  centimetre 
in  length,  into  the  lumen,  through  which  he  passed  a 
small  ureteral  sound  down  into  the  bladder.  In  two 
cases  of  the  three  he  found  the  ureters  free,  the  enlarge- 
ment being  simply  due  to  the  pressure  of  the  pelvic 
mass  previous  to  the  operation.  In  the  third  case, 
however,  he  found  that  the  ureter  had  been  included 
en  masse  with  a  large  area  of  bleeding  tissue  in  the 
pelvic  floor.  He  at  once  removed  the  constricting 
ligature,  and  was  able  to  pass  the  sound  into  the  blad- 
der. By  this  simple  operation  much  valuable  time 
was  saved,  and  uninterrupted  recoveries  in  each  case 
justified  the  statement  that  the  operation  is  without 
danger.  In  closing  the  slit  in  the  ureter,  he  used 
delicate  mattress  sutures  in  two  cases.  The  third  re- 
quired four  suture's  on  account  of  the  persistent  oozing 
of  urine.  These  sutures  were  very  lightly  passed  into 
the  outer  coat  of  the  ureter,  not  entering  its  lumen. 
The  cases  in  which  he  resorted  to  this  operation  were 
myoma  uteri,  carcinoma  uteri,  and  dense  pelvic  intiam- 
matory  disease.  All  of  the  patients  made  complete 
recoveries,  and  there  have  been  no  apparent  ill  effects 
from  the  operation  up  to  date.  He  used  gauze  drain- 
age in  each  case,  and  there  was  not  the  slightest  urinary 
odor  detected  at  any  time  on  the  dressings.  For  cases 
in  which  tliere  is  grave  doubt  as  to  whether  the  ureter 
has  been  ligated  or  cut,  lie  earnestly  ad\ises  this  diag- 
nostic measure. 

Chemical  and  Pathological  Characteristics  of  Milk. — 
Dr.  Rotch  states  that  tlie  infants' digestive  functions 
have  been  from  time  immemorial  adapted  to  the  diges- 
tion of  an  alkaline  or  neutral  fluid,  not  to  an  acid  one. 
Human  milk  is  the  food  on  which  the  greatest  number 
(if  infants  live  and  thrive,  and  on  which  the  smallest 
number  die  proportionately  to  any  other  known  food. 
\Vhether  the  moderately  alkaline  reaction  of  this  milk 
is  an  important  factor  in  the  problem  of  infant  feeding, 
is  a  question  not  yet  decided.  We  should  at  least  be 
very  suspicious  of  an  acid  breast  milk.  The  best  re- 
sults obtained  in  artificial  feeding  are  those  in  which 
the  tood  is  alkaline  in  reaction.  This  is  usually  accom- 
plished by  the  addition  of  an  alkali.  Mr.  G.  E.  Gor- 
don, in  the  course  of  extensive  observations  of  milk, 
found  that  cows  fed  in  certain  ])arts  of  Kentuckv  upon 
blue  grass,  and  also  in  other  pans  of  tlie  West,  jiroduced 
a  milk  which  was  alkaline,  and  which  remained  so  for 
a  number  of  hours  after  milking.  Analysis  of  this  food 
showed  its  composition  of  nitrogeneous  and  carbo-hy- 
drate elements  to  be  in  the  proportion  of  one  to  five  and 
one  lliird.  It  is  known  that  cows  fed  on  comparativelv 
dry  foods  produce  comparatively  acid  milk.  F.xtensive 
experiments  prove  that  cows  fed  freely  on  sugar  beets, 
which  supply  a  large  amount  of  carbo-hydrates,  pro- 
duced a  faintly  alkaline  milk.  These  e.xperiments  were 
conducted  with  the  utmost  care,  with  a  large  herd  for 


three  months,  with  the  following  uniform  results  : 
The  cows  fed  partially  on  beets  showed  neutral  or 
faintly  alkaline  reaction  ;  the  cows  that  received  no 
beets  showed  a  uniformly  acid  reaction.  This  milk 
was  carried  twelve  miles.  The  milk  from  one-third  of 
the  herd  which  had  been  fed  on  beets  was  added  to 
that  of  the  other  two-thirds.  The  reaction  was  even 
then  found  to  be  faintly  alkaline.  This  is  of  great  in- 
terest as  showing  that  the  product  of  the  cow  cannot 
only  be  made  to  correspond  in  reaction  to  that  of  hu- 
man beings  by  means  of  perfectly  natural  feeding,  and 
under  perfectly  normal  conditions,  but  that  this  alkaline 
modification  can  be  produced  to  such  a  degree  that 
one- third  of  the  milk  is  sufficient  to  destroy  by  its  alka- 
linity the  acidity  of  the  remaining  two- thirds. 

A  further  series  of  experiments  was  undertaken  to 
determine  the  source  of  the  bacteria  which  are  found  in 
milk.  It  was  found  that  the  direct  milking  of  the  first 
half,  performed  by  sterile  hands,  with  strict  antiseptic 
precautions,  showed  a  milk  with  a  comparatively  large 
number  of  micrococci  and  fine  bacilli.  It  was  found, 
further,  that  the  milk  drawn  through  a  sterile  cannula 
was  practically  sterile,  and  that  the  milk  drawn  in  the 
second  half  of  the  milking  by  hand  was  uniformly  ster- 
ile. These  experiments  provided  us  at  once  with  a 
means  of  producing  a  milk  practically  sterile,  but  not 
sterilized.  This  experiment  also  seems  to  prove  that 
the  bacteria  which  are  found  in  cows'  milk  do  not  nec- 
essarily come  from  external  sources,  whether  they  be 
of  the  cow  herself  or  of  her  surroundings,  but  that  they 
may  also  come  from  some  part  of  the  milk  tract  be- 
tween the  udder  and  the  end  of  the  teat. — Archives  of 
Pediotrics. 

Total  Extirpation  of  the  Patella. — According  to  Ur. 
Kununer,  total  extirpation  of  the  patella  can  be  per- 
formed without  impairing  the  patient's  gait  or  markedly 
interfe;ing  with  movements  of  the  knee-joint  :  The 
operation  is  indicated  in  cases  of  tubercular  osteitis  of 
the  patella,  provided  the  articulation  remains  yet  in- 
tact. Extirpation  can  actually  prevent  the  develop- 
ment of  articular  lesions  and  thus  save  the  knee-joint, 
provided  the  operation  is  resorted  to  sufficiently  early. 
In  cases  of  tubercular  osteitis  of  the  knee-cap,  total  re- 
moval of  the  bone  offers  better  chances  in  regard  tt> 
reco\ery  than  scraping  out  the  morbid  foci.  Dr.  Kum- 
mer  adduces  an  illustrative  case — a  girl,  aged  twenty- 
five,  with  primary  tuberculosis  of  the  right  patella,  but 
with  a  perfectly  intact  knee-joint — in  which  he  made 
excision  of  the  bone,  with  excellent  results.  When 
shown  to  the  Societe  Medi'cale  de  Geneve,  about  two 
months  after  the  operation,  the  patient  was  able  to  ex- 
tend her  right  lower  limb  as  under  normal  conditions  ; 
would  kneel  with  perfect  freedom,  and  without  any  pain 
or  discomfort  :  could  walk  four  or  five  hours  daily 
without  lameness  or  fatigue,  or  run  up  and  down 
staircases  with  ease.  etc.  In  short,  the  only  inconven- 
ience caused  by  the  absence  of  the  knee-cap  con- 
sisted in  a  relatively  weakened  extension  of  the  cor- 
responding limb.  -^  similarly  successful  case  of  total 
removal  of  the  i).itella  is  reported  by  Professor  Kaut- 
mann,  in  Ccriespcndenz-Blatt  fur  Sclnceizer  AdZU . 
The  patient,  a  married  lady  aged  thirty-three,  was 
suffering  from  fungoid  osteitis  of  the  left  knee-ca)'. 
of  eight  years'  standing.  .\  month  after  the  oper- 
ation she.  being  frightened  by  a  fire  next  door,  tore  oti 
all  dressings  and  ran  out  of  her  house,  having  swiftly 
descended  a  staircase.  Since  then  her  knee-joint  ha^ 
been  perfectly  movable  and  her  gait  normal.  Dr 
Kummer  mentions  further  two  cases  of  primary  tuber- 
cular osteitis  of  the  patella  in  boys,  in  which  the  whok- 
of  the  bone  was  removed  by  Professor  Th.  Kocher  of 
Berne.  An  interesting  case  of  total  excision  of  the 
patella  for  acute  necrosis  has  also  been  published  in 
Tlif  Lancet  by  Mr.  Page,  of  Ncwcastle-on-Tyne.  'X\\c 
patient  recovered  with  a  perfectly  useful  limb. — Pii  - 
vincial  AleJica/  Journal. 


September  28,  1895] 


MEDICAL    RECORD. 


449 


Medical   Record: 

A  Weekly  yournal  of  Medicuie  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43  45,  &  47  East  Tenth  Stres 


New  York,  September  28,  1895. 


IS   CANCER    INOCULABLE  ' 

The  recent  report  of  the  death  of  a  physician  of  this 
city  as  the  result  of  supposed  inoculation  of  cancer, 
while  in  attendance  upon  a  case  of  that  disease,  has 
again  revived,  in  the  public  press,  an  interest  in  the 
general  question  of  alleged  communicability  of  that 
form  of  malignant  growth.  The  gentlemen  who  were 
interviewed  on  the  probabilities  of  such  a  condition  of 
things  are  not  only  wisely  non-committal,  but  judi- 
ciously hide  their  identity  behind  the  general  state- 
ments of  "  eminent  specialists." 

The  subject  is,  however,  by  no  means  a  novel  one. 
From  the  time  that  the  malignancy  of  cancer  was  rec- 
ognized the  question  of  communicability  has  borne 
the  brunt  of  the  most  earnest  investigation,  and  the 
hope  of  its  solution  has  stimulated  the  most  ingenious 
experimentation  of  earnest  investigators.  The  results 
of  all  such  studies  have  been  entirely  negative.  There 
are  no  proofs  of  which  we  have  any  knowledge  that 
cancer  has  ever  been  directly  or  indirectly  propagated 
from  one  human  being  to  another.  It  is  true  that 
there  is  published  an  occasional  case  in  which  there 
would  appear  on  superficial  examination  to  be  a  direct 
relation  between  cause  and  effect,  but  when  such  are 
critically  examined  the  theory  of  propagation  vanishes 
in  face  of  a  conscientiously  critical  analysis.  At 
best  they  are  coincidental  circumstances  following  the 
general  law  of  accidents.  Experiments  in  the  lower 
animals  have  thus  far  amounted  to  nothing,  and  prac- 
tically we  are  as  much  in  the  dark  regarding  the  true 
etiology  of  cancer  and  its  real  methods  of  dissemi- 
nation as  ever. 

The  investigations  in  these  directions  have  been  ex- 
ceedingly interesting,  although  mostly  instructive  from 
a  negative  view.  Among  these  are  the  experiments  of 
Dr.  D'Arcy  Power,  made  in  1894  and  published  in  Sep- 
tember of  that  year  in  the  British  Medical  Journal. 
The  animals  experimented  upon  were  very  old  or  very 
young  white  rats,  which  may  be  assumed  to  be  more 
vulnerable  than  adult  animals  which  run  wild.  These 
animals  were  kept  in  low  wire  cages  resting  on  soil 
taken  from  those  districts  in  England  in  which  cancer 
most  prevails.  This  soil  was  thoroughly  mixed  with 
fresh  cancer  tissue,  and  kept  moist  with  water  in  which 
cancer  tissue  had  been  ground  and  pulped.  The 
rats  were  from  time  to  time  sprayed  with  a  thin  cancer 


pulp,  and  their  mucous  membranes  were  kept  in  a  state 
of  chronic  irritation  so  that  the  protozoon,  if  any 
existed,  might  find  a  suitable  medium  for  its  re- 
ception and  a  favorable  soil  for  its  growth.  The 
rats,  six  in  all,  lived  in  this  way  for  about  eleven 
months.  Two  died,  one  from  cold,  the  other  from 
intestinal  perforation  by  a  tape-worm,  and  four  were 
killed.  A  careful  examination  was  made  in  each 
case,  but  in  none  could  a  trace  of  cancer  be  found 
anywhere  either  by  the  naked  eye  or  under  the  micro- 
scope. 

These  facts,  although  reported  at  the  time  in  the 
Medical  Record,  are  interesting  enough  in  the  pres- 
ent connection  to  deserve  repetition. 

Again  we  remind  our  readers  of  a  report  in  this  jour- 
rial  two  years  ago  of  experiments  made  by  Dr.  Gratia, 
of  Brussels.  The  results  of  his  investigations  justified 
the  following  conclusions  :  i.  The  parasitic  nature  of 
cancer  has  not  been  satisfactorily  proved.  2.  The 
direct  or  indirect  contagiousness  of  this  neoplasm  has 
not  been  demonstrated  even  in  individuals  of  the  same 
species.  3.  In  those  instances  in  which  the  clinical 
history  of  a  patient  appears  to  prove  inoculability,  it 
has  been  shown  that  an  exceptionally  strong  predispo- 
sition to  cancer  already  existed,  awaiting  only  the 
slightest  and  most  ordinary  irritation  for  its  full  devel- 
opment. In  other  words,  the  supposed  inoculation 
amounted  to  nothing  beyond  a  possibly  determining 
traumatism.  The  latter,  it  seems  to  us,  is  the  key-note 
of  the  whole  question.  A  person  predisposed  to  any 
disease  is  always  an  easy  victim  when  any  definite  ex- 
citing cause  presents  itself,  while  one  without  such  ten- 
dencies escapes  every  time.  The  melancholy  case  in 
point  was  undoubtedly  one  of  predisposition  to  malig- 
nant disease,  that  developed  in  due  time,  the  supposed 
inoculation  from  a  cancerous  patient  having  no  more 
causative  relation  to  it  than  any  other  purely  coinci- 
dental circumstance. 


THE    REGISTRATION    OF    MIDWIVES. 

In  spite  of  the  very  strenuous  efforts  of  the  medical 
profession  of  Great  Britain  to  enforce  the  education  of 
midwives  and  insure  their  proper  qualification  by  reg- 
istration, it  would  appear  from  a  recent  discussion  in 
the  London  Times  that  the  object  is  very  far  from  at- 
tainment. This  will  be  somewhat  of  a  surprise  in  view 
of  the  fact  that  England  has  been  supposed  to  be  a 
long  way  in  advance  in  her  practical  solution  of  the 
problem.  Now,  however,  it  is  boldly  stated  that  a  large 
number  of  infant  lives  are  yearly  sacrificed,  especially 
in  the  Whitechapel  and  other  poor  districts,  by  the  in- 
competence of  the  ordinary  charwoman,  who  regularly 
officiates  as  nurse  to  the  lying-in  woman.  All  this 
proves  how  futile  are  the  present  laws  governing  regis- 
tration after  years  spent  in  the  most  laudable  efforts  in 
that  direction.  The  main  difficulty  appears  to  be  in 
the  want  of  education  of  the  ignorant  classes  to  the  ne- 
cessity of  aseptic  precautions  in  guarding  against  the 
numerous  and  fatal  sources  of  puerperal  infection. 
The  Englishman  of  the  lower  class  is  more  than  jealous 
of   his  'rights,    and    among  these  of  being   independ- 


450 


MEDICAL    RECORD. 


[September  28,  1895 


ently  dirty  is  not  the  least.  His  traditional  right  of 
guarding  his  hovel  as  his  castle,  in  which  the  king  can- 
not enter  without  an  invitation,  explains  his  stubborn- 
ness in  combatting  every  innovation  that  may  jar  the 
rhythm  of  his  jealously  guarded  personal  privileges. 
In  many  respects  the  poor  of  this  and  other  cities  in 
America  are  on  the  same  level,  especially  those  in  ten- 
ement-house districts.  In  our  own  endeavors,  however, 
to  insure  proper  qualifications  for  midwives,  we  are  not 
to  be  discouraged,  as  with  the  exceptional  powers  of  our 
health  authorities  it  is  quite  possible  to  so  enforce  nec- 
essary regulations  as  may  compel  our  lower  classes  to 
obedience,  rather  than  to  invite  the  opposition  of  argu- 
ment or  the  disputation  concerning  their  supposed  in- 
dividual rights.  The  fundamental  principle  of  all 
sanitary  laws  rests  upon  the  safety  of  the  majority  ; 
the  control  of  the  birth-rate  and  the  reduction  of  in- 
fant mortality  are  the  chiefest  of  these  in  estimating 
the  stability  and  prosperity  of  the  State.  .\s  there  is 
no  excuse  in  these  days  for  negligence  in  these  matters, 
there  is  no  argument,  even  in  the  face  of  the  most  stub- 
born opposition,  for  creating  and  enforcing  the  requi- 
site regulations  to  such  ends. 


men  to  fill  all  present  and  future  %'acancies.  The  pro- 
fession will  now  watch  with  interest  the  result,  in  the 
hope  that  the  best  may  win. 


THE  EX.A.MIN.\TION  FOR  POLICE  SURGEON- 
SHIP. 


The  civil  service  examination  in  this  city  for  one  va- 
cancy in  the  surgeoncy  of  the  police  called  together 
sixty-eight  candidates  for  the  position.  This  circum- 
stance shows  not  only  the  active  competition  for  such 
places,  in  which  a  salary  of  three  thousand  dollars  is 
assured,  but  also  proves  that  the  profession  takes  it  for 
granted  that  there  has  come  at  last  a  time  when  fair 
play  in  such  appointments  is  virtually  guaranteed  by 
the  new  Board  of  Police  Commissioners.  The  appli- 
cants were  much  above  the  average  grade  that  appear 
on  such  occasions,  and,  on  the  whole,  represented  a 
high  standard  of  professional  attainment.  We  can  pre- 
dict that  a  very  large  proportion  will  pass  satisfac- 
torily. The  questions  asked  were  reasonably  just, 
and  were  calculated  to  call  forth  a  practical  knowledge 
equal  to  the  usual  emergencies  of  the  office.  The 
average  age  was  thirty-three  years,  and  comprised  for 
the  most  part  men  who  are  engaged  in  actual  |)rac- 
tice,  with  a  large  percentage  of  hospital  graduates. 
While  there  is  only  one  vacancy,  caused  by  resigna- 
tion, in  a  corps  of  fifteen,  there  will  probably  be  alto- 
gether three  additional  places  to  be  filled,  in  case 
the  requisite  amount  of  appropriation  for  such  pur- 
pose is  made. 

Taking  this  into  account  in  connection  with  the  fact 
that  one  or  more  of  the  present  force  is  beyond  the  age 
limit,  there  may  be,  by  future  forced  resignation,  a 
corresponding  chance  for  six  or  more  places  to  be 
filled.  There  is  no  doubting  the  fact  that  the  time  has 
come  for  the  infusion  of  new  blood  in  the  board  and 
the  vacation  of  some  of  the  places  that  have  been  so 
long  held  by  political  appointees.  No  one  can  doubt 
that  from  the  sixty-eight  applications  there  will  be  ob- 
tained much  more  than  a  sufficient  number  of  first-class 


THE    MIR.A.CLES    AT    LOURDES. 

The  English  journals  contain  a  number  of  accounts  of 
the  wonderful  cures  that  are  being  daily  performed  at 
Lourdes.  Mr.  Chauncey  M.  Depew,  on  reaching 
America  after  a  European  trip,  also  gave  to  reporters 
an  interesting  account  of  an  alleged  miraculous  cure, 
of  which  he  was  personally  cognizant.  Lourdes  is  al- 
together having  a  decided  "  boom." 

The  description  of  the  way  in  which  the  pilgrims  to 
this  place  are  treated  shows  to  what  an  extraordinary 
state  of  nervous  excitement  and  expectation  patients 
who  come  there  are  subjected.  Hardly  anything  is 
lacking  to  produce,  in  a  most  intensified  way,  both 
psychical  and  physical  shock.  The  patients  are 
brought  into  the  grotto  during  the  chanting  of  hymns 
and  amid  the  noise  and  excitement  of  the  multitudes 
about  them.  Just  as  the  nerves  have  reached  the  high- 
est possible  tension,  the  patient  is  suddenly  plunged 
into  the  icy  cold  bath  ;  he  is  then  withdrawn,  and 
believes  he  is  cured.  Naturally,  some  extraordinary 
effects  are  produced.  There  can  be  no  doubt,  how- 
ever, that  these  effects  are  all  due  to  this  unique  com- 
bination of  exciting  and  stimulating  experiences.  Nor 
do  we  question  at  all  but  that  a  careful  investigation 
of  the  subsequent  history  of  the  numerous  cases  of  al- 
leged cure  would  show  that  there  was  a  relapse  in  all 
the  serious  organic  cases,  and  probably  a  relapse  in 
many  of  the  functional  ones.  We  are  informed  that  a 
young  physician,  well  known  for  his  careful  scientific 
methods  and  for  his  accomplishments  as  a  neurologist, 
is  investigating,  in  a  most  painstaking  way,  various 
cases  that  are  going  to  Lourdes,  and  is  following  up 
these  cases  after  they  have  been  through  their  treat- 
ment. A  report  upon  the  effects  of  the  alleged  mirac- 
ulous healing  from  such  a  source  would  undoubtedly 
have  a  practical  value  as  well  as  be  of  scientific  in- 
terest. 


SOME    THERAPEUTIC   TRADITIONS. 

Dr.  Walter  G.  Smith.  President  of  the  Royal  Col- 
lege of  Physicians  of  Dublin,  gave  an  address  recently 
upon  the  subject  of  therapeutical  traditions.  It  is 
always  instructive  to  hear  the  judgments  of  practition- 
ers of  long  experience  upon  therapeutics,  and  Dr. 
Smith's  contribution  on  this  subject  contains  much 
that  is  suggestive  and  useful.  The  learned  orator,  in 
giving  his  address,  did  not  attempt  to  cover  the  ground 
of  therapeutics  in  any  systematic  way.  He  begins  by 
talking  upon  the  subject  of  diet  in  its  relation  to  dis- 
eases of  the  skin.  He  avers  that  many  years  ago  he 
reached  the  conclusion  that  the  effect  of  diet  in  the 
treatment  of  this  class  of  cases  was  very  slight.  Some 
text-books  upon  diseases  of  the  skin  give  minute  dieteti< 
details,  details  which  he  believes  to  be  of  really  little 
value,  and  which  would  not  be  followed  by  the  authors 
of  the  book  if  they  had  such  diseases  themselves. 
With  the  exception  of  such  diseases  as  urticaria,  certain 


September   28,  1895] 


MEDICAL    RECORD. 


45^ 


of  the  erythemata,  and  some  cases  of  eczema,  there  is 
little  reason  to  particularize  in  the  matter  of  diet. 
The  patient  should  be  told  to  follow  the  simple  rule  of 
moderation  in  eating  as  well  as  drinking  ;  total  absti- 
nence from  alcohol  is  often  a  thing  very  much  needed. 
One  of  the  most  generally  believed  traditions  in  die- 
tetics of  skin  diseases,  according  to  Dr.  Smith,  is  the 
prohibition  of  salt  food,  most  patients,  he  says,  being 
assured  that  they  cannot  be  allowed  to  touch  a  morsel 
of  ham  or  bacon.  Dr.  Smith  does  not  believe  in  this 
special  tradition,  and  thinks  that  salt  food  has  no 
special  disadvantage,  except  that  salt  meats  are  not,  as 
a  rule,  as  digestible  as  those  which  are  fresh. 

Dr.  Smith  next  alludes  to  the  common  belief  regard- 
ing the  efficacy  of  lithia  and  other  alkaline  water  in 
the  treatment  of  gout  and  allied  affections.  This  is  a 
subject  to  which  we  have  ourselves  often  referred,  and 
it  is  not  necessary  to  go  over  Dr.  Smith's  line  of  argu- 
ment now.  He  shows  that  the  few  grains  of  lithia  or 
other  alkaline  salts  present  in  the  mineral  waters  can- 
not have  any  particular  effect  in  modifying  the  condi- 
tions which  underlie  gout  or  lith^emia.  He  says  that 
he  never  prescribes  lithia-water  to  such  patients,  but 
there  is  no  objection  to  their  taking  it  if  they  choose. 
A  pint  of  lithia-water  is,  to  all  intents,  equivalent  to  a 
pint  of  pure  water.  The  elaborate  analyses,  he  adds, 
nf  the  various  springs,  all  arising,  perhaps,  from  the 
same  geological  stratum,  only  prove  that  many  persons 
are  unable  to  see  a  joke,  and  cannot  perceive  the  dif- 
ference between  "tweedledum  "  and  " tweedledee." 

Another  therapeutic  superstition  which  Dr.  Smith 
attacks,  with  perhaps  less  force  and  justice,  is  the  use  of 
pills  coated  with  keratin,  or  other  substance  which  is 
insoluble  in  an  alkaline  medium.  Dr.  Smith  would 
have  us  believe  that  the  intestinal  contents  is  not  alka- 
line as  a  rule,  but  acid,  and  that,  consequently,  the  theory 
on  which  these  pills  are  given  is  false.  We  believe  that 
keratin- coated  pills  have  rather  fallen  out  of  use,  while 
the  general  fact  upon  which  they  are  based  is  true. 
The  contents  of  the  intestines  is  at  times,  and  in  cer- 
tain parts,  acid,  to  be  sure,  on  account  of  fermentative 
changes,  but  the  general  reaction  of  alkaline  and  thera- 
peutic measures  that  are  based  on  this  view  may  be 
assumed  to  be  correct. 


Heroic  Treatment  of  Pneumonia. — There  are  still 
some  people  who  believe  in  blood-letting  as  a  remedial 
measure.  In  the  Gazette  Jes  Hopitaux  for  .\ugust  27, 
1895,  Dr.  De  Duplaa  de  Garat  has  an  article  on  the 
"  Specific  Treatment  of  Pneumonia,"  in  which  he  coun- 
sels bleeding  from  the  arm  upon  the  first  appearame. 
The  following  day  a  second  venesection  is  to  be  prac- 
tised, if  the  fever  continue,  and,  if  there  is  no  improve- 
ment, still  another  on  the  third  day.  Occasionally, 
says  the  writer,  the  disease  is  jugulated  by  the  first 
bleeding,  more  often  by  the  second,  and  usually  by  the 
third.  If  the  latter  do  not  suffice,  however,  we  must 
bleed  again  on  the  fourth  day.  The  patient  is  further 
depleted  by  an  absolute  fast,  no  food  at  all  being  allowed 
until  the  third  day  of  convalescence.  Instead  of  bur\  - 
ing  all  his  pneumonia  patients,  the  writer  claims  that 
he  cures  them  all  without  exception. 


Misery  in  Italy. — In  a  letter  to  the  London  Truth 
"Ouida,"  the  novelist,  writes  :  "Official  statistics  state 
that  in  Italy  there  are  100,000  persons  dying  of  pella- 
gra, 6,000,000  living  on  malarious  land,  1,700  com- 
munes in  which  corn  is  rare,  1,400  communes  with 
scanty  and  foul  water  supplies,  600  communes  which 
have  no  doctor  within  reach,  and  over  300  communes 
which  have  no  burial-place."  As  "  Ouida,"  when  not 
writing  romances,  is  given  to  exaggeration,  and  as  the 
journal  in  which  her  letter  appeared  seldom  lives  up  to 
its  name  unless  by  accident,  we  may  hope  that  Italy  is 
not  in  quite  so  bad  a  way. 

China  has  twelve  hospitals  throughout  the  Empire, 
and  but  twenty-five  educated  medical  men  for  the 
population  of  400,000,000. 

The  Morals  of  the  British  Practitioner  are  carefully 
and  tenderly  regulated  by  a  number  of  estimable  gentle  • 
men  who  compose  what  is  known  as  the  General  Medi- 
cal Council.  This  august  board  of  censors  meets  sev- 
eral times  a  year,  and  tries  the  cases  of  those  who  have 
tried  to  let  their  light  shine  before  men,  whether  through 
a  paid  ad.  or  a  friendly  press  notice.  But  when  a  law- 
maker breaks  the  law,  when  a  vigilant  censor  himself 
permits  his  name  to  be  mentioned  in  the  columns  of  a 
lay  journal,  things  have  indeed  gone  wrong.  It  is  then 
the  duty  of  the  medical  press  to  administer  the  rebuke 
that  the  councillor  cannot  be  expected  to  administer  to 
himself,  and  this  is  the  way  the  Lancet  does  it :  "  We 
notice  in  the  columns  of  a  lay  contemporary  an  an- 
nouncement that  '  Sir  Dyce  Duckworth,  the  well-known 
physician,  has  gone  to  America.  He  intends  to  be 
back  in  this  country  about  September  i6th.'  We  are 
too  often  compelled  to  reprove  practitioners  with  adver- 
rising,  or  to  call  attention  to  their  being  advertised  by 
injudicious  or  stupid  friends,  and  we  cannot  ignore 
similar  occurrences  in  the  case  of  leaders  of  the  profes- 
sion, although  we  feel  sure  that  the  objectionable  notice 
has  been  inserted  without  Sir  Dyce  Duckworth's  knowl- 
edge or  leave.  The  curse  of  publicity  which  neces- 
sarily attends  upon  those  in  any  prominent  position 
makes  it,  perhaps,  more*  difficult  for  them  than  for 
humbler  members  to  avoid  this  sort  of  thing,  but  owing 
to  their  position  it  is  of  all  the  more  importance  that 
they  should  take  every  means  to  prevent  such  notices 
getting  into  the  public  press."  We  are  truly  sorry  for 
anyone  writhing  under  the  curse  of  publicity,  but  the 
only  remedy  that  we  can  suggest  to  our  suffering  col- 
league is  that  he  come  to  this  country  again  and  remain 
here,  for  we  have  so  many  in  prominent  positions  that 
he  might  with  less  difficulty  preserve  his  incognito. 

Dr.  Nelson  Isham.  who  was  the  oldest  living  grad- 
uate of  Vale  Medical  College,  died  at  Little  Falls, 
N.  Y.,  on  September  i8th.  He  was  born  in  Bolton, 
Conn.,  in  1805,  was  a  member  of  the  class  of  1828,  and 
was  surgeon  of  the  Ninety-seventh  Regiment,  New  York 
Volunteers. 

The  Cholera  in  Russia. — In  the  province  of  Voi- 
hynia,   Russia,  during  the   week  ending   August  24th 


452 


MEDICAL    RECORD. 


[September   28,  1895 


5,849  cases  of  cholera  were  reported,  and  2,134  deaths 
therefrom.  In  the  province  of  Podolln,  for  the  ten  days 
ending  August  31st,  loi  cases  of  cholera  and  45  deaths 
were  reported. 

Responsibility  for  Remarks  at  the  County  Medical 
Society. — The  meeting  of  the  New  York  County  Medi- 
cal Society  on  Monday  last  was  one  of  especial  interest 
and  excitement.  The  trouble  arose  from  an  appeal  by 
Dr.  Frank  Van  Fleet  to  the  society  against  the  decision 
of  the  Comitia  Minora.  The  Comitia  had  decided 
that  the  society  could  not  assume  responsibility  for  re- 
marks made  by  Dr.  Van  Fleet  at  one  of  the  meetings 
of  the  society  which  resulted  in  the  institution  of  a 
suit  for  §40,000  damages  against  Dr.  Van  Fleet.  The 
remarks  in  question  by  Dr.  Van  Fleet  were  made  in 
criticism  of  an  advertisement  of  an  optician  published 
in  the  Directory  of  the  County  Medical  Society  for 
1894.  A  very  warm  discussion  ensued,  in  which  the 
sympathies  of  the  society  were  apparently  strongly  in 
favor  of  Dr.  Van  Fleet.  However,  the  following  reso- 
lutions were  finally  adopted  : 

IVhereas,  It  has  come  to  the  notice  of  this  society 
that  one  of  its  members  has  had  suit  brought  against 
him  for  remarks  made  before  this  society  ;  and 

ir/iereas.  The  Comitia  Minora  has  decided  that  the 
society  has  no  responsibility  in  the  matter  ;  and 

W/icreas,  The  member  mentioned  has  appealed  to  the 
society  from  the  decision  of  the  Comitia  Minora,  and 
the  members  of  this  society  desire  to  know  just  what 
their  rights  and  privileges  are  in  matters  of  this  kind  ; 
therefore  be  it 

Resolved,  That  a  committee  of  five,  coinposed  of  the 
President  of  the  society,  Drs.  Richard  H.  Derby,  Joseph 
D.  Bryant,  D.  B.  St.  John  Roosa,  and  Henry  D.  Noyes, 
be  appointed  to  consider  just  what  the  merits  of  the 
case  may  be,  and  to  determine  what  action,  if  any,  the 
society  should  take. 

Vaccination  and  Marriage. — In  Sweden  and  Nor- 
way a  person  cannot  be  legally  married  until  after  the 
production  of  a  certificate  attesting  that  the  affianced 
parties  bear  genuine  vaccine  marks. 

Dr.  Adolphe  von  Bardeleben,  the  well-known  surgeon 
and  professor  at  the  University  of  Berlin,  died  in  that 
city  on  September  24th.  H?  was  born  in  Frankfort- 
on-Main,  on  March  i,  181 9. 

Diphtheria  in  St.  Louis.— Health  Commissioner  Stark- 
loff  of  St.  Louis  has  made  a  report  to  the  Board  of 
Health  to  the  effect  that  diphtheria  is  practically  epi- 
demic in  that  city,  170  cases  having  been  reported 
since  September  ist. 

Professor  Pasteur  was  reported  by  cable  the  other 
day  to  be  dying.  This  report  has  since  been  denied, 
but  it  is  stated  that  his  health  is  very  feeble. 

The  Summer  School  of  Medicine,  of  Chicago,  has 
been  incorporated  under  the  name  of  the  Illinois 
Medical  College,  It  held  its  first  commencement  on 
September  4th. 

The  Physicians'  Alliance  Monthly.— The  P/iysia'a/is' 
Alliance  Afonthlyi%the  title  of  a  journal  devoted  to  the 
financial  interests  of  the  members  of  the  Alliance.     It 


contains  smong  other  things  thirteen  and  a  half  page; 
and  fifty-two  columns  of  names  of  persons  resident  in 
New  York,  whom,  we  presume,  belong  to  the  class  who 
do  not  pay  their  bills.  We  did  not  suppose  that  the 
world  was  so  bad. 

The  First  Railway  Hospital  in  the  United  States 
was  started  in  1868,  at  Sacramento,  Cal.,  by  the  Central 
Pacific  Railroad.  The  first  surgeon  was  Dr.  S.  B. 
Thorn,  of  Sacramento.  The  first  hospital  of  the  Mis- 
souri Pacific  Railroad  was  established  in  1879  by  Dr. 
J.  W.  Jackson.  Dr.  A.  W.  Ridenour,  of  Massillon,  O.. 
was  the  projector  of  the  National  Association  of  Rail- 
way Surgeons.  Dr.  Frederick  H.  Caldwell  was  the 
first  to  practically  equip  and  run  a  hospital  car  on  his 
system  of  roads. —  Tri- State  Medical  Journal. 

A  Medical  Mission  College  has  been  organized  in 
Chicago.  It  is  to  have,  says  the  Chicago  Medical  Re- 
corder, a  dual  faculty,  one  section  of  which  is  composed 
of  clergymen  and  the  other  of  members  of  the  facultv 
of  various  homoeopathic  colleges. 

Medical  Education  of  Women. — The  University  of 
Durham  has  thrown  open  its  portals  to  women,  having 
obtained  a  supplementary  charter,  enabling  it  to  grant  to 
women  any  degrees  except  degrees  in  divinity.  Accord- 
ing to  Polk's  "Medical  Register,"  in  1893  more  than 
three  thousand  women  were  engaged  in  the  practice  of 
medicine  in  the  United  States,  and  a  later  census  puts 
the  number  at  a  little  more  than  five  thousand.  There 
are  from  thirty-five  to  forty  co-educational  medical  col- 
leges, besides  a  good  many  independent  colleges  which 
only  receive  women.  T/te  Practitioner  discusses  the 
question  whether  any  of  these  five  thousand  women 
have  reached  distinction  in  the  medical  world,  and  the 
editor  says  that  he  confesses  that  he  is  not  acquainted, 
by  reputation,  with  any  one  of  the  number.  This,  he 
modestly  admits,  may  only  be  due  to  the  limitation  of 
his  own  knowledge,  and  we  are  inclined  to  allow  the 
admission.  There  can  scarcely  be  any  intelligent  phy- 
sician to  whom  the  achievements  of  Dr.  Putnam-Jacobi, 
for  example,  and  perhaps  half  a  dozen  others,  are  not 
known. 


©bituarrj. 


JOHN    LAW    CAMPBELL,  M.D., 


John  L.a.\v  Campbell,  M.D.,  seventy-two  years  old, 
member  of  the  County  Medical  Society  and  the  Acad- 
emy of  Medicine,  and  for  more  than  twenty-five  years 
physician  to  the  New  York  Orphan  .\sylum.  died  on 
September  22d  at  his  residence  in  this  city.  He  had 
not  been  well  for  several  years,  but  his  death  was  unex- 
pected and  was  due  to  angina  pectoris.  Dr.  Campbell 
was  born  at  Duanesburg,  N.  Y.,  and  was  a  graduate  of 
Jefferson  College,  Philadelphia,  and  of  the  New  York 
College  of  Physicians  and  Surgeons.  He  was  a  trustee 
of  the  Franklin  Savings  Bank,  and  for  forty  years  a 
practising  physician  in  New  York  City. 

He  was  an  elder  in  the  West  Presbyterian  Church 
and  was  always  prominent  in  religious  and  charitable 
work. 


September  2S,   1895] 


MEDICAL    RECORD. 


45: 


J»ocieti3[  ^epoi'ts. 


MISSISSIPPI  VALLEY  MEDICAL   ASSOCIA- 
TION. 

Twenty-first  Annual  Meeting,  held  in  Detroit,  Alicli., 
September  j,  4,  j,  and  6,  iSqj. 

The  Association  convened  in  the  Strassburg  Academy, 
and  was  called  to  order  by  Dr.  H.  O.  Walker,  of 
Detroit,  Chairman  of  the  Committee  of  Arrangements. 
Prayer  was  offered  by  the  Rev.  Marcus  A.  Brownso.n". 
of  Detroit.  Dr.  Walker  then  introduced  Mayor  Pin- 
GREE.  who  paid  an  eloquent  tribute  to  the  medical  pro- 
fession, and  extended  a  cordial  greeting  to  the  Asso- 
ciation. The  Address  of  Welcome  on  behalf  of  Detroit 
physicians  w~as  made  by  Dr.  J.  Henry  Carstens,  of 
Detroit. 

President's  Address. — Dr.  Walker  presented  the 
President  of  the  Association,  Dr.  William  N.  Wish- 
ARD,  of  Indianapolis,  who  delivered  the  Presidential 
Address.  He  said  the  importance  and  advancement  of 
Detroit  was  represented  by  the  standing  and  intelli- 
gence of  the  local  physicians.  He  referred  to  the 
beginning  of  the  four  years'  course  in  medical  colleges, 
and  said  the  fear  that  the  new  rule  would  operate  io 
the  disadvantage  of  the  smaller  schools  was  unfounded. 
The  President  urged  the  advisability  of  publishing  the 
records,  papers,  and  discussions  in  some  manner  to 
make  them  accessible  to  all  members.  He  recom- 
mended a  permanent  Executive  Committee,  and  re- 
gretted that  the  large  number  of  papers  necessitated 
the  holding  of  two  meetings  at  the  same  time.  He 
commended  the  preparations  for  the  Convention,  and 
pledged  his  earnest  efforts  to  the  promotion  of  the 
profit  and  pleasure  of  the  Convention. 

The  reports  of  the  Secretary  and  Treasurer  were 
read  and  accepted. 

The  Gold  Combinations  as  Alteratives. — Dr.  Tho.mas 
Hl'NT  Stuckv,  of  Louisville,  read  a  paper  with  this 
title.  At  a  meeting  of  the  Medico-Chirurgical  So- 
ciety of  Louisville,  April  5,  1894,  the  author  had  the 
pleasure  of  exhibiting  a  series  of  cases  who  had  been 
taking  the  preparations  of  gold  and  arsenic,  known  to 
the  profession  as  arsenauro  and  viercauro.  He  was 
under  the  impression  at  that  time  that  the  good  effect 
claimed  was  produced  in  three  ways  :  i,  By  stimulation 
of  the  secreting  glands  of  the  stomach  ;  2,  by  the  prob- 
able alterative  effect  upon  these  secretions  ;  and  3,  that 
probably  there  was  a  local  antiseptic  influence  exerted. 
The  class  of  patients  in  which  he  had  used  the  prep- 
arations were  people  afflicted  mostly  with  consump- 
tion, Bright's  disease  in  its  various  stages,  chronic 
hepatic  troubles,  and  convalescents.  He  made  it  a 
rule  with  all  these  cases  to  withdraw  all  medicine  ex- 
cept the  combinations  of  gold  and  arsenic.  He  had 
S:;lected  from  a  series  of  cases  four  or  five,  which  he 
detailed. 

Case  I.— Patient,  a  male,  sixty  years  of  age,  with  tu- 
berculosis. History  good.  Eight  drops  of  the  mercuric 
bromide  of  gold  and  arsenic  were  given  hypodermically 
every  four  hours,  this  treatment  being  continued  for 
two  months.  No  deleterious  results  were  noticed. 
On  the  contrary,  he  is  decidedly  better  ;  physical  con- 
dition, color,  appetite,  and  bodily  strength  improved. 

He  reported  a  few  cases  out  of  a  large  number  to 
demonstrate  in  his  judgment,  conclusively,  that  by  the 
combinations  of  gold  and  arsenic  we  have  an  agent 
acting  as  neither  of  the  minerals  do  when  administered 
separately  ;  or,  in  other  words,  we  have  an  entirely  new 
agent  in  so  far  as  therapeutical  action  is  concerned. 

The  author  then  dwelt  at  considerable  length  upon 
the  chemical  differences  between  the  chloride  of  gold 
and  sodium  and  the  bromide  of  gold  and  arsenic  (ar- 


senauro)  with  reference  to  their  therapeutical  action 
and  subsequent  elimination.  He  believes  that  in  the 
action  of  the  combination  of  bromide  of  gold  and  ar- 
senic, it  is  entirely  different  from  any  therapeutic  agent 
known.  As  compared  with  mercauro,  iodine,  or  the 
combinations  of  iodides,  the  action  of  gold  in  the  com- 
binations named  is  greater  and  intensified  ;  that  these 
combinations  enter  into  the  circulation  as  gold  and  ar- 
senic and  spend  their  force  and  exert  their  influence  in 
an  alterative  way  upon  the  glandular  system  ;  that  a 
marked  alterative  effect  is  exerted  upon  all  sclerosis 
(non-malignant)  ;  that  it  is  not  only  a  blood-maker, 
but  a  blood  builder  ;  that  it  not  only  increases  the 
quantity,  but  the  quality  of  the  corpuscles  ;  that  under 
its  use  haemoglobin  is  markedly  increased  ;  that  it  is 
eliminated  by  the  kidneys  ;  that  they  produce  no  irri- 
tation either  when  given  per  orem  or  hypodermically. 

Cases  corroborating  the  beneficial  and  curative  ef- 
fects of  the  preparations  mentioned  by  the  essayist 
were  reported  by  Drs.  A.  P.  Buchman,  I.  N.  Love,  and 
William  F.  Barclay. 

Legitimate  Pharmacy. — This  paper  was  read  by  Dr. 
William  F.  Barclay,  of  Pittsburgh.  He  defined  le- 
gitimate pharmacy  as  that  which  meets  the  necessities 
and  demands  of  the  regular  medical  profession  and  the 
people.  The  medical  profession  is  entirely  separate 
and  distinct  from  pharmacy.  Medicines  are  divided 
into  four  classes — patented,  proprietary,  non-proprie- 
tary, and  secret.  There  are  a  large  number  of  cures, 
mixtures,  and  tonics  bearing  the  name  of  their  origina- 
tors and  deserving  of  consideration  as  proprietary 
preparations.  Pharmacists  and  physicians  are  inter- 
dependent and  should  work  together.  Legitimate 
pharmacy  has  called  into  service  educated  and  able 
men,  but  the  incompetent  and  dishonest  have  got  in 
too  and  cannot  be  too  severely  condemned.  Pharma- 
cists make  errors,  but  physicians  are  careless,  too,  in 
writing  prescriptions.  Physicians  should  not  favor  any 
particular  pharmacist  and  should  not  receive  pay  from 
them.  On  the  other  hand,  it  is  unworthy  and  unpro- 
fessional for  pharmacists  to  prescribe  drugs  or  medi- 
cines. Legitimate  pharmacy  should  protect  the  peo- 
ple from  the  nostrum  makers.  Physicians  have  a  right 
to  require  the  highest  skill  and  competence  upon  the 
part  of  the  pharmacist,  both  for  his  own  interests  and 
the  good  of  his  patients. 

Cod-Liver  Oil Dr.  F.  E.  Stewart,  of  Detroit,  con- 
sidered the  powerful  stimulant  action  of  cod-liver  oil 
on  nutrition,  also  demonstrating  with  specimens  the 
difference  in  the  color  of  oil  digested  from  fresh  livers, 
and  that  prepared  from  putrid  livers,  the  former  being 
pale,  golden,  or  light  brown,  according  to  the  number 
of  hours  digested,  and  the  latter  dark  brown.  The 
darker  oils  contained  more  extractive  matter.  Dr. 
Stewart  said  the  text-books  contained  many  errors  re- 
garding the  preparation  of  cod-liver  oil. 

Dr.  I.  N.  Love,  in  the  discussion,  conceded  the  mer- 
its of  the  paper,  but  expressed  himself  as  rather  scep- 
tical as  to  the  value  of  cod-liver  oil.  He  declared  that 
there  was  danger  of  our  getting  too  professional,  and 
said  that  that  which  brings  relief  to  the  patient  is  to  be 
commended.  He  favored  proprietary  remedies  which 
have  come  to  the  profession  through  pharmaceutical 
channels. 

TIterine  Fibroids — 'When  to  Operate. — Dr.  Tod  D. 
Gilliam,  of  Columbus,  O.,  read  the  paper.  The  medi- 
cal and  electrical  treatment  of  uterine  fibroids  is  to-day 
in  a  very  unsettled  state.  \\'hile  it  cannot  be  denied 
that  amelioration  or  even  recovery  has  folio  .ved  such 
lines  of  treatment,  there  has  not  been  that  degree  of 
uniformity  in  results  calculated  to  inspire  confidence. 
To  the  author's  mind  there  is  no  better  field  for  a  com- 
petent observer  than  the  study  of  the  natural  history 
of  uterine  fibroids.  It  will  enable  us  to  determine  the 
true  value  of  so-called  curative  agencies.  It  will  in- 
sure a  more  certain  prognosis.  It  will  give  the  proper 
cue  to  suri'ical  interference.     If  out  of  one  hundred 


454 


MEDICAL    RECORD. 


[September  28,  1895 


cases,  ninety  suffering  women  can  be  restored  to  lives 
of  usefulness  and  happiness,  would  it  not  be  better  to 
give  them  a  chance  ?  No  surgeon  is  justified  in  doing 
hysterectomy  or  the  more  serious  operations  for  uterine 
fibroids  when  the  patient  has  not  experienced  sufficient 
trouble  to  make  it  a  menace  to  her  life. 

Tubercular  Peritonitis. — This  paper  was  read  by  Dr. 
L.  H.  Dunning,  of  Indianapolis,  Ind.  In  the  domain 
of  surgery  there  is  no  more  attractive  study  than  tuber- 
cular peritonitis.  The  mode  of  invasion,  forms  of  the 
disease,  diagnosis  and  treatment  were  considered  in 
the  paper,  and  finally  a  brief  history  of  five  cases  was 
given. 

Tubercular  peritonitis  with  effusion  is  now  univer- 
sally considered  a  surgical  disease.  Even  in  the  acute 
suppurative  cases  abdominal  section  yields  a  sufficient 
number  of  successes  to  render  its  employment  impera- 
tive. Senn  excludes  all  forms  of  the  disease  from  sur- 
gical treatment  except  the  exudative  form.  Manclaire 
gives  as  the  chief  contra-indications  to  surgical  treat- 
ment the  generalization  of  the  lesion  and  the  existence 
of  profound  systemic  infection.  Linder  analyzes  the 
results  in  two  hundred  and  five  operations  with  a  mor- 
tality of  7.5  per  cent.  The  deaths  resulting  in  most 
of  these  cases  were  from  collapse.  In  cases  of  involve- 
ment of  the  tubes  and  ovaries,  they  should  be  extir- 
pated. His  experience  in  two  cases  leads  him  to  the 
belief  that  we  should,  if  possible,  avoid  using  silk  liga- 
tures in  tying  the  pedicle  when  it  is  necessary  to  re- 
move the  uterine  appendages. 

Case  I. — Mrs.  A.  B ,  aged  fifty-six.     Consulted 

the  author  concerning  the  extirpation  of  a  fibroid 
tumor  of  the  uterus.  She  had  passed  the  menopause 
five  years  previously,  but  the  tumor  had  gradually  in- 
creased in  size.  At  the  time  of  examination  it  had 
reached  the  umbilicus.  There  was  a  small  amount  of 
fluid  in  the  abdomen,  and  on  opening  it  probably  a 
quart  of  clear,  straw-colored  fluid  ran  out.  The  peri- 
toneum and  intestines  were  studded  with  innumerable 
small  grayish  deposits  of  the  size  of  a  millet  seed.  Sim- 
ilar deposits  thickly  studded  the  serous  covering  of  the 
tumor.  The  intestines  were  agglutinated,  but  were  not 
adherent  to  the  tumor.  After  removal  of  the  tumor  by 
supravaginal  hysterectomy  and  ventro-fixation  of  the 
stump  the  abdominal  cavity  was  irrigated,  and  then 
leaving  the  drainage-tube  just  behind  the  stump,  the 
abdominal  incision  was  closed.     Recovery. 

Case  II. — A  diagnosis  of  ovarian  tumor  had  been 
made,  and  examination  revealed  an  accumulation  of 
fluid  in  the  abdomen,  which  was  encysted.  The  uterus 
fixed,  and  an  immovable  mass  was  outlined  in  the  pel- 
vis upon  the  right  side,  which  the  author  believed  to 
be  a  small  ovarian  tumor  surrounded  by  inflammatory 
exudates.  An  exploratory  incision  was  made,  and 
three  gallons  of  dark  fluid  evacuated  from  the  abdom- 
inal cavity.  A  small  tumor  was  felt  in  the  pelvic  cav- 
ity. The  incision  was  enlarged,  the  tumor  enucleated, 
and  the  pedicle  tied  oft  together  with  the  Fallopian 
tube.  The  left  tube  and  ovary  were  likewise  extir- 
pated. On  exposing  the  abdominal  and  pelvic  cavi- 
ties to  view,  it  was  seen  that  the  viscera  were  thickly 
studded  with  small  grayish  deposits.  Microscopical 
examination  demonstrated  the  presence  of  tubercle 
bacilli.  Patient  now,  eleven  months  after  operation, 
in  good  health.  Two  of  the  five  cases  reported  by  the 
author  terminated  fatally. 

Dr.  GiLi.iA.M,  of  Ohio,  believes  that  where  we  have 
tuberculosis  of  the  ovaries  and  tubes,  it  is  better  to  re- 
move the  uterus  too. 

Dr.  J.  Frank,  of  Chicago,  asked  whether  any  of  the 
members  who  had  operated  for  tuberculosis  of  the 
peritoneum  had  noticed  a  recurrence,  or  how  long  the 
patient  was  immuned  from  further  attack. 

Dr.  Humiston,  of  Cleveland,  O.,  reported  two  cases 
upon  which  he  had  operated  successfully. 

Dr.  R.  S.  SfTTON,  of  Pittsburgh,  had  seen  a  good 
many  cases  of  tubercular  peritonitis,  upon   several   of 


which  he  had  operated  successfully.  Until  within  a 
year  he  had  been  in  the  habit  of  washing  out  the  cav- 
ity with  hot  water,  but  now  he  pays  no  attention  to  it, 
but  simply  opens  the  abdomen  and  cleans  out  every- 
thing. He  is  con\  inced  that  while  hot  water  does  no 
harm  it  does  no  good,  in  that  it  has  no  influence  upon 
the  disease.  He  believes  in  removing,  as  far  as  possi- 
ble, all  diseased  organs. 

Dr.  Henry  O.  Marcv,  of  Boston,  operated  in  1887 
for  the  first  time  on  a  case  of  tubercular  peritonitis,  the 
patient  making  an  easy  recovery.  He  had  operated 
several  times  since  then  for  this  disease  with  excellent 
results. 

Dr.  a.  H.  CoRDiER,  of  Kansas  City,  Mo.,  called  at- 
tention to  the  tact  that  Mr.  Wells,  as  early  as  1862,  op- 
erated for  tubercular  peritonitis,  simply  incising  the 
abdomen  and  draining,  thus  curing  his  cases.  He 
thinks  that  drainage  is  the  principal  thing  that  brings 
about  a  cure  in  this  disease,  but  how,  is  not  definitely 
settled.  He  said  the  theory  had  been  advanced  by  Dr. 
Morris,  of  New  York,  that  it  is  due  to  the  admission  of 
saprophytes  into  the  peritoneal  cavity. 

Dr.  Bavard  Holmes,  of  Chicago,  related  an  inter- 
esting case  of  adhesive  peritonitis  cured  by  operation. 

The  paper  was  further  discussed  by  Drs.  W.  S. 
Caldwell,  of  Freeport,  111 ,  Entriken,  of  Findlay, 
O.,  and  B.  M.  Ricketts,  of  Cincinnati,  O. 

Dr.  Dunning,  in  closing,  said  that  Linder's  obser- 
vations were  the  most  complete  of  any,  and  he  found 
very  little  tendency  to  recurrence  of  the  disease  where 
it  was  primary  and  of  the  adhesive  form  ;  but  where 
the  disease  was  secondary  and  of  the  adhesive  form, 
there  was  a  strong  tendency  to  recurrence.  His  own 
experience  had  not  been  sufficiently  extensive  to  fur- 
nish reliable  data  in  this  regard. 

Hysterectomy  for  Puerperal  Sepsis — When  shall  it 
be  Performed  ?— With  a  Report  of  Four  Cases.— The 
author  of  this  contribution  was  Dr.  Bayard  Holmes, 
of  Chicago.  The  paper  was  divided  into  four  parts. 
I.  A  report  of  four  cases  of  puerperal  sepsis  treated  by 
four  dift'erent  methods.  2.  The  pathology  of  puerpe- 
ral sepsis  in  various  stages.  3.  Curettement  in  the 
hands  of  its  advocates.  4.  Puerperal  sepsis  as  a  cause 
of  death  in  Chicago,  New  York,  Brooklyn,  and  in  the 
Charity  Hospital  at  Berlin,  with  an  abstract  of  79 
deaths  from  puerperal  sepsis  in  6,635  cases. 

Case  I. — A  multipara,  twenty-six  years  of  age,  of 
Irish  extraction,  having  a  history  of  tuberculosis  of  the 
lungs,  confined  under  unfavorable  circumstancec,  with 
retained  placenta,  post-partum  hemorrhage,  delivery 
without  an  anaesthetic  with  the  hand  of  the  physician, 
arrest  of  hemorrhage,  gradual  sepsis,  failure  of  curette- 
ment, and  death  seven  weeks  after  confinement. 

Case  II. — A  woman,  thirty  years  of  age,  normal 
confinement,  with  sepsis  appearing  upon  the  fourth 
day,  of  a  mild  character,  gradually  increasing  until  six 
weeks  after  delivery.  Temperature  was  high,  pulse 
rapid,  and  symptoms  of  peritonitis  with  obstruction  of 
the  bowels.  Laparotomy.  Removal  of  the  right  broad 
ligament,  tube,  and  ovary  ;  drainage  through  the 
vagina  ;  death  after  eight  days,  without  peritonitis,  from 
phlebitis  and  pulmonary  embolism. 

Case  III. — A  multipara  with  gonorrhoeal  history,  an 
abortion  followed  by  pelvic  inflammation,  peritonitis 
and  obstruction  three  weeks  after  delivery.  Removal 
of  both  tubes  and  abdominal  drainage  ;  death  after 
ten  days,  without  peritonitis,  through  phlebitis  and  pul- 
monary embolism. 

Case  IV. — A  multipara,  thirty-two  years  of  age,  de- 
livered by  a  midwife,  with  a  bad  history  of  puerperal 
infection,  rapid  onset  of  a  mild  infection,  no  curette- 
ment. Obstruction  of  the  bowels,  vomiting  six  weeks 
after  delivery  with  evidences  of  peritoneal  effusion. 
Laparotomy  ;  removal  of  the  uterus  and  its  adnexa,  ab- 
dominal drainage,  and  recovery.  This  uterus  and  these 
appendages  were  carefully  examined  microscopically. 
There  was  evidence  of  necrotic  endometritis,  suppura- 


September   28,  1895] 


MEDICAL    RECORD. 


455 


tive  endometritis,  suppurative  metritis,  suppurative 
lymphangitis  in  both  tubes  with  abscess  of  the  ovarian 
ligament  upon  the  right  side  and  adjacent  peritonitis. 
The  biood-vessels  throughout  the  broad  ligaments 
were  found  indicating  a  progressive  infective  thrombo- 
sis. The  utdrine  tissue  was  filled  with  pus  cells,  occu- 
pying the  perivascular  and  lymph  spaces  with  occa- 
sional obliteration  of  large  blood-vessels.  A  great 
number  of  mastzellen  were  found  throughout  the  in- 
fected tissues.  The  author  held  that  the  progress  of 
puerperal  infection  was  in  this  case  through  infective 
thrombosis  and  suppurative  lymphangitis,  and  that  the 
removal  of  both  tubes  and  drainage  would  have  been 
ineffectual.  He  then  proceeded  to  recount  the  patho- 
logical findings  in  cases  of  non-infected  puerperal 
women  dying  from  accidental  causes  during  the  first, 
third,  and  sixth  weeks  after  labor,  and  also  cases  dying 
at  somewhat  similar  times  after  labor,  stating  the  com- 
parison of  the  normal  and  abnormal  uterine  and  peri- 
uterine tissues. 

In  the  city  of  Chicago  during  the  years  1881  to  1894, 
inclusive,  there  were  2,127  deaths  from  pueperal 
fever.  In  New  York  during  six  years  ending  May  31. 
1880,  there  were  250,000  deaths,  of  which  number  one- 
sixth  were  females,  and  2,236  of  these  deaths  were  due 
to  the  puerperal  state.  Of  these  1,250  were  due  to 
puerperal  infection.  In  Brooklyn,  with  112,000  deaths 
during  the  same  period,  53,000  were  females,  and  of 
these  S67  died  of  the  puerperal  state,  462  dying  of 
puerperal  sepsis.  These  figures  show  the  importance 
of  the  subject. 

The  question  of  treating  puerperal  infection  b)'  evide- 
ment  or  curetting  was  discussed  by  presenting  the 
work  of  its  own  advocates,  showing  that  out  of  7,600 
cases  of  labor  in  the  hands  of  one  of  the  advocates  of 
curettement,  loi  were  treated  by  repeated  curettement 
and  irrigation.     Of  these  96  recovered  and  5  died. 

An  abstract  of  the  history  of  these  five  cases  was  pre- 
sented, showing  that  there  was  every  reason  to  believe 
that  after  curettement  had  failed  hysterectomy  would 
have  proved  efficient  in  saving  the  patients. 

A  series  of  6,635  cases  of  confinement  occurring  in 
the  Charity  Hospital,  in  Berlin,  under  the  care  of  Hen- 
soldt,  Schwarze,  Huenermann.  and  Hochselter  during 
tour  successive  years,  were  then  analyzed.  Seventy- 
nine  deaths  from  all  cases  occurred.  Of  these  deaths. 
33  resulted  from  puerperal  sepsis,  and  in  order  to  fully 
understand  the  possibility  of  these  cases,  a  short  epit- 
ome of  the  history  of  each  was  presented,  showing 
that  only  3  out  of  633  cases  were  of  such  a  character  as 
to  give  rise  to  the  suspicion  that  they  might  not  have 
been  saved  by  hysterectomy. 

The  author  gave  the  following  conclusions:  i. 
Puerperal  sepsis  has  its  origin  in  the  endometrium  and 
usually  travels  by  the  lymph-channels  or  by  the  throm- 
bosed blood-vessels  and  the  lymph-channels  together. 
2.  It  stiU  causes  almost  one-half  of  the  deaths  which 
occur  in  the  puerperal  state.  3.  Curetting  is  ineffectual  in 
many  cases  of  puerperal  sepsis.  4.  The  removal  of  an 
infected  broad  ligament  and  the  drainage  of  a  pelvic 
abscess  or  peritonitis  is  often  ineffectual.  5.  Hysterec- 
tomy should  be  performed,  therefore,  in  such  cases  of 
puerperal  infection  as  do  not  yield  to  uterine  curetting 
and  irrigation.  6.  Hysterectomy  should  be  done  when- 
ever peritonitis  is  present  in  the  course  of  puerperal 
fever.  7.  Hysterectomy  should  be  performed  in  cases 
of  puerperal  mania  where  there  is  a  history  of  endome- 
tritis without  uraemia.  S.  Hysterectomy  may  not  be 
helpful  in  the  course  of  diphtheritic  vaginitis  and  endo- 
metritis. 9.  Hysterectomy  may  not  be  helpful  in  cases 
of  rapid  early  infection.  10.  It  may  not  be  useful  in 
cases  of  septic  phlebitis  reaching  outside  the  pelvis. 

A  Method  of  Preventing  Thirst  Following  Celiotomy. 
— Dr.  William  H.Hu.MisTON  read  a  paperwith  this  title. 
He  said  no  one  who  has  had  any  experience  in  the  after 
care  of  abdominal  cases  will  deny  the  important  place 
that  thirst  occupies.    It  is  the  one  prominent,  annoying. 


and  distressing  symptom,  and  I  know  it  can  be  over- 
come.    This  is  my  method  of  procedure  : 

The  patient  should  have  the  usual  preparation  for 
celiotomy,  /.c".,  diet,  daily  b.iths.  cathartics,  etc.  For 
three  days  prior  to  operation  order  the  patient  to  drink 
one  pint  of  hot  water  an  hour  before  each  meal  and  on 
retiring,  thus  drinking  two  quarts  of  water  each  twenty- 
four  hours,  the  last  pint  to  be  taken  three  hours  before 
the  rime  set  for  operating.  Do  not  omit  to  give  the 
water  the  day  pre\'ious  to  the  operation,  while  the  pa- 
tient is  restricted  to  a  limited  amount  of  liquid  nourish- 
ment and  the  bowels  are  being  unloaded.  We  thus 
restore  to  the  system  the  large  loss  of  fluid  occa- 
sioned by  the  free  catharsis,  and  we  have  the  great 
satisfaction  of  seeing  our  patient  pass  through  the  try- 
ing ordeal  of  the  first  thirty  six  hours  after  the 
operation  in  comparative  comfort,  with  no  thirst, 
a  moist  tongue,  and  an  active  renal  function,  repre- 
sented by  an  excretion  of  from  twenty- eight  to  fifty 
fluid  ounces  of  urine  during  the  first  twenty-four  hours, 
catheterization  being  seldom  necessary.  This  is  in 
keeping  with  the  full  character  of  the  pulse  noted. 

The  above  detail  I  have  recently  carried  out  in 
twelve  cases.  To  eleven  chloroform  was  administered, 
to  one,  ether.  The  time  required  to  complete  the  oper- 
ation varied  from  ten  to  fifty-five  minutes.  Whether 
the  case  was  one  of  sclerotic  ovaries  or  a  pus  case  with 
universal  adhesion  of  all  the  pelvic  structures,  the  re- 
sult has  been  uniform  and  highly  satisfactory,  thirst  be- 
ing allayed  and  excretion  stimulated. 

I  believe  this  method  will  prove  to  be  efficient  in  the 
hands  of  abdominal  surgeons  generally,  and  I  publish 
it  early  with  all  confidence  that  the  twelve  cases  that  I 
have  had  will  soon  be  fortified  by  the  reports  of  man}- 
hundreds,  and  that  by  it  we  may  avoid  a  condition 
that  is  and  has  been  distressing  alike  to  the  patient, 
surgeon,  and  nurse. 

Celiotomy  in  General  Suppurative  Peritonitis,  with 

the  Report  of  a  Case This  paper  was  read  by  Dr. 

Miles  F.  Porter,  of  Fort  Wayne,  Ind.  The  author 
first  quoted  Grandin,  who  says  regarding  general 
puerperal  peritonitis  :  "  The  women  die,  no  matter 
what  the  form  of  treatment  employed."  Dr.  Baldy 
says  :  "  To  my  knowledge  there  has  never  been  re- 
ported an  undoubted  case  of  general  purulent  perito- 
nitis, from  any  cause  whatever,  in  which  an  abdominal 
section  or  any  other  line  of  treatment  has  succeeded  in 
saving  the  patient's  life."  That  the  mortality  of  gen- 
eral septic  peritonitis  is  large,  all  will  agree,  but  that  it 
is  always  fatal  is  certainly  not  true.  Dr.  Porter  then 
reported  the  case,  and  closed  by  saying  that  the  object 
in  writing  the  paper  was  to  assist  in  arousing  a  senti- 
ment against  the  too  prevalent  idea  that  in  general 
septic  peritonitis  death  is  ineWtable,  and  to  encourage 
in  these  cases  prompt  operative  interference. 

Peritoneal  Irrigation  and  Drainage  was  the  title  of  a 
paper  read  by  Dr.  .A.  H.  Cordier,  of  Kansas  City, 
Mo.,  in  which  he  said  that  the  latest  works  on  abdom- 
inal and  pelvic  surgery  contain,  like  the  older  text- 
books, very  short  and  misleading  articles  on  the  indi- 
cations for  peritoneal  irrigation  and  drainage,  and  still 
less  explicit  are  the  directions  how  to  use  these  agents 
for  good,  intelligently  and  correctly.  This  diversity  of 
opinion  among  authors  leaves  the  inexperienced  be- 
ginner in  a  position  of  perplexity  and  doubt  as  to  the 
special  course  he  is  to  pursue  in  his  early  work.  The 
same  principles  hold  good  in  draining  the  peritoneal 
cavity  that  are  applicable  to  other  parts  of  the  body. 
No  surgeon  with  all  the  antiseptic  precautions  possible 
to  be  used  in  opening  a  diffuse  abscess  of  the  thigh  or 
other  part  of  the  body  would  think  of  such  a  thing  as 
at  once  closing  a  wound  hermetically,  lea\-ing  many 
broken-down  shreds  of  diseased  tissue  dangling  in  the 
abscess  cavity.  He  might  have  irrigated  the  cavity 
thoroughly  with  a  i  to  1,000  solution,  yet  he  would  not 
feel  it  safe  to  close  the  wound  until  after  he  had  made 
counter-openings  and  introduced  a  drainage-tube,  this 


456 


MEDICAL    RECORD. 


[September  28.  10 


being  as  near  ideal  surgen"  as  it  is  possible  to  obtain  in 
these  cases.  Freshly  boiled  distilled  or  filtered  water, 
cooled  to  102°  to  110°  F.,  should  be  used  in  irri- 
gating. 

The  author  drew  the  following  deductions  :  i.  Drain- 
age is  a  life  saving  process  when  properly  used.  2.  To 
use  it  is  not  an  admission  on  the  part  of  the  surgeon 
that  his  work  during  the  operation  is  imperfect.  3.  The 
use  of  the  tube  alone  does  not  produce  or  leave  any 
condition  that  favors  the  development  of  hernia.  4. 
The  omentum  or  other  structures  do  not  become  en- 
tangled in  the  openings  in  the  tube.  5.  A  small-sized 
flint-glass  tube,  with  small  openings  and  open  end, 
should  always  be  selected  for  pelvic  drainage.  6.  The 
tube  does  not  produce  fecal  fistula.  7.  The  tube 
should  be  used  when  in  doubt  as  to  the  absence  or 
presence  of  drainage  indications.  8.  To  depend  upon 
microscopic  findings  as  to  whether  a  given  case  should 
or  should  not  be  drained  is  seemingly  scientific,  but  is 
neither  necessary  nor  practicable.  9.  Gauze  drains 
should  rarely  be  used  and  should  always  be  supple- 
mented by  a  glass  drain.  10.  There  is  no  danger  of 
infecting  the  patient  through  a  tube  if  the  attendant  is 
properly  instructed. 

Three  Cases  of  Hysterectomy  following  Celiotomy 
for  Pus-Tubes.  — Dr.  J.  Henry  C.\rstexs,  of  Detroit, 
summarized  his  remarks  as  follows  :  "  i.  It  seems  to 
me,  in  the  light  of  my  present  experience  in  cases  of 
bilateral  pus-tubes,  that  a  more  perfect  and  complete 
operation  can  be  performed  by  abdominal  section,  with 
less  danger  of  injury  to  the  bladder  and  intestines,  and 
with  smaller  mortality  and  better  ultimate  results.  2. 
That  in  certain  cases  a  better  immediate  result  is  ob- 
tained by  vaginal  hysterectomy  and  drainage,  but  these 
cases  frequently  require  a  second  operation  to  remove 
the  ovarian  tissue  and  parts  of  the  tube,  which  at  first 
in  many  cases  cannot  be  removed,  before  a  perfect  ul- 
timate cure  is  established.  3.  AVhere  the  sympathetic 
and  other  nerves  are  affected,  the  cause  is  not  in  the 
uterus,  ovaries,  or  tubes  alone,  but  part  in  each.  We 
are  unable  to  state  which  organ  is  at  the  bottom  of  the 
trouble.  Sometimes  it  may  be  only  one,  sometimes 
the  other,  sometimes  two  or  all  three  ;  hence,  in  such 
cases — I  would  say  in  many  cases — with  marked  ner- 
vous symptoms,  the  best  results  are  obtained  only  after 
the  complete  removal  of  every  particle  of  the  gener- 
ative organs — that  is,  uterus,  tubes,  and  ovaries,  be 
this  accomplished  at  one,  two,  or  three  operations,  per 
vagina  or  by  abdominal  section." 

Dr.  R.  S.  Sutton,  of  Pittsburgh,  favored  abdominal 
section  for  pus-tubes.  He  maintained,  first  and  fore- 
most, that  a  uterus  deprived  of  its  appendages  is  of  no 
use.  Second,  that  it  is  an  organ,  if  left,  which  is  liable 
to  tuberculosis,  gonorrhoea,  syphilis,  nasty  discharges, 
adhesions,  etc.  When  it  is  decided  to  remove  the  ap- 
pendages, the  uterus  also  should  be  taken  out. 

Dr.  Gilliam,  of  Columbus,  O.,  argued  against  the 
removal  of  the  uterus  with  the  appendages  in  order  to 
save  life,  the  objection  being  that  shortening  of  the 
vagina  resulted. 

Dr.  B.  M.  Ricketts,  of  Cincinnati,  believes  total 
e.Ktirpation  will  be  relegated.  The  dangers  are  cys- 
tocele,  hernia,  increased  danger  of  prolonging  the 
operation,  and  shortening  of  the  vagina. 

Dr.  Henry  O.  M.\rcy.  of  Boston,  favored  retaining 
the  cervix  when  it  is  healthy,  and  pointed  out  the 
reasons  why  it  should  not  be  removed.  It  helped 
materially  in  acting  as  a  support  to  the  vault  of  the 
vagina. 

Dr.  Holmes,  of  Chicago,  in  discussing  Dr.  Cordier's 
paper,  said  that  drainage  was  a  sort  of  vicarious  redemp- 
tion for  poor  surgery.  Whenever  it  is  impossible  to 
make  a  wound  clean  we  must  drain,  and  sometimes  we 
drain  when  the  wound  is  clean,  but  we  are  unable  to 
arrest  the  hemorrhage.  He  could  conceive  of  no  other 
indication  for  drainage,  whether  in  the  abdomen,  the 
brain,  or  any  other  part  of  the  body,  than  failure  to 


i 


meet  the  one  great  indication  of  wound  treatment — 
keep  the  wound  clean. 

Two  Successful  Operations  for  Traumatic  Insanity. 
Dr.  George  W.  Cale,  of  St.  Louis,  read  the  paper. 
He  said  that  insanity  due  to  injuries  of  the  head  is  of 
rather  infrequent  occurrence.  In  2,200  cases  of  in. 
sanity  treated  by  Kieman,  45  were  of  traumatic  origin  ; 
while  Hays  records  61  due  to  the  same  causes  out  of 
2,500  cases.  Schlager  reports  500  cases  of  insanity  due 
to  concussion  of  the  brain.  The  author  then  < 
sidered  the  causes  and  symptoms. 

Case  I. — .\  male,  twenty-six  years  of  age,  carpenter 
by  occupation.  Family  history  good  No  case  of  in- 
sanity or  of  serious  nervous  disease  had  ever  been 
present.  June,  1885,  the  patient  received  a  blow  from 
a  club  in  the  hands  of  a  negro,  the  wound  inflicted 
being  midway  between  the  fissure  of  Rolando  and  the 
external  occipital  protuberance,  slightly  to  the  left  of 
the  median  line.  It  was  treated  as  an  ordinan.'  sc.ilp 
wound,  as  it  suppurated  for  three  months.  Four  )c  '- 
after  the  inception  of  the  wound  he  complained  : 
severe  pain  in  the  left  parietal  and  occipital  regions  of 
the  head.  October,  18S8,  he  was  sent  to  an  insane 
asylum,  where  he  remained  sixteen  months.  His  con- 
dition improved,  he  returned  home,  but  was  again  sent 
back  to  the  asylum,  where  he  was  detained  five  months. 
Four  months  later  he  was  brought  to  Dr.  Cale,  who 
diagnosed  traumatic  insanity,  advised  ojjeration,  which 
was  consented  to.     Recovery. 

Case  II. — One  of  acute  mania  following  trauma. 
Operation  performed  the  same  as  in  Case  I.     Recovery. 

Dr.  William  Fuller,  of  Grand  Rapids,  Mich.,  had 
operated  on  two  cases  of  insanity,  due  to  traumatism, 
one  in  Montreal  in  1870.  The  patient  was  discharged 
from  an  insane  asylum  as  incurable.  When  the  dura, 
mater  was  opened  there  escaped  some  serum.  A  few 
days  subsequent  to  the  operation  the  patient  was 
rational,  but  as  soon  as  the  wound  closed  up  the  hallu- 
cinations returned.  He  then  punctured  the  brain  in 
two  or  three  diffeient  directions,  but  with  no  result  ex- 
cept to  establish  drainage.  The  man  died  two  months  ( 
later,  and  a  post-mortem  examination  revealed  a  tuber- 
cular abscess  in  the  fissure  of  Syhius,  containing  about 
two  teaspoon tuls  of  pus.  The  other  case  was  due  to 
syphilis,  and  was  relieved  by  the  removal  of  the  press- 
ure from  that  disease. 

Dr.  J.  Frank,  of  Chicago,  reported  an  interesting 
case  of  insanity  in  which  he  trephined,  removing  a 
large  piece  of  bone.  .\  piece  of  the  brain  was  also 
excised  for  e.xamination  and  seemed  to  be  healthy. 
The  patient,  after  being  in  an  insane  asylum  for  five 
years,  made  a  complete  recovery,  ani  took  up  the 
thread  of  life  where  she  left  it.  She  continued  in  thif 
way  for  one  year,  then  relapsed.  \Vhat  was  the  re.isor. 
of  her  recovery  ?  In  opening  the  dura  there  was  a 
gush  of  cerebral  fluid.  Dr.  Frank  firmly  believes  that 
it  is  not  the  depression  of  the  skull  which  produces  the 
bad  results,  but  that  at  the  dme  of  the  injury  there  is  a 
chronic  inflammation  of  the  meninges,  or  a  slow  inflam- 
matory process,  which  throws  out  cerebral  fluid.  Thi< 
fluid  may  be  in  the  ventricles  between  the  dura  and 
the  brain,  or  in  the  tissues  of  the  brain- filaments  them- 
selves, and  the  theory  of  concussion,  held  by  the  profes- 
sion, he  believes  is  erroneous.  He  had  repeatedly 
made  experiments  on  dogs  by  rapping  them  on  the 
head  and  rendering  them  insensible,  and  immediately 
thereafter  effusion  was  found. 

Dr.  F.  Ma  as,  of  Detroit,  thought  we  were  in  the 
dark  as  to  the  e.vact  cause  of  the  insanity  in  many  case^ 
and  that  there  was  evidently  some  vaso  motor  disturb- 
ance. He  read  a  paper,  which  was  largely  a  statistioA 
one,  in  which  he  pointed  out  the  comparative  value 
the  medical  and  surgical  treatment  of  a|ipendicitis. 

The  Use  of  Dry  Heat  of  High  Temperature  in 
Treatment  of  Joint  Diseases.— Ihis  paper  was  read  b; 
Dr.  William  E,  Wirt,  of  Cleveland,  O.     Shortly  afti 
readini;  a  description  of  this  treatment  in  the  medicare 


September  28,  1895] 


MEDICAL    RECORD. 


457 


journals,  the  essayist  encountered  a  case  of  rheumatoid 
:  anhritis  in  which  he  resorted  to  this  method.  The 
treatment  was  followed  by  great  improvement  in  the 
motion  of  the  joint  and  in  the  comfort  felt  by  the  pa- 
tient. He  also  reported  a  case  of  rheumatism  of  a 
year's  standing  in  which  there  was  more  or  less  fixation. 
He  broke  up  the  adhesions,  made  use  of  the  high  ap- 
plication of  heat,  and  raised  the  temperature  to  290°. 
which  was  followed  by  decided  improvement  in  the 
ease  with  which  the  patient  could  move  the  joint  and 
the  relief  of  pain. 

Ulcers  of  the  Leg ;  all  can  be  Ctired. — This  paper 
was  read  by  Dr.  Carter  S.  Cole,  of  New  York. 
The  constitutional  condition  of  pain  that  favors  morbid 
states,  or  that  retards  a  return  to  a  healthy  state,  creates 
a  diathesis  which  should  receive  its  proper  treatment, 
whether  or  not  ulcers  exist.  For  systematic  purposes 
ulcers  of  the  leg  were  designated  by  the  author  accord- 
ing to  their  appearance,  as  healthy,  irritable,  indolent, 
etc.  In  intractable  cases,  he  is  inclined  to  place  fore- 
most thorough  washing  with  soap  and  water  and  good 
scrubbing  with  a  stiff  bristle  hair-brush.  If  the  ulcer 
be  inflamed,  irritable,  or  painful,  anaesthesia  may  be  re- 
quired for  this  and  subsequent  steps.  The  next  step 
is  a  thorough  cleaning  out  of  all  soft  granulations  and 
1  the  base  of  the  ulcer  with  a  sharp  curette.  The  edges 
[  of  the  ulcer  are  freed  from  their  attachment,  and  in 
many  cases  with  a  curved  sharp  bistoury  he  knicks  the 
circumference  at  intervals  of  about  one-quarter  of  an 
inch.  If  much  hemorrhage  follows,  a  pad  of  gauze 
j  wrung  out  of  a  two  per  cent,  solution  of  carbolic  acid 
I  is  placed  over  the  wound  and  a  firm  compression 
bandage  from  the  toes  to  the  knee  applied,  the  wound 
having  previously  been  thoroughly  cleansed  with  the 
carbolic  solution.  The  dressing,  when  used,  is  allowed 
to  remain  for  twenty-four  or  forty-eight  hours,  after 
i  which  he  considers  the  ulcer  to  have  become  a  simple 
one  and  amenable  to  treatment  as  follows  :  No  further 
\  lotion  is  used.  The  wound  is  wiped  off  with  dry  cot- 
I  ton,  and  over  and  completely  covering  it  he  places 
strips  of  diachylon  plaster  to  protect  the  ulcer.  Over 
the  surgeon's  plaster  he  applies  a  pad  of  sterilized 
gauze,  held  in  place  by  strips  of  rubber  adhesive  plas- 
ter, or  often  simply  by  a  bandage.  He  then  uses  a 
firm  muslin  bandage  from  the  toes  to  the  knee,  making 
equable  compression.  Bandaging  should  be  carefully 
done.  Sometimes  he  uses  two  bandages  three  inches 
wide  and  eight  yards  long.  This  bandage  is  not  re- 
moved unless  the  discharge  comes  through,  or  the  leg 
becomes  painful,  or  the  bandage  gets  loose.  AVhen  he 
redresses  the  ulcer  he  again  uses  simply  dry  absorbent 
cotton  to  cleanse  the  wound  and  proceeds  as  before. 
Often  after  two  to  three  dressings  the  bandage  may 
remain  five  or  seven  days  without  being  disturbed.  In 
some  cases  a  thin  scum  forms  on  the  ulcer,  which  must 
be  removed  by  going  over  the  surface  lightly  with  a 
curette.  With  this  treatment,  in  ordinar)'  cases  about 
three  weeks  will  suffice  for  an  ulcer  of  even  a  dozen 
years'  standing.  In  extraordinary  cases,  as  much  as 
six  weeks  may  be  necessary. 

How  to  Diagnosticate  Sexual  Derangements  in  the 
Hale,  was  the  title  of  a  paper  by  Dr.  Eugene  Fuller, 
I,  of  New  York  City.     The  author  endeavors  to  impress 
^j  on  the  profession  the  fact  that  in  the  majoritj'  of  in- 
stances sexual  derangements  in  the  male  are  caused  by 
pathological  processes  in  or  about  the  seminal  vesicles, 
and  further,  that  they  accomplish  their  results  by  inter- 
fering with  the  mechanism  of  ejaculation.     He  calls  at- 
tention also  to  the  fact  that  this  side  of  the  question  has 
almost  wholly  been  neglected  by  preceding  writers  on 
'   sexual  disorders,  who  have  devoted  themselves  largely 
'   to  psychological  causes  in  this  connection,  the  result  be- 
j   ing  that  the  great  majority  of  the  profession  associate 
sexual  disturbances  with  some  radical  mental  defect. 
Sexual  derangements  in  the  male  should  be  diagnostic- 
ally  arranged  in  four  classes  :   i,  Those  dependent  on 
|i    seminal  vesiculitis  ;  2,  those  dependent  on  neuroses  ; 


3,  those  dependent  upon  primary  mental  disease  or  de- 
generation ;  4,  those  dependent  on  general  malnutrition 
and  debility.  The  order  of  this  classification  corre- 
sponds to  the  frequency  with  which  these  different  forms 
of  diseases  are  encountered  in  practice.  In  explanation 
of  the  first  class  of  causes  the  writer  states  that  it  is 
needless  to  go  into  detail,  since  he  has  recently  renewed 
that  subject  yery  fully  in  his  book  just  published. 

Where  seminal  vesiculitis  exists  there  is  generally  a 
previous  history  of  urethral  or  bladder  inflammation, 
sexual  abuse,  and  the  like,  all  of  which  are  agents  tend- 
ing to  produce  localized  inflammation  in  the  seminal 
vesicles.  The  second  class  of  causes  either  inhibit  or 
excite  the  sexual  centre  by  means  of  reflex  nenous  ac- 
tion. The  third  class  of  causes  includes  the  different 
forms  of  paranoia,  in  which  the  sexual  sense  exists  in  a 
perverted  form.  The  fourth  class  of  causes  is  a  small 
one.  It  includes  individuals,  generally  young  or  mid- 
dle aged,  who  make  complaint  that  they  are  capable  of 
little  sexual  exertion  and  that  feelings  of  prostration 
and  exhaustion  result  whenever  coitus  is  attempted. 

Dr.  Fuller  then  takes  up  the  clinical  examination. 
In  conclusion  the  writer  makes  some  special  remarks 
on  the  different  appearances  that  the  varying  grades  of 
seminal  vesiculitis  present  to  the  sense  of  touch,  and 
calls  attention  to  the  fact  that  in  cases  of  extensive 
perivesiculitis  involving  both  sacs  an  inexperienced 
examiner  is  liable  to  err  in  diagnosis,  mistaking  the 
condition  for  hypertrophy  or  inflammation  of  the  pros- 
tate. The  author  holds  that  to  become  perfected  in 
the  feel  of  the  seminal  vesicles  the  finger  needs  as  much 
practice  as  does  that  of  the  gynecologist  in  feeling  the 
ovaries  and  tubes.  To  obtain  the  necessary'  practice 
he  ad\ises  the  genito-urinary  surgeon  to  make  it  cus- 
tomary to  examine  in  this  manner  every  male  case  com- 
ing into  the  clinic  until  all  normal  and  pathological 
conditions  can  be  fully  appreciated. 

Chronic  Seminal  Vesictilitis  with  Hemorrhage. — Dr. 
S.  P.  CoLLiNGS,  of  Hot  Springs,  Ark.,  read  a  paper  on 
this  subject,  in  which  he  said  there  has  apparently  been 
little  known  of  the  pathological  conditions  of  the  semi- 
nal vesicles  until  within  recent  years.  The  usual  cause 
of  this  trouble  is  the  extension  of  gonorrhceal  inflamma- 
tion from  the  prostatic  urethra  through  the  ejaculatory 
duct  into  the  vesicle  itself  ;  at  least,  there  is  usually  a 
history  of  a  former  gonorrhoea  with  a  chronic  deep 
urethral  trouble  remaining.  The  vesicles  are  some- 
times involved  in  very  acute  and  severe  gonorrhceal  in- 
flammation with  or  without  the  implication  of  the  cord 
and  epididymis.  They  may  also  be  involved  with  a 
tubercular  inflammation,  although  practically  never 
primarily. 

One  observer  reports  a  case  in  which  the  autopsy 
showed  that  the  vesicle  was  primarily  involved.  The 
most  important  symptom  is  the  disturbance  of  the 
sexual  function.  The  character  and  appearance  of  the 
seminal  fluid  are  more  or  less  changed.  Its  consistency 
is  so  increased  at  times  that  it  is  gelatinous.  The  diag- 
nosis of  subacute  or  chronic  seminal  vesiculitis  would 
be  difficult  to  make  were  we  to  depend  entirely  upon 
symptoms  in  reaching  a  conclusion.  They  are  vague 
and  at  times  misleading,  except  the  appearance  of  the 
blood  in  the  semen,  which,  if  thoroughly  mixed  with  it, 
would  determine  a  diseased  condition  of  one  or  both 
vesicles  at  once.  The  author  reported  two  cases,  dis- 
cussed the  treatment  as  applied  to  them,  as  well  as  that 
generally  used  in  the  subacute  and  chronic  forms. 

In  conclusion,  he  said  that  if  inflammation  of  the 
vesicles  occurs  in  one  whose  urethra  is  strictured,  we 
must  cure  the  stricture  before  we  can  hope  for  perma- 
nent results  in  vesical  treatment. 

Syphilis  and  its  Treatment. — This  paper  was  contrib- 
uted by  Dr.  C.  T.  Drennen,  of  Hot  Springs,  Ark. 
The  author  spoke  more  directly  of  the  treatment  of 
this  disease  in  connection  with  the  use  and  abuse  of 
certain  so-called  antisyphilitic  remedies.  He  said  we 
are  unable  as  vet  to  form  definite  conclusions  as  to  the 


458 


MEDICAL    RECORD. 


[September  28,  189; 


usefulness  of  sero-therapy  in  the  treatment  of  syphilis 
from  the  most  recent  researches.  But  the  reports  are 
quite  encouraging,  and  there  is  hardly  adoubt  but  that 
it  possesses  value  in  at  least  the  tertiary  lesions.  Four- 
nier  believes  the  good  effect  to  be  due  not  to  any  spe- 
cific, but  to  its  rehabilitory  effect  upon  the  system. 
The  author  said,  in  closing,  that  the  hot  water  at  Hot 
Springs  was  well  known  to  exert  an  influence  peculiar 
ia  its  effect  for  good,  and  in  it  we  had  a  veritable  Mecca 
for  syphilis.  That  its  action  iseliminative,  stimulative, 
and  antiseptic,  and  that  larger  doses  of  mercury  and 
llie  iodide  of  potassium  can  be  given  without  harm  is 
known  to  the  writer  based  upon  experience  and  obser- 
\ation  ;  that  its  exact  or  specific  action  is  unknown, 
and  that  its  value  is  attested  to  by  the  multiplied  thou- 
sands throughout  the  country,  are  propositions  that  are 
uncontrovertible. 

Dr.  William  T.  Belfield,  of  Chicago,  described 
and  presented  an  instrument  for  the  purpose  of  secur- 
ing asepsis  in  bladder  and  prostate  operations. 
■  The  Element  of  Vascular  Compresson  in  Fracture 
Treatment. — This  paper  was  read  by  Dr.  Thom.a.s  H. 
Manlev,  of  New  York  City.  The  author  considered 
at  length  the  anatomical  structure  and  vascular  func- 
tion as  related  to  fracture.  The  extent  of  damage 
borne  by  the  vessels  in  a  given  case  of  fracture  will 
primarily  depend  upon  the  degree  and  quality  of  force 
applied  and  the  line  of  tieatment  adopted.  In  a  series 
of  experiments  made  during  the  past  year  on  the  blood 
and  blood-vessels,  under  a  multiplicity  of  conditions  in 
the  lower  animals  under  anesthetics,  one  question 
which  the  author  spared  no  pains  to  definitely  deter- 
mine was  whether  in  fracture,  as  a  general  rule,  the  cir- 
culation to  the  distal  part  of  the  limb  was  retarded  in 
cases  of  fracture.  Without  entering  into  detail  on  the 
great  diversity  of  vascular  phenomena  observed  in  a 
frog's  webbing  under  the  microscope  after  single,  mul- 
tiple, and  compound  fractures  were  produced,  it  will 
suffice  to  say  that  with  few  exceptions,  immediately  and 
for  a  considerable  period  of  time  after  the  bone  was 
broken,  the  circulation  in  the  capillaries  and  the  smaller 
arteries  was  completely  arrested.  In  several  it  was 
found  that  for  several  days  all  the  smaller  vessels  were 
motionless,  and  in  a  few  they  so  remained  until  the 
fractured  ends  of  the  bones  united.  These  experi- 
ments were  extended  to  the  mammalia — the  shafts  of 
tl;e  limbs  of  pups,  kittens,  and  adult  dogs,  of  different 
ages  and  of  various  sizes. 

The  Significance  of  Fissure  Fractures  of  the  Articu- 
lar Ends  of  the  Long  Bones  was  the  title  of  a  paper 
read  by  Dr.  H.  O.  Pantzer,  of  Indianapolis,  Ind. 
He  reported  a  case  of  fissure  fracture  involving  the 
outer  third  of  the  head  of  the  radius,  haying  loose  at- 
tachments to  its  body.  An  excessive  callus  had  like- 
wise developed  in  its  site,  without  affecting  union. 
This  splinter  and  callus  were  removed,  when  reposi- 
tion of  the  joint  was  easily  attained.  The  crepitus  felt 
at  the  first  examination,  and  the  failure  to  find  it  again, 
should  have  suggested  fissure  fraction  in  the  opinion 
of  the  author.  When  the  first  dressing  was  removed, 
the  limb  seemed  to  present  a  perfect  condition,  and  to 
promise  full  restoration.  These  prospects  were  clianged 
as  soon  as  passive  and  active  mobilization  was  begun. 
The  probability  is  thai  the  attempts  at  mobilization 
for  this  kind  of  injury  were  made  too  soon,  and 
that  they  were  at  least  partially  responsible  for  the 
subseciuent  unfavorable  developments.  The  author 
concludes  that  when  undue  painfulness  and  subse- 
quent swelling  with  no  gain,  or  even  a  loss  of  mo- 
bility, attends  the  efforts  of  mobilization  after  kindred 
lesions,  we  should  delay  further  efforts  at  mobiliza- 
tion. The  possibility  of  a  fissure  fracture  should  be 
considered  in  determining  the  diagnosis  and  treatment 
of  all  cases  of  joint  injur\-. 

Imbrication  or  Lap-joint  Method — A  Plastic  Opera- 
tion for  Hernia.— Dr.  E.  W.  Andrews,  of  Chicago, 
contributed  a  paper  on  this  subject.     The  principle  of 


imbrication  or  overlapping  the  several  aponeurotic 
layers  of  the  abdominal  wall  may  enter  into  other  ab- 
dominal operations  to  advantage,  as  he  had  repeatedly 
shown.  The  present  paper  referred  only  to  its  use  in 
inguinal  hernia.  Here  he  makes  use  of  it  to  supple- 
ment and  reinforce  existing  methods  without  losing 
sight  of  their  good  qualities.  \Vhile  based  upon  the 
best  modern  open  method,  and  while  confessedly  ar 
outgrowth  experience  with  the  Macewen,  Bassini,  Hai- 
sted,  and  similar  operations,  yet  the  carr>'ing  out  of 
the  imbrication  idea  so  far  changes  the  technique  as  to 
make  it  as  different  from  them  all  as  they  are  from 
each  other,  and  perhaps  entitle  it  to  the  term,  "  a  new 
operation."  It  was  impossible,  said  the  author,  to  de- 
scribe this  operation  without  going  into  details  con- 
cerning those  which  had  preceded  it,  which  he  did. 

The  interlocking  or  overlapping  principle  of  uniting 
the  musculo-aponeurotic  layers  of  the  abdomen  is  in 
reality  an  outgrowth  of  the  author's  clinical  experience 
rather  than  of  theory.  He  adopted  it  at  first  as  an  ex- 
pedient in  cases  where  the  Bassini  operation  seemed 
difficult  and  needed  supplementing,  but  of  late  the 
value  of  the  principle  had  seemed  to  him  more  and 
more  evident,  and  he  had  used  it  in  all  his  cases.  The 
author  concluded  as  follows  :  i.  Any  successful  method 
of  radical  cure  must  be  a  true  plastic  operation  upor 
the  musculo-aponeurotic  layers  of  the  abdominal  wall 
Cicatricial  tissue  and  peritoneal  exudates  are  of  no  per- 
manent value.  2.  A  large  strong  flap,  of  any  needei 
size,  to  fill  the  internal  ling.  3.  Triplicate  layers  j; 
aponeuroses.  4.  Interlocking  of  layers  giving  brciaa 
surfaces  of  union.  5.  Shortening  of  anterior  as  wc.; 
as  posterior  wall  of  canal,  making  them  mutually  sup- 
porting, and  relieving  tension  on  deep  sutures.  6 
Cord  amply  protected. 

Further  Observations  on  the  Radical  Cure  of  Rupture 
by  the  Intrapelvic  Method,  with  Illustrative  Cases. — 
This  paper  was  read  by  Dr.  Charles  A.  L.  Reed,  01 
Cincinnati.  In  what  essential  particulars  does  this 
intra-pelvic  method  differ  from  the  several  methods  of 
radical  operation  now  in  vogue  ?  It  differs,  in  the  fir~: 
instance,  in  the  fact  that  it  is  intra-pelvic,  while  *.'  ;■ 
others  —  Bassini's,  Halsted's,  McBurney's,  Macewer.  s 
— are  extra-pelvic. 

The  essential  point  of  difference  between  Dr.  Reed  s 
operation  and  that  of  Bassini  consists  in  :  i.  Lea\i'  .; 
undisturbed  the  extremely  tense  fascia  composing  ::.  ■ 
anterior  wall  of  the  ring.  2.  In  leaving  the  cord  ir.  1 
the  position  which  nature  designed  for  it,  and  entirely  | 
protected  by  the  normal  fascia.  3.  In  closing  the  in- 
ternal ring  on  the  inside  of  the  pelvis,  and  in  protect- 
ing it  by  a  strong  peritoneal  pad.  4.  In  avoiding  the 
menace  to  virility  arising  from  a  transplantation  of  the 
cord,  its  possible  constriction  by  an  artificial  ring  of 
tense  fascia,  and  its  necessary  investment  by  an  inflam- 
matory exudate.  5.  In  increasing  the  resistance  of 
the  parts  by  fortifying  the  fascia  comprising  the  ante- 
rior wall  of  the  ring,  and  by  increasing  and  making 
permanent  the  obliquity  of  the  cord  within  its  normal 
canal. 

The  advantages  of  the  operation  consist  in  securing, 
by  the  unfolding  of  the  redundant  but  attenuated  me- 
dian fascia,  the  formation  of  a  column  which,  when  " 
consolidated  by  inllammatory  adhesions,  has  a  certain  ' 
retentive  and  supportive  power,  the  influence  of  which 
is  of  value  in  preventing  recurrence.  The  anchorage 
of  the  recti  in  the  median  line  destroys  the  retentive 
power  of  the  wall. 

Surgical  Treatment  of  Hemorrhoids. — Dr.  Henrv 
O.  M.\RCV,  of  Boston,  followed  with  a  paper  which  was 
in  the  nature  of  a  reply  to  the  strictures  cast  tipon  the 
Whitehead  operation  by  Dr.  Edmund  Andrews,  of  Chi- 
cago, in  a  paper  read  before  the  last  meeting  of  the 
Illinois  State  Medical  Society.  Dr.  Marcy  believes 
that  if,  in  the  statistics  given  by  Dr.  Andrews,  the 
names  of  the  operators  were  mentioned,  most  of  the- 
disastrous  results  would  be  found  to  have  followed  the 


September  28,  1895] 


MEDICAL    RECORD. 


459 


work  of  incompetent  men.  His  results  have  been  ex- 
cellent in  those  cases  in  which  he  has  done  the  White- 
head operation,  slightly  modified  by  himself. 

Club-foot. — Dr.  John  Ridlox,  of  Chicago,  read  a 
paper  on  club-foot,  which  he  defined  as  a  distortion  of 
the  foot  in  its  relation  to  the  leg.  The  simple  and 
compound  varieties  of  club-foot  were  dealt  with.  Nearly 
all  of  the  congenital  cases  present  the  compound  vari- 
ety— equino-varus  ;  a  few  present  equino-valgus  ;  rarely 
there  is  seen  a  simple  calcaneus.  Of  simple  equinus 
the  author  had  met  with  but  a  single  instance,  and  of 
simple  varus  and  simple  valgus  he  had  seen  none.  Of 
the  acquired  variety,  simple  equinus  is  by  far  the  more 
frequently  found  ;  next  in  frequency  we  find  simple 
valgus  ;  then  equino-varus,  calcaneo-valgus,  equino- 
valgus,  simple  varus,  and  varus  in  one  foot,  and  valgus 
in  the  other.  The  acquired  deformity  occurs  more 
than  three  times  as  frequently  as  the  congenital  form. 
The  etiology  of  the  congenital  forms  was  next  dealt 
with,  as  well  as  of  the  acquired  forms.  Then  followed 
the  symptoms,  diagnosis  and  prognosis. 

The  treatment  of  club-foot  is  mechanical  or  opera- 
tive, or  both  mechanical  and  operative.  Both  these 
measures  were  dealt  with  at  length. 

Vaginal  Castration. — This  paper  was  read  by  Dr. 
E.  E.  TuLL,  of  New  \'ork.  The  author  claimed  for 
this  method  a  lower  mortality,  a  shorter  convalescence, 
and  a  wider  adaptability,  as  it  may  be  practised  in  cases 
too  weak  for  abdominal  section. 

A  New  Phase  of  Celiotomy. — Dr.  F.  G.  Groner,  of 
Grand  Rapids,  Mich.,  related  a  suit  for  malpractice 
which  had  just  been  terminated  in  Grand  Rapids.  The 
suit  was  commenced  against  a  doctor  some  time  ago, 
and  was  for  |!5o,ooo.  The  defendant  died,  but  the 
court  held  that  the  cause  of  action  survived,  and  that 
the  suit  could  be  brought  against  the  estate.  The  jury 
returned  a  verdict  for  iS;io,ooo.  The  author  claimed  . 
that  he  knew  there  was  no  malpractice,  because  he  was 
interested  in  the  case  and  knew  just  what  was  done  in 
the  operation.  He  found  fault  with  the  laws  which 
permitted  a  suit  against  the  doctor  to  survive  his  death 
and  be  a  menace  to  the  widow  and  children.  The 
speaker  thought  that  the  next  T,egislature  should  rem- 
edy the  law.  He  had  the  draft  of  a  bill  prepared  which 
he  ihought  would  remedy  the  present  law,  and  which 
lie  read. 

The  Results  of  Five  Years'  Experience  with  Intra-ab- 
dominal Shortening  of  the  Round  Ligaments. — This 
paper  was  contributed  by  Dr.  J.  Frank,  of  Chicago. 
Since  his  last  publication,  November,  1889,  he  had  had 
the  opportunity  of  performing  this  operation  seventeen 
times,  with  only  one  failure,  and  without  any  deaths. 
All  of  the  seventeen  cases  operated  upon  were  for  re- 
troversion, prolapsus,  and  retroversion  with  prolapsus 
of  the  uterus. 

Technique  of  the  Operation. — The  median  incision  is 
made  a  trifle  lower  than  for  ordinary  celiotomy.  The 
round  ligament  is  caught  up  anteriorly  with  a  sharp  or 
blunt  hook,  and  is  then  held  taut  by  an  assistant.  A 
small,  full-curved  needle  threaded  with  iine  silk  is  then 
passed  through  the  loop  of  the  round  ligament,  and  is 
brought  back  in  the  reverse  manner  through  the  other 
half  of  the  loop.  No  portion  of  the  broad  ligament  is 
included  in  any  of  the  sutures.  Too  much  stress  can- 
not be  placed  upon  this  particular  procedure  of  passing 
the  needle  through  a  part  of  the  cord,  and  not  around 
it,  for  in  passing  the  needle  around  the  cord  there  is 
danger  of  strangulation,  as  the  blood  and  nerve  supply 
would  be  entirel}'  shut  off  by  this  faulty  method  of 
placing  the  sutures  around  the  ligament. 

About  fifty  per  cent,  of  the  cases  have  been  under 
the  observation  of  the  author  since  the  time  of  opera- 
tion, which  in  some  instances  has  been  as  long  as  two 
years,  and  in  all  of  these  the  uterus  retains  its  corrected 
position.  This  operation  should  be  performed  in  pref- 
erence to  any  other  in  all  cases  where  the  uterus  is  pro- 
lapsed, or  immediately  falls  back  upon  replacing  it  with 


a  uterine  sound,  and  where  pessaries  and  tampons  afford 
no  relief,  clearly  showing  that  there  must  be  some  force 
which  does  not  permit  the  uterus  to  remain  in  its  nor- 
mal position. 

Address  on  Surgery. — Dr.  Theodore  A.  McGraw, 
of  Detroit,  selected  for  his  subject  "  The  Present  State 
of  Our  Knowledge  of  Cancers  and  Tumors."  He  said 
that  if  we  compare  the  ideas  that  prevailed  relative  to 
these  diseases  thirty  years  ago  with  those  the  profession 
hold  to-day,  we  would  find  a  change  which  marks 
rather  by  a  clearer  \iew  of  the  nature  of  the  problem 
than  any  actual  gain  in  its  solution.  Before  Virchow 
■  the  subject  of  tumors  and  cancers  was  wrapped  in  the 
greatest  confusion.  Tumors  were  divided  and  classi- 
fied in  that  era  according  to  their  clinical  histories. 
They  were  divided  into  the  innocent,  which  were  looked 
upon  as  purely  local,  and  the  malignant,  which  were  re- 
garded as  due  to  dyscrasi^,  the  seat  of  which  is  in  the 
blood.  Under  the  influence  of  the  new  cellular  pathol- 
ogy the  faith  in  so-called  dyscrasix  was  abandoned 
and  supplanted  by  a  new  doctrine,  which  taught  that 
tumors  and  cancers  resulted  ever  and  always  from  al)- 
errations  in  cellular  nutrition,  development,  and  growth. 
It  maybe  said  that  during  this  time  the  energies  of  the 
profession,  as  far  as  tumors  are  concerned,  have  been 
confined  almost  solely  to  this  channel.  The  most  suc- 
cessful attempt  to  account  for  the  origin  of  tumors  and 
cancers  was  that  of  Cohnheim. 

The  arguments  offered  in  defence  of  the  parasitic 
theory  of  cancer  are,  i,  the  microscopic  evidences  ;  2. 
the  frequent  occurrence  of  auto-inoculation,  and  the 
evidently  infectious  course  of  the  disease  in  the  organ- 
ism ;  3,  the  endemic  occurrence  of  cancer  in  certain  lo- 
calities, and  in  rare  instances  in  the  same  houses  ;  4, 
an  occasional  success  in  inoculating  the  disease  in  ani- 
mals. The  arguments  against  it  are  the  many  instances 
of  hereditary  tendency  ;  the  general  failure  of  experi- 
ments of  inoculation,  and  the  fact  that  metastases  occur, 
not  through  the  transfer  from  one  point  to  another  of  par- 
asitic germs  as  is  usual  in  parasitic  diseases,  but  by  the 
transmigration  of  cells  bearing  the  same  characters  as 
the  cells  of  the  original  tumor,  and  the  subsequent  pro- 
liferation of  the  migrating  cells  ;  the  fact  that  not  only 
cancers,  but  tumors  of  all  kinds,  have  a  more  or  less 
tendency  to  produce  metastases  ;  the  tendency  exhib- 
ited by  embryonic  remains  and  hystcid  tumors  to  de- 
velop into  malignant  disease. 

Dr.  McGraw  closed  by  saying  that  physicians  should 
be  better  instructed  in  the  means  of  diagnosis,  and  in 
the  necessity  of  early  operative  treatment.  And  last, 
but  not  least,  the  laity  could  be  induced  to  assist,  not 
only  by  liberal  contributions  of  means,  but  by  that 
intelligent  cooperation  which  would  lessen  our  diffi- 
culty in  collecting  evidence  and  making  post-mortems 
and  keeping  the  sufferers  out  of  the  hands  of  the 
quacks. 

The  Paranoiac — A  Menace  to  Society. — This  paper 
was  read  by  Dr.  C.  B.  Burr,  of  Flint,  Mich.  He  made 
brief  and  pointed  reference  to  the  numerous  recent 
murders  of  prominent  persons  by  so-called  "  cranks.'' 
What  to  do  with  these  persons  is  one  of  the  problems 
confronting  our  modern  civilization,  and  is  one  de- 
manding an  answer  from  students  of  the  subject.  We 
have  room  enough  in  our  asylums.  The  trouble  is  that 
harmless  lunatics  are  kept  in  confinement,  while  dan- 
gerous paranoiacs  are  allowed  their  liberty  These  mur- 
ders disturb  the  public  but  a  day  and  do  not  scare  us  into 
further  provision  for  a  safeguard.  The  public  do  not 
sincerely  seek  advice  from  profession  il  sources  in  the 
matter.  No  one  who  has  been  threatened  by  a  para- 
noiac would  be  willing  to  have  his  commitment  settled 
by  a  jury  without  medical  testimony  as  to  the  danger 
involved  in  granting  freedom  to  such  an  individual. 
The  paranoiac  is  a  menace  to  society,  and  should  be 
sequestrated.  But  doubtless  the  public  will  continue  to 
view  with  indifference  or  approval,  now  and  then,  the 
execution   of   a    criminally   insane    person    as    "  sane 


46c 


MEDICAL    RECORD. 


[September  28,  1895 


enough  to  hang,"  and  vainly  hope  for  a  deterrent  effect 
of  this  example  upon  other  deluded  minds. 

Dr.  I.  N.  Love,  of  St.  Louis,  remarked  that  doubt- 
less all  of  us  would  hesitate  to  offer  criticism  on  so 
valuable  and  thorough  a  paper  from  such  an  authority 
as  Dr.  Burr.  He  then  related  a  case  in  St.  Louis, 
where  a  man  had  murdered  his  wife  and  child,  having 
become  a  paranoiac  through  excesses  and  debauchery. 
The  entire  profession  of  St.  Louis  agreed  that  it  was 
the  deed  of  a  paranoiac,  yet  a  country  jury  declared  he 
was  sane  enough  to  hang.  He  emphasized  the  fact 
that  often  these  persons  are  stimulated  to  crime  by  the 
notoriety  the  newspapers  give  them,  and  consequently 
the  papers  should  be  encouraged  to  suppress  any  such 
items. 

Dr.  Hugh  T.  P.\trick,  of  Chicago,  called  attention 
to  the  fact  that  the  fixed  illusions  began  as  early  in  life 
as  five  or  eight  years,  and  then  in  such  cases  measures 
of  restraint  should  be  instituted.  These  illusions  are 
not  always  discovered,  even  by  the  family  physician. 

Toxicity  in  Hysteria,  Epilepsy,  and  Neurasthenia, 
was  the  title  of  a  paper  by  Dr.  .\.  E.  Sterne,  of  In- 
dianapolis. This  is  one  of  the  most  frequent  and  im- 
portant etiological  factors  in  these  diseases,  and  one 
which  has  received  the  least  attention.  The  term  tox- 
icity should  mean  functional  cellular  perversion,  caus- 
ing or  being  caused  by  abnormal  chemical  reactions. 
The  ordinary  forms  of  hysteria  are  functional.  There 
are,  however,  no  pathologic  alterations  in  the  central 
nervous  system  itself.  We  have  in  many  cases  a  con- 
dition of  cellular  intoxication.  It  is  not  necessary  that 
there  be  any  structural  change.  Many  drugs  produce 
a  condition  similar  to  hysteria  ;  shock  or  injury  does 
the  same  thing.  In  almost  every  case  there  will  be 
some  form  of  cellular  malnutrition,  and  by  not  seeking 
after  this  possibly  the  physician  misses  the  cause  and 
cure  of  his  case.  The  female  generative  organs  have, 
no  doubt,  been  too  often  blamed  as  an  etiological  fac- 
tor in  hysteria.  When  actual  disease  exists  in  these 
organs  it  should  be  properly  attended  to,  but  the 
organs  are  not  to  be  blamed  any  more  frequently  than 
other  organs.  Again,  some  of  the  worst  cases  of  hys- 
teria occur  in  males.  Epilepsy,  like  hysteria,  is  a 
diathesis,  but  of  a  more  profound  nature,  but  in  epi- 
lepsy we  find  true  pathological  changes  which  are  usu- 
ally of  a  vascular  nature,  in  the  walls  of  the  vessels, 
produced  by  some  toxic  agent,  acting  at  the  same  time 
on  the  ganglionic  cells  of  the  cortex.  The  attacks  of 
epilepsy  may  resemble  severe  hysteria,  but  there  is  a 
fundamental  difference.  The  attacks  of  the  latter  are 
never  dangerous,  while  the  former  may  frequently  be  so. 
Neurasthenia  is  not  often  complicated  by  either  epi- 
lepsy or  hysteria.  There  are  three  grades  of  neuras- 
thenia— weakness,  prostration,  and  exhaustion.  Sex- 
ual neurasthenia  is  essentially  a  masculine  affection, 
though  not  always  or  necessarily  resulting  from  a  vi- 
cious life.  In  the  treatment  of  all  these  cases  the  toxic 
element  should  always  be  kept  in  mind.  In  certain 
cases  surgical  interference  is  demanded.  Change  of 
scene  and  environment  are  the  best  treatment  for  hys- 
teria and  neurasthenia.  Divert  the  energies  into  other 
channels  ;  conserve  the  remaining  vital  forces,  and  add 
suggestive  therapy  as  much  as  possible,  but  do  not  hyp- 
notize. The  wakeful  state  is  much  better  for  suggestion. 
Electricity  and  the  "  rest  cure  "  play  an  important  part 
in  the  treatment  of  all  these  conditions.  But  always 
conserve  every  atom  of  nerve-force  in  ever)'  case. 

Dr.  Blech,  of  Detroit,  reported  two  cases  in  which 
he  considered  there  was  toxicity  of  cellular  function. 

Dr.  Dougherty,  of  .South  Bend,  Ind.,  said  it  should 
be  remembered  that  these  cases  do  not  all  come  as  re- 
flexes of  the  generative  organs.  It  has  become  almost 
a  habit  for  surgeons  and  physicians  to  think  so. 

Dr.  C.  B.  P.arker,  of  Cleveland,  said  that  more  care 
m  diagnosis  and  a  deeper  investigation  into  the  etiology 
of  these  cases  might  materially  assist  us  in  the  way  of 
results  in  treatment. 


Dr.  Hugh  T.  P.\trick,  of  Chicago,  held  that  trau- 
matic cases  must  be  excluded  from  this  consideration. 
They  come  under  another  class,  such  as  adhesions,  etc. 
He  is  quite  sure  that  very  many  of  these  cases  are  due 
to  a  direct  toxaemia.  Indeed,  all  conditions  which  may 
cause  any  functional  derangement  are  in  a  measure 
toxic. 

Dr.  Sterne,  in  closing,  said  he  was  convinced  that 
the  knife  was  being  used  too  much  in  these  cases.  If 
we  can  be  sure  of  the  lesion,  then  certainly  operate,  if 
it  is  advisable.  Relative  to  the  thyroid  enlargement, 
he  is  satisfied  that  there  are  very  many  cases  of  it  in 
hysteria,  particularly  if  the  patient  be  a  young  lady. 

Some  of  the  More  Recent  Methods  of  Staining  Nerve- 
Tissue. — This  paper  was  read  by  Dr.  Hugh  T.  Pat- 
rick, of  Chicago.  It  was  elegantly  illustrated  with 
water- color  drawings  of  each  of  the  stains  used  in  nerve- 
tissue,  and  a  most  thorough  and  practical  resume  ol  the 
subject,  with  its  application  and  technique,  was  given. 
He  considered  the  method  of  Nissl  to  be  the  method 
par  excellence  for  nerve-cells.  With  it  minute  changes 
in  the  cell-structure  could  be  detected  which  would 
elude  any  other  method.  The  method  of  Bevan  Lewis, 
while  marking  an  advance  in  technique,  was  thought  to 
be  less  perfect  than  claimed  for  it  by  the  originator. 
It  is,  however,  excellent  for  hypertrophied  neuroglia 
cells.  The  beautiful  results  obtained  by  the  Golgi 
method,  as  modified  by  Ramon  y  Cajal,  were  illustrated, 
and  the  importance  of  the  discoveries  due  to  it  were 
emphasized.  Rosin's  stain,  which  is  practically  the 
Ehrlich-Biondi  blood-stain,  gives  in  some  cases  almost 
ideal  results.  The  method  of  Platner — chloride  of 
iron  and  diniero-resorcin — was  illustrated  as  applied 
to  normal  and  degenerated  nerve-fibres,  and  the  doctor 
thought  the  method  was  to  have  an  important  future. 
The  method  of  Marchi  was  said  to  excel  any  other  for 
degeneration  of  from  three  weeks  to  three  months 
duration.  Allusion  was  also  made  to  the  develop- 
mental method  of  Flechsig,  and  to  an  unusual  but 
valuable  result  of  the  Weigert-Pal  stain  and  illustrated 
drawings  shown. 

Dr.  Sterne  said  that  the  carmine  stain  has  a  par- 
ticular adaptability  for  double  staining.  In  bringing 
out  the  anatomical  details  it  is  practically  a  necessit) , 
The  Nissl  stain  is  the  most  exact,  and  for  giving  an 
idea  of  the  ganglionic  structure  cannot  be  excelled. 
For  all  purposes  the  Marchi  method  is  perhaps  the 
most  reliable. 

Dr.  Patrick  said  he  had  simply  pointed  out  the 
advantages  of  each  method.  We  want  for  each  case 
that  which  will  give  us  the  best  results. 

Psycholog:y  in  Medicine,  by  Dr.  A.  P.  Buchman,  of 
Fort  Wayne,  Ind.  The  author  discussed  the  subjective 
and  objective  relations  of  mind  and  pathological  condi- 
tions. The  unit  force  acting  properly  is  health  ;  ab- 
normal action  of  this  unit  is  disease.  The  structure  of 
man  is  governed  by  a  connected  train  of  associated  move- 
ments called  ether,  the  existence  of  which  we  can  have 
no  anatomical  proof ;  but  to  which  the  growth  of  the 
body  must  bear  definite  relation.  Fear,  grief,  anger, 
or  joy  modify  the  functions  of  the  vital  centres.  The 
sympathetic  nervous  system  is  the  centre  of  the  emo- 
tions, and  the  cerebro-spinal  system  that  of  abstraction. 
Thus  we  come  to  psycho-physiology  and  bio-chemistry. 
Thence  we  step  to  the  subject  of  hypnotism.  The 
different  methods  used  in  producing  hypnotism  were 
minutely  described  ;  then  the  possible  uses  and  dan- 
gers of  hypnotism  in  medicine  were  discussed,  showing 
that,  while  good  might  be  done,  there  was  also  much 
danger  in  its  use. 

Dr.  Sterne  said  it  was  giving  to  the  hypnotizer  a 
dangerous  power,  .\nyone  can  hypnotize,  as  only  a 
certain  mental  concentration  is  necessary.  The  inter- 
est in  the  subject  is  not  so  much  a  medical  as  scientific 
one.  There  is  frequently,  if  not  always,  an  element  of 
fraud  in  hypnotism.  There  is  a  chance  of  murderers 
claiming  they  were  hypnotized. 


September  28,  1895] 


MEDICAL    RECORD. 


461 


Dr.  Patrick  emphasized  the  fact  that  the  hypnotizer 
has  no  hypnotic  power.  It  seems  almost  a  farce  to  dis 
courage  this  idea,  as  it  was  exploded  a  century  ago.  It 
is  purely  a  subjective  influence. 

Dr.  Burr  remarked  that  the  insane  could  not  fre- 
quently be  hypnotized.  They  could  if  the  hypnotizer 
had  any  power  in  reality.  It  is  possible  in  epilepsy  to 
do  much  with  it ;  also  in  h)'pochondriasis  and  melan- 
cholia it  might  be  valuable. 

Dr.  Buchm.ax  claimed  the  French  Academy  had  in 
the  past  ten  years  positively  demonstrated  the  existence 
of  hypnotic  power. 

Dr.  P.atrick  said,  in  rebuttal,  he  did  not  claim  that 
there  was  no  such  thing  as  hypnotism,  but  that  the 
hypnotizer  had  no  direct  power  in  himself  over  the  sub- 
ject hypnotized. 

The  Nervous  System  as  a  Factor  in  Disease. — Dr.  C. 
J.  Helm,  of  Peru,  Ind.,  then  presented  a  paper  on  this 
subject.  It  was  an  excellent  irst/m/  oi  a  great  subject, 
and  to  make  a  notice  of  the  points  made  without  free 
excerpts  is  impossible.  Slight  functional  disturbances, 
if  constant  and  continued,  may  produce  actual  organic 
lesions.  Change  is  the  great  remedy  for  these  troubles, 
not  necessarily  of  surroundings,  but  of  the  waste  places 
in  the  nervous  system  :  give  the  forces  some  new  direc- 
tion. Study  your  patient  in  every  phase.  Get  them 
out  of  the  ruts  they  have  gotten  into,  and  you  will  have 
then  cured  your  patients  before  you  know  it. 

Some  Considerations  with  Regard  to  the  Senile 
Heart — By  Robert  H.  B.vbcock,  of  Chicago.  The 
condition  is  not  always  due  to  or  necessarily  found  in 
the  aged.  Importance  should  always  be  given  to  the 
myocardial  changes.  Dyspnoea  is  a  most  frequent 
symptom  of  senile  heart,  although  it  occurs  in  other 
conditions  as  well.  It  finally  becomes  the  almost 
surely  fatal  symptom  —  Cheyne  -  Stokes  respiration. 
Various  remedies  were  advised,  and  among  them  the 
hypodermic  use  of  morphia  in  a  single  dose. 

Dr.  Futterer,  of  Chicago,  said  we  sometimes  find 
in  these  cases  a  m.ore  or  less  intermittent  pulse. 

Dr.  J.  B.  Herrick,  of  Chicago,  added  his  testimony 
with  regard  to  arythmia,  which  he  considers  a  fre- 
quent and  most  important  symptom. 

Dr.  Baecock  said  that  the  intermittence  is  not  nee 
essarily  a  dangerous  symptom,  but  at  the  same  time 
any  such  senile  heart  is  liable  to  stop  during  one  of 
these  diastolic  irregularities  coming  on  suddenly.  In 
Cheyne-Stokes  respiration  morphia  seemed  to  act  best 
with  small  doses  of  atropine. 

Dr.  Frank  Billings,  of  Chicago,  presented  a  paper 
on  "  Intercostal  Neuralgia."  The  disease  is  always  sec- 
ondary and  consequently,  in  reality,  only  a  symptom. 
It  may  be  due  to  toxic  forms  of  functional  nerve  dis- 
turbance, or  to  pressure  by  tumors.  The  functional 
form  is  most  common  and  usually  due  to  a  toxaemia,  or 
to  a  defective  excretion  or  malassimilation.  Indiges- 
tion is  a  most  frequent  factor,  whether  due  to  the 
character  of  food  ingested  or  to  nervous  conditions. 
Insufficient  food  and  lack  of  outdoor  exercise  are  fre- 
quent causes.  Intercostal  neuralgia  occurs  oftener  in 
females,  usually  on  the  left  side.  Palpitation  is  usually 
present.  Gas  in  the  stomach  with  eructation  is  always 
present.  In  diagnosis  we  must  search  for  the  cause. 
It  may  be  confounded  with  pleurisy  or  muscular  car- 
diac rheumatism.  In  treatment  remove  the  cause  and 
give  any  simple  restorative  tonic. 

Dr.  W.  H.  Porter,  of  New  York,  read  a  very  ex- 
haustive paper  entitled  "  New  Light  on  the  Role  which 
Iron  Plays  in  the  Physiological  Economy — How  and 
where  Does  the  Haemoglobin  Come  from?"  It  is 
not  the  product  of  synthesis.  It  is  difficult  to  formu- 
late a  nucleoalbumin.  The  iron  is  not  excreted  by 
the  salivary,  gastric,  or  sweat  glands.  The  hair  uses 
up  some,  the  urine  a  slight  amount.  The  bile  uses 
most,  but  the  total  in  both  hair  and  bile  is  only  one- 
tenth  grain  daily.  Some  writers  say  that  the  iron  is 
stored  up  in  the  liver,  but  this  is  not  practical.     The 


intake  and  output  both  being  very  small,  we  must  con- 
clude that  iron  in  the  body  is  very  stable.  There  is 
then  a  question,  whether  iron  should  be  so  frequenth" 
and  indiscriminately  used  in  anaemia. 

Dr.  John  North,  of  Toledo,  had  almost  given  up 
the  administration  of  iron  in  cases  of  anaemia.  In 
most  cases  we  should  correct  the  trouble  in  the  alimen- 
tary canal,  avoid  the  destruction  of  the  nucleo- albu- 
mins, and  no  iron  will  be  needed. 

The  Abortive  Treatment  of  Typhoid  Fever. — The 
paper  of  Dr.  John  .Aulde,  of  Philadelphia,  was  read  by 
tlie  Secretary  of  the  Section.  The  author  reviewed  the 
ad\  antages  of  guaiacol,  carbolic  acid,  salol,  betanaph- 
thol,  and  others,  and  finally  gave  his  own  and  others 
experience  with  arsenite  of  copper,  stating  that  in  his 
opinion  the  disease  could  be  aborted  at  almost  any 
stage  by  the  use  of  copper  arsenite  along  with  appro- 
priate constitutional  remedies.  As  a  rule  -j^o  grain 
should  be  given  every  four  or  six  hours.  The  remedy 
mav  be  given  hypodermically  if  the  disease  be  advanced 
to  the  second  or  third  week. 

Medicinal  Treatment  of  Typhoid  Fever. — This  was  a 
paper  read  by  Dr.  Gustav  Blech,  of  Detroit.  The 
author  opened  his  paper  with,  "  There  is  no  Specific 
Treatment  for  Typhoid  Fever."  Hydrozone,  i  to  32. 
is  a  most  valuable  intestinal  antiseptic.  Irrigation  of 
bowels  with  ^jld  water  is  a  necessary  adjuvant  in  all 
cases. 

The  two  pieceding  papers,  along  with  that  of  Dr.  J. 
E.  WooDBRiLGE,  of  Youngstown,  O.,  on  "Typhoid 
Fever  and  i'.s  Abortive  Treatment,"  were  read  in  suc- 
cession and  discussed  jointly. 

Dr.  Love  said  the  treatment  suggested  by  Dr.  Wood- 
bridge  was  not  original ;  that  all  physicians  had  used 
the  same  for  years.  He  protested  against  the  use  of 
the  term  abort,  as  he  thought  it  could  not  be  done. 
Rest  is  an  important  factor  in  the  treatment.  Typhoid 
fever  is  a  matter  of  diagnosis.  He  questioned  the  diag- 
nosis of  typhoid  in  some  of  the  cases  reported  by  Dr. 
Woodbridge. 

Dr.  North  would  change  the  word  abort  to  mis- 
carriage. The  germs  do  not  enter  the  circulation.  If 
we  can  discover  something  which  will  eliminate  the 
germs,  we  can  thus  cut  short  the  attack.  The  constant 
study  of  the  one  disease  is  the  only  way  to  progress. 
He  does  not  think  one  can  become  too  enthusiastic, 
but  conclusions  can  be  drawn  too  hastily. 

Dr.  Porter  said  "'  abort "  is  an  unfortunate  and 
misleading  word.  We  can  decrease  the  intensity 
and  cut  shorter  the  duration  of  an  attack"  with  such 
remedy. 

It  cannot  be  abortion  in  any  germ  disease. 

Dr.  J.  B.  Herrick  said  in  an  experience  with  over 
one  thousand  cases  of  typhoid  fever,  he  is  inclined  to 
think  that  there  is  no  specific  for  the  condition.  For 
the  febrile  condition  he  does  not  consider  anything 
equal  to  the  cold  bath.  Even  Woodbridge's  treatment 
is  an  expectant  one. 

Dr.  Woodbridge,  in  closing,  made  reference  to 
former  discussions  and  papers  by  himself  and  others. 
Even  if  we  could  exclude  the  diagnosis  of  genuine  ty- 
phoid in  these  cases,  what  better  treatment  can  we  find 
for  the  condition?  When,  however,  the  rose  spots  ap- 
pear along  with  the  usual  symptoms,  we  must  admit  it 
is  typhoid  fever,  and  these  cases  can  all  be  aborted  in 
a  few  davs. 

Treatment  of  Pulmonary  Consumption  in  Hospitals. 
— Dr.  E.  I..  SiuRLV,  of  Detroit,  presented  the  paper. 
For  many  reasons  the  treatment  in  general  hospitals  is 
not  practicable.  Other  patients  and  dangers  of  con- 
tagion, whether  real  or  imaginary,  are  important  fact- 
ors. Home  sickness  and  poverty  are  also  against  it. 
Foreign  hospitals  for  tuberculosis  are  successful,  but 
the  conditions  are  different  in  this  country.  The 
Harper  Hospital  of  Detroit  has  been  the  nearest  of 
success  of  any  American  institution.  Americans  are 
too  restless  and  have  not  patience  enough  to   test  the 


46: 


MEDICAL    RECORD. 


[September  28,  1895 


system.     The  hospital    must   not  only   be    thoroughly 
equipped,  but  located  in  an  equable  climate. 

The  Direct  Cause  of  Tuberculosis. — Dr.  Gustav 
FCtterer,  of  Chicago,  presented  this  paper.  The 
history  of  the  disease  was  given,  along  with  some  inter- 
esting remarks  regarding  Koch's  work  and  demonstra- 
tion of  the  tubercle-bacillus.  The  means  and  ways  of 
infection  were  detailed,  and  the  probability  of  danger 
to  the  healthy  individual  fully  demonstrated  inhala- 
tion, food,  drink,  direct  injection  of  bacillus  into  wound, 
and  heredity  being  the  chief  means  of  infection.  What 
can  be  done  to  arrest  its  spread  ?  i,  Early  diagnosis  ; 
2,  disinfection  by  every  possible  means  ;  3,  care  by  the 
patient ;  4,  care  by  friends  and  attendants  :  5,  personal 
cleanliness — bathing  ;  6,  avoid  kissing  at  all  times  ; 
7,  teeth  and  mouth  especially  clean  ;  8,  sleep  alone  ;  9, 
should  not  attend  public  or  private  gatherings  ;  10,  be 
careful  of  e.xpectoration  ;  11,  go  to  special  hospitals 
for  treatment. 

Scrofulosis  and  chlorosis  were  considered  in  their 
relation  to  tuberculosis,  and  treatment  and  diet  for 
each  dwelt  upon  at  length. 

The  curability  of  consumption  depends  greatly  on 
whether  the  patient  comes  early  for  treatment.  The 
author's  treatment  is  the  oil  of  cloves,  i.  A  No.  i  gel- 
atine capsule  is  filled  with  pure  oil  of  cloves  and  taken 
with  a  glass  of  milk  every  two  hours  from  8  a.m.  to  10 
P.M.  2.  If  the  oil  is  tolerated,  one  capsule  should  be 
given  every  hour.  3.  Oil  of  cloves  and  cold-pressed 
olive  oil  are  mixed  in  equal  parts  and  injected  hypo- 
dermically.  a  syringeful  once  or  twice  daily.  This  is 
continued  for  four  weeks,  stopped  for  two  weeks,  and 
then  resumed. 

The  Treatment  of  Acute  Inflammations  of  the  Mid- 
dle Ear  and  Mastoid  Process. — This  paper  was  read  by 
Dr.  E.  i).  Dexch,  of  New  York.  For  convenience, 
the  author  anatomically  divided  the  middle  ear  into 
two  parts  by  a  line  drawn  through  the  styloid  process. 
Inflammations  in  the  middle  ear  produce  the  ordinary 
results  of  the  same  process  elsewhere  within  a  ca\-ity 
lined  by  a  mucus-producing  membrane,  but  because 
of  transfusion  the  tissue  necrosis  is  not  so  extensive  ; 
yet  there  is  enough  retained  to  cause  an  outward  bulg- 
ing of  the  tympanic  membrane.  If  seen  early,  free 
blood-letting  should  be  practised  and  a  single  dose  of 
an  opiate  given.  Do  not  give  but  one  dose  of  the  opi- 
ate under  any  circumstances.  .-^.Iso  apply  dry  heat 
lofally.  Do  not  use  wet  heat.  If  not  seen  until  later, 
free  opening  is  the  only  thing  to  be  advised.  The 
technique  of  the  operation  was  minutely  and  carefully 
described.  The  more  acute  and  severe  the  case,  the 
more  prompt  should  be  the  measures  for  relief.  .\n 
incision  should  be  made  often,  even  when  it  is  known 
the  cavity  contains  no  fluid.  The  incision  does  not 
end  the  danger  ;  the  entire  cavity  must  be  thoroughly 
washed  out  and  made  antiseptic  by  irrigation. 

Sequels  of  la  Grippe. — This  paper  was  read  by  Dr. 
F.  C.  HEArH,  of  Indianapolis.  Several  cases  of  eye 
results  were  given,  and  the  more  common  condition  of 
ear  complications  noticed,  with  treatment  considered. 

In  the  discussion.  Dr.  Straight  thought  the  stom- 
ach was  the  most  frequently  affected  of  all  organs. 
Dr.  North  said  quinine  given  for  la  grippe  had  done 
more  damage  than  any  other  one  thing.  Dr.  Whee- 
LOCK  saw  two  distinct  kinds  of  reaction  following  in 
ear  cases  with  periostitis  or  middle-ear  abscess. 

Artificial  Ripening  of  Cataract. — Dk.  J.  M.  Ball,  of 
St.  Louis,  read  a  paper  with  this  title.  A  complete  his- 
tory of  the  operations  was  given  and  the  various  meth- 
ods were  explained.  Before  doing  any  of  them  the 
surgeon  should  be  sure  the  zonula  is  intact,  the  tension 
normal,  and  the  pupil  dilatable.  Division  of  the  an- 
terior capsule  in  these  cases  is  always  more  or  less 
dangerous,  and  may  be  serious.  Bettman's  operation 
or  direct  massage  or  trituration  is,  of  all,  the  most  de- 
sirable. It  is  the  least  dangerous,  most  certain,  and 
speedy.     It  has  stood  the  vital  test  of  e.xperience  and 


is  worthy  of  confidence.  If  prolapse  of  the  iris  occurs, 
snip  it  off  at  once,  contrary  to  most  authority,  but  he 
had  found  it  satisfactory  and  beyond  expectations. 

Complications  in  Cataract.  Arising  from  Diabetes, 
Albuminuria,  Etc.,  was  a  paper  by  Dr.  J.  O.  Stillson, 
of  Indianapolis.  The  diabetic  cataract  is  as  yet  a 
puzzle.  .\  serous  retinitis  is  often  a  symptom  of 
Bright's  disease.  Albuminuria  is  a  frequent  comple- 
ment of  catjract.  It  is  not  only  desirable  but  neces- 
sary to  treat  these  conditions  if  they  exist  before  oper- 
ating for  the  senile  cataract. 

Rhetunatism  and  Gout  in  its  Relation  to  the  Eye  was 
the  title  of  a  paper  by  Dr.  K.  K.  WHEELOCk,  of  Fort 
Wayne,  Ind.  The  paper  was  a  thoroughly  practical  one 
and  presented  this  somewhat  old  but  nevertheless  im- 
portant subject  in  an  interesting  manner  and  elicited  a 
warm  discussion. 

Bio-chemistry  in  its  Relation  to  Nervous  Diseases. — 
Dr.  G.  W.  McCaskev,  of  Fort  Wayne,  Ind.,  followed 
with  a  contribution  on  this  subject.  In  this  paper  the 
somewhat  peculiar  and  certainly  novel  attempt  was 
made  to  establish  the  general  theory  of  the  causation 
of  nervous  diseases  by  chemical  poisons  circulating  in 
the  blood  and  acting  by  a  process  of  selective  affinity 
upon  different  parts  of  the  nervous  system.  The  au- 
thor referred  to  these  poisons  under  the  following 
groups,  the  classification  being  entirely  tentative,  and 
based  upon  their  source  of  origin  instead  of  their  ul- 
timate chemical  analysis  or  physiological  action  :  i. 
Bacteriological  products — ptomaines  ;  2,  products  of 
perverted  tissue  metabolism  ;  3,  defective  elimination 
of  excretion  ;  4,  perverted  secretion  of  glandular  or- 
gans ;  5,  products  of  imperfect  digestion  ;  6,  chemical 
compounds  probably  present  in  independent  blood 
states  and  of  unknown  origin.  Many  conditions  here- 
tofore unknown  as  to  their  etiology  will  be  found  to  be 
due  to  one  of  the  above  conditions  existing  in  the  system. 

How  shall  we  Rear  our  Babies? — One  of  the  most 
practical  papers  of  the  section  was  that  read  by  Dr.  T. 
H.  Taylor,  of  Indianapolis.  The  suggestions  and  di- 
rections were  for  both  physician  and  mother,  and  put 
in  so  pointed  a  manner  that  the  paper  ought  to  have  a 
wide  circulation. 

Diseases  of  the  Mouth,  Nose,  and  Throat  as  Etiological 
Factors  in  Chronic  Glandular  Gastritis,  with  Bacterio- 
logic  Studies  of  the  Pharyngeal  'Vault. — This  was  the 
title  of  a  paper  by  Dr.  Fexton  B.  Turck,  of  Chicago. 
Bacteriologic  study  has  developed  the  fact  that  upon  the 
mucous  membrane  of  the  mouth,  nose,  and  pharj-nx 
groups  of  micro-organisms  may  form,  which  may  also 
be  found  growing  on  the  mucous  membrane  of  the 
stomach,  and  certain  germs  that  are  found  in  the  in- 
flamed mouth  may  also  be  found  growing  on  the  walls 
of  the  stomach  in  gastritis.  Under  normal  conditions 
the  mucous  membrane  of  the  stomach  does  not  favor 
colonization  upon  its  walls  :  but  let  some  etiologic 
factor  come  into  play  and  micro-organisms  will  develop. 
The  mouth,  nose,  and  throat,  when  in  a  diseased  state, 
become  incubators  ready  to  infect  when  the  conditions 
of  the  stomach  permit  the  development  of  growing 
micro-organisms  upon  its  walls.  The  author  then  re- 
ferred to  the  bacteriologic  studies  of  Miller,  Wurtz,  and 
Lindet.  Micro-organisms  of  the  mouth  are  carried  by 
the  food  after  mastication  into  the  stomach  ;  many  of 
them  are  again  recognized  in  the  stomach,  and  in  cases 
of  gastritis  are  found  in  colonies  growing  upon  the  mu- 
cous walls.  The  author  in  his  clinical  and  experimen- 
tal work  has  presented  similar  groups  of  micro-organ- 
isms taken  from  the  gums  and  cavities  in  the  teeth,  as 
well  as  from  the  material  removed  by  the  gyromele 
(revolving  sound)  from  the  walls  of  the  stomach.  In 
cultures  upon  the  prepared  raucous  membrane  of  the 
pig  he  has  been  able  to  cultivate  some  of  the  micro- 
organisms and  find  the  same  developing  in  the  stomach 
that  are  found  in  the  mouth.  But  in  the  control  ani- 
mal he  has  not  yet  found  micro-organisms  growing  in 
colonies  in  the  stomach. 


September  2S,  1895] 


MEDICAL    RECORD. 


463 


Alter  reporting  several  cases.  Dr.  Turck  concluded 
hat  clinical  observation  indicates  a  marked  relation 
etneen  diseases  of  the  mouth  and  post  nasal  cavity 
nd  chronic  inflammation  in  the  stomach  and  intestines  ; 
bat  the  invasion  of  the  stomach  from  the  infected 
louth  and  pharynx  is  supported  by  the  fact  that  many 
f  the  non-pathogenic  micro-organisms  present  the 
ientical  biological  and  physical  forms  in  cases  of  gas- 
ritis  the  same  as  those  found  in  diseases  of  the  mouth 
nd  post-nasal  cavities  of  the  same  patients. 

Dr.  Turck  exhibited  a  chart  showing  the  predominat- 
ig  micro-organisms  found  in  eight  cases  that  were 
tudied  bacteriologically. 

In  the  discussion,  Dr.  Larrabee,  of  Louisville,  said 
bat  the  germ  theor)-  had  been  superseded  by  germ 
lets  as  presented. 

Dr.  Frank  Billings,  of  Chicago,  complimented  Dr. 
"urck  on  his  excellent  clinical  and  experimental  work, 
aying  that  the  doctor  stands  at  the  head  of  his  pro- 
ession  in  the  work  he  has  accomplished.  He  had 
hown  that  when  there  is  a  lowered  vitality  of  the  mu- 
ous  membrane  of  the  stomach  by  errors  of  diet  that  a 
oil  is  produced  favorable  for  the  development  of  mi- 
ro-organisms. 

Experiences  with  Paquin's  Antitubercle  Semm  in  the 

"reatment  of   Laryngeal   Tuberculosis. — Dr.    H.   W. 

,OEB,  of  St.  Louis,  read  a  paper  in  which  he  gave  the 

istory  of  nine  cases  of  this  disease,  seven  of  which  had 

een  treated  with  the  serum.     The  patients  all  improved 

reatly.     One  case  particularly  lost  all  dysphagia,  pain 

1  the  larynx,  cough,  and  night  sweats.     Other  patients 

lowed  a  much  greater  improvement  than  under  any 

ther  plan  of  treatment  yet  tried.     The  doctor  quoted 

le  confirmatory  evidence   of  Maregliano,   of  Genoa, 

!ole,  Semon,  Wiggins,  and  Paquin.     He  will  continue 

is  investigations  and  present  further  conclusions  at  a 

Iter  date.  , 

In  the  discussion,  Dr.  Pall  Paquin,  of  St.   Louis 

xplained  in  detail  the  treatment  which  he   has  pro- 

uced.     He  said  it  was  just  in  its  beginning.     It  will 

ave  to  be  improved  as  we  go  along,  and  it  will  take 

ears  to  do  so.     The  best  results  have  been  obtained 

1  the  acute  forms  of  the  disease,  and  not  in  the  chronic. 

'he  law  underlying  serum  therapy  is  a  natural  one.     It 

trying  to  fight  bacteria  by  using   nature's  remedy. 

[e  had  had  failures  with  serum,  but  he  could  mention 

)rty  or  more  cases  of  recovery.     He  thought  that  in 

)me   cases  it  would  require  other   treatment   except 

;rum.     He  had  not  had  good  results  inside  of  two  or 

iree  months,    and  it  frequently  required  five   or  six 

•onths.  or  even  longer.     He  had  made  over  ten  thou- 

ind  injections  with  serum  in  tubercular  cases,  but  did 

3t  recall  one  which  was  attended  with  fatal  results. 

lie  counselled  study  of  the  climate,  as  well  as  the  pa- 

'ent,   before   sending   a   patient   away.     Tuberculous 

itients  could  not  live  in  Colorado  or  N"ew  Mexico. 

hey  will  die  quicker  there  than  anywhere. 

Yeast  Hucleinand  its  Therapeutic  tJses. — Dr.  Victor 

.  V.AUGHAN,  of  .A.nn  Arbor,  Mich.,  presented  this  paper. 

hysiologically  nucleins  form  the  chief  chemical  con- 

ituents  of  the  living  parts  of  cells  :  that  constituent  of 

.e  cell,  by  \-irtue  of  which  this  histologic  unit  grows, 

ivelops    and    reproduces.       The  nuclein   of    various 

;Us  differs,  and  is  limited  only  by  the  variety  of  cells. 

hemically  the  nucleins  contain  a  large  amount  of  phos- 

lorus.     Some  are  combined  with  albumin,  forming  the 

-called   nucleo-albumin.    The  nuclein  molecule  has  a 

markable  power  of  recuperation  after  partial  decom- 

)sition.     Some  nucleins  have  germicidal    properties. 

xperiments  were  made  with  animals  apparently  proving 

at  previous  treatment  by  the  nuclein  gave  immunity  to 

e  pneumococcus.     Some  thirty  experiments  were  de- 

iled  and  results  given  which  seemed  quite  promising. 

Diagnosis  of  Hysteria  was  the  title  of  a  paper  by  Dr. 

'S'jH  T.  Patrick,  of  Chicago.     The  writer  dwelt  par- 

:ly  upon  the  peculiarities  of  hysterical  anaesthesia, 

r    sihesia,  and  paralysi?.     The  principal  peculiar- 


ities of  the  first  are  its  distribution  in  the  form  of  a  glove, 
sleeve,  or  stocking,  with  sharply  cut  border,  and  in  dis- 
seminated and  irregular  patches.  Dr.  Patrick  called 
attention  to  a  disringuishing  trait  not  yet  described, 
namely,  almost  instantaneous  shifting  of  the  line  of  de- 
marcation between  the  anaesthetic  and  normal  areas. 
This  peculiar  feature  applies  equally  well  to  hyperses- 
thesia.  Among  the  hyperaesthesias  was  described  hys- 
terical joint  disease,  and  hysterical  angina  pectoris,  with 
the  differential  points  of  diagnosis  between  these  affec- 
tions and  organic  disease.  The  peculiarities  of  the 
hysterical  gait  were  described  at  some  length,  and  their 
relation  shown  to  the  affection  described  by  Blocq,  and 
called  by  him  astasia  abasia.  The  writer  protested 
against  this  affection  being  considered  a  nosological  en- 
tity, as  it  is  simply  an  exaggeration  of  a  common  feature 
in  hysterical  paralysis.  The  peculiarities  which  distin- 
guish a  hysterical  from  an  organic  paralysis  of  the 
upper  extremity  were  also  described,  and  hysterical 
affections  of  the  special  senses  were  briefly  alluded  to. 

Hasmorrhoids — Prolapse  Rectum — A  New  Operation. 
— Dr.  B.  M.  Ricketts,  of  Cincinnati,  read  the  paper. 
The  object  of  this  paper  was  to  present  means  more 
simple  than  had  heretofore  been  offered  for  the  radical 
cure  of  a  prolapsed  rectum  and  the  obliteration  of 
hemorrhoids.  After  widely  dilating  the  sphincter  with 
the  fingers  under  surgical  anaesthesia,  a  large  semi- 
circular needle  is  passed  subcutaneously  from  the  mu- 
-co-cutaneous  line  to  the  upper  border  of  the  pile-bear- 
ing area,  and  then  returned  to  make  its  exit  at  the 
point  of  entrance.  The  needle  is  then  removed,  and 
the  silk  ligature  made  tight  about  the  venus  plexus, 
and  the  ends  left  hanging  out.  These  ligatures  may  he 
from  one-half  to  ai  inch  apart  as  the  case  may  require. 
It  is  not  necessary  to  tie  all  the  varices  in  this  way,  as 
the  atrophic  changes  will  necessarily  obliterate  the  re- 
maining ones.  Xo  tissue  is  sacrificed  ;  the  mucous 
membrane  remains  intact  ;  there  is  no  hemorrhage, 
no  infection,  no  pain  of  consequence,  and  the  loss  of 
time  is  practically  mV.  The  sutures  are  allowed  to 
come  away  of  their  own  accord.  The  operarions  made 
in  this  way  for  this  condition  have  resulted  in  an  ab- 
solute cure,  and  the  patients  have  experienced  but  little 
pain  during  the  life  of  the  ligature. 

Prolapsed  rectum  is  treated  in  the  same  manner,  ex- 
cept a  great  number  of  ligatures  are  required.  If  they 
are  properly  and  evenly  adjusted,  the  atrophy  of  the 
tissues  is  symmetrical,  and  the  pathological  condition  is 
relieved  without  stenosis. 

Daniel  Drake,  or  Then  and  Now. — Dr.  William 
Pepper,  of  Philadelphia,  by  request,  delivered  the  ad- 
dress on  medicine.  He  selected  for  his  subject  "  Dan- 
iel Drake,  or  Then  and  Now."  Daniel  Drake  died  in 
Cincinnati  in  1852.  He  was  universally  recognized  as 
the  leading  medical  man  of  the  West.  He  graduated 
at  the  University  of  Pennsylvania  in  1S16,  the  excep- 
tional honor  of  a  special  commencement  held  for  this 
purpose  being  granted  to  him.  He  had  already  prac- 
tised medicine  for  twelve  years  without  a  diploma,  and 
had  won  a  high  reputation  by  his  scientific  and  literary 
work.  Dr.  Drake  received  no  fewer  than  thirteen  sep- 
arate calls  to  medical  professorships,  and  actually  held 
at  different  times  nine  chairs  in  five  separate  institu- 
tions, in  Cincinnati,  Lexington,  Louisville,  and  the 
Jefferson  Medical  College  in  Philadelphia.  Dr.  Gross, 
who  was  a  colleague  in  two  institutions,  pronounced 
him  the  most  forceful  and  eloquent  teacher  he  had  ever 
known. 

The  Deflected  Septum  and  its  Repair. — This  paper 
was  read  by  Dr.  J.  Homer  Coulter,  of  Chicago. 
The  author  first  dwelt  upon  the  etiology  of  the  condi- 
tion. In  stenosis  of  any  degree  there  is  created,  in 
each  inspiration,  within  the  cavity,  a  more  or  less  com- 
plete vacuum.  Thus  the  atmospheric  pressure  is  to 
that  degree  increased  and  is  a  constant  force  of  no  in- 
considerable gravity.  He  holds  further  that  such  a 
force  would  be  more  efficient  in  producing  structural 


464 


MEDICAL   RECORD. 


[September  28,  1895 


changes  in  the  cartilaginous  septum  than  would  a  more 
violent  force  suddenly  applied,  because  the  natural 
cartilaginous  resiliency  would  more  easily  recover  and 
throw  off  the  effect  of  the  latter. 

The  author  then  gave  the  points  in  the  operation, 
because  in  the  observance  of  those  lies  the  success  of 
the  operator.  Where  the  deviation  is  well  anterior,  or 
involving  merely  the  alse,  it  is  very  much  simplified 
because  of  convenience  in  operating  and  after-treat- 
ment as  well.  Until  recent  years  but  little  attention 
was  paid  to  the  preservation  of  the  mucous  membrane 
when  operating  on  a  deflected  septum.  A  new  form  of 
punch  was  suggested  for  removing  the  cartilage  and 
leaving  the  membrane  intact. 

A  Case  of  Comminuted  Fracture  of  the  Ilium  with 
Specimen  and  Photographs,  by  Dr.  \V.  F.  Breakev,  of 
Ann  Arbor,  Mich.  No  reports  show  such  an  exten- 
sive fracture  of  the  ilium  as  this  case.  It  was  literally 
shattered  into  pieces.  The  patient  fell  ten  feet  on  a 
pile  of  stones,  producing  this  fracture  and  also  a  Colles's 
fracture  with  dislocation  of  ulna.  The  patient  never 
rallied  from  the  shock  of  the  accident. 

The  Treatment  of  Cancer,  by  Dr.  Hal  C.  Wyman, 
of  Detroit.  The  cure  of  cancer  is  rare,  and  unless  the 
treatment  is  begun  early,  the  disease  terminates  in 
death.  In  the  treatment  of  cancer  there  is  still  an 
open  field.  The  cure  by  early  removal,  while  the  dis- 
ease is  local,  is  urged  and  practised  by  all  who  have 
opportunity.  But  the  opportunity  will  not  occur  with 
sufficient  frequency  to  stamp  out  the  disease  until  the 
people  are  educated  as  to  the  facts. 

Laryngitis  from  a  Rhinological  Stand-point.— Dr. 
Lewis  C.  Clixe,  of  Indianapolis,  read  a  paper  on  this 
subject.  The  author  adheres  to  Bosworth's  classification 
of  laryngitis,  and  applies  the  word  itis  only  to  inflam- 
mations of  a  purely  catarrhal  character,  which  excludes 
at  once,  syphilis,  tuberculosis,  and  other  constitutional 
diseases,  as  they  are  more  properly  called  syphilis  or 
tuberculosis  of  the  larynx.  The  cases  that  'are  least 
amenable  to  treatment  are  the  atrophic,  but  much  can 
be  done  to  comfort  and  palliate  these  cases  by  attention 
to  dress,  stimulant  and  lubricant  applications.  For 
stimulating  and  astringing  he  finds  nothing  equal  to 
nitrate  of  silver,  from  10  to  40  grains  to  the  ounce,  ac- 
cording to  indications.  For  overwork  cases  the  first 
law  is  rest,  with  occasionnl  mild,  stimulating  applica- 
tions with  an  atomizer.  The  great  majority  of  cases 
,  that  had  come  under  his  observation  had  had  atrophic 
or  hypertrophic  rhinitis  to  a  greater  or  less  degree. 
Spurs  and  deflected  septum  are  often  associated  with 
these  conditions.  The  lesions  most  frequently  ob- 
served are  hypertrophies  of  the  posterior  ends  of  the 
inferior  turbinate  body,  and  a  thickened,  lumpy  condi- 
tion of  the  posterior  end  of  the  septum.  The  drill, 
saw,  snnre,  and  galvano-cautery  are  aids  in  removing 
these  conditions  in  the  more  aggravated  forms,  while 
the  applications  of  silver  and  various  astringents  with 
sprays  had  served  the  author  in  the  mild  form. 

The  Therapeutics  of  Oleo-creosote  and  Creosote  Car- 
bonate.—Dr.  T.  A.  Wessinger,  of  .\nn  Arbor,  Mich., 
contributed  a  paper  on  this  subject.  He  summed  up 
his  experience  with  these  remedies  in  the  following 
conclusions  :  i.  The  dosage  is  practically  unlimited  as 
far  as  toxicity  is  concerned,  but  it  is  preferable  to  be- 
gin with  a  small  dosage,  two  to  three  drops  after  eat- 
ing, and  increase  until  the  desired  result  is  obtained. 
2.  To  be  of  value  in  tuberculosis  a  clinical  diagnosis 
must  be  made  early.  3.  While  these  agents  are  dis- 
tinctly germicidal,  they  also  serve  as  tissue-builders. 
4-  Creosote  carbonate  and  oleate  have  the  power  of  in- 
creasing the  number  of  red  blood-corpuscles,  and  they 
also  increase  the  percentage  of  h?emoglobin  in  the 
blood. 

The  Bicycle  from  a  Medical  Stand-point. — Dr.  I.  N. 
I.ovE,  of  St,  Louis,  read  a  paper  with  this  title.  Bicy- 
clists should  understand  the  importance  of  going  rea- 
sonably slow.     The  wheel  brings  into  play  all  the  mus- 


cles, and  the  maintaining  of  equipoise  has  beneficial 
results.  The  matter  of  position  is  important.  The 
rider  should  maintain  an  erect  posture  and  not  assume 
an  unsightly  stoop  in  imitation  of  the  hoop-snake, 
which  takes  its  tail  in  its  mouth  and  sails  through  the 
country.  A  study  of  the  question  of  the  wheel  for 
women  had  resulted  in  an  opinion  favorable  to  its 
moderate  use  in  cases  of  acute  diseases.  Specialists 
had  agreed  to  this.  Numerous  cases  of  long-standing 
pelvic  diseases  had  been  benefited  by  a  judicious  use 
of  the  bicycle.  Women  maintain  a  better  position  than 
men.  An  hour's  wheeling  three  times  a  day  is  ample. 
The  costume  is  important  from  the  stand-points  of 
health  and  art.  He  objected  most  emphatically  to 
bloomers,  which  lessened  the  respect  of  mankind  for 
womanhood  and  blemished  the  landscape.  Leggins 
and  accordion- plaited  skirts  were  about  the  thing. 
Corsets  should  be  put  aside.  Skirt  and  shirt  waist  were 
favored,  and  even  the  sweater  was  approved. 

The  discussion  was  opened  by  Dr.  C.  B.  Parker,  of 
Cleveland,  and  continued  by  Dr.  W.  M.  Wishard,  of 
Indianapolis  :  Dr.  Sterne,  of  Indianapolis  ;  and  Dr. 
Walker,  of  Evansxille,  Indiana.  They  all  advocated 
and  advised  a  moderate  use  of  the  wheel  for  both  men 
and  women. 

A  paper  was  read  by  Dr.  T.  O.  Summers,  of  St. 
Louis,  entitled  "  The  Physiological  Aspects  of  Le  ;co- 
cytosis."  and  one  by  Dr.  A.  Goldspohn,  of  Chicago, 
on  ■'  The  Proper  Indications  for  Repair  of  Pathologi- 
cal Lacerations  of  the  Cervix  L'teri,  and  for  the  Relief 
of  Pathological  Ante-flexions  and  the  Proper  1  'pera- 
tions  to  Meet  them." 

Election  of  Officers. — The  Nominating  Committee  re- 
ported as  follows  :  President,  Dr.  H.  O.  Walker,  or  De- 
troit ;  First  Vice-President,  Dr.  B.  M.  Ricketts.  of 
Cincinnati  ;  Second  Vice-President,  Dr.  F.  C.  Wood- 
burn,  of  Indianapolis  ;  Secretary,  Dr.  H.  W.  Loeb,  o' 
St.  Louis  ;  Treasurer,  Dr.  H.  N.  Moyer,  of  Chicago 
Judicial  Council,  Drs.  W.  N.  Wishard,  T.  E.  Holland 
and  -A^.  P.  Buchman.  The  report  of  the  committee  was 
adopted  and  the  nominees  declared  elected. 

The  Nomin.iiing  Committee  also  submitted  the  fol- 
lowing resolutions  :  1 

Resolved,  That  it  is  the  sense  of  this  Committee  tha' 
the  best  interests  of  the  Association  will  be  subservei 
by  the  appointment  of  a  permanent  Executive  Corri 
mittee,  composed  of  the  titulary  officers  of  the  Associ 
ation  and  the  ex- Presidents,  and  that  this  Committet 
shall  conduct  all  the  business  of  the  Association  :  be  i 
further 

Resolved,  That  we  recommend  the  creation  of  the  o- 
fice  of  .\ssistant  Secretary,    to   be   appointed   I 
Chairman  of  the  Committee  of  .\rrangements,  fro:     ; 
place  in  which  the  meeting  is  held. 

On  motion,  the  Association  adjourned,  to  meet  in  S 
Paul,  Minn.,  on  the  third  Tuesday  of  October.  1891 
Dr.  C.  A.  Wheaton,  of  St.  Paul,  was  selected  Chairma 
of  the  Committee  of  Arrangements. 


A  Woman  Coroner.  — The   Omaha    World- J: 
says  that  the  city  physician  and   coroner  of   Pt  ;•  le 
Neb.,  is  a  woman,  who  was  elected  unanimoufl\    1;- 
autumn  after  she  had  been  but  six  months  practisi:-.:  i 
the  town. 

Inherited  Age.— Dr.  B.  W.  Richardson  gives  a  serie 
of  ob.servations  on  the  duration  of  life  of  the  otfsprin 
as  compared  with  that  of  the  parents.  He  consider 
that  if  the  ages  of  the  two  parents  and  of  the  fou 
grandparents  be  added  together  and  divided  by  si^ 
the  age  of  the  case  in  point  will  be  told,  with  an  ave: 
age  variation  of  not  more  than  two.  If  the  ages  of  th  | 
parents  are  high  the  offspring  tends  to  improve  0 
them  ;  if  low  (say  an  average  of  forty  or  lower),  the  Hi 
of  the  offspring  will  probably  be  still  shorter. — DuUi' 
Journal  of  Medical  Science.  I 


September  28,  1895] 


MEDICAL    RECORD. 


465 


G^IiuicaX  department 

MATERNAL    IMPRESSION. 
By  F.  W.  MALONEY,  M.D., 

ROCHESTER,  N.    Y. 

V  Mrs.   F came  to  my  office  in  the  early  part  of 

■Jovember,  1894,  complaining  of  a  whitlow  about  her 
eft  thumb-nail.  She  was  about  six  months  pregnant. 
rhe  pain  was  severe,  and  I  made  a  small  incision  to 
et  out  the  pus  and  applied  antiseptic  dressings. 

On  the  25th  of  last  month  I  was  called  to  attend  her 
n  confinement,  and  delivered  her  of  a  male  child. 
Vhile  examining  the  infant,  as  it  was  being  washed  by 
he  nurse,  I  found  that  the  left  thumb  was  bifid,  that  is, 
here  was  a  supemumeraiy  thumb  fully  formed  wiih 
»ail,  apparently  grown  out  of  the  primary  articulation 
)f  the  first  phalanx.  The  double  thumb  gives  a  Y- 
haped  appearance.  The  mother  is  of  an  extremely 
lervous  character,  and  I  have  no  doubt  that  this  is  a 
:lear  case  of  maternal  impression. 


A    CASE    OF    PILONIDAL    FISTULA. 
By   H.\RLAN   M.   page.    M.D., 


•lEDlCAL.  SCIEN'CE  . 


BIOLOGV   IS  I 


vIr.  H.  V ,  aged  twenty-three,  stalwart  and  strong, 

vilh  negative  family  history,  sought  relief  at  my  hands 
or  a  discharge  from  the  anal  region,  which  he  had 
irst  noticed  as  staining  his  linen  some  four  weeks 
)rior  to  this  consultation,  which  was  February  10, 
7  894.  On  inspection  I  found  two  small  apertures — 
he  lower  one  at  about  the  sacro  coccygial  articulation, 
md  the  other  about  an  inch  above.  On  pressure  1 
^as  able  to  bring  to  light  some  considerable  pus  from 
)Oth  openings,  which  especially  attracted  my  attention 
n  that  it  was  devoid  of  odor.  I  next  demonstrated 
he  existing  channel  between  the  two  openings  by  the 
njection  of  peroxide  of  hydrogen,  which  procedure  is 
o  my  mind  much  more  satisfactory  than  the  use  of  the 
jrol.e,  which  so  often  is  made  to  demonstrate  fistulx- 
ind  sinuses  which  exist  only  in  the  mind  of  the  oper- 
itor.  Failure  to  pass  either  peroxide  or  probe  into  rec- 
um  committed  me  to  the  diagnosis  of  incomplete  ex- 
ernal  fistula.  As  the  patient  had  never  suffered  from 
jnstipation  and  was  unable  to  recall  the  receipt  of 
my  injuries  in  this  region,  I  finally  concluded  that 
iiuch  riding  upon  a  hard  and  often  damp  seat  of  a 
neai  wagon  must  stand  responsible,  at  least  tenta- 
ively.  The  patient  fearing  the  knife,  I  began  the  use 
.if  nitrate  of  silver  applications,  following  thorough 
:leansing  by  peroxide  of  hydrogen  ;  and  after  pursu- 
ng  this  course  for  some  ten  days,  I  was  slightly  sur- 
)ri.sed  to  find  at  one  of  the  openings,  in  the  debris 
.vhich  the  peroxide  of  hydrogen  had  brought  out,  a 
iozen  or  fifteen  hairs  about  three-fourths  of  an  inch  in 
ength  and  arranged  in  the  form  of  a  little  curl.  I 
;oniinued  my  treatment  for  another  ten  days,  with  no 
mprjvement  ;  however,  the  daily  appearance  of  two 
)r  three  hairs  was  slowly  stimulating  my  mind  to  a 
lew  diagnosis.  I  finally  recalled  an  obscure  sentence 
n  .\shhurst's  surgery,  which  I  quote  :  "  It  must  be  re- 
nembered  that  every  sinus  in  the  neighborhood  of  the 
inus  is  not  necessarily  a  fistula  in  ano  ;  it  may,  for  in- 
stance, be  connected  with  caries  or  necrosis  of  the 
:uber  ischii  ;  may  depend  upon  the  pressure  of  a  tuft 
)(  hair,  as  in  curious  cases  observed  by  J.  M.  Warren 
ind  other  surgeons,  including  Lamadrid  Gaston, 
Wyeth,  and  myself  ;  or  may  communicate  with  an  ab- 
scess arising  within  the  pelvis  or  proceeding  from  the 
nip-joint."     Having  verified  this  memory,  I  looked  in 


\ain  through  my  library  and  journals  for  another  hint 
on  this  subject.  At  the  next  visit  I  made  a  free  inci- 
sion connecting  the  two  openings,  and  was  rewarded 
by  bringing  to  the  surface  a  tuft  of  perhaps  a  hundred 
hairs.  Curettement  and  the  application  of  pure  car- 
bolic acid  secured  an  early  termination  to  this  rather 
unusual  case,  which  I  suppose  must  be  explained  as 
resulting  from  the  invagination  of  epithelial  cells  dur- 
ing the  embryonic  development  of  the  individual. 
How  much  the  irritation  of  the  hard,  damp  wagon-seat 
had  to  do  with  bringing  the  trouble  to  light  we  can 
only  conjecture. 

DERMOID  CYSTS  AND  PRECINANCV. 
By  JOHN  A.  PRINCE,  M.D., 

2>PR1NGF1ELD,   ILL. 

Mrs.    H.    D.    E ,    aged   twenty-six.       About    four 

months  ago  she  first  noticed  a  growth  in  the  right  side 
of  the  abdomen,  quite  low  down,  which  has  been  stead- 
ily enlarging  and  occasioning  considerable  pain.  Men- 
struation ceased  about  a  month  before  she  noticed  the 
tumor.  She  says  her  mother  told  her  that  when  she 
was  a  child  there  was  a  tumor  present,  which  as  she  grew 
older  disappeared.  An  examination  revealed  the  uterus, 
about  five  months  pregnant,  high  up,  with  the  os  close 
up  against  the  pubic  bone,  and  the  fundus  to  the  right. 
This  composed  the  tumor  noticed  by  patient.  Oc- 
cupying the  pelvis  was  a  cystic  'tumor  about  the  size 
of  a  cocoa-nut. 

.\n  early  operation  was  advised,  and  done  a  few  da)  s 
later,  April  6,  1894.  Considerable  difficulty  was  ex- 
[lerienced  in  removing  the  grow'th,  necessitating  the 
removal  from  the  abdomen  of  the  fundus  uteri,  in  re- 
placing which  a  good  deal  of  manipulation  was  neces- 
sary. This  was  finally  accomplished  by  passing  a  tube 
down  alongside  of  the  uterus  into  the  pelvis,  permitting 
the  air  to  escape  ;  then  the  uterus  slipped  in  easily. 

The  tumor  contained  an  oily  fluid  of  the  consistence 
of  melted  butter,  and  a  large  mass  of  hair.  On  .\])ril 
1 2th,  six  days  later,  there  were  strong  signs  of  labor, 
but  they  subsided  under  appropriate  treatment.  There 
was  a  normal  labor  at  term,  and  mother  and  child  did 
well. 


SUCCESSFUL  USE  OF  ANTITOXIN  FOR  DIPH- 
THERIA IN    COUNTRY    PRACTICE. 

By  DANIEL  B.  SPRECHER,  M.D., 

SVKESVILLE,    MD. 

On  .\pril  29th  the  grandmother  of  a  family,  in  which 
there  were  five  children  ranging  in  age  from  twenty- 
three  montlis  to  eleven  years,  died,  was  placed  on  ice 
in  an  icebox,  which  was  found  to  have  a  broken  or 
tracked  zinc  lining  running  two-thirds  the  length  of 
one  side,  the  wood  under  the  fissure  being  in  a  soggy 
state.  With  the  melting  of  the  ice  there  began  drip- 
ping from  this  side  a  stringy,  slimy,  mucus-looking  sub- 
stance, together  with  an  odor  so  horrible  and  sicken- 
ing as  to  require  the  removal  of  the  box  and  the  adoption 
of  other  methods  of  preservation  of  the  body.  Upon 
the  return  of  the  funeral  i)arty  the  granddaughter, 
eleven  years  of  age,  was  directed  to  wash  and  wipe  uyi 
tlie  stains  on  the  floor  made  by  drippings  from  the  ice- 
box. This  she  did  thoroughly,  and  on  Saturday,  four 
(la>s  later,  complained  of  sore  throat,  fever,  and  gen- 
eral malaise.  The  next  morning  it  was  ascertained  she 
was  suffering  from  di|)luheria.  Membranous  deposits 
over  tonsils,  pharyngitis.  lymi)hatic  tumefaction,  with 
chatacteri>tic  nasal  conditions,  appearing  in  a  iew  days. 
Notwithstanding  isolation  was  prompt  and  appar- 
ently thoroughly  maintained,  the  youngest  child  fell  a 
victim  to  the  disease  ten  days  later.  On  the  third  day 
of  its  illness  croup  complicated  the  case,  but   under 


466 


MEDICAL    RECORD. 


[September  28,  1895 


treatment  apparent  relief  was  obtained,  till  the  follow- 
ing evening,  when  it  (croup)  reappeared  in  such  a  se- 
rious form  that  1  called  Dr.  L ,  a  fellow  practitioner. 

He  advised  tracheotomy.  To  this  the  parents  objected. 
I  then  called  attention  to  antitoxin  and  obtained  consent 
to  its  use.  The  next  morning  10  c.c.  of  Berling's  an- 
titoxin was  injected  in  the  region  of  the  left  hip.  Two 
hours  later  the  struggling  for  breath,  which  was  painful 
to  witness  during  the  night,  together  with  cyanosis, 
coldness  of  extremities  and  anxious  restless  movements 
of  child,  grew  calm,  easy,  and  sleep  followed,  as  did 
also  glowing  surface  and  slightly  accelerated  tempera- 
ture, rising  from  a  subnormal  of  983*^  to  99°  F.  The 
sleep  continued  for  four  hours,  disturbed  more  or  less 
from  coughing,  after  which  the  child  awakened  refreshed, 
asked  for  beer,  and  drank  heartily.  Five  cubic  centime- 
tres were  injected  the  next  day  in  opposite  hip.  On  in- 
spection of  membranous  patches  as  far  as  could  be  seen 
in  the  throat  they  seemed  to  dissolve  away  to  thinness. 
The  15  c.c,  together  with  a  spray  of  peroxide  of  hydro- 
gen, twenty-two  per  cent.,  and  lime-water  inhalations  se- 
cured constant  improvement,  ending  in  recovery  within 
a  few  days. 

Interesting  facts  :  i.  Inspection  of  the  premises  failed 
to  reveal  any  cause  for  diphtheria  ;  absolute  absence  of 
diphtheria  in  neighborhood  ;  no  history  of  diphtheria 
in  any  person  or  family  attending  funeral.  Suggest 
cause  to  have  been  a  contaminated  defective  ice-box. 
2.  The  prompt  and  wonderfully  efficient  action  of  an- 
titoxin, even  after  the  disease  has  invaded  the  laryn- 
geal passages. 

MORPHINE    POISONING. 
Bv  A.  c.  McDonald,  m.d.. 


At  6.30  .\.M.,  August  22d,  I  was  called  to  a  young  man, 
aged  eighteen,  who  had  taken  twenty  grains  of  mor- 
phine with  suicidal  intent.  He  was  in  a  condition  of 
profound  stupor,  almost  comatose,  with  respirations  four 
a  minute  ;  pulse  no,  and  fairly  strong  ;  pupils  like  pin- 
holes. It  was  thought  that  he  had  taken  the  drug  at 
bedtime,  and  consequently  did  not  resort  to  the  stom- 
ach-pump at  once. 

Atropia,  J^  grain  was  injected  hypodermically,  and 
permanganate  of  potassium,  10  grains,  was  given  both 
internally  and  hypodermically.  In  the  course  of  an 
hour,  at  7.30,  his  condition  was  apparently  not  im- 
proved. I  now  injected  strich.,  sulp.  jV  grain,  and  half 
an  hour  later  his  respiration  reached  five  or  six  a  min- 
ute. At  this  time  he  aroused  himself  sufficiently  to  tell 
that  he  had  taken  the  poison  at  five  o'clock.  Consider- 
ing the  quantity  was  large  I  sent  for  Dr.  White  to  help 
me  use  the  stomach-pump.  We  thoroughly  washed 
out  the  stomach.  He  still  continued  in  a  deep  stupor, 
from  which  we  could  not  arouse  hira  save  with  elec- 
tricity ;  when  aroused  his  respirations  generally  in- 
creased about  one  a  minute. 

His  respiration  from  this  on  was  sustained  by 
strych.  sulp.,  ^  grain  every  hour  or  two,  accord- 
ing to  condition  of  respiration.  Of  this  he  had  taken 
about  J<^  of  a  grain  in  all  in  the  twenty-four  hours 
without  any  symptoms  of  strychnine  poisoning.  At  6.30 
P.M.  patient  seemed  sufficiently  improved  that  I  thought 
it  safe  to  leave  him  with  nurse  and  his  father,  who  was 
a  physician.  They  walked  him  about  considerable 
after  I  left.  Iwas  soon  called  back  in  haste,  and  found 
him  completely  comatose,  with  pulse  160,  scarcely  per- 
ceptible ;  respiration  two  a  minute.  I  now  injected 
spirit  of  ammon.  arom.  and  tincture  of  digitalis  every  fif- 
teen minutes.  Condition  appeared  almost  hopeless  at 
this  time.  Ammon.  and  digitalis  were  repeated  every 
fifteen  minutes,  with  occasional  trial  of  artificial  respi- 
ration and  strychnine.  Patient  soon  improved,  with  res- 
piration ten  or  twelve.    Pulse,  150. 

Patient  was  now  allowed  to  sleep  while  respiration 


kept  up,  and  heart  sustained  with  ammon.  and  str)xh- 
nine  during  the  night.  At  6  next  morning  patient  was 
conscious  and  recovery  soon  followed. 

The  above  case  seems  of  interest  from  three  points 
of  view.     In  the  first  place,  the  apparent  inefificiency  of 
the  potassium  permanganate  in  spite  of  the   reported  j 
success  by  many  physicians,    particularly   Dr.    Moor.  | 
Secondly,  the  greater  efficiency  of  strychnine  as  a  re-  ' 
spiratory  stimulant  compared  with  atropia.     I  believe  ' 
the  former  should  be  used  more  in  these  cases  and  in  j 
larger  quantities.     I  am  sure  I  could  have  used  more  I 
with  perfect  safety.     Thirdly,  the  great  harm  that  can 
be  done  by  exercising  an  exhausted  patient.     I  could 
scarcely  persuade  his  father  that  exercise  simply  helped, 
in  the  absence  of  other  sources,  to  keep  patient  awake 
that  he  might  voluntarily  help  in  maintaining  an  ex- 
hausted respiratory  centre. 

The  severe  exercise  baffled  an  exhausted  circulation,  , 
and  a  patient  which  was  apparently  doing  well  might  ' 
easily  have  been  lost  by  rash  and  injudicious  treat-  ' 
ment. 


Correspondeuce. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.^ 

THE  BATTLE  OF  THE  CLUBS  AT  CORK — THE  JUDICIAL 
PERSECUTION  OF  DR.  ANDERSON THE  LUNACY  RE- 
PORT  HEALTH    OF    LONDON.  I 

London,  September  7,  iSjs- 

The  question  of  club  attendance  at  Cork  is  not  yet 
settled.     A  conference  was  lately  held,  at  the  instance 
of  the  Mayor,  between  representatives  of  the  clubs  and 
the  profession.     The   rules   agreed  to  by   the  doctors  I 
were  carefully  considered  seriatim,  and  some  modifica- 
tions were  accepted  to  meet  the  views  of  the  clubs,  i 
But  these  concessions  did  not  satisfy  the   delegates,  ' 
who  wanted  the  doctors  to  take  into  association  and 
meet  in  consultation  the  three  practitioners  who  had  I 
been  imported  to  carry  on  the  contest.     This  proposal 
was  repudiated  by  the  representative  doctors,  who  de-  : 
clared  that  under  no  circumstances  could  they  hold 
professional  intercourse  with   these  persons.      As  the 
delegates  from  the  clubs  stood  firm  on  this  point,  the 
conference   proved  a  failure.     The   three  young  men 
who  went  to  Cork  to  supersede  those  who  were  fighting 
the  battle  of  the  profession,  knew  very  well  what  they 
were  doing,  and  can  hardly  have  expected  that  they 
would    be    received    as    professional    brethren    after 
they  had  behaved  in  this  way.     It  is  to  men  of  this 
stamp  that  the  profession  owes  many  of  its  troubles, 
and  they  must  take  the  consequences  of  their  disloyal- 
ty.    If  they  have  no  regard  to  professional  honor,  they 
would  do  well  to  follow  some  calling  in  which  the  con- 
duct and  feelings  of  a  gentleman  are  not  expected.     It  . 
is,  alas,  true  that  in  the  higher  walks  of  the  profession  | 
similar  conduct  has  been  known — witness  the  Throat 
Hospital  case  in   London — but  that  is  no  excuse,  and 
the  profession  in  London  ought  not  to  show  itself  less 
alive  to  its  honor  than  in   Cork.     It  would  be  well  if 
the  example  of  Cork  should  be  widely  imitated. 

The  case  of  Mr.  R.  B.  Anderson  excites  considerable 
interest  and  deserves  all  sympathy.  He  is  undoubtedly 
the  victim  of  a  monstrous  injustice.  His  wrongs  were 
so  manifest  in  Tobago  that  he  was  sent  by  public  sub- 
scription to  England  to  appeal  to  English  courts  against 
the  partiality  and  malice  of  the  local  judges.  In  the 
Queen's  Bench  the  facts  proved  could  not  but  excite 
astonishment.  A  Royal  Commission  was  issued  to  in- 
quire into  the  administration  of  justice  in  Tobago. 
The  result  was  that  one  of  the  judges  was  removed  from 
office,  the  other  was  interdicted  pending  the  trial  of  the 
charges  against  him,  but  he  has  in  the  meantime  died. 
The  jury  found  a  verdict  amounting  to  malice  in  the 


September  28,  1895] 


MEDICAL    RECORD. 


467 


exercise  of  their  functions  by  the  judges,  and  awarded 
damages.  But  the  judge  entered  judgment  in  their 
favor  on  the  ground  that  no  action  lies  against  a  judge 
for  an  act  done  in  his  judicial  capacity,  and  this  ruling 
has  been  confirmed  by  the  Court  of  Appeal.  It  is 
therefore  clear  that  Dr.  Anderson  is  the  victim  of  a  per- 
secution which  disgraces  the  judicial  bench,  and  for 
which  the  law  provides  no  redress.  The  boast  of  law- 
yers that  "  every  wrong  has  a  remedy  at  law,"  is  there- 
fore shown  to  be  a  fiction,  and  the  immaculate  purity 
of  English  judges  must  be  held  with  reserve  until  the 
Bench  find  some  method  of  upholding  the  right,  pun- 
ishing any  offending  member,  and  compensating  the 
victiin  of  such  persecution.  Dr.  Anderson  has  main- 
tained his  honor  against  all  the  diflficulties  thrown  in  his 
way  by  judicial  persecutions,  but  at  what  a  cost  !  prac- 
tically ruin.  The  prosecuting  judicial  criminals  ought 
to  be  made  to  compensate  him  and  to  retire  for  a  sea- 
son tj  the  seclusion  of  one  of  her  Majesty's  prisons. 
Such  an  e.xample  would  do  much  to  restore  confidence 
in  British  justice  and  the  impartiality  of  the  English 
Bench.  If  no  way  can  be  found  of  making  such  an 
example,  Parliament  should  interfere.  Xo  doubt  the 
ministry  would  be  willing  to  promote  an  act  of  simple 
justice  if  the  Bench  would  unanimously  recommend 
some  such  method  of  upholding  its  honor. 

The  Forty-fifth  Report  of  the  Commissioners  in  Lu- 
nacy shows  an  increase  in  the  number  of  patients  on 
January  i,  1S95,  over  that  of  1894.  There  has  in 
fact  been  a  continual  increase  for  many  years,  but  it 
does  not  follow  that  lunacy  is  absolutely  increasing  in 
the  country  ;  more  persons  are  now  received  in  the  asy- 
lums on  account  of  the  mental  decay  of  old 
age.  Then  there  is  the  constant  accumula- 
tion of  chronic  cases  and  the  diminution  in 
the  death-rate.  Taking  these  and  other  cir- 
cumstances into  account,  it  is  probable  that  the  na- 
tion does  not  contain  a  larger  number  of  lunatics  of 
late  years,  but  the  subject  has  certainly  received  more 
attention  than  formerly. 

The  Registrar-General's  returns  for  the  week  show  a 
slight  decrease  in  the  deaths  from  small-pox  and  scar- 
let fever,  but  there  is  an  increase  in  the  mortality  of 
whooping-cough  and  diphtheria.  Still  the  deaths  from 
all  causes  were  ninety  -  eight  less  than  the  decen- 
nial average.  Our  annual  death-rate  per  1,000  has 
fallen  from  i  7  to  159,  and  for  a  month  past  the  average 
has  only  been  17.3,  which  is  i.i  below  the  mean  rate  of 
the  last  ten  years,  so  that  London  cannot  be  called  un- 
heal thv. 


INTERNATIONAL    LANGUAGE. 


To    THE    EdITO 


Medical  Record 


Sir  :  It  is  impossible  to  answer  in  the  form  of  a  short 
letter  the  remarks  of  Dr.  Ferd.  C.  Valentine  on  the  ques- 
tion of  an  international  language,  which  appeared  in  the 
Medical  Record  issue  for  August  24,  1S95.  While 
I  intend  at  some  future  time  to  enter  quite  thoroughly 
on  the  choice  of  Dr.  \alentine  to  have  the  Spanish  in 
preference  of  the  Greek  language,  and  to  give  full 
credit  to  some  of  his  observations  which  are  quite  cor- 
rect, I  wish  to  call  attention  to-day  to  a  word  in  fa\or 
of  Greek,  said  in  the  year  1824,  that  is  before  Greece 
had  become  a  nation  again,  by  one  of  the  noblest  I'hil- 
hellenes,  the  great  philologist,  Claude  Charles  Fauriel  : 
"  The  modern  Greek  is  a  language  remarkable  in 
every  respect.  Having  a  foundation  as  homogeneous 
as  but  even  richer  than  the  German,  being  as  clear  as 
the  French,  smoother  than  the  Italian,  and  more  har- 
monious than  the  Spanish,  there  is  nothing  wanting  to 
consider  it  from  this  time  on  as  the  most  beautiful  lan- 
tliise  of  Europe.  She  is  without  the  shadow  of  a  doubt 
idiom  V,^  perfect.  ^^  ^^e  can  be  compared  with  an\ 
of  which  sRe'''^  ^^^  ^^^  from  which  she  originates,  anu 
■3  new  phase.     Granted  there  were  some 


inferiority,  it  will  be  only  temporary.  Let  the  Greeks 
become  a  nation  :  let  this  nation  have  great  writers  who 
understand  well  that  the  glory  and  the  prosperity  of 
their  country  are  things  of  the  future,  not  only  of  the 
past  ;  that  these  things  are  before  them,  not  only  be- 
hind them  :  that  they  are  to  come  in  the  ordinary  run, 
and  not  by  the  vain  attempt  of  a  return  to  the  past  ; 
and  the  modern  Greek  will  soon  be  a  language  which, 
without  resembling  more  the  ancient  as  it  does  now. 
will  have  no  cause  to  envv  it." 

A.  Rose.  M.D. 

-.•;6  East  Fifteenth  SrnEKT. 


^cxtJ  luBtrixments. 

A  KNIFE-NEEDLE  FOR  DIS-CI6SI0N  OF  THE 
CAPSULE  AFTER   CATARACT    EXTRACTION. 

Bv  JOHN  E.  WEEKS,  M.D.. 

NEW  YORK. 

T?iE  instrument  described  here  was  devised  for  the 
purpose  of  discission  of  the  lens  capsule  (not  thickened 
by  inflammatory  reaction),  which  remains  after  the  e.\- 
traction  of  cataract,  with  the  least  possible  traction  on 
that  membrane.  The  endeavor  has  been  made  to  pro- 
duce a  knife  in  the  use  of  which  the  cutting  edge  may 
be  made  to  present  at  right  angles  to  the  plane  of  the 
capsule  at  all  times  during  its  passage  through  the 
membrane.  For  this  purpose  a  curved  knife-needle  has 
been  devised    so  made  that  the  incision  through  the 


cornea  is  perfectly  filled  by  the  shank  after  the  blade 
has  entered  the  anterior  chamber,  preventing  loss  of 
the  aqueous  tumor.  In  order  to  have  knives  suitable 
for  all  cases  they  are  made  in  sets  of  three,  each  set 
containing  a  knife  have  a  cutting  edge  of  3.5  mm., 
4  mm.,  and  5  mm.  The  blade  is  about  two-thirds  of  a 
millimetre  wide  in  its  widest  part.  The  curve  of  the 
blade,  which  begins  near  its  heel,  is  such  that  the  ex- 
treme point  of  the  blade  is  found  to  be  about  two  milli- 
metres distant  from  a  line  projecting  along  the  axis  of 
the  shaft.  The  concave  edge,  the  point,  and  also  the 
convex  edge  to  a  distance  of  i  mm.  up  from  the  point, 
are  made  as  sharp  as  possible. 

The  passage  of  the  knife  through  the  cornea  is  not 
so  easily  effected  as  with  the  straight  knife-needle,  since 
the  curve  of  the  needle  must  be  followed  in  order  to 
avoid  making  an  incision  too  large  to  be  filled  by  the 
shank.  The  needle  is  entered  on  the  flat,  penetrating 
the  cornea  at  a  point  on  the  horizontal  meridian  midway 
between  the  centre  and  the  temporal  margin  of  the  cor- 
nea. The  cutting  edge  is  turned  toward  the  capsule 
after  the  blade  has  passed  fully  into  the  anterior  cham- 
ber ;  the  knife  is  withdrawn  in  the  reverse  order. 

The  curved  knife-needle  appears  to  possess  the  fol- 
lowing advantages  over  the  straight  knife-needle  :  i. 
The  incision  through  the  capsule  can  be  made  with 
more  ease  and  certainty.  2.  The  traction  on  the  cil- 
iary processes,  through  the  medium  of  the  capsule,  is 
less.  3.  It  can  be  manipulated  more  easily  when  the 
blade  is  in  the  anterior  chamber.  4.  The  point  of  the 
knife  need  not  enter  so  deeply  into  the  vitreous  humor. 

The  knife  is  made  by  E.  B.  Meyrowitz,  New  York. 


American  Students  in  France  are  admitted  to  the 
higher  courses  of  instruction  in  the  medical  and  other 
faculties  of  the  universities,  but  cannot  obtain  degrees 
unless  they  have  already  a  French  bachelor's  degree. 
A  movement  is  under  way  to  admit  to  the  higher  degrees 
graduates  of  American  universities  of  good  standing. 


468 


MEDICAL    RECORD. 


[September  28,  1895 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  September  21,  1895. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Oerebro-spinal  meningitis . 

Measles 

Diphtheria 


Pseudo-meningitis.  —  Dr.  Krannhals  reports  seven 
cases  in  which  the  symptoms  were  almost  exclusively 
nervous,  and  in  which  the  diagnosis  of  meningitis  was 
made,  although  some  of  the  more  characteristic  symp- 
toms were  wanting.  One  case  ended  in  recovery  ;  the 
termination  of  another  could  not  be  determined  ;  five 
died.  The  findings  at  the  post-mortem  examination 
did  not  confirm  the  diagnoses,  there  being  no  exudate, 
no  inflammatory  turbidity,  nothing  but  hyperajmia  and 
oedema  of  the  pia,  and  a  varying  number  of  hemor- 
rhages in  the  same  membrane.  The  microscopical  ex- 
amination of  two  cases  confirmed  the  pre-eminent 
hemorrhagic  character  of  the  affection,  and  the  ab- 
sence of  any  real  inflammatory  changes,  if  one  does 
not  regard  as  such  the  oedema  of  the  pia,  which  in 
reality  had  the  character  of  an  oedema  due  to  conges- 
tion rather  than  inflammation.  The  brain  itself  showed 
no  inflammatory  changes  ;  on  the  contrary,  here  and 
there,  in  the  superficial  layers  of  the  cortex,  there  was 
a  retrograde  metamorphosis,  a  beginning  necrosis  due 
to  a  disturbance  of  the  circulation  brought  about  by 
the  numerous  hemorrhages  in  the  ])ia.  Bacteriological 
examination  of  the  meningeal  serum  of  three  cases 
jjroved  negative.  Krannhals  seeks  to  explain  an  inti- 
mate relationship  between  influenza  and  these  cases  of 
"  pseudo-meningitis,"  occurring  as  they  did  during  the 
spring  of  1890,  following  the  influenza  epidemic.  He 
believes  that  the  symptoms  of  the  cases  of  "  pseudo- 
meningitis,"  due  to  some  infectious  process,  and  of 
acute  meningitis  in  general,  depend  especially  upon 
the  action  upon  the  central  nervous  system  of  certain 
toxines,  and  secondarily  upon  the  anatomical  lesions 
present. —  University  Medical  Magazine. 

Texas  Fever. — It  has  long  since  been  observed  that 
this  disease  is  of  an  entirely  infectious  character  ;  that  it 
is  not  communicated  from  cattle  to  cattle  by  direct  con- 
tact, but  that  cattle  bearing  the  infection,  when  allowed 
to  graze  on  unconiaminated  grounds,  will  sow  the  in- 
fection, being  all  the  time  in  apparent  health  them- 
selves, in  which  condition  they  will  remain.  When 
susceptible  cattle  are  allowed  to  graze  with  such  cattle, 
or  have  been  allowed  to  occupy  ])astures  that  have 
been  occupied  by  such  cattle,  they  will  contract  the 
disease  and  die.  This  curious  fact  that  cattle  can 
spread  fatal  infection  on  susceptible  grounds  while 
they  are  in  apparent  health  and  remain  so,  is  explained 
by  numerous  observers.  The  cattle  that  are  raised 
from  birth  on  the  range  lands  acquire  an  immunity 
against  the  disease,  by  gradual  inoculation  as  it  were, 
and  if  they  are  ever  affected,  it  occurs  during  their 
early  life,  assumes  a  light  form,  from  which  ihey  re- 
cover. At  an  early  date  in  the  investigation  ot  this 
disease  and  its  manner  of  communicaiion,  it  was  ob- 
served that  the  cattle-tick,  that  abounds  on  all  the 
range  lands  of  the  infected  area,  was  nearly  always 
present  in  large  numbers  where  outbreaks  occurred, 
and  was  in  some  way  connected  with  tiie  communica- 
tion of  the  disease.  Experiments  made  by  Dr.  Theo- 
h.ild  Smith,  I'atholo-'ist  for  the  Bureau  of  .\inmal  In- 


dustry, revealed  the  connection  the  cattle-ticks  have 
with  the  communication  of  the  poison  that  produces 
the  disease.  When  fully  matured  the  ticks  drop  from 
the  cattle  to  the  ground,  lay  their  eggs  and  perish,  thus 
ending  their  life  history.  The  young  ticks  are  hatched 
in  from  fifteen  to  thirty  days,  and  at  once  get  on  the 
cattle,  from  which  time  their  growth  is  rapid,  and  it  is 
during  this  time  that  they  inoculate  the  susceptible  cat- 
tle and  cause  the  disease. —  Tennessee  State  Board  of 
Health  Bulletin. 

The  Duties  of  Medical  Societies. — In  the  account  of 
the  meeting  of  the  Biitish  Gynecological  Society  which 
was  published  in  The  Lancet  of  July  6th,  it  is  stated 
that  the  first  business  of  the  society  was  to  witness 
three  specimens  :  i,  that  from  a  case  of  suppurating 
ovarian  tumor  with  purulent  peritonitis  and  adhesions: 
2,  fibroma  of  the  uterus  removed  by  enucleation  ;  and 
5,  total  extirpation  of  the  uterus  and  ovaries  for  pro- 
lapse. \\'ith  regard  to  the  third  case  a  few  remarks  are. 
we  think,  called  for.  The  surgeon  who  narrated  the 
case  explained  that  for  the  prolapse  he  tried  the  use  o!' 
pessaries,  and  not  succeeding  therewith  he  decided  to 
remove  the  uterus  and  appendages,  the  patient  being  a 
woman  aged  thirty.  We  do  not  pretend  to  write  as 
gynecologists  ;  but  we  do  not  for  that  reason  feel  it  at 
all  less  binding  on  us  to  say  that  in  our  opinion  the 
reasons  for  this  procedure  require  to  be  more  fully  sec 
out  than  appears  to  have  been  done  at  the  society.  \\'e 
note  that  the  president  (Dr.  Godson),  Dr.  Routh,  and 
Mr.  Taylor,  of  Birmingham,  criticised  the  procedure  in 
a  tone  of  disapprobation.  Ordinary  surgery  has  be- 
come more  conservative  with  its  increased  powers. 
The  removal  of  a  leg  is  felt  to  be  an  unsatisfactory  and 
opprobrious  proceeding,  except  as  a  last  measure  of  re- 
lief. A  fortiori,  any  operation  involving  a  much  more 
serious  mutilation  must  be  so  regarded,  and  we  are  of 
opinion  that  a  society  before  which  such  cases  are  re- 
corded does  not  discharge  its  duty  without  investigat- 
ing the  case  by  a  committee  appointed  for  the  purpose, 
and  placing  its  deliberate  judgment  on  the  facts  on 
record.  The  amount  of  suffering  and  disability  ex- 
perienced by  the  woman,  the  precautions  taken  by  the 
surgeon  before  operating,  and  the  degree  to  which  he 
shared  his  responsibility  by  consultation  and  by  full 
statements  of  the  facts  to  the  patient,  are  obvious  mat- 
ters for  inquiry.  We  gather  that  the  operator  acted 
with  perfect  satisfaction  to  himself  in  what  he  did,  and 
doubtless  when  the  full  facts  are  known  we  shall  find 
with  perfect  propriety.  But  for  the  sake  of  the  repu- 
tation of  surgery,  and  especially  of  gynecology,  we 
maintain  that  the  facts  should  be  fully  investigated  and 
published  by  the  society,  which  has  in  a  degree  in- 
curred responsibility  in  connection  with  the  case. —  The 
Lancet. 

A  Hospital  on  Wheels. — One  oi  the  most  novel  of 
the  recent  achievements  of  modern  philanthropy  is  the 
invention  of  a  hospital  on  wheels.  This  evolution  of 
the  travelling  van  is  due  to  the  genius  of  a  Scotchman, 
Dr.  Wylie,  of  I'athhead.  The  advantages  of  the  plan 
are  many  and  obvious.  An  infectious  patient  can  be 
called  for  and  carried  off  bodily  into  the  midst  of 
beautiful  scenery,  where  he  can  be  nursed  back  into 
health  and  strength  under  the  care  of  the  local  doctor. 
Under  such  circumstances  it  would  be  of  course  easy 
to  provide  for  the  most  perfect  isolation.  In  the 
middle  of  a  moor,  for  instance,  isolation  is,  so  to  speak, 
automatic  and  inherent.  The  risk  ol  conveying  inlec-- 
tion  would  ari.se  mainly  during  the  passage  of  the  cara- 
van from  starting-point  to  destination.  In  fine  summer 
weather  the  \A\\\  is  simply  fascinating.  .\  larger  hos- 
pital can  be  made  by  knocking  out  the  ends  of  two 
wagons  and  joining  them  together.  The  attractivenes"" 
of  Dr.  Wylie's  al  fiesco  hospital,  however,  would  _,yied 

likely  be  considerably  lessened  or  altogether  Jj xin 

by    bad    weather    or  by  the  advent    of    v'  ' 
Medical  Press. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  48,  No.  14. 
Whole  No.  1300. 


New  York.  October  5,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


THE    CLINICAJ.   ASPECT    OF    DYSPEPSIA, 
By  SIMON   BARUCH,   M.D., 

NEW  V08K  CITV. 
ATTENDING   PHYSIQAM    TO    THE    1 


As  a  disease  dyspepsia  fortunately  disappeared  from 
our  text-books,  and,  perhaps,  less  fortunately,  it  is 
rarely  chosen  as  a  subject  for  society  discussion.  As 
a  pathological  entity  dyspepsia  no  longer  exists,  but  as 
a  curse  to  mankind  in  every  station  of  life,  its  exist- 
ence is  a  sad  reality,  as  every  practical  physician  has 
ample  opportunity  to  observe.  My  choice  of  so  home- 
ly a  subject  for  a  paper  before  the  society  may  evoke 
some  criticism,  which  I  do  not  hesitate  to  encounter. 
A  discussion  of  dyspepsia  may  not  be  invested  with 
the  glamour  and  prestige  of  the  grand  surgical  achieve- 
ments with  which  \'isiting  colleagues  from  the  great 
medical  centres  are  wont  to  regale  you  ;  the  mental  and 
physical  suffering,  the  loss  of  time  and  money  which 
are  involved  in  it,  and  the  enormous  number  of  people 
afflicted  by  it,  lend  a  dignity  to  the  subject  which  no 
surgical  achievements  of  this  great  surgical  era  may 
exceed.  In  the  humblest,  as  in  the  most  palatial, 
homes  this  arch  fiend  makes  human  beings  miserable 
and  sends  them  sooner  or  later  to  the  physician.  Car. 
we  dismiss  these  sufferers  by  telling  them  that  dyspep- 
sia is  not  a  disease  ?  They  come  to  us  for  treatment. 
How  can  we  relieve  Xh.Qva,  tuto,  cifo  et  Jucunde  .'  This 
is  the  pressing  question  for  us. 

It  is  a  happy  circumstance,  for  both  physician  and 
patient,  that  dyspepsia  has  ceased  to  be  recognized  as 
a  disease  against  which  our  materia  medica  must  spend 
the  force  of  most  of  its  agents.  The  realization  that 
dyspepsia  (8vs — ditificulty  ;  -etmu — to  digest)  is  a  symp- 
tom or  manifestation  of  various  diseased  conditions  of 
the  stomach,  and  not  infrequently  also  of  no  stomach 
disease  at  all,  is  the  most  important  step  to  its  more 
successful  management.  The  symptoms  which  may 
be  grouped  under  this  term  are  general  and  local.  The 
general  symptoms,  /.r.,  those  affecting  the  entire  sys- 
tem, are,  as  you  well  know,  innumerable  :  there  is  not 
a  disease  whose  "  livery  may  not  be  worn  "  by  dyspep- 
sia. They  range  from  the  most  serious  psychoses 
(which  the  ancients  have  not  inaptly  termed  hypo- 
chondriasis)  to  all  those  minor  disturbances  which  are 
but  too  often  erroneously  grouped  by  superficial  ob- 
servers under  the  appellation  of  neurasthenia. 

Moodiness  leading  to  introspection,  sluggish  mental 
action,  loss  of  memory,  enfeebled  muscular  power,  giv- 
ing rise  to  exhaustion  after  the  ordinary  duties  of  the 
day,  which  in  health  were  performed  without  effort  : 
vertigo,  insomnia,  cardiac,  pulmonary,  and  lumbar 
aches  and  pains  which  render  the  patient  miserable  by 
referring  them  to  brain,  heart,  lung,  and  kidney  dis- 
eases ;  headaches  of  various  types,  dyspnoea  from  the 
mildest  form  to  the  most  labored  respiration  ;  inter- 
mittent pulse,  tachycardia — these  are  some  of  the  mani- 
festations that  may  be  traced  to  difficult  digestion. 
These  general  manifestations  are  the  chief  source  of 

*  Read  before  the  Soui!»   Carolina   .Medical  Association.  April  2-^, 


discomfort  and  unhappiness.  Which  of  us  has  not 
been  consulted  by  some  anxious  dyspeptic,  who  brings 
a  tale  of  woe  centring  around  a  pain  in  the  heart, 
with  palpitations,  etc.,  which  literally  "  vanishes  into 
the  thin  air  "  when  an  alkaline  carminative  is  adminis- 
tered ?  How  many  weary  dyspeptics  bring  in  a  bottle 
of  urine,  containing  a  thick  sediment  of  phosphates  or 
urates  which  they  interpret  into  kidney  disease.  Such 
cases  of  so-called  liver  disease  formerly  came  to  me 
almost  daily  when  I  practised  in  Camden,  where  they 
doubtless  come  to  you  in  great  numbers.  Such  cases 
crovvd  the  consulting-rooms  of  the  metropolitan  doc- 
tor, taxing  his  utmost  resources  of  tact  and  therapeu- 
tic skill.  When  they  are  carefully  questioned  and 
each  organ  is  successively  interrogated,  the  stomach 
often  stands  out  as  the  sole  culprit.  A  cloud  is  lifted 
from  physician  and  patient  alike  by  a  thorough  analy- 
sis of  all  the  symptoms.  As  in  all  other  diseases,  a 
painstaking  examination  is  the  most  important  ele- 
ment in  the  management  of  dyspepsia.  I  shall  pres- 
ently show  that  time  spent  for  this  purpose  is  well 
spent  in  the  interest  of  both  patient  and  physician. 
Without  asking  leading  questions,  we  may  often  obtain 
a  history  of  abnormal  sensations  and  taste  in  the 
mouth  and  fauces  ;  loss  of  appetite,  nausea  and  vomit- 
ing, a  sense  of  fulness,  oppression,  distention,  distress, 
or  pain  in  the  region  of  the  stomach,  which  is  absent 
before  breakfast  but  more  or  less  persistent  throughout 
the  day.  We  may  learn  of  eructations  of  gas,  acid,  or 
water,  following  more  or  less  rapidly  after  each  meal. 
There  may  be  pyrosis,  nausea,  vomiting,  etc. 

The  interpretation  of  these  symptoms  of  difficult  di- 
gestion has  passed  through  many  phases.  As  it  fur- 
nishes us  often  a  clue  to  their  management  it  may  not 
be  without  interest  to  summarize  briefly  their  concep- 
tion at  the  present  time. 

1.  Loss  of  appetitif  maybe  due  to  a  sense  of  satiety 
arising  from  overdistention  of  the  stomach  by  gases  or 
particles  of  undigested  food,  which  are  retained  by 
reason  of  enfeebled  motor  power  of  the  stomach.  In 
the  form  of  repugnance  to  food  it  may  be  traced  to 
that  often  groundless  apprehension  of  impending  gas- 
tric disturbances  ascribed  to  almost  every  kind  of  food, 
which  is  a  common  observation  among  nervous  dys- 
peptics. It  may  be  well  to  bear  in  mind  that  in  or- 
ganic disturbances  of  the  stomach  the  appetite  is  usu- 
ally fair,  sometimes  good. 

2.  Sense  of  fulness  and  pressure  in  the  epigastrium, 
which  the  patient  usually  designates  as  "  a  weight  in 
the  stomach."  This  symptom  is  readily  accounted  for 
by  dilatation  of  the  stomach  and  by  its  retention  of 
fermenting  and  fermented  particles  of  food,  and  gases 
arising  from  them.  That  gases  form  in  the  stomach  in 
certain  types  of  difficult  digestion  is  evidenced,  not 
only  by  these  eructations,  but  actual  demonstration  of 
their  presence  has  been  made  by  reliable  chemists. 
Formerly  the  idea  obtained  that  decomposition  of  food 
and  consequent  fermentation  giving  rise  to  gases,  only 
occurred  in  the  absence  of  a  sufficient  quantity  of 
hydrochloric  acid.  This  error  has  been  disposed  of 
by  Hoppe-Seiler,  who  demonstrated  that  hydrogen  aris- 
ing from  butyric  acid  fermentation  may  be  developed 
in  the  presence  of  two  percent,  of  hydrochloric  acid  in 
the  stomach  ;  but  when  free  hydrochloric  acid  is  en- 
tirely absent,  a  large  quantity  of  CO"  was  found.  The 
intensity  and  extent  of  the  fermentation  depends  upon 


470 


MEDICAL    RECORD. 


[October  5,  i! 


the  quality  of  the  food  and  upon  defective  motor 
power  of  the  stomach,  which  delays  the  passage  of  di- 
gested and  undigested  food  particles  into  the  upper 
bowel,  and  thus  renders  the  usual  quantity  of  HCl  in 
the  stomach  insufficient  to  prevent  alcoholic,  lactic, 
and  butyric  acid  fermentation.  Even  decomposition, 
evidenced  by  evolution  of  sulphuretted  hydrogen,  may 
occur,  and  may  be  clearly  recognized  in  the  eructations. 
Thus  may  the  stomach  be  distended  and,  pressing  upon 
the  diaphragm,  produce  a  sense  of  oppression  which 
renders  the  patient  miserable  and  despondent,  and  casts 
a  gloom  over  his  whole  life.  It  should  be  borne  in 
mind,  however,  that  in  certain  nervous  dyspepsias  these 
symptoms  are  present  without  manifest  organic  changes, 
and  in  a  perfectly  empty  state  of  the  stomach  the  eruc- 
tations sometimes  even  consisting  of  swallowed  air. 

3.  Absolute  gastric  distress  or  pain  may  arise  from 
various  causes.  In  gastric  catarrh  fermentation  of  the 
contents  may  cause  so  much  distention  of  the  stomach 
that  pain  is  e.\perienced  which  does  not  yield  to  ano- 
dynes. Pain  is  not,  however,  so  frequent  in  this  con- 
dition as  in  gastric  ulcer  or  in  nervous  dyspepsia.  The 
term  "gastralgia,"  usually  applied  to  these  pains,  is 
misleading,  because  its  treatment  is  apt  to  be  sympto- 
matic, viz.,  by  anodynes.  A  correct  differential  diag- 
nosis of  acute  gastric  pains  may  be  obtained  only  by  a 
correct  understanding  of  its  causation. 

In  gastric  ulcer  the  pain  is  chiefly  due  to  irritation 
by  the  secreted  hydrochloric  acid  of  the  delicate  nerve 
endings  which  the  ulcerative  process  has  exposed. 
Hence  we  have  a  distinctly  localized  pain  of  a  burning, 
agonizing  character,  radiating  to,  and  often  felt  in,  the 
region  of  the  dorsal  spine  ;  it  is  increased  by  pressure, 
if  the  latter  happens  to  be  made  near  the  locality  of 
the  ulcer  ;  it  is  aggravated  by  any  kind  of  food,  but 
more  especially  by  imperfectly  chewed  solid  food. 
Fortunately,  we  have  an  almost  certain  diagnostic  sign  in 
the  efficacy  of  alkalies  for  the  subdual  of  this  kind  of 
pain.  Even  when  large  doses  of  morphine  have  failed 
I  have  seen  pain  from  ulcer  of  the  stomach  disappear 
as  if  by  magic  after  a  dose  of  magnesia.  I  have  in 
mind  a  haggard,  sallow-faced  lady  from  San  Fran- 
cisco, who  had  come  to  New  York  to  consult  a  noted 
specialist  with  regard  to  a  severe  gastric  pain,  which  re- 
curred at  intervals  and  was  sometimes  accompanied  by 
jaundice.  This  gentleman  had  examined  her  carefully, 
and  concluded  that  there  was  no  disturbance  which  re- 
quir'ed  treatment  at  his  hands.  In  pursuance  of  this 
opinion  she  had  decided  to  return  home  on  the  following 
morning.  This  plan  was,  however,  frustrated  by  the 
sudden  illness  of  her  child,  which  I  was  called  to  at- 
tend. Suffering  severely  one  evening,  she  gave  me  a 
history  of  her  case  and  asked  my  advice.  I  declined  a 
positive  opinion  until  morning,  and  stated  that  if  her 
pains  should  be  relieved  by  the  powder  which  I  pre- 
scribed for  her  (bismuth  subnitrate  and  magnesia,  ust. 
aa  gr.  x.  every  three  hours),  I  should  decide  upon  the 
diagnosis  of  ulcer  of  the  stomach,  and  advise  her  to 
remain  six  weeks  for  treatment.  If,  upon  the  other 
hand,  the  gastric  pains  remained  unrelieved  in  twelve 
hours,  I  should  agree  with  her  previous  medical  ad- 
viser and  consent  to  her  returning  home.  On  the  fol- 
lowing day  she  was  entirely  free  from  pain,  and  by 
reason  of  the  positive  opinion  expressed,  she  consented 
to  remain  under  my  care.  The  treatment  adopted 
successfully  in  this  case  will  be  referred  to  later.  I  de- 
sire here  only  to  emphasize  the  diagnostic  value  of  al- 
kalies. In  gastric  pains  due  to  nerrvns  dyspepsia  alka- 
lies would  afford  some  relief,  but  not  entire  removal. 
The  pain  in  these  cases  is  not  so  distinctly  localized, 
but  more  diffused  ;  it  is  not  acute  and  boring,  but 
rather  spasmodic,  somewhat  relieved  by  eructation  and 
uninfluenced  by  food.  It  is  at  times  so  severe  that  a 
condition  of  collapse  may  ensue,  evidenced  by  cold 
extremities,  pallor,  and  feeble  pulse.  Such  cases  may 
be  differentially  diagnosed  sometimes  by  the  co-exist- 
ence of  a  systemic  neurosis  and  by  hyper.xsthesia  of 


the  abdominal  parietes,  which  not  infrequently  yield  to 
deep  pressure.  Such  attacks  often  resemble  angina 
pectoris.  I  have  seen  two  cases  mistaken  for  the  latter 
by  two  prominent  diagnosticians  in  this  city,  and  one 
of  my  own  cases  afforded  a  similar  observation. 

At  this  point  a  form  of  gastric  pain  may  be  referred 
to,  whose  early  recognition  is  of  great  diagnostic  im- 
portance, viz.,  the  gastric  crisis  of  Charcot.  Its  pecu- 
liarity is  a  periodical  character,  its  great  intensity,  spas- 
modic type,  and  tendency  to  radiate  downward  and 
backward.  The  vomiting  which  almost  invariably  ac- 
companies without  relieving  it,  renders  it  characteristic 
of  locoynotor  ataxia.  At  any  rate,  it  is  always  safe  to  ex- 
amine the  tendon  and  pupillary  reflexes  of  patients 
suffering  from  periodic  severe  gastric  pains  and  vom- 
iting. Much  bootless  medication  and  groping  in  the 
dark,  which  discredits  the  physician,  would  be  spared 
by  sach  a  course. 

Pyrosis  or  heart-bum  is  one  of  the  prominent  symp- 
toms of  difficult  digestion.  This  is  no  longer  regarded 
as  due  to  regurgitation  of  acid  fluids  from  the  stomach 
to  the  oesophagus,  for  it  has  often  been  found  to  exist 
when  the  stomach-tube  failed  to  discover  any  fluid  at 
all.  It  is  now  regarded  as  a  neurosis  affecting  the 
motor  apparatus  of  the  stomach. 

Nausea  and  vomiting  are  not  infrequent  manifesta- 
tions of  difficult  digestion.  In  long-persistent  gastric 
catarrh,  when  large  quantities  of  tenacious  mucus  line 
the  mucous  membrane,  nausea  is  not  rare  ;  it  is  often 
the  result  of  overdistention  of  the  stomach  by  ferment- 
ing materials,  being  more  of  a  gulping  up  of  the  latter 
than  a  real  expulsive  act.  Frequent  vomiring  of  food 
is  a  serious  symptom  (except  in  hysteria),  always  indica- 
ting organic  changes  in  the  stomach,  the  most  grave  of 
which  is  cancer.  In  the  latter  a  long  period  usually 
elapses  between  ingestion  and  vomiting  of  food.  Its 
expulsion,  unchanged  or  decomposed,  affords  a  clew 
which  may  be  verified  by  other  sjTiiptoms,  as  cachexia, 
malnutrition,  the  presence  of  a  tumor,  and  the  presence 
of  lactic  acid  in  the  test-meal.  Having  now  briefly 
passed  in  review  the  local  manifestations  of  difficult 
digestion,  and  the  manner  in  which  they  may  aid  in 
our  diagnostic  search,  which  is,  after  all,  the  great  pre- 
requisite to  successful  treatment,  I  desire  to  refer  to 
a  rapid  and  practical  method  of  securing  confirmation 
or  rejection  of  the  diagnosis  obtained  from  the  subjec- 
tive signs  of  dyspepsia. 

The  number  of  chemical  tests  which  have  been  pro- 
posed for  the  purpose  of  obtaining  a  reliable  measure 
of  the  digestive  capacity  of  the  stomach  is  bewildering 
to  the  general  practitioner.  One  by  one  I  have  aban- 
doned them,  except  in  obscure  cases.  There  is  a  sim- 
ple method  which  I  would  commend  to  your  attention, 
and  by  which  we  may  ascertain  without  much  delay, 
and  with  sufficient  accuracy  for  all  practical  purposes, 
not  only  the  type  of  dyspepsia  we  have  to  deal  with, 
but  to  a  certain  extent  also  the  dietetic  and  other  treat- 
ment most  appropriate  for  the  case.  I  refer  to  the  stom- 
ach-tube, which  is  doubtless  familiar  to  most  of  you. 
Ordinary  cases  of  dyspepsia  do  not  require  its  applica- 
tion :  they  usually  yield  to  a  properly  directed  treat- 
ment without  much  difficulty.  In  cases  of  chronic, 
obstinate,  and  long-persisting  dyspepsia,  however,  1 
advise  the  patient  to  eat  a  good  meal  of  mixed  food, 
especially  enjoining  upon  him  to  consume  those  articles 
which  he  has  long  avoided  as  indigestible.  He  is  re- 
quested to  ajjpear  at  my  office  five  hours  later  for  ex- 
amination of  the  stomach  contents.  A  strong  elastic 
tube  of  one-eighth  to  one-half  inch  in  diameter,  which 
is  sold  for  that  purpose,  is  introduced  into  the  stomach, 
six  ounces  of  warm  water  are  poured  into  it  from  time 
to  time,  and  siphoned  out  into  a  basin.  In  gastric 
catarrh  the  latter  will  contain  large  quantities  of  thick 
gelatinous  mucus,  floating  upon  the  surface  of  the 
water,  debris  of  food,  sometimes  unchanged  and  partly 
digested,  which  sinks  to  the  bottom,  and  much  foam 
from  gases  of  fermentation.     If  after  five  hours  much 


October  5,  1895] 


MEDICAL    RECORD. 


471 


food  remains  in  the  stomach,  second  and  third  ex- 
aminations are  made,  prolonging  the  interval  between 
eating  and  examination  an  hour  each  time,  until  ei"ht 
hours  have  been  reached.  It  has  been  definitely  ascer- 
tained by  Kretsch,  who  examined  patients  suffering 
from  gastric  fistula;  with  the  stomach-tube,  that  a 
moderate  breakfast  of  rolls  and  coffee  is  digested  in 
four  and  a  half  hours,  a  good  dinner  of  mixed  food  in 
seven  hours,  and  that  during  sleep  seven  to  eight  hours 
are  required  for  the  disposal  of  an  ordinary  supper  by 
the  healthy  stomach. 

If  the  patient  be  unable  to  eat  a  large  test-meal,  a 
smaller  one,  consisting  of  bread  and  tea,  is  ordered, 
and  he  is  examined  two  or  three  hours  later  by  lavage^ 
in  order  to  test  the  motor  capacity  of  the  stomach.  '^If 
we  have  a  case  of  nervous  dyspepsia  to  deal  with,  i.e., 
a  dyspepsia  without  organic  changes  in  the  mucous 
lining,  neither  mucus  nor  food  will  be  found,  or  these 
will  appear  in  very  small  quantity. 

This  is  a  very  simple  method  of  diagnosis,  and  seems, 
in  contrast  with  the  elaborate  chemical  tests  practised 
by  our  friends  the  gastrologists,  almost  insignificant. 
Far  be  it  from  me  to  underrate  the  value  of  the  test- 
meals  of  Ewald  and  others,  one  of  which  consists  of  a 
roll  and  a  glass  of  water,  which  are  siphoned,  or  rather 
dra-mi  out,  an  hour  or  two  later,  filtered  and  examined 
for  hydrochloric  acid,  ferments,  and  other  elements  in- 
volved in  the  digestive  act.     These  tests,  let  me  urge, 
are  troublesome  and  by  no    means  accurate,   or  weli 
established.     Each  prominent  gastrologist  has  a  method 
•  which  he  regards  as  superior  to  the  fallacious  method 
of  his  confrere.     For  instance,  there  is  not,  according 
to  Ewald,  at  the  present  time  a  single  unobjectionable 
or   e.xact    procedure   for    the   estimation  of  the   exact 
quatitity  of  hydrochloric  acid  contained  in  the  stomach. 
Again,   for  a  long  time  the   mere   absence   of  hydro- 
chloric acid  from  the  contents  of  the  stomach,  an  hour 
after  a  test-breakfast  of  rolls  and  water,  was  regarded 
as    pathognomonic    of  cancer.       Now   this   is   proven 
fallacious,    it   having  been    shown   that   only   in   open 
ulcerative  cancer  of  the  stomach  is  this  the  case,  be- 
cause the  secretions  from  such  surfaces  neutralize  the 
acid.     I  may  say,  in  parentheses,  that   at  the  present 
tinrie  the  presence  of  a  considerable  quantity  of  lactic 
acid  after  a  test-meal  is  regarded  as  a  positive   sign  of 
gastric  cancer.     These  tests  may  serve  a  useful  pur- 
pose,   nevertheless,  in   very  doubtful  cases,  in  which 
clinical  signs  are  insufficient  or  difficult  of  interpreta- 
tion.    They  may  be  resorted  to  in  cities  where  chemists 
and  specialists  abound.     But  I  desire  to  impress  upon 
you    the    fact   that   for   all    practical   purposes,  in   the 
majority   of   cases    the   practitioner   is   competent    to 
make  a  diagnosis,  without  these  tests,  with  sufficient 
accuracy  to  treat  the  patient,  if  he  exercise  care  and 
judgntient.     It  must  be  conceded  that  if  we  find,  upon 
examining   the    contents    of   the    stomach  five    or  six 
hours  after  a  hearty  meal,  that   every  particle  of   the 
latter  has  been  disposed  of,  we  have  good  reason  to 
believe  that  the  patient's  acids  and  digestive  ferments, 
as  well    as   the    motor   or  propulsive  capacity  of  his 
stomach,  are  normal.     This  is  the  outcome  of  perscmal 
observation  during  a  period  of  thirty  years,  before  and 
since  the  modern  tests  and  methods,  all  of  which  I 
have  faithfully  practised,  came  into  vogue.     I  well  re- 
member two  cases  of  cancer  of  the  stomach  in  which 
the   chemical    signs    were    plain,    in    one   of   which    a 
morning  irrigation  of  the  stomach  brought  out  putrid 
detritus  of  a  meal  taken  twelve  hours  previously.     In 
both  cases  a  noted  specialist  in  stomach  disease,  whose 
good  work  in  this  branch  induced  me  to  consult  him, 
declined  to  say  positively,  from  his  analysis,  that  the 
patients  suffered   from  malignant   disease.     Both  pa- 
tients  died,  one    after   an    operation.     On    the    other 
hand,  I  have  recently  been  consulted  by  a  gentleman 
who  gave  a  history  of  having  been  treated  for  several 
years  by  gastrologists.     Boas  had  pronounced  his  case 
nervous  dyspepsia  ;    a  New  York  specialist  called  it 


gastric  catarrh  and  made  him  "  swallow  electrodes  and 
undergo  all  kinds  of  torture,"  as  he  expressed  it,  with- 
out result.  Another  specialist  gave  him  a  test-meal 
and  pronounced  his  case  nervous  dyspepsia,  with  poor 
digestive  power.  'When  he  applied  for  water  treatment, 
which  had  benefited  him  a  year  ago  more  than  stomach 
treatment,  I  found  him  greatly  discouraged  by  the  dis- 
agreement of  the  specialists  and  their  failure  to  remove 
his  dyspepsia,  to  which  he  insisted  upon  being  a  martyr. 
.\  full  dinner  was  ordered  for  him,  with  the  injunction 
to  eat  such  articles  as  he  had  avoided  as  indigestible, 
including  chocolate  eclairs,  whose  mention  even  hor- 
rified him,  and  to  report  five  hours  later.  When  he 
witnessed  the  irrigation  of  his  stomach  and  saw  no  re- 
turn of  undigested  food,  the  water  returning  perfectly 
clear,  he  exclaimed  :  "  Now  I  am  convinced  that  my 
digestion  is  normal,  and  I  shall  no  longer  worry  myself 
about  dyspepsia  !  "  Such  positive  demonstration  is 
more  valuable  than  chemical  tests,  especially  for  its 
moral  effect  in  those  cases  of  nervous  dyspepsia  which 
are  the  bane  of  the  doctor's  life. 

Treatment.— A  differential  diagnosis  having  been 
clearly  established  between  gastric  catarrh,  nervous 
dyspepsia,  and  gastric  ulcer— the  three  most  prolific 
sources  of  difficult  digestion— each  disease  demands  a 
specific,  distinct  mode  of  management. 

Gastric  catarrh   is,  according   to  my  personal  obser- 
vation, the  most  frequent  cause  of  dyspepsia  in  rural 
districts  and  in  the  smaller  towns  ;  nervous  dvspepsia 
bearing  an   equal   share   of   prevalence  with   it   in  the 
larger  mercantile  and  manufacturing  centres.     In  dis- 
cussing catarrh  of  the  stomach,  it  is  important  to  dis- 
abuse ourselves  of  the   idea,  which   is  but  too  freely 
adopted,  that  it  is  like  other  catarrhs,  for  instance,  ca- 
tarrh of  the  pharynx.     The  latter  is  chiefly   a  hyper- 
secretion arising   from   inflammation   of   the  epithelial 
stratum  of   the   mucous  membrane.     Inasmuch  as  the 
lining  membrane  of  the  stomach  differs  materially  from 
that  of  the  pharynx  in  structure  and  function,  its  in- 
flammations assume  quite  a  different  aspect.     The  cyl- 
indrical epithelium  of  the  gastric  mucous  membrane  is 
continuous  into  the  gastric  glands,  with  which  it  is  al- 
most  imperceptibly   incorporated.      Hence   the   same 
epithelium  practically  covers  every  part  of  the  gastric 
Iming,  including  all  its  structures  and  glands.     Gastric 
catarrh,   therefore,  always  involves  the   latter,  if  it  is 
not  limited  to  the  little  elevations  between  the  edges  of 
the  glands,  which  is  rarely  the  case.     A  gastric  catarrh 
is,  therefore,  more  like  a  chronic  nephritis  in  its  essen- 
tial characteristics  than  like  a  simple  catarrhal  inflam- 
mation.      Bearing   these   crude   pathological   facts   in 
nnind,  the  salient  indications  for  treatment  should  be 
limited  to  the  restoration   of  Xh^  functions  of  the  stom- 
ach  to   a  normal   standard,  especially  of  that  portion 
which  produces  the  excessive  secretions  whose  inter- 
ference with  the  act  of  digestion  is  the  chief  source  of 
trouble.     The  stomach,  be  it  remembered,  is  no  longer 
considered  an  organ  of  absorption,  but  rather  is  it  now 
regarded  as  a  receptacle  for  food  coming  into  it  after 
preparation   by  mastication  and  insalivation,  which  it 
elaborates  chemically  and  mechanically  for  propulsion 
into  the  upper  intestinal  tract,   when  absorption   and 
the  first  step  of  utilization  of  the  food  is  accomplished. 
Not  even  water  is  absorbed  by  the  mucous  membrane 
of  the  stomach.     Indeed,  it  is  held  by  physiologists  of 
repute   that  if  well-masticated   food  could   reach  the 
duodenum   without   passing   through    the    stomach,   it 
would   be   utilized  almost  wholly,  but  that  such  food 
may  irritate  and  eventually  cripple  the  most  important 
portion  of  the  digestive  and  assimilative  organs.     The 
first  thing  to  be  done  in  treating  gastric  catarrh  is  to 
remove  the  causes  which  have  conspired  to  produce  it. 
The   second  indication  is  to  assist   the   muscular  or 
motor  apparatus  of  the  stomach  in  its  work  of  churn- 
ing, mingling,  and  propelling  of  ingesta  into  the  ab- 
sorbing chambers,  by  introducing  only  such  food   as 
may  not  embarrass  by  distending  it.     The  third  object 


472 


MEDICAL    RECORD. 


[October  5,  1895 


is  the  removal  of  the  accumulated   tenaceous  mucus, 
which  embarrasses  the  stomach  glands  at  every  point. 

These  being  the  prime  indications  for  treatment,  how 
are  they  to  be  fulfilled  ?  Among  the  causes  of  gastric 
■catarrh,  the  most  prominent  are  improper  food,  insuffi- 
cient mastication,  and  depreciation  of  the  general 
health.  The  removal  of  these  causes  would,  in  a  large 
proportion  of  cases,  remove  the  disease  entirely,  but 
the  enormous  difficulty  which  confronts  us  in  the  at- 
tempt soon  becomes  apparent  and  discouraging. 

1.  Imperfect  food.  The  subject  of  food  and  its 
preparation  is  too  extensive  for  discussion  in  the  lim- 
ited time  at  my  disposal.  Reference  to  a  few  salient 
points  must  suffice.  Saccharine  and  fatty  food  should, 
of  course,  be  avoided,  freshly  baked  breads  or  cakes 
being  especially  damaging.  Among  farinaceous  foods, 
most  of  which  are  objectionable,  rice  cooked  in  the 
true  South  Carolina  fashion,  viz.,  by  steaming  so  that 
each  grain  be  separate  and  dry  and  not  pultaceous,  is 
the  least  harmful.  Being  exceedingly  nutritious,  as  is 
evidenced  by  the  enormous  amount  of  physical  labor 
endured  by  the  Japanese  and  others  under  an  almost 
exclusive  rice  diet,  its  constant  use  at  one  of  the  daily 
meals  should  be  insisted  upon.  Excess  of  fluids  at 
meals  should  be  avoided,  also  all  alcoholic  and  fer- 
mented beverages  at  all  times.  Frying  is  a  pernicious 
mode  of  cooking,  especially  when  fat  is  used  to  in- 
crease palatability.  Boiled  and  broiled  meats  and  fish, 
eggs,  with  rice  and  stale  bread,  form  an  ideal  diet,  and 
hot  (not  lukewarm)  milk  an  ideal  drink  for  meals.  So 
much  for  the  diet  for  \ht  prevention  of  gastric  catarrh 
in  predisposed  persons. 

In  the  treatment  of  the  established  disease  I  limit 
my  patients  to  a  few  articles  of  diet.  Meat,  especially 
beef  from  the  round,  well-chopped  in  an  Enterprise 
chopper  and  freed  from  all  fibre  and  fat,  called  Salis- 
bury steak  in  our  restaurants  (after  the  physician  who 
claims  to  cure  all  chronic  diseases  from  dyspepsia  to 
phthisis  by  hot  water  and  beef)  ;  this  preparation  of  beef 
is  the  ideal  food  in  the  treatment  of  gastric  catarrh,  be- 
cause it  furnishes  but  little  debris  and  gives  rise  to  no 
fermentations,  hence  no  distentions,  and  is  easily  pro- 
pelled into  the  duodenum.  The  next  best  food  is  hot 
milk.  It  should  be  so  hot  that  it  cannot  be  consumed 
except  with  a  spoon,  and  very  slowly.  My  usual  diet- 
ary prescription  in  moderately  severe  cases  is  a  pint  or 
more  of  very  hot  milk  for  breakfast,  as  much  Salisbury 
steak  as  the  patient  desires  for  luncheon  and  dinner, 
with  perhaps  a  little  black  coffee  and  some  Italian 
bread  (long  dry  sticks)  to  lessen  the  monotony  to  the 
palate.  In  more  severe  cases  I  order  one  pint  of  very 
hot  water  sipped  one  hour  before  each  meal,  a  shorter 
interval  renders  its  use  futile  and  interferes  with  diges- 
tion, the  meals  to-  consist  entirely  of  chopped  meat, 
without  bread.  Before  broiling  this  meat  Delmonico's 
chef  pours  the  white  of  an  egg  over  it,  causing  cohe- 
sion without  packing.  I  have  imitated  this  excellent 
device  with  profit.  Patients  will  complain  of  the  mon- 
otony of  the  diet,  but  in  these  cases  it  is  the  only  means 
of  feeding  at  our  disposal  and  should  be  insisted  on, 
gradually  if  necessary,  but  always  peremptorily. 

2.  Imperfect  mastication  must  be  remedied.  It  is 
futile  to  instruct  the  patient  in  the  avoidance  of  this 
prolific  source  of  gastric  catarrh,  because  the  fault 
most  frequently  arises  from  thoughtlessness  and  habit. 
It  is  my  jjractice  to  advise  the  patient  to  request  those 
persons  who  are  his  habitual  table  companions,  to 
check  him  whenever  he  is  eating  rapidly.  Business 
men  should  be  advised  to  eat  a  very  light  luncheon  at 
their  restaurants,  because  this  meal  interrujUs  their 
work,  to  which  their  thoughts  constantly  revert  while 
eating,  and  thus  only  by  the  greatest  self-control  may 
proper  attention  be  given  to  thorough  mastication.  It 
goes  without  saying  that  the  teeth,  especially  in  elderly 
persons,  should  be  put  into  good  condition  or  replaced 
by  artificial  ones.  The  mouth  and  teeth  should  be 
mech.mically  cleansed  and  disinfected  several  times  a 


day  by  preparations  like  bovine  or  a  moderately  strong 
solution  of  chlorate  of  potash,  because  decomposition  of 
ingested  food  may  be  started  by  the  commingling  of 
bacteria  and  partly  decomposed  food  coming  from  the 
mouth. 

3.  Our  means  of  removing  mucus  from  the  stomach 
and  restoring  the  functions  of  the  latter  are  mechani- 
cal and  medicinal.  Among  the  former  may  be  count- 
ed the  anteprandial  potations  of  hot  water  referred  to. 
I  usually  prescribe  five  grains  of  resorcin  an  hour  be- 
fore each  meal  as  an  antifermentative,  and  if  hot  water 
is  not  well  borne  or  is  impracticable,  as  in  the  case  of 
business  men,  a  powder  of  ten  grains  each  of  bismuth 
and  magnesia,  half  an  hour  before  meals,  serves  a  good 
purpose.  The  most  potent  measure,  however,  for  the 
removal  of  mucus  and  stimulation  of  the  motor  func- 
tion is  stomach-washing  or  lavage.  The  technique  of 
this  little  operation  is  not  difficult,  but  without  atten- 
tion to  certain  details  failure  is  prone  to  attend  it. 
Hence  a  few  words  on  the  subject  \az.y  not  be  out  of 
place.  In  the  first  place  the  tube  should  be  made  of 
firm,  yet  elastic  soft  rubber  (hard  rubber  tubes  are  dan- 
gerous), five  feet  long,  from  one-quarter  to  three-eighths 
of  an  inch  in  diameter,  with  open  end,  one  inch  from 
which  should  be  located  a  narrow  fenestrum,  three- 
quarters  of  an  inch  long.  The  largest  size  tube  affording 
a  more  rapid  entrance  and  exit  of  water,  shortens  the 
duration  of  the  sometimes  unpleasant,  though  not  pain- 
ful, procedure.  A  medium-sized  or  small  tube  with 
firm,  thick  walls,  sometimes  passes  more  readily.  The 
patient  should  be  protected  with  a  rubber  apron  or 
other  covering,  seated  upon  a  chair  and  a  basin  placed 
upon  another  chair,  one  of  whose  corners  is  wedged 
between  the  knees.  The  procedure  should  be  ex- 
plained ;  he  should  be  instructed  to  breathe  through 
the  nose  and  open  mouth,  and  he  may  be  assured  not 
to  apprehend  choking  when  the  tube  enters  the  throat, 
by  the  fact  that  the  diameter  of  the  tube  is  much  small- 
er than  particles  of  meat  which  he  has  often  swallowed. 
A  quart  pitcher  of  tepid  water,  to  which  a  teaspoonful 
of  salt  has  been  added,  a  funnel,  and  several  towels 
having  been  placed  in  readiness,  the  mouth  is  exam- 
ined and  artificial  teeth  are  removed.  Bending  the 
head  slightly  forward,  the  patient  is  requested  to  pro- 
trude his  tongue,  which  should  never  be  pressed  out  of 
the  way.  The  lower  end  of  the  tube  having  been 
dipped  into  the  water  for  lubrication  (oil  damages  the 
rubber),  it  is  grasped  about  four  inches  from  its  ex- 
tremity, like  a  pen  ;  the  somewhat  rigid  portion  is  now 
gently  passed  into  the  pharynx,  avoiding  the  tongue  as 
much  as  possible.  When  it  touches  the  pharynx,  the 
patient  is  asked  to  swallow.  At  this  moment  the  tube 
is  pushed  gently  downward.  In  patients  having  lav- 
age done  for  the  first  time,  or  who  are  nervous  and 
fretful,  rasping  and  choking  will  ensue.  The  tube 
should  be  withdrawn  if  this  continues,  and  a  second 
and  third  effort  should  be  made  while  the  patient's 
morale  is  sustained  by  gentle  reassurance,  and  not  by 
scolding.  "Put  yourself  in  his  place  "  should  be  re- 
membered by  the  physician,  when  the  patient  seems 
alarmed  by  this  simple  and  absolutely  harmless  pro- 
cedure. 

In  persons  of  calm  temperament  and  in  those  who 
are  accustomed  to  the  tube,  it  will  slip  down  easily  upon 
gentle  yet  firm  pressure  being  made,  and  by  sliding  it 
through  the  thumb  and  forefinger  whenever  the  latter 
reaches  the  teeth,  until  the  black  ring  mark,  which  is 
from  twelve  to  eighteen  inches  from  the  lower  end, 
reaches  the  lips.  The  patient,  if  quiet,  otherwise  an 
assistant,  now  holds  the  tube  between  thumb  and  fore- 
finger of  the  left  hand  close  to  the  teeth,  which  must  not 
be  closed.  Adjusting  the  funnel  to  the  upper  end  of 
the  tube,  four  to  six  ounces  of  the  salt  water  are  poured 
into  it,  the  funnel  is  raised  to  insure  its  outflow  by 
gravity.  If  undigested  food  he  present  the  water  may 
not  flow  out  readily,  because  the  lower  ojienings  are 
clogged.     In  this  event,  raising  the  funnel  higher  may 


October  5,   1895] 


MEDICAL   RECORD. 


473 


force  the  obstruction  out,  otherwise  the  tube  must  be 
removed  and  reintroduced  after  clearing  the  fenestrum. 
About  half  a  pint  of  water  having  entered  the  stom- 
ach, the  funnel  should  be  lowered  while  water  is  still 
contained  in  it,  in  order  to  produce  siphonage  into  the 
funnel,  which  is  now  turned  to  allow  the  water  to  flow 
into  the  basin.  This  act  is  repeated  until  the  water 
flows  out  clear.  Some  patients — about  fifty  per  cent. — 
gag  and  vomit  during  lavage.  These  must  be  cau- 
tioned to  hold  the  teeth  apart  and  simply  bend  over 
the  basin  and  let  the  vomitus  flow  into  it,  while  they 
or  an  assistant  firmly  hold  the  tube  near  the  teeth. 
Otherwise  it  will  be  washed  out  with  the  rushing 
stream.  Perseverance  and  calmness  on  the  part  of  the 
physician  will  insure  against  failure.  Among  hundreds 
of  cases  I  have  failed  but  twice,  one  being  a  nervous 
woman  and  the  other  a  nervous  physician,  neither  one 
of  whom  would  permit  a  second  introduction.  Moit  pa- 
tients become  accustomed  to  the  tube  after  two  or  three 
introductions.  I  remember  well  an  old  lady  from 
Charleston,  who  consulted  me  about  eight  years  ago 
for  a  most  obstinate  gastric  catarrh  which  caused  vom- 
iting after  meals,  and  impaired  her  nutrition  badly. 
When  she  saw  the  tube  she  declined  to  have  that 
"  snake-like  thing  "  near  her.  In  two  weeks  she  intro- 
duced it  herself,  and  thus  did  more  to  complete  the 
cure  than  I  could  have  done.  Indeed,  there  is  no 
method  of  treating  this  disease  comparable  to  lavage. 
It  should  be  done  before  the  chief  meal  once  a  day,  in 
order  to  obtain  the  full  benefit  of  this  meal.  If  mucus 
accumulates  rapidly  and  the  quantity  does  not  dimin- 
ish each  day  after  several  irrigations,  lavage  may  be 
done  before  breakfast  also.  Mucus  is  removed,  the 
glands  are  freed  from  obstructions,  the  muscular  power 
is  increased  by  the  daily  filling  and  emptying  of  the 
stomach  and  removal  of  fermenting  material,  and  the 
introduction  of  the  foreign  body  increases  secretion 
from  the  gastric  glands. 

Another  valuable  effect  of  lavage  is  the  discovery  of 
those  articles  of  diet  which  are  best  adapted  to  each 
case,  and  in  some  cases  also  of  certain  defects,  as  in  the 
following  instance.  A  lady  from  Georgetown,  S.  C, 
consulted  me  several  years  ago  for  severe  colics,  for 
which  she  had  been  treated  in  vain  by  her  intelligent 
physician  at  home  :  Close  examination  led  me  to 
charge  her  with  too  rapid  eating  and  careless  mastica- 
tion. She  indignantly  repudiated  the  charge,  saying 
that  she  was  the  slowest  eater  in  her  family.  A  test- 
meal  of  rice,  beef,  tomatoes,  and  accessories,  showed 
particles  of  unmasticated  meat  and  even  some  of  the 
rice-grains  were  unscathed  and  had  swollen  to  thrice 
their  size.  This  ocular  proof  convinced  the  patient  of 
the  necessity  of  more  thorough  mastication  and  she 
recovered  entirely  from  gastric  catarrh,  which  was  the 
cause  of  her  colic,  under  the  treatment  here  outlined. 

The  irrigations  should  be  continued  daily  or  less 
frequently,  according  to  the  reaccumulation  of  mucus, 
until  the  stomach  remains  clear  for  a  week  or  two,  and 
the  symptoms  subside.  Contra-indication  to  the  use 
of  the  stomach-tube  are  aneurism  of  the  aorta,  innom- 
inate or  carotid  arteries,  angina  pectoris  and  uncom- 
pensated valvular  lesions,  fatty  heart,  pregnancy,  cere- 
bral congestion,  asthma,  and  very  great  debility.  In 
ulcer  of  the  stomach,  with  or  without  hemorrhage,  lav- 
age should  be  used  only  with  the  greatest  caution,  if 
at  all. 

I  have  perhaps  entered  into  tedious  detail  on  this 
subject,  but  my  desire  to  offer  you  personal  experience 
obtained  from  failures  and  successes,  must  be  my  war- 
rant therefor.  Among  medicinal  agents,  benefit  may 
be  derived  from  twenty  to  thirty  drop  doses  of  dilute 
hydrochloric  acid  in  four  ounces  of  water,  taken  im- 
mediately before  eating  each  solid  meal.  The  words 
immediately  before  eating  should  be  emphasized,  and 
it  must  be  insisted  on,  that  the  plate  be  served  and  the 
patient  ready  for  the  fork  or  spoon  when  the  acid  is 
taken.       This    I   learned  thirty  years   ago,  from  Dr. 


Thomas  King  Chambers,  London's  great  clinician,  and 
his  advice  has  served  me  well.  There  is  no  other 
medicinal  agent  that  is  of  any  value  in  this  condition, 
except  resorcin  and  bismuth,  already  mentioned  ;  I  have 
gone  through  them  all  and  discarded  them.  Pepsin 
I  have  not  used  at  all  in  the  last  ten  years,  although  I 
formerly  used  it  freely,  and  found  it  worthless  unless 
combined  with  muriatic  acid.  How  do  we  know  that 
it  acts  in  the  stomach  as  it  is  claimed  to  act  in  the  test- 
tube.  If  taken  before  meals  it  is  probably  absorbed 
or  expelled,  before  the  stage  of  digestion  for  which  it 
is  intended  is  reached.  Nor  can  we  expect  to  com- 
pensate for  deficiency  of  the  natural  hydrochloric  acid 
by  pouring  the  small  quantity  above  mentioned  into 
the  stomach.  It  is  more  its  agency  as  a  coagulant  of 
mucus,  and  as  a  disinfecting  agent,  that  its  good  effect 
may  be  ascribed. 

It  is  here  in  order  to  say  a  word  about  the  various 
commercial  combinations  of  pepsin,  lactopeptine,  wine 
of  pepsin,  mixed  with  medicinal  agents,  etc.  It  would 
seem  that  the  slightest  reflection  would  condemn  the 
use  of  any  and  all  of  these.  The  apparent  beneficial 
effect  sometimes  reported  is  due  to  the  otherwise  judi- 
cious management  of  the  diet,  exercise,  etc.,  in  the 
case.  Lactopeptine,  for  instance,  claims  to  be  com- 
posed of  several  elements  some  of  which  we  know 
would  be  destroyed  by  acid,  others  rendered  inert  in 
an  alkaline  medium.  And  yet  man)-  send  this  highly 
lauded  conglomeration  on  its  mission  through  the  saliva, 
gastric  juice,  without  reflecting  upon  the  physiological 
incongruity  involved.  The  more  simply  a  case  of  gas- 
tric catarrh  (and  for  that  matter  any  disease)  is  treated 
the  more  successful  will  be  its  management. 

The  fourth  therapeutic  indication  in  gastric  catarrh 
— the  improvement  of  the  general  health — will  be  referred 
to  at  length  when  considering  the  next  subject. 

Treatment  of  Nervous  Dyspepsia. — The  indications  in 
the  phase  of  difficult  digestion  are  entirely  different 
from  that  of  gastric  catarrh.  Instead  of  the  embar- 
rassment of  the  glandular  action  present  in  the  latter, 
we  have  a  hypersecretion  usually,  hydrochloric  acid 
having  even  been  found  in  the  empty  stomach  of  some 
of  these  patients.  A  detailed  description  of  nervous 
dyspepsia  is  not  required  before  this  audience.  You 
are  all  familiar  with  it,  although  it  is  not  as  common 
here  as  it  is  in  New  York  and  other  large  cities. 

A  diagnosis  having  been  clearly  made  by  the  stom- 
ach-tube and  lavage,  the  local  distress  demands  imme- 
diate attention.  For  this  purpose  bismuth  and  mag- 
nesia in  ten- grain  doses  are  extremely  helpful  if  given 
half  an  hour  before  meals.  The  postprandial  pains, 
heartburn,  and  other  manifold  distresses,  often  yield 
to  the  tablets  of  animal  charcoal,  magnesia,  and  gin- 
ger, as  made  by  Wyeth  and  others,  one  chewed  dry 
every  half  hour.  Sometimes  larger  doses  of  bicarbon- 
ate of  soda  arid  magnesia  may  be  required.  Lavage  is 
rarely  needed,  chiefly  when  there  is  an  accumulation 
of  gases.  A  hypersensitiveness  of  the  digestive  organ- 
ism exists  here,  which  may  be  in  a  comparatively  dor- 
mant state  for  a  time,  and  at  other  times  be  exasper- 
ated by  some  special  indiscretion  in  diet  or,  more 
frequently,  of  conduct.  We  find  no  organic  defect, 
but,  on  the  contrary,  an  over-active  function.  The 
aim  of  treatment  should  be  to  reach  the  cause,  which 
is  usually  psychical.  Close  confinement  to  indoor 
work,  especially  in  the  counting-room  and  library, 
must  be  abandoned  ;  the  patient  should  be  placed  in 
closer  communion  with  nature.  Yery  active  exercise 
is  to  be  deprecated,  but  change  of  air  and  scene  are  of 
inestimable  value,  indeed,  of  greater  value  than  any 
other  treatment.  When  the  patient  cannot  leave  home, 
or  is  not  benefited  by  change  of  air  and  scene,  or  the 
physician  desires  to  insure  the  permanence  of  the  ef- 
fect of  the  latter,  a  course  of  hydrotherapy  offers  the 
best  chance  for  him.  By  improving  the  general  tone, 
the  functional  activity  of  the  stomach  and  other  organs 
is  enhanced,  the  nutrition  is  improved,  and  in  a  brief 


474 


MEDICAL    RECORD. 


[October  5,  1895 


time  the  entire  aspect  of  the  case  is  changed.  This  is 
illustrated  by  the  history  of  the  following  cases  : 

Mrs.  O ,  aged  twenty-eight,  resident  of  Florida, 

consulted  me.  May  5,  1892,  for  "catarrh  of  the  stom- 
ach," because  of  agonizing  pains  after  meals.  She  has 
been  living  on  mush  and  milk,  and  has  had  medical 
treatment  for  several  years,  with  diminution  but  not 
disappearance  of  the  pains.  She  is  emaciated  ;  her 
voice  is  feeble  ;  she  is  depressed  and  hopeless.  Her 
wan  face  and  prematurely  old  appearance  bear  evi- 
dence of  a  life  of  constant  physical  suffering.  There 
is  not  a  particle  of  the  hysteric  element  in  this  case. 
Ordered  at  12.30  p.m.  a  full  test-meal  at  Delmonico's, 
which  she  reluctantly  accepted,  because  of  dreaded  in- 
crease of  pain.  The  stomach  was  washed  out  without 
difficulty  five  hours  later.  To  her  great  surprise,  my 
prediction  that  her  dinner  would  be  digested  was  veri- 
fied, a  little  tomato  peel  being  the  only  remnant  visible. 
The  diagnosis  of  a  gastric  neurosis  being  thus  con- 
firmed, she  was  ordered  a  mi.xed  diet,  chiefly  consisting 
of  hot  milk  and  stale  bread  and  hominy  for  breakfast, 
adding  eggs  (soft  boiled)  later.  Same  with  chops  or 
oysters  for  luncheon,  and  steamed  rice  and  roast  beef 
for  dinner.  Desserts  and  salads  were  forbidden.  The 
general  invigoratioii  of  the  entire  system  being  the  chief 
element  in  this  case,  she  was  placed  up'm  daily  hydri- 
atic  measures,  adapted  to  her  case  by  gradually  accus- 
toming her  to  lower  temperatures  and  stronger  press- 
ure.    Under  these  she  steadily  improved. 

June  20th. — Pain  returning,  the  constant  current,  12 
milliamperes,  was  applied  by  a  large,  flat,  sponge  elec- 
trode over  epigastric,  and  a  small  one  over  lumbar,  re- 
gion. 

June  27th.  —  Temperature  of  baths  having  been 
higher,  was  now  reduced,  patient  being  again  de- 
pressed. The  jet  douche  was  given  at  50"  F.  for 
thirty  seconds  ;  reaction  good. 

July  gth. — Electricity  having  been  unavailing,  and 
fermenting  material  being  found  in  the  stomach,  the 
Scotch  douche  was  applied  to  epigastric  region  for 
thirty  seconds  after  the  rain  bath,  70°  to  45°  F.  daily, 
and  followed  by  jet  douche  at  50°  F.  for  thirty  sec- 
onds. Patient  now  feels  sufficiently  restored  to  go  to 
Buffalo  to  her  parents. 

Under  date  of  November  26,  1892,  she  writes  that 
she  has  gained  fifteen  pounds  in  weight  and  is  much 
stronger  ;  has  continued  the  diet  prescribed,  because, 
like  most  of  these  neurotics,  she  "  feared  her  stomach 
was  not  equal  to  much  of  a  change."  Most  of  flie 
time  she  is  entirely  free  from  pain  ;  she  has  slight  dis- 
tress every  now  and  then,  but  expresses  the  warmest 
gratitude  for  the  help  given. 

Miss  W ,  daughter  of  an  Ohio  physician,  aged 

twenty-three,  was  sent  to  me  by  Dr.  Francke  Bosworth, 
the  well-known  rhinologist,  on  May  15,  18S9,  pale, 
emaciated,  despondent,  the  picture  of  woe  and  de- 
spair. She  was  brought  into  my  office  by  her  sister. 
She  had  been  ill  three  years,  suffering  first  from  faint- 
ing-fits at  the  menstrual  period,  afterward  from  violent 
pains  in  the  right  hand,  traversing  the  body  and  con- 
centrating in  the  epigastrium.  For  these  her  father 
and  brother  had  been  compelled  to  administer  morphia 
for  a  month.  Her  stomach  became  irritable,  and  has 
continued  so  up  to  the  present  time.  She  vomited  or 
spat  up  nearly  all  her  food,  mostly  the  solids.  Sea- 
baths  did  not  improve  her.  She  studied  hard  and 
grew  worse.  In  the  fall  of  188S  she  lived  on  milk  and 
farinaceous  mush,  and  her  stomach  was  regularly  ir- 
rigated, without  improvement.  She  grew  worse,  be- 
came emaciated  ;  took  peptonized  mild  for  a  month, 
but  vomited  it  ;  meat  produced  the  same  effect.  Last 
fall  she  lived  on  grapes,  which  agreed  with  her.  Now, 
she  had  tonics,  and  pepsin,  and  all  ])ossible  medica- 
tions which  her  father  and  brother  could  muster.  She 
was  sent  to  Dr.  Bosworth,  who  is  a  friend  of  her 
brother.  After  being  in  the  city  for  three  weeks  with- 
out improvement,  the  doctor  sent  her  to  me.      She 


now  vomits  every  day.  She  traces  her  ailment  to 
painting-lessons,  but  I  drew  from  her  the  history  of  a 
potent  psychical  factor  as  a  cause — the  sudden,  violent 
insanity  of  the  favored  nurse  of  her  childhood.  My 
diagnosis  was  nervous  dyspepsia.  The  stomach  was 
washed  out  twice  a  week  to  remove  mucus  and  fer- 
menting material.  She  had  general  faradization  daily. 
Every  morning  she  received  the  dripping  sheet  at  60° 
F.,  while  standing  in  warm  water,  and  other  hydriatric 
measures  as  she  progressed.  Under  this  systematic 
management  she  improved  slowly  ;  vomiting  ceased 
entirely.  She  went  to  the  seaside  ;  improved  in  July. 
On  her  homeward  journey  she  called  to  tell  me  that 
she  had  grown  stout  and  felt  perfectly  well.  A  year 
later  I  received  a  letter  from  her,  informing  me  that 
despite  family  troubles,  which  necessitated  her  adopt- 
ing teaching  as  a  means  of  livelihood,  her  health  had 
been  perfect.  "  You  would  not  know  me,"  she  wrote, 
"  as  the  same  girl  you  treated." 

Dr.   H asked  me  on  March  4,  1890,  to  give  him 

lavage.  He  looked  haggard  ;  suffered  from  migraine  : 
had  worked  hard  in  country  practice  on  Long  Island 
for  years  ;  voinited  often,  with  headaches  ;  had  tried 
everything,  including  rest  for  eight  months  ;  dieted 
ver)'  carefully,  and  recently,  under  one  of  our  most 
eminent  consultants,  who  regarded  him  as  suffering 
from  gastric  catarrh,  confining  himself  to  hot  water 
and  chopped  beef  without  avail.  He  had  section  of 
the  external  rectus  done  on  both  eyes  by  an  enthusiast 
on  that  subject ;  thought  he  was  astigmatic,  which  Dr. 
Carl  Roller  did  not  concur  in.  My  diagnosis  of 
nervous  dyspepsia  was  confirmed  by  lavage,  which 
showed  perfect  digestion  of  a  full  and  varied  meal 
taken  five  hours  previously.  A  mixed  diet  was  ordered, 
which,  together  with  judicious  water  treatment,  relieved 
him  greatly.  I  have  recently  seen  the  patient  in  con- 
sultation at  his  home,  and  found  him  much  improved 
in  flesh  ;  his  general  health  is  good  and  is  maintained 
by  continuing  the  daily  hydrotherapy  which  I  had 
prescribed  for  him,  and  by  visiting  his  patients  on  a 
bicycle  in  the  suinmer.  He  thinks  he  would  have  died 
if  he  had  continued  his  former  professor's  advice  to 
live  on  meat  and  hot  water. 

One  of  the  chief  difficulties  in  these  cases  of  nervous 
dyspepsia  is  the  dread  of  infringement  upon  what  they 
have  been  led  to  regard  as  dietetic  rules.  The  moral 
effect  of  lavage  is  marvellous  in  these  cases,  inasmuch 
as  it  enables  us  to  build  up  the  nutrition  and  thus  im- 
prove the  general  health  upon  which  the  local  disease 
seems  to  depend  in  most  cases.  Owing  to  the  lack  of 
time,  too  much  of  which  I  have  already  occupied,  I 
will  not  here  detail  the  methods  of  hydrotherapy  in- 
dicated, save  to  say  that  daily  ablutions  with  water  at 
85°  F.,  reduced  one  degree  every  day,  the  patient 
standing  in  a  little  warm  water,  is  a  good  domestic 
measure,  and  may  be  followed  by  daily  cold  effusions 
with  advantage,  and  afterward  by  institution  treatment 
where  the  temperature,  pressure,  and  duration  may  be 
applied  with  precision. 

In  ot'stinate  eases  of  dyspepsia,  be  they  ^^ catarrhal"  or 
lun'oiis,  referred  to  me  by  colleagues  after  trial  of  all 

known  remedies,  as  illustrated  by  the  case  of  Dr.  H ,  a 

judicious  'water-treatment  rarely  fails. 

The  most  rare  source  of  dyspepsia  is  gastric  ulcer. 
As  in  other  gastric  affections,  a  clear  diagnosis,  based 
on  the  presence  of  great  pain,  hemorrhage,  and  difiicult 
digestion,  should  precede  treatment.  In  these  cases 
the  stomach-tube  is  inapplicable,  even  when  symptoms 
of  fermentation  seem  to  demand  it.  Kussmaul  has 
devised  a  \aluable  method  of  treatment,  which  is  but 
the  outcome  of  common  sense,  because  the  great  de- 
sideratum of  all  traumatic  conditions,  rest,  is  best 
secured  by  it.  In  very  severe  cases,  in  which  vomit- 
ing and  great  gastric  tenderness  are  present,  the  stom- 
ach should  be  kept  undisturbed  even  by  water.  Pain 
may  be  subdued  by  lime-water  or  bismuth  in  large  doses. 
Fleiner  and  others  give,  with  benefit,  as  much  as  75  to 


October  5,   1895] 


MEDICAL    RECORD. 


475 


100  grains  as  a  dose  suspended  in  water.  I  use  30  to  40 
grain  doses  with  or  without  magnesia.  Rectal  eneraata 
of  Leube's  beef  solution,  liquid  or  solid  peptenoids  (Ar- 
lington Co.'s),  and  two  eggs  with  fifteen  grains  of  salt  in 
two  ounces  of  warm  water,  always  given  after  rectum 
has  been  washed  out,  will  sustain  the  patient  during  the 
first  days.  But  the  cardinal  remedy  for  gastric  ulcer 
is  milk  and  lime-water,  equal  parts,  given  warm  every 
two  hours,  beginning  with  two  ounces  and  increasing 
gradually  until  a  pint  or  more  is  taken,  at  each  meal, 
slowly  sipped  with  a  spoon.  I  have  seen  six  quarts 
consumed  in  one  day.  A  nurse  should  always  guard 
the  patient  against  intruders  ;  members  of  the  family 
should  be  kept  away  :  perfect,  absolute  rest  is  essential. 
The  patient  should  not  move  out  of  bed  for  any  pur- 
pose. All  entreaties  for  other  food  must  be  resisted. 
This  is  the  simple,  efficient  treatment  for  the  first  two 
or  three  weeks.  Gradually  farinaceous  gruel,  then 
broth,  may  be  given,  always  followed  by  several  ounces 
of  lime-water.  Carlsbad  salts  may  be  used  advantage- 
ously as  a  purgative  every  other  day. 

The  general  condition  should  be  carefully  looked 
after.  Most  of  these  patients  are  anjemic.  Judicious 
ablutions  with  gradually  reduced  cold  water,  gentle 
friction  of  the  extremities,  exposure  of  the  patient's 
face,  the  body  being  well  protected  in  a  well-ventilated 
apartment  all  day,  will  do  more  to  remove  the  faulty 
haematoses  than  iron,  which  cannot  be  tolerated.  The 
quantity  of  milk  which  these  patients  may  take  with 
lime-water,  despite  their  protests  in  the  beginning  of 
the  treatment,  is  marvellous,  if  it  be  administered  sys- 
tematically. The  little  woman  from  San  Francisco  re- 
ferred to  in  the  early  part  of  this  paper,  reached  six 
quarts  daily,  despite  her  claim  that  "  it  always  made 
her  bilious."  Sipping  it  slowly  with  a  spoon,  she  occu- 
pied from  five  to  fifteen  minutes  on  each  pint.  A 
good  nurse  is  essential.  The  disease  is  serious  and 
the  treatment  demands  attention  accordingly.  After 
recovery,  a  general  tonic  regimen,  in  which  hydro- 
therapy always  plays  the  most  important  role,  is  of  great 
value,  as  it  is  in  all  chronic  dyspepsias  in  which  the 
nutrition  has  been  depreciated. 

Conclusions. — In  the  presentation  of  these  views  it 
has  been  my  aim  to  remain  strictly  practical,  and  to 
offer  the  most  available  methods  of  treatment  only.  I 
trust  that  the  following  has  been  demonstrated  : 

1.  Dyspepsia,  though  not  a  disease  per  se,  demands 
the  utmost  interest  of  the  physician. 

2.  A  clear  diagnosis  of  the  source  of  the  various 
manifestations  of  difficult  digestion  offers  the  only  guide 
to  successful  treatment. 

3.  Few  cases  of  dyspepsia  will  be  encountered  v.hich 
resist  a  judicious  management  based  upon  correct  diag- 
nosis and  simple  treatment  of  the  local  and  general 
conditions,  especially  of  the  latter. 


Hospital  Advertisements. — The  London  Times  ot  J  uly 
23,  1895,  contains  the  following  : 

"  Anybody  in  London  having  spare  time  on  Monday, 
22d,  or  Tuesday,  23d,  July,  is  invited  to  visit  the  Pop- 
lar Hospital  for  Accidents  between  2  and  7  o'clock. 

"  Newly  built.  Newly  fitted.  No  debt.  No  horrors. 
No  infection. 

"  Best  Way. — Drive  or  bicycle,  45  minutes  from  West 
End. 

"  Another  Way. — Blackwall  Omnibus  from  Piccadilly 
Circus,  75  minutes. 

"Another  Way. — Train  to  Aldgate,  thence  by  yellow 
tram." 

A  Helmholtz  Tablet. — A  memorial  tablet  in  honor  of 
Professor  Helmholtz  has  been  affixed  to  the  house,  No. 
8  Haditzstrasse,  at  Potsdam,  where  he  was  born  in 
1821. 


TRAUMATIC  SEPARATION  (COMPOUND)  OF 
THE  LOWER  EPIPHYSIS  OF  THE  FEMUR.^ 

By  a.    H.    MEISENBACH.    M.D., 

ST.   LOUIS,  MO. 
PROFESSOR   OF  SUSGERV   IN   THE   MARION   SIMS  COU.LGE   OF   MEDICINE. 

The  separation  of  the  lower  epiphysis  of  the  femur  is 
so  rare  an  occurrence  when  compared  with  other 
lesions  of  the  thigh  bones,  fractures  of  the  shaft,  ex- 
tremities, and  dislocations,  that  every  additional  au- 
thentic case  deserves  to  be  reported.  I  say  authentic, 
because  there  is  room  for  error  of  diagnosis  in  these 
cases,  especially  in  cases  that  are  not  compound.  In 
simple  cases  (without  rupture  of  soft  parts  and  protru- 
sion of  the  bone)  this  injury  may  be  confounded  with 
supra-condyloid  fracture  of  the  femur,  or,  possibly,  a 
dislocation  of  the  femur  (knee)  backward.  In  com- 
pound injuries  mistakes  in  diagnosis  cannot  easily  oc- 
cur, on  account  of  the  form  and  character  of  the  pro- 
truding bone.  Surgical  text  -  books  afford  a  very- 
meagre  description  of  this  injury.  The  report  of  a 
case  that  came  under  my  observation  recently,  and  the 
specimen  I  herewith  present,  is  of  interest. 

On  March  28,  1895,  W.  P ,  aged  eleven,  had  his 

left  leg  caught  in  the  wheel  of  a  vehicle.  The  boy  dis- 
tributed an  evening  newspaper  by  means  of  a  horse 
and  cart.  He  had  a  habit  of  putting  his  foot  on  the 
spoke  of  the  wheel  and  then  starting  the  horse,  letting 
the  wheel  elevate  him  to  a  level  with  the  body  of  the 
cart  and  then  jumping  into  the  vehicle.  On  this  occa- 
sion he  must  have  slipped  ;  missing  his  hold  with  his 
foot  on  the  spoke,  his  leg  was  pushed  between  the 
spokes  of  the  wheel  and  the  body  of  the  cart  so  as  to 
give  it  a  severe  wrench.  He  was  brought  to  the  office 
of  my  friend,  Dr.  Benno  Bribach,  who,  on  removing  the 
boy's  trousers  and  recognizing  the  severity  of  the  in- 
jury, called  in  Dr.  Voelker,  and  they  together,  with 
great  difficulty,  reduced  the  dislocated  epiphysis,  hav- 
ing first  placed  the  boy  under  the  influence  of  chloro- 
form. The  femur  protruded  about  four  inches  through 
a  wound  on  the  outer  side  of  the  popliteal  space.  The 
arteries  were  intact.  The  wound  was  treated  antisep- 
tically,  partly  stitched,  a  drainage-tube  introduced, 
and  the  limb  placed  on  a  temporary  posterior  splint. 
I  was  called  in  consultation,  and  the  next  morning  at 
eight  o'clock  I  saw  the  case  with  Drs.  Bribach  and 
Voelker.  During  the  night  a  few  small  doses  of  mor- 
phine had  been  given,  and  the  boy  had  rested  pretty 
comfortably  in  consequence.  The  temperature  was 
good,  99.5°  F.  ;  pulse,  103,  full  and  strong.  The  an- 
terior and  posterior  ti'uial  pulse  was  also  full  and 
strong  ;  the  dislocation  had  been  perfectly  reduced. 

I  had  been  called  especially  to  discuss  the  advisabil- 
ity of  an  amputation.  L'p  to  this  time  the  boy  had 
shown  no  evidence  of  shock.  Taking  into  considera- 
tion the  fact  that  the  separated  epiphysis  had  been 
perfectly  reduced  and  that  there  was  no  evidence  of 
injury  to  the  vessels,  also  the  patient's  general  good 
condition,  I  did  not  favor  amputation  under  such  cir- 
cumstances, but  that  the  limb  be  placed  in  a  perma- 
nent dressing  and  that  we  then  await  developments. 
This  was  agreed  to,  and  at  three  o'clock  we  met  again 
to  put  the  limb  in  a  plaster  dressing. 

On  my  second  visit  I  found  a  change.  Shock  had 
begun  to  make  its  appearance,  the  pulse  was  increased 
in  frequency  and  of  weaker  character,  but  still  per- 
ceptible in  both  tibial  arteries.  The  plaster  dressing 
was  applied,  but  the  condition  of  the  patient  became 
worse  in  spile  of  stimulants  and  the  hypodermic  use  of 
strychnine. .  He  did  not  rally  from  the  shock  and  died 
within  forty-eight  hours  after  receiving  the  injury. 

Autopsy. — A  post-mortem  examination  was  allowed, 
but  not  as  satisfactory  a  one  as  I  should  have  liked,  i.e., 
a.  complete  dissection  of  the  parts.     I  found  the  sepa- 

'  Read  before  the  Missouri  State  Medical  .AiSoc:ation,  Hannibal, 
Mo.,  May  21,  22,  23,  1S95. 


476 


MEDICAL   RECORD. 


[October  5,  li 


rated  epiphysis  completely  reduced  and  had  consider- 
able difficulty  to  evulse  the  femur  so  as  to  separate  it. 
The  femur  was  stripped  of  its  periosteum  for  about 
four  inches.  The  soft  parts  of  the  popliteal  space  were 
much  lacerated.  The  knee  joint  was  not  involved,  the 
capsule  was  intact,  which  was  shown  by  an  absence  of 
effusion  of  blood  in  the  joint.  The  separation  from 
the  shaft  was  perfectly  smooth,  no  splinters  being  at- 
tached to  the  epiphysis,  as  has  been  found  in  some  cases. 

A  feature  that  is  of  interest  in  these  cases  of  trau- 
matic separation  of  the  lower  epiphysis  of  the  femur  is 
the  direction  of  diaphysis.  In  the  majority  of  cases, 
either  simple  or  compound,  the  diaphysis  is  dislocated 
backward  and  impinges  on  the  vessels  and  soft  parts  of 
the  popliteal  space  if  simple,  and  if  compound  per- 
forates the  soft  parts,  as  in  this  case.  In  pathological 
separation  the  opposite  frequently  obtains,  i.e.,  the 
diaphysis  is  dislocated  forward,  as  is  shown  in  a  case 
reported  by  myself." 

In  traumatic  cases  the  factors  that  favor  dislocation 
of  the  diaphysis  into  the  popliteal  space  are,  i,  the  char- 
acter of  the  force  applied  ;  2,  the  resistance  of  the 
parts  as  determined  by  anatomical  structures. 

The  character  of  the  force  is  usually  rotatory  or 
twisting,  with  a  long  leverage  exerted  by  the  limb, 
either  the  proximal  or  distal  extremity  of  the  limb  as  a 
fixed  point.  The  anatomical  structures  on  the  anterior 
aspect  of  the  thigh  are  more  resisting,  the  quadriceps, 
tendon,  and  patella  offering  greater  resistance  than  the 
loose  tissues  of  the  popliteal  space,  especially  so  during 
the  reception  of  the  injur)',  when  there  is  a  probability 
that  the  muscles  on  the  anterior  surface  of  the  thigh  are 
in  a  state  of  contraction  in  the  effort,  possibly,  on  the  part 
of  the  patient  to  avert  the  coming  injury.  Then,  also, 
the  position  of  the  patient  is  a  factor,  as  in  many  cases 
of  traumatic  separation  the  patient  is  in  an  upright  or 
semi-upright  position,  which,  along  with  the  direction 
of  the  force  and  the  resistance  on  the  part  of  the  tis- 
sues of  the  anterior  part  of  the  thigh,  will  tend  to  push 
the  separated  diaphysis  into  the  popliteal  space. 

In  pathological  cases,  as  I  have  shown  in  the  case  re- 
ferred to,  the  processes  that  favor  separation  are  grad- 
ual and  the  forces  exerted  different.  The  explana- 
tion of  the  manner  in  which  it  takes  place  is,  to  my 
mind,  the  following  :  The  shaft  of  the  femur,  at  the 
epiphyseal  line,  is  the  seat  of  an  osteomyelitis.  The 
surrounding  structures,  especially  the  joint,  may  be 
either  specifically  or  non-specifically  involved.  We 
know  that  flexion  of  the  joint,  especially  of  the  knee, 
takes  place  whenever  there  is  inflammation  in  or  about 
it  for  any  length  of  time,  if  not  prevented  by  apparatus, 
such  as  splints,  methods  of  extension,  etc.  This  takes 
place,  and  as  the  case  runs  on  ankylosis  (temporary  at 
first)  occurs,  with  the  knee  in  a  flexed  position.  By 
tie  time  separation  occurs  the  knee  is  pretty  firmly 
ankylosed.  Granting,  now.  we  have  separation  of  the 
epiphysis,  the  leg  cannot  be  elevated  by  the  will  of  the 
patient,  the  thigh  being  only  partially  under  the  con- 
trol of  the  will.  The  leg  is  not  supported  except  im- 
perfectly by  pillows,  the  occasion  to  move  the  patient 
perhaps  frequent.  Now,  whenever  the  leg  is  raised 
ihe  condyles,  being  fixed  to  the  tibia,  move  with  it. 
Owing  to  the  angle  that  the  tibia  occupies  to  the  con- 
dyles whenever  the  leg  is  elevated,  the  epiphyseal  line 
of  the  condyles  is  depressed  into  the  popliteal  space 
and  favors  the  slipping  of  the  end  of  the  femur  upon 
the  trochlear  surface  of  the  condyles.  The  action  of 
the  thigh  muscles,  which  are  attached  to  the  head  of 
the  tibia,  draws  the  head  upward  with  the  condyles  so 
that  the  femur  oxerrides  the  same.  The  action  of  the 
muscles  attached  to  the  neck  and  trochanters  of  the 
thigh  bone  also  elevates  the  end  of  the  femur  and 
favors  its  overriding  the  trochlear  surface  of  the  con- 
dyles. 

'  Annals  of  Surgery,  February,  1895.  Report  of  a  Cise  of  Patho- 
logical Separation  of  the  Lower  Epiphysis  of  the  Femur.  By  A.  H. 
Meisenbach,  St.  Louis. 


A  peculiar  feature  in  the  case  I  have  reported  is  the 
late  appearance  of  the  shock.  In  surgical  cases,  or- 
dinarily, the  shock  is  present  at  once  or  very  shortly 
after  the  injury  ;  in  this  case  it  made  its  appearance 
about  fourteen  hours  after  the  injury.  This  is  termed 
"  delayed  shock  "  by  some  authors.  The  explanation 
of  this  form  of  shock  is  still  very  unsatisfactorj'  to  my 
mind.  Some  say  it  is  due  to  "  reactionary  mental  ex- 
haustion," '  others  ascribe  it  to  "  commotio  cerebri,"'^- 
or  "delirium  traumaticum  or  nenorum." 

Packard '  has  collected  over  sixty  cases  of  this  in- 
jur}', including  a  case  of  his  own.  In  looking  over  the 
literature  at  my  command,  I  have  not  found  any  addi- 
tional cases  reported  since  then  (November,  1890).  In 
an  analysis  of  the  cases  reported,  Packard  has  found 
that  in  an  average  of  forty-five  cases  the  average  age 
was  a  little  over  seven  years.  The  youngest  was  eigh- 
teen months,  and  the  oldest  eighteen  years.  The  fact 
that  it  has  occurred  as  late  as  the  eighteenth  year  be- 
comes patent  when  we  remember  that  the  lower  epi- 
physis does  not  join  the  shaft  (ossification)  until  the 
twentieth  year. 

As  to  sex,  he  found  nine  to  have  occurred  in  girls, 
three  of  which  were  caught  in  wagon  wheels.  As  to 
causes,  he  shows  that  in  the  majority  of  cases  the  in- 
jury was  produced  as  in  the  case  I  have  cited,  by  en- 
tanglement of  the  limb  in  a  moving  wheel.  In  two  in- 
stances the  leg  was  caught  in  a  moving  cable.  In  five 
cases  the  injury  was  produced  by  surgical  procedure, 
as  for  correction  of  ankylosis  and  deformities.  One 
case  is  reported  where  the  injur)'  was  produced  by 
traction  on  the  leg  of  a  child  during  birth.  Another 
case  where  the  injury  was  produced  by  a  fall  in  a  pa- 
tient of  sixteen,  who  had  ankylosis  of  the  knee.  From 
the  above  cases  we  see  that  it  usually  takes  a  great 
force,  and  this  force  exerted  in  a  particular  direction, 
to  produce  this  injury.  Either  the  lower  leg  or  body 
is  a  fixed  point  and  the  exertion  of  a  long  leverage  of 
the  movable  portion  of  the  limb  at  the  same  time,  the 
force  at  right  angles  to  the  limb  and  of  a  rotator)- 
or  twisting  character. 

In  the  case  I  have  reported  there  was  also  a  stripping 
oft'  of  the  periosteum  from  the  diaphysis.  as  was  ob- 
served in  many  of  the  other  cases  by  Packard  and 
others.  In  my  case,  also,  the  vessels  were  uninjured, 
otherwise  the  tibial  arteries  would  not  have  performed 
their  function  up  to  the  time  of  death,  but  would  have 
shown  evidences  of  injur)'  soon  after  the  injury  was  re- 
ceived. 

How  shall  these  cases  be  treated  ?  This  is  an  inter- 
esting and  important  point.  In  the  cases  reported,  wc 
find  the  following  procedure  to  have  been  employed  : 
Primary  resection  of  the  diaphysis  ;  primary  amput.i- 
tion  :  reduction  successfully  accomplished  :  secondarx 
amputations.  In  Packard's  report  we  find  that  ampu- 
tation was  performed  twenty-eight  times  ;  twelve  prim- 
ary, nine  secondary,  seven  times  not  stated. 

Resection  of  the  shaft  was  performed  in  four  with 
complete  success,  one  doubtful  result,  the  others  not 
stated.  Resection  of  the  knee-joint  was  done  in  two 
cases,  afterward  followed  by  amputation.  In  the  cases 
where  amputation  was  done  primarily,  the  limb  was  de- 
stroyed or  the  blood-vessels  injured.  Secondar)'  am- 
putation was  done  for  gangrene,  and  abscess  reduction 
was  accomplished  in  fourteen  cases,  one  of  whom  died 
on  the  fifteenth  day  of  sepsis. 

From  the  methods  of  treatment  in  the  cases  reported, 
I  believe  we  can  find  the  course  to  be  pursued  in  the 
treatment  of  these  cases.  In  each  case  the  conditio; 
of  the  blood-vessels  should  be  determined.  This,  in 
conjunction  with  the  condition  of  the  soft  parts,  and 
the  practicability  of  reduction,  must  be  the  guidance 
for  our  procedure.  Where  the  blood-vessels  are  de- 
stroyed amputation,  of  course,  is  the  only  resource.     If 

'  Roberts.  '  Tillman. 

•  J.  H.  Packard,  Philadelphia :  Annals  of  Gynecology  and  Pedia- 
trics, Noyember,  1890. 


October  5,   1895] 


MEDICAL    RECORD. 


477 


the  blood-vessels  are  intact  and  reduction  can  be  accom- 
plished, this  sho\Jtd  be  done.  The  blood-vessels  and 
soft  parts  being  in  good  condition  and  reduction  under 
anaesthesia  still  difficult,  resection  of  the  end  of  the 
shaft  should  be  done,  cutting  away  only  so  much  as  to 
favor  reduction.  Resection  of  the  knee-joint  is  indi- 
cated only  where  the  blood-vessels  are  twisted  and  the 
joint  involved  to  such  an  extent  that  complications  in 
the  after-treatment  may  arise. 

It  goes  without  saying  that  all  of  these  procedures 
are  accomplished  under  the  most  rigid  antiseptic  pre- 
cautions. Immobilization,  by  means  of  a  posterior 
splint  or  p!aster-of-Paris,  should  be  employed. 


Pulmonary  Anthracosis. — Dr.  Tripier,  of  Lyons,  com- 
.  bats  the  idea  that  anthracosis  of  the  lung  is  in  any 
sense  a  specific  disease  peculiar  to  miners,  and  ad- 
vances arguments  to  prove  that  this  condition  is  sim- 
ply pulmonary  tuberculosis  modified  by  the  special 
circumstances  of  the  case.  (  The  Lancet.)  His  view  is 
as  follows  :  "  The  phthisis  of  miners  is  simply  of  a 
tuberculous  nature,  but  predominantly  fibrous,  in 
which  the  carbonaceous  infiltration  of  the  pulmonary 
tissue,  especially  as  regards  pathological  products,  may 
be  so  abundant  as  to  cause  the  lungs  to  assume  such  a 
peculiar  aspect  as  sometimes  to  render  difficult  of  rec- 
ognition the  tuberculous  lesions  thus  more  or  less  con- 
cealed by  the  accumulation  of  the  carbon."  He  be- 
lieves that  when  animals  are  made  experimentally  to 
breathe  air  full  of  particles  of  carbon  the  lungs  are 
I  simply  found  surcharged  with  these  particles,  but  with- 
out the  inflammatory  lesions  and  scleroses  character- 
istic of  pulmonary  anthracosis,  and  that  when  miners 
succumb  to  accidents  their  lungs  are  found  in  a  simi- 
lar state,  but  without  evidence  of  tubercle.  In  spite  of 
these  facts  which  Dr.  Tripier  regards  as  well  known, 
he  states  that  there  is  a  tendency  to  describe  pneumo- 
koniosis  (pulmonary  antracosis)  as  an  independent 
malady  produced  by  the  inhalation  of  particles  of  coal, 
silica,  or  oxide  of  iron.  The  object  of  his  communica- 
tion was  to  bring  forward  some  pathological  evidence 
in  support  of  his  own  view.  In  one  of  his  cases  the 
patient  had  succumbed  to  "la  phthisic  charbonneuse," 
and  on  post-mortem  examination  the  lungs  were  found 
to  be  full  of  particles  of  carbon,  and  much  sclerosed, 
but  further  examination  demonstrated  the  existence  of 
a  cavity  at  one  apex  and  the  presence  of  caseated 
tubercle.  It  is  possible,  of  course,  to  argue  that  the 
tubercle  was  a  secondary  result  of  the  infiltration  of 
the  lungs  with  particles  of  carbon.  Dr.  Tripier  com- 
bats this  view.  In  the  case  in  point  the  patient  had 
worked  for  fifteen  years  in  mines  without  developing 
any  pulmonary  lesion,  and  had  ceased  from  this  occu- 
pation for  six  years  before  showing  signs  of  commenc- 
ing disease  of  the  lungs.  In  a  second  case  brought 
forward  by  Dr.  Tripier,  the  patient  had  breathed  a  car- 
bonaceous atmosphere  for  thirty-one  years  without  any 
pulmonary  trouble,  and  finally  succumbed  to  cancer  of 
the  stomach.  On  post-mortem  examination  the  lungs 
were  found  to  contain  particles  of  carbon  widely  dis- 
seminated, and  specially  numerous  in  the  lymphatics, 
but  without  any  sign  of  tubercle.  The  writer  further 
argued  that  the  amount  of  carbonaceous  infiltration  of 
the  lungs  bears  no  relation  to  the  probability  of  find- 
ing tubercle.  The  latter  may  be  found  in  miners  with 
little  or  much  carbon  in  their  lungs,  and  in  those  who 
have  spent  few  or  many  years  in  occupations  involving 
the  constant  respiration  of  carbonaceous  particles. 
Cases  such  as  those  brought  forward  by  Dr.  Tripier 
are,  of  course,  inconclusive,  but  they  must  be  allowed 
reasonable  weight.  They  certainly  tend  to  corroborate 
the  view  that  pneumokoniosis  or  pulmonary  anthraco- 
sis is  not  an  independent  affection  with  a  definite  cause 
and  definite  natural  history,  but  simply  one  of  the 
many  varieties  of  pulmonary  phthisis. 


SIMPLE    MELANCHOLIA. 
By  HIRAM  ELLIOTT,  M.D., 

\VOODHAVEN,    N-.  V. 

Simple  melancholia  may  be  defined  as  that  disordered 
condition  of  the  mind  in  which  there  is  a  predominance 
of  subjectively  arising  painful  emotions  accompanied 
by  more  or  less  weakenirg  of  the  inhibitions  and  low- 
ering of  the  moral  tone  of  the  individual,  but  in  which 
the  perversion  of  the  understanding  and  narrowing  of 
the  range  of  intellectual  action  do  not  obtain  in  suffi- 
cient degree  to  constitute  actual  delirium  or  stupor. 
I  am  aware  of  imperfections  in  this  definition,  but  it 
will  serve  the  purpose  of  this  paper. 

Painful  emotions  are  not  necessarily  pathological. 
The  normal  mind  is  capable  of  suffering,  and  the  most 
intense  and  prolonged  mental  anguish  may  be  in  itself 
entirely  physiological.  Indeed  there  are  many  sensi- 
tive and  impressionable  people  whose  nervous  struct- 
ures always  react  violently  to  stimuli  of  a  disagreeable 
and  irritating  nature.  These  unfortunate  individuals 
readily  surrender  their  minds  to  the  control  of  painful 
emotions  and  their  inhibitions  readily  give  way.  For 
example,  the  neurotic  mother  is  thrown  into  a  most 
painful  mental  condition  by  the  death  of  her  child  ;  she 
can  neither  eat  nor  sleep  ;  she  is  practically  oblivious  to 
her  surroundings  ;  she  gives  herself  up  to  useless  lamen- 
tations and  is  wholly  unreasonable.  But  this  is  not 
melancholia,  and  indeed  bears  no  necessary  relation  to 
it.  The  emotional  states  described  arose  objectively 
and  out  of  adequate  and  immediate  causes,  and  though 
excessive  were  still  physiological.  And  it  is  only  when 
such  states  are  sufficiently  severe  or  prolonged  or  oft 
repeated  to  cause  the  brain  to  take  on  that  disordered 
action  which  is  the  essential  underlying  condition  of 
all  mental  alienation  that  they  even  stand  in  causative 
relation  to  melancholia. 

Normally  stimuli  of  an  unpleasant  nature  passing 
into  the  emotional  cerebral  planes  there  excite  those 
corresponding  cerebral  states  which  are  necessary  to 
the  production  of  mental  pain,  and  which  after  the  with- 
drawal of  said  stimuli  soon  disappear,  leaving  behind 
only  their  more  or  less  distinct  registration  in  memory. 
But  some  brains  are  so  vulnerable,  so  plastic,  so  to 
speak,  and  possess  such  low  reactive  power  that  these 
states  tend  to  persist  pathologically  after  the  stimuli 
are  withdrawn,  not  only  to  continue  to  present  the 
old  painful  sensations,  but  also,  by  extension  into  other 
areas,  to  develop  new  ones  subjectively  and  indepen- 
dently. .\nd  at  the  same  time  the  representative  power 
of  the  brain  is  interfered  with,  fresh  incoming  stimuli 
are  interrupted  or  distorted,  they  are  misrepresented 
to  the  mind,  and  hence  convey  the  idea  of  an  altered 
environment. 

Corresponding  to  this  over-activity  in  the  emotional 
cerebral  plains  is  a  condition  of  depression  in  the  in- 
tellectual. The  intellectual  side  of  the  brain  is  over- 
whelmed and  overshadowed  by  the  emotional  and  held 
in  abeyance.  The  attention  is  weakened  and  incoming 
stimuli  either  fail  of  recognition  or  tend  to  pass  over 
the  intellectual  spheres  and  into  the  emotional  ;  and 
the  cells  of  ideation  being  deprived  of  their  accustomed 
and  necessary  stimulus  to  activity  lie  stagnant ;  and 
their  energy,  thus  confined,  like  constrained  positions 
of  the  muscles,  gives  the  idea  of  i>n  all-pervading  resist- 
ance or  opposition.  The  so-called  muscular  element 
of  thought  is  weakened,  and  the  mind,  in  measuring  the 
resistance  of  the  environment,  over-estimates  it. 

For  this  reason  melancholiacs  complain  that  they  can 
no  longer  concentrate  their  thoughts  ;  that  when  they 
attempt  to  think  or  act  some  power  seems  to  restrict  or 
clog  their  efforts.  In  conversation  they  stop  in  the 
middle  of  their  sentences  as  though  the  cells  of  idea- 
tion acted  with  too  much  friction,  or  as  though  the 
stimulus  to  their  action  was  suddenly  withdrawn,  or  the 
cells    tiiemselves    overtaken    with    sudden    weakness. 


478 


MEDICAL    RECORD. 


[October  5,  1895 


They  complain  that  their  brain  is  tired  or  congealed 
or  worn  out :  they  sigh  and  manifest  many  symptoms 
similar  to  muscular  weariness. 

This  intellectual  torpor,  coupled  with  the  feeling  that 
the  environment  is  altered  as  already  described,  dis- 
qualifies the  individual  to  comprehend  his  surround- 
ings. Nothing  appeals  to  him  except  such  matters  as 
contribute  to  his  sense  of  wretchedness,  and  he  thus 
acquires  suspicions  and  fears  and  ideas  of  persecution 
out  of  an  environment  which  he  sees  only  through  the 
shadows  of  his  emotions  and  therefore  no  longer  clearly 
understands. 

Corresponding  to,  and  arising  out  of,  this  emotional 
domination  of  the  mind  is  a  weakening  of  its  inhibi 
tions.  Of  the  stimuli  which  crowd  in  upon  it  from  all 
directions  the  healthy  mind  is  able  to  select  a  certain 
few  to  be  registered  in  the  brain-cells,  and  to  reject  the 
others.  Indeed  the  education  and  refinement  of  the 
faculties  depend  not  more  upon  the  accumulation  of 
desired  cerebral  impressions  than  upon  the  exclusion 
of  the  undesirable  by  the  inhibitions.  Conduct  and 
character,  too,  depend  not  more  upon  the  activity  of 
those  faculties  and  propensities  which  are  manifest  than 
upon  the  inhibition  or  holding  in  abeyance  of  others 
which  do  not  appear.  We  may  not  be  aware  of  the  in- 
hibitory effort,  but  it  exists  though  sunk  into  uncon- 
sciousness. 

In  conditions  of  mental  alienation,  however,  the 
seemingly  changed  color  and  altered  behavior  of  the 
environment  already  described,  and  the  fears  and  sus- 
picions which  consequently  arise  are  so  startling  and 
obtrusive  that  they  force  themselves  upon  the  atten- 
tion, and  the  mind  is  no  longer  able  to  exclude  them. 
It  is  operating  under  new  conditions,  new  and  strange 
elements  are  entering  into  the  intellectual  life  which 
do  not  readily  submit  to  control.  Propensities  and 
peculiarities  hitherto  held  in  abeyance  burst  through 
the  weakened  inhibitory  barriers  and  more  or  less 
altered  and  intensified  run  riot  ;  and  thus  a  new  and 
anomalous  personality  is  developed  very  unlike  the 
original  in  outward  appearance  possibly,  but  astonish- 
ingly similar  to  it  in  intrinsic  qualities.  There  is  men- 
tal derangement  in  the  strictest  sense  of  the  term,  and 
out  of  the  resulting  disorder  certain  propensities  and 
characteristics  hitherto  existing  come  to  the  front  and 
predominate.  Thus  one  woman  loses  her  child  and 
falls  into  melancholia,  another  loses  hers  and  develops 
acute  mania,  the  mania  determining  conditions  pre- 
existing wholly  in  the  individual. 

Further  the  inhibitory  strength  in  a  great  measure 
determines  the  degree  of  mental  reduction  possible. 
Extremely  sensitive  emotions  may  coexist  with  strong 
inhibitory  and  intellectual  power.  The  emotional  cere- 
bral planes  may  be  very  impressionable  and  vulnerable 
while  the  intellectual  side  and  the  inhibitions  are  cor- 
respondingly potent.  In  such  brains  there  is  great 
capability  of  suffering,  but  also  strong  resisting  and  re- 
active power.  Painful  emotions,  with  their  attendant 
throng  of  gloomy  fears,  suspicions,  and  fancies  assail 
the  individual  ;  he  loses  much  of  his  interest  in  life, 
he  becomes  erratic  in  his  demeanor,  he  meditates  upon, 
plans  out,  and  often  executes  schemes  of  suicide  as 
ways  of  escape  from  his  torture,  but  his  judgment  for 
the  most  part  retains  its  integrity.  Cellular  activity  in 
the  intellectual  planes  may  be  labored  or  interrupted, 
but  the  product  is  essentially  genuine.  Such  an  indi- 
vidual, under  proper  exciting  causes,  falls  into  simple 
melancholia  because  his  cerebral  make-up  predisposed 
him  to  this  form,  and  is  such  as  to  render  him  ex- 
tremely unlikely,  and  probably  incapable,  of  taking  on 
any  other  form. 

Pathology. — Investigations  into  the  pathology  of  sim- 
ple melancholia  have  so  far  not  been  attended  with 
very  satisfactory  results,  for  the  reason  that  post  mor- 
tem material  is  not  very  abundant,  and  because  there  is 
no  certainty  that  the  slight  pathological  conditions  ob- 
taining in  life,  especially  in  recent  cases,  retain  their 


characteristics  after  death.  That  changes  in  the  nu- 
trition in  the  brain-cells  will  cause^nomalies  in  the 
manner  of  their  functioning  seems  plausible,  and  hence 
abnormal  action  of  the  vaso-motor  nerves  in  the  mus- 
cular coats  of  the  cerebral  vessels,  byproducing  irregu- 
larity in  the  blood-supply  to  the  various  areas  of  the 
brain,  and  in  this  way  interfering  with  the  uniform  nu- 
trition of  these  parts,  probably  best  explains  the  symp- 
toms in  life  and  the  scanty  post-mortem  findings  in 
these  cases.  Certain  it  is  that  the  brains  of  persons 
who  have  suffered  from  this  malady  for  a  number  of 
years,  and  who  have  fallen  into  terminal  dementia 
reveal  evidences  of  prolonged  congestion  in  certain 
areas,  and  also  certain  other  areas  where  the  gray  mat- 
ter is  thinned  either  from  lack  of  proper  nutrition  or 
disease. 

Cause. — The  conditions  predisposing  to  simple  mel- 
ancholia are  eminently  hereditary.  By  this  we  mean 
not  so  much  that  the  parentage  was  insane,  but  that 
the  brain  of  the  individual  in  question  possesses  some 
innate  vulnerability,  some  inborn  tendency  to  inhar- 
monious action  of  its  parts,  which  renders  it  prone  to 
take  on  disordered  or  pathological  action.  Drunken 
or  vicious  or  phthisical  parentage,  but  in  which  no  in- 
sanity appears,  may  beget  offspring  with  a  decided  pre- 
disposition to  melancholia,  and,  in  fact,  to  all  forms  of 
mental  alienation.  Again,  the  parents  may  merge  a 
common  peculiarity  or  weakness  which  appears  in  an 
exaggerated  form  in  the  offspring.  Careful  study  of 
the  family  history  of  persons  suffering  from  simple 
melancholia  will  rarely  fail  to  find  in  it  a  weak  spot 
somewhere,  and  it  is  always  to  be  remembered  that  the 
denials  of  the  patient  and  his  friends  regarding  insane 
parentage  are  no  sure  proofs  of  its  nonexistence.  . 

Again,  the  bringing  up  of  an  individual  may  be  a 
strong  predisposing  as  well  as  an  exciting  cause  of  this 
malady.  Many  a  mother  constantly  drums  into  the 
ears  of  her  children  that  they  are  delicate  and  nervous, 
and  objects  of  commiseration,  some  day  to  discover 
that  her  doctrines  have  been  imbibed  to  a  degree  of 
fidelity  which  more  than  fulfils  her  intentions.  Her 
children  feed  on  her  morbid  sympathy  until  it  dis- 
gusts, but  still  seems  essential  to  their  existence.  I  call 
to  mind  one  case  of  melancholia  in  which  a  careful 
study  of  the  possible  causes  left  little  doubt  but  that 
the  patient's  bringing  up  was  almost,  if  not  entirely,  re- 
sponsible for  her  condition.  This  patient  took  special 
delight  in  biting  her  arms  and  otherwise  wounding  her- 
self when  in  her  mother's  presence,  for  the  sole  sake  of 
the  horror  it  caused  and  the  deluge  of  morbid  sym- 
pathy which  she  knew  was  sure  to  follow. 

Of  the  exciting  causes  the  first  and  chief  are  disor- 
dered conditions  of  the  general  health.  Whatever 
tends  to  lessen  or  vitiate  the  blood-supply  to  the  brain 
weakens  its  resisting  and  reacting  power  and  tends  to 
depress  it.  Many  persons  indeed  are  so  sensitive  that 
slight  physical  weariness  or  hunger  produces  a  marked 
falling  off  in  their  buoyancy.  Uterine  troubles  in 
women  and  prostatic  troubles  in  men  are  very  fruitful 
causes  of  melancholia.  These  maladies  so  harass  the 
sensitive  patient  that  they  absorb  his  attention,  they 
undermine  his  health,  and  thus  increase  the  vulnerabil- 
ity of  the  nervous  system,  and,  in  short,  assail  the  pre- 
disposed brain  in  every  possible  way,  and  rarely  fail  to 
induce  in  it  disordered  action.  In  the  consideration 
of  this  subject  there  is  no  point  of  so  great  importance 
as  a  full  appreciation  of  this  relation,  which  in  such  a 
vast  majority  of  cases  exists  between  morbid  mental 
states  and  disordered  conditions  of  the  general  health. 
If  other  exciting  causes  are  to  be  named,  domestic  in- 
felicity in  women,  and  business  worries  in  men,  take 
first  rank. 

Course  and  Symptoms.— The  onset  of  this  trouble  is 
usually  very  gradual  and  insidious.  It  often  exists  for 
a  year  or  more  without  being  noticed  by  intimate 
friends  or  relatives,  or  even  the  family  physician.  An 
attempt  at  suicide,  successful  or  otherwise,  is  a  rude. 


October  5,   1895] 


MEDICAL   RECORD. 


479 


but  often  the  first,  awakening  of  the  friends  to  the  real 
condition,  and  at  the  same  time  affords  an  explanation 
of  many  peculiarities  in  the  patient's  manner  and  con- 
versation, which  are  recalled  upon  a  retrospect  of  the 
case. 

An  indefinite  sense  of  ill-being,  a  constant  feeling  of 
weariness,  which  rest  and  sleep  do  not  relieve,  a  dispo- 
sition to  frequent  sighing  and  gaping,  flagging  interest 
in  life  and  business,  unwonted  irritability  of  temper. 
growing  incapacity  for,  and  disinclination  to,  prolonged 
exertion  of  any  kind,  especially  mental,  are  among  the 
first  symptoms  complained  of.  Sleep  soon  becomes 
uncertain  and  unrefreshing,  and  patients  say  that  they 
always  awaken  with  a  sense  of  impending  danger.  In 
these  waking  moments  their  sluggishly  acting  minds  do 
not  quickly  grasp  and  understand  the  environment, 
and  hence  fear  it.  Appetite  and  digestion  partially 
fail,  and  the  patient  becomes  ansemic  and  thin,  and  his 
expression  haggard  and  anxious.  His  pupils  are  often 
widely  dilated,  his  tongue  is  large  and  flabby  and  in- 
dented by  the  teeth,  and  his  bowels  are  usually  obsti- 
nately constipated. 

Soon  the  ever-present  and  harassing  mental  pain  so 
absorbs  his  attention  that  the  patient  forgets  his  refine- 
ments and  becomes  rude  and  uncouth  in  manner.  The 
acrions  of  his  friends,  seen  through  the  shadow  of  his 
emotions,  seem  to  him  to  contribute  to  his  distress,  and 
hence  he  treats  those  friends  gruffly,  or  avoids  them 
enrirely.  His  suspicions  lead  him  to  watch  the  actions 
of  others  very  narrowly,  however,  and  he  is  often  a 
veritable  spy,  and  his  knowledge  of  that  part  of  his 
surroundings  which  is  none  of  his  business  is  fre- 
quently surprisingly  complete.  If  he  has  any  physical 
dise^e  he  goes  over  his  symptoms  again  and  again, 
and  curses  the  fate  that  has  afflicted  him.  As  his 
malady  becomes  more  chronic  he  usually  becomes 
very  profane  ;  beginning  with  expressions  of  disgust, 
as  his  inhibitions  weaken,  he  soon  indulges  in  fits  of 
the  most  impious  cursing.  These  chronic  cases  soon 
acquire  the  habit  of  making  odd  grimaces  and  queer 
motions.  One  patient  of  mine  delights  with  wetting 
her  fingers  with  spittle  and  rubbing  them  over  every- 
thing hand\\  This  same  patient  will  speak  to  you 
pleasantly  and  pretty  intelligently,  but  the  instant  your 
back  is  turned  she  will  make  wry  faces  and  give  you  a 
tongue-thrashing  in  an  audible  undertone  and  abun- 
dantly spiced  with  profanity. 

Notwithstanding  their  peculiarities  and  constant  de- 
pression these  patients  are  often  great  readers,  and 
keep  fairly  well  posted  on  the  news  of  the  day,  and 
sometimes  even  attend  to  their  business  in  a  fairly  in- 
telligent manner  throughout  the  whole  course  of  their 
disease.  Although  they  frequently  maintain  that  their 
friends  have  turned  against  them,  yet  when  cornered 
they  admit  the  foolishness  of  their  assertions,  and,  in 
short,  their  judgment  seems  too  sound  to  permit  them 
to  harbor  delusions.  Hallucinations  of  the  various 
senses  I  have  not  seen  in  these  cases.  Another  pecul- 
iarity of  these  patients  is  their  tendency  to  form  the 
drug  habits.  They  are  usually  inveterate  medicine- 
takers,  and,  sooner  or  later,  they  experience  the  pleas- 
ing sensations  produced  by  such  drugs  as  opium  and 
chloral,  to  fall  a  ready  prey  to  their  seductive  inriu- 
ence.  Some  take  to  whiskey  or  cologne,  or,  in  short, 
anything  that  stimulates. 

.\s  to  termination,  simple  melancholia  usually  ends 
in  one  of  four  ways.  First,  in  recovery,  a  large  pro- 
portion so  ending  if  treated  early  and  properly.  Second, 
in  death  by  suicide.  And  here  I  must  assert  that  there 
are  very  few  persons  suffering  from  this  disorder  who 
do  not  early  in  its  course  contemplate  or  attempt 
suicide.  Their  lowered  morale  and  weakened  inhibi- 
tions in  a  great  measure  remove  their  scruples  against 
such  an  action,  and  lessen  their  ability  to  keep  in  the 
background  the  constantly  arising  idea  that  death 
would  end  their  miser)-.  And  their  reason  remaining 
practically  intact,  they  plan  out  the   most   elaborate 


schemes  for  the  accomplishment  of  their  purpose,  and 
give  the  most  con\ancing  arguments  for  its  justifica- 
tion. Ver)-  recently  a  patient  suffering  from  this 
malady  handed  me  a  loaded  self-cocking  revolver, 
which  she  had  obtained,  and  had  in  her  possession  for 
some  rime,  notwithstanding  the  \"igilance  of  her  friends. 
She  remarked  that  she  had  placed  it  to  her  temple 
many  a  time,  but  that  it  was  one  thing  to  contemplate 
suicide  but  quite  another  thing  to  do  the  act.  Coward- 
ice prevents  more  suicides  than  all  other  agencies  com- 
bined. Third,  this  disorder  may  terminate  in  the 
more  profound  forms  of  insanitj-,  but  this  is  excep- 
tional unless  drug  or  \-icious  habits  are  formed.  And, 
fourth,  in  the  chronic  condition,  which  may,  or  may 
not,  end  in  terminal  dementia. 

Illustrating  this  last  method  of  termination  allow  me 

to  cite  the  case  of  Mr.  L .     Family  historj-  good. 

Following  an  attack  of  measles,  at  the  age  of  twenty- 
two  years,  this  man  became  depressed  :  he  early 
developed  morbid  fears  and  suspicions  and  a  tendency 
to  suicide.  He  was  a  bright  and  intelligent  man,  and 
spoke  freely  of  his  condition.  He  said  that  all  his 
mental  actions  were  carried  on  with  effort,  a  constant 
weight  of  misery  rested  upon  him,  and  he  saw  nothing 
in  life  to  live  for.  He  was  a  great  medicine-taker,  and 
at  one  time  attempted  suicide  vvith  '"  Perry  Daris's  Pain- 
killer," after  which  he  cursed  himself  by  the  hour  for 
being  such  a  fool  as  to  try  to  kiU  himself  by  swallow- 
ing hell-fire.  Outwardly,  he  was  a  verj'  religious  man 
and  a  prominent  member  of  his  church,  and  a  pretty 
good  and  useful  citizen.  He  frequently  made  arrange- 
ments to  take  his  life  by  hanging,  but  always  ended 
with  a  fit  of  cursing  at  that  cowardice  which  prevented 
him  from  putting  an  end  to  his  miseiy.  This  condi- 
tion of  depression,  according  to  the  reliable  testimony 
of  his  brother,  and  mj'  own  observation  for  the  last 
fifteen  years  of  his  life,  lasted  for  forty  years,  during 
which  time  he  made  a  li\"ing  for  himself  and  family, 
and  died  at  the  age  of  sixt)'-five  of  consumption,  with- 
out showing  any  marked  signs  of  dementia  beyond  the 
acquisition  of  many  queer  habits,  such  as  grimacing, 
licking  his  finger-tips,  and  giving  vent  to  grunts  of  dis- 
gust and  an  occasional  oath. 

To  illustrate  how  slight  is  the  tendency  for  simple 
melancholia  patients  to  fall  into  the  more  profound 
forms  of  mental  alienation,  even  under  strong  exciting 

causes,  I  will  cite  the  case  of  Mrs.  B .     A  delicate 

woman,  with  strong  hereditary  tendencies  to  insanity, 
in  fact,  her  insane  mother  was  living  in  the  same  house 
with  her,  intelligent  and  refined,  fell  into  simple  melan- 
cholia a  few  months  after  the  birth  of  her  second  child. 
She  was  mildly  depressed,  and  held  very  dismal  \'iews 
of  life,  but  never  evinced  any  real  delusions  or  hallu- 
cinations. She  took  very  little  interest  in  her  children, 
was  petulant  and  irritable,  and  resented  the  well-meant 
attentions  of  her  sister,  who  took  care  of  her.  She 
suffered  somewhat  from  indigestion,  constipation,  and 
insomnia.  She  early  showed  a  tendency  to  suicide, 
and  planned  out  several  schemes  for  its  accomplish- 
ment, of  which  one  was  unique.  Getting  up  in  the 
night  she  roused  her  mother,  who  was  so  depressed 
and  stupid  that  she  rarely  spoke  and  had  to  be 
dressed  like  a  child,  and  the  two  slipped  out  of  the 
house,  and  securing  a  step-ladder  from  the  basement, 
walked  half  a  mile  to  a  reservoir,  climbed  over  the 
fence  surrounding  it  by  means  of  the  step-ladder,  dis- 
cussed suicide  by  drowning,  and  decided  that  it  was 
too  horrible  and  returned  home.  .\  few  nights  after- 
ward they  repeated  their  journey,  and  again  their 
courage  failed.  The  third  time  they  made  the  experi- 
ment with  better  success,  for  when  they  reached  the 
water's  edge  they  jumped  in  together.  The  helpless 
old  lady  sank  without  a  struggle,  while  the  shock  of 

the  cold  bath  brought  Mrs.  B to  her  wits,  and  she 

was  glad  to  be  able  to  scramble  out  and  hurry  home  to 
inform  her  sister  what  she  had  done. 

Notwithstanding  this  terrible  shock  and  the  full  con- 


48o 


MEDICAL    RECORD. 


[October  5,   1895 


viction  that  she  was  mainly  instrumental  in  causing  her 
mother's  death,  sufficient  one  would  think  to  over- 
throw the  strongest  reason,  she  remained  without  de- 
lirium, and  within  a  year  was  reported  to  be  entirely 
recovered.  Shortly  after  the  above-described  occur- 
rence she  ceased  to  be  my  patient,  but  I  have  the 
statement  of  her  sister  that  at  no  time  since  the  catas- 
trophe did  she  manifest  a  tendency  to  delusions  mate- 
rially different  from  that  which  she  showed  before  it. 
This  case  also  well  illustrates  the  purely  subjective 
nature  of  the  emotional  pain  of  melancholia. 

As  an  example  of  simple  melancholia  running  into 
terminal  dementia  may  be  cited  the  following  case  of 

Miss  C ,  whose    alienation    has    now    lasted    seven 

years,  and  which  ran  the  ordinary  course.  At  the 
present  time  Miss  C is  silent  and  unsociable,  pre- 
ferring the  solitude  of  her  room,  where,  if  allowed,  she 
would  sit  by  the  hour,  examining  some  article  of  dress, 
or  biting  at  her  finger-nails,  occasionally  uttering  ex- 
clamations of  disgust  freely  interlarded  with  profanity. 
She  makes  many  odd  motions  and  gestures,  such  as  toss- 
ing her  head,  twitching  her  shoulder,  or  stamping  with 
her  foot.  At  the  table  she  delights  in  handling  the 
articles  of  food,  and  seems  to  be  at  a  loss  to  know  what 
to  select.  When  eating  she  makes  the  most  horrible 
faces,  and  watches  every  mouthful  of  food  taken  by  the 
other  patients,  at  times  uttering  grunts  of  disapproval. 
She  is  a  great  spy,  and  when  she  sees  persons  in  close 
conversation  she  sneaks  around  and  usually  manages 
to  catch  more  or  less  of  what  they  are  saying.  In  this 
way  she  manages  to  keep  pretty  well  posted  on  what  is 
going  on  about  her.  She  is  untidy  in  her  dress  and 
habits,  and  prefers  to  use  the  pot  dv  chambrc  in  her 
room  rather  than  go  to  the  closet,  which  is  but  a  few 
steps  away.  She  likes  to  wear  her  wrappers  threadbare, 
and  curses  roundly  when  she  is  compelled  to  put  on  a 
new  one.  Her  physical  condition,  always  poor,  im- 
proves somewhat,  and  her  functions  become  more  nearly 
normal  as  she  falls  deeper  and  deeper  into  dementia. 

Treatment. — If  physicians  will  keep  in  mind  the 
pretty  constant  relation  which  exists  between  simple 
melancholia  and  disorders  of  the  general  health,  they 
will  have  a  very  trustworthy  guide  to  therapeutics. 
The  correction  of  uterine  displacements  or  the  repair 
of  a  lacerated  cervix,  cure  of  a  prostatorrhoea,  or  the 
dilatation  of  a  stricture,  is  often  attended  with  the  most 
gratifying  effect  on  the  patient's  sense  of  wellbeing. 
Again,  someone  has  said  that  the  sources  of  human 
felicity  lie  chiefly  in  the  healthy  stomach,  and  certain  it 
is  that  the  relief  of  chronic  dyspepsia  often  lifts  a 
patient  out  of  despondency  and  gives  him  a  new  in- 
terest in  life.  Clouston  says  that  fat  and  melancholia 
are  natural  enemies.  In  short,  the  physician  will  re- 
sort to  every  means  which  will  increase  the  patient's 
strength  and  improve  his  i)hysical  condition,  and  to 
this  end  he  will  turn  his  attention  first  to  the  gastro-in- 
testinal  tract.  Early  treatment  will  be  the  most  effec- 
tive, alleviation  becoming  rapidly  more  and  more  diffi- 
cult of  accomplishment  after  the  malady  has  existed 
for  a  year.  Patients  prone  to  this  trouble  should  be 
informed  and  warned  that  any  falling  off  in  their  bodily 
health  is  pretty  certain  to  result  in  painful  mental  de- 
pression. 

And  there  is  the  matter  of  suicide,  the  responsibility 
for  which  the  friends  of  the  victim  usually  try  to  lay  at 
the  physician's  door.  Here  there  is  only  one  rule.  As 
already  stated,  all  persons  suffering  from  simple  melan- 
cholia, in  the  early  stages  of  their  disease,  at  least, 
should  be  regarded  as  suicidal  ;  and  the  physician  is 
false  to  his  trust  if  he  does  not  warn  and  instruct  the 
friends  accordingly. 

And  I  do  not  feel  justified  in  closing  this  paper 
without  emphasizing  the  following  facts  :  First,  simple 
melancholia  is  a  very  common  condition.  Second,  if 
treated  early  and  properly  it  is  a  very  curable  one. 
Thirdly,  it  is  out  of  this  unfortunate  class  that  sui- 
cide claims  probably  a  majority  of  its  victims. 


THE   ASSOCIATION    OF    TABES   AND    PARA- 
LYTIC DEMENTIA.' 

Report  of  Five  Cases. 
By  THEODORE  DILLER,  M.D., 

PITTSBURG. 
VISITING    PHYSICIAN   TO    ST.  FRANCIS    HOSPITAL. 

Nearly  all  observers  are  now  agreed  that  syphilis  is 
the  most  important  etiological  factor  in  the  production 
of  both  tabes  and  paralytic  dementia.  To  say  that 
syphilitic  history  is  present  in  four-fifths  of  all  cases  of 
tabes  and  in  two-thirds  of  all  cases  of  paralytic  demen- 
tia, would  probably  be  a  conservative  statement. 

It  has  been  observed  that  tabetic  symptoms  develop 
in  the  course  of  paralytic  dementia.  On  the  other 
hand,  general  paresis  may  develop  in  the  course  of 
locomotor  ataxia.  Just  how  frequent  the  association  of 
tabes  and  paresis  is,  cannot,  with  our  present  infoniia- 
tion,  be  determined.  Mickle '  takes  exception  to  the 
statement  of  Sachs'  that  the  development  of  general 
paresis  after  tabes  is  "  frequent,"  holding  (and  to  my 
mind,  very  properly)  that  we  must  distinguish  sharply 
between  true  tabes  and  the  mere  ataxic  or  tabetiform 
symptoms  which  are  common  enough  in  general  paral- 
ysis.* 

These  considerations  and  the  fact  that  some  of  the 
cortical  changes  characteristic  of  paresis  have,  by 
Nageotte  '  and  others,  been  found  in  those  dying  of 
tabes,  have  moved  Fournier,  Strumpell,  and  Jendrassik  " 
to  regard  tabes  and  paralytic  dementia  as  two  different 
clinical  manifestations  of  the  same  morbid  process, 
whose  seat  in  one  case  is  in  the  cord  and  in  the  other 
in  the  brain.  Then,  according  to  this  thought,  it  would 
be  very  natural  to  suppose  for  a  priori  reasons  that  in 
some  instances  the  pathologic  process  which  involves, 
first,  the  cord,  would  subsequently  involve  the  brain, 
and  vice  versa.  Whether  or  not  this  view  be  accepted, 
the  conviction  is  growing  that  the  association  between 
these  two  affections  is  very  close  indeed.  We  need  yet 
further  light  to  show  that  they  are  only  different  mani- 
festations of  the  same  diseased  process. 

It  would  seem  that  a  complication  or  association  as 
important  as  this  should  receive  mention  in  works  on 
nervous  diseases.  Unfortunately  this  is  not  the  case, 
(iowers,  however,  with  his  usual  grasp  of  all  aspects, 
complications,  and  association  of  nervous  diseases, 
points  out"  that  a  "  very  important  and  frequent  com- 
plication of  tabes  is  general  paralysis  of  the  insane." 
He  goes  on  to  remark  that  tabes  or  paresis  may  com- 
plicate each  other,  and  that  the  symptoms  of  one  or  the 
other  affection  may  preponderate,  and  states  his  belief 
that  the  "  correct  expression  of  the  facts  is  the  coexist- 
ence of  the  two  affections,  and  the  dominance  of  the 
symptoms  of  the  one  or  the  other." 

As  a  contribution  to  the  study  of  this  important 
question  the  clinical  records  of  the  following  five  cases 
are  submitted  : 

Case  I. — F.  H ,  policeman,  aged  fifty-eight,  ad- 
mitted to  St.  Francis  Hospital,  February  2,  1895.  He 
was  a  very  large,  heavy  man.  I'pon  admission  he  was 
very  noisy  and  excited,  and  slejU  poorly.  In  liis  con- 
versation, which  was  rambling  and  rather  incoherent, 
he  expressed  ideas  of  wealth  and  great  power.  Articu- 
lation, very  slurring.  There  was  a  tremulousness  of 
face  muscles  and  a  tremor  of  tongue  and  hands.  Con- 
trol over  sphincters  partially  lost.  His  gait  was  very 
ataxic  ;  knee-jerks  absent.     Pupils  responded  to  neither 

'  P.iper  re.id  by  title  at  meeting  of  Ameiican  Neurological  Associa- 
tion, held  in  Hoston,  June  8. 1895  Account  of  Case  V.  has  been  added 
to  the  paiier  as  originally  prepared. 

^  Brain,  Spring  Number,  1895.  p.  ill. 

'  New  York  Medical  Journal,  January  4.  1894. 

•  See  four  cises  reported  by  Zenner.  Cincinnati  Lancet-Clinic, 
May  13,  1893. 

■'  Soc   de  Biol..  January  28, 1893  (quoted  by  Mickle). 

«  Quoted  by  Mickle. 

■  Diseases  of  the  Nervous  System,  vol.  i.,  p.  417. 


October  5,  1895] 


MEDICAL   RECORD. 


481 


light  nor  accommodation.     He   died  from  exhaustion 
about  a  month  later.     No  autopsy  was  allowed. 

Case  II. — J.  M ,  diuggist,  aged  forty-three,  ad- 
mitted to  St.  Francis  Hospital,  September  30,  1894. 
At  that  time  he  presented  the  following  symptoms  : 
marked  static  and  locomotor  ataxia  ;  entire  absence  of 
knee-jerks ;  Argyle-Robertson  pupils.  Mentally  he 
was  quiet,  somewhat  depressed,  and  disinclined  to  talk. 
He  soon  changed  from  this  state  and  became  very 
noisy,  blusteringly  talkative.  He  spoke  of  electricity 
a  great  deal,  saying  that  he  had  devised  a  new  method 
of  generating  it  profitably,  and  expected  to  supply  the 
entire  city  of  Pittsburg  with  it.  He  declared  that  he 
was  possessed  of  great  wealth,  owned  many  fine  teams 
of  horses,  and  that  he  was  a  man  of  very  extraordinary 
and  peculiar  dignity.  During  this  excited  period  he 
had  much  difficulty  in  articulation,  his  words  being 
slurred  and  often  indistinct.  Tremor  in  tongue,  face, 
and  hands  was  noted. 

Twice  the  patient  improved  a  great  deal  as  to  his 
mental  symptoms.  At  present  (May,  1895)  he  enter- 
tains no  delusion,  is  quiet,  rational,  although  somewhat 
despondent,  and  some  element  of  dementia  is  apparent. 

The  ataxia  and  other  tabetic  symptoms  remain  un- 
changed. 

Case  III. — J.  J- — — ,  salesman,  aged  forty-four,  wid- 
ower, admitted  to  St.  Francis  Hospital,  August,  1893, 
with  the  history  that  he  had  become  rather  suddenly 
insane  four  weeks  previously,  and  that  he  had  since 
grown  constantly  worse.  Upon  admission  he  was 
noisy,  garrulous,  and  at  times  very  loud  and  excited. 
He  declared  that  he  was  possessed  of  enormous  wealth, 
and  frequently  offered  immense  sums  to  attendants  for 
trivial  favors.  His  gait  was  extremely  ataxic,  so  that 
he  could  with  the  greatest  difficulty  walk  a  short  dis- 
tance alone.  Both  knee-jerks  absent.  Pupils  some- 
what dilated,  responsive  to  neither  light  nor  accommo- 
dation. At  times  he  complained  of  severe  pains  in  his 
abdomen  and  thighs.  Slurring  articulation  ;  face  and 
hand  tremor.  It  was  thought  that  he  might  injure 
himself  in  his  efforts  to  get  about,  so  he  was  put  in  bed 
and  kept  there  during  the  few  months  he  was  in  the 
hospital.  He  grew  feebler  and  much  emaciated,  and 
became  careless  and  filthy  in  his  habits.  At  times  he 
was  quiet,  but  not  for  long  periods.  The  expansive  de- 
lusions never  left  him.  After  four  or  five  months  he 
was  removed  to  the  City  Farm,  where  he  died  a  couple 
of  months  later. 

Case  IV. — H.  E ,  tailor,  aged  forty-two  (seen  in 

consultation  with  Dr.  J.  M.  Douthett,  March,  1893). 
In  1870  he  contracted  syphilis,  for  which  he  was  treated 
and  believed  himself  cured.  Symptoms  broke  out  in 
1871  and  again  in  1881.  For  many  years  has  been  ad- 
dicted to  excessive  use  of  liquor.  He  states  that  for 
sixteen  years  past  he  has  been  troubled  at  times  with 
shooting  pains  in  the  lower  limbs  from  the  waist  down- 
ward ;  has  consulted  a  great  many  physicians  for  this, 
and  they  all  said  the  pains  were  rheumatic.  Before 
seen  by  me.  Dr.  Douthett  had  noted  the  symptoms  of 
ataxia,  Argyle-Robertson  pupils,  and  loss  of  knee-jerks, 
and  diagnosed  the  case  as  one  of  locomotor  ataxia. 
For  some  months  past  his  business  habits  had  been 
loose  and  he  had  become  careless  in  dress.  He  had  a 
number  of  optimistic  enterprises  on  hand.  Following 
a  debauch,  he  became  loud  and  excited  in  manner  and 
exhibited  some  delusions  of  grandeur.  When  I  saw 
him  the  tabetic  symptoms,  as  noted,  were  present.  He 
was  exceedingly  talkative  and  revealed  to  uie  a  number 
of  business  projects,  which  to  him  seemed  to  promise 
rich  returns.  He  stated  that  he  had  every  reason  to 
be  contented  and  hopeful,  whereas  his  personal,  do- 
mestic, and  business  conditions  were  such  that  an  ex- 
actly contrary  state  of  mind  would  have  been  most 
natural.  A  tremor  of  tongue  and  hands  was  noted. 
He  was  sent  to  an  asylum. 

Case  V. — William  L ,  bookkeeper,  aged  fifty,  ad- 
mitted to  St.   Francis   Hospital,  June  4,   1895.      Has 


been  married  eight  years  ;  no  children.  Six  years  ago 
contracted  syphilis  ;  had  secondary  eruption  and  mu- 
cous  patches.  A  year  and  a  half  ago  he  showed  some 
difficulty  in  walking,  and  this  has  been  slowly  increas- 
ing. Six  months  later  mental  symptoms  were  noted. 
He  became  dull,  careless  ;  showed  defects  of  memory  ; 
speech  became  thick,  slurring.  All  these  symptoms 
were  on  the  increase  when  he  was  admitted  to  the  hos- 
pital. 

Examination,  July  6,  1895. — Gait  ataxic  ;  walks  with 
feet  wide  apart  ;  cannot  stand  with  feet  together  when 
eyes  are  closed.  The  gait,  however,  is  not  a  typical 
tabetic  one,  in  that  the  high  step  and  quick,  jerky 
movements  are  absent.  Pupils  small ;  react  very 
slightly  to  accommodation  and  not  at  all  to  light. 

Mentally  there  is  a  marked  degivie  of  dementia. 
There  is  a  fatuous  sense  of  bien-ctre.  Speech  is  thick, 
slurring.  There  is,  especially  at  times  when  he  be- 
comes emotional,  a  tremulous  condition  of  the  facial 
muscles.  No  delusions  of  grandeur.  His  history  be- 
fore coming  to  the  hospital  is  imperfect,  and  it  is  not 
known  that  he  ever  possessed  any  delusions  of  grandeur. 

In  all  five  of  these  cases  the  diagnosis  of  tabes  seems 
quite  clear,  unless,  perhaps,  Case  V.  be  excepted,  and 
even  here  the  diagnosis  appears  very  probable.^  They 
are  not  cases  of  paralytic  dementia  presenting  tabeti- 
form  symptoms.  For  the  symptoms  of  tabes  in  all 
cases  except  Case  I.  (in  which  this  point  cannot  be 
determined,  because  of  the  meagre  history)  preceded 
the  paretic  symptoms.  In  Cases  II.  and  III.  the  his- 
tory does  not  state  this  point  definitely,  but  it  may 
fairly  be  inferred  from  the  fact  that  the  tabetic  symp- 
toms were  so  marked  when  treatment  for  mental  symp- 
toms was  sought. 

The  two  most  important  of  the  cardinal  symptoms  of 
tabes,  viz.,  ataxia  and  loss  of  knee-jerks,  were  present 
in  all  five  of  these  cases,  except  that  (as  previously 
noted)  ataxia  was  not  characteristic  in  Case  V.  The 
lightning  pains  were  known  to  have  been  present  in 
only  two  cases  (III.  and  IV.).  In  one  case  (IV.)  they 
were  present  for  many  years.  This  symptom  may  have 
been  present  in  the  other  three  cases,  but  the  history 
does  not  record  the  fact,  and  the  mental  condition  of 
these  patients  was  such  that  they  could  not  remember 
them. 

The  pupillary  symptoms  are  noteworthy.  In  Cases 
I.  and  III.  the  pupils  responded  to  neither  light  nor 
accommodation,  and  in  the  latter  case  they  were 
dilated.  In  the  remaining  three  cases  they  presented 
the  Argyle-Robertson  type  of  phenomena. 

As  to  the  symptoms  of  paresis,  dementia,  delusions 
of  grandeur,  tremor,  and  defective  articulation  they 
were  present  in  all  patients,  excepting  Case  IV.  (where 
speech  was  not  defective),  and  Case  V.  (where  delu- 
sions of  grandeur  were  not  noted).  In  view  of  the 
presence  of  these  symptoms  the  diagnosis  seems  plain 
in  all  these  cases. 

In  two  cases  (IV.  and  V.)  there  is  a  clear  history  of 
syphilis.  It  is  not  known  whether  or  not  any  of  the 
other  three  cases  were  syphilitic. 

WeSTINGHOUSE  HriLDING. 


Travail  and  Travel. — A  Boston  daily  is  the  authority 
for  the  statement  that  one  of  the  companies  that  run 
lines  of  steamers  on  the  great  lakes  announced  that  it 
would  give  a  prize  of  §250  in  gold  for  every  baby  born 
on  one  of  its  vessels  this  season  ;  §500  for  twins,  and 
$1,000  for  triplets.  This  was  certainly  encouraging, 
the  prize  for  triplets  being  notably  appreciative.  They 
are  worth  the  price,  the  writer  said,  and  the  money 
would  start  the  parents  off  very  handsomely  under  what 
would  otherwise  be  unfavorable  conditions.  We  have 
not  heard  that  the  birth- rate  on  the  great  lakes  was 
higher  than  usual  this  summer. 

'  Since  ihis  was  written  the_diagnosis  of  associated  tabes  and  pare- 
sis seems  plain. 


482 


MEDICAL    RECORD. 


[October  5,  1895 


INFLAMMATION      OF     THE     UTERINE 
PENDAGES   (SALPINGITIS).' 

By  SOLOMON  G.  KAHN,  M.D., 

LEADVILLE.    COL. 


AP- 


LATE   HOUSE  PHVSICIAN   AT  ST. 


:'S   HOSPITAL,  NEW  YORK   CIT 


Every  practitioner  is  aware  of  the  fact  that  the  present 
century  is  full  of  changes  in  the  theories  and  practice 
of  medicine.  Perhaps  in  no  branch  of  our  science  has 
more  been  done  for  the  alleviation  of  human  suffering 
than  in  that  pertaining  to  diseases  of  women,  and  to 
the  consideration  of  one  of  these  I,  for  a  momfcnt,  invite 
your  attention. 

As  we  are  informed  by  Pozzi  :  "  In  the  attempt  to 
understand  the  connections  between  the  uterus  and  the 
Fallopian  tubes,  it  must  be  borne  in  mind  that  they 
have  a  common  embryonal  origin. 

"  At  the  end  of  the  second  month  of  intra-uterine 
life,  Miller's  ducts  fuse  inferiorly  to  form  the  uterus 
and  the  vagina,  while  they  remain  distinct  above  and 
constitute  the  tubes.  The  latter  are,  in  reality,  only 
the  slender  prolongation  of  the  uterine  cornua.  There 
is  an  immediate  continuity  between  their  different 
coats,  from  which  arises  the  possibility  of  an  ascending 
salpingitis  consecutive  to  an  inveterate  cystitis.  The 
ovary  connected  to  the  tube  by  the  tubo-ovarian  liga- 
ment is  in  almost  immediate  contact  with  its  pavilion, 
and  may  be  infected  by  contiguity.  These  organs  are 
also  united  by  important  vascular  and  lymphatic  con- 
nections. I  need  scarcely  remind  you  of  anastomoses 
of  the  utero-ovarian  arteries  and  veins  with  those  of 
the  uterus ;  still  more  important  are  the  lymphatics. 
There  is  a  remarkable  lymphatic  group  occupying  the 
space  between  the  tube  and  the  ligament  of  the  ovary. 
Important  relations,  completing  the  already  close  ana- 
tomical connections,  are  thus  established  between  the 
ovary  and  the  tube.  Thus  there  is,  so  to  speak,  no 
ovaritis  without  salpingitis,  and  no  salpingitis  without 
ovaritis  ;  the  inflammations  of  the  appendages  are  then 
properly  combined  in  the  same  description.  Almost 
always  the  inflammation  passes  from  the  tube  to  the 
ovary  directly  by  contact  and  by  adhesion.  But  some- 
times there  is  also  observed  a  suppuration  of  the  ovary 
without  continuity  with  the  inflammation  of  the  tube. 
This  fact  can  then  be  e.Kplained  by  the  lymphatic  rela- 
tions. The  vessels  which  come  from  the  pavilion  fol- 
low the  external  lateral  ligament  and  empty  into  the 
large  lymphatic  ple.xus  called  the  subovarian  plexus. 
There  is  then  no  difficulty  in  comjjrehending  that  an 
abscess  of  the  ovary  may  be  observed.  With  relatively 
small  lesions  of  the  oviduct,  the  adhesions,  which  are 
rich  in  lymphatics,  may  serve  to  carry  the  inflammation. 
The  lymphatic  net- work  which  covers  the  surface  of  the 
ovary  also  communicates  e.xtensively  with  that  of  the 
peritoneum.  If,  then,  the  ])eritonitis,  consecutive  to 
inflammation  of  these  organs,  usually  remains  circum- 
scribed, it  is,  without  doubt,  because  an  early  stage  of 
the  process  consists  in  a  plastic  obliteration,  a  sort  of 
adhesive  lymphatic  thrombosis. 

"  Finally,  the  subperitoneal  cellular  tissue  that  exists 
in  the  wings  of  the  tube  and  of  the  ovary,  is  in  connec- 
tion with  that  of  the  broad  ligaments,  which  is  itself 
continuous  below  on  the  pelvic  floor,  and  on  the  sides 
with  the  lamellar  tissue,  folding  in  with  the  peritoneum 
and  offering  a  special  laxity  in  front  of  the  bladder  in 
the  pseudo-cavity  of  Retzius.  The  knowledge  of  these 
peculiarities  is  indispensable  for  the  explanation  of  the 
deep  and  the  superficial  propagation  of  the  inflamma- 
tion." 

The  importance  of  the  subject  and  the  frequency  of 
the  disease  may  be  inferred  from  the  fact  that  Winckel, 
out  of  five  hundred  autopsies  made  on  women,  found 
three  hundred  of  thtni  to  have  had  salpingitis  of  a 

'•    '  Read  at  a  meeting  of  the  Colorado  State  Medical  Society,  held 
June  20,  189s 


greater  or  less  degree.  There  have  been  many  classi- 
fications of  salpingitis  described.  The  one  to  which 
reference  will  be  made  in  this  paper  is  that  formulated 
by  Dr.  H.  J.  fiarrigues  and  given  in  his  text-book  on 
"  Diseases  of  Women." 

Different  Forms. — It  may  be  acute  catarrhal  or  acute 
purulent,  both  of  which  are  seated  in  the  mucous  mem- 
brane, and  are  therefore  called  endosalpingitis  ;  or  it 
may  be  chronic  interstitial,  which  is  also  called  pachy- 
salpingitis, mural  salpingitis,  or  parenchymatous  sal- 
pingitis, and  is  located  in  the  muscular  coat.  Salpingitis 
may  be  cystic,  and,  according  to  the  character  of  the 
fluid  contained  in  the  dilated  tube,  it  is  called  pyo- 
salpinx,  which  is  filled  with  pus  ;  hydrosalpinx,  which 
contains  a  watery  fluid,  and  hsematosalpinx,  the  con- 
tents of  which  are  bloody.  Perisalpingitis  is  the  in- 
flammation of  the  peritoneal  covering  of  the  tube,  a 
condition  which  only  occurs  as  part  of  a  more  extended 
pelvic  peritonitis. 

Profluent  salpingitis  is  a  variety  characterized  by  the 
discharge  of  a  watery  fluid,  pus,  or  blood  from  the  tube 
through  the  uterus  and  vagina.  When  the  fluid  is 
watery  the  disease  is  also  called  hydrops  tubae  pro- 
fluens,  or  intermittent  hydrocele  of  the  ovary. 

Under  the  name  of  salpingitis,  isthmica  nodosa  has 
been  described,  a  form  of  chronic  salpingitis  in  which 
nodules  can  be  felt  at  the  corners  of  the  uterus.  In 
their  interior  is  found  the  tubal  canal,  hyperplasia,  and 
hypertrophy  of  the  muscular  elements  of  the  wall,  and 
sometimes  cysts. 

Pyosalpinx  saccata  is  a  variety  of  pyosalpinx  in 
which  the  lumen  of  the  tube  is  partitioned  off  into  a 
series  of  pus-filled  sacs,  which  partitions  may  subse- 
quently become  absorbed  so  as  to  form  one  cavity. 
Taking  the  etiology  as  base  for  a  classification,  salpin- 
gitis may  be  divided  into  infectious  and  non-infectious. 
The  non-infectious  is  always  catarrhal  :  the  infectious 
is  nearly  always  purulent,  but  may,  in  the  beginning,  or 
toward  the  end  of  the  disease,  be  catarrhal. 

The  causes  of  salpingitis  in  many  cases  cover  a  multi- 
tude of  sins  and  imprudences,  either  produced  by  the 
woman  herself  or  someone  else.  Gonorrhoea  and  septic 
infection  cause  the  greater  number  of  cases.  Abortions, 
which  are  complete  or  incomplete,  causing  many  cases 
also,  which  sometimes  do  not  manifest  themselves  for 
several  years  ;  endometritis,  metritis,  too  frequent  coi- 
tion, exposure  to  cold  just  prior  to,  and  during,  men- 
struation, exanthematous  diseases,  syphilis,  tuberculosis, 
and  frequent  douche  of  cold  water.  Last,  but  not 
least,  any  manipulations  of  the  cervix  or  uterus  with- 
out surgically  clean  hands  or  instruments.  The  symp- 
toms are  many  and  varied.  When  seen  in  its  first 
stages  the  patient  may  only  complain  of  a  peculiar 
discomfort  of  the  external  genitals,  urethra,  and  uterus, 
on  one  or  both  sides.  Pain  may  be  slight  or  severe  ; 
referred  to  the  sacral  and  lumbar  regions  or  down  the 
thighs,  also  in  the  iliac  fossa  and  epigastrium,  exag- 
gerated by  undue  exercise.  Sometimes  they  have  pain 
caused  by  the  tumor  pressing  on  the  nerves  in  the 
pelvis.  Pain  more  or  less  severe  during  defecation,  . 
which  does  not  occur  daily  with  these  patients,  who 
usually  suffer  from  chronic  constipation  as  an  adjunct 
to  their  other  troubles.  Some  only  complain  of  pain 
during  coition.  Menstruation  may  be  profuse  and 
irregular,  the  pain  becoming  more  severe  at  that 
period.  Some  of  these  symptoms  may  be,  and  are, 
frequently  overlooked,  and  the  patient  treated  for 
hysteria  and  dosed  for  months ;  the  knowledge  of 
the  real  trouble  escaping  the  attention  of  the  attending 
physician.  Should  a  few  drops  of  pus  from  the  fimbri- 
ated end  of  the  tube  escape  into  the  abdomen,  thereby 
setting  up  a  pelvic  peritonitis,  the  cause  of  which 
might  still  escape  the  attention  of  the  medical  attend- 
ant, a  vaginal  examination  ought  not  to  be  neglected. 

As  regards  treatment,  it  is  well  for  us  to  remember, 
in  this  connection,  that  every  case  of  metritis  in  every 
instance,  whether  specific,   septic,  or  non-septic,  will, 


October  5,    1895] 


MEDICAL    RECORD. 


48c 


sooner  or  later,  extend  to  the  tubes,  causing  salpingitis. 
Therefore,  the  most  important  treatment  is  prevention. 
If  all  cases  were  recognized  before  the  tubes  are 
involved,  and  properly  treated,  vre  would  have  very 
few  cases  of  salpingitis.  When  a  salpingitis  is  acute, 
the  usual  palliative  measures  of  cold  applications  to 
the  abdomen,  with  hot  vaginal  injections,  absolute  rest 
in  bed,  a  fluid  diet,  and  opium  are  employed.  But  it 
is  the  subacute  and  chronic  cases  which  cause  us  the 
greatest  anxiety  and  make  confirmed  invalids  of  our  pa- 
tients, which  we  wish  to  consider.  It  has  become  quite 
a  fad  to  remove  all  diseased  tubes,  but  a  great  many 
tubes  can  be  saved  by  a  palliative  treatment,  if  properly 
carried  out.  Numerous  cases  may  be  seen,  which  were 
due  to  endometritis,  cured  by  curetting  the  uterus  and 
then  treating  the  diseased  tubes  locally ;  and  also 
where  an  eroded  and  enlarged  cervix  is  found  with  sal- 
pingitis, a  great  advantage  may  be  gained  by  treating  with 
applications  of  a  five-per-cent.  solution  of  aluminum 
acetate.  The  best  local  treatment,  perhaps,  is  to  use  ten 
per  cent,  ichthyol  glycerine  tampons  in  the  vagina  twice 
a  week,  at  the  same  time  employ  hot  vaginal  injections 
twice  a  day.  In  chronic  cases  have  them  use  a  Pries- 
nitz  at  night  and  remove  it  in  the  morning  ;  also  fre- 
quently paint  the  posterior  vault  of  the  vagina  with 
iodine.  Sometimes  a  better  result  will  be  obtained  by 
confining  the  patient  to  her  bed  for  a  week  or  two, 
giving  her  hot  vaginal  injections  three  times  a  day, 
and  introducing  the  ichthyol  tampons  every  night. 
Electricity  has  been  recommended,  but  it  may  be 
doubted  if  the  value  has  been  proven  ;  also  massage. 
If  massage  is  to  be  used,  it  should  only  be  in  chronic 
cases,  for  the  reason  that  if  used  where  there  is  any 
inflammation  it  will  aggravate  it.  If  none  of  these 
measures  cure  or  relieve  the  patient,  then  the  question 
of  removing  the  tubes  may  be  considered.  Laparotomy 
has  always  been  the  extreme  measure  employed.  But 
recently  the  operation  of  vaginal  hysterectomy  has  been 
advocated  and  substituted  by  Drs.  Polk  and  Boldt,  of 
New  York,  in  cases  where  both  appendages  must  be 
sacrificed,  as  ascertained  by  the  history  and  examina- 
tion. 

The  following  report  of  two  cases  are  selected  from 
a  number  of  similar  ones,  treated  agreeably  to  the  course 
laid  down  in  this  paper  : 

On  August  7,  1894,  Mrs.  Emma  S ,  thirty  years 

of  age,  applied  to  me  for  treatment ;  family  history 
good  ;  commenced  menstruating  at  the  age  of  thirteen 
years  ;  always  regular  and  free  from  trouble  at  those 
periods  ;  pregnant  three  times,  carrying  her  children  to 
full  term.  In  the  month  of  May,  1892,  she  was  de- 
livered of  a  healthy  child  at  full  term.  Her  trouble 
dated  from  that  time.  Complained  of  pain,  at  period 
of  menstruation,  on  left  side  and  back  ;  nausea  at  irreg- 
ular intervals,  accompanied  with  diarrhoea ;  constant 
feeling  of  lassitude,  all  of  which  incapacitated  her  from 
performing  her  household  duties.  On  bimanual  ex- 
amination I  found  the  left  tube  and  ovary  painful  to 
touch,  and  enlarged  to  the  size  of  a  goose-egg  ;  tem- 
perature of  vagina  elevated,  with  inflammation  of  entire 
pelvis.  Discharged  from  treatment,  October  8,  1894. 
Treatment  consisted  of  the  introduction  of  ichthyol 
tampons  twice  weekly,  with  a  general  tonic.  Patient 
reports  herself.  May,  1895,  entirely  free  from  her  former 
trouble,  from  date  of  discharge. 

On  February  27,  1895,  Mrs.  Kate  T ,  aged  thirty- 
four  years,  came  under  my  treatment.  Menstruated  at 
thirteen  years  of  age  ;  married  when  twenty-one  ;  has 
three  living  children.  In  July,  1894,  aborted  at  six 
weeks,  from  which  date  she  has  suffered  from  the  fol- 
lowing symptoms  :  Pain  referred  to  left  side ;  men- 
struated profusely  at  irregular  periods  ;  on  bimanual 
examination  found  an  enlarged  left  tube  ;  speculum 
revealed  an  enlarged  and  eroded  cervix.  Treatment  : 
-\pplication  of  aluminum  acetate  to  cervix,  followed  by 
introduction  of  ichthyol  glycerine  tampons.  Patient 
discharged    from    further  treatment  April  30th,  since 


which  time  she  has  been  free  from  pain  and  irregular 
menstruation. 

19-21  L'nio.n'  Klcck. 

A  METHOD  OF  EXPRESSING  THE  DEGREE 
OF  ACIDITY  OR  ALKALINITY  OF  ORGANIC 
AND  OTHER  FLUIDS. 

By  J.  B.  NICHOLS,  M.D., 

CLINICAL  .'^SIST.^.NT,   U.MIED   STATES  SOLDIERS'   HOME,   WASHINGTON,    D.C. 

In  laboratory  work  the  necessity  frequently  arises  of 
estimating  the  degree  of  acidity  or  alkalinity  of  organic 
and  other  fluids,  as  in  the  examination  of  stomach  con- 
tents. Various  methods  are  in  use  for  expressing  the 
acidity  or  alkalinity,  as  in  the  case  of  urine  by  the  terms 
of  an  equivalent  solution  of  oxalic  acid,  and  in  that  of 
stomach  contents  by  the  number  of  cubic  centimetres 
of  a  decinormal  alkaline  solution  required  to  neutralize 
100  c.c.  These  methods  are  more  or  less  arbitrary  and 
empirical.  It  would  seem  desirable  that  a  uniform  and 
rational  system  should  be  adopted  applicable  to  -all 
fluids  to  express  the  results  of  volumetric  acidimetry 
and  alkalimetry.  It  is  the  purpose  of  this  note  to  pre- 
sent a  scheme  which  I  use  in  my  own  work  with  urine 
and  gastric  fluid,  and  which  seems  admirably  suitable 
for  its  purpose. 

The  natural  standard  is  the  normal  solution.  This 
is  the  standard  adopted  in  the  system  here  presented, 
with  its  acidity  or  alkalinity,  as  the  case  may  be,  fixed 
at  the  number  i.  All  other  degrees  of  acidity  and 
alkalinity  are  expressed  by  the  numbers  (decimals  or 
integers)  indicating  their  strengths,  relative  to  the  nor- 
mal solution  as  i.  This  standard  may,  if  deemed  ad- 
visable, be  expressed  by  the  letter  N.  Thus,  an  acidity 
expressed  as  .022  (or  .022  N)  would  mean  that  the 
acidity  of  the  fluid  is  twenty-two  thousandths  that  of  a 
normal  acid  solution  ;  .001  N  would  represent  a  strength 
of  one-thousandth  of  a  normal  solution  ;  a  fluid  of 
which  10  c.c.  would  be  neutralized  by  4.5  c.c.  of  deci- 
normal acid  would  have  an  alkalinity  of  .045  N  ;  2  N 
would  represent  a  strength  double  normal  ;  decinormal 
and  seminormal  solutions  would  be  represented  by  .1  N 
and  .5  N  respectively.     The   latter  are   frequently  ex- 

N     N 
pressed  in  fractional  form, — '  — .      The    system    here 

suggested  contemplates  an  extension  of  this  method  of 
notation  to  acid  and  alkaline  fluids  of  all  strengths, 
only  the  decimal  form  is  more  generally  convenient 
than  the  fractional. 

It  might  at  times  be  also  found  convenient,  as  in 
tabular  matter,  to  denote  acidity  and  alkalinity  by  the 
signs  -1-  and  —  respectively.  This  method  of  notation 
appears  to  me  to  be  the  best  for  its  purpose.  It  is  of 
universal  applicability  to  all  acid  and  alkaline  fluids, 
and  expresses  results  in  a  uniform  manner.  As  all 
normal  solutions  are  of  equivalent  strength,  this  method 
affords  a  means  of  direct  comparison  not  only  between 
fluids  of  the  same  reaction,  but  also  between  acids  and 
alkalies.  It  is  simple,  rational,  and  natural,  the  normal 
method  as  it  were,  and  completely  corresponds  with  the 
system  of  normal  solutions. 

The  acidity  or  alkalinity  so  expressed  is  directly  pro- 
portional to  the  percentages  by  weight  of  acid  or  alka- 
line substances  present,  which  may  be  readily  computed 
by  means  of  normal  factors.  Thus,  a  strength  of  .001 
N  corresponds  to  .003637  per  cent,  by  weight  of  hydro- 
chloric acid,  .004489  of  absolute  oxalic  acid,  .003996 
of  sodium  hydrate,  .00219  "^^  carbonic  oxide,  etc.,  from 
which  the  weight  percentages  can  be  readily  determined. 

In  any  titration,  where  two  fluids  are  mixed  to  exact 
neutralization,  the  number  of  cubic  centimetres  of  the 
one  fluid  used,  multiplied  by  its  acidity,  is  eijual  to  the 
number  of  cubic  centimetres  of  the  other  fluid  multi- 
plied by  its  alkalinity.  The  number  expressing  the 
acidity  or  alkalinity  can  therefore  be  easily  calculated, 


484 


MEDICAL    RECORD. 


[October  5,    1895 


in  any  titration,  by  the  following  rule  :  Multiply  the 
number  of  cubic  centimetres  of  the  test  solution  used 
in  titration  by  its  alkalinity  or  acidity  and  divide  the 
product  by  the  number  of  cubic  centimetres  of  the 
fluid  being  tested  which  is  employed  ;  the  quotient  ex- 
presses the  acidity  or  alkalinity  of  the  latter.  Thus,  if 
it  requires  6.8  cc.  of  decinormal  sodium  hydrate  solu- 
tion to  neutralize  8  cc.  of  stomach  contents,  the  acid- 
ity of  the  latter  equals  6.8  x  .1  -^  8  =  .085. 


PALLIATIVE  TREATMENT  OF   HAV  FEVER. 
By  FREDERICK  G.  SMITH,  M.D., 

SOMERVILLE.   MASS. 

The  prevalence  of  hay  fever,  especially  at  certain  times 
in  the  year,  is  of  such  frequent  occurrence,  and  symp- 
toms so  characteristic,  that  its  recognition  is  not  diffi- 
cult even  by  the  laity.  So  periodically  regular  is  its 
appearance  that  the  practitioner  is  almost  sure  to  meet 
it-during  the  months  of  August  and  September.  Indeed, 
many  patients  can  foretell  its  onset  with  precision  even 
to  an  hour. 

In  endeavoring  to  treat  a  disease  on  a  rational  basis, 
the  regular  physician  always  strives  to  remove  the 
cause,  and  it  is  a  well-known  fact  that  diseases  in  which 
the  cause  is  imperfectly  understood  are  the  most  un- 
satisfactory to  treat.  It  is  not  intended  here  to  discuss 
the  etiology  of  hay  fever,  but  while  this  curious  disease 
has  been  very  closely  studied  for  many  years  and  brill- 
iant theories  and  ideas  advanced  relative  to  its  cause, 
there  are  none  that  are  at  present  universally  accepted. 
Confronted,  therefore,  by  these  facts,  the  hope  of  ob- 
taining a  specific  for  its  cure  must  necessarily  be  shaded 
until  further  investigation  has  been  made.  Where  the 
cautery  can  be  used,  it  undoubtedly  produces  the  best 
results  if  thoroughly  applied.  This  is  a  disagreeable 
procedure,  requiring  sometimes  several  sittings,  and  will 
not,  for  various  reasons,  be  used  by  many  physicians. 

A  large  majority  that  apply  for  treatment  to  the  gen- 
eral practitioner  are  not  possessed  with  the  means  to 
take  a  sea-voyage  or  to  spend  several  months  in  the 
mountains,  so  we  must  resort  to  means  more  within  the 
reach  of  all.  Referring,  then,  to  the  palliative  treat- 
ment, local  applications  are  to  be  recommended. 
Sprays  of  various  sorts  produce  only  a  transitory  effect, 
besides  not  being  convenient.  Cotton  has  been  used 
in  the  nose  with  a  view  of  preventing  the  irritating  sub- 
stance, whatever  it  may  be,  from  gaining  access  to  the 
hyperaesthetic  membrane,  but  most  people  do  not  like 
the  sensation,  and  the  cosmetic  effect  is  not  wholly  at- 
tractive. Ointments  produce  a  twofold  effect,  viz., 
combined  with  anesthetics  they  diminish  hyperoesthesia, 
and  shield  the  nerve-terminals  from  irritation.  The  fol- 
lowing combination  I  have  found  very  effectual,  and  I 
have  yet  to  see  a  case  where  it  did  not  give  almost  in- 
stant relief. 

R .  Mentholis grs.  xx. 

Olei  amyg.  dulcis 3  ij. 

Acidi  carbulici IH^x. 

Cocain  hydrochloi grs.  vj. 

Ung,  zinci  oxidi 3  ss. 

Sig. :  Apply  thoroughly  to  the  nostrils  on  cotton  .ittached  to  a 
tooth-pick. 

It  will  at  once  be  seen  that  cocaine  is  the  chief  drug 
to  be  relied  upon,  but  I  do  not  think  it  is  the  only  one, 
as  I  have  used  it  in  other  ways  with  much  less  satisfac- 
tion. It  is  the  combination  as  a  whole  that  I  think 
worthy  of  notice,  and  while  empiricism  ought  generally 
to  be  discouraged,  I  think  in  the  disease  under  consid- 
eration it  seems  justifiable.  There  are  adjuncts  that  are 
valuable  in  these  cases  depending  upon  the  general  con- 
dition of  the  system.  Out-door  exercise,  Blaud's  pill  in 
anteraia,  and  arsenic,  strychnine,  and  phosphorus,  as  in- 
dicated, are  too  well  known  to  warrant  comment. 


gragrjess  of  |5aetltcal  ,^cicnce. 

Intestinal  Obstruction  in  Children. — Dr.  Monti,  after 
discussing  the  causes  and  genera!  symptoms  of  in- 
testinal obstruction  in  children  and  accepting  in  the 
main  the  views  of  Leichtenstem,  gives  the  following 
points  as  those  whicli  are  of  value  in  forming  an  opin- 
ion as  to  the  site  of  the  obstruction  {^British  Medicai  - 
Journal.')  :  i.  In  the  lower  part  of  the  colon  the  first 
symptom  of  acute  obstruction  is  painful  colic,  and  the 
region  of  the  abdomen  in  which  the  colic  is  first  felt 
may  afford  some  indication  of  the  part  of  the  colon 
obstructed.  Vomiting  does  not  occur  until  the  colic 
has  lasted  for  some  hours  or  days  ;  it  is  at  first  bile- 
stained,  then  becomes  foul,  and  finally  feculent.  Col- 
lapse sets  in  late  ;  gaseous  distention  of  the  intestine 
begins  in  the  colon,  and  at  first  it  may  be  possible  to 
make  out  that  it  is  limited  to  the  region  occupied  by 
the  colon  (flanks  and  epigastrium),  but  later  the  ileum 
also  becomes  distended,  and  the  tympanites  may  reach 
a  very  high  degree.  In  incomplete  obstruction  the 
symptoms  are  the  same,  but  develop  more  slowly. 
Action  of  the  bowels  may  occur,  and  be  attended  by 
temporary  relief,  especially  of  the  tympanites.  If  the 
rectum  be  incompletely  obstructed,  constipation  alter- 
nates with  attacks  of  painful  tenesmus,  followed  by  the 
passage  of  small  scybala.  Circular  constriction  of  the 
rectum  causes  the  motions  to  be  of  small  calibre.  2. 
Acute  obstruction  in  the  lower  part  of  the  ileum  is  at- 
tended with  frequent  attacks  of  painful  colic,  starting 
in  the  ileo-caecal  region.  Each  paroxysm  of  colic  in- 
duces an  attack  of  vomiting,  the  vomited  matter  being 
at  first  the  contents  of  the  stomach,  but  later  fecal. 
Collapse  sets  in  early.  The  distention  of  the  abdomen 
is  most  marked  at  first  in  the  umbilical  and  hypogastric 
regions,  but  in  time  becomes  general  ;  it  is  not  notably 
diminished  by  vomiting.  At  first  several  fecal  stools 
may  be  passed,  but  after  a  few  days  there  is  complete 
constipation.  The  quantity  of  urine  is  diminished 
after  the  first  few  hours  or  days,  and  there  may  event- 
ually be  suppression.  When  the  obstruction  is  incom- 
plete the  colic  may  be  as  severe,  and  the  movements  of 
the  coils  of  intestines  perceptible.  The  degree  of  dis- 
tention may  vary  greatly  in  a  verj-  short  time,  and 
this  independently  of  the  passage  of  a  stool.  The 
constipation,  after  lasting  some  days,  may  be  succeeded 
by  copious,  foul  diarrhoea.  3.  Acute  obstruction  in  the 
duodenum  or  jejunum  causes  severe  colicky  pain,  start- 
ing about  the  umbilicus  and  radiating  toward  the  stom- 
ach. Vomiting  comes  on  early,  and  is  violent  ;  the 
vomited  matter  is  at  first  bile-stained,  later  it  becomes 
foul  smelling.  Gaseous  distention  is  slight,  and  is 
limited  to  the  epigastrium.  It  may  be  very  much  di- 
minished by  vomiting,  but  collects  again,  rhe  bowels 
may  at  first  act  spontaneously  or  after  enema,  but 
eventually  there  is  complete  constipation.  Suppression 
of  urine  is  established  early.  When  the  obstruction  is 
not  complete,  the  symptoms  are  similar  but  less  severe. 
The  colic  is  painful,  and  the  vomiting,  either  in  rela- 
tion with  the  colic,  or  independently,  very  frequent.  . 
The  quantity  of  urine  is  diminished.  There  is  no  dis-  f 
tention  of  the  abdomen,  and  diarrhoea  alternates  with  j 
constipation.  .Monti  considers  that  if  a  case  is  seen 
early  much  may  be  learned  as  to  the  probable  seat  of  ' 
the  obstruction  by  observing  the  way  in  which  the 
tympanites  develops. 


The  Library  of  the  Surgeon-General's  Office  of  the 
United  States  Army  now  contains  1 16,847  volumes  and 
191,598  pamphlets. 

Every  Fatal  Case  of  Typhoid,  says  Mr.  Ernest  Hart,  « 
is,  in  fact,  a  violent  death,  an  example  of  water  poison-  jP 
ing,  and  should  be  the  subject  of  sanitary  inquest. 


October  5,  1895] 


MEDICAL    RECORD. 


485 


Medical   Record: 

A  Weekly  journal 0/ Medicine  and  Surger'\ 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor 


Publishers 
WM.  WOOD  &  CO.,  43,  45.  &.  47  East  Tenth   Street 


New  York,  October  5,   1895. 


SUNDAY    LIQUOR-SELLING    FROM    A    DOC- 
TOR'S STANDPOINT. 

The  discussion  of  the  excise  question,  of  local  option 
and  of  Sunday  liquor-selling,  which  now  interests  so 
manv,  has  a  medical  and  scientific  side  which  should  not 
be  entirely  neglected.  It  is  very  proper  that  those  peo- 
ple who  are  anxious  to  provide  (or  deny)  opportunities 
for  drinking  every  day  in  the  week,  should,  in  a  measure, 
consider  not  only  the  question  of  "  personal  liberty  " 
and  the  "  poor  man's  rights,"  but  also  the  question 
whether  the  habit  of  drinking  liquor  on  any  day  may 
not  be  injurious  to  the  body  of  citizens  as  a  whole. 
Our  readers  will  remember  that  not  many  years  ago, 
the  question  of  the  danger  or  lack  of  danger  from  the 
use  of  alcoholic  drinks,  was  very  widely  agitated  among 
medical  men,  and  that  many  learned  opinions  were 
given,  very  largely  by  eminent  English  physicians,  as 
to  the  safety,  or  otherwise,  of  the  habit  of  moderate 
drinking.  The  conclusions,  at  that  time,  seemed  to  be, 
from  all  the  facts  and  opinions  that  could  be  gathered, 
that  a  large  number  of  persons  could  drink  temperately 
for  years  without  really  impairing  their  health  or 
shortening  their  lives.  Since  that  time  a  good  deal 
more  evidence,  as  to  the  action  of  alcohol  upon  the 
human  body,  has  been  collected,  not  by  hyjterical 
prohibitionists,  but  gathered  from  the  laboratory,  the 
autopsy-room,  and  the  bedside.  One  series  of  facts, 
opening  up  a  decidedly  new  field,  has  been  obtained 
through  the  works  of  the  experimental  psychologists. 
Through  the  efforts  of  some  of  these  gentlemen,  and 
we  may  mention  particularly  work  done  at  the  Heidel- 
berg University,  it  seems  to  be  established  that  alcohol 
has  an  effect  in  dulling  certain  mental  processes,  such, 
for  example,  as  learning  by  rote,  simple  arithmetical 
calculations,  and  the  simpler  association  of  ideas. 
.\nother  series  of  facts  which  tend  to  show  the  evident 
effects  of  alcohol,  is  that  which  have  been  collected  by 
students  of  heredity,  particularly  the  relation  of  hered- 
ity to  degeneration  in  families.  The  French  alienists, 
in  particular,  have  shown  that  one  of  the  most  promi- 
nent of  the  factors  in  leading  to  development  of  mental 
and  physical  degeneration,  is  the  use  of  alcohol,  and  it 
is  further  urged  by  these  investigators  that  alcohol  has 
more  than  an  individual  or  family  effect,  that  it  pro- 
duces serious  deterioration  of  the  human  race.  Of 
course,  the  effects  thus  claimed  are  all  due  to  the  abuse 
and  excess  of  alcohol.     Whether  a  further  and  more 


careful  investigation  would  show  that  a  moderate  use 
of  alcohol  leads,  eventually,  to  somewhat  similar  re- 
sults, we  cannot  say.  As  regards  the  evidence  against 
alcohol,  furnished  by  clinicians  and  pathologists,  there 
has  really  been  nothing  particularly  new  added  in  late 
years.  But  if  one  take  an  unbiassed  survey  of  the 
position  of  medical  knowledge  and  of  medical  men 
toward  alcohol,  and  compare  it  with  that  held  by  them 
fifteen  years  ago,  we  feel  sure  that  he  will  see  that 
the  feeling  against  the  use  of  it  is  much  stronger.  This 
is  because  there  has  been  a  gradual  accumulation  of 
facts  carefully  ascertained  and  thoroughly  proven, 
demonstrating  the  ill  effects  of  the  drug. 

It  is  for  the  reason  that  the  position  of  medical  men 
regarding  the  use  of  alcohol  has  been  always  conserva- 
tive and  never  fanatical,  that  the  present  slight  shifting 
of  the  front  deserves  the  attention  of  our  law-makers 
and  of  all  those  citizens  who  are  interested  in  good 
government  and  in  the  social  problems  of  the  day. 


TUBERCULOSIS    AND    THE    LIBRARY. 

The  statement  has  passed  current  that  a  librarian  of 
the  city  of  Omaha,  Neb.,  recently  died  of  tuberculosis 
contracted  from  books  which  had'  been  infected  by 
consumptive  patients.  This  report  has  naturally  re- 
newed the  discussion  regarding  the  danger  of  infection 
by  means  of  public  libraries.  There  are  many  physi- 
cians who  are  aware  of  cases  in  which  some  of  the  more 
actively  contagious  and  portable  diseases  have  been 
communicated  by  means  of  books,  though  not,  per- 
haps, by  the  books  of  a  public  librar)'.  We  recall,  for 
example,  instances  in  which  scarlet  fever  was  appar- 
ently communicated  in  this  way.  Practical  experience, 
however,  in  the  large  cities,  where  there  are  well-pat- 
ronized public  libraries,  seems  to  show  that  little  dan- 
ger is  to  be  apprehended  from  this  source.  This  is 
particularly  the  case  in  cities  that  are  supplied  with 
proper  health  boards  and  with  modern  sanitary  meth- 
ods. The  danger,  so  far  as  it  exists,  could  only  apply 
to  a  few  diseases  of  the  more  active  kind,  like  scarlet 
fever  and  perhaps  small-pox.  Regarding  this  latter 
disease.  The  Evening  Post  quotes  the  remarks  of  a 
Boston  physician,  who  says  that  he  has  never  known 
an  instance  where  there  was  any  grounds  for  believing 
that  contagious  diseases  were  carried  by  books  in  cir- 
culation in  the  public  library.  In  the  year  1872  a  se- 
vere epidemic  of  small-pox  prevailed  in  Boston,  and 
the  physician  in  question  saw  every  patient  and  traced, 
where  possible,  the  history'.  In  no  instance  did  he 
connect  the  infection  with  the  use  of  books.  As  the 
circulation  of  this  library  is  more  than  two  million  vol- 
umes a  year,  this  evidence  is  very  convincing.  We 
understand,  also,  that  the  American  Library  Associa- 
tion has  twice  investigated  the  subject  of  books  and 
contagion,  and  in  no  instance  was  it  able  to  trace  the 
spread  of  disease  to  the  circulation  of  library  books. 
The  American  Library  Association  might,  perhaps,  be 
considered  a  body  not  entirely  without  bias  in  favor  of 
circulating  books,  but  its  investigations  were  appar- 
ently thorough. 

Despite  all  this,  it  would  be  wise  to  exercise  a  sani- 
tary superv'isi.     over  the  circulation  of  books.     Their 


MEDICAL    RECORD. 


[October  5,  1895 


disinfection,  when  they  have  gone  into  neighborhoods 
that  are  at  all  suspicious,  would  be  extremely  easy,  and 
the  co-operation  of  a  public  library  with  the  sanitary 
officers  of  the  city  might  result  in  good  to  both  parties 
and  benefit  to  the  public. 


DOCTORS'  WIVES  AND  PROFESSIONAL  CON- 
FIDENCES. 

A  London  journal  lectures  medical  men  on  their 
"  leakiness "  as  regards  the  personal  affairs  of  their 
patients.  The  editor  says  (we  quote  from  the  British 
Medical  Journal)  that  the  great  sinner  is  the  country 
doctor.  It  is,  however,  adds  the  Journal,  only  a  mat- 
ter of  size.  "  Let  the  victim  be  but  big  enough,  and 
urbans  can  babble  as  incontinently  as  any  pagan  of 
them  all."  The  Journal  is  ungallant  enough  to  hint 
that  the  error  often  begins  by  the  doctor  telling  his 
wife.  The  partner  of  his  bosom  too  often  makes  it  a 
test  of  the  loyalty  of  her  husband  that  he  tells  her 
everything.  "  It  is  an  old  saying  that  a  secret  can  be 
kept  by  three  men  if  two  of  them  are  dead,  but  a 
woman  conceals — what  she  does  not  know.  A  wise 
man  will  make  it  a  rule  never  to  speak  to  his  wife  of 
professional  matters,  never  even  to  tell  her  the  names 
of  those  who  consult  him." 

A  man  may  be  wise  enough  to  make  such  a  rule,  but 
will  he  be  strong  enough  to  keep  it  ?  Experience 
seems  to  indicate  that  he  will  not.  The  doctor  is  hu- 
man and  feels  the  need  of  a  confidant  ;  the  wife  is 
very  human  and  likes  nothing  so  much  as  domestic 
details. 

We  must  deplore  the  "  leakiness  "  of  which  the  pro- 
fession is  accused.  It  is  wrong  ;  but  there  are  imper- 
fections in  our  social  fabric  which  must  exist  for  a  long 
time — until,  for  example,  woman  ceases  to  be  curious 
and  man — to  be  her  slave. 


HOSPITAL   CORPS   AND    THE    STATE    MILI- 
TIA. 

The  recent  meeting  in  this  city  of  the  medical  officers 
of  the  National  Guard  and  Naval  Militia  of  the  State 
of  New  York,  for  the  organizing  of  a  trained  hospital 
corps,  is  of  great  moment  to  everyone  interested  in  the 
welfare  and  efficiency  of  our  citizen  soldiery.  The  ex- 
perience in  the  late  riots  has  so  abundantly  proved  the 
prospective  necessity  of  such  a  measure  that  there  ap- 
pears to  be  no  reasonable  doubt  that  the  legislative  as- 
sistance to  that  end  which  will  be  sought,  will  be 
granted  accordingly.  It  will  be  a  matter  of  surprise  to 
many  to  learn  that  the  provisions  for  the  care  of  the 
sick  and  wounded  have  been  for  the  most  part  made 
through  voluntary  contributions  of  the  regiments  them- 
selves. In  fact,  it  would  appear  that  the  only  way  in 
which  proper  instruments  and  appliances  could  be  ob- 
tainable was  by  the  private  contributions  of  the  sur- 
geons themselves.  Now  that  these  facts  are  known, 
there  will  be  no  difficulty,  we  imagine,  in  obtaining 
from  the  State  a  sufficient  appropriation  to  cover  the 
actual  and  pressing  necessities  of  the  case.  The  mili- 
tia of  this  State^have  shown  their  valor  and  efficiency 


in  so  many  ways  that  their  necessity  as  a  State  organ- 
ization, liable  for  the  most  trying  duties  at  the  shortest 
notice,  can  no  longer  be  questioned.  It  is  then  of  the 
utmost  importance  that  these  self-sacrificing  citizens, 
ever  willing  to  do  and  dare  in  all  emergencies,  should 
be  properly  cared  for.  In  the  recent  Brooklyn  riot, 
this  was  made  strikingly  manifest.  It  was  on  that  oc- 
casion due  almost  solely  to  the  great  efficiency  of  the 
medical  staffs  of  the  different  regiments,  that  much 
real  suffering  and  sickness  were  reduced  to  the  mini- 
mum. 

The  organization  of  a  distinct  hospital  corps  becomes 
one  of  the  necessities  of  the  situation.  Ample  experi- 
ence in  the  inefficiency  of  the  prevalent  system  of 
special  and  chance  details,  has  abundantly  demon- 
strated this,  and  the  medical  staff,  always  alive  to  the 
best  interests  of  the  service,  are  becomingly  timely  and 
properly  earnest  in  the  advocacy  of  such  a  beneficent 
and  useful  measure. 


POLICE  ATTENTION  TO  ALLEGED  TRIVIAL 
ACCIDENTS. 

An  effort  is  being  made  by  the  several  hospitals, 
through  a  representation  of  the  surgeons  of  these  insti- 
tutions, to  relieve  the  ambulance  service  of  those  triv- 
ial cases,  which  might  be  treated  by  the  police  surgeons 
at  their  respective  police  stations.  This  would  appear 
to  be  eminently  proper  on  general  principles,  but  there 
are  so  many  difficulties  in  the  way  of  making  such  ser- 
vice practically  effective,  that  it  is  well  to  consider 
them  before  taking  definite  action.  While  it  is  very 
properly  argued  that  a  police  surgeon  of  experience  is 
better  qualified  to  make  a  diagnosis  as  to  the  real 
gravity  of  an  injury  in  obscure  cases,  than  is  the  or- 
dinary ambulance  surgeon,  such  chances  of  neglect  are 
more  than  overbalanced  by  the  loss  of  time  in  the  many 
^ases  requiring  the  prompt  assistance  which  the  police 
surgeon  is  confessedly  unable  to  give.  The  ambulance 
system,  as  it  is,  is  well  distributed  over  the  different 
districts,  and  hospitals  vie  with  each  other  in  their 
prompt  attention  to  accidents.  Not  a  few  of  the  am- 
bulance surgeons,  in  their  zeal  to  get  first  to  the  case, 
are  so  thoroughly  imbued  with  the  spirit  of  generous 
rivalry  that  they  always  dodge  the  penalty  of  the  "  hind- 
ermost." 

There  does  not  appear  to  be  any  unwillingness  on 
the  part  of  the  majority  of  the  hospitals  of  responding 
"early  and  often  "  to  all  summons  for  relief.  So  far, 
then,  the  system  can  hardly  be  improved  by  any  inter- 
mediate provision  of  expediency.  More  than  this, 
however,  would  be  the  difficulty  of  deciding  what  were 
and  what  were  not  trivial  cases.  As  the  responsibility 
of  so  doing  would  mostly  rest  upon  the  policeman  who 
first  saw  the  case,  rather  than  upon  the  police  surgeon 
who  might  or  might  not  be  within  reach  at  a  critical 
moment,  it  is  easy  to  see  that  the  ambulances  would 
have  and  should  have  the  first  choice. 


Small-pox  in  London.— The  English  journals  state 
that  the  outbreak  of  small-pox  in  London  goes  on  in- 
creasing, despite  the  energetic  measures  taken  by  the 
health  authorities. 


October  5,  1895] 


MEDICAL   RECORD. 


489 


^ociettj  ^e^jorts. 


MEDICAL    SOCIETY   OF     THE    COUNTY     OF 
NEW   YORK. 

Stated  Meeting,    September   2j,    i8g^. 

Egbert    H.    Grandin,    M.D.,    President,    ix    the 
Chair. 

Nomination  of  OflRcers,   Censors,  and  Delegates. — For 

President,  E.  H.  Grandin  (declined),  E.  D.  Fisher, 
Richard  Van  Santvoord  ;  First  Vice-President,  Wendell 
C.  Phillips,  Frederick  Peterson  ;  Second  Vice-President, 
J.  Henry  Fruitnight  ;  Secretary,  Charles  H.  Avery  : 
Assistant  Secretary,  W.  E.  Bullard  ;  Treasurer,  John  S. 
Warren  ;  Censors  (five  to  be  elected),  B.  F.  Curtis, 
Simon  Baruch,  Frederick  M.  Warner,  A.  M.  Jacobus, 
E.  H.  Grandin,  Seneca  D.  Powell,  Frank  Van  Fleet. 
C.  L.  Gibson.  About  forty  members  were  nominated 
as  delegates  to  the  State  Medical  Society,  thirty-five  to 
be  elected. 

The  Importance  of  Asepsis  in  the  Practice  of  Ob- 
stetrics.— Dr.  Adrian  Y.  Reid,  in  a  paper  with  this 
title,  compared  the  methods  and  results  of  aseptic  and 
antiseptic  midwifery  as  practised  in  four  city  institu- 
tions with  the  same  in  the  private  practice  of  four 
physicians.  The  institutions  included  the  Sloane 
Maternity,  the  City  Maternity  on  Blackwell's  Island, 
and  the  Lying-in  Hospital  for  the  Instruction  of  Medi- 
cal Students  at  Seventeenth  Street  and  Second  Avenue. 
In  the  first  named  there  had  been  but  three  deaths  out 
of  over  four  thousand  cases,  and  in  these  three  infec- 
tion had  taken  place  before  admission.  There  had 
been  no  deaths  in  the  last  thousand  cases  confined  at 
the  City  Maternity.  The  mortality-rate  in  the  several 
institutions  named,  under  present  aseptic  and  anti- 
septic methods,  was  about  one- eighth  of  one  per  cent., 
while  that  in  the  practice  of  the  four  physicians  quoted 
was  about  one-fifth  of  one  per  cent,  in  a  total  of  nearly 
one  thousand  confinements.  Dr.  John  Woodman  had 
had  no  deaths  from  sepsis  in  his  last  one  hundred  and 
fifty  cases  ;  Dr.  Reid  but  one  in  his  last  four  hundred 
and  fifty-eight  cases.  The  chief  difference  in  the 
methods  of  aseptic  and  antiseptic  practice  in  the  insti- 
tutions and  in  the  hands  of  the  private  practitioner,  was 
the  omission  by  the  latter  of  the  vaginal  douche  be- 
fore and  after  labor.  Whenever  possible,  Dr.  Reid 
insisted  on  cleanliness  of  clothing,  bed-linen,  towels, 
and  napkins,  washing  of  the  external  genitals  with 
soap  and  water  and  some  antiseptic,  cleansing  and  dis- 
infection of  hands  and  instruments.  The  physician 
seldom  arrived  before  the  woman  was  in  labor,  and  the 
surroundings  were  not  such  as  to  enable  him  to  give 
a  vaginal  douche  without  liability  of  defeating  the  pur- 
pose for  which  it  was  intended,  disinfection  and  asepsis. 
Nor  was  it  practical  to  shave  the  pubes  as  was  done  in 
hospitals.  He  would  irrigate  the  vagina  subsequent  to 
labor  only  in  case  of  rents,  and  the  uterus  only  after 
introduction  of  the  hand,  using  then  a  i  to  10,000  bichlo- 
ride solution.  If  no  complication  arose,  the  patient  was 
allowed  to  get  up  on  the  ninth  or  tenth  day.  While  he 
did  not  object  to  the  details  of  hospital  asepsis  being 
attempted  in  private  practice,  yet  he  did  not  think  all 
I  if  them  necessary. 

Antiseptic  Midwifery  Dates  from  1883. — Dr.  H.  J. 
Garrigues  said  October  i,  1883,  marked  a  new  era  in 
strict  antisepsis  in  the  United  States,  the  date  when  he 
I  hanged  the  prevailing  treatment  in  the  New  York 
Maternity.  Just  before  he  introduced  antiseptic  meth- 
ods, the  mortality  had  been  about  five  per  cent.  Dur- 
ing the  last  month  it  had  been  at  the  rate  of  twenty 
per  cent.  ;  the  four  months  after  introducing  antiseptic 
methods  no  deaths  occurred.  He  said  he  did  not 
igree  with  Dr.  Reid  when  he  spoke  of  the  fallibility  of 


human  effort  in  aseptic  midwifery,  for  there  were  few 
things  in  which  we  had  obtained  such  splendid  results. 

Sepsis  Due  to  the  Physician. — Dr.  R.  A.  Murray 
called  attention  to  the  fact  that  the  worst  cases  of  mid- 
wifery occurred  usually  in  maternity  hospitals,  yet 
these  now  gave  a  smaller  mortality-rate  than  was  seen 
in  private  practice.  The  reason  was  that  in  private 
jjractice  physicians  did  not  do  what  they  ought  to 
secure  asepsis.  He  believed  that  asepsis,  in  nine  cases 
out  of  ten,  was  conveyed  by  the  doctor.  \Mien  the 
physician  kept  himself  and  his  hands  clean,  he  did  not 
have  sepsis,  no  matter  what  the  surroundings  of  the 
patient.  The  chief  thing  to  do  was  to  clean  our  hands 
and  not  to  touch  anything  before  making  the  examina- 
tion. The  genitals  should  be  cleansed  with  soap  and 
water,  but  the  vaginal  douche  was  not  necessary.  He 
used  carbolic  acid  or  creosote  for  the  hands  ;  kept 
the  bed  as  clean  as  possible,  and  especially  had  anti- 
septic napkins  for  use  immediately  after  expulsion  of 
the  child.  The  nurse  must  not  examine  the  patient. 
He  had  yet  to  see  his  first  case  of  sepsis  in  his  own 
private  practice. 

Aseptic  Midwifery  Less  Pormidable  than  it  Looks. 
— Dr.  George  W.  Jarman  said  the  mention  of  the 
many  antiseptics  and  antiseptic  procedures  enumerated 
in  the  paper  might  lead  one  to  suppose  that  to  carry 
out  antiseptic  midwifery  was  very  difficult.  But  there 
was  no  physician  who  could  not  carry  with  him  every- 
thing which  was  necessary  in  order  to  secure  asepsis. 
One  or  two  antiseptics  were  sufficient,  and  these,  with 
soap  and  water  and  clean  cloths,  would  secure  asepsis. 
We  should  encourage  aseptic  and  antiseptic  practice. 
It  was  not  sufficient  that  the  patient  recovered  after 
labor  ;  she  should  be  left  well,  and  not  suffering  with 
an  endometritis,  crippled  tubes,  etc.,  as  so  often  hap- 
pened. 

Dr.  E.  a.  Tucker  said  that  on  little  inquiry  one 
still  learned  of  many  women  dying  of  septicaemia  after 
childbirth,  although  fewer  than  formerly.  This  showed 
the  necessity  for  a  more  general  application  of  antisepsis 
and  asepsis  as  practiced  in  maternities  where  the  death- 
rate  had  been  reduced  to  a  very  low  percentage.  Re- 
garding the  uterine  douche,  this  was  not  necessary  even 
after  the  introduction  of  the  hand,  provided  the  hand 
had  been  quite  clean  ;  it  certainly  was  not  necessary 
after  version,  since  here  the  hand  did  not  touch  the 
uterus.  He  would  not  advise  the  uterine  douche  un- 
less a  foul  fcetus  had  been  expelled,  or  some  such  in- 
dication were  present.  Shaving  the  pubic  hair  could 
be  done  in  a  hospital,  but  it  was  not  necessary  in  pri- 
vate practice.  He  was  glad  to  hear  the  view  expressed 
by  a  private  practitioner  that  milk  fever  was  septic.  It 
was  not  necessarily  so,  but  usually  it  was.  Asepsis 
could  be  carried  out  in  private  practice  as  well  as  in 
hospitals,  being  essentially  the  same  but  not  quite  so 
elaborate. 

Dr.  Thomas  Darlington  said  that  in  country  or 
sparsely  settled  districts  he  frequently  found  none  of 
the  conditions  permitting  of  antisepsis  as  practised  in 
the  maternities.  Sometimes  there  was  an  absence  of 
soap,  of  boiled  water,  or  water  of  any  kind.  He  had 
confined  nearly  one  thousand  women,  and  had  lost 
none  from  any  cause.  Whenever  there  was  sepsis,  it 
came  from  the  physician,  not  from  the  patient.  He 
carried  bichloride  tablets,  and  cleansed  and  disinfected 
his  hands.  He  thought  the  vaginal  secretions  helped 
the  passage  of  the  head,  and  that  the  douche  retarded 
it. 

Dr.  Rosenberg  thought  there  was  danger  of  infect- 
ing the  woman  by  giving  the  vaginal  douche.  He 
thought  the  secret  of  puerperal  infection  was  easily  un- 
derstood after  one  came  to  realize  that  the  womb  was 
absolutely  aseptic,  and  that  manipulations  and  douches 
were  both  unnecessary  and  harmful.  Simply  clean  the 
hands  before  making  examination  :  or  better,  do  not 
examine  at  all. 

Dr.  Reid,  in   some   concluding    remarks,  wished    to 


490 


MEDICAL    RECORD. 


[October  5,  1895 


impress  the  fact  that  accoucheurs  were  not  opposed  to 
gynecologists  and  surgeons  ;  all  stood  together  in  their 
aim  to  secure  asepsis  and  aseptic  results.  While  he 
believed  it  was  not  possible  to  carry  out  aseptic  details 
in  private  practice  to  the  extent  that  it  could  be  done 
in  hospitals,  yet  we  should  try  and  do  as  well  as  cir- 
cumstances would  permit. 

An  Appeal  from  a  Decision  of  the  Comitia  Minora. 
— Dr.  Frank  V.\n  Fleet  read  a  printed  statement 
containing  an  appeal  from  a  decision  of  the  Comitia 
Minora.  A  suit  has  been  brought  against  him  for 
damages  to  the  extent  of  forty  thousand  dollars  for  his 
remarks  before  the  Society  when  he  had  asked  to  have 
an  advertisement  expunged  from  the  medical  directory 
relating  to  eye-strain  and  the  fitting  of  glasses  by  an 
optician  not  a  physician.  He  thought  the  right  of 
free  speech  and  scientific  discussion  in  medical  meet- 
ings was  involved,  and  that  the  Society  should  interest 
itself  in  the  suit. 

The  Presidext  e^xplained  that  the  Comitia  Minora 
had  not  thought  it  right  to  involve  the  Society  in  the 
defence  of  a  suit  for  damages  which  was  based  in  part 
on  the  remarks  of  a  member  regarding  a  certain  case 
of  which  that  member  alone  had  any  knowledge. 

Dr.  H.  D.  Noyes  made  some  remarks  upon  a  reso- 
lution offered  by  Dr.  J.  B.  Emerson,  saying  that  he 
felt  very  warmly  upon  this  subject  because  he  believed 
the  right  of  free  scientific  discussion  was  involved. 
Much  was  exacted  of  physicians  before  they  were  per- 
mitted to  practise  medicine,  yet  in  the  medical  direc- 
tory published  under  the  auspices  of  the  Society  was 
the  advertisement  of  one  not  a  physician  presuming  to 
advise  physicians  in  the  matter  of  fitting  glasses  for  the 
relief  of  eye-strain,  etc. 

Dr.  Emerson's  resolution  was  adopted,  appointing 
a  committee  of  five — the  President,  and  Drs.  R.  H. 
Derby,  J.  D.  Bryant,  D.  B.  St.  John  Roosa,  and  H.  D. 
Noyes — to  act  with  the  Comitia  Minora  in  the  con- 
sideration of  the  matter. 


A  LONG  SURVIVAL  OF  INJURY  TO  THE 
SPINAL  CORD  IN  THE  CERVICAL  RE- 
GION.' 

By  tames   L.    KENT,    M.D., 


In  presenting  this  paper  I  do  not  aspire  to  teach  you 
anything  new,  but  to  interest  you  in  a  case  which  is  al- 
most unique. 

On  July  22,  1893,  a  healthy  miner,  aged  twenty-three, 
got  into  a  drunken  fight  with  several  others,  who  struck 
him  over  the  head  with  steel  knuckles,  caught  him  by  his 
feet,  and  rammed  his  head  against  the  ground  until  he 
was  supposed  to  be  dead.  He  was  carried  home  un- 
conscious, and  his  relatives,  presuming  that  he  was  only 
intoxicated,  paid  no  special  attention  to  him,  until  he 
failed  to  get  up  next  morning.  Then  I  was  summoned 
and  found  him  in  a  very  drowsy  condition,  from  which 
he  could  with  difficulty  be  sufficiently  aroused  to  an- 
swer questions.  There  were  several  cuts  over  the  left 
eye  and  a  small  scalp  wound  near  the  posterior  supe- 
rior angle  of  the  left  parietal  bone.  His  face  and 
hair  were  covered  with  dust.  His  face  was  markedly 
flushed,  there  was  a  slight  elevation  of  temperature, 
very  difficult  diaphragmatic  respiration,  retention  of 
urine,  and  absolute  sensory  and  motor  paralysis  of  the 
entire  body  below  the  second  ribs.  He  could  flex,  but 
could  not  extend  the  forearms  ;  could  flex  the  fingers 
slightly,  but  could  not  extend  them.  I  could  not  dis- 
discover  the  slightest  deformity  of  the  vertebral  column, 
but  the  patient  suffered  intensely  if  his  head  was  moved 

'  Read  before  the  Medical  Society  of  Virginia,  during  its  twenty- 
sixth  annual  session,  September  5,  1805. 


laterally  or  lowered  to  the  same  plane  as  his  shoulders. 
At  9  P.M.  the  same  day  his  intellect  had  become  much 
clearer,  and  he  said  that  he  did  not  remember  an}'thing 
that  had  happened  since  the  previous  evening,  before 
he  was  injured.  At  this  time  his  physical  condition 
was  much  worse  ;  pulse  138,  full  and  bounding  ;  respi- 
rations 35,  and  very  labored  ;  temperature  103°  F.  : 
suffering  very  great  pain  in  the  back  of  his  neck  and 
over  the  scapulae,  with  continued  retention  of  urine 
and  constipation. 

From  this  time  on  flexion  of  the  upper  extremities 
became  weaker  gradually,  sensation  in  the  fingers  was 
soon  lost,  emaciation  was  rapid,  and,  in  spite  of  early 
antiseptic  precautions,  cystitis  developed  at  the  end  of 
the  first  week.  Then  came  overflow  of  urine  and  fecal 
incontinence.  There  was  occasional  vomiting,  but 
never  any  dysphagia.  On  the  eighth  or  ninth  day  bed- 
sores appeared  over  the  sacrum  and  necrosis  soon  be- 
came so  deep  as  to  expose  the  sacral  nerves.  There 
was  at  no  time  that  sensation  of  a  band  or  constriction 
about  the  body,  a  symptom  so  often  complained  of  in 
cases  of  spinal  injury.  There  was  nearly  always  a  sen- 
sation of  heat,  but  there  was  never  any  special  elevation 
of  temperature  after  the  third  day.  The  difficulty  of 
breathing  was  greatly  increased  when  the  patient  was 
placed  on  either  side,  or  when  his  bowels  became  dis- 
tended with  gas.  With  the  exception  of  a  few  days, 
when  the  diaphragm  and  serratus-magnus  muscle  seemed 
ready  to  rebel  against  doing  the  work  of  all  the  muscles 
of  respiration,  he  breathed  fairly  comfortably,  but  dysp- 
noea came  on  oftener  toward  the  end,  showing  that  de- 
generation was  approaching  the  origin  of  the  phrenic 
nerves.  (I  could  relieve  the  dyspnoea  very  much  by 
four  ^V  grain  doses  of  strychnine  sulphate,  given  every 
two  hours  until  relief  was  obtained.)  His  conscious- 
ness remained  clear  until  8  p.m.,  September  7th,  when 
he  became  unconscious  and  died  one-half  hour  later, 
forty-seven  days  after  the  injury. 

On  September  9th,  assisted  by  Dr.  E.  M.  Wilkinson, 
of  Patterson,  Va.,  I  opened  the  spinal  canal  and  found 
the  cord  normal,  except  for  a  space  of  about  one  inch 
beginning  opposite  the  articulation  of  the  body  of  the 
sixth  on  that  of  the  seventh  cervical  vertebra,  and  ex- 
tending upward  to  near  the  origin  of  the  sixth  cervical 
nerves.  For  this  distance  the  membranes  of  the  cord 
were  not  broken  and  showed  only  slight  signs  of  an  old 
inflammation,  but  the  substance  of  the  cord  was  of  the 
consistence  of  thick  cream  and  exuded  from  the  roots 
of  the  nerves  as  they  were  severed,  leaving  nothing  but 
the  connective  tissue  and  membranes,  which  formed  a 
thin  flabby  connection  for  the  two  ends  of  the  cord. 
The  vertical  laminae  and  spinous  processes  were  intact, 
and  the  only  sign  of  violence  to  the  spinal  column  was 
the  ruptured  posterior  common  ligament  between  the 
sixth  an  seventh  cen-ical  vertebrae. 

I  could  not  remove  the  bodies  for  examination,  as 
the  autopsy  was  held  under  protest,  and  I  had  promised 
not  to  mutilate  the  corpse  more  than  was  absolutely  nec- 
essary to  ascertain  the  cause  of  death,  but  these  were 
in  normal  relation,  so  that  there  must  have  been  a  dis- 
placement to  tear  the  ligament  with  spontaneous  re- 
position. 

From  the  evidences  at  the  time  of  injury  and  post 
mortem  we  concluded  that  the  weight  of  the  body  was 
thrown  on  the  forehead  in  such  a  way  as  to  lift  the 
sixth  vertebra  up  and  slide  it  back  over  the  seventh,  as 
there  were  dirty  cuts  on  the  forehead  and  nose,  and  the 
posterior  common  ligament  was  torn  through  while  the 
ligamentum  nucliK  was  intact. 

The  violent  displacement  would  bruise  and  constrict 
the  cord  sufficiently  to  cause  its  death  at  this  point. 

I  regret  that  I  cannot  show  microscopic  sections  of 
this  cord,  but  it  did  not  harden  satisfactorily  after  ten 
months'  immersion  in  Muller's  fluid. 

Ashhurst  says  that  two-thirds  of  the  cases  of  injury  of 
the  cord  in  this  region  die  in  the  first  week  ;  this  one 
lived  nearly  seven  weeks. 


October  5,  1895] 


MEDICAL    RECORD. 


491 


A  peculiar  coincidence  connected  with  this  case  was 
that  his  nurse  had  sustained  a  fracture  of  the  spinal  col- 
umn in  the  lumbar  region  twelve  years  before,  and  recov- 
ered so  that  his  only  trouble  was  incontinence  of  urine 
and  a  slight  muscular  weakness  of  back. 

There  was  an  interesting  paper  on  this  subject,  by 
Dr.  Thomas  H.  Manley.  in  the  Medical  Record  of 
October  28,  1893. 


ovaries  successfully.  He  was  a  good  obstetrician, 
which  I  can  vouch  for,  and  yet  at  that  time  we  little 
thought  of  this  simple  method  of  delivering  a  woman. 

Briefly,  if  all  obstetricians  will  study  this  one  simple 
remedy  and  act  accordingly,  they  will  not  labor  in  vain. 


GUNSHOT    WOUND    OF    ABDOMEN. 
By    \VILLI.A.M    H.   SIMMONS,  M.D., 


The  following  case  is  reported  to  show  what  good  re- 
sults may  follow  immediate  operation  under  favorable 
circumstances  : 

Michael  M ,  aged  fifteen,  was  shot  with  a  2  2 -cali- 
bre rifle,  April  27,  1895.  Some  three  hours  after  the 
accident  he  was  seen  by  me  at  the  Bangor  General 
Hospital,  and  at  once  operated  upon  with  assistance  of 
other  members  of  the  hospital  staff.  The  bullet  had 
entered  about  an  inch  above  and  to  the  left  of  the 
navel,  and  on  the  abdomen  being  opened  was  found  to 
have  passed  through  the  edge  of  the  left  lobe  of  the  liver 
and  then  through  the  stomach.  Bleeding  was  going 
on  from  a  vein  near  the  greater  curvature,  and  there 
were  clots  in  the  abdominal  cavity.  These  were  re- 
moved, the  bleeding  point  tied,  the  wounds  in  the 
stomach  occluded  with  Lembert  suture,  the  intestines 
withdrawn  and  thoroughly  searched  for  other  punct- 
ures, finding  none.  The  wound  was  sutured  in  layers, 
the  boy  put  to  bed,  and  discharged  well  May  i6th. 
Convalescence  was  quite  uneventful,  no  rise  in  tem- 
perature occurring. 


TARTAR  EMETIC  IN  TEDIOUS  LABOR. 
By  JOHN  T.  DE  MUND,  M.D., 

Rl.VGWOOD,   N.    J. 

The  progressive  period  in  which  we  live  necessitates 
speedy  and  safe  medicament.  As  chance  has  no  law, 
I  avail  myself  of  clinical  observation  founded  on  facts. 
In  a  pretty  large  obstetrical  practice  of  over  thirty 
years,  alone  and  in  counsel,  I  have  found  that  in  the 
majority  of  confinement  cases  the  rigid  os  and  equally 
rigid  perineum  yield  readily  under  the  proper  adminis- 
tration of  tartar  emetic,  with  no  unpleasant  effect  upon 
the  child  in  utero  and  none  to  the  mother. 

Tartar  emetic  is  positively  0-\ytocic,  a  something  long 
looked  for.  It  almost  usurps  the  place  of  forceps — is  a 
great  aid  to  them  when  necessary  ;  it  casts  into  obliv- 
ion dilators — instruments  of  torture  ;  and  the  inhala- 
tion of  chloroform  or  ether  may  also  be  numbered  with 
the  things  of  the  past. 

The  emptied  bladder,  the  washed-out  rectum,  arc 
two  cardinal  points  in  deliver)' ;  and  third,  the  emptied 
stomach  enables  a  certain  stage  of  labor  to  progress 
rapidly,  as  well  as  favorably. 

I   will  cite  but  one  case  among  many.     Mrs.  , 

fourth  deliver)'.  Rigid  os,  strong,  lancinating  pains. 
I  spent  most  of  the  night  with  the  patient,  who  appar- 
ently made  no  progress.  I  then  dissolved  ten  grains  of 
tartar  emetic  in  one-half  tumbler  of  water  and  re- 
quested nurse  to  give  two  teaspoonfuls  every  ten  or 
fifteen  minutes  till  free  emesis  ensued.  Perfect  relaxa- 
tion followed  shortly,  the  expulsive  effort  was  intensi- 
fied, and  the  child,  a  bouncing  boy,  was  quickly  in  the 
world.  This  was  a  fair  case  for  forceps,  chloroform, 
etc.,  "  as  we  used  to  do." 

It  seems  passing  strange  to  the  writer  that  so  simple 
a  remedy  should  have  lain  dormant  till  the  present. 
My  preceptor,  the  late  Dr.  JohnL.  Atlee,  of  Lancaster, 
Pa.,  was  the  first  operator  in  the  world  to  remove  both 


A   CASE    OF    CARDIOCENTESIS. 
By  G.  G.  COTTAM,  M.D., 

ROCK  RAPIDS,   lA. 

I  PRESENT  this  brief  report  of  a  most  peculiar  case,  in 
view  of  the  general  interest  now  revived  in  cardiocentesis 
as  a  therapeutic  possiblity,  though  the  indefinite  historj-, 
complex  diagnosis,  and  irrational  results  do  not  war- 
rant me  in  offering  it  as  a  substantial  contribution  to 
our  knowledge  of  the  subject. 

Hans  L ,  aged  fifty,  Norwegian,  came  under  my 

care  in  February,  gi%'ing  a  history  of  rheumatic  ante- 
cedents, and  now  supposedly  suffering  from  asthma. 
His  account  of  himself  was  devoid  of  any  details  of 
practical  value. 

Examination  showed  him  to  be  affected  with  chronic 
bronchitis  and  mitral  regurgitation,  though  no  sec- 
ondary effects  of  the  latter  had  yet  appeared.  The 
possibilit)'  of  pulmonary  tuberculosis  in  an  incipient 
stage  was  entertained. 

He  was  then  placed  on  general  tonic  and  symp- 
tomatic treatment,  with  iodide  of  potassium  on  general 
principles.  The  symptoms  continued  without  much 
change  until  June,  when,  compensation  failing,  it  was 
found  necessar)-  to  supplement  the  treatment  with 
strophanthus,  diuretics,  and  occasional  hydrogogue 
purgatives.     Digitalis  did  not  act  well. 

The  man's  condition  did  not  improve.  Dilatation 
of  the  right  heart  set  in,  and  his  breathing  became 
much  oppressed,  orthopnoea  being  pronounced  and 
constant.  The  pulse  at  this  time  varied  from  1 14  to 
124,  and  was  weak  and  compressible.  The  feet  were 
oedematous,  and  there  was  a  small  peritoneal  effusion. 

The  extreme  symptoms  evidently  came  from  the 
distended  right  heart,  and  with  the  view  of  overcom- 
ing them  temporarily,  the  feasibility  of  cardiocentesis 
was  considered.  This  was  put  into  execution  a  week 
later,  the  man's  precarious  state  demanding  that  some- 
thing radical  be  done  to  avert  a  fatal  issue.  Accord- 
ingly, I  made  an  aseptic  incision  into  the  sixth  inter- 
space one  inch  from  the  sternum  and  inserted  a  long, 
slender  trocar.  By  percussion  this  point  had  been 
determined  on  preWously  as  the  most  favorable  for 
approaching  the  right  ventricle.  The  movement  of  the 
heart  was  distinctly  felt  as  the  point  of  the  instrument 
entered  the  organ,  the  motion  being  somewhat  of  a 
"  tugging  "  character.  Then  followed  a  continuous 
stream  of  blood,  and  I  was  puzzled  to  account  for  the 
color,  a  bright  scarlet.  The  trocar  was  withdrawn 
after  four  ounces  of  blood  had  passed  through  it. 
During  the  procedure  the  man  made  no  complaint, 
save  of  the  sharp,  pricking  sensation  caused  by  the 
entrance  of  the  trocar  through  the  chest-wall.  He 
conversed  without  eSort,  and  afterward  rested  quietly, 
though  with  but  slight  immediate  relief  from  the  dysp- 
noea. Five  days  later,  however,  he  was  breathing 
easily,  though  coughing  constantly  and  expectorating 
profusely.  His  appetite,  at  no  time  good,  failed  almost 
entirely,  and  he  became  greatly  emaciated.  He  was 
evident-ly  now  well  advanced  in  pulmonary  tuberculosis, 
and  six  weeks  after  the  operation  died  of  exhaustion. 

A  partial  necropsy  was  performed  ten  hours  after 
death.  Both  lungs  were  full  of  tubercular  deposits. 
The  heart  had  stopped  in  diastole.  Removing  the 
organ  t'ri  toto,  the  cicatrix  following  the  puncture  was 
plainly  made  out  and  the  course  of  the  instrument 
traced,  to  my  great  surprise,  through  the  wall  of  and 
into  the  cavity  of  the  left  ventricle.     The  mitral  diag- 


492 


MEDICAL    RECORD. 


[October  5,  1895 


nosis  was  verified  also,  but  nothing  else  of  note  devel- 
oped. 

The  case  was  an  ambiguous  one  throughout.  Death 
was  certainly  not  directly  due  to  the  heart  affection  ; 
and  yet  before  the  operation  was  performed  the  pa- 
tient was  rapidly  sinking  from  dyspnoea,  due  to  an 
overburdened  right  heart.  How  aspiration  of  the  left 
ventricle  could  relieve  this  and  apparently  prolong  the 
man's  life  is,  and  probably  always  will  be,  a  mystery  to 


CALCIFICATION     OF    AN     ORANGE     LYING 
FREE  IN  THE  PELVIC  CAVITY. 

By  JOHN  A.  PRINCE,  M.D., 


Miss  B ,  aged   forty,   had   been   a   sufferer   from 

ovarian  trouble  for  some  years,  having  pain  mostly  on 
the  left  side.  During  the  last  year  or  so  she  has  suf- 
fered also  from  prolapsus  uteri.  Examination  revealed 
the  uterus  studded  with  fibroid  nodules  of  small  size. 
I  advised  removal  of  the  ovaries  to  stop  the  ovarian 
pain  and  avert  the  growth  of  the  fibroids,  and  pro- 
posed also  to  do  ventro-fixation  for  the  prolapsus.  On 
passing  my  fingers  over  the  posterior  surface  of  the 
uterus  they  came  in  contact  with  a  hard  body,  loosely 
adherent,  and  easily  separated  from  its  attachments  to 
the  uterus.  The  right  ovary  was  present  and  cystic. 
This  with  the  tube  was  removed.  The  left  ovary  and 
tube  were  absent.  All  that  remained  was  a  short 
stump  of  the  tube  about  one-fourth  of  an  inch  long. 

On  examining  the  hard  body  removed  from  the  pos- 
terior surface  of  the  uterus,  it  was  found  to  be  of  the 
exact  shape  and  size  of  the  ovary.  It  was  free  in  the 
pelvic  cavity,  save  the  very  slight  attachment  to  the 
uterus  by  its  rough  surface. 

The  ovary  must  have  attained  full  size  in  its  normal 
position,  when  from  some  cause  it  became  detached 
with  the  tube,  probably  from  some  constricting  agency, 
which  has  done  a  far  neater  amputation  than  could 
have  been  done  by  any  surgeon.  All  vestige  of  any 
constricting  band  or  of  the  amputated  tube  had  dis- 
appeared. Ventro-fixation  was  done,  and  the  wound 
closed.     The  patient  is  making  a  good  recovery. 


ANENCEPHALOUS    MONSTER. 
By  J.  M.  PERKINS,  M.D., 

LEBANON,  MO. 

On  March   5,  1891,  I  was  called   to  see  Mrs.   H , 

aged  twenty-seven,  multipara.  She  and  her  husband 
thought,  and  all  who  had  seen  her  thought  she  was  go- 
ing to  give  birth  to  twins  on  account  of  her  unusually 
large  size.  From  her  appearance  I  thought  so  too,  but 
on  examination  I  changed  my  mind.  She  had  short 
sharp  cutting  pains,  commonly  called  by  old  women  wig- 
gling pains.  I  waited  on  her  for  three  or  four  hours  to 
see  if  pains  would  get  harder  and  cause  a  dilatation  of 
the  OS.  I  noticed  her  pinched  features,  which  was  un- 
usual with  her,  and  her  great  restlessness,  which  was 
gradually  becoming  more  and  more  in  any  position.  I 
concluded  to  rupture  the  membrane  and  relieve  her  of 
the  amniotic  fluid,  which  was  excessive  in  amount. 
Labor  pain  set  in  a  few  moments  after  the  membranes 
were  ruptured.  I  waited  a  while,  made  another  exam- 
ination, and  found  that  something  was  wrong,  but  what 
it  was  I  could  not  at  the  time  say.  After  great  diffi- 
culty, having  introduced  my  hand  and  made  traction 
with  the  finger  on  the  presenting  part,  I  delivered  my 
patient  of  an  anencephalous  monster. 

There  was  no  sign  of  a  neck,  excejita  depressed  rin 
all  round  the  place  the  neck  should  have  occupie 
The  body  was  rather  short,  about  two- thirds  of  the 


dinary  body  of  a  well-formed  foetus,  legs  very  long  and 
sturdy,  arms  long  and  slender,  male  organs  well  devel- 
oped, anus  closed,  mouth  very  large  and  opened  like 
the  mouth  of  a  bull  frog.  Eyes  well  developed,  but 
closed,  nose  flat  and  broad,  ears  back  at  point  of  scapu- 
las or  nearly  so  ;  no  occipital  or  frontal  bones,  eyes  ran 
back  to  origin  of  optic  nerve,  the  course  of  which  could 
be  traced  with  the  index  finger  as  there  were  no  orbital 
bones. 

On  August  9th,  prior  to  the  birth  of  this  monster,  a. 
picnic  was  had  at  which  a  brother  of  the  mother  of  this 
monster  drank  too  much  and  became  engaged  in  an  al- 
tercation with  another  intoxicated  man,  with  the  result 
that  he  was  terribly  whipped.  Both  eyes  and  the  top 
of  the  head  were  bruised  almost  to  a  jelly,  and  he  was 
also  shot.  I  was  called  to  dress  the  wounds  of  both 
men,  and  when  I  finished  my  work,  the  mother  of  this 
monster  arrived  from  home,  and  seeing  her  brother  in 
this  terrible  plight,  fell  on  his  neck  and  went  into  a  fit 
of  hysteria.  I  at  that  time  did  not  know  she  was  preg- 
nant, or  I  should  not  have  allowed  her  to  have  seen 
him.  My  opinion  is  that  the  impression  made  on  the 
mother  at  this  time  was  the  cause  of  the  non-develop- 
ment of  the  fcetus,  as  both  the  mother  and  father  had 
always  been  healthy. 


A    CASE    OF   TREPHINING    FOR    FRACT- 
URED   SKULL. 

By  W.  KIRKER  BEATTY,  M.D., 

SURGEON  TO  ANCHOR  LINE  OF  STEAMSHIPS. 

In  reporting  the  following  case,  in  many  points  open 
to  criticism,  my  object  is  to  illustrate  the  beneficial  re- 
sult obtained  by  immediate  operation  for  depressed 
fracture  of  the  skull. 

July  13,  1895,  four  days  from  the  port  of  New  York, 
the  following  case  came  under  my  observation  : 

Michael  McC ,  an  able-bodied  seaman  of  twenty- 
one  years  of  age,  Irish  by  birth,  a  strongly  built  man, 
slow  of  action,  and  of  a  rather  phlegmatic  temperament, 
while  at  work  on  deck  was  struck  on  the  head  by  a  bolt 
(from  a  shackle)  falling  from  aloft  from  the  main  try- 
sail. 

On  reaching  his  side  a  few  moments  later  I  found 
him  lying  senseless  in  a  large  pool  of  blood  with  a  ragged 
contused  wound  over  the  right  parietal  bone.  Upon 
examination  I  discovered  a  considerable  depression  in 
the  bone  of  an  oval  shape  ;  the  bone  was  much  commi- 
nuted and  closely  impacted,  so  that  it  was  impossible 
to  loosen  any  of  the  fragments  ;  the  depth  of  depression 
was  half  an  inch.  His  condition  was  that  of  such  pro- 
found shock  that  I  feared  dissolution  would  occur 
before  I  could  relieve  him.  After  dressing  the  wound 
temporarily  to  check  hemorrhage,  I  administered  two 
milligrammes  of  the  sulphate  of  strychnia  hypodermi- 
cally,  and  began   preparations  for  operating. 

Having  no  time  for  an  elaborate  sterilization  of  in- 
struments and  dressings,  my  main  reliance  for  antisepsis 
was  placed  on  carbolic-acid  solutions,  the  proportions 
being  roughly  estimated.  After  administering  chloro- 
form until  the  patient  was  thoroughly  anresthetized,  I 
gave  the  ana;stlietic  into  the  charge  of  the  steward,  quite 
an  intelligent  and  capable  man. 

I  commenced  tlie  operation  by  incision  at  either  end 
of  the  wound,  laying  bare  the  bone  for  an  inch  at  either 
end  of  the  fracture.  After  carefully  elevating  the  peri- 
osteum and  turning  it  aside,  I  obtained  a  better  view 
of  the  fracture  ;  it  was  located  in  the  lower  portion  of 
the  riglu  parietal  bone,  nearer  its  posterior  than  anterior 
border.  Placing  the  trephine  posteriorly  from  the 
fracture,  1  removed  a  disk  of  bone  half  an  inch  in 
diameter,  which  I  immediately  i)laced  in  a  glass  of  water 
at  about  37.8°  C.  (ioo°  F.).  I  tiien  inserted  an  elevator 
and  removed  the  comminuted  bone,  placing  the  larger 
fragments  into  the  water  witli  the  disk.     After cleanin- 


October  5,  1895] 


MEDICAL   RECORD. 


493 


away  all  visible  fragments,  with  the  aid  of  a  probe  bent 
at  right  angles,  I  removed  several  small  spicula  from 
between  the  dura  mater  and  the  calvarium.  After  the 
clearing  of  the  dura  I  allowed  none  of  the  carbolized 
solutions  to  be  used,  relying  solely  on  warm  water, 
which  had  been  previously  boiled.  When  all  active 
hemorrhage  had  been  checked,  I  replaced  the  trephined 
disk  and  two  of  the  larger  fragments  in  as  nearly  their 
original  position  as  possible,  and  closed  the  wound  by 
continuous  suture,  dressing  with  carbolized  cotton. 

The  immediate  result  of  the  operation  was  an  obvious 
relief  of  the  respiratory  symptoms,  which  before  the 
operation  had  been  marked  by  great  irregularity  ;  after 
removal  of  pressure  upon  the  cerebrum  respiration  be- 
came regular  and  easy. 

The  subsequent  history  was  that  of  steady  and  un- 
interrupted improvement  ;  he  regained  consciousness 
one  week  later,  and  in  twelve  days  insisted  on  being 
allowed  to  walk.  One  week  after  the  operation  I  re- 
moved the  stitches,  finding  the  wound  had  healed  per- 
fectly and  the  bone  beginning  to  unite  solidly.  July 
25th  I  removed  him  from  the  ship  and  placed  him  in 
the  Colonial  Hospital,  Gibraltar,  to  convalesce. 

During  the  operation,  which  of  necessity  had  to  be 
performed  on  the  upper  deck,  only  the  crudest  of  anti- 
septical  precautions  could  be  obtained  ;  had  his  con- 
dition permitted  delay  it  might  have  been  otherwise. 

I  attribute  the  gratifying  result  of  the  operation  to 
the  immediate  removal  of  pressure  from  the  cerebrum. 

August  2 2d  I  was  again  in  Gibraltar,  where  I  learned 
that  he  had  suffered  no  subsequent  mental  disturbance, 
and  that  he  was  in  a  perfectly  normal  condition  of  mind 
and  body. 


SPONTANEOUS  RUPTURE  OF  THE  BOWEI, 
Bv  W.  E.   LOWER,  M.D., 


CLEVELAND,    O. 


On  August  2 1  St,  about  twelve  o'clock,  a  laborer,  aged 
sixty-three,  reported  at  my  office,  and  stated  that  while 
lifting  one  end  of  a  24-foot  plank  he  strained  his  left 
side. 

He  complained  of  considerable  pain  in  the  left  iliac 
region,  the  pain  extending  into  the  left  inguinal  re- 
gion. He  was  placed  upon  the  table,  and  it  was  no- 
ticed that  a  considerable  fulness  existed  in  both  iliac 
and  inguinal  regions,  more  marked  on  left  side,  and 
extending  well  over  the  pubes  on  that  side.  After 
satisfying  myself  as  to  the  non-existence  of  a  hernia, 
Dr.  Bunts,  who  was  in  an  adjoining  office  at  the  time, 
was  asked  to  see  the  case.  He,  also,  found  no  evi- 
dence of  hernia.  Upon  closer  inquiry  relative  to  the 
fulness  on  the  left  side,  the  patient  informed  me  that 
there  always  had  been  more  or  less  fulness  there.  His 
pulse  was  78  and  of  good  volume.  He  was  rather 
anoemic,  which  he  stated  was  quite  natural  with  him  ; 
of  a  rather  waxy  complexion,  and  had  a  somewhat 
pinched  expression.  His  bowels  had  not  moved  on 
this  day,  but  had  on  the  day  previous,  although  he  was 
rather  constipated.  He  was  sent  to  his  home  and  in- 
structed to  go  to  bed,  a  laxative  was  prescribed,  and 
hot  applications  ordered. 

In  the  afternoon  he  was  still  suffering  considerable 
pain  and  vomited  several  times.  He  was  given  one- 
eighth  of  a  grain  of  morphine,  and  ordered  to  take  one 
such  dose  every  hour  until  relieved. 

In  the  evening,  about  seven  o'clock,  I  was  called  to 
his  home  and  found  him  suffering  quite  severely,  pain 
extending  over  the  entire  abdomen,  but  most  severe  in 
the  left  iliac  region.  His  abdomen  was  slightly  tym- 
panitic. 

I  again  examined  him  carefully  for  hernia,  believing 
from  the  nature  of  the  injury  and  the  symptoms  pres- 

'  Reported  to  the  Cleveland  Medical  Society,  September  14,  1895. 


ent,  there  might  be  strangulation,  but  again  failed  to 
find  any  objective  symptoms  of  hernia.  His  bowels 
not  having  moved,  an  enema  was  given,  which  caused 
a  slight  movement.  His  pulse  was  98,  and  temperature 
under  the  tongue  99°  F.  His  tongue  was  dry  and  cov- 
ered with  a  heavy  coating.  This  was  noted  when  he 
reported  at  the  office.  Hot  applications  were  contin- 
ued and  morphine  as  needed  to  relieve  pain.  The  ab- 
dominal symptoms  and  the  pinched  expression  pointed 
to  peritonitis.  I  again  saw  him  the  following  morning. 
He  had  slept  but  little  during  the  night,  but  became 
quite  easy  in  the  early  morning.  Another  enema  had 
been  given  during  the  night,  but  failed  to  move  his 
bowels.  He  had  vomited  frec[uently,  a  dark-colored 
vomit.  The  tympanitis  remained  about  the  same  as 
on  the  previous  evening  ;  tenderness  slightly  dimin- 
ished ;  pulse,  108  ;  temperature  under  the  tongue, 
99.4°  F. 

There  was  great  thirst.  A  diagnosis  of  probable 
septic  peritonitis  was  made,  though  no  satisfactory 
cause  could  be  assigned.  Hot  applications  and  mor- 
jshine  were  continued.  About  6  p.m.  I  again  saw  the 
case,  and  found  him  in  collapse  ;  pulse,  150,  and  very 
weak  ;  cold  perspiration  and  extremities  cold.  Respi- 
rations, 30  ;  and  a  persistent  hacking  cough  was  noted. 
He  was  rational.  Enemata  of  milk  and  brandy  were 
ordered.  At  eight  o'clock  Dr.  Ceile  saw  the  case  with 
me.  The  question  of  operative  interference  was  con- 
sidered, but  not  thought  advisable,  on  account  of  the 
condition  of  the  patient  and  the  hour  of  the  day. 
Stimulating  enemata  were  continued,  and  the  case 
again  seen  about  10  p.m.,  with  Drs.  Bunts  and  Ceile  in 
consultation.  An  operation  was  considered  inadvis- 
able, and  the  patient  died  at  2  a.m.,  August  23d,  thirty- 
nine  hours  after  receipt  of  injury. 

Autopsy. — Abdominal  wall  above  pubes  oedematous  ; 
a  considerable  accumulation  of  adipose  tissue  gave  the 
prominence  in  inguinal  regions  clinically  noted  ;  adhe- 
sions to  the  parietal  peritoneum  more  marked  on  left 
side  ;  the  under  surface  of  the  diaphragm  and  the 
intestines  adhered  to  each  other.  There  was  no 
gas  in  the  peritoneal  cavity,  but  about  half  a  gallon  of 
muddy  fluid.  A  large  amount  of  tenacious  exudation 
at  various  places  ;  very  marked  congestion  of  all  the 
superficial  coils  of  intestines,  especially  in  the  umbili- 
cal, left  iliac,  and  hypogastric  regions.  A  perforation 
presented,  one- fourth  inch  in  diameter,  half  an  inch 
from  the  median  line  of  the  convex  surface  of  the 
ileum,  six  feet  above  the  iliac-csecal  valve. 

The  perforation  was  round,  the  margins  of  which 
were  rounded  and  smooth.  The  mucous  membrane 
for  about  an  inch  around  the  perforation  was  markedly 
congested  ;  the  wall  of  the  intestine  was  not  percep- 
tibly altered  in  thickness.  No  evidence  of  ulceration. 
The  perforation  was  the  centre  of  an  intense  perito- 
nitis ;  the  immediate  coils  of  intestine  were  intimately 
adherent,  and  a  profuse  plastic  exudation  covered  this 
part.  The  entire  intestinal  tract  was  laid  open  and  in- 
spected. There  were  no  ulcers,  no  thickening,  but  in 
places  there  were  patches  of  considerable  congestion. 
The  mucous  membrane  was  everywhere  intact,  and 
not  easily  stripped  off.  The  appendix  was  normal. 
The  diaphragmatic  peritoneum  was  congested,  covered 
with  exudate,  and  could  be  easily  stripped  off.  The 
liver  rather  large  ;  the  gall-bladder  and  bile-ducts  nor- 
mal ;  kidneys  apparently  normal.  The  bladder  hyper- 
trophied  from  an  old  inflammation  ;  the  prostate  en- 
larged. There  were  no  old  adhesions  and  no  excessive 
amount  of  gas  in  the  intestines. 

Diagnosis. — Acute  septic  peritonitis,  caused  by  the 
spontaneous  perforations  of  the  ileum. 


A  Coroner's  Jury  in  England  once  brouglit  in  a  ver- 
dict that  "  a  three  months'  old  child  was  found  dead, 
but  there  was  no  satisfactory  evidence  that  it  had  ever 
been  alive." 


494 


MEDICAL    RECORD. 


[October  5,  il 


A  CASE  OF  TETANUS    (TRISMUS)  WITH  RE- 
COVERY. 

Bv  CARL  PROEGLER,  M.D., 

FORT  WAV>'B,    ISO. 

A  Two-VEAR-OLD  child  was  caught  with  her  right  hand 
in  a  feed-machine  and  brought  to  my  office  with  a 
badly  mangled  hand,  index-finger  nearly  torn  to  the 
tendons,  but  no  bones  broken.  The  wound  was  treated 
strictly  antiseptically,  three  silk  sutures  were  used  in 
uniting  the  loose  skin  of  the  finger,  and  then  the  whole 
hand  was  wrapped  up  in  moist  iodoform  gauze.  Re- 
dressings  were  always  done  antiseptically  ;  after  one 
week  the  stitches  came  out  with  hardly  any  suppura- 
tion. 

Two  weeks  afterward  the  child  was  brought  again  to 
my  office  with  confirmed  trismus.  The  jaws  were  so 
firmly  set  that  it  was  impossible  to  open  them  ;  opistho- 
tonos occurred  during  the  examination.  The  wound 
was  completely  healed.  I  prescribed  chloralamid,  five- 
grain  doses,  per  rectum,  every  three  hours. 

Next  morning  the  child  was  deeply  narcotized,  but 
the  jaw  was  a  good  deal  more  relaxed,  and  she  was 
able  to  swallow  milk  I  ordered  the  injection  then 
ever)-  four  hours.  Recovery  was  complete,  with  the 
exception  of  an  inabilitj'  to  swallow  solid  food,  prob- 
ably due  to  spasm  of  the  oesophagus.  With  a  few 
hypodermics  of  strychnia  (^  gr.)  this  was  overcome, 
and  the  child  is  now  as  well  as  ever.  The  wound  was 
already  healed  when  trismus  occurred,  therefore  no 
bacteriological  examination  was  made. 

161  Grifftth  Stref.t. 


ABSCESSES  OF  THE  EXTERNAL  AUDITORY 
CANAL,  FOLLOWED  BY  PERICHONDRITIS 
AURICUL.f.. 

Bv  S.  GOLDSTEIN,  M.D., 

NEW   YORK. 

Mr.  L came  to  me  on  July  i,  1894,  stating  that 

some  months  previous  he  had  suffered  from  what  he 
termed  "  aboil  in  his  ear."  For  this  he  went  to  a  spe- 
cialist for  treatment.  The  abscess  was  incised  and  re- 
covery was  uneventful. 

When  I  first  saw  him,  on  the  above-mentioned  date, 
he  complained  of  stenosis  of  the  nares,  foul  odors  from 
the  nose  and  mouth,  and  a  discharge  from  both  ears. 
Upon  examination  I  found  the  occlusion  of  the  an- 
terior nares,  due  to  extensive  hypertrophy  of  the  mid- 
dle and  inferior  turbinated  bones  on  both  sides  and 
ecchondroses  of  right  and  left  sides  of  the  septum  ;  he 
also  had  an  exceedingly  large  pendulous  uvula  and  a 
follicular  pharj-ngitis.  Upon  examining  the  ears  I  found 
a  chronic  suppurative  inflammation  of  both  ears,  the 
discharge  being  more  profuse  in  the  right.  At  that 
lime  I  advised  the  removal  of  the  hypertrophied  por- 
tions of  the  middle  and  inferior  turbinated  bones,  the 
pendulous  portion  of  the  uvula,  and  curettage  of  the 
pharynx  ;  also  antiseptic  treatment  of  the  ear.  To  this 
he  acceded.  Upon  completion  of  this  treatment  the 
discharge  from  the  ears  had  almost  ceased  ;  in  the 
meantime  the  odors  had  disappeared,  and  nasal  breath- 
ing and  drainage  were  well  established.  Unfortunately, 
my  patient  was  unexpectedly  compelled  to  leave  town, 
and  I  did  not  again  see  him  until  May  26,  1895.  He 
then  complained  of  the  discharge  from  both  ears.  For 
this  I  placed  him  upon  appropriate  treatment.  He  was 
improving  steadily  until  July  ist  :  he  then  had  a  small 
furuncle  on  the  concha  of  the  right  ear,  which  I  incised, 
and  from  which  a  few  drops  of  ])us  exuded.  On  July 
5th  he  complained  of  pain  over  the  right  mastoid,  cheek, 
and  within  the  external  auditory  canal.  I  found  the 
external  auditory  canal  almost  completely  closed  by 
a  swelling  in  front  of  the  tragus,  and  the  meatus  red 


and  swelling  quite  extensively.  Fluctuation  was  evi- 
dent over  and  in  front  of  the  tragus  and  within  the 
canal.  I  made  an  incision  anterior  to  the  tragus  and 
within  the  canal,  making  communication  between  the 
incisions  for  drainage.  A  large  quantity  of  thick, 
creamy  pus  poured  out.  I  then  curetted  the  part  and 
drained  with  iodoform  gauze.  The  patient  was  seen 
daily  for  a  week.  Each  day  the  canal  and  abscess 
cavity  were  thoroughly  cleansed.  An  uneventful  recov- 
ery took  place  at  the  end  of  the  second  week.  At 
that  time  there  was  still  some  discharge  from  both  ears. 
For  this  I  cleansed  each  canal  every  second  day,  and 
twice  weekly  made  applications  of  pure  iodine,  with 
happy  effect. 


(Co'cvesxionAznce. 


OUR    LONDON    LETTER. 


(Fron 


r  Special  CorrespODdent.) 


BRITISH  ASSOCI.XTION  FOR  THE  ADVANCEMENT  OF  SCI- 
ENCE—  ALARMING  INCIDENT  AT  THE  PRESIDENT'S 
ADDRESS — SCANDAL    AT    THE    CANCER    HOSPITAL. 

London,  September  14.  1895. 

The  British  Association  for  the  Advancement  of  Sci- 
ence is  in  session  this  week,  the  place  of  meeting  being 
Ipswich,  where  the  members  have  been  heartily  wel- 
comed. Lord  Salisbury  retires  from  the  presidency 
and  Sir  Douglas  Galton  takes  this  high  office.  He  gave 
one  of  the  least  technical  addresses  that  have  ever  been 
delivered  from  the  chair.  During  his  address  he  was 
seized  with  indisposition,  and,  to  the  great  alarm  of  the 
audience,  unable  to  proceed.  He  had  been  reading 
carefully  for  about  an  hour  under  a  rather  powerful 
argand  burner,  when  he  faltered,  stammered,  and  then 
stopped  amid  a  dead  silence.  He  was  seen  to  be  lean- 
ing rigidly  against  his  desk  with  his  papers  still  in  his 
hands,  which  were  trembling.  Sir  John  Evans,  who 
was  near,  sprang  forward,  and  so  did  the  Mayor,  who  is 
a  medical  man.  They  assisted  the  President,  who  tried 
to  utter  a  sentence,  to  his  chair  and  restoratives  were 
administered.  It  was  a  scene  of  a  most  painful  and 
agitating  kind.  It  was  presently  announced  from  the 
platform  that  there  was  no  danger  to  Sir  Douglas,  and 
the  strain  of  the  audience  was  thereby  greatly  relieved. 
It  was  then  suggested  that  the  remainder  of  the  Presi- 
dent's address  should  be  taken  as  read,  but  Sir  Doug- 
las had  by  this  time  sufficiently  recovered  to  express  a 
wish  that  Sir  John  Evans  should  read  for  him  the  con- 
cluding pages.  This  accordingly  was  done,  while  the 
President,  pale  and  looking  worn,  sat  smiling  and  listen- 
ing. At  the  conclusion  there  was  a  burst  of  applause 
which  could  not  be  exceeded,  and  which  was  probably 
none  the  less  hearty  as  it  was  a  reaction  from  a  state  of 
consternation.  .\  vote  of  thanks  was  carried  with  en- 
thusiasm, and  then  the  President  rose  and  slowly  ap- 
proached the  desk  and  said  he  wished  to  express  his 
thanks,  but  would  be  glad  under  the  circumstances  to 
be  excused.  He  was  able  to  leave  the  platform  lean- 
ing on  a  friend's  arm,  and  the  audience  quickly  dis- 
persed. 

The  next  morning  (Thursday,  12th)  the  first  ques- 
tion in  all  directions  was  as  to  the  health  of  the  Presi- 
dent, and  great  was  the  satisfaction  felt  on  the  an- 
nouncement that  the  faintness  was  but  a  temporar)" 
indisposition,  and  that  Sir  Douglas  was  sufficiently  re- 
covered to  fulfil  his  engagements  in  connection  with 
the  Association. 

The  meeting  at  Ipswich  has  been  successful :  it  has 
been  conducted  in  a  business-like  manner  and  the  sec- 
tions have  been  well  attended.  There  are  nine  of  these 
and  each  has  its  presidential  address — rather  a  surfeit 


October  5,  1895] 


MEDICAL   RECORD. 


495 


of  addresses  for  those  who  take  an  interest  in  many 
subjects.  But  this  arrangement  enables  a  number  of 
experts  to  bring  before  the  public  the  progress  made 
in  their  several  departments,  and  thus  scientific  matters 
are  made  to  interest  wide  audiences.  This  is,  of  course, 
desirable  for  science,  in  which  respect  this  Association 
stands  on  a  different  plane  from  that  of  its  imitator — the 
Medical — which  should  not  approach  the  public,  its 
proceedings  being  only  for  the  profession.  I  think, 
therefore,  these  sectional  addresses  may  do  much  good, 
but  would  be  better  omitted  in  the  case  of  the  Medical 
Association. 

Some  three  years  ago  a  dispute  at  the  Cancer  Hos- 
pital led  to  a  trial  for  libel,  in  which  Mr.  Jennings 
sought  to  vindicate  his  character.  He  had  advised  a 
woman  to  submit  to  amputation  of  her  arm.  Some  of 
his  colleagues  disagreed  with  this  recommendation,  and 
somehow  the  matter  was  brought  before  the  managers, 
who  dismissed  Mr.  Jennings.  He  is  now  asking  for 
some  apology  or  an  explanation  of  the  curious  alleged 
sequel.  It  is  stated  that  the  poor  woman  was  afterward 
readmitted  to  the  same  hospital,  that  amputation  was 
performed  there,  that  she  died  there,  and  that  the  cer- 
tificate of  death  assigns  as  the  cause  morbus  cordis  ! 
More  facts  should  be  forthcoming  promptly  if  the  man- 
agement or  staff  expect  to  vindicate  themselves.  AVTio 
signed  the  certificate  ?  Who  amputated  ?  If  Mr.  Jen- 
nings made  an  error  of  diagnosis,  though  he  was  sup- 
ported by  eminent  surgeons,  and  was  justly  dismissed 
for  it,  what  should  be  the  penalty  of  amputating  for 
morbus  cordis,  and  who  is  the  proposer  of  this  treat- 
ment ? 


CHOLERA  IN  KOREA. 

TXTERESTIXG  FACTS  CONNECTED  WITH  ITS  WIDE  PREV- 
ALENCE    THERE THE     REGULAR     MORTALITY THE 

EFFICACY    OF    SALOL  IN    ITS    TREATMENT. 

(Special  to  the  Medicai.  Rscord.) 

Seoul,  Kore-\,  August  19,  18^5. 

It  has  been  my  rare  privilege,  during  the  epidemic  of 
cholera  now  about  over,  to  see  more  of  the  disease  than 
anyone  else,  and  yet  in  the  month  that  we  have  had  it 
I  have  been  enabled  to  personally  see  only  about  five 
hundred  cases,  though  the  total  deaths  in  the  city  and 
vicinity,  comprising  a  population  of  about  three  hun- 
dred and  fifty  thousand  people,  have  been  at  least  six 
thousand.  The  same  ratio  in  New  York  Cit)'  would  be 
about  ten  thousand  a  week.  During  this  time  I  have 
had  charge  of  the  only  cholera  hospital  now  in  opera- 
tion, another  one,  run  by  a  number  of  physicians,  hav- 
ing proven  impracticable,  as  they  hadn't  many  con- 
veniences and  were  unfortunate  in  having  many  dying 
patients  sent  to  them — a  condition  from  which  we  did 
not  escape  either — and  consequently  their  death-rate 
was  so  high,  sixty-five  or  seventy  per  cent.,  that  it  had 
to  be  closed.  We  were  fortunate  in  reversing  those 
figures,  and  have  had  from  sixty-five  to  seventy  per 
cent,  of  recoveries,  and  as  I  think  it  was  in  great  part 
due  to  a  certain  plan  of  treatment,  I  think  it  is  ap- 
propriate for  me  to  send  you  a  brief  statement  with  a 
couple  of  typical  cases.  In  the  hospital  here  I  have 
had  but  one  hundred  and  forty  odd  cases  (some  were 
indeed  very  odd),  the  others  were  in  the  other  hospital, 
which  treated  about  one  hundred  and  twenty-five,  and 
around  town,  from  the  hovels  of  the  poor  to  the  palace 
of  the  king,  where  I  was  on  duty  for  a  while.  In  a 
general  way  the  disease  doesn't  seem  to  be  partic- 
ularly virulent,  though  it  has  swept  over  certain  jior- 
tions  of  the  city  like  as  if  a  wind  had  carried  the  germs. 
In  regard  to  the  disease  as  seen  here,  I  am  inclined 
to  think  that  of  one  hundred  people  attacked  ten  will 
recover  without  any  treatment  at  all.  A  sort  of  sur- 
vival of  the  fittest  proposition  which  may,  or  may  not, 
stand  against  theoretical  arguments.     Without  the  use 


of  drugs  by  the  mouth,  using  only  the  saline  or  tannic- 
acid  injection,  then  about  twenty  percent,  can  be  cured. 
With  all  the  drugs  usually  used  and  all  the  methods 
too,  then  fifty  per  cent,  will  recover  ;  but  with  salol  and 
the  rest,  I  am  strongly  of  the  opinion,  proven  by  our 
records,  that  eighty  or  ninety  per  cent,  can  be  cured. 
The  limited  supply  we  had  of  this  valuable  drug  en- 
abled us  to  use  it  in  but  few  cases,  and  the  percentage 
of  cures  in  those  was  over  ninety  per  cent. 

It  would  be  tedious  and  lengthy  to  go  into  the  details 
of  the  symptoms,  complications,  and  treatment  of  the 
various  patients,  but  a  general  idea  of  the  routine  car- 
ried out  from  the  two  cases  is  here  submitted,  though  the 
majority  did  not  receive  salol,  as  we  hadn't  it  to  give. 

In  regard  to  the  complications  we  had  some  very  di- 
verting ones.  Pregnancy  was  a  common  condition  in 
the  women,  and  they  usually  died.  One,  however,  had 
a  miscarriage  at  the  fourth  month,  and  I  said  if  she 
would  only  have  puerperal  fever,  that  I  thought  she 
would  recover.  There  was  no  evidence  of  fever,  but 
the  woman  came  out  of  cold  sweat,  collapse,  and  a 
most  unfavorable  condition,  and  recovered.  Two  cases 
dropped  off  suddenly  from  heart  failure  and  one  from 
cystitis.  In  one  case  of  retention,  I  drew  off  sixty 
ounces  of  urine. 

Case  XLIV. — Kim  Wun  Pal,  male,  aged  forty-eight. 
Received  at  the  hospital  at  4.30  p.m.,  August  8th.  Had 
had  severe  vomiting  and  continuous  watery  stools  since 
morning.  Symptoms  of  complete  collapse.  There 
seemed  to  be  no  chance  at  all  for  the  man's  recovery, 
so  I  wrote  on  the  record  paper,  "  No  pulse,  collapse. 

dying  condition.     We  only  receive  him  because ." 

Nevertheless,  I  set  the  Korean  nurses  I  have  trained  at 
work.  Gave  sixty  minims  sulphuric  ether  hypoder- 
matically  and  three  pints  of  a  saline  solution  (  3  j.  salt 
to  the  pint)  high  into  the  bowels,  using  two  long  soft- 
rubber  catheters,  enteroclysis  as  it  is  called,  being 
particular  as  to  all  the  details  of  the  procedure.  At 
5.20  his  condition  was  unchanged,  so  I  practised 
hypodermoclysis,  injecting  three  pints  of  the  saline 
solution,  at  a  temperature  of  104°  F.,  under  the  ab- 
dominal tissues.  I  did  this  many  times  on  many  pa- 
tients, but  was  unable  to  carry  out  the  fine  details  of 
antiseptics  usual.  My  water  wasn't  sterilized,  nor  the 
body  at  the  point  of  puncture  washed.  I  had  no  bad 
result  in  any  case,  except  a  slight  inflammation  in  one 
where  I  injected  into  the  thigh  instead  of  into  the  ab- 
dominal space.  In  regard  to  the  enteroclysis,  I  think 
it  ought  to  be  a  most  valuable  antipyretic  procedure, 
having  the  water  at  whatever  temperature  is  appro- 
priate. I  also  gave  twenty- five  more  minims  of  ether, 
having  had  the  patient  vigorously  rubbed  with  alcohol 
in  the  meantime  ;  at  6  p.m.  enteroclysis,  three  pints. 

The  characteristic  pains  and  cramps  which  they  ap- 
propriately call  "  snakes,"  as  the  muscles  contract  into 
hard  knots,  and  seem  to  creep  up,  so  that  many  pa- 
tients are  brought  in  with  cords  tightly  bound  around 
their  legs,  now  supervened.  For  the  relief  of  this  I 
gave  \  grain  of  morphine,  our  rule  being  to  use 
morphine  only  when  absolutely  necessary.  At  10  p.m. 
enteroclysis  and  brandy  at  intervals.  At  i  a.m.  there 
was  as  yet  no  reaction  and  no  pulse,  but  the  vigorous 
measures  were  continued.  At  6  a.m.  the  pulse  became 
barely  perceptible  and  the  body  slightly  warm  ;  30 
grains  of  salol  were  given,  which  was  continued  in 
i5grain  doses  every  three  hours  for  several  doses,  en- 
teroclysis with  the  saline  fluid,  cracked  ice  for  vomit- 
ing and  to  relieve  the  thirst,  milk,  rice-water,  brandy, 
and  beef-tea.  There  were  no  other  unusual  symptoms. 
The  man  made  an  uneventful  recovery,  and  in  a  few 
days  walked  home  well,  stopping  at  my  sarang  as  he 
went  out  to  make  his  profound  bows  and  orientally  ex- 
aggerated thanks.  Indeed,  this  feature  has  been  one 
of  the  most  pleasing  and  diverting  of  all. 

The  other  case  in  which  I  think  the  recovery  en- 
tirely due  to  salol,  was  in  this  wise  : 

Kim  Gung  Yun,  male,  aged  twenty-si.x.     Frail,  weak 


496 


MEDICAL    RECORD. 


[October  5,  1895 


young  man,  received  at  2.30  p.m.  on  August  5th.  He 
was  much  emaciated  and  looked  as  if  he  had  been 
through  a  threshing-machine.  His  mother  and  other 
members  of  the  family  had  just  died  of  cholera.  His 
severe  symptoms  had  only  commenced  in  the  morning, 
and  as  yet  he  had  had  no  vomiting.  The  pulse  was 
good.  I  ordered  at  once  the  saline  injection  to  thor- 
oughly wash  out  the  bowel,  and  gave  a  dose  of  sulph- 
uric acid  (dilute)  and  camphor  and  10  grains  of  salol. 
At  6  P.M.  enteroclysis,  sulphuric  acid,  and  camphor, 
internally.  The  man  grew  rapidly  worse,  vomiting 
came  on  and  was  uncontrollable.  At  midnight,  gave 
30  grains  of  salol,  and  had  the  usual  vigorous  rubbing 
with  alcohol  kept  up  constantly.  Champagne  was 
given  at  intervals  At  6  a.m.  5  grains  of  salol.  At 
7  .\.M.  those  awful  cramps  and  pains  doubled  him  into 
a  knot,  and  I  gave  ^  grain  of  morphine.  At  9  a.m.  the 
pulse  was  barely  perceptible,  so  I  gave  forty  minims  of 
ether  hypod.,  and  20  grains  of  salol.  At  10.30,  10 
grains  of  salol.  At  12,^  grain  of  morphine  and  sixty 
minims  of  ether.  Enteroclysis  was  repeated  at  regu- 
lar intervals.  At  3  p.m.  jV  grain  atropia  in  thirty 
minims  of  ether.  From  3  to  8  p.m.  we  kept  up  the 
work,  when  the  nurses  and  all  gave  him  up  and  sent  for 
his  father  and  friends,  who  came  in  the  morning,  bring- 
ing the  grave  clothes  ;  but  the  man  wasn't  dead  yet. 
At  3  A.M.  there  was  a  slight  improvement,  the  salol  was 
continued,  as  was  the  enteroclysis  and  other  routine  of 
food  and  stimulation,  and  on  the  sixth  day  the  man 
was  discharged  well.  There  were  scores  more  like  these 
two  cases,  presenting  many  interesting  details,  but 
alike  in  general  particulars.  The  last  case  illustrates 
the  general  symptoms  as  we  find  them  in  this  epidemic. 
As  to  salol,  it  is  not  necessary  for  me  to  more  than 
mention  its  physiological  action.  It  beads  up  into 
forty  per  cent,  of  carbolic  acid  and  sixty  per  cent,  of 
salicylic  acid  by  the  action  of  the  pancreatic  juice,  and 
so  comes  in  contact  with  the  comma  bacillus  and  when 
it  does  most  live  to  coagulate.  In  my  hands  it  has 
proven  a  most  remarkable  remedy  in  this  affection. 
I  used  a  small  quantity  of  the  sulpho  carbolate  of 
sodium,  all  I  could  obtain,  in  a  limited  number  of  cases, 
and  wish  to  report  most  satisfactory  results.  I  am  in- 
clined to  think  it  may  be  as  valuable  as  salol. 

J.  Hunter  Weli.s,  M.D. 


ANOTHER    BERIBERI   SHIP. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  The  bark  Lottie  Moore,  one  hundred  and  seven- 
teen days  from  Aleppy,  India,  opposite  Ceylon,  arrived 
in  New  York  harbor  this  morning  from'  Barbadoes, 
where  she  had  put  in,  with  her  entire  crew,  all  Eu- 
ropeans, sick  of  beriberi.  There  were  sixteen  persons, 
all  told,  on  the  ship.  All  were  affected  except  the  wife 
and  child  of  the  captain.  Before  reaching  Zanzibar, 
two  months  and  a  half  after  the  start,  the  first  cases  ap- 
peared, two  men  in  the  forecastle,  where  eight  men  were 
quartered.  The  captain  and  the  officers  were  quar- 
tered in  the  stern.  The  voyage  was  exceptionally  dry. 
At  no  time  did  the  water  on  the  decks  reach  to  the 
hatches,  which  shows  that  very  little  rain  fell.  The 
cargo  consisted  of  eight  hundred  tons  of  coir  garu 
(cocoa  fibre),  some  ginger,  cocoanut  oil  and  gamboge. 
The  cocoa  fibre  sweated.  I  found  in  the  hold  all  the 
iron  carburetted.  The  ship's  carpenter  told  me  that 
on  opening  the  hatches  large  volumes  of  steam 
streamed  from  them.  He  states  that  last  year  he  was 
on  a  boat  charged  with  a  similar  cargo  ;  this  ship  also 
had  to  put  into  Barbadoes,  where  the  captain  and  two 
of  his  men  died  of  beriberi.  The  same  man  was  on 
board  of  a  coffee  ship,  twelve  years  ago,  when  three 
men  were  stricken  with  beriberi.  This  coffee  cargo 
had  "  burned  "  on  the  voyage,  and  the  crew,  not  know- 


ing what  the  disease  was,  attributed  the  outbreak  to 
that  circumstance. 

I  may  add  that  here  again,  then,  we  find  evidence 
that  the  sweating  or  fermentation  of  a  vegetable  cargo 
is  the  main  cause  of  beriberi. 

Albert  S.  .^shmead,  M.D. 

New  York,  September  la,  1895. 


CRANIOTOxMY. 


To  THB  Editor  of 


.  Medical  Record. 


Sir  :  Dr.  F.  W.  Higgins,  in  his  article  in  the  Medical 
Record  of  September  14th,  quoted  Balestrini  on  his 
investigations  of  infanticide  and  abortion  as  saying 
that  what  is  killed  is  not  a  man,  but  a  being  inferior  in 
the  zoological  world.  Now  I  say  that  this  is  a  danger- 
ous and  most  abominable  doctrine,  particularly  at  a 
time  when  the  "  fashion  of  abortion  "  is  on  a  fair  way 
to  die  out  in  this  country.  I  hold  that  as  soon  as  the 
two  elements  meet  in  copulation  there  is  life,  and  it  is 
criminal  to  destroy  it,  whether  one  month  old  or  more, 
unless  justified  by  prevailing  grave  conditions. 

In  my  opinion  craniotomy  is  justified,  i,  when  the 
foetus  is  dead  ;  2,  when  abdominal  section  and  symphys- 
eotomy are  out  of  the  question. 

Referring  again  to  the  doctrine  of  Balestrini,  I  will 
say  that  this  will  be  balm  to  abortionists,  and  that  by  it 
they  will  have  a  means  to  defend  their  nefarious  prac- 
tice. If  it  is  inferior,  it  is  only  so  far  inferior  to  the 
infant  as  the  infant  is  to  the  man. 

Carl  Engel,  ^I.D. 

MiNDEN,  Ia. 


THE  ELECTRO-MAGNET  FOR  THE  RE- 
MOVAL OF  FOREIGN  BODIES  FROM 
THE    EYE. 

To  THE  Editor  of  the  Medic.\l  Record. 

Sir  :  Please  allow  me  space  through  your  columns  to 
explain  to  Dr.  S.  Mitchell,  of  Hornellsville,  N.  Y.,  why 
I  neglected  to  mention  the  electro-magnet  in  my  report 
of  "  Accidents  to  the  Eye  while  Chopping  with  a  Hoe." 
Had  my  theme  been  "  Foreign  Bodies  in  the  Eye  and 
their  Removal,"  then  perhaps  it  might  have  been  a 
crime  not  to  have  mentioned  the  use  of  the  electro- 
magnet, but  as  I  only  intended  to  show  the  frequency  of 
accidents  to  the  eye  while  chopping  with  a  hoe,  I  ask  for 
pardon.  In  looking  over  my  case-book  it  so  happened 
that  I  selected  cases  in  which  I  did  not  think  it  neces- 
sary to  use  the  electro-magnet.  Had  I  reported  all  of 
my  cases  of  this  nature,  the  use  of  the  electro-magnet 
would  have  been  mentioned,  inasmuch  as  I  really  own 
one,  and  have  at  various  times  used  it,  and  am  sorry 
to  have  to  report  that  at  various  times  I  found  it 
useless.  I  bought  the  instrument  during  a  sojourn  in 
London  in  1880.  Several  times  have  I  witnessed  Mr. 
Nettleship,  Lawson,  Tweedy,  and  other  surgeons  to 
Moorfields,  and  e(]ually  as  competent  and  celebrated 
men  in  the  different  cities  of  America,  manipulate  and 
manoeuvre  about  in  the  vitreous  with  an  electro-magnet 
for  corpus  alioiiim  of  steel,  with  more  failures  than  suc- 
cess. I  myself  have  tried  to  remove  pieces  of  steel 
with  the  magnet  from  the  vitreous,  only  a  limited  num- 
ber of  times,  from  the  fact  that  most  of  my  cases  when 
presented  had  commencing  or  advanced  panophthal- 
mitis, and  experience,  if  nothing  else,  dictated  to  me 
that  the  electro- magnet  would  be  of  no  use,  even  if  the 
extraction  of  the  foreign  body  were  certain.  But  in 
recent  cases — before  irido-cyclitis.  suppurative  choriodi- 
titis,  or  jianophthalmitis  has  set  in — a  careful  use  or 
trial  of  the  electro  magnet  is  certainly  advisable.  Two 
weeks  ago  to-day  a  patient — a  stone-cutter — consulted 
me,  saying  that  he  had  "  a  piece  of  grit  in  his  eye." 
The  accident  happened  the  day  before.    A  bead  of  vit- 


October  5,  1895] 


MEDICAL   RECORD. 


49; 


reous  could  be  seen  protruding  from  the  wound  in  the 
sclerotic,  made  In*  the  foreign  body.  I  was  satisfied 
that  the  offending  member  was  a  piece  of  steel  from 
the  hammer  or  chisel,  and  was  lodged  in  the  \atreous. 
I  at  once  extracted  from  my  armamentarium  an  electro- 
magnet, and  with  competent  assistance  used  every  effort 
to  extract  the  piece  of  steel,  but  am  sorr}'  to  have  to 
add  we  made  a  complete  failure.  Had  we  been  fortu- 
nate enough  to  have  extracted  it,  I  am  doubtful  as  to  the 
saving  of  the  ball  in  this  case,  as  I  suspected  incipient 
panophthalmitis,  and  advised  enucleation,  which,  how- 
ever, was  refused.  A  solution  of  atropia  and  anodyne, 
and  cold  applications  were  advised.  In  three  days  the 
patient  returned  with  an  advanced  case  of  panophthal- 
mitis, and  eager  to  have  the  ball  removed,  which  I  did, 
and  afterward  found  the  foreign  body — a  piece  of  steel, 
the  size  of  a  large  pin-head,  in  the  vitreous.  My  reason 
for  not  using  the  magnet  in  cases  of  foreign  bodies  in 
the  anterior  chamber  of  the  eye  is  simply  this  :  I  much 
prefer  to  use  forceps.  Why  not  have  an  electro  mag- 
netic pair  in  our  armamentarium  ?  I  might  announce, 
like  the  doctor,  "  I  am  now."  and  have  been  for  years 
past.  "  using  "  the  alternating  current  "  in  my  office, 
and  bv  means  of  a  converter,  manufactured  by  a  me- 
chanic in  this  city,  I  am  able  to  use  it  for  all  kind  of 
cauter)-  work,"  and  pardon  me  for  sajang  that  lots  of 
this  kind  of  work  might  be  left  undone,  with  no  detri- 
mental effect  to  suffering  humanity.  The  alternating 
current  is  not  suitable  for  the  use  of  the  electro-mag- 
net, in  consequence  of  which  I  am  forced  to  resort  to 
various  kinds  of  storage  batteries,  and  this  may  be  the 
cause  of  my  non-success  with  the  use  of  the  electro- 
magnet. 

William  L.  Bull.^rd,  M.D. 


''THE-   WRITER,    NOT    ''A"  WRITER. 

To  THE  Editor  cf  the  Medical  Record. 

Sir:  My  attention  has  just  been  called  to  the  fact 
that  in  my  article  upon  appendicitis  in  your  issue  of 
the  Medical  Record  for  August  31st  a  misprint  oc- 
curs, which  changes  the  meaning.  I  am  made  to  say. 
of  the  technique  which  I  there  advise,  in  appendix-op- 
eration, "  It  has  recently  been  described  by  a  writer  in 
the  International  Journal  of  Surgery  .■  together  with  a 
study  of  these  eleven  other  methods." 

This  should  read  "  t/ig  writer,"  as  the  article  in  ques- 
tion in  the  International  Journal  was  written  by  myself. 
I  ask  for  correction  of  this  typographic  error  simply 
because  it  leaves  me  in  the  apparent  attitude  of  using 
and  quoting  the  original  work  of  another  man  without 
doing  him  the  justice  to  mention  his  name. 
Respectfully  yours, 

Robert  H.  M.  Dawbarx. 

September  2o,  1855. 


•  A     SHORTER     SCALE     FOR     THE     THER- 
MOMETER." 


To  THE  Editor  of 


Medical  Record. 


Sir  :  Allow  me  to  suggest  to  Dr.  Elmar  C.  Fahrney,  and 
to  those  who  may  agree  with  him  as  to  the  desirability 
of  having  the  thermometer  scale  commence  at  98°  in- 
stead of  95°  F.,  the  utility  of  studying  subnormal  temper- 
atures. I  could  better  agree  with  him  in  his  letter  to 
the  Medical  Record  of  August  31st,  to  cut  down  the 
top  of  the  scale — though  I  did  run  across  a  temperature 
of  109°  F.  a  while  ago  in  a  scarlet-fever  case — than  to 
chop  off  the  scale  below  98°.  A  physician  who  sees 
his  chronic  cases  after  10  a.m.,  as  most  of  us  do,  is  not 
likely  to  catch  their  lowest  temperatures.  Let  such 
patients  have  a  thermometer  and  keep  their  own  record? 
at  seven,  ten,  one,  four,  and  eight  o'clock,  and  a  differ- 
ent phase  may  be  put  upon  their  thermal  condition. 
My  own  rule  is  to  choose  the  hours  8  to  9  a..m.,  i,  4, 


and  S  P..M.    In  tuberculosis  especially  we  ought  to  take 
cognizance  of  both  swings  of  the  heat  pendulum. 

Of  a  dozen  cases  of  tuberculosis  now  under  treatment, 
morning  temperatures  have  been  found  in  the  last  fort- 
night in  at  least  one-half,  ranging  from  94>^°  to  97°  F. 
Under  tuberculin  or  antiphthisin  treatment  this  deca- 
dence in  the  morning  record  is  especially  noticeable 
when  the  treatment  is  proving  effective,  and  it  is  a 
good  sign  to  see  the  morning  average  rise  as  the  even- 
ing record  lowers  under  the  continuance  of  any  reme- 
dial means. 

Charles  Dexison,  M.D. 

Denver,  Col. 


\      >' 


^jettJ  ^tistratmcnts. 


THE     AUTO-STERILIZING    THERMOMETER 
CASE. 

This  is  a  new  invention  which  furnishes  the  physician 
with  a  reliable  and  never-failing  means  for  preventing 
the  transmission  of  disease  by 
means  of  the  thermometer.  It 
keeps  the  instrument  sterile  and 
always  ready  for  instant  use,  with- 
out any  special  attention  on  the 
part  of  the  physician. 

Government  tests  of  the  auto- 
sterilizing  thermometer  case, 
made  under  the  direction  of  the 
Surgeon-General  of  the  United 
States  Army,  by  Dr.  Walter  Reed , 
the  curator  of  the  Army  Med- 
ical Museum,  show  that  althougi. 
the  thermometers  were  freely 
smeared  -n-ith  solid  cultures  ot 
bacillus  diphtherise,  staphylococ- 
cus pyogenes  aureus,  and  strepto- 
coccus pyogenes,  absolutely  no 
growths  occurred  after  an  ex- 
posure of  the  thermometer  for 
twenty-five  minutes  in  the  auto 
sterilizing  thermometer  case. 

As  the  tests  were  many  and 
exhaustive,  extending  over  the 
period  of  a  month,  from  June 
21,  1895,  to  July  23,  1895,  they 
appear  to  prove  conclusively  that 
the  auto-sterilizing  thermometer 
case  will  destroy  all  germs  of 
disease  with  a  maximum  expos- 
ure of  twenty-five  minutes  to  the 
action  of  the  vapor,  and  for  the 
ordinary  use  of  the  thermometer 
ten  minutes'  exposure  is  all  that 
is  necessary  to  render  it  aseptic. 

The  thermometer  rests  in  a  re- 
ceptacle like  the  hard  -  rubber 
cases  usually  sold  with  thermometers,  except  that  at 
the  lower  end  of  the  case  is  attached  an  extra  hard- 
rubber  chamber  one-half  inch  in  depth,  which  contains 
a  small  pledget  of  absorbent  cotton  soaked  with  the 
glyceraldehyde.  The  fluid  being  verj-  volatile,  the  va- 
por rises  to  the  interior  of  the  case  proper  through 
openings  provided  in  the  bottom  of  the  case,  and  keeps 
the  thermometer  sterilized  without  other  attention  than 
recharging  once  a  week  with  a  few  drops  of  glyceralde- 
hyde. 

Glyceraldehyde  is  composed  of   several  germicidal 
properties,  the  base  of  which  is  formaldehyde. 


Dilatation  of  the  Stomach. — .\t  no  distant  day  dilata- 
tion of  the  stomach  will  be  successfully  treated  by 
gastro-enterostomy. — Winiwarter. 


498 


MEDICAL   RECORD. 


[October  5,  1895 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  September  28,  1895. 

Cases.       Deaths. 


Tuberculosis 103 

Typhoid  fever I  36 

Scarlet  fever 25 

Cerebro-spinal  meningitis |  5 

Measles 56 

Diphtheria ;  121 

Small-pox I 


Some  Recent  Views  on  Immunity. — At  a  late  meeting 
of  the  Epidemicological  Society  of  London  (  The  Lan- 
cet) Dr.  J.  W.  Washbourn  read  a  paper  on  the  subject 
of  immunity,  which  was.  he  pointed  out,  a  problem  of 
the  deepest  scientific  interest,  and  of  no  less  practical 
importance  because  the  antitoxin  treatment  of  diph- 
theria, probably  the  first  step  toward  an  entirely  new 
field  of  therapeutics,  was  the  direct  outcome  of  the 
close  study  of  its  phenomena.  The  first  fact  to  be 
taken  into  consideration  was  that  pathogenic  bacteria 
produced  their  effects  on  the  organism  by  means  of 
poisons  or  "  toxins  "  which  they  elaborated  in  the  fluids 
of  the  body,  as  was  well  seen  in  the  production  of  all 
the  symptoms  of  diphtheria  or  of  tetanus  by  the  inocula- 
tion of  sterilized  culture  fluids,  without  a  trace  of  the 
bacilli  themselves.  These  toxins  were  intensely  viru- 
lent, but  others,  as  that  of  the  pneumococcus,  were  ex- 
tremely feeble.  The  bacilli  of  diphtheria  and  tetanus 
when  inoculated  did  not  invade  the  vascular  system, 
but  multiplied  in  and  around  the  seat  of  inoculation 
only,  though  the  toxins  they  produced  were  diffused 
throughout  the  body.  These  might  be  taken  as  types 
of  toxic  diseases  ;  though  in  the  case  of  tetanus  the  in- 
oculation of  washed  spores  into  a  healthy  wound  pro- 
duced no  effect  unless  the  tissues  were  lacerated  or  sup- 
purating, or  other  bacteria  were  introduced  at  the  same 
time  and  place.  In  septic  diseases,  on  the  other  hand,  the 
toxins  were  feeble,  but  the  bacteria  invaded  every  tissue 
and  fluid  of  the  organism.  This  was  well  seen  in  the 
study  of  the  coccus  of  pneumonia  in  the  rabbit.  Some, 
as  septicemic,  partook  of  the  character  of  both,  and 
some  acted  in  one  way  or  the  other  under  different  cir- 
cumstances. We  must  consider  the  power  of  the  body 
to  destroy  the  bacteria  or  inhibit  their  growth,  and  the 
power  of  resisting  the  effects  of  their  toxins,  the  former 
factor  being  most  important  in  the  case  of  the  septic 
and  the  latter  in  that  of  the  toxic  diseases.  Immunity 
might  depend  on  either  condition  or  on  both.  It  was 
either  natural  or  artificial  and  acquired.  Fowls,  pigs, 
and  white  rats  were  immune  to  anthrax  ;  birds  gener- 
ally to  the  pneumococcus  ;  mice  to  the  toxin  of  diph- 
theria ;  and  fowls  to  that  of  tetanus,  just  as  they  were 
to  large  doses  of  morphine.  They  would,  however, 
succumb  to  anthrax  if  depressed  by  cold  and  ill  fed. 
An  artificial  immunity  might  be  acquired  in  several 
ways,  as  by  inoculation  with  a  mild  or  artificially  attenu- 
ated virus,  or  by  minute  doses  of  a  virulent  one,  or  by 
non-fatal  doses  of  the  pure  toxin.  Anthrax  virus  could 
be  attenuated  by  cultivation  at  a  high  temperature  or 
by  the  addition  of  certain  antiseptics.  As  a  rule,  im- 
munity obtained  by  means  of  the  toxins  was  less  per- 
manent than  that  from  inoculation  of  living  microbes. 
Time  was  required  to  establish  immunity  by  means  of 
toxins,  and  such  immunity  did  not  last  long,  both  pe- 
riods being  longer  tlie  greater  the  effect  of  the  inocula- 
tion. It  was  easier  to  render  an  animal  immune  to 
fatal  doses  of  the  living  bacteria  than  to  those  of  the 
toxin  ;  and  when  this  latter  immunity  was  obtained 
that  to  the  bacteria  was  also,  but  the  converse  did  not 


hold  good.  A  fallacy  of  observation  might,  however, 
arise  from  the  fact  that  living  bacteria  were  often  re- 
tained in  the  tissues  long  after  apparent  recovery,  and 
called  into  renewed  activity  by  the  injection  of  toxin, 
they  and  not  it  being  the  cause  of  the  subsequent  fatal 
attack.  In  some  few  cases  a  very  transient  immunity 
had  been  produced  by  the  intra-peritoneal  injection  of 
dead  bacteria,  etc.  But  of  infinitely  greater  value  was 
that  conferred  by  injection  of  the  serum  of  a  highly 
immunized  animal.  The  immunity  was  of  far  shorter 
duration  than  that  produced  by  vaccination,  but  this 
method  had  a  therapeutic  as  well  as  or  even  greater 
than  its  prophylactic,  and  unlike  vaccination  was  avail- 
able after  the  disease  had  developed.  This  was  the 
antitoxin  treatment  of  diphtheria  and  tetanus.  Turn- 
ing to  the  properties  of  the  cells  and  fluids  of  the  body 
in  their  relation  to  bacteria.  Dr.  Washbourn  referred  to 
phagocytosis  as  the  most  seductive  theory  of  immunity. 
To  Metschnikoff,  who  had  studied  the  process  through- 
out the  animal  kingdom,  we  owed  all  our  knowledge  of 
the  subject.  The  amoeba,  as  was  well  known,  was  ca- 
pable of  surrounding  and  digesting  particles  of  food, 
including  living  bacteria,  .\mong  these  Metschnikoff 
had  observed  a  small  unicellular  micro-organism,  the 
microsphsera,  which,  however,  instead  of  being  digested 
multiplied  within  the  amoeba  and  ultimately  destroyed 
it.  Such  a  struggle  between  the  invading  microbes 
and  the  protoplasmic  cells  of  the  body  occurred,  ac- 
cording to  Metschnikoff,  in  every  case  of  infection, 
ending  in  recovery  or  in  death,  as  the  cells  or  the  mi- 
crobes were  victorious.  The  struggle  and  the  alterna- 
tive results  were  well  seen  in  the  daphnia,  a  small  fresh- 
water crustacean,  and  the  parasitic  monospora,  which 
entered  the  tissues  from  the  alimentary  canal,  and  in  a 
large  number  of  the  invertebrata  phagocytosis  played 
an  important  part.  Among  vertebrata  the  phagocytes 
belonged  mostly  to  the  class  of  leucocytes,  which 
Metschnikoff  divided  into  lymphocytes,  eosinophile, 
neutrophile,  and  mononuclear  leucocytes.  Of  these 
the  two  latter,  together  with  the  endothelial  cells  of  the 
lymphatics  and  kidneys,  were  phagocytic,  even  when 
removed  from  the  body,  and  that  they  were  capable  of 
thus  devouring  bacteria  in  the  living  animal  was  easily 
proved  by  experiments,  such  as  the  introduction  of  an- 
thrax bacilli  under  the  skin  of  a  pigeon,  or  of  those  of 
tubercle  into  the  blood  of  a  rabbit,  when  they  would  be 
found  to  be  taken  up  by  the  leucocytes  and  by  the  en- 
dothelium respectively,  and  successful  cultures  from 
such  leucocytes  showed  that  the  bacteria  might  resist 
digestion  for  some  time.  The  migration  of  leucocytes 
through  the  walls  of  the  vessels  in  inflammation  around 
the  seat  of  an  inoculation  was  due  to  a  power  possessed 
by  various  substances  of  attracting  or  of  repelling  amce- 
boid  cells,  and  known  as  positive  and  negative  chemio- 
taxis.  It  could  be  studied  in  certain  protozoa,  as  the 
myxomycetes,  and  in  the  vertebrata  by  inserting  under 
the  skin  capillary  tubes  open  at  one  end  and  contain- 
ing chemical  substances.  Ox\  removing  the  tubes  after 
some  days,  the  contents,  if  positively  chemiotaxic,  will 
be  filled  with  leucocytes.  That  tJie  blood  and  lymph 
serum  had  bactericidal  powers  was  first  observed  by 
Nuttell,  and  carefully  investigated  by  Buchner,  Behring. 
and  others.  If  serum  were  inoculated  with  a  cultiva- 
tion, and  the  number  of  bacteria  present  estimated  day 
after  day  by  plate  cultures,  it  was  found  that  they  grad- 
ually fell  off  until  they  disappeared  altogether,  or  after 
having  sunk  in  number  for  a  time  began  to  increase 
until  they  were  more  numerous  than  at  first.  It  has 
been  suggested  that  the  serum  contained  a  bacteri- 
cidal substance  called  '"  alexine."  and  that  the  bac- 
teria secreted  an  antagonistic  '  lysine  : "  both  were 
hypothetical,  but  the  fact  remained  that  bacteria,  if 
numerous,  could  resist  the  undoubtedly  baciericidal 
action  of  the  blood,  which  was  also  very  easily  de- 
stroyed by  physical  agencies,  such  as  the  exposure  of 
the  serum  to  a  temperature  of  60°  C.  The  bactericidal 
property  was  most  conspicuous  in  inflammatory  exuda- 


October  5,  1895J 


MEDICAL    RECORD. 


499 


tions,  and  was  doubtless  due  to  some  substance  secreted 
by  the  leucocytes,  among  which  Hankin  first  indicated 
the  eosinophile  cells  as  the  most  active.  But  the  serum 
was  not  merely  bactericidal ;  it  could  be  made  anti- 
toxic. Behring  and  Kitasato  were  the  first  to  show 
that  the  serum  of  animals  immunized  by  inoculation 
to  the  poison  of  diphtheria  or  tetanus  possessed 
the  power,  when  inoculated  into  others  affected  with 
the  respective  diseases,  of  neutralizing  the  poison 
and  cutting  short  the  morbid  process  ;  and  the  more 
frequently  the  immunized  animal  was  injected  with  the 
toxin  the  more  powerfully  antito-xic  its  blood  became. 
Ehrlich  had  shown  that  two  vegetable  poisons,  ricine 
and  librine,  acted  in  a  strictly  analogous  manner.  Se- 
rums were  thus  antibacteric  or  antitoxic,  the  latter  be- 
ing antibacteric  also.  The  bactericidal  property  of  a 
serum  was  very  easily  destroyed  by  heat,  but  the  anti- 
toxic or  protective  property  was  not,  and  the  substance 
in  which  it  resided  could  not  be  precipitated  without 
losing  its  efficacy.  It  was  scarcely  necessary  to  state  that 
all  antitoxins  were  specific  or  efficient  against  no  toxin 
but  that  of  the  disease  whence  they  were  derived. 
Such  were  the  factors  in  immunity — viz.,  phagocytosis, 
bactericidal  substances,  and  protecrive  serums,  the  last 
of  these  being  outside  of  the  question  of  natural  im- 
munity. Vet  the  problem  of  natural  immunitj'  was  a 
complex  one,  special  factors  coming  in  ;  thus  the  low 
temperature  of  the  frog's  blood  enabled  it  to  resist  in- 
oculation with  tubercle  bacilli,  and  fowls  were  unaf- 
fected by  tetanine  as  they  were  by  morphine.  The 
blood  serum  of  white  rats  destroyed  anthrax  bacilli 
even  out  of  the  body,  but  their  resistance  to  the  action 
of  the  pneumococcus  could  not  thus  be  explained. 
All  such  cases  Metschnikoff  would  refer  to  phagocyto- 
sis, but  marked  phagocytosis  might  occur  and  death 
yet  follow  ;  indeed,  in  the  case  of  rabbits  infected  with 
anthrax,  the  bacilli  had  been  seen  to  escape  from  the 
interior  of  the  phagocytes  and  multiply  in  the  fluids. 
Again,  in  the  exudation  around  the  seat  of  inoculations 
many  of  the  leucocytes  were  not  phagocytes,  and  the 
exudation  serum  might  be  a  powerful  bactericide. 
Both  agencies  were  involved  in  the  resistance  offered 
to  infection  and  phagocrtosis,  very  rarely  alone.  The 
problem  of  acquired  immunity  was  further  complicated 
by  the  introduction  of  a  new  and  artificial  factor — the 
protective  power  of  the  serum.  An  antitoxin,  as  that 
of  diphtheria  or  tetanus,  neutralized  the  paralyzing  ac- 
tion of  the  toxin  on  the  cells,  allowing  phagocytosis  to 
have  full  play  ;  for  the  serum  of  immunized  animals 
had  no  bactericidal  properties,  and  the  spores  of  tetan- 
us, if  washed  free  from  any  trace  of  toxin  and  intro- 
duced into  the  body  of  a  susceptible  animal,  were 
speedily  ingested  and  destroyed  by  the  phagecytes.  Im- 
munity acquired  toward  the  septic  diseases  was  even 
more  obscure  and  complex,  so  that,  pending  the  results 
of  experiments  which  might  throw  light  on  the  subject, 
it  was  better  to  refrain  from  conjecture. 

The  Section  on  Diseases  of  Children  of  the  British 
Medical  Association. — The  subjects  for  discussion  in- 
;ded  "  Congenital  Syphilitic  Manifestations  in  Bones 
d  Joints,"  introduced  by  the  President  of  the  Sec- 
■-.    and    the    treatment    of    "'  Hernia   in    Children." 
ere  was  a  very  good  attendance  of  members,  and. 
V  subjects  being  mainly  of  a  surgical  nature,  many 
vcll-known    surgeons    contributed    to    the    discussion. 
I  i.e   president,   in   opening   the    proceedings,   gave   a 
rt  review  of  the  work  done  by  the  Secrion  in  past 
rs,  which,  though  including  a  very  wide  range  of 
bjects,  had  still  left  undiscussed  a  large  number  of 
most  important  questions  of  disease  as  occurring  in 
rhildren.     He  was  in  hopes  that  a  section  of  such  im- 
rtance  as  this  had  established  a  permanent  place  in 
proceedings  of   the    Association.     The   president 
-.n  opened  the  discussion  on  "  Congenital  Syphilitic 
Manifestations  in  Bones  and  Joints,"  with  a  highly  in- 
teresting paper  in  which,  after  alluding  to  the  researches 


already  made  in  this  country,  he  proceeded  to  discuss  the 
pathology  and  clinical  features  of  the  atrophic  and  os- 
teophy  tic  varieties  of  the  disease.  The  relation  of  rickets 
to  congenital  syphilis  was  also  very  fully  discussed,  espe- 
cially with  reference  to  the  causation  of  cranial  bosses 
and  cranio  tabes,  and  to  the  occurrence  of  chronic 
effusion  into  joints.  Other  speakers  were  Mr.  Frederic 
Eve,  who  continued  the  discussion  of  these  last-men- 
tioned points ;  Mr.  D'Arcy  Power,  who  quoted  in- 
stances showing  the  difficulty  of  diagnosis  between 
syphilitic  and  tuberculous  joint  disease  ;  Mr.  H.  B. 
Robinson,  who  discussed  the  order  in  which  changes  in 
the  bones  begin  to  appear  ;  Dr.  Thomas  Barlow,  who 
laid  stress  on  the  modification  effected  in  cases  of 
rickets  by  the  existence  of  congenital  syphilis  ;  and 
Mr.  H.  Stansfield  Collier,  who  described  three  cases  of 
syphilitic  effusion  into  joints  unaccompanied  by  any 
previous  bone  disease.  Mr.  Rushton  Parker  (Liver- 
pool) read  an  interesting  paper  on  the  "  Treatment  of 
Hernia  in  Children."  During  the  last  four  years  he 
had  operated  on  forty  cases,  all  males,  and  all  for 
inguinal  hernia,  in  some  cases  double  :  out  of  these  he 
had  had  two  fatalities.  He  preferred  not  to  operate  if 
the  patient  was  under  six  months,  except  in  urgent 
cases.  He  considered  the  chances  of  recurrence  in 
children  very  small.  He  advocated  Macewen's  opera- 
tion as  the  most  secure,  if  not  the  easiest,  method.  He 
laid  great  stress  on  prolonged  rest  in  the  recumbent 
posirion  after  operation — six  weeks,  in  children  over  six 
years  of  age.  Mr.  C.  B.  Lockwood  emphasized  the  diffi- 
culty of  completely  separating  the  sac  from  the  spermatic 
cord  in  young  children.  Mr.  John  Langton  advocated 
treatment  by  truss  only  in  a  large  majority  of  cases. 
Professor  William  Macewen  spoke  of  the  impossibility 
of  dealing  effectively  with  hernia  in  hospital  pracrice 
by  means  of  a  truss — an  opinion  which  was  endorsed 
by  every  speaker  present.  He  considered  the  delicate 
tissues  of  children  were  quite  reliable  for  this  opera- 
tion, and  in  about  thirty  cases  operated  on  by  him  had 
met  with  perfect  success.  Dr.  Ward  Cousins  con- 
sidered the  operation  in  children  over  twelve  months 
old  eminently  satisfactory,  and  gave  an  interesting  ac- 
count of  his  own  method  of  procedure.  Mr.  J.  Mac- 
ready,  Mr.  F.  A.  Southam  (Manchester),  Mr.  H.  P. 
Symonds,  Mr.  Reginald  Lucy  (Plymouth),  Mr.  Darner 
Harrisson  (Liverpool),  and  Mr.  H.  Waterhouse,  all  con- 
tributed to  a  highly  interesting  discussion,  which 
included  methods  of  operation,  kind  of  sutures,  dress- 
ings, etc.,  advocated  by  each  speaker.  The  president 
referred  to  the  frequent  occurrence  of  strangulated 
hernia  in  young  children.  A  case  of  congenital 
syphilis  of  the  tongue  was  shown  at  the  conclusion  of 
the  meeting  by  Mr.  Jackson  Clarke.  Dr.  J.  Kingston 
Barton  introduced  a  discussion  on  the  "  Doses  of 
Various  Remedies  Suitable  for  Children  at  the  Several 
Ages,"  urging  that  sufficient  indication  was  not  given 
in  the  "  British  Pharmacopoeia  "  of  the  various  drugs 
to  which  children  were  peculiarly  susceptible,  and  that 
an  additional  list  of  doses  suitable  for  children  should 
be  given,  having  special  reference  to  age.  Mr.  Barton 
proceeded  to  give  a  list  of  twenty-seven  drugs,  which, 
in  his  personal  experience,  had  required  either  to  be 
increased  or  decreased  much  beyond  the  limits  usually 
recommended.  In  his  experience  belladonna  was  an 
overrated  drug,  and  its  ill-eft'ects  were  often  more 
marked  than  the  good  it  did.  He  advocated  a  smaller 
dose.  With  regard  to  a  general  rule  of  dosage,  he 
recommended  one-twelfth  of  an  ordinary  dose  for  a 
child  one  year  old,  and  for  under  that  age  a  reduction 
reckoned  by  the  months  of  the  child's  life.  The 
president,  in  commenting  on  the  use  of  chloroform  as 
an  anaesthetic  for  young  children,  expressed  his  prefer- 
ence for  ether  whenever  possible.  Dr.  A.  Foxwell  said 
that  he  agreed  with  Mr.  Barton  in  advocating  small 
and  frequent  doses  as  a  rule.  Dr.  Dawson  Williams 
said  that  he  altogether  doubted  the  age-limit  in  the 
administration   of  drugs.      In   his   experience  it  was 


500 


MEDICAL    RECORD. 


[October  5,  1895 


useless  to  give  too  minute  doses ;  especially  in  the 
administration  of  antiseptics  and  of  mercury,  he  be- 
lieved in  large  doses.  Dr.  Leech  (Manchester)  pointed 
out  that  the  doses  in  the  "  Pharmacopoeia  "  represented 
a\erage  doses.  Arithmetical  calculations  were  of  very 
little  value ;  physiological  considerations  were  more 
important.  Dr.  N.  J-  Tirard  said  that  the  main  con- 
siderations should  be  the  nature  of  the  patient  and  of 
the  disease,  as  well  as  the  purpose  for  which  the  drug 
was  employed.  After  some  discussion,  the  following 
resolution  was  carried  :  "  That  this  Section  thinks  it 
desirable  that  in  the  new  edition  of  the  '  British  Phar- 
macopoeia '  the  maximum  doses  of  powerful  drugs 
suitable  for  children  at  various  ages  should  be  in- 
dicated." Mr.  E.  Cautley  read  a  paper  on  the  "  Value 
of  Trephining  in  Tuberculous  Meningitis."  Mr.  Her- 
bert Waterhouse  and  Mr.  D'Arcy  Power  continued  the 
discussion.  Mr.  Nicholas  Grattan  (Cork)  showed  an 
apparatus  for  osteoclasis,  and  Mr.  C.  W.  Cathcart 
(Edinburgh)  showed  a  simple  form  of  milk  sterilizer. 
Mr.  C.  B.  Lockwood  reported  a  case  of  hernia  of  the 
ovary  in  an  infant  with  torsion  of  the  pedicle.  Dr. 
J.  Walter  Carr  read  a  protest  against  the  term  "  con- 
sumptive bowels,"  and  Mr.  Telford  Smith  com- 
municated the  "  After-history  of  Two  Cases  of  Crani- 
ectomy." A  vote  of  thanks  to  the  president,  proposed 
by  Mr.  D'Arcy  Power  and  seconded  by  Mr.  C.  W. 
Cathcart,  ended  the  proceedings.  —  British  Medical 
Journal. 

A  New  Treatment  for  Fever. — A  new  curati\e  treat- 
ment has  been  discovered  by  a  Transvaal  doctor.  Hav- 
ing noted  the  fact  that  milk  absorbs  poisonous  germs 
from  a  bucket,  he  decided  that  it  might  be  possible  to 
turn  this  germ-absorbing  power  to  a  therapeutic  ac- 
count. He  put  his  ideas  to  the  test,  and  now  asserts 
that  he  has  cured  persons  of  small-pox,  fevers,  diph- 
theria, and  other  maladies  by  simply  wrapping  them  in 
milk  sheets.  The  patient  is  laid  on  a  mattress  covered 
with  blankets,  and  is  packed  in  a  sheet  just  large 
enough  to  envelop  the  body.  This  sheet  has  first  been 
saturated  in  a  pint  and  a  half  of  warm  milk,  and  is  ap- 
plied to  the  body  without  wringing.  After  this  treat- 
ment, which  lasts  about  an  hour,  the  patient  is  sponged 
with  warm  water,  or  is  put  into  a  warm  bath. — Medical 
Press  and  Circular. 

A  Claim  to  Priority  in  Vaccination. — In  the  Uges- 
krift  for  Lager  Dr.  Friis  advances  a  claim  on  behalf 
of  a  Holstein  schoolmaster  named  Peter  Plett,  to  the 
honor  of  priority  in  the  discovery  of  vaccination.  Jen- 
ner's  first  vaccination  was,  he  says,  performed  on  ^lay 
14.  1796,  but  Plett  had  already  done  it  in  1791.  The 
latter  was  a  tutor  in  a  family  at  Schonweide,  in  Hol- 
stein, in  1790,  and  while  there  he  heard  that  it  was  a 
matter  of  common  knowledge  that  the  milkmaids  who 
had  previously  been  infected  with  cow  -  pox  never 
caught  small-pox.  Having  by  chance  seen  a  medical 
practitioner  perform  inoculation,  Plett  conceived  the 
idea  that  cow-pox  lymph  might  be  used  for  the  purpose 
of  conferring  protection  against  small-pox.  In  1791  he 
was  at  Hasselburg,  and  an  epidemic  of  cow-pox  occur- 
ring among  the  cows  on  a  farm,  he  told  the  children 
under  his  charge  to  rub  their  hands  with  matter  from 
the  pustules  ;  as  no  result  followed  he  himself  vacci- 
nati  d  three  of  them  without  the  consent  or  knowledge 
of  their  parents.  He  used  a  table-knife  for  the  purpose, 
making  the  incisions  on  the  back  of  the  hand,  between 
the  thumb  and  the  forefinger.  The  operation  was  suc- 
cessful, and  a  year  later,  when  the  other  children  of 
the  family  suffered  from  small-pox,  the  three  who  had 
been  vaccinated  by  Plett  remained  free  from  the  dis- 
ease. There  appears  to  be  no  record  of  his  having 
performed  any  other  vaccinations. 

Professor  Heim  on  Suicide.— What  ought  to  be  done 
by  the  Swiss  authorities,  we  wonder,  to  Professor  Heim, 
the  savant,  for  his  speech  at  the  Alpine  Club  in  Zurich  ? 


Only  a  week  or  two  ago  it  was  decreed  that  the  Swiss  press 
should  be  silent  concerning  suicides,  for  newspaper  re- 
ports of  suicides  gave  a  stimulus  to  some  people  to  go 
and  do  likewise.  And  here  is  a  Swiss  scholar  setting 
forth  at  a  public  meeting,  and  with  reporters  well  to  the 
fere,  the  fact  that  one  of  "  the  most  convenient,  elegant, 
and  agreeable  "  of  all  manners  of  death  is  that  which 
follows  a  fall  from  some  Alpine  height.  There  is 
neither  physical  nor  moral  suffering,  in  Professor 
Heim's  opinion,  in  being  hurled  through  space  ;  only 
a  "  delicious,  fine  taste  of  the  celestial  beatitudes." 
But  since  the  hurling  through  space  is  only  part  of  an 
Alpine  accident,  it  would  be  interesting  to  know  a  little 
more  of  the  sensations  which  result  when  the  body  of 
the  "accidentee  "  comes  in  contact  with  the  rocks,  and 
when  he  arrives  at  the  bottom  of  a  precipice,  mangled 
and  bleeding,  and  not  yet  dead.  It  will  be  asked  how 
Professor  Heim  obtained  his  information  on  this  sub- 
ject. By  plebiscite,  of  course.  But  whether  it  is  quite 
fair  to  conclude  from  the  testimony  of  those  who  have 
recovered  after  an  accident  that  dying  by  Alpine  acci- 
dent is  une  aiinable  facon  de  mourir,  is  to  be  doubted. 
A  more  satisfactory  way  would  perhaps  be  to  consult 
the  spirits  who  have  been  despatched  into  Borderland 
after  the  chute.  We  commend  the  idea  to  Mr.  Stead. — 
The  Jl'estmiuster  Gazette. 

The  Sensation  of  the  Stomach  and  Disordered  Diges- 
tion.— Dr.  Sollier  has  made  a  study  of  ner\-ous  dyspep- 
sias. He  says  that  the  sensory  innervation  of  the 
stomach  derived  from  the  sympathetic  may,  when  dis- 
turbed, lead  to  modification  in  the  gastric  chemistry. 
The  secretory  functions  of  the  stomach  depend  on  the 
nervous  system  as  well  as  on  the  state  of  the  glands. 
The  sensation  of  the  stomach  may  be  reflex  or  direct. 
{The  British  Medical  Journal.)  The  former  is  better 
known  ;  it  leads  to  the  movements  of  the  stomach  and 
also  to  secretion.  If  the  stomach  is  insensitive  to  the 
contact  of  food-stuffs,  the  glands  are  not  put  into  ac- 
tion. The  stomach  has  also  a  sensation  proper  to  itself, 
and  thus  heat  and  cold  can  be  appreciated.  This  sen- 
sation is  not  so  obtuse  as  has  been  thought.  The  most 
special  sensation  of  the  stomach  is  in  respect  to  food. 
The  sensation  of  hunger  disappears  when  the  stomach 
becomes  anaesthetic.  Thus,  without  its  own  proper 
sensation,  there  could  be  no  feeling  of  emptiness,  as  in 
hunger,  nor  yet  of  satiety,  and,  without  its  reflex  sen- 
sation, no  secretion  and  no  motion.  There  is  no  sub- 
ordination of  one  form  of  sensation  to  the  other.  In 
nervous  dyspepsia  there  may  be  a  modification  in  the 
gastric  chemistry  or  the  sensation  of  the  stomach  may 
be  involved.  Clinically,  this  is  best  studied  in  hysteri- 
cal anorexia,  .\ssimilation  appears  to  improve  when 
hunger  renirns,  and  the  feeling  of  hunger  reappears 
only  with  the  restoration  of  the  sensation  of  the  sto- 
mach. The  anesthesia  may  involve  only  the  super- 
ficial parts  of  the  mucous  membrane,  or  penetrate 
deeper  when  the  digestive  troubles  are  more  marked. 
The  author  refers  to  a  superficial  cutaneous  an.tsthesia 
corresponding  to  the  region  of  the  stomach.  If  the 
mechanical  functions  are  also  involved  there  may  be 
gastric  atony.  The  same  condition  of  the  stomach  is 
noted  in  melancholia  and  hypochondriasis.  When  the 
treatment  is  directed  to  the  nervous  system  these  cases 
improve  rapidly  without  any  special  regulation  of  diet. 

Insanity  in  the  Medical  Profession. — It  is  not  scien- 
tifically unwarrantable  or  unreasonable,  from  a  com- 
mon-sense point  of  view,  to  maintain  that  the  doctor 
should  be  judged  by  the  effect  his  physic  has  upon 
himself,  and  the  parson  by  the  character  which  his  re- 
ligion produces  in  himself.  We  ought  to  admit  that  an 
unhealthy  medical  man  is  an  evidence  of  unsoundness 
either  in  the  medical  theories  of  the  times,  or  in  the 
use  to  which  he  himself  puts  them.  {The  Hospital.") 
This  is  but  fair,  and  if  it  be  considered  rather  a  tran- 
scendental position  to  take  up  at  the  present  moment,  one 
can  hardly  doubt  that  it  will  be  regarded  as  a  common- 


October  5,  1895] 


MEDICAL    RECORD. 


501 


place  in  the  more  cultured  and  rational  times  which  lie 
in  the  womb  of  the  centuries  that  are  before  us.  Look- 
ing at  certain  aspects  of  medical  insanity  from  the 
stand-point  of  high  mental  detachment,  we  cannot  feel 
altogether  happy  at  the  figure  cut  by  our  profession  in 
the  lunacy  returns  of  recent  years.  Lunacy  varies  with 
callings,  as  the  recent  and  previous  reports  of  the  com- 

'  missioners  amply  prove.  Theoretically,  there  ought  to 
be  proportionately  fewer  lunatics  among  doctors  than 

t  among  any  other  class,  because  doctors  know  so  well 
the  causes  and  the  means  of  prevention  of  lunacy. 
But  what  are  the  facts  ?  The  facts  are  that  the  medi- 
cal profession  ranks  higher  in  the  production  of  luna- 

I  tics  than  all  other  classes  e.xcept  two.  Costermongers 
and  pedlers  rank  highest  of  all,  and  then  follow  wool- 
staplers  and  cloth  merchants.  The  very  next  in  order 
are  physicians,  surgeons,  and  general  practitioners. 
The  actual  figures  are  even  more  striking  than  the  bald 
statement  of  the  fact.  Thus,  in  ever)-  thousand  coster- 
mongers and  pedlers  there  were  20.1  lunatics  in  the  quin- 
quennium ending  with  1S93.  In  the  same  quinquennium 
there  were  18.2  lunatics  among  woolstaplers  and  cloth 
merchants,  and  15.S  among  physicians,  surgeons,  and 
general  practitioners.    In  marked  contrast  to  these  dam- 

I  aging  figures  are  the  figures  relating  to  railway  laborers, 
navvies,  and  miners.  Those  sturdy  sons  of  toil  only 
furnished  4.4  of  their  numbers  to  the  ranks  of  lunacy 

I  in  the  quinquennium.  We  hold  that  as  science  ad- 
vances, especially  medical  science,  lunacy  should  di- 
minish, not  increase  ;  and  that  the  sanest  and  soundest 
of   all   classes    should   be    doctors,  whose   business   is 

I  "health."  So  far  the  facts  are  against  us.  But  if  we 
are  to  continue  in  the  front  ranks  of  practical  science 
we  must,  without  delay,  find  some  means  of  so  con- 
ducting our  own  profession  as  to  at  least  preserve  our 
sanity  as  well  as  our  health  and  life.  "  Physician,  heal 
thyself  I  "  is  a  verj'  significant  dictum  indeed. 

A  Severe  Case. — Two  weeks  ago  I  was  summoned 
to  the  bedside  of  Djoahnne  Sdtleometzhler.     The  in- 
volute and  labyrinthinate  tangle  of  his  symptoms  made 
me  suspect  at  first  that  he  had  absorbed  his  own  name. 
But  further  examination  convinced  me  that  he  was  the 
victim    of    typhomalariopneumophthisicotrychinoteta- 
I    noataxionephreticosplenitis.     Owing  to  the  ubiquity  of 
I    pathogenic  bacilli,  antiseptics  are  always  indicated,  so 
i    I  exhibited  calcium  betanaphtholalphamononosulphon- 
'    ate.     As  the  patient  suffered  from  severe  non-localized 
pain  I  gave  orthooxyethylanamonobenzoylamidoquino- 
line  combined  with  salicylaldehydmethylphenylhydra- 
zine.     For  his  insomnia  I  gave  trichloraldehydphenyldi- 
methylpyrazolene. 

His  wife  asked  me  what  ailed  him,  and  what  I  was 
giving  him.  I  told  her,  and  she  said  "yes,"  and  turned 
very  pale. 

Upon  examining  him  on  the  next  morning  I  became 
convinced  that  the  vital  forces  had  misconstrued  the 
remedies,  and  that  a  congerie  of  retro-absorptions  had 
resulted.     I  then  wrote  out  the  following  prescription  : 

Tetrahydrot)etanaphlholamine, 
Sodium  thioparatoluidinesulphonate, 
Orthosulphamidobenzoic  anhydride, 

.\inidoacetoparapheneiidine aa  3  j. 

Nf.     Sig. :  A  teaspoonful  every  h<^ur. 

When   the   wife  presented   the   [irescription    to    tlie 
druggist  he  instantly  dropped  dead  !     The  patient  is 
up  and  about,  but  something  is  wrong  with  his  Brocas 
,    convolution — he  mutters  in  a  multi-syllabic  lingo  that 
i    is  intelligible  only  to  modern  pharmacal  chemists,     1 
'    am  in  hiding  where  the  spiral  melody  of  the  woodbine 
that  twineth  blendeth  ever  s«-eet,  low,  soothing,  mur- 
murous quadrisyllable  rhythmic  rune  of  the  gentle  poly- 
gonum punctatum. — Medical  Gleaner. 

Chyle  Cysts  of  the  Mesentery. — Dr.  W.  H.  Wenning 

says  that  the  origin  of   these  cysts  is  very  uncertain. 

I    In  some  instances  undoubtedly  rupture  of  a  Ijmphatic, 

i    in  consequence  of  an  accident  or  unusual  exertion,  may 


lead  to  the  formation  of  a  cyst.  Here,  in  all  probability, 
the  fluid  effused  between  the  layers  of  the  mesentery 
causes  some  irritation  and  the  formation  continues  to 
separate  the  layers  from  each  other.  In  other  instances 
a  rupture  may  lead  to  effusion  of  chyle  into  the  free 
abdominal  cavity.  Single  cysts  might  very  easily  arise 
in  the  first-mentioned  manner.  When  there  are  multi- 
ple cysts,  however,  the  origin  is  more  probably  due  to 
stenosis  of  the  thoracic  duct.  Mendes  de  Leon  thinks 
that,  although  a  stricture  of  this  nature  might  cause 
widening  at  the  bottom  of  the  duct,  it  does  not  suffi- 
ciently explain  the  formation  of  a  cyst.  Besides  this,, 
in  cases  of  stenosis,  collateral  channels  for  the  convey- 
ance of  chyle  into  the  blood  have  been  observed. 
Virchow,  Rokitansky,  and  Kilian  have  demonstrated 
the  fact  that  the  entire  closure  of  the  thoracic  duct 
may  give  rise  to  considerable  enlargement  and  crowd- 
ing up  of  the  chyle  vessels.  From  the  nature  of  the 
conditions  found  in  my  case  I  am  inclined  to  believe 
that  stenosis  and  obliteration  of  the  thoracic  duct  was 
the  cause  of  the  formation  of  these  numerous  cysts. 
Drs.  Jones  and  Cleveland,  who  made  an  autopsy  im- 
mediately after  death,  were  unable  to  find  the  thoracic 
duct.  There  were  no  cysts,  in  the  true  sense  of  the 
word,  if  we  look  upon  the  sac  as  an  adventitious  struct- 
ure, for  the  chyle  seemed  to  be  surrounded  by  the 
walls  of  the  mesentery  alone.  When  this  membrane 
was  pierced,  or,  as  I  have  shown  above,  simply  touched, 
it  would  collapse.  There  was,  however,  6\-idence  of 
considerable  inflammation  of  the  serous  membrane. — 
Lancet-Clinic. 

Honey  ia  Erysipelas.— Dr.  C.  E.  Hayward,  of  Crop- 
sey.  111.,  writes  ;  ''  Several  years  ago,  while  treating 
some  bad  cases  of  erysipelas,  a  lady  asked  me  why  I  did 
not  use  the  remedy  they  used  in  Montana.  I  asked  her 
what  that  was  ;  she  said  honey.  I  did  use  it  and  found 
it  very  effective,  and  since  then  have  used  it  in  every 
case  of  erysipelas  on  any  part  of  the  body.  •  My  first 
treatment  is  the  external  application  of  honey.  I  shave 
the  head  and  face  if  necessary,  spread  the  honey 
thickly  on  cloth,  cut  holes  for  the  eyes  if  the  face  is 
the  part  affected,  and  change  the  application  every 
three  or  four  hours.  I  have  never  had  it  fail  to  relieve 
the  pain,  heart  swelling,  and  nausea,  and  to  shorten 
very  much  the  attack.  I  also  give  internally  the  usual 
remedies  for  reducing  the  fever  and  stimulating  the 
emunctories.  Three  or  four  days  usually  suffice  to 
bring  about  convalescence  under  this  treatment.  I 
could  report  numerous  cases,  but  would  rather  every 
physician  would  give  it  a  trial,  and  I  am  sure  he  would 
find  a  practical  addition  to  his  armamentarium." 

An  Anti-vivisectionist  and  the  ftueen.  of  Italy. — 
While  the  king  and  queen  of  Italy  were  returning  from 
some  ceremony  in  connection  with  the  celebration  of 
the  occupation  of  Rome,  an  officer  of  the  Sicilian  in- 
fantry tried  to  mount  the  steps  of  the  royal  carriage,  at 
the  same  time  addressing  some  words  to  the  queen. 
It  was  thought  that  he  was  appealing  for  amnesty  for 
the  leaders  of  the  Sicilian  riots,  whom  the  king  had 
refused  to  pardon.  The  officer  was  arrested  and  taken 
to  the  barracks,  where  he  was  closely  questioned  and 
declared  himself  to  be  an  anti-vivisectionist,  saying  that 
his  sole  object  in  addressing  the  queen  was  to  beg  her 
to  use  her  influence  in  prohibiting  vivisection.  The 
man  was  an  epileptic. 

In  Pre-vaccination  Days. — A  contemporary  points 
out  that  at  the  time  of  the  announcement  of  vaccina- 
tion by  Jenner,  small  pox  caused  more  than  one-tenth 
of  all  the  deaths  of  the  human  race.  It  may  be  added 
that  50.000,000  people  died  in  Europe  from  small-pox 
during  the  eighteenth  century.  In  the  sixteenth  cen- 
tury the  disease  appeared  in  Mexico,  and  3,500,000  of 
the  pojjulation  yielded  up  their  lives  in  a  few  years, 
leaving  some  provinces  almost  depopulated.  In  1707, 
in  Iceland,  28,000  died  in  one  year,  the  entire  popula- 


502 


MEDICAL    RECORD. 


[October  5,  1895 


tion  being  but  50,000.  Seventy  per  cent,  of  the  peo- 
ple of  Greenland  died  of  small-pox  in  1734.  Macaulay, 
the  historian,  observed  that  the  disease  was  always  pres- 
ent, filling  the  churchyards  with  corpses,  and  leaving 
on  those  whose  lives  it  spared  the  hideous  traces  of 
its  virulence.  "If  a  modern  traveller,"  said  one  ob- 
server, "  could  be  transported  to  London  in  the  early 
part  of  the  present  century,  no  peculiarities  of  archi- 
tecture, dress,  or  behavior  would  be  so  conspicuous  as 
the  enormous  number  of  pock-marked  faces  he  would 
encounter  at  every  turn."  Neither  high  nor  low,  rich 
nor  poor,  escaped  the  ravages  of  small-pox  in  the  pre- 
vaccination  days. —  The  Medical  Press. 

Literature  for  Malingerers. — The  Rev.  Harry  Jones 
tells  a  story  drawn  from  Portland  Prison  which  is 
worth  reproducing.  On  going  into  the  library  Mr. 
Tones  asked  what  were  the  favorite  books  of  the  prison- 
ers, and  was  told,  to  his  surprise,  that  Buchan's  "  Do- 
mestic Medicine  "  was  more  frequently  asked  for  than 
any  other.  As  there  was  a  surgeon  always  ready  to 
attend  to  the  ailments  of  the  convicts,  the  reason  for 
this  searching  after  medical  knowledge  was  difficult  to 
find  ;  but  he  afterward  learned  that  the  description  of 
the  symptoms  of  illness  was  carefully  studied  by  the 
inmates  of  the  prison  as  a  scientific  guide  in  the  sham- 
ming of  sickness.  A  successful  malingerer  was  relieved 
of  his  tasks,  and  obtained  the  coveted  idle  time  on  sick 
leave. — British  Medical  Journal. 

The  Rights  of  Inebriates. — The  report  of  the  Scot- 
tish Departmental  Committee  appointed  to  inquire  as 
to  the  further  legislation  necessary  to  deal  with  habitual 
inebriates,  holds  that  they  should  be  regarded  as  wholly 
irresponsible.  It  denies  the  inebriate's  right  to  ad- 
minister his  property,  says  he  ought  not  to  be  allowed 
to  discipline  his  family,  and  recommends  legislation  for 
him  based  upon  the  assumption  that  he  is  a  lunatic  who 
ought  to  be  placed  under  restraint,  whether  he  likes  it 
or  not.  The  report  classes  the  victims  of  opium  and 
other  drugs  as  habitual  drunkards,  and  proposes  to 
give  their  relatives  the  power  of  putting  them  under 
restraint.  Gold-cures  and  other  alleged  specifics  are 
summarily  denounced,  and  their  use  will  be  prohibited 
if  the  recommendation  of  the  committee  be  accepted 
and  made  a  law  by  Parliament. 

Dr.  Kitasato  is  not  only  the  most  brilliant  scientific 
investigator  in  Japan,  but  one  of  the  most  original 
biologists  of  the  present  day  of  any  nation.  He  worked 
for  many  years  with  Koch  at  Berlin  ;  and  last  year, 
when  the  plague  was  devastating  Hong  Kong,  he  and 
Dr.  Aoyana  discovered  the  bacterial  cause  of  the 
plague,  and  were  thereby  instrumental  in  arresting  its 
ravages.  He  has  been  extremely  successful  in  carry- 
ing out  the  antitoxin  treatment  of  diphtheria,  and  out 
of  34  cases  treated  by  him  31  have  recovered.  He  is 
at  present  engaged  in  carrying  out  a  series  of  experi- 
ments on  leprosy  with  the  most  satisfactory  results.  If 
it  is  a  fact  that  Dr.  Kitasato  is  on  the  road  to  discover- 
ing not  only  the  cause,  but  the  cure,  of  leprosy,  he  will 
confer  an  immense  benefit  on  a  long-suffering  section 
of  the  human  race.  Japan  has  always  been  celebrated 
for  generously  acknowledging  the  services  of  her  men 
of  genius  in  art  and  literature,  and  it  is  gratifying  to 
learn  that  Dr.  Kitasato's  discoveries  are  looked  upon 
as  contributing  to  the  national  glory,  and  that  the  gov- 
ernment has  unanimously  voted  him  a  sum  of  money  to 
be  devoted  to  the  laboratory  superintended  by  him. — 
British  Medical  Jonrnal. 

Circulatory  Lesions  in  Influenza. — Those  of  the  pro- 
fession who  have  seen  any  considerable  number  of  cases 
of  influenza  cannot  fail  to  have  been  struck  with  the  com- 
parative frequency  of  alarming  cardiac  complications, 
often  occurring  during  convalescence.  Dr.  Cathomas 
refers  to  these  circulatory  lesions,  and  mentions  the 
following  varieties  met  with  :  Venous  thrombosis,  due 
to  phlebitis,  four  cases  of  arterial  embolism,  all  fatal, 


and  involving  respectively  the  popliteal,  femor.u, 
brachial,  and  Sylvian  arteries.  Arterio-thrombosis  oc- 
curred in  seven  cases,  exclusive  of  several  in  which 
the  Sylvian  artery  was  involved.  One  patient,  aged 
sixty-four,  in  hospital  for  extensive  eczema,  developed 
influenza  and  was  seized,  during  the  attack,  with  dif- 
ficulty of  breathing  and  later  with  severe  pain  in  the 
right  arm  ;  the  axillary  artery  was  obstructed  and  no 
pulse  could  be  felt  in  the  right  radial  artery.  After 
death  an  adherent  clot  was  found  in  the  axillary  artery, 
and  a  second  one  in  the  aorta  at  the  origin  of  the  in- 
nominate. In  conclusion,  the  author  is  of  opinion 
that  vascular  obstruction  may  occur  in  influenza  as  in 
other  infective  diseases  ;  and  that  it  may  be  due  to 
embolism  of  arteries  or  veins.  Arterio-thrombosis  is, 
happily,  a  rare  complication  of  influenza,  and  may 
begin  suddenly  like  embolism,  while  the  differentia', 
diagnosis  between  embolism  and  thrombosis  may  \<t 
very  difficult. — Medical  Times  and  Gazette. 

Water-borne  Cholera. — In  the  Annual  Report  of  the 
Chemical  Ex-aminer  and  Bacteriologist  to  the  Govern- 
ment of  India  for  1894,  Dr.  Hankin  refers  to  a  re- 
markable instance  of  exemption  of  one  company  in  a 
regiment  suffering  from  cholera.  The  East  Lanca- 
shire Regiment  consisted  of  companies  A,  C,  E,  F,  G, 
H.  When  the  cholera  broke  out  in  the  cantonments 
the  regiment  was  transferred  to  the  Kokrail  Cholera 
Camp.  Throughout  the  epidemic  the  E  company  re- 
mained immune  from  attack,  though  the  conditions  of 
life  were  identical  with  those  of  other  companies,  and 
their  barracks  were  almost  surrounded  by  those  of 
companies  who  suffered  severely  from  cholera.  At 
first  no  possible  explanation  of  this  escape  of  one  com- 
pany could  be  found.  "  On  cross-examining  the  color- 
sergeant  of  this  company,"  says  Dr.  Hankin,  "  the 
mystery  at  first  seemed  to  deepen,  for  he  roundly  as- 
serted that  the  men  of  his  company  had  exactly  the 
same  supplies  of  food  and  water  as  the  men  of  other 
companies.  But  on  his  being  pressed  as  to  how  he 
knew  that  the  water-supply  was  the  same  as  that  of 
other  companies  he  replied  that  he  ought  to  know,  if 
anybody,  as  he  boiled  it  himself .'  It  is  needless  to  say 
that  on  making  inquiries  we  found  that  this  sanitary 
precaution  had  not  been  taken  by  the  color-sergeants 
of  other  companies." 

"  Successful  Cancer  Institute." — The  following  curi- 
ous reading  notice  appeared  recently  in  the  editorial 
columns  of  a  medical  contemporary  :  "  From  several 
reports  that  we  have  seen  recently  in  our  exchanges  it 

seems  that   Dr. ,  who  has  an  institute  at ,  is 

having  remarkable  success  in  the  treatment  of  cancer 
and  malignant  growths.  He  does  not  resort  to  knife 
or  other  surgical  means,  but  treats  entirely  locally  and 
constitutionally." 

The  Cocada  is  a  measure  of  distance  employed  by 
the  Peruvian  Indians.  It  is  the  distance  that  an  In- 
dian cargo-bearer  can  walk  under  the  stimulating  efl'ect 
of  the  coca-leaf.  He  finds  that  the  nervous  excitation 
begins  in  eight  to  ten  minutes  after  introducing  a  fresh 
quid  of  leaves  into  the  mouth,  and  lasts  from  thirty- 
five  to  forty  minutes.  In  this  time  the  Indian  will  pass 
over  three  kilometres  on  a  level  road,  and  two  kilo- 
metres on  ascending  ground.  At  the  end  of  each  co- 
cada the  Indian  stops  to  rest  and  regale  himself  with  a 
fresh  chew  of  coca.  Along  the  Peruvian  highways  are 
definite  resting-places,  established  by  this  custom,  also 
called  cocadus. 

Ocular  Headaches. — Dr.  Landman  describes  the 
characters  and  peculiarities  of  the  forms  of  headache 
which  depend  upon  uncorrected  errors  of  refractioij. 
Migraine  is  rarely  caused  by  such  errors,  even  when  it 
accompanies  them,  and  the  headaches  caused  by  ocu- 
lar defects  are  usually  continuous.  They  are  more  fre- 
quent in  women  than  in  men,  and  can  generally  be 
localized,  a  diffused,  continuous  headache  being  usu- 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Su/gery 


Vol.  48,  No.  15. 
Whole  No.  1301. 


New  York,  October  12,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


A  PRELIMINARY  REPORT  ON  THE  USE  OF 
OXYGEN  GAS  WITH  ETHER  FOR  AN-«S- 
THESIA. 

By  carter   S.   COLE,    M.D., 

INSTSUCTOR   IS   sURGERY,    NEW     YOSK    POST-GRADITATS  'MEDICAL    SCHOCL  AND 
HOSPITAL, 

In  compliance  with  the  solicitations  of  a  number  of 
gentlemen  who  have  seen  ether-oxygen  anaesthesia,  and 
in  order  to  facilitate  the  introduction  of  what  seems  to 
promise  some  interesting  and  useful  advantages  in  ether 
narcosis,  by  gi^■ing  the  methods  which  have  so  far  proved 
successful  and  satisfactory  in  our  own  hands,  I  am  led 
to  offer  this  preliminar)-  report  on  the  observations 
made  thus  far  in  a  very  small  number  of  cases. 

The  idea  of  employing  oxygen  was  suggested  by  Mr. 
T.  Preston  Carson,  a  chemist,  who  had  never  seen 
an  ether  narcosis.  The  occasion  arose  a  short  time 
since  when  he  heard  a  friend  speak  of  the  "  bluing  "  that 
had  attended  an  etherization  he  had  witnessed.  The 
details  of  its  use  have  been  worked  out  independently 
by  Dr.  Markoe  and  myself.  Dr.  Francis  H.  Markoe 
was  approached  on  the  subject  and  consented  to  give 
the  matter  a  trial.  It  was  after  the  latter  had  used 
ether  with  oxygen  in  three  cases,  none  of  which  I  saw, 
that  Mr.  Carson  mentioned  the  matter  to  me  and  asked 
me  to  experiment  on  similar  lines.  This  I  readily 
agreed  to  do,  the  first  thing  that  was  necessary  being 
some  proper  apparatus  for  the  administration  ;  and  to 
the  task  of  devising  the  same  I  immediately  applied 
myself,  with  the  result  herein  related. 

The  cone  is  a  simple  tin  box  (Fig.  i),  shaped  like  a 
coffee  can.     In  the  middle  of  the  top  a  tin  tube  three 
r.  inches  long  is  obliquely  in- 

I  q  serted,  half   remaining   out- 

side. Two  rubber  tubes  leave 
the  bottle,  four-fifths  full  of 
ether,  one  of  which  fits  on  the 


/^ 


/^. 


I  ^ 


tube  in  the  top  of  the  cone,  the  other  on  the  oxygen 
tank.  The  bottle  used  has  been  the  "  wash  "  bottle 
ordinarily  employed  in  giving  oxygen  gas.  An  ad- 
ditional opening  in  the  top  of  the  cone  which  is 
stoppered  by  a  cork  provides  for  the  addition  of  ether 
without  removing  the  cone  from  the  face.  A  per- 
forated platform  (Fig.  2)  held  in  place  by  a  remov- 
able wire  frame  (Fig.  3)  keeps  the  gauze  and  cotton 
away  from  the  patient's  mouth,  and  a  rubber  mouth- 
piece that  fits  the  cone  and  the  patient's  face  completes 


the  apparatus  (Fig.  4).  The  method  first  tried  was  to 
pass  the  oxygen  through  the  regular  wash  bottle,  then 
through  the  ether  itself  in  another  bottle,  and  thence 
through  a  tube  to  the  cone,  into  which  gauze  and  cot- 
ton moistened  with  ether  had  been  placed.  Later  the 
wash  bottle  was  omitted  and  the  tube  run  from  the  oxy- 
gen tank  to  the  bottle  of  ether,  and  the  other  tube  di- 
rect to  the  cone,  the  gauze  and  cotton  still  being  kept 
in  the  cone.  Next  the  gauze  and  cotton  were  left  out 
of  the  cone  and  the  oxygenized  ether  passed  into  the 


cone.  In  some  cases  ether  was  added  several  times  to 
the  gauze  in  the  cone  during  the  anaesthesia  ;  in  some 
none  was  added.  The  history  of  each  case  gives  the 
details  of  the  variations  of  methods. 

The  amount  of  gas  used  has  probably  averaged  about 
a  gallon  a  minute,  although  it  has  been  impossible  to 
secure  the  gauge  for  a  number  of  the  cases.  The 
amount  of  ether  used  has  for  an  adult  averaged  about 
six  ounces  an  hour,  and  half  this  quantity  for  a  child. 
In  the  case  of  one  child  less  than  three  ounces  of  ether 
was  used  for  over  an  hour's  etherization  (Case  IX.). 
In  the  case  of  one  man  (Case  YIII.)  less  than  seven 
ounces  for  an  hour  and  a  half's  etherization. 

The  longest  time  for  complete  anaesthesia  in  any  of 
my  own  cases  has  been  fifteen  minutes  ;  the  shortest  a 
little  less  than  three  minutes.  The  time  of  recovery 
has  been  from  fifteen  to  fifty  minutes.  Salivation 
that  necessitated  a  cleansing  out  of  the  pharj'nx  has 
occurred  in  only  one  case.  Vomiting  has  not  been 
serious  or  troublesome  in  any  cases,  and  in  the  large 
majority  not  even  nausea  has  attended  the  etherization 
or  the  recover)'.  The  effect  of  increasing  the  flow  of 
oxygea  has  been  to  increase  the  rapidity  of  the  heart's 
action  and  vice  versa.  Respiration  has  been  easy  and 
comfortable,  and  no  struggling  nor  suffocation  has  been 
present.  The  stage  of  excitement  has  been  moderate 
and  never  troublesome.  The  color  has  been  uniformly 
excellent,  and  not  in  a  single  instance  has  any  "  bluing  " 
been  observed.  In  the  cases  in  which  the  temperature 
has  been  taken  no  change  has  been  noted.  The  largest 
amount  of  ether  used  in  any  one  case  has  been  eight 
ounces  (Case  I\'.) ;  the  smallest  less  than  three  ounces 
for  an  hour's  narcosis. 


5o6 


MEDICAL    RECORD. 


[October  12,  189  = 


These  then  are  the  facts  that  have  been  thus  far  ob- 
served. If  each  operator  will  compare  the  amount  of 
ether  used,  the  time  required  for  narcosis,  the  frequent 
absence  of  suffocating,  salivation,  struggling,  nausea, 
and  vomiting  with  the  conditions  that  now  attend  his 
etherization,  he  will  then  be  able  to  draw  a  conclusion 
as  to  the  value  of  the  method. 

For  hospital  work  a  slight  increase  in  the  cost  as 
compared  with  regular  ether  narcosis  may  be  an  im- 
portant factor  in  delaying  the  routine  use  of  such  a 
combination  ;  if  the  apparent  advantages  obtain  in  the 
experience  of  others  it  will  be  difficult  to  administer 
ether  to  private  patients  without  oxygen.  At  least  it 
will  take  but  a  short  time  for  others  to  test  the  matter, 
and  the  results  of  their  experience  will  be  of  great  ser- 
vice, whatever  be  the  outcome. 

I  subjoin  a  report  of  the  cases  in  which  I  have  so  far 
been  enabled,  by  the  courtesy  of  the  gentlemen  named, 
to  experiment  with  the  method.  Dr.  Markoe  has 
kindly  furnished  through  one  of  his  house  staff  at  St. 
Luke's  Hospital,  Dr.  Squier.  a  record  of  his  cases  to  be 
published  with  my  own.  and  they  are  also  given. 

These  then  are  the  paraphernalia  :  a  pure  oxygen  and 
a  good  ether.  A  tube  not  more  than  two  feet,  leading 
from  the  cone  to  the  bottle  of  ether,  and  another  from 
the  same,  as  long  or  short  as  may  be  desirable,  leading 
to  the  tank  of  oxygen. 

A  cone  that  receives  and  retains  the  vapor  and  that 
fits  fairly  snugly  over  patient's  face,  and  so  arranged 
that  at  a  little  distance  from  patient's  mouth  gauze  or 
cotton  or  both  can  be  retained,  moistened  with  ether  ; 
that  ether  can  be  added  if  necessary  without  remo^^ng 
the  cone,  and  yet  it  is  not  difficult  to  produce  the  anaes- 
thesia with  only  the  oxygenized  ether,  and  it  is  probable 
that  the  gauze  and  cotton  will  be  abandoned.  In  this 
report  I  have  endeavored  to  confine  myself  to  facts — 
not  to  offer  opinions.  In  a  fuller  report,  later,  I  hope  to 
be  able  to  harmonize  with  the  facts  the  explanation  of 
the  same. 

Case  I. — Dr.  Tull,  Cancer  Hospital.  Female,  aged 
about  forty,  weight  about  150  pounds  ;  amputation  of 
cervix.  Etherization  begun  at  9  a.m.  ;  primary  anaesthe- 
sia, 9.04  ;  full  ansesthesia,  9.08  ;  operation  begun,  9.13  ; 
operation  completed,  9.35.  Ether  used,  four  ounces  ; 
oxygen,  twenty-five  gallons.  No  struggling,  no  suffo- 
cation, no  gagging  or  vomiting,  except  when  patient 
was  being  wheeled  out  of  the  room,  then  a  mouthful 
of  fluid.  Recovery  without  vomiting,  without  nausea, 
without  headache,  in  thirty  minutes.  Color  excellent 
throughout  ;  pulse  increased  or  decreased,  by  a  cor- 
responding use  of  oxygen  ;  blood  noticeably  fresh  and 
bright  throughout  whole  operation.  Temperature  un- 
affected. Anesthesia  profound  :  no  anresthetic  added 
to  cone  or  bottle.  Gauze  used  in  cone,  and  wash  bot- 
tle used. 

Case  II. — Dr.  Tull,  Cancer  Hospital.  Female,  aged 
about  thirty,  weight  about  140  pounds  :  lacerated  cer- 
vix. Etherization  begun  at  9.48  a.ji.  ;  primary  an- 
esthesia, 9.50  :  complete  anesthesia,  9.52  ;  operation 
begun,  9.58  :  operation  completed,  10.45.  Ether,  five 
ounces  ;  oxygen,  thirty  gallons.  Anesthesia  complete 
throughout.  Water  was  siphoned  into  ether  bottle  at 
outset,  but  did  not  seem  to  influence  unfavorably  the 
method  of  administration.  No  ether  was  added  to 
cone  or  bottle.  No  struggling,  nor  nausea,  nor  froth- 
ing. Recovery  in  thirty  minutes,  without  nausea,  head- 
ache, or  vomiting.  Cone  not  removed  from  begin- 
ning to  end  of  anesthesia.  No  vomiting  at  any  time. 
Color  pure  throughout.  Gauze  in  cone  and  wash  bottle 
used. 

Case  III.— Dr.  Cole,  Post-Graduate  Hospital.  Boy. 
twelve  years  of  age  ;  weight.  So  pounds  :  circumcision. 
Objected  to  being  anesthetized,  and  struggled  at  out- 
set. Primary  anesthesia  inside  of  two  minutes  ;  oper- 
ation begun.  Complete  anesthesia  inside  of  four 
minutes,  although  patient  did  not  remain  fully  anes- 
thetized.     Operation   lasted   about    fifteen    minutes  ; 


recovery  took  as  much  more.  Some  nausea,  but  no 
vomiting  ;  patient  within  an  hour  or  a  little  more  took 
food.  Four  ounces  of  ether  used.  Wash  bottle  used  : 
no  gauze  used  in  cone. 

Ca?e  IV. — Dr.  Guiteras,  Columbus  Hospital.  Man, 
about  forty-five  years  of  age  ;  weight,  about  220  pounds. 
Displaced  testicle.  A  big  truckman,  a  difficult  subject 
for  ether  anesthesia.  Complained  for  two  or  three 
minutes  of  feeling  of  suffocation,  though  continued 
breathing  without  trouble.  Primary  anesthesia  in  nine 
minutes  ;  full  anesthesia  in  thirteen  minutes  :  opera- 
tion lasted  one  hour  and  fifteen  minutes.  Eight  ounces 
of  ether  used.  Gauze  in  cone  and  wash  bottle  used. 
Ether  added  to  cone  several  times  during  anesthesia. 

Case  V.— Dr.  Cole,  Post-Graduate  Hospital.  Child, 
male,  aged  twenty-six  months  ;  hydrocele  cord.  Pri- 
mary anesthesia,  two  minutes  ;  complete  anesthesia, 
four  minutes  ;  duration,  thirty  minutes.  Ether  used,  two 
ounces.  Usual  fright  at  beginning  anesthetic,  other- 
wise quiet  throughout.  Cone  not  kept  constantly  over 
face.  Vomited  a  few  minutes  after  operation  was  com- 
pleted, but  not  again.  Recovery  in  about  twenty  min- 
utes. Oxygen  passed  through  ether  directly,  and  no 
gauze  used  in  cone.  Wash  bottle  discontinued  from 
this  case  through  the  series. 

Case  VI.— Dr.  A.  M.  Phelps,  Post-Graduate  Hospi- 
tal. Woman,  aged  about  thirty-five  ;  weight,  175 
pounds  :  ununited  fracture  of  both  bones  of  forearm. 
Anesthesia  begun,  4.30  p.m.;  primary  anesthesia,  4.3S  : 
full  anesthesia,  4.42  ;  anesthetic  stopped,  5.35.  Ether, 
seven  ounces.  Patient  said  at  previous  operation  she 
had  taken  three  cans  of  ether.  Went  under  nicely, 
without  struggling  or  suffocation  or  vomiting.  While 
being  transferred  to  operating-table  she  vomited  mucus, 
and  again  once  or  twice  during  operation  when  cone 
had  been  removed  a  few  minutes.  No  wash  bottle 
used,  but  gauze  saturated  with  ether  put  in  cone  ;  re- 
freshed two  or  three  times  during  operation.  Anes- 
thesia so  profound  that  cone  was  kept  off  face  about  a 
fourth  of  the  time  and  oxygen  stopped.  Color  was 
always  fresh  and  excellent,  even  in  deepest  anesthesia. 
Patient  conscious  and  able  to  speak  distinctly  in  twenty 
minutes  after  cone  was  removed.  Pure  oxygen  was 
given  for  three  or  four  minutes  after  ether  was  stopped. 
Case  VII. — Dr.  Dowd,  Cancer  Hospital.  Alale, 
weight  about  150  pounds.  Necrosis  rib.  Anesthesia 
begun,  2.46  P.M.  ;  primary  anesthesia.  2.53  ;  complete 
anesthesia,  2.57  ;  operation  begun,  3.02  ;  anesthetic 
discontinued,  3.27  :  patient  conscious,  3.35.  Ether, 
five  and  a  half  ounces.  No  vomiting  nor  struggling. 
Considerable  accumulation  of  mucus  during  anes- 
thesia, necessitating  removal  of  cone  and  cleaning  out 
of  fauces.  Pure  oxygen  given  for  four  or  five  minutes 
after  anesthetic  was  discontinued.  At  previous  ether- 
ization (several  months  before)  patient  suffered  con- 
siderably from  effects  of  ether,  and  took  a  large  quan- 
tity of  the  anesthetic.  Later  report  from  patient  that 
only  slight  nausea  and  no  vomiting  followed  anesthe- 
sia, and  recovery  was  in  a  third  of  the  time  as  com- 
pared with  the  previous  anesthetization.  Gauze  used 
in  cone,  but  no  wash  bottle. 

Case   VIII. — Dr.   Willy   Meyer,  German  Hospital. 
Man  ;  gastro-enterostomy  for  malignant  growth.     Pri- 
mary anesthesia  in   six  minutes  ;    complete  in   tweh-- 
minutes.     Anesthetic  given  carefully  and  not  pushe  ' 
Patient  under  anesthesia  one  hour  and  a  half  ;  six  ar  /. 
a  half  ounces  of  ether  used  ;  absolutely  no  struggling 
no  vomiting  ;  no  gagging  ;  and  not  once  did  mucus  i  : 
saliva  have  to  be  wiped  off  his  mouth.     Color  and  pul- 
excellent  throughout.    Recovery  in  forty  minutes,  wit'. 
out  vomiting  or  distress.     Gauze  used  in  cone.     Ethe: 
added  several  times  during  operation,  about  a  drachm 
each  time. 

Case  IX. — Dr.  Willy  Meyer,  German  Hospital. 
Child  ;  sarcoma  of  kidney.  Primary  anesthesia  no: 
noted,  but  full  anesthesia  in  three  minutes.  Anes- 
thetic administered  one  hour  and  five  minutes,  no  gau. 


October  12,  1895] 


MEDICAL    RECORD. 


507 


in  cone,  and  total  ether  used  two  and  one-half  ounces. 
Color  excellent,  no  salivation,  gagging,  or  vomiting. 

Case  X. — Dr.  Cole,  Post-Graduate  Hospital.  Man  : 
epithelioma,  floor  of  mouth.  In  anticipation  of  a  diffi- 
culty in  deglutition,  I  determined  to  use  no  gauze  and 
cotton  in  the  cone,  in  order  to  reduce  as  much  as  possible 
the  saliva  to  be  swallowed,  and  to  give  the  minimum  of 
trouble  in  respiration.  Primary  anaesthesia  was  quiet 
and  easy,  but  secondary  anaesthesia  did  not  follow  in  a 
reasonable  time  ;  no  gauze  or  cotton  moistened  with 
ether  were  put  in  the  cone.  My  reasoning  as  to  inter- 
ference, of  which  the  physicians  present  were  advised 
at  the  outset,  proved  soon  to  have  been  well  founded  ; 
and  the  increased  irritation  from  the  ether  produced 
some  increase  in  saliva  and  secretions,  which,  instead  of 
being  swallowed,  accumulated  and  interfered  mate- 
rially with  respiration  ;  so  that  the  anesthetic  was  dis- 
continued, and 
the  operation 
rapidly  done  un- 
der partial  anes- 
thesia. Strange 
to  say,  even  when 
respiration  was 
exceedingly  i  m  - 
perfect,  the  color 
remained  good  ; 
and  it  was  with 
considerable  sat- 
isfaction, even  in 
the  face  of  my  first 
partial  failurewith 
ether- oxygen  an- 
aesthesia, that  I 
reflected  how  for- 
tunate for  the  pa- 
tient that  ether 
alone  had  not 
been  essayed.  A 
later  conversation 
with  the  patient 
developed  the 
fact  that  he  suf- 
fered no  pain,  and 
was  not  aware  that 
anything  had 
been  done  ;  in 
short  his  anaes- 
thesia, which  ap- 
peared very  im- 
perfect, was  at 
least  attended  by 
unconsciousness 
of  pain  during  the 
operation.  Only 
three  ounces  of 
ether  were  used  ; 
no  nausea  nor 
vomiting. 

C.\SE  XI. — Dr.  Bryant,  Bellevue  Hospital.  Woman, 
about  fifty  years  of  age  ;  weight  about  165  pounds. 
Tumor  of  breast ;  anaesthesia  primary  in  eight  min- 
utes ;  secondary  in  fifteen  minutes  ;  anesthetic  admin- 
istered for  fifty  minutes  :  four  ounces  of  ether  given. 
Patient  came  out  in  about  fifteen  minutes.  Was  restive 
during  early  part  of  operation,  but  absolutely  passive 
the  remainder.  Gauze  and  cotton  moistened  with 
ether  used  in  cone  :  wash  bottle  has  been  abandoned 
for  several  cases.  Recovery  without  vomiting,  and  anes- 
thesia not  accompanied  by  gagging  or  salivation.  Ether 
added  to  gauze  in  cone  several  times. 

It  is  by  the  courtesy  of  Dr.  Francis  H.  Markoe  that 
the  following  cases  in  which  ether  with  oxygen  has  been 
employed  are  reported. 

The  method  of  administration  has  consisted  in  pass- 
ing oxygen  from  a  cylinder  through  two  wash  bottles, 
the  first  containing  water,  the  second  ether,  into  a  cone. 


the  cone  being  so  arranged  that  ether  may  be  added 
directly  to  it  if  necessary. 

While  it  is  to  be  regretted  that,  the  method  still  being 
in  its  infancy,  more  definite  results  cannot  be  furnished, 
yet  the  majority  of  cases  upon  which  it  has  been  used 
have  shown  :  i.  An  absence  of  the  so  called  stage  of  ex- 
citement. 2.  No  cyanosis  nor  respiratory  disturbances 
during  anesthesia.  3.  A  tendency  to  regain  con- 
sciousness more  quickly  when  etherization  is  discon- 
tinued than  after  the  usual  methods.  4.  No  nausea  or 
vomiting  subsequent  to  etherization.  5.  The  amount 
of  ether  consumed  to  be  considerably  less  than  for- 
merly. 

C.\SE  I. — Female,  aged  fifty-seven.  Diagnosis,  car- 
cinoma of  stomach.  Operation,  exploratory  cceliotomy. 
Patient  greatly  emaciated  ;  lungs,  negative  ;  heart,  action 
very  feeble  ;  systolic  murmur  of  pulmonic  area  ;  ether 

and  oxygen  ad- 
ministered slow- 
ly ;  no  attempt  at 
rapid  anesthetiz- 
ation ;  no  primary 
laryngeal  spasm 
or  period  of  ex- 
citement. 

Patient's  pulse, 
respiration,  and 
color  remained 
excellent  until 
middle  of  opera- 
tion, when  ether 
was  given  alone. 
Almost  immedi- 
ately the  pulse 
and  respiration 
became  very 
rapid,  and  patient 
grew  cyanotic. 

O  n  resuming 
oxygen,  patient's 
condition  im- 
proved at  once 
and  remained  so 
until  close  of  op- 
eration. After 
etherization  there 
was  no  nausea  or 
vomiting  for 
twenty-four 
hours.  This  is 
interesting  from 
the  fact  that  be- 
fore operation  the 
patient  vomited 
every  two  or  three 
hours,  and  that 
nothing  was  done 
at  time  of  oper- 
ation to  alleviate 
local  condition,  the  walls  of  the  stomach  being  so  ex- 
tensively involved  that  gastro-intestinal  anastomosis 
was  impossible. 

C.-\SE  II. — Female,  aged  fifty.  Stout,  plethoric  pa- 
tient ;  heart  and  lungs  negative.  Operation  for  lacer- 
ated perineum,  extensive  rectocele,  and  hemorrhoids  ; 
patient  fully  anesthetized  in  four  minutes  ;  etherization 
lasted  two  and  one-half  hours,  during  which  time  pulse 
and  respiration  continued  the  same  as  before  opera- 
tion. There  was  no  stage  of  excitement  or  after-gastric 
disturbance. 

Case  III. — Male,  aged  about  fifty-seven.  Diagno- 
sis, enlarged  prostate.  Operation,  castration.  Patient 
fairly  well  nourished.  Heart,  systolic  murmur  over 
apex,  transmitted  to  left.  Lungs,  emphysematous. 
Some  very  slight  struggling. at  commencement  of  an- 
esthesia. Color  of  patient  during  operation  ruddy, 
although   the    anesthetic   was    clouded.     Respiration 


MEDICAL    RECORD. 


[October  12,  1895 


normal.  Recovered  from  ether  without  nausea  or  vom- 
iting, and  was  fully  conscious  in  twenty-five  minutes. 

Case  IV.  —  Female,  aged  forty-seven.  Operation, 
excision  of  irritable  urethral  carbuncle.  Patient's  phys- 
ical condition  very  poor.  Well-marked  tubercular 
changes  at  both  apices.     Heart  negative. 

In  this  case  patient  succumbed  to  anaesthetic  as  if 
simply  going  to  sleep.  There  was  no  disturbance  of 
respiration  during  operation,  and  no  cyanosis.  Un- 
pleasant after-effects  absent. 

Case  V. — Boy,  aged  about  thirteen.  Diagnosis, 
tubercular  knee-joint.  Operation,  incision  and  drain- 
age. Patient  very  poorly  nourished.  Heart,  systolic 
murmur  heard  along  left  border  of  sternum,  also  over 
pulmonic  area.  Lungs,  negative.  Pulse,  rapid,  poor 
force,  regular.  Anesthesia  commenced  by  use  of  ether 
alone.  Primary  stage  of  excitement  present.  After 
fifteen  minutes  of  etherization  patient's  pulse  became 
very  weak,  rapid,  and  irregular.  He  lost  all  color  and 
the  breathing  was  bad.  Oxygen  and  ether  was  now 
substituted  for  ether.  In  a  short  time  the  pulse  had 
improved  in  force  (although  it  remained  rapid).  Color 
returned  to  patient,  and  breathing  regained  more  of  its 
normal  character.  No  nausea  nor  vomiting  followed 
administration  of  the  anaesthetic.  Other  stimulation 
than  the  oxygen  was  not  employed  when  patient's  con- 
dition was  precarious. 

Case  VI.  —  Female,  aged  forty-three.  Diagnosis, 
adeno-fibro-sarcoma  of  breast.  Operation,  excision 
of  breast  and  axillary  contents.  Patient  in  good  phys- 
ical condition  ;  heart  and  lungs,  negative  ;  ansesthetized 
readily.  No  excitement.  Pulse  regular  throughout 
operation.  Blood  never  lost  its  bright  arterial  hue. 
Twelve  hours  after  operation  patient  vomited  once,  but 
this  after  taking  some  brandy  and  milk.  There  was  no 
feeling  of  nausea  directly  following  etherization. 

Case  VII. — Male,  aged  twenty.  Diagnosis,  vari- 
cocele. Operation,  excision.  Patient  strong  and  ro- 
bust ;  heart,  systolic  murmur  over  apex  ;  action  irregu- 
lar ;  lungs,  negative.  Marked  alcoholic  habit.  Patient 
took  anaesthetic  very  easily ;  no  stage  of  excitation. 
Complete  anesthesia  in  six  minutes.  Respiration  and 
circulation  very  good  during  operation.  It  took  rather 
longer  than  usual  for  patient  to  regain  consciousness 
(fifty  minutes),  and  both  nausea  and  vomiting  occurred 
after  discontinuance  of  anaesthetic. 

Case  VI 1 1. — Male,  aged  twenty  seven.  Diagnosis,  tu- 
be'rcular  arthritis  of  shoulder-joint.  Operation,  atypical 
resection.  Patient  fairly  well  nourished.  Lungs,  tuber- 
cular signs  at  left  apex  well  advanced.  Heart,  negative. 
Period  of  excitement  present.  Patient  slightly  cyanotic 
during  anesthesia.  Nausea  and  vomiting  present  after 
etherization.     Patient  conscious  after  one  hour. 

Case  IX. — Male,  aged  fifty-three.  Diagnosis,  cys- 
titis. Pyelo-nephritis.  Operation,  median  perineal 
cystotomy.  Patient  intensely  emaciated  ;  condition 
almost  uremic.  Heart  and  lungs,  negative  ;  pulse  and 
respiration,  rapid  and  irregular.  Only  five  minutes  re 
quired  to  anesthetize  patient.  Patient  in  such  a  weak 
state  that  inhalations  of  pure  oxygen  were  given  alter- 
nately with  the  oxygen  and  ether.  By  these  means  he 
stood  the  anesthetic  well,  although  he  looked  to  be  in 
extremis  throughout  the  operation.  No  nausea  nor 
vomiting  subsequent  to  etherization. 

Case  X. — Male,  aged  about  fifty  years.  Diagnosis, 
cellulitis  of  neck.  Operation,  incision  and  drainage. 
Patient  in  good  condition  ;  heart  and  lungs,  negative  ; 
breathing  difficult  on  account  of  abscess  in  neck  press- 
ing against  trachea.  Anesthesia  produced  slowly  from 
the  above  fact.  Slight  excitement  ;  no  cyanosis,  even 
though  trachea  was  obstructed.  Pulse  regulir,  good 
force  during  operation.  Recovered  from  ether  without 
gastric  irritability. 

The  intense  thirst  so  often  present  after  etherization 
has  been  greatly  moderated  in  every  instance,  and  the 
feeling  of  suffocation  less  marked.  Albumen  and  casts 
have  appeared  in  the  urine  with  about  the  same  per- 


centage of  frequency  as  when  ether  is  administered  by 
other  methods.  The  atmosphere  of  the  operating 
room  has  remained  almost  free  from  the  odor  of  ether. 
In  concluding  this  report  I  may  add  that  it  will  be 
interesting  to  experiment  with  compressed  air  similarly 
used,  and  possibly  other  gases  ;  but  for  the  present  we 
will  content  ourselves  with  recording  the  cases  and 
facts  as  we  have  observed  them,  and  of  submitting  the 
report  of  Dr.  Markoe's  cases  from  Dr.  Squier,  as  we 
received  it.  The  illustrations  are  of  the  simple  appa- 
ratus which  I  have  devised  and  used. 

loi  Wbst  Seventy-fourth  Street. 


THE   PROOFS   OF   PROGRESS.' 
By  GEORGE  M.  STERNBERG,  M.D.,  LL.D., 


N-GENERAL    UNITED  STATES  ARMY. 


The  great  obstacle  to  the  advancement  of  medical  sci- 
ence in  the  past  has  been  respect  for  authority  and  the 
acceptance  of  theories  and  supposed  facts  without  sub- 
mitting them  to  the  test  of  experimental  verification. 

The  humoral  pathology  which  Galen  (bom  a.d.  130) 
developed  from  the  previous  teachings  of  Hippocrates 
controlled  medical  thought  and  influenced  medical 
practice  for  1500  years.  But  we  have  been  emanci- 
pated from  the  trammels  of  theory  and  superstition,  and 
the  medicine  of  to-day  is  largely  based  upon  exact 
observation  and  experimental  demonstration.  In  other 
words,  we  may  now  properly  speak  of  medical  science, 
for,  while  our  knowledge  in  many  directions  is  far  from 
being  complete,  it  is  founded  upon  a  scientific  basis  of 
observation  and  experiment  and  is  being  rapidly  ex- 
tended by  scientific  methods. 

The  unthinking  and  unscientific  are  very  ready  to 
believe  that  not  knowing  is  due  to  ignorance  on  the 
part  of  the  individual,  when  in  reality  it  is  the  brief 
statement  by  a  well-informed  man  that  the  matter  re- 
ferred to  has  not  been  determined,  and  that  no  one  can 
give  the  desired  information.  Under  the  same  circum- 
stances an  ignoramus  or  a  charlatan,  instead  of  confess- 
ing ignorance,  would  perhaps  gain  great  credit  by  a 
positive  assertion  with  reference  to  a  matter  of  which 
he  could  not  possibly  know  anything.  But  science 
teaches  that  a  confession  of  ignorance  is  the  first  step 
toward  the  attainment  of  knowledge.  When  the  anx- 
ious mother  says  :  "  Doctor,  is  it  diphtheria  ?  "  and  re- 
ceives the  answer  "  I  don't  know  ;  there  is  a  somewhat 
suspicious  deposit  upon  the  tonsils,  and  I  will  at  once 
make  a  microscopical  examination  and  a  culture  which 
will  enable  me  to  determine  the  matter  within  twenty- 
four  hours,"  she  will  probably  not  be  as  well  satisfied 
with  her  medical  attendant  when  she  receives  the  as- 
surance after  such  an  examination,  that  "  it  is  not 
diphtheria,"  as  she  would  have  been  with  the  non- 
scientific  doctor,  who  claims  to  recognize  diphtheria  at  a 
glance,  announces  his  diagnosis  at  once,  and  "cures  " 
the  patient  within  a  day  or  two.  The  latter  has  earned 
the  mother's  lasting  gratitude,  and  she  will  not  fail  to 
recommend  him  to  her  friends  as  competent  to  cure 
any  ailment  to  which  humanity  is  liable.  But  our 
scientific  doctor  will  make  his  way  in  the  end.  He 
will  enjoy  the  confidence  of  his  fellow-practitioners,  and 
his  patients  will  learn  after  a  time  that  when  he  says 
he  knows  a  certain  thing  he  really  knows  it,  and  when 
he  says  he  don't  know,  he  will  do  his  best  to  find  out, 
if  the  question  can  be  solved  by  reference  to  the  medi- 
cal works  in  his  library,  or  by  an  experimental  investi- 
gation which  it  is  practicable  for  him  to  make  person- 
ally, or  which  can  be  made  for  him  in  a  laboratory 
devoted  to  scientific  research.  lie  does  not  make  a 
snap  judgment,  but  waits  until  all  the  evidence  is  i». 
It  is  evident  that  the  opinion  of  a  man  of  this  type  is 
of  value.     His  diagnosis,  his  prognosis,  and  his  advice 

>  Extracts  from  ;ui  address  delivered  at  the  Georgetown  Medica 
College,  September  i.  1895. 


October  12,   1895] 


MEDICAL   RECORD. 


509 


as  to  treatment  are  based  upon  a  careful  investigation 
of  the  case  in  hand,  a  full  knowledge  of  the  literature 
relating  to  similar  cases,  and  a  precise  appreciation  of 
the  indications  to  be  met  by  the  treatment  prescribed. 

The  conservatism  which  makes  the  scientific  physi- 
cian willing  to  confess  ignorance  is  a  very  different 
conseri-atism  from  that  of  the  pretentious  charlatan 
and  quack,  who  gives  an  emphatic  denial  to  facts  that 
are  well  established  upon  evidence  with  which  he  is 
not  familiar,  or  which  his  intellect  is  not  capable  of  ap- 
preciating. I  have  protested  against  calling  the  gradu- 
ates of  our  leading  medical  colleges  "'  old-school  "  doc- 
tors, but  it  must  be  admitted  that  there  are  still  some 
very  old-school  doctors  among  the  former  graduates  of 
regular  medical  colleges.  In  the  ranks  of  the  medical 
profession,  as  elsewhere,  there  are  men  who  have  been 
left  behind  in  the  rapid  development  of  our  knowledge, 
and  who  protest  against  the  acceptance  of  facts  which 
have  been  established  by  the  most  unimpeachable  ex- 
perimental evidence.  By  such  protest  they  simply  re- 
veal their  own  ignorance.  But  as  their  opinions  are 
often  stated  in  good  and  forcible  English,  other  per- 
sons, equally  ignorant  of  the  evidence,  frequently  accept 
them,  or  quote  the  old  saying — "  When  doctors  disagree, 
who  shall  decide  ? " 

As  examples  of  this  conservatism  of  ignorance  I  sub- 
mit the  following  quotations  from  two  recently  pub- 
lished papers,  having  the  names  of  regular  graduates 
in  medicine  attached  to  them.  In  a  report  to  a  State 
Medical  Society,  signed  by  a  reputable  physician. 
among  other  conclusions  formulated  I  find  the  follow- 
ing : 

(2.)  "  That  the  etiology  of  infectious  diseases  is  as 
yet  sub  judice,  and  that  therapeutic  methods  based 
upon  the  assumption  that  infectious  diseases  are  caused 
by  specific  micro-organisms  are  unscientific." 

.\nother  medical  writer  concludes  a  popular  maga- 
zine article  as  follows  : 

"  We  are  brought,  therefore,  to  the  conclusion  inevi- 
tably :  The  germ  theory  is  an  assumption  of  causes,  of 
the  existence  of  which  we  have  no  evidence,  to  account 
for  effects  which  they  by  no  means  explain." 

The  training  which  the  medical  student  of  the  pres- 
ent day  receives  in  the  laboratory  is  essential  for  other 
reasons  than  because  of  the  scientific  spirit,  which  is 
developed  by  personal  verification  of  the  facts  which 
are  recorded  in  his  text-books  of  chemistry,  histology, 
bacteriology,  etc.  Not  only  does  this  personal  verifica- 
tion impress  the  facts  upon  his  memory,  but  he  obtains 
that  technical  skill  in  the'  use  of  instruments  and 
methods  which  can  only  be  acquired  by  practice.  In 
the  chemical  laboratory  he  learns  to  detect  poisons,  to 
determine  the  nature  of  impurities  in  water  or  air,  to 
examine  urine,  etc.  His  practical  course  in  histology 
makes  him  familiar  with  the  use  of  the  microscope  and 
with  the  minute  anatomy  of  healthy  tissues.  In  the 
pathological  laboratory  he  learns  to  recognize  the  re- 
sults of  different  morbid  processes  and  the  presence  of 
parasitic  micro-organisms  in  the  blood  or  tissues,  to  dis- 
tinguish between  malignant  and  innocent  growths,  etc. 
By  cultivating  the  principal  pathogenic  bacteria  and 
examining  them  under  the  microscope,  after  treatment 
with  various  staining  agents,  he  becomes  familiar  witli 
their  biological  and  morphological  characters  and  is 
able  to  recognize  them  wherever  they  may  be  en- 
countered. In  short,  he  obtains  a  practical  knowledge 
of  many  things,  which  it  is  essential  for  him  to  know  in 
order  that  he  may  be  a  skilful  physician.  The  knowl- 
edge to  be  obtained  from  books,  which  enables  the 
student  to  pass  a  creditable  examination,  does  not 
make  him  a  chemist,  a  pathologist,  a  skilful  diagnos- 
tician, a  surgeon  or  a  physician  any  more  than  the 
knowledge  to  be  obtained  by  reading  books  on  agricult- 
ure makes  a  man  a  farmer,  or  than  the  study  of  books 
on  navigation  would  enable  a  man  without  practical  ex- 
perience to  take  command  of  a  trans-Atlantic  steamer. 
It   is   in    recognition   of   this   fact    that  the    Medical 


Faculty  of  the  University  of  Georgetown  has,  as 
already  stated,  decided  to  extend  the  hours  of  instruc- 
tion "  so  that  more  time  may  be  given  to  practical  work 
in  laboratories  and  hospitals."  Every  physician  of  ex- 
perience will  approve  of  this  decision.  It  is  true  that 
but  few  of  the  prominent  physicians  of  the  present  day 
enjo5'ed  such  advantages  as  it  is  proposed  to  give  to 
their  successors.  It  is  also  true  that  a  majority  of 
these  prominent  physicians  were  very  imperfectly  pre- 
pared for  the  duties  and  responsibilities  of  a  general 
practitioner  when  they  received  their  medical  degree. 
This  fact  has  long  been  recognized  within  the  ranks  of 
the  profession,  and  it  is  for  this  reason  that  hospital  ap- 
pointments^have  been  so  eagerly  sought  by  those  hav- 
ing a  proper  professional  ambition.  In  the  hospital  the 
young  doctor  learns  to  apply  his  knowledge  and  to 
meet  emergencies  with  composure  and  professional 
skill.  His  books  have  taught  him  what  to  look  for, 
what  to  listen  for,  and  what  to  feel  for,  but  practice 
alone  can  give  him  the  trained  eye,  the  trained  ear,  and 
the  tactus  eruditus  of  the  accomplished  physician. 

It  is  in  the  laboratory  that  the  student  acquires 
deftness  in  delicate  manipulations  required  in  his 
chemical,  histological,  and  bacteriological  studies  ;  here 
he  learns  to  measure  and  weigh  with  accuracy,  to 
appreciate  the  slight  differences  in  color-reaction,  in 
form  or  in  structure,  upon  which  he  must  often 
depend  for  the  recognition  of  toxic  agents,  patho- 
genic germs,  or  abnormal  growths  :  his  eye  becomes 
trained  to  recognize  the  malarial  plasmodium,  the  tu- 
bercle bacillus,  and  other  micro  organisms,  which  are 
only  revealed  to  us  by  the  highest  powers  of  the  micro- 
scope, under  proper  illumination,  and  in  skilfully 
mounted  preparations  ;  and  it  is  here  that  conditions 
are  most  favorable  for  the  development  of  that  spirit 
of  doubt  and  inquiry  which  is  so  essenrial  for  the  prog- 
ress of  scientific  medicine.  Where  there  is  no  doubt 
there  will  be  no  investigation.  The  farmer  who  ac- 
cepts the  traditional  belief  that  certain  seed  must  be 
planted  in  the  light  of  the  moon,  in  order  to  obtain  the 
best  results,  would  consider  it  a  waste  of  time  to  make 
a  comparative  experiment.  But  it  is  by  means  of  com- 
parative experiments  that  we  arrive  at  definite  conclu- 
sions in  the  laboratory,  and  the  great  diversity  of  opin- 
ions with  reference  to  the  curative  action  of  drugs  is 
largely  due  to  a  failure  to  apply  the  same  methods  in 
practice.  This  failure  has  been  partly  due  to  want  of 
appreciation  of  the  necessity  for  a  control-experiment 
in  judging  of  the  results  supposed  to  follow  a  certain 
course  of  treatment,  and  partly  to  the  diSiculty  of  mak- 
ing such  a  control-experiment  in  clinical  medicine.  The 
unscientific  mind  jumps  at  conclusions  that  are  entirely 
unjustified  by  the  facts.  The  warts  upon  the  child's 
hand  are  rubbed  with  a  piece  of  meat  which  is  thrown 
over  the  left  shoulder,  etc.,  and  they  subsequently  dis- 
appear ;  a  horse- chestnut  or  a  potato  is  carried  in  the 
pocket  for  years  and  the  individual  does  not  sufifer 
from  rheumatism  during  the  entire  time.  The  child 
has  a  high  fever  at  bed-time,  the  mother  gives  it  a  sugar 
pill  and  the  next  morning  the  fever  has  entirely  disap- 
peared, and  so  on  ad  infinitum.  Post  hoc  ergo  propter 
hoc'  But  the  man  of  science  asks  :  What  would  have 
happened  if  the  warts  had  not  been  rubbed  with  meat, 
or  saliva,  or  whatever  may  have  been  the  particular  fe- 
tich employed  ?  Would  the  man  have  had  rheumatism 
if  he  had  left  the  horse-chestnut  on  the  tree  or  the  po- 
tato in  the  ground  ?  Would  the  child's  fever  have  dis- 
appeared if  the  mother  had  failed  to  give  it  the  sugar 
pill  ?  To  determine  this  a  comparative  experiment  is 
evidently  required.  Take  the  case  of  the  child,  for  ex- 
ample. To  determine  whether  the  disappearance  of 
the  fever  was  in  fact  due  to  the  administration  of  the 
sugar  pill  we  should  have  another  exactly  similar  case 
— a  child  of  the  same  age,  under  similar  conditions  and 
suffering  from  an  elevation  of  temperature  due  to  the 
same  cause.  One  child  should  have  the  pill  and  the 
other  should  have  nothing.  Even  then  the  result  would 


5IO 


MEDICAL    RECORD, 


[October  12,    1895 


not  be  conclusive.  Science  demands  that  the  experi- 
ment should  be  repeated  several  times.  There  are  so 
many  chances  that  the  conditions  may  not,  after  all, 
have  been  exactly  identical.  No  truly  scientific  man 
would  venture  to  announce  a  fact  as  established  upon 
the  basis  of  a  single  successful  experiment.  And,  hav- 
ing in  view  the  fallability  of  human  judgment,  the  ten- 
dency to  draw  conclusions  favorable  to  the  prejudices 
or  desires  of  the  individual,  and  the  frequency  with 
which  erroneous  conclusions  are  published  upon  what 
appears  to  be  a  substantial  experimental  basis,  science 
demands  verification  of  reported  results  by  two  or  more 
independent  investigators  before  finally  accepting  these 
results  as  demonstrated  facts.  All  this  is  so  far  away 
from  the  ordinary  methods  of  arriving  at  conclusions, 
that  the  conservatism  of  the  scientific  physician  meets 
with  little  sympathy  on  the  part  of  the  general  public. 
The  man  with  a  horse-chestnut  in  his  pocket  is  not  only 
convinced  by  his  individual  experience  that  this  is  a 
sovereign  cure  for  rheumatism,  but  he  is  apt  to  resent 
your  non-acceptance  of  his  experiment  as  conclusive. 
We,  on  the  other  hand,  know  that  medical  literature 
abounds  in  instances  of  the  ultimate  failure  of  thera- 
peutic agents  and  methods  of  treatment,  which  have 
for  a  time  been  lauded  as  specific,  and  have  been  en- 
dorsed by  prominent  physicians.  We  are  therefore 
becoming  more  and  more  exacting  in  our  demands 
as  regards  proof,  and  as  a  result  medical  science  is 
making  rapid  progress.  How  great  this  progress  has 
been  is  not  fully  appreciated  by  the  non-medical  pub- 
lic. 

While  we  justly  pride  ourselves  upon  the  rapid  de- 
velopment of  our  knowledge  during  the  last  half  of  the 
present  century,  we  must  not  forget  that  in  some  direc- 
tions the  foundations  of  scientific  medicine  were  sub- 
stantially laid  by  the  illustrious  physicians  of  the  past. 
The  time  at  my  disposal  will  not  permit  me  to  give  an 
extended  review  of  the  development  of  medical  knowl- 
edge, but  a  brief  reference  to  some  of  the  more  impor- 
tant events  which  have  marked  this  progress  will  per- 
haps be  useful,  as  showing  the  extent  of  the  field  and 
the  advantages  which  the  physician  of  to-day  has  over 
his  predecessors. 

Hippocrates  and  his  illustrious  successors,  Celsus, 
Galen,  and  others,  were  certainly  the  peers  of  modern 
physicians  in  their  powers  of  observation,  and  we  are 
indebted  to  them  for  a  mass  of  recorded  facts  relating 
t6  disease,  which  have  been  verified  and  added  to  by 
subsequent  observers.  But  observation,  in  the  absence 
of  the  instruments  and  methods  of  modern  science, 
goes  but  a  short  distance  in  the  direction  of  unveiling 
truth,  and  often  leads  to  erroneous  conclusions.  Ob- 
servation led  the  ancient  philosophers  to  believe  that 
the  sun  goes  around  the  earth,  and  that  water  and  air 
are  elements.  The  experimental  methods  of  modern 
science  have  revealed  to  us  the  constant  presence  of 
three  elementary  gases  in  the  atmosphere,  one  of  which 
is  also  a  constituent  of  water,  while  one — argon — has 
only  just  been  revealed  to  us  by  the  researches  of  Pro- 
fessor Ramsey  and  Lord  Reyleigh.  One  of  the  first 
lessons  to  be  learned  by  the  student  of  medicine  is  not 
to  trust  implicitly  to  the  evidences  of  his  senses.  This 
is  the  fundamental  error  of  ignorant  persons,  and  the 
foundation  of  demonclogy  and  superstitions  of  all 
kinds.  The  eye  tells  us  that  water  from  the  well  is  per- 
fectly pure,  but  the  microscope  shows  us  that  it  swarms 
"vith  living  organisms.  The  touch  tells  us  that  the  pa- 
tient has  a  high  fever,  but  the  clinical  thermometer 
says  no — the  sensation  received  was  due  to  the  com- 
paratively low  temperature  of  our  own  hand  at  the 
time  of  making  the  observation,  etc. 

The  anatomical  knowledge  of  "  the  father  of  medi- 
cine "  was  very  imperfect,  because  it  was  not  obtained 
by  the  dissection  of  the  human  body.  The  Greek  phy- 
sicians Herophilus  and  Erasistratus,  of  the  .'Vlexandrian 
school  of  medicine,  who  lived  about  300  b.c,  are  be- 
lieved to  have  been  the  first  to  study  anatomy  in  this 


way,  and  from  that  time  our  knowledge  in  this  essen- 
tial department  of  medicine  has  steadily  increased,  until 
at  present  it  is  perhaps  more  nearly  complete  than  in 
any  other  branch.  The  medical  student  of  to-day  is 
expected  not  only  to  acquire  an  accurate  knowledge  of 
anatomy  in  the  dissecting  room,  but  he  must  study  the 
minute  anatomy  of  the  tissues  by  means  of  the  micro- 
scope and  the  methods  of  investigation,  which  he  will 
learn  in  the  histological  laboratory.  He  is  also  ex- 
pected to  have  at  least  an  outline  knowledge  of  com- 
parative anatomy,  a  branch  of  scientific  research  which 
dates  back  to  the  time  of  Aristotle  (384  B.C.)  and  which 
has  been  greatly  developed  during  the  present  cen- 
tury. Our  knowledge  of  minute  anatomy  has  been 
largely  acquired  during  the  past  sixty  years,  as  a  result 
of  the  improvements  in  the  compound  microscope  made 
about  1830.  The  perfecting  of  this  invaluable  instru- 
ment of  research  has  also  led  to  vast  additions  to  our 
knowledge  in  the  department  of  general  biology,  of 
which  it  is  important  that  the  medical  student  should 
possess  at  least  an  outline.  A  knowledge  of  the  struct- 
ure and  development  of  lower  organisms  is  justly  re- 
garded as  a  proper  introduction  to  the  study  of  human 
anatomy  and  physiology.  Embryology,  a  branch  of 
science  which  may  almost  be  said  to  have  had  its  birth 
in  the  present  century,  must  not  be  neglected  by  the 
student  of  medicine.  It  is  true  that  Galen  made  ob- 
servations upon  the  development  of  the  incubated  egg, 
and  that  Harvey,  in  the  seventeenth  century,  made 
some  important  observations  in  the  same  line  of  inves- 
tigation, but  the  minute  and  accurate  knowledge  of  the 
present  day  depends  upon  the  comparatively  recent 
improvements  in  the  compound  microscope  just  re- 
ferred to. 

Progress  in  physiology,  as  in  other  branches  of  nic  . 
cal  science,  has  resulted  from  the  application  of  the  ex- 
perimental method  to  the  problems  to  be  solved.  Galen 
made  an  important  addition  to  human  knowledge  when 
he  demonstrated  that  urine  is  secreted  by  the  kidneys, 
a  fact  which,  apparent  as  it  seems  to  us  to  be,  had  not 
previously  been  recognized.  It  was  nearly  fifteen  hun- 
dred years  later  that  Harvey  (162S)  demonstrated  the 
circulation  of  the  blood,  a  discovery  which  is  justly 
considered  one  of  the  most  notable  events  in  the  his- 
tory of  medicine.  The  subsequent  explanation  of  the 
process  of  respiration  by  Lavosier  (17S3),  the  experi- 
ments upon  gastric  digestion  by  Beaumont  (1S34),  and 
the  discovery  of  the  function  of  the  vaso-motor  nervous 
system  by  Claude  Bernard,  opened  the  way  to  a  fertile 
field  of  research  which  is'still  being  vigorously  prose- 
cuted in  physiological  laboratories  ;  and  the  results  at- 
tained constitute  an  essential  part  of  a  medical  educa- 
tion. The  progress  of  our  knowledge  of  physiology 
has  necessarily  been  secondary  to  the  advancement  of 
chemistry.  Indeed,  physics  and  chemistry  constitute 
the  foundation  of  medical  science.  We,  therefore,  place 
Priestley's  discovery  of  oxygen  (1783)  among  the  epoch- 
making  events  in  the  history  of  medicine.  It  is  due  to 
chemistry  that  we  are  able  to  use  the  active  principles 
of  various  drugs  of  demonstrated  value,  instead  of  the 
crude  material — leaf,  root,  or  bark  ;  and  the  chemists 
have  recently  made  many  valuable  additions  to  the  list 
of  approved  therapeutic  agents — principally  from  the  . 
series  of  coal-tar  products.  i 

The  importance  of  carefully  studying  the  results  off 
morbid  processes  in  the  post-mortem  room  and  in  the 
pathological  laboratory  is  now  generally  recognized, 
and  the  medical  student  will  find  that  since  Morgagai 
(1682-1771)  led  the  way  in  the  study  of  morbid  anat- 
omy, an  enormous  amount  of  work  has  been  done  in 
this  field  of  investigation.  He  will  be  required  to  make 
himself  familiar  not  only  with  the  facts  developed,  but 
with  the  methods  of  research  and  the  microscopical 
and  gross  appearances  of  tissues,  which  have  undergone 
the  changes  due  to  disease.  Important  as  these  stud- 
ies are,  the  results  obtained,  from  a  practical  point  of 
view,  are  eclipsed  by   the  brilliant  discoveries  which 


October  12,   1895] 


MEDICAL   RECORD. 


ill 


have  been  made  during  the  past  twenty  years  with 
reference  to  the  etiology  of  infectious  diseases,  which 
to  a  considerable  extent  have  been  prosecuted  in  labo- 
ratories devoted  to  pathological  research.  These  dis- 
coveries, like  others  heretofore  referred  to,  depend 
primarily  upon  the  improvements  which  have  been 
made  in  the  compound  microscope,  especially  in  high 
power  objectives  and  means  of  illumination  ;  and  upon 
methods  of  research  devised  by  the  pioneers  in  this  field 
of  investigation,  among  whom  the  names  of  the  French 
chemist  Pasteur,  and  the  German  physician  Koch  are 
preeminent. 

The  development  of  our  knowledge  relating  to  the 
bacteria  dates  from  the  controversy  relating  to  spon- 
taneous generation,  which  was  finally  settled  by  the  e.\- 
perimental  demonstration  made  by  Pasteur  (1S60),  that 
no  development  of  micro-organisms  occurs  in  organic 
infusions  which  have  been  sterilized  by  boiling  ;  and 
that  fermentation  and  putrefaction  depend  upon  the 
introduction  of  living  germs  into  such  infusions.  The 
distinguished  French  physician  Davaine  first  demon- 
strated the  etiological  relation  of  a  micro-organism  of 
this  class  to  a  specific  infectious  disease.  The  anthra.x 
bacillus  had  been  seen  in  the  blood  of  animals  dying 
from  this  disease  by  Pollender  in  1S49,  ^-nd  by  Davaine 
himself  in  1851,  but  it  was  not  until  1S63  that  the  last- 
named  observer  felt  justified  in  asserting,  as  a  result 
of  inoculation-experiments,  that  the  bacillus  was  the 
essential  etiological  factor  in  the  production  of  an- 
thrax. 

In  1S73  the  German  physician  Obermeyer  discov- 
ered the  spirillum  of  relapsing  fever  in  the  blood  of 
patients  suffering  from  that  disease.  The  typhoid  ba- 
cillus was  discovered  by  Eberth,  and  independently  by 
Koch  in  iSSo.  The  same  year  the  present  speaker 
discovered  the  pathogenic  micrococcus,  which  is  now 
recognized  as  the  cause  of  croupous  pneumonia.  In 
18S2  Koch  published  his  discovery  of  the  tubercle 
bacillus.  The  glanders  bacillus  was  discovered  by 
Loeffler  and  Shutz  in  1882  ;  the  bacillus  of  diphtheria 
by  Loeffler  in  1884  ;  the  bacillus  of  tetanus  by  Nico- 
laier  in  the  same  year.  It  was  also  in  this  eventful 
year  that  Koch  published  the  discovery  of  the  chol- 
era spirillum.  Since  these  important  discoveries  our 
knowledge  of  the  pathogenic  bacteria  has  rapidly  in- 
creased, and  it  is  now  demonstrated  that  erysipelas, 
septic;emia,  puerperal  fever,  wound  infections,  boils 
and  abscesses,  peritonitis,  pleurisy,  etc.,  are  due  to 
general  or  local  infection  with  germs  of  this  class. 

Evidently  the  medical  student  of  the  present  day 
must  be  made  familiar  with  these  recent  additions  to 
our  knowledge  of  disease,  and  his  acquaintance  with 
these  microscopic  foes  of  the  human  race  should  be  of 
that  practical  character  which  can  only  be  obtained  in 
the  laboratory. 

I  have  already  occupied  so  much  time  that  I  can 
refer  but  briefly  to  the  advancement  in  clinical  medi- 
cine, which  depends  largely  upon  additions  to  our 
knowledge  already  referred  to.  The  use  of  the  steth- 
oscope, the  clinical  thermometer,  the  laryngoscope,  the 
ophthalmoscope,  and  other  aids  to  diagnosis  has  intro- 
duced certainty  in  place  of  uncertainty,  science  in 
place  of  guess-work.  Our  knowledge  of  the  patho- 
genic bacteria  tells  us  not  only  where  to  find  them, 
but  how  to  destroy  them  when  they  are  accessible 
to  the  action  of  physical  or  chemical  agents.  This 
knowledge  has  undoubtedly  resulted  in  the  saving  of 
thousands  of  valuable  lives.  This  has  been  accom- 
plished by  means  of  antiseptic  or  aseptic  methods  in 
surgical  and  obstetrical  practice,  and  by  the  intelligent 
use  of  disinfectants  for  the  destruction  of  infectious 
material,  wherever  it  may  be  found.  As  a  result  of 
such  procedures  we  have  during  recent  years  escajjed 
any  devastating  epidemic  of  cholera  or  yellow  fever, 
although  the  first-mentioned  disease  has  twice  been 
introduced  into  the  harbor  of  our  principal  seaport, 
and   yellow    fever   prevails  annually  in    the   cities   of 


Havana  and  Vera  Cruz,  with  which  we  have  close 
commercial  relations. 

The  medical  student  is  expected  to  prepare  himself 
for  continuing  the  work  of  his  predecessors  in  preven- 
tive medicine,  although  this  work  has  a  constant  ten- 
dency to  diminish  the  demand  for  his  services.  To 
the  credit  of  our  profession  be  it  said  that  this  selfish 
point  of  view  has  ne\  er  controlled  its  action,  and  it  is 
largely  to  the  efforts  of  physicians  that  existing  laws 
and  regulations  have  been  enacted  for  the  prevention 
of  the  extension  of  infectious  diseases,  the  maintenance 
of  a  pure  water  supply  for  towns  and  cities,  and  gen- 
eral sanitary  supervision  exercised  by  local  and  State 
boards  of  health. 

The  most  notable  recent  additions  to  our  therapeu- 
tic resources  are  the  antitoxins  of  diphtheria  and  of 
tetanus,  and  the  use  of  thyroid  extract  for  the  cure  of 
myxoedema.  But  I  cannot  dwell  upon  the  possibilities 
in  the  way  of  specific  medication,  which  are  suggested 
by  these  recent  achievements  of  scientific  medicine. 
Certainly,  I  have  said  enough  to  indicate  to  the  young 
man  who  contemplates  entering  upon  the  study  of 
medicine,  that  his  best  energies  will  be  needed  to  mas- 
ter all  the  important  details  in  the  various  branches  to 
which  reference  has  been  made  ;  and  to  justify  the 
Medical  Faculty  of  the  University  of  Georgetown  in 
extending  the  hours  for  instruction  and  in  requiring 
that  students  shall  take  the  practical  laboratory  courses, 
which  have  been  arranged  for,  as  announced  in  the 
recent  "  Circular  of  Information  "  already  referred  to. 

Having  attempted  to  give  you  some  idea  of  the  pres- 
ent status  of  scientific  medicine,  I  desire  briefly  to  call 
your  attention  to  certain  matters  which  are  extremely 
discouraging  for  the  truly  scientific  physician,  although 
he  seldom  refers  to  them,  and,  perhaps  wisely,  trusts 
to  time  and  the  diffusion  of  knowledge  to  remedy  the 
evils  to  which  I  shall  refer. 

Hand  in  hand  with  the  progress  of  medical  science 
we  see  an  army  of  pseudo-scientific  quacks  who  trade 
upon  the  imperfect  knowledge  of  the  masses,  and  by 
plausibly  written  advertisements  convince  many,  even 
of  the  educated  classes,  that  their  particular  method  of 
treatment  is  based  upon  the  latest  scientific  discoveries. 
A  Priestley  discovers  oxygen  ;  the  physiologists  show 
that  this  gas  is  essential  to  life,  and  that  the  mainten- 
ance of  a  full  degree  of  vital  activity  depends  upon 
the  possession  of  healthy  lungs  of  ample  capacity  and 
the  respiration  of  pure  air  :  the  scientific  physician 
discovers  defects  in  the  respiratory  apparatus,  and  un- 
der certain  circumstances  prescribes  oxygen  for  the 
relief  of  symptoms  resulting  from  a  deficient  supply  of 
this  life-sustaining  gas.  But  the  pseudo-scientist  ex- 
tols oxygen  as  a  cure-all  for  pulmonary  complaints,  or 
invents  an  apparatus,  which  may  be  held  in  the  hand 
or  carried  in  the  pocket,  by  which  oxygen  will  be  ab- 
sorbed in  some  mysterious  way,  and  without  difficulty 
obtains  numerous  certificates  as  to  the  marvellous  cures 
effected  by  his  method.  A  Franklin  draws  lightning 
from  the  clouds  ;  a  Galvani  shows  that  an  electrical 
current  may  be  developed  by  the  contact  of  metals 
and  that  such  a  current  causes  muscular  contraction  ; 
and  innumerable  patient  investigators  add  to  our 
knowledge  of  electricity.  The  scientific  physician 
avails  himself  of  this  potent  agent  for  the  treatment  of 
certain  ailments,  in  which  it  appears  to  be  indicated, 
but  admits  that  he  meets  with  many  disappointments 
in  his  clinical  experiments.  The  pseudo  -  scientific 
quack  writes,  or  has  written,  advertisements  in  which 
fact  and  fiction  are  so  commingled  that  even  educated 
persons  may  be  deceived,  and  having  aroused  interest 
in  the  alleged  therapeutic  value  of  this  mysterious 
agent  offers  his  electric  belt,  or  finger- ring,  made  of 
two  metals,  or  pocket  battery,  as  a  sure  cure  for  certain 
specified  ailments  ;  or,  if  less  modest  and  more  certain 
of  the  credulity  of  the  public,  as  a  cure  for  all  of  the 
diseases  to  which  man  is  subject.  Again,  a  Pasteur 
proves  that  the  disease  of  sheeji  and  cattle  known  as 


512 


MEDICAL    RECORD. 


[October  12,  1895 


anthrax  is  due  to  a  microscopic  organism  found  in  the 
blood  ;  an  Obermeyer  discovers  a  different  micro-or- 
ganism in  the  blood  of  relapsing  fever  patients,  and 
numerous  patient  workers  in  laboratories  rapidly  add 
to  our  knowledge  of  pathogenic  bacteria.  Then  comes 
the  man  with  the  microbe  killer.  He  tells  you  that  all 
diseases  are  due  to  germs  in  the  blood  and  that  his 
fluid  kills  them  without  fail.  Science  has  demon- 
strated that  comparatively  few  of  the  infectious  dis- 
eases of  man  are  due  to  the  presence  of  pathogenic 
bacteria  in  the  blood,  and  that  the  microbe-killer  has 
but  little  germicidal  value  ;  but  a  credulous  public  ac- 
cepts the  interested  statements  which  appear  to  have  a 
scientific  basis,  and  swallows  the  microbe-killer  with 
impunity,  if  not  with  benefit.  And  so  it  goes,  science 
establishes  the  value  of  thyroid  extract  for  the  cure  of 
myxoedema,  and  immediately  the  public  are  called  upon 
to  swallow  extracts  of  brain  for  cerebral  troubles  ;  of 
heart,  for  cardiac  disease,  etc.  Even  the  Chinese  pulse- 
doctors  obtain  a  large  clientele  on  the  Pacific  coast. 
Their  solemn  looks  and  pretentious  claims  impose 
upon  the  ignorant,  and  it  is  said  that  educated  people 
not  infrequently  consult  them.  It  is  true  that  in  China, 
as  elsewhere,  there  are  two  classes  of  physicians. 
Those  who  are  educated  and  who  are  familiar  with  the 
medical  classics  of  their  country,  and  the  itinerant 
quacks,  who  are  not  only  ignorant  but  unprincipled. 
No  doubt,  the  regular  practitioner  in  China  believes  in 
his  own  pseudo-science.  According  to  a  recent  au- 
thor,* "  the  learned  Chinese  doctor  is  not  ignorant  in 
the  sense  that  he  has  not  studied,  as  from  early  youth 
he  has  been  subjected  to  a  degree  of  cramming  and  of 
learning  by  rote,  such  as  would  discourage  and  wear 
out  the  less  patient  and  less  toiling  Caucasian.  He  has 
been  obliged  to  learn  stacks  of  sacred  precepts  taken 
from  their  most  ancient  sages  ;  and  the  admixture  of 
intricate  and  bewildering  astronomy,  meteorological 
signs,  and  endless  physical  complication  of  concurrent 
signs,  appearances  and  detached  disturbances,  that  he 
has  been  compelled  to  learn  by  heart,  is  simply  appall- 
ing. Anatomy  and  physiology  cut  no  figure  in  these 
studies  and  they  are  considered  wholly  unnecessary, 
as  disease  is  a  matter  depending  on  good  or  bad  va- 
pors, and  is  either  of  divine  or  diabolical  origin.  In 
spite  of  their  most  elaborate  treatises  upon  the  pulse, 
from  which  they  profess  to  be  able  to  perform  the 
most  skilful  diagnosis,  they  are  even  unacquainted  with 
the  existence  of  the  circulation." 

The  time  at  my  disposal  will  only  admit  of  a  brief 
reference  to  the  Chinese  theories  relating  to  disease 
and  its  treatment.  As  was  the  custom  among  the  more 
enlightened  Occidental  nations,  until  a  comparatively  re- 
cent period,  their  prescriptions  often  contain  twenty  or 
more  ingredients,  apparently  given  with  a  vague  idea 
that  one  out  of  the  number  may  prove  to  be  the  right 
remedy.  These  ingredients  are  obtained  from  all  im- 
aginable sources  and  include  all  kinds  of  nastiness,  in 
the  way  of  excretions,  desiccated  animal  tissues,  etc. 
With  them  the  color  of  a  medicine  is  an  essential  char- 
acter :  red  medicines  being  suit.ible  for  diseases  of  the 
heart ;  white,  for  pulmonary  complaints  ;  black,  for  dis- 
eases of  the  kidneys  ;  green,  for  those  of  the  liver  ;  and 
yellow,  for  those  of  the  stomach.  In  the  use  of  reme- 
dies from  the  vegetable  kingdom  the  leaves  and 
branches  are  most  appropriate  for  diseases  of  the  ex- 
tremities, the  bark  should  be  used  for  skin  diseases,  the 
pith  for  derangements  of  internal  parts  of  the  body, 
etc. 

In  conclusion,  I  desire  to  emphasize  the  fact  that 
learning  does  not  enable  a  man  to  distinguish  be- 
tween science  and  pseudo-science.  The  learned  dis- 
ciples of  Conf\icius  in  the  Orient,  and  classical  schol- 
ars of  the  pre-scientific  epoch  in  Occidental  countries, 
formerly  failed  to  distinguish  between  the  fact  of  as- 
tronomy and  the  fancies  of  astrology.     And.  at    the 

'  Dr.  p.  C.  Remondino.  of  San  Diego,  Cal. 


present  day,  eminence  as  a  classical  scholar,  or  as  a 
theologian,  or  as  a  jurist,  or  as  a  metaphysician,  in  the 
absence  of  a  knowledge  of  the  methods  and  results  of 
modern  scientific  investigation,  does  not  enable  a  man 
to  distinguish  between  science  and  pseudo-science  in 
medical  practice.  This  kind  of  learning  is  therefore 
not  essential  for  the  physician  ;  but,  as  we  insisted  at 
the  outset,  he  should  not  enter  upon  the  study  of  medi- 
cine without  having  at  least  a  thorough  knowledge  of 
his  own  language  and  of  those  branches  of  study  pur- 
sued in  the  high  schools  of  our  large  cities  ;  we  now  add 
that  a  reading  knowledge  of  the  French  and  German 
will  be  very  desirable,  if  he  wishes  to  keep  entirely  au 
courant  with  the  progress  of  medical  science. 


A  CASE  OF  EXTENSIVE  TRAUMATIC  BRAIN 
LESION  WITH  VERY  MEAGRE  OBJECTIVE 
SYMPTOMS. 

By  a.   HRDLICKA,  M.D., 

STATE   HOSPITAL,    MIDDLETOWN,   N.   V. 

It  is  almost  inconceivable  how,  in  the  light  of  our  pres- 
ent knowledge  of  brain  functions  and  their  localiza- 
tion, extensive  brain  lesions  may  exist  with  objective 
and  even  subjective  signs  of  them  almost  wanting. 
Can  ounces  of  the  most  important  of  tissues  be  de- 
stroyed without  it  having  an  effect  on  the  system  in 
general  ?  Should  we  obey  simply  our  reason  and  logic, 
this  would  appear  impossible  ;  it  would  seem  that  the 
deficiency  of  sj-mptoms  is  not  due  to  their  absence, 
but  rather  to  their  strange  and  subtile  nature,  that 
evades  our  poor  means  of  investigation.  Gross  experi- 
ence, however,  and  especially  such  illustrations  as  the 
following,  would  seem  to  sustain  the  former  conclu- 
sion. 

The  case  reported  here  has  been  from  the  first  to  the 
last  day  under  my  steady,  more  or  less  direct,  observa- 
tion ;  mine  was  also  the  post-mortem  examination,  and 
these  causes,  combined  with  rareness  and  general  in- 
terest of  the  case  will,  I  hope,  authorize  its  somewh..-.- 
extended  report. 

The  case  is  that  of  a  young  Scotchman,  aged  twen:\ 
eight,  who  acquired  gonorrhoea,  followed  by  orchiti-. 
lost  work  on  this  account,  got  depressed,  and,  on  July 
i8,  1894,  shot  himself.  Dr.  Swartout,  of  Port  Jervis 
Hospital,  under  whose  care  the  suicide  was  committed, 
informs  me  of  the  following  : 

W.  D was  admitted  to  our  hospital  July  18,  iSi).;. 

at  10.30  P.M.,  with  a  pistol-shot  wound  of  the  abdomen 
and  of  the  head  just  back  of  the  right  ear.  He  was  a 
coachman  at  Glen  Spey,  N.  V.,  twelve  miles  distant, 
and  was  transferred  here  in  a  carriage,  having  received 
the  wounds  the  forenoon  of  the  same  day.  On  exam- 
ining the  case  we  deemed  it  not  a  case  for  operation, 
dressed  the  wounds  antiseptically,  and  treated  him  on 
the  expectant  plan,  thinking  it  would  be  only  a  few 
days  before  he  would  die.  On  removing  the  temporar\ 
dressing  from  the  head  about  one-half  ounce  of  brain 
matter  exuded.  He  remained  in  a  semi  comatose,  and 
at  times  wandering,  condition,  until  about  August  2d  or 
3d,  when  he  became  thoroughly  insane,  and  so  noisy 
that  he  disturbed  the  rest  of  our  patients,  and  on  .\\\- 
gust  4th  he  was  transferred  to  the  Middletown  State- 
Hospital.  He  was  thought  to  have  suffered  with  tem- 
porary melancholia  before  inflicting  on  himself  the 
wound. 

On  August  4th  the  patient  was  admitted  to  the  Mid- 
dletown State  Hospital  in  the  following  condition  : 
Temperature,  98.8°  F.  ;  pulse,  90,  soft  ;  tongue  clean  ; 
pupils  dilated :  bowels  and  urine  normal ;  appetite 
fair ;  heart  feeble.  No  paresis.  Would  not  speak. 
(Committing  certificate  speaks  of  some  facial  paralysis, 
which  cannot  be  detected.)     Wound,  situated  in  the 


October  12,  1895] 


MEDICAL   RECORD. 


5^3 


right  lower  part  of  the  abdomen,  almost  healed  :  the 
one  behind  the  ear  open  and  slightly  discharging. 
Bed-sores  over  sacrum.  Acknowledges  that  he  shot 
himself.  Hearing  on  the  right  side  deficient.  The 
temperature  on  the  second  day  rose  to  100.6°  F.  ;  but 
did  not  again  exceed  100 '^  F.  The  pulse  varied  between 
60  and  84. 

In  a  general  way  the  patient  became  very  sensitive. 
and  often  complains  of  pain  in  the  head  on  .least  mo- 
tion. At  times  appears  to  be  in  a  kind  of  stupor  and 
does  not  clearly  comprehend  then  what  is  said.  Sleeps 
and  eats  well. 

August  loth  and  nth. — No  discharge  from  the  wound 
on  the  head  ;  bed-sores  improving ;  mentally  much 
brighter  :  anxious  to  get  well. 

August  19th. — Wound  begun  to  discharge  little 
thick,  yellow  pus. 

September. — Doing  very  well ;  slightly  costive. 

October  13th. — Mental  improvement  continuous. 
Complains  occasionally  of  "  clicking  "  in  his  head  ;  lit- 
tle hypochondric  at  times. 

October  29th. — Two  convulsive  attacks,  at  10.30  a.m. 
and  12.5  P.M.  respecrively.  The  convulsions  came  unex- 
pected, and  were  general  in  character.  After  the  sec- 
ond the  patient  slept  three  hours  ;  no  recollection,  on 
waking,  of  any  attack.  No  disturbance  of  any  of  the 
special  senses. 

November. — Nothing  abnormal. 

December  17th. — A  convulsion,  similar  to  the  two 
pre\-ious,  at  3  p.  m.  ;  sleep  nil  night  after. 

January  i,  1895. — Another  convulsive  attack  this 
A.M.  ;  fell  out  of  bed  during  it  without  warning. 

January  5th. — Another  fit ;  nearly  kicked  off  his  left 
big  toe-nail. 

January  loth,  a.m. — Vomited,  and  had  a  rapid  rise 
of  temperature  to  101.2°  F.,  and  an  almost  equally 
sharp  decline  to  normal  the  following  day. 

January  12th.  —  Coming  and  going  pains  in  the 
head. 

January  i6th. — Head  aches  all  over. 

January  21st. — Irritable,  unreasonable. 

January  31st. — Splitting  headache. 

February  2d. — Very  weak  ;  depressed  ;  refuses  to 
eat  :  stubborn,  fault  finding. 

February  3d. — -\  sharp  pain  in  the  right  temple  over 
the  eye. 

February  19th. — A  bit  of  triangular  bone  removed 
from  the  wound. 

March  ist. — Headache  ;  groaning  ;  sullen  ;  sleepy  ; 
did  not  eat  breakfast  ;  complains  of  continuous  pain 
through  the  head  in  the  region  of  the  wound  ;  consid- 
erable nausea.     Hearing  on  right  still  deficient. 

March  3d. — Headache  terrible,  shooting,  splitting. 

March  5th. — Headache  continuing  ;  the  patient 
reasonable,  desires  an  operation.  His  wish  was  com- 
plied with.  .\n  exploratory  incision  was  made,  and 
three  large  fragments  of  the  inner  table,  all  loose  and 
pressing  on  the  brain,  were  removed.  Patient  stood  the 
operation  very  well,  and  after  it  slept  quietly.  His 
general  condition  improved  markedly,  and  remained  so 
until  the  loth,  when  he  grew  again  restless  and  begun 
to  complain  of  renewed  headache.  From  this  day  un- 
til the  17th  his  condirion  was  as  favorable  as  could  be 
wished.  He  had  no  more  convulsions  since  the  oper- 
ation. Never  complained  of  any  disturbance  of 
sight. 

March  17th. — Wound  in  good  condition;  incision 
healed  by  first  intention.  The  patient  looks,  acts,  and 
talks  better  than  he  has  for  weeks.  Says  his  head 
feels  easy.  At  4  p.m.,  while  the  wound  was  being  re- 
dressed the  patient  vomited  and  became  temporarily 
weak  and  dull.  At  S.15  p.m.  began  suddenly  having 
convulsions,  general,  almost  continuous,  but  not  very 
severe.  Convulsions  stopped  at  9.30  ;  breathing  begun 
to  assume  stertorous  character  ;  unconsciousness  set 
in  ;  temperature  rose  to  103  J^°  F.  ;  pulse,  76  ;  respira- 
tion, 30  ;  pupils  dilated  ;  exitus  lethalis  at  11.55  p.m- 


Autopsy,  March  iSth,  10  a.m.  Inspection. — Body 
moderately  nourished,  symmetrical,  face  very  anaemic. 
Rigor  mortis  very  marked.  Scrotum  loosely  pending, 
discolored,  brownish.     A  drop  of  pus  in  urethra. 

Signs  of  Injuries. — A  pouch-like  healed  scar  on  the 
right  side  of  the  abdomen,  two  inches  above  the  ante- 
rior superior  spine  in  McBumey's  line.  A  round 
with  extruding  tissues  filled  opening  on  the  right  side 
in  the  skull,  an  inch  and  a  half  above  the  tip  of  the 
mastoid  process,  and  two-thirds  of  an  inch  behind  the 
junction  of  the  exterior  ear  with  the  scalp.  From  this, 
leading  upward  and  forward,  an  irregularly  healed  cica- 
trix (incision). 

Section. — Scalp  thick,  well  nourished.  In  the  im- 
mediate vicinity  of  the  wound  and  upward,  along  the 
incision  line,  subcutaneous  tissues  thickened,  discol- 
ored light  brown,  and  slightly  soaked  with  thick  pus. 
Discoloration  of  the  scalp  tissues  all  over  the  occiput 
on  the  right  and  below.  At  the  lower  edge  of  the 
wound,  under  the  skin,  is  lodged  a  shell  of  a  buUet. 
On  removing  the  periosteum  the  opening  in  the  skull  is 
found  to  be  almost  regularly  circular,  of  almost  half  an 


Fig.  1. — I,  External  wound  ;  2,  anicnor  iiac:ure  ;  3,  poslerior  fracture 

inch  in  diameter.  The  edges  are  slightly  serrated,  but 
thin  and  dull.  Running  upward  and  forward  for  two 
and  a  half  inches  is  a  fracture  of  the  skull,  with  both 
ends  healed  and  the  middle  so  open  that  it  admits  the 
tip  of  the  scalpel  easily.  Running  backward  and 
downward,  in  almost  the  opposite  direction  from  the 
first,  is  a  second  fracture,  all  healed,  and  traceable  for 
about  one  inch  distance.  Through  the  opening  itself  pro- 
trude, like  a  bunch,  some  velvety,  tough  tissues.  Skull- 
cap very  thin,  but  mostly  compact.  Ethmoidal  rostrum 
very  high  (three-fourths  inch).  No  adhesions  to  the 
bone,  no  further  signs  of  injury.  The  opening  pre- 
sents the  same  characteristic  from  inside  as  it  did  from 
outside.  Dura  hyperaemic  ;  through  it  loom  greatly  con- 
gested vessels  of  the  pia.  Meningeal  fluids  diminished. 
Adhesions,  moderate,  along  the  margin  of  both  hemi- 
spheres in  the  median  line,  from  the  first  frontal  to  the 
first  occipital  convolutions.  Surface  of  the  brain  uni- 
formly discolored  dull  yellow  ;  consistency  augmented. 
Right  temporo-sphenoidal  lobe  soft ;  when  partially 
lifted  up  it  is  found  surrounded  with  a  small  quantity 
of  pus,  which  is  similar  in  character  to  that  found  on 
the  outside  of  the  skull.  Around  the  wound,  to  the 
e.x-tent  of  three  inches  vertically,  and  two  antero-pos- 
teriorly,  all  the  meninges  are  firmly  adherent  together 
and  thus  to  the  brain  substance,  which  appears  here  dark 
yellow.  On  trying  to  extract  the  brain  with  these  ad- 
hered membranes,  a  light  tension  induces  a  rupture  in 
the  brain  substance  of  the  temporo-sphenoidal  lobe,  and 
from  this  opening  wells  out  about  an  ounce  and  a  half 
of  thin,  greenish,  odorless,  flatulent  pus.  and  with  it 
another  small  shell  of  a  bullet.     On  closer  examination 


5H 


MEDICAL    RECORD. 


[October  12,  1895 


almost  the  whole  temporo-splienoidal  lobe  is  found  de- 
stroyed, what  is  not  pus  being  softened.  In  the  direc- 
tion of  the  wound,  and  slightly  upward,  the  finger  de- 
tects some  hard,  irregular,  firmly  embedded  body.  The 
whole  encephalon,  minus  the  jjus  escaped,  is  found  to 
weigh  fifty-six  ounces.  Base  of  both  brains  hyper- 
aemic.     Left  half  of  the  pons  larger  than  the  right. 

The  brain  was  taken  to  the  hospital  for  further  ex- 
amination, which  revealed  the  following  :  On  cutting 
down  to  the  hard  body  another,  double  cavity,  as  it 
later  proved,  was  opened,  and  from  it  escaped  about 
twelve  drachms  of  thick,  also  odorless,  grass,  or  rather 
malachite-green,  pus.  These  cavities  occupied  the  po- 
sition between  the  termination  of  the  fissure  of  Sylvius, 
gyri  supramarginal  and  angular,  and  sulcus  occipital 
anterior,  and  above  the  sulci  temporalis  super  and 
occipital  lateral ;  they  just  reached  to  the  internal  cap- 
sule in  front,  and  did  not  communicate  with  the  lateral 
ventricle.  The  wound  itself  was  situated  in  the  first 
temporal  convolution,  underneath  and  behind  the  lower 
termination  of  fistula  .'^ylvii,  and  extended  for  an  inch 
and  a  quarter  into  the  brain  substance.  The  course  of 
the  wound  was  filled  up  with  tough  connective  tissue  ; 


To  the  end,  let  it  be  added,  that  the  patient's  mental 
condition  was  always  much  nearer  simple  hypochon- 
dria than  insanity,  and  also,  that  his  intelligence  was 
rather  above  the  average,  so  that  no  sjTtiptoms  could 
have  been  lost  thiough  one  or  the  other  of  these  rea- 
sons. 


at  its  inner  termination  were  lodged,  also  surrounded 
by  fibrous  tissue,  four  small  fragments  of  the  skull,  and 
the  lower  crushed  half  of  a  pistol-bullet,  No.  32.  Gray 
matter  of  the  cerebrum  was  found  pale  -  yellowish, 
rather  thin.  Ventricles  filled  with  clear  fluid.  Puncta 
vasculosa  abundant  throughout  the  white  matter.  Basal 
ganlglia,  medulla,  and  cerebellum  normal. 

Thoracic  Organs. — Lungs  free,  congested,  especially 
the  left  ;  pleural  cavity  contains  about  a  pint  of  san- 
guinolent,  dark,  odorless  fluid.  Heart  and  great  blood- 
vessels normal. 

Abdominal  Organs. — The  scar  in  the  right  hypogas- 
trium  extends  straight  down  through  the  muscles  and 
peritoneum,  presenting  in  its  whole  course  a  dark  dis- 
coloration. The  internal  mark  of  it  lies  right  over  the 
head  of  the  c»cum,  but  nor  this,  nor  the  underlying 
very  long  appendix,  nor  any  of  the  intestines  or  struct- 
ures in  the  neighborhood  show  the  slightest  signs  of 
injury,  nor  could  the  bullet  be  found  after  the  most 
careful  examination.  Stomach,  liver,  and  pancreas 
normal  ;  spleen  large,  dark  (weight  fifteen  ounces)  ; 
kidneys  both  congested,  right  larger  ;  intestines  nor- 
mal ;  bladder  very  full  ;  testicles  in  a  state  of  sub- 
acute inflammation. 

On  resuming,  we  find  the  following  points  of  interest 
in  this  case  :  i.  Temporary  paralysis  of  the  facial  mus- 
cles ;  2,  prolonged  subnormal  respirnlion,  pulse,  and 
even  temperature  ;  3,  no  interference  with  assimilation 
and  sleep  ;  4,  absence  of  paresis,  normal  pupils  ;  5,  some 
mental  excitement,  followed  by  mental  clearing,  and 
ending  on  the  day  of  death,  with  unusual  brightness 
and  ease  ;  6,  after  four  months  the  appearance  of  con- 
vulsions bearing  epileptic  character  ;  their  probable 
disappearing  after  the  operation  ;  7,  considerable  loss 
of  hearing  on  the  wounded  side,  but  no  disturbance 
whatever  of  any  other  of  the  special  senses. 


A  SUBSTITUTE  FOR   THE    TR.^CHEA  TUBE. 
Bv   \V.    N.    MACARTNEY,  M.D., 


Ox  several  occasions  during  the  past  few  years  I  have 
used,  in  the  operation  of  tracheotomy,  a  little  appliance 
— I  can  hardly  dignify  it  by  the  name  of  instrument — 
as  a  substitute  for  a  trachea  tube,  and  it  has  invariably 
given  me  such  perfect  satisfaction  that  it  has  seemed 
to  me  proper  to  give  a  description  of  it  in  the  hope 
that  it  may  render  others  an  equal  service. 

The  appliance  is  simply  a  wish-bone-shaped  piece 
of  wire,  intended  to  keep  the  edges  of  the  tracheal 
wound  sufficiently  retracted  to  permit  easy  respiration 
and  to  be  self-retaining. 

It  has  some  essentially  practical  advantages  in  cer- 
tain cases  over  the  trachea  tube  :  in  its  adaptability, 
for  it  can  be  made  to  answer  the  purpose  nicely  in  al- 
most any  conceivable  case  of  tracheotomy  or  laryngot- 
omy  :  in  its  availability,  for  it  can  be  made  at  almost 
any  time  and  at  anyplace  at  a  moment's  notice  ;  in  its 
economy,  for  it  costs  absolutely  nothing,  which  is  cer- 
tainly more  than  can  be  said  of  the  trachea  tube. 

Of  late  years  the  use  of  O'Dwyer's  tubes  has  materi- 
ally diminished  the  number  of  cases  in  which  trache- 
otomy is  necessary,  but  there  yet  remains  a  large 
class  of  cases  of  laryngeal  stenosis  from  various  causes, 
for  which  intubation  is  either  not  adapted,  or  for  other 
reasons  cannot  be  performed,  so  that  the  operation  of 
tracheotomy  is  destined  to  hold  a  legitimate  and  useful 
place. 

For  instance,  the  country  practitioner  finds  himself 
miles  from  home,  perhaps  leagues  from  a  brother  prac- 
titioner, and  confronted  with  a  severe  case  of  laryngeal 
obstruction.  It  may  easily  happen  that,  not  knowing 
the  nature  of  the  case  when  called,  he  finds  himsel' 
without  the  proper  appliances  for  its  relief.  The  case 
is  urgent,  perhaps  very  urgent.  He  must  operate  at 
once  or  let  the  patient  die.  There  is  no  time  to  send 
to  the  city  for  a  surgeon,  who  might  possibly  arrive  in 
time  for  the  funeral  sermon,  or  for  that  matter,  to  send 
home  for  a  trachea  tube. 

Again,  take  the  practising  physician  in  the  city.  He 
also  has  an  urgent  case.  His  patient  is  cyanosed,  or 
perha])S  when  he  has  reached  the  bedside  respiration 
has  just  ceased.  Will  he  delay  to  call  in  capable  as- 
sistants, to  procure  a  set  of  O'Dwyer's  tubes,  to  secure 
a  tracheal  cannula  of  proper  size  and  correct  curve,  to 
have  everything  on  hand  which  may  possibly  be  re- 
quired, and  to  take  every  precaution  in  regard  to  anti- 
sepsis, or  will  he  operate  at  once  ? 

It  is  true  that  these  are  emergency  cases,  but  they 
are  not  overdrawn.  I  have  had  to  operate  more  than 
once  under  similar  circumstances,  and  it  has  been  my 
fortune  to  see  others  operate  at  a  moment's  notice.  I 
have  seen  Dr.  Stuart  Douglas,  then  resident  physician 
to  the  insane  at  Bellevue,  open  the  trachea  at  midnight 
with  a  penknife.  He  did  not  practise  surgery  ordinari- 
ly. I  have  no  doubt  he  would  have  preferred  daylight 
and  a  scalpel,  but  there  was  not  a  moment  to  lose  and 
he  had  the  courage  of  his  convictions. 

I  recall  a  similar  instance  happening  shortly  after 
where  the  operation  was  done  in  much  the  same  way. 
There  was  no  lack  of  instruments  in  a  neighboring 
ward,  but  there  was  not  a  second  to  waste.  Then  again 
I  saw  a  man  suffering  from  a  severe  case  of  Ludwig's 
angina  or  submaxillary  cellulitis.  The  swelling  was 
immense,  increased  rapidly,  the  cellular  tissue  in  the 


I 


October   12,  1895] 


MEDICAL    RECORD. 


515 


floor  of  the  mouth  was  gangrenous.  He  could  not 
swallow,  could  not  open  his  mouth,  and  respiration  was 
extremely  difficult.  He  finally  became  cyanosed,  and 
immediate  preparations  were  made  for  a  tracheotomy 
by  the  attending  surgeon,  Dr.  S.  J.  White,  now  of 
Franklin,  N.  Y.  Before,  however,  the  preparations 
were  complete  the  man  suddenly  ceased  to  breathe,  be- 
came pulseless,  and  to  all  appearances  was  dead.  Dr. 
White  seized  a  scalpel  and  with  two  rapid  but  sure 
strokes  of  the  knife  had  the  trachea  open.  Five  min- 
utes later,  respiration  having  been  established  by  the 
usual  means,  he  was  sitting  up  in  bed  with  a  good  pulse 
and  breathing  easily. 

Another  case  in  point :  I  was  hurriedly  called  to  a 
case  of  deep-seated  abscess  of  the  throat.  The  patient 
was  breathing  with  greaj^ifficulty.  Ether  was  given, 
I  evacuated  the  abscess,  which  contained  about  half  a 
pint  of  pus,  but  respiration  became  rapidly  worse,  and 
before  I  had  laid  the  knife  aside  he  ceased  to  breathe 
and  became  pulseless.  Artificial  respiration  and  other 
measures  failed.  A  hurried  examination  showed  oede- 
ma of  the  glottis.  I  could  have  procured  an  intuba- 
tion set  or  a  trachea  tube  in  three  minutes.  But  I 
could  open  the  trachea  and  save  two  minutes  and 
three-quarters,  and  I  did.  The  patient  never  found 
any  fault  with  me  for  doing  it  hurriedly,  though  he  has 
had  some  years  of  good  health  in  which  to  think  it 
over. 

These  are  merely  illustrative  cases.  Instances  of  this 
kind  have  occurred  and  may  occur  at  any  time  to  any 
of  us.  I  could  cite  others  from  my  own  personal 
knowledge,  but  it  is  unnecessary. 

It  is  an  axiom  that  every  practising  physician,  no 
matter  what  branch  or  specialty  he  may  follow,  should 
be  able  to  open  a  trachea  properly  and  rapidly  in  an 
emergency.  He  may  be  called  upon  to  do  it  on  short 
notice,  in  the  absence  of  skilled  assistants,  and  without 
all  the  instruments  which  he  might  desire.  Perhaps  he 
has  not  an  intubation  set  ;  he  may  not  have  even  a 
trachea  tube,  and  it  may  even  be  that  none  of  his 
brother  practitioners  wiThin  easy  reach  has  one.  Prob- 
ably he  has  a  tube  or  two,  but  not  one  of  the  proper 
size  or  shape  for  the  particular  case  in  hand.  In  such 
a  case  will  he  wait  for  the  mails  to  bring  him  one  from 
the  instrument-maker  ? 

If  tracheotomy  is  necessary,  and  a  trachea  tube  of  the 
proper  curve,  calibre,  and  construction  is  not  at  hand, 
what  must  he  do  ?  Theoretically  he  should  open  the 
trachea  at  once.  But  to  use  a  quotation  now  worn 
threadbare,  "  It  is  a  condition,  not  a  theory,  which  con- 
fronts us."  Does  the  average  rank-and-file  practitioner 
not  specially  skilled  in  surgery  do  this  ?  I  am  not 
aware  that  there  are  any  statistics  bearing  on  this  par- 
ticular point.  It  is  to  the  credit  of  the  profession  that 
so  many  physicians  do  operate  under  the  most  adverse 
circumstances.  But  others  find  excuses.  I  know  of 
one  case  at  least  in  point.  The  doctor  had  no  instru- 
ments with  him  for  the  case.  He  was  not  sure  of  his 
operative  skill.  He  was  not  sure  that  the  patient  would 
live  if  he  operated.  He  was  reasonably — very  reason- 
ably— sure  that  she  would  die  if  he  did  not  operate. 
So  he  informed  the  friends  only  of  that  which  lie  was 
"reasonably  "  sure  of.     Good  logic,  but  poor  practice. 

It  seems  to  me  therefore  that  any  suggestion  which 
will  facilitate  the  performance  of  tracheotomy  may  not 
be  wholly  without  value.  The  operation  in  itself  is  not 
difficult  under  ordinary  circumstances.  For  the  delib- 
•erate  operation  the  trachea  tube  is  well  suited  ;  but  for 
the  emergency  cases  this  little  wire  substitute  serves  an 
excellent  purpose,  in  that  an  instrument  always  at  hand 
is  worth  at  least  two  in  the  shop.  It  can  be  made  in  a 
moment  and  a  tube  can  be  sent  for  if  needed  at  the 
doctor's  leisure. 

Another  case  of  a  different  type  :  A  man,  while  en- 
gaged in  his  trade  as  blacksmith,  was  kicked  by  a  horse, 
the  toe  cork  striking  his  larynx.  When  I  first  saw  him 
he  was  enormously  swollen  with  emphysema  from  the 


lower  edge  of  the  sternum  to  the  crown  of  his  head. 
His  neck  was  nearly  as  large  as  his  body,  and  the  in- 
side of  his  mouth  and  throat  was  emphysematous.  He 
was  deeply  cyanosed  and  breathing  with  extreme  dif- 
ficulty. A  diagnosis  of  fracture  of  the  larynx  was  made 
and  his  windpipe  was  opened  with  some  difficulty  ow- 
ing to  the  extravasated  blood  and  the  enormous  depth 
of  tissue  which  covered  the  trachea.  No  tube  could 
be  found  to  reach  the  tracheal  cut,  although  several 
sizes  were  tried  ;  a  substitute  was  used  and  later  an  ex- 
tra long  tube  was  made  purposely  at  an  instrument 
store.  He  had  an  attack  of  pneumonia,  but  recovered, 
and  the  tube  was  removed  after  some  weeks. 

These  are  the  cases  where  our  most  skilful  and  well- 
equipped  surgeons  find  themselves  at  a  disadvantage 
occasionally.  I  have  in  my  office  several  extra  long 
tubes  which  were  made  for  such  cases  as  the  above, 
and  for  cases  of  inoperable  tumors  of  the  neck.  In 
one  case  of  the  latter  kind  we  could  not  find  in  New 
York  City  a  tube  long  enough  to  reach  and  used  a  large 
silver  catheter  for  the  time,  which  proved  a  serviceable 
but  extremely  awkward  arrangement.  Then  there  are 
cases  of  submaxillary  cellulitis,  where  the  jaw  is  tem- 
porarily but  firmly  closed,  and  therefore  an  intubation 
tube  cannot  be  used.  The  swelling  in  the  tissues  of 
the  neck  is  often  so  great  that  an  ordinary  trachea  tube 
will  not  reach.  These  are  cases  also  where  this  little 
substitute  is  applicable  and  in  which  it  fulfils  an  excel- 
lent purpose. 

Laryngotomy  also  calls  for  a  special  tube  flattened 
from  above  downward.  With  this  little  retractor  in  the 
larynx  one  can  wait  for  a  suitable  tube  by  mail,  or  by 
freight  for  that  matter. 

The  first  time  I  used  this  modest  little  substitute  was 
in  a  case  of  foreign  body  in  the  windpipe.  It  had 
been  in  for  some  weeks,  and  the  consulting  surgeons 
opened  the  trachea  and  made  a  thorough  but  unsuc- 
cessful search  for  it.  This  failing,  nothing  remained 
but  to  trust  to  its  natural  expulsion.  Several  trachea 
tabes  were  tried,  but  it  was  very  evident  that  the  for- 
eign body  was  much  too  large  to  escape  through  any 
of  them.  To  meet  the  necessities  of  the  case  it  oc- 
curred to  me  that  a  wire  retractor  could  be  constructed, 
and  this  little  affair  was  the  result.  It  opened  the 
trachea  widely  and  answered  the  purpose  so  satisfac- 
torily that  I  have  used  it  since  then. 

A  very  good  method  of  handling  these  cases — the  so- 
called  operation  without  tubes — is  to  introduce  a  sut- 
ure into  each  side  of  the  trachea  and  fasten  with  an 
elastic  band  behind  the  neck.  Yet  there  are  some  cases 
where  this  procedure  will  not  work  well  ;  and  it  is, 
simple  as  it  seems,  frequently  very  difficult  of  perform- 
ance, particularly  in  those  very  cases  of  emergency  for 
which  it  seems  so  well  adapted  and  for  which  this  same 
procedure  is  recommended.  It  appears  easy,  and  yet, 
with  a  poor  light,  with  great  swelling  of  the  tissues  in 
front  of  the  trachea,  with  a  thick-necked  patient,  in  the 
cases  of  children,  with  a  shuttle-like  trachea  moving 
rapidly  up  and  down,  and  in  the  absence  of  a  properly 
curved  needle  and  a  suitable  needle-holder,  I  have 
found  it  wholly  out  of  the  question. 

The  retractor  which  I  have  used  has  always  an- 
swered every  purpose.  It  reduces  the  number  of  nec- 
essary and  essential  instruments  to  one — a  knife.  It 
does  away  with  all  excuses.  It  is  practically  always  on 
hand,  in  any  place,  at  any  time.  If  a  tracheotomy 
must  be  done  at  a  moment's  notice,  the  handle  of  a 
scalpel,  a  pair  of  forceps,  a  hair-pin,  will  keep  the 
trachea  open  long  enough  for  one  to  be  constructed. 

Stove-pipe  wire  will  do,  or  better,  the  stiffer  tinned 
wire  from  the  stub  of  an  old  broom,  or  from  the  stylet  of 
an  English  catheter.  If  your  patient  has  neither  stove 
nor  broom  in  the  house,  and  there  are  none  in  the  neigh- 
borhood, it  will  be  a  pretty  poor  country  to  live  in  any 
way.  But  in  this  emergency  a  probe  from  your  pocket- 
case  or  a  hair-pin  may  be  bent  up  properly — any  straight 
piece  of  wire,  or  even  a  crooked  piece— which  will  give 


516 


MEDICAL    RECORD. 


[October  12,   1895 


him  a  chance  to  see  a  change  of  administration.  Bend 
the  wire  up  in  the  shape  of  a  wish-bone.  Give  a  turn  in 
the  centre  or  joint  of  the  wish-bone  around  a  lead-pencil 


or  a  thermometer-case,  to  give  it  the  necessary  spring. 
If  stove-pipe  or  other  soft  wire  is  used  give  it  two 
or  three  turns.  Bring  the  sides  parallel.  Bend  up  the 
ends  of  the  wire  so  as  to  form  broad  fenestrated  blades 
or  loops.  Give  these  blades  a  slight  outward  bend  at 
the  ends  to  make  it  self-retaining.  You  can  do  all  this 
with  your  fingers  if  you  have  no  pliers  or  artery  clamps 
handy.  Close  the  blades  and  insert  into  the  tracheal 
slit.  Release  the  blades  and  it  retracts  the  edges  of 
the  tracheal  wound  and  retains  itself.  You  can  make 
one  of  nickelled  wire  the  next  day  if  you  choose.  In 
the  meantime  you  can  go  to  bed. 

To  summarize  and  recapitulate,  this  simple  tracheal 
retractor  is  the  best  device  with  which  I  am  acquainted 
in  cases  of  tracheotomy  for  foreign  bodies  in  the  trachea 
or  bronchi,  where  a  trachea  tube  is  worse  than  useless. 
The  retractor  acting  as  a  speculum  gives  a  free  and 
unobstructed  view  of  the  interior  of  the  trachea,  dilat- 
ing the  opening  to  its  fullest  extent,  and  unlike  the 
trachea  tube,  which  furnishes  an  obstacle  to  the  escape 
of  the  foreign  body,  it  affords  every  facility  for  its  ex- 
pulsion during  one  of  the  coughing  spells. 

It  can  be  adapted  to  any  case  of  tracheotomy  or  of 
laryngotomy  by  making  the  blades  long  or  short, 
curved  or  straight.  Extra  expansile  strength  where 
the  trachea  is  rigid  and  resistant  can  be  secured  by 
making  the  coil  at  the  centre  smaller,  by  doubling  the 
wije,  or  by  using  heavier  wire. 

It  is  useful  as  a  retractor  before  the  trachea  is  open, 
when  in  the  absence  of  help  one  is  compelled  to  do  the 
operation  unaided,  in  retracting  the  skin  while  the 
trachea  is  being  steadied  for  the  incision. 

It  has  never  caused  irritation  or  discomfort,  and  pa- 
tients on  whom  it  is  used  do  not  complain  of  it.  I  have 
often  seen  ulceration  of  the  trachea  caused  by  the 
trachea  tube.  I  have  never  seen  it  occur  with  this.  In 
fact  1  do  not  see  how  it  can  occur  to  any  extent  if  the 
retractor  is  properly  made. 

It  has  no  tendency  to  slip  out  or  in.  It  can  only  get 
partially  displaced  by  swinging  round  at  right  angles  to 
its  proper  position,  when  the  blades  would  then  lie  in 
the  angles  of  the  wound.  This  is  immaterial,  inasmuch 
as  it  will  even  then  keep  the  trachea  as  well  open  as 
before. 

It  will  not  clog  with  mucus  in  the  absence  of  the 
doctor,  and  thus  endanger  the  i)atient's  life  as  tubular 
arrangements  are  prone  to  do. 

It  is  eminently  the  appliance  in  emergency  cases, 
being  always  available,  and,  lastly,  it  costs  absolutely 
nothing. 

One  objection  to  its  use  might  be  in  certain  cases  the 
presence  of  severe  hemorrhage  when  the  trachea  is 
opened.  In  practice  I  have  never  found  it  so.  By  in- 
serting the  retractor  and  turning  the  patient  on  the 
side,  or  sitting  him  up  leaning  slightly  forward,  the 
blood  will  not  run  into  the  trachea,  and  any  bleeding 
vessels  can  be  readily  caught  .ind  ligated  if  need  be 
with  the  retractor  in  situ. 


ROUTINE    MEDICATION    IN   ASYLUM   PRAC- 
TICE. 


By  W.  A.  McCLAIX.  M.D. 


A  STRENUOUS  effort  is  being  made  in  many  States  of  the 
Union  to  divorce  the  public  institutions  of  charity  from 
the  control  of  political  organizations,  and  place  them 
under  the  control  of  non-partisan  boards  of  supervision. 
This  is  certainly  a  praiseworthy  effort  and  will  meet 
the  hearty  approval  of  all  right-minded  citizens,  espe- 
cially among  those  in  the  profession  of  medicine.  I 
desire  more  particularly  to  point  out  the  pernicious  re- 
sults of  political  preferment  in  connection  with  the 
various  hospitals  for  the  in^pe  throughout  the  coun- 
try. For  it  is  in  the  peculiar,  I  might  say  special,  work 
of  these  institutions  that  incompetency  may  not  only 
result  in  loss  to  the  patient  of  the  necessary  intelligent 
treatment  they  demand,  but  it  may  entail  upon  them 
needless  suffering  by  the  unscientific  application  of 
means  at  hand,  and  a  baneful  routine  system  of  medi- 
cation by  unskilled  physicians. 

The  fact  is  patent  and  undeniable  that  of  all  classes 
of  patients  none  call  for  a  more  intelligent  and  scientific 
acquaintance  on  the  part  of  the  physician  with  the 
principles  of  medicine  and  their  application  to  the 
morbid  conditions  of  mankind,  than  do  the  unfortunate 
insane.  That  they  do  not  always  receive  this,  may  bc 
easily  ascertained  by  an  investigation  of  the  methof'.J 
pursued  in  most  any  of  the  institutions  of  the  land. 

In  the  AmeriiLin  Journal  of  Insanity  for  October, 
1894,  appeared  a  criticism  on  Dr.  Weir  Mitchell  s 
address  to  the  Medico-Psychological  Association,  by 
Dr.  Channing,  in  which  he  disagrees  with  Dr.  Mitchell 
in  the  latter's  Utopian  views  of  what  an  institution  for 
the  insane  should  be,  and  how  conducted.  While  we 
admit  that  the  criticism  in  the  main  is  just,  yet  Dr. 
Mitchell  certainly  struck  the  right  chord  in  directing 
attention  to  the  fact  that  a  much-needed  reform  in 
asylum  work  is  a  crying  need.  M'here  this  fault  lies, 
and  upon  who'".i  the  blame  rests  for  such  faults,  I  shall 
endeavor  to  point  out  in  this  paper. 

Having  visited  the  hospitals  for  the  insane  in  many 
States  of  the  Union,  and  having  studied  the  reports 
from  the  majority  in  both  the  United  States  and 
Europe,  I  am  more  than  ever  convinced  that  a  vast 
amount  of  routine  treatment,  so  far  as  medication  goes, 
is  the  rule,  and  the  absence  of  it  the  exception  in 
these  institutions  ;  while  all  alienists  will  admit  that  the 
greatest  benefit  derived  from  these  institutions  is  not 
from  any  course  of  medication,  but  from  gentle  re- 
straint, pleasant  surroundings,  change  of  environment, 
which  the  patients  enjoy,  and  the  regular  life  to  which 
they  are  subjected. 

From  these  sources  we  look  for  the  greatest  good. 
While  these  conditions  in  the  vast  majority  of  cases 
produce  marvellous  results,  yet  they  cannot  take  the 
place  of  careful  medication  in  many  singular  morbid 
conditions  to  be  met  with  among  the  insane.  To  illus- 
trate, let  us  take  the  ward  physicians  in  most  any  of 
our  hospitals  for  the  insane.  They  are  mostly  young 
men  who  have  had  little  or  no  experience  in  general 
practice.  They  have  treated  some  of  the  more  famil- 
iar diseases,  some  of  the  epidemic  diseases  of  child- 
hood, have  read  some  text-book  on  practice,  and  have 
a  very  hazy  idea  of  the  subject  alter  all.  If  a  patient 
is  able  to  describe  to  him  all  his  aches  and  pains,  and 
lay  before  him  a  complete  history  of  his  case,  then, 
according  to  rule  i,  2,  or  3.  he  may  pronounce  the  case 
one  of  asthma,  whether  caused  from  reflex  nervous 
trouble  or  heart  disease,  he  is  not  quite  certain  which. 
The  various  valvular  lesions  of  the  heart  he  has  never 
had  any  clinical  experience  to  enable  him  to  distinguish, 
and  the  curious  murmurs  and  turbulent  sounds  convey 
to  his  intelligence  nothing  of  diagnostic  value. 

And  perchance  it  may  be  lung  trouble  ;  here  again 


October   ]  2,  1895] 


MEDICAL   RECORD. 


517 


the  average  ward  physician  is  all  at  sea.  The  sounds 
he  hears  maybe  all  right  or  all  wrong,  but  he  could 
not  be  qualified  to  determine.  In  fact,  if  one-half  the 
physicians  who  place  their  ear  to  the  chest  in  such  a 
knowing  way  were  asked  by  a  scientific  clinician  to 
state  what  they  heard,  expected  to  hear,  and  what  it  all 
signified,  they  would  stand  speechless  with  doubt  and 
ashamed  of  their  own  pretences  to  knowledge. 

Again,  when  we  come  into  the  domain  of  the  dis- 
eases peculiar  to  women,  how  very  far  from  the  truth 
are  their  professions  and  practices.  In  no  class  of 
practice  are  these  diseases  so  wantonly  neglected  as  in 
asylum  work,  and  no  class  of  cases  demands  so  careful 
and  painstaking  knowledge  as  do  the  manifold  diseases 
of  women.  Owing  to  the  complicated  and  e.xtensive 
nervous  mechanism  of  the  organs  of  reproduction  in 
women,  any  disturbance  in  this  region  must  necessarily 
affect  the  general  nervous  system  very  profoundly,  and 
calls  for  a  critical  examination  to  discover  the  cause 
that  its  removal  may  be  possible. 

But  what  do  we  find  when  we  look  in  this  direction  ? 
While  nearly  all  the  State  hospitals  for  the  insane  are 
thoroughly  equipped  with  all  the  instruments  needed 
for  careful  examination  and  operation,  yet  the  uterine 
sound,  the  speculum,  and  the  curette  are  seldom  or 
never  used.  Why  this  dereliction  of  duty  ?  The  reason  is 
plain  again.  What  have  these  young  and  inexperienced 
physicians  learned  of  the  diseases  of  the  uterus  and  its 
appendages  ?  Their  knowledge  is  usually  so  indefinite 
in  regard  to  these  conditions,  that  anything  they  may 
do  would  be  done  blindly  and  misguidedly.  They 
remember  having  seen  at  the  free  clinics,  when  they 
went  to  college,  some  application  made  to  the  uterus 
by  means  of  a  pledget  of  cotton,  saturated  in  soine 
astringent  solution.  They  go  through  the  same  ma- 
noeuvre, but  just  what  results  they  expect  from  this 
treatment  they  are  not  able  to  state.  And  yet  I  have 
known  poor  deluded  patients  who  submitted  to  this  for 
months,  under  the  impression  they  were  being  treated 
for  womb  disease.  No  amount  of  glycerine  and  tannin 
applied  to  the  neck  of  the  womb  would  ever,  in  the 
least  degree,  arrest  or  mitigate  a  diseased  process  of 
the  tubes.     And  yet  this  is  the  routine  work. 

I  recall  one  instance  in  a  certain  asylum,  in  a  West- 
ern State,  where  a  patient  was  permitted  to  go  home  to 
die  from  some  unknown  disease,  and  yet  there  was 
every  evidence  of  an  enlarged  uterus  many  times  its 
normal  size.  An  examination  in  this  case  had  never 
been  made.  Another  case  was  entered  on  the  books 
as  "  acute  melancholia,"  due  to  domestic  trouble  and 
worry.  The  patient  had  not  menstruated  for  six 
months,  and  yet  there  were  no  indications  of  pregnancy. 
She  was  sent  back  to  the  ward,  and  the  usual  routine 
medicines  were  administered  to  produce  sleep.  The 
patient  did  not  improve,  and  her  family  took  her  home, 
where  she  fell  into  the  hands  of  a  specialist  in  diseases 
of  women.  He  dilated  the  neck  of  the  uterus  and 
curetted  its  cavity,  and  placed  the  patient  on  perman- 
ganate of  potash  and  la,xatives.  The  menstrual  func- 
tion was  re  established  and  her  mind  improved  from 
that  moment.  To  trace  the  exact  cause  and  connect- 
ing links  in  this  case  were  ditificult  indeed,  but  it  is 
evident  it  was  not  organic  brain  disease  alone.  These 
patients  cannot,  as  a  rule,  tell  their  troubles  and  ailments 
in  an  intelligent  manner.  Nor  will  they  usually  answer 
any  questions  put  to  them  by  the  physician,  and  in  such 
cases  the  medical  attendant's  duty  is  plain  and  should 
not  be  shrunk  from — a  careful  and  thorough  examina- 
tion of  every  organ  of  the  body  so  far  as  practicable. 
The  insane  are  subject  to  all  the  other  diseases  one 
meets  with  in  general  practice,  and  it  is  seldom,  indeed, 
that  we  meet  with  a  mental  disorder  independently  of 
other  and  organic  trouble,  if  we  could  only  know  how 
and  where  to  look  for  the  lesion.  One  other  instance 
occurs  to  my  mind  :  A  young  man  was  arrested  lor 
attempted  homicide.  While  in  jail  he  showed  marked 
symptoms  of  insanity.     A  physician  was  called,  the  pa- 


tient was  probated  and  sent  to  an  asylum.  His  case 
was  entered  on  the  books  as  "acute  mania."  He  was 
put  in  the  back  ward.  Of  course  the  young  man  wa& 
insane,  but  why  ?  This  was  not  asked,  but  large  dose& 
of  duboisine  and  morphia  were  given  to  produce  sleep 
and  quiet.  No  careful  examination  was  made  ;  the  case 
grew  worse,  and  in  about  ten  days  the  patient  suddenly 
died.  On  post-mortem  it  was  found  the  cause  of  death 
was  due  to  an  abscess  in  the  mastoid  region,  and  the 
insanity  to  the  meningeal  inflammation.  An  early  rec- 
ognition of  this  condition,  and  a  minor  operation  in 
surgery,  would  in  all  probability  have  saved  the  in- 
dividual's life.  These  are  but  a  few  of  the  many  cases 
of  routine  medication  which  prevails  in  most  of  our  hos- 
pitals for  the  insane. 

It  is  so  easy  to  fall  into  the  habit  of  thinking  that  all 
insane  persons  are  suffering  from  some  mysterious  af- 
fection of  that  still  more  mysterious  and  intangible 
something  called  mind,  and  inasmuch  as  they  know  but 
little  of  the  nature  of  mind,  and  the  normal  processes 
of  thought  and  feeling,  how  can  it  be  possible  for  them 
to  conceive  of  any  method  of  treating  that  which  they 
do  not  understand  and  thus  fail  to  recognize  ? 

Mental  disease  cannot  exist  in  a  perfectly  sound  phys- 
ical organization.  That  this  is  at  variance  with  the 
views  expressed  by  some  authors  on  metaphysics,  I  am 
well  aware,  but  to  assume  otherwise  is  certainly  con- 
trary to  all  we  know  of  the  pathology  of  mind,  and  the 
advanced  writers  on  mental  science  no  longer  speak  of 
the  relation  of  mind  and  brain  as  the  "  player  and  the 
instrument."  Simply  because  we  fail  to  discover  the 
pathological  condition  of  nerve  cells  in  these  cases  is 
no  evidence  that  it  does  not  e.xist.  Our  knowledge  of 
the  minute  anatomy  of  the  brain  and  its  complex  phys- 
iology is  at  present  very  imperfect.  Moreover,  the 
pathological  condition  which  underlies  insanity  —  the 
deep  substrata — may  exist  in  any  other  organ  of  the 
body  aside  from  the  brain. 

If  we  but  apprehend  clearly  that  the  relation  between 
the  supreme  nervous  centres  and  the  blood  is  but  the 
same  as  exists  between  the  blood  and  other  parts  of  the 
body,  and  that  the  disordered  mental  phenomena  are 
but  the  functional  exponent  of  morbid  organic  action — 
when  we  grasp  this  just  conclusion,  then  we  will  look  for 
physical  causes  and  seek  to  destroy  the  tree  of  insanity 
by  killing  its  roots  and  not  by  lopping  its  branches. 
A  delusion,  in  the  minds  of  most  physicians,  is  some 
terrible  octopus  which  settles  over  the  brain  like  a  can- 
opy and  obstructs  all  the  avenues  for  the  exit  of  healthy, 
rational  thought,  when,  in  fact,  a  delusion  is  nothing 
more  than  the  belief  in  an  hallucination,  which,  in  turn, 
is  but  sensations  of  subjective  origin  interpreted  ob- 
jectively, just  as  persons  who  are  victims  of  vertigo 
are  suffering  from  motor  hallucinations. 

Mind  and  matter  are  not  two  separate  entities,  neither 
are  they  to  be  thought  of  and  studied  as  such.  Mind 
is  no  more  apart  from  brain  than  sound  is  from  the 
organ  of  hearing,  and  any  philosophy  which  would 
teach  that  the  mind  is  anything  other  than  a  func- 
tion of  the  brain  is  fallacious,  and  leads  only  to  mys- 
ticism. 

One  other  organ,  the  diseased  action  of  which  may 
cause  a  morbid  condition  of  mental  processes,  must  not 
be  overlooked,  and  that  is  the  stomach  or  digestive 
tract.  Even  in  epilepsy  it  has  been  observed  that  lax- 
ative medicines,  like  calomel,  when  administered,  will 
defer  the  threatened  epileptic  seizure,  by  clearing  out 
the  alimentary  canal  and  by  increasing  the  secretion  of 
the  various  digestive  juices,  and  by  some  unknown  al- 
terative effect  upon  the  nervous  centres.  The  stom- 
ach's relation  to  the  system  of  the  great  sympathetic  is 
marvellous. 

No  single  organ  of  the  body  exerts  a  more  de- 
cided influence  upon  the  mind  than  the  stomach.  The 
myriad  symptoms  of  uneasiness  and  nervous  perturba- 
tions, the  morbid  appetite,  the  impulsive  nature  and 
jrascible  temper,  are  a  few  of  the  symptoms  due  to  dis- 


5i8 


MEDICAL    RECORD. 


[October  12,  1895 


ordered  digestion,  especially  that  caused  by  chronic 
malarial  poisoning,  and  not  infrequently  these  condi- 
tions result  in  a  form  of  mild  melancholia,  or  at  least 
are  the  exciting  causes. 

That  dream-life  is  closely  associated  with  the  con- 
dition in  some  forms  of  insanity  is  recognized  by  all 
psychologists,  and  what  uncanny  dreams  and  inexplica- 
ble nightmares  possess  those  who  suffer  from  indiges- 
tion !  If  this  be  true  of  dream-life,  why  may  it  not  be 
true  of  waking  existence  ?  For  it  is  only  a  matter  of 
degree  in  the  diseased  condition,  yet  in  the  wards  of 
most  hospitals  for  the  insane  are  many  patients  who 
receive  no  medication  whatever,  and  who  are  suffering 
from  stomach  or  intestinal  indigestion^and  there  is  no 
diseased  condition  which  places  an  individual  in  the 
hands  of  the  demon  of  unrest  as  does  intestinal  indi- 
gestion. If  a  patient  should  call  on  the  ward  for  med- 
icine and  speak  of  some  pain  or  uneasiness,  the  ward 
physician,  in  the  majority  of  instances,  would  set  it 
down  as  a  delusion  or  whimsical  demand,  and  it  goes 
unheeded.  I  am  fully  conscious  of  the  many  difficul- 
ties to  be  encountered  in  an  attempt  to  fully  under- 
stand the  exact  mental  condition  of  any  person.  In- 
sanity is  not  a  condition  to  be  diagnosed  by  the  aid  of 
the  stethoscope  or  thermometer,  but  its  diagnosis  rests 
upon  the  skilled  judgment  of  those  who  have  made  the 
phenomena  of  mind  a  careful  study,  and  in  addition  to 
this  have  studied  the  insane  and  are  familiar  with  all 
the  hidden  springs  of  their  actions,  and  have  traced 
every  impulse  to  the  secret  founts  of  their  being.  Such 
are  able  to  interpret  much  which  to  the  unskilled 
would  be  only  meaningless  and  purposeless  acts,  or  the 
silly  mutterings  of  delirium. 

I  am  aware  that  many  who  read  this  article  will  not 
admit  the  justice  of  the  criticism,  but  all  who  have  had 
extensive  facilities  for  studying  the  subject  and  of  veri- 
fying the  truth  of  the  statements  must  have  already 
noticed  the  same. 

Now,  if  these  conditions  exist,  where  rests  the  blame, 
and  how  may  it  be  remedied  ?  First  let  me  say  that 
all  this  is  no  fault  of  the  superintendent,  and  inefficient 
ward  physicians  is  no  wish  of  his.  The  arduous  and  ex- 
acting duties  of  his  position  render  it  impossible  for  him 
to  give  any  special  study  to  each  individual  case.  A 
superintendent's  qualifications  should  be  more  of  an 
executive  nature  than  of  a  skilled  pathologist  ;  the  med- 
ication must  rest  with  the  ward  physicians. 

Alid  so  long  as  these  institutions  are  subject  to  polit- 
ical caprice  of  the  dominant  party,  just  so  long  will  the 
ward  physician  be  selected  from  a  class  of  physicians 
who  by  nature  and  education  are  unfitted  for  the  posi- 
tion, and  who  from  the  very  nature  of  their  require- 
ments must  fall  into  a  routine  system  of  medication. 
And  so  prone  is  the  human  mind  to  be  satisfied  with 
its  own  work  that  it  soon  becomes  blinded  to  those 
higher  lifts  of  sky  and  broader  reaches  of  horizon  in 
the  realms  of  research  which  lie  out  and  beyond.  And 
as  the  "  fire-fly  only  shines  while  on  the  wing,  so  with 
the  mind  when  at  rest — it  darkens." 


Walking  Backward  Cure  for  Headache. — An  apostle 
of  physical  culture  says  that  an  excellent  and  never- 
failing  cure  for  nervous  headache  is  the  simple  act  of 
walking  backward.  Ten  minutes  is  as  long  as  is  usu- 
ally necessary  to  promenade.  It  sometimes,  however, 
requires  more  than  ten  minutes  to  walk  at  all,  if  one  is 
very  "  nervous."  But  it  is  not  understood  that  it  is 
necessary  to  walk  a  chalkline.  .\ny  kind  of  walking 
will  do,  provided  it  is  backward.  It  is  well  to  get  in  a 
long,  narrow  room,  where  the  windows  are  high,  and 
walk  very  slowly,  placing  first  the  ball  of  the  foot  on 
the  floor,  and  then  the  heel.  Hesides  curing  the  head- 
ache, this  exercise  promotes  a  graceful  carriage.  A 
half  hour's  walk  backward  every  day  will  do  wonders 
toward  producing  a  graceful  gait. 


SOME    OF    THE    DISADVANTAGES    OF   SPE- 
CIALISM. 

By  WOODS    HUTCHINSON,    A.M.,  M.D., 

DES    M0INE5,    IOWA. 

The  microscope  is  a  wonderful  instrument,  but  it  has 
its  limitations.  Inability  to  see  anything  half  an  inch 
beyond  its  own  objective,  for  instance.  It  will  detect 
a  bacillus  anthracis,  but  fail  to  see  a  panther  or  a 
trolley-car.  And  the  knowledge  of  the  specialist  is 
liable  to  similar  defects.  The  more  completely  he 
concentrates  his  attention  upon  one  thing  the  blinder 
he  becomes  to  all  surrounding  objects. 

Probably  there  is  nothing  of  which  we,  as  a  profes- 
sion, are  prouder  than  the  remarkable  division  "  of 
labor  "  which  has  taken  place  among  us.  It  is  a  mark 
and  a  means  of  progress,  and  plays  the  same  role  as  in 
other  departments  of  civilization.  The  specialist  has 
arrived  and  we  bow  down  before  him,  for  through  him 
alone  comes  accurate  and  scientific  knowledge  (and 
superb  fees).  Nay,  more,  we  are,  most  of  us,  one  of  him 
ourselves,  or  trying  to  be,  for  the  pure  and  intellectual 
joy  of  possessing  the  knowledge  aforesaid,  of  course. 
The  advantages  of  specialization  and  the  advances  due 
to  it  are,  of  course,  unquestionable  and  glorious,  but 
are  we  not  in  danger  of  overdoing  it?  As  to  the  in- 
juriousness  of  one  of  its  prevailing  tendencies  there 
can  be  little  doubt,  and  that  is  the  alarming  fact  that 
few  or  none  of  our  present  medical  students  are  quali- 
fying themselves  (in  intuition)  for  general  practition- 
ers ;  they  are  all  going  to  be  "  specialists  ;  "  some  for 
the  glory  of  the  thing,  others  for  the  pay,  and  others 
because  "  there  are  no  night-calls  to  make."  .\11  of 
which  is  about  as  rational  as  if  a  "'  kindergartner " 
should  announce  his  intention  to  confine  his  attention 
to  the  Italian  verb  as  soon  as  he  had  learned  to  write. 
It  ought  to  be  actively  discouraged  by  both  medical 
teachers  and  the  profession,  and  at  least  two  to  five 
years  of  general  practice  insisted  upon  as  a  proper  part 
of  the  preparation  for  any  special  work. 

A  specialty  should  be  drifted  into  by  a  sort  of  natu- 
ral selection,  after  a  man  has  tried  his  strength  and  as- 
certained his  tastes  by  years  of  general  practice.  No 
man  can  hope  to  properly  understand  any  single  region 
or  organ  of  the  body  or  class  of  diseases  who  does  not 
first  thoroughly  understand  the  whole  body  and  its 
variations,  both  in  health  and  disease.  The  bouquet- 
maker  may  get  along  with  a  knowledge  of  the  blossom 
alone,  but  the  horticulturist,  the  botanist,  must  know 
the  whole  plant-family  from  rootlet  to  seed-capsule, 
their  needs,  their  habits,  everything  about  them,  in  fact. 
But  the  undesirable  consequences  to  which  we  specially 
refer  are  those  to  the  specialist  himself  and  to  the  pro- 
fession at  large.  Specialization  in  essence  is  limiting, 
narrowing  of  one's  interest  to  a  single  subject  or  group 
of  subjects,  and  unfortunately  this  narrowing,  while 
necessary,  may  be  highly  injurious  to  the  general  men- 
tal development  of  the  student.  So  much  so  in  some 
cases  as  to  actually  defeat  its  own  ends,  just  as  a  high 
degree  of  myopia  may  interfere  with  a  man's  reading 
even  German  brevier  at  six  inches.  The  specialist  is 
in  peculiar  danger  of  seeing  the  whole  world  through 
his  own  particular  spectacles.  To  the  gynecologist 
woman  becomes  simply  a  uterus  and  its  appendages, 
and  every  disturbance  of  her  nutrition  must  originate 
in  these  organs.  The  rhinologist  traces  everything 
from  asthma  to  insanity  to  hypertrophy  of  the  turbi- 
nated bodies,  while  the  proctologist  is  sure  that  the  true 
view  of  most  diseases  can  only  be  obtained  through  a 
rectal  si)eculum.  To  such  an  extent  does  this  biassing 
of  view  extend  as  to  actually  blind  him  in  many  cases 
to  the  fact  that  some  diseases  he  is  called  upon  to  treat 
may  be  merely  extensions  of  general  pathological 
changes  of  the  whole  system  into  his  particular  pre- 
serve. For  instance,  we  recently  heard  of  a  case  of 
rapidly  developing  double  cataract  in  a  young  adult 


October  12,  1895] 


MEDICAL    RECORD. 


519 


who  had  consulted  two  ophthalmologists,  and  been 
advised  by  both  to  have  them  extracted.  A  general 
examination  revealed  sugar  in  the  urine  and  well- 
marked  symptoms,  both  local  and  general,  of  diabetes. 
Some  of  the  most  distressing  mistakes  we  have  ever 
seen  in  practice  have  been  made,  not  by  obscure  coun- 
try doctors,  but  by  specialists  of  skill  and  wide  reputa- 
tion, whose  ciliary  mechanism  had  become  permanently 
■'accommodated"  to  the  range  of  their  particular 
hobby  only. 

Perhaps  for  the  advance  of  medicine  as  a  science,  the 
more  minute  the  specialization  the  better,  but  for  its 
practice  as  an  art,  almost  the  reverse  is  true.  No  or- 
gan has  as  yet  succeeded  in  existing  by  itself  alone,  and 
the  average  human  being  will  insist  upon  having  a  full 
set  of  all  the  mechanisms  belonging  to  the  species,  so 
that  complications  are  liable  to  occur  at  any  moment. 
And  we  must  be  prepared  for  any  and  all  of  them.  As 
the  human  frame  is  at  present  constructed  no  man  can 
hope  to  practise  any  specialty  with  comfort  (to  his  pa- 
tient, at  least)  and  credit,  without  a  fairly  thorough 
working-knowledge  of  the  structure  and  diseases  of  all 
its  parts.  In  short,  the  man  who  knows  only  his  spe- 
cialty, does  not  know  even  that  as  he  ought  to.  Ho 
suffers  from  mental  myopia,  so  to  speak.  Another  un- 
desirable effect  of  specialization  is  the  temptation  it 
affords  to  multiply  refinements,  distinctions,  and  divis- 
ions with  corresponding  technical  terms  at  portentous 
length  and  appalling  sound.  So  far  has  this  been  car- 
ried of  late,  that  the  papers  read  in  many  of  the  sec- 
tions of  our  medical  gatherings  are  wellnigh  unintelli- 
gible to  the  average  general  practitioner  from  the 
technicality  of  their  language,  and  their  subject-mat- 
ter so  absolutely  divested  of  all  relation  to  or  bearing 
upon  anything  else  under  heaven,  as  to  be  utterly  un- 
interesting and  valueless  to  all  but  a  chosen  few.  More 
than  this,  the  very  fact  that  our  chosen  field  is  small 
renders  us  even  more  liable  than  usual  to  that  common 
human  delusion,  that  we  know  all  there  is  in  it.  We  are 
sometimes  even  proud  of  our  ignorance  of  other  de- 
partments of  the  healing  art.  And  this  is  unfortunate, 
for  diseases  are  most  inconsiderate,  and  often  abso- 
lutely decline  to  limit  their  action  to  any  given  region 
or  organ.  Two  or  three  of  them  will  even  mix  them- 
selves up  in  the  same  subject.  For  instance,  if  an 
ophthalmologist  were  called  to  treat  the  primary  con- 
junctivitis of  measles,  he  would  be  under  the  painful 
necessity  of  calling  in  a  laryngologist  to  attend  to  tlie 
naso-pharyngeal  complications,  a  chest  specialist  for 
the  cough,  and  a  dermatologist  for  the  eruption,  which 
would  be  somewhat  fatiguing  for  the  patient — as  well 
as  expensive. 

If  the  present  rate  of  progress  continues,  the  neurolo- 
gist in  charge  of  a  case  of  locomotor  ataxia  will  have 
to  call  in  a  genito-urinary  specialist  when  cystitis  de- 
velops. It  has  gone  almost  to  that  extent  already,  for 
as  Hughlings  Jackson  not  long  ago  remarked  at  a  med- 
ical gathering  where  it  had  been  stated  that  every  or- 
gan in  the  body  had  hospitals  specially  devoted  to  its 
treatment  except  the  umbilicus,  "  You  forget,  gentle- 
men, there  is,  in  this  very  city,  a  naval  hospital."  And 
any  physician  who  can  treat  only  a  fraction  of  the  body 
is  very  apt  to  become  only  a  fraction  of  a  doctor  liini- 
self.  Far  more  valuable  than  mere  knowledge  of  facts 
to  the  consultant  is  judgment,  ability  to  balance  ijrob- 
abilities,  and  this  can  never  be  developed  by  the  hemo- 
cytometer  or  the  cystoscope  alone.  Indeed,  the  more 
canvas  of  mere  special  information  that  an  expert  car- 
ries in  proportion  to  his  beam  of  broad  culture  and 
his  ballast  of  common-sense,  the  more  unsteady  liis 
course  is  likely  to  be.  Not  only  a  thorough  knowledge 
of  all  human  medicine,  but  a  fair  acquaintance  with 
some  of  the  allied  natural  sciences,  is  really  requisite 
for  the  soundest  judgment  and  the  clearest  insiglu, 
and  this  not  merely  for  his  own,  but  also  for  his  pa- 
tients' sake.  Such  a  man  will  make  fewer  mistakes 
and  be  more  likely  to  assist  nature,  instead  of  hindering 


her,  than  many  a  mere  technical  expert,  even  in  the 
latter's  own  domain. 

One  of  the  most  strikingly  unfavorable  results  at 
specialism  is  the  extraordinary  impetus  which  it  has 
given  to  our  natural  tendency  to  run  after  professional 
fads.  The  air  has  fairly  echoed  for  the  past  fifteen 
years  with  superb  trumpetings  of  wonderful  discoveries 
from  one  expert  quarter  after  another,  followed  by  a 
wild  stampede  of  the  profession  in  that  direction. 
Now  a  shout  goes  up  that  the  chief  cause  of  neuras- 
thenia and  hysteria  is  an  elongated  cervix  uteri,  and  the 
cure  is  to  split  it  ;  five  years  later  another  authority 
has  the  floor  and  is  equally  certain  that  all  these  things 
are  due  to  a  lacerated  cervix,  and  all  that  have  been 
split  have  to  be  repaired  again.  Again,  the  ophthalmolo- 
gist gains  the  professional  ear,  and  all  forms  of  back- 
ward cerebral  development  short  of  idiocy  are  to  be 
relieved  by  correcting  the  refraction,  and  a  host  of  ner- 
vous disturbances,  from  neurasthenia  to  epilepsy,  are  to 
be  cured  by  graduated  tenotomies  of  the  recti  muscles. 

Next,  the  bacteriologist  takes  the  rostrum,  and,  ac- 
cording to  him,  nearly  every  form  of  diseased  action, 
from  coryza  to  hydrophobia,  is  due  to  the  pernicious  ac- 
tivity of  some  germ.  The  only  thing  that  is  needed  is 
to  identify  your  germ,  administer  an  appropriate  germi- 
cide, and  the  thing  is  done.  The  cells  of  the  body  are 
mere  clay  in  the  hands  of  the  potter  before  the  dread 
bacterium.  The  only  thing  that  has  prevented  this  par- 
ticular craze  from  absolutely  revolutionizing  therapeu- 
tics has  been  the  impossibility  of  finding  any  antiseptic 
that  would  not  kill  the  patient  long  before  it  could  the 
germ.  This,  of  course,  matters  little  in  Germany,  but  it 
is  a  serious  drawback  here. 

Next,  the  cerebral  surgeon  gets  in  the  saddle  and  an- 
nounces his  intention  of  preventing  idiocy  in  the  future 
by  cutting  slices  out  of  the  thick  skull,  which  alone 
prevents  the  brain  from  growing.  If  this  line  of  argu- 
ment be  followed  out  we  should  all  be  more  intellectual 
without  any  skulls  at  all,  simply  protecting  our  surging 
brains  by  a  steel-ribbed  hat  of  some  sort,  through  which 
we  could  talk  to  our  hearts'  content — just  like  these 
craniotomists  did. 

Last,  and  worst  of  all,  is  the  gynecological  brass  band 
which  is  in  full  blast  at  present,  whose  Wagnerian  Leit 
Motif  \%  that  the  most  dangerous  and  deadly  thing  which 
a  woman  can  have  concealed  about  her  person  is  an 
ovary.  I  say  worst  because  its  echoes  penetrate  every- 
where, and  the  county-seat  doctor  with  any  pretensions 
to  surgery  who  has  not  done  a  dozen  celiotomies  is 
positively  ashamed  of  himself. 

However,  a  healthy  reaction  against  such  crazes  is 
setting  in  at  last.  The  specialist  is  beginning  to  ac- 
knowledge his  dependence  upon  the  practising  physi- 
cian. The  oculist  is  finding  out  that  many  of  his  cases 
of  asthenopia  need  iron  and  sunlight  rather  than  lenses. 
The  rhinologist  finds  that  he  obtains  more  permanent 
results  in  "catarrh  "  by  attending  to  the  skin,  the  cir- 
culation, and  the  muscles  of  liis  patient.  The  bacteri- 
ologist has  already  come  to  see  that  the  fluids  of  the 
bodies  of  certain  animals  contain  sozins  and  alexines 
which  are  even  more  deadly  to  bacteria  than  mercuric 
chloride,  and  may  even  admit  the  same  to  be  true  of  hu- 
man nuclei  before  long.  As  for  the  gynecologist,  his  own 
excesses  are  proving  his  ruin,  for  he  is  rapidly  approach- 
ing the  point  where  he  will  have  to  be  tolerated  as  a 
nuisance.  Even  the  inaccessible  and  haughty  neurolo- 
gist is  compelled  10  admit  that  several  of  his  choicest 
and  most  elaborate  diseases  are  due  to  ordinary  intes- 
tinal ])tomaine-absorption  or  common  every-day  sypii- 
ilis.  The  humble  general  practitioneris  the  real  "  Iron 
sides  "  of  the  army  of  medical  science. 


Medical  Ethics.— The  Columbus  Medical  Journal 
states  that  out  West  it  is  not  considered  ethical  for  a 
doctor  to  have  an  office  in  two  different  villages. 


520 


MEDICAL    RECORD. 


[October   12,  1895 


"^vaQVcss  of  pX^xltcal  Science. 

The  Hygiene  of  the  Kidney.— Dr.  J.  Henry  C.  Simes 
calls  attention  to  the  relation  between  the  skin  and  the 
kidneys,  and  observes  if  the  skin  is  not  in  healthy  con- 
dition the  kidneys  have  an  extra  volume  of  work  to 
perform.  The  importance  of  a  healthy  action  of  the 
kidneys  is  manifested  by  the  fact  that  serious  trouble 
may  arise  in  other  organs,  as  heart,  lungs,  brain,  and 
nervous  system,  when  the  excretory  work  of  the  kid- 
neys is  imperfectly  done.  In  watching  the  action  of  these 
organs  many  factors  must  be  taken  into  consideration, 
such  as  the  nature  of  the  diet,  the  amount  of  liquids 
consumed,  the  nature  of  the  exercise  and  activity  of 
perspiration.  Then  again,  as  the  urine  varies  so  much, 
a  correct  examination  cannot  be  made  unless  the  en- 
tire amount  voided  in  twenty-four  hours  be  collected, 
and  a  specimen  taken  from  this.  The  quantity  of 
urine  varies  greatly  with  the  amount  of  liquids  holding 
the  solid  constituents  of  the  food  in  solution.  When  it 
is  remembered  that  nine  hundred  and  fifty  parts  of 
every  thousand  of  the  urine  are  water,  the  importance 
of  this  element  in  the  dietary  becomes  evident.  On 
this  point,  the  author  is  strongly  of  the  opinion  that 
the  majority  of  men  eat  too  well  and  do  not  drink 
enough  water.  As  a  result  of  this,  there  is  deposited 
in  the  tissues  many  effete  products  that  should  be  car- 
ried off  by  the  kidneys.  The  work  done  by  those  or- 
gans is  in  this  way  interfered  with  ;  and  in  time  or- 
ganic disease  often  comes  on.  It  is  owing  to  the  large 
amount  of  water  that  much  of  the  benefit  from  a  milk 
diet  arises.  In  advocating  the  use  of  abundance  of 
water  with  the  solids,  the  author  again  calls  attention 
to  the  danger  of  washing  down  the  food  with  it,  and  tak- 
ing time  to  masticate  properly.  While  water  is  of  prime 
importance,  it  cannot  take  the  place  of  the  saliva.  The 
benefit  derived  from  a  sojourn  at  a  mineral  spring  is  al- 
most entirely  due  to  the  flushing  out  the  system  gets. 
Waste  products  are  dissolved  and  washed  away  by  the 
kidneys.  The  opinion  is  expressed  that  pure  water 
drank  for  a  lengthy  period  would  have  as  good  an  ef- 
fect. This  of  course  applies  to  cases  where  there  is  no 
organic  lesion,  and  efforts  are  directed  against  the  ill 
effects  of  a  sedentary  life  and  over-eating.  In  advo- 
cating the  use  of  water,  its  excessive  use  must  be 
guarded  against.  The  habit  of  taking  too  much  water 
may  be  indulged  in.  This  is  the  other  extreme,  and 
may  result  in  harm.  The  effect  of  water  is  to  make 
the  kidneys  act,  and  by  over-drinking,  these  organs  may 
be  overworked.  The  abuse,  therefore,  of  water  may 
prove  the  reverse  of  "in  aqua  sanitas."  In  the  cold 
season,  warm  clothing  is  of  much  value,  as  tending  to 
prevent  congestion  of  the  kidneys.  Should  such  hap- 
pen, it  must  be  relie\ed  by  acting  upon  the  skin 
and  bowels.  Judicious  bathing  is  useful,  as  tendinj^ 
to  maintain  the  healthy  action  of  the  skin,  and  thereby 
avoid  congestion  of.  the  kidneys.  If  many  people 
drank  more  water,  and  used  less  solid  food,  kidney 
diseases  would  not  be  so  common  as  they  are  at  pres- 
ent.— J)ietetic  Gazette. 

A  New  Method  of  Abdominal  Hysterectomy.— Ac- 
cording to  the  Paris  correspondent  of  The  Lancet,  M. 
Richelot  has  devised  an  original  and  improved  method 
of  performing  this  operation.  He  claims  for  his  pro- 
cedure great  advantages  over  the  current  methods, 
which  are  long  and  laborious,  and  the  tiuicker  methods 
sometimes  employed,  which  are  fretiuently  attended 
with  danger.  The  principal  advantage  ofM.  Riche- 
lot's  manner  of  operating  lies  in  the  complete  absence 
of  ligatures  and  sutures,  forci-pressure  only  being  used. 
A  scalpel,  a  dissecting  forceps,  a  long  and  a  short 
hemostatic  forcejis,  and  finally  two  long  Richelot's 
forceps  provided  with  a  long  "  bite  '"—this  is  the  onlv 
armamentarium  necessary.  The  patient  is  placed  on 
her  back  and  the  operator   takes  his  station   between 


the  separated  limbs.  The  vagina  is  first  thoroughly 
disinfected,  for  in  the  course  of  the  operation  the  sur- 
geon's hand  passes  alternately  into  that  canal  and  the 
abdomen.  The  usual  abdominal  incision  being  made, 
the  uterus  is  enucleated  and  laid  on  the  abdomen, 
covering  the  lower  angle  of  the  operation  wound. 
[When  fibromata  occupy  the  lower  segment  of  the 
organ  the  usual  fragmentation  is  at  once  practised  : 
when,  however,  they  are  interstitial  they  are  left  un- 
touched, and  the  operation  is  proceeded  with  as  fol- 
lows.] An  anterior  peritoneal  flap  is  fashioned  by 
means  of  an  incision  across  the  anterior  surface  of  the 
uterus,  extending  from  one  broad  ligament  to  the  other. 
The  broad  ligaments  are  thus  liberated  and  thrown 
downward  over  the  bladder.  The  lelt  index-finger  is 
introduced  into  the  vagina,  and  the  anterior  cul-de-sac 
is  incised  with  a  large  pair  of  scissors,  the  discission  of 
the  vagina  being  pushed  nearly  as  far  as  the  sides  of 
the  OS.  Then  leaving  the  uterus  in  situ,  the  broad  lig- 
ament on  one  side  is  seized  by  the  hand  quite  close  to 
the  uterus,  an  opening  in  the  posterior  cul-de-sac  is 
made  with  the  point  of  the  scissors,  and  through  this 
orifice  is  passed,  per  vaginam,  the  posterior  limb  of 
Richelot's  forceps,  the  anterior  limb  being  thrust 
through  the  corresponding  hole  in  the  anterior  cul- 
de-sac.  The  forceps  is  then  thrust  from  the  vagina 
from  below  upward  and,  guided  by  the  hand  holding 
the  broad  ligament,  is  placed  on  that  ligament.  The 
same  manoeuvre  is  practised  the  other  sidebymeai.- 
of  the  second  pair  of  Richelot's  forceps.  Both  liga- 
ments being  seized  by  the  forceps,  they  are  liberated 
from  their  extreme  attachments.  The  uterus  now- 
hangs  only  to  the  posterior  cul-de-sac,  which  is  in  iti; 
turn  divided  with  a  few  snips  of  the  scissors.  But  ..- 
this  section  gives  rise  to  hemorrhage,  three  hsemostatiL 
forceps  are  here  placed.  A  plug  of  iodoform  gauze  is 
inserted  into  the  upper  part  of  the  vagina,  none  being 
placed  in  the  abdomen.  The  abdominal  incision  is 
sutured  and  the  operation  is  over.  Of  five  hysterec- 
tomies thus  practised  by  M.  Richelot,  four  being  for 
fibromata  and  one  for  cancer,  the  four  first  mentioned 
were  successful.  The  duration  of  the  operation  varies 
from  thirty  to  thirty-five  minutes,  and  no  complications 
need  be  feared  during  the  healing  process.  M.  Riche- 
lot gives  to  his  method  of  operating  the  somewhat  cum- 
brous name,  "  hysterectomie  par  pinces  vaginales 
d'emblee  sans  ligature  ni  sutures." 

The  Etiology  of  Locomotor  Ataxy. — Dr.  Pitres,  of 
Bordeaux,  has  made  extensive  investigationsin  the  hope 
of  throwing  light  upon  the  still  doubtful  points  in  the 
etiology  of  this  disease.  His  first  results  were  pub- 
lished in  a  thesis  by  Dr.  Bereni  and  comprised  2^5 
cases.  The  influence  of  syphilis  was  found  to  be  great, 
but  not  overwhelming,  and  was  by  no  means  in  keeping 
with  recent  ideas  on  the  subject  {The  Lancet).  In 
considering  those  cases  in  which  the  etiology  was  certain, 
there  were  125  out  of  225 — i.e..  55.5  per  cent. — and 
even  in  many  of  these  cases  the  syphilis  was  associated 
with  other  cases  of  tabes  dorsalis  as  hereditary  joint 
affections,  alcoholism,  sexual  excess,  etc.,  so  that  the 
e.xact  percentage  which  could  safely  be  attributed  to 
syphilis  was  reduced  to  22.33  P^""  cent.  Of  the  other 
patients  about  33.44  per  cent,  had  no  sign  of  previous 
syphilis,  and  twice  during  his  experience  Dr.  Pitres  has 
seen  tabetic  symptoms  precede  syphilitic  manifesta- 
tions, so  that  these  statistics  tend  to  show  that  though 
syphilis  is  a  cause  it  is  not  by  any  means  the  only  one. 
but  that  many  other  conditions  also  play  their  part  in 
setting  up  the  disease.  There  is  also  in  Dr.  Bereni's 
work  a  chapter  on  the  investigation  of  the  heredity  of 
tabes,  but  no  direct  tendencv  to  inheritance  was  found. 


Anthelmintic  against  Tapeworm. — For  this  purpose, 
an  ounce  and  a  half  of  ether  may  be  administered  at 
once,  followed  in  two  hours  by  a  full  dose  of  castor-oil. 

BOURDIF.R  .\ND  HORTET. 


October  12,  1895] 


MEDICAL    RECORD. 


521 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Stirger-y. 


GEORGE   F.  SHIL\DY,  A.M.,  M.D.,  Editor 


WM    WOOD  &   CO..  43.  45.  &.  47  East  Tenth   Street 


New  York,  October  12,  1895. 


THE  ADULTERATION  OF  DRUGS. 

We  are  in  receipt  of  an  address  delivered  before  the 
Brooklyn  Institute,  by  Professor  Willis  G.  Tucker,  upon 
the  adulteration  of  drugs.  Dr.  Tucker  is  professor  of 
chemistry  in  the  Albany  Medical  College,  and  director 
of  the  New  York  State  Health  Board  Laboratory. 
His  remarks  upon  the  subject  of  adulteration,  there- 
fore, should  carry  with  them  much  weight.  We  ha\  e 
already  made  some  criticism  of  the  results  obtained  by 
the  State  Board  of  Health  through  their  investigations 
as  to  drug  adulteration.  Dr.  Tucker's  present  ad- 
dress, however,  is  in  some  sense  supplementary  to  the 
report  in  question. 

During  the  years  1891-94,  inclusive,  8,305  samples 
of  drugs  were  e-xamined.  Of  the  total  number,  not  one- 
half  could  be  rated  as  of  good  quality ;  about  fifteen 
per  cent,  were  of  fair  quality  ;  and  about  thirty  per 
cent,  were  of  inferior  quality.  Of  course,  many  of 
these  drugs  were  substances  not  commonly  used  or 
substances  of  no  very  great  importance.  There  were, 
however,  a  number  of  useful  drugs  to  the  adulteration 
of  which  Dr.  Tucker  called  special  attention.  It  is  his 
belief  that  many  of  the  old-fashioned  remedies  have 
gone  out  of  use,  not  because  better  substitutes  have 
been  found,  but  because  they  are  so  generally  of  in- 
ferior quality  as  sold  in  the  stores.  Thus,  out  of  607 
samples  of  Hoffman's  Anodyne,  only  153,  or  a  little 
more  than  one-quarter,  were  found  to  be  of  satisfactory 
quality.  Ordinary  Hoffman's  Anodyne,  as  usually 
furnished  to  physicians,  is  simply  a  mixture  of  alcohol, 
ether,  and  water,  without  any  of  the  ethereal  oil  on 
which  the  virtue  of  the  original  preparation  was  based. 

Sweet  spirits  of  nitre  is  another  of  the  old-fashii^ncd 
drugs  which  is  seldom  found  of  good  quality.  Chlo- 
roform was  found  to  be  impure  in  26  out  of  123 
samples.  Precipitated  sulphur  was  found  to  be  impure 
in  three-quarters  of  the  248  samples  examined.  Cream 
of  tartar  (potassium  bitartrate)  was  of  fairly  good 
quality  when  purchased  at  drug  stores,  but  at  the  retail 
grocery  stores  fully  one-half  were  found  to  be  impure 
specimens.  Among  other  articles  of  an  inferior  qual- 
ity are  mentioned  the  bromides  of  potassium,  sodium, 
and  ammonium,  and  the  iodide  of  potassium. 

There  is  another  class  of  drugs  which  become  more 
or  less  deteriorated  as  a  result  of  age  or  exposure. 
Carbonate  of  ammonia,  aqua  ammonii,  magnesia,  and 


lime-water  are  the  four  drugs  especially  mentioned  by 
Dr.  Tucker. 

Among  articles  which  are  likely  to  be  of  inferior 
strength  or  short  weight  are  the  dilute  acids  of  the 
Pharmacopoeia.  Hydrocyanic  acid  is  particularly 
mentioned.  Reduced  iron  is  found  to  be  rarely  full 
strength,  and  Seidlitz  powders  are  frequently  of  infe- 
rior quality.  Among  drugs  substituted  there  are  men- 
tioned saffron,  ether,  creosote,  distilled  water,  sulphur, 
and  solutions  of  citrate  of  magnesium. 


THE  DISINFECTION  OF    ROOMS  AFTER 
FECTIOUS  DISEASES. 


IN- 


The  absolute  disinfection  and  sterilization  of  a  room 
in  which  a  patient  with  an  acute  infectious  disease  has 
been  treated,  is  considered  at  present  extremely  diffi- 
cult, if  not  impossible.  We  refer,  of  course,  to  rooms 
in  ordinary  houses  which  cannot  be  washed  down  with 
large  amounts  of  strong  antiseptic  solutions.  The 
usual  procedure  of  burning  quantities  of  sulphur,  of 
washing  the  walls  and  removing  all  movable  pieces  of 
furniture,  is  considered  to  be  all  that  is  practically  pos- 
sible. Dr.  G.  Barnet  has  been  working,  in  co-operation 
with  Dr.  Trillat,  for  the  purpose  of  determining  whether 
a  better  method  cannot  be  found  for  the  disinfection 
of  infected  rooms,  and  he  claims  to  have  obtained  suc- 
cessful results.  The  substance  which  he  used  is  a 
solution  of  formaldehyde  in  alcohol.  He  has  devised 
an  apparatus  by  which  the  vapors  of  this  substance  are 
diffused  through  a  room,  and  he  says  that  with  it  he 
can  disinfect  with  absolute  certainty  in  six  hours  three 
hundred  cubic  metres  of  air.  Cultures  of  various 
specific  micro-organisms  placed  in  the  room  are  ren- 
dered absolutely  sterile  by  this  process.  The  vapors  of 
this  formaldehyde  have  no  injurious  action  upon  the 
furniture  of  the  room,  and  they  disappear  rapidly  after 
a  few  hours  of  airing.  The  process  suggested  and  the 
apparatus  devised  appear  to  us  to  be  rather  expensive, 
but  if  they  do  all  that  Dr.  Barnet  claims,  they  will 
prove  a  very  useful  addition  to  our  methods  of  fighting 
disease. 


THE  HEART  IN  THE  PHTHISICAL. 

The  necessity  of  a  proper  "  soil  "  for  the  development 
of  tuberculosis  under  ordinary  conditions  of  infection 
is  recognized  by  all.  In  what  this  "  soil "  consists, 
however,  we  do  not  definitely  know.  A  '"  hereditary 
weakness  of  constitution  "  expresses  about  all  that 
science  has  as  yet  determined,  though  to  this  many 
would  add,  perhaps,  certain  defects  in  the  configuration 
of  the  chest  and  a  feebleness  of  lymphatic  and  systemic 
circulation. 

Dr.  K.  Oppenheimer,  of  Munich,  has,  perhaps,  given 
one  certain  factor  in  the  tubercular  diathesis.  He 
made  a  study  of  the  relative  weights  of  the  organs  of 
young  people  who  had  died  of  tuberculosis  {Miinch. 
med.  Wochensch?).  The  number  of  cases  studied  was 
three  hundred  and  five.  The  conclusion  which  he 
reaches  is,  that  of  all  the  bodily  organs  the  heart  de- 
velops less  with  increasing  growth,  and  that  the  heart 
of  the  phthisical  patient  after  the  time  or  puberty  is 


522 


MEDICAL    RECORD. 


[October  12,  1895 


relatively  too  small.  Previously  to  that  time  it  is  rela- 
tively large.  For  example  :  In  the  second  year  of  life, 
in  the  normal  individual,  there  is  5.3  gr.  of  heart  to 
1000.9  of^  body  ;  in  the  phthisical  the  relation  is  3.6  to 
1000.  In  the  thirteenth  year  the  relation  is  changed 
and  becomes  5.5  to  1000  in  the  normal,  to  5.0  to  1000 
in  the  phthisical.  This  relative  smallness  of  the  heart 
continues  until  the  twenty-fifth  year. 

The  inference  from  these  figures  is,  that  those  chil- 
dren who  are  predisposed  to  tuberculosis  should  be 
made  to  follow  exercises  that  will  cause  some  hyper- 
trophy of  the  heart. 


PENSIONS  TO  MEDICAL  MEN. 

In  a  recent  speech  by  Mr.  Balfour  at  a  dinner  given 
by  the  Royal  Medical  Benevolent  College,  many  things 
in  praise  of  medicine  and  medical  men  were  uttered. 
Mr.  Balfour  kindly  sets  the  seal  of  his  approval  upon 
us,  for  which  we  are  duly  grateful.  He  recognizes  the 
great  amount  of  time  and  skill  which  is  expended  by 
physicians  gratuitously,  and  he  has  a  further  and  prac- 
tical suggestion  to  make  in  connection  with  it.  He 
suggests  that  there  should  be  established  by  the  sub- 
scriptions of  philanthropists,  or  perhaps  with  the  help 
of  the  municipalities,  funds  by  which  the  widows  and 
orphans,  and  even  the  old  age,  of  medical  men  may  be 
provided  for.  We  thank  Mr.  Balfour  for  his  sugges- 
tion, but  we  do  not  believe  that  in  this  country  it  would 
be  taken  kindly.  Medical  men  do  not  wish  to  be 
treated  as  persons  who  have  not  sufficient  foresight  or 
ability  to  take  care  of  themselves.  They  do  not  belong 
to  the  indigent  class,  and  aside  from  this  feeling  of  in- 
dependence which  medical  men,  in  this  country  at  least, 
possess,  we  believe  that  they  are  as  a  body  opposed  to 
the  socialistic  tendencies  which  the  attempt  to  pension 
the  professional  class  would  lead  to.  We  do  not  know 
of  anything  which  would  take  away  the  stimulus  for 
effort  more  certainly  than  the  feeling  that,  whatever 
happens,  whether  one  be  idle  or  industrious,  evil  or 
virtuous,  there  will  be  a  provision  for  himself  and  his 
family. 

A  NEW  INDEPENDENT  ORDER. 

There  is  in  the  Medical  Mirror  for  September,  1895, 
a  valuable  historical  description  of  the  rise,  develop- 
ment, and  final  effective  organization  of  the  Order  of 
"  Chutmucks,"  a  social  body  connected  with  the  work- 
ings and  speakings  of  the  Mississippi  Valley  Medical 
Association.  The  Chutmucks,  so  far  as  we  can  learn 
from  the  bibliography  and  history  of  the  Order,  as 
given  in  the  monograph  referred  to,  consists  of  persons 
"  who  know,  and  know  that  they  know."  The  creden- 
tials or  insignia  of  the  Order  are  the  four  B's,  one  B 
standing  for  the  Brains  which  direct  the  Chutmuck, 
the  second  for  the  Backbone  which  sustains  him,  the 
third  for  the  Blood  which  pours  plethorically  through 
his  vessels,  and  the  fourth  for  Beauty  which  radiates 
from  him.  There  should,  we  fancy,  be  a  fifth  B,  which 
would  stand  for  the  buzzing  of  the  wheels  in  the  Chut- 
muck's  head,  but  this  is  not  an  official  portion  of  the 
insignia.  At  the  meeting  of  the  Mississippi  Valley 
Medical  Association,  recently,  the  loyal  braves  of  the 


Chutmuck  clan  presented  to  the  President,  Dr.  I.  X. 
Love,  a  watch,  in  testimony  of  their  loyalty  and  affec- 
tion. The  purposes  of  the  Order  of  the  Chutmucks 
seem  to  be  to  encourage  kindliness  of  heart,  breadth  of 
sympathy,  optimism  in  judgment,  healthfulness  of 
body,  and  a  happy  combination  of  boastful  modesty 
with  an  aggressive  and  inconspicuous  self-depreciation. 
We  wish  the  Chutmucks  long  life  and  happiness. 


FORMALINE. 


From  the  frequent  references  to  the  successful  use  of 
formaline  and  its  preparations  in  the  laboratory  and 
the  operating-room,  it  seems  as  if  this  substance  were 
likely  to  take  a  permanent  place  among  the  useful  ad- 
ditions to  the  physician's  armamentarium.  Formaline, 
formaldehyde,  and  formal  are  synonymous  terms. 
Their  chemical  formation  has  been  referred  to  already 
several  times  in  these  columns.  Formaline  is,  we  be- 
lieve, the  proprietary  name  given  to  a  forty  per  cent, 
solution  of  formaldehyde,  while,  if  we  remember  cor- 
rectly, formal  is  a  still  weaker  proprietary  solution  of 
the  same  substance.  "  It  is  the  general  opinion,"  says 
Dr.  Squibb  in  his  Ephemeris,  "  that  formaline  is  supe- 
rior to  corrosive  sublimate  in  its  germicidal  action  and 
is  far  less  toxic."  Drs.  Gegner  and  Hauser  have  made 
experiments  in  testing  its  antiseptic  value,  and  similar 
work  in  this  line  has  been  done  by  Messrs.  Slater  and 
Rideal,  of  London.  Formaline  has  been  found  to  be 
an  excellent  preservative  of  pathological  specimens, 
and  it  has  largely  taken  the  place  of  alcohol  for  many 
purposes  in  the  laboratory.  Formaline  in  two  per  cent, 
solutions  is  said  to  preserve  the  brain  in  excellent  con- 
dition, as  well  as  other  tissues  of  the  body.  In  the 
June  number  of  the  Canadian  P raditioner  Dr.  Cullen, 
of  the  Johns  Hopkins  Hospital,  describes  a  rapid 
method  of  staining  fresh  tissues  by  the  aid  of  forma- 
line. By  its  use  a  piece  of  tumor  from  the  operating- 
room  can  be  examined  and  stained  within  fifteen  min- 
utes. His  method  is  said  also  to  be  very  useful  for 
the  examination  of  uterine  scrapings.  The  method  of 
using  formaline  and  its  products,  in  the  disinfection  of 
rooms  and  in  surgery,  has  been  referred  to  before  in 
the  Medical  Record,  and  we  call  attention  to  the 
subject  again  because  it  seems  to  us  that  the  substance 
has  a  practical  value  in  many  directions,  and  that  medi- 
cal men  should  be  familiar  with  it. 


Deaths  from   Chloroform   Anaesthesia.  —  Dr.   J.   W. 

Reiser,  of  Reading,  Pa.,  writes  to  the  University  Medical 
Magazine  that  in  that  neighborhood  a  large  number  of 
the  physicians  are  favorably  disposed  to  the  use  of 
cliloroform.  Five  years  ago  Dr.  Keiser  reported  two 
deaths  from  the  use  of  chlorofomi,  occurring  in  his 
locality,  and  since  then,  he  states,  there  have  been  two 
more. 

The  Rush  Monument  Fund. — The  total  of  contribu- 
tions to  this  fund  amounts,  to  date,  to  $3,357.39.  Re- 
cent donations  to  the  amount  of  $196  are  acknowl- 
edged by  the  committee.  Further  contributions  are 
earnestly  desired,  and  may  be  sent  to  the  secretary  and 
treasurer.  Dr.  George  H.  Rohe,  Baltimore,  Md. 


October   12,    1895] 


MEDICAL    RECORD. 


523 


%zvos  of  tlie  Wiztk. 

No  more  Infectious  School  Slates. — The  Health  Board 
has  approved  a  number  of  recommendations  suggested 
by  Professor  Herman  M.  Biggs,  the  department  bac- 
teriologist, and  ordered  that  a  copy  be  sent  to  the 
Board  of  Education.  Some  of  the  recommendations 
are  as  follows  :  i.  The  use  of  slates,  slate-pencils,  and 
sponges  shall  be  discontinued  in  all  the  public  schools. 
2.  According  to  requirement  pupils  shall  be  supplied 
with  pencils  and  penholders,  each  pupil  to  retain  those 
received  in  a  box  provided  for  the  purpose,  such  box  to 
be  marked  with  the  pupil's  name.  Pencils  and  pen- 
holders shall  not  be  transferred  from  one  pupil  to  an- 
other without  suitable  disinfection.  3.  All  school  prop- 
erty left  in  the  school  building  by  a  child  sick  with  any 
contagious  disease,  and  all  such  property  found  in  an 
apartment  occupied  by  a  family  in  which  a  case  of 
small-pox,  typhus  fever,  diphtheria,  scarlet  fever,  or 
(  measles  has  occurred,  shall  be  taken  by  the  Health  De- 
partment for  disinfection  or  destruction.  4.  Books 
which  are  taken  home  by  pupils  shall  be  covered  regu- 
larly once  each  month  with  brown  manilla  paper.  5. 
Places  for  drinking-water  on  the  ground  floors  of  the 
school  buildings  shall  be  discontinued,  and  a  covered 
pitcher  provided  for  each  class-room,  in  which  fresh 
water  shall  be  placed  before  every  session.  A  num- 
bered cup,  to  be  kept  in  the  class-room,  shall  be  issued 
to  each  pupil.  No  interchange  of  cups  shall  be  allowed. 
Provision  is  proposed  for  the  exclusion  of  children 
in  whose  homes  there  may  be  cases  of  contagious  dis- 
ease and  for  a  report  by  teachers  to  the  Board  of  Health 
of  all  cases  of  sickness  among  pupils.  Finally,  the 
recommendations  provide  for  more  closet- room  for 
hanging  clothes,  and  prohibit  principals  and  teachers 
from  sending  one  pupil  to  the  house  of  another  for  any 
reason. 

An  Army  Medical  Examining  Board  will  be  in  session 
at  Washington  City,  D.  C,  during  October,  1895,  for 
the  examination  of  candidates  for  appointment  to  the 
Medical  Corps  of  the  United  States  Army,  to  fill  exist- 
ing vacancies.  Persons  desiring  to  present  themselves 
for  examination  by  the  Board  will  make  application  to 
the  Secretary  of  War,  before  October  8th,  for  the  nec- 
essary invitation,  giving  the  date  and  place  of  birth, 
the  place  and  State  of  permanent  residence,  the  fact  of 
.\merican  citizenship,  the  name  of  the  medical  college 
frrim  which  they  were  graduated,  and  a  record  of  ser- 
vice in  hospital,  if  any,  from  the  authorities  thereof. 
The  application  should  be  accompanied  by  certificates 
based  on  personal  acquaintance,  from  at  least  two  re- 
putable persons,  as  to  his  citizenship,  character,  and 
habits.  The  candidate  must  be  between  twenty-two 
and  twenty-nine  years  of  age,  and  a  graduate  from  a 
regular  medical  college,  as  evidence  of  which  his 
diploma  must  be  submitted  to  the  Board.  Further 
information  regarding  the  examinations  may  be  ob- 
tained by  addressing  the  Surgeon-General,  United 
States  Army,  Washington,  D.  C. 

Pasteur's  Funeral.— The  funeral  of  Pasteur  took 
place  on  October  5th  with  great  state.     The  President 


of  the  Republic  and  many  civic  and  military  authorities 
were  present.  The  procession  following  the  hearse  was 
a  mile  long.  The  Minister  of  Public  Instruction  de- 
livered the  funeral  oration. 

Hydrophobia  from  a  Cat  Bite. — A  boy  in  this  city, 
sixteen  years  of  age,  was  bitten  by  a  cat  six  weeks  ago. 
He  died  on  October  5th,  at  Gouverneur  Hospital. 
The  official  certificate  of  death  states  that  the  cause 
was  hydrophobia.  The  brain  and  spinal  cord  are 
being  examined  by  the  pathologist  of  the  New  York 
Hospital. 

The  Illinois  Medical  Journal  is  the  name  of  a  new 
journal  published  in  DeKalb,  111.,  under  the  editorial 
management  of  Dr.  H.  Edward  Dunlop.  If  it  be  per- 
mitted to  judge  from  the  first  number,  that  for  Sep- 
tember, we  may  predict  for  our  young  contemporary  a 
long  and  successful  career.  In  the  first  issue,  among 
other  interesting  articles,  is  a  plea  for  modern  Greek  as 
an  international  language,  by  Dr.  Rose,  of  this  city. 
Dr.  Dunlop  also  endorses  the  suggestion  in  an  editorial 
note. 

A  New  Pathological  Building. — The  Massachusetts 
General  Hospital  is  to  have  a  new  pathological  build- 
ing costing  about  $22,000. 

Diphtheria  in  the  New  York  Juvenile  Asylum. — The 

New  York  Juvenile  Asylum  has  been  quarantined  for 
some  time  on  account  of  an  outbreak  of  diphtheria.  In 
two  months  about  fifty  cases  have  occurred. 

Prevention  of  Diphtheria  by  the  Use  of  Antitoxin. — 

At  a  meeting  of  the  Practitioners'  Society,  October 
4th,  Professor  H.  M.  Biggs  read  a  report,  based  on  a 
large  number  of  statistics,  and  tending  to  prove  that  by 
means  of  injections  of  the  diphtheritic  antitoxin  im- 
munity against  diphtheria  can  be  secured. 

A  Hair  from  the  Dog  that  Bit. — The  old  idea  that  a 
hair  from  the  dog  that  bit  was  good  for  the  person  who 
was  bitten,  seems  to  present  directly  the  converse  of 
the  truth,  as  established  by  modern  science,  which  is 
to  the  effect  that  a  dose  of  the  venom,  taken  under 
proper  conditions,  before  the  bite,  will  prevent  the 
fatal  consequences  of  the  bite.  Dr.  G.  Ranking,  in 
the  Indian  Medical  Gazette^  collects  a  number  of  facts 
to  show  that  in  ancient  times  people  were  accustomed 
to  secure  immunity  against  snake-bites  by  taking  cer- 
tain substances,  in  which  the  active  ingredient  was  the 
venom  itself.  In  particular  they  used  a  celebrated 
Persian  snake  antidote,  the  composition  of  which  is 
ascribed  to  one  of  the  Persian  kings.  The  essential 
ingredient,  he  shows  was  the  flesh  or  the  venom  of  the 
snake. 

Inoculations  against  Cholera. — The  results  of  Pro- 
fessor Haffkine's  system  of  inoculation  against  cholera, 
covering  another  year's  trial  in  India,  have  been  pre- 
sented. On  the  whole,  it  seems  that  the  inoculation 
method  does  have  some  protective  value,  although  the 
facts  supporting  this  view  are  not  yet  complete  and 
satisfactory.  It  is  probable  that  more  frequent  and 
perhaps  multiple  inoculations  will  be  necessary  to 
make  the  method  practically  useful  ;  at  any  rate, 
enough  has  been  done  to  justify  those  in  charge  of  the 


524 


MEDICAL   RECORD. 


[October  12,  1895 


matter  in  urging  a  further  grant  of  10,000  rupees  for 
the  further  prosecution  of  the  work. 

Carlsbad. — "To  those  who  have  it  shall  be  given." 
This  seems  to  be  particularly  true  of  Carlsbad,  which, 
having  got  a  certain  reputation  for  its  waters,  and  hav- 
ing worked  this  reputation  most  industriously  and  com- 
mercially, is  now  perhaps  one  of  the  most  prosperous 
of  the  German  cities  which  thrive  upon  invalid  visitors. 
We  are  told  that  the  total  number  of  patients  registered 
at  this  resort  during  the  last  season  was  forty  thousand. 
We  have  as  good  springs  and  as  good  climate  in  .\merica 
as  at  Carlsbad,  but  the  method  of  life  and  the  system 
of  treatment  are  the  outgrowth  of  years,  and  are  not  so 
easily  imitated. 

Perfect  Types  of  Women.— An  English  surgeon,  Mr. 
Frederick  J.  Gant,  has  written  a  novel  called  "Perfect 
Womanhood,"  in  which  types  of  perfect  modern 
womanhood  are  described.  To  his  mind  they  appear 
to  be  shown  in  the  characters  of  a  trained  nurse,  a 
deaconess  associate,  a  female  medical  missionary,  a 
ritualistic  maiden,  and  a  few  others.  We  see  no  men- 
tion of  the  bicycle  girl. 

Free  Medicine  and  a  Pound  of  Tea.— There  is  an  en- 
terprising firm  in  London  which  offers  to  its  customers 
groceries  and  other  material  comforts,  for  money,  while 
medical  opinions  are  thrown  in  far  nothing.  This,  we 
had  supposed,  was  a  distinctly  Chicago  idea.  At  any 
rate,  it  is  rumored  that  we  shall  have  in  this  city  before 
long  a  grand  bazaar,  run  by  a  Chicago  firm,  where  all 
kinds  of  goods  will  be  sold,  and  where  medical  men 
will  be  in  attendance  to  give  free  advice  to  the  cus- 
tomers. 

Posture  in  Cycling.— Many  physicians  prescribe  the 
bicycle,  and  when  prescribing  it,  give,  we  have  no 
doubt,  the  best  advice  within  their  light,  as  to  the 
amount  of  exercise,  the  adjustment  of  the  wheel,  and 
the  method  of  riding.  A  correspondent  of  the  British 
Medical  Journal,  who  claims  to  be  a  medical  man  and 
a  cyclist  of  twenty-five  years'  experience,  gives  the  fol- 
lowing description  of  the  posture,  and  the  arrangement 
of  the  seat  and  handle  bars  necessary  to  correct  and 
healthful  riding:  "With  the  laudable  intention  of 
gaining  an  upright  posture- many  riders  raise  the  han- 
dles until  they  are  above  the  level  of  the  seat,  or  even  of 
the  hips,  while  the  seat  is  placed  so  low  that  the  knees 
are  never  extended.  This  is  a  most  inefficient  and 
comfortless  posture  ;  all  control  is  lost  over  the  ma- 
chine, and  no  pulling  power  obtained  for  the  arms. 
The  arms  must  be  straight  and  the  handles  so  placed 
that  pulling  with  the  arms  shall  aid  the  thrust  of  the 
leg  without  disarranging  the  steering  or  shifting  the 
rider  on  the  seat.  The  seat  must  be  far  enough  back 
to  maintain  a  steady  hold  of  the  driving  (hind)  wheel 
on  the  road  and  to  place  little  weight  on  the  front 
wheel.  The  following  rules  apply  to  normal  individ- 
uals :  The  seat  should  be  placed  over  a  point  about 
half-way  between  the  hub  and  front  rim  of  the  hind 
wheel.  The  height  of  the  seat  should  be  such  that  the 
pedal  at  its  lowest  point  can  be  easily  reached  with  the 
ball  of  the  foot,  the  foot  being  horizontal  ;  this  means 
full  ankle  play.  The  handles  should  be  as  far  back  as 
a  lin«  passing  through  the  main  axle  of  the  driving  cog 


(bottom  bracket),  the  handle  bar  must  be  wide  enough 
to  clear  the  thighs  freely  and  to  carry  the  arms  clear  of 
the  sides.  The  handles  should  be  at  the  level  of  the 
seat,  or  at  least  in  such  a  position  that  the  arms  shall 
be  straight  downward  and  only  slightly  in  advance  of 
the  body.  The  point  of  the  handles  should  reach  half- 
way up  the  thigh  when  the  pedal  is  at  its  highest 
point,  but  wide  enough  to  avoid  fouling  the  thighs  in 
steering.  The  only  alteration  needed  to  any  modem 
safety  cycle  in  order  to  secure  these  positions  is  that 
the  handle  bar  should  be  some  inches  longer  than  the 
general  make.  The  weight  of  the  body  should  fall 
exactly  upon  the  tuberosities  of  the  ischia  on  the  cen- 
tre of  the  pads  of  the  seat  (Burgess's  or  similar  seat), 
the  thigh  not  falling  to  a  perpendicular  position  at  the 
lowest  point  of  the  stroke,  so  that  there  may  be  no  ten- 
dency to  slip  off  the  seat  fortrard  ;  the  pads  of  the  seat 
should  be  well  cupped  and  not  tightly  inflated.  Long 
experience  shows  that  these  points  constitute  the  most 
efficient,  comfortable,  and  healthy  posture  in  ordinary' 
road  cycling.  To  the  racing  man  or  the  "  road  scorch- 
er "  no  advice  is  offered. 

Translations  from  the  Russian. — We  are  glad  to 
know  that  some  of  our  naval  officers  do  good  work  in 
addition  to  their  routine  service.  Surgeon  F.  B. 
Stephenson,  U.  S.  N.,  has  lately  finished  translations 
from  several  Russian  publications  about  the  gypsy 
moth,  for  the  State  Board  of  Agriculture  of  Massa- 
chusetts. During  a  recent  cruise  on  the  Asiatic  sta- 
tion, Dr.  Stephenson  made  use  of  his  opportunities  to 
advantage  in  gaining  a  practical  knowledge  of  the  lan- 
guage of  this  nation,  so  rapidly  growing  in  strength 
and  influence. — Army  and  N^avy  Journal. 

The  Morals  of  a  Surgeon. — What  a  man  does  is  the 
proof  to  the  world  of  what  a  man  is.  Many  good  peo- 
ple fear  that  the  advance  of  science  will  bring  about 
the  retrogression  of  morals  and  religion.  We  do  not 
agree  with  them.  But  if  they  cannot  accept  our  judg- 
ment, let  them  weigh  well  a  fact  like  this :  Mr.  Jona- 
than Hutchinson,  F.R.S.,  and  ex-president  of  the  Royal 
College  of  Surgeons,  addressed  his  professional  breth- 
ren assembled  in  annual  congress  the  other  day,  and 
he  thus  spoke  :  "  I  bore  with  such  equanimity  as  I 
could  the  discovery  that  I  could  not  compete  with  my 
friend  in  the  ratio  of  successes  obtained  "  (in  opera- 
tions for  ovariotomy),  "  and,  acting  on  the  rule  of  con- 
duct that  1  would  never  keep  a  patient  in  my  own, 
hands  if  I  believed  that  someone  else  could  do  what 
was  needed  with  greater  prospect  of  success,  I  gave  up 
doing  ovariotomies,  both  in  public  and  in  private,  and 
used  to  transfer  my  patients  from  the  London  to  the 
Samaritan  Hospital."  Here  is  a  rule  of  conduct  which 
has  never  been  excelled  in  moral  worth  in  any  depart- 
ment of  professional  life  or  private  behavior.  A  most 
far-reaching  and  truly  noble  rule  is  this  of  Mr.  Jona- 
than Hutchinson's  ;  and  the  fact  that  he  announced  it 
toward  the  close  of  his  career  in  the  hearing  of  hun- 
dreds of  his  professional  brethren,  who  are  almost  as 
familiar  as  he  is  himself  with  the  conduct  of  his  pro- 
fessional life  is  proof  that  he  spoke  mere  truth.  If 
these  are  the  morals  of  men  of  science  may  we  not  say 
of  men  of  all  professions  and  callings,  O  si  sic  omnes!—^ 
The  Hosiital. 


October  12,   1895] 


MEDICAL    RECORD. 


525 


s^ocicty  Reports. 


THE    AMERICAN    DERMATOLOGICAL   ASSO- 
CIATION. 

Nineteenth  Annual  Meeting,  held  at  the  Windsor  Hotel, 
Montreal,  Canada,  September  77,  18,  and  ig,  iSg^. 

The  President's  Address.— The  Association  was  called 
to  order  by  the  President,  Dr.  S.  Sherwell,  of  Brook- 
lyn, N.  Y.,  who  in  a  brief  address  welcomed  the  mem- 
bers from  so  many  distant  points  of  the  continent,  and 
congratulated  them  upon  the  certain  success  of  the 
meeting,  as  promised  by  the  length  of  programme  and 
number  in  attendance.  He  spoke  of  the  limitations  of 
the  microscope  in  settling  many  dermatological  prob- 
lems, and  of  the  great  importance  of  considering  the 
science  of  dermatology  no  less  from  a  clinical  and 
empirical  standpoint.  He  would  regard  the  Associa- 
tion, as  it  were,  a  supreme  court  in  disposing  of  mooted 
questions  affecting  the  specialist  in  this  country,  and 
would  suggest  that  its  most  proper  work  was  in  the 
consideration  of  matters  of  high  scientific  interest,  ra- 
tional, academic,  and  polemic. 

A  review  was  made  of  the  speaker's  statistical  re- 
searches into  the  disparity  and  excess  of  the  alien  ele- 
ment applying  for  relief  at  the  various  clinics  of  our 
large  cities.  The  question  of  constitutional  treatment 
in  skin  diseases  was  then  discussed.  He  would  not 
rely  upon  it  wholly,  but  thought  in  most  cases  it  was 
to  be  employed  as  coincident  treatment  along  with 
local  measures. 

Angiokeratoma  of  the  Scrotum  was  the  title  of  a  paper 
by  Dr.  Foruvce,  of  New  \'ork.  He  described  a  pa 
tient  si.Kty  years  of  age,  and  showed  a  colored  picture 
of  a  scrotum  the  seat  of  a  great  number  of  dark  purple 
spherical  tumors  arranged  in  a  somewhat  linear  man- 
ner. They  vary  in  size  from  a  pin's  head  to  several 
times  that  size.  Pressure  causes  disappearance  of  the 
color  in  most  of  the  tumors,  which  are  slightly  elevated 
above  the  surface.  Some  are  covered  with  a  slightly 
thickened  horny  layer.     No  subjective  symptoms. 

In  cases  reported  chilblains  have  usually  preceded, 
and  the  feet  and  hands  have  been  the  parts  implicated. 
Many  photo-micrographs  were  passed  showing  the  his- 
tological appearances.  The  lesions  seem  to  consist  of 
lacunar  spaces  filled  with  blood,  occupying  the  papil- 
lary portion  of  the  derma.  The  atrophy  of  the  scrotal 
skin  removing  the  normal  support  to  the  vessels,  to- 
gether with  tendency  to  vascular  dilatation  as  shown 
by  a  condition  of  varicocele  present,  may,  the  author 
thinks,  have  had  an  influence  in  the  causation  of  the 
tumors.  The  author's  investigations  lead  him  to  be- 
lieve that  the  primar)'  change  is  vascular.  He  upholds 
Pringle's  view  that  the  blood-spaces  in  the  rete  Mal- 
pighii  are  caused  by  a  down  growth  of  the  cells  of  the 
layer,  producing  a  constriction  of  the  terminal  looi)s 
and  their  resultant  distention.  The  histological  ap- 
pearances correspond  closely  with  classical  cases  of 
angiokeratoma  reported  by  iMabelli  and  Pringle. 

Rajmaud's  Disease  of  the  Ears  was  described  in  an- 
other paper  by  the  same  author.  .'\  man,  thirty- nine 
years  of  age,  with  presumable  specific  history,  noticed 
that  the  ears  became  suddenly  cold  and  blue  on  a  warm 
day  and  remained  so  for  several  hours,  gradually  re- 
suming the  normal  color.  Such  attacks  were  frequent 
for  about  six  months,  when  a  portion  of  the  ears  re- 
mained bluish-black  and  are  so  still.  The  ears  feel 
numb  and  cold,  and  sometimes  there  is  a  burning  pain 
in  them.  A  gangrenous  area  formed,  having  a  diam- 
eter of  half  an  inch.  Cicatrization  followed,  and  the 
blue  color  disappeared.  Syphilis  is  suggested  as  a  pos- 
sible etiological  factor  :  implication  of  the  arterial  coats 
leading  to  obstruction  in  the  blood-supply,  especially 


when  an  element  of  vascular  spasm  due  to  cold,  etc.,  is 
added. 

Dr.  Zeisler  said  the  clinical  picture  of  angiokerat- 
oma had  hitherto  not  been  complete  ;  additional  feat- 
ures might  be  discovered.  His  own  case,  which  it 
seemed  to  him  corresponded  in  every  particular  with 
the  typical  pictures  of  Mabelli,  would  seem  to  differ  in 
features  pointed  out  by  Dr.  Fordyce.  At  the  same 
time  it  seemed  to  him  that  Dr.  'White's  criticism  is  not 
entirely  justified,  although  he  would  like  to  see  a  little 
stronger  development  of  the  horny  layer  to  deserve 
that  name.  It  does  not  seem  to  him  unreasonable  that 
the  scrotum  should  be  the  seat  of  keratoma.  He  be- 
lieves it  may  be  seen  often  in  cases  of  varicocele. 
Wherever  the  element  which  favors  stagnation  of  the 
blood  exists,  we  have  an  etiological  reason  for  the  pro- 
duction of  keratoma.  The  horny  layer  is  so  enor- 
mously enlarged  in  every  typical  case  of  keratoma, 
that  he  believes  it  to  be  an  essential  factor.  If  he 
compares  a  similar  case  with  that  of  Dr.  Fordyce,  he 
thinks  in  his  case  the  horny  layer  was  five  or  six  times 
as  extensive.  That  the  clinical  picture  in  angiokerat- 
oma is  by  no  means  complete,  he  had  another  instance 
within  the  last  two  weeks.  A  man,  aged  about  sixty- 
seven,  called  at  his  clinic.  The  lesions  were  on  vari- 
ous parts  of  the  body,  on  the  extremities  as  well  as  the 
trunk.  They  were  fiat  and  somewhat  elongated  angi- 
ectoides.  During  the  last  few  days  he  had  examined 
the  soles  of  the  feet,  and  on  one  sole  he  found  two  dis- 
tinct angiokeratomata,  corresponding  very  distinctly 
with  what  he  had  seen  before.  There  was  no  evidence 
of  the  previous  existence  of  angioma.  Keratoma 
should  be  the  essentia'  feature  in  angiokeratoma, 
otherwise  the  title  is  not  entirely  appropriate. 

Dr.  Hyde  wished  to  join  Dr.  Bowen  in  congratulat- 
ing Dr.  Fordyce  on  the  excellence  of  the  two  photo- 
graphs. He  wished  to  know  if  there  was  any  linear 
arrangement  of  the  lesions  on  the  scrotum,  and  whether 
he  had  any  reason  to  suppose  there  was  any  relation 
between  the  vitiligo  present  and  the  distribution  of  the 
lesions  on  the  scrotum. 

Dr.  Fordyce  did  not  think  there  was  any  relation. 
The  linear  arrangement,  it  seemed,  followed  the  course 
of  the  vessels  of  the  part. 

Dr.  Shepherd  asked  if  there  was  any  difference  be- 
tween this  and  the  ordinary  varicosity  without  the  kera- 
toma. He  had  seen  a  good  many  cases  of  varicosity 
of  the  scrotum,  and  in  a  large  proportion  of  them  he 
had  noticed  this  enormous  vascularity  of  the  skin  of 
the  part,  the  veins  of  which  seemed  to  be  generally  di- 
lated. 

Dr.  Fordyce  replied  that  the  horny  layer  of  the 
scrotum  is  naturally  thinner  than  on  the  hands,  and  as 
this  layer  is  stimulated  to  new  growth  by  some  form  of 
irritation  or  traumatism,  the  hypertrophy  reaches  a 
greater  height  in  the  hands  than  in  the  scrotum.  The 
essential  condition  on  which  stress  is  laid  by  all  pre- 
vious observers  is  the  existence  of  blood-spaces  in  the 
epidermis.  He  did  not  think  it  can  be  compared  to  a 
varix  condition  of  the  veins  ;  it  was  rather  a  varicose 
condition  of  the  papillary  capillaries.  In  some  tumors 
the  base  is  cut  off  entirely,  and  you  have  a  condition 
similar  to  that  found  in  an  aneurism,  where  there  is 
coagulation,  deposit  of  fibrin,  etc.,  in  the  spaces. 

Dk.  Whi  pe  said,  with  regard  to  the  localities  here 
affected,  he  thinks  these  do  not  preclude  the  idea  of 
Raynaud's  disease.  He  had  seen  a  case  of  this  disease 
affecting  the  fingers  and  precisely  this  locality  in  both 
ears.  He,  however,  had  never  seen  any  such  affection 
of  the  ears  alone. 

Dr.  Sherwell  thought  that  in  most  of  the  cases 
wiiich  had  come  under  his  observation  a  history  of 
syphilis  was  present.  He  mentioned  a  very  distinct 
and  typical  case,  which  recovered  under  antisyphilitic 
treatment,  but  where  the  disease  recurs  from  time  to 
time,  especially  durim;  the  colder  months,  local  an- 
esthesia and  a  very  slight  tendency  to  gangrene  on  the 


;26 


MEDICAL   RECORD. 


[October   12,  li 


tips  of  the  fingers  existed,  and  was  aggravated  by  the 
cold,  and  at  times  the  ears  were  disposed  to  show  sim- 
ilar phenomena. 

Dr.  Fordyce  said  Raynaud's  original  monograph 
did  not  discuss  the  pathological,  but  simply  the  clin- 
ical, aspect  of  the  cases.  Of  course,  in  the  speaker's 
cases  there  were  changes  in  the  arterial  coats  ;  but 
there  are  many  cases  of  the  disease  reported  by  Ray- 
naud himself  in  which  the  extremities  were  free  from 
gangrene.  Raynaud's  disease,  in  fact,  is  a  general 
term,  including  endarteritis  and  many  other  patholog- 
ical conditions. 

Dr.  Hyde  spoke  of  a  case  of  lupus  erythematosus 
upon  the  cheeks  of  a  woman,  which  rapidly  disappeared 
under  ordinary  treatment.  Almost  immediately  a  typ- 
ical lichen  planus  developed  upon  the  extremities.  He 
thought  we  must  enlarge  the  conditions  to  which  we 
apply  the  term  lupus  erythematosus. 

Dr.  Fordyce  also  thought  many  different  condi- 
tions had  been  included  under  lupus  erythematosus. 
Some  were  mere  localized  hyperemias,  some  cases  dis- 
appear spontaneously,  while  others  cannot  be  made  to 
go  away. 

Hydroa  .Slstivale. — Dr.  Graham,  of  Toronto,  read  a 
paper  upon  this  subject.  Two  cases  were  reported  of 
this  peculiar  and  rare  affection  occurring  after  expos- 
ure to  sunlight.  In  the  first  a  few  small  red  spots  ap- 
peared upon  the  face  and  hands  of  a  young  girl. 
These  recurred  as  soon  as  she  began  to  go  out  of  the 
house,  and  the  lesions  became  vesicular  and  pustular. 
These  became  black  in  the  centre  and  umbilicated,  fol- 
lowed by  crusting  and  subsequent  scarring.  No  spots 
appeared  on  the  hands  when  gloves  were  worn.  At 
times  the  face  was  much  swollen. 

In  the  second  case  a  young  blond  female  suffered 
from  burning  sensations,  swelling,  and  vesicular  erup- 
tions when  exposed  for  twenty  minutes  or  more  to  the 
sun's  direct  rays.  Malaise,  coryza,  sleeplessness,  and 
anorexia  accompanied  the  attacks.  In  this  case,  sitting 
near  an  open  window  produced  the  eruption  on  any 
exposed  part  of  the  body.  On  account  of  the  affec- 
tion the  patient  has  been  virtually  a  prisoner  in  the 
house  for  fourteen  years.  The  skin  is  at  times  fissured 
and  scaly  as  in  a  chronic  eczema. 

The  term  hydroa  vacciniforme  does  not  apply  to  all 
cases.  The  author  believes  that  it  is  not  only  the  ultra- 
violet rays  but  also  the  heat  rays  of  the  sun  which  play 
a  'part  in  producing  the  affection.  The  question  is 
how  they  produce  such  a  deep  effect.  This  is  hard  to 
explain  without  the  intervention  of  the  vaso-motor 
nerves.  The  inflammation  is  thought  then  to  be  of 
reflex  character.  Tiie  sun's  rays  seem  capable  of  pro- 
ducing a  dermatitis  of  variable  intensity.  The  amount 
of  necrosis  and  subsequent  cicatrization  will  depend 
upon  the  vulnerability  of  the  tissues  and  the  amount  of 
exposure.  Unlike  xeroderma  pigmentosum,  it  does  not 
seem  to  attack  more  than  one  member  of  a  family.  A 
covering  to  the  skin  which  would  exclude  the  light 
was  almost  always  effectual. 

Dr.  Zeisler  spoke  of  a  case  observed  where  the 
lesions  recurred  frequently  on  exposure  to  sunlight. 
The  gentleman  had  first  become  aware  of  liie  trouble 
after  horseback  exercise.  He  thought  the  condition 
one  of  erythema  multiforme  and  suggested  the  trial  of 
atropia  as  a  remedy. 

Dr.  White  would  also  look  upon  it  as  a  dermatitis 
rather  than  as  a  separate  affection  to  which  a  particu- 
lar designation  was  applicable.  No  absolute  type  of 
lesion  is  maintained  in  all  attacks. 

Dr.  Bowen  said  he  had  been  called  upon  to  exam- 
ine one  such  case  histologically  ;  the  inflammation  was 
here  followed  by  necrosis  ;  the  lesions  were  umbili- 
cated. The  microscope  showed  tliat  the  necrosis  ex- 
tended down  to  the  corium.  This  distinguishes  it  from 
erythema  multiforme,  which  is  never  followed  by  scar- 
ring, as  is  here  the  case. 

Dr.  Hartzell  had  seen  a  case  in  warm  weather 


where  the  lesions  came  in  the  absence  of  exposure  to 
direct  sunlight.  The  inflammation  was  not  severe 
enough  to  produce  necrosis.  It  differed  from  other 
cases  only  in  degree  of  inflammation. 

Dr.  Phillip^,  of  Toronto,  had  treated  Dr.  Graham's 
case,  and  on  invitation  spoke  of  his  treatment,  which 
had  been  mainly  soothing  and  protective.  He  thought 
the  ultra-violet  rays  of  light  those  which  produced  the 
effect.  He  had  intended  to  try  their  exclusion  by  cov- 
ering the  parts  with  bisulphate  of  quinine  in  bassorin 
paste,  or  to  cover  the  face  with  some  yellow-colored 
paste. 

Dr.  Jackson  had  had  for  several  years  a  boy  under 
his  care  at  the  Vanderbilt  Clinic  presenting  lesions. 
pittings,  and  scars  of  this  same  affection.  He  suffered 
more  in  winter  than  summer.  This  was  also  the  case 
in  Alps-clim'oers,  he  believed,  in  which  an  English  phy- 
sician, Bowles,  had  made  a  successful  use  of  such  a 
brown  ointment  as  actors  use. 

Dr.  Shepherd  had  within  two  weeks  seen  a  young 
lady  in  Montreal  with  a  dermatitis  of  three  years' dura- 
tion, which  would  appear  on  exposure  out  of  doors, 
accompanied  by  swelling,  bullous  lesions,  and  subse- 
quent scarring.  He  had  seen  it  appear  in  a  fellow- 
traveller  in  crossing  the  Alps. 

Dr.  Allen  remembered  Dr.  Jackson's  case,  and 
from  having  frequently  seen  the  boy,  could  substantiate 
the  fact  of  the  eruption  being  at  times  severe  in  the  win- 
ter. He  had  seen  other  cases  in  which  the  direct  sun- 
light acted  to  produce  lesions  on  face  and  hands. 
From  his  readings  he  came  to  believe  the  chemical 
rays  responsible,  and  considered  exclusion  of  light  the 
only  rational  treatment. 

Dr.  Sherwell  recommended  that  women  so  predis- 
posed should  always  wear  yellow  veils,  and  that  by  so 
wrapping  up  the  parts  as  to  make  virtual  developing 
chambers  the  disease  would  be  prevented. 

Dr.  Graham,  in  closing,  said  Dr.  Bowen's  investi- 
gations would  exclude  any  idea  of  the  condition  being 
an  erythema.  He  thought  the  degree  of  inflammation 
depended  upon  the  individual  rather  than  upon  the 
length  of  exposure.  Dermatitis  Solaris  would,  all 
things  being  considered,  probably  be  the  best  name. 

Lupus  Erythematosus  Disseminatus. — A  case  of  this 
affection  was  related  by  Dr.  Fordyce,  in  which  lesions 
upon  the  hands  and  arms  disappeared  during  pregnancy, 
leaving  atrophic  spots  surrounded  by  a  pigmented 
zone.  In  a  second  case  the  eruption  likewise  disap- 
peared, but  came  back  in  an  equally  severe  form  after 
the  confinement.  A  large  number  of  photographs  were 
exhibited. 

In  discussing  these  papers  Dr.  Bronson  asked  if 
there  were  sufficient  reason  for  including  the  second 
case  under  Raynaud's  disease.  He  had  seen  gangrene 
about  the  face  which  could  not  be  accounted  for. 
He  always  looked  for  a  trace  of  syphilis. 

Dr.  White  did  not  think  the  keratomatous  element 
very  marked  in  Case  No.  i. 

Dr.  Fordyce  answered  that  he  would  not  have 
called  it  angiokeratoma  if  the  angiomatous  changes 
were  not  present.  Changes  in  the  epidermis  are  sec- 
ondary and  the  result  probably  of  hyperemia  due  to 
irritation.     The  changes  in  the  rete  were  marked. 

Dr.  Morrow  had  seen  two  clinically  identical  cases 
during  the  year.  He  coincides  with  the  reader's  view 
that  they  should  be  called  angiokeratoma. 

Bromide  Eruptions,  with  a"  Report  of  Two  Cases. — 
This  jiaper  was  le.id  by  Dr.  J  acksox,  of  New  York, 
After  taking  bromide  of  potassium  for  several  weeks 
the  drug  was  stopped  in  a  young  woman,  and  shortly 
after  this  an  eruption  resembling  chicken-pox  ap- 
peared upon  the  forehead,  wiience  it  spread  over  the 
body.  Under  some  of  tlie  crusts  which  formed,  espe- 
cially upon  the  scalp,  there  was  found  a  raspberry-like 
appearance  witli  bleeding  points.  The  case  was  some- 
what puzzling  until  a  second  similar  case  presented 
itself.     The   lesions  here  looked  like  impetigo  conta- 


October   12,  1895] 


MEDICAL    RECORD. 


527 


giosa  followed  by  the  same  wart  like  lesions.  On  the 
legs  the  lesions  broke  down  into  indolent  irregular 
ulcers.  This  case  had  been  given  bromide.  The  feat- 
ures of  interest  in  the  cases  is  the  long  period  between 
the  cessation  of  drug  administration  and  the  appear- 
ance of  the  eruption. 

Dr.  Hyde  believed  that  bromide  eruptions  of  this 
pronounced  type  occurred  chiefly  in  young  subjects 
and  those  who  were  cachectic  or  below  par,  scarcely,  if 
ever,  being  seen  in  healthy  individuals.  He  had  ob- 
served quite  similar  lesions  from  the  iodides,  and  w^as 
prepared  to  believe  that  other  drugs  as  well  might  pro- 
duce these  effects. 

Dr.  Morrow  said  children  were  prone  to  vascular 
disorders,  and  the  severe  forms  of  bromide  eruption 
were  apt  to  be  seen  in  them.  All  our  knowledge  of 
drug  eruptions  opposes  the  view  that  lesions  continue 
to  appear  after  the  drug  administration  is  stopped.  It 
is  difficult  to  e.xplain  why  the  effect  should  be  pro- 
longed. 

Dr.  White  did  not  think  the  general  health  of  the 
patient  had  much  to  do  with  the  determination  of  a 
given  eruption.  It  is  the  result  of  individual  idiosyn- 
crasy. He  was  not  familiar  with  any  other  drugs  which 
could  produce  the  lesions  described  by  Dr.  Jackson. 

Dr.  Hartzell  recalled  the  frequency  with  which 
valvular  heart  disease  was  associated  with  the  severer 
forms  of  bromide  and  iodide  eruptions. 

Dr.  Fox  said  some  syphilides  in  children  resemble 
closely  the  bromide  eruptions.  Mistakes  are  likely  to 
occur  when  bromides  are  being  administered  to  chil- 
dren known  to  be  syphilitic.  The  drug,  too,  may  tend 
to  bring  out  as  it  were  the  cutaneous  syphilis. 

Dr.  Graham  spoke  of  cases  in  which  a  history  of 
bromide  administration  is  hard  to  obtain,  thus  leading 
to  doubt. 

Dr.  Allen  said  that  at  times  the  large  bullae  of 
iodide  origin  assumed  a  fungating  appearance  closely 
simulating  the  bromide.  He  had  seen  the  eruption  in 
an  epileptic  girl  persist  for  weeks  after  the  drug  had 
been  stopped.  When  an  eruption  follows  a  minute 
dose,  as  seen  from  quinine,  nerve  influence  rather  than 
skin  irritation  due  to  elimination  is  to  be  looked  for. 

Dr.  Sherwell  said  that  dermatological  knowledge 
had  advanced,  for  whereas  some  years  ago  such  a  case 
as  described  might  be  called  yaws  or  something  of  the 
kind,  now  the  true  nature  is  generally  recognized. 
Still,  cases  are  seen  by  him  now  and  then,  surely  due 
to  the  iodides,  which  are  practically  bromide  eruptions. 
He  had  seen  the  eruption  become  intensified  several 
weeks  after  the  drug  had  been  stopped. 

Dr.  Hyde  said  he  had  no  direct  positive  knowledge 
that  other  drugs  would  produce  these  same  effects,  but 
such  had  been  reported  to  him  by  fellow-practitioners. 
He  mentioned  hydriotic  acid  as  such  a  drug,  and  thought 
there  might  be  others. 

Dr.  Morrow  could  see  no  reason  why  an  eruption 
due  to  a  drug  should  continue  to  appear  after  the  drug 
is  withheld,  and  he  considered  the  histories  of  cases  in 
which  this  is  reported  as  generally  too  vague.  Long- 
continued  administration  is  usually  necessary  to  bring 
about  the  required  changes  of  nutrition  in  the  tissue. 

Dr.  Hyde,  while  admitting  that  most  drug  effects 
upon  the  skin  quickly  subside  on  stopping  the  injuri- 
ous agent,  still  this  particular  one  did  not  and  should 
be  placed  by  itself.  That  children  to  whom  bromides 
are  given  are  usually  in  some  way  out  of  health,  is 
shown  by  the  very  fact  of  the  drug  being  required. 

Dr.  Jackson  said  he  had  seen  bromide  lesions  per- 
sist for  weeks  after  the  drug  was  stopped  in  a  patient 
he  had  treated  since  writing  his  paper.  It  was  the  old 
lesions  which  refused  to  disappear  rather  than  the  de- 
velopment of  new. 

Value  and  Limits  of  Usefulness  of  Electrolysis  in 
Dermatology.— The  afternoon  session  opened  with  a 
discussion  on  this  subject.  Dr.  Zeisler  being  called 
upon,  said  he  thought  not  much  that  was  new  could  be 


said  upon  this  subject,  and  probably  the  best  form  for 
the  discussions  to  take  was  the  recounting  by  the  mem- 
bers of  their  individual  experience.  In  hypertrichosis, 
electrolysis  was  of  all  means  the  best  treatment ;  but 
he  thought  it  was  most  useful  in  dealing  with  stiff  hairs, 
and  should  not  be  employed  for  lanugo.  His  experi- 
ence had  caused  him  to  look  upon  it  with  hesitation  as 
a  means  of  remedying  congenital  and  angiomatous 
naevi.  Its  use  here  he  considered  limited  to  small 
naevi  in  infants.  He  mentioned  a  case  of  a  lady  with  a 
nsvus  covering  one  side  of  her  face — it  was  superficial, 
with  the  blood-vessels  chiefly  on  the  surface.  After 
fifteen  or  twenty  sittings  it  did  not  appear  to  the  speaker 
that  the  results  were  very  brilliant.  He  then  requested 
the  patient  to  desist  for  a  few  weeks,  when  the  results 
were  found  to  be  very  encouraging.  Electrolysis  was 
also  useful  in  small  growths  of  the  naivi  fibromatous 
types  ;  here,  however,  a  little  more  care  should  be  taken 
in  piercing  with  the  needle,  as  scars  are  apt  to  remain. 
He  thought  the  needle  should  be  inserted  in  such  a  way 
that  the  action  would  not  be  too  deep,  as  he  preferred 
repeating  the  operation  to  running  any  risk  of  scarring. 
He  used  the  electric  needle  also  in  xanthomata.  He 
thought  it  one  of  the  safest,  but  not  the  least  painful, 
methods  for  this  purpose,  especially  of  operating  near 
the  eye.  As  to  a  local  anaesthetic,  he  had  not  much 
faith  in  cocaine  in  such  cases  ;  the  only  way  he  used  it 
was  to  impregnate  the  electrode  with  the  drug  and  ren- 
der the  whole  area  anesthetic. 

Dr.  White  agreed  in  the  main  with  Dr.  Zeisler's  re- 
marks. He,  however,  did  not  recognize  the  impossi- 
bility of  removing  lanugo  hairs ;  he  had  done  so  a 
number  of  times.  As  to  the  desirability  of  doing  so, 
that  was  another  matter.  He  had  only  operated  on  oc- 
casions where  much  pressure  had  been  brought  to  bear 
upon  him.  He  did  not  think  electrolysis  suitable  for 
large  naevi  with  hypertrophied  vessels  ;  you  may  be  able 
to  remove  the  latter,  but  the  work  is  very  tedious,  re- 
quiring a  great  many  sittings.  As  to  port-wine  mark, 
he  had  been  very  unsuccessful,  save  when  the  area  af- 
fected was  very  small  ;  and  he  thought  it  an  operation 
that  should  only  be  undertaken  under  great  pressure. 
Relative  to  anaesthesia,  he  had  been  using  a  twenty  per 
cent,  alcoholic  solution  of  cocaine  and  he  believed  it 
helped  to  a  certain  extent.  He  did  not  believe  there 
was  much  absorption  by  the  skin,  but  a  penetration  of 
the  drug  into  the  hair-follicles.  He  did  not  claim  that 
total  anaesthesia  followed  ;  but  he  was  satisfied  that 
there  was  something  more  than  the  moral  influence  of 
the  application  to  account  for  the  lessened  sensation. 

Dr.  Morrow's  experience  corresponded  with  that 
of  the  other  two  speakers.  Relative  to  anaesthesia,  he 
wished  to  say  that  some  years  ago  he  had  experimented 
a  good  deal  on  the  practicability  of  rendering  certain 
limited  areas  of  the  skin  aniesthetic,  and  he  found  the 
most  thorough  method  to  be  that  of  kataphoresis.  By 
saturating  any  porous  material  with  cocaine  an  abso- 
lute anaesthesia  might  be  obtained  over  an  area  corre- 
sponding to  the  surface  of  a  small  electrode  covered 
with  it.  He  found  that,  in  those  cases,  by  scratching 
the  surface  just  enough  to  break  the  epidermis  without 
causing  exudation,  the  kataphoric  action  was  very  ma- 
terially favored.  He  thought  there  could  be  no  doubt 
whatsoever  of  the  efficacy  of  this  method. 

Dr.  Hyde's  experience  led  him  to  believe  that  the 
attempt  to  remove  the  fine,  downy  hairs  only  stimulated 
these  to  greater  activity  of  growth.  He  mentioned  the 
class  of  young  Jewish  girls  with  heavy  black  eyebrows 
and  abundant  hair  of  the  scalp  as  one  in  which  he  had 
often  found  this  to  be  the  case.  Electrolysis  he  be- 
lieved useful  in  spider-cancer,  with  small  telangiec- 
trodes,  and  in  rosacea  where  the  same  condition  exists. 
The  operation  was  useful  in  the  case  of  smaller  ves- 
sels, but  unsatisfactory  in  large.  Although  forced  to 
employ  cocaine  and  other  drugs  of  that  nature  in  cases 
of  severe  pain,  he  had  a  strong  objection  to  doing  so,  as 
he  found  they  had  a  tendency  to  cause  dermatitis.     As 


528 


MEDICAL    RECORD. 


[October  12,  1895 


to  contagious  mollusca  he  never  used  electricity,  find- 
ing them  much  more  easily  swept  away  with  the  cu- 
rette. 

Dr.  Fox  thought  there  could  be  no  doubt  of  the 
value  of  electrolysis  in  dermatology,  the  only  question 
to  consider  was  as  to  its  limits.  In  hypertrichosis  he 
thought  it  was  not  only  the  best  but  the  only  means  for 
the  permanent  removal  of  hairs,  although  often  a  tedi- 
ous operation.  As  to  the  finer  hairs,  he  believes  if 
they  can  be  seen  they  can  be  removed  ;  but  it  is  as- 
tonishing how  much  worry  a  few  scarcely  perceptible 
hairs  on  the  chin  will  give  some  women  possessed  of  far 
more  serious  facial  blemishes  ;  and  consequently  he 
made  a  rule  never  to  operate  upon  hairs  that  were  not 
conspicuous.  His  opinion  is  that  the  effect  of  electro- 
lysis, if  it  has  any  effect  at  all,  is  to  lessen  the  growth 
of  hair  upon  the  face.  He  does  not  believe  that  any- 
one can  prove  that  the  removal,  either  by  pulling  out, 
by  cutting,  or  by  electrolysis,  ever  affected  the  growth 
of  neighboring  hairs.  As  to  the  painfulness  of  remov- 
ing hairs  by  electrolysis,  his  experience  leads  him  to  be- 
lieve it  is  not  more  painful  than  the  filling  of  teeth, 
which,  we  know,  is  at  most  only  uncomfortable.  Of 
course  if  the  needle  were  not  properly  introduced  it 
might  be  very  painful  ;  it  should  never  be  jabbed  into 
the  follicle.  As  to  the  other  uses  of  electrolysis  he 
thought  too  many  claims  had  been  made.  Excellent 
results  might  be  obtained  in  nasvus  pilosus.  In  vascu- 
lar najvi  his  results  have  not  been  satisfactory.  In  the 
very  pinkish  wine-mark  he  preferred  dotting  the  sur- 
face with  carbolic  or  nitric  acid  ;  but  in  the  dark  slate- 
colored  wine  marks  he  believed  single  or  multiple  elec- 
tric needles  the  best.  In  xanthema  he  thought  he  had 
brilliant  success  with  electrolysis,  certainly  belter  than 
could  be  obtained  with  the  knife.  He  doubted  if  true 
keloid  could  be  removed  by  electrolysis.  In  some  cases 
resembling  keloid,  following  syphilitic  ulceration  of  the 
cervical  glands,  where  large  bunches  existed,  a  very 
good-looking  cicatrix  was  produced  by  the  use  of  elec- 
trolysis. In  angioma  he  thought  it  could  be  used  with 
success,  but  not  with  more  than  that  obtained  from 
other  methods.  He  recently  removed  from  the  fore- 
head of  a  child  an  angioma  the  size  of  a  chestnut  by 
electrolysis.  He  used  it  in  one  case  of  epithelioma  of 
the  lip  with  good  success.  One  should  not  attempt  to 
use  it  as  a  cure  in  very  many  skin  diseases. 

Dr.  Bronson  thought  that  most  of  the  members 
knew  the  advantages  and  disadvantages  of  the  process  ; 
as  to  its  limits,  that  was  for  time  to  decide.  He  thought 
its  chief  use  was  in  cosmetic  operations.  The  chief 
disadvantages  are  pain,  the  fact  that  the  neighboring 
hairs  sometimes  appear  to  be  stimulated,  and  the  dan- 
ger of  producing  scars.  In  some  measure  he  thought 
these  disadvantages  might  be  overcome.  Pain,  he 
thought,  rather  insignificant.  In  his  experience  it  was 
the  physician,  and  not  the  patient,  who  was  apt  to  cry 
"  Hold,  enough."  As  to  the  increased  growth  of  the 
hair,  he  thought  such  undoubtedly  occurred  in  many 
instances.  Lanugo  hairs  he  regarded  as  microscopic 
hairs,  invisible  to  ordinary  eyesight,  and  as  such  impos- 
sible to  remove  ;  but  such  was  not  the  case  with  the 
finer  downy  hairs  which,  after  removal  of  their  darker 
and  stiffer  fellows,  were  apt  to  suddenly  take  on  simi- 
lar characters  ;  and  it  was  by  the  total  removal  of  these, 
as  well  as  the  larger  ones,  which  he  believed  insured 
the  success  of  the  first  operation.  Something  should 
be  done  to  avoid  the  resulting  infiammation  which  ren- 
dered the  patient  so  unsightly  for  a  few  days.  He  had 
been  trying  the  paste  recommended  by  Unna  (ichthyol, 
gr.  XX. ;  starch,  gr.  xx.  ;  albumin,  gr.  j.  ;  water,  n],  xxx.), 
which  painted  on  at  night  seemed  to  limit  the  reaction. 
He  found  it  succeeded  in  rosacea  after  the  use  of  ich- 
thyol, resorcin,  and  multiple  scarifications  had  all 
failed.  By  making  multiple  punctures  as  close  to- 
gether as  possible,  after  the  removal  of  the  hairs,  a  con- 
siderable blanching  of  the  skin  resulted  from  destruc- 
tion of  blood-vessels,  and  permanent  benefit  followed. 


He  also  found  electrolysis  useful  in  hypertrophied  cica- 
trices. 

Dr.  Hertzell  thought  there  was  very  little  use  in 
dermatology  for  electrolysis  beyond  its  application  to 
cosmetic  operations,  such  as  removing  superfluous  hairs, 
small  telangiectodes,  etc.  He,  however,  agreed  with 
Dr.  Bronson  in  thinking  it  of  value  in  rosacea,  and  be- 
lieved that  here  it  not  only  destroyed  the  larger  ves- 
sels, but  the  cicatrices,  following  the  multiple  punct- 
ures by  contracting,  and  served  to  drive  the  blood  out 
of  the  part. 

Dr.  J.\ckson  thought  the  question  as  to  the  cause  of 
an  increased  growth  of  the  hair  a  difficult  one  to  decide. 
He  looked  upon  the  superficial  facial  hairs  in  young 
women  as  corresponding  to  the  beards  of  young  men, 
in  whom  fresh  hairs  keep  appearing  until  adolescence, 
and  it  was  only  reasonable  to  expect  the  same  condi- 
tion in  young  women.  There  may  be  some  increased 
growth  after  the  operation,  but  these  hairs  would  grow 
anyhow.  Relative  to  scarring,  he  believed  there  were 
some  women's  faces  where,  do  what  one  might,  it  was 
impossible  to  avoid  it  ;  and  he  consequently  thought  it 
a  wise  rule  never  to  commit  yourself  to  a  strange  case 
by  promising  that  no  such  effect  should  ensue.  It  is 
especially  apt  to  occur  about  the  corner  of  the  upper 
lip.  The  chief  difficulty  he  found  about  the  finer  hairs 
was  that  of  telling  when  they  were  really  removed  and 
not  broken  off.  He  had  often  noticed  pigmentation 
follow  the  removal  of  hairs.  As  to  the  question  of 
pain,  when  patients  complained  of  it,  he  employed  co- 
caine. Recently  he  had  been  dipping  his  needle  in  a 
lanolin  preparation  of  cocaine  before  each  puncture, 
and  it  seemed  to  help.  He  would  be  glad  if  someone 
could  tell  him  how  to  reduce  the  reactionary  inflamma- 
tion. He  used  to  try  hot  water,  etc.,  but  without  much 
apparent  benefit.  In  vascular  n^vi  he  found  linear 
punctures  with  a  single  needle  of  value.  Before  com- 
mencing he  takes  a  fine  pen  and  dots  the  area  he  in- 
tends to  operate  on.  There  is  no  doubt  about  its  ef- 
ficacy in  reducing  the  color  ;  the  art  comes  in  in  know- 
ing when  to  stop,  to  avoid  leaving  a  blanched  instead 
of  the  red  tint.  Even  in  cavernous  ntevi  he  believes 
much  good  can  be  derived  from  this  treatment  ;  he  has 
seen  some  of  the  large  spaces  shrink  up  into  a  fibres 
nodule.  In  rosacea  he  thought  there  was  a  tendency 
for  the  vessels  to  reappear  ;  in  general  redness  of  the  skin 
he  preferred  linear  scarification.  He  considered  kata- 
phoresis  as  a  very  painful  method  of  inducing  an.iis- 
thesia. 

Dr.  Morrow  thought  Dr.  Jackson's  experience  with 
kataphoresis  must  have  been  due  to  his  using  currents 
of  too  great  strength. 

Dr.  Wigglesworth  admitted  the  truth  of  Dr.  Jack- 
son's remark  concerning  the  futility  of  treating  the 
large  deep  vessels  in  rosacea  by  electrolysis,  he  also 
found  that  such  were  pretty  sure  to  grow  again.  In 
the  case  of  superficial  vessels,  however,  it  is  otherwise, 
and  he  had  often  succeeded  admirably.  In  lupus  ery- 
thematosus one  will  also  get  results  quite  as  good  as 
those  obtained  by  incisions.  He  also  found  electroly- 
sis successful  in  treating  acne  indurata.  He  thought 
the  best  way  to  use  cocaine  was  in  a  ten  per 
cent,  alcoholic  solution,  which,  lightly  applied  to  the 
parts,  gave  the  an.tsthetic  effect  of  the  cocaine  as  well 
as  the  cooling  and  sedative  effect  of  the  evaporating 
lotion.  He  thinks  it  should  not  be  rubbed  in,  as  this 
made  matters  worse  by  increasing  the  blood-supply. 
He  thinks  port-wine  marks  are  often  aggravated  by 
wrong  treatment  ;  one  case  in  which  a  small  mark  had 
been  made  a  very  large  one  by  the  use  of  potash,  under 
his  care,  yielded  to  electrolysis  entirely  at  one  sitting, 
The  current  used  was  ten  cells,  and  the  punctures 
made  around  the  entire  surface.  In  these  rapidly  ac 
quired  conditions,  the  results  were  much  better  than 
in  the  old  solidified  port-wine  marks  of  birth.  As  to 
scarring,  he  managed  to  avoid  it  by  paying  attention  to 
the  points  already  alluded  to  by  previous  speakers.    Ti.e 


ting.    I 
were    i 

v  ac-    i 


October  12,    1S95] 


MEDICAL   RECORD. 


5^9 


mistakes  made  were  in  using  too  strong  currents,  not 
looking  out  for  idiosyncrasies,  such  as  a  tendency  to 
the  formation  of  keloid,  or  to  the  development  of  pig- 
mentation. 

Dr.  GRAH.A.M  wished  to  know  if  any  of  the  members 
had  ever  used  electrolysis  for  the  removal  of  hairs  in 
obstinate  sycosis. 

Dr.  Robinson's  experience  was  that  the  irritation 
caused  by  the  introduction  of  the  needle  certainly  pro- 
duced an  increased  growth  of  the  neighboring  hairs. 
He  instanced  the  case  of  chronic  dermatitis  of  the 
scalp,  accompanied  by  a  great  stimulation  and  exfolia- 
tion of  the  corneal  layer  of  the  epidermis  ;  when  cured 
this  is  followed  by  an  abundant  growth  of  hair.  The 
same  is  seen  in  fracture  of  the  tibia  when  the  skin  is 
rear  the  broken  bone  ;  hairs  develop  in  increased  quan- 
tities. Shaving  is  another  instance  of  irritation  in- 
creasing the  growth  of  hair.  For  these  reasons  he 
never  used  electrolysis  on  any  part,  such  as  the  upper 
lip,  where  the  hairs  are  close  together  ;  but  he  thought 
it  was  very  useful  in  other  parts  of  the  face.  Electro- 
lysis is,  he  thought,  the  most  satisfactory  method  we 
know  of  treating  hairy  nsevus  :  it  sometimes  required 
a  great  number  of  sittings,  but  success  is  always  the 
reward.  In  regard  to  the  reactionary  inflammation,  he 
thought  the  method  of  using  the  needle  had  something 
to  do  with  it  ;  he  found  that  if  you  go  right  into  the 
follicle  the  irritation  is  less  than  if  you  go  outside  of  it. 
He  uses  powerful  spectacles,  which  enable  him  to  see 
every  follicle  opening. 

Dr.  Allen  had  seen  quite  a  number  of  cases  during 
the  summer  in  which  he  used  electrolysis,  and  had  been 
using  a  flat  needle  with  rather  sharp  edge,  carrying  it 
gradually  from  one  side  to  another  at  the  base  of  the 
growth,  especially  in  moles  and  warts.  He  generally 
succeeded  in  removing  these  in  a  single  sitting.  This 
he  found  the  nicest  and  neatest  way  to  get  rid  of  them, 
and  preferable  to  leaving  them  after  the  operation  to 
dry  up  and  fall  off.  A  ten  per  cent,  watery  solution 
of  cocaine  will  render  some  warts  a  great  deal  less  sen- 
sitive to  the  pain.  He  had  removed  several  large  moles 
lately  with  good  results,  and  knew  of  no  other  method 
where  they  could  be  removed  without  scarring  or  with 
so  little  pain.  Electrolysis  was  especially  useful  in  re- 
moving hairs  from  the  chin,  and  it  was  not  so  success- 
ful in  those  of  the  upper  lip.  He  did  not  think  it  was 
wise  to  operate  on  every  case  that  presented  itself. 
Many  of  these  women  have  morbid  notions  as  to  the 
extent  of  their  disfigurement,  and  if  one  operated  they 
might  not  find  the  improvement  as  marked  as  they  ex- 
pected. Many  of  these  little  abnormalities  of  the  skin 
of  the  face  really  enhance  the  beauty  of  the  individual, 
and  by  telling  her  so  he  found  it  possible  to  reconcile 
many  ladies  to  their  supposed  blemishes.  He  gave  an 
account  of  two  such  instances  recently  occurring  in  his 
practice.  Electrolysis  he  had  found  useful  in  super- 
ficial varieties  of  port-wine  mark,  and  in  such  he  found 
the  best  results  were  obtained  when  the  needle  was 
used  quite  superficially.  The  lanugo  hair  follicles 
mentioned,  it  seemed  to  him,  were  scarcely  to  be  spoken 
of  as  follicles,  being  merely  superficial  indentations  of 
the  skin,  and  care  should  be  taken  not  to  cause  the 
needle  to  penetrate  too  deeply.  He  did  not  think  it 
was  so  important  to  find  the  opening  as  to  tell  the 
exact  direction  the  follicle  took.  Glasses  would  not 
help  here.  He  did  not  think  the  deep  effect  of  cocaine 
necessary,  since  it  was  only  the  entrance  and  exit  of 
the  needle  that  caused  pain  at  the  surface.  For  the 
reactionary  inflammation  he  applied  some  sedative  or 
used  a  benzoated  collodion  or  protecting  powder  for 
this  purpose,  but  never  vaseline  or  ointments. 

Dr.  Fordvce  had,  during  the  past  year,  discarded 
batteries  altogether  in  favor  of  Edison's  current  from 
the  street,  with  which  one  can  get  a  current  as  low  as 
half  a  milliampere. 

Dr.  White  called  attention  to  the  comparatively 
few  years  after  Dr.  Hardaway  first  brought  this  opera- 


tion to  our  notice,  that  all  its  advantages  and  disad- 
vantages were  known.  It  seemed  to  him  that  they  had 
stopped  there,  as  there  was  nothing  said  to-day  that 
was  not  known  years  ago. 

Dr.  Zeisler  thought  members  should  be  more 
guarded  in  their  statements  about  the  increased  growth 
of  hairs  ;  he  did  not  think  that  was  true  so  far  as  the 
development  of  new  hairs  was  concerned.  .\  little 
stimulation  may  assist  hair  already  present  to  grow 
more  rapidly,  and  he  thought  that  was  the  most  that 
could  be  said. 

Dr.  Hvde,  in  answer  to  Dr.  Zeisler's  remarks,  wished 
to  mention  a  case  in  his  experience  which  he  felt  sure 
could  be  corroborated  by  other  members  present.  A 
man  with  an  obstinate  neuritis  over  one  scapula  which 
he  had  been  blistering  and  stimulating  continually  for 
years,  had  over  the  affected  region  a  growth  of  hair 
two  and  a  half  inches  long,  and  nowhere  else  in  that 
locality.  A  little  downy  hair  can  be  produced  on  the 
scalp  by  irritation  or  stimulation,  which,  however,  will 
soon  be  lost  again. 

Dr.  Sherwell,  while  fully  agreeing  as  to  the  pro- 
priety of  using  electrolysis  in  hairy  moles,  as  a  general 
remedy  in  dermatology,  has  been  much  disappointed 
in  it.  He  has  never  seen  much  good  following  its  use 
in  serious  angiomatous  conditions  :  there,  he  found  the 
galvano-cautery  or  the  igneous  puncture  to  give  more 
satisfactory  results'.  His  practice  was  to  scoop  out 
small  growths  or  make  an  elliptical  incision,  the  cica- 
trix following  which  is  small,  often  scarcely  perceptible, 
and  the  result  is  usually  good,  .^s  to  the  use  of  elec- 
trolysis in  hypertrichosis,  he  thinks  its  achievement 
does  not  excel  that  of  the  American  Indian  in  his  prac- 
tice of  self-epilation.  He  is  accustomed  to  extract  the 
hairs  from  the  face,  and  performs  it  most  thoroughly. 
They  keep  their  faces  bare  by  simply  pulling  out  the 
hairs.  He  has  recommended  a  similar  course  to  many 
people  with  hypertrichosis,  and  he  has  been  well  satis- 
fied with  the  result.  He  believed  the  continual  pluck- 
ing finally  destroyed  the  follicle. 

The  EpitricMai  Layer  of  the  Epidermis  and  its  Ee- 
lationsMp  to  Ichthyosis  Congenita. — Dr.  Bowen,  of 
Boston,  read  the  paper.  Attention  was  called  to  a 
well-marked  layer  of  cells  in  the  epiderm  of  embryos, 
forming  a  distinct  membrane  covering  the  hairs,  in 
certain  lower  animals.  In  man  this  layer  has  not  re- 
ceived recognition.  The  reader's  attention  had  been 
directed  to  the  subject  by  the  observation  of  Dr.  C.  S. 
Minot,  that  certain  shreds  of  foetal  skin  contained  a 
layer  of  large  polygonal  cells,  with  a  granular  body  in 
the  centre,  and  within  this  a  nucleolus.  He  thought 
these  cells  a  part  of  the  epitrichial  layer  described  by 
Welcker  in  1864,  and  since  forgotten. 

The  reader  of  the  paper  has  found  that  in  embryos 
of  from  two  to  three  months  the  epidermis  has  an 
outermost  layer  of  large  nucleated  polygonal  cells  of 
peculiar  shape.  In  the  sixth  month  this  layer  has  dis- 
appeared over  most  parts  of  the  body.  "The  resem- 
blance of  this  layer  of  cells  to  the  epitrichium  covering 
the  hairs  and  the  epitrichial  layer  of  certain  animals 
makes  the  author  conclude  that  they  are  homologous 
structures. 

A  case  was  related  of  a  child  born  with  a  thin,  per- 
fectly smooth,  membrane  completely  covering  it,  and 
closely  adherent,  suggesting  a  paraffine-paper  envelope. 
This  began  to  peel  off  after  five  weeks  in  large  strips, 
leading  normal-looking  skin.  There  were  no  fissures 
as  in  ichthyosis.  This  condition  seemed  to  be  due  to 
the  persistence  of  the  epitrichial  layer,  and  the  author 
believes  that  similar  cases  reported  by  Hallopeau, 
Grass,  and  Torok  belong  to  the  same  category.  In- 
stead of  gradually  exfoliating  and  disappearing  by  the 
seventh  foetal  month  the  epitrichial  layer  retains  its  in- 
tegrity. The  true  horny  layer  underneath  desqua- 
mates in  small  scales  after  this  covering  is  removed. 

Dr.  White,  referring  to  the  desquamation  of  the 
early  formed  hairs  which  takes  place  in  utero,  wished 


530 


MEDICAL    RECORD. 


[October   12,  li 


to  know  from  Dr.  Bowen  if  he  had  noticed  whether  or 
not  they  were  connected  with  this  epitrichial  layer,  or 
whether  they  penetrated  deeper  and  were  a  part  of  the 
composition  of  the  foetus. 

Dr.  Bowen,  in  answer  to  Dr.  White,  said,  in  the  ani- 
mals experimented  upon  the  hairs  were  all  underneath 
the  epitrichial  membrane,  which  was  situated  outside 
them.  In  man  the  hairs  do  not  appear  until  after  this 
membrane  was  lost,  at  least  not  to  any  e.xtent. 

Statistical  Report. — Dr.  Hyde,  of  Chicago,  reported 
for  the  Committee  on  Statistics  that  during  the  year 
the  total  number  of  skin  cases  reported  by  members 
was  24,321.  No  cases  of  scleroma  neonatorum,  rhino- 
sclerma,  pemphigus  neonatorum,  anthrax,  myoma,  pel- 
lagra, nor  impetigo  herpetiformis  have  been  reported, 
while  of  eczema  there  were  6,270  instances.  Syphilis 
gave  2,452,  and  acne  2,261.  About  one-eighth  of  all 
cases  (3,107)  were  of  the  rarer  cutaneous  affections. 

A  Remarkable  Case  of  Purpuric  Eruption  Ending  in 
Gangrene  and  Apparently  Caused  by  Sodium  Salicylate. 
— Dr.  Shepherd,  of  Montreal,  presented  a  paper  on 
this  subject.  A  patient  in  the  Montreal  General  Hos- 
pital suffering  from  a  swelling  of  the  knee,  due  to 
acute  synovitis,  was  given  three  twenty-grain  doses  of 
salicylate  of  sodium,  when  an  urticaria-like  eruption 
appeared  and  soon  became  petechial.  These  lesions 
were  followed  by  deep  sloughing,  leaving  ulcerations 
slow  to  heal.  The  upper  portion  of  the  body,  espe- 
cially the  region  of  the  shoulders,  was  mostly  affected. 
There  was  also  an  eruption  in  the  pharynx  and  larynx 
leading  to  oedema  and  alarming  symptoms.  The  erup- 
tion disappeared  only  after  thirty  days.  In  some  in- 
stances the  whole  spot  became  dark  from  infiltrated 
blood,  and  at  times  the  whole  body  was  covered  with 
coffee-colored  spots  ;  some  disappeared,  going  through 
the  various  color-stages  of  a  bruise.  Local  gangrene 
occurred,  especially  over  the  shoulders,  but  also  in  the 
mouth  and  pharynx.  About  the  shoulders  gangrenous 
areas,  ranging  in  size  from  a  fifty-cent  piece  to  that  of 
the  palm  were  seen  (these  were  well  shown  in  the  pho- 
tographs). During  the  separation  of  the  sloughs  there 
was  a  rise  of  from  two  to  three  degrees  of  temperature. 
The  patient  was  presented  at  the  meeting  and  showed 
extensive  red  cicatrices  in  the  regions  where  sloughing 
had  taken  place.  A  small  ulcer  on  the  right  arm  still 
remained. 

Dr.  Elliot  thinks  that  it  resulted  from  the  admin- 
istration of  the  sodium  salicylate,  and  he  does  not 
think  it  a  manifestation  of  peliosis  rheumatica. 

Dr.  Buckley  never  remembered  a  lesion  of  peliosis 
rheumatica  where  the  lesion  broke  down,  whereas  in 
drug  eruptions  we  have  sloughing.  In  the  absence  of 
any  other  explanation  he  inclines  toward  the  opinion 
that  it  was  artificial  and  produced  by  the  sodium  sali- 
cylate. 

Dr.  Bronsox  thought  the  diagnosis  should  be  a 
composite  one,  partly  peliosis  rheumatica  modified  by 
the  use  of  the  drug  salicylate  of  sodium.  Peliosis 
rheumatica  never,  as  far  as  he  knows,  causes  gangrene. 

Dr.  Robinson  was  not  prepared  to  state  the  cause, 
but  does  not  think  it  a  case  of  peliosis  rheumatica, 
which  he  considers  incapable  of  producing  such  a  con- 
dition. 

Dr.  IJRAHAM  thinks  it  may  be  of  a  rheumatic  char- 
acter. Altliough  the  germ  has  never  been  isolated,  we 
know  that  rheumatism  is  an  infectious  disease.  Some 
of  the  most  extraordinary  symptoms  result  from  it, 
profound  nervous  trouble,  hyperpyrexia,  etc.  It  is 
therefore  possible  that  some  such  condition  as  this 
might  be  produced  ;  or  in  conjunction  with  the  rheu- 
matism we  might  have  some  other  non  detected  organ- 
ism present  as  a  cause. 

Dr.  White  said  we  have  to  consider  the  affections 
it  most  closely  approaches,  not  what  it  is.  One  might 
think  of  three  affections  in  connection  with  these  symp- 
toms :  I.  Peliosis  rheumatica,  but  the  distribution  and 
outcome    of  the  disease  are   entirelv  at  variance  with 


the  affection.  2.  Drug  eruptions.  As  these  have  no 
bounds  set  to  them,  and  our  knowledge  of  them  is  at 
present  very  limited,  it  would  be  unwarrantable  to  con- 
clude that  they  might  be  manifestations  of  salicylic-acid 
poisoning.  Any  of  these  cases  of  salicylic-acid  irrita- 
tion of  the  skin  which  he  had  seen,  never  approached 
anything  like  this  in  severity.  3.  The  next  affection  to 
be  considered  is  rare:  hemorrhagic  form  of  dermatitis — 
dermatitis  multiform  or  herpetiformis.  The  early  urti- 
carial nature  of  the  lesion,  the  vesicular,  bullous,  and 
hemorrhagic  varieties  are  all  within  the  limits  of  this 
affection.  The  only  objections  against  it  are  the  gan- 
grenous and  necrotic  condition  at  the  end  of  the  proc- 
ess. Were  it  not  for  the  symptoms  of  synovitis,  etc., 
preceding  the  exhibition  of  the  drug,  he  would  have 
been  inclined  to  favor  the  drug  as  a  cause  of  the  erup- 
tion. 

Dr.  Morrow  thought  it  impossible  to  determine 
the  precise  etiology  of  the  eruptoin.  He  was  inclined 
to  look  upon  the  sodium  salicylate  as  the  causal  factor 
here,  and  the  unusual  character  of  the  eruption  as  due 
to  the  peculiar  constitution  of  the  patient. 

Dr.  Allen  had  seen  some  severe  cases  of  eruption 
after  salicylates  in  rheumatic  patients,  but  never  any- 
thing equal  to  this  ;  still  he  could  hardly  doubt  the 
causal  action  of  the  drug. 

Dr.  Klotz  did  not  see  that  the  presence  of  gangrene 
should  exclude  the  possibility  of  peliosis  rheumatica  : 
we  have  hemorrhage  in  the  latter  disease,  and,  given 
hemorrhage,  it  is  only  a  question  of  intensity  whether 
or  not  gangrene  will  follow. 

Dr.  Shepherd  only  began  to  doubt  the  sodium  sali- 
cylate as  a  cause  when  he  noticed  crops  of  the  erup- 
tion continuing  to  appear  after  the  stoppage  of  the 
drug.  Then  the  eruption  was  preceded  by  the  rheu- 
matic pains.  Then  the  eruption  seemed  to  be  incom- 
patible with  such  a  small  quantity  of  the  drug  as  had 
been  given  (only  four  doses,  amounting  to  about  eighty 
grains).  He  had  never  seen  a  case  of  peliosis  rheu- 
matica become  gangrenous,  but  he  quite  agrees  as  to 
its  only  being  a  matter  of  intensity.  Hutchison  reported 
a  case  of  purpura  thrombica  which  resembled  this  one. 

Mycetoma  of  the  Foot. — Dr.  Hyde,  of  Chicago,  read 
a'contribution  to  the  study  of  mycetoma  of  the  foot 
as  it  occurs  in  the  United  States.  The  patient  de- 
scribed was  born  in  America,  of  Bohemian  parents,  and 
had  never  travelled  out  of  his  native  State.  The  dis- 
order began  thirteen  years  ago,  at  the  age  of  seven. 
He  was  in  the  habit  of  wading  in  the  river  near  his 
home  in  Iowa.  A  hard  nodule  first  appeared  within 
the  skin  of  the  footsole,  and  gradually  spread  until  the 
anterior  third  of  the  foot  was  extensively  involved. 
The  diagnosis — tuberculosis  and  sarcoma — had  been 
made  by  various  physicians.  The  feature  was  fungoid 
projections  from  irregular  surfaces  of  infiltration.  A 
central  canal  perforated  the  axis  of  each  tubercle, 
often  blocked  by  flabby  granulation.  Examination 
showed  granulation  tissue  with  a  considerable  number 
of  giant-cells  in  the  derma.  Nothing  resembling  the 
"  clubs  "  of  other  observers  were  found. 

Madura  foot  is  apparently  a  local  disorder.  The 
differences  between  the  fungus  of  mycetoma  and  thit 
of  actinomycosis  is  that  the  latter  grows  readily  in  a 
hydrogen  atmosphere  and  the  former  with  much 
greater  slowness.  They  differ  also  in  the  rapidity  with 
which  they  take  up  aniline  stain.  There  is  no  agree- 
ment as  to  what  constitute  the  differences  between  the 
white,  red,  and  black  varieties.  In  some  cases,  where 
fish-roe-like  particles  have  been  surgically  evacuated 
from  sinuses  existing  in  unquestioned  subjects  of  ma- 
dura  foot,  no  fistulous  tracts  have  opened  externally  to 
the  outer  surface  of  the  skin. 

The  author  concludes  that  there  are  clinical  symp- 
toms of  mycetoma  which  are  to  be  recognized  in  some 
cases  and  not  in  others.  l"n<|uestioned  instances  are 
on  record  where  none  of  the  usual  features  was  exhib- 
ited.    The  constant  symptoms  are  practically  reduced 


October  12,  1895] 


MEDICAL   RECORD. 


531 


to  a  characteristic  deformity  of  the  affected  part, 
prominently  the  foot,  but  also  the  hand,  knee,  and  a 
few  other  regions.  There  is  a  history  of  slow  involve- 
ment of  tissues.  There  is  a  notable  absence  of  pain 
and  of  complicating  accidents,  such  as  erysipelas,  ec- 
zema, etc.  The  separate  vegetable  fungi  are  set  in 
granulation  or  necrotic  tissue,  with  a  number  of  un- 
usually large  giant-cells,  which  seem  to  be  exercising  a 
phagocytic  effect  upon  the  intruder.  In  a  well-marked 
case  there  is  usually  a  central  body,  made  up  of  semi- 
lunar or  reniform  bodies,  traversed  by  a  net-work  of 
mycelium. 

Conclusions. — There  are  clinical  symptoms  of  myce- 
toma which  are  to  be  recognized  in  some  forms  and  not 
in  others.  These  may  be  termed  non-essential  features 
of  the  malady.  They  are  :  i.  The  appearance  of 
blackish  or  reddish  granules  of  pigment,  free  and 
within  the  cells  furnished  by  the  secretion  ;  2,  the  dis- 
covery of  particles  resembling  the  roe  of  fish,  either  ex- 
pelled from  the  sinuses  or  imprisoned  within  the  un- 
broken surface  of  the  skin  ;  3,  the  occurrence  of 
sinuses  leading  from  without  inward  as  far  as  muscle, 
tendon,  or  blood-vessel.  Cases  of  unquestioned  myce- 
toma are  on  record  where  none  of  these  features  are 
exhibited. 

Dr.  Elliot  wished  to  know  whether  Dr.  Hyde 
made  an  absolute  distinction  between  the  fungus  that 
caused  niadura  foot  and  that  recognized  as  the  cause 
of  actinomycosis. 

Dr.  Hyde,  in  reply,  said  he  was  not  justified  in 
drawing  any  conclusions  from  his  observations  on  this 
case.  But  from  Indian  observations  and  his  experi- 
ence in  this  case  combined,  he  was  inclined  to  think 
that  there  were  probably  several  varieties  of  the  ray 
fungus,  and  that  the  variety  causing  madura  foot  was 
not  identified  with  that  causing  actinomycosis.  He 
thought  there  might  be  an  American  variety  of  the  ray 
fungus  which  caused  mycetoma. 

An  Etiological  Puzzle. — Dr.  White,  of  Boston, 
Mass.,  in  this  paper  described  a  tuberculosis  of  the 
skin  of  the  hand  in  a  young  girl  who  had  been  accus- 
tomed to  wash  the  handkerchiefs  of  a  parent  who  died 
of  phthisis — the  patient  was  beginning  to  develop  the 
same  disease  herself.  Another  case  came  to  the  clinic 
with  characteristic  tuberculosis  of  the  lobes  of  both 
ears  gradually  coming  on  for  eight  years.  The  ears 
had  remained  long  inflamed  after  piercing  for  earrings 
and  never  healed.  The  woman  who  bored  the  ears 
died  soon  after  of  consumption  ;  the  sister  who  dressed 
the  ears  died  also  of  the  same  disease.  The  operator 
may  have  wet  her  needle  or  end  of  the  silk  in  the 
mouth,  or  subsequent  dressings  may  have  caused  the 
infection,  or  bacilli  may  have  entered  through  the 
medium  of  the  air.  The  puzzle  is  which  was  the 
case. 

Dr.  Shepherd  thought  the  first  explanation  of  wet- 
ting the  fingers  a  correct  one. 

Dr.  Fordvce's  last  case  of  tuberculosis  cutis  was  in 
the  finger  of  a  doctor  who  had  used  this  finger  when 
percussing.  A  couple  of  years  previously  bacilli  were 
found  in  his  lungs,  and  it  was  always  a  question  to 
the  speaker  as  to  whether  the  bacilli  were  derived  from 
the  lungs  or  whether  they  appeared  independent  of  the 
lung  lesions  by  the  irritation  of  the  part. 

Dr.  Hartzell  had  a  tubercular  case  of  undoubted 
local  infection.  The  child's  father  had  recently  died 
of  consumption  (three  months  previously).  The 
lesions  on  the  child  were,  one  at  metacarpal  joint  of 
the  thumb,  one  upon  the  knee,  and  another  upon  the 
opposite  leg — in  fact,  in  just  such  situations  as  a  child 
exposed  to  tubercular  sputum  could  become  infected 
when  crawling  over  the  floor.  The  suggestion  was  ob- 
vious. 

Dr.  Graham  recounted  the  history  of  a  case  of  a 
young  lady  patient  of  his,  affected  with  phthisis.  She 
was  nursed  by  her  mother,  who,  contrary  to  instructions, 
washed  the  handkerchiefs,  etc.,  used  by  her  daughter 


in  expectoration.  She  developed  several  tuberculous 
sores  about  the  knuckles,  and  three  or  four  months 
afterward  also  developed  pht-hisis. 

Unique  Case  of  Agminate  Folliculitis  of  Parasitic 
Origin. — Dr.  Hartzell,  of  Philadelphia,  read  the 
paper.  A  man  aged  thirty-two  presented  two  varie- 
ties of  lesions  on  the  leg  belonging  to  some  morbid 
process  :  an  oval  elevated  patch  covered  with  scanty 
crusts  over  a  bright-red,  uneven  granular  surface  ; 
smaller  patches  closely  examined  were  seen  to  be  made 
up  of  swollen  and  inflamed  hair-follicles.  There  were 
also  pin-head  to  pea-sized  pustules  in  groups  and 
singly.  The  primary  lesions  were  pustular  and  in- 
creased the  patch  by  appearing  at  the  periphery  ;  some 
furuncles  formed.  Examined  portions  showed  a  small 
cavity  surrounding  the  hair  in  the  upper  part  of  the 
epidermis  ;  a  few  spores  and  mycelial  threads.  The 
rete  was  thickened.  The  follicles  were  enlarged  and 
distorted.  In  some  sections  were  grape-like  clusters 
of  spores  attached  to  mycelium.  The  fungus  presented 
larger  elements  than  are  usually  seen  in  tinea  circinata. 
Under  sulphur  improvement  began  at  once,  but  the 
disease  had  existed  for  about  ten  months,  incapacitat- 
ing the  patient  for  about  half  the  time.  Contact  with 
animals  as  a  source  of  infection  could  not  be  made  out. 
The  author  believes  that  the  agminate  folliculitis  of 
authors  is  most  probably  a  deep  trichophytosis  such  as 
here  described.  Particular  attention  is  called  to  the 
Biondi  -  Haidenhain  stain  as  applicable  for  the  tri- 
cophycton.  The  case  illustrates  that  the  trichophytosis 
may  cause  extensive  painful  disease  in  other  locations 
than  upon  the  hairy  part. 

Dr.  Wigglesworth  wished  to  ask  whether  Dr. 
Hartzell  considered  there  was  any  relation  as  to  the 
extent  and  severity  of  the  lesion  and  the  sources  from 
which  it  was  derived,  whether  from  the  horse  or  some 
smaller  animal. 

Dr.  White  thought  we  recognized  how  deeply  into 
the  tissues  of  the  skin  some  forms  of  trichophyton  can 
penetrate,  as  seen  in  kerion,  a  much  more  common  type 
of  this  affection  than  the  agminate  forms. 

Dr.  Hyde  had  seen  a  couple  of  cases  of  exceedingly 
severe  trichophyton  derived  from  sheep  in  sheep-shear- 
ing cases  brought  a  long  distance  from  the  city,  and  in 
these  cases  it  had  always  taken  the  form  of  sycosis. 

Dr.  Fox  objected  to  title  of  paper,  and  thought  it 
should  have  been  reported  as  a  unique  case  of  tricho- 
phytosis. Most  of  them  had  seen  these  peculiar  forms 
of  trichophyton  which  occasionally  develop  these  small 
folliculate  patches. 

Dr.  Sherwell  at  former  meetings  had  spoken  of 
ravages  of  trichophyton  in  lower  animals.  He  thought 
scratching  had  something  to  do  with  the  implication 
of  tissues. 

Dr.  Hartzell,  in  answer  to  Dr.  Wigglesworth, 
said  he  believed  the  severity  of  the  disease  was  de- 
termined to  a  very  considerable  extent  by  the  var- 
iety of  the  plant,  but  much  more  by  the  character  of 
the  soil.  The  fungus,  he  thought,  grew  much  more 
luxuriantly  in  deep  cases  than  upon  the  surface,  and 
the  elements  are  larger  than  in  the  superficial  variety. 
In  this  case  there  was  a  double  infection,  and  he  be- 
lieved to  a  certain  extent  in  an  antagonism  between 
the  staphylococcus  and  the  trichophyton.  The  fungus 
did  not  grow  at  all  well  in  the  pustules  ;  but  it  was 
found  deep  down  where  there  were  no  pus-cells.  He 
called  this  an  uncommon  case,  because,  so  far  as  he 
knew,  no  other  case  of  this  character  occurring  in  this 
situation  had  ever  been  reported. 

Drug  Eruptions. — Dr.  Fordvce,  of  New  York,  read 
notes  on  "  Drug  Eruptions."  The  speaker  referred  to 
the  nodular  form  of  iodic  erujition  in  a  woman,  where 
the  lesions  reached  the  size  of  the  fist,  and  were  not 
to  be  looked  upon  as  erythema  nodosum.  It  is  prob- 
able that  all  iodic  eruptions  are  secondary  to  certain 
vascular  changes,  and  this  may  account  for  the  exag- 
gerated lesions  seen  upon  a  paralyzed  member.     An- 


532 


MEDICAL    RECORD. 


[October  12,  1895 


other  case  was  of  a  rupia-like  eruption  due  to  the 
iodide  of  potassium,  but  simulating  syphilis,  in  a  syphi- 
litic subject.  The  lesione  healed  under  boric-acid 
ointment.  A  second  case  of  similar  nature  showed 
ulcerations  which  healed  when  the  iodides  were 
stopped.  The  lesions  in  both  cases  corresponded 
with  the  anthracoid  variety  of  iodide  eruptions.  The 
cases  would  seem  to  show  that  the  skin  in  some  per- 
sons reacts  to  iodide  in  much  the  same  manner  as  to 
the  syphilitic  process. 

A  colored  plate  was  shown  of  an  erythematous  rash 
covering  the  whole  central  portion  of  the  body  as  a 
diffuse,  and  the  other  parts  as  a  scattered,  eruption,  fol- 
lowing the  use  of  mercurial  ointment.  Another  case 
similarly  produced  was  one  of  erythema  scarlatini- 
forme,  which  had  been  taken  for  scarlet  fever.  The 
last  case  was  one  of  erythematous  eruption  from  the 
internal  use  of  boric  acid  given  in  thirty-grain  doses 
daily  for  a  month  ;  a  multiform  erythema  of  the  trunk, 
and  a  swelling  of  the  upper  lids  were  present.  There 
was  also  inflammation  of  the  conjunctiva.  On  stop- 
ping the  boric  acid,  the  symptoms  disappeared. 
Other  cases  have  been  reported  from  this  cause,  but 
the  author  has  seen  no  mention  of  the  hard  rcdema  of 
the  eyelids  as  seen  in  his  case. 

Dr.  Jackson  related  the  history  of  a  case  in  which 
he  had  been  called  in  consultation  ;  it  was  supposed  to 
be  scarlatina.  Previously  had  been  treated  with  blue 
ointment.  He  found  patient  with  no  fever  or  any 
other  clinical  signs  of  scarlet  fever  except  the  rash  ; 
decided  case  was  not  scarlet  fever,  but  one  of  scarla- 
tiniform  rash  from  mercurial  ointment. 

Dr.  White  thought  it  had  been  occasionally  ob- 
served that  the  use  of  stimulating  applications  to  the 
skin  was  capable  of  lighting  up  widely  spread  derma- 
titis conditions.  He  had  seen  two  cases  of  boric-acid 
eruptions. 

Dr  Klotz  had  recently  seen  a  case  of  fatal  poison- 
ing following  use  of  boric  acid,  which  is  generally  con- 
sidered an  innocent  drug.  He  had  seen  a  dermatitis 
occur  after  prolonged  use  of  small  doses.  In  the  fatal 
case  death  was  due  to  desquamative  nephritis,  result 
of  irritating  action  on  the  kidneys.  He  thought  there 
was  some  doubt  whether  death  was  due  to  the  poison 
or  to  the  kidney  trouble. 

Urticaria  Pigmentosa.  —  Dr.  Morrow,  of  New  York, 
reported  a  case  of  urticaria  pigmentosa  of  twenty  years' 
dujation,  with  remarks  on  dermographism.  The  case 
was  the  first  recognized  as  one  of  this  affection  observed 
in  this  country.  It  is  unique  in  being  under  observa- 
tion through  infancy  into  adult  life.  Many  cases  show 
a  spontaneous  tendency  to  disappear  at  about  the 
eighth  or  ninth  year.  The  skin  at  the  present  time 
shows  the  property  known  as  factitious  urticaria,  and 
this  has  been  a  constant  feature  throughout.  The 
formation  of  figures  ujjon  the  skin  after  irritation  shows 
irregular  elevation  or  a  beaded  appearance,  each  bead 
representing  the  site  of  a  lesion.  Quotations  were 
made  from  an  already  published  description  of  the 
case.  Lesions  suggesting  minute  pigmentary  moles 
have  appeared  in  recent  years,  and  the  large  nodular 
masses  formerly  present  have  disappeared  to  a  large 
extent.     There  is  too  much  less  pruritus  than  formerly. 

It  must  be  conceded,  the  reader  says,  that  in  the 
clinical  course  of  this  disease  and  in  the  anatomical 
changes  which  it  presents,  it  shows  many  points  of  dif- 
ference from  urticaria  perstans. 

In  the  present  case  the  sound  skin  has  always  been 
subject  to  dermographism,  although  in  a  less  marked  de- 
gree tiian  the  i)igmented  lesions.  It  maybe  questioned 
whether  the  urticarial  elevations  and  the  pigmented 
patches  are  expressions  of  the  same  or  of  different 
morbid  processes.  Is  there  a  causal  or  merely  a  coinci- 
dental connection  between  them  ?  In  the  present  state 
of  our  knowledge  it  is  impossible  to  give  a  satisfactory 
solution  of  these  pathogenic  jiroblems.  In  most  cases 
there  is   a  history  of  urticarial  attacks  preceding  the 


appearance  of  the  pigmented  patches.  The  hyperpla- 
sia and  pigmentation,  the  author  believes,  are  the  result 
of  the  intense  and  more  or  less  constant  congestion  of 
the  skin  from  the  frequent  recurrent  attacks.  He  has 
always  regarded  it  as  belonging  to  the  urticaria  group 
rather  than  as  presenting  a  distinct  type  of  disease. 
There  is  probably,  conjoined  with  a  vaso-motor  hyper- 
excitability,  a  disturbance  of  the  trophic  centres  which 
regulate  nutrition. 

Dr.  White  believed  one  of  the  most  notable  feat- 
ures of  this  disease  was  its  more  general  prevalence  in 
England  than  in  other  civilized  parts  of  Europe.  The 
number  of  cases  of  this  disease  recorded  in  this  .Asso- 
ciation is  very  small  (24). 

Dr.  Bronson  asked  Dr.  Morrow  how  long  this  ap- 
pearance of  factitious  urticaria  remained,  and  whether 
when  it  disappeared  it  could  be  revoked  immediately 
or  only  after  an  interval. 

Dr.  Morrow  said  the  patient  was  stripped  forty 
minutes  Within  fifteen  or  twenty  minutes  the  lines 
intervening  between  the  lesions  would  become  effaced, 
and  the  urticarial  elevations  still  remain  persistent. 
By  slightly  rubbing  the  surface  these  lines  had  a  ten- 
dency to  reappear.  The  urticaria  on  the  sound  skin 
has  a  tendency  to  disappear  in  from  forty  to  sixty  min- 
utes. 

Dr.  Bronson  said,  in  a  perfectly  graphical  picture 
of  urticarial  pigmentation,  there  is  a  striking  difference 
between  the  distinct  lines  and  these  little  bead  likt 
elevations.  The  latter  are  no  more  numerous  at  these 
points  than  one  would  expect  from  common  irritation 
of  the  surface.  The  irritation  seemed  only  to  affect 
the  old  lesions  between  them  in  a  common  factitious 
urticaria. 

Dr.  Allen  had  had  one  case  of  urticaria  pigmen- 
tosa in  his  practice  off  and  on  for  several  years. 
With  reference  to  the  rapidity  with  which  the  urtica- 
rial wheals  came  out  on  the  permanent  lesions,  or  on 
the  neighboring  healthy  skin,  it  often  happened  that 
in  removing  his  clothes,  or  in  indulging  in  a  little 
scratching  or  rubbing  after  their  removal,  there  was  an 
almost  immediate  appearance  of  plaques  as  large  as  the 
palm,  which  became  diffused  over  the  healthy  skin 
and  the  dark-brown  pigment  spots. 

Ulerythema  Sycosiform. — Dr.  C.\ntrell,  of  Phila- 
delphia, presented  a  paper  in  conjunction  with  Dr. 
Schamberg,  with  the  above  title.  He  described  a  case 
of  the  affection  to  which  Unna  called  attention  under 
the  above  title  in  1889.  A  man  aged  fifty-five  had  suf- 
fered in  1886  from  a  pustular  disease  of  the  beard  last- 
ing for  two  years  and  ending  in  recovery.  In  1891  he 
again  became  affected  with  what  seemed  to  be  a  non- 
parasitic sycosis.  Two  years  later  a  smooth  glistening 
area  of  atrophic  appearance  occupied  portions  of  the 
cheeks,  showing  complete  loss  of  hair  in  places.  No 
pustules,  but  over  the  area  a  few  vesicles  and  blebs, 
which  dried  into  brownish  crusts.  The  affection  proved 
very  obstinate,  new  vesicles  appearing  every  few  days. 
Arsenic  aggravated  the  condition.  There  is  a  follicular 
and  perifollicular  inflammation  which  goes  on  to  de- 
struction of  the  hair-follicle  and  formation  of  atrophic 
scars.  Histologically  the  stratum  corneum  and  lucidum 
were  missing  ;  the  granulosum  was  well  marked.  In- 
tense shari)ly  defined  cell  infiltration,  nests  with  walls 
consisting  of  fibres  of  connective  tissue.  Cell  infiltra- 
tion most  marked  around  hair-follicles.  Overgrowth  of 
connective  tissue  in  jiapillary  layer.  Few  hair-follicles 
and  no  sebaceous  glands  in  section.  Giant  cells  absent. 
The  disease  simulates,  but  is  not  identical  with,  lupus 
vulgaris.  No  nodules,  no  bacilli.  The  writers  agree 
with  Unna  in  considering  the  condition  a  distinct  en- 
tity and  accept  the  name. 

Erysipelas. — Dr.  Ali  en,  of  New  York,  read  a  paper 
on  Erysipelas  based  upon  his  personal  experience  in 
treating  fifty  cases.  He  had  [ueviously  reported  fifty 
others  to  the  .Vssociation,  and  now  studied  this  series  of 
one  hundred  in  the  li^ht  of  the  etiological  bearing  of 


October   12,  1895] 


MEDICAL    RECORD. 


531 


preceding  skin  affections  upon  the  production  of  the 
disease,  and  secondly  in  regard  to  the  effect  of  local 
treatment. 

He  had  found  ichthyol  the  best  drug,  its  combina- 
tion with  collodion  the  best  way  to  apply  it,  and  strongly 
advocated  the  application  of  the  tight  adhesive  band 
to  check  the  spread.  He  explained  its  action  by  press- 
ure made  upon  the  lymphatics.  Since  reading  a  paper 
on  this  subject  four  years  ago,  he  had  applied  the  band 
in  thirty  or  more  instances,  with  the  result  of  checking 
the  spread  in  about  half.  Many  cases  recovered  under 
this  combined  local  dressing  very  promptly. 

Dr.  Shepherd  said  erysipelas  was  a  self- limited  dis- 
ease. He  had  never  been  able  to  check  its  progress 
by  any  treatment. 

Dr.  Fordyce  has  secured  better  results  from  ich- 
thyol than  any  other  drug. 

Dr.  Zeisler  said  that  in  Chicago,  where  they  had 
separate  wards  for  erysipelas,  boric  acid  had  been  re- 
placed by  ichthyol,  which  had  been  found  superior. 

Dr.  White  thought  extension  to  the  margin  of  the 
bands,  as  advocated  by  Dr.  Allen,  would  indicate  a 
greater  amount  of  spreading  than  he  would  expect  to 
get  in  his  own  cases,  treated  with  carbolic-acid  solu- 
tion in  alcohol  and  water. 

Dr.  Robinson  preferred  black  wash  or  lead  and 
opium.  The  latter  constricting  the  lymphatics,  and 
thus  opposing  spread  of  the  process. 

Dr.  Broxson  used  resorcin  in  strong  solution  for 
superficial  erysipelas.    He  also  recommended  ichthyol. 

Dr.  Elliot  treats  a  large  proportion  of  his  cases  with 
ichthyol  solution,  but  ten  per  cent,  ointment  of  lactate 
of  lead  also  acts  well.  He  thought  that  when  recovery 
was  observed  in  two  or  three  days  one  must  attribute 
it  to  the  effect  of  the  drug. 

Dr.  Allen,  in  closing,  said  that  while  erysipelas  was 
self-limited,  the  limit  was  too  often  the  death  of  the  pa- 
tient. There  were  no  deaths  in  the  series  reported,  but 
he  related  two  fatal  instances  in  infants.  The  limita- 
tion caused  by  the  strappings  he  thought  significant. 

Election  of  Officers. — President,  Dr.  A.  R.  Robinson, 
of  New  Vork  ;  Vice-President,  Dr.  F.  J.  Shepherd,  of 
Montreal  ;  Secretary  and  Treasurer,  Dr.  C.  W.  Allen, 
of  New  York. 

Other  papers  were  read  by  Drs.  Klotz,  Elliot,  White, 
Robinson,  Zeisler,  Bulkley,  and  Fox,  which  will  appear 
later. 


Chloroform  was  discovered  by  Mr.  Samuel  Guthrie,  of 
Sickett's  Harbor,  N.  Y.,  in  1831,  and  is  produced  b}' 
action  of  chlorine  upon  alcohol. 

Alcohol  in  Liquors. — The  average  percentage  by 
measure  of  alcohol  (specific  gravity,  0.825)  of  the  fol- 
lowing wines,  liquors,  etc.,  is:  Sherry,  19;  Madeira. 
22:  Malaga,  18;  Tokay,  9;  Burgundy,  14;  Claret, 
15  ;  Hock,  12  ;  Champagne,  13:  Rum,  53;  Gin,  51; 
Beer,  i  to  3  ;  Ale,  7  ;  Porter,  4  ;  Stout,  7  :  Cider,  7. 
— Wood  and  Dunolison. 

![        Convulsions  produced  by  a  drug  can  be  produced 
}     only  in  five  ways  :   i.  They  may  be  epileptiform — i.e., 
I     cerebral ;  2,  they  may  be  conceivably  due  to  stimula- 
I     lion  of   the  peripheral  ends  of  the  motor  nerves  ;  3, 
'     they  may  be  conceivably  caused  by  irritation  of  periph- 
eral ends  of  sensory  nerves  ;  4,  they  may  be  muscu- 
lar— i.e.,  due  to  a  direct  action  on  the  muscles  ;  5,  they 
may  be  spinal. — Wood. 

A  Misprint. — We  find  in  one  of  our  contemporaries 
the  following  old  misprint  :  "  Even  nowadays  the  defi- 
nition of  inflammation  :  rubor,  calor,  tumor,  et  doll.ak, 
is  worthy  of  consideration." 
\\        This  is  true.     The  dollar,  however,  nowadays  comes 
[1    first. 


Tracheotomy. — An  incision  in  the  anterior  region  of 
the  neck  causes  anaesthesia-  of  surrounding  parts,  and 
hence  it  is  only  the  first  incision  that  gives  pain.- — 
Brown-Sequard. 

Ascites. — 

B .    Potassii  bitartratis §  jss. 

Potassii  sulphatis 3  ss. 

Pulveris  scill<e 5  ij. 

Antimonii  et  potassii  tartratis gr-  j- 

M.  Sig.  :  One  teaspoonful  every  four  hours  unlil  active  purga- 
tion and  diuresis  follows. 

— Eberle. 
The  Face   during  etherization   is  reddish  ;  marked 
pallor  and  lividity  are  respectively  important  indica- 
tions of  failure  of  the  heart's   action   and  failure    of 
respiration. — Wood. 

Organs  of  the  Neck. — The  sensations  in  the  most 
different  parts  of  the  organs  of  the  neck  are,  as  a  rule, 
jointly  referred  to  a  region  in  which,  so  to  say,  the 
joint  sphere  of  sensation  (the  sensorium  commune,  ac- 
cording to  Zeissl's  analogy)  of  the  entire  throat  is  situ- 
ated. This  region  is  the  front  part  of  the  neck,  the 
laryngo-tracheal  region. — Gottstein. 

Intra-cranial  Pressure.— The  classical  symptoms  of 
intra-cranial  pressure  are  headache,  vomiting,  and  optic 
neuritis. 


Ganglion. — Inject  from  five  to  ten  drops  of  the  tinct- 
ure of  iodine  into  the  ganglion.  A  bandage  is  applied, 
partly  with  the  object  of  exercising  pressure  and  partly 
of  fixing  the  adjacent  articulation.  The  pain  is  but 
slight,  and  ceases  on  the  second  or  third  day.  The  cure 
is  usually  complete  in  five  or  six  days.  Sometimes  a 
second  injection  may  be  necessary  on  the  fifth  or  sixth 
day.  Recurrence  has  been  known  after  all  the  usual 
methods  of  treatment  :  and  in  one  of  the  author's  cases 
the  ganglion  had  already  been  twice  removed. 

DUPL.W. 

"  Peritoneum  to  Peritoneum." — Some  years  ago  vari- 
ous accidental  experiem  es  combined  to  unsettle  my 
belief  in  this  axiom.  During  the  past  two  years  I  have 
deliberately  and  intentionally,  where  possible,  acted  as 
if  the  axiom  were  an  error,  and  the  result  of  this  experi- 
ence has  been  to  convince  me  that,  for  all  purposes 
where  sound,  speedy,  permanent  union  is  desired,  the 
apposition  of  two  intact  serous  surfaces  is  a  surgical 
mistake. — J.  Greig  Smith. 

In  Syncope  during  ether  narcosis,  alcohol  should 
never  be  used. — \V<iod. 

Dislocations  of  Clavicle  at  sternal  end,  when  other 
means  fail  to  retain  bone  in  place.  The  hypodermic 
injection  of  absolute  alcohol  is  indicated,  deep  into 
tissues  about  the  displaced  end  ;  this  sets  up  an  adhe- 
sive inflammation,  which  retains  bone  in  place. 

Sprains  of  Foot. — Most  successful  treatment  is  use  of 
hot  foot-baths  for  fifteen  minutes  three  times  a  day  ;  fol- 
low eacli  bath  with  massage  for  fifteen  (15)  minutes  ; 
then  ai)ply  snugly  a  Martin  rubber  bandage  from  toes 
up  as  high  as  ankle  and  have  patient  walk.  Ballet 
dancers  use  this  method  with  such  success  that  they 
are  seldom  incapacitated  for  work  longer  than  a  week. 

Rigidity  of  Os  Cervix.— Ten  (lo)  grains  antimonii  et 
potassii  tartras,  dissolved  in  half  tumbler  of  water ; 
give  teaspoonful  every  ten  or  fifteen  minutes  till  free 
emesis.  Under  proper  use  of  tartar  emetic  lacerated 
cervices  et  perinei  will  be  the  exception  in  complicated 
cases. 

Disinfection  of  'Vaults  and  Cesspools. — The  disinfect- 
ant should  kill  all  pathogenic  microbes,  including  the 
bacillus  coli  communis  and  the  bacteria  of  putrefaction. 


534 


MEDICAL    RECORD. 


[October  12,  1895 


The  best  of  all  disinfecting  agents  for  the  destruction 
of  fecal  matters  in  vaults  and  cesspools  is  sulphate  of 
copper,  employed  in  connection  with  one  per  cent,  of 
sulphuric  acid.  The  quantity  of  sulphate  of  copper 
required  is  one  pound  for  every  three  cubic  feet  of 
fecal  matter  mi.xed  with  urine.  Half  this  quantity  was 
found  sufficient  to  destroy  the  cholera  bacillus.  It  was 
found  necessary  that  the  disinfectant  should  remain  in 
contact  with  the  infectious  material  for  at  least  twelve 
hours. — Vincent. 


OUR   LONDON    LETTER 

(From  our  Special  Correspondent.) 

GRIEVANCES   OF  HOSPITAL  NURSES — SEWAGE  FLOODING 
OF   HOUSES  —  NEWSPAPERS   ON    MEDICAL   MATTERS — 

DURHAM    MEMORIAL  AT    GUY's SCARLET    FEVER    AT 

BIRMINGHAM ADULTERATION    LAWS DR.    RUFFER 

CHOLERA HEALTH    OF    LONDON. 

London,  September  21,  1895. 

The  grievances  of  hospital  nurses  are  once  more  be- 
fore the  public.  All  the  week  the  Daily  Navs  has 
been  inserting  letters  under  the  title  of  "  White  Slaves 
in  our  Hospitals,"  and  a  leading  article  has  directed 
attention  to  this  correspondence.  No  doubt  there  is 
much  necessary  hardship  in  a  nurse's  lot,  but  this  does 
not  excite  complaint.  It  is  the  unnecessary  imposi- 
tions which  become  the  proverbial  straw  to  the  camel. 
The  managers  of  our  hospitals  have  much  of  their 
business  to  learn  and  are  too  apt  to  take  their  views 
from  their  officials.  One  committee  is  in  the  hands  of 
its  secretary,  another  listens  more  attentively  to  the 
matron.  Neither  of  these  should  be  suffered  to  usurp 
the  authority  of  the  Board. 

Too  often  the  matron  rules  the  nurses  and  hood- 
winks the  committee,  and  her  rule  is  a  terrible  tyranny. 
1  am  inclined  to  agree  with  those  who  think  woman 
constitutionally  incapable  of  just  administration,  for 
when  she  rises  to  positions  of  authority  over  her  sisters 
her  yoke  is  not  only  heavy,  but  armed  with  many  tiny 
teeth  to  torture  the  bearer.  But  to  return  to  the  com- 
plaints made.  Food  of  inferior  quality  or  insufficient 
quantity  is  mentioned.  Surely  any  hospital  board  per- 
mitting this  deserves  to  be  exposed,  and  should  not  be 
allowed  to  plead  ignorance.  It  is  true  such  boards  are 
unpaid,  but  if  men  do  not  attend  to  the  duties  they 
undertake  in  the  name  of  charity,  they  cannot  escape 
the  responsibility  of  their  neglect.  If  they  let  their 
paid  officials  blind  them  it  is  their  own  fault.  Author- 
ity over  a  great  hospital  is  a  position  of  trust  and  must 
neither  be  abused  nor  neglected.  The  question  of  long 
hours  is  not  so  easily  disposed  of  as  that  of  diet.  It  is 
a  question  of  cost,  and  all  the  hospitals  are  crying  aloud 
for  more  funds.  It  is  true,  however,  as  pointed  out  by 
the  Daily  A'etvs,  that  managers  are  ready  enough  to 
spend  on  extensions  and  new  buildings,  and  to  get  up 
special  funds  for  such  purposes,  and  the  public  would 
quite  as  willingly  support  a  special  fund  for  providing 
good  food,  reasonable  hours,  and  comforts  for  the 
nurses.  That  the  hours  are  too  long  is  admitted  on 
every  hand,  while  the  many  who  break  down  in  health 
offer  a  standing  proof  of  the  wrong  that  is  done  them. 
Unfortunately  there  has  been  too  much  romance  thrown 
round  the  occupation  of  the  nurse,  and  many  have 
therefore  entered  on  the  calling  without  proper  appre- 
ciation of  its  duties.  But  this  is  no  excuse  for  those 
matrons  and  boards  that  have  taken  money  to  teach 
nursing  and  kept  their  victims  at  hard,  menial  work  for 
hours  which  no  man's  trade  union  would  permit,  until 
their  health  has  broken  down  and  they  have  been  told 
they  are  unfit  for  a  calling  the  real  duties  of  which 
they  have  not  been  allowed  to  attempt.     This  kind  of 


swindle  (for  what  else  is  it  ?  )  has  often  been  perpe- 
trated on  paying  probationers,  and  should  be  made  im- 
possible in  the  future.  If  a  man  pays  a  premium  to 
apprentice  his  boy  to  a  trade  the  master  is  bound  to 
teach  the  trade,  and  a  "  paying  probationer  "  expects 
to  be  trained  in  nursing — not  in  menial  work,  which 
she  can  learn  at  home. 

The  water  famine  in  East  London  is  not  the  only 
sanitary  danger  that  has  lately  been  prominently  before 
the  public.  Westminster  has  been  suffering  from  sew^ 
age  overflowing  into  cellars  and  basements,  and  strong 
representations  have  been  made  by  the  magistrate  ta 
the  local  authorities  on  the  urgency  of  the  case  and  the 
necessity  of  immediate  action.  It  seems  surprising 
that  most  of  the  property  involved  belongs  to  the  Ec- 
clesiastical Commissioners,  but  I  suppose  it  is  let  on 
long  repairing  leases  to  tenants  who  let  to  others,  and 
these  in  their  turn  underlet,  so  that  it  is  not  easy  to  fix 
responsibility  without  full  inquiry.  Our  leasehold  sys- 
tem has  other  disadvantages  besides  those  relating  to 
sanitary  responsibilities,  but  the  latter  are  enough  to 
make  the  cry  for  easy  enfranchisement  reasonable. 
Neither  leaseholders,  freeholders,  nor  Ecclesiastical 
Commissioners  are  solely  concerned.  The  County 
Council  has  some  authority,  and  one  of  our  medical 
officers  of  health,  some  years  ago,  reported  to  his  vestry 
on  the  "  Sewage  Flooding  of  Basements  Due  to  the 
Inadequacy  of  Main  Sewers  Vested  in  the  Londtr. 
County  Council."  It  would  be  interesting  to  learn 
what  became  of  that  report,  though  the  attention  of  ti.e 
Council  has  been  repeatedly  called  to  the  matter  fr^  >i 
other  sources.  No  doubt  something  must  eventuallv 
be  done,  and  it  would  be  well  for  experts  to  inquirc- 
what  can  be  done  to  abate  the  recurrent  nuisance. 

Some  allowance  for  the  dead  season  must  be  made 
for  the  newspapers  which  have  ventured  in  search  '.t 
copy  into  medical  pastures.  The  Chrpnich  is  a  well- 
conducted  daily  which  does  not  often  commit  itself  m- 
much  as  it  has  done  anent  the  report  of  the  Local 
Government  Board.  Such  blue  books  are  very  properly 
noticed  by  the  newspapers.  In  fact,  one  of  the  chief 
uses  of  these  reports  is  the  circulation  of  caref.'.i 
abstracts  of  their  contents.  Criticism  of  such  produc- 
tions, to  be  admissible,  must  be  thorough,  and  the 
popularization  of  such  reports  by  abstracts  in  the 
newspapers  is  perhaps  the  best  use  to  make  of  them. 
The  Daily  Chronicle  has,  however,  ventured  to  remor. 
strate  with  the  chief  medical  adviser  for  devoting  S" 
much  energy  to  the  study  of  bacteria,  rather  than  :  > 
the  routine  of  administration  !  Such  a  complaint  .is 
this  in  our  influential  organ  must  surely  be  attributed 
to  illness  or  absence  of  the  generally  judicious  editor, 
who  would  scarcely  have  allowed  an  article  to  appear 
stigmatizing  bacterial  investigations  as  the  outcome  of 
"freakish  theory,"  and  seriously  urging  the  authorities 
to  "banish  the  microbe  curators  to  an  attic  not  re- 
quired for  other  purposes  I  "  I  hope  the  editor  w.is 
only  absent,  not  ill,  or  if  the  latter,  that  the  indisp.i>i- 
tion  was  not  mental. 

It  is  proposed  to  endow  in  perpetuity  two  beds  .;t 
Guy's  Hospital  in  memory  of  the  late  Mr.  Durham.  .-\. 
sum  of  _£^2,ooo  is  being  asked  for  to  endow  these 
"  Arthur  Durham  beds." 

Birmingham  has  suffered  from  a  sharp  epidemic  of 
scarlet  fever,  which  the  Medical  Officer  of  Health  hopes 
has  reached  its  highest  point  and  will  now  decline.  At 
the  close  of  last  month  there  were  four  hundred  and 
sixty  cases  under  treatment.  Cases  have  been  received 
from  all  districts  of  the  city,  so  that  the  disease  seems 
widely  diffused. 

The  Select  Committee  on  the  .\dulter.-ttion  Laws  has 
reported  to  Parliament  the  evidence  taken,  and  asks  to  \ 
be  reappointed  next  session  in  order  to  complete  its  { 
■work.  It  has  obtained  through  the  Hoard  of  Trade  a  ' 
precis  of  the  adulteration  laws  of  other  countries,  which  , 
will  prove  a  valuable  work  of  reference  to  many. 

I  regret  to  say  that  Dr.  Ruffer's  attack  of  diphtheria 


J 


October   12,  1895] 


MEDICAL    RECORD. 


535 


has  been  followed  by  paralysis,  so  that  he  will  not  be 
able  to  resume  work  for  some  time. 

Cholera  having  reappeared  in  Europe,  cases  of  diar- 
rhoea at  Grimsby  and  other  ports  are  being  anxiously 
watched  lest  early  cases  of  the  epidemic  should  be 
overlooked.  The  tendency  to  recrudescence  is  not 
forgotten,  and  the  sanitary  department  seems  to  be 
active,  so  that  we  may  escape  serious  invasion,  although 
a  few  isolated  cases  may  occur. 

The  health  of  London  and  the  Provinces  continues 
to  be  satisfactory,  and  the  death-rate  is  generally  low. 


ALKALINE   INJECTIONS  IN  GONORRHCEA. 

To  THK  Editor  of  the  Medical  Record. 

Sir  :  In  reference  to  the  discussion  of  alkaline  injec- 
tions in  gonorrhoea,  I  beg  leave  to  call  attention  to  the 
following  extract  from  an  article  of  mine,  on  the  path- 
ology and  treatment  of  that  disease,  which  appeared  in 
the  Atlanta,  Ga.,  Medical  and  Surgical  Jourftal  for 
August,  1894. 

The  treatment  of  gonorrhoea  is  a  matter  of  impor- 
tance to  every  surgeon,  for,  like  the  poor,  we  have  it 
with  us  always.  A  few  points  must  be  borne  in  mind. 
The  first  is  that  we  have  a  narrow  tube  filled  with  a 
muco-purulent  secretion,  not  readily  miscible  with  water, 
and  behind  this  liquid  plug  is  a  sphincter  muscle  closing 
the  channel.  If  an  injection  be  made,  it  will  but  play 
on  the  end  of  this  plug,  and  will  not  affect  the  portion 
of  the  urethra  in  which  the  seat  of  the  disease  lies. 
Again,  this  secretion  is  actively  contagious,  and  if 
forced  into  the  bladder,  will  extend  the  disease  to  that 
organ.  It  is  therefore  necessary  to  remove  the  secre- 
tion from  behind  and  treat  a  clean  membrane. 

This  may  be  done  in  several  ways.  If  the  patient 
be  told  to  urinate  immediately  before  the  treatment  is 
to  be  administered,  the  urethra  will  be  fairly  clean,  but 
irrigation  is  far  better.  A  small  flexible  catheter,  lu- 
bricated with  glycerin,  may  be  introduced  into  the 
triangular  ligament,  and  a  warm  solution  of  sodium  bi- 
carbonate run  through  it,  washing  the  urethra  as  it  re- 
turns. From  a  pint  to  a  quart  will  suffice,  and  the 
whole  quantity  of  pus  will  be  dissolved  by  the  alkaline 
bath,  and  will  be  entirely  removed.  By  raising  the 
fountain-syringe  containing  the  soda  solution,  any  de- 
sired pressure  may  be  obtained,  and  enough  pressure 
should  be  used  to  dilate  the  urethra  sufficiently  for  the 
wash  to  reach  the  bottom  of  the  crypts. 

The  use  of  the  glycerin  is  very  important,  for  if  any 
oil  be  employed,  the  urethra  will  receive  a  waterproof 
coating  which  will  defeat  the  treatment,  and  if  corro- 
sive sublimate  be  applied  to  the  tube  coated  with  albu- 
minous muco-pus,  the  resulting  precipitate  affords  an 
impenetrable  covering  for  the  gonococci. 

Charles  Minor  Blackford,  Jr.,  M.D. 

LVNCHBLRG,   Va. 


THE   ABUSE    OF    MEDICAL   CHARITY. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  The  article  by  Dr.  Van  Fleet  on  the  Abuse  of 
Medical  Charity,  in  a  recent  number  of  the  Medical 
Record,  ought  to  be  of  interest  to  every  physician 
practising  in  the  larger  cities  where  hospitals  and  free 
clinics  abound. 

From  personal  experience  in  dispensary  and  hospital 
work,  it  seems  to  me  that  the  time  has  arrived  when 
every  physician  should  give  this  subject  serious  thought 
and  use  his  best  endeavors  to  prevent  this  wholesale 
abuse  of  medical  charity.  Dr.  Van  Fleet  has  offered 
some  valuable  suggestions,  and  it  would  undoubtedly 
be  well  to  hear  from  other  gentlemen  who  are  working 
in  the  free  clinics.  Another  suggestion,  which  is  not 
original,  is  for  the  applicant  to  obtain  a  note  from  a 
physician  living  in  applicant's  neigliborhood. 


Of  course,  any  suggestion  made  is  only  for  those 
clinics  which  attempt  to  prevent  this  abuse,  and  I  re- 
gret to  say  that  there  are  some  which  do  not  attempt 
to  prevent  it,  but  seemingly  encourage  it.  In  this  re- 
spect I  have  in  mind  the  New  York  Hospital  Dispen- 
sary, where  patients  are  treated  for  a  dollar  per  month, 
medicine  extra,  doing  away  with  any  idea  of  pauperism, 
and  unless  the  method  of  investigation  of  applicants 
has  recently  been  changed,  it  is  a  very  lax  one. 

At  St.  Bartholomew's  Dispensary  the  applicants  are 
hardly  questioned  as  to  their  financial  resources.  As 
in  many  other  clinics,  a  very  large  percentage  of  pa- 
tients attending  here  can  readily  afford  to  pay  moder- 
ate fees  for  treatment. 

Last,  but  by  no  means  the  least,  is  the  Vanderbilt 
Clinic.  There  is  now,  I  believe,  no  investigation  of  ap- 
plicants. When  applicants  were  investigated  by  the 
Charity  Organization  Society  for  this  clinic,  about  fifty 
per  cent,  were  found  able  to  pay  or  unknown  at  address 
given  to  the  receiving  clerk.  The  material  for  clinical 
instruction  is  far  in  excess  of  the  demand,  and  still  the 
clinic  is  being  enlarged.  It  certainly  seems  as  though 
something  ought  to  be  done  to  prevent  tliese  abuses  of 
medical  charity.  It  was  only  recently  a  young  woman 
applied  at  one  of  the  classes,  and  asked  to  be  attended 
to  at  once  as  she  had  left  her  bike  outside. 

Applicants  from  out  of  town  are  not  a  curiosity  at 
any  of  the  clinics. 

The  abuse  of  medical  charity  seems  a  fit  subject  for 
agitation,  and  it  would  be  well  to  hear  from  others  on 
the  subject. 

C.    F.    G. 

New  York,  September  25,  1895. 


THE    COMMITMENT    OF    THE    INSANE. 

To  THE  Editor  op  the  Medical  Record. 

Sir  :  In  view  of  the  laxity  of  the  laws  governing  the 
commitment  of  the  insane,  experienced  and  practical 
observers  must,  perforce,  endorse  some  of  the  views 
of  Mr.  Albert  Bach  on  the  subject.  It  is  well  perhaps 
to  take  the  ideas  of  Mr.  Bach  on  some  matters  '"cum 
grano  salis,"  such,  for  instance,  as  the  statement  in  his 
recent  paper  on  suicide  concerning  the  practice  of 
physicians  in  promoting  euthanasia.  Such  rhetorical 
hyperbole  causes  us  to  suspect  that  at  times  Mr.  Bach 
is  given  to  extravagance  of  language,  if  not  wilful  falsi- 
fication. However,  that  the  present  lunacy  law  is  in- 
adequate, as  he  claims  it  to  be,  is  a  fact  apparent,  if 
we  examine  for  a  moment  some  of  its  features  and  the 
results  arising  from  the  necessary  observance  of  it,  in 
its  imperfection. 

It  may  be  stated  that  the  present  law  was  enacted 
in  1890,  and  is  an  amendment  to  the  revised  statutes  of 
1S89.  The  law  of  1SS9  was  in  most  respects  the  same 
as  that  in  force  since  1S74,  except  that  the  certificate, 
or  a  duplicate,  must  be  registered  with  the  State  Com- 
mission in  Lunacy.  Let  us  see  what  the  law  requires 
in  a  medical  man  before  he  can  qualify  as  an  ex- 
aminer in  lunacy.  The  first  requisite  is,  that  he  must 
have  been  in  the  practice  of  his  profession  for  three 
years;  and  the  second  is,  that  he  must  be  registered, 
after  approval  by  a  judge  of  a  court  of  record,  with 
the  Lunacy  Commission  ;  that  is  all. 

Now,  of  course,  insanity  as  a  rule  is  not  hard  of 
diagnosis,  almost  any  one  can  do  it.  The  certificate  is 
easy  to  make  out ;  signing  and  swearing  to  its  state- 
ments are  simple  matters,  and  it  may  seem  absurd  that 
we  should  need  a  specialist  to  do  something  an  intelli- 
gent layman  might  do.  But  this  is  not  all ;  the  aver- 
age medical  man  is  able  to  say  of  the  plain  case  of 
mania  or  of  melancholia,  such  and  such  are  the  symp- 
toms, and  this  the  diagnosis  ;  more,  however,  is  re- 
quired of  him.  The  question  is  not  always  is  the 
patient  insane  ?  but  it  is,  also,  is  his  insanity  of  the 


536 


MEDICAL    RECORD. 


[October  12,  li 


kind  that  would  be  benefited  by  hospital  treatment  ? 
Should  a  patient  suffering  from  simple  melancholia, 
with  its  terrifying  depression,  and  often  its  keen  reali- 
zation of  surroundings,  have  the  often- time  unpleasant 
sights  of  a  hospital  for  the  insane  added  to  the  many 
subjective  miseries  incident  to  his  disease  ?  Will  a 
three  years'  experience  in  practising  medicine,  the 
practice  consisting  often  of  "holding  down  "  an  office 
chair,  enable  a  man  to  pass  upon  such  a  question  ? 
Again,  there  are  many  cases  whose  symptoms,  although 
an  open  book  to  one  that  has  had  practical  experience 
in  psychiatry,  will  seem  normal  and  of  sound  mind  to 
a  man  that  knows  more  of  fractures  than  of  physio- 
logical psychology,  and  is  more  versed  in  the  varieties 
of  bacilli  than  in  the  anatomy  of  the  cerebral  convolu- 
tions. 

It  may  be  well  to  state  here  that  I  do  not  claim  that 
every  examiner  in  lunacy  should  be  one  that  has 
made  alienism  a  life-long  study  ;  but  he  should  have  a 
well-grounded  theory  of  mental  medicine,  and  a  cer- 
tain amount  of  practical  experience  in  its  diagnosis 
and  treatment.  The  chairs  of  psychiatry  in  most  of 
our  colleges  are  more  ornamental  than  useful,  and  the 
few  lectures  delivered  on  the  subject  are  sparsely  at- 
tended as  a  rule.  So  we  cannot  expect  an  average 
examiner  in  lunacy  to  know  very  much  on  the  subject 
whereof,  by  reason  of  his  power  of  certification,  he 
professes  to  be  an  expert. 

So  much,  then,  for  the  requirements  of  the  present 
law  in  regard  to  the  qualifications  of  the  examining 
physician,  and  when  it  is  stated  that  in  New  York  City 
alone  there  are  five  hundred  and  two  registered  ex- 
aminers in  lunacy,  it  will  be  seen  that  many  have 
availed  themselves  of  the  simple  requirements  of  the 
position  to  pose  occasionally  as  expert  alienists  and 
add  materially  to  their  income  by  so  doing. 

In  regard  to  the  other  provisions  of  the  law,  requir- 
ing the  approval  by  a  judge  of  a  court  of  record,  the 
operation  in  its  simplicity  and  ease  of  accomplishment 
make  the  approval  almost  farcical.  The  readiness  of 
our  judges  to  approve  of  medical  certificates  of  lunacy 
applies  more  to  the  rural  districts  ;  there  the  procedure 
is  done  in  a  hap-hazard  way  only  too  frequently,  the 
real  committing  magistrates  being  the  physicians.  Of 
course,  physicians  should  be  like  Cssar's  wife  ;  but,  un- 
fortunately, the  millennium  is  afar  as  yet.  In  New 
York,  lately,  certain  of  our  prominent  judges  have 
ceased  signing  certificates  in  a  promiscuous  manner, 
and  have  shown,  by  their  unwillingness  to  sign,  their 
disapproval  of  the  law's  laxity. 

The  safeguards  against  mistakes  and  false  commit- 
ment are  more  numerous  than  in  former  years,  but 
that  they  are  far  from  perfect  I  think  most  practical 
alienists  will  agree.  The  remedies  are  simple  and 
easily  applied.  Cut  down  this  immense  list  of  insanity 
experts  (?)  by  making  it  imperative  that  an  examina- 
tion, practical  and  theoretical,  in  which  experience 
will  largely  count,  must  be  passed,  to  determine  the 
competency  of  the  physician.  Lengthen  the  time  for 
the  physician  required  to  be  in  practice.  Make  it 
compulsory  for  the  judge  to  see  the  lunatic  about  to 
be  committed  before  signing  any  certificate,  for  no 
patient  is  so  violent  that  he  may  not  be  seen,  at  least 
privately,  by  the  magistrate.  By  means  of  these  and 
other  precautions  our  lay  friends,  with  minds  as  richly 
imaginative  as  Mr.  Albert  Bach,  will  no  longer  have 
cause  for  alarm. 

WhiTMORE    SXEELli,    M.D. 
155  East  Sevkntv-seventh  Street. 


THE  ABUSE  OF  PUBLIC  CHARITIES,  AS 
SEEN  FROM  A  HUMANITARIAN  STAND- 
POINT. 


To   THE    ErJiTOR 


Medical  Recobp. 


How  to  Rescue  a  'Woman.— A  French  medical  jour- 
nal says  that  the  authorities  at  Dieppe  have  issued  in- 
structions to  the  bathing-police,  among  which  is  a 
paragraph  directing  them  never  to  seize  a  drowning 
woman  by  the  hair,  as  that  might  come  off,  leaving  the 
owner  to  sink. 


Sir  :  The  present  is  an  age  in  which  pessimism  flour- 
ishes with  a  fecundity  astonishing  to  even  the  greatest 
of  the  brotherhocd.  That  the  medical  profession  is 
remarkably  free  from  this  noxious  quality  goes  with- 
out saying  ;  yet,  now  and  then,  a  solitary  case  will  oc- 
casionally make  its  appearance  upon  the  surface,  even 
where  the  intention  is  of  the  best.  When  such  occurs 
the  majority  of  the  jjrofession  are  inclined  to  regard 
the  idiosyncrasies  of  the  individual  with  a  regretful 
eye,  that  one  who  is  a  member  of  an  honorable  pro- 
fession should  allow  himself  to  become  morbid.  And 
yet  it  is  a  misnomer  to  call  him  an  extremist,  for  he  is 
a  pessimist  in  the  widest  sense  of  the  term  who  permits 
himself  to  hold  such  a  misanthropic  estimation  of  his 
fellow-men  as  does  the  author  of  "  The  Abuse  of  Medi- 
cal Charities,"  which  appeared  in  the  issue  of  the  Medi- 
cal Record  of  August  31st. 

A  cursory  perusal  would  lead  the  reader  to  believe  it 
to  be  a  most  erudite  and  profound,  logical  and  sound 
discussion  of  a  matter  in  which  it  must  be  admitted  we 
are  alike  interested.  But  a  close  and  critical  examina- 
tion of  the  article  reveals  that  it  is  made  up  of  a  tissue 
of  generalities  and  assertions,  few  of  which  are  sub- 
stantiated, and  a  mass  of  tiresome  repetitions.  In  fact, 
the  writer  betrays  a  lamentable  lack  of  knowledge  with 
regard  to  worldly  affairs  and  people,  and  makes  a  furi- 
ous onset  upon  those  who  appear  respectably  clad  at 
free  dispensaries,  claiming  that  if  well  dressed  the  ap- 
plicant must  be  able  to  undertake  the  expense  entailed 
on  treatment  by  a  specialist. 

He  cites,  or  rather  indulges  in,  the  parable  of  a 
wealthy  brother  bringing  his  poorer  relative  to  be 
treated  at  the  free  dispensary  ;  of  wealthy  employers 
sending  female  help  ;  of  family  physicians  who,  having 
exhausted  their  every  known  remedy  in  the  treatment 
of  some  complaint,  consign  their  patient  to  the  tender 
mercies  of  a  free  dispensary. 

And  now,  what  is  to  be  understood  by  a  free  dispen- 
sary ?  Does  it  mean  a  place  where  one  afflicted  with 
disease  may  be  treated  without  charge,  or  is  it  an  in- 
stitution where  there  is  a  class  distinction  and  only 
those  clad,  or,  rather,  not  clad,  in  becoming  garments 
may  be  prescribed  for  ?  > 

Is  it  any  wonder,  then,  that,  dreading  the  treatment 
which  a  number  have  experienced,  many  will  appear  in 
costumes  which  at  least  cause  them  to  be  treated  with 
respect  and  courtesy  ?  Is  it  to  be  supposed  that  only 
those  who  are  financially  well  off  are  sensitive  to  the 
gibes  of  some  follower  of  .I'sculapius  ?  Let  one  in- 
terested visit  one  of  these  dispensaries  where  poverty 
is  predominant  and  listen  and  witness  the  scenes  there 
to  be  found.  Why,  then,  should  these  institutions  ad- 
vertise free  treatment,  and  when  once  the  patient  is 
within  the  toils  demand  a  fee  ?  As  well  might  the 
attending  physician  make  a  demand  as  to  the  amount 
of  money  in  the  patient's  possession  and  hold  him  up 
in  the  regular  fashion  of  Claude  Duval.  It  would  be 
fully  as  honorable  and  far  more  manly.  In  other 
words,  it  is  nobody's  business,  and  is  an  impertinence 
which  in  any  other  profession  or  business  would  be 
sharply  resented.  Frankly  speaking,  a  free  dispensary 
is  an  institution  open  to  all  who  stand  in  need  of  treat- 
ment, and  if  any  physician  feels  that  he  is  being  robbed 
of  his  just  profits  in  attending  patients  who  may  happen 
to  appear  in  becoming  dress,  he  may  easily  find  a 
remedy  by  severing  his  connections  with  an  institution 
where  such  patients  are  liable  to  put  in  an  appearance. 

It  is  folly  to  inveigh  against  applicants  of  foreign 
extraction  who  appear  at  the  clinics  for  treatment,  and 
claim  that  a  very  large  number  of  them  are  able  to  pay. 
Statistics  plainly  prove  the  fallacy  of  the  assertion. 
True,  there  are  some  who  could  pay,  but  the  number 


October  12,  1895] 


MEDICAL   RECORD. 


537 


is  infinitesimal  in  proportion  to  the  number  of  ap- 
plicants for  relief.  The  evil  may,  as  the  worthy  author 
of  "  The  Abuse  of  Medical  Charities  "  asserts,  be  in- 
creasing, but  I  deny  most  emphatically  that  it  is 
begetting  habits  which  tend  to  degrade  the  undeserv- 
ing recipients.  Such  cannot  be  degraded,  as,  in  a  cer- 
tain sense,  they  have  tasted  the  very  dregs  of  degrada- 
tion, inherited,  unfortunately,  from  a  long  line  of 
ancestors  born  in  serfdom.  Is  there  a  remedy  ?  Per- 
haps, and  yet  to  find  and  cut  off  the  evil  in  this  direc- 
tion we  would  be  obliged  to  check  the  tide  of  im- 
migration, and,  as  does  the  great  wall  of  China, 
effectually  shut  off  this  invasion  of  the  vandals  who, 
devoid  of  conscience,  rob  the  poor  physician  of  his 
just  fees  at  the  free  dispensaries. 

Imagine  the  able-bodied  mechanic,  clerk,  type- 
writer, bookkeeper,  etc.,  with  the  princely  salaries  of 
$8,  $10,  $12  to  $18  per  week,  many  with  large 
families  dependent  upon  their  daily  toil,  paying  for 
special  treatment  I  Or  take  a  school-teacher  (many  of 
whom  receive  but  $400  per  year,  and  few  of  whom 
have  visited  a  dispensary)  ;  how  long  is  it  to  be 
imagined  they  could  undertake  a  special  treatment  .- 
.A.11  of  these  people  must  appear  well  dressed  at  their 
places  of  business  or  discharge  would  quickly  follow. 
And  yet,  it  is  asserted,  if  these  holders  of  lucrative 
positions  (?)  appear  at  the  free  dispensaries,  treatment 
should  be  refused  them.  Yet  the  school-teacher  dares 
not  appear  other  than  becomingly  clothed.  How, 
then,  are  professional  men  to  judge  of  the  abilitv  ot 
the  patient  to  pay?  "Ay,  there's  the  rub."  They 
dare  not  say,  "  Pay  me  at  once,"  for  then  they  assume 
the  character  of  extortioners,  and  as  they  have  the  at- 
tributes of  honor  and  manhood  they  will  have  a  natural 
repugnancy  thereto. 

It  is  useless  to  raise  the  alarm-cry  of  pauperism,  be- 
cause a  large  number  of  people  financially  embarrassed, 
and  among  whom  is  a  small  proportion  of  well-dressed 
individuals,  are  obliged  to  visit  the  institutions  known 
as  free  dispensaries.  A  large  number  of  those  treated 
have  a  natural  pride  which  forbids  their  attending  these 
places.  But  necessity  knows  no  law,  and  they  per- 
force do  that  which  is  obnoxious  to  their  feelings. 

The  abuse  of  these  public  charities,  if  such  exists. 
has  produced  no  visible  impression  upon  the  public 
mind.  On  the  contrary,  with  the  exception  of  some 
disgruntled  individuals,  the  general  verdict  is  one  of 
approval.  This  is  the  more  marked  that,  considering 
the  proportion  of  patients  who  receive  free  treatment 
to  our  enormous  population,  the  number  who  abuse 
the  privilege  is  infinitesimally  small.  Can  as  much  be 
said  of  cities  of  like  population  in  other  parts  of  the 
universe  ?     Statistics  fail  to  reveal  it. 

As  to  a  remedy  for  the  correction  of  the  abuse  of 
charity,  I  can  suggest  nothing  which  could  be  put 
into  practical  operation.  As  long  as  free  institutions 
continue  to  exist,  so  long  will  the  people  continue  to 
fill  the  reception-rooms  of  clinics.  If  the  precept  and 
principles  of  the  Good  Samaritan  are  to  be  thrown 
aside,  then  take  down  the  placard,  "Free  Treatment," 
and  at  once  advocate  the  total  abolition  of  free  dis- 
pensaries. When  this  is  accomplished,  and  not  till 
then,  will  the  poor  physician  of  the  free  dispensary 
receive  his  just  proportion  of  the  fees  which  should 
accrue  to  him,  and  likewise  the  execrations  of  millions 
of  his  unhappy  fellow-beings. 

Tho.mas  J.  Moss,  M.D. 


A   BIT    OF    ANCIENT    HISTORY. 

To  THE  Editor  of  the  Midical  Record. 

Sir  :  In  the  Southern  Journal  of  Medicine  and  Phar- 
macy for  September,  1847,  Dr.  W.  T.  Wragg  states  that 
he  has  been  in  the  habit  of  using  animal  ligatures  for 
upward  of  ten  years,  and  for  several  years  has  used 
none  but  these.  During  this  period  he  has  tied  arte- 
ries of  the  fingers,  arm,  forearm,  leg,  and  thigh,  and  has 
never  seen  any  symptoms  result  from  which  he  could 
infer  that  the  knot  had  not  been  removed  by  absorp- 
tion. 

His  deductions  are  :  i.  That  the  deer-sinew  ligature, 
if  properly  applied,  will  effectually  arrest  hemorrhage 
from  vessels  of  even  large  size.  2.  That  they  produce 
less  inflammation  of  the  li\-ing  tissues  with  which  they 
are  placed  in  contact  during  the  time  they  remain 
within  their  substance.  3.  That  they  are  susceptible 
of  being  absorbed  and  carried  away  by  the  action  of 
the  living  parts  in  which  they  are  placed. 

John  A.  Wyeth,  M.D. 


W^zQxcsCi  stems. 

Contagious  Diseases — "Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  October  5,  1895. 


Troubles  of  the  German  Insane  Asylums.  —  There 
seems  to  be,  says  the  Mediial  Magazine,  a  general 
awakening  in  the  German  insane  asylums.  Following 
on  the  exposures  at  Mariaberg  and  .Anelsburen  comes 
news  of  trouble  at  the  Bielefeld  Institute  for  the  Insane. 
The  doctor  in  charge  accuses  the  directors  of  "  gross 
excesses  "  against  the  inmates  of  the  asylum. 


Tuberculosis ii6 

Typhoid  fever 36 

Scarlet  fever ,  27 

Cerebro-spinal  meningitis 2 

Measles 37 

Diphtheria 142 


Strychnine  Delirium.— Those  members  of  the  medi- 
cal profession  who  have  employed  caffeine  very  largely 
in  the  treatment  of  cardiac  and  renal  disease,  have 
recognized  that  large  doses  of  this  drug,  continuously 
administered  for  a  considerable  period,  developed  in 
certain  individuals  what  has  been  popularly  called 
"caffeine  craziness."  In  other  words,  the  full  medici- 
nal doses  required  by  the  condition  of  the  heart  or 
kidneys  have  also  been  sufficiently  large  not  only  to 
produce  an  increased  activity  of  the  brain,  such  as  is 
seen  when  coffee  is  taken  in  large  amounts,  but  also 
have  gone  farther  than  this,  and  by  the  very  cerebral 
stimulation  produced  temporary  insanity.  Within  the 
last  few  years  the  medical  profession  has  been  employ- 
ing in  certain  States  what  may  be  considered  as  massive 
doses  of  strychnine  in  the  treatment  of  failing  respira- 
tion or  circulation,  and  has  obtained  therefrom  very 
good  results.  It  having  been  found  that  these  full  doses 
of  strychnine  acted  favorably  when  given  in  an  emer- 
gency, we  have  been  tempted  to  continue  their  admin- 
istration where  the  symptoms  were  relieved  but  tem- 
porarily, and,  as  a  result,  have  oftentimes  been  pleased 
with  their  effect.  On  the  other  hand,  a  sufficient  num- 
ber of  cases  have  been  seen  in  which  cerebral  disturb- 
ance has  followed  these  large  doses  to  put  us  continu- 
ally on  the  lookout  for  such  untoward  symptoms.  As 
a  rule,  he  who  administers  large  doses  of  strychnine  in 
an  emergency  is  on  the  qui  vive  for  some  twitching  of 
the  muscles  of  the  forearm  or  other  portion  of  the 
body  as  an  evidence  of  the  physiological  action  of  the 
drug.  While  we  believe  that  these  symptoms  are  com- 
monly produced  by  a  single  administration  of  the 
remedy,  we  are  also  confident  that  its  continued  admin- 
istration in  full  doses  frequently  fails  to  produce  these 
evidences  of  heightened  reflex  activity,  and  in  their 
place  causes  a  more  or  less  active  delirium,  in  which 


538 


MEDICAL   RECORD. 


[October  12,  1895 


the  patient  frequently  refuses  to  take  his  medicine,  or 
develops  the  delusion  that  his  attendants  are  conspiring 
to  poison  him  or  do  him  some  other  injury. 

Dividing  Fees  with  Midwives. — At  the  meeting  of 
the  Aerztekammer  held  on  the  i8th  ult.,  under  the 
presidency  of  Dr.  Achenbach,  the  new  Medzinal  Taxe 
proposed  by  the  Cultus  Minister  was  the  chief  object 
discussed.  In  almost  every  instance  the  fees  proposed 
by  the  Minister  were  considered  as  too  low,  and  altera- 
tions from  this  point  of  view  were  made  as  counter- 
proposals. It  is  scarcely  likely,  however,  that  they  will 
meet  with  the  acceptance  they  deserve.  A  second 
matter  discussed  was  the  practice  of  paying  a  fee  of 
three  shillings  for  every  case  of  labor  introduced  by  a 
midwife.  This  curious  practice  was  not  originated  by 
some  practitioner  in  need  of  practice,  but  by  the  Uni- 
versity and  Charitie  kliniks.  There  was  a  fear  that,  as 
Berlin  was  a  large  teaching  centre,  the  number  of  cases 
of  midwifery  would  fall  short  of  the  requirements  for 
due  instruction  ;  it  was  agreed,  therefore,  that  a  reward 
of  three  shillings  should  be  given  for  every  obstetric 
case  introduced.  This  went  on  for  a  number  of  years. 
When  Professor  Martin  began  his  extra-mural  teaching 
as  lecturer  on  obstetrics,  he  found  he  was  handicapped 
by  the  premium  thus  given  in  working  in  rivalry  with 
the  official  institutions,  and  it  became  a  necessity  for 
him  to  offer  the  usual  fee  paid  by  the  two  official 
bodies.  It  was,  however,  considered  improper  for  a 
private  individual  to  pursue  the  same  course  as  the  two 
public  bodies,  and  his  action  came  before  the  Aerzte 
Vereinen  for  discussion,  and  was  referred  by  them  to 
the  Central  Committee.  It  was  recognized  by  this 
body  that  Dr.  Martin  did  not  pay  the  objectionable  fee 
for  his  own  direct  emolument,  but  simply  in  order  that 
his  teaching  facilities  should  not  suffer  by  the  action 
of  the  colleges.  They,  therefore,  declined  to  interfere. 
The  way  was  thus  paved  for  others,  and  very  soon  in- 
dividual practitioners  agreed  with  midwives  to  pay 
them  the  fee  for  introductions  to  midwifery  cases. 
These,  however,  were  without  the  necessary  excuse  that 
these  cases  were  required  for  teaching  purposes,  and  it 
was  considered  that  by  their  action  they  infringed  the 
rules  that  ought  to  govern  the  relations  of  medical  men 
among  each  other.  After  some  discussion,  in  which 
no  one  attempted  to  defend  the  payment  of  premium 
for  introduction,  the  Chamber  unanimously  agreed  to 
request  the  Staatsregierung  to  compel  th6  Royal  Ob- 
stetric Institution  to  put  a  stop  to  the  payment  of  such 
fees.  The  Chamber  further  declared  all  business  ar- 
rangements of  medical  men  with  the  lower  "Heilper- 
sonal  "  to  be  improper. —  The  Medical  Press. 

Charaka-Samhita. — Part  XIII.  of  this  interesting  and 
curious  work  deals  with  food  and  drink,  showing  what 
purposes  are  served  by  the  fluid  into  which  food  is 
changed  in  the  stomach  and  what  by  the  refuse  of  food. 
Those  bodies  which  are  particularly  liable  to  disease, 
and  those  which  are  capable  of  resisting  disease,  are  in- 
dicated. Then  are  mentioned  the  different  diseases 
which  arise  in  different  parts  of  the  body,  owing  to  the 
excitement  of  wind,  bile,  and  phlegm,  individually,  or 
in  pairs,  or  all  together.  \Vhen  they  all  get  excited  to- 
gether the  condition  is  serious,  and  can  only  be  sub- 
dued by  the  treatment  indicated.  The  difference  is 
set  forth  between  men  that  are  wise  and  those  that  are 
foolish  or  ignorant.  The  wise  observation  is  also  made 
that  things  which  are  beneficial  for  some  are  not  always 
so  for  others.  The  concluding  pages  deal  principally 
with  the  distinction  between  good  and  bad  physicians. 
The  bad  physicians  are  called  killers  of  life  and  help- 
ers of  disease.  These  men,  wearing  the  robes  of  phy- 
sicians, are  the  thorns  of  the  world,  liehaving  after 
the  manner  of  those  whom  they  imitate,  those  persons, 
through  the  heedlessness  of  kings,  move  about  in  all 
countries.  This  is  their  especial  indication,  viz.:  clad 
in  the  robes  of  physicians  and  indulging  in  self-praise, 
they  walk  along  the  public  streets,  in  expectation  of 


calls.  The  translator  adds  that  to  this  day  many  phy- 
sicians who  have  no  calls  pass  and  repass  along  the 
public  thoroughfares  in  their  good  and  handsome  car- 
riages drawn  by  excellent  steeds,  to  create  the  impres- 
sion that  their  practice  keeps  them  engaged  for  the 
whole  day. 

The  Craig  Epileptic  Colony. — Craig  Colony,  named 
for  the  late  Oscar  Craig,  of  Rochester,  formerly  Presi- 
dent of  the  State  Board  of  Charities,  consists  of  nearly 
one  thousand  nine  hundred  acres  of  land  in  the  Gene- 
see Valley.  It  is  reached  by  two  trunk  lines  of  rail- 
ways (the  Erie  and  the  Delaware  &  Lackawanna)  and 
from  roads  centring  at  Rochester  by  the  Western  Xew 
York  &  Pennsylvania  Railroad.  The  colony  has  its 
own  post-office  and  railway  station,  known  as  Sonyea, 
an  Indian  word  signifying  sunny  place.  The  law  es- 
tablishing the  colony  required  that  it  should  be  ar- 
ranged on  the  village  plan.  Craig  Colony  will  not  re- 
semble an  institution  in  any  particular,  but  will  look 
more  like  a  country  town  than  anything  else.  As  the 
patients  are  received  they  will  be  set  to  work  or  at 
study  in  various  ways.  They  will  take  care  of  the 
farms,  gardens,  and  orchards  ;  they  will  plan  and  build 
new  houses.  There  will  be  among  them  tailors,  shoe- 
makers, printers,  bookbinders,  masons,  ironworkers, 
carpenters,  painters,  and  so  on.  In  fact,  every  sort  of 
employment,  every  sort  of  recreation,  everything  in 
short  that  goes  to  make  up  the  life  of  a  country  village, 
will  be  found  in  this  colony,  the  only  difference  being 
that  the  citizens  of  this  community  will  be  epileptics. 
The  resources  of  the  land  are  such  that  almost  every- 
thing in  the  way  of  food  for  the  inhabitants  of  the  vil- 
lage can  be  raised  by  themselves,  and  their  surplus 
agricultural  and  manufacturing  products  judiciously 
managed  can  make  the  colony  practically  self-support- 
ing. Work  has  been  progressing  very  rapidly  during 
the  year  to  prepare  existing  buildings  for  the  reception 
of  patients.  The  first  quota  of  patients,  numbering 
sixty,  will  be  taken  from  the  almshouse  early  in  No- 
vember. The  patients  taken  from  the  almshouses  and 
asylums  will  be  known  as  State  patients,  and  they  will 
be  provided  for  before  any  private  patients  can  be  re- 
ceived. They  will  be  sent  to  the  colony  by  the  poor 
authorities  of  each  county  according  to  a  form  required 
by  law,  the  blanks  for  which  will  be  furnished  on  ap- 
plication to  the  -State  Board  of  Charities,  or  the  super- 
intendent of  the  colony.  As  soon  as  all  epileptics  now 
upon  public  charge  eligible  for  admission  to  the  colony 
are  provided  for,  private  patients  will  be  received  at 
prices  to  be  regulated  by  the  Board  of  Managers,  ac- 
cording to  the  kind  and  extent  of  care  and  attention 
required.  Such  patients  may,  if  it  be  desired,  erect 
cottages  for  their  own  use  upon  the  grounds,  upon  ap- 
plication to  the  Board  of  Managers.  There  will  be  no 
restriction  as  to  the  age  of  patients  admitted,  and  the 
only  restriction  practically  applies  to  the  mental  con- 
dition. Insane  epileptics,  or  epileptics  subject  to  in- 
sane outbreaks,  cannot  be  taken  into  the  colony.  The 
law  permits  the  Board  of  Managers  to  take  and  hold 
in  trust  for  the  State  any  grant  of  land,  gift,  or  bequest 
of  money,  or  any  donation  to  be  applied,  principal  or 
income,  or  both,  to  the  maintenance  and  education  of 
epileptics,  and  the  general  uses  of  the  colony.  Dr. 
Frederick  Peterson  is  President  of  the  Board  of  Man- 
agers, and  Mr.  H.  E.  Brown,  Secretary.  The  medical 
superintendent  is  Dr.  William  P.  Spratling.  Craig 
Colony,  Sonyea,  N.  '\'. 

An  Early  Sign  of  Tabes. — Dr.  James  J.  Putnam, 
writing  in  tlio  lUnton  ^^<\u\■al  and  Surgieal  Journal, 
says  that  a  number  of  years  ago,  while  trying  the  effect 
of  hyperllexion  of  the  legs  for  relief  of  pam  in  tabes, 
he  observed  that  it  was  frequently  possible  to  flex  the 
leg  at  the  hip,  without  bending  it  at  the  knee,  so  far 
that  it  would  almost  touch  the  ear  without  exciting  the 
painful  sense  of  popliteal  tension  which  is  so  speedily 
felt  by  a  person  in  health.     Since  then  he  had  con- 


October  12,  1895] 


MEDICAL    RECORD. 


539 


vinced  himself  that  this  sign  is  not  only  an  interesting 
feature  of  advanced  cases  of  the  disease,  but  that  it 
may  help  one  out  at  an  early  stage  where  the  diagnosis 
is  doubtful.  The  degree  to  which  the  hyperflexion  is 
possible  without  exciting  pain  seems  to  be  proportion- 
ate rather  to  the  pain  than  to  any  other  symptom,  and 
is  not  proportionate  to  the  ataxia.  The  sign,  Dr.  Put- 
nam thinks,  is  certainly  one  which  deserves  study, 
tliough  it  is  not  invariably  present. 

The  Treatment  of  Chancroids  in  Women. —  The 
standard  treatment  for  soft  chancres  is  the  application 
of  iodoform,  but  there  are  several  difficulties  to  be  met 
with  in  carr5-ing  out  this  method  with  females.  It  is, 
perhaps,  less  easy  to  obtain  rest  than  it  is  with  males, 
while  the  disagreeable  and  penetrating  odor  of  iodo- 
form often  causes  women  to  shirk  its  application. 
Even  if  the  drug  be  used  as  ordered,  the  lodgement  of 
urine  between  the  labia  after  micturition  and  the  free 
vaginal  discharge  rapidly  decompose  the  chemical  and 
neutralize  the  good  it  might  do.  Von  Herff  recom- 
mends the  employment  of  immediate  cauterization  by 
phenol,  his  method  being  as  follows  :  Having  first  well 
cleansed  the  genitals  with  sublimate  solution,  search  is 
made  for  the  full  extent  of  the  disease  in  a  good  light. 
Each  ulcer  is  then  touched  with  a  concentrated  solu- 
tion of  phenol,  a  wooden  probe  being  used  for  the  pur- 
pose. The  edges  of  each  sore  must  be  especially  well 
touched  up.  Dry  wool  is  then  placed  over  the  ulcer, 
and  hip-baths  and  weak  antiseptic  injections  used 
afterward.  A  further  examination  need  not  be  made  . 
for  about  five  days,  when  the  ulcers  will,  as  a  rule,  be 
found  healing. — Medical  Times  and  Gazette. 

A  Choice  of  Occupations. — The  editor  of  the  Provin- 
cial Medical  Journal  says  that  he  attended  a  meeting 
of  the  Section  on  Ethics  of  the  British  Medical  Asso- 
ciation in  company  with  a  successful  practitioner  who 
takes  only  guinea  fees.  The  gentleman  listened  with 
attention,  but  upon  leaving  the  room  he  said  "  You 
have  lost  your  sense  of  humor.  Why,  they  were  actu- 
ally talking  about  the  dignity  of  the  profession,  while 
in  the  same  breath  they  discussed  the  question  whether 
they  should  attend  a  man  for  36,  4',  or  10/  a  year." 
He  had  never  before  heard  of  such  a  thing,  and  as  his 
idea  of  dignity  was  associated  with  a  guinea  fee  for 
each  consultation  he  could  not  understand  it,  nor  does 
he  yet,  says  the  writer,  though  we  had  a  long  conversa- 
tion on  the  subject,  and  we  told  him  of  the  conditions 
of  practice  among  the  vast  majority  of  the  profession. 
"  Well,"  he  said,  "  I  would  break  stones  first."  "  It  is 
easy  to  talk,"  adds  our  esteemed  contemporary,  "about 
breaking  stones  for  a  living,  but  this  form  of  avocation 
would  not  be  available,  for  there  are  already  too  many 
applicants  even  for  that  very  unremunerative  form  of 
making  a  living." 

A  Glass  Syringe  as  a  Feeding-cup. — Dr.  Aulad 
writes  to  the  Medical  Times  and  Hospital  Gazette  that 
he  was  one  day  attending  a  child  who  struggled  vio- 
lently when  any  vessel  or  spoon  was  brought  near  her 
mouth.  He  filled  a  small  glass  syringe  with  milk  and 
held  the  nozzle  over  her  mouth  as  she  lay  in  the  semi- 
recumbent  position,  pushing  the  piston  and  allowing 
the  liquid  to  fall,  drop  by  drop,  into  her  mouth.  Very 
soon  she  made  no  objection  to  allowing  the  nozzle  to 
be  inserted  between  the  lips,  and  commenced  to  draw, 
as  from  a  teat.  Dr.  Aulad  subsequently  employed  this 
method  with  adults  only,  using  a  larger  syringe,  and 
he  says  that  it  is  surprising  with  what  ease  and  com- 
fort patients  can  thus  be  induced  to  take  a  large 
amount  of  liquids — from  a  few  drops  to  an  ounce  at  a 
time. 

Hereditahility  of  Cancer. — Mr.  Roger  Williams  holds 
that  the  fact  which  he  has  demonstrated,  that  cancer 
is  so  often  homotopic  in  its  transmission,  that  is  to  say, 
that  it  attacks  the  corresponding  organ  in  each  of  the 
related    individuals   with    preponderating   frequency, 


proves  conclusively  that  the  disease  may  be  inherited. 
The  following  cases,  which  he  mentions  in  a  letter  to 
the  British  Medical  Journal,  appear  to  illustrate  this, 
he  thinks,  in  a  particularly  striking  manner  :  i.  A 
woman,  aged  fifty-three,  came  under  his  observation 
with  uterine  cancer,  whose  maternal  grandmother, 
mother  (aged  forty-five),  mother's  sister,  and  the  pa- 
tient's two  sisters  (aged  thirty-two  and  thirty-six)  had 
all  died  of  cancer  of  the  uterus.  2.  In  a  case  re- 
corded by  Sibley,  a  mother  and  her  five  daughters  all 
died  of  cancer  of  the  left  breast.  3.  Of  the  celebrated 
Bonaparte  family,  Napoleon  I.,  his  father,  his  brother 
Lucien,  and  two  of  his  sisters,  all  died  of  cancer  of  the 
stomach. 

The  Average  British  Practitioner  is  a  funny  creature, 
if  we  may  be  permitted  to  generalize  from  the  samples 
we  find  revealing  themselves  in  the  columns  of  our 
London  contemporaries.  He  never  seems  to  know 
how  to  act  in  emergencies  not  provided  for  specifically 
in  the  decalogue  or  in  "  The  Manners  and  Rules  of 
Good  Society."  Some  time  ago  the  question  was  agi- 
tated in  the  Times  whether,  when  a  man  met  his  wife's 
maid  or  the  cook  on  the  street  he  should  raise  his  hat 
and  smile,  or  should  simply  ignore  her  presence.  Now 
it  is  a  question  of  raising  one's  hat  to  one's  rival's 
wife,  and  "  Perplexed  "  appeals  to  the  British  Medical 
Journal  for  advice  in  the  following  terms  :  "  A  is  a 
practitioner  in  a  neighborhood,  who,  till  lately,  was  un- 
opposed. B  comes  in  and  sets  up  against  A.  As  is 
customary  B  calls  on  A,  but  does  not  see  A's  wife 
during  his  call,  and  yet  a  few  days  afterward  B  meets 
A's  wife  in  the  street  and  raises  his  hat  to  her.  A's 
wife  tells  her  husband,  and  A  calls  on  B  and  remon- 
strates with  him,  and  considers  his  wife  insulted.  Was 
it  an  insult,  or  was  B  merely  indiscreet  ?  Allowing 
that  it  is  a  breach  of  ordinary  etiquette  to  raise  one's 
hat  to  a  lady  to  whom  one  has  never  been  introduced, 
is  it  not  possible  that  B,  in  his  anxiety  to  be  cour- 
teous to  A,  overstepped  the  bounds  of  propriety  ?  " 

The  answer  of  our  esteemed  contemporary  is  tender 
and  judicial,  but  not,  in  our  opinion,  satisfactory,  for  it 
leaves  the  question  undecided,  and  "  Perplexed  "  is  no 
better  off  than  before.  "  Although,"  so  the  decision 
runs,  "  in  the  absence  of  a  personal  introduction  B 
would  have  been  more  than  justified  by  the  rules  of 
social  etiquette  in  passing  A's  wife  unnoticed,  and, 
probably,  under  the  peculiar  circumstances,  would 
have  acted  more  prudently  by  so  doing,  still,  the  sim- 
ple raising  of  his  hat  would  not,  as  alleged  by  her  hus- 
band, constitute  an  insult,  but  should  rather  be  looked 
upon  as  a  natural  and  courteously  intended  act  toward 
the  wife  of  a  brother  practitioner  to  whom,  in  accord- 
ance with  the  medico-ethical  rules,  he  had  recently  paid 
the  customary  visit  of  courtesy  as  a  newcomer  ;  and, 
in  our  opinion,  A  would  have  acted  wisely  in  accept- 
ing it  as  such.  Probably,  however,  and  not  unnatu- 
rally, his  mind  and  temper  were  somewhat  disturbed  by 
the  prospect  of  professional  competition  in  his  hitherto 
unopposed  practice." 

The  next  time  B  sees  Mrs.  A  coming  in  the  dis- 
tance he  should  quicken  his  pace,  take  off  his  hat,  and 
mop  his  brow  as  though  suffering  from  heat  and  hu- 
midity. He  will  thus  avoid  the  insult  of  passing  the 
lady  with  covered  head,  and  will  not  commit  the  dis- 
courtesy of  raising  his  hat  to  an  unknown  lady  ;  he 
will  also  appear  to  be  busy,  and  that  will  make  the 
other  children  feel  real  bad. 

An   Austrian  View  of   American   Medicine. — The 

Wiener  Mcdizinische  Blatter  says  that  of  the  one  hun- 
dred and  forty  medical  schools  in  the  United  States 
only  fourteen  require  a  four  years'  course  in  order  to 
obtain  the  degree  of  Doctor  of  Medicine.  One  hun- 
dred give  a  diploma  on  the  completion  of  three  courses 
of  lectures,  and  twenty-five  schools  require  but  two 
courses  of  lectures.  The  length  of  these  lecture- 
courses  varies  from  five  to  nine  months.     The  same 


540 


MEDICAL   RECORD. 


[October   12,  i< 


journal  asserts  that  the  practice  of  the  healing  art  in 
the  United  States  is  entirely  unrestricted. 

The  Alleged  Achievements  of  the  Orificial  Surgeon, 
as  set  forth  in  an  orificial  exchange,  are  little  short  of 
the  marvellous,  and  force  the  conclusion  that  the  fool- 
killer  has  abandoned  his  occupation.  We  read  of  a 
late  case  of  "  phthisis  cured  by  the  operation  for  lacer- 
ation of  the  cervix."  A  case  of  chronic  eczema  of  the 
hands  was  "cured  by  stretching  the  rectum."  Another 
case  of  eczema  was  treated  by  "  clipping  irritated 
points  at  the  various  outlets  of  the  body."  This  seems 
vague  but  heroic.  And  so  on.  For  all  the  ills  that 
afflict  the  flesh,  the  blame  is  laid  at  the  door  of  one,  or 
some,  of  the  orifices  of  the  body,  from  the  puncta  lach- 
rymalis  to  the  meatus  urinarius,  and  this,  or  they,  must 
needs  be  opened  and  stretched  by  the  most  approved 
orificial  methods.  A  worse  species  of  quackery  was 
never  invented.  One  orificial  gentleman  thinks  that  a 
''  conservative  orificial  surgeon  should  be  connected 
with  each  of  our  State  hospitals  for  the  insane."  An 
exchange  says  this  idea  is  an  excellent  one,  if  he  be 
connected  in  the  proper  capacity — as  patient  rather 
than  as  surgeon. — Atlanta  Medical  and  Surgical  Jour- 
nal. 

Sanitary  Science. — At  a  test-examination  for  sanitary 
inspectors,  one  of  the  candidates,  when  asked  what  a 
death-rate  was,  replied  that  it  was  a  rate  levied  on  the 
living  to  support  the  cemeteries.  There  is  a  weird  sar- 
casm in  this  answer,  and  also  in  the  reply  to  the  ques- 
tion about  the  wilful  exposure  of  a  person  suffering 
from  an  infectious  disease.  "  He  must  not,"  said  the 
examinee,  "  ride  in  any  conveyance  except  a  hearse 
without  first  informing  the  driver."  Another  reply  to 
the  same  question  laid  it  dowii  as  imperative  that  "  a 
person  dying  of  an  infectious  disease  must  give  notice 
to  the  local  authority  within  twenty-four  hours."  A 
candidate  who  evidently  thought  drastic  measures 
should  be  employed  in  cases  of  infectious  disease,  said 
that  "  members  of  a  family  where  small-pox  has  broken 
out  must  be  sent  to  a  hospital  and  well  boiled."  An- 
other mildly  remarked  that  "among  the  precautions 
against  small-pox  vaccination  might  be  looked  for." 
In  answer  to  some  physiological  questions,  one  exam- 
inee asserted  that  nitrogeneous  foods  built  up  the 
"  waist  "  of  the  body,  and  that  "  milk  is  the  best  food 
for  children  because  it  does  not  require  any  chewing." 
Another  candidate  gave  the  following  elaborate  and 
curious  reply  to  some  questions  with  regard  to  cloth- 
ing :  "  In  hot  countries  the  perspiration  which  is  in 
the  skin  is  evaporated  into  steam,  which  goes  up  to 
form  clouds,  and  comes  down  in  the  form  of  rain." 
Sometimes  the  answers  are  most  illogically  "  mixed," 
as  in  the  case  of  one  which  stated  "  that  it  would  be 
necessary  to  get  an  order  from  the  Sheriff  to  seize  and 
destroy  the  Medical  Officer  of  Health,"  and  in  another 
which  affirmed  that  "  many  articles  of  food  have  to  be 
adulterated  to  keep  them  pure." — Bristol  Medico-Chi- 
niri:;ical  Journal. 

The  Pathology  of  Thomapa's  Disease. —  It  is  barely 
twenty  years  since  there  wis  described  in  the  Arcliiv 
fur  Psychiatric  an  affection  characterized  by  singular 
muscular  phenomena  in  several  members  of  one  fam- 
ily. The  affection,  since  known  by  the  name  of  the 
physician  who  then  first  described  it,  has  been  studied 
by  many  observers,  among  whom  may  be  especially 
mentioned  Professor  Erb,  who  termed  the  condition 
"  myotonia  congenita."  The  main  features  of  the  af- 
fection, apart  from  its  hereditary  character,  consist  in 
an  increased  volume  of  muscular  masses,  suggestive  of 
a  kinship  to  pseudo  hypertrophic  paralysis,  accom- 
panied by  notable  impairment  of  i)ower,  and  the  as- 
sumption of  a  state  of  tonic  spasm  on  the  contraction 
of  tile  affected  muscles.  There  is,  furtiier,  an  in- 
creased excitability  to  faradism  and  galvanism,  with  a 
tendency  to  the  reaction  of  degeneration.  Moreover, 
I^rofessor  Krb  found  that  ensuing  on  the  "closure  con- 


traction "  of  galvanism  there  occurred  a  series  of  slow 
and  regular  undulatory  contractions,  which  gradually 
spread  from  the  negative  to  the  positive  pole,  a  phe- 
nomenon which  he  termed  the  "  myotonic  reaction." 
Hitherto  no  opportunity  has  occurred  for  full  observa- 
tion of  the  morbid  anatomy  of  Thomsen's  disease,  but 
a  paper  in  the  Reiue  de  MMecine  for  March  by  Dr. 
D^jerine  and  Dr.  Sottas  supplies  this  deficiency.  It  is 
founded  upon  the  case  of  a  man  who  first  came  under 
observation  at  the  age  of  thirty-two,  having  since  in- 
fancy suffered  from  this  affection.  It  was  character- 
ized in  him  by  marked  hypertrophy  of  the  muscles  of 
the  lower  limbs  and  trunk,  and  less  obvious  change  in 
those  of  the  upper  limbs.  All  the  muscles  of  the  body 
were  rigid  when  in  contraction,  and  were  but  slowly 
relaxed  ;  the  myotonic  reaction  was  present.  The  pa- 
tient succumbed  at  the  age  of  thirty-seven,  from  acute 
nephritis.  No  change  was  found  in  the  nervous  sys- 
tem, central  or  peripheral,  but  an  examination  of  the 
muscular  system,  specimens  being  taken  from  all  parts, 
afforded  an  insight  into  the  nature  and  progress  of  the 
lesions  therein.  These  lesions  consisted,  in  the  first 
place,  in  a  nuclear  overgrowth,  following  which  the 
muscular  substance  proper  apparently  becomes  swol- 
len, the  fibrillae  becoming  fused  together,  while  the 
transverse  striation  is  retained  or  is  even  more  pro- 
nounced than  normal.  Measurement  showed  a  notable 
increase  in  the  diameter  of  the  affected  fibres.  There 
is,  further,  a  like  increase  in  the  interfibrillar  proto- 
plasm, rendering  the  "  Cohnheim's  fields  "  more  dis- 
tinct. In  more  advanced  stages  the  muscular  sub- 
stance disintegrates,  and  vacuolar  spaces  are  formed  in 
and  between  the  fibres.  It  is  remarkable  that  the  con- 
nective tissue  does  not  undergo  any  hyperplasia,  nor  is 
there  any  excess  of  adipose  tissue  as  in  pseudo-hyper- 
trophic  paralysis.  It  may  be  remarked  that  the  changes 
described  in  this  paper  agree  in  the  main  with  those 
found  by  others  who  have  examined  fragments  of  the 
hypertrophied  muscles  excised  during  life  ;  but  th-e 
record  of  Dr.  Dejerine  and  Dr.  Sottas  is  far  more  com- 
plete, since  they  had  the  opportunity  of  tracing  the 
changes  from  early  to  advanced  stages.  It  is  pointed 
out  that  the  hypertrophy  commences  and  is  most 
marked  in  those  musoles  which  are  the  most  exercised, 
and  it  is  concluded  that  in  Thomsen's  disease- we  have 
to  do  with  a  "  hypertrophy  of  functional  origin."  The 
affection  thus  ranks  with  the  group  of  dystrophies  of 
the  muscular  system  known  as  primary  myopathies. — 
The  Lancet. 

Suicide  and  Crime  in  Russia. — Professor  Sikobski,  of 
the  University  of  Kief,  writing  upon  the  psychology  of 
the  Russian  people,  brings  forward  some  interesting 
statistics  concerning  the  fiequency  of  suicide  in  the 
different  nations  of  Europe.  {The  Lancet.)  Accord- 
ing to  these  figures,  the  death-rate  from  suicide  per 
million  living,  is  in  Saxony,  311  ;  in  France,  210  ;  in 
Prussia,  133  ;  in  Austria,  130  ;  in  Bavaria,  90  ;  in  Eng- 
land, 66  ;  while  in  Russia  it  is  as  low  as  30.  Further, 
it  is  found  that  during  the  last  thirty  years  the  suicide- 
rate  has  in  Russia  remained  stationary,  while  in  all 
other  European  countries  it  has  increased  by  thirty  or 
forty  per  cent.  The  exact  significance  of  figures  such 
as  these,  relating  to  so  complex  a  phenomenon  as  sui- 
cide, is  not  easily  brought  out.  Few,  however,  will  be 
disposed  to  question  the  assertion  that  much  of  the 
explanation  of  the  low  rate  in  Russia  is  to  be  found  in 
the  patience  and  long-suffering  of  the  Russian  peasant 
under  even  the  worst  misfortunes.  Among  other  char- 
acteristics. Professor  Sikobski  also  finds  a  certain  inde- 
cision of  character  which  fears  to  say  a  word  or  do  an 
action  which  shall  not  admit  of  retreat  or  withdrawal. 
Crime  is  comparatively  rare  in  Russia  :  thus,  the  num- 
ber of  jiersons  tried  for  murder  per  million  living  in  the 
year  1887,  was  in  Italy,  90  ;  in  Spain,  55  :  in  Austria, 
2i  ;  in  France,  15  ;  in  Russia,  10;  in  I'lermany,  9; 
and  in  England,  only  6. 


I 


Medical   Record 

A  Weekly  jfournal  of  Medicine  and  Surgery 


Vol.  48,  No.  16. 
Whole  No.  1302. 


New  York,  October  19,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


®rtgttial  Articles. 


THE  TREATMENT  OF  FEVERS  WITHOUT 
FOOD,  ANTIPYRETICS  OR  ALCOHOL  — 
WITH    RECORDS    OF    VARIOUS    CASES. 

By  a.   MONAE  lesser.  M.D., 


In  1886  I  began  to  treat  all  fevers,  medical  and  sur- 
gical, without  food,  antipyretics,  or  alcohol.  Instead 
I  used  large  quantities  of  water  and  a  few  simple  rem- 
edies which  I  shall  describe  in  detail  later  on.  Ab 
initio,  my  results  were  far  better  than  they  had  been 
when  I  still  adhered  to  the  older  and  yet  recognized 
plan  of  feeding  and  stimulation. 

There  is  scarcely  anything  new  in  my  method,  which, 
in  a  primitive  way,  was  practised  by  the  ancients.  Thus 
I  do  not  come  as  the  herald  of  an  entirely  new  and 
startling  discovery.  Researches  into  the  physiology 
and  pathology  of  the  subject  have  taught  me  that  in  all 
forms  of  fever,  medical  or  surgical,  the  exanthematous, 
typhoid,  or  the  traumato-septic  varieties,  we  invariably 
find  changes  in  the  gastro-intestinal  mucous  mem- 
branes. In  some  instances  these  changes  are  anatom- 
ical, while  in  the  acute  and  more  simple  varieties  they 
are  chemico-mechanical  in  character  ;  yet  in  both  the 
physiological  function  of  the  membranes  is  changed 
and  impaired. 

It  may  not  be  out  of  place  in  this  connection,  before 
touching  the  question  of  treatment,  to  refer  briefly  to 
the  observations  of  distinguished  physiologists  who 
have  enlightened  us  on  this  point.  Beginning  with  the 
saliva,  Uffelmann '  says  :  "  The  secretion  of  the  saliva 
becomes  diminished  by  fever,  and  in  high  temperature 
no  saliva  is  secreted  at  all.  In  the  lower  ranges  of 
temperature — he  evidently  refers  to  acute  conditions^ 
the  saliva — normally  alkaline — becomes  turbid,  thick, 
and  sour,  and  with  the  increase  of  the  fever  the  power 
of  the  saliva  to  convert  starch  into  diastase  is  materially 
diminished." 

Passing  over  the  function  of  the  muscular  action  of 
the  stomach  in  digestion,  Beaumont"  records,  as  the 
result  of  his  e.xperiments,  that  in  cases  of  fever  the 
gastric  juice  is  only  sparsely  secreted,  and  the  mucous 
membrane  is  soft  and  irritable. 

Hoppe-Seyler  '  e.xamined  the  gastric  juice  of  a  pa- 
tient with  typhoid  fever  and  found  no  free  hydrochlo- 
ric acid.  This  was  also  the  case  in  other  instances 
where  the  gastric  juice  was  taken  from  subjects  in 
whom  there  was  an  elevation  of  temperature.  He 
found  it  utterly  inadequate  to  carry  on  digestion  arti- 
ficially even  after  the  addition  of  hydrochloric  acid. 
The  same  author  expresses  the  opinion  that  under  these 
conditions  the  gastric  juice  has  a  tendency  to  become 
neutral  in  reaction,  and  stomach  digestion  can  no  longer 
go  on.  Instead,  we  get  lactic-  and  butyric-acid  fer- 
mentation and  the  formation  of  gases,  and  with  them  we 

'  Munk  and  Uffelmann  :  Die  Emahrung  des  gesunden  und  kranken 
Menschen.     Berlin,  1887. 

'  Beaumont,  Leipsic.  1834. 

'  Die  Verdauung  und  Resorption  der  Nahrstoffe,  p.  241.  Berlin, 
1S78. 


find  the  sarcinae  ventriculse  and  other  micro- organisms, 
first  observed  and  described  by  Goodsir  ^  and  Manas- 
sein,'^  who  also  proved  that  the  observations  of  Hoppe- 
Seyler  were  correct. 

Gluzinski,  of  Cracow,  records  that  he  found  neither 
hydrochloric  acid  nor  peptones  in  the  gastric  juice  dur- 
ing the  entire  stages  of  typhoid  fever. 

Explaining  the  cause  of  dyspepsia  in  fever,  Landois^ 
says  :  "  The  secretion  of  a  peptone  forming  fluid  is  ar- 
rested when  the  fever  begins  very  violently,  when  there 
is  great  weakness,  or  when  high  temperature  long  con- 
tinues." This  author  also  emphasizes  the  fact  that 
the  gastric  juice  is  diminished  in  all  cases  of  fever. 

It  is  well  kno.vn  that  in  acute  febrile  conditions,  not- 
withstanding that  the  bile  is  diminished  in  quantity,  it 
is  more  watery  and  poorer  in  specific  ingredients. 
That  similar  changes  occur  in  the  pancreatic  and  in- 
testinal juices  is  shown  by  Siolnikow,^  who  says  :  "In 
high  ranges  of  temperature  the  pancreatic  juice  is  di- 
minished. Examination  shows  fat  in  the  form  of 
drops  and  bundles  of  cr)stals  which  may  be  isolated 
from  the  stools."  He  also  found  that  fluids  are  quickly 
absorbed  in  persons  with  elevated  temperature,  whereas 
the  absorption  of  peptones  is  much  diminished.  This 
is  also  established  by  Beaumont  and  others. 

In  the  face  of  these  facts  it  became  a  question  to  me 
whether  it  was  justifiable  to  introduce  into  the  animal 
economy  food  that  cannot  be  disposed  of  and  utilized, 
and  that  can  at  best  only  act  as  a  foreign  body,  under- 
go putrefaction,  and  give  rise  to  ptomaines,  that  in 
themselves  must  tend  to  elevate  temperature. 

My  experiments  and  observations  at  the  bedside 
have  in  every  way  borne  out  my  reasoning.  At  the 
meeting  of  the  Academy  of  Medicine,  last  March,  in 
discussing  a  paper  on  the  treatment  of  typhoid  fever,^ 
I  said  :  "  I  have  in  times  gone  by  employed  the  milk 
diet  in  typhoid  fever.  One  patient  refused  it  and  I 
gave  her  only  water,  and  she  was  able  to  live  upon  it 
for  twenty-one  days. 

"  From  that  time  on  I  began  to  investigate  how  much 
or  how  little  food  my  typhoid-fever  cases  needed.  While 
I  do  not  yet  presume  to  generally  recommend  the 
method  so  new,  still  what  little  I  have  to  say  upon  the 
subject  of  allowing  typhoid-fever  patients  no  nourish- 
ment whatever,  save  water,  is  based  upon  my  results  in 
eight  cases,  all  of  which  made  a  good  recovery  without 
relapses,  and  in  which  from  five  to  fourteen  days  I  per- 
mitted the  patients  to  take  nothing  but  water  ad  libitum, 
only  administering  diluted  milk  at  the  expiration  of  that 
time,  or  rather  when  the  patient  expressed  a  desire  for 
some  nourishment.  In  these  cases  I  had  no  occasion 
to  use  alcohol  or  antipyretics,  although  the  range  of 
temperature  was  such  that  according  to  the  recognized 
methods  of  treating  typhoid  fever  I  would  have  been 
justified  in  administering  them.  I  have  since  adopted 
this  plan  in  all  fevers  in  which  the  temperature  is  over 
102°  F." 

My  method  of  procedure  is  as  follows :  First  of  all 
the  bowels  are  flushed  well  with  a  high  enema  of  luke- 
warm saline  water.  If  the  tongue  of  the  patient  is  pale, 
covered  with  a  white  or  grayish  coating,  I  prescribe 
two  hourly  doses  of  a  teaspoon!  ul  of  a  solution  of  sodium 

'  Biological  Memoir.     Edinburgh.  l£68. 

'  .Archiv  fur  path.  Anat..  Band  55,  1872. 

'  Physiologic  des  Menschen,  p.  351.     Leipsic,  1885. 

*  Pfliiger  :  Archiv  d.  Physiologic. 

'■'  Medic.\l  Record,  May  26,  1894,  p.  671, 


542 


MEDICAL    RECORD. 


[October  19,  1895 


sulphite,  4.00  to  60.00  of  water  while,  if  the  tongue  has 
a  red  base,  clean,  or  is  covered  with  a  dark  brown  or 
grayish  coating,  I  administer  dil.  muriatic  acid  i.oo  to 
100.00  water  in  the  same  doses  at  the  same  intervals. 

Should  the  stomach  be  in  a  highly  irritable  condition, 
nothing  has  given  me  greater  satisfaction  than  a  two- 
hourly  teaspoonful  dose  of  a  mixture  of  carbolic  acid, 
1.00  suspended  in  a  solution  made  of  30.00  of  mucilage 
to  125.00  of  peppermint-water.  If  the  disease  be  a 
painful  one  or  involve  serous  membranes,  doses  of  0.6 
sodium  salicylate  in  100.00  of  water  are  repeated  every 
two  hours  until  all  pain  has  subsided  :  I  have  found 
this  remedy  to  be  most  serviceable  and  far  preferable 
to  the  opiates. 

There  are  occasions  in  which  the  stomach  may  be 
found  to  contain  a  large  quantity  of  food.  In  such 
instances  I  freely  lavage,  or  if  the  case  is  suitable,  be- 
gin with  an  emetic  before  administering  any  otherdrug. 
I  have  seen  cases  watched  by  careful  nurses  where  large 
quantities  of  undigested  milk  coagula  were  returned  in 
the  lavage.  I  recall  a  case  in  which  washing  revealed 
an  unusually  large  quantity  of  milk  coagula  taken  nine- 
teen hours  before,  and  another  which  returned  a  partly 
putrified  oyster  which  the  patient  had  swallowed  whole 
tvventy-three  hours  previous. 

It  is  from  experiences  like  these  that  I  have  made  it 
an  absolute  rule  to  empty  the  stomach  in  cases  where  I 
suspect  the  presence  of  food.  The  results  which  have 
followed  this  apparently  heroic  commencement  of 
treatment  were  such  that  I  did  not  find  it  necessary  to 
continue  medication  in  large  doses  for  any  length  of 
time.  The  pulse  improves  and  very  soon  the  patient 
begins  to  be  more  comfortable,  the  headache,  malaise, 
and  other  annoying  symptoms  gradually  diminishing  in 
severity. 

Be  it  understood,  however,  that  I  do  not  claim  to 
lessen  the  duration  of  any  disease  of  certain  course. 

I  also  have  the  patient  sponged  frequently  with  water 
three  degrees  lower  than  the  prevailing  temperature. 
If  this  be  above  104°  F.,  under  no  circumstances  do  I 
permit  any  nourishment  to  be  taken.  However,  when 
the  pyrexia  is  lower  than  this,  and  the  patient  craves  for 
something,  I  give  clear  broths,  containing,  as  I  believe, 
the  salts  of  the  meat  only  ;  rice  and  barley-water  with 
a  pinch  of  salt,  but  never  do  I  attempt  to  induce  the 
patient  to  partake  of  food.  Simultaneous  with  the 
lowe/ing  of  the  temperature  I  have  observed  that  the 
patients  become  desirous  for  nourishment,  while  on 
the  other  hand  their  aversion  to  it  increases  as  the  tem- 
perature rises. 

I  now  continue  with  whatever  medication  is  indi- 
cated. I  have  altogether  discarded  the  internal  ad- 
ministration of  antipyretics,  as  I  think  they  diminish 
the  tone  of  the  heart,  thereby  deluding  us  into  the  be- 
lief that  our  patient  has  improved  simply  because  the 
temperature  is  so  many  degrees  lower,  when  in  reality 
his  vital  powers  are  much  weakened  and  he  has  less 
resistance  to  combat  his  disease.  This  fact  Cantani  ' 
has  so  beautifully  made  clear  to  us.  The  bacillus  also 
can  thrive  and  propagate  much  better  in  lower  than  in 
higher  temperature. 

As  to  medication,  I  emjjloy  aconite  in  0.6  to  250.00 
of  water,  of  which  I  give  teaspoonful  doses  every  hour, 
not  to  diminish  the  temperature  or  lessen  the  frequency 
of  the  pulse,  for  aconite  in  these  doses,  in  my  ojjinion, 
acts  as  a  heart  tonic,  in  that  it  relieves  the  pressure 
upon  the  capillaries  and  so  equalizes  the  circulation. 

I  administer  aconite  at  the  onset  of  the  disease 
if  the  pulse  is  frequent  and  weak,  the  extremities  cold, 
while  1  prefer  veratrum  viride  in  the  same  doses  and 
same  intervals  as  the  aconite,  when  the  pulse  is  rapid 
and  full. 

It  is  astonishing  to  sec  how  rapidly  the  small  doses  of 
these  two  drugs  act.  I  have  not  yet  had  occasion  to 
have  recourse  to  alcohol  in  any  of  my  cases.     If  heart 

'Transactions  of  tlie  Iiiiernational  Medical  Congress,  Berlin,  1890 
vol.  I.  »  I       »  1 


tonics  are  needed,  I  rely  upon  caffein,  providing  the 
heart-sounds  are  weak,  and  upon  nitro-glycerin  when 
its  beats  are  rapid  or  intermittent. 

The  dose  of  caffein  I  employ  repeated  as  required 
is  0.15,  and  of  nitro-glycerin  0.0003  every  three,  four, 
or  five  hours,  as  the  case  may  require.  Strychnine 
in  0.0005  doses  I  give  in  addition  to  either  of  these 
drugs,  principally  when  I  use  nitroglycerin,  always, 
however,  giving  these  drugs  uncombined,  and  most 
frequently  hypodermatically. 

In  all  these  cases  water  with  a  trace  of  sodium 
chloride,  not  sufficient  to  affect  its  taste,  is  given  ad 
libitum.  The  quantity  taken  in  twelve  hours  varies 
from  1,000.00  to  1,300.00.  It  is  remarkable  to  obser\-e 
how  readily  it  is  retained  by  the  most  sensitive  stomach, 
provided  that  the  organ  is  free  from  other  food.  It  is 
readily  absorbed,  restoring  to  the  blood  the  fluids  which 
the  intense  febrile  condition  robs  from  it,  and  thereby 
keeping  the  cells  in  the  different  tissues  in  a  mild  but 
constant  state  of  activity  ;  it  increases  the  action  of 
the  liver  as  also  the  action  of  the  kidneys,  lessening 
their  work  by  secreting  bile  and  urine  of  lower  specific 
gravity,  and  holding  the  specific  elements  in  higher  so- 
lution. 

Of  its  effect  on  the  intestinal  tract  it  may  be  said 
that  the  juices,  although  changed  in  character,  become 
less  irritating  in  their  local  action,  when  thus  highly 
diluted,  and  excessive  diarrhoea  therefore  does  not  be- 
come a  complication  of  the  disease — on  the  contrarj',  I 
have  found  it  has  a  tendency  to  enhance  easy  stools 
from  the  very  beginning. 

Thus,  in  every  instance  I  flush  the  bowels  daily,  and 
have  often  observed  that  its  returns  contained  quanti- 
ties of  undigested  matter,  including  coagulated  milk, 
encased  in  intestinal  secretions,  even  eighteen  days  after 
the  patient  had  partaken  of  any  food. 

This  method  of  treatment  has  given  me  abundant 
proof  of  its  efficacy,  and  it  is  reasonable  to  assume  that 
when  nothing  offensive  is  carried  through  the  digestive 
tract,  nothing  deleterious  can  be  carried  into  the  blood 
and  nothing  additional  brought  into  the  system  to  sup- 
port the  micro-organism  of  the  disease  ;  while  at  the 
same  time  a  constant  washing  of  every  portion  of  the 
less  affected  parts  of  the  body  is  continually  going  on, 
until  the  hungry  state  of  the  tissues  requires  nourish- 
ment, as  is  evidenced  by  the  patient's  demand  for 
food. 

That  this  will  ease  and  lessen  the  danger  of  febrile 
disease  more  than  the  feeding  or  stuffing  methods,  I 
beg  to  illustrate  in  a  case  of  croup,  treated  in  February 
of  last  year,  and  which  was  seen  in  daily  consultation 
by  Dr.  b'Dwyer. 

When  first  I  suggested  the  advisability  of  administer- 
ing no  food,  save  water,  Dr.  O'Dwyer  dissented,  and 
for  two  days  we  gave  milk  at  regular  intervals.  We  ob- 
served that  within  half  an  hour  after  the  administration 
of  the  milk,  the  patient  was  seized  with  paroxysms  that 
were  associated  with  a  rise  of  temperature  and  general 
indisposition.  After  forty-eight  hours  of  this  state  of 
affairs,  Dr.  O'Dwyer  agreed  to  continue  the  treatment 
without  nourishment,  on  water  alone.  We  pursued  this 
course  for  three  days,  during  which  time  the  tempera- 
ture gradually  drojiiied,  and  the  paroxysms  became  less 
frequent  and  the  jxitient's  general  condition  materially 
improved,  until  at  the  end  of  the  third  day  the  temper- 
ature had  fallen  to  100°  F.,  and  the  favorable  out- 
come of  the  case  was  assured.  We  then  resorted  to 
mild  feeding  with  well-diluted  milk,  and  in  one  week 
our  case  was  fully  recovered  without  any  sequela;. 
The  usual  remedies,  including  fumigation,  were  used, 
but  intubation  was  not  resorted  to. 

Knowing,  as  we  do,  that  it  requires  a  certain  time 
to  digest  milk,  even  with  normal  secretions,  and 
considering,  as  IJcnichard  '  has  shown,  that  milk  in- 
creases the  tem])erature  when  administered  in  any  feb- 
rile  state,   and   especially  in   view   of   the    fact   that 

Auto-intoxication  in  Dise.isc,  p.  217.     PliilaJelphia,  1894. 


October   xg,  1895] 


MEDICAL   RECORD. 


54; 


peptones  cannot  be  absorbed  under  such  conditions, 
does  it  not  speak  loudly  against  the  giving  of  nourish- 
ment as  is  so  frequently  practised,  with  digestive  secre- 
tions abnormal,  deficient,  or  altogether  absent  ? 

I  have  observed  that,  contrary  to  what  we  might  ex- 
pect, patients  kept  on  water  alone  lose  less  weight  than 
those  fed  upon  a  mild  and  easily  digested  diet,  which 
leads  me  to  believe  that  water  maintains  the  patient's 
vitality  better  than  food — that  is  a  food  in  the  truest 
sense  of  the  term. 

It  is  almost  obvious  that  where  the  intestinal  glands 
are  affected,  and  the  stomach  secretions  changed  on 
account  of  an  elevated  temperature,  and  with  blood 
containing  excrementitious  matter,  we  cannot  hope  for 
the  utilization  of  anything  that  has  been  taken  in  for 
absorption. 


Since  first  I  made  known  my  views  upon  this  manner 
of  treating  fevers,  I  find  that  others  have  also  made 
clinical  observations  in  line  with  mine.  Among  the 
papers  recently  published,  that  will  repay  perusal,  are 
those  of  Dr.  Licorish,'  Dr.  Page  of  Boston,'  and  Dr. 
A.  P.  Henry.= 

In  the  appended  reports  of  the  several  cases,  I  have 
detailed  the  record  and  progress  of  their  issue  as  far  as 
it  concerns  us  most. 

I  trust  that  the  method  of  treating  fevers  as  I  have 
described  it  above  from  careful  notes  from  my  case- 
book, will  prove  worthy  of  further  investigation,  and  I 
hope  my  colleagues,  especially  those  who  are  fortunate 
enough  to  possess  hospital  facilities,  will  give  it  honest 
consideration,  and  report  their  results  at  an  early  day. 

72  East  Sixtv-first  Street. 


Report  of  Cases. 


Rud.  H 5 jrs. 

John  F 17  mos 

ElUB 6^Ts. 

Anton  M 4yrs. 

OlgaA ijmoi, 

Freda  L lo  mos. 

Carrie  G ziyrs. 

Anna  W isyrs. 

Mrs.  S 28  yrs. 

Vic.  F 12  yrs. 

Mrs.  J 28  yrs. 

Mrs.  W.J... .  23  yrs. 

Bertlia  R ig  yrs. 

Mrs.  B 29  yrs. 

Mrs.  H 24  yrs. 

Mrs.  M 34  yrs. 

Henry  G 17  yrs. 


Diagnosis. 


I        Range  and  Duration  ( 

Elevated  Temperature.* — 

no  food  except  water  giv 


.\cute lobar  pneumonia. 
.\cute  lobar  pneumonia . 
Scarlatina  and  diphtheri 


Entero-colitis 

Entero-colitis 

Typhoid Extremely  neurasthenic. 

Typhoid Uncomplicated,   but 

pyrexia  

Typhoid Treated  at  Red  Cross  Hospital. 

Typhoid Seen  with  Dr.  G.  Stcger 

Puerperal  fever Curettage  first  day 

Erysipelas  of  vagina  and  vulva, 

with  croupous  exudation  . . .      Seen      by     Dr.    T.     Gaitlard 

Thomas 

Appendicitis Seen  with  Dr.  McNicoll;  op- 
erated ninth  day 

Peritonitis,   metritis,  and  pyo-  ' 

salpinx  '  Hysterectomy  on  sixth  day .... 

Abscess  of  ovary,  with  circum- 

scriiied  peritonitis Seen  with  Dr.  McXicoU 

Double   pyosaipin-x    and    peri- 

typhlitic  abscess .Seen  with  Dr.  A.  Zeh 

Erysipelas — nose,    throat,   and 

face  Seen  by  Dr.  .A.  Jacob:  and  with 

Dr.  Steger 


The  lower  temperature  and  pulse  i 


"     to  104.5"—  5  days 
°     to  105°    —  5  days 
*     to  105"    —  9  days 

120  to 
14010 

;- 

5  days 
7  days 
IS  days 

Recovery. 
Reco\erj-. 
Recovery;  no   albu- 

mtn  ;  ariic.  rheum- 

a  t  is  m,    lasting  5 

days. 
Reco\ery,  with  acute 

arthritis,  lasting    2 

weeks. 
Recovery. 
Recovery. 
Recovery. 

.6°  to  103.8"-  3  days 
°     10103.5°—  7  days 
.6"  to  104"    — 13  days 

17410 

2OOt0 

14410 

I  So 
130 

21  diys 

7  days 
11  days 
5  weeks 

"     to  107"    —  8  days 

102  to 

96 

27  days 

Reco\er>'  ;      no    re- 
lapse. 
Recoven>\ 
Recovery. 
Recovery. 

"      to  106"    — 21  days 
°      lo  105.8°- 18  days 
n  jump  to  105.4—4  days 

IJOIO 

16410 

160  to 

S5 
■96 

28  days 
26  days 
21  days 

°     to  105.4°—  2  days 

00 

12  weeks 

Recovery. 

°     to  103°    —  4  days 

So 

16  days 

Recovery. 

°     to  105°    —  7  days 

1  120  to 

80 

21  days 

Recovery. 

°     to  104°    — 12  days 

180  to 

90 

5  weeks 

Recovery. 

stantly  103"— 16  days 

12410 

84 

8  weeks 

Recovery  with  albu- 
min, lasting  5  days. 

'     to  105.4°- lodays 

100  to 

76 

2, days 

Recovery ;      no    se- 

quelse. 

food  had  been  withheld 

I  few  days. 

THE  CAUSES  AND  PREVENTION  OF  PUER- 
PERAL SEPSIS  (FEVER).  1 

By  WM.  E.  ground,  M.D., 


After  so  many  centuries  of  vain  speculation  regard- 
ing this  dread  disease,  which  surrounded  childbearing 
with  such  gloom  and  apprehension,  truth  and  science 
are  at  last  prevailing.  Volumes  have  been  written 
about  the  nature  of  puerperal  fever.  All  sorts  of  causes 
have  been  adduced  to  explain  the  protean  manifesta- 
tions of  the  morbid  conditions.  A  few  great  minds 
have  occasionally  grasped  in  the  direction  of  the  true 
etiological  factors.  Even  Hippocrates  and  Galen  re- 
ferred to  the  fact  that  erysipelas  will  affect  the  womb 
of  the  parturient  woman,  and  cause  a  fatal  inflamma- 
tion ;  but  as  often  ignorance  and  superstition  ignore 
and  cry  down  these  great  truths.  Man  has  ever  sought 
the  source  of  disease  in  mysterious  and  remote  causes, 
and  has  ascribed  them  to  the  decree  of  a  blind  fatality, 
or  to  the  caprices  of  whimsical  and  fantastic  beings. 
When  man  comprehends  the  nature  of  the  elements 
which  surround  him,  and  also  his  own  nature,  he  will 
then  know  the  true  causes  of  his  evils,  and  the  remedies 
he  should  apply. 

The  true  infectious  nature  of  puerperal  fever,  so- 
called,  has  within  the  last  century  so  gradually  dawned 
upon  the  minds  of  physicians,  that  instead  of  being  con- 

'  Read  before  the  Wisconsin  State  Medical  Society  at  the  forty-ninth 
annual  meeting,  held  in  Superior,  June  19  to  21,  1895. 


sidered  next  to  suicidal  for  a  woman  to  enter  a  mater- 
nity for  confinement,  a  well-regulated  maternity  hos- 
pital is  now  considered  one  of  the  safest  places  in  which 
a  woman  can  be  confined.  At  the  Preston  Retreat,  in 
Philadelphia,  there  were  more  than  twelve  hundred  de- 
liveries without  a  death. 

In  1843  Oliver  Wendell  Holmes  said  :  Puerperal  fever 
is  so  far  contagious  as  to  be  frequently  carried  from 
patient  to  patient  by  physicians  and  nurses.  Two  or 
three  years  later,  Semmelweiss  attributed  childbed 
fever  to  decomposing  animal  matter  conveyed  to  the 
mother  from  without.  Pasteur,  in  18S0,  was  the  first  to 
cultivate  the  streptococcus  from  the  organs  of  women 
dead  of  puerperal  fever.  Similar  observations  were  sub- 
sequently made  by  Frankel,  Winkle,  Doderlein,  Winter, 
Widal,  and  others,  so  that  now  there  can  be  no  doubt 
that  the  streptococcus  pyogenes  stands  in  a  direct  cau- 
sal relation  to  most  of  the  severe  and  fatal  cases  of 
puerperal  sepsis.  Widal  found  the  streptococcus  in  a 
great  variety  of  puerperal  affections,  including  puer- 
peral ulcers,  endometritis,  parametritis,  peritonitis,  sep- 
ticaemia, pyemia,  and  phlegmasia  alba  dolens.  Many 
other  germs  bear  an  important  etiological  relation  to 
puerperal  affections.  Briger,  and  later  Fehling,  Doder- 
lein, and  others,  pointed  out  the  fact  that  a  fatal  puer- 
peral fever  might  be  caused  by  the  staphylococcus, 
but,  as  a  rule,  this  germ  does  not  produce  the  severer 
forms  of  puerperal  sepsis. 

'  Medical  Record,  June  2,  1894,  p.  706. 
-  Ibid.,  February  24,  1894,  p.  230. 
=  Ibid.,  May  25,  1895,  p.  646. 


544 


MEDICAL    RECORD. 


[October  19,   1895 


However,  streptococci  and  staphylococci  are  fre- 
quently found  existing  together  in  these  affections. 
Kronig,  who  is  Doderlein's  assistant  at  Leipsic,  has  ob- 
tained a  pure  culture  of  the  gonococcus  from  the  inte- 
rior of  the  uterus  in  nine  cases  in  which  there  was  a 
slight  febrile  disturbance  after  labor.  None  of  the 
cases  were  serious.  Energetic  research  during  the  last 
few  years  has  demonstrated  that  the  diplococcus  pneu- 
moniae, the  bacterium  coli  communis,  the  micrococcus 
tetragonus,  and  the  bacillus  pyogenes  fetidus,  possess 
pyogenic  powers. 

Puerperal  sepsis  (or  surgical  sepsis  occurring  in  the 
parturient  woman)  is  an  infectious  disease  due  to  germ 
inoculation  of  the  wounds  resulting  from  the  separation 
of  the  decidua  and  the  placenta,  and  from  the  passage 
of  the  child  through  the  genital  canal,  in  the  act  of 
parturition. 

The  next  point  to  consider,  then,  is  what  affords 
these  germs  an  opportunity  to  inoculate  the  bruised 
and  abraded  parturient  canal  ?  This  brings  us  to  one 
of  the  most  important  phases  of  our  discussion  ;  viz., 
do  micro-organisms  exist  normally  in  the  uterus  and 
vagina  of  pregnant  women,  or  are  they  placed  there  by 
outside  influences  ?  Without  referring  to  earlier  inves- 
tigators, I  will  proceed  at  once  to  the  consideration  of 
the  work  of  Doderlein.  He  examined  the  vaginal  se- 
cretions of  one  hundred  and  ninety-five  pregnant 
women,  and  distinguished  two  sorts  of  secretions,  one 
normal  and  another  pathological.  The  normal  secre- 
tion was  found  in  55.5  per  cent,  of  all  cases.  It  is  a 
whitish,  friable  substance  of  the  consistence  of  coagu- 
lated milk.  The  author  thinks  it  is  derived  from  the 
superficial  layers  of  vaginal  mucous  membrane,  the 
cells  of  which,  when  cast  off  and  mixed  with  lymphatic 
fluid,  form  a  white  mass.  The  reaction  of  the  normal 
vaginal  secretion  is  intensely  acid.  The  acid  is  lactic 
acid,  and  is  derived  from  the  tissue  changes  produced 
by  a  definite  species  of  bacillus  which  is  always  present 
in  normal  secretions,  and  is  called  by  him  "  vaginal 
bacillus."  Besides  this  species  of  bacillus,  Doderlein 
found  in  the  normal  secretion,  in  a  large  number  of 
cases,  a  scizomycete  or  yeast  germ,  which  he  recognized 
as  the  germ  of  thrush,  and  which,  as  is  known,  grows  in 
acid  media.  He  found  other  micro-organisms,  both 
saprophytic  and  pathogenic,  in  normal  secretions,  but 
only  quite  rarely,  and  he  is  of  the  opinion  that  the  vag- 
inal bacilli,  inasmuch  as  they  produce  acid,  render  the 
vagina  unfitted  for  the  growth  of  other  germs,  and 
thereby  protect  it  from  infection.  The  author  was  able 
to  support  it  by  experiment.  He  introduced  the  staphy- 
lococcus pyogenes  aureus  into  the  vagina  of  a  virgin 
in  which  tlie  vaginal  bacilli  were  present,  and  as  early 
as  the  fourth  day  they  had  jierished.  The  pathological 
secretion  differs  from  the  normal  by  being  very  fluid 
and  yellowish-white,  and  containing  pus  corpuscles. 
Its  reaction  is  only  faintly  acid,  or  neutral,  or  it  may 
even  be  alkaline.  In  the  jjalhological  secretion  the 
vaginal  bacilli  are  supplanted  by  various  other  sapro 
phytic  and  pyogenic  micro- organisms.  The  author  as 
sumes  that  the  pathological  secretion  is  caused  by  an 
increa.sed  influx  of  alkaline  tissue  fluids,  such  as  is  oc- 
casioned by  excess  in  venere,  by  pessaries,  by  frequent 
digital  examinations,  and  by  gonorrhoeal  cervical  catarrh. 
Williams,  of  Johns  Hopkins  University,  has  practically 
substantiated  the  results  of  Doderlein.  Kronig  exam- 
ined the  vaginal  secretion  of  about  five  hundred  preg- 
nant women,  and  found  them  to  possess  reactions  of 
varying  degrees  of  acidity.  He  found  the  bacterial 
flora  usually  found  in  the  healtliy  vagina.  In  no  case 
did  he  find  jiathogenic  cocci.  Kronig  and  Menge  in- 
troduced streptococcus  pyogenes  and  pyogenic  staphy- 
lococci in  large  numbers  into  the  vagina  of  pregnant  and 
non-pregnant  women,  and  found  tliey  disappeared  in  a 
short  time.  Their  observations  differ  from  those  of 
Doderlein  only  in  respect  to  the  rapidity  with  which 
foreign  organisms  disappeared  in  the  normal  and  path- 
ological secretions.    Irrigation  of  the  vagina  with  water 


or  with  antiseptic  solution  diminished  the  rapidity 
with  which  bacteria  in  the  vagina  disappeared.  Bac- 
teria introduced  into  the  cervix  uteri  likewise  disap- 
peared in  a  very  short  time. 

Recently  Walthard  made  some  observations  regard- 
ing the  presence  or  absence  of  pathogenic  micro-organ- 
isms in  the  genital  canal  of  pregnant  women,  in  the 
Obstetric  Clinic  of  Bern.  He  found  the  secretions 
from  the  cervical  canal  to  be  directly  antagonistic  to 
the  growth  of  germs,  and  that  the  vaginal  secretions 
possessed  antiseptic  properties.  The  author  regarded 
the  cervical  canal  as  the  border-line  between  those  por- 
tions of  the  genital  tract  that  contain  bacteria  and  those 
that  contain  none.  An  examination  of  the  mucus 
found  in  the  vagina  occasionally  revealed  the  presence 
of  streptococci,  with,  however,  a  much  less  degree  of 
virulence  than  the  same  germs  possessed  when  derived 
from  tissues  in  phlegmonous  inflammation,  or  from  the 
lochia  in  puerperal  septicaemia.  The  virulence  of  strep- 
tococci found  in  the  vagina  is  the  same  as  that  of  the 
same  germs  found  upon  healthy  mucous  membrane  in 
other  portions  of  the  body.  They  are,  in  fact,  not  viru- 
lent, but  are  saprophytic  germs  upon  healthy  tissue. 
They  can,  however,  take  upon  themselves  a  malignant 
character  when  the  resistance  of  the  tissue  is  dimin- 
ished, and  become  the  infective  germs  of  puerperal  sep- 
sis. In  addition  to  vaginal  streptococci,  the  staphy- 
lococci, gonococci,  and  the  bacterium  coli  commune, 
produce  puerperal  sepsis.  The  bacterium  coli  com- 
mune is  occasionally  found  in  the  amniotic  fluid. 
The  presence  of  these  germs  may  turn  the  lochial  dis- 
charge brownish  and  offensive,  but  this  condition  of 
the  discharge  does  not  necessarily  point  to  sepsis. 
Highly  virulent  streptococci  and  staphylococci  may  be 
present  on  the  exposed  parts  of  the  healthy  body  with- 
out doing  harm,  owing  to  the  defences  which  have  been 
set  up  against  their  invasion,  and  to  the  local  and  gen- 
eral resistance  offered  to  their  growth.  These  barriers 
may,  however,  be  overthrown,  and  under  these  circum- 
stances pathogenic  bacteria,  originally  present  on  ex- 
posed surfaces  of  the  body,  may  cause  various  local  and 
general  diseases.  These  are  the  conditions  to  which 
the  absurd  and  meaningless  term  auto-infection  is  some- 
times applied.  The  term  auto-infection  has  no  place 
in  a  scientific  discussion. 

Summing  up  the  results  of  the  investigations  of  num- 
erous and  reliable  observers,  we  may  justly  conclude 
that  the  normal  vagina  does  not  often  contain  path- 
ogenic bacteria.  With  the  exception  of  the  gonococ- 
cus, such  bacteria  do  not  long  survive  the  vaginal 
secretions.  The  practical  deductions  are  that  vaginal 
injections  before  labor  are  not  only  not  necessary,  but 
may  actually  favor  septic  infection  in  cases  where  anti- 
septic precautions  are  not  carried  out  strictly.  In  rare 
cases  with  aggravate  pathological  secretions  it  may  be 
necessary  to  flush  the  vagina  with  hot  sterilized  water 
daily  before  confinement. 

In  view  of  this  there  can  be  no  disputing  the  fact 
that  septic  infection  in  the  puerperal  state  occurs  almost 
always  from  an  imperfect  aseptic  technique  on  the  part 
of  the  accoucheur  or  his  assistants  in  the  preparation 
of  themselves  or  the  patient  for  the  lying-in  ordeal. 
The  term  auto-infection  is,  strictly  speaking,  not  a  fact, 
and  the  condition,  therefore,  a  myth.  The  occurrence 
of  puerperal  sepsis  is //////(//(Ji/V  evidence  that  patho- 
genic germs  ha\  e  at  some  time  gained  admission  to  the 
maternal  parts  from  without.  That  they  are  always 
placed  there  by  the  surgeon  or  his  assistants  is  not  an 
established  fact.  Prioleau  '  insists  that  there  are  cer- 
tainly inevitable  forms  of  puerperal  infection  which 
defy  rigorous  antisepsis  during  labor  and  the  puerpe- 
rium.  Infection  is  observed  when  ilie  labor  occurs  in 
an  infected  or  mephiiic  environment,  when  labor  coin- 
cides with  the  development  of  an  infectious  disease,  cir 
when  the  patient  has  old  lesions  in  or  near  the  genital 

'  .^rch.  de  Toeol.  et  de  Gynec,  )anu.iry,  iS.»(. 


October  19,   1895] 


MEDICAL   RECORD. 


545 


tract.  The  mechanism  of  this  kind  of  infection  is  ex- 
plained. Air  charged  with  noxious  principles  enters 
the  genital  tract.  The  infected  blood  of  the  patient 
may  bring  germs  to  the  placental  wound  in  the  uterus. 
Phagocytosis  is  weak  when  the  blood  is  already  infected, 
hence  the  germs  develop  rapidly  in  the  wound.  The 
primary  infection  is  thus  stimulated  :  an  old  genital  le- 
sion, abscess,  etc.,  may  be  awakened,  or  an  old  wound 
or  lesion  outside  the  vulva  may  set  up  infection  in  the 
uterine  wound,  just  as  a  blood  lesion  does  when  preex- 
isting.  Dumont  describes  a  type  of  puerperal  infection 
from  intestinal  origin.  The  cause  is  alteration  of  the 
intestinal  mucous  membrane  from  pressure  of  the  gravid 
uterus,  and  accumulation  of  faeces  causing  stasis  and  in- 
filtration of  the  intestinal  walls.  The  alteration  con- 
sists in  desquamation  of  intestinal  mucous  membrane, 
thereby  favoring  the  advent  of  germs  by  removing 
nature's  barrier.  This  alteration  permits  the  bacillus 
coli  communis  to  pass  through  the  walls  into  the  peri- 
toneal cavity.  The  colon  bacillus  is  a  constant  inhabi- 
tant of  the  intestinal  canal,  but  where  intestinal  leiions 
exist  they  frequently  invade  the  internal  organs,  caus- 
ing all  degrees  of  septic  conditions. 

Puerperal  sepsis  contains  the  same  germs  that  any 
other  septicaemia  contains;  the  same  micro-organisms 
which  cause  suppuration  elsewhere.  Surgeons  formerly 
regarded  a  febrile  reaction  as  a  necessary  accompani- 
ment of  the  normal  processes  of  repair  after  all  surgical 
procedures  ;  now  they  usually  regard  it  as  an  avoidable 
blunder.  Still  we  do  have  a  post- operative  aseptic  fever, 
that  occurs  independent  of  pathogenic  germs.  This 
fever  is  characterized  by  the  absence  of  inflammatory 
symptoms  and  with  little  constitutional  disturbances. 
In  a  large  wound  healing  by  first  intention,  we  find  not 
only  extravasated  blood  and  exuded  serum,  but  minute 
fragments  of  tissue  which  have  been  separated  from  the 
surface  of  the  wound  during  the  operation,  and  are  sub- 
sequently disintegrated  and  absorbed.  These  materials 
when  absorbed  exert  a  pyrogenic  action  upon  the  sys- 
tem. The  exact  nature  of  this  pyrogenous  substance 
is  not  clearly  known,  but  the  results  of  experiments  seem 
to  prove  its  existence  in  the  fibrin  generators  and  fibrin- 
ferment  of  the  blood.  At  any  rate  their  close  relation- 
ship to  living  substances  renders  them  but  slightly  in- 
jurious, and  they  produce  in  consequence  only  a  mild 
type  of  fever. 

The  most  common  seat  of  infection  is  probably  in  the 
uterus  itself.  The  sinuses  at  the  placental  site  are  oc- 
cupied by  large  clots,  which  readily  become  infected, 
and  from  this  location  the  putrefactive  and  sejjtic 
elements  are  readily  absorbed,  owing  to  the  highly 
active  lymphatic  circulation.  The  lacerated  vessels  of 
the  cervical  canal  are  also  plugged  with  similar  though 
smaller  clots.  The  cervical  absorbents  are  not  so  highly 
developed,  hence  septic  absorption  cannot  be  so  active 
at  this  point  as  at  the  fundus  uteri.  The  comparatively 
lessened  lymphatic  circulation  of  the  vulva  and  vagina 
render  erosions  and  contusions  of  these  parts  less  likely 
to  communicate  infecting  material  to  the  general  circu- 
lation. 

The  character  and  gravity  of  a  septic  infection  will 
depend,  not  only  upon  the  nature  and  virulence  of  the 
infecting  germ,  but  too  upon  local  predisposing  causes 
and  constitutional  conditions  which  diminish  the  resist- 
ing power  of  the  tissues,  such  as  nephritis,  valvular 
heart  disease  without  compensation,  syphilis,  diabetes, 
intercurrent  infections,  and  anxmia. 

Briefly,  we  distinguish  three  principal  types  of  infec- 
tion :  First,  putrid  intoxication  or  poisoning  by  to.Kines 
secreted  by  germs  growing  upon  putrefactive  foci,  be- 
fore these  germs  have  themselves  found  their  way  into 
the  blood.  The  process  is  due  to  the  putrefaction  of 
retained  clots  or  placental  or  decidual  fragments  in  the 
uterus.  The  poison  may  gain  admission  to  the  general 
circulation  through  the  uterine  sinuses  or  the  denuded 
placental  site,  or  through  abrasions  in  the  vaginal  mu- 
cous membrane.     This  condition  is  the  so-called  sapre- 


mia  of  most  authors,  and  is  intended  to  be  limited  to 
the  products  of  saprophytic  germs,  but  I  do  not  think 
we  are  justified  in  ex(  hiding  the  chemical  products  of 
pathogenic  germs.  The  symptoms  depend  entirely 
upon  the  dose  of  the  poison.  The  onset  of  the  fever  is 
generally  within  twenty-four  hours.  The  preliminary 
chill  is  usually  wanting,  but  there  is  a  rapid  rise  of  tem- 
perature to  101°  or  103°  F.  The  prompt  removal  of  the 
putrefying  material  from  the  uterus  is  soon  followed  by 
a  rapid  fall  of  temperature,  and  a  disappearance  of  all 
alarming  symptoms.  Sapremia  follows  most  frequently 
manual  expression  of  the  placenta,  prolonged  and  for- 
ceps deliveries,  version,  and  extraction. 

The  second  type  of  infection  is  bacterial  invasion 
and  ptomaine  poisoning.  The  form  of  bacteria  is  not 
always  the  same,  and  any  of  the  pyogenic  germs  may 
produce  septicaemia.  The  most  fatal  type  is  that  caused 
by  the  streptococcus.  The  next  in  order  of  virulence 
are  the  bacterium  coli  commune,  the  staphylococci,  and 
the  gonococci.  These  germs  invade  the  uterine  sinuses 
and  the  lymphatics  surrounding  them,  and  from  here 
they  penetrate  the  uterine  parenchyma,  to  the  larger 
lymphatics  underlying  the  peritoneal  covering  of  the 
uterus.  The  endometrium  contains  multitudes  of  bac- 
teria swarming  in  its  outer  layers,  while  just  underneath 
this  layer  we  find  an  abundant  round-celled  formation 
of  granulation  tissue,  which  is  the  rampart  thrown  out 
by  nature  to  prevent  the  further  penetration  of  invad- 
ing micro-organisms.  In  septicaemia  the  absorption  is 
more  gradual,  and  is  aggravated  by  the  more  rapid  de- 
velopment of  the  germs.  This  septic  process  may  ex- 
tend by  continuity  of  tissue  through  the  uterus  to  the 
tube  and  ovaries,  setting  up  all  forms  of  inflammation 
in  them,  and  finally  involving  the  pelvic  peritoneum  ;  or 
the  septic  infection  may  extend  by  the  lymphatics 
through  the  uterine  parenchyma  to  the  pelvic  cellular 
tissue,  and  ultimately  causing  a  true  pelvic  abscess. 

The  third  type  of  septic  infection,  pytemia,  is  merely 
an  advanced  or  aggravated  stage  of  septicemia,  charac- 
terized by  abscess  formation,  the  localization  of  the 
septic  material  causing  thrombi  embolism,  and  subse- 
quently multiple  abscesses  in  the  viscera  and  joints. 

The  sources  of  infection  are,  first,  the  midwife  or 
nurse  ;  second,  the  surgeon  ;  third,  the  husband,  or 
patient  herself  ;  fourth,  the  air. 

Of  all  the  sources  of  infection,  I  consider  the  mid- 
wife or  nurse  the  most  fruitful.  Most  of  the  puerperal 
cases  I  have  seen  have  been  attended  by  midwives. 
They  use  no  antiseptic  precautions  whatever,  making 
frequent  vaginal  examinations  with  filthy,  unwashed 
hands.  Untrained  nurses  are  often  in  attendance  at  our 
confinement  cases,  and  not  infrequently  make  internal 
examinations  of  the  %voman  about  to  be  confined. 
Some  do  this  to  show  that  they  know  as  much  as  the 
doctor  ;  others,  again,  do  it  to  ascertain  the  degree  of 
dilatation,  to  aid  them  in  determining  when  to  send  for 
the  doctor.  When  engaged  to  attend  a  woman  we 
should  instruct  her  not  to  permit  any  attempt  at  exam- 
ination by  the  nurse  or  midwife,  otherwise  we  cannot 
always  prevent  infection  from  this  source. 

That  the  attending  surgeon  is  ever  the  cause  of  in- 
fection is  greatly  to  be  regretted.  Happily  this  is  not 
as  often  the  case  now  as  formerly,  but  still  it  does  ex- 
ist. A  physician  of  this  age,  who  attends  a  case  of  con- 
finement with  less  preparation  and  care  than  he  would 
bestow  upon  a  capital  operation,  should  be  held  culpa- 
ble in  case  complications  of  a  septic  nature  should 
arise.  When  called  upon  to  attend  a  case  of  confine- 
ment, proceed  at  once  upon  true  surgical  principles. 
If  time  permits,  have  the  patient  take  a  full  hot  baih. 
Empty  the  rectum  and  bladder,  the  former  by  enema. 
The  robe  of  the  patient  and  the  bedding  should  be  ab- 
solutely clean.  The  surgeon  should  then  render  his 
arms  and  hands  aseptic,  paying  special  attention  to  the 
subungual  spaces.  Ethereal  soap  and  hot  water  should 
be  used  freely  with  a  stiff  clean  brush.  Here  it  may 
be  necessary  to  remind  you  of  the  danger  lurking  in 


546 


MEDICAL    RECORD. 


[October  19,  1895 


questionable  soaps  and  dirty  nail-brushes.  Xail-brushes 
should  be  kept  clean  and  in  an  antiseptic  solution  when 
not  in  use.  I  have  used  ethereal  soap  with  great  satis- 
faction. The  external  genitals  of  the  mother  should 
be  treated  much  in  the  same  manner.  After  the  scrub- 
bing process  has  been  gone  through  with,  the  surgeon's 
hands  and  the  maternal  parts  should  be  rinsed  in  a  so- 
lution of  creolin.  Aseptic  towels  should  be  pinned 
around  the  thighs  and  over  the  mons.  The  patient  is 
now  ready  for  an  internal  examination,  which  should 
be  repeated  as  seldom  as  possible.  It  is  a  good  prac- 
tice to  disinfect  the  hands  each  time  the  maternal  parts 
are  touched,  and  to  keep  the  towel  wrung  from  a  creo- 
lin solution  against  the  external  genitals  constantly. 
Should  any  accident  occur  to  infect  the  field  of  opera- 
tion, disinfect  as  from  the  first,  always  keeping  in  mind 
surgical  cleanliness.  After  delivery  the  nurse  should  be 
instructed  rot  to  touch  the  mother,  either  to  change 
dressing  or  to  draw  the  urine,  without  first  scrubbing 
the  hands  and  nails  thoroughly. 

Gum  catheters  had  better  be  discarded  altogether, 
for  they  are  never  clean.  Use  only  glass  catheters, 
they  can  be  easily  sterilised.  The  field  around  the 
meatus  should  be  carefully  cleansed  before  the  catheter 
is  used,  and  everything  clearly  in  view.  After  delivery 
of  the  placenta  an  aseptic  gauze  pad  should  be  worn 
next  the  external  genitals,  and  frequently  changed. 

The  husband  and  the  patient  are  often  the  sources  of 
contagion.  The  husband,  as  a  factor  in  the  production  of 
puerperal  sepsis,  has  not,  I  believe,  received  the  consid- 
eration he  deserves.  He  often  initiates  the  septic  process 
in  his  wife  soon  after  marriage,  by  inoculating  her  with 
the  gonococcus,  and  when  she  is  near  the  end  of  preg- 
nancy he  comes  home  with  a  soft  chancre,  and  con- 
tinues his  septic  and  sexual  relations  with  her.  Most 
men  touch  their  penis  several  times  a  day  while  urinat- 
ing, and  yet  I  dare  say  few  of  them  ever  think  of  wash- 
ing it,  no  matter  how  dirty  their  occupations,  before 
thrusting  it  into  the  parturient  canal  at  night.  Men 
sometimes  have  sexual  relations  with  their  wives  within 
a  week  or  two  after  confinement,  the  woman  develops 
symptoms  of  puerperal  fever,  and  the  doctor  is  puzzled 
to  explain  the  cause,  and  perhaps  lays  it  to  the  breasts, 
or  catching  cold,  or  to  auto-infection. 

The  patient  does  not  have  many  opportunities  for 
infecting  herself,  but  the  methods  she  employs  are  cal- 
culated to  be  very  successful.  Most  women  think  any 
old  rags  are  good  enough  to  receive  the  lochial  dis- 
charge, and  this  they  must  be  prohibited  from  doing. 
She  must  also  be  discouraged  from  using  the  family 
sponge,  to  bathe  herself  with.  The  surgeon  would  do 
well  if  he  ordered  all  wash-rags  and  sponges  used  for 
such  purposes  burned  before  labor  begins,  for  they  will 
turn  up  unexpectedly  a  dozen  times  during  confine- 
ment, unless  they  are  entirely  out  of  reach.  Only 
recently  I  had  prepared  a  parturient  woman  in  a  thor- 
oughly aseptic  manner,  she  found  it  necessary  to  visit 
the  closet,  and  while  there  the  waters  broke  and  began 
dribbling  away,  when  she  promptly  applied  the  bath- 
room sponge  to  the  vulva,  where  I  found  it  an  hour 
later.  These  may  seem  to  be  little  things,  but  if  we 
expect  to  do  aseptic  surgery  and  get  desirable  results, 
we  must  be  externally  vigilant. 

Vitiated  air  may  greatly  increase  the  predisposition 
or  be  a  direct  cause  of  puerjieral  infection.  Here,  in 
our  northern  climate,  houses  are  built  with  a  view  of 
keeping  out  the  cold,  and  incidentally  of  course  fresh 
air.  In  the  winter  double  doors  and  windows  are  put 
on.  The  natural  vitiation  of  tlie  air  is  increased  by  an 
■untrapped  or  defective  drain  connected  with  the  sewer. 
The  British  Registrar-General's  report  shows  that  the 
smallest  number  of  deaths  from  puerperal  fever  every 
year,  for  the  last  twenty-five  years,  has  always  been  in 
August,  when  all  the  windows  are  open,  and  the  de- 
fective drains  have  least  chance  to  do  harm  ;  and  the 
largest  number  of  deaths  has  always  been  in  January, 
when,  the  windows  being  closed,  sewer-gas  laden  with 


bacteria,  remains  for  a  long  time  undiluted  in  the  house. 
Puerperal  fever  is  relatively  common  in  the  bedrooms 
of  the  rich,  where  the  elegant  marble  basin  is  directly 
connected  with  the  city  sewer.  The  lowest  death-rate 
ever  yet  attained  is  in  the  Sloane  Maternity,  where  there 
is  absolutely  no  plumbing  in  the  building,  and  at  the 
Preston  Retreat,  where  a  steam  fan  blower  forces  half  a 
million  cubic  feet  of  fresh  air  every  hour  into  the  lying- 
in  wards. 


IMPORTANCE  OF  FRESH  AIR  AND  EXER- 
CISE IN  THE  TREATMENT  OF  TUBER- 
CULOSIS. 

By  A.  H.  STEWART,  M.D., 

RICHMOKD.    KV. 

The  unmistakable  evidences  of  pre-existing  and  pro- 
gressive weakness  in  the  vital  and  physical  energies  of 
the  body  organisms  found  in  the  vast  majority  of  cases 
of  tuberculosis,  and  the  fact  that  the  disease  progresses 
just  in  proportion  to  the  extent  of  this  weakness  makes 
plain  the  line  of  hygienic  treatment  to  be  adopted. 
Reinforce  these  weakened  energies  with  an  abundance 
of  flesh  air,  sunshine,  wholesome  nutritious  diet,  and,  in 
suitable  cases,  moderate  judicious  exercise  should  be 
the  watchword  all  along  the  line.  As  to  the  value  of 
these  measures  there  is  quite  a  unanimity  of  opinion, 
except  as  to  the  amount  of  exercise  that  should  be  al- 
lowed in  connection  with  the  fresh-air  treatment,  and  on 
this  point  there  is  quite  a  diversity  of  opinion.  Many 
of  those  who  use  the  terras  physiological  weakness 
and  physiological  exhaustion  synon)'mously,  and  con- 
sider exhaustion  to  be  a  necessary  consequence  of  any 
form  of  exercise,  require  absolute  rest  in  all  classes  of 
cases  ;  while  many  of  those  who  believe  that  strength 
comes  through  stimulation,  and  that  exercise  is  the 
best  form  of  stimulation,  take  the  opposite  view,  and 
favor  active  exercise  in  nearly  all  cases,  regardless  of 
the  physical  condition  of  the  patient.  Now,  it  is  ap- 
parent that  there  is  some  truth  and  much  error  in 
each  of  these  propositions,  and  that  the  logical  course 
to  pursue  is  to  regulate  the  exercise  to  suit  the  physical 
condition  of  each  individual  case.  The  most  positive 
indications  for  rest  are  pyrexia,  haemoptysis,  and  ex- 
treme debility,  because  :  a,  except  in  some  hectic  con- 
ditions pyrexia  indicates  progressive  inflammation  at 
the  seat  of  the  disease  in  the  lungs  ;  b,  hemoptysis  in- 
dicates disintegration  of  tissue  and  giving  way  of  ves- 
sel walls,  small  or  large,  according  to  the  extent  of  the 
hemorrhage  :  and  c,  debility  indicates  exhaustion  of 
the  physical  forces,  potential  and  kinetic,  through 
fever,  exercise,  or  defective  assimilation,  all  of  which 
conditions  are  best  treated  by  absolute  quietude  and 
rest  in  bed.  The  first  two  because,  like  similar  condi- 
tions elsewhere,  they  need  rest,  which  in  these  condi- 
tions is  best  secured  by  reducing  the  number  of  heart- 
beats, lowering  the  force  of  the  blood-pressure,  and 
checking  the  flow  of  blood  to  the  parts  by  absolute 
quietude,  and  the  last  because  in  this  way  the  tissues 
are  given  an  opportunity  to  recuperate  their  exhausted 
forces.  But  this  does  not  indicate  that  absolute  rest 
should  be  continued  after  these  ends  have  been  at- 
tained, nor  does  it  indicate,  especially  in  the  last  case, 
that  after  partial  recovery  the  process  may  not  be  fa- 
cilitated by  moderate  judicious  exercise,  limited  al- 
ways, however,  to  the  needs  of  the  body.  In  this  con- 
nection it  is  important  to  make  a  distinction  between 
cell  weakness,  defective  cell  energy,  or  imperfect 
metabolism,  and  cell  exhaustion,  as  these  terms  are  or- 
dinarily used  and  understood.  That  high  fever  and 
excessive  exercise  are  potent  factors  in  bringing  about 
exhaustion  through  consumption  of  the  forces  and 
energies,  and  that  the  logical  way  to  check  this  is  to 
arrest  the  cause,  are  too  well  understood  to  even  be 
mentioned  here,  if  it  were  not  for  the  fact  that  in  many 


October  19,  1895] 


MEDICAL   RECORD. 


547 


cases  the  process  is  carried  so  far  that  the  basis  from 
which  these  forces  draw  their  supply  are  so  far  injured 
that  no  amount  of  rest  will  restore  them  to  their  nor- 
mal condition.  Something  similar  to  this  occurs  in  the 
case  of  old  ulcerated  sores.  The  minute  histological 
structures  that  form  the  line  of  demarcation  between 
the  healthy  and  diseased  tissue  are  neither  dead  nor 
alive,  nor  will  any  amount  of  rest  restore  them  to  their 
normal  state.  There  is  too  much  vitality  to  permit  dis- 
integration, but  not  enough  to  allow  new  blood  to 
come  in  and  impart  new  life.  The  surgical  treatment 
in  such  cases  would  be  to  remove  all  the  tissue  not  sus- 
ceptible of  being  restored  to  healthy  vitality,  or  stimu- 
late by  counter-irritants,  or  by  friction  and  massage 
force  the  blood  into  the  parts  and  stimulate  them  to 
normal  activity  ;  while  nature's  method  would  be  to 
increase  the  quantity  and  quality  of  the  blood, 
strengthen  the  heart,  and  force  this  new  blood  into 
these  parts,  and  thereby  drive  back  the  broken-down 
debris,  and  heal  by  granulation.  This  is  largely  the 
condition  that  prevails  in  many  cases  of  chronic  tuber- 
culosis, and  this  is  the  way  a  cure  is  brought  about  by 
nutritious  diet,  the  dry  rarefied  air  of  high  altitudes, 
and  pulmonary  gymnastics.  A  vastly  increased  amount 
of  fresh  air  is  brought  to  the  lungs,  much  of  which  finds 
its  w^  to  un  ventilated  nooks  and  crevices,  where  it  im- 
parts its  oxygen  to,  and  takes  up  carbonic  acid  from, 
the  residual  air  in  the  air-vesicles,  and  forces  oxygen 
into  the  blood  circulating  in  the  pulmonary  capillaries. 
The  large  amount  of  new  blood  thus  brought  to  the 
margins  of  the  ulcers  forces  its  way  into  the  weakened, 
sluggish  tissues,  facilitates  expulsion  of  broken-down 
dibris,  and  hastens  the  healing  process  by  throwing  out 
protoplasmic  granular  processes,  which  by  degrees  en- 
croach upon  and  fill  up  the  diseased  area. 

But  still  there  is  another  general  morbid  condition 
in  which  a  distinction  should  be  made  between  cell 
weakness  and  cell  exhaustion  as  the  terms  are  ordi- 
narily used,  and  that  is  in  the  strumous  or  tubercular 
diathesis.  Here  the  defects  seem  to  be  rather  a  stag- 
nation than  an  exhaustion  of  the  energies  and  forces. 
The  lymph  possesses  but  little  vitality,  moves  sluggish- 
ly along  the  lymph  channels,  and  is  easily  obstructed 
in  its  course.  The  capillary  circulation  is  often  with- 
out force  or  potency,  the  villi  often  fail  to  absorb, 
and  the  tissues  fail  to  appropriate  and  to  assimilate 
the  nutriment  intended  for  them.  It  is  this  character 
of  cell  weakness  that  is  found  in  a  large  number  of 
consumptives.  It  is  this  weakness  that  enables  the  or- 
ganisms of  the  disease  to  make  such  rapid  inroads  into 
the  tissues,  and  it  is  this  weakness  which  is  not  bene- 
fited by  rest,  except  so  far  as  it  has  been  further  re- 
duced by  fever  or  exercise  that  is  to  be  overcome  in 
the  treatment  of  this  disease.  It  is  in  this  class  of  cases, 
when  there  is  no  fever  and  no  great  amount  of  debil- 
ity, that  a  favorable  change  is  often  brought  about  by 
stimulation  through  such  moderate,  judicious  exercise 
as  will  gradually  increase  the  force  rather  than  the  fre- 
quency of  the  pulsations,  and  the  depths  rather  tlian 
the  number  of  respirations.  In  this  way  oxygenation 
and  assimilation  are  facilitated,  and  all  the  metabolic 
processes  are  carried  on  more  perfectly  and  energeti- 
cally, and  the  tissue  resistance  thereby  proportionately 
increased.  The  average  daily  consumption  of  oxygen 
during  quietude  being  estimated  in  round  numbers  at 
thirty  thousand  cubic  inches,  and  the  average  increase 
in  the  number  of  respirations  while  standing  up,  over 
the  number  while  lying  down,  being  estimated  at  one- 
third,  there  are,  other  things  being  equal,  a  daily  in- 
creased consumption  of  ten  thousand  cubic  inches  of 
oxygen  while  standing  up  over  that  consumed  while 
lying  down.  But  after  reducing  this  even  one-half,  for 
sleep  and  repose,  there  is  still  an  excess  of  five  thou- 
sand cubic  inches,  which  counts  for  much  when  an  in- 
valid is  starving  for  oxygen.  Besides,  the  amount  of 
oxygen  taken  in  is  augmented  nearly  or  quite  as 
much    by   the   increased    depths   as    by   the   increased 


number  of  respirations  during  ordinary,  and  espe- 
cially during  ptilmonary,  gymnastic  exercises.  It  is 
pulmonary  rather  than  bodily  exercise  and  an  increase 
in  the  depth  rather  than  in  the  number  of  respirations, 
then,  that  is  wanted.  This  accounts  in  a  measure 
for  the  benefits  derived  from  high  altitudes,  from 
horseback  riding,  and,  to  some  extent,  from  carriage 
driving.  But  in  the  latter  cases  the  change  of  the 
position  of  the  body  (without  body  exertion)  brings  it 
into  contact  with  more  air,  or  at  least  it  brings  the  body 
more  forcibly  into  contact  with  the  air,  the  same  as 
does  increased  velocity  of  the  air,  and  this  of  itself  stimu- 
lates respiration  and  increases  the  amount  of  air  con- 
sumed. The  main  object,  then,  being  to  catch  and  con- 
sume as  much  available  air  as  possible,  the  essential 
idea  intended  to  be  conveyed  when  contending  for  out- 
door open-air  exercise  is  the  living  and  revellirg  in  the 
fresh  air,  rather  than  the  taking  of  active  exercise 
therein.  But  just  to  the  extent  that  the  volume  of  air 
consumed  can  be  increased  by  sitting  up,  by  moving 
leisurely  about,  or  by  being  conveyed,  as  in  a  carriage 
or  on  horseback,  from  place  to  place  without  drawing 
on  the  weak  stock  of  energy  in  bank,  to  that  extent  it 
is  beneficial.  Consequently  a  careful  invoice  of  the 
energy  in  bank  to  the  credit  of  the  tissues  should  be 
taken  by  the  physician  and  the  patient  before  any  ex- 
ercise is  recommended.  Some  of  the  indices  to  this 
are  the  number,  force,  and  volume  of  pulsations,  num- 
ber and  depth  of  respirations,  the  elevation  of  tempera- 
ture, and  the  nervous  susceptibility  of  the  individual. 
The  amount  of  stock,  too,  may  be  tested  by  drawing 
on  it  cautiously  and  temporarily,  by  going  up  and 
down  a  flight  of  stairs,  lifting  weights,  or  walking  brisk- 
ly a  short  distance.  In  each  case  the  amount  of  energy 
exhausted  may  be  approximated  by  the  increased  pul- 
sations and  respirations,  the  increased  elevation  of  tem- 
perature, and  the  perceptible  amount  of  exhaustion  to 
the  patient. 

A  temperature  of  100°  F.,  and  especially  of  over  101° 
F.,  contraindicates  any  kind  of  exercise.  Rapid,  feeble 
pulse,  quick,  shallow  respirations,  much  increased  by 
slight  exertion,  and  much  exhaustion  after  slight  exer- 
tion, indicate  great  feebleness,  and  call  for  much  cau- 
tion and  discretion  in  deciding  upon  the  character  and 
kind  of  the  exercise  to  be  recommended.  Some  may  re- 
cline on  a  couch,  or  sit  up  in  a  chair  in  the  open  air  ; 
others  may,  if  they  wish,  play  checkers  or  dominoes,  read 
a  magazine,  or  do  light  needlework  ;  while  others  may 
go  riding  or  driving,  and  even  hunting,  fishing,  rowing  ; 
tennis  and  ball-playing  may  be  engaged  in  by  those 
who  enjoy  such  sport,  and  those  able  to  engage  in 
them.  Manual  labor  on  a  farm,  driving  a  market- 
wagon,  or  canvassing,  may  be  permitted  by  the  more 
robust,  not  so  much  for  financial  as  for  physical  gain. 
Hill  climbing,  flower,  plant,  and  mineral  gathering — 
something  to  make  out-door  exercise  pleasant — are  es- 
pecially to  be  recommended.  Tliose  who  look  upon 
exercise  as  a  task  to  be  performed,  and  think  the  ear- 
lier it  is  commenced  and  the  sooner  completed,  and 
the  more  energy  expended  the  better  the  task  will  be 
done,  usually  return  from  such  exercise  entirely  ex- 
hausted and  much  worse  off,  physically,  than  before 
they  started.  This  is  why  a  morning  or  evening's  walk, 
horseback  ride,  or  buggy  drive,  do  not  count  for  much. 
Instead  of  building  up,  they  often  exhaust  the  vital 
and  physical  energies  on  account  of  the  haste  that  is 
taken  and  energy  expended  during  such  exercise. 
Fresh  air  is  not  a  luxury  to  be  indulged  in  only  occa- 
sionally, at  brief  periods,  and  at  long  inter\  als,  but  to 
the  consumptive,  whose  natural  sujiply  of  fresh  air  i-s 
greatly  reduced  on  account  of  defective  ])ulmonary  ex- 
pansion, and  whose  blood  is  hourly  becoming  more  and 
more  impoverished,  it  is  a  constant  necessity. 

For  him  to  seek  fresh  air  at  such  periods  is  like 
starting  on  an  important  mission  and  making  one  step 
forward  and  three  backward.  The  final  result — ^com- 
plete failure — would  inevitably  be  the  same.     In  living 


548 


MEDICAL    RECORD. 


[October  19.  1895 


out  of  doors,  however,  some  consideration  must  always 
be  given  to  the  most  inclement  weather,  it  is  true  ;  yet 
if  properly  prepared  with  water  -  proof,  shoes,  and 
wraps,  the  climate  out  doors  must  be  very  bad  indeed 
if  it  is  worse  than  badly  ventilated  houses.  In  any 
event,  one  cannot  ordinarily  wait  to  see  if  it  is  going 
to  clear  up,  or  if  the  sun  will  come  out,  while  such  ene- 
mies as  the  tubercle  bacilli  are  invading,  or  even  threat- 
ening to  invade,  the  tissues,  when  the  most  effective 
method  of  obstructing  their  progress  is  by  building 
fortifications  out  of  the  invaded  or  threatened  tissue 
by  filling  them  with  new  blood  through  fresh  air  and 
wholesome  exercise.  Fortify  the  strength  and  increase 
the  number  of  the  phagocytes  in  the  blood,  array  them 
in  one  solid  phalanx  against  the  enemy,  and  in  a  large 
per  cent,  of  cases  they  will  come  off  victorious.  If 
they  cannot  annihilate  the  enemy  they  can  stop  their 
further  progress,  imprison  them  in  cavities,  or  encap- 
sulate them  in  a  net-work  of  fibrous  connective  tissue 
so  effectively  that  they  cannot  make  their  escape.  In 
climates  where  the  atmosphere  is  dry  and  pure  the  pa- 
tient should  camp  on  the  field  at  night  ;  he  should 
pitch  his  tent  in  the  open  air  so  that  the  enemy  cannot 
take  advantage  of  stagnant  air  in  a  close  room,  in  which 
they  like  to  carry  on  their  deadly  work,  to  recuperate 
their  weakened  forces  and  be  ready  to  renew  the  attack 
in  the  morning.  If  the  house  must  be  occupied  even 
during  the  night,  it  must  be  well  ventilated  from  cellar 
to  garret,  and  from  centre  to  circumference.  The  bed 
is  to  be  placed,  not  in  the  draught,  it  is  true,  but  away 
from  stagnant  corners,  where  the  patient  can  get  the 
benefit  of  all  the  fresh  air  in  the  room.  It  has  been  well 
said  that  the  greatest  trouble  about  draughts  is  that 
they  are  not  large  enough.  What  constitutes  a  draught 
when  the  air  enters  at  a  small  opening  may  not  be  even 
a  gentle  breeze  when  all  the  doors  and  windows  are 
thrown  open.  The  inequality  in  the  temperature  of 
the  inside  and  outside  air  gives  rise  to  draughts.  The 
cold  air  on  the  outside  rushes  in  through  every  little 
crevice  to  take  the  place  of  the  evaporated,  rarified  air 
on  the  inside. 

Perhaps  rather  thin  flannel  underwear  is  best  at  all 
seasons  of  the  year  while  taking  out- door  exercise,  as 
it  will  take  up  moisture  without  becoming  damp  and 
sticky,  but  even  this  should  be  changed  frequently. 

When  it  is  absolutely  impossible  to  take  out-door 
exercise  on  account  of  the  extreme  inclemency  of  the 
weather,  pulmonary  gymnastics  should  be  persistently 
carried  on  at  home.  Indeed,  a  consumptive  should 
allow  no  day  to  pass  without  such  exercise,  even  when 
other  exercise  is  taken. 

Constancy  and  regularity  in  such  exercise  can  only 
be  carried  on  under  the  supervision  of  a  physician. 
The  patient  can  no  more  be  trusted,  though  his  life  be 
at  stake,  without  some  oversight  by  others,  than  an 
athlete  preparing  for  the  world's  championship  con- 
test can  be  trusted  to  lake  the  proper  exercise  without 
a  competent  trainer.  The  will  cannot  summon  cour- 
age sufificient  to  meet  such  extra  requirements  of  the 
body.  With  the  body  erect,  as  it  should  always  be,  and 
the  head  rather  thrown  back,  full,  deep,  prolonged  res- 
pirations should  be  taken  for  five  to  ten  minutes,  three 
to  six  times  a  day.  The  arms  should  be  slowly  raised 
from  the  sides  in  a  circle  till  the  hands  meet  above  the 
head  during  deep  inspiiations,  and  then  be  lowered  in 
the  same  way  during  exhalations.  This  should  be  re- 
peated from  six  to  ten  times,  then  the  arms  should  be 
raised  and  brought  forward  in  a  circle  till  the  palms 
meet  in  front  on  a  level  with  the  forehead  while  the 
■  lungs  are  being  inflated,  then  lowered  or  moved  as  far 
backsrard  as  possible  during  expiration  ;  or  better 
still,  after  the  lungs  have  been  fully  inflated,  while  the 
arms  are  elevated  or  in  front,  the  breath  should  be 
held  while  the  fullest  possible  circles  are  made  with 
the  arms  in  every  direction,  tapping  the  chest  occa- 
sionally with  one  and  then  with  the  other  open  hand, 
while  weights,  dumb-bells,  or  Indian  clubs  should  be 


lifted  from  the  floor  by  the  side,  or  with  arms  out- 
stretched till  they  are  brought  together,  either  in  front 
on  a  level  with  the  forehead,  or  above  the  head  during 
inspiration,  and  then  lowered  during  expiration.  At 
least  one  half  hour  should  be  devoted  to  such  exercise 
every  morning  and  evening,  even  when  other  exercise 
is  taken,  and  two  or  three  times  as  often  in  the  open 
air  when  little  or  no  other  exercise  is  taken.  It  is  well 
always  to  have  some  primary  work  on  physical  culture 
a*:  hand,  and  study  the  various  movements  as  they  are 
described  and  illustrated. 

These  exercises  should  always  be  carried  on  in  the 
open  air,  or  where  the  windows  are  open.  By  such 
respiratory  gymnastics  the  lungs  are  thoroughly  in- 
flated, the  air  reaching  many  nooks  and  crevices  filled 
with  stagnant  residual  air  and  lurking  bacilli.  For  this 
reason,  if  for  nothing  else,  the  inhalation  of  non-irri- 
tating, volatile  substances  should  always  be  recom- 
mended. 

In  order  to  interest  the  patients  and  insure  their 
hearty  co-operation,  it  is  recommended  by  some  to  at- 
tach great  importance  to  the  medicaments  used,  and 
sometimes  to  use  complicated  apparatus  in  order  to 
throw  as  much  mystery  around  the  treatment  as  possi- 
ble. But  usually  this  is  not  best.  To  intelligent  pa- 
tients it  is  always  best  to  be  frank,  speak  plainly,  and 
tell  the  truth.  Indeed,  if  a  little  pains  be  taken  to 
explain  the  nature  of  the  lesions,  their  course,  and  the 
effect  of  fresh  air  and  constant  inflation  of  the  lungs, 
it  is  much  better. 

Complicated  instruments  should  usually  be  discarded 
and  irritating  medication  never  used.  While  it  has  not 
been  demonstrated  that  any  specific  influence  is  ex- 
erted on  the  tubercle  bacillus  by  any  method  of  anti- 
septic inhalation  treatment  so  far  used,  yet  it  is  agreed, 
with  singular  unanimity,  that  when  non- irritating  bal- 
samic or  volatile  substances  are  used  there  is  a  decided 
amelioration  of  many  of  the  most  aggravating  symp- 
toms of  the  disease  under  such  treatment.  Withal- 
most  equal  unanimity,  too,  it  is  agreed  that  great 
benefit  is  also  derived  from  continued  deep  inspira- 
tions, whether  the  inhaled  air  contains  any  medica- 
ment or  not. 

While  I  have  unbounded  faith  in  the  ultimate  suc- 
cess of  the  antiseptic  inhalation  medication,  and  believe 
that  even  now  much  good  is  derived  from  it,  yet  for 
the  present  the  question  of  paramount  interest  is  con- 
tinued respiratory  gymnastics,  frequent,  full  respira- 
tions, constant,  complete  inflation  of  the  lungs. 

For  this  purpose  some  of  the  simple,  cheap,  vest- 
pocket  inhalers,  made  of  glass  or  hard  rubber,  are  usu- 
ally to  be  preferred  to  the  more  expensive,  complicated 
atomizers  and  inhalers,  and  even  to  the  much-lauded 
but  cumbersome  and  unsightly  muzzles  to  be  worn 
over  the  mouth  and  nose.  Evans's  glass  inhaler,  which 
has  a  dilated  end  for  the  sponge,  or  Dennison's  hard- 
rubber  inhaler  and  exhaler,  which  has  a  roll  of  blot- 
ting-paper for  medication  in  one  end,  will  answer  every 
purpose.  They  can  be  carried  in  the  vest  pocket,  and 
a  few  drops  of  some  non  irritating  volatile  or  balsamic 
preparation,  as  terebene,  oils  of  fir-wood,  southern 
pine,  or  eucalyptus,  thymol,  creosote,  or  compound 
tincture  of  benzoin,  dropped  on  the  absorbent  and  in- 
haled ten  to  fifteen  minutes  six  to  ten  times  a  day.  It 
is  not  necessary,  nor  even  advisable,  that  the  medicine 
should  be  renewed  every  time  the  inhaler  is  used. 
Usually  five  to  fifteen  drops  of  one  or  more  of  the 
above  preparations  once  a  day  will  be  sufficient. 
Whenever  jiain  or  any  disturbance  is  caused  by  the  use 
of  any  jireparation,  the  quantity  should  be  reduced, 
or  its  use  discontinued  altogether,  for  a  while  at  least. 
Usually  any  existing  nasal  post-]>haryngeal  catarrh, 
laryngitis,  or  bronchitis,  is  very  much  benefited,  and 
even  the  tuberculous  process  in  the  deeper  portions  of 
the  air-jiassages  are  often  benefited  ;  cough  is  relieved, 
rest  secured,  appetite  increased,  and  the  condition  of 
the  patient  much  improved.     The  healing  process  is 


October   19,  1895] 


MEDICAL    RECORD. 


549 


facilitated  by  the  increased   amount  of  blood  brought 
to  the  lungs. 

No  plan  of  hygienic  treatment  is  complete  without 
the  daily  bath — not  for  cleanliness  alone,  but  for  the 
purpose  of  stimulating  the  activity  of  the  skin  and  su- 
perficial blood-vessels,  as  well  as  to  remove  all  waste 
matter  from  the  surface.  To  most  persons  a  bath  at 
night  in  cold  or  tepid  water  is  the  most  agreeable. 
Others,  more  delicate,  receive  great  benefit  from  the 
sponge-bath  with  a  damp  cloth,  and  then  rubbed  down 
briskly  with  a  crash  towel.  Some  prefer  the  bath  in 
the  morning,  to  which  there  is  no  objection.  The  one 
essential  condition  is  that  some  kind  of  a  bath  or  rub 
down  be  taken  daily.  Where  a  thorough  bath  is  taken 
at  night  in  water  containing  a  little  borax  or  aqua  am- 
monia, it  is  well  in  many  cases  to  anoint  the  patient 
thoroughly  with  fresh,  clean  lard,  thoroughly  beaten 
till  it  has  the  appearance  of  cream,  or  with  cotton-seed 
oil,  petroleum,  or  cocoa-butter.  Whatever  ointment  is 
used  should  be  delicately  perfumed.  The  hands  and 
feet  should  be  kept  warm,  the  bowels  moved  at  least 
once  a  day,  and  rest  and  sleep  at  night  secured.  The 
uniform  success  attending  the  treatment  of  tuberculosis 
in  sanitariums  established  for  that  purpose,  a  number 
of  which  are  in  successful  operation  in  this  country  and 
in  Europe,  especially  those  conducted  on  the  cottage 
plan,  is  due  to  the  intelligent,  systematic  combination 
of  the  hygienic,  dietetic,  and  medical  treatment  carried 
on  at  these  institutions.  Under  the  influence  of  the 
compressed,  rarified,  and  medicated  air-baths,  nutri- 
tious diet,  fresh  air,  and  wholesome  exercise,  a  large 
per  cent,  of  patients  improve  rapidly,  for  a  while  at 
least,  without  any  medicine  whatever.  For  except  in 
the  best  equipped  hospitals  it  is  here  that  the  pneu- 
matic cabinet  and  all  the  needed  appliances  are  the 
most  perfectly  arranged  and  systematically  applied  to 
the  needs  of  each  individual  case. 


A  BRIEF  STUDY  OF  THE  PHYSIOLOGICAL 
EPOCHS  THAT  PREDISPOSE.  TO  INSANITY, 
WITH  OBSERVATIONS  ON  THE  MAN.AGE- 
MENT  OF  EACH.' 

By  WILLIAM  PHILIP  SPRATLING,  M.D., 

MEDICAL  SUPEf 


The  grave  responsibility  of  treating  insanity  in  its  in- 
cipiency  rests  in  a  greater  degree  on  the  physician  in 
general  practice  than  on  the  specialist  in  the  diseases 
of  the  mind.  Budding  mental  infirmities  almost  in- 
variably come  first  under  the  observation  and  care  of 
the  family  physician,  and  it  is  difficult  to  properly  es- 
timate the  greater  measure  of  success  that  can  often  be 
obtained  when  insanity  is  early  recognized,  its  signifi- 
cance appreciated,  and  the  disease  properly  treated.  It 
is  because  of  these  indisputable  facts  that  I  feel  justi- 
fied in  bringing  this  subject  to  the  attention  of  a  rep- 
resentative society  like  this. 

Charles  Mercier,  an  English  alienist  of  distinction, 
suras  up  the  causes  of  insanity  in  a  concise  and  pleas- 
ing manner  as  follows  :  "'  Insanity  is,  in  mathematical 
terms,  a  formula  of  two  variables ;  that  is  to  say,  there 
are  two  factors  and  only  two  in  its  causation,  and 
these  factors  are  complementary.  Both  enter  into  the 
causation  of  every  case  of  insanity,  and  the  stronger 
the  influence  of  one  factor  the  less  of  the  other  factor 
is  needed  to  produce  the  result.  These  factors  are 
heredity  and  stress." 

Now,  while  heredity  and  stress  aie  words  that  admit 
of  great  breadth  of  meaning,  as  they  must  to  include  all 
cases  of  insanity,  they  constitute  a  very  acceptable  dual 
head  under  which  to  crystallize  the  inexhaustible  list  of 
active  and  contributory  causes  that  give  rise  to  mental 

'  Read  before  the  Medical  Society  of  the  County  of  New  York, 
September  24,  1894, 


degeneration.  Moreover,  we  will  find,  when  we  come 
to  study  the  various  states  of  mental  instability  that 
arise  directly  out  of  the  physiological  epochs,  that 
heredity  and  stress,  with  their  subdivisions,  constitute 
the  only  etiological  factors.  There  is  no  variation 
from  this. 

There  are  certain  well-defined  physiological  epochs 
that  appear  at  fixed  periods  during  the  growth  and  de- 
velopment of  the  body.  These  epochs  are  all  strictly 
physiological  in  the  order  and  nature  of  their  occur- 
rence, save  one,  the  epoch  of  heredity,  and  that  may 
be  said  to  be  pathological,  or  patho-physiological. 
These  epochs  are  six  in  number,  and  I  have  designated 
them  as  follows  :  i.  The  Epoch  of  Early  Childhood  ; 
2,  the  Epoch  of  Puberty  ;  3,  the  Epoch  of  Maternity  ; 
4,  the  Epoch  of  Heredity  :  5,  the  Epoch  of  the  Meno- 
pause ;  6,  the  Epoch  of  Senility. 

The  epoch  of  early  childhood  covers  the  period  from 
the  end  of  the  sixth  month  to  the  seventh  year.  Strictly 
speaking,  the  period  should  be  regarded  as  an  indirect 
epoch  only,  since  insanity  occurring  so  early  in  life  is 
extremely  rare.  There  are,  however,  frequent  cases  in 
which  the  accidents  and  incidents  of  early  life  facili- 
tate the  establishment  of  insanity  in  after-years. 

The  epoch  of  puberty  in  the  female  extends  from  the 
thirteenth  to  the  fifteenth  year  ;  in  the  male  from  the 
fourteenth  to  the  sixteenth  year. 

The  third  epoch  covers  the  entire  child-bearing  pe- 
riod, from  the  fifteenth  to  the  forty-fifth  year.  Insanity 
occurs  more  frequently  during  the  first  than  during  the 
last  half  of  the  period. 

The  epoch  of  heredity,  I  believe,  has  not  had  special 
attention  called  to  it  by  writers  in  this  country.  A 
French  authority.  Regis,  uses  the  term  "  Phrenas- 
thenia"  to  include  all  forms  of  inherited  insanity.  The 
epoch  of  heredity  is  an  important  and  variable  one, 
and  embraces  that  critical  period  in  the  life  of  every 
individual  whose  ancestors  were  accustomed  to  exhibit 
evidences  of  insanity  on  reaching  a  certain  age. 

The  fifth  epoch  embraces  the  climacteric,  and  ex- 
tends in  women  from  the  forty-third  to  the  forty-fifth 
year.  Rare  exceptions  may  extend  the  line  a  little 
either  way.  It  is,  perhaps,  the  best- defined  epoch  of 
them  all,  inasmuch  as  the  changes  that  occur  during 
this  period  are  most  perceptible  and  oftenest  lead  to 
mental  instability. 

The  sixth  and  last  epoch,  that  of  senility,  or  old  age, 
needs  no  particular  designation,  but  it  is  of  interest  to 
note  that  when  the  ipreceding  epochs  were  not  strictly 
physiological  in  their  occurrence,  that  pathological 
conditions  of  mind  are  more  apt  to  be  encountered  on 
the  approach  of  extreme  old  age. 

Returning  now  to  the  first  epoch,  that  of  early  child- 
hood, let  us  briefly  review  the  accidents  and  incidents 
that  are  common  to  this  period,  and  that  may  serve  to 
render  the  child  a  fit  subject  for  mental  disorder  in  the 
future. 

The  first,  and  undoubtedly  the  most  important  of 
these,  because  it  is  the  most  universal,  is  dentition. 
Gowers  is  authority  for  the  statement  that  one-eighth 
of  all  cases  of  epilepsy  begin  during  the  first  three  years 
of  life  ;  and  adds  that  with  rickets  as  a  combining  cause 
seventy- five  per  cent,  of  all  cases  of  epilepsy  that  begin 
during  the  first  three  years  of  life  are  due  to  infantile 
convulsions  ascribed  to  teething.  Here  the  vicious 
tendencies  of  an  inherited  taint  change  a  perfectly 
physiological  process,  that  ought  to  be  free  from  dan- 
ger to  the  child,  into  a  period  fraught  with  influences 
of  a  most  pernicious  kind.  Syphilis,  chronic  alcohol- 
ism, insanity,  or  epilepsy  in  the  parent,  stamp  on  the 
nervous  system  of  the  child  a  congenital  taint  that  un- 
fits it  to  cope  with  the  serious  disturbances  that  mark 
the  steps  of  growth  and  development.  Genuine  epi- 
lepsy probably  never  occurs  in  the  first  instance  out  of 
difficult  dentition  alone.  I'^pileptiforni  convulsions, 
however,  do  quite  frequently  arise  from  this  cause,  and 
these  in  time  take  on  all  the  characteristics  of  genuine 


550 


MEDICAL    RECORD. 


[October  19.  1895 


epilepsy,  and  finally  become  fully  established  as  such. 
That  insanity  often  follows  in  the  footsteps  of  epilepsy 
is  a  matter  of  common  knowledge.  In  the  Journal  of 
the  American  MeJiVal  Association  for  August  18,  1894, 
Wilmarth,  gives  some  interesting  facts  regarding  idiocy, 
epilepsy,  imbecility,  and  insanity,  as  he  studied  them  at 
the  Pennsylvania  Institute  for  Feeble-Minded  Children. 
Out  of  1,000  cases  admitted  to  the  institution  he  found 
322  suffering  from  illness  of  such  a  nature  as  to  require 
medical  treatment  and  care  prior  to  being  sent  from 
home.  That  is  to  say,  322  cases  out  of  1,000  were  af- 
fected in  such  a  manner  as  to  indicate  that  medical 
treatment  would  possibly  have  brought  about  recovery. 

This  excluded  of  course  all  cases  of  congenital  troub- 
les that  it  was  not  possible  for  medical  skill  to  relieve. 
It  also  excluded  all  cases  in  which  congenital  defect 
was  even  noted  before  the  sixth  month,  that  is,  just 
prior  to  the  commencement  of  dentition.  But  more 
important  still,  he  found  that  the  disorder  in  75  cases 
out  of  the  322  was  recorded  as  having  begun  during 
the  spasms  of  dentition.  Up  to  the  sixth  month  2  were 
recorded  as  having  thus  begun  ;  between  the  sixth  and 
twelfth  months,  29  ;  between  the  twelfth  and  eighteenth 
months,  25  ;  between  the  eighteenth  and  twenty-fourth 
months,  19.  In  these  cases,  likewise,  hereditary  taint 
was  not  perceptible  prior  to  the  first  dentition.  The 
growth  of  the  child's  brain  is  rapid,  and  anything  that 
interferes  with  its  nutrition  is  a  serious  matter.  The 
period  of  most  active  growth  is  over  at  the  seventh 
year. 

Besides  dentition  a  great  variety  of  other  causes  are 
constantly  acting  on  the  organism  of  the  young  child 
that  threaten  to  disarrange  the  adjustment  of  the  more 
highly  developed  parts.  Among  these  may  be  men- 
tioned traumatism,  blows  and  falls  on  the  head,  infan- 
tile paralysis,  effects  of  excessive  heat,  mental  shock, 
fevers  of  specific  origin,  diphtheria,  whooping-cough, 
strictures  and  malformations  of  the  genital  organs. 

It  is  not  necessary  that  I  should  attempt  to  review 
the  approved  methods  of  treatment  in  all  these  cases. 
Such  knowledge  belongs  to  every  physician.  I  desire 
to  emphasize  only  my  belief  that  in  a  vast  number  of 
selected  subjects  some  of  the  physiological  processes 
of  childhood  become  distinctly  pathological,  and  that 
prompt,  active,  and  intelligent  treatment  will  often  avail 
in  saving  the  mental  life  of  the  child. 

Next  comes  the  period  of  puberty.  The  excito- 
motor  exaltation  of  the  nervous  system  during  the  first 
dentition  has  also  its  parallel  in  the  explosive  condi- 
tion of  the  nervous  centres,  in  the  higher  plane  of  the 
cerebral  activities,  during  the  evolution  of  the  genera- 
tive functions,  and  the  sexual  divergence  or  the  epoch 
of  early  adolescence.  This  period  is,  therefore,  the 
second  great  trial  of  the  constitutional  powers  of  the 
subject,  and  is  especially  prone  to  reveal  any  dormant 
inherited  vices.  Indeed,  such  epoch  may  be  character- 
ized as  one  of  the  search-lights  of  the  science  of  psy- 
chiatry, since  it  serves  to  reveal  weak  spots  in  the  men- 
tal organization  of  every  individual.  The  mental  dis- 
orders that  so  frequently  develop  at  this  age  are  due 
to  indirect  stress  of  internal  origin. 

The  period  of  puberty  is  fixed  in  the  female  between 
the  thirteenth  and  the  fifteenth  years,  and  in  the  male 
from  fourteen  to  sixteen.  Pubescent  insanity,  however, 
may  develop  anywhere  between  the  ages  of  fifteen  and 
twenty-two.  The  pubescent  epoch  is  attended  with 
more  danger  to  the  female  than  to  the  male  ;  the  rea- 
son of  this  is  obvious.  In  the  female  the  period  con- 
sumed in  passing  through  this  stage  is  much  shorter 
than  in  the  male.  The  male  attains  maturity  gradually, 
whereas  the  female  acquires  it  almost  at  a  bound  : 
consequently  the  shock  is  greater.  The  insanity  of 
this  period  in  the  male  is  characterized  by  a  silly, 
childish  disposition  ;  depression  that  may  terminate  in 
profound  melancholia,  mental  enfeeblement,  bodily  in- 
activity, and  later  on  by  systematized  delusions  that  per- 
tain chiefly  to  self.     The  manner  of  the  origin  of  men- 


tal obliquity  at  this  period  is  explained  as  follows  :  The 
period  of  puberty  in  the  male  is  the  transitional  stage 
from  boyhood  to  manhood.  The  psychical  and  physi- 
cal life  of  the  boy  are  threatened  with  extermination,  as 
they  have  reached  a  period  when  carelessness,  lack  of 
judgment,  natural  egotism,  and  the  sportive  tendencies 
of  youth  are  about  to  be  superseded  by  the  attributes 
that  characterize  the  man.  The  conflict  is  inevitable, 
the  result  of  the  union  of  two  opposing  forces  giving 
rise  to  a  display  of  the  mental  symptoms  above  de- 
scribed. If  the  boy  is  not  handicapped  by  inherited 
or  acquired  vicious  tendencies  that  serve  to  lower 
nerve-tone  he  will  escape  mental  blight  at  that  time. 
But  if  he  inherit  a  predisposition  to  insanity,  to  alco- 
holism, to  epilepsy,  or  if  he  begin  to  masturbate,  evi- 
dences of  grave  mental  disorder  quickly  become  ap- 
parent. 

Insanity  in  the  female  at  this  period  is  essentially 
an  acute  neurosis.  As  before  stated  this  is  due  to  the 
shorter,  sharper  transitional  period  through  which  the 
girl  is  forced  to  go  in  order  to  reach  womanhood. 
Acute  mania  is  the  form  of  insanity  that  is  most  fre- 
quent. The  preponderance  of  the  maniacal  states  over 
states  of  depression  is  also  a  feature  of  the  insanity  of 
the  puerperal  period. 

After  the  acute  stage  has  somewhat  subsided  evi- 
dences of  intellectual  derangement  appear,  and  fixed 
delusions  become  manifest.  Sometimes,  however,  mel- 
ancholic perversions  are  noted,  and  marked  by  delu- 
sions of  persecutions  and  fears  of  impending  evil. 

Hallucinations  of  the  special  senses  appear  in  about 
one- fourth  of  the  cases  in  both  sexes.  Visual  and  au- 
ral hallucinations  predominate,  and  sixteen  per  cent,  of 
such  cases  entertain  ideas  of  poisoning,  and  religious 
delusions  are  not  uncommon.  The  prognosis  in  such 
cases  is  very  good,  when  uncomplicated  by  hereditar)' 
taint,  since  nearly  eighty  per  cent,  get  well.  The  man- 
agement and  treatment  of  insanity  in  the  pubescent 
stage  consists  in  the  early  removal  of  the  patient  from 
home,  should  prejudicial  influences  exist  there-  Nour- 
ishment should  be  given  in  an  easily  assimilable  form, 
and  the  secretory  organs  should  receive  special  atten- 
tion, since  they  are  peculiarly  liable  at  this  period  to 
sluggish  action.  Sleep  should  be  secured  by  open-air 
exercise.  Narcotics  and  sedatives  should  not  be  given 
unless  imperatively  demanded  ;  only  when  insomnia 
has  existed  for  several  nights  in  succession,  in  spite  of 
an  observance  of  the  above  means,  are  sedatives  ad- 
missible ;  of  these  we  have  many  to  choose  from  and 
I  need  not  enumerate  them  here. 

The  menstrual  irregularities  of  this  epoch  will  re- 
quire special  attention.  In  cases  where  the  rate  of 
development  has  been  excessively  rapid,  and  where 
the  nutritive  and  assimilative  capacities  have  been 
overtaxed  by  the  demands  of  the  growing  organism, 
anaemia  of  a  most  troublesome  form  is  often  encoun- 
tered. Here  a  strictly  hygienic  regimen  is  to  be  en- 
forced, and  iron,  preferably  in  the  form  of  the  car- 
bonate, freely  given.  The  extract  of  nux  vomica  and 
rhubarb  in  pill  form  are  of  service,  and  I  have  seen 
excellent  results  follow  the  use  of  malt  extract  in  com- 
bination with  the  compound  syrup  of  the  phosphates, 
in  such  cases. 

The  third  epoch  embraces  the  child-bearing  period. 
The  puerperal  state,  in  the  wider  sense  in  which  Rep- 
ping  uses  the  term,  has  more  important  relation  to  the 
causation  of  insanity  than  the  other  physiological  pe- 
riods, not  excluding  those  of  the  climacteric  and  of 
the  senile  evolution.  During  pregnancy,  during  labor 
itself,  which  is  sometimes  accompanied  by  extreme 
transitory  frenzy,  and  during  lactation,  the  mental  life 
of  the  woman  is  in  peril.  Insanity  occurring  during 
pregnancy  is  more  frequent  in  mothers  who  are  about 
to  bear  illegitimate  children.  The  elements  of  grief 
and  remorse,  as  they  affect  the  emotional  sphere,  ac- 
count for  this  fact.  The  mental  anomalies  of  this 
period  vary  all  the  way  from  simple  morbid  appetites 


October  19,  1895] 


MEDICAL    RECORD. 


551 


to  well-marked  melancholia  with  well-marked  suicidal 
impulses.  The  transitory  frenzy  occurring  during  la- 
bor, mentioned  above,  is  dependent  either  on  the  ex- 
treme agony  of  childbirth,  or  it  appears  as  the  fore- 
runner of  delirium  of  the  puerperal  state.  Infanticide 
and  suicide  are  acts  common  to  the  subjects  of  this 
condition.  Hereditary  predisposition  increases  the 
gravity  of  the  attacks  of  this  period.  Insanity  follow- 
ing childbirth  may  develop  suddenly  after  delivery, 
or  may  come  on  gradually  after  evidences  of  nerve 
exhaustion  ;  when  it  begins  suddenly  it  almost  always 
takes  the  form  of  acute  mania.  Out  of  si.xty-eight 
puerperal  cases  studied  by  Bevan  Lewis,  fortv-iive,  or 
si.xty-six  per  cent.,  suffered  from  mania,  while  only 
thirty- three  per  cent,  showed  states  of  depression. 
The  symptoms  in  acute  mania  comprise  intense  excite- 
ment, great  incoherence,  continuous  garrulity,  and  a 
dangerous  explosiveness,  which  is  manifested  in  acts  of 
violence  and  destructive  tendencies.  Visual  and  aural 
hallucinations  are  frequent,  being  present  in  about 
eighteen  per  cent,  of  such  cases.  Delusions  of  a  varied 
character  are  present  in  over  sixty  per  cent.  Impul- 
sive acts  are  common,  leading  most  frequently  to  at- 
tempts at  suicide.  The  etiology  of  this  disorder  is 
interesting,  but  cannot  be  discussed  here.  The  treat- 
ment is  most  important :  in  the  majority  of  cases  it  is 
a  good  practice  to  begin  it  with  a  saline  aperient. 
Search  for  the  cause  of  fever.  It  may  be  due  to  putres- 
cible  matter  in  the  uterine  cavity,  or  to  septic  absorp- 
tion through  a  raw  surface  of  a  rupture  or  tear,  or  it 
may  be  due  to  peritonitis,  phlebitis,  or  an  inflamed 
mammary  gland.  If  it  is  due  to  septic  absorption, 
measures  must  be  promptly  instituted  to  check  further 
infection  ;  a  vitiated  condition  of  the  blood  may  de- 
mand the  free  use  of  iron,  but  none  of  the  chalybeate 
preparations  should  be  given  until  all  traces  of  acute 
excitement  have  subsided. 

The  infant  must  be  early  removed  from  the  mother's 
care.  The  mother's  diet  should  consist  of  milk,  beef- 
tea,  broths,  and  eggs,  and  should  be  administered  in 
small  quantities  at  frequent  intervals. 

To  secure  sleep  chloral,  potassium  bromide,  sulfonal, 
or  paraldehyde  should  be  given.  My  personal  prefer- 
ence is  paraldehyde  in  two-drachm  doses,  or  more  if 
required,  given  in  a  small  quantity  of  port  wine.  Warm 
baths  often  suffice  to  produce  refreshing  sleep,  and, 
when  practicable,  deserve  a  trial  before  medicines  are 
given. 

Insanity  occurring  during  lactation  differs  in  no  es- 
sential feature  from  that  which  occurs  just  after  child- 
birth. 

The  fourth  epoch,  that  of  heredity,  requires  only 
brief  mention.  The  form  of  insanity  that  develops  at 
this  period  is  determined  very  largely  by  the  form  of 
insanity  with  which  the  ancestors  suffered.  And  it  is 
especially  prone  to  occur  in  the  offspring  at  nearly  or 
about  the  age  at  which  it  became  manifest  in  the  par- 
ent. An  instance  recently  came  under  my  observation 
in  which  the  members  of  a  family  for  four  generations 
'suffered  more  or  less  from  insanity  just  as  soon  as  they 
reached  a  certain  age.  In  the  first  generation  only  one 
person  was  insane,  in  the  fourth,  four  are  now  or  have 
been  insane. 

The  fifth  epoch  embraces  the  menopause.  The  psy- 
chic manifestations  attendant  upon  this  critical  period 
are  well  marked.  For  women  who  have  an  inherited 
tendency  to  mental  disease,  or  who  have  suffered  from 
previous  attacks  of  insanity  during  one  of  the  former 
epochs,  this  period  has  added  dangers.     The  type  of 

-anity  common  to   this  period  is    constant;    painful 

ental  states  invariably  prevail. 

Doctor  Skae  characterizes  the  alienation  occurring  at 
this  period  as  follows  :  "  A  monomania  of  fear,  de- 
spondency, remorse,  hopelessness,  passing  occasionally 
into  dementia."  Fifty-five  per  cent,  of  cases  at  this 
period  are  of  the  depressed  type.  Acute  maniacal  con- 
ditions   sometimes  exist.     The  suicidal  impulse  is  fre- 


quent, more  than  one-half  possessing  it.  The  prog- 
nosis may  be  considered  as  favorable,  if  inherited 
weaknesses  do  not  prevail,  and  if  the  subject  has  not 
previously  been  insane. 

The  treatment  consists  mainly  in  a  tonic  regimen, 
out- door  life,  strict  attention  to  dietetic  matters,  and 
change  of  environment.  Anssmia  must  be  met  by  the 
administration  of  iron,  preferably  the  ammoniated 
citrate  of  iron,  and  in  combination  with  small  doses  of 
arsenic.  Such  patients  often  require  artificial  feeding, 
and  we  have  four  methods  of  accomplishing  this  to 
choose  from.  Sleep  usually  has  to  be  secured  by  arti- 
ficial means — chloral  hydrate  in  a  single  large  dose,  or 
paraldehyde,  is  to  be  preferred. 

The  sixth  and  last  epoch  is  senility,  and  I  will  make 
only  brief  reference  to  it.  The  most  common  form  of 
insanity  at  this  epoch  is  senile  dementia  ;  it  is  ques- 
tionable, however,  whether  we  are  justified  in  regarding 
this  form  of  dementia  as  a  separate  and  distinct  psychi- 
cal disorder,  dependent  upon  pathological  conditions 
of  its  own.  Senile  dementia  is  really  nothing  more  or 
less  than  the  physiological  loss  of  mind.  Retrograde 
changes  occurring  in  the  brain,  in  the  form  of  wide- 
spread atrophy,  give  rise  to  the  symptoms  common  to 
extreme  old  age. 

Senile  mania  and  senile  melancholia  occur  as  dis- 
tinct disorders.  In  senile  mania  we  usually  have  sim- 
ple maniacal  excitement  without  any  obvious  involve- 
ment of  the  intellectual  faculties.  Such  attacks  are 
marked  by  incessant  garrulity,  severe  disturbance  of  the 
emotional  sphere,  restlessness,  persistent  insomnia,  in- 
coherence of  speech,  and  outbursts  of  passion.  ^Vhen 
uncomplicated  by  hereditary  taint,  or  previous  alcoholic 
excesses,  such  cases  usually  recover.  But  they  must 
not  be  mistaken  for  one  of  a  series  of  excitements  that 
usually  terminate  in  dementia. 

Senile  melancholia  is  a  frequent  accompaniment  of 
the  physiological  involution  of  the  brain  on  the  advent 
of  senility.  The  tendency  to  suicide  is  strongly  marked 
in  this  condition,  seventy-nine  per  cent,  of  such  cases 
showing  this  tendency.  But  little  can  be  said  of  the 
treatment  of  these  cases.  The  most  important  thing  to 
do  is  to  maintain  so  close  a  supervision  of  the  patient 
that  self-destruction  will  be  impossible.  The  most  sat- 
isfactory results  I  have  obtained  from  the  use  of  any 
drug  in  treating  the  insanities  incident  to  old  age  have 
come  from  the  use  of  opium.  Nature  in  the  second 
childhood  seems  as  susceptible  to  its  influence  as  in  the 
first  childhood.  When  there  is  great  restlessness  and 
fixed  insomnia,  the  use  of  opium,  beginning  with  small 
doses,  has  a  happy  efl^ect.  Moreover,  in  persons  who 
have  lived  the  allotted  time  of  threescore  years  and  ten, 
the  danger  of  establishing  the  opium  habit  is  not  to  be 
feared  so  much  as  if  the  patient  was  still  in  the  prime 
of  life.  

Antivivisection  and  Polo-playing. — We  notice  that  the 
editor  of  Our  Dumb  Animals  is  starting  a  war  on  polo- 
playing.  Polo-playing,  according  to  our  contemporary, 
is  '  a  meaner  sport  than  prize-fighting.  It  is,"  he  says, 
"cruel  and  brutal,  and  one  which  ladies  that  profess  to 
respectability  and  refinement  ought  to  be  ashamed  to 
countenance."  This  same  gentleman,  who  thus  attacks 
polo,  offers  a  prize  for  persons  who  detect  evidence  of 
vivisection,  and  gives  over  his  own  signature  a  most  ex- 
travagant eulogy  of  a  certain  cholera  and  dysentery 
syrup,  which,  he  says,  "  cured  a  lady  at  Rye  Beach, 
who  was  not  expected  to  live  through  the  night,"  and 
"cured  a  lady  in  Maine,  who  was  in  great  agony,  which 
the  doctor  did  not  relieve." 

A  Prominent  Sanitarian  asserts  that  if  all  the  chol- 
era germs  in  the  world  were  dumped  into  Lake  Michi- 
gan, Chicago  would  be  in  no  danger.  We  are  a  little 
in  doubt  whether  this  assertion  is  meant  to  be  con- 
sidered a  tribute  to  Chicago's  greatness,  or  the  diluent 
power  of  Michigan  water. 


55^ 


MEDICAL    RECORD. 


[October  19.  il 


ACUTE    (EDEMA    OF    THE     LARYNX,  WITH 
REPORT  OF    A  CASE.* 
By  F.  E.  HOPKINS,  M.D., 

NEW  YORK. 

ASSISTANT  SURGEON  TO  THE  MANHATTAN  EYE  AND  EAR  HOSPITAL  (THKOAT 
department);  assistant  surgeon  to  the  new  YORK  eve  AND  EAR  INFIR- 
MARY (EAR   department):    fellow  of   new  YORK  ACADEMY  OF   MEDICINE. 

Acute  cedema  of  the  larynx  is,  fortunately,  a  rare  af- 
fection, so  rare  and  of  such  gravity  as  to  warrant  the 
reporting  of  the  following  case  : 

On  January  24,  1895, 1  was  called  to  attend  J.  G , 

whom  I  found  suffering  from  a  mild  attack  of  la  grippe, 
which  was  epidemic  at  that  time.  The  patient,  a  stout, 
florid  male  of  Irish  birth,  about  forty-eight  years  of 
age,  a  dealer  in  masons'  supplies,  had  been  drinking 
both  spirits  and  malt  liquors  for  two  years,  and  grow- 
ing stout,  until  he  had  reached  a  weight  of  two  hundred 
and  thirty-five  pounds.  His  average  weight  for  the  six 
preceding  years  had  been  somewhat  less  than  two  hun- 
dred pounds.  His  attack  of  la  grippe  proved  a  mild 
one,  its  most  prominent  symptom  being  a  constant 
spasmodic  cough,  without  any  marked  pulmonary 
lesion.  I  saw  him  but  three  times.  On  the  29th  he 
seemed  quite  well,  and  he  was  left  with  a  ciution  against 
exposure.  The  patient  had  always  enjoyed  good  health, 
and  finding  confinement  to  the  house  irksome,  returned 
at  once  to  business.  Four  diys  later  I  was  called  to 
see  him  again,  when  he  was  suffering  from  acute  amyg- 
dalitis and  pharyngitis.  This  yielded  promptly  to  treat- 
ment and  the  patient  had  so  far  improved,  that  on  my 
visit  on  February  4th  I  told  him  that  I  would  not  call 
again  for  two  days.  We  were  at  that  time  having  the 
coldest  weather  of  an  unusually  cold  winter.  The  pa- 
tient again  recklessly  exposed  himself,  and  I  was  has- 
tily summoned  early  on  the  morning  of  February  6th. 
He  had  passed  a  restless  night  and  I  found  him  sitting 
in  a  chair,  breathing  with  some  difficulty  ;  his  voice 
was  hoarse  and  he  coughed,  but  without  expectoration. 
Examination  of  his  chest  revealed  no  lesion.  His  tem- 
perature was  100°  F.  and  pulse  112.  The  posterior 
wall  of  pharynx  and  the  larynx  were  much  congested, 
the  aryepiglottic  folds  and  the  ventricular  bands  were 
somewhat  swollen.  I  prescribed  warm  steam  inhala- 
tions, gave  tincture  a;onite  internally,  and  directed 
that  he  make  frequent  use  of  hot  nourishing  fluids. 

The  symptoms  grew  rapidly  worse  and  by  7  p.m.  his 
condition  was  truly  alarming.  He  was  restless,  inces- 
santly moving  about  and  demanding  that  the  windows 
be  opened,  that  he  might  get  more  air.  He  was  cya- 
notic and  his  expression  anxious.  His  respirations  were 
short  and  rapid,  all  the  accessory  muscles  being  brought 
into  the  utmost  activity.  Inspiration  was  stridulous, 
expiration  not  so  much  obstructed,  while  the  voice  was 
nearly  suppressed.  Swallowing  was  all  but  impossible, 
apparently  more  from  mechanical  obstruction  than 
from  pain,  though  the  latter  was  considerable.  His 
temperature  had  risen  somewhat,  being  102°  F.,  pulse, 
130.  On  examination  with  the  laryngoscope,  nothing 
but  the  epiglottis  could  be  seen.  This  appeared  enor- 
mously enlarged  in  every  direction — doubtless  the  ap- 
parent elongation  was  due  to  the  angle  at  which  the 
tumefaction  forced  it  to  stand.  The  oedema  was  great- 
est at  the  sides,  and  this  had  the  curious  effect  of  doub- 
ling the  epiglottis  upon  itself.  Its  upper  free  edge  was 
not  oedematous,  for  anatomical  reasons  pointed  out  by 
Hajek  ',  but  it  was  intensely  congested,  and  the  mucous 
membrane  covering  it  seemed  thickened  and  loose. 
On  each  inspiration  the  lateral  edges  of  the  epiglottis 
approximated  posteriorly,  and  then  this  tliickened  and 
loose  mucous  membrane  on  the  upper  free  edge  col- 
lapsed, falling  in  like  a  valve,  narrowing  still  further 
the  small  chink  through  which  the  patient  breathed. 
I  conclude  from  this  appearance  that  the  arytenoids 
and  aryepiglottic  folds,  which  I  could  not  see,  and  ow- 

•  Presented  as  a  candidate's  thesis  to  the  American  Laryngologtcal 
Association,  and  accepted  by  the  Association  at  its  Seventeenth 
Annual  Meeting.  June  17.  1895. 


ing  to  the  intense  dyspnoea  I  did  not  dare  attempt  to 
explore  with  my  finger — were  so  swollen  that  the  epi- 
glottis in  its  unnatural  position  rested  upon  them,  and 
the  patient  got  air  only  through  the  curious  opening 
just  described.  A  condition  of  the  epiglottis  similar  to 
this  has  been  reported  by  Baron.  ^ 

Earlier  in  the  day  I  had  planned  to  intubate,  should 
that  promise  to  afford  relief,  but  after  this  view  of  the 
parts  decided  to  scarify  instead.  Guided  by  the  mirror 
I  made  deep  incisions  first  upon  the  right  side  of  the 
epiglottis  and  then  .upon  the  left.  I  was  surprised  to 
see  my  incisions  as  gaping  clefts  in  a  mass  of  gelatine, 
followed,  by  little  hemorrhage  or  exudation  of  serum 
and  no  apparent  shrinking  of  the  oedematous  tissue. 
The  excitement  of  the  patient  and  his  struggle  for 
breath  were  making  him  so  restive  that  it  became  ap- 
parent that  if  anything  were  to  be  accomplished  by 
scarification  it  must  be  immediately.  Accordingly  fur- 
ther free  incision  was  made  into  the  tumid  mass.  This 
was  followed  by  more  free  bleeding,  and  evidently 
some  of  the  fluid  entered  the  larynx,  as  a  spasm  was  at 
once  excited  and  attended  by  most  frightful  dyspnoea. 
I  seized  a  bistoury,  intending  to  plunge  it  into  the 
trachea.  This  is  not  so  simple  a  matter  when  the  pa- 
tient; a  man  of  two  hundred  and  thirty-five  pounds,  is 
standing  in  bed  and  tearing  wildly  at  his  throat.  After 
watching  the  patient  a  moment,  and  being  convinced 
that  he  was  getting  air  enough  to  prevent  immediate 
suffocation,  1  did  what  I  could  to  calm  him  and  sent 
for  Dr.  J.  W.  Hurley,  the  nearest  physician,  to  assist 
in  performing  tracheotomy.  The  severity  of  the  spasm 
gradually  subsided  and  the  patient  could  breathe  with 
less  terrific  effort.  A  hypodermic  of  morphia  was  ad- 
ministered which  aided  still  further  in  the  relief  of 
spasm  of  the  larynx.  Leeches  were  applied  over  the 
larynx  and  following  them,  a  cold  coil. 

When  the  excitement  had  sufficiently  subsided  to 
allow  of  noting  the  pulse  it  was  found  dangerously  rapid 
and  weak,  and  free  stimulation  was  required  for  some 
days.  The  coil  was  worn  almost  continuously  for  three 
days,  and  the  air  of  the  room  kept  constantly  moistened. 
The  oedema  of  the  epiglottis  continued  sufficient  to 
prevent  a  view  of  the  arytenoids  until  the  fourth  day 
after  the  scarification,  when  they,  as  well  as  the  aryepi- 
glottic folds,  were  still  cedematous. 

The  patient  had  been  ill  to  such  a  slight  degree,  up 
to  the  time  of  the  laryngeal  symptoms,  that  my  atten- 
tion was  not  called  to  the  condition  of  his  kidneys.  No 
specimen  of  urine  could  be  secured  on  the  night  of  the 
6th,  the  urine  being  suppressed.  The  first  spaciraen  of 
urine  was  small  in  quantity,  of  dark  color  and  high 
specific  gravity,  containing  albumin  and  casts.  It  was 
noticed  by  the  Sth  that  his  lower  extremities  were 
oedematous,  and  he  became  somewhat  delirious.  Casts 
were  found  only  at  the  first  examination,  and  the  albu- 
min disappeared  from  the  urine  in  two  weeks  from  the 
onset  of  the  laryngeal  symptoms.  The  convalescence 
was  slow.  Although  the  element  of  danger  involved  in 
the  laryngeal  stenosis  seemed  to  have  passed  in  about 
three  days,  the  patient  did  not  recover  sufficient 
strength  to  allow  of  his  return  to  business  for  two 
months  from  the  beginning  of  the  original  attack. 

I  shall  but  touch  upon  the  history  of  the  subject,  as 
this  has  been  so  exhaustively  treated  by  many  writers, 
and  shall  consider  only  acute  crdema  affecting  the  up- 
per part  of  the  larynx. 

According  to  Mackenzie,^  the  ancient  authors  show 
no  clear  knowledge  of  the  disease.  Morgagni  in  1765 
gave  the  first  correct  account  of  it,  founded  upon  post- 
mortem examinations,  but  the  literature  of  the  subject 
dates  from  its  scientific  portrayal  by  Bayle,  in  1S15. 
In  1852  Sestier,  who  had  gathered  a  vast  amount  of 
statistical  evidence,  issued  a  standard  treatise,  and  this 
author  had  since  been  i]uoted  by  every  writer  who  has 
treated  the  subject  with  anything  like  thoroughness. 

That  the  disease  is  a  comparatively  rare  one  is  shown 
by  the  fact  that  the   Index  Medicus  for  1SS5  hid  no 


October  19,   1895] 


MEDICAL   RECORD. 


553 


reference  to  a  case  of  this  affection  ;  also  by  the  inves- 
tigation of  Peltesohn,'  who  found  that  of  5,161  patients 
treated  in  a  clinic  for  diseases  of  the  throat  and  nose, 
between  April  i,  1887,  and  June  i,  18S9,  there  were 
only  eight  cases  of  acute  oedema  of  the  larynx.  Of 
these  seven  were  men  between  twenty-one  and  forty- 
eight  years  of  age,  and  one  a  woman  fifty  eight  years 
of  age.  Seven  occurred  in  connection  with  local  in- 
flammatory conditions.  The  etiology  could  not  be  de- 
termined in  the  eighth.  Systemic  disease  could  not 
be  discovered  in  any  of  the  cases.  This  number  of 
cases  is  less  than  one-fifth  of  one  per  cent.,  and  these 
were  from  a  throat  clinic.  The  per  cent,  in  a  general 
clinic  would  be  small  indeed.  Peltesohn  also  examined 
the  records  of  autopsies  made  under  charge  of  Virchow, 
between  1873  and  1878,  with  the  following  results  :  In 
3,887  examinations,  oedema  of  the  lar)nx  was  noted 
210  times — 149  in  men,  40  in  women,  and  21  in  chil- 
dren. The  majority  of  men  were  between  the  ages  of 
eighteen  and  sixty  years,  and  women,  between  twenty- 
one  and  fifty-four  years,  while  13  of  the  children  were 
less  than  five  years  of  age.  Forty-four  cases  were  due 
to  local,  and  one  hundred  and  thirty-six  to  systemic, 
disease.  It  is  thus  seen  that  men  are  much  more  liable 
to  the  affection  than  women,  and  that  relatively  few 
cases  occur  in  childhood. 

Etiology. — The  causes  of  the  afifection  are  many  and 
various.  The  influence  of  age  and  sex  is  marked,  as 
appears  from  the  above  statistics,  while  those  of  Ses- 
tier  are  similar.  The  influence  of  exposure  to  cold  is 
seen  in  the  fact  that  the  greatest  number  of  cases  occur 
during  the  winter  season.  Recent  writers  seem  in- 
clined to  the  theor>'  of  infection  as  a  common  cause. 
Exposure  to  cold,  or  any  similar  condition  which  re- 
duces the  resisting  power  of  the  mucous  membrane  of 
the  larynx,  makes  possible  the  very  entrance  of  strep- 
tococci or  pneumococci,  bacteria  which  are  at  all  times 
to  be  found  in  the  mouth  and  nose.  Such  is  the  opin- 
ion of  Garel,'  Barjon,'^  and  Kuttner,'  and  bacteriologi- 
cal examinations,  as  reported  by  them,  have  shown  the 
presence  of  the  bacteria  named.  Primary  erysipelas 
of  the  larynx,  first  alluded  to  by  Radcliffe,"  but  thor- 
oughly investigated  by  Massei,'  belongs  to  the  diseases 
of  infectious  origin  and  falls  into  this  categorj-.  Mas- 
sei  is  quoted  by  every  recent  writer  upon  the  subject 
of  oedema  of  the  larynx,  and  has  the  support  of  the 
best  authorities.  Virchow"  says  that  these  acute 
cases  of  oedema  of  the  larynx,  on  closer  analysis,  prove 
to  be  cases  of  erysipelas  of  the  larynx.  Anatomically, 
erysipelas  is  but  an  oedematous  swelling.  At  first 
Massei  was  inclined  to  base  his  diagnosis  upon  the 
presence  of  Fehleisen's  coccus,  but  recent  investiga- 
tions "  have  proven  that  it  is  impossible  to  differentiate 
between  this  and  staphylococcus  pyogenes  aureus ; 
and  he  now  depends  upon  three  principal  points  in  the 
clinical  aspect  of  the  case  :  the  rapid  dysphagia,  the 
character  of  the  oedema — -as  its  livid  color  and  easy 
displacement — and  the  remitting  temperature. 

Acute  cedema  may  occur  during  the  course  of  sys- 
temic disease.  Some  renal  disease  is  mentioned  by 
writers  as  the  one  most  often  thus  complicated  ;  but 
this  must  evidently  be  rare,  for  Mackenzie"  examined 
the  laryn.x  in  two  hundred  cases  of  Bright's  disease 
without  finding  oedema  present  in  a  single  instance. 
'  Albumin  is  often  present  during  a  grave  case  of  oede- 
ma of  the  larynx,  but  according  to  Barjon  *  this  is  to 
be  looked  for  as  a  usual  accompaniment  of  the  local 
disease,  and  the  urine  is  free  from  albumin  within  two. 
or  at  the  latest  three,  weeks.  This  was  true  in  my  case, 
the  albumin  disappearing  in  about  two  weeks.  It  may 
occur  in  the  case  of  small- pox,  typhoid  fever,  diphtheria, 
scarlet  fever,  or  any  of  the  exanthems."  A  curious  neu- 
rotic affection  closely  connected  with  urticaria,  and  char- 
acterized by  the  sudden  appearance  of  circumscribed 
areas  of  oedema  in  different  parts  of  the  surface  of  the 
body,  has  been  described  by  Osier  in  a  paper  read  before 
the  Philadelphia  Neurological  Society.'^     The  larynx 


may  be  invaded  by  the  same  process.  The  term  angio- 
neurotic oedema  has  been  applied  to  this  condition.  A 
case  of  this  kind  was  reported  by  Pryor.'^  The  patient, 
a  healthy  male,  thirty  years  of  age,  a  dentist,  devel- 
oped a  sudden  oedema  of  the  larynx  without  ascertain- 
able cause.  This  reached  a  dangerous  degree  of  infil- 
tration, but  under  active  treatment  subsided,  and  the  man 
resumed  work  within  forty-eight  hours  of  the  attack. 

Cases  af  acute  cedema  following  the  use  of  iodide  of 
potassium  have  been  reported  by  Avellis  ^^  and  by 
Baumgarten  ^'^  and  others.  I  have  seen  one  such  case 
in  a  woman  of  about  thirty  years  of  age,  in  whom  so 
small  a  dose  as  twelve  grains  three  times  a  day  for  two 
days  produced  decided  symptoms.  It  may  occur  dur- 
ing the  course  of  rheumatism  affecting  the  crico-arj'te- 
ndid  articulation.  It  may  occur  from  traumatism, 
scalds,  the  presence  of  a  foreign  body,  the  swallowing 
of  corrosive  poisons,  or  the  inhalation  of  flame.^' 

Recently  several  cases  have  been  reported  as  follow- 
ing or  complicating  la  grippe.  Dr.  Robertson  ^'  re- 
ports three  such  cases  in  children,  the  youngest  eight 
months  old,  the  oldest  seven  years.  Rhu ''  reports 
three  cases  in  adults.  Tucker  "°  describes  a  case  of 
septicaemia  occurring  during  the  prevalence  of  la 
grippe,  complicated  by  cedema  of  the  larynx.  In  this 
case  the  true  cords  were  much  involved  in  the  cedema-. 
tous  process.  The  cases  following  la  grippe  should 
perhaps  properly  be  classed  with  those  due  to  infec- 
tion. I  do  not  know  of  any  bacteriological  examina- 
tion in  this  connection,  but  all  the  conditions  necessary 
to  infection  are  present,  the  patient  being  debilitated 
by  disease  and  the  bacteria  present  in  the  throat  ready 
to  set  up  infection.  Indeed,  several  of  the  cases  re- 
ported followed  a  faucial  or  pharyngeal  inflammation. 
One  by  Rhu  '  complicated  a  posterior  pharyngeal  ab- 
scess and  terminated  fatally.  Seious  effusion  into  the 
laryn.x  may  also  occur  as  the  result  of  an  obstruction 
to  the  return  of  venous  circulation,  caused  by  the  pres- 
ence of  an  aneurismal  or  other  tumor  in  the  cervical 
or  upper  thoracic  region  ;  "  and  in  the  various  forms 
of  cardiac  disease,  and  the  direct  complication  of  spe- 
cific forms  of  inflammation  of  the  larynx,  as  syphilis, 
tuberculosis,  and  perichondritis.'' 

Pathology. — The  disease  is  due  to  a  transudation 
from  the  blood-vessels  into  the  submucous  connective 
tissue,  and  this  transudation  is  most  abundant  in  those 
parts  in  which  there  is  the  most  connective  tissue,  that 
is,  in  the  arjepiglottis  folds,  the  ventricular  bands,  and 
the  anterior  face  of  the  epiglottis  to  within  a  short  dis- 
tance of  its  free  edge.'  It  is  exceedingly  rare  that  this 
process  involves  the  true  vocal  cords  or  extends  to  the 
subglottic  region.  This  character  of  the  cedema  pro- 
duced varies  greatly.  In  those  cases  which  have  been 
called  primary  erysipelas  of  the  larj-nx.  the  exudation 
is  superficial  and  the  parts  are  easily  drained  of  the 
contained  serum  by  scarification.  According  to  Mas- 
sei, as  quoted  by  Garel,  the  appearance  is  quite  like 
that  of  a  nasal  myxoma  in  color,  and  the  tumor,  easily 
displaced,  is  of  a  trembling  gelatinous  consistency.  In 
the  most  acute  and  rapidly  fatal  cases  pure  serum  only 
is  found.'  It  must  be  in  these  cases  that  scarification 
is  followed  by  such  prompt,  not  to  say  magical,  results. 

In  certain  cases  the  network  of  submucous  connec- 
tive tissue  holds  the  imprisoned  serum  so  rightly  with- 
in its  meshes,  that,  as  Bayle  expressed  it,  it  cannot  be 
squeezed  out.  This,  however,  does  not  prevent  the 
cedema  from  gradually  emptying  itself  through  the 
punctures  made  in  scarification.-  It  is  in  these  cases 
that  the  immediate  results  of  scarification  are  disap- 
pointing. One  may  be  led  by  his  reading  to  anticipate 
prompt  relief  to  the  dyspnoea  upon  incising  the 
oedematous  tissue,  but  in  this  form  the  patient  may  for 
a  brief  period  be  thrown  into  a  still  more  alarming 
state.  The  flow  of  blood  following  incision  may  enter 
the  larynx  and  excite  spasm  so  severe  as  to  threaten 
instant  suffocation.  In  the  phlegmonous  variety, 
which,  according  to  Kuttner,-"  may  be  regarded  as  a 


554 


MEDICAL   RECORD. 


[October  19,  1895 


later  stage  of  the  serous,  the  transudation  changes  to 
sero-purulent,  or  becomes  purulent  with  abscess  forma- 
tion. In  this  event  the  abscess  is  usually  limited  to  one 
side.'"  Mackenzie  says  the  pus  is  always  diffused,  cir- 
cumscribed abscess  never  occurring  as  a  sequel  of  acute 
inflammation  of  the  larynx.  Post,*'  however,  reported 
an  autopsy  upon  a  case  in  which  he  found  fibrinous 
exudation  in  the  larynx  with  points  where  suppuration 
had  occurred. 

Symptoms. — The  attack  may  be  ushered  in  by  a 
chill,  but  the  temperature  following  is  not  usually  high  ; 
101°  F.  was  noted  in  my  case.  This  chill  may  simply 
be  the  result  of  exposure  to  cold.  Cough,  hoarseness, 
and  pain  are  observed,  but  the  symptoms  of  prime  im- 
portance are  those  referable  to  respiration.  Owing  to 
the  rapid  infiltration,  especially  in  the  serous  form, 
respiration  is  early  obstructed,  and  the  infiltration  often 
advances  so  rapidly  that  within  twelve  hours  of  the  at- 
tack the  patient's  condition  becomes  one  of  great 
gravity.  Inspiration  is  at  first  more  obstructed  than 
expiration,  as  the  swollen  tissue  tends  to  roll  in,  and, 
valve-like,  to  close  the  larynx,  while  expiration  is  not 
so  much  interfered  with. 

The  rapid  progress  of  the  disease  is  well  illustrated 
by  the  case  reported  by  Edes."  The  patient,  an 
athlete  in  excellent  health,  aged  thirty-five,  after  ex- 
posure to  cold  had  a  chill  followed  by  faucial  inflam- 
tion.  A  few  hours  later  he  suddenly  sprang  out  of 
bed,  said  he  was  suffocating,  ran  a  few  steps,  and  died 
within  a  few  moments.  At  no  time  previous  to  the 
final  seizure  had  there  been  any  complaint  of  difficulty 
in  breathing,  nor  had  dyspnoea  been  noticed  by  the  at- 
tendants. The  autopsy  showed  a  marked  degree  of 
oedema  of  the  submucous  connective  tissue  of  the  epi- 
glottis, aryepiglottic  folds,  and  cords. 

The  voice,  at  first  not  much  altered,  becomes  gradu- 
ally hoarse,  and  later  may  be  lost  or  only  a  hoarse  whis- 
per, due  to  the  overhanging  masses  of  swollen  tissue, 
the  interarytenoid  tumefaction,  or  to  infiltration  of  the 
muscles  themselves.  The  cough  is  unproductive.  It 
seems  to  be  an  effort  to  rid  the  throat  of  what  the  pa- 
tient describes  as  some  foreign  body.  Pain  is  not  al- 
ways severe,  but  an  effort  to  swaliow,  especially  if  the 
epiglottis  is  involved,  causes  distress,  chiefly  because  of 
the  mechanical  obstruction.  The  patient  assumes  the 
sitting  posture,  seeking  some  support  for  his  hands, 
that  the  auxiliary  muscles  aiding  respiration  may  be 
brought  into  the  fullest  possible  activity.  The  face  be- 
comes first  flushed,  then  cyanotic,  and  the  whole  body 
trembles  from  the  excitement  and  the  muscular  tension 
required  to  sustain  respiration.  The  symptoms  are  ag- 
gravated at  night,  for,  as  the  i)atient  falls  asleep,  the 
conscious  effort  to  aid  respiration  which  has  been 
maintained  during  the  day  is  suspended.  The  urine  is 
scanty  and  of  high  color,  and  in  the  grave  cases  con- 
tains albumin." 

Diagnosis. — In  acute  laryngeal  stenosis  we  have  to 
determine  whether  the  given  case  be  one  of  oedema  or 
of  foreign  body  in  the  larynx.  The  history  of  the  case 
will  usually  afford  some  aid  ;  but  the  laryngoscope  is 
to  be  relied  upon  not  only  for  differential  diagnosis, 
but  at  the  same  time  to  reveal  the  degree  of  the 
stenosis.  One  also  gains  a  knowledge  of  the  location 
and  character  of  the  ojdema,  whether  it  be  superficial 
serous  exudation  or  the  intense  congestion  indicative 
of  phlegmon.  Palpation  has  been  employed,  but  it  is 
brutal  and  not  devoid  of  danger,  as  it  may  excite  dan- 
gerous spasm  of  the  larynx.  Harjon  mentions  an  in- 
teresting point  in  external  palpation.  If  one  seize  a 
healthy  larynx  between  the  thumb  and  fingers,  and 
pressing  it  backward  upon  the  spinal  column,  give  it  a 
lateral  movement,  there  is  produced  a  very  perceptible 
crackling  sound,  caused  by  the  spring  of  tlie  cartilage 
against  tiie  vertebra.  In  laryngeal  irdema  the  infiltra- 
tion of  the  posterior  portion  of  the  larynx  forms  an  iso- 
lating cushion  which  prevents  this  crackling  sound. 
Prognosis. — This  is  always  grave  except  in  those  rare 


cases  in  which  the  oedematous  process  is  limited,  as  to 
one  side  of  the  larynx.  Even  the  apparently  mildest 
case  may  develop  a  rapid  oedema  which  proves  fatal 
within  a  few  hours.  Much  depends  upon  the  stage  at 
which  the  case  comes  under  observation,  and  the 
promptness  and  vigor  with  which  measures  for  relief 
are  employed.  Those  cases  of  superficial  serous 
oedema,  if  seen  early,  offer  better  hope  of  recovery 
than  those  of  the  phlegmonous  variety.  Primary 
oedema  is  less  likely  to  prove  fatal  than  secondary. 
Prospect  of  recovery  in  the  latter  depends  in  part  upon 
the  general  disease  or  the  local  condition  with  which  it 
is  associated.  Secondary  oedema  coming  on  in  con- 
nection with  typhoid  fever  and  small-pox  is  likely  to 
be  fatal. 

The  period  of  the  most  urgent  symptoms  does  not 
usually  last  beyond  three  or  four  days.  If  the  infiltra- 
tion has  not  reached  a  suffocative  degree  within  that 
time  it  will  probably  not  be  the  direct  cause  of  death.'-' 
There,  however,  remains  the  danger  of  complications — 
pneumonia,  septicemia,  or  cardiac  involvement — and 
in  any  case  of  continued  dyspnoea  the  convalescence  is 
likely  to  be  prolonged  because  of  the  patient's  great 
prostration. 

Sestier,  quoted  by  Mackenzie,"  found  that  the  affec- 
tion proved  fatal  in  158  out  of  213  cases  in  spite  of 
tracheotomy  performed  thirty  times.  In  the  55  cases 
which  recovered  tracheotomy  was  performed  twenty 
times.  Bayle's^  statistics  are  much  less  favorable,  as 
he  reports  17  cases  with  r6  deaths.  It  would  be  inter- 
esting to  know  if  the  mortality  is  less  at  present  by 
reason  of  treatment.  I  have  not  found  statistics  of 
any  large  number  of  cases,  but  those  I  have  gathered 
from  medical  journals  of  the  past  few  years  make  a 
much  better  showing.  They  are,  however,  not  numer- 
ous enough  to  allow  of  any  definite  deductions. 
There  is  the  suspicion,  too,  that  only  the  more  favor- 
able results  secure  publication. 

Treatment. — After  attempting  to  read  even  one  of 
the  exhaustive  and  laborious  German  monographs 
upon  the  subject  of  oedema  of  the  larynx,  in  which  the 
history  of  the  subject,  its  etiology  and  bacteriology  re- 
veal a  faithfulness  of  research  which  excites  one's  ad- 
miration— and  proves  at  the  same  time  a  trifle  appall- 
ing— it  is  a  relief  to  come  to  the  subject  of  treat- 
ment. 

Notwithstanding  the  gravity  of  the  condition  which 
confronts  one,  and  the  conflicting  ideas  on  etiology, 
there  is  a  reassuring  definiteness  in  the  i)lan  of  treat- 
ment ;  and  in  a  portion  of  the  cases  the  response  to 
vigorous  and  well-timed  measures  of  relief  is  prompt 
and  gratifying.  If  a  case  be  seen  at  the  beginning  of 
an  attack,  the  treatment  for  a  severe  acute  inflamma- 
tion of  the  larynx  is  to  be  recommended.  The  inhala- 
tion of  warm  medicated  vapor,  the  use  of  diaphoretics, 
the  maintenance  of  the  patient's  room  at  an  equable 
temperature,  72°  F. — with  the  air  moistened  by  the 
vapor  of  boiling  water  ;  and  at  a  later  stage  the  appli- 
cation of  leeches  over  the  region  of  the  larynx,  to  be 
followed  by  the  continuous  use  of  the  cold  coil.  The 
sucking  of  pellets  of  ice  is  also  to  be  recommended. 
Upon  the  appearance  of  a-dema,  however,  scarification 
with  the  laryngeal  lancet  should  be  performed.  By 
the  aid  of  the  laryngoscope  this  can  easily  be  done,  for. 
in  spite  of  the  struggle  for  breath,  patients  readily  and 
quietly  submit  to  the  operation.  In  those  cases  of 
superficial  ix^dema  the  relief  which  follows  scarification 
is  spoken  of  as  little  less  than  magical ;  but  it  is  well 
to  remember  that  the  particular  case  before  one  may 
be  that  of  more  solid  a-denia,  in  whicli  the  exuded 
serum  is  held  tightly  imprisoned  in  the  meshes  of  the 
connective  tissue,  so  that  the  serum  drains  olT  but 
slowly  and  little  relief  immediately  follows  the  scarifi- 
cation. Indeed,  spasm  of  the  larynx  may  be  excited 
and  for  a  time  tiie  patient's  condition  seem  even  more 
critical.  This  method  of  affording  relief  was  first  em- 
ployed by  I.isfranc  in  1823,''  but  the  operation  fell  into 


October  19,   1895] 


MEDICAL    RECORD. 


555 


disuse.  It  was  first  done  in  this  country  by  Buck,"'' 
who  reported  cases  in  1S48.  He  was  led  to  the  adop- 
tion of  the  method  by  his  own  reasoning,  not  being 
aware  that  it  had  previously  been  employed.  During 
a  period  of  eleven  months  he  saw  the  surprising  num- 
ber of  eight  cases.  Five  of  these  he  scarified,  and  all 
of  them  recovered. 

Lennox  ISrowne-'  recommends  the  hypodermic  injec- 
tion of  muriate  of  pilocarpine,  one  twelfth  to  one-fourth 
a  grain,  and  the  International  Medical  Magazine  for 
1892,  Vol.  I.,  contains  a  report  of  two  cases  in  which 
the  use  of  one-eighth  grain  hypodermically  was 
promptly  followed  by  the  constitutional  effects  of  the 
drug,  and  within  an  hour  there  was  marked  subsidence 
of  the  laryngeal  cedema.  In  serous  cedema  Garel  ^ 
recommends  the  application  of  pure  tincture  of  iodine 
after  cocainizing,  and  reports  good  results  from  its  use. 


INTESTINE  CONSTRICTED  BY  VERMIFORM 
APPENDIX— OBSTRUCTIONS— OPERATION 
—RECOVERY. 

By  DWIGHT    H.  MIRKAV,   M.D., 


On  Friday,  June  14th,  at  5  p.m.,  I  was  called  by  Dr.  J. 

A.  Belch   to  see  Wesley  D ,  aged  seven  and  a  half 

years.     The  following  history  of  the  case  was  given  : 

On  Monday,  June  loth,  he  had  eaten  very  heartily  of 
"potted  meat ;"  on  Tuesday  he  vomited  and  purged 
five  or  six  times,  which  was  followed  by  a  very  severe 
pain  in  the  bowels,  so  that  "  he  danced  about  the  house," 
as  the  mother  expressed  it.  •This  vomiting  and  pain 
continued  until  Thursday,  June  13th,  when  the  father 
consulted  Dr.  Belch  at  his  office,  thinking  it  unnecessary 


Various  drugs,  as  cocaine,  astringents,  etc.,  have 
been  sprayed  into  the  larynx,  and  while  these  may 
be  of  some  avail,  one  should  not  temporize  too 
long  in  their  use,  but  employ  scarification,  which 
is  to  be  repeated  if  necessary.  The  recurrence  of 
(jedema,  however,  is  less  likely  to  take  place  if  one 
persists  in  the  use  of  the  cold  coil  and  pilocarpine. 
The  temperature  is  not  usually  sufficiently  elevated 
to  call  for  attention.  It  should,  however,  be  watched 
as  affording  a  warning  of  the  beginning  of  complica- 
tions. Of  these,  pneumonia  and  septiciemia  are  the 
most  frequent. 

In  case  all  the  measures  suggested  fail  to  afford 
relief,  then  tracheotomy  should  be  done,  nor  should 
this  be  delayed  till  the  patient  has  become  so  e.\- 
hausted  as  to  render  the  operation  almost  hopeless. 
Intubation -^  has  been  performed  in  several  cases, 
and  will  have  a  limited  application  in  this  affection, 
especially  in  those  rare  cases  where  the  1  ords  or  the 
parts  immediately  adjacent  are  principally  in- 
volved. One  should  be  prepared  either  to  intu- 
bate or  perform  tracheotomy,  as  may  seem  indi- 
cated. The  exhausting  character  of  the  affection  m\ist 
be  borne  in  mind,  and  feeding,  stimulation,  and  tonic 
medication  receive  careful  attention,  both  during  the 
attack  and  during  the  convalescence,  which  in  many 
cases  is  jjrolonged. 


Hajek  :  Archiv.  fur  klin.  Chir..   xln.,pp   46-93,  Berlin,  i8c,i. 
Baron     ------- 

M.ickenzie  :  Diseases  ofthe   Pharynx,  Larynx,  and  Tracli 


British  Medical  Journal,  December  17. 
of  thi 
200.    William  Wood  &  Co 


a,   p. 


'  Peltesohn  :  Ab^tracls  in  Sajous's  Annals  of  the  University  of 
Medical  Sciences,  1890,  vol.  iv. 

■  Garel :  .\nnalcs  des  Maladies  de  I'Oreille,  du  Larynx,  Paris, 
)uly,  1891. 

«  Barjon  ;  Gazette  des  Hnpitaux,  Paris,  May  19,  1894 

'■  Kuttncr:   Larynxodem  und  submucose  laryngitis,  Berlin,  iSt/5 

•  Radcliffe  ;   Lancet,  1835. 

'  Massei :  Ueber  d.as  primitre  Erysipel  des  Kehlkopfs,  Berlin,  1886. 
(German  translation  ) 

I"  Virchow  :  Verhandlungen  dcr  medicinischen  Gesellschaft,  Berlin, 
May  II,  1887,  i.,  p.  80. 

"Kuttner:   Pages  43  and  44. 

"  Bosworth  :   ijisea.ses  of  thi;  Nose  and  Throat,  vol.  if,  p.  5-i3. 

'■'  O-sler  ;  .\merican  Journal  of  the  Medical  Sciences,  vol.  xcv. ,  ])  362. 

"  Pryor :  Mkuicai,  R»cord,  July  28,  1894. 

'■■'  Avellis  :  Wiener  med.  Woch  ,  -Xos.  46  to  48,  1892.  (Abstr.ict  of 
journal  of  Laryng.  and  Rhin  .  1894.) 

|«  Baumgarten:  Deutsche  med.  Woch.,  1892,  No.  9.  (Abstract  ol 
journal  of  Laryng.  and  Khin  ,  1894.) 

".\rnold:  System  of  Diseases  of  the  Ear,  Nose,  and  'throat, 
vol.  ii.,  p.  318,  Philadelphia,  1894. 


for  the  doctor  to  call  at  the 
house,  saying  that  it  was  a  bil- 
ious attack. 

On  Thursday  he  began  with 
stercoraceous  vomiting,  which 
continued  until  Friday  morning, 
when  Dr.  Belch  was  called  to 
the  house.  The  doctor  used 
several  high  rectal  enemata  (the 
boy  having  had  no  bowel  move- 
ment since  Tuesday,  the  nth). 
No  result  was  obtained  from 
the  rectal  enemata.  and  at  this 
time  I  first  saw  the  case.  After 
a  careful  examination  we  de- 
cided the  case  to  be  one  of  in- 
testinal obstruction,  and  after 
giving  a  serious  prognosis  the 
patient  was  removed  to  the 
Women's  and  Children's  Hos- 
pital on  Washington  Street.  At 
7.30  P.M.  the  hospital  staff  was 
''"^-  '■  called  together  and   after  con- 

sultation it  was  decided  to  defer 
operation  until  morning,  continuing  high  rectal  ene- 
mata of  glycerine  and  saturated  solution  of  magnesium 
sulphate,  alternating  each  hour,  and  applying  hot  stupes 
externally.  At  8.30  p..m.  a  large  quantity  of  stercora- 
ceous material  was  vomited,  after  which  the  patient 
rested  quietly  all  night. 

At  8.30  A.M.  on  the  15th,  the  hospital  staff,  with  the  ad- 
dition of  Drs.  Heffron,  .Mfred  Mercer,  and  Belch  met, 
all  preparations  having  been  made  for  ojieration  The 
boy  having  passed  a  comfortable  night,  and  his  general 
condition  being  good,  he  was  i)laced  upon  the  table  at 


'«  Robertson:  Northwestern  Lancet   St.  Paul,  December  i,  1892. 

'»  Rhu :  International  Medical  Magazine,  Philadelphia,  1892,  vol.  i., 
p,  839. 

so  Tucker:  Chicago  Medic^il  Record.  1892,  vol.  iii.,  p.  40. 

'"  Brown;  Diseases  ofthe  Throat,  3d  edition,  p.  299. 

••'■•'  De  Blois  :  Transactions  of  the  American  Laryngological  Associa- 
tion, 1886. 

"  Kuttner,  p.  61. 

•-'  Post :  New  York  Medical  Press,  1859.  p.  557. 

"  Edes  :  Boston  Medical  and  Surgical  Journal,  February  4,  i8f6. 

-»  Buck:  Transictions  ofthe  .-\mencan  Medical  Association,  vol.  i., 
p.  135. 

-■  Medical  Record,  May  5,  1888,  p.  499;  Chicago  Medical  Rec- 
ord, 1892,  vol.  iii.,  p.  41  ;  Medical  Record,  September  10,  1887,  p. 
355. 


556 


MEDICAL   RECORD. 


[October  19,  iJ 


9  A.M.  A  careful  examination  was  given  under  an 
anesthetic  :  no  tumor  or  other  evidence  of  obstruction 
except  constipation  being  present,  it  was  advised  to 
give  a  dose  of  calomel  and  wait  a  still  longer  time. 
Several  high  enemata  were  given  through  a  long,  stiff, 
rectal  tube,  with  no  result  except  the  clear  water  re- 
turning. At  2.30  P.M.  ten  grains  of  calomel  were  admin- 
istered, stupes  continued,  and  three  high  enemata  were 
given  before  9  a.m.,  Sunday,  the  i6th,  no  further  vom- 
iting occurring.  I  again  saw  him  at  9  a.m.  on  the  i6th, 
and  feeling  that  no  further  time  should  be  lost  called 
the  staff  together,  and  it  was  agreed  to  operate,  which  I 
did  at  12  M.,  assisted  by  Dr.  Breese  ;  anesthetic  given 
by  Dr.  Wynkoop.  Present,  Drs.  A.  B.  Randall,  R.  C. 
McLennan,  F.  W.  Sea^s,  Alfred  Mercer,  and  J.  A. 
Belch. 

Median  incision  was  made,  the  presenting  gut  held 
by  Dr.  Breese.     I   followed  the  gut  down  to  the  right 


''(0////r-:^^ 


At  2.45  P.M.  he  passed  one  ounce  of  urine  and  had  a 
small  movement  from  the  bowels,  which  was  thin  and 
dark  brown  in  color  ;  at  3.45  an  involuntary  movement 
of  the  same  character.  Between  this  time  and  6.10 
P.M.  he  had  three  other  movements  ;  at  2  a.m.  a  formed 
movement,  and  from  this  time  to  the  time  of  his  dis- 
charge from  the  hospital  there  were  no  bad  symptoms 
of  any  kind,  the  temperature  only  going  to  101°  F.  at  9 
in  the  forenoon  after  the  operation,  falling  to  normal 
at  5  the  next  morning,  never  going  to  100°  after  that. 
He  was  discharged  from  the  hospital  July  5th,  entirely 
recovered. 

This  forra  of  intestinal  obstruction,  so  far  as  I  have 
been  able  to  find  from  the  literature,  is  very  rare,  if 
not  unique.  Dr.  Treves  in  his  work  on  intestinal  ob- 
struction states  that  this  form  of  obstruction  has  been 
claimed  to  have  existed,  but  that  it  is  difficult  to  credit 
it.     On  this  account  I  feel  that  it  is  important  to  place 


i'/jlv/'l/'ni    //■■■  'Ijii '"'        ■  '  /    '^■7/ 


iliac  fossa,  where  I  found  a  hard 
mass,  which  was  brought  up  into 
the  incision  and  proved  to  be  the 
obstruction,  which  was  caused  by 
the  vermiform  appendix  wound 
around  a  loop  of  the  ileum,  over 
and  under,  the  end  of  the  appen- 
dix having  passed  upward  from 
the  back  side  of  the  mass  be- 
tween the  ileum  and  the  caput 
coli.  The  end  of  the  appendix 
was  enlarged  and  slightly  adher- 
ent to  the  ileum  by  newly  formed 
adhesions.  The  constriction 
was  very  tight,  producing  com- 
plete obstruction  to  the  gut.  It 
was  with  difficulty  that  the  ap- 
pendix could  be  pulled  away 
frorri  the  ileum  so  that  the  con- 
stricted loop  of  the  intestine 
could  be  drawn  through  the  knot 
that  had  been  tied.  When  this 
was  done,  however,  the  appendix 
lay  free  in  the  abdominal  cavity,  ^^^  , 

the  end  of  it  being  clubbed,  then 

a  narrow  portion  under  the  enlargement,  and  the  remain- 
der being  of  normal  size,  as  shown  by  Figs.  3  and  4.  The 
appendix  was  two  inches  in  length,  and  was  removed  at 
a  point  one-half  inch  from  the  caput  coli.     Figs,  i   and 


this  case  upon  record  as   an  authentic  case  seen  by 

several  physicians. 

The  lesson  I  would  draw  from  this  case  is  :  That  the 
cessation  of  pain  and  stercoraceous  vomiting,  the  con- 
stipation being  unrelieved,  is  neither  a  reason  for  dela\- 
nor  renders  an  operation  less  urgent.  The  operation 
in  this  case  was  delayed  twenty-six  hours  on  account 
of  the  stopping  of  vomiting,  pain,  and  the  apparent 
absence  of  tumor. 

426  James  Street. 


2  show,  respectively,  the  front  and  back  views  of  the 
obstruction  as  it  existed  at  the  time  of  opening  the  ab- 
dominal cavity. 

The  time  of  operation  was  twenty-five  minutes  ;  the 
recovery  from  the  anesthetic  was  good,  no  vomiting. 


The  Legibility  of  the  Prescription. — In  an  amusing 
French  farce,  "  Le  Homard,"  a  husband  suddenly  re- 
turning home  one  evening  surprises  a  stranger  with  his 
wife.  The  latter  does  not  lose  her  presence  of  mind, 
and  says  to  the  husband  that,  having  suddenly  been 
seized  with  illness  she  had  sent  her  maid  for  the  first 
available  doctor,  and  that  this  gentleman  was  the  doctor. 
The  husband  thanks  the  gallant  for  his  speedy  appear- 
ance, and  asks  if  he  has  already  prescribed  anything. 
The  gallant,  who,  of  course,  is  not  a  doctor,  tries  to 
make  himself  scarce  ;  but  the  anxious  husband  insists 
on  having  a  prescription,  so  that  the  Galen,  bathed  in 
cold  perspiration,  is  compelled  to  give  one.  The  hus- 
band casts  a  glance  at  it  ;  it  consists  of  wholly  illegi- 
ble marks.  "  And  will  the  chemist  be  able  to  read 
that  ?  ■'  asks  the  husband,  shaking  his  head.  "  As  if  it 
were  print,"  asseverates  the  false  physician,  again  try- 
ing to  make  his  escape.  The  husband,  however,  ad- 
jures him  to  remain,  and  holds  him  fast  till  the  maid 
returns  from  the  chemist.  In  a  few  minutes  she  makes 
her  appearance.  The  llalen  prejiares  himself  for  a 
catastrophe.  No.  The  maid  brings  a  phial  of  medi- 
cine, a  box  of  pills,  and  some  powders.  "  Did  the 
chemist  give  you  those  ?  "  demands  the  Galen  in  be- 
wilderment. "Certainly."  "On  my  prescription-  ' 
"Of  course  it  was  on  your  prescription,"  replies  the 
astonished  maid.  "  Has  the  chemist  made  some  mis- 
take ?  '  interposes  tlie  troubled  husband.  "  No,  no." 
our  Galen  hastens  to  reply  :  but  he  contemplates  tl.c 
medicines  for  a  lon^  time  and  becomes  lost  in  reverie. 


October  19,    1895] 


MEDICAL    RECORD. 


557 


Medical    Record: 

A  Weekly  Journal  of  ^lediciHe  and  821) goy. 


GEORGE    F.  SHR.\DY,  A.M.,  M.D.,  Editor. 


PUBLISHBRS 

WM.  WOOD  &  CO.    43   ^5   &  47  East  Tenth   Street. 


New  York,  October  19,  1895. 


OYSTERS   AND   TYPHOID   FEVER. 

Professors  Herdman  and  Boyce  recently  presented 
to  the  British  Association  for  the  Advancement  of  Sci- 
ence a  report  upon  the  cultivation  of  oysters  and  their 
relation  to  typhoid  fever  and  other  diseases.  This  re- 
port is  the  result  of  an  experimental  inquiry  into  the 
effect  of  oysters  of  various  external  conditions,  includ- 
ing pathogenic  organisms.  This  country,  which  is 
such  an  extensive  consumer  of  oysters,  ought  not  to  be 
indebted  to  European  scientists  for  knowledge  regard- 
ing the  relation  of  oysters  to  infective  diseases.  For 
some  reason,  however,  not  very  much  has  been  done 
here  in  this  direction,  except  to  investigate  certain 
special  epidemics.  The  facts  established  by  Professors 
Herdraan  and  Boyce,  therefore,  should  be  of  much 
practical  value  to  oyster  growers  and  oyster  consumers. 
The  observations  of  the  gentlemen  in  question  showed 
that  oysters  were  very  much  benefited  by  having  plenty 
of  air,  or,  in  other  words,  by  being  supplied  by  water 
in  which  there  is  an  active  change  produced  by  tidal  or 
other  currents.  They  established  the  fact  that  oysters 
can  be  made  to  grow  fat  or  to  become  sick  and  die, 
according  to  the  kind  of  food  with  which  they  are  sup- 
plied. The  oyster  is,  for  example,  verj'  much  harmed 
by  the  action  of  sugar,  and  it  does  not  thrive  upon  oat- 
meal. The  oyster  is  injured  also  by  the  micro-organ- 
isms that  develop  in  stagnant  water ;  on  the  other 
hand,  it  seems  to  tolerate  sewage  very  well,  and  it  was 
found  that  it  even  has  a  certain  capacity  for  clearing 
contaminated  water  of  its  sewage.  It  can  even  live  for 
a  prolonged  period  in  water,  made  quite  opaque  by  the 
addition  of  fsecal  matter.  It  was  further  established, 
though  this  fact  was  already  known,  that  the  oyster 
takes  up  the  micro-organisms  that  are  in  the  water 
about  it.  They  are  found,  however,  more  plentiful  in 
the  pallia!  cavity  than  in  the  rectal,  showing  that  the 
organisms  are,  to  a  certain  extent,  digested.  The 
typhoid  bacilli,  in  particular,  were  found  to  decrease 
in  number  as  they  passed  down  the  alimentary  canal. 
The  most  important  practical  point,  perhaps,  reached 
by  the  experimenters,  was  the  determination  of  the 
fact  that  oysters  could  be  practically  cleansed  of  all 
their  pathogenic  germs  by  a  suitable  process  of  feed- 
ing, that  is,  by  supplying  them  with  a  sufficiency  of 
clean,  aerated  water.  Professors  Herdman  and  Boyce 
found,  as  others  have  done,  that  the  typhoid  bacillus 
does  not  grow  in  salt  water. 


RAILWAY   DISCOMFORTS. 

The  report,  which  we  give  briefly  in  another  column, 
of  the  International  Conference  on  Railway  Hygiene, 
suggests  that  very  much  helpful  work  might  be  done 
by  organizations  of  this  kind.  We  have  plenty  of  so- 
cieties of  railway  surgeons,  and  we  have  a  copious  sup- 
ply of  insurance  companies  of  all  kinds.  We  have  also 
very  many  enterprising  railway  companies,  but  there  is 
no  organization  which  takes  upon  itself  the  task  of 
supervising  or  suggesting  measures  for  the  sanitary  im- 
provement of  railway  travel.  We,  in  America,  boast 
often  of  the  superiority  of  our  cars,  and  of  our  tracks, 
and  of  the  swiftness  of  our  express  trains,  but  those 
who  travel  much  cannot  fail  to  see  there  are  number- 
less deficiencies,  which  a  little  more  intelligence  and 
care  on  the  part  of  railways  might  correct.  The  ven- 
tilation, for  example,  of  our  so-called  parlor-cars  is 
admitted  to  be  an  utter  failure.  The  cars  are  close 
and  stifling  in  winter,  and  hot  beyond  endurance  in 
summer.  There  seems  to  have  been  no  real  intelligence 
or  special  skill  in  ventilation  applied  to  the  architecture 
of  the  American  parlor-car.  The  question  of  smoke, 
and  dust,  and  cinders,  is  one  also  which  deserves  atten- 
tion, from  a  sanitary  point  of  view.  The  harm  done 
to  the  eyes  and  to  the  mucous  membrane  of  the  nose 
and  respiratory  tract,  by  the  constant  inhalation  of 
more  or  less  carbonaceous  particles,  is  certainly  very 
considerable,  and  one  that  must  eventually  amount  to 
something  to  the  commuter.  The  question  of  the 
water-supply  upon  cars  and  of  the  food  furnished 
upon  them  and  at  railroad  stations,  is  also  one  that 
well  desers-es  the  supervision  of  the  sanitarian.  In 
fact,  if  a  national  congress  on  railway  hygiene  were 
organized  in  this  countr}-,  we  feel  sure  that  it  would  be 
able  to  secure  a  great  many  interesting  papers,  and 
would,  perhaps,  stir  up  a  sentiment  in  favor  of  better 
and  more  sanitary  conditions  of  railway  travel,  the  re- 
sult of  which  would  be  to  keep  a  great  many  of  the 
Americans,  who  now  go  to  Europe,  at  home. 


TWO  MILLIONS  OF  PATIENTS. 

There  is  a  doctor  in  St.  Louis  who  says  that  he  has 
treated  two  million  cases  of  insanity  in  the  last  thirty 
years.  This  statement,  we  understand,  was  made  while 
he  was  serving  in  the  capacity  of  an  expert  on  the  wit- 
ness stand.  He  subsequently  affirmed  the  correctness 
of  the  statement  in  a  letter  to  the  Medical  Weekly. 

Two  million  cases  in  thirty  years  means  66,666  cases 
every  year.  This  means  182  cases  a  day.  Allowing 
that  the  doctor,  with  this  active  practice,  slept  only  six 
hours  and  worked  the  remaining  eighteen  seeing  his 
two  million  cases,  this  would  give  him  about  ten  cases 
of  insanity  ever)-  hour  in  the  day,  or  one  every  six 
minutes.  This,  of  course,  is  quite  a  possible  feat,  but 
it  shows  an  extraordinary  activity  on  the  part  of  the 
St.  Louis  mind.  The  more  fairy-like  side  of  the  tale 
comes  out  when  one  studies  the  source  from  which  the 
two  million  cases  of  insanity  came.  If  the  statistics  of 
this  country  are  correct,  there  have  not  been  two  mil- 
lion cases  of  insanity  in  all  United  States,  within  the 
last  thirty  years.     There  may  be  unc9unted  millions  pf 


558 


MEDICAL    RECORD. 


[October  19,  1895 


lunatics,  however,  in  Missouri,  being  so  near  to  Kansas. 
But  upon  the  whole  we  fear  that  the  esteemed  expert 
must  have  been  suffering  somewhat  from  an  expansive 
delusion  in  regard  to  his  experience  in  insane  matters. 
We  have  heard  of  people  who,  having  had  a  few  minutes 
interview  with  a  lunatic,  felt  as  though  they  had  seen 
sixteen,  and  no  doubt  this  sense  of  numerical  exaggera- 
tion which  attacked  the  St.  Louis  doctor,  was  due  to 
some  such  subjective  influence  as  this.  Still,  it  would 
have  been  more  to  the  credit  of  Southwestern  medical 
expert  testimony,  if  arithmetic  were  a  branch  of  sci- 
ence carefully  studied.  At  present  it  seems  as  though 
there  is  one  medical  expert  who  lisped  in  numbers,  be- 
cause the  numbers  came. 


A  MEN.\CE  TO  PUBLIC  HEALTH. 

The  Board  of  Health  of  this  city  has  recently  had  its 
attention  directed  to  several  cases  of  flagrant  violation 
of  the  sanitary  code  through  the  transportation  in  pub- 
lic conveyances  of  patients  suffering  from  contagious 
diseases.  The  danger  of  spreading  disease  by  such 
means  would  seem  to  be  apparent  to  even  the  most 
ignorant  of  laymen,  yet  it  is  said  that  many  physicians 
are  guilty  of  this  practice.  Nearly  every  week,  so  it  is 
stated  by  Dr.  Benedict,  chief  inspector  of  contagious 
diseases,  patients  are  brought  from  their  homes  to  the 
Willard  Parker  Hospital  in  public  cabs,  and  on  inquiry 
it  is  found  in  many  cases  that  this  is  done  on  the  advice 
of  the  family  physician.  In  other  cases  the  physician 
has  simply  directed  that  the  patient  be  taken  to  the 
hospital,  but  has  given  no  directions  as  to  how  the 
transportation  shall  be  effected.  The  friends  then 
have  the  alternative  of  taking  the  patient  in  a  public 
carriage  or,  worse  yet,  in  a  street  car.  If  a  cab  is  used, 
the  vehicle  is  seized  upon  arrival  at  the  hospital  and 
disinfected,  and  the  danger  to  others  is  comparatively 
slight  ;  but  when  the  patient  goes  in  a  street  car,  there 
is  practically  no  limit  to  the  number  of  persons  exposed 
to  contagion  both  during  the  transit  and  afterward. 

This  could  be  avoided  by  merely  notifying  the 
Health  Board,  when  an  ambulance  will  be  sent  to 
transport  the  patient.  When  so  simple  a  remedy  is  at 
hand,  it  seems  strange  that  any  physician  would  per- 
mit himself,  or  his  patient,  to  incur  the  expense  of  a 
carriage,  expose  others  to  the  risk  of  contagion,  and 
moreover  violate  a  law,  for  which  there  is  a  penalty  of 
$250  and  imprisonment. 


MESCAL  BUTTONS. 

Drs.  U.  W.  Prentiss  and  Francis  P.  Morgan  publisli, 
in  the  Therapeutic  Gazette  ^ox  September  i6th,  an  ac- 
count of  some  experiments  made  with  the  mescal  but- 
ton, a  vegetable  substance  of  which  the  botanical  name 
is  Antralonium  Lcwinin. 

The  attention  of  the  medical  world  was  first  attracted 
to  this  drug  by  Lewin,  but,  aside  from  his  observations, 
little  attention  has  been  given  to  this  substance.  The 
mescal  button  is  obtained  from  a  plant  which  grows  in 
a  valley  of  the  Rio  Grande,  in  Mexico.  The  tops  of  the 
plants  when  dried  constitute  the  commercial  form  of 


Antralonium  Lewinin.  They  are  brownish  in  color 
circular,  and  from  one  to  one  and  a  half  inch  in 
diameter.  The  button  is  hard  and  can  be  pulverized 
in  the  mortar  with  difficulty.  In  the  mouth,  however, 
under  the  action  of  the  saliva,  it  swells  and  rapidly 
becomes  soft,  giving  a  nauseous  and  bitter  taste,  with 
a  marked  sensation  of  tingling  in  the  fauces.  Two  or 
three  alkaloids  have  been  abstracted  from  this  sub- 
stance, as  well  as  some  resinous  bodies.  The  mescal 
button  is  said  to  be  used  by  the  Indians  in  connection 
with  some  of  their  religious  ceremonies.  Upon  cer- 
tain festal  occasions,  the  Indians  seat  themselves  in  a 
circle  around  a  large  camp  fire  ;  then  they  begin  to 
swallow  the  buttons,  one  after  another,  until  ten  nr 
twelve  are  taken  during  the  course  of  the  night.  .\ 
sort  of  reverie  or  quiet  intoxication  is  produced,  and 
the  participants  in  the  ceremony  continue  under  the 
influence  of  the  button  until  sundown  or  noon  of  the 
next  day. 

The  therapeutic  investigations  made  by  Drs.  Prentiss 
and  Morgan  consisted  simply  in  the  administration  of 
buttons  in  different  doses  to  six  different  adults,  noting 
the  effects.  Not  more  than  three  or  four  buttons  were 
taken,  as  a  rule.  The  result  produced  seemed  to  be  in 
all  cases  somewhat  alike.  The  most  striking  was  the 
development  of  visions,  ranging  from  ill-defined  flashes 
of  color  to  most  beautiful  figures,  landscapes,  dances, 
etc.  The  principal  feature  of  the  visions  was  the  color 
effect.  The  pleasurable  effect  of  the  drug  seemed  to 
be  mainly  due  to  the  development  of  these  entrancing 
visions.  The  effect  upon  the  muscular  system  was  de- 
pressing, and  there  was  at  no  time  any  general  stimula- 
tion or  intoxication,  such  as  is  produced  by  alcohol. 
Dilatation  of  the  pupil  was  well  marked  in  all  cases,  and 
this  persisted  for  twenty-four  hours.  Partial  anesthe- 
sia of  the  skin  was  present  in  three  of  the  cases ;  the 
heart  action,  if  anything,  was  somewhat  depressed  ;  the 
respiration  was  unaffected ;  the  stomach  was  some- 
times irritated  and  nausea  was  felt.  The  drug  is  not  a 
sleep-producing  one,  but  has  rather  the  contrary  effect. 
No  constant  disturbance  of  the  pulse,  skin,  or  the  tem- 
perature was  noted.  The  drug  seems  to  have  an 
effect  to  some  extent  resembling  that  of  Indian  hemp, 
and  in  a  slight  degree  that  of  cocaine,  .\ccording  to 
the  description  as  cited  above,  its  effects  are  on  the 
whole  somewhat  unique.  We  ought  to  add  that  Lewin 
reports  one  case  in  which  the  drug  was  taken  experi- 
mentally by  an  adult,  and  in  which  it  produced  a  rapid 
ri.se  of  pulse,  headache,  and  difficulty  in  respiration, 
which  was  so  great  that  the  patient's  life  was  imperilled 
and  he  became  unconscious. 

It  is  possible  that  when  the  various  constituents  of 
the  drug  are  obtained,  and  their  effects  carefully  stud- 
ied, we  may  have  in  the  mescal  button  an  addition  to 
our  Pharmacopoeia  of  some  value. 


The  State  Board  of  Health  of  Missouri  has  issued 
regulations  regarding  the  requirements  of  persons  who 
intend  to  study  medicine.  The  minimum  requirement 
recognized  by  the  Board  is  one  which  demands  the 
presentation  of  a  diploma  of  graduation  from  a  good 
literary  or  scientific  college  or  high-school,  or  a  first- 
grade  teacher's  certificate. 


October  19,  1895] 


MEDICAL    RECORD. 


559 


BRAIN    INJURY    AND    CONSCIOUSNESS. 

The  article  in  the  Medical  Record,  of  October  12th, 
by  Dr.  Hrdlicka,  upon  a  case  of  extensive  traumatic 
brain  lesion,  affords  an  interesting  commentary  upon 
the  question  of  the  amount  of  injury  which  the  brain 
can  receive  without  consciousness  being  lost,  or  the 
mental  functions  being  very  seriously  impaired.  This 
subject  has  been  occupying  the  attention  of  some  of 
our  contemporaries  in  the  last  few  weeks.  In  a  recent 
murder  trial,  it  seems  that  a  woman  was  shot  with  a 
pistol  while  in  bed,  and  it  is  claimed  that  she  rose, 
spoke  to  her  husband,  and  walked  through  several 
rooms  to  the  rear  of  the  house.  The  prosecution  as- 
sert that,  with  such  a  wound  as  she  received,  she  could 
not  have  spoken  or  walked,  but  would  have  relapsed  at 
once  into  unconsciousness.  The  description  of  the 
wound  seems  to  show  that  the  bullet  must  have  passed 
pretty  nearly  horizontally  through  both  frontal  lobes. 
All  surgical  writers  agree  as  to  the  great  tolerance  of 
the  brain  to  injury,  when  in  particular  the  latent  por- 
tions of  the  brain  are  affected.  In  connection  with  the 
particular  medico-legal  case  referred  to,  comes  up  the 
history  of  the  celebrated  Yankee  who,  through  a  pre- 
mature explosion,  received  a  tamping-iron  in  his  head, 
destroying  a  considerable  portion  of  his  frontal  lobes 
without  very  serious  after-effects.  In  Dr.  Hrdlicka's 
case,  however,  there  was  some  serious  immediate  effect 
due  to  the  shock,  as  there  was  also  in  the  tamping  iron 
case,  and  it  is,  so  far  as  experience  goes,  extremely  un- 
likely that  any  human  being  can  sustain  the  effects  of 
the  concussion  and  shock,  that  would  be  produced  by 
a  ball  passing  through  the  brain,  without,  at  least,  a 
temporary  disturbance  of  consciousness. 


WLcws  erf  tire  "SSaLcefe. 

Medical  Society  of  the  State  of  New  York. — The  fol- 
lowing gentlemen  constitute  the  business  committee 
for  the  next  meeting  of  the  State  Society,  to  be  held  in 
Albany  during  the  last  week  in  January  :  Dr.  H.  R. 
Hopkins,  of  Buffalo,  Chairman  ;  Dr.  Nathan  Jacob 
son,  of  Syracuse  ;  and  Dr.  J.  M.  Winfield,  of  Brooklyn. 
Members  desiring  to  present  papers  are  requested  U> 
promptly  notify  the  Chairman  of  this  Committee.  -Ad- 
dresses have  been  promised  by  Professor  William  Peji- 
a,  per,  of  Philadelphia  ;  Professor  James  H.  Etheridge, 
of  Chicago  ;  and  President  Eliot,  of  Harvard  Univer- 
sity, who  will  speak  on  the  subject  of  "  Medical  Edu- 
cation of  the  Future." 

Johns  Hopkins  University,  Baltimore. — Dr.  W.  W. 

Russell  has  been  appointed  .Associate  in  Gynecology, 
and  Dr.  Thomas  S.  Cullen  Instructor  in  Gynecolog- 
ical Pathology,  in  the  Johns  Hopkins  University,  Balti- 
more. Dr.  Otto  Ramsay  has  gone  to  Freiburg  for  a 
year  to  study  gynecological  pathology  under  Professor 
E.  Ziegler. 

The  Hartford  Medical  Society  have  purchased  a  cen- 
trally situated  building  site  for  the  location  of  the  Soci- 
ety building,  for  which  Mrs.  Mary  C.  Hunt  left  them  a 
legacy  of  $20,000,  provided  they  acquired  a  site,  free 


from  encumbrance,  upon  which  to  erect  a  building  ex- 
clusively for  the  use  of  the  Society,  as  a  memorial  to 
her  husband,  the  late  Ebenezer  K.  Hunt,  M.D. 

Errata. — In  Dr.  Hayward's  article  on  "  Honey  in 
Erysipelas,"  read  /leaf  swelling  instead  of  /tear/  swell- 
ing. In  Dr.  Baruch's  article,  on  top  line,  second  col- 
umn, p.  472,  read  bon?ie  instead  of  bovine.  On  fifteenth 
line  from  bottom,  second  column,  p.  474,  read  "  has 
rarely  failed,"  instead  of  "  rarely  fails." 

Railway  and  Marine  Hygiene. — Among  the  numer- 
ous conferences  of  an  international  character  which 
have  been  held  during  the  fall,  is  one  which  took  place 
at  xAmsterdam,  September  20th,  and  which  was  con- 
cerned with  the  hygiene  of  railway  and  marine  travel. 
The  conference  was  started  by  certain  Dutch  officials, 
and  the  gentlemen  taking  part  were  mainly  from  Hol- 
land and  England.  The  question  of  the  examination 
of  eyesight  of  railway  employees  was  the  only  one 
that  seems  to  have  been  extensively  discussed.  The 
speakers  reported  a  very  great  improvement  in  the 
methods  of  such  examinations,  and  also  in  the  extent 
to  which  they  were  applied.  In  France,  England,  and 
Holland  eye-tests  are  required,  but  not  in  Belgium. 
Dr.  Zwaardemaker,  of  Utrecht,  read  a  paper  upon  the 
importance  of  the  acoustic  examination  of  railway  ser- 
vants, and  urged  that  every  railway  man  should  have 
at  least  one  ear  possessing  normal  acuteness.  Papers 
dealing  with  the  question  of  medical  aid  on  railway 
trains  were  read,  and  also  papers  on  "  Overwork,"  on 
"  Traumatic  Hysteria,"  the  "  Disinfection  of  Stations 
and  Restaurants." 

Telling  the  Story  of  Surgical  Progress. — A  weekly 
religious  paper,  T/ie  Independent,  has  recently  pub- 
lished a  series  of  articles  by  a  number  of  prominent 
American  surgeons,  of  which  the  object  is  to  show  to 
the  public  how  great  a  thing  is  modern  surgery.  There 
is  no  question  whatever  as  to  the  wonderful  progress 
made  in  surgery  in  modern  times,  but  we  observe  that 
modern  surgery  has  never  lacked  sweet  singers  to  chant 
its  praise,  as  the  mighty  wheels  of  the  chariot  of  its 
progress  go  rolling  along.  We  believe  thoroughly  in 
allowing  the  public  to  estimate  the  medical  profession 
at  its  full  worth,  but  it  sometimes  seems  as  though  the 
exploitation  of  the  wonders  of  surgery  was  a  little  over- 
done, the  result  being,  that  as  soon  as  a  person  has  any 
ailment  of  any  part  of  the  body,  the  people  at  once 
want  to  have  it  cut  out. 

Typhoid  Fever  in  Washington. — The  Health  Office 
of  Washington  states,  October  nth,  that  an  epidemic 
of  typhoid  fever  exists  in  that  city.  During  the  last 
week,  at  least  six  hundred  cases  were  reported.  The 
epidemic  is  attributed  to  the  lowness  of  the  water  in 
the  Potomac  River  (from  which  the  city  is  supplied), 
and  to  the  use  of  well-water  in  families. 

Congress  of  Physiologists. — The  International  Con- 
gress of  Physiologists  held  its  annual  meeting  at  Berne, 
Switzerland,  on  September  9th,  loth,  and  nth.  Pro- 
fessors Goltz  and  Ewald  showed  a  dog  all  of  whose 
spinal  cord  had  been  removed,  from  the  middle  dorsal 
region  downward.  The  removal  had  been  performed 
at  three  different  operations,  during  a  year  and  a  half, 
and   the  animal  had   survived  the   last   operation   two 


56o 


MEDICAL    RECORD. 


[October  19,  1895 


years.  There  was  a  degeneration  of  the  muscles  below 
the  line  of  the  lesion,  but  the  animal  had  retained 
power  over  the  sphincters,  both  of  the  bladder  and 
rectum,  and  since  the  last  operation  had  given  birth 
to  pups.  Dr.  Demoor,  of  Brussels,  showed  that  an  ac- 
tual anatomical  change  takes  place  in  the  processes  of 
the  cortical  nerve-cells  in  animals  to  which  a  strong 
dose  of  morphine  or  chloral  hydrate  has  been  given. 
Professor  Herzen,  of  Lausanne,  read  a  paper  in  which 
he  brought  evidence  to  show  that  the  spleen  exerts  an 
important  influence  on  pancreatic  digestion.  Professors 
Hiirtle  and  Mosso  showed  a  new  apparatus  for  the  de- 
termination of  blood-pressure  in  man.  Dr.  Jacquet, 
of  Basle,  read  a  paper  on"  The  Influence  of  Cold  Baths 
on  the  Circulation  in  Fever."  He  showed  that  in  fever 
the  red  blood-cells  disappear  from  the  systemic  veins 
and  collect  in  the  loin  and  abdominal  veins,  and  that 
cold  baths  prevent  this,  while  antipyrin  does  not. 
Professor  Mosso  read  a  paper  on  "Respiration  and 
Circulation  in  Man  at  High  Altitudes."  These  studies 
were  made  at  a  height  of  15,000  feet.  Mosso  found 
that  at  this  height,  during  repose,  respiratory  exchange 
is  less. 

The  Congress  accepted  an  invitation  from  Professor 
Foster  to  hold  its  next  meeting  at  Cambridge.  Dr. 
Bowditch,  of  Boston,  was  elected  one  of  the  presidents. 

Medical  Morals. — The  British  Medical  Journal  con- 
tains a  medico-ethical  column,  in  which  the  serious 
problems  of  medical  etiquette  are  gravely  discussed 
and  judiciously  decided.  The  editor  of  this  ethical 
section  has  recently  discussed  the  question  of  whether 
charges  should  be  made  for  attendance  upon  the  wives 
of  medical  men.  The  question  is  answered  in  the 
negative,  and  now  the  query  is  raised,  should  charges 
be  made  for  attendance  upon  the  husbands  of  medical 
women. 

^  Railway  Surgeon  in  Trouble.— The  path  of  the 
Western  railway  surgeon  is  not  always  strewn  with 
roses.  Dr.  R.  V.  Smith,  of  Cleveland,  O.,  was  recently 
sued  for  $25,000  for  an  alleged  malpractice.  The 
plaintiff  was  a  man  who  was  injured  while  working  for 
one  of  the  Western  railroads,  of  which  Dr.  Smith  was 
the  surgeon.  The  company  is  said  to  have  settled  with 
the  patient  for  a  certain  sum  of  money,  but,  despite 
this,  the  plaintiff  claims  damages  for  maltreatment,  and 
we  presume  that  the  company  will  promptly  deny  its 
responsibility,  and  shift  it  on  to  their  poor  servant,  the 
railway  surgeon.  At  any  rate,  it  is  stated  that  railway 
surgeons,  who  work  under  contract,  are  not  thereby 
necessarily  protected  from  malpractice  suits.  The 
companies,  to  be  sure,  generally  protect  the  surgeons, 
but  they  are  not  obliged  to  do  so. 

Antirabic  Sero-Therapy.— 77ic  Lancet  publishes  a 
series  of  articles  by  Drs.  Tizzoni  and  Centanni  on  the 
subject  of  the  use  of  the  serum  of  animals  protected 
against  rabies.  Their  investigations  extended  over  a 
long  period,  and  the  conclusions  they  have  reached 
seem  the  result  of  a  very  careful  work.  They  assert 
that  by  taking  the  serum  of  animals  that  have  been 
protected  against  rabies,  and  preparing  this  for  diges- 
tion by  means  of  pepsin,  they  have  secured  an  anti- 
rabic serum  which  protects  animals  better  than  is  done 


by  the  original  Pasteur  method.  The  value  of  this 
preparation  has  so  far  been  only  tested  upon  animals, 
but  if  it  should  prove  to  be  what  its  originators  claim, 
it  will  do  away  with  the  expense  of  Pasteur  institutes, 
for  the  serum  can  be  dried  or  made  antiseptic,  and 
kept  so  that  anyone  can  use  it.  It  is  to  be  hoped, 
therefore,  that  the  new  antirabic  serum  will  really 
prove  to  be  of  value. 

Artificial  Human  Milk. — A  Berlin  physician  has  de- 
vised what  seems  to  be  a  rather  novel  method  of  imi- 
tating the  modern  milk.  Cow's  milk  is  fermented  by 
means  of  rennet,  and  the  whey  thus  obtained  is  care- 
fully sterilized,  and  then  enriched,  as  required  by  dif- 
ferent individuals,  by  the  addition  of  cream. 

The  Medical  and  Surgical  Reporter  has  moved  back 
its  publishing  office  to  Philadelphia. 


©l^itwartj. 


FREDERIC  M.  WARNER,  M.D., 

NEW  YORK. 

Dr.  Frederic  M.  Warner  died  at  his  residence  in  this 
city  on  October  9th,  at  the  age  of  thirty-eight.  A  man 
of  bright  attainments,  of  sterling  professional  zeal,  of 
brilliant  future  promise — his  death  is  not  alone  a  loss  to 
the  medical  fraternity,  but  also  to  the  community. 

Dr.  Warner  was  born  in  Jersey  City,  July  14,  1857. 
He  was  educated  at  Lehigh  University,  and  was  grad- 
uated at  the  College  of  Physicians  and  Surgeons,  New 
York. 

After  a  protracted  sojourn  in  Europe,  he  began  the 
practice  of  medicine  in  this  city  in  1881,  and  at  the 
time  of  his  death  he  had  acquired  a  large  general  prac- 
tice, and  for  a  man  of  his  years  no  inconsiderable  con- 
sulting work.  His  special  leaning  was  toward  internal 
medicine  in  particular  diseases  of  the  heart  and  lungs. 
In  these  affections  he  was  a  most  astute  diagnostician, 
and  he  possessed  the  rare  faculty  of  being  able  to  im- 
part his  knowledge  to  others  in  terse,  descriptive  terms, 
which  marked  him  as  a  brilliant,  clinical  teacher.  His 
solicitude  for  the  patients  under  his  charge  at  the  City 
and  the  F"rench  Hospitals  will  long  be  remembered  by 
his  colleagues.  His  unique  devotion  to  his  patients, 
whether  pauper  or  rich,  irrespective  of  personal  com- 
fort or  health,  profoundly  impressed  those  who  had 
the  privilege  of  knowing  him  well.  He  was  just  begin- 
ning to  publish  in  the  medical  press  the  results  of  his 
observations  in  hospital  and  in  private  practice,  and  he 
was  of  material  assistance  to  Dr.  J.  Lewis  Smith,  in  the 
preparation  of  the  last  edition  of  "  Diseases  of  Chil-  ' 
dren."  From  the  inception  of  the  enterprise  he  had 
contributed  to  the  "  Annual  of  the  Medical  Sciences  " 
(Sajous). 

At  the  time  of  his  death,  Dr.  Warner  was  a  member 
of  the  Committee  on  Library  of  the  Academy  of  Medi- 
cine, and  of  the  Committee  on  Ethics  of  the  County 
Medical  Society.  He  was  visiting  physician  to  the 
City  Hospital,  and  special  consultant  for  heart  and 
lungs  at  the  French  Hospital. 

Reserved  in  manner,  upright  in  action,  steadfast  in 
purpose,  those  who  were  admitted  to  his  friendship 
could  not  help  but  love  as  well  as  admire  him.  Al- 
though young,  he  has  left  an  impress  suggestive  of  a 
most  brilliant  future. 

Dr.  Warner  was  married  to  a  daughter  of  Dr.  J.  Lewis 
Smith.     The  widow  and  two  children  survive  him. 


October   19,  1895] 


MEDICAL    RECORD. 


561 


^eutextis  and  ^xrtices. 

Atlas  of  the  Diseases  of  the  Skin.  By  H.  Rad- 
CLIFFE  Crocker,  M.D.,  F.R.C.P.  Physician  to  the  De- 
partment for  Diseases  of  the  Skin,  University  College 
Hospital  ;  formerly  physician  to  the  East  London  Hospi- 
tal for  Children,  etc.  Edinburgh  and  London  :  Youn;_r  J. 
Pentland.     New  York  :  Macmillan  &  Co. 

Fasciculus  Eleven  of  this  series  of  plates  has  now  been 
published.  The  illustrations  comprise  :  Lichen  Planus 
Acutus  ;  Lymphangiectodes  ;  Papilloma,  with  Xeroderma 
Pygmentosuni,  Milium,  Acne  Vulgaris,  and  Tinea  Circinata. 

The  first  represents,  in  a  striking  manner,  acute  lichen 
planus  of  the  trunk  ;  the  arms  being  free.  The  second 
plate  has  four  figures  showing  groups  of  lesions  of  different 
appearance  upon  the  trunk,  neck,  and  inner  surface  of  the 
lip.  The  picture  of  xeroderma  resembles  closely  the  other 
cases  which  have  become  familiar,  but  shows,  in  addition  to 
the  characteristic  lesions,  a  large  papilloma  occupying  the 
region  of  the  ear.  The  next  plate  illustrates,  very  well,  mil- 
ium in  an  infant,  showing  in  a  second  figure  lesions  upon 
the  hand,  and  in  another,  grouped  lesions  about  the  eye- 
lids in  an  adult.  Fig.  4  is  a  group  of  milium  followin;^ 
pemphigus  ;  and  Fig.  5,  grouped  comedones  of  childhood. 

Two  large  figures  are  devoted  to  acne  ;  one  beautifully 
showing  acneiform  folliculitis  of  the  buttocks,  the  other  be- 
ing of  a  rather  aggravated  type  of  acne  vulgaris  of  the  back. 
The  last  plate  has  four  figures,  the  largest  being  of  a  map- 
like ringworm  involving  the  trunk  and  arms  of  a  child  ;  the 
other  showing  different  varieties  of  lesion  upon  the  nape  of 
the  neck,  the  arm,  and  buttock.  In  the  latter  the  circular 
patch  has  not  cleared  in  the  centre,  and  the  whole  area  is 
filled  with  minute  papules  more  or  less  covered  with  fine 
scales.  The  general  high  character  of  the  work,  to  which 
we  have  already  referred,  is  being  maintained  both  in  text 
and  illustration. 

Practical  Dietetics,  with  Special  Reference  to  Diet 
in  Disease.  By  W.  GiLMAN  Thompson,  M.D.,  Profes- 
sor of  Materia  Medica,  Therapeutics,  and  Clinical  Medi- 
cine in  the  University  of  the  City  of  New  York  ;  Visiting 
Physician  to  the  Presbyterian  and  Bellevue  Hospitals. 
New  York  :   D.  Appleton  &  Co.     1S95. 

Dr.  Thompson  has  rendered  good  service  in  preparin;^ 
this  volume  on  dietetics,  for  the  subject  is  one  upon  whicli 
comparatively  little  has  been  written,  and  concerning  which, 
it  is  safe  to  say,  even  less  is  known  by  the  ordinary  physi- 
cian. Yet  no  one  will  dispute  that  the  regulation  of  the 
diet  in  many  diseases  is  at  least  as  important  as  the  admin- 
istration of  drugs. 

The  first  chapters  are  devoted  to  a  description  of  the 
various  foods,  their  mode  of  preparation,  and  their  value  in 
nutrition.  Following  these  is  a  chapter  upon  digestion  and 
the  special  conditions  which  aft'ect  it  favorably  or  injurious- 
ly. Then  the  author  takes  up  the  subject  of  diet  in  disease, 
devoting  to  this  the  second  half  of  the  work.  After  treating 
upon  the  diseases  caused  by  improper  food,  by  over-eating, 
or  under-eating,  the  subject  of  feeding  the  sick  is  taken  up, 
and  treated  in  general  very  satisfactorily.  The  concluding 
pages  of  the  book  contain  a  chapter  on  army  rations,  hos- 
pital dietaries,  milk,  grape,  and  other  "  cures,"  athletic 
training,  the  relation  of  diet  to  occupation,  etc. 

The  work  will  be  found  a  useful  supplement  to  the  ac- 
cepted treatises  in  therapeutics. 

Medical  and  Surgical  Reports  ok  the  Boston  Ci  j  v 
Hospital.  Sixth  Series.  Edited  by  George  B.  Sua  1- 
tuck,  M.D.,  W.  T.  Councilman,  M.D.,  H.  L.  Bui<- 
RELL,  M.D.     Boston  :   Published  by  the  Trustees.     1895. 

This  excellent  publication,  which  the  editors  announce  will 
probably  be  henceforth  an  annual,  contains  twenty-five  pa- 
pers and  reports  upon  the  cases  treated  in  the  Boston  City 
Hospital  during  the  past  year,  embracing  a  great  variety  of 
subjects. 

Index  Catalogue  of  the  Library  of  the  Surgecjn- 
General's  Office,  United  States  Army,  Vol,  X\l,, 
W-Zythus.  Washington  :  Government  Printing  Office. 
1S95, 

This  volume,  which  is  probably  the  last  to  be  issued  under 
the  personal  supervision  of  Dr.  Billings,  completes  the  al- 
phabet and  is  therefore  the  final  volume  of  the  first  series. 
The  second  series,  including  the  titles  of  books  and  articles 
received  too  late  for  insertion  in  the  first  series,  of  which  the 


manuscript  is  already  prepared,  will  comprise  five  volumes 
of  the  same  size  as  those  of  the  first  series.  An  appropria- 
tion for  the  printing  of  this  first  volume  has  been  made  by 
Congress,  and  we  are  therefore  assured  that  there  will  be 
no  delay  in  its  publication  or  in  that  of  those  that  are  to  fol- 
low. 

Transactions  of  the  Medical  Society  of  the  State 
of  Pennsylvania,  at  its  Forty-fifth  Annual  Session,  held 
at  Chambersburg,  1895.  \'ol,  XX\'L  Philadelphia  : 
The  Edwards  &  Docker  Co,     1895, 

Transactions  of  the  Medical  Society  of  the  State 
of  California,  Session  of  1S95.  San  Francisco  :  \V. 
A..  Woodward  &  Co.     1893, 

These  reports  of  the  meetings  of  two  of  the  most  important 
State  societies  contain  a  number  of  valuable  and  interest- 
ing papers.  It  is  to  be  regretted,  however,  that  they  should 
be  practically  buried  in  this  way,  instead  of  being  given  to 
the  world  through  the  columns  of  some  live  journal. 

Text-book  of  Practical  Therapeutics.  By  Hobart 
Amory  Hare,  M.D.,  B.Sc.  ;  Professor  of  Therapeutics 
and  Materia  Medica,  Jefferson  Medical  College,  etc. 
Fifth  Edition.  Enlarged  and  thoroughly  Revised.  Svo, 
pp.  740.     Philadelphia  :   Lea  Brothers  &  Co.     1895, 

The  fifth  edition  of  this  admirable  work  has  been  somewhat 
enlarged  and  thoroughly  revised.  A  distinguishing  feature 
of  the  work  is  a  discussion  of  the  antitoxin  treatment  of 
diphtheria.  The  author  is  a  believer  in  this  new  method, 
and  gives  a  very  lucid  description  of  its  rationale,  embody- 
ing the  advanced  views  on  the  subject.  As  we  have  re- 
marked concerning  previous  editions,  the  work  is  of  excep- 
tional value  to  the  general  practitioner  who  is  ambitious  of 
obtaining  the  most  recent  and  advanced  views  of  leading 
therapeutists,  as  well  as  the  opinion  of  an  acknowledged  au- 
thority. 

The  Science  and  Art  of  Obstetrics.  By  Theophilus 
Parvin,  A.M.,  M.D.,  LL.D. ;  Professor  of  Obstetrics  and 
Diseases  of  Women  and  Children,  Jefferson  Medical  Col- 
lege, Philadelphia,  etc,  Svo,  pp.  685,  Philadelphia  :  Lea 
Brothers  &  Co.     1895. 

The  general  plan  of  this  classical  work  remains  substan- 
tially unchanged  in  its  third  edition,  although  some  of  the 
subjects  have  a  different  order.  Additions  of  great  practi- 
cal value  have  been  made,  and  nearly  one-third  of  the  work 
has  been  rewritten.  As  a  whole  it  is  destined  to  maintain 
its  hold  in  obstetric  literature  as  one  of  the  leading  works 
of  its  kind.  The  experience  of  the  author  as  a  \eteran 
teacher  gives  him  great  advantages  in  the  practical  treat- 
ment of  his  subjects,  which,  added  to  a  perspicuous  and 
graceful  style,  leave  nothing  to  be  desired  in  the  full  ap- 
preciation of  a  model  of  its  kind, 

A  System  of  Surgery.  Edited  by  Frederick  Treves, 
F.R.C.S.  Surgeon  to  and  Lecturer  on  Surgery,  London 
Hospital,  etc.  Vol.  I.,  pp.  1152.  Philadelphia:  Lea 
Brothers  &  Co,     1895, 

The  progress  which  surgery  has  made  during  the  past  few- 
years  has  made  its  impress  upon  the  literature  of  its  art  and 
practice.  The  richness  and  extent  of  contributions  in  that 
line  are  manifest  by  the  number  of  excellent  treatises  that 
are  constantly  making  their  appearance,  giving  the  experi- 
ence of  the  leading  teachers,  Mr,  Treves's  work  is  one  of 
these,  which  is  destined,  as  far  as  can  be  judged  by  the  show- 
ing in  the  first  volume  now  before  us,  to  take  a  leading 
place.  Following  what  appears  to  be  the  better  accepted 
plan  of  special  contributors  to  different  departments,  he  has 
secured  as  his  collaborators  many  of  the  leading  surgeons 
of  Great  Britain.  Each  writer  has  striven,  from  a  concise 
and  practical  standpoint,  to  exhaust  his  subject  within  the 
space  allotted,  and  to  carry  out  the  spirit  of  the  treatise  by 
"  presenting  concisely  and  with  authority  an  account  of  the 
science  of  surgery  as  it  exists  at  the  present  day."  The  il- 
lustrations are  numerous,  well  placed,  and  are  mostly  orig- 
inal in  character.  Two  plates  are  introduced  showing  the 
bacteriological  character  of  infectious  discharges,  but  are 
hardly  up  in  point  of  detail  execution  to  the  other  illustra- 
tions so  plentifully  and  judiciously  sprinkled  throughout  the 
text.  The  number  and  variety  of  subjects  treated  in  the 
present  volume  can  be  duly  estimated  by  the  following  list  : 
Surgical  Bacteriology,  by  (ierman  Sims  Woodward, 
M.D.  ;  Inflammation.  Suppuration,  Ulceration,  Gangrene, 
Syncope,  Shock,  and  Wounds  and  Contusions,  by  W. 
\Vatson  Cheyne,   F.R.S.,   F.K.C.S.  ;    Erysipelas,   Pyemia, 


562 


MEDICAL    RECORD. 


[October  19,    1895 


Tetanus,  Tetany,  Burns,  and  Scalds,  by  C.  B.  Lockwood, 
F.R.C  S.  ;  Military  Surgery,  by  Surgeon-Major  Andrew  Dun- 
can, I. M.S.,  etc.  ;  An<-ESthetics,  by  Frederick  W.  Hewitt, 
M.D. ;  Infectious  Surgical  Diseases  and  Rickets,  by  George 
Henry  Makins,  F.R.C. S.  ;  Tuberculosis,  Rickets,  Hemo- 
philia, and  Surgical  Hysteria,  by  the  Fditor,  Frederick 
Treves,  F.R.C.S.  ;  Syphilis  and  Gonorrhoea,  by  Jonathan 
Hutchinson,  Jr.,  F.R.C.S.  ;  Injuries  and  Diseases  of  Blood- 
vessels, and  Aneurism,  by  A.  Pearce  Gould,  M.S.,  Lond.  ; 
Injuries  and  Diseases  of  the  Lymphatics,  by  John  H.  Mor- 
gan, F.R.C.S.  ;  and  lastly.  Injuries  and  Diseases  of  the 
Nerves,  by  Anthony  Bowlby,  F.R.C.S. 

To  such  as  are  acquainted  with  Mr.  Treves's  Operative 
Surgery,  no  prediction  will  be  necessary  for  the  success  of 
the  present  work. 


gvogress  ot  W^ctUcaX  Science. 

The  Paralysis  of  Infancy. — The  following  convenient 
classification  of  these  paralyses  is  given  by  the  Madrid 
correspondent  of  the  Medical  Press  : 

Painful  Paralysis  of  Children. — Was  described  by 
Ciiassaignac  in  1855,  and  by  Brunon  in  1893.  It  is  a 
temporary  functional  paralysis,  of  which  the  pain  is  an 
essential  symptom.  Prognosis  is  favorable.  Diagnosis 
is  made  by  the  evanescent  character  of  the  affection, 
and  the  pain  accompanying  it,  though  there  is  no  lesion 
of  the  articulations  or  bones. 

Syphilitic  Pseudo-Paralysis  of  Parrot. — Occurs  only 
in  infancy.  The  epiphyses  are  attacked,  and  crackling 
can  be  got  between  the  epiphysis  and  the  diaphysis  as 
if  they  were  separated.  The  affected  limb  appears  to- 
tally paralysed.  The  muscles  of  the  face,  neck,  and  of 
respiration  are  never  affected.  No  sensory  troubles, 
except  pain  on  movement.  The  sphincters  are  not 
affected.  Electrical  examination  gives  negative  re- 
sults. 

Cerebro- spinal  Syphilis. — The  paralysis  involves  also 
the  face  ;  the  epiphyses  are  not  affected. 

Syphilitic  Paralysis  of  Peripheral  Origin. — Diagnosis 
is  based  on  the  fact  of  the  integrity  of  the  bones,  and 
on  the  modification  of  the  electric  reaction.  When  the 
syphilitic  origin  of  the  paralysis  is  not  clear,  diagnosis 
from  infantile  paralysis  is  made  by  considering  the  ra- 
pidity and  iever  with  which  this  latter  presents  itself, 
the  generalness  of  the  paralytic  phenomena,  and  the 
absence  of  pain. 

Lille's  Malady. — -Is  a  congenital  spasmodic  paraple- 
gia of  the  four  extremities,  more  marked  in  the  lower, 
and  occurring  in  children  born  prematurely.  It  is  not 
accompanied  by  convulsions  or  psychical  phenomena. 
It  cannot  be  confounded  with  spasmodic  tabes,  for  this 
belongs  to  adolescence  and  tends  to  grow  worse. 

Spasmodic  Infantile  Hemiplegia. — Is  congenital,  or 
manifests  itself  soon  after  birth  ;  begins  with  convul- 
sions. There  are  athetetic  movements  with  convulsive 
crises,  which,  when  they  are  bilateral,  may  be  con- 
founded with  epilepsy.  There  is  loss  of  intelligence, 
if  not  itliocy.  The  growth  of  the  bones  is  hindered. 
.\s  etiological  factors,  cysts,  areas  of  cerebral  softening, 
meningeal  hemorrhage,  meningo-encephalitis,  and  scle- 
rosis have  been  found. 

Friedreich's  Disease  (Hereditary  .\taxy). — Does  not 
present  phenomena  of  motor  inco-ordination.  Is  not 
congenital.  Nystagmus  and  defective  speech  are  pres- 
ent. The  lightning  pains,  ana;sthesia,  and  trophic 
changes  of  locomotor  ataxy  are  wanting. 

Primary  Myopatias. —  l'.seudo-hy|)ertrophic  paralysis 
and  atrophic  myopatia  are  forms  which  jjresent  them- 
selves in  childhood.  Thomsen's  malady  is  a  congen- 
ital form  characterized  by  spasmodic  rigidity  of  the 
\oluntary  muscles,  which  shows  itself  on  beginning  to 
make  a  movement. 

Infantile  Paralysis. — There  is  initial  fever.  'I'he 
jiaralysis  affects  many  muscles  at  first,  and  then  be- 
comes  restricted  to  groups  of  muscles,  or  individual 


muscles.  No  sensory  disturbances,  and  the  intelligence 
remains  normal. 

Pott's  Paralysis. — Frequent  in  int'ancy  and  youth. 
Follows  disease  of  the  dorso-lumbar  vertebra. 

Diphtheritic  Paralysis. — There  is  the  history.  An  im- 
portant symptom  is  the  dysphagia  and  regurgitation  of 
food  by  the  nose. 

Post-Morbillic  Paralysis. — This  occurs  during  con- 
valescence ;  of  paraplegic  type  ;  and  after  some  six 
weeks  ends  in  recovery. 

Obstetric  Paralysis. — Caused  by  traumatism  inflicted 
at  birth  ;  the  muscles  usually  affected  are  those  supplied 
by  the  brachial  plexus  or  facial  nerve. 

Hysterical  Paralysis. — In  these  the  reflexes  are  not 
abolished.     Diagnosis  by  exclusion. 

Choreic  Paralysis. — .\ffects  the  monoplegic  or  henii- 
plegic  form.  Sometimes  the  paralysis  precedes  the 
chorea.  Ordinarily  it  is  post-choreic,  or  during  the 
evolution  of  the  neurosis. 

The  Blood  in  Bright's  Disease. — Dr.  Freund  nas 
studied  this  subject  for  the  past  three  years,  and  now 
publishes  his  observations.  They  refer  to  cases  of 
Bright's  disease  (chronic  parenchymatous  nephritis, 
with  dropsy),  in  which  the  clinical  features  were  well 
marked,  and  which  were  verified  by  pathological  exa- 
mination. The  results  were  compared  with  other 
cases  of  albuminuria  and  dropsy,  without  Bright's  dis- 
ease. I.  Analysis  of  the  blood  of  nine  cases  showed 
no  changes  in  the  absolute  quantities  of  either  or- 
ganic or  inorganic  constituents.  The  only  alteration 
was  in  the  relative  amounts  of  the  globulins  compared 
with  the  albumins  in  the  serum.  While  in  normal  and 
other  pathological  conditions  the  relation  was  i  to  i  and 
1.5,  in  the  9  cases  of  Bright's  disease  it  was  i  to  2.3. 
In  2  cases,  in  spite  of  the  clinical  diagnosis  of  Bright's 
disease,  the  relation  of  globulins  to  albumins  was  t  toj 
I.I  and  I  to  1 1.3  ;  in  one  of  these  cases  the  necropsy] 
showed  cystic  kidney,  in  the  other  contracted  granular] 
kidney.  This  alteration  of  the  relation  of  globulins 
albumins  cannot  be  held  as  specific,  because  in  a  case] 
of  pernicious  anaemia  it  was  found  to  be  i  to  2.  2.  .\s| 
regards  the  alkalinity  of  the  blood,  no  specific  abnor- 
mal condition  was  found.  3.  The  conditions  of  co- 
agulation were  found  to  be  altered.  While  normal  I 
serum  coagulates  uniformly  at  a  temperature  of  70° 
74°  C.  to  a  firm  jelly,  in  Bright's  disease  coagulation, 
does  not  occur  till  78°  to  82°  C,  and  the  clot,  instead 
of  remaining  firm,  is  easily  broken  up  by  shaking.  It 
has  been  shown  that  much  dilation  alters  the  point  of 
coagulation  as  well  as  the  condition  of  the  clot,  and  a 
dilution  of  1.018  generally  raises  the  coagulation  point. 
Normal  serum  diluted  to  the  same  specific  gravity  as 
serum  from  Bright's  disease  was  found  to  behave  in  the 
same  way,  and  similar  results  were  obtained  in  serum 
from  dropsy  without  Bright's  and  in  pernicious  an.emia. 
4.  Semmola  in  1881  showed  that  serum  from  Bright's 
disease  had  a  greater  power  of  diffusion  than  normal 
serum,  or  serum  from  cases  of  albinninuria  without 
Bright's  ;  Freund's  experiments  confirm  this  view,  for 
in  15  cases  of  Bright's  disease  the  diffusibility  with 
egg  albumin  was  0.006  to  0.025  'i-  P"^""  cent.  ;  in  3  out 
of  16  control  experiments  from  other  diseases  the  dif- 
fusibility was  0.003  'o  0.004  per  cent.,  13  giving  nega- 
tive results. —  Wiener  klinische  Rundschau. 

Suprapubic  Cystotomy  for  Tubercular  Ulceration. — 

The  following  case  of  this  kind  is  recorded  by  Dr. 
MoiiUin  in  The  Lancet :  .\  woman  twenty- two  years  of 
age  was  admitted  into  the  London  Hospital  in  January, 
1894,  suffering  from  cystitis.  Her  illness  began  three 
years  before,  with  an  attack  of  hajmaturia,  which  lasted 
upward  of  six  weeks.  ,\pparently  it  was  caused  by  lift- 
ing a  heavy  weigiit.  At  the  same  time  micturition 
became  more  frequent.  There  was  no  pain,  but  she 
grew  weak  and  ill,  and  was  unable  to  continue  at  work 
as  a  domestic  servant.  A  few  months  later,  after  rest- 
ing at  home,  she  began  to  suffer  from  pain  shooting 


October   19,  1895] 


MEDICAL    RECORD. 


^6- 


down  the  right  leg  from  the  loin.  Micturition  became 
more  and  more  frequent,  until  at  last  it  took  place  nearly 
every  hour.  Each  act  was  attended  by  intense  smart- 
ing, felt  chiefly  at  the  neck  of  the  bladder,  and  continu- 
ing for  some  time  after  the  bladder  was  emptied. 
Blood  made  its  appearance  again.  The  urine  became 
foul  and  loaded  with  mucus  ;  and  for  the  si.x  months 
previous  to  admission  the  suffering  was  so  great  that 
she  was  almost  confined  to  bed,  any  attempt  at  walking 
causing  intense  dragging  pain  over  the  pubes.  The 
patient  was  slightly  built,  but  fairly  well  nourished. 
There  was  no  history  of  previous  illness  of  any  impor- 
tance. The  lymphatic  glands  were  not  enlarged,  the 
heart  and  lungs  were  normal,  and  there  was  no  history 
of  phthisis  in  the  family.  The  hypogastric  region  was 
very  sensitive  to  pressure,  but  there  was  no  tenderness 
over  the  kidneys  on  either  side.  Micturition  was  ex- 
ceedingly frequent,  night  and  day,  and  was  accompanied 
by  the  greatest  suffering.  The  average  amount  of  urine 
passed  in  twenty-four  hours  was  only  twenty-five  ounces 
of  1. 015  specific  gravity.  It  was  alkaline  in  reaction,  al- 
ways contained  a  large  amount  of  blood  intimately  mixed 
with  it,  and  threw  down  a  heavy  precipitate  of  blood,  mu- 
cus, pus,  and  phosphates.  Microscopic  examination 
showed  the  presence  of  tubercle  bacilli  upon  one  occa- 
sion. Benzoate  of  ammonia  was  given  internally,  and  the 
bladder  was  washed  out  at  regular  intervals  with  boracic 
acid  and  lactic  acid,  but  without  result.  No  improvement 
followed,  and  as  the  patient,  who  had  been  under  treat- 
ment for  many  months,  was  beginning  to  lose  weight,  it 
was  determined  to  explore  the  bladder  under  an  anes- 
thetic. A  number  of  ulcers  coated  over  with  an  adher- 
ent, blood-stained,  caseous  deposit  were  found  just  in- 
side the  orifice.  A  week  later  supra-pubic  cystotomy 
was  performed.  The  sides  of  the  bladder  were  held 
apart  with  sutures  passed  through  the  edges  of  the 
muscular  coat  ;  a  Ferguson's  speculum  was  introduced 
through  the  wound,  and  all  the  ulcers  that  were  acces- 
sible were  scraped  and  cauterized  with  Paquelin's  cau- 
tery. Those  that  were  situated  on  the  anterior  surface  of 
the  bladder,  and  which  could  not  be  reached  in  this  way, 
were  scraped  with  a  Volkmann's  spoon,  and  then  iodo- 
form was  thoroughly  rubbed  in.  All  the  ulcers  were  sit- 
uated near  the  orifice  of  the  bladder  ;  there  were  none 
to  be  seen  or  felt  on  the  fundus.  The  lower  angle  of 
the  wound  was  left  open  and  a  drainage-tube  intro- 
duced into  the  bladder  ;  the  rest  was  sutured  and  dress- 
ings of  sal  alenibroth  gauze  and  w-ool  applied.  The 
tube  was  shortened  on  the  third  day  and  removed  a 
few  days  later.  Urine  acid  in  reaction  was  passed  nat- 
urally on  the  fifteenth  day,  and  at  the  end  of  three 
weeks  the  wound  was  soundly  healed  and  the  patient 
was  allowed  to  get  up.  At  first  there  was  considerable 
pain  on  micturition,  but  this  soon  wore  off.  Five  weeks 
after  the  operation  the  patient  passed  urine  four  times 
during  the  day  and  twice  at  night.  Six  months  later, 
when  she  was  seen  again,  the  fretjuency  during  the  day 
remained  the  same,  but  she  had  to  rise  only  occasion- 
ally at  night.  The  urine  was  acid  and  contained  only 
a  little  mucus,  and  the  patient  had  gained  flesh  and 
strength. 

The  number  of  cases  in  which  supra-pubic  cystotomy 
and  cauterization  have  been  performed  for  tuberculnus 
disease  of  the  bladder  is  not  very  large.  Guyon  has 
recorded  two  ;  Reverdin  one  ;  Battle  one,  in  which,  ow- 
ing to  the  size  of  the  ulcer,  chloride  of  zinc  was  used 
instead  of  the  actual  cautery;  Pilcher  four;  and  Hell 
three.  In  three  cases  Bardenheuer  has  dissected  away 
the  entire  mucous  membrane,  practically  abolishing  the 
bladder,  for  very  little  of  the  lining  was  reproduced.  I  n 
nearly  every  case  of  cauterization  the  results  as  reported 
were  good,  and  there  can  be  little  doubt  that  in  many 
instances  this  operation  might  be  resorted  to  with  ad- 
vantage. Ulceration  of  the  bladder  attended  by  stran- 
gury and  hematuria  is  of  not  uncommon  occurrence  in 
young  adults  of  both  sexes,  and  in  a  large  proportion 
of  cases  yields  readily  to  local  and  palliative  treatment. 


In  these  the  ulceration  is  not  tuberculous,  or,  if  it  is, 
the  ulceration  is  very  recent  and  involves  only  the  most 
superficial  layers  of  the  mucous  membrane.  When  the 
disease  has  lasted  some  time,  as  in  the  present  instance, 
and  has  affected  the  whole  thickness  of  the  mucous 
membrane,  and  perhaps  the  submucous  tissue  as  well, 
leaving  deep  ulcers  coated  over  with  a  dense  adherent 
layer  of  caseous  debris,  pus,  and  phosphates,  the  mo- 
mentary application  of  dilute  solutions  of  lactic  acid  or 
other  drugs  can  be  of  no  avail.  They  can  never  pene- 
trate unaided  through  the  protecting  layer.  In  such 
cases  the  prognosis  is  so  unfavorable,  the  suffering  as 
the  disease  advances  so  intense,  and  the  risk  of  supra- 
pubic cystotomy  as  it  is  performed  afthe  present  day 
so  slight,  that  it  is  difficult  to  understand  why  it  is  not 
more  frequently  resorted  to.  Tuberculosis  of  the  blad- 
der may  not  be  common  as  a  primary  affection.  It  is 
usually  regarded  as  secondary  to  disease  of  the  kidneys 
or  (in  males)  of  the  genital  organs.  But  the  fact  that 
many  of  the  cases  in  which  it  has  occurred  have  been 
women,  who  do  not  suffer  in  the  same  way  from  genital 
tuberculosis,  and  whose  kidneys  were  healthy,  makes  it 
rather  doubtful  whether  in  the  case  of  men  there  is  not 
a  tendency  to  exaggerate  the  secondary  character  of 
the  disease.  The  neck  of  the  bladder  is  involved  more 
frequently  than  the  fundus,  not  because  of  the  prox- 
imity of  the  orifices  of  the  ureters  or  of  the  vasa  defer- 
entia,  but  because  its  blood-supply  is  so  much  larger, 
and  it  is  so  liable  to  attacks  of  congestion,  and  because 
its  functional  activity  is  so  much  greater. 

Vaginal  Eesection  of  the  Rectum Dr.  Rehn  states 

that  in  cancer  of  the  rectum  in  females  the  affected 
gut  can  be  readily  removed  through  a  vertical  incision 
made  in  the  middle  line  of  the  posterior  wall  of  the 
vagina,  and  carried  backward  in  the  perineum  as  far 
as  the  external  sphincter  ani.  By  such  an  incision  he 
was  able,  with  very  little  difficulty  and  without  much 
hemorrhage,  to  remove  an  extensive  cancer  from  the 
rectum  of  an  aged  woman.  The  incision  of  the  pos- 
terior wall  of  the  vagina,  he  states,  permits  of  free  re- 
moval of  a  large  malignant  growth  and  facilitates  the 
separation  of  the  diseased  mass  from  the  surrounding 
soft  parts.  The  rectum  having  been  plugged  with 
antiseptic  gauze  and  the  vagina  thoroughly  disinfected, 
the  posterior  vaginal  wall  is  carefully  incised  and 
separated  from  the  diseased  gut.  The  perineum  is 
next  incised  in  the  middle  line  and  the  rectum  below 
the  seat  of  disease  isolated,  ligatured,  and  divided. 
The  upper  and  cancerous  portion  of  the  gut  is  now 
drawn  through  the  vaginal  w'ound  and  excised.  This 
stage  of  the  operation,  it  is  asserted,  can  be  effected 
with  but  little  hemorrhage  and  with  free  exposure  of 
the  diseased  structures.  An  opening  in  the  ])eritoneum 
can  be  readily  dealt  with  in  this  operation,  and  any  en- 
larged glands  in  the  meso-rectum  can  be  removed 
without  difficulty. — Centralblait  fur  Chirurgie. 

Congenital  Constipation. — Marfan,  in  a  clinical  lec- 
ture on  constipation  in  infants,  discusses  at  some 
length  the  so  called  congenital  or  anatomical  constipa- 
tion associated  with  undue  length  of  the  colon  and 
folding  of  the  sigmoid.  (  The  British  Medical  Journal^ 
Instead  of  making  the  simple  S  or  2  curve,  the  sigmoid 
is  thrown  into  several  folds,  which  may  be  variously  dis- 
posed. He  quotes  from  the  These  of  Bourcart  (Paris, 
1863)  a  classification  into  three  types — ascending, 
transverse,  and  descending.  Of  these  the  commonest 
is  the  ascending  type,  in  which  the  colon,  after  enter- 
ing the  pelvis  and  passing  across  it  near  the  middle, 
turns  sharp  upon  itself  and  ascends  out  of  the  pelvis 
again  before  descending  once  more  to  open  into  the 
rectum.  This  anatomical  peculiarity  favors  delay  of 
faeces  in  this  part  of  the  intestine,  with  consequent  ab- 
sorption of  fluid,  and  the  formation  of  large  hard 
masses  difficult  of  expulsion.  The  stools  are  firm  or 
pasty,  or  dry  solid  balls,  sometimes  streaked  with  blood, 
an  indication  of  excoriation  of  the  anus.     When  there 


564 


MEDICAL   RECORD. 


[October  19,  1895 


has  been  no  stool  for  several  days  there  may  be  a  good 
deal  of  flatulent  distention,  which  causes  discomfort, 
but  pain  is  not  a  prominent  symptom.  By  palpation 
the  mass  of  faeces  may  be  felt,  generally  in  the  left 
iliac  fossa.  Occasionally  the  efforts  which  the  child 
makes  appear  to  determine  the  production  of  hernia, 
most  commonly  of  the  umbilicus,  and  also  prolapsus 
ani.  A  convulsion  may  occur  at  the  time  of  expulsion 
of  a  large  mass  of  faeces.  Anal  fissures  are  liable  to  be 
produced  by  the  passage  of  these  large  masses  ;  and 
when  not  seen  exteriorly  their  presence  may  be  sus- 
pected if  the  child  cries  much  and  ceases  to  make  ef- 
fort, or  if  the  solid  faeces  are  streaked  with  blood. 
The  coprostasis  may  lead  to  colitis — simple,  mucous, 
or  ulcerative.  Marfan  believes  that  the  cases  of  so- 
called  congenital  dilatation  of  the  colon,  of  which  a 
few  instances  have  been  described,  are  really  second- 
ary to  prolonged  coprostasis  due  to  this  congenital  pe- 
culiarity of  the  sigmoid.  As  to  treatment,  he  thinks 
that  something  might  be  done  by  attending  to  the  diet, 
and  especially  by  using  sugar  water  to  dilute  the  milk. 
If  in  children  at  the  breast  there  is  reason  to  believe 
that  the  milk  is  deficient  in  sugar,  it  is  well  to  give  the 
child  a  small  quantity  of  sweetened  water  before  suck- 
ling. Laxatives  and  purgatives  are  not  to  be  recom- 
mended. The  best  treatment  is  injections  of  tepid 
water,  of  water  with  a  little  sea  salt  (gr.  j.  to  3  j.),  or 
with  glycerine  (  3  ss.  in  3  vj.),  or  of  oil.  He  prefers  the 
last-named,  3  j.  of  oil  in  emulsion  with  the  yellow  of  an 
egg  in  about  3  viij.  of  water.  He  uses  a  long  soft 
tube,  which  he  says  usually  passes  easily  after  a  small 
quantity  of  the  injection  has  been  introduced.  He 
sees  no  objection  to  giving  the  injections  daily  or  even 
oftener  ;  though  there  may  be  some  prejudice  to  over- 
come before  the  nurse  can  be  induced  to  do  this.  In- 
jections may  sometimes  be  replaced  by  suppositories  ; 
for  this  purpose  he  uses  a  hollow  suppository  of  cocoa 
butter  containing  about  eight  grains  of  glycerine  and  a 
little  soap.  In  older  children  a  small  quantity  of  aloes 
(gr.  ^)  or  calomel  (gr.  '3)  may  be  added,  but  in  in- 
fants these  drugs  should  be  avoided.  Massage  of  the 
abdomen  along  the  course  of  the  colon  may  also  be  of 
use.  When  a  case  is  seen  presenting  signs  of  obstruc- 
tion the  best  treatment  is  to  wash  out  the  stomach,  and 
then  to  endeavor  to  remove  the  hard  masses  from  the 
rectum  with  the  finger  or  a  spoon.  Electricity  may 
also  succeed  in  cases  of  obstruction,  and  the  author 
relates  one  case  in  point.  Occasionally  faradization 
may  succeed — one  electrode  in  the  rectum  and  the 
other  moved  about  over  the  course  of  the  colon.  If 
the  continuous  current  be  used  the  strength  ought  not 
to  exceed  15  to  20  milliampcres.  The  positive  pole 
should  be  in  the  rectum  at  first  for  five  minutes,  and 
the  current  then  reversed  and  interrupted  subsequently 
every  twenty  seconds  for  another  five  minutes. 

Vesical  Hernia. — The  subject  of  vesical  hernia  has 
lately  received  considerable  attention.  Dr.  Ernst 
Michels  recently  communicated  to  the  Medico-Chirur- 
gical  Society  a  case  in  which,  during  the  operation  for 
radical  cure  of  hernia,  the  bladder  was  found  and  a 
portion  removed  in  mistake  for  the  sac.  The  stump 
was  put  back  into  the  abdomen  and  the  inguinal  canal 
closed.  The  mistake  was  not  discovered  until  twenty- 
four  hours  after  the  operation,  when  the  patient  began 
to  complain  of  pain  in  the  hypogastrium  and  to  pass 
blood  with  the  urine.  The  bladder  was  fully  exposed 
by  abdominal  section,  and  the  wound,  which  was  dis- 
covered in  its  extra-peritoneal  part,  closed  with  sutures, 
the  bladder  being  drained  by  a  Jacques'  catheter.  The 
author  of  the  communication  ])ointed  out  that  there 
were  two  distinct  kinds  of  vesical  hernia  ;  in  one  the 
bladder  was  contained  within  a  peritoneal  sac,  but  in 
the  other  the  extra-peritoneal  portion  of  the  bladder  de- 
scended, and  this  was  a  much  rarer  condition.  The 
bladder  had  been  wounded  in  almost  all  the  cases  the 
records  of  which   the  author  had  examined,  as  it  was 


exceedingly  difficult  to  recognize  it.  With  this  Mr. 
Macready  agreed,  and  stated  that  the  accidental  open- 
ing of  the  bladder  in  these  cases  had  been  done  by 
many  accomplished  surgeons,  and  that  he  had  himself 
done  so.  In  his  case  the  wound  of  the  bladder  was 
not  discovered  until  the  ninth  day,  when  urine  was 
found  trickling  from  the  wound.  Mr.  Arbuthnot  Lane 
records  a  case  in  which  a  hernial  protrusion  of  the 
bladder  was  found  outside  the  true  sac  in  the  operation 
for  the  cure  of  a  large  inguinal  hernia.  On  pressure 
fluid  could  be  forced  out  of  it  into  the  abdomen.  It 
was  thought  to  be  a  portion  of  the  bladder,  but  to 
make  sure  was  opened  and  then  sutured.  It  was  freed 
from  its  adhesions  to  the  outside  of  the  hernial  sac, 
and  returned  into  the  abdomen.  A  case  in  which  a 
portion  of  the  bladder  formed  part  of  a  hernia  is  re- 
ported by  Mr.  Rose,  which  differs  from  the  other  re- 
corded cases  in  that  symptoms  of  bladder  trouble  were 
present.  Micturition  was  very  painful  at  times,  and 
there  was  retention  occasionally,  associated  with  some 
increa.se  in  the  size  of  the  hernia.  The  radical  cure 
operation  was  performed,  and  the  painful  micturition 
ceased.  The  hernia  was  an  inguinal  one,  although  the 
patient  was  a  young  woman.  The  cases  of  Mr.  Lane 
and  Mr.  Rose  are,  however,  quite  different  from  Dr. 
Michels'  case,  in  which  the  bladder  alone  protruded, 
and  resembled  the  hernial  sac  itself,  a  condition  in 
which  the  bladder  has  almost  always  been  taken  for 
the  sac,  and  opened  as  such,  happily  without  any 
serious  consequences,  the  opening  thus  accidentally 
made  having  been  carefully  sutured  in  each  case. — 
TAe  Hospital. 

The  Pathogenesis  of  Diabetes  Mellitus. — Dr.  Kauf- 
mann  upholds  the  view  that  the  excess  of  sugar  in  the 
blood  in  diabetes  is  always  due  to  an  increase  in  the 
sugar  formation,  and  not  to  a  diminished  sugar  destruc- 
tion in  the  capillaries.  He  believes  that  in  the  normal 
condition  the  destruction  of  sugar  in  the  blood  is  always 
compensated  by  an  equivalent  sugar  formation  by  the 
liver,  and  that  any  modification  of  the  destruction  of  ■ 
sugar  in  the  tissues  reacts  at  once  on  the  liver  by  the 
nervous  paths  or  by  the  blood,  and  impresses  on  the 
sugar  formation  an  activity  in  direct  relation  to  the  sugar 
destruction.  In  hibernating  animals  the  sugar  in  the 
blood  diminishes  during  the  period  of  torpor,  although 
the  sugar  destruction  in  the  tissues  is  greatly  de- 
creased. After  the  revival  the  sugar  in  the  blood  in- 
creases greatly,  though  the  consumption  of  sugar  in 
the  tissues  is  increased.  LInder  normal  conditions  the 
amount  of  sugar  in  the  blood  of  the  horse  is  increased 
during  muscular  activity  ;  also  during  digestion  there 
is  an  increase  of  the  sugar  in  the  blood.  In  these  phys- 
iological conditions  the  increase  of  sugar  in  the  blood 
is  to  be  explained  by  increased  sugar  formation.  This 
is  also  the  cause  of  the  glycosuria  after  poisoning  by 
curare  and  morphine,  in  asphyxia,  after  the  adminis- 
tration of  anesthetics,  after  lesions  of  the  nervous  sys- 
tem, and  after  extirpation  of  the  pancreas  in  animals. 
In  the  case  of  pancreas  extirpation  the  evidence  against 
the  increased  sugar  production  is  stronger.  But  the 
chief  argument  against  the  increased  sugar  formation 
is  the  supposed  diminution  of  oxidation  in  diabetes. 
Recent  researches  have  shown,  however,  that  in  many 
cases  of  diabetes  the  activity  of  oxidation  and  nutrition 
is  the  same  as  in  the  normal  state.  Lepine  and  Barral, 
from  the  chemical  examination  of  the  blood,  conclude 
that  in  experimental  pancreatic  diabetes,  and  in  dia- 
betes in  man,  the  glycolytic  power  of  the  blood  is  di- 
minished— that  is,  the  power  of  sugar  destruction  is 
diminished.  Kaufmann  and  Chauveau  have  made  a 
series  of  analyses  of  the  arterial  and  venous  blood  in 
healthy  persons  and  in  cases  of  diabetes,  but  they  have 
never  found  any  ditference  between  the  normal  sugar 
destruction  and  that  in  diabetes.  Kaufmann  has  iso- 
lated the  liver  by  tying  all  its  vessels  in  a  healthy  dog, 
and  also  in  another  dog  which  had  been  rendered  dia- 


October  19,  1895] 


MEDICAL    RECORD. 


S6: 


betic  by  extirpation  of  the  pancreas.  The  action  of 
the  sugar-producing  focus  being  suppressed,  the  sugar 
in  the  blood  gradually  became  diminished  during  its 
circulation  in  other  parts  of  the  body.  But  an  hour 
after  the  insolation  of  the  liver  the  blood  had  lost  the 
same  proportion  of  sugar  both  in  the  healthy  and  in 
the  diabetic  animals.  After  having  determined  the 
diminution  of  sugar,  Kaufmann  re-established  the  cir- 
culation in  the  liver  by  removing  the  ligatures  placed 
on  the  vessels.  He  found  that  the  sugar  in  the  blood 
soon  regained  its  previous  percentage.  Hence  he  con- 
cludes that  sugar  destruction  proceeds  with  the  same 
activity  in  dogs  rendered  diabetic  by  pancreas  extirpa- 
tion as  in  the  normal  condition,  and  that  the  excess  of 
sugar  in  the  blood  is  due  to  increased  sugar  formation 
by  the  liver,  lie  believes  that  increased  sugar  forma- 
tion and  not  diminished  destruction  in  the  capillaries  is 
the  cause  of  the  excess  of  sugar  in  the  blood  in  the  dia- 
betes produced  by  pancreas  extirpation,  by  lesions  of 
the  medulla,  and  in  all  other  ways. — La  Semain  McJi- 
cale. 

Congenital  Obliteration  of  the  Bile  Duct. — At  a  recent 
meeting  of  the  Pathological  Society  of  London  (77;(- 
Lancet)  Dr.  Francis  Hawkins  exhibited  a  specimen 
showing  congenital  obliteration  of  the  ductus  com- 
munis choledochus.  This  duct  was  obliterated  and 
appeared  as  a  mere  thread  about  one  inch  before  join- 
ing the  duodenum.  The  hepatic  and  cystic  ducts  were 
pervious,  as  was  also  the  ductus  communis  choledochus 
for  nearly  an  inch  before  becoming  obliterated.  The 
gall-bladder  was  not  enlarged  and  was  empty.  The 
liver  was  enlarged,  very  firm,  and  of  a  dark  olive-green 
color,  with  fibrous  bands  running  over  the  surface, 
which  was  slightly  irregular.  The  blood-vessels  were 
normal.  The  pancreatic  duct  was  pervious  and  the 
opening  into  the  duodenum  was  seen.  Microscopical 
examination  on  section  of  the  liver  showed  it  to  be  cir- 
rhotic. There  was  a  right  inguinal  hernia  containing 
the  caecum  and  appendix.  There  was  also  a  small 
localized  empyema  at  the  left  pulmonary  base.  The 
specimen  was  removed  from  a  male  child,  aged  at  death 
four  months  and  two  weeks,  who  was  admitted  into  the 
Royal  Berkshire  Hospital  suifering  from  jaundice, 
which  had  first  been  noticed  eight  days  after  birth. 
The  jaundice  was  of  a  deep  olive  color  and  the  stools 
were  white.  Hemorrhage  from  the  mouth  occurred  on 
two  occasions  and  epistaxis  once.  The  family  history 
was  not  important.  Only  two  similar  cases  had  been 
shown  before  the  society,  and  from  a  diagrammatic 
representation  of  the  local  condition  of  obliteration 
of  the  bile  ducts  made  by  Dr.  John  Thomson,  of  Edin- 
burgh, it  would  appear  that,  including  the  two  cases 
above  mentioned,  only  six  were  recorded  in  medical 
literature  where  the  ductus  communis  choledochus 
was  alone  obstructed.  The  cause  of  the  jaundice  was 
thought  to  be  due  to  the  change  in  the  liver  itself 
owing  to  the  bile  ducts  becoming  constricted  and  ob- 
literated. The  cystic  and  hepatic  ducts  were  pervious 
and  yet  contained  no  bile. 

Digestive  Troubles  in  Diabetics  and  their  Treatment. 
—Dr.  Grube,  of  Neuenahr,  has  several  times  observed 
in  diabetic  patients  gastric  crises  very  similar  to  those 
of  tabes  {The  British  Medical  Journal).  The  patient 
all  at  once  experiences  a  violent  pain  in  the  abdomen, 
especially  at  the  pit  of  the  stomach,  accompanied  ordi- 
narily with  swelling  of  the  belly  and  eructations.  Vio- 
lent contractions  of  the  stomach  are  appreciable  on 
simple  inspection.  Very  soon  there  supervene  nausea, 
acid  vomitings,  and  sometimes  diarrhoea  and  cramps  in 
the  calves  of  the  legs.  The  tongue  is  foul,  the  pulse 
quickened,  the  buccal  mucous  membrane  dry  ;  a  little 
fever  is  noted.  The  urine  may  contain,  besides  sugar, 
acetone,  but  it  does  not  give  the  reactions  of  diacetic 
nor  oxybutyric  acids.  Lastly,  the  breath  acquires  an 
odor  recalling  that  of  chloroform.  The«e  symptoms, 
which  Grube  attributes  to  an  irritation  of  the  vagus  by 


toxic  substances  circulating  in  the  blood,  last  from 
some  hours  to  one  or  two  days,  and  leave  behind  them 
a  more  or  less  prolonged  state  of  enfeeblement.  The 
best  treatment  of  these  gastric  crises  consists  in  imme- 
diately provoking  an  alvine  evacuation  by  means  of 
aqueous  or  oily  enemata,  and  in  applying  hot  fomenta- 
tions over  the  belly.  Internal  medicaments  and  feed- 
ing are  impossible,  owing  to  the  vomiting.  The  drinks 
best  supported  immediately  after  the  cessation  of  the 
crisis  are  milk,  chicken  broth,  tea,  or  weak  brandy  and 
water.  These  crises,  although  not  dangerous /cr  se,  are 
of  bad  augury,  for  they  indicate  that  the  disease  is 
reaching  its  final  stage.  To  avoid  their  recurrence,  the 
diet  must  be  altered,  so  that  fleshy  foods  do  not  pre- 
dominate too  much,  and  the  regularity  of  the  action  of 
the  bowels  must  be  attended  to.  Besides  these  acute 
digestive  troubles,  at  certain  periods  of  the  disease  a 
state  of  chronic  dyspepsia  is  frequently  observed,  char- 
acterized by  diminution  of  appetite,  especially  by  dis- 
like for  meat,  by  painful  digestion  and  constipation. 
The  best  treatment  Grube  believes  to  be  an  alcoholic 
extract  of  pancreas  taken  after  the  three  principal 
meals,  a  remedy  which,  though  not  improving  the  gly- 
cosuria, may  undoubtedly  be  beneficial  in  relieving  the 
digestive  disturbances. 

Varices  of  the  (Esophagus. — According  to  Dr.  Fried- 
reich, the  veins  of  the  oesophagus  are  divided  into  two 
groups,  one  of  which  enters  the  superior  cava,  and  the 
other  the  portal  vein.  In  the  anastomosis  about  the 
oesophagus  these  veins  far  outnumber  the  arteries. 
There  is  an  inner  plexus  in  the  submucosa,  and  an 
outer  plexus  on  the  periphery.  Both  these  plexuses 
anastomose  freely.  There  is  a  free  anastomosis  be- 
tween the  portal  vein  group  and  the  superior  cava 
group  which  gives  a  direct  communication  between, 
the  portal  and  general  venous  system.  In  most  of  the 
cases  of  varices  of  the  oesophagus  the  liver  has  been 
the  organ  affected  as  the  primary  cause  of  the  dilata- 
tion of  the  vessels.  The  author  reports  the  following 
case  :  A  girl,  six  years  of  age,  began  to  be  sick  when 
two  and  a  half  years  old.  She  began  to  get  weak  and 
pale,  and  complained  of  pain  in  the  head  and  in  the 
region  of  the  liver.  There  were  signs  of  indigestion. 
One  year  before,  1892,  the  child  had  a  sudden  vomit- 
ing of  blood,  with  continued  vomiting  and  diarrhoea. 
In  the  following  summer  the  child  had  another  attack 
of  vomiting  and  diarrhoea.  October  13,  1893,  the  child 
was  admitted  to  hospital  with  vomiting  of  blood. 
There  was  no  abnormality  of  heart  or  lungs.  The  ab- 
domen was  distended,  but  not  tender.  It  was  thought 
that  the  child  was  suffering  from  an  ulcer  of  the  stom- 
ach. In  five  days  another  severe  attack  of  hemateme- 
sis  occurred,  this  time  followed  by  bloody  stools.  This 
was  followed  in  ten  days  by  a  typical  attack  of  chorea, 
which  gradually  improved  as  the  child  gained  strength. 
There  were  no  stomach  symptoms  after  this  until  the 
child  died  of  a  third  attack  of  hemoptysis.  At  the 
autopsy  the  ventricles  were  dilated  and  the  muscle 
soft.  The  endocardium  was  flecked  with  spots  and 
stripes  of  intense  yellow  color.  The  pericardium  and 
lungs  were  normal.  The  peritoneal  cavity  contained 
about  a  pint  of  milky  fluid.  The  peritoneum  and 
glands  were  normal.  The  liver  and  the  much- enlarged 
spleen  were  the  seat  of  fatty  degeneration.  Section  of 
the  portal  vein,  thoracic  duct,  and  vena  azygos  were 
negative.  The  only  positive  lesion  was  an  extensive 
varicose  condition  of  the  oesophageal  veins.  They 
were  knotted  and  thickened,  and  some  almost  as  large 
as  a  lead-pencil.  The  point  of  bleeding  could  not  be 
discovered. — Deiitschcs  Archiv  fiir  klinische  Medicin. 


The  University  of  California. — The  Medical  Depart- 
ment held  its  annual  commencement  on  July  13th. 
The  number  of  medical  students  during  the  past  year 
was  one  hundred  and  twenty-two. 


566 


MEDICAL    RECORD. 


[October  19,  1895 


^ociztQ  "^epoxts. 


NEW   YORK    ACADEMY  OF   MEDICINE. 

Stated  Meeting,  October  j,  18^5. 

Joseph  D.  Brvant,  M.D,,  Presidext,  in-  the  Chair. 

Abstract  of  a  Report  of  the  Gynecological  Service  at 
Mount  Sinai  Hospital  for  the  Twelve  Years  Ending 
January  1,  1895. — Dr.  Paul  F.  Mundi:  read  the  paper. 
The  number  of  patients  admitted  to  his  service  at  the 
hospital  during  these  twelve  years  was  4,211.  Of 
these  2,211  were  discharged  cured,  1,456  improved,  191 
unimproved,  102  died,  313  were  discharged  after  ex- 
amination as  not  gynecological. 

Laceration  of  the  Perineum, — There  were  184  cases 
of  laceration  of  the  perineum  ;  121  incomplete,  63  com- 
plete. One  hundred  and  forty-one  were  cured  by 
operation,  the  others  were  improved.  Up  to  1886  he 
performed  the  operation  employed  by  Emmet  and 
Thomas,  making  a  butterfly-shaped  denudation  and 
using  silver-wire  suture.  While  he  could  not  deny 
that  his  results  were  good,  still  he  had  a  few  failures, 
and  the  operation  had  the  fault  of  being  long  and 
somewhat  difficult.  In  the  summer  of  1886  he  saw 
Mr.  Tait  do  the  so-called  flap  operation,  without  re- 
moval of  any  tissue,  and  operating  so  rapidly  that  only 
those  nearest  him  could  see  what  was  being  done.  Dr. 
Munde  had  since  preferred  this  method,  and  had  em- 
ployed it  in  30  or  40  cases  without  a  single  failure. 
He  had  discarded  silver  wire  because  it  produced  pain. 
*  After  referring  to  catarrh,  ulcer,  and  stricture  of  the 
rectum  as  not  infrequent  causes  of  symptoms  seemingly 
of  a  gynecological  origin,  and  their  treatment  by  stretch- 
ing the  sphincter  and  applying  a  solution  of  nitrate  of 
silver,  he  next  referred  to  urethral  tenesmus,  for  which 
he  had  found  dilatation  usually  an  efficient  remedy. 
In  chronic  cystitis,  with  decided  disease  of  the  mucosa, 
mouth  medication  was  of  little  value.  The  bladder 
should  be  washed  out  once  or  twice  a  day  with  a  solu- 
tion of  borax  or  Thiersch's  solution.  In  decided  dis- 
ease of  the  mucosa  a  cure  could  not  be  effected  with- 
out making  a  vaginal  fistula. 

Fistulae. — Of  13  cases  of  fistula  between  the  bladder 
and  sexual  organs,  2  were  between  the  bladder  and 
uterus,  II  between  the  bladder  and  vagina.  In  one  of 
the  former  he  turned  the  uterine  canal  into  the  blad- 
der, menstruation  taking  place  through  the  bladder. 
The  other  patient  died  from  an  ovarian  abscess  which 
had  not  been  suspected,  and  which  ruptured  during  the 
operation.  Of  the  cases  of  vesico-vaginal  fistula,  9 
were  cured,  i  improved,  i  refused  an  operation.  The 
Sims  method  of  operating  was  employed,  namely,  shal- 
low paring  of  the  edges  of  the  fistula,  not  including 
the  bladder-walls  in  the  sutures.     Silver  wire  was  used. 

Rectocele,  alone  or  along  with  prolapse  of  the  ante- 
rior vaginal  wall  and  bladder,  was  present  in  no  cases. 
If  an  operation  were  required,  the  two  conditions  were 
treated  at  the  same  sitting.  The  symptoms  of  recto- 
cele, without  decided  laceration  of  the  perineum,  could 
be  relieved  by  holding  up  the  backwardly  displaced 
uterus  with  a  pessary.  If  the  perineum  were  torn  and 
the  posterior  vaginal  wall  were  very  much  relaxed  a 
pessary  could  not  be  retained,  and  only  narrowing  that 
portion  of  the  vagina  would  give  relief.  A  pessary, 
however,  might  still  have  to  be  worn  for  the  uterine 
displacement.  He  was  decidedly  in  favor  of  curing  a 
pronounced  rectocele  by  operation,  and  employed 
Hegar's  method  of  triangular  denudation  of  the  poste- 
rior vaginal  wall  and  mattress  stitch,  which  he  preferred 
to  the  method  of  Thomas  and  the  later  one  of  Emmet. 

Dr.  Munde  did  not  operate  as  often  on  cystocele  as 
on   rectocele,  for  the   reason  that,  unless  there  were 


complete  vaginal  prolapsus  calling  for  narrowing  of 
both  posterior  and  anterior  walls,  the  simple  cystocele 
operation  was  not  so  successful  in  its  permanent  results 
as  that  on  rectocele.  This  was  because  of  greater 
pressure  on  the  bladder  and  anterior  vaginal  wall  in 
the  erect  position.  Where  there  was  not  too  much 
vaginal  prolapsus  along  with  the  cystocele,  and  no  dis- 
placement of  the  uterus,  Gehrung's  pessary  sufficed 
without  a  plastic  operation.  In  the  combined  opera- 
tion, he  preferred  to  use  the  tobacco-pouch  suture,  rec- 
ommended by  Stoltz,  anteriorly. 

In  fifteen  cases  of  stenosis  and  atresia  of  the  vagina, 
he  restored  the  canal  or  made  a  new  one.  In  one  case 
there  was  double  uterus  and  vagina,  the  vaginal  canal 
on  one  side  being  closed  and  causing  pain  by  retention 
of  menstrual  blood.  He  excised  the  septum  and  made 
one  canal  from  vulva  to  fundus.  In  two  cases  there 
was  epithelioma  originating  in  the  posterior  wall  of  the 
vagina,  a  rare  seat  of  the  disease.  The  cervix  was 
healthy.  He  could  only  use  the  curette  and  caustic, 
giving  but  temporary  relief. 

Cervical  Laceration;  Cancer. — The  most  common 
disease  of  the  uterus  was  laceration  of  the  cervi.x — 
518  cases.  Emmet's  operation  was  performed  in  342 
cases,  with  316  recoveries.  In  160  cases  an  operation 
was  not  considered  necessary,  the  symptoms  being  re- 
lieved by  the  sharp  curette,  iodized  phenol,  and  nitric 
acid.  A  lacerated  cervix  required  operation,  not  so 
much  for  the  laceration  itself  as  for  the  symptoms 
which  it  produced.  He  had  become  convinced  that 
absolute  rest  in  the  recumbent  position  was  not  at  all 
necessary  for  union  of  the  lacerated  lips  after  Emmet's 
operation,  but  if  it  were  not  enforced  and  there  should 
be  failure,  one  would  be  blamed  for  not  having  taken 
the  necessary  precautions.  His  custom  had  been  of 
recent  years  to  direct  patients  to  remain  abed  a  week, 
then  get  up  and  go  about,  and  come  to  his  office  after 
the  first  menstrual  period,  when  he  usually  removed 
the  stitches.  He  had  seen,  in  properly  selected  cases, 
more  benefit  result  from  operation  on  the  lacerated 
cervix  than  from  any  other  treatment  of  any  one  of  the 
minor  lesions  of  the  female  sexual  organs.  Another 
reason  for  operating  was  the  possibility  of  malignant 
disease  developing  in  the  raw,  bleeding  tear.  How 
many  of  the  54  cases  of  epithelioma  of  the  cervix  which 
appeared  in  his  list  were  due  to  laceration  of  the  cer- 
vix he  was  unable  to  say.  At  any  rate,  probablj'  more 
than  two-thirds  of  all  the  patients  with  epithelioma  of 
the  cervix  seen  by  him  had  borne  children,  and  proba- 
bly had  suffered  from  more  or  less  cervical  laceration. 
In  only  3  of  the  54  cases  was  he  able  to  achieve  a  cure. 
The  galvano-cautery  wire  was  used.  Of  the  remaining 
51  cases  all  he  was  able  to  do  in  40  was  to  remove  as 
much  of  the  diseased  tissue  as  possible  with  the  sharp 
curette  and  chloride  of  zinc.  One  of  the  patients  lived 
four  years  after  one  such  treatment.  In  11  cases  the 
entire  uterus  was  removed  per  vaginam,  but  in  no  in- 
stance with  permanent  recovery.  In  fact,  out  of  26 
cases  of  vaginal  hysterectomy,  with  3  deaths,  not  one 
patient  had  remained  free  from  disease  longer  than 
nine  months,  and  in  no  case  had  life  been  prolonged 
more  than  two  years.  The  uterus  was  extirpated  in  6 
cases  for  malignant  disease  of  the  body — 4  epithelioma 
and  2  sarcoma.  The  patient  recovered,  but  the  dis- 
ease returned.  He  was  perfectly  aware  that  vaginal 
hysterectomy  was  attended  by  a  smaller  mortality,  but 
he  could  not  help  feeling  that  the  supra- pubic  method 
of  complete  hysterectomy  was  more  surgical  and  tech- 
nically superior.  "  I  do  not  feel  that  my  own  experi- 
ence justifies  me  in  attempting  again  to  remove  a  can- 
cerous uterus,  unless  a  thorough  careful  examination, 
if  necessary  under  anaisthesia,  has  convinced  me  that 
the  uterus  alone  is  involved  and  that  the  parametrium 
is  absolutely  free  from  disease.  I  do  not  see  the  use 
of  subjecting  the  patient  to  the  danger,  discomfort,  not 
to  mention  expense,  of  a  hysterectomy,  whether  vaginal 
or  supra-pubic,  for  the  removal  of  her  cancerous  uterus. 


October  19,  1895] 


MEDICAL   RECORD. 


567 


unless  there  are  at  least  seventy-five  chances  out  of  a 
hundred  in  her  favor  for  a  permanent  cure.  Acting  on 
this  principle,  I  have  refused  many  an  operation  which 
I  have  good  reason  to  believe  has  afterward  been  per- 
formed by  others,  who  could  not  possibly  have  had  any 
reasonable  expectation  of  curing  the  patient.  Many 
cases  of  cancer  of  the  cervix,  indeed,  in  which  the  pa- 
tient does  not  bleed  and  has  only  a  comparatively 
trifling  discharge,  suffers  no  pain,  in  fact,  hardly  knows 
that  she  is  afflicted  with  an  incurable  disease — many 
such  cases,  I  repeat,  should,  I  think,  be  left  alone.  The 
disease  progresses  more  slowly,  I  am  sure,  if  it  is  not 
interfered  with,  and  when  the  case  is  at  once  recog- 
nized to  be  incurable,  what  is  the  use  of  inflicting  un- 
necessary pain  and  discomfort  upon  the  patient  ?  Sim- 
ple palliative  remedies  will  in  such  cases,  it  is  my 
honest  conviction,  do  much  better  for  the  patient  than 
doubtful  or  hopeless  operative  procedures. 

I  may  as  well  say  here  that,  so  far,  I  have  not  hap- 
pened to  meet  with  a  case  where  I  could  conscien- 
tiously perform  the  now  so  popular  operation  of  ex- 
tirpation of  the  uterus  per  vaginam  for  diseased  ap- 
pendages and  pelvic  suppuration.  I  do  not  question 
the  justifiability  of  vaginal  extirpation  of  the  uterus 
for  suppuration  of  the  appendages  and  pelvic  tissues, 
in  properly  selected  cases,  but  my  experience  certainly 
leads  me  to  regard  such  cases  as  not  very  common, 
as  rather  the  exception  than  the  rule  in  diseases  of  the 
adnexa  and  pelvic  inflammation,  and  1  cannot  hel|) 
questioning  the  judgment  of  surgeons  who  report  witli 
pride  several  hundred  such  operations  performed  by 
them  during  the  last  three  or  four  years,  with  but  tri- 
fling mortality.  It  seems  to  me  that  these  gentlemen  are 
riding  a  hobby  as  fascinating  as  it  is  likely  to  be  ephem- 
eral. 

Endometritis. — Only  such  cases  of  endometritis  were 
admitted  as  could  not  be  safely  treated  at  the  office  or 
clinic,  yet  the  number  admitted  was  two  hundred  and 
ninety-seven.  The  chief  significance  of  chronic  non- 
puerperal endometritis  was  the  production  of  sterility, 
and  it  was  for  this  reason  chiefly,  and  also  for  the  irri- 
tating discharge,  that  the  cases  were  admitted.  The 
treatment  consisted  of  dilatation  and  curettage  of  the 
uterine  cavity,  followed  by  thorough  application  to  the 
endometrium  of  fifty  per  cent,  solution  of  chloride  of 
zinc  in  the  worst  cases,  and  of  a  solution  of  iodized 
phenol  in  milder  cases.  A  sterilized  drain  was  then 
inserted  through  the  internal  os,  the  patient  put  to  bed, 
and  all  precautions  taken  against  inflammatory  reaction, 
.•\  repetition  of  the  cauterization  with  milder  solution, 
if  thought  best,  usually  resulted  in  a  permanent  cure  in 
the  course  of  two  or  three  weeks,  There  were  197 
cures,  94  cases  of  improvement  out  of  297  operations,  on- 
ly 6  being  mentioned  as  discharged  unimproved.  The 
best  hope  for  a  permanent  cure  of  chronic  endometritis 
would  result  from  impregnation  and  normal  delivery. 

Fibroids. — There  were  130  cases  of  fibroids  of  the 
uterus  ;  in  only  3  was  the  growtli  limited  to  the  cervix, 
and  was  removed  by  enucleation  and  traction  througli 
the  vagina.  In  one  instance  the  patient  was  pregnant 
in  the  fifth  montli,  and  rupture  of  the  membranes  and 
iirolapse  of  the  umbilical  cord  necessitated  immediate 
i  in.  He  first  removed  the  tumor,  weighing  three 
;ids,  and  then  easily  extracted  the  child  and  pla- 
'  iua.  The  other  two  cases  occurred  in  virgins,  and 
'  •  I■^  ix  and  perineum  had  to  be  split,  after  which  the 
t  'iior  was  extracted  with  the  obstetric  forceps,  the 
•  r\ix  and  perineum  being  repaired  subsetiuently.  In 
;  I  cases  the  fibroid  had  developed  into  a  polypus  and 
was  removed  with  comparative  ease.  In  29  cases  ab- 
dominal hysterectomy  was  performed,  with  25  re- 
coveries. The  extra-peritoneal  treatment  of  the  stump 
was  adopted  in  all  cases  up  to  within  two  years,  since 
which  time  he  had  employed  the  intra-peritoneal 
method,  leaving  a  small  portion  of  the  cervix  which 
he  covered  with  peritoneum.  All  these  cases  had  re- 
covered. 


In  46  cases  the  symptoms  were  improved  in  the 
course  of  time  by  ergot,  curetting,  and  intra-uterine 
galvanization.  In  3  cases  galvanopuncture  of  the 
fibroid  was  practised  through  the  vagina,  and  a  current 
up  to  150  milliamperes  was  passed  through  the  tumor 
and  uterus  for  fifteen  minutes  under  anaesthesia,  only 
one  sitting  being  given  in  each  case.  The  treatment 
was  followed  by  quite  extensive  inflammation  and 
sloughing,  but  the  tumor  gradually  disappeared  and  all 
three  of  the  patients  were  discharged  cured. 

In  nearly  one-half  of  all  the  cases  of  fibroids  the 
symptoms  were  not  regarded-  as  sufficiently  severe  to 
warrant  any  dangerous  operative  procedure.  His  cus- 
tom was  to  advise  the  expectant  treatment  in  all  cases 
of  fibroids  which  do  not  call  for  immediate  surgical  in- 
terference, but  he  had  been  careful  to  recommend  to 
such  patients  to  present  themselves  two  or  three  times 
a  year  for  examination,  or  whenever  sudden  increase 
in  the  tumor  or  alarming  symptoms  manifested  them- 
selves. In  numerous  cases  the  tumor  was  found,  after 
a  year  or  more,  in  its  original  condition  or  diminished 
in  size,  causing  no  symptoms.  He  had  seen  great  bene- 
fit result  from  the  persistent  use  of  galvanism,  without 
puncture,  in  the  arrest  of  growth  or  diminution  in  the 
tumor. 

Dilatation  for  Sterility. — Discission  and  dilatation  of 
the  uterine  canal  for  congenital  constriction  was  per- 
formed ninety  times,  the  object  being  chiefly  to  cure 
sterility.  The  canal  was  kept  open  in  former  years  by 
hard  rubber  stem,  lately  by  packing  with  iodoform 
gauze.  What  the  results  were  on  the  sterility  he  was 
unable  to  say,  since  such  patients  seldom  returned  to 
report. 

Retroversion  or  Retroflexion  was  present  in  161 
cases  :  85  recoveries,  66  improved,  10  unimproved. 
The  recoveries  were  mostly  due  to  Alexander's  opera- 
tion, a  few  to  ventral  fixation  ;  the  improvements  were 
due  to  retention  of  the  uterus  by  pessary.  He  still 
preferred  Alexander's  operation  to  all  others  for  radi- 
cal cure  of  displacement,  had  performed  it  seventy-five 
times  in  this  list,  with  very  few  failures.  If  there  were 
uterine  prolapsus,  Alexander's  operation  alone  would 
not  suffice  to  retain  the  organ,  but  it  was  necessary  to 
also  narrow  the  vaginal  canal  anteriorly  and  posteriorly, 
and  do  perineorrhaphy.  Twice  he  operated  by  Freund's 
new  method  for  prolapsus  of  uterus  and  vagina,  by  in- 
serting a  series  of  circular  thick  wire  sutures  round  the 
prolapsed  mass,  beginning  at  the  external  and  replac- 
ing it  step  by  step  as  each  suture  was  twisted.  The 
result,  so  far  as  he  could  judge,  was  perfect.  Of 
course  the  vagina  was  almost  entirely  closed,  the 
stitches  being  left  in  as  permanent  splints. 

In  one  case  of  inversion  of  the  uterus  of  a  year's  du- 
ration, repeated  efforts  to  replace  the  organ  failed.  Pie 
was  finally  obliged  to  remove  the  ovaries,  close  the  ab- 
dominal wound,  and  apply  an  elastic  ligature  to  the 
pretty  well  mutilated  uterus,  the  result  being  a  slough- 
ing of  the  organ  and  a  complete  recovery.  He  would 
hardly  recommend  this  procedure,  but  under  the  cir- 
cumstances saw  no  other  way  out  of  the  difficulty, 

Hysterorrhaphy,  or  ventral  fixation  of  the  fundus 
uteri,  was  performed  ten  times  for  retroflexion  and  twice 
for  prolapsus,  with  one  death  in  prolapsus.  He  could 
not  conscientiously  favor  this  operation  for  a  condition 
which  in  no  way  endangered  life. 

Disease  of  the  Ovaries  and  Tubes. — Salpingitis,  acute 
or  chronic,  more  or  less  associated  with  chronic  oopho- 
ritis, occurred  651  times,  with  75  recoveries  after  re- 
moval, 41  cured  after  local  treatment  without  opera- 
tion, 512  improved  after  |)alliative  local  treatment,  22 
unimproved,  i  death  after  operation.  He  said  it  would 
have  been  very  easy  for  him  to  have  operated  on  proba- 
bly 500  of  the  651  cases,  without  putting  his  conscience 
to  a  very  dangerous  tension,  but  he  had  always  felt 
that,  while  it  was  easy  to  remo\e  the  appendages,  it  was 
never  possible  to  restore  them,  and  he  did  not  believe  any 
patienthad  seriously  suffered  through  delay  in  removal  of 


568 


MEDICAL    RECORD. 


[October  19,  1895 


the  appendages  for  which  he  might  have  been  to  blame. 
When  it  came  to  distention  of  the  tube  with  pus  the 
case  was  quite  different,  for  out  of  40  cases  recorded 
he  removed  the  diseased  organs  by  coeliotom)-  in  26, 
with  21  recoveries,  and  cured  11  others  by  vaginal  in- 
cision and  drainage.  As  a  rule  he  preferred  to  remove 
every  pus  tube  by  abdominal  section,  unless  it  was  firmly 
adherent  to  Douglas's  pouch,  was  unilateral,  and  could 
be  easily  and  safely  opened  and  drained  by  the  vagina. 

Tubal  Pregnancy.— In  15  cases  the  Fallopian  tube 
was  removed  for  pregnancy,  before  or  after  rupture, 
with  13  recoveries.  He  was  no  longer  a  convert  to 
galvanism  for  the  arrest  of  tubal  pregnancy,  although 
he  had  had  a  successful  case  of  the  kind  twelve  years 
ago.  It  was  exceedingly  difficult  to  lay  down  positive 
rules  for  the  guidance  of  the  surgeon  where  hemor- 
rhage had  ceased  and  the  patient's  condition  was  good, 
yet,  unquestionably,  the  proper  course  was,  if  the  diag- 
nosis were  reasonably  certain  and  the  blood  was  not 
encapsulated,  to  open  the  abdomen  at  once  and  remove 
the  ruptured  tube.  In  one  of  his  cases  the  rupture  had 
occurred  a  month  previously,  there  was  general  peri- 
tonitis, the  abdominal  cavity  was  full  of  foul,  decom- 
posing blood  ;  yet  the  patient  recovered. 

Cculiotomy  for  ovarian  tumors  and  cysts  of  the  broad 
ligaments  was  performed  149  times  Of  these,  128 
were  ovarian  tumors,  with  1 1  deaths.  The  rest  com- 
prised hematoma,  carcinoma,  papilloma,  acute  oedema 
of  the  ovary,  and  7  cases  of  cyst  of  the  broad  liga- 
ment. Two  cases  of  fibroid  of  the  ovary,  both  recov- 
ered after  operation.  In  25  cases  the  ovarian  tumor 
was  dermoid,  10  of  the  right,  10  of  the  left  ovary, 
5  of  both  ovaries.  In  one  case  the  dermoid  on  one 
side  contained  a  large  sn-itch  of  black  hair  about  six 
feet  long.  In  23  cases  torsion  of  the  pedicle  of  the 
tumor  was  found,  all  recovering  but  one.  The  torsion 
was  usually  to  the  right  in  cysts  of  the  left  ovary,  to  the 
left  in  cysts  of  the  right  ovary,  so  that  it  was  usually 
found  on  the  opposite  side  from  its  origin. 

A  number  of  coeliotomies  were  performed  for  other 
conditions  of  the  abdominal  organs,  such  as  tubercular 
peritonitis,  general  purulent  peritonitis,  sarcoma  of  rec- 
tus muscle,  displaced  kidney,  perityphlitic  abscess, 
and  for  exploratory  purposes. 

Pelvic  Peritonitis  and  Pelvic  Cellulitis.— Pelvic  peri- 
tonitis was  the  most  common  affection  in  his  service  : 
602  cases,  with  304  recoveries,  2S1  improved,  10  dis- 
charged unimproved,  7  deaths.  The  attack  might  last 
a  long  time,  even  for  months,  yet  the  exudate  com- 
pletely disappear,  and  the  pelvic  organs  be  restored 
apparently  to  their  normal  condition.  In  a  large  ma- 
jority of  cases  the  disease  had  its  origin  in  an  acute 
salpingitis,  and  the  worst  prognosis  regarding  ultimate 
restoration  to  entire  health  was  certainly  found  after 
gonorrhceal  infection.  Pelvic  cellulitis  was  noted  in 
79  cases,  with  67  recoveries,  8  cases  improved,  4  not 
benefited,  no  deaths.  With  rare  exceptions  the  cases 
of  pelvic  cellulitis  followed  parturition.  The  differen- 
tial diagnosis  between  the  two  classes  of  cases  was  not 
easy.  His  treatment  had  usually  been  absolute  rest, 
thorough  cleaning  out  of  the  bowels  to  begin  with, 
then  regular  but  easy  evacuations  every  two  or  three 
days.  Cold  or  hot  applications  to  the  abdomen.  When 
the  temperature  had  gone  down  and  only  the  exudate 
remained,  he  applied  blisters  with  hot  poultices  over 
the  abdomen.  Opium  only  to  relieve  pain.  In  103 
cases  the  pelvic  e-\udate  underwent  suppuration,  with 
87  recoveries,  6  improved,  i  not  improved,  9  deaths. 
In  95  cases  the  abscesses  were  opened  by  lateral  ab- 
dominal section,  in  quite  a  number  through  the  vagina 
also — opening  wliere  the  mass  pointed  most  prominent- 
ly, but  preferring  the  vagina. 

Pelvic  Hsematocele  atid  Hsematoma. — When  the  effu- 
sion of  blood  was  free  in  the  peritoneal  cavity,  and  ap- 
peared not  to  have  reached  its  limit,  abdominal  section 
should  be  made  ;  but  when  it  had  become  encapsulated, 
or  was  extra-peritoneal  and  bulged  deep  into  the  va- 


gina, he  had  found  its  evacuation  through  the  vaginal 
roof,  no  matter  where  it  may  originally  have  started 
from,  to  be  a  perfectly  safe  and  efficient  method.  Out 
of  eleven  cases  of  hjematocele  treated  in  this  manner  he 
had  three  deaths,  and  out  of  sixteen  cases  of  haematoma 
two  deaths.  He  did  not  believe  the  results  after  ab- 
dominal section  would  have  been  nearly  as  good. 

To  show  the  increase  in  the  service  of  the  hospital, 
there  were  admitted,  in  1883,  181  patients,  and  47  operar 
tions  were  performed  ;  in  1894,  505  patients,  with  295 
operations.  He  had  always  sought  to  cure  his  patients 
without  resorting  to  the  knife  whenever  it  was  possible. 
If  he  had  erred  on  the  side  of  conservatism,  there  were 
plenty  other  operators  ready  to  correct  his  error. 

Dr.  R.  a.  Murray  asked  Dr.  Munde  what  had  been 
the  difference  between  the  results  of  the  former  method 
of  doing  trachelorrhaphy  alone,  and  of  the  later  method 
of  doing  curettement  and  trachelorrhaphy. 

Dr.  Brettauer,  who  had  assisted  Dr.  Munde  in 
many  of  his  operations  and  had  acted  in  his  place  part 
of  the  time  during  his  vacations,  expressed  his  pleasure 
at  the  author's  conservatism  in  view  of  the  many  radi- 
cal operations  being  done  by  others. 

Dr.  p.  a.  Harris  wished  to  know  whether  the  author 
had  found  the  ureters  ever  in  danger  while  narrowing 
the  vagina  for  prolapsus  of  the  bladder.  He  had  never 
injured  them  himself,  but  had  feared  that  he  might. 

Dr.  C.  E.  Quimbv  thought  it  strange  that,  as  a  gen- 
eral practitioner,  he  saw  so  few  cases  of  suppurative  dis- 
ease of  the  appendages  when  gynecologists  reported  so 
many.  A  writer  in  the  Medical  Record  had  stated 
that  in  the  vast  majority  of  cases  of  pus-tubes  gonor 
rhoea  was  the  cause.  He  wished  to  know  if  this  was  in 
accord  with  Dr.  Munde's  observations,  and  whether  the 
pus  had  been  examined  for  gonococci. 

Dr.  H.  L.  Collver  said  he  had  seen  a  good  deal  of 
Dr.  Munde's  work,  and  knew  that  he  could  have  made 
a  better  showing  in  his  operative  statistics  had  he  been 
less  conservative  ;  but  it  would  have  been  at  the  expense 
of  more  mutilated  women.  In  his  opinion  the  effect  of 
electricity  on  fibroids  was  to  cause  an  absorption  of 
exudate  rather  than  absorption  of  the  fibroid  itself. 

Medical  Treatment  of  Chronic  Endometritis.— Dr.  A. 
J.^COBI  said  there  was  no  chapter  in  the  paper  which 
had  not  given  him  instruction.  He  hoped  the  author, 
who  had  used  the  material  chiefly  for  drawing  surgical 
lessons,  would  write  another  paper  showing  the  influ- 
ence of  disease  of  the  pelvic  organs  on  other  organs  of 
the  body  and  on  the  general  health,  and  also  on  the 
etiology  of  the  diseases  treated.  Regarding  chronic 
endometritis,  of  which  he  had  himself  seen  a  good 
deal,  he  had  given  up  its  treatment  by  chloride  of 
zinc  because  of  the  tendency  of  this  agent  to  produce 
cicatrization  of  the  surface.  In  parametritis  Dr.  Jacobi 
had  been  able  to  do  a  good  deal  by  bichloride  of  mercury 
internally,  amounting  to  a  quarter  of  a  grain  a  day,  kept 
up  with  intervals  for  perhaps  six  weeks.  If  he  wished 
a  speedier  effect,  he  changed  off  from  bichloride  of 
mercury  to  iodide  of  potassium  weekly.  This  treat- 
ment certainly  did  good. 

Dr.  Mlin'de  closed  the  discussion.  Replying  to  Dr. 
Murray's  question,  he  said  both  classes  of  cases  had  got- 
ten well  when  treated  by  trachelorrhaphy,  but  those  in 
which  curettement  was  done  at  the  same  sitting  got 
well  sooner.  He  had  never  wounded  the  ureters  in 
operating  for  cystocele,  the  vaginal  denudation  not  ex- 
tending deep  enough.  There  was  danger  of  chloride 
of  zinc  producing  contraction  of  the  uterine  canal,  still 
he  used  it  with  precautions  in  endometritis,  because  of 
its  beneficial  effects.  He  did  not  think  old  plastic  or 
fibrous  adhesions  could  be  inlluenced  by  internal 
medication,  as  mercury  or  iodide  of  potassium. 

The  Loomis  Entertainment  Fund. — The  President 
stated  that  the  trustees  had  provided  a  modest  refresh- 
ment from  the  Loomis  Entertainment  Fund.  In  donat- 
ing ten  thousand  dollars,  the  interest  of  which  was  to 
be  devoted  to  this  purpose.  Dr.  Loomis  had  wished  to 


October  19.  1895] 


MEDICAL    RECORD. 


569 


awaken  interest  in  the  Academy,  and  it  was  hoped  the 
members  would  wait  and  partake  of  the  refreshments. 
It  is  understood  that  a  collation  will  be  announced  on 
the  card  regularly  hereafter. 


THE  NEW  YORK   PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  May  22,  iSgj. 

George  P.  Bigg?,  M.D.,  President. 

Lacer's  Liver. — Dr.  Donald  M.  B.^rstow  exhibited 
a  liver  that  had  been  taken  from  a  woman,  sixty  years 
of  age,  who,  while  crossing  one  of  the  ferries,  had  been 
suddenly  seized  \\-ith  vomiting  and  faintness,  and  who 
had  become  unconscious  before  the  arrival  of  the  am- 
bulance from  the  Hudson  Street  Hospital.  She  died  a 
few  hours  later.  At  the  autopsy,  which  was  made  by 
Dr.  George  P.  Biggs,  it  was  found  that  the  cause  of 
death  had  been  an  extensive  cerebral  hemorrhage,  the 
result  of  an  endarteritis.  The  liver  was  a  t}'p!cal  ex- 
ample of  what  is  known  as  "  lacer's  liver."  A  groove 
or  sulcus  ran  across  the  anterior  surface  of  the  organ, 
and  indicated  that  the  constricting  force  had  pressed 
the  lower  half  of  the  liver  down  below  the  tightly  laced 
corset.  The  liver  also  presented  the  general  appear- 
ance of  cirrhosis  of  syphilitic  origin. 

Displaced  Caecum  with  Volvulus. — Dr.  George  P. 
Biggs  presented  a  specimen,  removed  from  a  male 
Italian,  thirty  years  of  age,  who  had  been  admitted  to 
the  Hudson  Street  Hospital,  complaining  of  constipa- 
tion which  had  existed  for  eleven  days.  He  had  ab- 
dominal pain,  most  marked  on  the  left,  and  the  abdo- 
men was  moderately  distended.  His  temperature  was 
99.4°  F.,  in  the  rectum.  Examination  showed  an  indis- 
tinct mass  in  the  left  inguinal  region.  A  number  of 
enemata  were  given  with  negative  result.  As  his  con- 
dition grew  steadily  worse  laparotomy  was  performed 
on  the  following  day.  The  incision  was  first  made  in 
the  median  line,  and  a  mass  was  felt  in  the  left  side  of 
the  abdomen  which  was  thought  to  be  a  distended  and 
strangulated  sigmoid  flexure.  A  second  incision  was 
then  made  over  this  mass,  and  a  considerable  quantity- 
of  thin  fecal  matter  escaped  through  this  incision. 
Supposing  that  the  gangrenous  sigmoid  flexure  had 
been  opened  into,  it  was  sutured  to  the  abdominal  end 
and  packed  with  gauze.  The  patient  died  within  a  few 
hours. 

The  specimen  presented  showed  that  the  gangre- 
nous gut  found  in  the  left  iliac  fossa  was  not  the  sig- 
moid flexure,  but  the  cjecum.  The  latter  had  a  long. 
free  mesentery,  and  thecascum  had  become  completely 
twisted  upon  itself,  and  folded  over  to  the  opposite 
side  of  the  abdominal  cavity.  The  speaker  said  that 
it  was  not  uncommon  to  find  a  caecum  with  such  a 
long  mesentery,  but  he  had  never  before  seen  one 
twisted  upon  itself  in  this  manner. 

Gunshot  Wound  of  the  Skull. — Dr.  Biggs  presented 
two  portions  of  skull,  showing  the  points  of  entrance 
and  exit  of  a  bullet.     The  bullet  had  entered  the  tem- 

'al  region,  six  inches  above,  and  a  little  anterior  to, 
external  auditory  meatus.  The  skin  about  the 
.■  lind  for  a  distance  of  nearly  half  an  inch  had  been 
blackened  by  the  powder.  There  was  a  comminuted 
fracture  in  the  centre  of  the  left  parietal  bone,  about 
two  centimeters  in  diameter.  The  bullet,  as  shown  in 
the  specimen,  was  found  lying  in  the  substance  of  the 
bone  itself.  It  had  produced  a  comminuted  fracture, 
particularly  of  the  external  plate,  and  had  become 
flattened  against  the  bone.  The  course  of  the  bullet 
was  from  the  lower  end  of  the  right  fissure  of  Rolando 
through  the  upper  portion  of  the  right  lateral  ventricle 
to  the  upper  end  of  the  left  fissure  of  Rolando.  Frag- 
ments of  bone  were  found  along  the  course  of  the  bul- 
let.    A  small  fragment  driven  off  from  the  bone  at  the 


point  of  entrance  of  the  bullet  was  forced  downward, 
and  to  the  left,  through  the  right  corpus  striatum,  and 
across  to  the  left  hemisphere,  and  through  the  left 
frontal  lobe,  and  was  finally  arrested  at  the  orbital 
plate  of  the  frontal  bone.  This  fragment  was  large 
enough  to  produce  considerable  laceration  of  the  cere- 
bral substance. 

Puerperal  Septicaemia  in  a  Dog. — Dr.  Biggs  then  pre- 
sented the  organs  from  a  dog.  dying  of  puerperal  sep- 
ticaemia. The  dog  had  been  originally  one  of  the 
attractions  at  a  neighboring  museum.  About  four 
weeks  ago  it  had  been  confined.  Almost  immediately 
thereafter  the  animal  was  observed  to  be  ill,  and  to 
have  diarrhoea.  After  about  a  week  fluid  began  to 
accumulate  in  the  peritoneal  ca^-ity.  and  the  animal 
became  markedly  emaciated.  About  one  week  ago 
the  dog  was  sent  to  a  veterinary  hospital,  and  here 
some  of  the  fluid  was  withdrawn  from  the  abdominal 
canty  and  found  to  be  almost  clear.  The  animal  died 
shortly  afterward.  Examination  of  the  uterus  showed 
an  acute  inflammation,  invohnng  the  entire  thickness  of 
the  wall-organ  at  one  comu.  There  was  endence  also 
of  a  subacute  peritonitis.  The  spleen  was  soft,  con- 
gested, and  enormously  enlarged.  There  was  a  throm- 
bosis of  the  left  ventricle  of  the  heart,  located  behind 
the  posterior  cusp  of  the  mitral  valve.  The  kidneys 
showed  very  marked  parenchymatous  nephritis.  Both 
the  small  and  large  intestine  showed  a  diffuse  inflam- 
mation, and  in  places  deep  ulcerations. 

The  Society  then  adjourned. 


L 


©liuical  ge:partment. 

TOTAL  REMOVAL  OF  TONGUE— KOCHER": 
METHOD— RECOVERY. 

Bv  WILLIAM  WATKYXS  SEYMOl-R,   M.D.   H.\rv.\rd. 


July  2,  1895,  Mr.  L ,  fifty-four  years  of  age,  black- 
smith, was  referred  to  me  by  my  friend  Dr.  H.  C. 
Gordinier  for  opinion  as  to  the  proprietj-  of  operation. 
The  patient  had  never  used  tobacco  and  had  never  had 
any  venereal  disease  ;  but  seven  or  eight  years  ago  he 
had  had  some  obstinate  fissures  on  the  dorsum  of  the 
tongue.  The  teeth  were  poor,  ragged,  and  ill  kept.  Five 
months  ago  he  first  noticed  an  ulcer  on  the  left  border  of 
the  tongue,  and  had  two  teeth  removed  by  Dr.  Lyman, 
of  Troy,  who  advised  the  patient  to  consult  a  compe- 
tent surgeon.  He  consulted  a  physician,  who  made 
light  of  his  trouble,  and,  while  daily  cauterizing  the 
tongue,  told  him  he  was  getting  better.  So  far  was 
this  from  the  fact  that  in  the  five  weeks  previous  to 
his  consulting  Dr.  Gordinier  and  his  reference  to  me, 
the  tongue,  from  being  readily  protruded  beyond  the 
teeth,  had  become  as  hard  as  a  bone  and  so  painful  as 
to  prevent  restful  sleep. 

The  tongue  was  wart)',  but  at  no  part  was  there  any 
ulceration,  and  only  from  the  history  could  I  deter- 
mine the  point  of  origin.  The  left  sublingual  gland  was 
greatly  enlarged,  and  in  addition  there  was  also  a  mass 
of  enlarged  lymphatics  in  the  submental  triangle.  Ex- 
cept for  symptoms  due  to  the  malignant  disease  the 
patient  seemed  in  good  physical  trim  and  of  unlimited 
grit.  The  dangers  of  the  disease,  the  improbability  of  a 
radical  cure,  and  the  risks  of  operation  were  thoroughly 
explained  to  him.  and  he  consented  to  an  operation. 

On  July  7th,  with  the  assistance  of  Drs.  J.  W.  Morris, 
Donald  and  Archibald  Buchanan,  I  operated  by  Koch- 
er's  method.  The  patient  was  on  his  back,  and  Vi- 
enna mixture  was  used  for  the  anaesthetic.  The  right 
lingual  arter)-  was  first  tied  ;  then  tracheotomy  was 
done,  and  the  pharynx  was  packed  with  a  sponge.      I 


57° 


MEDICAL    RECORD. 


[October  19,  1895 


then  made  a  submental  flap  on  the  left  side  so  that  at 
the  same  time  I  could  remove  the  implicated  glands. 
The  ligature  of  the  right  lingual  was  a  tiresome  piece 
of  work,  as  pulsation  in  it  was  so  feeble  that  I  was  at 
a  loss  to  know  whether  it  was  an  artery  ;  even  a  slight 
change  in  the  position  of  the  head  would  stop  all  pul- 
sation. AVhen  the  trachea  was  opened  res[)iration 
stopped,  necessitating  artificial  respiration.  Again, 
when  all  bleeding  from  the  tracheotomy  wound  ap- 
peared to  be  controlled  and  the  tube  and  sutures  had 
been  inserted,  I  was  obliged  to  reopen  the  wound  and 
ligate  a  small  vessel.  The  submental  dissection  gave 
admirable  access  to  the  diseased  structures  and  ready 
control  of  the  bleeding  vessels.  Through  this  opening 
the  entire  tongue  and  floor  of  the  mouth  were  readily 
removed.  The  ligature  wound  was  sutured  and  sealed 
with  iodoform  collodion,  and  the  same  was  done  with 
the  flap  wound,  save  at  the  upper  part  of  the  posterior 
limb,  where  a  feeding-tube  was  passed  into  the  stomach 
and  allowed  to  remain.  The  sponge-packing  of  the 
pharynx  having  been  removed,  the  mouth  was  irrigated 
with  a  weak  carbolic  solution,  and  iodoform  gauze 
packing  was  introduced  into  the  floor  of.  the  mouth. 
A  thick  dressing  of  sterilized  gauze  was  applied  over  all. 

Despite  the  duration  of  the  operation  (nearly  two 
hours)  there  was  absolutely  no  shock. 

As  is  my  custom  in  all  operations  on  the  throat  or 
mouth,  the  patient  was  put  in  a  bed  with  the  foot  very 
considerably  raised  so  as  to  favor  drainage  into  the 
mouth  and  away  from  the  respiratory  tract. 

P'or  the  first  twenty-four  hours  the  patient  was  fed  by 
enemata,  and  afterward  by  the  feeding-tube  in  the 
neck.  After  the  first  twenty-four  hours  the  gauze- 
packmg  was  removed,  and  the  mouth  was  washed  with 
a  mild  carbolized  solution.  The  after-progress  was 
uneventful.  The  patient  was  up  and  out  on  the  fifth 
day — not,  however,  with  my  consent.  The  tracheot- 
omy-tube was  removed  on  the  tenth  day,  and  the  feed- 
ing-tube on  the  eleventh  day,  after  which  the  patient 
fed  himself  with  a  "duck,"  to  which  was  attached  a 
piece  of  rubber  tubing.  This  was  rendered  easier  by 
the  practice  which  he  had  taken,  at  my  suggestion,  be- 
fore operation.  Although  the  patient  before  the  opera- 
tion had  been  racked  with  pain,  he  has  not  retpiired  a 
single  dose  of  medicine  since,  and  is  now  working  daily 
at  his  trade,  feeling  as  strong  as  ever  ;  he  can  swallow 
meat  by  washing  it  down  with  fluid  after  it  has  been 
well  chewed,  and  one  can  understand  most  of  what  he 
says. 

The  total  excisions  of  the  tongue  which  I  had  here- 
tofore seen  had  either  been  done  by  bisecting  the  lower 
jaw  or  by  Billroth's  or  Regnoli's  substantial  excision, 
and  none  of  them  seemed  to  afford  the  thorough  view 
given  by  Kocher's  operation.  The  ligation  of  the  lin- 
gual was  the  hardest  part  of  the  operation.  Of  prelim- 
inary tracheotomies  I  have  always  been  a  little  shy, 
having  seen  the  respiration  cease  instantly  in  two  cases 
on  seizing  the  trachea  with  a  tenaculum,  and  twice  when 
the  trachea  was  oi)ened.  Three  of  these  cases  were 
tracheotomies  for  diphtheria,  and  one  a  tracheotomy 
preliminary  to  excision  of  the  upper  jaw  by  my  former 
visiting  surgeon.  Dr.  George  W.  Gay,  of  Boston.  This 
latter  case  finally  breathed  noticeably  a  very  long  time 
after  Dr.  Gay  had  finished  his  operation.  Following 
my  Boston  training,  1  used  ether  almost  entirely  in  my 
early  work,  but  after  myself  taking  it  for  a  cosliotomy, 
and  ending  most  diabolical  laryngeal  irritation  from  it,  I 
have  come  to  use  more  and  more  the  so-called  Vienna 
mixture,  especially  in  abdominal  work.  I  have  found 
it  expeditious,  not  at  all  irritating  to  the  respiratory 
organs,  and  to  occasion  less  nausea  than  has  come  from 
ether  alone,  whether  administered  profusely  as  in  Bos- 
ton, or  with  Clover's  or  Ormsby's  inhalers.  In  the  after- 
treatment  of  such  operations  on  the  mouth,  in  trache- 
otomy, and  in  intubation,  permanent  inversion  for 
drainage  I  believe  to  be  a  great  advance. 

Dr.  Casselbury,  of  Chicago,  suggested  inversion  as  a 


means  of  feeding  intubation  cases,  but  nowhere  have  I 
found  any  evidence  of  its  employment  over  a  period  of 
several  days  for  drainage.  It  is  wonderfully  efficient, 
and  I  am  sure  will  minimize  inspiration  in  pneumonias 
if  employed  in  such  operations  as  excision  of  tongue, 
tracheotomy,  intubation,  thyrotomy,  and  laryngectomy. 
Trever's  suggestion,  to  have  the  patient,  for  some  time 
before  operation,  practise  feeding  himself  with  a  vessel, 
to  the  spout  of  which  a  rubber  tube  is  attached,  is  an 
excellent  one  ;  although  I  should  in  any  subse<iueht 
case  again  employ  a  feeding-tube  such  as  I  used,  and 
which  is  very  highly  recommended  by  Mr.  Arthur 
Baker.  In  these  cases  the  important  factors  are  early 
recognition,  radical  operation,  drainage,  and  feeding. 
Jonathan  Hutchinson  has  very  recently  declared  li.a: 
no  one  should  die  from  cancer  of  the  tongue  ;  but  to 
attain  this  Utopian  state  of  surgical  practice  time,  and 
with  time  life,  must  not  be  frittered  away  by  needless 
delay  or  harmful  cauterizations. 

The  cautery,  chemical  or  actual,  does  not  go  to  ;.  c 
root  of  the  evil,  and  the  same  may  be  said  of  the  partial 
operations — the  wedge  and  hemi-excisions.     The  total 
excision  does  go  as  far  as  possible,  and  should  be  done  , 
early  for  cure.     If  the  tongue  is  movable  and  the  floor  ; 
of  the  mouth   and  glands  free,  I  would,  as  a  rule,  pre-  ' 
fer  Whitehead's  operation  through  the  mouth,  but  in 
more  extensive  disease  I  cannot  imagine  an  operation 
which,  better  than  Kocher's,  satisfies  all  the  conditions 
of  operation.     Hemorrhage  is  well  controlled,   impli- 
cated glands  are  accessible  as  well  as  the  whole   floor 
of  the  mouth,  and  the  field  of  operation  is  better  ex- 
posed  than   by  any  other  method.     By   it   also  both 
drainage  and  feeding  are  easier  than  by  other  methods. 

To  prevent  infarction  and  inspiration  in  pneumonia 
invert  the  patient  until  granulation  is  well  advanced. 

Specimens  from  the  mass  we  hardened  in  formalin 
and  then  cut  by  embedding  in  celluloidin,  and  subse- 
quently stained  with  hiemotoxylin,  and  with  alum 
carmine.  The  disease  was  shown  to  be  clearly  epithe- 
liomatous.  Sections  showing  toward  the  surface  great 
masses  of  scjuamous  epithelium  with  innumerable  nests 
everywhere.  The  small-celled  infiltration  extended 
everywhere,  between  the  muscles  and  into  the  areolar 
tissue.  The  patient,  two  weeks  after  operation,  weighed 
116  pounds,  and  now  weighs  148  pounds. 


TREATMENT  OF  GONORRHCEA. 

By  ISA.«iC  E.   WILLIAMS,   M.D., 

ST.    M.\RV,    O. 

I  WRITE  this  article  not  because  I  am  a  specialist  in 
this  line  of  work,  but  with  the  hope  of  offering  a  few 
good  suggestions  which  have  aided  me  much  in  the 
treatment  of  gonorrhoea. 

In  the  beginning,  I  wish  to  state  that  my  experience 
teaches  me  :  i.  That  the  abortive  treatment  by  nitrate 
of  silver  injections  is  a  success.  2.  That  many  injec- 
tions in  common  use  are  not  strong  enough  to  do  any  1/ 
good,  and  that  they  may  be  made  stronger  with  better  f 
effect  and  without  danger  of  stricture  or  other  harm. 
3.  That  nearly  all  cases  of  gonorrhoea  should  be  cured 
in  a  time  not  exceeding  three  weeks,  and  that  seventy- 
five  per  cent,  of  them  should  be  cured  in  from  ten  to 
fifteen  days.  These  facts  I  can  demonstrate  in  pnic- 
tice.  I  have  been  the  entire  rounds  of  injections  and 
internal  medication.  The  former  I  regard  of  more  im- 
portance than  the  latter.  I  think  it  is  a  mistaken  idea 
to  obstruct  the  posterior  urethra  with  the  finger  to  pre- 
vent the  fluid  from  reaching  far  back,  as  it  can  do  no 
harm  if  the  urine  be  passed  immediately  before  inject- 
ing. The  sphincters  will  guard  the  bladder.  The  in- 
jection should  be  held  in  for  a  few  minutes  by  closing 
the  meatus. 

In  the  beginning  of  an  acute  attack,  before  the  dis- 


October   19,  1895] 


MEDICAL    RECORD. 


571 


charge  becomes  purulent,  I  advise  the  following  injec- 
tion : 

Q.   Argenti  nit gr.  5. 

Aqua  dest oz.  I . 

M.  Sig. ;  Inject  after  urinating,  every  ten  hours,  until  the  dis- 
chaige  becomes  purulent.  Use  a  blant-pointed  syringe,  holding 
two  drachms.  A  calomel  purge  (five  grains)  may  be  given  with 
benefit,  followed  by  alkaline  diluents  and  cannabis  sativa  in  suiall 
doses  for  four  days.     Then  the  following  : 

8 .   Plumbi  acet gr.  20. 

Zinc,  acet gr.  12. 

Aqua  dest oz.  i. 

M.    Sig. :  Inject  four  times  a  day  after  urinating. 

This  injection  should  cause  slight  burning  sensation. 
If  too  severe,  add  half  an  oz.  distilled  water.  If  after 
using  one  or  two  days  it  cause  no  smarting  at  all,  in- 
crease the  plumbi  acet.  to  24  gr.  to  the  4  oz.  It  w^ill 
be  seen  that  our  aim  in  the  first  stage  is  to  destroy  the 
more  superficial  parts  of  the  infected  mucous  mem- 
brane, and  in  the  second,  to  lessen  hyperemia  by  as- 
tringents. If  the  penis  is  red  and  swollen,  with  lips 
of  meatus  everted,  the  second  formula  will  afford 
prompt  relief.  Nothing  will  so  quickly  disperse  a 
chronic  gleet.  If  the  prostate  is  involved,  I  give  fld. 
e.\t.  saw  palmetto  one-half  teaspoonful  every  four 
hours.  When  the  bladder  becomes  irritable  or  in- 
flamed, fld.  e.\t.  couch  grass  idr.,  with  4  drops  fld.  e.\t. 
gelsemium  every  four  hours.  Nothing  but  distilled 
water  should  ever  be  used  as  the  vehicle  for  the  injec- 
tion. 

For  gonorrhoea  in  the  woman,  the  infected  parts 
should  be  well  swabbed  with  the  following  : 

IJ .  Argenti  nit gr.  5. 

Aqua  dest oz.  I. 

The  vagina  should  be  well  opened  with  a  speculum 
before  swabbing.  Alum,  60  gr.  to  the  oz.  of  vaseline, 
may  be  introduced  on  a  tampon  before  going  to  bed. 
This  should  be  taken  out  in  the  morning  and  the  va- 
gina well  washed  out  with  warm  water. 


A   PRELIMINARY    NOTE    ON    THE    USE    OF 
PHENOL   AS  A  PRESERVATIVE    OF    DIPH- 
-     THERIA   ANTITOXIN. 

By    CHARLES   B.    FITZPATRICK,    M.D., 


On  the  2d  inst..  Dr.  J.  L.  Kortright  and  I  had  a  con- 
versation about  the  young  girl,  named  Valentine,  which 
he  had  treated  for  diphtheria.  As  is  generally  known, 
he  administered  antitoxin,  and  the  patient  died  in  about 
three  minutes.'  Immediately  after  the  injection,  a 
"lump  "  was  felt  by  the  patient  at  the  seat  of  the  in- 
jection ;  this  was  followed  by  a  general  tingling  sensa- 
tion, convulsions,  opisthotonos,  and  cessation  of  respi- 
ration. The  autopsy  showed  a  congestion  of  the  brain, 
meninges,  liver,  and  kidneys.  No  microscopical  exam- 
ination was  made. 

In  the  discussion  mentioned  we  went  over  a  number 
of  the  possible  causes  of  the  death,  and  could  come  to 
no  satisfactory  conclusions.  Finally,  it  occurred  to  mc 
that  the  above-described  symptoms  could  very  well 
have  been  caused  by  carbolic  acid.  I  then  described 
to  Dr.  Kortright  some  of  my  experiences  with  guinea- 
pigs  which  had  been  poisoned  by  phenol,  and  he 
agreed  that  it  could  account  for  the  symptoms.  The 
serum  he  had  used  in  the  Valentine  case  contained 
phenol  as  a  preservative. 

The  second  point  to  decide  is  :  Could  a  poisonous 
amount  of  phenol,  by  some  oversight  or  accident,  have 
been  present  in  a  flask  of  antitoxin  which  had  been 
preserved  by  it  ?     By  going  over  the  steps  of  the  tech 

'  Dr.  Kortright's  article  describing  this  case  will  appear  in  an  early 
number  of  a  Brooklyn  medical  journal. 


nique  it  will  be  seen  that  such  an  occurrence  might  be 
readily  brought  about. 

After  the  blood  is  drawn,  it  is  put  in  an  ice-box. 
The  serum  is  then  drawn  off.  The  usual  way  is  to  col- 
lect a  large  quantity,  so  as  to  make  one  test  do  for  as 
much  as  possible.  The  phenol  is  then  added  to  this 
serum. 

It  is  a  well-known  fact  that  phenol  is  not  readily  dis- 
solved in  cold  aqueous  solutions.  If  it  be  added  to 
such  solutions,  even  when  thoroughly  shaken  up,  it 
forms  a  much  stronger  solution  near  the  bottom,  after 
it  has  been  allowed  to  settle. 

My  experience  with  guinea-pigs,  although  incom- 
plete, is  interesting,  and,  taken  together  with  the  liter- 
ture,  strengthens  the  probability  that  phenol  caused  the 
death  of  the  Valentine  case. 

A  guinea-pig,  weighing  542  grains,  received  2  ctm. 
of  a  I  to  40  solution  of  phenol,  subcutaneously.  On 
the  third  day  it  developed  fairly  well-marked  opistho- 
tonos and  clonic  convulsions,  which  resulted  in  death 
in  four  hours.  Autopsy  showed  congestion  of  the 
brain,  liver,  and  kidneys. 

At  another  time,  while  testing  some  serum,  I  was 
very  much  put  out  to  find,  in  a  series  of  tests,  that  the 
guinea-pig  which  had  received  the  largest  amount  of 
antitoxin  died  within  twenty-four  hours,  with  convul- 
sions resembling  those  in  the  preceding  case.  I  have 
no  doubt  now  but  that  this  was  due  to  phenol. 

I  have  also  produced  convulsions  in  rabbits.  Sal- 
kowski '  records  the  same,  and  death  in  the  midst  of  a 
convulsion.  In  the  dog  similar  symptoms  are  pro- 
duced. 

In  man,  Dr.  Taylor  -  records  a  case  in  which  the  man 
fell  unconscious  within  ten  seconds  after  taking  a  fatal 
dose  of  phenol  ;  two  minutes  later  he  was  completely 
unconscious,  pulseless,  with  irregular  respiration,  and 
in  less  than  a  minute  more  was  dead. 

Convulsions  may  also  be  present  in  man.  These 
observations  show  that  if  phenol  be  administered  it 
can  cause  death,  with  practically  the  same  symptoms 
as  those  were  which  occurred  in  the  Valentine  case. 

It  is  not  my  intention  to  give  an  elaborate  treatment 
of  this  subject,  but  just  to  indicate  what  would  justify 
a  belief  in  the  probability  that  phenol  might  have  been 
the  cause  of  death  in  Dr.  Kortwright's  case. 

In  my  article  "  Notes  on  the  Preparation  of  Diph- 
theria Antitoxin,"^  I  have  spoken  of  the  use  of  phenol 
as  a  preservative,  when  the  antitoxin  is  sufficiently 
strong  to  be  used  in  doses  of  to  c.c,  or  approximat- 
ing that.  My  present  judgment  is  that,  although  phe- 
nol is  the  best  preservative,  it  is  too  dangerous  to  be 
used.     Camphor  answers  all  the  necessary  indications. 

October  14,  1895, 


GOLD  SPECTACLES  AS  A  CAUSE  OF  ASTHE- 
NOPIA. 

By  W.  H.  bates,  M.D., 


Case  I. — The  first  case  was  reported  in  the  Medical 
Record,  February  25,  1893.  It  is  so  typical  that  with 
its  further  progress  it  deser\es a  brief  notice  here.  The 
patient  was  a  lady,  who  had  worn  steel  frames  for  some 
years.  She  desired  to  wear  gold  spectacles,  but  could 
not  do  so  because  of  the  headache  and  pain. in  her 
eyes,  produced  by  the  glasses.  It  was  discovered  that 
she  could  wear  the  glasses  when  the  gold  nose-piece 
did  not  touch  the  skin.  A  piece  of  rubber  was  vul- 
canized on  the  under  surface  of  the  nose-piece  and  the 
])atient  wore  the  glasses  with  comfort.  Since  then  the 
rubber  has  worn  through  from  time  to  time,  and  the  pa- 

•    '  PflUgers  .^rchiv. .  B.  V. 

'  Philadelphia  Medical  Times,  vol.  ii. ,  p.  284. T 
!?^  New  York  Medic.-d  Journal,  April  27,  1895.    ^ 


5/2 


MEDICAL   RECORD. 


[October  19,  1} 


tient  has  been  compelled  to  have  it  replaced.  The 
patient  was  seen  recently,  more  than  three  years  after 
the  glasses  were  ordered,  and  she  still  wears  her  gold 
spectacles  with  comfort. 

Case  II. — The  wife  of  a  physician.  She  complained 
of  headaches  and  asthenopia.  Her  general  health  is 
good,  and  she  says  that  she  has  never  been  sick.  She 
does  not  impress  one  as  being  hysterical.  The  vision 
of  both  eyes  is  §{}. 

September  25,  1894. — Under  homatropine  hydro- 
bromate,  three  per  cent,  solution  :  Right  eye  with  +  1.5 
D.S.  =  IJ  ;  left  eye  with  x  1.25  D.S.  =  fj}.  These 
glasses  were  ordered  in  steel  frames,  to  be  worn  all  the 
time. 

November  2d. — The  patient  is  relieved  of  her  head- 
aches from  wearing  the  glasses  constantly.  She  now 
obtained  gold  frames.  Her  headaches  returned  at 
once.  If  a  piece  of  paper  was  placed  under  the  nose- 
piece,  preventing  the  gold  from  touching  her  nose,  she 
had  no  discomfort  from  the  glasses.  The  optician 
fastened  a  piece  of  cork  on  the  nose-piece  to  prevent 
the  gold  from  touching  the  skin.  Headaches  occurred 
as  usual.  A  careful  examination  of  the  frames,  while 
worn  by  the  patient,  showed  that  the  cork  did  not 
prevent  contact  of  the  gold  with  the  nose.  A  piece  of 
rubber  was  vulcanized  on  the  under  surface  of  the  nose- 
piece  of  the  gold  frames,  which  prevented  the  gold 
from  coming  in  contact  with  the  skin.  The  patient 
was  able  to  wear  the  gold  spectacles  with  relief  to  her 
headaches  and  asthenopia. 

Case  III. — Mrs.  G ,  aged  thirty-three,  has  suf- 
fered from  headaches  and  asthenopia  for  several 
years.  Her  general  health  is  poor.  Under  three  per 
cent,  solution  homatropine,  May  16,  1894,  her  refrac- 
tion was  as  follows  :  O.D.  -f-  1.5  D.S.  3  +  o-5  D.C.  60°. 
O.S.-  -I-  1.5  D.S.  3  +  1.25  D.C.  90°.  These  glasses 
were  ordered  in  steel  spectacle-frames  for  constant 
wear.  Her  headaches  and  asthenopia  were  relieved. 
In  the  following  September  she  obtained  gold  spec- 
tacles. She  was  unable  to  wear  them  because  the 
pains  in  her  eyes  and  head  produced  by  the  glasses  were 
too  severe.  After  having  a  piece  of  rubber  vulcanized 
on  the  under  surface  of  the  nose-piece,  thus  preventing 
contact  of  the  gold  with  the  skin,  the  patient  was  able 
to  wear  the  gold  spectacles. 

Case  IV. — Miss  W ,  aged  twenty-eight,  has  suf- 
fered from  asthenopia  for  several  years.  She  had  also 
blepharitis  and  chronic  conjunctivitis.  Under  homa- 
tropine her  refraction,  October  8,  r894,  was  :  O.D.  + 
1.0  D.S.C  +  o  75  D.C.  45°.  O.S.  -I-  0.5  D.S.C  +  0.5 
D.C  1 20°.  These  glasses  were  ordered  and  worn  in  steel 
frames  with  relief  to  all  her  symptoms.  About  Christ- 
mas-time  she  was  presented  with  a  pair  of  gold  frames. 
She  was  unable  to  wear  the  gold  frames  because  of  the 
severe  pain  which  began  in  both  eyes  as  soon  as  the 
glasses  were  worn.  Wearing  the  gold  frames  also  in- 
creased the  redness  of  the  edges  of  the  eyelids  and  made 
the  eyes  stream  tears.  The  patient  returned  to  find  out 
if  her  glasses  were  all  right.  She  was  an.\ious  to  wear  the 
gold  frames.  In  order  to  determine  if  the  gold  frames 
caused  the  trouble,  a  piece  of  paper  was  placed  under 
the  nose-piece,  preventing  contact  of  the  gold  with  the 
skin  of  the  nose.  She  now  felt  all  right,  wearing  the 
gold  frames.  With  a  note  to  the  optician  she  hurried 
down  town  to  have  her  gold  frames  fixed.  The  opti- 
cian placed  tortoise-shell  on  the  under  surface  of  the 
nose-piece  to  prevent  contact  of  the  gold  with  the 
skin.  The  patient  felt  better  than  with  the  gold  frames, 
but  they  were  still  troublesome.  An  examination 
showed  that  the  tortoise-shell  was  held  fast  by  metal- 
lic pins,  which  may  have  caused  the  trouble.  Vulcan- 
ized rubber  was  substituted  and  the  patient  was  able  to 
wear  the  gold  spectacles  with  comfort. 

Summary. — i.  Steel  spectacles  relieved  ;  2,  gold 
spectacles  could  not  be  worn  :  3.  gold  spectacles  with 
the  gold  not  in  contact  with  the  skin,  relieved. 

64  East  Eiftv-kighth  Street. 


©orrjespontlence. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

HOSPITAL  NURSES THE  LATE  SUMMER  PUBLIC  HEALTH 

CHARGE    OF  MANSLAUGHTER DIFFICULTIES   FROM 

INFECTIOUS  HOSPITAL    OVERCROWDING MR.  ERNEST 

hart's  STATEMENTS^REPUDIATION    from    MADKA-. 

London,  September  a8,  iz  .- 

The  correspondence  on  "  White  Slaves  in  Hospital - 
still  goes  on,  and  excites  as  much  interest  as  can  be  e  - 
pected.  Many  grievances  have  been  named  whif. 
must  fall  heavily  on  the  nurses,  and  after  the  expo.--  :_■ 
which  has  taken  place  managers  must  move  or  t  c 
charities  will  suffer.  Surprise  is  here  and  there  ex- 
pressed that  the  nurses  do  not  themselves  complain, 
but  the  truth  is  they  dare  not.  The  rule  of  the  matron 
or  secretary  is  absolute,  and  often  these  officials  are 
not  fit  for  their  post.  The  matron  may  be  an  experi- 
enced nurse  but  unrefined,  a  housekeeper  without  the 
tact  or  knowledge  required  to  provide  an  appetizing 
but  economical  diet.  Even  when  a  lady  occupies  the 
position  her  rule  is  despotic,  and  she  is  apt  to  forget 
that  some  at  least  of  those  under  her  are  of  equal  so- 
cial position,  and  often  better  educated.  An  appeal  to 
the  Board  is,  I  know,  almost  always  hopeless,  and  re- 
sults in  dismissal  with  a  view  of  maintaining  discipline. 
The  Boards  of  Management  have  now  had  warning. 
The  public  requires  them  to  maintain  justice  as  well  as 
discipline.  It  is  admitted  on  every  hand  that  the  wom- 
en who  take  to  nursing  are  very  easy  to  manage,  as 
they  expect  to  sacrifice  many  comforts.  They  are  cer- 
tainly prepared  to  endure  every  hardship  incidental  to 
their  vocation,  but  that  is  no  reason  why  Boards  should 
increase  those  hardships  by  neglecting  their  own  duties 
of  supervision,  and  committing  undue  authority  to  any 
one  they  cannot  or  will  not  control. 

No  doubt  the  question  of  finance  will  come  before  ' 
these  Boards.  Let  them  remember  that  economy  do'es  j 
not  consist  in  buying  inferior  food  for  nurses,  or  in  ar-  I 
ranging  a  dietary  which  is  not  nutritious.  The  ques-  I 
tion  of  long  hours  is  more  serious,  as  a  great  increase  :i 
of  the  staff  would  be  costly.  But  it  will  never  pay  to  v 
knock  up  the  nurses  by  overwhelming  them  with  work,  -' 
and  the  numerous  women  one  meets  who  have  broken 
down  under  the  strain  proves  the  real  urgency  of  the  'i 
grievance. 

We  are  enjoying  or  enduring — according  to  the  tem-  .1 
perament — a  period  of  prolonged  fine  weather  and  al-  i 
most  unpar.alleled  heat  for  this  time  of  year.  I 

In  town  it  is  oppressive,  but  in  the  country  delightful,  I 
though  in  the  full  sunshine  it  is  too  hot  for  many.     In   n 
the  early  mornings  and  evenings  I  have  experienced 
nothing  like  it  for  many  years. 

The  health  of  both  London  and  country  continues 
good.  There  was  a  slight  rise  of  mortality  in  London 
last  week,  but  only  to  sixteen  per  one  thousand,  and  in 
other  towns  the  returns  were  as  favorable,  while  Croy-*' 
don  only  registered  nine.  There  is  an  increase  of 
scarlet  fever  in  some  districts,  and  diphtheria  main- 
tains its  hold. 

A  sad  case  of  death  in  parturition  has  occurred,  and 
resulted  in  the  arrest  of  the  doctor  in  attendance  on  a 
charge  of  manslaughter  from  neglect  or  recklessness. 
At  the  inquest  it  was  alleged  that  he  was  intoxicated, 
but  other  statements  were  that  he  was  ill  and  had 
taken  chloral.  He  had  been  in  practice  some  thirty 
years,  and  had  attended  over  five  thousand  labors. 
He  will  have  to  stand  a  trial,  when  perhaps  it  will  be 
shown  that  the  preliminary  investigation  is  incom; 
plete.  A 

An  incident  at  the  East  End  last  week  seems  to  point 
to  the  need  of  some  further  supervision  of  cases  of  in- 


October  19,   1895] 


MEDICAL    RECORD. 


573 


factious  disease  for  which  the  hospitals  have  not  room. 
A  child  with  scarlet  fever  was  taken  to  the  London 
Hospital.  An  ambulance  was  sent  for  and  the  patient 
removed  to  the  hospital  of  the]  Asylums  Board,  but  as 
this  was  full  the  child  was  conveyed  home  again  in 
the  ambulance.  No  further  steps  were  taken  by  the 
parents,  and  no  bed  seems  to  have  been  vacant.  The 
child  died  in  ten  days,  and  at  the  inquest  the  father 
said  that  it  was  no  use  sending  for  a  doctor,  as  he 
would  only  have  ordered  removal  to  hospital.  Either 
ignorance  or  carelessness  seems  to  have  been  partly  to 
blame.  The  hospital  accommodation  is  sometimes 
overstrained,  and  there  has  been  great  difficulty  in 
providing  more.  It  is  suggested  that  when  a  patient  is 
sent  back  to  his  home  some  account  should  be  kept  to 
prevent  his  remaining  unattended  ;  but  surely  most  peo- 
ple would  send  for  a  doctor. 

The  Madras  branch  of  the  British  Medical  Associa- 
tion has,  at  a  special  meeting,  adopted  a  vigorous  pro- 
test against  the  resolution  of  the  Public  Health  section 
on  Indian  sanitation,  which  it  declares  to  be  based  on 
erroneous  statements  of  Mr.  Ernest  Hart. 

Many  members  of  the  Association  have  been  led 
away  by  Mr.  Hart's  statements,  some  of  which  are  cer- 
tainly erroneous.  The  Indian  medical  officers,  too, 
have  been  disgusted  by  the  superciliousness  and  con- 
tempt for  their  e.xperience  he  has  displayed.  Some  of 
his  remarks  respecting  the  senior  officers  in  the  service 
were  most  insulting,  and  coming  from  one  whose  knowl- 
edge of  the  matters  he  spoke  of  was  altogether  second- 
hand, naturally  give  offence.  Some  previous  protests 
have  accordingly  appeared,  in  reply  to  one  of  which  a 
leading  article  was  issued  in  the  journal  of  the  offen- 
sive kind  Mr.  Hart  is  so  capable  of.  This  article 
holds  up  to  ridicule  a  distinguished  medical  officer  as 
the  holder  of  military  rank,  lieutenant -colonel,  and 
this  after  all  that  has  been  claimed  for  officers  in  the 
service  !  also  as  having  been  engaged  largely  in  civil 
practice  1  Then  it  extols  Mr.  Hart  and  his  knowledge, 
which  is  purely  theoretical,  while  that  of  veteran  offi- 
cers is  practical.  Mr.  Hart  has  never  been  nice  about 
giving  offence,  and  has  delighted  to  dip  his  pen  in  gall, 
but  it  is  time  he  gave  up  his  bitter  personalities. 
Already  many  are  remarking  that  the  Association  pays 
him  to  edit  the  journal,  not  to  insult  members,  and  a 
few  are  anxious  to  know  what  he  has  been  paid  for  his 
trip  to  India,  and  whether  the  Association  has  been 
paying  for  his  other  tours.'  But  the  financial  reform- 
ers of  the  Association  are  not  likely  to  extract  informa- 
tion. 


OUR    PARIS    LETTER. 

(From  our  Special  Correspondent.) 

MEDICAL  PARIS  HERSELF  AGAIN  —  BEQUEST  TO  THE 
FACULTY — THE  PUBLIC  AND  THE  PASTEUR  INSTI- 
TUTE— HIGH  INFANTILE  MORTALITY — QUACKS  AND 
CHARLATANS — GOOD  RULES  FOR  BICYCLISTS — MUSIC 
AS  MEDICINE. 

Paris,  September  35,  1895. 

Paris,  that  is  medical,  professional  Paris,  is  beginning 

i  to  be  herself  again  ;  almost  all  the  leading  practitioners 

I  are  back  from  their  long  outing,  and  nearly  every  day 

'  sees  the  arrival  of  some  distinguished  professor  of  the 

Faculty.     All  the  buildings  making  that  formidable  pile 

known  as  the  "  Ecole  de  Mtiiecine,"  are  being  cleaned, 

j  the  schedule  of  lectures  and  courses  are  posted,  and  all 

li  will  very  shortly  be  ready  for  the  formal  opening  of  the 

winter  semestre,  which  nominally  takes  place  October 

15th  ;  but  it  will  be  fully  a  month  later  before  every- 

!  thing  is  in  full  working  order. 

(I  Professor  Brouardel,  the  Dean,  has  been  authorized 
by  the  Faculty  to  accept  the  bequest  of  Mr.  Ch.  1, 
Mautter  according  to  the  conditions  of  his  will,  for  the 
foundation  of  an  annual  prize  in  favor  of  a  woman  dot - 
tor,  authoress  of  a  work  on  the  diseases  of  children. 


The  General  Council  of  the  Seine,  considering  that 
the  prefectoral  administration  has  sent  to  the  different 
mayors  of  Paris  instructions  regarding  admission  to 
the  Institut  Pasteur  of  persons  bitten  by  mad  dogs, 
and  that  these  instructions  are  not  within  reach  of  the 
public,  who  mostly  ignore  them  altogether,  have  voted 
that  precise  instructions  regarding  the  formalities  to  be 
complied  with  for  the  admission  of  wounded  to  the  In- 
stitut Pasteur  be  posted  in  every  commune  ;  and  that 
they  be  printed,  with  all  other  instructions  relative  to 
hygiene,  upon  the  inside  covers  of  copy-books  used  in 
the  public  schools,  just  as  tables  of  botany  or  historical 
synopsis  would  be.  This  is  an  example  that  your  New 
York  Board  of  Health  would  do  well  to  follow,  at  least 
in  so  far  as  hygiene  is  concerned,  and,  of  course,  vac- 
cination. The  health  of  Paris  is  not  quite  as  good  as 
in  the  corresponding  month  in  previous  years.  For  in- 
stance, the  Bulletin  de  Statislique  Miinicipale  records  982 
deaths  during  the  last  week  ;  whereas  there  were  880 
the  week  before,  the  average  for  September  being  S32. 
Torrid  weather  has  prevailed  in  Paris  for  some  days 
past,  the  sun  has  shone  mercilessly  in  a  cloudless  sky, 
running  the  thermometer  up  into  the  nineties,  and  this 
accounts  largely  for  the  increase  in  the  mortality-rate. 
The  number  of  deaths  from  infantile  diarrhoea,  athrep- 
sis,  etc.,  during  the  first  year  of  life  has  been  152,  al- 
most the  double  of  the  ordinary  (78)  at  this  season  ; 
moreover,  those  caused  by  diarrhoea,  between  the  ages 
of  one  and  four  years,  have  amounted  to  36,  or  nearly 
triple  the  average  (13).  As  is  always  the  case,  the 
heat  has  fallen  heaviest  upon  the  poorer  population  in 
the  sequestered  quarters  of  the  city,  who  do  not  give 
sufficient  care  to  cleanliness  nor  to  the  alimentation  of 
their  young  children,  and  where  pure  milk  and  scrupu- 
lously clean  vessels  are  the  exceptions.  Epidemic  dis- 
eases are  rare.  Typhoid  fever  has  caused  but  S  deaths 
instead  of  13 — the  average. 

Notwithstanding  the  severe  requirements  to  attain 
the  grade  of  "  Doctor  "  and  the  stringent  new  laws  regu- 
lating the  practice  of  medicine  in  France,  many  quacks 
and  charlatans  still  remain  to  be  dealt  with.  AH  the 
medical  societies  have  now  a  legal  standing  as  syndi- 
cates ;  the  secretary  has  only  to  notify  the  authorities 
of  any  case  of  illegal  practice  that  may  have  come  to  his 
knowledge,  and  such  person  is  proceeded  against  at 
once.  Nevertheless,  we  counted,  only  yesterday,  ten 
medical  posters  giving  the  name  of  a  "  doctor  "  on  each, 
his  address,  and  hours  of  consultation,  in  ])ublic  urinals 
on  the  Boulevards.  One  of  these  has  just  been  con- 
demned by  the  tribunals  to  a  fine  of  i.ooo  francs.  Next, 
the  Court  of  Appeals  of  Paris  has  likewise  condemned 
a  druggist  to  25  francs  fine,  and  100  francs  damages  for 
counter-prescribing,  an  evil  from  which  physicians  and 
the  public  suffer  in  other  large  cities  as  well.  It  seems 
that  the  druggist  in  question  prescribed  a  prolonged 
application  of  a  two  per  cent,  solution  of  carbolic  acid 
on  an  excoriated  thumb. 

M.  Rochebave  has  just  formulated  the  following  pre- 
cepts, which  every  bicycle  amateur  would  do  well  to 
follow:  I.  Only  ride  on  a  bicycle  after  consulting  your 
doctor.  An  examination  should  be  made,  not  only  be- 
fore but  after  riding,  as  certain  cardiac  derangements 
only  manifest  themselves  under  the  influence  of  fatigue 
or  over-exertion.  2.  Only  go  at  moderate  speed,  twelve 
kilometres  an  hour.  Only  increase  that  rate  of  speed 
after  methodical  and  daily  training.  Even  after  a 
few  days  of  interruption,  recommence  at  a  low  speed. 
3.  Overcome  as  much  as  possible  the  desire  to  go  fast. 
Bicycles  almost  roll  of  themselves.  It  is  very  difficult 
not  to  yield  to  the  "delirium  of  rapidity."  With  a 
light  machine  on  a  good  road,  the  slightest  breeze  aid- 
ing, an  amateur  can  easily  do  twenty  kilometres  an 
hour.  This  is  too  much  ;  since  at  twelve  or  fourteen 
kilometres  the  pulse-beats  rise  to  150  per  minute. 

An  interesting  work  has  just  been  given  us  by  Dr. 
Ferrand,  a  psychological  essay  on  music. 

From  a  medical  stand-point  music  may  truly  be  con- 


574 


MEDICAL    RECORD. 


[October  19,  1895 


sidered  a  profound  moderator  of  the  activity  of  the 
nervous  system,  and  deserves  a  place  in  therapeutics  in 
the  same  category  as  the  antispasmodics,  that  is  to  say, 
agents  that  modify  the  activity  of  the  nerve-centres  in 
communicating  to  them  impressions  other  than  those 
which  they  are  accustomed  to  obey.  In  varying  its  dif- 
ferent measures,  the  mechanism  of  its  rhythm,  the  vivac- 
ity of  its  melody,  the  complexus  of  its  harmony,  music 
would  seem  to  act  as  an  antispasmodic,  either  simple, 
stimulant,  or  moderating.  Finally,  music  is  capable  of 
acting  upon  the  seat  of  motor  and  auditive  sensations, 
and  upon  the  seat  of  images  corresponding  to  those 
sensations — capable,  consequently,  of  exciting  sensory 
ideas  and  the  sentiments  belonging  to  them.  Dr.  Fer- 
rand's  conclusions  are  certainly  very  interesting  to  those 
making  diseases  of  the  nervous  system  a  specialty.  The 
subject,  however,  is  by  no  means  new  and  the  remedy 
not  difficult  of  application  ;  only  the  physician  himself 
should  have  a  thorough  knowledge  of  it  in  order  to 
know  exactly  what  conditions  to  fulfil,  or  what  choice 
to  make,  how  much  musical  exercise  to  prescribe,  and 
what  works  would  be  best  for  his  patient  to  hear  or 
perform. 


MEDICAL   LANGUAGE. 

To  THK  Editor  of  the  Medical  Record. 

Sir  :  A  paragraph  in  your  issue  of  September  17th,  p. 
342,  under  the  head  of  "  Hippopyrrhine,"  suggests  to 
me  the  following  remarks  :  Of  course  it  is  stupid  and 
out  of  place  to  use  the  word  "vaccinate"  or  "vacci- 
nation "  for  anything  that  has  no  connection  with  the 
cow  or  with  "  vaccinia."  Dr.  Badour  takes  great  pains 
to  forge  a  new  word,  which,  if  not  intelligible,  is  at  least 
barbarous,  though  being  Greek.  The  term  is  certain- 
ly clumsy,  as  you  well  style  it.  I,  a  humble  member  of 
tlie  profession,  not  "  learned  nor  fond  of  word-making, 
venture  to  remind  you  that  there  are  two  good  old 
words,"  which  seem  to  me  to  hit  "  off  the  case  neatly 
and  euphonically  :  "  I  mean  "  to  inoculate  with  "  or  "  to 
imp  with."  See  New  High  German,  imp/en ;  Middle 
High  German,  impfen,  impfetcii,  impetcn  :  Old  High 
German,  impfoii,  impffitSti,  iwpiton,  anglosam,  impian. 

By  the  way,  I  am  much  afraid  that  my  friend  Dr. 
Achilles  Rose's  scheme,  to  have  New  Greek  adopted 
as  the  international  medical  language,  has  little  chance 
ever  to  become  realized.  Greek,  old  or  modern,  is 
just  as  little  known  as  Hebrew  or  Chinese  in  a  great 
part  of  the  world,  namely,  at  least,  where  people  speak 
Spanish  or  Portuguese.  Honestly  though,  being  a 
German,  I  would  rather  propose  to  adopt  English, 
which,  besides  its  other  advantages,  has  that  the  Eng- 
lish-speaking people  form  so  great  a  majority  of  the 
civilized  world.  That  is  a  fact,  and  there  is  no  fighting 
against  facts.  If  we  are  not  able  to  have  a  soul  above 
national  pride  and  vanities,  we  are  not  yet  fit  for  any- 
thing really  "  international." 

Dr.  Semeleder. 

Cordoba,  State  of  Vera  Ckuz,  Mexico, 
September  36,  1895. 


The  Health  Department  and  the  Examination  of 
Tubercle  Bacilli.— The  St.  Louis  Health  Department 
makes  free  microscopic  examinations  of  sputum  for 
tubercle  bacilli.  The  Health  Commissioner  asserts  that 
certain  doctors  send  specimens  to  the  Health  Depart- 
ment for  examination,  and  then  charge  their  patients  §5 
each  for  this.  Such  a  proceeding  does  not  seem  right 
to  the  Health  Commissioner,  and  is  not  in  accord  with 
medical  or  other  ethics.  When  a  government,  however, 
undertakes  the  job  of  providing  free  examinations, 
free  medicines,  free  inspections,  free  vaccinations,  free 
disinfections,  etc.,  it  must  expect  some  friction  before 
the  state  of  perfected  paternalism  is  reached. 


picdical  Stems. 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  October  12,  1895. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. 

Measles 

Diphtheria 

Small-pox 


Dual  Personality  and  the  Double  Brain. — A  favorite 
theory  with  some  speculative  psychologists,  and  one 
which  appears  to  be  gaining  ground,  is  that  the  two 
cerebral  hemispheres  are  capable,  to  some  extent,  of 
independent  activity.     The   theory  has  been    evoked 
to  account  for  those  strange  but  well-established  cases 
in  which  an  individual  appears  to  possess  two  states  of 
consciousness,  two  personalities  as  it  were — such  cases 
as  afford   the  basis  of  fact  for  Stevenson's  weird   ro- 
mance of  "  Dr.  Jekyll  and  Mr.  Hyde."     Dr.  Lewis  C. 
Bruce,  in  the  last  number  of  Brain,   records  a  case 
which  is  more  strongly  in   favor  of  the  double-brain 
theory  than  any,  so    far  as  we  know,    previously  re- 
ported.    The  man  was  an  inmate  of  the  Derby  Bor- 
ough Asylum.     He  was  a  Welshman  by  birth,  and  had 
been  a  sailor  by  occupation.     He  was  a  lunatic,  but  his 
mental  characteristics  were  very  different  at  different 
times.     In   one   state   he   was    English,   in  the  other, 
Welsh.     In  the  English  stage  he  was  the  subject  of 
chronic  mania.     He  spoke  English,  but  understood  and 
could  converse  in  Welsh.     He  was  restless,  destructive, 
thievish,  and  fond  of  playing  practical  jokes.     He  ex- 
hibited a  fair  amount  of  intelligence,  wrote,  drew  pict- 
ures of  ships,  related  incidents  in  his  past  life,  recog- 
nised the  doctors  and  attendants,  and   was  bold   and 
fearless  in  his  manner.     His  memory,  however,  was  a 
blank  as  to  what  occurred  in  the  Welsh  stage.     Thus, 
on  one  occasion  he  burnt  his  arm  during  the  Welsh 
stage,  but,  passing  a  few  days  later  into  the  English 
stage,  he  could  give  no  account  of  how  he  suffered  the 
injury.       Vet  he  could  remember  events    which    had 
happened  earlier  in  an   English  stage  ;  for  instance,  a 
year  later  he  could  recall  accurately  particulars  about 
Christmas  decorations.     He  knew  coins  and  their  pur- 
pose, he  recognized  varieties  of  tobacco,  and  sought  to 
obtain  the  weed  by  fair  means  or  foul.     He  named  the 
primary  colors,  and  was  pleased  with  the  sound  of  a 
tuning-fork.     Taste,  smell,  and  touch    seemed  to   be 
unimpaired.     His  circulation  was  good  (pulse  of  high 
tension),  he  had  a  good  appetite,  his  bowels  acted  well, 
and  he   was  very  fond  of  his  bath.     Into  the  Welsh 
stage  he  passed  either  suddenly  or  by  way  of  an  inter- 
mediate stage  ;  in  the  Welsh  stage  he  was  in  a  condi- 
tion of  dementia.     He  understood  Welsh,  but  talked  a 
gibberish  in  which,  however,  some  Welsh  words  were 
recognizable  ;  he  did  not  understand  English.     He  sat 
doubled  up  in  a  chair  for  hours,  did  not  attempt  to 
move  at  meal-times,  was  sly  and   suspicious,  did   not 
recognize  doctors  or  attendants,    his   circulation    was 
weak,  his  extremities  livid,  his  legs  often  cedematous 
(pulse  of  lower  tension).     He  suffered  from  constipa- 
tion, disliked  bathing,  did  not  recognize  coins  or  to- 
bacco, was  alarmed  at  the  sound  of  a  tuning-fork,  and 
appeared  to  have  no  power  of  discriminating  by  smell 
or  taste.     .\s  far  as  the  symptoms  so  far  mentioned  go, 
it  might  be  i>ossible  to  explain  the  man's  dual  states, 
taking  our  clew  from  the   fact  that  he  retained  some 
knowledge  of  Welsh  in  his  demented  stage,  by  suppos- 


October  19,  1895] 


MEDICAL    RECORD. 


575 


ing  that  some  variation  in  the  blood-supply  might  have 
thrown  in  and  out  of  action  the  more  recently  organized 
centres,  which,  as  the  man  was  born  Welsh,  would  be 
the  organization  for  speaking  English,  while  the  Welsh 
part  of  the  speech-centre  would  still  remain  capable  of 
some,  though  a  ver\-  imperfect,  form  of  acti\ity.  This 
hypothesis,  however,  appears  to  be  negatived  by  the 
fact  that  he  was  right  handed  while  in  the  English 
stage,  left-handed  while  in  the  Welsh  stage.  While  in 
the  intermediate  stage,  when  this  was  observed,  he  was 
ambidextrous,  and  spoke  a  mixture  of  English  and 
Welsh,  understanding  both  languages.  This  fact  seems 
to  leave  us  no  alternative  but  to  conclude  that  in  the 
English  stage  the  left,  in  the  Welsh  stage  the  right 
hemisphere  was  the  more  active.  In  the  Welsh  stage. 
when  he  attempted  to  write,  the  result  was  practically 
illegible,  but  he  used  the  left  hand  and  traversed  Ihe 
paper  from  left  to  right.  In  the  English  he  wrote  with 
the  right  hand  from  left  to  right,  and  rather  more  legi- 
bly. He  could  also  write  with  his  left  hand,  but  then 
traversed  the  paper  from  right  to  left,  and  his  writing 
had  the  characters  of  mirror-writing — that  is,  it  could 
be  read  when  held  up  to  a  mirror.  —  The  British 
Medical  Journal. 

Provident  Associations  and  the  East-Side  Doctors. — 
A  writer  in  the  New  York  Herald  calls  attention  to  a 
new  kind  of  co-operative  scheme  of  medication,  which 
has  been  started  in  this  city,  on  the  plan  of  an  insur- 
ance association.  Although  the  scheme  is  spoken  of 
as  "new,'"  it  is  practically  a  form  of  the  provident  in- 
si:  ranee  associations,  such  as  have  been  attempted  in 
England.  The  writer  says  :  "  Nearly  every  head  of  a 
family,  in  this  eastern  section  of  the  city,  belongs  to  a 
secret  benefit  society  of  some  sort.  Until  lately  these 
societies  confined  their  acti\aty  to  life  insurance,  fu- 
neral benefits,  and  sick  benefits,  but  lately  the  feature 
of  medical  insurance  has  been  added  to  several  of 
them.  The  plan  is  to  engage  some  young  physician 
who,  for  a  fee  of  seventy-five  cents  per  quarter  from 
each  member  of  the  society,  undertakes  to  attend  the 
member  or  his  family  in  case  of  sickness.  At  first 
sight  it  seems  as  if  this  might  be  a  profitable  arrange- 
ment in  the  case  of  a  society  with  one  thousand  or 
more  members,  but  in  practice  it  is  not  so.  Everv 
member  of  the  society  has  several  children,  one  or 
more  of  whom  are  almost  constantly  ailing,  and  the 
slightest  ailment  furnishes  an  excuse  to  call  the  doctor 
when  his  visit  costs  nothing  extra.  One  young  physi- 
cian who  rashly  entered  into  contracts  with  three  of 
these  societies,  having  an  aggregate  membership  of  fif- 
teen hundred,  told  me  that  he  estimated  that  he  got 
three-quarters  of  a  cent  for  each  call  he  made.  '  I  can 
find  no  time  for  private  practice,'  he  said.  'Today  I 
have  had  forty-two  calls  from  my  society  patients,  and 
I  have  an  average  of  thirty  a  day.  I  am  all  worn  out 
with  the  work,  and  when  my  quarter  runs  out  nothing 
will  induce  me  to  renew  the  contract.  Why,  if  a 
child  scratches  its  finger  I  have  to  go  and  dress  it,  and 
1  have  even  found  cases  where  the  society  members 
called  on  me  to  visit  their  neighbors,  passing  them  off 
as  members  of  their  own  family  and  charging  them  a 
small  fee  for  the  accommodation.'  " 

The  Adventtires  of  a  Scientific  Paper. — In  conse- 
quence of  his  communication  on  the  serum  treatment 
of  tuberculosis  presented  to  the  recent  annual  meeting 
of  the  British  Medical  Association,  Professor  Marag- 
liano,  of  Genoa,  says  The  British  Medical  yournal,  has 
had  an  amount  of  greatness,  or  at  any  rate  celebritv. 
thrust  upon  him  which  he  is  probably  beginning  to  find 
somewhat  inconvenient.  Though  the  paper  was  pro- 
fessedly inter  ded  for  the  British  Medical  Association. 
it  seems,  by  a  mysterious  process  of  thought  transfer- 
ence, to  have  been  brought  immediately  to  the  knowl- 
edge of  the  editor  of  our  esteemed  contemporary  the 
Berliner  klinische  JVochenschri/t,-KhQ  published  it  in 
•xtenso  in  his  issue  of  August  12th,  before  we  ourselves 


had  had  the  opportunity  of  seeing  the  document.  Al- 
most simultaneously  it  appeared  in  the  Gazzefta  degli 
Ospitali,  the  Riforma  Medica,  and  other  Italian  journals, 
and  copious  extracts  from  it  were  given  in  the  leading 
political  papers  of  Europe.  Immediately  after  the 
London  meeting  the  Professor's  philanthropic  zeal  ap- 
pears to  have  led  him  to  Bordeaux,  where  he  presented 
the  same  communication  to  the  Congress  of  Internal 
Medicine  which  met  in  that  city.  Several  of  the  French 
medical  journals  are  angry  with  Professor  Maragliano 
for  having  offered  a  second-hand  article  to  the  Bordeaux 
Congress,  and  have  therefore  declined  to  let  the  paper 
appear  in  their  report  of  the  proceedings. 

Malingering  and  Miracles. — Pierre  Delanay,  sup- 
posed to  have  been  cured  in  a  miraculous  way  at 
Lourdes,  has  confessed  that  he  only  shammed  illness. 
He  describes  his  case  as  follows  :  Having  served  for 
some  time  as  a  hospital  assistant,  and  thus  become  famil- 
iar with  the  clinical  jargon,  Pierre  one  day  declared  him- 
self the  victim  of  an  attack  of  locomotor  ataxia.  For 
five  years  he  fooled  the  doctors  and  had  a  good  time 
in  bed,  wilh  nothirg  to  do  but  to  dispose  of  the  nour- 
ishing diet  which  his  sad  case  called  for.  The  doctors 
seem  to  have  had  their  suspicions,  however,  and  a  se- 
vere course  of  "  the  fire  and  hanging  method  "  decided 
Pierre  that  the  game  was  not  worth  the  candle  ;  so  he 
decided,  in  the  words  of  the  song,  to  "  go  where  he  was 
respected."  At  Lourdes  he  was  received  with  open 
arms,  and  when  in  the  sacred  grotto  he  threw  away  his 
crutches  and  proclaimed  himself  cured,  he  was  received 
with  cries  of  acclamation.  Archbishops  and  bishops 
hastened  to  testify  to  the  miracle,  the  Marquis  de  VLl- 
leneuve  gave  him  an  easy  and  lucrative  post,  and  the 
world  was  made  easy  for  the  "  brand  plucked  from  the 
burning." 

To  Avoid  Poisoning  by  Tinned  Food. — Some  light  is 
thrown  by  The  Lancet  upon  the  mysterious  cases  of 
poisoning  by  tinned  food  which  from  time  to  time  are 
reported.  "They  are  believed  to  be  due  to  neglect  of 
the  caution  against  eating  tinned  foods  that  have  been 
exposed  to  the  air  for  some  time  after  being  opened. 
The  exact  manner  in  which  poisonous  substances, 
technically  known  as  "  ptomaines  "  are  generated  so 
rapidly  is  not  known  with  certaint)-,  but  the  fact  that 
they  are  produced  in  sufficient  quantity  to  cause  very 
grave  symptoms  of  poisoning  have  been  brought  out  in 
a  multitude  of  instances.  In  one  well-known  case  the 
first  half  of  the  contents  of  a  tin  of  lobster  was  con- 
sumed with  no  ill  effect,  but  the  rest,  a  few  days  after- 
ward, proved  extremely  poisonous.  It  is  suggested 
that  as  a  safeguard  manufacturers  might  label  the  tins 
with  some  such  notice  as, "  The  contents  of  this  tin  are 
perfectly  wholesome  when  eaten  fresh  from  the  tin,  and 
afford  good  food,  but  the  public  is  advised  not  to  ex- 
pose the  contents  for  any  length  of  time  to  the  injuri- 
ous influences  of  the  atmosphere."  The  writer  goes  so 
far  as  to  suggest  that  some  such  warning  might  be  in- 
sisted on  by  the  Legislature. 

Petrifaction  of  the  Hnman  Subject. — There  exists  in 
a  Florentine  museum  in  Italy  a  number  of  examples  of 
the  skill  of  petrifying  the  dead  and  preserving  their 
features,  which  was  possessed  by  the  late  Dr.  Girolamo 
Segato.  The  Lancet  notes  the  recent  finding  of  a  pet- 
rified head  of  a  young  woman,  who  had  died  of  tuber- 
culosis, which  is  the  most  striking  specimen  of  his  art. 
In  the  ])ast  sixty  years  there  seems  to  have  been  no 
particular  change  in  this  head,  which  preserves  the  feat- 
ures and  even  the  complexion,  with  the  most  weird 
realism. 

Denver's  Home  for  Consumptives,  which  has  been 
erected  by  Mrs.  W.  D.  Sloane  and  Mrs.  Auchmuty  and 
others  at  a  cost  of  $150,000,  was  opened  a  few  days 
ago.  The  home  is  not  a  hospital.  Only  incipient 
cases  are  taken.  There  are  to  be  no  nurses  and  no 
resident  physician,  and  each  will  pay  for  medical  at- 


576 


MEDICAL   RECORD. 


[October  19,  1895 


tendance.  There  will  be  a  "  mother,"  or  matron,  who 
will  preside  over  the  liome,  and  there  will  be  no  rules 
except  those  that  enforce  hygienic  cleanliness.  The 
cost  of  living  at  the  home  is  $6  a  week.  We  take  it  that 
the  purpose  of  the  home  is  to  help  poor  people  who 
are  in  the  incipient  stage  of  consumption  only. 

The  Walker  Memorial  Hall.— Dr.  Henry  F.  Walker, 
of  New  York,  who  was  for  many  years  associated  in 
practice  with  Dr.  T.  Gaillard  Thomas,  has  jiresented 
his  native  town,  Pittsford,  Vt.,  with  a  handsome  build- 
ing, to  be  known  as  Walker  Memorial  Hall,  in  memory 
of  his  parents,  the  Rev.  Dr.  Charles  Walker  and  wife  ; 
and  the  dedication  services  were  held  on  September 
I  ith.  Addresses  were  made  by  Dr.  Walker,  his  brother. 
Rev.  George  Leon  Walker,  of  Hartford,  the  Rev.  Dr. 
George  A.  Boardman,  and  others.  The  building  is  to 
be  mainly  occupied  by  the  MacClure  Circulating  Li- 
brary, which  was  founded  nearly  a  century  ago.  Dr. 
Walker,  besides  being  the  donor  of  Walker  Memorial 
Hall,  has  furnished  Pittsford  with  an  excellent  system 
of  water-works  and  sewerage. 

The  Three  Kinds  of  Doctors.— The  .SV.  Lauis  Medical 
Jounial  divides  physicians  into  three  classes  :  Those 
who  read,  those  who  do  not  read,  and  those  who  pre- 
tend to  read.  Our  contemporary  does  not  make  any 
attempt  to  give  the  census  of  these  different  classes, 
but  intimates  that  the  third  class  is  unduly  prominent 
in  this  country. 

Absorption  of  Drugs  by  the  Bladder  and  Urethra. — 

Dr.  J.  P.  Walsh  says  that  absorption  takes  place  from 
the  bladder,  vagina,  and  urethra  (  Unhersity  Magazine). 
Absorption  is  a  matter  of  lymphatics,  not  of  epithelial 
cells.  The  various  forms  of  cells  lining  different  parts 
of  the  respiratory,  digestive,  and  genito-urinary  tracts 
play  mainly  a  protective  part  for  the  lymphatic  struct- 
ures beneath.  That  in  some  places  they  have  a  height- 
ened activity,  and  seemingly  a  selective  action  in  ab- 
sorption is  true  ;  but  at  no  part  do  they  absolutely 
prevent  absorption.  Even  the  cutaneous  epithelium, 
with  its  horny  epiderm  will  allow  the  passage  of  a  num- 
ber of  substances.  Rapidity  of  absorption,  then,  de- 
pends on  the  richness  of  the  lymphatic  structures  in  a 
part,  and  not  on  the  character  of  the  mucous  membrane 
covering  it.  The  lymphatics  in  the  bladder  are  not 
numerous,  but  they  are  easily  demonstrable.  Absorp- 
tion should  take  place  then,  though  not  rapidly.  His 
specific  conclusions  are  that  :  i.  The  bladder  absorbs 
somewhat  slowly  the  drugs  that  are  injected  into  it,  but 
it  has  a  true  absorptive  power.  2.  The  urinary  constitu- 
ents, water  and  solids,  are,  to  a  certain  extent,  reab- 
sorbed from  the  bladder,  when  allowed  to  remain  in  it 
for  some  time.  3.  The  anterior  urethra  absorbs  more 
readily  and  rapidly  than  the  bladder.  The  posterior 
urethra,  about  as  the  bladder  does.  4.  The  vagina  ab- 
sorbs very  readily  ordinary  drugs  that  are  injected 
into  it. 

Nine  Days  Asleep. — An  experiment  which  the  West- 
ern /ieserve  Medical  Journal  caW?,  interesting,  but  which 
we  should  say  was  dangerous  and  uninstructive,  was 
recently  conducted  in  Cleveland  by  a  professional  hyp- 
notist. A  boy  was  ])ut  to  sleep  on  July  15th  and  told 
not  to  wake  up  for  seven  days  About  2  .\..m.  on  the 
morning  of  July  iSth  the  boy  awaked,  however,  but 
was  at  once  put  to  sleep  again  by  the  hypnotist  and  re- 
mained so  until  the  evening  of  July  25th.  He  had  then 
slept  seven  days  and  gone  without  food  nine  days. 
Two  physicians  were  in  charge  of  the  experiment,  and 
watches  of  eight  hours  each  were  assigned  to  students 
of  the  second-year  class  of  the  Western  Reserve  Medi- 
cal College,  so  that  at  no  time  was  the  boy  alone,  and 
at  no  time  were  less  than  two  students  present.  The 
experiment,  says  the  Journal,  was  unquestionably  scien- 
tifically conducted,  and  is  of  no  little  interest  to  medi- 
cal men  in  showing  that  the  hypnotic  state  may  be  pro- 
longed at  least  a  week,  during  which  time  tissue-change 


goes  on  as  in  natural  sleep  (Sohn  lost  some  twenty 
pounds  in  the  week),  but  the  natural  sensation  of  hun- 
ger does  not  seem  to  awaken  the  subject. 

Aristocratic  Doctors. — According  to  the  Gaulois, 
Count  de  Goyan,  a  prominent  Royalist,  and  formerly  a 
member  of  the  Chamber  of  Deputies,  has  taken  the  de- 
gree of  Doctor  of  Medicine  at  the  Paris  Faculty,  with 
the  object  of  giving  himself  up  to  the  treatment  of  the 
sick  poor.  In  this.  Count  de  Goyan  has  followed  the 
example  of  the  Due  de  Rivoli  (also  a  former  Deputy), 
Count  de  Sinety  (a  member  of  the  Jockey  Club),  and 
M.  Rembielinski  (well  known  in  Paris  society).  All 
these  gentlemen  began  the  study  of  medicine  after  the 
age  of  thirty,  and  went  through  the  prescribed  course, 
passing  their  examinations  and  taking  their  degree  in 
the  ordinary  way.  Baron  Henri  de  Rothschild,  who  is 
also  preparing  for  the  medical  profession,  entered  him- 
self as  a  student  when  very  young.  He  has  a  pro- 
nounced taste  for  surgery,  and  his  present  intention  is 
said  to  be  to  found  a  surgical  hospital  at  his  own  ex- 
pense. 

The  New  McLane  Hospital. — This  hospital,  which  is 
winning  a  good  deal  of  reputation  for  its  hospitality,  as    1 
well  as  its  architectural  appointments,  held  a  reception     1 
to  the  officers  of  kindred   institutions,  and  the  physi- 
cians of  Boston  and  neighborhood,  on  October  ist. 

Dr.  Frank  Parsons  Norbury,  who  recently  removed 
to  St.  Louis  to  assume  the  editorial  management  of  the 
Medical  Fortnightly,  has  been  elected  to  the  chair  of 
Practice  of  Medicine  and  Clinical  Medicine  in  the  St. 
Louis  College  of  Physicians  and  Surgeons. 

Snake-bite  Antitoxin. — In  British  India  alone  there 
are  each  year  from  eighteen  to  twenty  thousand  deaths 
from  snake-bite.  Hence  the  unusual  interest  of  Pro- 
fessor Fraser's  recent  lecture  before  the  Royal  Society  <.  f 
Edinburgh,  giving  data  obtained  by  him  during  several 
years  experimental  work  on  an  antidote  for  snake-poison, 
obtained  by  following  principles  similar  to  those  util- 
ized in  the  antitoxin  treatment  of  diphtheria.  The 
Popular  Science  Monthly  states  that  he  first  immunized 
an  animal  by  repeated  small  doses  of  the  snake-poison, 
slowly  increasing  the  quantity,  until  the  animal  was 
taking  at  a  single  dose  many  times  the  minimum  lethal 
amount  for  a  non-immunized  individual.  Into  another 
animal  was  then  injected  some  of  the  blood-serum  from 
the  immunized  case,  and  it  was  found  that  this  prevented" 
any  ill  effects  from  a  subsequent  injection  of  venom. 
Still  a  third  animal  was  given  an  injection  of  pure; 
venom  ;  and,  when  distinct  symptoms  of  poisoning  ap- 
peared, was  treated  with  the  immunizing  serum  with 
the  result  that  the  symptoms  of  poisoning  disappeared 
and  no  ill  effects  followed. 

Therapeutic  Use  of  Extract  of  Bone-marrow. — In  a 

paper  by  Dr.  John  S.  Billings,  Jr.,  read  before  the  John^ 
Hopkins  Medical  Society,  the  efficacy  of  bone-marro\\r< 
was  considered,  and  its  use  illustrated  by  the  history  of 
selected  cases.  The  first  case  of  anaemia  treated  by 
this  agent  was  reported  by  Fraser.  Results  were  ex-' 
cellent.  Bigger  gave  an  account  of  a  boy  suffering 
from  leucocythajmia,  who  also  was  treated  with  bone^ 
marrow.  There  was  rapid  diminution  in  the  size  of 
the  spleen  and  marked  improvement  within  a  week. 
In  the  author's  cases,  those  of  chlorosis,  were  benefited^; 
while  the  persons  suffering  from  pernicious  anieniiai 
were  not  improved.  The  conclusion  is  that  the  extrai 
of  bone- marrow  may  be  of  value  in  cases  of  ordinar] 
anxmia  and  chlorosis  that  would  be  benefited  by  iroi 
in  other  forms.  The  marrow  was  given  in  a  glyceri 
extract.  Twelve  ribs  of  sheep  were  carefully  scraped 
and  chopped  into  small  fragments,  then  rubbed  up  ia 
a  mortar  with  one  pound  of  glycerine.  This  was 
allowed  to  macerate  for  three  or  four  days,  being  kept 
in  a  refrigerator  during  that  time.  It  was  then  strained 
through  gauze,  and  the  resultant  liquid  given  in  tea- 
spoonful  doses  three  times  a  day. 


lUlMf 

% 

inS 


Medical   Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  48,  No.  17. 
Whole  No.  1303 


New  York,  October  26,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


33tXc(lical  iVcldrcss. 


THE     PRACTICE 
LIGHT        OF 
SEARCHES.' 


OF      MEDICIXE     IN 
BACTERIOLOGICAL 


THE 
RE- 


By  a.  ALEXANDER   SMITH,  M.D., 


The  scientific  and  accurate  demonstration  of  the  rela- 
tionship of  micro- organisms  to  disease  is  of  compara- 
tively recent  date.  Although  prior  to  1882  a  large 
number  of  observations  had  been  published  in  the  at- 
tempt to  establish  the  relationship  of  cause  and  effect 
between  microbes  and  disease,  the  medical  profession 
was  slow  to  accept  the  conclusions.  Koch's  researches, 
published  in  18S2,  marked  a  long  step  in  advance.  His 
method  was  the  first  exact  one,  and  by  its  aid  he  was 
able  to  discover  many  new  points  in  the  morphology 
and  biology  of  micro-organisms.  His  method,  an  ac- 
count of  which  was  published  at  that  time  (1882),  has 
been  very  little  modified  to  the  present  day,  and 
"  Koch's  law,"  to  the  postulates  of  which  a  micro-or- 
ganism must  conform  before  it  can  be  considered  the 
cause  of  a  certain  disease,  is  still  the  authority.  Scien- 
tific men  had  been  prepared  by  the  labors  of  earlier 
investigators  to  accept  Koch's  conclusions.  Indeed 
it  is  doubtful  if,  without  such  earlier  investigations, 
Koch's  conclusions  would  have  been  so  readily  ac- 
cepted. Koch's  investigations  demonstrated  the  rela- 
tionship of  a  specific  micro-organism  to  disease,  first 
by  showing  the  constant  presence  of  such  micro-organ- 
ism in  the  tissues  or  fluids  of  the  individual  suffering 
from  such  disease  ;  then  its  absence  in  all  other  diseases  ; 
then  its  isolation,  growth,  and  repeated  cultivation,  and 
finally  its  power  of  reproducing  that  disease  after  inoc- 
ulation in  certain  animals. 

The  pioneer  worker  in  modern  bacteriology  was 
Colm,  professor  of  botany  in  Breslau.  He  had  stu- 
dents but  no  systematic  course.  Koch  was  probably 
the  first  to  give  a  systematic  course  ;  this  was  given  in 
Berlin  in  1880  and  1881,  but  was  not  open  to  all  appli- 
cants, being  under  governmental  control.  The  first 
open  courses  were  given  in  Munich,  by  Frobenius, 
and  in  Guttingen,  by  Fliigge,  in  1883  and  1S84.  Dr. 
Welch,  now  of  the  Johns  Hopkins  Hospital,  took  these 
courses,  and  in  1886  and  1887  gave,  in  the  Pathological 
Institute  of  the  Johns  Hopkins  Hospital,  the  first  open 
course  in  instruction  in  bacteriology  in  the  United 
States.  This  was  modelled  after  Koch's  course.  In 
the  spring  of  1S85  Dr.  Herman  Biggs  gave  instruction 
in  bacteriology  in  the  Carnegie  Laboratory  in  this  city, 
he  having  taken  instruction  in  the  winter  of  1S84  and 
1885  from  Miiller,  a  director  in  the  Dental  Institute  of 
the  University  of  Berlin.  In  the  last  ten  years  courses 
of  instruction  have  been  established  in  many  places 
in  Europe  and  this  country,  and  medical  students  are 
given  the  opportunity  for  instruction  in  this  important 
branch  of  medical  study.  In  this  country,  recently, 
laboratories  have  been  established  in  connection  with 
boards  of  health,  local  and  State,  for  the  prosecution 
of  bacteriological  work. 

'  Being  the  Address  on  Medicine  delivered  before  the  New  York 
State  Medical  .Association,  October  15,  1895. 


It  may  prove  not  uninteresting  to  glance  at  the  work 
of  the  past. 

Leuwenhoeck  first  observed  micro  organisms  in  1675. 

Pleuciz,  a  contemporary  of  Leuwenhoeck,  was  the 
first  to  advance  the  idea  that  micro  organisms  are  the 
cause  of  disease,  and  that  each  disease  has  its  specific 
organism,  transmitted  through  the  air.  He  was  un- 
sparingly ridiculed,  however. 

Miiller,  in  1773,  was  the  first  to  make  any  close  study 
of  micro-organisms  ;  he  first  classified  them  (yeasts, 
fungi,  etc.). 

Davaine,  in  1863,  first  demonstrated  the  probable 
relation  of  a  specific  organism  to  a  specific  disease. 

Rindfleisch,  in  1866,  first  demonstrated  the  presence 
of  micro-organisms  in  pathological  lesions. 

Pasteur  may  be  said  to  have  been  the  first  to  thor- 
oughly study  microorganisms.  He  was  originally  a 
chemist,  but  noticing  one  day  that  certain  solutions  of 
the  tartrates,  after  standing,  underwent  changes  in  their 
polarizing  properties,  he  investigated  the  subject  and 
thus  started  on  his  life's  work,  the  results  of  which 
have  been  so  wonderful  and  valuable.  In  1857  he 
published  his  investigations  of  the  lactic-acid  fermenta- 
tion, following  this  up  with  his  work  on  the  diseases  of 
vines,  beer,  etc.  He  proved  each  fermentation  to  be 
due  to  a  certain  organism,  and  that  if  its  entrance  be 
prevented  fermentation  could  not  take  place.  While 
his  early  work  does  not  come  directly  into  the  field  of 
medicine,  it  influenced  it  greatly.  The  process  which 
destroyed  grape- vines  was  a  true  disease  ;  he  con- 
sidered it  as  such,  and  after  determining  its  etiology, 
pointed  out  a  mode  of  cure.  His  later  work  on  anthrax, 
gangrenous  septicemia,  and  suppuration,  brought  him 
directly  into  human  medicine.  "The  value  of  his  work 
is  inestimable.  Our  ideas  of  sterilization  are  based  on 
his  work,  and  he  first  succeeded  in  isolating  an  organ- 
ism by  means  of  his  method  of  "  successive  cultures." 
Koch's  solid  media  method  is  simply  an  advance  on 
the  same  line.  Pasteur  first  stated  that  micro-organ- 
isms are  absolutely  essential  to  life  on  the  globe,  that 
they  occupy  a  middle  position  between  the  animal  and 
higher  vegetable  kingdom,  and  by  decomposing  animal 
matter  into  its  component  elements,  renders  it  available 
as  food  for  the  plant  world,  which  in  turn  supplies  the 
animal  world  with  food  and  oxygen.  In  a  word,  he 
demonstrated  the  fallacy  of  "  spontaneous  generation." 

Lemaire  discovered  the  value  of  carbolic  acid  as  an 
antiseptic,  and  believing  suppurations  of  wounds  to  be 
due  to  germs  from  the  air,  he  treated  such  wounds  with 
carbolic  acid.  This  was  the  first  step  toward  the  anti- 
septic treatment  of  wounds  which  Lister  worked  out  to 
such  brilliant  results  afterward. 

Villemin,  in  1865,  first  demonstrated  the  infectious 
nature  of  tuberculosis,  by  showing  that  it  could  be 
transmitted  to  animals  by  inoculation. 

In  the  early  half  of  this  century  it  was  enough  to  say 
that  a  disease  was  due  to  inflammation  of  a  particular 
organ  or  organs,  and  that  such  inflammation  could  be 
caused  by  cold,  sudden  changes,  and  so  on.  The  con- 
tagious and  epidemic  nature  of  the  various  acute  dis- 
eases was  well  recognized.  Thirty  years  ago  the  spread 
of  such  diseases  was  thought  to  be  through  the  air. 
Cholera  and  typhoid  fever  alone  were  thought  by  many 
to  be  transmitted  by  means  of  drinking-water  or  food. 
We  now  know  that  transmission  through  the  air  plays  a 
very  minor  role,  at  least  in  those  diseases  in  which  the 


MEDICAL   RECORD. 


[October  26,  i{ 


micro-organism  has  been  demonstrated.  It  has  been 
proven  that  solid  particles  of  matter,  such  as  micro-or- 
ganisms, do  not  rise  from  moist  surfaces.  Bacteria  are 
mainly  diffused  by  adhesion  to  the  hands,  to  clothing, 
etc.,  or  by  drying  up,  when  they  take  the  form  of  dust 
and  are  blown  about.  How  easy  to  demonstrate  from 
this  the  great  value  of  prophylactic  measures.  It  is 
comparatively  easy  to  destroy  the  vitality  of  microor- 
ganisms  in  the  moist  state,  as  in  typhoid-fever  stools,  for 
example,  and  correspondingly  difficult  where  they  are 
all  around  us  in  the  atmosphere  in  the  form  of  infected 
dust. 

The  changes  brought  about  by  our  present  knowl- 
edge of  bacteria  are  more  marked  in  surgery  than  in 
internal  medicine.  The  discovery  of  the  organisms  of 
suppuration,  of  the  effects  produced  upon  them  by  bi- 
chloride of  mercury,  carbolic  acid,  and  other  substances, 
and  the  demonstration  that  an  operator  can  go  almost 
anywhere  in  the  body  so  long  as  he  keeps  everything 
clean  and  aseptic — these  facts  have  revolutionized  sur- 
gery and  obstetrics.  We  no  longer  hear  that  a  wound 
is  "  suppurating  nicely,"  but  if  it  does  suppurate  the  sur- 
geon wants  to  know  the  reason,  whether  it  is  his  fault 
or  that  of  his  assistants.     There  is  blame  somewhere. 

In  obstetrics,  if  proper  precautions  are  taken,  the 
many  dangers  from  sepsis  which  formerly  surrounded 
the  patient  have  been  reduced  to  the  minimum.  In 
internal  medicine,  on  the  other  hand,  there  has  been  no 
such  marked  progress.  While  the  discovery  of  the 
bacterial  nature  of  certain  diseases  has  been  of  great 
value  in  prophylaxis,  and  has  demonstrated  the  futility 
of  certain  lines  of  treatment,  no  material  advance  has 
been  made  in  the  actual  treatment  of  disease  by  in- 
ternal medication.  Exception  may  be  made  in  the  case 
of  diphtheria,  which  will  be  discussed  later.  This  is 
chiefly  due  to  the  fact  that  in  diseases  we  do  not  find 
the  specific  organisms  localized  in  limited  and  acces- 
sible areas.  Where  surfaces  are  accessible,  such  as  the 
skin  and  mucous  membranes,  and  cavities  like  the  pleu- 
ral and  peritoneal  cavity,  specific  local  treatment  based 
on  the  knowledge  of  the  microbe  origin  of  many  dis- 
eases affecting  them,  has  been  of  great  practical  utility. 
We  have  not  yet  found  an  agent  which,  if  given  inter- 
nally, will  surely  and  rapidly  kill  the  micro-organisms, 
and  not  at  the  same  time  kill  or  injure  the  living  tis- 
sues of  the  body.  Antiseptic  and  aseptic  methods  are, 
for  this  reason,  only  beginning  to  be  employed  in  in- 
ternal medicine.  The  tendency  now  is  to  prevention 
of  tjie  spread  of  the  disease  by  individual  prophylaxis. 
The  application  of  the  various  methods  can  only  be 
thoroughly  and  effectively  carried  out  when  the  physi- 
cian understands  the  reasons  for  his  actions,  keeping 
clearly  in  mind  the  objects  to  be  attained.  It  is  the 
practising  physician  to  whom  is  intrusted  the  applica- 
tion of  the  discoveries  and  advances  made  by  the  labora- 
tory workers  ;  hence  the  importance  of  a  familiarity 
with  the  theories  and  principles  of  bacteriology  on  the 
part  of  every  physician.  The  present  ideas  as  to  the 
contagion  and  diffusion  of  disease  have  been  extended 
to  other  diseases,  the  precise  micro-organism  of  which 
we  are  as  yet  ignorant  of  ;  for  example,  scarlet  fever, 
measles,  small-pox,  etc. 

The  study  of  the  products  of  micro-organisms,  the 
toxins,  antitoxins,  bacterio-proteins,  toxalbumins,  etc., 
has  become  most  important.  In  the  early  bacteri- 
ological work  it  was  thought  the  bacteria  themselves 
were  the  direct  cause  of  the  manifestations  of  disease. 
It  has  now  been  ])roven,  however,  that  these  manifesta- 
tions are  due  to  the  toxins  produced  by  the  bacteria. 
It  is  through  the  study  of  the  action  of  these  substances 
that  our  modern  ideas  of  immunity  have  been  evolved. 
Many  observers  hold  that  it  is  by  the  artificial  ])roduc- 
tion  of  immunity  that  we  shall  bo  able  to  conil)at  the 
infectious  diseases  in  the  future.  There  are  three  chief 
ways  of  producing  it  in  man. 

First,  by  producing  a  modified  form  of  the  disease 
(vaccination).    Over  a  hundred  years  have  elapsed  since 


Jenner  first  applied  in  medicine  the  principles  of  im- 
munity against  disease,  by  employing  vaccination  as  a 
protective  means  against  small-pox.  Neither  he  nor  his 
immediate  followers  understood  the  principles  of  im- 
munity as  brought  about  by  vaccination.  His  first  ob- 
servations, however,  have  stood  the  test  of  time,  and 
clinical  facts  have  only  served  to  strengthen  his  position. 
It  was  reserved  for  the  genius  of  Pasteur  to  make  a 
satisfactory  scientific  demonstration  of  their  truth  by 
his  eminently  brilliant  discoveries  concerning  the  pro- 
tective power  of  inoculation  in  animals  and  fowls. 
Pasteur's  method  of  securing  immunity  depended  es- 
sentially on  submitting  the  individual  or  animal  to  the 
attack  of  the  disease-producing  organism  itself  in  an 
attenuated  form — at  least  in  a  form  modified  in  such  a 
way  as  to  lessen  its  virulence.  Soon,  however,  other 
methods  were  devised.  These  later  methods  of  secur- 
ing immunity  do  away  with  the  necessity  of  any  con- 
tact whatever  between  the  individual  and  the  bacteri.i 
themselves.  One  of  these  methods  is  by  the  introdui  - 
tion  into  the  system  of  the  bacterial  poisons  produce! 
by  the  specific  organisms,  but  without  the  bacteria. 

The  third  chief  method,  the  latest,  is  by  the  intro- 
duction into  the  system  of  the  serum  of  an  animal, 
which  is  either  naturally  or  artificially  immune  to  the 
disease  in  question.  Koch,  Chauveau,  Buchner,  and 
in  later  times  Behring,  Roux,  and  Kitasato,  have  done 
the  most  important  work  on  this  subject. 

So  far,  the  treatment  of  disease  by  injections  of  the 
toxic  products  or  toxins  of  the  specific  micro-organ- 
isms has  not  been  of  marked  value.  It  has  been  tried 
in  tuberculosis  (Koch's  tuberculin),  typhoid  fever,  and 
latterly  in  cancer,  by  injection  of  the  toxins  of  the 
micro- organism  of  erysipelas.  Serum  therapy  offers 
the  most  promising  results,  and  in  view  of  the  won- 
derful effects  of  the  antitoxin  treatment  of  diphtheria 
we  may  look  for  a  similar  treatment  in  typhoid  fever, 
lobar  pneumonia,  and  cerebro  spinal  meningitis  ;  in 
fact  in  all  the  diseases  produced  by  micro-organisms  in 
which  the  micro-organisms  themselves  are  the  source 
or  the  cause  of  the  production  of  the  curative  sub- 
stances. 

The  very  fact  that  recovery  from  infectious  diseases 
is  spontaneous,  suggests  that  there  is  in  such  diseases 
a  power  on  the  part  of  the  blood  to  produce  an  agent 
which  is  antagonistic  to  the  toxins  which  have  caused 
the  manifestations  of  the  disease  ;  and  after  the  toxins 
have  been  neutralized  by  such  antitoxin,  the  remaining 
antitoxin  affords  such  immunity  as  is  generally  ob- 
served. It  has  long  been  known  that  in  many  of  the 
infectious  diseases  one  who  has  suffered  one  attack  is 
usually  immune  against  a  subsequent  attack. 

Let  us  glance  at  some  of  the  infectious  diseases  in 
detail,  and  trace  the  influence  bacteriology  has  pro- 
duced upon  our  views  concerning  them. 

In  lobar  pneumonia  early  treatment  was  based  upon 
the  idea  of  its  being  an  inflammation  pure  and  simple. 
Bleeding  and  purging  were  resorted  to,  counter-irrita- 
tion in  its  various  forms  was  thought  highly  of.  The 
necessity  of  stimulation  was  well  recognized.  Relief. 
as  far  as  possible,  of  the  main  symptoms  occupied  an 
important  place.  The  occurrence  of  pneumonia  in  so- 
called  epidemic  form  was  recognized  by  Liiennec. 

The  discovery  of  the  bacillus  of  Friedlander  in  iSS?. 
and  that  of  the  "  diplococcus  pneumonia^  "  byFraenkel 
in  1886,  while  modifying  and  confirming  some  of  the 
existing  views,  has  had  practically  very  little  influence 
upon  the  treatment  of  the  disease.  Sternberg,  in  our 
own  country,  discovered  this  micro- organism  in  the 
saliva  in  1S80.  Other  bacilli  than  those  named  have 
been  demonstrated  as  present  in  different  forms  of 
])neumonia,  such  as  streptococci,  staphylococci,  tuber- 
cle bacilli,  and  influenza  bacilli.  The  pneumonia  due 
to  the  diplococcus  of  T'raenkel  is  believed  to  be  the 
one  which  runs  the  typical  course  of  a  lobar  pneumonia, 
and  constitutes  about  seventy-five  per  cent,  of  all  cases. 
Those  pneumonias  running  an  irregular  course  are  ex- 


October  26,  1895] 


MEDICAL    RECORD. 


5/9 


plained  by  the  bacteriologist  on  the  ground  of  the 
presence  and  influence  of  one  or  more  of  the  other 
bacteria  named.  It  has  been  proven,  too,  that  in  a 
pneumonia  due  to  the  pneumococcus  alone,  the  prog- 
nosis is  more  favorable  than  in  the  irregular  forms  al- 
luded to.  For  some  years  prior  to  the  discovery  of 
these  organisms  the  recognized  treatment  was  an  ex- 
pectant and  supporting  one,  and  in  the  main  is  so  still. 

The  only  attempts  that  have  been  made  to  evolve  a 
line  of  treatment  from  our  knowledge  of  the  pneumo- 
coccus were  those  of  the  brothers  Klemperer.  They 
believed  that  the  pneumococcus  produced  an  "  anti- 
pneumotoxin  "  which,  when  present  in  sufficient  quan- 
tity, put  an  end  to  the  disease  by  crisis.  They  claimed 
to  have  isolated  this  substance,  and  the  first  results  by 
its  use  were  promising.  Further  investigation  has  not 
substantiated  their  claims.  While  pneumonia  is  occa- 
sionally contagious,  it  is  of  such  rare  occurrence  that 
prophylaxis,  even  if  we  knew  how  to  bring  it  about, 
would  be  superfluous.  The  pneumococcus  being  a 
very  frequent  inhabitant  of  the  mouths  of  healthy  in- 
dividuals, it  seems  impossible  to  make  use  of  any 
prophylactic  measures  other  than  avoidance  of  con- 
stitutional depression  of  any  kind.  The  frequent  asso- 
ciation of  otitis  media,  cerebral  meningitis,  pericarditis, 
and  the  occasional  occurrence  of  endocarditis  and 
peritonitis  in  the  course  of  an  attack  of  pneumonia,  was 
formerly  thought  to  be  accidental  accompaniments. 
Their  occurrence  is  now  explained  by  the  presence  in 
the  exudate  of  the  pneumococcus  of  one  or  more  of  the 
other  organisms  named. 

The  cholera  spirillum,  discovered  by  Koch  in  18S4, 
is  generally  admitted  to  be  the  specific  organism  pres- 
ent in  the  production  of  cholera.  Our  knowledge  of 
this  fact  has  had  little  effect  on  the  actual  treatment  of 
the  disease,  unless  the  large  tannin  and  water  injections 
be  considered  an  outcome  of  this  knowledge.  It  was 
found  by  experiment  that  tannin  was  to  a  certain  ex- 
tent antagonistic  to  the  virulence  of  the  cholera  spiril- 
lum. Because  of  this  fact  and  its  known  astringent 
effects  it  was  suggested  in  the  treatment  of  cholera. 

The  discovery  of  the  specific  organism  has  been  of 
the  greatest  value  in  preventing  the  spread  of  the  dis- 
ease. 

It  is  also  possible  to  determine,  by  means  of  the 
proper  bacteriological  methods,  at  the  beginning  of  an 
epidemic  of  some  diarrhceal  disease,  whether  it  is  true 
cholera  or  not.  In  quarantine  work  this  method  of 
diagnosis  is  especially  valuable,  and  leads  at  once  to  the 
use  of  proper  precautions  to  prevent  the  spread  of  the 
disease.  Work  is  now  being  done  in  Germany  upon  a 
cholera  antitoxin,  but  the  reports  so  far  published  are 
insutticient  to  warrant  our  forming  any  conclusion  as  to 
its  value. 

Tuberculosis  has  been  one  of  the  most  thoroughly 
studied  of  diseases,  and  was  generally  ascribed  to  a 
micro-organism  before  Koch,  in  1882,  reported  his  dis- 
covery of  the  tubercle  bacillus.  The  climatic  and  die- 
tetic treatment  of  tuberculosis  cannot  be  said  to  have 
been  advanced  by  this  discovery.  On  the  other  hand,  in 
diagnosis,  prognosis,  and  prevention  of  the  spread  of 
the  disease,  it  has  been  of  the  utmost  service.  The 
demonstration  of  the  presence  of  the  bacillus  in  the 
sputum,  the  stools,  the  urine,  the  secretions  from  sinuses 
— indeed  its  presence  in  many  situations — have  often 
made  definite  a  suspected  diagnosis.  It  has  shown 
that  at  least  many  of  the  so-called  scrofulous  condi- 
tions are  tuberculous.  While  the  communicability  of 
tuberculosis  was  recognized  long  before  1882  by  clini- 
cal observation,  the  discovery  of  the  bacillus  and  sub- 
sequent researches  served  to  emphasize  the  fact  that 
tuberculosis  must  be  placed  among  the  infectious  com- 
municable diseases,  and  that  communicability  must  be 
recognized  under  certain  conditions.  Since  the  dis- 
covery of  the  bacillus  the  modes  of  infection  by  it 
have  been  more  definitely  demonstrated.  Our  views  of 
heredity  in  regard   to  tuberculosis  have  been  greatly 


I 


modified.  The  disease  was  formerly  thought'  to  be 
directly  transmitted  from  parent  to  child.  Now  it  is 
believed  to  be  transmitted  very  rarely,  and  that  only  by 
the  mother.  Heredity  does  play  an  important  role  in 
many  cases,  in  that  it  transmits  a  soil  ready  for  the  re- 
ception, growth,  and  development  of  the  specific  germ 
when  this  is  implanted. 

The  importance  of  infection  by  inhalation  was  rec- 
ognized early  after  the  discovery  of  the  bacillus.  It 
led  quickly  to  the  thorough  sterilization  of  the  moist 
sputum.  The  sputum  is  found  to  contain  the  virus  in 
large  quantity,  and  when  dried  takes  the  form  of  dust 
and  disseminates  everywhere.  It  has  been  demon- 
strated that  the  dust  of  rooms  and  wards  of  hospitals 
which  have  been  occupied  by  tuberculous  patients  is 
in  many  instances  infective.  Any  condition  under 
which  the  dust  infected  with  tuberculous  virus  can  be 
inhaled  may  be  the  means  of  infection.  The  impor- 
tance of  this  fact  cannot  be  too  highly  emphasized  in 
the  direction  of  the  prevention  of  the  spread  of  ihe 
disease.  Direct  intimate  contact  may  communicate 
the  disease.  It  may  be  communicated  by  inoculation, 
but  it  then  usually  remains  localized.  Milk  may  be 
the  means  of  infection.  We  are  all  constantly  exposed 
to  the  infection  from  the  presence  of  millions  of 
the  micro-organisms  in  the  air  we  breathe  at  times. 
Some  of  us  escape  because  of  the  fortunate  lack  of 
vulnerability  of  our  tissues.  All  possible  means  should 
be  resorted  to  for  the  prevention  of  infection.  Koch's 
tuberculin  has  been  a  disappointment.  It  still,  how- 
ever, retains  the  confidence  of  a  few  observers  in  a 
modified  form,  but  is  now  mainly  used  in  the  diagno- 
sis of  tuberculosis  in  cattle. 

It  is  generally  believed  that  the  bacillus  discovered 
by  Eberth  in  1S80  is  the  cause  of  typhoid  fever. 
TJased  upon  this  discovery  efforts  have  been  made  to 
introduce  methods  of  treatment  directed  toward  the 
destruction  of  the  bacilli  or  their  toxic  productions,  but 
without  definite  success.  It  is  only  in  prophylaxis  and 
in  the  prevention  of  the  spread  of  the  disease  that  this 
discovery  has  had  any  great  effect  upon  internal  medi- 
cine. It  has  confirmed  the  belief,  held  by  many  before 
its  discovery,  that  milk  and  water  and  food  are  the 
chief  modes  of  infection.  In  many  instances  the  bac- 
teriologist has  been  able  to  definitely  trace  the  source 
of  an  epidemic  of  typhoid  fever  by  discovering  the 
bacillus  in  the  water-supply.  The  typhoid  bacillus 
has  wonderful  vitality.  The  bacteriologist  has  demon- 
strated that  it  is  capable  of  withstanding  for  a  brief 
period  a  dry  temperature  of  194°  F.,  but  if  exposed  to 
a  moist  heat  at  a  temperature  of  140°  F.  for  twenty 
minutes  its  vitality  is  destroyed.  Enclosed  in  a  block 
of  ice  at  a  temperature  considerably  below  freezing- 
point,  it  maintains  its  vitality  for  months,  but  if  the 
water  in  which  it  is  contained  be  alternately  frozen 
and  thawed  five  times  a  day  its  vitality  is  destroyed  in 
three  days.  I  only  name  these  among  the  many  points 
illustrating  its  vitality. 

The  Germans  have  lately  tried  treating  typhoid  with 
sterilized  cultures  of  the  typhoid  bacillus  grown  in 
thymus  bouillon.  The  results  at  first  were  promising, 
but  subsequent  trials  have  been  far  from  satisfactory. 

Tetanus  was  first  shown  to  be  infectious  and  the 
bacillus  isolated  in  1884.  Soon  after  Nicolaier  demon- 
strated the  presence  of  the  same  bacillus  in  various 
kinds  of  soil,  and  inoculation  of  animals  with  the  soil 
containing  these  bacilli  produced  tetanus. 

It  is  interesting  to  note  the  extraordinary  virulence 
of  tetanus  toxin,  it  being  from  two  hundred  to  four 
hundred  times  as  virulent  as  strychnine.  Immunity  to 
tetanus  has  been  procured  by  inoculating  an  animal 
with  the  blood-serum  of  another  which  has  had  the 
disease.  An  antitoxin  prepared  from  the  blood-serum 
of  immunized  animals  has  been  used  and  reported  as 
successful.  The  testimony  in  regard  to  the  results  is 
conflicting  and  the  treatment  by  this  method  is  still  on 
trial.     Perhaps  with  improved  methods  of  preparation 


580 


MEDICAL   RECORD. 


[October  26,  1895 


of  the  antitoxin,  and  a  better  knowledge  of  the  quan- 
tity required  in  any  given  case,  better  results  may  be 
obtained. 

The  greatest  influence  exerted  over  internal  medi- 
cine by  bacteriology  has  been  in  connection  vi'ith  diph- 
theria. The  profession  has  been  slow  in  accepting  the 
view  that  the  bacillus  discovered  by  Loffler  in  1884  is 
the  cause  of  diphtheria,  and  there  are  still  many  who 
disbelieve  it.  The  prevailing  opinion  now  is,  however, 
that  this  bacillus  is  the  cause  of  true  diphtheria.  The 
first  effect  of  the  discovery  was  the  abolition  of  cer- 
tain useless  lines  of  treatment,  and  the  recommenda- 
tion of  others.  Constitutional  and  local  treatment 
were  not  displaced  by  this  discovery,  nor  are  they  now. 
The  greatest  change  in  treatment  brought  about  by 
the  discovery  at  first  was  the  more  persistent  and  in- 
telligent use  of  local  treatment.  The  next  step  was 
the  recognition  of  bacteriological  methods  and  results 
in  diagnosis,  many  believing  the  presence  of  the  Loff- 
ler bacillus  the  only  positive  criterion  of  diagnosis. 
Diphtheria  had  long  been  recognized  as  highly  con- 
tagious. The  discovery  of  the  specific  organism  but 
served  to  emphasize  that  fact.  It  is  now  possible  to 
find  out  how  long  the  micro-organisms  remain  in  the 
throat  and  nasal  passages  after  the  patient  is  appar- 
ently cured,  and  how  long  it  is  necessary  to  resort  to 
quarantine. 

One  very  important  feature  has  been  the  demon- 
stration that  many  of  the  milder  forms  of  inflammation 
of  the  mucous  membrane  of  the  throat  and  nasal  pas- 
sages are  diphtheria  and  are  capable  of  communicating 
the  disease.  It  has  recently  been  shown  that  this  ba- 
cillus is  not  infrequently  found  on  the  mucous  mem- 
branes of  the  throat  and  nasal  passages  of  persons 
otherwise  apparently  well.  This  is  true,  too,  of  other 
bacilli  in  this  and  other  situations.  The  mere  presence 
of  a  bacillus  of  any  kind  is  not  sufficient  to  account  for 
the  manifestations  of  the  disease  of  which  such  bacil- 
lus is  the  specific  cause.  Some  additional  factor  seems 
necessary.  Some  agency  causing  such  bacillus  to  show 
its  pathogenic  activity. 

As  to  the  final  and  greatest  steps  in  advance,  the 
results  of  the  researches  of  Loffler,  Behring,  Aronson, 
Roux,  and  others,  "  the  antitoxin  treatment  of  diph- 
theria," it  has  been  the  foremost  subject  in  the  medical 
world  the  past  year.  It  has  had,  and  still  has,  its  op 
ponents,  some  claiming  the  serum  acts  harmfully  on 
the  kidneys,  others,  that  it  causes  destruction  of  the 
blood-corpuscles,  enfeebles  the  heart's  action,  and 
favors  the  occurrence  of  paralysis.  All  these  objec- 
tions have  been  met  and  contradicted.  Even  ad- 
mitting there  are  possibilities  of  occasional  deleterious 
effects,  the  wonderful  beneficial  results  many  times  out- 
weigh the  possible  harm. 

The  first  publication  demonstrating  the  principles  of 
serum  therapy  were  made  in  1890.  In  the  autumn  of 
1891,  the  first  trial  of  serum-therapy  in  human  diph- 
theria was  made.  The  first  attempts  were  with  a  weak 
serum  and  insufficient  doses.  From  time  to  time 
articles  on  the  subject  appeared  up  to  August,  1894, 
when  the  serum  prepared  at  Hocht  was  placed  on  sale. 

Roux's  address  at  Budapest,  in  September,  1894, 
aroused  the  attention  of  the  whole  medical  world  to 
the  possibilities  of  the  serum-therapy  of  diphtheria. 
During  the  jiast  year  it  is  estimated  that  :  00,000  injec- 
tions will  fall  far  below  the  number.  It  needs  no  argu- 
ment now  to  establish  its  value.  The  testimony  is 
overwhelmingly  in  its  favor  as  a  curative  agent. 
From  all  sources  in  Europe  and  this  country  comes 
the  clinical  evidence  of  its  power.  It  has  reduced  the 
mortality  enormously.  Not  only  have  its  wonderful  ef- 
fects been  shown  on  the  disease  when  established,  but 
its  power  of  securing  immunity  to  those  who  have  been 
exposed  to  the  contagion  is  maiked. 

The  results  of  serum  therapy  in  diphtheria  being  so 
favorable,  the  field  for  work  of  like  character  in  con- 
nection witli  other  infectious  diseases  is  almost  without 


limit.  The  outlook  for  the  future  is  most  promising. 
Bacteriological  researches  of  a  most  important  kind 
have  been  made  in  connection  with  veterinary  medi- 
cine. Of  interest  to  us  as  physicians  is  particularly 
the  work  in  connection  with  such  diseases  as  can  be 
communicated  to  man.  I  need  only  mention  them 
here.  Hydrophobia,  anthrax,  actinomycosis,  glanders, 
and  we  may  include  tuberculosis  in  this  group.  To 
name  hydrophobia  without  associating  with  it  Pasteur's 
name  would  be  a  neglect  of  recognition  of  eminent 
scientific  work.  It  was  his  investigations  in  connection 
with  this  disease  which  may  be  said  to  have  led  up,  in 
part  at  least,  to  the  study  of  immunity  by  means  of 
serum-therapy. 

Bacteriological  researches  have  made  clear  many 
points  in  the  etiology  of  diseases  which  before  were  ob- 
scure. It  offers  a  satisfactory  scientific  explanation  of 
the  communicability  of  certain  diseases.  It  has  made 
diagnosis  more  definite,  and  in  some  instances  aided  in 
diagnosis  which  was  impossible  by  any  other  method. 
It  has  led  to  more  accurate  prognosis.  It  has  ex- 
plained complications  which  before  were  considered 
accidental  occurrences.  It  has  revolutionized  surgical 
and  obstetrical  practice.  It  has  made  it  possible  by 
intelligent  sanitary  surveillance  to  restrict  and  prevent 
the  spread  of  dangerous  epidemics.  It  has  led  up  to 
the  specific  treatment  of  diphtheria  (and  possibly  teta- 
nus), and  to  conferring  immunity  for  a  longer  or  shorter 
period  to  those  exposed  to  it. 

A  recognition  of  these  conclusions  brings  the  bac- 
teriologist and  clinician  into  most  intimate  relationship, 
each  one  as  a  necessary  aid  to  the  work  of  the  other. 
The  results  of  the  work  of  the  laboratory  must  be  con- 
firmed by  the  careful,  conservative  tests  of  the  clinician. 
By  their  combined  work  only  can  the  results  of  labo- 
ratory investigations  be  made  of  wide-spread  practical 
benefit. 


An  Epidemic  of  Toothache. — One  of  the  most  curi- 
ous features  of  the  Chitral  campaign  is  the  extraordi- 
nary prevalence  of  toothache — "  the  hell  o' a"  diseases  "' 
Burns  calls  it — among  the  officers.  The  matter  is  re- 
ceiving the  serious  attention  of  the  medical  authorities, 
and  it  is  hoped  that  some  very  interesting  statistical 
results  will  be  gained  from  the  careful  investigation 
which  is  now  taking  place.  The  epidemic  first  made 
its  appearance  after  the  active  operations  were  over, 
and  the  various  regiments  had  received  orders  to  stand 
fast  for  the  summer,  and  reached  its  most  violent  form 
just  before  the  long-expected  order  to  partially  evacu- 
ate the  country  had  arrived.  .\n  epidemic  of  tooth- 
ache is  something  unusual. 

Knives  should  never  be  placed  in  carbolic  lotion, 
for  even  a  diluted  solution  of  the  acid  quickly  impairs 

their  edges. 

Reform  Needed  in  Oerman  Insane  Asyloms. — That  a 
thorough  reform  of  the  German  system  of  dealing  with 
the  insane  and  with  those  wrongfully  charged  with  be- 
ing insane  is  needed  admits  now  of  no  doubt.  Since 
the  sensational  Forbes  case,  which  proved  the  convent 
asylum  at  Mariaberg,  in  the  Rhine  district,  a  veritable 
torture-chamber  worthy  of  the  dark  ages,  a  number  of 
similar  discoveries  have  been  made  in  other  institutions, 
such  as  the  one  in  Bremen,  and  one  in  Dortmund. 
With  that  quite  a  string  of  individual  cases  have  been 
brought  into  daylight,  of  persons  wholly  sane,  yet  de- 
tained for  years,  at  the  instigation  of  powerful  enemies 
or  greedy  relatives,  in  private  or  public  institutions  for 
the  insane.  I  ust  at  present  the  National  Association 
of  Physicians  for  the  Insane  is  holding  a  conclave  in 
Hamburg,  the  principal  theme  of  their  discussions  be- 
ing "  Reform  of  Insane  Practice."  I'nder  existing 
laws  and  methods  nobody  is  safe  from  the  danger  of 
being,  at  a  moment's  notice  and  without  any  formality, 
torn  from  his  homo  and  confined  in  some  mad-house,     i 


October  26,    1895] 


MEDICAL   RECORD. 


5S1 


TENDON    GRAFTING. 

A  New  Operation  for  Deformities  Following 
Infantile  Paralysis,  with  Report  of  a  Suc- 
cessful Case.^ 

By  SAMUEL  MILLIKEN.   M.D., 


GBON  TO  THE  INFANTS'   AND  CH 

Believing  this  to  be  the  first  case  reported  where  a 
healthy  muscle  has  been  made  to  do  the  work  of  one 
which  was  completely  paralyzed  without  in  any  way  in- 
terfering with  its  own  function,  the  following  details  are 
presented,  as  the  success  of  the  operation  speaks  for 
itself.  It  is  a  well-known  fact  that  cases  of  anterior 
poliomyelitis,  where  the  muscles  of  the  lower  e.xtremi- 
ties  are  paralyzed  during  early  childhood,  offer  little 
encouragement  from  electrical  treatment  beyond  the 
development  of  certain  muscular  fibres  which  escaped 


apparently  recovered  so  far  as  the  disposition  to  take 
nourishment  was  concerned,  it  was  noticed  that  the 
right  leg  was  almost  powerless,  so  much  so  that  the 
child  could  not  walk.  The  case  was  subsequently 
treated  by  massage  and  electricity,  and  at  the  age  of  two 
vears  a  brace  was  applied  which  enabled  him  to  walk. 

Examination. — When  I  first  saw  the  case,  on  remov- 
ing the  brace  with  the  patient  sitting  on  a  chair,  it  was 
easily  seen  that  the  trouble  was  with  the  anterior  tibial 
group  of  muscles,  as  the  right  foot  dropped  into  the 
position  of  equinus.  On  attempting  to  voluntarily  flex 
the  ''oot  on  the  leg,  all  the  toes  were  seen  to  respond, 
but  the  whole  foot  was  forced  into  extreme  valgus. 
This  led  me  to  conclude  that  it  was  the  innermost 
muscle  of  the  group,  viz.,  the  tibialis  anticus,  which  was 
mostly,  if  not  solely,  involved  ;  this  muscle,  from  its 
prominent  position  in  a  healthy  condition  antagonizes 
not  only  the  peroneal  group,  but  the  tibialis  posticus  as 
well.  Owing  to  the  paralysis  of  the  tibialis  anticus  the 
power  of  flexing  the  foot  on  the  ankle  was  limited  to 
the  three  remaining  muscles  of  the  group,  viz.:  the  ex- 
tensor proprius  pollicis,  the  extensor  longus  digitorum, 
and  the  peroneus  tertius,  which,  from  their  distal  at- 
tachment, were  of  little  use  in  this  direction  ;  while,  on 


Fig.  1.— a,  showing  tendon  of 
cis  :  B,  showing  tendon  of  tibialis 


Fig.  2. -a, 
of  tibialis 
D,  annular  lig: 


don  of  exterior  proprius  pollicis  :  \^ 
:  C,  flaps  united  with  interrupted  : 
ent  of  ankle. 


the  inflammatory  process  ;  while  the  mechanical  appli- 
ances are  only  employed  with  the  hope  of  aiding  the 
victim  in  locomotion  and  preventing  deformities,  such 
as  tendinous  and  muscular  contractions  and  bony  dis- 
placements. The  neurologist  and  orthopedic  surgeon 
have  learned  long  ago  that,  combined  with  the  above 
conservative  measures,  so  far  as  offering  a  cure,  it  was 
folly  to  even  anticipate  it  ;  thus  thousands  of  cases  of 
infantile  paralysis  are  doomed  to  the  wearing  of  braces 
all  their  lives. 

The  delay  of  most  two  years  in  reporting  this  case 
was  for  the  purpose  of  allowing  sufficient  time  to  elapse 
without  the  use  of  the  brace  that  I  might  be  sure  the 
deformity  was  permanently  relieved. 

Joseph  H ,  nine  years  of  age,  came  under  my  ob- 
servation in  December,  1893,  and  at  that  time  was  wear- 
ing the  ordinary  club-foot  brace  on  the  right  side.  The 
previous  history  given  was  that  of  the  ordinary  cases 
of  infantile  paralysis.  When  about  eighteen  months  of 
age,  and  (juite  healthy,  the  child  was  attacked  with 
fever,  which  was  sufficiently  severe  as  to  cause  him  to 
be  put  to  bed  and  the  family  physician  called  in.  The 
attack  was  of  only  a  few  days'  duration,  and  although 

'  Read  at  the  meeting  of  the  New  York  State  Medica!  .Association, 
October  15,  1805. 


the  Other  hand,  in  the  absence  of  such  an  important  an- 
tagonist it  is  easy  to  account  for  the  extreme  valgus 
into  which  the  foot  was  forced.  In  addition  to  the 
above  deformity  there  was  a  marked  "  hammer  toe," 
due  to  the  over-exertion  of  the  extensor  proprius  polli- 
cis. An  electrical  examination  only  verified  the  above, 
and  as  the  anterior  tibial  nerve  supplied  all  four  mus- 
cles, it  was  decided  to  take  part  of  the  extensor  pro- 
prius pollicis  tendon  and  graft  it  into  the  tendon  of 
the  tibialis  anticus,  which  was  paralyzed. 

Operation. — On  February  14,  1894,  under  ether  an- 
aesthesia, an  incision  one  and  a  half  inch  long  was 
made,  extending  from  just  below  the  annular  ligament 
obliquely  over  the  tendons  of  the  extensor  proprius 
pollicis  and  tibialis  anticus.  (See  Fig.  i.)  The  sheath 
of  each  tendon  was  carefully  opened  for  a  distance  of 
about  one  inch.  The  tendons  were  then  split  with  a 
small  Adams  fascia  knife,  and  an  inch  flap  taken  off  of 
each.  The  flap  from  the  tibialis  anticus,  of  course,  be- 
ing left  attached  to  the  distal,  while  that  from  the  ex- 
tensor of  the  great  toe  was  attached  at  its  proximal  or 
muscular  end. 

Before  incising  the  tendon  of  the  extensor  of  the 
great  toe,  it  was  pulled  down  by  means  of  a  blunt  hook, 
so  that  a  flap  could  be  gotten  as  high  up  as  possible. 


582 


MEDICAL    RECORD. 


[October  26,  1895 


This  was  done  for  two  reasons  :  ist,  so  as  to  relax  the 
tendon,  thus  relieving  the  "hammer  toe,"  and  2d,  so  as 
to  insure  the  action  of  the  extensor  propriuspollicis  on 
its  new  insertion  if  union  was  obtained.  The  cut  sur- 
faces of  the  flaps  were  adjusted  and  sutured  with  three 
fine  kangaroo  tendons  interruptedly  (Fig.  2).  The 
outer  flap  of  the  sheath  of  the  extensor  proprius  polli- 


FlG.  4  — Showing  Adduction  of  Kisht  Foot  following  Dpi 


cis  was  then  sewn  to  the  inner  flap  of  the  sheath  of  the 
tibialis  anticus  (Fig.  3),  with  a  continuous  suture,  so  as 
to  prevent  the  newly  united  tendons  becoming  adherent 
to  the  overlying  structures,  thus  making  a  new  sheath 
which  would  not  interfere  with  the  action  of  the 
muscle,  which  was  to  do  its  own  work  and  that  of  the 
one  which  was  paralyzed.  The  skin  was  closed  with 
fine  interrupted  catgut-sutures,  and  dressed  aseptically. 


\"oluntary  Flcxtoa  of  Right  Foot  following  Operation. 


The  foot  was  immobilized  with  a  plaster-of- Paris  splint, 
the  deformity  having  been  ])reviously  corrected  by 
manual  force.  The  case  progressed  uninterruptedly, 
and  it  was  dressed  for  the  first  time  on  the  tenth  day,  a 
window  being  made  over  the  wound  in  the  pla.ster  for 
that  purpose.  The  catgut  sutures  had  been  absorbed, 
but  the  skin  had  not  united  primarily,  as  I  had  hoped 
it  would  ;  however  there  was  no  pus,   nor  had  there 


been  as  much  as  one  degree  elevation  of  tempera- 
ture since  the  operation.  The  non-union  was  caused 
by  the  pressure  of  the  plaster-of-Paris  splint  which  had 
been  put  on  rather  snugly.  Under  balsam-of-Peru 
dressing  the  skin  wound  healed  in  ten  days.  Every 
day  for  three  weeks  after  the  operation  gentle  passive 
motion  of  the  great  toe  was  made,  so  as  to  prevent  the 
tendon  becoming  adherent  to  its  sheath.  The  foot  was 
kept  in  a  plaster-of-Paris  splint  for  six  weeks,  when  a 
very  light  brace  with  a  limited  joint  at  the  ankle  was 
applied.  The  immediate  improvement  in  the  case  was 
even  noticed  by  the  parents,  as  the  foot  no  longer  be- 
came abducted  when  an  attempt  was  made  to  raise  it. 
such  having  always  resulted  before  the  operation  was 
performed.  It  is  now  five  months  since  the  brace  was 
left  off  altogether,  and  although  there  has  never  been 
any  electricity  or  massage  employed,  the  boy  has  been 
encouraged  to  take  all  the  exercise  possible.  He  ;- 
now  quite  an  expert  on  roller-skates,  walks  without  -1 
limp,  and  can  adduct  the.  foot  to  almost  normal  (Fig. 
4).  There  is  still  a  slight  "  hammer  toe  "  on  extreme 
flexion  of  the  foot,  but  nothing  as  compared  to  the  con- 
dition before  operation  (Fig.  5),  while  flexion  of  this 
foot  on  the  leg  is  almost  as  good  as  the  unaffected 
side  (Fig.  6). 


Fig.  6. — Showing  Voluntary  Flexion  of  Left  or  Normal  Foot. 

My  Other  work  in  this  line  is  so  recent  as  to  prevent 
further  report  of  cases  at  present,  but  I  think  with  this 
excellent  result  the  field  has  been  opened  for  tendon 
grafting  in  these  otherwise  hopeless  cases  of  infantile 
paralysis. 

640  Madison  .'\vlnue. 


Vacancies  in  the  Medical  Corps  of  the  Army. — De- 
spite the  fact  that  the  last  C'ongress  reduced  the  num- 
ber of  officers  in  the  medical  department  of  the  aniiy, 
it  is  reported  that  the  corps  is  already  nearly  down  to 
the  new  limit.  ^Vith  two  retirements  recommended 
some  time  ago,  and  that  of  another  officer  which 
occurs  in  less  than  ten  days,  and  a  fourth  in  December, 
the  corps  will  then  be  three  below  the  maximum.  Ac- 
cordingly an  examination  for  the  vacancies  will  be  • 
held  during  the  next  few  months. 

Prince  Edward  of  York,  wlio  mav  some  day  be  the 
king  of  England,  was  reported  to  be  deaf  and  dumb. 
This  story  is,  however,  denied  "  authoritatively  "  by 
The  Lancet,  which  says  that  "  he  is  in  every  respect  a 
fine  child,  that  he  displays  remarkable  intelligence  for 
his  age,  and  that  he  can  already  repeat  a  number  of 
words."  Our  esteemed  contemporary  thinks  the 
Americans,  to  whom  it  credits  the  origin  of  the  report, 
are  very  unreasonable  to  exjiect  a  child,  even  the  great 
grandson  of  a  queen,  to  be  able  to  converse  fluently  in 
several  languages  during  the  first  vear  of  its  existence. 


October  26,   1895] 


MEDICAL    RECORD. 


583 


OBSERVATIONS    ON    PELVIC    CONTRAC- 
TIONS.' 

By   AUSTIN  FLINT,  Jr.,  M.D., 


Contractions  of  the  pelvis  in  which  the  deformity  is 
marked  occur  but  rarely  and  are  always  easy  to  recog- 
nize. Contractions  of  a  minor  degree,  however,  occur 
very  frequently,  and  the  diagnosis  is  often  very  diffi- 
cult. To  prove  that  this  is  true,  I  have  analyzed  six 
thousand  cases  of  confinement  with  reference  particu- 
larly to  the  diagnosis,  the  frequency  with  which  con- 
tractions occur,  and,  if  possible,  to  draw  some  general 
conclusions  in  regard  to  prognosis  and  treatment. 

The  influence  which  even  a  moderate  degree  of  con- 
traction has  upon  labor  is  not  entirely  mechanical.  So 
many  other  conditions  must  be  taken  into  account, 
such  as  the  size  and  compressibility  of  the  foetal  head. 
a  faulty  presentation  or  position,  or  a  prolapse  of  the 
cord,  due  often  to  the  e.vistence  of  contraction,  that 
rules  for  treatment  cannot  be  based  on  measurements 
alone.  A  pelvis  with  certain  diameters  may  in  one  case 
permit  the  spontaneous  delivery  of  a  well-developed 
child,  and  a  pehis  with  the  same  diameters  may  in 
another  case  demand  operatise  interference,  often  of  a 
serious  nature.  Such  examples  are  frequently  met 
with  and  are  difficult  to  explain.  I  have,  therefore, 
not  attempted  to  fi.x  upon  any  exact  measurements  un- 
der whi(  h  all  pelves  are  strongly  contracted,  and  over 
which  all  pelves  are  moderately  contracted,  but  shall 
take  all  cases  together,  remembering,  however,  that  the 
vast  majority  belong  to  the  latter  class.  In  the  first 
place,  I  may  define  what  I  have  called  "  contraction," 
explaining  at  the  same  time  the  methods  of  diagnosis. 

As  it  is  rare,  if  not  impossible,  to  find  two  pelves 
with  the  same  diameters  throughout,  some  standard 
must  be  fixed  separating  the  normal  from  the  abnor- 
mal. In  describing  the  size  of  a  pelvis,  we  speak  of 
the  distance  between  the  spines  and  crests  of  the  ilia, 
the  external  conjugate  diameter,  which  is  measured 
from  the  fessa  beneath  the  spine  of  the  last  lumbar 
vertebra  to  the  middle  of  the  upper  border  of  the  sym- 
physis in  front.  The  diagonal  conjugate  diameter  ex- 
tends from  the  lower  border  of  the  symphysis  to  the 
promontory  of  the  sacrum.  The  true,  or  obstetrical 
conjugate,  is  the  distance  between  the  promontory  and 
a  point  on  the  inner  surface  of  the  pubis  just  below  its 
upper  border.  All  of  these  diameters  can  be  measured 
accurately,  with  the  exception  of  the  last,  which  must 
be  calculated  from  the  diagonal  conjugate.  I  have  not 
considered  as  contracted,  pelves  in  which  the  distances 
between  the  spines  and  crests  of  the  ilia  alone  were 
diminished.  In  all  cases  in  which  these  measurements 
were  very  much  below  the  normal  standard,  the  other 
diameters  were  also  diminished.  When  the  normal 
jjroportion  was  disturbed,  that  is,  when  the  distance  be- 
tween the  spines  was  as  great  as,  or  greater  than,  the 
distance  between  the  crests,  a  diagnosis  of  rachitis  was 

lade,  and  in  these  cases  the  other  measurements  were 
usually  found  to  be  abnormal.  This  leaves  but  two 
diameters  which  must  be  measured — the  external  and 
the  diagonal  conjugates.  The  true  conjugate  is  the 
more  important,  and  is  the  one  which  is  designated  in 
defining  the  degree  of  contraction.  The  method  of 
determining  the  true  conjugate  is  to  subtract  from  the 
diagonal  two-thirds  to  three-fourths  of  an  inch,  or,  in 
my  experience,  even  more,  this  depending  on  an  esti- 
mate of  the  height  and  inclination  of  the  symphysis 
and  the  position  of  the  promontory.  The  personal 
equation — the  individual  skill  and  experience  of  the 
examiner — enters  so  largely  into  the  determination  of 
this  diameter,  where  a  difference  of  even  one-fourth  of 
an  inch  is  of  the  utmost  importance,  that  it  seemed  to 
me  safer,  in  collecting  cases,  to  rely  on  the  diagonal 

'  Read  before  the  New  York  Slate  Medical  Association,  October  i6, 
1895. 


and  external  measurements,  which  can  be  determined 
exactly. 

We  owe  much  of  uur  knowledge  of  pelvic  deformities 
to  the  investigations  of  Litzmann  ;  and  I  have  followed 
as  nearly  as  possible  the  limits  as  defined  by  him. 
The  same  limits  have  been  adopted  by  all  the  German 
observers  whose  reports  I  have  been  able  to  examine 
or  have  seen  quoted.  Litzmann  places  in  the  class  of 
contracted  pelvis  all  cases  in  which  the  external  conju- 
gate measures  iS  cm.  or  less,  or  7.2  inches.  I  have 
taken  only  pelves  with  an  external  conjugate  of  7 
inches  or  less.  For  the  true  conjugate,  he  places  the 
limit  at  92  cm.,  or  3.8  inches.  I  have  adopted  a  di- 
agonal conjugate  of  45  inches  or  less,  which,  reduced 
to  the  true  conjugate,  would  make  yg  inches  for  the 
largest  by  the  subtraction  of  only  |  of  an  inch. 

The  statistics  which  I  have  to  present  wdll  be  better 
understood  if  I  first  explain  briefly  certain  details  of 
the  manner  in  which  they  were  obtained.  The  records 
are  from  the  written  histories  of  six  thousand  consecu- 
tive cases  of  confinement,  cared  for  by  the  Society  of 
the  Lying-in  Hospital  of  the  City  of  New  York. 

A  woman  applying  for  care  during  confinement  is 
first  subjected  to  a  thorough  physical  examination,  in- 
cluding careful  pelvic  mensuration.  At  this  time  the 
history  of  previous  confinements,  an  examination  of  the 
urine,  and  other  minor  details  are  inquired  into  and 
recorded  on  a  blank  which  is  called  a  Pregnancy  Sheet. 
This  is  numbered  and  filed  away  until  the  onset  of 
labor,  when  it  is  taken  out,  brought  to  the  case,  and  is 
finally  bound  with  the  record  of  the  labor  and  puer- 
perium,  making  a  complete  history  of  that  individual 
case.  If,  at  the  time  this  "  ante-partum  examination  " 
is  made,  there  exists  any  abnormality,  it  is  first  verified 
by  one  of  the  resident  staff,  or  the  attending  physician 
on  duty,  and  a  special  "  abnormality  blank  "  is  filled 
out  and  filed,  thus  guarding  as  far  as  possible  against 
error. 

A  consideration  of  the  class  of  patients  from  which 
these  observations  have  been  obtained  is  of  interest. 
Comparing  ordinary  hospital  statistics  with  statistics 
obtained  from  private  practice,  it  is  natural,  and  usu- 
ally correct,  to  assume  that  complicated  and  difficult 
cases  come  to  the  hospitals  ;  and  therefore,  abnormali- 
ties, including  contractions,  occur  more  frequently  in 
institutions.  In  my  statistics,  however,  the  patients 
are  all  "  out-door  cases  "  of  the  poorer  class,  attended 
in  their  own  homes,  and  thus  fulfil  more  exactly  the 
conditions  met  with  in  ordinary  private  practice.  In 
other  words,  they  represent,  as  nearly  as  is  possible,  the 
actual  average  condition.  It  is  only  recently,  since  the 
figures  here  presented  have  been  analyzed,  that  an  in- 
door service  has  been  added  to  the  hospital. 

I  have  looked  over  the  pregnancy  sheets  of  these 
6,000  cases  and  noted  the  confinement  number  of  each 
one  in  which  the  external  conjugate  measured  7  inches 
or  less,  and  the  diagonal  conjugate  4i  inches  or  less. 
Contractions  were  noted  in  654  of  the  6,oco  cases,  or 
in  10.9  per  cent. 

In  round  numbers,  the  frequency  of  contractions  in 
Germany  is  said  to  be  fourteen  per  cent.  The  report 
from  Leopold's  clinic  for  1895  gives  610  cases  out  of  a 
total  of  2,512,  or  24.3  per  cent.,  nearly  one-quarter  of 
all  cases.  This  is  the  largest  proportion  in  any  report 
that  I  have  seen.  Schwarz,  in  Gottengen,  reports 
twenty  per  cent.  ;  Spiegelberg,  fourteen  per  cent.,  and 
sixteen  per  cent,  is  reported  by  MUller  from  the  clinic 
at  Berne.  As,  however,  the  Lying-in  Hospital  in  New 
York  is  often  called  upon  to  treat  premature  cases  and 
abortions,  which  are  entered  in  the  history  numbers 
among  these  6,000  cases,  it  would  be  more  exact,  in 
computing  the  frequency,  to  disregard  them.  Sub- 
tracting 347 — the  number  of  abortions  and  premature 
cases — from  the  total,  the  percentage  of  contractions 
would  be  raised  to  11.56,  which  is  nearer  the  conservative 
estimate  of  Litzmann  and  Schroeder.  In  563  of  these 
654  cases  of  contraction,  or  in  86.08  per  cent.,  the 


584 


MEDICAL    RECORD. 


[October  26.  1895 


presentation  was  a  vertex,  and  the  delivery  was  without 
operative  interference.  A  study  of  these  spontaneous 
deliveries  shows  that  in  all  cases  the  contraction  was 
slight,  a  true  conjugate  of  3)^  inches  or  more,  but  3 
cases  of  3_5;(,  and  i  of  ^}i  being  noted.  A  certain  pro- 
portion had  a  protracted  first  stage,  in  some  cases  as 
long  as  twenty-four  hours.  Frequently  I  would  find 
it  recorded  that  the  head  was  delivered  in  the  right 
occiptal  position  ;  but  in  one  or  two  cases  only  was  the 
occiput  posterior.  I  have  not  attempted  to  obtain 
exact  figures  on  the  frequency  of  right  positions,  for 
the  reason  that  I  have  doubts  about  the  accuracy  of 
diagnosis.  Many  of  these  were  undoubtedly  occipito- 
posterior  positions  at  the  beginning  of  labor,  and  ro- 
tated anteriorly  before  delivery.  Some  of  the  cases  of 
protracted  first  stage  were  undoubtedly  due  to  a  slow 
forward  rotation  of  a  posterior  occiput.  The  per- 
centage of  spontaneous  deliveries  reported  from  Leo- 
pold's clinic  was  69.5. 

It  is  well  known  that  the  size  of  the  pelvis  is  not  the 
only  factor  that  must  be  considered,  but  that  the  di- 
ameters of  the  child's  head  are  of  equal  importance. 
I  had  hoped  to  be  able  to  report  some  definite  conclu- 
sions in  regard  to  this  point  also,  but  regret  that,  al- 
though the  measurements  of  the  head  are  in  every 
case  taken,  as  well  as  the  weight  and  length  of  the 
child,  a  comparison  of  the  figures  gave  no  definite  re- 
sults. In  some  instances,  when  the  labor  was  pro- 
tracted and  difficult,  the  head  measurements  were 
found  to  be  large  and  the  weight  of  the  child  above 
the  average  ;  'out  in  other  cases  the  reverse  was  true. 

In  the  remaining  cases  in  which  interference  became 
necessary,  10 1  operations  were  done  as  follows  :  For- 
ceps, 43  ;  version,  29  ;  breech  extraction,  iS  ;  sym- 
physeotomy, 5  ;  craniotomy,  2  ;  Cajsarean  section,  i  ; 
decapitation,  i  ;  induced  labor,  1  ;  conversion  of  brow 
to  vertex,  i. 

In  some  instances  more  than  one  operation  was  done 
on  a  single  case,  as,  for  example,  symphysiotomy  fol- 
lowed by  version,  so  that  the  number  of  operations  is 
greater  than  the  number  of  cases — loi  operations  on 
gr  cases.  A  study  of  the  results  of  these  operations  is 
interesting  as  regards  the  effect  on  the  child.  In  the 
43  forceps  operations,  6  children  were  stillborn,  and  of 
the  37  born  alive,  i  died  in  a  few  hours,  2  on  the  sec- 
ond day,  and  2  on  the  fourth  day.  The  remaining  32 
were  alive  and  apparently  healthy  when  discharged 
from  observation,  usually  about  the  tenth  day.  This 
is  an  infant  mortality  in  forceps  cases  of  251  f  per  cent. 
It  must  be  remembered,  however,  that  forceps  were 
applied  to  only  the  more  difficult  cases.  A  patient  is 
reported  as  not  progressing  satisfactorily,  and  a  call 
for  assistance  is  sent  back  to  the  hospital.  The  case  is 
then  visited  by  one  of  the  staff,  and  finally  the  attend- 
ing physician  is  summoned.  The  result  of  this  routine 
is  that  practically  only  those  cases  were  delivered  by 
forceps  which  could  not  have  been  delivered  without 
aid,  and  some  of  them  were  exceedingly  difficult. 

Of  the  29  versions  which  were  done,  the  operation 
was  undertaken  in  only  9  cases  by  reason  of  the  pel- 
vic deformity  alone.  'fhe  remaining  20  cases  were 
complicated  :  7  times  by  a  prolapse  of  the  cord  ;  5 
times  by  a  previous  symphyseotomy  ;  4  times  by  a 
placenta  previa,  or  "hemorrhage;"  twice  by  tra- 
verse presentations  ;  and  once  each  by  a  prolapsed  arm 
and  a  face  presentation.  Of  the  entire  29  cases  only 
3  children  were  stillborn.  One  child  died  on  the  sec- 
ond day.  What  is  remarkable,  none  of  the  stillbirths 
occurred  in  complicated  cases.  In  the  version  cases 
the  total  infant  mortality  was  13!  J  per  cent.  As  re- 
gards the  other  operations  mentioned,  all  were  done  in 
strongly  contracted  pelves,  with  the  exception  of  the 
iS  cases  of  breech  extraction.  An  analysis  of  these 
operations  would  necessitate  a  detailed  history  of  each 
case,  which  would  be  beyond  the  scope  of  this  paper. 

The  general  results  in  the  654  cases  of  contraction 
observed,  are  as  follows  :  One  maternal  death  ;  a  case 


of  placenta  praevia,  almost  exsanguinated  when  seen, 
dying  from  shock  four  hours  after  delivery.  Twins 
occurred  nine  times,  making  a  total  of  663  children. 
Of  these  31  were  stillborn.  In  only  4  cases  was  I  un- 
able to  find  a  cause  for  death  ;  4  were  premature  ;  4 
macerated  ;  2  craniotomy  cases,  and,  of  course,  dead 
before  operating  ;  3  died  from  hemorrhage  from  a 
placenta  praevia  ;  2  deaths  were  due  to  a  prolapse  of 
the  cord  ;  i  child  was  hydrocephalic  ;  i  was  decapi- 
tated ;  I  during  a  breech  extraction  ;  and,  finally,  the 
6  forceps  and  3  version  cases  mentioned  before,  leav- 
ing 4  deaths  unexplained.  Including  the  5  deaths 
subsequent  to  a  forceps  delivery  and  the  i  following  a 
version,  the  total  infant  mortality  is  37  out  of  663.  or 
5.58  per  cent.,  an  exceedingly  small  proportion  when 
we  consider  that  all  were  in  cases  of  contracted  pelvis, 
and  some  of  them  operative  cases,  as  difficult  and  under 
as  unfavorable  surroundings  as  could  well  be  imagined. 

The  most  important  conclusion  that  can  be  drawn 
from  these  observations  is  in  regard  to  the  frequency 
of  contraction.  Using  the  standard  of  measurements 
adopted  in  the  German  hospital  reports,  contractions 
occur  here  with  nearly  the  same  frequency — ten  or 
eleven  per  cent,  here,  as  against  fourteen  per  cent, 
abroad.  To  determine  the  average  frequency,  it  is 
necessary  to  collect  a  large  number  of  cases.  In  mak- 
ing up  the  figures  which  I  have  reported,  the  cases 
were  taken  in  groups  of  one  hundred  each.  In  three 
different  series  of  a  hundred,  but  one  case  of  contrac- 
tion was  noted  ;  while  in  one  series  of  a  hundred, 
twenty  cases  were  noted.  Observations  on  only  100 
cases,  therefore,  might  in  one  instance  show  a  fre- 
quency of  one  per  cent.  ;  and  in  another  100,  a  fre- 
quency of  twenty  per  cent.  Grouping  the  cases  in 
series  of  500,  the  smallest  number  in  a  series  was  9 
and  the  largest  number  83,  a  very  wide  variation.  In 
groups  of  1,000  cases,  the  variation  was  from  53  to  137. 
In  three  groups  of  2,000  cases  each,  the  frequency  was 
respectively  154,  249,  and  251. 

Diagnosis  of  contraction  is  possible  only  by  careful 
actual  measurements.  A  pelvimeter  should  form  part 
of  the  obstetrical  outfit  of  every  practitioner.  Pelvic 
mensuration  should  be  employed  as  a  routine  practice 
in  every  case  of  confinement.  Referring  once  more  to 
the  frequency,  it  will  be  observed  that  the  number  of 
cases  progressively  increases,  showing  that  with  prac- 
tice and  increased  skill  slight  degrees  of  contraction 
may  be  recognized  which  are  ordinarily  overlooked. 
In  the  last  two  groups  of  2,000  cases  each,  the  varia- 
tion is  only  2,  viz.  :  249  for  the  first  group,  and  251 
for  the  second.  The  diagnostic  value  of  a  shortened 
external  conjugate  is  questionable.  I  have  included 
such  cases  in  my  statistics,  for  the  reason  that  they  are 
included  in  other  statistics  with  which  I  desired  to 
make  comparisons.  An  external  conjugate  of  seven 
inches  or  less  may  be  said  to  render  the  existence  of  a 
true  contraction  extremely  probable.  If  the  pelvic 
bones  are  slight,  the  external  conjugate  may  be  seven 
inches  or  even  slightly  less  and  slill  there  be  no  actual 
flattening. 

It  has  been  shown  that  the  majority  of  cases  of  con- 
traction are  spontaneously  delivered,  and  the  results 
are  good  for  both  mother  and  child.  When  there  is 
only  a  slight  degree,  a  true  conjugate  of  three  and  a 
half  inches  or  more,  the  treatment  which  gives  the  best 
results  is  expectant  and  non-operative  ;  aid  the  natural 
forces  ;  keep  the  bladder  and  rectum  empty  ;  stimulate 
pains  ;  support  the  strength  of  the  patient,  and,  when 
considering  operative  interference,  be  guided  by  other 
conditions.  The  obstetrician  knowing  the  pelvic  di- 
ameters, the  presentation  and  position  being  normal 
and  the  pains  good,  who  treats  his  patient  expectantly, 
will  have  better  results  than  one  who  operates  simply 
because  labor  is  delayed. 

In  pelves  with  a  true  conjugate  of  less  than  three 
and  a  half  inches,  operative  interference  usually  is  im- 
perative.    Only   four  such  cases   were   spontaneously 


October  26,  1895] 


MEDICAL    RECORD. 


58  = 


delivered.  The  nature  of  the  operation  depends  both 
on  the  degree  of  contraction  and  the  size  of  the  child's 
head.  Just  under  three  and  a  half  inches,  either  for- 
ceps may  be  used  or  version  done.  The  infant  mortal- 
ity in  the  use  of  forceps  was  a  little  more  than  twenty- 
five  per  cent.,  and  in  version  a  little  more  than  thirteen 
per  cent.  This  seems  to  show  that  version  is  the  better 
operation  ;  but  a  larger  number  of  observations  may 
demonstrate  the  reverse.  Pelves  in  which  the  true  con- 
jugate is  much  less  than  three  and  a  half  inches  call  for 
more  severe  operations,  and  each  case  must  be  treated 
according  to  its  individual  requirements.  At  present  the 
indeterminate  factor  is  the  size  of  the  child's  head.  It 
is  to  be  hoped  that  the  instrument  recently  invented 
by  Farabeuf  for  measuring  the  size  of  the  head  will 
prove  of  value.  Should  this  be  so,  one  of  the  main 
difficulties  in  treatment,  namely,  the  necessity  and 
choice  of  operations,  will  be  at  least  partially  removed, 
and  a  plan  of  procedure  based  on  ascertained  me- 
chanical conditions  alone,  will  become  practicable. 


SOME  FR.\CTURES  AND  EPIPHYSEAL  SEP- 
ARATIONS OF  THE  UPPER  EXTRE.MITIES 
IN   CHILDREN.' 

IJy  JOHN  F.   ERD.\1.\N.\',   M.D., 


Mr.  President  and  Gentlemen  :  In  considering  the 
subject  of  fractures  of  the  upper  extremities  of  chil- 
dren it  is  not  the  intention  of  the  writer  to  enter  into 
the  classification  of  fractures,  so  well  understood 
already,  but  to  present  instead  some  cases  with  their 
means  of  diagnosis  and  treatment. 

Considerable  has  been  written  upon  simple  fractures 
in  children,  but  comparatively  little  upon  the  subject  of 
epiphyseal  separations.  It  is  this  latter  subject  that 
will  be  largely  dealt  with,  particularly  those  occurring 
at  the  shoulder,  elbow,  and  wrist  joints.  Although 
fractures  in  children  are  usually  considered  green- 
stick,  or  incomplete,  the  individual  work  of  the  writer 
in  this  class  of  cases,  both  on  the  living  subject  and 
the  cadaver,  leads  him  to  believe  that  the  majority  of 
these  cases  are  complete  fractures  with  no  displace- 
ment. This  is  due  to  the  dense  periosteum  found 
in  the  young  acting  to  a  great  extent  as  a  fibrous 
splint. 

During  the  past  summer  the  long  bones  were  fract- 
ured in  all  situations  with  varying  force,  and  upon  dis- 
section in  the  majority  of  cases  it  was  found  that  the 
fractures  were  complete,  but  held  firmly  by  the  perios- 
teum that  remained  intact,  while  in  a  few  cases  only 
there  were  a  few  bony  bands  of  connection  between 
the  two  fragments. 

Owing  to  the  greater  elasticity  of  bones  in  children 
due  to  the  vascularity  and  less  compactness,  the  bones 
are  able  to  withstand  a  greater  relative  amount  of  vio- 
lence, without  sustaining  fractures,  than  those  of  adults, 
in  whom  the  bone  is  more  compact,  less  vascular,  and 
supported  by  a  thinner  layer  of  periosteum. 

Causes. — In  the  greater  number  of  cases  reported  in 
this  paper  the  injury  was  the  result  of  a  fall  from  a 
low  chair  or  out  of  bed.  The  well  and  ill  nourished, 
suffered  about  equally.  In  several  instances  it  was  found 
that  one  of  the  patients  had  suffered  from  one  or  more 
fractures.  The  season  of  the  year  has  no  relative  in- 
fluence in  these  cases.  Age  is  a  predisposing  factor 
only  when  considering  the  diagnosis  of  epiphyseal  sep- 
arations. As  a  predisposing  factor  we  are  well  aware 
that  the  epiphyses  can  be  separated  from  the  diaphyses 
by  trauma  and  disease  up  to  eighteen  or  twenty  years. 

'  Read  before  the  New  York  .State  Medical  Assocftion,  October 
17,  1895. 


Anatomy. —  The  upper  epiphysis  of  the  humerus 
unites  with  the  shaft  at  about  the  eighteenth  or  twen- 
tieth year,  and  consists  of  the  tuberosities  and  the 
head.  The  line  of  epiphyseal  union  corresponds  inter- 
nally with  the  lower  margin  of  the  articular  surface  of 
the  humeral  head.  The  lower  epiphysis  unites  with 
the  shaft  about  the  sixteenth  or  eighteenth  year,  and 
the  line  of  union  is  such  that  most  separations  take 
place  backward.  la  the  lower  end  of  the  radius  and 
ulna  the  epiphyseal  union  takes  place  about  the  twen- 
tieth year. 

Fractures  of  the  Clavicle. — There  are  four  cases  of 
fracture  of  this  bone  to  report,  two  of  which  were  seen 
some  ten  days  after  the  injury,  with  a  history  of  a  fall, 
slight  pain  over  the  clavicle  upon  manipulation,  and  in- 
ability on  the  part  of  the  patients  to  use  the  arm  as 
usual.  Also  that  immediately  after  the  injury  was  re- 
ceived nothing  diagnostic  of  fracture  of  the  clavicle  was 
to  be  observed.  After  the  eighth  or  tenth  day  either 
a  mass  or  overriding  of  the  fragments  was  found.  Two 
of  these  cases  were  seen  shortly  after  the  injury,  i.e., 
within  a  few  hours  to  a  couple  of  days  ;  in  these  latter 
cases  nothing  was  found  except  the  sensitiveness  or 
pain  at  or  near  the  seat  of  the  injury,  and  upon  ask- 
ing the  child  to  take  some  object  held  upward  and  out- 
ward from  the  shoulder,  but  feeble  attempts  would  be 
made.  With  the  history  of  the  first  two  cases  a  diag- 
nosis was  made  of  fracture  of  the  clavicle  and  so 
treated.  Upon  the  patient's  return  in  each  of  the  latter 
cases,  in  the  second  week  following  the  injury,  a  nod- 
ule of  callus  was  found  over  the  original  site  of  pain, 
thus  verifying  the  diagnosis. 

In  the  cases  of  deformity  reduction  was  followed  by 
the  application  of  a  bandage  to  retain  the  fragments  in 
proper  position.  In  cases  where  no  deformity  was 
present,  the  bandage  was  placed  upon  the  patient  to 
prevent  the  laceration  of  the  periosteal  splint  and  mak- 
ing a  complete  fracture  in  case  a  few  bony  bands  re- 
mained intact  at  the  time  of  the  injury.  The  dressings 
were  removed  in  three  weeks,  in  each  case,  at  the  lat- 
est, and  upon  examination,  firm  union  and  good  results 
were  found. 

Case    I. — A.    G ,    three   years  of  age,  girl,  was 

knocked  down  four  or  six  steps  by  the  slamming  of  a 
door,  on  September  2,  1894;  complained  to  her  par- 
ents of  pain,  especially  so  when  she  made  efforts  that 
required  abduction  and  extension  of  the  arm.  She 
was  treated  for  a  sprain  for  several  days.  Examina- 
tion revealed  a  slight  deformity  over  the  junction 
of  the  outer  and  middle  thirds  of  the  right  clavicle, 
with  considerable  pain  upon  pressure  and  no  ecchym.o- 
sis.  Diagnosis  :  Fracture  of  the  clavicle.  Treat- 
ment :  A  flannel  bandage  to  retain  the  reduced  frag- 
ments. 

Discharged  with  excellent  results  on  September  2Sth. 
I  am  indebted  to  Dr.  W.  H.  Guilfoy  for  this  case. 

Case    II. — M.    Van   W ,    aged    three,   girl  :  fell 

from  an  ordinary  chair  on  August  28,  1894,  striking 
directly  upon  her  right  shoulder.  She  was  seen  Sep- 
tember Sth,  twelve  days  after  the  injury,  having  been 
treated  during  these  twelve  days  for  a  dislocation  of 
the  sternal  end  of  the  clavicle. 

For  the  first  ten  days  she  gave  evidence  of  pain,  as 
in  Case  I.,  and  on  the  night  of  the  nth  a  promi- 
nence was  noted  by  her  parents  and  the  family  physi- 
cian. Examination  revealed  an  overriding  at  the 
inner  and  middle  thirds  of  the  clavicle,  pain  and  ec- 
chymosis. 

This  case  was  treated  exactly  as  Case  1.,  and  was 
discharged  in  twenty- one  days,  with  a  slight  prom- 
inence that  was  supposed,  from  its  shape,  to  be  callus. 

Case  III.— A.   K ,   aged   five  a^.d   one-half,  on 

May  17,  1895,  was  knocked  down,  falling  on  her  right 
shoulder.  For  three  days  she  complained  of  pain  near 
her  right  shoulder,  especially  while  being  disrobed  or 
lifted  into  bed.  Her  mother  also  noticed  that  she 
reached  very  gingerly  for  her  food. 


586 


MEDICAL    RECORD. 


[October  26,  1895 


She  was  seen  on  May  20th,  three  days  after  the  in- 
jury. Upon  examination  no  deformity  was  present,  but 
pain  upon  pressure  over  the  clavicle,  and  also  upon 
abducting  and  extending  the  arm,  was  found.  Having 
the  histories  of  Cases  I.  and  II.  in  mind,  diagnosis  ot 
fracture  of  the  clavicle  was  made.  Treatment,  same  as 
the  previous  cases.  June  3d,  or  fourteen  days  after  see- 
ing her,  there  was  an  ovoid  mass  at  the  original  site  of 
pain,  that  was  diagnosticated  as  provisional  callus. 
This  mass  disappeared  within  three  weeks. 

Case  IV. — M.  W ,  two  years  of  age,  fell  out  of 

bed  June  29th  ;  could  not  use  her  left  arm  in  play, 
owing  to  pain  near  her  left  shoulder.  Examination  re- 
vealed only  pain  upon  pressure  over  the  outer  and  mid- 
dle thirds  of  the  clavicle,  and  also  pain  at  this  point 
when  she  made  an  effort  to  grasp  anything  held  above 
her  head.  Diagnosis  :  Fracture  of  the  left  clavicle. 
Treatment  :  The  same  as  in  the  preceding  cases. 

July  15th. — Small  mass  near  the  original  site  of  pain, 
and  on  August  12th  discharged,  cured. 

Throughout  the  remainder  of  this  paper  only  epi- 
physeal separation  of  the  upper  and  lower  ends  of  the 
humerus,  fractures  of  the  lower  end  of  the  humerus, 
and  epiphyseal  separation  of  the  radius  and  ulna  in  their 
lower  extremities  will  be  considered. 

Epiphyseal  separation  of  the  upper  extremity  of  the 
humerus  does  not  occur  later  than  the  twentieth  year, 
owing  to  the  union  of  the  epiphysis  with  the  shaft  about 
this  peiiod  of  life.  The  average  age  in  these  cases,  ac- 
cording to  Tubby,  in  "  Guy's  Hospital  Reports  of  1889," 
is  eleven  years.  Causes  of  separation  of  the  epiphy- 
sis are  a  fall  from  a  height,  or  a  glancing  blow  from 
above  downward  upon  the  shoulder,  or  disease  of  the 
epiphysis. 

Anatomy. — As  previously  stated  the  epiphysis  of  the 
humerus  consists  of  the  articular  surface  of  the  bone 
with  the  two  tuberosities  ;  as  a  result  of  its  separation, 
owing  to  the  attachment  of  the  capsular  ligament  to 
the  anatomical  neck  of  the  bone,  we  have  the  joint  in- 
volved at  its  inner  aspect.  The  capsular  ligament  is 
attached  to  the  shaft  by  fibrous  expansions  at  the  in- 
ternal aspect  of  the  head  of  the  bone,  and  blends  with 
the  periosteum  throughout  the  circumference  of  the 
shaft.  By  this  blending  there  is  formed  a  strong  re- 
sisting fibrous  tissue  and  an  agent  that  limits,  to  a  great 
degree,  the  displacements  one  may  find  in  these  cases. 
When  a  deformity  is  marked,  it  is  due  to  laceration  of 
this  tissue,  allowing  the  upper  fragment  or  the  epiphy- 
sis to  be  displaced  forward  and  downward  toward  the 
subcoracoid  region,  resembling  a  subcoracoid  dis- 
placement. 

Signs  :  The  arm  hangs  helplessly  to  the  side  ;  the 
elbow  projects  little  or  none  at  all  ;  there  is  a  striking 
and  abrupt  projection,  slightly  round,  beneath  the 
acromion.  In  the  absence  of  swelling  we  can  fre- 
quently outline  the  border  of  this  projection  as  the 
upper  part  of  the  shaft  with  its  bicipital  groove,  as  shown 
in  Case  VII.  Crepitus,  if  present,  is  of  a  soft,  velvety 
character.  The  shoulder  is  broadened  from  before 
backward,  but  the  natural  roundness  may  be  present  ; 
while  in  case  of  complete  separation  of  the  head  and 
displacement  of  it,  there  is  a  characteristic  flattening, 
and,  as  a  rule,  a  mass  downward  and  forward,  in  the 
region  of  the  coracoid.  Shortening  is  present  only  in 
cases  of  complete  separation,  and  then  usually  about 
one  inch.  Little  or  no  ecchymosis  except  that  due  to 
contusion. 

Differential  Diagnosis  :  These  cases  are  liable  to  be 
mistaken  for  dislocations  of  the  subcoracoid  of  sub- 
clavicular variety,  but  the  usual  manifestations  of  dis- 
location are  absent. 

Mobility  's-  present,  crepitus  very  frequently  is 
found,  and  compression  symptoms  of  the  brachial 
plexus  are  absent. 

Fracture  of  the  upper  extremity  of  the  shaft  of  the 
humerus  can  be  diagnosticated  by  the  age  of  the  pa- 
tient, false  motion,  shortening  little  or  none  in  fractures, 


shape  of  the  upper  portion  of  the  shaft,  ecchymosis 
usually  marked,  and  grating  crepitus. 

Prognosis  :  Union  usually  occurs  early,  and  is  due, 
according  to  Mr.  Tubby,  of  England,  to  the  rich  vascu- 
lar supply  of  the  rotator  muscles  attached  to  the  tuber- 
osities sending  to  the  epiphysis  the  required  nutrition. 
The  upper  epiphysis  is  chiefly  instrumental  in  the 
growth  of  the  shaft  of  the  humerus,  and  as  a  result  of 
its  separation  the  growth  of  the  length  of  the  bone  is 
liable  to  be  materially  interfered  with.  In  a  number  of 
cases  reported  by  Tubby,  in  "  Guy's  Hospital  Reports  of 
1889,"  shortening  of  five  inches  has  been  noted.  The 
prognosis  referring  to  shortening  is  modified  with  the 
age  of  the  patient ;  the  younger  the  patient,  the  greater 
the  danger  of  considerable  shortening  :  the  older  the 
patient,  the  less  the  shortening. 

Shortening  and  vicious  union  also  is  frequently 
caused  by  inability  to  properly  replace  the  epiphysis. 

Treatment  :  As  in  fracture  of  the  surgical  neck  of 
the  humerus.  In  cases  in  which  it  is  impossible  to  re- 
duce the  displaced  epiphysis,  the  author  would  recom- 
mend cutting  down  upon  the  head  of  the  humerus,  us- 
ing the  ordinary  guide  for  an  excision,  reducing  the 
deformity,  then  retaining  proper  apposition  by  means 
of  sutures  through  the  periosteum  of  the  shaft  and  the 
capsule  of  the  joint. 

Case  V. — J.  D ,  boy,  thirteen  years  of  age  ;  was 

knocked  down  in  1891  by  a  mail  wagon  and  thrown 
forward  upon  his  right  shoulder.  He  was  seen  within 
half  an  hour  after  the  injury.  Swelling  was  very  slight, 
pain  considerable,  no  deformity  ;  high  up  false  motion 
could  be  felt  ;  by  grasping  the  shoulder  with  the  left 
hand,  and  moving  the  arm  with  the  right  at  the  same 
time,  grating  of  a  peculiar  soft  character  was  obtained. 
He  was  discharged  at  the  end  of  the  third  week  by  his 
regular  family  physician.  The  family  report  "  that  j-ou 
would  not  know  the  arm  had  been  broken."  Measure- 
ments in  this  case,  four  years  after  the  injury,  reveal  a 
shortening  of  three-quarters  of  an  inch. 

Case  \'l. — P.  B ,  seventeen  years  of  age,  was  seen 

on  August  15,  1895,  with  the  following  history  :  While 
jumping  down  the  stairs  of  an  elevated  railroad  station, 
four  days  before,  he  fell  forward  and  down  about  ten 
steps,  striking  on  his  left  shoulder.  Upon  examination 
broadening  of  the  shoulder  from  before  backward, 
flattening,  and  a  movable  body  high  up  in  the  joint  re- 
gion, soft  crepitation,  a  slight  amount  of  ecchymosis, 
considerable  swelling,  and  an  inch  shortening  were 
found.  Diagnosis  :  Epiphyseal  separation  of  the  upper  « 
extremity  of  the  humerus.  He  refused  anaesthesia  and 
further  treatment. 

Case  VII. — M.  McG ,  aged  sixteen,  was  seen  on 

the  same  date  as  Case  VI.,  with  a  history  of  a  fall 
upon  his  left  shoulder,  as  the  result  of  a  push  while 
skylarking  some  five  weeks  before.  He  had  been  an 
inmate  of  one  of  our  large  hospitals  and  was  being 
treated  for  a  dislocation  of  the  head  of  the  humerus  of 
the  subcoracoid  variety. 

Upon  examination  no  swelling,  but  marked  flatten- 
ing, broadening  from  before  backward,  and  shortening 
one  and  one -quarter  inch  were  found.  A  slightly 
convex  deformity,  continuous  with  the  shaft,  with  the 
bicipital  groove  well  marked  upon  it,  was  found  be- 
neath the  acromion,  and  downward  and  in  front,  prac- 
tically subcoracoid,  a  round  fairly  movable  mass  was 
felt. 

Diagnosis  of  epiphyseal  separation  was  made  and 
further  hospital  treatment  suggested,  it  being  the  inten- 
tion to  cut  down  upon  the  joint  and  reduce  the  head 
and  retain  it  by  silkworm  sutures.  Refused  furth.er 
treatment. 

I  am  indebted  to  Dr.  George  Stewart  for  the  follow- 
ing case  : 

Case  VIII. — Girl,  fifteen  years  of  age,  fell  upon  the 
right  shoulder  about  September  i.  1S95.  On  October 
loth  the  condition  is  as  follows  :  Arm  helpless  to  the 
side  of  the  budv.  no  tilting  of  the  elbow,  one-half  inch 


I 


October  26,  1895] 


MEDICAL    RECORD. 


587 


shortening,  flattening  of  the  shoulder,  apparent  broad- 
ening from  before  backward,  no  swelling,  a  mass  down- 
ward and  inward  from  the  joint  and  solid  with  the  shaft 
immediately  beneath  the  acromion,  with  internal  rota- 
tion slightly  marked.  Diagnosis  :  Epiphyseal  separa- 
;      tion  with  \-icious  union. 

Elbow.— Too  great  stress  cannot  be  placed  upon  the 
proper  diagnosis  and  treatment  of  fractures  occurring 
at  and  about  the  elbow-joint ;    how  frequently  anky° 
losis  is  seen  at  varying  angles,  as  a  result  of  these  inju- 
ries. In  some  cases  there  is  a  moderate  degree  of  func- 
I      tion  of  the  e.xtremity,  while  others  are  practically  useless. 
;      The  most  frequent  injuries  occurring  at  this  region  are 
;     fractures  of  the  condyles  of  the  humerus,  epiphyseal  sep- 
aration of  the  lower  extremity,  and  dislocation  of  the 
bones  of  the  forearm. 

The  cause  of  these  injuries  is  usually  a  fall  upon  the 
elbow  or  upon  the  volar  surface  of  the  hand.  The 
'  symptoms  and  signs  vary  with  the  conditions  ;  if  seen 
1  shortly  after  the  injury  diagnosis  is  readily  made. 
;  Later  the  swelling  is  frequently  so  extensive  as  to  ob- 
'  literate  all  landmarks  of  the  bony  joint,  and  an  ac- 
I  curate  diagnosis  can  only  be  made  after  the  swelling 
I  has  subsided  to  a  great  degree,  or  by  the  assistance  of 
1     an  anajsthetic. 

In  cases  of  epiphyseal  separation  seen  early  there  is 
I     a  broadening  from  before  backward,  with  a  sharp,  shelv- 
!     ing  border  presenting  below  and  posteriorly,  as' a  rule, 
;     andextendingacross  the  entire  width  of  the  bone.     An- 
I    teriorly  the  shaft  projects  with  a  sharp  border  over  the 
;    backward  displaced   lower    fragment.     Motion  of  the 
joint  is  perfect,  upon   holding  the  lower  fragment  be- 
tween the  thumb  and  forefinger.     The  head  of  the  ra- 
dius bears  its  usual  relationship  to  the  external  con 
dyle.     Crepitus,    when   elicited,  is   of   a   soft,  velvety 
,    variety,   in  contradistinction  to  the  grating  found   in 
!    fractures. 

Prognosis  :  No  extensive  shortening  is  to  be  ex- 
j  pected,  as  the  length  of  the  humerus  depends  mainly  on 
i    the  growth  from  the  upper  epiphysis. 

Treatment  :  Reduction  can  be  accomplished  without 
I   much  difficulty,  then  a  posterior  splint  is  placed  upon 
i   the  arm  and  forearm,  with  the  latter  almost  completely 
extended. 

In  these  cases,  it  has  been  the  custom  of  the  writer  to 
remove  the  dressing  in  from  ten  to  twelve  days,  and 
make  slight  passive  motion,  while  the  lower  fragment  is 
grasped  and  held  firmly  in  contact  with  the  shaft.  The 
splint  is  removed  at  the  end  of  the  third  week  ;  then 
have  the  patient  carry  his  arm  in  a  sling  for  a  week,  al- 
lowing him  to  exercise  the  arm  gradually. 

Fractures  of  the  condyles  are  due  to  the  same  causes 
as  the  former,  but  more  frequently  due  to  violence  di- 
rectly received,  as  in  falls  and  occasionally  a  blow  upon 
the  condyle.  The  signs  are  broadening  of  the  joint, 
movable  body  on  either  side,  depending  on  the  condyle 
broken.  Displacement  can  be  made  of  the  forearm  to 
the  side  of  the  fracture  ;  the  head  of  the  radius  is  fre- 
quently pushed  upward  in  case  the  external  condyle  is 
fractured,  impairment  of  joint  motions,  and  deformity 
of  an  oblique  variety. 

Treatment :  Reduction  ;  the  use  of  adhesive  strips 
to  hold  the  condyle  in  place,  and  the  limb  treated  in 
almost  complete  extension,  slight  passive  motion  in  ten 
to  fourteen  days,  then  placing  the  forearm  at  an  angle 
of  90°  with  the  humerus,  or  continuing  the  third  week 
with  extension. 

One  factor  in  treating  fractures  of  the  elbow  should 
be  emphasized,  and  that  is  never  to  forget  that  the 
forearm  should  be  placed  in  a  position  of  slight  ab- 
duction, so  as  to  preserve  its  carrying  properties,  and 
that  no  upward  pressure  should  be  made  upon  the  in- 
ternal condyle.  In  fractures  of  both  condyles  the  treat- 
ment has  been  the  same  as  in  cases  of  fracture  of  a  sin- 
gle condyle,  with  the  exception  of  the  retaining  strip  of 
adhesive  plaster. 
Fracture  oftheEpicondyle.— Of  this  injury  the  writer 


presents  the  clinical  history  of  but  one  case.  The  vio- 
lence is  direct  and,  upon  examination,  a  small  foreign 
body  is  found,  usually  forward,  and  downward  below 
the  elbow-joint.  In  the  case  cited,  the  internal  epicon- 
dyle  was  pulled  upward. 

Treatment :  Reduction,  if  necessary,  by  flexing  the 
elbow  ;  retain  the  fragment  by  an  adhesive  strip  and 
bandage  over  all.  Remove  the  dressing  on  the  four- 
teenth to  twentieth  day. 

Differential  Diagnosis  :  Fractures  of  the  lower  ex- 
tremity of  the  humerus  are  to  be  diagnosticated  from 
dislocation  backward  of  both  bones. 

The  signs  and  symptoms  of  fracture  in  a  recent  case 
are  so  evident  that  this  error  should  not  be  made,  but 
in  a  case  of  epiphyseal  separation,  it  is  more  likely  to 
occur. 

In  dislocation,  there  is  immobility  of  the  joint,  the 
head  of  the  radius  is  pushed  backward,  or  backward 
and  upward,  the  olecranon  protrudes  posteriorly  as  a 
rounded  or  conical  mass,  while  anteriorly  there  is  a  de- 
pression over  the  site  of  the  elbow.  These  signs,  when 
compared  to  the  signs  of  epiphyseal  separation  as  given, 
should  enable  one  to  arrive  at  a  proper  diagnosis. 

Case  IX. — D ,  boy,  aged  ten,  fell  from  a  tree  dur- 
ing the  summer  of  1892.  Came  to  me  through  the 
kindness  of  Dr.  E.  T.  T.  Marsh  during  the  fall  of  the 
same  year.  Upon  examination,  a  ridge  fully  one-quar- 
ter inch  wide  and  flat  was  found  protruding  backward 
and  continuous  with  the  lower  end  of  the  humerus, 
while  anteriorly  there  was  a  ridge  protruding  forward 
and  continuous  with  the  shaft  of  the  same  bone.  Ex- 
tension was  perfect.  Efforts  at  flexion  were  checked 
with  a  dull  sound,  as  if  some  object  were  being  struck 
by  the  coronoid  of  the  ulna,  as  the  forearm  came  to 
about  90°.  The  elbow  was  not  widened  nor  deformed, 
as  is  usual  in  cases  of  fracture. 

Diagnosis  :  Old  epiphyseal  separation.  Operative 
interference  was  advised,  but  not  accepted.  The  boy's 
father  stated  recently  that  the  condition  was  still  the 
same. 

Case  X. — M.  D ,  two  and  one-half  years  of  age, 

came  under  observation  on  May  12,  1894,  with  the  his- 
tory of  a  fall  from  a  chair,  striking  on  her  left  elbow. 
The  ordinary  signs  of  epiphyseal  separation  were  pres- 
ent. 

Treatment :  The  deformity  was  readily  reduced  and 
easily  retained.  The  forearm  was  then  placed  in  a  con- 
dition of  almost  complete  extension  and  bandaged  to  a 
posterior  splint,  extending  from  the  upper  third  of  the 
arm  down  to  the  wrist-joint.  The  splint  was  removed 
in  twenty  days  and  the  limb  bandaged  for  a  week.  Re- 
sult excellent. 

In  connection  with  cases  VIII.  and  IX.  the  writer 
refers  you  to  the  history  of  Case  XV.  for  another  epi- 
physeal separation  at  the  elbow-joint. 

Case  XI. — M.  O ,  five  years  of  age,  fell  down 

two  steps  .\ugust  2,  1894,  striking  upon  her  left  elbow. 
She  was  seen  on  August  4th,  with  a  straight  splint 
upon  the  dorsal  aspect  of  the  arm  and  forearm.  Upon 
examination,  false  motion,  and  deformity  over  the  in- 
ternal condyle  and  grating  crepitus  were  found. 

In  this  case  there  was  also  considerable  swelling  and 
ecchymosis.  The  deformity  was  reduced.  A  small 
strip  of  adhesive  plaster  was  wound  around  the  inner 
aspect  of  the  forearm  to  retain  the  fractured  condyle, 
the  forearm  was  then  abducted  slightly  and  extended! 
and  a  posterior  splint  applied.  She  was  discharged,' 
with  a  good  result,  on  September  2,  1894. 

Case  XII. — A.  K ,  five  years  of  age,  in  June, 

1S93,  fell  four  stories,  striking  the  roof  of  an  extension, 
then  bounded  off,  falling  to  the  ground.  The  case 
was  seen  immediately  by  Dr.  DeGarmo,  who  very 
kindly  referred  it  to  the  writer. 

The  boy  was  seen  about  an  hour  after  the  injury  ; 
upon  examination,  false  motion  at  the  site  of  the  ex- 
ternal condyle,  deformity,  some  swelling,  ecchymosis, 
and  crepitus  were  found,  with  general  contusion  of  the 


588 


MEDICAL    RECORD. 


[October  26,  1895 


trunk  ;  otherwise  he  was  in  excellent  condition.  The 
limb  was  put  in  extension  under  chloroform  anesthe- 
sia and  kept  extended  for  three  weeks,  at  the  end  of 
which  time  the  splint  was  removed  permanently.  A 
week  later  the  result  was  excellent,  and  owing  to  the 
boy's  activity,  he  had  regained  complete  function  of 
his  joint  about  the  fifth  week. 

Case  XIII. —  C.  O ,  five  years  of  age,  fell  down 

stairs  about  four  steps  on  March  17,  1895,  striking  his 
right  elbow.  He  was  treated  four  weeks  at  two  hospi- 
tals, previous  to  coming  to  St.  Vincent's  Hospital  Dis- 
pensary. He  was  seen  on  April  19,  1895.  one  month 
after  the  injury,  at  which  time  the  following  conditions 
were  found  :  forearm  flexed  at  right  angle,  the  exter- 
nal condyle  displaced  outward  and  downward,  a  cuta- 
neous slough,  the  result  of  pressure,  about  the  size  of 
a  ten-cent  piece,  over  the  tip  of  the  condyle,  joint 
ankylosed,  and  atrophy  of  the  muscles  of  the  arm  and 
forearm.  Under  chloroform  ansesthesia,  the  ankylosis 
was  broken  up,  and  the  fractured  and  displaced  con- 
dyle was  reduced,  and  the  limb  treated  in  extension  for 
three  weeks.  At  the  end  of  this  time,  there  was  no 
union  of  the  fragments.  For  four  weeks  the  boy  re- 
mained under  observation  without  union  taking  place, 
and  was  then  sent  into  the  hospital  to  keep  him  oft  the 
streets.  He  was  discharged  in  two  weeks,  with  union 
and  a  fair  result. 

Case   XIV. — E.  M •,  aged  seven,  referred  to  the 

writer  by  Dr.  Joseph  Collins,  three  years  ago,  fell 
from  an  iron  fence,  striking  upon  his  left  elbow.  He 
was  seen  four  days  after  the  injury  with  an  enormously 
swollen  arm  and  forearm. 

Evaporating  lotions  were  applied  for  almost  a  week, 
with  the  forearm  extended.  Then  ether  was  given 
and  a  diagnosis  of  fracture  of  the  external  condyle  was 
made  ;  the  usual  treatment  by  extension  was  carried 
out  for  about  a  week,  when  the  limb  was  encased  in 
plaster,  with  the  forearm  flexed.  The  plaster  was  re- 
moved in  two  weeks.  Within  six  weeks,  the  boy  had 
almost  complete  flexion  and  extension.  Recent  re- 
ports in  this  case  are  entirely  satisfactory. 

Case  XV. — Boy,  seven  years  of  age,  was  struck  upon 
the  inner  side  of  his  left  elbow.  Examination  revealed 
a  hard  mass,  about  the  size  of  a  large  pea,  upward  and 
backward  from  the  internal  condyle.  No  ecchymosis 
or  swelling.     Some  pain  at  the  elbow. 

'  Diagnosis  :  Fracture  of  the  epicondyle.  Treated  by 
adhesive  straps  and  pad  for  fifteen  days.    Result  good. 

Radius  and  Ulna. — There  is  but  one  case  of  interest 
to  report,  that  involves  the  bones  of  the  forearm.  This 
was  an  epiphyseal  separation  occurring  in  both  bones 
at  the  wrist  and  a  separation  of  the  lower  epiphysis 
of  the  humerus.  The  injury  was  received  by  falling 
down  a  flight  of  stairs,  fourteen  or  fifteen  in  number. 

As  the  main  growth  of  the  forearm  depends  upon 
the  lower  epiphysis,  the  importance  with  a  view  to 
prognosis,  in  cases  of  epiphyseal  separation  at  this  ex- 
tremity, can  readily  be  estimated.  This  injury  is  due 
to  direct  violence  or  by  hyper-extension  of  the  hand. 
The  signs  of  this  injury  are  a  marked  transverse  de- 
formity just  above  the  wrist  posteriorly,  as  compared 
to  the  oblique  deformity  in  Colles's  fracture ;  an  an- 
terior prominence  due  to  the  lower  ends  of  the  shafts 
of  the  radius  and  ulna,  also  of  a  transverse  variety,  and 
abnorm.il  mobility  above  the  wrist. 

Treatment  :  .\  dorsal  splint  after  reduction,  extend- 
ing to  the  fingers  and  retained  for  about  three  weeks. 

Cases  of  epiphyseal  separation  of  both  bones  are  ex- 
tremely rare,  as  compared  to  those  of  the  radius  or 
ulna  alone.  Dolbeau  rejjorts  a  multiple  case,  in  which 
both,  radius  and  ulna  on  the  one  side  and  the  radius 
on  the  opposite  side,  suffered  separations. 

Owing  to  the  fact  that  the  main  growth  of  the  fore- 
arm depends  upon  the  lower  epiphysis,  prognosis  with 
a  view  to  shortening  is  bad  ;  in  single  separations,  lat- 
eral deformity  is  usual.  Numbers  of  cases  of  separa- 
tion of  the  lower  epiphysis  in  either  bone  have  been 


reported,  and  a  large  proportion  were  followed  as  a  re- 
sult of  the  diminished  growth  of  the  injured  bone  by 
marked  lateral  curvature,  the  normal  bone  during  its 
growth  curving  toward  the  injured  side.  In  these 
cases  it  is  advised  to  excise  a  length  of  the  uninjured 
bone  sufficient  to  overcome  the  deformity. 

Case  XVI. — M.  D ,  girl,  four  years  of  age.     On 

May  17,  1894,  fell  down  stairs  and  was  brought  to  St. 
Vincent's  Hospital  Dispensary  for  treatment.  She 
complained  of  pain  in  the  wrist  and  elbow  of  her  right 
side.  Upon  examining  the  wrist,  a  peculiar  trans- 
verse deformity,  sharply  outlined,  presenting  upon  the 
posterior  aspect  of  the  forearm  about  a  half  inch  above 
the  wrist-joint,  was  observed,  while  anteriorly  there  was 
a  deformity  continuous  with  the  shafts  of  the  bones  of 
the  forearm.  At  the  site  of  the  deformity  during  ma- 
nipulation a  soft  crepitation  was  apparent.  At  the  elbow 
there  were  the  characteristic  evidences  of  an  epiphy- 
seal separation  of  the  lower  end  of  the  humerus. 

Diagnosis  :  Epiphyseal  separation  of  the  lower  end 
of  the  radius  and  ulna,  and  also  at  the  lower  end  of  the 
humerus.  The  separations  were  reduced  and  the 
limb  was  then  placed  upon  a  long  posterior  splint,  ex- 
tending down  to  the  metacarpo-phalangeal  articulations. 
She  was  discharged  in  four  weeks  with  a  good  result. 

In  conclusion,  the  author  desires  to  express  his  in- 
debtedness to  Drs.  Joseph  D.  Bryant  and  Carl  Beck 
for  their  kind  permission  to  use  such  of  their  hospital 
material  as  might  be  of  service  to  him. 

149   Wl  -T    lO    TV-F    I'ETH    StRKE^. 


A  CASE  OF  INVERSION  OF  THE  UTERIS 
OF  FIVE  DAYS'  STANDING— SUCCESSFUL 
REDUCTION. 

Bi'  A.   A.  DAVIS,  M.D., 

AND 

C.  \V.  PACKARD,  M.D., 

NEW    YORK  CITV. 

The  rarity  of  this  accident  is  shown  by  the  statement 
of  Braun,  who  says  that,  in  the  clinic  under  the  charge 
of  Spaeth  and  himself,  not  one  case  of  complete  inver- 
sion of  the  uterus  occurred  in  one  hundred  and  fifty 
thousand  labors.  At  the  Rotunda  Hospital  in  Dublin 
there  was  one  case  in  one  hundred  and  ninety  thou- 
sand confinements.'  Meadows  had  only  one  case  in  his 
practice.  Probably  most  physicians — even  those  in  ex- 
tensive obstetrical  practice — never  meet  with  a  casein  a 
lifetime.  We  report  the  following  case,  believing  that 
it  will  be  found  of  unusual  interest  to  the  profession  : 

Mrs.  B -,  aged  twenty-eight,  primipara,  was  taken 

witli  labor  pains  early  Sunday  morning,  September  29, 
1S95,  and  was  delivered  of  a  living  child  with  forceps 
under  chloroform  at  about  seven  o'clock  the  same 
evening,  the  perineum  and  vagina  being  much  torn. 
The  placenta  was  removed  with  some  difficulty  and 
a  severe  hemorrhage  followed. 

When  the  patient  came  out  from  under  the  influence 
of  the  chloroform,  she  complained  of  intense  pelvic  pain 
and  a  feeling  of  impending  dissolution.  Symptoms  of 
collapse  ensued.  The  attending  physician  had  already 
gone  to  his  home,  two  miles  distant,  so  that  it  was  neces- 
sary to  call  in  a  neighboring  physician,  who  did  what  he 
could  to  help  the  patient  through  the  night. 

The  next  day,  September  30th,  patient  had  some 
fever.  Temperature,  100°  F.;  pulse.  So  :  respiration,  20  ; 
and  complained  of  pains  which  were  thought  to  be  the 
ordinary  after-pains.  Hemorrhage  about  double  the 
amount  of  the  usual  lochial  flow.  Retention  of  urine. 
Catheter  used  once. 

October  ist,  12  m.:  Temperature,  ioi|°  F. ;  pulse, 
120  ;  respiration,  20.  4  p.m.  :  Temperature,  loof"  F. 
Pain  and  flow  about  as  yesterday. 

'  Lusk's  Midwifery,  p.  563.  '; 


October  26,  1895] 


MEDICAL    RECORD. 


October  2d. — Temperature,  ioo|  F.  ;  pulse,  112; 
respiration,  25.  Flow  diminishing.  Uterine  pains 
about  every  half  hour. 

October  3d,  11  a.m. — Temperature,  102^°  F.;  pulse, 
128  ;  respiration,  26.  i  p.m. — Temperature,  103°  F.  ; 
pulse,  130  ;  respiration,  30. 

The  preceding  notes  I  make  from  chart  records  kept 
by  a  trained  nurse,  and  from  the  mother  of  the  patient 
who  was  with  and  took  care  of  her  during  Sunday  and 
Sunday  night. 

I  first  saw  patient  at  6  p.m.  of  this  day,  October  3d, 
the  husband  bringing  me  a  note  from  the  attending 
physician,  asking  me  to  see  the  case  and  write  my  sug- 
gestions in  a  note  to  him,  as  he  was  not  able  to  meet  me 
in  formal  consultation. 

I  found  Mrs.    B with  the  following  symptoms  : 

Temperature,  103!°  F.;  pulse,  128  ;  respiration,  40. 
Face  pale  and  anxious  in  expression.  No  great  pain, 
but  quite  restless  and  wearied,  having  had  but  little 
sleep  since  Sunday.  Lochia  free  and  not  particularly 
offensive.  Bowels  just  freely  opened  by  sulphate  of 
magnesia  ;  hypogastrium  very  prominent  from  tumor, 
reaching  quite  to  the  umbilicus.  The  nurse  telling  me 
that  after  the  catheterization  on  Monday  the  patient 
had  passed  considerable  water  every  two  or  three  hours, 
I  came  to  the  conclusion  that  she  had  had  an  internal 
hemorrhage  just  after  delivery,  thus  accounting  for  the 
symptoms  of  collapse  upon  coming  out  from  under  the 
influence  of  chloroform  ;  that  the  uterus  was  now  filled 
with  clots,  and  that  her  fever  was  due  to  sepsis.  I  did 
not  make  a  vaginal  examination,  not  feeling  at  liberty, 
under  the  circumstances,  to  pursue  my  investigations 
any  further.  I  accordingly  s:ated  my  conclusion  in  a 
note  to  the  doctor,  who,  however,  did  not  visit  the  pa- 
tient again,  but  withdrew  from  the  case  the  next  morn- 
ing. At  the  request  of  the  husband  I  now  took  charge 
of  the  patient. 

Friday,  October  4th. — Saw  the  patient  at  11  a.m. 
Temperature,  103!°  F.;  pulse,  130;  respiration,  30. 
General  condition,  in  aspect,  worse  than  when  I  saw 
her  last  evening.  I  proposed  to  clear  the  uterus  of  sup- 
posed clots  and  then  wash  it  out  with  a  hot  carbolic 
solution.  Upon  placing  her  in  position  for  this  pur- 
pose and  introducing  my  finger  into  the  vagina,  I  found 
it  filled  nearly  to  the  perineum  by  a  large  mass,  quite 
hard,  and  with  a  surface  not  unlike  a  placenta  to  the 
feel.  I  did  not  succeed  in  finding  the  cervix.  An  in- 
verted uterus  occurred  to  my  mind,  but  I  was  puzzled 
by  the  presence  of  the  hypogastric  tumor.  I  now  di- 
rected the  nurse  to  pass  the  catheter  and  draw  off  what 
water  there  was  in  the  bladder,  although  she  had  re- 
ported that  the  patient  had  urinated  just  before  my  ar- 
rival. The  result  of  the  catheterization  was  forty-eight 
ounces  of  dark-colored  urine  and  a  great  diminution  in 
the  size  of  the  tumor.  But  still  feeling  what  I  thought 
to  be  the  uterus  above  the  pubes,  I  desisted  from  further 
attempts  to  complete  my  diagnosis,  judging  it  to  lay 
between  an  inversion  of  the  uterus  and  a  large  hiuma- 
tocele.  I  accordingly  sought  the  advice  and  aid  of  my 
friend.  Dr.  C.  W.  Packard,  who  saw  the  patient  with  me 
at  3.30  P.M.  the  same  day.  His  report  is  herewith  pre- 
sented. 

At  the  request  of  Dr.  Davis  I  met  him  in  consultation 

in  the  case  of  Mrs.  B on  Friday  afternoon,  October 

4th,  nearly  five  full  days  after  her  instrumental  delivery 
at  full  term.  I  found  the  patient  lying  on  her  back  with 
the  legs  extended,  and  apparently  indifferent  to  all  that 
was  going  on  around  her.  Her  face  was  pale,  and  its 
expression  staring  and  apathetic.  She  roused  sufti- 
1  icntly  to  answer  "  no  "  to  my  inquiry,  as  to  whether  she 
felt  any  pain.  Her  pulse  was  126  ;  respiration,  36  ; 
temperature,  103!°  F.,  per  rectum.  The  abdomen  was 
slightly  tumid,  but  soft,  and  a  distended  bladder  was 
easily  outlined  through  its  walls.  Fifty  ounces  of  urine 
were  at  once  drawn  off  by  catheter,  although  forty-eight 
ounces  had  been  drawn  only  four  hours  before.  It 
then  became  easy  to  discover  that  no  uterus  could  be 


felt  in  the  abdominal  cavity,  but  that  there  was  a  hard 
mass  behind  the  pubis,  and  low  down  in  the  pelvis. 
Examination  per  vaginam  revealed  a  hard  tumor,  the 
size  of  a  child's  head,  just  inside  the  vulva,  and  that 
completely  filled  the  pelvic  cavity.  It  was  sensitive  to 
touch,  and  felt  like  the  inside  of  the  uterus  after  de- 
livery. Passing  the  finger  high  up,  a  thin  flap  of  the 
cervix  could  be  felt  on  the  right  side  of  the  tumor. 
The  patient  was  then  turned  gently  upon  her  side,  and 
by  means  of  a  large  Sims  speculum  a  part  of  the  tu- 
mor was  brought  into  good  view.  Its  surface  was 
mo'st  with  lochial  discharge  of  normal  odor,  and  cov- 
ered here  and  there  with  films  of  loosely  adherent 
coagula.  The  tumor  as  a  mass  was  pale  and  anae- 
mic from  the  diminished  blood  supply  through'^^the 
vessels  of  the  constricted  cervix. 

Having  determined  that  we  were  dealing  with  an  in- 
verted uterus,  it  was  decided  to  etherize  the  patient  and 
at  once  attempt  its  reduction.  At  the  request  of  Dr.  Da- 
vis I  prepared  to  begin  the  operation  that  most  certain- 
ly promised  to  be  more  tedious  than  successful.  The 
finger-nails  were  trimmed  short,  and  the  usual  antisep- 
tic precautions  observed.  The  patient  was  brought  to 
the  point  of  full  surgical  anaesthesia.  The  patient,  ly- 
ing upon  her  back,  with  my  two  fingers  within  the  vulva, 
and  with  the  other  hand  passed  deep  behind  the  pubis, 
it  was  found  that  the  tumor  was  to  some  extent  mova- 
ble, and  that  it  moved  as  a  solid  mass.  The  deep- 
seated  pelvic  portion  as  felt  through  the  abdominal 
wall  presented  to  the  touch  a  hard  and  round  surface, 
but  no  cupping  of  the  cervix,  such  as  writers  de- 
scribe, was  distinctly  appreciable.  The  whole  mass, 
above  and  below,  was  very  firm  and  hard,  as  if  from 
tonic  contraction  of  the  entire  organ. 

The  operation  was  begun  by  pressing  the  index 
and  middle  fingers  firmly  and  steadily  against  the  pre- 
senting fundus,  at  the  same  time  making  gentle  counter 
pressure  through  the  abdominal  wall,  (jradually  the 
uterine  wall  yielded,  so  that  at  the  end  of  fifteen  min- 
utes the  two  fingers  were  buried  in  the  tumor  as  far  as 
the  distal  joint.  The  whole  hand  was  now  passed  into 
the  vagina,  and  four  fingers  pressed  firmly  against  the 
mass,  thus  pushing  it  toward  the  cervix  by  continuous 
pressure,  the  elbow  meanwhile  resting  on  the  bed  as  a 
point  of  support.  \Vith  the  help  of  the  thumb,  some 
degree  of  massage  to  the  uterine  walls  was  accom- 
plished, with  a  view  to  rendering  them  more  pliable  and 
thus  more  tractable  to  further  manipulations.  Very 
soon  the  uterine  walls  began  to  soften,  whether  from 
the  relaxing  effect  of  the  anaesthetic,  or  from  the  manip- 
ulations, or  from  both  combined,  and  the  cervix  as  felt 
behind  the  pubis  grew  appreciably  softer.  At  the  end 
of  half  an  hour  it  was  possible  to  carry  the  fundus  be- 
fore the  four  fingers  fairly  into  the  mouth  of  the  con- 
stricting cervix,  where  they  were  steadily  held  as  a 
wedge.  The  cervix  now  dilated  rapidly  before  the 
advancing  hand.  At  this  stage  of  procedure  some- 
thing was  gained  by  seizing  the  cervix  through  the  ab- 
dominal wall,  and  pressing  it  down  behind  the  pubis 
in  opposition  to  the  fingers  inside  the  cervix,  which 
were  pressing  the  fundus  up — very  much  as  in  the  ma- 
noeuvre for  reducing  a  strangulated  hernia  by  pushing 
down  the  neck  of  the  sac,  and  at  the  same  time  push- 
ing up  the  contents  of  the  sac.  After  this  process  had 
gone  on  for  some  time,  it  became  evident  that  the  mass 
in  the  vagina  was  rapidly  diminishing  in  bulk,  and  that 
in  the  abdomen  growing  larger.  The  fundus  was  still 
held  in  the  cervix,  and  seemed  almost,  but  not  ([uite, 
ready  to  pass  through.  Meanwhile,  under  the  steady 
pressure  from  below,  and  with  increasing  dilatation  of 
the  cervix,  the  uterus  was  slowly  returning  itself,  not 
by  movement  at  the  fundus,  but  at  the  ceivix.  The 
body  of  the  uterus  was  unfolding  itself  back  through 
the  cervix,  the  tissues  nearest  the  cervix  returning 
first.  At  the  end  of  forty-five  minutes  the  uterine  walls 
had  become  soft  and  completely  relaxed,  and  the  uter- 
ine  mass   in    the  abdomen  had  steadilv  accumulated 


59° 


MEDICAL   RECORD. 


[October  26,  1895 


in  volume,  until  it  was  estimated  that  three-fourths  of 
the  bulk  of  the  uterus  had  been  returned  through  the 
cervix.  In  the  now  completely  relaxed  condition  of 
the  uterine  walls  no  help  toward  further  reposition 
could  be  expected  from  muscular  action,  such  as  is  re- 
ported to  have  suddenly  completed  the  reposition  in 
other  cases,  and  it  became  evident  that  the  paralyzed 
fundus  must  be  carried  to  its  place.  In  the  early  stages 
of  the  operation  occasional  contractions  of  the  uterus 
were  observed,  but  they  gradually  grew  less  frequent, 
and  had  now  entirely  ceased,  so  that  the  fundus  clung 
around  the  hand  in  a  flabby  mass.  At  the  end  of  an 
hour's  hard  work,  and  at  this  stage  of  the  operation, 
my  hand  had  become  so  benumbed  and  powerless  that  I 
was  compelled  to  resign  my  work  to  Dr.  Davis,  by 
whom  the  reduction  was  soon  happily  completed. 

"  Owing  to  the  patient's  very  low  condition  much 
anxiety  was  felt  lest  she  should  prove  unable  to  bear  the 
shock  of  operation  added  to  the  depressing  effect  of  the 
necessarily  long-continued  administration  of  ether,  but 
so  far  as  could  be  determined  no  such  ill  effects  were 
produced,  and  her  condition  at  the  end  of  the  opera- 
tion seemed  to  be  quite  as  good  as  at  the  beginning. 

"In  considering  this  case  the  following  points  ap- 
pear to  be  of  special  interest  :  i.  The  remarkable 
softening  and  relaxation  of  the  uterus,  without  which 
reduction  of  the  inversion  would  have  been  impossible. 
2.  The  absence  of  all  hemorrhage  from  the  relaxed 
uterus  during  and  after  its  reduction.  3.  The  order  in 
which  the  uterine  tissues  slowly  found  their  way  back 
to  normal  position,  the  tissues  nearest  the  cervix  rolling 
back  first." 

I  now  take  up  the  report  where  Dr.  Packard  leaves  it. 
\\'hen  I  followed  Dr.  Packard  in  his  attempts  to  ac- 
complish complete  reduction,  I  found  the  change  in 
the  condition  of  affairs  surprising  and  very  gratifying. 
The  vagina  was  now  entirely  empty  of  any  portion  of 
the  inverted  uterus,  the  cervix  well  dilated,  and  the  un- 
reduced fundus  could  be  felt,  I  should  judge,  two  inches 
within  the  cervix  as  a  singularly  flabby  and  elusive 
mass.  The  latter  ([uality  prevented  my  making  any 
gain  in  attempts  at  reduction,  until  I  introduced  my 
whole  hand  into  the  uterus.  Then  by  grasping  the 
uterus  with  the  left  hand  through  the  abdominal  walls, 
and  by  exercising  steady  pressure  with  the  fingers  and 
thumb  of  the  right  hand  upon  the  tumor  in  its  circum- 
ference rather  than  upon  the  centre,  in  about  five  min- 
utes complete  reduction  was  accomplished.  I  hesitated 
at  first  to  withdraw  my  hand  lest  reinversion  should  take 
place.  But  this  accident  did  not  take  place  upon  with- 
drawal, and  there  has  been  no  symptom  of  it  since. 

The  patient  bore  the  ether  well,  and  suffered  less 
from  shock  than  we  had  a  right  to  expect.  No  hemor- 
rhage occurred,  either  during  or  after  the  operation. 
The  condition  of  the  patient  for  ten  days  following  the 
operation  was  exceedingly  precarious,  and  then  seemed 
so  much  better  for  a  few  days  that  hopes  were  enter- 
tained of  her  recovery.  She,  however,  became  worse 
again  October  17th,  rapidly  sank,  and  died  October 
igih  of  pelvic  peritonitis  and  metritis. 


Epilepsy. — Every  case  of  epilepsy  subjected  to  opera- 
tion should  be  kept  on  proper  medical  treatment  for  at 
least  two  years. — Lanphear. 

Felon. — The  application  of  fuming  nitric  acid  to  a 
felon  in  any  stage  will  produce  entire  relief. — Hirsch. 

Snuff  for  Hiccough.— Dr.  P.  Slevin  reports  in  the 
I.aiuet  a  case  of  obstinate  hiccough  whicli  had  resisted 
a  great  variety  of  remedies  for  twelve  days.  The  pa- 
tient was  seventy  eight  years  of  age,  of  g<)od  physique. 
Finally,  in  the  hope  of  exciting  a  new  reflex,  he  was 
ordered  one  evening  to  take  several  jiinches  of  snuff. 
Tnis  he  did.  and  the  following  morning  was  found  free 
from  hiccough.     The  cure  was  a  permanent  one. 


TUBERCULAR  PERITONITIS. 
By  C.  M.   LENHART,  M.D., 

ZANESVILLE,    O. 
PHVSICIAN  TO  ZANESVILLE  CITY  HOSPITAI- 

In  presenting  this  subject,  it  is  with  special  reference 
to  the  difficulties  in  diagnosing  some  cases,  and  also 
the  treatment. 

As  is  well  known,  tubercular  peritonitis,  per  se,  in 
children  or  adults,  is  rare  without  a  previous  or  simul- 
taneous manifestation  of  tuberculosis  in  some  other 
part  of  the  body.  In  the  case  which  I  will  presently 
present,  the  invasion  of  the  disease  was  slow  and  insid- 
ious, without  the  ordinary  symptoms  of  this  affection 
which  are  laid  down  in  text-books,  viz.,  tubercular  dis- 
ease in  some  other  part  of  the  body,  hereditary  ten- 
dency, irregular  fever,  diarrhoea  or  alternating  with 
constipation,  abdominal  enlargement  from  gas,  fluid, 
pus,  or  mesenteric  glands,  nausea  or  vomiting,  abdom- 
inal pains,  growing  weakness,  and  emaciation.  These 
symptoms  may  develop  so  suddenly  in  acute  cases, 
that  this  disease  has  been  mistaken  for  typhoid  fever, 
which  it  may  closely  simulate,  or  enteritis,  or  simple 
peritonitis  ;  or  it  may  be  so  latent  as  to  not  present  a 
single  symptom  of  abdominal  disease,  only  to  be  dis- 
covered during  a  laparotomy  for  some  other  disease. 

Was  called  November  3,  1S94,  to  attend  Mrs.  A.  W. 

B ,   white,  aged  thirty-three.      Found  her  in  her 

third  pregnancy,  between  the  seventh  and  eighth 
months.  The  previous  labors  had  been  normal,  and 
her  children,  aged  three  and  five  years,  are  in  perfect 
health.  No  history  of  miscarriages.  The  patient  has 
always  enjoyed  good  health,  and  appears  healthy  at 
this  examination,  except  that  she  has  had  a  diarrhcea 
for  two  weeks  past.  The  diarrhoea  was  checked  only 
for  a  day  or  two.  She  was  delivered  December  23. 
1894,  of  a  healthy  baby.  The  secretion  of  milk  w,i> 
plentiful  and  recovery  was  uninterrupted,  .^fter  the 
diarrhoea  had  lasted  about  four  months  a  thorough 
examination  was  made.  The  thoracic,  abdominal,  and 
pelvic  organs,  as  well  as  the  rectum,  were  found  normal. 
Pulse,  respiration,  and  temperature  were  normal,  ap- 
petite fair,  no  nausea  or  vomiting,  stools  from  six  to 
twelve  in  the  twenty-four  hours,  but  the  patient  is 
gradually  losing  flesh  and  strength.  No  permanent 
benefit  has  been  derived  from  treatment.  Has  very 
slight  abdominal  pains,  not  localized,  or  severe  enough 
to  call  for  an  ojnate. 

In  the  fifth  month  a  swelling  was  discovered  over 
the  region  of  the  appendix,  about  the  size  of  a  goose 
egg,  slightly  tender  on  firm  pressure.  The  case  was 
now  thought  to  be  appendicitis,  with  probably  the 
formation  of  an  abscess  discharging  into  the  bowels,  or 
a  catarrhal  condition  of  the  cjecum.  In  either  case 
we  would  have  diarrhcea  alone  or  alternating  with  con- 
stipation. The  case  was  watched  closely,  and  in  the 
sixth  month  of  the  disease  this  swelling  had  percepti- 
bly diminished,  but  never  entirely  disappeared.  .\n 
operation  was  projjosed,  but  was  given  up  for  the  time. 
Subnormal  temperature  was  noticed  at  times  in  the 
morning.  The  baby  had  been  healthy  up  to  this  time, 
but  weaning  was  advised  because  a  latent  tubercular 
trouble  had  been  thought  of. 

In  the  seventh  month  of  her  sickness  the  woman 
had  become  very  weak  ;  temperature  from  97°  in  the 
morning  to  99°  in  the  afternoon,  under  the  tongue  ; 
pulse,  100  to  \2o  \  takes  large  doses  of  morphine  to  re- 
lieve ])ain  ;  bowels  are  now  obstinately  constipated. 

A  laparotomy  was  consented  to  and  she  was  removed 
to  the  Zanesville  City  Hospital  loroiieration.  The  ab- 
domen had  been  repeatedly  examined,  but  nothing  ab- 
normal was  found  excepting  slight  tenderness  and  a 
little  swelling  over  the  appendix.  The  operation  was 
lierformed  June  17.  1S95,  by  Dr.  I.  G.  F.  Holston,  as- 
sisted by  Dr.  G.  Warburton  and  myself.     The  appen- 


October  26,    1895] 


MEDICAL    RECORD. 


591 


dix  was  found  inflamed,  and  about  as  thick  as  the  lit- 
tle nnger  ;  a  particle  of  hard  fecal  matter  was  found 
in  it,  otherwise  it  was  normal  ;  it  was  amputated  and 
the  stump  cauterized  over  a  previous  ligation  ;  about 
a  half-pint  of  fluid  was  drained  from  the  peritoneal 
cavity  and  the  latter  was  thoroughly  dried  out  ;  the 
peritoneum  was  found  studded  with  hard  miliary  tuber- 
cles over  a  limited  extent.  The  other  abdominal  and 
pelvic  organs  were  found  healthy.  The  abdominal 
cavity  was  completely  closed.  Her  recovery  was  un- 
interrupted ;  on  the  eighth  day  there  was  complete 
union.  She  has  continued  to  improve,  appetite  better, 
bowels  fairly  regular,  little  or  no  pain  in  abdomen,  and 
looks  brighter.  She  left  the  hospital  eighteen  days 
after  the  operation,  her  health  improving  in  every  re- 
spect. It  is  now  four  months  since  the  operation,  and 
her  health  continues  good. 

Now,  here  was  a  case  in  which  it  was  impossible  to 
diagnose  the  morbid  condition.  The  only  signs  we 
had  of  the  e.xisting  disease  were  diarrhoea,  growing 
weakness,  emaciation,  and  a  general  cachectic  appear- 
ance. In  this  case  the  loss  of  flesh  and  strength  were 
attributed  to  the  diarrhoea  and  defective  assimilation. 
A  subnormal  temperature  was  frequently  noted,  and  it 
appears '  that  subnormal  temperature  for  weeks  or 
months  is  frequent  in  cases  of  fibrous  tubercles,  where 
there  is  slight  inflammation  and  small  effusion,  or  there 
may  be  slight  fever  and  subnormal  temperature.  It 
appears  that  my  case  was  after  this  type.  Tubercular 
peritonitis  was  formerly  thought  to  be  one  of  the  most 
fatal  of  diseases.  Alonzo  Clark  -  says  "  it  is  believed 
to  be  uniformly  fatal."  Evidence,  however,  has  lately 
accumulated  to  show  that,  in  a  certain  proportion  of 
cases,  spontaneous  recovery  in  this  disease  is  possible 
both  in  children^  and  adults.^  It  also  appears  that  the 
cases  most  likely  to  terminate  favorably  are  those 
where  the  infection  is  confined  to  the  peritoneum,  and 
that  to  a  limited  e.xtent.  It  is  even  possible  that  the 
disease  may  run  a  latent  course  and  a  cure  be  effected 
without  any  sign  of  e.\isting  peritonitis.'  There  is  no 
reason  why  tubercles  in  the  peritoneum  may  not  un- 
dergo involution  the  same  as  in  other  parts  of  the 
body. 

The  anatomical  changes  are  in  brief  :  the  tubercles 
undergo  fibroid  pigmentary  induration,  exudations  are 
absorbed,  and  there  is  a  transformation  of  the  fibroid 
material  into  connective  tissue  with  adhesions. 

Osier'' and  others '  describe  three  varieties  of  this 
disease — miliary,  fibroid,  and  caseous  ;  clinically,  how- 
ever, it  is  not  always  possible  to  classify  all  cases  of 
tubercular  peritonitis.  Infection  of  the  peritoneum 
may  come  through  the  blood,  intestines,  Fallopian 
tubes,  tubercular  ulcers  of  intestines,  mesenteric  glands, 
or  pleura.  We  have  tubercular  peritoneal  tumors 
which  are  very  difficult  to  diagnose  in  every  case  ; 
they  may  be  omental,  sacculated  exudations,  retracted 
and  thickened  intestinal  coils,  or  mesenteric  glands. 
The  serious  difficulty  is  best  shown  by  the  fact  that  in 
96  cases  of  laparotomy  in  tubercular  peritonitis,  in  not 
less  than  30  ovarian  disease  was  thought  to  be  pres- 
ent. In  1862  Spencer  Wells  performed  laparotomy 
for  a  supposed  ovarian  tumor,  and  he  found  a  tubercu- 
lar condition  of  peritoneum;  the  fluid  was  drawn  off 
.iiid  his  patient  recovered.  As  we  have  seen  above, 
many  mistakes  in  diagnosis,  with  consequent  opening 
01  the  abdominal  cavity,  have  been  made,  and  a  cure 
ui  the  patients  has  been  the  result  in  the  majority  of 
cases.  The  beneficial  effect  of  opening  the  peritoneal 
cavity  and  draining  off  the  fluid  has  caused  this  to  be- 
'  -me  a  generally  recognized  operation.  As  Mr.  Law- 
Johns  Hopkins  Hospital  Report  for  1890.  by  Osier. 

-  Pepper's  System  of  .Medicine,  vol.  ii..  page  1168. 
Keating  :  Cyclopaedia  of  Diseases  of  Children,  voL  iii.,  page  280, 
and  214. 

'  •  ozzi :  Medical  and  Surgical  Gynecology,  vol.  ii.,  page  216. 

'■'  Warren  :  Surgical  Pathology  and  Therapeutics,  page  572. 

'  Johns  Hopkins  Hospital  Report  for  1890,  quoted  by  Pozzi. 

"  American  Text  boolc  of  Gynecology. 


son  Tait '  says,  "the  great  majority  of  cases  are  cured 
by  these  simple  means."  According  to  Morris,-  eighty 
per  cent,  of  these  cases  are  cured  by  exposing  the  peri- 
toneal cavity  to  the  air. 

It  is  of  much  interest  to  inquire  why  so  simple  a  treat- 
ment produces  such  radical  changes  in  this  disease. 
Whether  the  curative  action  is  due  to  the  removal  of 
the  ascitic  fluid,  or  the  removal  of  the  ptomaines  of 
the  bacilli,  or  because  the  bacteria  of  putrefaction  pro- 
duce a  toxalbumin  which  is  fatal  to  the  tubercle  bacilli 
in  the  peritoneum,  or  because  of  the  action  of  the  light, 
dryness,  and  air  exerted  during  the  removal  of  the  fluid, 
it  is  difficult  to  say.  "  The  absorbent  action  brought 
about  by  traumatic  inflammation,  so  common  elsewhere, 
may  make  itself  felt  on  such  an  occasion,  and  it  may 
favor  the  removal  of  the  broken-down  products  of 
the  disease  "  (Warren).  Undoubtedly  the  removal  of 
the  fluid  and  other  irritating  products  leaves  the  per- 
itoneum in  a  condition  to  remove  the  products  of  in- 
flammation and  thus  favor  fibroid  changes,  or  to  the 
"  reaction  processes,"  round-celled  infiltration,  phago- 
cytosis, active  connective-tissue  development. 

As  has  been  mentioned  before,  the  cases  most  likely 
to  be  benefited  by  operation  are  those  similar  to  the 
one  presented  above,  and  also  those  accompanied  with 
considerable  exudation,  either  free  or  encysted.  Such 
cases  are  most  likely  to  be  primary  in  the  peritoneum, 
the  chances  of  general  infection  are  less,  and  the  gen- 
eral condition  of  the  patient  is  usually  better.  In  cases 
with  purulent  exudation  and  large  caseous  masses  in 
the  peritoneum  the  prospect  for  recovery  is  less  hope- 
ful, but  many  cures  are  recorded,  and  surprising  results 
often  follow  abdominal  section  in  these  cases. 

In  chronic  adhesive  or  dry  tubercular  peritonitis, 
when  there  is  little  or  no  serum  or  purulent  exudate, 
and  the  coils  of  intestines  are  matted  together,  with 
probably  enlarged  caseous  masses,  little  or  no  benefit 
can  be  expected  to  follow  an  operation. 

Tuberculosis  is  a  common  cause  of  peritonitis  in 
children.  Ashby,  in  105  autopsies  in  children  dead  of 
tuberculosis,  found  tubercles  in  the  peritoneum  in  38 
cases,  and  of  127  cases  of  tuberculosis  noted  by  Wood- 
head,  caseation  of  the  mesenteric  glands  was  found  in 
100  cases,  or  seventy-nine  per  cent.  The  general  treat- 
ment will  not  be  discussed  here,  as  it  is  on  the  same 
plan  as  that  of  tuberculosis  elsewhere  in  the  body. 

The  results  which  have  been  obtained  by  incision 
and  drainage  are  very  encouraging,  demonstrating  the 
impunity  with  which  the  abdominal  cavity  can  be 
opened  in  children,  and  proving  that  a  large  percent- 
age can  be  benefited,  and  some  cured,  by  an  opera- 
tion. Successful  cases  have  been  reported  by  Treves,^ 
Knaggs,  Clarke,  Conitzer,'  and  many  others. 

The  figures  given  by  Aldibert  are  exceedingly  inter- 
esting. Of  the  52  cases  in  which  laparotomy  was  per- 
formed in  children,  there  were  45  recoveries  and  7 
deaths  ;  of  these  45,  9  had  lived  for  more  than  one 
year,  and  2  for  more  than  two  years.  Of  32  cases  of 
laparotomy  performed  for  ascites,  there  were  29  recov- 
eries and  3  deaths  ;  4  had  lived  for  more  than  one  year. 
In  the  ulcerative  variety,  if  the  process  is  generalized, 
the  results  are  not  so  satisfactory,  and  it  also  appeared 
from  a  study  of  these  cases  that  in  the  chronic  adhesive 
form  an  operation  is  hardly  indicated,  as  in  the  major- 
ity of  cases  nature  is  healing  the  tubeiculosis  ;  but  even 
here,  where  there  is  much  pain  associated  with  adhesion, 
cases  have  been  relieved  by  an  exploratory  incision. 

It  is  to  be  remembered,  however,  that  cases  both  in 
adults  and  children,  if  the  symptoms  are  not  urgent, 
and  the  patient's  strength  is  not  failing,  good  authority 
advises  us  not  to  interfere  surgically,  but  to  treat  the 
case  by  medical  measures  and  to  wait  on  nature's  ef- 
forts to  effect  a  return  to  health.' 

'  Edinburgh  Medical  Journal  for  June,  1889 
•-■  Mkdicai,  Kecokd.  October  6,  1894. 
'  Lancet.  November  5,  1887. 

*  Deutsche  med.  Wochenschrift,  1893.  No.  29. 

*  American  Text-book,  Diseases  of  Children. 


592 


MEDICAL    RECORD. 


[October  26.  1895 


Other  methods  of  treatment  have  been  practised — 
thus  Rendu  '  has  used,  wth  apparent  success,  cam- 
phorated naphthol.  After  draining  off  seven  litres  of 
ascitic  fluid,  he  injected,  through  the  cannula,  still  in 
the  abdominal  cavity,  ten  grains  of  camphorated  naph- 
thol ;  his  patient  completely  recovered.  Beck,  in  a 
paper  read  before  the  Eleventh  International  Medical 
Congress,  reports  five  cases  treated  by  injecting  into 
the  peritoneal  cavity  iodoform,  one  part,  and  glycerine, 
ten  parts.  Of  the  cases  treated  by  this  method  only 
one  resulted  fatally,  the  others  were  apparently  cured. 


'^TCOQtzss  of  pXetltcaX  Science. 

Puncture  of  the  Spinal  Meninges. — Professor  Ftir- 
bringer  states  that  he  has  now  punctured  the  mem- 
branes more  than  100  times  in  86  cases.  The  pro- 
cedure is  easy.  He  recommends  that  the  patient  should 
sit  up,  at  the  same  time  bending  well  forward,  and  that 
the  needle  be  introduced  on  a  level  with  the  under  sur- 
face or  exact  extremity  of  the  spinous  process.  An 
anaesthetic  is  unnecessary.  Sometimes  the  aspiration 
of  the  fluid  was  found  to  cause  pain  in  the  neck,  back, 
or  head,  so  that  the  author  uses  the  Pravaz  syringe  al 
most  exclusively.  The  amount  of  fluid  withdrawn 
varied  from  a  few  drops  to  no  c.c.  The  amount 
evacuated  does  not  always  correspond  to  the  amount 
present  or  to  the  pressure.  Occasionally  a  bloody  or 
blood-stained  fluid  was  withdrawn.  Once,  owing  to 
pain  in  the  legs,  it  was:  hought  that  a  nerve-root  had 
been  pierced.  In  four-fifths  of  37  cases  of  tuberculous 
meningitis  the  diagnosis  was  established  with  certainty 
by  the  presence  of  tubercle  bacilli.  Improvement  is 
so  rare  that  any  curative  action  can  hardly  be  thought 
of.  In  the  author's  opinion  the  symptom  complex  of 
this  disease  is  not  in  any  great  measure  the  direct  re- 
sult of  increased  pressure.  In  2  cases  with  meningeal 
symptoms  in  which  no  tubercle  bacilli  were  found,  the 
after-examination  showed  a  serious  meningitis.  In  i 
case  of  chronic  hydrocephalus  the  fits  lessened  after 
the  puncture  ;  the  necropsy  eventually  showed  the 
hydrocephalus  to  be  due  to  a  tuberculous  nodule  in 
the  cerebellum.  In  i  case  pus  was  withdrawn.  In 
3  'cases  of  cerebral  tumor  there  was  slight  improve- 
ment in  the  headache  in  one  case.  There  was  but 
slight  change  in  a  second  case,  which  subsequently  re- 
covered under  antisyphilitic  treatment.  In  a  third  case 
sudden  death  occurred  the  day  after  the  puncture.  In 
a  fourth  case,  much  improved  by  trephining,  lumbar 
puncture  was  practised  owing  to  a  relapse.  The  symp- 
toms improved  slightly,  but  death  occurred  twenty-four 
hours  later.  It  cannot  be  said  whether  the  puncture 
had  anything  to  do  with  the  sudden  deaths.  In  two 
ursemic  cases  90  and  50  c.c.  of  fluid  were  withdrawn 
without  result.  In  one  case  of  cerebral  hemorrhage 
with  rupture  into  the  ventricles  blood  was  withdrawn, 
as  well  as  in  a  case  of  hemorrhage  into  the  cerebellum 
rupturing  into  the  fourth  ventricle.  P'or  diagnostic 
purposes  spinal  puncture  is  most  valuable  in  tuber- 
culous meningitis  and  when  pus  is  withdrawn.  In 
hemorrhages  into  the  ventricles  or  subarachnoid  space 
it  may  also  be  of  service.  Therapeutic  results  are 
either  absent  or  only  rarely  to  be  seen. — Berliner  Klin- 
ische  Woihnnchrift. 

Antral  Empyema  of  Tuberculous  Origin. — A  case  of 
antral  euipyema,  ajiparently  of  tuberculous  origin,  is 
recorded  by  J.  Kekwick  {British  Medical  Journal). 
The  patient,  a  woman,  aged  thirty,  complained  of  the 
usual  symptoms  indicative  of  antral  empyema.  The 
left  upper  second  bicuspid  was  extracted  and  a  free 
opening  into  the  antrum  made  through  the  socket. 
For  twelve  months  local  treatment  combined  with 
change  of  air  and  ihe  administration  of  tonics  was  car- 

'  Bulletin  Medic.il,  Ko.  86,  1893. 


ried  out,  but  to  no  avail,  the  patient's  condition  remain- 
ing practically  unchanged.  The  pus  being  of  a  curdy 
character  and  the  history  of  the  patient  led  to  a  sus- 
picion of  tubercle,  etc.,  and  on  the  discharge  being  ex- 
amined microscopically,  the  tubercle  bacillus  was  found 
in  large  quantities.  Constitutional  treatment  for  tuber- 
cle, combined  with  the  insufflation  into  the  antrum 
every  day  of  powdered  iodoform,  led  to  rapid  improve- 
ment in  the  patient's  condition,  the  discharge  becoming 
less  and  the  hectic  condition  which  the  patient  had 
commenced  to  acquire  being  lost.  The  following  rea- 
sons are  given  in  support  of  the  diagnosis  :  i.  The 
chronic  course  of  the  case,  with  no  local  causes,  such 
as  loose  sequestra  ;  2,  the  tuberculous  character  of  the 
pus  ;  3,  the  amenability  of  the  disease  to  iodoform  ;  4. 
the  history  of  the  patient  (uncle  died  from  phthisis  : 
sisters  suffering  from  phthisis  ;  no  signs  of  tubercle  in 
the  patient  herself,  but  a  queried  history  of  tuberculous 
cervical  glands — cicatrices)  ;  and  5,  the  bacilli  in  the 
pus  which  was  washed  directly  out  of  the  antrum 
through  the  nose. 

Acute  Non-suppurative  Encephalitis. — Dr.  Oppen- 
heim  believes  that  the  separation  of  the  non-suppura- 
tive  from  the  suppurative  disease  is  most  important. 
The  etiology  of  the  hemorrhagic  form  of  the  disease  is 
not  always  the  same.  By  some  it  has  been  attributed 
to  alcohol,  by  others  to  influenza,  and  there  are  a  num- 
ber of  cases  of  no  known  etiology.  It  begins  with 
severe  symptoms,  but  usually  runs  a  favorable  course 
The  author  gives  short  details  of  five  cases  observed  by 
him,  all  of  which  recovered.  Three  cases  were  acute, 
occurring  respectively  in  girls  aged  sixteen  and  ten, 
and  in  a  young  woman.  In  two  subacute  cases  in  a  girl 
aged  twelve,  and  a  man  aged  twenty-one.  the  lesion  lay 
in  the  floor  of  the  fourth  ventricle,  and  a  complete 
ophthalmoplegia  developed  itself.  In  none  of  these 
cases  was  there  any  evidence  of  syphilis.  In  the  litera- 
ture of  this  disease  the  prognosis  has  not  always  been 
looked  upon  as  very  favorable,  but  in  recent  writings 
recoveries  have  been  noted.  The  author's  experience 
has  been  most  favorable.  Polioencephalitis  must  be 
distinguished  from  disseminated  sclerosis,  which  not 
very  rarely  takes  an  acute  form  and  which,  according 
to  the  author,  may  end  in  complete  recovery.  Acute 
course,  rapid  development,  high  temperature,  etc.,  are 
unfavorable  signs,  whereas  low  temperature  and  a  pro- 
tracted course  make  the  outlook  favorable. — Central- 
Matt  fiir  innere  Mcdicin. 

Physometra  or  Tympanites  Uteri. — Dr.  Hermes  ob- 
served this  condition  in  a  ])rimipara,  aged  thirty-seven, 
and  syphilitic.     The   child    had  evidently  died  some 
time   before  labor,  which   listed  over  five  days,  and 
was    mismanaged    {British    Medical   Journal^.       The 
child's  thigh  was  broken  in  an  attempt  to  deliver  with 
the  blunt  hook.      The  practitioner  sent  the  patient  into 
hospital.     She  was  in  a  sinking  condition,  the  abdo- 
men greatly  distended.     The  perineum  was  torn.      The 
pelvis  was  slightly  contracted   in   all  diameters.     On 
passing  the  finger  into  the  os  a  great  quantity  of  fetid 
gas  escaped.      The  child,  very   large,   and  in   an    ad- 
vanced  state  of  decomposition,  was  extracted.      The 
placenta,  quite  putrid,  had  to  be   removed  manually. 
The  uterus  contracted  bodily  :  it  was  carefully  washed 
out  with  a  solution  of  carbolic  acid  at  i::2°  F.     There 
was  no  severe  flooding.     The  patient  died  about  one 
hour  after  delivery.      There  were  no  air  emboli,  said  to 
be  the  main  cause  of  fatal  results  in  tympanites  uteri.    1 
There  was    perimetritis.     I'nder  the  endocardium  in    j 
the  left  ventricle  wereabundant  ecchymoses  ;  the  peri-    I 
cardium  contained   a  considerable  amount  of  serum.    \ 
The   fetid  air  which  issued   from   the  uterus,  clearly    1 
came  from  the  dead  fanus.     The  frequent  attempts  to    | 
deliver,  badly  followed  up,   admitted   air  and  germs    j 
from  without.     In  other  cases  it  has  been  found,  that   I 
when  the   foetus   had    died   quite  recently,    fetid    gas    i 
rapidly  collects  if  air  be  admitted  into  the  uterus.  I 


October  26,    1895] 


MEDICAL    RECORD. 


59; 


Medical    Record: 

A  Weekly  yotcrnal  of  Medicine  and  Surgci-y. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth   Street 


New  York,  October  26,  1895. 


THE  REORGANIZATION  OF  THE  CITY  HOS- 
PITALS. 

The  recent  reorganization  of  the  attending  staffs  of  the 
different  city  hospitals  by  the  Commissioners  of  Chari- 
ties and  Correction  has  naturally  given  rise  to  much 
discussion  in  medical  circles.  Considering  the  radical 
changes  effected,  the  manner  in  which  they  have  been 
made,  and  the  apparent  motives  that  actuated  them,  it 
is  no  more  than  could  have  been  expected.  In  order  to 
understand  the  wide-spread  character  of  the  movement 
and  the  many  different  interests  involved,  it  is  only 
necessary  to  state  that  the  Commissioners  have  directly 
under  their  charge  a  large  number  of  important  hospi- 
tals, namely,  Bellevue,  Gouverneur,  Fordham,  City 
Hospital,  the  Workhouse  and  Almshouse  and  the 
Randall's  Island  Hospitals,  besides  the  Maternity  Hos- 
pital and  the  Hospital  for  Nervous  Diseases,  which  are 
in  close  relations  with  the  City  Hospital  proper,  or,  as  it 
used  to  be  known,  the  Charity  Hospital.  The  medical 
appointments  to  these  institutions  are  entirely  under 
the  control  of  this  Department  of  Charities,  and  the 
various  attending  staffs  hold  their  positions  at  the 
pleasure  of  the  appointing  power.  While  much  can 
truthfully  be  said  of  the  political  elements  entering  into 
these  appointments,  the  latter,  of  late  years  especially, 
have  in  the  main  met  with  a  general  approval  by  the 
profession.  The  desirability  of  the  positions,  particu- 
larly those  of  Bellevue,  in  affording  clinical  facilities, 
tempted  the  various  medical  colleges  to  fight  for  what 
they  considered  their  rights.  By  skilful  wire-pulling 
and  the  ostensible  exhibition  of  a  charitable  and  gen- 
erous rivalry  in  promoting  the  interests  of  medical  edu- 
cation, the  Commissioners  were  forced  to  make  a  deal 
with  the  colleges,  and  give  them  the  lion's  share  of  the 
patronage.  This  much  was  done  with  Bellevue,  and  to  a 
certain  extent  with  old  Chatity.  It  was  then  agreed,  as  a 
forced  compromise,  that  each  of  the  three  colleges  should 
have  an  equal  share  in  three-fourths  of  the  available  po- 
sitions, while  the  profession  at  large  should  have  the  re- 
maining quarter.  The  colleges  named  their  candidates 
when  vacancies  occurred  in  their  respective  divisions, 
and  the  appointments  were  made  accordingly.  The 
remainders,  who  represented  the  profession  at  large, 
skirmished  around  as  best  they  could,  and  meekly 
dodged  into  the  few  places  left. 

It  appeared  to  be  a  necessity  of  the  situation  that 
Bellevue  should  be  so  delivered  to  college  privileges, 
particularly  as  two   of  the  latter  institutions   were   in 


such  close  and  convenient  neighborhood  to  the  hos- 
pital. Meanwhile  the  positions  in  the  other  hospitals 
of  the  department  were  apportioned  indiscriminately  to 
different  applicants  with  as  much  fairness  as  could  be 
expected  under  the  conditions  of  political  pull  and 
ordinary  professional  fitness.  At  all  events  the  appoint- 
ments were  generally  acceptable  to  the  profession,  and 
fairly  represented  its  distributive  interests.  These  latter 
gentlemen  did  their  work  well,  and  there  was  no  ap- 
parent cause  for  any  complaint  on  the  part  of  the  Com- 
missioners, save  that  a  few  of  the  bolder  spirits  in  dif- 
ferent medical  staffs  rightfully  protested  against  the  bad 
food  supplied  to  the  patients,  and  the  want  of  suitable 
appliances  for  the  proper  treatment  of  their  diseases. 
Such  men  were  either  promptly  dismissed  or  snubbed 
into  submission  by  unnoticed  appeals. 

Now,  with  an  ostensible  awakening  to  the  necessities 
of  the  reforms,  so  long  delayed  and  so  urgently  re- 
quested by  the  different  medical  attendants,  it  has  been 
decided  by  the  Commissioners  to  make  a  clean  sweep 
along  the  whole  line,  declare  all  places  vacant,  and 
model  the  patronage  of  all  the  hospitals  on  the  Bellevue 
plan.  This  gives  the  three  colleges  three-fourths  of 
the  patronage  of  appointments  to  all  these  hospitals, 
and  the  profession  at  large  but  one-fourth. 

In  the  matter  of  equitable  representation  of  interests 
it  is  not  difficult  to  estimate  the  justice  of  the  so-called 
reform.  If  we  mistake  not,  the  voice  of  the  profes- 
sion of  this  city  will  yet  be  heard  in  no  uncertain 
sound  of  earnest  protest  against  the  position  taken  by 
the  Commissioners.  While  willing  to  accept  the  situa- 
tion for  Bellevue  proper,  there  is  no  good  reason,  even 
on  the  score  of  better  or  more  available  clinical  teaching, 
for  expanding  such  a  policy  to  the  other  hospitals.  The 
Commissioners  may  yet  learn  to  their  sorrow  that  the 
large  majority  of  competent  medical  men  not  connected 
with  t'ne  colleges,  have  some  rights  for  proper  represen- 
tation, which  may  yet  command  respect  when  the  de- 
partment itself  is  reorganized  and  new  appointments  in 
its  own  board  are  to  be  made. 

This  entirely  unnecessary,  unjust,  and  discourteous 
removal  of  medical  men  from  positions  they  have  so 
acceptably  filled,  involves  a  great  deal  more  than  the 
question  of  the  outs  against  the  ins.  It  is  an  arrogant 
assumption  of  partiality  by  the  Commissioners  that  de- 
serves a  becoming  rebuke.  Every  medical  man  who  is 
not  directly  connected  with  a  college  consistently  asks 
why  so  much  favor  is  shown  such  institutions,  and  so 
little  to  the  profession  at  large.  Are  the  colleges  them- 
selves altogether  innocent  in  the  matter  ? 


Statistics  of  the  Antitoxin  Treatment  of  Diphtheria 
in  Berlin. — Dr.  Behring  has  recently  published  a  com- 
parison of  the  results  of  the  treatment  of  diphtheria  in 
two  of  the  Berlin  hospitals.  In  the  Charite,  where 
antitoxin  was  employed,  there  were  299  patients  with 
t^2,  deaths,  or  17.7  per  cent.  ;  in  the  Bethania  Hospital, 
where  antitoxin  was  excluded,  there  were  249  patients 
with  112  deaths,  or  forty-five  per  cent. 

Strychnine  Delirium. — An  item  with  this  title  appear- 
ing in  a  recent  issue  should  have  been  credited  to  the 
Therapeutic  Gazette.  Through  inadvertence  this  credit 
was  not  given. 


594 


MEDICAL   RECORD. 


[October  26,  1895 


RECKLESS  SELF-DOSING. 

A  RECENT  death  in  this  city,  directly  traceable  to  self- 
dosing  with  nitrite  of  amyl,  serves  to  emphasize  once 
more  what  we  have  so  often  insisted  upon,  the  danger 
in  lay  people  prescribing  for  themselves  and  for  each 
other.  In  no  other  condition  of  life  is  a  little  knowl- 
edge a  more  dangerous  thing,  and  yet  in  none  is  this 
little  knowledge  presumed  upon  to  a  more  reckless 
extent  than  in  the  treatment  of  disease.  Sensible  and 
prudent  men,  who  would  never  think  of  writing  their 
wills  or  even  of  signing  a  lease  without  consulting  a 
lawyer,  will  yet  take  large  doses  of  antipyrin  or  of 
some  equally  dangerous  drug  if  they  have  but  a  slight 
bilious  headache.  Even  babies  are  dosed  with  sooth- 
ing sirups  compounded  of  opium  and  other  poisons, 
and  of  late  years  the  drug  which  forms  the  text  of  this 
warning,  nitrite  of  amyl,  has  acquired  a  most  alarming 
popularity  with  the  mothers  of  croupy  children. 

The  responsibility  for  this  practice  of  self-dosing 
often  rests  upon  the  physician,  who  puts  a  remedy  into 
the  patient's  hands  with  directions  to  use  it  as  occasion 
arises.  In  this  way  the  patient  acquires  a  knowledge 
of  one  of  the  effects  of  the  drug,  and  when  another 
person  presents  symptoms  which  seem  to  be  in  some 
respects  similar  to  his  own,  he  at  once,  with  that  pecul- 
iar passion  for  prescribing  that  has  become  an  instinct 
of  the  human  race,  recommends  the  new  medicine 
which  had  helped  him.  The  other  takes  it  and  be- 
comes in  his  turn  a  new  centre  of  self-dosing  infection. 
But  even  if  the  administration  of  the  drug  went  no 
further  than  the  first  patient,  the  physician  takes  a" 
grave  responsibility  upon  himself  who  gives  a  poison  to 
a  person  ignorant  of  its  dangers  with  permission  to  take 
it  whenever  his  own  judgment  regards  it  as  indicated. 

It  is  quite  true  that  nitrite  of  amyl  will  relax  spasm, 
and  if  this  were  its  only  action  it  might  be  safely  and 
pleasantly  employed  to  put  an  end  to  the  distress  of  an 
infant  gasping  for  the  breath  cut  off  by  laryngeal 
spasm.  But  unfortunately  the  drug  is  a  powerful 
spinal  and  heart  poison,  the  action  of  which  is  evanes- 
cent, it  is  true,  yet  so  rapid  that  death  may  be  caused 
almost  instantaneously,  before  any  antidote,  even  were 
such  at  hand,  could  act.  And  yet  physicians  have 
actually  given  this  violent  poison  to  mothers  to  use 
on  their  babies  during  an  attack  of  whooping-cough,  or 
of  laryngeal  spasm  from  any  other  cause  !  It  is  little 
wonder,  when  physicians  are  so  reckless,  that  laymen 
come  to  think  they  too  can  prescribe  drugs  as  though 
they  were  chocolate  drops  or  maple  sirup. 


muscular  affection,  being  often   described   as  a  rheu- 
matic  myositis.     Dr.  Robin  bases   his  theory   of  the- 
articular  nature  of  the  trouble  upon  a  number  of   facts, 
of  which  we  can  only  summarize  a  few  :  He  says,  in 
the  first  place,  that  the  points  of  greatest  pain  are  usu- 
ally in  the  median  line  over  the  vertebrae,  or  else  over 
the  sacro-iliac   junctions.     He  calls  attention   also  to 
the  fact  that  the  position  of  the  patient  is  such  as  would 
not  be  easily  tolerated  if  the  muscles  were  mainly  at 
fault.     The  sufferer  stands  with  the  body  bent  slightly 
forward,   sometimes   bending  to   one  side,  a  position 
which  would  put  the  erector  muscles  of  the  back  in  a 
state    of   tension    that   should   be  uncomfortable   and 
painful.    On  the  other  hand,  this  position  is,  he  thinks, 
best  adapted  to  relieve  the  articular  surfaces  from  press- 
ure.    The  muscles  themselves,  also,  he  states,  are  usu- 
ally less  painful   than  the  joints.     Dr.  Robin's  reason- 
ing is  ingenious,  and  we  believe  that  there  can  be  no 
doubt  but  that  in  many  cases,  at  least,  the  joints  and 
their  supporting  ligaments  are  really  the  most  at  fault. 
The  more  practical  point  connected  with  this  subject 
is  that  of  the  treatment  of  lumbago.     In  most  cases,  of 
course,  patients  get  well  rather  promptly  by  simply  be- 
ing put  in  bed,  kept  warm,  and  their  sjTiiptoms  relieved 
by  local  applications  and  the  milder  anodyne  remedies. 
The  old-fashioned  treatment  of  a  piece  of  flannel  and 
a  hot  flat-iron  still  has  its  advocates.     Electrical  appli- 
cations, blisters,   and  various  forms  of  counter-irrita- 
tion also  are  useful.     Robin  asserts,  however,  that  he 
has  discovered  a  drug  which  he  thinks  has  a  certain 
specific  action  on  lumbagoes,  namely,  jaborandi.     In 
acute  cases,  and  in  many  of  the  more  chronic  forms, 
the  use  of  the  infusion  of  the  leaves  is  attended,  accord- 
ing to  this  writer,  with  the  greatest  success.     He  gives 
the  infusion  of  the  leaves,  a  form  of  preparation  which 
we  believe  is  rarely  employed  in  this  country.     This 
infusion  is  taken  in  the  morning,  and  repeated  in  a  day 
or  two,  if  needed.    It  produces  profuse  perspiration  and 
salivation,  with,    in    acute   cases,  immediate   relief  of 
symptoms.     In  the  more  chronic  cases  the  dose  is  to 
be  repeated  three  or  four  times.     We  see  no  reason 
why,  if  the  drug  is  really  valuable,  the  simpler  prepara- 
tions, such  as  pilocarpin  or  the  fluid  extract,  should 
not  prove  equally  serviceable.     Dr.  Robin  cautions  his 
readers  against  the  use  of  this  drug,  however,  in  all 
cases  where  there  is  anj'  heart  lesion. 


THE  NATURE  AND  TREATMENT  OF  LUM- 
BAGO. 

A  YEAR  ago  Dr.  Albert  Robin,  of  Paris,  published  an 
article  in  collaboration  with  Dr.  Londe  in  the  Rei'ue  de 
Mc'decine,  in  which  he  contended  that  lumbago  and 
many  cases  of  torticollis  were  articular  affections, 
rather  than  muscular.  He  returns  to  this  subject  in 
a  current  issue  of  the  Bulletin  GlnJral  de  Thirapeu 
tique.  The  view,  as  he  admits,  is  not  entirely  origi- 
nal with  him,  but  he  asserts  correctly  that  most 
authorities  look  upon  lumbago,  at  least,  ^s  essentially  a 


ALLEGED    FAILURE    OF    NEW    YORK   CON- 
SULTING   PRACTICE. 

It  will  furnish  some  wonder,  and  perhaps  amusement, 
to  New  York  physicians  to  learn  that  the  medical  papers 
are  publishing  editorials  and  various  comments  upon 
the  fact  that  the  New  York  consulting  practice  has  be- 
come a  failure  ;  that  many  consultants  who  have  had 
large  practices  have  lost  them  gradually  but  well-nigh 
completely. 

There  are  ups  and  downs,  in  the  course  of  the  con- 
sulting practice,  in  all  great  centres  of  population.  At 
one  time,  probabh-,  the  consulting  gynecologist  had  a 
larger  share  of  work,  proportionally,  than  he  does  now, 
and  this  may  be  true  of  some  other  branches  of  medi- 
cine, especially  among  young  men  who  started  life  as 


October  26,  1895]' 


MEDICAL    RECORD. 


595 


consulting  specialists  ;  but  where  the  consulting  prac- 
tice diminishes  in  one  direction  it  increases  in  another, 
and,  taking  it  upon  the  whole,  we  presume  that  there  is 
probably  more  consulting  work  done  now  in  New  York 
than  there  ever  has  been  in  the  past  history  of  the  city. 
The  work  of  the  general  consultant,  who  is  called  upon 
for  diagnosis  and  help  in  all  kinds  of  diseases,  has  cer- 
tainly not  fallen  ofif,  as  those  who  are  acquainted  with 
the  few  men  in  this  city  who  make  general  consultation 
a  specialty  can  abundantly  testify. 

Meanwhile  the  general  practitioner  is  doing  as  well 
as  can  be  expected  in  a  city  of  wealthy  dispensaries  and 
palatial  hospitals. 


ANOTHER    MEDICAL    POET. 

Our  French  contemporaries  celebrate  in  somewhat 
doubtful  praise  the  poetical  work  of  Jean  Labor,  M  D. 
Dr.  Labor,  unlike  a  good  many  medical  men  who  are 
poets,  indeed,  unlike  most  medical  men  who  are  real 
poets,  selects  largely  medical  topics  for  his  artistic  la- 
bors. We  note  a  poem  called  "  Songs  of  Love  and 
Death,"  and  another,  the  "  Drunkenness  of  the  Lovers," 
a  poem  on  the  "  Hospital,"  and  a  good  many  poems 
which  have  a  bearing  on  emotions  connected  with  cer- 
tain physiolQgical  conditions. 

"  Be  then  drunk,  oh,  my  soul,  and  be  always  drunk," 

sings  Dr.  Labor. 

"  It  is  only  illusion  that  makes  things  beautifnl," 

he  adds. 

"  My  thought  is  serene  and  my  dream  perfumed. 
Like  the  happy  chamber  where  my  true  love  died," 

is  another  exquisite  but  not  very  loyal  verselet  of  the 
poet.  The  professional  poem  about  the  "Hospital" 
seems  to  be  in  much  the  same  cheerful  spirit.  The 
Hospital,  according  to  the  doctor,  consists  of  children 
who  suffer  because  they  were  bom,  women  who  die  be- 
cause they  had  to  bear  them,  men  who  are  howling  as 
though  they  were  damned,  and  all  begging  for  death 
and  extinction  of  suffering.  Dr.  Labor  seems  to  have 
gathered  all  that  is  unpleasant  and  pathological  and 
pessimistic  in  his  medical  studies,  and  turned  it  into 
most  depressing  rhymes.  For  our  part,  we  hope  when 
doctors  turn  poets  they  will  take  a  little  more  as  mod- 
els the  late  Dr.  Holmes,  or  the  still  later  Dr.  Oliver 
Goldsmith.  It  is  better  to  be  a  very  healthy  and  happy 
poet  than  to  be  an  extremely  great  one,  if  the  great- 
ness is  so  intertwined  with  the  pathological. 


Typhoid  Fever  Prevails  to  an  Unusual  Degree  in 
Toronto,  due,  apparently,  to  the  fact  of  an  insufficient 
supply  of  pure  water.  According  to  the  returns  of  the 
Board  of  Health,  during  the  first  fifteen  days  of  the  pres- 
ent month,  there  were  77  cases  of  typhoid  fever  against 
29  in  the  whole  month  of  October  last  year,  and  27 
in  October,  1893.  There  are  many  patients  suffering 
from  typhoid  fever  at  the  different  hospitals.  .^t 
Grace  Hospital  there  are  36,  at  St-  Michael's  22.  and 
at  the  General  40  cases. 


^eitrs  of  tUt  "^tcek. 

Eeorganization  of  the  City  Hospitals. — The  following 
is  the  text  of  the  resolutions  adopted  by  the  Commis- 
sioners of  Charities  and  Correction,  and  providing  for 
the  reorganization  of  the  city's  hospitals  : 

Resolved,  That  the  College  of  Physicians  and  Surgeons, 
the  University  Medical  CoUege,  the  Bellevue  Hospital 
Medical  College,  and  the  Fourth  Di\-ision  of  Bellevue 
Hospital  be  requested  each  to  nominate  one  physician 
and  one  surgeon,  who  shall  constitute  the  consulting 
staff  of  Belle\'ue  Hospital,  and  who  shall  be  members 
of  the  Medical  Board  of  Bellevue  Hospital,  but  without 
service  in  Bellevue  Hospital  proper. 

Resolved,  That  the  Consulting  and  Medical  Boards 
of  the  Gouvemeur  Hospital,  the  Fordham  Hospital,  the 
City  Hospital,  the  Maternity  Hospital,  the  Hospital  for 
Nervous  Diseases,  the  Workhouse  and  Almshouse  and 
Incurable  Hospitals,  and  the  Randall's  Island  Hospital 
be  and  are  hereby  abolished,  to  take  effect  November 

I,  1895- 

Resolved,  That  the  College  of  Physicians  and  Sur- 
geons, the  University  Medical  College,  the  Bellevue 
Hospital  Medical  College,  and  the  Fourth  Division  of 
Belle\-ue  Hospital  be  requested  each  to  make  the  fol- 
lowing nominations,  which,  when  confirmed,  shall  take 
effect  on  November  i,  1S95  : 

1.  For  the  Gouvemeur  Hospital,  one  physician 
and  one  surgeon  each,  making  a  Medical  Board  of 
eight. 

2.  For  Fordham  Hospital,  one  physician  and  one 
surgeon  each,  making  a  Medical  Board  of  eight. 

3.  For  the  City  Hospital,  two  physicians,  one  sur- 
geon, one  genito-urinary  surgeon,  one  gynecologist, 
one  ophthalmologist,  and  one  dermatologist  each,  mak- 
ing a  Medical  Board  of  twenty-eight. 

4.  For  the  Maternity  Hospital,  one  obstetrician  each, 
making  a  Medical  Board  of  four. 

5.  In  the  Hospital  for  Ner\-ous  Diseases,  one  neu- 
rologist each,  making  a  Medical  Board  of  four. 

6.  For  the  Workhouse,  Almshouse,  and  Incurable 
Hospitals,  one  physician  and  one  surgeon  each,  making 
a  Medical  Board  of  eight. 

7.  For  the  Randall's  Island  Hospital,  one  physician, 
one  surgeon,  one  ophthalmologist,  and  one  dermatolo- 
gist each,  making  a  Medical  Board  of  sixteen. 

Resolved,  That  the  Medical  Board  of  Bellevue  Hos- 
pital be  and  is  hereby  constituted  a  Consulting  Board 
for  the  Gouvemeur  Hospital,  the  Harlem  Hospital,  the 
Fordham  Hospital,  the  City  Hospital,  the  Maternity 
Hospital,  the  Hospital  for  Ner\'ous  Diseases,  the  Work- 
house, Almshouse,  and  Incurable  Hospitals,  and  the 
Randall's  Island  Hospital. 

Resolved,  That  the  Medical  Boards  of  the  Gouver- 
neur  Hospital,  the  Harlem  Hospital,  the  Fordham 
Hospital,  the  City  Hospital,  the  Maternity  Hospital, 
the  Hospital  for  Neri'ous  Diseases,  the  Workhouse, 
Almshouse,  and  Incurable  Hospitals,  and  the  Randall's 
Island  Hospital  shall  be  governed  and  conducted  in 
strict  accordance  with  the  plan  of  organization  of  the 
Bellevue  Hospital  adopted  by  this  Board  on  May,  i?, 


596 


MEDICAL    RECORD. 


[October  26,   1895 


The  Hospital  Sunday  Association. — At  a  regular 
meeting  of  this  Association,  on  the  21st,  the  question  of 
uniting  with  the  Brooklyn  Association  was  discussed. 
The  Hahnemann  Hospital  has  applied  for  admission  to 
the  Association. 

Sir  Joseph  Lister  has  been  elected  President  of  the 
British  Association  for  the  Advancement  of  Science, 
which  is  to  hold  its  next  meeting  in  Liverpool. 

Professor  Hafkine  has  been  compelled,  by  ill-health, 
to  leave  India,  where  he  has  been  experimenting  with 
cholera  antitoxin.  It  is  reported  that  he  has  inoculated 
more  than  forty  thousand  persons,  and  the  results  of 
his  experiments  are  said  to  have  been  most  encourag- 
ing. 

A  Doctors'  Stable  Club. — An  organization  has  been 
formed  by  a  number  of  physicians,  residing  in  this 
city,  for  the  care  of  their  horses  and  carriages.  The 
services  of  a  carriage-maker,  a  harness-maker,  and  a 
horseshoer  will  be  engaged  for  a  fixed  monthly  sum, 
and  all  repairs  on  the  outfits  of  the  members  of  the  as- 
sociation will  be  made  by  these  men.  The  cost  of  the 
whole  service  to  each  member  of  the  association  will  be 
about  thirty  dollars  a  month. 

Women  Students  Decreasing  in  Number. — At  a  meet- 
ing of  the  Board  of  Regents  of  the  University  of 
Michigan,  held  a  few  days  ago,  President  Angell  re- 
ported that  the  attendance  of  women  at  Ann  Arbor 
had  fallen  off  in  percentage  in  the  past  two  years. 

The  Committee  on  the  Treatment  of  Leprosy,  estab- 
lished by  the  Board  of  Health  of  the  Hawaiian  Islands, 
is  composed  of  the  following  physicians  :  Drs.  C.  B. 
Wood,  President;  R.  P.  Mytrs,  Recording  Secretary  ; 
N.  B.  Emerson,  Corresponding  Secretary  ;  G.  Herbut, 
F.  R.  Day,  and  H.  N.  Howard. 

The  Medical  Association  of  the  Hawaiian  Islands. — 
The  officers  of  this  association,  elected  at  the  annual 
meeting  in  May  last,  are  :  Drs.  John  S.  McGrew,  Presi- 
dent;  Henry  W.  Howard,  Vice-President  ;  and  Robert 
P.  Myers,  Secretary. 

Practising  Homoeopathy  in  Peru.^Despatches  to  the 
daily  press  announce  the  important  fact  that  an  Ameri- 
can physician,  after  five  years  of  struggle,  has  secured 
the  right  to  practise  homoeopathy  in  Peru. 

Death  of  Dr.  Harry  B.  Conrad. — Dr.  Conrad,  of  this 
city,  died  suddenly  on  October  20th,  aged  forty-three. 
Dr.  Conrad  was  born  in  Philadelphia,  and  graduated  at 
the  University  of  New  York,  in  1877. 

Dr.  Abbey  J.  Seymour. — Dr.  Seymour,  one  of  the 
most  prominent  medical  women  of  Buffalo,  was  killed 
by  the  West  Shore  train,  on  October  17th.  Dr.  Sey- 
mour was  born  in  Batavia,  N.  Y.,  in  1853,  and  gradu- 
ated from  the  Rush  Medical  College,  of  Chicago. 

The  Fifth    International    Congress  of  Otology    has 

been  holding  its  meetings  in  Florence,  Italy,  beginning 
September  3d.  A  correspondent  of  The  Lancet  de- 
scribes the  sessions  and  the  discussion  as  being  very 
satisfactory.  Professor  Gradenigo, of  Turin,  read  a  paper 
on  the  "  General  Treatment  of  Internal  Otitis,  "  and  Dr. 


Delstanche,  of  Brussels,  a  paper  on  the  "  Employment 
of  Liquid  Vaseline  in  the  Treatment  of  Affections  of 
the  Middle  Ear."  Dr.  Macnaughton  Jones  read  an 
elaborate  paper  on  "  Hypertrophy  of  the  Turbinated 
Bones,  and  its  Relations  to  Deafness."  Dr.  T.  Barr 
read  a  paper  on  "  Treatment  of  Intracranial  Abscess 
following  Ear  Diseases,"  and  Professor  Politzer  was 
credited  with  an  original  and  "epoch-making  "  memoir 
on  the  "  Present  State  of  the  Pathological  Anatomy  of 
the  Labyrinth."  One  feature  of  the  meeting  was  an 
exhibition  of  otological  instruments  and  appliances. 
Dr.  Jones  showed  his  auto-insufflating  aural  bag  for  re- 
spired air  and  vapors,  and  also  his  magnifying  aural 
speculum  and  nasal  bougies  and  dilators  ;  also  his  tur- 
binotome and  scale  with  rule  for  operation  on  the  mas- 
toid, antrum,  temporo-sphenoidal  lobe,  and  cerebellum. 
Professor  Gradenigo  exhibited  an  original  and  inge- 
nious diapason.  The  Congress  adjourned  to  meet  next 
year  in  London. 

The  New  Pirogoff  Museum  of  Anatomy  and  Surgery 

is  now  being  erected  in  St.  Petersburg,  with  the  help  of 
the  Government  and  private  subscriptions.  While  the 
foundations  were  being  dug,  a  large  quantity  of  human 
bones  were  found  in  the  earth,  giving  a  somewhat  grew- 
some  appropriateness  to  the  selection  of  the  site.  The 
bones  are  still  a  matter  of  investigation. 

A  Poet  to  the  Doctors. — Sir  Edwin  Arnold  recently 
delivered  the  address  at  St.  Thomas's  Hospital,  on  the 
occasion  of  the  distribution  of  prizes  to  the  students  in 
the  Medical  School. 

Presentation  to  Dr.  Hughlings  Jackson.  —  At  the 
opening  day  of  the  Medical  Session  of  the  London 
Hospital  Medical  School  Dr.  Hughlings  Jackson  was 
presented  with  his  portrait  and  a  silver  ewer  and  stand. 
Sir  James  Paget  presided  and  made  the  presentation 
speech.  Sir  James  referred  to  the  statement  of  Mr. 
Jonathan  Hutchinson,  that  the  greatest  work  he 
(Hutchinson)  had  ever  done  was  to  discover  Dr.  Hugh- 
lings Jackson. 

New  York  State  Commission  on  Lunacy. — The  Sixth 
Annual  Report  of  the  State  Commission  on  Lunacy  of 
the  State  of  New  York  has  just  been  received.  It 
shows  that  there  are  now  20,000  insane  patients  under 
the  care  of  the  State  and  in  city  and  private  institu- 
tions. This  means  an  increase,  during  the  year,  of  736. 
The  cost  to  the  State  of  maintaining  the  State  hospi- 
tals for  the  year  was  $1,627,766.  This  means  a  reduc- 
tion, per  capita,  during  the  year,  of  $30  ;  in  other 
words,  it  now  costs  the  State  $184.84  yearly  to  take 
care  of  each  lunatic.  The  percentage  of  recoveries 
during  the  year  was  6.03  per  cent,  and  the  mortality 
rate  was  ten  per  cent.  Of  16,000  persons  admitted  to 
the  State  hospitals  within  the  last  six  years,  6,000  were 
foreign  born,  and  forty-four  per  cent,  were  of  foreign 
parentage.  In  the  New  York  City  Asylum  nearly 
eighty  per  cent,  were  of  foreign  parentage.  The  Cora- 
mission  recommend  that  appropriations  be  made  to 
provide  for  the  erection  on  the  grounds  of  the  State 
hospitals  of  some  buildings  designed  for  the  special- 
ized treatment  of  recoverable  cases  ;  also,  that  a  patho- 
logical laboratory  be  established  for  the  benefit  of  all 
the  State  Hospitals. 


October  26,  1895] 


MEDICAL   RECORD. 


597 


The  Medical  Register  of  New  York,  New  Jersey, 
AND  Connecticut.  New  York  Medico-Historical  So- 
ciety. John  Shrady,  M.D.,  Editor.  Vol.  xxxiii.  New- 
York  :   G.  P.  Putnam's  Sons.     1895. 

A  welcome  manual,  evidently  printed  and  bound  for  per- 
manency. It  contains,  besides  the  list  of  physicians  in  the 
three  States,  much  valuable  information  regarding  associa- 
tions, hospitals,  colleges,  and  executive  departments.  The 
chronological  record  and  necrology  cannot  fail  to  throw 
many  side-lights  upon  the  medical  history  of  the  times.  At 
all  events,  the  literary  terseness  and  compactness  of  the 
work  make  it  very  readable. 

The  Science  of  Vital  Force.  Its  Plan,  Division  of 
Function,  and  Operative  Methods  in  Health  and  Disease. 
Bv  W.  R.  Dunham,  M.D.  Boston  :  Damrell  &  Upham. 
1894. 

Interesting  and  well  written,  this  little  book  scarcely 
reaches  the  exhaustive  ideal  of  the  preface,  which  is  to 
designate  and  demonstrate  the  fundamental  principles  of 
the  science  of  vital  force,  and  also  to  revolutionize  the 
imaginary  fundamental  principles  upon  which  medical  prac- 
tice, both  regular  and  irregular,  is  based.  The  four  ulti- 
mate properties  of  vital  force,  the  author  states,  are  sensi- 
bility, instinct,  sensation,  and  contractility.  The  term 
sensibility  is  used  to  represent  certain  life  abilities  com- 
prised in  all  the  varieties  of  brain  functions  and  conscious 
intelligence.  This  vital  property  is  implied  in  the  ability  to 
command  ai«i  execute  voluntary  acts,  having  perceptive 
abilities  that  may  recognize  things,  conditions,  and  relations 
both  in  contact  with  the  organism  and  external  and  beyond 
contact.  It  superintends  all  the  voluntary  acts.  Instinct 
presides  over  involuntary  acts,  superintending  the  con- 
struction of  the  organic  body.  Sensation  is  a  vital  property 
expressed  by  certain  nerves,  whose  function  is  implied  in 
conveying  information  of  existing  conditions  and  the 
presence  of  material  contacts  both  to  sensibility  and  to  in- 
stinct. It  is  a  kind  of  telegraph,  and  was  created  for  no 
other  purpose  than  to  express  feeling  from  contact.  Con- 
tractility is  an  invisible  instrument  of  motion  in  hands  of 
both  instinct  and  sensibility.  It  is  the  animal  strength 
property.  These  four  are  the  only  properties  by  which  life 
is  carried  on.  Material  does  not  act  ;  nature — vital  force — 
does  the  acting.  It  may  act  spontaneously  or  by  invitation, 
as  from  medicine.  Medicinal  contact  causes  a  sensation, 
to  which  instinct  responds  with  an  involuntary  act.  Medi- 
cine has  no  active  principles  of  operative  influence  within 
itself;  but  its  presence  may  cause  the  involuntary  active 
vital  principle  to  act  differently.  What  constitutes  physio- 
logical action  ?  Pathological  action  ?  The  involuntary  ac- 
tive vital  principle  acting  in  relation  to  nutritive  material 
for  organic  constructive  purpose  and  for  the  elimination  of 
normal  waste  and  wornout  tissues  is  physiological  action. 
Pathological  action  is  vital  action  acting  on  surplus  nutriti\e 
material,  or  on  foreign  material  not  of  possible  use  at  the  time. 
They  are  both  manifestations  of  instinct  for  unlike  purposes. 
Dr.  Dunham's  treatment  of  his  subject  is  sincere  and  earnest. 
Evidently  the  present  exposition  of  his  views  is  intended  as 
an  introduction  to  a  larger  work. 

The  Uric-acid  Diathesis  Gout,  Sand,  and  Gravel.  By 
Dr.  F.  Levison,  Kreisarzt  in  Copenhagen.  Translated 
from  the  German  and  edited  by  Lindley  Scott.  M.A., 
M.D.,  Aberd.     New  York  :  Cassell  &  Co.     1S94. 

The  uric-acid  diathesis  has  of  late  been  the  subject  of  valu- 
able and  important  research.  These  investigations  and  a 
plan  of  treatment  based  upon  the  newer  view,  is  the  sub- 
ject of  this  interesting  and  valuable  treatise.  The  theory 
that  urea  and  uric  acid  excreted  stand  in  constant  propor- 
tion (the  normal  ratio  said  by  some  to  be  as  l  of  uric  acid 
to  33  of  urea),  is  completely  overthrown  by  the  experiments 
of  Horbaczewski,  Bleitsen,  Schultze,  Hirshfeld,  and  Bus- 
quet.  The  excretion  of  uric  acid  in  each  individual  is  a 
fairly  constant  quantity,  while  that  of  urea  has  a  wide  range 
of  variation.  There  exists,  however,  a  constant  proportion 
between  the  number  of  white  blood-corpuscles  and  the 
amount  of  uric  acid,  for  its  production  is  increased  in  a 
whole  set  of  abnormal  conditions,  characterized  by  the  forma- 
tion and  destruction  of  large  numbers  of  leucocytes,  as  leu- 
cocythaemia,  anjeniia,  pneumonia,  carcinoma,  and  exten- 
sive burns.  Certain  poisons  increase  it  :  Carbon,  monoxide, 
pilocarpine,  alcohol.     Exercise  also  adds  to  its  production 


Normally  present  in  urine,  the  author  thinks  it  will  one  day 
be  clearly  demonstrated  that  uric  acid  is  also  normally  pres- 
ent in  blood.  The  constitution  of  blood  and  urine  may  be 
so  altered  that  uric-acid  salts  are  readily  deposited  or  de- 
composed. If  not  eliminated  by  the  kidney,  the  increased 
quantity  tends  to  its  deposition  in  the  body  as  a  biurate. 
There  are  only  two  ways  in  which  this  overcharging  of  the 
blood  by  uric  acid  appears  possible  :  It  must  either  be 
formed  so  abundantly  that  some  is  stored  up  in  the  blood 
in  spite  of  the  fact  that  the  normal  quantity  is  still  excreted; 
or,  the  production  being  normal  or  even  diminished,  an  ab- 
normal quantity  is  retained  in  the  blood,  owing  to  functional 
irregularity  of  the  kidney.  Against  this  supposition  that 
retention  of  uric  acid  is  the  origin  of  gout,  the  reply  has 
been  made  that  the  disease  would  progress  quickly  and  uni- 
formly if  this  were  the  case.  Why,  when  its  production  is 
influenced  in  such  marked  degree  by  various  conditions  and 
diseased  processes,  and  when  it  may  frequently  return  to 
the  normal?  The  entire  extent  of  the  kidney  is  not  simul- 
taneously attacked,  and  the  anatomical  changes  are  very 
few,  the  primary  cause  being  a  decrease  in  the  secretory 
power  of  the  kidney,  whereby  certain  constituents  of  urine 
are  less  easily  eliminated.  Though  this  pathogenesis  of  gout 
requires  further  proof,  it  has  the  advantage  over  other 
theories  that  it  brings  into  one  category  all  the  etiological 
and  pathogenetic  factors  with  which  we  are  acquainted,  and 
gives  a  plausible  explanation  of  the  gout  of  wealth,  the  gout 
of  poverty,  and  the  gout  of  lead-poisoning.  It  also  makes 
possible  a  rational  form  of  treatment. 

Uric  Acid  as  a  Factor  in  the  Causation  of  Disease. 
A  Contribution  to  the  Pathology  of  High  Arterial  Ten- 
sion, Headache.  Epilepsy,  Mental  Depression,  Gout, 
Rheumatism,  Diabetes,  Bright's  Disease,  and  other  Dis- 
orders. By  Alexander  Haig,  M.A.,  M.D.,  Oxon., 
F.R.C.P.,  Physician  to  the  Metropolitan  Hospital,  etc. 
Second  edition,  with  thirtv-six  illustrations.  London  :  J. 
&  A.  Churchill.     1894. 

This  second  edition,  the  rt'sume  of  some  twenty-five  papers, 
is  in  a  measure  a  new  book,  as  much  of  the  earlier  work 
required  revision  in  reference  to  new  discoveries.  Instru- 
ments and  methods  receive  attention  in  response  to  requests 
from  readers  of  the  first  edition.  Dr.  Haig's  theories  are 
too  well  known  to  need  explanation,  and  his  suggestions  in 
regard  to  the  management  and  treatment  of  the  uric-acid 
diathesis  are  embodied  in  all  general  practice. 

The  Care  of  the  Baby.  A  Manual  for  Mothers  and 
Nurses.  Containing  Practical  Directions  for  the  Man- 
agement of  Infancy  and  Childhood  in  Health  and  in 
Disease.  By  J.  P.'  Crozer  Griffith,  M.D.,  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the 
University  of  Pennsylvania,  etc.  Philadelphia  :  W.  B. 
Saunders.      1895. 

The  result  of  much  experience  and  observation  here  finds 
expression  in  plain,  practical  directions  for  persons  of  in- 
telligence who  are  not  physicians.  The  right  way,  easier 
always  than  the  wrong  way.  is  clearly  emphasized  and 
made  attractive.  Dr.  Griffith's  manual  is  of  great  value  to 
the  young  and  inexperienced  mother  who  earnestly  is  seek- 
ing guidance.  In  no  sense  does  it  aim  to  take  the  place  of 
a  physician,  or  to  do  away  with  sound  medical  advice.  It 
simply  states  every-day  facts  familiar  to  all  acquainted 
with  childhood,  but  which  are  unknown  to  others.  The 
author's  object  is  to  diffuse  necessary  knowledge  in  non- 
technical form. 

The  Prevention  of  Epidemics  ;  and  the  Construction 
and  Management  of  Isolation  Hospitals.  By  Roger 
McNeill,  M.D.,  Edin.,  D.P.H.  Camb.,  etc.  With  Illus- 
trations.     Philadelphia  :   P.  Blakiston,  Son  &  Co.     1895. 

I.N  this  thoughtful  and  carefully  arranged  survey  of  an  im- 
portant subject  the  author  has  endeavored  to  bring  out 
points  that  affect  chiefly  small  towns  and  rural  districts, 
where  preventive  measures  are  far  from  being  traditions. 
As  Itfng  as  infectious  disease  spreads  in  such  localities,  it 
will  be  impossible  to  prevent  epidemics  from  breaking  out 
in  more  populous  centres.  The  term  "  isolation  hospital" 
is  used  instead  of  fever  or  infectious  hospital,  as  more  ac- 
ceptable and  conveying  the  true  meaning,  which  is  that  of 
a  sanitarium  where,  by  isolation,  the  patient  ceases  to  be  a 
source  of  danger  to  others.  The  nine  chapters  treat  re- 
spectively of  the  dissemination  of  infectious  diseases  :  the 
influence  of  effective  measures  against  the  sjiread  of  infec- 
tion ;  the  gain  to  the  community  ;  the  nature  of  infection 
and  its  influence  upon   the  construction   and   management 


598 


MEDICAL    RECORD. 


[October  26,  1895 


of  isolation  liospitals  ;  the  establishment  and  erection  of 
isolation  hospitals  ;  hospital  construction  ;  disinfection  ;  re- 
marks on  hospital  management ;  and  private  sanitary  aid 
associations.  The  appendix  contains  illustrated  plans  of 
isolation  hospitals  now  in  active  and  efficient  operation. 

The  Dyn.\MICS  of  Life.  An  Address  Delivered  before 
the  Medical  Society  of  Manchester,  October  3,  1894,  by 
W.  R.  GOWERS,  M.D.,  F.R.S.  Philadelphia:  P.  Blak- 
iston,  Son  &  Co.     1894. 

This  is  a  reprint  from  The  Lancet,  with  minor  alterations  and 
additions.  No  novelty  is  claimed  for  the  ideas  expressed. 
As  their  form  seemed  to  possess  some  freshness  when  the 
address  was  first  delivered,  they  are  now  given  to  a  larger 
audience  as  of  possible  usefulness  to  others.  "  Life  eludes 
our  search  and  resists  our  efforts.  We  may,  indeed,  trace 
the  relations  to  vitality  of  matter,  and  of  the  energy  it  bears. 
.  .  .  We  must  be  content  with  what  knowledge  we 
can  gain,  secure  or  insecure  ;  and,  while  using  it  as  best 
we  may,  should  realize,  in  all  humility,  how  much  there  is 
we  cannot  know,  yet  cannot  doubt." 

Trattato  di  Patologia  e  Terapia  Chirurgica 
^   Generale   e  Speciale.      Del   Professore  Francesco 

Durante,  Direttore  della    Clinica    Chirurgica  della  R. 

Universitk   di   Roma.     Volume   L,   Puntata  3a.    Roma  : 

Societk  Editrice  Dante  Alighieri.     1895. 

This  fasciculus  completes  the  first  volume  of  the  excellent 
surgical  manual  of  Professor  Durante.  In  the  preface  ad- 
dressed to  his  students  the  author  very  modestly  disclaims 
the  intention  of  writing  an  exhaustive  treatise  on  surgery, 
his  aim  being  to  provide  an  elementary  guide  to  surgical 
practice  suitable  for  students  and  young  practitioners  who 
are  just  beginning  their  work  in  this  art.  As  to  how  well  he 
has  done  this  we  cannot  so  readily  judge  from  this  first  vol- 
ume, which  is  of  a  general  nature,  dealmg  with  the  subjects 
of  inflammation,  surgical  fever,  traumatisms,  and  tumors. 
We  can  assert,  however,  that  the  learned  and  skilful  Roman 
professor  has  written  a  work  that  no  surgeon  who  is  famUiar 
with  Italian  can  afford  not  to  have  in  his  library,  and  in 
which  few,  no  matter  what  their  attainments,  cannot  find 
much  that  is  new  and  practically  helpful.  We  hope  before 
long  to  learn  that  English  readers  will  be  able  to  enjoy  the 
work  in  a  translation.  This  third  part,  which  is  before  us, 
deals  entirely  with  tumors. 

Statistische  Beitrage  zur  Pathologiedes  Gehoror- 
gans,  Gewonnen  aus  den  Daten  in  Bd.  i.-v.  des  Klinischen 
Jahrbuches.  Von  Paul  Kruschewskv,  M.D.  Mit  Acht 
Lithographiesten  Tafeln.    Jena:   Gustav  Fischer.   1895. 

This  is  a  most  exhaustive  collection  of  statistics  relating  to 
diseases  of  the  ear,  which  the  author  has  gathered  from  the 
first  five  volumes  of  the  Klinisches  Jahrbuch,  published  in 
Berlin,  1889-93. 

Ueber  die  Auto-intoxicationen  des  Iniesiinaltrac- 
TUS.  Von  Dr.  Albert  Albu.  I.  Assistenten  an  der 
Inneren  Abtheilung  des  Stadtischen  Krankenhauses  Moa- 
bit  in  Berlin.     Berlin  :  August  Hirschwald.     1895. 

Auto-intoxication  the  writer  defines  as  a  poisoning  of 
the  organism  through  the  products  of  its  own  metabolism, 
which  products  may  be  normal  but  in  too  great  amount,  or 
abnormal  ;  among  the  latter  arc  to  be  distinguished  those 
which  usually  undergo  a  further  change  in  the  body  and 
those  which  are  not  formed  in  the  healthy  body,  or,  if  formed 
at  all,  are  in  very  minute  quantities.  Under  this  etiological 
head  the  author  includes  a  great  variety  of  aff"ections  of  the 
blood,  nerves,  skin,  and  organs  of  the  body.  The  mono- 
graph is  well  considered  and  well  written,  and  is  one  that 
has  a  tendency  to  cause  the  reader  to  think  a  little  closer, 
and  to  speculate  a  little  for  himself.  Few  books  in  these 
times  have  the  power  to  do  that. 

Modern  Materia  Medica,  with  Therapeutic  Notes. 
For  the  Use  of  Practitioners  and  Students  of  Medicine. 
By  Dr.  OlTo  Roth.  Seventh  edition.  Revised  Uy  Dr. 
Grecor  Smith,  Director  of  the  Royal  National  and  Pro- 
vincial Board  of  Health  in  Wurzburg.  New  York  :  Will- 
iam Wood  &  Co.     1895. 

The  first  edition  of  this  popular  treatise  on  materia  medica 
formed  one  of  the  series  of  Wood's  Medical  and  Surgical 
Monographs.  The  present  is  a  translation  of  the  seventh 
edition,  recently  published  in  Germany,  and  contains  refer- 
ences to  many  of  the  newer  remedies.  The  work  is  exceed- 
ingly practical.  Very  little  space  is  occupied  with  discus- 
sions on  the  physiological  action  of  drugs,  almost  all  being 


devoted  to  the  use  of  remedies  in  disease  and  to  the  best 
modes  of  their  administration.  The  latter  are  illustrated  by 
numerous  prescriptions,  which  add  greatly  to  the  value  of 

the  work  to  the  practitioner. 

Personal  Reminiscences  and  Recollections  uf 
Forty-six  Years'  Me.mbership  in  the  Medical 
Society  of  the  District  of  Columbia,  etc.  By 
Samuel  C.  Busey,  M.D.,  LL.D.,  President  of  the  Med- 
ical Society,  Washington,  D.  C.  Svo,  pp.  373.  Wash- 
ington, D.  C.     1895. 

This  pleasantly  reminiscent  contribution  to  medical  litera- 
ture comprises,  as  its  title  indicates,  a  history  of  the  doings 
of  a  medical  society  in  Washington,  in  which  the  usual  dif- 
ferences of  opinions  as  to  ethics  and  other  matters  provoked 
much  discussion,  and  which  is  possibly  of  interest  to  some 
of  the  surviving  participants.  Outside  of  such  a  limited 
field  of  interest  it  is  difficult  to  imagine  why  the  book  was 
ever  written. 

Dr.  Bailey's  Physician's  Complete  Pocket  Account 
Book.     Chicago  :  Gross  &  Delbridge  Co. 

This  is  a  very  convenient  and  practical  account  book,  com- 
pactly arranged,  irrespective  as  to  order  of  dates,  and  for 
one  or  more  patients,  on  a  conveniently  sized  page. 

A  Manual  of  Obstetrics.  By  A.  F.  A.  King,  A.M., 
M.D.,  Professor  of  Obstetrics,  Medical  Department  of 
Columbian  University,  Washington,  D.  C.  l2mo,  pp. 
533.     Philadelphia  :   Lea  Brothers  &  Co.     1895. 

The  sixth  edition  of  this  useful  manual  within  a  compara- 
tively short  period  proves  its  popularity  and  its  well-merited 
success. 

Transactions  of  the  Semi-centennial  Meeting  of 
the  Ohio  State  Society,  May,  1895.  8vo,  pp.  47S 
Toledo:  Blade  Printing  Co.     1895. 

This  volume  contains  a  large  number  of  short,  practical 
papers  on  the  various  topics  that  interest  and  edify  the  gen- 
eral practitioner.  The  frontispiece  is  a  fine  steel  engraving 
of  the  President  of  the  Society. 

An  Introduction  to  Pathology  and  Morbid  ANAr- 
OMY.  By  T.  Henry  Green,  M.D.,  F.R.C.P.,  Physician 
and  Lecturer  on  Clinical  Medicine,  Charing  Cross  Hos- 
pital, London.  Seventh  American,  and  eighth  English, 
edition.  Revised  and  enlarged  by  H.  Mont.ague  Mur- 
ray, M.D.,  F.R.C.P.,  Physician  to  Out-patients  and  Lect- 
urer on  Pathology,  Charing  Cross  Hospital.  Svo,  pp.  598. 
Philadelphia  :  Lea  Brothers  &  Co.     1895. 

The  distinguishing  features  of  the  seventh  American  edi- 
tion of  this  work  are,  aside  from  numerous  interpolations  by 
the  editor,  made  necessary  by  the  rapid  advances  in  patho- 
logical study  ;  there  are  added  sixty  new  illustrations  and  a 
colored  frontispiece  ;  a  chapter  on  "  Diseases  of  the  Ner- 
vous System,"  by  Dr.  .Mott  :  and  a  Section  on  "  Tubercular 
Diseases  of  the  Bones  and  Joints,"  by  Mr.  Boyd.  The  gen- 
eral character  of  the  work  is  maintained  throughout,  not- 
withstanding the  numerous  additions  by  various  collabora- 
tors, as  all  have  imitated  the  admirable  conciseness  and 
lucidity  of  the  author.  From  a  practical  stand-point  the 
work  made  for  itself  long  ago  an  enviable  reputation.  No 
space  nor  words  are  wasted  in  theorizing  elaboration  of  the 
subject  in  hand,  but  the  simple  facts  and  general  principles 
are  given  in  the  fewest  possible  words  and  in  the  most  re- 
freshing perspicuity  of  style.  It  is  fair  to  say  that  few  books 
within  the  scope  of  the  present  one  could  give  a  better  idea 
of  the  present  state  of  pathology  than  the  one  in  question. 

The  Disorders  of  Speech.  By  John  Wyli.ie,  M.D.. 
F.R.C.P.  Ed.,  Physician  to  the  Royal  Infirmary,  Edin- 
burgh, etc.  F.dinburgh  :  Oliver  &  Boyd.  London  : 
Simpkin,  Marshall,  Hamilton,  Kent  &  Co.,  Limited. 

The  text  of  this  work  has  already  been  published  as  a  series 
of  articles  in  the  Edinburgh  Medical  Journal,  between  Oc- 
tober, 1891,  and  May,  1894.  The  Appendix  consists  of  (a) 
Notes  of  three  illustrative  cases  of  speech  disorders  which 
have  been  under  observation  too  recently  to  be  available 
for  the  text  of  the  work :  and  (b)  a  reprint  of  the  author's 
graduation  thesis  (1865)  on  the  physiology  of  the  larynx, 
\\  hich  was  also  published  in  the  Eiiinhiiri;h  .Ucilical  'Journal. 
There  are  twenty  chapters,  devoted  in  turn  to  stammering, 
hysterical  mutism,  aphonia,  functional  spasms  :  the  troubles 
of  professional  voice-users  ;  the  functions  of  the  voice  ;  the 
speech  of  idiots  and  imbeciles  ;  the  development  of  lan- 
guage in  the  normal  child  ;  congenital  aphasia  ;  the  devel- 


October  26,  1895] 


MEDICAL    RECORD. 


599 


opment  of  speech  in  the  human  race  ;  speech  in  its  relations 
to  insanity  ;  aphasia  in  relation  to  organic  disease  of  the 
brain  ;  disturbances  of  speech  in  relation  to  evanescent  or- 
ganic affections  and  functional  disorders  of  the  cerebral 
cortex  :  and  dysarthric  and  anarthric  disturbances  of  speech 
due  to  lesions  affecting  the  motor  speech  tracts.  These 
contain  an  immense  amount  of  valuable  information,  and 
make  Dr.  Wyllie's  book  one  of  rare  usefulness  for  study  and 
reference.  It  is  probably  the  most  complete  work  on 
speech  disorders  in  general  that  has  ever  been  given  to  the 
English-speaking  public. 


Society  ^epotts. 

NEW  YORK  STATE  MEDICAL   ASSOCIA- 
TION. 

Twelfth  Annual  Meeting,  held  in  Neiv  York,   October 
I  J,  16,  and  17,  i8gs- 

Austin  Flint,  M.D.,  President,  in  the  Chair. 

First  Day,  Tuesday,  October  15TH. 

Dr.  Charles  E.  Denison,  of  New  York,  Chairman 
of  the  Committee  of  Arrangements,  stated  that  about 
fiftv  papers  would  be  read. 

Report  of  the  Council. — Dr.  E.  D.  Ferguson,  Secre- 
tary of  the  Society,  read  the  report.  The  Treasurer's 
account  showed  total  funds,  October  i,  1895,  of  $5,694. 
The  net  increase  in  the  funds  of  the  Association  for  the 
year  was  $443. 

The  question  had  arisen  whether  a  member  who  had 
resigned  from  a  branch  association  could  remain  a  mem- 
ber of  the  State  Association.    The  decision  of  the  Coun- 
cil was  that  resignation  from  a  branch  association  car-  . 
ried  with  it  loss  of  membership  in  the  State  Association. 

The  Secretary,  Dr.  Ferguson,  stated  that  inasmuch 
as  he  had  acted  as  Secretary  of  the  Association  since  its 
inception,  twelve  years  ago,  he  thought  it  would  be  in 
the  interests  of  the  Association  to  elect  a  successor  to 
the  office. 

Library. — There  had  been  added,  since  the  last  re- 
port, two  hundred  and  seventy-seven  volumes,  over  two 
hundred  of  which  were  from  the  library  of  the  late  Dr. 
A.  L.  Carroll. 

Amendment  to  the  Constitution. — The  constitution 
was  so  amended  as  to  permit  members  of  branch  associa- 
tions to  all  the  privileges  of  the  State  Association,  e.xcept 
voting  on  amendment  to  the  constitution  and  by-laws. 
Dr.  McLeod  alone  voted  in  favor  of  their  having  all 
privileges  without  exception,  while  others  were  opposed 
to  this,  inasmuch  as  full  members  had  to  pay  dues  to 
both  branch  and  State  Associations. 

A  Clinical  Report  on  Orthopedic  Surgery. — Dr.  S.  E. 
Milliken,  of  New  York,  read  this  paper.    (See  p.  sSt.) 

Dr.  a.  B.  Judson  thought  the  tendon  operation 
would  prove  a  valuable  help  in  the  treatment  of  polio- 
myelitis cases. 

A  Domestic  Test  for  Albuminous  Urine. — Dr.  John 
G.  Truax,  of  New  York,  read  this  paper.  He  first 
stated  objections  to  the  heat  and  nitric-acid  tests,  the 
picric-acid  and  other  tests,  the  greatest  being  their  in- 
convenience. The  test  which  he  had  to  propose  he 
called  the  alcohol  test.  It  consisted  in  pouring  alco- 
hol into  a  test-tube,  say  an  inch  or  an  inch  and  a  half 
in  depth,  and  dropping  upon  this  a  little  urine.  If  al- 
bumin were  present  it  would  be  precipitated  as  a  white 
streak,  not  as  a  general  cloudiness,  which  would  result 
if  mucus  were  present.  If  the  alcohol  were  placed  on 
the  urine  a  white  ring  would  form  if  albumin  were 
present,  a  general  cloudiness  if  mucus.  Further,  in 
order  to  exclude  mucus  as  a  cause  of  the  precipitate,  the 
urine  could  be  filtered.  The  alcohol  need  not  be  of 
full  strength,  and  a  tumbler  would  answer  for  a  test- 
tube. 


Dr.  Truax  said  he  offered  this  method  because  of  its 
great  convenience,  and  the  fact  that  after  using  it  for  a 
year  he  had  found  it  even  more  reliable  than  any  other 
single  test.  Like  with  the  nitric-acid  and  other  tests, 
this  one  required  control  tests  in  doubtful  cases.  It 
would  reveal  albumin  present  i  to  10,000  of  urine, 
being  indeed  a  more  delicate  test  than  others  which  he 
had  tried,  some  thirty  in  number. 

Dr.  J.  W.  S.  GouLEY  said  he  had  tried  the  alcohol 
test  and  had  found  it  of  greatest  convenience.  Control 
tests  with  other  agents  could  be  resorted  to  if  thought 
necessary. 

Dr.  Truax  added  that  alcohol  did  not  precipitate 
urates  and  phosphates,  this  element  of  doubt  which  ap- 
plied to  the  acid  test  being  therefore  eliminated. 

A  Cause  of  Much  Sickness  which  is  Often  Overlooked. 
— Dr.  W.  H.  RoiiB,  of  Amsterdam,  read  a  paper  with 
this  title.  The  cause  referred  to  was  dry-rot  in  wood, 
so  common  in  damp,  warm,  badly  ventilated  cellars. 
Whether  dry-rot  in  wood  was  due  to  chemical  process, 
as  had  been  claimed  by  some,  or  to  fungous  growth, 
had  not  been  fully  decided,  but  the  latter  cause  was 
the  more  probable.  From  the  damp,  dark  cellar,  with 
its  decaying  substances,  various  disease  germs  were 
spread  to  all  ponions  of  the  house.  Where  other 
known  cause  for  disease  in  a  family  could  not  be  dis- 
covered, this  one  should  be  thoroughly  investigated. 

Dr.  Robb  cited  two  examples.  In  oneinstance  there 
was  diphtheria  and  a  persistent  case  of  malaria  in  the 
house,  for  neither  of  which  he  could  find  a  cause  ex- 
cept decaying  wood.  The  cellar  was  altered,  with  the 
result  that  there  had  been  no  sickness  in  the  house 
since.  The  second  instance  was  similar,  except  that 
the  maladies  present  before  the  change  made  in  the 
cellar  were  one  case  of  pneumonia  and  two  fatal  ones 
of  cerebro-spinal  fever. 

Dr.  a.  T.  Van  Vranken,  of  West  Troy,  thought 
Dr.  Robb  had  not  proven  that  the  diseases  named 
were  due  to  decaying  wood  or  old  houses.  They  were 
known  to  occur  at  times  in  new  houses  as  well. 

Dr.  T.  H.  Manley  thought  the  paper  was  an  ex- 
tremely valuable  one  in  that  it  called  attention  to  a 
possible  cause  of  a  great  many  diseases.  The  kinds  of 
moulds  in  cellars  were  very  numerous,  and  he  believed 
that  microscopists  and  bacteriologists  would  yet  be 
able  to  prove  their  etiological  relation  to  many  diseases 
whose  origin  was  still  obscure  or  quite  unknown.  He 
cited  a  case  of  peculiar  membrane  in  the  throat  which 
seemed  to  have  been  due  to  dry-rot  in  wood. 

The  Present  Status  of  Obstetrics. — Dr.  Henry  McM. 
Painter,  of  New  York,  read  the  paper,  which  will  be 
published  in  a  future  issue. 

Recent  Studies  on  Diphtheria  and  Pseudo-Diphtheria. 
— Dr.  W.  H.  Park  read  this  paper.  In  the  table  con- 
structed by  Dr.  W.  H.  Welch  it  was  found  that  in  5,777 
cases  of  diphtheria  treated  with  antitoxin  in  hospitals, 
there  was  a  mortality  of  but  18.7  percent.  These  same 
hospitals  gave  an  average  mortality  of  43  6  per  cent, 
during  the  years  preceding  the  use  of  antitoxin.  This, 
he  said,  was  too  great  a  difference  to  explain  by  any 
remarkable  lessening  of  the  virulence  of  diphtheria  all 
over  Europe,  at  the  very  moment  of  commencing  the 
use  of  antitoxin,  nor  could  it  be  explained  on  the  sup- 
position that  many  more  cases  were  sent  to  the  hospital 
than  formerly.  In  private  practice.  Dr.  Welch  sum- 
marized 663  cases  with  a  death-rate  of  only  6.6  per  cent. 

It  was  interesting  to  note  the  effect  of  antitoxin  in 
laryngeal  diphtheria.  With  hardly  an  exception  the 
statistics  showed  that  a  less  proportion  of  laryngeal 
cases  came  to  operative  relief  now  than  before  the  use 
of  antitoxin.  The  mortality  in  cases  coming  to  opera- 
tion was  also  reduced  in  all  hospitals.  In  1,016  cases 
there  was  a  mortality  of  less  than  thirty-eight  ]ier  cent., 
as  contrasted  with  the  average  mortality  before  the  use 
of  antitoxin,  of  over  seventy  per  cent. 

In  New  York  City  the  mortality  statistics  were  very 
interesting.     The  average  mortality  for  the  past  four 


6oo 


MEDICAL    RECORD. 


[October  26,  1895 


years  for  all  cases  reported  had  been  over  thirty-four 
per  cent.  During  the  past  nine  months  the  mortality 
had  been  only  seventeen  per  cent. 

Dr.  Park  believed  that  if  antitoxin  had  been  used  in 
all  cases  the  mortality  would  not  have  been  more  than 
ten  per  cent.  In  Willard  Parker  Hospital  the  mortal- 
ity had  been  reduced  one-third,  and,  lately,  one-half. 
Regarding  the  ill-effects,  in  some  the  injection  caused 
a  slight  temporary  rise  in  temperature.  In  about  ten 
per  cent,  a  local  or  general  urticaria  or  other  form  of 
rash  made  its  appearance  between  the  fifth  and  twen- 
tieth days,  and  lasted  twelve  to  forty-eight  hours.  In 
a  few  this  was  accompanied  by  a  rise  of  temperature. 
In  about  one  per  cent,  of  the  cases  with  this  rash  one 
or  more  joints  became  tender  ;  the  temperature  might 
be  considerably  elevated.  As  a  rule  these  symptoms 
subsided  within  forty-eight  hours,  but  in  a  few  there  was 
swelling  of  the  joints  some  weeks  or  even  for  months, 
as  in  one  case.  In  a  small  per  cent,  albumin  appeared 
in  the  urine,  but  with  this  there  were  no  other  symp- 
toms showing  any  deleterious  effects  on  the  kidneys. 
He  had  seen  at  the  hospital  during  the  past  nine 
months  no  serious  effects  upon  the  heart,  kidney,  or 
nervous  system  which  seemed  attributable  to  the  anti- 
toxin. Those  who  had  read  Dr.  J.  E.  Winter's  re- 
marks might  wonder  at  this,  but  as  a  matter  of  fact  he 
had  not  seen,  after  careful  observation,  the  evil  effects 
mentioned  by  him. 

Regarding  the  use  of  diphtheria  antitoxin  in  prevent- 
ing, by  immunization,  the  development  of  diphtheria, 
he  referred  to  its  use  in  four  asylums  in  the  city,  where 
outbreaks  of  diphtheria  had  occurred,  the  entire  num- 
ber of  inmates  being  over  six  hundred.  In  every  in- 
stance after  commencing  the  injections  no  further 
cases  of  diphtheria  developed.  The  following  is  an 
example  :  At  the  Reception  House  of  the  Juvenile  Asy- 
lum four  cases  of  diphtheria  developed  during  the 
week  ending  April  nth.  On  the  12th  the  children 
(about  seventy)  were  injected  with  from  200  to  400 
units.  No  cases  occurred  afterward  except  that  an  at- 
tendant and  an  engineer  who  handled  the  clothes  from 
the  diphtheria  children,  and  who  had  not  received  im- 
munizing injections,  developed  diphtheria. 

Dr.  Park  said  to  him  these  results  seemed  conclu- 
sive as  to  the  immunizing  power  of  injections  of  from 
100  to  400  units  of  antitoxin.  About  one-sixth  of  the 
children  developed  albuminuria,  and  a  much  smaller 
percentage  developed  it  to  a  greater  extent.  In  none, 
however,  were  there  any  other  symptoms  pointing  to 
any  deleterious  action  on  the  kidneys,  and  in  none  was 
the  albuminuria  more  thaa  transitory.  On  the  blood 
there  was  noticed  a  slight  temporary  diminution  in  the 
number  of  the  red  blood-cells.  No  other  changes  were 
noticed. 

Dr.  Thornton,  of  Buffalo,  had  noticed  in  a  good 
many  cases,  after  the  pseudo-membrane  had  disap- 
peared, that  recurrence  took  place  in  a  few  days. 

Dr.  Park  answered  questions  put  by  Dr.  Didema 
and  Dr.  Ferguson,  and  stated  that  the  antitoxin  was 
manufactured  by  the  Healtli  Department,  and  was  sup- 
plied to  the  poor,  free. 

The  Emergency  Treatment  in  Acute  Diseases  and 
Injuries  of  the  Eyes. —  1)k.  Jdhx  E.  Wkers  was  the  au- 
thor of  this  paper.  The  subject  was  considered  sys- 
tematically under  the  headings  acute  diseases  of  the 
lids,  of  the  conjunctiva,  of  the  cornea,  etc.  Abscess  of 
the  lids  should  be  treated  as  abscess  in  other  parts  of 
the  body  is  treated  ;  when  it  pointed,  make  an  incision 
parallel  with  the  edge  of  the  lid.  In  this  and  various 
other  conditions  and  operations  antiseptic  irrigation 
was  employed,  solution  of  boric  acid,  or  bichloride,  i 
to  S,ooo.  In  purulent  conjunctivitis,  whether  gonor- 
rhoeal,  diphtlieritic,  or  other  form,  every  precaution 
should  be  taken  to  prevent  spread  of  the  disease  to 
other  persons  and  to  the  other  healthy  eye.  A  watch- 
glass  might  be  sealed  over  the  healthy  eye,  leaving 
ventilation  at  the  lower  edge.     As  a  wash,  use  boric 


acid  by  pipette  or  absorbent  cotton.  Sponges  should 
not  be  used  about  the  eye,  solution  of  nitrate  of  silver, 
one  or  two  per  cent.,  once  or  twice  during  twenty  four 
hours.  If  much  swelling  of  the  lids,  cold  applications. 
But  continue  the  cleansing.  In  phlegmon  of  the  lach- 
rymal sac,  apply  moist  heat  (not  over  the  entire  eye), 
and  when  fluctuation  developed  make  a  free  incision 
into  the  sac,  remove  the  contents,  scrape  with  curette, 
wash  with  bichloride.  In  cellulitis  of  the  orbit,  remove 
cause,  apply  cold,  then  heat,  when  pus,  open.  In 
bruises  or  contusions,  the  first  six  to  twenty-four  hours 
apply  cold.  Then  absorption  of  serum  or  blood  would 
be  hastened  by  hot  water.  In  burns  with  acids,  neu- 
tralize the  acid  by  alkaline  application.  Foreign  bodies 
should  be  removed  if  possible  by  cotton  probang,  or,  if 
embedded,  with  knife,  or  be  dislodged  with  pointed  in- 
strument. Carefully  cleanse  wound  with  bichloride,  i 
to  5,000. 

The  whole  paper  was  not  read. 

Some  Unusual  Cases  of  Orbital  and  Intra-ocular  Tu- 
mors, Emphasizing  the  Necessity  of  Careful  Differen- 
tial Diagnosis. — Dr.  C.  S.  Bull  read  the  histories  of 
the  cases.  The  first  was  one  in  which,  placing  too 
much  importance  upon  the  family  history  of  cancer,  he 
made  a  diagnosis  of  malignant  disease,  while  operation 
showed  the  case  to  be  one  of  abscess  of  the  ethmoid 
cells.  In  two  weeks  the  patient  was  discharged,  at  the 
end  of  a  month  diplopia  and  exophthalmos  had  disap- 
peared. In  the  second  case  the  diagnosis  was  made  of 
tumor  of  the  lachrymal  gland,  probably  malignant. 
Removal  was  advised,  and  done.  It  proved  to  be  an 
adeno-sarcoma  of  the  gland.  There  had  been  no  re- 
currence. The  next  case  proved  on  operation  to  be  a 
fibro-sarcoma  instead  of  an  hypertrophy  of  the  lachry- 
mal gland.  The  patient  subsequently  had  a  suspicious 
tumor  in  the  neck,  and  died  of  exhaustion. 

The  next  case  was  one  of  sarcoma  of  the  sphenoid 
and  ethmoid  bones.  It  extended  after  removal.  Still 
another  case  was  cited  of  malignant  tumor  involving 
the  bones  of  the  orbit  and  dura  mater,  and  extending 
backward,  causing  optic-nerve  atrophy.  A  cystoid  an- 
gioma of  the  orbit  was  removed  in  another  case  ;  no 
recurrence. 

Notes  on  the  Diagnosis  of  Interstitial  Cerebritis. — 
Dr.  Neil  J.  Hepburn  read  a  paper,  giving  the  his- 
tories of  two  cases. 

The  Practice  of  Medicine  in  the  Light  of  Bacteriolog- 
ical  Researches. — Dr.  a.  A.  S.mith,  of  New  York,  read 
the  Address  in  Medicine.     (See  p.  577.) 

Empyema  of  the  Antrum.— Dr.  William  Carr,  of 
New  York,  read  a  paper  on  this  subject.  In  consider- 
ing the  question  of  the  causation  of  this  condition  the 
author  referred  to  the  research  of  Fletcher,  who  found 
that  out  of  fifty-seven  cases  of  ulcerated  teeth  only 
four  had  perforated  into  the  antrum.  From  this,  this 
observer  inferred  that  suppuration  of  the  sinus  was 
usually  the  result  of  some  nasal  affection,  and  not  from 
diseased  teeth.  To  this  view,  however,  the  reader  of 
the  paper  took  decided  exception,  believing  that  in 
about  eighty  per  cent,  of  the  cases  the  empyema  was 
due  to  disease  of  the  teeth  and  their  alveoli.  The  first 
step  in  the  treatment  of  this  condition  is  the  establish- 
ment of  an  opening  into  the  antrum,  either  by  way  of 
the  nose  or  through  the  alveolus.  The  latter  method 
he  preferred,  and  where  possible,  the  opening  would  be 
made  at  the  second  molar  tooth.  Having  made  the 
opening,  a  llexible  probe  should  be  inserted,  and  the 
cavity  carefully  explored  to  determine  the  existence  of 
foreign  bodies  or  of  septa.  The  cavity  is  next  irri- 
gated with  some  weak  antiseptic  solution,  and  a  plug  of 
sterilized  gauze  placed  in  the  opening  that  has  been 
made.  Silver  drainage-tubes,  the  sjjeaker  said,  became 
corroded  very  quickly,  and  in  general  it  might  be  said 
that  drainage-tubes  were  unnecessary  and  harmful  in 
the  treatment  of  tliis  condition. 

General  Suggestions  Regarding  the  Diagnosis  and 
Treatment   of  Acute    Aural   Inflammation. — Dr.   Ed- 


I 


October  26,  1895] 


MEDICAL   RECORD. 


601 


WARD  B.  Denxh,  of  Nevi-  York,  read  the  paper.  He 
said  that  primary  inflammation  of  the  external  auditory 
meatus  was  exceedingly  rare  in  infancy,  while  acute 
otitis  media  was  quite  common.  In  cases  of  acute  in- 
flammation of  the  external  canal  the  onset  of  the  pain 
was  usually  sudden  and  severe,  and  there  was  associat- 
ed with  it  more  or  less  fever.  In  the  mild  cases  a  se- 
rous discharge  appeared  in  the  course  of  a  few  hours, 
and  quickly  gave  relief,  but  in  the  severer  form  of  the 
affection  the  pain  and  constitutional  disturbance  rap- 
idly increased  in  severity.  It  should  be  remembered 
that  while  tenderness  on  moving  the  auricle,  or  by 
pressing  near  the  meatus  in  an  adult,  was  almost  pa- 
thognomonic of  inflammation  of  the  exteraal  canal,  it 
would  indicate  in  a  child,  with  almost  equal  certainty, 
the  existence  of  an  inflammation  of  the  middle  ear.  In 
a  case  of  external  otitis  in  an  adult,  examination  with 
a  speculum  showed  the  drum-membrane  to  be  of  nor- 
mal color,  and  the  deeper  portions  of  the  canal  of  nor- 
mal size,  but  the  introduction  of  the  speculum  was 
often  a  difficult  and  painful  procedure.  If  seen  early, 
the  local  abstraction  of  from  one  to  four  ounces  of 
blood  often  gave  marked  relief,  and  checked  the  in- 
flammatory process.  One  dose  of  morphine  was  allow- 
able, but  it  should  not  be  repeated.  Further  relief  was 
obtained  by  the  application  of  dry  heat,  which  could  be 
conveniently  done  by  the  use  of  the  miniature  salt- 
bags  made  out  of  glove-fingers,  or,  more  elegantly,  by 
the  use  of  the  Japanese  pocket-stove.  The  use  of 
moist  heat  should  be  avoided,  as  its  tendency  was  to 
favor  tissue  necrosis.  If  these  simple  measures  failed 
to  relieve  the  urgency  of  the  symptoms,  no  time  should 
be  lost  in  making  a  free  incision  with  the  object  of  de- 
pleting the  tissues  and  controlling  the  inflammation. 
This  little  operation  does  not  require  the  aid  of  the 
specialist  ;  it  can  be  safely  done  by  the  general  practi- 
tioner if  he  will  take  care  to  use  sterile  instruments, 
and  to  have  the  canal  thoroughly  aseptic  both  before 
and  after  the  incision.  There  is  very  little  pain  con- 
nected with  making  this  incision,  and  the  previous  ap- 
plication of  cocaine  is  unnecessary  and  useless.  'When 
the  case  is  seen  later  on,  when  there  is  already  a  dis- 
charge from  the  ear,  the  physician  should  see  that  the 
discharge  is  kept  free  and  aseptic. 


Second  D.w,  Wednesday,  October  i6th. 

Preamble  and  Resolution  on  the  Late  Reorganiza- 
tion of  the  Harlem  Hospital  Staff  and  the  Ethical 
Questions  Involved. — Dr.  Th^imas  E.  Ma.xlev  offered 
the  following : 

iV/iereas,  As  the  action  of  the  Bellevue  Hospital 
Medical  College  and  the  University  Medical  College 
in  the  late  reorganization  of  the  Harlem  Hospital 
medical  staff,  whereby  the  members  of  the  said  staff 
were  displaced  without  charges  of  any  description  hav- 
ing been  preferred  against  them,  after  years  of  faithful 
and  gratuitous  service,  has  seemed  in  wide  contraven- 
tion to  the  spirit  of  the  Code  ;  and 

JVhereas,  This  action  is  without  precedent,  and  in- 
volves a  principle  which  concerns  the  entire  profession, 
and  has  imposed  an  injustice  on  members  of  this  Asso- 
ciation ;  therefore,  be  it 

Resolved,  That  the  Council  of  New  York  State  Medi- 
cal .\ssociation  be  instructed  to  institute  a  searching 
investigation  into  this  transaction  and  report  their  con- 
clusions thereon  before  this  annual  meeting  adjourns. 

On  motion  of  Dr.  Ferguson  the  matter  was  referred 
to  the  Council  with  power. 

A  Case  of  Extrauterine  Pregnancy ;  Death  of  Fcetns  ; 
Unusual  Complications. — Dr.  George  E.  McDonald 
in  this  paper  gave  the  history  of  a  case  in  which  he  had 
made  the  diagnosis  of  extra-uterine  pregnancy  ;  no 
operation.  Pains  appeared  connected  with  gall-stones, 
some  of  which  were  passed  ;  hepatic  abscess  developed 
which  opened  into  a  bronchus  ;  later  peritonitis  killed 
the  patient,  and  autopsy  confirmed  the  diagnosis.    The 


foetal  bones  were  in  the  broad  ligament,  and  evidently 
had  not  been  the  cause  of  the  peritonitis.  The  sinus 
communicating  between  the  hepatic  abscess  and  bron- 
chial tube  had  cicatrized.     Peritonitis  was  present. 

Foreign  Bodies  in  the  CEsophagus. — Dr.  H.  M.  Silver, 
of  New  York,  in  a  paper  on  this  subject,  related  two  or 
three  cases  coming  under  his  own  observation,  and  re- 
viewed certain  statistics  in  relation  especially  to  the 
treatment.  The  first  patient,  a  man,  had  swallowed  a 
bone  with  his  food,  which  stuck  in  his  throat.  A  phy- 
sician was  called  who  tried  to  push  the  obstacle  on  into 
the  stomach,  but  failed.  Dr.  Silver  being  called  had 
the  man  sent  to  a  hospital  for  external  oesophagotomy. 
The  graduated  metallic  bougie  a  boule  was  introduced, 
and  came  in  contact  with  the  obstruction  eight  inches 
from  the  upper  incisors.  The  cesophagus  was  opened 
on  a  sound  introduced  within  a  distance  of  an  inch, 
and  the  foreign  body  was  found  an  inch  below.  It  was 
impossible  to  extract  it  because  of  a  sharp  point  em- 
bedded in  the  soft  parts  above,  nor  could  it  be  pushed 
down  on  account  of  a  similar  penetration  of  the  tissues 
below.  It  was  necessary  to  enlarge  the  incision,  after 
which  the  tissues  were  pressed  away  from  the  sharp 
edge,  and  the  bone,  measuring  one  inch  and  a  quarter 
by  five-eighths  of  an  inch,  was  extracted. 

Statistics  were  given  of  165  cases  of  oesophagotomy. 
Of  this  number  127  recovered,  38  died,  a  mortality  of 
twenty-three  per  cent.  The  causes  of  death  were  star- 
vation, perforation  and  abscess,  secondary  hemorrhage, 
pneumonia,  etc.  In  four  cases  gastrotomy  was  per- 
formed— four  recoveries. 

The  author's  conclusions  were:  i.  That  neglected 
bodies  should  be  removed  at  once  by  operation  without 
making  an  attempt  at  e.xtraction  through  the  mouth  or 
to  push  it  down  into  the  stomach.  2.  A  foreign  body 
of  moderate  size  should  be  removed  by  operation  as 
soon  as  impaction  is  considered  complete.  3.  Where 
a  small  sharp  body  has  been  swallowed  the  oesophagus 
should  at  once  be  opened  ;  and  where  difficult  degluti- 
tion is  present  and  constitutional  symptoms  point  to  sep- 
tic inflammation.  4.  The  use  of  small  catheter,  bougie, 
and  sponge  probang  should  be  condemned.  A  metal- 
capped  oesophageal  sound,  with  graduated  scale,  was  the 
only  reliable  instrument.  5.  Where  the  foreign  body 
was  less  than  thirteen  inches  from  the  upper  incisors  it 
should  be  removed  by  asophagotomy,  if  farther  down, 
by  gastrotomy.  6.  Stitching  the  wound  was  unessen- 
tial, yet  if  it  was  healthy  sutures  could  be  passed,  but 
only  through  the  muscular  and  subcutaneous  coats. 
The  external  wound  should  be  left  open,  although  a 
few  sutures  could  be  introduced  at  the  upper  corner, 
leaving  it  open  below.  7.  Absolutely  no  food  should 
be  taken  by  the  mouth  the  first  twenty-four  hours,  thus 
giving  the  planes  of  the  tissues  opportunity  to  become 
glued  together  and  prevent  infiltration  and  infection  of 
the  deeper  tissues.  Feeding  by  tube,  whether  through 
the  mouth,  wound,  or  anus,  was  unnecessary,  although 
rectal  injection  of  water  might  be  given  the  first  twenty- 
four  hours  if  there  were  thirst.  After  the  lapse  of 
twenty-four  hours  liquid  food  could  be  given  by  the 
mouth.  To  prevent  its  escape  through  the  wound  he 
would  advise  resort  to  Dr.  Bryant's  plan  of  making 
firm  pressure  with  cotton  over  the  wound  while  swal- 
lowing. 

Dr.  Silver  said  surgeons  had  at  times  made  the  mis- 
take of  continuing  rectal  alimentation  until  the  patients 
had  been  actually  starved.  One  very  serious  objec- 
tion to  passing  a  tube  through  the  wound  for  alimenta- 
tion was  the  great  pain.  It  also  endangered  sepsis 
by  allowing  the  patient  to  swallow  after  the  first 
twenty-four  hours.  The  wound  healed  eight  or  nine 
days  sooner  than  when  other  methods  of  feeding  had 
been  resorted  to. 

A  Case  of  Carcinoma  Ventriculi,  with  the  Continued 
Presence  of  Free  Hydrochloric  Acid  and  the  Absence 
of  Lactic  Acid. — Dr.  Charles  G.  Stockton,  of  Buf- 
falo, read  the  history  of  the  case.     For  two  years  the 


6o2 


MEDICAL    RECORD. 


[October  26,  1895 


patient  had  complained  of  disturbance  of  the  stomach, 
suffering  from  pain  and  vomiting  at  times.  Two 
months  before  he  saw  her  the  attending  physician  be- 
gan rectal  alimentation.  She  was  greatly  emaciated 
and  cachectic.  The  diagnosis  of  cancer  of  the  stomach 
had  been  made,  and  Dr.  Stockton  concurred  in  this 
diagnosis  and  regarded  the  condition  as  beyond  relief. 
The  patient  then  weighed  only  eighty  pounds.  The 
stomach  was  extremely  dilated,  and  there  was  a  mova- 
ble, kidney-shaped  tumor  in  the  epigastric  region. 
Examination  of  the  stomach  contents  under  different 
conditions  revealed  a  high  degree  of  acidity,  which  de- 
pended mostly  upon  hydrochloric  acid.  No  lactic  acid 
was  present.  It  was  one  of  the  rare  and  interesting 
cases  in  which  advanced  malignant  disease  of  the  stom- 
ach was  accompanied  by  free  hydrochloric  acid  while 
lactic  acid  was  absent.  Under  these  circumstances  he 
was  able  to  prescribe  a  diet  and  medication  by  the 
mouth  which  markedly  increased  her  weight  and  com- 
fort for  some  months,  or  until  the  tests  showed  that 
hydrochloric  acid  had  disappeared  from  the  gastric  se- 
cretions. He  now  recommended  surgical  interference. 
Dr.  Roswell  Park  operated,  found  carcinoma  of  the 
pylorus,  and  performed  gastro- enterostomy.  The  pa- 
tient soon  became  able  to  take  food,  which  she  did 
with  avidity,  and  increased  her  weight  to  one  hundred 
and  thirty  pounds,  and  was  still  improving  in  health. 
Hydrochloric  acid  was  still  absent,  lactic  acid  was 
present.  Discussion  on  this  paper  was  taken  up  with 
that  on  Dr.  Einhorn's,  which  was  next  read. 

Gastro  Suceorrhoea  Continua  Chronica. — Dr.  M.\x 
EiNHORN,  of  New  York,  read  a  paper  with  this  title. 
It  will  be  published  in  full  in  a  future  issue  of  the  Med- 
ical Record. 

Dr.  Stockton  thought  the  class  of  cases  referred  to 
by  Dr.  Einhorn  were  sufficiently  numerous  to  have 
been  seen  by  most  practitioners.  He  was  of  opinion 
that  they  were  usually  of  nervous  origin  or  due  to  a 
neurosis,  and  it  was  important  to  give  attention  to  the 
patient's  general  nervous  state,  as  well  as  to  any  local 
nervous  irritation.  While  the  author  had  found  bene- 
fit from  the  continuous  galvanic  current,  Dr.  Stockton 
had  thought  this  agent  caused  the  succorrhcea  to  be 
aggravated  and  therefore  he  had  discontinued  its  use 
notwithstanding  its  efficacy  in  relieving  pain. 

Dr.  Jones's  experience  with  galvanism  had  been  sim- 
ilar to  that  of  Dr.  Stockton's.  He  thought  pyloric 
stenosis  was  in  some  instances  only  temporary,  and  due 
to  a  tumor-like  state  of  the  folds  in  the  neighborhood, 
caused  by  stimulation  and  irritation  of  condiments. 

Dr.  Gallant,  of  New  York,  believed  that  eye-strain 
was  often  the  primary  factor  in  the  neurosis  leading  to 
the  conditions  of  the  stomach  under  consideration,  and 
he  was  accustomed  to  send  such  patients  to  Dr.  Weeks 
for  treatment  of  hypermetropic  astigmatism.  Regard- 
ing washing  out  the  stomach,  he  thought  the  necessity 
for  it,  except  for  diagnostic  purposes,  could  be  obviated 
by  giving  ichthyol,  which  patients  regarded  as  the  less 
disagreeable  of  the  two  remedies.  Dr.  Weeks  had  sup- 
posed the  ichthyol  produced  beneficial  results  as  an 
antiseptic,  but  Dr.  Gallant  believed  it  also  restored 
function. 

Dr.  Austin  Flint,  commenting  upon  the  cases  of 
Dr.  Einhorn,  of  the  great  amount  of  gastric  secretion, 
said  that  while  this  juice  might  possess  some  of  the 
qualities  of  gastric  juice,  it  could  not  be  considered  as 
entirely  normal.  He  believed  that  any  person  with 
absolutely  normal  digestion  could  occasionally  commit 
gastronomic  indiscretions  with  impunity.  In  the  same 
way  that  nature  had  provided  two  kidneys  for- extra 
work  ;  in  the  same  way  that  she  had  provided  more 
lung  substance  than  was  absolutely  required  for  ordi- 
nary respiration,  had  she  also  provided  for  extra  de- 
mands upon  the  digestive  functions.  He  did  not  be- 
lieve that  she  would  regard  an  occasional  gastronomic 
indulgence  as  an  unpardonable  sin,  calling  for  pro- 
longed  punishment  of   the   sinner.      But    one   of    the 


greatest  difficulties  which  he  had  encountered  in  treat- 
ing persons  with  digestive  disturbance  was  to  get  them 
to  observe  regularity  in  eating  and  to  avoid  taking 
more  than  they  wanted.  With  such  errors  he  could 
imagine  the  stomach  saying,  in  the  condition  described 
by  Dr.  Einhorn,  I  will  comply  with  your  demands 
and  supply  you  with  enough  gastric  juice,  but  I  doubt 
whether  any  stomach  can  secrete  such  an  amount  of 
normal  quality. 

Cases  of  Atresia  and  of  Stenosis  Vaginalis,  with  One 
Hundred  Tabulated  Cases  in  Labor. — D.r.  J.  J.  E. 
Maher  recited  a  few  cases  of  atresia  or  stenosis  of  the 
vagina  seen  by  himself,  and  then  made  use  of  a  tabu- 
lated list  in  considering  the  site  of  the  constriction, 
its  calibre,  thickness,  resistance,  etc.  In  3  the  whole 
canal  was  said  to  be  involved  ;  in  57  the  narrowing 
was  in  the  middle  third  ;  in  Si  below  the  middle 
third  ;  in  15  no  opening  had  been  found,  while  in  the 
remainder  it  had  varied  from  the  size  of  a  pin-head  up 
to  only  a  slight  amount  of  constriction.  Its  nearness 
to  the  vulva  should  exclude  the  error  of  mistaking  it 
for  the  03  and  cervix  uteri.  As  to  etiology,  post-par- 
tum  cicatrization  had  been  responsible  in  42  out  of  86 
cases,  difficult  operations  on  the  vagina  in  2,  trauma- 
tism in  5,  31  were  congenital.  It  was  surprising  in  how 
large  a  number  there  had  been  complication  of  preg- 
nancy, such  as  unusual  presentation,  etc.  Dr.  ^Iaher 
was  of  opinion  that  the  constriction  should  be  pene- 
trated in  the  presence  of  pregnancy,  or  if  this  were 
not  possible  he  would,  in  opposition  to  the  teaching  of 
Breisky,  apply  forceps.  In  13  cases  of  death  the  fatal 
result  was,  no  doubt,  due  to  dilatory  treatment. 

Discussion  on  Malignant  Tumors. — This  discussion 
was  in  the  nature  of  a  number  of  papers  prepared  and 
read  by  different  authors  on  sub-titles. 

The  Prognosis  of  Malignant  Tumors  as  Modified  by 
their  Management. — Dr.  Joseph  D.  Bryant  opened 
the  discussion.  He  advocated,  as  did  the  authors  who 
followed  him,  early  removal  of  all  malignant  tumors, 
and  indeed  of  all  tumors  of  whatever  nature  as  a  form 
of  prophylaxis.  Tabulated  statistics  were  given,  show- 
ing that  malignant  disease  was  on  the  increase  in  the 
human  family.  In  the  United  States  the  mortality 
from  this  cause  in  1S50  was  9.0  for  100,000  living  ;  in 
i860  it  was  II. 7  ;  in  1870  16;  in  iSSo  26:  in  1890 
33.5.  This  difference  could  not  be  entirely  due  to  a 
fuller  report  of  cases  for  the  later  decades.  The  death- 
rate  from  malignant  disease  was  greater  in  the  cities 
than  in  the  country.  The  increase  had  been  shown  in 
all  parts  of  the  body,  but  not  in  equal  proportion.  In 
the  parts  most  commonly  affected,  as  the  genitals  and 
breasts  of  women,  the  increase  had  not  been  so  rapid 
as  in  the  alimentary  tract.  The  organs  of  most  phys- 
iological significance  were  most  involved.  The  in- 
crease was  greatest  with  increasing  years,  which  was 
against  the  theory  of  infection  as  more  than  a  rare 
cause  at  best.  Germans  were  more  often  affected  than 
Italians  or  Irish  in  New  York. 

The  importance  of  removing  enlarged  or  neighbor- 
ing lymphatics  while  removing  the  tumor  was  shown 
by  earlier  recurrence  and  earlier  death  where  this  was 
not  done.  The  advantages  of  removal  by  the  knife 
over  caustics  were  that  it  could  be  done  quickly, 
cleanly,  completely,  circumscribedly,  securing  early 
healing  of  the  wound,  and  avoiding  irritation  and 
spreading  the  disease.  The  patient  should  be  im- 
pressed with  the  necessity  for  remaining  under  obser- 
vation, and  of  speedy  removal  should  there  be  recur- 
rence. Everything  lowering  the  health  should  be 
avoided.  After  removal,  special  internal  remedies 
might  at  times  be  used  with  discretion — arsenic,  mer- 
cury, etc.  They  should  never  be  employed  as  a  sub- 
stitute for  the  knife,  but  simply  as  an  aid. 

The  Early  Detection  and  Prompt  Ablation  of  Tu- 
mors.— Dr.  J.  ^\■.  S.  GouLEV  discussed  this  phase  of 
the  subject.  He  thought  the  question  was  one  which 
could  not  be  too  frequently  discussed.     Early  removal 


October  26,  1895] 


MEDICAL   RECORD. 


60-: 


had  for  its  object  not  only  possible  radical  cure  and 
prolongation  of  life,  but  also  of  rendering  life  more 
comfortable  even  in  cases  hopeless  of  cure.  In  1885 
he  removed  the  breast  of  a  patient  which  contained  two 
hard  nodules  in  an  old  scar,  microscopical  examination 
showing  them  to  be  typical  carcinoma.  There  had 
been  no  recurrence.  Similar  cases  could  be  multiplied. 
It  was  possible  for  tumors  of  different  kinds  to  exist 
at  the  same  time,  as  in  Bryant's  case,  where  the  patient 
had  in  different  localities  a  benign,  carcinomatous,  and 
a  sarcomatous  tumor,  and  on  whom  sixteen  operations 
were  done  at  different  times,  counting  also  those  per- 
formed for  recurrences.     At  last  accounts  he  was  well. 

Dr.  Gouley  regarded  it  as  of  prime  importance  for 
physicians  to  understand  that  partial  extirpation  and 
caustics  favored  spreading  the  disease.  Benign  tu- 
mors were  liable  to  become  malignant,  and  should  be 
removed.  It  was  possible,  he  thought,  for  a  malignant 
tumor,  or  one  of  low  organization,  to  take  on  the 
higher  organization  of  the  benign  forms,  or  at  least  to 
become  so  far  transformed  as  to  remain  quiescent  a 
long  time.  Yet  the  oft-repeated  dictum,  that  so  long 
as  a  tumor  remained  stationarj-  and  caused  no  incon- 
venience it  should  not  be  removed,  was  contrary  to 
the  true  principles  of  conservatism,  and  was  fraught 
with  the  greatest  danger  to  the  patient.  Early  re- 
moval was  likewise  indicated  whenever  recurrence  took 
place.  None  of  the  so-called  specifics  for  malignant 
disease  had  ever  been  of  any  ser%'ice.  Dr.  Goulev 
formulated  his  points  in  fourteen  conclusions. 

The  Nature.  Modes  of  Propagation,  and  Commoner 
Sites  of  Tumors. — Dr.  Edward  K.  Duxh.^m  dis- 
cussed the  metastatic  nature  of  tumors,  which  he  made 
out  to  be  peculiar  to  those  of  malignant  form  alone  ; 
their  mode  of  extension  and  transplantation,  which  he 
attributed  to  cell  transplantation  and  growth  under 
new  surroundings  ;  also  the  commoner  sites  of  tumors, 
which  he  explained  in  the  case  of  recurrence  on  the 
basis  of  the  usual  channels  through  which  the  cells 
were  transported.  While  cases  of  metastasis  of  benign 
tumors,  such  as  cartilaginous  tumors  which  had  a  high 
cell  organization,  had  been  reported,  Dr.  Dunham  had 
come  to  the  conclusion  on  studying  these  that  they 
were  really-mixed  tumors,  containing  sarcomatous  ele- 
ments, and  that  therefore  they  did  not  constitute  ex- 
ceptions to  the  rule  that  metastasis  was  a  sign  of  ma- 
lignancy. He  regarded  the  susceptibility  of  malignant 
tumors  to  metastasis  to  be  dependent  upon  their  cellu- 
lar structure,  with  little  or  none  of  the  inter-cellular 
substance  characteristic  of  other  tissues.  In  a  great 
many  instances  the  transported  cells  would  die,  and 
to  this  fact  was  to  be  attributed  the  usual  failure  of 
inoculation  experiments,  especially  in  animals  of  differ- 
ent species.  In  the  same  individual  the  time  of  me- 
tastasis appeared  to  bear  no  relation  to  the  duration  of 
the  primary  neoplasm  nor  to  its  size.  As  soon  as  the 
tumor  formed,  it  was  liable  to  metastasis.  No  more 
conclusive  argument  could  be  offered  in  favor  of 
prompt  operative  interference. 

Dr.  Dunham  also  discussed  the  greater  liability  of 
certain  malignant  neoplasms  to  metastasis  than  others, 
basing  the  explanation  upon  their  difference  in  struct- 
ure. 

Dr.  Charles  Phelps,  of  New  York,  also  read  a 
japer  on  "The  Early  Detection  and  Prompt  Ablation 
f  Tumors."  To  those  who  held  that  all  tumors  should 
e  removed  at  once,  diagnosis  of  the  nature  of  the 
growth  was  not  so  important  ;  to  those  who  held  that 
only  malignant  tumors  should  be  removed  at  once, 
early  diagnosis  was  extremely  important.  The  conten- 
tion that  removal  stimulated  growth  or  extension  of 
the  disease  seemed  to  him  most  irrational,  and  was  not 
'  orne  out  by  experience  with  radical  operations.  The 
ossibility  that  all  tumors  might  degenerate  was  ad- 
•litted.  It  was  a  logical  necessity  that  if  malignant 
"-umors  required  removal,  safety  demanded  equally 
radical  treatment  of  those  other  structures  which  might 


assume  the  character  of  malignancy  even  while  we 
hesitated.  It  was  hard  to  remove  the  breast  of  a  young 
unmarried  woman  when  it  contained  an  adenoma,  but 
an  experience  like  one  which  he  related,  of  a  change  to 
carcinoma  within  a  few  months  and  death  after  pro- 
longed and  severe  suffering,  would  convert  one  to  the 
surgical  treatment. 

Means  of  Eradication  of  Tumors  :  the  Knife  Versus 
Caustics. — Dr.  Parker  Svms,  of  New  York,  arrived  at 
the  following  conclusions  in   a  paper  on  this  subject  : 

1.  Malignant  neoplasms  were  the  result  of  cell-prolifera- 
tion. 2.  Their  development  was  frequently  caused  or 
determined  by  local  irritation  or  trauma.  3.  It  was 
purely  a  local  condirion,  coniined  to  the  seat  of  the 
growth.  4.  Any  general  infection  arose  from  the  orig- 
inal local  focus.  5.  If  this  were  completely  removed 
while  localized,  the  patient  could  be  completely  cured. 
6.  Distribution  was  through  the  lymphatics.  7.  When 
the  growth  was  situated  where  the  anatomy  would  per- 
mit of  complete  removal,  along  with  removal  of  the 
lymphatics,  the  resulting  operation  was  most  likely  to 
be  successful. 

From  the  foregoing  the  following  deductions  were 
drawn  :  i.  Thorough  removal    of  all   visible    disease. 

2.  Thorough  removal  of  all  in\'isible  disease.  Hence, 
removal  of  tissue  surrounding  the  growth.  3.  Removal 
of  the  neighboring  lymphatic  system.  4.  Removal  of 
the  disease  en  masse  as  far  as  possible,  so  as  to  avoid 
cutting  into  and  liberating  infectious  elements.  5. 
Save  the  patient's  strength  as  far  as  possible.  6.  Ab- 
lation of  the  disease  in  the  early  stages. 

How  could  these  objects  be  best  accomplished  ? 
Decidedly  by  a  well- carried- out  surgical  operation. 
Among  the  advantages  of  the  knife  over  caustics  was 
that  it  caused  less  deformity. 

The  Necessity  of  Complete  Extirpation  of  Tumors, 
and  the  Importance  of  Rapid  Cicatrization  of  the 
Wound. — Dr.  Frederick  H.  Wiggix,  of  New  York, 
read  on  this  subject.  He  first  showed  why  the  older 
surgeons  had  less  favorable  immediate  and  remote  re- 
sults from  their  operations  on  malignant  disease  than 
did  modem  surgeons.  The  mortality'  had  been  re- 
duced from  twenty-five  per  cent,  before  the  introduc- 
tion of  antisepsis  to  practically  ml  since.  Less  fre- 
quent recurrence  or  prolonged  life  obtained  by  recent 
surgery  was  due  to  a  cleaner,  more  radical  operation, 
as  well  as  to  an  earlier  one.  Sir  Astley  Cooper  had 
pointed  out  the  fact  that  the  radicles  of  the  disease 
spread  out,  and  that  the  lymphatics  were  involved,  and 
he  advised  removal  of  these,  but  many  years  elapsed 
before  this  advice  was  followed.  Halsted,  Curtis,  and 
Meyer  had  reported  little  deformity  or  disturbance  of 
function  from  so  radical  an  operation  as  removal  of 
the  pectoral  muscle  in  addition  to  the  tumor  and 
lymphatics. 

As  to  rapid  cicatrization  of  the  wound,  while  it  was 
important  that  the  wound  should  heal  as  rapidly  as  pos- 
sible, yet  it  was  secondary  in  importance  to  removal  of 
parts  adjacent  to  the  tumor. 

The  Value  of  Subsequent  Constitutional  Treatment, 
and  of  Long  Surveillance  of  the  Patient  After  the  Op- 
eration.— Dr.  Frederic  S.  Dennis,  of  Xew  York,  said 
in  this  paper  that  some  regarded  constitutional  treat- 
ment as  absolutely  valueless,  but  the  practical  surgeon 
could  not  adopt  this  view,  although  he  might  have 
doubts.  There  were  some  who  had  published  statis- 
tics apparently  proving  the  value  of  certain  internal 
remedies,  as  arsenic,  bichloride  of  mercury,  LugoU's 
solution,  pyoctanin,  gold,  etc.  Dr.  Dennis  thought 
there  was  little  to  be  hoped  or  expected  from  the  ad- 
ministration of  constitutional  remedies,  and  believed 
that  where  there  had  been  a  result,  it  had  been  due 
more  to  the  radical  character  of  a  preceding  operation 
than  to  the  drug.  If  the  drug  produced  an  effect,  it 
was  probably  as  a  tonic,  enabling  the  patient  to  resist 
the  advance  of  the  disease.  It  was  a  question  whether 
iodide  of  potash  had  not  some  influence  on  sarcomas, 


6o4 


MEDICAL    RECORD. 


[October  26,  1895 


but  disappearance  under  its  use  might  have  been  spon- 
taneous, as  sometimes  occurred  with  no  treatment. 
Cicatricial  contraction  was  not  to  be  confounded  with 
disappearance,  a  mistake  which  some  made  in  lauding 
a  remedy. 

The  remainder  of  Dr.  Dennis's  paper  was  devoted  to 
impressing  the  necessity  of  keeping  an  accurate  sys- 
tematic history  of  every  case  of  tumor  from  the  begin- 
ning. A  photograph  should  also  be  taken.  The  con- 
dition present  after  operation  should  be  recorded  at 
stated  intervals.  Prompt  removal  should  be  the  rule 
in  cases  of  recurrence,  and  the  need  of  this  should  be 
impressed  upon  the  patient.  Like  Dr.  Wiggin,  he 
placed  three  years  as  the  period  after  which  recurrence 
was  not  likely  to  take  place,  say  in  only  two  per  cent, 
of  the  cases. 

The  Management  of  Cases  of  Recurring  Tumors :  In- 
dications and  Contra-indications  of  Repaired  Operations. 
— Dr.  Stephen-  Smith  having  been  called  away,  Dr. 
Ferguson  read  his  brief  paper.  After  quoting  ^'ir- 
chow  and  Cohnheim,  he  said  it  thus  appeared  that 
every  tumor  was  developed  from  a  pre-e.xisting  cell  or 
cells  by  proliferation,  and  that  the  tumor  was  not  an 
independent  being,  but  was  a  part  of  the  body,  and 
subject  to  the  laws  which  covered  the  body.  The 
mere  statement  of  these  facts  seemed  to  indicate  very 
clearly  what  should  be  the  management  of  every  access- 
ible tumor.  Common  sense  dictated  that  the  only 
method  to  eradicate  a  growth  which  had  its  origin  in  a 
germ,  was  to  destroy  the  germ  itself,  and  such  was  now 
the  universal  practice  of  surgeons.  This  rule  applied 
no  less  to  tumors  at  a  distance  from  the  parent  growth 
than  to  the  parent  growth  itself. 

The  Indications  of  Non-Operative  Local  Treatment ; 
the  Therapeutic  Value  of  Toxins. — Dr.  W.  B.  Coley, 
of  New  York,  gave  his  experience  with  toxins,  mostly 
mixed  toxins  of  erysipelas  and  bacillus  prodigiosus,  in 
the  treatment  or  malignant  tumors.  The  number  of 
patients  so  treated  exceeded  one  hundred.  The  great- 
est benefit  had  been  in  sarcoma.  He  said  that  he  did 
not  propose  to  discuss  the  theories  on  which  the  treat- 
ment of  cancer  by  toxins  is  based,  but  he  would  give 
the  results  of  his  practice  in  that  direction  during  over 
four  years,  which  he  had  spent  in  the  application  of  the 
treatment  at  the  New  York  Cancer  Hospital.  I  do  not 
say  that  all  cases  of  cancer  can  be  cured  by  the  toxin 
treatment.  I  can  only  give  to  the  profession  the  results 
which  have  been  reached  by  the  use  of  the  erysipelas 
serum  and  other  toxins.  I  have  had  good  results  in 
many  cases  of  both  sarcoma  and  carcinoma.  In  some 
cases  the  patients  have  been  greatly  benefited  by  the 
treatment,  and  their  lives  have  been  certainly  prolonged, 
if  an  entire  cure  has  not  been  achieved.  In  the  most 
successful  cases  the  malignant  growths  have  been  en- 
tirely abated,  no  symptoms  of  their  presence  can  be 
detected  by  the  most  rigorous  examination,  and  the 
patients  are  in  apparently  perfect  health.  There  has 
been  no  recurrence  of  the  cancerous  growth  since  the 
cessation  of  the  treatment,  although  the  time  from  the 
cessation  of  the  treatment  in  the  different  cases  ranges 
from  seven  months  to  three  years.  The  reason  that 
other  practitioners  have  not  been  as  successful  and  have 
not  achieved  such  good  results  as  I  am  able  to  report, 
can  probably  be  traced  to  the  fact  either  that  the  treat- 
ment has  been  slip-shod  or  has  not  been  sufficiently 
persisted  in.  .A.11  the  cases  which  I  have  treated  suc- 
cessfully have  been  pronounced  inoperable  by  the  best 
authorities  in  this  and  other  cities,  owing  to  the  posi- 
tion of  the  malignant  growths  or  other  conditions. 
Several  of  tiie  patients  had  been  operated  on  previously, 
and  came  under  my  care  at  the  hospital  on  a  recurrence 
of  the  cancer.  In  cases  where  the  toxin  treatment  was 
successful,  the  patients  are  now  going  about  apparently 
in  perfect  health. 

Dr.  Coley  then  enumerated  eight  cases  which  had 
been  treated  by  him  with  success.  He  detailed  at 
length  the  condition  of  the  patients  when  they  came 


into  his  hands,  the  exact  nature  of  the  malignant 
growth  from  which  they  suffered,  and  the  course  of 
treatment  pursued  in  each  case.  Six  of  Dr.  Coley's 
patient's  who  had  been  successfully  treated  —  four 
women  and  two  men — visited  the  hall,  and  the  doctors 
subjected  them  to  a  rigorous  inspection. 

The  President's  Annual  Address. — The  President, 
Dr.  Austin  Flint,  of  New^  York,  chose  for  the  sub- 
ject of  his  address  "  The  Coming  Role  of  the  Medical 
Profession  in  the  Scientific  Treatment  of  Crime  and 
Criminals." — Society,  he  ventured  to  say,  was  not  pre- 
pared to  accept  Rondeau's  view,  that  crime  being,  as 
he  claimed,  the  outcome  of  disease,  its  penalty  should 
be  nothing  else  than  medical  treatment  ;  but  it  must 
be  admitted.  Dr.  Flint  said,  that  the  treatment  of  crime 
and  criminals,  under  existing  laws,  and  their  execution 
is  a  failure,  and  a  failure  so  serious  in  its  results  that  it 
is  difficult  to  imagine  what  will  occur  before  a  revolu- 
tion takes  place,  and  scientific  criminology  and  penology 
become  established  as  part  of  the  social  fabric.  The 
chief  object  of  a  penal  system  is  the  protection  of  so- 
ciety, the  quoted  fact  which  showed,  he  said,  that  the 
protection  of  society  against  crime  and  criminals  is  be- 
coming more  and  more  alarmingly  inefficient.  The 
United  States  census  showed  in  1S50  ratio  of  prisoners 
to  population,  i  in  3,442  ;  in  1880,  i  in  855  ;  in  1S90, 

I  in  75.7- 

Sentimentality  in  questions  of  criminology  and  pe- 
nology should  be  put  aside.  It  has  no  more  place  in 
criminal  law  and  penal  administration  than  in  medicine 
and  surgery.  Crime  is  a  disease  of  our  social  organiza- 
tion. It  is  true  that  it  is  ineradicable,  but  it  may  be 
restricted  within  much  narrower  limits  than  at  present 
exist.  While  crime  cannot  be  abolished,  all  criminals 
are  not  hopelessly  affected  with  crime.  It  has  been 
abundantly  shown  that  criminals  may  be  divided  into 
two  great  classes,  the  curable  and  the  incurable,  and  so- 
ciety needs  the  aid  of  competent  men  to  undertake  the 
task  of  separating  the  two  classes,  to  restore  the  curable 
to  usefulness,  and  to  protect  our  social  organization 
against  the  incurable.  In  Dr.  Flint's  opinion,  the  only 
hope  is  in  the  medical  profession  ;  yet  he  feared  the 
profession  can  have  little  direct  influence  in  the  mak- 
ing or  repeal  of  laws.  Our  chief  hope  at  present  is  to 
induce  judges,  lawyers,  and  law-makers  to  study  law  in 
the  light  of  'modern  scientific  knowledge.  In  its  ap- 
plication to  the  treatment  of  crime  and  criminals,  the 
idea  of  the  word  law,  in  the  minds  of  jurists  and  legis- 
lators, needs  revision.  Law  existed,  and  was  only  dis- 
covered by  man,  not  created.  Scientific  progress  will 
lead  us  finally  to  abandon  the  ancient  idea  of  punish- 
ment of  crime,  and  to  substitute  for  it  treatment  and 
correction.  The  only  punishments  will  be  those  neces- 
sary for  the  enforcement  of  discipline  in  prisons  and 
elsewhere.  The  treatment  of  criminals  will  resolve 
itself  into  measures  to  reform  the  curable,  to  protect 
society  against  the  incurable.  To  his  mind,  it  should 
not  often  be  difficult  to  distinguish  between  criminality 
and  insanity,  provided  the  data  were  sufficient.  There 
are  the  criminal  insane  and  the  insane  criminal  ;  the 
one  an  insane  person  who  commits  crime  under  an  in- 
sane impulse  ;  the  other,  simply  a  criminal  who  has 
become  insane. 

In  the  scientific  study  of  crime,  the  physician  has  to 
do  mainly  with  the  occasional  criminal,  the  habitual 
criminal,  and  the  born  criminal ;  and  in  this  study, 
the  first  thing  is  to  separate  these  from  the  offender 
who  is  not  a  criminal  and  the  occasional  criminal. 
The  born  criminal  is  seldom  without  physical  evidences 
of  what  is  now  called  degeneration.  The  criminal  by 
occasion  may  lack  physical  and  moral  characteristics 
of  criminality  and  have  no  criminal  heredity,  being 
simply  a  weak  and  pliable  organization.  This  unfor- 
tunate should  be  treated  most  carefully,  and  be  pro- 
tected, as  far  as  possible,  from  influences  which  may 
render  him  an  habitual  criminal. 

The  President  then  discussed  some  of  the  character 


I 


October  26,  1895] 


MEDICAL    RECORD. 


605 


istics  of  the  different  classes  of  criminals.  On  convic- 
tion of  a  criminal,  he  should  be  turned  over  to  the 
State  for  treatment.  The  judge  should  not  fix  the  so- 
called  punishment.  Fortunately,  laws  were  not  want- 
ing in  the  State  of  New  York  to  render  possible  this 
beginning  of  an  intelligent  criminal  administration. 
All  will  admit  the  value  and  saving  to  society  of  the 
reformation  of  criminals  ;  and  all  criminologists,  with- 
out exception,  regard  the  indeterminate  sentence  as 
indispensable  to  proper  reformatory  measures.  The 
good  results  of  the  reformatory  method  were  shown  in 
the  Elmira  Reformatory.  Prisoners  should  be  under 
the  supervision  of  physicians. 

Speaking  of  capital  punishment,  he  said  we  certainly 
should  be  able  to  prevent  a  murderer  from  repeating 
his  crime  without  committing  a  legalized  murder.  The 
only  argument  to  his  mind  that  remained  in  defense  of 
capital  punishment  was,  that  it  may  be  deterrent. 

In  conclusion,  he  said  that  while  it  would  be  desir- 
able to  adjust  our  criminal  laws  so  as  to  bring  them  in 
accord  with  the  present  scientific  status  of  criminology, 
existing  laws  admit  of  important  reforms.  A  scientific 
spirit  might  be  infused  into  the  prison  commission,  if 
it  included  members  of  the  medical  profession.  Phy- 
sicians to  prisons  should  study  criminals,  according  to 
modern  methods,  and  not  simply  prescribe  for  their 
bodily  ailments. 

Observations  on  the  Minor  Degrees  of  Contracted 
Pelvis. — Dr.  Austin  Flint,  Jr.,  read  the  paper.    (See 

p.  583) 

Dr.  George  T.  Harrison  said  the  impression  had 
seemed  to  prevail  here  that  pelvic  deformities  existed 
chiefly  in  foreign  countries.  He  thought  Dr.  Flint  had 
done  a  good  service  in  showing  the  frequency  of  minor 
contractions  of  the  pehis  in  New  York.  He  could  not 
understand  how  any  person  could  prefer  high  forceps 
to  version.     Yersion  was  much  safer. 

Dr.  ^V.  T.  Lusk  said  the  subject  of  pelvic  deformi- 
ties was  one  of  such  importance  that  it  had  been  set 
down  for  special  discussion  at  the  next  meeting  of  the 
International  Obstetrical  Congress.  He  had  been  as- 
signed the  work  of  tabulating  statistics  from  America, 
and  the  paper  of  Dr.  Flint  would  be  of  great  service  to 
him.  Contraction  of  the  pelvis  in  this  country  was  usu- 
ally slight  in  degree  compared  with  that  in  Europe.  If 
the  contraction  were  not  below  three  inches  and  a  half 
for  the  true  conjugate,  spontaneous  deliver)-  might  take 
place,  or  it  might  be  necessary  to  resort  to  version  or 
forceps.  Dr.  Lusk  would  not  condemn  high  forceps 
entirely,  as  it  would  seem  Dr.  Harrison  would  do.  He 
hoped  craniotomy  on  the  living  child  would  give  place 
either  to  one  of  the  methods  just  mentioned,  or  to 
symphyseotomy  on  Caesarean  section. 

Kotes  on  the  Diagnosis  of  Interstitial  Cerebritis. — 
Dr.  M.  J.  Hepetrn,  of  New  York,  related  two  cases 
bearing  upon  the  early  recognition  of  this  affection,  or 
as  it  is  generally  termed,  general  paresis. 

The  first  was  that  of  a  physician  who  was  under  ob- 
servation for  two  years  and  whose  earliest  symptoms 
were  discomfort  in  or  about  the  eyes,  followed  by 
gradual  lowering  of  vision,  and  periodic  dilatation  of 
the  right  pupil.  The  ophthalmoscopic  appearances 
were  slight  creamy  redness  of  the  optic  disk,  later  pal- 
lor, going  on  to  the  appearance  of  primary  atrophy  of 
the  nerve,  the  retinal  vessels  showing  no  signs  of  change. 
A  gradual  narrowing  of  the  visual  field  accompanied  the 
change  in  the  nerve,  mostly  confined  to  the  temporal 
side.  The  general  symptoms  of  the  disease  appeared 
as  the  eye  symptoms  increased,  and  he  died  in  an  asy- 
lum. 

The  second  case  was  that  of  an  artist  who  presented 
similar  changes  in  the  earlier  period  of  observarion, 
and  later  developed  lines  of  change  in  the  retina  near 
the  disk.  The  general  signs  of  beginning  paresis  be- 
gan to  manifest  themselves  some  months  later,  and  the 
affection  of  the  optic  nerve  being  considered  an  inter- 
stitial neuritis,  he  was  put  under  treatment  for  that  af- 


fection, with  the  result  that  not  only  was  there  entire 
recovery  so  far  as  the  eye  was  concerned,  but  the  gen- 
eral symptoms  also  disappeared,  and  there  was  appar- 
ently complete  restoration  to  health. 

These  cases  would  seem  to  support  the  theorj*  that 
the  earliest  stage  of  what  is  called  general  paresis  is  a 
low  grade  of  interstitial  inflammation,  with  slight  and 
transient  exudation  which,  however,  when  undisturbed 
may  go  on  to  the  destruction  of  nerve  tissue  and  cells, 
yet  not  leaving  much  if  any  traces  of  the  first  deposit. 


Third  Day,  Thursday,  October  17TH. 

Dr.  Darwin  Colvin,  of  Wayne  County,  was  elected 
President  for  the  ensuing  year :  Dr.  E.  D.  Ferguson 
was  re-elected  Secretary  and  Treasurer. 

A  New  and  Orig-inal  Method  of  Obtaining  Material 
for  Skin  Grafting.— Dr.  Zera  J.  Lusk  read  a  paper 
describing  his  experience  with  a  method  of  skin  graft- 
ing which  he  first  employed  rather  by  accident.  The 
dry  epidermis  hanging  from  the  skin  after  a  burn  was 
used  successfully  for  grafting  a  large  raw  area.  The 
method  could  be  carried  out  on  any  occasion  by  rais- 
ing the  epidermis  through  the  application  of  a  blister. 
The  epidermis,  when  drj',  was  cleansed  and  moistened, 
a  piece  an  inch  square  was  cut  into  perhaps  twelve 
pieces  and  applied  on  the  wound.  Little  islands  were 
formed  which  spread  and  covered  the  entire  surface. 

A  Study  of  Hysteria  and  Hypochondriasis.  — Dr. 
Charles  E.  Lockwood,  of  New  York,  in  this  paper 
enumerated  about  fifteen  conditions  favoring  or  causing 
hysteria  or  hypochondriasis.  Some  were,  hereditarj" 
neurosis,  unfavorable  environment,  improper  mental  and 
physical  training,  physical  defects,  lack  of  definite  pur- 
pose in  life  and  mental  occupation,  superstitious  notions, 
especially  as  to  one's  own  ill  health  and  remedies  there- 
for, tobacco,  alcoholic,  and  opium  habits,  lack  of  phys- 
ical exercise,  circulation  in  the  blood  of  poisonous 
germs  and  toxic  matters,  syphilis,  uric-acid  diathesis, 
etc. 

The  author  emphasized  the  importance  of  mental  oc- 
cupation, of  having  the  patient  forget  himself  and  take 
an  interest  in  other  people's  welfare.  Diet  and  medic- 
inal treatment  were  also  considered. 

The  Techniqtie  of  Maunsells  Method  of  Intestinal 
Anastomosis. —  Dr.  Frederick  Holme  Wiggin,  of 
New  York,  described  the  method  and  cited  its  results. 
Maunsell's  original  description  was  recognized  as  some- 
what obscure,  and  Dr.  Wiggin  wrote  him,  suggesting 
that  he  rewrite  it.  Maunsell  ha\-ing  died,  at  the  request 
of  his  wife  Dr.  Wiggin  had  undertaken  the  work.  Dia- 
grams were  used,  and  the  third  patient  ever  operated 
upon  by  this  method,  by  himself  (1893)  was  shown. 
There  had  been  no  pain,  no  evidence  of  contraction. 
The  operation  was  done  as  an  emergency,  by  lamp- 
light, wth  a  woman  domestic  administering  ether.  In 
all,  nine  successful  cases  of  anastomosis  by  Maunsell's 
method  had  been  reported,  and  two  unsuccessful  ones, 
death  in  the  latter  being  readily  explained.  The 
method  commended  itself  for  simplicity,  rapidity,  and 
safety,  and  applicability  under  any  conditions.  Objec- 
tion had  been  found  to  be  without  basis. 

A  Review  of  the  Treatment  and  Results  in  Nine 
Cases  of  Fracture  of  the  Neck  of  the  Femur. — Dr. 
Douglas  .\yres.  of  Montgomery  County,  took  oc- 
casion to  impress  the  fact  that  much  damage  might 
be  done  by  manipulations  carried  to  the  extent  which 
might  be  necessary  to  establish  the  diagnosis  of  the 
exact  condition  present,  whether  the  fracture  was 
within  or  without  the  capsule.  Much  manipulation 
made  for  this  purpose  was  especially  reprehensible,  in- 
asmuch as  the  treatment  would  be  the  same  in  either 
case.  Much  injury  was  liable  to  arise  from  trying  to 
obtain  crepitus.  The  cases  treated  by  him  were  nine 
in  number,  the  first  one  having  been  seen  in  1882.  All 
of  the  patients  recovered  with  a  useful  limb.  Four 
were  treated  without  extension,  five  with.     Most  of  the 


6o6 


MEDICAL    RECORD. 


[October  26,  il 


patients  were  aged.  The  shortening  was  from  half  an 
inch  to  an  inch  and  a  quarter.  If  there  were  doubt  as 
to  whether  fracture  really  existed,  especially  at  the  age 
when  very  slight  force  was  sufficient  to  produce  it,  it 
was  best  to  give  the  patient  the  benefit  of  the  doubt 
and  immobilize  the  limb.  Regarding  the  indications 
for  extension,  if  there  were  much  shortening  it  should 
be  overcome  by  moderate  e.xtension.  In  the  young, 
extension  should  be  the  rule. 

Diseases  of  the  Ankle-joint. — Dr.  Thomas  M.  Lud- 
low Chrvstie,  of  New  York,  in  this  paper  considered 
the  anatomy  and  function  of  the  ankle-joint,  related 
some  cases  of  disease,  stated  that  they  usually  gave  a 
history  in  the  commencement  of  some  wrenching  or 
trauma,  and  finally  in  connection  with  the  treatment 
showed  a  steel  shoe  which  he  preferred  to  plaster  of 
Paris  in  immobilization. 

A  Brief  Contribution  to  the  Therapeutics  of  Diabetes. 
— Dr.  J.  Dl.^ke  White,  of  New  York,  expressed  the 
view  in  a  paper  on  the  above  subject  that  diabetes 
could  be  classed  among  the  neuroses.  Indeed,  he 
thought  the  disease  obviously  arose  in  the  sympa- 
thetic chain  which  controlled  certain  secreting  func- 
tions. His  own  experience  coincided  with  that  of 
others,  that  the  best  response  came  from  treatment  di- 
rected to  the  digestive  tract,  but  he  thought  it  was  ow- 
ing to  the  influence  upon  the  nervous  system.  In 
addition  to  dietetic  management  he  had  found  in- 
testinal antisepsis  of  value,  and  dwelt  more  upon  the 
administration  of  benzoazol.  Fifteen  grains  a  day  was 
sufficient,  given  in  capsules.  It  was  aided  by  carbo- 
nated lithia  and  Fowler's  solution. 

Dr.  J.  Ci.  Truax  added  his  testimony  to  the  influ 
ence  of  the  nervous  system  in  causing  sugar  to  appear 
in  the  urine.  He  had  witnessed  it  in  shock  from  trau- 
ma and  operations.  Diabetic  patients  were  troubled, 
too,  with  some  form  of  indigestion,  and  it  was  this 
which  usually  first  drove  them  to  the  doctor. 

The  Criminal :  His  Social  and  Legal  Status,  and  the 
Philosophy  of  Reformation. — Dr.  William  A.  White, 
of  Broome  County,  read  a  paper  of  considerable  length 
on  this  subject,  in  which  he  expressed  views  similar  to 
those  contained  in  the  President's  Address.  There  was 
no  subject  of  a  medical  nature  in  which  the  public  was 
taking  so  much  interest  at  present  as  criminology. 
Arid  it  was  well  that  it  should  be  so,  for  our  defective, 
dependent,  and  delinquent  classes  were  largely  consti- 
tuted of  degenerates,  and  statistics  showed  that  it  was 
being  increased  from  year  to  year.  Society  thus  seemed 
threatened,  but  let  us  hope  that  science  would  be  able 
to  organize  efficient  methods  of  attack  upon  this  form 
of  disease  in  the  body  social. 

Upon  the  potent  causes  in  the  production  of  the 
degenerate  were  such  economic  disturbances  as  had 
been  illustrated  by  the  recent  financial  crisis  and  the 
war  going  on  between  labor  and  capital.  The  delete- 
rious effects  always  fell  with  greatest  force  upon  the 
poor. 

There  were  many  classes  of  criminals.  There  was 
the  criminal  by  passion,  the  criminal  by  force  of  cir- 
cumstances, and  with  these  we  had  less  to  do.  Then 
there  was  the  occasional  criminal  and  the  habitual 
criminal.  These  required  more  serious  consideration 
on  the  part  of  physicians.  Attempts  had  been  made 
to  recognize  the  signs  which  separated  them  from  the 
rest  of  society,  and  of  recent  years  with  considerable 
success,  special  mention  being  made  of  the  Italian 
school  headed  by  Lombrosi.  It  was  in  the  brain  that 
one  would  expect  to  find  the  clearest  evidences  of  de- 
generacy, but  while  defects  doubtless  existed  here,  we 
knew  as  yet  little  of  their  nature  owing  to  the  compli- 
cated and  delicate  structure  of  this  organ.  It  was 
rather  in  the  skeleton  that  we  found  variations  from 
the  normal  readily  appreciable.  Thus,  in  criminals 
there  had  been  recognized  anomalies  of  cranial,  orbi- 
tal, and  other  cavities,  strabismus,  arching  of  the  pal- 
ate, etc.     In  proportion  as  one  possessed  these  anoma- 


lies of  structure,  was  he  less  highly  organized  than 
should  be,  and  predisposed  to  commit  crime.     Lom- 
brosi professed  to  be  able  to  recognize  the  criminal  by 
his  chirography,  and   even   to  tell  the  character  of   his 
crime  thereby. 

The  true  criminal  was  a  degenerate,  and  this  being 
so,  what  should  be  our  attitude  toward  him  ?  Before 
answering  this  question  we  should  first  decide  that  of 
responsibility.  The  ijuestion  of  responsibility  was  one 
of  degree,  depending  upon  knowledge  of  the  nature  of 
the  act,  of  the  character  and  forces  which  impelled  to 
the  action,  and  of  the  character  and  forces  restraining 
from  action. 

Dr.  White  thought  it  ridiculous  for  a  jury  of  laymen 
to  pass  judgment  upon  the  testimony  of  expert  medi- 
cal witnesses.  He  thought  the  latter  should  be  ap- 
pointed by  the  State,  and  should  investigate  the  case 
impartially,  in  a  scientific  spirit,  and  hand  their  report 
to  the  judge.  In  the  treatment  of  criminals,  reforma- 
tion and  restriction  should  be  held  in  view,  while  re- 
taliation should  take  no  part.  To  inflict  legal  murder 
was  no  less  than  brutal  and  barbarous. 

Dr.  White  thought  our  prison  system,  while  an  im- 
provement on  the  past,  should  be  still  further  changed. 
The  best  example  of  what  it  should  be  which  we  had 
at  present  was  the  Elraira  Reformatory,  where  over 
fifty  per  cent,  of  the  inmates  were  discharged  as  cured 
of  criminality. 

Dr.  John  G.  Truax  wished  to  say  a  word  for  the 
New  York  Juvenile  Asylum.  All  the  reformatory 
measures  referred  to  as  desirable  by  the  author  were 
carried  out  there  except  that  isolation  of  different 
classes  was  impracticable  for  want  of  room.  Ninety  per 
cent,  of  the  criminals  sent  to  this  institution  were  per- 
manently reformed. 

Dr.  Austin  Flint  said  there  was  an  essential  o;:- 
ference  between  the  New  York  Juvenile  Asylum  and 
the  Elmira  Reformatory,  for  in  the  former  the  inmates 
were  young  and  had  committed  their  first  crime,  while 
in  the  latter  they  were  older  and  more  confirmed,  hav- 
ing been  sentenced  to  State  prison. 

Committee  to  Consult  with  the  Prisoners'  Associa- 
tion.— Dr.  T.  W.  S.  Gouley  moved  that  the  Council  be 
instructed  to  appoint  a  committee  on  the  question  of 
criminality,  to  confer  with  a  similar  committee  to  be 
appointed  by  the  Prisoners'  .Association,  and  to  report 
at  the  next  meeting  of  the  .Association.  The  resolution 
was  adopted. 

Some  Fractures  of  the  Upper  Extremities  in  Chil- 
dren.— Dr.  John  F.  Erdmann,  of  New  York,  read  ti.c 
paper  (see  p.  585). 

Dr.  Austin  Flint  introduced  his  successor  in  tlie 
presidential  office.  Dr.  Darwin  Colvin,  who  thanked 
the  .Association  for  the  high  honor  conferred  upon 
him.     The  Association  then  adjourned. 


Tumors  of  the  Mammary  Gland. — i.  Mammary  car- 
cinoma submitted  to  operation  before  infection  of  t'lie 
axillary  glands  should  promise  fifty  per  cent,  of  cures. 
2.  Although  the  axillary  glands  seem  not  to  be  involved, 
the  axilla  should  be  opened  in  every  case  and  thor- 
oughly cleared  of  glands  and  fat.  3.  Infected  axillary 
glands  are  of  bad  prognostic  import,  but  a  radic.il 
operation  that  removes  them  and,  at  the  same  time. 
the  supra-clavicular  glands,  may  cure  eleven  per  cent,  oi 
the  cases.  4.  The  complete  operation  should  be  prac- 
tised in  every  case  of  malignant  disease.  5.  The  mor- 
tality following  the  complete  method  is  doubtless 
somewhat  greater  than  is  that  of  partial  operations. 
The  difference  in  results,  however,  is  so  conspicuous, 
when  the  question  of  "  cure  "  is  considered,  that  the 
radical  operation  is  the  only  one  to  be  countenanced. 
7.  Statistics  gathered  many  years  ago  are  as  valueless 
as  are  those  made  use  of  in  estimating  the  mortality 
after  amputation  of  the  extremities. — Rodman. 


October  26,    1895] 


MEDICAL    RECORD. 


607 


NEW   YORK  ACADEMY  OF    MEDICINE. 

SECTION   ON    GENERAL    MEDICINE. 

Stated  Meeting,  October  I§,i8()s. 

W.  H.  Porter  M.D.,  Chairm.\n. 

Morphinism  in  the  Old :  Cases  at  Threescore  and  Ten ; 
Eecovery.  — Dr.  J.  B.  Mattison  read  the  paper  on  this 
subject. 

He  said  morphinism  in  the  old  was  rare.  Most  cases 
of  that  neurosis  occurred  between  thirty  and  forty,  the 
number  steadily  declining  in  later  decades.  In  a  paper, 
"  Morphinism  in  the  Young,"  he  had  called  attention 
to  the  rarity  of  that  disorder  in  children,  as  evidenced 
by  reported  cases,  but  he  believed  it  prevailed  more 
than  records  or  mortality  tables  showed.  In  children 
there  were  many  cases  of  unsuspected  heritage  from 
maternal  ancestry  tainted  along  narcotic  lines,  death 
usually  coming  before  the  fourth  day.  Also  many  ac- 
quired cases  resulting  from  ignorant  or  indiscreet 
opium  giving.  In  the  aged  this  toxic  factor  was  more 
patent.  Some  of  the  genetic  factors  of  morphinism  in 
middle  life  played  a  part  in  the  old,  but  the  absence 
of  the  most  common  cause,  pain,  might  be  put  down 
as  the  main  reason  for  its  infrequeney  in  the  old. 

Dr.  Mattison  said,  in  his  e.xperience  neuralgia  was 
the  most  prolific  cause  of  morphinism,  but  as  that  was 
a  disease  of  the  first  four  decades  mainly,  unless  from 
structural  lesions  or  morbid  growth,  morphinism  would 
not  be  caused  so  often  in  the  old.  Of  the  two  cited  in 
the  paper,  pain  was  the  cause  in  both.  One  was  due  to 
sciatica,  the  other  to  melancholia.  Both  patients  were 
laymen,  one  seventy,  the  other  seventy-two,  years  of 
age.  In  the  former  the  disease  had  persisted  four 
years,  the  opiate  used  was  laudanum,  and  sometimes 
rum,  to  e.xcess.  The  other  had  used  morphia  twenty 
years,  but  reaching  only  four  grains,  subcutaneously,  per 
day.  His  physical  condition  was  impaired.  The  one 
that  used  the  hypodermic  was  under  treatment  eleven 
weeks,  the  other  twelve.  Both  recovered.  The  one 
that  had  used  morphia  lived  fifteen  months  after  com- 
plete cure,  and  died  of  albuminuria.  The  other  sur- 
vived four  years,  free  from  opium,  and  died  of  old  age. 
•  Regarding  the  results  of  morphinism  in  the  old,  they 
are  not  as  disastrous  as  in  earlier  years.  This  is  mainly 
due  to  the  less  lavish  use  of  the  drug,  the  old  seldom 
taking  it  to  excess.  The  writer  said  he  believed  a  mod- 
erate use  of  opium,  in  a  not  small  proportion  of  cases 
after  threescore  and  five  was  salutar)',  and  conducive 
to  length  of  life.  In  addition  to  the  supporting  effect 
at  this  time  of  life  it  undoubtedly  exercised  a  prophy- 
lactic power  against  inflammatory  diseases.  This  power 
obtained  in  opium  habitues  in  early  life  and  diminished 
as  the  drug  was  withdrawn. 

Dr.  Mattison  cited  a  case  of  a  woman  who  lived  to 
be  eighty-six,  but  suffered  from  sciatica.  At  his  sug- 
gestion she  had  used  opium,  in  the  form  of  deodorized 
tincture,  in  doses  seldom  exceeding  ten  to  twelve  drops 
per  day.  It  worked  well,  she  did  not  suffer,  so  en- 
joyed life  much  more,  the  demand  did  not  increase, 
and  life  was  surely  lengthened. 

Among  cases  eligible  for  treatment,  the  prognosis 
for  morphinism  in  the  old  was  good.  The  proportion 
of  permanent  recoveries  in  patients  above  sixty  under 
his  care  had  been  greater  than  in  those  below  that  age. 
This  was  due  to  the  liability  of  recurring  causes  in 
ex-morphinists  of  middle  life,  and  a  lack  of  time  taken 
in  the  post-active  treatment.  This  was  especially  true 
of  medical  men.  In  these  there  was  the  danger  of 
premature  return  to  professional  work,  and  this,  in  his 
experience,  had  been  the  most  frequent  cause  of  the 
return  of  the  disease.  The  author  said  the  remote  fu- 
ture of  his  patients  gave  him  most  concern.  Even  phy- 
sicians did  not  seem  to  realize  that  it  took  not  only 
months  of  hygienic  care  and  environments,  but  even 
years  in  many  cases,  to  secure  a  lasting  cure. 


There  was  some  cases  in  the  aged  not  eligible  for 
treatment,  and  in  these  cases  it  was  best  to  give  that 
form  of  the  drug  which  was  the  least  destructive. 
This  he  thought  was  the  crude  drug  or  the  deodorized 
tincture.  Morphia,  subcutaneously,  was  the  most  dis- 
astrous. 

In  cases  where  it  was  deemed  best  to  entirely  with- 
draw the  opiate,  the  treatment  must  be  adapted  to 
each  case.  The  patient  as  well  as  the  disease  should 
be  treated.  In  proper  cases  the  Mattison  method  could 
be  used  with  full  promise  of  good  result.  In  others  a 
more  gradual  withdrawal  of  the  drug  was  best.  To 
abruptly  withdraw  the  drug  was  brutal,  and  need  be 
mentioned  only  to  be  condemned.  It  sometimes  caused 
fatal  collapse  in  the  vigor  of  middle  life,  and  was  much 
more  likely  to  do  so  in  the  weakened  organism  of  the 
old. 

On  Haemogallol,  and  the  Assimilation  of  Iron  by 
the  Organism. — Dr.  L.  H.  Friedburg.  read  the 
paper  on  the  above  subject.  He  said  of  the  normal 
iron  of  the  body  which  was  excreted  by  metabolism 
about  ten  per  cent,  appeared  in  the  urine  and  about 
ninety  per  cent,  in  the  faeces.  Iron  injected  hypo- 
dermically  or  intravenous  appeared  in  a  few  minutes 
in  large  quantities  in  the  urine,  but  it  was  not  firmly 
linked  to  organic  material.  The  iron  received  by  the 
mouth  and  assimilated  by  the  system  was  represented 
by  this  ten  per  cent,  in  the  urine,  and  this  ten  per  cent, 
then  must  be  considered  the  amount  of  assimilated  iron. 
The  average  amount  voided  in  twenty-four  hours  was 
one  milligramme.  To  determine  the  amount  of  iron 
assimilated  when  given  as  a  compound  it  must  be  de- 
termined whether  this  normal  ten  per  cent,  in  the  urine 
had  been  increased  or  not.  It  had  to  be  stated  that 
none  of  the  existing  iron  medicines  sensibly  increased 
the  mentioned  amount,  and,  hence,  could  not  be  con- 
sidered as  having  been  assimilated. 

Bunge  had  said  at  the  May  meeting  of  European 
naturalists  at  Munich,  that  the  best  place  to  buy  iron 
was  not  at  the  drug  store,  but  at  the  vegetable  and  egg 
market,  referring  to  yolks  and  spinach.  He  was  right 
as  far  as  in  those  substances  the  iron  is  linked  in  such 
a  form  as  to  be  assimilated,  but  he  forgot  that  success- 
ful research  had  been  made  to  find  compounds  in 
which  iron  was  firmly  linked  to  albuminoid  substances. 
Robert  satisfied  himself  that  none  of  the  iron  com- 
pounds were  assimilated,  but  faced  the  fact  that  from 
their  administration  there  were  certain  beneficial  re- 
sults, which  he  explained  was  due  to  its  secondary  ac- 
tion in  combining  with  the  intestinal  gases,  mainly 
hydric  sulfid,  eliminating  it  as  one  of  the  poisonous 
gases,  and  rendering  its  action  upon  the  iron  contained 
in  the  blood  impossible. 

Kobert  found  that  the  blood  was  the  starting-point 
for  the  administration  of  iron  to  be  assimilated.  All 
the  blood  iron  preparations  existing  heretofore  had 
two  objections  :  first,  they  consisted  of  pure  dried 
blood,  which  was  objectionable  as  covering  the  intes- 
tinal track  with  a  tarry  mass  ;  or,  second,  such  blood 
was  mixed  with  iron  salts,  which  as  such  had  no  other 
effect  than  to  neutralize  the  H„S,  but,  eventually,  this 
impaired  digestion  or  produced  metal  kidney  after 
prolonged  use. 

After  long  experiment  Kobert  discovered  that  the 
reductive  action  of  pyrogallol  upon  blood  resulted  in  a 
substance  called  hajmogallol.  By  different  manipu- 
lation of  the  primary  impure  reddish-brown  precipitate, 
a  pure,  tasteless,  non-smeary  powder,  dark-brown  in 
color,  and  insoluble  in  water,  was  obtained,  9.7  grammes 
of  iron  in  the  form  of  haemogallol  increased  the  amount 
of  firmly  linked  iron  in  the  urine  to  one  hundred  and 
fifty  per  cent. 

Dr.  Friedburg  cited  experiments  by  which  it  was 
positively  proven  that  free  pyrogallol  did  not  exist  in 
the  h;emogallol.  The  use  of  haemogallol  upon  chlo- 
rotic  or  anaemic  patients  was  invariably  an  extraordi- 
narily favorable  one. 


6o8 


MEDICAL    RECORD. 


[October  26,   1895 


The  profession  of  Austria,  Germany,  and  Russia, 
had  decided  favorably  in  regard  to  the  action  of  haemo- 
gallol,  and  the  profession  of  this  country  need  no  longer 
look  upon  its  use  as  an  experiment. 

The  author  said  hsemol  as  well  as  hasmogallol  was 
the  form  of  iron,  par  excellence,  which  had  no  detri- 
mental action  whatever,  and  allowed  successful  applica- 
tion in  the  gravest  forms  of  anaemia. 

Kobert  also  prepared  compounds  of  haemol  with  the 
heavy  metals,  iron,  copper,  mercury,  and  with  the  hal- 
loids,  iodine  and  bromine.  Also,  a  mercuro-iodo-ha;- 
mol  had  been  prepared. 

Professor  Koch  had  e.xperimented  with  copper 
hffimol  upon  lupus  patients  with  good  results.  The 
mercuro-iodo-hfemol  and  bromo-hsmol  were  recom- 
mended for  the  double  action  of  blood  reconstructors 
and  specifics,  the  former  being  a  positive  specific 
against  syphilis. 

Rille,  one  of  the  most  reliable  European  syphilido- 
logues,  said  we  could  not  thank  Kobert  enough  for  his 
preparations  containing  mercury  and  iodine,  which 
produce  less  undesirable  secondary  results. 

Dr.  Friedburg  closed  his  paper  by  giving  the  history 
of  a  number  of  cases  treated  by  these  preparations  of 
iron. 

In  discussing  the  last  paper,  the  Chairman,  Dr.  Por- 
ter, said  that  he  had  used  hfemogallol  for  a  con- 
siderable length  of  time,  and  was  convinced  that  its 
therapeutical  advantages  were  fully  established.  It 
did  not  have  the  irritating  effects  that  many  prepara- 
tions of  iron  had.  The  iron  in  this  form  satisfied  the 
sulphides,  etc.,  of  the  intestines,  and  permitted  of  the 
assimilation  of  food. 


©0  rresp  0  utljeuce. 


OUR    LONDON    LETTER. 


(Fr< 


r  Special  Correspondent) 


THE     OPENING     OF     THE     WINTER    SESSION NOTES     ON 

THE    INTRODUCTORY    LECTURES. 

LoNDO.s,  October  4,  1S95. 

THE-itraditional  ist  of  October  was  celebrated  by  the 
opening  of  the  medical  schools.  As  this  occurred  on 
Tuesday,  we  are  already  in  full  working  order.  Those 
schools  which  continue  the  introductory  lecture  show 
no  falling  off  in  the  ability  displayed  by  the  lecturers, 
some  of  whom  took  up  subjects  of  public  interest. 

The  London  Hospital  College  had  perhaps  the  most 
memorable  opening.  For  the  public  presentation  to  Dr. 
Hughlings  Jackson  of  his  portrait  in  oils  and  some  sil- 
ver plate  was  an  event  to  interest  not  only  his  own 
sphere  of  labor  but  all  earnest  members  of  his  profes- 
sion. Sir  James  Paget  presided  with  his  usual  inimit- 
able felicity.  He  spoke  of  Dr.  Jackson  as  a  former 
pupil  of  his  own,  and  said  it  gave  him  consolation  as 
he  grew  old  to  find  a  former  pupil  who  had  gone  so 
far  beyond  him  in  knowledge.  He  said  the  subscrib- 
ers to  the  testimonial  had  vied  with  each  other  in  their 
expressions  of  esteem  and  gratitude  for  Dr.  Jackson's 
person  and  work,  and  he  concluded  with  the  hearty 
wish  that  Dr.  Jackson  might  live  long  to  enjoy  the  su- 
preme happiness  of  doing  good  and  prolonging  the  life 
of  others. 

The  portrait,  a  striking  one,  was  here  unveiled  amid 
loud  cheers,  and  Dr.  Jackson,  acknowledging  the  gift, 
said  he  could  not  express  how  much  he  appreciated 
the  kindness.  He  had  been  thirty-one  years  connected 
with  the  hospital,  and  made  many  friends.  Sir  James 
Paget  afterward  presented  the  prizes  to  the  successful 
candidates. 

At  St.  George's  Hospital  the  lecture  was  delivered 
by  Mr.  George  Pollock,  who  took  occasion  to  urge  the 
public  to  come  forward  and  enlarsje  and  modernize  the 


buildings  so  as  to  make  them  worthy  of  the  noble  site 
they  occupy.  He  advised  students  to  bear  in  mind 
the  temperaments  and  idiosyncrasies  of  patients,  and 
gave  some  interesting  examples  of  peculiarities.  A 
relative  of  his  own,  he  said,  was  unable  to  take  the 
smallest  quantity  of  rice  without  suffering,  and  yet 
that  was  a  most  wholesome  food.  On  one  occasion 
the  friends  of  that  gentleman,  unknown  to  him,  made 
some  biscuits,  placing  a  single  grain  of  rice  in  each. 
He  took  one  or  two,  but  became  ill  enough  to  leave 
the  table,  declaring  that  if  he  were  not  morally  certain 
he  had  not  taken  rice,  he  should  think  he  had  been 
poisoned  by  it.  He  had  heard  of  a  gentleman  who 
could  not  take  gooseberries  without  inducing  a  rash, 
and  on  one  occasion,  at  a  fashionable  party,  after  the 
champagne  had  gone  round,  turned  up  his  sleeve  and 
showed  his  friends  the  peculiar  rash  coming  out.  Idio- 
syncrasies as  to  drugs,  such  as  calomel,  opium,  and 
belladonna,  were  not  so  uncommon,  and  the  lecturer 
warned  his  hearers  against  disbelieving  the  statements 
of  their  patients  and  giving  drugs  which  they  said  dis- 
agreed with  them. 

Lord  Byron  had  said,  in  his  rather  exaggerated  way, 
that  what  would  cure  one  man  would  kill  another,  but 
the  lecturer  objected  to  the  word  cure,  and  said  we  do 
not  cure — we  treat  "  the  ills  that  flesh  is  heir  to." 
Some  credit  was  due  to  nature,  and  cure  is  the  expres- 
sion of  empirics. 

At  University  College  Professor  Bradford  urged  the 
necessity  of  scientific  training,  and  held  that  the  sci- 
ence selected  for  this  purpose  should  be  one  in  which 
students  could  see  for  themselves  the  data  on  which  its 
deductions  were  founded.  Biology  was  not  suitable 
on  account  of  the  great  claim  it  made  to  study  it 
properly.  Human  anatomy  he  held  to  be  by  far  the 
most  appropriate,  and  it  afforded  great  facilities  for 
students  to  become  accurate  obsers-ers.  Students  must 
become  careful  clinical  observers  to  attain  success. 

At  the  Middlesex  Hospital  Dr.  Julius  Mickle  de- 
voted his  address  to  discussing  the  manner  in  which 
we  obtain  knowledge  of  external  objects,  and  thence 
deducing  the  natural  and  proper  methods  of  studying 
medicine.  Study  and  research  should  be  one  honest, 
consistent,  persistent  search  after  truth. 

At  the  Westminster  Hospital  Dr.  Monckton  Cope- 
man  passed  in  review  the  steps  through  which  we  had 
arrived  at  the  bacteriological  diagnosis  and  treatment 
of  disease,  and  then  gave  a  brief  account  of  his  own  re- 
searches in  connection  with  small-pox  and  vaccinia. 
His  results  seem  to  indicate  that  the  specific  organism 
of  both  these  diseases  is  a  small  bacillus,  which  is  dem- 
onstrated with  great  difficulty.  It  can  be  cultivated  in  a 
special  medium,  though  with  very  great  difficulty,  and 
calves  have  been  successfully  inoculated  with  these 
cultures,  so  that  in  the  future  we  may  have  the  means 
in  vaccination  not  only  of  preventing,  but  of  combat- 
ing, small-pox  after  its  invasion  of  the  system. 

At  St.  Alary's  Hospital  Mr.  A.  P.  Laurie  took  for  his 
subject  "  The  Medical  Profession  and  Unhealthy 
Trades,"  and  unfolded  a  scheme  for  utilizing  the  work 
of  the  medical  staff  of  the  Factory  Department  in  a 
scientific  manner,  from  which  valuable  information 
would  be  obtained  and  the  health  of  the  operatives 
improved. 

At  the  School  of  Medicine  for  Women  Miss  Ellaby, 
M.D.,  addressed  the  students,  urging  them  to  "  make 
haste  slowly."  and  to  put  on  a  triple  armor — courage, 
wisdom,  speed.  But  she  warned  against  overworking, 
and  recommended  her  audience  to  take  time  for  recre- 
ative thought,  meditation,  and  even  dreaming. 

At  Guy's  Hospital  an  excellent  example  was  set  by 
bringing  up  a  former  student  from  the  Provinces  to  in- 
augurate the  Physical  Society.  This  was  Mr.  G.  H. 
De'Ath,  Medical  Officer  of  Health  for  Buckingham, 
who  spoke  many  wholesome  truths  on  "  our  profession, 
our  patients,  our  public,  and  our  press."  Many  racy 
remarks  of  his  must.  I  fancv,  have  touched  some  of  his 


October   26,  1895] 


MEDICAL    RECORD. 


609 


London  audience,  and  will,  it  is  to  be  hoped,  bring 
forth  fruit  in  the  more  rigid  adherence  to  ethical  con- 
duct. He  would  have  us  see  men  and  things  as  they 
really  are,  rather  than  as  they  appear  to  be,  for  he 
declared  that  no  man  and  no  thing  is  what  he  or  it 
seems  to  be.  So  many  subjects  were  crowded  into  this 
address  that  it  is  impossible  to  do  more  than  say  thev 
were  all  dealt  with  incisively  and  in  a  manner  that  sep- 
arates it  from  the  other  lectures. 

At  the  Leeds  School  Dr.  Leech,  of  Manchester,  de- 
voted his  address  to  "  Our  Forefathers,"  and  traced 
from  the  earliest  times  the  use  of  remedies,  and  held 
against  Spencer  that  our  art  did  not  arise  in  magic  or 
priestcraft,  but  in  observation  on  the  effects  of  various 
foods  and  herbs.  This  view  is  supported  with  much 
learning. 

At  Birmingham  Professor  P.  Frankland  traced  the 
stor}'  of  Pasteur's  wonderful  work  from  his  first  discov- 
ery of  the  difference  between  the  two  forms  of  tartaric 
acid  to  the  close  of  the  great  savant's  career,  which  has 
just  plunged  science  in  mourning  for  her  greatest  son. 
Nothing  could  have  been  more  timely. 

At  Liverpool  Mr.  Hutchinson  undertook  the  duty 
of  the  day,  and  discoursed  familiarly  of  "  the  examina- 
tion system  "  of  the  present  day,  pointing  out  many  of 
its  effects,  both  good  and  bad,  on  education,  both  gen- 
eral and  professional. 

At  other  schools  the  time-honored  Introductorj'  has 
fallen  into  disuse,  but  the  Dinner  holds  its  ground  al- 
most ever)'where,  though  there  are  not  a  few  who  fail 
to  see  the  use  of  the  convivial  meetings.  The  distri- 
bution of  prizes  is  interesting  to  both  students  and 
teachers.  At  St.  Thomas's  Hospital  this  year  it  was 
particularly  interesting,  as  it  was  undertaken  by  Sir 
Edwin  Arnold,  who  expressed  in  happy  terms  the  ob- 
ligations and  sympathy  with  which  the  successes  of 
scientific  medicine  are  followed  in  the  sphere  of  litera- 
ture and  journalism,  and  put  in  a  plea  for  animals  con- 
demned to  vivisection  for  the  benefit  of  humanity,  for 
an  enhanced  regard  and  a  special  consideration  toward 
creatures  thus  doomed  to  perish  for  human  good. 


APPENDICITIS    DURING    PREGNANCY    AND 
LABOR. 

To  THE  Editor  of  the  Medicu,  Record. 

Sir  :  A  reluctance  to  trespass  on  your  valuable  space 
and  the  good-nature  of  your  readers  for  a  third  time  on 
the  subject  of  "Appendicitis  during  Pregnancy  and  La- 
bor "  '  was  the  reason  why  I  refrained  from  sending  you 
a  few  remarks  on  the  very  interesting  and  instructive 
paper  on  this  occurrence  by  Dr.  J.  W.  Thomason,  of 
Huntsville,  Tex.,  published  in  your  issue  of  September 
2 1  St  last.  But  an  exceedingly  typical  case  of  this  kind 
which  has  since  come  under  my  observation  leads  me 
to  again  ask  your  indulgence. 

I  will  premise  by  saying  that  Dr.  Thomason  quotes 
the  delay  in  operating  in  the  case  reported  by  me  in 
the  Medical  Record  for  December  i,  1894,  which 
apparently  has  set  this  particular  ball  rolling,  as  a  part 
justification  for  his  delay  in  operating  in  the  case  re- 
lated by  him,  where  the  patient  recovered  without  oper- 
ation, and  was  delivered  at  term  of  a  healthy  child. 
While  this  result  undoubtedly  warranted  the  delay,  and 
eventually  the  non-performance  of  an  operation,  I 
would  not  be  understood  as  advising  such  delay  in  oper- 
ating in  other  similar  cases.  In  the  case  I  saw  with 
Dr.  Hochheimer,  in  September,  1894,  to  which  Dr. 
Thomason  refers  as  "now  famous  in  medical  litera- 
ture," we  delayed  the  operation  only  four  days  (not 
■'about  six  days,"  as  Dr.  Thomason  says),  and  I  ex- 
pressly stated  at  the  end  of  my  article,  in  regard  to  the 
time  when  the  operation  should  be  performed,  as  fol- 

'  Medical  Record,  December  i,  1894,  and  March  23.  1895. 


lows  :  "  I  think  that  in  a  future  similar  case  I  would 
open  the  abscess  at  once,  as  soon  as  a  reasonable 
probability  of  its  existence  could  be  settled,  without  ref- 
erence to  the  pregnancy  or  the  impending  or  completed 
delivery.  I  would  rather  take  the  chances  of  puerperal 
infection  from  the  abscess  than  of  its  unexpected  rupt- 
ure at  any  moment  into  the  peritoneal  ca\'ity." 

The  above  statement  makes  my  position  as  regards 
the  time  of  operation  in  such  cases  sufficiently  clear  and 
positive.  Would  that  the  question  of  diagnosis  were  as 
easily  settled  !  Dr.  Thomason  refers  to  this  point,  and 
quotes  several  authors  who  have  written  since  my  arti- 
cle appeared,  and  who  report  difficulty  in  diagnosis  and 
unfavorable  results  from  early  operations,  the  women 
aborting  and  d>ing  several  days  later.  They  do  not 
say,  however,  nor  can  they  say  with  any  certainty,  how 
long  the  acute  inflammation  of  the  appendix  (probably 
with  perforation  already  accomplished)  had  existed 
before  the  patient  was  seen  by  the  operator.  These 
questions  of  difficulty  of  diagnosis,  and  time  of  opera- 
tion when  the  diagnosis  has  been  suggested  or  made, 
will  be  brought  out  in  the  case  I  am  about  to  relate. 

On  October  2d  last  I  was  asked  by  Dr.  David 
Franklin,  of  17  East  129th  Street,  to  see,  wnth  him,  Mrs. 

H.  S ,  forty  years  of  age,  mother  of  nine  children, 

who  had  been  confined  by  a  midwife  two  days  before 
of  a  dead  anencephalic  foetus  at  term.  There  had  been 
an  unusual  amount  of  amniotic  fluid,  and  the  placenta 
failed  to  come  away.  Hence  Dr.  Franklin  was  sent 
for,  but  not  being  at  home.  Dr.  Charles  M.  Ford,  of 
218  West  135th  Street,  was  called  in  his  place,  and 
detached  and  delivered  the  completely  adherent  pla- 
centa. It  was  attached  to  the  right  side  of  the  uterus. 
(Compare  with  Dr.  Thomason 's  statement  as  to  the  site 
on  the  right  side  and  the  calcareous  degeneration  of 
the  placenta  in  his  case,  with  a  healthy,  living  child,  p. 
408,  December  i,  1894.)  The  patient  at  that  time  com- 
plained of  no  more  than  the  usual  after-pains.  Within 
twelve  hours,  however,  she  began  to  vomit,  and  as  the 
vomiting  increased  the  abdomen  became  tympanitic, 
and  pain  was  localized  in  the  right  iliac  region.  There 
had  been  a  large  ahine  evacuation  from  castor-oil  be- 
fore deliver}',  but  none  afterward. 

When  I  saw  her,  at  three  o'clock  on  the  afternoon  of 
October  2d,  she  was  retching  and  vomiting  inces- 
santly, the  stomach  being  empty  :  the  pulse  was  63, 
fairly  strong,  but  dicrotic  ;  temperature  and  respira- 
tions normal  ;  tongue  moist  and  clean  ;  extremities 
warm  :  no  particular  sign  of  collapse.  .A.bdomen  much 
distended  and  very  tense.  Pain  chiefly  in  right  iliac 
region,  but  no  perceptible  dulness  or  resistance  at  that 
spot.  Vaginal  examination  showed  nothing  abnormal. 
On  questioning  the  patient  as  to  her  health  just  before 
confinement,  she  said  it  was  good,  and  that  she  had  no 
pain  then.  But  on  asking  her  whether  she  had  ever 
had  similar  attacks  of  pain  in  the  right  iliac  region, 
she  said  that  during  her  last  three  or  four  pregnancies 
she  had,  up  to  the  fourth  or  fifth  month,  more  or  less 
pain  in  that  region,  which  gradually  wore  away  and  did 
not  return  until  the  next  pregnancy.  Her  husband 
added  the  information  that  sixteen  years  ago  she  had 
been  very  ill  with  pain  in  the  right  side. 

Judging  from  the  present  symptoms  and  the  history, 
I  felt  justified  in  making  the  diagnosis  of  recurrent  ap- 
pendicitis, with  probable  rupture  of  an  adhesion  during 
this  confinement,  produced  either  by  the  uterine  con- 
tractions, or  possibly  by  the  manual  detachment  of  the 
placenta.  The  diagnosis  and  former  probability  were 
imparted  to  the  husband,  the  latter  possibility  to  Drs. 
Franklin  and  Ford  privately.  The  probability  of  a 
perforation  of  the  appendix  was  not  then  entertained 
since  there  was  as  yet  no  sign  of  general  peritonitis. 
The  vomiting,  however,  I  decided  to  be  undoubtedly 
reflex  from  a  local  peritonitis  in  the  right  iliac  region, 
and  I  gave  as  my  opinion  the  necessity  of  first  control- 
ling the  vomiting  by  hypodermics  of  morphine  admin- 
istered over  the  epigastrium,  and  of  reducing  the  tym- 


6io 


MEDICAL    RECORD. 


[October  26,  1895 


panites  by  oxgall,  glycerine,  and  turpentine  enemata, 
so  as  to  enable  us  to  arrive  at  a  more  positive  diagno- 
sis as  to  the  actual  presence  of  an  appendiceal  abscess 
and  the  advisability  of  operative  interference.  The 
patient  certainly  at  that  time  did  not  seem  in  a  good 
condition  for  angesthesia  and  laparotomy.  Nutrition 
by  the  rectum  was  also  recommended. 

On  the  5th,  three  days  later,  I  received  a  note  from 
Dr.  Franklin  that  the  patient  had  improved  very  much 
up  to  that  morning  ;  the  vomiting  had  ceased,  large 
quantities  of  gas  and  considerable  faeces  had  been 
passed,  the  abdomen  was  soft  and  much  less  distended, 
and  her  general  condition  good.  On  that  morning, 
however,  the  fifth  day  after  confinement,  the  tympa- 
nites returned,  and  temperature  and  pulse  began  to  go 
up  a  little,  to  101°  F.,  and  112°,  respectively.  I  saw  her 
again,  with  Dr.  Franklin,  that  afternoon  and  found  her 
as  tympanitic  as  ever.  The  stomach  was  good,  but  the 
tongue  coated.  Strength  still  very  good.  No  decided 
dulness  or  resistance  on  right  side.  Lochia  offensive. 
I  advised  that  decided  efforts  be  now  made  to  empty  the 
intestines  of  gas  and  whatever  fceces  they  might  contain 
by  means  of  doses  of  one-half  grain  of  calomel  every  half- 
hour  until  twenty  had  been  taken,  followed  by  drachm 
doses  of  Rochelle  salts  and  oxgall  enemata  if  necessary. 
In  any  case  to  let  me  know  in  the  morning,  and  if 
there  was  no  improvement  an  exploratory  incision  into 
the  right  iliac  region  should  no  longer  be  postponed. 

On  the  next  morning,  Sunday,  October  6th,  word  was 
sent  me  by  Dr.  Franklin  that  the  tympanites  still  per- 
sisted, and  that  there  had  been  no  movement.  I  rec- 
ommended puncturing  the  most  distended  coils  of  in- 
testine with  several  hypodermic  needles  (a  proceeding 
repeatedly  employed  by  me  with  benefit  and  no  dan- 
ger), and  arranged  to  meet  the  doctor  at  3  p.m.  prepared 
to  operate.  But  little  gas  escaped  through  the  needles, 
and  at  three  o'clock  I  found  the  abdomen  still  quite  dis- 
tended. No  more  than  a  trace  of  dulness  in  the  right 
iliac  region.  At  3.30,  with  the  assistance  of  Drs.  Frank- 
lin, E.  Sternberger,  Ford,  and  Richards,  I  made  the  usual 
right  lateral  incision  and  soon  discovered  from  the  infil- 
tration of  the  tissues  that  there  was  deep-seated  inflam- 
mation. On  incising  the  peritoneum  a  large  quantity 
of  gas  and  solid  and  fluid  fasces  escaped,  showing  that 
a  perforation  of  the  appendix  had  taken  place.  The 
general  peritoneal  cavity  was  apparently  entirely  shut 
off  by  the  adherent  intestines.  Turning  the  patient  on 
the  right  side,  I  gently  irrigated  the  abscess  cavity  with 
warm  sterilized  water,  and  packed  it  loosely  with  iodo- 
form gauze.  The  patient  rallied  from  the  operation  re- 
markably well,  and  during  the  next  twenty-four  hours 
enormous  quantities  of  gas  escaped  and  fluid  fnsces 
oozed  through  the  dressing,  and  were  passed  per  anum. 
On  the  next  day  the  temperature  was  normal,  and  the 
patient's  condition  fairly  good,  except  an  unpleasantly 
rapid,  although  good,  pulse.  The  deep  dressing  was 
not  disturbed  for  fear  of  rupturing  fresh  adhesions. 
Stimulants  ad  lib.  were  ordered,  chiefly  champagne. 
On  the  next  day,  however,  after  a  good  night,  a  change 
for  the  worse  took  place.  The  temperature  remained 
normal,  but  the  pulse  went  up  to  140  and  became 
thready,  and  when  I  saw  her  at  2.30  p.m.  she  seemed 
almost  moribund.  The  dressing  was  changed,  oxygen 
inhalations  were  ordered,  and  of  course  stimulation 
hypodermically,  etc.,  resorted  to  as  much  as  feasible. 
Still,  I  hardly  expected  that  she  would  survive  the 
night,  but  she  rallied  and  lived  nearly  three  days 
longer,  dying  from  exhaustion. 

How  long  the  appendicitis  had  existed  in  tliis  case  I 
cannot  say.  Probably,  as  the  history  states,  there  had 
been  a  number  of  attacks  during  a  period  of  years.  In 
consequence  of  these  attacks,  undoubtedly  the  appen- 
dix was  adherent,  and  in  a  soft,  friable  condition  at 
the  time  of  the  last  labor  ;  and  during,  or  immediately 
following,  the  labor  j)erforation  took  place,  and  fecal 
matter  was  discharged  into  a  cavity  sealed  off  by  the 
previous  attacks.     This  perforation  was  the  cause  of 


the  reflex  vomiting  and  the  intestinal  paresis  causing 
tympanites. 

If  the  diagnosis  of  perforation  could  have  been  made 
with  absolute  certainty  at  the  time  it  occurred  (the 
diagnosis  of  appendicitis  was  made  thirty  hours  later, 
when  I  first  saw  her),  that,  in  my  opinion,  would  have 
been  the  time  to  open  the  abscess.  The  next  best 
time  was,  the  perforation  being  certain,  when  I  saw  her 
thirty  hours  later.  Whether  she  would  have  surWved 
the  operation  in  her  then  collapsed  state  is  the  ques- 
tion. And  still  I  think  the  sooner  after  perforation 
the  operation  is  performed  the  better,  supposing,  of 
course,  that  the  patient's  condition  is  good  enough  as  to 
warrant  moderate  delay.  And  even  then,  one  never 
knows  when  an  internal  perforation  may  take  place. 
The  diagnosis  of  the  occurrence  of  perforation  is,  after 
all,  the  chief  difficulty.  With  a  well-defined  dull  tu- 
mor in  the  right  iliac  region,  and  the  usual  (it  is  true, 
rather  vague)  history  of  appendicitis,  the  advisability 
of  immediate  operation  need  not  be  discussed. 

But  it  is  these  doubtful,  obscure  cases,  with  ques- 
tionable history  of  previous  attacks,  or  with  the  pres- 
ent illness  masked  by  the  distention  of  the  abdomen 
during  pregnancy  and  labor,  by  labor  pains  during  the 
confinement,  and  after-pains  and  tympanites  afterward, 
which  render  the  diagnosis  so  difficult  and  the  indica- 
tion for  operation  so  uncertain. 

The  insidious  character  of  recurrent  attacks  of  ap- 
pendicitis and  the  possibility  of  recovery  after  perfo- 
ration were  illustrated  to  me  in  a  case  this  summer, 
that  of  Professor  Worthen,  of  Dartmouth  College, 
whom  I  was  asked  to  operate  upon  while  I  was  deliver- 
ing my  annual  course  of  lectures  at  the  Medical  College. 
He  had  been  a  perfectly  healthy  man  (even  an  athlete) 
up  to  about  two  years  before,  since  which  time  he  had 
complained  of  occasional  colicky  pains  in  different 
parts  of  the  abdomen,  and  had  lost  some  flesh.  Noth- 
ing of  the  nature  of  appendicitis  had  been  suspected. 
About  ten  days  before  his  illness  he  lifted  a  heavy  log 
to  show  his  strength.  He  felt  a  pain  in  the  right  side 
of  his  abdomen  at  the  time.  He  thought  nothing  of 
it,  however,  until  about  a  week  later,  when,  returning 
from  a  visit  to  the  Wild  West  Show  at  White  River 
Junction,  on  dismounting  from  the  stage  he  was  seized 
with  so  severe  a  pain  in  the  right  iliac  region  that  he 
went  to  bed.  He  was  seen  by  Dr.  C.  P.  Frost,  his  phy- 
sician, the  next  day,  and  the  diagnosis  of  probable  ap- 
pendicitis was  made.  The  following  day  I  was  asked 
by  Dr.  G.  D.  Frost,  who  was  attending  the  patient  with 
his  father,  to  operate.  I  agreed  to  do  so,  if  I  found 
the  case  a  suitable  one.  I  saw  the  patient  at  the  Mary 
Hitchcock  Hospital,  where  he  had  been  moved  from 
his  house,  at  three  o'clock  that  afternoon,  found  a  de- 
cided swelling  in  the  right  iliac  region,  and  operated 
as  soon  as  the  patient  could  be  prepared,  that  is,  about 
forty-two  hours  after  the  severe  attack  of  pain  on  de- 
scending from  the  stage,  when  I  think  the  perforation 
occurred.  On  opening  the  peritoneum,  gas,  fecal  mat- 
ter, and  pus  escaped.  The  appendix  was  found  loosely 
adherent,  and  on  attempting  to  tie  it  off,  it  broke  away 
piecemeal.  The  abscess- cavity  seemed  closed  off  ex- 
cept below,  where  Dr.  G.  D.  Frost,  who  assisted  me, 
and  I  both  thought  the  finger  reached  into  the  open 
peritoneal  cavity.  I  did  not,  therefore,  irrigate,  but 
rapidly  packed  the  jiocket  with  iodoform  gauze.  This 
was  removed  in  part  tliree  days  later,  being  then  soaked 
with  fecal  matter,  and  under  the  subsequent  care  of 
Dr.  G.  D.  Frost  the  wound  gradually  healed  and  com- 
plete recovery  took  place.  Here,  1  think,  the  early 
operation  saved  the  patient's  life,  since  probably  a  per- 
foration of  the  abscess  downward  into  the  open  peri- 
toneal cavity  would  soon  have  taken  place. 

I  have  no  hesitation  in  mentioning  the  patient's  name 
in  this  case,  as  a  report  of  his  illness  and  the  operation 
appeared  in  the  Boston  papers  at  the  time,  and  since 
then  in  the  Dartmouth  Cc/Avr  Join  ml,  of  course  with- 
out mv  connivance. 


October  26,  1895] 


MEDICAL    RECORD. 


611 


In  conclusion,  I  think  that  the  numerous  instances 
of  appendicitis,  with  and  without  suppuration,  occur- 
ring during  pregnancy  and  labor,  which  have  been  re- 
ported since  my  paper  appeared  nearly  a  year  ago, 
should  induce  us  to  watch  for  this  accident  at  those 
times  quite  as  much  as  on  other  occasions,  and  to  treat 
the  disease  entirely  regardless  of  the  existence  of  preg- 
nancy. I  do  not  agree  with  those  gentlemen,  there- 
fore, who  would  induce  abortion  or  premature  labor 
during,  and  on  account  of,  appendicitis. 

I  think  the  cases  of  appendiceal  abscess  occurring 
during  labor  and  the  puerperal  state  particularly  inter- 
esting, and  difficult  to  diagnose  and  manage. 

P.\UL    F.    MUNDE,    M.D. 
20  West  FoRT^■-F^^Tn  Street.  October  14,  1855.  ] 


"MATERNAL  IMPRESSION." 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Does  not  Dr.  F.  W.  Maloney,  of  Rochester,  N.  V., 
in  his  report  in  the  Medical  Record  of  September 
28,  1895,  of  a  case  of  "maternal  impression,"  where  a 
whitlow  on  the  thumb  of  a  woman,  six  months  preg- 
nant, is  said  to  have  caused  a  supernumerary  thumb 
on  her  unborn  child,  mistake  cause  for  effect  ?  Isn't 
there  about  as  great  a  likelihood  that  the  supernumer- 
ary thumb  caused  the  whitlow  as  that  the  whitlow  caused 
the  supernumerary  thumb  ?  Is  it  not  quite  probable 
that  "  a  supernumerary  thumb  fully  formed  with  nail, 
apparently  grown  out  of  the  primary  articulation  of  the 
first  phalanx,"  had  its  origin  about  as  early  as  the 
thumbs  that  weren't  supernumerary  had  theirs  ;  or,  at 
all  events,  long  before  the  whitlow  was  thought  of  ? 
When  it  is  remembered  that  there  is  no  more  con- 
nection between  the  nervous  system  of  the  mother  and 
the  nervous  system  of  the  child  in  utero  than  there  is 
between  the  nervous  system  of  the  setting-hen  and 
that  of  her  unhatched  chick,  is  it  not  nearly  inexcusa- 
ble for  anyone  to  assert  that  maternal  impressions  of 
any  sort  can  produce  malformations  in  the  foetus,  es- 
pecially as  late  as  the  fifth  or  the  sixth  month  ? 

E.  T.  Shelby,  M.D. 

Atchison,  Kan. 


opium  or  morphine  have  been  found  in  the  stomach  of 
persons  who  have  died  from  this  poison.  Applying  these 
facts  to  the  case  in  question,  we  may  take  it  for  most 
probable  that  at  the  time  when  Dr.  McDonald  ad- 
ministered potassium  permanganate,  a  large  quantity 
of  morphine  was  still  in  the  patient's  stomach.  The 
doctor  states  ten  grains  of  the  antidote  were  given 
partly  by  the  mouth,  partly  hypodermically.  Even  if 
the  quantity  given  by  the  mouth  did  not  exceed  five 
grains,  it  will  be  seen  that,  most  probably,  at  least  five 
grains  of  morphine  were  decomposed  by  the  antidote. 
The  final  issue  of  the  case  might  have  been  quite  differ- 
ent had  Dr.  McDonald  not  administered  the  perman- 
ganate. Every  physician  may  well  be  satisfied  if  his 
patient  regains  consciousness  one  hour  and  a  half  after 
the  ingestion  of  twenty  grains  of  morphine  ! 

Permit  me  to  call  once  more  the  attention  of  your 
readers  to  the  mode  of  administration  of  the  antidote 
to  opium  : 

1.  One  grain  of  permanganate  of  potassium  decom- 
poses one  grain  of  morphine  (six  grains  of  opium  or 
one  drachm  of  laudanum). 

2.  If  the  quantity  of  the  opium  or  morphine  ingested 
is  unknown,  eight,  ten,  or  fifteen  grains  of  the  potas- 
sium salt,  diluted  in  one  pint  of  water,  should  be  given, 
and  repeated  twice  or  three  times  at  intervals  of  thirty 
minutes.  In  cases  of  poisoning  by  opium  (laudanum), 
a  teaspoonful  of  diluted  sulphuric  acid  or  white  vinegar 
— preferably,  diluted  sulphuric  acid — can  be  advanta- 
geously added  to  the  antidotal  solution. 

3.  Hypodermic  injections  of  a  well-diluted  perman- 
ganate solution  should  be  administered  at  short  inter- 
vals. One  grain  in  one  ounce  of  water,  injected  with 
an  antitoxin  syringe  or  an  aspirator,  will  probably  give 
better  results  than  the  use  of  concentrated  solutions. 

4.  One  grain  of  the  antidote  dissolved  in  a  cupful  of 
water  should  be  given  from  time  to  time,  in  order  to 
decompose  the  morphine,  which  the  glandular  lining 
of  the  stomach  continues  secreting  for  many  hours. 

I  take  this  opportunity  to  express  my  hope  that  the 
day  is  not  distant  when  our  representative  medical 
bodies,  for  the  sake  of  science  and  humanity,  will  in- 
vestigate the  relation  between  potassium  permanganate 
and  opium.  Academical  committees  have  studied 
atropine  in  its  relation  to  opium  ;  why  should  the  per- 
manganate receive  no  attention  ? 

William  Moor,  M.D. 

103  West  Fiftv-eighth  Street.  New  York,  October  lo,  1895. 


POTASSIUM    PERMANGANATE    IN    MOR- 
PHINE POISONING. 

To  THE  Editor  of  the  Medical  Record. 


NUCLEIN  IS  NATURE'S  ANTITOXIN. 


I 


Sir  :  I  fee!  it  my  duty  toward  the  profession  to  com- 
ment upon  a  case  of  morphine-poisoning,  reported  by 
Dr.  McDonald  in  the  Medical  Record  of  September 
28,  1895.  One  of  the  conclusions  arrived  at  by  the 
writer  is  "  the  apparent  inefficiency  of  potassium  per- 
manganate." Now,  the  latter,  intrinsically,  cannot  pos- 
sibly be  inefficient  in  antidoting  morphine.  One  may 
just  as  well  state  that  a  strong  alkali  is  incapable  of 
neutralizing  a  mineral  acid.  In  the  case  reported  by 
'  McDonald,  the  patient  had  taken,  at  5  a.m.,  the 
rmous  quantity  of  twenty  grains  of  morphine.  At 
').3o  a.m.  he  was  given  ten  grains  of  the  permanganate, 
partly  internally  and  partly  hypodermically.  As  the  pa- 
tient showed  no  improvement  in  the  course  of  an  hour, 
the  doctor  evidently  concluded  that  the  permanganate 
was  inefficient.  In  my  opinion  the  potash  salt  was  emi- 
nently instrumental  in  saving  the  patient's  life,  as  will 
be  readily  understood  from  the  following  :  As  soon  as 
opium  begins  to  exert  its  narcotic  influence,  gastric 
and  intestinal  activity  is  greatly  reduced,  and,  conse- 
quently, the  absorptive  power  of  the  gastric  mucous 
membrane  is  very  much  lessened.  It  is,  therefore,  not 
surprising  when  we  hear  that  considerable  quantities  of 


To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  have  read  carefully  the  interesting  dissertation 
on  "  Nuclein,"  written  in  your  issue  of  September 
28th,  by  Dr.  J.  Mount  Bleyer,  of  New  York.  Not  only 
have  I  found  it  well  written,  but  its  contents  are  en- 
tirely in  accord  with  reason  I  am  of  the  opinion  also, 
that  from  his  point  of  view,  it  will  be  the  end  and  the 
natural  explication  of  the  Brown-Sequard  theory,  and 
it  explains  the  role  of  the  leucocyte  in  phagocytosis. 

I  think,  also,  that  nuclein  is  certainly  the  best  way  to 
destroy  the  infectious  virus  ;  although  I  think  that 
nuclein  and  protoplasm  must  be  constantly  together, 
and  it  will  not  be  possible  to  consider  either  apart 
from  the  other.  But  however  correct  his  theory  may 
be,  I  do  believe  that  although  nuclein  is  the  best, 
it  is  not  the  only  and  single  way  to  destroy  the  infec- 
tious material.  I  think  antitoxins,  single  and  alone, 
when  attenuated,  will  be  also  cajjable  of  destroying  the 
infectious  virus,  although  that  may  be  through  the 
modifications  impressed  to  the  potoplasm  and  nuclein. 

Dr.  Vertiz, 

Professor  of  General  Pathology  a>id  Bacteriology, 
School  or  MsDicrNE,  Citv  of  Mexico,  Mex. 


6l2 


iMEDICAL    RECORD. 


[October  26,  1895 


Medical  Items. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  October  19,  1895. 


Tuberculosis    

Typhoid  fever , 

Scarlet  fever 

Gerebro-spinal  meningitis 

Measles 

Diphtheria 


The  Infantile  Causes  of  Epilepsy. — In  Gower's  latest 
book,  "  Clinical  Lectures  on  the  Nervous  System," 
some  careful  observations  on  this  subject  are  elaborated 
in  detail.  The  most  frequent  infantile  cause  of  epi- 
lepsy is  rachitis.  Clouston  has  also  emphasized  its  in- 
fluence in  the  production  of  other  nervous  diseases.  It 
was  Sir  William  Jenner  who  demonstrated  that  the  con- 
dition of  rickets  is  a  general  retardation  of  develop- 
ment, with  various  secondary  necessary  results,  and  of 
the  association  of  convulsions  with  this  general  state. 
Backward  teething  is  also  a  manifestation,  but  is  now 
fully  understood  not  to  be  a  cause  in  itself  of  the  con- 
vulsions of  infancy.  These  are  a  consequence  of  the 
retarded  development  which  occurs  so  often  toward  the 
end  of  the  first  year.  It  is  the  epoch  at  which  the  char- 
acter of  the  food-supply  undergoes  change,  or  does  not 
undergo  the  change  that  is  natural.  It  is  also  a  period 
when  much  functional  capacity  passes  into  functional 
use.  The  influence  of  rickets  in  causing  the  convul- 
sions of  infancy  are  of  great  importance  in  connection 
with  epilepsy.  They  leave  behind  a  residual  disposi- 
tion to  a  like  morbid  action,  which  may  be  continuous 
in  its  results,  or  may  become  active  at  a  later  period  of 
life.  Every  variation  of  interval  is  met  with.  It  is  im- 
possible to  doubt  that  the  convulsions  of  dentitions  are 
a  definite  element  in  the  causation  of  epilepsy.  And  it 
is  also  impossible  to  doubt  that  the  prevention  of  rickets 
would  have  a  considerable  influence  on  the  prevention 
of  epilepsy. 

Convulsions  due  to  retarded  development  are  gen- 
eral ;  so  also  are  the  epileptic  attacks  that  follow  them. 
This  is  an  important  point  to  remember.  Moderate  in  se- 
verity, when  continued  in  epilepsy,  the  attacks  often  be- 
come slighter,  until  they  are  merely  minor  attacks  with 
loss  of  consciousness.  There  may  be  only  the  slightest 
indication  of  spasm  or  no  trace  of  it  after  a  time. 
Minor  attacks  may  continue  a  few  years,  and  thus 
muscular  contractions  may  be  added  to  loss  of  conscious- 
ness. There  are  two  other  forms  of  epileptic  attacks 
that  can  be  traced  to  the  convulsions  of  infancy.  In 
the  first,  the  spasm  can  be  observed  to  commence  locally, 
in  the  hand  or  face  ;  and  appears  on  one  side  before  h 
does  on  the  other.  The  attacks  during  babyhood  in 
these  cases  were  also  of  this  nature,  the  first  seizure 
being  often  of  great  severity.  Such  convulsions  mean 
unilateral  instability  of  the  motor  structures  of  the 
brain,  and  the  local  change  excludes  a  general  cause 
that  would  act  on  the  whole  brain.  There  is  organic 
disease  in  the  cortical  region.  If  profound,  and  in  the 
motor  region,  hemiplegia  is  the  result.  This  may  be 
slight  or  severe,  lasting  a  lifetime,  or  passing  away  in 
a  few  months.  The  third  class  of  cases  in  which  epi- 
lepsy has  its  origin  in  infancy  is  found  among  first-born 
children  who  make  their  entrance  into  life  under  great 
difficulties,  and  the  symptoms  of  their  convulsions  are 
due  commonly  to  the  effect  of  meningeal  hemorrhage. 
A  small  number  of  cases  dating  back  to  infancy,  and 
not  belonging  to  these  three  classes,  are  those  associ- 
ated with  congenital  brain  defect.  Underlying  all  the 
phenomena    of   epilepsy,    whatever   its  cause    and    its 


features,  there  is  one  fact  which  it  is  important  to  rec- 
ognize. Convulsions  are  far  nearer  normal  action  than 
this  startling  aspect  suggests.  In  health,  nerve-centres 
are  always  ready  for  the  instant  vigorous  liberation  of 
nerve  force.  A  perception  of  danger  induces  in  an 
animal,  and  often  also  in  man,  motor  activity  as  intense 
as  that  of  an  epileptic  fit.  By  their  nutritional  state, 
the  nerve-structures  hold,  ever  ready  for  release,  in  vast 
amount,  the  latent  energy  that  excites  the  muscles.  Con- 
sidered from  the  dynamic  point  of  view  the  amount  is, 
no  doubt,  trifling,  not  to  be  measured  by  its  manifesta-  • 
tion  in  the  muscular  contraction  it  excites.  The  per- 
fect readiness  which  underlies  its  instant  release  in 
health,  underlies  also  its  instant  liberation  in  dis- 
ease. Thus  may  be  explained  the  fact  that  the  appar- 
ent causes  of  epilepsy  are  often  such  as  seem  inade- 
quate. 

Dead  Chinamen  as  Freight. — A  curious  freight  which 
is  shipped  exclusively  from  San  Francisco  to  China  is 
"fish-bone,"  which  pays  $20  a  ton.     It  is  sent  in  large 
boxes  consigned  to  the  Tung  Wah   Hospital  at  Hong 
Kong,  but  the    contents   of  the.  boxes   are    really  the 
bodies  of  dead  Chinamen  sent  home  for  burial.     Most 
of  the  Chinamen  who  come  to  the  United  States  are 
under  the  care  of  the  Six  Companies,  who  sign  a  con- 
tract guaranteeing  to  return  the  bones  of  the  dead  for 
burial  with  their  ancestors  in  the  Celestial  Empire,  and 
the  Tung  Wah  Hospital  acts  as  the  agent  on  this  side 
in  carrying  out  the   agreement.     They  are  shipped  as 
"  fish  bones  "  in  order  to  evade  the  rule  of  the  steam- 
ship  companies,  who  charge  full  first-class  passenger       ; 
rates    for   the   dead.     Nearly  every  ship  leaving    San 
Francisco  for  China  carries  among  the  steerage  passen-      > 
gers  a  number  of  invalids  who  hope  to  live  until  they      I 
reach  their  native  country,  but  several  usually  die  on      | 
every  voyage.     There    is   an    agreement  between    the      j| 
steamships  and  the  Six  Companies  which  forbids  the 
burial  of  these  ^jodies  at  sea,  and  the  latter  furnishes 
coffins  of  the  peculiar  Chinese  pattern  for  use  in  such 
emergencies.     They  are  made  of  slabs,  the  first  cut  of 
the   log,  so  that  the    sides   and   bottom  and    top    are 
rounded.     A  dozen  or  more  are  carried  on  each  ship, 
and  the  surgeon  is  furnished  with  a  supply  of  embalm- 
ing fluid.     When  a  Chinaman  dies  at  sea,  the  surgeon 
embalms  the   bod)-,  which  is  then  placed   in  a  coftin, 
sealed  up,  and  lowered  into  the  hold.     The  expense  is 
paid  by  voluntary  contributions  from  the  other  Chinese 
passengers,  the  crowd,  and  the  stewards  of  the  ship — 
all  of  whom  belong  to  that  race.     No  subscription  paper      \ 
is  passed  around,  but  a  pan  containing  Chinese  sugar  is 
placed  beside  the  coffin,  and  every  Chinaman  on  board     1 
drops  in  his  contribution,  from  a  dime  to  a  dollar,  and     I 
takes  a  piece  of  sugar  from  the  pan,  which  is  supposed     | 
to  bring  him  good  luck  and  prolong  his  life.     When     ' 
the  ship  reaches  Hong  Kong,  the  coffins  and  the  be- 
longings  of  the  dead   are   delivered  to  the  Tung  Wah      , 
Hospital,  which  disposes  of  them  to  the  surviving  friends 
in  China.     Every  Chinaman  in  the  United  States  is  sup-     ■ 
posed  to  be  registered  at  the  Tung  Wah  Hospital  and     I 
with  the  Six  Companies  at  San  Francisco.  I 

Empyema  in  Children. — i.  When  pus  is  found  to  be  " 
present  in  the  pleural  cavity,  the  proper  treatment  is  to 
remove  it.  2.  The  best  method  is  simple  incision  and 
drainage.  3.  The  best  site  for  the  operation  is  the 
fifth  space  in  the  mid- axillary  line.  4.  Irrigation  is 
unadvisable,  and  is  indicated  only  in  cases  of  fetid 
effusion.  5.  Exploration  and  scraping  of  the  cavity 
are  not  necessary.  0.  Resection  of  the  rib  is  prac- 
tically never  necessary  in  children  as  a  primary  pro- 
cedure to  procure  eflicient  drainage,  but  may  be 
required  to  secure  the  closure  of  the  sinus,  subse- 
quently, by  allowing  the  chest- wall  to  fall  in.  7.  Col- 
lapse of  the  chest-wall  is  not  a  result  to  be  desired  in 
the  early  stages  of  the  treatment.  S.  Rapid  and  com- 
plete expansion  of  the  lung  is  the  great  object  of  treat- 
ment.    9.  The  tube  must  be  removed  early. — Cautlex 


.i 


Medical   Record 

A  IVeekly  journal  of  Medicine  and  Surgery 


Vol.  48,  No.  18. 
■Whole  No.  1304. 


New  York,  November  2,  1895. 


S5.00  Per  Annum. 
Single  Copies,  loc. 


©utgiiiaX  Articles. 


I 


ox  THE  DEFORMITIES  AND  MALFORMA- 
TIONS RESULTING  J^-ROM  ACUTE  INFEC- 
TIONS  IN    BONE.i 

By  ROSWELL  PARK,  A.M.,   .M.D.. 

BUFFAtO,  N*.  T. 
PROFESSOR  OF  St'fGBRV,   i!P.DIC.\L  DEPARTMENT,  UM(\'ER51TV  OF   BLTFALO. 

It  is  apparently  the  depth  and  the  concealed  location 
of  the  bone-marrow  which  has  prevented  a  more  gen- 
eral and  wide-spread  recognition  of  the  readiness  with 
which  the  internal  structure  of  bone  succumbs  to  in- 
fection and  to  destruction.  The  clinical  consequences 
of  this  internal  disease  have  long  been  recognized,  but 
accurate  notions  regarding  its  pathology  have  not  been 
in  vogue  until  comparatively  quite  recently.  At  the 
very  outset  it  is  well  to  make  an  abrupt  distinction  be- 
tween those  alterations  in  texture,  contour,  density. 
etc.,  of  bone  which  are  the  result  of  perverted  nutri- 
tion, of  alterations  of  trophic-nerve  influence,  etc.,  and 
which  are  distinctly  not  infectious,  and  another  series 
of  changes  similar  perhaps  in  gross  results,  very  dis- 
similar in  etiology,  which  are  the  consequences  of  acute 
infectious  processes,  which  have  their  analogies  in  va- 
rious of  the  soft  structures  of  the  body,  where  they 
have  been  longer  recognized  and  more  carefully  stud- 
ied, because  more  easy  of  access.  Indeed,  as  Savory 
some  years  ago  showed,  bone  and  lung  react  in  a  very 
similar  way  to  infections,  the  analogy  in  some  respects 
being  even  striking.  Both  bone  and  lung  are  surround- 
ed by  a  firm,  investing  membrane  ;  both  have  a  more 
or  less  spongy  te.xture  ;  both  are  extremely  liable  to 
tubercular  invasion,  while  in  either  case  the  disease 
usually  selects  the  apices  for  its  primary  manifesta- 
tion ;  both  are  in  close  relation,  the  bones  especially 
by  their  joint  ends,  with  serous  cavities  which  become 
secondarily  involved  in  the  majority  of  instances — in 
the  one  case  as  a  pleuritic  effusion  or  an  empyema,  in 
the  other  case  as  a  joint  effusion  or  a  pyarthrosi?  : 
while  the  picture  of  miliary  tubercle  in  either  structure 
is  beautifully  distinct  and  clear.  Savory  did  not  point 
out,  however,  that  which  I  would  like  to  emphasize 
here  ;  for  instance,  that  bone  as  a  tissue  is,  neverthe- 
less, subject  to  an  acute  miliary  invasion  of  tubercle 
corresponding  to  an  acute  miliary  tuberculosis,  as  well 
as  to  certain  streptococcus  and  staphylococcus  inva- 
sion, producing  a  condition  of  affairs  corresponding 
materially  to  acute  lobar  pneumonia,  in  which  tlie 
whole  structure  of  an  epiphysis  or  a  shaft  is  involve(i, 
and  in  which,  owing  to  the  intensity  of  the  process, 
local  gangrene  may  result,  producing  in  the  one  case  a 
gangrene  of  the  lung,  in  the  other  a  gangrene  of  the 
bone,  a  fulminatingly  acute  necrosis  which  means 
death  of  the  patient  if  not  speedily  attended  to. 

U'e  need  not  hesitatei  then,  to  compare  bone  and 
lung,  if  only  we  take  the  view  concerning  the  former, 
that  students  are  not  generally  enough  taught,  that 
•J  calcareous  infiltration  of  bone  is  simply  an  incident 
voring  its  physiological  function,  and  that  it  may  bc- 
nie  inflamed  and  act  in  every  other  way  like  any  of 

Read  before  the  American  Orthopaedic  .Association,  in  Chicago, 

^-'7 'ember,  1895. 


the  soft  tissues.  When  we  cease  to  make  artificial  dis- 
tinctions, which  nature  does  not  make,  we  shall  have 
much  clearer  ideas  of  bone  pathology.  The  acute 
lihases  of  these  infectious  processes  are  not  usually 
considered  in  works  on  orthopjedic  surger)-,  nor  do 
they  often  come  under  the  observation  of  orthopaedists, 
who  are  so  often  concerned  with  their  remote  conse- 
quences. Nevertheless,  in  order  that  the  matter  may 
be  the  better  appreciated,  I  deem  it  wise  to  say  a  little 
more  about  the  acute  condition  first.  That  acute  in- 
flammation {i.e.,  infection)  of  all  or  any  of  the  struct- 
ures which  go  to  make  up  the  bone  is  possible,  is  new 
a  well-established  fact.  Inasmuch  as  each  one  of  these 
tissues  conies  at  least  into  close  contact  and  relation 
with  the  others,  even  if  it  does  not  insensibly  merge 
into  it,  it  is  not  often  that  one  meets  with  an  infection 
of  one  which  is  not  conveyed  to  the  others.  Clinically, 
however,  there  are  three  locations  in  which  these  mani- 
festations are  most  commonly  met  with  :  a.  Beneath 
the  periosteum  ;  b.  in  the  epiphyses  ;  c,  in  the  diaphy- 
ses. 

From  the  pathological  side,  infections  are  of  four 
main  varieties  :  <z.  The  tubercular  ;  h,  the  staphylococ- 
cus ;  c,  the  streptococcus  :  f/,  the  pneumococcus.  To 
these  may  be  added,  e,  rare  instances  in  which  other 
organisms  are  primarily  or  secondarily  present. 

Of  these  certainly  the  more  common  is  the  tubercu- 
lar form,  whose  manifestations,  however,  are  usually 
not  acute.  The  other  three  may  be  grouped  in  a  gen- 
eral way  as  pyogenic  forms  of  invasion  in  which  pus  is 
practically  invariably  produced,  providing  only  that 
sufficient  time  has  elapsed. 

Although  it  is  not  exactly  germane  to  my  subject,  I 
cannot  let  this  opportunity  pass  without  calling  special 
attention  to  one  manifestation  of  tubercular  bone  dis- 
ease, which  I  grant  is  rare,  but,  nevertheless,  which  is 
not  sufficiently  recognized.  I  allude  to  the  acute  mil- 
iary tuberculosis  of  bone  which  corresponds  in  most 
essentials  with  similar  invasions  of  the  lungs,  and  of 
which  I  have  seen  occasional  examples.  This  is  not 
generally  described,  even  in  the  most  recent  literature, 
and  would  deserve  more  space  than  I  can  give  it  here 
were  this  the  place  in  which  to  consider  it.  It  is  not 
quite  so  rapid  as  the  pyogenic  forms,  and  it  may  take 
two  or  three  weeks  to  produce  such  destruction  of  the 
bone  as  to  necessitate  operation.  It  stands,  therefore, 
in  intermediate  position  between  the  acute  infections 
and  the  slower  {i.e.,  usually  the  tubercular)  lesions. 
Nevertheless,  it  is  sufficiently  acute  to  demand  prompt 
recognition,  and  when  recognized  may  often  be  re- 
lieved by  prompt  operative  interference. 

The  course  of  a  bone  disease,  then,  will  depend  first 
upon  the  location  of  the  lesion,  and  secondly  upon  its 
character.  If  it  assume  a  very  acute  type,  and  if  prompt 
evacuation  of  morbid  products  be  carried  out,  such  a 
bone  disturbance  will  usually  subside  with  very  little 
deformity,  there  remaining  perhaps  only  a  scar  mark- 
ing the  site  of  the  operation.  Take,  for  instance,  a  sub- 
periosteal infection  of  the  ulna  or  fibula.  If,  now,  this 
be  recognized  during  the  first  day  or  two,  and  if  a  long 
incision  be  made  down  on  the  bone,  there  is  ample  op- 
portunity for  escape  of  pus  and  of  other  morbid  pro- 
ducts, and  there  will  be  prompt  reapplication  and  re- 
union of  periosteum  and  bone  with  a  minimum  of  loss 
of  function,  occasioned  only  by  the  occurrence  of  a 
cicatrix.     If  a  deep  and  acute  bone  abscess  form  in  the 


6i4 


MEDICAL    RECORD. 


[Xovember  2,  1895 


shaft  of  a  bone,  and  the  same  be  promptly  opened,  it 
corresponds  to  an  acute  abscess  in  the  neck  or  else- 
where, and  onl}-  a  scar  will  remain  to  indicate  what  has 
happened.  If,  however,  prompt  recognition  and  imme- 
diate incision  do  not  occur,  the  consequence  will  be 
extension  of  the  disease,  increasing  destruction  of  bone, 
possibly  necrosis  of  the  entire  bone  shaft  between  epi- 
physeal junctions,  possibly  spontaneous  perforation, 
with  sinuses  through  which  sequestra  may  protrude,  or 
at  least  be  recognized.  These  usually  come  to  the  sur- 
face by  a  reasonably  direct  route,  which  affords  exit 
with  a  minimum  of  disturbance  of  surrounding  soft 
parts  ;  but  this  is  by  no  means  always  the  case.  Final- 
ly, if  the  acute  focus  be  located  in  an  epiphysis,  there 
is  usually  prompt  involvement  and  infection  of  the 
joint,  loosening  of  epiphyseal  connection,  with  a  result- 
ant pyarthrosis  and  necrosis  of  a  bone  end,  which  will 
require  something  more  than  a  mere  opening  and  evacu- 
ation of  a  joint,  which  may  call  for  resection,  or  even 
amputation.  In  such  a  case  dislocation  finally  occurs. 
I  have  seen  this  condition  most  often  at  the  hip,  and 
have  repeatedly  known  of  an  acute  osteomyelitis  of  the 
upper  epiphysis  of  the  femur,  which  has  pursued  a 
rapid  and  unbroken  course  until  such  destruction  has 
occurred  as  to  permit  of  spontaneous  luxation  during 
the  act  of  lifting  the  patient,  with  the  production  of 
two  inches  of  shortening  within  half  an  hour.  Such  a 
case  is  an  aggravated  one,  to  be  sure,  not  illustrating 
the  common  phases  of  this  disease,  yet,  nevertheless, 
not  so  rare  as  could  be  wished,  and  not  one  whit  over- 
drawn. I  have,  moreover,  repeatedly  seen  such  absorp- 
tion of  calcareous  stiffening — in  other  words,  such  an 
artificial  and  pathological  flexibility  of  bone  produced 
— that  torsion  of  the  shaft  of  long  bones  or  more  or 
less  angular  deformity  was  produced,  either  rapidly, 
in  some  instances  by  mere  muscle  spasm,  or  in  other 
cases  by  too  early  or  indiscreet  effort  to  support  the 
weight  of  the  body. 

Osteomyelitis  may  be  a  tedious  and  long-drawn-out 
disease,  which  may  also  be  characterized  by  acute  ex- 
acerbations. It  is  well  to  keep  this  fact  in  mind,  for  it 
does  not  follow  that  every  bone  fistula  or  sinus  is  due 
to  tubercular  disease,  though  it  is  always  open  to  the 
presumption  of  having  become  tubercularly  infected. 
Albert,  for  instance,  has  called  attention  to  the  confu- 
sion between  the  two  conditions,  especially  in  the  lat- 
ter part  of  certain  cases.  The  anatomical  picture  about 
the  ioint  involved  in  the  one  case  is  not  materially  dif- 
ferent from  that  of  the  other. 

Concerning  the  character  and  extent  of  possible  de- 
struction in  these  cases,  one  meets  with  all  degrees  of 
destructive  changes,  from  the  mildest  appreciable  up 
to  total  destruction  of  an  entire  bone,  or  even  to  gan- 
grene of  an  entire  extremity.  Other  things  being  equal, 
the  most  destructive  lesions  are  those  which  produce 
the  greatest  deformity.  Vet,  of  the  inveterately  de- 
formed cases,  it  is  sometimes  those  which  are  least 
involved  which  will  be  subjected  to  orthopaedic 
treatment,  while  those  in  which  deformity  is  very 
great  would  be  subjected  to  resection  or  amputa- 
tion. 

If  one  seek  for  the  reason  why  one  bone  is  involved 
oftener  than  another,  it  may  possibly  he  explained  by 
the  normal  rapidity  of  bone  growth  in  different  bones. 
According  to  the  investigations  of  Langer,  the  co-effi- 
cient of  growth  in  the  femur  is  4.38,  in  the  tibia  4.32, 
in  the  humerus  3.97.  in  the  radius  3. S3.  This  scale 
perfectly  coincides  with  the  frequency  of  disease  in  the 
bones  mentioned.  Studying  for  a  moment  the  prevail- 
ing localities  in  which  remains  of  lesions  are  found, 
and  basing  this  study  upon  181  patients  collected  by 
Helferich,  we  find  that  the  lower  end  of  the  femur  was 
involved  in  40  instances,  the  upper  end  of  the  tibia  in 
29,  the  tibial  shaft  in  19,  the  lower  end  of  the  tibia  in 
18,  the  upper  end  of  the  humerus  in  16,  the  remainder 
being  scattering.  These,  to  be  sure,  were  cases  of  ne- 
crosis as  the  result  of  the  disease  ;  and,  nevertheless. 


they  serve  our  purpose  in  showing  relative  frequency 
of  location  of  foci. 

As  showing  also  the  relative  frequency  of  parts  in- 
volved, of  30  cases  observ'ed  by  Kocher  the  disease 
occurred  13  times  in  the  tibia  and  11  in  the  femur.  Of 
98  cases  collected  by  Leucke  and  Volkmann,  the  femur 
was  involved  36  times,  the  tibia  34,  and  the  humerus 
II.  Disease  in  the  immediate  neighborhood  of  the 
hip-joint  is  about  five  times  as  common  as  in  that  of 
the  knee.  Comparing  epiphyses  with  diaphyses,  and 
accepting  Schede's  67  cases,  we  find  that  of  28  cases  in 
which  the  femur  was  involved,  half  of  them  were  in  the 
shaft  and  half  in  the  diaphysis.  In  the  tibia,  of  27 
cases  only  9  concerned  the  epiphysis,  and  of  7  cases  of 
the  humerus,  2  involved  the  epiphysis. 

Arrests  of  development  in  bone  as  due  to  bone  in- 
flammations have  long  been  known.  Blasius,  for  in- 
stance, described  a  case  in  which  an  adult  arm  never 
passed  beyond  the  dimensions  of  that  of  a  child  ;  and 
numerous  such  cases  are  on  record.  Mild  differences 
of  this  kind  have  been  often  overlooked,  as  Helferich 
emphasizes.  As  between  the  two  femora  and  the  two 
humeri  considerable  changes  may  often  be  noted, 
which  will  be  explained  if  one  gets  a  careful  history  of 
the  patient's  life.  I  may  also  remind  this  Association 
of  that  form  of  increase  in  the  length  of  long  bones 
spoken  of  by  Oilier  and  Mondan  as  "  atrophic  elonga- 
tion," to  which  I  called  attention  a  few  years  ago  in  a 
paper  to  which  I  would  refer  those  who  are  further  in- 
terested. 

Relative  to  persistent  joint  lesions  which  may  result 
from  acute  bone  infections,  we  may  get  ver}'  interest- 
ing statistics  from  the  memoir  of  Haaga.  Out  of  28 
cases  in  which  the  upper  end  of  the  femur  was  in- 
volved, in  22  there  were  more  or  less  well  marked 
persistent  lesions.  Of  these  22,  in  14  mobility  was  di- 
minished, and  in  10  of  these  there  was  absolute  an- 
chylosis, twice  in  the  straight  line,  8  times  with  more 
or  less  flexion  of  the  thigh.  In  the  other  8  cases  there 
was  spontaneous  luxation  to  a  greater  or  less  extent. 
Out  of  28  cases  involving  the  arm,  the  humerus  was 
involved  7  times,  and  of  these  7  cases  one  presented 
a  subcoracoid  luxation,  and  in  another  a  very  marked 
limitation  of  movement  existed.  In  2  others  there 
was  a  persistent  hydrarthrosis.  Of  19  cases  invohing 
the  elbow,  the  humerus  was  involved  in  10,  the  radius 
in  6,  the  ulna  in  3  ;  the  elbow-joint  was  destroyed  in 
2  of  them,  was  anchylosed  in  4,  and  presented  distinct 
lesions  in  all  the  others.  Of  these  19  cases  the  im- 
mediate neighborhood  of  the  joint  was  involved  in 
only  7  ;  in  the  other  12  the  lesion  was  more  or  less 
remote  from  the  joint.  In  7  cases  involving  the  wrist, 
the  radius  was  involved  in  4,  the  ulna  in  3  ;  in  each 
instance  anchylosis  was  complete,  and  in  4  others  there 
was  marked  restriction  of  motion. 

Haaga  has  epitomized  470  cases  of  distinct  osseous 
foci  altogether,  in  which  189  showed  distinct  joint 
lesions,  which  were  more  or  less  persistent. 

Out   of    24   cases    involving    the    ankle,   the   lower  . 
extremity  of  the  fibula  was   involved  in  but   i.      Of  ,i 
these    21  were  more  or  less  anchylosed  ;    in    i    case  ^ 
there  was  a  flail  joint  :  in  two  instances  the  joint  was 
destroyed  ;  and  in  one  there  was  chronic  hydrarthrosis. 
Secondary   affections   of   the   knee  were  extremely 
frequent.     Of  107  cases  of  disease  of  the  lower  end  of 
the  femur,  the  knee  was  involved  in  71.     Of  54  cases 
of  involvement  of  the  upper  end  of  the  tibia,  the  knee 
was  involved  in  21.     Studying  109  lesions  of  the  knee, 
Haaga  found  luxation  forward   once  ;  subluxation,  9 
times;   flail  joint,    11   times;   articular  destruction,  5 
times  ;  late  suppuration,  6  times  ;   while  motility  was 
diminished  in  77  cases,  of  which  in  20  the  difficulty 
was  caused  by  anchylosis,  and  in  57  by  a  contracture. 

Another  kind  of  deformity  is  that  produced  by  ar- 
rest of  growth  of  the  joint  end  of  one  bone  and  com- 
pensatory hypertrophy  or  parallel  alterations  in  the 
other  and  participating  bone.     -Absolute  arrest  of  de- 


November 


5] 


MEDICAL    RECORD. 


61=; 


velopment  occurs  naturally  only  in  growing  children 
or  adolescents ;  and  these  deformities  will  at  least  arise 
during  youth,  although  they  may  be  met  with  much 
later.  I  have,  for  instance,  in  my  possession  a  speci- 
men illustrating  arrest  of  growth  of  the  lower  end  of 
the  tibia,  while  the  fibula  continued  to  grow,  so  that 
its  lower  end  assumed  a  literally  circular  shape,  the 
lower  two  and  one-half  inches  constituting  90°  of  a 
circle  of  four  or  five  inches  in  radius.  In  a  case,  for 
instance,  reported  by  !Marchant,'  the  region  of  the 
knee  was  greatly  enlarged  and  deformed  by  the  presence 
on  the  inner  side  and  posteriorly  of  the  head  of  the 
fibula,  whose  upper  styloid  process  was  on  a  line  with 
the  upper  border  of  the  patella,  having  been  pressed 
there  by  the  weight  of  the  body  and  lack  of  growth  in 
the  tibia.  The  upper  half  of  the  fibula  was  greatly 
thickened,  but  flexion  was  possible  to  a  right  angle. 

One  should  also  speak  in  this  connection  of  that 
class  of  deformities  which  are  produced  by  muscle 
contractures,  which  have  at  the  time  seen  not  yet  pro- 
ceeded to  the  point  of  anchylosis,  except  so  far  that 
motion  beyond  certain  degrees  was  impossible  because 
of  these  same  contractures.  In  other  words,  these  are 
joints  whose  function  is  much  interfered  with  and  in 
which  extremes  of  motion  are  not  permitted,  and 
which,  nevertheless,  ser\-e  still  a  useful  purpose  in  most 
respects.  I  do  not  know  that  there  is  any  marked 
difference  in  the  frequency  with  which  the  various 
joints  present  lesions  of  this  kind.  In  more  or  less 
mild  degree,  and  for  greater  or  less  length  of  time, 
these  conditions  obtain  in  the  neighborhood  of  any 
joint  which  lies  in  proximity  to  a  focus  of  acute  bone 
infection. 

Torsion  and  flexion  of  bone  which  has  been  the 
seat  of  previous  disease  is  not  at  all  infrequent.  Even 
muscle  pull  alone  is  sufficient  to  account  for  many  of 
these  cases.  Richter  has  reported  from  the  Breslau 
Clinic  a  specimen  of  diseased  bone  in  which  fracture 
had  been  diagnosed  because  of  the  deformity.  Dies- 
terweg  has  also  described  a  similar  case  from  Volk- 
mann's  clinic,  in  which  there  was  such  remarkable 
curvature  of  the  trochanteric  part  of  the  femur  as  to 
permit  of  luxation.^ 

In  a  general  way  I  would  divide  the  deformities 
which  are  due  to  inflammatory  bone  changes,  into  those 
which  pertain  to  juxta-articular  lesions  and  those  which 
have  their  anatomical  seat  in  the  shafts  of  the  long 
bones.  This  is  a  classification  purely  for  purposes  of 
convenience,  and  implies  nothing  regarding  pathologi- 
cal differences.  Of  the  former  class,  the  most  con- 
spicuous are,  first,  those  produced  by  anchylosis.  This 
will  be  readily  appreciated  as  due  to  the  intensity  of 
inflammatory  change  and  to  organization  of  solid  ex- 
udate, to  cicatricial  contraction,  etc.  It  is  usually  of 
the  spurious  or  fibrous  type,  but  is  occasionally  of  true 
osseous  character.  I  could  show,  were  it  desirable, 
numerous  specimens  indicating  the  rigid  consolidation 
and  stiffening  of  such  joints  by  osseous  tissue. 

There  is  a  variety  of  change,  of  which  frequent  ex- 
pressions are  seen,  which  is  due  to  compensatory  en- 
largement of  one  bone  in  order  to  atone  for  more  or 
less  weakening  of  another.  This,  of  course,  is  met 
with  only  in  the  leg  and  forearm,  where  we  have  paired 
bones.  I  have  seen  several  instances  where,  after 
serious  weakening  of  the  tibia,  the  fibula  has  enlarged 
almost  to  the  previous  size  of  the  tibia,  and  has  gradu- 
ally prepared  itself  in  this  way  for  sustaining  the  weight 
of  the  body  and  assuming  the  functions  of  the  tibia. 
.■\Jong  with  these  changes  in  the  bone-shaft  there  are 
also  changes  at  the  extremities,  which  would  be  difficult 
19  describe  in  a  few  words,  and  which  hardly  call  for 
it,  the  present  paper  being  concerned  rather  with  state- 
ment of  facts  than  with  minute  description  of  cases. 
One  may  see  the  same  condition  in  milder  degree  in 

'  Re\Tie  d'Orthope'die.  March,  1895. 

'  Ueber  die  Verbiegungen  der  Diaphysen  nach  Osteomyelitis  Acuta, 
Inaug.  Diss.     HalK',  1882. 


the  metacarpal  and  metatarsal  bones.  I  am  not  aware 
of  similar  changes  having  been  noted  in  the  ribs,  al- 
though I  consider  them  possible. 

Dislocations  and  subluxations  constitute  another 
variety  of  joint  deformities  which  may  have  been  pro- 
duced either  by  muscle  spasm  alone,  as  in  the  slower 
forms  of  tubercular  disease  ;  by  destruction  of  the 
ligaments  and  removal  of  opposition  to  displacement  ; 
or  by  epiphyseal  separations,  which  sometimes  occur  in 
connection  with  acute  cases  of  the  pyogenic  type. 

The  dislocations  met  with  as  the  consequences  of 
bone  infections  may  be  described,  first,  as  of  the  dis- 
tention form — that  is,  they  are  permitted  through  the 
great  distention  of  the  joint  as  the  result  of  outpour  of 
products  of  inflammation  and  infection.  These  are  the 
most  genuine  of  the  spontaneous  luxations.  A  remark- 
able case  of  this  kind  was  observed  at  the  shoulder  by 
Stromeyer. 

A  second  form  is  due  to  the  early  consolidation  be- 
tween epiphysis  and  diaphysis,  and  the  consequent 
cessation  of  growth  at  this  point.  When,  for  instance, 
this  occurs  in  the  tibia,  the  corresponding  fibula  end 
will  continue  to  grow,  and  subluxation  must  be  the  re- 
sult. I  have  now  under  occasional  observation  a  young 
lad  whose  radius  was  nearly  destroyed  by  an  acute  in- 
fection of  this  character,  but  whose  ulna  has  continued 
to  grow.  The  styloid  process  of  his  ulna  now  presents 
nearly  half-way  down  on  the  outside  of  the  fifth  meta- 
carpal, and  great  displacement  and  deformity  of  the 
hand  result.  In  this  case  I  have  advised,  and  expect 
to  perform,  a  resection  very  soon. 

A  third  case  of  osteomyelitic  dislocation  is  due  to 
overgrowth  of  the  ligaments,  due  to  h}-peraemia  of  the 
parts  and  increase  of  nutriment  conveyed  toward  the 
seat  of  activity.  Ligamentous  bands  thus  overgrown, 
stretch  and  give  rise  to  flail-like  conditions  of  the  joints. 

Albert  has  also  alluded  to  the  spontaneous  fracture 
due  to  epiphyseal  separation.  In  most  of  these  cases 
the  epiphyseal  cartilage  will  be  found  normal,  and  it  is 
rather  in  and  about  the  shaft  of  the  bone  that  one 
would  look  for  most  evidence  of  disease. 

Epiphyseal  separations,  accurately  speaking,  are 
among  the  most  serious  of  complications.  According 
to  observ-ations  made  by  Garre,  in  Tiibingen,  they  oc- 
cur in  from  twelve  to  fifteen  per  cent,  of  cases.  These 
occur  most  frequently  of  all  at  the  lower  end  of  the 
femur,  then  at  the  upper  extremity  of  the  tibia,  and 
then  at  the  hip. 

Epiphyseal  separation  without  suppuration  is  rare, 
but  has  been  distinctly  established.  Until  further  in- 
vestigations clear  up  its  pathology,  we  must  hold  it  to 
be  due  to  alterations  in  nutritive  supply  and  vas- 
cular conditions  of  the  involved  bone  ;  that  there  is 
solution  and  disappearance  of  those  calcium  salts 
which  are  usually  regarded  as  cementing  by  their  de- 
position the  union  of  epiphysis  to  shaft. 

Ullmann  reports  a  twelve-year-old  patient  with  eight 
centimetres  shortening  of  the  thigh  with  angular  de- 
formity. Here  it  was  very  evident  that  spontaneous 
fracture  had  taken  place  at  the  site  of  an  old  bone 
focus.  Fracture  may  also  occur  as  the  result  of  rarefy- 
ing ostitis  without  the  necessary  presence  of  a  seques- 
trum. Spontaneous  fractures  also  occur  sometimes 
after  operations  made  necessary  for  removal  of  large 
sequestra,  and  I  have  myself  twice  seen  the  tibia  break 
in  this  way.  Such  cases  constitute  in  effect  a  sort  of 
infected  compound  fracture,  and  it  is  not  to  be  ex- 
pected that  recovery  will  ensue  without  considerable 
shortening,  distortion,  or  other  changes. 

Some  special  manifestations  of  osteomyelitis  are  met 
with  in  somewhat  novel  and  unusual  places.  Thus 
Froehner  has  published  a  unique  case  of  infectious 
osteomyelitis  of  the  nasal  bones.  It  occurred  in  a 
young  man,  aged  seventeen,  and  was  followed  by  fever 
with  tumefaction  of  the  region  involved.  The  jaws  are 
known  to  be  occasionally  involved  as  well,  and  per- 
haps most  often  in  those  instances  of  multiple  lesion 


6i6 


MEDICAL    RECORD. 


[November  2,  1895 


1  •  -L,  are  of  pathological,  rather  than  of  orthopedic, 
which  j^^  ^^^  instance,  mentioned  by  Gangolphe, 
interest.  -   ..Qived  along  with   both  tibia,  a  meta- 

S;dltis';:?^he  aw  is  to  be  dist.ngu.hed  f.^ the^os^ 
febrile  form  of  periostitis,  to  which  Sa  ter  has  particularly 
c. lied  attention,  as  following  measles,  scarlatina,  etc. 
While  the  latter  is  distinctly  a  secondary  infection,  it. 
nev'enheless,has  an  etiology  somew^jat  different  from 
that  met  with,  for  instance,  in  Gangolphe  s  case. 

Osteonryeli  is  of  the  skull  is  usually  followed  by 
.cute Tcrosis,  and  will  frequently  terminate  w.thm  a 
sho  t      me  by  meningitis,  sinus  phlebitis    pneumonia, 

T  IJa\u^  or  other  pysmic  manifestations  ;  it  has 
for'u"atonhop?di:ts,^Jnlya  remote  interest  at  this 

'■"But  osteomyelitis  of  the  vertebral  column  although 
rire  mav  concern  us  very  deeply.  Such  a  case  has 
been  reported  for  instance,  by  Lannelongue  as  one  of 
been  reporieu  vertebral  column,  with   meta- 

^tadc'Li  She  leg  and  m  the  forearm.  The  result 
ri  is  case  was  death;  bat  the  fact  that  these  lesions 
may  occur  in  this  location  should  by  no  means  be  for- 

^°So"too  in  the  clavicle,  osteomyelitis  is  usually  fol- 
lovved  by 'acute  and  total  necrosis.  In  some  instances 
there  has  been  a  very  tardy  reproduction  of  bone,  due 
o  activky  of  the  osteoblasts  which  remained  upon  the 
periosteum  Such  disease  in  this  bone  may  give  rise 
o"reit  disfigurement  about  the  shoulder,  as  well  as 
osf  or  disturbance  of  function.  So,  too,  m  the  nbs 
and  in  the  sternum.  One  meets  m  literature  with  iso- 
lated cases  which  are  not  without  considerable  interest. 
Thus  Foehner  observed  a  case  of  this  kind  in  a  young 
child  a<.ed  four,  in  which  suppuration  occurred  and 
ncr'osis^  followed.  Considerable  attentioi^  has  been 
paid  to  this  matter  in  t^o  or  three^  ^^f  1 '  B^i^  ci  = 
ses  as  bv  Berthomier,'  by  Hasle,- and  by  Baibatcr 
As  in  the  other  long  bones,  the  favorite  locations  in 
the  r^s  appear  to  be  close  to  their  terminat|ons^  The 
disturbance  and  swelling  due  to  lesions  of  this  cha  ac 
ter  near  the  head  of  a  nb,  may  give  rise  to  a  great 
deal  "uncertainty  in  diagnosis,  Benhomier  has  in 
his  paper  discussed  the  physical  signs,  different  al  d  ag 
nosis,etc.  Salomon  has  reported  the  case  of  a  man 
a<.ed  nventy-one,  sick  for  ten  days,  who,  on  the  sixth 
da  com,2ned  of  pain  in  the  right  sterno  c  avicular 
region  with  swelling  and  A^etuation  On  he  tendi 
da°y  inflammation  of  the  lower  lobe  °f^he  right  lung 
was  evident,  and  delirium,  followed  ^^V  death  occued. 
On  autopsy  it  was  shown  that  there  had  been  osteo- 
Sjeitls'of  tie  sternum  with  perforation  «  P-  -  o 
the  right  sterno-clavicular  joint.  ^  ^^^^^l  '^f^  J'" 
three  cases  of  acute  or  chronic  les>on  of  1  us  kind  o 
the  sternum,  in  which  there  was  more  ""^  ^e  ^  disfi^^^^, 
ment  of  the  chest,  though  I  <=an"ot  f  y  that  it  a  tai  ed 
a  de-ree  of  deformity  which  would  a  tract  attention 
then"  he  patient  was  clothed.  Several  cases  o  con- 
siderable deformity  due  to  this  cause  are,  however,  on 

'■'inihe  pelvic  bones  these  infections  occur  rarely-^  but 
give  rise  to  most  serious  symptoms  when  they  do  occur 
iccordfng  to  the  part  in/olved  and  '!-.  arrangement  o 
muscles,  we  will  have  posture  detorm.y  ot  he  thigh 
with  fixation  by  muscle  rigidity,  etc.  his  P^'u re  de- 
formity may  even  become  permanent,  ^e  °rmit  e 
from  this  source  would  be  probably  more  of ten  me 
with  were  it  not  for  the  fact  that  acute  o^teomyehti  o 
the  iliac  bones  is  followed  by  death  in  more  than  half 
of  the  c^ses 

Acute  infection  of  the  patella  is  by  "o.^'ea"^^;;"- 
known,  and  has  been  seen  in  very  young  children  e  en 
to  such  an  extent  that  almost  total  necrosis  has  res  It- 
ed.  In  some  instances,  and  very  slowly,  new  bone  has 
been  reproduced  to  take  the  place  of  that  which   has 

'  Congri'S  FratKjais  de  Chir.,  1877.  p.  522. 

■■'  Paris,  Tbrse  do  1892.  "  I.o  Sperimentalei  September  15,  1891. 


been  thus  lost.  It  would  appear  in  these  instances  as 
if  the  posterior  cartilaginous  surface  of  the  patella 
served  as  the  barrier  by  which  perforation  into  the 
joint  were  prevented. 

It  is  perhaps  more  often  in  the  larger  bones  of  the 
tarsus,  particularly  the  calcaneuni  and  the  astragalus, 
that  we  meet  with  multiple  but  small  foci,  each  of  which 
is  followed  by  limited  necrosis,  and  which  gives  rise  to 
what  Oilier  has  spoken  of  as  "  disseminated  necrotic 
ostitis." 

Necrosis  forms,  by  all  means,  the  most  common  re- 
sult of  osteomyelitis.  '  It  may  assume  either  of  the  fol- 
lowing types,  with  corresponding  variations  in  result- 
ing deformity  (UUmann)  : 

1.  Peripheral  necrosis  or  cortical  necrosis,  in  which 
a  more  or  less  thick  scale  is  detached  from  the  exter- 
nal portion  of  the  bone. 

2.  Central  necrosis,  connected  with  the  marrow  cav- 
ity, at  leastj  connecting  that  part  of  the  bone  which 
comes  into  direct  contact  with  the  bone-marrow. 

3.  A  lamellated  form,  in  which  an  intermediate  por- 
tion of  the  compact  substance  dies  and  a  sequestrum 
results  which  extends  neither  to  the  surface  nor  to  the 
interior  cavity. 

4.  Penetrating  necrosis,  where  to  some  extent  the 
entire  thickness  of  the  bone  is  involved,  i.e..  from  peri- 
osteum to  centre. 

5.  Transverse  necrosis  ;  the  same  as  4,  except  that 
it  extends  completely  around  the  bone. 

6.  Total  necrosis,  where  the  entire  shaft  is  separated 
as  a  sequestrum. 

7.  A  disseminated  form,  particularlv  described  by 
Oilier. 

Necrosis  concerns  us  here  as  orthopaedists  mainly  in 
this,  that  it  produces  in  many  instances  a  weakening 
of  the  bone  which  may  lead  either  to  fracture,  deform- 
ity, or  curvature.  Spontaneous  fractures  of  necrotic 
bone  have  ociiurred  under  my  observation  ;  and  I  re- 
member one  case  of  necrotic  femur  which  broke  as  we 
were  lifting  the  patient  upon  the  operating- table. 

Incidentally,  there  is  danger  of  cancer  in  some  of 
these  cases,  for  Yolkmann  collected  thirty- two  cases  in 
which  old  and  fistulous  passages  became  the  site  of 
epitheliomatous  changes,  and  in  which  cancer  was  the 
final  result. 


SOME  GENERAL  CONSIDERATIONS  ON  PAR- 
ESIS—IS   IT    A    MICROBIC    DISEASE? 

By  LOUIS  C.  PETTIT,  M.D., 

WVRD's  island,  new  YORK  CITY. 

The  following  paper  is  the  result  of  the  study  of  the 
clinical  histories  of  over  thirteen  hundred  cases  of  par- 
esis, and  is  supplemented  with  a  few  of  the  great 
changes  observed  in  over  fifty  autopsies.  In  such  a 
large  number  of  cases  of  paresis  an  observer  is  neces- 
sarily and  perhaps  unwillingly  impressed  by  frequent 
anomalies  in  tlie  clinical  and  histological  features  of  a 
disease  progressively  involving  the  entire  cerebro-spinal 
system  and  directly  or  secondarily  interfering  with 
every  function  requisite  to  life. 

Paresis  as  already  defined  is  a  disease  tolerably  uni- 
form and  speciiUy  classified  among  the  insanities  and 
differentiated  from  other  forms  not  only  by  somatic 
signs,  but  by  an  almost  constant  dementia  and  a  gen- 
eral enfeeblement  of  intelligence  ;  a  disease  of  the 
body  and  of  the  mind,  a  morbid  connecting  link  be- 
tween the  "material  basis  of  mind"  and  immaterial 
entity  ;  a  disease  that  steers  its  own  way  in  the  whim- 
sical classifications  of  insanities,  and  at  the  same  time 
embodies  every  conceivable  psychical  type,  with  true 
dementia  as  a  basis,  and  affective  and  intellectual  dis- 
order in  bas-relief. 

The  etiology  of  paresis  has  not  as  yet  revealed  to  us 
much  that  really  enlightens  as  to  the  direct  source  of 


November  2,  1895] 


MEDICAL    RECORD. 


61; 


the  disease.  We  have  only  the  complex  conditions 
undei*  which  it  may  occur.  In  our  present  state  we  can 
say  that  two-thirds  of  the  paretics  have  been  immoder- 
ate drinkers  ;  at  least  one-fourth  have  had  syphilis  ;  a 
small  proportion  have  indulged  in  sexual  e.xcesses,  and 
the  remainder  have  been  moral  and  temperate,  and  ac- 
quired the  disease  in  the  legitimate  pursuits  of  life. 
Many  have  indulged  in  the  entire  category  of  supposed 
inciting  causes.  A  rationalist  will  ask,  Why  should 
alcohol  or  syphilis  or  both  cause  paresis  in  man,  and 
almost  never  in  woman  ?  or.  Why  should  such  causes 
produce  in  one  paresis  and  in  another  a  dementia 
wholly  different  ?  Syphilis  and  intemperance  have  ex- 
isted almost  since  the  advent  of  man  upon  earth.  Par- 
esis has  grown  upon  us,  or  rather  we  have  grown  to 
recognize  it,  during  the  last  few  decades.  Even  ad- 
mitting that  the  above  mental  strain  and  a  rapid  ex- 
haustion and  stasis  of  nerve  force  may  cause  or  produce 
similar  early  symptoms  or  the  prodromic  disease,  what 
causes  its  progression  after  these  supposed  causes  have 
ceased  to  exist  ?  The  cerebro-spinal  system  needs  only 
touching  by  this  disease  and  the  rest  is  done.  A  pos- 
sibly novel  or  at  least  not  generally  known  fact  is,  that 
paresis  occurs  frequently  among  the  robust  children  of 
phthisical  parents.  Without  any  effort  on  my  part,  or 
special  object  in  view,  knowledge  of  this  fact  was  im- 
pressed upon  me  by  the  very  large  percentage  of  phthis- 
ical relatives  in  the  families  of  over  thirteen  hundred 
patients  dying  of  paresis.  Again,  contemporaneous 
heredity,  and  its  occurrence  in  two  or  more  brothers  or 
other  members  of  the  same  family,  where  attributed 
inciting  causes  were  not  sufficient,  may  argue  toward  a 
predisposition.  Paresis  and  phthisis  may  in  some  man- 
ner be  related  to  each  other  in  some  mysterious  etio- 
logical sense.  Paresis  is  no  respecter  of  persons,  at 
least  of  men,  neither  does  it  select  persons  already  in- 
fected with  disease,  unless  the  forerunner  be  either 
syphilis  or  phthisis.  At  times  the  materies  niorbi  of 
these  two  diseases  are  interchangeable,  and  may  not 
these  impose  their  duties  upon  others,  or  could  the  al- 
ready present  schisomycetes  undergo  an  autochthonous 
evolution  and  thereby  produce  a  new  micro-organism, 
the  cause  of  paresis  ?  \Miile  much  may  be  found  in  the 
present  etiology  of  paresis  to  substantiate  the  theory  of 
micro-organisms,  vastly  more  is  shown  at  the  necropsies 
and  will  be  treated  of  later. 

The  characteristic  or  pathognomonic  somatic  signs 
of  paresis  are  not  many,  neither  are  they  uniformly  and 
collectively  present.  While  there  is  the  widest  range 
of  disturbance  of  the  intellectual  sphere,  the  physico- 
motor  phase  of  the  disease  in  a  large  majority  of  cases 
is  manifested  by  rather  few  but  usually  well  defined 
symptoms.  The  psychical  symptoms  are  first  to  attract 
attention  ;  friends  of  the  patient  recognize  something 
wrong,  a  change  from  the  normal  state  ;  the  physician 
recognizes  the  physical  signs  and  the  diagnosis  is  com- 
plete. The  early  recognition  of  psychical  symptoms 
by  friends  and  relatives  is  no  criterion  by  which  we  can 
judge  of  the  time  of  appearance  of  physical  signs.  It 
must  be  assumed  that  the  psychical  and  motor  symp- 
toms of  this  disease  appear  simultaneously  ;  clinical 
history  substantiates  this,  and  our  present  knowledge 
does  not  permit  us  to  say  that  the  disease,  selects  pref- 
erably the  "  basis  of  mind  "  to  that  of  motion. 

.\mong  the  earlier  manifestations  of  paresis  we  study 
the  physiognomy.  One  long  associated  with  paretics 
grows  to  recognize  them  almost  at  a  glance.  The  ex- 
pression in  addition  to  being  an  index  to  the  mind  is 
accompanied  by  more  or  less  permanent  physical 
change,  an  asymmetrical  lack  of  muscular  and  dermal 
tone.  There  is  a  lack  of  expression,  a  want  of  stimu- 
lation from  the  brain.  A  slight  dropping  of  the  lower 
jaw,  a  tendency  toward  roundness,  especially  when 
there  is  delirium  of  an  expansive  type  present ;  or  there 
may  be  a  (ixed,  stony  expression,  a  lack  of  that  reaction 
which  gives  character  to  mental  acts  ;  later  there  is  an 
increase  of  ideo-motor  reflex  action.     The  face  at  rest 


once  put  into  motion  brings  out  an  entire  new  feature 
of  the  disease,  a  physical  lack  of  proper  co-ordination. 
Probably  of  all  the  physical  signs  of  paresis  none  are 
more  pathognomonic  than  a  slight  clonus  of  the  upper 
lip  on  retraction,  not  in  all  cases  observed,  but  when 
present  needs  fewer  associative  symptoms  than  any 
other  to  establish  a  diagnosis.  The  presence  of  fine 
fibrillary  tremor  in  the  upper  eyelids  on  easy  closure 
will  reveal  remarkably  slight  loss  of  co-ordinating 
power.  Tremor  of  the  tongue  is  rarely  absent.  Any 
or  all  may  be  present  ;  at  times  they  are  transitory,  dis- 
appearing after  treatment.  Leaving  the  face  we  exam- 
ine the  hands  by  placing  the  finger-tips  on  the  dorsal 
surface  of  the  interdigital  folds,  and  the  same  distinct 
fibrillary  tremor  is  felt  and  is  frequently  accompanied 
by  a  fine  crepitation.  Lastly  comes  the  knee-jerk  ;  be 
it  either  exaggerated  or  diminished  it  has  weight  in  the 
general  phenomenon,  and  is  of  much  more  value  when 
increased  than  diminished.  In  testing  the  knee-jerk  in 
this  disease  the  free  hand  should  be  placed  lightly  upon 
the  quadriceps  and  its  contraction  estimated  ;  the  arc 
subtended  by  the  foot  does  not  always  fairly  represent 
the  increased  irritability,  and  depends  on  the  tonic 
state  of  the  muscle  at  rest.  There  may  be  a  violent 
contraction  of  the  muscle  and  but  little  response  in 
the  foot.  The  foregoing  symptoms  must  be  associated 
with  some  evidence  of  mental  disturbance,  transitory 
or  permanent,  or  with  vertiginal  attacks,  or  temporary 
loss  of  speech,  or  hemi-paresis,  and  the  diagnosis  will 
be  positive.  There  is  a  diagnostic  value  in  this  associ- 
ation of  symptoms  that  cannot  be  overestimated,  no 
matter  how  slightly  developed.  Out  of  five  thousand 
cases  of  insanity  in  the  male,  the  nearest  approach  to 
this  chain  of  symptoms  was  exhibited  in  a  few  para- 
noiacs,  about  the  only  difference  being  in  the  character 
of  tremor,  which  in  the  latter  was  coarse  and  more  gen- 
eral in  distribution,  and  obviously  due  to  emotional 
disturbance  and  a  maligned  feeling.  Acute  alcoholism 
may  confuse  one  for  a  short  time  ;  in  such  cases  the 
diagnosis  should  be  in  abeyance.  Pupillary  symptoms 
usually  come  later  in  the  disease,  and  little  early  change 
may  be  sought  for  other  than  a  slight  akinesis  and  de- 
crease in  range  of  action  in  the  iris.  Myotic  and  spastic 
pupils  are  of  serious  import  and  may  be  prodromic  ;  if 
"  pin-holed,"  a  long  course  of  disease  may  be  premised. 
Probably  not  more  than  five  per  cent,  of  cases  will  pre- 
sent this  symptom,  usually  alcoholics  or  rheumatics 
over  forty  ;  at  times  it  appears  to  be  merely  concomi- 
tant and  from  a  different  cause.  There  is  a  remarka- 
ble acuteness  of  vision  in  such  patients,  but  they  re- 
quire more  light. 

Some  detail  of  the  psychical  disturbances  in  the  early 
or  prodromic  stage  of  the  disease  will  not  be  out  of 
place,  as  we  assume  that  mental  reductions  must  always 
be  present ;  they  are  the  result  of  external  psychical 
stimuli  and  the  increased  reflexion  from  spontaneity  of 
thought.  The  prevailing  impression  is,  that  paresis  is 
accompanied  by  expansive  morbid  delirium  ;  this  to  a 
certain  extent  is  true,  but  misleading  ;  probably  more 
than  one-fourth  of  all  paretics  pass  entirely  through 
the  disease  without  manifesting  I'alienation  ambitieuse  ; 
once  exhibited  there  is  no  symptom,  psychical  or  motor, 
of  more  diagnostic  value.  Transitory  expansive  alien- 
ation, in  fact  a  single  sentence  in  this  tenor,  has  given 
many  a  clew  ;  "  this  clew  once  found  unravels  all  the 
rest."  The  early  psychical  symptoms  are  commonly  a 
mere  absent-mindedness,  not  wholly  inconsistent  with 
perfect  health  ;  at  times  mental  restlessness  or  unrest, 
broken  by  a  painfully  acute  perception  of  something 
being  wrong  or  a  morbid  fear  of  death. 

At  the  present  time  public  knowledge  of  paresis  is 
so  wide-spread  tiiat  it  is  not  unusual  to  receive  patients 
who  knowingly  are  afflicted.  Such  patients  are  given 
at  times  to  a  painful  self-consciousness,  and  pitifully 
appeal  to  the  physician  for  help.  A  recent  case  said 
that  his  greatest  ambition  was  to  die,  and  prayed 
that  his  life  might  be  speedily  taken.     Transitory  al- 


6i8 


MEDICAL   RECORD. 


[November  2,  1895 


ternating  states  of  depression  and  exaltation,  however, 
soon  flicker  and  are  smothered  by  progressive  dementia. 
Leptomania,  where  the  morbid  desire  is  accompanied  by 
an  irrational  act,  is  common.  A  sense  of  confusion  is 
present  with  a  bewilderment,  during  which  mental  inhi- 
bition is  lost  and  ludicrous  ;  sometimes  marvellous  feats 
are  performed.  Vague  and  indescribable  sensations 
and  hallucinatory  sounds  are  often  prodromic.  One 
patient  spent  months  trying  to  grow  a  pansy  to  the  size 
of  a  sunflower,  and  ransacked  Jersey  for  rich  earths  ; 
finally  he  became  irritable  and  morose,  and  a  menace 
to  his  family.  Another  purchased  six  clocks.  A  third, 
after  many  wonderful  experiences  and  hair-breadth  es- 
capes, extending  over  a  period  of  one  year,  presented 
himself  at  his  mother's  door  at  one  o'clock  in  the  morn- 
ing with  two  red  lanterns  swinging  on  his  arm  ;  so  on 
ad  infinitum.  There  is  a  change  in  demeanor  or  habits 
toward  spendthriftiness  or  demoralization  ;  attempts 
toward  insuring  one's  life  without  appropriate  means  ; 
gamomania  and  the  consummation  of  the  desire  by  the 
act  :  the  predicament  of  having  more  than  one  wife  is 
pleasing  enough  when  one's  turrets  are  armored  with 
dementia.  Rarely  is  there  anything  like  distinct  sex- 
ual perversion.  ]'">xpansive  ideation  (megalomania)  is 
usually  a  later  manifestation,  but  may  be  present  from 
the  beginning.  The  ordinary  psychical  course  is  first 
an  indefinite  period  of  mild  mental  deterioration  with 
some  confusion  of  ideas  or  apathy  ;  during  this  stage 
purposeless  acts  are  performed.  Then  follows  a  short 
period  of  depression  during  which  homicidal  or  sui- 
cidal tendencies  develop.  Mental  stasis  followed  by 
an  aestheticism  and  delirium  of  grandeur  complete  the 
cycle. 

It  is  impossible  here  to  detail  at  length  the  premon- 
itory symptoms  in  many  cases.  I  will  refer  merely  to 
those  of  a  single  case.  A  patient  at  present  thirty- seven 
years  of  age,  whose  mother  died  of  phthisis,  and 
whose  sister  is  suffering  from  melancholia,  had  syphilis 
nineteen  years  ago.  He  was  treated  in  the  Hamburg 
(Germany)  City  Hospital,  and  was  informed  that  he 
was  "cured,"  as  the  profession  at  present  accepts  the 
term.  He  married  nine  years  ago  and  has  three 
healthy  children  ;  has  been  a  moderate  drinker,  and 
states  as  follows  :  "  I  was  apparently  in  good  health 
four  years  ago,  but  began  to  suffer  from  insomnia  and 
headaches  to  a  slight  degree  only,  when  previous  to  re- 
tiring one  niglit  I  felt  a  heavy  feeling  around  my  chest 
and  went  to  the  window  to  get  more  air  and  then  to 
bed.  1  did  not  sleep  ;  was  sitting  up  in  the  bed  when 
suddenly  everything  seemed  to  pass  out  of  sight  ;  then 
I  felt  a  burning  sensation  as  if  I  was  being  cut  in  two 
lengthwise  with  a  knife.  I  lost  consciousness  for  a 
few  seconds  ;  on  regaining  it  I  felt  an  intense  burning 
all  over  my  body,  which  I  could  not  cool  with  water. 
I  was  then  weak  on  the  right  side  and  unable  to  speak 
distinctly,  and  my  head  felt  as  if  an  iron  cap  were  be- 
ing pressed  down  upon  it.  In  two  days  I  had  recov- 
ered my  usual  strength  and  went  to  work.  I  continued 
to  suffer  from  insomnia,  and  began  to  worry  about  my 
future  and  family,  and  suffered  from  headaches  and 
pains  in  the  right  leg  and  knee  and  over  the  spine  ; 
these  symptoms  lasted  over  two  years."  The  patient's 
friends  state  that  during  the  past  two  and  a  half  years 
he  has  been  more  or  less  at  times  confused,  mildly  ex- 
citable and  emotional,  and  during  such  periods  has 
had  difficulty  with  his  speech.  He  lost  his  position,  and 
through  unreasonable  jealousy  became  a  source  of  ap- 
prehension and  a  menace  to  his  family.  With  the 
above  premonitory  symptoms  of  nearly  three  years' 
standing  the  patient  was  admitted  to  this  institution 
one  year  and  a  half  ago,  presenting  the  following  so- 
matic signs  :  His  pupils  responded  to  both  light  and 
accommodation  sluggishly,  were  regular,  and  the  left 
showed  a  slight  paradoxical  reflex.  There  was  a 
marked  tremor  of  the  upper  lids  on  closure,  a  slight  clo- 
nus of  the  upper  lip,  and  a  fine  fibrillary  tremor  around 
the  margin  of  the  tongue,  which  was  moist  but  deeply 


fissured.  There  was  a  crepitation  of  the  hands  and  the 
usual  tremor.  The  knee-jerk  was  slightly  diminished. 
The  above  conditions  continued  to  exist  in  spite  of  an- 
tisyphilitic  treatment.  The  grandiose  ideation  was 
shown  in  a  single  letter  which  he  wrote  to  a  friend  ;  in 
this  he  characterized  himself  as  "  like  to  Him."  The 
dementia  was  seen  in  the  accumulation  of  trash  in  his 
bed.  It  is  needless  to  state  that  he  is  well  on  in  the 
trodden  path,  far  beyond  "  old  sheet-anchor  iodides." 
There  are  many  reasons  why  I  have  chosen  such  a  case 
for  illustration  :  First,  the  typical  paretic  is  repre- 
sented ;  secondly,  those  who  believe  in  a  pseudo-pare- 
sis will  find  solace  in  syphilis  ;  again,  the  long  period 
of  prodromes  furnishes  almost  every  prominent  psychi- 
cal symptom  of  paresis  to  a  certain  degree.  Such  cases 
have  been  called  syphilitic  peri-encephalitis.  If  there 
is  any  positive  means  of  demonstrating  that  this  pa- 
tient's disease  is  syphilis,  then  I  shall  believe  that  syphi- 
lis and  paresis  are  convertible  terms.  Similar  cases  to 
the  above  are  of  common  occurrence.  The  danger  in  di- 
agnosing syphilis  will  only  be  fully  appreciated  by  those 
who  have  seen  identical  cases  without  either  syphilitic, 
phthisical,  or  neurotic  predisposing  or  contributing 
causes.  Is  paresis  an  atavistic  anomaly  of  syphilis, 
or  can  we  differentiate  supposed  causes  until  we  are 
compelled  to  individualize  a  new  micro-genesis  ?  Again, 
is  it  not  possible  that  the  specific  virus  of  syphilis  in  pass- 
ing through  generations  of  men  has  been  modified  so  as 
to  become  the  progenitor  of  a  xenogenitic  cause  of 
paresis  ? 

The  tabetic  type,  and  in  fact  all  other  "  types,"  of 
paresis  are,  as  we  progress  in  knowledge,  being  absorbed 
by  the  disease  proper.  At  one  time  there  existed  in 
the  minds  of  some  a  co-relation  between  paresis  and 
tabes.  It  is  a  notable  fact  that  in  less  than  three  per 
cent,  of  paretics  do  we  find  the  classical  symptoms  of 
tabes,  and  in  the  male  asylum  of  this  city  there  are  at 
present  as  many  melancholiacs  and  terminal  dements 
as  paretics  with  such  symptoms.  Their  co-relation  is 
certainly  not  semeiological.  Paresis  is  accompanied  by 
no  "  type  "  of  cord  affection.  The  cord  as  a  part  of 
the  cerebro-spinal  system  is  nearly  always  subjected  to 
the  ravages  of  this  disease,  and  may  be  primarily  so 
affected  ;  but  there  cannot  be  a  co-relation  in  the  de- 
generative or  sclerosed  sense.  There  may,  however, 
be  a  common  etiology,  by  which  cord  disease  (not  nec- 
essarily tabes)  and  paresis  are  related  ;  if  so,  it  is  a 
mere  chance  in  a  hundred  that  the  posterior  columns 
are  the  first  foci  of  infection.  Paresis  is  no  more  a  re- 
specter of  the  cords  columns  than  it  is  of  men  ;  the 
morbid  appearances  after  death  indicate  this  and  ex- 
clude no  part  of  the  cerebro-spinal  axis.  Looked  at 
in  the  sense  of  a  localization  of  a  general  disease,  the 
concurrence  of  tabes  and  paresis  is  a  mere  coincidence. 
If  paresis  attacks  the  cord  first  it  will  attack  the  cortex 
eventually,  just  as  certain  as  when  it  attacks  the  cortex 
only  the  intervention  of  death  prevents  the  disease 
from  involving  the  cord.  All  that  necropsies  have  yet 
shown  indicate  that  paresis  attacks  through  the  circu- 
lation and  not  through  psychical  nonentities. 

Duration  of  Disease.— 'lliis  is  not  at  variance  with 
the  other  general  features  of  the  disease  and  shows 
the  widest  range.  Thirteen  hundred  cases  were  under 
asylum  care  an  average  period  of  eleven  months  each, 
and  had  an  average  duration  previous  to  admission  of 
fifteen  and  three-fourths  months  each ;  this  would 
make  a  total  average  duration  of  twenty-six  and  three- 
fourths  months,  and  may  be  considered  as  the  minimum 
average,  it  being  difticult  to  obtain  accurate  data  as  to 
the  invasion  of  the  disease  in  some  cases.  A  less  num- 
ber of  cases  with  more  accurate  histories  raised  the 
average  to  about  twenty-eight  months.  The  duration 
of  treatment,  or  period  of  asylum  restraint,  in  the  total 
cases  does  not  equal  the  period  of  duration  previous 
to  admission,  a  unique  feature,  and  argues  that  the 
greater  portion  of  the  paretic's  diseased  life  is  spent  in 
a  state  of  quiet  dementia,  motor  disturbance  predomi- 


November  2,  1895] 


MEDICAL   RECORD. 


619 


nating  throughout  the  disease.  In  the  entire  number 
the  duration  was  under  five  years  in  twelve  hundred 
cases,  from  five  to  ten  years  in  eighty-six,  from  ten 
to  fifteen  years  in  twelve,  and  for  twenty-five  years  in 
one  and  thirty-five  in  another.  It  might  be  a  source  of 
"  professional  pride  "  to  know  that  fourteen  years  ago 
some  of  our  expert  alienists  were  called  to  testify  in  a 
then  well  known  case  brought  into  court  on  a  writ  of 
habeas  corpus  and  discharged  as  sane,  in  spite  of  their 
testimony  of  e.xisting  paresis  ;  that  the  patient  died 
only  a  short  time  ago  after  an  attack  of  fifteen  years' 
duration.  After  having  passed  through  a  complete 
cycle  of  mental  phenomena  he  settled  down  into  a 
state  of  quiet  self-contentment  and  dementia,  for  years 
manifestmg  no  other  somatic  signs  than  spastic  myosis 
and  a  very  slight  fibrillary  tremor  of  the  tongue,  hands, 
and  lips.  Approaching  deterioration  was  observed  sev- 
eral months  previous  to  death  by  increased  loss  in  co- 
ordinating power  only.  He  was  suddenly  attacked 
with  convulsions,  apparently  of  the  respiratory  and 
cardiac  type,  the  temperature  rapidly  reached  106°  F., 
and  death  ensued  in  a  few  hours.  Owing  to  a  liability 
at  any  time  to  convulsive  attacks,  dural  hsematomata, 
or  hydro-meningitis,  it  is  difficult  to  prognosticate  the 
duration  of  the  disease.  Younger  men  seem  to  suffer 
more  acutely  and  to  give  way  to  the  disease  earlier  and 
easier  than  men  of  forty  years  and  upward  ;  likewise, 
they  are  more  liable  to  maniacal  attacks  and  morbid 
impulses.  Affection  of  speech  and  expansive  delirium, 
accompanied  by  motor  excitement,  paralysis  of  sphinc- 
ters, and  the  "  Romberg  "  symptom,  mean  progression 
and  an  early  termination,  although  such  extreme  cases 
may  remit  and  pass  into  a  state  of  quintescence  and 
life  be  prolonged  for  years. 

Thirty-two  nations  and  over  two  hundred  and  fifty 
occupations  are  represented  in  the  death-roll  from  this 
disease  in  a  single  asylum.  America  takes  the  lead 
with  436  white  and  48  colored  ;  Germany  furnishes 
335;  Ireland,  244;  England,  71;  France,  31.  The 
balance  is  about  evenly  divided  between  twenty 
nations,  and  includes  two  Chinamen.  This  is  not  a 
very  bright  showing  for  the  native-born  in  an  institu- 
tion where  over  two-thirds  are  of  foreign  birth  and 
over  eighty  per  cent,  of  foreign  parentage.  There  may 
be  a  greater  morbidity  at  home  ;  this  we  will  not  dis- 
cuss at  present. 

There  is  a  general  impression  among  the  laity  and 
some  of  our  profession  that  paresis  prevails  largely 
among  those  who  follow  the  stage  ;  this  cannot  be 
substantiated  by  facts.  While  that  profession  cares 
for  its  own  to  a  greater  extent  than  does  any  other,  a 
large  portion  of  its  paretics  go  to  private  institutions.  I 
may  state  that  the  medical  profession  and  that  of  law 
furnished  equally  as  many  cases  for  the  great  charitable 
institutions.  In  the  entire  number  of  cases  of  death 
from  paresis  only  8  were  actors,  7  lawyers,  and  5  phy- 
sicians.    The  ministry  was  not  represented. 

Without  going  into  any  extensive  detail,  I  will  state 
that  no  profession,  trade,  or  occupation,  predisposes  to 
paresis.  Investigation  shows  that  the  out-door  and 
sedentary  occupations  each  furnish  their  quota.  The 
ordinary  laborer  takes  the  lead  with  109  cases,  followed 
by  59  clerks,  45  tailors,  37  drivers,  35  bartenders,  32 
painters,  32  cigarmakers,  31  carpenters,  29  salesmen,  28 
shoemakers,  26  waiters,  23  merchants,  20  machinists, 
16  printers,  16  butchers,  17  bakers,  16  barbers,  16 
engineers,  15  pedlers,  14  cooks,  13  musicians,  13 
porters,  12  blacksmiths,  and  so  on  down  through  over 
two  hundred  different  ])ursuits,  with  a  single  repre- 
sentative of  the  Rogues'  Gallery,  No.  1,878.  Vital  and 
mortuary  statistics  show  that  man's  means  of  livelihood 
is  not  an  etiological  factor  in  this  disease,  and  leaves 
an  inherited  tendency  as  highly  probable,  and  a  com- 
mon cause  staring  us  in  the  face. 

Age  at  Death. — It  will  be  seen  by  the  following  table 
that  paresis  rarely  occurs  during  adolescence,  and  while 
it  frequently  attacks  early  manhood,  it  usually  selects  its 


victims  from  those  mature  in  years.  Thirteen  hundred 
deaths  were  distributed  through  the  various  periods  of 
life  as  follows  : 


Age  at  Death. 

Cases. 

.\jc  at  Death. 

Cases. 

20  to  25 

4 

50  to  55 

152 

25  to  30 

72 

55  to  60 

89 

30  '0  35 

173 

60  to  65 

53 

35  '0  40 

2,0 

65  to  70 

20 

40  to  45 

272 

70  to  75 

2 

45  w  50 

212 

75  to  So 

I 

Making  due  allowance  for  the  duration  of  disease,  it 
will  be  observed  that  paresis  occurs  most  frequently 
between  the  thirty-fifth  and  fortieth  year,  and  the 
greater  number  die  between  the  ages  of  forty  and 
forty-five.  Statistics  in  this  country  vary  but  little 
from  those  already  taken  from  abroad  in  this  respect. 
If  there  really  was  a  greater  morbidity  with  us,  it  would 
probably  be  exhibited  by  an  earlier  manifestation  of  the 
disease.  The  above  would  indicate  that  paresis  does 
not  usually  begin  until  the  age  at  which  acute  diseases 
most  frequently  occur  is  passed.  The  immunity  of 
nerve  structure  against  disease  is  well  known.  Th& 
frequent  occurrence  of  paresis  among  the  robust — those 
'■  never  sick  a  day  " — would  hint  at  immunization  of 
those  who  had  suffered  from  other  acute  infections 
against  paresis.  The  effects  of  acute  infection  of  the 
cerebral  cortex  from  disease,  as  ordinarily  seen,  are 
deliria  of  transitory  nature.  What  is  there  in  paresis 
that  prolongs  that  state  and  adds  to  it  a  destruction  of 
every  accessible  part  of  an  entire  nervous  system  ?  No 
disease  manifests  the  persistent  progression  of  paresis  ; 
its  function  is  to  destroy.  There  may  be  an  acquired 
immunity  that  we  have  not  yet  discovered.  Paresis 
gathers  in  the  phthisical  and  syphilitic  human  residuum 
of  prolonged  subsidency,  and  well  on  in  the  road  of 
life,  beyond  the  age  where  sexual  excesses  most  weaken 
and  nerve-cells  least  resist. 

Finally,  it  may  be  well  to  offer  more  substantial  aid 
to  the  cause  by  a  few  microscopic  observations  on  the 
paretic  brain.  It  is  these,  more  than  all  others,  that 
tend  to  convince  one,  after  frequent  autopsies,  that 
paresis  is  micro-genetic  in  origin.  It  is  a  remarkable 
fact  that  in  this  disease  there  is  a  characteristic  uni- 
formity in  the  morbid  appearances  of  its  earlier  stage 
(when  death  occurs  through  intercurrent  disease),  while 
the  late  appearances  are  in  a  true  sense  panoramical. 

Only  a  small  percentage  of  paretics  die  in  the  ex- 
treme stage  of  the  disease.  Exhaustion  from  maniacal 
excitement,  frenzy,  and  depression,  malnutrition  and 
insomnia,  epileptiform  convulsions,  dural  hcematomata, 
and  morbid  accumulation  on  one  hand,  and  intercur- 
rent diseases  on  the  other,  carry  off  nearly  ninety  per 
cent,  of  the  cases.  The  final  typical  paretic  stage  is 
rarely  seen  ;  that  is  where  the  entire  cerebro-spinal 
axis  has  been  extensively  involved.  In  such  cases  the 
foetal  posture  is  assumed,  the  extremities  become  atro- 
phied, and  are  rigidly  flexed  ;  decubitis  appears  over 
the  prominent  parts  ;  paralysis  of  tlie  sphincters  has 
occurred  long  since,  and  with  a  spark  of  intelligence 
there  remains  only  the  more  invincible  trophic  centres 
to  complete  the  annihilation.  In  this  stage  even,  they 
may  greet  you  with  a  smile,  a  mere  consciousness  ex- 
cited by  a  presence,  and  possibly  an  attempt  at  speech  ; 
the  eyes  seem  bright,  and  there  seems  to  be  a  playful, 
flickering  mind  quietly  carousing  with  and  cajoling 
death.  Consciousness,  or  the  mind  we  associate  with  a 
material  basis  long  since  destroyed,  loathes  to  leave  a 
body  now  inert.  The  destruction  of  cortical  substance 
in  two  such  cases  was  almost  complete,  and  apparently 
caused  by  advanced  and  extensive  lepto  cerebro-spinal 
meningitis.  The  sub-arachnoid  trabecula  and  the 
spinal  canal  were  almost  filled  with  pus.  The  cauda 
equina  was  simply  macerated  and  the  posterior  nerve- 
root  sheaths  were  dripping  with  pus  which  had  evi- 
dently originated  within  the  spinal  membranes  and 
percolated    downward.      The  sulci  over  the   vertexes 


620 


MEDICAL    RECORD. 


[November  2,  i< 


were  filled,  and  in  places  the  gyri  were  decorticated  by 
the  distention  from  pus  within  the  epicerebral  space. 
In  the  second  case  the  pus  was  confined  to  the  subarach- 
noid space,  and  in  a  third  it  was  subdural.  The  in- 
flammatory effusion  had  not  yet  appeared  in  the  basilar 
cisternEB  ;  they  contained  only  congested  capillaries. 
The  cisternae  fossae  Sylvii  were  filled  with  pus.  The 
arachnoid  over  the  interpeduncular  space  was  opaque 
and  thickened,  but  no  pus  was  observed  ;  the  subarach- 
noid sinus  was  empty.  The  spinal  and  cerebral  menin- 
geal affections  appeared  to  be  contiguous  ;  the  disease 
was  equally  advanced  in  both  brain  and  cord,  with  a 
strong  possibility  of  the  cord  disease  being  either  metas- 
tatic or  having  had  an  independent  foci  of  infection. 
I  have  not  as  yet  found  a  case  in  which  leptomenin- 
gitis of  the  cord  alone  existed.  In  one  case  alone  was 
there  pus  in  the  cerebral  sulci  and  none  in  the  spinal 
canal. 

It  is  probable  that  the  disease  when  well  established 
eventually  involves  the  entire  cerebro  -  spinal  mem- 
branes. In  the  most  advanced  case  the  lateral  ventri- 
cles were  dilated  to  three  times  their  normal  capacity, 
their  ependyma  much  thickened  and  shrivelled,  but 
very  tough  and  leathery,  and  not  granular  or  latticed 
over  the  surface  as  is  usually  the  case  in  ependymal  in- 
flammations. Two  of  the  cases  apparently  presented 
three  independent  foci  of  infection — the  cortex,  spinal 
membranes,  and  ependyma.  Almost  every  advanced 
case  of  paresis  presents  some  marked  or  peculiar  path- 
ological appearance. 

The  above  were  cases  in  which  there  was  an  ex- 
tensive purulent  exudate  seemingly  of  inflammatory 
origin.  In  wide  contrast  I  may  mention  two  cases  in 
which  the  changes  were  apparently  degenerative  and 
necrotic  ;  clinically  they  did  not  exhibit  the  trophic 
disturbances,  so  marked  in  the  former  cases  ;  there  was 
no  decubitus,  no  muscular  atroph}-,  no  contracture  of 
the  extremities.  The  cords  presented  little  to  the 
naked  eye  other  than  thinness  of  the  meningeal  vessels. 
The  degenerative  changes  were  far  advanced  over  the 
cerebral  vertexes.  On  removal  of  the  dura  the  cortex 
presented  diagonally  across  the  vertex  an  undermined 
and  sunken  appearance.  The  gyri  in  some  places  re- 
tained their  full  rotundity,  but  were  depressed  to  a 
much  lower  level  than  the  surrounding  parts.  In  places 
the  membranes  were  entirely  absent  and  the  gyri  pre- 
sented nude.  The  disease  extended  in  this  manner 
from  the  left  supra-marginal  gyrus  to  a  width  of  75 
mm.',  and  proceeded  forward  and  upward  toward  the 
vertex  ;  reaching  the  paracentral  lobule  it  cut  several 
wide,  deep  notches,  and  completely  destroyed  the  gray 
cortex  in  this  region  ;  reaching  the  cerebral  falx  it 
seemed  to  ricochet,  leaving  the  cingula  intact,  and  ap- 
peared again  on  the  opposite  (right)  side  in  the  exact 
location  on  the  paracentral  lobule,  proceeded  about  the 
same  distance  and  width,  and  ceased  at  the  gyrus  fron- 
talis mediiis.  The  meningeal  remains  over  the  entire 
diseased  surface  was  of  a  rusty  color  and  extremely 
thin  and  pellucid.  In  this  case  the  lateral  ventricles 
were  filled  with  a  clear,  straw-colored  albuminous  fluid, 
specific  gravity  i.oio,  and  of  slightly  alkaline  reaction. 
There  was  no  ependymal  granulation  or  sclerosis.  In 
the  second  terminal  case  of  this  type  of  late  degeneration 
the  disease  appeared  to  have  exhausted  itself  along  the 
pars  horizontalis  of  both  hemispheres  ;  a  double  chain 
of  depressions,  necrotic  softenings  following  cystic  de- 
generation, reached  the  entire  length  of  the  fissure,  and 
each  angular  gyrus  presented  gelatinous  cysts  about  the 
size  of  a  hazel-nut,  beneath  which  the  gray  cortex  was 
entirely  perforated  by  the  necrotic  degeneration.  Over 
such  necrosed  spots  there  was  in  many  instances  a 
mere  pellucid  film  sometimes  encvsting  a  transparent 
fluid. 

In  the  above  cases  both  an  inflammatory  and  degen- 
erative terminal  state  of  the  disease  are  shown,  and 
these  in  the  cortical  envelope.  I  would  here  desire  to 
show  from  a  pathologico-anatomical  view  another  tyjie 


of  the  disease,  viz.,  that  in  which  the  disease  locates 
itself  upon  or  beneath  the  ependyma  and  within  the 
ventricles.  In  such  cases  only  the  earlier  cortical 
changes  were  observed.  The  ordinary  granular  epen- 
dyma occurred  in  about  ten  per  cent,  of  the  cases,  and 
included  both  the  syphilitic  and  non-syphilitic.  It  is 
possible  that  this  granular  state  may  be  an  early  mani- 
festation of  another  form  of  ependymal  disease.  In 
two  cases  where  the  ependymal  changes  were  promi- 
nent, there  was  an  entire  absence  of  anything  like  gran- 
ulation. The  morbid  processes  were  exerted  in  the 
floor  of  the  lateral  ventricles,  usually  in  the  anterior 
horns  or  the  cella  media.  In  one  case  there  was  a  large 
area  of  necrosed  neuroglia  implicating  the  stria  cornea 
and  the  tail  of  the  caudate  nucleus  ;  the  morbid  proc- 
ess had  obviously  begun  on  the  under  surface  of  the 
ependyma  and  proceeded  downward  into  the  basil 
ganglia  ;  the  membrane  itself  was  thickened  and  on  its 
surface  presented  a  latticed  appearance,  and  there  was 
an  entire  new  connective-tissue-like  formation  ;  this 
state  of  aftairs  also  existed  in  the  floor  of  the  fourth 
ventricle  in  both  cases,  but  was  not  accompanied  there 
by  necrotic  changes  in  the  ganglia  beneath  ;  there  was 
a  true  heteroplasia  extending  over  the  whole  epen- 
dymal surface.  The  necrosed  cavities  were  empt)-  ; 
the  serous  membrane  above  not  distended  but  some- 
what shrivelled  and  sunken  into  the  space  caused  by 
the  absorption  of  the  products  of  disease. 

Throughout  the  whole  number  of  autopsies  the  ad- 
vanced cases  more  frequently  showed  degenerative 
than  inflammatory  changes  ;  the  suppurative  conditions 
were  probably  consecutive.  However,  it  must  be  ap- 
parent to  one  making  many  autopsies  on  paretics  that 
the  disease  is  not  strictly  cortical,  and  may  first  select 
the  cord,  or,  perhaps  rarely,  the  serous  lining  of  the 
ventricles.  There  is  no  reason  why  paresis,  if  it  is  the 
localization  of  a  general  disease,  might  not  as  easily  first 
locate  itself  within  the  inner  vascular  cerebral  system 
as  in  the  cortical  envelope.  The  common-cause  theory 
will  eventually  assert  itself.  The  cases  described  were 
all  said  to  have  been  "  fast  livers  ;  "  two  had  stricture  of 
the  urethra,  one  gave  history  of  specific  disease,  and 
two  were  negative.  I  am  not  prepared  to  say  that  all 
or  any  were  free  from  syphilitic  infection  ;  but  there 
was  an  entire  absence  of  gummatous  deposit  in  the 
nerve  structure.  If  syphilis  presents  all  the  pathologi- 
cal manifestations  of  paresis,  then  our  present  knowl- 
edge of  cerebral  syphilis  is  wofuUy  meagre.  It  is  said 
by  some  that  syphilis  causes  pseudo  paresis.  I  have 
noticed  that  the  "  pseudo-paretics "  are  subject  to 
iodism  and  die  in  the  allotted  time  given  to  the  true 
disease.  There  can  be  no  neutral  ground  ;  paresis  and 
syphilis  may  be  convertible  terms  ;  but  it  is  difticult  to 
believe  that  syphilographers  have  been  waiting  for  a 
century  or  more  on  students  of  paresis  to  discover  the 
brain  lesions  of  their  disease.  Syphilis  may  present  dif- 
ferent types  of  virility,  if  so  the  "  paretic  type  "  is  the 
most  virile. 

The  theory  of  a  psychical  paresis  has  long  since  been 
discarded  by  investigators.  The  common  and  constant 
vascular  changes  seen  on  the  autopsy  table  tend  to  re- 
lieve one's  mind  of  theorizing  on  the  mysteries  con- 
necting psychical  redaction  with  paresis  in  an  etiologi- 
cal sense.  It  was  not  "  that  which  has  escaped  "  that 
acted  on  the  living  matter  to  produce  paresis.  It  is 
also  time  that  the  Rolandic  area  and  paresis  were  di- 
vorced. The  motor  cells  in  this  area-  suft'er  no  more 
than  other  cells  suffer  in  other  areas  ;  and  we  certainly 
cannot  connect  a  general  loss  of  voluntary  muscular 
control  and  co-ordinating  power  with  this  specialized 
cortex,  its  clusters,  or  its  laminations. 

In  conclusion  I  would  reiterate  that  the  future  of  par- 
esis depends  on  the  discovery  of  a  common  cause  ; 
that  preserved,  sterilized,  and  hardened  specimens  of 
the  paretic  brain  will  be  searched  over  as  ruins  only, 
and  their  value  will  be  in  the  sense  of  a  connecting  link 
between  paresis  and  what  was  once  physiological. 


November  2,  1895] 


MEDICAL   RECORD. 


621 


THE   ALLEGED   PARASITE    OF    MALARL\. 
By  W.  MOSER,  M.D., 

TO  ST.   CATHAK19CE*S  HOSPITAt,   BROOKLYN,   N.  Y. 


That  the  red  blood  corpuscle  is  not  always  round  in 
shape  has  long  been  known.  Quincke  saw  peculiar- 
shaped  corpuscles  in  pernicious  anaemia  and  called 
them  poikilocytes,  and  at  one  time  regarded  them  as 
characteristic  of  that  disease.  AVhile  it  is  true  that 
these  peculiar  shapes  are  best  seen  in  pernicious  an^;- 
mia,  they  do  occur  in  many  conditions.  Their  exact 
nature  being  unknown,  they  were  simply  denominated 
poikilocytes.  Friedreich  and  Mosler  were  first  to  see 
distinct  amoeboid  processes  in  a  few  instances  in  the 
red  blood-cells  of  pernicious  ansmia,  and  Jaksch  too 
made  this  observation  and  says  :  "  Ich  mochte  gerade- 
2U  behaupten,  dass  durch  die  Eigenschaft  der  rothen 
Blutzellen,  in  abnormen  Masse  contractil  zu  sein,  das 
Bild  der  Poikilocytose  entsteht."'  And  this  theory  of 
Jaksch  I  regard  as  the  proper  one.  Owing  to  some 
poison  in  the  blood  the  cells  are  stimulated  to  abnor- 
mal contractility,  while  ordinarily  they  remain  more 
passive  ;  in  the  same  manner  in  which  the  white  blood- 
corpuscle,  ordinarily  round,  may  under  certain  influ- 
ences as  heat,  acids,  etc.,  be  stimulated  into  activity 
and  show  varied  shapes.  I  saw  and  described  am  he- 
boid processes  in  heaJthy  blood  while  experimenting 
with  methyl  blue  in  1S93.-  And  again  I  saw  and  de- 
scribed contractions  in  red  blood-cells — see  articles, 
"  The  Pathology  of  Pernicious  Anaemia,"  "  and  "  Have 
the  Red  Blood  -  corpuscles  Amoeboid  Movement  ?  "  ' 
Contractions  in  the  red  blood-cells  and  distinct  amoe- 
boid processes  were  seen  and  described  b)'  me  as  phys- 
iological processes,  and  for  this  I  claim  priority. 

Further  observations  on  this  subject  only  tend  to 
confirm  those  previously  made.  In  about  fifty  exami- 
nations from  the  blood  of  a  patient  now  lying  in  St. 
Catharine's  Hospital  I  saw  time  and  again,  and  likewise 
demonstrated  to  several  colleagues,  the  poh-morphic 
picture  represented  in  the  figure.  The  blood  was 
examined  fresh  without  the  warm  stage,  and  strange 
to  say,  many  of  the  cells  exhibited  motion.  A  bird's- 
eye  view  of  the  figure  will  show  many  cells  which  have 
sent  out  prolongations  in  different  directions,  such  as 
occur  in  the  white  blood-corpuscles,  and  which  cannot 
be  anything  else  but  amoeboid  processes.  The  cells  in 
this  blood  varied  much  in  size  ;  some  were  small,  while- 
others  were  large,  only  a  few  retaining  their  rounded  out- 
line and  inactive,  motionless  state,  while  most  cells  were 
very  irregular  in  contour  and  showed  distinct  move- 
ment. A  few  of  the  smaller  cells  were  acrively  mobile, 
constantly  changing  shape  and  exhibiting  inherent  con- 
tractions, while  in  some  cells  only  the  prolongation — 
the  amoeboid  process — could  be  seen  faintly  yet  dis- 
tinctly moving  back  and  forth. 

In  No.  I   of  the  figure  the  artist  has  sketched  the 
different  shapes  which  he  saw  under  the  microscope 
within  one  minute,  which  we  regard   as  quite   acti\e 
movement.     1  placed  the  cell  in   the  centre    of    the 
field  and  let  him  sketch  what  he  saw  after  that — and 
ask  no  questions.     The  two  last  cells  in  No.  i   show 
what  took  place  within  thirty  seconds.     In  No.  2  he 
reproduces  what  he  saw  within  one  minute  in  another 
vll  which  I  placed  in  the  field  for  him.     In  No.  3  he 
■produces  different  cells   which  I  placed  in  the  field 
ccessively,  and  we  note  their  irregular  outline  and 
•culiar  bodies  in  the  protoplasm  of  the  ceil.    In  some 
.lis  we  see  small  round  bodies,  while  in  the  other  cells 
c  see  larger  irregular-shaped  bodies.     In  No.  4  we 
- ce  peculiar-shaped  cells,  and  a  few  showing  these  ir- 
regular bodies  within   them.     No.  5  shows  irregular- 

'  Klinische  Diagoostik,  p.  27. 

-Medical  Rkcord    article:    Have   the  Red  Blood-corpuscles  a 
•  ■.cleu5  ? 
-  New  York  Medical  ]ouma!,  July  31,  1894. 

\!g-,i   -yt     Ktr,    v,  ".\ugu«t  II,   iS^. 


shaped  cells,  a  few  containing  round  or  irregular  bodies, 
and  the  last  contains  a  large  irregular  body  partly  with- 
in, partly  without  the  cell.  This  body  is  nothing  more 
or  less  than  a  red  blood- cell  itself  lying  on,  not  in,  an- 
other cell,  and  may  be  mistaken  for  a  parasite.  In  No. 
6  a  few  of  the  cells  in  this  series  show  long  and  distinct 
amoeboid  processes.  The  peculiar  body  in  this  series, 
partly  within  and  partly  without  the  cell,  is  merely  an- 
other red  blood-cell  undergoing  movement  and  could 
be  mistaken  for  a  parasite.  In  Nos.  7,  8,  and  9,  cells 
may  be  seen  in  different  phases  of  amceboid  movement, 
and  a  few  contain  irregular-shaped  bodies  within  them. 
No.  10  shows  a  small  red  blood-cell  which  was  actively 
mobile.  I  placed  No.  i  in  the  field,  and  within  thirty 
seconds  it  had  assumed  the  changes  in  shape  depicted 
in  Nos.  I,  3,  4,  5,  and  6,  and  the  artist  endeavors  to  show 
the  relarive  change  in  position  which  it  took  within  that 
time  from  No.  i  to  No.  6.  The  larger  body  in  the 
centre  is  a  red  blood-cell  only  slightly  altered  in  out- 
line as  compared  to  the  others.    Now,  in  looking  at  the 

X  Mtrtu-te. 


SXrScC, 


.3/^ 


figure  we  have  a  very  polymorphic  picture,  one  which 
we  are  not  accustomed  to  see  in  ordinary  blood  exam- 
inations. In  No.  10  the  cell  is  so  altered  in  shape,  or 
rather  it  is  undergoing  such  alterations  during  life,  as  to 
be  mistaken  for  a  worm  or  parasite. 

The  question  arises,  What  are  the  peculiar  bodies 
within  the  cell  ?  I  regard  them  as  degeneration  prod- 
ucts and  not  a  parasite.  In  fact,  when  we  compare 
these  bodies  with  what  has  been  described  as  the  Plas- 
modium malarioe,  and  when  we  consider  how  actively 
mobile  a  few  of  these  cells  and  how  altered  their  ap- 
pearance may  become,  there  may  be  a  suspicion  that 
that  the  life  history  of  the  cell  has  been  confounded 
with  that  of  a  parasite — the  plasmodium  malari.-e  of 
Laveran. 

In  reviewing  the  literature  on  the  plasmodium  %ye  see 
that  no  two  authors  are  agreed  as  to  what  constitutes 
the  parasite.  It  is  true  that  oval  bodies  varying  in 
size,  some  within  the  cells  and  some  free  in  the  blood, 
e.xhibiting  active  amceboid  movements,  have  been  de- 
scribed. But  the  red  blood-cell  itself  may  vary  much 
in  size  and  exhibit  active  amoeboid  movements.  It 
may    become    oval,   semi-lunar,    or    crescent-shaped, 


622 


MEDICAL    RECORD. 


[November  2,    1895 


scythe-like,  etc.  In  short,  it  manifests  the  same  poly- 
morphism as  does  the  plasmodium  malaria,  and  we  fear 
that  possibly  we  may  have  confounded,  at  least  in  some 
instances,  these  two,  and  naturally  ask  which  is  which? 
The  ])resence  of  pigment  simply  means  that  degenera- 
tive changes  are  taking  place  in  the  cell,  but  shows  no 
relation  to  a  parasite.  The  patient  from  whom  the 
blood  examination  was  taken  has  been  in  the  hospital 
some  three  months.  The  case  in  question,  to  be  brief, 
has  been  diagnosed  by  different  physicians  as  perni- 
cious malaria.  She  was  very,  and  is  still  slightly,  anre- 
mic,  has  had  irregular  chills,  and  now  and  then  vomit- 
ing. No  enlarged  spleen  or  liver.  Whether  the  case 
is  one  of  malaria  or  not,  microscopical  examination  of 
the  blood  showed  what  the  figure  represents.  The 
blood  at  times  contained  free  pigment.  Now,  until  the 
Plasmodium  malaria;  of  Laveran  is  demonstrated  out- 
side of  the  blood  or  outside  of  the  body,  we  become 
perplexed  and  hardly  know  which  is  which.  The 
question  naturally  is  asked,  if  what  I  describe  are  the 
varying  phases  in  the  life  cycle  of  the  red  blood-cell, 
why  is  it  we  do  not  see  them  oftener  or  ordinarily  when 
examining  the  blood  ?  The  red  blood-cell  generally  is 
round  and  exhibits  no  amceboid  motion  unless  it  be 
placed  on  the  warm  stage,  and  there  the  motion  is  slow. 
But  is  not  the  white  blood-cell  ordinarily  round,  in  a 
passive  condition,  unless  when  stimulated  by  certain 
factors  it  becomes  active  ?  And  so  here,  in  the  case  in 
question,  owing  to  some  poison  or  "  noxa  "  in  the  blood, 
the  cells  are  stimulated  to  abnormal  activity,  and  re- 
tain this  activity  when  we  examine  the  blood,  and,  as 
in  this  case  the  cells  retained  their  vitality  for  an  in- 
credible length  of  time  (in  some  cells  over  five  hours, 
and  in  a  few  over  twenty  hours),  and  I  repeat  the 
blood  was  examined  fresh  without  the  warm  stage. 
Now,  this  activity  in  the  cells,  coupled  with  de- 
generative changes  with  the  cells,  and  the  presence 
of  pigment,  may  have  led  us  to  believe  we  were 
dealing  with  a  parasite.  At  least,  I  feel  as  though  I 
may  have  been  mistaken  in  my  previous  observations, 
and  I  am  at  a  loss  now  to  say  which  is  which.  Let 
me  ask  why .  do  we  not  see  karyokinetic  changes  in 
the  nuclei  of  the  red  blood-cells  as  often  and  as  con- 
stantly as  we  see  them  in  infantile  pseudo-leucsmia, 
or  why  do  we  see  them  at  times  in  the  nuclei  of  the 
white,  blood-cells  in  the  leucajmia  of  adults  ?  Are 
these  not  physiological  processes,  part  and  parcel  of 
cell  life  ?  And  yet  ordinarily  the  nucleus,  like  the  cell 
itself,  is  round,  or,  as  in  the  case  of  the  white  blood- 
corpuscles,  at  most  a  little  irregular,  but  not  in  process 
of  mitosis.  This  subject  is  a  little  large  and  requires  a 
little  review. 

My  thanks  are  due  Mr.  Charles  Perpente,  who  made 
the  drawings,  and  who  would  not  be  so  apt  to  draw  on 
his  imagination  as  I  might  have  done,  had  I  made  them. 

158  Ross  Street. 

Another  Quarrel  between  Hospital  Staff  and  Board 
of  Managers.— We  are  informed  by  the  Medical  Seiiti- 
«t7  that  the  entire  medical  staff  of  the  Portland  (Ore- 
gon) Hospital  resigned  recently  in  order  to  uphold  one 
of  their  colleagues,  whom  they  evidently  thought  was 
in  the  right.  The  Board  01  Trustees  accepted  all  their 
resignations,  and  promptly  appointed  a  Homceopathic 
staff  instead  of  tlie  previous  regular  one. 

Mercury  in  Heart  Disease.— A  correspondent  of 
The  Laneet  reports  the  case  of  a  patient  who,  in  the 
course  of  fourteen  years,  took  over  twenty  tliousand 
blue  pills  of  three  grains  each.  The  patient  was  suf- 
fering from  heart  disease,  and  had  been  given  up  by 
his  physicians.  The  persistent  use  of  mercury,  how- 
ever, brought  him  out  of  his  moribund  state,  and  he 
continued  to  take  his  three  grains  or  more  of  blue  pills 
every  night  for  fourteen  years.  Whenever  he  stopped 
the  use  of  the  drug  the  symptoms  began  to  return. 
He  asserted  that  his  continued  use  of  mercury  never 
produced  any  diarrhoea  or  salivation. 


TWO  CASES  OF  AN  UNUSUAL  PAPULO- 
PUSTULAR  AND  FUNGOID  BROMIDE  OF 
POTASSIUM    ERUPTION    IN    BABIES.' 

By  GEORGE  T.  ELLIOT,  M.D., 

HEDICAL    SCHOOL,   NEW 


The  question  of  cutaneous  eruptions,  the  result  of  the 
internal  administration  of  drugs,  is  one  of  peculiar  in- 
terest to  both  the  dermatologist  and  the  general  practi- 
tioner. The  former  sees  many  artificial  conditions  of 
such  origin,  which  simulate  in  their  clinical  phenom- 
ena well-known  skin  diseases  of  entirely  different  or- 
igin and  causation,  and  the  latter  is  often  confronted 
by  cutaneous  processes  of  his  own  making,  which  he 
fails  to  recognize,  as  the  result  of  the  drugs  given  by 
him,  but  he  refers  them  rather  to  some  peculiar  and 
unknown  cause,  and  regards  them  as  an  unfortunate 
complication  of  an  existing  disease.  In  consequence, 
I  do  not  think  an  excuse  is  necessary  in  calling  atten- 
tion to  such  a  banale  subject  as  bromide  of  potassium 
eruptions,  in  view  of  the  severe  and  exaggerated  exam- 
ples of  the  effects  of  the  drug  to  which  I  would  call 
your  attention  in  this  paper. 

Case    I.  —  E.    M ,    female,    aged    nine    months, 

came  under  my  care  June  5,  1894.  Though  born  at 
full  term  and  well  nourished,  she  had  always  been  sus- 
ceptible to  catching  cold.  When  four  months  of  age 
she  had  had  tonsillitis,  followed  by  a  bronchitis,  which 
had  persisted  for  several  months.  During  that  time 
she  had  received  some  medicine,  the  nature  of  which 
could  not  be  ascertained.  When  five  months  old  she 
had  developed  a  tonsillar  abscess,  which  was  opened 
four  times.  In  the  beginning  of  March  an  abscess, 
originating  apparently  from  the  same  region,  was 
opened  externally  on  the  left  side  of  the  neck,  and  a 
little  later  another  one  was  operated  upon  on  the  right 
side.  Prior  to  the  opening  of  the  first  abscess  the 
baby  had  been  taking  syr.  ferri  iodidi,  gtt.  xv.  t.  i.  d. 
for  two  weeks,  and  shortly  after  the  operation  a  diffuse 
erythematous  eruption  had  appeared  over  the  trunk. 
The  exact  duration  of  this  "  rash  "  was  not  ascertained, 
but  it  was  stated  that  the  iodide  of  iron  was  continued 
until  March  30th,  and  the  first  eruption  had  been 
gradually  succeeded  on  the  body,  the  face,  and  the 
scalp,  by  crops  of  small  pinhead-size  pustules,  which 
had  dried  up  into  small  crusts  and  had  left  no  trace  of 
their  presence. 

Owing  to  an  increase  in  the  bronchitis  the  iodide  of 
iron  was  discontinued  March  30th  and  a  mixture  con- 
taining in  each  dose  bromide  of  potassium,  grs.  iiss., 
acetat.  of  potass.,  gr.  i.,  and  a  few  minims  of  buchu, 
hyoscyamus,  and  Elixir  of  Calisaya  was  given  every  four 
hours.  The  pustular  eruption  then  became  more 
abundant  and  appeared  on  the  legs,  the  arms,  and 
over  the  body  generally.  These  new  lesions  were 
larger  and  more  deeply  seated  than  the  former  ones  : 
they  did  not  dry  up  into  crusts,  but  tended  to  increase 
in  size  and  to  become  more  prominent.  The  same 
medicine  was  continued  until  May  7th,  and  then  the 
bromide  was  increased  to  grs.  vss.  every  four  hours. 
May  13th  a  further  increase  was  made,  and  the  baby 
received  grs.  xiss.  every  four  hours,  and  this  dose  was 
kept  up  until  June  5th,  when  she  came  under  my  care. 
The  mother  of  the  child  was  a  very  sensible  and  con- 
scientious woman,  and  she  told  me  that  she  had  fol- 
lowed literally  the  instructions  and  had  given  her  baby 
the  mixture  every  four  hours,  or  six  times  daily.  She 
also  furnished  me  with  copies  of  all  the  prescriptions, 
and  from  them  I  have  calculated  that  the  baby  had  re- 
ceived from  March  30th  to  June  5th,  2,376  grains  of 
bromide  of  potassium. 

The  child  was  fairly  well  nourished  when  seen  by 
me.     Her  mother  nursed  her.     There  were  no  gastro- 

»  Read  at  the  meeting  of  the  Ameiican  Dermatological  .'Association, 
held  at  Montreal,  September,  1893. 


( 


November  2,  1895] 


MEDICAL    RECORD. 


62' 


intestinal  disturbances  and  the  bowel  movements  were 
normal  in  regularity,  consistency,  and  color.  She  still 
had  some  bronchitis,  however,  and  was  decidedly 
anaemic.  The  eruption  was  very  generally  dis- 
tributed over  the  body.  Its  primary  lesion  was  a 
tense,  deep-seated,  and  prominent  papulo-pustule,  vary- 
ing in  size  from  a  pinhead  to  a  small  pea,  and  round, 
oval,  or  elongated  in  shape.  It  was  surrounded  by 
a  narrow  red  zone,  and  sharply  delimited  toward 
the  surrounding  healthy  skin.  In  the  course  of  its 
existence  it  enlarged  slowly  to  the  size  of  a  three-cent 
piece  or  larger,  became  prominent  and  covered  with 
a  yellowish,  clear,  glazed  coating,  beneath  which  yel- 
low miliary  points  of  pus  could  be  seen,  or  progressing 
still  further,  it  became  elevated  and  fungoid  in  charac- 
ter, and  covered  with  thick,  soft,  black  or  greenish, 
crumbly  crusts.  The  base  upon  which  these  rested  was 
fungating  and  studded  with  miliary  abscesses.  Many 
pigmented  and  dark-red  stains  were  also  present,  the 
sites  of  lesions,  which  had  already  undergone  involution. 
On  the  scalp  papulo-pustules  and  crusts  were  alone 
present.  On  the  face  small  and  large  pustules  were 
noted,  and  on  the  cheeks  a  few  prominent,  champig- 
non-like growths.  Only  few  of  the  lesions  had  at- 
tained this  development  on  the  trunk,  and  here  only 
pinhead  and  a  little  larger  papulo-pustules  were  seen. 
The  e.xtensor  surfaces  of  the  extremities  were  severely 
affected,  and  the  flexors  to  a  very  much  slighter  extent. 
On  the  arms  a  large  number  of  fungating  growths  were 
grouped  together,  though  still  remaining  discrete,  but 
on  the  legs  confluence  had  taken  place,  and  diffuse 
patches  were  found  extending  from  the  ankles  nearly 
up  to  the  knees. 

To  judge  by  the  behavior  of  the  child,  itching  was 
not  a  feature  of  the  eruption,  though  it  is  possible  that 
it  was  painful,  in  view  of  the  baby's  restlessness  and 
insomnia.  In  treating  the  child,  absolute  discontinu- 
ance of  the  bromide  salts  was  primarily  directed.  Its 
functional  health  and  its  hours  of  nursing  were  prop- 
erly regulated,  and  a  tonic  suitable  for  the  existing 
anaemia  was  ordered.  Externally  an  ichthyol  oint- 
ment was  applied  to  the  lesions.  Retrogression  began 
very  quickly  and  continued  steadily,  though  for  some 
weeks  new  pustules  appeared,  but  were,  however,  of 
ephemeral  duration.  By  the  end  of  August  no  traces 
of  the  process  remained  except  numerous  scars  mark- 
ing the  sites  of  the  former  growths. 

Case  II. — F- — — ,  male,  aged  six  months,  was  brought 
to  me  June  15,  1894.  He  had  been  born  at  full  term, 
was  healthy,  and  well  nourished.  He  had  been,  and 
was  still,  nursed  by  his  mother.  No  gastro-intestinal 
or  other  functional  disturbances  existed.  About  the 
middle  of  May  he  had  developed  a  bronchitis,  and 
had  become  restless  and  sleepless.  May  21st  his  phy- 
sician had  given  him 

Q.    Kali  bromidi. 

Sodii  bromidi aa  J  iss. 

Syr.  acacia; 3  iss. 

M.  Sig. :  One-halt  leaspoonful  every  hour  until  tlie  cough  was 
quieted. 

Calculating  the  dose  ordered  as  representing  thirty  min- 
ims, the  baby  received  three  and  three-fourth  grains  of 
each  of  the  bromide  salts  each  time  the  medicine  was 
administered.  This  mixture  was  continued  for  four 
days,  but  was  stopped  May  25th,  the  baby's  tempera- 
ture having  risen  to  103"  F.     It  then  received 

B  .    Aconite gtt.  xij . 

Tr.  opii.  camph. 

Spts.  nitrosi  dulc. 

Spts.  mindcreri, 

Syr.  scillce SS  J  ii. 

M.   Sig.:  Fifteen  drops  every  two  hours. 

At  the  end  of  a  few  days,  the  temperature  having  fallen 
and  the  baby's  condition  being  improved,  the  original 
prescription  of  bromide  was  substituted  for  the  aconite, 
etc.,  mixture,  and  given  up  to  June  4th.     On  June  7th, 


the  bronchial  symptoms  becoming  worse,  the  child 
again  received  kali  bromidi,  two  grains  in  syrup,  every 
two  hours,  and  this  was  continued  until  the  12th,  or 
three  days  before  I  saw  him.  The  cutaneous  eruption 
had  begun  about  June  ist,  but  had  been  slight  and  re- 
ceived little  attention.  It  had  subsided  somewhat 
when  the  first  bromide  mixture  had  been  stopped,  but 
it  had  increased  in  quantity  and  in  severity  after  taking 
the  one  given  on  June  7th. 

When  examined  by  me  the  baby  was  found  to  have 
an  eruption  distributed  (|uite  abundantly  over  the  scalp 
and  the  face,  and  also  here  and  there  on  the  extrem- 
ities. It  consisted  of  papulo-pustules,  about  the  size 
of  a  small  pea,  or  smaller,  which  on  the  scalp  had 
formed  around  a  hair-follicle.  Many  of  these  lesions 
were  pierced  by  a  hair.  These  primary  lesions  had 
enlarged  on  the  extremities  to  the  size  of  a  penny, 
and  they  were  prominent,  sharply  defined,  surrounded 
by  a  narrow  red  margin,  fungoid  in  appearance  and 
covered  with  a  glazed  coating,  below  which  minute 
miliary  pustules  could  be  seen  clustered  and  aggregated 
together.  In  some  instances  thick  crusts  had  devel- 
oped. 

In  treating  the  child  all  the  bromide  salts  were  dis- 
continued, and  ichthyol  was  used  locally.  In  a  few 
weeks  the  skin  was  again  normal.  No  perceptible 
scars' remained  even  at  the  sites  of  the  larger  lesions. 

The  histories  of  these  two  cases  thus  show  that  an 
eruption  of  a  severe  type  and  of  wide  distribution,  con- 
sisting primarily  of  papulo-pustules,  and  later  of  dis- 
crete, aggregated,  and  confluent  fungating  and  crusted 
lesions,  appeared  after  the  ingestion  for  a  more  or  less 
long  period  of  time  of  a  certain  drug — bromide  of  po- 
tassium— and  continued  cropping  out  during  the  entire 
period  of  its  ingestion,  but  subsided  after  its  discon- 
tinuance. These  particulars  of  origin,  course,  and  in- 
volution represent  the  crucial  tests  determining  the 
relation  between  a  drug  and  an  eruption,  and  being  so 
decidedly  apparent  as  they  were  in  these  two  cases,  it 
is  perfectly  proper  for  me  to  connect  together  the 
cutaneous  disturbances  observed  and  the  bromide  of 
potassium  in  the  position  of  cause  and  effect.  The 
great  differences  noted  in  the  severity  and  the  extent 
of  the  eruption  in  each  of  these  cases  are  not  of  im- 
portance, in  view  of  the  fact  that  in  Case  I.  the  bromide 
was  given  for  several  months  and  in  excessive  doses, 
while  in  Case  II.  it  was  administered  for  only  a  short 
time  and  in  such  quantities  as  could  or  would  be  given 
with  entire  safety  in  the  majority  of  cases.  Besides,  it 
must  not  be  forgotten  that  the  first  baby  received  daily, 
for  more  than  a  month  prior  to  the  administration  of 
the  bromide  of  potash,  forty-five  drops  of  the  iodide  of 
iron,  an  inordinate  dose  for  its  age. 

It  is  a  well  established  fact  that  a  bromine  following 
an  iodine  compound  will  lead  to  exaggerated  and  in- 
tense cutaneous  effects,  and  it  is  therefore  not  surpris- 
ing that  in  this  case  the  baby  was  so  severely  affected, 
so  much  more  so  than  was  the  subsequent  case  which 
came  under  my  care.  Independently  of  the  bromide  of 
potash  effect,  the  eruption  which  occurred  while  Case 
I.  was  taking  the  iodide  of  iron  is  most  interesting. 
There  are  few  cases  mentioned  in  literature  of  the 
iodide  of  iron  producing  any  cutaneous  manifestations 
of  iodism,  though  there  is  no  reason  why  it  should  not 
do  so,  since  it  is  not  a  very  stable  iodine  compound,  and 
the  union  between  the  two  is  easily  dissolved,  each  then 
existing  free  in  the  solution.  The  eruption  which  did 
occur  in  the  case  (Case  I.) — an  erythematous  rash  fol- 
lowed by  one  which  was  papulo-pustular — was  such  as 
iodine  produces,  and  the  increased  bronchial  symp- 
toms which  developed  with  the  administration  of  the 
drug  certainly  suggest  that  the  baby  was  suffering 
from  general  iodism.  It  may  be  claimed,  however,  that 
the  early  erythematous  rash  was  a  toxic  erythema  un- 
connected with  the  iodine,  but  resulting  from  the  ton- 
sillar abscesses  through  absorption  of  toxines  ;  or  it 
might  be  regarded  as  one  developing  from  shock  after 


624 


[MEDICAL   RECORD. 


[November  2,  1895 


the  operation  of  opening  the  abscesses.  Such  occur- 
rences are  perfectly  possible,  and  rubeloid,  scarlatini- 
form,  and  papulo-pustular  eruptions  have  occurred  very 
commonly  under  such  circumstances.  Such  eruptions 
are,  however,  accompanied  by  febrile  temperature,  sys- 
temic symptoms  of  grave  import,  are  usually  of  short 
duration,  and  very  commonly  followed  by  desquama- 
tion of  the  epidermis  at  the  end  of  a  very  few  days. 
None  of  these  features  were,  however,  met  with  in  this 
case,  but  the  rash  persisted  for  a  while  and  then  disap- 
peared, being  followed  by  a  higher  type  of  eruption — 
the  papulo-pustular — and  this  remained  until  the  new 
drug — the  bromide  of  potash — being  administered,  the 
subsequent  symptoms,  as  already  detailed,  developed 
and  existed  until  the  medicament  was  discontinued.  I 
do  not  think  it  is  necessary  to  insist  further  on  this  point, 
as  it  cannot  but  be  apparent  to  any  one  familar  with 
eruptions  produced  by  drugs  that  there  is  no  question 
but  that  the  symptoms  referred  to  were  the  result  of 
iodine  and  not  of  any  septic  intoxication  or  of  other 
cause. 

The  manner  in  which  bromine  and  its  compounds, 
or,  in  fact,  any  drug,  produces  its  effects  on  the  skin  is 
a  mooted  point.  In  regard  to  the  former,  with  which 
we  are  particularly  interested,  owing  to  the  cases  re- 
ported in  this  paper,  there  are  many  who  regard  the  cu- 
taneous manifestations  developing  after  its  administra- 
tion as  the  result  of  an  e.xaggeration  in  its  physiological 
effects,  believing  that  individual  idiosyncrasy  plays  a 
small  part  and  has  little  influence.  There  are  as  many 
others  who  attribute  the  eruptions  to  the  local  effects 
of  the  drug  upon  the  glands  of  the  skin,  which  seek  to 
eliminate  it  from  the  system  ;  and  there  are  again  others, 
who,  believing  in  a  more  recent  theory,  find  an  explana- 
tion for  the  occurrence  of  the  lesions  in  a  supposed 
foreign  material  generated  in  the  blood  by  the  drug, 
which  then  acts  directly  upon  the  skin. 

There  is  no  question  but  that  authorities  can  be 
found  substantiating  either  one  of  these  opinions,  but 
in  view  ofour  practical  ignorance  of  the  mode  and  man- 
ner in  which  the  drug  does  in  reality  produce  cutane- 
ous disturbances,  it  would  seem  to  me  to  be  preferable  to 
leave  the  choice  of  theoretical  conviction  to  the  preju- 
dices or  to  the  pre-  or  post-conceived  desires  of  each 
individual  observer,  rather  than  by  speculation  to  sup- 
port one  side  or  the  other.  I  do  this  owing  to  the  fact 
that.positive  proof  in  favor  of  one  view  or  the  other  of 
the  question  is  entirely  wanting,  and  all  that  can  be 
said  is  that  the  drug,  when  given  to  certain  or  perhaps 
the  majority  of  individuals,  does  produce  cutaneous  le- 
sions of  greater  or  lesser  severity,  but  how  it  does  it,  I 
frankly  confess  that  neither  observation  nor  theory  has 
yet  been  able  to  satisfactorily  explain. 

The  action  of  bromine  and  its  compounds  upon  the 
cutaneous  surface  are  manifold  and  multiform.  Though 
the  most  common  type  of  eruption  produced  by  the 
drug  is  the  socallid  bromide  acne,  represented  by 
papulo-pustular  or  tubercular  lesions,  occurring  particu- 
larly on  the  face  and  the  scalp,  but  also  more  or  less 
generally  over  the  body,  yet  even  this  banale  type  may 
develop  into  furuncular-like  lesions  and  ulcers  leaving 
scars.  More  rarely  the  eruption  may  be  erythematous 
in  character,  and  occur  in  either  a  diffuse  form,  and 
then  especially  on  the  lower  extremities,  or  it  simulates 
a  roseola.  Urticarial  lesions  have  been  observed,  and 
it  has  even  been  possible  to  produce  them  by  rubbing 
or  irritating  the  surface.  A  maculo  papular  eruption 
has  also  been  seen,  and  it  has  led  to  the  mistaken  di- 
agnosis of  syphilis,  while  cases  of  nodular,  furuncu- 
loid,  anthracoid,  and  carbuncular  lesions  abound  in  the 
literature  of  the  subject.  Seguin  has  de.scribed,  ad- 
mirably, a  peculiar  elevated  ulcer  due  to  its  long-con- 
tinued use,  and  Amidon  has  called  attention  to  an 
"epithelial"  ulcer  observed  by  him.  Veiel  reported 
a  verrucous  or  warty  eruption,  strictly  resembling  or- 
dinary warts,  and  others  have  recorded  bullous,  squam- 
ous, and  seborrhoeic  maniftstations. 


I  find  it  rather  difficult  to  include  the  cases  report- 
ed in  my  paper  among  any  of  these,  owing  to  their 
peculiar  type,  one  evolved  from  an  ordinary  papulo- 
pustular  lesion.  Jacquet  reported  a  case  which,  be- 
ginning as  a  bullous  eruption,  became  fungating  in 
character  after  rupture  of  the  bullje.  Miiller  very  re- 
cently has  described  one  which  presented  f rambcesia-like 
growths,  together  with  superficial  ulcerations  and  other 
lesions,  but  none  that  I  know  of  showed  the  peculiari- 
ties in  evolution  of  the  lesions  from  a  papulo-pustule  to 
a  fungating  and  crusting  excrescence.  The  exaggera- 
tion in  character  in  Case  I.  was  undoubtedly  favored 
by  the  iodine  compound  given  at  first,  and  precisely 
similar  eruptions  have  been  seen  by  me  resulting  from 
iodide  of  potash.  The  type  of  eruption,  however,  can- 
not be  ascribed  to  that  fact  alone,  since  Case  II.  de- 
veloped the  same  lesions  and  yet  had  not  received  any 
iodine.  In  consequence  I  would  regard  these  cases  as 
representing  a  very  unusual  type,  which  may  be  de- 
scribed as  a  papulo-pustular  fungoid  and  crusting  bro- 
mide of  potash  eruption. 

The  production  of  cutaneous  phenomena  is  not  lim- 
ited to  any  particular  one  of  the  compounds  of  bromine. 
Though  bromide  of  potash  usually  seems  to  exert  the 
strongest  effect,  yet  the  same  results  have  been  caused 
by  the  sodium  or  ammonium  salt,  by  bromine  vapor, 
and  any  and  all  of  the  combinations  of  the  drug. 
Miiller's  case,  referred  to  in  my  paper,  was  due  to 
bromoform,  a  comparatively  new  bromine  compound, 
and  personally  I  have  seen  bromide  acne  arise  after 
taking  bromo-caffeine  and  hydrobromic  acid  in  com- 
bination with  quinia  and  with  conium,  an  occurrence 
not  mentioned  in  our  text-books  or  in  those  treating  of 
drug  eruptions. 

The  diagnosis  of  the  bromine  eruptions  is  not  al- 
ways a  facile  one,  particularly  when  the  lesions  are 
of  an  unusual  type,  and  it  has  most  frequently  to  be 
made  by  exclusion  and  by  a  careful  investigation 
into  the  patient's  history  previous  to  the  appearance 
of  the  cutaneous  symptoms,  and  by  an  examination 
into  the  drug  or  drugs  which  have  been  taken.  The 
acneic  form  may  be  mistaken  for  acne  vulgaris,  but 
its  location  on  the  hairy  surfaces  by  preference,  its 
wide  distribution,  and  the  absence  of  any  comedones 
should  suggest  its  drug  origin.  The  macular  form, 
owing  to  its  coppery  color,  may  easily  be  regarded 
as  due  to  syphilis,  but  the  absence  of  all  concom- 
itant symptoms  accompanying  that  early  syphilide 
should  be  sufficient  to  guard  the  patient  against  such 
an  error.  Still  it  has  been  made,  and  even  more  seri- 
ous mistakes  have  been  recorded.  The  prognosis  is 
always  good.  As  a  rule  the  lesions  disappear  after 
cessation  of  the  drug.  Not  always,  however,  as  once 
produced  they  may  persist  for  months  and  years,  even 
without  any  more  bromide  being  taken.  I  have  had 
in  the  last  winter  a  number  of  cases  of  folliculitis  of 
the  face,  which  had  begun  a  year  or  more  before  they 
were  seen  by  me,  and  which  had  appeared  after  taking 
bromide  of  potash  for  some  weeks  or  months.  The 
lesions  had  not  disappeared  in  these  cases,  but  had 
continued  appearing,  even  though  none  of  the  salt  had 
been  taken  for  months  and  months.  These  cases  are, 
however,  exceptions,  the  opposite  being  the  rule. 

In  view  of  this  rule  there  is  little  to  be  said  in  re- 
gard to  the  treatment  of  these  eruptions.  Cessation  of 
the  drug  is  the  essential  and  only  step  to  be  taken, 
though  when  ulcerations  or  bullous  or  other  severer 
lesions  have  occurred,  local  antisepsis  should  be  ob- 
served and  they  should  receive  such  general  care  as  any 
wound.  All  means  should  also  be  used  to  prevent 
scarring. 

14  West  Thikty-third  Strbet 


f 


New  York  Obstetrical  Society. — At  a  recent  meeting 
of  the  Society  Dr.  Henry  C.  Coe  was  elected  Presi- 
dent. 


November  2,  1895] 


MEDICAL   RECORD. 


62  = 


RUPTURE  OF  THE  TEXDON  OF  THE  QUA.!)- 
RICEPS  EXTENSOR  FEMORIS.' 

By  J.  J.  BUCHANAN,  M.D., 

SURGEON   TO  MEI.Cy  HOSPITAL,  PITTSBOKG,  PA. 

Rupture  of  the  tendon  of  the  quadriceps  extensor 
femoris  appears  to  be  a  comparatively  rare  injury,  or.  at 
least,  one  rarely  recorded,  for  a  careful  examination  of 
the  literature  has  disclosed  but  1 20  cases.  The  most  im- 
portant papers  yet  published  on  this  subject  are  bv  Karl 
Maydl,  of  Vienna,  in  1883  ;  W.  T.  Bull,  of  New' York, 
in  18S9,  and  T.  Haferaan,  of  Berlin,  in  the  same  year. 

Maydl  collected  61  cases,  all  but  one  treated  without 
operation.  To  these  Bull  added  23  cases,^  of  which  4 
were  operated.  In  the  table  appended  to  this  paper  is 
a  record  of  36  additional,  making  a  total  of  120  cases. 

Statistical  tables  are  of  great  value  in  determining 
the  results  of  treatment  in  this  injury,  and  the  careful 
perusal  and  comparison  of  tabulated  cases  will  give  the 
inquirer  a  very  good  general  idea  of  the  value  of  dif- 
ferent methods  and  the  results  to  be  expected    from 

f  '  Read  before  the  Medical  Society  of  the  State  of  Pennsylvania 
May  22,  1895. 

*  Buil  duplicates  Hulke's  case,  recorded  by  Maydl,  and  adds  a  ca^e 
of  fracture  of  the  patella  by  Hartley. 


them  ;  but  the  data  furnished  will  be  found  insufficient 
for  accurate  conclusions.  To  formulate  such,  in  cases 
of  this  kind,  the  following  particulars  are  desirable  : 
The  nature  of  the  lesion — whether  only  the  central 
portion  of  the  tendon  is  torn  away  or  the  lateral  ex- 
pansions of  the  vasti  also  are  ruptured  ;  the  position  of 
the  rupture,  whether  close  to  the  patella  or  higher  ; 
the  amount  of  separation  ;  the  exact  method  of  treat- 
ment, and  the  duration  of  its  various  stages  ;  the 
length  of  time  allowed  to  elapse  before  passive  motion 
at  the  knee  was  employed  ;  the  result  as  to  union  of 
the  tendon  ;  the  amount  of  permanent  separation  ;  the 
ultimate  mobility  of  the  joint  ;  the  final  strength  of  the 
limbs,  and  the  length  of  time  which  elapsed  from  the 
date  of  injury  till  the  last  observation  of  the  case.  An 
examination  of  the  tables  of  Maydl,  of  Bull,  and  the 
one  herewith  appended,  as  well  as  the  original  report  of 
cases,  will  show  that  all  of  these  particulars  have  been 
furnished  in  such  a  small  number  of  cases  as  to  render 
it  impossible  to  draw  from  them  many  general  con- 
clusions of  value  which  can  beput  into  numerical  form. 
Bull,  however,  in  his  excellent  paper,  while  realizing 
this  difficulty,  has  made  a  careful  study  of  the  cases 
collected  by  Maydl  and  himself,  and  has  arrived  at  the 
conclusion  that,  without  operation,  an  imperfect  result 
occurs  in  about  one-half  of  all  cases. 


AODITIONAL  CaSBS   0»   ROPTl/RE   OF   Thndo.S    TO   THOSE    REPORTED   BY   MaVDL  ANO   BuLL. 


Spong,  A.,  Lancet,      M.,  50. 
■835-36.  i-,  203. 


Christison.    Toogood,  | 
I      loc.  cit.  infra.  > 

BUtckman.  G.  C,  ', 
^Vmencan  Journal  of 
Medical  Sciences,  > 
1847.N.  S.,  xiii..325. 

Brushfield,  Lancet. 
1847.  i.,  389.  (Un- 
der Mr.  Curling.)      1 


'^''          I  *"'=^'?°""^'=»^'»'^'^S  I  RuPI""  of  middle  portion  Bandage  and  sitting  post-    Union     complete  ;   three 

ngnt  xnee.                              only  of  tendon  of  right  ure  for  a  month.                     months  later,  walks  near- 

quadnceps.  ly  as  „^[i  35  „er. 

"" Confinement    to    bed     for     Complete     recoverj-     witli- 

}  Fell  down  * 


5  backward.    Ruptureof  tendon  of  rght  !  Loral   treatment    at  first; 
quadriceps.  three  months  later,  pos- 

terior   splint    for    three 


It  laniene: 
Ten  months  later,  walked 
very  little  and  still  with 


37.         Aug.,  1S46.       FeU  from   a  loft,  ciusiiig     Rupture  of  tendon  of  left     Posterior 


Kubel.  Zeit.furWund- 
arzte  u.  Ocburis.. 
1850.  p.  8. 

Toogood,  J.,  Remin- 
iscences of  a  .Medi 
cal  Life.  8to.  Taun- 
ton, 185^.  p.  82. 

Trent.  P.,  Virginia 
Medical  and  Sur- 
gical Journal,  1854, 
ui..  5. 

Zickcrs.  E.,  Allg. 
Wien.  Med.  Zlg.,  ! 
1863,  J78.  I 

Oosseiin,  M.,  London  ' 
Medical        Record, 
March  25,  1874. 

*  Margucl,  CI.  Inaug. 


extreme  flexion  of  knei 


M.,  60.       March  r,  1850.   Fell  on  right  knee. 


quadriceps  about  a 
above  the  patella. 


Rupture  of  tendon  ol  right    Bandage,  splint,  deration, 
quadriceps. 

Rupture  of  tendon  of  quad-   None, 
nceps. 


M„  aged Blow    abo' 

heavy  post. 


e    knee    by 


Rupture  oi  tendon  of  quad- 
riceps ;  separation  of 
two  inches. 


ated  as  a  bruis 
vo  weeks ;  then  i 
on  and  bandage. 


Flexion  and  extension  lim- 
ited ;  patella  immo\-able. 
By  aid  of  leather  knee- 
cap walks,  but  imper- 
fectly: no  union. 

In  si.\  weeks  and  a  half 
w.alked  with  cane  ;  slight 
stiffness. 

Tendon  united  to  femur  ; 
six  years  later  ct>uld  walk 
several  miles  daily. 

for    No  result  given. 


<^^"'^°  Rupnireofiendonsofboth    Extended  position  ;  mould-   In   seventeen  weeks  could 

I      °<^*">"»-  quadriceps  on   different  .      ed  splints  and  bandages.       use  the  right  Umb  freely - 

I  '      occasions.  j  talked    eighteen    weeki 

'  ""'J' p^ce^ofVi^^tu'r^'on     «"?-"' «"<i- of  quad-'  Unrecognized    for  four    Trel'Sli'rVn'^'in^'ca. 
,      SieTmr"^™"""  ""        "''^'-  ,      ■"O"*-  'ious. 


UisserL  S  u  b  c  u  t 
Rupt.  of  I'endo 
M.    Kx.    (,)uad.   T. 
Hafcman,       Beilin, 


of 


Rupture  of  tendon  of  quad-   Unrecognized     for 
nceps.  weeks. 


.\fler  long-continued  treat- 
ment could  walk  only 
with  difficult}-,  even  with 
crutches. 


13 


Review.  1878.  i.,  i. 

Morton.  T.  G.,  .Sur- 
Kcrv  in  the  Pennsyl- 
vania Hospital.  Phil- 
adelphia,   i83o,    p. 

„336.- 

Guenn,  J.,  Hafeman, 
loc.  cit. 


Oct  7,  .878.    jS-j-lj^bovcpa^lla    by    Comple'e  rupture  of  ten- j  Elevauon  of  h^^^  Union  seems    quite  dose. 


don  of  quadriceps  ju 
above  patella. 


bandage    for    five 


M.,  55.      Jan.  12,  1879.     Fell  while 


Ruptureof  tendoiioff^uad  I  Posterior  splint, 
ncepi  at  its  insertion ;  i 
slight  atuchment  of  vas    ' 
tus  cxiemus  unbroken.   ! 


14  Weinlcchncr,      Wien. 

.Med,     Blait.,    1881. 
No.  51. 

15  Tonckcr.      R.,    Gazx. 

Med.  di  Roma,  1881, 
vii..  p.  189. 
x6     Weinlcchncr,  loc-  cit. 


.ey.Ce 


.rk  Medical  Jour- 
1.  1884.  xxxix. 
),    and     pcrson;tl 


M. 


Had  existed  for 
years. 


Partial  rupture  of  tendi 
of  quadriceps.  .      ^ 

Complete     rupture     four  1  No  bandage, 
inches  above  patella.         I 

M.,  s6.      Dec.  30, 1880.  I  Fell,   forcibly   flexing    his     Rupture  of  tendon  of  right  '  Gypsum  spli 
r.orhi  tn*.^  quadticcps,  thrcc  inches  j 

separaii 


M.,  aged. 


H.,58. 


right  kn 
Fell. 


Slipped  < 


Complete   rupture  of  ten-     Posterior  splint  2 
don    of  left  quadriceps  '       tiun. 
one  half  cm.  above  pa 
tcHa.  ^ 

Double  ;  six  years  apart.      


Rupture  oftendons  of  both     Straight  position, 
quadriceps ;    lateral  ex- 
pansions remained. 


ith  proapcctof  a  perfcccr 
ly  good  lcg»  though  he 
has  yet  exercised  it  little. 
Walked  with  crutch  in 
nine  weeks;  at  four 
months  and  a  half  had 
almost  perfect  use  of  leg. 


walk  abijut  with  safely. 
Walks  without  interference. 


Case  four  years  old  :  pecu- 
li-iriiy  III  walk ;  right 
patdla  immovable ;  left 
iuice  has  guod  motion. 

Both  tendons  united : 
three  months  later,  able 
to  walk  slowly  ;  ultimate 
result  very  good. 


*  Hafeman  slates  that  MarRuet  had  two  cases  and  give«t  the  ! 
only.  Uiinking  it  unlikely  that  the  two  cases  should  be  exactly  sim 


:  particulars  (or  both.    Not  having  access  to  Marguet's  original  report  I  have  enured  c 


626 


MEDICAL    RECORD. 


[November  2,  1895 


Additional  Cases  of  Rupture  of  Tendon  to  those  Reported  by 

Maydl  and  BuLi^- CoHitnugd, 

z 

Reporter. 

Sex  and 

Date, 

Manner  of  Injury. 

LcstOB.                    1                Treatment. 

Result. 

Hirn,    A.,     Disserta- 

M., 66, 

i88s. 

Injured  by  falling  tree. 

Rupture  of  tendon  of  left .  Not  stated. 

Complete  recovery. 

tion  :  Wurzburg. 
Bardeleben,     Hafe- 

M,,  63. 

1886. 

Fell. 

quadriceps. 
Ruptureofright  tendon  at     Bandage    and   elevation; 

Eight  weeks  later,  normal 

man,  loc.  cit. 

patellar  insertion.               '      later,  splint.                              limb. 

^  J 

Childs,  W.  R., Trans- 

M., 38. 

March  14, 1886. 

Slipped  on  an  iron  grating, 

Rupture  of  tendon  of  left  ■  SUver  wire   passed  trans-     Union  :    wire  removed   in 

act  io  n  s    Homcco- 

striking  on  his  right  knee 

quadriceps ;  right  patella  1      versely    subcutaneously  .      four  weeks  ;    splints  re- 

pathic  Medical  Soci- 

and   extending   his  left 

also  broken.                        i      through    each    tendon ;  '      moved   in   two   months : 

ety,   of    Pennsylva- 

leg. 

the  external  ends  united  ,      walked  in  three  months  ; 

nia,  1886,  xxii..  281. 

10  form  a  ,loop,  through  ;      walked  without   cane  in 
;      which  a  loop  of  adhesive  |      six  months. 

plaster  was  passed,   on  ■ 

which  traction  was  made 

and  which  was  fastened  ' 

to  the  sole  of  the  foot : 

plaster  dressing  and  el-  | 

evation  ;     fractured   pa-  ' 

tella     treated    in    same 

22 

Ormsby,  L.,  Medical 

M.,30. 

March  7,  1886. 

Fell  down  stairs. 

Rupture  of  tendon  of  quad- 

Plaster strips  below  patella;    In   six   weeks    and   a  half 

Press  and  Circular, 

riceps. 

posterior  splint ;    eleva- 

could   sund    and    walk 

Dublin,  18S9,  N.  S., 
xlviii.,  491. 
Socin,    Haieman,  loc. 

Carrington,     P.     M., 

tion. 

with  comparative  ease. 

Rupture  of  tendon  of  quad- 
riceps. 
Rupture  of  tendon  of  right 

23 

34 

M,,  65. 



Nov,  19,  1887,   A  board  on  which  he  was 

Aspiration,   bandage  and 

Firm  union  in  two  months  : 

Report     Supervisor 

walking  broke  under  him 

quadriceps   (fourteen 

posterior    splint :     later. 

crutches    then    allowed ; 

Surgeon      General, 

and  he  fell,  striking  fair- 

years before  sustained  a 

g^^psum  dressing. 

walks  well  with  stick  and 

Marine  Hospital, 

ly  on  his  right  knee. 

rupture  of  left    quadri- 

can perform  light  work. 

1888,  243- 

ceps   and   a    secondary- 
rupture   which   left   him 
permanently  lame)  :  sev- 
eral inches  separation. 

LowenfeId.J.,Munch. 
Med.   Woch.,   1S87, 

M.,  40. 

Rupture  of  tendon  of  left 
quadriceps  at  insertion. 

In  five  months  able  to  walk 

»S 

'■             "'kCergr"ound, 

with  crutches. 

36 

No.  20. 
Cluness.  W.  R.,  Sac- 

M., 75. 

Oct,  20,  1888, 

While  walking  tendon  rup- 

Rupture of  tendon  of  quad- 

Bandage   and  immovable     Limb  almost  or  quite  use- 

ramento    Medical 

tured  without  any  appa- 

riceps at  insertion,  two 

apparatus,                                    less    without  felt   splint; 

Times.  1888,  ii..  515, 

rent    cause   other    than 

inches  separation. 

i      three  or  four  years  later. 

and  Personal  Com- 

ordinary locomotion. 

j      required  crutches. 

27 

ments, 
Kaufmann,  Corresp.  f. 
Schweiu.      Aerztc, 
May  15.  1888. 

M,,  48. 

1888, 

Fell  down  stairs. 

Tendon  torn  from  muscle. 

Sutured  with  catgut.             |  Arose   in   four    weeks:   in 
six  months  could  use  leg 
I      freely;  in  fourteen  months 
'      normal. 

28 

Midelfast,    Centralbl. 

M„  12. 

1888,             Fell, 

Rupture  of  tendon  at  in- 

Reduction of  luxation  and     Complete  recovery. 

f.    Chirurg.,    Mar., 

sertion  ;    patella    forced 

suture. 

188S. 

between  femur  condyles 
and  tibia. 
Rupture  of  tendon  of  left 
quadriceps. 

1 

Gross,  F.  H.,  Medical 
News,  1889,  Iv.,  191. 

March  2  1889. 

'  Three  months  later,  a  fair 

29 

degree     of     usefulness, 
mainly  through  the  acces- 

sory tendons  of  the  vasti. 

30 

Chaput,  Bull.  etMem. 

M.,  60, 

Aug.  16,  1889.    Fell  upon  his  back. 

Rupture  of  tendon  of  quad- 

Open incision  and  catgut     Three  months  later,  perfect 

Soc.  de  Chir.,  Par., 
1891,  N.    S.,   xvii., 

Bowden,  J.  B.,  Lan- 

riceps and  lateral  expan- 

suture.                                        union  ;    extension    com- 
plete and  flexion  beyond 

1 

right  angle. 

31 

M.,  69. 

Dec.  30, 1890.  !  Slipped   on   ice    and    fell 

Rupturc  of  tendon  of  quad- 

Extension of  knee  ;  appo-    Three-fourths    inch    separ- 

cet,  1893,  i.,  277. 

backward   with   leg  un- 

riceps with  three   inches        sition   ot  parts  :    piaster        auon  ;  able  to  walk  eignt 

der  him. 

separation.                                strips:    posterior   splint        or  ten  miles  a  day  with 

and  swing  ;  gypsum  in        just  the  slightest  halt  m 

five  weeks,    left  in  four        his  gait ;  can  walk  with- 

weeks  ;  leather  knee-cap.'      out   knee-cap,    but    docs 

not  feet  quite  safe. 

3= 

Cecaldi,  Bull. etMem. 

M„  60, 

June,  1892. 

Fell  down  stairs. 

Rupture  of  tendon  of  quad- 

Bandage :  electricity;    Walked  slowly  at  end  of  a 

Soc.  de  Chir.,  Par., 

riceps  ;  rupture  of  rectus 

passive  motion.                    '     week. 

1S91    N.    S.,   xvii.. 

only.                                   '                                _                J 

33 

*  45^. 

Shepherd,      Montreal 
Medical    Journal, 
1892-93,  xxi.,  106. 

K.,  41. 

June  10,  1892. 

Slipped   and  fell   duwn  a 
couple  of  steps. 

Rupture  of  tendon  of  right    Figure-of-eight  bandage 
quadriceps  immediately        and  gypsum  splint ;  el- 

Left  hospital  on  30th  day. 
and  **  since  then  has  re- 

above patella.                           evation  ;  rest  in  bed  for 

ported    herself  perfectly 

s  i  X  w  e  e  k  s  ;    posterior 

well." 

leather   splint  and 

crutches. 

r-„,.l,t     p       Ctw      V\     f 

Rupture  of  right  quadri- 
ceps. 

Suture. 

34 

is.oeni,  c,.,  ^^or.    IjI.  1. 
Schw.  Aerzte.  Basel.. 

35 

1S93,  yxiii.,  454. 
Oueu,   J.  L.,    British 
Medical    JouHnal, 
1893,  ii.,  1425. 

M.,44. 

March  20, 1893 

Man  ran  aganist  him  and 

Rupture     of    tendons   of 

Inclined    plane    and    ad-     Nine  months  later,  still  a 

he  fell. 

both  quadriceps. 

hesivc   straps  for  seven        sepaxation  ;  cannot  fully 
weeks.                                     extend  knees;  can  walk 

fairly  well  on  level  ground 

with  aid  of  a  stick. 

36 

Buchanan.  J.  J.,  Re- 
ported hercm. 

v.,  45- 

June  24, 1894. 

'  Slipped  and  feU. 

Rupture  of  tendon  ol  left 
quadriceps  at  its  inser- 

Open incision  ;  drilling  of    Result    mechanically    per- 
patclla  and  suture  with        feet  and  functionally  al- 

tion.                                      1      silkworm  gut.                            most  so. 

Of  the  36  cases  tabulated  in  the  present  paper,  5 
were  operated  on  by  open  incision  (Chaput,  Kaufmann, 
Midelfast,  Koehl,  and  Buchanan),  and  one  by  sub- 
cutaneous wire  (Childs)  ;  2  were  not  recognized  till 
too  late  for  treatment  (Gosselin  and  Marguet)  ;  2 
had  no  efficient  treatment  at  first  (Blackniau  and  Too- 
good)  ;  in  3  the  result  is  not  stated  (Trent,  Guerin, 
and  Socin),  and  in  5  the  result  was  imperfect,  but 
sufticient  time  had  not  elapsed  to  preclude  further  im- 
provement (  Kiibel,  Thompson,  Weinlechner,  Ormsby, 
and  Cecaldi),  This  leaves  18  cases  treated  by  ex- 
ternal appliances,  from  which  to  draw  conclusions  as 
to  results.  Of  these,  4  were  perfect  (Hirn,  Bardele- 
ben,  Shepherd,  and  Christison)  ;  5  were  favorable 
(Spong,  Zickero,  Toncker,  Weir,  and  Morton)  ;  4 
were  unfavorable  (Weinlechner,  Carrington,  Bowden, 
and  Owen)  ;  and  5  were  bad  (Brushfield,  Gibney, 
Lowenfeld.  Cluness,  and  Gross).     Placing  the  perfect 


and  favorable  results  in  one  group  and  the  unfavor- 
able and  bad  in  another,  we  have  9  of  the  former  and 
9  of  the  latter,  which  exactly  corresponds  with  the  con- 
clusions of  Bull, 

This  lesion  furnishes  the  same  indication  for  treat- 
ment as  does  fracture  of  the  patella,  but  the  difficulties 
of  fulfilling  the  indication  by  external  appliances  are 
very  much  greater.  The  upper  border  of  the  upper 
fragment,  in  transverse  fracture  of  the  patella,  furnishes 
an  offset,  over  which  can  be  looped  the  turns  of  mus- 
lin, plaster,  leather,  or  other  material  used  to  make 
traction  on  the  quadriceps  muscle  and  thus  approxi- 
mate the  fragments  ;  but,  in  rupture  of  the  quadriceps 
tendon,  no  such  purchase  exists,  and  reliance  has  to  be 
placed  on  rest  in  bed,  the  extended  position,  bandage 
of  the  thigh  from  above  downward,  and  of  the  patella 
from  below  upward,  and  the  posterior  or  immovable 
splint.     That  this  method  of  treatment  is  inefficient  is 


November  2,   1895] 


MEDICAL   RECORD. 


627 


evident,  and  that  its  results  are  poor  is  shown  by  the 
statistics  already  quoted.  The  application  of  buried 
sutures  through  the  open  incision  is  the  ideal  method 
of  treating  this  injury,  but  the  cases  so  treated  have  yet 
been  too  few  to  furnish  data  for  reliable  conclusions  as 
to  the  risk  of  the  operation  and  the  functional  result. 
It  seems  reasonalily  certain,  however,  that  the  mortality 
will  be  found  the  same  as  in  the  open  operation  for 
fractured  patella,  which,  with  proper  precautions,  in 
recent  cases  is  practically  ;n7. 

My  attention  was  drawn  to  this  subject  by  the  follow- 
ing case,  which  came  under  my  own  care  : 

On  June  24,   1894,  Mrs.  S ,  a  corpulent  woman, 

about  forty-five  years  of  age,  slipped  and  fell  to  the 
ground  and  found  herself  unable  to  rise.  She  at  once 
summoned  Dr.  H.  D.  Rickenbach,  by  whose  courtesy  I 
was  asked  to  take  the  case  in  charge.  The  diagnosis  of 
rupture  of  the  tendon  of  the  left  quadriceps  femoris  at 
its  insertion  into  the  patella  was  easily  made.  The 
power  of  extension  was  lost  and  an  hiatus,  about  two 
inches  in  extent,  was  discovered  between  the  upper 
border  of  the  patella  and  the  extremity  of  the  tendon. 
The  probabilities  as  regards  usefulness  of  the  limb 
without  operation,  based  on  the  statistics  of  Bull's 
article,  were  laid  before  the  patient,  together  with  the 
slight  amount  of  risk  incurred  by  open  incision.  The 
patient,  a  woman  of  more  than  ordinary  intelligence, 
decided  to  have  the  operation  performed. 

Eight  days  after  the  injury,  with  the  usual  antiseptic 
precautions,  a  free  transverse  incision  was  made  at  the 
level  of  the  upper  border  of  the  patella,  and  the  joint 
thereby  freely  opened.  The  tendon,  together  with  its 
lateral  expansions,  was  found  entirely  torn  through,  no 
part  of  it  remaining  attached  to  the  patella.  As  before 
stated,  there  was  about  two  inches  of  retraction.  Two 
holes  were  drilled  through  the  patella  and  the  shelving 
extremity  of  the  broad  tendon  of  the  (juadriceps  was 
seized  with  volsella  forceps  and  drawn  down  into  place. 
A  double  strand  of  heavy  silk-worm-gut  was  passed 
through  each  hole  in  the  patella  and  deeply  through 
the  tendon,  tied,  and  cut  short.  The  superficial  parts 
were  accurately  sutured  and  the  joint  drained.  An 
antiseptic  dressing  and  posterior  plastic  splint  of  plaster 
of  Paris  were  applied.  Primary  union  resulted  and  the 
buried  sutures  yet  remain  in  place. 

The  splint  was  left  on  and  the  patient  confined  to 
bed  for  four  weeks,  when  she  was  allowed  to  rise  with- 
out the  splint  ;  at  the  end  of  five  weeks  she  was  al- 
lowed to  walk  with  crutches,  which  she  discarded 
about  three  weeks  later.  She  now,  at  the  end  of  ten 
months,  walks  with  the  least  perceptible  halt  and  the 
anatomical  conditions  appear  normal.  She  considers 
the  limb  as  good  as  the  other. 

The  following  is  a  list  of  all  the  cases  operated  on  by 
open  incision  of  which  record  can  be  found  :  1.  Lister 
(1878)  (Roxburgh's  case),  by  a  complicated  pilastic 
operation,  repaired  an  old  rupture  of  the  tendon  with 
buried  catgut  sutures,  with  a  very  good  result.  2. 
Liining  (18S0)  sutured  the  tendon  with  catgut,  as  a 
part  of  the  rejjair  of  an  open  wound,  made  by  a  butch- 
er's cleaver,  v/ith  result  of  a  freely  movable  joint.  3. 
McBurney  (1885)  sutured  the  tendon  with  catgut  and  a 
wire  retention  stitch,  with  a  perfect  result.     4.  Wilkin 

(1887)  sutured  the  tendon  with  silk-worm-gut  as  part  of 
the  repair  of  an  incised  wound  of  the  thigh,  with  good 
function    and    almost   perfect    flexion.     5.   Kaufmann 

(1888)  sutured  the  tendon  to  the  muscle,  from  which  it 
had  been  torn.  Complete  recovery.  6.  Midelfast 
{1888)  operated  on  a  case  in  which  the  patella  was 
found  driven  between  the  femur  and  tibia.  He  sutured 
the  tendon  and  secured  primary  union.  7.  Bull(i8S8) 
sutured  the  tendon  with  catgut,  with  good  result.  8. 
Chaput  (1889)  sutured  the  tendon  with  catgut,  with 
perfect  result.  9.  Koehl '  (1893)  sutured  the  tendon. 
10.  Buchanan  (1S94)  drilled  the  patella  and  sutured 

'  I  Iiave  not  been  able  to  secure  the  full  record  of  this  case. 


the  tendon  to  it  with  silk-worm-gut,  with  jierfect  re- 
sult. 

In  view  of  the  favorable  results  in  these  operated 
cases,  the  extremely  unfavorable  statistics  of  cases 
trusted  to  external  appliances,  and  the  safety  of  the 
operation,  I  think  we  are  fully  justified  in  recommend- 
ing this  procedure  to  our  patients,  laying  before  them 
the  advantages  of  the  treatment,  and  not  failing  to  state 
the  possibilities,  however  remote  we  may  consider  them, 
of  failure  in  our  antiseptic  efforts,  failure  which,  in 
such  case  as  this,  may  carry  with  it  loss  of  limb  or  loss 
of  life. 


'^voQV^ss  of  l^jetltcat  Science. 

Experimental  Appendicitis.— Dr.  Roux  says  that  the 
mechanism  of  perforation  of  the  appendix  is  little 
known  ;  it  has  been  attributed  to  an  ulceration  caused 
by  the  presence  of  a  calculus,  to  an  ulcerative  lesion 
caused  by  compression  of  the  vessels,  to  a  dilatation 
of  the  appendix  from  retention  of  mucus,  and,  finally,  to 
an  infective  process.  M.  Roux  has  studied  the  question 
experimentally,  and  chose  swine  as  suitable  subjects. 
The  colon  was  drawn  out,  the  c»cum  isolated,  and  an 
artificial  appendix  made  by  passing  a  row  of  parallel 
silk-threads  around  it  just  beneath  the  serous  coat,  and 
drawing  them  moderately  tight.  Farther  up  in  the 
cajcum  an  incision  was  made,  and  through  this  foreign 
bodies  were  introduced.  Sixty-seven  swine  and  two 
dogs  were  thus  operated  upon  ;  the  two  dogs  died  in 
twenty-four  hours  from  gangrenous  peritonitis.  Two 
swine  also  died  from  faulty  technique  ;  the  others  bore 
the  operation  with  scarcely  any  reaction.  The  results 
as  to  a  formation  of  an  artificial  appendix  were  good. 
The  silk  cut  through,  and  was  passed  from  the  anus, 
the  pocket  persisted.  At  the  end  of  some  months 
the  foreign  body  had  disappeared,  the  mucous  mem- 
brane was  found  to  be  intact.  In  a  single  case  a  sup- 
purating appendicitis  was  produced.  The  presence  of 
a  foreign  body  alone,  therefore,  was  not  sufficient  to 
cause  perforation  ;  some  other  factor  must  be  added. 
Roux  thinks  that  upon  the  occurrence  of  a  traumatism 
or  a  chill  the  mucosa  becomes  turgid,  presses  firmly 
upon  the  foreign  body,  and  the  circulatory  disturbances 
which  result  ultimately  lead  to  gangrene  and  perfora- 
tion.— Annals  of  Sur^^eiy. 

The  Mortality  from  Tuberculosis  in  German  Cities. — 
Dr.  Bollinger  has  succeeded  in  procuring  the  mortality 
tables  of  various  German  cities,  extending  over  long 
periods,  with  the  special  intention  of  inquiring  into  the 
mortality  from  tuberculosis.  From  a  comparison  of 
the  tables,  it  is  certain  that,  as  regards  the  large  cities, 
such  as  Vienna,  Berlin,  and  Hamburg,  a  distinct  dim- 
inution in  the  death-rate  from  tuberculosis  is  taking 
place.  In  the  city  of  Munich,  for  instance,  a  diminu- 
tion of  18  per  10,000  has  taken  place  during  the  last 
twenty-six  years.  In  correspondence  with  this,  the 
tuberculous  material  in  the  Pathological  Institute  has 
diminished,  so  that  in  the  space  of  five  years  eight  per 
cent,  fewer  cases  of  tubercle  are  met  with  on  the  post- 
mortem table.  Formerly  one-third  of  all  post- mortem 
examinations  were  on  subjects  that  had  died  from 
tuberculosis  in  some  form,  where  they  now  number 
only  one-fourth.  As  regards  the  ]irevalence  of  tuber- 
culosis in  cattle  the  doctor  states  that  in  one  year  21,- 
000  cattle,  found  to  be  suffering  from  tuberculosis,  were 
slaughtered  in  the  Berlin  slaughter-houses,  and  that  in 
the  kingdom  of  Saxony  one  ox  in  seven  and  one  cow 
in  four  were  affected  with  tubercle.  In  the  years  1893 
and  1894  a  remarkable  increase  in  tuberculosis  in  cattle 
took  place  in  Schwerin,  and  this  increase  corresponded 
with  a  dearth  of  fodder  for  cattle.  Dr.  Bollinger  men- 
tions this  fact  as  a  wholesale  exjieriment  illustrating 
the  effects  of  deficient  nutrition  in  predisposing  to  dis- 
ease.— Miouhencr  AIcdi'Anische  Wochenschrift. 


628 


MEDICAL    RECORD. 


[November  2,  1895 


The  Management  of  the  Pregnant,  Parturient,  and 
Lying-in  Woman  Suffering  from  Cardiac  Disease. — Dr. 

Phillips  does  not  believe  that  during  pregnancy  the  left 
ventricle  is  hypertrophied,  as  is  often  taught.  During 
pregnancy  the  work  of  the  heart  is  greatly  increased, 
owing  to  the  larger  quantity  of  blood  and  the  resistance 
to  the  circulation  caused  by  the  enlarged  uterus.  Dur- 
ing labor  the  greatest  strain  comes  upon  the  heart,  the 
blood  pressing  strongly  upon  the  ventricular  walls  with 
the  contraction  of  the  uterus,  while  the  right  heart  does 
not  receive  venous  blood  as  usual,  and  hence  the  partial 
cyanosis  which  is  so  often  observed.  After  the  birth 
of  the  child  the  abdominal  pressure  sinks,  while  the 
right  heart  becomes  overfilled.  To  obviate  the  dis- 
turbances caused  by  this  change  of  pressure  a  large 
sand-bag  may  be  placed  upon  the  abdomen  so  soon  as 
the  presenting  part  passes  through  the  vulvar  orifice  ; 
the  bag  should  be  retained  for  at  least  an  hour.  Several 
forms  of  cardiac  disease  are  found  during  pregnancy  : 
adhesion  from  pericarditis,  degeneration  of  the  heart 
muscle,  valvular  heart  disease,  and  endocarditis  grafted 
upon  a  chronic  form  may  be  present.  In  the  treatment 
of  these  cases,  if  the  patient  passes  through  pregnancy 
without  bad  symptoms,  treatment  should  be  confined 
to  keeping  the  bowels  open  and  avoiding  fatigue  and 
climbing  of  stairs.  Compensatory  disturbances  may 
appear  as  early  as  the  ninth  week,  although  usually  not 
until  the  fifth  month.  Albuminuria  is  a  serious  com- 
plication. 

These  cases  are  best  treated  by  arsenic,  iron,  and 
strychnia,  while  ether  and  ammonia  should  be  given 
for  attacks  of  syncope  ;  if  serous  effusion  with  dyspncea 
be  present  digitalis  or  strophanthus  may  be  employed. 
Over-exertion  and  straining  during  defecation  should 
be  carefully  avoided.  During  labor  the  patient  will  be 
better  in  a  sitting  posture  if  severe  dyspnoea  develops  ; 
ether  and  brandy  must  be  given  by  injection.  The  pa- 
tient should  be  delivered  so  soon  as  dilatation  will  per- 
mit. If  dilatation  is  not  complete,  incision  may  be 
practised ;  ether  should  be  used  as  an  anaesthetic. 
After  the  birth  of  a  child  a  twelve-pound  sand-bag 
should  be  laid  over  the  fundus  of  the  uterus  to  coun- 
teract the  rapid  fall  from  abdominal  pressure.  The 
greatest  danger  to  the  mother,  however,  lies  in  the  first 
few  days  of  the  puerperal  state.  Post-partum  bleeding 
should  not  be  prevented  ;  but,  if  anything,  a  moderate 
loss  of  blood  will  reliev-e  the  patient.  Ergot  is  often 
followed  by  good  results.  In  cases  of  great  dyspncea 
and  cough,  nitrite  of  amyl  should  be  inhaled  ;  better 
results  are  obtained  from  this  agent  than  from  vene- 
section. Phillips  reports  four  cases,  one  of  aortic  ste- 
nosis, two  of  mitral  disease,  while  the  fourth  was  a  case 
of  chronic  mitral  disease  in  which  labor  was  followed 
by  acute  endocarditis  with  regurgitation.  In  one  of 
his  cases  of  chronic  mitral  disease  the  patient  was  not 
seriously  ill  until  the  third  day  after  delivery,  when  she 
was  suddenly  attacked  by  profound  syncope  ;  three  of 
his  cases  recovered  from  labor,  while  the  fourth  perished 
from  endocarditis.  In  studying  the  literature  of  the 
subject  Phillips  finds  that  labor  should  not  be  induced. 
Two-thirds  of  the  cases  which  he  collected  perished 
during  the  puerperal  stale.  These  patients  are  especi- 
ally liable  to  septic  infection. —  The  American  Journal 
of  the  Medical  Sciences. 

Suturing  the  Pericardium.— The  following  case  was 
recently  observed  by  Dr.  Dalton  (.SV.  Louis  Medical 
Journal)  :  A  man  in  a  fight  was  stabbed  over  the  left 
breast  ;  the  wound  was  an  inch  in  length  and  an  inch 
and  a  half  above  the  left  nipple.  There  was  little 
hemorrhage  from  the  wound,  and  normal  cardiac  dul- 
ness  was  found  on  percussion.  The  percussion  of  the 
chest  showed  absence  of  dulness.  The  wound  was 
closed  and  antiseptic  dressings  applied.  Ten  hours 
after  admission  to  the  hospital,  percussion  revealed 
dulness  over  the  entire  left  side,  and  much  pain  was 
complained  of.     The  patient  was  removed  to  the  op- 


erating theatre,  and  the  dressings  taken  off,  when  it 
was  found  that  blood  and  air  gushed  from  the  wound 
with  each  inspiration.  An  incision  was  accordingly 
made,  eight  inches  in  length,  over  and  parallel  to  the 
fourth  rib,  and  six  inches  of  the  rib  resected.  The 
intercostal  artery  having  been  tied,  the  pleural  cavity 
was  found  full  of  clotted  and  fluid  blood,  which,  with 
each  inspiration,  poured  from  the  wound  with  great 
force.  The  patient  was  turned  on  his  left  side,  and 
with  a  long  pair  of  forceps  armed  with  a  sponge  the 
pleural  cavity  was  cleansed  of  blood.  Subsequently 
it  was  discovered  that  a  transverse  wound  of  the  peri- 
cardium existed  to  the  extent  of  two  inches,  and  steps 
were  taken  to  suture  the  lesion.  In  carrying  out  this 
procedure  great  difiiculty  was  experienced  owing  to 
the  pulsation — at  the  rate  of  140  per  minute — of  the 
heart.  The  pericardium  with  each  pulsation  of  the 
heart  rose  and  fell,  and  in  order  to  carry  into  effect 
that  which  was  being  attempted  it  was  necessary  to 
follow  the  movements  of  the  organ.  Ultimately,  a 
continuous  suture  of  catgut  was  satisfactorily  inserted 
in  the  wounded  pericardium,  the  yjleural  cavity  was 
then  thoroughly  irrigated  with  hot  sterilized  water,  the 
external  wound  closed,  without  a  drainage-tube,  and 
antiseptic  dressings  applied.  It  may  be  noted  that  at 
several  stages  of  the  operation,  which  lasted  an  hour, 
the  patient  seemed  to  be  dying,  and  in  order  to  avert 
collapse  hypodermic  injections  of  whiskey  and  strych- 
nine were  resorted  to.  Before  the  pericardial  wound 
was  sutured,  examination  of  the  heart  was  made  with 
a  view  to  the  discovery  of  a  wound  in  the  organ,  but 
no  lesion  was  found.  The  patient  made  an  uninter- 
rupted recovery. 

Jacksonian  Epilepsy  from  Old  Cerebral  Abscess. — 
Dr.  Lepine  reports  the  case  of  a  woman,  aged  sixty-two, 
who  ten  years  before  her  admission  to  hospital  had  had 
a  series  of  convulsions  with  loss  of  consciousness,  and 
these  were  succeeded  by  left  hemiplegia,  which  lasted 
fifteen  days.  Since  then  she  had  had  frequent  attacks, 
which  had  been  regarded  sometimes  as  Jacksonian  at- 
tacks, sometimes  as  hysterical.  In  December  last  .she 
had  several  attacks  in  one  day,  and  these  continued  to 
recur  day  after  day.  There  was  loss  of  consciousness  in 
the  severe  ones,  but  there  were  also  slighter  ones  in 
which  there  were  jerkings  of  the  fingers  and  forearm, 
but  no  loss  of  consciousness.  On  the  day  after  her  ad- 
mission, following  a  severe  attack,  left  hemiplegia  was 
noted,  affecting  both  arm  and  leg,  but  sparing  the  face. 
The  attacks  came  on  more  frequently,  and  although 
bromides  lessened  their  severity  it  did  not  control 
them,  and  the  patient  gradually  sunk  and  died.  At  the 
autopsy  it  was  found  that  in  the  light  frontal  lobe, 
rather  nearer  to  the  anterior  border  of  the  hemisphere 
than  to  the  fissure  of  Rolando,  there  was  a  cyst  two  to 
three  centimetres  in  diameter,  with  caseous  contents. 
It  was,  in  fact,  apparently  a  cold  abscess,  and  there 
seems  every  reason  for  believing  that  it  must  have  ex- 
isted for  the  ten  years  during  which  symptoms,  only 
explicable  on  the  hypothesis  of  such  a  lesion,  had  been 
present. — Revue  de  Me'decine. 


A  Suit  for  Contracting  Typhoid  Fever. — The  widow 

of  a  man  wlio  died  of  typhoid  fever  in  Ashland,  Wis., 
has  brought  .'^uit  against  the  Ashland  Water  Company 
for  $5,000  damages,  alleging  that  the  corporation  per- 
mitted the  water  to  become  polluted  by  typhoid  germs, 
and  that  her  husband's  death  was  due  to  this  pollution. 
There  is  no  doubt,  as  our  contemporary,  The  Times, 
states,  that  suits  of  this  kind  will  in  the  future  increase, 
and  that  damages  will  sometimes  be  obtained.  At 
present,  however,  it  is  asking  a  good  deal  of  corpora- 
tions to  keep  germs  out  of  the  aqueducts  and  reservoirs, 
especially  where  these  latter  are  large  and  drain  a  wide 
aea  of  ground. 


November  2,   1895] 


MEDICAL   RECORD. 


629 


Medical    Record: 

A  IVcck/y  you7'nal of  JMedicinc  and  Surgery. 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor. 


WM.  WOOD  &.  CO. 


Publishers 

43,  45,  &  47  East  Tenth   Street. 


New  York,  November  2,  1895. 


THE    NERVOUS   SEQUEL.^    OF  LNFECTIOUS 
DISEASE. 

The  above  was  the  title  of  a  subject  chosen  for  discus- 
sion before  the  Section  on  Children's  Diseases  of  the 
British  Association  for  the  Advancement  of  Science. 
The  discussion  was  opened  by  Dr.  Henry  Hanford,  of 
Nottingham,  who  read  a  lengthy  paper.  Taking  up 
the  subject  of  the  brain  first,  Dr.  Hanford  presented 
statistics  regarding  the  percentage  of  post-febrile  insan- 
ity. Out  of  229  cases  of  typhoid  fever,  reported  by 
Osier,  there  were  3  cases  of  melancholia  arising  during 
convalescence.  Clouston  found  that  among  1,000  cases 
of  insanity,  10  followed  an  attack  of  fever.  Epilepsy, 
according  to  Dr.  Hanford's  figures,  and  according  to 
common  observation,  follows,  especially,  scarlet  fever, 
next  measles,  and  least  after  typhoid  fever.  Meningi- 
tis occasionally  follows  the  acute  fevers,  but  it  is  usu- 
ally a  complication  rather  than  a  sequel,  and  is  of  sep- 
tic origin.  Taking  up  ne.xt  the  spinal  cord.  Dr.  Han- 
ford found  that  acute  myelilis  sometimes  follows  small- 
pox, measles,  and  scarlet  fever,  but  were  very  rare 
sequelae.  It  seems  to  be  more  particularly  the  venereal 
diseases  which  are  followed  by  inflammatory  disturb- 
ances of  the  spinal  cord.  Attention  is  called  to  the 
curious  fact  that  after  an  attack  of  acute  infectious  fever 
certain  degenerative  diseases,  such  as  progressive  muscu- 
lar atrophy,  sometimes  develop  in  families  predisposed 
to  this  disorder.  It  is  under  the  head  of  neuritis  that 
we  find  the  largest  number  of  nerve  disorders  following 
infectious  disease,  especially  those  of  an  acute  and 
febrile  type.  Dr.  Hanford  gives  briefly  the  history  of 
the  discovery  and  description  of  the  various  types  of 
neuritis  following  typhoid  fever,  scarlet  fever,  measles 
and  influenza.  The  conclusion  is  that,  excluding 
diphtlieria  and  influenza,  more  cases  of  peripheral  neu- 
ritis follow  typhoid  fever  than  all  of  the  other  acute  in- 
fectious diseases  put  together.  It  is  a  somewhat  curious 
fact  that  while  diphtheria  is  not  infrequently  followed 
by  neuritis,  scarlet  fever  is  never  followed  by  it,  or,  if  so, 
the  neuritis  is  due  to  some  other  than  the  specific  poi- 
son of  the  scarlatina.  Dr.  Hanford's  paper  was  dis- 
cussed by  eleven  other  gentlemen  whose  experience, 
on  the  whole,  confirmed  that  given  by  the  first  speaker. 
Dr.  Fletcher  Beach  s])oke  especially  regarding  the 
question  of  idiocy,  and  stated  that  among  2,000  his- 
tories of  idiots  which  he  had  collected,  he  found  only 
37  in  which  the  trouble  seemed  to  follow  some  acute  in- 


fectious disease.  The  disease  which  caused  it  oftenest 
was  measles,  then  came  scarlet  fever,  whooping-cough, 
and  typhoid  fever.  Dr.  Cheadle,  physician  to  St. 
Mary's  Hospital,  observed  that,  with  the  exception  of 
diphtheritic  paralysis,  nervous  sequelre  in  children 
were  exceedingly  rare,  and  this  opinion  was  apparently 
the  common  one.  It  is  a  matter  of  importance  to  bring 
this  matter  into  prominence,  because  the  too  assiduous 
investigation  of  rare  morbid  conditions  sometimes 
brings  them  into  disproportionate  relation.  We  must 
not  forget  the  fact  that  although  the  acute  infectious 
fevers  of  childhood  do  leave  some  nervous  wrecks,  the 
vast  majority  pass  through  the  trouble  without  the 
slightest  apparent  after-effect. 


MEDICAL    REFORM    IN    OUR    CITY    HOSPI- 
TALS. 

In  an  editorial  which  appeared  in  our  last  issue  we 
predicted  that  the  high-handed  action  of  the  Commis- 
sioners of  Charities  and  Correction  would  not  fail  to 
call  forth  a  vigorous  protest  from  the  members  of  the 
profession  who  are  not  "  in  the  ring."  Our  prediction 
was  verified  at  the  annual  meeting  of  the  County  Medi- 
cal Society,  held  last  Monday  evening,  when  a  resolu- 
tion condemnatory  of  the  "  deal  "  was  unanimously 
adopted,  and  was  forwarded  to  the  Mayor  and  Commis- 
sioners.    The  following  is  the  text  of  the  resolution  : 

Resolved,  That  we,  the  Medical  Society  of  the 
County  of  New  York,  protest  against  this  outrage  upon 
the  medical  profession  of  the  county  of  New  York, 
and  condemn  the  action  of  the  Commissioners  of 
Charities  and  Correction  in  delivering  to  these  incor- 
porated colleges  three-fourths  of  the  appointments 
upon  the  consulting  and  medical  boards  of  these  hos- 
pitals, to  whose  support  the  profession  at  large,  as  tax- 
payers, contribute. 

In  the  preamble  attention  is  called  to  the  fact  that 
under  the  new  arrangement  "  three  thousand  physi- 
cians are  excluded  from  i)ositions  upon  the  medical 
boards  of  the  city  hospitals,  except  by  courtesy  of  the 
faculties  of  the  incorporated  colleges  and  the  Fourth 
Division  of  Bellevue  Hospital,"  which  "are  composed 
of  less  than  one  hundred  physicians." 

This  is  certainly  a  fair  and  temperate  presentation 
of  the  question  from  the  stand-point  of  the  general  pro- 
fession, though,  of  course,  it  will  not  produce  any  im- 
pression upon  those  who  do  not  recognize  the  rights  of 
any  except  the  oligarchy,  which  has  arrogated  to  itself 
the  right  to  dictate  the  future  policy  of  the  Commis- 
sioners. But,  while  there  is  a  general  disposition  to 
blame  the  Commissioners  for  the  wholesale  degrada- 
tion of  faithful  medical  officers,  without  the  bare  cour- 
tesy of  an  explanation,  we  should  not  lose  sight  of  the 
fact  that  the  politicians  were  merely  tools  in  the  hands 
of  their  medical  advisers,  and  doubtless  accepted  the 
suggestions  of  the  latter  without  thinking  of  the  injus- 
tice which  they  were  doing  to  worthy  members  of  the 
profession. 

We  are  accustomed  to  regard  the  system  of  political 
patronage  as  the  most  pernicious  feature  of  organized 
tyranny.  But  what  is  the  present  spasm  of  reform  in 
its  recent  application  to  the  city  institutions  but  an 
organized  scheme  on  the  part  of  the  colleges  to  control 


630 


MEDICAL   RECORD. 


[November  2,  1895 


political  patronage,  and  thus  to  increase  their  power 
and  influence  ? 

The  situation  is  not  without  its  humorous  side 
even  to  those  who  are  smarting  under  the  sense  of  in- 
justice. As  the  late  Mr.  McAllister  defined  the  nu- 
merical limits  of  our  best  society,  so  in  the  future 
the  elite  of  the  profession  may  come  to  be  known  as 
the  one  hundred,  outside  of  whose  mystic  circle  are 
only  the  "  riff-raff,"  as  one  of  the  Commissioners  is  re- 
ported to  have  designated  the  members  of  the  abol- 
ished medical  boards.  The  sharp  distinction  will  natu- 
rally appeal  to  the  laity,  who  are  prone  to  judge  of 
professional  ability  by  the  possession  of  high-sounding 
titles.  Granted  that  the  faculties  of  the  three  under- 
graduate schools  include  in  their  ranks  a  fair  propor- 
tion of  the  ability  and  learning  of  the  profession.  Do 
they  include  all  ?  Are  there  no  flowers  that  "  blush  un- 
seen ?  "  But  we  are  assured  that  under  the  new  ar- 
rangement not  only  will  better  men  be  secured  on  the 
attending  staffs  of  the  various  city  hospitals,  but  thase 
institutions  will  be  utilized  for  the  purpose  of  clinical 
teaching.  Oh  !  Come  now,  gentlemen  of  the  new  re- 
gime, be  honest.  You  know  how  little  the  institutions 
on  the  island  are  available  for  this  purpose,  and  that 
you  have  more  clinical  material  than  you  can  utilize  in 
close  proximity  to  your  schools.  Why  not  admit  that 
you  simply  saw  a  favorable  opportunity  to  utilize  the 
present  reform  mo.vement  to  your  own  advantage,  with 
a  cold-blooded  disregard  of  the  rights  of  your  confthes, 
many  of  whom  had  served  the  city  faithfully  for  years  ? 

However  cute  this  "  deal  "  may  appear  as  a  political 
trick,  there  is  a  general  feeling  among  the  medical  pro- 
fession of  New  York,  as  expressed  in  the  resolution 
quoted,  that  the  victors  are  more  deserving  of  sym- 
pathy than  the  vanquished. 


THE    CASE    OF    MEDICAL    INSPECTOR 
KERSHNER. 

The  case  of  Medical  Inspector  Kershner,  of  the  navy, 
to  which  reference  has  been  previously  made  in  these 
columns,  now  awaits  the  action  of  the  President  of  the 
United  States,  who  may  or  may  not  approve  the  finding 
of  the  recent  court-martial  for  dismissal  from  the  ser- 
vice. As  the  proper  discharge  of  such  a  responsibility 
on  the  part  of  the  chief  executive  necessarily  involves 
many  weighty  considerations  bearing  on  the  character 
of  an  efficient  officer  of  the  service,  and  indirectly  upon 
the  medical  corps  of  the  navy,  it  is  to  be  hoped  that  no 
pains  will  be  spared  in  arriving  at  a  calm  and  neces- 
sarily just  decision  regarding  the  facts  as  brought  out 
in  the  aforesaid  trial. 

With  every  incentive  on  our  part  to  view  the  situation 
from  a  strictly  impartial  stand- point,  it  must  not  be  for- 
gotten that  from  time  immemorial  there  has  been  a  bit- 
ter and  unreasonable  jealousy  between  the  line  and 
staff  concerning  the  very  matters  of  medical  authority 
upon  which  the  questions  of  prerogative  in  the  trial  ap- 
pear to  hinge. 

Whatever  else  may  be  said  there  can  be  no  doubt  in 
the  mind  of  an)'one  who  studies  the  record  of  the 
court-martial  that  the  defendant  was  in  any  way  lack- 
ing in  the  proper  motives  for  the  discharge  of  his  duties 
as  he  understood  them  ;  in  fact  as  everyone  else  must 


understand  them  who  is  acquainted  with  the  regulation - 
defining  them.     These  regulations  direct  that  the  medi- 
cal officer  shall  keep  the  commanding  officer  informed 
in  regard  to  all  diseases  that  may  appear  on  board  shi;>. 
invade  the  ship,  or  directly,  or  indirectly,  endanger  thit 
crew.    Too  frequently,  however,  this  provision  becomes 
a  dead  letter  unless  the  superior  authority  of  the  cap- 
tain sees  fit  to  enforce  it.     It  will  be  recollected  that 
the  present  unfortunate  misunderstanding  of  relative 
obligations  grew  from  an  unreasonable,  injudicious,  and 
unjust  charge  of  inhumanity  against  the  ship  surgeon, 
who,  having  the  medical  safety  of  the  crew  at  heart  and 
in  fear  of  yellow  fever,  then  prevailing,  protested  against 
the  visiting  of  a  patient  on  a  suspected  merchant  ship 
that  was  nearer  help  from  the  shore  than  from  the  war 
vessel.    P"or  calling  attention  to  such  danger  the  captain 
of  the  ship  reported  the  fact  to  the  admiral,  who  sent  to 
the  Navy  Department  the  infamous  charges  against  the 
humanity,  the  moral  character  and  professional  ability 
of  said  surgeon  of  the  fleet.       In  natural  distress  of 
mind  Surgeon  Kershner  forwarded  a  verbatim  copy  of 
the  charges  to  Surgeon-General  Tryon,  who  was  asked 
to  lay  the  case  before  the   Secretary  of  the  Navy.     He 
also  wrote  to  several  of  his  personal  friends  and  to  the 
members  of  his  family  in  a  general  way  to  the  same 
effect.     Accounts  of  the  difficulty  then  found  their  way 
to  a  daily  paper,  but  whether  these  were  obtained  from 
the  official  reports  or  indirectly  through  some  of  Dr. 
Kershner's  friends,  does  not  appear.    It  was  charged,  on 
general  principles,  however,  that  the  defendant  was  the 
guilty  party,  thus  violating  navy  regulations  and  wilfully 
subverting  discipline.     In  a  court-martial  at  Kingston, 
Jamaica,  an  attempt  was  made  to  prove  that  a  verbatim 
copy  of  the  so-called  charges  was  sent  directly  or  in- 
directly to  the  daily  press  by  the  defendant,  and  resulted 
in  the  inspiration  of  a  widely  published  criticism.    The 
witness  admitted  writing  the  substance  of  the  charges 
to  friends,  but  being  informed  that  an  explicit  answer 
was  requested  only  in  connection  with  a  verbatim  copy 
to  the  newspapers,  formally  and  explicitly  denied  the 
latter   charge.      The   report  of   the   trial   at   Jamaica 
formed  the  basis  of  a  second  trial   at   the    Brooklyn 
Navy  Yard,  in  which  it  was  charged  that  the  witness 
had  sworn  falsely  on  the  previous  trial,  to  the  effect 
of  denying  that  he  not  only  did  not  send  any  verbatim 
reports  to  the  papers  but  that  no  reports  were  sent  at 
all  by  him.     The  omission  in  the  imperfectly  reported 
proceedings  of  the  first  court-martial,  accidentally  or 
purposely,  of  the  word  verbatim,  on  the  use  of  which 
the  only  denial  of  the  defendant  was  based,  made  it 
appear  that  no  answers  whatever  were  offered  or  no 
testimony  given  as  to  the  written  reports  to  friends  ox 
even  a  verbatim  copy  to  Surgeon-General  Tryon.    Nor 
was  it  possible,  in  spite  of  the  efforts  of  the  learned 
counsel  for  the  defence,  to  refresh  the  minds  of  the  first    m\ 
jury  concerning  such  essential  points.     Not  even  the  I 
benefit  of  a  reasonable  doubt  as  to  motive  or  intent  by  "' 
defendant  was  allowed,  the  jury  simply  voting  to  dis- 
miss the  officer  from  the  navy  on  the  charge  of  "mak- 
ing false  statements  wilfully,  knowingly,  and  with  inten- 
tion to  deceive." 

It  certainly  appears  quite  remarkable  that  on  such 

quibbling  charges,  based  on  incomplete  and  inaccurate 

-  reports,  a  faithful  officer,  a  thoroughly'competent  sur- 


November  2,  1895] 


MEDICAL   RECORD. 


631 


geon,  and  an  honorable  gentleman  should,  from  the 
spite  of  any  one — admiral,  captain,  or  commander — be 
the  victim  of  such  a  dreadful  conspiracy  of  adverse  cir- 
cumstances. There  is  yet  one  chance  for  justice,  in 
an  impartial  review  of  the  whole  case  by  the  President 
himself. 


^eius  ot  the  ^ceU. 

The  Reorganization  of  the  City  Hospitals — Another 
Protest. — The  following  resolutions  were  adopted  at  a 
meeting  of  the  New  York  County  Medical  Association, 
held  October  21,  1895  : 

JV/tereas,  Infomiation  comes  to  us  from  reliable 
sources  that  the  Medical  Boards  of  the  Gouvemeur, 
Fordham,  City,  Maternity,  Nervous  Diseases,  Work- 
house and  Almshouse,  and  Randall's  Island  Hospi- 
tals have  been  abolished,  to  take  place  November  ist, 
and  that  the  members  composing  said  boards  are  to 
be  removed  without  cause  ;  and 

Whereas,  In  the  case  of  the  Harlem  Hospital  the 
Committee  of  the  New  York  County  Medical  Associa- 
tion appointed  to  consider  matters  of  interest  to  the 
medical  profession,  asked  for  a  hearing  before  the 
Commissioners  of  Public  Charities  and  Correction,  in 
the  interest  of  the  medical  men  who  had  been  unjustly 
deposed,  and  urged  upon  the  appointing  boards  of  the 
medical  colleges  that  they  defer  action  until  charges 
had  been  preferred,  or  that,  in  the  absence  of  charges, 
they  be  reappointed  ;  and 

IV/iereas,  The  medical  colleges  and  the  Commis- 
sioners ignored  the  communications,  and  thereby  ex- 
pressed their  apparent  contempt  for  your  representa- 
tives, and  their  indifference  to  any  wrong  done  to  the 
profession  ;  therefore,  be  it 

Resolved,  That  this  Association  condemns  the  whole- 
sale dismissal  of  medical  men  from  hospital  positions 
without  cause  or  hearing. 

Resolved,  That  we  express  our  disapproval  of  the  ac- 
tion of  the  Faculties  of  the  four  divisions  of  Bellevue 
Hospital  and  Commissioners  of  Public  Charities  and 
Correction  in  ignoring  the  communications  of  your 
Committee. 

Resolved,  That  copies  of  the  preamble  and  resolu- 
tions be  forwarded  to  the  Faculties  of  the  Medical 
Department  of  the  University  of  the  City  of  New  York, 
the  Bellevue  Hospital  Medical  College,  and  the  Col- 
lege of  Physicians  and  Surgeons,  to  the  Commissioners 
of  Public  Charities  and  Correction,  and  to  the  medical 
press. 

The  Eegents'  Preliminary  Examinations  for  Medical 
Students. — The  following  is  a  copy  of  a  notice  just  is- 
sued by  the  Examination  Department  of  the  University 
of  the  State  of  New  York  to  all  medical  schools  in  the 
United  States  and  Canada  : 

"  \Vill  you  kindly  call  the  attention  of  students  to 
the  following  amended  New  York  statute  relative  to 
degrees  in  medicine,  which  took  effect  May  13,  1S95  : 

"  The  degree  of  Bachelor  or  Doctor  of  Medicine 
shall  not  be  conferred  in  this  State  before  the  candi- 
date has  filed  with  the  institution  conferring  it  the  cer- 
tificate of  the  Regents  that,  three  years  before  the  date 
of  the  degree,  he  has  either  graduated  from  a  registered 


college  or  satisfactorily  completed  a  full  course  in  a 
registered  academy  or  high  school,  or  had  a  prelimi- 
nary education  considered  and  accepted  by  the  Regents 
as  fully  equivalent  ;  or  had  passed  Regents'  examina- 
tions representing  for  degrees  conferred  in  1898,  one 
year  of  academic  work,  for  degrees  conferred  in  1899, 
two  years  of  academic  work,  and  for  degrees  conferred 
in  1900,  a  full  high-school  course." 

"  This  law  prohibits  us  from  admitting  to  the  New 
York  licensing  examination  any  applicant  on  any  lower 
requirement  than  that  exacted  for  M.D.  degrees,  and 
for  admission  to  the  licensing  examination  in  the  case 
of  graduates  of  New  York  schools.  Hereafter  no  ap- 
plicant not  matriculated  in  a  registered  medical  school 
before  May  i,  1S95,  will  be  eligible  for  a  card  of  ad- 
mission to  the  New  York  licensing  examinations,  un- 
less he  met  the  standard  in  point  of  preliminary  edu- 
cation three  years  before  the  date  of  his  medical  degree. 
According  to  an  opinion  of  the  Attorney-General  the 
Regents  should  not  discriminate  against  the  New  York 
medical  schools  and  New  York  medical  students  by 
registering  any  medical  school  out  of  the  State  whose 
minimum  graduation  standard  is  less  than  that  fixed 
by  statute  for  New  York  medical  schools." 

Health  Board  of  the  City  of  New  York.— The  Board 
of  Estimate  and  Apportionment  have  appropriated 
$40,000  for  a  new  Ambulance  Station  and  Vaccine 
Laborator)'.  The  Health  Department  this  year  re- 
ceives $498,918,  which  is  an  increase  of  nearly  forty 
thousand  dollars  over  last  year. 

Obituary  Notes. — Dr.  Fr.\nk  E.  B.\rrington,  late 
house  surgeon,  Hartford  Hospital,  Hartford,  Conn., 
died  at  Windsor.  Vt.,  October  16,  1895,  of  acute  tuber- 
culosis. He  was  graduated  from  the  University  of 
New  York,  Medical  Department,  in  1883,  with  honor. 
Dr.  Barrington  was  a  young  man  of  rare  talent,  not 
only  in  his  chosen  profession,  but  also  in  music,  hav- 
ing composed  many  sweet  songs.  He  was  twenty-eight 
years  of  age  and  unmarried. — Dr.  George  A.  Mur- 
siCK,  of  Nyack,  died  at  his  home  in  that  city  on  Oc- 
tober 17th.  He  was  born  in  New  York  City  on  Feb- 
ruary 26,  1834,  and  was  graduated  from  the  New  York 
College  of  Physicians  and  Surgeons  in  i860.  In  Jan- 
uary, 1863,  he  entered  the  Union  Army  as  assistant 
surgeon,  and  was  assigned  to  hospital  service.  Later 
he  was  surgeon  in  charge  of  the  army  general  hospital 
at  Duvall's  Cliff,  Ark.,  and  became  medical  purveyor 
of  the  Department  of  .\rkansas  in  April,  1865.  Dr. 
Mursick  went  to  Nyack  in  1869,  where  he  has  since 
practised.  His  wife  and  two  sons  survive  him. — Dr. 
Timothy  B.  Cox,  of  Frankfort,  Ind.,  died  at  his  home 
in  that  city  on  Wednesday,  October  T6th,  aged  seven- 
ty-eight years. — Dr.  John  S.  Young,  of  Brooklyn, 
died  on  September  24th,  at  his  home  in  that  city,  aged 
sixty-two  years.  He  was  a  graduate  of  St.  John's  Col- 
lege, Fordham,  and  of  the  College  of  Physicians  and 
Surgeons  of  New  York,  in  1854.  He  served  as  Secre- 
tary of  the  Health  Department  in  Brooklyn  from  i886 
to  1888,  and  for  the  five  years  following  as  Deputy 
Commissioner. — Dr.  Francesco  Vall.ardi,  the  well- 
known  medical  publisher,  died  in  Milan,  on  September 
1 8th,  after  a  brief  illness.  He  was  born  in  that  city  in 
1809,  and  obtained  his  medical  degree  in   1833.     He 


632 


MEDICAL   RECORD. 


[November  2,  1895 


practised  for  a  short  time  only  and  then  became  a  pub- 
lisher, first  of  ethical  and  religious,  and  later  of  medi- 
cal works. — Dr.  Abbie  J.  Seymour,  of  Buffalo,  was 
found  dead  on  October  17th,  her  body  lying  on  the 
track  of  the  New  York  Central  Railroad.  Her  skull 
was  crushed,  and  one  of  her  hands  and  both  feet  were 
cut  off.  It  is  supposed  that  she  was  struck  by  a  West 
Shore  train  which  passed  shortly  before  she  was  found. 
Dr.  Seymour  was  the  most  prominent  professional  wom- 
an in  Buffalo.  She  was  born  in  Batavia  forty-two  years 
ago,  and  was  a  graduate  of  Rush  Medical  College,  Chi- 
cago. Of  late  she  had  been  in  bad  health,  and  only 
returned  from  a  sanitarium  on  the  morning  of  the  day 
of  her  death.  In  the  afternoon  she  left  her  home,  and 
was  not  seen  again  until  her  dead  body  was  found. — 
Thomas  Keith,  M.D.,  LL.D.,the  well-known  surgeon, 
died  on  October  9th,  aged  sixty-eight.  He  has  long 
been  known  as  being  one  of  the  early  ovariotomists, 
and  as  being  one  of  the  most  successful  of  gyneco- 
logical surgeons.  Dr.  Keith  performed  his  first  ovari- 
otomy in  1862.  Before  many  years  he  had  become  re- 
nowned for  his  successful  work  in  this  line,  and  he  did 
a  great  deal  to  increase  the  fame  of  the  Edinburgh 
Hospital  and  School.  In  1888  he  went  to  London, 
and  practised  in  that  city  until  about  three  years  ago. 
In  1894  he  published  the  results  of  some  of  his  experi- 
ences in  the  work  entitled  "  A  Text-Book  of  Surgery," 
which  was  written,  however,  for  the  most  part,  by  his 
sons. — Baron  Larrey  died  recently  at  his  home  near 
Paris.  He  was  the  son  of  the  celebrated  surgeon  to 
the  great  Napoleon,  and  was  born  in  1808.  He  was  at 
one  time  surgeon  to  the  Emperor  Napoleon  III.,  and 
was  Surgeon- General  of  the  Army  in  Italy.  He  was 
for  a  short  time  a  member  of  the  Chamber  of  Depu- 
ties. Baron  Larrey  was  a  man  of  considerable  ability, 
but  he  owed  a  good  deal  to  his  father's  fame. 

Surgeoncy  of  Police.— Dr.  Marvin  R.  Palmer,  of  this 
city,  reached  the  highest  grade  in  the  recent  competi- 
tive Examination  for  the  vacancy  in  the  surgical  staff 
of  the  police  force,  and  was  appointed  to  the  position 
accordingly.  This  is  a  becoming  recognition  of  fair 
play  against  the  political  pull  which  has  in  times  gone 
by  so  strongly  actuated  the  department.  We  con- 
gratulate the  Commissioners  on  this  new  evidence  of 
their  determination  to  do  the  right  thing  in  the  right 
way. 

French  Centenarians. — At  the  date  of  the  last  French 
census  there  were  213  genuine  centenarians,  of  whom 
47  were  women  and  66  men  ;  33  of  the  women  were 
old  maids  and  1 1  of  the  men  bachelors. 

Tea  and  Indigestion. — Dr.  McKechnie  reports  in  the 
Medical  Netvs  some  experiments  to  determine  the  in- 
fluence of  tea  upon  digestion.  The  experiments  were 
carried  on  by  himself  by  means  of  test-tubes  and  of  a 
gastric  fistula  formed  in  a  monkey's  stomach.  Dr. 
McKechnie  finds  that  tea  infusions  retard  digestion 
somewhat,  but  is  of  the  opinion  that  it  is  not  the  tannic 
acid  that  is  the  injurious  agent,  but  some  of  the  less 
soluble  extractive  matters.  Tea  is  not,  however,  very 
indigestible,  especially  teas  that  are  freshly  made. 

The  Late  Dr.  W.  B.  Conrad. — At  a  special  meeting 
of  the  London  Medical  and  Surgical  Society,  held  Oc- 


tober 21,  1895,  the  following  preamble  and  resolutions 
were  adopted  : 

Whereas,  In  the  death  of  Dr.  H.  B.  Conrad  the 
Society  has  lost  one  of  its  earliest  and  most  zealous 
supporters,  and  its  members  a  genial  and  generous 
friend  ; 

Resolved,  That  we  deplore  his  sudden  and  untimely 
end,  and  offer  to  his  bereaved  family  our  most  heartfelt 
sympathy  ;  and 

Resolved,  That  these  resolutions  be  entered  upon  the 
minutes  of  the  society,  published  in  the  Medical 
Record  and  Medical  Journal,  and  a  copy  sent  to  the 
family  of  our  late  member. 

J.  Blake  White, 
Frederic  S.  Sellew, 
H.  H.  Seabrook, 

Committee. 

The  New  York  Obstetrical  Society  Officers  for  the 
Year  l%9ib-^^.— President,  Henry  C.  Coe,  M.D.  ;  First 
Vice-President,  J.  Riddle  Goffe,  M.D.  ;  Second  Vice- 
President,  A.  Palmer  Dudley,  M.D.  ;  Recording  Secre- 
tary, Arthur  M.  Jacobus,  M.D.  ;  Assistant  Recording; 
Secretary,  George  W.  Jarman,  M.D.  ;  Corresponding 
Secretary,  Robert  L.  Dickinson,  M.D.  ;  Treasurer,  J. 
Lee  Morrill,  M.D.  ;  Pathologist,  George  C.  Freeborn, 
M.D. 

A  Brave  Doctor. — Our  English  contemporaries  are 
sounding  the  praise  of  Dr.  Charles  Toller,  of  Ilfra- 
combe.  Dr.  Toller  allowed  himself  to  be  lowered  over 
a  perpendicular  cliff,  one  hundred  and  fifty  feet  high, 
in  a  strong  gale  of  wind,  so  that  he  could  rcjch  and 
give  assistance  to  a  shipwrecked  sailor  who  liy  on  the 
rocks  below.  Dr.  Toller's  act  was  one  requiring  great 
courage  and  nerve,  and  he  justly  deserves  the  encomi- 
ums of  his  brethren.  It  looks  as  though  he  would,  for 
the  time,  become  almost  as  famous  as  Mr.  Grace,  who 
made  one  hundred  runs  at  cricket. 

Homicidal  Mania. — A  case  of  homicidal  mania  has 
recently  developed  in  Italy  which  resembles  very  much 
that  of  ■'  Jack  the  Ripper"  in  London.  The  criminal 
in  this  case,  however,  chose  for  his  victims  babies. 
After  having  strangled  five  of  these,  he  was  discovered, 
tried,  and  sentenced  to  twenty  years'  imprisonment — a 
rather  mild  punishment  for  so  many  murders. 

Sensitive  Ethics. — .\  correspondent  of  The  Lancet 
writes  a  most  indignant  letter,  complaining  that  he  has 

seen  in  the  daily  papers  the  statement  that  "  Dr.  

and  Dr. have  returned  to  their  respective  homes 

after  a  holiday."  This,  as  it  seems  to  the  correspond- 
ent, is  a  most  unwarrantable  breach  of  ethics  ;  and  the 
correspondent  has  taken  the  pains  to  place  a  large  black 
mark  against  the  names  of  the  criminals.  The  world 
is  a  silly  place,  but  there  seems  to  be  no  place  quite  so 
supremely  silly  as  the  head  of  the  average  London  doc- 
tor when  he  gets  on  the  subject  of  medical  ethics. 
Why  the  daily  press  should  not  state  that  Sir  WilHam 
Broadbent  has  returned  from  his  vacation,  if  this  is  a 
matter  of  interest  to  its  readers,  we  do  not  see.  The 
daily  press  is  full  of  the  comings  and  goings  of  lawyers, 
clergymen,  and  business  men,  of  far  less  worth  than  he. 

Philadelphia  has  2,610  medical  students  this  year,  as 
against  2,345  last  year  ;  285  are  homoeopathic  and  200 
are  women. 


November  2,  1S95] 


MEDICAL    RECORD. 


63: 


The  Diseases  of  the  Liver  :  Jaundice,  Gall-stones, 
Enlargements,  Tumors,  and  Cancer,  ant)  their 
Treatment.  By  J.  Compton  Burnett,  M.D.  Second 
revised  and  enlarged  edition.    Boericke  &  Tafel.     1S95. 

The  author  of  this  homoeopathic  treatise  is  evidently  one  of 
the  minority  who  still  adhere  to  the  original  doctrines  pro- 
pounded by  Hahneman.  He  prescribes  chelidonium  for 
jaundice  and  enlargement  of  the  liver,  because  the  plant  has 
a  yellow  juice.  But  this  remedy  must  be  used  only  when  the 
enlargement  is  in  a  perpendicular  direction.  If  pain  starts 
on  the  right  side  and  goes  toward  the  left,  one  remedy  is  to 
be  given  ;  another  if  the  pain  has  a  contrary  direction. 

The  most  remarkable  statement  in  the  book  is  that  sev- 
eral cases  of  carcinoma  of  the  liver,  which  have  been  diag- 
nosed as  such  by  several  reputable  physicians,  have  been 
thoroughly  and  permanently  cured  by  the  administration  of 
cholesterine  in  small  doses. 

It  would  require  many  grains  of  sodium  chloride  to  make 
this  statement  digestible,  and  we  are  forced  to  the  con- 
clusion that  the  reputable  physicians  made  a  mistake  in 
diagnosis. 

The  Pocket  Materia  Medica  and  Therapeutics,  .'l 
resume'  of  the  Action  and  Doses  ot  all  Officinal  and 
Non-officinal  Drugs  now  in  Common  Use.  By  C.  Henri 
Leonard,  A.M.,  .M.D.,  Professor  of  Medical  and  Surgi- 
cal Diseases  of  Women  and  Clinical  Gynecology,  Detroit 
College  of  Medicine.  Second  edition,  enlarged  and  re- 
vised. The  Illustrated  Medical  Journal  Co.,  Detroit, 
Mich.     1895. 

It  would  require  a  much  larger  pocket  than  is  usually  found 
in  the  modern  style  of  dress  to  carry  this  volume.  Never- 
theless, it  contains  a  great  deal  in  a  compact  form,  making 
it  useful  to  the  student  and  busy  practitioner  as  a  book  of 
ready  reference.  While  undoubtedly  most  physicians  are 
inclined  to  diminish  rather  than  increase  the  number  of 
drugs  used  in  daily  practice,  yet  it  is  perhaps  well  to  ha\  e 
some  knowledge  of  all.  The  author  claims  that  the  arrange- 
ment of  the  various  drugs  is  original  ;  and  this  part  of  the 
work  especially  commends  itself. 

Exercise  and  Food  for  Pul.monarv  Invalids.  By 
Charles  Denison,  A.M.,  M.D.,  Professor  of  Diseases 
of  the  Chest,  University  of  Denver.  Denver  :  The  Chapin 
&  Hardy  Co.     1895. 

This  little  manual  should  be  in  the  hands  of  every  physician 
for  distribution  to  his  patients  suffering  from  pulmonary 
tuberculosis.  Its  principle  of  treatment  in  this  disease  is 
the  correct  one,  viz.,  the  preservation  of  the  vitality  of  the 
living  cell  in  its  battle  with  the  tubercle  bacillus.  The  vital- 
ity of  the  cell  depending  upon  the  nutrition  which  it  re- 
ceives, nutrition  must  be  carried  to  the  highest  point  by  ra- 
tional exercise  and  proper  diet. 

The  rules  laid  down  for  the  guidance  of  patients  in  these 
respects  are  practical  ;  they  are  the  result  both  of  personal 
experience  and  extended  observation,  are  simple,  easily 
carried  out,  and  if  followed  in  detail  will  do  much  to  restore 
to  health  many  who  are  in  the  early  stages  of  phthisis. 

The  Urine  in  Health  and  Disease,  and  Urinary 
Analysis  Physiologically  and  Pathologically 
Considered.  By  D.  Campbell  Black,  L.R.C.S. 
Edin.,  F.F.P.  and  S.  Gl.is.  ;  Professor  of  Physiology  in 
Anderson's  College  Medical  School  ;  Physician  to  the 
Glasgow  Public  Dispensary.  Philadelphia  :  Lea  Broth- 
ers &  Co.     1895. 

This  new  work  on  a  very  important  subject  can  be  recom- 
mended to  the  profession.  The  author  first  takes  up  the 
anatomy  and  physiology  of  the  kidney.  This  portion  of  the 
work  is  condensed,  but  is  complete  and  clear.  A  consider- 
ation of  the  normal  elements  of  the  urine  follows,  and  the 
tests  for  each  given.  The  most  important  are  treated  quite 
exhaustively,  and  the  methods  of  quantitative  analysis  given, 
which  can  be  carried  out  by  the  general  practitioner.  All 
of  the  latest  tests  for  the  abnormal  constituents  of  the  urine 
are  presented,  and  a  comparison  of  their  delicacy  and  value 
made. 

The  details  of  the  experiments  are  clearly  stated,  so  that 
the  book  is  an  e.\cellent  working  manual  of  urinary  analy- 
sis. The  author  has  omitted  a  great  deal  of  the  purely 
speculative  work    found  in  larger  text-books,  and   has  in- 


cluded only  that  which  is  of  importance  from  a  clinical 
stand-point. 

Modern  Medicine  and  Homceop.ithv.  By  John  B. 
Roberts,  A.M.,  M.D.  Philadelphia:  The  Edwards  & 
Docker  Co.     1S95. 

The  author  of  this  little  work,  comprising  two  addresses  de- 
livered before  the  Philadelphia  County  Medical  Society, 
has  written  in  a  liberal  spirit. 

He  shows  that  the  instruction  given  in  the  homoeopathic 
medical  colleges  to-day  differs  very  little  from  that  of  the 
other  schools,  and  that  the  doctrines  of  similars  and  the  po- 
tency of  infinitesimal  doses  have  been  abandoned  by  the 
majority  of  the  best  educated  members  of  the  so-called 
"new  school."  On  the  other  hand,  it  is  just  as  evident 
that  many  of  their  prominent  writers  and  teachers  adhere 
firmly  to  these  doctrines.  In  the  minds  of  the  people  they 
are  still  closely  associated  with  the  name  homoeopathy. 
Therefore,  as  the  author  states,  harmony  of  action  and  true 
fellowship  among  those  who  tacitly  or  openly  accept  the 
doctrines  of  Hahneman,  and  those  members  of  the  profes- 
sion who  endeavor  to  practise  upon  broad  scientific  princi- 
ples, is  impossible. 

Clinical  Lectures  on  Diseases  of  the  Nervous 
System.  Delivered  at  the  National  Hospital  for  the  Par- 
alyzed and  Epileptic,  London.  By  W.  R.  Gowers,  M.D., 
F.R.S.,  Physician  to  the  Hospital,  etc.  Philadelphia  : 
P.  Blakiston,  Son  &  Co.     1S95. 

These  are  reprints  from  various  English  journals,  with  the 
exception  of  two  that  now  appear  by  permission  of  an  Amer- 
ican publisher.  Originally  delivered  at  the  National  Hos- 
pital, they  cover  an  instructive  set  of  abnormal  conditions. 
Two  chapters  of  the  twenty  are  devoted  to  locomotor  ataxia, 
two  others  to  the  infantile  causes  of  epilepsy,  and  two  to  the 
exposition  of  optic  neuritis.  Lead  palsy,  saturnine  tabes, 
neuralgia,  syringomyelia,  acute  ascending  myelitis,  bulbar 
paralysis,  syphilitic  hemiplegia,  facial  paralysis,  argyria  and 
syphilis,  facial  contraction  after  palsy,  the  treatment  of 
muscular  contraction,  mistaken  diagnosis  and  the  principles 
of  diagnosis  of  diseases  of  the  nervous  system  complete  the 
list  of  subjects.  The  style  is  clear,  forceful,  and  insinuat- 
ing, which  adds  greatly  to  the  valuable  information  that  the 
book  contains. 

Lectures  on  Appendicitis,  and  Notes  on  other 
Subjects.  By  Robert  T.  Morris,  A.M.,  .M.D.  G.  P. 
Putnam's  Sons.     1895. 

The  large  number  of  cases  of  appendicitis  which  are  seen 
every  year,  the  importance  of  early  diagnosis  and  prompt 
treatment,  make  any  contribution  to  this  subject  by  one 
who  has  had  considerable  experience  in  it  of  decided  value 
to  the  profession.  The  author  of  this  book  has  devoted 
most  of  his  time  to  surgical  work,  has  decided  opinions,  and 
is  not  afraid  to  express  them,  though  they  may  run  counter 
to  the  general  opinion.  Though  one  may  not  altogether 
agree  with  the  theories  expressed,  yet  it  must  be  acknowl- 
edged that  the  author  has  reached  his  conclusions  through 
practical  study  of  the  subject. 

No  exception  can  be  taken  to  that  part  of  the  work  relat- 
ing to  the  preparation  of  the  surgeon  and  the  patient  for  all 
operations.  It  contains  the  principles  of  modern  aseptic 
surgery,  and  the  minute  details,  so  often  omitted,  are  given 
with  a  clearness  and  precision  which  their  importance  war- 
rants. The  results  obtained  under  their  guidance,  not  only 
by  the  author  but  others,  are  a  guarantee  of  their  effi- 
ciency. 

Bacteria  invading  the  tissues  of  the  appendix  through 
some  injury  to  its  wall  is  believed  to  be  the  true  cause  of  all 
cases  of  appendicitis.  When  once  this  infection  has  taken 
place,  though  nature  may  be  able  in  the  first  attack  to  limit 
the  action  of  the  bacteria,  yet  some  will  remain  ready  to 
start  the  destructive  process  afresh.  Therefore,  the  only 
safe  plan  when  an  appendix  has  been  infected  is  to  remove 
it  at  once.  Prob.ably  the  severest  criticism  will  be  made  in 
regard  to  the  technique  of  the  operation  advised.  The 
author  claims  that  a  long  incision  through  the  abdominal 
wall  heals  more  slowly  than  a  short  one,  necessarily  keeps 
the  patient  in  bed  longer,  and  is  more  apt  to  be  followed 
by  hernia.  Therefore  he  advises  the  shortest  incision  pos- 
sible compatible  with  easy  removal  of  the  appendix,  and 
fixes  the  limit  at  one  and  one-half  inch.  He  claims  that 
through  this  opening,  in  uncomplicated  cases,  the  appen- 
dix can  be  safely  removed  by  an  operator  expert  in  abdom- 
inal surgery,  and  that  the  average  time  in  bed  required 
will  be  onlv  nine  days. 


634 


MEDICAL    RECORD. 


[November  2,  1895 


The  statistics  of  one  hundred  consecutive  operations  are 
given.  In  forty  of  these  the  one  and  one-half  inch  incision 
was  used,  and  all  recovered.  Of  these  forty,  in  five,  there 
was  suppuration  in  the  wound  coming  on  after  union,  and 
one  developed  a  hernia.  Of  the  sixty  operated  upon  by  a 
long  incision  there  was  suppuration  or  sloughing  in  five,  and 
only  one  hernia  is  reported.  That  occurred  where  for  some 
reason  the  wound  had  to  be  kept  open.  The  number  of 
days  spent  in  bed  by  each  patient  is  not  given. 

From  these  statistics  it  would  seem  that,  so  far  as  healing 
of  the  wound  and  hernia  is  concerned,  the  short  incision 
has  not  much  in  its  favor.  The  question  of  its  advantages 
can  only  be  settled  by  a  large  number  of  cases  extending 
over  a  considerable  period  of  time.  The  notes  on  other 
subjects  included  in  this  volume  are  mostly  papers  which 
have  appeared  from  time  to  time  in  various  medical  jour- 
nals. 

Some  Physiological  Factors  of  the  Neuroses  of 
Childhood.  By  B.  K.  Rachford,  M.D.,  Professor  of 
Physiology  and  Clinician  to  Children's  Clinic,  Medical 
College  of  Ohio.     The  Robert  Clarke  Co.     1895. 

This  book  is  an  important  contribution  to  a  subject  which 
has  been  almost  entirely  neglected  by  writers  on  diseases  of 
children.  The  author  uses  the  term  neuroses  to  cover  all 
local  and  general  nervous  disorders  which  do  not  depend  on 
known  local  pathological  lesions  of  the  nervous  system. 
To  these  disorders  belong  what  are  commonly,  but  incor- 
rectly, called  functional  nervous  diseases.  No  one  who  has 
looked  into  the  subject  can  deny  that  troubles  of  this  sort 
are  very  prevalent  among  the  children  of  the  present  gener- 
ation. Therefore  anything  which  throws  light  upon  the 
causes  which  produce  them,  and  the  means  for  their  pre- 
vention, is  distinctly  of  value.  While  these  neuroses  may 
not  be  dangerous  to  the  life  of  a  child,  yet  they  exert  a 
tremendous  influence  upon  its  future. 

The  opening  chapters  deal  with  the  physiology  of  the 
nerve-cell.  Its  functions  are  three  :  First,  the  generation 
of  energy,  and  the  amount  of  energy  generated  depends 
upon  the  degree  of  its  functional  development  and  the 
amount  of  healthy  metabolism.  Second,  to  discharge 
energy.  Third,  to  inhibit  energy.  Both  of  these  functions 
may  be  voluntary,  involuntary,  or  reflex. 

The  brain  of  the  normal  healthy  child  is  morphologically 
and  functionally  immature,  and  during  childhood  it  de- 
velops much  more  slowly  in  function  than  in  size  and 
weight.  The  inhibitory  function  is  naturally  more  feeble 
and  slower  in  development  than  the  other  functions  ;  and 
unfavorable  conditions  of  food,  heredity,  and  environ- 
ment may  produce  abnormally  feeble  inhibition.  Accord- 
ing to  the  author,  it  is  the  higher  degree  of  excitability  of 
the  nerve-cell  in  a  child,  due  to  the  functional  immaturity, 
plus  the  feeble  inhibitory  power,  which  causes  most  of  the 
nervous  diseases  in  childhood. 

The  variable  temperatures  of  infancy  and  childhood  are 
e.\plained  by  the  activity  of  the  thermogenic  centre  at  the  base 
of  the  brain  and  the  feeble  inhibitory  centre  in  the  cortex. 
The  exciting  causes  of  fever  are  bacterial  products  of  in- 
solation, which  the  author  considers  the  etiological  factor  of 
cholera  infantum,  muscular  action,  and  reflex  irritation. 

The  chapters  on  auto-intoxication  and  reflex  irritation  as 
causes  of  the  neuroses  are  worthy  of  close  attention.  Auto- 
intoxication may  occur  through  the  urine,  not  by  urea  and 
uric  acid,  as  Haig  believes,  but  by  the  presence  in  the 
blood  of  the  leucomains,  paraxanthin  and  xanthin,  and  other 
unnamed  poisons.  Certain  forms  of  epilepsy,  with  migraine, 
gastric  neuroses,  neurasthenia,  etc.,  are  probably  dependent 
upon  this  form  of  auto  -  intoxication.  Such  neuroses  as 
chorea,  hysteria,  nocturnal  nacentium,  and  convulsions, 
may  be  due  to  bacterial  toxines  produced  by  the  organisms 
of  tuberculosis,  malaria,  or  intestinal  fermentation.  Final- 
ly, the  author  shows  what  powerful  factors  excessive  brain 
work  and  nerve  excitement  are  in  the  production  of  neurotic 
disease,  especially  in  delicate  children. 

He  deprecates  the  modern  social  life  of  children  and 
the  forcing  process  of  education,  which  are  adding  thou- 
sands each  year  to  the  vast  army  of  neurasthenics  and  hys- 
terics which  inhabit  our  cities.  Parents,  nurses,  and  teach- 
ers should  be  taught  that  precocity  is  frequently  an  evi- 
dence of  physical  weakness,  and  should  be  discouraged 
rather  than  fostered.  No  child  should  be  advanced  in  its 
studies  until  its  physical  development  is  up  to  the  standard. 
Vegetation  is  the  ideal  life  for  infancy  and  childhood.  The 
individuality  of  the  child  is  frequently  destroyed  by  nurses 
and  governesses.  He  should  be  allowed  some  solitude  each 
day,  and  companionship  with  his  intellectual  equals.     Nu- 


merous playgrounds  in  our  cities  are  of  more  value  to  the 
community  than  hospitals  and  monuments. 

We  recommend  the  book  to  all  who  are  interested  in  the 
treatment  of  children. 

Atlas  of  Clinical  Medicine.  By  Byrom  Bramwell, 
M.D.,  F.R.C.P.  Edinburgh,  Assistant  Physician  to  the 
Royal  Infirmary,  etc.  \'ol.  III.,  Part  II.  Edinburgh  : 
Printed  by  T.  &  A.  Constable,  at  the  University  Press. 
1895. 

This  number  contains  the  following  :  A  consideration  of 
hereditary  syphilis  ;  a  description  of  plates  illustrating  pro- 
gressive muscular  atrophy  ;  a  chapter  devoted  to  progres- 
sive muscular  dystrophies,  viz.,  pseudo-hypertrophic  paral- 
ysis, the  juvenile  form  of  myopathic  muscular  atrophy  of 
Erb,  the  pseudo-scapulo-humeral  form  of  Landouzy  and 
Dejerine,  the  hereditary  form  of  progressive  muscular  atro- 
phy of  Lcyden,  the  (purely)  atrophic  form  of  myopathic 
muscular  atrophy,  generalized  progressive  muscular  atrophy 
of  early  childhood,  and  the  peroneal  type  of  progressive 
muscular  atrophy  :  points  to  be  observed  in  the  clinical  ex- 
amination of  cases  of  pseudo-hypertrophic  paralysis  and 
other  forms  of  progressive  muscular  dystrophy  ;  notes  of 
cases  of  pseudo-hypertrophic  paralysis  and  other  forms  of 
muscular  dystrophy  (to  be  continued  in  Part  III.).  There 
are  also  ten  large  plates,  illustrating  ichthyosis,  multiple 
cancer  of  the  breasts  and  other  organs,  congenital  syphilis, 
progressive  muscular  atrophy,  and  cyanosis.  The  atlas  con- 
tinues to  be  a  model  of  style  in  medical  literature  and  book- 
making,  and  is  also  the  embodiment  of  much  practical  and 
well-selected  knowledge.  Undertaken  at  great  expense, 
each  new  fasciculus  keeps  to  the  original  standard  of  excel- 
lence and  interest.  This  atlas  is  one  of  the  many  impor- 
tant works  that  the  Edinburgh  school  is  constantly  gi\'ing  to 
the  widely  scattered  English-speaking  medical  public.  It 
deserves  ample  recognition  everywhere. 

Diseases  of  the  Female  Bladder  and  Urethra. 
By  Howard  A.  Kelly,  M.D.,  Baltimore,  Md. 

Dr.  Kelly's  pamphlet,  beginning  at  p.  664  and  ending  at 
p.  726,  suggests  that  it  is  part  of  a  book  that  is  to  be.  It 
contains  a  description  of  methods,  posture,  and  instruments 
used  in  the  investigation  of  diseases  of  the  urethra,  bladder, 
and  ureters  in  women.  Up  to  the  present  time  this  class  of 
disease  has  been  the  most  neglected  field  in  the  whole  range 
of  scientific  medicine.  There  is  a  groundwork  of  reason  in 
this  neglect,  for  the  commoner  urinary  diseases  of  men  are 
far  more  apt  to  prove  dangerous  to  life.  Then,  too,  dis- 
eases of  the  lower  urinary  tract  in  women  have  not  been 
made  the  subject  of  exclusive  study  by  specialists.  Gyne- 
cologists, to  whom  they  have  been  referred  by  common  con- 
sent, have  too  often  slighted  them  as  difficult  or  impossible 
to  diagnosticate  and  intractable  to  treatment.  The  whole 
urinary  tract  in  women  may  now  be  examined  without  pain 
or  injury,  and  its  disorders  successfully  treated.  Dr.  Kelly 
is  one  of  perhaps  half  a  dozen  gynecological  surgeons  who 
have  given  special  attention  to  a  neglected  source  of  pain, 
discomfort,  expense,  and  disablement.  There  are  over 
twenty  illustrations,  a  careful  explanation  of  methods,  in- 
teresting references,  and  histories  of  cases  relieved  and 
cured. 

A  Clinical  ^Ianual.  A  Guide  to  the  Practical  Exami- 
nation of  the  Excretions,  Secretions,  and  the  Blood,  for 
the  Use  of  Physicians  and  Students.  By  Andrew  Mac- 
Farl.\ne,  A.B.  ,  M.D.,  Instructor  in  Neurology  and  Dis- 
eases of  the  Chest  in  the  Albany  Medical  College,  etc. 
New  York  and  London  :  G.  P.  Putnam's  Sons.     1894. 

Written  for  the  purpose  of  giving  in  a  concise  manner 
methods  employed  to  utilize  the  marvellous  advances  of  the 
past  ten  years  in  physiological  chemistry  and  in  clinical  mi- 
croscopy, the  author  acknowledges  his  indebtedness  to 
Jaksch,  Vicrodt,  Ewald,  Leube,  Eichhorst,  Fraenkel,  Ber- 
heim.  Osier,  Councilman  and  Lafleur,  Delafield  and  Prud- 
den,  and  others,  and  especially  to  Tappeiner's  "  Anleitung 
zu  Chemisch  Diagnostischen  Untersuchungen  am  Kranken- 
betta,"  ai"ter  which  this  clinical  manual  has  been  to  some  ex- 
tent modelled,  and  from  which  certain  procedures  have  been 
directly  translated.  There  are  thirty-nine  wood-cuts  and 
several  colored  plates.  The  work  described  can  be  carried 
on  by  any  physician  in  his  own  oflice,  with  a  suitable  micro- 
scope and  a  small  amount  of  apparatus.  The  directions  are 
plain  and  precise,  embodying  all  that  a  physician  need  know 
of  chemistry,  and  not  more  than  is  necessary  for  successful 
practice.     It  is  a  very  useful  manual. 


November  2,  1895] 


MEDICAL   RECORD. 


635 


The  Theory  and  Practice  of  Counter-irritation. 
Bv  H.  Cameron  Gillies,  M.D.  London:  Macmillan 
&  Co.     1895. 

The  author  states  that  he  likes  the  plan  of  this  essay  very 
much  ;  so  does  the  critic.  First  comes  a  complete  history 
of  the  subject,  then  a  new  theory  is  formulated  and  dis- 
cussed, and  the  whole  second  part  devoted  to  a  considera- 
tion of  the  uses  of  counter-irritants  generally.  The  new- 
theory  is  not  absolutely  startling  in  its  novelty,  since  it  is  to 
the  effect  that  every  process  of  inflammation  is  a  natural  ef- 
fort toward  cure,  and  that  the  beneficial  effects  of  counter- 
irritations  always  result  from  their  facilitating  or  accelerat- 
ing that  process.  The  term  counter-irritation  is  a  misno- 
mer, since  it  does  not  in  any  sense  check  or  divert  or  act 
counter  to  the  processes  of  inflammation.  The  expression 
external  stimulant  or  irritant  application  is  better.  It  does 
not  counter-irritate  when  it  serves  any  good  purpose.  The 
best  known  and  most  useful  irritant  applications  are  the 
actual  cautery,  the  Spanish  fly,  mustard,  turpentine,  iodine, 
and  a  few  others.  They  are  so  carefully  described  and  dis- 
cussed by  the  author  that  it  is  impossible  to  imagine  any- 
thing further  being  said  upon  the  subject. 

A  Manual  of  Organic  Materia  Medica.  Being  a 
Guide  to  Materia  Medica  of  the  Vegetable  and  Animal 
Kingdoms,  for  the  Use  of  Students.  Druggists,  Pharma- 
cists, and  Physicians.  By  John  M.  MaisCH,  Ph.M., 
Phar.D.,  late  Professor  of  Materia  Medica  and  Botany 
in  the  Philadelphia  College  of  Pharmacv.  Sixth  edition. 
Revised  by  Henrv  C.  C.  Maisch,  Ph^G.,  Ph.D.  With 
two  hundred  and  eighty-five  Illustrations.  Philadelphia  : 
Lea  Bros.  &  Co.     1895. 

The  sixth  edition  of  any  manual  speaks  for  itself.  Although 
the  last  edition  was  issued  in  the  autumn  of  1892,  the  sub- 
sequent publication  of  the  Pharmacopoeia  of  the  United 
States  has  necessitated  some  additions  and  alterations. 
Where  necessary,  specific  names  have  been  changed  to 
correspond  with  those  officially  recognized.  Articles  that 
have  received  official  recognition  now  appear  in  large  type. 
The  text  has  received  careful  revision,  and  the  results  of  re- 
cent investigations  and  observations  have  been  incorporated 
in  the  present  edition,  which  is  somewhat  reduced  in  size 
through  condensation,  though  the  matter  contained  has 
been  increased. 


©Uuical  gqjartmeut. 

THE    USE    OF    THE    CURETTE    IN    OPERA- 
TIONS FOR  EMPYEMA. 

By  J.   A.  FULTON,  M.D., 

SURGEON  TO  ST.    MARv'S    HOSPITAL,    ASTORIA,    ORE. 

In  the  treatment  of  a  number  of  cases  of  empyema  by 
resection  of  the  rib.  followed  by  drainage,  experience 
has  shown  that  a  majority  of  the  cases  so  treated  termi- 
nate in  a  way  which  is  entirely  satisfactory  to  all  con- 
cerned, while  a  small  percentage  of  the  cases,  instead  of 
going  onto  recovery,  require  further  operative  treatment 
or  terminate  fatally.  The  reason  for  the  very  different 
results  thus  obtained  from  practically  the  same  treat- 
ment, no  doubt,  may  be  due  to  some  differences  in  the 
constitution,  temperament,  previous  condition,  or  the 
present  conditions  surrounding  the  patient.  These 
differences,  of  course,  include  those  cases  of  tuber- 
culous origin  as  well  as  those  which  have  acquired  the 
tuberculous  disease  as  a  sequela  to  the  empyema. 

How  to  reduce  the  already  small  percentage  of  fail- 
ures from  the  operation  is  now  the  important  question 
to  consider.  To  the  writer  it  seems  that  often  the 
cause  of  failure  to  secure  the  desired  results  from  oper- 
ation may  be  due  to  the  incompleteness  of  the  operation. 
In  operating  on  these  cases  we  may  find  anyone  of  two 
or  three  different  conditions  to  be  present.  In  the 
first,  we  may  find  only  pus  in  the  pleural  cavity  ;  in 
the  second,  we  may  find  also  large  masses  of  coagu- 
lated lymph  ;  and  in  the  third  we  find,  in  addition  to 


the  former  conditions,  that  the  wall  of  the  pleural 
cavity  is  lined  with  a  deposit  of  lymph  varying  in 
thickness  from  a  mere  coating  to  a  deposit  several 
lines  in  thickness.  In  the  first  of  these  conditions  free 
drainage,  under  aseptic  precautions,  will  result  in  a 
cure  ;  in  the  second,  drainage  alone  will  not  remove 
the  large  coagula,  they  must  be  removed  with  a  scoop 
or  the  finger  of  the  operator,  if  a  cure  is  to  be  ex- 
pected. The  third  condition  is  the  one  to  which  the 
writer  desires  to  draw  attention.  In  this  variety  the 
finger  of  the  operator  and  the  scoop  may  remove  the 
floating  lymph,  but  it  requires  something  more  to  de- 
tach the  deposit  from  the  walls  of  the  chest.  It  has 
been  the  writer's  custom  to  look  upon  empyema  as  he 
looks  upon  pus  elsewhere,  or  as  a  large  pus  cavity 
which  should  be  treated  as  any  other  large  pus  cavity 
is  treated. 

To  open  and  drain  an  ordinary  abscess,  if  of  large 
size,  is  barely  sufficient  ;  it  is  necessary  to  curette 
thoroughly,  wash  thoroughly,  and  pack  carefully  under 
the  strictest  aseptic  precautions.  This  is  the  method 
adopted  by  the  writer  in  the  treatment  of  those  cases 
of  empyema  where  the  wall  of  the  cavity  is  lined  with 
the  lymph  deposit.  After  resection  and  thorough 
douching  with  plain  hot  water,  the  entire  cavity  is 
gone  over  carefully  with  the  curette  ;  the  douche  is 
kept  going  all  the  time,  and  as  fast  as  the  deposit  is 
loosened  it  floats  away.  Care  is  used  to  avoid  wound- 
ing the  pleura,  and  curettes  with  fle.xible  handles  are 
needed,  so  the  entire  surface  may  be  reached.  After 
the  entire  cavity  has  been  thoroughly  gone  over  and 
everything  washed  away,  it  is  dried  and  carefully 
packed,  and  from  that  time  on  treated  very  much  as 
if  it  were  a  large  abscess  cavity  elsewhere. 

The  experience  of  the  writer,  with  this  method  of 
treating  empyema,  while  not  extensive,  has  proven  so 
satisfactory  that  he  feels  justified  in  the  continuance 
of  the  same  ;  and,  furthermore,  it  has  encouraged  him 
to  report  it  to  the  profession.  It  has  not  been  deemed 
necessary  to  report  cases,  or  to  enter  into  a  long  de- 
scription of  an  operation,  which  has  only  to  be  men- 
tioned by  name  to  be  clearly  understood  by  the  sur- 
geon. Tlie  object  of  the  writer  in  this  paper  is  simply 
to  draw  attention  to  the  indications  for  the  use  of  the 
curette  in  the  treatment  of  certain  cases  of  empyema. 
It  is  possible  that  the  method  practised  by  the  writer 
in  these  cases  is  not  new  to  others,  but  after  a  rather 
extensive  experience  with  the  works  and  writings  of 
others  he  can  find  no  reference  to  this  practice  ;  in 
fact,  the  authors  accessible  to  the  writer  seem  to  be 
more  or  less  opposed  to  doing  anything  more  in  these 
cases  than  to  furnish  an  outlet  for  the  pus.  The  fact 
that  something  more  than  drainage  is  indicated  in 
many  cases  is  apparent  to  anyone  with  experience, 
and  any  method  which  holds  a  jjromise  for  a  better  and 
more  penect  and  certain  result  is  certainly  worthy  of 
consideration. 

The  Late  Dr.  Charles  F.  J.  Lehlbach. — At  a  meeting 
of  the  Practitioners'  Club  of  Newark,  N.  J.,  held  Sep- 
tember 2,  1895,  the  following  minute  was  adopted: 
"Charles  F.  J.  Lehlbach,  M.D. ,  died  August  14,  1895. 
Dr.  Lehlbach  was  one  of  the  founders  of  the  Practi- 
tioners' Club,  and  by  voice  and  pen  contributed  largely 
to  its  successful  establishment.  He  possessed  a  schol- 
arly mind  richly  stored  by  extensive  reading  and  ob- 
servation. His  keen  logic,  brought  to  bear  upon  the 
varied  abstruse  points  in  our  discussions,  readily  seji- 
arated  the  wheat  from  the  chaff  and  made  his  presence 
among  us  invaluable.  Admirably  gifted  with  genial 
social  traits,  he  embodied  within  himself  those  qualifi- 
cations which  it  is  the  chief  aim  and  design  of  the 
Practitioners'  Club  to  promote.  With  profound  sorrow 
for  the  loss  of  our  late  associate,  and  grateful  remem- 
brance of  his  valuable  labors  among  us,  the  Practi- 
tioners' Club  affectionately  directs  this  minute  to  be 
recorded." 


636 


MEDICAL   RECORD. 


[November  2,  1S95 


A  NEW  OPERATION  FOR 
TARRHAL  AND  CHRONIC 
DEAFNESS. 


CHRONIC     CA- 
SUPPURATIVE 


By  THOMAS  H.  SHASTID.  A.B.,  M.D., 


In  several  cases  of  deafness,  of  the  kinds  mentioned 
above,  I  have  noted  the  results  of  traction  on  the  handle 
of  the  malleus  by  means  of  a  blunt  hook  carried  through 
an  incision  in  the  drum-membrane.  This  procedure, 
so  far  as  I  know,  has  not  been  per- 
Cv         formed  or  proposed  before. 

It  was  suggested  to  me  by  an  ac- 
cident, which,  in  the  course  of  an 
operation,  occurred  in  consequence 
of  the  unruliness  of  the  patient. 
This  patient  had  long  been  a  sufferer 
from  catarrhal  deafness  with  sub- 
jective noises,  for  which  all  the  or- 
dinary means  of  treatment  had  been 
tried  in  vain.  I  was  therefore  at- 
tempting, by  an  original  method,  to 
produce  a  permanent  perforation 
of  one  of  her  tympanic  membranes. 
Just  at  a  moment  when,  as  a  part 
of  the  technique  of  my  method,  I 
was  introducing  through  the  per- 
I'/S  foration  an  angular  spatula,  the  pa- 

kis  tient  suddenly,  and  without  a  word 

of  warning,  jerked  her  head  away, 
and  the  spatula,  engaging  in  the 
tympanum,  was  pulled  from  my  fin- 
gers. When  I  recovered  the  instru- 
ment she  declared  that  she  heard 
better.  A  moment  later  she  de- 
clared also  that  her  "  head  noises  " 
had  almost  ceased.  The  assertion 
regarding  the  hearing  I  verified, 
finding  that  the  hearing- distance 
had  increased  for  the  acoumeter 
from  4  feet  to  25  feet,  for  loud 
speech  from  S  feet  to  30  feet,  and 
for  whispers  from  o  inch  to  8  feet.^ 
Exactly  what  it  was  that  had  taken 
place  to  produce  the  improvement 
I  could  not  determine ;  but  from 
the  position  in  which  I  had  held  the 
spatula  I  thought  that  it  must  have 
been  a  traction  made  by  the  instru- 
ment upon  the  handle  of  the  mal- 
leus. Whether  or  not  this  explana- 
tion was  right,  the  procedure  of 
traction  on  the  handle  of  the  mal- 
leus applied  intentionally  I  have 
frequently  found  to  give  good  re- 
sults. 

The  way  in  which  I  do  the  opera- 
tion is  this  :  The  auditory  canal  having  been  thor- 
oughly cleansed  and  antisepticized,  a  slight  scratch  is 
made  with  the  lance-knife  on  the  anterior  portion  of 
the  drum-membrane  and  a  twenty  per  cent,  solution  of 
cocaine  instilled  into  the  ear  and  allowed  to  remain  for 
five  minutes.  This  not  only  produces  perfect  anaes- 
thesia for  the  incision,  but  alsa  decidedly  lessens  the 
unpleasant  sensations  that  accompany  the  tractions. 
These  sensations,  it  may  be  as  well  to  remark,  are  usu- 
ally whistling,  ringing,  or  roaring  sounds,  together  with 
dizziness  and  sometimes  actual  pain.  The  incision  is 
made  with  the  lance-knife  just  anterior  to  the  handle  of 
the  malleus,  parallel  with  it,  and  from  two  and  a  half 

'  The  first  figures  in  these  comparisons  represent  the  hearing  dis- 
tance as  it  was  after  having  been  improved  by  the  artificial  perfora- 
tion It  is  an  interesting  fact  in  this  case  that  when  the  artificial  per- 
loration  closed  no  diminution  in  the  hearing  occurred.  This  can  be 
explained  by  supposing  that  the  hindrance  to  sound-conduction  hav- 
ing been  removed  by  the  accident,  the  perforation  was  no  longer  ad- 
vantageous. 


to  three  millimetres  in  length.  It  is  made  in  froni  of 
the  handle  rather  than  behind  it,  since  in  the  former 
place  the  hemorrhage  is  less — though  in  neither  place 
is  it  of  much  consequence.  The  first  instrument  that  I 
used  for  applying  the  traction  was  the  angular  spatula  ; 
but  I  have  since  had  made  a  blunt  hook  which  I  find 
far  easier  to  introduce  through  the  simple  slit.  This 
hook  (shown  in  the  illustration  a  trifle  too  heavy  and 
too  long)  is  ij'2  mm.  in  length,  slightly  enlarged  and 
rounded  at  the  extremity,  very  slightly  curved  toward 
the  operator,  and  mounted  on  a  shaft  at  an  angle  of  one 
hundred  degrees.  It  is  introduced  through  the  inci- 
sion and  rotated  in  such  manner  that  it  comes  to  lie 
directly  across  the  handle  of  the  malleus,  when  with  it 
are  made  three  or  four  rather  quick,  but  of  course  per- 
fectly gentle,  tractions.  It  is  then  turned  and  with- 
drawn. If,  upon  test,  no  improvement  be  found,  the 
instrument  may  be  again  introduced  and  the  tractions 
repeated  with  a  little  more  force.  This  technique  has 
been  employed,  practically  without  variation,  in  all  the 
cases  whose  record  follows,  the  single  modification  hav- 
ing been  the  substitution  in  the  last  four  cases  of  the 
blunt  hook,  or  tractor,  for  the  spatula.  The  incision, 
it  is  true,  instead  of  being  made  parallel  with  the  handle 
of  the  malleus,  might  be  made  at  right  angles  to  it, 
when  the  necessity  for  rotating  the  hook  would  be  ob- 
viated ;  but  since  I  have  observed  that  now  and  then 
during  the  performance  of  the  tractions  the  hook  slips 
along  the  handle  of  the  malleus,  I  have  thought  that  if 
the  incision  were  at  right  angles  the  hook  in  slipping 
might  possibly  tear  the  membrane  and  thus  inflict  upon 
it  an  unnecessary  traumatism. 

Case  I. — A  woman,  thirty-two  years  of  age,  com- 
plained of  bilateral  deafness  with  loud  subjective  noises. 
The  noises  she  had  had  for  many  years,  the  deafness 
she  had  noticed  for  only  two  years.  The  drum-mem- 
branes exhibited  no  changes,  except  slight  retraction. 
The  tuning-fork,  however,  localized  the  trouble  in  the 
middle- ear.  The  hearing  distance  of  the  right  ear  was, 
for  the  acoumeter,  15  foot ;  for  loud  speech,  12  feet ;  of 
the  left  ear,  for  the  acoumeter,  2  feet  ;  for  loud  speech, 
10  feet.  Politzerization  and  massage  of  the  ossicles  for 
six  weeks  produced  no  improvement.  Traction  was  per- 
formed on  both  sides,  and  the  hearing  distance  of  the 
right  ear  was  found  to  be,  for  the  acoumeter,  18  feet  ; 
for  loud  speech,  20  feet ;  for  whispers,  5  feet.  Of  the 
left  ear,  for  the  acoumeter,  20  feet  ;  for  loud  speech,  20 
feet  ;  for  whispers,  5  feet.  At  the  end  of  a  week  this  im- 
provement had  almost  subsided.  Traction  was  applied 
a  second  time  with  a  quicker,  sharper  touch,  and  the 
hearing  distance  of  the  right  ear  found  to  be,  for  the 
acoumeter,  25  feet ;  for  loud  speech,  25  feet  ;  for  whis- 
pers, 5  feet ;  of  the  left  ear,  for  the  acoumeter,  25  feet  ; 
for  loud  speech,  25  feet ;  for  whispers,  5  feet.  These 
distances,  at  the  end  of  six  months,  were  found  to  have 
remained  unaltered. 

Case  II. — A  man,  thirty  years  of  age,  had  had  sup- 
purative otitis  media  for  twelve  years,  during  the  last 
six  of  which  he  had  noticed  a  gradually  increasing 
deafness.  Both  ears,  at  the  time  he  came  to  me,  were 
discharging.  The  drum-membranes  presented,  each,  a 
large  perforation,  through  which  could  be  seen  a  mass 
of  granulations.  The  granulations  were  removed  and 
the  tympana  treated  to  a  cure.  The  hearing  distance 
of  the  right  ear  was  then  found  to  be,  for  the  acoumeter, 
5  feet ;  for  loud  speech,  5  feet  ;  of  the  left  ear,  for  the 
acoumeter,  15  feet  ;  for  loud  speech,  20  feet.  Politzer- 
ization and  catheterization  had  frequently  been  applied 
during  the  treatment  of  the  otitis,  and  hence  were  not 
further  indicated.  Traction  was  tried,  but  gave  no  re- 
sults. At  the  end  of  a  week  it  was  tried  again,  and  at 
the  end  of  another  week  a  third  time,  but  each  time 
without  results.  The  reason  why  traction  was  not  ser- 
viceable in  this  case  was,  I  thought,  that  here  there 
was  no  restricting  tissue  to  be  loosened  or  torn  ;  on  the 
contrary,  the  ossicular  ligaments  were  relaxed  and  the 
ossicles  themselves  alreadv  too  mobile. 


November  2,   1895] 


MEDICAL   RECORD. 


637 


Case  III. — A  woman,  aged  thirty-five,  had  had 
deafness  and  tinnitus  aurium  for  five  years.  The  phar- 
ynx was  co\ered  with  granulations.  The  drum-mem- 
branes were  opaque  and  moderately  retracted.  The 
hearing  distance  of  the  right  ear  was,  for  the  acoume- 
ter,  15  feet ;  for  loud  speech,  20  feet ;  of  the  left  ear, 
for  the  acoumeter,  10  inches  ;  for  loud  speech,  1 2  inches. 
Politzerization  and  massage  of  the  ossicles  for  four 
weeks  increased  the  hearing  distance  of  both  ears, 
for  the  acoumeter,  by  3  feet,  but  the  hearing  for  speech 
it  did  not  improve.  Traction  was  applied,  and  increased 
the  hearing-distance  of  the  right  ear,  for  the  acoumeter, 
to  25  feet  ;  for  loud  speech,  to  28  feet ;  but  the  hear- 
ing of  the  left  ear  it  did  not  improve.  At  the  end  of 
four  weeks  the  increase  in  the  distances  of  the  right  ear 
had  totally  subsided.  Traction  was  not  re-performed, 
as  the  patient  was  shortly  to  pass  from  observation. 

Case  IV. — A  girl,  aged  sixteen,  had  been  deaf  from 
catarrh  for  one  year.  She  had  been  treated  by  Polit- 
zerization and  catheterization  with  the  result,  she  said, 
that  she  got  worse.  The  pharynx  was  covered  with  gran- 
ulations, and  the  mucous  membrane  covering  the  in- 
ferior turbinated  bones  was  hypertrophied.  The  drum- 
membranes  were  opaque  and  moderately  retracted. 
The  hearing  distance  of  the  right  ear  was,  for  the  acou- 
meter, 9  inches  ;  for  loud  speech,  5  feet ;  of  the  left 
ear,  for  the  acoumeter,  5  feet ;  for  loud  speech,  to  feet. 
Under  three  weeks'  treatment  of  the  nose  and  pharynx 
the  hearing  of  both  ears  increased,  for  the  acoumeter, 
3  feet,  but  for  speech  not  at  all.  Traction  was  applied, 
and  the  hearing  of  the  right  ear  increased,  for  the  acou- 
meter, to  15  feet ;  for  loud  speech,  to  20  feet ;  of  the  left 
ear,  for  the  acoumeter,  to  20  feet  ;  for  loud  speech,  to  35 
feet.  The  treatment  of  the  catarrh  was  continued  to  a 
cure,  and  the  results  are  now,  six  months  after  traction, 
practically  unaltered. 

Case  V. — ^A  girl,  aged  ten.  had  been  deaf  from 
catarrh  since  the  age  of  six.  She  had  repeatedly  been 
treated,  with  but  slight  and  temporary  results.  The 
Politzer  air-bag  had,  by  her  last  physician,  been  placed 
in  the  hands  of  her  parents  with  instructions  to  ''  use 
it."  It  had  been  used  vigorously  and  frequently,  often 
several  times  a  day.  The  membranes  were  atrojihic 
and  flaccid,  and  the  one  on  the  right  side  was  ruptured. 
The  hearing-distance  of  the  right  ear  was,  for  the  acou- 
meter, 4  inches  ;  for  loud  speech,  2  feet ;  of  the  left 
ear,  for  the  acoumeter,  6  inches ;  for  loud  speech,  2 
feet.  The  air-douche  was  discontinued,  and  the  pharynx 
was  treated  for  four  weeks.  At  the  end  of  this  time 
no  improvement  could  be  found  in  the  hearing.  Trac- 
tion was  applied,  and  the  hearing-distance  of  the  right 
ear  found  to  be,  for  the  acoumeter,  30  feet ;  for  loud 
speech,  35  feet ;  for  whispers,  12  feet ;  of  the  left  ear, 
for  the  acoumeter,  35  feet ;  for  loud  speech,  35  feet ; 
for  whispers,  15  feet.  These  distances,  five  months 
afterward,  were  found  to  be  unaltered. 

Case  \T. — .\  woman,  aged  thirty,  had  been  deaf  since 
the  age  of  four.  At  the  latter  age  she  had  got  a  sup- 
purative otitis  media  from  an  attack  of  measles.  The 
discharge  had  persisted  till  the  age  of  ten  or  twelve. 
For  the  last  eight  or  ten  years  the  deafness  had  steadily 
grown  worse.  The  drum-membranes  were  white,  per- 
fectly opaque,  and  slightly  retracted,  the  left  one  pre- 
senting a  small  perforation.  The  acoumeter  could  be 
heard  by  the  left  ear  only  at  4  inches  ;  by  the  right  ear, 
not  at  all.  Speech  could  be  heard  only  when  very  loud 
and  very  near.  Under  Politzerization  with  treatment 
of  the  naso-pharynx  the  hearing  did  not  improve. 
Traction  was  applied,  and  the  hearing-distance  of  the 
"ip;ht  ear  increased,  for  the  acoumeter,  to  2  feet ;  of 

c  left  ear,  to  4  feet.     The  gain  in  hearing  for  speech, 
■iwever,  was  much  more  remarkable,  moderately  loud 

eech  being  distinctly  heard  by  either  ear  at  16  feet. 

iiis,  in  effect,  restored  to  the  patient  her  power  to  con- 

rse.     It  is  now  three  months  since  the  results  were 

r  ured. 

To  sum  up  the  report :  Of  the  six  cases  four  were 


of  catarrhal,  two  of  suppurative  origin.  Of  the  four 
cases  of  catarrhal  origin  traction  was  found  useless  in 
one,  decidedly  beneficial  in  three.  Of  the  two  cases  of 
suppurative  origin  traction  was  found  useless  in  one, 
decidedly  beneficial  in  one.  All  the  cases  had  pre- 
viously been  treated  by  ordinarj'  methods,  either 
entirely  without  benefit  or  with  benefit  of  only  a  slight 
or  only  a  temporary  character. 

How  can  we  explain  the  fact  that  in  some  of  these 
cases  traction  succeeded  when  the  usual  methods  had 
failed  ?  In  this  way  :  By  traction  the  force  was  applied 
to  the  ossicles  directly  ;  by  the  usual  methods  it  was 
applied  to  them  indirectly — that  is,  through  the  medium 
of  the  drum-membrane.  This  structure,  in  many  cases 
of  middle-ear  deafness,  is  so  thickened  and  stiffened 
that  when  the  blast  of  air  strikes  upon  it  it  either 
entirely  refuses  to  draw  the  handle  of  the  malleus  out- 
ward, or  draws  it  outward  to  only  a  very  slight  extent. 
Even  when  the  membrane  willingly  stretches  till  the 
umbo  has  described  as  great  an  outward  arc  as  it  could 
possibly  do  under  the  influence  of  traction — even  then, 
by  its  very  stretching,  the  membrane  lessens  the  sud- 
denness with  which  the  force  acts  upon  the  ossicles. 
But  it  is  precisely  suddenness  of  action  that  we  want. 
The  truth  of  this  last  assertion  we  may  know  not  only 
from  the  supposition  that,  in  these  cases,  the  good  that 
is  done  is  accomplished  by  the  rupturing  of  limiting 
adhesive  bands,  and  hence  is  accomplished  in  greater 
degree  the  greater  the  rupturing  power  or  suddenness 
with  which  the  force  acts,  but  also  from  the  well-known 
clinical  fact  that  frequently  when  inflation,  by  means  of 
a  slow,  gradually  increased  blast,  has  been  tried  in  vain, 
a  quick,  sharp,  sudden  blast  opens  the  gates  of  sound 
like  magic. 

In  conclusion,  I  desire  that  in  laying  before  the  pro- 
fession the  facts  concerning  this  operation  I  be  not 
misunderstood.  As  a  measure  for  routine  I  do  not 
think  the  procedure  worth  the  slightest  attention.  Po- 
litzerization, catheterization,  and  massage,  in  the  kinds 
of  cases  we  have  been  considering,  have  long  been,  and 
are  likely  long  to  remain,  our  chief  reliance,  to  the  al- 
most total  exclusion  of  intra-tympanic  operations.  All 
that  I  wish  to  claim  for  traction  on  the  handle  of  the 
malleus  is  that  it  is  simple  and  safe,  and  that,  judging 
from  the  results  in  the  few  cases  in  which  1  have  tried 
it,  it  is  likely  to  prove  of  real  and  decided  service  in 
some  of  the  many  cases  in  which  ordinary  treatment  is 
ineffective. 


REPORT    OF    TWO    TRACHEOTOMIES    FOR 
LARYNGEAL   CELLULITIS.' 

Bv    T.    C.    EVANS,   M.D., 


LOUISVILLE,    KY. 


LBCTURBR   ON   OPH 


Case  I. — On  March  11,  1895,  I  was  called  to  attend  a 
man  who  was  said  to  be  choking  to  death.  I  found 
the  patient,  aged  twenty-nine  years,  in  the  throes  of  a 
most  urgent  and  agonizing  inspiratory  dyspnoea.  Not- 
withstanding the  extreme  dyspnoea,  his  voice  was  but 
little  impaired  except  from  exhaustion.  From  his 
friends  I  learned  that  on  the  afternoon  of  Saturday,  the 
9th,  he  complained  of  chilly  sensations  and  some  dis- 
comfort on  swallowing.  The  indisposition  was  not  of 
sufficient  importance  to  cause  any  alarm,  as  he  went  to 
the  theatre  in  the  evening,  and  after  that  slept  well 
during  the  night,  and  went  to  church  on  Sunday  morn- 
ing. After  this  he  had  paroxysmal  attacks  of  cough- 
ing and  dyspnoea.  His  family  physician  was  called, 
and  remained  with  him  until  early  on  Monday  morn- 
ing, the  I  ith,  when  I  was  called  to  do  an  intubation. 
On  laryngoscopic  examination  I  found  the  epiglottis 

"  Read  before  the  Louisville  Clinical  Society. 


638 


MEDICAL    RECORD. 


[November  2,  1895 


enormously  swollen,  and  of  a  deep  red  color,  the  free 
margin  forming  apparently  a  complete  ring  with  a 
small  central  aperture  about  the  size  of  a  crow's  quill, 
the  swelling  being  more  pronounced  on  the  right  side. 
Of  course  the  condition  of  the  epiglottis  made  an  ex- 
amination of  the  cavity  of  the  larynx  impossible,  but 
the  fact  that  the  voice  remained  good  made  it  clear  to 
my  mind  that  the  swelling  was  confined  to  the  epiglot- 
tis. An  intubation  being  neither  possibli  nor  practi- 
cable, I  advised  a  tracheotomy,  to  which  the  patient 
readily  consented.  Dr.  Ap  Morgan  Vance  was  called, 
and  performed  the  low  operation  under  cocaine  anres- 
thesia.  Owing  to  the  unusual  depth  of  the  trachea  it 
was  found  impossible  to  keep  the  tube  in  position,  so  a 
stout  ligature  was  passed  through  the  lip  of  the  tracheal 
wound  and  the  two  ligatures  tied  around  the  neck, 
keeping  the  wound  open  by  tension.  These  ligatures 
came  away  on  the  fourth  day.  The  swelling  of  the 
epiglottis  reached  its  climax  forty-eight  hours  after  the 
operation.  At  the  time  of  the  operation  the  patient 
had  a  temperature  of  103°  F.,  and  it  ranged  from  this 
to  105°  F.  for  four  or  five  days  after  the  operation. 
On  the  second  day  after  the  operation  the  patient  de- 
veloped considerable  cellulitis  of  the  neck  above  and 
to  the  right  of  the  tracheotomy  wound,  but  apparently 
having  no  connection  with  the  wound.  The  swelling 
subsided  without  the  formation  of  pus,  as  did  also  the 
swelling  of  the  epiglottis.  Eight  days  after  the  opera- 
tion he  was  able  to  breathe  comfortably  through  the 
larynx.  The  tracheal  wound  was  allowed  to  heal  by 
granulation,  and  the  patient  discharged  on  March  27th, 
sixteen  days  after  the  operation.  Several  times  since 
his  recovery  I  have  made  laryngoscopic  examination 
and  found  nothing  abnormal  or  pathological.  If  he 
has  any  constitutional  disorder,  he  has  up  to  this  time 
(six  months  after  the  operation)  failed  to  develop  any 
symptoms. 

Case  II.- — April  28,  1895,  I  was  called  to  see  Sallie 

L ,  colored,   aged    twenty-two  years.     Found    her 

suffering  with  marked  dyspnoea  ;  she  could  speak  only 
in  a  faint  whisper.  From  her  mother  I  learned  that  she 
had  been  hoarse  for  three  or  four  days,  and  had  been 
attended  by  a  general  practitioner  until  within  a  few 
hours  of  the  time  that  I  was  called,  when  he  retired 
from  the  case,  advising  them  to  call  a  specialist.  With 
the  laryngoscope  I  found  the  obstruction  in  the  aryte- 
noid and  inter- arytenoid  region.  I  thought  it  would 
be  possible  to  introduce  an  intubation  tube.  Trying 
first  the  medium-sized  rubber  tube,  and  finding  it  impos- 
sible to  introduce  this,  I  next  tried  the  small  adult  tube, 
and  was  able  to  engage  the  point  of  the  tube  in  the 
chink,  but  could  not,  with  all  the  force  that  I  felt  at 
liberty  to  use,  introduce  the  tube  into  the  trachea. 
She  readily  consented  to  a  tracheotomy.  Dr.  \V.  C. 
Dugan  was  called.  In  the  few  minutes  that  elapsed 
between  the  time  he  was  called  and  his  arrival,  the  pa- 
tient became  unconscious.  The  conditions  were  now 
so  serious  as  to  demand  an  immediate  operation. 
AVithout  waiting  for  cocaine  I  made  extension  of  the 
head,  and  Dr.  Dugan  fixed  the  trachea  with  his  left 
hand  and  plunged  the  knife  into  the  tube.  With- 
drawing the  knife  the  wound  was  kept  open  by  a  pair 
of  artery  forceps.  The  tracheotomy  tube  was  intro- 
duced between  the  blades  and  the  forceps.  The  pa- 
tient's head  was  then  lowered  to  prevent  the  blood 
from  flowing  into  the  trachea.  The  hemorrhage  was 
inconsiderable,  and  stopped  of  its  own  accord.  The 
incision  was  through  the  first  or  second  ring  of  the 
trachea,  and  evidently  severed  the  thyroid  isthmus. 
After  a  few  full  inspirations  the  patient  regained  con- 
sciousness, and  passed  a  fairly  comfortable  night.  An 
examination  of  the  larynx  twelve  hours  after  the  opera- 
tion showed  the  oedema  involved,  also  the  ventricular 
bands.  This  swelling  did  not  perceptibly  diminish  un- 
til the  fourth  day,  when  it  began  slowly  to  diminish. 
On  the  eighth  day  the  tube  was  removed.  There  was 
no  return  of  the  dyspnoea,  though  the  hoarseness  con- 


tinued for  nearly  six  weeks.  After  the  swelling  sub- 
sided it  was  plainly  evident  that  the  antero-posterior 
diameter  of  the  larynx  was  abnormally  short,  and  the 
arytenoids  actually  or  apparently  taller  than  usual. 
The  site  of  the  tracheal  wound  was  plainly  visible  with 
the  laryngoscope  for  several  months  after  the  opera- 
tion. 

Up  to  this  time,  five  months  after  the  operation,  she 
has  developed  no  symptoms  of  any  constitutional  dis- 
ease. 

A  few  words  in  regard  to  the  anatomy  of  the  parts 
involved  and  the  pathological  conditions  present  in 
the  acute  obstructive  diseases  of  the  larynx  will,  I  hope, 
be  sufficient  apology  and  explanation  for  having  re- 
ported the  foregoing  cases  under  the  above  title. 

The  mucous  membrane  of  the  larynx,  as  all  well 
know,  is  more  or  less  intimately  attached  to  the  under- 
lying structures  by  a  layer  of  connective  tissue  varying 
in  thickness  and  density  in  different  regions  of  the  lar- 
ynx. This  connective  tissue  is  especially  abundant  and 
lax  in  the  ary-epiglottic  folds,  the  ventricular  bands, 
and  posterior  surface  of  the  epiglottis.  These  areas  of 
connective  tissue  are  of  course  subject  to  the  same  dis- 
eases as  the  connective  tissue  in  other  parts  of  the  body, 
and  under  certain  conditions  become  the  seat  of  an  in- 
flammatory infiltration  or  serous  transudation  sufficient 
in  extent  or  quantity  to  lessen  or  altogether  occlude 
the  lumen  of  the  larynx,  and  produce  death  by  me- 
chanical interference  with  respiration.  Much  confu- 
sion, in  the  nomenclature  as  well  as  in  the  treatment  of 
the  acute  obstructive  diseases  of  the  larynx,  has  been 
caused  by  grouping  together  the  several  different  path- 
ological conditions  of  the  connective  tissue  of  the  lar- 
ynx under  the  general  term  "  Qildema  of  the  Glottis," 
or  "  Oidema  of  the  Larynx,"  the  first  of  which  is  not 
only  a  misnomer,  but  an  anatomical  impossibility,  from 
the  fact  that  in  the  true  vocal  cord  the  mucous  mem- 
brane is  firmly  adherent  to  the  underlying  structures. 
The  last  is,  to  say  the  least,  ill-chosen,  or  should  be 
used  in  a  restricted  sense  to  apply  to  the  non-inflam- 
matory cases  :  for  this  reason  I  have  presumed  to  say 
a  few  words  in  regard  to  the  nosology  of  this  particu- 
lar branch  of  laryngology. 

In  enumerating  the  pathological  conditions  of  the 
laryngeal  connective  tissue  we  have  left,  after  eliminat- 
ing those  infiltrations  and  exudations  which  form  a  part 
of  the  clinical  history  of  perichondritis,  tubercular  and 
syphilitic  laryngitis,  two  distinct  affections,  one  an 
inflammatory  infiltration  due  to  some  form  of  sepsis, 
and  which  may  terminate  in  resolution  (as  in  the  two 
cases  reported),  or  in  suppuration,  either  circumscribed 
or  diffuse  ;  the  other  a  non-inflammatory  serous  trans- 
udation, due  to  some  renal  or  hepatic  disease,  some 
blood  dyscrasia,  or  circulatory  disturbance.  Now,  in 
order  to  describe  the  conditions  more  explicitly  to 
avoid  confusion,  and  at  the  same  time  to  conform  to 
the  nomenclature  of  general  medicine  and  surgery,  I 
would  designate  the  former  aft'ection  as  laryngeal  cell- 
ulitis, the  latter  as  laryngeal  anasarca.  As  to  what 
proportion  of  the  cases  are  inflammatory,  and  what  are 
dropsical,  I  have  no  means  of  knowing,  but  am  in- 
clined to  think  that  by  far  the  larger  proportion  of 
cases  are  inflammatory,  as  localized  anasarcas  are 
rather  rare  in  any  part  of  the  body. 

I  have  purposely  laid  considerable  stress  upon  the 
fact  that  in  the  so-called  oedema  the  lesion  is  in  the 
sub-mucous  connective  tissue  and  not  in  the  mucous 
membrane,  for  the  reason  that  the  opinion  seems  to  be 
more  or  less  prevalent  that  oedema  is  a  sequela  or  com- 
plication of  catarrhal  laryngitis,  an  opinion  which  seems 
to  me  to  be  entirely  erroneous. 

A  marked  impairment  of  the  voice  may  follow  an 
acute  catarrhal  laryngitis,  but  an  obstruction  sufficient 
to  interfere  to  any  considerable  extent  with  respira- 
tion is  always  due  to  some  involvement  of  the  connec- 
tive tissue.  The  literature  on  "  Gidema  of  the  Lar- 
ynx "  is  rather  voluminous,  but  confusing,  ambiguous. 


November  2,    1895] 


MEDICAL    RECORD. 


639 


and  unsatisfactory.  Most  of  the  authors  that  I  have 
consulted  quote  largely  from  the  statistics  and  conclu- 
sions of  Sesteir,  of  Paris,  who  collected  and  tabulated 
two  hundred  and  forty-five  cases  of  oedema  of  the  lar- 
ynx, and  wrote  a  monograph  on  the  subject  in  1852. 
You  will  remember  that  this  was  before  the  day  of  the 
laryngoscope,  and  that  four-fifths  of  these  cases  were 
gleaned  from  medical  literature  of  that  day  when  it  was 
customary  to  call  all  forms  of  laryngeal  obstruction 
"  Qidema  Glottitis."  Again,  several  authors  quote  from 
the  statistics  of  Peltesohn,  who  in  3,887  autopsies  found 
oedema  of  the  larynx  210  times,  or  i  in  18,  while  Hoff- 
man, in  the  same  city,  in  6,062  autopsies  found  only  33, 
or  I  in  183.  The  divisions  that  these  statisticians  make 
of  their  cases  into  primary  and  secondary  oedemas  fail 
to  convey  to  me  any  definite  impression  either  of  the 
pathology  or  etiology  of  the  affection.  Owing  to  the 
faulty  classification,  and  the  fact  that  the  statistics  are 
made  almost  entirely  from  post-mortem  examinations, 
it  is  impossible  to  form  an  intelligent  estimate  of  the 
mortality. 

As  to  the  treatment,  the  text- books  recommend  hy- 
podermatic injections  of  pilocarpine,  steam  inhalations, 
and  especially  scarification.  As  to  scarification  I  wish 
to  demur  ;  I  can  see  how  in  cases  of  anasarca  it  would 
lessen  the  effusion,  or  in  slight  inflammatory  affections 
the  local  depletion  might  be  beneficial,  but  when  the 
case  has  become  at  all  urgent,  scarification  would  add 
a  serious  complication  in  the  way  of  hemorrhage,  which 
would  be  sufficient  to  excite  paroxysms  of  coughing, 
which  may  at  any  time  prove  fatal.  Aside  from  this, 
we  know  that  the  swelling  due  to  cellulitis  in  other 
parts  of  the  body  is  not  readily  controlled  by  incisions. 
Most  of  the  cases  will  require  the  more  radical  measure 
of  tracheotomy,  which  should  be  performed  early  with- 
out subjecting  the  patient  to  hours  and  days  of  danger 
and  distress.     Intubation  is  not  suited  to  these  cases. 


wall  of  the  appendix  had  taken  place  at  the  site  of  the 
bone.  Microscopically  the  thickening  was  found  to 
be  due  to  a  local  hyperplasia  of  the  submucous  coat, 
and  the  mucous  membrane  had  been  denuded  of  its 
epithelium.  From  the  localized  thickening  of  the  wail 
it  may  be  assumed  that  this  body  has  been  in  the  ap- 
pendix for  a  long  time. 

A  complete  history  would  add  much  interest  to  the 
case.     Tlie  bone  is  larger  than  the  lumen  of  the  ap- 


A     PIECE    OF     BONE     IN     THE     APPENDIX 
VERMIFORMIS. 

Bv  WARREN  COLEMAN,    M.D., 

NEW  YORK. 
INSTRLCTOR   IN    PATHOLOGY    AT    THE    LOOMIS    LABORATORY. 

The  piece  of  bone  shown  in  Fig.  i  was  found  in  a 
man,  aged  sixty-seven,  who  died  at  the  Metropolitan 
Hospital.  Death  occurred  from  chronic  diffuse 
nephritis  and  a  complicating  broncho-pneumonia. 

On  opening  the  abdominal  cavity  the  tip  of  the  ap- 
pendix, uncovered  by  the  small  intestine,  was  found 
enlarged  and  lying  on  the  sacral  i)ro- 
montory.  The  appendix  itself  arose 
from  the  lower  end  of  the  caecum,  and 
curved  inward  and  upward.  As  a  whole 
,^7  it  was  longer  and   larger  than  normal. 

It  had  a  mesentery  for  more  than  half 
its  length,  but  was  not  bound  down,  nor  was  there 
any  evidence,  old  or  recent,  of  inflammation.  When 
the  appendix  was  slit  open  a  foreign  body,  which 
upon  examination  proved  to  be  a  piece  of  bone,  was 
found  at  the  point  of  enlargement.  From  the  shape 
and  appearance  of  the  piece  I  should  say  it  is  a 
fragment  of  a  large  bone.  It  is  rounded  at  one  end, 
while  the  other  presents  four  projecting  points.  It 
seems  probable  that  any  one  of  the  points  would  have 
penetrated  the  intestinal  or  appendicular  wall  during  a 
strong  contraction.  The  bone  measures  five-eighths  of 
an  inch  in  its  long  diameter  and  one-fourth  of  an  inch 
in  its  broadest  transverse  diameter.  It  entered  the  ap- 
pendix, blunt  end  foremost,  and  travelled  as  far  as  it 
could  go  (Fig.  2).  The  wall  of  the  appendix  encircled  it 
so  closely  that  the  point  of  the  scissors  was  introduced 
with  diflSculty.  The  piece  of  bone  was  enveloped  in 
mucus,  which  filled  the  lumen  of  the  appendix  through- 
out its  whole  length.     A  localized  thickening  of  the 


pendix,  and  must  have  caused  marked  distention  as  it 
travelled  along.  The  length  of  time  occupied  in  the 
passage  would  be  an  interesting  point.  Reasoning 
from  analogous  conditions  in  the  ureters  and  bile- 
ducts,  the  man  probably  had  a  protracted  attack  of 
sharp  colic,  the  pain  having  its  centre,  at  least,  in  the 
neighborhood  of  the  right  iliac  fossa. 

In  a  valuable  contribution  to  the  pathology  of  the 
vermiform  appendix '  we  find  the  following  statements 
with  reference  to  foreign  bodies  : 

"  The  literature  of  the  subject  reveals  a  most  extraor- 
dinary collection  of  substances  which  are  stated  to 
have  been  found  within  the  cavity  of  the  appendix. 
Thus  fruit-seeds,  cherry-stones,  hairs,  bristles,  shot, 
pins,  gall-stones,  lumbricoids,  pills,  teeth,  peanuts, 
shells,  and  bones  have  at  all  times  been  recorded  as 
having  been  found  within  the  appendix.  I  venture  to 
assert  that  many  of  them  are  inaccurate.  From  their 
similarity  in  size,  shape,  and  appearance,  so-called  fecal 
concretions  have  frequently  been  mistaken  for  foreign 
bodies.  It  may  be  said  that  the  occurrence  of  foreign 
bodies,  properly  so  called,  within  the  cavity  of  the  ap- 
pendix, is  exceedingly  rare,  and  probably  much  more 
so  than  has  been  usually  believed  ;  in  proof  of  this 
statement  there  are  the  following  facts  :  That  in  my 
series  of  anatomical  cases  in  no  single  instance  did  I 
find  a  foreign  body  of  any  description.  Concretions 
were  found  in  several  instances,  but  these  are  not  in- 
cluded under  the  present  term." 

In  further  proof  of  the  above  statements  the  claim 
is  made  that  "  the  anatomical  position  of  the  appendix 
renders  it  a  physical  improbability  that  any  foreign 
body,  particularly  one  the  size  of  a  cherry-stone,  or 
even  a  shot,  could  enter  the  organ."  Without  wishing 
to  discredit  the  author's  observations,  I  should  like  to 
say  that  my  own  are  not  in  accord  with  this  statement. 
While  it  must  be  admitted  as  true  of  a  large  number  of 
cases,  it  is  not  true  of  all.  The  point  of  origin  of  the 
appendix  is  variable.  In  the  majority  of  cases  which  I 
have  examined  it  has  arisen  from  the  wall  of  the 
caecum  a  little  above  its  lower  extremity,  and  in  a 
recent  autopsy  as  much  as  four  inches  above,  though 
in  others  it  has  arisen  directly  from  the  lower  end. 
Moreover,  the  direction  of  the  appendix  is  not  always 
the  same.  It  may  pass  upward  or  downward,  and  in 
almost  all  cases  where  it  has  come  off  from  the  blind 
extremity  of  the  cajcum  it  has  passed  over  the  pelvic 
brim  and  downward  into  the  pelvic  cavity.  Such  a 
point  of  origin  and  such  a  direction,  instead  of  render- 
ing it  physically  im])robable,  renders  it  probable  that  a 
foreign  body  would  enter  the  appendix.  The  action 
of  gravity  would  tend  to  carry  it  into  the  neighborhood 
of  the  opening  with  the  individual  in  the  upright  posi- 
tion.    In  the  case   under   consideration  the  point  of 

'  Pathology  of  the  Vermiform  Appendix,  by  Richard  J.  A.  Berry. 
M.D.,  Journal  of  Pathology-  and  Bacteriology,  April,  1895. 


640 


MEDICAL   RECORD. 


[November  2,  li 


origin  was  at  the  blind  extremity,  but  the  appendix 
curved  upon  itself  so  that  its  tip  lay  upon  the  promon- 
tory of  the  sacrum. 

In  the  absence  of  any  evidence  as  to  the  direction  of 
the  peristaltic  wave  in  the  human  appendix,  no  positive 
statements  can  be  made  as  to  the  assistance  it  would 
lend  in  carrying  a  body  onward.  While  in  the  intes- 
tine, as  a  whole,  the  peristaltic  wave  is,  for  the  most 
part,  in  one  direction,  it  does,  under  certain  conditions, 
travel  in  the  other.  Dr.  W.  Oilman  Thompson  tells 
me  that  in  the  appendix  of  the  rabbit  the  wave  travels 
in  both  directions,  and  this  must  be  true  of  all  animals 
in  whom  the  appendix  has  a  digestive  function  10  per- 
form. After  the  partially  digested  food  has  entered 
that  organ,  the  refuse  must  find  exit,  and  that  only  by 
reversed  peristalsis. 

In  the  present  case  the  foreign  body  is  too  large  to 
have  moved  along  the  lumen  of  the  appendix  without 
the  aid  of  muscular  contraction,  and  its  expulsion 
would  have  been  prevented  by  the  sharp,  projecting 
points.  The  fact  that  the  so-called  fecal  concretions 
(appendicular  calculi)  remain  in  the  appendix,  at  least 
long  enough  for  their  formation,  would  make  it  appear 
probable  that  the  reverse  peristaltic  wave  is  feeble,  if  it 
occurs  at  all. 


A    CASE    OF   ACUTE    THYROIDITIS. 
By  JOHN  H.  BRADSHAW,  M.D., 


Early  in  December,  1894,  I  was  consulted  by  a  young 
married  lady  for  a  sore  neck  and  throat.  A  history  of 
exposure  to  cold  was  given,  the  lady  having  taken  the 
day  previous  a  five  hours'  drive  in  an  open  carriage 
with  insufficient  clothing.  During  this  ride  she  had  re- 
peatedly expressed  herself  as  being  very  chilly.  Sore- 
ness of  the  neck  was  felt  the  same  night.  Upon  ex- 
amination of  the  neck  and  throat  nothing  abnormal  was 
seen  or  felt.  No  redness  of  the  pharynx,  no  laryngitis, 
no  swelling  of  the  tonsils  or  cervical  glands  could  be 
found  to  account  for  the  dysphagia,  which  was,  when 
seen  by  me,  the  principal  symptom  complained  of  by  the 
patjent. 

The  patient  was  told  she  suffered  from  muscular 
rheumatism,  and  was  put  on  fair  doses  of  salicylate  of 
soda  without  relief.  Even  phenacetine,  which  was  after- 
ward added,  gave  but  little  intermission  to  the  pain. 
The  dysphagia  increased,  even  talking  caused  the  pa- 
tient to  clutch  at  her  throat  with  every  evidence  of 
acute  suffering.  I  confess  I  was  puzzled  ;  but  in  the  ab- 
sence of  any  sore  throat,  properly  speaking  ;  in  the  ab- 
sence of  any  elevation  of  temperature  ;  in  the  absence 
of  any  physical  signs,  I  confidently  told  the  patient  she 
undoubtedly  had  one  of  those  obscure  forms  of  that 
strange  and  erratic  complaint  called  the  grip.  This 
seemed  to  satisfy  her  completely,  for  the  early  diagno- 
sis of  rheumatism  of  the  throat  the  patient  herself  had 
scouted. 

But  I  watched  the  case  rather  carefully.  There  was 
so  much  prostration  on  the  fifth  day  of  the  attack  that 
the  patient  took  to  her  bed.  Eating  was  now  almost  an 
impossibility  ;  she  looked  badly  and  felt  very  weak. 
It  was  only  toward  the  end  of  the  first  week  that  any 
enlargement  of  the  neck  was  to  be  seen.  By  the  tenth 
day  there  was  a  typical  enlargement  of  the  thyroid 
gland,  as  one  sees  it  in  true  goitre.  As  the  gland  en- 
larged, the  pain  in  deglutition  diminished,  and  the  pa- 
tient was  able  to  go  about  the  house  and  attend  to  her 
•duties.  During  the  next  ten  days  the  gland  grew 
smaller  and  smaller,  and  at  the  end  of  the  third  week 
from  the  attack  the  swelling  and  soreness  disappeared 
entirely. 

I  report  this  case  of  acute  thyroiditis  because  it  is 
the  first  I  have  met  with  in  my  practice,  and  because  I 


do  not  think  the  affection  receives  much  notice  in  our 
text-books  or  literature. 

The  disease  is  an  acute  disease,  running  a  regular 
course,  having  a  tendency  to  spontaneous  cure,  like  so 
many  acute  infectious  glandular  affections.  The  cause 
in  my  case  was  exposure  to  cold.  The  first  and  prin- 
cipal symptom  throughout  the  attack  was  pain  located 
in  the  thyroid  region,  with  intense  dysphagia,  some  ex- 
pectoration of  mucus,  and  afterward  enlargement  of  the 
thyroid  gland.  The  pain  is  greatest  during  the  first  of 
the  disease,  while  the  gland  is  enlarging.  The  disease 
ran  its  course  without  fever.  Whether  the  natural  ten- 
denc)'  of  the  disease  without  treatment  is  to  the  forma- 
tion of  pus,  from  the  experience  of  one  case  I  should 
think  such  not  to  be  the  case.  Local  and  internal 
medication  did  not  prevent  the  attack  lasting  three 
weeks. 

Should  I  meet  with  another  case,  and  early  recognize 
its  nature,  I  would  keep  hot  anodyne  fomentations  over 
the  thyroid  gland  ;  and  I  would  administer  aconite, 
small  doses  of  quinine,  and  enough  of  the  analgesics  to 
keep  the  patient  from  acute  suffering. 


ATROPHY    OF    THE    UTERUS. 
By    HILBERT   B.    TINGLEV,    M.D., 


I  REPORT  the  follomng  case  as  one  of  more  than  ordi- 
nary interest,  especially  as  to  the  result  : 

I  was  called  on  Saturday  morning,  August  12,  1893, 

at   about   nine    o'clock,  to   attend    Mrs.  C ,  aged 

twenty-two,  and  found  her  just  entering  upon  the  sec- 
ond stage  of  labor.  She  gave  the  following  history  : 
Some  two  years  before  she  was  delivered  of  a  large 
child,  which  '"  could  not  be  born  alive,"  and  she  had 
some  trouble  afterward  which  left  her  with  a  "'  sore 
spot "  in  the  right  side.  She  had  been  told  that  she 
could  not  be  delivered  of  a  living  child,  consequently 
she  expected  trouble  and  was  very  nervous.  Upon  ex- 
amination I  found  a  narrow  pelvis,  but  not  abnormally 
so.  The  head  was  engaged,  but  movable.  About  1 1 
A.M.  the  pains  became  weak  and  the  head  was  found 
to  be  impacted.  I  then  gave  an  anaesthetic,  and  after 
some  trouble  succeeded  in  delivering  the  woman  of  a 
fine,  big  boy.  In  a  few  minutes  I  attempted  to  remove 
the  placenta  by  the  combined  method,  but  it  refused  to 
come.  After  a  short  wait  I  attempted  to  remove  it  by 
the  hand  within  the  vagina,  but  found  it  adherent  to  al- 
most the  whole  uterine  wall,  but  principally  upon  the 
right  side  and  the  fundus,  so  firmly  that  I  could  not 
remove  it.  In  a  few  minutes  hemorrhage  began.  I 
then  sent  for  Dr.  Van  Valzah,  and  upon  consultation 
we  decided  that  the  only  thing  to  do  was  to  empty  the 
uterus  as  quickly  as  possible,  and  we  then  began  to  re- 
move the  placenta  piecemeal,  and  by  seven  o'clock  had 
removed  it  as  thoroughly  as  possible  in  the  weakened 
condition  of  the  patient  ;  we  then  irrigated  and  packed 
the  uterus  with  iodoform  gauze,  ten  per  cent. 

August  13th. — Temperature  normal  ;  patient  doing 
well. 

August  14th. — Removed  gauze,  irrigated,  and  re- 
packed. 

August  i6th. — Removed  the  gauze  and  irrigated 
each  day  until  2^th,  when  she  was  able  to  sit  up  in 
bed. 

August  26th. — About  midnight  she  had  a  severe 
hemorrhage,  which  was  checked  with  some  difficulty. 
I  then  kept  the  patient  in  bed  until  September  2d,  when 
I  gave  an  anaesthetic  and  curetted,  removing  a  large 
handful  of  fragments  of  placenta,  etc.,  after  which  the 
uterus  was  kept  packed  for  about  one  week,  being  irri- 
gated at  intervals.  The  patient  made  an  uninterrupted 
and  perfect  recovery. 


November  2,  1895] 


MEDICAL   RECORD. 


641 


In  October,  1894,  she  weaned  the  baby,  and  as  she 
had  not  menstruated  by  July,  1S95.  she  came  to  me  for 
consultation,  although  she  felt  perfectly  well.  Upon 
examination  I  found  the  cervix  gone,  the  03  appearing 
like  a  small  hole  in  the  vault  of  the  vagina,  the  ovaries 
and  tubes  almost  obliterated  and  the  uterus  in  normal 
position,  but  about  one  and  one-half  inch  long  and 
about  as  thick  as  a  man's  thumb.  Upon  attempting  to 
pass  a  sound  I  could  not  get  above  the  internal  os — in 
fact  the  uterus  and  appendages  were  almost  entirelv 
atrophied.  What  was  the  cause  of  the  atrophy  ?  The 
sexual  function  and  desire  was  unimpaired. 


a  slight  cough  when  the  tube  slipped  down  to,  and  was 
withdrawn  through,  the  incision,  .\fter  fifteen  minutes 
longer  of  forced  respiration  it  became  natural  and  the 
child  soon  regained  consciousness.  A  tracheotomy 
tube  was  procured  and  inserted  in  the  wound,  where  it 
was  allowed  to  remain  six  days.  In  spite  of  a  septic 
broncho-pneumonia  the  patient  made  a  perfect  re- 
covery. The  particular  tube  was  one  which  had  been 
used  by  me  in  three  previous  cases. 

With  a  considerable  experience  in  intubation  and 
knowledge  of  its  literature  I  have  heretofore  had  no 
fear  of  this  most  rare  accident. 


REMOVAL  OF  AX  INTUBATIOX-TUBE  FROM 
THE  BRONXHUS  BY  TR.\CHEOTOMY— RE- 
COVERY. 

Bv  CHARLES  H.   M.WO,   M.D., 

SCltGEOH  TO   ST.  5L\Ry*3   HOSPITAI ,   ROCHESTEKj  MINN. 

On  July  6,  1895,  I  was  called,  in  consultation,  by  Dr.  F. 
R   Mosse,  to  make  an  immediate  intubation  upon  H. 

F ,   a   boy    five   years   old.      He    had   been   sick 

four  days  with  an  increasing  croup  cough  and  fever, 
was  cyanotic  and  struggling  for  air,  and  although  a 
bacteriological  examination  was  not  made,  the  case  was 
one  which,  in  practice,  is  considered  and  treated 
as  membranous  croup.  The  third  in  the  series  of 
O'Dwjer's  intubation- tubes  (the  one  directed  to  be 
used  in  children  from  four  to  six  years  of  age)  was  in- 
serted, the  result  being  complete  relief  of  the  dyspnijea. 
The  head  of  the  tube  rested  well  above  the  vocal  cords, 
easy  to  reach  with  the  finger.  The  condition  of  the 
child  improved,  and  the  tube  was  removed  at  the  end 
of  the  third  day.  The  breathing  was  comparatively 
easy,  and  after  watching  the  patient  half  an  hour  it 
was  considered  safe  to  leave  the  house.  Three  hours 
later  I  was  hurriedly  called  to  reinsert  the  tube  for 
rapidly  developing  dyspnoea.  The  tube  was  allowed 
to  remain  two  days  this  time,  when  it  was  removed 
without  difficulty  ;  but,  as  before,  it  became  necessary 
to  reinsert  it  six  hours  later  for  impending  suffocation. 
Shreds  of  membrane  with  tenacious  mucus  were  loosened 
and  thrown  out  by  the  manipulation  of  finger  ard  tube. 
The  tube  was  left,  head  well  up  and  fitting  snugly  in  the 
swollen  tissues  of  the  larynx,  .\fter  remaining  fort)- 
two  hours  this  third  time,  it  was  noticeable  that  the 
breathing  was  more  difficult  and  noisy.  On  examining 
with  the  finger  I  was  surprised  not  to  feel  the  head  of 
the  tube,  and  to  find  that  the  swelling  and  oedema  of 
the  larynx  and  immediate  structures  had  disappeared. 
Reaching  further  over  into  the  cesophagus,  the  head  of 
the  tube  could  now  be  felt  in  the  trachea,  just  below  the 
vocal  cords.  The  trachea  was  compressed  about  the 
tube  and  forced  up,  while  the  extractor  was  introduced 
into  the  larynx,  the  finger  behind  the  larynx  holding 
the  tube  forward.  The  difficulties  will  be  readily 
understood  by  those  accustomed  to  intubating.  Dur 
ing  the  third  attempt  at  extraction  the  tube  was  felt  to 
slip  down  into  the  bronchus.  Efforts  at  respiration 
became  furious,  cyanosis  corning  on  rapidly,  and  it  was 
evident  that  the  tube  must  be  removed  at  once.  Im- 
mediate and  rapid  preparations  for  tracheotomy  were 
made.  The  child's  condition  had  grown  worse,  and 
respiration  had  entirely  ceased  just  before  the  first 
i'cision  of  a  low  tracheotomy.  The  operation  was 
:shed  rapidly  until  the  trachea  was  opened  and  caught 
' ;•  two  artery  clamps  at  the  sides  of  the  incision.  My 
assistant  grasped  the  child  by  the  feet  and  held  him 
head  downward.  Efforts  at  artificial  respiration  were 
now  commenced.  A  probe  was  inserted  through  the 
incision  into  the  left  bronchus,  but  coming  in  contact 
with  nothing  metallic,  it  was  passed  into  the  right  where 
it  clicked  the  lost  tube.     It  loosened  it  and  occasioned 


(Caw&svon&znce. 

OUR   PARIS   LETTER. 

(From  our  Special  Correspondent.) 

PASTEUR — L.A.RREY. 

Paris,  October  12,  1895. 

Two  great  losses  have  just  befallen  the  scientific  world 
— Pasteur,  the  illustrious  savant,  was  buried  on  Satur- 
day, a  national  funeral  having  been  accorded  him  by 
the  Government,  and  Baron  Larrey,  the  eminent  mili- 
tary surgeon,  has  since  passed  away.  A  brief  review 
of  their  remarkable  careers  well  merits  the  earnest  at- 
tention of  all  interested  in  science  and  military  sur- 
gery. 

Pasteur  was  a  quiet,  laborious  student  from  his  youth 
up,  and  after  having  gone  through  all  the  grades  except 
that  of  Doctor,  taught  chemistry  ;  he  soon  began  to 
turn  his  attention  more  especially  to  the  study  of  fer- 
mentation and  contagion,  it  being  from  this  that  his 
grand  discoveries  came.  We  arrange  them  in  the  fol- 
lowing order  :  i.  Pasteur  saw  that  contagion,  like  fer- 
mentation, was  always  the  function  of  a  living  organ- 
ism— a  microbe.  2.  In  his  experiments  with  pebrine, 
a  parasitic  disease  of  the  silkworm,  he  demonstrated 
conclusively  the  modes  of  contagion  or  penetration  of 
microbes  into  the  economy  by  alimentation,  by  con- 
tact, as  well  as  by  atmospheric  dust.  3.  Charbon- pus- 
tule maligne,  or  anthrax,  and  afterward  chicken  cholera, 
led  him  to  his  greatest  discovery,  viz.,  the  attenuation 
of  virus  and  the  fixity  of  the  different  classes  of  atten- 
uated virus,  proceeding  all  from  a  fixed  virus.  4. 
Finally,  the  treatment  of  hydrophobia  learned  us,  among 
other  things,  that  a  virus  can  be  successfully  neutral- 
ized even  after  penetration  into  our  tissues. 

Every  discovery  of  Pasteur's  was  a  struggle — for 
each  discovery  raised  him  determined  adversaries. 
The  biologists  and  physicians  resented  that  a  chemist 
should  dare  infringe  upon  their  territory,  and  one  of 
them  declared,  at  the  Academy  of  Medicine,  "  Yes, 
microbiology  constitutes  for  medicine  at  once  a  social 
and  intellectual  peril,  for  it  leads  to  homicide  and  in- 
fatuation." Pasteur  lived,  however,  to  see  his  most 
violent  opposers  become  his  most  ardent  supporters. 
Professor  Grancher  tells  us  how  his  labors  in  the  treat- 
ment of  hydrophobia  began.  He  says  :  "  I  had  been 
working  for  some  months  in  Pasteur's  laboratory  when 
he  did  me  the  honor  to  consult  me  in  the  case  of  little 
Meister.  He  was  a  boy  that  had  come  from  Alsace, 
upon  the  advice  of  Dr.  Weber,  to  be  treated  by  Pasteur. 
>Ieister  had  been  seriously  bitten  in  fourteen  different 
places  by  a  mad  dog.  But  Pasteur,  in  spite  of  his  sci- 
entific faith  in  experimental  pathology,  in  spite  of  his 
belief  in  the  identity  of  human  and  animal  physiology 
and  pathology,  hesitated  to  inoculate  Meister ;  he 
therefore  asked  Vulpian  and  myself  to  give  him  our 
opinions.  It  appeared  to  us  that  the  experiments  of 
Pasteur  authorized  him  to  obey  a  natural  sentiment  of 
humanity  and  inoculate  .Meister.     He  then  delegated 


642 


MEDICAL   RECORD. 


[November  2,  1895 


me  to  make  the  inoculations,  which  I  did,  with  more 
concentrated  virus  each  day,  under  the  skin  of  the  ab- 
domen. This  was  in  the  month  of  July,  1885,  and  the 
26th  of  October  of  the  same  year  Pasteur  communi- 
cated the  facts  to  the  Academy  of  Medicine.  A  cloud 
of  distrust  followed  the  burst  of  enthusiasm.  Then 
came  the  case  of  Jupille,  who  was  bitten  in  the  same 
month  of  the  same  year  in  the  Jura,  while  rescuing 
from  a  mad  dog  some  school  children  at  play,  and  of 
whom  a  statue  now  stands  in  front  of  the  Institute  Pas- 
teur. Jupille  was  entirely  cured,  and  is  still  an  attend- 
ant in  the  Institute.  In  1887  there  was  still  some  dis- 
trust of  the  method  upon  the  part  of  the  medical  pro- 
fession, but  the  day  soon  came  when  it  triumphed  ; 
people  belonging  to  all  nations  came  for  the  prophy- 
lactic or  curative  treatment,  and  Pasteur  Institutes 
were  established  in  different  parts  of  the  world.  Pas- 
teur's most  brilliant  experiment  was  with  the  sheep  that 
were  being  decimated  by  charbon.  His  work  for  the 
prevention  and  cure  of  Asiatic  cholera  was  not  entirely 
concluded  when  death  put  an  end  to  his  labors.  In 
speaking  to  his  class  and  co-workers,  Pasteur  had  that 
simple  but  powerful  eloquence  that  goes  to  the  soul  by 
sure  and  comforting  truths  ;  his  expressions  were  al- 
ways noble  because  he  had  noble  ideas.  He  died  hav- 
ing faith  in  a  better  humanity.  He  said  :  "I  believe 
invincibly  that  science  and  peace  will  triumph  over 
ignorance  and  war  ;  that  peoples  will  be  of  accord  not 
to  destroy  but  to  edify,  and  that  the  future  will  belong 
to  those  who  have  done  most  for  suffering  humanity." 
What  more  fitting  epitaph  for  the  world's  greatest  sci- 
entist ? 

Baron  Larrey,  father  and  son,  whose  names  have  been 
identified  with  the  Napoleonic  dynasty  for  nearly  a 
hundred  years,  was  the  student  of  Dupuytren  and  of 
his  father,  the  great  surgeon  of  the  armies  of  Napo- 
leon I. 

Professor  Agrege  of  Surgery  at  the  Faculty  of  Medi- 
cine of  Paris,  of  External  Pathology  at  Valde-Grace, 
and  Surgeon-in-chief  of  the  Military  Hospital  of  Gros- 
Caillou,  he  subsequently  became  the  physician  of  Na- 
poleon III.,  Surgeon-in-Chief  of  the  Army  of  Italy, 
President  of  the  Society  of  Surgery  and  of  the  Academy 
of  Medicine,  also  Member  of  the  Academy  of  Sciences, 
where  he  occupied  Civiale's  chair.  He  was  a  grand 
officer  of  the  Legion  of  Honor  and  attained  to  numer- 
ous other  positions  of  honor,  including  that  of  deputy 
as  well.  From  the  double  point  of  view  of  professional 
courage  and  military  virtue  he  was  a  brave  man  ;  at 
twenty-four  years  of  age  he  took  service  in  the  Picpus 
Hospital  at  the  height  of  the  terrible  epidemic  of  Asi- 
atic cholera  in  1832  ;  he  had  a  horse  killed  under  him 
at  the  battle  of  Solferino  ;  during  the  siege  of  Paris  in 
187 1  he  was  Surgeon-in-chief  of  the  besieged  armies, 
when  he  was  more  prodigal  of  his  services  than  his  rank 
demanded. 

Baron  Larrey  was  a  man  of  science  of  high  value,  and 
although  he  does  not  leave  behind  him  any  resounding 
discoveries  yet  he  has  written  voluminously,  as  his  father 
before  him  had  done,  on  military  surgery,  of  which  he 
had  become  the  apostle  and  oracle.  He  was  very 
proud  of  having  seen  the  Emperor  Napoleon  I.  at  a 
review,  to  which  his  father  took  him  in  1815.  He  was 
then  only  six  years  of  age.  After  passing  along  the 
front  line  of  troops,  he  recounts,  "  the  emperor  came 
toward  us.  My  sister,  who  was  with  me,  made  a  gracious 
courtesy,  while  I  inclined  my  head  respectfully.  Na- 
poleon I.,  who  was  accompanied  by  my  father,  addressed 
him  :  '  Are  those  your  children,  Larrey,'  and  tapping  me 
on  the  cheek  with  his  right  hand  he  added,  '  we  will 
try  and  make  something  of  him,  won't  we  ?  As  for  the 
rest,  he  has  only  to  resemble  you.'"     This  he  did. 


CHLOROFORM  WITH   OXYGEN. 

To  THE  Editor  of  the  Medical  Record* 

Sir  :  The  valuable  and  instructive  paper  of  my  friend 
Dr.  Cole,  in  your  issue  of  the  12th  ultimo,  will  doubtless 
set  many  other  surgeons  to  experimenting  with  oxygen 
combined  with  ether,  and  probably  other  anesthetics, 
and  it  is  to  be  hoped  that  their  results  will  be  recorded 
as  accurately  and  carefully  as  Dr.  Cole's  seem  to  have 
been.  The  matter  is  a  vital  one.  My  only  excuse  for 
trespassing  upon  your  valuable  space  is  that  I  have 
heard  of  a  case  which  ought  to  be  reported,  if  it  has 
not  been,  in  M-hich  oxygen  was  combined  with  chloro- 
form with  the  happiest  results. 

The  operator,  whose  name  I  do  not  know,  is  said  to 
have  produced  complete  anesthesia  in  a  feeble  old  man 
with  senile  gangrene  with  a  few  drachms  of  chloroform 
combined  with  oxygen,  so  that  he  was  able  to  ampu- 
tate the  leg  at  the  knee-joint,  the  patient  standing  the 
operation  well  and  making  a  good  recovery,  although 
the  case  was  so  unpromising  that  a  number  of  other 
surgeons  had  declined  to  operate. 

If  oxygen  will  sustain  the  heart  and  respiration,  and 
keep  up  the  anassthesia  in  feeble  and  unpromising 
cases  when  combined  with  ether,  as  it  surely  seemed  to 
do  in  the  cases  reported  by  Dr.  Cole,  is  it  unreasonable 
to  hope  that  its  combination  with  chloroform  may  ob- 
viate the  dangers  attendant  upon  the  use  of  that  more 
elegant  and  efficient  anaesthetic  .' 

Very  truly  yours, 

Richard  C.  Newton,  M.D. 

MONTCLAIR,  N.  J.,  October  21,  1895. 


"  How  is  Practice,  John  ?  " 

"  All  gone  I  She  died  last  week  !  " 


THE    QUESTION    OF    AN    INTERNATIONAL 
LANGUAGE. 

To  THE  Editor  of  the  Medical  Record, 

Sir  :  I  am  interested  and  amused  by  the  letters  on 
this  subject  appearing  in  your  columns,  and  would  not 
for  the  world  say  a  word  in  disparagement  of  either 
Greek  or  Latin.  I  love  the  former,  it  is  our  lingua 
sancta,  and  am  moderately  pleased  with  the  latter 
language,  but  when  I  see  a  correspondent  recommend- 
ing the  adoption  of  a  barbarous  dialect  of  the  grand 
old  Latin  tongue,  I  must  confess  my  blood  begins  to 
boil,  French  is  bad  enough,  but  Spanish  is  worse,  and 
practically  unintelligible  to  any  person  unacquainted 
with  Latin  or  French.  How  many  of  your  readers,  who 
know  nothing  of  the  language  of  old  Rome,  or  of  that 
of  modern  Paris,  could  make  out  a  word  of  the  para- 
graph given  by  your  correspondent  in  what  he  fondly 
assumes  to  be  Spanish  ?  Not  one,  I  venture  to  say, 
bar  the  word  "  gonorrea,"  which,  of  course,  is  Greek 
pure  and  simple.  Is  it  not  a  fact  that  considerably 
over  one  hundred  millions  of  people  to-day  speak 
and  write  English,  and  its  use  is  spreading  daily 
and  hourly ;  there  is  a  ready  -  made  international 
language  for  you,  and  what  more  can  anybody 
want  ? 

I  dare  say  the  Frenchman  and  the  German  would 
squirm  at  the  idea — let  them — their  fancies  do  not  alter 
facts  ;  both  nations  have  annexed  many  of  our  words, 
and  now  that  the  L^nited  States  are  increasing  their 
population  by  leaps  and  bounds  ;  that  a  great  English- 
speaking  nation  is  springing  up  in  South  and  Central 
Africa  and  another  in  .\ustralia  ;  that  Russia  has  made 
the  teaching  of  English  obligatory  in  her  schools  ;  that 
the  Japanese  have  done  the  same,  and  almost  adopted 
it  as  their  national  tongue  ;  that  it  is  daily  becoming 
more  familiar  to  the  millions  of  India,  I  consider  it 
is  very  bad  taste  and  shows  a  great  deal  of  ignorance 
on  the  part  of  any  English-speaking  person  to  stand 


I 

I 


1 


Xovember  2,  1S95] 


MEDICAL    RECORD. 


64: 


■up  and  advocate  its  being  forsaken  by  those  whose 
language  it  is  in  favor  of  any  other,  new  or  old. 

Even  in  diplomatic  circles  English  is  gaining  ground, 
and  I  venture  to  predict  that  before  the  end  of  the 
next  century  English  will  be  the  language  of  the  world. 

It  is  nor  a  perfect  language,  perhaps,  but  it  is  a 
good,  practical  one.  I  remember  when  I  was  in 
Australia  a  French  blacksmith  on  the  diggings  (a 
Parisian  by  the  way)  once  said  to  me  :  "  Without  Eng- 
lish the  work  of  the  mines  could  not  be  got  through. 
A  Frenchman  comes  into  my  forge  and  he  says  to  me, 
'  Bonjour,  monsieur,  voulez-vous  me  faire  une  pointe  a 
ciseau  (ou  aigiie),  a  ce  pic  ? '  What  circumlocution  ! 
An  Englishman  comes,  holds  up  his  pick,  and  says, 
'  Square  '  (or  '  round  '),  et  tout  est  dit  I  " 

Perhaps  your  readers  can  apply  the  moral,  but  for 
goodness'  sake  let  us  hear  no  more  about  the  want  of 
an  international  language  ;  we  have  one — English — 
and  so  much  the  worse  for  those  who  are  too  proud  or 
too  stupid  to  use  it.     Yours,  etc., 

W.  T.  Greene,  M.D. 

UeLVEDERE,  Kent,  Engl.\kd,  October  10,  1S95. 


THE   CURVED    CAPSULE    KNIFE. 

To  THB  Editor  of  the  Medicai,  Record. 

Sir  :  The  undersigned  has  an  especial  reason  to  feel 
flattered  by  the  distinguished  mark  of  appreciation 
bestowed  upon  an  instrument  designed  by  him  several 
years  ago,  and  described  in  the  Medical  Record  of 
September  28,  1895,  in  that  Dr.  John  E.  Weeks,  of  New 
York,  has  concluded  to  appropriate  (by  inference)  the 
paternity  of  the  design,  under  the  name  of  "  A  Knife- 
needle,"  etc.,  in  the  Medical  Record  of  September 
28th.  This  knife  was  made  for  me  by  Tiemann  four  or 
five  years  ago,  and  has  been  used  by  me  ever  since  as  a 
better  instrument  for  its  purpose  than  the  straight  cap- 
sule knife,  commended  by  H.  Knopp.  To  save  space, 
I  described  the  knife,  together  with  a  slight  modifica- 
tion of  it  designed  for  operations  on  the  membrana 
tymparii,  well  knowing  that  any  instruction  to  those 
competent  to  use  such  a  knife,  as  to  the  method  of  use, 
would  be  entirely  unnecessary.  Mr.  E.  B.  Meyrowitz, 
who  obtained  from  me  the  model  after  which  the  in- 
strument delineated  on  page  467  of  the  Medical 
Record  has  been  constructed,  in  asking  me  to  de- 
scribe the  two  instruments,  i.e.,  capsule  knife  and 
tympanic  knife,  furnished  me  with  only  one  cut,  and 
that  is  how  I  came  to  speak  of  both  knives  under  one 
caption.  The  ophthalmic  surgeon  will  find  the  use  of 
the  curved  capsule  knife  to  be  attended  with  fewer 
difficulties  than  that  of  the  straight  knife.  In  certain 
cases  a  knife  with  a  very  much  greater  curvature  to  its 
blade  than  that  shown  in  the  cut  of  my  capsule  knife, 
might  be  used  to  great  advantage,  and  the  principle  of 
the  inclined  plane  be  still  further  ])roduced  in  the 
knife  ;  the  mechanism  through  which  curved  blades 
cut  being  well  known  to  all  surgeons. 

The  discission  knife  devised  by  me,  and  which 
Meyrowitz  himself  saw  me  operate  with  more  than  two 
years  ago,  at  which  time  I  explained  to  him  its  ad- 
vantages over  Knopp's  knife  and  also  the  lechniijue  of 
its  use,  has  not  a  two-edged  point.  The  two-edged 
point  exploited  by  Dr.  Weeks,  in  his  description,  is  not 
an  advantage  but  the  contrary.  The  back  of  the  knife 
must  be  closely  applied  to  the  corresponding  angle  of 
the  corneal  wound,  and  the  whole  thickness  of  the 
cornea  is  the  pivot  along  which  the  blade  glides  as  it 
enters  the  anterior  chamber,  there  being  just  sufficient 
division  of  tissue  effected  by  the  cutting  edge  to  pro- 
vide space  for  the  entrance  of  the  blade.  The  trian- 
gular wound  is  exactly  filled  by  the  blade  and  subse- 
quently by  the  shank.  Now,  if  the  initial  puncture 
has  any  other  shape  than  that  of  the  blade  of  the  knife. 


there  will  result  a  minute,  in  this  case  triangular,  space 
between  the  back  of  the  knife  and  the  corresponding 
angle  of  the  wound,  -\gain,  the  sweep  of  the  handle, 
made  necessary  to  maintain  the  tangent  as  between 
the  blade  and  the  plane  of  the  cornea,  as  the  anterior 
chamber  is  entered,  wiU  inevitably  cause  the  edged 
back  of  the  knife  to  cut,  which  is  not  desired. 

The  increased  intra-ocular  tension  induced  by  the 
pressure  of  the  fixation  forceps,  and  the  pressure  of 
the  point  of  the  knife,  together  with  a  faulty  incision, 
will  result  often  in  escape  of  aqueous.  This  in  turn 
embarrasses  the  surgeon,  increases  the  difficulties  of  the 
operation  and  the  danger  to  the  patient,  and  may 
necessitate  the  abandonment  of  the  operation  for  the 
time.  It  may  be  claimed  that  the  double-edged  knife 
is  easier  of  introduction  than  the  one  properly  made, 
and  this  claim  is  too  puerile  to  discuss. 

Cornelius  AVilli.\ms,  M.D. 

St.  Paul,  Minn.,  October  i,  1895. 


REQUIREMENTS      FOR      INSANE      ASYLUM 
PHYSICIANS. 

To  THE  Editor  of  the  Medic.u.  Record, 

Sir  :  After  reading  Dr.  McClain's  article  I  would 
suggest  the  following  notice  for  insertion  in  the  medi- 
cal journals  when  a  vacancy  occurs  in  any  insane  hos- 
pital : 

Vacancy. — The  posirion  of  Junior  Assistant  at  the 
Blank  Asylum  is  vacant.  Applications  will  be  received 
by  the  Superintendent  for  the  next  six  months.  Ap- 
plicants must  be  expert  surgeons,  specialists  in  eye  and 
ear,  nose  and  throat,  brain,  lungs  and  heart,  liver  and 
stomach,  diseases  of  women,  etc.  Applicants  must  not 
be  identified  with  any  political  party  or  have  any  \-iews 
on  the  polirical  questions  of  the  day,  and  must  not  be 
under  forty-five  years  of  age.  The  salary  is  si.x  hun- 
dred dollars  a  year,  including  board  and  washing. 
Respectfully, 


Indianapous,  Ind 


F.  M.  Wiles,  M.D. 


ALKALINE    INJECTIONS    IN    GONORRHCEA. 

To  THB  Editor  op  the  Medicai.  Record. 

Sir  :  In  the  Medic.\l  Record  of  September  7th  there 
appears  an  article  on  gonorrhoea  by  Dr.  Philip  Jaisohn. 
In  speaking  of  the  mixed  infection  in  this  form  of  ureth- 
ritis he  writes  :  "  There  is  nothing  which  will  destroy 
these  pyogenic  cocci  more  effectually  than  the  solution 
of  bichloride  of  mercury."  "  For  this  purpose,"  he 
says,  "  I  use  the  mercurial  solution  at  the  strength  of 
one  to  ten  thousand,  making  this  alkaline  by  adding 
liquor  potassii  at  the  proportion  of  one-half  drachm  to 
the  ounce." 

I  wish  to  call  his  attention  to  the  fact  that  his  injec- 
tion contains  no  bichloride  of  mercury  whatever.  The 
mixture  consists  of  a  solution  of  chloride  and  hydrate 
of  potassium,  with  a  precipitate  of  the  yellow  oxide  of 
mercury.  The  last  salt  may  be  a  good  application  in 
gonorrhoea,  but  if  it  is  desired,  in  this  case,  a  "  shake  " 
label  must  be  put  on  the  bottle.  When  solutions  of 
the  caustic  alkalies  are  mixed  with  solutions  of  salts  of 
mercury,  the  oxide  of  mercury  is  formed,  which,  being 
insoluble,  is  thrown  down  in  the  form  of  a  precipitate 
thus  :  HgCI,  +  2KHO  =  HgO  -t-  2KCI  +  H,0.  This 
is  not  written  with  a  desire  to  be  over-critical ;  chemi- 
cal incompatibilities  in  prescriptions  may  be  allowable, 
or  even  sometimes  desirable.  Long  experience  in  com- 
pounding prescriptions  has  led  me  to  believe  that  doc- 
tors are  very  prone  to  lose  sight  of  the  fact  that  chemi- 
cal compounds  may  not  partake  of  any  of  the  properties 


644 


MEDICAL   RECORD. 


[Xovember  2,   1895 


of  their  factors.  If  good  results  are  obtained  frcm  any 
treatment,  it  is  desirable  that  we  trace  the  results  to 
the  real  cause.  A  physician  once  came  into  a  drug 
store  and  asked  me  to  compound,  quickly,  a  prescrip- 
tion containing  ammonium  carbonate.  As  I  rubbed 
up  the  salt  with  the  menstruum  in  the  mortar,  he  be- 
came impatient  and  said  :  "  Now,  I'll  give  you  a 
pointer  ;  just  add  a  little  acetic  acid  to  that  and  it  will 
dissolve  without  trouble."  To  my  protest  that  the 
therapeutic  effect  might  not  be  the  same  he  replied  : 
"\ou  put  the  carbonate  of  ammonia  in,  it  must  be 
there,  so  what's  the  difference .'  A  little  acetic  acid 
will  do  no  harm."  Yours  very  truly, 

D.  H.  Gallow.w,  Ph.G.,  M.D. 

Chicago,  Oclober  13,  1895. 


J>ocictu  §l^orts. 

MEDICAL    SOCIETY    OF    THE    COUNTY    OF 
NEW   YORK. 

A  tin II al  Meeting,  October  28,  iSgj. 

Egbert    H.    Grandin,    M.D.,    President,    in    the 
Chair. 

The  meeting  was  devoted  to  the  reading  of  reports, 
election  of  officers,  and  executive  and  new  business. 
The  Treasurer's  report  showed  a  smaller  balance  than 
at  the  close  of  last  year.  The  Committee  on  Hygiene 
made  no  report.  The  report  of  the  Board  of  Censors 
consisted  of  the  report  of  the  Counsel  of  the  Society, 
Mr.  Taylor.  Only  five  hundred  dollars  had  been  col- 
lected as  fines  against  illegal  practitioners  during  the 
year,  but  the  way  had  been  made  easier  for  the  en- 
forcement of  the  law  in  the  future.  It  would,  how- 
ever, involve  much  work,  no  less  work,  indeed,  than  in 
the  past. 

Action  of  Commissioners  of  Public  Cliarities  and  Cor- 
rection Condemned. — By  unanimous  consent  Dr.  N.  E. 
Brill  was  permitted  to  offer  a  resolution  out  of  the 
regular  order  of  business. 

IVhereas,  The  Commissioners  of  Public  Charities 
and  Correction  have,  without  preferring  charges  against 
them,  abolished  the  consulting  and  medical  boards  of 
ceptain  hospitals  (named)  ;  and, 

IVhereas,  These  Commissioners  have  conferred  upon 
the  College  of  Physicians  and  Surgeons,  University 
Medical  College,  Bellevue  Medical  College,  and  Fourth 
Division  of  Bellevue  Hospital  the  power  to  fill  all 
vacancies  upon  the  medical  boards  of  these  hospitals, 
and  to  appoint  all  internes  in  these  hospitals  ;  and, 

UViereas,  The  colleges  named  are  incorporated  insti- 
tutions, and  their  faculties  with  the  Fourth  Division  of 
Bellevue  Hospital  are  composed  of  less  than  one  hun- 
dred physicians  ;  and. 

Whereas,  There  are  in  the  county  of  New  York 
about  three  thousand  physicians  ;  and, 

Whereas,  These  three  thousand  physicians  are  ex- 
cluded from  positions  upon  the  medical  boards  of  the 
hospitals  mentioned,  as  well  as  of  Bellevue  and  Harlem 
Hospitals,  except  by  courtesy  of  the  faculties  of  the  in- 
corporated colleges  and  the  Fourth  Division  of  Bellevue 
Hospital  ;  and. 

Whereas,  These  hospitals  are  county  hospitals,  sup- 
ported by  the  tax-payers  of  the  county  ;  be  it 

Resolved,  That  we,  the  Medical  Society  of  the  County 
of  New  York,  protest  against  this  outrage  upon  the 
medical  profession  of  the  county  of  New  York,  and 
condemn  this  action  of  the  Commissioners  in  delivering 
to  these  incorporated  colleges  three- fourths  of  the  ap- 
pointments upon  the  consulting  and  medical  boards  of 
those  hospitals  to  whose  support  the  profession  at 
large,  as  tax-payers,  contribute. 

The  resolution  was  adopted  with  scarcely  a  dissent- 


ing voice,  and  the  President  was  given  power  to  appoint 
a  committee  of  five,  himself  a  member  of  it,  to  carrj' 
the  resolution  at  once  to  the  Commissioners  and  the 
Mayor. 

Eights  of  Free  Speech  to  be  Defended. — The  Society 
in  executive  session  decided  to  defend  Dr.  Van  Fleet 
in  the  suit  brought  against  him  by  a  refracting  optician 
for  some  remarks  made  in  relation  to  the  latter's  ad- 
vertisement in  the  Medical  Directory. 

Officers. — The  following  were  elected  to  office: 
President,  E.  D.  Fisher  ;  First  Vice-President,  Frederic 
Peterson  ;  Second  Vice-President,  J.  H.  Fruitnight  ;  Sec- 
retary, C.  H.  Avery  ;  Assistant  Secretary,  W.  E.  Bullard  ; 
Treasurer,  John  S.  Warren  ;  Censors,  B.  F.  Curtis,  E. 
H.  Grandin,  S.  D.  Powell,  A.  M.  Jacobus,  C.  L.  Gib- 
son. Thirty-five  delegates  were  elected  to  the  State 
Medical  Society. 

Dr.  R.  A.  Murray,  of  the  Committee  on  Prize  Es- 
says, stated  that  no  essay  had  been  received  deetned 
worthy  of  the  prize. 

Dr.  E.  B.  Bronson  read  the  report  of  the  Committee 
on  Ethics.  Charges  had  been  brought  against  several 
members  for  violating  Chapter  XVI.  of  the  By-Laws, 
relating  to  afiixing  one's  certificate  to  proprietary  arti- 
cles, etc.  Little  could  be  done  except  call  the  atten- 
tion of  the  offenders  to  the  by-laws,  and  receive  their 
apologies. 

A   NEW   NASAL   SEPTUM   KNIFE.' 
By  SAMUEL  GOLDSTEIN,  M.D., 

NEW  YORK. 

ATTENDING  SURGEON,  NEW  VORK  THROAT  AND  NOSE  HOSPITAL ;  ASSISTANT 
VISITING  SURGEON,  INFANTS*  AND  CHILDREN'S  HOSPITAL,  RANDALL'S  ISLAND, 
NOSE,  THROAT,   AND   E.AR  DIVISION,   ETC. 

This  instrument,  that  I  with  pleasure  place  before  you, 
will,  I  hope,  receive  the  benefit  of  your  favorable  atten- 
tion. The  simplicity  of  construction,  ease,  and  expedi- 
tion with  which  it  can  be  manipulated,  and  facility 
in  taking  it  apart  for  cleaning,  will  at  once  be  manifest 
to  you.  The  knife  consists  of  a  staff,  at  the  proximal 
end  of  which  is  a  ring  for  the  thumb  ; 
near  its  distal  extremity  the  staff  is 
made  wider  and  perforated.  The  per- 
foration is  of  such  size  and  shape  as 
to  allow  it  to  pass  over  growths  of  any 
kind  usually  seen  on  the  septum.  Be- 
low this  perforation  is  a  slit,  to  allow 
the  passage  of  the  blade  of  the  knife, 
which  has  perfect  freedom  of  motion 
in  two  grooves,  one  on  each  side  of  the 
staff. 

The  cutting  edge  of  the  staff  is  con- 
vex, very  sharp,  and  so  curved  as  to  fit 
around  the  growth,  before  it  is  pushed 
home  in  the  act  of  cutting  ;  the  two  ! 
ends  of  the  knife  are  blunt,  in  order 
the  more  surely  to  avoid  any  damage 
to  the  mucous  membrane  of  the  parts 
not  included  in  the  growth.  There 
are  two  rings  on  the  staff,  one  on  each 
side,  for  the  index  and  middle  fingers  ; 
fj  these  rings  allow  the  operator  to  keep 
a  firm  hold  of  the  instrument,  when  in  ^; 
position  over  the  growth  that  is  to  be  -* 
removed. 

The  thumb-ring  at  the  proximal  end 
of  the  staff  is  fastened  by  a  screw,  so 
that  it  can  be  removed  when  taking 
the  instrument  apart.  The  purpose  of 
making  this  ring  detachable  is  to  allow 
the  blade  of  the  knife  to  be  easily  pushed  forward, 

'  Presemeci  before  the  Metropolitan   Medical  Society,  September 

24,  1805. 


Xovember  2,    1895] 


MEDICAL    RECORD. 


645 


and  removed  from  the  staff  of  the  instrument  lor 
■cleansing. 

The  method  of  using  the  instrument  is  as  follows  : 
The  nose  is  examined,  the  growth  located  ;  the  knife 
is  placed  in  position,  completely  surrounding  the 
growth  ;  the  thumb,  in  the  ring  at  the  end  of  the  staff, 
is  pushed  forward  from  the  operator  (the  index  and 
middle  fingers  in  the  rings  on  each  side  of  the  staff, 
pressing  the  instrument  tightly  against  the  septum), 
and  the  growth  is  cut  through,  and  may  then  be  re- 
moved with  any  nasal  forceps. 

To  me,  this  septum  knife  has  made  the  operation 
simplicity  itself  ;  there  need  be  no  scraping,  or  curet- 
ting, or  boring,  or  mangling  of  the  mucous  membrane, 
or  fear  of  the  danger  of  perforating  the  septum. 

The  operation  is  done  with  ease  and  rapidity,  and  is 
consequently  painless  under  the  usual  cocaine  anaes- 
thesia, as  it  consumes  so  little  time. 

The  septum  knife  is  adjustable  for  growths  of  any 
size  or  consistency,  and  may  be  employed  equally  well 
■on  either  side  of  the  septum.  My  plans  have  been 
very  accurately  carried  out  bv  Messrs.  George  Tiemann 
A:  Co. 

East  Ninety-third  Street, 


A  NEW  NASAL  SAW. 
By  H.    DUDLEY  YOUNG,  M.D., 

BOSTON',    MASS. 

Acco.MP.\NyiN"G  is  a  diagram  of  a  nasal  saw,  I  recently 
■designed  for  the  removal  of  small  cartilaginous  and 
■osseous  outgrowths.  The  blade  is  less  than  a  milli- 
metre thick,  three  millimetres  wide,  and  about  one  inch 
and  one-quarter  in  length,  probe-pointed,  and  attached 
to  a  straight  handle,  which  is  of  metal,  nickel-plated.    In 

the  experience  of  the  writer  the  obtuse-angle  handled 
instruments,  while  allowing  a  better  view  during  an 
operative  procedure,  are  not  so  easily  controlled. 

The  advantages  claimed  for  this  saw  are  its  short, 

narrow  blade,  with    probe-point,    and    long    straight 

>i'indle,  all  of  which  make  it  a  convenient  instrument 

the  removal  of  outgrowths  from  any  portion  of  the 

.us  The  cut  represents  the  saw  at  about  one-half  its 
actual  size. 

Acknowledgment  is  tendered  Messrs.  Feick  Brothers, 
Pittsburg,  Pa.,  whose  superior  workmanship  has  en- 
■abled  me  to  place  this  little  instrument  in  the  hands  of 
the  iirofession. 


*uv0tcal  ^ungcBtions. 

Malignant  Disease  of  the  Rectum. — In  choosing  be- 
tween extirpation  and  colotomy,  it  is  necessarj-  to  con- 
sider the  compass  of  the  disease,  hence  the  extent  of 
the  operation  and  the  ability  of  the  patient  to  go  safely 
through  with  it.  When  the  neoplasm  is  of  limited  ex- 
tent, movable,  and  easily  approached  by  the  dorsal 
incision,  and  the  patient  in  a  fair  general  condition, 
extirpation  is  to  be  preferred  ;  in  other  cases,  colotomy. 
It  must  be  remembered  that  a  rectum  after  the  opera- 
lion  of  extirpation  is  seldom  a  perfect  one  in  function, 
and  that  we  often  pay  a  high  price  in  the  way  of  risk 
for  the  choice  between  incontinence  in  the  perineum 
and  incontinence  in  the  groin.  I  think  it  safe  to  say 
that  in  the  near  future  colotomy  will  be  made  oftener 
and  earlier  the  world  over. — Ev.axs. 

Dr.  A.  Leveran,  who  was  an  army  surgeon  at  Algiers, 
was  the  first  to  observe  in  blood  taken  from  malarious 
soldiers,  pigmented  discoid  bodies,  and  also  spherical 
pigmented  bodies  possessing  flagella,  whose  extremely 
rapid  and  varied  movements  left  no  doubt  as  to  their 
nature  ;  this  was  on  November  6,  1880. 

The  Treatment  of  Chancroids  in  Women. — After  an 
extensive  trial  of  other  remedies.  Dr.  Herff  expresses  a 
preference  for  liquefied  carbolic  acid,  which  he  has 
successfully  em{)loyed  in  over  one  hundred  cases.  His 
manner  of  procedure  is  as  follows  :  After  careful  disin- 
fection of  the  genitals,  with  sublimate  solution,  the 
ulcers  are  dried  with  cotton,  and  then  lightly  touched 
with  carbolic  acid,  any  excess  being  wiped  off  with 
cotton.  If  the  ulcers  are  verj'  large  and  situated  in  the 
vicinity  of  the  clitoris  or  urethra,  previous  cocaining  is 
advisable.  The  after-treatment  consists  of  sitz-baths, 
and  irrigation  of  carbolic  acid  or  permanganate  of 
potash  solutions.  .\t  the  end  of  four  or  five  days,  the 
majority  of  the  ulcers  have  begun  to  cica- 
trize, although  it  may  be  necessary  to  cauter- 
ize one  or  more  which  refuses  to  heal.  If 
the  adjacent  lymphatic  glands  are  already  affected, 
this  usually  subsides  spontaneously  in  a  short  time. 
Occasionally  rest  in  bed  maybe  required. — ^fonatscJlr. 
f.  Geburtsh.  and  Gyntxkol. 


pXedicHiI  gtems. 

Contagious  Diseases — "Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  October  26,  1895. 


Caies.    I  Deatiu. 


Free  Medical  Treatment  and  Tea. — A  Liverpool  gro- 
has  issued   a  circular   to  his  hoped-for  customers 
jeing  to  provide  them  with  free  medical  attendance 
never  they  may  fall  ill,  the  only  condition  being 
:  they  purchase  a  quarter  of  a  pound  of  tea  each 
k.     The   intending   patient   must   have  bought   a 
ifter  of  a  pound  a  week  for  at  least  four  weeks  be- 
:  ■  he  can  avail  himself  of  the  free  treatment,  and  it 
'ails  to  buy  his  tea  for  two  weeks  in  succession  he 
i  forfeit  all  right  to  the  services  of  the  grocer's  medi- 
ciil  assistant.     In  the  circular  announcing  this  wonder- 
ful scheme  are  the  names  and  addresses  of  the  medical 
men  who  are  ready  to  further  the  enterprising  grocer's 
advertising  dodge  by  contracting  with  him  to  treat  his 
•customers. 

Professor  Schede,   Director  of  the  Surgical  Depart- 
ment of  the  Hamburg  General  Hospital,  has  been  ap- 
nted  to  the  Chair  of  Surgery  in  the  fni versify  of 
nn,  in  succession  to  Professor  Trendelenburg. 


Tuberculosis    jo2  113 

Typhoid  fever 67  9 

Scarlet  fever 45  3 

Cerebro-spinal  meningitis 2  6 

Meailcs 51  7 

Diphtheria 175  38 

Small-pox I  I 


The  Dispensary — A  Disease  of  the  Body  Politic. — 

Julius  Weis.^,  M.D.,  New  York,  writes  ; 

Synonyms. — Out-door  department,  ante  and  post-grad- 
uate's reservoir,  embryonic  specialists'  and  writers'  El- 
dorado, etc. 

Definition. — A  chronic  contagious  disease,  manifested 
by  degeneration  and  atrophy  of  the  pocket-books  of 
the  bulk  of  physicians  and  druggists,  and  by  peculiar 
cerebral  developments  in  patients,  as,  hallucinations  of 
poverty  and  delusions  of  getting  something  for  nothing. 

Pathogenesis  and  Etiology. — The  chief  factor  in  cau- 
sation is  the  desire  of  building  up  a  reputation  as  a 


I 


646 


MEDICAL   RECORD. 


[November  2,  1895 


specialist  by  increased  opportunities  for  observation 
and  experience  and  the  naturally  accompanying  finan- 
cial gain. 

About  twelve  years  ago,  after  a  meeting  of  the  Ger- 
man Medical  Association  on  Second  Avenue,  a  few  of 
us  retired  to  a  cosey  refreshment  place,  and  the  scheme 
of  launching  the  German  Polyclinic  was  hatched. 
Each  colleague  that  joined  the  corporation  thought  it 
expedient  to  contribute  $100.00  C.  O.  D.  Since  that 
time  the  usual  Board  of  Directors  and  other  parapher- 
nalia have  appeared  and  tertiary  symptoms  developed 
in  the  shape  of  St.  Mark's  Hospital.  Six  years  ago  a  col- 
league called  on  me  to  assist  him  in  starting  the  East-side 
Dispensary,  327  East  Third  Street.  He  was  shocked 
to  learn  that  foreign  doctors  were  reducing  medical  fees 
to  twenty-five  cents.  How  much  better  to  treat  people 
free  of  charge  !  A  faculty  was  gathered,  per  capita 
tax  of  §35. 00  was  imposed,  and  another  successful  in- 
stitution is  the  result.  The  inevitable  tertiary  symp- 
toms will  follow,  as  a  hospital  is  threatened.  On  the 
West  Side  we  had  considerable  trouble.  We  had  about 
§25,000  (collected  from  philanthropic  citizens).  But 
business  in  the  old  building  of  the  German  West-side 
Dispensary  was  bad.  A  new  set  of  doctors  took  hold 
of  the  matter,  and  erected  a  beautiful  centre  for  pau- 
perization in  Forty-second  Street,  between  Eighth  and 
Ninth  Avenues.  From  last  reports  business  has  im- 
proved considerably.  These  few  instances  will  suffice 
to  illustrate  the  contagiousness  of  the  disease,  and  the 
nature  of  the  disease  germ,  viz.,    competition  and  gain. 

Symptoms. — These  vary  according  to  the  severity  of 
the  ailment.  In  some  dispensaries  as  the  East  Side, 
Good  Samaritan,  Bellevue,  Centre  Street,  Grove  Street, 
Northwestern,  the  deserving  poor  form  ninety-five  per 
cent,  of  the  number  of  patients  treated.  In  others,  as 
the  New  York  Hospital,  Vanderbilt  Clinic,  Manhattan 
Eye  and  Throat,  Presbyterian,  New  York  Polyclinic,  the 
number  of  deserving  poor  is  probably  only  twenty  per 
cent.  The  Mt.  Sinai  and  German  Dispensaries  also  treat 
a  large  number  of  undeserving  people.  In  the  New 
York  Hospital,  out-door  patients  pay  one  dollar  initia- 
tion fee.  But  practically,  since  such  patients  seldom 
return  a  second  time,  this  so-called  charitable  insti- 
tution charges  as  much  as  the  ordinary  practitioner. 
The  Yanderbilt  Clinic  has  injured  the  West-side  practi- 
tiQner  very  noticeably.  While  the  purses  of  the  attend- 
ing staff  undergo  a  peculiar  fatty  infiltration,  those  of 
the  majority  of  doctors  suffer  fibroid  changes  and  con- 
sequent atrophy  and  shrinkage. 

Therapeusis. — A  committee  might  be  appointed  by 
our  medical  societies  to  investigate  the  true  state  of 
affairs  in  various  dispensaries,  and  prepare  a  full  report 
upon  the  same.  Some  practical  remedy  may  possibly 
be  suggested  by  such  a  body.  The  Charity  Organization 
Society  will  be  of  great  aid  in  such  an  investigation. 
Prophylaxis  in  the  way  of  discouraging  future  unneces- 
sar)'  institutions  may  be  tried.  Above  all,  physicians 
ought  to  insist  upon  'getting  paid  for  their  work,  and 
not  allow  a  false  sense  of  pride  and  dignity  to  breed 
among  the  people  an  habitual  misconception  that  the 
service  of  doctors  are  not  to  be  paid  like  those  of  the 
lawyer,  engineer,  or  mechanic.  Loose  business  methods 
among  physicians,  more  than  dispensaries,  create  a  sen- 
timent of  financial  valuelessness  of  medical  work.  The 
very  men  who  shout  against  dispensaries  send  well-to- 
do  patients  there  for  treatment  by  specialists.  In  brief, 
reform  must  come  from  harmonious  co-operation 
among  practitioners  themselves. 

The  Beginning  of  Structural  Disease. — In  the  treat- 
ment of  organic  or  structural  diseases,  as  of  the  nervous 
system,  the  blood-vessels,  and  various  vital  organs,  the 
fact  is  quite  generally  overlooked  that  the  structural 
change  is  a  consequence,  and  not  an  actual  disease. 
The  real  disease  is  the  morbid  process  which  has  re- 
sulted in  the  tissue-change.  Nothing  could  be  more 
unphilosophical  than  the  limitation  of  the  therapeutic 


efforts  to  such  measures  as  may  be  supposed  to  be  cal- 
culated to  affect  favorably  the  morbid  structures.  A 
rational  mode  of  treatment  must  be  based  upon  a  rec- 
ognition of  the  producing  cause  of  the  morbid  changes 
which  have  taken  place.  The  researches  of  Bouchard 
and  other  modem  investigators  have  thrown  great  light 
upon  this  subject,  and  have  placed  upon  more  than 
probable  grounds  the  theor)'  that  the  presence  in  the 
blood  and  tissues  of  various  morbid  substances  of  a 
toxic  character,  such  as  uric  acid,  and  various  leuco- 
maines  and  ptomaines,  originating  in  the  tissues  as  the 
result  of  imperfect  oxidation  or  absorbed  from  the  ali- 
mentary canal  wherein  they  are  produced  by  microbic 
action  and  morbid  digestive  processes,  constitutes  the 
real  morbid  entity  in  a  large  number  of  organic  or  struct- 
ural maladies,  especially  those  of  the  nervous  system 
and  kidneys.  In  the  treatment  of  these  affections,  it 
is,  then,  of  the  utmost  importance  that  the  physician 
should  look  carefully  after  the  processes  of  digestion 
and  respiration.  These  are  the  two  great  means  by 
which  the  blood  is  to  be  purified.  The  exclusion  from 
the  dietary  of  poisonous  substances,  and  of  such  food 
substances  as  readily  undergo  putrefactive  processes  in 
the  alimentary  canal,  and  the  introduction  of  an  in- 
creased quantity  of  oxygen  whereby  the  poisons  result- 
ing from  morbid  tissue-changes  may  be  destroyed  by 
oxidation,  constitute  the  most  important  measures  for 
combating  the  onward  march  of  an  organic  affection. 
Remedies  of  any  sort,  if  aimed  directly  at  the  morbid 
tissue  itself,  will  fail  to  accomplish  anything  more  than 
temporary  palliation,  unless  combined  with  measures 
which  strike  at  the  root  of  the  disease.  An  ideal  mode 
of  treatment  will  necessarily  include  both  classes  of 
remedies.  Bacteriology  and  physiological  chemistry 
are  opening  up  for  us,  almost  daily,  new  lines  of  thought, 
new  methods  of  treatment,  and  new  possibilities  of 
cure. — Modern  Medicine. 

The  Last  Illness  of  Pasteur. — Pasteur  was  a  striking 
example  of  the  fact  that  sometimes  a  person  may  have 
a  cerebral  hemorrhage  and  live  many  years,  there- 
after doing  the  very  best  work  of  his  life.  Pasteur  was 
first  attacked  with  a  hemorrhage  in  1S68,  twenty-seven 
years  ago.  But  it  left  scarcely  any  traces,  and  he  con- 
tinued in  good  health  until  18S8,  when  his  health  began 
to  decline.  It  was  about  this  time  that  he  was  made 
the  object  of  the  most  violent  attacks  from  many  mem- 
bers of  the  medical  profession  and  the  scientific  world, 
on  account  of  his  claims  regarding  the  prevention  of 
rabies.  In  1S92  he  had  several  attacks  of  uraemia,  and 
at  that  time  he  was  found  to  have  some  cardiac  lesion. 
His  last  illness  was  due  to  a  sudden  accession  of  urae- 
mia, with  very  intense  dyspnoea,  and  a  feeble  and  ir- 
regular pulse.  He  succumbed  within  a  few  hours  after  ^ 
the  attack  came  on. 

The  Late  Dr.  Henry  W.  Band. — At  a  meeting  of  the 
College  Faculty  of  the  Long  Island  College  Hospital, 
held  October  8,  1895,  the  following  report  was  unani- 
mously adopted  :  "  The  Committee  appointed  at  the  last 
meeting  of  the  Faculty  to  take  action  in  regard  to  the 
death  of  Professor  Henry  W.  Rand,  submits  the  follow- 
ing :  The  pain  at  parting  from  our  beloved  associate. 
Professor  Rand,  cannot  be  expressed  in  words.  We 
can  only  say  that  his  loss  is  deeply  felt,  and  that  our 
sorrow  is  as  profound  as  was  our  love  for  him.  Our 
admiration  for  the  man  was  the  highest  and  most  en- 
during, and  was  inspired  by  his  many  noble  qualities 
of  head  and  heart.  In  all  his  relations  to  us,  the  teach- 
ing Faculty  of  this  institution,  he  was  always  honest, 
honorable,  earnest,  and  competent.  He  was  securely 
established  upon  the  highest  plane  of  professional  suc- 
cess, and  while  we  were  rejoicing  in  the  hope  that 
he  would  continue  his  good  work  for  many  years,  he 
was  suddenly  called  hence.  We  all  feel  that  his  devotion 
to  his  profession,  his  interest  in  his  brethren,  and  his 
ceaseless  services  to  those  committed  to  his  care,  were 
instrumental  in  taking  him  from  us  at  the  noon-time  of 


Xovember  2,  1895] 


MEDICAL    RECORD. 


647 


his  noble  life.  While  this  thought  adds  greatly  to  the 
burden  of  our  grief,  it  magnifies  the  greatness  and 
goodness  of  the  man.  There  was  no  shadow  of  sel- 
fishness in  the  heart  of  this  man,  who  gave  all  for  the 
welfare  of  others.  Feeling  keenly  our  own  loss,  we 
naturally  think  of  his  family,  and  our  sympathy  is  ex- 
tended to  them  in  all  kindness  and  sincerity.  The 
Committee  suggests  that  this  all  too  meagre  tribute  to 
the  memory  of  our  deceased  associate  be  spread  in  full 
upon  the  minutes,  and  be  published  in  the  medical 
press  and  in  the  daily  press  of  Brooklyn  ;  and  that  a 
copy  be  transmitted  to  his  family. 

"Alex  J.  C.  Skene. 
"Jarvis  S.  Wight, 
"Frank  E.  West, 

"  Committee." 

The  Annual  Meeting  of  the  Association  of  German 
Uattiralists  and  Medical  Men  was  held  at  Lubeck, 
from  September  15th  to  2T5t,  the  President  being 
Professor  ^\■islicenus,  of  Leipsic.  Professor  Klebs  read 
a  paper  of  a  theoretical  character  on  some  problems 
concerning  the  physiology  of  generation.  Professor 
Behring  made  a  speech  on  the  results  and  objects  of 
serotherapy.  Behring  stated  that  the  time  had  passed 
when  medical  men  should  use  expressions  like  "  genus 
epidemicus."  in  order  to  explain  the  degree  of 
mortality.  He  stated  that  vaccination  had  succeeded 
in  compelling  this  genus  to  withdraw  ;  this  had  been 
done  in  the  case  of  malaiia  by  quinine  and  in  small- 
pox by  vaccination.  He  believed  that  the  same  effect 
on  the  "  genus  epidemicus  "  of  diphtheria  was  produced 
by  antitoxin.  Professor  Behring  then  went  on  to  give 
a  large  number  of  statistics  in  rebuttal  of  criticisms 
that  had  been  made  upon  his  method,  and  expressed 
the  opinion  that  the  mortalit)-  from  diphtheria  could 
be  made  to  fall  to  five  per  cent.  Even  if  something 
less  than  this  were  done,  forty-five  thousand  lives  would 
be  yearly  saved  in  Germany.  At  present  mortality  rates 
the  lives  of  fifteen  thousand  people  had  already  been 
saved.  The  protecting  or  immunizing  effect,  he  added, 
was  not  yet  so  obvious  as  the  curative,  because  the 
number  of  cases  reported  was  still  too  small.  Professor 
Ridle,  of  Vienna,  read  a  paper  on  surgical  operations 
on  the  skull.  He  stated  that  of  one  hundred  brain 
tumors,  six  only  are  found  and  operated  on  ;  in  three 
of  these  death  occurs  from  the  operation,  and  that 
three  per  cent,  only  have  a  favorable  issue. 

The  Late  Dr.  Frederick  M.  Warner. — At  a  special 
meeting  of  the  Medical  Board  of  the  City  Hospital, 
held  at  the  Academy  of  Medicine  on  October  21,  1895, 
the  following  resolutions  were  adopted  by  the  Board  : 

"  Whereas,  It  has  pleased  God  to  remove  our  late 
colleague,  Frederick  M.  Warner,  M.D.,  from  his  field 
of  labor  in  the  City  Hospital :  and 

"  Whereas,  He  was  by  temperament,  experience,  and 
education  thoroughly  equipped  for  the  alleviation  of 
human  suffering  in  the  City  Hospital,  where  he  labored 
zealously  and  conscientiously  for  several  years  ; 

"  Resolved,  That  we,  his  late  colleagues,  express  our 
sincere  admiration  of  him  as  an  associate,  and  our 
profound  regret  that  his  future — so  full  of  brightness 
and  promise — should  be  lost  by  death. 

"Resolved,  That  we  tender  his  family  our  deep  sym- 
pathy with  them  in  their  bereavement,  and  that  a 
memorial  page  be  set  aside  in  our  book  of  minutes. 

"  Resolved,  That  an  engrossed  copy  of  these  resolu- 
tions be  sent  his  family. 

"  J.  Bl.vke  White, 
"  Thomas  H.  Allen, 

"  J.  R.  Hayden,  "  Simon  J.  Walsh, 

Secretary.  "  Committee." 

The  Slowness  of  our  System  of  Advancement. — The 
slowness  with  which  promotion  sometimes  arrives  in 
our  system  of  advancement  by  seniority  is  illustrated 
by  the  recent  "  elevation  "  of  Dr.  Lauder  Brunton  to  a 


full  physicianship  at  Bartholomew's.  The  name  of 
Lauder  Brunton  is  certainly  anything  but  unknown. 
yet  for  twenty-five  years  his  field  of  energy  has  been 
limited  by  the  walls  of  the  out-patient  room.  Indeed, 
this  promotion  has  only  occurred  through  the  institu- 
tion of  an  extra  post,  and  it  has  been  calculated  that 
but  for  its  creation  Dr.  Brunton  might  have  reached 
the  limit  of  age  before  he  had  been  relieved  from  the 
drudgery  of  the  ambulatorium. — London  Correspond- 
ent of  the  Therapeutic  Ga  xette. 

Hew  Anatomy  Law  in  Wisconsin. — Section  1437, 
of  chapter  58,  of  the  annotated  statutes  of  Wisconsin, 
was  amended  by  the  last  legislature  so  that  every  pub- 
lic officer  having  charge  of  the  body  of  any  deceased 
person,  required  to  be  buried  at  the  public  expense, 
not  merely  "ma}-,"  but  "  shall,  without  charge."  deliver 
such  body  to  that  member  or  agent  of  the  State  or  any 
county  medical  society,  or  of  any  legally  organized 
medical  college,  who  shall  first  present  to  him  an  order 
therefor,  signed  by  the  president  or  secretary  thereof, 
"  stating  "  that  such  body  will  be  used  only  for  the  pro- 
motion of  anatomic  science  within  the  State,  and  that 
the  remains  shall  be  afterward  decently  buried  without 
public  charge.  But,  as  heretofore,  no  body  of  any  per- 
son who  in  his  last  sickness  requests  to  be  buried,  or 
of  any  stranger  or  traveller  who  shall  have  suddenly 
died,  shall  be  so  disposed  of.  And  no  person  so  hav- 
ing charge  of  any  such  body,  it  is  added,  shaU  sell  or 
deliver  the  same  to  anyone  to  be  used  for  scientific  or 
any  other  purposes  outside  of  the  State  of  Wisconsin. 
Any  officer  or  other  person  ^^olating  any  of  the  p^o^•i- 
sions  of  this  act  shall  be  liable  to  the  person,  society,  or 
corporation  aggrieved  in  the  sum  of  $50  damages,  to 
be  recovered  in  an  action  therefor. 

Subcutaneous  Emphysema  caused  by  Straining  dur- 
ing Parturition. —  Dr.  Ulrik  was  called  in  to  see  a 
primipara,  aged  twenty- eight,  who,  after  having  been 
delivered  of  a  stillborn  twin,  had  suddenly  become  in- 
capable of  further  assisting  the  progress  of  the  labor, 
{British  Medical  Journal').  An  hour  and  a  half  after  the 
birth  of  the  twin  the  woman's  strength  seemed  almost 
gone,  but  on  some  strong  pains  again  commencing  she 
was  told  by  the  midwife  to  attempt  further  straining 
efforts,  during  one  of  which  a  sudden  swelling  of  the 
face  and  neck  was  produced,  coincident  with  a  com- 
plete cessation  of  the  pains,  which  did  not  again  re- 
turn. The  second  twin  was  easily  delivered  by  the 
forceps.  The  face  had  the  appearance  of  pronounced 
oedema  ;  the  deformity  was  considerable,  the  skin  pale 
and  tightly  stretched,  especially  over  the  cheeks  and 
under  the  eyes,  which  the  patient  could  scarcely  open. 
Downward  the  swelling  extended  over  the  whole  neck 
region  and  the  upper  part  of  the  chest,  and  also  into 
the  axillae,  and  behind  as  far  as  the  scapular  spines. 
Everywhere  the  characteristic  crepitant  sensation  was 
experienced.  The  breathing  was  unimpaired,  and  there 
were  no  signs  of  lung  disease.  The  emphysema  began 
to  disappear  after  a  couple  of  days,  and  was  quite  gone 
in  a  fortnight.  The  patient  had  not  subsequently  de- 
veloped any  lung  affection.  The  author  believes  that 
the  air  after  the  rupture  of  the  air-cells  must  have 
found  its  way  to  the  hilum,  and  thence  along  the  great 
vessels  and  trachea  through  the  mediastinum  to  the 
loose  tissues  of  the  neck  and  face  ;  the  nervous  shock 
produced  by  the  accident  evidently  caused  the  sudden 
cessation  of  the  pains.  He  considers  the  accident  so 
natural  that  it  seems  strange  that  it  should  not  occur 
more  often. 

Stirgery  of  Contusions  of  the  Abdomen. — The  Paris 
correspondent  of  the  Medical  Press  writes  that  M. 
Michaux  spoke  at  great  length  recently  on  the  results 
of  surgical  intervention  in  cases  of  contusion  of  the 
abdomen.  He  said  that  all  authors  were  agreed  on 
the  subject  of  early  interference,  but  the  greater  num- 
ber advised  that  the  surgeon  should  wait  at  least  for 


MEDICAL    RECORD. 


[Xovember  2,   1895 


the  symptoms  of  peritonitis,  while  he  considered  that 
the  best  treatment  of  grave  contusions  of  the  abdomen 
consisted  in  an  immediate  operation,  for,  if  no  visceral 
lesion  were  discovered  no  harm  would  have  been  done 
to  the  patient.  He  had  occasion  to  operate  eleven 
times  in  the  last  four  years  for  contusions  of  the  abdo- 
men, the  history  of  which  he  would  not  give  in  detail, 
but  would  mention  some  particulars  of  a  few  of  the 
cases.  The  first  was  that  of  a  drayman  who  was 
knocked  down  by  a  large  barrel  of  wine,  and  was 
carried  to  the  hospital  with  all  the  signs  of  rupture  of 
the  intestines.  Laparotomy  was  performed,  but  the 
patient  succumbed  the  following  day.  A  second  was 
operated  on  for  a  tear  in  the  transverse  colon  and 
made  a  rapid  recovery,  in  spite  of  a  considerable 
effusion  of  blood  into  the  abdominal  cavity.  Another 
case  was  operated  on  with  success  on  the  third  day 
after  the  accident,  while  a  similar  result  was  obtained 
in  a  fourth  laparotomy  performed  on  the  seventeenth 
day  for  rupture  of  the  biliary  ducts.  In  April,  last  year, 
M.  Michaux  operated,  ten  hours  after  the  accident,  on 
a  railway  employee  caught  between  the  buffers  of  two 
wagons  on  a  level  with  the  epigastrium.  About  three 
quarts  of  blood  were  found  in  the  abdomen  and  a  rent 
in  the  mesentery  of  six  inches  in  length  ;  this  tear  was 
sutured  and  the  man  recovered.  A  short  time  after- 
ward he  was  called  to  operate  on  a  mason,  aged  thirty- 
nine,  who  had  fallen  from  the  second  story  of  a  house 
on  the  angle  of  a  marble  table.  By  this  accident  some 
of  the  lower  ribs  on  the  left  side  were  broken  and  a 
rent  on  the  under  surface  of  the  left  lobe  of  the  liver, 
with  a  small  effusion  of  blood,  was  produced.  The 
man  got  well  without  much  trouble.  In  an  anatomical 
point  of  view,  the  eleven  cases  might  be  classed  as  fol- 
lows :  Three  ruptures  of  the  intestines  ;  one  of  the 
biliaryducts,  two  of  the  liver  (slight),  three  of  the  mesen- 
tery, one  of  probable  rupture  of  the  kidney,  and  one 
(double)  rupture  of  the  bladder,  with  fracture  of  the 
isones.  His  friend,  M.  Gross,  in  a  recent  publication, 
mentions  seven  similar  cases,  so  that  of  the  total  eigh- 
teen cases,  twelve  were  exceedingly  grave,  and  all  were 
accompanied  with  considerable  effusion  of  blood.  In 
a  clinical  point  of  view,  these  contusions  of  the  abdo- 
men submitted  to  his  observation,  presented  the  two 
characters  :  i.  Period  traumatic,  collapse  more  or  less 
prolonged.  2.  Reaction,  characterized  by  high  tem- 
peratiire,  delirium,  and  the  premonitory  symptoms  of 
peritonitis.  The  shock  was  always  intense  and  more 
marked  in  slight  contusions  than  in  the  graver  cases. 
At  the  end  of  from  two  to  seven  hours  the  patient 
enters  the  second  stage.  In  this  first  period,  also,  the 
abdomen  is  retracted,  the  muscles  strongly  contracted 
over  the  .seat  of  the  lesion,  and  great  pain  is  experi- 
enced to  the  touch.  As  soon  as  the  temperature  rises 
the  patient  must  be  closely  watched,  as  the  time  for 
interfering  is  at  hand.  However,  during  the  first 
twenty-four  hours,  no  certain  sign  denoting  a  lesion  of 
the  viscera,  such  as  a  rupture  of  the  intestine,  is  mani- 
fest. But  experience  having  shown  that  in  three- fifths 
of  the  cases  grave  lesions  do  exist,  and  that  death  is 
almost  always  the  consequence,  it  can  easily  be  under- 
stood that  laparotomy,  for  the  purpose  of  exploring  the 
region,  imposes  itself  as  an  absolute  necessity,  as  alone 
it  permits  us  to  recognize  with  certainty  the  nature 
and  extent  of  the  evil  and  the  application  of  the  treat- 
ment. It  should  be  practised  within  the  first  twenty 
hours  after  the  accident,  and  as  rapidly  as  possible, 
care  being  taken  to  remove  the  blood  and  any  other 
liquid. 

A  Death  from  Nitrous  Oxide. — Mrs.  Flora  Joseph, 
forty-two  years  of  age,  died  on  October  5th,  under  the 
influence  of  nitrous-oxide  gas,  in  a  dentist's  chair  in 
East  Eighty-sixth  Street.  Artificial  respiration,  the  hy- 
podermic use  of  whiskey  and  strychnia,  and  other  ap- 
propriate measures  were  promptly  resorted  to,  but  with- 
out result. 


BOOKS   RECEIVED. 

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cations which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  t/iat  its  necessities  are  such  that  it  cannot 
be  considered  under  obligation  to  notice  or  review  any  publication 
received  by  it  which  in  the  judgnunt  of  its  editor  will  not  be  of  in- 
terest to  its  readers^ 

Cutaneous  Medicine.  A  System  on  Diseases  of  the  Skin. 
By  Dr.  Louis  A.  Duhring.  8vo,  221  pages.  Illustrated.  Part  1. 
Published  by  J.  B.  Lippincott  Company,  Philadelphia,  Pa. 

Modern  M.\teria  Medica,  with  Ther.\peutic  Notes.  For 
the  Use  of  Practitioners  and  Students  of  Medicine.  By  Dr.  Otto 
Roth.  Seventh  Edition.  8vo,  461  pages.  Price,  $2.  Published 
by  William  Wood  &  Co.,  New  York  City. 

Text-book  on  Nervous  Diseases.  By  American  Authors. 
Edited  by  Francis  X.  Dercum,  M.D.  8vo,  1056  pages.  Illus- 
trated.    Published  by  Lea  Brothers  &  Co.,  Philadelphia,  Pa. 

Transactions  of  the  Medical  Society  of  the  State  of 
Nevst  York,  for  the  Year  1895.  8vo,  510  pages.  Illustrated. 
Published  by  the  Society. 

A  Hand-book  of  Medical  Diagnosis  for  Students.  By 
James  B.  Herrick,  M.D.  i2mo,  429  pages.  Illustrated.  Price, 
$2.50.      Published  by  Lea  Brothers  &  Co.,  Philadelphia. 

A  Text- BOOK  ok  Pr.\ctical  Medicine.  By  Alfred  L.  Loomis, 
M.D.  Revised  and  enlarged.  Eleventh  Edition.  Illustrated. 
Cloth,  $6  ;  sheep,  I7.  Published  by  William  Wood  &  Co.,  New 
York  City. 

A  Text-book  of  Physiology.  By  M.  Foster,  M.D.  Sixth 
Edition.  8vo,  929  pages.  Illustrated.  Published  by  Lea  Brothers 
&  Co.,  Philadelphin,  Pa. 

Transactions  of  the  Association  of  American  Physicians. 
Tenth  Session,  held  at  Washington,  May  30  and  31,  1895.  ^'°'' 
10.  Printed  for  the  Association,  Philadelphia,  Pa.  8vo,  406 
pages.     Illustrated. 

Text-book  of  Forensic  Medicine  and  Toxicology.  By 
Dr.  Arthur  P.  Luff.  Vol.  i.  lamo,  416  pages.  Illustrated.  Price, 
$7.50  net.     Published  by  Longmans,   Green,  &   Co.,   London   & 

New  York. 

Text-book  of  Forensic  Medicine  and  Toxicology.  By 
Dr.  Arthur  P.  Luff.  Vol.  2.  l2mo,  360  pages.  Illustrated. 
Price,  $7.50  net.  Published  by  Longmans,  Green,  &  Co.,  London 
and  New  York. 

Physical,  Intellectual,  and  Moral  Advantages  of 
Chastity.  By  Dr.  M.  L.  Holbrook.  i2mo,  I20  pages.  Price, 
$1.     Published  by  M.  L.  Holbrook  &  Co.,  New  York. 

Functional  and  Organic  Diseases  of  the  Sto.mach. 
By  Dr.  Sidney  Martin.  8vo,  498  pages.  Illustrated.  Published 
by  J.  B.  Lippincott  Co.,  Philadelphia. 

Directions  for  Working  in  the  Histological  L.\bora- 
TORY.  By  G.  Carl  Huber.  Second  Edition.  8vo,  174  pages. 
Illustrated.  Price,  $1.50.  Published  by  George  Wahr,  Ann  .\r- 
bor,  Mich. 

Mentally  Deficient  Children.  Their  Treatment  and 
Training.  By  Dr.  G.  E.  Shuttleworth.  Illustrated.  l2mo,  134 
pages.  Published  by  H.  K.  Lewis,  136  Go  ver  Sirtei,  1  ci  d(  n, 
W.  C,  England. 

A  TRE.vnsE  on  Nervous  and  Mental  Diseases,  for  Stu- 
dents and  Practitioners  of  Medicine.  By  Dr.  Landon  Gray. 
Second  edition,  revised  and  enlarged.  Illustrated.  8vo,  733 
pages.     Published  by  Lea  Brothers  &  Co. ,  Philadelphia. 

The  Pathology  and  Treatment  of  Venkre.\l  Diseases. 
By  Dr.  Robert  W.  Haylor.  Svo,  102  pages.  Illustrated.  Pub- 
lished by  Lea  Brothers  &  Co.,  Philadelphia,  Pa. 

Transactions  of  the  Michigan  State  Medical  Society 
FOR  THE  Year  1895.  ^'°'-  ^I^.  Svo,  613  pages.  Published  by 
the  Society,  Griind  Kapids,  Mich. 

Plea  FOR  a  Simpler  LiFK.  By  George  S.  Keith,  M.D.  i2nio, 
149  pages.  Piice,  $1.  Published  by  Macmillan  &  Co.,  New 
York  City. 

Medical  Djagxosis  with  Special  Reference  to  Practical 
Medici.ne.     Guide  to  the  Knowledge  and  Discrimination  of  Dis-j 
eases.      By  Dr.    J.   M.    da  Costa.       Eighth  Edition.     8vo,   II04I 
pages.     Illustrated.      Published  by  J.  Lippincott  Co.,  Philadelphia, 
Pa. 

An  Atlas  of  the  Fertilization  and  K.\ryokinesis  ofthk 
Ovum.  By  Edmund  B.  Wilson  and  Dr.  Edward  Learning. 
Quitrto,  32  p.^gcs.  Illustrated.  Published  by  Macmillan  &  Co., 
Mew  York  City. 


Medical   Record 

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SOME  CONSIDERATIONS  WITH  REGARD  TO 
THE    SENILE    HEART.' 

By   ROBERT   H.    BABCOCK,  A.M.,    M.D., 

CHICAGO,  ILL. 


iESSOR  OF  CLINICAL  .MELJ 
.'HVSICIANS  AND  bUKGEONS. 
.  \:,  CHICAGO. 

The  term  "  Senile  Heart  "  is  an  unfortunate  one,  since 
it  implies  that  the  disease  thus  characterized  exists 
only  in  the  aged.  Degenerative  changes  in  the  myo- 
cardium and  in  the  arteries  underlie  the  group  of  symp- 
toms that  constitute  the  clinical  history  of  this  affec- 
tion, and  yet  these  degenerative  changes  are  by  no 
means  limited  to  persons  of  advanced  age.  Balfour, 
although  fully  acquainted  with  this  myocardial  degen- 
eration, repeats  all  through  his  book  that  the  senile 
heart  is  a  weak  heart,  which  having  become  hyper- 
trophied  as  years  advanced,  is  deprived  at  length  of 
sufficient  nutrition,  either  through  anaemia  or  through 
vascular  changes  in  the  organ  itself,  and  thus  weakened, 
becomes  incapable  any  longer  of  carrying  on  the  cir- 
culation against  the  peripheral  resistance  set  up  by  the 
arterial  rigidity  incident  to  senility.  This  is  undoubt- 
edly true  ;  but  it  seems  to  me  that  greater  stress  should 
be  laid  on  degeneration  of  the  myocardium  in  consid- 
ering the  etiology  and  pathology  of  the  senile  heart. 

The  man  who,  at  forty-seven,  perchance,  with  rigid 
arteries,  succumbs  to  ingravescent  cardiac  asthenia — to 
use  Balfour's  favorite  e.xpression — "dies  because  dis- 
ease of  the  heart  mascie  has  paved  the  way  for  gradual 
heart  failure."  This  degeneration  may  not  be  fatty, 
and  may  not  be  apparent  after  death  to  the  unaided 
eye.  It  is  more  often  what  is  known  as  "  chronic 
myocarditis,"  or  "  hyperplasia  of  the  interstitial  con- 
nective tissue,"  and  requires  the  microscope  for  its  de- 
tection. Even  then  its  real  extent  may  not  be  discov- 
ered, because  of  faulty  methods  or  of  inadequate 
search.  We  have  been  accustomed  to  think  of  degen- 
eration of  the  myocardium  as  affecting  generally  the 
ventricles,  and  of  these,  particularly  the  left ;  whereas 
recent  observations  indicate  that  the  auricles  may  be 
more  frecjuently  and  extensively  degenerated  than  ap- 
pears microscopically,  or  than  are  the  ventricles. 

Radazewsky  ■  has  ])ublished  an  account  of  his  pains- 
taking investigations  into  the  condition  of  the  myocar- 
dium in  six  cases  of  heart  disease.  Two  were  chronic 
valvulitis,  two  chronic  myocarditis,  one  was  cardiac 
debility  and  dilatation  of  the  right  ventricle  with  pul- 
monary emphysema,  and  one  a  hypertrophied  and  di- 
lated heart  in  an  old  man  of  seventy- two.  The  author's 
object  was  to  determine  the  extent  and  location  of  fi- 
broid, not  fatly,  degeneration,  with  special  reference  to 
its  bearing  on  the  clinical  characters  of  the  pulse. 
Numerous  small  pieces,  amouniing  in  some  instances  to 
as  many  as  one  hundred  and  five,  were  taken  from  the 
auricles  and  ventricles,  and  after  being  appropriately 
prepared,  were  studied  microscopically  and  compared 
with  similar  fragments  taken  from  a  young  and  healthy 

'  Re;vl  .It  the  Mibiissip[)i  Valley  .Vledic.il  Association's  Taciiiy-first 
Annual  .Meeting,  held  at  Detroit,  September  3,  1895. 
-Zeitschrift  f.  klin.  Med.,  Band  27,  S.  381. 


heart.  In  four  of  the  six,  the  connective- tissue  changes 
were  most  marked  in  the  auricles— sometimes  the  right, 
sometimes  the  left — but  involving  both.  In  these 
four,  arrhythmia  of  the  pulse  !iad  been  a  marked  clini- 
cal feature,  wlicreas  regularity  of  the  pulse  had  been 
noted  in  the  two  cases  in  which  fibroid  degeneration 
of  the  ventricles  exceeded  the  clianges  in  the  auricles. 
With  reference  to  the  conjunction  of  a  regular  pulse 
with  degeneration  of  the  left  ventricle,  Radazewsky 
cites  the  conclusion  of  Hampeln,  who,  in  a  study  of 
five  cases  of  myocarditis  that  had  manifested  regular- 
ity of  the  pulse,  says  essentially  that  the  character  of 
the  pulse,  as  to  regularity  or  irregularity,  affords  no 
basis  for  conclusion  concerning  the  condition  of  the 
heart  muscle.  In  other  words,  perfect  regularity  of 
the  pulse  does  not  exclude  the  existence  of  degenera- 
tion of  the  myocardium. 

On  the  other  hand,  although  Radazewsky  recognizes 
his  material  as  too  meagre  to  establish  his  conclusions, 
he  nevertheless  thinks  it  sufficient  to  justify  the  deduc- 
tion that  arrhythmia  indicates  a  preponderating  degen- 
eration of  the  auricles.  Furthermore,  this  assumption 
accords  with  the  discoveries  of  Romberg,  Krehl,  and 
others,  who  have  shown  that  the  automatic  and  rhyth- 
mic action  of  the  heait  originates  in  the  muscle-fibres 
themselves,  and  not  in  the  cardiac  ganglia  as  formerly 
supposed,  and  that  the  primary  impulse  to  contraction 
starts  in  the  walls  of  the  auricles  near  the  openings  of 
the  great  venous  trunks.  To  us  Radazewsky's  studies 
are  valuable  by  teaching  that  degeneration  of  the  auri- 
cles may  exist  even  when  the  myocardium  of  the  ven- 
tricles is  comparatively  healthy.  But  they  are  not  alone 
valuable  from  the  stand-point  of  morbid  anatomy  ;  they 
may  aid  us  in  forming  our  diagnosis  and  prognosis.  If 
Hampeln  is  right,  that  regularity  of  the  pulse  may  co- 
exist with  dangerous  degeneration  of  the  ventricles, 
and  if  it  shall  be  proved  that  degeneration  of  the  auri- 
cles causes  cardiac  arrhythmia,  tlien,  in  any  given  case, 
the  character  of  the  heart's  action  may  aid  us  in  locat- 
ing the  chief  seat  of  myocardial  sclerosis.  Moreover, 
as  it  seems  to  me,  the  prognosis  as  to  life  may  depend 
somewhat  upon  the  seat  of  this  change.  As  the  walls 
of  the  left  ventricle  are  subjected  to  the  greatest  strain, 
so  preponderating  degeneration  of  these  is  tlie  most 
serious  and  likely  to  prove  the  most  rapidly  fatal.  On 
the  other  hand,  disease  of  the  auricles,  unless  having 
caused  destruction  of  the  individual  muscle-fibres, 
may  give  rise  to  an  irregular  pulse  without  seriously 
threatening  life.  Radazewsky's  observations  helj)  me 
to  understand  some  cases  that  at  the  time  were  rather 
puzzling.  For  instance,  I  can  recall  an  elderly  man 
who  was  suffering  from  cardiac  feebleness,  with  so  ir- 
regular and  intermittent  a  jjulse  that  it  seemed  to  me 
the  poor  overstrained  and  dilated  organ  was  likely  to 
give  up  the  struggle  at  any  moment ;  and  yet  this  heart 
went  on  beating  for  more  than  a  year  and  a  half  before 
it  succumbed. 

I  have  under  occasional  observation  a  gentleman  of 
seventy-one  who,  a  year  ago  this  time  suffered  with 
cardiac  asthma  of  such  severity  that  he  thinks  he  was 
snatched  from  the  grave,  and  who  is  now  able  to  at- 
tend to  business  in  a  moderate  fashion.  Yet  this  pa- 
tient's pulse  is  at  times  too  irregular  to  be  counted,  and 
according  to  his  statement  has  been  so  for  several 
years.  On  the  other  hand,  I  have  known  patients  with 
dilated  and  degenerated  hearts  who  seemed  in  no  ira- 


6--0 


MEDICAL   RECORD. 


[November  9    1895 


minent  danger,  and  yet  died  suddenly  a  short  time 
afterward,  or  failed  steadily  and  rapidly  in  spite  of 
treatment  ;  and  in  these  cases  the  pulse,  though  more 
or  less  rapid  and  weak,  presented  little,  if  any,  irregu- 
larity. 

Although  recognizing  the  folly  of  attempting  to  base 
prognosis  in  these  cases  on  the  rhythm  of  the  pulse 
alone,  I  have  come  to  dread  the  weak  accelerated,  but 
regular,  pulse  sometimes  observed  in  connection  with 
dilatation  of  the  heart  in  elderly  men,  and  to  regard  a 
pulse  irregular  in  force,  volume,  and  rhythm,  apart  from 
other  grave  symptoms,  as  much  less  serious  than  I  for- 
merly did.  It  is  quite  otherwise  with  intermittence  of 
the  heart's  action,  if  the  intermissions  set  in  unexpect- 
edly after  a  period  of  rapid  regular  action.  There  is 
positive  danger  in  such  cases  of  the  inhibition  result- 
ing in  permanent  asystole.  Furthermore,  valuable 
prognostic  data  are  furnished  by  the  effect  of  exercise 
on  the  character  of  the  pulse.  If  gentle  walking  cause 
a  weak,  irregular  pulse  to  become  fuller,  stronger,  and 
more  regular,  it  is  a  favorable  indication.  If,  on  the 
contrary,  it  occasions  greater  feebleness  and  rapidity, 
with  irregularity,  perchance  intermittence,  it  portends 
evil,  and  indicates  physical  rest.  It  is  a  sure  sign  that 
the  heart  muscle  is  unequal  to  the  strain. 

Another  symptom  common  to  senile  hearts,  although 
of  very  variable  severity,  is  dyspncea.  We  have  been 
taught  to  believe  this  due  to  pulmonary  engorgement, 
together  with  accumulation  of  carbonic  acid.  But  re- 
cent experiments  and  observations  by  Zerner '  have 
shown  that  two  other  factors  are  concerned  in  its  pro- 
duction, namely,  increased  volume  or  swelling,  to- 
gether with  lessened  elasticity,  that  is,  rigidity  or  stiff- 
ness of  the  lungs.  This  enables  us  to  understand  the 
striking  difference  in  the  degree  of  dyspncea  displayed 
by  patients,  who  otherwise  manifest  on  examination  no 
great  dissimilarity  in  the  dilatation  of  their  hearts  or 
the  rigidity  of  their  arteries.  During  the  past  few 
months  I  have  attended  two  men — one  aged  forty-seven, 
the  other  aged  fifty-three — in  whom  this  sympton  was  a 
most  distressing  feature.  The  former  used  to  say  he 
could  breathe  only  about  an  inch  deep,  while  the  latter 
suffered  from  paroxysms  of  such  frightful  dyspncea 
that  he  seemed  in  imminent  danger  of  strangulation. 
Indeed,  during  the  last  few  weeks  of  life  his  want  of 
breath  was  so  extreme  and  constant  and  the  veins  of 
the  neck  were  so  turgid  as  to  resemble  pressure  from  a 
mediastinal  tumor,  and  to  necessitate  frequent  resort  to 
large  doses  of  morphine  hypodermatically.  Yet  the 
post-mortem  examination  in  this  case  revealed  nothing 
to  explain  the  dyspnoea  aside  from  the  usual  changes  in 
the  lungs,  heart,  and  kidneys,  depending  upon  sclerosis 
of  the  coronary  arteries  and  of  the  general  aortic  sys- 
tem. A  peculiar  characteristic  of  breathlessness  due 
to  coronary  sclerosis  is  its  occurrence  during  the  act 
of  dressing,  as  in  raising  the  arms  to  comb  the  hair  or 
fasten  the  necktie.  Stooping  to  tie  the  shoes  also  oc- 
casions dyspncea  in  these  cases.  Yet  this  is  much  less 
trustworthy  as  an  indication  of  coronary  sclerosis,  since 
individuals  with  abdominal  corpulence  are  often  unable 
to  stoop  without  shortness  of  breath,  probably  from 
pressure  of  the  abdominal  on  the  thoracic  viscera.  In 
such  I  have  often  found  more,i^jef  to  follow  a  brisk 
purge  than  is  the  case  in  coroii^^Sclerosis. 

Another  manifestation  of  dj^tocea  of  quite  a  differ- 
ent sort  is  that  paroxysmal  exac^^ttion  wliich  comes  on 
at  night  most  commonl)^  and  is  called  cardiac  asthma. 
Conheim  has  shown  its  dependence-  on  inequality  in 
the  strength  of  the  two  ventricles,  whereby  the  right 
forces  more  blood  into  the  lungs  than  the  left  can  for- 
ward into  the  aorta.  This  results  in  acute  hyperi^emia 
.and  cedema  of  the  lungs,  with  the  sen^e  of  suffocation, 
tiie  copious  rales,  cough,  muco-serous  expectoration, 
and  small  feeble  pulse,  which  constitute  the  chief  phe- 
nonu'n.a  of  these  attacks,     lialfour  speaks  of  them  as 


aiigi?ia  sine  do/ore,  ado])ting  the  term  invented  by  Gaird- 
ner.  They  are  truly  paroxysms  of  suffering  akin  to 
agony,  but  I  am  not  convinced  of  their  possessing  suf- 
ficient etiological  relationship  to  angina  pectoris  to  like 
the  term  ciii,i^ina  sine  dolore.  Since  disproportionate 
feebleness  of  the  left  ventricle  is  present  in  these  at- 
tacks, it  has  always  seemed  to  me  that  the  use  of  nitre 
fumes,  asthma  pastilles,  etc.,  might  be  dangerous. 
Cardio-vascular  depressants,  which  assuredly  nitre 
fumes  are,  are  contra-indicated,  unless  arterial  spasm  be 
clearly  determined,  to  precipitate  or  maintain  the  at- 
tacks. By  all  odds  the  best  treatment  for  such  a  par- 
oxysm is  the  hypodermic  administration  of  an  eighth  of 
a  grain  of  morphine  with  a  two-hundredth  of  atropine. 
Relief  afforded  is  generally  prompt  and  complete,  the 
patient  soon  falling  into  quiet  sleep,  from  which  he 
wakes  next  morning  refreshed  and  apparently  none 
the  worse. 

Finally,  tliere  is  a  form  of  dyspncea  which  is  gener- 
ally thought  to  usher  in  the  last  stage  of  the  struggle  ; 
this  is  the  Cheyne  -  Stokes  respiration.  It  is  very 
rightly  regarded  as  a  very  grave  prognostic  omen,  but 
that  it  may  appear  for  a  time  and  then  vanish  com- 
pletely pari  passu,  with  improvement  in  other  symp- 
toms, is  borne  out  by  the  case  of  an  old  gentleman, 
aged  eighty,  whom  I  now  have  under  observation. 
Last  April  this  patient  manifested  this  type  of  breath- 
ing in  a  typical  manner — so  much  so,  that  a  physician 
who  saw  him  in  consultation  assured  the  family  that 
the  end  could  not  be  far  distant,  as  he  had  never 
known  Cheyne  Stokes  respiration  to  last  for  longer 
than  about  three  weeks.  Nevertheless,  this  symptom 
has  now  been  absent  for  three  months  or  more,  and 
the  old  gentleman  declares  he  is  better  now  than  he 
was  a  year  ago.  In  his  case  the  respiration  assumed 
the  Cheyne- Stokes  type  chiefly  when  he  was  asleep,  al- 
though it  was  not  always  absent  during  waking  hooirs. 
The  patient  of  seventy- one  years  of  age,  previously  re- 
ferred to  in  this  paper,  exhibited  this  type  of  breathing 
only  when  unconscious  in  sleep  ;  and  it  has  seemed  to 
me  that  when  such  is  the  case,  Cheyne-Stokes  respira- 
tion may  be  regarded  as  of  less  evil  portent  than  when 
it  is  constant  both  waking  and  sleeping.  Of  course,  I 
do  not  refer  to  that  physiological  form  of  Cheyne- 
Stokes  respiration  which  Murri  has  shown  may  some- 
times be  observed  during  profound  sleep,  even  when 
the  heart  is  health}-.  In  the  case  just  cited  there  was 
a  pathological  condition  to  account  for  the  occurrence 
of  this  type  of  breathing. 

The  treatment  of  this  form  of  dyspntea  has  been  the 
subject  of  considerable  contention  in  Germany.  At 
the  meeting  of  the  Congress  for  Internal  Medicine  in 
Wiesbaden,  in  1892,  Unverricht  read  a  paper  in  which 
he  expressed  the  decided  opinion  that  morphine  and 
atropine  exert  no  antagonistic  influence  upon  Cheyne- 
Stokes  respiration.  Indeed,  some  observers  have  even 
gone  so  far  as  to  assert  that  morphine  intensifies  this 
phenomenon.  Stadelmann  '  has  jjublished  the  results 
of  something  like  twenty-five  observations  of  the  effect 
of  morphine  and  atropine,  alone  and  combined,  upon 
this  type  of  breathing.  The  observations  were  made 
on  two  patients,  and  the  doses  were  o.oi  to  0.02  of 
morphine,  and  o.ooi  to  0.0015  of  atropine.  The  effect 
was  neither  uniform  nor  constant ;  sometimes  shorten- 
ing a  period  of  apnoea,  sometimes  that  of  dyspncea, 
and  then  again  at  other  times  lengthening  one  or  the 
other,  or  both.  In  five  experiments  Cheyne-Stokes 
l)reathing  v,as  lessened  or  removed  by  the  morphine, 
as  against  four  trials  in  which  it  was  aggravated.  Al- 
though Stadelmann's  observations  showed  so  incon- 
stant and  unreliable  an  effect  on  the  part  of  morphine 
as  to  appear  to  confirm  l"nverricht"s  assertions,  he 
nevertheless  concluded  that  the  effect  of  this  agent  on 
the  whole  was  to  mitigate  the  severity  of  the  attacks. 
Tliere  certainly  seemed  to  be  no  injurious  effect  exerted 


'  Zeitschrift  f.  klin.  Med.  Band  27,  S.  529. 


Zeiischrift  f,  klin.  Med..  Baa(l26.  .S   267. 


November  9,  1895] 


MEDICAL   RECORD. 


651 


by  the  morphine,  and  since  it  undoubtedly  blunts  the 
patient's  sensibility  and  induces  sleep,  I  can  see  no 
contraindication  to  its  employment,  even  if  it  seems 
occasionally  to  change  an  irregular,  unperiodic  foim  of 
dyspncea  into  the  periodic  type  characteristic  of 
Cheyne-Stokes  respiration.  Its  beneficial  action  was 
so  marked  in  the  case  of  the  gentleman,  aged  seventv- 
one,  already  cited,  that  I  think  it  best  to  append  a 
brief  description  of  its  effects  in  this  case.  The  nicrht 
before  1  was  called  to  see  this  patient  had  been  one  of 
intolerable  suffering  ;  so  soon  as  he  dozed  off,  if  but 
for  a  moment,  he  would  wake  up  with  a  start,  clutch- 
ing his  throat  and  declaring  he  was  going  to  be  suffo- 
cated. Nitro-glycerine  and  other  cardiac  stimulants 
had  been  administered  freely  without  relief.  His 
dread  of  the  forthcoming  night  was  so  great  that  it 
was  decided  I  should  remain  with  him.  I  resolved  to 
try  morphine,  but  notwithstanding  my  assurance  that 
he  would  certainly  experience  relief  and  pass  a  com- 
fortable night  in  sleep,  I  could  not  obtain  his  consent 
to  its  use  before  midnight.  At  length,  after  his  suffer- 
ing of  the  night  previous  had  begun  to  be  repeated,  he 
yielded.  One-eighth  grain  of  morphine  with  one  two- 
hundredth  grain  of  atropine  was  injected,  and  in  a  few 
minutes  he  was  sleeping  peacefully,  although  e.xhibiting 
Cheyne-Stokes  respiration.  From  that  time  forward, 
for  two  months,  he  received  his  nightly  injection  of 
morphine,  which  never  lost  its  effect  and  never  had  to 
be  increased.  When,  at  last,  in  response  to  treatment, 
his  heart  had  regained  something  of  its  former  vigor. 
chloralamid  and  bromide  of  potash  were  substituted  as 
a  hypnotic.  Depression  following  the  withdrawal  of 
the  morphine  was  trifling,  and  lasted  but  for  a  day. 
At  the  present  writing,  this  patient  considers  himself 
in  pretty  fair  health,  although  still  under  occasional 
observation. 

It  may  be  that  this  was  an  example  of  irregular 
dysijncta  having  been  changed  by  the  morphine  into 
the  Cheyne-Stokes  type  of  breathing.  Yet,  if  my  mem- 
ory is  not  at  fault,  this  character  of  respiration  did  not 
wholly  disappear  with  the  withdrawal  of  the  morphine. 
The  two-hundredth  grain  of  atropine  was  not  sufticient 
to  antagonize  the  influence  of  the  morphine.  Never- 
theless, I  shall  hereafter  employ  morphine  alone,  using 
as  small  a  dose  as  will  suffice.  The  remedy  should  al- 
ways be  administered  hypodermically,  not  only  because 
more  prompt  than  by  the  mouth,  but  because  more  ef- 
ficient. Another  reason  for  its  use  in  this  manner  is 
its  action  as  a  cardiac  stimulant. 

Conclusions. —  i.  The  term  senile  heart  is  unfortunate, 
because  the  degenerative  changes  underlying  the  dis- 
ease are  not  limited  to  the  aged. 

2.  Tiie  changes  in  the  heart  muscle  are  generally 
those  of  chronic  myocarditis,  and  their  real  extent  and 
location  often  escape  recognition. 

3.  Radazewsky's  investigations  indicate  that  the 
connective  -  tissue  changes  affect  the  auricles  more 
often  than  is  generally  supposed,  and  often  exceed  de- 
generation of  the  ventricles. 

4.  Fibrosis  of  the  auricles  causes  cardiac  arrhythmia, 
whereas  fibroid  degeneration  of  the  ventricles  does  not 
produce  irregularity  of  the  pulse. 

5.  Cardiac  dyspnctia  has  been  shown  by  /erner  to 
depend  upon  swelling  and  rigidity  of  the  lungs,  in  ad- 
dition to  pulmonary  engorgement  and  accumulation  of 
carbonic  acid  in  the  blood  ;  and  this  jirobably  explains 
the  striking  difference  in  the  degree  of  dyspncua  dis- 
played by  patients  with  similar  cardiac  lesions. 

6.  That  paroxysmal  exacerbation  of  dyspncea,  called 
cardiac  asthma,  is  due  to  disjjroiJortionate  weakness  of 
the  left  ventricle,  and  is  most  promptly  and  efficiently 
relieved  by  the  hypodermic  injection  of  morphine,  one- 
eighth,  and  atropine,  one  two-hundredth  of  a  grain. 

7.  Stadelmann's  experiments  appear  to  confirm  Un- 
verricht's  assertion,  that  morphine  and  atropine  exert 
no  antagonistic  influence  over  attacks  of  Cheyne-Stokes 
resi)iration. 


8.  Nevertheless,  since  morphine  hypodeimically  was 
shown  to  sometimes  modify  in  a  favorable  manner  the 
severity  of  the  attacks,  and  since  it  blunts  the  patient's 
sense  of  dyspno?a  and  induces  sleep,  its  employment 
hypodermically  is  justified  in  these  cases. 

9.  Morphine  should  be  administered  in  cardiac  cases 
hypodermically,  and  in  as  small  a  dose  as  will  accom- 
plish the  result  desired  ;  and  given  in  this  manner  it 
acts  as  a  powerful  cardiac  stimulant. 

Veneti.\n  Building. 


WHAT   SHOULD    BE    THE    POLICV    OF    THE 
STATE    TOWARD    PROSTITUTION  :■ '■ 

By    DENSLOW   LEWIS,    M.D., 


OBSTETRICI.^N   AKO   GY.NECOLOGi: 


)OK    COUNTY    HOSPITAL  CHICAGO,  ILL. 

A  DISCUSSION  of  this  trite  subject  would  be  useless  to- 
day, were  there  not  a  possibility  that  the  time  had 
come  when  an  enlightened  public  sentiment  might  ef- 
fect something  of  real  value.  This  discussion  of  the 
subject  of  prostitution  must  be  based  upon  facts.  His- 
tory must  be  recognized,  efforts  already  made  toward 
the  restriction  of  the  vice  and  the  results  obtained 
must  be  appreciated  at  their  true  value.  It  is  the  truth 
that  in  all  large  cities  the  habitat  of  the  prostitute  is 
to  most  people  of  respectability  as  much  an  undiscov- 
ered country  as  the  interior  of  Africa  ;  it  is  truly  as 
much  a  Umj  incognita  as  the  island  of  Tierra  del  Fuego. 

Indeed,  there  is  an  involuntary  feeling  of  disgust  and 
abhorrence  when  prostitution  is  mentioned.  The  whole 
matter  is  to  most  people  so  loathsome  that  they  cannot 
even  speak  of  it  without  horror.  However,  it  is  needless 
to  say  to  medical  men  that  the  importance  of  the  sub- 
ject justifies  its  scientific  study  and  its  very  serious 
consideration.  It  is  said  one  cannot  touch  pitch  with- 
out being  defiled  ;  nevertheless,  the  annals  of  medicine 
show  many  instances  of  martyrdom  to  the  cause  of 
science.  The  deaths  due  to  sucking  of  the  tracheot- 
omy wound  in  diphtheria,  and  the  many  deaths  that 
have  occurred  throughout  the  world  due  to  scientific 
effort  made  in  the  study  of  disease,  suffice  to  demon- 
strate the  courage  of  the  medical  man  and  the  sociolo- 
gist in  the  discharge  of  what  they  believe  to  be  their 
duties. 

In  reference  to  the  study  of  prostitution,  moreover, 
the  effects  of  this  vice  must  be  judged  by  the  truth  as 
demonstrated  by  actual  observation  and  experience. 
Inherent  notions  of  right  and  wrong  are  out  of  place, 
tor  they  are  at  best  Init  relative — often  geographical. 
Preconceived  ideas,  founded  on  religion,  are  inconsist- 
ent with  the  spirit  of  the  times  and  incompatible  with 
the 'scientific  methods  of  a  liberal  profession. 

Let  us,  then,  very  Ijriefly  study  this  matter,  let  us 
know  what  it  is,  why  it  jjersists,  how  it  thrives,  and  as 
we  take  cognizance  of  the  etiological  factors  incident 
to  its  existence  and  perpetuation,  let  us  endeavor,  if 
we  cannot  do  away  with  it  entirely,  at  least  to  suggest 
some  remedial  measures  tending  to  diminish  its  extent, 
to  control  its  objectionable  features,  and  to  eliminate 
its  pernicious  effects.  Some  people  object  to  this,  as  I 
have  already  said.  They  claim  the  whole  subject  of 
prostitution  is  so  degrading  that  its  very  mention  is 
contaminating.  I  need  not  stop  liere  to  demonstrate 
to  medical  men  the  absurdity  of  tliis  position.  Nor  do 
I  need  to  insist  further  upon  the  imi)ortance  of  its  con- 
sideration. .\s  a  matter  of  fact  liistory  shows  that  it 
has  always  existed.  We  certainly  know  its  prevalence 
everywhere  today.  I  for  one  cannot  see  how,  for 
many  generations  to  come  at  least,  we  can  expect  to 
eradicate  it.  As  a  matter  of  fact,  next  to  the  instinct 
of  self-preservation  the  instinct  whicii  dictates  the  per- 
petuation of  the  species  is  dominant  in  all  animals. 
Fortunately,  in  the  genus //(W/ti  this  instinct  does  not  exist 

'  Rcm.irks  made  at  the  Septcmlier  Meeting  of  the  Doctors'  Club  of 
Chicago. 


652 


xMEDICAL    RECORD. 


j  November  9    189  = 


in  the  female  to  the  extent  that  it  is  found  in  the  male, 
otherwise  there  would  be  no  such  thing  as  virtue  or 
morality.  There  are  philosophers — master  minds — who 
after  conscientious  and  critical  study  of  the  subject  in 
all  its  relationships  do  not  hesitate  to  assert  that  pros- 
titution is  desirable.  Be  this  as  it  may,  it  is  certain  it 
is  less  objectionable  than  certain  other  evils.  The  great 
historian  Lecky  characterizes  the  prostitute  as  the 
eternal  priestess  of  humanity,  blasted  for  the  sins  of 
the  entire  people.  There  is  no  doubt  that  she  is  of 
value  as  a  safeguard  to  the  virtue  of  the  family.  If,  in 
a  word,  our  religion,  our  education,  and  our  civilization 
cannot  teach  our  young  men  to  refrain  from  the  sexual 
act  until  such  time  as  it  may  legitimately  be  indulged 
in,  it  is  decidedly  better  for  us  to  have  these  young  men 
cohabit  with  women  of  the  town  rather  than  with  the 
wives  and  daughters  of  their  neighbors.  It  is  better 
for  them  to  do  this  rather  than  indulge  in  the  disgrace- 
ful practices  and  degrading  crimes  against  nature,  which 
prevail  even  in  our  midst  to-day. 

When  we  consider  what  shall  be  done  with  the  pros- 
titute, certain  persons  in  the  community,  dominated  by 
a  sense  of  disgust,  which  all  must  entertain  for  her  if 
they  had  not  thought  in  a  sense  of  justice  regarding  the 
causes  that  have  made  her  what  she  is,  cry  out  :  "  Away 
with  her.  Prostitution  is  so  baneful,  let  us  stamp  it 
out,  let  us  have  none  of  it."  How  little  such  persons 
know  of  history  or  of  human  nature.  The  most  strin- 
gent measures  have  at  different  times  been  adopted. 
Invariably  they  have  proven  ineffectual.  Prostitutes 
have  been  publicly  horsewhipped  ;  their  noses  and 
ears  have  been  cut  ;  they  have  been  ordered  thrown  in 
the  river  ;  they  have  suffered  every  degradation,  but 
they  still  exist.  Indeed,  St.  Louis,  in  1254,  was  forced 
to  the  conclusion  that  suppression  was  worse  than  use- 
less, and  I  think  I  may  safely  say  that  a  consistent  study 
of  the  facts  will  reveal  that  since  that  time  all  efforts  at 
restricting  the  vice  by  summary  legislation  have  ig- 
nominiously  failed.  If  prostitution  has  not  been  al- 
lowed to  exist  publicly,  it  has  existed  clandestinely,  and 
its  evils  have  been  greater  because  no  longer  under 
supervision  or  control. 

I  will  not  go  into  the  history  of  prostitution.  The 
recent  edition  of  Sanger's  work  and  the  comprehensive 
treatises  of  Jeannel  and  Parent  du  Chatelet  give  full 
details  of  a  most  interesting  character.  My  own  obser- 
vation teaches  me  that  women,  as  a  rule,  become  pros- 
titijtes  not  from  passion  but  from  necessity.  With 
imperfect  and  insufficient  education,  with  degrading 
environments,  without  the  fostering  care  of  family, 
young  women  only  too  often,  dominated  by  love  and 
vanity,  which  Chesterfield  has  described  as  the  two  uni- 
vtrsal  characteristics  of  women,  fall  ready  victims  to 
the  lust  of  man.  Then,  again,  the  insufficient  wages 
paid  by  many  of  our  leading  merchants  to  young  wom- 
en in  their  employ  is  un(iuestionably  an  etiological 
factor  in  the  development  of  prostitution.  Illegitimate 
pregnancy,  as  I  have  abundant  opportunity  of  noting, 
causes  many  a  woman  to  adopt  a  life  of  shame.  She 
does  this  not  because  she  wishes  it,  but  because  in  the 
present  state  of  our  society  in  all  large  cities  there  is 
no  place  for  the  illegitimate  infant — no  helping  hand 
for  the  erring  woman.  Many  women  through  force  of 
circumstances  find  themselves  burdened  with  an  ille- 
gitimate child  which  perhaps  they  desert.  Ignorant  of 
all  reputable  means  of  maintaining  life,  realizing  after 
a  few  days  of  effort  the  impossibility  of  finding  employ- 
ment adeijuate  for  her  miintenance,  let  me  ask  you,  as 
matter  of  fact,  "  what  is  there  for  such  a  woman  to  do  ?  " 
There  is  but  really  and  actually  one  method  by  which 
she  can  live.  She  becomes  a  prostitute  rather  than 
starve. 

I  will  not  attempt  to  describe  her  daily  life.  In  the 
works  I  have  referred  to  you  may  read  all  details  if  you 
choose.  As  a  matter  of  fact,  in  this  country  when  a 
worn  in  enters  a  house  of  prostitution,  she  too  often 
enters  what  is  practically  a  prison,  from  which  escape 


is  impossible.  The  methods  of  the  proprietors  of  these 
houses  are  generally  known.  The  young  woman  is 
furnished  with  clothing  and  anything  else  she  may  de- 
sire, so  that  she  may  remain  constantly  in  the  debt  of 
the  proprietor.  .\s  long  as  her  attractions  make  her 
capable  of  adding  to  the  revenue  of  the  house,  she  re- 
mains there.  When  distase  or  debauchery  shall  have 
degraded  her  to  such  an  extent  that  she  is  no  longer 
sought  by  the  patrons  of  the  house,  she  is  thrown  out 
as  a  worthless  piece  of  merchandise.  Then  conies 
further  degradation,  still  mote  debauchery,  from  which 
transient  relief  is  obtained  only  by  the  use  of  opium. 
Finally,  and  in  a  very  few  years,  death  closes  the  scene. 
One  more  woman  has  run  her  course,  one  more  victim 
has  met  her  fate,  that  is  all. 

Prostitution  is  not  attractive.  Pope's  lines,  where  he 
speaks  of  vice  and  sa)s  : 

•'  But  seen  too  oft,  familiar  with  her  face. 
We  first  Lndure,  then  pi'.y,  then  embrace," 

do  not  apply  here.  To  many  an  unfortunate  woman 
the  prospect  of  proper  clothing,  three  meals  a  day,  and 
no  work,  is  undoubtedly  preferable  to  starvation  on  the 
public  streets  or  a  sojourn  in  the  bridewell.  The  hide- 
ousness  of  her  calling,  the  revolting  characteristics  of 
her  occupation  are  soon  revealed  to  her  oftentimes 
when  no  turning  back  is  possible,  when  she  has  become 
in  effect  a  slave  of  lust  for  life. 

Few  women  become  votaries  of  the  vice  from 
choice.  In  the  great  majority  of  cases  the  prostitute  is 
what  she  is  because  man  has  in  one  way  or  another 
made  her  so.  Under  these  circumstances,  however  dis- 
gusting and  degrading  may  be  her  calling,  I  cannot  in 
justice  bring  myself  to  look  upon  her  with  abhorrence, 
for  I  appreciate  the  circumstances  that  have  made  her 
what  she  is. 

Now  if  we  are  to  consider  calmly  and  dispassionately 
the  remedy  of  prostitution,  we  must  take  cognizance  of 
its  etiological  factors  and  our  remedy  must  be  largely 
sociological.  We  cannot  eradicate  one  of  the  great 
instincts  of  human  nature,  but  we  can  and  should  teach 
its  control.  \V'e  should  improve  the  economic  condi- 
tions under  which  dependent  women  live,  and  we 
should  open  up  all  possible  avenues  of  honest  industry 
where  women  can  find  means  of  support.  We  can 
teach  our  young  girls  the  perils  that  beset  them.  This 
may  be  immodest,  but  in  certain  States  of  the  Union 
where  the  age  of  consent  occuis  before  the  girl  has  men- 
struated, or  very  soon  afterward,  it  is  only  just  to  teach 
the  child  that  knowledge  which  may  enable  her  in  a 
small  degree  to  realize  the  dangers  against  which  she  is 
called  upon  to  protect  herself. 

\Vith  these  remarks  upon  the  subject  of  prostitution 
in  general,  the  causes  which  determine  its  existence 
and  are  instrumental  in  its  maintenance,  and  with  this  ' 
reference  to  the  prophylaxis  of  the  condition,  a  prophy- 
laxis based  on  facts,  attested  by  history  and  by  every- 
day observation,  I  proceed  to  the  consideration  of  the 
policy  of  the  State  toward  what  is  called  the  social 
evil. 

As  a  matter  of  fact,  in  Illinois  we  are  permitted  to 
take  no  official  cognizance  of  prostitution,  nor  to  pass 
laws  legulating  it  in  any  way.  There  is  a  State  law 
against  such  action,  just  as  I  am  informed  there  is  a 
State  law  against  keeping  saloons  open  on  Sunday.  I 
hold  this  law  to  be  wrong  in  piinciple  and  ineffectual 
in  practice.  I  believe  in  the  supremacy  of  the  indi\id- 
ual,  and  while  I  do  not  regard  license  as  liberty,  I  think 
prostitution,  which  exists  everywhere,  can  best  be  con- 
trolled by  municipal  rather  than  State  legislation,  for 
its  evils  vary  in  accordance  with  local  rather  than  gen- 
eral conditions. 

If  this  is  true,  the  State  law  must  first  be  repealed 
before  we  can  take  action  of  any  sort.  For  the  pur- 
pose of  discussion,  assuming  this  to  have  been  done, 
assuming  the  possibility  of  doing  what  we  think  best 
in  the  matter,  let  us  now  determine  if  we  wish  to  do 


November  9,  1895] 


MEDICAL   RECORD. 


6=; 


3o 


anything  and  to  what  extent,  without  infringing  on  the 
constitutional  prerogative  of  every  individual  not  a 
criminal,  we  are  capable  of  limiting  the  extent  or  con- 
trolling the  ill  effects  of  prostitution.  This  brings  us 
to  the  consideration  of  another  matter  of  vital  im[)or- 
tance  in  this  connection.  I  refer,  of  course,  to  venereal 
disease,  which  is  chiefly  disseminated  by  promiscuous 
sexual  intercourse.  Right  here  we  are  again  met  by 
objectors — not  bigots  or  fanatics  alone,  but  medical 
men  of  sincerity  and  honesty,  whose  motives  cannot  be 
gainsaid.  They  say  :  "  If  a  man  does  such  things  let 
him  take  the  consequences.  He  ought  to  know  better." 
Armstrong,  of  New  \'ork,  says  that  arc-cal  emptor 
is  the  maxim  of  the  market-place.  I  am  glad  to  reply 
to  him  that  it  is  not  the  mixim  of  the  sanitarian,  whose 
duty  consists  in  doing  more  than  crying  "  Beware," 
otherwise  we  had  better  abolish  all  our  Boards  of 
Health.  As  a  matter  of  fact,  there  is  no  thought  of 
guaranteeing  the  health  of  an  individual  anymore  than 
there  is  thought  of  a  government  pledging  itself  to 
guarantee  immunity  from  epidemics. 

Venereal  disease  is  recognized,  by  those  who  know 
about  it,  as  wide-spreading  in  its  effects.  The  position 
has  been  taken  that  any  attempt  at  controlling  disease 
results  in  the  extension  of  prostitution.  It  is  said  that 
if  men  knew  they  were  safe,  they  would  gratify  their 
sexual  passion  more  freely  than  they  do  now.  In 
other  words,  men  are  said  to  be  restrained  by  the  fear 
of  disease  more  than  anything  else.  And  then  some 
persons  say  it  serves  them  right  if  they  are  wicked 
enough  to  consort  with  prostitutes.  They  get  only 
whit  they  deserve.  The  wages  of  sin  is  death.  The 
absurdity  of  this  statement,  as  White  has  pointed  out, 
is  seen  if  it  is  followed  to  its  logical  conclusion.  If  it 
is  right  for  every  man  who  has  intercourse  with  a  pros- 
titute to  become  diseased  as  a  divine  retribution  for  his 
indiscretion,  we  must  encourage  disease  in  each  pros 
titute  to  make  sure  that  no  transgressor  fails  to  receive 
his  just  punishment  for  his  sin.  Moreover,  the  man  is 
often  not  the  only  victim.  His  wife,  his  children,  his 
neighbors,  all  persons  he  comes  in  contact  with,  may 
fall  innocent  victims  to  the  disease  that  he  dissemi- 
nates. 

For  this  reason,  if  for  no  other,  medical  men  must 
consider  the  prophylaxis  of  venereal  disease  in  its  re- 
lations to  prostitution.  All  will  agree,  I  am  sure,  that 
there  is  a  possibility  of  improving  the  present  condi- 
tions ;  all  will  acknowledge  that  something  should  be 
done  rather  than  persist  in  the  "let-alone  "  policy  now 
in  existence. 

This  thought  leads  to  the  consideration  of  the 
mellujd  called  regulation,  which  means  usually  a  sys- 
tematic registration  of  all  prostitutes  and  periodical  in- 
spection by  deputized  medical  men.  It  means  in  some 
CO  mtries  many  things  besides,  dependent  on  local 
conditions.  I  will  not  detail  the  varied  statistics  that 
hive  been  compiled  in  attempts  at  determining  the 
value  or  worthlessness  of  regulation.  It  is  ea«y  to 
prove  almost  anything  by  statistics.  I  will  simply  say 
now  that  in  every  instance  where  regulation  has  been 
persisted  in  for  any  considerable  length  of  time  under 
proper  supervision  by  qualified  ofticials,  the  result  has 
been  in  the  main  satisfactory.  It  has  not  always  been 
as  satisfactory  as  we  would  wish,  but  it  has  accomplislied 
something.  It  his  diminished  venereal  disease  among 
soldiers  and  civilians,  and  brought  more  cases  to  the 
proper  hospitals  where  the  disease  could  be  most  sat- 
isfactorily treated.  It  has  decreased  the  number  of 
public  women  and  produced  a  marked  disappearance 
of  young  prostitutes.  It  has  lessened  the  number  and 
improved  the  character  of  the  public  houses.  It  has 
made  segregation  a  possibility,  so  that  police  surveil 
lance  and  sapervision  have  been  more  systematic.  It 
has  restricted  debiuchery  and  prevented  the  use  of 
these  houses  as  the  harborers  of  thieves  and  other 
criminals.  Can  it  truthfully  be  said  that  the  "let- 
alone  "  policy  has  accomplished  even  one  of  these  re- 


sults? The  proper  policy  of  the  political  body,  be  i' 
State  or  municipality,  that  has  jurisdiction  over  pros- 
titution, should  be  not  to  close  the  eyes  and  say  noth- 
ing exists  because  nothing  is  seen.  ^luch  less  should 
the  presence  of  prostitution  be  disregarded  on  account 
of  its  loathsomeness  or  its  contaminating  influence. 
By  education,  by  religious  instruction,  by  the  judicious 
inculcation  of  adequate  knowledge,  by  proper  environ- 
ment, and  above  all  by  a  radical  improxement  in  the 
economic  conditions  of  our  dependent  young  women, 
by  teaching  our  young  men  principles  of  honor,  of  jus- 
tice, of  chivalry,  and  of  charity  for  those  who  in  pity 
should  be  able  to  look  to  them  for  protection  and  sup- 
port— by  these  means  we  shall  tend  to  restrict  prosti- 
tution by  preventing  its  increase  through  the  agency  of 
rational  measures  consistently  applied. 

As  for  the  prostitute  of  to- day,  let  us  grant  her  that 
liberty  to  which  she  is  entitled  ;  let  us  realize  why  she 
is  what  she  is,  and  be  just  to  her.  At  the  same  time, 
when  we  are  permitted  by  the  repeal  of  the  State  law 
to  act  in  her  case  as  we  act  toward  every  other  source 
of  infection,  we  will  take  all  proper  measures  to  dimin- 
ish the  extension  of  the  disease  to  which  she  is  specially 
liable,  and  in  our  endeavor  to  act  in  this  manner  for 
the  welfare  of  the  public,  history  shows  we  may  count 
on  her  active  co-operation. 

I  have  made  my  answer  to  the  question  of  the  even- 
ing. You  will  pardon  me  if  I  add  a  thought  as  to  im- 
mediate action.  There  are  matters  of  importance  that 
can  receive  attention  at  once.  They  pertain  not  to 
prostitution  as  such,  nor  to  its  regulation  nor  restriction, 
except  incidentally.  They  concern  medical  men  espe- 
cially, for  they  relate  to  a  medical  matter  worthy  of 
very  serious  consideration. 

Something  can  be  done  now  to  lessen  the  extent  of 
venereal  disease.  In  corporate  institutions  where  large 
bodies  of  men  are  congregated,  there  can  be  proper  in- 
spection and  suitable  treatment  which  will  diminish  the 
spread  of  disease.  In  our  houses  of  correction,  our 
jjrisons,  our  asylums,  our  refuges,  free  treatment  can  be 
offered,  and  in  most  cases  it  will  be  gladly  accepted.  Our 
dispensary  and  hospital  facilities  for  the  care  of  venereal 
diseases  are  singularly  inadequate  for  a  metr  ipolis  like 
Chicago.  Hospitals  should  be  built  and  maintained  ex- 
clusively for  the  treatment  of  this  class  of  cases.  The 
interests  of  the  community  demand  that  if  we  must  have 
the  prostitute,  we  shall  do  our  best  to  have  her  free  from 
disease.  Our  treatment  may  not  be  all  we  would  de- 
sire. It  is,  however,  better  to  have  a  certain  amount 
of  treatment  than  to  have  none  at  all.  If  we  cannot 
take  a  woman  with  gonorrhcjea  and  cart  her  off  to  a 
hospital  to  be  kept  locked  up  there  until  she  is  well,  as 
is  done  in  Berlin  and  Paris,  we  can  treat  her  as  much 
as  she  will  allow  and  instruct  her  in  the  use  of  antisep- 
tic douches,  for  by  that  means  some  man  may  escape 
infection.  If  we  cannot  detain  a  woman  with  chan- 
croid, we  can  destroy  the  virulence  of  the  disease  as 
far  as  possible,  for  it  is  better  to  do  that  than  to  do 
nothing.  If  we  cannot  keep  a  syphilitic  woman  under 
observation  for  two  years,  as  I  believe  should  invaria- 
bly be  done,  we  can  treat  her  as  long  as  she  will  permit, 
for  incomplete  treatment  is  better  than  none  at  all. 

In  a  word,  let  us  do  all  we  can  to  treat  disease,  for 
that  is  the  main  object  of  our  existence.  Let  us  do 
the  best  we  can  in  these  cases,  for  there  is  much  left 
undone  that,  with  proper  facilities,  might  be  done  to- 
day. 

While  awaiting  the  time  when  prophylactic  measures 
shall  diminish  prostitution,  let  us  for  the  present  devote 
our  energies  toward  t!ie  institution  and  perfection  of 
such  means  as  in  our  judgment  will  best  tend  to  min- 
imize its  pernicious  effects. 


The  Insane  in  Scotland. — On  January  1st,  in  the 
present  year,  there  were  13.852  insane  persons  under 
official  cognizance  in  Scotland. 


654 


MEDICAL    RECORD. 


[November  9,  1895 


DIET  AND  SYSTEMATIC  MUSCULAR  EXER- 
CISE IN  THE  TREATMENT  OF  TUBER- 
CULOSIS.' 

By   T.    J.    McGILLICUDDY,  A.M.,  M.D., 


SURGEON   TO  THE 


Up  to  about  twelve  years  ago  the  treatment  of  tuber- 
culosis was  entirely  empirical.  In  1882  Robert  Koch, 
of  Berlin,  for  the  first  time  proved  beyond  a  doubt  that 
this  disease  was  caused  by  bacilli  which,  on  account  of 
their  peculiar  behavior  toward  strong  acid,  could  be 
positively  diagnosed  in  every  case  of  tuberculosis.  All 
subsequent  experiments  have  shown  that  Koch's  state- 
ments were  perfectly  correct,  and  to-day  we  can  say 
that  there  is  no  tuberculosis  without  the  presence  of 
these  characteristic  tubercle  bacilli.  It  is  true  that  at 
the  commencement  of  the  affection  it  is  not  always  easy 
to  find  the  bacilli,  but  careful  examination  of  the  sputa 
at  different  times  will  invariably  show  their  presence  in 
a  greater  or  less  degree. 

Tuberculosis  may  start  very  slowly  and  gradually  ; 
so  much  so  that,  physically,  no  characteristic  symptoms 
of  the  disease  may  be  found,  but  examination  of  the 
sputa  will  already,  at  this  early  period,  demonstrate  the 
presence  of  the  bacilli.  In  every  case  of  cough  which 
has  lasted  for  some  time  the  physician  should  invaria- 
bly make  it  the  rule  to  examine  the  sputum,  whether  be 
suspects  tuberculosis  or  not.  If  this  is  done,  and  only 
then,  can  we  expect  better  results  from  our  treatment 
than  we  have  heretofore  achieved. 

In  a  large  number  of  cases  bacilli  may  be  found  in 
the  sputa  long  before  there  are  any  well-marked  physi- 
cal signs,  so  that  their  detection  will  afford  the  first 
clue  to  the  patient's  malady.  Even  at  the  present  day 
some  physicians  claim  that  there  are  cases  of  phthisis 
without  the  presence  of  tubercle  bacilli.  The  trouble 
with  them  will,  however,  simply  lie  in  the  meaning  of 
the  word  "  Phthisis,"  as  some  will  call  a  chronic  catar- 
rhal pneumonia  fibroid  phthisis.  That  this  is  not 
tuberculosis  need  hardly  be  mentioned. 

.-\nother  mistake  which  is  often  made  is  to  call  tuber- 
cle bacilli  the  sole  cause  of  tubercular  infection,  since 
tuberculosis  will  never  affect  people  with  good  consti- 
tutions, but  only  those  with  poor,  broken-down  consti- 
tutions. People  with  good  constitutions  may  continu- 
ally inhale  the  bacilli  without  any  bad  effects  whatever. 
The  human  body  may  be  in  a  condition  that  is  termed 
health,  and  stilt  pathogenic  bacteria  may  be  present  ; 
these  are  kept  in  abeyance  by  the  defensive  action  of 
the  blood-serum  and  leucocytes.  It  is  this  repressive 
power  of  the  blood  that  keeps  them  from  propagating 
and  doing  injury  to  the  economy. 

Bacteria  often  seem  to  be  destroyed  by  ])hagocytosis. 
There  is  an  antibacterial  jiroperty  in  the  tissues,  fluids, 
and  secretions  of  the  body,  and  these  are  natural  de- 
fences against  the  growth  of  micro-organisms.  The 
contact  of  germs  does  not  lead  to  infection  unless  the 
material  i,  present  to  favor  their  develo])ment.  One 
of  these  causes  is  a  poor  or  broken-down  constitution. 
When  this  is  present  any  existing  bacteria  will  multiply 
and  thrive.  Another  cause  is  the  presence  of  the  pro- 
ducts of  fermentation,  inflammatory  exudates,  and  di- 
minished blood-supply.  If  the  constitution  is  im- 
proved, and  the  pabulum  upon  which  the  bacteria 
thrive  removed  or  its  formation  stopped,  their  develop- 
ment is  hindered  or  entirely  checked,  and  thus  the 
severer  forms  of  inflammation  are  obviated.  A  plant 
cannot  grow  upon  a  rock  or  thrive  upon  barren  soil, 
and  so  it  is  with  all  forms  of  life,  even  the  minute  or- 
ganisms. The  substances  upon  the  surfaces  of  wounds 
which  cause  the  development  of  micro-organisms  and 
thus  produce  infection,  are  readily  removed  by  the  most 
important  and  chief  means  for  all  sterilization,  that  is, 


the  mechanical  purification  by  washing  and  cleansing 
with  water.  Why  should  not  the  substances  in  the 
interior  of  the  organism,  which  are  the  pabulum  for 
bacterial  development,  also  be  removed,  at  least  to  a 
great  extent,  through  the  channels  of  the  body  which 
terminate  directly  in  the  emunctory  organs.  It  is  quite 
possible  that  the  sewage  system  of  the  tissues,  when 
properly  stimulated  in  the  work  of  elimination,  will 
carry  along  in  its  circulation  much  of  the  material 
which  causes  infection,  and  thus  produce  what  might 
be  termed  an  internal  sterilization  or  asepsis.  Many 
seem  to  think  that  because  a  germ  once  entered  the 
body,  it  cannot  be  removed  until  it  is  thoroughly  di- 
gested ;  l)ut  why  should  not  cleanliness,  applied  to  the 
internal  organs  whenever  possible,  aid  in  the  elimination 
of  the  micro-organisms  ?  If  we  cleanse  the  oral  cavity 
daily,  we  may  just  as  well  go  farther  and  cleanse  the 
stomach  and  intestines.  Tubercle  and  other  bacilli 
usually  enter  the  organism  by  the  canals  and  ducts 
which  communicate  with  the  outside  of  the  body.  The 
alimentary  canal  in  many  cases  is  the  primary  means 
of  entrance.  The  infection  then  extends  by  following 
various  routes.  The  bacilli  are  carried  along  the  lym- 
phatic channels  into  the  tissues  or  lymphatic  glands. 
These  glands  appear  to  have  the  power  of  arresting 
the  infection  for  a  time  at  least,  before  it  finally  passes 
into  the  blood,  and  this  would  seem  to  be  the  critical 
period  in  the  treatment.  Pure  or  sterilized  granite  or 
trap-rock  waters,  taken  hot  in  sufficient  quantities  and 
at  proper  times,  combined  with  systematic  muscular 
exercise,  hot  baths,  and  massage,  will  certainly  help  to 
cleanse  out  the  tissues  of  the  body. 

We  may  furthermore  take  advantage  of  the  bacteri- 
cidal properties  of  the  blood-serum.  This  protective 
property  of  nature  is  best  enhanced  by  enriching  the 
blood  by  the  various  means  within  our  power,  one  of 
the  most  important  of  which  is  scientific  dieting.  The 
ordinary  diet  of  individuals  is  often  extremely  bad,  the 
place  of  wholesome  food  being  taken  by  sweets  and 
stimulants,  such  as  sugar,  pastry,  tea,  coffee,  and  alco- 
holic drinks,  so  that  not  infrequently  patients  will  grow 
weak  and  the  constitution  will  suffer  simply  on  ac- 
count of  the  deprivation  of  proper  nourishment. 

The  plan  of  treatment  which  I  have  already  de- 
scribed in  the  A"<7i'  Vi>rk  Medidil  Journal  for  October, 
1894,  consists  in  giving  at  rather  frequent  intervals  a 
considerable  quantity  of  carefully  roasted  or  broiled 
beef  or  mutton,  raw  eggs,  stale  bread,  butter,  sterilized 
milk,  and  vegetables.  After  a  few  days  of  treatment 
the  meat  should  not  be  less  in  amount  than  a  pound  a 
day,  and  the  quantity  of  bread  and  vegetables  shoulu 
be  even,  if  possible,  somewhat  larger,  ^^"hen  there  is 
a  disgust  for  the  meat  diet  the  stomach  needs  special 
treatment,  for  a  short  time  only,  by  the  addition  of  a 
digestant  such  as  dilute  hydrochloric  acid  and  hot  water 
to  remove  irritations. 

Tuberculosis  is  the  great  destroyer,  as  it  is  the  most 
frequent  of  all  fatal  diseases  ;  and  malnutrition  and 
defective  elimination,  which  will  sooner  or  later  break 
down  the  constitution,  are  at  its  foundation.  It  is  esti- 
mated that  in  tlie  United  States  nearly  five  hundred 
individuals  die  of  this  disease  every  twenty  four  hours. 
Its  extreme  prevalence  and  destructiveness  have  urged 
physicians  in  all  countries  to  make  strenuous  efforts  for 
its  prevention  and  extermination. 

It  has  been  mentioned  in  this  paper  a  number  of 
times  that  constitution  is  one  of  the  most  important 
points  in  the  development  of  tuberculosis.  It  may  be 
well  to  show  how  the  constitution  of  the  patient  can 
easily  be  determined  under  the  microscope.  Not  only 
may  this  be  done  by  the  colorless  blood-corpuscles,  but 
also  by  the  inflammatory  pus-corpuscles  which  we  will 
invariably  find  present  in  every  sputum  in  which  there 
is  an  inflammation  of  any  kind  whatever. 

These  views  were  first  announced  by  Carl  Heitz- 
mann  in  1879,  and  have  since  been  corroborated  by  a 
number  of  independent  observers  both  here  and  abroad. 


November  9,   1895] 


MEDICAL   RECORD. 


655 


They  are  the  following  :  The  amount  of  living  matter 
within  a  limited  bulk  of  a  corpuscle  varies  greatly  in 
different  individuals.  It  is  obvious  that  what  is  called 
a  healthy  or  vigorous  constitution  is  based  upon  a  large 
amount  of  living  matter  in  the  body,  the  new-growth 
of  which  in  morbid  processes  is  very  lively  ;  w}iile  a 
phthisical  or  so-called  scrofulous  diathesis  must  be 
caused  by  a  relatively  small  amount  of  living  matter, 
the  new- growth  of  which  is  scanty  in  morbid  processes. 
In  other  words,  a  corpuscle  will  exhibit  coarse  granula- 
tion, or  it  will  be  almost  homogeneous-looking,  under 
the  microscope,  owing  to  the  large  amount  of  living 
matter  in  strong  individuals  of  good  constitution  ;  while 
a  corpuscle  taken  from  a  person  with  a  weak  or  tuber- 
culous constitution  will  be  pale  and  finely  granular, 
as  but  little  living  matter  is  present  in  it.  In  a 
given  case,  therefore,  the  more  numerous  the  coarse- 
ly granular  pus-corpuscles  or  colorless  blood-corpus- 
cles present,  the  better  the  constitution  ;  and,  on  the 
other  hand,  the  more  abundant  the  finely  granular 
ones,  the  worse  the  constitution  :  and  when  the  corpus- 
cles become  broken  up  and  disintegrated  we  can  say 
that  death  is  not  far  distant.  As  long,  then,  as  u'e  find 
the  coarsely  granular  homogeneous  corpuscles  pre- 
dominating, so  long  there  will  be  no  danger  of  the  in- 
dividual contracting  tuberculosis  ;  and  when  upon  ex- 
amination we  find  that  the  corpuscles  do  not  contain  a 
sufficient  amount  of  living  matter,  that  is,  they  have 
become  more  or  less  finely  granular,  we  should  at  once 
resort  to  all  possible  means  to  increase  the  living  mat- 
ter, as  otherwise  tuberculosis  may  set  in  at  any  time. 

Klebs,  in  the  Journal  of  the  American  Medical  As- 
sociation for  October  12,  1895,  says,  in  speaking  of 
antiphthisin  in  tubercular  affections  of  children  : 

"  It  would  certainly  be  unreasonable  to  demand  that 
this  remedy,  which  has  a  specific  germicidal  effect  upon 
the  tubercle  bacillus  only,  shall  also  remove  and  cause 
the  cure  of  pathologic  changes,  which  result  remotely 
from  the  primary  cause  and,  more  unreasonable  still, 
that  the  remedy  shall  also  favorably  influence  and  cure 
complications,  which  like  infection  with  other  pathogenic 
germs  have  no  relation  to  tuberculosis  at  all,  more  than 
that  they  may  be  associated  in  the  same  patient. 

"  In  all  such  cases  it  is  necessary  to  remove  the  com- 
plications by  other  treatment,  either  before  or  in  con- 
junction with  the  application  of  the  specific  remedy  ; 
but  the  final  results  are  determined  by  the  importance 
and  curability  of  such  attending  pathologic  processes. 

"  W'e  see  thus,  that  the  use  of  a  specific  germicidal 
remedy  can  only  be  fully  effective  when  the  disease  is 
still  uncomplicated  by  sei  ondary  degenerations,  and 
is  free  from  complications  which,  unfortunately,  are 
present  in  most  cases  of  tubercular  disease  as  they 
come  under  our  notice  ;  there  are,  however,  not  a  few 
cases  of  purely  tubercular  affections  in  an  early  stage 
in  which  the  results  of  specific  medication  are  highly 
satisfactory.  .  .  .  For  these,  as  in  all  other  thera- 
peutic efforts,  the  only  unavoidable  condition  is  that 
the  organism  itself  shall  still  have  the  power  to  use 
and  appropriate  the  introduced  curative  substance  ; 
for  under  no  circumstances  can  we  otherwise  conceive 
the  cure  of  disease,  than  that  the  living  organism  must, 
itself,  take  an  active  part  in  its  removal." 

In  closing  his  paper  he  says,  "  Finally,  I  wish  to 
point  out  that,  in  all  tubercular  affections  the  same  as 
in  many  other  severe  and  serious  diseases,  their  treat- 
ment in  hospitals  or  special  institutions  offers  great 
advantages  over  that  of  private  practice." 

The  means  of  improving  the  general  constitution 
have  already  been  jjartly  stated  above,  but  I  wish  to 
dwell  especially  upon  tlie  good  results  obtained  from 
regular  systematic  physical  exercise.  The  medical 
profession  has  always  deemed  physical  education  a 
hygienic  measure  of  the  greatest  importance. 

The  well-known  Dr.  Gustaf  Zander  says  :  "  I'-xpe- 
rience  having  shown  that  regular  muscular  exercises, 
gradually  made  more  strenuous,  not  only  develoj)  and 


strengthen  the  muscles,  but  promote  the  removal  of 
pathological  changes  in  the  tissues,  give  tone  to  the  ner- 
vous system,  and  vitali/.e  the  circulation  of  the  blood  and 
lymph,  and  the  activity  of  many  organs,  it  is  natural  that 
such  exercises  should  be  included  among  therapeutic 
agents.  For  this  purpose  there  was,  however,  requisite  the 
power  to  execute  these  exercises  according  to  jihysio- 
logical  laws,  and  to  modify  their  action,  like  that  of  any 
other  therapeutic  agent,  according  to  the  needs  of  each 
individual  case."  Therefore  those  persons  who  take 
up  physical  culture  without  a  competent  medical  in- 
structor, may  do  themselves  serious  injury,  or  at  least 
obtain  no  special  benefit  from  it,  by  attempting  meth- 
ods unsuited  to  their  physical  condition,  or  neglecting 
to  carry  out  a  practical  system  in  a  proper  manner. 
Physical  culture  at  home  soon  becomes  a  matter  of 
drudgery  to  the  weak  and  illy  developed,  who  espe- 
cially require  it.  As  the  interest  is  lost,  it  is  neglected 
or  carried  out  in  a  desultory  manner,  and  thus  the 
beneficial  results  are  not  obtained  Under  a  compe- 
tent medical  instructor  there  is,  along  with  sustained 
interest,  a  rapid  and  harmonious  development  of  those 
portions  of  the  body  which  most  need  it.  Hysterical 
wotnen  and  neurasthenic  patients  of  both  sexes  espe- 
cially, and  also  children,  should  not  be  allowed  to  take 
this  exercise  at  home,  as  they  perform  it  without  system, 
overdoing  it  one  day  and  entirely  neglecting  it  the 
next.  Very  judicious  passive  exercise  should  begin 
the  treatment,  which  should  be  gradually  increased  :  at 
the  same  time  they  are  under  control,  which  strength- 
ens their  will-power,  and  they  have  to  obey  instead  of 
ordering  others  about. 

The  indications  and  contra-indications  for  muscular 
exercise  should  be  carefully  determined.  Exercise 
does  not  do  everything  ;  sometimes  rest  and  drugs  are 
needed.  Therapeutics  always  belong  to  the  physician, 
and  not  to  the  layman.  The  pleasurable  massage  fol- 
lowing the  bath  is  something  difficult,  and  with  many 
impossible,  to  obtain  at  liome,  and  it  should  not  be  in 
the  hands  of  laymen. 

To  overcome  the  deformity  of  round  shoulders, 
the  muscles  of  the  back  and  abdomen  must  be 
systematically  exercised  and  strengthened.  The  flat- 
tening of  the  chest,  which  is  the  result  of  the  shoulders 
falling  forward,  tends  to  the  production  of  lung  dis- 
ease, by  interfering  with  their  complete  expansion.  To 
overcome  this  deformity,  the  patient  should  stand  with 
head  erect,  with  the  abdomen  drawn  back  and  chest 
projecting,  and  then  forcibly  draw  the  shoulders  back 
as  far  as  possible,  as  if  to  make  the  shoulder-blades 
meet.  This  should  be  performed  from  ten  to  fifty 
times  daily  ;  in  fact,  at  frequent  intervals  during  the 
day,  whether  exercising  or  not.  All  shoulder-braces 
are  useless  for  this  purpose. 

For  broadening  the  chest,  assume  the  erect  posture. 
The  movement  should  be  as  follows  :  starting  with  the 
hands  in  front  of  the  hips,  to  force  them  by  a  lateral 
and  backward  movement  as  high  above  and  behind 
the  head  as  possible.  A  modification  of  this  move- 
ment, which  is  easier  and  more  graceful,  consists  in 
starting  with  the  arms  extended  behind  the  back,  and 
letting  them  go  up  alternately  as  far  as  possible,  while 
keeping  the  elbows  perfectly  rigid.  .Ml  these  exer- 
cises are  best  performed  with  light  dumb-bells,  from 
two  to  five  pounds  in  weight.  This  last  movement  is 
of  especial  advantage  in  drawing  upward  and  outward 
the  sides  of  the  chest,  thus  increasing  its  capacity. 

Another  beneficial  exercise  for  dcejiening  the  chest 
and  straightening  back  the  shoulders,  is  to  stand  with 
arms  projecting  straight  forward,  elbows  perfectly  stiff. 
Let  the  arms  go  straight  backward  as  far  as  they  will, 
on  a  level  with  the  shoulders.  .Meanwhile,  the  erect 
posture  must  be  maintained — head  erect,  chest  pro- 
jecting, and  chin  drawn  in.  This  is  a  splendid  exer- 
cise for  increasing  the  lung  capacity.  These  move- 
ments should  be  repeated  until  the  particular  muscles 
involved   become   fatigued,  when  the   instructor   will 


656 


MEDICAL    RECORD. 


[November  9.  1895 


change  them  and  bring  into  use  another  set  of  mus- 
cles, and  so  on.  The  respirations  should  be  full  and 
free,  and  the  air  perfectly  pure.  A  system  of  this  kind, 
carried  out  in  a  scientific  manner,  strengthens  not  only 
the  mu.scles,  but  all  the  vital  functions,  and  is  adapted 
not  only  to  adults  but  to  children  as  well.  Respiration 
and  digestion  are  improved  with  the  increase  of  vital- 
ity, and  the  elimination  of  the  waste  of  the  body  is 
greatly  enhanced.  By  specific  exercises  the  chest  cav- 
ity is  broadened  and  deepened,  and  the  chest  expan- 
sion and  manner  of  breathing  greatly  improved  and 
])ermanently  benefited.  Not  only  the  lungs,  but  the 
l.)rain  and  nervous  system  are  powerfully  influenced  by 
systematic  bodily  exercise  The  brain  will  accomplish 
only  imperfect  results  if  the  body  is  not  in  a  state  of 
health. 

Everywhere  we  see  the  lack  of  physical  culture,  men, 
women,  and  children,  with  narrow  chests,  pale,  emaci- 
ated faces,  and  a  general  look  of  exhaustion,  are  met 
daily.  If  extreme  leanness  is  not  present,  obesity  pro- 
duces ugliness  of  the  human  form.  A  comely,  erect, 
well-formed  body  is  much  less  common.  Judicious, 
systematic  muscular  exercise,  and  a  proper  dietary, 
give  vigor,  activity,  and  courage,  botli  mental  and 
physical. 

The  supply  of  oxygen  is  greatly  increased  by  deep, 
full  inhalations  in  the  open  air,  thus  increasing  the  lung 
capacity,  purifying  the  blood,  and  strengthening  the 
nervous  system.  The  temperature  of  the  body  is 
equalized  as  a  result  of  the  muscular  exercise,  and  the 
eliminative  system  stimulated  to  increased  activity  ; 
while  digestion  and  assimilation  are  brought  to  their 
highest  point  of  efficiency. 

I  desire  to  refer  at  this  point  to  Dr.  Wischnewetzky, 
who  first  established  a  complete  mechanico-therapeutic 
Zander  institute  in  this  country,  and  directed  it  for 
five_  years,  but  at  present  has  no  connection  with  the 
institution.  Therefore  he  cannot  be  held  responsible 
for  its  present  methods  of  advertising  in  the  daily 
newspapers.  He  says,  in  "  Contributions  to  Mechanico- 
therapeutics  and  Orthopedics,"  vol.  i..  No.  2  :  "  By 
affording  a  basis  for  the  scientific  medical  application 
and  discussion  of  Mechanico  therapeutics.  Dr.  Zander 
has  placed  the  subject  above  the  level  of  a  peculiarly 
Swedish  method,  and  has  enriched  the  science  of  medi- 
cine. Hence,  although  Dr.  Zander  is  a  Swedish  phy- 
sician,'his  method  can  no  more  be  called  Swedish  than 
pathological  anatomy,  which  has  been  so  effective- 
ly promoted  in  German)',  is  German,  or  antiseptic 
surgery  English,  because  Joseph  Lister  was  born  in 
England.     . 

"  The  physician  has  here  forced  the  mechanical  prog- 
ress of  our  age  into  the  service  of  medicine  for  the 
solution  of  problems  of  an  anatomical  nature.  He  en- 
ables us  to  exercise  any  given  group  of  muscles  strictly 
in  accordance  with  the  laws  of  physiology  ;  to  exclude 
any  other  group  at  will  ;  to  determine  which  groups 
are  called  into  action,  and  to  what  extent  in  every  move- 
ment made. 

B)  subjecting  to  localization,  measurement,  and  con- 
trol a  therapeutic  agent  which,  for  want  of  these  quali- 
fications, was  not  susceptible  of  rigid  scrutiny.  Dr. 
Zander  has  created  the  basis  for  the  use  of  mechanical 
treatment  as  an  agent  capable  of  fulfilling  all  the  con- 
ditions imposed  by  the  most  exigent  scientific  crit- 
icism. 

"The  importance  of  systematically  organized  mus- 
cular exercise  is  no  longer  a  subject  of  debate.  The 
question  always  open  for  the  conscientious  physician 
is  :  '■  How  shall  such  treatment  be  administered  with 
out  risk  of  harm  and  with  all  the  benefit  which  is  in 
many  cases  obtainable  from  it  ?  " 

In  this  article  nothing  has  been  slid  of  the  medical 
treatment  by  inhalations,  creosote,  terebene,  and  its 
allies,  etc.,  which  is  often  curative  and  of  great  im- 
jjortance  in  this  disease. 

776  M.^DISON   AVKNUE. 


A  REPORT  OF  A  SERIES  OF  CASES  OF  MUL- 
TIPLE NEURITIS  IX  INFANTS  IN  THE  CITY 
OF    BRIDGEPORT,   CONN.' 

By  GR.EME  M.   H.\MM0XD.  M.D., 


Isolated  cases  of  multiple  neuritis  in  infants  are  of 
rare  occurrence.  A  sequence  of  such  cases  occurring 
within  a  limited  geographical  area  is  particularly  inter- 
esting, both  from  clinical  and  etiological  points  of  view. 
Cases  of  neuritis  in  children  are  perhaps  more  common 
than  is  generally  believed.  Browning,  of  Brooklyn, 
pointed  out  a  short  time  ago  that  many  cases  of  so- 
called  anterior  poliomyelitis  in  childhood  were,  in  real- 
ity, cases  of  neuritis,  probably  of  malarial  origin,  and 
Sachs,  in  his  text-book,  refers  to  many  cases  of  neuritis 
in  children,  who  have  been  exposed  to  some  toxic  poi- 
son. But  I  have  not  been  able  within  the  limited  time 
since  this  series  of  cases  became  known  to  me,  to  dis- 
cover, at  least  in  this  country,  any  similar  group  of 
cases  occurring  in  such  a  circumscribed  locality. 

Epidemic  neuroses,  with  the  exception  of  cerebro- 
spinal meningitis,  are  of  very  infrequent  occurrence. 
In  this  country  an  epidemic  of  poliomyelitis  was  re- 
ported over  fifty  years  ago  by  Dr.  Colmer,  and  then  not 
again  until  1894,  when  a  similar  epidemic  occurred  in 
Vermont,  the  details  of  which  were  reported  in  full  by  Dr. 
Caverly  in  the  Medical  Record  of  December  4,  1894. 
In  Europe  epidemics  of  poliomyelitis  have  been  re- 
ported by  Briegleb  in  1890,  and  in  Stockholm  by  Medin 
in  1 89 1.  None  of  these  were  described  to  be  epidem- 
ics of  multiple  neuritis,  nor  can  I  find  any  trace  in  lit- 
erature of  epidemics  similar  to  the  series  of  cases  I 
propose  presenting  to  you  this  evening.  The  Vermont 
epidemic  affected  many  of  the  lower  animals  as  well  as 
the  human  species.  I  am  inclined  to  believe,  from  a 
study  of  Dr.  Caverly's  cases,  that  only  a  certain  pro- 
portion were  examples  of  poliomyelitis  pure  and  sim- 
ple. In  that  epidemic  there  seemed  to  be  some  undis- 
covered morbid  agent  which  profoundly  impressed  the 
nervous  system  affecting  different  individuals  with  a 
similar  inflammatory  process,  but  implicating  different 
portions  of  the  cerebro-spinal  system.  Thus  it  seems 
to  me,  merely  from  reading  Dr.  Caverly's  account  of 
the  epidemic,  that  there  were  cases  not  only  of  polio- 
myelitis, but  also  of  spinal  meningitis  and  cerebral 
meningitis,  either  independently  or  in  combination. 
Medin's  analysis  of  forty-four  cases  in  the  Stockholm 
epidemic  shows  there  was  more  than  simple  poliomye- 
litis. There  were  ophthalmoplegias,  facial  and  laryn- 
geal paralyses,  and  in  a  few  cases  distinct  implication 
of  the  vagus,  symptoms  which  are  quite  foreign  to  typ- 
ical poliomyelitis. 

The  present  series  of  cases,  comprising  ten,  occurred 
between  December,  1894,  and  the  present  time.  This 
is  hardly  sufficient  to  be  regarded  as  an  epidemic,  and 
yet  the  nature  of  the  disease  is  such,  and  its  occurrence 
in  infancy  is  so  rare,  that  ten  cases  discovered  in  one 
locality  and  all  within  a  few  months  may  properly  be 
regarded  as  an  epidemic.  They  may  certainly  be  re- 
garded as  extraordinary,  and  the  |)resumption  does  not 
seem  unreasonable  that  some  atmospheric  germ  as  un- 
known to  us  as  that  which  caused  the  N'ermont  epi- 
demic, and  probably  similar  to  it,  is  responsible  for  the 
cases  I  propose  to  bring  to  your  notice  this  evening. 

Last  January,  Dr.  J.  \V.  Wright,  of  Bridgeport,  asked 
me  to  see  his  little  girl,  then  twenty-one  months  of  age. 
The  history  of  the  case  was  as  follows  :  She  had  al- 
ways been  a  strong  and  vigorous  child.  About  Christ- 
mas she  did  not  appear  to  be  feeling  well,  and  after  a 
few  days  of  discomfort,  complained  of  pain  in  her  feet. 
The  pain  ascended  and  seemed  to  aitect  both  feet  and 
legs  equally.  With  tl.e  advent  of  the  pain,  progressive 
paralysis  appeared,  beginning  in  both  feet  and  gradu- 
ally extending  upward.    When  I  saw  her  both  legs  were 

'  Read  before  tlie  New  York  Neurological  Society,  October  i,  1895. 


November  9,  1S95J 


MEDICAL   RECORD. 


657 


absolutely  paralyzed.  The  muscles  of  the  back  were 
so  weakened  that  she  could  not  sit  up,  both  arms  were 
greatly  weakened  but  retained  feeble  motion.  The 
child  seemed  to  be  free  from  pain  so  long  as  she  re- 
mained quiescent,  but  as  soon  as  the  limbs  were  moved 
or  even  pressed,  particularly  over  the  nerve-trunks,  she 
shrieked  with  pain.  There  was  apparently  little  or  no 
pain  in  the  arms.  The  gums  were  swollen  and  ex- 
quisitely tender.  Tests  in  regard  to  the  different  forms 
of  sensibility  could  not  be  made  both  on  account  of 
the  youth  of  the  patient,  and  because  of  the  suffering 
such  an  examination  would  necessarily  entail.  I  saw 
the  patient  about  two  weeks  later,  in  consultation  with 
Dr.  Garlick.  Her  condition  was  unchanged,  e.xcept 
that  she  had  been  seized  with  a  double  pneumonia, 
which  may  or  may  not  have  been  part  of  the  infec- 
tious process.  From  this  she  recovered.  A  few  weeks 
later  the  symptoms  of  neuritis  began  to  diminish.  The 
pain  subsided,  motion  gradually  returned,  and  in  about 
four  months  she  seemed  restored  to  her  normal  con- 
dition. 

C.\SE  II. — About  a  hundred  yards  from  Dr.  Wright's 
residence,  I  found  a  child,  three  and  a  half  years  of 
age,  who  had  had  the  first  case,  as  far  as  I  could  ascer- 
tain. His  initial  symptoms  began  a  few  weeks  before 
those  of  the  case  just  described,  and  differed  but  little 
and  immaterially  in  their  clinical  features.  This  case 
also  recovered. 

The  notes  of  the  next  six  cases  have  been  given  to 
me  by  Dr.  John  C.  Lynch.  They  were  all  cases  oc- 
curring in  his  practice  in  Bridgeport. 

C-^SE  III. — Francis  P ,  9  Grand  Street,  Bridge- 
port, Conn.;  aged  fourteen  months  ;  Irish  parents,  fam- 
ily history  good  ;  no  syphilis,  father  intemperate.  The 
child  is  the  youngest  of  four  and  has  always  been  healthy 
till  the  present  trouble.  Thursday,  May  30th,  his  mother 
took  him  in  a  baby- carriage  to  see  a  parade.  The  child 
was  restless  that  night  and  slept  poorly,  but  the  mother 
thought  it  was  due  to  teething.  Three  or  four  days 
before  this  the  child  rolled  out  of  the  bed,  but  did  not 
seem  to  be  hurt  very  much  as  he  did  not  wake  up  or 
cry.  The  next  day  the  mother  noticed  that  he  could 
not  use  his  right  hand,  then  his  left  hand  became  af- 
fected, and  finally  both  legs  were  paralyzed.  On  June 
2d  his  mother  brought  him  to  my  office.  The  tem- 
perature was  103°  F. :  pulse,  127  ;  respiration,  3S,  with 
paralysis  of  both  upper  and  lower  extremities.  There 
was  hypersesthesia  and  tenderness  and  stiffness  on  mo- 
tion. Reflexes  were  abolished  and  the  characteristic 
wrist  and  foot  drop  were  present.  Faradic  excitability 
was  lost,  but  the  paralyzed  muscles  responded  slowly  to 
strong  currents  of  galvanism.  His  condition  remained 
about  the  same  for  ten  days.  It  then  remained  station- 
ary for  fourteen  days,  and  then  slight  improvement  was 
noticed  in  the  right  arm,  left  leg,  and  right  leg.  The 
pain  was  very  severe,  markedly  so  at  night,  requiring 
one-quarter  grain  morphia  six  times  a  day  to  control  it. 
The  child  recovered. 

Case  1\'. — .-Vnnie  S ,  aged  twenty  months  ;  born 

in  the  city  :  mother  American  and  father  Irish.  No 
hereditary  history.  On  June  13,  1895,  the  child  was 
taken  with  a  chill  which  recurred  every  other  day  for 
three  days.  On  June  16th  consulted  Dr.  W.,  who  said 
^he  had  malaria  in  the  worst  form.  Tuesday  evening, 
June  19th,  patient  was  brought  to  my  office,  at  that  time 
lad  projectile  vomiting,  strabismus,  and  arching  of  the 
-;iine  backward.  The  temperature  was  105°  F.  ;  pulse, 
<jG  ;  respiration,  24.  The  bowels  were  costive,  tongue 
neavily  coated,  urine  highly  colored  and  stained  the 
linen.  The  diagnosis  of  meningitis  was  made.  On 
June  20th,  the  condition  was  unchanged,  the  child  very 
restless  and  seemed  to  be  in  extreme  pain.  On  June 
22d,  I  noticed  loss  of  power  of  the  right  arm.  A  mi- 
croscopical examination  of  blood  showed  the  presence 
jf  Plasmodia.  On  June  23d  both  legs  became  |)ara- 
iyzed.  There  was  intense  pain  on  passive  movements 
■jf  the  linlbs,  and  also  on  pressure  particularly  along  the 


course  of  the  nerves.  The  reflexes  were  absent  and 
the  muscles  failed  to  respond  to  faradism,  and  the  reac- 
tions to  galvanism  were  greatly  diminished.  The  pa- 
tient's condition  remained  practically  unchanged  up  to 
July  16th,  then  slight  motion  of  the  hands  was  observed. 
Patient  has  continued  to  improve  gradually  up  to  the 
present  time,  with  complete  use  of  both  arms,  but  is  still 
unable  to  use  the  legs. 

Case  V. — Francis  G ,  aged  twenty-two  months  ; 

born  in  the  city  :  parents  Irish  :  heredity  negative.  On 
May  16,  1895,  had  a  mild  attack  of  scarlet  fever.  On 
Tune  1 6th,  after  his  usual  afternoon  sleep,  awoke  with 
headache  and  fever.  His  temperature  was  ioi°  F.; 
pulse,  no:  respiration,  28.  The  next  day  the  pa- 
tient was  comparatively  well.  Microscopical  examina- 
tion showed  Plasmodia.  One  week  later,  he  was  seized 
with  the  loss  of  power  of  both  legs.  His  mother  said 
she  thought  the  right  leg  was  first  involved,  and  then 
the  left  one.  She  had  noticed  the  loss  of  power  com- 
ing on  for  three  or  four  days.  He  remained  about  the 
same  for  three  weeks,  then  he  began  gradually  to  im- 
prove. He  has  now  fair  motion  of  both  legs.  There 
was  diminished  reaction  to  the  galvanic  current  and 
slight  response  to  a  very  strong  faradic  current. 

Case  VI. — Thomas  O'Brien,  aged  four  jearsand  six 
months  ;  parents  Irish,  healthy  ;  no  history  of  intemper- 
ance or  specific  trouble.  Youngest  but  one  of  eight 
childien,  two  of  whom  are  dead.  One  was  still-born 
and  the  other  died  of  cholera  infantum,  aged  seven 
months.  One  child  aged  eight  idiotic.  The  child  in 
question  presents  stigmata  of  degeneration.  On  June 
23d,  it  complained  of  appetite  and  general  sore- 
ness, and  there  was  vomiting  and  fever  several  days. 
When  I  was.  called,  there  was  loss  of  power  of  both  legs, 
the  temperature  was  101°  F.;  pulse,  120  ;  respiration,  40. 
The  muscles  of  both  legs  refused  to  respond  to  faradisin, 
but  did  respond  to  galvanism.  Plasmodium  malaria  in 
the  blood.  There  was  a  loss  of  the  reflexes,  and  there 
was  foot  drop  of  the  left  foot.  The  child  slowly  im- 
proved, and  at  the  present  time  is  able  to  stand. 

Case  VII. — John  S ,  aged  twenty  months  ;  born 

in  Hartford  ;  parents  American,  healthy.  Xo  specific 
history  or  intemperance.  Patient  youngest  of  three  chil- 
dren. '  Healthy,  except  congenital  club-foot,  which  has 
been  corrected  by  operation.  On  August  21st  he 
awoke  with  severe  pains  at  3  a.m.  Mother  sup- 
posed it  due  to  colic  and  gave  castor-oil  and  paragoric. 
I  saw  the  patient  three  days  afterward  and  found 
him  suffering  from  loss  of  power  of  both  legs  and  right 
arm.  Temperature,  102°  F.;  pulse,  130  ;  respiration,  ^z- 
There  was  some  opisthotonos,  and  also  severe  pain  on 
attempting  to  move  the  limbs  or  on  lifting  the  child. 
There  was  slight  response  to  faradisin,  diminished  re- 
action to  galvanism.  The  patient  gradually  improved, 
and  now,  nearlv  six  weeks  after  the  disease  began,  can 
sit  up  and  has  regained  the  complete  use  of  the  right 
hand.     The  legs  are  improving. 

Case  VIIL— Charles  M ,  twin  child  ;  aged  nine- 
teen months;  parents  American  :  good  family  history. 
Last  January,  1895,  had  acute  pneumonia.  He  is  the 
youngest  of  six  children.  One  child  died  of  meningitis 
and  complicated  otitis  media.  On  August  22d  he  was 
taken  sick  with  fever,  vomited  three  or  four  tinies  dur- 
ing the  afternoon  and  evening.  I  saw  the  patient  at  9 
P..M.  His  temperature  was  100°  F.;  pulse,  105.  He  was 
restless  and  seemed  to  be  in  considerable  pain.  The 
mother  thought  the  child  suffered  most  pain  on  being 
moved  or  lifted  up.  Threeor  fourdays  later  it  was  no- 
ticed that  the  child  could  not  draw  his  legs  up,  and 
finally  both  legs  became  paralyzed.  The  muscles  re- 
sponded slightly  to  strong  faradic  currents  and  also  to 
galvanism.     This  patienthas  not  yet  recovered. 

Case  IX. — This  case  occurred  in  the  practice  of  Dr. 
[.  W.  Wright.  The  patient  was  four  months  and  a 
half  old.  The  disease  came  on  with  fever,  which  va- 
ried from  101°  to  105°  F.  The  pain  in  this  case  began 
in  the  trunk  on  both  sides  of  the  body  over  the  ribs. 


658 


MEDICAL    RECORD. 


[November  9.    1895 


Touching  the  skin  over  this  region  gave  rise  to  great 
pain.  There  was  vomiting,  the  head  and  back  were 
stiff,  and  there  was  persistent  insomnia.  All  the  limbs 
could  be  moved,  but  the  child  would  become  rigid 
when  he  was  picked  up.  The  paralysis  gradually 
ascended  and  finally  involved  the  muscles  of  degluti- 
tion, and  the  infant  died  about  one  month  after  the  be- 
ginning of  the  disease. 

C.ASE  X. — This  case  I  saw  in  consultation  with  Dr. 
Samuel  M.  Garlick  and  I)r.  John  C.  Lynch.  The  sick- 
ness began  with  fever  and  vomiting.  First  one  leg  and 
then  the  other  gradually  became  paralyzed  until  all  mo- 
tion was  completely  arrested.  There  was  spontaneous 
pain  in  the  legs,  and  increased  pain  when  the  limbs  were 
moved.  The  nerve-trunks  were  sensitive,  the  reflexes 
were  absent,  and  electrical  contractility  was  entirely 
abolished.  The  arms  were  slightly  paralyzed  and  for  one 
day  swallowing  was  interfered  with.  Like  the  others, 
improvement  began  after  several  weeks'  illness  and  is 
still  going  on,  but  the  child  has  not  by  any  means  re- 
covered yet. 

A  brief  summary  of  the  most  important  details  of 
these  cases  is  stated  in  the  accompanying  table.  The 
average  age  of  the  ten  cases  is  two  years  and  three 
months.  Eight  out  of  the  ten  cases  began  in  the  warm 
weather  of  June  and  August.  Medin's  cases  of  polio- 
myelitis all  occurred  in  the  summer  months,  and  Saelis  ' 
states  that  seventy-five  per  cent,  of  his  cases  of  polio- 
myelitis began  between  the  months  of  July  and  Octo- 
ber. In  three  cases  both  arms  and  both  legs  were 
paralyzed  ;  in  two  cases  both  legs  and  the  right  arm 
were  affected  :  in  four  cases  only  the  legs  were  impli- 
cated, and  in  one  case  the  intercostal  muscles  were  the 


primary  seat  of  the  paralysis.  The  fourth  and  ninth 
cases  presented  typical  symptoms  of  meningitis.  The 
fourth  case  recovered,  and  the  ninth  case,  who  died, 
was  unfortunately  not  subjected  to  a  postmortem  ex- 
amination, but  it  is  quite  possible  that  in  both  these 
cases  the  meninges  were  affected. 

None  of  the  physicians  in  Bridgeport  whom  I  have 
questioned  have  ever  met  cases  presenting  these  clin- 
ical features,  until  this  series  of  cases  began  last  winter. 
In  regard  to  the  diagnosis,  I  do  not  see  how  any  other 
conclusion  can  be  reached  than  that  they  were  cases  of 
multiple  neuritis.  The  combination  of  sensory  and 
motor  symptoms  ;  the  gradual  and  symmetrical  exten- 
sion of  the  disease  ;  the  local  tenderness  over  the  nerve- 
trunks  ;  the  length  of  time  the  illness  lasted  ;  the 
gradual  and,  in  some  instances,  complete  recovery  of 
the  patients,  and  the  absence  of  characteristic  symp- 
toms of  other  diseases,  makes  a  diagnosis  of  neuritis 
comparatively  simple.  The  succession  of  cases  and 
their  great  similarity  point  to  a  common  cause  of  ori- 
gin. In  one  case  Dr.  Lynch  discovered  the  grippe  ba- 
cillus in  the  blood,  and  in  two  other  cases  the  blood 
showed  the  characteristic  evidences  of  malaria.  But 
this  proves  nothing.  Grippe  and  malaria  are  common 
among  infants,  but  such  a  series  of  cases  as  these  is  al- 
most unique.  Careful  inquiry  in  towns  in  the  neigh- 
borhood of  Bridgeport  fails  to  bring  to  light  any  similar 
cases.  In  FairSeld.  about  four  miles  from  Bridgeport, 
there  is  one  case  of  anterior  poliomyelitis.  I  did  not 
see  this  case.  The  diagnosis  was  made  by  Dr.  Gar- 
lick,  of  Bridgeport,  and  confirmed  by  Dr.  N.  P.  Gib- 
ney.  It  is  possible  that  the  etiology  of  this  case  may 
be  identical  with  that  of  the  cases  just  reported. 


Table  of  Gases. 


(3 

.    Age. 

Disease 
Began. 

Initial  Symptoms. 

Ixjcaiion  of  Paralysi>.. 

Improvement  Be^un. 

Duration  of  Disease. 

Associated  Symptoms. 

^ 

^                        ,^T-,^ 

r.otli    lower    limbs ;    both 

Three  months. 

Four  .nonths. 

None  obsened. 

upper    limbs    (sligliily) 

and  muscles  of  the  back. 

""i 

3>4  JTS. 

bariyin  Dec.. 
1804. 

None  observed. 

Hoih  legs. 

Two  months. 

Three  months. 

None  obser\'ed. 

3 

14  mos. 

June-  I,  ,893. 

Fever  Cioi"  F.). 

Both  upper  and  both  low- 
er limbs. 

In  about  one  month. 

Not  known  positively,  but 
about  three  months. 

None  observed. 

* 

20  mos. 

June  13,  ,893. 

Chills,  fever  (105"=  F.), 
and  vomiting. 

Right  arm.  then  both  legs. 

In  about  one  mnnth. 

Recoverj- not  completed  at 

the  end  of  three  months 
and  3  half. 

Strabismus  and  opistho- 
tonos. 

5 

22  mos. 

June  .6,i3o3. 

Headache  and  fex-er. 

Right  leg.  then  l-^ft  leg. 

Three  weeks. 

Three  months. 

None  obser\'ed. 

6 

4)4  VK. 

June 23.  ,895. 

Vo.Tiitiiig     and    fever 

(loi'  F.I. 
Pain   and   fever  ( 102" 

Both  legs. 

Not  known. 

I'our  months. 

None  observed. 

7 

20  mo5. 

Aug.  21,1895. 

Both  legs,  then  right  arm. 

Not  known. 

Recovery-  of  arm  at  end  of 

None  ob>er\-cd. 

:       *■>■ 

four   months  :    legs  still 
weak. 

19  mos. 

Aug.  22. 1895. 

Vomiting    and    fever 

Both  legs. 

Not  l>egun  yet. 

It  is  now  five  weeks  since 
the   disease  began  and 
patient  is  not  yet  well. 

None  obser\-ed. 

9 

4X  mos. 

Aug.,  1895. 

Fever  (105°  F.). 

.  Intercostal     muscles    and 
muscles  of  deglutition. 

No  improvement. 

Died  in  one  month. 

Vomiting  and  stiflfness  of 
the  Lack  :  rigidity  of  all 
the  muscles  when  child 
%v^s  lifted. 

10^ 

*)4  yrs. 

Aug.,  1895. 

Vomiting  and  fever. 

Both  legs,  upper  extrem- 

In  about  six  week>. 

Not  yet  recovered. 

None  observed. 

! 

i 

,      ities  slightly. 

THE  LIMITS  OF  DISEASES  OF  THE  RECTUM 
AS   A   SPECIALTY. 

By  CH.\RLES  B.  KELSEY,  M.D., 

NEW   YORK. 

For  two  years  now  we  have  had,  in  America,  a  quar- 
terly journal  devoted  chiefly  to  diseases  of  the  rectum, 
but  not  exclusively.  During  the  last  meeting  of  the 
-American  Medical  Association,  an  effort  was  made  to 
organize  a  Society  of  Rectal  Surgeons — whether  suc- 
cessful or  not  I  do  not  know. 

I  believe  I  may  venture  to  say,  without  fear  of  suc- 
cessful contradiction,  that  no  man  has  ever  attained 
any  great  prominence  in  surgery  who  has  confined 
himself  absolutely  to  diseases  of  the  rectum,  to  the  ex- 
clusion of  correlated  lines  of  work  and  study. 

Van  Baren,  up  to  the  time  of  his  death,  was  Amer- 

>  Nervous  Diseases  of  Cliildren. 


ica's  greatest  authority  on  the  rectum,  but  the  rectum 
was  never  his  "  specialty."  .\llingham  is,  perhaps,  the 
best  living  English  authority  in  the  same  field,  but  he, 
although  like  Van  Buren  the  author  of  a  standard  text- 
book on  diseases  of  the  rectum,  has  always  been  a  gen- 
eral surgeon. 

These  facts  lead  one  interested  to  consider  the  scope 
of  this  particular  branch  of  surgery,  and  to  question 
seriously  whether  the  surgery  of  the  rectum  alone  can 
ever  properly  take  its  place  among  the  w^ellestablished 
specialties. 

The  simple  fact  is  that  the  lower  four  inches  of  the 
alimentary  canal  do  not  afford  sufficient  scope  for  the 
mental  activity  of  a  man  of  active  mind  and  surgical 
tendencies.  To  sucli  an  one,  after  a  time,  piles,  fis- 
sures, fistula;,  and  pruritus  become  simply  routine  prac- 
tice, affording  very  little  field  for  original  thought. 

Ten  or  twenty  times  a  year  he  is  called  upon  to  do 
real  surgery — capital  surgery.  Colotomy  interests  him, 
both  in  deciding  when  it  should  be  done  artd  in  its 


I 


November  9,  1895] 


MEDICAL    RECORD. 


659 


actual  performance  :  and  an  extirpation  calls  forth  all 
his  powers.  There  is  probably  to-day  no  more  diffi- 
cult surgical  operation  than  extirpation  of  the  rectum, 
and  there  is  little  question  but  that  the  man  who  can 
do  that  well  is  more  than  equal  to  the  average  demands 
made  upon  the  technical  skill  and  nerve  of  the  general 
surgeon.  But  the  man  who  can  do  extirpations  and 
colotomies  will  not  be  content  to  pass  his  life  in  dis- 
cussing whether  the  ligature  or  ths  clamp  and  cautery 
is  the  better  operation  for  piles  ;  and  the  man  who  can- 
not do  these  operations  when  called  upon,  has  little 
claim  to  the  reputation  of  a  surgeon,  though  he  may  be 
a  very  successful  practitioner. 

The  fact  is  that  piles  are  only  piles  even  after  a  man 
has  become  familiar  with  them  and  knows  best  how  to 
cure  them  :  and  so  it  is  with  fistula,  fissure,  and  pruri- 
tus. The  specialist  will  do  better  in  all  these  cases 
than  the  general  practitioner  ;  he  will  know  better 
when  to  operate  and  how  to  operate  ;  and  will  get 
better  results  and  less  failures  :  but  his  work  will  still  be 
confined  in  the  main  to  rninor  surgery,  and  unless  he 
can  go  a  long  way  outside  of  and  beyond  these  cases, 
he  sinks  sooner  or  later  into  a  groove  and  must  lose  his 
place  and  his  interest  in  the  great  surgical  advances  of 
the  day. 

On  the  other  hand,  the  man  who  can  successfully 
treat  all  the  cases  that  are  sent  to  the  office  of  a  spe- 
cialist as  cases  of  diseases  of  the  rectum,  must  be  famil- 
iar with  a  very  wide  range  of  work,  and  must  be  ready 
at  any  moment  to  step  into  the  field  of  gynecology,  ab- 
dominal, and  genito- urinary  surgery,  and  compete  on 
equal  terms  with  those  who  make  a  specialty  of  these 
lines  of  work  ;  otherwise  he  must  transfer  a  certain 
large  proportion  of  his  cases  to  them  for  treatment  in 
the  first  place. 

Outside  of  the  plain  cases  of  piles,  fistula,  pruritus, 
etc.,  about  one  half  of  all  the  cases  that  come  to  my 
own  office  are  cases  complaining  of  the  one  symptom 
of  painful  or  irregular  defecation,  with  or  without  some 
palpable  disease  of  the  rectum  ;  and  I  do  not  hesitate 
to  say  that  these  are  the  cases  that  have  really  exer- 
cised my  thought  and  surgical  ability  in  a  constantly 
increasing  proportion  for  years. 

Painful  and  irregular  defecation  !  What  may  this 
not  mean  ?  What  may  be  necessary  to  relieve  it  ?  It 
may  mean  anything  from  a  fissure  to  uterine  fibroids, 
from  constipation  to  intestinal  obstruction  by  a  band 
in  the  abdomen  ;  and  for  its  cure  almost  any  opera- 
tion in  rectal,  abdominal,  gynecological,  or  genito- 
urinary surgery  may  be  necessary.  It  is  just  here  that 
the  surgeon  may  discover  the  great  difference  between 
curing  a  patient  and  curing  a  case  of  piles  by  operat- 
ing on  the  manifest  disease,  and  finding  his  patient  no 
better  after  the  operation  than  before. 

In  women  one  of  the  first  things  to  learn  is  to  make 
a  complete  and  satisfactory  examination  of  the  pelvic 
organs,  either  with  one  finger  in  the  rectum  or  by  con- 
joined manipulation  per  rectum  instead  of  per  vagi- 
nam.  In  all  of  these  cases  of  painful  or  irregular  de- 
fecation in  woman  which  come  to  a  rectal  specialist,  an 
examination  per  rectum  is  expected,  and  I  do  not  hesi- 
tate to  say  that  when  no  mechanical  or  painful  obstacle 
to  a  com|)lete  examination  is  found,  a  more  thorough 
and  satisfactory  examination  of  the  pelvic  viscera  may 
be  made  while  the  finger  of  the  surgeon  is  still  in  the 
rectum,  than  by  withdrawing  it,  changing  the  position 
of  the  patient,  and  introducing  the  finger  into  the  va- 
gina. To  the  man  with  a  long  finger  it  is  simply  sur- 
prising how  liigh  into  the  pelvis  he  can  reach  per  rec- 
tum, when  there  is  no  vaginal  vault  to  limit  his  digital 
exploration.  I  would  not  seem  to  argue  for  the  sub- 
stitution of  rectal  for  vaginal  digital  examination — as 
the  rule — in  uterine  cases,  but  would  call  attention  to 
the  fact  that,  when  the  finger  has  been  inserted  into  the 
rectum  for  an  examination  of  that  canal,  there  is  no 
reason  to  withdraw  it  and  make  a  vaginal  examination 
to  find  out  the  condition  of  the  tubes,  ovaries,  liga- 


ments, or  uterus.  To  discover  the  condition  of  the 
cervix  may  require  a  vaginal  examination,  and  it  may 
also  be  impossible  to  tell  which  end  of  the  pear-shaped 
uterus  is  pressing  upon  the  rectum  with  only  the  finger 
in  that  canal,  and  without  conjoined  touch  ;  but  all 
other  conditions  may  be  made  out  at  least  as  well,  if 
not  better,  by  the  finger  in  the  rectum  as  by  the  finger 
in  the  vagina.  Every  gynecologist  knows  this  fact,  and 
I  state  it  now  simply  from  the  standpoint  of  one  who 
for  years  has  been  in  the  habit  of  making  his  pelvic  ex- 
aminations in  this  way  instead  of  in  the  usual  way, 
simply  because  his  patients  come  to  him  for  a  rectal. 
and  not  necessarily  for  a  vaginal,  examination,  and  be- 
cause he  seldom  finds  it  necessary  to  interrogate  both 
canals.  The  gynecologist  proceeds  merely  in  a  re- 
verse order,  but  the  result  reached  is  the  same  in  both 
cases. 

Ever  since  the  country  began  to  be  flooded  with 
"  rectal  specialists,"  it  has  been  a  standing  joke  whether 
a  case  of  recto- vaginal  fistula,  or  of  laceration  through  the 
sphincters,  belonged  properly  to  the  gynecologist  or  the 
rectal  specialist.  The  answer,  I  conceive,  is  that  it  be- 
longs to  the  man  who  by  skill  in  technique  and  experi- 
ence is  best  fitted  to  do  the  necessary  operation.  To 
whom  does  a  case  like  the  following,  which  was  cured 
at  my  clinic  last  winter,  belong  ?  An  unmarried  woman, 
aged  thirty-eight,  had  for  ten  years  been  living  in  sani- 
tariums for  difficulty  in  defecation,  generally  consid- 
ered as  chronic  constipation.  She  was  a  miserable 
wreck,  and  most  of  her  time  confined  to  her  bed. 
Once  or  twice  a  week  she  had  a  movement  of  the 
bowels  by  laxatives  and  enemata,  and  as  a  result  of  the 
consequent  exhaustion,  generally  passed  the  balance  of 
her  time  in  her  room.  The  mere  introduction  of  a  fin- 
ger through  the  anus  showed  that  the  mechanical  ob- 
struction to  defecation  came  from  a  retroverted  mova- 
ble uterus,  closing  the  rectal  canal  like  a  ball-valve 
when  any  pressuie  was  brought  to  bear  upon  it  from 
above.  A  simple  ventral  fixation  has  made  the  woman 
a  new  creature. 

My  point  is  that  if  such  a  case  as  this  does  not  come 
properly  within  the  range  of  rectal  surgery,  then  the  rec- 
tum is  no  proper  specialty  for  any  surgeon  ;  but  that  if 
it  does,  and  if  the  so-called  rectal  specialist  is  prepared 
to  treat  all  the  cases  that  come  to  him  complaining  of 
symptoms  referable  directly  to  the  rectum,  then  is  his 
specialty  no  less  a  proper  one  than  gynecology,  and 
[jerhaps  rather  a  larger,  from  the  fact  that  his  cases  will 
include  as  many  men  as  women. 

This  case  is  merely  mentioned  as  one  of  a  type. 
Every  gynecologist  knows  how  many  of  his  cases  of 
proctocele,  laceration  of  the  cervix  or  perineum,  pro- 
lapsus of  the  uterus,  misplaced  and  bound-down  ova- 
ries, uterine  fibroids,  and  enlargement  of  the  uterus — 
in  fact  how  much  of  all  his  gynecology — comes  to  him 
complaining  [)rimarily  of  some  trouble  with  the  rectum. 
The  same  class  of  cases  come  as  often  to  the  rectal 
specialist  for  the  same  thing.  Shall  the  gynecologist 
send  his  cases  to  the  rectal  specialist  because  they  have 
pain  in  the  rectum  ?  If  so  he  curtails  his  specialty  at 
least  one-half.  On  the  other  hand,  shall  the  rectal 
specialist  send  the  same  cases  to  the  gynecologist  be- 
cause they  do  not  hapjien  to  have  either  piles  or  fissure  ? 
If  so  he  becomes  merely  a  "pile-doctor"  and  is  little 
of  a  surgeon,  nor  is  liis  specialty  worthy  the  name,  for 
all  that  he  does  can  be  done  as  well,  with  a  little  prac- 
tice, by  anybody  else. 

The  question  is  larger  than  this,  however,  for  not 
only  must  the  rectal  specialist  be  prepared  to  do  the 
minor  surgery  of  the  gynecologist,  but  also  the  major, 
l-'or  example,  take  the  following  case,  also  cured  at  my 
clinic,  last  winter.  A  young  married  woman  tells  me 
that  for  twelve  years  she  has  had  occasional  attacks  of 
severe  pelvic  pain,  confining  her  to  bed  for  a  longer  or 
shorter  time,  and  that  each  has  been  followed  by  a  free 
discharge  of  pus  from  the  rectum,  after  which  the  se- 
verity of  the  suft'ering  decreased,  the  discharge  gradu- 


66o 


MEDICAL   RECORD. 


[November  9,  1895 


ally  diminished,  and  she  sank  back  into  her  usual  state 
of  semi- invalidism  with  all  the  symptoms  common  to 
cases  of  old  pelvic  trouble.  The  case  was  sent  to  me 
by  her  physician,  as  one  of  abscess  of  the  rectum,  but 
examination  revealed  the  source  of  the  pus  to  be  an 
old  pelvic  inflammation  which  had  filled  the  floor  of 
the  pelvis  with  exudate,  and  which  contained  two  ab- 
scess cavities.  Under  ether  the  smaller  of  these  was 
punctured  through  the  rectum,  the  opening  thus  made 
dilated  with  forceps  introduced  while  closed  and  re- 
moved while  open,  and  the  cavity  stuffed  with  iodo- 
form gauze.  After  recovery  from  this  a  laparotomy 
was  done  for  the  removal  of  tubes  and  ovaries,  or  at 
least  for  the  exploration  and  proper  treatment  of  the 
second  pus  cavity,  by  whatever  plan  might  seem  indi- 
cated after  opening  the  abdomen.  It  was  found  that 
all  that  could  be  hoped  for  by  this  method  was  the 
evacuating  of  the  abscess  into  the  free  peiitoneum,  with 
drainage  through  the  abdominal  incision,  and  this  was 
abandoned,  the  abdomen  closed,  and  the  second  ab- 
scess treated  like  the  first  by  free  incision,  and  drainage 
into  the  rectum.  The  result  was  good,  and  although 
the  patient  will  never  be  entirely  free  from  symptoms 
caused  by  the  old  trouble,  she  has  been  relieved  of  her 
chief  cause  of  suffering. 

This  certainly  is  gynecology,  but  is  it  not  as  much 
rectal  surgery  ?  Is  the  rectal  specialist  to  say  to  a  case 
like  this,  "  If  the  pus  came  from  an  abscess  outside  of 
the  pelvis  or  just  below  the  peritoneum,  it  would  be 
within  my  specialty  ;  but  coming  from  an  inch  or  so 
higher,  you  should  apply  to  somebody  else  for  relief  ?  " 
Is  a  perityphlitic  abscess  pressing  upon  the  rectum  and 
causing  constant  tenesmus  to  be  shunned,  while  one 
originating  in  an  inflammation  of  the  peri- rectal  cellu- 
lar tissue  high  up  and  causing  the  same  symptoms  is  to 
be  incised  ?  Is  intestinal  obstruction  due  to  stricture 
within  reach  of  the  anus  to  be  operated  upon  by  lapa- 
rotomy, while  exactly  the  same  condition  due  to  strict- 
ure just  beyond  the  reach  of  the  finger  in  the  rectum, 
but  plainly  within  reach  by  deep  palpation  of  the  left 
side  of  the  pelvis,  and  requiring  exactly  the  same  oper- 
ation, is  to  be  considered  general  surgery  ?  The  answer 
rests  entirely  with  the  men  who  make  diseases  of  the 
rectum  a  specialty. 

Reviewing  the  work  at  my  own  clinic  for  the  past 
year,  I  find  the  usual  number  of  cases  of  disease  con- 
fined solely  to  the  lower  four  inches  of  the  alimentary 
canal— haemorrhoids,  fissure,  fistula,  etc.  These  cases 
are  always  interesting  ;  they  are  the  ones  the  average 
Student  comes  to  study  ;  and  I  hold  that  the  man  who 
has  devoted  his  chief  study  to  them  is  better  able  to 
treat  them  successfully  than  the  general  surgeon.  But 
it  is  also  conceivable  that  after  twenty  years  a  man  may 
become  wearied  of  any  particular  routine  of  minor  sur- 
gery, and  may  consign  nine- tenths  of  all  the  current  lit- 
erature concerning  it  to  the  waste-basket  without  read- 
ing- 

But  in  addition  to  these  cases  I  find  also  laparoto- 
mies for  pelvic  trouble  in  women,  cases  of  acute  intes- 
tinal obstruction  in  men,  perityphlitis,  closure  of  fecal 
fistute  both  by  suture  and  ^Murphy's  button,  intussus- 
ception, cancer  of  the  prostate,  abscess  of  the  prostate, 
the  usual  lesser  gynaecological  operations,  extirpations 
of  the  rectum,  colotomies,  and  finally  a  case  demanding 
Cjesarian  section  on  account  of  what  was  supposed  to 
be  cancer  of  the  rectum  when  it  was  sent  to  me,  but 
what  was  also  cancer  of  the  uterus  and  vai^ina  compli- 
cated by  labor.  This  case  was  kindly  operated  upon 
by  my  friend  Dr.  Edebohls.  The  others  were  operated 
upon  by  myself.  I  do  njt  speak  of  them  in  detail,  be- 
cause there  was  nothing  remarkable  about  them  except 
that  one  and  all  were  sent  to  me  as  cases  of  trouble 
with  the  rectum,  and  almost  all  of  them  by  fellow-prac- 
titioners ;  and  in  all  of  them  one  of  two  prominent 
symptoms  was  present — either  pain  in  the  rectum  or 
difficult  and  irregular  defecation,  which  had  caused 
them  to  be  considered  as  cases  of  rectal  disease. 


There  has  never  been  any  question  as  to  the  propri- 
ety or  the  status  of  gynecology  as  a  specialty,  because 
the  gynecologist  has  never  considered  and  taught  that 
his  field  of  work  was  confined  to  the  vagina,  and  that 
everything  outside  that  canal  should  go  to  the  man  best 
fitted  for  abdominal  surgery.  And  yet  this  is  exactly 
the  status  of  the  rectal  specialist,  both  in  his  own  esti- 
mation and  consequently  in  that  of  the  medical  profes- 
sion at  large  and  the  public. 

Our  leading  gynecologists  have  always  been  surgeons 
— bold,  original,  great  surgeons.  Men  confining  them- 
selves to  a  certain  line  of  work,  it  is  true,  but  not  limit- 
ing that  work  solely  to  the  vagina,  and  capable  of  cur- 
ing the  patients  who  come  to  them.  If  the  men  who 
are  constantly  starting  out  as  rectal  specialists  are  will- 
ing to  take  the  same  broad  view,  and  fit  themselves  by 
years  of  surgical  training  to  live  up  to  it  in  practice, 
then  may  rectal  surgery  as  a  specialty  hope  for  a  firm 
and  honorable  position  in  the  future.  But  if  to  the 
coming  generation  as  to  the  past,  the  rectal  specialist  is 
to  be  either  an  advertising  .quack,  or  a  man  who  has 
taken  a  six  weeks'  special  course  at  a  post-graduate 
medical  college,  has  seen  a  few  operations  for  piles  and 
fistula,  and  iinagines  himself  thus  fitted  for  his  life- 
work  as  a  surgeon  ;  then  is  the  future  of  the  specialty 
not  difficult  to  foresee. 


ENDOCARDITIS    IN  COUNTRY    PR.\CTICK. 
By  JAMES  E.  FREE,  M.D., 

DILLING?,    .M'  NT. 

A  TYPHOID-FEVER  patient  began  to  exhibit  an  irregular 
temperature  after  the  fastigium.  One  day  the  ther- 
mometer registered  97.6°,  next  day  103°,  another  day 
100°  F.  Profuse  perspirations  came  on  at  irregular  in- 
tervals, when  no  acetanilide  had  been  administered. 
At  the  commencement  of  the  fever  this  antipyretic  had 
been  used,  and  the  hope  was  indulged  that  these  symp- 
toms were  due  to  the  cumulative  action  of  the  drug. 
An  odd  pulse,  exhaustion,  and  dyspnoea  supervened. 
Gradually  the  symptoms  of  enteric  fever  faded,  ten- 
derness abated,  but  the  patient  did  not  convalesce. 
He  grew  worse.  There  was  a  tricuspid  murmur  and 
a  sort  of  blowing  systolic  thrill.  Death  ended  the 
painful  suspense,  and  at  the  autopsy  there  was  found 
perforation  of  the  auricular  septum.  There  was  no 
valvular  disease  on  the  left  side  of  the  heart.  The 
perforation  was  large  enough  to  admit  the  end  of  an 
ordinary  lead-pencil.  Around  it  was  a  collar  of  fibrin, 
which  was  the  seat  of  a  swarm  of  micrococci,  the 
streptococcus  pyogenes  aureus.  Injection  of  cultures 
of  this  microbe  into  a  prairie  dog  produced  no  effect. 
Following  out  the  ideas  and  directions  of  Wyssoko- 
vitch,  a  fine  probe  was  passed  into  the  carotid  artery, 
and  an  effort  made  to  abrade  the  aortic  valves.  Sev- 
eral dogs  died  from  the  pseudo  scientific  handling,  but 
one  lived  to  develop  symptoms  of  ulcerative  endo- 
carditis. Vegetations  were  found  on  all  the  valves  of 
the  heart.  Injections  of  the  same  material  into  the  in- 
testinal canal  and  peritoneum,  after  wounding  with  the 
probe,  were  without  results  where  the  dogs  lived  more 
than  twenty-four  hours. 

The  typhoid  process  in  the  case  mentioned  brought 
to  light  a  lesion  of  the  tricuspid  valv^,  perhaps,  which 
had  been  unsuspected.  Insutticiency  and  venous  en- 
gorgement made  their  difiuf,  vegetations  developed, 
and  an  embolus  was  found  located  in  the  brain,  in  front 
of  the  fissure  of  Sylvius,  which  was  the  explanation  of 
the  difficulty  of  speech  noticed  for  several  days  prior 
to  death.  This  embolus  was  the  resting-place  of  mi- 
crococci. An  inflammatory  process  was  lighted  up  by 
the  products  of  the  typhoid  poison  in  the  auricular 
septum  and  in  the  brain.  Necrosis  of  tissue  resulted. 
If  the  circulation  could  be  carried  on  around   these 


November  9,  1895] 


MEDICAL    RECORD. 


661 


dead  spots,  and  the  poisonous  material  could  be  en- 
cysted, nothing  more  serious  than  a  temporary  paresis 
of  function  might  result,  and  the  disappearance  of  the 
tj'phoid  fever  might  have  saved  the  body  from  further 
attack.  The  perforation  of  the  septum  permitted  a 
side-tracking  of  some  of  the  blood.  Poisoned  by  the 
endocarditis,  the  blood  did  not  nourish  the  tissues 
properly.  Foreign  substances  demanded  too  much  at- 
tention from  the  excretory  organs,  and  the  usual  prod- 
ucts of  waste  weie  not  handled  in  a  workmanlike 
manner.  Nature,  goaded  to  desperation,  made  heroic 
efforts  to  fulfil  her  contract  to  get  rid  of  unneces- 
sary material  by  vicarious  perspirations.  With  every 
portion  of  the  body  invaded  by  the  septic  matter,  the 
problem  of  getting  rid  of  it  was  a  serious  one.  What 
method  was  used  to  supply  the  enormous  waste  of  fluid- 
constituents,  further  than  thirst,  is  not  known.  Trans- 
fusion of  normal  saline  solution  might  have  been  of 
value,  but  was  not  tried.  Not  having  the  true  Athe- 
nian thirst  for  new  things,  in  emergencies,  is  sometimes 
a  misfortune  to  the  physician,  and  a  calamity  to  the 
patient.  An  artificial  serum  in  such  a  case  would  at  least 
be  aseptic.  The  sweat  did  not  remedy  the  diflSculty. 
It  was  a  gallant  effort,  but  barren  of  results.  .An  e.\- 
amination  of  the  sweat  would  perhaps  have  shown 
some  of  the  germs  cleverly  entrapped  and  forced  out 
of  the  body.  How  the  glands  managed  to  make  their 
captures  would  be  an  interesting  study.  Investigators 
tell  of  marvellous  motions  and  selective  actions  in  pro- 
toplasm, which  it  would  be  worth  while  to  recognize, 
if  possible,  in  country  practice.  Some  of  the  ])tomaines 
would  be  forced  out  of  the  circulation  also.  Ptomaines 
would  not  likely  have  an  elective  affinity  for  the  solid 
constituents  of  the  blood.  From  its  ravages  in  the 
body  it  would  seem  as  if  it  could  penetrate  any  tissue 
in  company  with  serum — for  instance,  into  joints,  peri- 
toneal cavity,  etc  The  product  of  the  sweat-glands 
may  be  infective  in  some  disease. 

The  heart  and  uterus  are  two  organs  which  can  be 
seriously  disabled  without  showing  the  red  flag  of  pain. 
This  cannot  be  from  lack  of  nerve-supply,  either  direct 
or  indirect,  but  must  be  a  provision  of  nature  with  the 
object  in  view  of  pensioning  these  mainsprings  of 
life. 

The  death  of  a  patient  is  regarded  as  an  intervention 
of  Providence.  Any  other  way  of  looking  at  the  mat- 
ter would  consign  the  inexperienced  medical  man  to  a 
hell  on  earth,  or,  at  least,  to  purgatory.  Experience 
stimulates  the  hypothesis-centre  and  develops  the 
thinker.  In  medicine  we  must  think  ourselves  out  of 
purgatory. 

Most  cases  of  tricuspid  diseases  are  said  to  be  con- 
genital. It  is  easy  to  fall  back  on  congenital  excuses 
when  the  devil  and  the  deep  sea  are  on  either  hand. 
Cases  of  cancer  and  tuberculosis  may  be  due  to  pre- 
ventable hygienic  causes.  A  woman  might  be  called 
upon  to  bear  about  in  her  body  wrongs  due  to  having 
a  sexual  hog  for  a  husband.  Prolific  childbcaring 
wears  out  the  uterine  tissue,  on  the  same  principle  that 
makes  the  gun-barrel  wear  out.  Orgasm  in  the  male 
may  be  like  the  firing  of  a  rocket.  The  stick  is  coming 
down  after  the  explosion  before  the  female  can  attain 
the  climax.  Specific  infection  could  be  imagined  to 
have  some  relation  to  orgasm  and  the  ejaculatory  act 
to  absorption.     The  presence  of  seminal  fluid  upon  the 

i  genitalia,  when  satisfaction  has  not  been  complete,  may 
have  an  irritating  effect  on  the  mucous  membrane. 
Heart-action  can  be  irritable  from  ungraiiried  sexual 
desire,  just  as  it  may  be  from  the  use  of  tobacco,  lo.--s 
of  sleep,  fatigue,  and  anxiety.  The  morbid  habit  f)nce 
established  takes  care  of  itself.  Chronic  congestion, 
unhealthful  function,  permanent  disability,  abortive 
nerve  force,  and  the  birth  of  pathological  cell.s.  are 
steps  in  degeneration.  .\  hunchback  is  nature's  effort 
to  make  a  correct  vertebrate.  Cancer  and  tuberculosis 
result  from  nature's  failure  to  score  one  hundred  per 
cent.     If  the  healthy  young  woman,  who  marries  and 


breaks  down  in  middle  life,  and  develops  carcinoma  of 
the  genital  organs  at  the  climacteric,  had  remained 
single,  worn  bloomers,  and  cultivated  her  physical 
powers  on  a  bicycle,  fhe  would  have  escaped  the 
gynecologist.  There  is  physiology  in  the  new  woman's 
knickerbockers.  People  tainted  with  tuberculosis  who 
are  in  the  habit  of  developing  the  air-cells  of  the  lungs 
are  la)ingup  treasure  for  the  future.  Normal  demand 
for  oxygen  is  a  good  barometer  to  measure  the  demand 
and  supply  of  fat.  The  inherited  vice  may  not  be  in 
an  organ,  but  depend  upon  a  poorly  developed  nervous 
system,  which,  when  stimulated,  does  not  give  the 
Macedonian  cry  to  the  pa-sive  parts  of  the  body. 
What  an  organ  does  not  do,  may  be  from  a  lack  of 
knowledge.  It  must  be  taught,  developed,  strength- 
ened. Give  it  a  crutch,  or  open  its  blind  eyes,  as  the 
case  may  be.  Club  foot,  twins,  red  hair,  spinal  curva- 
ture, are  evidences  of  abnormal  tendency  ;  so  is  spina 
bifida,  or  open  foramen  ovale  One  man  may  give  a 
monstrosity  a  start  in  life,  another  may  write  a  French 
novel. 

When  a  patient,  who  has  had  a  reasonably  healthy 
heart  before  an  attack  of  typhoid  fever,  begins  during 
convalescence  to  manifest  a  set  of  foreign  symptoms, 
grafted  on  the  original  complaint,  there  is  not  a  re- 
lapse, but  a  new  birth.  Pallor,  diaphoresis,  shallow 
and  rapid  respiration,  Cheyne-Stokes  breathing,  mur- 
murs behind  the  ensiform  cartilage,  and  to  the  left, 
which  die  out  toward  the  apex,  jugular  congestion,  and 
venous  pulse,  are  omens  of  evil.  Tricuspid  disease 
produces  this  picture.  In  the  present  case  how  are 
they  explained  ?  The  blood-stream  first  strikes  the 
right  heart.  It  carries  with  it  the  product  of  the  ty- 
phoid bacillus  toward  the  nervous  centres.  Delirium 
o'  fever  is  one  evidence  of  this  intoxication,  and  the 
mental  unsoundness  and  general  systemic  unsteadiness 
is  further  proof  of  the  effects  of  the  toxin.  Deafness, 
insanity,  and  baldness  are  so  many  display  advertise- 
ments. 

If  the  patient,  years  before,  had  rheumatism,  he  need 
not  be  aware  of  the  fact  that  it  involved  and  crippled 
the  heart.  Carrying  an  insurance  policy  is  not,  nowa- 
days, a  certificate  to  the  absence  of  the  trademark  of 
rheumatism,  a  valvular  vaccination.  The  lactic  acid, 
or  whatever  the  deposit  may  be  composed  of,  is  just  as 
likely  to  accumulate  on  the  valves  of  the  heart  as 
around  the  joints. 

There  is  a  mechanical  explanation  for  this  result. 
Nature  had  a  hard  problem  to  solve  in  making  a  pass- 
able bridge  for  the  soft  structures  over  the  jointed 
bones.  The  circulation  does  go  over  these  bridges  ; 
but  sometimes  it  requires  the  sacrifice  of  tremendous 
energy  on  the  part  of  the  heart.  There  is  muscular 
force,  often  inevitably  applied  to  the  vessels  and  tis- 
sues, which  makes  some  of  their  contents  exude.  It  is 
not  normal  exosmose  and  endosmose,  but  the  effect  of 
the  pressure  of  extension  and  llexion  ;  abduction  and 
adduction.  The  tricuspid  valve,  let  us  say,  is  fed  in- 
ternally and  externally  with  rheumatoid  blood.  Con- 
stant systole  interferes  wi.h  nutrition.  Motion  and 
pressure  cause  an  exudate.  Once  the  process  is  light- 
ed up,  no  winged  angel  of  rest  ever  comes  to  its  re- 
lief. The  process  is  destined  to  extend  and  become 
chronic.  Nature  must  cut  her  coat  according  to  her 
cloth.  An  adjustment  to  surroundings  takes  place. 
Such  is  the  condition  of  affairs  when  the  typhoid  poi- 
son is  taken  aboard.  Before  this  time  the  only  s'gn 
of  inflammation  of  the  tricuspid  cusps  visible  would 
sho'.v  themselves  when  violent  exercise  is  taken.  Sud- 
den demands  on  the  heart's  reserve  force  would  cause 
a  circulatory  commotion.  It  could  not  respond  with 
vigor ;  shortness  of  breath,  faintness.  fluttering,  would 
evidence  an  atheromatous  degeneration.  Sleeping  on 
the  left  side  is  usually  impossible  in  endocarditis.  The 
liver,  stomach,  and  lungs,  all  jumping  up  and  down 
over  the  heart,  would  cause  irregular  blood-supply  to 
the  brain,  which  would  be  manifested  by  troublesome 


662 


MEDICAL    RECORD. 


[November  9,  1895 


drearns,  nightmare,  or  sense  of  discomfort  sharp  enough 
to  rouse  the  patient,  or  at  least  to  roll  him  over. 

Systemic  typhoid  infection  would,  of  course,  result 
in  high  temperature.  That  would  mean  a  stimulated 
heart.  The  fluid  it  was  engaged  in  pumping  to  every 
part  of  the  body  would  be  abnormally  heated.  It 
would  have  a  deleterious  action  on  cell  elements. 
Rapid  combustion  of  tissues  would  be  going  on.  The 
candle  is  burning  at  both  ends.  The  choicest  proto- 
plasm would  be  crippled  or  killed.  The  survival  of 
the  fittest  is  the  rule  in  health.  Tissues  select  the  per- 
fect article. 

What  is  only  half-baked  is  passed  by.  Any  kind  of 
a  supply  is  thankfully  received  in  diseases  which  in- 
terfere with  the  manufacturing  process.  To  avoid 
starvation  nature  drops  her  standard. 

The  heart  draws  its  sustenance  from  the  blood  en 
passant.  A  perforated  auricular  septum  would  lead  to 
a  mixed  blood-current.  Each  contraction  would  send 
some  of  the  material,  destined  to  be  excreted  by  the 
lungs,  into  the  heart  muscles.  Here  is  a  factor  in  en- 
docarditis, because  the  enemy  has  obtained  an  entrance 
into  the  very  citadel.  Then  the  starved  blood  adds 
fuel  to  the  flame,  for  failure  to  nourish  would  have  its 
evil  influences  multiplied  by  matter  fit  only  for  excre- 
tion, to  say  nothing  of  possible  putrefaction.  The 
micrococci  and  ptomaines  are  still  other  elements  of 
danger,  likewise  the  rheumatic  affection. 

What  measures  can  be  adopted  to  relieve  such  a 
heavily  handicapped  heart  ?  Occasionally  quinine, 
sulpho-carbolate  of  soda,  or  some  antiseptic  may  post- 
pone the  fatal  termination.  A  heart  often  carries  much 
poisonous  excretory  matter  through  the  circulatory 
system.  Witness  the  puerperal  state,  which  is  in  itself 
a  favorite  stamping  ground  of  endocarditis.  Deposit 
of  fibrin  is  another  result  of  blood  degeneration.  The 
tricuspid  insufficiency  permits  longer  contact  with  val- 
vular surface  than  health  makes  provision  for.  One 
of  the  laws  of  the  circulation  is  that  the  blood  must  cir- 
culate. Blood  brought  to  a  standstill  is  liable  to  co- 
agulate, deposit  fibrin. 

The  condition  of  the  spleen  in  endocarditis  is  an 
anomaly  to  a  country  practitioner.  It  becomes  rapid- 
ly enlarged  ;  circulation  is  interfered  with.  The  func- 
tion of  the  spleen  seems  to  be  to  receive  a  large  quan- 
tity of  blood,  for  which  no  visible  return  is  made  to 
the  body.  It  may  be  the  pressure  regulator  in  health 
and  the  garbage-box  in  disease.  Enormous  increase 
of  function  causes  hypertrophy.  The  spleen  is  unpro- 
vided with  an  apparatus  to  manufacture  a  secretion. 
Otherwise  there  would  be  provision  made  to  neutralize 
poisonous  material  sent  to  it.  The  virulence  of  the 
disease,  probably,  has  some  relation  to  the  extent  of  the 
hypertrophic  dilatation.  Here  the  proteids  of  the  blood 
not  being  required  to  elaborate  an  organic  product  are 
appropriated  for  food  by  the  micro-organisms  and  fer- 
ments. The  ulcerative  endocarditis  in  this  instance 
was  a  septicemia,  showing  itself  in  the  heart,  because 
there  it  found  a  joint  in  nature's  armor. 


The  Increase  of  Crime  in  France. — Professor  Joly 
declares  that  crime  is  rapidh  on  the  increase  in  France. 
In  1S60  the  number  of  minors  brought  up  for  trial  was 
5,400,  whereas  in  1S91  their  number  exceeded  7,000. 
In  1S92  the  number  of  habitual  criminals  known  to  the 
police  exceeded  100,000.  The  offences  which  escape 
punishment  are  also  constantly  on  the  increase.  In 
1891  there  were  83,000  offences  which  escajied  punish- 
ment, and  in  1892,  89,000.  With  regard  to  the  nature 
of  the  unpunished  offences,  M.  Joly  says  that  first  of 
all  come  robberies,  ninety  per  cent,  of  which  were  un- 
punished in  1890.  Then  follow  criminal  attempts 
against  trains  and  railways,  thefts,  counterfeiting,  arson, 
the  infliction  of  personal  injury  by  stabbing,  etc.,  and 
infanticide. 


gr00vess  of  ||Xctltcal  Science. 

The  Relation  Between  Serous  Pleurisy  and  Tuber- 
culosis.— Professor  Eichhorst,  of  Zurich,  at  the  annual 
meeting  of  the  Swiss  Medical  Association,  remarked 
that  in  a  certain  number  of  cases  the  relation  between 
serous  pleurisy  and  tuberculosis  should  not  be  over- 
looked, because  patients  cured  of  serous  pleurisy  run  a 
great  risk  of  becoming  tuberculous  later  on.  Bass  has 
found  that  at  the  end  of  five  years  only  thirty-three 
per  cent,  of  such  patients  were  still  living.  However, 
tuberculous  areas  are  not  always  found  at  autopsies, 
and  the  two  diseases  are  so  frequent  that  it  is  often 
difficult  to  say  which  of  them  was  the  primary  affec- 
tion. For  a  long  time  he  has  submitted  the  pleuritic 
effusion  to  microscopical  examination,  and  when  bacilli 
were  present  the  diagnosis  is  not  doubtful  ;  if  they  are 
not,  however,  one  has  not  the  right  to  exclude  tuber- 
culous infection,  but  should  then  have  recourse  to  ex- 
periments. In  a  series  of  such  experiments  he  injected 
with  a  Pravaz  syringe  fifteen  minims  of  effusion  into 
the  peritoneal  cavities  of  eleven  guinea-pigs  ;  ten  of 
these  remained  perfectly  healthy,  while  one  only 
showed  a  tuberculous  infection  of  the  abdominal  lym- 
phatic glands.  These  results  correspond  to  the  ob- 
servations of  other  authors.  He  thought  that  jierhaps 
the  volume  injected  was  insufficient  to  insure  the  in- 
variable presence  of  bacilli  in  the  injected  dose.  He 
therefore  had  a  syringe  made,  by  means  of  which  he 
injected  one-half  fluid  ounce,  and  the  results  were 
entirely  changed  ;  twenty-three  such  injections  of 
serous  effusion  to  as  many  guinea-pigs  infected  fifteen, 
or  sixty-five  per  cent.  Five  of  the  patients,  whose 
pleuritic  effusions  have  been  used  in  these  experi- 
ments and  infected  the  animals  with  tuberculosis,  re- 
turned to  his  service  later  on  with  tuberculosis.  It 
must,  therefore,  be  admitted  that  two-thirds  of  the 
cases  of  serous  pleurisy  are,  in  fact,  tuberculous,  and 
that  recoveries  in  most  of  the  cases  are  but  conditional. 
The  infection  originates  but  rarely  in  the  lungs,  gen- 
erally in  the  tracheo-bronchial  glands.  By  the  same 
method  he  found  that  in  twenty-seven  cases  of  se- 
rous pericarditis,  eight,  or  twenty-nine  per  cent.,  were 
of  tuberculous  origin.  It  is  probably  the  same  with 
other  serous  affections,  and  those  which  are  called 
spontaneous  are  without  doubt  very  often  infectious 
tuberculous  cases.  In  the  discussion  which  followed, 
M.  de  Cerenville,  of  Lausanne,  expressed  the  opinion 
that  tuberculous  pleurisy  presented  differential  charac- 
teristic signs  :  hyperthermia  was  much  less,  often  not 
exceeding  100.4°  F-<  and  the  effusion  was  more  quickly 
produced.  On  the  other  hand,  it  sometimes  happens 
that,  even  if  the  pleurisy  were  tuberculous,  tuberculosis 
never  develops.  He  considered  the  prognosis  of  Dr. 
Eichhorst  as  perhaps  a  little  too  gloomy.  Dr.  Socin, 
of  Bale,  believed  that  in  patients  stricken  with  surgical 
tuberculosis,  a  history  of  serous  pleurisy  may  be  often 
found  ;  in  several  hundred  cases  where  no  pulmonary 
symptoms  could  be  proved,  eight  per  cent,  had  had 
anterior  serous  i)leurisy,  and  often  many  years  had 
elapsed  before  the  appearance  of  surgical  tuberculosis. 
This  form  of  the  disease  seems  to  develop  sooner 
than  pulmonary  tuberculosis. — Corrcspondenz-Blatt  fiir 
Schweizcr  Acrzlc. 

Alkalinity  of  the  Blood  and  Infection. —  Dr.  F"odor 
records  a  number  of  experiments  showing  the  influence 
of  the  alkalinity  of  the  blood  on  diseases  produced  by 
micro  organisms.  Four  series  of  experiments  on  ani- 
mals are  first  reported  which  show  clearly  that,  by  the 
administration  of  alkalies  (sodium  bicarbonate  by  the 
mouth  or  by  subcutaneous  injection),  the  power  of 
resistance  against  infection  with  cultures  of  anthrax 
bacilli  is  greatly  increased.  The  normal  alkalinity  of 
the  blood  was  determined  by  the  examination  of  seventy- 


{ 


November  9,  1895] 


MEDICAL    RECORD. 


66: 


six  healthy  rabbits,  and  four  experiments  are  reported 
showing  the  increase  in  the  alkalinity  of  the  blood  which 
occurs  after  the  administration  of  sodium  bicarbonate. 
The  author  then  records  the  results  of  a  large  number  of 
observations  on  the  alkalinity  of  the  blood  in  rabbits  after 
infection  with  the  bacilli  of  anthrax,  cholera,  typhoid 
fever,  tuberculosis,  and  erysipelas.  These  observa- 
tions show  that  in  the  living  organism,  after  infection 
with  certain  bacilli,  there  is  first  an  increase  of  the  alka- 
linity of  the  blood  and  then  a  diminution  of  the  same, 
more  or  less.  If  the  infection  is  fatal,  the  diminution 
of  the  alkalinity  is  marked  and  progressive  ;  if  not 
fatal,  the  diminution  is  slight,  and  is  followed  by  an 
increase  of  the  same,  inconsequence  of  which  the  alka- 
linity of  the  blood  becomes  permanently  higher  than 
before  the  infection.  Thus  there  exists  a  connection 
between  the  pathological  action  of  certain  bacteria  and 
the  alkalinity  of  the  blood.  Those  rabbits  having  the 
greater  alkalinity  of  the  blood,  as  well  as  those  in  which 
the  alkalinity  of  the  blood  is  increased  to  a  greater  ex- 
tent after  infection,  have  greater  power  of  resistance 
against  certain  infectious  organisms  (anthrax  bacilli) 
than  the  rabbits  in  which  the  alkalinity  of  the  blood  is 
less.  It  appears,  therefore,  that  the  degree  of  alka- 
linity of  the  blood,  as  well  as  the  power  of  the  organ- 
ism to  increase  this  alkalinity  with  corresponding  in- 
tensity after  infection,  is  of  essential  influence  upon 
immunity. — Centralblatt  fiir  Bakteriologie. 

Suture  of  the  Heart. — Dr.  Del  Vecchio,  as  the  re- 
sults of  experiments  on  dogs,  concludes  that  suture  of 
the  heart  in  cases  of  wound  is  possible.  (  The  British 
Medical  Journal})  At  the  Congress  in  Rome,  he 
showed  a  dog  whose  left  ventricle  had  been  wounded 
in  two  places  (one  penetrating  into  the  ventricular 
cavity)  forty  days  previously.  The  author  had  sutured 
the  two  wounds  with  catgut  and  silk,  and  the  dog  ap- 
peared at  the  time  of  exhibition  to  be  in  perfect  health  ; 
it  was  killed  on  the  forty-second  day  after  suture.  The 
apex  of  the  heart  was  found  firmly  adherent  to  the 
thoracic  parietes.  Both  wounds  were  firmly  healed, 
and  in  one  the  scar  could  be  seen  on  the  endocardium, 
proving  the  penetration.  An  interrupted  suture  was 
found  to  answer  better  than  a  double  continuous  suture, 
as  necrosis  generally  followed  the  use  of  the  latter. 
Dogs  present  a  special  difficulty  in  these  exjjeriments, 
inasmuch  as  one  has  to  open  the  pleural  ca\ity  to  reach 
the  heart.  In  cases  of  wound  of  the  human  heart  Del 
Vecchio  proposes  the  following  operative  procedure  : 
Two  longitudinal  incisions  to  be  made  from  the  lower 
border  of  the  third  rib  to  the  upj^er  border  of  the 
seventh,  the  one  along  the  lower  margin  of  the  sternum, 
the  other  5  to  10  mm.  inside  the  nipple  line  ;  these  in- 
cisions to  be  joined  by  a  horizontal  one  made  in  the 
fourth  intercostal  space.  The  fourth,  fifth,  and  sixth 
ribs  and  cartilages  to  be  divided,  and  the  outer  cutane- 
ous flaps  turned  up.  The  pleura  to  be  separated  and 
pushed  on  one  side  with  the  finger,  exposing  the  peri- 
cardium, which  is  incised  longitudinally.  The  wound 
is  then  united  by  interrupted  sutures.  Death  in  cases 
of  wound  of  the  heart  seems  to  be  chiefly  due  to  press- 
ure from  the  blood  effused  into  the  pericardial  sac. 
Since  this  pressure  is  also  a  check  to  furtlier  hemor- 
rhage, it  is  a  nice  question  whether  operative  interfer- 
ence may  not  do  more  harm  than  good  as  far  as  the 
hemorrhage  is  concerned.  Paracentesis  may.  however, 
be  practised,  to  be  followed,  if  necessary,  by  free  in- 
cision of  the  pericardium.  Fischer  1  oilected  376  cases 
of  heart  wound  with  a  mortality  (two  to  three  minutes 
after  injury)  of  twenty  per  cent.  Death  has  been 
noted  in  periods  varying  from  a  few  seconds  to  nine 
months  after  the  injury. 

Mechamsm  and  Treatment  of  Complete  Procidentia 
Tlteri. —  Dr.  (".race  Peckham  -  .Murray,  of  this  city, 
has  presented  in  clear  and  comprehensive  outline  all 
definite  information  upon  this  subject  developed  in 
modern  thought  and  experience.     In  regard  to  mech- 


anism, the  following  summary  and  conclusions  are 
given:  i.  The  pelvic  floor  has  little  to  do  in  causing 
complete  procidentia.  The  proofs  of  this  are  :  It  occurs 
in  children,  in  )  oung  women,  without  so  much  as  de- 
stroying the  hymen.  It  is  rarely,  if  ever,  seen  in  cases 
of  complete  laceration  of  the  perineum.  2.  The  vagina 
may  have  both  an  active  and  a  passive  action  in  the 
mechanism  of  descent.  If  the  band  of  levator  and 
muscles  which  surrounds  its  tube  in  the  lower  third  is 
lacerated,  and  its  lower  portion  is  still  held  by  the 
rectum,  the  muscles  surrounding  it  act  with  powerful 
traction  to  bring  down  the  posterior  wall  of  the  rectum  ; 
the  traction,  with  traction  of  a  like  nature  on  the  part 
of  the  bladder,  causes  a  prolapse  of  the  vagina  alone  if 
confined  to  the  lower  portion,  but  when  it  involves  the 
upper  portion  there  is  dragging  of  the  neck  of  the 
uterus,  which,  if  the  uterine  supports  are  not  lax,  re- 
sults in  the  great  hy[)ertrophy  and  lengthening  of  the 
neck  which  simulates  complete  procidentia.  If  the 
uterine  ligaments  are  relaxed,  the  uterus  will  follow 
sooner  or  later.  The  softening  and  relaxing  of  the 
connective  tissue  during  pregnancy  make  the  detach- 
ment of  the  utero-  and  vagino-vesical  attachments  an 
easy  matter,  rendering  and  predisposing  to  prolapsus. 
The  uterus  can  press  down  the  vagina  before  it,  mak- 
ing the  vagina  a  passive  agent  in  cases  of  rapid  labor 
when  the  osis  not  dilated  and  the  uterus  descends  tow- 
ard the  vulva  with  the  expulsive  force  of  the  third  stage  ; 
also  when  it  is  heavy  from  lack  of  involution,  as  when 
the  patient  gets  up  too  soon  after  confinement,  or 
when  subinvolution  does  not  take  place.  The  vagina 
affords  support  to  the  uterus  by  its  attachment  to  its 
neck  ;  but  it  is  a  question  whether  it  acts  as  a  supporting 
column  in  the  sense  expressed  by  some  writers,  and 
whether  the  angle  it  forms  with  the  uterus  has  a  sup- 
porting value.  Clinical  experience  shows  many  cases 
in  which  the  walls  of  the  vagina  bulge  and  are  pro- 
lapsed, in  which  the  uterus  retains  its  position,  and  also 
many  cases  of  congenital  retro-displacements,  in  which 
the  uterus  remains  at  iis  normal  plane.  3.  The  action 
of  the  ligaments  is  more  passive  than  active.  They  are 
naturally  lax,  owing  to  the  necessity  of  uterine  move- 
ments and  uterine  growth  in  pregnancy.  If  traction 
occurs  from  below,  and  the  ligaments  are  lax,  descent 
of  the  uterus  is  more  facile.  The  importance  of  the 
utero-sacral  ligaments  is  exaggerated  by  most  writers. 
The  appearance  of  the  ligaments  in  cases  of  prolapse 
does  not  show  iheir  action  ;  the  stretching,  breaking, 
elongating  is  the  result  of  the  displacement,  not  the 
cause.  In  this  respect  experiments  on  the  cadaver  may 
be  trusted  for  displacements  of  the  uterus  on  the  nor- 
mal plane,  but  not  in  descent.  4.  The  greatest  factor 
to  be  considered  in  uterine  displacements,  and  the 
least  understood,  is  intraabdominal  pressure.  In  the 
normal  state  there  is  such  an  adjustment  of  this  that 
the  uterus  is  easily  maintained  in  position,  with  little 
aid  from  ligaments,  vagina,  or  perineum,  in  spite. of 
weight  of  abdominal  viscera,  or  the  great  and  con- 
stantly recurring  force  of  expulsive  effort.  When  this 
equation  is  disturbed  descent  becomes  easy.  The 
maintenance  of  the  uterus  in  its  normal  position  is 
more  a  matter  uf  physico  dynamics  than  is  generally 
supposed.  5.  Owing  to  a  laxity  of  tissues,  inherited 
or  the  result  of  disease  or  subinvolution,  there  may  be 
a  greater  predisposition  to  ijrrcideniia  uteri.  The  loss 
of  fat  has  nothing  to  do  with  it,  cases  occurring  very 
frequently  in  women  with  great  accumulation  of  ab- 
dominal and  other  fat.  The  shape  and  inclination  of 
the  pelvis  may  also  favor  this  condition.  Some  writers 
think  that  too  much  is  attributed  to  pregnancy  as  an 
etiological  factor.  Owing  to  its  relaxing  effects  on  all 
the  ligaments  and  connective  tissues,  the  heavy  uterus 
of  subinvolution,  and  insufficient  care,  it  can,  in  the 
author's  estimation,  be  held  responsible  for  ninety  per 
cent,  of  the  cases. 

The  treatment  resolves  itself  into  two  classes — non- 
surgical treatment,  which  includes  therapeutics,  support, 


664 


xMEDICAL    RECORD. 


[November  9    1895 


and  massage  ;  and  surgical  operations.  The  summarj- 
of  treatment  is  as  follows  :  i.  Restore  the  uterus  to 
place.  If  sensitive  and  eroded,  use  antiseptic  tampons 
of  cotton.  If  the  tissues  are  soft  and  relaxed,  astrin- 
gents, as  tannin  and  iodine,  should  be  used.  Ileal  the 
erosions  with  five  per  cent,  solution  of  nitrate  o*  silver. 
If  the  tissues  are  hardened  by  long  exposure  outside 
the  vagina,  astringents  should  not  be  used,  but  vaseline 
or  oily  preparations  employed.  2.  Massage  has  not 
been  found  of  much  benefit  in  these  cases.  If  it  is  to 
be  of  use,  the  improvement  will  be  immediate.  It  will 
not  avail  in  cases  where  there  is  a  congenital  tendency 
to  displacements,  but  in  those  in  which  involution  has 
not  gone  on  to  completion,  or  there  is  trouble  with  the 
circulation,  massage  and  gymnastics  may  be  of  service. 
3.  Pessaries  which  are  well  fitting  may  relieve  the  pa- 
tient greatly,  and  should  be  used  as  soon  as  possible, 
as  they  hold  the  uterus  better  in  place  than  any  tam- 
pon. Many  patients  are  made  very  comfortable  with 
■pessaries,  which  they  learn  to  take  care  of  themselves, 
and  some  cases  have  been  cured  after  a  time  by  the 
support  of  the  organ  ;  the  congestion  has  been  relieved, 
the  tissues  have  become  normal,  and  the  ligaments  have 
regained  their  tonicity.  4.  The  surgical  procedures 
have,  from  the  earliest  times,  been  without  number. 
Not  much  reliance  has  been  placed  upon  those  which 
simply  narrow  the  vaginal  outlet.  The  most  service- 
able of  all  is  Le  Fort's  operation,  not  as  popular  among 
American  surgeons  as  it  deserves  to  be,  owing  to  its 
supposed  interference  with  childbirth.  French  physi- 
cians say  it  is  no  obstruction.  The  partition  which 
this  operation  forms,  practically  making  two  vaginae, 
becomes  thinned  and  attenuated  in  labor,  and  at  the 
last  moment  can  be  cut.  The  cases  operated  upon 
by  the  author  proved  successful,  the  good  results  re- 
maining after  a  lapse  of  years.  For  complete  proci- 
dentia uteri  many  surgeons  perform  high  amputation 
of  the  cervix  ;  and,  if  the  case  demands  it,  combine 
with  it  some  of  the  operations  for  narrowing  the  vagina. 
The  shortening  of  the  round  ligaments  is  generally 
conceded  at  the  present  time  as  not  applicable  to  the 
cure  of  complete  procidentia,  and  many  believe  that  the 
day  is  not  far  distant  when  it  will  cease  to  be  con- 
sidered. Conservative  surgeons  regard  ventro-fixation 
and  hysterectomy  as  measures  too  radical  to  be  em- 
ployed generally,  and  the  succe.'^s  of  vaginal  fixation, 
as  recommended  by  SchiJcking  and  many  others  who 
have  followed  his  method,  has  not  been  established. 
Gynecologists  will  look  for  the  results  of  the  new  ard 
simple  procedure  recomm.ended  by  Freund  with  the 
greatest  interest.  This  consists  in  encircling  the  vagina 
with  silver-wire  sutures,  quilted  in  at  equal  distances, 
beginning  near  the  cervix,  and  restoring  the  uterus  to 
place  in  much  the  same  way  as  in  Le  Fort's  operation. 

Displacements  of  the  Liver. — Dr.  Graham  states  that 
within  certain  limits  the  liver  is  freely  movable,  and 
that  in  women  with  pendulous  abdomens  it  may 
descend  one  inch  below  its  normal  position  with- 
out causing  any  unpleasant  symptoms.  Cases  with 
marked  undoubted  displacement  of  the  liver  are 
rare,  however  {^The  American  Journal  of  the  Medical 
Sciences). 

A  short  account  of  the  literature  on  the  subject  is 
given,  also  a  representation  of  Heister's  remarkable 
case,  published  in  1754,  in  which  the  normal  trans- 
verse diameter  of  the  liver  had  become  practically 
vertical.  In  1892  Faure  published  fifty- four  cases  col- 
lected from  the  literature.  Since  then  several  others 
have  been  reported,  and  these  have  been  collected, 
making  a  total  of  seventy  cases,  which  are  given  in 
tabulated  form. 

The  author  is  of  the  opinion  that  the  recorded  cases 
might  be  divided  into  two  classes  :  i,  Tlie  wanderleber 
of  the  Germans,  fegato  ambulante  of  the  Italians,  float- 
ing liver,  a  condition  found  in  women  with  pendulous 
abdomens,    usually   after    frequent    childbearing ;    2, 


cases  in  both  males  and  females  in  which  the  causes  of 
displacement  are  varied. 

Floating  liver  is  a  comparatively  rare  condition,  an)- 
marked  degree  of  mobility  of  this  organ  being  pre- 
vented by  the  number  and  strength  of  its  ligaments. 
The  ligaments  are  in  all  probability  of  sufficient 
strength  to  carry  the  full  weight  of  the  liver  without 
the  aid  of  the  abdominal  wall.  This  the  writer  has 
demonstrated  in  the  majority  of  a  series  of  experiments 
on  the  cadaver,  the  details  of  which  are  given.  The 
strength  of  the  ligaments  of  the  liver  are  further  shown 
by  the  results  of  several  experiments  which  Faure  con- 
ducted, in  which  he  found  that  it  took  a  weight  twenty- 
five  times  that  of  the  liver  in  order  to  rupture  them. 

Graham  reports  three  cases  which  occurred  in  his 
practice,  one  of  which  illustrates  well  the  great  relief 
to  the  symptoms  produced  by  hepatic  displacement  by 
the  use  of  a  properly  applied  abdominal  support.  In 
this  case  relative  hepatic  dulness  did  not  begin  till  the 
seventh  rib  in  the  raammillary  line  was  reached,  and 
the  lower  border  of  the  liver  was  distinctly  palpable 
two  inches  below  the  umbilicus.  The  patient  com- 
plained of  a  weight  in  the  abdomen,  dyspnoea,  and 
was  very  cyanotic.  These  symptoms  were  relieved  by 
an  abdominal  bandage,  always  returning  whenever  it 
was  removed. 

Winkler  is  quoted  as  giving  the  following  causes  for 
hepatic  displacement,  one  acting  in  succession  to  the 
other  :  r.  Pregnancy  of  full  term  ;  2,  pendulous  abdo- 
men ;  3,  hepar  pendens  ;  4,  stretching  of  the  liga- 
ments ;  5,  tearing  and  twisting  of  the  suspensory  liga- 
ments. Rapid  emaciation  and  disappearance  of  the 
abdominal  fat  are  considered  by  Landau  as  causes  of 
displacement.  Other  etiological  factors  which  have 
been  mentioned  are  coughing,  sneezing,  vomiting,  and 
tight  lacing,  the  latter,  however,  tending  more  to  pro- 
duce a  change  in  form  rather  than  a  change  in  posi- 
tion of  the  organ.  Repeated  pregnancies  in  women, 
producing  pendulous  abdomens,  seem  to  be  an  impor- 
tant etiological  factor.  Of  the  cases  recorded  a  synop- 
sis shows  that  males  and  females  are  affected  in  the 
proportion  of  one  to  four.  Displacement  comes  on 
later  in  life  in  females  than  in  males. 

The  symptoms  usually  complained  of  by  patients 
are  a  feeling  of  weight  in  the  abdomen  and  a  dull  pain 
on  exertion.  A  few  instances  have  been  recorded  with 
a  sudden  onset  of  symptoms,  which  were  those  prac- 
tically of  shock.  Other  symptoms  which  have  been 
noted  are  dyspnoea,  cyanosis,  nausea,  vomiting,  and,  in 
some  cases,  jaundice.  An  examination  of  the  abdo- 
men should  show  the  presence  of  a  tumor,  which  can 
be  easily  felt  and  which  resembles  the  liver  in  size, 
shape,  and  consistence.  There  should  be  tympanitic 
resonance  over  the  area  where  he  jatic  dulness  normally 
exists. 

The  conditions  for  which  a  floating  liver  is  most 
likely  to  be  mistaken  are  typhlitis,  ovarian  cyst,  mova- 
ble right  kidney,  and  hydronephrosis.  The  former 
condition  should  be  distinguished  by  the  following 
points  :  r,  The  tumor  having  an  upper  smooth  surface 
and  a  sharply  defined  anterior  border  and  notch  ;  2, 
tympanitic  resonance  over  the  normal  area  of  liver- 
dulness  ;  3,  possibility  of  partial  or  complete  replace- 
meni.  when  dulness  will  be  found  in  the  normal  area. 
Greatest  relief  to  the  symptoms  seems  to  have  been  ob- 
tained by  the  use  of  a  properly  applied  abdominal  sup- 
port. 

The  'Woman's  Medical  Institute  in  St.  Petersburg. — 
Professor  von  Anrep,  formerly  Director  of  the  Russian 
Imperial  Institute  of  Experimental  Medicine,  has  been 
appointed  Director  of  the  Woman's  Medical  Institute, 
to  be  opened  within  a  few  months  in  St.  Petersburg. 
He  is  at  present  the  Government  representative  on  the 
sanitary  commission  of  the  Pan- Slavic  Exposition  to  be 
held  in  Nijni  Novgorod  in  1S96. 


November  9,   1895] 


MEDICAL   RECORD. 


665 


Medical    Record: 

A  Weekly  yoiirnal 0/ Medicine  and  Surgery. 


GEORGE    F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth   Street. 


New  York,  November  9,  1895. 


REPORT    OF    THE    SURGEON-GENERAL    OF 
THE    NAVY. 

The  report  of  Surgeon-General  Tryon  of  the  navy, 
just  submitted  to  the  Secretary  of  the  Navy,  contains 
many  important  suggestions  bearing  upon  the  increase 
of  the  efficiency  of  the  Medical  Department  and  the 
consequent  benefit  of  the  sick  and  wounded  of  the  ser- 
vice. With  a  zeal  for  necessary  improvements  which 
cannot  be  too  highly  commended,  the  chief  medical 
officer  of  the  navy  has  lost  no  opportunity  for  pressing 
the  claims  of  needy  ones  under  his  immediate  super- 
vision. The  recommendation  to  improve  the  general 
sanitation  and  ventilation  of  our  war-ships  is  timely 
and  necessary.  Up  to  the  present  time  so  much  atten- 
tion has  been  given  to  the  increase  of  the  purely  fight- 
ing resources  of  the  ships  that  all  other  matters  have 
been  more  or  less  neglected.  Suggestions  in  this  line 
are  eminently  proper  from  the  Surgeon -General  himself 
as  the  spokesman  of  his  corps.  He  emphasizes  the 
urgent  need  of  improved  naval  architecture  by  the  fol- 
lowing significant  facts. 

During  the  year  fifty-five  cases  of  heat  exhaustion 
among  the  engineer  force  have  been  reported,  the  great- 
est number  of  cases  appearing  on  the  following  vessels  : 
Bennington,  11;  Bancroft,  8;  Columbia,  6;  Amphi- 
trite,  5  ;  Raleigh,  5. 

These  figures  are  significant  and  merit  attention  by 
the  department 

The  average  temperature  of  the  engine-rooms  of 
modem  ships,  under  ordinary  cruising  conditions,  may 
range  from  106°  F.,  with  hatches  large  and  open  like  the 
Charleston,  to  152°  F.,  in  badly  arranged  and  closed 
ships  like  the  Amphitrite. 

In  the  fire-rooms  the  average  temperature  under  the 
above  conditions  may  range  from  124°  F.  in  ships  with 
only  one  set  of  fires  in  each  fire-room,  like  the  Charles- 
ton, to  189°  F.  when  the  fire-room  is  between  two  sets 
of  fires,  like  the  Cincinnati  and  Amphitrite.  In  the  case 
of  the  Cincinnati,  when  only  one  set  of  fires  is  used  in 
each  fire-room,  the  average  temperature  is  reduced  from 
189°  to  159°  F. 

The  result  of  these  high  temperatures,  together  with 
overwork  and  other  trj'ing  conditions,  is  plainly  shown 
by  the  number  of  disabilities  in  the  engineer  corps  at- 
tributed to  this  cause. 

The  necessity  of  an  organized  hospital  corps  for  the 
navy,  instructed,  drilled,  and  equipped  for  all  duties 
pertaining  to  such  service,  is  fully  set  forth.     A  bill 


with  this  object  in  \aew,  combining  every  feature  re- 
quired to  meet  the  immediate  wants  of  the  service,  has 
been  prepared  and  will  be  submitted  at  an  early  date. 
The  general  plan  proposes  a  naval  hospital  corps  con- 
sisting of  men  enlisted  for  that  special  duty,  and  in- 
structed from  the  beginning  at  preparatory  schools  for 
nurses,  to  be  established  at  all  naval  hospitals,  in  order 
to  qualify  them  for  all  hospital  work  ashore  and  afloat, 
giving  the  Secretary  of  the  Navy  authority  to  enlist,  or 
cause  to  be  enlisted,  as  many  men  in  the  hospital  corps 
as  the  service  may  require,  and  to  limit  or  fix  the  num- 
ber and  make  such  regulations  for  their  government  as 
may  be  necessar)'. 

The  demand  for  more  space  on  shipboard  for  the  use 
of  the  Medical  Department  is  founded  on  the  experiences 
not  only  of  our  own  navy,  but  of  that  of  every  similar 
service  throughout  the  civilized  world.  The  number 
of  wounded  in  action  is  not  only  surprising,  but  truly 
appalling.  It  is  stated  "  that  a  battleship  with  a  com- 
plement of  five  hundred  men  in  action,  if  not  sunk,  will 
have  within  a  few  minutes  30  killed  and  120  wounded." 

In  the  battle  between  the  Chinese  and  Japanese 
fleets,  ofif  the  Yalu  River,  September  17,  1894,  the  frag- 
ments of  one  shell,  fired  at  long  range  at  the  Tsi  Yuen, 
killed  7  men  and  wounded  14.  Commander  McGiffen 
states  in  his  account  of  the  battle  that  one  steel  shell, 
having  a  bursting  charge  of  ninety  pounds  of  powder, 
struck  the  Japanese  flagship  and  killed  instantly  49  of- 
ficers and  men  and  wounded  over  fifty. 

It  is  regretted  that  the  number  killed  and  wounded 
by  every  shot  on  board  the  several  vessels  in  the  en- 
gagement cannot  be  followed,  for  it  would  establish, 
approximately,  the  number  of  casualties  probable  in  a 
naval  engagement  at  the  present  day. 

The  figures  given,  .however,  must  impress  everyone 
with  the  gravity  of  the  entire  question  and  the  necessity 
of  making  a  commencement  of  better  methods  in  the 
service.  We  are  glad  to  learn  that  with  this  end  in 
view  a  great  deal  of  attention  has  been  paid  to  the  sub- 
ject during  the  past  year,  and  medical  officers  of  the 
navy  have  been  requested  to  present  to  the  bureau  their 
views  regarding  the  subject. 

Attention  is  also  called  to  the  utility  of  ambulance 
ships  built  specially  for  the  care  and  transfer  of  sick 
and  wounded  during  action  and  at  other  times,  and 
protected  from  injury  or  interference  by  the  flag  of  the 
Geneva  Cross. 

We  regret  to  learn  that  vacancies  in  the  medical 
corps  still  exist.  Although  there  were  two  hundred  and 
sixty-nine  applications  for  information  only  thirty-three 
men  were  enrolled  as  candidates  for  examination,  and 
of  these  only  nineteen  presented  themselves  before  the 
Board,  and  only  four  were  found  to  be  (jualified. 
This  is  in  strong  contrast  with  the  similar  corps  of  the 
army  and  hospital  marine,  positions  in  which  are 
promptly  filled  by  eager  and  competent  applicants. 
All  this  proves,  as  has  been  stated  often  before, 
that  the  navy  does  not  tempt  the  young  medical  man  as 
does  either  the  army  or  marine  hospital  service. 
Nor  will  this  condition  of  things  be  different  until  the 
Navy  Department  makes  the  position  of  the  surgeon,  as 
to  rank,  pay,  and  privileges,  equal  to  that  of  his  brother 
in  the  tent  or  quarantine  hospital.  We  are  pleased  to 
note  that  the  general  health  of  the  navy  has  been  good. 


66(> 


MEDICAL    RECORD. 


[November  9,  1895 


A  SATISFIED  REFORM  COMMISSIONER. 

On  November  ist  occurred  the  change  in  the  attending 
staffs  of  the  various  city  hospitals,  whereby  a  number 
of  experienced  men  who  had  given  years  of  faithful 
service  to  the  care  of  the  city  poor  were  replaced  by 
representatives  of  the  colleges.  A  reporter  of  an  even- 
ing paper  called  upon  President  Porter,  of  the  Board 
of  Charities  and  Corrections,  to  ask  him  how  the  change 
was  made.  Mr.  Porter  expressed  himself  as  charmed 
with  the  new  move,  and  assured  the  reporter  that  "  there 
was  no  friction  whatever,  and  that  everybody  was  pleased 
with  the  reform  "  i^sic).  "  Not  only,"  he  said,  "  are  the 
medical  colleges  delighted  at  the  change  as  in  the  in- 
terest of  the  poor  and  of  medical  science  and  surgery, 
but  the  most  prominent  and  eminent  physicians  and 
surgeons  in  the  city  have  come  to  me  to  express  their 
satisfaction." 

Of  course  the  medical  colleges  were  delighted  at  the 
change  "  in  the  interest  of  the  poor  and  of  medical 
science  and  surgery."  The  interest  of  the  poor  is  the 
special  concern  of  the  colleges,  and  we  do  not  for  a 
moment  doubt  this  part  of  Commissioner  Porter's  state- 
ment ;  but  it  would  be  interesting  to  have  the  names  of 
"  the  most  prominent  and  eminent  physicians  and  sur- 
geons in  the  city  "  who  took  the  trouble  to  call  upon 
him  to  express  their  satisfaction.  In  the  absence  of 
authentic  information  we  might  hazard  the  guess  that 
they  would  be  found  upon  the  roll  of  newly  appointed 
visiting  physicians  and  surgeons  to  the  city  hospitals. 

The  genial  Commissioner  has  had  opportunity  re- 
cently of  correcting  this  impression  and  modifying  his 
views  as  to  substantial  endorsement  after  reading  the 
condemnatory  resolutions  so  unanimously  adopted  by 
the  Medical  Society  of  the  County  of  New  York  and 
the  New  York  County  Medical  Association.  The  New 
York  Academy  of  Medicine  is  next  to  be  heard  on  the 
question  of  fair  play  toward  many  of  its  most  dis- 
tinguished members.  Probably,  however,  the  gentle- 
men of  these  associations  represent  only  "  the  riff-raff 
of  the  profession." 


estimates  that  the  proportion  of  true  diabetes,  of  grave 
form,  to  glycosuria  is  only  about  five  per  cent. 

It  is  interesting  to  learn  that  glycosuria  is  one  of  the 
innumerable  attendants  upon  a  progressive  and  "  hus- 
tling "  civilization,  and  also  to  know  that  it  is  not  one 
of  the  painful  and  malignant  manifestations  of  our 
evolution.  Glycosuria,  in  its  mild  form,  is  quite  com- 
patible with  long  life,  but  it  compels  the  sufferer  to 
live  a  most  hygienic  existence,  both  as  to  diet  and 
mental  and  physical  activity.  Glycosuria  of  this  type 
especially  is  often  associated  with  excessive  nervous 
activity.  The  glycosurias  that  are  bred  in  indolence 
and  over-indulgence  are  much  more  severe  and  dan- 
gerous in  form. 

MEDICAL   BIBLIOGRAPHY. 

One  of  the  editors  of  Lc  Progrcs  Medical  discusses 
the  problem  of  medical  bibliography  apropos  la  mart 
lamentable  of  the  Index  Medicus.  The  editor  of  the 
Progrls  thinks  that  the  death  of  this  journal  was  de- 
plorable indeed,  but  yet  was  a  somewhat  legitimate 
and  natural  event.  He  avers  that  the  Index  Medicus, 
while  extremely  useful  and  erudite  and  complete,  did 
not  solve  fully  the  bibliographic  problem  ;  it  was  rather 
an  opportunist  effort,  and  he  opposes,  therefore,  a  re- 
habilitation of  the  journal  in  its  present  form.  There 
is  a  science  of  bibliography,  and  the  editor  of  the  In- 
dex Medicus  is,  he  believes,  a  master  of  it,  but  the 
periodical  did  not  give  the  true  solution  of  the  best 
way  to  present  to  the  medical  public  the  current  sci- 
entific work  of  the  world. 

This  is  precisely  the  idea  which  the  Medical  Rec- 
ord has  presented  and  advocated  on  several  occasions. 
We  have  disliked  to  show  antagonism  to  so  useful  a 
journal,  but  it  has  always  seemed  to  us  as  though  the 
publication  would  be  more  popular  if  the  arrangement 
were  different,  if  the  number  of  annual  issues  were  less 
frequent,  and  if  the  classifications  were  somewhat  more 
in  accordance  with  modern  nosology. 


THE  INCREASE  OF  GLYCOSURIA. 

If  we  may  believe  Dr.  Worms,  of  Paris  {Bulletin  dc 
VAcad^tnie  dc  Mi'deeine),  one  of  the  manifestations  of  ad- 
vancing civilization  is  an  increase  in  the  production  of 
sugar,  not  through  the  agency  of  the  corn-stalk  or  sor- 
ghum plant,  but  through  the  activity  of  the  human 
organism.  M.  Worms  has  come  to  the  conclusion  that 
in  persons  engaged  in  brain  work  and  leading  a  seden- 
tary life,  the  proportion  of  glycosurics  is  seven  per  cent. 
This  conclusion  was  reached  from  examining  the  urine 
of  one  hundred  such  persons.  Further  investigations 
have  raised  the  proportion  of  glycosurics  to  ten  per 
cent.,  and  he  considers  this  the  rate  in  any  series  of  one 
hundred  scientists,  artists,  business  men,  doctors,  and 
lawyers,  etc.,  between  the  ages  of  forty  and  sixty.  Dr. 
Worms  quotes  Bertilly's  statistics,  which  show  that 
diabetes  is  on  the  increase,  the  mortality  in  Paris  hav- 
ing almost  doubled  in  the  last  ten  years.  The  author's 
own  experience  tends  to  show  that  glycosuria  is  increas- 
ing, but,  happily,  it  is  not  the  severe  type  ;  in  fact,  he 


MONUMENTS  IN  AMERICA  TO  FOREIGNERS. 

The  proposal  to  erect  a  beautiful  statue  to  the  German 
poet,  Heine,  in  the  Plaza,  at  the  entrance  to  Central 
Park,  naturally  aroused  a  good  deal  of  protest.  This 
was  partly  because  Heine  was  a  foreigner,  partly  be- 
cause the  same  statue  had  been  rejected  by  a  German 
city  to  which  it  had  been  offered,  and  perhaps  partly 
to  the  fact  that  Heine's  genius  did  not  warrant  such  a 
tremendous  exploitation.  A  project  quite  as  prepos- 
terous has  been  started  by  some  enthusiastic  admirers 
of  Dr.  Samuel  Hahnemann.  They  propose  to  erect  a 
statue  to  this  particular  foreigner  in  Washington.  Ac- 
cording to  the  Journal  of  the  Ameriean  Medical  As- 
sociation the  subscriptions  to  the  monument  go  on 
swimmingly,  while  those  to  the  American,  Dr.  Ben- 
jamin Rush,  are  somewhat  halting  and  insufficient.  It 
would  seem  wise,  apart  from  any  questions  of  creed  or 
sect,  that  America  wait  until  a  man's  own  country  hon- 
ors him  before  they  do  it  themselves.  Germany  has 
never  ventured  to  erect  a  statue  to  Hahnemann,  al- 
though he  has  been  dead  long  enough  to  allow  all  per- 


November  9,  1895] 


MEDICAL    RECORD. 


66^ 


sonal  prejudices  to  subside,  and  there  is  no  tendency 
in  that  direction  among  the  Germans  now.  In  fact, 
the  prevailing  opinion  among  his  countrymen,  so  far 
as  we  can  ascertain,  is  that  Hahnemann,  although  an 
earnest  student,  was  a  self-deceived  philosopher.  How- 
ever, if  our  Amercan  confrires  wish  to  put  up  a  statue, 
they  have  a  right  to  do  so,  and  we  say,  let  the  work  go 
merrily  on.  We  can't  have  too  many  good  statues  to 
great  doctors. 


MEDICAL    LIBRARIES    AND    MEDICAL   COL- 
LEGES. 

Dr.  Bav.ard  Holmes,  of  Chicago,  has  written  an  arti- 
cle upon  the  subject  of  the  relations  of  medical  li- 
braries to  medical  schools.  He  asserts  what  now  all 
agree,  that  the  lecture  system  of  teaching  medical 
students  is  a  relic  of  ancient  methods  that  is  ineffec- 
tive, and  should,  in  a  large  part,  be  done  away  with. 
Among  the  newer  and  better  agencies  for  teaching 
medical  students  is  the  use  of  the  medical  library. 
Each  school,  he  thinks,  should  have  a  well-equipped 
library,  by  the  aid  of  which  students  would  be  enabled 
to  study  out  special  questions  connected  with  their 
regular  work,  and  by  which  they  might  be  trained  in 
medical  bibliography  and  methods  of  bibliographical 
research.  It  would  certainly  be  a  great  help  if  stu- 
dents, before  graduating,  were  taught  how  to  use  medi- 
cal books,  where  to  go  to  hunt  up  special  information, 
and  how  to  present  the  results  of  their  later  practical 
work  in  a  proper,  scientific,  and  interesting  manner. 


Tax  upon  Corsets. — A  correspondent  of  the  Acade- 
mie  de  Medecine  of  Paris  has  written  a  letter  propos- 
ing to  the  Academie  to  ask  for  the  creation  of  a  tax 
upon  corsets. 

The  Hypo  Club.— The  death  of  a  Chicago  man, 
known  popularly  as  "  Hypo  Joe,"  calls  from  the  C/tuago 
Tribune  a  statement  that  there  exist  in  Chicago  a  small 
band  of  men  habitually  using  opiates  and  other  drugs. 
"  Hypo  Joe "  was  known  as  the  president  of  this 
"  Hypo  Club." 

The  "Medical  News"  and  "Life." — We  tender  our 
very  warmest  congratulations  to  our  esteemed  contempo- 
rary the  Medical  jVeu's,  and  more  especially  to  its  ener- 
getic editor,  Dr.  Gould,  for  the  successful  way  in  which 
he  has  "  turned  down"  the  anti- vivisection  periodical 
known  as  Li/e,  and  circulated  in  this  town  as  a  humor- 
ous weekly.  We  also  congratulate  the  editors  of  Li/e 
for  the  unusual  courage  and  honesty  shown  by  them 
in  publishing  a  letter  from  Dr.  (Jould,  which  so  lumin- 
ously portrays  their  methods  and  their  arguments.  We 
are  sure  that  all  readers  of  the  correspondence  between 
the  editors  of  /.i/e  and  the  Medical  Neivs  will  appre- 
ciate the  fact  that  Dr.  Gould  is  master  of  the  situation. 

Tri-State  Medical  Society. — At  the  last  meeting  of 
the  Tri-State  Medical  Society  (of  Iowa,  Illinois,  and 
Missouri)  the  following  officers  were  elected  :  Presi- 


dent, Dr.  Robert  H.  Babcock,  of  Chicago  ;  First  Vice, 
President,  Dr.  A.  H.  Cordier,  of  Kansas  City  ;  Second 
Vice-President,  Dr.  W.  A.  Todd,  of  Chariton,  la.; 
Treasurer,  Dr.  C.  S.  Chase,  of  A\'aterloo,  la.  ;  Secre- 
tary, Dr.  G.  W.  Cale,  of  St.  Louis.  The  next  meeting 
will  be  held  in  Chicago  the  first  Tuesday,  Wednesday, 
and  Thursday  in  April,  1896. 

The  Southern  Surgical  and  Gynecological  Associa- 
tion meets  in  Washington,  D.  C,  on  November  1 2th  to 
14th. 

First  Naval  Battalion  of  New  York.— Dr.  H.  Hayle 
Butts  has  been  appointed  surgeon  to  the  First  Naval 
Battalion  of  New  York,  vice  Dr.  Van  der  Poel,  resigned. 

J.  E.  Tryon,  M.D.,  LL.D.,  Surgeon- General  United 
States  Navy. — Union  College,  New  York,  conferred,  at 
its  recent  Centennial  Commencement,  the  degree  of 
LL.D.  on  Surgeon- General  Tryon,  United  States  Navy. 
This  is  a  well-merited  compliment  to  the  distinguished 
chief  of  the  Naval  Medical  Bureau. 

The  Late  Dr.  Frederic  M.  Warner. —  Whereas,  The 
Medical  Board  of  the  French  Hospital  have  learned  of 
the  decease  of  an  esteemed  colleague,  Frederic  M. 
Warner,  in  the  thirty-ninth  year  of  his  age  ; 

Whereas,  For  a  period  of  three  years  the  said  Board 
derived  great  benefit  from  the  wise  counsel,  scientific 
attainments  and  devotion  of  Dr.  Warner  ; 

Whereas,  The  patients  in  the  hospital  were  uniformly 
attended  with  skill  and  exemplary  solicitude  by  Dr. 
Warner  ; 

Resolved,  That  an  expression  of  deep  regret  and  a 
testimonial  of  profound  admiration  be  entered  on  the 
minutes  in  memory  of  our  late  colleague. 

Resolved,  That  a  copy  of  these  resolutions  be  for- 
warded to  the  family  of  the  deceased  and  be  published 
in  the  medical  press. 

Egbert  H.  Grandin,  M.D.,  Vice-President. 
Ramon  Guiteras,  M.D. 
J.  Darwin  Nagel,  M.D. 

Old  Charity  Hospital. — The  Commissioners  of  Char- 
ities and  Correction  suggest  that  still  another  new  name 
be  given  to  Charity  Hospital.  Not  long  ago  it  was 
changed  to  City  Hospital,  and  now  Island  Point  Hos- 
pital is  suggested.  There  never  was  any  necessity  for 
changing  in  the  first  place,  but  the  Commissioners  still 
believe  in  unreasonable  and  radical  reforms. 

A  Pathological  Institute  for  Dublin. — Ireland  is  usu- 
ally as  quiet  a  country,  so  far  as  medical  science  is  con- 
cerned, as  it  is  lively  in  the  matter  of  politics.  We 
learn  that  a  little  evidence  of  mental  activity  is  taking 
place  in  Dublin.  It  is  proposed  to  undertake  the  es- 
tablishment of  a  pathological  and  bacteriological  insti- 
tute in  that  city. 

The  White  Cross  Society. — An  association  by  this  name 
has  sprung  up  in  Italy  for  the  relief  of  civilians  who, 
from  illness  or  accident,  are  unable  to  work.  An  or- 
ganization in  Rome,  bearing  the  name  of  the  Crosce 
Bianca,  has  at  its  disposal  a  well-disciplined  corps  of 
young  men  and  women,  whose  duty  it  is  to  pick  up  and 
transport  to  hospitals  the  victims  of  accidents  or  the 
wounded  "  soldiers  of  industry,"  administering  first  aid 
in  urgent  cases  and  attending  or  nursing  them  after- 
ward. 


668 


MEDICAL    RECORD. 


[November  9,  1895 


Small-pox  is  slowly  diminishing  in  London  and  in 
the  provinces. 

Erratum. — Dr.  Frank  W.  Maloney,  of  Rochester,  N. 
Y.,  writes  that  in  his  article  on  "  Maternal  Impression," 
in  the  Medical  Record  of  September  28th,  his  patient 
was  about  six  weeks  pregnant,  instead  of  six  months,  as 
it  there  reads. 

A  New  Dispensary  for  Brooklyn. — The  plans  for  the 
Polhemus  Memorial  Dispensary,  which  is  to  be  an  ad- 
junct to  the  Long  Island  College  Hospital,  have  been 
drawn  up  and  approved.  This  new  dispensary  will 
cost  $250,000,  and  is  to  be  a  building  six  stories  in 
height,  with  all  the  modern  improvements  for  dispen- 
sary work.  When  complete,  the  Long  Island  College 
Hospital,  the  Hoagland  Laboratory,  and  Polhemus 
Dispensary  will  form  a  complete  set  of  buildings  for 
purposes  of  medical  education  and  philanthropic  work. 

Dr.  Franklin  Townsend,  of  Albany,  died  on  October 
31st,  aged  forty-one. 

A  Continental  Medical  Temperance  Association  has 
been  organized  in  Europe,  with  Dr.  Smith,  of  Groo- 
sherz,  Baden,  as  president.  The  object  of  this  asso- 
ciation is  similar  to  that  of  the  American  and  English 
Medical  Temperance  Associations. 

Red  Cross  Hospital  Association.— This  association, 
which  was  founded  four  years  ago  in  this  city  by  the 
American  National  Red  Cross  Association,  recently  held 
its  annual  meeting. 

Dr.  Catherine  C.  Runyon  has  been  admitted  to  mem- 
bership in  the  Virginia  Medical  Society.  She  is  the 
first  female  physician  admitted  to  membership. 

Successful  Excision  of  Spleen. — There  have  recently 
been  three  successful  cases  of  excision  of  the  spleen 
for  injury  at  St.  Thomas's  Hospital,  London.  These, 
we  are  told  by  The  Lancet,  are  the  first  successful  cases 
that'have  occurred  in  Great  Britain. 

The  Doctor  on  the  Stump. — Dr.  Alexander  J.  Stone, 
Professor  of  Gynecology  in  the  Minnesota  State  Uni- 
versity, has  been  stumping  the  State  of  Ohio  in  behalf 
of  ex- Governor  Campbell.  Incidentally,  he  has  prom- 
ised to  advocate  the  Mosgrove  Bill  for  medical  educa- 
tion. Professor  Stone  is  wandering  a  little  from  the 
beaten  paths  of  gynecological  practice,  but  if  he  helps 
along  the  cause  of  higher  education  in  Ohio  he  will 
be  doing  a  good  work. 

The  Doctors'  Campaign  in  Ohio. — Judging  from  the 
activity  shown  by  the  Cincinnati  Lancet  and  Clinic  and 
the  other  medical  journals  in  Ohio,  the  medical  profes- 
sion of  that  State  have  this  year  entered  very  heartily 
into  the  fall  campaign.  There  are,  it  seems,  in  the 
State  issues  a  number  of  political  questions  which  have 
no  especial  medical  interest,  but  the  question  of  proper 
medical  legislation  has  at  last  been  forced  into  consid- 
erable prominence.  Time  and  again  attempts  to  regu- 
late medical  practice  and  oust  the  quacks  and  diploma 
manufacturers  of  Ohio  have  been  tried  and  have  uni- 
formly failed.  This  time  there  is,  we  hope,  some 
promise  of  success.  Great  credit  is  due  to  the  Lancet 
and  Cli?iic  and  its  energetic  editor  for  the  activity 
shown  in  this  matter. 


The  Testimonial  Fund  to  Dr.  W.  G.  Grace,  the  crick- 
eter, has  reached  the  sum  of  §25,000,  and  that  sum  has 
been  forwarded  to  the  distinguished  gentleman.  He 
should  send  a  good  contribution  to  the  Sir  Andrew 
Clarke  Memorial  Fund,  which  needs  additions. 

The  Medico-Legal  Society  of  Jersey  City  intends  to 
secure  a  building  suitable  for  a  club-house,  and  large 
enough  to  accommodate  all  the  doctors  and  lawyers  in 
Hudson  County. 

Another  Whiskey  Cure. — Since  the  development  of 
the  Keeley  cure  there  have  not  many  months  passed 
without  some  new  cure  for  the  alcohol  or  morphine 
habit  appearing  on  the  market.  The  latest  of  which 
we  have  seen  an  account  is  that  published  by  Dr. 
Matchette  in  the  Medical  World.  Dr.  Matchette 
modestly  claims  that  he  has  had  but  two  per  cent,  of 
failures.  He  has  this  merit,  at  least,  that  he  is  willing 
to  publish  his  method  to  the  world,  and  does  so.  Dr. 
Matchette  notes  incidentally  that  the  beer  habit  is 
more  stubborn  and  resists  treatment  more  than  any 
other.  We  call  the  attention  of  this  interesting  fact  to 
the  civic  patriots  of  the  German  Reform  Union.  The 
method  of  cure  consists  in  giving  the  patient  a  hot 
bath  and  a  cathartic.  He  is  then  given  a  hypodermic 
injection  of  the  sulphate  of  hydrastine,  beginning  with 
one-fiftieth  of  a  grain,  which  is  increased  until  one- 
twentieth  of  a  grain  is  given  four  times  a  day.  If  the 
patient  is  very  nervous,  he  is  given  mixtures  containing 
valerian  and  bromide.  During  the  first  few  hours,  or 
even  days,  the  patient  is  furnished  with  a  generous 
quantity  of  liquor  of  the  best  brand.  The  essence  of 
Dr.  Matchette's  cure  seems  to  be  sulphate  of  hydras- 
tine.  Hydrastine  is  put  down  as  "  a  simple  bitter,  a 
hepatic  stimulant,  an  antiperiodic,  an  emmenagogue." 
This  alleged  property  of  being  antialcoholic  is  cer- 
tainly somewhat  new. 

New  College. — A  Woman's  Medical  College  has  been 
established  at  Kansas  City,  Mo. 

Defeated  Law. — A  clerical  error  defeated  the  Medi- 
cal Practice  Act  recently  passed  by  the  Michigan 
Legislature.  The  Governor  refused  to  affix  his  signa- 
ture. 

Death  from  Riding  a  Bicycle. — Professor  C.  V. 
Riley,  the  well-known  scientist,  and  for  years  ento- 
mologist of  the  Department  of  Agriculture  at  Wash- 
ington, was  killed  while  riding  a  bicycle,  on  September 
15th,  in  that  city.  His  skull  was  fractured  at  the  base 
of  the  brain,  his  head  coming  in  contact  with  the  curb- 
stone when  thrown  from  his  wheel. 

Medical    Etiquette   at    Mineral  -  water  Cures.  —  A 

French  association,  including  a  large  number  of  phy- 
sicians who  practise  at  watering-places,  has  sent  out  a 
circular  in  which  it  is  stated  that  when  a  physician 
sends  a  patient  to  a  water-cure,  he  should  give  him  a 
letter  addressed  to  his  confrere  at  that  place,  and  that 
it  is  not  etiquette  for  him  to  prescribe  for  his  patient 
while  there. 

The  Paris  Academic  de  Mddecine  has  appointed  a 
commission,  with  Dr.  Laveran  as  chairman,  to  investi- 
gate the  means  of  combating  malaria. 


November  9,  1895] 


MEDICAL   RECORD. 


669 


^ciTtcxtTs  nn&  Notices. 

Leprosy  ix  its  Clinical  and  Pathological  Aspixts. 
By  Dr.  G.  Armauer  Hausen,  Inspector-General  of 
Leprosy  in  Norway  ;  and  Dr.  Carl  Looft,  Former 
Assistant  Physician  to  the  Lungegaards  Hospital.  Trans- 
lated by  XORMAN  Walker,  ]\I.D.,  F.R.C.P.  Edinburgh. 
Assistant  Physician  for  Dermatology,  Edinburgh  Royal 
Infirmary.  With  numerous  Photographs  and  Colored 
Plates.  Bristol  :  John  Wright  &  Co.  London  :  Simp- 
kin,  Marshall,  Hamilton,  Kent  &  Co.  (Ltd.).     1895. 

Though  contained  in  but  125  pages,  exclusive  of  tables, 
and  histological  plates,  this  work  is  replete  with  valuable 
knowledge.  The  authors  have  had  so  fruitful  a  field  from 
which  to  draw  their  information,  and  Dr.  Hausen  atleast  has 
had  such  wide  experience  in  all  matters  pertaining  to  the 
question  that  one  feels  great  confidence  in  all  one  reads. 

Five  photographic  plates  are  added,  which  did  not  exist 
in  the  original  German  edition.  The  translator  has  appar- 
ently followed  the  original  with  great  accuracy.  The  cha])- 
ter  on  treatment  has  been  rewritten,  giving  the  views  of  the 
late  Dr.  Danielssen.  The  closing  sentence  is  significant. 
It  reads  :  "  But  we  are  firmly  convinced  that  isolation  >'/us/ 
be  carried  out  in  some  appropriate  fashion."  We  commend 
the  work  to  all  interested  in  the  subject. 

Physical  and  Natural  Therapeutics.    The  Remedial 
Uses  of  Atmospheric  Pressure,  Climate,  Heat  and  Cold, 
Hydrotherapcutic  Measures,  Mineral  Waters,  and  Elec- 
tricity.    By  Georges  Havem,  M.D.,    Professor  of  Clini- 
cal Medicine  in  the  Faculty  of  Medicine  of  Paris.     Ed- 
ited   by    HoBART   Amorv    Hare.    M.D.,    Professor    of 
Therapeutics  and  Materia   Medica  in  the  Jefferson  Medi- 
cal College  of  Philadelphia.  With   113  Illustrations.    Phil- 
adelphia :  Lea  Brothers  &  Co.     1S95. 
The  editor  has  acted  upon  the  author's  text  in  such  a  wav 
as  to  adapt  it  to  the  needs  of  the  American  physician,  anil 
short  articles  have  been  added  on  the  climate  and  mineral 
springs  of  our  own  country.     The  author  is  regarded  as  one 
of  the  most  advanced  therapeutists  of  the  day,  and  chapters 
on  atmosphere,   climate,  thermic  agents,  hydrotherapeutic 
measures,  mineral  waters,  and  electricity  all  show  not  only 
a  wide  personal  experience  but  familiarity  with  the  views 
and  writings  of  other  recognized  authors.     Besides  a  very 
full  general   index  there   is  a  therapeutic  index,  giving  the 
diseases  in  their  alphabetical  order  and  the  various  [ihysical 
measures  applicable  to  their  cure. 

Cutaneous   Medicine.     A    Systematic  Treatise  on  Dis- 
eases of  the  Skin.     By  Louis  A.  Duhring,  M.D..  Pro- 
fessor of  Diseases  of  the  Skin  in  the  University  of  Penn- 
sylvania ;  Author  of  "  A  Practical  Treatise  on  Diseases  of 
the  Skin,"  and  "  Atlas  of  Skin  Diseases."     Parti.   Anat- 
omy of  the  Skin,  Physiology  of  the  Skin,  General  Symp- 
tomatology, General  Etiology,   General  Pathology,  Gen- 
eral  Diagnosis,  General   Treatment,  General  Prognosis. 
Illustrated.     Philadelphia  :  J.  B.  Lippincott  Co.     1895. 
An  American  work  on  dermatology  of  which  American  phy- 
sicians should  be  proud,  and  especially  the  members  of  the 
American  Dermatological  Association,  "  who,"  as  the  author 
says  in  his  dedication  to  them,  "by  their  faithful  service 
and  valuable  contributions  to  this  department  of  medicine 
have  gained   the  universal   respect  and  honor  of  the  profes- 
sion."    The  author's  earlier  work,  which  is  now  out  of  print, 
was  for  many  years  a  standard  text-book  not  only  in  this 
country  but   abroad.     The   intention   has  been  to  amplify, 
modernize,  and  improve  upon   the  previous  work,  making 
"Cutaneous    Medicine"   a   more   comprehensive   treatise. 
The  chapters  arc  characterized  by  a  conservatism  which  has 
not  been  unduly  influenced  by  the  many  attractive  theories 
continually  coming   up.     Where  a  theory  has  been  proven 
true,  it  has  been  incorporated  in  the  text. 

Part  I.  deals  with  generalities.  After  seventy  pages  of 
anatomy  and  physiology  we  have  "  General  Symptomatol- 
ogy," "General  Etiology,"  "General  Pathology,"  "Gen- 
eral Diagnosis,"  "  General  Treatment,"  and  "  General 
Prognosis." 

Under"  Pathology"  much  pertaining  to  bacteriology  will 
be  ne«'  to  those  possessing  Dr.  Duhring's  "  Diseases  of  the 
Skin."  Under  "Treatment"  chapters  will  be  found  on 
plastrr-muslins,  pastes,  jellies,  salve-pencils,  skin-grafting 
by  the  various  methods,  electrolysis,  cataphoresis,  etc. 

The  illustrations  are  text-inserted  cuts  mainly  of  anatom- 
ical or  pathological  subjects,  for  the  most  part  taken  from 
standard  works. 


^acictij  Reports. 


NEW    YORK    ACADEMY  OF    MEDICINE. 
S/att'd  Afeetins;.  October  ij.  iSipj. 

Joseph     D.     Bryant,     M.D.,    President,    in    the 
Chair. 

The  ftuestion  of  Operative  Interference  in  Abscess  of 
Chronic  Tubercular  Disease  of  the  Joints.— Dr.  New- 
ton M.  Schaffer  read  the  paper.  He  said  there  was 
no  other  subject  whiclihad  come  before  the  orthopedic 
section  of  the  Academy  or  before  the  .American  Ortho- 
pedic Association  which  had  provoked  more  discussion 
or  given  rise  to  a  greater  difference  of  opinion.  But 
while  there  had  been  much  said  about  the  treatment  of 
chronic  abscess  in  tubercular  disease  of  joints,  there 
had  been  no  statistics.  In  September,  1891,  he  had 
ventured  to  read  a  paper  on  the  benign  course  of  ab- 
scess in  Pott's  disease  under  mechanical  treatment,  be- 
fore the  American  ( )rthopedic  Association,  and  there 
was  much  difference  of  opinion,  but,  as  usual,  no  sta- 
tistics on  either  side.  Under  these  circumstances  he 
then  decided  to  treat  all  cases  which  should  come  to 
the  New  York  Orthopedic  Hospital  without  operative 
interference,  and  to  report  the  result,  which  he  now 
did  at  the  end  of  four  years.  He  first  quoted  his  for- 
mer paper,  just  referred  to,  in  justification  of  this 
course,  for  it  showed  that  there  were  many  favorable 
cases  under  the  mechanical,  non  operative  treatment, 
while  patients  who  were  operated  upon  by  himself  or 
by  others  were  likely  to  die  of  septicemia.  But  a  sine 
(jtia  non  of  successful  non  operative  treatment  was  long 
and  efficient  mechanical  protection.  The  surgeon  must 
give  the  same  attention  to  it  that  he  would  in  treating  a 
fracture. 

The  fundamental  principle  in  the  treatment  of 
chronic  joint  disease  was  protection  of  the  diseased 
parts  while  maintaining  the  activity  of  other  parts  of  the 
body.  Dr.  Schaffer  said  the  plaster  of-Paris  splint  was 
not  suitable  in  these  cases,  and  that  it  ought  to  be  rele- 
gated to  eighteenth  century  practice,  where  it  belonged. 

At  this  point  he  emjjhasized  the  fact  that  there  was 
a  great  difference  between  the  so-called  cold  abscess  of 
chronic  tubercular  disease  and  ordinary  acute  abscesses 
which  contained  pus.  The  contents  of  cold  abscesses 
were  frequently  quite  sterile,  their  presence  gave  rise 
to  no  temperature  :  why,  then,  should  we  be  in  a  hurry 
to  incise  them  and  admit  pathogenic  organisms  ?  Such 
abscesses  were  simply  a  sign  of  disease,  the  location  of 
which  was  often  at  a  distance. 

But  a  simple  tubercular  abscess  might  undergo 
change  and  inflammation  occur,  with  some  increase  in 
size,  or  extension  by  burrowing.  It  was  under  circum- 
stances of  this  kind  that  the  judgment  of  the  surgeon 
would  be  tested.  The  temptation  was  to  use  the  knife 
at  once,  but  Dr.  Schaffer's  advice  was  to  wait  a  while, 
for  the  septicitmia  progress  would  be  likely  to  pass  over 
if  the  joint  were  protected,  the  ])atient  kept  in  the  air 
and  r.unshine,  and  api)etite  and  digestion  maintained. 
Even  if  the  temperature  rise  to  101°  or  102°  F.,  do 
not  be  worried,  for  in  children  this  is  not  a  serious 
menace.  But  if  the  symptoms  should  go  on.  make  a 
free  incision.  He  had  often  wailed,  and  nature  had 
solved  the  problem  by  causing  absori)tion  or  making  a 
spontaneous  opening. 

One  heard  a  great  deal  ahout  the  burrowing  of  ab- 
scesses and  the  maceratioi  of  healthy  jiarts.  Dr. 
Schaffer  had  learned  to  have,  under  ordinary  circum- 
stances, no  fear  of  burrowing,  and  maceration  existed 
largely  only  in  the  imagination  of  the  doctor.  The 
slow  burrowing  of  a  chronic  abscess  in  tubercular  dis 
ease  need  not  be  feared.  Rapid  burrowing  of  a  more 
acute  process  demanded  immediate  attention. 


670 


MEDICAL    RECORD. 


[November  9,  1895 


Did  incision,  asepsis,  irrigation,  drainage,  etc.,  meet 
the  indications  in  the  present  state  of  our  knowledge  of 
these  cases  ?  Did  making  an  opening  which  communi- 
cated with  the  diseased  joint  favor  ultimate  cure  ?  In 
the  very  nature  of  the  case  it  was  often  impossible  to 
remove  all  the  tubercular  material,  and  it  was  equally 
impossible  to  secure  perfect  sterilization  of  the  opening 
or  sinus  for  a  long  period  of  time. 

The  author  then  gave  the  results  of  the  treatment  of 
all  the  cases  admitted  to  the  New  York  Orthopedic 
Hospital  during  the  four  years  commencing  with  May 
I,  1892.  During  this  time  there  had  been  admitted, 
63  patients  with  hip- joint  disease,  18  with  Pott's  dis- 
ease, 12  with  knee-joint  disease,  93  in  all.  Of  these  93 
cases  of  joint  disease,  35  had  abscess.  The  treatment 
consisted  of  efficient  mechanical  protection,  and  the 
administration  of  cod-liver  oil,  etc.  The  patients  were 
up  and  about  nearly  all  the  time.  In  most  cases  only 
simple  external  dressings  were  used  ;  in  a  few,  drain- 
age and  irrigation. 

Of  the  35  cases  which  included  all  the  abscess 
cases  which  had  entered  the  hospital  during  these 
four  years,  27  remained  under  the  care  of  the  institu- 
tion a  sufficiently  long  time  to  test  the  value  of  non- 
interference. In  6  of  the  27  cases  the  abscesses, 
all  large  ones,  underwent  complete  absorption.  In  2 
of  them  there  were  two  abscesses,  making  eight  abscesses 
which  became  absorbed.  In  15  of  the  27  cases  the 
abscess,  after  opening  spontaneously,  closed  completely 
in  periods  varying  from  two  months  to  twenty- one 
months.  Of  the  27  cases  5  still  had  small  sinuses,  but 
nearly  all  were  practically  well  and  suffered  no  incon- 
venience. In  I  case  a  large  abscess  was  in  the  w-ay  of 
applying  proper  mechanical  apparatus.  Of  the  7  other 
cases  out  of  the  35,  5  died  for  reasons  not  attributable 
to  the  treatment.  The  other  two  patients  still  had 
small  sinuses  which  discharged  slightly. 

Dr.  Virgil  P.  Gibney  opened  the  general  discus- 
sion. However  much  we  might  differ  from  Dr.  Schaf- 
fer  in  our  treatment  of  these  cases,  we  certainly  must 
admire  him  for  having  the  courage  of  his  convictions 
in  carrying  out  the  plan  of  non-interference  in  all 
cases  for  four  years.  The  results,  too,  had  been  good, 
but  he  imagined  general  hospitals  received  severer 
cases. 

Probably  Dr.  Schaffer's  results  in  private  practice 
were  even  betterthan  those  just  narrated.  The  question 
of  best  mode  of  treatment  was  still  an  unsettled  one,  but 
he  was  inclined  to  believe  that  when  the  surgeon  could 
make  himself  master  of  all  the  details  of  aseptic  sur- 
gery, he  would  obtain  even  better  results  by  operative 
interference  than  those  given  by  Dr.  Schaffer.  He  did 
not,  however,  believe  in  simply  opening  an  abscess, 
scraping  out  the  sac,  and  sewing  it  up.  It  was  our  duty 
to  take  a  little  more  time  and  follow  the  abscess  or 
sinus  down  to  its  origin,  and  scrape  away  the  dead  bone 
which  was  feeding  it.  Of  course,  he  realized  the  diffi- 
culty of  reaching  all  the  foci  of  disease,  yet  we  had  to 
work  in  that  direction  in  order  to  accomplish  much  by 
surgery. 

He  summed  up  his  opinion  about  tubercular  ab- 
scesses as  follows  :  \Vhere  the  abscess  was  small,  or 
even  where  it  was  large,  if  it  did  not  interfere  with  the 
application  of  a  protection  apparatus  to  the  sjiinc,  hip, 
or  knee,  it  was  well  to  let  it  alone,  but  watch  it  care- 
fully, and  if  it  seemed  to  be  undergoing  absorption, 
proceed  with  this  mode  of  treatment.  But  if  the  ab- 
scess should  become  larger  and  larger,  or  if  it  should 
become  pyogenic  after  bursting,  then  it  was  our  duty 
to  open  it  freely  if  aspiration  failed  to  cause  its  perma- 
nent disappearance.  If  the  sinus  led  up  to  the  dorso- 
lumbar  vertebrje  we  could  often  reach  bits  of  bone  and 
scrape  them  away  with  the  long  curette  ;  then  pack  the 
abscess  well,  and  aim  to  get  healing  from  the  bottom. 
Tliat  meant  a  long  period  of  patient  aseptic  dressing. 
If  the  abscess  stood  in  the  way  of  efficient  mechanical 
treatment,  it  should  be  opened  as  soon  as  possible. 


The  kind  of  abscesses  most  difficult  to  handle  were 
those  which  had  sinuses  and  pockets  in  different  direc- 
tions. They  often  went  on  for  years,  and  finally  the 
patient  succumbed  to  lardaceous  disease.  Then  there 
were  some  patients  who  came  from  the  slums,  and  who 
could  not  be  made  to  thrive  do  wha:  we  might.  Again, 
some  did  poorly  in  the  hospital,  but  on  being  taken  to 
their  filthy  homes  they  began  to  improve.  For  some, 
it  might  be  advantageous  to  make  a  change  of  climate, 
as  in  pulmonary  tuberculosis. 

Dr.  a.  B.  Jl'dsox  said  :  I  have  arranged  a  few  pro- 
positions which  I  will  present  briefly,  as  my  contribu- 
tion to  the  evening's  discussion.  Opening  an  abscess 
of  chronic  tubercular  disease  of  the  joint  is  equivalent 
to  treating  a  symptom  and  not  the  disease.  So  is  deal- 
ing with  an  unimportant  incident  of  the  disease  under 
treatment.  It  distracts  attention  from  the  seat  of  the 
disease  in  the  bone,  where  attention  is  most  urgently 
needed.  It  is  the  application  of  a  minor  surgical  pro- 
ceeding in  the  course  of  a  surgical  case  of  the  greatest 
importance.  It  subjects  the  patient  to  the  distress  and 
inconvenience  of  a  prolonged  discharge,  which  would 
be  readily  submitted  to  if  recovery  depended  upon  it, 
but  which,  if  these  other  propositions  are  correct,  is  in- 
defensible. It  e.\poses  the  patient  to  the  danger  of 
an  infected  wound. 

So  far  as  my  short  experience  goes,  it  is  in  accord 
with  these  propositions.  Beginning  studies  in  this  di- 
rection twenty  years  ago.  I  followed  the  authorities  of 
that  day  and  the  traditions  of  the  naval  medical  ser- 
vice, and  made  early  and  free  incisions.  But  I  saw  rea- 
sons to  change,  and  for  several  years  have  not  seen, 
and  do  not  expect  to  see,  abscesses  of  this  kind  that 
require  opening  or  any  local  treatment  beyond  a  sim- 
ple dressing. 

This  rule   of   practice   has  led    to  some   gratifying 
observations ;    for    instance,    the    not    infrequent   ab- 
sorption or  disappearance  of  fluid  collections  coinci- 
dent with  recovery  from  the  bone  disease  ;  the  spon- 
taneous, painless,  and  bloodless  opening  and  collapse 
of  abscesses,  followed  by  rapid  and  permanent  closure 
with   recovery  from  the  bone  disease  :  and  in   other 
cases,  in  which  wide  tracts  of  the  skeleton  were  deeply  , 
diseased,  multiple  abscesses   pursuing  a  long   course] 
without    serious    reaction   or   impairment    of   general! 
health,  and  followed  by  recovery,  delayed  not  by  the^ 
deportment  of  the  soft  parts,  but  by  the  obstinate  nat- 
ure of  the  disease  in  the  bony  tissue. 

These  statements  would  be  misleading  if  I  did  not 
also  recall  attention  to  the  necessity  of  urgent  and  as- 
siduous treatment  of  the  disease. 

Mechanical  Treatment  Prevents  Abscess. — Dk.  S.\m- 
UEL  Ketch  thought  efticient  mechanical  treatment  was 
important,  not  only  for  the  cure  of  chronic  tubercular 
abscess,  but  also  for  its  prevention,  when  resorted  to  at, 
the  commencement  of  the  disease.  He  felt  sure  that^ 
all  orthopedic  surgeons  would  agree  to  let  those  ab-l 
scesses  alone  which  produced  no  symptoms.  He  had 
been  connected  with  the  New  York  Orthopedic  Hoi 
pital  and  Dispensary  for  many  years — since  he  served 
as  house-surgeon  ten  years  ago.  At  that  time  the  staflf| 
consisted  of  general  surgeons,  and  all  abscesses  were 
opened  under  full  Listerian  dressings.  The  cases  in 
which  this  treatment  was  applied,  and  those  in  which 
exsection  was  made,  continued  to  have  abscesses  which 
gave  much  more  trouble  and  for  a  much  longer  time 
than  abscesses  which  were  allowed  to  open  sponta- 
neously. 

Regarding  the  suggestion  of  Dr.  Gibney,  that  the 
cases  treated  in  the  hospital  might  have  been  selected, 
he  would  say  that  the  results  of  the  same  treatment  in 
the  dispensary  cases  had  been  similar,  and  there  cases 
had  to  be  accepted  as  they  came.  Abscesses  of  acute 
character,  however,  should  be  opened. 

Dr.  TviHN  Dane,  of  Boston,  had  made  some  studies 
Ijointing  to  the  number  of  leucocytes  as  an  indication 
of  mixed  infection  in  the  abscesses  under  considera- 


November  9,  1895] 


IMEDICAL   RECORD. 


671 


tion.  Cases  in  which  permanent  drainage  was  attempted 
almost  invariably  showed  that  they  had  been  contam- 
inated, although  in  the  beginning  they  might  have  con- 
tained no  germs  capable  of  producing  pus. 

Dr.  Johx  a.  Wyeth  said  :  Modern  pathology  holds 
that  a  tuberculous  abscess  does  not  contain  true  pus. 
^Vhile  in  gross  appearance  it  resembles  pus,  the  micro- 
scope shows  that  the  normal  elements  of  pus  do  not  ex- 
ist. Under  such  a  condition  the  danger  of  general 
infection  from  the  bacillus  of  tuberculosis  is  very  small. 
This  bacillus  produces  a  subacute  inflammatory  pro- 
cess, which  results  in  a  rich  granulation  tissue,  the  base 
of  which  is  composed  of  newly  formed  cells,  the  embry- 
onic tissue  of  the  inflammatory  process,  which  hedges 
in  the  tuberculous  focus  and  prevents  systemic  inva- 
sion. The  tendency  of  these  products  of  the  tubercu- 
lar process  is  to  undergo  rapid  degeneration,  due  in 
part  to  the  toxic  product  of  the  bacillus  of  tuberculosis 
(chemical  action)  as  well  as  by  anajmia,  party  local  and 
partly  systemic.  As  a  result  of  this  retrograde  meta- 
morphosis, caseation  and  liquefaction  of  caseous  ma- 
terial occur,  the  product  being  a  white  liquid  of  vary- 
ing consistence,  resembling  but  not  being  pus. 

Under  favorable  conditions  these  collections  of  tu- 
berculous fluid  tend  to  absorption.  In  the  majority  of 
instances  the  wall  of  embryonic  cells  offers  sufficient 
resistance  to  invasion  of  the  tuberculous  germs  into  the 
general  system.  The  liquid  is  absorbed  ultimately  and 
carried  away  as  a  harmless  product,  and  the  remaining 
caseous  matter  undergoes  granular  metamorphosis  and 
of  itself  ultimately  disappears.  Such  pathological  pro- 
cesses do  not  have  symptoms  in  any  way  in  common 
with  abscesses  proper,  which  are  the  seat  of  acute 
inflammation  caused  by  pyogenic  germs.  Pain  is  not 
a  marked  symptom,  since  they  can  exist  for  months,  as 
in  psoas  abscesses,  and  are  not  suspected  until  the  col- 
lection of  this  milky  fluid  is  sutificient  to  attract  atten- 
tion by  its  pressure  upon  the  abdominal  viscera,  or  pro- 
trusion due  to  its  bulk. 

It  is  a  recognized  fact  that  these  tuberculous  foci 
can  become  infected  with  pyogenic  micro-organisms 
without  a  direct  or  external  wound.  Certainly  if  the 
medulla  of  bone  can  become  infected  without  a  direct 
or  external  communication,  it  is  just  as  easy  to  infect 
a  deep-seated  tuberculous  fluid  when  conditions  for  in- 
fection are  favorable,  the  germs  travelling  through  the 
blood  and  being  deposited  in  a  suitable  pabulum. 

.\ccepting  as  I  do  the  foregoing,  the  treatment  of  the 
two  classes  is  clearly  indicated.  The  simple  tubercu- 
lous focus,  under  ordinary  conditions,  may  be  left  alone 
to  undergo  absorption,  taking  pains  by  careful  nourish- 
ment and  hygienic  precautior.s  to  increase  the  normal 
resistance  of  the  tissues  and  prevent  general  infection. 
On  the  other  hand,  when  a  tuberculous  accumulation 
is  the  seat  of  a  mixed  infection,  as  determined  by  the 
ordinary  symptoms  of  se])tic  infection,  local  and  gen- 
eral, then  a  careful  aseptic  invasion  and  evacuation  of 
these  abscesses  is  indicated. 

Believes  in  Operating. — 1)k.  A.  M.  Phei.i's  said  he 
had  to  express  a  somewhat  different  view.  He  believed 
that  the  surgical  profession  was  fully  agreed  that  ab- 
scesses, including  those  of  tubercular  nature,  should  be 
opened  wherever  they  existed,  whether  in  the  shaft  of 
bones,  in  the  joints,  in  the  liver,  in  the  cellular  or  mus- 
cular tissue,  or  elsewhere.  The  reason  was,  that  when 
these  tubercular  abscesses  were  left  to  themselves  tiiey, 
by  contact  with  surrounding  tissues,  invaded  and  de- 
stroyed them. 

He  knew  that  some  cases  recovered  without  opera- 
tive interference,  as  quoted  by  the  reader  of  the  paper, 
but  one  swallow  did  not  make  the  summer,  and  in 
proof  of  his  view  he  quoted  several  cases  which  had 
gone  wrong  until  in  his  hands  they  were  submitted  to 
excision  of  the  diseased  tissue.  In  hip-joint  disease 
accompanied  by  abscess,  in  all  cases  in  which  he  had 
operated  for  exploratory  purposes,  he  had  found  the 
head  of  the  bone  separated  from  the  neck,  and  had  re- 


moved it  as  a  foreign  body.  In  neglected  cases  of  dis- 
ease of  the  knee-joint  he  had  found  both  articulating 
surfaces  destroyed,  and  in  some  instances  the  shaft  of 
the  bones  invaded.  Excision  had  been  followed  by 
cure.  Dr.  Phelps  showed  numerous  photographs,  illus- 
trating, he  said,  destruction  of  bone  by  maceration  from 
neglected  and  burrowing  abscesses. 

Dr.  Phelps  said  he  operated,  and  the  surgical  world 
operated,  for  the  following  reasons,  and  others  :  i. 
Years  of  suppuration  and  mechanical  treatment  were 
avoided.  2.  To  intelligently  explore  the  joint.  3.  To 
get  rid  of  the  foreign  body.  4.  To  avoid  amyloid  dis- 
ease of  the  liver  and  kidneys.  5.  To  prevent  bur- 
rowing into  important  structures  and  cavities.  6.  To 
prevent  destruction  by  maceration  and  infection,  which 
in  turn  led  to  destruction  by  necrosis  and  caries.  7. 
To  get  rid  of  extra-capsular  disease  and  prevent  inva- 
sion of  the  joint.  8.  By  early  operation  prevent  destruc- 
tion of  bone.  Finally,  he  believed  that  nearly  all  ab- 
scesses should  be  opened  and  explored  with  the  finger. 
But  to  simply  scrape  a  sinus  when  dead  bone  was  at 
the  bottom  of  it  was  bad  practice.  It  opened  the  way 
for  infection.  All  the  diseased  tissue  at  the  original 
seat  of  the  disease  should  be  removed  if  possible. 

Dr.  R.  H.  S.wre  took  issue  with  one  or  two  state- 
ments in  the  paper,  i.  That  the  recumbent  posture  in 
Pott's  disease  was  a  failure.  In  a  certain  proportion  of 
cases  he  had  found  it  essential.  2.  He  disagreed  with 
the  statement  that  plaster  of  Paris  was  useless  in  afford- 
ing protection  in  Pott's  disease.  Regarding  the  gen- 
eral treatment  of  chronic  abscess,  he  said  Dr.  Wyeth 
had  expressed  his  views  better  than  he  could  do  it  him- 
self. 

Dr.  Lerov  W.  Hubbard,  Chairman  of  the  Orthope- 
dic Section,  under  whose  auspices  the  discussion  was 
held,  said  his  training  had  first  been  in  a  general  hos- 
pital, and  favored  operative  treatment  in  nearly  all 
cases  of  abscess.  Therefore,  when  he  entered  upon 
his  service  at  the  New  York  Orthopedic  Hospital  and 
Dispensary,  he  found  himself  rather  prejudiced  against 
the  non-operative  methods  adopted  there  ;  but  the  re- 
sults of  such  treatment  soon  led  him  to  change  his 
views.  He  could  certainly  endorse  the  conclusions  pre- 
sented so  clearly  by  Dr.  Wyeth,  that  there  were  some  ab- 
scesses which  should  be  let  alone,  others  which  should 
be  opened,  and  if  opened,  it  should  be  treated  asepti- 
cally,  while  at  the  same  time  efficient  protection  and 
mechanical  treatment  of  the  joint  should  be  applied. 

Dr.  Schamer,  in  closing  the  discussion,  said  his 
cases  had  not  been  selected.  He  would  like  the  gen- 
tlemen to  do  as  he  had  done,  bring  forward  all  the  cases 
which  they  had  treated  for  a  term  of  years,  and  not 
isolated  ones  intended  to  support  opposing  views. 
Judging  by  some  of  the  photographs  passed  around,  he 
would  doubt  whether  the  bone  disease  attributed  in 
some  of  the  cases  to  burrowing  and  maceration  by  pus 
had  that  origin. 


SECTION  ON  SUKGEKV. 

Stak-J  Micting,  Octohcr  14,  iSg^. 

B.   Fak<.>liiar  Cikiis,  jM.D.,  Chairman. 

Nephrectomy  for  Pyonephrosis. — The  Chairman,  Dr. 
Curtis,  [iresented  a  man,  aged  twenty-three,  on  whom 
he  had  performed  nephrectomy  for  surgical  kidney. 
When  twelve  years  of  age  he  had  received  a  kick  in 
the  left  lumbar  region,  after  which  he  passed  bloody 
urine  for  three  days,  and  had  severe  pain  for  six 
weeks.  There  was  also  a  history  of  two  attacks  of 
urethritis,  the  latter  taking  on  a  chronic  form.  Five 
years  ago  he  had  had  severe  [)ain  in  the  left  side,  some- 
times over  the  bladder.  Later  the  urine  contained  a 
large  amount  of  pus.  When  he  entered  the  hospital,  a 
year  ago  in  July,  Dr.  Curtis  felt  a  tumor,  the  size  of 
a  man's  head,  immovably  fixed  in  the  left  side,  and 


672 


MEDICAL    RECORD. 


[November  9,  1895 


extending  as  high  as  the  diaphragm.  On  operating,  a 
vertical  incision  was  made  anteriorly  on  the  left  side, 
joined  by  a  shorter  transverse  incision  e.xtending  out- 
ward. Through  this  opening  the  shell  of  kidney  was 
felt,  filled  with  pus,  which  was  evacuated  and  the 
tumor  then  removed.  The  patient  had  done  well 
since  the  operation. 

Dr.  Curtis  thought  nephrotomy  should  be  reserved 
for  those  cases  of  nephrosis  less  in  extent  than  in  this 
case,  or  where  a  considerable  portion  of  the  kidney  yet 
remained  healthy,  or  where  the  other  kidney  was  also 
diseased  and  one  did  not  care  to  sacrilice  any  healthy 
tissue  whatever. 

Congenital  Backward  Displacement  of  the  Head  of 
the  Humerus  under  the  Spine  of  the  Scapula. — Dr.  A. 
M.  Phelps  presented  another  case  of  dislocation  of 
the  head  of  the  humerus  backward  under  the  spire 
of  the  scapula,  probably  of  congenital  origin.  It  was 
by  courtesy  of  Dr.  Le  Roy  AV.  Hubbard  that  he  was 
able  to  present  this  boy,  aged  about  twelve,  and  it  was 
jiroposed  that  the  same  operation  be  done  which  he 
had  performed  for  the  first  time  in  a  case  reported  at 
the  Section  last  spring.  This  patient  had  visited 
various  surgeons  in  .San  Francisco,  Chicago,  and  New 
York,  and,  strange  to  say,  all  were  of  opinion  that 
nothing  could  be  done.  The  operation  performed  in 
the  former  case,  and  proposed  in  the  present  one  by 
Dr.  Phelps,  consisted  in  cutting  down  posterior  to  the 
deltoid,  freeing  the  head  of  the  humerus,  and  shaving 
this  off  so  as  to  make  it  fit  the  glenoid  cavity.  It  was 
not  advisable  to  enlarge  the  glenoid  cavity  at  the  same 
time,  as  it  would  endanger  anchylosis.  Dr.  Phelps  be- 
lieved these  dislocations  at  the  shoulder,  and  also  dis- 
locations at  the  hip,  arose  from  trauma  inflicted  at 
birth,  or  possibly  they  occurred  sometimes  during  intra 
uterine  gestation. 

Dr.  Le  Roy  W.  Hcbe-\rd  thought  it  rather  remark- 
able that  within  tivo  months  after  he  had  seen  his  first 
case  of  the  kind  described  by  Dr.  Phelps,  two  others 
had  come  under  his  notice.  It  seemed  strange  that  so 
many  surgeons  had  discouraged  operation,  for,  ap- 
parently, it  was  a  simple  procedure,  and  a  very  neces- 
sary one  in  view  of  the  fact  that  the  patient's  arm  was 
quite  disabled  and  he  was  obliged  to  earn  his  own  liv- 
ing. He  was  of  the  opinion  with  Dr.  Phelps,  that  it 
was  better  to  reduce  the  size  of  the  head  of  the 
humefus  than  to  enlarge  the  glenoid  cavity. 

Dr.  Roval  Whitman  was  disposed  to  think  that 
these  cases  may  originally  have  belonged  to  that 
rather  numerous  class  called  obstetrical  paralysis  lead- 
ing to  subluxation,  and  that  the  arm  having  for  years 
been  left  in  this  position  assumed  the  attitude  shown. 

Dr.  Phei  p3  said  that  against  this  supposition  and  in 
favor  of  dislocation,  was  the  fact  that  in  his  first  case 
he  found  the  posterior  border  of  the  glenoid  cavity 
broken  away,  where  the  head  of  the  bone  liad  slipped 
back  to  make  a  new  articulation. 

Carcinoma  of  Breast ;  Excision,  including  Glands  and 
Pectoral  Muscles.— Dr.  F.  J.  A.  Torfk  presented  a 
woman,  about  forty  years  of  age,  on  whom  he  had 
operated  for  cancer  of  the  breast,  removing  not  only 
the  breast,  but  also  both  pectoral  muscles  and  the 
axillary  and  clavicular  fat,  all  in  one  mass,  as  recently 
described  in  the  Medical  Record  by  Dr.  Willy  Meyer. 
His  reason  was  that  the  operation  for  carcinoma  could 
not  be  made  too  radical.  In  this  instance  a  gland, 
the  size  of  a  lentil,  was  found  in  the  pectoralis  minor, 
which  could  not  be  felt  before  the  operation,  and 
which  would  have  been  left  to  bring  on  recurrence, 
had  the  ordinary  operation  been  performed.  The  pa- 
tient was  able  to  move  her  arm  in  every  direction,  but 
there  was  some  stiffness  in  the  deltoid,  which  was  grad- 
ually disap]5earing  with  use. 

Thk  Chairman  thought  this  more  radical  operation 
for  carcinoma  of  the  breast  ought  to  be  encouraged. 
It  did  not  destroy  the  utility  of  tlie  arm. 

Recent  Advances  in  the  Surgical  Treatment  of  Ma- 


lignant Disease  of  the  Larynx. — Dr.  D.  Brvson  Df.la- 
van  in  tliis  ])aper  described  the  three  methods  of 
operating  in  malignant  disease  of  the  larynx,  and  gave 
the  recent  statistics  of  Semon.  Butlin,  and  others. 
The  three  varieties  of  operations  were,  i,  thyrotomy  ; 
2,  laryngotomy  ;  3,  complete  laryngectomy  in  cases  of 
extensive  laryngeal  disease  with  glandular  involve- 
ment. 

Thyrotomy  had  been  practised  chiefly  by  Butlin  and 
Semon,  of  London,  and  was  applied  to  cases  in  which 
the  disease  was  absolutely  confined  to  the  interior  of 
the  larynx.  The  second  variety  of  operations  was 
only  more  extensive.  Dr.  Delavan  was  of  opinion  that 
in  all  the  cases  preliminary  tracheotomy  ought  to  be 
performed,  at  least  a  week  in  advance.  Among  the 
cases  of  intrinsic  epithelioma  which  had  been  operated 
upon  by  Butlin  and  Semon,  one  was  well  after  five 
years  and  a  half,  one  after  three  years,  and  one  after 
two  years.  Recent  statistics  showed  a  percentage  of 
cures  by  operation  of  from  twenty-eight  to  forty  per 
cent.,  as  contrasted  with  ten  to  thirteen  per  cent,  given 
formerly. 

The  method  of  Solis-Cohen,  of  Philadelphia,  where- 
by the  mouth  was  shut  off  from  the  trachea,  removing 
danger  to  life,  yet  permitting  of  swallowing  with  ease, 
had  been  followed  in  at  least  three  cases  so  operated 
upon  by  acquiring  power  of  phonation.  The  comfort  of 
the  patient  was  greatly  increased,  and  the  disfiguration 
of  the  other  operation  was  largely  done  away  with.  It 
was  a  question,  however,  whether  these  cases  were  not 
the  result  of  a  happy  accident  which  might  not  repeat 
itself  in  the  future.  Regarding  the  third  variety  of 
operations,  the  author  said  that  experience  had  shown 
glandular  enlargements  not  to  be  so  serious  an  obstacle 
as  had  heretofore  been  supposed. 

The  suggestion  of  Mr.  Butlin,  that  every  tumor  of 
the  larynx  which  was  suspected  of  being  malignant 
disease  justified  exploratory  thyrotomy,  seemed  to  Dr. 
Delavan  unsafe  even  if  acted  upon  by  one  so  expert  as 
Mr.  Butlin.  He  thought,  however,  that  Mr.  Butlin 
had  in  mind  only  such  cases  in  which  all  other  pos- 
sible means  of  diagnosis  had  been  exhausted.  Papil- 
loma might  be  suspected  to  be  malignant  disease,  at 
least  by  one  not  so  expert  as  Mr.  Butlin,  and  he  had 
seen  tumors  of  this  sort  disappear  under  repeated  use 
of  the  alcohol  spray. 

Finally,  it  must  be  admitted  that  cases  of  malignant 
disease  demanding  these  operations  were  dangerous  at 
best,  and  Dr.  Delavan  thought  that  not  every  laryn- 
gologist  or  surgeon  should  undertake  to  operate,  but 
should  send  cases  to  those  who  had  already  had  some 
experience,  until  the  limits  of  the  operation  could  be 
better  defined.  The  possibility  of  certain  accidents 
must  be  admitted  and  guarded  against,  such  as  en- 
trance of  foreign  substances  into  the  air-passages,  bad 
management  of  the  tube,  poisoning  by  antiseptic  dress- 
ings. The  reader  was  of  opinion  that  poisoning  by 
antiseptic  dressings  had  occurred  in  four  cases,  iodo- 
form being  the  chief  offender.  The  substitution  for 
this  of  compound  tincture  of  benzoin  had  been  at- 
tended with  success. 

Dr.  Delavan  then  showed  some  new  tracheal  tubes 


SECTION   ON  OBSTETRICS  AND  GYNECOLOGY. 

S/iit,<f  Mfitiiig,  Odober  24,  iSgs- 

Henry  C.  Coe,  M.D.,  Chairman. 

Unusual  Entanglement  of  Umbilical  Cord :  Death  of 
Foetus. — Dr.  1..  F.  Bishor  related  the  case,  illustrated 
by  pencil  drawing.  .\  woman,  about  twenty-eight  years 
of  age,  had  been  delivered  previously  of  one  living 
child  by  forceps.  Pregnant  again,  nearly  full  term  ; 
foetal  movements  had  ceased  for  some  days.  Examina- 
tion showed  a  justo-minor  pelvis,  no  fo2tal  heart,  left 
occipito  anterior  position.  The  head  would  not  en- 
gage, and  Dr.  Bishop    was  about   to  do   craniotomy, 


November  9,    1895] 


MEDICAL    RECORD. 


6;, 


when  suddenly,  under  a  strong  uterine  contraction,  the 
head  collapsed  and  delivery  was  soon  completed.  The 
cause  of  the  death  of  the  fcetus  then  became  apparent, 
for  the  cord  was  found  entwined  around  the  left  thigh 
in  the  form  of  a  slip  knot,  so  that  every  movement  of 
the  leg  caused  it  to  draw  tighter.  The  leg  was  edema- 
tous, showing  that  the  knot  had  only  gradually  drawn 
so  tight  as  to  completely  obstruct  circulation.  He  had 
found  no  record  of  exactly  a  similar  case,  and  Dr.  E. 
A.  Tucker,  of  the  Sloane  Maternity,  said  he  had  seen 
none. 

Multiloctilar  Cyst  of  the  Ovary. — Dr.  Polak  related 
a  case  of  multilocular  cyst  of  the  ovary  removed  by 
coeliotomy.  The  peritoneum  was  torn  while  strapping 
up  the  vesico- uterine  fold,  and  troublesome  hemorrhage 
followed.  The  patient  was  doing  well  after  the  opera- 
tion, when  scanty  urinary  secretion  was  noticed,  which 
was  attributed  to  ether  and  digitalis.  Later  abdominal 
•^actuation  was  felt,  the  original  incision  was  reopened 
•nd  a  pint  of  pus  was  evacuated.  The  temperature 
then  fell,  but  an  unusual  amount  of  fluid  escaped 
through  the  drain,  which  was  shown,  by  administration 
of  methylin  blue  and  by  Kelly's  method  of  direct 
catheterization  of  the  ureter,  to  be  from  a  uretero-ab- 
dominal  fistula.  The  ureteral  fistula  closed  of  its  own 
-ccord  ;  the  abdominal  fistula  was  still  open,  but  the 
:  atient  was  doing  well, 

Ruptnre  of  the  Uterus. — Dr.  S.  JSIarx  related  two 
cases  of  rupture  of  the  uterus  during  labor  to  which  he 
had  been  called  in  consultation  after  the  accident. 
They  pointedly  illustrated  the  necessity  for  great  care 
when  one  thought  it  necessary  to  use  forceps.  The 
first  case  was  in  a  woman  who  had  previously  given 
birth  to  four  children.  The  attending  physician  made 
a  diagnosis  of  knee  presentation,  and  without  attempt- 
ing to  rectify  the  position  the  fcrceps  were  applied 
under  deep  chloroform  anaesthesia.  As  soon  as  trac- 
tion was  begun  symptoms  of  intense  collapse  devel- 
oped. The  baby  was  extracted  and  the  diagnosis  was 
'.iiade  of  chloroform  heart  failure.  The  second  day 
acute  symptoms  of  peritonitis  developed,  and  Dr.  Marx 
sa\v  her  within  six  hours  after  the  initial  chill,  and  made 
the  diagnosis  of  rupture  of  the  uterus  at  once,  which 
was  then  confirmed  by  introduction  of  the  hand.  The 
only  thing  to  do  was  to  wash  out  the  entire  peritoneal 
cavity  through  the  ruptured  uterus  and  drain.  The 
patient  died  a  few  hours  afterward. 

The  second  case  occurred  in  a  very  stout  woman,  in 
her  fifth  labor,  all  previous  labors  having  been  normal. 
.She  had  not  felt  life  for  several  days.  The  os  dilated 
sloivly,  and  the  physicians  in  charge  applied  forceps  to 
the  head  through  the  undilated  os.  The  foetus  was 
macerated  and  the  head  was  torn  off.  Then,  instead 
jf  doing  version  immediately,  the  doctor  drew  down  an 
arm  and  pulled  it  off,  then  the  other  arm  was  pulled 
off.  He  then  introduced  a  sharp  hook,  intending  to 
perforate  the  body  ;  but,  instead  he  penetrated  through 
the  uterus  into  the  peritoneal  cavity.  When  Dr.  Marx 
saw  the  patient  she  was  in  collapse.  On  careful  exami- 
nation he  found  that  the  uterine  wall  was  between  his 
hand  and  the  remainder  of  the  fcetus,  this  having  es- 
caped into  the  abdominal  cavity.  He  was  able  to 
express  it  between  his  hands,  as  in  expressing  the 
placenta.  The  rent  had  been  enormous.  Here  again 
the  only  thing  to  do  seemed  to  be  to  wash  out  the  cav- 
ity and  pass  up  a  large  amount  of  gauze.  The  patient 
died.  Still,  the  cjuestion  always  arose,  in  ruptures  of 
the  uterus  into  the  peritoneal  cavity,  whether  to  do 
laparotomy  and  sew  up  the  tear  or  to  remove  the 
uterus.  In  the  two  cases  related  the  patients  were  al- 
ready moribund,  and  any  o[)eration  attended  by  shock 
would  have  caused  immediate  death.  Saline  solution 
was  injected  into  the  bowel.  It  was  not  injected  into 
the  veins,  as  these  under  the  circumstances  were  col- 
lapsed and  difficult  to  find  ;  it  was  not  made  under  the 
skin,  since  with  the  fountain  syringe  and  a  large  needle 
— the  only  instruments  at  hand — it  would  have  been  a 


slow,  painful  process,  requiring  twenty  to  twenty- five 
minutes  to  inject  a  pint  of  the  solution,  which  by  that 
time  would  have  become  cocl. 

Dr.  Marx  said  that  in  these  cases  of  rupture  cf  the 
uterus,  and  in  some  others  which  he  had  seen,  there 
had  been  emphysema  of  the  external  genitals,  a  fact  of 
diagnostic  value,  the  cause  of  which  was  to  him  un- 
known. 

The  Chairman,  Dr.  Coe,  thought  that  not  infre- 
quently rupture  of  the  uterus  passed  unrecognized,  the 
patient's  condition  being  attributed  to  collapse,  with- 
out careful  examination  being  made.  As  to  treatment, 
he  remembered  seeing  cases  in  Vienna  which  made  a 
good  recovery  without  operative  interference,  only 
drainage  being  established.  Of  four  cases  in  which 
Dr.  Coe  had  sewed  up  the  ruptured  uterus  only  one, 
operated  upon  within  an  hour,  recovered.  The  opera- 
tion was  always  a  formidable  one,  and  done  usually 
under  very  unfavorable  conditions,  and  the  mortality 
must  always  be  high.  He  had  about  made  up  his  mind 
not  to  do  laparotomy  again  unless  the  case  were  quite 
recent  and  there  were  a  fair  chance  that  the  i)alient 
would  not  die  of  shock. 

Dr.  p.  a.  Harris  said  the  uppermost  idea  with 
practitioners  usually  was,  when  they  had  a  case  of 
labor  which  they  did  not  understand,  to  get  the  baby 
into  the  world.  It  did  not  seem  to  make  much  differ- 
ence to  them  how,  if  only  the  child  were  born.  It  was 
only  those  who  did  a  good  deal  of  consulting  work  in 
obstetrics  who  knew  of  the  frequency  with  which  diffi- 
cult and  bad  cases  were  made  much  worse  by  under- 
taking to  deliver  under  disadvantageous  circumstances 
or  without  sufficient  expeiience.  As  Dr.  Marx  had 
stated,  it  was  the  duty  of  the  attending  physician  to 
seek  experienced  help  before  he  had  made  the  case  a 
hopeless  one. 

Turning  versus  Forceps. — Dr.  Malcolm  McLean 
said  that  practitioners  too  often  applied  high  forceps 
where  the  head  refused  to  engage,  theoretically  claim- 
ing that  they  were  placed  in  relation  to  the  longer  axis 
of  the  superior  strait,  but  in  reality  across  it,  thus  mak- 
ing a  bad  case  worse.  Having,  perhaps,  torn  the  ute- 
rus, they  resorted  to  version,  and  afterward  the  case 
was  reported  as  one  showing  the  great  danger  of  rupt- 
ure or  other  accidents  attending  version. 

The  Chairman  remarked  that  high  forceps  should 
be  considered  a  capital  operation,  one  not  to  be  under- 
taken without  the  best  counsel  and  assistance. 

Dr.  Marx  said  he  had  only  recently  had  to  take  a 
teacher  in  one  of  our  medical  schools  to  task  for  advo- 
cating forceps  instead  of  version.  Dr.  McLean  had 
done  a  service  in  pointing  out  the  greater  danger  of 
forceps. 

Morphinism  in  Women. — Dr.  J.  B.  Mattison,  of 
Brooklyn,  read  the  paper.  Morphinism  in  women  was 
not  rare.  He  had  not  found  it  less  frequent  than  in 
men.  Physical  necessity,  relief  of  pain,  and  not  a  ten- 
dency to  do  wrong,  was  the  chief  cause  among  the 
better  class.  Usually  the  diagnosis  was  not  difficult, 
but  some  morphinists  were  able  to  hold  out  for  years 
with  little  departure  from  mental  or  physical  health. 
In  refusing  a  second  trial  of  Carlyle  Harris,  Recorder 
Smyth  had  said  that  if  a  wife  were  a  morphinist  the 
husband  would  surely  know  it.  This  was  a  grave  judi- 
cial error,  for  the  writer  had  known  again  and_  again 
of  morphinism  on  the  part  of  the  wife,  of  years'  dura- 
tion, without  the  knowledge  of  the  husband. 

There  were  two  tests  of  morphinism,  one  by  urine 
analysis,  the  other  by  enforced  abstinence.  The  urine 
test  consisted  in  rendering  the  specimen  alkaline  by 
addition  of  bicarbonate  of  sodium,  to  this  add  a  cer- 
tain proportion  of  chloroform  or  amylic  alcohol,  shake 
thoroughly,  let  settle,  draw  off,  add  a  small  proportion 
of  hydriodic  acid.  If  morphine  were  present  there  would 
be  a  violent  tinge  to  the  urine.  Regarding  enforced  ab- 
stinence from  morphine,  no  morphinist  could  stand  it 
for  forty-eight  hours  without  showing  reflex  symptoms. 


674 


MEDICAL    RECORD. 


[November  9,   1895 


Morphinism  in  women,  like  in  men,  was  disastrous. 
Regarding  its  effects  upon  the  functions  peculiar  to 
the  sex,  he  said  menstruation  was  almost  always  dis- 
turbed, often  long  absent,  sooner  or  later  there  was 
sterility,  although  to  this  rule  there  had  been  some 
marked  exceptions.  The  case  reported  by  the  late  Dr. 
Earl,  of  Chicago,  was  referred  to,  in  which  the  newly 
born  children  had  the  disease  and  died. 

The  prognosis  of  morphinism  in  women  eligible  for 
treatment  was  good,  and  based  on  his  personal  experi- 
ence it  was  better  than  in  men.  Recovery  took  place 
sometimes  in  apparently  hopeless  cases.  In  fact  the 
most  hopeless  case  which  he  had  ever  seen  was  cured 
completely,  and  was  well  to-day,  eleven  years  after  the 
treatment.  It  was  the  only  case  in  which  he  had  ever 
seen  hullucination  of  touch.  Hallucination  of  sight 
and  hearing  was  common. 

The  treatment  depended  upon  the  individual  case, 
for  the  patient,  as  well  as  her  disease,  must  be  treated. 
Speaking  generally,  a  more  prolonged  treatment  was 
required  than  for  men.  The  extremes  of  recovery 
under  his  management  had  been  five  weeks  and  six 
months.  Abrujjtly  taking  away  all  opium  was  brutal, 
entailed  needless  suffering  and  sometimes  fatal  col- 
lapse.    The  withdrawal  should  be  more  or  less  gradual. 

Prevention  of  morphinism  was  more  important  than 
cure,  and  physicians  should  be  careful  in  prescribing 
the  drug  for  menstrual  and  other  pains. 

Morphinism  and  Melancholia. — Dr.  Bishop  had  had 
occasion  to  treat  melancholia  two  or  three  times  with 
opium,  and  he  had  felt  that  in  doing  so  he  was  running 
the  risk  .of  establishing  the  morphine  habit,  notwith- 
standing the  fact  that  very  good  authorities  had 
claimed  that  no  danger  attended  the  use  of  the  drug 
in  these  cases.  He  would  like  Dr.  Mattison  to  express 
his  opinion  upon  that  point. 

Opium  in  Dysmenorrhcea.— Dr.  H.  N.  Vinebekg  said 
he  knew  of  some  women  who  used  preparations  con- 
taining opium  for  dysmenorrhcea,  but  personally  he 
never  prescribed  it,  finding  that  he  could  give  relief 
by  a  compound  containing  bromide  of  potash,  anti- 
pyrin,  and  phenacetin.  In  the  few  cases  of  morphin- 
ism which  had  come  under  his  observation  the  drug 
had  been  given  less  frequently  for  acute  pain  than  for 
mental  depression. 

Dr.  Collver  remarked  that  there  were  many  condi- 
tions giving  rise  to  pain,  and  that  patients  obtained 
opium'  not  alone  from  doctors,  but  even  more  fre- 
quently from  druggists  or  in  patent  medicines.  The 
physician  who  put  a  hypodermic  s}ringe  and  morphine 
into  the  hands  of  a  patient  did  a  great  wrong.  Mor- 
phine patients  should  be  treated  in  the  most  humane 
manner  ;  the  brutal  handling  to  which  they  were  some- 
times submitted  was  inexcusable. 

Susceptibility  to  Morphinism. — Dr.  Malcolm  Mc- 
Lean had  observed  that  some  patients  would  contract 
the  morphine  habit  after  use  of  the  drug  two  or  three 
times,  others  could  take  it  safely  for  several  weeks. 
Morphinism  should  never  be  regarded  as  hopeless. 
He  related  one  instance  in  which  he  cured  the  patient 
at  her  home,  in  ten  weeks'  time,  by  gradually  diminish- 
ing the  amount  of  opium  in  the  solution,  both  at  the 
drug  store  and  at  the  patient's  room,  until  it  consisted 
essentially  of  water. 

Dr.  Ma  itison,  in  some  closing  remarks,  expressed 
his  belief  that  this  was  not  a  habit,  but  a  disease. 
\\'hile  it  was  a  generally  accepted  fact  among  neurolo- 
gists that  patients  suffering  from  melancholia  or  insan- 
ity were  less  likely  than  the  sane  to  contract  the  dis- 
ease, yet  it  was  true  that  morphinism  was  possible 
under  all  conditions  provided  the  drug  were  taken 
sufficiently  long.  He  did  not  believe  the  man  or  wom- 
an lived  who  could  resist  the  snare  of  opium,  should 
they  take  it  for  some  time. 

Codeine  was  much  less  dangerous  than  opium  or 
morphine,  and  should  be  given  in  its  stead  if  necessary 
for  the  relief  of  pain.     It  had  to  be  used  in  about  three 


times  the  quantity.  It  had  not  that  exhilarating  effect 
on  the  mind,  which  was  the  basis  of  the  morphine  dis- 
ease when  opium  was  given.  Dr.  Mattison  recognized, 
however,  some  risk  even  in  the  careless  use  of  codeine. 

Notes  on  Ectopic  Gestation.  —  Dr.  Egbert  H. 
Grandix  gave  as  a  reason  for  presenting  this  paper 
the  fact  that  in  the  practice  of  individuals  there  oc- 
curred cases  or  groujjs  of  cases  of  sufficient  interest  to 
make  them  worthy  of  report  before  a  scientific  body, 
even  though  the  subject  to  which  they  related  had  been 
gone  over  frequently  before. 

Electricity  Abandoned. — The  author  had  repeatedly 
stated  his  conversion  from  the  erroneous  doctrine 
which  for  years  he,  in  common  with  many  others,  had 
promulgated — the  doctrine  that  ectopic  gestation  might 
very  properly,  from  the  eighth  to  the  tenth  week,  be 
treated  by  non-surgical  means,  particularly  electricity. 
His  conversion  from  this  doctrine  had  been  due  to  the 
fact  that  experience  had  taught  him  that  even  before- 
the  eighth  week  there  might  be  hemorrhage  of  a  slowly 
progressive  character.  Thus,  in  a  nuinber  of  cases 
where  the  symptoms  had  not  been  very  urgent,  abdom- 
inal section  had  shown  free  hemorrhage  and  old  clots. 
Further,  his  wider  experience  had  taught  him  to  accept 
the  view  enunciated  by  Dr.  Janvrin,  that  so  called  col- 
icky pains  in  these  patients  were,  in  fact,  signals  of 
hemorrhage.  Further,  his  experience  had  taught  him 
that  women  might  bleed  internally  even  though  there 
had  been  absence  of  colicky  pains.  Hence  he  had 
ranged  himself  in  line  with  those  who  claimed  that  in 
the  presence  of  diagnosis  of  ectopic  gestation  immedi- 
ate section  should  be  the  rule.  Indeed,  his  personal 
experience  had  led  him  to  think  that  even  if  the  diag- 
nosis were  only  presumptive,  a  clean  exploratary  punct- 
ure was  safer  than  expectancy.  It  was  only  a  question 
of  very  early  diagnosis,  and  this  was  not  impossible. 
In  his  experience  strong  presumption  prior  to  opera- 
tion was  the  rule,  and  absolute  diagnosis  the  exception. 
Yet  if  due  weight  were  given  the  earlier  symptoms,  he 
was  satisfied  that,  as  specialists,  we  would  be  less  fre- 
quently called  upon  to  operate  on  women  practically 
in  collapse. 

It  was  stated  that  the  symptoms  of  ectopic  gestation 
were  the  following  :  Relative  sterility,  with  recent  dis- 
ease of  the  pelvic  organs  ;  amenorrhoea  ;  enlargement 
of  the  uterus  ;  sympathetic  disturbance  :  change  in 
the  breasts  ;  irregular  hemorrhage  :  colicky  pain  : 
presence  of  tumor  at  one  side  of,  or  behind,  the  uterus. 
With  such  a  history,  ectopic  gestation  could  be  pre- 
dicted. Unfortunately,  however,  the  woman  seldom 
consulted  a  physician  before  the  colicky  pains  had  be- 
come severe  and  rupture  had  already  occurred.  An 
early  operation  would  in  all  likelihood  rescue  the  pa- 
tient from  her  peril,  and  in  order  to  carry  it  out  women, 
as  well  as  physicians,  should  be  educated  to  recognize 
the  first  signs,  stress  being  laid  upon  hemorrhage  even 
before  the  occurrence  of  colicky  pains.  Hemorrhage 
was  inconsistent  with  normal  pregnancy,  and  it  was  the 
symptom  which  should  call  for  pelvic  exploration, 
not  colicky  pains.  Hemorrhage  after  a  period  had  been 
passed  meant  that,  even  though  uterine  pregnancy  ex- 
isted, there  might  be  a  complication.  The  woman 
should  be  put  to  bed,  and  if  daily  examination  should 
reveal  progressive  increase  in  the  local  findings,  we 
would  often  have  strong  enough  presumptive  diagnosis 
to  warrant  exploratory  section  before  the  woman  was 
///  extremis  or  had  lost  so  much  blood  internally  as  to 
greatly  retard  convalescence.  Two  cases  illustrative  of 
this  point  were  cited. 

The  first  case  was  that  of  an  unmarried  woman,  aged 
twenty-four,  regular  in  menstruation  :  had  suffered  only 
occasionally  from  pelvic  pains.  After  exposure  to  preg- 
nancy, she  missed  a  period  and  consulted  a  profes- 
sional abortionist,  who  passed  a  sound  into  the  uterus. 
Two  days  afterward,  or  five  weeks  after  exposure  to 
pregnancy,  she  passed  a  clot.  Having  some  pain,  she 
consulted   Dr.  Crandin,  but   he    was  not  prepared  to 


November  9,  1895] 


MEDICAL    RECORD. 


675 


give  an  opinion  until  at  the  end  of  the  sixth  week  after 
the  exposure,  pain  continuing,  a  hemorrhage  having 
occurred,  and  a  somewhat  greater  swelling  existing  at 
the  site  of  the  tube,  he  expressed  the  presumptive  be- 
lief in  ectopic  gestation  and  advised  that  she  enter  an 
institution  to  undergo  exploratory  laparotom)'.  He 
found  not  only  free  hemorrhage,  but  old  clots  as  well. 
The  tube  was  removed,  the  belly  washed  out,  and  the 
patient  made  an  uneventful  recover}-. 

The  second  case  was  similar,  except  that  there  had 
been  atypical  hemorrhage  for  three  weeks,  and  the 
colicky  pains  were  not  at  all  marked.  He  removed  the 
unruptured  tube,  which  lay  between  the  uterus  and 
bladder,  there  being  ample  evidence  of  ectopic  gesta- 
tion in  chorionic  villi.  The  patient  made  a  good  re- 
covery. 

After  relating  two  other  cases  of  more  advanced  ec- 
topic pregnancy.  Dr.  Grandin  concluded  his  paper  by 
impressing  the  value  of  atypical  flow  as  a  diagnostic 
sign  of  ectopic  gestation,  and  the  fallacy  of  placing  too 
much  dependence  upon  the  symptom  of  colicky  pain. 

The  paper  was  discussed  b)-  the  Chairman  and  by 
Drs.  McLean,  Leroy  Broun.  E.  A.  Avers,  Tull,  Collyer, 
Jarman,  R.  .V.  Murray,  and  the  discussion  was  closed 
by  the  author. 

Dr.  Malcolm  McLean  had  not  discarded  electric- 
.  ity  altogether  in  ectopic  gestation. 

Dr.  H.  J.  Garrigces  exhibited  several  instruments, 
principally  those  used  by  Jacobs  in  operations  by  the 
vaginal  route,  and  also  showed  two  uteri  which  he  had 
removed  by  the  latter  method,  and  stated  that  clamps 
had  interfered  with  easy  control  of  hemorrhage  which 
had  taken  place  in  one  of  the  cases.  He  said  the  vagi- 
nal route,  of  which  we  heard  so  much  at  present,  was 
only  a  revival. 


NEW    YORK    COUNTY     MEDICAL     ASSOCL\- 
TION. 

Stated  Meeting.  October  21.  iSgj. 

Samuel  B.   W.   McLeod,  ^LD.,  President,  in  the 
Chair. 

AatOBCope.  —  Dr.  J.  \V.  Gleits.mann  demonstrated 
Kirstein's  perfected  autoscope,  an  instrument  for  exami- 
nation of  the  interior  of  the  larynx.  It  had  a  handle, 
an  electric  light  calling  for  twelve  volts  and  thirty  am- 
peres, a  spatula  covered  by  a  horizontal  plate.  Its 
chief  advantage  over  the  laryngoscopic  mirror  was  the 
fact  that  it  enabled  one  to  see  not  only  as  much  as  was 
shown  by  the  mirror,  but  also  the  posterior  wall  of  the 
larynx.  Usually  patients  were  tolerant  of  examination 
but  about  a  minute  at  a  time,  but  the  young  man 
shown  permitted  a  demonstration  of  ten  minutes'  dura- 
tion. Kirstein,  of  Berlin,  had  also  devised  instru- 
ments for  operating. 

Lymphoid  Hypertrophies  at  the  Vault  of  the  Phar- 
ynx—  So  called  Adenoids;  their  Relation  to  Rhino- 
pharyngeal  Catarrh.— Dr.  J.  S'.lis  C'>hen,  of  Phila- 
delphia, read  this  paper.  The  first  part  was  a  brief 
historical  review.  Only  recently  had  the  atten- 
tion of  the  general  profession  been  directed  to  dis- 
ease of  the  glands  at  the  vault  of  the  pharynx,  al- 
though the  anatomy  of  the  parts  had  received  atten- 
tion from  Winslow  and  William  Hunter.  The  paper 
of  the  late  Wilhelm  Meyer,  of  \'ienna,  had  been  so 
complete  as  to  leave  little  for  future  elucidation.  Its 
or.ly  defect  lay  in  grouping  hypertrophies  with  vege- 
tations. Having  described  the  gross  appearance  and 
stated  that  the  structure  of  the  follicles  was  identi- 
cal with  that  of  the  solitary  follicles  of  the  intes- 
tin-i,  Dr.  Cohen  took  up  the  diseases  to  which  they 
were  liable.  The  adenoid  structure  at  the  vault  of  the 
;  ii.irynx  might  take  on  inflammation,  hypersecretion, 
even  ulceration  ;  it  was  liable  to  take  on  simple 


hypertrophy  or  vegetative  hyperplasia,  and  also,  as  had 
been  claimed,  certain  varieties  of  rhino-neoplasm. 

Hypertrophy  of  the  lymphoid  nodules  showed  itself 
either  en  7nass-:  or  as  an  enlargement  of  individual  or 
groups  of  the  nodules,  irregularly  distributed  upon  the 
vault  and  lateral  walls  of  the  pharynx.  Both  forms 
might  occur  independently  of  other  disease,  or  in  con- 
nection with  changes  in  the  mucous  membrane  of  the 
naso-pharynx,  etc. 

The  clinical  history  of  these  affections  related  to  ob- 
struction of  respiration,  mouth-breathing,  the  so-called 
nasal  voice,  irritation  of  dropping  and  dried  secretions, 
leading  to  snorting  inspiratory  acts,  headache,  inabil- 
ity to  concentrate  the  attention  upon  school  or  other 
work  ;  when  of  long  standing  in  children,  in  whom  it 
occurred  most  frequently,  it  caused  the  lower  jaw  to 
drop,  the  nose  became  pinched,  the  chest  sunken,  the 
shoulders  round.  Deafness  might  accompany  the  con- 
dition. The  subjects  looked  stupid  and  were  stupid. 
This  was  not  surprising  when  one  remembered  that 
only  the  occipital  protuberance  intervened  between 
the  lymphoid  bodies  and  the  brain,  and  that  the  lym- 
phatic system  within  the  cranial  cavity  was  connected 
with  that  in  the  pharynx. 

The  treatment  was  b)-  astringents,  caustics,  electroly- 
sis, cauterization,  extirpation  by  the  gouge,  the  forceps, 
the  snare,  the  finger.  Dr.  Cohen  preferred  in  general 
to  use  forceps.  They  brought  away  the  hypertrophied 
tissue,  and  thus  avoided  the  possibility  of  suffocation 
by  the  pieces  dropping  into  the  larynx,  as  had  happened 
in  a  few  cases.  If  the  mass  refused  to  be  withdrawn, 
twist  the  handle  of  the  forceps  round  and  round. 
Hemorrhage  was  rarely  excessive.  Topical  after-treat- 
ment was  superfluous,  but  astringent  and  caustic  appli- 
cations were  sometimes  made.  If  repeated  operations 
were  required,  an  interval  should  elapse  for  inflamma- 
tion to  subside,  otherwise  otitis  media  might  result. 

This  treatment,  which  also  relieved  the  rhino-pharyn- 
geal  catarrh,  was  followed  by  disappearance  of  the 
symptoms  already  named,  and  also  in  some  patients  by 
disappearance  of  pain  in  the  sternum,  beneath  the 
mamms  or  scapula,  of  nightmare,  asthma,  etc.  Catarrh 
of  the  vault  of  the  pharynx  was  by  no  means  infre- 
quent in  tuberculosis.  Constitutional  treatment  should 
be  carried  out  according  to  the  indications.  Yarious 
instruments  were  shown  for  operating.  Dr.  Cohen  was 
not  in  the  habit  of  using  an  ana;sthetic  except  in  very 
nervous  patients.  It  was  not  so  important  to  get  all 
the  tissue  away,  but  enough  so  that  the  hyperplasia 
would  subside.  The  lymphoid  structure  here,  like  all 
other  tissues,  had  some  necessary  function  which 
should  not  be  destroyed  by  removing  it  entirely. 

Dr.  Gleitsmann  thought  that  every  rhinologist 
found  less  difficulty  in  diagnosticating  these  conditions 
than  in  treating  them,  for  the  appearance  of  the  child 
suggested  the  nature  of  the  trouble.  All  were  agreed 
that  the  hypertrophies  should  be  removed,  but  there 
were  many  procedures  for  accomplishing  this.  His 
own  plan  was  to  make  removal  thorough,  so  as  to  pre- 
vent recurrence  :  he  therefore  gave  an  an;vsthetic.  But 
it  was  not  always  incomplete  removal  which  caused  re- 
turn ;  the  disease  seemed  then  to  invade  the  mucous 
membrane  to  its  full  depth.  Hemorrhage  was  some- 
times severe,  but  it  usually  stopped,  although  there 
were  about  six  cases  on  record  of  fatal  hemorrhage. 
Disease  of  the  lymphoid  structure  in  the  vault  of  the 
pharynx  was  not  infrequently  accompanied  by  disease 
of  the  accessory  sinuses. 

Advocates  Thorough  Removal. — Dr.  D.  B.  Delavax 
practised  the  method  described  by  Dr.  Gleitsmann, 
which  was  known  as  the  English  method,  for  in  Eng- 
land it  had  been  adopted  by  every  man  of  note.  \\\- 
cesthesia  was  one  of  the  greatest  aids  in  thorough  re- 
moval of  the  growths.  The  proportion  of  recurrences 
had  been  increasing,  and  he  thought  it  was  due  to  lack 
of  thorough  removal.  A  fact  which  he  thought  had 
not  been  s'afficiently  appreciated  was  the  frequency  of 


676 


MEDICAL   RECORD. 


[Nov^ember  9,  1895 


these  troubles  in  tubercular  patients,  and  it  was  ex- 
tremely important  to  treat  the  local  difficulty  without 
delay. 

Dr.  Delavan  called  attention  to  the  fact  that  money 
was  being  raised  to  erect  a  modest  monument  to  the 
memory  of  Dr.  Meyer,  of  Vienna,  who  had  done  so 
much  to  advance  our  knowledge  of  throat  troubles. 

Dr.  Fr.-\ncis  J-  QuiNL.AN  believed  that  nearly  seven 
out  of  every  twelve  children  showed  the  facial  mani- 
festations of  the  pathological  conditions  at  the  vault 
of  the  pharyn.x  under  discussion.  These  conditions 
were  like  an  open  wound  through  which  the  system  was 
being  constantly  infected.  They  were  very  commonly 
present  in  children  contracting  diphtheria  and  scarlet 
fever.  It  was  almost  impossible  to  cleanse  the  parts 
thoroughly.  The  patients  were  often  sleepless,  suffered 
from  pains,  had  trouble  with  the  ear,  became  dull,  had 
chorea,  etc.  These  symptoms  had  repeatedly  disap- 
peared under  treatment  directed  to  the  pharyn.x.  He 
presented  some  patients  in  illustration  of  Dr.  Cohen's 
paper. 

Diet  and  Muscular  Exercise  in  the  Treatment  of  Tu- 
berculosis.— Dr.  T.  J.  -McGiLLiLUDDV  read  the  paper 
(see  p.  654). 

Dr.  J.  Bl.\ke  White  did  not  doubt  but  what  diet 
and  exercise  were  the  most  important  factors  in  the 
treatment  of  tuberculosis.  When  one  recalled  the  fact 
that  all  flesh  was  but  solid  blood,  he  could  readily  see 
the  necessity  for  a  plentiful  supply  of  the  normal  cir- 
culatory fluid  whereby  the  system  was  built  up  and 
effete  material  was  carried  away.  The  author  had 
properly  laid  stress  on  the  importance  of  'attention  t6 
details  in  exercise.  He  thought,  however,  that  it  was 
best  to  take  exercise  in  the  open,  pure  air,  and  he 
recommended  bicycle  riding,  which  permitted  the  body 
to  remain  passive  while  the  respiration  and  circulation 
were  active.  With  regard  to  the  diagnostic  value  of 
the  bacillus  tuberculosis  in  the  sputum,  he  believed  the 
physical  signs  were  often  present  first. 

Butter  for  Phthisical  Patients. — Dr.  Max  Einhorx 
said  tuberculous  patients  should  take  plenty  of  food  in 
almost  any  variety  so  long  as  they  had  not  much  dis- 
tress from  it.  Butter  was  one  of  the  fats  most  easily 
assimilated,  and  should  be  given  freely.  A  quarter  of 
a  pound  of  it  contained  about  as  much  heat  as  a  quart 
of  milk,  and  could  easily  be  taken  if  it  were  accom- 
panied by  some  meat,  bread,  and  milk.  He  usually 
told  phthisical  patients  to  take  some  milk  at  each  meal, 
and  to  take  five  meals  a  day.  To  the  milk  might  be 
added  some  meat  broth.  He  would  certainly  advise 
e.xercise.  but  it  was  best  to  take  it  out  of  doors.  The 
patient  should  not  overdo. 

Hot  Water  and  Ulcer  of  the  Stomach. — Dr.  Achil- 
les Rose  said  he  was  aware  that  drinking  hot  water 
had  become  very  popular,  and  it  had  become  necessary 
to  sound  a  warning.  It  had  been  shown  by  collective 
investigation  that  a  great  many  cases  of  ulcer  of  the 
stomach  occurred  in  cooks.  This  had  led  to  the  sup- 
position that  it  might  be  due  to  tasting  hot  soups,  etc., 
consequently  laboratory  experiments  were  instituted 
on  dogs  by  pouring  water,  about  of  the  temperature 
usually  prescribed  for  patients,  through  a  tube  into  the 
stomach.  These  dogs  were  killed  from  day  to  day  and 
week  to  week,  and  it  was  found  that  the  hot  water  first 
caused  a  hyperi-emic  spot,  and,  in  the  course  of  time, 
ulcer  of  the  stomach.  Dr.  Rose  was  once  visited  by  a 
cook  whose  master's  jihysician  had  prescribed  for  her 
drinking  very  hot  water.  Dr.  Rose  found  that  she  was 
suffering  from  ulcer  of  the  stomach,  a  condition  con- 
traindicating  hot-water  treatment. 

Exercise  and  Expansion  of  the  Chest. — Dr.  Taciu; 
Teschneu  showed  tables  and  photographs,  illustrating 
chest  expansion  and  lung  capacity  as  increased  by  sys- 
tematic gymnastic  exercise  which  had  been  carried  out 
under  his  supervision  in  eight  cases  of  spinal  deform- 
ities. In  one  case  the  capacity  of  the  lung  was  in- 
creased forty  cubic  inches  in  two  months. 


Dr.  McGillicuddy  believed  that  many  phthisical 
patients  had  been  killed  by  milk  punches.  Milk  did 
not  contain  enough  proteids,  and  was  too  liable  to  fer- 
ment. Yet  it  was  an  excellent  food  for  those  with 
whom  it  agreed. 

An  Improved  Uterine  Nozzle. — Dr.  Samuel  Broth- 
ers demonstrated  a  method  of  making  a  uterine  nozzle 
by  holding  the  hollow  glass  rod  across  the  alcohol  flame 
until  it  became  hot  enough  to  bend.  By  passing  the 
rod  along  and  heating  it  and  bending  it  at  several 
points  successively,  it  could  be  made  to  assume  any 
desired  shape.  The  canal  could  be  cleansed  by  intro- 
ducing a  fine  wire  and  pulling  a  brush  through. 


'glxcvnpcxxtxc  glints. 

Paludic  Pathology. — There  is  very  little  doubt  that 
the  periodicity  of  ague  depends  in  part  on  the  sudden 
production,  and  subsequent  liberation  in  the  blood,  of 
the  toxins  of  this  specific  sporozoon.  In  certain  forms 
of  paludism,  segmentation  proceeds  rapidly  ;  the  sub- 
jects of  these  forms  suffer  from  the  tertian  and  the 
double  tertian  forms  of  ague  :  while  the  long  evolu- 
tions lead  to  a  quartan,  and  the  irregular  forms  are 
accounted  for  by  different  generations  of  germs,  run- 
ning independent  courses,  at  times  parallel  but  not 
coincident.  The  stirring  events  which  underlie  the 
phenomenon  of  periodicity  in  ague  are  intensely  in- 
teresting. Let  us  take,  as  an  example,  the  phases  in 
the  evolution  cycle  of  the  parasite  of  quartan  fever. 

J^i'rsi  Dav  of  Apyrcxia. — There  is  a  progressive 
growth  of  the  parasite,  with  progressive  transformation 
of  haemoglobin  into  a  kind  of  melanin. 

Second  Day  of  Apyrcxia. — The  parasite  has  invaded    >; 
the  greater  part  of  the  blood-corpuscle. 

Third  Day. — This  is  the  day  of  the  paroxysm.  It  is 
understood  that  the  paroxysm  begins  about  midday  ; 
at  this  time  the  blood- pigment  collects  in  the  centre 
of  the  protozoon,  the  parasite  breaks  up,  segmentation 
being  complete,  and  the  toxins  of  the  organism  are 
suddenly  liberated  in  the  circulation.  They  soon 
reach  the  nervous  system,  for  which  they  appear  to 
possess  an  elective  affinity.  These  toxins  may  arrest 
the  downward  metabolism  of  the  tissues,  leading  to  a  \ 
fall  of  temperature,  or  they  may  stiaiulate  the  thermo- 
genic centres,  which  would  lead  to  an  increase  of  body 
heat. — Edward  Blake. 

Anti-Fat. — 

In  order  to  reduce  his  weight 

fie  purchased  him  a  wheel  ;  i 

Before  he'd  lidden  it  a  week  I 

He  fell  uff  a  good  deal.  ■ 

Fetid  Diarrhoea. —  J 

IJ.   Calomel lo  ctgr. 

Sulplio- carbonate  of  zinc 15  cigs. 

Subnitrate  of  bismuth 8  gm. 

Pepsin 2  gm. 

M.  Sig. :  Sufficient  for  twelve  powders.  Three  per  diem  in  a 
cliild  of  one  )ear. 

— Tompkins. 

Morphine  Habit. — M.  J.  Luvs  reports  the  case  of  a 
physician  who  had  been  accustomed  to  take  about 
seven  grains  of  morphine  daily.  Small  doses  of  sodium 
phosphate  were  given  subcutaneously  with  glycerine 
and  water,  and  as  they  were  gradually  increased  the 
morphine  was  progressively  diminished.  In  two  months 
the  morphine  was  discontinued  entirely,  and  then  the 
doses  of  sodium  phosphate  were  progressively  dimin- 
ished and  finally  stopped  altogether  in  two  weeks  more. 
There  remained  no  desire  for  the  morphine. — New 
York  Medical  Times. 

Lupus  "Verrucosus. — A  woman,  aged  forty,  had 
slightly  wounded  the  back  of  her  hand  while  making 
the  bed  for  a  phthisical  patient.  The  wound  did  not 
heal,  and  eighteen  months  later  a  patch  of  lupus  ver- 


November  9    1S95] 


MEDICAL    RECORD. 


67; 


i 


rucosus  appeared  in  the  scar,  and  reached  the  size  of  a 
two-franc  piece.  It  is  specially  to  be  noted  that  the 
warty  form  of  lupus  is  that  usually  observed  after  pro- 
fessional inoculation. — Thib.-vudet. 

Ardor  TJrinae  of  Gonorrhoea.— Cubebs  is  useful  in 
gonorrhoea,  not  because  it  possesses  any  specific  action 
against  this  disease,  but  because  it  has  a  beneficial  ef- 
fect in  modifying  the  ardor  urins,  which  is  generally 
the  most  distre.ssing  symptom  in  gonorrhoea. — Hare. 

For  Seminal  Emissions.— Hyoscine  has  not  proved 
successful  in  my  hands,  but  I  have  attained  perfect  re- 
sults by  the  administration  of  Thuja  occidentaiis  (fluid 
extract)  in  six-  to  eight-drop  doses,  thrice  daily^  half 
an  hour  before  each  meal.— De  Witt. 

Diarrhoea  in  Infants.— 

B.    Benz..nai.li'.hoI, 
Bismuth  su'.jniir., 

Kes  )rcin §3  gr.  jss. 

M.  Sig. :  For  a  child  one  or  two  j-ears  of  age  one  such  [.owder 
every  two  hour?  utiiil  six  have  been  taken. 

_.    ,     ,  — EWALD. 

Diphtheria. — 

B.    Alcohol 60  parts. 

Toluol 36  parts. 

Liq.  ferri  perchloridi 4  parts. 

For  the  relief  of  pain  menthol  may  be  added.  The  infected 
patches  are  to  be  swabbed  with  this  every  l»-o  to  four  hours. 

— LOEFFLER. 

Reflex  Causes  of  Nervous  Disease. — i.  The  essential 
feature  in  the  production  of  many  neuroses  is  the  neu- 
ropathic state — the  degeneracy  of  the  subject.  2.  In 
hysterical  subjects  suggestion  plays  an  important  part 
both  in  the  development  and  in  the  cure  of  the  symp- 
toms. 3.  Disease  of  any  organ  may  give  rise  to  re- 
feried  pain  in  some  definite  area,  but  not  to  other  ner- 
vous disturbances,  except  as  a  secondary  result  of  local 
disease  of  the  organ.  This  local  disease  manifests  itself 
by  the  ordinary  local  symptoms,  and  the  nervous  phe- 
nomena are  due  to  exhaustion,  anemia,  intoxications, 
etc.  4.  In  a  few  rare  cases  injury  of  a  sensory  nerve 
may  give  rise  to  epileptiform  seizures.  5.  Surgical 
operations  for  the  relief  of  nervous  symptoms  should 
never  be  performed  unless  there  are  clear  indications, 
apart  from  such  symptoms,  for  an  operation. — Kxapp. 

Croup.  —  Use  pilocarpine  as  a  specific  in  all  cases  in 
which  the  mucous  membrane  becomes  covered  with  a 
transudate  apt  to  coagulate.  The  abundant  secretion 
of  muctis  produced  by  the  pilocarpine  tends  to  loosen 
the  fibrinous  exudate  adherent  to  the  membrane,  and  it 
is  readily  expelled  from  the  larynx.  The  pilocarpine 
not  only  assists  in  dissolving  and  removing  the  mem- 
brane i>resent,  but  also  tends  to  prevent  its  reforming. 
It  can  be  administered  to  children  from  one  to  three 
years  of  age  in  doses  of  o.oi  to  0.03  gm.  ;  three  to 
six  years  of  age.  o  03  to  0.04  gm.  ;  six  to  ten  years  of 
age,  0.05  gm.  ;  ten  to  fifteen  years  of  age,  0.06  to  0.07 
gm.  ;  adults,  0.07  too.i  gm. — Sziklai. 

Chorea. — The  disease  to  which  the  term  chorea  has 
come  to  be  almost  entirely  confined,  viz.;  chorea  irinor, 
or  Sydenham's  chorea,  is  essentially  a  disease  of  child- 
hood, the  vast  majority  of  cases  occurring  between  the 
ages  of  five  and  fifteen  :  but  common  though  it  be  in 
childhood,  it  is  very  rare  indeed  in  early  infancj',  very 
few  cases  having  been  recorded  under  four  years  of 
age.  One  or  two  have  been  met  with  in  children  at 
the  breast,  and  from  time  to  time  accounts  appear  in 
the  medical  journals  of  instances  of  "congenital  cho- 
rea." In  systematic  treatises  on  medicine  these  cases, 
as  a  rule,  are  not  even  referred  to. — Johnsiox- 

Insomnia. — 

li.    .Vntlni.mii  ct  potass,  tartrate gr.  i.-ij. 

Morphia  sulphat gr.  j.ss. 

A<:|.  laurocerasi '^j. 

M.  Sig.:  Teaspoonful  every  two,  three,  or  four"  hours  as  le- 
quired  (in  wakefulness  of  feveis^. 

— Bartholow. 


Nasal  Catarrh. — In  cases  of  chronic  nasal  catarrh 
where  the  mucous  membrane  is  congested  and  irritable, 
a  solution  of  equal  parts  of  distilled  extract  of  hama- 
melis  and  water  sprayed  in  the  nose  often  does  very 
well,  but  first  the  nasal  cavities  must  be  well  cleaned. — 
Hare. 

Chronic  Constipation. — 

B .    Aloes gr.  iv. 

Strychnia;  sulphat gr.  } 

E.ictract.  belladonna; gr.  j4 

1  pecac.  pulv gr.  v'ss. 

Divide  in  pil.  .xij. 

M.     Sig.:  One  everj*  evening. 

Chronic  Pharyngitis. — 

"•    I«'' gr.  vi. 

Potassii  iodidi   gr.  xij. 

Mentholis, 

Glycerini,  q.s.  ad aa  Z  j. 

M.     -A^pply  with  a  camel's-hair  brush  twice  or  thrice  daily. 

The  Argyll-Robertson  pupil  has,  in  its  typical  form, 
three  sj-mptoms,  viz.,  loss  of  light  reflex,  retention  of 
accommodative  movements,  though  they  may  be  slug- 
gish, and  myosis,  as  minute,  perhaps,  as  the  pin-point 
pupils  of  opium  narcosis. — Gordinier. 

Bronchitic  Asthma. — 

H.    Potassii  iodidi t  jj 

Animon.  carb 3  J. 

Tinct.  lobelia- f  3  ij. 

Sp.  chloroformi f  ■  iv. 

Vin.  ipecac f  3  j- 

Infu^.  seneg.-t,  q.s.  ad f  1  vj. 

M.   A  taMespoonful  in  a  wineglassful  of  water  every  four  hours. 

Blisters  of  Feet  from  Long  Walks. — 

B  .  Saponis  nigri 52  parts. 

Aqux 27  parts. 

Vaselin 15  pans 

Zinci  oxidi 6  pans. 

EssentiEc  lavandulas,  q.s. 
M. 

Incontinence  of  Urine. — 

B.    Tincuir.^  belladonn.c, 

Tinctur.-e  cul)eba; a5  f  3  ij. 

Tinctur.e  nucis  vomicae, 

Tinctur.-c  rhei  aromaticae .hS  f  3  j. 

Tinctur.-e  cascarilUf f  3  ij- 

Twelve  drops  at  bedtime  for  a  child  from  seven  lo  ten  years. 


Conjunctivitis. 

B  .    Acidi  b.>rici . . 


gr.  XX. 


Sodii  chloi idi gr.  viij. 

Aqu;t  destillal f      •  ij. 

M.    Siij.  :  I'se  freely  as  a  loli  jn  every  four  hours,  first  warming. 

Membranous  Dysmenorrhoea. — The  os  externuin  is 
scarified  at  intervals  of  three  or  four  days  between  the 
periods  ;  just  before  the  flow  is  expected  the  cervix  is 
dilated,  the  interior  of  the  uterus  is  thoroughly  curet- 
ted, and  a  spiral  wire  stem  is  introduced,  which  is  worn 
continuously  during  at  least  three  subsequent  periods, 
the  patient  being  directed  to  take  hot  vaginal  douches 
even  when  menstruating.  No  harm  has  resulted  from 
the  use  of  the  stem,  and  the  patient  is  able  to  attend  to 
her  ordinary  duties. — Dike. 

Herpes  Zoster. — 

B  .    l!  Jiic  acid gr.  i. 

( ilycerine,  q  s. .  vaseline grs.  30. 

Cocaine  hydrochlorate. 

Extract  of  opium afi  cigr.  30. 

M.  The  neuralgia  following  the  eruption  is  best  treated  by 
Fowler's  solution. 

— Kaposi. 
"  New  Drugs  are  added  every  day  for  the  benefit 
chiefly  of  those  who  do  not  know  how  to  employ  the 
old  ones." — KFOADr.ENT. 

Gonorrhceal  Rheumatism. — In  an  equal  number  of 
males  and  females  attacked  with  gonorrhoea  the  males 
will  be  found  to  suffer  more  frequently  from  gonor- 
rhceal rheumatism  than  the  females. — Loxgstreth. 

Heart  Disease  Treatment.— The   system   comprises 

bathing  in  a  mineral  water,  associated  with  slowlv  ron- 


678 


1\IEDICAL   RECORD. 


[November  9    1895 


ducted  exercises.  The  water,  which  is  strongly  im- 
pregnated with  common  salt,  is  also  charged  with  large 
quantities  of  carbonic-acid  gas,  the  presence  of  which 
causes  the  water  to  escape  from  a  depth  of  several  hun- 
dred feet  below  the  earth's  surface  at  considerable  press- 
ure. The  water  is  conveyed  to  the  baths  by  this 
natural  pressure,  and  when  the  tap  allowing  its  en- 
trance into  a  bath  is  turned  on,  the  foaming  water 
rushes  in  with  such  rapidity  and  force  that,  unless  care 
is  exercised,  spray  may  be  scattered  over  the  bath- 
room. After  the  tap  has  been  turned  off  the  turmoil 
quickly  ceases,  but  multitudes  of  small  babbles  rising 
through  the  clear  water  reveal  the  presence  of  carbonic- 
acid  gas. SCHOTT. 

Psoriasis. — 

9.    Ichthyol, 

Acid,  salicylic. 

Acid,  pyrcgallic. , 

Aristol aa  gra.  2 ;. 

Vaselin, 

Adipis, 

Lanolin aa  gm.  30. 

M.      A  powerful  oinmient,  to  be  used  in  small  quantities. 

Haemostatic  Action  of  Antipyrine. — One  of  the  anti- 
pyretics most  in  use,  namely,  antipyrine,  has  a  power- 
ful hremostatic  action.  This  property  I  discovered  in 
18S4,  in  the  course  of  some  experiments  with  the  drug. 
The  hemostatic  action  is  local,  and  its  mechanism  is 
vaso-constriction  and  retraction  of  the  tissues,  with 
formation  of  a  minute  clot  which  is  extremely  retractile 
and  aseptic.  Antipyrine  has  also  a  favorable  effect  on 
cicatrization. — Henocqui:. 

Chronic  Rheumatism. — 

^.    Sodii  salicylatis 3  iv. 

Potassii  iodidi 3  j. 

Melliylis  salicylatis f   3  j. 

E.'ctracti  cimicifugre  fluidi    f   3  ij. 

Alcoholis f   3  iv. 

Aqui^  anisi q.s.  ad  f   3  iij. 

M.  Sig.  :  Shake  well  and  take  a  teaspoonful  in  water  three  times 
a  day. 

High  Altitudes  in  Phthisis. — It  is  unsuitable  for 
those  in  whom  a  large  area  of  lung  is  involved,  or  when 
pyrexia,  sweats,  and  great  loss  of  flesh  exist.  Nervous 
cases  and  those  with  cardiac  complications  should 
avoid  the  higher  altitudes. — Waxham. 

.  Tuberculosis. — The  process  extends  in  the  lungs  in 
the  following  ways  :  First,  by  direct  continuity,  pref- 
erably along  lymph  channels  ;  secondly,  by  the  forma- 
tion of  fresh  foci  by  tubercular  bacilli,  which  are  car- 
ried in  the  lymphatic  circulation  for  some  little  distance 
in  the  lung  ;  thirdly,  the  most  important  of  all,  a  cavity 
having  formed  in  the  lung,  its  secretion  escapes  into 
the  surrounding  bronchus,  and  is  expelled  by  cough. 
But  the  discharge  of  sputum  is  apt  to  be  incomplete, 
and  their  infective  material  is  liable  to  be  sucked  back 
into  other  bronchi,  and  into  healthv  lung  tissue,  and 
thus  arise  fresh  centres  of  disease. — Pekcv  Kidu. 

Marasmus.— From  the  bodies  of  dead  bacilli  a  toxic 
product  is  formed,  unaffected  by  light,  heat,  drying,  or 
time,  causing  marasmus  even  when  in  the  most  minute 
doses.  It  is  transmitted  to  the  fcetus  from  the  parent, 
and  sets  up  chronic  bronchitis,  and  during  life  it  is 
very  rarely  diagnosed  froin  simple  chronic  bronchitis. 
— Maffucci. 

A  Grave  Offence. — Whoever  adds  one  tittle  that  is 
unnecessary  to  medical  education  is  guilty  of  a  very 
grave  offence. — Huxlev. 

Tuberculosis. — 

3.    Morsnn's   creosote TH_  cxxviij. 

01.  menih.  pip , TH  xxx. 

Spls.  chloroform 3  ij. 

Tr,  gent,  co ^  j. 

Tr.  mix  vom . 3  iij. 

Spts.  frumenti ad  3  viij. 

Pig.  :  One  draclim  three,  four,  or  five  times  a  day  in  water  (a 
wine  glassful). 

— Makk. 


Abdominal  Incision. — i.  The  line  of  parietal  incision 
should  be  made  parallel  with  the  direction  of  the  most 
important  muscular  fibres.  2.  Separate  where  possible 
and  do  not  divide  aponeurotic  fibres  :  where  division 
is  necessary,  let  it  be  in  a  direction  which  will  permit 
of  the  leaving  intact  one  or  other  of  the  muscular  lay- 
ers behind  the  division,  or  in  front  of  it,  or  parallel  to 
it.  If  no  one  of  these  practices  is  possible,  then  a  flap 
entrance  should  be  made,  that  is  to  say,  the  weak 
points  do  not  all  overlie  ;  they  are  made  at  different 
levels  in  the  parietes  when  union  is  made.  3.  Keep 
away  from  the  bony  margins,  and  avoid  the  thickest 
and  most  mobile  parts  of  the  parietes.  4.  Let  the  in- 
cision be  as  short  as  is  consistent  with  efficiency.  A 
long  incision  with  separation  of  muscular  and  aponeu- 
rotic fibres  is  better  than  a  short  one  with  division  of 
fibres.  The  leading  principles  for  our  guidance  in  the 
closing  of  a  parietal  incision  are  :  i.  The  apposition 
of  raw  surfaces  should  be  as  broad  as  possible.  2. 
Each  divided  structure  should  be  placed  and  kept  op- 
posite its  fellow.  3.  The  sutures  should  not  be  re- 
moved early.  If  the  parts  are  kept  together  firmly  for 
three  weeks  or  a  month,  we  have  done  the  best  we  can 
to  prevent  stretching  of  the  cicatrix. — Greig  S.mith. 

The  Causes  of  Shortening  of  the  Femur  maybe  classi- 
fied as  follows,  viz.  : 

(a)  Impacted  fracture  of  the  neck  of  the  femur.  ( /') 
Arrest  of  growth  of  the  neck  following  disease  the  re- 
sult of  injury.  (<■)  Disease  of  the  hip-joint.  (</)  Ar- 
rest of  growth  at  the  lower  end  of  the  femur  from  dis- 
ease of  the  epiphysis,  (c)  Arrest  of  growth  of  the 
lower  endof  the  femur  following  disorganization  of  the 
knee-joint. — Thomas  Brvant. 

Furuncles. — In  the  treatment  of  boils  coming  in  croiis, 
colchicum  is  recommended  in  doses  of  from  one-third 
to  one-half  of  a  grain  each  day. — Dominion  Medi.al 
Monthly. 

Appendicitis. — In  operating,  as  a  rule,  remove  the 
appendix.  It  is  bad  surgery  to  leave  the  appendix 
unless  the  adhesions  are  very  marked  and  cannot  be 
separated  without  the  risk  of  harm.  Where  there  is 
liability  of  breaking  into  the  general  peritoneal  cavity, 
do  not  search  for  the  ajipendix  Where  there  is  a 
tumor  make  the  incision  over  the  tumor.  We  shii.;!d 
not  go  through  the  peritoneal  cavity.  It  is  rare  to  ha\  e 
an  appendicitis  going  on  to  a  condition  of  distir.rt 
tumor  without  pus  being  present.  It  is  better  ;ii 
operate  before  any  appreciable  tumor  has  formed.  In 
cases  of  tumor  operation  is  advisable,  even  with  a  ncir- 
mal  temperature  or  a  declining  temperature.— Keen. 

Keloid. — \Vhile  a  keloid  is  growing,  its  removal  by 
the  knife  should  not  be  attempted  ;  repeated  scarifica- 
tion or  multiple  electrolytic  punctures  sometimes  suc- 
ceed in  destroying  it. — Keen. 

Ulceration  of  Rectum. — The  three  great  factors,  there- 
fore, in  my  opinion,  in  producing  ulceration  of  rectum 
are  tuberculosis,  syphilis,  and  cancer. — Matthews. 

Fistula  in  Ano. — i.  Never  sever  the  sphincters  at 
more  than  one  place  at  the  same  operation,  no  matter 
what  the  complications  may  be.  otherwise  incontinence 
is  sure  to  follow.  2.  Unless  all  the  channels  are  fol- 
lowed up  and  laid  open,  the  operation  will  fail  of  its 
purpose.  3.  Fistula  resulting  from  tubercular  abscess 
must  not  be  operated  upon  if  there  is  stitificient  tissue 
descruciion  of  lung  to  produce  hectic  fever,  sweats, 
etc.,  unless  the  fistula  is  causing  severe  painful  spasms, 
of  the  sphincters,  then  it  should  be  divided  at  anf 
stage.  4.  After  laying  the  fistula  tract  open,  the  wounj 
must  be  made  to  heal  from  the  bottom,  and  as  the 
cutaneous  or  mucous  side  of  the  wound  is  better  nour- 
ished, it  will  throw  out   a  more  healthy   granulation 


November  9,  1895J 


MEDICAL    RECORD. 


679 


that  tends  to  bridge  over  and  close  the  slower  granular 
surface  at  the  bottom,  thus  leaving  a  fistula  remaining. 
5.  When  the  fistulous  tract  is  not  too  complicated  it 
should  be  dissected  out  entire  and  the  wound  brought 
together,  beginning  at  the  bottom  with  continuous  cat- 
gut^utures  and  approximating  the  surface  in  succes- 
sive layers  until  the  whole  wound  is  closed. — B.acox. 

Pott's  Disease  is  an  osteitis,  usually  tuberculous,  of 
one  or  more  vertebrje,  resulting  in  necrosis  or  caries. — 
Burr. 

Extra-uterine  Pregnancy. — Every  diagnosed  extra- 
uterine   pregnancy    calls   for    surgical    interference. — 

PlNARl). 

Carbuncle,  it  is  said,  has  been  arrested  in  its  develop- 
ment by  the  injection  into  different  parts  of  the  tumor 
of  five  drops  of  pure  liquid  carbolic  acid  at  each  point. 

Fungus  Cerebri. — Pressure  by  sponges  or  dressings 
sometimes  yields  good  results,  but  at  other  times  con- 
vulsions follow  the  application  of  pressure,  when  it 
must  be  abandoned. —  Kf.e.v. 

Hemorrhoids. — 

B  .  Acid,  g.illic   gf.  ^■• 

ENlracl,  opii gr.  iv. 

Extract,  lielladonnse gr.  v. 

Unguent,  simplicis 3  iv. 

M.   Sig.  :  Apijly  locally  night  and  morning. 

— Hare. 

Tuberculosis. — Surgical  tuberculosis  is  of  far  more 
frequent  occurrence  than  is  generally  supposed.  Kocher 
states  that  ninety  per  cent,  of  the  bone  and  joint  cases 
in  his  clinic  are  tuberculous.  Tizzoni,  in  Italy,  has 
lately  examined  lymphatic  glands  of  47  persons  who 
met  violent  deaths  and  who  were,  apparently,  in  per- 
fect health.  Strange  to  say,  he  found  tubercle  bacilli 
present  in  43  of  the  subjects. 

Suppurative  Nephritis.— i.  Pyelonephritis  is  the  re- 
sult in  the  great  majority  of  cases  of  infection  by  the 
bacterium  coli  commune  ;  in  a  fewer  number  of  cases 
through  proteus  or  the  more  ordinary  forms  of  suppu- 
rative cocci.  2.  In  a  certain  number  of  cases  in  which 
the  ordinary  pyogenic  microbes  are  the  cause  of  irrita- 
tion a  consecutive  pyemia  results.  3.  Pyelonephritis 
resulting  from  the  irritation  of  staphylococci  and  strep- 
tococci is  not  to  be  differentiated  from  the  other  forms 
alone  by  the  pyremia  present,  but  also  microscopically 
by  the  marked  necrosis  of  tissue,  and  the  absence  of 
increased  inflammatory  tissue-formation  which  is  pro- 
duced by  the  bacterium  coli  commune.  4.  It  is  not 
probable  that  the  typical  ascending  pyelonephritis  can 
be  produced  by  the  passage  of  micro-organisms  from 
the  bladder  through  the  circulation. — Von  Wunsch- 

HEIM 

Epithelioma. — The  formula  for  Marsden's  paste  is 
as  follows  : 

Acid  arsenious 2  drachms. 

Pulv.  gum  arabic i  drachm. 

Cocaine  muriate 18  grain?. 

When  you  are  ready  to  use  this  it  should  be  made 
into  a  paste  by  adding  water.  The  paste  should  be  of 
the  consistency  of  rich  cream  and  should  be  applied 
on  a  small  piece  of  cloth,  which  is  left  on  from  eigh- 
teen to  thirty-six  hours.  This  can  be  repeated  as 
often  as  is  necessary.  The  above  is  the  formula  for 
the  stronger  paste.  In  tlie  weaker  preparation  use 
only  one  drachm  of  arsenious  acid  and  twelve  grains 
of  cocaine.  Marsden's  original  formula  consisted  only 
of  e(;ual  parts  of  arseniotis  acid  and  gum  arabic.  The 
cocaine  has  been  added  to  counteract  the  pain. 

Essentials  for  Administration  of  Anaesthetics. — .Mlis's 
ether  inhaler  and  ether  bottle  (graduated),  Esmarch's 
chloroform  inhaler  and  chloroform  bottle  (graduated), 
hypodermic  syringe  and  tablets  of  morphine,  morphine 
and  atropine,  atropine,  strychnine,  digitalin,  and  nitro- 
glycerin, whiskey  and   aqua  ammonia  F.,  mouth-gag, 


throat  sponge-holder  and  small  sponges,  catheter,  pock- 
et-case, and  tracheotomy  tubes.  By  many  the  battery 
is  considered  an  additional  safeguard,  although  I  have 
found  little  or  no  use  for  it. — Strouse. 

Carcinoma  of  Stomach. — i.  The  treatment  of  these 
tumors  differs  in  no  respect  from  that  of  cancer  else- 
where. It  is  purely  surgical.  2.  Operation  is  to  be 
recommended  when  possible,  before  the  turaor  is  pal- 
pable. 3.  Examination  should  only  be  made  under 
deep  narcosis,  and  an  exploratory  incision  made  if  re- 
quired. 4.  Those  cases  only  should  be  recommended 
for  resection  of  the  pylorus  where  the  tumor  is  freely 
movable,  and  there  is  no  metastatic  involvement.  5.  If 
these  conditions  are  not  present,  the  formation  of  a 
fistula  between  the  stomach  and  jejunum  is  indicated. 
6.  This  operation  should  not  be  delayed  until  the  pa- 
tient is  nearly  dead  of  hunger,  and  the  knife  then 
used  as  a  last  resource,  for  the  mortality  is  then  mu<-h 
greater. — Klem.m. 

Tumors  of  the  Subcutaneous  Tissue  or  of  the  inter- 
muscular facia  should  be  removed  as  often  as  they  re- 
cur, and  if  a  limb  is  deeply  involved  it  should  be  am- 
putated.— Keen. 

Fractures. — The  time  has  come  when  all  compound 
fractures  should  be  treated  by  uniting  the  ends  of  the 
bone,  the  wound  being  thoroughly  irrigated.  Five 
cases  of  apparently  hopeless  fractures  of  the  ankle- 
joint  are  reported  by  Balch  as  terminating  in  very 
good  results. — Tyson. 

I  indorse  the  view  that  the  angle  between  the 
neck  and  the  shaft  was  normally  unaffected  by  age, 
and  that  osseous  union  might  take  place  in  several 
forms  of  fracture  of  the  cervix  femoris. — Sir  William 
Stok.es. 

Coccygeal  Dermoid  Cysts. — I'oints  of  interest  in  con- 
nection with  them  are  :  i.  Their  comparative  fre- 
quency ;  2,  their  tendency  to  suppurate  ;  3,  the  diffi- 
culty of  getting  healing  by  first  intention  after  excising 
them  (doubtless  on  account  of  the  close  proximity  of 
the  anus)  ;  and  4,  the  tendency  they  have  to  undergo 
epitheliomatous  degeneration.  —  Wveth,  .\)iHK,  .\nd 
Others. 

Fear  in  Chloroform  Narcosis.  —  From  the  effect  just 
n.amed  I  should  be  in(?lined  to  put  down  fear  as  one  of 
the  most  determinate  causes  of  fatality  from  chloro- 
form. I  have  before  me  several  instances  in  which  it 
is  impossible  that  chlorofortn,  minus  fear,  could  have 
been  the  direct  cause  of  death,  because  sufficient  of  it 
was  not  administered  to  produce  death. — Richardson. 

Boils. — Gouty  people  are  often  attacked  by  successive 
crops  of  boils.  Treat  such  cases  by  the  internal  ad- 
ministration of  colchicutn.  In  one  case  the  boils 
quickly  disappeared  under  the  influence  of  the  colchi- 
cum,  but  reappeared  when  the  drug  was  stopped.  Lo- 
cally apply  strong  tincture  of  canijihor. — Brocq. 

Sycosis.— The  following  treatment  is  recommended 
for  sycosis  dependent  on  staphylococci  :  In  slight 
cases  I  apply  a  sulphurated  zinc  paste,  to  which  a 
five-per  cent,  solution  of  carbolic  acid  has  been  added, 
and  in  severe  cases  advise  cauterization  with  a  twenty 
to  fifty-per  cent,  solution  of  resorcin  in  alcohol.  In 
the  most  rebellious  cases  use  an  ointment  of  pyrogallol 
or  of  chrysarobin. — Leistikow. 

Trusses. — Trusses  for  hernia  were  known  to  the 
Phoenicians  nine  hundred  years  before  Christ,  as  is 
shown  by  a  votive  image  recently  found  at  Soussa,  in 
the  possession  of  Dr.  Poucet,  chief  medical  officer  of 
the  I'rench  army  in  Tunis.  The  statuette  is  of  terra 
cotta,  representing  the  F^gyptian  god  Bizou  ;  but 
around  its  waist  is  an  elaborate  and  efficient  metallic 
truss.  X'arious  forms  of  hernia  are  shown  in  the  figure, 
which  The  Lancet  calls  a  perfect  museum  of  hernial 
pathology. 


68o 


MEDICAL    RECORD. 


[November  9    1895 


OUR    LONDON'    LETTER. 

(From  our  Special  Correspondent.) 

OPENING  SOCIETIES INEBRIETY- — -HOSPITAL  SATUR- 
DAY FUND — CHARING  CROSS  HOSPITAL — AGED  PRO- 
FESSORS  PUBLISHING     SEASON DEATHS     OF     SIR    T. 

LONGMORE  AND  SURGEON-GENERAL  MASSY — SCAR- 
LET FEYER TYPHOID — MEDICAL  PAPERS  AT  A  TEM- 
PERANCE     CONGRESS  —  THE     SOCIETIES,     CLINICAL, 

MEDICAL,        OBSTETRICAL,        PATHOLOGICAL  LORD 

WOLSELEY  AND  ARMY  SURGEONS — DEATHS  OF  SIR  T. 
CRA\YFORI)    AND  DR.  THOMAS  KEITH. 

London,   October  12,   1895. 

Now  that  the  schools  are  in  full  work,  the  societies  are 
waking  up,  and  we  shall  soon  be  flooded  with  papers 
and  discussions.  Some  societies,  indeed,  have  already 
met,  and  one  or  two  took  very  brief  vacations.  There 
is  some  sort  of  a  fixture  for  every  day  in  the  coming 
week,  and  those  who  have  hardly  digested  the  papers  of 
the  several  Congresses  which  have  been  held  here  or 
on  the  Continent,  may  well  sigh  at  the  copious  pabulum 
provided.  As  an  oppressed  one  lately  observed,  there 
are  too  many  courses  at  our  dinners,  and  our  intellec- 
tual diet  is  just  as  heavy. 

The  Society  for  the  Study  of  Inebriety  puts  in  an  ap- 
pearance early  in  the  session.  On  the  3d,  Dr.  Norman 
Kerr,  president,  opened  a  discussion  on  Probationary 
Curative  Detention,  and  pointed  out  the  difficulties  of 
the  poor  as  compared  with  the  rich.  The  latter  can 
enter  an  asylum  as  voluntary  boarders,  without  being 
certified  as  lunatics,  but  the  poor  have  not  this  oppor- 
tunity. He  advocated  hospitals  for  the  treatment  of 
mental  disease,  in  which  patients  could  remain  six  or 
eight  weeks,  and  if  then  not  improved  could  be  sent  to 
an  asylum.  He  predicted  that  twenty  years  hence  we 
shall  have,  i,  probationary  curative  mental  hospitals  ;  2. 
asylums  in  separate  blocks  as  in  some  American  build- 
ings ;  3,  convalescent  homes  to  render  the  re-entrance 
of  patients  into  ordinary  life  less  abrupt  and  less  trying 
to  them.  The  proposals  were  well  received  and  sup- 
ported by  several  speakers. 

The  Hospital  Saturday  Fund  is  appealing  for  fur- 
ther support.  It  has  been  established  twenty  one  years 
and  has  disbursed  about^?2oo,ooo,  but  the  need  of  the 
hospitals  is  always  increasing.  For  some  time  now  this 
society  seems  to  have  been  well  managed.  It  is  free 
from  the  absurd  prejudices  of  the  Sunday  Fund,  which 
is  gathering  up  against  it  all  the  supporters  of  special 
hospitals.  The  Saturday  Fund  treats  all  applicants 
fairly,  and  assists  ambulance  service  and  the  societies 
which  provide  surgical  appliances. 

Charing  Cross  Hospital  appears  to  be  the  owner  of 
Toole's  Theatre,  and  the  lease  having  lately  terminated 
the  County  Council  insists  on  some  alterations.  These 
will  cost  money,  and  the  hospital  is  in  low  water.  Of 
course,  the  Council  is  bound  to  see  that  its  require- 
ments are  carried  out  for  the  protection  of  the  public. 
If  the  hospital  managers  are  in  such  straits  for  money, 
they  might  have  been  wiser  to  fall  in  with  the  recent 
proposal  to  remove  to  South  London,  and  sell  their 
very  valuable  site.  We  could  well  spare  it,  as  there  is 
ample  hospital  accommodation  within  a  short  distance. 

Worn-out  professors  are  threatened.  A  treasury 
committee  has  presented  a  report  recommending  fixed 
rules  to  be  applied  as  to  tlie  retirement  of  professors. 
It  is  proposed  that  at  the  age  of  sixty- five  years  the 
president  of  his  college  shall  make  a  report  as  to  the 
working  of  the  incumbent's  chair.  If  satisfactory,  he 
may  occupy  it  u\)  to  seventy  years,  but  not  longer. 
Presidents  themselves  are  to  retire  at  seventy  years — in 
special  cases,  seventy-five  years.  What  will  be  the 
good  of  such  rules?  A  president  of  sixty-six  years 
say,  reporting  on  a  professor  of  sixty-five  I  Should  not 


each  case  be  considered  on  its  merits  by  competent 
persons,  outside  the  probability  of  prejudice  for  or 
against  ? 

The  medical  publishing  season  is  likely  to  be  a  busy 
one.  A  number  of  new  books  and  new  editions  are 
already  out,  and  fresh  announcements  are  following 
fast.  The  three  first  volumes  of  the  "Twentieth  Cen- 
tury Practice  "  have  reached  subscribers,  and  the 
scheme  excites  some  interest  among  the  more  literary 
members  of  the  profession.  The  undertaking  is  con- 
sidered a  great  one,  and  the  publishers  are  commended 
for  their  enterprise  and  the  editor  for  his  industry  and 
care. 

The  first  volume  of  a  report  of  a  committee  of 
the  Medico  Chirurgical  Society,  on  "  The  Climates  and 
Baths  of  Great  Britain,"  forms  a  notable  publication. 
The  committee  is  continuing  its  labors.  It  consists,  of 
course,  of  Fellows  of  the  Society,  so  that  some  of  our 
chief  climatic  authorities  are  conspicuous  by  their  ab- 
sence, and  one  or  two  names  almost  excite  a  smile — 
though  it  is  quite  possible  they  know  more  about  cli- 
matology than  their  devotion  to  other  subjects  would 
lead  us  to  suppose.  This  volume  is  devoted  to  our 
southern  climates  and  our  chief  springs  ;  it  includes  a 
mass  of  facts  more  or  less  interesting,  collected  wiih  no 
little  trouble,  and  it  will  prove  a  good  storehouse  for 
those  who  are  capable  of  critically  examining  the  sub- 
ject ;  for  a  critical  digest  is  not  attempted  in  this  report, 
and  would  hardly  be  expected  from  a  committee  con- 
stituted in  this  manner,  and  which  has  spent  much  of 
its  energy  in  collecting  facts  from  local  doctors,  and 
deputing  one  or  other  of  its  members  to  visit  some  of 
the  resorts. 

Of  other  works  ready  or  announced,  I  may  mention 
"  Munk's  Life  of  Sir  H.  Halford,"  who  was  physi- 
cian to  four  of  our  sovereigns  ;  "  Translations  of  Ka- 
posi's Skin  Diseases,"  "  Herab's  Ophthalmoscopy," 
'■  Knie's  Eye  Diseases  in  Relation  to  (,)ther  Diseases," 
a  new  edition  of  "  Barr's  Ear  Diseases,"  and  a  book 
on  "  Deaf-mutism,"  by  Drs.  Love  and  Addison.  Pro- 
fessor Macalister  has  ready  a  "  Textbook  of  Physical 
Anthropology,"  and  a  second  edition  of  Darwin  and 
Acton's  "  Physiology  of  Plants  "  is  announced.  Then 
the  first  volume  of  "  Transactions  of  the  Recent  Con- 
gress of  Hygiene  and  Demography  "  is  being  delivered 
to  members,  and  the  others  will  follow  in  due  course. 

Sir  Thomas  Longniore,  formerly  Professor  of  Mili- 
tary Surgery  at  Netley.  died  suddenly  on  the  30th.  He 
went  to  see  his  son  start  by  an  early  train,  and  died 
within  an  hour  and  a  half.  He  served  through  the 
Crimea  and  the  Indian  Mutiny,  and  was  a  Surgeon- 
General,  Knight  Commander  of  the  Bath  and  of  the 
Legion  of  Honor,  Honorary  Surgeon  to  the  Queen,  etc. 
His  "  C)ptical  Manual  "  is  a  standard  on  the  eyesight 
of  soldiers,  and  besides  contributions  to  journals  he 
wrote  "  Gunshot  Injuries,"  of  which  a  new  edition  is 
just  out,  "Transport  of  Sick  and  \\ounded  Troops," 
and  other  works,  including  a  "  Life  of  Wiseman,"  the 
surgeon  of  Cnarles  II. 

Surgeon-General  Massy,  C.B.,  died  on  September 
27th,  aged  seventy-five.  He  had  a  distinguished  career, 
served  through  the  Crimea  and  the  Indian  Mutiny. 
He  receiYed  the  Crimean  medal  with  four  clasps,  the 
Turkish  medal,  the  Medjidie,  and  the  Indian  medal 
with  clasp.  He  retired  in  1S80,  with  a  "good  service 
pension,"  after  thirty-six  years'  army  service. 

Scarlet  fever  is  jirevalent  at  the  West  End.  In  Ma- 
rylebone.  Dr.  Blylh,  medical  officer  of  liealth,  reported 
last  week  that  day  after  day  cases  were  occurring  for 
which  the  asylums  board  failed  to  find  room  in  their 
fever  hospitals.  The  chairman  of  the  smitary  com- 
mittee proposed  to  ]irovide  for  such  cases,  but  his  ves- 
try rejected  the  motion  in  order  to  compel  the  asylums 
board  to  do  their  duty.  But  this  board's  hospitals  are 
crowded,  and  the  ditticulty  of  obtaining  sites  for  new 
ones  is  notorious.  Still  a  dead-lock  must  not  be  per- 
mitted in  [iresence  of  a  threatened  epidemic. 


November  9,    1895] 


MEDICAL    RECORD, 


681 


At  the  East  End  typhoid  fever  is  prevalent.  Diph- 
theria, if  not  spreading,  seems  to  be  taking  a  fatal 
type. 

London,  October  iS.  1S95. 

A.MOXG  the  recent  congresses  that  have  demanded 
attention  from  the  public  and  profession,  that  held 
at  Chester  by  temperance  reformers  claims  notice, 
inasmuch  as  it  devoted  a  section  to  the  scientific  aspect 
of  the  questions  involved.  The  congress  was  called 
by  the  National  Temperance  League,  an  organization 
which  attempts  to  promote  its  views  exclusively  by 
moral  suasion,  and  not  by  any  form  of  compulsion  or 
legislation.  It  was  a  bold  stroke  to  assemble  at  Chester 
— the  bishop  of  which  diocese  is  the  author  of  the 
programme  for  improving  public-houses.  The  con- 
gress was  a  remaTkable  success,  largely  due  to  the 
energy,  zeal,  and  organizing  capacity  of  the  Secretary 
of  the  League,  Mr.  Robert  Rae.  But  it  is  to  the 
scientific  section  I  must  confine  my  notes,  and  in  this 
the  doctors  had  it  almost  to  themselves.  Sir  B.  Rich- 
ardson presided  in  his  usual  genial  and  confident 
manner.  He  was  President,  too,  of  the  whole  con- 
gress, and  gave  a  capital  address.  If  any  fault  can  be 
found  with  his  appearance  in  such  a  capacity,  it  is  on 
account  of  the  self  consciousness  which  he  wears  so 
obviously.  He  has  done  very  good  work,  none  better 
than  his  temperance  advocacy  :  but  he  is  not  the  only 
scientific  student,  and  may  excuse  an  American  journal 
for  reminding  him  of  this  fact,  so  patent  to  others. 

Ur.  \V.  Carter,  Professor  of  Materia  Medica  in  the 
Liverpool  College,  and  Physician  to  the  Infirmary,  laid 
down  in  his  paper  that ;  i,  Abstainers  from  alcohol  live 
longer  than  those  who  use  it  moderately  ;  2,  they  work 
harder  and  longer  ;  and,  3,  their  intellectual  energy  is 
as  great  and  as  well  sustained,  .\llman  showed,  in  1879, 
that  as  little  as  i  of  alcohol  in  800  was  injurious  to 
protoplasm,  and  yet,  said  Dr.  Carter,  moderate  drink- 
ers send  to  their  several  organs  more  than  i  in  800  at 
least  once,  often  several  times  daily. 

The  next  paper  was  by  Dr.  Cosgrove,  Professor  of 
Biology  at  the  Royal  College  of  Surgeons  in  Ireland, 
who  said  various  observers  in  the  last  few  years 
had  tested  the  effect  of  alcohol  on  the  special  senses, 
and  all  agreed  that  it  was  a  narcotic  ab  initio,  and  not, 
as  formeily  supposed,  a  stimulant  first.  "Short  Life, 
Less  W^ork,  Worse  Work,  that  is  the  Output  of  Alcohol," 
was  the  burden  of  this  paper.  In  exchange  it  "  nar- 
cotizes the  mind  as  well  as  the  body,  hides  from  us  the 
truth  about  ourselves,  and  makes  us  satisfied  when  we 
ought  to  be  ashamed." 

-Mr.  \'acher,  ^Medical  Officer  of  Health  for  the 
County  of  Cheshire,  read  a  paper  entitled  "  Alcohol, 
the  Antagonist  of  Hygiene."  He  maintained  that  par- 
taking of  alcohol  was  o|)posed  to  personal  hygiene  and 
stood  in  the  way  of  sanitary  improvements,  thwarting 
the  efforts  of  the  authorities  by  renderirg  the  peojjle 
less  capable  of  distinguishing  between  the  good  and 
evil  of  their  surroundings  as  they  drink  of  the  river  of 
Lethe. 

Dr.  Walmsley,  Superintendent  of  the  Metro]>olitan 
IJi(jt  .-Vsylum,  took  as  his  subject,  "  Drink  as  a  Factor 
in  the  Production  of  Insanity."  He  pointed  to  the 
well  known  fact  that  alcohol  is  responsible  for  more 
mental  and  physical  suffering  and  incapacity  tlian  any 
01  her  single  cause.  We  do  not  cure  insanity,  he  said, 
but  of  1 1  persons  who  became  insane,  9  ultimately 
died  insane,  and  of  the  other  1  only  i  recovered.  -\ 
single  law  forbidding  the  marriage  of  tainted  jiersons, 
and  one  preventing  jjeople  driving  themselves  mad 
witti  drink  would,  he  declared,  be  worth  more  than  all 
our  lunacy  laws.  The  discussion  was  joined  in  i)y  one 
or  two  laymen,  and  several  suggestions  made  res|)ect- 
ing  the  mannc  r  of  prescribing  alcohol  when  physicians 
thought  it  jiroper  to  do  so  After  which  Dr.  Williams, 
of  Flint,  remaiked  on  the  difficulty  arising  from  the 
l)ublic  faith  m  alcohol,  for  they  were  continually  asked 
if  a  little  wine  or  spirits  would  do  good,  and  when  the 


doctor  said  no,  other  advice  was  sought  and  he  lost 
the  patient.  He  thought  the  battle  could  only  be  fought 
by  the  doctors  becoming  abstainers  themselves. 

The  Clinical  Society  met  last  Friday,  when  Mr.  God- 
lee,  Vice  President,  took  the  chair  in  the  absence  of 
the  President,  whose  inaugural  address  was  therefore 
postponed.  Mr.  .\.  Lane  read  notes  of  four  cases  of 
bony  ankylosis  of  the  temporo  maxillary  joint  on 
which  he  had  operated  with  success.  Several  such 
cases  were  mentioned  by  the  speakers  who  discussed, 
and  it  was  remarked  that  it  would  be  well  if  the  cases 
could  be  seen,  as  it  would  be  interesting  to  notice 
whether  any  deformity  resulted.  One  or  two  other 
speakers  said  the)  could  bring  cases. 

"Cardiac  Syphiloma"  was  the  next  subject,  several 
cases  of  sudden  death  being  mentioned,  in  some  of 
which  gummata  were  found.  It  was  held  that  cardiac 
symptoms,  which  could  not  be  due  to  an  ordinary 
lesion,  if  they  occurred  in  a  patient  who  had  had 
syphilis,  might  be  ascribed  to  gumma  or  fibrosis  of 
that  character,  and  should  be  treated  by  iodide.  A 
case  of  injury  to  the  knee-joint,  for  which  arthrotomy 
was  performed,  was  then  related,  and  some  other  cases 
mentioned. 

The  Medical  Society  of  London  held  its  first  meet- 
ing on  Monday,  when  the  new  President,  Sir  Crichton 
Browne,  delivered  an  inaugural  address  on  the  "  Cen- 
eralization  of  Specialism,"  after  which  a  paper  on  the 
"Radical  Cure  of  Hydrocele  by  Excision  of  the  Sac  " 
was  read  by  Mr.  Lockwood,  and  discussed  by  several 
of  the  surgeons  present. 

.\t  the  Obstetrical  Society  there  was  a  paper  on  the 
"  V^ariation  in  Height  of  the  Fundus  above  the  Sym- 
physis during  the  Puerperium,"  and  another  on  "  Cer- 
tain Micro  organisms  of  Interest  to  Obstetricians  and 
Oynecologists."  It  was  stated  that  the  next  meeting 
should  be  special  for  the  purpose  of  considering  pro- 
posed alterations  of  rules. 

The  Pathological  Society  opened  without  an  address 
and  went  straight  to  work.  There  was  a  good  show  of 
specimens.    Most  of  the  other  societies  are  in  full  work. 

I  told  you  Lord  Wolseley  would  be  no  improvement 
on  the  Duke  of  Cambridge,  so  far  as  friendliness  or 
justice  to  army  surgeons  is  concerned.  I  predicted 
the  change  would  only  be  between  King  Stork  and 
Log.  The  Pall  Mall  Gaziite  seems  wakening  to  this, 
and  alludes  to  rumors  of  drastic  changes  contemi)lated 
by  the  new  commander-in  chief.  He  had  belter  take 
warning,  or  he  may  yet  l)e  lield  responsible  for  the  de- 
struction or  disorganization  of  the  medical  deijartment. 
At  one  of  his  last  paiades  he  said  of  the  medical  staff 
corps  :  "  They  are  not  soldiers,  but  civil  attendants  on 
the  sick."  He  has  on  other  occasions  been  most 
offensive  ;  in  fact,  his  conduct  toward  medical  officers 
has  more  than  once  been  rather  that  of  a  snob  than  of 
an  ofiicer  or  a  gentleman. 

Sir  Thomas  Crawford,  K.C.B.,  died  on  Saturday  last. 
He  entered  the  army  medical  service  in  1848,  and  had 
a  distinguished  career.  He  served  in  the  Crimea  and 
India,  and  became  Sargeon-General  of  Her  .Majesty's 
Indian  forces.  l-",ventu.illy  he  became  Director-Gen- 
eral of  the  Medical  Department  of  the  Army,  from 
which  he  retired  in  i88y.  As  head  of  the  department 
he  was  assiduous  in  his  office  and  careful  of  the  rights 
of  officers  serving  under  him.  Though  there  ma\  per- 
haps be  here  and  there  one  who  thinks  he  deserves 
more  than  he  has  received,  he  may  be  sure  Sir  Thomas 
carefully  weighed  the  circumstances  and  did  what  lie 
believed  to  be  justice,  as  far  as  it  was  possible  for  the 
head  of  the  department  to  do.  He  was  a  man  capable 
of  an  immense  amount  of  work,  was  a  master  of  detail, 
and  the  success  of  the  department  in  every  expedition 
in  which  he  was  the  chief,  is  a  standing  proof  of  his 
zeal  and  forethought.  His  wife  died  in  the  spiing, 
this  year,  leaving  him  with  eleven  (  hildien.  His 
intimate  friends  noticed  that  Sir  Thomas  never  seemed 
the  same  man  after  Lady  ( 'rawford's  death.     Lately  he 


682 


MEDICAL    RECORD. 


[November  9,  1895 


suffered  from  bladder  trouble,  and  uraemia  came  on  and 
closed  the  career  qf  one  of  the  most  zealous  and  con- 
scientious public  servants.  All  who  knew  him — of 
which  I  am  one — speak  well  of  him. 

Another  distinguished  surgeon,  with  whom  also  I 
was  acquainted,  has  passed  away  ;  Dr.  Keith,  the  suc- 
cessful ovariotomist,  is  dead.  His  greatest  results 
were  obtained  in  Edinburgh,  where  he  passed  most  of 
his  life,  but  for  the  last  few  years  he  has  lived  in  Lon- 
don. He  was  one  of  the  pioneers  in  ovariotomy,  hav- 
ing performed  his  first  operation  in  1S62,  from  which 
time  he  continued  to  have  remarkable  success :  his 
mortality- rate  on  the  average  not  exceeding  five  per 
cent.  Before  the  antiseptic  period  his  extreme  care  to 
insure  perfect  cleanliness  was  noteworthy.  Never- 
theless he  embraced  the  Listerian  views,  and  his  suc- 
cesses increased,  and  once  he  had,  I  believe,  eighty 
consecutive  successful  operations.  Dr.  Keith  was 
more  or  less  of  an  invalid  throughout  his  career,  yet 
he  bore  his  troubles  so  bravely  that  many  may  be  sur- 
prised that  he  endured  them.  Those  who  knew  him 
wondered  rather  at  the  spirit  he  displayed,  and  that, 
handicapped  by  ill-health,  he  should  have  achieved  so 
much.  It  is  needless  to  dwell  on  what  he  did,  for  his 
name  is  a  household  word  with  your  readers.  America 
mourns  with  England  his  loss. 


I  find  by  referring  to  the  Medical  Register  that  only 
about  two  hundred  men  are  directly  connected  with  the 
five  medical  schools  in  this  city,  while  the  entire  num- 
ber of  regular  physicians  exceeds  three  thousand. 
This  seems  a  ridiculous  minority  to  dictate  to  the 
larger  number,  which  includes  some  of  the  best  and  most 
distinguished  physicians  and  surgeons,  not  only  of  Xew 
York  but  of  the  world. 

It  is  high  time  that  some  organized  movement  was 
instituted  to  combat  the  college  rings,  for  not  only  do 
we  find  through  their  agency  abuses  of  medical  charity, 
such  as  exist  at  the  Vanderbilt  Clinic  and  Xew  York 
Hospital  particularly,  but  at  least  one  institution  that 
has  been  run  for  the  financial  benefit  of  the  faculty  has 
made  an  application  for,  and  obtained,  a  $60,000  ap- 
propriation from  the  city  for  next  year. 

Ax  Outsider. 

New  Vork.  October  ijth. 


A    NEW   AND    IMPE.OVED    STETHOSCOPE. 
Bv  MARK  I.  KXAPP,   M.D.. 


THE    ETIOLOGY    OF   CANCER. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  your  recent  editorial  in  answer  to  the  question, 
"  Is  Cancer  Inoculable  ?  "  you  state  that  "  A  person 
predisposed  to  any  disease  is  always  an  easy  victim 
when  any  definite  exciting  cause  presents  itself,  while 
one  without  such  tendency  escapes  every  time."  This 
remark  is  the  very  key  that  unlocks  the  secret  cause  of 
this  terrible  disease.  Years  ago  I  became  satisfied  that 
such  predisposition  exists  in  every  case,  and  this  predis- 
position, or  remote  cause,  I  have  found  to  be  slow  mer- 
curial poisoning.  Such  a  condition  existing,  any  trau- 
matism may  develop  the  disease.  Smoking  a  dirty 
pipe  may  start  it  on  the  lips  or  tongue,  irritation  of  the 
breast  or  uterus  in  female,  or  any  other  traumatism  that 
may  accidentally  occur  in  any  part  of  the  organization. 
I  haAe  carefully  searched  out  the  history  of  many  cases 
and  have  never  yet  failed  to  discover  that  such  persons 
had  been  subjected  to  a  process  of  slow  poisoning  from 
the  use  or  abuse  of  this  poison.  Remember  this,  and  see 
what  the  future  brings  to  light  on  this  subject. 
Truly  yours, 

J.  S.  Prettv.m.ax,  M.D. 

MiLFORD,  r>£L.,  October  i,  1803. 


HOSPITAL  REFORM— A  GROSS    INJUSTICE. 

Tj  the  Editor  of  the  Medical  Rscokd. 

Sir  :  As  one  who  is  not  a  "  Professor,"  and  has  long 
since  retired  from  active  hospital  work,  permit  me  to 
express  my  indignation  at  the  methods  of  the  medical 
schools  and  the  "combine,"  that  has  resulted  in  the 
precipitate  dismissal  of  a  number  of  much  respected  and 
well-equipped  medical  men  from  hospital  positions  they 
have  long  and  honorably  held.  Why  a  small  body  of 
men  should  arrogate  to  themselves  the  right  to  keep 
the  larger  number  of  their  fellows  who  have  had  no  col- 
lege position  either  from  choice,  bad  fortune,  or  mod- 
esty, from  the  privilege  of  practising  in  the  hospitals  is 
a  distinct  infringement  of  individual  liberty,  and  a  show- 
ing of  conceit  which  should  promptly  be  met  by  a  re- 
fusal to  call  any  of  them  in  consultation  by  the  rank 
and  file  of  the  profession  whose  rights  have  been  as- 
sailed. 


The  proximal  and  distal  parts  of  this  instrument  con- 
sist of  the  hardest  suitable  metal,  German  silver,  cov- 
ered with  a  layer  of  hard  rubber.  The  elastic  tube  is 
made  of  a  spiral  German  silver 
wire,  the  rings  of  which  are  in  very 
close  apposition,  so  as  to  practi- 
cally be  one  solid  tube.  This  i- 
also  covered  with  rubber,  which  i^ 
either  soft  vulcanized,  to  retain  its 
elasticity  without  breaking,  or  re- 
mains entirely  soft  and  is  then 
woven  around  with  wool  or  silk. 
This  metal  elastic  tube  is  soldered 
on  to  the  heart  and" ear  parts  in 
such  a  manner  as  to  present  one 
continuous  equable  calibre.  For 
that  reason  the  ear  parts  at  the 
point  of  joining  with  the  middle 
part  bulge  out  so  as  to  receive  the 
latter.  The  spring  is  screwed 
into  a  projection  of  hard  rubber 
in  such  a  mode  that  the  screws 
do  not  touch  the  metal  of  the 
ear-pieces.  Besides  the  specific, 
intention  of  such  a  union  between 
the  spring  and  the  ear-pieces,  it 
has  the  advantage  that  the  spring. 
when  rusted  or  otherwise  injured, 
can  easily  be  replaced. 

Now,  as  to  the  absolute  supe- 
riority of  this  instrument,  or  rather 
to  its  being  the  ideal  stethoscope, 
long  sought  for. 

When  beginning  to  learn  the 
value  and  practice  of  auscultation, 
as  a  student.  I  found  what  all  of  us 
know,  that  while  striving  to  perceive  the  pure  cardiac  cr 
pneumonic  sounds,  I  heard  along  with  them  the  hum- 
ming, buzzing  sound  so  familiar  to  us  with  all  stetho^ 
scopes  but  one — Denison's.  As  a  consolation  for  that 
misery  our  teachers  told  us  that  we  would  have  to  get 
used  to  it  ;  but  unfortunately,  by  the  time  we  can  get 
used  to  these  disturbing  sounds  we  are  able  to  do  away 
with  the  stethoscope  altogether. 

Meditating  over  the  possible  causes,  so  plentifully 
inquired  after,  it  occurred  to  me  that  the  buzzing 
came  not  from  within,  the  stand  taken  by  all  my  pre- 
decessors, but  from  without.  It  seemed  to  me  that  the 
humming  came  from  the  sound-waves  always  and  ever 


November  9,  1895] 


MEDICAL   RECORD. 


68- 


present  in  the  atmosphere — not  heard  bj-  the  naked 
ear.  although  appreciated  by  some  animals — and  whicb. 
are  noted  through  the  medium  of  the  metallic  ear- 
pieces, which  are  good  conductors  of  sound.  Sound- 
waves are  always  present,  due  if  to  nothing  else  than  to 
the  motion  of  the  several  layers  of  the  atmosphere 
which  are  of  different  density.  The  remedy  suggested 
itself  at  once.  Retain  the  good  sound  conductor — 
metal — to  convey  the  sounds  which  we  want,  and  stop 
the  sounds  we  do  not  want  by  a  bad  sound  conductor. 
I  therefore  covered  my  metal  stethoscope  with  a  piece 
of  soft- rubber  tube,  and  my  reasoning  proved  to  be 
successful. 

The  instrument  I  now  present  to  the  profession, 
made  by  the  best  firm  in  surgical  instruments,  Messrs. 
Tiemann  &  Co.,  is  of  unexcelled  quality  as  a  stetho- 
scope, based  upon  a  true  scientific,  physical,  acoustic 
law.  It  is  all  metal  within,  to  best  convey  the  sounds 
we  search  for,  and  all  rubber  without,  to  cut  off  all  ex- 
ter.ial  sounds,  thus  giving  us  not  onlj'  a  very  clear  and 
distinct,  but  a  very  much  intensified,  sound.  If  I 
should  be  permitted  to  use  microscopic  terms,  I  would 
say  that  this  new  instrument  is  the  high-power  stetho- 
scope. True  enough,  we  hear  no  buzzing  with  the 
Denison  stethoscope,  it  being  made  of  rubber,  but  un- 
fortunately we  hear  with  it  yet  less  than  with  the  or- 
dinary instruments. 

Therefore  I  recommend  this  new  stethoscope,  tested 
by  prominent  gentlemen,  for  its  unexcelled,  ideal  qual- 
ities, and  its  very  neat  and  pleasing  appearance. 

141  .^rFFOLK  Street. 


A   T  Y  M  P  .\  N  O  T  O  M  E  . 

Bv   \V.   K.   COLE,   M.D.. 


\    NEW    URETHROMETER. 
Ev  K.  \V.  STEW.ART.  ^r.D., 


SURGEON'   T3 


A  GOOD  urethrometer  should  have  the  following  requi- 
sites :    I.    It    should    be    simple   in   construction    and 
easily  taken  apart  for  the   purpose  of 
"*TKyy*(i     cleansing.     2.  It  should  be  small  in  cal- 
Wf     '        ibre  in  order  to  permit  of  its  passage 
\[  through  a  narrow  urethral  canal.     3.  It 

shoula  be  so  constructed  that  it  will 
autoraaticp'ly  exert  a  uniform  degree  of 
pressure  against  the  urethra,  regardless 
of  the  variability  in  the  size  of  the  dif- 
ferent portions  of  the  latter. 

After  considerable  experimentation, 
with  the  view  of  constructing  an  instru- 
ment that  would  conform  to  the  above 
\-d  requirements,  the  writer  begs  to  submit 
to  the  profession  the  following  instru- 
ment. 

The  cut  given  of  the  instrument  illus- 
trates it  so  well  that  a  detailed  descrip- 
tion would  be  superfluous.  Suffice  it  to 
say  that  it  consists  essentially  of  a  can- 
nula aa,  terminating  in  two  measuring 
arms  M\  which  open  by  virtue  of  their 
spring-like  action  aided  by  the  spring  t: 
on  the  handle  of  the  instrument.  The 
measuring  arms  are  closed  and  liberated 
by  moving  the  tube  </  up  or  down  on 
the  cannula  aa. 

To  use  this  instrument  it  is  inserted 
as  far  as  the  bulbous  portion  of  the  ure- 
thra, and  the  measuring  arms  liberated 
by  the  withdrawal  of  the  tube  </.  It 
only  remains  to  withdraw  the  instru- 
ment from  the  urethra  and  at  the  same 
time  observe  the  reading  of  the  index. 
This  instrument  has  proven  to  be  not  only  accurate 
and  easily  manipulated,  but  also  to  be  less  painful  than 
any  urethrometer  I  have  heretofore  used. 

It  has  been  made  for  me  by  Feick  Brothers,  of  Pitts- 
burg, Pa. 


I  HEREWITH  present  to  the  Medical  Record  a  cut  of 
a  new  instrument  which  I  have  designated  "  tympan- 
otome."  The  instrument,  as  its  name  implies,  is  de- 
signed to  perforate  the  drum  of  the  ear.     Anyone  who 


-" 


has  had  occasion  to  perforate  the  drum  of 
the  ear  will  appreciate  the  difficulties  usu- 
ally encountered  with  the  ordinary  instru- 
ments. 

The  present  instrument,  devised  by  me, 
I  have  used  several  times  with  the  greatest 
facility  and  success.  The  instrument  is 
substantially  as  set  forth  in  the  drawings, 
the  principal  parts  consisting  of  a  perforat- 
ing lance  resting  in  a  guide,  which  being 
attached  to  the  handle  by  means  of  a  per- 
foration and  screw,  regulates  the  depth  of 
the  penetration  of  the  lance  through  the 
drum.  The  lance  perforates  the  drum  by 
an  instantaneous  impulse  given  by  a  spring  hammer 
attached  to  the  handle,  which  hammer  is  fired  by  means 
of  a  catch  trigger,  as  shown  in  the  cut.  This  instru- 
ment makes  an  arc-shaped  perforation  near  the  per- 
ipherj'  of  the  drum.  The  perforation  is  made  instan- 
taneously and  with  absolute  safety,  as  the  depth  of  the 
perforation  is  regulated,  and  the  lance  is  withdrawn 
automatically  into  the  guide  after  being  fired. 

This  instrument  is  manufactured  by  G.  Tiemann  ^: 
Co.,  to  whom  I  am  indebted  for  useful  modifications 
and  for  the  excellent  finish  of  the  instrument. 


Treatment  of  Habitual  Drunkards  in  Austria. — .\us- 
tria  proposes  to  deal  with  persistent  drunkards  by  treat- 
ing them  as  mentally  incapable  and  detaining  them  in 
special  retreats  for  a  term  of  two  years.  They  may  go 
in  of  their  own  accord  or  on  compulsion,  but  cannot 
leave  at  will  until  their  term  has  expired,  except  in  cer- 
tain cases  on  probation.  Persons  may  be  sent  to  the 
retreat  either  by  the  order  of  a  magistrate,  or  on  the 
jietition  of  the  parents  or  children,  or  of  the  husband 
or  wife  or  trustee,  or  of  the  chief  of  a  lunatic  asylum  in 
which  the  drunkard  may  be  detained.  Inebriates  may 
.further  be  assigned  to  retreats  by  the  action  of  the  pub- 
lic prosecutor,  or  by  the  mayor  of  the  town  or  village 
in  which  the  habitual  drunkard  resides.  In  all  cases 
the  inebriate  must  be  legally  tried  and  convicted,  the 
court  being  bound  to  hear  witnesses,  including  the 
drunkard  himself,  as  well  as  the  doctors,  more  espe- 
cially experts  on  mental  diseases.  The  term  of  deten- 
tion will  be  generally  for  two  years,  but  the  patient 
may  be  released  on  leave  after  one  year,  but  will  be 
confined  again  in  case  he  relapses  into  his  former  bad 
habits.  After  the  two  years'  tenn  he  must  be  released, 
but  if  his  drink  impulse  persists,  he  may  be  sentenced 
again  for  a  fresh  term  of  two  years,  and  eventually  may 
be  confined  in  a  lunatic  asylum,  if  he  is  shown  to  be 
incurable. 

Trouble  Ahead  for  the  Baby, — A  Canadian  news- 
paper calls  attention  to  a  nursing-bottle  advertisement, 
which  concludes  with  the  words  :  "  When  the  baby  is 
done  drinking  it  must  be  unscrewed  and  laid  in  a  cool 
place  under  a  tap.  If  the  baby  does  not  thrive  on  fresh 
milk,  it  should  be  boiled." 

Queen  Amelia  of  Portugal,  so  it  is  reported,  is  de- 
voting all  her  spare  time  to  the  study  of  medicine. 


684 


MEDICAL   RECORD. 


[November  9,  1S95 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  November  2,  1895. 


Tuberculosis    

Typhoid  fever 

Scarlet  fever 

Gerebro-spinal  meningitis 

Measles 64 

Diphtheria 174 


A  Silly  and  Untruthful  Canon. — One  of  the  canons 

of  Westminster  Abbey,  Wilberforce  by  name,  has  suc- 
ceeded in  making  himself  ridiculous  several  times  by 
intemperate  invective  against  the  practice  of  vivisec- 
tion. In  one  of  his  latest  utterances  he  said  that  he 
would  rather  die  than  owe  his  recovery  from  disease  to 
discoveries  made  by  vivisection.  Anent  this  absurd 
speech  the  British  Medical  Journal  remarks  that  the 
clergyman  cannot  in  any  way  be  complimented  on  his 
consistency,  inasmuch  as  the  physician  whom  he  has 
publicly  and  widely  eulogized,  in  whom  he  placed  his 
personal  confidence,  and  to  whom  he  professes  his 
deepest  obligation — Sir  Andrew  Clark — was  himself  a 
vivisector. 

Indigestion  and  Baldness. — Dyspepsia  is  not  only  one 
of  the  most  common  diseases,  but  it  is  also  one  of  the 
most  common  causes  for  the  loss  of  hair.  Nature  is 
very  careful  to  guard  and  protect  and  supply  the  vital 
organs  with  the  proper  amount  of  nutriment,  but  when 
she  cannot  command  a  sufficient  quantity  of  blood- 
supply  for  all  the  organs,  she  very  naturally  cuts  off 
the  supply  of  parts  the  least  vital,  like  the  hair  and 
nails,  so  that  the  most  important  organs,  like  the  heart, 
lungs,  etc.,  may  be  better  nourished  and  perform  their 
work  more  satisfactorily.  In  cases  of  severe  fevers  one 
can  readily  see  how  nature  economizes.  If  one  will 
e.xamine  a  hair  very  closely  from  the  beard  or  head,  it 
will  be  seen  that  it  gives  somewhat  of  a  history  of  an 
individual  during  the  time  it  was  growing.  It  will  be 
observed  that  it  shows  attenuated  places,  showing  that 
at  some  period  of  its  growth  the  blood-supply  was  de- 
ficient from  overwork,  anxiet)-,  or  under-feeding.  Speak- 
ing of  dyspepsia  being  one  of  the  most  common  causes 
of  alopecia,  I  will  add  that  a  very  common  cause  of  in- 
digestion is  irregularity  of  meal  hours.  The  human 
system  seems  to  form  habits,  and  it  performs  its  func- 
tions in  a  great  measure  in  accordance  with  the  habits  . 
formed.  This  seems  to  be  particularly  so  in  regard  to 
eating,  and  you  might  say  drinking,  too.  Your  stomach 
gets  into  the  habit  of  accepting  your  meals  at  a  certain 
hour  every  day,  and  at  that  hour  it  is  ready  for  it.  If 
you,  however,  take  meals  at  irregular  hours  you  take 
your  stomach  by  surprise,  and  it  does  not  know  when 
to  expect  a  meal,  and  it  is  not  in  that  state  of  readiness 
for  prompt  and  perfect  performance  of  its  work.  Be 
more  careful  about  what  you  eat,  when  you  eat  it,  and 
you  will  have  less  dyspepsia  and  fewer  bald  heads. — 
Charlotte  Medical  Journal. 

Advice  to  Intending  Wheelmen. — The  following  ju- 
dicious remarks  concerning  moderation  in  cycling  are 
from  The  Lancet :  Xo  one  should  become  an  habitual 
cyclist  without  medical  authorization.  Before  com- 
mitting himself  to  an  opinion,  the  medical  man  con- 
sulted will  do  well  to  examine  the  beginner  on  dis- 
mounting from  the  machine  as  well  as  beforehand  ; 
there  are  certain  cardiac  defects  which  only  become 
recognizable  when  the  subject  is  under  the  influence  of 
excitement  or  fatigue.  A  cyclist  should  at  first  be  con- 
tent with  a  moderate  pace,  not  exceeding  twelve  kilu- 


metres  per  hour  (about  seven  miles  and  a  half).  A 
higher  rate  of  speed  should  only  be  indulged  in  after 
the  rider  has  gone  through  a  regular  course  of  training 
If  a  break  in  the  practice  occurs,  lasting  even  a  few 
days,  the  cyclist  should  recommence  at  the  slower 
rate.  The  temptation  to  go  quickly  must  be  con- 
trolled as  far  as  possible.  A  bicjcle  travels  well-nigh 
of  its  own  accord,  and  it  is  very  hard  to  resist  the  "  de- 
lirium of  speed."  With  a  light  machine  on  a  good 
road,  and  helped  ever  so  little  by  the  breeze,  an  ama- 
teur, even  when  only  half-trained,  can  easily  achieve 
his  twenty-five  kilometres  within  the  hour  (fifteen  miles 
and  a  half).  This  is  too  much,  seeing  that  when  doing 
from  fourteen  to  sixteen  kilometres  the  rider's  pulse 
rises  to  150. 

Foreign  Bodies  in  the  Throat.— The  difficulty  of  re- 
moving fish  bones  and  similar  obstructions,  impacted 
at  the  lower  end  of  the  oesophagus,  is  well  known,  and 
various  mechanical  measures  and  appliances  have  been 
invented  to  deal  with  the  difficulty.  One  of  the  most 
simple,  however,  and  as  reported  one  of  the  most  ef- 
fectual, remedies  in  the  case  of  impaction  of  such  foreign 
bodies  is  to  administer  to  the  patient  a  pint  of  milk,  and 
forty  minutes  afterward  an  emetic  of  sulphate  of  zinc. 
The  fluid  easily  passes  the  obstruction,  and  is,  of  course, 
rapidly  coagulated  in  the  stomach  into  a  more  or  less 
solid  mass,  which,  on  being  ejected,  forces  the  obstruc- 
tion before  it,  and  so  effects  its  removal. — Medical 
Times. 

Medico-Legal  Points  in  Regard  to  Malpractice. —  i. 
A  physician  is  guilty  of  criminal  malpractice  when  se- 
rious injury  results  on  account  of  his  gross  ignorance 
or  gross  neglect.  2.  A  physician  is  guilty  of  criminal 
malpractice  when  he  administers  drugs  or  employs  any 
surgical  procedure  in  the  attempt  to  commit  any  crime 
forbidden  by  statute.  3.  A  physician  is  guilty  of  crim- 
inal malpractice  when  he  wilfully  or  intentionally  em- 
ploys any  medical  or  surgical  procedure  calculated  to 
endanger  the  life  or  health  of  his  patient,  or  when  he 
wilfully  or  intentionally  neglects  to  adopt  such  medical 
or  surgical  means  as  may  be  necessary  to  insure  the 
safety  of  his  patient.  4.  A  physician  is  civilly  respon- 
sible for  any  injury  that  may  result  to  a  patient  under 
his  care,  directly  traceable  to  his  ignorance  or  negli- 
gence. 5.  A  physician  is  expected  by  the  law  to  ex-  , 
hibit  in  the  treatment  of  all  his  cases  an  average 
amount  of  skill  and  care  for  the  locality  in  which  he 
resides  and  practises.  Further  than  this  he  is  not  re- 
sponsible for  results,  in  the  absence  of  an  express  con- 
tract to  cure.  6.  A  physician  is  not  relieved  of  his 
responsibility  to  render  skilful  and  proper  treatment, 
or  reasonable  care  and  attention,  by  the  fact  that  his 
services  are  gratuitous.  7.  A  physician  is  not  obliged 
to  undertake  the  treatment  of  any  case  against  his  will, 
but  having  once  taken  charge  he  cannot  withdraw  with- 
out sufficient  notice  to  allow  his  patient  to  procure 
other  medical  assistance.  S.  A  physician  having 
brought  suit  and  obtained  judgment  for  services  ren- 
dered, no  action  for  malpractice  can  be  thereafter 
brought  against  him  on  account  of  said  services.  9.  A 
physician  is  relieved  of  all  responsibility  for  bad  results 
in  connection  with  the  treatment  of  a  case  when  there 
can  be  proven  contributory  negligence  on  the  part  of 
the  patient.  10.  .\  physician  is  civilly  responsible  for ' 
any  injury  to  his  patient  resulting  from  the  ignorance 
or  carelessness  of  his  acknowledged  assistants,  but  he 
is  in  no  way  responsible  for  their  wilful  criminal  acts. 
—  The  General  Practitioner. 

Summer  Attendance  at  the  Swiss  Universities. — 
There  were  3,108  regular  students  in  attendance  at  the 
seven  Swiss  universities  last  summer,  247  of  them 
women.  Of  34S  Russian  students  199  were  women,  as 
were  7  of  the  ^2  from  the  L'niied  States.  Women 
form  one-fifth  of  the  total  number  of  the  two  largest 
universities — Zurich  and  Geneva. 


Medical   Record 

A  IVeekly  youyiial  of  Medicine  and  Suygery 


Vol.  48,  No.  20. 
Whole  No.  1306. 


New  York,  November  16,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigiual  Articles. 

SOME  SUGGESTIONS  CONCERNING  THE  EX- 
AMINATION OF  BLOOD.' 

By  jo.  H.  LINSLEY,  M.D., 

BURLI.NGTON,    VT. 

M.\NY  physicians  are  deterred  from  making  blood- 
examinations  by  the  supposed  difficulty  of  technique 
in  the  work  and  the  instruments  and  paraphernalia 
necessary  for  its  conduct.  I  shall  endeavor  to  show- 
that  this  conception  of  the  matter  is  incorrect,  and  that 
a  vast  amount  of  exceedingly  valuable  information 
concerning  the  condition  of  the  patient  can  be  obtained 
by  the  examination  of  a  drop  of  blood,  with  no  greater 
outfit  than  a  good  microscope,  clean  cover-glass  and 
slide,  a  little  vaseline,  a  slip  of  paper,  and  a  steel  pen. 
First  a  cover-glass  and  slide  are  carefully  cleaned  ;  a 
piece  of  ordinary  writing-paper  is  then  folded  into  a 
triangular  shape,  and  after  taking  up  a  small  quantity 
of  vaseline  on  the  point  of  the  paper,  a  narrow,  thin 
film  of  the  vaseline  is  placed  around  the  edge  of  the 
cover-glass.  The  end  of  one  of  the  index-fingers  is 
carefully  cleansed  with  water  (it  is  better  to  employ  a 
nail-brush  in  doing  this),  and  the  finger  pricked  by  a 
sharp,  rapid  movement  of  the  hand  of  the  operator,  the 
instrument  used  being  either  a  sterilized  needle,  or  a 
new  sharp-pointed  steel  pen,  one  of  the  points  of  which 
has  been  broken  off.  .\s  soon  as  a  small  drop  of  blood 
has  collected,  the  glass-slide  is  brought  in  contact  with 
the  same,  the  slide  placed  on  a  level  surface,  and,  as 
soon  as  possible,  the  cover-glass  placed  over  the  blood 
— vaseline- side  down — and  sufficient  gentle  pressure 
made  over  the  cover-glass  to  produce  a  contact  every- 
where between  the  border  of  vaseline  and  the  slide. 

In  this  simple  manner  a  most  effective  moist  cham- 
ber is  provided  which  is  completely  seated  by  the 
vaseline,  and  in  which  the  blood  will  remain  in  a  suit- 
able condition  for  microscopical  investigation  for  sev- 
eral hours. 

Another  method  much  employed,  and  especially 
useful  where  staining  is  desired,  is  the  dry  process.  -A. 
clean  cover-glass  is  brought  in  contact  with  the  summit 
of  the  drop  of  blood,  obtained  in  the  manner  I  have 
described,  quickly  removed,  and  a  second  cover-glass 
— or  the  end  of  a  glass-slide — is  immediately  drawn 
across  the  blood,  producing  a  thin,  flat  layer  whicli 
dries  almost  at  once.  The  preparation  is  then  kept 
for  ten  or  fifteen  minutes  at  a  temperature  of  iio°  to 
i2o°  C,  and  is  then  ready  for  whatever  staining  is 
desired. 

Before  proceeding,  allow  me  to  call  your  attention 
briefly  to  the  composition  of  normal  blood,  and  to 
suggest  the  absolute  necessity  of  familiarity,  on  the  part 
of  the  investigator,  with  the  condition  and  appearance 
of  normal  blood. 

For  present  purposes  the  chemistry  of  the  liquor 
sanguinis  and  corpuscles,  with  the  exception  of  haemo- 
globin, need  not  be  considered  ;  I  prefer  to  deal  only 
with  the  corpuscular  elements. 

As  you  all  know,  the  cells  of  the  blood  are  of  two 

'  Part  of  the  President's  annual  .iddress  before  the  Vermont  Medi- 
cal Society,  at  Burlington,  Vt.,  October  lo,  1895. 


great  classes,  the  colored  or  red,  and  the  colorless  or 
white.  I  prefer  the  terms  "colored  "  and  ''colorless," 
because  none  of  the  individual  corpuscles  are  "  red," 
but  only  a  light  shade  of  amber,  or  yellow,  while  the 
others  are  devoid  of  color. 

The  normal  colored  blood- corpuscle  of  man  is  a  bi- 
concave circular  disk,  having  an  average  diameter  of 
32*55-  of  an  inch.  This  diameter  is  liable  to  great  varia- 
tions, at  least  one-third  in  the  same  individual,  and  per- 
sons differ  very  much  in  the  variance  in  size  of  their 
colored  corpuscles.  In  some,  the  examination  of  thou- 
sands of  cells  will  show  no  appreciable  difference, 
while  in  others  the  most  remarkable  variety  of  sizes  is 
seen. 

I  am  not  satisfied  that  this  variability  in  size  is  of  any 
pathological  significance.  The  same  cannot  be  said 
from  a  medico-legal  standpoint.  Given  a  suspected 
blood-stain,  on,  or  about,  the  clothing  of  an  accused,  or 
implement,  or  utensils,  supposed  to  have  been  used  by 
him  at  the  time  of  an  assault,  and  the  investigator  finds 
but  a  few  colored  blood-corpuscles  which  are,  appar- 
ently, of  the  same  size  as  human  colored  blood-cells, 
can  the  physician,  however  expert,  go  on  the  witness- 
stand  and  conscientiously  swear  that  they  are  even 
probably  human  blood-corpuscles  ?  In  the  light  of  our 
present  knowledge  of  this  subject,  I  say  he  cannot.  It 
may  be  said  in  opposition  to  this  statement  that  with 
proper  micrometres  the  exact  size  of  the  corpuscles 
can  be  measured.  Now  it  is  a  fact  that  only  a  very 
expert  microscopist  can  make  such  a  measurement 
accurately,  and  even  then  there  is  the  liability  to  error, 
as  was  shown  by  Ewell.'  This  expert  ruled  a  glass- 
slide  with  fifteen  lines,  making  spaces  approximately  of 
■'Tir  to  ,2 J  of  an  inch,  and  caused  the  same  to  be 
measured  by  six  well-known  microscopists,  who  were 
instructed  to  take  the  mean  of  at  least  five  measure- 
ments of  each  space.  Using  standard  micrometres  by 
the  same  maker,  the  result  showed  that  the  measure- 
ments of  the  same  space  by  different  observers  \aried 
from  o.  to  1.9090.  This  is  a  greater  difference  than  that 
between  the  average  diameters  of  the  blood-corpuscles 
of  man  and  any  of  the  common  domestic  animals,  ex- 
cept the  sheep  and  goat,  according  to  all  observers. 

Again  it  is  not  always  possible  to  restore  to  cor- 
puscles which  have  become  dried  in  a  stain,  their  nor- 
mal diameter,  after  the  most  approved  treatment  of 
the  same. 

It  is  to  be  greatly  regretted,  in  the  cause  of  justice, 
that  notwithstanding  the  facts  just  given,  we  often  see 
medical  men,  with  but  a  moderate  amount  of  micro- 
scopical acumen,  go  on  the  witness-stand  and  declare, 
with  positiveness,  as  to  the  origin  of  a  few  colored 
blood-corpuscles  which  they  had  found  in  a  suspected 
stain. 

Nay,  I  can  go  farther  and  point  to  the  spectacle  of  a 
professional  man  with  but  the  most  meagre  knowledge 
of  microscopical  technique,  posing  as  an  expert,  and 
giving  testimony  of  the  nature  I  have  just  indicated. 
The  citation  of  a  case  in  point  may  be  pertinent. 

"  In  the  case  of  Commonwealth  vs.  Piper,  tried  in 
Boston  in  1875,  the  defendant,  a  sexton,  was  charged 
with  the  murder  of  a  child  in  the  belfry  of  his  church. 
Certain  articles  having  upon  them  suspicious  stains, 
were  placed  in  the  hands  of  several  local  experts  for 
examination,  .\mong  the  specimens  was  about  a  half- 
I  AlL-in  McLane  Hamilton:  System  of  Legal  Medicine,  p.  173. 


686 


MEDICAL    RECORD. 


[November  i5,  1895 


pint  of  water  found  in  the  basement,  in  which  it  was 
thought  that  the  prisoner  had  washed  his  bloody  hands. 
A  short  time  previous  to  the  trial,  the  experts,  four  in 
number,  made  their  report  of  the  results  of  their  ex- 
amination to  the  prosecuting  officers,  and  every  one  of 
the  four  stated  that  the  water  contained  blood  corpus- 
cles which  measured  on  the  average  about  ^^Vir  of  an 
inch  in  diameter. 

"  This  evidence  was  not  given  at  the  trial,  because  the 
government  decided  not  to  introduce  any  testimony  in 
relation  to  blood,  but  the  results  stated  in  the  report 
would  undoubtedly  have  been  given  if  it  had  been 
called  for.  A  portion  of  the  water  was  critically  exam- 
ined by  Professor  AVormley,  and  the  bodies  which  had 
been  confidently  measured  as  corpuscles  were  proved 
to  be  merely  the  spores  of  a  confervoid  alga." 

We  could,  therefore,  find  in  stagnant  water,  in  drain- 
age, surface  pools,  some  springs,  and  in  many  other 
places,  these  bodies  which  are  of  the  same  diameter  as 
the  human  blood-corpuscles,  and  resemble  them  so 
closely  as  to  have  been  mistaken  for  them  by  experts, 
as  I  have  quoted. 

The  number  of  colored  blood-corpuscles  in  man  is 
about  5,000,000  per  c.  mm.  (or  about  one  drop)  in  the 
male,  and  500,000  less  in  the  female.  The  number  is 
ascertained  by  the  use  of  the  hjemocytometer — that 
devised  by  Thoma  and  Zeiss  being  the  most  practical 
in  use. 

Soon  after  blood  is  shed,  the  colored  corpuscles  be- 
come adhered  to  each  other  at  their  broader  surfaces, 
forming  rouleaux,  or  rolls.  The  extent  and  rapidity 
with  which  this  peculiar  form  of  massing  of  the  col- 
ored corpuscles  takes  place  varies,  apparently,  accord- 
ing to  the  amount  of  fibrine  present  :  the  greater  the 
amount  of  the  latter  the  sooner  and  more  rapidly  will 
rouleaux  be  formed.  The  cause  of  this  phenomenon 
is  not  accurately  determined.  After  a  short  time, 
under  ordinary  conditions,  the  cells  lose  their  roll-for- 
mation and  become  more  or  less  separated  from  each 
other. 

The  adult  colored  blood-corpuscles  of  the  mammalia 
(with  the  exception  of  the  camel  family)  have  no  nu- 
clei. This  is  not  true  in  very  early  life,  and  in  some 
forms  of  ansemia,  when  a  nucleus  is  observed  in  many 
of  the  colored  corpuscles. 

The  presence  or  absence  of  a  cell-wall  is  still  a  mat  ■ 
ter  of  dispute,  although  I  believe  the  weight  of  author- 
ity is  now  in  favor  of  considering  the  colored  blood- 
corpuscle  as  simply  consisting  of  a  pale,  transparent, 
plastic,  and  homogeneous  stroma  charged  with  color- 
ing matttr,  or  hcemoglobin. 

The  colorless  or  so-called  "white"  blood-cells  are 
not  peculiar  to  the  blood,  as  their  origin  is  the  lymphoid 
tissues,  from  which  they  pass  into  the  lymphatic  circu- 
lation, and  then  into  the  blood.  They  are  also  called 
"leucocytes,"  "lymph-corpuscles,"  "  lymphoid  cells," 
"  leucoblasts,"  "  amoeboid  "  or  "  wandering  cells,"  and 
are  nearly  similar  in  structure,  though  differing  in 
function  from  the  pus-corpuscle. 

Two  chief  varieties  of  the  colorless  blood- corpuscles 
are  found  in  the  normal  human  blood,  namely,  the 
granular,  and  the  paler,  less  granular  variety.  Ehrlich 
describes  five  varieties  of  colorless  blood-corpuscles, 
and  Prudden  relies  upon  the  determination  of  an  in- 
crease in  number  of  one  variety  or  another,  in  diagnos- 
tigating  the  various  morbid  conditions  accompanied  by, 
or  dependent  upon,  leucocytic  hyperplasia. 

There  is  a  great  diversity  of  shape,  size,  and  struct- 
ure of  these  cells,  much  more  so  in  fact  than  is  the 
case  with  the  colored  cells.  In  every  instance  they 
are  composed  of  living  matter,  or  differentiated  ])roto- 
plasm,  or  "  bioplasm  "  (Beale),  or  "  bioplasson  "  ( Heitz- 
mann). 

The  active  living  matter  of  the  colorless  blood-cor- 
puscle is  arranged  in  a  more  or  less  well-defined  and 
compact  delicate  network,  or  reticulum.  The  appear- 
ance of  the  material  composing  these  cells  is  liable  to 


great  variations,  and,  to  the  experienced  eye,  offers  a 
very  certain  index  to  the  general  condition  of  the  per- 
son from  whom  it  came.  In  the  healthy,  strong,  and 
robust  constitution  these  colorless  corpuscles  are  com- 
paratively small,  the  reticulation  very  slightly,  if  at  all, 
perceptible,  no  nucleus  is  visible,  usually,  and  the 
active  living  matter,  or  bioplasm,  is  very  bright  and 
highly  refractive.  On  the  other  hand,  in  one  of  these 
corpuscles  taken  from  a  person  broken  down  in  health, 
or  after  long  and  wasting  sickness,  the  cell  contains  a 
greater  or  less  number  of  vacuoles,  and  the  living  mat- 
ter presents  a  dull,  lustreless  appearance  very  little  re- 
fractive, and  presenting  a  picture  vastly  different  from 
the  one  first  drawn.  Between  the  two  there  are  many 
grades,  or  conditions,  depending,  apparently,  upon  the 
general  condition  of  the  individual  from  whom  they 
were  taken 

The  average  size  of  the  colorless  blood-corpuscle  is 
usually  given  as  -j-Jou  o(  an  inch. 

To  be  sure,  my  work  in  this  line  has  not  as  yet  been 
very  extensive,  but  in  the  considerable  number  of 
specimens  which  I  have  thus  far  investigated,  in  every 
instance  have  I  been  enabled  to  form  an  intelligent 
opinion  of  the  constitutional  condition  of  the  patient, 
and  in  selecting  cases  to  examine,  in  order  to  verify 
this  theory  (which  is  not  at  all  my  own),  I  have  been 
uniformly  successful  in  demonstrating  the  apparent 
relation  between  the  person's  condition  and  the  appear- 
ance of  the  protoplasm  of  the  colorless  blood  corpus- 
cles. 

The  theory  h  xs  been  advanced  that  the  activity  dis- 
played by  the  colorless  blood- corpuscle  on  a  properly 
warmed  stage,  and  surrounded  by  an  appropriate  me- 
dium, would  indicate  more  or  less  accurately  the  vi- 
tality of  the  individual,  that  the  greater  the  vitality  of 
the  person,  the  more  active  the  movements  of  the  leu- 
cocyte. So  many  conditions,  such  as  pressure,  elec- 
tricity, temperature,  and  probably  bacterial  ptomaines, 
etc.,  affect  the  cell,  that  an  intelligent  opinion  cannot  be 
formed  from  these  premises. 

The  relative  number  of  the  colorless  to  the  colored 
blood-corpuscles  in  healthy  human  blood  is  about 
I  to  350,  although  this  is  liable  to  great  variation  in  dif- 
ferent individuals,  and  in  the  same  person  at  different 
times  of  the  twenty-four  hours  ;  the  proportion  of  leu- 
cocytes being  greater  during  digestion  and  less  during 
periods  of  fasting.  The  number  of  the  colorless  blood- 
corpuscles  is  determined  by  the  use  of  the  Thoma- 
Zeiss  apparatus  already  described.  Instead  of  diluting 
the  blood  with  the  salt  solution,  as  in  the  case  of  count- 
ing the  colored  corpuscles,  Thoma  dilutes  the  blood 
with  water  containing  one-third  per  cent.  sol.  glacial 
acetic  acid  in  the  proportion  of  i  to  10.  In  this  way  the 
colored  corpuscles  are  destroyed,  and  the  leucocytes 
alone  remain  in  the  field  of  vision. 

The  colorless  blood-corpuscle  usually  contains  a  sin- 
gle nucleus,  though  rarely  ;  this  is  multiple.  The  nu- 
cleus may  or  may  not  be  visible.  The  addition  of 
acetic  acid  has  the  same  effect  on  this  cell  that  it  has 
on  all  other  nucleated  cells  of  the  body,  namely,  that 
of  making  the  nucleus  prominent. 

The  action  of  the  colorless  blood-cell  seems  to  be 
twofold.  Aside  from  being  a  reserve  of  active  proto- 
plasm, to  be  called  upon  to  repair  the  normal  waste  of 
the  body,  as  well  as  the  destructive  processes  of  dis- 
ease, certain  of  these  corpuscles,  ;'.{•.,  the  phagocytes  of 
Metschnikoff,  seem  to  have  an  especially  aggressive 
action  against  offending  foreign  substances,  including, 
possiblv,  a  successful  combat  with  pathogenic  microbes. 

Blood-platelets.— The  blood-platelets,  first  described 
by  Bizozzero,  are  small,  irregular,  more  or  less  refractive 
masses  of  protoplasm,  the  nature  of  which  is  still  a  mat- 
ter of  dispute.  They  are  very  unstable,  tend  to  disin- 
tegrate, and  vary  in  size,  having  about  an  average  di- 
ameter of  one-third  that  of  the  colored  blood-cor- 
puscle. 

Heitzmann  believes  that  the  blood-platelets  are  off- 


November   i6,  1895] 


MEDICAL    RECORD. 


687 


shoots  from  the  colored  corpuscle,  and  that  their  pres- 
ence, to  any  extent,  is  evidence  of  a  below-par  condition 
of  the  individual.  So  far  as  I  liave  studied  this  matter, 
I  am  inclined  to  agree  with  this  observer. 

Certain  it  is  that  one  may  see,  in  many  a  specimen  of 
fresh  blood,  without  tlie  addition  of  any  reagent,  the 
separation  from  the  colored  corpuscles  of  little  masses 
of  protoplasm,  which,  when  entirely  divided  from  the 
parent-cell,  and  after  parting  with  their  color,  present 
every  peculiarity  to,  and  are  apparently  identical  with, 
Bizozzero's  blood-platelets.  Then,  too,  in  those  cases  in 
which  the  structure  of  the  colorless  blood-corpuscle  was 
such  as  to  indicate  a  condition  of  the  individual  below 
the  average  of  health,  there  has  been  observed  an  in- 
crease of  these  platelets.  The  identity  of  these  bodies 
with  the  so-called  "  microcytes,"  or"  small  hemoglobin- 
containing  elements,"  found  in  many  morbid  states,  is 
suggested. 

The  greatest  difference  betn-een  the  latter  and  the 
platelets,  aside  from  that  of  size,  is  the  presence  of 
haemoglobin  in  the  former,  and  yet  the  fragment  that  I 
have  mentioned,  which  separates  from  the  colored  cor- 
puscle, very  soon  parts  with  its  haemoglobin  after  com- 
plete isolation  from  the  cell.  In  cases  approaching 
death,  the  exceedingly  rapid  formation  of  these  bodies 
can  often — if  not  always — be  seen,  as  I  have  demon- 
strated. 

According  to  Halliburton,  the  blood-platelets,  or  tab- 
lets, are  only  found  in  the  blood  of  mammals.  Gibson 
believes  that  these  blood-plates,  which  he  calls  "color- 
less microcytes,"  are  derived  from  the  nuclei  of  young 
red  blood  cells,  or,  occasionally,  from  the  nucleus  of 
white  corpuscles.  The  nature  of  these  small  blood  ele- 
ments is  so  little  understood,  that  I  am  not  aware  that 
any  considerable  pathological  significance  has  hereto- 
fore been  attached  to  them. 

Haemoglobin.^HKmoglobin  is  a  crystallizable  body 
which  forms  by  far  the  greater  part  of  the  colored 
blood-corpuscles.  It  is  intimately  distributed  through- 
out the  stroma  of  the  cell,  and  must  be  dissolved  and 
extracted  before  it  will  undergo  crystallization.  Its 
most  interesting  properties  are  its  power  of  crystalliz- 
ing, and  its  attraction  for  oxygen  and  other  gases.  The 
haemoglobin  of  human  blood  crystallizes  with  diffi- 
culty. 

The  determination  of  the  amount  of  haemoglobin,  or 
blood-coloring  matter,  is  easily  and  fairly  satisfactorily 
obtained  by  the  use  of  \'on  Fleischel's  haemometer. 
The  application  of  this  instrument  depends  upon  the 
principle  that  thecolorof  the  blood,  diluted  with  water, 
may  be  comi)ared  with  that  of  a  glass  wedge  tinted  with 
Cassius's  golden-purple,  or  some  pigment. 

Spectroscope. — The  presence  of  htemoglobin,  or  of 
one  of  its  derivatives,  can  be  positively  detected  by  the 
use  of  the  spectroscope  only  by  an  expert  manipulator 
with  this  instrument,  and  I  therefore  will  not  dwell  on 
this  method  for  the  detection  of  blood-coloring  matter. 

Guiacum  Test. — In  applying  this  test  for  bloodcolor- 
ing  matter,  a  drop  of  the  blood  solution  (or  a  solution 
of  a  sus])ected  stain)  placed  over  a  white  surface,  or  in 
a  porcelain  dish,  is  first  treated  with  a  drop  of  fresh 
tincture  of  gum  guiac,  and  then  a  drop  of  ozonic  ether 
added,  when,  if  only  a  trace  of  the  coloring  matter  of 
the  blood  be  present,  a  blue  color  will  immediately,  or 
very  quickly,  appear. 

A  drop  of  a  i-iooo  solution  of  blood  will  thus  imme- 
diately yield  a  decided  blue  coloration  ;  and  a  1-5000 
solution  a  quite  distinct  reaction.  If  on  a  white  fabric, 
the  test  may  be  applied  directly  to  the  stain,  by  first 
moistening  the  latter  with  a  drop  of  water  before  the 
addition  of  the  tincture  of  guiac.  'I'his  test  will  react 
even  with  very  old  stains,  provided  they  are  first  well 
moistened  with  water ;  and  even  when  the  stains 
have  been  washed,  evidence  of  their  nature  may  be 
obtained. 

Haemin  Test. — When  the  blood  is  in  solution,  a  drop 
of  the  liquid  is  evaporated  on  a  thin  glass  slide,  or  in 


a  watch-glass,  the  residue  scraped  together  and  pulver- 
ized, a  trace  of  finely  powdered  salt  added,  and  then  a 
drop  or  two  of  glacial  acetic  acid.  The  heat  of  a  very 
small  flame  of  a  spirit-lamp  is  now  applied  to  the  mixt- 
ure, first  around  and  slightly  beyond  the  edges  of  the 
disposed  liquid,  until  it  has  collected  beyond  the  edges 
of  the  slide  in  the  form  of  a  globule.  This  is  then 
heated  until  bubbles  of  gas  appear,  and  the  liquid  ac- 
(juires  a  reddish-brown  color,  when  the  heat  is  gradu- 
ally withdrawn,  until  only  a  minute  portion  of  liquid 
remains,  this  being  allowed  to  evaporate  by  the  heat  of 
the  slide.  The  residue  thus  obtained  usually  consists 
of  brownish-red  lines  or  stains,  more  or  less  curved  or 
circular  in  form.  Under  the  microscope  the  ha;min 
will  appear  as  minute  crystals,  of  a  yellowish,  reddish, 
or  brown  color,  more  or  less  transparent,  and  frequently 
arranged  in  the  form  of  stellate  groups.  When  from 
only  a  minute  quantity  of  blood,  the  crystals  are  single, 
and  usually  range  in  size  from  yj'fnr  to  TTs'rir  of  an  inch 
in  length,  and  from  cTiVt  to  tjJzttt  of  ^''^  inch  in  width. 
With  care,  crystals  may  be  obtained  from  even  yj^j  of 
a  grain  of  blood. 

Regarding  the  relative  merits  of  the  two  tests  just 
described,  Professor  Wormley,  in  answer  to  an  inquiry 
made  some  time  since,  writes  me  :  "  I  think  it  possible 
to  have  an  old  blood-stain  from  which  a  certain  mac- 
eration in  water  would  fail  to  yield  sufficient  coloring- 
matter  to  the  fluid  to  react  with  the  guiacum  test,  and 
yet  the  same  stain,  under  proper  treatment,  might  yield 
satisfactory  results  under  the  hremin  test.  If  the  guia- 
cum reagents  are  in  proper  condition,  this  test  would,  I 
think,  give  a  positive  reaction  with  a  more  minute 
quantity  of  blood-coloring  matter  when  in  solution 
than,  perhaps,  any  of  the  other  chemical  tests  used  for 
this  purpose." 

I  Avould  submit  the  following  propositions  in  sum- 
marizing :  I.  The  medical  expert  cannot  state  posi- 
tively that  a  certain  stain  has  been  made  by  human 
blood.  2.  It  cannot  be  stated  that  a  certain  blood- 
stain was  not  made  by  the  blood  of  any  one  of  the 
lower  animals,  except  the  sheep  and  goat.  3.  That  in 
measuring  the  blood-corpuscles,  at  least  three  or  four 
hundred  should  be  used  in  the  determination.  4.  It 
is  possible  to  determine  that  a  given  stain  is  of  mam- 
malian blood  (excepting  that  of  the  camel  family). 
5.  If  the  witness  is  able  to  say  that "  stains  are  of  mam- 
malian blood,  and  that  the  diameters  of  the  corpuscles 
are  consistent  with  human  blood,"  and  if  he  expressly 
states  that  they  may  be  of  other  blood,  he  is  giving  tes- 
timony which  will  doubtless  be  accorded  the  weight  to 
which  it  is  entitled,  and  which  cannot  be  effectively 
contradicted  by  the  defence  (Hamilton). 

When  I  first  began  preparing  this  paper,  it  was  my 
intention  to  treat  my  subject  more  exhaustively,  but 
almost  before  a  good  introduction  is  reached,  I  find  the 
time  usually  considered  requisite  for  the  President's 
address  consumed.  The  field  which  I  have  entered  is 
a  large  and  fertile  one,  r  .d,  I  assure  you,  a  rich  har- 
vest, indeed,  awaits  the  patient  laborer  in  its  domain. 
To  at  all  properly  consider  the  subject  of  clinical 
blood  examination  would  require  tno  i)apers,  and  it 
was  the  cognizance  of  this  fact  that  led  me  to  select 
the  title  of  the  present  address. 

I  had  hoped  to  be  able  to  bring  to  your  notice  many 
valuable  facts  in  connection  with  this  subject,  such  as 
the  condition  of  the  blood  in  malaria,  in  appendicitis, 
anaemia,  chlorosis,  etc.,  but  time  forbids.  1  might  say, 
by  way  of  parenthesis,  that  differential  diagnoses  be- 
tween appendicitis  and  typhoid  fever  are  being  made 
in  some  of  our  hospitals  entirely  by  blood  examina- 
tions. 

I  am  afraid  it  is  often  the  case  that  many  medical 
men  look  at  the  assertions  and  suggestions  of  a  micro- 
scopist  with  more  or  less  incredulity.  That  there  has 
been  some  excuse  for  such  skepticism,  in  the  immoder- 
ate claims  made  by  some  over-zealous  and  unscrupu- 
lous investigators,  I  admit,  but  I  also  insist  that  I  have 


688 


MEDICAL   RECORD. 


[November   i6,  1S95 


an  abiding  faith  in  my  ability  to  convince  the  rankest 
unbeliever,  by  an  hour's  laboratory  communication  with 
him,  of  the  great  clinical  value  of  an  intelligent  micro- 
scopical examination  of  the  blood. 

Bibliography'. 

Reference  to  the  following  works  has  been  had  in  the  preparation  of 
this  address  : 
Von  Jaksch  :  Clinical  Diagnosis. 
Heitzmann :  Microscopical  Morphology. 
Hamilton  and  others  :  System  of  Legal  Medicine. 
Wormley  :  Micro-Chemistrj'  of  Poisons. 
Piersol :   N'ormal  Histology. 

Kirke"s  Handbook  of  Physiology,  thirteenth  edition. 
Landois  and  Sterling's  Physiolog>'. 

Halliburton :  Text-Book  of  Chemical  Physiology  and  Pathology. 
Delafield  and  Prudden  :  Pathological  Anatomy  and  Histology. 
263  Sooth  U.^'ION  Street.  Bl'blington,  Vr., 
September,  1S95. 


SLEEP  IN  IT.S  RELATIONS  TO  DISEASES  OF 
THE  SKIN. 

Bv  L.   DUKCAN  BULKLEV,  A.M.,  M.D., 

NEW   YORK. 


To  those  who  look  upon  affections  of  the  skin  as 
wholly  or  largely  local  affairs,  dependent  upon  extra- 
neous influences,  whether  parasitic  or  other,  the  discus- 
sion of  the  topic  here  proposed  will  probaLly  seem 
quite  unnecessar)-,  and  some  of  the  statements  unsound. 
But  to  those  who  take  the  broadest  \'iew  of  demiatol- 
ot^y,  and  regard  the  aggregations  of  s\-mptonis  to  which 
are  given  the  names  of  different  diseases  as  only  the 
expression  of  various  forms  of  disordered  tissue-action, 
influenced  by  ever)'  element  which  conduces  to  perfect 
or  imperfect  nutrition  and  innervation,  the  subject  is 
fraught  with  the  greatest  interest  and  is  one  of  a  most 
practical  character. 

Sleep  is  undoubtedly  one  of  nature's  sweet  restorers, 
and  yet  in  the  literature  of  dermatology,  both  in  text- 
books, monographs,  and  journal  articles,  I  can  find 
hardly  an  allusion  to  the  subject,  and  I  do  not  know,  of 
its  having  been  referred  to  in  any  society  discussions 
on  dermatological  subjects,  except  in  the  briefest  and 
most  superficial  manner. 

Ot  the  other  hand,  with  me  it  is  one  of  the  most  im- 
portant elements  to  consider  in  connection  with  many 
diseases  of  the  skin,  and  for  twenty-five  years  I  have 
made  notes  in  regard  to  this  element  in  large  numbers 
of  my  patients  ;  so  important  do  I  consider  it  that  on 
my  printed  paper  for  recording  cases  the  word  "  sleep  " 
appears  twice,  once  in  connection  with  the  "  previous 
history  of  the  patient,"  and  again  in  recording  the  con- 
dition of  the  patient  at  the  time  of  first  observation  ; 
record  in  regard  to  sleep  also  is  commonly  made,  in  very 
many  patients,  at  each  subse -aent  visit. 

It  is  not  necessary  at  the  picsent  time,  even  if  I  were 
able,  to  discuss  the  nature  of  sleep  or  the  causes  that 
produce  it  in  the  healthy  individual.  Every  one  recog- 
nizes "  that  natural  condition  of  restful  unconscious- 
ness into  which  the  system  falls  normally  with  more  or 
less  regularity  daily." '  Every  one  also  recognizes  the 
difference  between  this  restful  and  perfectly  refreshing 
sleep  and  that  which  is  disturbed  in  varying  degrees  ; 
the  disturbance  may  vary  from  a  slight  insomnia  to  a 
more  or  less  well-marked  vigil  or  wakefulness,  and 
there  may  be  also  various  degrees  of  deranged  sleep, 
from  a  not  unpleasant  dream  to  the  agonizing  distress 
seen  in  children  or  others  starting  up  with  "  night  ter- 
rors," also  the  varying  degrees  of  sleep-talking,  sleep- 
walking, etc. 

Normal,  healthy  sleep  is  certainly  one  of  the  ele- 
ments of  health  of  the  body  and  all  its  tissues,  whereas 
disturbed  or  deranged  sleep  is  a  contributing  factor  to 

'  Foster  ;  Encyclopedic  Medical  Dictionary. 


many  diseased  conditions  of  various  structures  of  the 
body.  As  already  remarked,  the  relations  between 
sleep  and  diseases  of  the  skin  have  not  hitherto  re- 
ceived the  attention  of  dermatologists,  but  is  it  not 
quite  reasonable  that  the  state  or  condition  in  which 
more  tha«  one-third  of  the  human  life  is  spent  must 
have  something  to  do  with  the  nutrition  and  inneri'a- 
tion  of  the  skin  as  well  as  of  other  organs  ?  We  all 
know  how  readily  the  expression  of  the  face  and  the 
tone  of  the  tissues  will  show  the  results  of  continued 
loss  of  sleep,  while  the  fresh,  vigorous  tone  of  the  skin 
of  the  person  in  perfect  health,  with  perfect  sleep,  is 
equally  well  recognized  by  everyone. 

But  it  is  largely  in  the  direction  of  the  s}'mptomatic 
character  of  disturbed  sleep  that  this  feature  is  of  prac- 
tical importance  in  dermatology.  Normal  sleep  de- 
pends upon  the  perfect  functionating  of  all  the  parts  of 
the  system,  so  that  the  periodical  rest  occurs  in  a  natu- 
ral manner  ;  conversely,  disturbance  in  the  perform- 
ance of  the  function  of  various  portions  of  the  body 
may  lead  to  an  imperfect  sleep. 

Illustrations  of  this  are,  of  course,  familiar  to  all  ; 
such  are  the  restlessness  in  sleep  with  vivid  dreams, 
and  unrefreshing  sleep  dependent  upon  digestive  disor- 
ders ;  the  insomnia  accompanj'ing  diseases  of  the  heart 
and  blood-vessels  ;  that  due  to  excessive  use  or  abuse  of 
tea,  coffee,  and  tobacco  ;  the  wakefulness  following  ex- 
cessive brain-work,  grief,  emotion,  etc.,  and  that  due 
to  extraneous  influences,  as  itching,  pain,  noise,  etc. 

For  convenience  of  consideration  we  may  arrange  the 
causes  of  disturbance  of  sleep  under  six  main  classes, 
as  follows  : 

I,  Digestive;  2,  circulatory;  3,  toxic;  4,  nervous 
(direct  or  reflex)  ;  5,  psychic  ;  and  6,  extraneous. 

Time  and  space  forbid  my  entering  here  fully  into 
the  subject,  or  elaborating  in  detail  the  features  be- 
longing to  these  six  classes  of  causes,  which  exhibit 
themselves  more  or  less  frequently  in  disturbed  sleep 
in  many  patients  with  diseases  of  the  skin  ;  some  of 
them  will  appear  later  in  our  consideration  of  the  mat- 
ter in  hand. 

We  may  now  study  our  subject  somewhat  more  in 
detail  and  will  consider  :  i.  Disturbances  of  sleep  pre- 
ceding or  causing  diseases  of  the  skin  ;  2,  disturbances 
of  sleep  accompanying  or  caused  by  diseases  of  the 
skin  ;  and  3,  means  of  removing  disturbances  of  sleep 
in  connection  with  diseases  of  the  skin. 

1.  Disttirbances  of  Sleep  Preceding  or  Causing  Dis- 
eases of  the  Skin, — In  speaking  of  disturbances  of 
sleep  preceding  or  causing  diseases  of  the  skin  I  do 
not  wish  to  be  misunderstood.  It  is  not  claimed  that 
the  disturbances  of  sleep  which  shall  be  spoken  of  are 
often  the  direct  causative  agents  which  induce  diseases 
in  the  skin,  nor  that  their  removal  will  necessarily  be 
followed  by  recovery  of  the  skin  trouble.  I  only  as- 
sert that  for  many  years  I  have  so  constantly  observed 
the  concurrence  of,  and  relations  between  the  two,  in 
very  many  patients,  that,  to  my  mind,  the  former 
should  be  observed,  regarded,  studied,  and  more  or 
less  treated  from  its  basic  stand-point,  to  obtain  the 
very  best  results  in  the  treatment  of  the  latter. 

In  endeavoring  to  learn  the  exact  character  of  the 
sleep  of  patients  some  considerable  care  will  often  be 
necessary.  In  questioning  in  regard  to  sleep  the  com- 
mon and  hasty  answer  will  usually  be  that  the  sleep 
is  "  all  right,"  or  "  very  good,"  or  even  "  too  good," 
when  a  careful  cross- questioning  will  very  frequently 
elicit  the  fact  that  this  is  far  from  being  the  case. 
Many  are  forgetful ;  many  become  so  accustomed  to 
the  character  of  sleep  which  they  have  had,  that  they 
do  not  appreciate  that  it  can  be  othenvise  ;  and  I 
have  found  large  numbers  of  persons  who,  for  many 
years  at  least,  have  not  had  at  the  right  times  and  un- 
der the  right  conditions  that  "natural  condition  of 
restful  unconsciousness  "  which  constitutes  perfectly 
normal,  healthy  sleep.  Many  will  have  drowsiness  dur- 
ing the  day  or  evening,  and  insomnia  or  unrefreshing 


November  i6,  1895] 


MEDICAL   RECORD. 


6S9 


sleep  at  night.  Many  will  have  long  periods  of  vigil 
or  wakefulness  on  retiring,  or  will  waken  frequently, 
or  very  early  in  the  morning,  with  inability  to  further 
sleep.  In  some  the  sleep  will  be  heavy,  "like  a  log," 
and  troubled  or  not  with  vivid  and  annoying  dreams  ; 
in  others  the  sleep  may  seem  fairly  good,  but  is  wholly 
unrefreshing  in  character,  and  the  patient  will  be  as 
tired  in  the  morning  as  on  retiring,  or  even  more  so  ; 
and  patient  inquiry  will  often  discover  many  other 
aberrations  from  healthy,  restful  sleep.  These  may  de- 
pend upon  any  one  or  more  of  the  si.\  principal  causes 
already  mentioned,  or  perhaps  others. 

Now,  while  these  conditions  exist,  and  they  could  be 
amplified  very  much  more,  perfect  nutrition  and  inner- 
vation do  not  and  cannot  exist,  and  the  skin-tissue, 
even  if  restored  to  a  comparatively  normal  state,  by 
either  external  or  internal  measures,  will  readily  yield 
again  and  become  diseased.  It  is  the  failure  to  prop- 
erly recognize  and  treat  these  and  other  derange- 
ments of  the  system  which  has  led  in  some  measure  to 
the  recognized  obstinacy  of  skin  diseases  ;  and  the 
dermatologist  can  never  practise  his  branch  in  the 
highest  and  best  manner  unless  he  is  thoroughly  com- 
petent in  general  medicine,  and  skilled  to  recognize 
and  treat  the  functional  and  other  disturbances  of  the 
system  which  have  so  much  to  do  with  the  vigor  and 
health  of  the  individual  and  all  his  tissues. 

In  a  not  inconsiderable  number  of  cases  of  eczema  I 
have  known  the  eruption  to  first  appear  after  a  period 
of  sleeplessness,  which,  in  different  cases,  had  occurred 
from  quite  different  causes  ;  and  time  and  again  I  have 
known  fresh  attacks  of  eruption  to  come  on,  apparent- 
ly from  the  same  cause.  How  far  this  element  of  im- 
perfect sleep  has  to  do  with  the  causation  of  other  skin 
diseases  I  cannot  tell  at  the  present  time.  It  is  hoped 
that  others  will  observe  the  matter  closely  and  report 
their  experience  in  the  matter. 

2.  Distarbances  of  Sleep  Accompanying  or  Caused  by 
Diseases  of  the  Skin. — The  first  disturbance,  which  will 
occur  to  everyone,  is  that  arising  from  itching.  As  all 
know  this  is  often  a  most  distressing  feature  in  many 
cases.  From  earliest  infant  life  to  extreme  old  age  one 
afflicted  with  eczema  may  have  sleep  largely  interrupted 
by  itching  ;  indeed  the  nocturnal  sufferings  of  these  pa- 
tients will  often  far  exceed  those  of  the  day,  and  after 
a  night  of  real  agony,  with  only  snatches  of  broken 
sleep,  the  patient  enters  on  the  day  wholly  unrefreshed. 

The  reasons  for  the  greater  distress  from  itching 
during  the  night,  in  many  skin  disorders,  seem  to  be 
numerous  :  i.  The  exhaustion  of  the  nervous  system 
by  the  activity  of  the  day  renders  it  more  liable  to  dis- 
turbances, until  the  loss  of  nervous  energy  has  been 
restored  by  sleep.  2.  During  sleep  there  is  a  cer- 
tain withdrawal  of  the  general  nervous  control  of 
the  system,  which  allows  special  irritations  to  as- 
sert themselves  ;  this  is  observed  also  in  relation  to 
other  disorders  of  the  system,  as  in  asthma,  in  certain 
neuralgias,  in  urinary  and  bladder  affections,  etc.  3. 
During  the  condition  of  somnolence  there  is  also  an 
absence  of  self-control,  which  leads  the  patient,  per- 
haps unconsciously  at  first,  to  scratch  and  rub,  even  for 
a  slight  pruritus,  and  so  to  excite  an  already  irritated 
skin  to  an  increased  erethism  and  to  the  development 
of  new  lesions,  requiring  fresh  scratching.  4.  In  the 
same  manner  that  the  brain  is  especially  excited  at 
night  by  the  product  of  faulty  metabolism,  from  diges- 
tive disorders,  and  the  ner\e-elements  of  the  healthy 
skin  suffer  a  like  irritation  during  the  period  of  sleej* 
(manifested  by  restlessness  and  even  burning  and 
moderate  itching),  so  patches  of  diseased  skin  are  espe- 
cially irritated  at  night  by  the  circulation  of  imperfect- 
ly elaborated  blood.  5.  Finally,  the  warmth  of  the 
bed  favors  a  congestion  of  the  skin,  which  congestion, 
pressing  upon  nerve-elements  already  in  a  state  of  irri- 
tation, excites  them  to  renewed  activity. 

I  have  known  cases  where  complete  nervous  exhaus- 
tion has  thus  occurred,  and  remember  vividly  a  lady 


who,  having  tried  an  infinity  of  remedies  to  get  relief, 
had  finally  been  given  chloroform  repeatedly  by  her 
husband  for  this  purpose,  with  disastrously  prostrating 
effects. 

Other  diseases — urticaria,  pruritus,  dermititis  herpeti- 
formis, etc. — will  often  act  in  the  same  manner,  and  the 
resources  of  the  physician  will  frequently  be  taxed  to 
the  uttermost  in  meeting  this  element  of  the  case.  In 
some  instances,  as  in  zoster,  dermatalgia,  and  syphilis, 
the  sleep  will  be  broken  by  pain,  which,  indeed,  may 
be  also  a  formidable  obstacle  to  overcome  ;  various  ul- 
cerative affections,  and  also  bullous  eruptions,  as  pem- 
phigus, may  in  like  manner  interfere  with  sleep. 

But,  as  mentioned  in  the  preceding  section,  it  is  nec- 
essary to  recognize  certain  other  less  marked  disturb- 
ances of  sleep,  which  will  not  infrequently  be  found  ac- 
companying some  diseases  of  the  skin,  if  indeed  they 
are  not  caused  by  the  conditions  which  lead  up  to  the 
latter  :  for,  as  already  mentioned,  we  should  not  in  a 
study  like  the  present  consider  these  diseases  of  the 
skin  as  entities,  but  only  as  expressions  of  a  disordered 
physical  state,  the  changes  in  the  skin  taking  various 
forms,  which  we  for  convenience  designate  by  different 
names  of  diseases. 

In  a  not  inconsiderable  proportion  of  my  cases  of 
ache,  in  private  practice,  I  find,  on  close  questioning, 
that  disorders  of  the  sleep  are  very  common  ;  and  con- 
tinually, as  the  case  progresses  to  a  cure,  I  find  the 
character  of  the  sleep  change  for  the  better.  Many  a 
patient  has  told  me,  during  treatment,  that  for  the  first 
time  in  years  the  sleep  had  been  of  the  natural  refresh- 
ing character  of  health.  The  same  is  true,  though  to 
a  somewhat  lesser  extent,  in  psoriasis  and  in  other  dis- 
eases, and  also  in  eczema,  even  where  the  disturbance 
had  not  been  from  the  itching,  but  only  from  the  gen- 
eral systemic  derangement. 

The  form  of  the  sleep  disorder  in  these  cases  has 
varied  greatly.  At  times  it  has  been  vigil  on  retiring, 
in  others  an  early  wakefulness,  perhaps  even  toward 
morning,  say  after  three  o'clock  ;  in  many  patients  it 
has  been  only  a  disturbed  character  of  sleep,  with  fre- 
quent dreams,  of  a  pleasant  or  terrifying  nature  ;  or 
again,  simply  a  restlessness  at  night,  with  a  total  want 
of  refreshment  in  the  morning,  etc. 

As  I  said  before,  I  do  not  claim  that  all  these  sleep 
derangements  are  directly  caused  by  the  particular  skin 
disorder  present,  but  do  believe  that  they  are  elements 
which  go  to  make  up  the  complex  state  finally  ex- 
hibited by  an  eruption  on  the  surface,  and  that  unless 
they  are  more  or  less  rectified,  permanent  good  cannot 
be  done. 

In  closing  this  section  of  our  discussion  mention 
should  be  made  of  the  restlessness  in  sleep  belonging 
to  the  eruptive  fevers,  and  also  of  that  accompanying 
some  other  conditions,  as  jaundice,  glycosuria,  and 
chronic  kidney  disease,  where  a  dry  and  itchy  skin  pre- 
vents sleep. 

3.  Means  of  Removing  Disturbances  of  Sleep  in  Con- 
nection with  Diseases  of  the  Skin. — To  rightly  under- 
stand and  apply  the  correct  principles  and  measures  of 
treatment  with  success,  that  is,  in  the  generality  of 
cases,  it  is  necessary,  first,  to  keep  well  in  mind  the  nat- 
ure of  physiological  sleep,  and  the  causes  which  dis- 
turb it,  as  already  alluded  to  ;  and  second,  to  study  the 
individual  case,  in  reference  to  the  existing  condi- 
tions antagonistic  to  sleep.  Routine  prescribing  may 
occasionally  give  relief,  but  far  oftener  does  harm.  A 
vast  weight  of  responsibility  rests  on  those  who  in  times 
past  and  present  have  vaunted  this  or  that  new  sopori- 
fic, which  has  too  often  been  employed  with  but  little 
thought,  except  to  heed  the  enticing  claims  put  forth 
by  those  who  manufacture  and  push  it  for  commercial 
purposes. 

Sleep  is,  always  has  been,  and  probably  always  will 
be,  a  great  mystery.  \\'hile  we  undoubtedly  know  con- 
siderable in  regard  to  the  conditions  of  the  brain  dur- 
ing  sleep,  and  the  experiments   and  observations   of 


690 


MEDICAL   RECORD. 


[November  16,   1895 


many  prove  very  conclusively  that  the  brain  is  in  a 
condition  of  anaemia  during  sleep,  it  is  not  known 
whether  that  aniemiais  a  primary  condition,  or  whether 
it  is  secondary  to  changes  in  the  brain-cells,  induced  by 
a  "  periodic  exhaustion  of  intra-ganglionic  energy." 

Fortunately,  however,  it  is  not  necessary  practically 
to  fully  understand  the  exact  order  of  precedence  of 
the  causative  elements  of  sleep  ;  for  we  do  know  posi- 
tively that  agencies  can  cause  insomnia  which  operate 
in  either  of  two  directions,  namely,  by  furnishing  stimu- 
lus to  the  nerve-cells,  reflex  or  otherwise,  or  by  caus- 
ing excitement  to  the  cerebral  circulation. 

A  most  interesting  experiment  by  Chapin,  cited  by 
Long  Fox,'  demonstrates  the  latter  perfectly.  He  ap- 
plied amyl  nitrite,  which  promotes  the  circulation  of 
the  brain,  very  carefully  to  the  nostrils  of  a  number  of 
patients  who  were  sound  asleep,  and  in  every  case  they 
awoke  promptly  ;  this  was  repeated  on  several  even- 
ings on  different  patients  with  a  uniform  result.  Asa 
counter-experiment  he  applied  bisulphide  of  carbon 
and  oil  of  peppermint  to  other  patients,  not  a  third  of 
w^hom  were  roused  ;  showing  that  the  results  were  from 
the  action  of  the  amyl  nitrite  on  the  circulation,  and  not 
simply  from  the  odor,  or  from  his  presence  near  the 
bed,  etc.  All  recognize,  of  course,  that  stimulus  to  the 
brain-cells,  as  by  light,  sound,  severe  pain,  or  itching, 
brings  consciousness,  and  also  that  intense  mental  ac- 
tivity prevents  sleep. 

The  disturbance  of  sleep  by  reflex  action  from  other 
parts  of  the  system,  and  by  the  irritating  effects  of  the 
product  of  imperfect  assimilation  and  disassimilation, 
are  more  or  less  commonly  recognized,  even  by  the 
laity.  The  child  who  tosses  in  sleep  will  often  be 
rightly  thought  to  have  intestinal  worms,  or  will  be  suf- 
fering from  indigested  substances,  and  all  degrees  of 
restlessness  and  deranged  sleep  will  be  noticed  from 
the  latter,  up  to  violent  manifestations  of  "  nightmare  " 
and  "night  horrors." 

All  recognize  the  perturbed  sleep  after  partaking  of 
heavy  or  indigestible  substances,  especially  late  at 
night,  and  also  that  associated  with  many  forms  of 
chronic  indigestion.  Now,  it  is  just  these  conditions 
which  so  frequently  exist  in  those  suffering  from  many 
diseases  of  the  skin,  and  which  often  play  an  impor- 
tant part  in  the  ill  health  which  leads  up  to  them,  which 
it  is  often  of  the  greatest  importance  to  consider  and 
treat,  if  the  best  results  would  be  obtained  in  the  skin 
lesions. 

I  am  convinced  that  often  when  itching  exists,  and 
seems  to  be  the  cause  which  prevents  or  disturbs 
sleep,  the  real  cause,  in  part  at  least,  will  be  found  else- 
where, and  that  the  patient  will  sleep  well  if  that  is  re- 
moved, even  in  spite  of  some  itching.  I  will  therefore 
consider  this  last  section  of  our  subject  under  the  six 
main  classes  of  the  causes  of  disturbance  of  sleep  al- 
ready rnentioned,  namely,  i,  Digestive  ;  2,  Circulatory  ; 
3,  Toxic  ;  4,  Xervous  (direct  or  reflex)  ;  5,  Psychic  ; 
and  6,  Extraneous. 

1.  Digestive. — The  subject  of  the  disturbances  of  sleep 
by  digestive  derangements  is  so  great  that  it  can  be 
hardly  more  than  touched  upon  at  the  present  time. 
But,  on  the  other  hand,  it  is  one  of  the  most  important 
points  to  consider  in  connection  with  many  diseases  of 
the  skin,  and  must  not  be  passed  by  with  a  single  ques- 
tion or  two.  Not  only  should  remedies  be  given  to 
correct  the  digestive  disorders,  but  accurate  directions 
should  be  given  as  to  diet  ;  for,  with  modern  life,  the 
temptation  to  errors  in  eating  and  drinking  are  so  great 
that  few  escape  some  digestive  disorder,  and  with  many 
this  affects  sleep  ;  indeed,  sometimes  sleep  disturbance 
will  be  about  its  only  marked  symptom.  Late  eating 
at  night,  and  that  generally  of  indigestible  substances, 
is  a  fertile  cause  of  sleep  disorder  ;  on  the  other  hand, 
long  abstinence  from  food  will  also  frequently  inter- 
fere with  sleep.     In  this  latter  case,  if   patients  are 

'  Long  Fox  :  The  Influence  of  the  Sj-mpathetic  on  Disease,  p.  217. 
London.  1883.  f       / 


awake  four  or  five  hours  after  finishing  supper,  say  un- 
til midnight,  a  warm  drink,  such  as  pure  milk  alone,  or 
a  very  weak  broth  of  meat  extract,  or  a  thin  gruel,  will 
commonly  secure  perfect  sleep. 

It  will  often,  however,  be  quite  difficult  to  determine 
exactly  the  dietary  error  at  the  bottom  of  the  sleep- 
lessness, but  it  can  be  accomplished  by  patient  in- 
vestigation. Sometimes  constipation  will  be  the  sole 
cause  of  deranged  sleep,  and  all  must  have  noticed 
how  much  better  and  more  refreshing  sleep  is  apt  to 
be  after  a  free  purgation,  when  this  has  been  needed. 

2.  Circnlatory  Disorders. — Not  only  in  marked  dis- 
ease of  the  heart,  in  aneurism,  and  in  atheroma  may 
there  be  derangement  of  sleep,  but  this  is  apt  to  hap- 
pen frequently  where  no  gross  lesions  of  the  heart  or 
blood-vessels  exist,  but  where  there  is  only  heart  weak- 
ness and  functional  disturbance  of  the  circulation. 
This  may  manifest  itself  in  many  ways.  With  an 
excited  circulation,  often  evidenced  by  throbbing  in 
the  head,  the  warm  bath,  or  even  a  foot-bath  on  retir- 
ing, will  so  withdraw  the  blood  current  from  the  brain 
that  the  symptom  will  no  longer  cause  annoyance. 
Recently  a  patient  of  mine  with  lichen  planus,  who  was 
very  actively  engaged  as  a  lawyer,  under  great  and 
prolonged  excitement  connected  with  some  recent 
public  trials,  obtained  sweet  and  refreshing  sleep  in 
this  way  for  many  nights  in  succession.  In  some 
cases  one  of  the  bromides,  with  a  trace  of  aconite, 
will  give  entire  relief.  In  some  cases,  on  the  other 
hand,  where  there  is  heart  weakness  and  a  general 
weak  tonicity  of  the  blood-vessels,  digitalin,  given  be- 
fore meals,  and  at  bedtime,  will  act  better  than  any- 
thing else,  as  I  have  repeatedly  witnessed. 

Another  form  of  deranged  circulation  will  be  mani- 
fested in  cold  and  clammy  hands  and  feet,  which  are 
continually  observed  in  skin  patients,  and  which  often 
prevent  sleep  long  after  retiring.  Digitalin  will  often 
remove  this,  as  will  also  the  appropriate  treatment  for 
the  anjemia  causing  it  ;  relief  is  obtained,  likewise,  by 
plunging  the  members  alternately  into  basins  of  hot 
and  cold  water,  and  other  measures  which  readily  sug- 
gest themselves. 

3.  Toxic. — Toxic  disturbances  of  the  sleep  are  much 
more  common  than  is  supposed.  These  include  not 
only  the  effects  of  excessive  use  of  coffee,  tea,  and  to- 
bacco, but  also  other  disturbing  elements,  such  as  qui- 
nine and  some  other  drugs.  The  toxic  character  of 
many  of  the  products  of  gout  will  also  prevent  or  de- 
range sleep,  and  should  always  be  taken  into  considera- 
tion. This  is,  of  course,  closely  connected  with  the 
preceding  section,  and  much  care  should  be  given  in 
these  cases  to  securing  the  most  perfect  metabolism 
possible,  which  is  to  be  accomplished  by  various  means, 
including  diet,  hygiene,  exercise,  and  remedies  affect- 
ing the  chylo-poietic  viscera.  Hypnotics  should  be 
rarely  resorted  to. 

4.  Nervous.— Nervous  (direct  or  reflex)  causes  of  the 
derangement  of  sleep  in  patients  with  diseases  of  the 
skin  are  numerous,  and  will  often  require  some  care  in 
their  discovery  and  removal.  In  many  a  case  the  skin 
lesion  will  be  but  one  of  the  signs  of  a  general  break- 
down which  has  come  from  excessive  or  injudicious  use 
of  the  brain,  and  the  insomnia  which  has  resulted  has 
in  turn  contributed  much  to  the  further  debility  of  tis- 
sue ;  in  some  instances  it  has  come  from  overwork,  or 
from  social  or  other  dissipation,  with  restricted  hours  of 
sleep.  These  cases  often  require  very  delicate  han- 
dling, by  all  means  tending  to  restore  exhausted  brain- 
cells  ;  it  is  worse  than  useless  to  give  the  so-called  seda- 
tive remedies,  and  even  bromide  of  potassium  will 
sooner  or  later  increase  instead  of  diminish  the  trouble 
we  seek  to  remove.  Good  and  proper  feeding,  with 
nerve  tonics,  and  friction  of  the  surface,  such  as  a 
thorough  rubbing  of  the  body  and  limbs  with  a  Turk- 
ish towel  at  night,  after  a  brisk  sponge  with  tepid  water, 
or  even  a  cold  pack,  etc.,  will  often  restore  the  nervous 
vitality  and  permit  of  sleep.  ■  In  some  cases  digitalisi 


November   i6,    1895] 


MEDICAL    RECORD 


691 


by  restorins  tone  to  the  overstrained  and  relaxed  ca- 
pillaries of  the  brain,  will  Le  of  much  service,  as  may 
aho  ergot. 

If  the  sleep  disturbance  is  caused  by  lefiex  nervous 
irritation,  whether  it  he  by  intestinal  woims,  uterine, 
bladder,  or  other  disease,  these  will  require  attention 
before  the  sleep  can  be  of  the  refreshing  character 
which  leads  to  a  perfect  restoration  to  health. 

5.  Psychic  Disturbances  of  Sleep  are  not  at  all  un- 
common, and  will  often  have  to  be  met  in  treating  dis- 
eases of  the  skin.  Mental  cares,  whether  of  business, 
domestic,  or  social  character,  may  all  at  times  act  as 
powerful  depressants,  and  by  interfering  with  perfect 
sleep  hinder  the  cure  of  skin  lesions.  In  addition  to 
general  rules,  and  the  endeavor  to  free  the  mind  from 
the  disturbing  load,  these  cases  will  often  receive  the 
greatest  benefit  from  the  judicious  use  of  proper  hyp- 
notic remedies  for  a  short  period.  I  well  remember 
the  case  of  ayoang  lady,  much  afflicted  with  acne,  who 
had  been  utterly  sleepless  for  some  little  time,  owing  to 
an  unfortunate  love  affair.  A  few  full  doses  of  urethan 
insured  prolonged  and  refreshing  sleep,  after  which  the 
preceding  troubles  vanished  under  the  appropriate 
treatnier.r. 

6.  Eztraneous. — Extraneous  causes  disturbing  sleep, 
accompanying  or  caused  by  diseases  of  the  skin.  Be- 
fore speaking  of  the  relief  of  sleep  disturbed  by  pain 
and  itching,  I  wish  to  make  a  single  cautionary  remark, 
namely  :  It  is  an  error  to  suppose  in  every  instance 
where  the  patient  complains  that  the  sleep  is  disturbed 
by  these  causes  that  this  is  wholly  the  case.  In  very 
many  instances  some  of  the  other  elements  which  we 
have  considered  are  really  at  the  bottom  of  the  sleep 
disturbance,  and  when  the  patient  is  thus  deprived  of 
sleep  the  pain  or  itching  asserts  itself,  and  then  forms 
an  additional  cause  of  wakefulness.  A  single  illustra- 
tion will  suffice  to  recall  others.  How  often  do  we  find 
that  those  who  are  called  upon  to  empty  the  bladder  at 
night  are,  when  thus  aroused,  distressed  and  then  kept 
awake  by  the  itching  which  is  induced  by  the  exposure 
of  the  surface  to  the  air  after  warmth  in  bed.  The  same 
occurs  when  some  are  awakened  by  troublesome 
dreams,  by  palpitation,  by  indigestion,  or  perhaps  by  a 
laryngeal  cough,  of  gouty  origin,  it  may  be.  Now,  the 
careful  and  proper  attention  given  to  these,  and  their 
removal  by  appropriate  measures,  will  often  be  of  the 
very  greatest  importance  in  securing  rest  in  sleep  for 
those  afflicted  with  diseases  of  the  skin.  And  if  this 
refreshing  sleep  is  obtained,  then,  with  the  resulting 
gain  to  the  nervous  system  the  very  pain  or  itching  will 
be  less  annoying,  and  so  will  be  more  easily  controlled. 

We  may  dismiss  very  briefly  the  subject  of  pain  as  a 
disturber  of  sleep  in  connection  with  diseases  of  the 
skin.  This  should  always  be  attended  to.  and  special 
methods  will  suggest  themselves  to  all.  The  pain  from 
syphilitic  lesions  will  generally  yield  more  or  less 
promptly  to  very  actively  pushed  specific  medication 
suitable  to  the  special  stage  of  the  disease  or  character 
of  the  lesion  present  ;  but  opium  or  morphia  may  oc- 
casionally be  needed.  I  have  also  repeatedly  found  the 
very  greatest,  indeed  perfect  relief  to  osteocopic  and 
neuralgic  pains  in  syphilis,  from  antifebrin,  in  about 
five-grain  doses,  given  every  hour  or  two,  with  hot 
water,  and  a  little  whiskey  if  there  seems  to  be  any  de- 
pression. 

In  the  distressing  pain  often  accompanying  or  fol- 
lowing herpes  zoster,  especially  in  elderly  persons, 
galvanism  will  prove  very  valuable,  and  I  recall  a  pa- 
tient who,  having  previously  had  distressing  nights 
from  ophthalmic  zoster,  would  drop  off  to  sleep  while 
galvanism  was  being  applied,  .\ntifebrin  is  also  ex- 
tremely serviceable,  and  will  secure  sleep  even  when 
the  pain  has  previously  produced  great  wakefulness  ; 
it  must  be  used  freely,  however,  to  be  of  great  service, 
and  needs  to  be  watched. 

Itching  as  a  cause  of  sleep  disturbance  is  unfortu- 
nately too  well  known  to  everyone,  and  all  are  familiar 


with  the  ditticulties  often  attending  its  relief.  Proper 
local  treatment,  of  course,  plays  the  most  important 
part  in  securing  sleep  under  these  conditions  ;  but  I 
will  net  attempt  to  develop  this  subject,  which  could 
alone  occupy  our  entire  time.  A  few  woids,  however, 
may  not  be  out  of  place  in  regard  to  some  of  the  de- 
tails connected  with  it,  which  are  sometimes  over- 
looked. 

Patients  generally  understand  very  little  in  regard 
to  modes  of  making  applications  to  the  skin,  and  very 
explicit  directions  are  often  necessary  to  secure  the 
desired  result.  The  same  application  used  in  a  right 
and  a  wrong  way  may  produce  very  different  results. 
This  is  strikingly  illustrated  in  connection  with  eczema 
of  the  scroti;m.  With  the  exactly  proper  application 
of  hot  water,  followed  immediately  by  the  peifect  ad- 
justment of  an  ointment  of  tar  and  zinc,  spread  on 
lint,  closely  applied  and  kept  firmly  in  position,  we 
may  often  get  perfect  rest  at  night,  when  a  previous 
application,  wrongly  made,  has  been  followed  by  great 
insomnia.  I  have  frequently  seen  sound  sleep  secured 
in  infants,  with  the  most  severe  and  general  eczema, 
by  a  proper  dressing,  firmly  bound  on  only  to  the  parts 
which  were  most  liable  to  be  scratched,  when  a  former 
dressing,  quite  proper  in  itself,  but  loosely  and  wrongly 
applied,  had  given  no  results. 

In  some  instances  the  exposure  of  the  body  to  the 
cool  air,  on  undressing  at  night,  will  e.xcite  so  much 
pruritus  that  sleep  is  prevented  ;  much  of  this  can  be 
prevented  by  avoiding  this  exposure,  the  patient  going 
to  bed  with  the  underclothing  on,  making  an  applica- 
tion beneath  the  clothing;  in  the  morning  a  general 
dressing  of  the  affected  parts  can  be  made,  if  desired, 
and  fresh  underclothing  put  on.  Also  in  regard  to 
taking  baths,  whether  medicated  or  not,  errors  may 
occur  which  will  result  in  the  sleep  being  disturbed  or 
altogether  prevented.  Sometimes  baths  will  be  taken 
so  hot  as  to  e.\cite  the  circulation  and  prevent  sleep  ; 
in  the  process  of  drying  the  skin  after  them,  patients 
may  also  so  stimulate  the  surface  with  towels  that  sub- 
sequent applications  do  not  suthce  to  allay  the  irrita- 
tion, which  then  prevents  sleep.  In  a  word,  regard 
must  always  be  had  for  sleep  in  giving  directions  for 
treatment  to  skin  patients,  for,  as  stated  before,  a  rest- 
less or  sleepless  night  will  often  operate  so  disadvan- 
tageously  to  the  patient  that  much  of  the  good  effect 
of  treatment  may  be  lost. 

In  the  matter  of  the  administration  of  internal  rem- 
edies to  secure  sleep  in  patients  disturbed  by  itching, 
there  is  need  of  the  exercise  of  much  discretion  ;  they 
are  often  needlessly  given,  they  not  infrequently  prove 
useless,  and  are  sometimes  harmful.  From  what  has 
preceded  the  restlessness  of  hypnotics  in  many  cases 
has  been  abundantly  shown.  Their  uselessness  is  seen 
where  the  irritation  from  the  skin  is  very  great  ;  for 
they  rarely  serve  to  secure  sleep  until  the  irritating 
element  is  in  a  large  measure  removed.  Their  harm- 
fulness  frequently  appears  in  the  attempt  to  substitute 
them  for  the  proper  measures  of  relief,  generil  or  local, 
or  to  press  stronger  and  stronger  remedies,  even  to  the 
great  depression  of  the  nervous  system. 

But,  on  the  other  hand,  in  the  judicious  use  of  these 
we  can  occasionally  accomplish  very  much  both  for 
the  comfort  of  the  patient  and  for  the  cure  of  the  dis- 
ease. 

The  first  point  to  remember,  which  is  often  for- 
gotten by  the  profession,  is  the  utter  futility  of  pre- 
scribing preparations  of  opium  to  secure  sleep,  when 
it  is  disturbed  by  itching  ;  the  skin  irritation  is  com- 
monly so  aggravated  thereby  that  the  narcotic  effect  of 
the  drug  is  largely  nullified,  and  if  sleep  or  stupor  is 
secured  by  a  large  dosage,  it  is  of  the  most  unrefresh- 
ing  nature,  and  the  scratching  during  sleep,  which 
commonly  occurs,  will  often  greatly  aggravate  the  dis- 
ease. But  there  are  remedies  which  often  aid  in  quiet- 
ing the  pruritus,  and  which  may  be  given  with  advan- 
tage.    When   not  otherwise  contraindicated,  bromide 


692 


MEDICAL    RECORD. 


[November  16,  1895 


of  soda  in  good  dose,  with  a  fair  amount  of  tincture  of 
aconite,  will  often  produce  a  quiescent  effect  which  is 
most  happy.  Tincture  of  gelsemium,  in  increasing 
doses,  given  every  half  hour,  for  three  doses,  has  acted 
e.Kcellently  in  my  hands  ;  cannabis  indica,  employed 
in  the  same  way,  is  also  often  very  efficient. 

I  may  remark  that  the  method  of  preparing  three 
increasing  doses  of  a  remedy,  and  placing  them  under 
the  patient's  control,  by  the  bed,  before  retiring,  will 
also  aid  in  the  action  desired  ;  the  expectancy  of  the 
result  augments  its  efficiency.  I  direct  that  one  dose 
shall  be  taken  on  getting  into  bed,  the  second  half  an 
hour  later,  if  needed,  and  the  third,  still  half  an  hour 
or  an  hour  later.  Repeatedly  I  have  found  that  the 
third  dose  was  left  untouched,  and  rarely  do  the  three 
doses  fail  of  action.  The  patient  should  be  instructed 
to  have  the  doses  ready,  properly  diluted,  in  separate 
glasses,  so  that  they  can  be  drank  in  bed,  with  as  little 
rousing  as  possible,  and  certainly  without  rising  to 
prepare  or  take  them. 

Phenacetin  often  proves  a  most  valuable  hypnotic  in 
pruritic  cases ;  three  doses  may  be  arranged  in  the 
manner  above  described.  .A.ntifebrin  is  also  serviceable, 
but  requires  greater  caution  in  its  use.  Sulphonal  is 
frequently  given  to  secure  sleep  under  the  circum- 
stances, but  in  my  experience  it  is  not  a  very  satisfac- 
tory remedy.  When  used  thus  there  seems  to  be  a  later 
depression  of  the  nervous  system,  which  in  the  end  ag- 
gravates the  skin  complaint.  I  have  used  trional  to  some 
extent,  but  have  not  yet  been  very  well  satisfied  with 
the  results.  Chloral  has  also  a  secondary  nervous  re- 
action which  is  often  harmful,  although  in  certain  cases 
its  use  for  a  night  or  two  will  seem  to  so  induce  the  sleep 
habit  that  patients  can  afterward  do  without  any  aid  : 
it  can  often  be  combined  with  bromide  of  soda  with  ad- 
vantage. Paraldehyde  will  also  occasionally  act  very  fa- 
vorably, and  is  a  relatively  safe  remedy.  Chloralamide 
I  have  seldom  used.  Urethrane  has  sometimes  proved 
of  very  great  service  where  the  itching  was  not  severe, 
but  when  the  latter  is  excessive  it  has  little  if  any 
effect  on  the  sleep. 

In  many  cases,  even  where  there  has  been  consider- 
able sleeplessness  from  itching,  which  local  or  general 
treatment  fails  to  relieve  sufficiently  to  allow  of  sleep, 
an  excellent  effect  may  be  produced  by  a  large  warm 
drink  on  retiring,  without  the  aid  of  any  hypnotic  drug. 
For  ihis  purpose  I  have  made  use  of  warm  milk  (not 
boiled),  if  sufficient  time  (at  least  four  hours)  has 
elapsed  after  eating,  to  allow  of  the  stomach  being  per- 
fectly empty  ;  the  milk,  even  to  the  amount  of  a  pint, 
being  drank  pure  and  alone,  without  other  food  or 
medicament.  Gruels  made  of  wheat  preparations  also 
serve  admirably  well,  and  in  many  cases  one  of  the 
meat  extracts,  such  as  bovox,  a  tablespoonful  in  a  large 
tumbler  of  hot  water,  acts  as  a  perfect  hypnotic.  In 
some  instances  the  best  addition  to  the  hot  water  is  a 
half  teaspoonful  of  Horsford's  acid  phosphate. 

In  all  these  instances  the  action  is  much  the  same, 
namely,  diverting  blood  to  the  stomach,  and  so  aiding 
in  producing  the  brain  ischemia  necessary  to  sleep. 

In  bringing  this  memoir  to  a  close  I  must  again 
emphasi/.e  some  of  the  points  already  mentioned  : 

1.  Sleep  is  an  exceedingly  important  factor  to  con- 
sider in  connection  with  many  diseases  of  the  skin, 
disorders  in  sleep  occurring  both  as  a  contributing 
cause  and  as  an  effect  of  the  same. 

2.  The  disorders  of  sleep  occurring  in  patients  with 
diseases  of  the  skin  may  arise  from  many  different  con- 
ditions ;  the  six  principal  causes  may  be  classed  as,  a, 
digestive ;  /',  circulatory  ;  c,  toxic ;  d,  nervous  (direct 
or  reflex)  ;  e,  psychic  :  and  /,  extraneous. 

3.  These  causes  of  disturbances  of  sleep  should  be 
searched  for  and  relieved,  because  of  the  injury  result- 
ing from  imperfect  sleep  in  producing  or  aggravating 
many  diseases  of  the  skin. 

4.  In  cases  where  the  sleep  disturbance  is  caused  by 
the  disease  of  the  skin,  the  effort  should  be  made  to 


get  relief  to  the  insomnia  by  the  proper  internal  and 
external  treatment  of  the  skin  affection,  before  resort- 
ing to  hypnotics  ;  attention  to  details  is  often  very 
necessar}-  to  secure  this  end. 

5.  Preparations  of  opium  may  be  resorted  to  when 
the  disturbance  of  sleep  is  caused  by  pain  connected 
with  the  skin  disease,  but  these  are  useless  or  harmful 
when  the  wakefulness  results  from  itching.  Chloroform 
or  ether  are  also  not  to  be  advised  for  this  purpose. 

6.  Some  of  the  newer  so-called  anti-neuralgic  and 
hypnotic  remedies  are  often  of  great  ser\nce  in  quiet- 
ing the  general  irritation  and  inducing  sleep,  and  gel- 
semium and  cannabis  indica  are  also  valuable.  It  is 
often  desirable  to  give  repeated  doses,  at  half  hour  in- 
tervals, until  the  desired  effect  is  produced. 


SOME    RE.M.\RKS    ON    THE    MORPHIXE 
HABIT.' 

Bv   HENRY   FREEMAN   WALKER,   M.D.. 

KEW  YORK. 

No  one  denies  the  evil  effect  of  the  habitual  use  of 
morphia,  and  all  admit,  I  think,  that  its  employment 
hypodermically  is  peculiarly  seductive.  I  have  seen 
the  craving  established,  so  that  it  was  clearly  manifest, 
after  the  third  daily  repetition  of  the  dose.  Opium  in 
no  other  form,  and  by  no  other  method  of  administra- 
tion, will  so  speedily  produce  this  untoward  result.  In 
a  measure  this  would  seem  due  to  the  fact  that  the  re- 
lationship of  cause  to  effect  is  so  clearly  established. 
In  a  moment  one  passes  from  intense  suffering  to  com- 
plete relief  ;  and  at  the  same  time  experiences  such 
sensations  that  he  realizes  the  process  ;  which,  in  other 
methods  of  exhibiting  the  drug,  is  obscure  or  wholly 
occult. 

Opium  itself,  its  tinctures,  extracts,  or  elixirs,  may 
be  given  for  weeks  in  oft- repeated  dose,  and  their  with- 
holding may  be  followed  by  only  slight  depression  and 
little  craving  for  the  definite  thing.  But  this  cannot 
be  affirmed  of  the  surest  and  speediest  method  of  re- 
lieving suffering.  The  depression  is  greater  and  the 
consequent  craving  is  stronger. 

I  feel  the  more  strongly  with  reference  to  the  use  of 
morphia  by  the  hypodermic  needle,  because  it  is  a  Nice 
for  which  the  physician  is  peculiarly  responsible. 
Opium  smoking  or  eating  may  be  first  begun  in  curi- 
osity, and  the  habit  continued  for  the  pleasure  in- 
duced. But  the  first  in  the  long  series  of  hypodermic 
injections  is  always  given  by  the  physician.  Unpleas- 
ant consequences,  in  the  way  of  nausea  or  active  sick- 
ness are  no  safeguard  to  the  patient,  though  these  may 
deceive  him.  Often  I  have  heard  patients  say,  "  There 
is  no  fear  that  I  shall  take  morphine,  for  its  effects  are 
so  unpleasant."  Thei'r  very  self-confidence  betrays 
them.  They  soon  discover  that  the  repetition  of  the 
dose  affords  relief  to  the  unpleasant  feeling,  and  that 
in  one  respect  the  bane  is  its  own  antidote. 

Opium  taken  by  the  mouth  habitually  hardly  seems 
to  shorten  life,  except  through  the  accident  of  an  over- 
dose, sleepily  taken.  But  the  hypodermic  needle 
surely  undermines  the  health,  as  care  in  asepsis  is  al- 
ways after  a  time  neglected.  But  I  do  not  think  we 
compass  the  evil  of  the  habit  when  we  view  it  alone  or 
chiefly  in  its  physical  effects. 

To  me  the  greatest  evil  of  the  morphine  habit  is  the 
perversion  of  the  moral  sense.  It  obliterates  in  the 
victim's  mind  the  distinction  between  truth  and  false- 
hood, right  and  wrong.  And  here  the  evil  may  not  be 
limited  to  the  ])atient  himself,  but  this  may  entail  hard- 
ship and  suffering  on  all  those  about  him. 

The  first  effect  of  opium,  in  all  its  forms,  is  stimu- 

'  Read  before  the  Practitioners'  Society  of  New  York,  November  i, 
1895. 


November  i6,   1895] 


MEDICAL    RECORD. 


701 


Medical    Record: 

A  Weekly  Journal  of  Medicine  atid  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth   Street. 


New  York,  November  16,  1895. 


THE  TREATMENT  OF  OBSTINATE  COUGHS. 

In  a  recent  number  of  the  American  Journal  of  the 
Medical  Sciences  Dr.  Beverley  Robinson,  in  his  usual 
convincing  and  practical  way,  discusses  the  subject  of 
the  cause  and  treatment  of  certain  kinds  of  cough.  Dr. 
Robinson  states  that  while  the  great  majority  of  coughs 
are  symptomatic  of  conditions  that  are  easily  recognized 
and  easily  relieved,  yet  there  remains  a  certain  remnant 
which  are  baffling,  obscure,  and  obstinate.  It  is  to 
these  various  obscurer  types  of  cough  that  he  directs 
attention.  Among  the  cases  in  which  the  general 
practitioner  is  often  at  fault  he  places  the  cough  which 
is  dependent  upon  an  engorged  lingual  tonsil.  Here 
there  is  no  chest  affection,  no  apparent  throat  trouble 
sufficient  to  cause  the  distressing  symptom.  Anodynes 
fail  to  afford  relief,  and  sprays  and  vapors  are  equally 
inefficient.  Along  with  the  cough  there  may  be  a 
continuous  desire  to  swallow,  and  the  effort  of  swallow- 
ing maybe  somewhat  disagreeable.  There  may  also  be 
a  constant  feeling  of  constriction,  which  increases  when 
the  patient  lies  down  at  night.  Such  patients  are  some- 
times looked  upon  as  phthisical,  and  sometimes  as 
hysterical.  A  laryngoscopic  examination  shows  that 
the  fossa  between  the  epiglottis  and  the  base  of  the 
tongue  is  more  'ess  filled  up  and  distended  by  a  mass 
of  lymn'-   '  "oraetimes  large  veins  pass  over 

thp  -egacies  to  Hospitals.— The  late  o.-^ally  bleeding 
left  bequests  of  $5,000  each  to  the  Manhai»  menstrual 
Ear  Hospital,  and  to  the  Sanitarium  founded  by'^. 
E.  L.  Tradeau  at  Saranac  Lake,  N.  Y. 

Trouble  with  a  Hospital  Staff.— The  members  of  the 
house-staff  of  the  Lebanon  Hospital,  in  the  annexed 
district,  have  sent  in  their  resignations.  The  resigna- 
tion of  house-staffs  is  generally  due  to  some  friction 
with  the  superintendent  or  head-nurse.  In  this  case, 
we  believe,  it  is  the  superintendent. 

The  Author  of  "Yankee  Doodle."— It  is  not  generally 
known  probably  that  the  author  of  that  stirring  ballad 
"  Yankee  Doodle,"  was  a  young  surgeon  of  Albany 
named  Dr.  Richard  Shuckburg.  "Yankee  Doodle' 
has  probably  had  more  influence  upon  the  course  o 
public  affairs  than  many  more  ambitious  pieces  o 
literature. 

Central  Park  Ambulance.— The  ambulance  servic 
in  Central  Park  has  been  abolished  by  the  Park  Com 
missioners  for  economical  reasons.     The   service  wi 


this  condition.  Such  children,  however,  in  addition, 
need  to  receive  general  treatment.  They  should  re- 
ceive a  light  supper,  and  the  bowels  should  be  kept  in 
good  condition. 

In  connection  with  this  subject  the  writer  speaks  of 
coughs  produced  by  reflex  irritation  from  sensitive 
areas  in  the  nose  and  pharynx.  All  local  applications, 
at  times,  he  says,  are  futile  in  such  cases,  and  of  the 
internal  remedies  which  do  good  he  prefers  codeia  and 
terpine  hydrate. 

When  the  cough,  as  is  sometimes  the  case,  comes 
from  aural  irritation,  the  removal  of  wax  and  cleansing 
of  the  ear  is  often  sufficient  to  relieve  it.  Repeated 
applications  of  alcohol,  or  a  mild  solution  of  bichloride, 
are  recommended  over  the  sensitive  canal. 

Dr.  Robinson  states  that  the  mucous  membrane  of 
the  vocal  cords  may  be,  objectively,  in  a  morbid  condi- 
tion, and  yet  have  its  apparently  physiological  func- 
tions ;  but,  on  the  other  hand,  there  is  sometimes,  with 
only  the  same  amount  of  objective  disorder,  a  great 
deal  of  coughing.  Some  of  these  cases  are  benefited 
by  changing  from  one  place  to  another,  and  especially 
to  the  air  of  pine  forests.  Trout  fishing,  or  a  visit  to 
some  sulphur  spring,  also  are  of  help.  Such  patients 
are  usually  litheemic  and  need  to  be  given  salicylates 
and  antirheumatic  drugs.  Indeed,  Dr.  Robinson  lays 
very  considerable  stress  throughout  his  paper  upon  the 
importance  of  studying  the  general  condition  of  the  pa- 
tient, a  thing  which  we  have  heard  that  many  laryngo- 
logists  ignore.  He  especially  finds  that  a  lithaemic  or 
gouty  condition  underlies  a  good  many  larjmgeal 
affections. 

The  suggestions  which  he  makes  concerning  these 
frequently  annoying  forms  of  cough  are  very  practical 
and  timely. 


--„?.ALGIA    PARESTHETICA. 

Dr.  Wladimir  K.  Roth,  a  professor  in  the  University 
of  Moscow,  sends  us  a  short  monograph,  entitled  "  Me- 
ralgia  Paraesthetica."  The  term  meralgia  means  pain 
in  the  thigh,  and  the  title  of  the  professor's  paper  might 
be  translated  into  English  under  the  name  of  "  paraes- 
thetic  neuralgia  of  the  thigh."  The  author  has  ob- 
served a  large  number  of  patients  who  suffered  from 
symptoms  of  a  quite  definite  and  fixed  character,  to 
which  the  above  name  he  thinks  can  be  given.  The 
symptoms  consist  of  a  constant  burning  pain  on  the 
outer  side  of  the  thigh,  following  mainly  the  distribu- 
tion of  the  external  cutaneous  femoral  nerve.  The 
pain  sensation  is  not  always  marked,  and  indeed,  in 
some  patients  the  sensory  trouble  consists  only  in  a 
feeling  of  numbness  and  discomfort,  or  slight  burning 
or  prickling,  or  perhaps  a  feeling  of  cold.  Severe  pains 
occur  only  on  standing  or  walking,  but  they  then  some- 
times increase  so  much  that  the  patient  is  obliged  to 
keep  perfectly  quiet.  Rest  of  the  body,  with  slight 
flexion  of  the  leg,  relieves  the  distress  very  much.  Ob- 
jectively, one  can  sometimes  recognize  a  diminution  of 
sensation,  or  slight  anaesthesia  to  touch,  and  pain.  The 
limits  of  the  sensory  disturbance  generally  fall  in  closely 
with  the  distribution  of  the  external  or  lateral  cuta- 
neous nerve  of  the  hip,  which  comes  from  the  second 
lumbar  nerve.    Rarely,  the  trouble  extends  upward  and 


702 


MEDICAL    RECORD. 


[November  i6,  1895 


downward  somewhat.  Usually  only  one  side  is  affected, 
but  this  is  not  an  invariable  rule.  There  are  not  often 
any  disturbances  of  an  atrophic  or  vaso-motor  char- 
acter. The  disease  develops  slowly,  and  its  course  is 
usually  very  chronic,  though  sometimes  a  rapid  cure  is 
effected.  As  to  the  cause  of  the  trouble,  the  male  sex 
is  more  frequently  affected  than  the  female,  out  of 
fourteen  cases  there  having  been  only  two  women- 
The  patients  vary  in  age  from  thirty  to  fifty.  Persons 
who  lead  a  sedentary  life  are  more  disposed  to  the 
trouble,  and  Professor  Roth  has  never  met  with  a  case 
in  the  working  classes.  In  about  half  of  the  patients 
excessive  use  of  alcohol  was  admitted.  The  previous 
existence  of  syphilis  and  acute  infectious  diseases,  such 
as  influenza  and  typhoid,  were  observed  in  some  of  the 
cases.  The  exciting  cause  was  rarely  found  ;  in  one 
instance  only  the  trouble  began  directly  after  exposure 
to  cold  ;  in  two  others  injury  was  the  cause.  Professor 
Roth  thinks  that  the  anatomical  change  is  a  slight  de- 
gree of  perineuritis  of  the  lateral  cutaneous  nerve,  and 
he  made  a  number  of  examinations  upon  the  cadaver 
in  order  to  determine  whether  there  were  any  mechan- 
ical conditions  which  would  explain  the  fact  that  this 
particular  nerve  was  affected,  rather  than  other  branches 
of  the  lumbar  or  sacral  plexus.  He  found  that  there 
were  four  places  in  the  course  of  the  nerve  which  were 
more  or  less  under  the  influence  of  disturbing  mechan- 
ical causes  :  First,  at  the  exit  under  the  psoas  muscle  ; 
second,  at  the  point  of  bending  directly  under  the  an- 
tero-superior  spinous  process  of  the  ilium  ;  third,  at 
the  fibrous  canal  in  the  fascia  lata  femoris,  which  sur- 
rounds the  nerve  ;  and  fourth,  at  the  point  of  exit  from 
the  canal.  The  treatment  of  the  trouble  does  not  re- 
ceive very  much  attention  from  our  author.  He  pre- 
scribes blisters,  local  massage,  regulation  of  the  diet, 
and  attention  to  the  bowels.  In  two  cases  rapid  heal- 
ing followed  the  use  of  galvanization  of  the  nerve. 
We  suspect  that  if  Professor  Roth  had  looked  up  the 
bibjiography  of  the  neuralgias  of  the  lumbar  nerves,  he 
would  have  found  that  his  peculiar  stereotyped  set  of 
symptoms  had  been  recognized  and  more  or  less  de 


happens  that  a  medical  journal  is  started  by  some  doc- 
tor who  is  desirous  of  exploiting  his  own  abilities  and 
skill,  and  at  the  same  time  add  to  his  library  such 
books  as  he  may  be  able  to  induce  publishers  to  send 
to  it  for  "review."  We  know  of  journals  published  in 
this  country,  by  individuals  and  by  associations  of 
physicians,  whose  almost  sole  raison  iTitre  is  the  ex- 
changes and  editorial  copies  of  books  which  they  ob- 
tain, without  which  they  would  cease  to  exist,  and  to 
obtain  which  they  must  always  speak  of  them  in  terms 
of  commendation.  The  publishers,  not  the  subscrib- 
ers, must  be  considered  first.  Medical  journals  of  their 
class  are  a  delusion  and  a  snare  to  the  profession,  and 
an  injury  to  all  rightly  conceived  and  conducted  peri- 
odicals. 

As  we  have  often  stated,  we  believe  in  local  medical 
journals  and  their  generous  support  by  their  legitimate 
constituency ;  and  we  cannot  but  regret  that  they 
should  have  to  compete  with  journals  such  as  we  have 
mentioned.  Of  course,  there  is  no  way  to  prevent  the 
publication  of  these  illegitimate  journals,  and  the  only 
recourse  in  the  hand  of  the  profession  is,  as  far  as 
possible,  to  patronize  only  those  of  whose  origin  and 
management  they  have  some  personal  knowledge.  In 
other  words,  avoid  subscribing  to  medical  journals 
which  have  not  good  and  well-known  pedigrees  on 
the  sides  of  both  publisher  and  editor. 


MONEY  AND  UNCLEAN  HANDS. 

Money  is  proverbially  filthy,  but  whether  constant 
handling  of  small  coin  is  accountable  for  the  disgust- 
ingly grimy  condition  of  the  hands  of  street-car  con- 
ductors is  questionable.  It  is  certain,  however,  that,  as 
a  class,  their  hands  are  conspicuously  unclean.  Many 
passengers  may  be  observed,  who,  in  paying  their  fare, 
avoid  touching  them  as  they  would  the  plague. 

It  would  probably  be  somewhat  ahead  of  the  times  for 
boards  of  health  to  impose  personal  cleanliness  upon 
men  who  come  in  such  close  contact  with  the  public, 
scribed  before  ;  nevertheless,  the  subject  is  one  which     but  the  superintendents  of  all  rail'-jj^g  Imes  might  be 
he  has  made  interesting  by  his  own  special  and  careful     supposed  to  take  a  little  oride  j-series  of  hypoV cleanly 

condition  of  thfvs  given  by  the  physician.  Unplej-ap, 
and  an  insi-ices,  in  the  way  of  nausea  or  active  sick- 
j_,,,--.^  .lO  safeguard  to  the  patient,  though  these  may 
deceive  him.  Often  I  have  heard  patients  say,  "  There 
is  no  fear  that  I  shall  take  morphine,  for  its  effects  are 
While  the  Medical  Record  hails  with  satisfaction  so  unpleasant."  TheiY  very  self-confidence  betrays 
the  advent  of  any  new  medical  journal  which  appears^them.  They  soon  discover  that  the  repetition  of  the 
to  have  a  legitimate  sphere,  and  always  extends  tojt  dose  affords  relief  to  the  unpleasant  feeling,  and  that 

°  '^   ..       .      .  ■'    .  .in  one  respect  the  bane  is  its  own  antidote. 

such  encouragement  as  lies  in  its  way,  it  seems  right  Qpi^,^^  ^^j^g^  by  the  mouth  habitually  hardly  seems 
that  a  word  of  condemnation  should  be  uttered  re-  to  shorten  life,  except  through  the  accident  of  an  over- 
specting  the  too  numerous  periodicals  which  are  dose,  sleepily  taken.  But  the  hypodermic  needle 
launched  upon  the  profession  without  any  reasonable  surely  undermines  the  health,  as  care  in  asepsis  is  al- 
.     .-c     ,•  XT  ^       <■  -J    kvavs  after  a  time  neglected.     But  I  do  not  think  we 

necessity   or   iiistincation        Not    a    fpw    are    rnnrpivpH    •"»;■'"  ■,      .•    ,      ,     ,  •         i  •         •..     i  ^^ 

ompass  the  evil  of  the  habit  when  we  view  it  alone  or 


researches. 


BOGUS   MEDICAL   JOURNALISM. 


necessity  or  justification.  Not  a  few  are  conceived 
solely  by  advertising  agents — men  who  have  neither 
interest  nor  sympathy  with  the  profession  save  as  they 
can  make  it  a  means  of  livelihood  for  themselves — and 
published  at  more  or  less  nominal  prices  in  anticipation 
of  a  circulation  which  will  enable  them  to  obtain  the 
advertisements  upon  which  they  depend  for  their  profits. 
It  is  unfortunate  that  there  are  always  medical  gentle- 
men to  be  found  who,  for  a  small  sum,  are  willing  to 
"  run "   these    journals.      Again,   it   not   infrequently 


-.hiefiy  in  its  physical  effects. 

To  me  the  greatest  evil  of  the  morphine  habit  is  the 
)erversion  of  the  moral  sense.  It  obliterates  in  the 
■ictim's  mind  the  distinction  between  truth  and  false- 
lood,  right  and  wrong.  And  here  the  evil  may  not  be 
imited  to  the  patient  himself,  but  this  may  entail  hard- 
hip  and  suffering  on  all  those  about  him. 

The  first  effect  of  opium,  in  all  its  forms,  is  stimu- 

'  Re.-id  before  the  Practitioners'  Society  of  N>»  York,  November  i, 
'95- 


November  i6,  1895] 


MEDICAL    RECORD. 


703 


It  is  This  Way. — The  members  of  the  old  staff  of  the 
city  hospitals  were  not  put  out,  but  only  a  few  were 
put  back  in  the  vacant  places. 

The  National  Guard's  Medical  Department. — The 
special  committee  of  surgeons  appointed  by  Surgeon- 
General  Terry,  of  the  National  Guard,  to  discuss  the 
needs  of  its  medical  department  and  make  suggestions 
accordingly,  met  here  yesterday.  The  committee  de- 
cided not  to  concur  in  a  recommendation  that  the 
medical  corps  be  made  a  separate  organization.  It  was 
decided  to  increase  the  number  in  the  hospital  corps 
to  twelve  for  each  regiment,  six  for  battalions,  and  two 
for  separate  companies.  Of  the  twelve  in  the  regi- 
mental corps  three  are  to  rank  as  corporals,  and  two 
of  the  battalion  corps  likewise.  It  was  decided  to  rec- 
ommend that  each  member  of  the  corps  be  provided 
with  an  instrument  case  and  revolver,  and  each  corps 
with  a  surgical  and  medical  outfit.  It  was  voted  that 
to  procure  competent  hospital  stewards  they  be  paid 
§50  a  year  in  addition  to  pay  for  duty. 

A  Correction. — Dr.  T.  G.  Davis,  of  Bridgeton,  N.  J., 
writes  :  "  You  made  a  misstatement  when  you  said  '  Ger- 
many has  never  ventured  to  erect  a  statue  to  Hahne- 
mann.' There  is  one  at  Leipsic,  in  the  public  park, 
or  was  in  1891." 

The  Idaho  Medical  Society  held  its  third  annual 
meeting  in  Boise  on  September  9th,  loth,  and  nth. 
There  was  a  good  attendance,  and  the  meeting  was  a 
very  successful  one.  The  members  of  the  society  are 
making  a  gallant  struggle  for  the  passage  of  a  law  reg- 
ulating the  practice  of  medicine  in  that  State.  The 
law-makers  have  hitherto  been  deaf  to  their  arguments, 
but  the  legislative  committee  of  the  society  is  persistent 
in  its  efforts,  and  all  friends  of  higher  medical  educa- 
tion hope  to  see  them  successful  with  the  next  Legisla- 
ture of  1896-97.  The  president  of  the  society  is  Dr. 
W.  D.  Springer  ;  the  secretary.  Dr.  C.  L.  Sweet,  both 
of  Boise. 

Legacies  to  Hospitals.— The  late  Samuel  Inslee  has 
left  bequests  of  $5,000  each  to  the  Manhattan  Eye  and 
Ear  Hospital,  and  to  the  Sanitarium  founded  by  Or. 
E.  L.  Tradeau  at  Saranac  Lake,  N.  Y. 

Trouble  with  a  Hospital  Staff. — The  members  of  the 
house-staff  of  the  Lebanon  Hospital,  in  the  annexed 
district,  have  sent  in  their  resignations.  The  resigna- 
tion of  house-staffs  is  generally  due  to  some  friction 
with  the  superintendent  or  head-nurse.  In  this  case, 
we  believe,  it  is  the  superintendent. 

The  Author  of  "Yankee  Doodle." — It  is  not  generally 
known  probably  that  the  author  of  that  stirring  ballad, 
"  Yankee  Doodle,"  was  a  young  surgeon  of  Albany, 
named  Dr.  Richard  Shuckburg.  "Yankee  Doodle" 
has  probably  had  more  influence  upon  the  course  of 
public  affairs  than  many  more  ambitious  pieces  of 
literature. 

Central  Park  Ambulance. — The  ambulance  service 
in  Central  Park  has  been  abolished  by  the  Park  Com- 
missioners for  economical  reasons.     The   service  will 


be  supplied  hereafter  by  the  ambulances  of  the  general 
hospitals. 

Golfer's  Elbow. — Every  sport  has  its  special  disease, 
and  it  seems  that  the  pastime  of  golfing,  which  is  now 
being  very  enthusiastically  adopted  by  the  Americans, 
has  a  little  pathological  attachment.  This  is  best  de- 
scribed by  printing  the  letter  from  a  sufferer,  written 
to  TAe  Field.  The  writer  says  :  "  I  am  a  sufferer  from 
what  is,  I  suppose,  '  golfer's  elbow."  The  point  of  the 
funny  bone  is  very  sore,  and  on  bending  the  elbow  to 
and  fro  a  tendon  seems  to  slip  in  and  out  of  its  place 
with  a  sort  of  jerk.  I  have  not  been  able  to  play  for 
the  last  two  months.  If  anyone  could  tell  me  of  a 
remedy  likely  to  be  efl&cacious  I  should  be  much 
obliged." 

Drunkards  in  America. — The  total  number  of  drunk- 
ards in  this  country  is  modestly  estimated  by  the  Quar- 
terly Journal  of  Inebriety  to  be  1,600,000  persons.  As 
there  are  about  twenty-five  millions  of  adults  in  this 
country,  this  means  that  one  person  out  of  every  fifteen 
drinks  intoxicating  liquors  to  excess,  that  is  to  say, 
drinks  to  drunkenness,  and  may  be,  therefore,  classed 
as  more  or  less  a  drunkard.  The  journal  thinks  that 
this  estimate  is  a  very  modest  one,  and  rather  under 
the  mark  than  above  it.  Still  people  want  saloons  open 
seven  days  in  the  week. 

New  Scale  of  Fees  for  Medical  Examiners. — One  of 
the  leading  life  insurance  companies  of  this  city  and 
country  has  proposed  the  following  schedule:  The  fees 
for  examination  for  insurance  of  $3,000  or  less  is  to  be 
$3.  Between  $3,000  and  $25,000  the  fee  is  to  be  $5, 
and  for  sums  above  $25,000,  $7.50.  This  is  going  to 
cut  down  the  fees  for  examinations  made  by  physicians, 
in  country  practice  especially,  about  forty  per  cent., 
and  the  country  doctor  is  protesting  vigorously  against 
the  reduction.  Such  things,  however,  are  matters  of 
pure  business,  and  if  insurance  companies  can  get 
good  service  for  $3,  there  is  no  reason  why  they  should 
pay  $5.     "  Business  is  business." 

An  Honest  Editor. — The  editor  of  the  National 
Medical  Rci'iew  remarks,  "  We  can't  discuss  the  ques- 
tion of  free  dispensaries,  for  we  do  not  understand  it." 
This  state  of  mind  is,  perhaps,  not  unnatural,  but  the 
candor  which  accompanies  it  is  certainly  rare. 

Another  Post-graduarte  School. — A  post-graduate 
school  has  recently  been  established  in  Washington, 
D.  C.  The  prospectus  states  that  there  is  no  post- 
graduate school  south  of  New  York  and  Philadelphia 
and  that  a  school  such  as  they  propose  is  very  much 
needed.  The  faculty,  as  we  find  it  given  in  the  Na- 
tional Medical  Rn'iew,  contains  some  familiar  names, 
including  that  of  Dr.  Samuel  C.  Burey,  Dr.  W.  W. 
Johnston,  and  Dr.  J.  Ford  Thompson. 

A  New  MedicalJoumal. — The  Los  Angeles  Polyclinic 
is  a  new  medical  monthly,  published  at  Los  Angeles, 
Cal,  by  Dr.  J.  F.  T.  Jenkins. 

"  Climate  and  Health  "  is  the  title  of  a  publication 
issued  by  the  United  States  Department  of  Agriculture. 
It  is  edited  by  Professor  W.  L.  Moore,  Chief  of  the 
Weather  Bureau,  and  Dr.  W.  F.  R.  Phillips.  It  con- 
tains  statistics,  tables,  and   charts   relating  to  atmos- 


704 


MEDICAL    RECORD. 


[November  i6,  1895 


pheric  pressure  and  temperature,  humidity,  rainfall, 
wind,  sunshine,  morbidity,  mortality,  etc.,  in  the  vari- 
ous States  of  the  Union. 

The  Woman  Who  Did.— A  young  woman  of  Lon- 
don recently  announced  to  her  family  and  friends  that 
she  was  going  to  live  with  a  certain  man,  named  Sul- 
livan, without  the  preliminary  formality  of  matrimony. 
Her  parents  protested  and  asserted  that  she  was  in- 
sane. Dr.  Blandford,  well-known  as  an  alienist  and 
man  of  high  character,  as  well  as  learning,  examined 
her  and  committed  her  to  a  private  asylum.  The 
newspapers  took  up  the  matter,  the  lunacy  commis- 
sioners were  forced  to  examine  into  the  case,  and  the 
girl  was  released.  We  do  not  know  the  facts  upon 
which  Dr.  Blandford  based  his  opinion  of  insanity,  but 
it  seems  extremely  unlikely  that  a  man  of  his  position 
would  make  a  mistake  on  such  a  matter.  This  girl, 
who  is  currently  known  as  "  the  woman  who  did,"  has 
succeeded  in  making  quite  a  noise  in  the  world  by  her 
performance. 

The  Colorado  State  Board  of  Medical  Examiners  has 
passed  a  resolution,  declaring  that  hereafter  it  will 
not  recognize  the  diploma  of  any  medical  college  that 
does  not  require  an  entrance  examination  and  a  four 
years'  graded  course  of  not  less  than  seven  months  in 
each  session.  This  seems  to  hit  some  of  the  numerous 
Denver  medical  colleges  rather  hard,  and  the  Denver 
Medical  Times  makes  a  protest  against  the  position 
thus  taken.  All  the  same,  we  think  that  the  profession 
of  Colorado  will  be  the  better  off  if  the  Board  sticks  by 
its  resolution. 

The  Success  of  the  London  Hospital  Sunday  Fund.— 
For  the  first  time  in  ten  years  the  response  to  the  ap- 
peals in  behalf  of  the  hospitals  in  London  has  been  suc- 
cessful beyond  expectations,  the  sum  realized  for  the 
hospitals  through  the  Sunday  fund  being  ^70,000. 
In  previous  years  it  has  ranged  at  about  ;^4o,ooo. 

Trained  Nurses  to  Travel  with  Insane  Patients.— 
In  South  Dakota,  one  of  the  asylums,  that  at  Yankton, 
has  adopted  the  plan  of  sending  trained  and  uni- 
formed nurses  to  attend  patients  who  were  about  to  be 
taken  to  the  asylum.  The  plan,  it  is  said,  is  working 
well.  The  New  York  Lunacy  Commission  has  ordered 
trained  attendants  to  be  sent  after  patients,  due  notice 
being  given.  There  is  an  item  of  $25,000,  paying  for 
the  transportation  of  patients. 

A  Siphon  for  the  Communion  Cup. — The  attempt  to 
make  the  ceremony  of  the  communion  aseptic  has  led 
to  a  great  many  ingenious  and  some  rather  grotesque 
devices.  A  communion  siphon  is  one  of  the  latest 
inventions.  This  is  a  small  silver  tube,  about  five 
inches  in  length,  and  not  larger  than  a  straw.  Each  in- 
dividual is  supposed  to  have  a  siphon,  and  it  practically 
turns  the  taking  of  the  wine  into  the  undignified  pro- 
ceeding of  sucking  through  a  straw. 

Chicago  Medical  Inspectors. — The  Civil  Service 
Commission  of  the  city  of  Chicago  has  so  arranged 
that  the  examinations  of  the  medical  inspectors  con- 
form to  those  required  for  entrance  into  the  Govern- 
ment medical  service.  The  salary  of  the  Chicago  in- 
spectors is  $i,20o  a  year. 


American  Physicians  to  whom  Monuments  Might 
be  Baised. — In  an  address  on  "  .\merican  Medicine," 
delivered  at  the  annual  dinner  of  the  Chicago  Gyneco- 
logical Society,  Dr.  John  H.  Hollister  referred  to  some 
of  the  distinguished  medical  men  who  were  identified 
with  the  early  history  of  our  country.  Dr.  Joseph  War- 
ren, for  example,  was  President  of  the  Committee  of 
Public  Safety,  in  Boston,  and  was  a  major-general  in 
the  army.  His  brother,  John,  was  the  founder  of  the 
medical  department  of  Harvard  College.  In  Philadel- 
phia, aside  from  Dr.  Benjamin  Rush,  Dr.  Hollister 
refers  to  Dr.  Nathaniel  Chapman,  who  founded  the 
first  American  medical  journal,  and  influenced  greatly 
the  medical  progress  of  the  early  part  of  the  century. 
Valentine  Mott,  Willard  Parker,  Alonzo  Clark,  Fordyce 
Barker,  Gurdon  Buck,  Nathan  Smith,  Gross,  Drake,  and 
McDowell,  would  all  deserve  a  monument  if  we  adopted 
the  standard  of  patriotism  which  exists  in  some  of  the 
countries  abroad. 

President  Eliot  on  the  Future  of  the  Harvard  Medi- 
cal College. — In  an  address  delivered  at  the  annual 
meeting  of  the  Harvard  Medical  Alumni  Association, 
of  Boston,  President  Eliot  outlined  the  three  different 
steps  in  the  advancement  of  the  school  which  he  hoped 
to  see,  sooner  or  later,  brought  about.  The  first  of 
these  was  increasing  the  teaching  facilities  of  the  school, 
so  that  everything  known  to  medical  science  could  be 
learned,  and  so  there  should  be  opportunity  for  persons 
to  study  medicine,  not  four  years  alone,  but  twenty 
years,  if  necessary.  The  second  step  was  the  raising 
of  the  standard  of  admission  to  the  school,  so  that  no 
one  should  be  admitted  who  did  not  possess  a  degree 
in  Arts  or  Science.  The  third  step  was  the  establish- 
ment of  an  hospital  in  connection  with  the  school,  so 
that  the  medical  department  could  be  independent  of 
the  great  public  hospitals  of  the  city.  Only  in  this  way, 
he  thought,  would  it  be  possible  to  secure  for  the  medi- 
cal school  the  best  teaching  talent  in  the  land.  Presi- 
dent Eliot's  ambition  for  Harvard  Medical  College  is 
evidently  great,  and  his  ideals  are  the  highest. 

The  St.  Louis  College  of  Optical  Science  is  the  name 
of  a  college  in  St.  Louis,  where  opticians  are  educated 
to  fit  glasses  to  lame  eyes. 

A  Plea  for  Venesection. — One  of  the  most  eminent 
physicians  of  Austria,  Professor  Jaksch,  recently  read 
a  paper  before  the  Medical  Society  at  Prague,  advo- 
cating the  use  of  venesection.  He  advises  it  in  pneu- 
monia, uraemia,  pleurisy,  and  certain  forms  of  heart 
disease.  Professor  Jaksch,  however,  does  not  give  us 
any  especially  new  indications. 

Obituary  Notes.— Dr.  John  Lloyd  Zabriskie,  of 
Brooklyn,  died  suddenly  on  November  nth,  aged 
sixty-four.  Dr.  Zabriskie  graduated  from  the  Univer- 
sity Medical  College  in  1S58  and  had  practised  medi- 
cine in  Flatbush  ever  since.  He  was  a  trustee  of  the 
Long  Island  College  Hospital,  and  was  one  of  the  staff 
of  consulting  physicians  of  that  institution.  He  was 
also  one  of  the  consulting  staff  of  the  Flatbush  Hos- 
pital.— Dr.  Ei.m.an  H.  Borst,  a  leading  physician  in 
Newburgh,  N.  Y.,  died  on  November  7th,  aged  thirty- 
three.  He  was  a  graduate  of  the  College  of  Physicians 
and  Surgeons. 


November  i6,  1895] 


MEDICAL   RECORD. 


705 


A  Text-book  of  Practical  Medicine.  Designed  for  the 
Use  of  Students  and  Practitioners  of  Medicine.  By  Al- 
fred L.  LOOMIS,  M.D.,  LL.D.,  Professor  of  Pathology 
and  Practical  Medicine  in  the  Medical  Department  of  the 
University  of  the  City  of  New  York  ;  Visiting  Physician 
to  Bellevue  Hospital,  etc.  Revised  and  enlarged,  with 
two  hundred  and  seven  illustrations  and  one  chromo- 
lithographic  plate.  Eleventh  Edition.  New  York  :  \Vill- 
iam  Wood  &  Company.     1895. 

It  is  stated  in  the  preface  of  this  edition  of  Dr.  Loomis's 
well-known  work,  that  the  lamented  author  was  actively  en- 
gaged upon  the  revision  of  the  volume  at  the  time  of  his 
death.  The  most  important  changes  and  additions  are  in 
the  sections  on  diseases  of  the  heart  and  lungs,  in  the  study 
of  which  Dr.  Loomis  had  always  shown  a  special  interest. 
The  sections  on  affection  of  the  nose  and  throat  were  revised 
and  in  part  rewritten  by  Dr.  Coakley,  and  that  on  nervous 
diseases  by  Dr.  E.  D.  Fisher.  Concerning  the  work  itself 
we  need  not  speak,  for  it  is  so  well  and  favorably  known  as 
an  authoritative  guide  to  medical  practice  that  any  praise  is 
superfluous.  The  fact  that  it  has  gone  through  ten  editions 
is  evidence  enough  of  its  excellence. 

The  Practice  of  Massage  :  Its  Physiological  Effects  and 
Therapeutic  Uses.  By  A.  SvMONS  Eccles,  M.B.  Aberd. 
New  York  :  Macmillan  &  Co.     1895. 

As  this  book  is  dedicated  to  Lauder  Brunton,  it  must  have 
his  endorsement ;  and  this  in  itself  is  somewhat  a  guarantee 
of  its  value. 

Massage  has  come  to  be  something  of  a  fad,  with  the  re- 
sult that  many  incompetent  persons  have  taken  it  up,  and 
with  very  little  instruction,  or  perhaps  none  at  all,  advertise 
that  they  are  ready  to  treat  patients. 

Massage  improperly  applied  does  no  good  and  may  do 
considerable  harm,  and  should  therefore  be  employed  only 
by  one  who  has  received  thorough  instruction  ;  and  prefer- 
ably by  one  who  understands  something  of  anatomy  and 
physiology.  Even  under  these  circumstances  the  work 
should  be  done  under  the  direction  of  the  physician. 

The  author  of  this  book  is  an  educated  physician,  and  has 
evidently  given  considerable  attention  to  this  subject,  upon 
which  he  has  been  writing  since  18S7.  Many  of  his  articles 
in  journals  are  referred  to,  as  well  as  the  works  of  other 
authors. 

In  addition  to  the  various  disorders  which  have  long  been 
recognized  as  receiving  benefit  from  massage,  viz.,  certain 
forms  of  skin  diseases,  injuries  of  muscles,  sprains  of  joints, 
atrophy  after  disuse,  etc.,  disorders  of  digestion,  and  some 
forms  of  paralysis,  the  author  claims  to  have  seen  much 
benefit  from  massage  in  heart  disease  and  asthma. 

The  various  manipulations  are  clearly  described,  but  it  is 
doubtful  if  anyone,  by  reading  such  directions,  could  become 
a  skilful  masseur.  Work  which  requires  manual  dexterity 
can  be  satisfactorily  performed  only  by  one  who  has  had 
practical  instruction  and  experience. 

To  such  a  one  the  book  will  appeal  more  than  to  the  pro- 
fession in  general. 

Lehrbuch  der  Vergleichenden  Pathologie  und 
Therapie  des  Menschen  und  der  Hausthiere.  Von 
George  Schneidemijhl.  Erste  Lieferung  :  Die  Infck- 
tionskrankhciten  des  Menschen  und  der  Hausthiere.  Pp. 
206.     Leipzig:  verlag  von  Wilhelm  Engelmann.     1895. 

This  work  is  somewhat  novel  in  its  scope,  and  though  writ- 
tenespecially  for  veterinarians,  ought  to  be  most  useful  and 
instructive  to  the  human  practitioner.  We  find  here  re- 
corded, first,  a  succinct  account  of  infectious  diseases  of 
man,  and  then  a  description  of  the  same  diseases  in  the  lower 
animals.  The  description  of  each  disease,  as  it  occurs  in 
man,  is  somewhat  brief,  while  the  part  in  which  diseases  of 
the  lower  animals  is  described  is  more  extensive.  A  pe- 
rusal of  comparative  pathology,  as  presented  in  this  way, 
throws  a  new  and  broader  light  upon  our  conceptions  of  dis- 
ease. Looking  over  this  volume  at  random,  we  find,  for  ex- 
ample, a  description  of  diphtheria  in  man,  followed  by  thai 
of  diphtheria  in  fowls,  in  calves,  and  in  horses.  A  subse- 
quent chapter  describes  influenza  or  grip,  as  it  occurs  in  man 
and  horses.  L'nder  the  same  head  comes  a  description  of 
the  contagious  pleuro-pneumonia  of  horses  (brustseiu/ie).  A 
somewhat  allied  disease  is  that  known  as  skalma,  a  mias- 
matic contagious  disease  of  horses.   The  author  has  shown  a 


great  deal  of  thoroughness  and  erudition  in  his  description 
of  the  infectious  diseases  of  man  and  the  domestic  animals, 
and  we  think  that  even  well-informed  physicians  will  be  some- 
what surprised  at  the  number  of  maladies  which  are  com- 
common  to  us  and  our  animal  associates.  The  author  is  a  pri- 
vat  docent  in  veterinary  medicine  at  the  University  of  Kiel. 

.A  Text-book  of  Nervous  Diseases  bv  American 
Authors.  Edited  by  Franxis  X.  Dercum,  A.M., 
M.D.,  Ph.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jefferson  .Medical  College.  8vo,  pp.  1056.  Philadelphia  : 
Lea  Brothers  &  Co.     1895. 

This  goodly  sized  volume  embodies  the  work  of  twenty- 
two  leading  authorities  in.  neurology  in  the  different  and 
special  lines  of  their  individual  fitness  for  the  same.  The 
general  arrangement  is  as  systematic  and  practical  as  it  well 
can  be  under  the  existing  difficulties,  pathological  and  clin- 
ical, of  definitely  separating  allied  affections.  The  division 
of  subjects  is  the  natural  one,  and  is  mainly  based  on  the 
special  or  leading  pat'.-.ological  lesions  rather  than  the  clin- 
ical features.  Notwithstanding  this  is  the  case,  the  clinical 
features  of  each  of  the  varied  affections  are  made  to  take  a 
leading  part  to  impress  the  student  and  reader  with  the  fact 
that,  only  with  the  mastery  of  them  can  any  clear  perception 
be  gained  of  their  purely  pathological  significance.  This  is 
placing  within  easy  and  intelligible  reach  of  the  student  the 
most  rational  method  of  mastering  by  easy  stages  a  knowl- 
edge of  what  are  generally  considered  very  abstruse  points. 
Thus  the  general  affections  are  first  considered  in  their  purely 
clinical  manifestations,  and  incidentally  are  pathologically 
explained.  When  this  ground  plan  is  properly  understood 
and  the  general  laws  of  nervous  troubles  are  duly  manifest, 
the  reader  is  prepared  to  appreciate  the  bearing  and  im- 
portance of  the  special  and  rarer  forms  of  disease.  The 
result  of  such  an  arrangement  is  shown  in  the  interest  which 
grows  upon  the  reader  as  he  follows  the  order  of  the  pro- 
gressive chapters.  There  is  one  feature  which  cannot  be  too 
strongly  commended  in  any  text -book,  and  that  is  the  aim 
in  every  writer  to  bring  out  the  really  salient  distinctions  of 
special  diseases  by  themselves,  and  not  at  the  beginning 
confusing  the  mind  with  exceptions  and  qualifications.  The 
latter  very  properly  come  in  with  the  more  or  less  compli- 
cated building  of  the  necessarily  wider  and  more  mature 
conception.  It  is  this  mechanical  make-up  of  the  book 
and  the  apportionment  of  individual  work,  showing  skill  in 
editorial  direction,  that  will  assure  for  the  treatise  a  wide 
range  of  adaptability.  The  illustrations,  although  not  very 
numerous,  are  quite  illustrative  of  leading  types  of  deform- 
ities or  other  conditions,  and  serve  to  round  out  the  admira- 
ble descriptions  of  the  trained  and  able  contributors. 

The  Climates  and  Baths  of  Great  Britain.    Being 
the  Report  of  a  Committee   of  the   Royal    Medical   and 
Chirurgical  Society  of  London.     By  W.   M.  Ord,  M.D., 
Chairman,  A.  E.  Garrod,  M.D..  Hon.  Secretary.     VoL 
I. 
The  CLIM.A.TES  of  the  South  of  England  and  the 
Chief  Medicinal  Springs  of  Great  Britain.    Lon- 
don and  New  York  :  Macmillan  &  Co.     1895. 
Eleven  contributors  from  the  eighteen  gentlemen  consti- 
tuting the  committee  have  articles  in  the  present  volume  of 
640  pages. 

The  Chairman,  Dr.  Ord,  contributes  the  "  Introductory 
Remarks  on  the  Climates  of  the  South  Coast  of  England," 
and  also  "  Introductory  Remarks  on  the  Medicinal  Springs 
of  Great  Britain."  "  Bath  "  and  "  Buxton  "  are  written  by 
Drs.  Ord  and  Garrod  conjointly,  while  the  latter  has  written 
upon  many  of  the  other  springs.  Malcolm  Morris  has  writ- 
ten upon  Harrogate,  Moffat,  and  Strathpepper.  It  is  alto- 
gether quite  a  pretentious  work,  and  has  been  prepared  with 
much  care.  There  are  numerous  statistical  tables,  and  a 
large  colored  map  is  inserted  opposite  the  title-page.  The 
press-work  is  attractive.  To  anyone  seeking  the  latest  au- 
thentic reports  upon  health-resorts  in  England  the  work 
commends  itself. 

Disorders  of  the  Male  Sexual  Organs.    By  Eu- 
gene Fuller.   M.D.,  New  York,  Member  of  the  New 
York   County   Medical  Society,   Academy  of  Medicine, 
American  Association  of  Genito-urinary  Surgeons  ;  In- 
structor in  Genito  urinary  and  X'cnereal  Diseases  in  the 
New  York   Post-Graduate   Medical   School,  etc.     Phila- 
delphia :   Lea  Brothers  &  Co.     1895. 
The  author  opposes  the  view  held  by  many,  that  the  majority 
of  functional  disorders  of  the  male  sexual  organs  are  of  the 
neurotic,  neurasthenic,  or  psychic  type.     He  believes  that 


700 


MEDICAL    RECORD. 


[November  16,   1895 


physiological  and  pathological  factors  have  been  ignored  by 
many  writers,  while  in  his  opinion  disorders  independent  of 
nervous  conditions  are  primarily  at  fault.  Differential  diag- 
nosis is  of  the  utmost  importance,  and  the  anatomy  of  the 
parts  is  so  necessary  that  a  chapter  has  been  devoted  to  this 
subject,  to  which  is  added  a  report  on  the  histology  of  the 
seminal  vesicle  and  vas  deferens,  by  Dr.  James  Ewing. 
There  are  seven  chapters,  the  last  being  devoted  to  the  his- 
tories of  thirty-eight  instances  illustrating  the  author's  views 
and  methods. 

The  chapter  on  anatomy  is  illustrated  with  drawings  from 
photographs  of  post- mortem  specimens.  Some  of  these 
show  what  is  intended  in  a  clear  manner,  while  others  have 
to  be  accepted  more  or  less  on  faith.  Much  attention  has 
been  paid  throughout  the  work  to  seminal  vesiculitis  in  its 
various  forms,  and  the  author's  observations  bearing  upon 
the  question,  which  are  already  somewhat  known  through 
his  writings,  especially  in  the  Journal  of  Cutaneous  and 
Genito-urinary  Diseases,  are  amplified  and  elaborated.  A 
more  fitting  title  for  the  work  would  be  "  Some  disorders  of 
the  male  sexual  organs,"  since  most  of  them  are  left  out. 

Le  PhtisiqUE,  et  son  Traitement  Hygienique.  Par  Ic 
Dr.  E.  p.  Leon-Petit,  Medecin  de  I'hopital  d'Ormesson, 
Secretaire-General  de  I'CEuvre  des  Enfants  Tubeiculeux. 
Preface  de  M.  le  Dr.  Herard,  IVIembrs  de  I'Academie  de 
Medecine.  Avec  20  gravures  dans  le  texte.  Paris  :  An- 
cienne  Librairie  Germer,  Bailliere  et  Cie.  Felix  Alcan, 
Editeur.     1895. 

Tuberculosis  is  becoming  more  and  more  a  great  and 
serious  question.  The  great  minds  of  the  century  are  no 
longer  concerning  themselves  about  what  to  do  for  the  indi- 
vidual consumptive  patient,  but  rather  what  plans  can  be 
formulated  and  carried  out  to  make  an  impression  upon  the 
disease  as  a  whole.  How  to  treat  large  bodies  of  patients 
so  as  to  make  them  less  of  a  danger  to  the  community  at 
large  and  to  each  other,  is  a  problem  to  be  solved.  Hy- 
giene, open-air  life,  sanatoria,  diet,  medicinal  measures,  all 
must  be  carefully  studied.  The  author  has  made  a  praise- 
worthy attempt  in  this  direction.  Under  authority  he  has 
examiiied  the  resorts  and  institutions  of  Europe,  and  de- 
scribes the  organization  in  paying  as  well  as  in  public  sana- 
toria. 

The  question  is  treated  almost  wholly  from  the  hygienic 
side,  but  the  work  (300  pages)  contains  valuable  statistics 
and  information  concerning  tuberculosis. 

A  Text-book  of  Physiology.  By  M.  Foster,  A.M., 
M.D.,  LL.D.,  F.R.S.,  Professor  of  Physiology  in  the 
University  of  Cambridge,  etc.  Sixth  American  Edition. 
8vo,  pp.  929.     Philadelphia  :     Lea  Brothers  &  Co.     1895. 

The  sixth  American  edition  of  this  widely  appreciated 
te.xt-book  makes  its  appearance  with  the  announcement  that 
every  page  has  been  subjected  to  careful  scrutiny,  all  use- 
less verbiage  omitted,  obscure  sentences  revised,  histologi- 
cal details  materially  abridged,  and  much  theoretical  discus- 
sion omitted.  No  one  questions  the  authority  of  Professor 
Foster,  and  the  work  in  question  fully  expresses  his  views  on 
all  questions  of  interest  to  the  student. 

A  Manual  of  Electro-therapeutics  for  Students 
AND  General  Practitioners.  By  C.  T.  Hood,  A.M., 
M.D.  S\o,  pp.  8S1.  Chicago  :  Gross,  Uelbridge  Co. 
1895. 

This  book  is  written  m  a  simple,  conversational  style, 
somewhat  in  the  form  of  short  lectures.  The  first  twelve 
chapters  are  devoted  to  a  description  of  the  physics  of  elec- 
tricity, and  a  great  many  familiar  experiments  are  described 
to  show  electrical  phenomena.  Chapters  follow  on  batteries, 
electrodes,  and  electro-physiology.  The  rest  of  the  book, 
embracing  about  one-half  of  the  contents,  is  devoted  to 
electro-therapeutics.  This  portion  seems  to  be  very  much 
like  the  ordinary  discourses  upon  this  subject,  that  is  to  say, 
the  author  asserts  in  a  general  way  that  electricity  relieves 
paralysis,  spasms,  pains,  strictures,  etc.,  and  is  of  help  in 
various  uterine  disorders.  There  is  nothing  at  all  critical 
or  scientifically  valuable  in  this  part  of  the  work  or  in  tlie 
book  as  a  whole.  The  chief  merit  is  in  its  presenting  a.;aiii 
the  subject  of  eleclro-therapeutics  in  a  simple  and  elemen- 
tary way.  The  book  is  about  as  good  as  others  of  its  size 
and  class. 

Health  Authorities  Punish  a  City. — The  city  of  Mon- 
treal was  recently  fined  $500  at  the  instance  of  the 
health  authorities  for  having  useless  sanitary  apparatus 
in  the  city  hall. 


J^ociety  Reports. 


THE    PRACTITIONERS'     SOCIETY    OF    NEW 
YORK. 

Stated  Meeting,  November  i,  iSqj. 

Andrew  H.  Smith,  M.D.,  President,  in  the  Chair. 

Intra-cranial  Neurectomy  for  Chronic  Tic  Douleureux 
(Hartley's  Operation). —  Dr.  Robert  Abbe  showed  one 
patient,  and  related  the  history  of  another,  relieved  of 
chronic  tic  douleureux  by  intra-cranial,  but  extra-dural, 
section  and  tearing  out  of  the  branches  of  the  fifth 
cranial  nerve.  The  patient  presented  was  a  woman, 
sixty-five  years  of  age,  who  had  had  for  eleven  )  ears 
inveterate  tic  douleureu.x  of  the  right  side  of  the  face. 
Twice  physicians  had  operated  on  the  lower  jaw,  once 
on  the  middle  branch,  but  without  giving  any  relief, 
the  patient  being  no  better,  perhaps  even  worse,  imme- 
diately after  the  operation.  When  she  consulted  him, 
two  weeks  ago,  she  was  constantly  holding  the  head  in 
the  hands  and  dodging  the  pains,  which  would  come  in 
paroxysms  every  two  or  three  minutes  and  were  of  the 
severest  type.  Although  she  was  rather  old  to  submit 
to  the  Hartley  operation,  her  life  was  not  worth  much 
without  relief  from  the  pain  ;  the  operation  was  under- 
taken and  proved  in  every  respect  successful.  The 
patient  was  immediately  relieved  and  had  felt  no  pain 
since.  The  steps  of  the  operation  consisted  in  making 
an  incision,  the  form  of  a  horseshoe,  down  to  the  bone 
over  the  temporal  region,  base  downward,  then  without 
dissecting  the  soft  parts,  chiselling  the  bone  along  the 
line  of  incision,  until  it  could  be  pried  up  with  one  or 
two  chisels,  snapping  it  directly  across  below.  On 
turning  down  this  osteoplastic  flap,  the  dura  came  into 
view.  The  edge  of  bone  was  then  gnawed  away, 
the  dura  was  lifted,  two  branches  of  the  fifth  pair,  pass- 
ing through  the  foramen  rotundum  and  the  foramen 
ovale,  were  exposed,  were  seized,  cut  across  at  the  for- 
amina, the  distal  end  tucked  forward,  the  proximal  end, 
just  in  front  of  the  Gasserian  ganglion,  were  twisted, 
wrenching  their  roots  out  of  the  ganglion,  the  piece 
brought  away  being  broom-shaped  and  about  an  irch 
long.  Considerable  venous  hemorrhage  came  from  the 
cavernous  sinus,  which  was  close  by,  but  it  was  checked 
in  a  few  moments  by  packing  with  iodoform  gauze. 
The  whole  channel  was  lightly  packed  with  the  gauze, 
and  the  flap  was  left  loose  until  next  day,  when  the 
packing  was  removed,  and  the  brain,  the  dura  interven- 
ing, again  filled  the  space.  Immediate  union  followed. 
Although  the  patient  had  suffered  no  pain  since  the  op- 
eration, as  usual  in  these  cases  the  anaesthesia  was  not, 
or  did  not  remain,  complete.  In  her  case  the  anies- 
thesia  was  complete  in  the  lower  branch,  and  during 
the  first  week  it  \vas  nearly  complete  in  the  second 
branch,  but  not  complete  in  the  first.  Half  of  the 
tongue  and  lips  were  quite  aniesthetic.  The  pain  be- 
fore the  operation  had  begun  in  the  lower  branch  and 
had  extended  until  all  the  branches  were  more  or  less 
affected,  the  upper  least.  A  dentist  had  drawn  four- 
teen teeth  without  giving  any  relief. 

The  other  case,  related  later  in  the  evening,  was  the 
wife  of  a  physician,  was  fifty-four  years  old,  and  had 
suffered  from  tic  douleureux  for  twenty  years,  the  pain 
being  no  less  severe  than  in  the  other  case.  Two  or 
three  operations  had  been  performed,  one  on  the  infe- 
rior dental  and  one  on  the  middle  branch,  without  giv- 
ing relief.  When  Dr.  .Abbe  saw  her  two  years  ago  he 
performed  Sulzer's  operation,  reaching  the  two  branches 
of  the  nerve  in  the  temporo  sphenoidal  fossa  at  their 
exit  through  the  foramen  rotundum  and  foraaien  ovale 
by  making  section  of  the  zj'gomatic  arch  and  dissecting 
the  temporal  muscle.     The  operation  proved  not  difli- 


November  i6,  1895] 


MEDICAL   RECORD. 


707 


cult,  half  an  incli  of  each  nerve  branch  was  dissected 
out  and  the  wound  closed.  The  patient  was  relieved 
of  pain  for  two  months.  It  then  returned,  and  for  ten 
months  was  as  great  as  it  had  been  before.  He  then, 
last  January,  performed  the  Hartley  operation.  Like 
the  other  case,  this  one  bled  very  little  for  this  opera- 
tion. Relief  was  perfect  and  remained  so  until  the 
patient's  death,  three  months  later,  from  some  cause 
not  connected  with  the  facial  trouble. 

Dr.  Abbe  said  that  in  a  number  of  cases  of  inveter- 
ate neuralgia  of  the  inferior  dental,  he  had  taken  out 
an  inch  or  an  inch  and  a  half  of  this  nerve  and  given 
permanent  relief,  but  some  cases  had  retuKied.  The 
same  was  true  of  the  eight  or  nine  cases  in  which  he 
had  performed  Carnochan's  operation  for  neuralgia  of 
the  middle  branch,  dividing  the  nerve  back  of  Meckel's 
ganglion  ;  some  of  the  patients  had  been  permanently 
relieved,  others  had  returned.  Sulzer's  operation  was 
somewhat  more  difficult  than  Carnochan's,  and  left 
more  of  a  scar,  and  was  not,  he  thought,  as  satisfactory 
as  the  intra-cranial  operation.  He  had  done  the  Sulzer 
operation  with  satisfaction  in  three  cases,  but  in  two 
there  was  return  of  the  pain.  The  Hartley  operation 
was  the  final  one,  and  although  it  was  more  recent  than 
the  others,  it  bade  well  to  give  permanent  relief.  It 
was  quite  due  Dr.  Hartley  that  it  should  go  by  his 
name.  Out  of  fifty  or  si.xty  reported  cases  there  had 
been  a  few  deaths  from  hemorrhage  or  cerebral  abscess, 
but  Dr.  Abbe  thought  that  with  due  care  these  acci- 
dents could  be  avoided. 

Dk.  Brv.4NT  asked  Dr.  Abbe  how  he  knew  the  hem- 
orrhage in  his  case  came  from  the  cavernous  sinus. 

Dr.  Abbe  replied  that  there  were  two  sources  of 
hemorrhage.  The  first  was  from  the  middle  menin- 
geal artery  at  the  foramen  spinosum,  a  jet  coming  out 
which  stopped  after  ligation.  The  other  was  venous 
hemorrhage,  which  took  place  while  he  was  isolating 
and  evulsing  the  nerve,  the  inner  side  of  the  bundle 
lying  close  to  the  cavernous  sinus,  which,  doubtless, 
was  torn  and  gave  rise  to  the  hemorrhage.  This  was 
controlled  by  packing.  He  had  no  other  proof  of  the 
origin  of  the  hemorrhage. 

Dr.  Bryant  thought  it  was  an  interesting  fact,  if 
proven,  that  the  cavernous  sinus  could  be  torn,  the 
hemorrhage  checked  by  gauze  packing,  and  no  further 
trouble  follow  its  removal  next  day. 

Dr.  Abbe  remarked  that  a  number  of  operators  had 
resorted  to  packing,  and  that  Dr.  Keene  had  used  a 
bundle  as  large  as  one's  fist,  showing  that  the  brain 
could  be  considerably  compressed,  yet  everything  go 
well  after  removing  the  packing. 

Dr.  Robinson  inquired  whether  the  ordinary  means 
for  overcoming  pain  had  been  tried  in  these  cases,  and 
whether  Dr.  Abbe  would  resort  to  an  operation  at  once. 

Dr.  Abbe  replied  that  opium,  sulphonal,  and  other 
agents  had  been  used.  He  would  not  operate  until 
the  pain  had  become  unbearable. 

Some  Remarks  on  the  Morphine  Habit. — Dr.  H.  F. 
Walker  read  a  paper  bearing  this  title  (see  p.  692). 

Dr.  George  L.  Peahoi)\-,  referring  to  Dr.  Walker's 
first  case,  wished  to  know  whether  the  patient  had  had 
a  strong  enough  will,  on  going  to  the  country,  to  en- 
tirely refrain  from  morphine. 

Dr.  Walker  replied  that  he  had,  but  at  the  begin- 
ning he  took  a  little  codeia. 

Dr.  Peabouv  thought  the  patient  had  shown  unusual 
power  of  will.  Regarding  codeia,  while  it  was  recom- 
mended as  a  means  of  weaning  patients  from  morphine, 
he  believed  that  in  the  form  in  which  it  usually  came 
it  was  equivalent  to  morphine,  and  giving  it  to  these 
patients  was  practically  allowing  them  to  taper  off 
from  the  morphine  habit.  So  far  as  he  had  been  able 
to  learn,  the  weight  of  evidence  was  in  favor  of  rather 
rapid  withdrawal  of  morphine  in  the  treatment  of  those 
addicted  to  its  use.  He  would  suppose  that,  like  with 
alcoholism,  gradual  withdrawal  of  the  drug  would  not 
be  successful. 


In  the  second  case,  it  seemed  an  unusual  train  of 
circumstances  had  favored  the  success  of  the  treatment 
adopted.  The  patient  was  a  doctor,  he  wished  to  be 
hypnotized,  had  faith  in  it,  and  desired  to  be  rid  of  his 
habit.  Dr.  Peabody  doubted  the  general  applicability 
of  hypnotism  to  the  morphine  habit. 

Dr.  Robert  Abbe  had  been  impressed  with  the  fact 
emphasized  by  Dr.  Walker — absence  of  moral  force  on 
the  part  of  the  morphine  habitue.  He  thought  the 
loss  of  will-power  was  equally  striking.  The  few  whom 
he  had  seen  who  wished  to  break  themselves  of  the 
habit  had  followed  the  physician's  directions  to  a  cer- 
tain point,  but  when  it  came  to  cutting  the  drug  down 
below  a  certain  amount  their  resolution  always  failed. 
He  had  seen  two  or  three  very  earnest  people  try  it,  but 
after  reaching  a  relatively  small  dose  they  seemed  ab- 
solutely unable  to  go  farther.  Morphine  habitues  suf- 
fered from  certain  sensations  or  cravings  which  they 
called  pain,  but  which  probably  were  only  allied  to  the 
pain  sense,  and  these  prevented  them  from  giving  the 
drug  up  entirely,  although  only  a  small  dose  might 
prove  sufficient  to  allay  these  sensations.  He  believed 
there  was  a  mental  deterioration  in  the  chronic  cases 
which  possibly  might  be  overcome  by  hypnotism,  but 
he  had  had  no  experience  with  it.  The  loss  of  the 
moral  sense  seemed  to  him  a  grave  phase  of  the  ques- 
tion. Personally  he  would  not  trust  all  the  statements 
of  morphine  habitues. 

Morphinism  and  Glycosnria.  —  Dr.  Her.maxn  M. 
Biggs  asked  an  opinion,  based  on  two  cases  of  the  mor- 
phine habit  seen  by  him.  A  woman,  fifty-three  years 
of  age,  had  begun  to  take  morphine  seven  or  eight 
years  ago,  for  the  relief  of  pelvic  pain,  and  during  the 
last  three  or  four  years  had  taken  the  drug  continuously. 
She  was  taking  eight  grains  a  day  when  he  first  saw 
her.  Within  four  or  five  days  the  amount  was  reductd 
considerably,  and  it  was  then  that  he  had  occasion  to 
examine  the  urine  carefully  and  found  that  it  con- 
tained sugar.  On  inquiring  into  her  previous  history, 
it  proved  very  suggestive  of  glycosuria,  from  which  she 
had  not  entirely  recovered.  There  had  been  frequent 
micturition,  great  irritation,  thirst,  etc.  He  reduced 
the  quantity  of  morphine  from  seven  or  eight  grains  to 
half  a  grain  in  the  course  of  a  week,  and  the  sugar  in 
the  urine  increased  considerably,  until  it  was  about 
four  per  cent.  .She  had  used  in  the  interval  some  tri- 
onal  and  bromide.  She  became  somnolent,  with  mut- 
tering delirium,  and  her  condition  became  so  serious 
that  he  did  not  dare  withdraw  more  morphine,  nor  did 
he  think  it  desirable  in  view  of  the  glycosuria.  Indeed, 
he  gradually  increased  the  ([uantity  to  a  grain  a  day. 
The  patient  improved  slowly,  and  at  the  end  of  two 
weeks  was  in  her  normal  condition,  taking  a  grain  of 
morphine  a  day.  The  diet  was  then  restricted,  and  the 
glycosuria  disappeared,  but  if  a  quantity  of  starch  were 
eaten  the  sugar  immediately  reappeared  in  the  urine. 
She  had  been  under  observation  over  two  years,  the 
([uantity  of  morphine  taken  had  remained  at  one  grain 
a  day,  being  administered  by  her  daughter  or  son,  and 
it  seemed  she  had  made  no  attempt  to  obtain  morphine 
outside.  She  had,  however,  a  craving  for  stimulants, 
and  it  was  necessary  to  keep  these  out  of  her  reach. 
Her  health  was  very  fair. 

The  second  patient  was  a  woman,  aged  about  fifty, 
who  had  been  addicted  to  the  use  of  morphine  twenty- 
five  years.  She  had  begun  taking  the  drug  occasion- 
ally when  she  was  twenty-five  years  old  for  the  relief 
of  pain  during  the  menstrual  period,  and  for  fifteen 
years  had  taken  it  continuously,  in  any  form  she  could 
get  it.  ^\'hen  a  year  before  he  saw  her  the  opiimi  was 
cut  off.  She  had  been  taking  ten  ounces  of  AIcMunn's 
elixir  a  day.  For  seven  months  before  he  saw  her  she 
had  received  no  opium,  but  during  that  time  she  was 
in  poor  health  and  had  had  several  attacks  of  serious 
illness.  During  the;e  attacks  she  was  given  alcoholic 
stimulants,  and  later,  during  an  attack  of  hay  fever  was 
given  cocaine  in  spray,  and  she  immediately  contracted 


7o8 


MEDICAL   RECORD. 


[November  16,  1895 


the  cocaine  habit.  She  had  always  had  a  craving  for 
stimulants,  and  when  Dr.  Biggs  first  saw  her  she  was 
taking  a  large  quantity  of  cocaine  (about  twelve  grains 
a  day)  and  as  much  alcohol  as  she  could  get.  On 
withdrawing  the  cocaine  she  passed  into  a  condition 
resembling  acute  alcoholism —  delirium,  sleeplessness, 
hallucinations,  illusions,  delusions. 

The  question  arose  whether  in  such  a  case  it  was 
possible  or  desirable  to  entirely  withdraw  the  opium 
and  attempt  to  keep  the  patient  free  from  narcotics. 
He  supposed  it  was  a  sort  of  heresy,  but  he  had  had 
the  feeling  that  where  a  patient  had  been  so  long  ad- 
dicted to  the  habit,  had  lost  the  power  of  moral  and 
physical  resistance  to  its  influence,  and  yet  who  was  in 
good  health,  as  this  patient  was,  the  entire  withdrawal 
of  the  drug  would  require  constant  surveillance,  and 
would  be  followed  by  enfeeblement  of  health,  and  it 
had  also  seemed  to  him  that  if  any  narcotic  were  al- 
lowed^ opium  by  the  mouth,  in  restricted  amount,  would 
prove  the  least  harmful.  He  asked  for  an  expression 
of  opinion  upon  that  point. 

Dr.  a.  Alexander  Smith  said  he  felt  more  hope- 
ful after  hearing  the  histories  of  Dr.  Walker's  cases 
than  he  had  felt  before,  for  he  had  always  doubted  the 
ultimate  result  in  any  case  of  confirmed  opium-taking. 
Many  years  ago  Dr.  Sands  had  remarked  to  him,  on 
observing  a  morphine  habitue  in  the  street,  that  he  did 
not  believe  any  woman  who  had  become  confirmed  in 
the  use  of  the  drug  could  stop  it.  Dr.  Smith  was  then 
inclined  to  doubt  this  statement,  but  many  years'  ob- 
servation had  since  convinced  him  that  it  was  exceed- 
ingly rare  for  patients  to  become  entirely  cured  of  this 
habit. 

How  Much  Opium  is  Necessary  to  Coastitute  One  an 
Habitug  ? — Dr.  A.  A.  Smith  said  further,  that  he  had  been 
interested  in  the  medico-legal  aspect  of  these  cases. 
"  Some  years  ago  I  was  asked  by  a  friend  to  go  to  a 
neighboring  State  and  testify  in  a  suit  which  he  had 
brought  against  his  father-in-law  for  keeping  his  wife 
and  children  from  him.  '  What  is  the  matter  with  your 
wife  ?  '  '  She  is  an  opium-eater.'  '  You  had  better  let 
the  case  stand,  then.  If  she  is  an  opium-eater,  it  seems 
to  me  your  father-in-law  has  relieved  you  of  a  very 
great  responsibility.'  '  I  accept  that,  but  I  want  the 
children.'  And  then  he  asked  me  what  view  I  took 
with  regard  to  the  reliability  of  the  testimony  of  any 
opium-taker,  and  I  said  I  thought  it  was  absolutely  un- 
reliable. I  felt  that  an  habitual  opium-taker  was  an 
habitual  liar,  and  when  I  took  the  witness-stand  and 
made  that  statement  I  was  berated  by  the  opposing 
counsel,  and  was  asked  what  I  regarded  as  a  habitual 
opium-taker.  The  judge  seemed  very  much  interested 
in  the  question  of  the  reliability  of  the  opium-taker,  and 
he  turned  to  me  and  said  :  '  Are  you  not  making  a  very 
strong  statement  ? '  'I  hope  so,  for  that  is  exactly 
what  I  intended  to  make,  having  been  impressed  with 
the  utter  unreliability  of  these  people.  It  is  not  because 
of  a  vicious  purpose,  but  rather  a  want  of  capacity  to 
tell  the  truth.'  I  should  like  to  ask  Dr.  Walker  what 
he  considers  the  smallest  quantity  of  morphine  which 
will  make  one  a  confirmed  opium-taker,  and  render  his 
testimony  unreliable  ?  "  Dr.  Walker  having  replied  that 
he  thought  it  would  depend  upon  the  case,  and  the 
effect  upon  the  patient.  Dr.  Smith  went  on  to  say  that 
his  reply  on  that  occasion  was,  two  grains  at  least,  and 
from  that  amount  up.  That  it  would  differ  according 
to  the  individual  and  the  circumstances.  On  that  state- 
ment his  testimony  was  very  much  damaged,  for  in  the 
case  in  court  it  was  shown  that  the  woman  tolerated 
large  quantities  of  morphine  because  of  severe  pain. 

Opium  and  the  Temperature. — Dr.  F.  P.  Kinni- 
CUTT  thought  it  would  be  a  very  important  fact  if 
further  experience  should  corroborate  Dr.  Walker's 
as  to  the  value  of  hypnotism  in  the  treatment  of  opium 
habitues.  He  had  also  seen  some  striking  examples  of 
the  perversion  of  the  moral  sense  in  the  particular  di- 
rection of  inability  to  distinguish  between  truth  and 


falsehood.  The  word  of  the  opium-taker  was  not  to  be 
relied  upon  ;  absolutely  not.  Regarding  the  semiology, 
one  point  had  been  impressed  upon  his  mind  many 
years  ago  which  now  was  probably  well  known  to  all. 
He  was  asked  to  see  a  case  with  an  eminent  physician, 
to  determine  the  cause  of  an  irregular  fever  from 
which  the  patient  seemed  to  be  suffering.  They  were 
baffled,  but  later  he  read  of  observations  made  in 
Europe  on  temperature  of  irregular  type  observed  in 
opium-takers,  which  at  once  explained  the  case. 

As  to  treatment :  For  the  past  ten  years  he  had  em- 
ployed only  one  method,  that  of  sudden  withdrawal  of 
all  opium,  not  even  permitting  the  patient  to  use  co- 
deia.  While  the  suffering  was  great,  yet  patients  who 
had  used  both  methods  had  told  him  that  they  pre- 
ferred sudden  withdrawal  to  the  prolonged  suffering  of 
gradual  withdrawal.  In  some  cases  the  symptoms  had 
appeared  alarming,  but  no  untoward  result  had  ensued. 
He  allowed  the  patients  alcohol  in  any  form,  in  any 
quantity,  and  also  trional,  sulphonal,  or  bromide,  dur- 
ing the  treatment.  Regarding  the  ultimate  prognosis 
he  must  say  that  he  had  not  very  great  hope.  Out 
of  a  considerable  number  of  patients  treated  by  him, 
only  one  had  left  off  the  drug  for  a  long  period.  In 
the  one  case  there  had  been  freedom  for  ten  years. 
Of  course  he  was  speaking  of  the  habit  of  months'  and 
years'  duration. 

Prefers  Gradual  Withdrawal  of  Opium. — Dr.  Bev- 
erley Robinson  said  he  agreed  in  the  main  with  the 
previous  speakers,  but  he  did  not  think  it  wise  to  sud- 
denly withdraw  all  opium  from  one  who  had  long  been 
in  the  habit  of  taking  a  large  quantity.  It  caused  un- 
necessary distress.  Nor  did  he  think  other  stimulants 
would  take  its  place  satisfactorily.  Regarding  the 
question  of  prescribing  opium,  he  thought  that  some- 
times it  could  not  be  avoided.  That  day  he  had  used 
morphine  in  a  case  of  headache  in  a  woman  who  had 
consulted  many  prominent  practitioners  in  the  city 
without  obtaining  relief.  There  were  certain  mental 
troubles  calling  for  it,  and  a  neurologist  had  given  it 
occasionally  to  one  of  his  patients  suffering  from  mel- 
ancholia. Druggists  sometimes  prescribed  the  drug, 
or  repeated  prescriptions  containing  it  without  instruc- 
tion from  the  doctor.  He  thought  our  prescriptions 
for  opium  should  be  allowed  to  go  only  to  druggists 
whom  we  knew  to  be  too  conscientious  to  repeat  them 
unless  so  directed. 

Dr.  Peabody  said,  in  relation  to  giving  morphine 
subcutaneously  for  the  relief  of  headache,  that  about 
five  years  ago  he  was  asked  by  a  woman  to  see  her 
husband,  a  doctor,  who  had  been  in  receipt  of  a  very 
large  income  from  his  practice,  but  who  had  suddenly 
gone  abroad  for  many  months  and  had  only  recently 
returned.  The  doctor  patient  quieted  his  suspicions 
by  immediately  telling  him  that  morphine  was  the  cause 
of  all  his  trouble.  He  asked  Dr.  Peabody  if  he  re- 
membered who  had  given  him  his  first  dose  of  mor- 
phine, and  stated  that  it  was  Dr.  Peabody  himself,  who, 
seventeen  years  before,  had  administered  a  hypodermic 
injection  for  the  relief  of  headache.  The  patient  had 
continued  its  use  ever  since,  although  there  had  been 
intervals. 

Dr.  Peabody  thought  we  ought  not  to  administer 
morphine  to  people  troubled  with  headache. 

Dr.  Kinnicutt  said  he  fully  agreed  with  Dr.  Pea- 
body. Women  came  to  us  with  sick  headache,  and  it 
did  sometimes  seem  that  morphine  was  the  only  drug 
which  would  give  them  relief,  but  he  was  positively 
of  the  opinion  that  it  should  not  be  used  in  those  cases. 
A  migraine  was  likely  to  last  a  number  of  years,  and  if 
morphine  were  once  used  it  would  likely  be  contin- 
ued. 

Dr.  Pe.\bodv  added  that  his  patient  died  a  most 
miserable  death  as  a  result  of  a  combination  of  mor- 
phine and  cocaine  habit.  Neurotic  people,  suffering 
from  chronic  neuralgia,  were  the  very  ones  to  whom 
morphine  should  not  be  given. 


November  i6,  1895] 


MEDICAL    RECORD. 


709 


Dr.  Robinson  said  it  must  be  assumed  that  those 
physicians  who  sometimes  gave  morphine  exercised 
some  precaution  and  solicitude.  They  did  not  put  the 
drug  into  the  patient's  hands  and  walk  away.  There 
were  some  cases  which  could  not  be  afforded  relief  in 
any  other  way,  so  that  all  one  could  do  was  either  to 
administer  morphine,  or  walk  out  of  the  room  and  leave 
the  patients  to  suffer  for  hours  with  extreme  headache. 
He  was  not  talking  to  the  general  practitioner,  but  to 
members  of  the  Practitioners'  Society. 

Why  Opium  Habitues  Prevaricate. — The  President, 
Dr.  Andrew  H.  Smith,  could  see  no  reason  why 
opium  should  tend  any  more  toward  destruction  of  the 
moral  sense  than  alcohol.  The  only  difference  was,  he 
thought,  that  the  person  taking  alcohol  usually  found 
no  necessity  for  concealing  it,  while  one  taking  opium 
always  did  so  stealthily.  At  first  he  lied  only  with  re- 
gard to  this  habit,  but  by  degrees  he  became  accus- 
tomed to  prevaricate.  He  thought  it  was  wrong  to  try- 
to  corner  such  patients  and  con-s-ict  them  of  their  habit 
against  their  statement,  for  it  only  precipitated  the  habit 
of  untruthfulness. 

Regarding  gradual  withdrawal  of  opium,  the  usual 
method  was  to  reduce  the  quantity  by,  say,  one  drop  a 
dose.  This  meant  a  reduction  perhaps  of  one-tenth 
the  first  day,  one-ninth  the  next,  one-eighth  the  next, 
and  so  on,  the  increase  becoming  rapid  and  distressful 
to  the  patient.  The  President  had  found  a  better 
method  to  consist  in  filling  up  the  bottle,  if  a  liquid 
preparation  were  taken,  by  adding  water  or  alcohol 
after  each  use.  By  this  method  the  reduction  was  by 
a  smaller  percentage  each  subsequent  dose,  but  the 
amount  of  opium  taken  finally  became  infinitesimal. 
He  found  in  practice  two  classes  of  opium  habitues. 
The  first  class  took  the  drug  for  the  relief  of  pain  or 
some  form  of  suffering,  and  for  that  reason  had  not 
the  fortitude  to  lay  it  aside.  The  second  class,  much 
less  numerous,  could  lay  it  aside,  but  continued  to 
take  it  because  of  the  mental  excitement  which  it 
caused.  The  latter  were  the  most  intractable.  He 
had  known  such  persons  to  drop  opium  for  a  long  time, 
until  all  necessity  for  it  must  have  been  lost,  and  then, 
when  the  favorable  opportunity  came,  they  deliberately 
returned  to  its  pleasant  sensations. 

The  President  said  he  had  not  been  able  to  detect 
opium  in  the  urine  unless  it  were  taken  in  considerable 
quantity.  He  asked  for  the  experience  of  others  in 
that  direction.  He  supposed  all  knew  that  a  single 
dose  might  send  the  temperature  up,  but  he  did  not 
know  whether,  after  continued  use  of  the  drug,  the 
system  ceased  to  respond  in  this  way. 

As  to  depriving  the  patient  of  the  drug  suddenly  and 
entirely,  he  recalled  the  case  of  a  physician,  an  intel- 
ligent man,  who  had  been  under  the  care  of  many 
doctors  at  different  times.  At  one  time  his  life  seemed 
to  be  a  complete  wreck.  Finally  it  was  found  that  by 
allowing  him  a  certain  amount  of  morphine  every  day 
it  would  not  incapacitate  him,  and  he  could  attend  to  a 
large  consultation  practice.  There  was  no  reason  why 
this  moderate  amount  of  morphine,  which  was  essential 
to  him  as  his  daily  food,  should  be  cut  off.  He  knew 
one  woman  who  had  become  a  wretched  creature 
through  the  use  of  morphine,  mentally,  morally,  and 
physically.  Under  some  influence  she  gave  up  the 
drug,  regained  her  health  and  beauty,  and  happiness 
was  restored  to  her  family.  After  a  number  of  years, 
within  the  last  year  or  two,  she  had  gone  back  to 
opium,  and  was  again  becoming  a  wreck.  It  was  dif- 
fioult  to  understand  why  a  person,  after  such  an  expe- 
rience, and  after  so  long  a  respite,  should  fall  a  victim 
to  the  drug  again. 

Regarding  habitual  headaches,  they  were  difficult  to 
meet  at  times,  and  often  it  seemed  cruel  to  withhold  a 
single  injection  of  morphine  which  was  capable  of 
giving  relief.  He  could  hardly  bring  himself  to  say 
that  it  was  wrong  to  use  the  drug  in  such  cases  when 
the  intervals  were  long  and  the  danger  of  establishing 


the  morphine  habit  was  not  so  great.  In  one  case  the 
woman  had  suffered  about  once  a  month  for  years,  and 
he  was  in  the  habit  of  giving  her  relief  with  a  single 
hypodermic  injection  of  morphine.  Finally,  he  in- 
duced her  to  consent  to  an  operation  for  very  slight 
strabismus,  and  from  that  time  the  headaches  had 
ceased,  and  she  had  received  no  more  morphine. 
Dr.  W.\lker  closed  the  discussion. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  October  i,  iSqs- 

Edw.\rd  D.  Fisher,  M.D.,  President,  in  the  Ch.-mr. 

Neuritis  of  the  Brachial  Plexus,  as  a  Sequel  of  Pneu- 
monia.— Dr.  W.  >L  Leszynsrv  presented  a  man, 
thirty-six  years  of  age,  who  five  months  ago  had  suf- 
fered from  an  attack  of  neuritis  involving  the  brachial 
plexus  upon  both  sides.  This  condition  had  developed 
during  convalescence  from  acute  pneumonia.  There 
was  no  history  of  traumatism  or  exposure  to  cold,  nor 
was  there  any  e\idence  of  alcoholism,  syphilis,  or  rheu- 
matism. He  looked  upon  the  pneumonic  infection  as 
the  direct  cause  of  the  neuritis.  The  speaker  said  that 
at  present  there  was  a  pronounced  and  typical  paraly- 
sis of  the  left  serratus  magnus,  and  also  some  atrophy 
of  the  deltoid  and  supra-spinatus.  Upon  the  right  side 
there  was  well-marked  atrophy  of  the  deltoid,  with  ab- 
solute anaesthesia  in  the  cutaneous  distribution  of  the 
circumflex  ner^-e,  and  complete  loss  of  faradic  irrita- 
bility. There  was  also  some  atrophy  of  the  supra-spina- 
tus. 

Hereditary  Cerebellar  Ataxia. — Dr.  Joseph  Col- 
lins presented  a  patient  illustrating  so-called  heredi- 
tary cerebellar  ataxia.  The  patient,  a  boy  eleven  years 
of  age,  was  the  second  of  two  children.  Both  his  par- 
ents were  still  living,  and  aside  from  a  marked  tuber- 
cular history  on  the  paternal  side  of  the  family,  no 
hereditary  taint  could  be  traced.  The  child  had  never 
had  spasms,  and  had  passed  through  the  ordinary  in- 
fectious diseases  of  childhood.  He  began  to  talk  and 
walk,  and  the  teeth  developed,  at  the  customary  time. 
The  mother  said  he  had  never  been  able  to  walk  or 
talk  like  other  children.  He  was  always  "  stiff  in  his 
joints,"  "  easy  to  fall,"  etc. ;  he  never  climbed  and  played 
like  other  children,  though  he  tried  to  do  so.  When 
four  years  of  age  it  was  noticed  that  he  was  becom- 
ing very  near-sighted,  and  glasses  were  applied  and 
had  been  worn  since  that  time.  In  February-,  1S94, 
after  returning  from  an  outing  with  his  father,  he 
vomited  a  large  quantity  of  liquid,  and  later  clotted 
blood.  A  few  days  before  this  he  had  had  a  fall  down 
a  flight  of  stairs,  and  to  this  fall  the  parents  attributed 
his  illness.  He  had  been  attending  school  since  his 
fifth  year,  and  had  been  repeatedly  sent  home  on  ac- 
count of  inability  to  make  any  advance.  A  year  ago 
he  had  been  returned  from  school  permanently.  For 
a  year  or  more  there  had  been  periods  when  his  mother 
said  he  could  not  use  the  left  side  of  the  body,  and  at 
such  times  the  arm  and  leg  had  become  very  steady, 
and  his  speech  more  unintelligible.  Great  difficulty 
had  been  experienced  in  keeping  him  warm,  and  especi- 
ally in  the  winter.  The  speaker  said  that  mentally 
the  boy  was  peevish,  irritable,  and  irascible.  He  was 
affectionate,  fond  of  animals  and  pictures,  and  while 
he  could  be  led,  he  could  not  be  dominated.  When 
seen  on  July  21,  1895,  it  was  noted  that  he  was  tall  for 
his  years  ;  face  looked  very  old  ;  the  skin  looked  and 
felt  dry  and  the  flesh  pultaceous  ;  no  enlargement  of 
the  thyroid  gland  ;  right  side  of  face  more  innervated 
than  left  ;  very  slight  grip  in  hands  ;  knee-jerks  ex- 
aggerated, especially  on  the  right  ;  elbow-jerk  lively  ; 
moderate  ankle  clonus  ;  gait  shambling  and  reeling  ; 
head  bent  forward  ;  walks  as  if  intoxicated  ;  stands  fairly 
well  with  feet  wide  apart ;  no  Romberg  ;  genital  or- 


7IO 


MEDICAL    RECORD. 


[November  i6,    1895 


gans  extremely  undeveloped.  His  manner  of  rising 
from  the  recumbent  posture  resembled  that  of  one 
suffering  from  progressive  muscular  d)-strophy,  except 
that  he  did  not  "crawl  up  the  legs."  There  was  no 
real  nystagmus,  but  the  fixation  power  of  the  eyes  was 
not  good,  and  the  eyeballs  twitched,  and  there  was  slight 
weakness  of  the  external  ocular  muscles.  There  was 
progressive  myopia,  but  Dr.  W.  A.  Holden,  who  ex- 
amined the  eyes,  stated  that  in  the  background  no  real 
abnormality  could  be  stated.  His  speech  was  ataxic, 
explosive,  and  thick,  and  sometimes  quite  jerky.  It 
was  almost  impossible  for  him  to  go  up  and  down 
stairs.  Ataxia  of  the  upper  extremities  very  marked. 
Mentally,  he  was  very  defective,  particularly  his  as- 
sociative faculties. 

The  speaker  said  that  this  case,  although  not  a  pure 
one,  would  tend  to  corroborate  the  view  taken  of  these 
cases  by  Nonno,  to  whom  more  than  to  anyone  else 
credit  was  due  for  calling  intelligent  attention  to  them. 
Marie,  who  discussed  Nonno's  cases,  and  some  others, 
had  suggested  the  name  heredo-ataxic  cerebelleuse. 
He  took  for  granted  a  factor  which  apparently  was  not 
necessarily  constant,  viz.,  heredity,  unless  we  use  the 
terms  hereditary  and  familiary  interchangeably.  The 
sister  of  this  boy,  who  died  in  her  second  year,  was  af- 
fected in  the  same  way,  for  the  parents  give  a  very  clear 
description  of  her  condition.  Another  element  stated 
by  Marie  to  be  constant  was  optic  atrophy,  yet  in  some 
cases  recently  reported,  and  in  Eraser's  case,  the  first 
to  be  substantiated  by  autopsy,  this  symptom  was  ab- 
sent. The  condition  has  been  more  commonly  ob- 
served in  patients  older  than  the  one  just  presented. 
In  fact  adolescence  is  the  period  in  which  it  is  usual- 
ly recognized.  It  was  hardly  necessary  to  refer  to  the 
apparent  relationship  between  Friedrich's  disease  and 
this  condition. 

Cystic  Tumor  of  the  Brain.— Dr.  L.  Stieglitz  pre- 
sented a  young  woman  whom  he  had  exhibited  to  the 
Society  in  January,  1S93,  after  she  had  been  operated 
upon  in  June,  1892,  for  a  cystic  tumor  of  the  brain, 
situated  in  the  right  arm  centre.'  The  cystic  tumor 
was  subcortical,  about  one  inch  and  a  half  deep,  and 
its  walls  had  been  found  perfectly  smooth.  About  an 
ounce  of  straw-colored  serous  fluid  had  escaped  from 
the  cyst  at  the  operation.  In  discussing  the  case  at 
the  time,  it  was  clearly  shown  that  the  cyst  could  not 
have  been  of  vascular  or  of  parasitic  origin,  and  the  con- 
clusion had  been  arrived  at,  that  a  glioma  was  at  the 
bottom  of  the  trouble,  and  on  that  account  a  recur- 
rence of  the  growth  had  been  feared.  During  the  fol- 
lowing two  years  the  patient  had  done  very  well,  and 
had  recovered  the  use  of  her  arm  sufficiently  to  attend 
to  her  housework,  but  had  been  subject  to  more  or  less 
frequent  focal  epileptic  seizures  involving  the  left 
hand,  or  the  entire  left  arm  and  side  of  the  face.  Dur- 
ing this  period  she  had  also  had  about  five  general 
convulsions  which  had  set  in  with  the  same  focal  symp- 
toms. In  March  of  this  year,  the  patient  had  begun 
to  complain  of  headaches,  the  power  in  her  left  hand 
had  again  perceptibly  diminished,  and  the  focal  seiz- 
ures had  occurred  more  frequently  than  ever,  from  one 
to  three  times  a  day.  Dr.  Roller,  who  had  examined 
her  eyes  frequently,  found  a  beginning  cloudiness  and 
swelling  of  the  disk  for  the  first  time.  A  recurrence  of 
the  original  neoplasm,  or  a  refilling  of  the  old  cyst, 
was  suspected,  and  Dr.  Gerster  performed  a  second 
operation  upon  the  patient  in  April  of  this  year.  Upon 
exposure  of  the  brain,  a  very  small  maroon-colored 
mass  about  the  size  of  a  filbert  was  found  at  the  point 
where  the  cyst  had  been.  This  mass  was  removed,  and 
as  it  evidently  infiltrated  the  surrounding  brain-tissue, 
a  broad  ring  of  the  latter  was  excised.  The  patient 
made  a  good  recovery.  She  had  two  severe  general 
convulsions  when  the  dressings  were  first  removed,  but 
had  been  free  from  all  seizures  ever  since,  a  period  of 

'  American  Journal  of  the  Medical  Sciences,  June,  1S93. 


six  months.  Her  arm  was  at  first  completely  para- 
lyzed, but  she  had  now  recovered  its  use  to  a  certain 
extent,  the  only  marked  paralysis  left  pertaining  to  the 
index-finger,  which  could  not  be  fully  extended,  and  to 
the  thumb,  which  could  be  flexed,  extended,  abducted, 
and  adducted  only  very  imperfectly.  Tactile  sensibil- 
ity was  less  acute  in  the  paralyzed  limb  than  on  the 
other  side.  There  was  a  very  marked  disturbance  of 
the  muscular  sense,* the  patient  being  very  uncertain 
about  passive  movements  in  her  finger- joints,  especial- 
ly in  those  of  the  thumb  and  index-finger.  The  deep 
reflexes  of  the  arm  and  knee-jerk  were  greatly  exag- 
gerated on  the  affected  side.  Curiously  enough,  they 
were  also  distinctly  exaggerated  on  the  healthy  side, 
though  to  a  far  less  degree.  The  microscopic  exami- 
nation of  the  excised  tumor  was  very  interesting.  The 
old  cyst  wall  was  found  collapsed  :  originating  from  a 
point  in  this  wall  a  small  spindle- cell  sarcoma  was 
found.  This  could  be  seen  in  the  specimen.  Sections 
through  the  ring  of  brain-tissue  removed  showed  the 
new  growth  to  be  of  a  very  malignant  and  complex 
type.  From  its  character  at  different  points  it  would 
have  to  be  termed  a  melano-glio-angio-spindle-cell- 
fibro-sarcoma.  The  brain-tissue  was  infiltrated,  and 
no  doubt  sooner  or  later  the  patient  would  have  a  re- 
currence of  the  growth. 

The  case  showed  that  cystic  tumors  of  the  brain  were 
not  as  innocent  in  character  as  many  would  believe, 
and  on  that  account  the  excision  of  the  cyst-wall  would 
be  advisable  in  all  cases  of  this  kind.  If  this  were  not 
possible  at  the  first  operation,  it  could  be  easily  done  at 
a  subsequent  operation,  a  few  months  later,  when  the 
wall  would  be  found  compressed  into  a  small,  solid 
mass. 

Dr.  B.  Sachs  expressed  the  belief  that  the  original 
cyst  might  very  well  have  been  of  hemorrhagic  origin. 

The  President  said  that  the  clinical  history  of  the 
case  prior  to  the  first  operation  would  throw  light 
upon  that  question. 

Dr.  Stieglitz  said  that  in  order  to  save  time  he 
had  omitted  the  details  of  the  original  history.  The 
patient  had  been  perfectly  well  up  to  December,  1S91, 
when  she  had  been  suddenly  taken  with  twitching  in 
her  right  thumb  and  fore-finger.  The  twitching  had 
spread  rapidly  up  the  arm  to  the  face,  and  had  ended 
in  a  general  convulsion.  In  December  the  patient  had 
had  three  or  four  more  general  convulsions  of  the  same 
character,  but  none  after  this  time.  She  had  been 
subject,  however,  to  frequent  focal  seizures  confined  to 
the  right  hand.  When  first  seen  in  December  there 
had  been  no  loss  of  power  in  the  arm.  The  weakness 
in  the  arm  had  developed  the  following  March,  and 
had  gradually  increased,  until  in  June,  the  time  of  the 
first  operation,  it  had  become  very  marked.  In  spite 
of  the  absence  of  all  general  cerebral  symptoms,  the 
diagnosis  of  progressive,  destructive  focal  process, 
probably  a  tumor,  had  been  made.  The  slow  and  late 
development  of  the  paralysis  after  the  onset  of  the 
symptoms  of  cortical  irritation  positively  excluded  any 
vascular  lesion. 

AmyotropMc  Lateral  Sclerosis.  —  Dr.  Willi.\m 
HiRSCH  presented  a  case  of  amyotrophic  lateral  sclero- 
sis, which  had  developed  in  a  patient  who  had  formerly 

had  anterior  poliomyelitis.     AI.  D ,  forty- five  years 

of  age,  gave  a  negative  history  as  regards  syphilis  and 
heredity.  About  three  years  ago  he  noticed  a  stiffness 
and  weakness  in  his  left  leg,  which  gradually  became 
worse.  After  some  time,  the  right  leg  also  became  af- 
fected. He  soon  became  unable  to  use  his  legs  in 
working  his  sewing-machine  (being  a  tailor),  and  his 
gait  became  so  much  impaired  that  he  was  not  able  to 
stand  or  walk  for  any  length  of  time.  When  he  came 
under  treatment,  four  weeks  ago,  he  had  complained 
of  nothing  else,  and  there  were  no  sensory  symptoms 
or  disturbance  of  bladder  or  rectum.  The  examination 
showed  an  atrophy  of  some  of  the  muscles  of  the  trunk 
and  the  upper  extremities.     The  right  deltoid,  the  su- 


November  i6,  1895] 


MEDICAL   RECORD. 


pra-spinatus,  and  especially  the  thenar  eminence  on  the 
right  hand,  showed  a  fairly  marked  atrophy.  There 
was  fibrillation  in  the  muscles  of  the  trunk  and  shoul- 
der, increased  by  tapping  them  with  a  percussion  ham- 
mer. There  was  also  diminished  electric  excitabilit)-, 
and  in  some  muscles  the  reaction  of  degeneration  was 
present.  There  was  no  atrophy  in  the  muscles  of  the 
lower  extremities,  and  the  electric  reaction  was  per- 
fectly normal  in  these  parts.  The  tendon  reflexes  of 
the  lower  extremities  were  considerably  increased,  the 
knee-jerks  were  extremely  exaggerated,  and  there  was 
bilateral  ankle  clonus.  The  last  very  frequently  came 
on  spontaneously,  to  the  great  annoyance  of  the  patient. 
Sensation  was  perfectly  normal  in  all  parts  of  the  body, 
and  the  senses  of  pain  and  temperature  were  unim- 
paired. There  were  no  abnormal  conditions  in  the 
function  of  the  cranial  nerves,  with  the  exception  that 
the  tongue  was  slightly  atrophied,  and  there  was  a 
marked  masseter  reflex.  Speech  was  in  no  way  af- 
fected. There  was  no  nystagmus,  and  the  ophthalmo- 
s;opic  examination  showed  perfectly  normal  conditions. 

This  was  evidently  a  typical  case  of  amyotrophic 
lateral  sclerosis,  and  the  man  was  brought  here  because 
of  a  possible  relation  between  the  present  disease  and 
an  old  affection. 

An  examination  of  the  case  at  present  showed  a  very 
marked  atrophy  of  the  muscles  of  the  left  shoulder 
and  upper  arm,  but  the  patient  did  not  think  it  worthy 
of  mention,  as  he  said  it  had  existed  as  long  as  he  could 
remember.  This  appearance  together  with  the  history 
show  that  he  had  had  in  childhood  an  attack  of  infan- 
tile paralysis.  This  brought  up  the  interesting  question. 
Does  there  exist  any  relation  between  the  present 
disease  and  the  anterior  poliomyelitis,  and  if  so,  what 
is  the  nature  of  this  relation  .'  Dr.  Hirsch  said  that 
Ballet  and  Dutil  were  the  first  to  enter  upon  a  discus 
sion  of  this  subject.  They  pointed  out  that  an  infan- 
tile spinal  paralysis  might  give  rise  in  later  life  to  va- 
rious affections  of  the  spinal  cord,  but  that  they  were 
all  limited  to  the  gray  matter  of  the  anterior  horns. 
The  irritation  of  the  cord  by  the  old  lesions  enfeebled, 
they  said,  the  medulla  and  made  it  a  locus  minoris  re- 
sistentia,  which  on  any  occasion  might  become  subject 
to  further  disease.  Charcot  expressed  the  vieiv  that 
there  existed  in  some  individuals  a  certain  disposition, 
a  kind  of  hereditary  vulnerability  of  the  ganglion  cells 
of  the  anterior  horns,  which  at  one  period  of  life  might 
give  rise  to  an  acute  poliomyelitic  anterior,  and  at  an- 
other, to  a  progressive  muscular  atrophy,  so  that  in  fact 
both  diseases  would  form  different  periods  of  one  and 
the  same  pathological  process.  In  some  cases  of  in- 
fantile spinal  paralysis,  Charcot  said,  the  old  scar  which 
was  produced  by  the  inflammatory  process  in  the  gray 
matter  of  the  anterior  horns,  formed  a  latent,  but  per- 
manent, inflammatory  focus,  which  at  any  time  might 
light  up  afresh  and  cause  a  new  set  of  symptoms.  A 
similar  view,  the  speaker  slid,  was  held  by  Strum])ell, 
who,  on  the  theory  of  the  infectious  origin  of  poliomy- 
elitis anterior,  compared  the  scar  in  the  anterior  horns 
to  an  old  tubercular  focus  which  was  capable  of  set- 
ting up  a  new  inflammation  at  any  time.  So  far  as  he 
knew,  the  case  presented  differed  from  all  others  re- 
corded in  literature,  in  that  the  later  disease  was  not 
limited  to  the  anterior  horns  of  the  gray  substance,  but 
that  other  parts  of  the  cord  were  also  involved,  i.e., 
both  lateral  pyramidal  tracts.  He  would  not  attemjjt 
to  decide  upon  which  of  the  theories  applied  to  this 
case,  but  it  could  be  proved  with  absolute  certainty,  by 
the  history  of  the  clinical  symptoms,  that  the  patho- 
logical process  of  the  present  disease  started  from  the 
place  where  the  old  scar  of  the  poliomyelitis  anterior 
was  located.  This  lesion  lay  apparently  in  the  left 
horn  of  the  cervical  region  of  the  cord.  As  the  man 
first  noticed  weakness  and  stiffness  of  the  left  leg,  the 
process  must  have  approached  first  the  left  pyramidal 
tract,  which  lay  next  to  the  scar.  Then,  after  the  af- 
fection of  the  right  horn,  which  shewed  itself  in  atrophy 


of  the  muscles  of  the  right  upper  extremity,  the  patho- 
logical process  spread  over  to  the  right  pyramidal  tract, 
causing  a  spastic  condition  in  the  right  leg.  Whatever 
the  theory  regarding  the  nature  of  the  relation  between 
the  two  diseases,  there  could  be  no  doubt  that  there 
existed  such  a  relation  between  infantile  spinal  paraly- 
sis and  various  spinal  diseases  of  later  life.  Further 
observation  and  study  of  similar  cases  might  throw 
more  light  upon  this  subject,  as  well  as  upon  the  eti- 
ology and  rature  of  the  diseases  in  question. 

A  Report  of  a  Series  of  Cases  of  Multiple  Neuritis  in 
Infants  in  the  City  of  Bridgeport,  Conn. — Dr.  Gr.+  me 
M.  Hammoxd  read  a  jiaper  in  which  he  reported  a  series 
of  cases  of  multiple  neuritis  in  infants  in  the  city  of 
Bridgeport,  Conn.  There  were  ten  cases  in  all,  ranging 
from  four  and  a  half  months  to  four  and  a  half  years  in 
age.  In  all  but  two  cases  there  were  distinct  premoni- 
tory symptoms  of  headache,  vomiting,  and  fever.  Fol- 
lowing this  there  was  a  gradual  and  progressive  paraly- 
sis, usually  beginning  in  the  foot  and  extending  to  the 
upper  extremities,  and  in  some  instances  involving  the 
muscles  of  the  trunk,  and  in  two  cases  the  muscles  of 
deglutition.  Accompany ing  the  paralysis  there  was  pain, 
both  spontaneous  and  on  passive  motion,  and  the  nerve- 
trunks  were  very  sensitive  to  pressure.  The  area  of 
pain  and  tenderness  accompanied  the  extension  of  the 
paralysis.  The  reflexes  were  abolished,  and  the  elec- 
trical reactions  of  degeneration  were  well  marked. 
Two  of  the  cases  exhibited  symptoms  of  spinal  menin- 
gitis in  addition  to  the  neuritis.  One  case,  the  )oung- 
est,  aged  four  and  a  half  months,  died  after  an  illness 
lasting  one  month.  The  muscles  of  deglutition  became 
jjaralyzed,  and  the  child  died  from  exhaustion.  In  the 
other  cases  recovery  began  in  from  lour  to  six  weeks, 
but  was  not  completed  until  from  three  to  four  months. 
No  similar  cases  were  discovered  in  neighboring  towns. 
After  referring  to  the  epidemics  of  anterior  ])oliomyeli- 
tis  which  have  in  the  past  been  reported,  both  in 
Europe  and  in  America,  the  reader  concluded  by  ac- 
cepting the  theory  of  their  microbic  origin,  and  ex- 
pressed his  belief  that  these  cases  of  neuritis  were  due 
to  a  similar  cause. 

The  author  expressed  his  indebtedness  to  Dr.  lohn 
C.  Lynch,  Dr.  Samuel  M.  Garlick,  and  Dr.  ]'.  W. 
AVright,  of  Bridgeport,  for  the  reports  of  cases,  and  for 
their  courtesy  in  affording  him  the  opportunities  for 
personal  examinations. 


THE   NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  October  g,  iSgj. 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Diseased  Placenta. — Dr.  Mary  Putnam-Jacobi  pre- 
sented an  extremely  diseased  placenta,  together  with 
the  liver,  heart,  lungs,  and  kidneys  of  the  child.  As 
the  child  had  been  born  only  two  days  before,  no  op- 
portunity had  been  given  for  a  microscopical  examina- 
tion. It  was  the  mother's  third  child,  and  the  first  one 
born  at  term.  All  three  children  had  died  with  ex- 
actly the  same  symptoms.  The  mother  had  been  mar- 
ried about  twelve  years,  and  had  been  apparently 
healthy  at  the  time  of  her  marriage.  For  the  first  two 
or  three  years  afterward  she  had  been  under  treatment 
for  sterility.  No  obvious  uterine  disease  had  been  dis- 
covered. Afterward,  she  had  had  two  early  miscar- 
riages. When  about  three  months  ])regnant,  a  watery 
discharge  from  the  uterus  began,  and  became  more 
and  more  abundant  until,  at  about  the  seventh  month, 
l.ibor  had  come  on  spontaneously.  The  child  lived 
two  hours.  About  three  years  later  she  again  became 
pregnant,  and  again,  at  about  the  third  month,  there 
was  a  similar  discharge  of  water.  As  a  result  of  keep- 
ing absolutely  quiet  the  discharge  was  diminished,  but 
by  the  sixth  month  it  had   become  very  profuse,  and 


712 


MEDICAL   RECORD. 


[November  16,  1895 


the  uterus  almost  empty  of  fluid.  This  gave  rise  to 
strong  uterine  contractions,  several  times  a  day.  She 
was  kept  under  opiates  with  the  hope  of  postponing 
labor  until  the  period  of  viability.  This  was  done,  for 
labor  occurred  when  she  was  seven  months  and  one 
week  pregnant.  The  child  was  placed  in  an  incuba- 
tor and  did  well  for  a  short  time.  It  then  began  to 
breathe  with  great  rapidity,  and  after  a  few  minutes  of 
this  excessively  rapid  respiration  it  died.  Last  Jan- 
uary this  woman  again  became  pregnant.  She  was  at 
once  placed  on  milk  diet,  and  medication  with  iodide 
of  potassium  and  bichloride  of  mercury.  This  time 
the  child  was  carried  to  within  four  days  of  full  term  ; 
then  there  was  spontaneous  labor,  and  after  four  or  five 
hours  a  child  weighing  about  four  pounds  was  delivered. 
The  child  was  cyanosed  and  extremely  feeble.  Just 
before  labor  the  fcetal  pulse  had  been  very  strong,  and 
140  per  minute.  The  child  was  wrapped  in  cotton  and 
kept  warm  by  artificial  heat.  For  one  hour  after  its 
birth  the  fontanelle  beat  forcibly.  Seven  hours  after 
birth  the  respirations  suddenly  rose  to  70,  and  a  few 
minutes  later  the  heart  stopped  beating.  An  autopsy 
was  made  two  or  three  hours  later,  and  the  pleural 
cavities  were  found  distended  with  fluid  which,  on  the 
right  side  was  sanguinolent,  but  on  the  left  side  clear. 
The  fluid  in  the  pericardium  v/as  also  very  abundant. 
There  was  no  fluid  in  the  peritoneal  cavity.  The  lungs 
had  evidently  expanded,  as  they  floated  perfectly  on 
water,  but  they  were  found  to  be  intensely  congested 
throughout.  There  was  no  evidence  of  there  having 
been  any  intra-uterine  respiration.  The  greatest  con- 
gestion was  located  in  the  upper  lobe  of  the  right  lung, 
and  in  the  lower  lobe  of  the  same  lung.  The  right 
heart  was  completely  empty,  while  the  left  ventricle 
was  distended  with  a  large  quantity  of  dark  coagula, 
and  these  extended  into  the  left  auricle.  It  would 
appear,  therefore,  that  the  arrest  of  the  heart  began, 
not  in  the  lungs,  in  which  case  the  damming  up  of 
the  circulation  should  have  been  in  the  right  heart, 
but  in  the  left  heart,  and  hence,  as  the  left  ventricle 
was  unable  to  empty  itself,  there  was  a  damming  up  of 
the  blood  toward  the  auricle  and  the  lungs.  On  this 
theory  it  was  inferred  that  the  congestion  of  the  lung 
might  be  the  immediate  consequence  of  a  failure  of  the 
left  ventricle  to  contract.  The  liver  was  of  normal 
size,  and  in  the  fresh  state  looked  quite  normal.  With- 
out a  microscopical  examination,  the  speaker  said,  she 
could  not  state  at  all  positively  regarding  the  condi- 
tion of  the  kidneys.  The  placenta  was  excessively 
small,  and  there  was  an  entire  absence  of  the  normal 
lobulation  of  the  placenta.  From  the  gross  appear- 
ance, the  maternal  side  of  the  placenta  seemed  healthy, 
but  on  the  foetal  side  the  placenta  was  almost  com- 
pletely converted  into  a  tough,  thick  mass.  The  man- 
ner in  which  the  blood-vessels  entered  the  placenta 
would  seem  to  indicate  some  form  of  degeneration, 
either  fibroid  or  amyloid,  which  had  caused  contrac- 
tion of  the  tissue  around  it.  The  exact  form  of  de- 
generation could  not  be  stated  without  microscopical 
examination.  The  placenta  probably  represented  that 
type  formerly  called  "  fatty  placenta,"  but  now  known 
to  be  a  condition  in  which  the  blood-vessels  have  be- 
come degenerated.  The  existence  of  hydro-thorax 
and  hydro-pericarditis  in  this  case  was  interesting  from 
several  points  of  view.  In  the  first  place,  there  was 
nothing  in  the  child  typical  of  "  general  dropsy  of  the 
foetus."  Ballantine,  an  authority  on  this  subject  of 
general  dropsy,  says  that  this  condition  hardly  ever 
occurs  in  women  having  renal  disease.  This  mother, 
ever  since  the  first  pregnancy,  had  presented  more  or 
less_  pronounced  indications  of  chronic  interstitial  ne- 
phritis. At  that  time  there  had  been  no  albuminuria, 
and  the  urea  had  been  sufficient  in  quantity.  The  dis- 
charge of  amniotic  fluid  the  speaker  was  inclined  to 
attribute  rather  to  a  disease  of  the  chorion  primarily, 
because  the  patient  had  had  a  slight  endometritis.  In 
the  interval  between  the  first  and  second  pregnancies 


the  symptoms  of  nephritis  had  become  more  pro- 
nounced— there  had  been  a  marked  diminution  in  the 
urotoxic  coefficient.  Normally,  from  thirty  to  sixty 
cubic  centimetres  of  urine  were  necessary  to  poison  a 
single  kilogramme  of  rabbit,  while  in  this  patient  from 
seventy-three  to  eighty  cubic  centimetres  had  been  re- 
quired. In  the  second  pregnancy  this  diminution  of 
toxicity  persisted,  and  she  also  began  to  exhibit  a  slight 
dilatation  of  the  heart.  She  had,  during  the  preg- 
nancy, two  or  three  distinct  attacks  of  transient  apha- 
sia and  hemiplegia.  There  was  no  albuminuria,  but 
after  the  birth  of  the  child  marked  oedema  of  the  lower 
extremities  and  albuminuria  were  present  for  a  short 
time.  During  the  last  pregnancy  a  tricuspid  insuffi- 
ciency developed,  there  was  some  oedema,  the  albumi- 
nuria was  marked  about  one  month  before  confinement, 
and  there  were  one  or  two  ursemic  attacks  before  con- 
finement. 

Dr.  Jacobi  closed  by  propounding  the  following 
questions  :  Is  not  the  degeneration  of  the  placenta  an 
expression  of  the  poisoning  of  the  maternal  blood  ? 
Was  the  hydro-thorax  and  hydro-pericarditis  the  direct 
expression  of  this  poisoning  derived  from  the  maternal 
blood,  or  was  there  any  renal  disease  inherited  by  the 
foetus,  and  there  being  an  obstruction  of  the  peripheric 
circulation,  the  heart  was  unable  to  overcome  it,  and 
heart  failure  resulted  ?  Or,  was  it  an  expression  sim- 
ply of  asthenia  from  the  cachexia  ?  Could  this  abun- 
dant effusion  into  the  cavity  have  occurred  during  the 
seven  hours  of  extra-uterine  life,  or  did  it  occur  before 
birth  ? 

Dr.  H.  S.  Stearns,  in  answer  to  the  query  regard- 
ing the  rapidity  with  which  an  effusion  might  occur, 
referred  to  the  rapidity  with  which  the  pleural  cavity 
filled  up  in  cases  of  empyema.  He  had  at  the  present 
time  under  observation  a  case  which  would  discharge 
about  ten  ounces  in  twenty-four  hours. 

Dr.  Donald  M.  Barstow  thought  it  unlikely  that 
the  lungs  would  have  expanded  so  well  had  this  effu- 
sion existed  before  birth.  He  recalled  several  autop- 
sies in  which  there  had  been  apparently  a  very  rapid 
effusion  of  fluid  into  the  pleural  cavity  just  before 
death. 

Dr.  Warren  Coleman  said  that  he  had  seen  at  au- 
topsy, on  the  preceding  day,  a  case  which  had  been  pre- 
viously carefully  examined  physically  by  a  competent 
physician,  and  no  fluid  detected,  yet  at  autopsy  a  con- 
siderable quantity  of  perfectly  clear  liquid  was  found 
in  both  pleural  cavities.  In  this  case,  the  actual  cause 
of  death  was  thrombosis  of  both  pulmonary  arteries. 
To  be  sure,  there  was  in  this  instance  a  decided  ob- 
struction to  the  circulation,  but  in  the  case  now  under 
discussion,  the  marked  congestion  of  the  lungs  might 
be  considered  as  an  obstruction  to  the  circulation. 

The  President  said  that  it  was  very  common,  at 
autopsies  on  very  young  infants,  to  be  unable  to  deter- 
mine satisfactorily  from  the  pathological  findings  the 
cause  of  death.  It  was  particularly  difficult  to  discern 
slight  changes  in  the  kidneys  of  such  infants,  at  least 
without  microscopical  examination.  He  had  also  fre- 
quently observed  at  autopsy  a  considerable  quantity  of 
fluid  in  the  pericardial  and  pleural  cavities,  in  cases  in 
which  careful  physical  examination  just  before  death 
had  failed  to  show  the  existence  of  such  an  effusion. 

Rupture  of  the  Liver. — Dr.  Donald  M.  Barstow 
presented  a  liver  removed  from  a  man  who  had  been 
brought  into  the  Hudson  Street  Hospital  on  June  2d. 
About  half  an  hour  previously  a  rope  had  been  twisted 
around  him,  thus  squeezing  the  body  forcibly.  He 
was  in  a  condition  of  collapse  at  the  time  of  admission, 
apparently  from  internal  hemorrhage.  Before  infusion 
could  be  performed,  the  man  died.  At  autopsy,  m.ade 
about  three  hours  after  death,  abrasions  were  found  on 
the  two  sides,  on  the  lower  part  of  the  thorax,  marking 
the  location  of  the  rope.  Curiously  enough,  the  ribs 
did  not  appear  to  have  been  at  all  injured.  The  heart 
and  lungs  were  normal.     About  four  quarts  of  blood 


November  i6,  1895] 


MEDICAL   RECORD. 


were  removed  from  the  peritoneal  cavity.  The  only 
■injury  was  in  the  liver,  the  tissue  of  which  had  been 
completely  ruptured  between  the  lobes. 

Dr.  Coleman  asked  the  experience  of  the  President 
as  to  the  seat  of  rupture  with  reference  to  the  point  at 
which  the  external  violence  had  been  applied — was 
the  rupture  at  this  point  or  on  the  opposite  side  ? 

The  President  said  that  he  had  not  observed  that 
these  injuries  followed  any  definite  rule  of  this  kind. 
He  could,  however,  recall  seeing  the  rupture  at  some 
distant  point  from  the  spot  at  which  the  violence  was 
applied. 

Dr.  Colem.\n  said  that  he  had  seen  on  the  preced- 
ing day  an  autopsy  on  a  man  who  had  fallen  off  a  fire- 
escape.  The  external  marks  of  violence  extended  from 
the  ensiform  cartilage  to  the  umbilicus.  The  cause  of 
death  was  found  to  be  a  very  similar  rupture  of  the 
liver.  All  the  organs  were  markedly  anaemic,  and  the 
abdominal  cavity  was  filled  with  blood.  In  this  in- 
stance it  seemed  as  if  the  blow  had  thrown  the  liver 
back,  and  that  the  tension  thus  produced  in  the  sus- 
pensory ligament  had  resulted  in  the  rupture  at  this 
point.     There  was  no  other  internal  injury. 

"  Dissecting  Aneurism  of  the  Aorta,  Eupturing  into 
the  Pericardium.'— Dr.  W.^rren  Colem.\n  reported  a 
case  of  this  kind.  The  subject  was  a  muscular,  well- 
developed  man,  forty-seven  years  of  age,  a  meat-carver 
by  occupation,  found  dead  in  his  room.  As  he  lived 
alone,  no  history  could  be  obtained,  and  all  that  could 
be  learned  was  that  he  had  failed  to  report  for  work  one 
morning,  and  on  investigation  he  had  been  found  dead. 
When  the  sternal  plate  had  been  removed,  the  peri- 
cardium was  found  full  of  blood,  and  in  addition  a  dis- 
tinct swelling  at  the  ascending  portion  of  the  aortic 
arch  was  noted.  Suspecting  rupture  of  the  heart,  or  an 
aneurism  at  the  arch,  the  thoracic  viscera  were  re- 
moved, including  the  thoracic  portion  of  the  aorta,  and 
then  the  parts  were  carefully  dissected.  The  examina- 
tion of  the  heart  excluded  rupture,  and  the  calibre  of 
the  aorta  was  normal,  at  least  as  far  as  the  diaphragm. 
The  outer  portion  of  the  aortic  wall,  however,  had  been 
dissected  off  throughout  almost  the  whole  of  its  circum- 
ference, and  from  the  diaphragm  to  the  heart,  by  an 
effusion  of  blood  which,  upon  reaching  the  pericardium, 
had  broken  into  it  at  the  reduplication  of  the  mem- 
brane upon  the  aorta.  The  blood  had  not  suffused  it- 
self between  the  aorta  and  pulmonary  artery,  but  had 
passed  down  on  the  right,  or  outer  side  of  the  arch. 
The  inner  surface  of  the  thoracic  i)ortion  of  the  aorta 
was  normal  except  for  a  few  atheromatous  patches, 
none  of  which  had  ruptured,  .•\neurism  of  the  abdom- 
inal aorta  was  then  sought  for  as  a  source  of  the  blood, 
and  the  abdominal  viscera  carefully  removed.  But  the 
aorta  was  of  normal  size  down  to  the  bifurcation,  as 
were  the  common  and  external  and  internal  iliac  arter- 
ies. The  aorta  and  the  iliacs  were  removed  as  far  as 
Poupart's  ligament,  especial  care  being  taken  not  to 
wound  the  vessel  wall.  The  separation  of  the  coats  of 
the  vessel  extended  to  the  bifurcation  of  the  aorta,  and 
thence  down  the  left  common  iliac  to  its  division  into 
external  and  internal.  Upon  opening  the  vessels,  ex- 
tensive atheromatous  patches  were  discovered  in  the 
region  of  the  coeliac  axis,  and  above  it  to  the  diaphragm, 
while  below  the  patches  were  few  and  discrete.  None 
of  these  patches  had  ruptured.  Atheromatous  changes 
were  found  also  around  the  mouths  of  the  lumbar 
branches  of  the  aorta.  With  a  probe  sufficiently  large 
and  blunt  to  prevent  an  accidental  puncture,  these 
branches  were  tested,  and  it  was  found  that  three  had 
been  torn  just  at  their  junction  with  the  aorta,  and  that 
a  communication  existed  between  the  lumen  of  the 
aorta  and  the  space  in  its  wall.  The  torn  vessels  were 
in  the  region  of  the  coeliac  axis,  the  portion  of  the  aorta 
showing  the  most  extensive  atheromatous  changes  The 
fact  that  more  than  one  of  the  lumbar  arteries  was 
ruptured,  of  course,  cast  some  doubt,  the  speaker  said, 
on  his  interpretation  of  the  case  :  but  admitting  the 


method  pursued  to  have  been  defective,  it  did  not  seem 
likely  that  each  of  the  three  arteries  would  have  been 
cut  just  at  its  junction  with  the  aorta.  Cutting  them 
from  within  would  have  been  impossible,  as  an  entero- 
tome  was  used  in  opening  the  aorta,  and  an  accidental 
cut  from  without  might  be  excluded  also,  for  the  wound 
did  not  involve  the  outer  portion  of  the  aortic  wall,  but 
extended  only  to  the  space  formed  by  the  effusion  of 
blood.  The  explanation  offered  by  Dr.  Coleman  was, 
partial  rupture  of  the  aortic  wall  at  the  mouth  of  per- 
haps one  of  the  lumbar  arteries,  the  other  two  being 
tern  subsequently  as  the  result  of  \'iolent  physical  ex- 
ertion, or  a  blow  on  the  abdomen  followed  by  an  effu- 
sion of  blood  both  below  and  above,  until  the  rupture 
into  the  pericardial  sac  occurred.  It  was  impossible, 
owing  to  the  absence  of  a  history,  to  determine  the 
length  of  time  between  the  rupture  of  the  artery  and 
the  occurrence  of  death.  As  nearly  as  could  be  ascer- 
tained, this  interval  was  not  greater  than  forty-eight 
hours,  and  perhaps  less  than  thirty-four  hours.  The 
rupture  of  more  than  one  of  the  lumbar  arteries  must 
have  increased  the  amount  of  blood  extravasated,  and 
have  hastened  the  onset  of  death. 

The  speaker  said  that  dissecting  aneurisms  were  rare 
as  compared  with  the  other  varieties.  They  were  sel- 
dom recognized  during  life.  The  duration  of  life  after 
the  rupture  of  the  artery  varied  greatly  in  different 
cases.  Holmes  states  that  "  when  the  coverings  of  the 
blood  are  strong,  and  the  fluid  finds  a  ready  passage 
back  into  the  artery,  life  may  be  prolonged  for  a  con- 
siderable period  :  in  fact,  the  symptoms  referred  to  the 
disease  have  been  observed  to  last  for  years."  The 
blood,  however,  instead  of  re-entering  the  arter)%  might 
suffuse  itself  into  the  surrounding  tissues,  or  pass  up- 
ward along  the  course  of  the  vessel  until  it  finally  rup- 
tured into  the  pericardium.  Holmes  says  :  "  The  po- 
sition of  the  original  rent  seems  always  to  be  in  the 
aorta,  and  generally  in  the  arch,  quite  close  to  its  ori- 
gin ;  though  it  has  been  known  to  be  situated  in  the 
abdominal  aorta,  even  as  low  as  its  bifurcation.  The 
position  of  the  secondary  rupture  of  the  inner  coats,  by 
which  the  blood  passes  back  into  the  cavity  of  the  ves- 
sel, varies  much.  A  case  is  mentioned  in  which  the 
separation  extended  into  the  popliteal  artery  ;  and  in 
another  case,  in  which  the  primary  rent  was  in  the 
transverse  arch,  the  secondary  opening  was  in  the  sub- 
clavian. Death  occurs  soon  in  all  cases  where  the 
blood  passes  out  of  the  artery,  either  into  the  pericar- 
dium or  into  the  surrounding  tissues  :  and  in  most  ol 
those  in  which  the  blood  makes  its  way  back  into  the 
artery.  The  patient  is  usually  advanced  in  life,  very 
probably  a  female,  and  suffering  from  hypertrophy  or 
other  disease  of  the  heart." 

Abdominal  Aneurisms. — Dr.  George  P.  Biggs  pre- 
sented an  abdominal  aneurism  removed  from  a  male, 
aged  thirty-one,  an  ice-man  by  occupation.  He  had 
been  admitted  to  the  New  York  Hospital  on  Septem- 
ber 1 6th,  and  had  died  the  same  night.  It  was  said 
that  a  week  before  admission  he  had  begun  to  have 
constant  pain  in  the  left  shoulder,  and  three  days  be- 
fore admission,  pain  in  his  right  shoulder  and  neck,  and 
occasionally  across  the  chest.  For  these  three  days  he 
had  been  unable  to  retain  any  food.  He  had  been  ac- 
customed at  his  work  to  carry  very  heavy  blocks  of  ice. 
C)n  the  day  before  admission  he  had  had  severe  head- 
ache and  pain  in  the  back.  .A.t  autopsy  a  number  of 
old  cicatrices  were  found  on  the  legs,  suggestive  of  spe- 
cific disease.  The  peritoneal  cavity  contained  1,500 
CO.  of  blood  ;  the  left  pleural  cavity  contained  200  c.c, 
and  the  right  pleural  cavity,  400  c.c.  of  blood  ;  there 
were  a  few  old  tubercular  lesions  in  both  lungs.  In  the 
abdominal  aorta  was  a  sacculated  aneurism.  It  was 
just  below  the  diaphragm  on  the  anterior  aspect  of  the 
artery,  and  just  above  the  superior  mesenteric  artery. 
The  aneurism  pressed  forward  just  about  the  cardiac 
end  of  the  stomach,  and  near  the  cardiac  orifice.  The 
opening  from  the  artery  to  the  aneurism  was  circular. 


714 


MEDICAL    RECORD. 


[November  16,  1895 


and  lyi  ctm.  in  diameter.  The  aneurismal  sac  was  10 
ctm.  in  diameter,  and  was  filled  with  coagulated  blood 
and  thick  layers  of  fibrin.  In  the  adventitia  of  the 
aorta  there  was  an  extensive  dissection  of  blood  for 
some  distance  below  the  point  of  the  aneurism,  and 
upward  about  the  oesophagus  and  aorta  to  the  middle 
of  the  transverse  portion  of  the  arch.  No  distinct 
point  of  rupture  into  the  left  pleural  cavity  was  found, 
but  on  the  right  side  there  was  a  distinct  rent  through 
the  pleura  near  the  root  of  the  lung.  It  was  about 
half  an  inch  in  length.  There  was  also  a  large  rupt- 
ure at  the  peritoneum.  In  addition  to  these  lesions, 
there  were  chronic  diffuse  nephritis  and  a  fairly  well- 
marked  cirrhosis  of  the  liver.  The  interesting  feature 
was  the  multiple  points  of  extravasation  of  blood. 

Dr.  Biggs  then  presented  another  aneurism.  He 
said  that  in  an  autopsy  occurring  within  a  few  days  of 
the  preceding  one,  another  abdominal  aneurism  had 
been  found — or  rather,  three  aortic  aneurisms  in  the 
one  case.  The  specimen  presented  had  been  removed 
from  a  man,  aged  forty-five,  an  engineer  by  occupation. 
He  had  been  found  by  an  ambulance  surgeon  in  the 
street,  where  he  had  suddenly  fallen  while  walking.  It 
was  said  that  consciousness  had  been  lost  for  a  short 
period  after  the  fall.  When  first  seen  he  was  com- 
plaining of  severe  pain  in  the  right  hy|jochondriac  re- 
gion. For  two  or  three  days  previously  he  had  not 
been  feeling  very  well.  From  the  location  and  charac- 
ter of  the  pain,  together  with  the  statement  that  these 
pains  had  been  experienced  several  times  before,  the 
ambulance  surgeon  thought  the  man  was  suffering  from 
biliary  colic.  Examination  at  the  hospital  showed  the 
whole  right  side  of  the  thorax  to  be  extremely  tender. 
Dyspnoea  was  quite  marked,  but  was  thought  to  be  due 
to  the  pain  caused  by  respiratory  movements.  He 
died  quite  suddenly  during  the  night  on  which  he' was 
admitted,  and  after  the  expectoration  of  a  few  ounces 
of  fluid  blood.  At  autopsy  there  was  such  extreme 
emaciation  present  that  the  case  appeared  on  inspec- 
tion to  be  one  of  phthisis.  The  diaphragm  on  the  left 
side  was  at  the  level  of  the  fifth  space  in  the  mammary 
line,  whereas  on  the  right  side  it  was  very  much  de- 
pressed, having  a  convex  instead  of  a  concave  under- 
surface,  and  being  on  a  level  with  the  sixth  space  on 
the  mammary  line,  and  extending  nearly  down  to  the 
free  border  of  the  ribs  in  the  axillary  line.  The  left 
pleura  presented  only  a  few  old  adhesions.  The  right 
pleural  cavity  contained  400  c.c.  of  coagulated  and 
fluid  blood  in  about  equal  quantity.  The  heart  was 
normal  in  size,  the  ventricles  were  contracted,  the 
muscle  was  apparently  normal.  There  were  slight 
atheromatous  changes  in  the  mitral  and  aortic  valves. 
Both  primary  bronchi  contained  a  small  quantity  of 
coagulated  blood,  and  the  small  bronchi  in  the  lung 
contained  also  a  considerable  quantity  of  blood.  The 
left  lung  appeared  normal.  The  pleura  over  the  pos- 
terior and  outer  surfaces  of  the  right  lower  lobe  was 
completely  dissected  up  from  the  lung  by  extensive 
hemorrhage.  No  distinct  point  of  rupture  into  the 
bronchi  could  be  detected,  but  it  was  thought  that  the 
small  quantity  of  blood  in  the  bronchi  came  from  mul- 
tiple extravasations  into  the  pulmonary  tissue.  The 
spleen  and  kidneys  were  normal.  The  liver  was  dis- 
tinctly cirrhotic,  but  not  of  the  syphilitic  form.  The 
aorta  was  the  seat  of  advanced  atheromatous  changes 
throughout.  It  presented  three  aneurismal  dilatations  ; 
the  first  one,  situated  in  the  upper  part  of  the  descend- 
ing portion  of  the  aortic  arch,  was  about  the  size  of  a 
hen's  egg.  It  projected  forward,  and  was  adherent  to 
the  apex  of  the  left  lung.  The  mouth  of  the  aneurism 
was  3) J  ctm.  in  diameter,  and  the  wall  ij.-  to  2  mm. 
in  thickness.  The  inner  surface  was  not  lined  with 
fibrin.  The  second  aneurism  was  found  in  the  thoracic 
portion  of  the  aorta,  opposite  the  root  of  the  lung.  It 
projected  backward,  and  had  eroded  superficially  the 
soft  tissues  over  the  seventh,  eighth,  and  ninth  dorsal 
vertebroe.     Its  diameter  was  7  ctm.,  and  the  opening 


into  the  lumen  of  the  aorta  was  of  about  the  same  size. 
The  wall  was  only  i  mm.  in  thickness  in  certain  por- 
tions. It  was  not  lined  by  fibrin.  There  was  a  large, 
ragged  rupture  2  ctm.  in  diameter  at  the  root  of  the 
right  lung,  and  blood  escaped  through  this  rupture  be- 
tween the  visceral  pleura  and  the  lung.  The  third 
aneurism  was  located  in  the  abdominal  aorta,  just 
above  the  origin  of  the  renal  arteries.  It  had  a  diam- 
eter of  4  ctm.,  and  an  opening  of  about  the  same  size. 
The  superior  mesenteric  artery  and  the  cceliac  axis 
arose  from  the  interior  of  the  aneurism.  The  former 
was  of  large  size,  while  the  latter  was  completely  oc- 
cluded just  at  the  origin  of  the  vessel  from  the  aneur- 
ismal sac.  The  occlusion  seemed  to  be  due  to  the 
contraction  of  new  fibrous  tissue  in  the  wall  around 
the  lumen.  The  manner  in  which  the  blood-supply 
was  kept  up  under  these  circumstances  could  not  be 
determined,  as  the  specimen  had  not  been  carefully 
dissected,  and  this  point  was  not  discovered  until  the 
foUov/ing  day. 

Dr.  Coleman  said  that  in  view  of  the  occlusion  of 
the  cceliac  axis,  he  would  like  to  know  the  exact  condi- 
tion of  the  stomach  and  spleen. 

Dr.  Biggs  replied  that  both  these  organs  were  nor- 
mal, although  it  was  difficult  to  understand  ho.v  that 
could  be. 

The  -Society  then  went  into  executive  session. 


ACUTE    (EDEMA   OF   THE    LARYNX. 
By  E.   B.   BAYLIES,    M.D., 


Dr.  F.  E.  Hopkins,  in  reporting  an  interesting  case  of 
this  distressing  affection  in  the  issue  of  the  Medical 
Record  dated  October  19th,  goes  exhaustively  into  the 
subject  of  etiology,  but  seems  to  have  forgotten  that 
malaria  has  shown  one  of  its  many  ways  of  attacking 
mortals  by  appearing  in  this  form. 

Dr.  Jacob  D.  Arnold,  in  his  article  on  acute  laryn- 
gitis contributed  to  Burnett's  "  System  of  Diseases  of 
the  Ear,  Nose,  and  Throat,"  pages  312  and  313,  de- 
scribes what  he  terms  miasmatic  epiglottitis,  and  cites 
cases  in  point. 

The  following  case  is  reported  on  account  of  iis 
uniqueness  in  demonstrating  the  possibility  of  malaria 
causing  oedema  of  the  glottis,  as  well  as  showing  how 
readily  it  can  be  controlled  by  the  proper  remedies. 

A.  B ,  aged  thirty,  a  letter  carrier,  presented  him- 
self at  the  office  on  June  4th  last,  relating  a  history  of 
having  been  under  the  care  of  a  homoeopathic  physician 
for  about  a  week,  on  account  of  difficulty  in  breathing 
and  swallowing,  the  diagnosis  having  been  tonsillitis. 

At  this  time  breathing  was  moderately  difficult,  and 
deglutition  was  not  exceedingly  painful. 

Examination  revealed  a  reddened  pharynx,  but  no 
evidence  of  the  enlargement  of  the  tonsils. 

A  laryngoscopic  examination  brought  to  view  a  typ- 
ical case  of  oedema  of  the  larynx,  though  the  tissues 
were  not  so  much  swollen  as  to  prevent  a  very  fair  view 
of  the  cords. 

After  cocainizing  the  parts,  a  thorough  application 
of  zinc  chloride  two  per  cent,  solution  was  made,  and 
the  patient  sent  home,  to  report  next  day,  taking,  in  the 
meantime,  lozenges  composed  of  mild  astringents,  to 
be  dissolved  in  the  mouth  at  stated  intervals  and  swal- 
lowed. No  report  was  heard  from  him  the  next  day, 
but  the  day  following  a  call  to  come  in  haste  was  re- 
ceived. On  arriving  at  the  house  it  was  seen  that  all 
the  symptoms  were  very  much  aggravated,  though  the 
patient  said  that  the  day  before  he  had  concluded  that 
entire  recovery  had  taken  place.  The  treatment  was 
as  before,  with  the  addition  of  cold  applications  to  the  j 


November   i6,  1S95] 


MEDICAL   RECORD. 


715 


threat,  and  proper  medication  for  an  elevation  of  tem- 
perature to  101°  F.,  which  was  found.  Toward  even- 
ing the  symptoms  abated,  and  the  night  and  following 
day  were  spent  in  comparative  comfort.  The  fifth  day 
of  his  being  under  my  care  was  the  worst  of  the  series. 
The  temperature  was  above  101°  F.,  and  all  the  symp- 
toms were  more  grave.  The  voice  vi'as  husky,  and  in 
fact  it  began  to  look  as  if  more  radical  measures  would 
have  to  be  employed  if  life  was  to  be  saved. 

The  peculiarity  of  the  action  of  the  disease  had  im- 
pressed me  with  the  fact  that  perhaps  it  was  of  mala- 
rial origin,  and  I  began  the  exhibition  of  quinine  as  soon 
as  the  fever  subsided.  Five  grains  that  night,  ten  the 
next  morning  and  night,  with  five  on  the  morning  of 
the  seventh  day,  had  a  happy  effect,  the  attack  on  that 
occasion  being  very  mild.  A  continuation  of  the  treat- 
ment as  outlined  above  prevented  any  further  trouble 
and  restored  the  man  to  health. 

This  cannot  be  called  a  malarious  country,  but  if  the 
action  of  remedies  has  anything  to  do  with  determin- 
ing the  nature  of  diseases,  my  case  was  surely  one  pro- 
duced by  miasmatic  influences. 


A  YOUNG  MOTHER. 
Bv    C.    W.    GLEAVES,    M.D., 


WVTHEVILLE, 


I  WISH  to  report  the  case  of  the  youngest  motlier  in 

Virginia.      Annie  H was  born  in  Bland   County 

July  15,  1885,  and  September  10,  1895,  she  was  deliv- 
ered of  a  well-formed  child  weighing  five  pounds.  She 
was  only  ten  years  and  nearly  two  months  old.  The 
girl  has  no  developments  of  a  woman,  although  she 
has  menstruated  regularly  since  she  was  five  years  old. 

The  labor  was  a  short  and  uneventful  one,  and  two 
hours  afterward  the  child-mother  wanted  to  get  up  and 
dress,  and  would  have  done  so  had  she  been  per- 
mitted. 

There  were  no  developments  of  the  mammre,  or  secre- 
tion of  milk  ;  the  baby  was  nourished  through  its  short 
existence  (as  it  only  lived  a  week)  by  its  grandmother, 
who  had  a  child  only  a  few  months  old.  The  parents 
of  this  child,  Mr.  and  Mrs.  J.  P.  H. ,  are  prosper- 
ous, intelligent,  and  worthy  people,  and  there  is  no  doubt 
of  their  child's  age. 

The  child  is  now  well,  and  plays  about  with  the  other 
children  as  if  nothing  unusual  had  happened. 


CANCER  OF   THE    PROSTATE   GL.\ND. 
By   ERLY   H.    MADISON,   M.D., 


WiLLi.\M  D ,  aged  sixty-seven,  carpenter  by  trade  ; 

health,  previous  to  last  illness,  was  always  good.  Gave 
the  following  history  : 

In  the  winter  of  1890  he  received  an  injury  in  the 
region  of  the  prostate  gland,  caused  by  being  thrown 
on  the  pommel  of  a  saddle  while  riding  horseback. 
This  injury  caused  him  trouble  for  some  little  time, 
but  he  finally  recovered,  as  he  thought,  perfectly. 

In  the  winter  of  1S94  he  complained  of  uneasiness 
and  pain  in  the  neck  of  the  bladder  and  in  the  region 
of  the  prostate,  accompanied  by  a  frequent  desire  to 
urinate  ;  also  pain  upon  defecation.  These  symptoms 
gradually  increased  in  severity  until  about  May  i, 
1895,  when  he  was  confined  to  the  house,  with  com- 
plete retention  of  the  urine  and  great  pain  at  stool. 
.\bout  this  time  he  had  an  attack  of  localized  peritoni- 
tis on  the  left  side,  which  readily  yielded  to  treatment. 

The  most  prominent  symptoms  in  this  case  were  fre- 
quent desire  to  urinate,  pain  upon  defecation,  and  in- 


tense pain  in  the  region  of  the  bladder  and  prostate 
gland,  emaciation,  and  loss  of  appetite. 

Cancer  of  the  prostate  gland  was  diagnosed.  About 
January  lo,  1895,  I  called  Dr.  A.  H.  Lyman,  of  Fill- 
more, N.  Y.,  in  consultation,  who  confirmed  my  diag- 
nosis and  who  watched  the  case  with  me  during  the 
remainder  of  his  illness.  The  s)mptoms  already  de- 
scribed steadily  increased  until  death,  July  3,  1895. 

Post-mortem  showed  a  scirrhus  of  the  prostate  gland 
about  as  large  as  a  hen's  egg,  nodular  and  very  hard. 
The  peritoneum  was  also  infiltrated  with  cancerous 
masses.  There  was  also  a  small  secondary  cancer  of 
the  liver,  some  portions  of  which  had  undergone  cal- 
careous degeneration.  The  bladder  contained  about 
one  ounce  of  purulent  liquid,  evidently  partly  urine, 
partly  pus.  The  mucous  membrane  at  the  base  of  the 
organ,  while  extremely  red,  could  hardly  be  said  to  be 
ulcerated.  A  more  correct  description  of  it  would  be 
conveyed  by  the  term  granular  inflammation.  The 
rectal  wall  was  infiltrated  by  the  growth  and  was  ad- 
herent to  the  tumor,  although  rectal  symptoms  were 
surprisingly  few  and  slight,  being  practically  limited  to 
pain  on  defecation. 

The  peculiar  characteristics  of  this  case  are  :  i.  The 
rarity  of  the  disease.  I  have  been  able  to  find  only 
three  cases  reported,  two  by  Sir  Henry  Thompson. 
Dr.  Samuel  D.  Gross  says  he  never  saw  in  all  his  prac- 
tice a  scirrhus  of  the  prostate,  the  only  form  he  ever 
saw  being  colloid.  2.  The  obscurity  of  the  symptoms, 
making  diagnosis  extremely  difficult.  3  The  amount 
of  opiate  required  to  control  the  pain.  The  last  three 
weeks  of  his  illness  I  gave  him  four  grains  of  morphine, 
hypodermically,  every  four  hours,  and  this  amount  did 
not  produce  complete  narcosis,  the  effect  lasting  only 
from  two  to  three  hours.  A  hypodermic  needle  was 
used  on  this  case  something  over  one  thousand  times. 

Such  cases  as  this  are  extremely  suggestive  in  the 
light  of  present  pathological  knowledge.  Here  was  a 
growth  no  larger  than  a  hen's  egg  which  had  not  ulcer- 
ated and  which  caused  no  pressure  symptom  whatever 
excepting  inability  to  urinate.  The  urine,  to  with- 
in a  few  days  of  death,  remained  entirely  normal  as  far 
as  chemical  analysis  showed.  The  microscope  only 
showed  a  small  amount  of  mucus  from  the  bladder. 
There  was  never  any  rectal  discharge,  and  the  post- 
mortem showed  no  breaking  down  of  the  tumor.  And 
still  the  growth  caused  death. 

Death  from  malignant  disease  is  generally  attributed 
to  sepsis  from  absorption  from  ulcerated  surfaces  and 
to  hemorrhage.  But  such  cases  as  this  seem  to  point 
to  a  specific  cancer  poison,  to  a  specific  cancer  germ 
which,  though  it  now  eludes  the  microscope,  still  prob- 
ably exists  and  will  some  day  be  discovered. 


Quackery  in  Bavaria. — Official  statistics  which  have 
recently  been  published  show  that  the  total  number  of 
])ersons  practising  the  healing  art  without  a  legal  ciual- 
ification  in  Bavaria,  at  the  end  of  1894,  was  1,168  as 
against  1,152  in  the  previous  year.  Of  the  number  866 
were  men  and  302  were  women.  With  the  exception 
of  17  Austrians,  2  Americans,  r  Italian,  and  i  Swiss, 
the  whole  of  this  noble  army  of  quacks  was  a  home 
product.  As  regards  the  special  form  of  ([uackery,  the 
statistics  show  some  curious  features.  Thus,  12  philan- 
thropists devote  themselves  to  freeing  their  fellow- 
creatures  from  tapeworms  ;  12  practise  "  electrohomce- 
opathy,"  whatever  that  may  be  ;  while  84  are  set  down 
as  apostles  of  homoeopathy,  pure  and  simple  ;  129  offer 
to  sufferers — for  a  consideration — "secret  remedies 
and  sympathy,"  and  3  deal  in  uroscopy. — British  Med- 
ical Journal. 

Phoenix,  Ariz.,  is  progressive.  It  has  recently  or- 
ganized an  .Vnti- Noise  League.  When  the  league  is  in 
good  running  order  we  hope  it  will  send  missionaries 
to  New  York  and  other  suffering  places. 


7i6 


MEDICAL    RECORD. 


[November  i6,  1895 


Caries  of  Vertebrae. — Fontan  describes  a  new  operation 
for  reaching  the  bodies  of  the  vertebrae  ;  he  makes  an 
incision  one  centimetre  from  the  middle  line,  splits 
the  common  mass  of  muscles  in  order  to  come  upon 
the  apophyseal  tubercle  ;  then  outside  this  he  plunges 
in  his  finger,  in  order  to  recognize  the  costal  apophysis 
which  lies  at  a  deeper  level.  Then  with  a  chisel  he 
cuts  this  at  its  base,  seizes  it,  and  excises  it  completely. 
From  here  he  follows  the  vertebral  column  from  be- 
hind forward  with  the  raspatory,  keeping  close  to  the 
bone  under  the  periosteum,  until  he  reaches  the  seat  of 
the  caries. — ]M.  Foxtan. 

Diphtheritic  Conjunctivitis.— The  only  local  treat- 
ment was  by  washing  with  warm  water  and  with  a  so- 
lution of  boric  acid,  and  the  serum  was  administered 
in  doses  of  from  ten  to  thirty  cubic  centimetres,  ac- 
cording to  severity  and  to  the  age  of  the  patient.  In 
two  of  the  cases  single  doses  of  ten  cubic  centimetres 
were  sufficient. — Mor.\x. 

Appendicitis. — I  have  been  led  to  feel  that  when  the 
S)-mptoms  indicate  appendicitis,  the  combination  of  a 
rapid  pulse  and  respiration,  going  with  a  temperature 
normal,  or  nearly  so,  points  to  the  necessity  for  prompt 
operation. — Dawbarn. 

Bone  -  grafting. — Dead  bone  seems  to  answer  the 
same  purpose  as  the  living,  if  it  fills  the  defect  properly, 
the  formation  of  bone  in  each  case  taking  place 
throughout  the  implanted  portions  of  bone.  With  de- 
calcified bone  the  case  is  different ;  the  deposition  of 
bone  takes  place  only  on  the  surfaces  of  the  fragments. 
Bone  in  which  the  animal  matter  has  been  destroyed 
by  heat  answers  the  same  purpose.  The  beneficial  in- 
fluence seems  to  depend  upon  the  presence  of  the  cal- 
cium salts.  The  author  states  that  calcined  bone 
placed  in  the  soft  parts,  or  even  in  the  abdominal  cav- 
ity, is  followed  by  bone-formation. — Barth. 

Vaginal  Secretion  of  New-born  Infants. — For  twelve 
hours  after  birth  the  vulva  and  vagina  are  sterile. 
From  this  time  until  the  third  day  germs  are  occasion- 
ally found,  and  after  the  third  day  they  are  present  in 
most  cases.  In  four  per  cent,  of  cases  staphylococci 
were  discovered,  while  in  14.6  per  cent,  streptococci 
were  isolated. — V.\hle. 

Is  it  Peritoneum  or  Transversalis  Fascia  ? — Rei^ard- 
ing  the  recognition  of  peritoneum  as  distinguished 
from  transversalis  fascia,  these  membranes  cannot  al- 
ways be  distinguished  by  a  differing  appearance.  I 
have  often  seen  transversalis  fascia  that  did  not  look 
fibrillated,  and  was  just  as  shining  as  the  peritoneum. 
Possibly  it  may  be  worth  while,  for  others  than  the 
members  of  this  Society,  to  refer  to  a  valuable  point 
which  many  years  ago  I  obtained  from  Dr.  McBurney, 
and  have  never  seen  in  print,  namely,  that  after  cutting 
the  deepest  muscle,  its  cut  edge  be  lifted  and  its  deep 
surface  e.xamined.  If,  now,  that  surface  be  found  bare, 
then  the  transversalis  fascia  has  not  yet  been  cut.  But 
if  that  under-surface  of  the  deepest  muscle  be  found 
covered  with  a  fascia,  however  thin,  that  is  the  trans- 
versalis fascia,  which  has  already  been  cut,  and  then 
the  next  membrane  attacked  will  of  course  be  the  peri- 
toneum.— Dawdarx. 

Cancer. — He  believes  that  both  on  rf//w/-/ grounds 
and  on  the  existing  evidence  the  germ-theory  of  cancer 
should  be  rejected  unhesitatingly,  and  thinks  that 
"  the  microbe  of  cancer  has  not  yet  been  discovered, 
because  in  all  probability  it  does  not  exist."  As  to  con- 
tagion, there  is  not  a  single  authentic  instance  of  the 
transmission  of  cancer  from  one  individual  to  another. 


and  the  alleged  successes  in  the  attempts  to  transmit 
it  to  lower  animals  should,  he  thinks,  be  accepted  only 
in  a  tentative  sense. — Williams. 

Correlated  Variability. — It  is  a  very  remarkable 
fact  that  in  every  female  all  the  secondary  male  char- 
acters, and  in  every  male  all  the  secondary  female  char- 
acters, exist  in  a  latent  state,  ready  to  be  evolved  under 
certain  conditions.  It  seems  perfectly  warrantable  to 
assume  that  the  normal  condition  of  the  mammae  in 
each  sex  is  determined  by  correlation  with  the  essen- 
tial sexual  organs.  When  the  latter  are  destroyed  the 
correlated  integrated  force  determining  mammary  de- 
velopment also  fails,  so  that  the  latent  tendency  to  de- 
velop the  opposite  sexual  characters  then  becomes 
manifest. — ^^'ILLIAMS. 

Foul  and  Sloughy  Wounds.  —  In  the  treatment  of 
this  sloughing"  surface  sterile  gauze  soaked  in  oil  of 
turpentine  was  freely  employed  and  changed  daily,  the 
skin  being  thickly  dusted  with  compound  talcum  or 
bismuth  subnitrate,  to  avoid  turpentine  blistering. 
This  treatment  was  not  much  complained  of,  and  was 
ideal  in  its  results.  Indeed,  in  foul  and  sloughy  wounds, 
everywhere,  the  writer  knows  of  no  plan  of  equal  value 
with  this,  which  he  first  saw  suggested  many  years  ago 
by  Dr.  Banks,  the  Liverpool  surgeon. — Da\vb.a.rn. 

Lithotomy. —  The  supra-pubic  method  seems  so 
thoroughl)  to  have  established  itself  among  surgeons 
that  one  may  easily  look  forward  to  its  being  the  ope- 
ration of  the  future. — Heath. 

Flat  Foot. — I.  The  feet  of  the  infant  at  birth  are  not 
flat ;  the  tracing  at  that  time  resembles  the  adult  nor- 
mal foot.  2.  A  body  of  fat  develops  under  the  arch 
which  gives  the  appearance  of  flat  foot  for  some  years, 
and  at  four  or  five  years  of  age  this  is  absorbed.  3. 
The  smoke  tracing  is  not  a  perfect  method  of  studying 
abnormality  of  the  arch  of  the  foot,  because  it  fails  to 
detect  the  slighter  cases  or  to  record  pronation.  4. 
The  element  of  pronation  is  more  constant  than  break- 
ing down  of  the  arch  of  the  foot,  and  may  be  entirely 
separated  from  it.  5.  The  condition  of  pronated  foot 
without  breaking  down  of  the  arch  of  the  foot, 
should  be  recognized  and  not  confused  with  flat  foot. 
6.  The  treatment  of  pronate  and  flat  -  foot  is  the 
same,  and  consists  in  the  use  of  proper  boots,  the  ap- 
plication of  a  pad  or  plate,  the  stretching  of  the  gas- 
trocnemius muscle  where  it  is  shortened,  and  in  the 
routine  use  of  massage  if  obtainable,  and  always  of  ex- 
ercises to  develop  the  muscles  which  hold  up  the  arch. 
— HovETT  axd  Daxe. 

Ectopic  Pregnancy. — The  etiology  of  ectopic  preg- 
nancy is  still  shrouded  in  doubt,  but  after  examining  a 
large  number  of  cases  and  the  prior  history  of  these 
patients,  I  am  led  to  the  opinion  that  the  true  cause  is 
a  former  salpingitis,  which  has  either  destroyed  or  im- 
paired the  integrity  of  the  ciliated  epithelium  of  the 
Fallopian  tube  to  that  extent,  that  the  ovum  is  impeded 
in  its  i)assage  through  the  tube,  together  with  the  im- 
pairment of  the  peristaltic  action  of  the  tube  through 
the  same  inflammatory  process. — Sheldox. 

Acetanilid  as  an  Antiseptic. — The  action  of  aceta- 
nilid  upon  wounds,  especially  granulations,  when  used 
in  full  strength,  is  to  produce  intense  dryness,  blue- 
ness,  and  to  check  at  once  and  prevent  the  formation 
of  pus.  Upon  extensive  granulating  surfaces  and 
chronic  ulcers  a  slight  burning  sensation  is  at  first  per- 
ceived, which  is  rapidly  succeeded  by  a  sedative  or 
anassthetic  effect.  If  used  in  sufficient  quantity,  a  thin 
scab  of  acetanilid,  combined  with  the  wound  secretions, 
forms,  under  which  healing  rapidly  progresses.  If  a 
very  large  surface  is  exposed  to  the  action  of  the  undi- 
luted drug,  toxic  symptoms  promptly  supervene  in  sus- 
ceptible individuals. — Mortox. 


November  16,   1895] 


MEDICAL    RECORD. 


■17 


^Ticrapcutic  gints. 

Alcohol  in  Fevers. — i.  If  the  tongue  becomes  drv, 
discontinue  ;  if  moister,  the  drug  is  doing  good.  2.  If 
the  pulse  becomes  quicker  harm  is  being  done,  and 
the  contrary  if  slower.  3.  If  the  skin  becomes  moister 
the  antipyretic  effect  of  alcohol  is  obtained,  and  again 
good  is  being  done.  4.  If  the  breathing  becomes 
easier  continue  the  drug. — Armstroxg. 

Alcoholic  Intolerance. — The  fact  that  many  persons 
use  spirits  to  excess  at  intervals,  or  in  moderation  for  a 
lifetime,  and  from  superficial  observation  are  appar- 
ently no  worse,  is  both  misleading  and  dangerous.  In 
one  case  it  conveys  the  impression  that  spirits  are 
harmless  in  small  quantities,  and  occasional  excesses 
are  of  little  injury  from  which  restoration  quickly  fol- 
lows. In  the  second  case  the  danger  of  repeated  path- 
ologic disturbances  are  masked  until  organic  changes 
take  place,  and  most  serious  results  follow,  that  are  not 
apparent  except  in  other  departures  from  health. — 
Crothers. 

Cimex  Lectularius  and  Phthisis. — Parisian  scientific 
circles  are  exercised  over  the  discovery  that  bedbugs 
are  active  agents  in  the  transmission  of  the  bacillus  of 
tuberculosis  from  one  person  to  another. 

Adenoid  Growths. — The  retle.x  spasms  of  the  larj-nx 
and  a  condition  closely  resembling  that  of  croup  is  fre- 
quently caused  by  reflex  ner\-e-irritaUon  from  the 
pressure  of  such  growths  ;  and  general  convulsions, 
attacks  of  asthma,  or  deafness,  are  all  well-known  com- 
plications resulting  from  the  same  nervous  irritation. 

Local  Tuberculosis. — The  caustic  action  of  iodine  is 
limited  and  prolonged  when  the  metalloid  is  introduced 
in  the  powdered  form  into  a  tubercular  focus,  and  it  is 
still  more  prolonged  when  the  sublimed  crj'stals  are 
put  in  even  to  completely  fill  the  cavit)'.  Iodine  seems 
to  have  an  elective  action  on  tuberculous  tissues.  It 
acts  deeply,  and  is  painless  when  applied  to  tubercular 
nodules,  but  it  is  painful  and  merely  superficial  in  its 
action   when   applied   to    healthy   tissue. — Guermon- 

PREZ. 

Arsenic  in  Skin  Diseases. — The  diseases  for  which 
arsenic  seems  to  be  especially  useful  are  few.  .\t  the 
top  of  the  list  stands  psoriasis,  then  chronic  eczema, 
and  the  lichens,  with  some  of  the  hydroa  type.  Some 
cases  of  psoriasis  are  benefited. 

Bemoval  of  Tattoo  Marks. — After  asepsis  of  region 
the  tattoo  is  remade  with  a  solution  of  thirty  parts  of 
zinc  chloride  in  forty  parts  of  sterilized  water  ;  with 
due  precautions  no  great  inflammatory  reaction  takes 
place.  After  a  few  days  a  crust  forms,  which  falls  off 
from  the  fifth  to  the  tenth  dav. — Br.^ult. 


The  Contagion  of  Scarlet  Fever. — Dr.  Edward  G.  Gil- 
bert writes  to  the  British  Medical  Journal  that  in  a 
considerable  practice  for  the  last  twenty  years  he  has 
acted  on  the  conviction  that  in  a  desquamating  skin 
after  scarlet  fever  there  is  no  danger  to  others :  and 
that  if  the  throat  and  nose  are  quite  sound  again,  isola- 
tion of  the  patient  is  not  necessary  for  more  than  a 
month,  .\cting  on  this  theor)',  he  has  uniformly  suc- 
ceeded in  preventing  the  spread  of  the  disease,  although 
often  children  with  free  desquamation  still  going  on 
have  mixed  and  played  freely  with  others  who  have 
never  had  the  disease.  During  the  period  of  isolation 
he  has  the  skin  smeared  daily  with  a  weak  solution  of 
carbolic  acid  in  oil,  and  during  the  last  week  of  it  the 
patients  have  three  good  scrubbings  with  hot  water  and 
soap,  immediately  after  the  last  of  which  they  are  sent 
from  their  rooms,  leaving  all  their  belongings  behind 
them. 


Corvcspoiulencc. 

OUR    LONDON    LETTER. 

^From  our  Special  Correspondent.) 

king's    college DR<     BEALE's    -ADDRESS — ORIGIN    OF 

LIFE — SIR  CRICHTON  BROWXE's  -ADDRESS — MIND  AND 
MATTER — HARVEI.4X  OR.ATION  .AT  THE  COLLEGE  OF 
PHYSICIANS — SOCIETIES — MEDICO-CHIRURGICAL  NEW 
ENTRIES. 

London,  October  25,  iSgj. 

King's  College  is  a  Church  institution,  and  all  its  pro- 
fessors are  accordingly  required  to  accept  the  articles 
of  the  Episcopal  Established  Church.  In  consequence 
of  this,  opposition  was  raised  to  a  grant  from  the  public 
funds,  and  the  late  government  withdrew  the  grant  un- 
less the  College  would  give  up  its  sectarian  demand. 
The  College  refused,  and  the  new  government  has  re- 
stored the  grant.  Whatever  may  be  said  in  favor  of 
tests  in  the  theological  faculty,  there  are  departments 
of  knowledge  in  which  sectarianism  might  well  be  ex- 
cluded. King's  was  founded  avowedly  as  a  Church 
school,  to  counteract  the  influence  of  L'niversity  Col- 
lege, which  was  established  on  non-sectarian  lines.  No 
doubt  there  would  be  legal  diflSculties  in  the  way  of 
altering  the  constitution  of  either. 

The  professor  of  medicine  at  King's  and  physician 
to  the  hospital  is  Lionel  Beale,  F.R.S.,  whose  researches 
on  bioplasm,  a  word  of  his  coining,  must  be  as  familiar 
to  your  readers  as  his  great  authority  on  microscopical 
researches.  -\t  his  opening  lecture  he  took  the  oppor- 
tunity of  declaring  his  continued  conviction  that  the 
materialists'  views  of  the  origin  of  life,  of  late  years  so 
ardently  advocated  by  a  small  section  of  scientific  men, 
are  contrary  to  all  living  nature,  and  to  make  them 
popular  it  was  necessary  to  invent  a  new  nature — a 
nature  which  has  been  shown  to  be  impossible.  Then 
he  remarked  that  lately  a  change  has  come  over  these 
advocates,  and  not  a  few  have  begun  to  doubt  whether 
the  purely  physical  doctrine  of  life  is  supported  by  facts. 
Even  the  president  of  the  Chemical  Section  at  the  late 
Scientific  Congress  pleaded  "  for  a  little  more  \ntality," 
and  Dr.  Beale  naturally  joins  in  the  plea,  as  he  has  for 
years  been  the  prominent  supporter  of  the  ^•iew  that  a 
\'ital,  guiding,  arranging,  regulating,  constructing  power 
is  working  in  everything  that  has  life.  It  is  some  five 
and  thirty  years  since  Dr.  Beale  laid  down  the  distinc- 
tion between  forming  and  formed  material.  He  has 
taught  that  every  form  of  living,  growing  matter  is  ab- 
solutely distinct  from  every  kind  of  formed  material 
produced  by  it,  and  that  the  influence  on  the  non-living 
pabulum  is  peculiar  and  belongs  to  all  living  matter, 
but  to  this  only,  and  is  not  comparable  with  or  allied 
to,  any  other  property,  power,  or  action.  Many  new 
facts  have  been  discovered  about  living  matter,  but  ob- 
servation and  experiment  go  to  show  that  all  its  powers 
have  been  derived  from  pre-existing  living  matter  and 
may  be  transmitted  without  loss,  though  sometimes 
with  temporary  modifications.  We  have  been  told 
again  and  again  that  we  are  on  the  eve  of  finding  out 
how  life  works,  but  Dr.  Beale  says  we  are  further 
off  than  ever  from  this  discovery,  and  asks  whether, 
in  the  whole  range  of  knowledge,  one  fact  can  be 
pointed  out  as  comparable  with  vital  characteristics  ; 
whether  anyone  of  the  powers  of  living  matter  has  re- 
ceived anything  like  adequate  explanation  ;  and  whether 
there  is  anything  in  the  non-living  world  comparable 
with  the  ordinary  changes  that  have  taken  place  in 
every  living  particle  that  has  ever  existed.  Dr.  Beale 
then  observed  that,  in  the  wonderful  operations  of  liv- 
ing matter,  we  must  look  for  the  foundations  of  physio- 
logical, pathological,  and  medical  science,  and  indeed, 
of  that  of  the  whole  living  world  as  distinguished  from 
the  lifeless  cosmos.  Here,  too,  we  must  look  for  ori- 
gin of  the  changes  characteristic  of  the  living  state,  and 


7i8 


MEDICAL    RECORD. 


[November  i6,  1895 


account  must  be  taken  of  these  vital  phenomena  in 
discussions  about  consciousness,  thought,  and  will,  and 
the  life  that  has  been,  is,  and  is  to  be. 

Approaching  the  subject  from  a  somewhat  different 
stand-point,  but  travelling  to  the  same  goal,  Sir  J. 
Crichton  Browne,  in  his  presidential  address  at  the 
Medical  Societ\%  on  Monday  last,  treated  of  relations  of 
mind  to  matter.  Admitting  that,  as  often  asserted, 
there  is  an  inbred  predisposition  to  adopt  materialistic 
constructions  of  the  external  world,  and  that  if  it  be  so 
it  would  be,  it  follows,  as  Arthur  Balfour  argues,  that 
such  belief  is  necessary,  he  remarked  that  the  tendency 
may  have  been  strengthened  by  medical  studies,  so  that 
some  had  come  to  regard  thought  as  a  cerebral  secre- 
tion. No  doubt  a  few  medical  writers  have  used  lan- 
guage of  this  kind,  which  Sir  Crichton  proceeded  to 
controvert — maintaining  that  investigations  would  be 
more  fruitful  if  unhampered  by  this  false  hypothesis. 
He  held  it  necessary  to  again  and  again  insist  on  the 
truth  that  mental  activity  cannot  be  referred  to  any 
physical  agency,  and  that  ingenious  analogies  with  heat, 
light,  and  electricity,  though  useful  for  illustrative  pur- 
poses, can  never  bridge  the  gulf  betiveen  mind  and 
matter.  Mind  and  matter,  he  declared,  were  two  dis- 
tinct essences,  irreconcilable  in  their  nature,  but  ac- 
cordant in  their  operations.  One  kind  of  motion  may 
be  transformed  into  another,  but  under  no  condition 
can  mind  pass  into  a  thought,  or  a  thought  into  motion. 
Even  a  neural  process  and  a  mental  process  have  noth- 
ing in  common.  The  discoveries  in  the  histology  of 
the  brain  have  not  brought  us  a  hair's-breadth  nearer 
a  solution  of  the  mystery  of  mind.  But  mental  changes 
are  definitely  linked  with  changes  of  body,  and  to  ac- 
count for  this  Sir  C.  Browne  supposed  a  parallelism  of 
two  causal  series  running  side  by  side,  but  never  inter- 
fering with  each  other.  This  is  somewhat  akin  to 
Leibnitz's  pre  established  harmony,  which  likened 
mind  and  body  to  two  clocks,  side  by  side,  keeping  ex- 
act time.  A  psycho-physical  parallelism  is  thus  as- 
sumed as  an  ultimate  scientific  fact,  and  the  two  sets  of 
sequences  must  await  a  higher  synthesis  to  unite  them. 
That  higher  synthesis  is  an  ideal  to  which  perhaps  we 
cannot  attain  with  our  present  faculties,  though  it 
would  introduce  us  to  a  coherent  theory  of  the  uni- 
verse. 

But  this  psycho-physical  parallelism,  though  close  and 
exact  as  far  as  it  goes,  is  very  limited  in  extent.  \'ital 
phenomena  are  insignificant  if  compared  with  the  forces 
of  the  material  universe,  and  of  these  vital  phenomena 
there  are  only  a  few  in  which  we  discern  mental  pro- 
cesses. The  whole  mass  of  organic  life,  animal  and 
vegetable,  is  but  a  film  of  exquisite  tenuity  spread 
over  patches  of  the  material  surface  like  the  bloom  on 
a  ripe  plum.  Brain  substance  in  this  film  is  only  an  in- 
finitesimal sprinkling  like  grains  of  gold  in  the  earth's 
crust,  and  of  this  brain  substance  only  a  tithe,  the  gray 
matter  of  the  cerebral  hemispheres,  is  concerned  with 
man's  mental  life.  The  parallelism  is  only  between 
mind  and  the  highest  level  of  nervous  evolution,  and 
does  not  apply  to  the  elaborate  products  of  mental  life. 
In  other  respects  obvious  limitations  were  pointed  out. 
What  we  perceive  is  but  a  fraction  of  physical  events 
beyond  our  cognizance.  The  spectrum  is  only  a  meas- 
ure of  the  degree  in  which  we  are  not  color-blind. 
Stone-deafness,  except  for  a  paltry  eleven  and  a  half  oc- 
taves, is  universal  in  our  species,  and  there  are  in  nature 
vibrations  laden  with  tastes,  smells,  and  tactile  impres- 
sions that  cannot  reach  us.  So  limited  after  all  is  the 
parallelism,  that  we  miglit  perhaps  rather  liken  mind 
and  matter  to  two  vast  spheres  that  only  impinge  on 
each  other  at  one  point.  Sir  Crichton  repudiated  there- 
fore some  of  the  localizationists  as  quite  as  ridiculous 
as  their  predecessors,  the  phrenologists.  In  breaking 
up  the  faculties  into  constituent  ideas  and  distributing 
them  among  morphological  units  of  the  brain,  thevhave 
overlooked  the  complex  processes  involved  in  the  forma- 
tion of  an  idea.     There  is  no  mental  atom  indivisible. 


unalterable,  and  eternal.  A  single  rod  or  cone  of  the 
retina  cannot  be  the  seat  of  a  visual  image,  and  no 
more  can  a  single  cell  of  the  visual  area  be  the  seat  of 
a  visual  idea.  The  young  medical  psychologist  who 
piqued  himself  on  having  discovered  a  delusion  cell 
was  only  the  victim  of  a  profound  delusion. 

While  I  was  writing  my  last  week's  letter,  the  Royal 
College  of  Physicians  was  commemorating  Harvey  and 
its  other  benefactors  by  the  Harveian  oration,  which  was 
delivered  this  year  by  Dr.  W.  S.  Church  and  was,  I  am 
assured,  a  good  specimen  of  these  discourses.  This  is 
the  two  hundred  and  thirty-ninth  celebration,  or  nearly 
so,  for  I  believe  there  have  been  a  few  intermissions 
of  the  annual  function,  which  is  not  to  be  wondered  at 
in  so  long  a  period.  Of  course,  one  does  not  expect 
anything  new  about  Harvey  by  this  time,  but  a  fresh 
aspect  is  sometimes  given  at  these  orations  to  some  facts 
in  connection  with  him  or  his  work.  On  this  occasion, 
I  learn,  his  views  on  "  innate  heart "  were  prominently 
considered.  At  the  conclusion  of  the  oration  the  Baly 
medal  was  presented  to  Dr.  Gaskell.  This  medal  was 
founded  in  1866  in  memory  of  Dr.  Baly,  physician  to 
the  Queen  and  translator  of  Muller's  Physiology. 

At  the  Medico-Chirurgical  it  was  considered  "a 
graceful  act  "  to  present  to  the  country  doctors  who  had 
contributed  valuable  information  to  the  Report  on 
Health-Resorts,  a  copy  of  the  part  of  the  report  con- 
taining their  contributions.  A  very  graceful  act  !  If 
the  report  is  worth  anything  I  should  have  supposed 
each  contributor,  not  being  paid,  would  have  expected 
a  complete  copy.  Considering  how  soon  the  volume 
will  be  almost  unsalable,  I  should  think  the  society 
might  distribute  copies  to  those  who  have  assisted. 

There  was  a  paper  on  "  Posture  in  Relation  to 
Operations  and  Aneesthesia,"  but  the  debate  on  it  was 
adjourned,  so  I  defer  any  remarks. 

There  has  been  a  meeting  of  one  or  other  society  or 
else  a  lecture  every  day  this  weak,  and  to  night  the 
Clinical  Society  is  to  have  the  president's  address  and 
several  papers.  You  will  see,  therefore,  that  there  is 
plenty  going  on  to  occupy  those  who  can  or  will  spare 
time  for  attendance,  and  this  society's  work  is  well  worth 
the  fatigue  it  entails,  for  even  at  the  dullest  meetings 
there  is  generally  something  to  be  picked  up,  and  of 
course  always  the  opportunity  of  meeting  friends  ; 
though  it  must  be  confessed  that  sometimes  "  the 
bores  "  have  long  innings. 

The  new  entries  at  the  London  schools  are  not  quite 
so  discouraging  as  was  feared. 

The  death  of  another  surgeon-general  is  announced, 
that  of  Dr.  Shelton,  of  paralysis,  in  his  seventy-fourth 
year.  Death  has  been  very  busy  of  late  among  the 
retired  army  surgeons. 


MATERNAL   IMPRESSIONS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  The  case  of  supernumerary  thumbs,  recently  re- 
ported in  your  columns,  recalls  a  case  in  which  my 
informant  believed  that  a  child  was  born  with  cleft 
palate,  because  the  pregnant  mother  had  been  surprised 
at  seeing  her  roommate  remove  from  her  mouth  a  set  of 
artificial  teeth. 

As  counter-evidence  allow  me  to  contribute  the  fol- 
lowing :  Mrs.  S ,    who  had   recently  lost  an    only 

child,  a  daughter,  aged  ten,  to  whom  she  had  been  de- 
votedly attached,  and  for  whom  she  "  mourned,  and 
mourned,  and  mourned,"  became  pregnant.  Living 
in  the  neighborhood  was  an  intimate  friend  who  had 
an  idiot   child.     During  the  whole  of  the  pregnancy 

Mrs.  S was  profoundly  impressed   with  the  idea 

that  the  coming  babe  would  be  a  girl,  and  she  an 
idiot ;  but  at  the  proper  time  she  was  delivered  of  a 
well-nourished  boy.  and  he  as  intelligent  "  as  they 
make  them." 


November  i6,  1895] 


MEDICAL    RECORD. 


■19 


My  experience  leads  me  to  the  following  conclu- 
sions :  If  maternal  impressions  could  produce  the  ef- 
fect some  claim,  i,  the  majority  of  conceptions  would 
abort  soon  after  the  mother  discovered  she  was  preg- 
nant ;  and,  2,  the  minority  would  be  "marked"  or 
crippled,  mentally  or  physically. 

Frederick  H.  S.  Ames.  M.D. 

D  WER,  Col. 


WHERE    THE    PRINCIPAL    BL.\ME    SHOULD 
REST. 

To  THB  Editor  of  the  Medical  Record. 

Sir  :  I  have  read  your  recent  editorials  concerning  the 
"  reform  "  in  the  charity  hospitals,  secured  through 
the  summary  removal  of  men  who,  for  years,  had  given 
their  time  and  talents  toward  the  succor  of  the  poor, 
and  the  substitution  of  supposedly  equally  competent 
men  prepared  to  similarly  serve  the  worthy  poor.  You 
have  laid  stress  on  the  gross  outrage  thus  inflicted  on  a 
deserving  body  of  professional  men,  and  you  have  paid 
your  respects  in  an  honest,  upright,  manly  way  to  the 
so-called  "  reform  "  Commissioners  who,  on  the  sur- 
face, have  dictated  this  act.  You  have  also  inciden- 
tally noticed  the  statement  that  certain  of  these  Commis- 
sioners claim  that  everyone  is  satisfied  except  the  "  sore- 
heads "  who  have  been  removed. 

Since  I  may  properly  figure  as  not  being  a  "  sore- 
head," having  voluntarily  resigned  last  spring  after 
duty  properly  done  —  otherwise  the  Commissioners 
presumably  could  not  have  appointed  me — I  feel 
safe  in  calling  your  attention  to  a  fact  you  seem  to 
have  overlooked,  which  is,  that  the  obloquy  and  the 
shame — everlasting  shame — of  this  wholesale  and  un- 
called-for removal  belongs  to,  and  shall  rest  with,  the 
small  number  of  medical  men  who  instigated  and  ad- 
vised the  act,  rather  than  with  the  Commissioners,  who 
were  simply  tools.  This  fact  it  behoves  the  medical 
profession  to  ponder  over  and  to  remember.  Respect- 
fully, Egbert  H.  Gr.-vkdin,  M.D.. 

Consulting  Ohstit.ic  Surgeon  ( Emciitiis)  Neiv  York 
Materuiiy  Hospital. 


German  physicians  there  is  hardly  one  who  speaks 
English  ;  in  France  it  is  certainly  not  better.  It  is 
amusing,  however,  to  read  in  his  letter  that  the  French 
and  the  Germans  have  annexed  many  English  words. 
The  German  would  say,  "  Umgekehrt  wird  ein  Schuh 
draus."  I  think  I  understand  German  and  French 
both  pretty  well,  but  I  know  only  one  English  word 
which  all  Germans  and  Frenchmen  employ,  namely,  the 
word  '■  beefsteak." 

Far  be  it  from  me  to  say  one  word  in  disparagement  of 
the  English  language,  the  English  or  the  American  peo- 
ple ;  on  the  contrary,  I  fully  admire  both  language  and 
nations.  In  one  of  my  pamphlets  on  Greek  I  even  have 
quoted  the  enthusiastic  praises  of  the  greatest  German 
linguist,  Jacob  Grimm,  which  he  has  given  to  the  Eng- 
lish language.  English  is  certainly,  as  Dr.  Greene  says, 
a  good  and  a  practical  language  ;  but.  as  I  have  said 
already,  it  is,  as  little  as  the  German  or  the  French,  the 
language  to  be  selected  for  international  communica- 
tions of  scholars. 

There  can  be  no  doubt  that  the  study  of  the  classic 
languages,  and  of  the  Greek  more  especially,  is  indis- 
pensable to  the  formation  of  a  truly  cultured  mind.  It 
has  been  said  that  no  truly  liberal  education  is  possible 
without  the  study  of  Greek.  It  is  impossible  to  imag- 
ine a  polished  gentleman  devoid  of  knowledge  of  it. 
Especially  an  Englishman,  in  order  to  understand  his 
own  language,  must  necessarily  know  Latin  and  Greek. 

I  am  sure  Dr.  Greene  will  not  dispute  these  facts, 
and  since  Greek  has  to  be  on  the  school  plan,  since 
every  true  scholar  is  obliged  to  know  it.  I  only  ask  for 
a  consideration  of  the  living  Greek,  and  that  it  be 
taught  in  a  rational  way  in  our  schools. 

A.  Rose,  M.D. 

336  East  Fifteenth  Street,  New  York. 


l^ccXical  Stems. 

Contagions  Diseases — Weekly   Statement Report  of 

cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  November  9.  1895. 


THE    QUESTION    OF    AN    INTERNATIONAL 
L.\NGUAGE. 

To  the  Editor  of  the  Medical  Record. 

Sir  :  Your  correspondent.  Dr.  W.  T.  Greene,  of  Belve- 
dere, Kent,  England,  simply  ignores  the  question  at 
issue.  In  my  first  paper  on  Greek,  read  before  the 
Academy  of  Medicine,  I  said  ;  "  The  rivalry  of  nations  is 
against  the  employment — as  an  international  language 
— of  one  of  those  principally  spoken  in  the  civilized 
world,  such  as  English,  French,  or  German.  In  addi- 
tion, these  languages  are  insufficient  for  the  expression 
of  new  ideas  and  for  the  composition  of  words.  Even 
as  it  is  now,  the  English,  French,  and  German  have 
one  thing  in  common,  they  borrow  from  one  and  the 
same  language,  which  has  many  claims  to  be  preferred 
to  every  other  in  the  selection  of  a  universal  language 
for  scholars.  In  choosing  Greek  no  mutual  rivalry 
need  be  taken  into  consideration.  .  .  .  While  an 
universal  language  sufficient  to  satisfy  the  intellectual 
want  of  every  people  and  of  every  time  can  be  as  little 
imagined  as  the  equality  of  all  mankind,  still  such  an 
uniformity  is  possible  in  a  restricted  part  of  human  so- 
ciety, viz.,  in  that  aristocracy  formed  by  art  and  sci- 
ence. It  is  not  the  masses  who  need  such  an  universal 
language,  but  the  men  of  science." 

Dr.  Greene  himself  confirms  my  views  in  saying,  "  I 
dare  say  the  Frenchman  and  the  German  would  squirm 
at  the  idea  [to  have  English  the  universal  language]. 
Let  them."  Now,  this  settles  it :  as  long  as  the  French- 
man and  the  German  squirm,  English  will  simply  be 
an  impossibility  as  an  international  language. 

Dr.  Greene  is  perhaps  not  aware  that  of  hundreds  of 


Cases.    I   Deaths. 


"S 
IS 


Tuberculosis    iii 

Typhoid  fever 39 

Scarlet  fever 55 

Cerebro-spinal  meningitis 2 

Measles 112 

Diphtheria 188 

Whooping-cough 


The  Dangers  of  Long  Jonrneys. — Huchard  calls 
special  attention  to  arterial  cardiopathy  and  interstitial 
nephritis.  Some  years  ago,  he  says,  a  man  fifty  years 
old,  who  had  arterial  cardiopathy,  showed  slight  symji- 
toms  of  renal  insufficiency,  with  hyposystole,  although 
there  were  no  traces  of  albumin  in  the  urine.  The  pa- 
tient intended  to  make  a  long  journey  by  rail,  and  M. 
Peter,  who  saw  him  in  consultation  with  M.  Huchard, 
made  no  objection  to  this.  They  were  very  much  as- 
tonished, says  the  author,  to  hear  that,  two  days  after 
his  arrival  at  Nice,  he  had  been  taken  with  dangerous 
symptoms  of  acute  uraemia  and  had  died  in  less  than  a 
week.  In  the  same  year  another  patient,  suffering  with 
the  same  trouble,  died  after  a  journey  of  twenty- six 
hours  by  rail.  M.  Huchard  has  also  seen  the  same 
symptoms  supervene  in  identical  conditions,  but  with- 
out a  fatal  termination.  The  trembling  motion  of  the 
train,  says  M.  Huchard,  which  so  quickly  jjroduces 
symptoms  of  renal  congestion  and  genito  urinary  exci- 
tation, leads  to  the  transformation,  in  arterial  cardi- 
opathy, and  especially  interstitial  nejihritis,  of  incom- 
plete renal  impermeability  to  a  complete  impermeability, 
from  which  sometimes  arise  the  fulminant  sym])toms  of 
uraemia.     M.  Huchard  thinks  that  patients  who  suffer 


720 


MEDICAL    RECORD. 


[November  16,  1895 


with  arterial  cardiopathy  or  with  interstitial  nephritis, 
with  slight  symptoms  of  renal  insufficiency,  should 
avoid  long  journeys  by  rail.  If,  however,  a  long  jour- 
ney has  to  be  taken,  it  should  be  done  in  easy  stages, 
with  intervals  of  several  days  for  rest.  The  following 
examples,  says  M.  Huchard,  demonstrate  the  unfavor- 
able influence  of  long  journeys  on  patients  suffering 
with  these  troubles  :  A  patient  who  had  come  under 
Prout's  observation  suffered  very  much  from  cold  and 
sea-sickness  during  a  tiresome  voyage,  and  died  the 
following  morning.  Charcot  mentions  the  case  of  a 
woman  who,  before  leaving  Paris  for  Switzerland,  made 
a  number  of  calls  on  foot  and  returned  home  com- 
pletely exhausted.  The  following  morning  she  be- 
came comatose,  and  death  occurred  very  rapidly. 
Foster  cites  an  observation  of  a  man  who  took  a  very 
long  walk  in  order  to  reach  his  home.  He  complained 
of  feeling  very  tired,  and  on  the  next  day  symptoms  of 
diabetic  poisoning  set  in  and  he  died  on  the  third  day. 
M.  Huchard  himself  has  observed  a  diabetic  who  suf- 
fered with  arterial  cardiopathy.  This  patient  went  to 
Paris,  where  he  spent  some  time  in  taking  long  walks 
about  the  city.  Eight  days  afterward  he  became  com- 
atose, and  death  rapidly  supervened.  Here,  says  M. 
Huchard,  the  aggravation  of  the  disease  cannot  always 
be  attributable  to  renal  congestion,  nor  can  the  long 
journeys  by  rail  be  given  as  the  pathogenic  cause  of 
the  symptoms.  It  is  known  that  the  muscles,  which 
are  alkaline  in  a  state  of  repose,  become  acid  after  re- 
peated and  energetic  contractions,  for  a  muscle  that  is 
tired  is  a  muscle  poisoned  by  acids,  and  especially  by 
lactic  acid.  Now,  fatigue,  long  walks,  and  violent  ex- 
ercise act  in  the  same  way  as  diabetic  poisoning,  which 
is  nothing  but  an  acid  poisoning. — A'co  York  Medical 
Journal. 

The  Ductless  Glands.— The  equivocal  position  of  the 
ductless  glands  in  the  animal  economy,  and  the  inter- 
esting nature  of  the  facts  that  have  recently  been  ascer- 
tained in  regard  to  them,  give  a  special  interest  to  a  re- 
cent address  by  Professor  Schafer.  The  functions  of 
the  spleen,  thyroid,  thymus,  and  supra-renal  capsules 
have  long  been  shrouded  in  obscurity,  and  many  points 
in  their  life-history  still  remain  to  be  elucidated.  ( The 
Lancet.)  The  similarity  of  the  structure  of  these  bodies 
to  that  of  glands,  but  unprovided  with  ducts,  their 
large  volume,  and  the  evident  activity  of  the  processes 
that  take  place  in  their  interior,  as  indicated  by  their 
large  vascular  and  nervous  supply,  which  militates 
against  the  supposition  that  they  are  useless  or  that 
they  are  mere  degenerate  remains  of  once  more  im- 
portant organs  ;  and,  on  the  other  hand,  the  possibility 
of  removing  the  whole  or  the  greater  part  of  their  sub- 
stance without  apparent  injury  to  the  health  of  the 
animal — all  these  and  many  otlier  facts  combine  to 
render  them  a  physiological  puzzle.  For  many  years 
past,  however,  the  conviction  has  been  growing  in  the 
minds  of  physiologists  that  their  true  function  consisted 
in  the  separation  of  certain  materials  from  the  blood, 
acting  in  the  same  fashion  as  the  salivary  glands  or 
pancreas,  but  that  these  secretions,  instead  of  being 
discharged  from  the  surface  of  the  body,  as  is  the 
sweat,  or  into  the  alimentary  canal,  are  reabsorbed 
into  the  blood,  and  fulfil  certain  definite  purposes  in 
the  economy.  Hence  the  term  applied  to  them  by 
Professor  Schafer,  of  internal  secretions.  In  one  sense 
every  part  of  the  body,  be  it  nerve  or  muscle,  bone  or 
fat,  modifies  the  blood  in  a  similar  manner,  by  abstract- 
ing from  the  blood  the  materials  of  its  own  nutrition 
and  restoring  to  that  fluid  the  products  of  its  disinte- 
gration. In  the  cases  of  the  liver  and  pancreas  the  in- 
ternal secretion  is  ijiore  important  than  the  external, 
since  the  secretion  of  the  former  of  these  glands,  at 
least,  may  be  permanently  diverted  by  a  fistula  without 
interference  with  the  vital  functions,  while  removal 
of  the  whole  gland  is  invariably  fatal.  As  our  knowl- 
edge of  the  liver  and  its  functions  has   extended  we 


begin  to  see  the  reason  of  this.  The  liver  visibly  se- 
cretes bile  which  may  be  abstracted  before  entering 
the  alimentary  canal  without  harm,  but  it  also  forms 
urea  and  glycogen,  and  it  is  the  accumulation  and  de- 
composition of  these  products  that  cause  death  when 
the  whole  gland  is  removed.  Analogous  experiments 
on  the  pancreas  enable  similar  deductions  to  be  drawn. 
The  pancreatic  juice  can  be  diverted  by  a  fistula  from 
the  intestine,  and  the  major  part  of  the  gland  can  be 
cut  away  without  harm,  but  if  the  whole  be  removed 
death  results  from  diabetes.  The  internal  secretion  of 
the  gland  is  more  important  than  the  secretion  it  dis- 
charges by  its  ducts.  After  discussing  the  relations  of 
the  thymus  and  thyroid  bodies  Professor  Schafer  dwelt 
at  length  on  the  supra-renal  capsules,  on  which  he, 
with  the  assistance  of  Dr.  Oliver  and  Mr.  Moore,  has 
been  working  for  some  years.  He  sums  up  his  results, 
which  show  conclusively  that  the  medullary  portion  of 
the  adrenals  contains  a  dialysable  organic  principle,  sol- 
uble in  water  and  not  destroyed  by  boiling  for  a  short 
time,  which  produces  a  powerful  physiological  action 
upon  both  striated  and  unstriated  muscular  tissue,  es- 
pecially affecting  the  skeletal  muscles  and  the  muscles 
of  the  blood-vascular  system,  causing  these  contrac- 
tions to  be  greatly  prolonged,  and  in  this  respect  re- 
sembling the  action  of  veratria.  It  also  has  some  ex- 
citing influence  on  the  cardio-inhibitory  centres  in  the 
medulla  oblongata,  causing  the  heart  to  slow  down  : 
but  after  section  of  the  vagi  it  exercises  an  opposite 
effect,  increasing  the  force  and  frequency  of  the  heart's 
action,  and  thus  leading  to  a  great  rise  in  the  blood- 
pressure,  which  is  enormously  increased  by  its  power 
of  inducing  contraction  of  the  muscular  tissue  of  the 
arterioles. 

Pastor  Kneipp's  Medical  Practice. — The  IVestminsttr 
Gazette,  of  recent  date,  contains  an  account  of  the  way 
in  which  Father  Kneipp,  of  cold-water  fame,  treats  his 
patients  at  Woerishofen.  He  could  give  points,  as  re- 
gards rapidity  of  diagnosis,  to  many  a  dispensary  doc- 
tor in  New  York,  for  the  average  time  which  he  de- 
votes to  each  patient  is  about  twenty-four  seconds. 
When  receiving  patients  on  a  busy  day  the  pastor  sits 
at  a  long  table  in  a  large,  plainly  furnished  room,  smok- 
ing a  huge  cigar.  He  dictates  his  "prescriptions"  to 
an  assistant  in  a  solemn  tone,  as  if  he  were  presiding 
at  a  religious  ceremonial.  Men,  women,  and  children 
of  every  station  in  life  file  past  him.  In  an  hour  and 
a  quarter  he  gets  through  one  hundred  and  eighty 
without  difficulty.  There  is  no  examination,  and  few 
questions  are  asked.  Indeed,  there  is  little  necessity, 
for  cold-water  baths  and  bandages  and  walks  on  wet 
grass  with  bare  feet  exhaust  the  worthy  pastor's  phar- 
macopoeia. There  is  one  exception — an  ointment  com- 
posed of  honey  and  medicinal  herbs  for  those  who  suf- 
fer from  diseases  of  the  eye.  But  then  the  ointment  is 
a  sovereign  one  for  everything,  and  so  Pastor  Kneipp 
manages  to  break  the  record  as  an  oculist  as  well. 

Experimenting  upon  Criminals. — The  Governor  of 
the  Punjab,  in  India,  has  ordered  that  half  the  prisoners 
in  the  jails  there  be  kept  on  fresh  water,  and  half  on 
boiled,  records  being  kept  to  see  whether  the  boiled 
water  has  any  effect  in  the  way  of  preventing  ordinary 
sickness. 

Deaths  from  Lightning. — During  the  five  years, 
1S90-1S94,  lightning  caused  the  death  of  one  thousand 
one  hundred  and  twenty  persons  in  the  United  States. 
The  greatest  number  occurred  during  June  and  July, 
and  all,  with  but  few  exceptions,  between  the  months 
of  April  and  September. 

A  ftuartette  in  Himself. — .\ccording  to  a  newspaper 
paragraph,  now  going  the  rounds,  Dr.  Stuart,  of  Syd- 
ney, N.  S.  W.,  has  invented  an  artificial  larynx,  which 
has  been  successfully  applied,  the  mechanism  of  which 
can  be  so  regulated  as  to  make  the  voice  bass,  soprano, 
tenor  or  contralto,  at  will. 


Medical   Record 

A  Weekly  you/iial  of  Medicine  ami  Siiygeyy 


Vol.  48,  No.  21. 
Whole  No.  1307. 


New  York,  November 


1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©liijinal  ^vticlcs. 

SOME  OBSERVATIONS  UPON   THE  EFFECTS 
OF    HORSE-SERUM    INJECTIONS.' 

Bv   HENKV    DWIGHT  CHAPIN,    M.D., 

The  special  appeal  that  serum  therapy  makes  to  all 
thoughtful  physicians  is  the  fact  of  its  not  being  em- 
piric, but  based  upon  a  long  and  laborious  study  con- 
ducted on  scientific  principles.  At  last  we  seem  to 
have  reached  a  therapy  that  is  directly  founded  upon 
a  knowledge  of  the  natural  history  of  the  disease  it  is 
intended  to  combat.  The  products  of  the  diseased  pro- 
cess in  one  animal  may  be  employed  to  check  the  rav- 
ages of  the  same  disease  in  another  animal.  Experi- 
menters have  not  been  slow  in  following  up  this  new 
field,  and  protective  or  curative  inoculations  of  serum 
have  been  tried  in  many  diseases.  Diphtheria,  cholera, 
hydrophobia,  influenza,  pneumonia,  small-pox,  tetanus, 
tuberculosis,  typhoid  fever,  and  syphilis  may  be  men- 
tioned as  diseases  in  which  serum  therapy  has  been 
proposed,  and,  in  some,  given  a  more  or  less  extensive 
trial.  The  serum  from  various  animals  has  been  tried. 
Thus,  Tommasoli  treated  six  syphilitic  patients  with 
intra-muscular  injections  of  sheep  blood-serum,  and 
the  same  author  used  dog- serum  upon  five  cases  of 
lupus.  Kollman  tried  sheep,  calf,  dog,  and  rabbit  se- 
rum in  syphilis,  some  of  the  patients  remaining  under 
treatment  for  eight  and  a  half  months.  In  all  the 
studies  that  have  been  made,  comparatively  little  at- 
tention seems  to  have  been  given  to  the  action  of 
blood-serum  itself  upon  the  economy,  entirely  apart 
from  any  curative  effects  upon  certain  diseases  or  the 
development  of  antitoxins.  The  new  works  on  serum- 
therapy  do  not,  as  a  rule,  mention  any  dangers,  or  con- 
tain any  warnings  as  to  the  limit  of  its  use.  In  the 
absence  of  such  caution,  last  winter  the  writer  experi- 
mented with  horse-serum  injections  in  a  number  oi 
children  suffering  from  syphilis  and  allied  diseases. 
The  treatment  was  continued  for  about  two  weeks, 
and  all  the  cases  did  badly.  It  then  occurred  to  me 
that,  in  serum,  we  are  dealing  with  a  physiological 
fluid  of  great  potency  and  that  damage  might  result 
from  its  careless  or  too  prolonged  use.  .\  glance  at  the 
jjhysiologies  shows  that  serum  is  described  as  a  trans- 
parent, yellowish,  alkaline  fluid,  with  a  specific  gravity 
of  from  1.025  t-o  1032,  being  the  liquid  part  of  the  blood 
or  of  the  plasma  which  remains  after  the  separation  of 
the  clot.  Serum  differs  from  j)lasma  in  that  it  contains 
no  fibrinogen  ;  it  contains  paraglobulin  and  serum-al- 
bumin in  the  same  proportion  as  does  the  plasma. 
Thus  it  appears  tliat  these  fluids  are,  above  all,  highly 
albuminous  solutions,  containing  nearly  as  much  pro- 
teid  as  is  contained  in  ordinary  white  of  egg.-' 

With  reference  to  the  effect  of  serum,  as  sucii,  upon 
other  bodies,  little  is  said.  Landois  and  Sterling  state 
that  the  blood-serum  of  some  mammals  dissolves  the 
blood-corpuscles  of  other  mammals.  Thus,  dog- se- 
rum and  frog-serum  dissolve  the  blood-corpuscles  of 
the  rabbit  in  a  few  minutes.  They  do  not  say,  how- 
ever, in  what  manner  the  serum  is  applied  to  the  cor- 

■  Read  before-  the  New  York  Academy  of  Medicine  Novc-mber  7, 
1S95.  -  Waller's  Physiology. 


puscles.  Hermann,  under  Transfusion,  in  the  "  Hand- 
buch  der  Physiologic,"  also  mentions  blood-serum  as  a 
destroyer  of  the  red  blood-corpuscles.  Hayem,  upon 
the  same  topic,  states  that  autopsies  on  animals  that 
have  received  transfusion  of  blood  from  one  species  of 
animal  to  another,  show  that  of  the  lesions  resulting, 
those  of  kidney  congestion  and  changes  in  the  uropo- 
etic  apparatus  take  first  rank.  In  order  to  study  some 
of  the  effects  of  blood-serum  injections  various  ani- 
mals were  subjected  to  injections  for  different  lengths 
of  time  and  then  killed.  In  all  of  the  cases,  plain, 
sterilized  horse-serum  was  employed.  The  horses  had 
not  been  inoculated  with  any  toxins,  and  were  appar- 
ently healthy.  Certain  conditions  of  the  blood  were 
noted  before  and  after  the  injections. 
In  1,000  parts  of  serum  there  are  : ' 

Water about  900 

Proteids : 

a.   Serum-albumin ) 

/3.   Serum-globulin '■       So 

7.   Fibrin  ferment ) 

Salts. 

Fats,  including  fatty  acids,  cholesterin,  lecithin,  and  some] 
soaps I 

Grape  sugar  in  small  amount | 

Extractives — creatin,  creatinin,  urea,  etc [•      20 

Yellow  pigment,  which  is  independent  of  hasmoglobin 

Gases — small   amounts   of  oxygen,  nitrogen,   and  carlionic  | 
acid  . .    J 

I, coo 

July  2,  1S95. — Large  rabbit  ;  two  months  ;  count  of 
the  red  blood-corpuscles,  8,316,666  ;  ha;moglobin,  105  ; 
5  c.c.  serum  injected.  In  three  hours  :  corpuscles, 
7,170,000  ;  haemoglobin,  90.  July  loth,  after  daily  in- 
jecting 5  c.c.  serum  :  corpuscles,  8,246,666  ;  haemoglo- 
bin, 95.  Autopsy  :  Spleen  enlarged  and  congested  ; 
kidneys  showed  cloudy  swelling. 

July  4th.— Sheep,  two  years  old  ;  weight,  60  pounds  ; 
healthy;  hfemoglobin,  no;  16  c.c.  serum  injected. 
In  three  hours  :  h;vnioglobin,  no;  12  c.c.  serum  in- 
jected daily  until  July  16th  ;  temperature  varied  from 
104°  F.  to  105°  F.  (normal,  about  101°  F.)  ;  respira- 
tion and  pulse  increased,  but  the  animal  ate  well  ;  no 
(xdema  nor  infiltration  around  points  of  injection. 
July  16th,  temperature  105!°  F.;  haemoglobin,  100. 
The  animal  was  killed  by  being  bled  to  death.  Au- 
topsy :  Kidneys  enlarged,  soft,  and  congested,  with  all 
evidences  of  cloudy  swelling  :  glomeruli  prominent, 
with  granular  prominences  marked  over  the  cortex  ; 
very  marked  congestion  at  base  of  pyramids  ;  infarction 
in  one  kidney  :  spleen  enlarged. 

July  5th. — Guinea-pig  ;  corpuscles,  9,253,333  ;  lue- 
moglobin,  105  ;  2  c.c.  serum  injected.  In  three  hours  ; 
corpuscles,  8,453,333  ;  hicmoglobin,  100.  More  white 
blood-corpuscles,  and  quite  a  number  of  blood  plaques 
to  be  seen.  J  uly  1 1  th,  after  daily  injecting  2  c.c.  serum  : 
corpuscles,  7,783,000  ;  hxmogloljin,  105.  .Vutopsy  : 
Spleen  enlarged  and  congested  ;  kidneys,  congestion 
and  cloudy  swelling. 

July  nth. —  Large  dog;  ha;moglobin,  120;  8  c.c. 
serum  injected.  In  three  hours:  hxmoglobin,  118. 
Daily  injections  were  given,  increasing  each  dose  by 
2  c.c.  until,  on  July  lyth,  24  c.c.  was  injected,  and  the 
animal  killed;  haemoglobin,  118.  Autopsy:  Spleen 
enlarged,  with  Malpighian  tufts  greatly  congested  ; 
kidneys,  capsule  adherent  :  cortex  shows  cloudy  swell- 

'  KirkeN  Hand-book  of  Physiology. 


722 


MEDICAL    RECORD. 


[November  ^j,  1895 


ing  ;  medullary  rays  very  prominent  ;  pyramids  show 
very  marked  congestion. 

July  iSth.  —  Guinea-pig;  corpuscles,  9,320,000; 
hsemoglobin,  112  ;  2  c.c.  serum  injected,  and  in  three 
hours  :  corpuscles,  8,970,000  ;  hsemoglobin,  no  :  2  c.c. 
injected  daily  until  July  25th  ;  corpuscles,  10,983,333  ; 
hsemoglobin,  106.  Autopsy  ;  Spleen  enlarged  and  con- 
gested, with  Malpighian  tufts  prominent  ;  kidneys,  con- 
gestion and  cloudy  swelling. 

August  3d. — Large  rabbit  ;  corpuscles,  7,436,666  ; 
hsmoglobin,  105  ;  2''2  c.c.  serum  injected,  and  in  three 
hours:  corpuscles,  7,343,333  ;  haemoglobin,  105:  2'^ 
c.c.  injected  daily  until  .\ugust  9th  :  corpuscles, 
6,983.333  ;  haemoglobin,  105.  Autopsy  :  Spleen  en- 
larged and  congested  ;  kidneys,  cloudy  swelling. 

In  the  remaining  experiments  only  three  injections 
were  given,  in  place  of  the  repeated  injections  of  the  first 
experiments.  The  speedy  recuperative  powers  of  the 
blood  are  well  known,  hence  the  tests  were  made  a  few 
hours  after  the  first  injection  and  repeated  at  the  end  of  a 
goodly  number  of  injections  in  the  first  experiments. 

October  14th. — Small  rabbit  ;  corpuscles,  8,036,666  ; 
haemoglobin,  98  ;  2  c.c.  of  serum  were  daily  injected 
on  October  14th,  15th,  and  i6th. 

October  1 7th — Corpuscles,  6,656,666  ;  haemoglobin,  95. 
Autopsy  :  Spleen  not  enlarged.  Microscopical  examina- 
tion of  frozen  sections  of  the  kidneys  showed  cloudy 
swelling  and  numerous  small  areas  of  fatty  degeneration. 

October  21st. — White  rabbit,  i  pound,  5^^  ounces 
in  weight  ;  corpuscles,  11,716,666  ;  haemoglobin,  85  : 
i^^  c.c.  serum  injected  on  October  21st,  22d,  and 
23d.  October  24th,  weight,  i  pound,  6  ounces  ;  cor- 
puscles, 10,196,666  ;  haemoglobin,  85.  Autopsy  :  Mi- 
croscopical examination  of  kidneys  showed  cloudy 
swelling  and  a  few  small  areas  of  fatty  degeneration  ; 
spleen  not  enlarged. 

October  21st. — White  rabbit,  weight,  i  pound  s>-' 
ounces  ;  control,  uninjected  ;  corpuscles,  12,040,000  ; 
haemoglobin,  90.  Kept  under  same  conditions  as  for- 
mer rabbit. 

October  24th: — Corpuscles,  11,023,333  !  haemoglobin, 
85  ;  weight  i  pound  6J2  ounces.  Autopsy  :  Kidneys 
normal  ;  microscopical  examination. 

October  30th. — Rabbit,  i  pound  15  ounces  ;  cor- 
puscles, 9,686,666  ;  haemoglobin,  95  ;  1J12  c.c.  serum 
injected  on  October  30th,  31st,  and  November  ist. 
November  2d  :  Urine  had  specific  gravity,  1.015,  with 
a  trace  of  albumin.  Under  the  microscope,  a  large 
number  of  abnormal  blood-corpuscles  and  a  few  fine 
granular  cells  ;  corpuscles,  8,083,533  ;  haemoglobin, 
§5  ;  weight,  i  pound,  15  ounces.  Autopsy  :  Kidneys 
showed  cloudy  swelling  and  some  fatty  degeneration. 

October  30th. — Rabbit,  i  pound  7'i  ounces  ;  con- 
trol, uninjected  ;  corpuscles,  9,206,666  ;  hjemoglobin, 
105.  November  2d  :  Microscopical  examination  of 
the  urine  showed  a  number  of  abnormal  corpuscles 
and  one  fine  granular  cast  ;  no  albumin  ;  corpuscles 
7,233,333  ;  haemoglobin,  105.  Autopsy  :  Microscopi- 
cal examination  showed  cloudy  swelling  of  the  kidneys 
and  some  fatty  degeneration. 

November  4th. — One  per  cent,  of  egg  albumin  was 
mixed  with  a  six-tenths  percent,  salt  solution  ;  2  c.c.  of 
this  was  injected  into  a  guinea-pig  on  November  4th, 
5th,  and  6th.  November  7th  the  urine  contained  a  faint 
trace  of  albumin,  a  few  abnormal  blood-corpuscles,  and 
two  or  three  fine  granular  cells;  no  casts.  Autopsy: 
Kidney,  slight  amount  of  cloudy  swelling  ;  liver,  marked 
cloudy  swelling  and  fatty  infiltration. 

.•\s  a  control,  another  guinea-pig  was  injected  on 
November  4th,  5th,  and  6th  with  2  c.c.  of  a  simple  six- 
tenths  per  cent,  salt  solution.  November  7th  :  Urine, 
specific  gravity,  1.018,  and  trace  of  albumin  ;  a  large 
number  of  abnormal  blood-corpuscles  and  several  fine 
granular  cells.  Autopsy  :  Kidney,  simple  cloudy  swell- 
ing ;  no  fat  :  liver,  cloudy  swelling  and  fatty  infiltration. 

In  attempting  to  draw  conclusions  from  experiments 
upon  animals,  especially  rabbits  and  guinea  pigs,  two 


considerations  must  be  borne  in  mind.  The  worry  and 
annoyance  to  which  they  are  subjected  by  repeated 
handling  and  opening  of  vessels,  with  a  certain  loss  of 
blood,  has  an  unfavorable  effect  upon  their  health. 
Again,  these  animals  that  have  been  kept  cooped  up 
for  experiments  are  often  in  an  unsound  condition  to 
begin  with.  Thus,  two  of  my  controls  had  about  as 
bad  a  state  of  the  kidneys  as  the  animals  experimented 
on.  In  Dr.  Vissman"s  experiments  with  rabbits,  how- 
ever, the  injection  of  antitoxin  serum  invariably  pro- 
duced nephritis,  which  was  not  found  in  the  controls. 
In  summing  up  the  experiments  here  narrated,  they 
are  to  a  certain  extent  inconclusive,  except  that  the  in- 
jections of  the  serum  do  not  appear  to  have  produced 
any  very  marked  effect  in  these  animals,  save  upon  the 
kidneys.  Serum  injections,  as  ordinarily  employed  in 
therapeutics,  probably  have  little  effect  upon  the  blood- 
corpuscles.  The  kidneys  are  the  vulnerable  point,  and 
must  always  be  carefully  watched  when  injections  are 
employed.  Another  possible  danger  is  noted  in  the 
June  number  of  the  London  Veterinary  Journal.  It  is 
here  stated  that  M.  Nocard  recently  reported  to  the 
Society  of  Biology  of  Paris  the  results  of  some  experi- 
ments that  he  has  been  conducting,  from  which  it  ap- 
pears that  the  blood  sometimes  contains  microbes,  al- 
though no  germs  could  be  found  by  microscopic  study 
of  the  blood.  Cultures  made  from  the  serum  of  blood, 
collected  with  such  precautions  as  to  prevent  the  pos- 
sibility of  infection,  indicate  that  microbes  are  some- 
times present,  and  especially  during  digestion.  The 
latter  has  led  M.  Nocard  to  believe  that  microbes  find 
their  way  into  the  blood  through  the  intestinal  wall. 
Examinations  made  upon  dogs  recently  fed,  and  upon 
fasting  dogs,  have  shown  that  the  blood  of  fasting  dogs 
is  always  sterile. 

In  conclusion,  the  final  verdict  upon  serum  injec- 
tions and  serum  therapy  must  rest  upon  clinical,  rather 
than  laboratory,  evidence.  Studies  in  the  laboratory 
thus  far  made,  warn  us  to  use  this  powerful  agent  care- 
fully. If  prolonged  and  careful  clinical  observ'ations 
made  under  varying  conditions  and  by  different  ob- 
servers prove  its  utility,  serum  therapy,  in  spite  of  pos- 
sible dangers,  will  have  a  brilliant  future.  Research  in 
the  line  of  separating  the  antitoxins,  so  that  they  may 
be  given  in  an  innocuous  vehicle,  or  highly  concen- 
trating them  in  small  quantities  of  serum,  seems  to  be 
the  next  step  desirable.  I  am  indebted  to  Dr.  Gill  for 
supplying  me  with  serum,  and  to  Drs.  Brooks,  Wyman. 
Lewright,  and  Wilson  for  aid  in  the  experiments. 


When  May  Gonorrhoeics  Marry? — The  question  when 
may  syphilitics  marry  has  been  often  discussed  and 
answered.  The  inquiry  now  is  turned  toward  the  vic- 
tims of  chronic  gonorrhoea.  Dr.  Lowenhardt  asserts 
that  the  prospective  bridegroom  should  be  subjected  to 
repeated  examinations  in  order  to  determine  the  pres- 
ence or  not  of  the  gonococcus.  A  slight  secretion  is 
not  sufficient  for  this  purpose,  but  the  urethral  mucosa 
must  be  irritated  in  such  a  manner  as  to  place  it  in 
analogous  condition  (excess  in  bacchoet  venere')  to  those 
which  light  up  an  indolent  case.  The  best  means  to 
obtain  this  result  is  to  inject  a  few  drops  of  a  one-fifth 
per  cent,  solution  of  silver  nitrate.  If,  then,  the  secre- 
tion contains  no  gonococci,  but  is  strictly  made  up  of 
epithelial  cells,  marriage  can  be  permitted.  The  pres- 
ence of  numerous  pus  corpuscles  necessitates  renewed 
examinations  and  treatment  of  this  pseudo-gonorrhoea. 
Lowenhardt  insists  upon  the  fact  that  the  gonococcus 
is  alone  responsible  for  the  virulence  of  the  exudate 
and  the  serious  results  that  follow  inoculation  with  it  in 
the  genital  apparatus  of  women. 

Antitoxin  Treatment  of  Syphilis. — Dr.  Vievorovsky 
has  been  employing  antitoxin  serum  in  the  treatment 
of  syphilis,  in  the  Moscow  Military  Hospital,  and 
claims  to  have  observed  most  satisfactory  results. 


November,   23   1895] 


MEDICAL    RECORD. 


723 


ERYSIPELAS  IX  ITS  ETIOLOGICAL  RELA- 
TION TO  PRECEDING  SKIN  LESION,  AND 
ITS   LOCAL    TREATMENT.' 

By  CHARLES  W.   ALLEX,  M.D., 
KEW  voaif. 


Gentlemen'  :  In  the  preparation  of  the  following  brief 
paper  I  have  been  influenced  : 

1.  By  the  belief  that  originating,  as  erysipelas  so  often 
does,  in  some  skin  affection  or  lesion  of  the  integu- 
ment, and  being  in  itself  so  pre-eminently  a  skin  dis- 
ease, its  study  should  receive  greater  consideration 
from  dermatologists  than  has  often  been  accorded  it 
in  the  past. 

2.  By  the  fact  that  certain  suggestions  as  to  treat- 
ment, made  in  a  paper  read  by  me  at  our  Fifteenth  An- 
nual Meeting,  have  in  a  further  test  given  results  which 
warrant  their  being  reported. 

3.  By  the  statement  from  no  less  an  authority  than 
one  of  our  honorary  members,  Professor  Kaposi  (Eng- 
lish translation  of  last  edition  of  his  "  Handbook,"  p. 
289),  that  the  plan  of  surrounding  the  parts  with  adhe- 
sive plaster  has  not  acted  as  a  preventive  of  the  spread 
of  er)-sipelas. 

In  defence  of  my  first  reason  I  may  state  that  in  Mr. 
Crocker's  excellent  "  Handbook  "  of  recent  date,  the 
subject  of  erysipelas  is  omitted.  Jamieson  likewise  ex- 
cludes it  from  his  work  on  skin  diseases.  Other 
authors  show  the  same  inclination  to  ignore  this  dis- 
ease in  their  dermatological  writings.  It  was  only  re- 
cently, and  on  my  motion,  that  the  erysipelas  wards  of 
the  New  York  City  Hospital  were  made  a  part  of  the 
dermatological  senice — a  change  which  I  feel  sure  has 
proven  advantageous  to  all  concerned.  It  seems  to 
me  that  if  there  is  any  one  disease  which  should  be  in 
ever}-  way  disconnected  from  the  surgeon  and  his  work, 
it  is  eiysipelas  ;  and  this  is  equally  true  of  the  gyne- 
cologist and  obstetrician.  There  is  still  much  to  be 
learned  about  erysipelas  in  its  migrating  and  erratic 
forms,  and  as  a  recurrent  affection  in  such  dermato- 
logical conditions  as  are  presented  by  elephantiasis. 
It  should  also  receive  further  study  as  a  causative 
agent  in  the  production  of  pseudo-elephantiasis,  and  it 
is  probable  that  much  could  still  be  found  out  about 
the  relation  which  true  erysipelas  bears  to  certain  at- 
tacks of  pseudo-er)-sipelas  observed  after  vaccination. 
In  the  realm  of  diagnosis  as  well,  the  specialist  for  the 
skin  should  find  an  interest  and  a  field  of  usefulness, 
for  it  must  be  the  experience  of  all  that  numerous  af- 
fections of  inflammatory  nature — dermatitis,  poison 
ivy,  and  drug  eruptions,  certain  erj-themas,  and  even 
occasional  rarer  forms  of  eczema,  have  at  times  been 
wrongly  diagnosticated  as  erysipelas  by  the  unwary. 

The  etiological  relationship  of  erj'sipelas  to  derma- 
toses and  to  certain  lesions  of  the  skin,  is  likewise  of  in- 
terest, and  I  have  been  impressed  with  the  frequency 
with  which  some  cutaneous  parte  lentre'e  for  the  infec- 
tion can  be  discovered  if  sufficient  attention  is  given 
to  the  e.xamination.  Thus  in  100  cases,  which  include 
50  reported  to  this  Association  four  years  ago,  just  one- 
half  were  clearly  traceable  to  pre-existing  skin  lesion. 
Of  these,  vaccination  furnished  12  instances  ;  varicella, 
5  ;  ulcer,  5  ;  impetigo,  4  ;  ulceration  of  the  skin  fol- 
lowing circumcision,  4  ;  syphilis  of  the  scalp,  3  ;  ecthy- 
ma, 2  ;  ulcerating  naevus,  2  ;  fissure,  2  ;  dermic  ab- 
scess, 2  ;  elephantiasis,  2  ;  pediculosis,  i  :  pustular 
eruption  upon  the  legs,  i  :  excoriation,  i  ;  eczema,  i  ; 
dermatitis  from  kerosene,  i  ;  dermatitis  calorica,  i  ; 
rosacea,  i  ;  total,  50. 

Of  the  remaining  50  cases,  in  29  the  origin  is  either 
not  accounted  for  or  is  not  put  down  in  the  notes. 
Throat  disease  is  made  accountable  for  9  instances ; 

'  Read  at  the  Nineteenth  Annual  Meeting  of  the  Medical  Associa- 
tion, Montreal,  September  17..1S95. 


trauma  has  5  to  its  credit  ;  catarrh,  3  :  lachrymal  fis- 
tula, 2  ;  salivation,  i  :  and  ulcerating  tooth,  i. 

The  frequency  with  which  soreness  of  the  throat  pre- 
cedes the  earliest  manifestations  of  erysipelas  upon  the 
skin  surface,  has  led  me  to  look  upon  the  former  re- 
gion, and  especially  that  of  the  tonsil,  as  one  furnish- 
ing in  many  instances  the  conditions  necessary  for  the 
entrance  of  streptococci.  I  have  already  stated  my  be- 
lief that  in  the  proximity  of  the  faucial  and  nasal  mu- 
cous membranes,  and  their  liability  to  present  denuded, 
excoriated,  or  granulating  surfaces,  and  especially  in 
the  peculiar  anatomical  conformation  of  the  tonsil  it- 
self, is  to  be  found  the  explanation  of  the  relatively 
great  frequency  of  erysipelas  of  the  face. 

This  frequency  is  indicated  in  the  following  table, 
which,  so  far  as  the  facial  cases  are  concerned,  agrees 
closely  with  the  statistics  given  by  various  authors,  as 
well  as  with  my  own  made  up  from  a  large  number  of 
cases.     Of  these  fifty  cases  now  to  be  considered  : 

25  involved  the  face  (fifty  per  cent.). 
12         "  "   arm. 

S        "  "   leg. 

3        •■  "   genitals. 

I         "  "   hand. 

I         "  "   scalp. 

The  treatment  of  erysipelas  has  been  an  ever-chang- 
ing one,  but  in  recent  years  it  must  be  admitted  that 
the  modifications  of  the  methods  have  been  influenced 
by  Fehleisen's  discover)'.  The  reason  that  so  many 
different  drugs  have  had  their  warm  advocates  at  vari- 
ous times,  lies  partly  in  the  fact  that  scarcely  any  one 
remedy  had  been  found  which  exerted  a  decided  influ- 
ence upon  the  course  of  the  affection,  and  partly  in  the 
self  limited  nature  of  the  disease,  which,  in  most  in- 
stances, tends  to  spontaneous  resolution  in  about  a  fort- 
night, when  uncomplicated,  and  occurring  in  middle 
life. 

The  claim  of  any  plan  of  management  must  therefore 
be  based  upon  its  powers  to  jugulate  the  process,  or  to 
confine  it  to  a  period  of  a  few  days.  The  statement 
sometimes  made  by  authors,  that  there  is  no  treatment 
which  arrests  the  march  of  erysipelas,  will  not  stacd  at 
the  present  day,  nor  can  I  accept  the  statement  of  those 
who  would  include  the  plan  of  adhesive  bandaging 
among  the  useless  dences  for  checking  its  spread. 

The  plan  of  treatment  which  I  have  for  the  most 
part  employed  during  the  past  few  years,  aims  to  accom- 
plish its  purpose,  first  by  preventing  extension  of  the 
disease  process  into  new  territory  ;  and  then  to  restore 
the  skin  to  its  normal  state  by  making  compression,  ex- 
cluding the  atmospheric  oxygen,  and  exerting  an  anti- 
septic and  reducing  action  upon  the  already  inflamed 
and  infiltrated  area.  While  perfectly  well  aware  that 
there  is  nothing  new  either  in  the  theory  or  in  the  em- 
ployment of  the  particular  agents  for  the  practical  ac- 
complishment of  the  desired  end,  still  I  have  been 
forced  to  the  belief  that  in  the  following  procedure, 
which  I  have  termed  the  "'  combined  method,"  we  pos- 
sess an  effectual  means  of  preventing  the  extensive  in- 
vasion of  new  territory,  as  well  as  of  cutting  short  the 
existing  process  in  a  verj-  large  proportion  of  cases. 

The  plan  consists  simply  in  the  application  of  bands 
of  rubber  adhesive  plaster,  as  advocated  by  Wolfler,  in 
such  a  way  as  to  entirely  shut  in  the  region  implicated, 
and  then  in  covering  over  the  whole  of  the  enclosed 
area,  including  the  apparently  healthy  skin,  with  ich- 
thyol  in  collodion  var)'ing  in  strength  from  ten  to  fifty 
per  cent.  The  bands,  one  inch  wide  for  a  child  and 
one  and  a  half  inch  for  an  adult,  are  applied  in  such  a 
manner  about  the  limb,  trunk,  or  head,  that  a  decided 
pressure  is  exerted  upon  the  skin  against  the  underly- 
ing bony  or  softer  parts.  The  bands  are  applied  at  a 
distance  of  from  one  to  three  inches  from  the  visible 
margin  of  the  advancing  patch,  varying  with  the  region, 
rapidity  of  the  advance,  and  degree  of  intensity  of  the 
inflammation.  The  theory  of  action  is  that  the  lym- 
phatic vessels  and  channels,  in  which  the  streptococci 


724 


MEDICAL    RECORD. 


[November  23,  1895 


are  believed  to  circulate,  are  compressed  in  such  a  way 
as  to  prevent  the  penetration  of  the  latter  to  the  parts 
beyond.  Upon  a  limb  I  apply  the  bands,  if  possible, 
both  above  and  below  the  patch  of  erysipelas  ;  upon  the 
trunk  I  surround  the  part,  lavnng  the  bands  in  a  direc- 
tion where  the  best  points  for  counter  pressure  are  to 
be  found  ;  ujjon  the  head  I  apply  them  tightly  about 
the  forehead,  and,  if  required,  across  the  vertex  or  any 
portion  of  the  scalp  after  a  swath  of  hair  has  been  cut 
close  for  its  reception. 

In  my  former  paper  I  advised  the  application  of  the 
method  to  head  cases,  and  my  subsequent  experience 
has  shown  that  it  acts  here  quite  as  well  as  elsewhere. 
-A.  lotion  or  ointment  of  ichthyol,  or  possibly  the  substi- 
tution of  some  other  local  dressing,  is  here  advisable, 
though,  upon  the  face,  I  have  found  little  opposition  to 
the  disfiguring  nature  of  the  paint.  Ichthyol  has  been 
experimentally  shown  to  possess  decided  antibacterial 
properties,  and  to  be  fatal  to  erysipelas  cocci  in  cultures 
even  in  weak  solution.  Its  action  as  a  reducing  agent  is 
also  known.  When  these  qualities  are  combined  with 
those  which  collodion  furnishes  for  making  compres- 
sion and  excluding  air  from  a  part,  we  possess  a  local 
dressing  which  is  not  alone  theoretically  admirable,  but 
one  which  has  been  practically  demonstrated  to  pos- 
sess decided  merit. 

The  results  of  treatment  by  the  combination  of  the 
adhesive  strips  and  the  ichthyol  varnish,  so  applied  as 
to  include  the  still  healthy-appearing  skin,  making  one 
continuous  occlusive  dressing,  have  been  very  satisfac- 
tory. My  notes  were  not  made  at  the  time  with  the 
view  of  incorporating  them  in  a  paper,  and  are  frag- 
mentary and  lacking  in  detail.  It  is  shown  by  them, 
however,  that  at  least  30  cases  were  treated  by  the  re- 
stricting band  ;  22  of  them  in  conjunction  with  the 
ichthyol  varnish  ;  2  with  solutions  of  ichthyol  ;  2  with 
aristol  in  collodion  ;  and  in  4  the  form  of  local  dressing 
is  not  recorded. 

In  II  instances  ichthyol  varnish  was  alone  applied 
without  the  band,  or  at  least  no  mention  is  made  of  the 
latter  ;  6  received  ichthyol  ointment  or  solution,  and 
in  the  3  others  the  treatment  employed  is  not  in  evi- 
dence. 

In  the  30  cases  treated  by  the  combined  method,  14 
are  recorded  as  showing  no  extension  beyond  the  bar- 
riers. In  9  the  result  is  not  put  down.  In  3  extension 
of  the  erysipelas  beyond  the  band  is  noted.  In  3  the 
result  is  marked  "  recovery  ;  "  i  of  them  being  entered 
as  "prompt,"  i  as  "well  in  three  days,"  and  i  "  in  a 
few  days."  In  i  the  patch  ceased  spreading  before  the 
margin  reached  the  band.  In  i  a  recurrence  is  noted 
after  some  days,  and  this  in  turn  was  recovered  from  in 
eight  days.  In  2  of  the  11  cases  treated  without  the 
band  no  spreading  occurred  beyond  the  limits  of  the 
ichthyol  varnish. 

The  dates  do  not  show,  as  a  rule,  just  how  long  the 
cases  were  treated  before  being  considered  well,  but 
many  were  seen  only  a  few  times,  and  several  were 
practically  well  after  one  application  of  the  ichthyol.  It 
was  frequently  observed  that  the  painful  sensations 
subsided,  the  fever  fell,  and  general  improvement  in 
the  patient's  condition  set  in  promptly  after  the  dress- 
ings had  been  applied.  In  scarcely  any  of  the  cases 
was  internal  treatment  employed,  and  then  drugs  were 
given  only  syniptomatically.  Alcoholic  stimulation 
was,  however,  usually  advised.  With  few  exceptions  the 
cases  were  seen  quite  early  in  the  course  of  the  disease, 
usually  upon  the  first  day.  They  were  mostlv  treated 
at  their  homes,  but  some,  especially  those  following  vac- 
cination in  children,  at  the  dispensary.  Under  such 
conditions  I  think  the  results  of  treatment  can  be  bet- 
ter judged  than  in  hospital  cases,  which,  as  a  rule,  enter 
the  wards  only  after  the  disease  has  existed  for  some 
time,  and  probably  without  any  preceding  treatment  to 
speak  of. 

Local  foci  of  pus,  or  sources  of  purulent  secretion, 
must  always  be  sought  out  and,  by  the  use  of  peroxide 


of  hydrogen  or  other  agent,  eliminated  so  far  as  possi- 
ble from  the  problem  while  the  attempts  are  being 
made  to  check  the  advance.  Open  surfaces  must  be 
included  in  the  antiseptic  dressings.  In  a  number  of 
instances  where  the  erysipelas  originated  in  skin 
lesions,  the  happiest  results  have  followed  their  inclu- 
sion in  the  ichthyol  applied.  This  benefit  was  espe- 
cially noticeable  in  the  vaccination  ulcer.  An  impor- 
tant point,  which  has  already  been  pointed  out,  is  the 
necessity  of  leaving  the  plaster  bands  a  long  time  /// 
situ,  and  in  applying  a  second,  when  the  erysipelas  has 
passed  the  first,  of  not  removing  the  first  at  once.  There 
seems  often  to  be  an  intensity  of  the  inflammation  either 
at  the  margin  of  the  band  or  sometimes  beneath  it, 
and  bullK  are  often  large  in  this  situation.  After  re- 
covery, too,  there  should  be  no  haste  in  removing  the 
dressings. 

The  advantages  of  this  treatment  over  the  Kraske- 
Riedel  scarification  method,  which  often  necessitates  the 
use  of  an  ansesthetic,  rises  to  the  importance  of  a  sur- 
gical operation,  and,  after  all,  frequently  fails  of  its 
object,  need  scarcely  be  dwelt  upon. 

Even  if  the  process  most  often  oversteps  the  bounds, 
as  many  authors  claim,  this  is  no  argument  against  the 
method  ;  for  even  if  a  much  smaller  proportion  are  cut 
short  than  is  indicated  by  my  results,  there  is  no  plan 
which  offers  as  much.  In  cases  originating  in  patients 
the  subjects  of  grave  disorder,  and  where  the  lesions 
occur  in  remote  regions  simultaneously,  or  where  rapid 
migration  is  observed,  it  is  probable  that  the  infection 
is  more  deeply  seated,  perhaps  in  the  blood,  and  in  such 
cases  our  method  must  of  necessity  fail.  In  the  pres- 
ent series  I  have  applied  it  in  none  such. 

126  East  Sixtieth  Street. 


ON  FUNCTIONAL  DISORDERS  OF  THE 
STOMACH  ACCOMPANIED  WITH  HYPER- 
SECRETION.^ 

i.  hvperchlorhydria. 

2.  Gastro-succorrhcea  Coxtixla  Periodica. 

3.  Gastro-succorrhcea  Continua  Chronica. 

By   max    EINHORN,    M.D., 


1.  HypercMorhydria.  —  By  the  term  "  Hyperchlorhy- 
dria  "  ("Hyperacidity,"  "Hypersecretion")  is  desig- 
nated a  condition  in  which  the  stomach  secretes  a  juice 
that  is  more  acid  than  normally  and  richer  in  the  fer- 
ments. While  the  quantity  of  the  juice  is  very  often 
likewise  increased,  its  secretion,  however,  takes  place 
only  during  the  digestive  period. 

Although  disturbances  of  digestion  associated  with 
an  hyperacid  gastric  juice  were  vaguely  known  to  the 
old  writers  (Pemberton,  Copland,  and  others),  it  is  onlv 
in  recent  years  that  these  fomis  have  been  thoroughly 
studied  and  placed  on  an  exact  scientific  basis.  For- 
merly it  was  thought  that  in  most  disturbances  of  the 
stomach  the  gastric  secretion  was  deficient.  Nowa- 
days, since  the  publications  of  Riegel,  Reichmann. 
Jaworsky,  Glusinsky,  Ewald.  and  others,  we  know  that 
in  almost  one-half  of  all  the  patients  sun'ering  with 
digestive  disorders,  the  gastric  juice  is  rather  increased. 

.\ccording  to  my  own  experience,  the  gastric  disor- 
ders accompanied  with  hyperchlorhydria  form  more 
than  one-half  of  the  number  of  patients  troubled  with 
digestive  affections.  With  reference  to  this  point  the 
following  table  may  be  of  interest.  Among  5O4  patients 
whose  gastric  contents  I  have  analyzed  during  the  years 
1889-95,  286  showed  a  hyperacid  state  of  the  gastric 
juice.  In  all  these  patients  the  degree  of  acidity  one 
hour  after  the  test-breakfast  was  above  60,  and  in  more 
than  half  of  them  above  80. 

I  Read  before  the  New  York  Slate  .Medical  .Association,  October 
16,  1895. 


November  23,  1895] 


MEDICAL   RECORD. 


725 


Table  of  Private  Patients  whose  Gastric  Content^ 
have  been  analyzed  during  18s9-95. 

.,      .  ,  •  1.  u  (    in  89  :  HCl  =  o,  acidity  =    2  10    40 

Number  of  panems  with  hypo- J    ;„  3?  :  HCl  =  o,  acidity  =  40  to    80 

chlorhydna,  187.  j    i^  §7  .  hCI  +  .    acidity  =  15  to    40 

Number   of  patients   with   eu-  I    .  i,„,  ...  ,      , 

chlorhydria,  91.  \   '°  9'  ■  "^I  +  .    acidity  =  40  to    60 

Number  of  patients  with  hyper    1.       .,     „„,  ....        ,    . 

chlorhydria,  286.    "^       ,•  m  286  :  HCl  +  .    acd.ty  =  60  to  140 

Total  number  of  patients,  564. 

Whether  hyperacidity  should  be  considered  as  a  dis- 
ease sui  generis  or  not,  is  difficult  to  decide.  Hyper- 
acidity certainly  describes  only  one  symptom,  show- 
ing that  the  secretory  function  is  increased  without 
pointing  to  any  definite  anatomical  lesion  ;  but  this 
sjTnptom  may  be  of  the  greatest  importance,  and  very 
often  covers  the  whole  ground  upon  which  is  based 
the  subjective  suffering  of  the  patient  and  the  rational 
treatment  at  our  command.  That  is  the  reason  why 
we  think  it  best  to  discuss  hyperchlorhydria  as  a  sepa- 
rate disease. 

Does  hyperchlorhydria  always  give  rise  to  digestive 
disturbances  and  other  symptoms  ?  In  order  to  answer 
this  question  it  will  be  best  to  determine  more  exactly 
where  hyperchlorhydria  begins,  i.e..  to  what  degree  of 
acidity  we  may  apply  this  term.  According  to  the  ex- 
perience of  Ewald  and  others,  to  which  I  add  my  own, 
the  degree  of  acidity  of  the  gastric  contents,  about 
one  hour  after  Ewald's  test  -  breakfast  varies,  as  a 
rule,  in  healthy  people  between  40  and  60.  A  de- 
gree of  acidity  of  70  and  above  is  therefore  con- 
sidered as  hyperacidity.  The  above  question  will  now 
be  put  in  the  following  way  :  Must  people  with  an 
acidity  of  their  gastric  contents  of  70  and  above,  al- 
ways present  morbid  phenomena  ?  To  this  I  must  an- 
swer in  the  negative.  From  a  very  large  experience  I 
must  assert  that  we  occasionally  meet  with  persons 
whose  degree  of  acidity  of  the  gastric  contents  is  as 
.  high  as  100,  and  even  more,  without  producing  any  dis- 
turbance whatever.  This  condition  need  not  even  be 
a  transient  one.  but  may  last  for  years  and  still  cause 
no  discomfort.  This,  however,  is  not  the  rule,  and  the 
greater  number  of  persons  with  an  hyperacid  juice  are 
not  free  from  disturbances,  and  rather  present  a  very 
characteristic  train  of  symptoms.  We  speak  of  a  patho- 
logical hyperchlorhydria  whenever  this  condition  is  as- 
sociated with  subjective  complaints. 

Etiology.  —  Hyperchlorhydria  is,  as  we  have  just 
stated,  of  very  frequent  occurrence.  It  is  met  with 
chiefly  in  adults,  although  neither  the  young  nor  the 
old  are  exempt.  In  the  majority  of  cases  the  origin 
may  be  traced  to  either  a  psychological  cause,  such  as 
grief  or  worry,  or  to  mental  overwork.  It  is,  as  a  rule, 
more  frequent  among  the  wealthier  and  more  educated 
class  of  people,  as  lawyers,  bankers,  etc.,  although  hy- 
perchlorhydria may  be  met  with  also  among  the  poor. 
But  in  addition  to  this  so-called  reflex  action  of  the 
brain  as  an  etiological  factor  of  the  disease,  there  may 
also  be  direct  causes  ;  thus,  for  instance,  the  habit  of 
taking  highly  spiced  dishes,  much  ice-water,  and  strong 
alcoholic  drinks  is  liable  to  produce  this  trouble. 

Symptoiihitoi'gy. — The  development  of  this  disorder 
is  usually  gradual.  The  patient  at  first  begins  to  feel 
uneasy  about  two  or  three  hours  after  dinner.  After- 
ward this  uneasy  feeling  changes  into  a  somewhat  pain- 
ful sensation  experienced  in  the  gastric  region,  and  in- 
stead of  appearing  after  dinner,  it  occurs  about  two 
hours  after  each  meal.  The  pain  lasts  for  about  an 
hour  or  two,  or  even  three,  and  then  disappears.  Very 
often  pyrosis  accompanies  the  pain,  and  occasionally 
regurgitation  or  water-brash  takes  place.  The  patients, 
as  a  rule,  can  ease  their  pain  by  taking  some  nourish- 
ment, especially  one  that  is  rich  in  albumin  ;  thus  the 
white  of  an  egg,  milk,  meat  is  capable  of  dispersing  the 
pain.  It  also  disappears  after  the  ingestion  of  some  al- 
kali, as  Vichy  water,  or  bicarbonate  of  soda.  The  ap- 
petite  is   ordinarily   not    diminished,   but    frequently 


rather  increased.  Thirst  is  generally  enhanced.  The 
bowels  in  most  cases  are  constipated. 

The  composition  of  food  is  frequently  of  significance 
with  reference  to  the  character  of  the  pains,  which  are 
less  intense  in  people  partaking  of  large  quantities  of 
meat  and  eggs,  while  they  are  much  more  severe  in 
persons  living  chiefly  on  vegetable  diet. 

Besides  the  attacks  of  pain,  patients  affected  with 
hyperchlorhj'dria  very  often  suffer  from  severe  head- 
ache, or  attacks  of  dizziness,  which  may  appear  either 
independently  or  accompanied  by  gastric  pains.  The 
patients,  as  a  rule,  do  not  lose  in  weight  except  in  some 
rare  instances,  in  which  a  faulty  and  insufficient  diet 
has  been  instituted  for  quite  a  long  time. 

Objective  Symptoms. — On  palpation  the  gastric  region 
is  frequently  found  tender  to  pressure,  although  not 
actually  painful,  this  tenderness  not  being  limited  to 
one  circumscribed  spot,  but  to  a  larger  area  covering 
the  greater  part  of  the  gastric  region.  The  contours 
and  the  size  of  the  stomach  are  frequently  found  en- 
larged, although  this  condition  is  by  no  means  charac- 
teristic of  the  affection  in  question.  A  splashing  sound 
can  be  produced  after  the  ingestion  of  water  into  the 
stomach,  or  after  meals,  but  not  in  the  fasting  condi- 
tion. 

On  examination  of  the  stomach  with  a  tube  in  the 
fasting  condition  it  is  found  to  be  empty,  or  only  a  few 
c.c.  (5-10)  of  gastric  juice  can  be  obtained.  One 
hour  after  Ewald's  test-breakfast,  or  two  to  four  hours 
after  Leube-Riegel's  test-dinner,  the  gastric  contents 
contain  an  abundance  of  hydrochloric  acid  and  of  the 
ferments,  the  acidity  being,  as  a  rule,  much  higher  than 
normally  (twice  or  three  times  as  high).  A  disk  of  egg- 
albumin  becomes  digested  in  the  filtrate  of  the  contents 
in  a  very  short  time  (sometimes  in  half  an  he  ur).  The 
gastric  contents  obtained  three  to  four  hours  after  the 
test-dinner  show  microscopically  that  the  meat  has  been 
perfectly  digested,  while  starchy  substances  are  yet 
either  unchanged  or  very  little  altered.  The  filtrate  of 
the  gastric  contents,  either  after  the  test-dinner  or  after 
the  breakfast,  will  reveal  the  presence  of  either  starch 
or  large  quanrities  of  ery thro- dextrine.  The  addition 
of  a  few  drops  of  Lugol's  solution  to  the  filtrate  will 
produce  either  a  blue  color  or  an  intense  dark  red. 

The  high  degree  of  acidity  is  most  commonly  caused 
by  free  hydrochloric  acid.  The  difference  between  the 
amount  of  free  hydrochloric  acid  (as  determined  by 
Mintz's  method)  and  the  total  acidity  is  not  great,  the 
figure  very  frequently  being  from  10  to  20. 

The  motor  faculty  of  the  stomach  is  usually  not  im- 
paired ;  in  a  few  instances  it  is  rather  increased. 
Thus,  two  hours  after  the  test-breakfast,  or  six  to  seven 
hours  after  the  test  dinner,  the  stomach  is  found  to  be 
either  empty,  or  contains  but  very  little  food.  The  salol- 
test  likewise  shows  salicyluric  acid  in  the  urine  aS  early 
as  an  hour  after  the  ingestion  of  the  salol. 

The  degree  of  acidity  of  the  urine  is  frequently  di- 
minished during  the  digestive  period.  This,  however, 
is  not  always  the  case,  for  occasionally  the  degree  of 
acidity  of  the  urine  and  of  the  gastric  contents  may  be 
found  increased  at  the  same  time. 

Course  of  the  Disease. — .\t  the  beginning  hyperchlor- 
hydria is  most  frequently  intermittent.  The  patient 
may  suffer  from  this  affection  for  several  days,  weeks,  or 
even  months,  becoming  free  from  this  ailment  for 
periods  of  time  which  vary  from  several  weeks  to 
months,  or  even  years,  .\fter  this  interval  the  trouble 
recurs,  either  spontaneously  without  any  apparent  cause, 
or  is  evoked  by  a  severe  mental  shock  or  worry.  Later, 
the  periods  of  hyperchlorhydria  become  longer,  and  at 
last  this  condition  may  become  permanent. 

Prognosis. — The  prognosis  in  hyperchlorhydria  is,  as 
a  rule,  quite  good,  except  in  some  cases  of  a  very  pro- 
tracted and  severe  nature,  in  which  the  prognosis  re- 
garding the  complete  disappearance  of  this  condition  is 
bad,  although  even  then  there  is  no  danger  of  a  fatal 
issue. 


726 


MEDICAL    RECORB. 


[November  23,  1895 


Diai^nosis. — The  diagnosis  of  hyperchlorhydria  is 
made  either  by  the  subjective  symptoms  alone,  or  in 
connection  with  the  results  of  chemical  examination  of 
the  gastric  contents.  The  subjective  symptoms  char- 
acteristic of  hyperchlorhydria  are  :  i.  Pains,  appearing 
constantly  about  two  to  three  hours  after  meals.  The 
relief  from  the  pains  felt  immediately  after  the  ingestion 
of  an  alkali,  or  a  little  while  after  the  partaking  of  some 
food,  especially  albuminous.  2.  Appetite  and  thirst 
are  either  in  a  healthy  condiiion  or  increased.  3.  No 
marked  cachexia.     4.  Constipation. 

Although  all  the  symptoms  mentioned  make  the 
diagnosis  of  hyperchlorhydria  probable,  it  can  be  made 
with  certainty  only  after  a  repeated  examination  of  the 
gastric  juices,  i.  On  examination  of  the  stomach  in 
the  fasting  condition  the  organ  is  either  found  empty, 
or  contains  only  a  few  c.c.  of  juice.  2.  One  hour 
after  Ewald's  test-breakfast  the  degree  of  acidity  is 
found  highly  increased,  due  to  the  great  amount  of 
free  hydrochloric  acid. 

Differential  Diagnosis. — In  making  the  diagnosis  of 
hyperchlorhydria  we  shall  have  to  exclude  all  condi- 
tions which  are  liable  to  give  similar  symptoms — thus, 
for  instance,  gastric  ulcer,  permanent  hypersecretion, 
and  biliary  colic.  The  characteristic  symptoms  of 
ulcer  are  too  well  known  to  necessitate  their  perusal. 
We  shall  limit  ourselves  to  the  remark  that  the  pains  of 
an  ulcer,  even  if  this  is  accompanied  by  hyperchlorhy- 
dria, do  not  disappear  entirely  after  the  ingestion  of 
large  doses  of  alkalies.  Permanent  hypersecretion  is 
very  frequently  accompanied  by  vomiting,  and  the 
most  intense  attacks  of  gastric  pain  appear,  as  a  rule, 
in  the  middle  of  the  night  or  early  in  the  morning.  On 
examination  with  the  tube,  the  stomach  in  the  fasting 
condition  is  found  to  contain  considerable  quantities  of 
gastric  juice  (So  c.c.  to  100).  Biliary  colic,  not  ac- 
companied by  jaundice  nor  by  considerable  palpable 
swelling  of  the  gall-bladder,  may  give  rise  to  errors  as 
to  the  real  cause  of  the  pain.  In  biliary  colic,  however, 
the  pains,  as  a  rule,  appear  later  than  in  hyperchlor- 
hydria (four  to  five  hours  after  a  meal),  and  are  not 
eased  by  the  ingestion  of  food  or  by  alkalies.  Another 
means  of  differential  diagnosis  is,  that  the  pains  in  bil- 
iary colic  most  commonly  extend  over  the  right  epigas- 
tric and  hypochondriac  regions,  whereas  the  pains  of 
hyperchlorhydria  are  felt  more  in  the  middle  of  the 
epigastrium,  although  sometimes  radiating  further  to 
the  right. 

Treatment :  Hygienic  Regimen. — As  hyperchlorhydria 
is  most  frequently  caused  by  too  much  mental  work, 
the  daily  life  of  the  patient  as  to  amount  of  work,  bod- 
ily exercise,  mental  rest,  and  pleasure,  will  have  to  be 
regulated.  \\  ith  regard  to  this  point  the  same  rules 
will  not  apply  to  all,  but  it  will  be  necessary  to  indi- 
vidualize each  case  for  itself.  Thus,  business  men  with 
a  great  deal  of  responsibility  resting  upon  them,  law- 
yers, politicians,  and  physicians  must  be  sent  away 
from  their  work  to  some  country  place,  so  as  to  relieve 
their  brains  temporarily  from  the  strain.  Ladies  mov- 
ing in  high  social  circles,  and  participating  in  all  man- 
ners of  festivities,  will  have  to  be  reduced  to  a  more 
quiet  life.  Again,  there  are  people  with  large  fortunes 
and  without  any  occupation  whatever,  who  become 
sick  from  paying  too  much  attention  to  their  own  bod- 
ily functions.  Here  it  will  be  necessary  to  occupy  the 
mind  of  these  patients  with  some  kind  of  work. 

Cold  sponge-baths  in  the  morning,  bodily  exercise  of 
about  eight  to  ten  minutes  during  every  morning,  are 
in  most  instances  of  value.  Walking  once  or  twice  a 
day  for  half  an  hour  to  an  hour,  horseback  riding, 
driving,  bicycle  riding,  should  be  highly  recommended. 

Diet. — All  substances  that  are  liable  to  intensely  ex- 
cite the  glands  of  the  stomach  must  be  excluded  from 
the  dietary  of  such  patients.  Therefore  all  kinds  of 
acids,  including  organic  acids  (citric,  tartaric,  acetic 
acid),  all  kinds  of  spices,  such  as  pepper,  mustard, 
horse  radish,  and  the  like  must  be  forbidden.      The 


food  should  consist  of  nourishments  rich  in  albumin, 
while  the  quantity  of  starchy  substances  should  be 
diminished.  Thus,  all  kinds  of  meat  (even  game),  fish, 
oysters,  eggs,  milk,  should  be  taken  in  large  tjuantities. 
Bread  and  butter  is  permitted.  Potatoes,  spinach, 
asparagus,  green  peas,  farina,  and  rice  should,  as  a  rule, 
be  given  in  only  small  ijuantities.  Cocoa,  weak  tea, 
weak  coffee,  and  beer  can  be  given  in  moderate  quan- 
tities. 

As  a  rule  it  is  advisable  to  have  the  patient  partake 
of  five  rneals  daily,  three  larger  and  two  smaller.  The 
larger  meals  should  not  deviate  much  from  the  ordi- 
nary bill  of  fare,  while  the  two  smaller  ones  should  con- 
sist either  of  a  glassful  of  milk  or  matzoon,  with  bread 
and  butter,  or  a  cup  of  cocoa  and  a  few  crackers,  or 
occasionally  a  cup  of  bouillon  vv-ith  an  egg  beaten  up  in 
it,  and  some  bread,  or  half  a  dozen  oysters,  a  few 
crackers,  and  a  glass  of  beer.  The  patient  must  be  im- 
pressed with  the  importance  of  masticating  the  food 
thoroughly,  and  eating  slowly,  besides  resting  fifteen  or 
twenty  minutes  after  each  meal. 

Medicaments. — All  kinds  of  alkalies  can  be  applied  in 
the  treatment  of  this  affection,  ^^'here  hyperchlorhy- 
dria is  not  complicated  with  constipation,  bicarbonate 
of  soda  may  be  given,  either  alone  or  in  combination 
with  sugar  of  milk  or  peppermint  sugar  (German 
Pharmac.)  in  doses  of  half  a  teaspoonful  to  about  one 
teaspoonful  three  times  a  day,  two  hours  after  meals. 
In  cases  which  are  accompanied  by  constipation,  mag- 
nesia usta  and  some  rhubarb  can  be  added,  and  here  I 
frequently  prescribe  the  following  : 

5.    Magnes.  ust. , 

Pulv.  rad.  ihei iia     7. 5 

Natr.  carbon,  exsiccat., 

Natr.  bibarbon. , 

Elaeosacch.  meiilli.  pip  .    Sa  15.0 

M.    Exactissim,  f.  pulv. 
D.    Ad  scatulam. 

S.  :  One-half  teaspoonful  to  a  teaspoonful  three  times  daily,  two 
hours  after  meals.     To  be  taken  in  plain  water  or  in  Vichy  water. 

Bouveret  uses  sodium  bicarbonate  in  two-gramme 
doses,  to  be  taken  two  hours  after  lunch  and  supper,  and 
to  be  repeated  after  an  hour's  interval.  The  alkaline 
treatment  can  be  continued  for  very  long  periods  with- 
out any  ill  effects  whatever.  In  cases  in  which  the 
nervous  element  is  more  disturbed  (sleeplessness,  head- 
aches, over- excitability,  etc.),  we  should  give  a  good 
dose  of  a  bromide  salt.  I  am  in  the  habit  of  prescrib- 
ing strontium  bromate  : 

5.    Stront.  broniat.  puriss 12.0 

Aq.  menth.  pip 60.0 

D.  S.   One  teaspoonful  twice  daily  in  milk,  at  meal-time. 

Sodium  bromide  and  ammonium  bromide  can  be 
employed  in  the  same  \va)'.  The  bromides  should, 
however,  be  given  only  for  a  week  or  two,  and  their 
use  then  discontinued  for  a  short  time,  after  which  they 
may  be  resumed  for  the  same  length  of  time.  Boas 
advises  the  administration  of  small  doses  of  morphia  or 
codeine.     He  frequently  prescribes  the  following  : 

IJ.    Magnes.   ust 15.0 

Morphii  hydrochlorici o.  I 

M.  f.  pulv.  d.  in  scat. 

D.  S. — A  point  of  a  knife  to  a  teaspoonful  three  times  daily. 

I  have  very  seldom  seen  the  necessity  of  prescribing 
either  morphia  or  codeine  in  this  affection. 

Of  the  watering-places,  Vichy  and  Neuenahr  are  to 
be  highly  recommended.  For  the  treatment  of  these 
patients  at  home  these  mineral  waters  are  taken  most 
advantageously  in  small  quantities. 

Electricity. — In  cases  of  a  protracted  nature,  the  di- 
rect application  of  the  electric  current  to  the  inside  of 
the  stomach  is  frequently  of  the  greatest  benefit.  In 
most  instances  the  faradic  current  should  be  applied, 
but  in  cases  in  which  the  pains  are  very  severe,  galvan- 
ization should  be  employed. 

As  to  the  mode  of  application  of  the  current,  and  the 
length   of   time   required    for  this   treatment,  see   my 


November   23,    1895J 


MEDICAL    RECORD. 


727 


papers  on  intra-gastric  electrization.  The  electric  cur- 
rent applied  in  this  manner  exerts  a  stimulating  tonic 
influence,  not  only  upon  the  stomach  but  also  upon  the 
small  and  large  intestines.  I  have  frequently  seen  cases 
of  hyperchlorhydria,  accompanied  by  the  most  obstinate 
constipation,  perfectly  cured  by  means  of  the  current, 
even  when  no  medicament  whatever  has  been  given. 

II.  Gastro-succorrhcea  Continua  Periodica  ( Reich - 
mann),  Gastro-xynsis  (Rossbach). — By  "  gastro-succor- 
rhcea continua  periodica  "  (or  "  periodic  continuous  flow 
of  gastric  juice  ")  is  designated  an  affection  which  is 
characterized  by  a  constant  secretion  of  gastric  juice 
giving  rise  to  spells  of  vomiting  and  severe  pains  and 
lasting  only  several  days. 

General  Remarks. — The  affection  is  met  with  either 
in  persons  suffering  from  some  organic  lesion  of  the 
peripheral  or  central  nervous  system,  or  in  persons 
whose  nerves  appear  to  be  in  a  normal  state.  The  pe- 
riodic continuous  flow  of  gastric  juice  was  first  de- 
scribed by  Reichmann  ;  ^  a  few  years  later  Rossbach  - 
had  described,  under  the  name  of  gastro-xynsis,  a  ner- 
vous affection  of  the  stomach,  which  consists  in  a  sud- 
den appearance  of  severe  headaches  accompanied  by 
gastric  pains,  and  vomiting  of  very  acid  chyme  or  gas- 
tric juice.  In  accordance  with  Boas,  I  consider  gas- 
tro-xynsis and  gaslro-succorrhoea  continua  periodica,  as 
one  and  the  same  affection,  and  I  do  not  think  they 
should  be  treated  under  different  headings. 

Symptomatology. — In  the  midst  of  perfect  health  a 
sensation  of  discomfort  is  experienced  in  the  gastric 
region,  which  is  associated  with  restlessness.  Soon 
afterward  the  discomfort  changes  into  a  rather  painful 
sensation,  and  a  feeling  of  nausea  appears.  The  pa- 
tient is  compelled  to  occupy  a  recumbent  position. 
The  symptoms  just  described  continue,  or  rather  in- 
crease in  severity,  and  in  about  an  hour  or  two  the 
nausea  ends  in  vomiting  of  a  large  quantity  of  gastric 
contents.  The  patient  may  now  feel  a  little  relieved 
for  a  short  time,  but  soon  the  same  symptoms  return. 
The  appetite  is  entirely  lost,  and  instead  there  is  ex- 
treme thirst.  The  more  the  patient  drinks,  the  more, 
as  a  rule,  he  has  to  vomit.  If  he  abstains  from  drink- 
ing the  vomiting  is  less  frequent,  but  persists  neverthe- 
less. Thus,  as  a  rule,  in  the  middle  of  the  night  or 
early  in  the  morning,  the  patient  has  to  vomit  a  large 
quantity  of  a  watery  liquid  which  is  very  acid  in  char- 
acter, and  either  quite  clear  or  greenish  from  the  ad- 
mixture of  bile.  If  this  liquid  be  examined,  it  will  be 
found  that  free  hydrochloric  acid  is  present  in  large 
quantities,  as  well  as  the  ferments  (rennet  and  pepsine). 
No  food  particles  can  be  discovered  in  the  fluid.  It 
consists  of  either  clear  gastric  juice  or  gastric  juice  with 
admixture  of  a  little  bile.  After  such  an  attack  f  re(iuently 
a  constant  desire  to  vomit  persists,  and  the  patient  suffers 
from  very  violent  and  j)ainful  retching.  Often,  a  quarter 
of  an  hour  after  the  last  paroxysm  of  vomiting,  the  pa- 
tient's efforts  to  vomit  cause  a  small  quantity  of  clear 
yellow  bile  to  be  ejected.  Even  if  the  patient  absolutely 
abstains  from  all  kinds  of  food  and  drink,  a  few  hours 
later  a  large  quantity  of  gastric  juice  may  again  be 
vomited.  The  patient  in  this  condition  is  hardly  able 
to  sleep  for  any  length  of  time,  as  tlie  pains  awake  him 
soon  after  he  has  fallen  asleep.  The  abdomen,  as  a 
rule,  is  sunken.  The  patient  looks  extremely  pale  and 
his  extremities  are  frequently  cold.  Severe  headaches 
often  accomi)any  this  train  of  symptoms,  and  constipa- 
tion is  almost  a  constant  concomitant.  After  this 
condition  has  lasted  for  about  two  or  three  days,  or 
sometimes  even  longer,  the  nauseous  feeling  begins  to 
disappear,  the  pains  subside,  and  the  patient  expe- 
riences for  the  first  time  a  desire  for  food.  He  is  now 
able  to  eat  without  vomiting,  and  in  a  day  or  two  feels 
himself  again.  It  is  characteristic  of  this  affection  that 
the  symptoms  disappear  almost  suddenly,  and  that  the 
patient,  who  seemed  to  be  in  a  wretched  state  a  few 

'  Reichmann  :  Berl.  klin.  Wochenschrift,  1882.  N.  40. 
'Rossbach:  Deutsch.  Arch.  f.  klin.  Med.,  1865,  lid.  35. 


hours  before,  may  now  appear  nearly  well.  After  a  pe- 
riod of  perfect  euphoria,  varying  from  several  weeks  to 
a  few  months  or  a  year,  or  even  longer,  a  similar  attack 
may  occur.  The  attacks  may  then  recur  either  after 
the  same  period  of  lime,  or  the  intermission  of  health 
may  become  gradually  shorter,  so  that  at  last  the  pa- 
tient has  hardly  recuperated  from  his  last  attack  be- 
fore a  new  one  supervenes.  The  latter  condition  forms 
the  intermediary  stage  between  periodic  and  chronic 
gastro-succorrhcea.  During  the  free  intervals  the  gas- 
tric secretion  takes  place  either  in  a  perfectly  normal 
manner,  or  hyperchlorhydria  may  exist.  In  both  in- 
stances, however,  the  stomach  remains  free  from  secre- 
tions in  its  empty  state. 

The  following  case,  which  I  observed  recently,  may 
serve  as  a  good  illustration  of  this  affection.     R.  B.  I. 

,  aged  thirty  seven,  business  man.    During  1 890  and 

1891  patient  had  several  attacks  of  the  then  prevailing 
grippe.  In  December,  1892,  after  the  third  attack  of 
the  grippe  he  was  taken  ill  with  a  stomach  trouble,  the 
nature  of  which  patient  described  as  follows  :  "  I  was 
taken  suddenly  by  a  fit  of  vomiting,  entirely  emptying 
the  stomach  apparently,  but  followed  by  successive 
spells,  at  an  interval  of  one  to  two  hours,  accompanied 
by  the  most  intense  pain.  This  would  last  from  twenty- 
four  to  thirty-six  hours,  and  sometimes  forty-eight,  after 
which  the  stomach  would  gradually  quiet  down  so  that 
nourishment  in  the  form  of  milk — either  hot  milk  or 
kumyss — could  be  taken  in  small  quantities  at  intervals 
of  about  two  hours,  until  a  normal  condition  was  re- 
stored, which  usually  took  from  two  to  three  days  to 
accomplish. 

"  The  character  of  the  vomit  was,  first,  that  of  undi- 
gested food,  followed  by  a  strong  and  very  acid  nature 
of  a  whitish  color,  and  finally  that  of  a  greenish  color, 
qpnsisting  principally  of  bile.  After  each  of  the  spells 
mentioned  the  intense  pain  would  subside,  and  I  would 
fall  to  sleep — to  be  awakened  again  by  a  recurrence  of 
the  pain — the  intervals  of  sleep  and  suffering  varying 
from  an  hour  to  three  as  I  became  better,  and  continu- 
ing until  vomiting  had  ceased. 

"  During  all  these  spells  I  was  exceedingly  nervous — 
the  slightest  noise  or  vibration  causing  pain  and  some- 
times causing  the  vomiting,  (leneral  condition  after 
becoming  able  to  sit  up  was  one  of  extreme  weakness — 
having  lost  from  ten  to  twenty  pounds,  as  the  attacks 
were  longer  or  shorter. 

"  During  1893  I  was  ill  four  or  five  times,  in  1894  as 
often,  and  in  1895  four  times.  Weight  previous  to 
grippe  averaged  135  to  138  pounds;  since  these  attacks 
it  has  varied  from  125  to  133." 

Present  Condition.— ]\x\y  22,  1895.— Chest  organs  nor- 
mal. The  palpation  of  the  abdomen  does  not  reveal 
any  pathological  condition.  The  splashing  sound  can 
be  easily  produced  in  the  gastric  region,  and  extends 
downward  to  about  two  fingers'  width  below  the  navel. 
Knee-reflex  present.  Urine  does  not  contain  any 
sugar  or  albumin,  liesides  the  above  described  at- 
tacks of  vomiting,  patient  complains  of  a  feeling  of 
heaviness  in  his  gastric  region  about  one  hour  after 
meals,  and  of  slight  constipation. 

July  23d.— Examination  of  the  gastric  contents  one 
hour  after  Ewald's  test-breakfast  :  HCl  +  Acidity  = 
100  ;  free  HCl  =  86. 

October  8lh. — Patient  is  in  bed  suffering  from  one 
of  the  attacks  mentioned  ;  he  had  vomited  several 
times  during  the  day  and  is  suffering  from  intense  pain. 
On  inspection  the  abdomen  is  slightly  sunken  ;  on  pal- 
pation the  whole  gastric  region  is  found  extremely  sen- 
sitive and  painful  to  pressure.  The  hands  and  also  the 
face  (|)articularly  nose  and  forehead)  are  somewhat 
cold  ;  pulse,  1 10  ;  temperature,  98°  F.  The  vomited 
matter  consists  of  a  pretty  clear  fluid  with  an  abundant 
admixture  of  mucus  ;  no  food  particles  can  be  discov- 
ered in  the  liquid.  On  chemical  examination  free  HCl 
as  well  as  pepsin  and  rennet  are  found  present  in  large 
amount.     Patient  complains  of  intense  thirst,     lender 


728 


MEDICAL    RECORD. 


[November  23,  1895 


the  administration  of  opiates  the  patient  grew  better  and 
was  able  to  leave  his  bed  after  three  days. 

Diagnosis.  —  The  diagnosis  of  gastro  -  succorrhoea 
continua  periodica  can  be  made  by  the  above- described 
symptoms,  in  connection  with  the  examination  of  the 
vomited  matter  (which  is  found  to  consist  principally 
of  clear  gastric  juice  without  admixture  of  much  food), 
or  the  examination  of  the  stomach  in  the  fasting  condi 
tion  by  means  of  the  tube  (which  results  in  the  with- 
drawal of  a  considerable  quantity  of  clear  gastric  juice). 
Inasmuch  as  similar  attacks  of  gastro-succorrhcea  may 
occur  as  a  consequence  of  either  an  open  ulcer  or 
a  cicatrix  within  the  stomach,  the  pylorus,  or  the  duo- 
denum, it  will  be  necessary  to  exclude  such  organic 
affections  before  making  a  diagnosis  of  continuous 
periodic  gastric  flow,  which  we  consider  as  a  nervous 
affection.  It  will  also  be  of  importance  to  exclude  or- 
ganic, spinal,  or  cerebral  troubles,  which  may  cause  a 
similar  disorder  of  reflex  origin. 

Prognosis. — The  prognosis  of  pure  cases  of  gastro- 
succorrhoea  continua  periodica  is,  as  a  rule,  not  bad. 
In  many  instances,  it  is  possible  either  to  make  the  at- 
tacks less  severe,  or  in  some  instances  to  efifect  a  cure 
by  rational  treatment. 

Treatment. — It  will  always  be  advisable  to  analyze 
the  gastric  juice  of  the  patient  during  the  free  intervals. 
If  hyperchlorhydria  is  found,  this  will  have  to  be 
treated  as  such,  even  if  there  should  be  no  subjective 
complaints  ;  for  hyperchlorhydria  is  frequently,  al- 
though not  always,  the  cause  of  such  attacks.  At  any 
rate,  a  hygienic  way  of  living  should  be  inaugurated  by 
the  physician.  I  am  in  the  habit  of  prescribing  a  good- 
sized  dose  of  bromide,  as  soon  as  the  patient  feels  an 
attack  coming  on,  and  find  that  occasionally  it  may  be 
cut  short  from  the  very  beginning  In  some  instances 
the  attack,  although  not  interrupted  in  its  progress*  is 
thereby  rendered  less  severe.  When  the  attack  has  ap- 
l)eared  the  patient  must  be  kept  in  bed.  A  hot-water 
bag  is  placed  over  the  gastric  region,  and  if  the  pains 
are  severe  an  opiate,  either  alone  or  in  combination 
with  belladonna,  is  administered.  During  the  first  day 
of  the  attack  no  nourishment  whatever  should  be  given. 
A  teaspoonful  of  cold  water,  or  a  small  ice-pill,  can  be 
administered  from  time  to  time,  especially  if  the  pa- 
tient is  very  thirsty  and  dry.  The  next  day  small 
quantities  of  milk,  matzoon,  or  egg-water,  one  or  two 
tablespoonfuls,  are  given  every  hour.  On  the  third 
day  the  quantity  of  nourishment  may  be  increased  to 
half  a  cupful  at  a  time,  administered  every  two  hours, 
and  besides  the  above  liquid  food,  the  white  of  a  hard- 
boiled  egg,  chopped  up  fine,  may  also  be  given  (one  or 
two  eggs  a  day).  On  the  fourth  day  meat  (scraped, 
raw,  or  broiled)  may  be  tried,  and  afterward  the  diet 
gradually  arranged  as  for  cases  of  hyperchlorhydria. 
The  system  of  diet  as  laid  down  here  for  every  day 
from  the  beginning  of  the  attack  will  certainly  depend 
upon  the  condition  of  the  patient,  and  will  have  to  be 
modified  accordingly.  As  there  is  always  constipation 
during  the  attack,  it  will  be  best  to  move  the  bowels  on 
the  second  or  third  day,  either  by  a  glycerin  supposi- 
tory, or  by  a  large  injection  of  water  (a  quart  of  water 
and  a  teaspoonful  of  salt),  or  an  injection  of  sweet  oil 
(one  pint). 

III.  Gastro  -  succorrhoea  Continua  Chronica 
("  Chronic  continuous  flow  of  gastric  juice,"  or 
"  Reichmann's  disease  ").  — Under  the  above  name 
Reichmann,'  in  1882,  described  a  pathogenic  condition 
which  is  characterized  by  a  constant  secretion  of  gas- 
tric juice,  even  when  there  is  no  food  whatever  in  the 
stomach.  The  stomach  is  found  to  contain  considerable 
quantities  of  gastric  juice  in  the  morning,  even  in  the 
fasting  condition. 

General  Remarks. — In  describing  this  new  disease, 
Reichmann,  in  18S7,  mentioned  that  he  had  observed 
sixteen  cases.     An  exact  scientific  diagnosis  had  been 

'  Reichmann  :  Berl.  klin.  Wocheiisclirift.  18S2,  N.  40;  1884,  X.  48, 
and  1887.  \.  12. 


made,  however,  only  in  six  of  them.  "  In  the  remain- 
ing cases."  says  Reichmann,  "  I  was  unable  to  find  in 
the  stomach  in  the  morning,  in  the  fasting  condition,  a 
large  quantity  of  a  liquid  containing  hydrochloric  acid 
and  pepsin,  and  exhibiting  digestive  properties,  but 
containing  also  much  peptone  and  remnants  of  amyla- 
ceous food." 

Among  the  six  cases  which  Reichmann  considered 
as  typical  of  gastro- succorrhoea  chronica,  I  think  that 
only  one  (Case  3)  deserves  this  name,  for  the  remain- 
ing five,  aside  from  the  constant  secretion  of  gastric 
juice,  presented  other  important  lesions  of  the  stomach, 
which  in  all  probability  were  rather  the  cause  than  the 
effect  of  the  constant  gastric  flow.  In  all  the  cases 
described  by  Reichmann  (except  in  Case  3)  the  stom- 
ach in  the  fasting  condition  contained  a  considerable 
quantity  of  liquid,  consisting  of  gastric  juice,  and 
containing  amylaceous  food  remnants.  When  the 
stomach  had  been  washed  out  on  the  previous  night, 
and  the  patient  had  abstained  from  food  or  drink,  the 
stomach  in  the  morning  nevertheless  contained  clear 
gastric  juice.  These  cases  are  then  undoubtedly  cases 
of  dilatation  of  the  stomach,  or  more  correctly  speak- 
ing, of  stenosis  of  the  pylorus,  in  which  hypersecretion 
must  be  considered  as  a  concomitant  factor.  Reich- 
mann, and  following  him,  especially  the  French  writers 
Bouveret,'  Debove,  and  Remond,"  and  among  the  Ger- 
mans, Riegel,^  have  laid  too  little  stress  upon  the  dis- 
tinction between  the  constant  flow  of  gastric  juice  and 
dilatation  of  the  stomach  due  to  stenosis  of  the  py- 
lorus. On  this  account  the  picture  given  by  these 
authors  of  the  true  gastro-succorrhcea  chronica  bears  a 
closer  resemblance  in  many  points  to  that  of  dilatation 
of  the  stomach,  than  to  the  picture  of  the  affection  in 
question.  Inasmuch  as  the  treatment  of  cases  of  sten- 
osis of  the  pylorus  in  most  essential  points  differs  from 
the  treatment  of  cases  of  gastro-succorrhcea  (I  need  only 
mention  that  the  most  rational  treatment  for  the  former 
is  a  surgical  one),  it  is  absolutely  necessary  to  strictly 
differentiate  between  these  two  conditions. 

About  two  years  ago  Schreiber,''  of  Koenigsberg. 
published  an  extensive  paper  in  which  he  doubted  the 
existence  of  the  new  disease,  and  considered  all  the 
cases  described  by  Reichmann  as  cases  of  dilatation 
of  the  stomach  with  stagnation  of  food.  Shortly  after- 
ward, two  other  important  papers  appeared  with  refer- 
ence to  this  question  :  Riegel  '  defended  Reichmann's 
views,  while  Martius''  was  inclined  to  favor  Schreiber"s 
opinion.  Whether  Schreiber's  view,  that  the  stomach 
normally  secretes  gastric  juice  even  while  in  its  empty 
state,  is  correct  or  not,  is  a  question  that  is  quite  diffi- 
cult to  decide,  although  I  am  personally  of  the  opinion 
that  when  there  is  no  food  in  the  stomach  there  is  no 
secretion.  But  leaving  aside  this  question  about  the 
physiology  of  the  stomach,  there  is  no  doubt  that,  as  a 
rule,  the  stomach  in  the  fasting  condition  does  not 
contain  any  considerable  quantity  of  gastric  juice. 
Whenever  considerable  quantities  are  found,  the  stom- 
ach must  be  considered  as  affected.  In  this  respect  I 
agree  with  Reichmann,  as  to  the  existence  of  a  patho- 
logical continuous  gastric  succorrhoea,  although  I  shall 
restrict  this  name  only  to  cases  not  presenting  any  or- 
ganic lesions  of  the  stomach.  Whenever  the  latter 
exist  I  deem  it  best  to  look  upon  the  accompanying 
gastric  succorrhcxa  as  a  consequence  of  the  main  troub- 
le, but  not  as  a  primary  affection.  According  to  my 
experience,  which  coincides  with  that  of  Ewald,  cases 
of  genuine  gastro-succorrhcea  chronica  are  quite  rare. 
They  are  less  frequent  than  the  gastro-succorrhcea  peri- 
odica. During  the  last  seven  years  I  have  met  with  six 
cases  of  this  affection,  one  of  which  I  •  pubilshed  in  1887. 

'  Bouveret :  Traite  des  Maladies  de  I'Estomac. 
'  Debove  et  Romond  :  Les  Maladies  de  I'Estomac. 
3  Riegel :  Deutsche  med.  Wochenschrift,  1893,  N.  31  and  32. 
*  Schreiber  :  Deutsche  nied.  Wochenschrift.  1893,  N.  29  and  30. 
'  Riegel :  1.  c.  '  Martins  :   Deutsche  med.  Wochenschrift,  1894. 

■  Max  Einhorn  :  New  Yorker  Medic.  Presse.  1887,  and  Dietetic 
Gazette.  December,  1889. 


November  23,  1895] 


MEDICAL   RECORD. 


729 


Before  entering  into  the  discussion  of  the  pathology  of 
this  disease,  it  might  be  best  to  briefly  describe  one  of 
my  recently  observed  typical  cases  of  gastro-succor- 
rhoea. 

A.  S ,  twenty- one  years  of  age,  has  suffered  since 

early  youth  from  digestive  troubles.  As  far  back  as 
he  can  remember,  he  has  felt  hungry  very  soon  after 
meals  (one  hour).  The  bowels,  although  regular,  were 
occasionally  very  constipated.  Patient  was  always 
weakly,  but  in  the  last  three  years  had  been  troubled 
in  a  higher  degree.  He  felt  extremely  weak,  became 
dizzy  after  meals,  and  was  overcome  by  a  feeling  of 
sleepiness.  The  bowels  became  constipated  all  the 
time.  During  the  last  six  or  seven  months  there  was 
a  sensation  of  extreme  weakness  in  the  hands  and  feet. 
The  appetite  was  constantly  increased,  and  a  hungry 
feeling  appeared  very  frequently.  Since  three  months 
there  had  been  present  a  burning  sensation  in  the  gas- 
tric region,  which  increased  in  severity  about  an  hour 
or  two  after  meals.  From  that  time  on,  patient  began 
to  vomit  frequently.  The  vomiting,  as  a  rule,  oc- 
curred very  soon  after  a  meal,  although  occasionally  it 
took  place  either  in  the  middle  of  the  night  or  in  the 
morning  before  breakfast.  Patient  had  lost  lately  in 
weight  (about  ten  pounds). 

Present  Condition. — Chest  organs  intact.  On  palpa- 
tion, the  gastric  region  is  somewhat  sensitive  to  press- 
ure. There  is,  however,  no  circumscribed  painful 
area.  .\  splashing  sound  can  be  produced,  extending 
to  about  one  finger's  width  above  the  navel.  Tongue 
is  thickly  coated.  Color  of  lips  and  cheeks  (juite  good, 
and  the  patient  does  not  look  emaciated.  The  knee- 
reflex  is  present,  and  the  urine  does  not  contain  any- 
thing abnormal.  The  examination  of  the  stomach  one 
hour  after  a  test-breakfast,  showed  the  quantity  of 
chyme  to  be  small  (about  thirty  cubic  centimetres)  ; 
hydrochloric  acid  +  ;  acidity  =  100. 

The  examination  of  the  stomach  in  the  fasting  con- 
dition revealed  that  the  organ  contained  a  considerable 
quantity  of  pure  gastric  juice  ;  120  c.c.  of  a  somewhat 
turbid  liquid,  not  containing  any  food  remnants  what- 
ever, were  withdrawn  with  the  tube.  This  fluid  con- 
tained free  hydrochloric  acid,  had  an  acidity  of  80, 
gave  only  weak  biuret  reaction,  while  erythro-dextrine, 
dextrine,  and  sugar  were  totally  absent.  During  the 
first  three  months  of  treatment  the  condition  of  the 
stomach  in  reference  to  its  secretion  of  juice  did  not 
change  in  any  way.  Repeated  examinations  which 
had  been  made  in  the  fasting  condition  of  the  patient 
always  gave  the  same  result  :  presence  of  about  one 
hundred  cubic  centimetres  or  more  of  pure  gastric  juice. 

The  treatment  consisted  at  first  in  regulation  of  the 
diet  and  in  the  administration  of  large  doses  of  alka- 
lies. Later  on,  washing  of  the  stomach  and  spraying 
of  the  organ  with  a  i  to  2  pro  mille  solution  of  nitrate 
of  silver  was  instituted.  The  latter  means  proved 
more  effective  than  the  above  treatment,  and  after 
about  two  weeks  it  was  noticed  that  the  stomach  in  the 
fasting  condition  contained  considerably  smaller  cjuan- 
tities  of  juice.  Thus,  thirty  or  twenty  cubic  centi- 
metres of  juice  were  frequently  found.  The  spraying 
was  continued  for  two  months,  after  which  time  the 
stomach  in  the  fasting  condition  was  usually  found 
empty.  This  objective  improvement  was  connected 
with  a  subjective  amelioration  of  all  the  symptoms  : 
the  vomiting  ceased,  the  hunger  was  much  less 
marked,  the  dizziness  subsided,  and  the  patient  felt 
stronger  and  could  do  his  work  much  better.  The 
examination  of  the  stomach  one  hour  after  the  test- 
breakfast,  however,  showed  that  the  hyperchlorhydria 
still  persisted.  In  this  case  we  frequently  tried  to  de- 
termine the  motor  (or  transportation)  faculty  of  the 
stomach  ;  one  and  a  half  hour  after  the  test-breakfast, 
as  a  rule,  the  stomach  was  found  empty,  showing  that 
this  faculty  was  rather  increased.  This  is  of  interest, 
inasmuch  as  it  shows  that  continuous  hypersecretion 
need  not  be  associated  with  sluggishness  in  the  mus- 


cular action  of  the  organ,  a  theory  which  is  accepted 
by  most  investigators  who  have  written  on  the  subject. 

Etiology. — Gastro-succorrhoea  chronica  is  met  with 
much  more  frequently  in  men  than  in  women.  In 
some  instances  there  is  present,  besides  this  affection, 
some  other  functional  neurotic  disturbance.  In  three 
of  my  cases  the  latter  was  very  marked.  Thus  one  of 
these  patients  complained  of  a  burning  sensation  all 
over  his  limbs,  which  lasted  for  three  months  and 
then  suddenly  disappeared.  Like  hyperchlorhydria, 
the  gastro-succhorrhoea  seems  to  arise  from  great  men- 
tal worry  or  strain. 

Symptomatology . — After  a  more  or  less  prolonged  pe- 
riod of  different  dyspeptic  disturbances,  which  are 
similar  in  character  to  those  caused  by  hyperchlorhy- 
dria, there  appears  a  pronounced  sensation  of  pain  sev- 
eral hours  after  and  shortly  before  meals.  Very  soon 
vomiting  supervenes  as  a  new  symptom.  At  first  it 
occurs  only  occasionally,  but  constantly  grows  more 
frequent,  until  at  last  there  is  either  one  or  several 
vomiting  spells  every  day.  The  vomiting  appears  most 
frequently  soon  after  breakfast,  sometimes  also  after 
supper.  In  only  a  few  cases  does  it  occur  at  night, 
about  two  or  three  o'clock,  preceded  by  long  and  se- 
vere attacks  of  pain.  The  vomited  matter  is  always 
very  acid,  and  more  or  less  liquid.  The  night  vomit 
especially  consists,  as  a  rule,  of  a  clear  liquid  contain- 
ing hardly  any  food. 

The  appetite  is  generally  increased,  although  there 
are  exceptions  to  this  rule.  In  some  cases  periods  of 
extreme  hunger  alternate  with  periods  of  severe  ano- 
rexia. In  most  cases  the  sensation  of  thirst  is  greatly 
increased.  In  all  of  ray  cases  constipation  was  marked. 
In  some  there  was  present  loss  of  weight,  but  none  of 
my  patients  was  emaciated  in  any  great  degree. 

Diagnosis. — Although  the  symptoms  described  might 
suggest  the  presence  of  gastro-succorrhcea  in  certain 
cases,  the  exact  diagnosis  can  be  made  only  by  a  re- 
peated examination  of  the  stomach  in  the  fasting  con- 
dition. By  inserting  the  tube  into  the  stomach,  and 
telling  the  patient  to  exert  some  pressure  with  his  ab- 
dominal muscles,  a  more  or  less  large  quantity  of  li- 
quid (60-100  c.c.)  is  obtained  from  the  stomach.  This 
contains  no  food  particles,  but  exhibits  all  the  properties 
of  the  gastric  juice.  It  may  look  greenish  from  the  ad- 
mixture of  bile,  but  this  is  not  an  important  sign.  The 
filtrate,  as  a  rule,  shows  a  somewhat  increased  degree  of 
acidity.  It  never  contains  any  starchy  products  (ab- 
sence of  erythro-dextrine,  achroo-dextrine,  and  sugar). 
Microscopically  no  sarcina;  or  other  signs  of  decompo- 
sition are  found.  Frequently  cell-nuclei  are  met  with 
in  large  numbers.  In  examining  the  patient  one  hour 
after  Ewald's  test-breakfast  the  gastric  contents  will  be 
found  to  contain  more  liquid  than  usually,  and  the  de- 
gree of  acidity  will  be  quite  high  (So-ioo).  As  a 
rule,  the  degree  of  acidity  of  the  gastric  contents  is 
higher  than  that  of  the  gastric  juice  when  withdrawn 
from  the  stomach  in  the  fasting  condition.  In  exam- 
ining the  filtrate  of  the  gastric  contents  as  regards  the 
starchy  products,  it  will  be  found  that  the  lugol  solu- 
tion will  produce  a  deep  violet  or  even  blue  color, 
showing  that  the  starch  has  not  been  much  changed. 
A  thin  disk  of  a  hard-boiled  egg  will  be  digested  in 
the  filtrate  at  blood  temperature  in  about  half  an  hour 
to  an  hour.  The  difference  as  to  the  degrees  of  diges- 
tion of  the  albuminates  and  starches  (the  former  being 
quicker,  the  latter  much  more  slowly  digested)  can  be 
best  studied  after  I.eube-Riegel's  test-dinner.  Three 
to  four  hijurs  after  such  a  dinner,  the  obtained  gastric 
contents  contain  hardly  any  meat  particles  (all  being 
digested),  whereas  particles  of  starchy  food  form  the 
principal  part  of  the  mixture.  In  this  way  the  differ- 
ence between  the  digestion  of  meats  and  starchy  foods 
existing  in  this  affection  is  seen  at  once. 

Differential  Diagnosis. — In  making  the  diagnosis  of 
gastro-succorrhcea.  all  organic  lesions  of  the  stomach 
(ulcer  and  stenosis  of  the  pylorus). which  are  liable   to 


72,0 


MEDICAL    RECORD. 


[November  23,  1895 


be  accompanied  with  gastro-succorhoea,  will  have  to  be 
excluded.  According  to  my  experience,  it  is  easy  to 
exclude  stenosis  of  the  pylorus,  but  not  an  ulcer.  In 
stenosis  of  the  pylorus  the  stomach  in  the  fasting  con- 
dition is  also  found  to  contain  a  liquid,  but  this  is 
mixed  with  food  ("  ischochymia"  ),  and  the  filtrate  al- 
ways shows  the  presence  of  starch  or  sugar  products. 
But  the  main  thing  is  that  food  particles  can  be  seen  even 
with  the  naked  eye,  whereas  the  liquid  found  in  the 
stomach  in  case  of  genuine  gastro-succorhoea  does  not 
contain  any  food  particles,  as  described  above.  The 
presence  of  an  ulcer  will  be  suspected  if  there  has  been 
a  preceding  htematemesis  or  melsena,  or  a  circumscribed 
spot  (in  the  gastric  region)  very  painful  to  the  slightest 
pressure.  The  absence  of  these  symptoms  will  tend  to 
justify  the  diagnosis  of  gastro-succorhcea. 

Prognosis. — According  to  my  experience,  the  prog- 
nosis of  gastro-succorhoea  is  not  bad.  As  a  rule,  most 
patients  improve  under  rational  treatment.  Frequently, 
however,  there  are  relapses.  Some  very  obstinate  cases 
are  occasionally  met  with,  and  the  trouble,  although 
yielding  somewhat  to  treatment,  may  persist  for  years. 
There  is,  however,  no  danger  of  a  fatal  issue  resulting 
from  this  disease  alone. 

Treatment. — As  we  have  seen,  gastro-succorhoea  is 
always  associated  with  hyperchlorhydria.  The  treat- 
ment of  the  latter  condition  in  reference  to  diet,  medi- 
caments, and  mode  of  living,  will  have  to  be  resorted 
to  here  also.  With  reference  to  diet,  I  have  only  to 
add  that  it  is  of  great  importance  not  to  permit  the 
patient  to  partake  of  any  large  quantities  of  liquid.  In 
this  affection  more  stress  must  be  laid  upon  this  point 
than  in  hyperchlorhydria.  The  treatment  of  gastro- 
succorrhoea  must  be  directed  toward  decreasing  the 
undue  amount  of  gastric  secretion. 

1.  Medicaments  :  With  this  end  in  view,  Voinovitch  ' 
recommends  the  use  of  atropia  in  doses  of  two  milli- 
grammes daily.  Bouveret  prefers  morphia  to  atropia. 
Following  the  advice  of  Leubuscher  and  Schaeffer,'-  he 
administered  two  to  three  centigrammes  of  sulphate  of 
morphia  three  times  daily,  in  subcutaneous  injections. 
This  author  doubts,  however,  whether  this  treatment, 
which  seems  to  be  effective  in  the  initial  state  of  the 
affection,  will  prove  useful  in  cases  that  have  pro- 
gressed further.  The  use  of  either  atropia  or  morphia 
may  be  tried  for  a  short  time,  but  they  should  never  be 
administered  for  a  long  period.  The  subcutaneous  in- 
jections of  morphia  especially  should  be  avoided,  as 
the  patient  runs  the  risk  of  becoming  an  habitue  of 
this  drug. 

2.  Lavage  :  Reichmann,  and  latter  Riegel,  recom- 
mend the  use  of  lavage  of  the  stomach  as  the  best 
means  of  improving  its  condition.  While  Riegel  washes 
out  the  stomach  in  the  evening,  six  to  seven  hours  after 
the  last  meal,  Reichmann  and  most  writers  administer 
the  lavage  in  the  fasting  condition.  The  latter  way 
is  also  employed  by  myself ;  it  has  the  following  ad- 
vantages : 

a.  That  by  emptying  the  stomach  in  the  fasting  con- 
dition we  are  better  enabled  to  judge  the  quantity  of 
juice  present  at  a  time  when  normally  there  should  be 
none. 

/'.  That  no  food  whatever  is  removed  from  the  stom- 
ach. 

Instead  of  lavage  Boas  recommends  emptying  the 
stomach  by  means  of  a  tube  in  the  fasting  condition 
(expression  method).  In  order  to  more  effectually 
combat  the  undue  secretion,  Reichmann  recommends 
adding  nitrate  of  silver  to  the  water  used  in  washing 
out  the  stomach.  After  it  has  been  washed  out  with 
plain  water,  300  c.c.  of  a  1  to  2  per  1,000  solution  of 
nitrate  of  silver  are  poured  into  the  organ,  and  left 
there  for  about  live  minutes,  when  it  is  withdrawn  by 
siphonage. 

3.  Spraying  the  stomach  :  Instead  of  the  latter  pro- 

'  Voinovitch  :  Semajne  mt'dicale,  April  6,  1892. 

'  Leubuscher  and  Schaeffer :  Deutsche  med.  Wochenschr.,  1392. 


ceeding  I  have  sprayed  out  the  stomach  after  the 
washing  with  a  i  to  2  per  1,000  nitrate  of  silver  solu- 
tion. In  two  cases  I  found  this  method  of  treatment 
of  great  benefit. 

4.  Direct  galvanization  of  the  stomach  :  The  first 
of  my  observed  cases  of  gastro-succorrhoea  chronica 
was  a  very  obstinate  one,  and  the  affection  did  not 
yield  much  to  the  medicinal  treatment  or  to  the  use  of 
lavage.  I  empirically  tried  direct  galvanization  of  the 
organ,  and  after  a  treatment  of  a  few  weeks  the  stom- 
ach began  to  be  empty  in  the  morning,  and  has  remained 
so  for  several  years.  Since  then  it  has  been  my  custom 
to  make  use  of  this  method  in  this  affection,  and  I 
must  say  that  the  result  has  been  very  gratifying. 
Very  often  I  employ  both  spraying  with  nitrate  of  silver 
and  direct  galvanization,  applying  them  alternately. 

20  E-\ST   SiXTV-THIRD  STREET. 


EXTINCTION    OF    TUBERCULOSIS    IN 
HERDS.' 

By  professor  JAMES  LAW, 

CORNELL  L*Nn'ERSITy,    ITHACA,   N.  Y, 

In  dealing  with  diseases  of  the  lower  animals  there  are 
various  possibilities  and  limitations  which  do  not  enter 
the  field  of  medicine  as  applied  to  man.  These  must 
ever  be  borne  in  mind  if  the  veterinary  sanitarian  would 
have  his  work  prove  a  success.  As  applied  to  tubercu- 
losis these  considerations  must  largely  influence  us  in 
the  choice  of  methods,  and  in  their  application  in  the 
sanitary  field.  Prominent  among  such  considerations 
are  : 

1.  The  facility  with  which  the  contagion  may  be 
checked  by  the  death  of  all  infected  animals. 

2.  The  possibility  of  arresting  the  career  of  contagion 
by  breeding  only  from  insusceptible  strains  of  blood. 

3.  The  impossibility  of  applying  effective  methods 
because  of  the  financial  ruin  which  would  be  entailed. 

1.  Destruction  of  the  Infected.^ — Under  the  first  head 
— the  checking  of  the  contagion  by  the  killing  of  the 
infected — the  principle  being  altogether  inapplicable  to 
dealing  with  man,  the  physician  naturally  thinks  first  of 
segregation,  disinfection,  and  a  police  control  of  the 
sick.  With  the  veterinarian,  on  the  other  hand,  free 
from  any  sense  of  the  sacredness  of  the  life  of  the  sick, 
the  first  thought  is  a  purely  economical  one,  namely  : 
Will  the  cost  of  the  seclusion  and  care  of  this  animal, 
and  of  the  probable  infection  of  others,  outvalue  the 
prospect  of  its  recovery,  and  the  actual  value  of  the 
animal  when  well  again  ?  With  any  virulent  and  dan- 
gerous disease  there  can  only  be  one  answer  to  this 
question,  namely,  that  economy  demands  the  extinction 
of  the  contagion  at  the  expense  of  the  first  victim,  before 
ten  or  a  hundred  more  shall  contract  the  disease.  With 
a  subject,  the  actual  sound  value  of  which  may  have 
been  anywhere  between  §10  and  $ioo,  the  administra- 
tion of  such  police  control  as  would  guarantee  the  pre- 
vention of  the  extension  of  the  infection,  through  man, 
beast,  bird,  or  inanimate  object,  would,  as  a  rule,  more 
than  use  up  the  actual  price  of  the  first  victim.  Every 
day  of  delay  in  shutting  up  these  living  factories  of  con- 
tagion places  a  greater  balance  on  the  wrong  side. 
The  economical  soundness  of  this  position  has  been 
now  so  often  illustrated  on  a  large  scale  and  in  regard 
to  so  many  different  diseases,  as  rinderpest,  lung 
plague,  sheep-pox,  glanders,  and  rabies,  that  for  those 
who  have  made  a  special  study  of  it,  it  has  passed  from 
the  field  of  discussion  to  that  of  established  truths. 

2.  Insusceptible  Families. — In  regard  to  the  second 
question,  that  of  propagating  insusceptible  families 
only,  while  it  is  equally,  with  our  first  proposition,  im- 
possible of  adoption  in  the  human  family,  as  interfering 

1  Presented  to  the  .\cademy  of  Medicine,  New  York,  November  8, 


November  23,  1895] 


MEDICAL    RECORD. 


JZ'i- 


with  personal  rights,  it  is  certainly  available  for  the 
lower  animals  over  which  the  State  can  exercise  the 
right  of  eminent  domain  and  enforce  a  police  control 
for  the  common  good.  In  animals,  as  in  man,  there  are 
certain  families  which  show  a  strong  susceptibility  to 
given  infections,  and  others  that  show  an  equally  po- 
tent resistance,  and  if  it  can  be  shown  that  no  more  se- 
rious interest  is  threatened  by  such  a  course,  it  is  quite 
within  the  power  of  the  State  to  exclude  the  first-named 
class  from  reproduction,  and  to  breed  only  the  animals 
that  show  the  comparative  immunity.  A  principle  of 
this  kind  is  already  in  force  in  certain  countries,  in 
which  all  stallions  are  licensed,  and  those  are  excluded 
from  stud  uses  which  are  calculated  to  deteriorate  the 
breed  of  the  district.  The  same  principle  is  in  force  in 
the  Channel  Islands,  where  no  cattle  except  those  of 
the  native  breed  are  ever  allowed  to  enter  a  herd. 

3.  Economic  Limitations. — In  the  third  place,  we  are 
confronted  with  the  question  of  economic  limitations. 
It  may  be  said  that  where  human  health  and  life  are 
concerned  no  question  of  mere  economy  should  be  al- 
lowed to  enter.  But  the  economic  question  may  be  so 
far-reaching  that  the  evil  to  humanity  would  be  greater 
in  the  end,  and  our  boasted  liberality  for  sanitary  needs 
would  itself  finally  defeat  the  much-coveted  sanitary 
object. 

Deferring  for  a  moment  the  question  of  the  immedi- 
ate influence  on  human  health,  let  us  glance  at  the  na- 
tional wealth  in  farm  animals.  The  United  States  own, 
in  round  numbers,  $1,500,000,000  worth  of  farm  stock, 
and  in  this  are  included  16,000,000  head  of  milch  cows, 
and  20,000,000  head  of  other  cattle.  The  cows  pro- 
duce yearly  5,209,125,567  gallons  of  milk,  or  315  gal- 
lons per  head.  Of  the  other  cattle,  probably  5,000,000 
are  killed  yearly  for  human  food,  representing  1,000,000 
tons  of  beef.  This  cannot  be  materially  restricted 
without  dealing  a  serious  blow  at  our  national  pros- 
perity. 

While  it  must  be  conceded  that  animals  would 
acquire  a  greater  power  of  resistance  to  tuberculosis  if 
kept  in  the  open  air  and  in  a  condition  more  nearly 
approximating  the  natural  one,  yet  if  we  let  the  milch 
cow  revert  to  the  condition  of  the  native  Texan  cow, 
which  can  only  scantily  support  its  calf,  and  if  we  re- 
mand the  beef  animal  to  its  native  state,  in  which  it 
took  four  years  to  reach  maturity,  in  place  of  putting  him 
on  the  market  as  prime  beef  at  two  years  old,  we  render 
the  whole  cattle  business  unprofitable.  Under  such 
conditions  our  stockowners  can  no  longer  compete  in 
the  markets  of  the  world,  and  this  branch  of  live  stock 
must  be  abandoned.  But  if  abandoned,  the  exhaustion 
of  our  soils  is  a  necessary  consequence,  and  in  due 
time  agriculture,  in  its  turn,  must  become  unprofitable, 
and  with  its  decay  we  shall  reach  the  end  of  our  whole 
national  prosperity,  built  upon  our  abundant  agricultu- 
ral products. 

\Vhatever  we  do  with  our  domestic  animals  we  dare 
not  cause  them  to  revert  to  a  state  of  nature.  This 
would  be  to  throw  away  the  achievements  of  the  labor 
and  the  skill  of  centuries,  and  would  entail  the  most 
serious  retrogression  of  the  nineteenth-century  civiliza- 
tion. As  well  propose  to  abandon  the  modern  triumphs 
in  steam  and  electrical  engineering. 

The  abnormal  productiveness  of  the  present  fami 
animal  is  one  of  the  most  substantial  foundations  of 
modern  prosperity,  and  it  would  be  an  economical 
blunder,  and  finally  a  sanitary  one,  to  seek  its  abandon- 
ment or  limitation.  So  far  as  we  can  secure  an  innate 
immunity  within  the  productive  families,  our  work  will 
be  sound,  and  so  far  as  we  can  produce  an  acquired 
immunity  by  hygienic  measures  we  are  laboring  in  the 
right  line  ;  but  the  line  must  be  drawn  wherever  these 
protective  measures  tend  to  seriously  impair  the  capa- 
city of  the  breed  for  profitable  uses. 

These  considerations  serve  to  clear  up  our  field  of 
veterinary  sanitary  police,  and  to  narrow  it  to  the  lim- 
its which  are  at  once  the  most  indispensable  and  the 


most  effective.  One  measure  stands  out  above  all 
others  as  the  one  which  must  never  be  lost  sight  of, 
and  to  which  all  others  must  be  held  as  accessory  and 
subservient.  This  measure  is  the  extinction  of  the 
disease  germ. 

Feeding  from  Separate  Troughs. — Where  from  any 
cause  the  immediate  extinction  of  the  germ  is  impracti- 
cable, an  all-important  precaution  is  to  teach  each  ani- 
mal to  use  its  own  stall  only,  and  to  have  the  stall  so 
separated  in  front  that  no  two  cattle  can  feed  from  the 
same  trough.  For  the  same  reason  no  common  feeding- 
trough  should  be  used  in  yard  or  field,  and  there  may 
be  danger  in  using  a  common  drinking- trough  or  bucket. 

Salting  Troughs  and  Front  of  Stalls. —  In  view  of 
the  fact  that  tuberculosis  is  largely  propagated  by  the 
dried- up  virulent  expectorations  which  are  raised  and 
diffused  in  the  form  of  dust,  the  daily  sprinkling  with 
a  strong  brine,  of  the  front  of  the  stall,  the  manger,  and 
the  passage  in  front,  proves  an  important  protective 
measure.  Condensing  the  moisture  of  the  air,  the  salt 
keeps  the  surface  constantly  damp,  and  prevents  the 
sputa  from  drying  up  and  rising  as  an  impalpable 
powder.  The  salt  is  not  only  harmless,  but  whole- 
some, and  has,  besides,  a  very  slight  bactericidal 
action.  In  a  cold  barn,  below  freezing,  a  weak  solution 
of  sulphuric  acid  may  be  substituted. 

Open-air  Life. — So  far  as  possible  a  free,  open-air  life 
should  be  secured  for  the  stock.  In  city  and  suburban 
stables  the  infected  may  reach  anywhere  from  six  to 
ninety  per  cent.,  whereas  among  2,250,000  of  our  fat 
range  cattle  the  tuberculous  did  not  exceed  0.02  per 
cent.  The  comparative  absence  of  viable  bacteria  in 
the  air  of  the  pastures,  and  the  operation  of  full  sun- 
shine in  devitalizing  the  bacillus  tuberculosis  in  a  few 
hours,  while  it  may  live  for  months  in  an  ordinary 
room,  are  sufficiently  instructive  in  this  connection.  In 
the  Northern  States,  where  cattle  must  be  sheltered  in- 
doors for  five  or  six  months  of  the  year,  too  great  care 
cannot  be  taken  to  secure  ample  windofvs  and  sun- 
shine, as  well  as  free  air  in  the  stables.  Darkness  in 
the  stalls  reduces  the  quality  and  number  of  the  red 
globules,  and  the  vitality  and  power  of  resistance  of 
the  animal ;  so  that  it  virtually  burns  the  candle  at 
both  ends,  preserving  and  multiplying  the  germ  and 
increasing  the  susceptibility  of  the  animal. 

These  considerations  strongly  condemn  the  city  and 
suburban  dairy.  Other  things  being  equal,  the  larger 
the  city  the  greater  the  number  of  floating  bacilli  and 
the  greater  the  susceptibility  of  the  animal  system.  In 
French  towns  of  five  thousand  inhabitants  the  ratio  of 
tuberculous  persons  is  only  half  as  much  as  it  is  in 
towns  of  one  hundred  thousand  to  five  hundred  thou- 
sand. In  German  abattoirs  the  ratio  of  tuberculous 
cattle  is  about  five  per  cent,  of  all  slaughtered,  yet  Os- 
tertag  gives  the  ratio  for  old  cows  in  the  Berlin  slaugh- 
ter-houses as  seventy-five  per  cent.  The  ratio  is  greater 
in  our  city  and  suburban  dairies  to-day  than  it  was 
years  ago,  when  a  large  proportion  of  the  fresh  cows 
were  killed  off  by  lung  plague  within  three  months  of 
their  purchase.  There  remains,  however,  this  redeem- 
ing element,  that  the  city  dairyman  finds  it  unprofitable 
to  keep  the  same  cows  from  year  to  year,  and  as  a  slow 
disease  like  tuberculosis  finds  insufficient  time  for 
abundant  development,  the  result  is  better  for  the  city 
dairy  than  it  otherwise  would  be.  The  case  is  worse 
with  a  thoroughbred  herd  kept  in  the  city  or  suburbs 
as  long  as  the  cows  will  breed,  as  there  are  here  the 
combined  evils  of  a  generally  contaminated  atmosphere 
of  indoor  life  in  a  barn  too  often  infected,  and  in  too 
many  cases  a  bodily  constitution  rendered  increasingly 
susceptible  by  inbreeding.  Once  start  the  infection 
under  such  conditions  and  the  affection  is  liable  to  be- 
come concentrated  by  a  number  of  successive  reinfec- 
tions in  the  same  animal,  so  that  not  only  are  cases  mul- 
tiplied, but  generalized  cases  soon  come  to  prove  the 
rule  rather  than  the  exception.  Everything  considered, 
the  city  and  suburban  dairies  are  surrounded  by  greater 


732 


MEDICAL    RECORD. 


[November  25,   1895 


dangers  than  the  country  ones,  and  this  should  be  taken 
into  account  alike  by  the  dairyman  himself  and  by  the 
sanitarian  who  would  protect  humanity  against  the 
bovine  source  of  infection. 

Precautions. — Among  the  further  precautions  which 
are  within  the  control  of  the  stockowner  himself  are 
the  following  : 

Avoid  Breeding  too  Young. — The  immature  system  is 
easily  debilitated. 

Don't  unduly  Stimulate  the  Milk  Secretion. — Let  the 
diet  be  always  sufficient  to  fully  sustain  the  vital  powers 
as  well  as  lactation. 

When  the  Co7L<  goes  Dry  don't  Allow  Her  to  Suffer  from 
Insufficiency  nor  UnsuitaHlity  of  the  Food. 

Correct  all  Conditions  of  III  health. — Debility  is  an 
urgent  imatation  to  the  bacillus.  On  the  other  hand, 
the  most  phenomenal  powers  of  digestion,  assimilation, 
and  rapid  growth  and  fattening  give  no  guarantee  of 
protection  when  the  germ  is  implanted. 

Bang  tells  us  that  the  disease  was  virtually  unknown 
in  Danish  cattle  until  1840,  when  it  was  introduced  in 
some  purchases  from  Schleswig,  and  later,  in  1850,  by 
large  importations  of  English  short-horns,  and  now  the 
Copenhagen  abattoirs  show  seventeen  per  cent,  of  the 
cattle  tuberculous,  and  the  tuberculin  test  on  19,462 
cattle  showed  61.6  per  cent,  tuberculous. 

Old  and  Unthrifty  Cows  should  be  Excluded  from  the 
Herd. — Twice  to  six  times  as  many  old  cows  as  of 
young  ones  are  tuberculous.  The  first  sign  of  un- 
thriftiness  should  be  a  warrant  for  separation  from  the 
rest  of  the  herd,  and  especially  in  the  case  of  the  aged. 
Better  still  to  use  the  tuberculin  test  to  decide  whether 
the  animal  should  be  promptly  slaughtered. 

Don't  Buy  from  a  Herd  that  has  Furnished  Cases  of 
Tuberculosis  in  Recent  Years. — Here,  again,  the  safe 
course  is  to  admit  only  such  as  have  stood  the  test  with 
tuberculin. 

let  no  Tuberculous  Person  Care  for  the  Herd. — The 
tuberculous  person  is  a  source  of  greater  danger  to  the 
herd  than  is  even  the  tuberculous  animal.  The  latter 
can  be  confined  to  one  place  and  the  virulent  sputa 
can  be  prevented  from  drying  and  rising  as  dust,  but 
for  the  attendant  there  is  no  such  limitation,  and  his  dis- 
charges are  all  the  more  dangerous.  In  one  herd  where 
three  of  the  family  in  charge  had  died  of  tuberculosis, 
I  found  nineteen  of  the  twenty-six  cows  badly  affected. 

By, attending  to  such  precautions,  by  killing  all  tuber- 
culous animals  and  safely  disposing  of  the  carcases,  and 
by  thoroughly  disinfecting  all  the  products,  the  stock- 
owner  may  reasonably  hope  to  purify  his  herd  of  the 
infection  and  to  keep  it  sound. 

I  have  purposely  omitted  all  reference  to  methods  of 
treatment,  as  these,  however  good  for  a  human  patient 
whose  life  must  be  spared,  necessarily  entail  a  long- 
continued  administration,  and  are  attended  by  too 
great  expenses  and  uncertainty  of  result  to  warrant 
their  recommendation  for  animals  when  the  object  is 
to  stamp  out  the  disease. 

Sanitary  Police  for  Tuberculosis  in  Herds. — In  con- 
sidering police  methods  for  tuberculosis  in  herds,  our 
past  experience  in  dealing  with  plagues  of  animals  does 
not  furnish  an  exact  counterpart.  The  absolutely  suc- 
cessful results  in  different  parts  of  the  world  with 
rinderpest,  lung  plague,  sheep-pox,  rabies,  and  glan- 
ders, were  obtained  with  diseases  which  confined  their 
ravages  to  animals,  or  which,  in  attacking  man,  entailed 
an  acute  and  fatal  disorder,  so  that  the  agency  of  man 
in  propagating  the  contagium  could  be  practically  elim- 
inated. In  tuberculosis,  on  the  other  hand,  we  con- 
front a  disease  which,  even  in  man,  often  follows  a 
tardy  and  occult  course,  and  which  is,  at  all  events, 
habitually  chronic,  so  that  the  contagium  must  be  pre- 
served so  long  as  the  phthisical  man  is  allowed  to  go 
at  large.  It  is  not,  however,  so  diffusive  as  the  con- 
tagia  of  rinderpest,  lung  plague,  or  sheep-pox,  and 
hence  the  same  absolute  seclusion  is  not  necessary  to 
prevent  its  propagation. 


If  we  could  exclude  dairy  herds  from  cities  and 
other  dense  aggregations  of  humanity,  and  see  to  it  that 
consumptive  persons  were  debarred  from  caring  for,  or 
mingling  with,  cattle  and  other  susceptible  animals 
elsewhere,  we  could  proceed  with  the  extinction  of 
bovine  tuberculosis  with  the  same  confident  expecta- 
tion of  success  as  we  have  in  the  past  undertaken  the 
extinction  of  the  plagues  of  animals  already  referred 
to. 

So  long,  however,  as  such  separation  is  unattain- 
able, we  must  be  content  to  be  satisfied  with  less  per- 
fect results,  and  must  stand  ready  to  repeat  the  process 
of  extinction  in  the  same  herd  as  often  as  it  may  be- 
come necessary.  Even  with  this  drawback,  however, 
we  can  promise  a  practical  extinction  of  the  affection 
in  our  herds,  and  a  reasonable  guarantee  of  the  sound- 
ness of  our  dairy  and  butcher  products. 

For  the  Speedy  Extinction  of  Tuberculosis  in  Herds. 
— In  this  direction  I  cannot  do  better  than  to  repeat 
my  suggestion  in  the  report  of  the  Tuberculosis  Cora- 
mission  for  1894  :  "All  herds  of  the  State  would  be 
examined  and  tested  with  tuberculin  as  speedily  as 
possible,  the  diseased  animals  would  be  condemned, 
appraised,  killed,  and  safely  disposed  of,  the  premises 
disinfected,  other  genera  of  animals  that  have  lived 
with  the  diseased  "  (cattle)  "  would  be  examined,  and, 
if  necessary,  safely  disposed  of,  vermin  would  be 
killed,  and  all  consumptive  persons  would  be  advised  "' 
(enjoined)  "  against  attending  on  the  purified  herd  or 
preparing  their  food.  Finally,  all  new  purchases  would 
be  kept  apart  from  the  herd  until  they  had  been  tested 
\\-ith  tuberculin.  In  this  way  everj^  step  would  be  so 
much  clear  gain,  and  what  had  been  once  accom- 
plished could  be  looked  upon  with  reasonable  confi- 
dence as  a  permanent  success." 

The  continued  testing  of  new  purchases  and  the  re- 
peated examination  of  the  herds  at  long  intervals  would 
be  required,  as,  at  first,  isolated  cases  would  appear 
from  bacilli  that  had  lodged  on  the  digestive  or  respir- 
atory mucosae,  but  which  had  not  colonized  the  tissues 
prior  to  the  tuberculin  test,  and  also  from  other  acci- 
dental outside  sources.  Necropsies  of  all  animals  dy- 
ing or  killed  would  also  be  requisite,  so  as  to  insure 
that  no  seeds  of  the  disease  should  be  overlooked  in 
the  herd,  so  as  to  break  out  later.  The  most  serious 
objection  to  this  prompt  and  effectual  method  is  the 
lack  of  a  sufficient  appropriation.  For  indemnities 
alone,  at  $25  per  head,  four  per  cent,  of  our  2,500,000 
head  of  cattle  (roo,ooo)  would  demand  $2,500,000.  If 
we  add  to  this  the  cost  of  the  inspection  of  the  whole 
bovine  race  in  the  State,  and  of  animals  kept  with 
them,  of  appraisements  and  of  administration  gener- 
ally, we  could  not  calculate  on  less  than  $3,000,000  as 
a  working  fund.  Another  drawback  is  the  lack  of  pro- 
fessional men  sufficiently  acquainted  with  the  use  of 
tuberculin,  and  with  the  diseases  of  animals  generally, 
to  satisfactorily  fill  the  r?lc  of  inspectors.  It  would 
take  a  length  of  time  to  organize  a  satisfactory  sanitary 
force  for  the  entire  State,  so  that,  even  if  the  money 
were  forthcoming,  the  inauguration  of  the  enterprise 
would  be  necessarily  slow. 

Registration  of  Herds  and  Necropsies  as  a  Means  of 
Tracing  Tuberculosis. — A  most  effective  but  less  speedy 
means  of  dealing  with  tuberculosis  in  herds  would  be 
based  on  an  universal  registration  of  the  bovine  ani- 
mals. To  each  county  or  district  could  be  assigned 
one  or  more  trustworthy  veterinarians  who  should  keep 
an  accurate  record  of  bovine  animals,  and  of  all  addi- 
tions and  removals,  and  who  should  examine  all  cattle 
killed  or  that  died.  On  the  discovery  of  a  case  of  tu- 
berculosis, the  disease  would  be  identified  by  the  chief 
veterinarian,  and  the  whole  herd  would  be  subjected  to 
the  tuberculin  test,  and  those  found  tuberculous  would 
be  condemned,  appraised,  killed,  and  safely  disposed 
of,  and  the  premises  disinfected.  Similar  precautions 
as  under  the  speedy  method  would  be  adopted  toward 
other  domestic  animals  on  the  same  place,  toward  ver- 


November  23,  1895] 


MEDICAL   RECORD. 


7i3, 


rain,  and  toward  tubercular  attendants,  and  new  pur- 
chases. 

In  this  way  every  tuberculous  herd  would  be  discov- 
ered and  purified  without  serious  delay,  and  at  the 
same  time  the  expensive  tuberculin  test  would  be 
reserved  for  herds  in  which  tuberculosis  was  known  to 
exist.  The  unfounded  stock  objection  to  the  tubercu- 
lin test,  that  it  might  introduce  disease,  would  in  this 
way  be  rendered  absurd  even  to  the  objector  himself. 

This  work  could  probably  be  accomplished  by  one 
hundred  inspectors  at  a  cost  of  $150,000  or  $200,000  a 
year.  Indemnities  also  would  be  lessened,  as  many  of 
the  occult  cases  would  be  detected  only  at  the  butch- 
ers, and  at  least  the  demand  for  values  would  be  more 
gradual  and  more  easily  met. 

Abattoir  Inspections  to  Trace  Tuberculosis. — A  third 
method  of  tracing  tuberculosis  is  to  provide  municipal 
or  other  official  abattoirs  in  which  alone  farm  animals 
designed  to  be  marketed  as  human  food  can  be  killed. 
This  has  long  been  in  use  in  Europe,  and  must  one  day 
be  adopted  in  America,  as  a  purely  sanitary  measure, 
no  matter  how  it  may  interfere  with  the  vested  interests 
and  monopolies  of  individuals.  Inspection  in  private 
abattoirs  can  never  be  made  as  satisfactory  as  in  pub- 
lic institutions  in  which  everj'thing  is  done  according 
to  rule.  Incidentally  the  government  stamp  and  en- 
dorsement furnished  with  all  sound  meats  would  open 
to  all  competitors  interstate  and  foreign  trade,  which  is 
now  the  monopoly  of  the  packers  in  certain  large  cit- 
ies. Its  effect  in  tracing  the  centres  of  animal  tubercu- 
losis may  be  inferred  from  the  reports  of  the  Berlin 
abattoirs,  where  seventy-five  per  cent,  of  the  old  cows 
are  tuberculous  ;  of  Leipzig,  where  twenty-eight  per 
lent.  prove  affected  ;  of  Schwerin,  where  thirty-five  per 
cent,  are  diseased  ;  of  Paris,  London,  and  Edinburgh, 
where  twenty-two  per  cent,  prove  consumptive. 

With  such  data  it  is  easy  to  follow  each  animal  back 
to  its  herd  and  subject  that  to  the  tuberculin  test.  If 
we  were  to  combine  this  restricting  of  slaughter  to  the 
inspected  government  abattoirs,  with  a  careful  record 
of  the  herds  and  their  individual  animals,  it  would 
prove  easy  and  certain  to  discover  every  centre  of  dis- 
ease and  to  speedily  eradicate  the  contagium. 

The  desideratum  in  our  present  methods  is  a  definite 
and  effective  system.  Our  tuberculosis  commissions 
are  in  a  sense  free  lances,  with  power  to  rove  about  the 
State  and  test  a  herd  here  and  a  herd  there,  as  the  ur- 
gency of  the  demand  or  their  own  judgment  may  dic- 
tate. And  in  the  preliminary  inquiry  into  the  existence 
and  relative  prevalence  of  tuberculosis  in  different  dis- 
tricts this  has  served  a  good  purpose.  But  now  that 
this  purpose  has  been  accomplished,  this  should  give 
place  to  a  system  which  will  look  toward  something 
more  definite  in  the  way  of  the  extinction  of  the  dis- 
ease. When  a  herd  or  district  is  purified  of  the  infec- 
tion, due  precautions  should  be  taken  to  prevent  its  re- 
infection, so  that  the  same  work  will  not  be  demanded 
again  and  again  in  the  same  district,  and  above  all,  that 
the  purified  herd  shall  not  be  exposed  to  diseased 
herds  on  all  sides  of  it. 

Let  herds  be  excluded  from  cities  and  suburbs,  or  let 
the  herds  in  such  localities,  as  are  the  most  dangerous 
to  themselves  and  to  humanity,  be  the  first  to  be  put 
under  a  rigid  system  for  the  suppression  of  the  conta- 
gium. Next  to  this,  the  dairy  counties,  in  which  the 
bovine  population  is  the  densest,  should  be  systemati- 
cally attacked.  When  these  shall  have  been  purified, 
the  herds  of  the  State  at  large,  where  the  danger  of  the 
concentration  of  infection  is  least,  should  be  taken  in 
hand.  Every  step,  however,  should  be  subordinated 
to  the  maintaining  of  the  ground  that  has  been  already 
gained,  and  the  advance  of  the  work  in  such  lines  as 
will  make  it  possible  or  easy  to  hold  all  newly  acquired 
territory.  The  general  plan  must  therefore  yield  in 
many  cases,  so  as  to  clear  up  a  whole  district — the  less 
densely  peopled  with  cattle,  as  well  as  the  more  densely 
uopulated — so  that  the  conquered  territory  shall  be  kept 


compact  and  easily  defensible  from  first  to  last.  The 
time  for  the  sporadic  dealing  with  individual  herds, 
remote  from  each  other,  is  past.  The  knowledge  and 
the  needs  of  to-day  unite  in  demanding  such  an  appro- 
priation and  such  supervision  as  will  secure  a  system- 
atic and  progressive  advance  over  the  whole  State,  and 
which  will  look  toward  the  purifying  of  our  herds  in 
every  locality. 


A   STUDY   OF    HYSTERIA   AND    HYPOCHON- 
DRIASIS.' 

By  CHARLES  E.  LOCKWOOD,  M.D., 


■  VORK    CITV, 


HE  NERVE?,   OUT-DOOR 


The  period  in  which  we  live  seems  to  be  peculiarly 
fruitful  in  the  production  of  malnutrition,  degenera- 
tion, and  diseases  of  the  great  nerve-centres,  which  has 
been  variously  ascribed  to  different  factors.  The  fact 
that  the  census  of  1S90  showed  that  eighty-seven  per 
cent,  of  the  total  population,  over  ten  years  of  age,  could 
read  and  write,  would  seem  to  be  of  interest  in  this 
connection  ;  as  one  writer  remarks,  "  it  may  be  fearlessly 
asserted  that  in  the  history  of  the  human  race,  no 
nation  ever  before  possessed  forty-one  million  in- 
structed citizens."  Then,  in  this  age  and  in  this  coun- 
try, the  problems  of  human  existence  have  been  rapidly 
growing  more  vast  and  complicated,  and  the  rapid 
succession  of  events,  which  are  now  daily  reported  to 
us  from  all  quarters  of  the  globe,  together  with  the 
great  strain  on  the  higher  cerebral  centres  incidental  to 
the  great  struggle  for  wealth  and  existence,  combined 
with  the  absence  of  proper  periods  of  rest,  and  the  lack 
of  general  systematic  cultivation  of  out-door  games  and 
sports,  and  means  of  mental  diversion,  are  hardly  cal- 
culated to  favor  healthy  cerebral  nutrition. 

It  may  also  be  reasonably  asked  whether  the  human 
brain  is  not  passing  through  a  period  of  great  strain 
and  readjustment  to  a  new  environment,  and  is  suf- 
fering as  a  consequence  until  such  time  as  advanced 
ideas  shall  indicate  the  proper  methods  of  meeting  the 
new  conditions,  and  here  it  seems  proper  to  call  atten- 
tion to  the  tendency  to  centralization,  specialism,  and 
the  increased  interest  in  athletics  as  a  step  in  the  right 
direction.  However  this  may  be,  rich  and  poor  seem 
to  be  equally  affected,  and  in  the  field  of  my  observa- 
tion, the  Out-door  Department  of  Bellevue  Hospital, 
New  York,  I  have  been  surprised  to  observe  the  great 
prevalence  of  such  conditions  of  the  higher  nerve  cen- 
tres among  the  poorer  laboring  classes,  embracing  such 
occupations  as  are  not  usually  thought  to  be  attended 
with  excessive  mental  strain,  and  on  investigation  one 
finds  that  they  are  all  men  and  women  of  like  passions 
with  us,  and  that  the  unsettled  intellectual  convictions 
of  the  present  century,  ancestral  tendencies,  individual 
environment,  all  the  various  causes  which  tend  to 
excite  or  depress  the  emotional  nature,  alcoholic  ex- 
cesses, absorption  of  nicotine  and  lead  among  workers 
in  tobacco  and  lead,  self-abuse,  sexual  excess,  and 
syphilis,  all  play  their  role  here,  as  well  as  elsewhere,  in 
producing  vital  depression  and  favoring  malnutrition 
and  degeneration  and  abnormal  mental  states.  In  the 
study  of  the  causes  of  hysteria  and  hypochondriasis  we 
have  to  do  with  mental  and  physical  factors,  and  largely 
with  mental  disturbance  ;  it  seems,  therefore,  fit  to 
inquire  carefully  as  to  what  favors  healthy  brain  action 
and  its  opposite. 

The  human  body  may  be  compared  to  a  kingdom 
inhabited  by  a  large  number  of  different  denizens  and 
visited  by  many  intruders,  who,  having  effected  an 
entrance,  gain  control  and  work  mischief.  The  think- 
ing brain  is  the  ruling  monarch,  and  should  be  most 

■  Read  before  the  Twelfth  Annual  Meeting  of  the  New  York  State 
Medical  Association,  held  in  New  York  October  17,  1895. 


73^ 


MEDICAL   RECORD. 


[November  23,  1895 


carefully  guarded  and  kept  in  the  most  perfectly 
healthy  condition,  and  should  reign  supreme,  choosing 
its  code  of  principles  and  carrying  them  out  inflexibly 
through  its  prime  minister,  the  will.  Anything  which 
interferes  with  the  healthy  tone  or  working  of  the  brain 
or  its  powerful  agent,  the  will,  affects  the  whole  body 
unfavorably,  and  each  reacts  on  the  other,  hence  the 
maxim,  "  Mens  sana  in  sano  corpore."  Now,  what  are 
some  of  the  mental  and  physical  conditions  which  are 
needed  to  secure  healthy  tone  and  action  for  the  think- 
ing portion  of  the  human  brain. 

1.  Hereditary'  transmission. 

2.  Proper  mental  and  physical  training,  combined 
with  a  suitable  environment,  based  on  a  careful  study  of 
the  mental  and  physical  conditions  of  the  ancestry  and 
the  individual. 

3.  The  correction  of  all  physical  defects  calculated 
to  interfere  with  the  general  nutrition.  "  If  the  brain 
is  not  well  supplied  with  an  abundance  of  nourishing 
and  pure  blood,  its  functions  cannot  be  well  per- 
formed. 

4.  The  adoption  of  the  most  reasonable,  convincing, 
and  soul-satisfying  theory  of  man's  place  in  nature,  his 
origin,  mission,  and  destination. 

5.  The  recognition  of  the  animal  propensities  in  the 
man,  and  the  importance  of  their  control  by  educated 
higher  centres. 

6.  The  adoption  of  a  code  of  principles  best  adapted 
to  promote  the  securing  of  the  highest  development, 
mental  and  physical. 

7.  The  selection  of  some  line  of  mental  or  physical 
work,  based  on  a  careful  study  of  mental  and  physical 
peculiarities  of  the  individual  and  ancestry,  which 
shall  give  a  definite  and  useful  aim  to  life. 

8.  The  keeping  out  of  the  mind  all  influences,  ideas, 
and  habits  calculated  to  defeat  the  end  in  view,  or 
cause  mental  or  physical  deterioration. 

9.  The  keeping  out  of  the  mind  all  superstitious  im- 
aginations and  unrealities  which  are  calculated  to 
weaken  reason  and  self-control. 

This  is  an  age  of  materialism  run  riot.  Every  one 
seems  to  be  looking  for  some  cause  which  can  be  ap- 
preciated by  the  five  senses,  not  laying  enough  empha- 
sis upon  the  thoughts  which  are  allowed  to  enter  the 
human  brain  and  which  are  just  as  powerful  to  produce 
disease  as  germs.  We  come  into  the  world  with  pow- 
erful appetites  and  special  centres  for  their  functional 
exercise,  and  above  them  a  higher  centre,  the  seat  of 
the  reason  and  will,  weak  in  many  cases  and  not  fit  to 
rule,  through  inexperience,  without  the  help  of  the  most 
able  and  far  sighted  advisers — is  it  any  wonder  that 
with  a  certain  hereditary  predisposition  and  environ- 
ment the  lower  centres  in  many  cases  gain  control 
while  the  higher  centre  sleeps,  and  mind  and  body  are 
deteriorated  by  force  of  evil  habit  and  malnutrition 
until  there  seems  to  be  no  hope  of  healthy  mental 
action,  and  every  variety  of  morbid  thought  and  mor- 
bid impulse  runs  through  the  poor,  weak,  unresisting 
brain,  until  all  mental  control  is  lost  and  the  poor  suf- 
ferer is  like  a  ship  which  has  lost  its  rudder,  at  the 
mercy  of  the  winds,  storms,  and  waves  of  evil  and  un- 
restrained passions,  appetites,  and  morbid  thoughts  and 
impulses. 

10.  The  early  training  of  the  young  in  the  habit  of 
self-control,  as  here  parents  most  frequently  lay  the 
foundation  for  future  hysteria  and  hypochondriasis. 

11.  The  careful  avoidance  of  alcoholic  excess,  espe- 
cially in  hereditarily  predisposed  individuals,  and  drug 
habits. 

12.  The  selection  of  proper  forms  of  mental  diver- 
sion and  recreative  physical  exercise,  and  the  cultiva- 
tion of  such  social  relations  as  will  stimulate  the  higher 
faculties  and  emotions. 

13.  The  forming  of  habits  of  self-reliance  and  indi- 
vidual thought  and  action,  regardless  of  external  influ- 
ences, so  as  to  increase  the  power  of  each  individual 
factor. 


14.  Submission  to  destiny. 

Having  enumerated  some  of  the  conditions  necessarj- 
to  promote  healthy  brain  action,  without  claiming  to 
have  exhausted  the  subject,  let  us  look  for  a  moment  at 
some  of  the  causes  which  are  productive  of  unhealthy 
brain  action,  and  again  we  must  mention  : 

1.  Hereditary  transmission. 

2.  Improper  mental  and  physical  training,  combined 
with  unsuitable  environment. 

3.  Physical  defects,  which  interfere  with  general  heal- 
thy nutrition. 

4.  The  lack  of  adoption  of  definite  principles,  look- 
ing toward  uniformity  of  thought  and  action  and  for- 
mation of  fixed  habits,  which  tend  to  the  making  of  a 
well-balanced  mind. 

5.  The  constant  indulgence  of  the  animal  appetites 
against  the  voice  of  conviction,  involving  the  weaken- 
ing of  self-control. 

6.  The  lack  of  occupation  and  motive  in  life,  allow- 
ing of  too  much  introspection. 

7.  The  harboring  of  beliefs  based  on  superstitions 
and  imaginations,  involving  the  stifling  of  reason. 

8.  The  excessive  use  of  alcoholic  stimulants,  opium, 
or  tobacco. 

9.  The  lack  of  proper  mental  diversion  and  physical 
exercise. 

10.  The  effect  of  low  states  of  health,  due  to  some 
poison  in  the  system,  invohnng  continuous  watching 
for  outbreaks,  or  of  chronic  diseases,  especially  of  the 
sexual  organs,  so  that  the  mind  is  almost  constantly 
pervaded  by  the  same  train  of  thought. 

11.  Climatic  changes,  especially  when  sudden  and 
of  extensive  range,  involving  a  frequent  readjustment 
of  the  system,  with  consequent  vital  depression. 

12.  The  circulation  in  the  blood  of  poisonous  germs, 
metals,  or  toxic  matters,  the  result  of  malassimilation 
or  indigestion,  as  happens  in  malarial  poisoning,  syphi- 
lis, lead  and  mercurial  poisoning,  alcoholic  excess, 
uraemia,  or  uric-acidamia,  rendering  the  circulating 
fluid  unfit  for  healthy  nutrition,  and  predisposing  to 
degeneration. 

13.  The  tendency  of  the  thought  and  practice  of  the 
present  age,  among  young  men  and  women,  seems  to 
be  antagonistic  to  the  consummation  of  marriage  and 
the  assumption  of  the  duties  of  motherhood  and  father- 
hood. Young  men,  discouraged  by  the  extravagant 
demands  of  the  other  sex  and  their  longing  for  luxury, 
idleness,  and  excitement,  are  led  to  lead  isolated  lives, 
finding  their  social  pleasures  in  various  ways,  which 
lead,  in  any  case,  to  unsettled  convictions,  a  lack  of 
definite  aim,  selfishness  and  introspection,  and  many 
deserving  young  women  are  driven  to  seek  employ- 
ment in  various  occupations  or  lead  lives  devoid  of  the 
incentives  which  tend  to  the  highest  development  of 
the  female  nature. 

14.  The  influence  of  a  degenerate  literature  and  art 
inculcating  the  following  of  the  lead  of  the  emotions, 
and  the  consequent  stimulation  of  the  lower  centres 
and  lowering  of  the  influence  of  reason  and  self-con- 
trol. 

To  sum  up,  anything  which  favors  healthy  ratiocina- 
tion and  increases  the  habit  of  self-control,  or  favors 
the  consers-ation  of  that  mysterious  something  which 
we  call  vital  force,  together  with  favorable  hereditary 
transmission,  or  the  use  of  proper  measures  looking 
toward  the  correction  of  hereditary  defects,  or  un- 
healthy conditions  peculiar  to  the  individual,  these 
tend  to  favor  healthy  brain  action,  and  the  opposite 
conditions  unhealthy  brain  action. 

There  are  two  affections  to  which  humanity  is  liable 
— hysteria  and  hypochondriasis — which,  in  my  opinion, 
are  peculiarly  the  result,  in  great  measure,  of  defective 
action  of  the  higher  centres,  the  reason  and  will,  in 
their  inhibitory  action  on  the  lower  centres  ;  in  other 
words,  long  weakening  of  reason  and  will  and  defec- 
tive training  of  the  higher  centres,  the  seat  of  these 
faculties,  is  followed  by  undue  and  unrestrained  action 


November  23,  1895J 


MEDICAL    RECORD. 


735 


of  the  lower  centres,  producing  diseased  conditions. 
mental  and  physical,  and  this  result  is  naturally  favored 
by  any  cause  which  interferes  with  healthy  nutrition. 

Hysteria  is  a  yielding  of  the  mind  to  any  morbid  im- 
pulse that  enters  it. 

Hypochondriasis  is  a  mind  habit  of  dwelling  on 
bodily  functions  until  it  becomes  second  nature,  and 
the  mind  becomes  in  this  way  sensible  to  impressions 
which,  in  health,  are  unperceived,  and  are  now  misin- 
terpreted ;  or,  in  other  words,  it  is  a  morbid  concen- 
tration of  the  mind  on  the  various  bodily  organs,  func- 
tions, and  sensations,  to  which  the  subject  attributes 
false  pathological  significance. 

The  causes  of  the  two  conditions  are  partly  physical, 
but  largely  mental  ;  any  physical  condition  which  in- 
terferes with  healthy  nutrition,  such  as  indigestion, 
malassimilation,  reflex  irritation,  the  circulation  of 
to.\ic  matters  in  the  blood,  may  be  a  potent  initial 
factor,  but  the  habit  of  mental  non-resistance,  self-con- 
centration, the  paralysis  of  will,  and  the  neglect  to  use 
the  reasoning  faculties  in  the  interpretation  of  symp- 
toms presented,  are  largely  responsible  for  the  phe- 
nomena presented  by  these  two  affections.  The  class 
of  persons  most  liable  to  these  affections  are  those  of 
neurotic  ancestry,  and  possessing  a  neurotic  or  mer- 
curial temperament,  with  strong  imagination  and  emo- 
tions, easily  elated  or  depressed,  and  rather  moved  by 
impulse  than  reason,  deficient  in  self-control,  and  with- 
out definite  aim  in  life  and  mental  occupation. 

Following  Dr.  G.  L.  Walton's  classification  in  Wood's 
"  Reference  Handbook  of  the  Medical  Sciences,"  the 
symptoms  may  be  briefly  classified  under  Disturbances 
of  Sensation,  Disturbances  of  Motion,  Circulatory, 
Secretory,  and  Excretory  Disorders,  and  Disturbed 
Mental  Conditions. 

As  illustrative  of  disturbances  of  sensation,  I  refer 
briefly  to  the  following  cases,  which  have  come  under 
my  observation. 

Mrs.  R ,  a  widow,  had  a  sensation  as  though  all 

the  blood  in  the  body  was  flowing  into  a  space  about 
the  size  of  the  hand,  on  the  right  side,  accompanied 
with  pain,  a  sense  of  tightness,  and  suffocation.  She 
was  suffering  from  fatigue  at  the  time  I  saw  her,  and 
had  been  told  that  one  lung  was  diseased.  She  also 
had  a  sensation  as  though  the  house  was  moving. 
She  was  completely  relieved  by  teaspoonful  doses  of 
elixir  of  valerianate  of  ammonia,  given  every  hour  or 
two  during  the  entire  night. 

Mrs.  H ,  while  taking  lunch  with  some  friends, 

had  a  sensation  as  though  a  corkscrew  was  being  bored 
up  through  her  brain,  and  was  told  by  her  friends  that 
her  face  was  turning  purple.  I  was  asked  by  her  hus- 
band to  see  her,  as  he  feared  apoplexy.  Under  the 
elixir  of  valerianate  of  ammonia,  in  drachm  doses, 
when  needed  to  combat  symptoms  of  nervousness,  and 
a  course  of  Fellow's  hypophosphites,  there  were  no 
further  attacks. 

Mr.  S.  S ,  never  ill,  except  having  had  the  grippe 

two  years  ago,  followed  by  neuralgia,  which  was  cured 
by  galvanism  and  tonic  treatment.  He  complains  of  a 
peculiar  sensation  when  he  gets  run  down  and  tired, 
as  of  something  rushing  from  below  the  right  clavicle 
and  spreading  over  him  ;  can  bring  on  these  attacks  by 
thinking  of  them. 

The  following  case  well  illustrates  disorders  of  mo- 
tion and  circulation.  Dr.  T ,  aged  forty- three,  un- 
married, practised  self- abuse  excessively  when  young, 
having  gotten  into  the  habit  while  climbing  a  tree. 
Six  months  ago,  while  studying  assiduously,  had  ner- 
vous tremor  or  excitement,  and  discovered  on  left  side 
of  the  face,  over  the  malar  bone,  a  decided  flushing, 
extending  to  the  median  line  in  front,  and  the  face  was 
hot  and  red  on  that  side  ;  a  hissing  or  buzzing  was 
noticed  in  the  ears,  and  subsultus  tendinum  in  different 
parts  of  the  body  was  discovered,  legs  jerked  and  hands 
jumped  in  bed,  and  there  was  sighing  respiration. 

As  illustrating  disorders  of  secretion  and  excretion, 


Mr.  T.  D ,  aged  thirty-one,  in  November,  1S91,  had 

slight  attacks  characterized  by  a  feeling  of  apprehen- 
sion and  as  though  the  heart  was  quivering  from  side  to 
side,  like  jelly,  .\fter  these  attacks  the  stomach  was 
distended  with  wind,  and  he  passed  about  two  quarts  of 
straw-colored  urine.  In  this  case  there  was  also  a  dis- 
turbed mental  condition.  In  April,  1892,  he  com- 
plained that  his  brain  felt  like  a  ball  surrounded  by  a 
rind,  and  the  brain  wanted  to  work,  but  the  rind  re- 
mained passive. 

A  diagnosis  of  hypochondriasis  or  hysteria  should  be 
made  only  after  most  careful  e.xamination  and  interro- 
gation of  the  different  organs  of  the  body,  as  organic 
disease  is  often  masked  by  these  two  affections.  The 
following  history  of  a  case  which  came  under  my  care 
will  illustrate  this  point  : 

Mrs.   M.  W ,  aged  fifty-three,  consulted  me  in 

1894,  complaining  of  intermittent  action  of  the  heart, 
burning  sensation  in  the  region  of  the  left  ovary,  tender 
spot  over  the  seventh  cervical  vertebra,  which  aches 
and  burns  when  she  is  tired,  and  great  exhaustion  after 
exertion,  with  mental  depression  and  crying  spells. 
She  had  undergone  considerable  treatment,  for  two 
years,  at  the  hands  of  different  physicians,  with  indif- 
ferent results.  A  careful  examination  of  the  urine 
showed  a  slight  trace  of  albumin  (specific  gravity,  1.024), 
and  mucous  and  hyaline  casts,  one  with  a  renal  epithe- 
lial cell  attached.  Treatment  was  conducted  on  the 
lines  of  a  diet  to  restrict  the  intaking  of  nitrogenous 
matters,  elimination  and  dilution  of  the  urine,  keeping 
the  skin  and  bowels  open  to  promote  the  elimination 
of  waste  and  relieve  the  kidneys,  but  two  months  after 
I  first  saw  her  nausea  and  vomitmg  set  in  ;  with  symp- 
toms of  uremic  poisoning,  and  in  spite  of  careful  treat- 
ment the  patient  died. 

As  regards  the  prognosis  of  these  cases,  all  depends, 
it  seems  to  me,  as  to  whether  we  can  so  change  the 
mental  condition  as  to  reinstate  reason  and  self-contrtil 
and  divert  the  mind  from  self  and  introspection,  to 
outside  subjects  and  objects,  and  this  can  only  be  ac- 
complished by  supreme  confidence  of  the  patient  in 
the  correct  interpretation  of  his  condition  and  the 
methods  employed,  and  unwavering  perseverance  until 
the  mind  regains  a  healthy  equilibrium. 

The  pathology  of  these  cases  is  obscure,  but  prob- 
ably consists  in  a  disturbance  of  the  balance  of  nutri- 
tion, either  through  mental  influence  or  otherwise. 

Treatment. — Treatment  may  be  considered  under 
the  heads  preventive  and  curative.  Prevention  of  the 
conditions  under  consideration  may  not  always  be  pos- 
sible owing  to  inherited  predisposition,  individual  en- 
vironment, and  physical  states  ;  but  in  the  line  of  pre- 
ventive or  modifying  measures  we  may  mention  the 
cultivation  of  reason  and  self-control,  the  maintenance 
of  healthy  nutrition,  the  adoption  of  definite  principles 
of  living,  based  on  the  ambition  to  reach  the  highest 
mental  and  physical  development,  and  the  giving  to 
life  a  definite  aim  and  purpose  by  pursuing  some  line 
of  work  beneficent  to  others  and  self,  the  avoidance  of 
all  unnatural  methods  of  stimulation  of  the  animal  a])- 
petites,  a  careful  study  of  the  individual  and  his  ances- 
try, and  so  ordering  his  life  as  not  to  bring  excessive 
strain  on  the  great  nerve-centres,  but  by  careful  culti- 
vation of  the  higher  centres  to  bring  about  that  mental 
equilibrium  characteristic  of  a  well-balanced  mind,  in 
which  the  emotions  are  held  in  check  by  reason  and 
will.  A  doctor  must  be,  in  the  interests  of  health,  a 
moralist,  a  close  student  of  human  nature  and  life  in 
general,  and  not  a  mere  giver  of  drugs. 

In  the  way  of  curative  treatment  it  must  first  be  well 
established  that  there  is  no  underlying  organic  disease, 
and  all  physical  disorders,  such  as  are  due  to  functional 
derangement  of  different  organs  or  the  circulation  of 
toxic  matters  in  the  blood,  must  be  attended  to,  to- 
gether with  proper  directions  as  to  diet,  mental  diver- 
sion, physical  exercise,  and  the  cultivation  of  cheerful 
social  surroundings,  which",  having  been  accomplished, 


736 


MEDICAL    RECORD. 


[November  23,  1895 


the  mental  condition  most  urgently  claims  our  atten- 
tion, and  here  the  words  of  M.  Paul  Bourget,  in  his 
masterly  address  before  the  French  Academy,  on  June 
13,  1895,  seem  most  pertinent.  In  speaking  of  the  life 
of  his  eminent  predecessor,  M.  Du  Camp,  he  points  to 
his  youth  as  a  time  cf  emotional  and  intellectual  confu- 
sion and  revolt,  when  he  wrote  what  he  called  "  sad 
books,"  and  he  goes  on  to  say,  "  To  me  the  most  singu- 
lar and  least  agreeable  fact  is  that  I  have  suffered  hor- 
ribly from  this  condition  of  mind.  Indeed,  when  I 
turn  back  to  judge  myself  impartially,  I  perceive  that  I 
found  my  equilibrium  only  when  near  my  fortieth  year. 
Vague  aspirations,  hours  of  gloominess  without  a  cause, 
motions  without  object,  all  these  bordered  close  on 
hypochondria,  and  if  any  one  should  show  me  to-day 
that  I  have  been  somewhat  insane,  I  should  be  neither 
indignant  nor  astonished."  M.  Bourget  then  says, 
"  You  recognize  the  very  definition  of  that  which  was 
long  called  '  the  disease  of  the  century.'  Call  it  by 
whatever  name  you  please,  it  is  an  incapacity  for  ac- 
cepting life,  and  the  advice  given  by  the  English  essay- 
ist 'that  man's  great  work  is  to  carve  for  himself  in  the 
hard  marble  of  life  the  white  statue  of  serenity.'  " 

Finally,  M.  Bourget  sums  up  as  follows  :  "  Having 
commenced  by  considering  life  like  a  true  child  of  the 
century,  as  a  matter  of  emotions  to  be  hated  when  it 
was  not  conformed  to  our  desires,  he  arrived  at  a  rec- 
ognition of  the  fact  that  the  whole  worth  in  this  life  is 
in  work,  in  submission  to  destiny,  in  the  accomplish- 
ment of  a  beneficent  task  ;  "  and  here,  it  seems  to  me, 
we  find  the  prevention  and  the  remedy  for  all  hypo- 
chondriacal states — the  occupation  of  the  mind  by  em- 
ployment useful  to  others  and  ourselves,  and  serene 
submission  to  destiny.  Such  a  plan  will,  I  believe, 
bring  about  a  larger  percentage  of  good  results,  in  the 
way  of  prevention  and  cure,  than  Christian  science, 
treatment  by  suggestion,  faith  cure,  etc.,  without  the 
damaging  effects  produced  in  the  minds  of  subjects  by 
those  unscientific  theories. 

As  regards  drug  medication,  it  is  a  good  rule  not  to 
use  them  unless  the  indications  are  very  well  marked, 
as  they  serve  more  or  less  to  fix  the  patient's  attention 
on  self.  The  drugs  useful  in  these  conditions  and  ac- 
companying functional  derangements  of  different  or- 
gans, which,  when  they  include  those  of  digestion  and 
circulation,  interfere  seriously  with  the  general  nutri- 
tion, rnay  be  classed  under  the  heads  of  sedatives,  anti- 
spasmodics, e.xcito-motors,  anti-ferments,  artificial  di- 
gesters, and  tonics.  The  sedative  that  I  have  found 
most  generally  useful  is  a  combination  of  bromide  of 
ammonium  and  tincture  of  cannabis  indica  in  the  pro- 
portion of  fifteen  grains  of  bromide  ammonium  and  ten 
minims  of  tincture  of  cannabis  indica  to  one  teaspoon- 
ful  of  mucilage  of  acacia,  flavored  with  essence  of  pep- 
permint ;  this  being  given  in  teaspoonful  doses  every 
four  hours  for  ten  days.  In  cases  where  it  seems  ad- 
visable to  administer  the  sed  live  in  pill  form,  I  have 
used  a  tablet  made  by  the  Fraser  Manufacturing  Com- 
pany, which  contains  two  and  a  half  grains  each  of 
bromide  of  soda,  bromide  of  potash,  and  bromide  of 
ammonium,  with  five  drops  each  of  tincture  of  hyoscy- 
amus  and  tincture  of  cannabis  indica.  giving  one  tab- 
let three  or  four  times  a  day.  The  elixir  of  the  vale- 
rianate of  ammonia,  containing  about  one  to  two  grains 
of  the  salt  to  the  teaspoonful,  has  given  me  much  satis- 
faction as  an  anti  spasmodic.  j\.s  an  excito-motor  in 
cases  of  sluggish  action  of  the  nerve-centres,  attended 
with  symptoms  of  slow  digestion  and  general  atony,  I 
have  found  strychnia,  in  doses  of  one-fortieth  to  one- 
tenth  of  a  grain,  most  efficient.  As  an  anti-ferment  in 
cases  of  nervous  dyspepsia,  so  called,  subgallate  of  bis- 
muth, in  doses  of  five  to  ten  grains  after  meals,  has 
given  me  most  excellent  results.  The  artificial  digest- 
ers which  I  have  found  most  helpful,  have  been  prepa- 
rations representing  the  dift'erent  digestive  ferments 
and  an  extract  of  malt  rich  in  diastase.  In  the  line  of 
tonics   I  may  mention   sirup  of  hypophosphites,   with 


small  cases  of  strychnia,  combinations  of  strychnine, 
quinine,  pyrophosphate  of  iron,  and  dilute  phosphoric 
acid,  as  in  the  Hammond  mixture  in  use  at  the  Out- 
door Department,  Bellevue  Hospital,  and  another  of 
the  tincture  of  the  citrio-chloride  of  iron,  quinine, 
strychnine,  and  arsenite  of  soda,  the  formula  of  which 
is  as  follows  : 

B.   Tr.  feni  citro-clilor §  j. 

Quinis  siilphat gr.  Ixiv. 

Strychnine   gr.  ss. 

Sodii  arsenite gr.  ij. 

Alcohol J    ij. 

Elix.  aurant. ,  N.  F §   viij. 

Sig.  :  One  teaspoonful  after  meals. 

Pure  cod-liver  oil. 

As  to  exercise  in  these  cases,  I  have  found  walking 
in  the  open  air  the  most  useful  form  when  taken  in 
moderation,  short  of  fatigue.  Exercise  on  the  bicycle 
may  be  of  service  if  carried  on  with  great  care,  but  in 
many  cases  the  nerve  strain  incidental  to  this  form  of 
exercise  has  seemed  to  be  great  and  attended  with  un- 
pleasant after-effects.  Frequent  change  of  air  and 
scene,  and  mental  diversion,  so  as  to  fill  the  mind  with 
new  ideas,  is  most  helpful. 

In  giving  directions  as  to  diet,  our  aim  should  be  to 
secure  the  taking  of  as  much  digestible  and  nourishing 
food  as  possible,  and  aid  its  digestion  and  assimilation 
by  such  artificial  digesters  as  are  at  our  command  ;  to 
avoid  taking  food  when  fatigued,  and  take  the  hearti- 
est meal  in  the  middle  of  the  day. 

In  the  line  of  hydropathic  treatment  the  nutrition  of 
the  central  nervous  system  may  be  improved  by  the 
proper  use  of  the  hot  and  cold  douche. 

34  Whst  Thirtv-eighth  Street. 


Failure   of  the  Andrew   Clarke  Memorial  Fund. — 

Through  some  bungling  on  the  part  of  the  managers 
it  seems  that  the  attempt  to  raise  a  fund  for  a  memo- 
rial to  the  late  Sir  Andrew  Clarke  has  failed.  The  re- 
sponses, in  answer  to  requests  for  money,  did  not  come 
as  was  expected.  The  reason  was  that  the  managers 
of  the  fund  did  not  choose  the  right  kind  of  thing  to 
put  the  money  into.  They  attempted  to  organize  a 
new  ward  or  pavilion  in  the  hospital  as  a  memorial. 
Now,  however  beneficent  an  isolation  ward  may  be, 
and  however  strongly  it  may  appeal  to  the  well-attuned 
instincts  of  the  philanthropist,  a  ward  for  contagious 
diseases  is  not  a  thing  that  arouses  enthusiasm.  One 
cannot  really  think  of  a  quarantine  pavilion  as  being  a 
great  and  inspiring  memorial  to  the  life  and  character 
of  a  brilliant  and  useful  man.  Furthermore,  the  senti- 
ment among  physicians  is  not  one  of  extravagant  fond- 
ness for  more  hospitals.  The  charities  of  this  kind 
have  been  much  abused,  and  the  medical  profession 
has  suffered  thereby.  On  the  whole,  we  are  not  sur- 
prised that  the  Sir  Andrew  Clarke  memorial  has  been 
a  temporary  failure.  We  hope  that  those  interested  in 
the  project,  however,  will  start  again,  and  pick  out  a 
better  object  for  their  labors,  and  we  are  sure  they  will 
succeed.  After  all,  a  statue  or  a  bust,  which  stands 
forever  in  some  public  place,  and  which  calls  the  at- 
tention of  the  public,  as  well  as  the  profession,  to  the 
fact  that  this  man  lived  a  great  life,  is  the  form  of  me- 
morial that  cannot  be  much  improved  upon,  when  the 
sum  of  money  to  be  raised  is  rather  limited. 

The  Prize  of  the  French  Institute,  amounting  to 
12,000  francs,  has  been  bestowed  upon  Professor 
Raoult,  of  Crencble,  for  his  researches  in  chemistry. 
The  award  this  year  was  made  by  a  committee  of  the 
Academy  of  Sciences. 

Teetotalism  in  the  Indian  Army. — Out  of  seventy 
thousand  English  soldiers  in  India,  twenty-four  thou- 
sand are  reported  to  have  joined  the  Army  Temperance 
Association,  and  profess  to  be  total  abstainers. 


November  23,    1895] 


MEDICAL    RECORD. 


IZl 


Medical    Record: 

A  Weekly  '/ourtial  of  Medicine  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43,  45.  &  47  East  Tenth   Street. 


New  York,  November  23,  1895. 


COMPULSORY  VACCINATION. 
The  verdict  for  damages  recently  given  in  Brooklyn 
against  a  medical  officer  of  the  Health  Department  of 
that  city,  for  the  compulsory  vaccination  of  a  protest- 
ing citizen,  carries  with  it  a  wide-spread  significance  as 
bearing  upon  the  surrender  of  the  personal  rights  of  a 
citizen  to  the  greater  interests  of  the  community  at 
large.  In  the  particular  instance  in  question,  it  is  al- 
leged that  the  vaccinator  used  force  in  compelling  the 
submission  of  the  plaintiff,  who  at  the  time  was  con- 
fined to  bed  by  illness.  It  was  also  claimed  that  the 
sick  man  stated  he  had  a  tumor  of  the  brain,  and  that 
he  feared  the  vaccination  might  injure  him.  Notwith- 
standing all  this,  the  vaccination  was  done,  the  victim 
swearing  that  when  the  dreadful  incision  was  made  in 
his  arm  "  the  blood  spurted  out  "  and  he  "  nearly  bled 
to  death." 

This  is  certainly  a  pretty  bad  case  for  an  ordinary 
jury,  whose  intelligence  was  capable  of  such  credulity 
as  to  impossible  surgical  accidents.  Not  only  was  a 
general  verdict  rendered  in  favor  of  the  plaintiff,  with 
money  damages  fixed  at  $1,500,  but  the  jury  added  a 
supplement,  to  the  effect  that  the  defendant  was  guilty 
of  assault  and  battery.  As  a  result  of  all  this,  other 
similar  suits  against  the  health  authorities  in  Brooklyn 
are  threatened. 

The  vaccinator  very  prudently,  and  we  believe  truth- 
fully, denies  the  use  of  violence  even  in  language,  and 
avers  that  he  simply  reasoned  with  the  man,  and  then 
insisted  on  vaccinating  him.  No  tumor  of  the  brain  was 
manifest,  nor  were  there  evidences  of  anything  else  with- 
in the  skull  case.  The  fact  that  the  inspector  vaccinated 
the  unwilling  victim  at  all,  was,  under  the  circumstances, 
considered  by  the  jury  as  a  criminal  invasion  of  individ- 
ual liberty,  and  an  utter  disregard  of  personal  privileges. 

It  is  very  unfortunate  that  the  oft-asked  question 
concerning  the  personal  rights  of  individuals  as  bear- 
ing on  the  regulations  of  health  departments,  should 
be  so  pointedly  and  directedly  answered  as  in  the  pres- 
ent instance.  Under  a  claim  of  legal  damages  it  es- 
tablishes a  precedent  which  may  tend  in  many  ways 
to  hamper  the  action  of  health  boards,  not  only  in  their 
efforts  to  prevent  the  spread  of  disease  on  the  one 
hand,  but  to  arrest  its  progress  on  the  other.  This  is 
to  be  regretted,  more  particularly  as  there  is  no  statu- 
tory law  providing  for  compulsory  vaccination.  Nor 
can  the  latter  be  urged  without  endangering  the  sacred 
rights  of  personal  liberty. 


There  is,  however,  a  very  effectual  offset  to  the 
aforesaid  conditions  in  the  extraordinary  powers,  ad- 
visory and  administrative,  that  are  given  to  depart- 
ments of  health.  This  is  as  it  should  be  in  view  of 
the  great  interests  at  stake.  The  community  at  large 
looks  to  the  health  boards  for  the  guarding  of  its 
health  and  life,  and  there  is  a  tacit  understanding  that 
said  boards  shall  be  thoroughly  defended  and  pro- 
tected in  the  performance  of  these  legitimate  duties. 
Hence  not  infrequently  even  personal  liberty  must  be 
sacrificed  to  public  safety.  Although  this  may  not  be 
done  directly,  the  ultimate  result  is  the  same  in  cur- 
tailing or  temporarily  abolishing  the  privileges  of  an 
otherwise  morally  free  agent. 

If  an  individual  refuses  to  be  vaccinated,  he  can  be 
confined  in  quarantine  until  it  is  demonstrated  that  he 
can  go  about  with  perfect  safety  to  others.  The  same 
principle  applies  to  quarantine  on  shipboard.  In  both 
instances  no  direct  bodily  harm  is  done  the  individual, 
but  the  community  nevertheless  is  effectively  guarded 
against  contagion.  The  health  authorities  do  not  actu- 
ally compel  the  scholar  to  be  vaccinated,  but  they  con- 
sistently and  wisely  prevent  attendance  at  school  until 
such  means  of  protection  are  taken.  While,  however, 
the  law  gives  ample  scope  for  the  exercise  of  due 
power  and  discretion  on  the  part  of  a  board  as  a  body 
corporate,  it  does  not  appear  that  such  a  function  can 
be  delegated  to  any  of  its  agents.  The  assumption  by 
a  single  representative  of  such  authority  in  a  given 
case,  in  which  also  a  reasonable  protest  is  made,  and 
especially  when  a  given  community  is  not  in  extreme 
peril,  was  the  mistake  made  under  the  present  circum- 
stances. A  great  deal  of  trouble  would  have  been 
saved  if  the  case  had  been  simply  reported  to  the  board 
and  the  entire  responsibility  of  enforcing  the  letter  and 
spirit  of  the  law  had  been  shifted  accordingly.  The 
time  has  gone  by  for  any  more  arguments  in  proof  of 
the  utility  and  efficacy  of  vaccination,  but  it  would 
seem  that  more  experience  is  yet  needed  to  teach  us 
the  best  means  of  enforcing  a  provision  which  every 
right-minded  citizen  considers  a  very  necessary  one. 
The  charge  that  the  victim  was  injured  by  the  opera- 
tion is,  of  course,  too  absurd  for  sober  consideration. 

Whatever  regret  may  be  expressed  at  the  outcome  of 
the  unfortunate  verdict,  there  can  be  no  doubt  that  the 
inspector  acted  in  perfect  good  faith,  and  with  a  proper 
motive  to  do  his  best  under  what  he  supposed  were 
surmountable  difficulties,  and  it  is  no  more  than  just 
that  the  Health  Department  of  Brooklyn  should  stand 
by  him  in  his  trouble. 


Medical  Degrees  in  Russia. — New  regulations  are 
about  to  be  made  in  Russia  in  relation  to  the  degree  in 
medicine.  Doctors  of  medicine  will  in  the  future  be 
regarded  as  belonging  purely  to  the  scientific  grades 
of  professional  calling.  The  degree  can  only  be  taken 
after  medical  men  have  held  the  diploma  to  practise 
for  three  years.  Within  the  five  years  following  the 
examination  the  candidate  must  write  a  thesis  on  some 
professional  subject,  and  if  he  fails  to  do  this  he  must 
pass  another  examination.  The  new  regulations  are 
destined  to  make  the  acquisition  of  a  degree  harder 
than  before,  and  tend  toward  encouraging  specialism, 
which  is  carried  on  to  a  very  great  extent  in  Russia. 


738 


MEDICAL    RECORD. 


[Nov'ember  23,  1895 


THE  "REFORM"  AS  APPLIED  TO  THE  NEW 
YORK   MATERNITY    HOSPITAL. 

Our  former  editorials  in  relation  to  the  so-called  "  re- 
form "  of  the  medical  boards  connected  with  the  hos- 
pitals under  the  care  of  the  Commissioners  of  Public 
Charities  have  not  dealt  in  a  specific  manner  with  the 
injustice  of  the  act  from  a  specific  stand-point.  Since 
we  do  not  propose  that  the  profession  shall  lose  sight 
of  the  issue  at  stake,  nor,  as  too  often  happens,  to  al- 
low the  apparent  victors  to  exult  too  freely  over  the 
apparent  vanquished,  we  would  refer  to  the  honored 
and  honorable  record  of  the  Maternity  Hospital  under 
the  removed  Board  as  glaring  evidence  of  the  injustice 
of  the  "  deal,"  and  of  the  self-seeking  aim  of  the  pro- 
moters of  the  "  deal." 

For  the  past  ten  to  twelve  years  the  Maternity  Hos- 
pital has  easily  been  the  peer  of  any  similar  institution 
in  the  world.  It  taught  the  profession  how  to  eradi- 
cate sepsis  from  the  lying-in  room  ;  it  inculcated  the 
fact,  by  precept  and  practice,  that  death  from  puerpe- 
ral septicaemia  meant  fault  in  technique  ;  it  proved  the 
feasibility  of  saving  the  foetus  without  imperilling  the 
life  of  the  woman  through  resort  to  major  operation, 
instead  of  doing  embryotomy  ;  it  was  instrumental 
in  dealing  a  death-blow  to  careless  and  to  dirty  obstet- 
rics ;  its  visiting  and  its  consulting  staff,  irrespective  of 
comfort,  health,  or  money,  responded  night  and  day  to 
the  call  of  the  pauper — at  night  crossing  the  river  in  a 
row-boat,  deferred  neither  by  ice  nor  fog  ;  its  roster 
carried  the  names  of  men  recognized  by  the  world  as 
experts  ;  up  to  January,  1895,  its  record  was  1,601 
consecutive  deliveries  without  a  death  from  sepsis  ;  it 
had  ever  been  kept  free  from  political  influence  as  re- 
gards appointments — when  lo  !  at  the  instigation  and 
dictation  of  a  small  number  of  professional  men  the 
Commissioners,  without  hearing  the  other  side,  acting 
as  blind  tools  insensible  to  justice,  remove  this  Board 
without  trial,  without  cause  !  A  new  Board  is  substi- 
tuted. Whatever  the  future  promise  of  this  Board — 
doubtless  brilliant,  for  the  budding  ability  is  obvious 
— the  dower  of  obstetric  renown,  or  even  experience, 
is  not  yet  theirs  ! 

The  removed  Board,  we  are  informed,  have  no  griev- 
ance as  far  as  loss  of  official  position  is  concerned,  but 
naturally  enough  think  it  a  poor  reward  for  duty  well 
done  and  unselfishly  done,  particularly  since,  if  the  in- 
stigators of  this  deal  needed  professors  they  were  there 
in  full  maturity  and  therefore  superior  to  the  embryo. 

Acts  such  as  this  tend  to  make  pessimists  of  medical 
men — for  the  blow  came  from  within  the  house,  the 
fable  of  the  cuckoo  being  again  exemplified  ! 


WILL  THERE  BE  A  CONGRESS   IX  MOSCOW 
NEXT   YEAR? 

The  cable  brings  word  that  cholera  still  prevails  to  an 
alarming  extent  in  many  parts  of  Russia,  as  extensively, 
indeed,  as  it  did  during  the  heats  of  midsummer. 
During  the  two  weeks  ending  October  26th,  there  were 
1,490  cases  of  cholera,  with  616  deaths,  in  the  province 
of  Volhynia,  and  38  cases,  with  1 2  deaths,  in  the  prov- 
ince of  Kieff.  There  have  been  persistent  rumors  of 
cholera  in  St.  Petersburg,  but  they  are  as  persistently 


denied  by  the  authorities,  so  it  is  an  even  chance  that 
there  is  no  cholera  there.  The  fact  of  the  continued 
prevalence  of  the  disease  in  Russia  for  several  years 
past,  and  of  the  probability  that  it  will  still  be  there 
next  summer,  renders  the  holding  of  the  proposed  In- 
ternational Congress  in  Moscow  during  the  coming 
August  somewhat  doubtful.  It  is  true  that  it  is  some 
time  from  now  to  August,  and  also  that  it  is  a  long  dis- 
tance from  Kieff  to  Moscow,  so  that  the  presence  of 
cholera  in  Kieff  and  the  adjoining  province  now  may 
seem  to  have  a  remote  bearing  upon  the  question  of  a 
meeting  in  Moscow  in  August.  Nevertheless,  if  we  are 
to  credit  the  published  reports,  there  has  been  more 
or  less  cholera  in  Moscow  each  summer  during  the 
past  three  years — much  more  than  there  was  in  Rome 
and  its  neighborhood  when  the  assembling  of  the  Con- 
gress in  that  city  was  postponed  from  October  to  April. 
We  hope  there  will  be  no  postponement  from  that  cause, 
for,  not  to  speak  of  the  disappointment  of  many  who 
are  already  beginning  to  plan  for  a  visit  to  the  ancient 
capital  of  the  Tsars,  it  would  be  humiliating  for  an  as- 
semblage of  physicians  to  run  away  a  second  time  from 
a  preventable  disease. 

But  there  is  another  event,  the  forerunning  shadow  of 
which  seems  to  be  deepening  over  Europe,  which 
would  more  certainly  postpone  the  Congress  than 
would  the  most  wide-spread  epidemic.  If  the  seeming- 
ly inevitable  partition  of  Turkey  should  lead  to  a  Eu- 
ropean war,  as  is  possible,  if  not  probable,  there  would 
be  no  chance  for  a  peaceful  assemblage  of  doctors  in 
any  of  the  large  countries  of  Europe.  For,  even  if  the 
place  of  meeting  could  be  changed  to  Madrid  or  some 
Swiss  city,  the  difficulties  of  travel  on  the  Continent 
would  be  too  great  to  make  the  attempt  to  hold  a 
Congress  at  all  practicable. 

However,  war  and  disease  do  not  always  come  when 
they  are  most  expected,  and  we  trust  that  the  Congress 
will  be  held  at  the  appointed  time  in  the  appointed 
city  ;  and  if  it  is,  the  readers  of  the  Medical  Record 
will,  as  usual,  have  the  earliest,  most  complete,  and 
best  reports  of  the  proceedings. 


THE    COMMISSIONER    OF    LUNACY    AS    AN 
EXPERT. 

Attention  has  been  called  more  than  once  to  the 
reprehensible  conduct  of  the  medical  member  of  the 
State  Commission  in  going  upon  the  witness-stand  for 
pay.  That  he  has  no  right  to  do  so  in  this  State  can- 
not be  disputed,  for  his  testimony  in  court,  when  it  is 
given  by  him  as  an  "  expert,"  may  send  the  prisoner 
to  a  lunatic  asylum  or  a  prison.  As  the  doctor  and 
his  associates  are  bound  by  law  to  recommend  the  dis- 
charge of  improper  subjects  from  the  former,  it  can  be 
seen  how  dangerous  must  be  his  position  if  he  has 
given  testimony  in  a  particular  case.  If  he  has  held 
on  the  witness-stand  that  a  certain  criminal  is  sane  and 
the  jury  disagree  with  him,  so  that  the  prisoner  is  com- 
mitted to  Matteawan  or  elsewhere,  the  position  of  med- 
ical commissioner  must  be  anything  but  pleasant,  if 
he  is  consistent  in  his  opinion,  or  possessed  with  an 
especially  nice  sense  of  honor.  The  law  which  gives 
the  three  members  of  the  commission  unbridled  liberty 


November  23,  1895] 


MEDICAL    RECORD. 


739 


to  make  their  own  regulations  and  exercise  a  species 
of  petty  tyranny,  if  not  something  worse,  in  the  way  of 
exaction  regarding  dismissals  and  appointments  of 
physicians,  does  not  curtail  their  power  in  any  way  to 
do  what  they  choose,  so  there  is  no  existing  law  to 
prevent  them  accepting  retainers.  To  those  who  are 
familiar  with  the  Field  and  other  cases,  the  necessity 
for  some  restriction  must  be  apparent,  and  the  section 
which  legalizes  their  actions  should  be  amended  at 
Albany  during  the  coming  winter. 


B<^wjs  of  the  Witek. 

Hospital  Reformer  to  the  Colleges. — I  was  a  commis- 
sioner and  ye  took  me  in. 

Better  than  Cannon-balls.— Some  years  ago  Dr.  Sahli, 
of  Berne,  advised  the  use  of  a  cannon-ball,  weighing 
about  five  pounds,  for  constipation.  This  cannon-ball 
was  not  to  be  taken  internally,  but  rolled  for  some  ten 
minutes  every  morning  over  the  abdomen.  Dr.  Doug- 
las Graham  says,  in  the  Boston  Afedical  and  Surgical 
Journal,  that  a  much  more  effectual  mechanical 
means,  for  the  relief  of  constipation,  is  for  the  patients 
to  percuss  and  pound  their  abdomens  for  a  few  min- 
utes, morning  and  evening,  with  the  inner  border  of 
their  fists.  It  is  well,  he  says,  to  do  this  in  the  direction 
of  the  ascending  transverse  and  descending  colon. 
Along  with  the  percussion,  friction  and  deep  kneading 
may  also  be  of  use,  but  these  are  less  effectual  and 
more  tiresome. 

The  Bulletin  of  the  American  Publishers'  Association 
has  come  to  us.  It  is  a  monthly  publication,  issued  in 
the  interests  of  medical  publishers  and  advertisers. 

The  Texas  Sanitarian  has  changed  its  name  to  The 
Texas  Medical  Xe'u's. 

Dentistry  in  Nebraska.— Nebraska  has  a  new  law 
regulating  the  practice  of  dentistry.  It  requires  the 
registration  of  dentists,  and  their  examination,  unless 
they  are  graduates  from  a  reputable  dental  college. 

Tragedies  of  the  Medical  Profession.— The  wife  and 
daughter  of  a  Vienna  physician  committed  suicide,  and 
a  few  days  later  the  doctor  shot  himself.  A  French 
doctor,  who  had  once  held  a  good  position,  and  who 
received  the  much-coveted  ribbon  of  the  Legion  of 
Honor  for  his  devoted  service  during  a  cholera  epi- 
demic, and  his  wife,  recently  committed  suicide  to  save 
themselves  from  starvation. 

Medical  Portraits.- The  Journal  of  the  American 
Medical  Association  is  energetically  urging  that  the 
members  of  the  Association  send  in  their  photographs. 
It  thinks  that  in  later  years,  when  the  post-historic  Fiji 
Islander  wanders  over  the  ruins  of  the  cities  by  the 
lakes  and  seas,  he  will  find  great  pleasure  and  comfort 
in  looking  over  the  portraits  of  the  medical  men  of  by- 
gone years.  The  American  Medical  Association  num- 
bers several  thousand  members,  and  our  descendants 
will  have  to  have  abundant  leisure  if  they  e.vpect  to 
study  appreciatively  the  faces  of  the  deceased  doctors 
of  the  nineteenth  century.  We  suggest  that  it  might 
be  better  for  the  Journal  to  collect  only  portraits  of 


men  who  have  arrived  at  a  certain  age  limit,  or  who 
have  reached  some  definite  distinction.  These  are 
times  when  a  man  is  very  inconspicuous  indeed  if  he 
does  not  get  his  picture  printed,  in  the  public  press  or 
the  medical  press,  several  times  during  his  professional 
career.  The  swan  is  supposed  to  sing  before  he  dies, 
but  the  doctor  gets  his  photograph  reproduced. 

Dr.  J.  W.  Carhart  has  written  a  novel,  which  is  called 
"  Norma  Trist,"  a  story  of  inversion  of  the  sexes,  based 
upon  the  Alice  Mitchell  episode. 

Anarcotine. — This  substance  is  one  of  the  alkaloids 
of  opium,  and  possesses  no  narcotic  properties.  Dr. 
William  Roberts  calls  attention  to  it,  and  says  that  it 
ranks  next  in  value,  as  an  antiperiodic,  to  quinine.  A 
dose  ranges  from  i  to  3  grains. 

Took  the  Wrong  Drug.— .\  death  occurred  recently 
in  New  Haven,  Conn.,  caused  by  the  carelessness  of  a 
drug  clerk.  The  facts  in  the  case  were,  according  to 
the  Yale  Medical  Journal,  that  the  man  asked  for  what 
was  essentially  a  harmless  medicine,  of  which  he  took, 
as  he  thought,  a  proper  dose,  and  death  resulted.  The 
Journal  very  naturally  suggests  it  is  high  time  that 
legislative  action  be  taken  in  regard  to  this  matter,  not 
only  for  the  security  of  the  physician  who  prescribes, 
but  for  the  safety  of  the  public. 

A  Thanksgiving  Mistake.  —  An  eighteen-year-old 
boy,  living  in  Lilly,  Pa.,  was  shot,  in  mistake  for  a  tur- 
key, in  the  woods  near  his  home.  His  friends  waited 
fifty  hours  for  him  to  die,  and  then  sent  for  Dr.  T.  L. 
Armitage,  who  describes  {Medical  Standard)  how  he 
dressed  the  wound  and  cured  the  boy.  We  trust  that 
the  patient  will  yet  get  square  with  the  turkey. 

Legacy  to  a  Surgeon.— It  is  stated  that  .Sir  Henry 
Thompson  has  received  a  legacy  of  $500,000  from  a 
grateful  patient.     The  heirs  are  contesting  the  will. 

Queer  Experiences  by  Doctors.— .\  doctor  of  Bren- 
ham,  Tex.,  was  recently  horsewhipped  by  a  young 
lady  because  he  was  so  unpleasant. — .\  doctor  living  in 
Amsterdam,  Mo.,  has  been  threatened  with  tar  and 
feathers  if  he  doesn't  leave  the  town.  This  just  at  the 
beginning  of  the  cold  season. — Two  doctors  of  Paris, 
Tex.,  had  a  fight,  characterized  by  the  local  press 
as  "  bitter."  One  used  a  knife  ;  but  the  other  a 
fence  rail.  To  the  latter  we  should  say,  "A>  sutor 
ultra  crepidam." — .\  doctor  in  Petrona,  Ind.,  was 
shot  by  one  of  his  patients,  because  he,  the  doctor, 
would — or  would  not— (the  account  is  vague)  give  the 
patient  a  hypodermic  injection.  The  gun  is  some- 
times mightier  than  the  hypodermic. — The  South 
.\frican  press  advertises  that  there  is  a  good  opening  for 
"  a  sober,  steady,  and  handsome  bachelor  doctor  "  in 
one  of  the  Transvaal  towns.  .Send  photo.  This 
news  is  likely  to  cause  a  flutter  among  the  younger 
members  of  the  .-Vcademy  of  Medicine. 

Iowa  State  Association  of  Railway  Surgeons. The 

annual  meeting  of  the  Iowa  State  .Association  of  Rail- 
way Surgeons  was  convened  at  Des  .Moines,  October 
10th.  A  report  on  accidents  to  railway  employees 
showed  one  employee  killed  for  every  six  hundred  and 
eight  employed,  and  one  injured  for  every  seventy-nine. 
The  election  of  officers  resulted  as  follows  :  President 
C.  W.  Coyt,  of   Missouri  Valley ;   Vice-President,  B.  H. 


740 


MEDICAL   RECORD. 


[November  23,  1895 


Criley,  of  Dallas  Center;  Secretary,  A.  A.  Deering,  of 
Boone  ;  Treasurer,  D.  S.  Fairchild,  of  Clinton  ;  Judi- 
cial Committee,  J.  M.  Warren,  of  Sioux  City ;  C.  H.  Phil- 
pott,  of  Ottumwa  ;  V.  B.  Knott,  of  Sioux  City. — Medi- 
cal Standard. 

The  Late  Dr.  Edward  R.  Palmer. —  A  meeting  in 
memory  of  the  late  Dr.  Edward  R.  Palmer  was  held  by 
the  Louisville  Surgical  Society  on  October  26th.  Let- 
ters of  sympathy  and  regret  were  read,  and  eloquent 
tributes  to  the  deceased  were  paid  by  Drs.  Joseph  M. 
Mathews,  L.  S.  McMurtry,  and  T.  L.  McDermott. 

Utah  State  Medical  Society.  —  The  first  annual 
meeting  of  the  Utah  State  Medical  Society  convened 
at  Salt  Lake,  on  October  3d,  with  about  fifty  members 
of  the  profession  present.  A  number  of  interesting 
papers  were  presented.  Several  new  members  were 
admitted.     The  following  resolution  was  adopted  : 

Resolved,  That  it  be  the  sense  of  this  Society  that 
every  member  of  it  interest  himself  personally  in  se- 
curing the  election  of  men  for  the  next  legislature  who 
favor  the  maintenance  of  a  high  standard  of  medical 
excellence  in  the  State  of  Utah,  and  that  he  continue 
to  use  his  influence. 

The  election  of  officers  resulted  in  the  selection  of  : 
President,  Walter  R.  Pike,  of  Provo  ;  First  Vice-Presi- 
dent, G.  W.  Perkins,  of  Ogden  ;  Second  Vice-President, 
J.  S.  Richards,  of  Salt  Lake ;  Treasurer,  C.  M.  Wilson, 
of  Park  City ;  Secretary,  J.  N.  Harrison,  of  Salt  Lake  ; 
Board  of  Censors,  Drs.  Bower,  Gregor,  Ewing,  Beatty, 
and  Jones.  Salt  Lake  was  chosen  as  the  next  place 
of  meeting. — Medical  Standard. 

The  Character  of  Dr.  William  MacLure. — There  has 
never  been  portrayed  in  fiction  a  more  beautiful  char- 
acter than  Dr.  William  MacLure,  the  hero  of  some  of 
the  "  Bonnie  Brier  Bush  "  stories  by  Ian  Maclaren,  or 
in  real  life  Rev.  John  Watson.  At  a  recent  dinner 
given  by  the  Liverpool  Medical  Institute,  the  novelist 
•was  tasked  to  make  a  speech,  and  he  paid  a  tribute  to 
the  medical  profession  which  we  hope  and  believe  is 
deserved.  We  publish  it  because  it  should  be  read — • 
as  should  the  story  of  Dr.  MacLure.  "One  is  to  an- 
swer a  question  that  has  been  often  and  fairly  asked — 
was  there  ever  any  doctor  so  self- forgetful  and  so  ut- 
terly Christian  as  William  MacLure  !  To  which  I  am 
proud  to  reply — on  my  conscience,  not  one  man  but 
many  in  Scotland  and  in  the  south  country — I  will  dare 
to  prophecy  also  across  the  sea.  It  has  been  one  man's 
good  fortune  to  know  four  country  doctors,  not  one  of 
whom  was  without  his  faults— Weelum  was  not  perfect 
- — but  who  each  one  might  have  sat  for  my  hero. 
Three  are  now  resting  from  their  labors,  and  the  fourth, 
if  he  ever  should  see  these  lines,  would  never  have 
identified  himself.  Then  I  desire  to  thank  my  readers, 
and  chiefly  the  medical  profession,  for  the  reception 
given  to  the  doctor  of  Drumtochty.  For  many  years  I 
have  desired  to  pay  some  tribute  to  a  class  whose  ser- 
vice to  the  community  is  known  to  every  country  man, 
but  after  the  tale  had  gone  forth  my  heart  failed.  For 
it  might  have  been  despised  for  the  little  grace  of  let- 
ters in  the  style,  and  because  of  the  outward  roughness 
of  the  man.  But  neither  his  biographer  nor  his  circum- 
stances have  been  able  to  obscure  MacLure,  who  has 
himself  won  all  honest  hearts  and  received  afresh  the 


recognition  of  his  more  distinguished  brethren.  From 
all  parts  of  the  English-speaking  world  letters  have 
come  in  commendation  of  William  MacLure,  and  many 
were  from  doctors  who  have  received  new  courage.  It 
is  surely  more  honor  than  a  new  writer  could  ever  have 
deserved,  to  receive  the  approbation  of  a  profession 
whose  charity  puts  us  all  to  shame." 

Medical  Reform  in  Germany. — In  future  the  State  di- 
ploma, which  alone  confers  the  right  to  practise  medi- 
cine and  surgery,  will  not  be  granted  to  students  until 
they  have  fulfilled  ten  half-year  periods  of  study,  in- 
stead of  nine  as  at  present.  The  degree  of  doctor  in 
medicine  will  only  be  bestowed  upon  candidates  who 
have  successfully  surmounted  the  State  examination  ; 
and  after  passing  that  test  it  will  be  necessary  to  at- 
tend the  practice  of  a  large  hospital  during  twelve 
months. 

A  Medical  Tariff. — The  German  Government  has  is- 
sued a  regulation  fixing  the  amount  of  fees  for  medical 
men.  A  practitioner  in  that  happy  land  can  claim 
20  marks  for  an  ordinary  visit,  and  if  it  be  necessary 
for  him  to  make  a  profound  investigation  into  the  state 
of  any  organ  he  may  increase  his  demand  to  22  or  23 
marks.  In  the  event  of  a  prolonged  visit  his  time  is 
valued  at  3  marks  for  every  half-hour  commenced. 
Night  visits  may  be  charged  for  at  double,  or  even 
triple,  the  foregoing  rates  ;  and  a  visit  of  urgency  costs 
twice  as  much  as  an  ordinary  visit. 

An  Austrian  Innovation. — A  medical  woman  has 
been  appointed  house  physician  to  a  Vienna  hospital — 
Officierstochter  Institute.  This  innovation  has  made 
much  talk  in  Vienna  medical  circles. 

"  3-  for  A  Hers." — A  Western  veterinarian  sent  the 
following  to  be  filled  : 

Send  this  by  this  Boy 
Tinker  of  Asfetty    I  ounc 
—  Campher  I  ounc 

Cappicom  i 

Lodman  I 

Mix 

Anknite  loc 

Cloraforn  I  ounc 

do  not  think  this  is  spelt  wright 

but  you  will  know  what  it  is 

it  is  for  a  hors  dock M  D 

— Louisville  Aledical  Neivs. 

Overdose  of  Medical  Charities. — Dublin,  too,  has  an 
overdose  of  medical  charities.  In  a  population  of 
356,240  there  are  27  dispensaries  which  treat  annually 
100,216  persons,  and  24  hospitals  which  treat  36,412. 
There  are  also  4,674  women  annually  who  receive  free 
attendance  during  confinement. 

New  York  and  the  Mortality  from  Phthisis. — The 

State  of  New  York  has  the  largest  absolute  mortality 
from  consumption,  viz.  :  14,894  deaths  in  the  year  1890. 
Boston  has  the  largest  relative  death-rate  from  this  dis- 
ease, viz.  :  164. 88  per  1,000  deaths.  Out  of  the  total 
102,199  deaths  from  phthisis  in  the  whole  country.  New 
York  has  about  one-seventh.  This  is  due  chiefly  to 
the  denser  population. 


November  23,  1895] 


MEDICAL   RECORD. 


741 


CTintcat  53cpa:rtment. 

A  CASE  SHOWING  THE  ANTIDOTAL  EFFECT 
OF  ALCOHOL  IN  CARBOLIC-ACID  POISON- 
ING. 

Bv  DONALD  B.  ERASER,  M.B.,  M.R.C.S.  Eng., 

STRATFORD,  ONTABin. 

Ox    May  4,  1S93,  about   1.30   p.m.,  Mts.  X ,  while 

dining,  quarrelled  with  her  husband,  rushed  upstairs, 
and  swallowed   an   ounce  of  liquid   carbolic  acid  with 

suicidal  intent.     Mr.  X followed  his  wife  in  less 

than  fifteen  minutes,  to  find  her  lying  on  the  floor  in  a 
deep  sleep,  from  which  he  could  not  rouse  her.  He 
noticed  an  empty  bottle  on  the  bureau,  labelled  car- 
bolic acid,  and  felt  its  odor  through  the  room. 

Medical  aid  was  immediately  summoned,  when  two 
physicians  promptly  responded,  made  a  hurried  ex- 
amination of  the  condition  and  surroundings  of  the 
patient,  who  was  in  a  profound  stupor,  with  pupils  con- 
tracted to  pin-points,  injected  atropine  to  antagonize 
the  poison  supposed  to  have  been  taken,  and  then  used 
the  stomach-pump. 

Arriving  on  the  scene  half  an  hour  later,  I  made  a 
hasty  investigation  of  the  circumstances  of  the  case, 
recognizing  the  characteristic  odor  of  carbolic  acid  in 
the  breath  and  evacuations  from  the  stomach,  and  di- 
rected attention  to  the  quiet,  normal  breathing. 

After  a  brief  consultation,  although  there  was  no 
staining  or  other  evidence  of  the  corrosive  action  of 
carbolic  acid  on  the  lips,  tongue,  or  about  the  mouth, 
throat,  etc.,  we  diagnosed  carbolic-acid  poisoning,  and 
decided  to  use  the  stomach-pump  until  the  disappear- 
ance of  the  carbolic-acid  odor  in  the  water  evacuated 
after  washing  the  stomach.  This  odor  was  easily  per- 
ceived three  hours  after  the  accident  by  a  physician 
who  then  called,  but  it  disappeared  in  the  course  of 
the  next  hour. 

The  physical  condition  of  the  patient  four  hours 
after  swallowing  the  poison  was  as  follows  ;  The  pulse 
was  strong,  regular,  and  not  much  accelerated  ;  respi- 
rations undisturbed  ;  temperature  slightly  under  98° 
F.;  arms  and  legs  occasionally  jerking  ;  and  no  sensa- 
tions were  elicited  on  pricking  ends  of  fingers  or  toes. 

Demulcents — such  as  olive-oil,  glycerine,  etc. — and 
lime-water  and  sulphuric  acid  were  also  administered 
with  the  stomach-pump  about  this  time,  and  an  effort 
was  made  to  waken  the  patient  with  the  faradic  cur- 
rent, but  without  result.     Mrs.  X was  now  allowed 

to  remain  undisturbed  until  9.30  p.m.,  when  an  attempt 
to  restore  her  to  consciousness  succeeded.  On  first 
aivakening  she  was  dazed,  rambled,  and  was  unable  to 
realize  her  position  for  a  few  minutes,  but  soon  rallied 
and  answered  questions  readily.  When  asked  what 
she  had  used,  without  hesitation  she  replied  carbolic 
acid  in  whiskey  ;  and  that  she  experienced  but  little 
pain  or  burning  sensation,  and  declared  she  slept 
soundly,  having  pleasant  dreams. 

N'oniiting  soon  tet  in,  and  continued  almost  without 
interruption  twenty  -  four  hours,  when  it  suddenly 
ceased  :  and,  with  the  exception  of  slight  nausea  and 
depression  of  spirits  for  a  fe»v  days,  she  suffered  little  or 
no  more  inconvenience,  and  made  a  rapid  and  satisfac- 
tory convilescence,  enjoying  robust  health  ever  since. 

Mrs.  X gave  the  following  explanation  for  mix- 
ing the  carbolic  acid  in  whiskey.  It  appears  she  had 
previously  seen  a  young  woman  take  it  in  water,  when 
the  victim  was  severely  burned  about  the  mouth, 
throat,  etc.,  and  suffered  excruciating  pain.  This  in- 
cident dissuaded    Mrs.    .\ from    taking  a  similar 

dose. 

From  subsequent  events,  however,  Mrs.  X ap- 
pears to  have  had  a  fascination  for  carbolic  acid  as  a 
poison,  for  she  first  mixed  it  in  beer  and  cautiously 
drank  a  small   quantit),  when   she  suffered    but  little 


pain  or  burning  sensation.  Next  she  took  it  in  whiskey, 
v/hen  she  felt  less  pain  or  burning,  and  determined  to 
try  the  last  combination  if  she  ever  took  poison. 

The  slight  corrosive  action  and  freedom  from  pain 
experienced  on  the  present  occasion  proved  the  value 
of  her  experiments,  and  suggests  a  new  and  efficient 
plan  of  treatment  in  carbolic-acid  poisoning.  A  mixt- 
ure of  equal  parts  of  carbolic  acid  and  alcohol  may 
be  poured  over  the  back  of  the  hand,  leaving  scarcely 
a  trace  of  corrosive  action  if  promptly  washed  off  with 
alcohol.  The  white  stain  caused  by  the  li(iuid  carbolic 
acid  can  be  removed  by  the  immediate  and  continued 
application  of  alcohol.  In  the  case  of  a  young  man 
who  came  to  my  office  suffering  from  intense  itching 
caused  by  a  spider  bite  I  applied  liquid  carbolic  acid, 
which  stained  the  skin  white.  This  application  was 
left  on  the  affected  part  until  it  caused  severe  pain, 
when  it  was  thoroughly  removed  with  alcohol,  followed 
by  the  application  of  a  pad  of  absorbent  cotton  satu- 
rated with  alcohol. 

By  this  means  the  stain  was  removed  and  pain  re- 
lieved until  heat  was  felt  in  the  pad,  when  both  stain 
and  pain  reappeared.  The  heated  pad  was  now  dis- 
carded and  replaced  by  one  of  a  similar  kind  freshly 
prepared,  when  stain  and  pain  vanished  a  second  time, 
to  return  with  heat  in  the  pad.  This  phenomenon 
continued  as  long  as  heat  developed  in  the  pad,  and 
ceased  when  it  was  no  longer  evolved.  The  only  re- 
sult of  this  treatment,  besides  relieving  the  itching,  was 
an  intense  redness  of  the  skin  over  the  affected  area, 
which  disappeared  in  a  few  days,  attended  by  desqua- 
mation of  the  cuticle. 

This  case  also  affords  a  striking  illustration  of  the 
resembance  in  the  symptoms  produced  to  carbolic-acid 
and  opium  poisoning.  The  diagnostic  feature  in  the 
present  case  was  the  quiet  and  regular  breathing. 

Alcohol,  apart  from  its  power  as  an  antidote,  is  re- 
quired as  a  stimulant  in  the  majority  of  cases  of  car- 
bolic-acid poisoning,  to  combat  the  intense  depression 
usually  experienced  :  and  it  would  therefore  appear  as 
if  alcohol  were  a  true  antidote  in  carbolic-acid  poison- 
ing. 


A  CASE  OF  GUNSHOT  WOUND  OF  THE  AB- 
DOMEN FOLLOWED  BY  PURULENT  PERI- 
TONITIS, OPERATION,  AND    RECOVERY. 

Bt  JOHN   RUHRAH,  M.D., 

RESIDENT  PHYSICIAN,    BALTIMORE  CITV   HOSPITAU 


C.  S ,  white,  male,  aged   thirteen,   family  history 

negative.  Previous  history  good.  Brought  into  the 
City  Hospital  June  3,  1S95,  suffering  from  a  gunshot 
wound  of  the  abdomen. 

The  wound  was  inflicted  accidentally,  with  a  twenty- 
two  calibre  revolver,  held  only  a  few  inches  away  from 
the  abdomen. 

The  ball  entered  about  the  middle  of  a  line  drawn 
from  the  umbilicus  to  the  anterior  superior  spinous 
process  of  the  ilium.  When  seen  by  the  visiting  sur- 
geon. Dr.  John  W.  Chambers,  it  was  seventeen  hours 
after  the  reception  of  the  injury.  The  abdomen  was 
distended  and  tympanitic,  very  tender.  Boy  was  suffer- 
ing considerable  pain  and  was  very  restless.  He  was 
placed  on  the  operating-table  immediately,  and  under 
chloroform  anaesthesia  and  the  usual  aseptic  precau- 
tions, the  abdomen  was  opened.  An  incision  six  inches 
long  was  made  in  the  median  line  and  the  viscera  ex- 
posed. There  was  evidence  of  an  inflammation  of  con- 
siderable intensity.  The  visceral  layer  of  the  peri- 
toneum was  reddened,  and  covered  in  many  places 
with  flaky  lymph.  In  the  cavity  of  the  abdomen  there 
was  about  five  hundred  cubic  centimetres  of  thin  red- 
dish pus.  The  c:ecum  was  jierforated  in  two  places 
by  the  bullet,  and  the  intestinal  contents  had  escaped 
from   the  gut.     There  was  a  gangrenous   patch  three 


742 


MEDICAL    RECORD. 


[November  23,  1895 


centimetres  long  by  one  and  a  half  broad,  evident- 
ly caused  by  the  bullet.  The  bullet-wounds  were 
closed  with  the  Lembert  suture,  the  gangrenous  patch 
turned  in,  and  the  edges  of  the  gut  stitched  together. 
The  cavity  of  the  abdomen  was  well  irrigated  with  hot, 
normal  salt  solution.  The  bullet  was  not  found.  The 
bullet-wound  was  enlarged,  and  a  gauze  drain  inserted. 
The  surgical  incision  was  closed  with  silkworm-gut 
sutures. 

Patient  rallied  from  the  anaesthetic  very  nicely,  and 
sustained  but  little  shock  from  the  operation.  Nothing 
was  given  the  patient  the  day  of  the  operation  except 
cracked  ice.  There  was  considerable  nausea  after  the 
patient  rallied,  and  when  teaspoonful  doses  of  iced 
milk  and  lime-water  were  given  they  were  rejected. 

The  nausea  continued  on  the  following  day,  and  the 
stomach  rejected  all  food.  Sulphate  of  magnesia,  two 
drachms,  with  ac.  sulphuric,  dil.,  five  drops,  was  given 
every  hour.  After  the  administration  of  this  the  vom- 
iting ceased,  and  there  was  no  return  of  the  nausea  or 
vomiting.  This  medication  was  continued  during  the 
day  and  an  enema  given  in  the  evening,  but  the  patient 
had  no  stool. 

The  following  day  the  same  doses  were  continued 
and  another  enema  given,  and  there  was  a  free  passage 
from  the  bowels. 

June  8th. — Dressings  were  removed  and  the  drain 
partially  withdrawn.  There  had  not  been  very  much 
discharge,  though  there  was  sufficient  to  stain  the 
dressings. 

June  loth. — Wound  was  redressed  ;  drainage  entirely 
removed. 

June  I  ith. — Retention  of  urine  ;  catheterized.  From 
this  date  until  the  19th  he  was  catheterized  three  times 
a  day. 

June  13th. — Stitches  removed. 

June  19th. — Tenderness  about  the  rectum  ;  some 
swelling  and  redness.  This  increased  until  on  June 
26th,  when  an  abscess  had  formed.  This  was  opened, 
and  about  two  hundred  c.c.  of  pus  evacuated.  This 
came  from  high  up  in  the  pelvic  cavity.  Patient  ex- 
perienced great  relief  and  was  able  to  pass  his  urine 
voluntarily.  Abscess  cavity  packed  with  iodoform 
gauze.  This  healed  rapidly,  and  patient  made  a  rapid 
recovery. 

November  5th. — Patient  was  seen  yesterday.  Per- 
fectly healthy  ;  suffers  no  inconvenience. 


A    PECULIAR   CASE    OF    TRISMUS. 
By   R.    C.   MATHENY,    M.D., 

Mrs.  R ,  aged  thirty,  the  mother  of  four  children, 

has  for  a  number  of  years  suffered  from  recurring  at- 
tacks of  intense  headache.  The  attacks  were  of  vary- 
ing duration  and  severity,  lasting  from  twelve  to  forty- 
eight  hours,  seldom  accompanied  by  nausea.  On 
August  13,  1895,  she  suffered  an  unusually  severe  at- 
tack, during  the  course  of  which  she  noticed  that  her 
jaws  had  become  locked  and  she  was  unable  to  open 
them  ;  neither  could  they  be  forcibly  separated.  This 
condition  lasted  for  seven  weeks,  the  jaws  remaining 
absolutely  closed,  and  all  nourishment  was  taken 
through  the  interstices  between  the  teeth.  This  con- 
dition occurred  during  pregnancy,  and  continued  until 
October  i,  1895,  when  she  was  delivered  of  a  female 
child.  The  mother  fell  asleep  shortly  after  the  deliv- 
ery, and  when  after  a  few  hours  she  awoke,  to  her  sur- 
prise the  jaws  readily  opened.  At  first  there  was  some 
stiffness  of  the  muscles,  but  the  condition  gradually 
disappeared,  and  she  has  been  entirely  free  from  the 
lock-jaw  ever  since. 


Dr.  Duclaux,  it  is  said,  will  be  appointed  to  the  head 
of  the  Pasteur  Institute,  in  place  of  the  late  Dr.  Pasteur. 


NEW   YORK    ACADEMY   OF    MEDICINE. 

SECTION   ON   PUBLIC   HEALTH. 

Stated  Meeting,  November  8,  iSgj. 

Henry  D.  Chapin,  M.D.,  Ch.\irman. 

The  Relation  of  Bovine  to  Human  Tubercnlosis. — Sev- 
eral authors  read  papers  on  subdivisions  of  this  subject. 

Tuberculosis  as  Viewed  by  a  Veterinarian. — Pro- 
fessor H.  D.  Gill,  of  the  New  York  College  of  Veter- 
inary Surgeons,  read  an  introductory  paper  bearing 
this  title.  The  danger  of  meat  conveying  disease  had 
been  recognized  since  Moses  forbade  the  use  of  certain 
meats.  But  it  was  only  of  recent  years  that  the  sub- 
ject had  become  of  special  interest  to  the  public  and 
veterinarians.  Several  causes  had  contributed  to  this, 
chiefly  the  discovery  of  the  tubercle  bacillus  by  Koch. 
The  e.xtent  of  the  live-stock  industry  in  the  United 
States  caused  the  subject  to  be  of  special  interest  here. 

Veterinarians  had  discovered  that  herds  of  cattle 
chosen  with  the  greatest  care,  and  considered  from  ap- 
pearances to  be  in  absolutely  perfect  health,  were  in 
many  instances  riddled  with  tuberculosis.  On  taking 
the  milk  and  flesh  of  these  animals  to  the  laboratory 
he  found  disease  germs  ready  for  transmission  to  man. 
Tuberculosis  in  man  and  cattle  was  caused  by  the 
same  germ.  In  New  York  City  there  were  over  five 
thousand  deaths  annually  from  this  disease  in  man. 
Some  herds  of  cattle  in  the  vicinity  of  this  city  showed 
tuberculosis  in  as  high  a  percentage  as  si.xty  or  even 
seventy  per  hundred.  In  many  instances  the  diseased 
animal  was  to  all  outward  appearances  in  perfect 
health.  The  disease  could  be  transmitted  from  ani- 
mal to  animal,  from  animal  to  man,  man  to  animal,  or 
from  without.  The  infection  could  come  through  the 
respiration,  through  the  food,  through  objects  licked  by 
the  animal.  The  infectious  agent,  when  derived  from 
without,  had  come  from  the  discharges  from  the  nose, 
mouth,  bowels,  milk,  rarely  from  the  uterus  or  vagina. 
The  milk,  especially,  was  liable  to  transmit  tubercu- 
losis when  the  udder  was  diseased,  or  possibly  when 
it  came  from  an  animal  with  generalized  tuberculosis, 
the  udder  being  free.  Of  infected  cattle,  probably 
one-half  had  been  infected  by  inhaling,  bacilli  in  the 
air,  and  a  large  proportion  from  taking  bacilli  in  the 
food.  Very  rarely  calves  from  the  cows  wath  advanced 
tuberculosis  were  born  with  the  disease.  Dr.  Gill 
thought  there  was  more  danger  of  transmission  from 
man  to  animals  than  from  animals  to  man.  The  only 
safeguard  for  New  York  was  to  get  milk  from  herds 
which  had  been  tested.  While  recognizing  that  the 
tubercle  bacillus  was  the  chief  agent,  it  should  not  be 
forgotten  that  a  favorable  soil  added  greatly  to  the 
risks.  By  inbreeding  animals  not  predisposed  to  tu- 
berculosis and  already  healthy,  we  might  hope  to  get 
a  stock  capable  of  combating  this  dread  disease. 

The  Work  of  Foreign  Veterinarians  in  Tuberculosis. 
— Prof.  Leoxakd  Pe.\rson,  of  the  University  of  Penn- 
sylvania, read  a  paper  on  this  subject.  Tuberculosis  had 
been  a  live  topic  many  years  in  Europe.  Most  Euro- 
pean countries  had  a  more  or  less  perfect  system  of 
meat  inspection  which  was  carried  out  in  great  centres 
of  population,  and  usually  insured  the  consumer 
against  harmful  flesh.  The  method  in  Germany  con- 
sisted in  erecting  municipal  abattoirs,  in  which  all 
slaughtering  must  be  done  and  the  flesh  examined. 
The  question  of  what  must  be  done  with  the  tubercu- 
lous carcass  had  excited  much  discussion. 

The  author  gave  the  following  summary,  based  on 
resolutions  passed  by  representative  bodies,  or  the 
views  of  distinguished  veterinarians,  in  Europe.  The 
system  of  compulsory  meat  inspection  should  be  gen- 
eral.    The  flesh  of  tuberculous  animals  should  be  sub- 


November  23,  1895] 


MEDICAL    RECORD. 


74: 


jected  to  special  regulation.  A  part  of  this  flesh  must 
be  destroyed,  but  some  of  it  may  safely  be  used  for 
food.  The  milk  from  cows  with  tuberculous  udders 
is  extremely  dangerous.  Milk  from  tuberculous  cows 
with  healthy  udders  may  be  dangerous,  and  is  always 
suspicious.  Tuberculin  is  a  reliable  diagnostic  agent. 
There  need  be  no  fear  that  tuberculin,  properly  used, 
will  cause  generalization  of  pre-existing  disease.  All 
herds  should  be  tested  with  tuberculin,  and  tubercu- 
lous and  healthy  animals  separated.  Since  tubercu- 
losis is  of  importance  in  relation  to  public  health  as 
w^ell  as  in  relation  to  the  live-stock  industry,  it  is  of  in- 
terest to  everyone  that  the  disease  should  be  restricted 
as  far  as  possible.  Hence,  when  it  becomes  necessary 
to  condemn  tuberculous  animals  and  carcasses,  the 
public  should  share  the  loss  with  the  owner. 

The  Control  of  Tuberculosis  in  Massachnsetts. — Pro- 
fessor F.  H.  Osgood,  of  Harvard  University,  read  on 
this  subject.  In  1892  tuberculosis  was  first  put  on  the 
list  of  contagious  diseases  in  cattle  in  Massachusetts, 
and  affected  animals  were  ordered  killed  and  their  car- 
casses disposed  of  otherwise  than  in  food,  but  no  com- 
pensation should  be  received  by  the  owner.  At  that 
time  they  relied  simply  upon  physical  examination. 
The  first  year  there  was  not  much  opposition,  but  after 
the  inspection  service  had  been  improved,  and  the 
wording  changed  from  "  cities  and  towns  may  appoint  " 
to  the  words  "  shall  appoint,"  opposition  increased.  The 
duties  of  these  inspectors  were  :  i.  To  examine  every 
herd  in  their  respective  districts  by  physical  examina- 
tion. They  should  make  such  examinations  as  often 
as  the  Board  of  Cattle  Commissioners  should  direct. 
During  the  year  1893  two  inspections  were  ordered. 
As  a  result,  a  large  number  of  emaciated,  tuberculous 
animals,  detected  by  physical  examination,  were  de- 
stroyed. The  law  also  provided  for  the  inspection  of 
carcasses  at  the  time  of  slaughter  by  these  local  inspec- 
tors, and  those  found  tuberculous  were  to  be  disposed 
of  by  burial  or  rendering.  At  the  expiration  of  the 
year  they  met  with  considerable  opposition  from  farm- 
ers and  butchers,  who  went  to  the  legislature  in  1S94 
and  made  a  demand  for  compensation.  The  legislat- 
ure then  allowed  one- half  value.  The  commission's 
power  was  enlarged,  permitting  them  to  make  such 
regulations  as  they  deemed  adsdsable  for  the  eradica- 
tion of  tuberculosis  from  the  herds.  It  also  became 
their  duty  to  at  once  provide  some  measures  for  the 
prevention  of  importation  of  tuberculous  animals.  For 
these  animals  they  applied  the  tuberculin  test,  and  al- 
though some  mistakes  were  made,  that  year  18,692  cattle 
were  excluded  from  the  State.  While  some  mistakes 
did  occur,  yet  only  one  quarter  of  one  per  cent,  of  tests 
proved  erroneous,  the  test  being  verified  in  every  in- 
stance by  post-mortem.  Since  that  time,  and  under 
the  new  law  which  went  into  operation  last  June,  they 
had  tested  in  the  neighborhood  of  six  thousand  ani- 
mals, and  the  percentage  of  errors  had  been  only  one- 
tenth  of  one  per  cent.  If  the  lesions  were  not  found 
sufficiently  developed  to  be  evident  to  the  eye  of  the 
owner,  the  case  was  put  down  as  an  error.  The  local 
inspectors  (quarantined  animals  suspected  to  have  tu- 
berculosis, and  since  June  the  percentage  of  these 
proven  to  have  tuberculosis  was  fifty-two.  The  com- 
mission, during  the  last  year,  had  only  been  able  to  ad- 
vise systematic  examination  of  all  herds.  The  law  had 
been  changed,  providing  full  compensation,  and  after 
that  many  owners  of  herds  asked  to  have  examination 
made.  The  average  ])rice  paid  for  condemned  animals 
under  full  compensation  had  been  §37  as  against  $21 
under  half  compensation.  Now,  too,  they  were  al- 
lowed to  use  tuberculin  as  a  test,  which  he  said  had 
been  shown  not  to  be  deleterious.  During  the  past 
twelve  months  the  cattle  commission  had  tested  24,000 
cattle,  and  of  this  number  3,450  had  been  destroyed  as 
tuberculous.  In  several  large  herds  as  high  as  ninety- 
five  per  cent,  had  been  found  diseased.  One  noted 
dairy,  with  70  cattle,  which  had  been  regarded  by  him 


as  healthy  from  physical  examination,  showed  under 
tuberculin  30  tuberculous  cows.  There  had  been  no 
cases  since  destroying  these  and  disinfecting  the  prem- 
ises with  steam,  bichloride  solution,  and  whitewash. 
New  cases  were  not  likely  to  arise  unless  from  in- 
troduction of  infected  cattle  into  the  herd.  New 
arrivals  should  always  be  examined  before  admitted. 
A  number  of  drugs  had  been  sent  them  for  cure  of 
tuberculosis,  but  as  far  as  tested  they  had  proven  use- 
less. 

The  Best  Methods  for  the  Eradication  of  Tuberculo- 
sis.— Professor  J.\mes  L.\w,  of  Cornell  University, 
read  on  this  subject  (see  p.  730). 

The  Transmission  of  Tubercle  Bacilli  and  Tubercular 
Products  in  Milk. — Professor  H.\rold  C.  Ernst,  of 
Harvard  Medical  School,  read  on  this  subject.  He 
divided  it  into  two  parts:  i.  The  possibility  of  the 
occurrence  of  the  infectious  element  in  milk  from  cows 
with  tuberculous  disease  in  the  udder.  2.  The  more 
difficult  question,  whether  this  infectious  element  was 
ever  present  in  milk  from  cows  with  no  appreciable 
lesion  of  the  udder. 

Regarding  the  first  question,  the  most  recent  work 
with  which  he  was  familiar  was  contained  in  the  Report 
of  the  Royal  Commission  upon  Tuberculosis,  published 
this  week.  The  gist  of  the  report  was  that  the  com- 
mission had  found  tubercle  bacilli  in  milk  from  cows 
whose  udder  was  diseased,  but  not  in  the  milk  of  cows 
whose  udder  was  free  from  tuberculous  disease.  This 
latter  part  of  the  report  did  not  coincide  with  Dr. 
Ernst's  work,  for  while  the  tubercle  bacilli  found  by 
him  in  the  milk  of  cows  with  tuberculosis,  but  with  a 
healthy  udder,  were  few,  yet  careful  search,  with  use 
of  many  cover-glasses  and  going  over  a  large  field,  had 
revealed  some.  By  feeding  pigs  with  milk  from  cows 
with  tuberculosis,  but  without  apparent  lesion  of  the 
udder,  about  one -third  developed  tuberculosis,  but 
with  other  animals  there  was  less  success.  So  that,  as 
a  result  of  his  own  work,  it  would  seem  that  milk  from 
tuberculous  cows  with  no  apparent  lesion  of  the  udder, 
was  possessed  of  the  infectious  element  of  tuberculosis 
in  not  a  very  small  proportion  of  the  cases,  and  he 
thought  a  positive  result  of  this  nature  was  worth  more 
than  a  long  series  of  negative  results. 

But  the  first  point  having  been  settled,  the  next  one 
of  interest  to  us  as  physicians  was,  how  much  this  in- 
fectious element  in  milk  threatened  the  human  being. 
As  bearing  on  this  question.  Dr.  Ernst  quoted  several 
letters  received  by  him  in  response  to  interrogatories 
sent  out  five  years  ago,  and  while  the  evidence  was  not 
absolutely  positive,  yet  in  a  number  of  instances  it  was 
highly  probable  that  tuberculosis  had  been  contracted 
from  taking  milk  from  the  tuberculous  mother  or  ani- 
mal. Dr.  Ernst  said  that  all  milk  from  tuberculous 
cows,  whether  with  or  without  disease  of  the  udder, 
should  be  condemned  for  food. 

Dr.  George  B.  Fowler  said  it  was  extremely  diffi- 
cult for  boards  of  health  to  execute  laws  in  the  line  of 
their  duty  when  they  had  not  with  them  the  sympathy 
of  the  public  and  the  board  of  appropriation  ;  but  with 
the  weight  of  authority  of  to-night  in  their  favor,  they 
felt  that  it  would  be  possible  to  go  ahead  boldly  against 
the  use  of  food  containing  the  infection  of  tubercu- 
losis. 

Dr.  William  H.  Thomson  said  that  he  had  been 
taught  early  to  look  upon  tuberculosis  as  an  hereditary 
disease.  One  of  the  greatest  advances  was  made  when 
it  was  shown  to  be  infectious.  For  some  time  he  had 
accepted  the  general  view,  that  the  infection  usually 
look  place  through  dried  sputum,  etc.,  floating  in  the 
air  and  being  inhaled.  More  recently  experiments 
had  been  made  in  the  London  hospitals  for  consump- 
tion, going  to  prove  that  the  dust  taken  from  con- 
sumptive wards  was  very  slightly  infectious  to  animals, 
and  he  felt  convinced  that  food  containing  tubercle 
bacilli  and  becoming  lodged  in  the  fauces  and  pharynx 
was  the  chief  source  of  infection.      The  tonsils  and 


744 


MEDICAL   RECORD. 


[November  23,  1895 


mucous  membrane  of  the  fauces  were  often  sore  or 
abraded,  food  became  lodged  there,  and  fatty  foods 
especially  were  difficult  of  removal.  Lesions  in  the 
intestinal  tract  were  also  a  source  of  infection.  Dr. 
Thomson  said  one  practical  lesson  was  to  keep  the 
mouth  clean  and  disinfected.  Asking  pardon  for  a 
personal  allusion,  he  said  that  formerly  he  had  been 
subject  to  sore  throat,  but  during  the  past  four  years 
he  had  not  had  an  attack,  and  he  attributed  it  to 
washing  the  mouth  after  every  meal  with  a  mixture  of 
eucalyptus,  benzoic  acid,  and  peppermint  water. 

Dr.  Joseph  D.  Bryant  hoped  that  through  the 
Board  of  Health,  so  ably  represented  by  Dr.  Fowler, 
the  consumers  of  milk  in  New  York  would  soon  have 
the  positive  assurance  that  their  milk  came  from  cows 
which  were  free  from  tuberculosis.  He  thought  this 
could  be  accomplished  without  any  great  difficulty, 
provided  the  Board  of  Health  applied  the  screws  in 
such  a  way  as  to  touch  the  pockets  of  those  who 
wished  to  sell  milk  in  this  city. 


SECTION    QN  GENERAL  SURGERY. 

Stated  Meeting,  November  11,  i8g^. 

B.  Farquhar  Curtis,  M.D.,  Chairman. 

Aluminium  Corset. — Dr.  A.  M.  Phelps  showed  an 
aluminium  corset,  and  also  a  Hessing  corset  for  use  in 
cases  of  crooked  spine,  especially  lateral  curvature 
without  disease  of  the  vertebrje.  The  Hessing  corset 
was  much  used  in  Germany,  was  made  of  steel  bands 
riveted  together  and  covered  by  cloth,  and  differed  en- 
tirely from  putting  on  a  brace  and  turning  up  a  screw 
in  order  to  keep  the  patient  in  corrected  position.  It 
was  fairly  light,  and  useful  in  mild  cases  in  women. 
There  were  two  or  three  varieties  of  it.  Plaster- of - 
Paris  was  rather  thick,  heavy,  and  hardly  porous 
enough,  yet  it  was  the  best  jacket  we  had  for  Pott's 
disease  of  the  spine,  and  it  was  also  serviceable  in  lat- 
eral curvature  ;  but  in  the  latter  class  of  cases  aluminium 
was,  so  far  as  he  had  tested  it,  freer  from  objections 
than  the  others,  but  it  was  somewhat  expensive,  cost- 
ing fifty  dollars  or  more.  A  plaster  corset  was  first 
made,  the  patient  being  suspended  ;  this  was  filled  with 
plaster,  and  over  the  latter  the  aluminium  corset  was 
hammered  into  shape.  It  had  numerous  perforations 
smaller  than  a  dime. 

Answering  Dr.  Gallant,  he  said  that  if  the  patient 
changed  much  in  shape  and  size,  it  would  be  necessary 
to  make  a  new  corset.  The  weight  of  the  instrument, 
aluminium,  was  about  two  pounds. 

Epithelioma  of  the  Roof  of  the  Mouth. — Dr.  C.  N. 
DowD  presented  a  man,  near  fifty  years  of  age,  on 
whom  he  had  operated,  removing  the  teeth,  alveolar 
processes,  and  considerable  of  the  roof  of  the  mouth 
on  the  upper  right  jaw  for  extensive  epithelioma  of 
these  parts.  The  operation  was  performed  fifteen 
months  ago,  and  the  patient  had  since  been  in  excellent 
health.  The  operation  left  a  slight  perforation  into 
the  nostril,  which  the  patient  stuffed  with  cotton.  It 
caused  no  annoyance. 

Cure  of  Flat  foot. — Dr.  Royal  Whitman  presented 
a  young  man  on  whom,  a  number  of  months  before,  he 
had  done  forcible  osteotomy  on  the  right  foot  for  a 
marked  degree  of  flat-foot.  The  left  foot  showed  the 
same  deformity,  less  marked  and  uncorrected.  In  this 
instance,  and  in  others  when  necessary,  he  performed 
tenotomy  on  the  tendo- Achilles,  in  addition  to  forcing 
the  foot  into  position.  Plaster-of- Paris  bandage  was 
put  on  for  a  while,  and  the  patient  was  still  wearing 
what  was  called  the  Whitman  splint,  consisting  of  a 
broad  piece  of  metal  fitting  the  sole  and  sides  of  the 
corrected  foot,  worn  in  the  shoe.  Patients  submitting 
to  this  treatment  and  carrying  out  instructions  sulise- 
quently,  attained  a  physiological  cure  of  their  flat  or 
weak  foot,  and  could  be  assured  that  there  would  be 
no    return    of    it.      Four    weeks    was    frequentlv    loniir 


enough  in  the  hospital,  and  even  during  most  of  this 
time  they  could  walk  about.  This  patient  now  stood 
about  sixteen  hours  a  day  at  his  work,  without  pain. 

Dr.  Willy  Meyer  thought  surgeons  had  usually 
done  cutting  operations  in  hospitals  for  flat-foot  be- 
cause other  treatment  required  too  long  a  time.  If  by 
the  method  mentioned  by  Dr.  Whitman  the  patient 
could  go  out  in  six  weeks,  the  method  would  become 
a  practical  one  in  general  hospitals. 

Dr.  a.  M.  Phelps  said  that  spasm  of  the  muscles 
prevented  many  of  his  patients  from  returning  to  work 
so  soon — within  a  month. 

Dr.  Whitman  said  he  would  not  advise  heavy  lift- 
ing so  soon,  but  it  was  better  for  the  patient  to  walk 
about,  since  it  tended  to  keep  the  foot  in  correct  posi- 
tion. 

Casper's  Ureter  -  cystoscope.  —  Dr.  Willy  Meyer 
showed  this  instrument,  and  mentioned  two  cases  in 
which  he  had,  with  its  aid,  successfully  catheterized 
the  ureters,  one  patient  being  a  man,  the  other  a  wom- 
an. The  instrument  differed  from  Nitzer's  cystoscope, 
being  more  especially  adapted  to  illuminating  the  site 
of  the  urethral  orifices  and  introduction  into  them  of  a 
small  catheter  connected  with  the  instrument,  and 
directed  at  an  angle  of  forty-five  degrees,  correspond- 
ing to  that  of  entrance  of  the  ureters  into  the  bladder 
walls.  Nitzer  had  accused  Casper  of  copying  his  in- 
strument, but  Casper  claimed  originality,  and  Dr. 
Meyer  thought  he  certainly  deserved  credit  for  pre- 
senting a  very  ingenious  and  practical  instrument 
to  the  profession.  By  its  aid  Casper  had  succeeded  in 
catheterizing  the  ureter  thirty  times,  in  twenty-two  pa- 
tients, with  only  one  failure.  Dr.  Meyer  had  used  it  in 
three  cases,  catheterizing  the  ureters  six  times  in  all. 
To  catheterize  the  other  ureter  in  the  male  it  was 
necessary  to  withdraw  and  reintroduce  the  ureter-cys- 
toscope,  in  the  female  it  was  not.  In  the  female  he 
would  prefer  Kelly's  method  of  urethral  work,  for  his 
instruments,  though  more  numerous,  could  be  boiled, 
while  the  ureter-cystoscope  could  not  be  disinfected  in 
this  manner. 

Dr.  Frederic  E.  Sondern  said  that  six  cubic  centi- 
metres of  urine  was  sufficient  for  analysis  if  one  used 
economy,  which  was  necessary  in  connection  with 
catheterization  of  the  ureters.  The  ordinary  urinome- 
ter,  or  any  modification  of  it,  could  not  be  employed  for 
taking  the  specific  gravity  of  this  small  amount,  but  for 
this  purpose  he  used  Westphal's  specific-gravity  bal- 
ance. The  whole  amount  was  then  put  into  a  tube 
and  a  centrifugal  apparatus  was  employed  to  precipi- 
tate sediment  for  examination  for  tubercle  bacilli,  etc. 
The  urine  was  then  filtered  through  filter-paper,  and 
about  five  cubic  centimetres  remained.  The  reaction 
was  taken.  One  cubic  centimetre  was  sufficient  to  de- 
termine the  ])ercentage  of  urea,  i  for  sugar,  i  for  al- 
bumin, the  remaining  2  for  chlorides  or  other  chemical 
tests. 

Dr.  Bancjs  and  Dr.  F.  Tilden  Brown  thought  it 
likely  the  mouth  of  the  ureter  could  be  found  more 
easily  with  the  ureter-cystoscope  presented  by  Dr. 
Meyer  than  with  others  which  they  had  tried. 

Disadvantages  of  Non-absorbable  Sutures  in  Hernia 
Operations. — Dr.  W.  B.  Coley  reported  a  number  of 
cases  of  abscess,  sinus,  and  recurrence  of  hernia  after 
"  radical  "  operations  in  which  non- absorbable  sutures 
had  been  used,  the  cases  having  been  operated  upon 
by  various  surgeons,  and  subsequently  appearing  at  the 
Hospital  for  the  Ruptured  and  Crippled.  Four  cases 
had  been  reported  by  him  on  a  former  occasion.  To 
this  number  he  added  thirteen  others. 

In  the  first  case  silk  had  been  used  ;  sinus  remained  ; 
sutures  came  out  at  different  times  ;  relapse  after  four 
months.  Case  2  :  Silkworm  gut  ;  sinuses  followed  ;  two 
months  in  healing  ;  several  sutures  came  out  ;  relapse 
in  a  few  months.  Case  3  :  Modified  Macewen  opera- 
tion ;  silver-wire  suture  ;  patient  in  hospital  several 
weeks  ;    two  months  afterward  sinus  ;    relapse  a   few 


November  23,  1895] 


MEDICAL    RECORD. 


745 


months  later.  Case  4  :  Operation  in  April,  1S88  ;  un- 
der treatment  for  sinus  until  October,  1888  ;  hernia  a 
few  months  later.  Case  5  :  Double  hernia  ;  opera- 
tions at  separate  periods  :  silk  :  recurrence  on  both 
sides.  Case  6  :  Buried  silk  ;  sinus  followed  ;  four  sut- 
ures extruded  :  sinus  scraped  out  ;  two  more  sutures 
were  removed  ;  second  operation  for  recurrence,  silk- 
worm gut  being  used  ;  same  year  a  second  relapse  oc- 
curred. The  other  seven  cases  were  more  or  less  sim- 
ilar, sinuses  following  non-absorbable  suture  ;  recurrence 
of  hernia. 

Dr.  Coley  said  his  personal  experience  with  non-ab- 
sorbable suture  in  hernia  was  limited  to  three  cases, 
silk  being  used  ;  one  case  refused  to  heal  until  the 
sutures  were  cast  off,  and  relapse  occurred  after  three 
months.  The  second  patient  was  well  three  years  after 
the  operation. 

Out  of  two  hundred  and  fifty  cases  of  hernia  opera- 
tions, in  which  he  had  used  tendon  suture,  there  had 
not  been  trouble  with  the  suture  in  a  single  instance. 

Non  -  absorbable  suture  acting  as  a  foreign  body, 
must  be  held  responsible  for  the  bad  result  in  the  other 
cases.  The  suppuration  and  weakening  of  the  walls 
caused  relapse,  and  in  Dr.  Coley's  opinion  non  absorb- 
able suture  material  should  be  entirely  abandoned,  un- 
less for  special  conditions. 

The  Chairman,  Dr.  Curtis,  thought  Dr.  Coley  may 
have  exaggerated  the  disadvantages  of  non-absorbable 
suture,  for  surgeons  who  performed  a  good  many  opera- 
tions for  hernia  seldom  saw  the  suture  suppurate  its 
way  out.  Dr.  Coley  was  unusually  well  situated  to  see 
many  of  these  cases,  as  far  as  they  occurred  in  the 
hands  of  various  surgeons,  yet  it  would  be  observed 
that  he  had  really  seen  comparatively  few. 

Dr.  Crarv  had  seen  no  trouble  arise  from  cases  in 
which  silver  wire  had  been  used. 

Dr.  Cole  thought  a  strong  point  in  Dr.  Coley's 
paper  was  the  fact  that,  in  a  few  cases  in  which  he  had 
used  non-absorbable  suture  material  suppuration  had 
occurred,  while  in  two  hundred  and  fifty  cases  in  which 
absorbable  suture  was  used,  no  trouble  had  arisen. 
Dr.  Cole  said  they  had  given  up  non-absorbable  suture 
in  tenotomy,  because  of  its  acting  as  a  foreign  body 
and  causing  trouble,  even  when  primary  union  had 
been  obtained. 

Dr.  Dowd  remarked  that,  theoretically,  non-absorb- 
able suture  ought  to  be  all  right,  but  we  were  dealing 
with  a  practical  question.  In  practice  there  was  a 
good  percentage  of  cases  in  which  trouble  did  arise. 
Therefore  he  thought  we  should  use  absorbable  suture. 
Dr.  Coley  referred  again  to  some  of  the  cases  re- 
ported in  his  paper,  to  show  that  it  was  not  a  question 
alone  of  primary  union,  for  even  when  this  had  been 
obtained  the  non  -  absorbable  suture  had  at  times 
caused  trouble  subsequently  as  a  foreign  body,  work- 
ing its  way  out  and  establishing  a  sinus,  thus  weaken- 
ing the  walls  and  leading  to  secondary  hernia. 


Medical  Fees  in  Eussia.— The  Russian  Government 
is  nothing  if  it  is  not  parental.  How  wisely  the  "  Czar 
of  all  the  Russias  "  looks  after  his  "children  "has  been 
aptly  illustrated  by  his  government  taking  in  hand  the 
question  of  medical  fees.  Medical  men  in  Russia  have 
now  to  charge  according  to  a  fixed  scale,  of  which  the 
following  are  the  chief  details.  The  towns  are  divided 
into  three  classes  :  those  having  more  than  fifty  thou- 
sand inhabitants,  those  having  between  that  number 
and  five  thousand,  and  those  having  fewer  than  five 
thousand.  Patients  are  also  divided  into  three  classes, 
the  first  including  capitalists,  landowners,  manufactur- 
ers, bankers,  merchants,  and  superior  government 
officials,  the  third  the  rest  of  the  population.  The  fees 
for  the  first  class  have  been  fixed  at  five  roubles  ;  for 
the  second,  three  roubles  ;  and  for  the  third,  thirty 
kopecks. —  The  Sanitarian. 


NEW   YORK    NEUROLOGICAL   SOCIETY. 

Stated  Meeting,    November  j,  iSpj. 

Edward  D.  Fisher.  M.D.,  President. 

Traumatic  Neurasthenia.— Dr.  C.  E.  Nammack  pre- 
sented a  policeman  who,  on  October  12,  1S93,  had  at- 
tempted to  stop  three  runaway  horses  attached  to  a 
steam  fire-engine  in  the  Centennial  Parade.  He  was 
successful  in  this,  but  although  not  physically  injured 
he  received  a  profound  psychical  shock.  One  week 
later  it  became  necessary  for  him  to  seek  medical  ad- 
vice for  the  relief  of  pains  in  his  chest.  On  the  advice 
of  Dr.  C.  L.  Dana,  he  went  abroad,  and  remained  there 
from  June,  1894,  to  October,  1895.  He  had  been  per- 
fectly well  up  to  the  time  of  this  accident,  and  his  family 
and  personal  history  were  excellent.  He  remained  on 
police  duty  for  some  time,  but  found  himself  unable  to 
attend  to  his  work,  even  though  his  promotion  to  the 
rank  of  roundsman  had  rendered  this  less  monotonous 
than  formerly.  The  first  symptoms  noticed  were  di- 
minished power  of  persistent  application  and  nervous 
irritability.  Mental  exaltation  then  became  marked, 
and  insomnia  became  most  distressing.  Hyperaesthesia 
and  parassthesia  were  not  noticed.  The  principal  sub- 
jective symptoms  were  pain  over  the  heart  and  dyspnoea 
on  exertion,  profuse  sweating,  and  insomnia.  Examina- 
tion recently  showed  the  pain  and  temperature  senses 
normal,  tactile  sensibility  impaired,  and  hyperesthesia 
wanting.  Both  visual  fields  showed  the  shifting  type 
of  contraction.  Color  perce])tion  was  fairly  good. 
There  was  no  motor  weakness  of  the  eyes,  and  no  ab- 
normal pupillary  reaction.  .Smell  and  taste  were  not 
affected  ;  station  and  gait  were  good  ;  there  was  some 
tremor  of  the  hand.  The  knee-jerks  were  slightly  ex- 
aggerated. The  heart  action  was  weak  and  greatly  ac- 
celerated by  walking  ;  there  was  no  enlargement  of  the 
heart  or  valvular  disease.  Slight  irritation  of  the  skin 
led  to  persistent  redness.  His  weight  had  fallen  from 
two  hundred  and  twenty  to  one  hundred  and  seventy- 
five  pounds.  Micturition  was  not  vigorously  performed. 
The  urine  was  normal.  The  sexual  desire  was  weak, 
although  the  power  was  good.  The  diagnosis  in  this 
case,  the  speaker  said,  lay  between  traumatic  neuras- 
thenia, traumatic  hysteria,  and  simulation.  The  last 
was  excluded  by  the  absence  of  motive,  of  striking 
symptoms,  and  of  efforts  to  exaggerate  slight  symptoms. 
Hysteria  was  excluded  by  the  absence  of  anxsthesia, 
contractures,  spasms,  etc.,  and  of  paroxysmal  phenom- 
ena. The  patient  had  had  the  benefit  of  skilful  treat- 
ment, and  improvement  had  been  slow  but  steady. 
Apparently  hydrotherapy  had  benefited  the  patient  the 
most.  The  case  was  interesting  as  being  free  from  the 
usual  complications  arising  from  prospective  lawsuits. 

Dr.  C.  L.  Dana  said  that  when  he  saw  this  case  he 
made  the  diagnosis  of  traumatic  neurasthenia.  The 
case  was  an  interesting  and  typical  one,  and  was 
chiefly  of  importance  on  account  of  the  absence  of  the 
complications  referred  to. 

Dr.  Na.mmack,  in  closing,  said  that  formerly  consid- 
erable stress  had  been  laid  upon  the  condition  of  the 
visual  fields  as  a  differential  point  between  traumatic 
neurasthenia  and  hysteria,  but  that  now  this  had  been 
pretty  much  abandoned. 

A  Case  for  Diagnosis.— Dr.  Pearce  Bailey  pre- 
sented a  man,  sixty  years  of  age,  a  carpenter  by  occu- 
pation. There  was  no  hereditary  taint  except  that  the 
father  had  had  tic  convulsif.  The  patient  had  been 
healthy  up  to  forty  years  of  age,  at  which  time  the 
symptoms  referable  to  the  nervous  system  first  appeared. 
The  first  symptoms  followed  a  severe  shock  from  fall- 
ing into  water,  and  were,  slight  headache,  dizziness,  im- 
pairment of  memory,  and  nausea.  Twelve  years  ago 
his  left  leg  became  numb  and  ])»ralyzed,  and  this  lasted 
for  two  weeks,  when  it  temporarily  disajjpeared.  Six 
years  ago  the  right  leg  became  similarly  affected,  and 
now  one  leg  was  as  bad  as  the  other.     Two  years  ago 


746 


MEDICAL   RECORD. 


[November  23,  1895 


his  hands  became  so  uncertain  in  their  movements  that 
he  could  no  longer  use  his  hammer.  At  this  time  he 
noticed  that  when  he  accidentally  struck  his  fingers 
with  the  hammer  it  did  not  cause  him  pain.  He  was 
also  obliged  to  use  a  cane  when  walking.  At  the  pres- 
ent time  there  is  no  active  pain,  no  trophic  disturbance, 
and  no  bladder  or  rectal  affection.  There  is  slight 
roughening  of  the  first  sound  of  the  heart.  The  left 
palpebral  fissure  appears  to  be  smaller  than  the  right, 
and  there  is  slight  inequality  of  the  pupils.  There  is 
no  paralysis  of  the  ocular  muscles  ;  the  optic  disks  are 
rather  pale.  The  disorders  of  motion  consist  in  a  spas- 
tic and  ataxic  gait.  The  Romberg  symptom  is  well 
marked.  Fibrillary  twitchings  are  not  observed  e.xcept 
when  the  arms  are  held  out  from  the  body  for  some  time. 
The  only  sensory  s)'mptom  of  note  is  an  almost  abso- 
lute insensibility  to  pain  all  over  the  body.  The  tem- 
perature sense  is  retained. 

The  speaker  said  that  he  had  been  unable  to  classify 
this  case. 

Dr.  B.  Sachs  said  he  saw  no  reason  why  this  case 
should  not  be  considered  one  of  combined  sclerosis. 
The  ataxia  of  both  upper  and  lower  extremities,  the  in- 
crease of  the  deep  reflexes,  and  the  marked  sensory 
disturbances  all  pointed  in  that  direction. 

Dr.  M.  Allen  Starr  said  he  also  thought  it  was 
probably  a  case  of  combined  sclerosis,  both  posterior 
and  lateral  columns  being  affected.  It  was  not  usual 
to  have  a  loss  of  the  pain  sense  in  such  cases,  but  he 
thought  instances  of  this  kind  had  been  reported. 

The  President  said  that  in  the  absence  of  the  pain 
sense  all  over  the  body,  including  the  head,  would  re- 
move the  case  from  the  ordinary  class  of  combined 
sclerosis. 

Dr.  Joseph  Collins  said  that  while  he  believed  the 
case  was  one  of  combined  sclerosis  yet  it  was  quite 
possible  that  the  entire  symptom  complex  in  this  case 
was  dependent  upon  a  functional  condition.  It  must  at 
least  be  conceded  that  the  universal  analgesia  in  this 
case  was  functional,  as  no  possible  anatomical  lesion 
can  be  postulated  to  explain  it. 

Dr.  Frederick.  Peterson  said  that  it  seemed  to 
him  that  all  the  symptoms  were  those  of  a  typical  case 
of  combined  sclerosis  and  ataxic  paraplegia.  General 
analgesia  was,  of  course,  extraordinary,  and  could  not 
be  explained  by  combined  sclerosis,  but  must  be  ac- 
counted for  in  some  other  way. 

Dr.  Sachs  said  that  admitting  that  the  general  anal- 
gesia was  not  common  in  combined  sclerosis,  still  there 
might  be  functional  symptoms  superimposed  on  an  or- 
ganic condition.  The  walk,  the  increased  reflexes,  and 
the  moderate  amount  of  ataxia  all  seemed  to  point  in- 
evitably to  a  combined  sclerosis. 

Dr.  Dana  said  there  could  hardly  be  any  doubt 
that  the  general  analgesia  was  a  functional  condition. 
No  such  analgesia  could  be  produced  by  any  known 
organic  lesion.  It  seemed  to  him  to  be  a  hysterical 
condition  superimposed  upon  the  sclerosis. 

The  President  said  that  the  loss  of  the  pain  sense 
could  be  explained  on  its  functional  character.  The 
ataxia  in  the  hand  seemed  to  be  not  the  ordinary  ataxia, 
but  that  form  seen  frequently  in  hysteria.  He  had  for 
a  long  time  observed  a  case  of  hysterical  paraplegia,  in 
which  there  had  been  a  beautiful  ataxia  very  similar  to 
that  shown  in  the  case  before  the  Society. 

Dji.  Bailev  expressed  the  opinion  that  in  a  purely 
functional  case  there  would  be  some  affection  of  the 
sense  of  touch  as  well.  The  left  palpebral  fissure  was 
certainly  smaller  than  the  right,  and  the  left  pupil  was 
also  considerably  smaller  than  its  fellow  ;  hence,  there 
was  evidently  some  organic  lesion  higher  up  than  an 
ordinary  cord  lesion.  He  had  never  seen  a  functional 
sensory  involvement  of  just  that  character. 

Lumbar  Puncture  of  the  Subarachnoid  Space. — Dr. 
George  W.  Jacouv  read  a  paper  with  this  title.  He 
said  that  his  experience  with  this  comparatively  new 
method  dated  back  only  six  months,  but  it  had  com- 


prised 35  cases,  with  as  many  as  six  punctures  in  one 
case.  Among  the  cases  treated  were  17  of  tubercular 
meningitis,  i  of  purulent  meningitis,  i  of  abscess,  and 
3  of  acute  mania.  The  operation  was  done  between 
the  third  and  fourth  lumbar  vertebrae,  in  the  inter- 
laminar  space,  using  preferably  the  needles  measuring 
8  ctm.  in  length  and  i  mm.  in  diameter,  with  rather 
broad  bases,  so  as  to  dispense  with  the  syringe,  which 
is  chiefly  used  as  a  handle.  The  depth  of  the  punct- 
ure and  the  amount  of  force  to  be  used  were  matters 
of  experience.  If  the  anatomical  relations  were  first 
carefully  studied  upon  the  cadaver,  there  was  no  more 
danger  from  lumbar  puncture  than  from  opening  a 
deep-lying  abdominal  abscess.  In  a  case  of  cerebro- 
spinal meningitis  treated  by  Von  Ziemssen,  the  removal 
of  sixty  or  seventy  cubic  centimetres  at  various  inter- 
vals gave  relief  from  headache  for  several  days  after 
the  puncture.  In  the  experience  of  the  reader  of  the 
paper,  beyond  the  relief  of  headache  in  cases  of  brain 
tumor,  no  change  had  been  noticed  to  follow  the 
puncture,  except  in  cases  of  meningitis.  In  these 
general  improvement  was  noted.  That  the  brain  press- 
ure was  actually  reduced  could  be  shown  in  infants 
before  the  closure  of  the  fontanelles.  In  cases  of 
brain  tumor  immediately  following  the  operation,  the 
headache  became  almost  unbearable  for  about  fifteen 
minutes  ;  then  it  gradually  subsided,  and  there  was  a 
comparative  freedom  from  pain  for  several  days.  He 
had  also  noticed  an  increase  in  the  pulse- rate  after 
puncture,  lasting  twenty-four  hours.  In  one  case,  a 
child,  six  years  of  age,  suffering  from  headache,  un- 
able to  stand  or  walk,  and  having  bilateral  choked 
disk,  there  was  marked  relief  after  removal  of  the 
fluid.  It  did  not  follow,  of  course,  that  there  was  any 
relation  of  cause  and  effect  between  the  puncture  and 
the  improvement.  In  another  case,  one  of  meningitis, 
occurring  in  a  child,  four  years  of  age,  who  was  in  a 
serai-comatose  condition  at  the  time  of  the  puncture, 
60  c.c.  of  fluid  were  withdrawn.  The  next  day  the 
temperature  was  almost  down  to  the  normal,  and  the 
child  completely  recovered  in  a  week.  It  is  probable 
that  this  was  not  a  true  case  of  meningitis.  Practically 
he  had  seen  little  or  no  benefit  from  this  treatment  in 
cases  of  tubercular  meningitis.  In  these  cases  death 
was  due  to  toxins  rather  than  to  brain  pressure  ;  hence 
there  was  an  excellent  reason  for  the  removal  of  the 
fluid.  Reports  of  cured  cases  of  tubercular  meningitis 
had  always  been  doubted,  but  one  well-observed  case 
was  known  to  have  recovered.  It  had  been  asserted 
that  inasmuch  as  ordinarily  only  twenty  cubic  centi- 
metres were  removed,  it  was  probable  that  only  the 
spinal  fluid  was  removed,  and  that  the  communication 
between  the  spinal  sac  and  the  brain  was  obstructed. 
Puncture  in  cases  of  hydrocephalus,  and  the  effect  on 
the  fontanelle,  show  that  the  fluid  can  be  made  to  pass 
from  the  spinal  sac  into  the  brain.  The  reader  of  the 
paper  then  detailed  experiments  that  he  had  made 
upon  a  rabbit,  using  considerable  pressure  and  a  col- 
ored fluid.  They  showed  that  the  communication  be- 
tween the  spinal  and  subarachnoid  cavity  was  not  as 
free  as  we  had  been  led  to  assume.  Further  experi- 
mentation, however,  served  to  confirm  what  had  already 
been  known  anatomically  and  clinically — that  a  free 
communication  existed.  From  this  consideration  it 
was  evident  that  we  were  warranted  in  utilizing  lumbar 
puncture. 

The  value  of  the  lumbar  puncture  as  a  diagnostic 
aid  could  not  be  denied.  Attention  must  be  paid  to 
the  pressure  on  the  fluid,  the  presence  and  amount  of 
albumin  and  sugar,  and  the  presence  or  absence  of 
blood  or  pus,  and  of  micro-organisms,  such  as  bacilli. 
Normally  the  fluid  comes  out  drop  by  drop,  but  if  it  is 
under  much  pressure  it  may  gush  out.  The  scientific 
gravity  is  not  of  much  value,  and  cannot  ordinarily  be 
determined  on  account  of  the  small  quantity  of  fluid 
removed.  The  presence  or  absence  of  albumin  ard 
sugar  is  likely  in  the  future  to  furnish  important  cor- 


Xovember  23.  1895] 


MEDICAL    RECORD. 


747 


roborative  information.  In  brain  tumors  and  brain 
abscess  the  albumin  is  only  slightly  increased.  In 
the  differential  diagnosis  between  meningitis  and  brain 
tumor  the  presence  of  more  than  one  per  mille  of  albu- 
min in  the  fluid  would  be  additional  testimony  in  favor 
of  an  inflammator)-  condition.  It  should  be  remem- 
bered that  after  repeated  punctures  the  amount  of  al- 
bumin increases  very  considerably.  Examination  for 
pus,  blood,  and  micro-organisms  is  more  important 
It  IS  hardly  to  be  expected  that  tubercle  bacilli  would 
be  found  in  the  cerebro-spinal  fluid,  for  in  sero-fibrin- 
ous  exudation  of  pleurisy  it  was  well  known  that  tuber- 
.  cle  bacilli  were  not  found.  However,  in  the  majority 
of  lumbar  punctures  in  cases  of  tubercular  meningitis, 
tubercle  bacilli  have  been  found  in  the  cerebro-spinal 
fluid.  The  fluid  should  be  allowed  to  stand  for  twelve 
hours,  and  then  the  coagiilum  teased  out,  dried,  and 
prepared  for  examination  in  the  usual  way.  As  a'  rule 
there  are  but  few  bacilli  present.  As  the  clinical  diag- 
nosis IS  difficult  except  in  well-developed  cases,  it  is 
highly  important  to  have  in  this  examination  of  the 
cerebro-spinal  fluid  an  additional  aid  to  the  diagnosis 
In  tubercular  meningitis  the  fluid  is  clear  and  contains 
tubercle  bacilli :  in  purulent  meningitis  the  fluid  is 
creamy,  and  contains  streptococci  or  other  micro-or- 
ganisms ;  in  brain  abscess  the  fluid  is  clear  and  con- 
tains no  micro-organisms. 

Blood  found  in  the  cerebro-spinal  fluid,  and  not  due 
to  the  accidental  puncture  of  a  meningeal  vessel,  may 
be  found  in  spinal,  meningeal,  and  in  inter-ventricular 
hemorrhage.  The  diagnosis  of  secondary  ventricular 
hemorrhage  has  been  exceedingly  unsatisfactorj-. 
Blood  has  been  found  in  the  spinal  sac  in  cases  of  ven- 
tricular heinorrhage.  We  are  not  justified  in  all  cases 
in  diagnosticating  this  condition  from  the  presence  of 
a  small  quantity  of  blood  in  the  cerebro-spinal  fluid, 
as  such  contamination  is  often  produced  by  the  punct- 
ure. -Again,  in  subdural  hemorrhage  the  passage  of 
blood  from  the  cerebral  to  the  spinal  membranes  might 
take  place.  Two  of  the  author's  cases  emphasized  the 
importance  of  lumbar  puncture  when  there  was  hemor- 
rhage into  the  spinal  canal.  The  removal  of  the  blood 
in  these  cases  reduced  the  local  pressure,  and  so  at 
least  placed  the  patient  in  a  condition  more  favorable 
to  recovery.  In  any  spinal  injury,  whatever  its  nature, 
lumbar  puncture  must  increase  the  patient's  chances  of 
recovery.  In  three  cases  of  acute  mania  lumbar 
puncture  has  been  done.  The  fluid  was  found  to  be 
sterile. 

In  conclusion,  the  speaker  said  that  by  means  of 
lumbar  puncture  cerebro-spinal  fluid  might  be  easilv 
removed  from  the  subarachnoid  space,  spinal  cord,  and 
cavities  of  the  brain.  It  is  only  of  direct  therapeutic 
value  as  a  palliative  in  reducing  excessive  pressure. 
It  is  very  important  in  the  diagnosis  of  various  inflam- 
matory affections  of  the  different  membranes,  and  in 
the  recognition  of  hemorrhage  into  the  ventricles,  as 
into  the  spinal  canal. 

Dr.  W.  M  Leszvnsky  asked  if  it  were  necessary  to 
use  the  syringe. 

Dr.  C.  L.  D.an.\  said  that  the  Society  should  express 
Its  gratitude  to  the  author  for  calling  attention  to  this 
subject,  which  had  been  rather  neglected  in  this  coun- 
try. He  had  himself  tried  lumbar  puncture  on  a  num- 
ber of  cases  of  alcoholic  meningitis,  or  so-called  cere- 
bral oedema,  but  with  a  purely  negative  result.  He 
had  also  found  that  in  this  class  of  cases  lumbar  punct- 
ure was  not  very  easily  carried  out  on  account  of  the 
restlessness  of  the  patient,  and  the  tendency  to  large 
deposits  of  adipose  tissue  in  such  subjects.  The  oper- 
ation was  also  quite  painful.  He  had  seen  the  fluid 
gush  out  in  a  steady  stream  in  some  cases. 

Dr.  St.arr  asked  if  there  were  any  difficulty  in  stop- 
ping the  flow  of  fluid.  In  operations  on  the  spinal  cord 
he  had  encountered  great  difficulty  in  closing  the 
wound  and  stopping  the  flow  of  cerebro-spinal  fluid. 
In  two  recent  operative  cases  the  flow  had  obstinately 


continued,  and  had  been  associated  with  an  exceeding- 
ly severe  headache.  In  both  of  these  cases  the  gush 
of  fluid  had  been  verj-  considerable. 

The  President  said  that  he  had  not  always  ob- 
served such  a  great  quantity  of  intra-spinal  fluid  as  had 
been  alluded  to  by  the  last  speaker.  As  he  recalled 
autopsies  on  cases  of  ventricular  hemorrhage  it  did 
not  seem  to  him  that  blood  in  the  spinal  canal  had 
been  very  commonly  found. 

Dr.  Leszv.vskv  said  that  since  a  paper  had  been 
read  before  the  -American  Neurological  Society  about 
one  year  ago,  ver>-  little  had  been  said  in  this  country 
regarding  the  dangers  of  this  method,  and  he  would 
like  to  ask  the  reader  of  the  paper  for  information  on 
this  point. 

Dr.  T.acobv.  in  closing  the  discussion,  said  that  the 
synnge  should  not  be  used  at  all  except  in  those  cases 
in  which  a  very  small  quantity  of  fluid  was  to  be  with- 
drawn for  purely  diagnostic  purposes.  If  the  needle 
were  simply  introduced,  and  the  fluid  aUowed  to  drop 
away,  the  pressure  in  the  spinal  canal  would  not  be 
dangerously  reduced.  The  operation  is  exceedingly 
simple,  but  it  is  not  so  in  the  adults.  In  the  latter  he 
preferred  to  operate  under  an  anesthetic.  Children 
should  be  held  on  the  lap  with  the  back  arched  so  as 
to  facilitate  the  introduction  of  the  needle.  A  little 
iodoform  collodion  over  the  puncture  was  all  that  was 
necessar)-  to  stop  the  flow  of  cerebro-spinal  fluid. 
There  were  no  dangers  connected  with  the  operation 
except  such  incidental  ones  as  breaking  of  the  needle 
against  the  vertebrae.  If  an  anaesthetic  were  not  used 
in  an  adult,  and  the  patient  suddenly  straightened  out, 
the  needle  would  snap  off. 

Deformities  of  the  Hard  Palate  in  Degenerates, 
with  Exhibition  of  Casts.— Dr.  Frederick  Peterson 
offered  a  paper  on  this  subject.  (Only  a  portion  of  it 
was  read.)  He  said  that  his  observations  in  this  direc- 
tion extended  over  a  period  of  eleven  years,  and  com- 
prised examinations  on  upward  of  one  thousand  per- 
sons, one  hundred  criminals,  six  hundred  idiots,  and 
five  hundred  neuropaths  of  other  kinds.  On  account 
of  the  frequent  mention  of  the  Gothic  palate  he  had 
adopted  an  architectural  nomenclature  in  the  following 
classification  which  he  offered  : 

Pathological  Palates.— (,-/)  palate  with  Gothic  arch  ; 
(/')  palate  with  horseshoe  arch  ;  (c)  the  dome-shaped 
palate;  {d)  the  flat-roofed  palate;  (<f)  the  hip-roofed 
palate  ;  {/)  the  asymmetrical  palate  ;  and  (^')  the  torus 
palatinus.  In  illustration  of  these  varieties  of  abnor- 
mal palate,  seventeen  casts  of  the  hard  palate  were  then 
presented,  mostly  selected  from  among  the  four  hun- 
dred and  fifty  idiots  on  Randall's  Island.  The  seven 
varieties  are  to  be  looked  upon  merely  as  types.  Each 
type  presents  variations  and  combinations  with  other 
forms.  Among  the  flat-roofed  palates  would  be  in- 
cluded all  such  as  are  nearly  horizontal  in  outline,  as 
well  as  those  with  inclined  roof  sides  but  flattened 
tables.  In  the  hip-roofed  palate  there  is  a  marked 
pitch  of  the  palate  roof  in  front  and  behind.  It  is 
usual  to  find  asymmetry  of  the  face  and  sku*l  in  cases 
with  an  as>-mmetrical  palate.  The  torus  palatinus  ( Latin, 
/orus,  swelling)  was  first  mentioned  by  Chassaignac  as 
medio-palatine  exostosis.  It  is  a  projecting  ridge  of 
swelling  along  the  palatine  suture,  sometimes  in  its 
whole  length.  It  is  always  congenital,  and  varies  con- 
siderably in  both  shape  and  size.  But  two  or  three 
cleft  palates  were  found  among  the  many  idiots  ex- 
amined, and  as  a  number  of  such  palates  had  been 
found  in  subjects  who  were  far  from  being  degenerates 
it  was  not  thought  proper  to  include  the  cleft  palate 
among  the  well  marked  stigmata  of  degeneration. 

The  Committee  on  the  Terminology  of  the  Ner\-e 
Cell  reported  as  follows  :  The  term  natron,  applied  by 
Waldeyer  in  1891  to  the  nerve-cell,  with  all  its  ramifica- 
tions and  processes,  has  been  adopted  by  current 
writers  on  neurology,  and  by  such  eminent  neuroana- 
tomists  as  Cajal,  Van  Gehuchten,  Lonhossok,  Edinger, 


748 


MEDICAL    RECORD. 


[November  23,  1895 


Dejerine,  and  others,  therefore  we  advise  that  it  con- 
tinue to  be  used  and  understood  in  Waldeyer's  sense, 
as  indicating  the  nerve-unit.  Assuming  for  the  pur- 
poses of  terminology  that  this  cell-unit  be  divided  into 
(a)  cell-body  ;  (/')  protoplasmic  processes,  including 
all  processes  except  {()  ;  and  (<)  axis-cylinder  process 
with  collaterals  and  end  brashes.  The  term  neuron  in- 
cludes a,  b,  and  c. 

As  a  matter  of  convenience  to  the  members  of  the 
Society,  and  as  a  justification,  if  any  were  needed,  of 
the  utility  of  the  committee's  work,  the  following  list  of 
synonyms  and  proposed  substitutes  for  the  word  neu- 
ron is  given  : 

To  indicate  the  cell-unit  or  neuron  : 

Neuro-dendron,  proposed  by  KoUiker. 

Neura,  proposed  by  Rauber. 

Neurocyte,  proposed  by  P.  A.  Fish. 

Neure,  proposed  by  Frank  Baker. 

The  cy//,  the  iitioon,  and  the  dendrons,  proposed  by  Schaeffer. 

The  axis-cylinder  process  has  received  the  following 
names  : 

Neuron,  proposed  by  Schaeffer. 
Neuraxon,  proposed  by  Kolliker. 
Neurit,  proposed  by  Rauber. 
Neurite,  proposed  by  Fish. 

The  other  (protoplasmic,  etc.)  processes  have  re- 
ceived the  names  : 

Dendrons,  or  dendrites,  proposed  by  Schaeffer. 

Dendrites,  proposed  by  His  and  Fish. 

Cellulipetal  processes,  proposed  by  Cajal  and  Van  Gehuchten. 

The  committee  would  recommend  that  the  term 
axis-cylinder  process  be  still  used  in  its  long-accepted 
sense,  to  indicate  part  c  of  the  neuron.  Without  mak- 
ing the  recommendation  it  expresses  the  opinion  that 
some  word  like  neurite  will  probably  come  into  use  as 
a  synonym  for  this  axis-cylinder  process.  The  com- 
mittee also  recommend  that  the  old  term,  "  proto- 
plasmic processes,"  continue  to  have  its  ordinary  and 
legitimate  use,  but  express  the  view  that  the  word 
dendrite  will  be  a  useful  synonym. 

The  committee  beg  to  express  obligations  to  Dr. 
Frank  Baker,  of  Washington  ;  to  Professor  Burt  G. 
Wilder,  and  to  Dr.  Pierre  A.  Fish,  of  Utica.  Signed  : 
Drs.  Charles  L.  Dana,  Edward  D.  Fisher,  William  H. 
Thomson,  B.  Sachs,  Joseph  Collins,  and  J.  Arthur 
Booth. 


The  Samuel  D.  Gross  Prize, — The  second  quinquen- 
nial prize  of  one  thousand  dollars,  under  the  will  of  the 
late  Samuel  D.  Gross,  M.D.,  will  be  awarded  January 
I,  1900.  The  conditions  annexed  by  the  testator  are 
that  the  prize  "  Shall  be  awarded  every  five  years  to  the 
writer  of  the  best  original  essay,  not  exceeding  one  hun- 
dred and  fifty  printed  pages,  octavo,  in  length,  illustra- 
tive of  some  subject  in  Surgical  Pathology  or  Surgical 
Practice,  founded  upon  original  investigations,  the  can- 
didates foi*the  prize  to  be  American  citizens.  It  is  ex- 
pressly stipulated  that  the  successful  competitor,  who 
receives  the  prize,  shall  publish  his  essay  in  book  form, 
and  that  he  shall  deposit  one  copy  of  the  work  in  the 
Samuel  D.  Gross  Library  of  the  Philadelphia  Academy 
of  Surgery.  The  essays,  which  must  be  written  by  a 
single  author  in  the  English  language,  should  be  sent 
to  Dr.  J.  Ewing  Mears,  1429  Walnut  St.,  Philadelphia, 
before  January  i,  1900.  Each  essay  must  be  distin- 
guished by  a  motto,  and  accompanied  by  a  sealed  en- 
velope bearing  the  same  motto,  and  containing  the 
name  and  address  of  the  writer.  No  envelope  will  be 
opened  except  that  which  accompanies  the  successful 
essay.  The  committee  will  return  the  unsuccessful 
essays  if  reclaimed  by  their  respective  writers,  or  their 
agents,  within  one  year.  The  committee  reserves  the 
right  to  make  no  award  if  the  essays  submitted  are  not 
considered  worthy  of  the  prize. 


^voQtess  of  pXetUcal  J>cicucc. 

A  Simple  Expedient  for  the  Treatment  of  Nocturnal 
Enuresis. — Dr.  Stumpf  has  given  an  account  of  a  sim- 
ple and  apparently  rational  expedient  which  he  has 
successfully  adopted  in  the  treatment  of  nocturnal  en- 
uresis, especially  in  older  children.  He  was  led  to  try 
it  on  the  basis  of  the  fact  that  the  passage  of  even  a 
few  drops  of  urine  through  the  sphincter  vesicae  ex- 
cites the  action  of  the  detrusor  to  such  an  extent  that 
the  call  to  urinate  becomes  almost  imperative.  It  is 
well  known  how  difificult  it  is  to  restrain  the  act  of 
urination  after  even  a  small  amount  of  urine  has  passed 
the  sphincter  vesica;  and  entered  the  urethra.  His 
theory  is  that  during  sleep  the  sphincter  of  the  bladder 
is  apt  to  become  relaxed,  so  that  as  the  child  lies  hori- 
zontally in  bed,  a  little  urine  passes  the  sphincter  and 
enters  the  deep  urethra.  The  irritation  of  this  urine 
causes  at  once  strong  reflex  action  of  the  detrusor,  and 
the  bladder  is  at  once  emptied  in  a  full,  strong  stream. 
It  is  a  well-known  fact  that  in  nocturnal  enuresis  in 
children  the  urine  does  not  leak  away  gradually,  but 
the  bladder  is  emptied  at  once,  a  point  which  is  in 
support  of  this  theory.  In  order  to  prevent  the  pas- 
sage of  the  urine  into  the  urethra  when  the  sphincter 
becomes  relaxed  during  sleep,  a  simple  expedient  is 
adopted,  namely,  the  elevation  of  the  pelvis,  so  that  an 
accumulation  of  urine  of  ordinary  amount  in  the  blad- 
der will  gravitate  back  and  distend  the  fundus,  and  not 
press  against  and  tend  to  pass  the  sphincter.  The  ele- 
vation is  secured  by  allowing  the  child  only  a  single, 
small,  flat  pillow  under  the  head,  and  placing  one  or 
two  ordinary  pillows  under  the  thighs  so  that  they  lie 
at  an  angle  of  130°  to  150"  with  the  horizontal  spine. 
This  simple  expedient  was  entirely  successful  in  curing 
two  inveterate  cases,  one  of  a  boy,  aged  nine,  and  one 
of  a  girl,  aged  fifteen.  It  was  then  tried  in  twelve 
cases  and  was  uniformly  successful.  It  was  usually 
necessary  to  continue  the  treatment  for  three  weeks, 
after  which  time  the  children  were  able  to  return  to 
their  former  sleeping  position  without  relapsing.  The 
writer  has  found  it  unnecessary  to  have  recourse  to  the 
time  -  honored  measures  of  limiting  the  amount  of 
liquids,  frequent  waking  up  during  the  night,  etc.  The 
chief  difficulty  about  the  treatment  is  to  see  that  the 
children  maintain  the  position  throughout  the  night. 
Small  children  particularly  are  apt  to  wiggle  and  toss 
about  and  have  to  be  watched,  put  back  in  position, 
etc.  The  method  is  therefore  especially  adapted  to 
older  children,  in  whom  the  position  can  be  more  eas- 
ily maintained.  This  method  is  certainly  so  simple 
and  apparently  so  reasonable  as  to  merit  extended 
trial,  especially  as  the  time-honored  methods  of  treat- 
ing this  pernicious  habit  are  in  so  many  cases  unsuc- 
cessful. It  will  be  rather  interesting  if  the  elevation 
of  the  pelvis,  which  Trendelenburg  introduced  into  ab- 
dominal surgery,  and  which  has  so  extended  and  facil- 
itated work  in  that  field,  should  also  prove  of  service 
in  preventing  children  from  wetting  the  bed. —  The 
Boston  Medical  and  Surgical  Journal. 

The  Treatment  of  Acute  Rheumatic  Endocarditis. — 
In  the  Liverpool  Medico-Cliirurgical  Journal,  July, 
1S95,  Dr.  Richard  Caton  gives  the  results  of  a  definite 
inquiry  pursued  for  thirteen  years  concerning  acute 
rheumatic  endocarditis  and  its  treatment.  Upward  of 
three  hundred  cases  of  acute  and  subacute  rheumatism 
came  under  close  observation  in  the  hospital  ward,  a 
certain  proportion,  perhaps  one  in  three  or  four,  devel- 
oping cardiac  difficulty.  The  usual  history  is  that  the 
patient  leaves  the  hospital  cured  of  rheumatism,  but 
with  a  maimed  lieart  that  causes  much  suffering  and 
shortens  life.  The  great  questions  are  :  How  can  en- 
docarditis be  prevented  during  acute  rheumatism  ? 
And  what  treatment  during  its  incipient  stage,  when  it 


November   23,  1895] 


MEDICAL    RECORD. 


749 


occurs,  best  favors  recovery  '  To  answer  these,  the 
recorded  experience  of  Europe  and  America  was  care- 
fully consulted.  The  opinion  of  modern  writers  proved 
highly  conflicting,  Xiemeyer  and  Osier  holding  all 
measures  preventative  or  curative  as  practically  use- 
less :  while  Sibson  and  others  pointed  out  the  value  of 
absolute  and  protracted  rest,  both  as  prophylactic  and 
as  an  aid  in  the  cure  of  incipient  endocarditis. 

Treating  the  rheumatic  trouble  bv  salicvlates  and 
doing  practically  nothing  for  the  heart   inflammation 
gave  such  poor  results  that  in  i88s  a  definite  plan  of 
treatment  was  adopted  in  all  cases,  with  a  view  of  pre- 
ventmg  endocarditis  if  possible,  and  mitigating  its  se- 
venty  when    present.      As    the  outcome    of   the    new 
measures,  twenty-nine  out  of  thirty-nine  cases  left  the 
hospital  well  and  with  normal  heart-sounds.     Ten  were 
less  fortunate  and  were  discharged  with  a  bruit  pres- 
ent.    These  results  are  so  good  that  Dr.  Caton  fears 
his  readers  may  fail  to  accept  it  altogether,  thinking 
that  perhaps  mistake  or  error  has  crept  in  somehow. 
^  et  such  is  not  the  case,  to  the  best  of  his  knowledge 
and  belief.     The  method  in  brief  is  this  :  Prolonged 
absolute  rest  in  bed,  the  bodv  clothed  in  flannel  gar- 
ments only,  a  milk  diet,  gentle  cholagogues,  salicylates 
m  such  measures  as  the  disease  seems  to  demand,  and 
small  blisters  followed  by  poultices  in  any  joint  where 
pain   fails  to  yield.     When  an  abnormal'  heart-sound 
IS  heard,  even  simple  "  woolliness  "  of  sound,  or  what 
the  French  call  assourdissement,  ten  grains  of  potassiun^ 
or  sodium  iodide  are  given  three  times  a  day  in  additior 
to  the  salicylates,  and  a  blister  about  the  size  of  a  florii 
IS  placed  over  the  ape.x  of  the  heart.     As  soon  as  tht 
irritation  of  this  blister  is   subsiding,  a  second  is  ap 
plied  close  to  it,  then  a  third,  and  so  on,  the  patient 
being  kept  perfectly  quiet  and  strictlv  forbidden  ali 
exertion  and    exposure.     The   blisters 'occasion    little 
or  no  discomfort.     The  heart  is  examined  daily.     In  a 
week  or  ten  days  there  is  a  gradual  subsidence  of  the 
murmur  :  day  by  day  it  is  less  distinct  and  then  is  en- 
tirely absent.     Sometimes  several  weeks  will  elapse  be- 
fore this  desirable  change  is  established.     Prolonged 
rest  IS  an  important  factor  in  bringing  it  about.     The 
thirty-nine  cases   thus   treated  were,  on   the  average, 
forty-one   days  in  the   hospital,  and  confined  to  bed 
thirty-five  or  thirty-six  days. 

How  does  the  blister  act  ?  Not,  surely,  on  the  old- 
tashioned  theory  of  so  called  counter-irritation.  Or- 
gans situated  some  distance  beneath  a  small  blister  can 
be  affected  solely  through  the  nervous  system,  and 
acted  upon  through  reflex  centres.  If  a  cutaneous 
nerve  is  stimulated,  nerve-cells  in  the  spinal  and  sym- 
pathetic centres  are  influenced  and  the  impressio'n  is 
reflected  to  the  visceral  branches.  It  may  be  said  that 
this  IS  a  mere  theory.  But  it  is  a  theory  which  explains 
many  things.  It  explains  the  fact  that  a  slight  chilling 
of  the  skin  of  the  thorax  may  cause  pneumonia  and 
bronchitis  ;  that  a  splash  of  cold  water  will  e.xcite  res- 
piration in  the  infant,  or  set  agoing  the  action  of  the 
heart  during  a  faint.  The  nervous  system  consists  of 
a  series  of  segments  arranged  in  a  line,  corresponding 
to  the  various  somites  of  the  body.  Each  nerve-sesT- 
ment  governs,  to  some  extent,  the'  nutrition  of  its  own 
somite,  alike  as  regards  epi-,  meso-,  and  hypo-blastic 
structures.  In  a  previous  paper,  read  before  the  Physi- 
ological Society  at  Oxford,  the  author  thinks  he  proved 
his  theory  by  demonstrating  the  fact  that  stimulation 
of  the  surface  skin  alters  the  diameter  of  the  arterioles 
in  the  lung,  and  causes  variation  in  the  electrical  con- 
ditions of  the  thoracic  and  abdominal  organs,  as  mani- 
fested by  the  galvanometer.  Stimulation  of  the  skin 
of  the  abdomen  by  heat,  by  chemical  irritation,  by 
faradism,  or  by  mechanical  irritation,  produces  in- 
stantly a  variation  in  the  electrical  potential.  The 
subject,  occupying  many  months  of  hard  work  in  the 
laboratory,  is  too  extensive  to  be  made  clear  in  the 
space  of  a  few  lines.  Turning  to  more  familiar  evi- 
dence, few  persons  will  deny  the  soothing  effect  of  a 


poultice  in  bronchitis,  nor  can  any  one  explain  it  satis- 
factorily in  any  other  manner  than  the  one  just  stated. 
Inflammation  is  impaired  vitality.  This  impaired  or 
perverted  vitality  exists  in  the  tissues  of  the  heart  when 
rheumatic  endocarditis  is  set  up.  A  temporary  stimu- 
lus is  applied  by  reflex  means  to  the  trophic  nerves  of 
the  heart,  helping  nature  to  overcome  the  defective 
action.  That  is  the  theory  on  which  this  treatment  by 
blistering  is  based.  The  assisted  natural  powers  suc- 
ceed, where,  if  unstimulated,  they  would  fail. 

Senile  Epilepsy  and  Griesinger"s  Symptom  of  Basilar 
Thrombosis.— In  the  Zdtschrift  f.  klinisch.-  Med..  Bd. 
:;S,  Dr.  Naunyn  reports  some  interesting  cases  of 
i^"i'f.5El'^Ewl;..  ■^Pil^J",!?.^^^ u'lk^  .i""^  especially  com- 
addicted  to  the  tobacco  habit.  To  them  tobacco  is 
not  a  relaxation  after  a  day's  work,  but  a  nerve  stimu- 
lant which  enables  them  to  accomplish  tasks  which 
would  othenvise  be  difficult  of  accomplishment.  Not 
infrequently,  too,  when  the  mouth  becomes  parched  as 
the  result  of  continuous  smoking,  recourse  is  had  to 
alcohol  in  some  form  or  another  to  give  a  further  fillip 
while  enabling  him  to  tolerate  still  another  cigar  or  two. 
Under  these  circumstances  tobacco  acts  as  a  cerebral 
irritant,  and  interferes  with  the  vasomotor  centres  of 
the  brain  to  such  an  extent  that  the  vessels  are  unable 
to  adjust  themselves  forthwith  to  the  condidon  re- 
quired for  healthy  and  untroubled  sleep.  Every 
smoker  is  familiar  with  the  fact  that  a  change  of 
tobacco  or  an  unusually  strong  cigar  is  apt  to  keep 
one  awake  at  night,  and  this  tendency  is  accentuated 
when  smoking  is  an  aid  to  work  and  not  a  mere  pastime. 
The  same  remark  applies  to  alcohol  when  it  is  used  as  a 
stimulant.  The  real  cause  is  often  overlooked,  and 
drugs  are  employed  where  a  change  of  habit  ought  to  be 
insisted  upon.  Attention  to  the  ordinary  rules  of  "  to- 
bacco hygiene  "  would  save  many  from  this  distressing 
condition  of  chronic  insomnia.  Smoking  early  in  the 
day  should  be  discountenanced,  and  it  is  equally  un- 
desirable within  an  hour  or  so  of  retiring  to  rest.  The 
best  remedy  for  the  tobacco  habit,  short  of  total  absten- 
tion, is  to  take  a  short  walk  in  the  open  air  after  \\>f 
•^^coiittv  a.i..7j  uuitruction.  i\aunyn  trunks  the  spon- 
taneous attacks  in  his  three  pauents  were  due  to 
cerebral  anremia,  occurring  from  the  deficient  supply 
of  blood  to  the  brain  that  is  caused  by  arterial  sclerosis 
and  weak  heart-action.  Senile  epilepsy,  he  believes, 
as  a  rule,  due  to  cerebral  circulatory  disturbances  that 
have  their  origin  in  disease  of  the  heart  or  bloodves- 
sels.  Such  cases  do  not  improve  under  bromides. 
Small  doses  of  digitalis  are  to  be  preferred. 

Appendicitis  and  Rheumatism.— In  The  Lancet,  Au- 
gust  24,  1895,  Ur.  c;.  A.  Sutherland  advances  a  theory 
which,  if  true,  may  perhaps  prove  that  the  constitu- 
tional treatment  of  appendicitis  is  as  important  as  local 
and  surgical  measures.  The  vermiform  appendix  is 
rich  in  lymphoid  or  adenoid  tissue,  which  suggests  the 
possibility  of  its  being  the  centre  for  the  production  of 
leucocytes  or  lymphocytes.  Elsewhere  in  the  ali- 
mentary canal  the  importance  of  adenoid  tissue  is 
fully  recognized,  and  the  action  of  the  lymphoc)tes 
produced  there  has  been  fully  explained.  According 
to  Berry's  researches,  the  function  of  the  appendix  is. 
(i)leucocyte  producing,  and  (2)  secretory.  Leucocytes 
he  considers  useful  in  the  destruction  of  micro-organ- 
isms and  the  absorption  of  proteids.  Such  protective 
power  would  be  of  great  service,  for  processes  of  de- 
composition going  on  unchecked  in  the  ca:cal  region 
would  probably  result  in  symptoms  of  auto-intoxication 
that  woiild  be  extremely  common.  Usually  regarded 
(appendicitis)  as  a  purely  local  condition,  due  to  such 
local  causes  as  catarrh,  concretion,  cystic  dilatation, 
etc.,  the  author  thinks  it  also  quite  possible  that  the 
vermiform  appendix  may  be  acted  upon  by  poison  cir- 
culating in  the  blood  and  thus  become  acutely  or 
chronically  inflamed.  Rheumatism  may  be  such  a 
poison.     The  term  "abdominal  tonsil"  has  been  ap- 


750 


MEDICAL    RECORD. 


[November  23,  1895 


plied  to  the  appendix  ;  and  there  are  in  reality  many 
points  of  resemblance,  both  anatomical  and  pathologi- 
cal, between  the  tonsils  and  the  vermiform  appendix. 
If  the  former  constitute  the  "  first  line  of  defence  for 
the  alimentary  canal,"  the  latter  may  be  regarded  as 
the  second  line  of  defence.     Rheumatism  afflicts  ade- 
noid tissue  elsewhere.     Why  not  here  ?     While  purely 
local  or  mechanical  causes  of  appendicitis  do  exist, 
there  may  be  others.     And,  in  certain  cases,  the  path- 
ology may  be  this  :  The  presence  of  a  constitutional 
poison  producing  inflammation  of  the  lymphoid  tissue 
in  the  appendix,  depriving  it  of  its  normal  protective 
functions,  and  thus  inducing  a  condition  that  permits 
the  entrance  of  micro-organisms  and  a  resulting  septic 
neritnnitiij  nr  ^rvi^a.,.i;«:«:~ 
Xeuro-dendron,  jjroposed  by  Kolliker. 
Neura,  proposed  by  Rauber. 
Neurocyte,  proposed  by  P.  A.  Fish. 
Neure,  proposed  by  Frank  Baker. 
The  cell,  the  neuron,  and  the  dendrons,  proposed  by  Schaefler. 

The  axis-cylinder  process  has  received  the  following      1 
names :  1 

Neuron,  proposed  by  Schaeffer. 

Neuraxon,  proposed  by  Kolliker. 

Neurit,  proposed  by  Rauber.  i 

Neurite,  proposed  by  Fish. 

The    other    (protoplasmic,  etc.)  processes    have    re-      ■ 
ceived  the  names  : 

Dendrons,  or  dendrites,  proposed  by  Schaeffer. 

Dendrites,  proposed  by  His  and  Fish. 

Cellulipetal  processes,  proposed  by  Cajal  and  Van  Gehuchten.  ' 

The   committee  would   recommend    that   the   term 
axis-cylinder  process  be  still  used  in  its  long-accepted 
sense,  to  indicate  part  ■;  of  the  neuron.     Without  mak- 
ing the  recommendation  it  expresses  the  opinion  that 
some  word  like  neurite  will  probably  come  into  use  as      ; 
a   synonym   for  this  axis-cylinder  process.     The  com- 
mittee also    recommend    that    the    old    term,   "  proto- 
plasmic processes,"  continue  to  have  its  ordinary  and      , 
legitimate  use,   but   express  the   view   that  the  word      , 
dendrite  will  be  a  useful  synonym. 

Post-diphtheritic  Cardiac  Paralysis?— Dr.'  "(^rotiese 
says  that  no  case  has  yet  appeared  in  literature  where 
death  occurred  entirely  without  warning,  some  sus- 
picious symptoms  having  always  been  present  for 
twenty  four  hours  at  least.  It  attacks  boys  more  fre- 
quent than  girls,  and  is  most  common  between  the 
ages  of  six  and  fourteen.  Children  under  six  are  al- 
most never  attacked,  probably  because  in  severe  cases 
they  usually  succumb  early  in  the  disease  ;  but  adults 
are  not  altogether  exempt.  It  varies  in  different  epi- 
demics, but  occurs  also  among  sporadic  cases.  Puny 
children,  especially  the  tubercular  and  nervous,  are 
more  apt  to  be  affected  than  the  strong,  yet  in  all 
cases  it  is  preceded  by  severe  general  or  local  symp- 
toms. The  latent  stage,  that  is,  the  period  between 
recovery  from  the  local  process  and  the  appearance  of 
cardiac  symptoms,  lasts  usually  from  two  to  eight 
days,  but  may  cover  from  four  to  six  weeks,  although 
in  the  latter  case  the  cardiac  paralysis  is  the  termina- 
tion of  a  severe  general  post-diphtheritic  paralysis. 
The  reason  that  the  cardiac  appears  so  much  earlier 
than  other  forms  of  paralysis  is  due  to  the  fact  that, 
owing  to  the  delicate  mechanism  of  the  heart,  a  tiny 
lesion,  by  affecting  important  nerve-centres,  may  pro- 
duce most  serious  results  on  an  organism  already  weak- 
ened or  degenerated  by  the  diphthiretic  process.  In 
the  so-called  latent  period  a  series  of  suggestive  symp- 
toms will  not  escape  close  observation,  of  which  the 
most  important  are  great  prostration,  apathy,  somno- 
lence by  day,  sleeplessness  and  restlessness  at  night, 
increasing  dilatation  of  the  heart  with  corresponding 
changes  in  the  sounds,  alterations  in  the  character  and 
rhythm  of  the  pulse,  increased  frequency  of  respiration 
and  signs  of  pulmonary  oedema,  nausea,  more  or  less 
constant  pain  in  the  epigastrium  and  increasing  albu- 


minuria. Fever  is  never  present,  at  least  as  a  result  of 
the  cardiac  affection.  An  attack  of  syncope  announces 
that  the  disease  has  reached  its  height,  but  the  first  one 
is  rarely  fatal.  In  cases  which  recover  after  two  or 
three  anxious  days,  the  symptoms  of  stasis  due  to  car- 
diac weakness  begin  to  pass  off,  cedema  rarely  lasting 
more  than  two  weeks  ;  but  convalescence  is  very  slow, 
requiring  from  two  weeks  to  six  or  more  months. 
Permanent  lesions,  apart  from  a  mild  grade  of  hyper- 
trophy, do  not  seem  to  follow  post-diphtheritic  paraly- 
sis. The  prognosis  is  very  doubtful,  though  not 
always  fatal  ;  the  milder  the  symptoms  and  the  slower 
their  development  the  better  the  outlook.  The  ana- 
tomical lesion  may  be  a  parenchymatous  degeneration 
of  the  heart  with  interstitial  changes,  fatty  degeneration 
of  the  myocardium,  parenchymatous  and  interstitial 
degeneration  of  the  vagi  and  the  nerves  and  ganglia 
of  the  heart,  or  degeneration  of  the  sympathetic,  espe- 
cially the  ganglion  and  plexus  coeliacus.  It  is  probable 
that  death  is  due  less  to  degeneration  of  the  heart  than 
of  its  nerves  and  ganglia,  and  reflexly  to  degeneration 
of  the  sympathetic,  especially  the  coeliac  plexus. —  The 
Boston  Medical  and  Surgical  Journal. 

Recent  Advances  in  Cerebral  Surgery. — According 
to  Professor  von  Bergmann,in  cases  of  tumorof  the  brain 
surgery  has  of  late  done  very  little  beyond  facilitating  a 
correct  diagnosis,  and  rendering  operative  interference 
less  dangerous.  In  Jacksonian  epilepsy  surgical  treat- 
ment is  usually  followed  by  relapse,  and  can  effect  a 
certain  cure  only  in  those  cases  in  which  the  convul- 
'  sions  are  due  to  the  compression  of  a  circumscribed 
cortical  motor  centre  by  a  tumor,  as  for  instance,  a  cyst 
of  traumatic  origin.  On  the  other  hand,  very  decided 
progress  has  been  made  in  the  operative  treatment  of 
different  forms  of  intra-cranial  suppuration  of  otitic 
origin,  such  as  cerebral  abscess,  epidural  suppuration, 
ineffective  thrombosis  of  the  lateral  sinus,  and  lepto- 
meningitis. The  most  dangerous  forms  of  chronic 
aural  suppuration,  which  is  usually  excited  by  a  col- 
lection of  cholesteatoma  in  the  interior  of  the  ear,  are 
indicated  by  intercurrent  acute  and  subacute  attacks, 
with  fetid  discharge,  and  by  the  presence  of  polypoid 
granulations  on  the  tympanic  cavity  and  the  auditory 
meatus.  The  extension  of  the  inflammation  through  ' 
the  thin  and  carious  tegmen  tympani  sets  up  pachy- 
meningitis, which  in  its  turn  gives  rise  to  an  extra-dural 
or  epitympanic  abscess,  or  to  an  intra-dural  cerebral 
abscess.  The  cerebral  abscess,  when  small  and  in  an 
early  stage  of  development,  is  situated  at  the  surface  of 
the  brain,  but  as  it  enlarges  it  sinks  into  the  substance 
of  the  affected  lobe.  As  the  diagnosis  between  a 
superficial  and  epitympanic  abscess  on  the  one  hand, 
and  a  cerebral  abscess  on  the  other,  is  attended  with 
much  difficulty,  von  Bergmann  holds  that  it  is  necessary 
in  performing  an  operation  to  expose  to  view  both  the 
extra- dural  abscess  and  the  part  of  the  temporal  lobe 
most  likely  to  be  involved  in  the  extension  of  suppu- 
rative process.  An  operation  is  described  by  which 
the  upper  and  anterior  surfaces  of  the  petrosal  bone 
are  exposed  through  a  quadrangular  opening  made  in 
the  squamous  portion  of  the  temporal  bone,  just  above 
the  line  of  the  zygoma,  and  between  a  line  in  front 
drawn  directly  upward  to  the  sagittal  suture  from  the 
tragus  and  a  parallel  line  behind  carried  upward  from 
the  posterior  border  of  the  mastoid  process.  By  this 
wound  the  mastoid  antrum  and  cells  may  be  opened  if 
necessary,  and  the  sigmoid  fossa  be  reached.  In  con- 
clusion Bergmann  alludes  to  the  successful  results  of 
the  surgical  treatment  of  infective  thrombosis  of  the 
lateral  sinus.  Exposure  and  incision  of  the  sinus,  with 
ligature  of  the  internal  jugular  vein,  proved  successful 
in  6  out  of  13  cases  treated  by  Jansen,  of  Berlin.  These 
cases,  added  to  those  of  Macewen  and  other  surgeons, 
show  that  the  operative  treatment  resulted  in  recovery  1 
in  27  out  of  45  patients.  Thrombosis  of  the  lateral 
sinus,  it  is  pointed  out,  is  often  associated  with  extra- 


November  2^,  1895] 


MEDICAL   RECORD. 


751 


dural  abscess  on  the  roof  of  the  tympanic  cavity,  and 
in  most  cases  of  cerebellar  abscess  forms  a  communi- 
cation between  this  collection  of  pus  and  the  suppura- 
tion in  the  middle  ear.  In  exposing  the  outer  surface 
of  the  mastoid  process  and  the  bone  lying  behind  this, 
search  should  be  made  for  the  mastoid  emissary  vein. 
Not  only  is  the  orifice  a  good  guide  to  the  sinus,  but 
in  addition  the  state  of  the  vessel  may  help  the  diagno- 
sis. If  it  contains  pus,  suppuration  in  and  about  the 
lateral  sinus  is  indicated  ;  if  it  be  blocked  by  a  throm- 
bus, this  will  be  a  sure  sign  of  thrombosis  extending  to 
the  cavernous  sinus. — Centralblatt  fiir  Chirurgie. 

Extract  of  Suprarenal  Gland. — The  attention  paid 
to  tissue  extracts  lends  some  interest  to  the  recent 
physiological  researches  of  Dr.  D.  Gourfein  made  a 
series  of  experiments  in  the  therapeutic  laboratory  of 
Professor  Provost.  The  experiments  were  made  upon 
frogs,  guinea-pigs,  rabbits  and  cats.  The  investigators 
showed  that  one  could  extract  from  the  supra-renal  cap- 
sule a  toxic  substance  which  is  soluble  in  alcohol  and 
is  not  destroyed  by  heat.  This  substance  injected  un- 
der the  skin  of  animals  produces  a  constant  series  of 
symptoms.  In  mammals  it  consists  in  a  progressive 
weakness  and  dyspncea,  which  continues  until  death. 
If  respiration  is  kept  up  artificially,  death  ensues  from 
paralysis  of  the  heart.  Animals  that  can  vomit  do  so 
rapidly  after  the  injection.  The  sensorium  is  not  af- 
fected. The  principal  action  of  this  substance  is  exer- 
cised upon  the  central  nervous  system.  The  special 
point  of  interest  in  connection  with  the  investigations 
of  Dr.  Gourfein  is  the  determination  of  the  fact  that 
the  supra- renal  capsule  possesses  a  powerful  poison 
which  acts  upon  the  nervous  system,  rather  than  upon 
any  of  the  glandular  or  muscular  tissues.  In  this  con- 
nection we  may  refer  to  the  results  of  the  studies  made 
in  the  same  direction  by  Dr.  Oliver  and  Professor 
Shafer,  of  London.  They  found  that  the  supra-renal 
capsules  were  glands,  which,  like  the  thyroid,  were 
strictly  secreting  organs.  The  material  which  they 
secrete  was  an  active  principle,  which  increases  the 
tone  of  all  muscular  tissue,  and  especially  produces  this 
effect  upon  the  heart  and  arteries.  On  the  other  hand, 
they  found  that  the  removal  of  the  capsule  produces 
extreme  weakness  of  the  heart  and  muscular  system 
generally,  and  a  great  loss  of  tone  in  the  vascular  sys- 
tem— a  similar  condition  to  that  found  in  Addison's 
disease.  Their  experiments  have  been  confirmed  by 
Szymonowicz  and  Cybulsky.  Their  results,  however, 
seem  to  be  almost  identically  opposite  to  those  ob- 
tained by  the  experimenter  above  referred  to.  Dr. 
(iourfein,  however,  used  a  substance  obtained  by  a 
special  process  from  the  gland,  and  it  is  possible  that 
the  method  he  employed  had  something  to  do  with  the 
difference  in  the  results  secured. 

A  Case  of  Recovery  after  Trephining  in  Tuberculous 
Meningitis.— Dr.  James  Kerr,  of  Bradford,  England, 
reports  in  The  Lancet  the  history  of  a  tuberculous  men- 
ingitis, occurring  in  a  boy  of  ten.  The  disease  having 
progressed  to  the  stage  of  coma  in  the  course  of  the 
third  week  he  was  trephined.  An  opening  was  made 
one  inch  and  a  quarter  above,  and  the  same  distance 
behind,  the  left  auditory  meatus  ;  a  half-inch  button 
was  removed,  and  the  dura-mater  opened.  Very  little 
fluid  was  removed.     The  patient  made  a  recovery. 

Tobacco  Insomnia. — Among  the  distressing  ailments 
to  which  the  brain-worker  is  exposed  one  from  which 
no  small  proportion  of  them  suffer  is  the  inability  to 
sleep.  This  is  particularly  frequent  among  those  who 
are  called  upon  to  burn  the  midnight  oil,  to  use  the 
consecrated  phrase.  These  sufferers  complain  that 
they  feel  most  lively  just  when  the  time  has  come  to 
retire  to  rest,  and  that  a  long  period  of  restlessness 
precedes  a  troubled  slumber  from  which  the  slightest 
noise  awakens  them,  that  is  to  say,  not  only  may  to- 
bacco temporarily  prevent  sleep,  but.  short  of  that,  it 
renders  it  less  deep,  and  consequently  less  refreshing. 


The  result  of  an  inadequate  amount  of  refreshing 
sleep  is  to  render  them  irritable  and  heavy  during  the 
day,  and  the  feeling  of  lassitude  and  incapacity  for  in- 
tellectual work  is  especially  pronounced  during  the 
forenoon.  But  too  frequently  the  complaisant  practi- 
tioner counsels  recourse  to  this  or  that  narcotic  or 
hypnotic,  with  the  immediate  result  in  a  certain  pro- 
portion of  cases  of  the  formation  of  a  habit  which  not 
infrequently  culminates  in  physical  and  mental  wreck. 
A  grave  responsibility  attaches  to  those  who  lightly 
seek  to  relieve  a  symptom,  which  is  really  a  warning,  by 
recourse  to  a  dangerous  palliative.  The  inability  to 
sleep  is  often  merely  the  outcome  of  an  unnatural 
mode  of  life,  and  if  this  be  corrected  the  disability  dis- 
appears of  itself.  Men  who  work  late  are  commonly 
addicted  to  the  tobacco  habit.  To  them  tobacco  is 
not  a  relaxation  after  a  day's  work,  but  a  nerve  stimu- 
lant which  enables  them  to  accomplish  tasks  which 
would  otherwise  be  difficult  of  accomplishment.  Not 
infrequently,  too,  when  the  mouth  becomes  parched  as 
the  result  of  continuous  smoking,  recourse  is  had  to 
alcohol  in  some  form  or  another  to  give  a  further  fillip 
while  enabling  him  to  tolerate  still  another  cigar  or  two. 
Under  these  circumstances  tobacco  acts  as  a  cerebral 
irritant,  and  interferes  with  the  vaso-motor  centres  of 
the  brain  to  such  an  extent  that  the  vessels  are  unable 
to  adjust  themselves  forthwith  to  the  condition  re- 
quired for  healthy  and  untroubled  sleep.  Every 
smoker  is  familiar  with  the  fact  that  a  change  of 
tobacco  or  an  unusually  strong  cigar  is  apt  to  keep 
one  awake  at  night,  and  this  tendency  is  accentuated 
when  smoking  is  an  aid  to  work  and  not  a  mere  pastime. 
The  same  remark  applies  to  alcohol  when  it  is  used  as  a 
stimulant.  The  real  cause  is  often  overlooked,  and 
drugs  are  employed  where  a  change  of  habit  ought  to  be 
insisted  upon.  Attention  to  the  ordinary  rules  of  "to- 
bacco hygiene  "  would  save  many  from  this  distressing 
condition  of  chronic  insomnia.  Smoking  early  in  the 
day  should  be  discountenanced,  and  it  is  equally  un- 
desirable within  an  hour  or  so  of  retiring  to  rest.  The 
best  remedy  for  the  tobacco  habit,  short  of  total  absten- 
tion, is  to  take  a  short  walk  in  the  open  air  after  the 
last  pipe.  Under  no  circumstances  should  drugs  be 
recommended  for  this  form  of  nocturnal  restlessness. — 
Medical  Press. 

Cure  of  Uterine  Disease  by  Vibrations. — Dr.  Bour- 
cart  would  rcvolutitmize  uterine  therapeutics  by  ex- 
tending Brandt  and  Kelgren's  principle  of  using  manual 
vibrations  to  insure  absorption  of  inflammatory  exuda- 
tions {  The  British  Medical /ournal).  In  the  case  of  the 
uterus  instruments  are  required.  Liedbeck  has  already 
invented  a  good  apparatus  for  producing  vibrations  by 
electric  means.  In  the  case  of  the  uterus  the  vibrations 
must  be  rapid,  very  regular,  and  penetrating.  The  vi- 
brations can  be  perfectly  transmitted  through  the  abdo- 
minal walls.  Bourcart,  acting  on  the  knowledge  of 
these  facts,  has  contrived  a  portable  dynamo,  to  which 
he  fits  on  a  vibrator,  which  he  places  with  his  right 
hand  against  the  parietes.  The  uterus  is  pushed  toward 
the  parietes  by  the  left  forefinger  passed  into  the 
vagina.  In  the  same  way  the  Fallopian  tubes  and 
ovaries  may  be  pressed  in  the  direction  of  the  vibrator. 
Bourcart  declares  that  subinvolution  is  particularly 
benefited  by  the  vibration  treatment.  In  metrorrhagia 
from  fibroids  it  is  equally  useful ;  the  tumor  may  even 
diminish  in  size  under  a  course  of  this  treatment.  He 
treats  endometritis  by  vibrations  transmitted  by  means 
of  a  specially  constructed  stem,  but  he  admits  that 
further  study  of  this  new  variety  of  uterine  therapeutics 
is  required. 

Mixed  Infection  in  Phthisis. — At  the  close  of  a  paper 
on  this  subject  Eisner  draws  the  following  conclu- 
sions {The  Boston  Medical  and  Surgical  Journal): 
I.  Tubercle  bacilli  can,  without  the  presence  of  added 
bacterial  infection,  cause  changes  in  the  lung,  giving 
rise  to  symptoms  of  acute  pneumonia  in  chronic  or 


752 


MEDICAL    RECORD. 


[November  23,    1895 


latent  phthisis,  which  cannot  be  differentiated  without 
bacteriological  examination  from  non- tuberculous  pneu- 
monia. 2.  Concurrent  infection  in  tubercular  phthisis 
modifies  very  materially  the  course  of  the  disease,  giv- 
ing rise  to  many  acute  exacerbations  and  anatomical 
changes  ;  hence  the  conclusion  is  justified  that  the 
clinical  picture  of  the  disease  is,  as  a  rule,  complex. 
The  double  infection  must  be  taken  into  account  when 
indications  for  treatment  are  considered.  3.  An  acute 
croupous  pneumonia  can  attack  lung  tissue,  the  seat  of 
tuberculous  infection,  or  run  its  course  in  any  part  of 
the  healthy  or  diseased  lung.  As  a  rule,  the  tubercu- 
losis, if  latent,  is  lighted  into  activity.  4.  Aspiration 
from  cavities  of  streptococci  or  other  bacteria  may  give 
rise  to  acute  pneumonia,  a  streptococcus  pneumonia. 
Early  and  profuse  haemoptysis  is  present  in  a  majority 
of  these  cases.  5.  Mi.xed  infection  in  pulmonary 
tuberculosis  is  an  important  factor  in  lowering  vitality 
and  the  resistance  of  the  patient ;  all  septic  and  pyse- 
mic  processes  arising  in  the  course  of  tuberculous  dis- 
ease may  be  traced  to  it.  6.  The  differential  diagnosis 
of  tubercular  pneumonia  is  ofttimes  made  with  great 
difficulty.  In  all  cases  bacteriological  examination  must 
be  made  repeatedly,  and  culture  experiments  add  to 
the  refinement  of  such  diagnoses.  Without  repeated 
microscopic  and  bacteriological  examinations  it  is  im- 
possible to  determine  the  pathological  significance  of 
the  innumerable  exacerbations  of  pulmonary  tubercu- 
losis. 

Spengler  has  endeavored,  in  fifty  cases,  by  means  of 
bacteriological  examinations  of  the  sputum  and  care- 
fully conducted  autopsies,  both  from  the  bacteriologi- 
cal and  anatomical  stand-point,  as  well  as  by  a  careful 
comparison  of  their  clinical  histories,  to  get  some  ex- 
planation of  the  different  types  in  which  phthisis  mani- 
fests itself.  As  a  result  he  arrives  at  the  following 
conclusions  :  i.  In  tubercular  phthisis  only  a  small 
percentage  of  the  cases  are  uncomplicated  cases  of 
tuberculosis  of  the  lungs.  If  fever  is  present  in  the.se 
pure  cases,  the  extent  of  the  mischief  is  much  greater 
than  the  physical  examination  would  lead  one  to  sup- 
pose, and  the  prognosis  is  unfavorable.  They  become 
still  more  unfavorable  in  case  a  mixed  infection  is 
added.  These  cases  are  adapted  to  the  tuberculin 
treatm.ent.  2.  Most  cases  of  phthisis  are  complicated 
by  a  mixed  infection  with  streptococci,  and  may  be 
classified  as  active  or  passive,  according  as  fever  is 
present  or  not.  The  prognosis  of  the  active  form  is 
good  if  it  complicates  a  local  tuberculosis,  remains  cir- 
cumscribed, and  receives  prompt  climatic  treatment. 
Other  bacteria,  as  well  as  the  streptococcus,  may  com- 
plicate tuberculosis,  such  as  Friinkel's  diplococci, 
staphylococci,  tetrageni,  influenza  and  pseudo-influenza 
bacilli,  and  others.  If  secondary  bacteria  appear  in  a 
few  colonies  only  in  several  sputum  examinations, 
fever,  if  it  be  present,  is  not  due  to  the  mixed  infection 
but  to  the  tuberculosis,  or  to  some  focus  of  infection 
other  than  the  lungs.  If  fever  is  absent  and  yet  strep- 
tococci are  found  in  considerable  abundance,  the  spu- 
tum should  be  carefully  washed  in  order  to  rid  it  of 
accidental  impurities  from  the  upper  air-passages  ;  and 
then,  if  they  still  persist,  the  presence  of  bronchiectasis 
or  cavities  ma\-  be  inferred. 

The  therapeutic  indications  are  self-evident.  Early 
diagnosis  is  essential  before  secondary  infection  has 
occurred  ;  and  the  treatment  should  be  specific,  that  is, 
with  tuberculin.  Mixed  infection  can  only  be  com- 
bated by  pure  air,  either  at  sea,  in  the  desert,  or  on  the 
mountains. 

After  the  secondary  infection  has  been  overcome, 
and  tuberculosis  alone  remains,  tulierculin  is  again 
indicated.  Huguenin  arrives  at  similar  conclusions, 
and  says  that  the  prevalent  idea  that  patients  with 
fever  are  not  fitted  for  high  altitudes  is  radically 
wrong,  as  it  is  those  cases  with  pus-infection  in  the 
lungs  and  secondary  fever  who  are  fitted  for  that,  and 
only  that. 


Curative  Treatment  of  Puerperal  Infection. — Dr. 
Pinard  states  that  the  new  therapeutics  of  puerperal 
infection  comprise  three  methods  of  treatment  well 
known  :  intra  uterine  intermittent  irrigation,  continued 
irrigation,  and  curettage.  These  methods  have  been 
employed  separately  or  combined,  according  to  the 
exigencies  of  the  case.  (  The  Medical  Press/)  Inter- 
mittent irrigation,  first  employed  by  Recolin  and  Lev- 
ret,  and  recommended  by  Gensoul,  Roche,  and  Lemuel 
Weiss,  in  r858,  has  become  current  treatment,  especi- 
ally since  Pasteur  revealed  the  true  nature  of  infection. 
For  the  purpose  Professor  Pinard  uses  the  glass  sound 
of  Fariner,  which  is  very  easy  to  introduce,  and  when 
ordinary  precautions  are  taken,  cannot  break.  The 
antiseptic  liquid  he  employs  is  a  solution  of  biniodide 
of  mercury  (1-4,000)  at  103°  F.  Being  a  partisan  of 
low  pressure,  he  places  the  reservoir  containing  the 
liquid  for  injection  only  ten  inches  above  the  level  of 
the  patient,  as  in  this  manner  the  liquid  cannot  pene- 
trate into  the  veins,  or  the  uterine  sinuses.  The 
amount  injected  generally  exceeded  three  quarts,  or 
until  the  liquid  returned  is  quite  clear.  Continued 
intra- uterine  injections  is  entirely  of  French  origin,  but 
to  a  German,  Schiicking,  of  Halle,  is  due  the  honor  of 
being  the  first  to  apply  it  to  obstetrics.  Since  1885 
Professor  Pinard  has  employed  it  frequently  in  his 
service.  The  method  of  operating  is  about  the  same 
as  in  the  first  case,  but  the  sound  is  made  of  metal,  as 
the  glass  might  break.  The  antiseptic  liquids  are  :  A 
solution  of  biniodide  of  mercury  (1-4,000)  ;  a  solution 
of  phenic  acid  (i-ioo)  ;  a  saturated  solution  of  boric 
acid.  Fifteen  quarts  of  the  first  solution  are  injected, 
and  followed  by  the  second,  and  as  soon  as  the  temper- 
ature of  the  patient  has  come  down  to  the  normal  it  is 
replaced  in  its  turn  by  the  third.  Objections  have 
been  made  against  this  method,  not  only  as  regards 
the  difficulty  of  adopting  it  in  private  practice,  but  also 
as  regards  the  fact  of  leaving  a  sound  a  demeure  for  days 
and  nights,  which  might  produce  an  accident  by  the 
movements  of  the  patient.  M.  Pinard  considers  that 
such  a  danger  could  only  be  feared  where  the  instru- 
ment was  not  properly  fixed  to  the  patient.  In  any 
case  he  never  witnessed  the  slightest  accident  in  all 
the  cases  he  had  tried  it.  The  operation  of  curettage  \ 
followed  by  Pinard  differs  but  slightly  from  that  usu- 
ally practised,  with  the  exception  of  the  absence  of  an- 
aesthetics and  the  non  employment  of  the  speculum. 
As  to  the  former,  M.  Pinard  considers  it  both  needless 
and  dangerous — needless  because  the  pain  produced 
by  the  operation  is  very  slight,  and  dangerous  because 
in  post-partum  curettage  the  hemorrhage  is  frequently 
abundant  under  anaesthetics.  In  concluding,  Pinard 
said  that  it  was  admitted  by  all  that  no  physiological 
phenomenon  produces  a  rise  in  the  temperature 
throughout  the  course  of  a  normal  confinement,  and 
for  this  reason  any  increase  should  put  the  attendant 
on  his  guard  against  the  invasion  of  septic  matter. 
Consequently,  in  every  lying-in  woman  who  presented 
within  the  six  days  following  the  delivery,  a  rise  in 
temperature,  puerperal  infection  should  be  suspected 
and  treated  accordingly.  A  temperature  of  101°  F.  in 
the  axilla  was  a  certain  indication  for  intra-uterine  in- 
jections. If  after  a  second  injection  the  temperature 
continued  to  rise,  continued  irrigation  or  curettage 
should  be  substituted.  The  latter  operation  should 
not  in  any  case  be  done  until  three  days  have  elapsed  • 
since  the  delivery. 


i 


Septic  Surgery. — We  have  left  unwashed  those  things 
which  we  ought  to  have  washed,  and  we  have  handled 
those  things  which  we  ought  not  to  have  handled,  and 
there  is  no  health  in  us. 

Opium  Eaters,  in  India,  average  from  four  to  twelve 
grains  of  tiic  drug  per  day. 


November  23,    1895] 


MEDICAL   RECORD. 


753 


Cotrespontlence. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 
THE  women's    petition     TO    THE    COLLEGE    OF    PHYSI- 
CIANS  DR.  BUZZ.IRD's   address CLINICAL  SOCIETY 

MEDICAL  SOCIETIES  OF  LONDON THE  CASE  OF  DR. 

R.     B.     ANDERSON— DEATH     OF     INSPECTOR-GENERAL 

SIR     WILLIAM    MACKENZIE,    K.C.B.,    ETC.  HOSPITAL 

SUNDAY  FUND — DR.  BARRY,  THE  FEMALE  ARMY  SUR- 
GEON  ANTI-TOBACCOXISTS  ON  HEALTH. 

London,  November  i,  1895, 

The  women  have  made  an  assault  on  the  Royal  Col- 
lege of  Physicians,  the  oldest  of  our  corporations,  and 
came  within  view  of  victory.  The  form  of  attack 
adopted  was  a  petition  from  the  staff  of  the  .School  of 
Medicine  for  Women  to  recognize  the  institution  and 
admit  its  students  to  examination.  The  petition  was 
also  signed  by  the  staff  of  the  Royal  Free  Hospital,  at 
which  these  students  receive  their  clinical  instruction. 
Further,  a  great  array  of  influential  names  was  appended. 
Before  the  meeting  to  consider  it,  a  counter- statement 
was  got  up  by  some  of  the  fellows  and  signed  by  some 
most  influential  opponents.  This  is  rather  piquant 
considering  the  secrecy  in  which  the  ancient  college 
has  usually  tried  to  shroud  its  proceedings.  There 
was  a  serious  discussion  on  the  subject,  but  several  of 
the  speakers  addressed  themselves  to  the  question 
whether  medicine  was  a  suitable  calling  for  woman, 
rather  than  that  before  the  meeting,  which  was,  whether 
the  college  should  follow  the  e.xample  of  several  other 
bodies  and  open  its  doors  to  both  sexes.  The  former 
question  will  settle  itself,  for  there  are  now  some  two 
hundred  female  physicians  among  us,  and  if  the  calling 
should  prove  unsuitable  or  in  opposition  to  public  opin- 
ion, another  generation  will  determine.  As  to  the  second 
question,  fears  were  expressed  that  if  admitted  to  the 
licentiateship,  these  "  new  women "  would  aspire  to 
membership,  then  to  the  sacred  order  of  fellowship,  and 
perhaps  ultimately  grasp  —  horrilnlc  Jutii  —  the  presi- 
dency itself. 

The  college,  as  the  oldest  body,  may  fairly  hesitate 
to  follow  the  lead  of  some  of  the  more  advanced  cor- 
porations. It  has  interests  and  traditions  to  consider 
and  respect,  and  there  are  internal  changes  which  are 
far  more  urgent  to  enable  it  to  retain  its  position. 
Some  eighteen  years  ago  the  question  was  discussed, 
but  the  changes  since  then  have  altered  the  circum- 
stances. There  is  now  no  difficulty  in  the  way  of 
women  obtaining  registerablc  diplomas,  and  admission 
to  one  more  would  do  nothing  to  determine  their  right 
to  study  medicine.  The  men  may  therefore,  without 
any  injustice,  retain  to  themselves  some  of  their  insti- 
tutions. The  vote  has  been  a  surprise  to  both  sides. 
One  hundred  and  nine  fellows  took  part  in  it,  and  of 
these  fifty  voted  in  favor  of  the  admission  of  the  other 
sex  and  fifty-nine  against  ;  a  majority  of  only  nine  for 
the  stains  i/no  is  a  surprising  event,  and  the  women  re- 
gard it  as  a  great  victory.  On  a  former  occasion  tlie 
votes  were,  I  think,  fifty  to  thirty-six,  so,  it  looks  as  if 
the  trend  of  opinion  was  in  favor  of  the  women. 

Next  week  the  question  will  come  before  the  annual 

meeting  of  the  College  of  Surgeons,  and  we  shall  see 

whether  the  members  will  attend  in  sufficient  force  to 

represent  fairly  the  o])inion  of  the  working  practitioners, 

who  are  threatened  with   the  (:omi)etition   of  women, 

for  it  is  to  be  remembered  the  late  meeting  consisted 

I  only  of  consultants.     At  tlie  coming   one  of   the  sister 

college  those  in  general  i)ractice  have  the  suffrage. 

Dr.  Buzzard  delivered  liis  address  to  the  Clinical  So- 

this  day  week.     He  glanced  at  the  great  change 

'  has  taken  place  since  the  establishment  of  the  So- 

>  t)  twenty-eight  years  ago,  when  the  first  president's 

'lid less  did  not  hint  at  the  investigation  of  diseases 


with  a  view  to  their  prevention  as  appropriate  work  for 
such  a  society,  but  was  occupied  chiefly  with  the  ad- 
ministration of  remedies.  The  change  brought  about 
may  be  said  to  be  largely  due  to  the  researches  of  Pas- 
teur and  the  patient  work  of  Lister.  As  an  application 
of  the  scientific  method  the  president  naturally  men- 
tioned what  has  been  done  in  myxoedema,  for  the  work 
has  been  largely  identified  with  the  Society.  Other 
examples  named  were  the  great  number  of  cases  of 
paralysis  and  convulsive  diseases  now  known  to  depend 
on  syphilis,  and  the  recognition  of  the  influence  of 
alcohol  in  causing  a  form  of  [jrogressive  jjaralysis.  In 
reference  to  micro-organisms  he  remarked  that  in  dis- 
eases of  the  nervous  system  the  infective  origin  of 
hydrophobia,  tetanus,  leprosy,  and  diphtheritic  paraly- 
sis admitted  no  reasonable  doubt,  and  he  suggested  as 
a  field  of  inquiry  the  possible  dependence  of  some 
chronic  nervous  diseases  upon  infection.  Infantile 
paralysis,  from  the  occurrence  of  epidemics,  he  had 
little  doubt,  was  infective,  and  perhaps  the  form  of 
progressive  muscular  atrophy,  in  which  the  lesion  occu- 
pied the  same  anatomical  position,  might  have  a  similar 
origin.  Insular  cerebro-spinal  sclerosis  probably  was 
another  example,  as  to  chorea  and  some  forms  of  epi- 
lepsy the  suggestion  was  only  a  conjecture  at  present, 
but  one  worthy  of  investigation.  The  supposed  hered-^ 
ity  of  Friedreich's  ataxy  and  other  family  diseases 
might  be  open  to  the  doubts  some  express  respecting 
tuberculosis  and  cancer.  The  subject  must  be  con- 
sidered from  its  clinical,  bacteriological,  and  chemical 
aspects,  and  no  society  was  better  qualified  to  pursue 
the  investigation. 

After  the  address  there  was  a  paper  on  a  rare  form 
of  contagious  impetigo,  and  one  detailing  three  success- 
ful cases  of  pleural  effusion  treated  by  early  e.vcision. 
The  latter  gave  rise  to  some  discussion  as  to  whether 
paracentesis  would  not  have  been  sufficient.  Mr.  Park- 
er gave  the  history  of  a  case  of  excision  of  the  patella 
for  primary  sarcoma,  recorded  in  the  "  Transactions  " 
(vol.  XX.).  The  girl,  aged  eighteen,  continued  well  for 
three  years,  when  recurrence  took  place.  Another  op- 
eration was  done,  and  three  years  more  of  freedom  ob- 
tained. Then  new  growth  in  the  lymphatic  glands  deep 
in  the  pelvis  occurred,  and  an  attempt  to  remove  them 
was  onlypartially  successful,  and  death  from  exhaustion 
followed  in  a  few  weeks. 

.V.t  the  Medical  Society,  on  Monday  last,  the  battle  of 
buttons  and  bobbins  in  intestinal  operations  was  waged 
with  some  energy.  One  speaker  objected  to  all  "artifi- 
cial contrivances,"  a  rather  large  objection  for  a  sur- 
geon. Another  repeated  the  stale  joke  that  we  all  had 
.Murphy's  buttons  in  our  mouths,  and  should  soon 
have  them  in  our  intestines.  Another  remarked  that 
the  results  in  the  cases  brought  forward  were  no  better 
than  those  obtained  by  the  older  method  in  much 
graver  conditions,  such  as  gangrenous  gut  in  hernia. 
Another  deprecated  the  importance  attached  to  rapid- 
ity in  operating. 

The  case  of  Dr.  R.  B.  Anderson  has  gone  through 
another  step,  though  I  am  afraid  not  one  in  advance. 
He  endeavored  to  get  the  High  Court  to  pronounce 
that  its  former  decision  was  void,  or  at  least  voidable, 
on  the  ground  that  Lord  Ksher  was  interested  in  the 
decision  on  account  of  an  action  which  was  then  ]jend- 
ing  against  him,  and  which  would  be  influenced  by  the 
judgment  in  his  case.  The  contention  was  repudiated 
by  all  the  judges  of  the  court  as  nonsense,  and  Lord 
Lsher  suffered  himself  to  sjieak  in  terms  1  hardly  (are 
to  characterize  as  coming  from  the  bench.  He  migiit 
at  least  have  refrained  from  insulting  remarks  if  he  had 
not  the  sense  of  judicial  im]jartiality  sufficiently  strong 
to  impose  silence  on  him  in  such  a  case.  It  only  re- 
mains for  Dr.  Anderson  to  take  his  case  to  the  House 
of  Lords,  and  I  trust  the  Civil  Rights  Committee  will 
be  supplied  with  funds,  for  which  they  have  appealed 
to  the  public,  to  enable  them  to  see  him  through. 
It  is  with  great  regret  I  have  to  report   the  death  of 


754 


MEDICAL    RECORD. 


[November  23.  189; 


Sir  William  Mackenzie,  K.C.B.,  C.S.I.,  M.D.  He  died 
on  Tuesday,  last  "  full  of  days  "  and  full  of  honor.  He 
was  eighty-four  years  of  age  and  served  his  country 
well.  His  Indian  career  extended,  I  believe,  over  forty 
years,  and  of  course  he  had  long  since  retired.  His 
rank  was  Inspector-General.  I  had  the  honor  and 
pleasure  of  his  friendship,  and  regarded  him  as  one  of 
the  ornaments  of  his  profession.  In  every  society  in 
which  he  moved  he  was  the  type  of  a  perfect  gentle- 
man. Si  s/c  omnes.  Such  men  are  indeed  "  the  salt  of 
the  earth." 

The  Hospital  Sunday  Fund  has  this  year  gone  up  by 
some  ^15,000.  It  was  feared  at  first  that  the  average 
might  not  be  reached  as  some  of  the  collections  were 
known  to  have  fallen  off.  But  The  Hospital  got  up  a 
special  appeal  which  has  produced  the  noble  sum  of 
^18,000.  This  quite  eclipses  The  Lancet,  vi\v\Qk\  has 
done  so  much  for  the  fund  all  along,  but  I  am  glad  to 
see  that  no  jealousy  of  such  an  unexpected  success  has 
been  produced.  In  fact  The  Lancet\\s.s  some  very  gen- 
erous words  of  congratulation  for  its  smaller  contem- 
porary, which  though  not  exactly  a  medical  journal, 
being  devoted  to  the  interests  of  hospitals  and  chari- 
ties, and  the  special  organ  of  nurses,  is  read  by  a  good 
many  doctors.  The  editor  of  The  Hospital  is  Mr.  Bur- 
dett,  the  originator  of  the  Nurses'  Pension  Fund.  He 
is  also  one  of  the  secretaries  of  the  Stock  Exchange, 
and  no  doubt  his  city  influence  has  been  exercised  to 
help.  I  hope  now  the  administrators  of  the  Sunday 
Fund,  which  has  leaped  up  to  ^60,000  from  about 
;^42,ooo,  will  do  justice  by  putting  aside  the  ignoble 
jealousy  of  specialties  which  has  so  marred  their  valu- 
able work. 

Some  amusing  correspondence  has  lately  appeared 
respecting  the  career  of  Dr.  James  Barry,  who  served 
as  an  army  surgeon  from  1813  or  1815  to  1859,  then  re- 
tired on  half -pay,  and  died  in  1865,  when  it  was  found 
at  the  autopsy  that  the  army  surgeon,  who  had  attained 
the  rank  of  Inspector-General,  was  really  a  woman  ! 

There  have  been  other  impersonators  of  sex,  e.g., 
Chevalier  d'Eon,  but  few,  if  any,  can  have  gone  through 
all  that  Dr.  Barry  must  have  endured.  "  A  Modern 
Sphinx  "  is  the  title  of  a  novel  by  Lieutenant-Colonel 
Rogers,  whose  hero,  Dr.  Fitzjames,  is  drawn  from  the 
life  of  Dr.  Barry.  This  novel  was  reproduced  under 
tl)e  title  of  "  Madeline's  Mystery,"  and  contains  many 
anecdotes  said  to  be  true.  I  think  both  volumes  are 
out  of  print. 

The  Anti-tobacco  Society  thinks  that  smoking  in  the 
streets  should  be  put  down  by  proceeding  against  the 
offenders  under  the  health  acts  for  creating  a  nuisance. 
Surely  these  amiable  people  might  take  up  some  nuis- 
ance more  obviously  injurious  to  the  public  health. 


ONE  CAUSE  OF  ATROPHY  OF  THE  UTERUS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  your  issue  for  November  2,  1895,  p.  640,  Dr. 
Hilbert  B.  Tingley  narrates  a  case  of  atrophy  of  the 
uterus  in  a  woman,  twenty-two  years  of  age,  following 
the  birth  of  her  second  child,  and  asks  the  question, 
"  What  was  the  cause  of  the  atrophy  ?  " 

The  report  states  that  owing  to  a  uterine  hemorrhage 
on  August  26th  (fourteen  days  after  labor),  she  was 
thoroughly  curetted  under  anaesthesia  on  September 
2d,  "and  a  large  handful  of  fragments  of  placenta, 
etc.,"  was  removed.  The  most  reasonable  inference 
as  to  the  cause  of  the  atrophy  is  the  curettage  that  had 
been  resorted  to.  This  probably  was  followed  by  com- 
plete obliteration  of  the  uterine  cavity,  with  subse- 
quent atrophy  of  the  organ.  An  exactly  similar  case 
has  been  reported  by  H.  Fritsch,  in  the  Cetitralblatt 
fiir  Gyniikologie,  1894,  No.  52.  A  young  woman, 
twenty-five  years  of  age,  was  delivered  of  her  first  child 
on  January  21,  1892.     "The  puerperium  was  free  from 


fever,  but  there  was  a  continuous  discharge  of  blood. 
A  consultant  advised  a  curettage,  which  was  carried 
out  under  anaesthesia  by  the  attending  physician  on 
February  24,  1892.  The  husband  stated  that  he  saw 
the  doctor  remove  "a  large  piece  of  flesh,"  which  was 
quite  hard.  The  uterus  was  packed  with  gauze,  then 
hemorrhage  ceased,  and  the  patient  made  a  good  re- 
covery. But  since  then  she  had  not  menstruated  and 
had  remained  sterile.  She  was  perfectly  healthy,  had 
no  symptoms  save  the  amenorrhea  and  sterility.  On 
examination  the  vaginal  portion  of  the  cervi.x  was 
found  entirely  gone,  there  being  only  a  small  opening 
in  the  vaginal  vault.  It  was  impossible  to  pass  the 
finest  sound  through  this  into  the  uterus,  which  on  bi- 
manual examination  was  found  to  be  very  much  atro- 
phied. Fritsch  made  an  attempt  to  bore  an  opening 
into  the  uterus,  but  failed.  These  cases  are  instruc- 
tive, and  must  serve  as  a  warning  that  during  the  period 
of  post-puerperal  fatty  degeneration  of  the  uterine  tis- 
sues a  vigorous  curettage  may  be  followed  by  very  seri- 
ous consequences. 

Hiram   N.  Vikeberg,  M.D. 

127  East  SixTv-FiRST  Street.  November  4,  1895. 


"  BACTERIOLOGICAL    DIAGNOSIS." 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  July,  1894,  I  had  occasion  to  complain  to  the 
Health  Department  that  cultures  were  being  taken  by 
their  inspectors  from  typical  cases  of  diphtheria  where 
no  useful  end  could  be  gained  by  so  doing.  I  com- 
plained of  the  danger  to  a  very  weak  and  nervous 
child  of  having  a  strange  doctor  insert  the  swab  and 
make  the  necessary  examination  to  secure  reliable  cult- 
ures. 

In  doubtful  cases  it  was  suggested  by  me  that  the  at-     1 
tending  physician  would,  for  his  own  protection,  send  in     ' 
the  culture-tube  ;  to  make  a  cultivation  from  a  typical 
case  was  only  finding  work  for  inspectors,  and  expos- 
ing cases  to  a  serious  and  unnecessary  risk. 

Dr.  Edson  immediately  replied  :  '  The  matter  will 
be  thoroughly  investigated  at  once.  I  consider  the 
point  made  by  you  an  excellent  one."  I  believe  some 
time  since  there  was  a  motion  adopted  by  the  Board 
of  Health  that  employees  were  not  to  interfere  with 
private  cases  unless  for  unavoidable  reasons,  which 
would  be  in  the  same  lines  as  my  suggestion. 

I  had  occasion  to  report  two  cases  of  diphtheria,  No- 
vember 5th,  and  was  e.xcessively  annoyed  to  find  cult- 
ures had  been  taken  from  the  two  patients  on  Novem- 
ber 7th.  Both  were  typical  cases  that  there  could  be 
no  shadow  of  doubt  regarding  diagnosis. 

Imagine  my  amazement  at  receiving  a  report,  "  Lab- 
oratory No.  7,705,"  saying  "  the  case  did  not  admit  of 
an  exact  bacteriological  diagnosis  as  the  inoculation 
was  made  at  so  late  a  period  of  the  disease."     The  case    , 
was  about  forty-eight  hours  old,  and  the  pharynx  is    1 
now  (three  days  after  taking  culture)  covered  with  e.\- 
udate.      The  other  report,    "Laboratory  No.    7,729,"    J 
said  :  "  Bacilli  present,  slightly  resembling   diphtheria 
bacilli,  not   sufficiently  characteristic  for  positive  iden-    \ 
tification  ;  a  prompt  confirmatory  culture  is  requested." 
This  could  not  be  furnished  as  the  infant  died  from  ex-    , 
haustion  before  receipt  of  request.     This  case  was  not 
twenty-four  hours  old  when  culture  was  taken.     Both 
cases  were  very  severe  in  local  and  constitutional  symp- 
toms, and  typical  cases  of  diphtheria. 

The  question  occurring  to  me,  and  which  must  sug- 
gest itself  to  all  general  practitioners  is  this  :  If  we  can- 
not get  a  correct  and  definite  report  in  a  typical  case, 
how  can  we  rely  on  the  report  in  a  doubtful  case  ?  I 
have  frequently  had  reports  on  cultures  from  the 
Health  Department  Laboratory  where  the  clinical 
symptoms  did  not  bear  out  the  bacteriological  report ; 
but  this  is  the  first  time  it  has  been   clearly  demon- 


November  30,  1895] 


MEDICAL    RECORD. 


76: 


A  CONTRIBUTION  TO  THE  STUDY  OF  THE 
NATURE,  CAUSE,  AND  TREATMENT  OF 
SUSPENDED  ANIMATION  IN  THE  NEW- 
BORN.i 

By  J.    DOUGAL    BISSELL,  M.D., 


ATTENDING  PHYSICIAN  ' 


DISPENSARY. 


The  age  of  empirical  medicine  has  passed,  and  we 
live  to-day  in  an  era  which  demands  experimentation 
as  the  foundation  of  all  theories  and  doctrines.  "  The 
truly  scientific  investigator  is  an  analyst  and  purist 
who  seeks  to  establish  the  values  of  single  in  place  of 
combined  forces."  He  searches  for  the  hidden  laws 
of  nature  where  alone  he  believes  truth  to  dwell,  and 
accepts  only  that  which  is  demonstrable.  History 
tells  of  but  few  men  living  before  the  sixteenth  century 
who  sought  to  unravel  the  complex  problems  of  disease 
through  the  study  of  the  laws  governing  the  body  in 
health.-  It  was  not  until  1543  that  Vesalius^ published 
his  experiments,  which  demonstrated  the  effect  pro- 
duced upon  the  heart  when  the  Jungs  of  animals  were 
inflated  by  air.  In  1664  Robert  Hook'  introduced 
artificial  respiration,  the  principle  of  which  has  ever 
since  been  the  recognized  means  of  reviving  life  where 
suspended  animation  exists.  But  to  Marshall  Hall  we 
are  indebted  for  having  made  the  first  great  advance 
in  the  study  of  the  nature  and  cause  of  asphyxia,  one 
of  the  forms  of  suspended  animation,  and  for  having 
established  a  procedure  for  inducing  artificial  respira- 
tion superior  to  any  previously  suggested.'  While  his 
researches  greatly  advanced  our  knowledge  upon  the 
subject,  yet  we  are  also  indebted  to  many  other  ob- 
servers, and  to  some  even  before  his  time,  for  valuable 
suggestions  regarding  resuscitation.  In  1S24  Dewees 
described  a  plan  of  extreme  value,  which,  unfortu- 
nately, has  not  received  until  of  late  much  considera- 
tion. He  advised  "  placing  the  child's  mouth  down- 
ward, and  holding  the  body  and  hips  higher  than  the 
head  .  .  .  renew  the  inflation  alternately."  He 
further  stated  that  "owing  to  the  tenacity  of  the  fluid 
within  the  windpipe  we  cannot  at  first  force  air  into 
the  lungs,  but  by  a  little  perseverance  we  overcome  the 
obstacle,  and  the  mucus  becomes  so  thinned  as  to  flow 
readily  from  the  mouth  and  at  once  relieve  the  child. 
This  operation  should  never  be  neglected,  nor  should 
it  soon  be  given  up,  especially  if  we  can  excite  a  few 
pulsations  of  the  heart,  or  in  the  cord.'' 

In  1883  Professor  Simpson,  of  Edinburgh,  in  dis- 
cussing a  paper  on  "  Resuscitation  of  the  New-born 
Infant,"  remarked  that  his  practice  was  to  "  first  hold 
the  infant  up  by  the  heels,  to  allow  any  fluid  to  run 
out  of  the  air-passages,  and  then  perform  artificial  respi- 
ration by  Schultze's  method.  The  danger  of  blowing 
air  into  the  lungs  was  that  the  lungs  might  be  injured 
by  the  forcible  distention."  During  the  past  year 
Prochownick  also  advocated  suspension  by  the  feet 
with  the  same  object  as  did  Dewees  and  Simpson.* 

While  it  is  a  common  practice  among  many  accou- 
cheurs of  the  present  day  who  recognize  the  value  of 
gravity  in  assisting  in  the  removal  of  mucus  from  the 
air-passages,  to  invert  the  child  for  a  few  minutes  pre- 
vious to  putting  into  execution  one  or  more  of  the  gen- 
erally accepted  methods  of  resuscitation,  yet  no  ob- 
server, to  my  knowledge,  has  advocated  the  persistence 
of  this  procedure  without  the  aid  of  any  other  method, 
and  with  the  principal  object  in  view  of  encouraging 
circulation  and  thereby  inducing  respiration. 

'  Read  by  invitation  before  the  Obstetric  Section  of  the  New  York 
Academy  of  Medicine  May  »3,  1895. 

■'  In  IhK  Appendix  to  the  last  scientific  address  of  Dr.  A.  L.  Loomis, 
entitled  The  Influence  of  Animal  Experimentation  on  Medical  Sci- 
ence, there  will  be  found  a  full  account  of  the  experiments  con- 
ducted by  Aristotle,  G.ilen,  Vesalius,  Hook,  and  others. 

=  Andrea  Vcsalii  :  De  Huinani  Corporis  Fabrica.  Lib.  Septem,  De 
Vivorum  Sectione.       '  Philosophical  Trans.,  London,  No.  28,  p.  S39- 

'  Marshall  Hall  on  Asphyxia:  its  .Nature  and  Remedy.  Published 
January,  1894.  "  Dewefs  :  System  of  Midwifery,  p   195. 

'  American  Journal  of  Obstetrics.  June,  1893,  p.  636. 

»  Centrablatt  fUr  GynUkologie,  1894,  No.  10. 


Among  recent  observations  upon  the  subject  of 
asphyxia  neonatorum,  those  made  by  Dr.  Alexander 
Morrison  are  perhaps  of  the  most  interest  and  impor- 
tance. In  an  article  published  February  24,  1894,'  he 
describes  this  condition  as  being  a  disease  of  the  circu- 
latory and  not  of  the  respiratory  system.  The  conclu- 
sion I  arrived  at  from  the  study  of  the  cases  herein 
cited  is  practically  the  same,  though  reached  by  an 
entirely  different  line  of  reasoning,  and  entirely  inde- 
pendent of  any  knowledge  of  his  work.  His  views 
upon  the  important  relation  which  the  ductus  arterio- 
sus bears  to  cyanosis,  and  thus  to  asphyxia  neonatorum 
suggested  to  me,  however,  the  additional  value  of  sus- 
pension as  respecting  its  influence  through  the  ductus 
arteriosus  upon  the  change  in  the  direction  of  the  cir- 
culation lungward. 

The  value  of  inversion, /^r  .y^,  as  a  direct  means  of 
resuscitation,  was  first  advanced  by  Nelaton.  Dr. 
Chisolm  states,  in  speaking  of  the  way  in  which  resus- 
citation is  accomplished  by  suspension  under  these 
circumstances,  that  "  it  is  a  mooted  point  whether  re- 
suscitation is  brought  about  by  an  additional  supply  of 
blood  to  the  anaemic  brain  alone,  or  by  the  emptying 
of  the  blood  from  the  great  reservoir,  the  liver,  through 
the  vena  cava,  into  the  cavities  of  the  heart,  stimulating 
them  into  renewed  activity.  Most  likely  both  of  these 
influences  work."'" 

The  application  of  inversion  to  conditions  of  sus- 
pended animation  in  the  new-born  is  the  outcome  of 
my  experience  with  it  in  chloroform  narcosis,  and  in 
Case  I.  of  the  following  series : 

Case  I. — On  September  i,  1893,  I  was  hastily  sum- 
moned to  a  child  I  had  delivered  the  previous  day  at 
the  New  York  Asylum  for  Lying-in  Women.  Living 
in  the  institution  at  the  time,  my  response  was  immedi- 
ate. On  arrival  I  found  the  child  presented  every  ap- 
pearance of  death,  being  cold,  blue,  limp,  and  breath- 
less. While  questioning  the  nurses  concerning  the 
circumstances  under  which  the  child  was  found,  I  no- 
ticed a  shallow  gasp,  followed  by  the  dropping  of  the 
chin,  so  characteristic  of  approaching  death.  Finding 
that  there  still  remained  a  spark  of  life,  I  ordered  a 
vessel  of  hot  water  to  be  brought,  hoping  to  revive  the 
infant  by  immersing  it.  While  the  nurse  was  prepar- 
ing the  water,  a  new  thought  occurred  to  me.  The 
similarity  between  the  condition  presented  in  the  child 
and  that  of  chloroform  narcosis  when  cyanosis  occurs, 
suggested  the  idea  of  treating  the  condition  as  due  to 
a  similar  cause.  Having  on  several  occasions  suc- 
cessfully treated  chloroform-poisoning  by  Nelaton's 
method,  i.e.,  suspension  by  the  feet,  I  at  once  resorted 
to  this  procedure.  Great  was  my  delight  when,  after 
the  lapse  of  a  few  minutes,  breathing,  though  feeble, 
was  resumed  with  some  regularity,  and  the  appearance 
of  the  child  became  more  lifelike.  On  placing  the  in- 
fant in  a  horizontal  position,  respiration  again  ceased, 
with  the  accompanying  cyanosis,  complete  muscular 
relaxation,  slow  and  feeble  pulse.  Again  suspending 
it,  I  was  rewarded  at  the  end  of  about  two  minutes 
with  the  same  satisfactory  result.  During  the  cyanotic 
state  the  pulse  was  45  to  the  minute  and  very  feeble. 
Almost  immediately  after  the  first  deep  inspiration  it 
increased  to  150  per  minute.  Concluding  from  these 
observations  that  suspension  by  the  feet  would  give 
the  best  chances  of  recovery,  I  determined  to  keep  the 
child  in  this  position  and  await  the  result.  During  the 
first  ten  minutes  breathing  and  heart  action  were  quite 
regular,  and  the  general  appearance  comparatively 
good,  though  complete  muscular  relaxation  continued. 
Suddenly  respiration  again  became  labored  and  heart- 
action  slow  and  feeble  as  before.  For  one  minute  and 
a  half  there  was  no  effort  at  breathing,  then  a  feeble 
gasp  or  two,  followed  by  regular  breathing  and  in- 
creased heart-action.     This  seizure  was  not  nearly  as 

'  The  Lancet,  February  24,  1894,  p.  457. 

"  Chisolm  on  Chloroform,  the  Best  of  Ana;sthetics,  p.  14.  Read 
before  the  Baltimore  Academy  of  Medicine,  1888. 


764 


MEDICAL   RECORD. 


[November  30,  1895 


bad  as  those  which  occurred  when  the  child  was  in  the 
horizontal  posture.  I  therefore  felt  greatly  encouraged 
as  to  the  ultimate  result,  and  persisted  in  the  inverted 
position.  Voluntary  movements  of  the  head  and  arms 
were  not  observed  until  more  than  twenty  minutes  had 
elapsed.  During  the  first  two  hours  collapse  occurred 
four  times,  lasting  in  each  instance  from  one  and  one- 
half  to  two  minutes.  These  seizures  were,  however, 
not  so  severe  as  the  first,  and  their  intervals  became 
successively  greater.  At  the  end  of  this  time  one  of 
the  attending  physicians.  Dr.  Tull,  for  whom  I  had 
sent,  arrived.  The  condition  of  the  infant  then  was 
incomparably  better  than  when  first  discovered,  yet  so 
grave  as  to  cause  the  doctor  to  express  little  hope  of 
restoration.  Finding  now  that  the  horizontal  position 
still  occasioned  depression  when  resumed,  I  arranged 
with  pillows  an  inclined  plane,  upon  which  the  child 
was  placed  and  kept  with  its  head  down  for  four  hours. 
It  steadily  continued  to  improve,  and  the  seizures  be- 
came less  frequent  and  less  severe.  Six  hours  after 
efforts  at  resuscitation  were  begun,  the  horizontal  po- 
sition was  resumed,  without  apparently  any  deleterious 
effects.  Nourishment  was  then  administered  every 
few  hours,  and  from  that  time  on  recovery  was  unevent- 
ful. At  the  end  of  two  weeks  it  left  the  hospital  in 
good  health. 

I  am  unable  to  say  whit  occasioned  this  asphyxiated 
condition.  The  child  had  been  noticed  half  an  hour 
before  calmly  sleeping.  It  is  possible  that  it  vomited 
and  strangled,  but  there  were  found  no  evidences  of 
such  about  its  crib  or  clothing.  The  exact  length  of 
time  the  child  was  cyanotic  is  uncertain,  as  it  was 
found  in  that  condition  ;  at  least  three  minutes  elapsed 
from  the  time  it  was  discovered  to  the  time  I  first  in- 
verted it. 

To  resume  ;  There  was  found  cyanosis,  feeble  respi- 
ration, slow  and  weak  heart-action,  want  of  volition. 
Suspension  by  the  feet  for  two  hours,  succeeded  by  an 
inclined  ^losition,  with  head  down  for  four  hours,  re- 
sulting ultimately  in  the  restoration  of  the  normal  func- 
tioning of  the  heart  and  lungs,  and  natural  appearance 
and  powers  of  the  infant.  Prolonged  suspension  with 
head  down  showed  no  bad  after-effects.  During  each 
cyanotic  seizure  while  respiration  was  suspended  (from 
one  to  two  and  a  half  minutes)  the  pulse  -  rate  re- 
mained at  45  per  minute,  but  on  the  first  deep  inspira- 
tions'it  invariably  increased  to  150  per  minute. 

My  thoughts  were  directed  by  this  success  to  the 
study  of  the  probable  advantages  such  a  procedure 
would  possess  in  cases  of  suspended  animation  in  the 
new-born  ;  but  it  was  not  until  November  20,  1893, 
that  an  opportunity  was  presented  to  put  the  idea  into 
practice. 

Case  II. — On  the  above  date  I  attended,  at  the  New 
York  Asylum  for  Lying-in  Women,  now  known  as  the 
Old  Marion  Street  Maternity  Hospital,  a  primipara, 
aged  twenty-nine,  nine  months  gravida.  She  was  a 
large,  strong,  and  well-proportioned  German  woman  ; 
presented  no  history  of  special  interest  during  her 
pregnancy,  excepting  that  there  was  present  in  her 
urine  a  small  amount  of  albumin.  Presentation  of 
child,  vertex  ;  position,  L.  O.  A.  Up  to  about  twenty 
minutes  before  delivery  the  foetal  heart  was  regular  and 
strong — 140  beats  to  the  minute.  Labor  progressed 
normally  until  within  a  few  minutes  before  I  delivered, 
when  there  suddenly  occurred  a  profuse  discharge  of 
blood.  The  uterus  had  spontaneously  and  almost 
completely  emptied  itself  of  the  amniotic  fluid  half  an 
hour  after  the  second  stage  began,  and  one  hour  be- 
fore delivery,  so  that  the  discharge  was  almost  entirely 
pure  blood.  I  then  examined  for  foetal  heart- sounds, 
but  was  unable  to  find  them.  Low  forceps  were  imme- 
diately applied  and  child  extracted.  The  condition 
of  the  child  was  that  of  apparent  death,  the  form  of 
asphyxia  neonatorum  spoken  of  in  text  -  books  as 
anemic.  It  was  pale  to  a  marked  degree,  with  general 
and  complete  muscular  relaxation.      No  appreciable 


pulsation  could  be  discovered  in  the  cord,  or  over 
heart,  and  no  respiratory  action.  With  the  assistance 
of  a  nurse  the  child  was  held  up  by  the  feet  between 
the  mother's  limbs,  while  a  warm  receiving  blanket  was 
thrown  around  it  and  the  umbilical  cord.  I  then 
placed  my  mouth  to  the  child's  mouth,  and,  pressing 
upon  the  throat  to  prevent  the  air  from  entering  the 
stomach,  blew  the  mucus  out  of  the  pharynx  through 
the  nose.  I  might  here  incidentally  state  that  I  now 
consider  the  step  unnecessary,  and  by  no  means  devoid 
of  danger  ;  and,  as  will  be  seen,  was  not  resorted  to  in 
any  of  the  succeeding  cases. 

About  three  minutes  after  birth  a  feeble  gasp  was 
made,  following  which  a  considerable  quantity  of 
bloody  mucus  flowed  from  the  nose.  The  mouth  and 
throat  were  then  mopped  out  with  a  piece  of  cotton  on 
a  stick.  Finding  that  the  almost  imperceptible  pulsa- 
tion in  the  cord  did  not  improve  at  the  end  of  the 
fourth  minute,  I  tied  and  severed.  The  flow  of  blood 
from  the  untied  or  placental  end  was  very  slight.  The 
child,  covered  well  with  a  warm  blanket,  was  taken  in  the 
inverted  position  near  a  lighted  gas  stove,  and  the  po- 
sition persisted  in  (two  hours  and  twenty  minutes)  until 
recovery.  Two  minutes  after  the  first  gasp,  or  five 
minutes  after  delivery,  another  faint  effort  to  breathe 
was  noticed.  These  gasps  continued  about  one  every 
two  minutes  during  the  first  half  hour,  and  in  the  suc- 
ceeding half  hour  improved  to  one  every  ninety  sec- 
onds, and  one  every  seventy  seconds.  After  the  first 
hour  the  gasps  were  a  little  deeper  and  for  fifteen  min- 
utes occurred  one  every  sixty  seconds,  improving  dur- 
ing the  next  thirty  minutes  to  one  in  every  forty  sec- 
onds, then  in  the  remaining  thirty-five  minutes  one  in 
every  twenty  seconds,  which  ended  the  two  hours  and 
twenty  minutes  of  suspension,  when  breathing  became 
suddenly  regular.  Heart-action  was  not  sufficiently 
strong  to  be  counted  until  after  the  first  gasp  had  been 
taken  ;  then  it  was  noticed  to  be  about  forty  to  the  min- 
ute, and  remained  so,  with  slight  variation  occurring 
immediately  after  gasps,  until  regular  breathing  was 
established,  when  it  increased  to  85  per  minute.  At 
the  end  of  the  first  hour  the  conjunctiva  and  skin  were 
as  dry  as  parchment  and  as  lifeless  as  if  death  had  oc- 
curred. There  was  absolutely  no  reflex  action  until 
just  before  respiration  assumed  regularity.  At  that 
time  slight  muscular  volition  was  also  noticeable,  and 
in  an  effort  to  cough  there  was  expelled  a  considerable 
quantity  of  bloody  mucus.  This  mucus  evidently  came 
from  the  trachea,  where  it  was  lodged  either  by  the  ef- 
forts on  the  part  of  the  child  to  breathe  in  utero,  or  my 
attempt  at  clearing  the  air-passage  by  the  mouth-to- 
mouth  method.  The  position  of  inversion,  that  is,  the 
head  down,  with  legs  and  arms  up,  which  was  main- 
tained from  the  beginning  to  the  end,  was  the  only- 
procedure  adopted  after  freeing  the  mouth  and  nose  of 
mucus.  The  child  was  of  course  very  feeble  for  a  time 
after  resuscitation,  but  soon  rallied,  thrived,  and  left  the 
hospital  on  the  twenty-first  day  perfectly  well.  It  was 
seen  eight  months  after,  enjo)ing  excellent  health. 

The  points  of  especial  interest  in  the  above  case  are  : 
The  extreme  anpemic  condition  of  infant  ;  the  gradual 
but  steady  improvement  in  respiration  ;  the  dryness 
of  the  skin  and  conjunctiva  during  the  first  hour — 
becoming  less  and  less  as  respiration  and  circulation 
improved  ;  the  length  of  time  reflex  action  was  ab- 
sent;  the  completeness  with  which  the  air- passages 
were  freed  from  mucus  ;  the  length  of  time  elapsed 
before  regular  breathing  was  established. 

Case  III. — Labor  began  at  3  .-^..m.,  November  22, 
1893  ;  second  stage,  10  a.m.  Membranes  ruptured  spon- 
taneously at  10.15  a.. m.  Presentation,  vertex ;  position, 
R.  O.  P.  The  mother,  a  multipara,  aged  twenty-nine, 
was  strong  and  healthy.  During  second  stage  she  suf- 
ered  severely,  head  of  fa'tus  making  very  slow  progress. 
At  1.45  P.M.  foetal  heart  was  strong  and  regular,  140  per 
minute.  At  2.15  I  discovered  that  the  heart-sounds 
were  very  feeble,  and  determined  to  deliver  immediately. 


November  30,  1895] 


MEDICAL   RECORD. 


765 


The  operation  was  uncomplicated  and  took  but  a  few 
minutes.  The  instruments  inflicted  no  appreciable 
injury  to  the  child.  Considerable  hemorrhage,  though 
not  of  an  alarming  nature,  immediately  followed  its 
birth.  Its  condition,  however,  was  that  of  complete 
exhaustion,  muscular  relaxation  and  want  of  reflex  ac- 
tion ;  pulsation  in  cord  about  forty  to  the  minute  ;  dis- 
tinct though  very  feeble.  The  infant,  weighing  9 
pounds,  was  well  developed,  but  pale,  though  not  so  an;u- 
mic  as  the  previous  case  reported.  It  was  immediately 
suspended  by  the  feet  and  covered  with  a  warm  receiv- 
ing-blanket. The  mouth  and  throat  were  then  mopped 
out  with  a  piece  of  dry  cotton  on  a  match-stick. 

Four  minutes  after  birth  the  cord  was  ligated  and 
severed.  The  first  gasp  was  made  about  three  minutes 
after  delivery,  and  was  followed  immediately  by  a  flow 
of  bloody  mucus  from  the  nose  and  mouth.  Shallow 
inspiration  was  continued  at  the  rate  of  one  every  eighty 
seconds,  for  fifteen  minutes,  at  the  end  of  which  time 
five  or  six  short  breaths  were  taken  in  rapid  succession. 
These  were  followed  by  an  interval  of  two  minutes 
without  an  effort  to  breathe.  Inspirations  were  then 
resumed,  somewhat  more  full,  and  continued  one  every 
sixty  seconds  for  fifteen  minutes,  again  terminating  in 
a  succession  of  rapid  respiratory  acts.  Another  inter- 
val of  two  minutes  then  elapsed  when  breathing  was 
resumed  at  the  rate  of  one  every  forty  seconds,  and 
continued  so  for  twenty  minutes,  terminating  as  before 
in  a  rapid  succession  of  respirations,  followed  again  by 
another  interval  of  two  minutes.  Breathing  was  then 
resumed  at  one  every  thirty  seconds,  becoming,  with 
heart-action,  stronger  and  better,  and  at  the  end  of  one 
hour  and  twenty  minutes  from  the  time  suspension  was 
begun  both  lungs  and  heart  functioned  normally, 
During  the  first  half-hour  heart-action  grew  stronger, 
but  did  not  increase  beyond  45  to  the  minute,  except- 
ing during  the  several  successive  and  rapid  respirations, 
when  it  was  always  accelerated,  but  at  no  time  reached 
as  much  as  60  per  minute  until  regular  breathing  was 
established,  when  it  became  normal,  or  130  per  minute. 

Nothing  eventful  occurred  in  connection  with  the 
case  during  the  following  thirteen  days  while  the  child 
remained  in  the  hospital.  It  left  in  perfect  health. 
What  occasioned,  in  this  case,  interference  in  foetal 
circulation,  I  am  not  positive.  There  was  a  discharge 
of  blood  before  delivery  and  immediately  after  birth, 
but  no  more  than  is  often  seen  in  uneventful  labors. 
The  cord  was  of  usual  length  and  position  ;  the  pla- 
centa had  upon  its  uterine  surface  a  blood-clot,  but 
not  of  sufficient  size  to  indicate  an  extensive  separa- 
tion of  that  organ  from  the  uterus.  The  peculiar  feat- 
ure of  this  case  was  the  succession  of  rapid  breaths 
occurring  every  fifteen  or  twenty  minutes,  being  inva- 
riably followed  by  an  interval  of  two  minutes  before 
breathing  was  resumed. 

Case  IV. — Primipara,  aged  twenty,  entered  hospital 
May  14,  1894,  8  a..m.,  in  labor.  She  had  had  several 
labor-pains  before  admission.  Examination  showed 
vertex  presentation  ;  L.  O.  A.  position.  Cervix  tense 
and  not  sufficiently  dilated  to  allow  the  passage  of  the 
forefinger.  She  complained  a  little  of  backache,  but 
had  only  one  labor-pain  during  the  remainder  of  the 
day.  At  5  p.m.  the  cervix  was  softer  and  more  patu- 
lous ;  the  vagina  well  lubricated  with  mucus.  At  6  p.m., 
finding  that  the  head  was  descendmg,  but  that  there 
was  no  protrusion  of  the  bag,  1  passed  my  finger  up 
through  the  cervix  and  discovered  that  the  amniotic 
sac  was  intimately  attached  to  the  lower  segment  of  the 
womb.  These  adhesions  I  immediately  broke  up  as 
high  as  I  could  reach.  In  about  half  an  hour  the  bag 
was  found  descending  and  distending  the  cervix.     At 

10  P..M.  labor-pains  began  again.  At  10  a.m.  the  next 
morning  (May  15th)  pains  became  so  severe  that  mor- 
phine, grain  ^^  hypodermatically,  was  administered.    At 

11  A.M.  bag  of  waters  was  ruptured  artificially,  and  at 
1 1.58  A.M.  child  was  born.  Foetal  heart-sounds  remained 
throughout  labor  about  132,  full  and  strong.     Greatly 


to  my  surprise  the  child's  condition  at  birth  was  that  of 
extreme  cyanosis,  with  complete  muscular  relaxation. 
It  was  immediately  suspended  by  feet,  covered  with  a 
warm  receiving-blanket,  and  mouth  and  throat  mopped 
out.  Pulsation  in  the  umbilical  cord,  at  birth,  was  125 
to  the  the  minute,  quite  regular  and  strong.  At  the 
end  of  four  and  a  half  minutes,  although  the  child  had 
made  no  effort  at  respiration,  I  tied  and  severed  cord, 
thinking  that  in  so  doing  the  infant,  being  thrown  upon 
its  own  resources  for  oxygen,  would  soon  breathe.  It 
was  not  until  two  and  a  half  minutes  after  severing 
cord,  however,  that  any  effort  at  respiration  was  notice- 
able. This  feeble  effort  was  succeeded  by  an  interval 
of  three  minutes,  during  which  time  mucus  flowed 
from  the  mouth  and  nose.  Then  a  deeper  inspiration 
was  made,  followed  by  an  interval  of  two  minutes,  ter- 
minating in  a  succession  of  respirations.  But  it  was 
not  until  sixteen  minutes  after  delivery  that  respiration 
became  regular  and  muscular  volition  was  established. 
A  considerable  quantity  of  mucus,  slightly  tinged  with 
blood,  was  then  expelled  from  the  throat.  Pulsation 
before  ligation  of  cord  was  125  to  the  minute.  Imme- 
diately alter  ligation  it  fell  to  60  per  minute,  and  re- 
mained so  until  respiration  became  regular,  when  it 
rose  again  to  125  per  minute. 

To  resume  :  There  was  a  marked  degree  of  cyanosis 
at  time  of  birth.  Though  no  effort  to  respire  had  been 
made  for  several  minutes  after  birth,  the  appearance  of 
the  child  steadily  improved  under  the  influence  of  the 
inverted  position.  The  first  inspiration  was  made  about 
four  minutes  after  the  mouth  and  throat  were  mopped 
out  and  two  and  a  half  after  the  cord  was  tied  and 
cut.  The  heart-action  fell  immediately  upon  ligat- 
ing  the  cord  from  125  per  minute,  full  and  strong,  to 
60  per  minute,  and  did  not  assume  -its  normal  func- 
tioning until  regular  respiration  was  established.  No 
blood  was  allowed  to  escape  when  the  umbilical  cord 
was  severed. 

I  have  attended  three  other  cyanotic  or  apoplectic 
cases  since  this  one  ;  but  as  none  were  extreme  nor 
presented  any  features  of  peculiar  interest,  I  will  not 
impose  upon  the  reader  a  further  account  than  to  say 
that  they  were  all  resuscitated  from  within  six  to  nine 
minutes  by  the  same  procedure  as  that  employed  with 
those  cases  whose  histories  have  been  given  in  detail. 

The  following  procedure  I  now  invariably  adopt 
where  suspended  animation  exists  ; 

As  soon  as  delivery  is  completed  the  child  is  held  up 
by  the  feet.  Any  mucus  that  may  be  in  the  mouth  or 
throat,  obstructing  the  free  entrance  of  air,  is  wiped  out 
with  a  cotton  swab.  A  warm  receiving-blanket  is  imme- 
diately wrapped  around  the  child,  and  also  about  the 
umbilical  cord,  if  it  remain  unsevered  for  any  length  of 
time.  In  placing  the  covering  about  the  babe  it  is 
best  to  bring  the  arms  up  alongside  of  the  body,  so 
that  there  will  be  no  hindrance  to  the  act  of  respiration 
when  it  is  begun.  The  child  is  then  removed,  still  in 
the  inverted  position,  near  to  a  warm  stove  or  radiator, 
that  it  may  not  suffer  from  the  loss  of  heat,  and  is  kept 
suspended  until  resuscitation  has  taken  place.  If  im- 
provement is  satisfactory,  however,  the  child  may  soon 
be  placed  in  an  inclined  position  in  the  lap  of  the  nurse. 
If  we  have  to  deal  with  the  apoplectic  form  it  is  well 
to  allow  the  umbilical  circulation  to  continue  for  sev- 
eral minutes  after  birth  ;  the  engorged  vessels  are 
thereby  relieved  without  the  loss  of  blood,  as  occurs 
when  leakage  is  allowed  from  the  severed  cord.  Should 
efforts  at  respiration  not  be  made  during  the  first  two 
or  three  minutes,  it  is  best  to  ligate  and  sever  cord,  and 
thus  throw  the  child  upon  its  own  resources.  With 
the  anx-mic  variety  I  think  it  is  best  to  tie  and  sever 
the  cord  immediately  after  birth  so  as  not  to  allow  an 
increased  loss  of  blood. 

Of  all  methods  adopted  to  insure  artificial  respira- 
tion that  of  alternately  flexing  and  extending  the  body 
upon  itself  is  perhaps  the  most  highly  valued  and  uni- 
versally used.    There  are  many  varieties  of  this  method, 


766 


MEDICAL    RECORD. 


[November  30,  1895 


but  in  principle  they  are  all  essentially  the  same.  On 
flexing  the  body  the  thoracic  cavity  is  compressed, 
causing  expiration.  On  extending  the  body  the  thora- 
cic cavity  is  expanded,  causing  inspiration.  The  best 
plans  of  procedure  are  probably  those  advocated  by 
Schroder,  Schultze,  Sylvester,  and  Dew.  Schultze's 
method  is  perhaps  the  most  powerful  and  successful  of 
the  above  named,  and  for  these  reasons  we  will  con- 
sider it  as  the  type  of  this  class. 

In  order  to  handle  the  infant,  according  to  the 
prescribed  plan,  it  should  be  naked.  In  this  condition 
it  is  thrown  up  over  the  shoulder  and  down  between 
the  legs  with  considerable  violence.  This  rough  hand- 
ling of  the  uncovered  child  must  necessarily  expose  it 
to  a  loss  of  heat,  exhaustion,  and  physical  injury. 

In  the  newly  born  asphyxiated  the  congestion  in 
venous  organs,  such  as  the  liver,  has  been  shown  by 
autopsies  to  be  very  great.  Schultze  claims,  as  one  of 
the  advantages  of  his  method,  that  the  manipulation 
induces  the  emptying  of  the  right  heart,  and  in  that 
way  relieves  this  internal  congestion.  He  seems  to 
lose  sight  of  the  fact,  however,  that  the  position  which 
the  child  is  made  to  assume  in  inducing  expiration 
forces  the  blood  suddenly  from  a  considerable  area 
into  the  engorged  organs  themselves,  and  that  such 
manipulation  may  therefore  play  no  small  part  in  the 
rupture  of  vessels  already  distended  to  their  utmost 
capacity.  In  this  connection  I  might  state  that  both 
Korber  and  Koffer  have  each  reported  a  case  of  rupt- 
ure of  the  liver  with  fatal  termination  as  the  result  of 
Schultze's  method.^ 

If  violence  or  sudden  force  is  used  in  any  of  the 
methods  which  alternately  flex  and  extend  the  child, 
the  same  danger  is,  of  course,  incurred,  and  when 
benefit  is  derived  from  them  I  believe  it  to  be  due 
partly  to  the  pressure  on  the  liver,  encouraging 
thereby  the  emptying  of  that  organ  into  the  heart. 
The  difficulty  is  to  regulate  or  determine  the  amount 
of  force  to  be  used  under  these  conditions. 

Schultze  advises  that  "  where  spontaneous  effort  at 
respiration  is  made  the  method  is  to  be  desisted  from 
in  order  that  the  spontaneous  respiratory  process  may 
not  be  interfered  with  by  the  artificial."-  It  is  im- 
possible always  to  tell  when  spontaneous  respiratory 
efforts  are  being  made,  because,  while  the  operator  is 
throwing  the  child  up  and  down,  it  is  part  of  the  time 
comj^letely  out  of  the  line  of  vision,  and  the  first  efforts 
at  respiration  are  too  shallow  and  too  feeble  to  be 
heard.  The  possibility  of  inflicting  injury  also  offers  a 
serious  objection.  Schultze  himself  reports  a  case  which 
suddenly  died  soon  after  resuscitation,  the  autopsy  re- 
vealing a  fractured  clavicle,  the  broken  bone  having 
perforated  the  pleura  and  lung.^ 

Inflation  of  the  lungs  stands,  perhaps,  next  in  im- 
portance. It  may  be  accomplished  by  the  mouth-to- 
mouth  method,  or  through  tubes  passed  into  the 
trachea.  Budin  says  that  while  the  throat  is  freed  by 
the  mouth-to-mouth  method,  the  mucus  being  blown 
through  the  anterior  nares,  yet  it  does  not  insure  the 
entrance  of  air  into  the  lungs,  because  of  the  flaccidity 
of  the  air-passages,  and  that  even  if  such  is  accom- 
plished, viscid  matter  may  be  driven  before  and  ob- 
struct a  certain  number  of  bronchi.^ 

Munde  states  that  "  post-mortem  examination  of  the 
lungs  of  children  that  have  died  after  efforts  had  been 
made  to  resuscitate  them,  showed,  frequently,  points 
of  ecchymosis,  which  was  evidence  that  too  much  force 
is  often  used  in  such  cases."  ^  He  also  remarks,  in 
speaking  of  cases  where  the  Marshall- Hall  and  Syl- 
vester methods  were  used  without  success,  that  the 
mouth-to-mouth  method  was  resorted  to,  and,  "  by  this 
means  some  were  resuscitated,  but  too  frequently  the 

'  Centr.^lblatt  fur  Gynakologie.  1893,  No.  15. 
'  CyclopEedia  of  Obstetrical  Gynecology,  vol.  i.,  p.  468. 
'  Centralblatt  fur  Gynakologie,  1894,  No.  8  ;  American  Journal  of 
the  Medical  Sciences. 
*  Archives  de  Tocologie  et  de  Gynocologie,  1893,  No.  7. 
'  American  Journal  of  Obstetrics,  October,  18S1,  p.  885. 


air  instead  of  entering  the  lungs  simply  went  into  the 
stomach."' 

Before  meeting  with  the  above,  in  the  study  of  the 
literature  of  the  subject,  I  delivered  a  syphilitic  foetus 
which  had  been  dead  in  utero  several  days.  I  tried  to 
inflate  the  lungs  by  blowing  through  its  mouth,  but 
found  that  instead  of  filling  the  chest  I  distended  the 
abdomen.  The  air-passage  is  almost  as  flaccid  in  the 
"  still-born  "  child  as  in  the  dead-born  ;  therefore  such 
a  procedure  is  always  accompanied  by  a  grave  risk. 
This  mishap  might  to  some  extent  be  averted  by  press- 
ing upon  the  throat  so  as  to  close  the  oesophagus,  which, 
however,  must  also  hinder  somewhat  the  passage  of  air 
into  the  lungs. 

There  have  been  many  instruments  devised  for  in- 
flating the  lungs,  but  the  ordinary  gum-elastic  catheter 
is  perhaps  most  frequently  used.  In  adopting  instru- 
mental insufflation  we  are  always  liable  to  use  too 
much  force  ;  but  aside  from  this  danger,  the  neces- 
sary skill  and  practice  which  it  requires  constitute  a 
considerable  objection,  for,  as  Budin  says,  "  Any  in- 
strumental insufflation  is  often  very  difficult  ;  it  is  a 
true  catheterization."'  He  might  have  added  that 
an  inexpert  operator  is  just  as  apt  to  pass  the  instru- 
ment into  the  oesophagus  as  the  trachea. 

Several  successful  cases  have  been  reported,  treated 
by  the  faradic  current.^  In  order  to  make  the  dia- 
phragm act  by  this  means,  the  current  must  be  applied 
so  as  to  stimulate  the  phrenic  nerve.  Dr.  Polk  has 
well  observed  that  stimulating  the  diaphragm  to  act  by 
the  electric  current  was  one  of  the  most  uncertain 
things  in  medicine.^ 

Munde  thinks  that  one  is  apt  to  do  too  much  with 
the  faradic  current  ;  to  make  it  too  strong  or  to  re- 
peat it  too  frequently,  thus  producing  convulsive  con- 
traction of  the  diaphragm,  which  interferes  quite  as 
much  with  the  resuscitation  of  the  child  as  if  nothing 
had  been  done.' 

But  aside  from  these  objections,  were  the  method 
even  more  certain,  we  could  not  on  all  occasions  avail 
ourselves  of  it,  because  batteries  are  not  always  to  be 
had  when  wanted. 

Hypodermatic  injections  of  brandy  or  whiskey  have 
also  proven  efficacious  in  some  cases.  But  it  is  not 
always  possible  to  gauge  the  amount  necessary.  Dr. 
Rodenstein  reports  a  case  where,  after  a  faithful  trial 
of  both  Sylvester's  method  and  the  catheter  without 
success,  brandy  was  injected  and  restoration  soon  fol- 
lowed. "  He  acknowledged  a  fault,  however,  in  that 
he  overdid  the  matter,  over-stimulating  the  child,  and  it 
died  within  twenty-four  hours  of  convulsions."'' 

Hot  and  cold  water  plunges  alternately,  spanking, 
etc.,  are  means  adopted  to  induce  respiration  by  reflex 
action.  Where  the  cases  are  not  extreme  they  hasten 
restoration,  but  in  exhausted  cases  the  accompanjnng 
shock  from  such  procedures  only  increase,  I  believe, 
the  exhaustion,  and  subject  the  infants  to  greater  dan- 
ger. With  regard  to  artificial  respiration  in  general,  I 
believe  it  to  be  of  value  when  it  is  performed  without 
the  accompanying  shock  and  injury  which  may  be  oc- 
casioned by  some  of  the  recognized  methods.  I  think  ^ 
that  the  artificial  expansion  and  contraction  of  the  I 
lungs  induces  a  blood  flow  to  and  from  these  organs 
which  must  in  turn  affect  beneficially  the  entire  circula- 
tion and  necessarily  the  nerve  centres  governing  res- 
piration. 

The  value  of  inversion  as  an  agent  in  restoring  life  in 
the  still-born  but  yet  viable  child  will  be  more  fully 
appreciated  by  bearing  in  mind  the  following  important 
points  in  tlie  foetal  circulation. 

Nearly  the  whole  of  the  maternal  or  placental  blood, 

'  American  Journal  of  Obstetrics.  October,  1881,  p.  884. 

=>  American  Journal  of  the  Medical  Sciences,  January,  1894,  p.  100. 

•  Drs.  Walker  and  Munde:  .American  Journal  of  Obstetrics,  Octo- 
ber, 1881.  pp.  S83-4-5. 

*  American  Journ.il  of  Obstetrics,  October,  1881,  p.  8S4.  * 
»  Ibid.,  October,  18S1.  p.  885.  i 
•Ibid,  October,  18S1,  p.  888. 


November  30,  1895] 


MEDICAL   RECORD. 


767 


on  its  passage  to  the  foetal  heart,  traverses  the  liver,' 
where,  during  this  stage  of  life,  a  quarter  or  more  of 
the  entire  volume  of  the  system  is  to  be  found.-  In 
this  organ,  the  liver,  we  therefore  have  a  great  reservoir 
for  the  storing  of  autrient  blood,  which,  to  the  infant 
who  has  not  yet  ^ 

breathed,   is  ^ 

practically    its  ^ 

only  source   of 
oxygen. 

In  the  foetus 
and  the  still- 
born child  the 
blood  "  passes 
almost  directly 
to  the  arch  of 
the  aorta,  and  is 
distributed  by 
the  branches  of 
that  vessel  to 
the  head  and 
upper  extremi- 
ties. "^  The 
pulmonary  ar- 
teries transmit 
only  sufficient 
blood  to  nour- 
ish the  lung  tis- 
sue, while  the 
ductus  arteri- 
o  s  u  s  conveys 
the  blood  of  the 
right  ventricle 
into  the  general 
circulation. 

Suspended 

animation  in  the  new-born  may  be  due,  first,  to  impair- 
ment of  the  umbilical  circulation  occasioned  by  pressure 
upon  the  cord,  or  entanglement  of  the  cord  upon  itself 
or  around  the  child  ;  second,  to  the  loss  of  blood  re- 
sulting from  placenta  praevia,  or  partial  or  complete 
separation  of  placenta  before  birth  of  child  ;  third,  to 
shock  following  injuries  received  during  labor,  from 
instrumental  interference,  or  traction  on  body  in  breech 
presentation.^ 

These  may  be  classified  under  the  two  recognized 
forms,  viz.,  apoplectic  or  cyanotic,  and  anaemic  or 
syncopal.  In  the  apoplectic  form,  which  is  occasioned 
by  a  direct  interference  with  the  umbilical  circulation, 
there  exists  not  only  superficial  venous  congestion,  but 
also  general  stagnation  in  the  circulatory  system,  and 
diminished  supply  of  maternal  or  placental  blood. 

In  the  anaemic  form,  when  due  alone  to  the  loss  of 
blood,  there  exists  a  depletion  of  the  circulatory  sys- 
tem as  well  as  a  deficiency  in  maternal  blood- supply. 
When  due  alone  to  shock  from  injury,  the  maternal 
blood-supply  is  also  affected,  it  being  lessened  because 
of  the  enfeebled  heart- action  of  the  child. 

//;  both  forms  we  find  the  circulation  to  be  of  primary 
consideration,  and  it  is  to  the  improvement  of  this  'we  must 
look  for  the  awakening  to  activity  of  the  nerve-centres 
governing  the  respiratory  organs. 

According  to  the  theory  of  Dr.  Hall,  respiration  is  es- 
tablished in  suspended  animation  through  a  centric 
influence  which  he  terms  "  ecstaltic  ;  "  '  that  is  to  say, 
in  the  apoplectic  variety  respiration  is  caused  by  the 
action  upon  the  medulla  of  the  excessive  carbonic  acid 
in  the  circulation.  In  the  anajmic  it  is  occasioned 
through  "  the  impression  produced  upon  the  medulla 
by  the  loss  of  blood."  ^ 


'Gray  :  p.  841. 

'  Chapin  :    Keating's  Encyclopredia  of  Diseases  of  Childre 
i..  p.  403- 
'  Gray  :  p.  841. 


vol. 


'  It  may  be  incident.-Jly  noted  that  severe  traction  in  breech  cases 
often  results  in  injury  to  the  medulla,  under  which  circumstances  re- 
suscitation is  impossible,  as  death  must  inst.intaneously  follow. 

•Hall  on  Asphyxia  Neonatorum:  its  Cause  and  Treatment, 
p.  II.  'Cazeau.x  :  Midwifery,  p.  506. 


The  physiological  cause  of  the  first,  as  well  as  the 
succeeding  inspirations,  /  believe  to  be  du4  to  the  appre- 
ciation on  the  part  of  the  medulla,  through  probably  the 
sympathetic  system  of  lurves,  of  the  want  of  a  proper  pro- 
portion of  oxygen  in  the  system,  a  similar  cause  to  that 
which  occasions  the  demand  for  food  or  drink  when 
true  hunger  and  thirst  exists. 

The  respiratory  centre  remains  inactive  during  foetal 
life  because  the  placental  blood  contains  the  required 
proportion  of  oxygen  ;  but  when  from  any  sudden 
cause,  natural  or  unnatural,  this  proportion  is  decidedly 
interfered  with,  the  activity  of  the  medulla  will  be 
aroused  and  respiration  attempted. 

During  the  act  of  labor  the  sinuses  of  the  uterus 
diminish  in  size  in  direct  proportion  to  the  contraction 
of  that  organ,  and  the  capacity  for  maternal  blood 
must  diminish  likewise  ;  through  this  physiological  pro- 
cess nature  shuts  off  from  the  child,  about  the  time  of 
birth,  the  accustomed  supply  of  nutriment.  If  the 
body  is  bom  without  delay  after  the  head  has  passed 
the  perineum,  attempts  at  respiration  will  generally  be 
made  at,  or  soon  after,  expulsion  ;  but  if  the  head  rests 
over  the  perineum,  and  the  body  in  the  genital  canal, 
for  any  length  of  time,  the  child  will  almost  invariably 
attempt  to  breathe,  but  without  success,  as  the  pressure 
upon  the  chest  and  abdomen  is  too  great  to  allow  their 
expansion. 

If  there  exists  an  abnormal  condition,  such  as  the 
birth  of  cord  before  the  head,  entanglement  of  it  around 
neck  or  body,  or  pressure  upon  it  in  breech  presenta- 
tion, the  interference  in  blood-supply  to  child  is  more 
sudden  and  decided  than  from  uterine  contraction 
alone  ;  hence  the  demand  for  oxygen  becomes  more 
urgent,  resulting  generally  in  active  efforts  being  made 
by  the  foetus  to  inspire  before  birth. 

While  the  immediate  change,  after  delivery,  of  pla- 
cental breathing  to  that  of  lung  breathing  is  not  essen- 
tial, as  life  can  be  maintained  for  several  minutes  on 
the  reserved  supply  of  oxygenated  blood,  the  continu- 
ance of  heart-action  is  essential,  and  may  be  con- 
sidered as  the  test  of  the  viability  of  the  child.'  It 
may  be  too  feeble  to  be  immediately  recognized,  but 
if  the  condition  is  that  of  suspended  animation,  and 
not  death,  nature  will,  I  believe,  invariably  restore  her- 
self if  aided  by  the  child  being  placed  in  such  a  posi- 
tion as  will  enable  her  to  work  to  the  greatest  advan- 
tage. 

When  the  infant  is  very  feeble  the  first  inhalations 
are  extremely  shallow,  and  sometimes  do  not  increase 
in  depth,  though  the  interval  between  each  may  lessen 
until  an  hour  or  more  has  passed.  Each  inhalation, 
however,  increases  the  amount  of  oxygen  in  the  sys- 
tem until  the  required  proportion  is  reached  to  estab- 
lish rhythmical  functioning  of  the  lungs. 

When  complete  exhaustion  or  injury  to  the  medulla 
occurs,  heart-action  must  necessarily  cease  forever, 
and  under  these  circumstances  no  method  of  resusci- 
tation employed  should  be  charged  with  failure. 

The  position  of  inversion  effectually  aids,  by  the 
action  of  gravity,  the  emptying  of  the  contents  of 
the  liver  into  the  heart,  nourishing  in  turn  that  organ, 
and  by  the  continued  action  of  the  same  law  the  flow 
from  the  heart  to  the  medulla  is  also  materially  as- 
sisted. 

Therefore,  as  the  course  of  the  nutrient  blood  from  the 
liver  to  the  nerve  centre  of  respiration  is  almost  direct, 
and  as  the  circulation  is  encouraged  by  the  influence  of 
gravity,  a  greater  volume  of  this  blood,  consequently  a 
greater  quantity  of  oxygen,  is  supplied  to  the  nerve-centre 
in  a  given  length  of  time  than  icould  be  if  the  body  were 
kept  in  any  other  position. 

'  In  tl.U  c  III.-.  i-,n  I  niitiht  state  :)..n  Pr  !I.r,:!!.,in.  .T  F.Jinburgh, 
ha^  f  i-tance 

of  1  IS  in- 

spl:  basal 

ntre 


without  atVccting  the  circulation  \Ldiuturgh  Mctiical  Journal,  April, 
1895,  p.  941).     Such  a  condition  is  exceptional. 


768 


MEDICAL    RECORD, 


[November  30,  1895 


Gravity  also  exerts  an  important  influence  upon  the 
direction  of  the  circulation  lungwards,  for  it  aids  di- 
rectly the  emptying  of  the  contents  of  the  right  ven- 
tricle into  the  pulmonary  arteries,  and  by  the  increased 
blood-pressure  in  the  aorta  which  it  occasions,  hinders 
■the  flow  through  the  ductus  arteriosus,  and  encourages 
thereby  the  pulmonary  circulation. 

Under  the  influence  of  this  law  the  direction  of  the 
blood-current  from  the  right  ventricle  is  therefore 
changed,  the  general  circulation  encouraged  and  im- 
proved, and  the  vigor  of  the  exhausted  ne?-ve-centres  re- 
vived by  an  increased  supply  of  oxygen  to  them. 

Inversion  is  not  associated  with  the  slightest  danger. 
Nature  seems  to  favor  the  position  in  utero,  and  if  the 
position  is  not  maintained  long,  after  regular  circula- 
tion has  been  established,  the  danger  of  congestion  of 
the  brain  is  no  greater  than  it  was  before  birth.  The 
head  and  neck  are  sufficiently  e.xtended  under  the  in- 
fluence of  gravity  to  allow  of  the  unobstructed  ingress 
and  egress  of  air,  and  the  escape  of  mucus  from  the 
air- passages.  The  capacity  of  thoracic  and  abdominal 
cavities  is  in  no  way  encroached  upon,  and  by  keeping 
the  arms  up  against  the  chest,  entire  freedom  of  the 
respiratory  muscles  is  insured. 

The  apoplectic  form  of  suspended  animation  is  re- 
stored more  quickly  than  the  anaemic,  and  the  general 
appearance  will  be  found  to  improve  soon  after  inver- 
sion is  begun.  With  the  ansemic  the  death-like  pallor 
and  want  of  reflex  action  may  continue  even  for  hours, 
or  almost  up  to  the  time  regular  respiration  is  estab- 
lished. 

After  the  child  has  been  severed  from  its  mother, 
the  continuance  of  the  position  may  be  maintained  by 
an  assistant  or  nurse,  while  the  accoucheur's  attention 
is  directed  to  whatever  else  demands  it.  This  proced- 
ure may  be  used  in  connection  with  some  of  the  recog- 
nized methods,  and  will  be  found  of  great  assistance  to 
them  all  ;  but  where  it  is  desired  to  test  its  indepen- 
dent value,  there  should  be  none  other  used  with  it  ;  for, 
where  there  is  a  combination  of  methods  we  cannot 
tell  with  certainty  which  is  the  efficacious  one.  When 
the  infant  has  considerable  vitality,  almost  any  method, 
or  combination  of  methods,  may  be  serviceable  in 
hastening  restoration,  but  in  cases  where  vitality  is  low, 
extreme  manipulation,  being  exhausting,  is  detrimental. 

So  that  as  long  as  there  is  vitality  in  the  child  the 
value,  of  inversion  o\er  other  methods  increases  in  pro- 
portion to  the  exhaustion. 

The  simplicity  of  this  procedure  will,  I  believe,  be 
the  greatest  obstacle  to  its  popular  favor,  for  it  seems 
that  the  natural  impulse  on  seeing  a  still-born  infant  is 
to  "work  over  it,"  to  "spank  life  into  it,"  and  thereby 
often  to  spank  life  out  of  it. 

That  no  artificial  means  was  adopted  to  stimulate 
respiration  in  the  above-cited  cases  would  seem  to  jus- 
tify the  conclusion  that  the  recuperative  power  of 
nature  is  a  more  important  and  valuable  factor  in  the 
restoration  of  the  still  born  yet  viable  child  than  has 
been  heretofore  conceded  ;  and  should  there  be  estab- 
lished from  this  beginning  a  means  by  which  coming 
generations  will  be  benefited,  I  would  ask  only  for  the 
credit  of  having  directed  the  old  maxim,  vis  mediatrix 
naturce,  into  a  new  channel. 


TWO  CASES  OF  MORPHINE  -  POISONING 
TREATED  PRINCIPALLY  BY  FORCED  RES- 
PIRATION. 

By  J.\MES  D.  VOORHEES.  M.D., 

HOUSE   rHVSICIA.V,    PRESBYTERIAN    HOSPITAL,    NEW   VOKK. 


Miss  Kate  Marsden,  who  figured  for  a  time  as  a 
friend  of  the  Siberian  lepers,  and  enjoyed  the  patron- 
age of  the  English  and  Russian  royal  families,  as  well  as 
the  approval  of  many  notable  clergymen  and  philanthro- 
pists, has  apparently  ended  her  career.  Certain  charges 
were  brought  against  her  which  a  committee  of  inves- 
tigation found  to  be  sustained  by  the  facts.  The  Lon- 
don Times  published  the  committee's  report,  and  was 
sued  for  libel  by  Miss  Marsden.  She  has  now.  how- 
ever, withdrawn  the  suit  and  so  abandoned  her  strug- 
gle. 


Cases  of  acute  morphine-poisoning  occurring  in  a  city 
hospital  are  more  of  a  rarity  than  one  would  imagine, 
but  when  they  do  come  in,  no  matter  how  extreme  the 
condition  of  the  patient,  they  should  all  get  well. 

The  drug  kills  by  paralysis  of  the  respiratory  centre, 
so  if  the  body  is  artificially  supplied  with  air,  and  if  it 
can  be  done  completely  in  a  well  regulated  manner 
and  long  enough,  so  that  all  the  poison  has  been  gotten 
rid  of  by  excretion,  the  organism  ought  to  return  to  its 
normal  condition.  This  artificial  respiration  cannot  be 
kept  up  adequately  and  sufficiently  by  the  Sylvester 
method,  as  we  all  know,  but  Dr.  O'Dwyer,  of  this  city, 
has  contrived  a  modification  of  the  method  originated 
by  Dr.  Fell,  of  Buffalo,  to  do  this.  It  is  by  means  of  a 
tube  inserted  into  the  larynx,  the  air  being  forced  in  by 
a  bellows,  thus  avoiding  tracheotomy. 

The  apparatus,  then,  consists  of  a  foot-bellows,  rub- 
ber tubing,   and  an  intubation  attachment.     The  last 


consists  of  a  metal  tube  (as  in  cut),  curved  at  right  an- 
gles, on  the  distal  end  of  which  is  a  grooved  cone 
which  fits  the  laryngeal  socket.  The  cones  are  of  differ- 
ent sizes.  The  proximal  end  has  two  openings,  one  re- 
ceiving air  from  the  bellows  and  the  other  closed  by 
the  thumb  during  forced  respiration.  The  thumb  is 
removed  during  expiration,  or  the  collapse  of  the  chest. 
The  insertion  is  comparatively  easy.  A  mouth  gag  is 
used,  the  tongue  drawn  out,  the  epiglottis  held  back  by 
the  first  finger  of  the  left  hand,  and  the  tube  inserted  in 
the  median  line  by  the  right  hand.  When  well  in  the 
larynx,  on  inspiration  the  chest  rises  fully  and  no  air 
escapes  e.xcept  when  the  cone  is  too  small,  when  a  larger 
size  can  be  put  in.     This  is  kept  up  regularly  twelve 


November  30,  1895] 


MEDICAL   RECORD. 


709 


times  a  minute,  and  atomized  water  is  forced  into  the 
tube  occasionally  to  keep  the  passages  moistened. 

Case  I. — A  German,  thirty-seven  years  of  ao-e,  a 
cook,  had  taken  morphine  irregularly,  but  had  no  hab- 
it. After  a  fracture  of  the  leg  he  became  despondent, 
and  at  6  p.m.,  on  July  23,  1895,  took  twelve  grains  of 
morphine  in  shellaced  pills,  ^  grain  each.  He  was 
brought  to  the  hospital  at  9.30  p.m.,  comatose,  cyanotic, 
pupils  contracted,  respirations  feeble,  and  four  a  min- 
ute ;  pulse  feeble,  irregular,  and  150  a  minute.  He 
was  given  strychnine  sulphate,  ^V  grain,  and  atropine 
sulphate,  -gV  grain,  hypodermatically  immediately,  and 
then  his  stomach  was  washed  out.  The  Sylvester 
method  was  tried,  as  his  color,  breathing,  and  pulse  be- 
came worse,  but  with  no  benefit  0'Dw)'er's  tube  was 
then  (10.30  P.M.)  inserted  and  worked  at  twelve  a  min- 
ute. The  patient's  whole  condition  improved — pulse 
and  color  soon  normal.  The  stomach-tube  was  again 
inserted  alongside  of  the  laryngeal  tube,  and  the  organ 
washed  completely,  and  then  four  grains  permanganate 
of  potash  left  in. 

At  10.45  P.M.  atropine,  grain  j^,  was  given.  At  11.30 
P.M.  the  patient  could  be  aroused,  but  pulse  was  not  good, 
and  he  was  given  coffee,  eight  ounces,  by  rectum,  and 
strychnine,  grain  -jV.  hypodermatically.  At  12  m.  patient 
became  restless.  The  tube  was  removed  and  he  was  made 
to  sit  up.  Notwithstanding  efforts  to  keep  him  awake,  he 
in  about  two  minutes  became  cyanotic,  and  pulse  rapid 
and  feeble.  The  tube  was  replaced  and  condition  be- 
came good  immediately.  At  i  a.m.  potassium  perman- 
ganate, grain  J^,  was  given  hypodermatically  ;  no  ap- 
preciable effect.  At  2.30  A.M.  tube  was  again  removed, 
but  cyanosis  returned.  It  was  put  back  again  and 
kept  in  place  till  5.45  a.m.,  when  the  patient  became  so 
restless  that  its  removal  was  a  necessity.  Even  after 
this,  till  7  a.m.,  to  keep  him  awake  the  slapping  of  a 
towel  was  required,  for  when  left  alone  his  respirations 
would  go  down  to  eight  and  ten  a  minute.  At  6  a.m. 
atropine,  grain  ^7^,  was  givtn.  From  2  to  6  a.m.  his 
temperature  gradually  arose  from  101.6°  to  105.8°  F., 
when  he  was  given  a  cold  sponge,  from  which  he  got  a 
drop  to  102°  F.  At  7.45  a.m.  he  was  sent  to  the  ward. 
Temperature,  101.5°  ^-  !  pulse,  120  ;  respiration,  16. 
Patient  was  able  to  sit  up  and  speak,  though  hoarse, 
and  complained  of  thirst.  He  was  given  whiskey  every 
four  hours  and  a  croup  kettle  started. 

Besides  this  laryngitis  he  developed  a  glossitis  from 
the  use  of  a  tongue  forceps.  These  complications 
kept  his  temperature  up  five  days,  when  he  was  dis- 
charged cured.  Tube  remained  in  seven  hours  and 
fifteen  minutes. 

Case  H. — A  German,  aged  fifty-six  ;  a  druggist. 
No  previous  morphine  habit.  Out  of  work  and  de- 
spondent, and  on  July  24,  1895,  at  12  M.  took  thirty 
grains  morphine  in  powder.  He  was  found  in  Cen- 
tral Park  about  4.30  p.m.,  and  brought  in  by  the  ambu- 
lance, the  Sylvester  method  being  used  on  the  way. 
On  admission,  at  5  p.m.,  pupils  contracted  ;  cyanosed  ; 
no  effort  at  respira'.ion  ;  pulse  fair.  O'Dwyer's  tube 
was  immediately  inserted  and  atropine,  grain  3"^,  given 
hypodermatically.  The  tube  did  not  fit  well,  and  it 
was  removed  and  a  smaller  cone  inserted,  but  this 
worked  worse  and  the  former  was  replaced,  and  by 
pressure  against  the  teeth  did  better.  It  was  difficult 
to  get  the  stomach- tube  by  the  laryngeal  tube,  but  after 
about  an  hour  attempting  it  was  successful,  and  the  or- 
gan was  thoroughly  washed  with  water  and  tannic  acid, 
and  four  grains  of  potassium  permanganate  left  in. 

At  10.30  P.M.  the  patient  was  fairly  conscious  and  his 
throat  full  of  secretions,  so  the  tube  was  removed  and 
he  was  made  to  sit  up.  Attempts  to  keep  him  awake 
and  breathing,  by  the  wet  towel  and  electricity,  were 
fruitless,  and  in  two  minutes  pulse  became  bad  and 
color  cyanotic.  Dr.  O'Dwyer  himself  inserted  the 
tube,  and  his  condition  became  good  immediately. 
At  II  p.m.  he  was  given  potassium  permanganate,  grain 
Yz,  hypodermatically. 


July  25th,  2.05  a.m. — Patient  became  very  restless 
and  tube  was  removed.  During  this  time,  besides  the 
initial  dose  of  atropine,  he  received  yJ^  grain  three 
times,  and  coffee  and  whiskey  by  rectum  twice.  Tem- 
perature rose  to  103.5°  F-  Admitted  to  ward  at  3  a.m., 
and  kept  awake  with  towel.  At  10  a.m.  temperature 
104.5°  F-'  face  a  little  cyanotic,  coughs,  and  is  hoarse. 

Complications  :  Glossitis,  laryngitis,  and  bronchitis, 
which  kept  his  temperature  up  for  five  days,  and  then 
discharged  cured.  Tube  was  in  nine  hours  and  five 
minutes. 

Bemarks. — i.  The  above  cases  are  very  bad  ones,  al- 
most in  extremis  when  first  seen. 

2.  They  show  how  ineffectual  artificial  respiration  by 
the  Sylvester  method  was  ;  how  atropine,  stimulation, 
and  potassium  permanganate  would  have  been  without 
results.  Of  course  each  helped  toward  a  safe  termina- 
tion, and  perhaps  the  permanganate  was  not  used  in 
large  enough  doses  and  as  frequently  as  required. 

3.  They  show  how  easily  the  tube  and  bellows  can 
be  used  and  how  quickly  it  acts,  and  that  the  stomach- 
tube  can  be  used  at  the  same  time. 

4.  One  interesting  result  is  the  high  temperature.  Is 
it  due  to  the  effects  of  the  drugs,  to  its  antidotes,  to 
hyperoxidation,  or  to  the  beginning  inflammations  of 
the  tongue,  lar)nx,  and  bronchi  ?  It  seems  most  rea- 
sonable to  suppose  to  the  last. 

5.  This  apparatus  can  be  bought  cheaply  and  should 
be  in  every  hospital,  for  it  can  be  used  in  other  emer- 
gencies, as  in  apnoea  due  to  ether  or  chloroform  nar- 
cosis, and  it  has  been  used  in  this,  the  Presbyterian 
Hospital,  in  cases  of  apoplexy,  tumors  of  the  brain,  and 
fractures  of  the  skull  where  the  respirations  stop  first. 
In  two  cases  operations  on  the  skull  were  performed 
while  the  tube  was  in  the  larynx. 

6.  So  we  see  that  in  prolonging  life,  as  well  as  in 
saving  it,  this  intubation  is  of  the  highest  value. 

The  above  cases  occurred  at  the  Presbyterian  Hos- 
pital during  the  service  of  Dr.  Walter  B.  James,  with 
whose  kind  permission  I  publish  them. 


WHAT     CONSTITUTES     THE     WELL  QUALI- 
FIED   DOCTOR.' 

By  EDWIN  STERNBERGER,  M.D., 

SURGEON  TO  MOUNT  SINAI  HOSPITAL  DISPENSARY,  NEW  VOfK. 

Without  any  introductory  remarks  whatever,  in  order 
to  give  you  the  gist  of  my  paper  at  the  outset,  I  will 
say  that,  in  my  judgment  and  in  the  opinion  of  others, 
the  general  practitioner  and  the  specialist  of  to-day  are 
not  properly  equipped,  or  perhaps  I  had  better  use  the 
term  schooled,  or  experienced,  for  the  scientific  work 
which  they  are  called  upon  to  do.  Now,  this  statement 
may  seem  to  you,  on  first  thought,  to  be  rather  a  broad 
one.  But  I  feel  sure  that  after  you  follow  me  care- 
fully in  what  I  am  going  to  say  you  will,  on  further  de- 
liberation, concur  with  me  in  the  above  apparently  bold 
assertion.     You  certainly  will  admit  the  following  : 

1.  To  be  a  thoroughly  scientific  and  conscientious 
general  practitioner,  as  the  term  implies,  the  doctor 
must  be  trained,  or  rather  educated,  in  all  the  branches 
of  medicine. 

2.  For  the  specialist  to  be  absolutely  thorough  in  his 
especial  sphere  or  specially,  it  is  necessary  that  he  be 
familiar  with  all  other  branches  outside  of  his  own. 

Both  of  these  statements  require  qualifying,  other- 
wise you  might  think  that  I  am  entirely  too  radical  in 
my  views.  Perhaps  if  all  of  us  in  the  medical  profes- 
sion were  more  radical,  i.e.,  more  thorough  in  our 
methods,  far  better  results  and  more  scientific  work 
would  obtain.  Does  it  not  appeal  to  you  that  in 
order  for  the  general  practitioner  to  render  the  very 
best  possible  treatment  to  his  patient,  or  perhaps  I  had 

I  Read  before  the  Metropolitan  Medical  Society  of  New  York,  Oc- 
tober 22,  1895. 


770 


MEDICAL    RECORD. 


[November  30,    1895 


better  say,  to  give  an  intelligent  opinion  to  his  patient, 
he  must  necessarily  be  versed  in  all  the  departments  in 
medicine  ?  Only  by  doing  so  does  he  ]XTform  his 
duties  or  obligations  honestly  and  scientifically  to  his 
patient  ?  It  is  not  to  be  expected  that  the  general 
practitioner  should  conduct  the  treatment  of  a  spe- 
cial form  of  disease  that  requires  the  expert  or  special- 
st.  But  I  do  claim  that  it  is  his  duty  to  learn  what 
the  nature  of  the  disease  is,  in  short,  to  make  the  scien- 
tific diagnosis.  How  often  does  it  happen  that  the  un- 
fortunate patient  is  treated  by  the  family  doctor  for  a 
disease,  the  diagnosis  of  which  is  never  made,  simply 
because  of  the  ignorance  of  the  attending  physician  ? 

Ignorance  in  medicine  as  well  as  in  law  does  not  ad- 
mit of  an  excuse.  The  patient  certainly  relies  upon  his 
medical  attendant  for  receiving  the  proper  treatment. 
He  surely  does  so  until  he  is  convinced  he  is  not  get- 
ting the  right  treatment,  or  until  a  friend,  or  perchance 
a  friendly  physician,  advises  him  to  make  a  change  by 
consulting  Dr. ,  who  is  a  specialist  in  the  depart- 
ment to  which  his  malady  belongs.  I  am  referring  now 
to  an  ordinary  case,  one  that  a  well-educated  physician 
with  proper  experience  would  recognize  and  either  treat 
properly  or  refer  to  the  proper  specialist.  Such  an  in- 
stance as  the  above,  I  am  sure,  happens  repeatedly — 
not  only  in  the  small  town  but  in  the  large  city  as  well. 

You  must  not  think,  gentlemen,  that  I,  for  a  mo- 
ment, am  finding  fault  with  the  physic'ian  who  is  attend- 
ing an  obscure  case.  Far  from  it.  For  in  such  a  case 
the  well-meaning,  the  honest,  the  conscientious  physi- 
cian will  then  seek  further  counsel  by  suggesting  a  con- 
sultation. By  way  of  parenthesis  1  would  say  that  it 
does  happen,  and  not  so  very  infrequently,  that  the  ex- 
perienced and  well-educated  physician,  believing  that 
he  himself  knows  it  all,  takes  it  upon  himself  to  con- 
duct the  whole  case  without  consultation,  even  though 
the  family  persistently  wishes  it.  Such  action  on  the 
part  of  a  physician  is  surely  open  to  harsh  criticism. 

Let  us  consider,  now,  the  importance,  the  great  ne- 
cessity for  the  general  practitioner  to  be  thoroughly,  or 
at  least  partially,  familiar  with  all  the  branches  of  medi- 
cine. Take  any  one  of  the  specialties,  gentlemen,  the 
skin  for  example,  and  I  am  sure  it  will  appeal  to  every 
one  of  you  that  a  knowledge  of  this  specialty  is  indis- 
pensable for  the  general  doctor.  It  will  stand  him  in 
good  stead  to  be  a  moderately  good  dermatologist  to  pre- 
vent at)y  unpleasantness  which  might  arise  through  ignor- 
ance, even  though  his  conscience  doesn't  tell  him  that  he 
owes  it  to  his  patient  to  recognize  a  skin  eruption. 

I  don't  suppose  for  a  moment  that  I  am  exaggerat- 
ing when  I  say  that  many  an  eruptive  fever  case  of  a 
virulent  character,  under  the  care  of  a  general  practi- 
tioner of  limited  experience,  progressing  favorably  or 
unfavorably,  as  the  case  happens  to  be,  causes  the 
physician  or  the  family  very  little,  if  any,  concern,  not- 
withstanding the  grave  conditions  prevailing.  Again, 
see  how  exceedingly  important  it  is  for  the  general 
practitioner  to  make  a  correct  diagnosis  in  small-pox 
or  typhus.  Suppose  he  isolates  a  case  that  he  is  posi- 
tive of  as  being  contagious.  Just  look  at  the  discom- 
fort, outside  of  the  trouble  and  expense,  it  puts  a  fam- 
ily to.  Now,  I  am  not  referring  to  a  suspected  or 
doubtful  case.  This  method  of  conducting  a  case  is 
jierfectly  in  order  when  practised  by  the  experienced 
doctor,  who  does  it  then  solely  as  a  precaution.  I  am 
referring  to  the  doctor  whose  lack  of  proper  experience 
does  not  justify  his  making  a  positive  diagnosis.  I 
cannot  help  believing  that  many  of  the  cases  of  small- 
pox and  typhus,  especially  the  former,  that  we  read  and 
hear  of,  even  those  reported  by  the  Board  of  Health, 
are  not  genuine  cases.  It  takes  a  great  deal  of  experi- 
ence to  be  able  to  make  the  positive  diagnosis  of  either 
one  of  these  diseases.  One  must  have  seen  verified 
cases  before  venturing  a  positive  diagnosis. 

Not  long  ago  1  had  occasion  to  refer  a  suspicious 
case,  which  I  thought  might  be  small-pox,  to  one  of  our 
prominent  dermatologists.     After  assuring  me  that  it 


was  not  small-pox,  he  commented  on  this  very  subject, 
and  virtually  remarked  exactly  what  I  have  just  said. 

How  imperative  it  is  for  the  general  practitioner  to 
know  positively  what  he  says  when  he  informs  his  pa- 
tient that  he  is  suffering  from  syphilis.  By  erring  in 
such  an  instance  as  this,  from  lack  of  proper  education 
and  experience,  is  certainly  worthy  of  much  censure. 

Let  us  now  turn  to  ophthalmology.  To  the  improp- 
erly trained  practitioner  a  case  of  virulent  purulent  con- 
junctivitis never  suggests  itself  as  one  likely  to  be  gon- 
orrhoea! in  character.  He  perhaps  has  heard  of  such  a 
condition.  But  to  recognize  it,  or  even  have  the  dis- 
ease occur  to  him,  is  altogether  out  of  the  question. 

In  just  such  an  instance  as  the  above,  see  how  much 
depends  on  a  correct  early  diagnosis  and  the  proper 
treatment.  The  ignorance  of  the  physician  in  such  a 
case  might  cost  the  innocent  patient  one  or  both  eyes. 

In  obstetrics  it  is  of  the  greatest  importance  that  the 
general  practitioner  should  be  thoroughly  experienced  ; 
for  in  this  branch  of  medicine,  which  is  ordinarily  con- 
ducted by  the  family  doctor,  where  emergencies  can  arise 
at  any  moment,  the  physician  must  have  at  his  finger's 
end  the  proper  method  to  pursue  at  the  critical  time. 

How  many  doctors  are  there  who  regularly  attend 
cases  of  labor,  in  conjunction  with  their  general  prac- 
tice, who  have  had  the  proper  scientific  training  in 
midwifery?  I  venture  to  say  it  is  the  great  exception 
for  a  general  doctor  to  have  had  any  experience  or 
systematic  schooling  whatever  as  an  accoucheur 
when  he  begins  his  private  practice.  I  am  sure  none 
of  you  will  take  exception  to  this  assertion,  because 
you  all  know  or  have  seen  cases  that  have  been  mis- 
managed by  the  general  physician,  simply  on  account 
of  deficient  early  training. 

I  know  from  my  own  experience,  while  an  interne  at 
the  Sloane  Maternity  Hospital,  that  this  specialty  re- 
quires personal  management  and  manipulation  under 
careful  supervision — not  merely  observation  and  book- 
reading — to  properly  fit  one  to  conduct  a  labor  case. 

That  the  general  practitioner  should  be  conversant 
with  the  principles  and  practical  part  of  surgery,  par- 
ticularly minor  surgery,  cannot  be  disputed  by  any- 
body. Yet  how  many  of  our  general  practitioners  are 
at  all  able  to  conduct  a  minor  surgical  case  according 
to  true  scientific  principles  ?  I  venture  to  say  mighty 
few  ;  especially  is  this  so  of  those  who  have  been  in 
practice  for  many  years.  You  might  say  that  the  old 
practitioner  has  an  excuse  for  not  practising  surgery 
(simple  or  minor)  according  to  modern  methods,  be- 
cause the  present  methods,  particularly  the  aseptic  and 
antiseptic  ones,  were  unknown  to  him  when  student 
and  interne  This  I  contend  is  no  legitimate  excuse. 
It  certainly  behooves  a  conscientious  practitioner,  just 
because  modern  methods  have  superseded  old-time 
ones,  to  familiarize  himself,  not  alone  by  reading  but  by 
actual  experience,  with  a  more  recent  technique.  How 
many  take  the  pains  to  do  so  ?  Surely  very  few. 
All  of  you  present,  I  am  sure,  have  seen,  as  I  have, 
most  wretched  minor  surgery  practised  by  men  who 
have  tremendous  reputations  as  conscientious  and  sci- 
entific practitioners.  I  am  not  in  the  least  exagger- 
ating, and  I  know  you  don't  think  that  I  am,  by 
making  these  sweeping  assertions.  I  could  quote  in- 
numerable cases,  but  I  am  so  positive  that  you  all  can 
recall  cases,  as  I  can,  that  I  liardly  think  it  necessary  to 
take  up  your  time  by  doing  so.  I  hardly  deem  it 
necessary  to  take  up  any  more  of  the  specialties  to 
show  you  the  indication  for  the  general  practitioner 
being  jiroficient  in  all  departments.  The  mere  fact 
that  I  have  directed  your  attention  into  this  channel  of 
thought  will  be  sufficient  to  cause  convincing  exam- 
ples to  suggest  themselves  in  those  specialties  not 
dwelt  upon. 

Coming  now  to  the  different  specialties,  I  will  take, 
first,  that  of  neurology,  to  illustrate  the  truth  of  my 
second  statement,  namely,  "  For  the  specialist  to  be 
absolutely  thorough  in  his  especial  sphere  or  specialty  " 


November  30,    1895] 


MEDICAL   RECORD. 


771 


it  is  necessary  that  he  be  familiar  with  all  other  branches 
outside  of  his  own.  All  of  us,  even  those  who  are  not 
neurologists,  know  how  important  it  is  for  the  nerve 
specialist  to  be  well  acquainted  with  ophthalmology, 
particularly  with  ophthalmoscopy.  The  nerve  special- 
ist, again,  must  be  familiar  with  dermatology,  for  we 
well  know  that  there  are  many  skin  diseases  depending 
directly  on  a  derangement  of  the  nervous  system,  if 
the  neurologist  has  not  had  a  good  skin  training,  he 
might,  while  treating  a  nervous  case  with  an  eruption, 
have  difficulty  in  determining  whether  the  eruption  is 
due  to  the  disordered  nervous  condition  or  to  some 
other  cause  unbeknown  to  him.  With  a  proper  der- 
matological  experience  the  neurologist  could  seldom 
be  placed  in  such  a  dilemma,  and  a  differential  diag- 
nosis would  be  [jlain  sailing  for  him.  Furthermore, 
when  you  consider  how  frequently  a  cough  is  of  a  ner- 
vous or  hysterical  origin,  how  much  more  satisfaction 
would  it  be  to  the  neurologist  if  he  were  familiar  with 
laryngology,  so  that  he  might  determine  for  himself 
that  there  was  no  throat  lesion  that  could  account  for 
the  cough.  Again,  before  he  can  conclude  that  the 
cough  is  of  nervous  origin  he  must  have  excluded  the 
lungs  ;  hence  you  see  the  indication  for  the  neurologist 
to  be  apt  at  making  a  physical  examination  of  the  chest. 

When  we  consider  the  department  of  surgery  no  one 
can  dispute  the  fact  that  for  a  surgeon,  above  all  other 
specialists,  to  be  thorough  in  his  sphere,  particularly  as 
a  diagnostician,  he  must  be  well  qualified  in  all  branches 
of  medicine.  It  is  apparent  to  every  one  of  us,  with- 
out citing  examples,  that  the  surgeon  must  be  a  good 
physical  diagnostician.  The  ability  to  percuss  and 
auscultate  is,  perhaps,  as  important  a  quality  for  the 
surgeon  to  possess  as  the  general  practitioner.  That 
the  general  surgeon  should  be  a  gynecologist  admits  of 
only  one  argument. 

In  doing  an  exploratory  laparotomy,  for  instance,  it 
does  not  infrequently  happen  that  the  surgeon  after 
entering  the  abdomen  finds  a  condition  of  affairs  that, 
strictly  speaking,  belongs  to  the  domain  of  gynecology. 
How  embarrassing  it  must  be  for  the  surgeon  and  how 
unfair  to  the  unfortunate  patient  when  a  condition  like 
this  is  met  with  and  the  operator  is  not  competent  to 
manage  the  case  simply  because  it  turns  out  to  be 
j)urely  gynecological.  Such  an  instance  as  this,  gen- 
tlemen, is  by  no  means  a  fanciful  one,  for  believe  me 
when  I  tell  you  that  I  was  an  eye- witness  to  such  a  case. 

Conversely,  I  can  well  state  at  this  point,  that  for  the 
gynecologist  to  do  justice  to  his  work  and  to  save  him- 
self from  embarrassment,  he  must  have  had  a  good  sur- 
gical training.  It  often  happens  that  the  gynecologist 
in  performing  a  laparotomy,  even  though  he  is  quite 
sure  of  his  diagnosis,  has  to  deal  not  with  a  gyneco- 
logical case  but  with  a  surgical  one. 

Thus  you  see,  gentlemen,  in  the  several  specialties 
that  I  have  referred  to,  the  strong  indication,  the  ne- 
cessity, for  the  siiecialist  to  be  well  informed  and  ex- 
perienced in  other  departments  besides  his  own. 

Possibly  the  instances  I  have  brought  up  have  not 
been  very  striking  ones,  but  I  feel  sure  they  will  serve 
my  purpose  in  calling  your  attention  to  this  exceed- 
ingly important  question  of  a  broader  and  more  liberal 
education  and  training  of  the  doctor. 

I  cannot  close  my  paper  without  dwelling  for  a  mo- 
ment on  the  important  subject  of  emergencies,  the 
proper  management  of  which  all  doctors,  whether  spe- 
cialists or  general  practitioners,  ought  to  be  thoroughly 
familiar  with.  Every  one  of  us  who  practises  medicine 
should  know,  not  from  reading  but  by  actual  experience, 
how  to  administer  an  anajsthetic,  and  how  to  manage  a 
possible  emergency  in  connection  with  its  administra- 
tion. I  contend  that  the  |)osition  of  anajstheii/.ei  is,  often- 
times, if  not  always,  as  important  as  that  of  the  operator. 

That  all  of  us  should  know,  instinctively,  how  to 
cope  with  hemorrhage  cannot  be  emphasized  too 
strongly.  There  are  doctors,  and  many  at  that,  who 
either   become    flustered    or    are    wholly   incompetent 


when  confronted  with  a  severe  case  of  hemorrhage. 
In  connection  with  hemorrhage  I  cannot  let  this  op- 
portunity pass  by  without  referring  to  the  extraordi- 
nary results  from  infusion  when  practised  properly. 

It  is  not  my  purpose  here,  gentlemen,  to  describe 
the  methods  and  technique  of  infusion  or  how  to  con- 
trol hemorrhage.  I  merely  want  to  attract  your  atten- 
tion to  a  subject  that  above  all  others  requires  careful 
consideration  by  the  medical  fraternity. 

43  East  Sixtieth  Street. 


SARCOMA  OF  THE  NASAL  CAVITY  ;  LIGA- 
TION OF  BOTH  EXTERNAL  CAROTIDS  ; 
DECIDED   BENEFICIAL    EFFECT. 

By   M.   D.    LEDERMAN,   M.D., 


Malignant  disease  of  the  nasal  passages  is  happily 
not  a  frequent  manifestation.  Unfortunately  its  origin 
is  so  insidious  that  when  symptoms  arise  which  demon- 
strate its  existence  the  disease  has  already  assumed  a 
formidable  aspect.  As  the  prognosis  in  such  cases  is 
usually  of  a  serious  character,  we  can  only  hope  to  al- 
leviate suffering  by  employing  strenuous  measures.  No 
remedy  is  so  prompt  in  its  action,  nor  so  justifiable  in 
its  application  in  suitable  cases  as  surgical  interference  ; 
and  as  the  latter,  though  extrinsic  in  my  case,  has  had 
so  marked  an  effect  upon  the  pathological  process,  I 
offer  this  curtailed  contribution,  trusting  it  may  prove  of 
some  interest. 

Observers  have  reported  instances  of  adeno  sarcoma, 
fibro-sarcoma,  myxo  sarcoma,  spindle-celled  sarcoma, 
round-celled  sarcoma,  osteo-sarcoma,  and  rarely  melano- 
sarcoma,  invading  this  region.  The  round- celled  va- 
riety probably  appears  most  frequently.  Sarcoma  in 
this  vicinity,  if  not  stimulated  by  medicinal  or  mechani- 
cal irritation,  is  inclined  to  run  a  slow  course.  It  is 
more  often  met  with  before  the  age  of  forty  years,  in  a 
number  of  recorded  cases  presenting  itself  before  the 
age  of  puberty,  and  terminating  fatally  after  an  av- 
erage duration  of  from  three  to  four  years.  It  is 
claimed  that  the  small  round- celled  type  is  the  most 
malignant,  developing  very  rapidly  and  prone  to  reap- 
pear even  after  it  has  been  seemingiy  eradicated.  The 
malignant  nature  of  the  growth  grows  less  as  the  pro- 
portion of  normal  tissue  elements  in  the  structure  of 
the  tumor  increases.  The  osteosarcoma  is  another  of 
this  group  which  grows  with  astounding  jiace.  In  a 
patient  suffering  from  the  latter  form  of  the  disease, 
whom  I  had  the  opportunity  of  examining,  the  tumor, 
which  originally  started  in  the  nasal  chamber,  had 
eroded  through  the  basilar  jjortion  of  the  occipital  bone, 
extending  into  the  maxillary  antrum  ;  into  the  eth- 
moidal and  sphenoidal  cells  ;  through  the  floor  of  the 
orbit,  causing  pronounced  exophthalmos,  necessitating 
enucleation  of  the  eye  ;  descending  through  the  soft 
and  hard  palate,  appearing  in  the  mouth.  Attempts  at 
extirpation  were  made  before  it  had  reached  such 
enormous  proportions,  but  they  failed  to  arrest  its 
growth.  When  last  seen  the  neoplasm  occupied  the 
entire  right  side  of  the  face.  Morphine  in  ten-grain 
doses  was  taken  as  the  only  relief. 

Direct  surgical  treatment  in  cases  of  sarcoma  of  the 
nasal  passages  should  be  carried  out  early  and  thor- 
oughly. At  times,  however,  we  meet  with  patients  in 
whom  this  i)rocedure  is  not  feasible  nor  justifiable,  ow- 
ing to  the  extensive  sjjrcad  of  the  disease.  Such  was 
the  state  of  affairs  existing  in  the  case  which  1  herewith 
report.  The  (juestion  naturally  arises,  what  means  are 
to  be  employed  in  similar  conditions  ? 

Dr.  Coley  has  had  some  promising  results  from  injec- 
tions of  erysipelas  and  bacillus  piodigiosus  toxins. 
Prolonuclein  has  been  recommended  as  being  of  service 
in  diseases  of  a  malignant  nature. 


772 


MEDICAL    RECORD. 


[November  30,  1895 


As  far  back  as  1 849,  Van  Buren  '  ligated  the  right  com- 
mon car  )tid  artery  in  a  patient  afflicted  with  sarcoma  of 
the  nasal  cavity,  attempting  to  retard  the  progress  of 
the  growth  in  this  manner.  Though  the  patient  suc- 
cumbed eighty-two  hours  after  the  operation,  the  tumor 
had  already  appreciatively  diminished.  Dr.  W.  C.  Jar- 
vis  -  mentions  a  cure  of  a  similar  case  by  ligation  of 
both  common  carotids  and  the  subsequent  e.xsection  of 
a  portion  of  the  superior  maxilla. 

The  history  of  my  case  is  as  follows  :  Charles  B , 

varnisher,  twenty-six  years  of  age,  was  referred  to  me 
in  May,  1895,  by  Dr.  A.  Mayer,  for  a  growth  in  the 
nose,  which  he  thought  was  malignant.  For  over  three 
years  the  young  man  had  repeated  attacks  of  nose- 
bleeding,  lasting  for  several  hours,  which  were  difficult 
to  arrest,  and  compelled  him  to  stop  work.  As  a  child 
he  remembered  having  an  occasional  hemorrhage  from 
the  nose,  and  also  recalled  having  colored  blotches 
over  his  body  (very  likely  some  variety  of  purpura). 
He  felt  quite  weak  after  the  prolonged  epistaxis,  and 
had  to  rest  before  he  felt  able  to  resume  work.  Frontal 
headaches  were  very  severe  for  two  years  past,  and 
were  the  principal  cause  of  complaint.  Obstructed 
nasal  respiration  on  the  right  side  became  annoying. 
Anosmia  gradually  followed,  but  no  ocular  disturbances 
appeared.  At  that  time  he  was  examined  by  a  surgeon, 
■who  evidently  recognized  the  disease,  as  he  suggested 
exsection  of  the  superior  maxilla,  with  the  possible 
enucleation  of  the  right  eye.  To  this  Mr.  B —  ob- 
jected, as  the  eye  had  not  troubled  him  in  the  least, 
and  he  did  not  suppose  his  affliction  to  be  so  serious  a 
matter.  The  patient's  general  appearance  aroused  sus- 
picion. He  was  cachectic  and  emaciated.  On  inspect- 
ing the  nose  a  large  fleshy  mass  was  observed  pre- 
senting at  the  right  vestibule,  the  anterior  and  lower 
portion  of  the  growth  being  of  a  grayish  color.  It  was 
impossible  to  see  the  attachment,  as  the  tumor  filled 
the  entire  cavity.  On  attempting  to  locate  same  by 
means  of  a  probe  a  profuse  bleeding  resulted.  Cocaine 
was  applied  to  arrest  the  hemorrhage  and  at  the  same 
time  to  facilitate  the  examination.  On  posterior  rhi- 
noscopy the  growth  was  found  occupying  the  right  and 
left  choanae,  being  attached  to  the  pharyngeal  vault  and 
upper  portion  of  pharynx,  and  to  the  pterygoid  plates 
of  sphenoid  bone.  It  almost  encroached  upon  both 
Eustachian  orifices,  the  hearing  being  slightly  affected. 
Owing  to  a  deflected  septum  to  the  left,  no  view  could 
be  obtained  through  this  side  anteriorly.  There  was 
some  space  on  the  left,  posteriorly,  along  the  floor  of 
the  nose,  through  which  the  patient  was  able  to  breathe. 

Fearing  a  prolonged  bleeding  the  galvano-cautery 
was  employed  in  removing  a  portion  of  the  tissue  from 
the  right  side.  A  tampon  of  punk  (surgical  sponge) 
checked  the  copious  bleeding  which  followed.  Micro- 
scopical examination  showed  the  specimen  to  be  a 
small,  round-celled  sarcoma,  with  very  little  intercellu- 
lar structure.  As  the  disease  was  so  extensive,  a  bad 
prognosis  was  made.  Suggested  some  possible  benefit 
from  the  use  of  the  erysipelas  and  bacillus  prodigiosus 
toxins.  The  patient  received  the  first  injection  of  two 
minims  into  the  anterior  portion  of  the  tumor  on  the 
morning  of  May  25,  1895.  Dr.  H.  A.  Cohrs,  of  Brook- 
lyn,  who  lived  near  Mr.  R ,  was  kind  enough  to 

note  the  effects  of  the  toxins  during  the  interim.  He 
informed  me  that  the  patient  developed  chills  after 
leaving  my  office,  and  that  they  continued  until  he  saw 

the  patient  at  2  p.m.  same  day.    Mr.  B had  vomited 

several  times  ;  complained  of  violent  pains  in  the  back 
and  joints,  and  of  severe  headache.  The  face  was  con- 
siderably swollen,  and  the  conjunctiva  much  injected. 
Temperature  (rectal),  104.8°  F.  ;  pulse,  120.  At  5 
p.M  :  The  vomiting  had  ceased  ;  pain  was  less  ;  temper- 
ature, 103.6°  F.  ;  pulse,  115.  At  8  p.m.  :  Pain  in  joints 
and  back  absent ;  conjunctiva;  normal  ;  headache 
milder;  temperature,   102.8°    F.  ;    pulse,    no.     At    11 

•  Bosworth;  Diseases  of  the  Nose  and  Throat. 

»  Burnett :  System  of  Diseases  of  the  Ear,  Nose,  and  Throat 


P.M.  :  Temperature,  101.8°  F.  ;  pulse,  100  ;  was  very 
restless  ;  morphia  sulph.  (gr.  J{)  was  given  by  mouth. 

May  26,  1895,  II  .\.M. — Temperature,  normal ;  pulse, 
88  ;  felt  very  weak  ;  was  not  able  to  come  to  the  office. 

May  28,  1895. — Mr.  B came  to  see  me.     He  felt 

much  depressed  ;  had  no  appetite,  and  stated  that  his 
throat  was  very  sore.  This  was  due  to  an  herpetic 
eruption,  situated  on  the  uvula  and  hard  palate.  The 
mucous  membrane  was  swollen  and  painful.  A  similar 
lesion  existed  at  the  corners  of  the  mouth.  Odontalgia 
was  also  troublesome.  Infection  was  quite  marked  in 
this  instance.  As  the  temperature  had  remained  nor- 
mal another  injection  of  one  minim  was  given.  At 
7.30  that  evening  the  temperature  was  101°  F.  ;  pulse, 
90,  and  intermittent.  Similar  symptoms  reappeared, 
but  in  milder  form. 

As  the  reaction  was  severe  it  was  thought  best  to 
have  the  patient  under  daily  observation,  so  he  was 
placed  in  the  Pol5'clinic  Hospital. 

On  June  3d,  1.30  p.m.,  gave  an  injection  of  one 
minim.  At  4  30  p.m.,  temperature  was  103°  F.  ;  chills 
and  nausea  became  pronounced.  Whiskey  administered 
on  account  of  depression  ;  headache  became  agonizing. 
Sulfonal  given  to  promote  sleep.    Temperature  receded 

to  99°  F.    the  following  day,  and  Mr.  B felt  more 

comfortable. 

June  4th,  1.30  P.M. — Same  quantity  as  last  was  in- 
jected. Similar  train  of  symptoms  arose.  Tempera- 
ture, 101°  F.  Cephalalgia  became  unbearable,  and 
hypodermics  of  Magendie's  solution  had  to  be  repeated 
daily.  Iodide  of  potassium  in  ascending  doses  gave  no 
relief.  Patient  refused  further  injections  of  the  "  tox- 
ins," so  a  surgical  measure  was  proposed.  He  willingly 
acquiesced  to  any  procedure  that  would  offer  some  ame- 
lioration, as  the  headache  caused  him  great  suffering. 

Drs.  Wyeth  and  Dawbarn  examined  Mr.  B ,  and 

came  to  the  conclusion  that  the  attachments  of  the 
sarcoma  were  too  extensive  to  permit  of  direct  surgical 
manipulation.  Ligation  of  both  external  carotid  arte- 
ries was  suggested  as  being  justifiable  in  this  case.  Dr. 
Dawbarn  kindly  performed  the  double  ligation  ;  eight 
days  intervening  between  the  operations.  The  veins 
of  the  neck  were  found  greatly  engorged.  Our  patient 
made  a  good  recovery,  and  left  the  hospital  at  the  end 
of  the  month.  At  the  time  of  his  departure  the  head- 
ache was  much  improved. 

Being  advised  to  go  to  the  mountains,  he  spent  the 
remainder  of  the  summer  among  the  Catskills.  There 
he  lived  on  fresh  albuminous  food.  His  appetite 
promptly  returned  after  reaching  the  higher  altitude. 
On  his'  return,  August  27,  1895,  the  parts  were  exam- 
ined, and  I  was  surprised  to  find  so  decided  a  diminu- 
tion in  the  nasal  portion  of  the  growth.  It  was  about 
one-third  of  its  previous  size,  and  its  attachments  to 
the  middle  turbinated  body  could  now  be  readily  seen. 
Breathing,  in  a  modified  degree,  could  be  carried  out 
through  this  side,  but  it  was  still  considerably  ob- 
structed owing  to  the  mass  occupying  the  posterior 
nares,  which,  though  somewhat  reduced,  yet  occluded 
the  greater  part  of  the  choan».  The  breathing  was 
better  on  the  left  side.  The  tumor  seemed  less  vascu- 
lar and  more  fibroid  in  character.  Probing  did  not 
cause  any  bleeding. 

As  the  patient  was  much  improved,  further  local 
operative  treatment  was  postponed.  My  intention  is 
to  remove  the  pendulous  nasal  mass  with  the  cold 
snare,  avoiding  the  possible  stimulation  of  the  disease, 
which  might  arise  if  the  galvano-cautery  wire  was  em- 
ployed. Furthermore,  direct  treatment  can  now  be  at- 
tempted without  starting  what  might  previously  have 
been  a  serious  hemorrhage.  As  the  collateral  circula- 
tion increases,  this  danger  is  naturally  augmented. 

Mr.  B ,  in  the  meantime  is  taking  an  alterative 

tonic,  and  living  on  a  nourishing  diet.  He  is  again 
able  to  continue  at  his  work,  having  gained  twenty 
pounds  in  weight. 

128  East  Sixtieth  Street. 


November  30,    1S95] 


MEDICAL    RECORD. 


IT, 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  November  30,   1895. 


THE  ARMY  RATION. 

The  recent  experiments  of  the  United  States  Govern- 
ment to  test  the  value  of  a  concentrated  army  ration 
have  quite  naturally  proved  a  failure.  They  were  in- 
stituted by  the  Secretary  of  War  with  a  view  of  reduc- 
ing the  bulk  and  weight  of  food  without  impairing  its 
nutritive  functions.  This  appeared  to  be  necessi- 
tated by  the  fact  that  the  American  army  is  more  in 
need  of  possible  improvements  in  this  line,  in  \'iew  of 
the  heavy,  tedious  and  long  transportation  of  supplies 
across  the  plains  and  through  districts  that  are  incapa- 
ble of  affording  the  proper  amount  and  quality  of  food 
in  times  of  emergencies.  The  German  army,  for  ex- 
ample, when  moving  in  small  bodies,  always  purchases 
supplies  on  the  march  as  wanted.  The  same  is  true  of 
the  French,  Russian,  Austrian,  and  other  European 
armies,  but  at  the  same  time  the  soldiers  usually  have 
in  their  knapsacks  what  is  called  an  "  emergency  "  ra- 
tion, generally  sausage  or  preserved  meat  of  some  kind. 
The  soldiers  of  the  Japanese  army  in  the  late  war  with 
China  carried  an  emergency  ration  of  rice  in  a  little  tin 
case  strapped  to  the  top  of  their  knapsacks. 

The  reports  made  by  the  different  military  depart- 
ments to  whom  the  questions  were  referred  are  inter- 
esting as  bearing  upon  the  value  of  food  products  gen- 
erally, and  on  the  physiological  questions  involved  in 
the  digestive  and  nutritive  processes  more  particularly. 
Theoretically  speaking  it  would  appear  that  the  prob- 
lem had  been  solved  regarding  the  amount  of  food 
necessary  to  sustain  life  and  the  varieties  of  sustenance 
that  gave  in  minimum  compass  the  greatest  amount  of 
nourishment. 

All  the  observers  agree,  however,  that  the  old-fash- 
ioned ration  of  bacon  and  hard-tack  in  suitable  bulk  is 
the  most  practical  that  has  ever  been  suggested.  The 
(juantity  of  food  necessary  to  keep  a  soldier  in  good 
condition  is  fixed  at  twenty-two  ounces.  The  latter 
amount  is  increased  for  ob%-ious  reasons  to  twenty-six 
ounces. 

When  the  theories  were  put  to  a  practical  test  the  re- 
sult was  as  might  have  been  anticipated.  Various  con- 
centrated food  tablets  were  employed  in  Colorado,  but 
more  than  half  the  men  who  were  victims  to  the  exper- 
iment became  candidates  for  hospital  treatment.  The 
following  extract  from  the  report  speaks  very  signifi- 
cantly on  some  very  essential  and  striking  facts : 

"  A  company  of  the  Seventh  Infantry,  at  Fort  Logan, 
near   Denver,  was  Retailed  and  furnished    with  con- 


densed rations,  consisting  of  coffee,  soup,  bread,  and 
bacon.  The  coffee  and  soup  were  in  small  tablets, 
which,  when  placed  in  boiling  water,  were  ready  for 
consumption  in  two  minutes.  The  bread  was  in  small 
flat  cakes,  the  weight  and  hardness  of  a  brick,  but  when 
moistened  swelled  out  like  a  sponge.  The  bacon  was 
compressed  and  needed  only  to  be  warmed  in  a  frying- 
pan.  The  soldiers  started  out  with  ten  days'  rations,  but 
the  campaign  was  brought  to  an  abrupt  end  after  four 
days  of  fifteen-mile  marches.  The  food  not  only  did  not 
satisfy  the  hunger  or  give  strength,  but  seemed  to  irri- 
tate the  stomach.  After  the  first  meal  two  of  the  en- 
listed men  had  to  be  placed  under  the  surgeon's  care. 
At  the  end  of  the  second  day  thirty  of  the  seventy  men 
in  the  company  were  Ul,  and  on  the  fourth  day  the 
whole  command  went  into  camp,  and  couriers  were 
sent  to  town  for  hard-tack  and  ordinary  coffee  and  ba- 
con. Some  of  the  soldiers  were  seriously  ill  with  a 
stomach  complaint,  and  were  confined  to  the  hospital 
for  several  days." 

All  this  goes  to  show  that  not  only  ver>'  much  is  to 
be  learned  regarding  laboratory  feeding,  but  that  we  are 
also  far  from  the  proper  appreciation  of  nature's  com- 
plex requirements  in  food  taking.  Thus  far  the  hu- 
man laboratory,  with  its  multiple,  interdependent,  and 
complementary  methods,  has  a  monopoly  of  its  own  in 
fixing  the  proper  standards  for  digestion,  assimilation, 
and  subsequent  growth.  There  is  a  natural  law  per- 
vading the  whole  that  must  not  be  violated  by  too  rad- 
ical attempts  at  modification  or  improvement.  The 
stomach  pouch  is  constructed  with  a  certain  capacity 
for  food  which  cannot  be  gainsaid  by  any  chemical 
formula  which  mere  human  ingenuity  may  create  or 
theoretical  reasoning  de^^se.  Each  of  the  varied  and 
subtle  processes  of  digestion  must  necessarily  adapt 
themselves  to  the  construction  and  functions  of  an  or- 
gan that  has  a  purely  vital  as  well  as  a  merely  chem- 
ical dut)'  to  perform.  The  stomach  must  earn  its  liv- 
ing in  its  own  way,  as  by  such  purely  physiological 
effort  in  bringing  each  and  all  of  its  mechanical,  vital, 
and  chemical  functions  into  play,  it  can  best  main- 
tain its  health,  acti\-ity,  and  usefulness.  No  prepared 
or  concentrated  food  can  relieve  it  of  any  or  all  of  its 
activities  in  that  gradual  conversion  of  a  legitimate 
quantity  and  quality  of  food  that  constitutes  a  natural 
and  perfect  digestion.  In  such  an  aspect  a  moder- 
ately full  stomach  is  something  more  than  a  feeling. 
Its  work  must  be  distributive  rather  than  restrictive. 
It  must  be  healthfully  distended  with  food  bulky 
enough  to  occupy  spare  places,  otherwise  its  most  im- 
portant function  is  hampered,  while  for  lack  of  me- 
chanical stimulus  the  intestines  become  stagnated  into 
almost  helpless  inactivity.  Hence  it  is  easy  to  see  how 
the  experiments  failed,  and  the  victims  paid  the  pen- 
alty of  outraged  physiological  laws.  So  far,  at  least, 
there  is  not  sufficient  reason,  because  a  man  becomes  a 
soldier,  that  his  stomach  should  be  puckered  around  a 
desiccated  soup  tablet,  or  that  it  should  wrestle  alone, 
in  some  dark  comer  of  an  accommodating  fold,  with 
some  soggy  and  glazed  albuminoid. 


Horseless  Carriages  are  used  by  the  country  physi- 
cians in  France. 


774 


MEDICAL    RECORD. 


[November  30,  1895 


QUESTION    OF    PRIORITY    IN    SERO-THER- 

APY. 
There  are  many  names  honorably  associated  with  recent 
discoveries  concerning  the  immunizing  and  curative 
properties  of  the  blood  of  immunized  animals,  and  the 
future  alone  will  determine,  if  it  is  possible  ever  to  know 
with  certainty,  who  was  actually  the  first  to  state  the  doc- 
trine of  artificial  immunity  with  an  appreciation  of  its 
stupendous  bearing  upon  modem  medical  science. 
But  while  the  future  will  render  the  final  judgment,  the 
documents  and  the  evidence  must  be  presented  now 
while  the  chief  actors  are  still  on  the  scene.  One  of 
the  claimants  to  this  honor  is  Professor  Victor  Babes, 
of  Bucharest,  who  presented  his  side  of  the  controversy 
in  a  communication  addressed  to  the  Academy  of  Medi- 
cine of  Paris,  early  in  the  present  year. 

While  Behring  and  Kitasato,  he  said,  published  their 
first  communication  on  tetanus  in  the  Deutsche  Medicin- 
ische  Wochenschrift,  No.  49,  1S90,  the  writer,  in  collab- 
oration with  Lepp,  had  established  the  same  principle 
in  relation  to  rabies  in  a  paper  published  in  the  An- 
nales  de  Vlnstittit  Pasteur  for  July,  1889.  He  thought 
at  the  time  that  Richet  and  Hericourt  were  the  first  to 
immunize  animals  by  means  of  serum  from  animals 
already  immunized,  but  on  reading  again  the  works  of 
these  authors,  he  found  that  they  had  made  no  such 
claim.  They  inoculated  rabbits  with  septicemia  and 
then  treated  them  with  the  blood-serum  of  non-immu- 
nized dogs,  and  also  of  dogs  which  had  recovered  from 
a  previous  attack.  They  apparently,  however,  did  not 
appreciate  the  significance  of  this  experiment,  remark- 
ing simply  that  the  blood  of  these  last  dogs  seemed  to 
be  more  efficacious  than  that  of  the  others.  If,  then, 
the  claim  of  these  authors  to  priority  be  disproved  by 
their  own  writings.  Babes  holds  that  his  must  be  con- 
ceded. 

He  quotes  from  his  paper  to  show  that  he  employed 
the  serum  of  an  immunized  animal  with  a  curative 
aim/  His  experiments  were  thus  described  in  the 
article  above  mentioned.  Four  dogs  with  shaven 
heads  were  put  into  a  cage  with  a  mad  dog,  which  bit 
them.  Two  of  these  dogs  were  untreated,  the  other 
two  had  received  an  injection  of  five  grammes  of 
blood  from  an  immunized  dog  every  day  for  a  week. 
The  two  control  animals  were  attacked  with  hydropho- 
bia sixteen  and  seventy-eight  days,  respectively,  after 
being  bitten.  One  of  the  vaccinated  dogs  died  a  month 
after  being  bitten,  but  without  having  exhibited  any 
symptoms  whatever  of  rabies,  and  experiments  showed 
that  its  brain  substance  was  not  virulent.  The  second 
dog  lived  many  years  free  from  disease. 

We  think  the  objection  might  hold  that  this  was  only 
a  preventive  inoculadon  and  not  an  attempt  at  cure— a 
disdnctiou  with  a  difference  when  it  comes  to  deciding 
a  question  of  priority  or  determining  whether  the  sig- 
nificance of  a  discovery  was  appreciated  at  the  time  it 
was  made,  in  other  words,  whether  it  really  was  a  dis- 
covery. Vaccination  was  employed  solely  as  a  preven- 
tive of  small-pox  for  a  long  time  before  its  value  as  a 
curative  agent  in  the  eariy  stages  of  the  disease  was 
recognized.  However,  that  Dr.  Babes  did  soon  recog- 
nize the  actual  curative  value  of  the  serum  of  immunized 
animals  is  evidenced  by  the  fact  that  he  used  it  the  fol- 
lowing year— in  1890— as  a  curative  agent  in  man. 


The  discoveries  which  Professor  Babes  claims  as  his 
own,  and  upon  which  he  bases  his  contention  of  prior- 
ity, are  the  following  : 

1.  That  immunity  against  infectious  disease,  in  this 
particular  instance  rabies,  may  be  transmitted  to  sus- 
ceptible animals  by  means  of  the  blood  of  animals  pre- 
viously rendered  in  high  degree  immune  to  this  disease. 

2.  That  this  method  will  effectively  prevent  the  de- 
velopment of  the  disease  even  in  animals  that  have 
been  inoculated  with  the  virus  prior  to  the  beginning 
of  treatment. 

The  writer  expressly  disclaims,  however,  the  assump- 
tion that  Behring  had  based  his  work  upon  the  discov- 
eries made  by  himself  in  Pasteur's  laboratory,  which 
Behring  might  possibly  never  have  heard  of  ;  and  he 
desires  in  no  way  to  belittle  the  epoch-making  labors 
of  Kitasato,  Ehriich,  Roux,  and  others,  for  without  the 
researches  made  by  them,  he  admits,  his  own  discov- 
ery might  have  remained  hidden  and  barren  of  results. 
But  he  contends  that,  in  the  recording  of  the  part  taken 
by  individual  workers  in  laying  the  foundations  of 
sero-therapy,  the  future  medical  historian  cannot  in 
justice  omit  all  reference  to  the  part  he  himself  has 
taken  in  it. 


THE  DENVER  HEALER. 
A  MOST  extraordinary  social  and  psychological  phe- 
nomenon has  been  exciting  the  population  of  Denver 
and  the  great  Divide.  A  certain  person,  known  as 
"  Schlatter  the  Healer,"  has  been  the  principal  figure 
in  it.  The  facts  in  the  history  of  this  man  and  his 
works  have  been  published  in  the  daily  papers,  and  are 
probably  pretty  well  known  to  our  readers.  This  man, 
it  seems,  became  possessed  with  the  idea  that  he  was 
a  second  Messiah,  and  that  he  was  sent  to  the  earth 
with  healing  powers.  He  passed  a  long  period  of 
solitude  and  deprivation  in  the  Arizona  deserts,  and 
then  came  to  Denver,  where  he  announced  his  mission. 
He  talked,  dressed,  and  acted  in  a  curious  and  eccen- 
tric fashion,  so  that  public  attention  was  soon  called  to 
him,  and  he  was  helped  to  carry  out  his  work  of  heal- 
ing by  the  assistance  of  an  enthusiastic  friend.  Schlat- 
ter's fame  as  a  ''  healer  "  soon  spread  throughout  the 
West,  and  people  flocked  to  him  from  distant  regions, 
with  the  result  that  the  business  of  the  railroad  com- 
panies running  into  Denver  was  distinctly  increased. 
It  is  reported  that  he  saw  and  treated  many  thousands 
of  people  daily.  The  Denver  "  healer's  "  methods 
were  very  simple.  He  stood  at  one  side  of  a  fence 
which  enclosed  the  house  where  he  lived,  while  the 
people  who  came  to  be  healed  passed  slowly  by  in  a 
row  on  the  other  side.  He  took  each  one  by  the  hand 
and  uttered  some  words  of  promise,  direction,  and  en- 
couragement. Schlatter's  views  as  to  his  powers  were 
very  ingeniously  adapted  to  this  kind  of  treatment,  for 
he  did  not  claim  to  cure  at  once,  but  told  the  people  that 
they  would  get  well  after  a  few  days  or  a  few  weeks  or  a 
few  months.  Naturally,  among  many  thousands  of  peo- 
ple who  went  through  this  curious  ordeal,  a  certain  per 
cent,  would  get  well,  either  by  mental  influence  or  the 
natural  course  of  events.  The  peculiar  mysticism  of 
the  man,  his  apparent  unselfishness,  for  there  seemed 
to  be  no  money-making  in  connection  with  the  work. 


November  30,  1895] 


MEDICAL    RECORD. 


775 


lent  a  somewhat  additional  credence  to  his  claims,  and 
his  popularity  and  fame  were  growing  steadily,  up  to 
within  a  few  days  from  the  time  of  the  present  writ- 
ing, when  he  suddenly  disappeared,  leaving  the  mes- 
sage that  his  work  was  finished.  Nothing  could  have 
been  more  dramatic  or  better  timed  than  this  sudden 
breaking-off  in  the  very  height  of  his  popularity.  So 
far  as  reports  go,  it  seems  that  Schlatter  would  ver\- 
soon  have  far  out- done  the  healing  springs  of  the 
waters  of  Lourdes,  and  there  is,  in  the  history  of 
this  curious  man,  something  quite  as  surprising  and 
interesting  as  that  connected  with  the  French  faith- 
curing  resort.  As  to  the  reality  of  his  cures,  however, 
or  the  percentage  of  them,  we  are  told  by  the  Rev.  Mr. 
Heisler,  of  Denver,  who  has  investigated  the  matter,  that 
very  few  real  cures,  even  of  fanciful  ailments,  have  taken 
place,  and  Mr.  Heisler  is  of  the  opinion  that  Schlatter 
is  by  no  means  what  he  represents  to  be.  Most  people, 
however,  we  believe,  take  the  view  that  he  is  a  self- 
deluded  enthusiast,  and  more  or  less  insane.  From 
the  accounts  that  reach  us,  it  would  be  fair  to  conclude 
that  Schlatter's  is  a  case  of  what  is  known  to  alienists  as 
"  paranoia  religiosa,"  and  the  pictures  that  are  given  of 
him  represent  quite  distinctly  the  degenerative  physi- 
cal characteristics  of  a  well-marked  paranoiac. 


THE  MORTALITY   OF  MEDICAL   MEX. 

Dr.  Cortright,  in  the  Brooklyn  Medical  Journal,  has 
written  a  paper  on  the  ''  Mortality  and  Causes  of  Death 
in  Medical  Men."  This  paper  is  based  on  the  records 
of  four  hundred  and  fifty  physicians  who  died  in  New 
York  and  Brooklyn  during  the  past  eight  years.  The 
average  age  of  death  was  54.6  years,  and  the  mortality 
was  about  25.23  as  compared  with  a  mortality  of  15.93 
in  clergymen  and  20.23  ^^  lawyers.  There  is  a  consid- 
erable mortality  from  the  self-administration  of  drugs  ; 
that  from  consumption  is  about  half  the  general  rate, 
while  that  from  typhoid  fever  is  very  high.  There  is  a 
high  death-rate  due  to  arterial  sclerosis  and  other  de- 
generative changes. 

The  practical  conclusion  deduced  from  Dr.  Cort- 
right's  statistics,  says  the  British  Medical  Journal,  is 
that  doctors  should  take  at  least  three  weeks'  complete 
rest  and  change  yearly,  should  be  extremely  moderate 
in  the  use  of  stimulants,  should  be  regular  in  their 
meals,  never  worry  and  never  hurry.  This  is  the  kind 
of  advice  that  doctors  give,  but  do  not  take.  The  fur- 
ther suggestion,  however,  that  they  all  join  some  med- 
ical sickness  and  life  assurance  society,  is  a  wise  one. 


STIMULANTS    FOR   ATHLETES. 

The  alert  mind  of  the  modern  drug  manufacturer  has 
not  failed  to  take  note  of  the  extraordinary  interest  and 
widespread  indulgence  in  athletics  and  sports  of  every 
kind.  The  bicycle,  field  and  track  athletics,  foot-ball, 
golf — all  these  things  have  increased  enormously  the 
number  of  contests  in  which  the  person  who  has  the 
greatest  physical  vigor  and  endurance  wins.  It  has 
occurred  naturally  to  the  pharmaceutist,  therefore,  that 
some  substance  which  would  make  the  competitor  in 
athletic  sports  keep  his  wind  and  his  strength  a  little 


longer  would  be  eagerly  seized  upon.  We  hear  already 
of  bicyclists  who  use  various  coca  and  kola  compounds 
in  order  to  help  them  in  their  work.  It  is  even  rumored 
that  preparations  of  cocaine  are  consumed  to  some  ex- 
tent. We  feel  sure  that  all  true  athletes  would  disdain 
any  such  injurious  and  adventitious  aids,  but  there  is  a 
vast  number  of  persons  who  take  such  things  thought- 
lessly and  injury  is  done  thereby.  The  announcements 
which  are  made  in  advertisements  of  various  stimulants, 
in  which  it  is  claimed  that  they  save  the  strength  and 
promote  the  endurance  of  bicyclers  and  athletes  gener- 
ally, are  very  much  to  be  deprecated.  There  are  no 
drugs  which  will  help  one  to  win  a  game  that  could  not 
be  won  without  them,  and  the  general  effect  of  drug- 
taking,  and  especially  of  the  use  of  drugs  belonging  to 
the  caffein  and  cocaine  class,  is  distinctly  bad.  We  be- 
lieve that  the  medical  profession  ought  seriously  to 
warn  those  with  whom  they  come  in  contact  profes- 
sionally, against  the  use  of  such  things. 


"THE   PASSING   OF   HYPNOTISM." 

The  Journal  of  the  American  Medical  Association  has 
an  editorial,  the  general  trend  of  which  is  to  show  that 
hypnotism  has  had  its  day,  and  is  practically  being  laid 
upon  the  shelf,  or,  at  least,  its  use  confined  to  irregu- 
lars outside  of  the  recognized  school  of  medicine.  This 
is  a  rather  curious  statement  to  make,  at  least,  if  one 
measures  the  interest  of  a  medical  topic  by  the  number 
of  articles  written  about  it.  There  are  few  subjects 
about  which  German  physicians  are  writing  more 
monographs  at  present,  or  in  which  they  seem  to  take 
a  more  active  interest.  The  sensational  side  of  hyp- 
notism is  certainly  dying  out,  but  a  certain  practical 
side,  which  is  represented  by  the  word  "suggestion," 
has  undoubtedly  come  to  stay,  and  to  be  used  in  ther- 
apeutics. 


GREEK   AS    THE    LANGUAGE    OF    MODERN 
MEDICINE. 

Dr.  Achilles  Rose  is  to  be  congratulated  on  having 
won  over  another  adherent  to  his  cause.  The  Post- 
Graduate  devotes  a  page  of  editorial  to  pleading  for 
the  use  of  modern  Greek  as  an  international  language. 
"What  a  start  medical  science  would  take,"  it  says, 
"  if  we  could  have  a  congregation  of  doctors  from  vari- 
ous sections  of  the  earth  who  could  address  us  in  a 
language  known  to  all." 


Fibroids  Cured  by  Extract  of  Thyroid  Gland.— Jouin 
{Bulletins  et  Mc'moires  de  la  Soc.  Obst.  et  Gynec.  de  Paris, 
No.  8,  1895)  states  that  he  has  successfully  treated  sev- 
eral cases  of  myoma  of  the  uterus  by  doses  of  Nielsen's 
dry  extract  of  sheep's  thyroid  gland.  He  gives  four  to 
eight  tablets  daily,  equivalent  to  half  a  thyroid  gland. 
Out  of  five  cases,  the  two  which  have  been  fairly  long 
under  treatment  have  distinctly  improved  in  health. 
In  the  first  case  the  tumor  has  distinctly  diminished  in 
size.  Menorrhagia  is  much  diminished  by  this  treat- 
ment. In  other  classes  of  patients,  hemorrhoids  pres- 
ent in  at  least  one  case  were  greatly  relieved. 


n^ 


MEDICAL    RECORD. 


[November  30,  1895 


Prostatic  Catheter. — Shove  me  little,  shove  me  long. 

laflnenza  in  London. — Influenza  has  reappeared  in 
London  and  is  becoming  daily  more  prevalent.  In 
this  city  there  is  not  yet  any  special  development  of 
the  disease. 

A  Freak  of  Nature. — A  young  woman  living  in  Paris 
recently  gave  birth  to  a  child  whose  eyes  were  placed 
on  the  top  of  its  head.  The  infant  seems  to  be  doing 
well  and  crowds  of  people  have  tried  to  satisfy  their 
curiosity  by  visiting  the  house. 

Death  of  Dr.  Richmond  Lennox,  of  Brooklyn. — Dr. 

Richmond  Lennox  died  on  November  14th,  aged 
thirty-four.  He  was  a  graduate  of  the  Polytechnic  In- 
stitute and  of  the  College  of  Physicians  and  Surgeons 
of  New  York  City. 

Medical  Mission  Work  in  China. — Referring  to  the 
recent  Szchuan  riots  and  massacre,  the  China  Medical 
Missionary  Journal  says  :  "  Foolish  and  exaggerated 
statements  of  the  esteem  in  which  the  foreign  doctor 
is  held  in  China,  a  too  exclusive  dwelling  upon  suc- 
cesses and  their  impression  on  the  populace,  has 
caused  people  to  forget  that  there  are  two  sides  to  this 
shield.  AVhile  on  the  one  side  it  is  undeniable  that 
medical  work  operates  powerfully  to  remove  prejudice 
and  hostility,  yet  on  the  other  side  it  must  never  be 
forgotten  that  it  gives,  and  must  give,  however  cautious 
one  may  be,  abounding  opportunities  to  ignorant  and 
superstitious  and  malignant  people  to  spread  all  sorts 
of  evil  stories.  The  removal  of  an  eye  to  arrest  sym- 
pathetic ophthalmia,  or  the  amputation  of  a  leg  for 
a  compound  comminuted  fracture,  are  deeds  which, 
though  they  may  be  absolutely  necessary,  are  powerful 
for  either  good  or  evil,  and  one  can  never  be  sure  in 
which  direction  they  will  operate.  This  is  true  not  only 
of  hospitals  conducted  by  missionary  medical  men,  but 
also  of  those  benevolent  establishments  to  which  so 
many  port  doctors  freely  give  their  services.  Now,  there 
can  be  no  question  that  in  Szchuan  ugly  stories  were 
afloat  about  the  hospitals  and  the  doctors." 

The  New  York  State  Association  of  Railway  Sur- 
geons.— This  Association  held  its  annual  meeting  in 
New  York  City  on  November  12th,  Dr.  R.  S.  Hardin 
presiding.  The  president,  in  his  address,  advocated 
strongly  a  co-operative  system  between  railway  man- 
agers and  employees,  whereby  hospitals  may  be  erected 
along  the  railroads,  and  medical  services  rendered  to 
injured  passengers,  as  well  as  the  employees  themselves. 
A  tax  of  one  cent  on  each  dollar  of  an  employee's 
monthly  salar)',  and  a  contribution  of  the  railway 
management,  would  be  sufficient  to  put  up  hospitals, 
sustain  them  and  pay  funeral  expenses,  provide  expert 
service,  and  furnish  a  relief  fund.  The  association 
indorsed  the  views  of  the  president.  Another  point 
considered  by  the  president  was  the  transportation  of 
persons  suffering  from  infectious  and  contagious  dis- 
eases. Instances  were  given  of  the  loss  of  life  result- 
ing from  passengers  contracting  scarlet  fever  and  other 
diseases  during  railroad  travel.  The  hangings  and 
furnishings  of  the  Amercian  sleeping-cars  were  criticised 


as  being  liable  to  become  infected  with  the  germs  of 
tuberculosis  and  other  diseases.  It  was  suggested  that 
there  be  isolation  cars,  and  that  certain  compartments 
might  be  arranged  like  those  of  the  quarantine  or 
operating  wards  in  a  hospital— compartments  which 
could  be  thoroughly  cleansed  and  disinfected,  and  in 
which  infectious  cases  could  be  transported.  A  paper 
was  read  by  Dr.  W.  L.  Estes,  of  South  Bethlehem,  on 
"  Multiple  Synchronous  Amputation."  The  writer  ad- 
vocated immediate  amputation  in  all  cases  where  the 
injured  person  is  not  too  weak.  The  subject  of 
"  Shock  "  was  discussed,  and  the  use  of  strychnia  rec- 
ommended, some  preferring  that  to  the  administration 
of  whiskey  and  brandy. 

Judge  Dailey,  of  Brooklyn,  read  a  paper  which  did 
not  seem  to  meet  the  sympathetic  approval  of  his 
audience.  He  cited  instances  in  which  railway  sur- 
geons had  overstepped  their  professional  duties  in 
order  to  adjust  claims  and  accidents  advantageously  to 
their  employers.  He  stated  that  this  practice  of  taking 
notes  for  the  benefit  of  their  employers,  and  to  be  used 
against  the  injured  persons  in  prospective  trials,  was 
illegal  as  well  as  immoral,  and  that  raliway  surgeons 
rendered  themselves  liable  to  criminal  prosecution 
thereby.  Dr.  George  Chaffee  agreed  with  the  speaker 
that  the  railway  surgeon  had  no  right  to  perform  any 
legal  functions.  The  officers  elected  for  the  ensuing 
year  were  as  follows  :  President,  Dr.  C.  S.  Parkhill,  of  the 
Erie  Railroad  ;  First  Vice-President,  Dr.  J.  F.  Valentine, 
of  the  Long  Island  Railroad  ;  Second  Vice-President,  Dr. 
J.  K.  Stockwell,  of  the  Ontario  and  Western  ;  Secretary, 
Dr.  C.  B.  Herrick,  of  the  Delaware  and  Hudson  Rail- 
road ;  Treasurer,  Dr.  Theodore  S.  Mills,  of  the  Ontario 
and  Western;  Chairman  of  the  Executive  Board,  Dr. 
George  Chaffee. 

Death  from  Sin  and  Fear. — The  papers  report  the  case 
of  a  child  living  in  Anderson,  Ind.,  who  was  attacked 
with  diphtheria.  During  the  course  of  the  disease 
the  child  was  attended  by  a  Christian  Scientist.  The 
patient  died  and  the  Scientist  made  out  a  death  return. 
"  Died  from  sin  and  fear."  The  authorities  made  an  in- 
vestigation and  found  that  the  child  had  died  of  diph- 
theria. It  was  also  found  that  the  "  doctor  "  and  the 
parents  had  relied  upon  faith  entirely  in  the  treatment 
of  the  disease.  Warrants  have  been  issued  for  the  ar- 
rest of  both  the  parents  and  the  "  doctor." 

Dr.  John  Ridlon  has  been  appointed  orthopedic  sur- 
geon to  Michael  Reese  Hospital,  Chicago. 

The  Moscow  Congress. — Dr.  K.  Jabobi  writes  that  it 
has  been  decided  to  hold  the  International  Medical 
Congress  in  Moscow,  August  7  to  14,  1S97,  instead  of 
in  1896,  as  was  originally  announced. 

The  New  Orleans  Polyclinic.  —  Dr.  Isadore  Dyer 
writes  that  a  statement  in  the  prospectus  of  a  newly 
established  school,  that  there  is  no  post-graduate 
medical  school  south  of  Philadelphia,  is  incorrect,  for 
the  New  Orleans  Polyclinic  is  a  flourishing  institution 
that  has  been  in  existence  for  eight  years. 

The  Alert  Managers  of  Certain  Mineral  Springs  in 
France  have  already  discovered  that  the  new  elements 
argon  and  helium  exist  dissolved  in  the  healing  waters 
which  they  sell. 


November  30,   1895  J 


MEDICAL    RECORD. 


m 


SOUTHERN    SURGICAL    AND     GYNECOLOG- 
ICAL  ASSOCIATION. 

Eighth  Annual  Meeting,  held  in  Washington,  D.  C,  Xo- 
vejnber  12,  ij,  and  14,  zSQj. 

The  Association  met  in  the  banquet  hall  of  the  Hotel 
Shoreham,  at  10  a.m.  Tuesday,  November  i  ith,  and  was 
called  to  order  by  the  President,  Dr.  L.  McL.axe  Tif- 
fany, of  Baltimore,  Md. 

Address  of  Welcome.— Dr.  H.  C.  Busey,  of  Wash- 
ington, delivered  an  address  of  welcome  on  behalf  of 
the  medical  profession  of  the  District  of  Columbia. 
In  his  closing  remarks.  Dr.  Busey  said  :  I  solicit  your 
aid  and  co-operation  in  our  effort  to  secure  the  protec- 
tion of  our  people  from  the  horde  of  impostors  and 
charlatans  which  you  have  driven  from  your  borders 
by  the  enactment  and  enforcement  of  medical-practice 
laws,  and  which  has  made  the  District  of  Columbia  a 
common  rendezvous,  where  the  most  atrocious  methods 
of  the  charlatan  and  mercenary  impositions  are  openly 
and  flagrantly  committed  to  the  wrong,  injury,  and 
robbery  of  its  citizens.  You  represent  the  most  influ- 
ential and  intelligent  class  of  suffragists,  for  whose  aid 
on  the  hustings  and  at  the  polls  we  plead. 

To  state  the  deplorable  condition  of  this  District 
fully  and  broadly,  there  are  five  medical  schools  and 
several  medical  societies  chartered  by  acts  of  Congress, 
or  under  the  general  incorporation  law  authorized  and 
empowered  to  license  persons  to  practise  the  art  and 
science  of  medicine,  without  any  uniform,  and,  by 
some,  without  any  standard  of  qualification  beyond  the 
ability  and  willingness  of  the  applicant  to  pay  the  re- 
quired fees  or  give  promissory  notes  for  such  payment  ; 
and,  under  the  provisions  of  the  general  incorporation 
law,  any  dozen  of  persons  can  obtain  a  charter  upon 
payment  of  the  fee  for  recording  the  same,  authorizing 
them  as  a  body  corporate  to  confer  the  degree  of  M.D. 
at  their  pleasure  and  will.  Such  is  the  status  of  this 
Federal  territory,  which  is  under  the  exclusive  juris- 
diction of  the  highest  tribunal  of  legislation  in  the 
land,  made  up  of  the  representatives  and  Senators  from 
forty-nine  States  and  Territories,  which  have  enacted 
medical  practice  laws  for  the  protection  and  welfare  of 
their  citizens.  Take  these  facts  home  with  you,  and 
re-echo  them  throughout  the  length  and  breadth  of  the 
land,  that  such  criminal  neglect,  not  less  disgraceful 
and  scandalous  than  the  slums  of  vice,  may  not  con- 
tinue to  afflict  the  citizens  of  the  Federal  territory. 

President  Tiffany  responded  to  the  address  of 
welcome  for  the  Association. 

After  some  announcements  had  been  made  by  Dr. 
Joseph  Taber  Johnson,  of  Washington,  Chairman  of 
the  Committee  of  Arrangements,  the  reading  of  papers 
was  taken  up. 

Personal  Experience  in  the  Treatment  of  Stab  Wounds 
ofthe  Intestines  and  Peritoneum. —  Dr.  Alfred  Brdwn, 
of  Alexandria,  Va.,  read  a  paper  on  this  subject.  At 
the  outset  the  author  stated  that  about  one  hundred 
and  thirty  cases  of  stab  wounds  of  the  peritoneum  and 
intestines  had  come  under  his  care  during  his  entire 
professional  experience  in  both  private  and  military 
practice.  In  less  than  one-third  of  the  cases  the  intes- 
tines were  wounded.  It  is  a  little  remarkable,  said  the 
author,  that  there  should  be  such  a  disproportion  in 
the  number  of  intestinal  wounds  in  these  cases  ;  in 
other  words,  it  is  a  singular  fact  that  in  a  large  major- 
ity of  abdominal  wounds  the  intestines  escape  injury, 
even  when  such  wounds  are  extensive.  Transverse 
and  longitudinal  stab  wounds  of  the  intestines  were 
then  considered  at  length.  Dr.  Brown  regards  the 
sabre  wound  as  one  of  the  most  dangerous  in  its  imme- 
diate and  remote  results.  If  the  edge  and  point  of  the 
sabre  are  sharp,  the  wound  inflicted  is  large  and  deep. 


The  weapon,  cutting  through  the  intestines  and  mesen- 
tery, usually  passing  through  the  abdomen,  severs  large 
blood  vessels  and  causes  frightful  hemorrhage,  which 
is  speedily  fatal.  He  had  only  seen  three  sabre  wounds 
of  the  abdomen,  and  they  ended  fatally  in  a  brief  time. 
The  stiletto  is  a  dangerous  instrument,  as  it  almost  in- 
variably enters  an  intestine  or  other  organ.  It  does 
not  kill  by  hemorrhage  usually,  but  makes  an  opening 
in  the  intestine  sufficiently  large  to  permit  the  escape 
of  a  small  quantity  of  fecal  matter,  causing  septic  in- 
flammation. It  is  one  of  the  most  difficult  of  all  intes- 
tinal wounds  to  detect. 

The  diagnosis  of  intestinal  wounds  was  then  dwelt 
upon,  reference  being  made  to  Senn's  hydrogen-gas 
test  to  detect  wounds  of  the  intestine.  While  he  con- 
sidered it  a  useful  test,  in  remote  sections  of  the  coun- 
try, far  from  large  cities  and  towns,  it  is  not  practicable 
because  of  the  impossibility  of  procuring  the  apparatus 
and  generating  the  gas.  In  all  abdominal  stab  wounds 
the  author's  rule  has  been,  after  cleansing  the  hands 
and  thoroughly  disinfecting  them  to  insert  the  index 
finger  and  explore  the  intestine,  to  ascertain  if  there  is 
an  opening.  In  certain  cases  a  wound  may  exist  in 
the  intestine,  but  it  may  be  so  small  as  to  escape  de- 
tection. But  if  the  intestine  is  wounded,  whether  we 
can  insert  the  finger  or  not,  there  is  always  more  or 
less  extravasation  of  fecal  matter  and  gases,  and  if  the 
finger  comes  in  contact  with  this  matter,  it  is  certain  to 
retain  for  a  length  of  lime  the  peculiar  odor  of  human 
faeces.  This  will  always  afford  positive  evidence  of  an 
intestinal  wound. 

In  treating  simple  wounds  of  the  peritoneum,  the 
author's  rule  has  been  to  close  them  with  silver-wire 
sutures  after  thorough  disinfection.  Formerly  he  closed 
these  wounds  without  regard  to  antiseptic  measures, 
except  that  the  wound  was  washed  with  hot  water  and 
soap.  On  the  battlefield  and  infield  hospitals,  wounds 
were  washed  with  any  water  that  was  convenient,  and 
were  not  washed  at  all  when  water  could  not  be  ob- 
tained. Previous  to  the  introduction  of  antiseptic 
treatment  in  dressing  wounds  but  little  attention  was 
paid  to  the  condition  of  instruments,  sutures,  sponges 
or  dressings,  except  the  practice  of  ordinary  cleanli- 
ness, and  the  percentage  of  cases  of  healing  by  first  in- 
tention of  simple  wounds  of  the  peritoneum  was  large. 
In  dressing  simple  wounds  of  the  peritoneum  scrupu- 
lous attention  should  be  paid  to  the  laws  of  cleanli- 
ness. In  treating  wounds  of  the  intestines  two  vital 
procedures  are  necessary,  one  is  a  complete  and 
thorough  closure  of  the  intestinal  wound  ;  the  other  is 
to  cleanse  the  peritoneal  cavity  of  all  fecal  matter, 
blood,  and  gases  escaping  from  the  intestine. 

Dr.  Brown  then  described  a  simple  method  of  reduc- 
ing a  protruded  intestine  in  stab  wounds.  He  takes 
two  long  slender  curved  needles,  threaded  each  with  a 
silken  cord  ten  or  twelve  inches  long.  One  of  these 
needles  is  passed  midway  through  the  margin  of  the 
wound,  the  other  needle  is  passed  through  the  opposite 
margin  and  then  each  cord  is  tied  in  a  separate  loop. 
These  cords  are  drawn  in  opposite  directions  by  two 
assistants,  upward  and  outward,  firmly  and  tightly.  By 
this  means  the  wound  is  made  to  expand  or  gape  widely 
and  at  the  same  time  the  walls  of  the  abdomen  for  a  large 
area  around  the  wound  are  very  considerably  elevated 
above  the  intestines,  while  the  patient  reclines  in  the 
dorsal  position,  and  a  considerable  vacuum  is  in  this 
way  created  and  the  intestines  will  glide  back  with- 
out force  or  manipulation  to  fill  this  newly  created 
vacuum. 

Dr.  Richard  Douglas,  of  Nashville,  said  that  in 
peritoneal  wounds  we  always  have  a  mixed  infection, 
which  is  more  serious  than  an  infection  from  the  colon 
bacillus.  Peritonitis,  whether  local,  adhesive,  general 
or  septic,  should  be  considered  of  germicidal  orign. 
In  closing  the  abdominal  wound,  he  thinks  it  is  pro  er 
to  always  approximate  the  jjeritoneum,  as  by  so  doing 
we  lessen  the  danger  of  hernia. 


778 


MEDICAL   RECORD. 


[November  30,  1895 


Dr.  C.  a.  L.  Reed,  of  Cincinnati,  expressed  himself 
as  being  apprehensive  about  mere  exploration  with  the 
finger  to  detect  stab  wounds  of  the  intestines.  How- 
ever erudite  the  tactile  sense  of  the  surgeon  may  be,  at 
times  it  would  prove  misleading,  and  therefore  in  cer- 
tain cases  it  was  exceedingly  important  to  enlarge  the 
original  incision  or  wound,  and  that  part  of  the  viscera 
lying  immediately  beneath  it  should  be  brought  out  and 
carefully  inspected.  He  believes  with  Dr.  Douglas 
that  the  peritoneal  margins  should  be  carefully  ap- 
proximated. 

Dr.  J.\mes  Evans,  of  Florence,  S.  C,  related  an  in- 
stance where  nine  men  had  received  chest  wounds  by 
the  bayonet  during  the  war,  the  bayonets  having  been 
previously  stuck  in  the  ground,  and  yet  all  of  the  men 
recovered.  He  attributes  their  recovery  to  the  form  of 
wound  made  by  the  bayonet.  In  another  case,  a  man 
had  been  shot  within  half  an  inch  of  the  navel.  He  had 
no  rise  of  temperature,  yet  when  he  saw  the  patient  the 
omentum  had  extruded  to  the  size  of  both  his  hands. 
He  applied  a  double  ligature,  then  put  a  piece  of  ad- 
hesive plaster  over  the  surface,  and  the  man  recovered. 
He  had  frequently  seen  gunshot  wounds  of  the  abdo- 
men during  the  war  in  which  there  was  extravasation 
of  fecal  matter  through  the  wound,  but  unaccompanied 
by  shock. 

Dr.  a.  Vander  Veer,  of  Albany,  had  always  made 
it  a  practice  to  first  inquire  carefully  as  to  the  kind  of 
weapon  by  which  the  wound  is  made.  He  had  seen 
several  of  the  wounds  inflicted  by  bayonets  during  the 
war,  but  does  not  remember  of  having  seen  the  intes- 
tines or  stomach  penetrated  by  them.  There  should 
be  no  delay  in  treating  stab  wounds.  The  surgeon 
should  act  promptly  and  not  wait  for  symptoms  to 
present  themselves.  Just  as  a  case  of  perforative  ap- 
pendicitis will  terminate  fatally  in  a  short  time,  so  will 
stab  wounds  of  the  intestinal  tract,  unless  timely  inter- 
ference is  resorted  to. 

Dr.  Hugh  T.  Nelson,  of  Charlottesville,  Va.,  said 
the  necessity  of  enlarging  the  abdominal  wound,  under 
all  circumstances,  was  an  imperative  one.  Four  years 
ago  he  saw  a  case  in  which  the  small  bowel  was 
wounded  by  a  knife  and  the  patient  refused  operation 
for  twenty- four  hours,  believing  that  this  viscus  was 
not  cut.  Symptoms  became  alarming,  and  the  patient 
finally  consented  to  have  an  operation  performed.  Dr. 
Nelson  opened  the  abdomen  by  a  long  incision,  finding 
it  impossible  to  remove  from  the  peritoneal  cavity  the 
extruded  contents  of  the  bowel,  owing  to  the  fact  that 
an  adhesive  inflammation  had  taken  place  and  had  ag- 
glutinated them  to  the  bowel  so  firmly  that  he  could 
not  wash  them  away.  He  attempted  to  resect  the  peri- 
toneum into  the  pelvic  cavity  where  the  fecal  matter 
had  burrowed,  but  could  not  do  so.  Peritonitis  be- 
came general  and'the  patient  died.  The  sooner  the  ab- 
dominal incision  is  enlarged  in  stab  wounds  the  better. 

Dr.  George  Ross,  of  Richmond,  asked  whether 
there  was  any  way  of  distinguishing  between  the  symp- 
toms of  nervous  shock  and  shock  due  to  hemorrhage'. 

Dr.  Brown  replied  that  one  of  the  most  unerring 
symptoms  was  rapid  reduction  of  temperature,  but 
there  was  no  symptom  that  would  enable  the  practi- 
tioner to  distinguish  accurately  between  the  different 
forms  of  shock  except  the  gravity  of  the  condition. 

Dr.  W.  E.  B.  Davis,  of  Birmingham,  desired  to 
speak  of  the  point  in  reference  to  injuries  of  the  gall- 
bladder. The  essayist  referred  to  the  fact  that  injury 
to  this  viscus  would  ])roduce  a  septic  peritonitis.  An 
injury  that  would  produce  peritonitis  would  result  in 
death  very  soon  if  there  is  a  large  escape  of  bile  into 
the  peritoneal  cavity,  but  Dr.  Davis  does  not  believe  it 
is  a  septic  peritonitis.  He  believes  that  in  the  major- 
ity of  cases  the  shock  following  abdominal  injuries  is 
due  to  hemorrhage,  and  that  hemorrhage  plays  an  im- 
portant role  in  the  production  of  symptoms  in  these 
injuries.  It  was  the  hemorrhage  from  these  wounds 
that  frequently  caused  death. 


Dr.  John  D.  S.  Da\is,  of  Birmingham,  expressed 
himself  in  regard  to  the  diagnosis  of  intestinal  wounds, 
as  having  very  little  confidence  either  in  Senn's  hydro- 
gen-gas test  or  the  flushing  method  spoken  of  by  the 
essayist.  He  had  seen  perforative  wounds  of  the  ab- 
dominal viscera  where  it  was  impossible  from  their 
character  and  location  to  flush  the  abdominal  cavity 
through  the  opening  sufficiently  to  thoroughly  clean  it. 
In  addition  to  the  three  forms  of  shock  mentioned  by 
the  essayist  there  should  be  added  the  shock  of  sepsis. 

Dr.  Brown,  in  closing,  agreed  with  Dr.  W.  E.  B. 
Davis,  that  all  cases  of  violent  or  dangerous  shock  were 
due  to  hemorrhage.  In  regard  to  approximating  the 
peritoneum,  he  had  always  left  it  untouched  in  closing 
simple  wounds  in  the  abdominal  wall,  and  had  found  it 
good  practice. 

Report  of  Seven  Cases  of  Abdominal  Surgery  in 
which  the  Murphy  Button  was  Applied. — This  paper 
was  read  by  Dr.  A.  Vander  Veer,  of  Albany,  N.  Y. 
The  author  stated  that  the  seven  cases  he  desired  to 
present  had  a  bearing  upon  the  use  of  the  Murphy  but- 
ton, which  is  now  receiving  attention  both  in  this  country 
and  abroad,  and  as  a  method  of  intestinal  anastomosis 
is  being  placed  thoroughly  on  its  merits.  It  is  difficult 
to  understand  some  of  the  unfavorable  reports  made 
by  English  and  German  surgeons,  when  we  contrast 
the  very  successful  results  indicated  by  so  many  of  our 
American  operators,  in  the  practical  application  of  this 
mechanical  device.  Perhaps  there  is  no  part  of  sur- 
gery that  within  the  past  (piarter  of  a  century  has  pre- 
sented so  much  in  theory,  and  in  which  there  has  been 
so  much  disappointment,  when  practical  use  has  been 
made  of  the  suggestions,  as  in  the  field  of  abdominal 
work  with  all  its  complications.  In  other  words,  how 
much  we  have  changed  from  time  to  time  our  methods 
of  treatment  of  many  complications,  and  yet  withal  there 
have  come  certain  reliable  advances  that  have  met  all 
requirements  for  which  they  were  indicated,  leaving  per- 
manently in  our  possession  the  comforting  thought  that 
a  grand  progress  in  the  sum  total  has  been  made  ;  that 
we  can  treat  all  manner  of  pathological  conditions, 
traumatisms,  malformations,  etc.,  of  the  intestinal  tract 
and  abdominal  cavity  with  less  embarrassment  than 
perhaps  in  any  other  part  of  the  body,  and  yet  there 
are  very  few  jjortions  of  the  human  system  upon  which 
we  operate  where  more  rapid  thought  and  best  judg- 
ment are  to  be  employed  than  in  abdominal  work. 

Case  I. — The  first  case  was  one  in  which  gastro-in- 
testinal  anastomosis  was  made  for  carcinoma  of  the 
pyloric  end  of  the  stomach  by  means  of  the  medium- 
sized  Murphy  button,  between  the  upper  end  of  the 
jejunum  and  greater  curvature  of  the  stomach.  Patient 
was  comfortable  after  the  operation,  but  died  from  ex- 
haustion on  the  third  day. 

Case  II. — Case  II.  was  carcinoma  of  the  sigmoid 
flexure,  removal,  and  end-to-end  anastomosis.  Opera- 
tion consisted  of  removing  a  mass  in  connection  with 
the  sigmoid  flexure  three  inches  in  length  and  an  anas- 
tomosis of  the  large  intestine  by  means  of  the  button. 
Cause  of  constriction  was  found  to  be  carcinoma. 
Patient  died  from  exhaustion  on  the  eleventh  day, 
but  was  much  exhausted  and  emaciated  previous  to 
the  operation. 

Case  III. — Removal  of  gall-stones  from  the  gall- 
bladder, using  the  long  drainage-tube  button.  Recov- 
ery. 

Case  IV. — Removal  of  eight  inches  of  the  small  in- 
testine with  papillomatous  ovarian  cyst.  End-to-end 
anastomosis  by  the  button.     Perfect  recovery. 

Case  V.— Anastomosis  of  the  gall-bladder  with  small 
intestine.     Recovery. 

Case  VI. — Operation  revealed  a  tumor  the  size  of  a 
cocoanut  in  the  immediate  vicinity  of  umbilicus,  a  por- 
tion the  size  of  a  silver  dollar  implicating  the  umbili- 
cus and  in  a  gangrenous  condition.  On  making  an  in- 
cision there  was  found  a  strangulated  hernia  and  many 
old  and  firm  adhesions.     Peritoneum   intensely   con- 


November  30,  1895] 


MEDICAL    RECORD. 


779 


gested  ;  very  dark  in  color.  Loop  of  small  intestines 
included  in  tumor  and  gangrenous  for  space  of  ten 
inches.  Vessels  in  mesentery  secured,  and  this  portion 
of  the  intestines  excised.  Murphy  button  used  for 
end-to-end  anastomosis.  Button  passed  thirteen  days 
after  operation,  followed  by  a  large  movement  of  the 
bowels.     Uninterrupted  recovery. 

Case  ^'II. — .\  diagnosis  of  biliary  calculi  was  made 
in  this  case.  Dr.  Vander  Veer  made  the  usual  incis- 
ion for  exploration  of  the  gall-bladder,  found  it  con- 
taining about  two  ounces  of  bile,  and  through  the 
walls  and  down  into  the  cystic  duct  could  be  felt  a 
number  of  small  calculi.  There  were  some  adhesions. 
He  made  use  of  the  long  drainage-tube  button  to  the 
fundus  of  the  bladder,  and  closed  the  wound,  after  a 
careful  examination  for  any  possible  cancerous  mass, 
which  was  not  found  to  be  the  case,  then  placed  the 
patient  in  bed.  He  regarded  the  use  of  the  button  in 
this  instance  as  a  saving  of  time,  leaving  the  patient  in 
good  condition  for  removal  of  the  gallstones  later. 
Several  days  after  he  had  made  the  exploratory  incis- 
ion the  attending  j)hysician  removed  five  irregularly 
shaped  calculi,  which  Dr.  Vander  Veer  exhibited.  At 
this  time  the  patient  began  to  show  marked  symptoms 
of  cetebral  anaemia,  with  delirium,  which  continued, 
patient  finally  passing  into  a  comatose  state  and  died, 
temperature  just  before  death  reaching  105.5°  F. 

Dr.  Vander  Veer  said  that  although  the  cases  he 
had  reported  were  not  many,  yet  they  covered  a  field  in 
which  the  Murphy  button  might  be  made  use  of  so 
readily  and  easily,  and  the  result  so  satisfactory,  that 
he  had  considered  them  worthy  of  attention  as  having 
a  bearing  upon  statistics.  He  believes  he  had  given  a 
just  criticism  of  the  accumulation  of  facts,  so  that  we 
could  reach  and  determine  definitely  as  to  the  value 
and  usefulness  of  this  contrivance.  The  Murphy  but- 
ton will  not  answer  for  every  lesion  about  the  intestinal 
tract,  but  surely  has  its  sphere  of  usefulness,  being 
clean,  easily  handled,  and  saves  the  patient  from  a 
much  longer  operation,  when  time  alone  is  the  great 
desideratum,  which  cannot  be  secured  by  some  of  the 
other  methods. 

Intestinal  Resection  and  Anastomosis. — Dr.  H.  H. 
Grant,  of  l-ouisville,  said  there  had  always  been  a  di- 
vision of  judgment  u])on  the  ([uestion  of  immediate 
suture  in  acute  obstruction  or  injury  requiring  resection 
of  the  intestine,  which  even  the  improvements  in  tech- 
nique and  means  of  aid  in  operative  work  have  not  ad- 
justed. The  members  were  all  familiar  with  the  Mur- 
phy button,  and  doubtless  many  had  employed  it. 
What  it  is  intended  to  do,  it  does  well  ;  but  too  often 
it  does  what  is  not  intended,  and  disaster  and  death 
result.  'I'here  is  abundant  evidence  that  it  becomes  a 
foreign  body  ;  that  it  occasions  spreading  necrosis, 
which  involves  the  peritoneal  coat  ;  that  recontraction 
takes  jjlace  after  lateral  anastomosis  ;  that  fatal  results 
are  frecjuently  directly  attributable  to  its  use,  besides 
other  less  important  objections. 

Lateral  anastomosis  is  now  beyond  all  question  the 
most  acceptable  method  of  resection  of  the  continuity 
of  the  bowel,  if  we  exclude  the  button.  It  is  best  to 
accomplish  by  direct  suture,  and  direct  suture  is  of  diffi- 
cult execution  except  in  very  skilled  hands.  In  order 
to  facilitate  this  suture.  Dr.  (Irant  presented  a  device 
for  clani|jing  opposing  surfaces  of  the  bowel,  cutting  off 
fenestra  between  them,  and  retaining  them  so  op[)Osed 
until  the  suture  can  be  completed.  He  then  demon- 
strated the  modus  opt-randi  of  his  device. 

He  had  experimentally  used  the  clamp  sixteen  times, 
with  fourteen  consecutive  recoveries,  but  had  had  but 
one  opportunity  to  use  it  in  practice.     On  May  25th  he 

operated   on   Mrs.  E ,   aged  fifty-three,  who  had  a 

fecal  fistula  at  the  right  femoral  o[)ening,  the  result  of  a 
strangulated  hernia,  operated  on  eight  months  ago. 
An  incision  was  made  just  above  Poupart's  ligament, 
near  the  fistulous  opening.  The  fingers  easily  liberated 
the  intestine,  which   presented   an  opening  occupying 


half  its  lateral  surface  and  as  large  as  a  quarter  of  a 
dollar.  The  mesentery  was  greatly  thickened  ;  the  dis- 
tal segment  of  the  bowel  was  reduced  in  size,  the  prox- 
imal dilated  at  the  site  of  the  fistula.  About  four 
inches  of  the  intestine  was  resected  ;  the  blades  of  the 
clamp  were  applied  opposite  the  mesenteric  borders  of 
each  segment,  and  the  anastomosis  made  as  above  de- 
scribed. After  suturing,  the  communication  between 
the  opposing  surfaces  was  found  ample.  The  cut  ends 
were  then  invaginated  and  the  anastomosis  returned  ; 
the  abdominal  wall  closed  with  silkworm-gut  sutures  ; 
the  site  of  the  fistula  curetted  and  filled  with  iodoform 
gauze,  and  the  patient  put  back  to  bed  in  forty-two 
minutes.  There  was  very  little  shock.  At  the  present 
time  the  patient  is  well. 

The  advantages  of  this  method  over  the  other  aids, 
except  the  button,  are  manifest.  Not  only  does  it  do 
away  with  the  foreign  body,  but  cuts  an  o])ening  three 
or  four  inches  long  at  the  fenestra.  It  is  fully  as  easily 
accomplished  and  takes  less  time.  It  is  no  more  diffi- 
cult to  use  than  is  the  button,  but  the  operation  cannot 
be  so  quickly  completed,  as  the  invagination  of  the  ends 
is  not  necessary  after  the  end-to-end  approximation  by 
the  button.  The  clamp  merely  makes  direct  suture 
easy  to  any  ordinarily  skilled  hand. 

Dr.  C.  a.  L.  Reed  said  experience  would  establish 
the  fact  that  the  Murphy  button  ought  not  to  be  used 
in  approximation  of  the  large  intestine,  for  the  reason 
that  the  intestinal  contents  were  not  sufficiently  liquid 
to  pass  through  the  small  opening  in  the  button.  In 
the  small  intestine  it  is  different.  There  we  have  liquid 
contents  that  will  pass  through  the  opening  in  the  but- 
ton and  the  approximation  is  satisfactorily  accom- 
plished. Dr.  Reed  reported  a  case  of  resection  of  the 
sigmoid  for  malignant  disease  (which  terminated  fatally) 
in  substantiation  of  the  above  remarks,  the  anastomosis 
being  made  by  means  of  the  Murphy  button.  He  com- 
mended the  device  presented  by  Dr.  (irant,  and  although 
he  preferred  the  end-to-end  procedure,  he  would  try 
the  device  in  the  next  case  in  which  he  performed  lat- 
eral anastomosis.  Cholecystenterostomy  by  means  of 
the  Murphy  button  was  one  of  the  easiest,  neatest,  and 
altogether  most  satisfactory  operations  known  to  sur- 
gery. 

Dr.  Joseph  M.  Mathews,  of  Louisville,  said  he  had 
taken  occasion  more  than  once  to  call  attention  to  the 
difficulty  that  attends  diagnosticating  tumor  of  any 
kind  in  the  sigmoid  flexure.  Time  and  again  he  had 
been  mistaken,  as  he  believed  others  had,  in  supi)osing 
that  he  had  malignant  tumor  of  the  sigmoid  w^hen  he 
had  not,  and  supposing,  on  the  other  hand,  that  he  did 
not  have  when  he  really  did.  A  few  years  ago  a  pa- 
tient was  brought  to  him  from  an  adjoining  State,  and 
from  evidence  outside  of  palpation  he  believed  that  the 
man  had  malignant  trouble  of  the  sigmoid  flexure.  A 
few  days  thereafter  he  was  taken  to  Chicago,  w-as  ex- 
amined by  a  very  eminent  surgeon,  who  positively  stated 
that  there  was  no  tumor  of  any  kind  in  the  flexure,  and 
advised  the  patient  to  go  home  and  goto  work.  In  less 
than  a  week  the  man  was  dead.  Autopsy  revealed  car- 
cinoma of  the  sigmoid  flexure.  His  reasons  for  oppos- 
ing resection  of  the  sigmoid  and  making  anastomosis 
by  the  Murphy  button  were  in  substance  the  same  as 
Dr.  Reed's.  Cancer  in  the  sigmoid  flexure  was  not 
only  usually  attended  by  systemic  infection,  but  there 
is  an  involvement  of  other  organs  and  tissues  of  the 
body.  He  would  therefore  ask,  could  a  man  live  any 
longer  after  a  surgeon  had  removed  the  tumor  than  he 
would  if  it  was  left  untouched  ?  Granting  that  there  is 
total  obstruction,  would  it  not  be  better  to  ])erform 
colotomy  and  let  the  man  live  out  his  allotted  days  with 
cancer  in  a  more  pleasant  way  than  he  would  if  an 
operation  were  done  ?  In  lieu  of  this,  it  had  occurred 
to  him  that  the  plan  suggested  by  Dr.  Bacon,  of  Chi- 
cago, of  anastomosing  the  colon  to  the  rectum,  leaving 
the  growth  there,  would  be  a  more  favorable  operation 
than  extirpation  of  the  carcinoma. 


78o 


MEDICAL    RECORD. 


[November  30,  1895 


Dr.  a.  M.  Cartledge,  of  Louisville,  said  in  doing 
a  cholecystenterostomy  there  was  not  much  time  saved 
by  using  the  Murphy  button,  and  it  was  not  as  useful 
as  the  ordinary  method  of  suturing.  He  thought  this 
was  well  illustrated  in  one  of  the  cases  reported  by  Dr. 
Vander  Veer,  in  which  there  was  a  passage  of  stones 
after  the  operation,  and  where  it  was  necessary  on  ac- 
count of  the  extremely  feeble  condition  of  his  patient. 
In  cases  vvith  numerous  small  calculi  extending  into 
the  cystic  and  common  ducts,  he  had  made  a  com- 
paratively large  incision  in  the  gall-bladder  and  sutured 
it  to  the  peritoneum,  where  the  stones  could  not  be  re- 
moved, and  they  would  then  pass  for  days  externally 
through  the  drainage-tube.  The  orifice  in  the  button 
is  too  small  to  permit  the  stones  to  pass,  whereas  they 
would  escape  through  a  drain  and  come  out.  He  ex- 
pressed himself  in  favor  of  Dr.  Grant's  device,  and 
considered  it  an  excellent  one  for  lateral  anastomosis. 

Dr.  W.  E.  B.  Davis  believes  the  Murphy  button  can 
be  used  to  advantage  in  intestinal  work  where  it  is 
necessary  to  do  operations  quickly  ;  otherwise  the 
method  of  stitching,  similar  to  that  practised  by  Abbe, 
is  better,  is  more  certain,  and  accidents  are  not  so 
likely  to  follovi'  it  as  by  the  use  of  a  mechanical  ap- 
pliance which  is  non- absorbable.  Cholecystenteros- 
tomy by  the  button  should  be  resorted  to  only  in 
those  cases  where  it  is  impossible  to  remove  the  ob- 
struction in  the  common  duct.  The  old  method,  as 
pointed  out  by  Dr.  Cartledge,  is  decidedly  better  in  the 
other  class  of  operations. 

Dr.  Vander  Veer,  in  closing,  was  satisfied  that 
end- to- end  anastomosis  with  the  button  in  the  large 
intestine  was  not  likely  to  be  a  satisfactory  procedure, 
inasmuch  as  the  calibre  of  the  button  was  such  as  not 
to  permit  of  the  passage  of  hardened  ffeces  through  it, 
while  in  the  small  intestine  the  faeces  would  easily  pass 
through  the  orifice  in  the  button.  He  believed  Dr. 
Grant  had  presented  an  appliance  that  would  be  of 
value  to  the  profession.  The  fact  that  new  devices 
were  being  presented  from  time  to  time  before  medical 
gatherings  for  intestinal  anastomosis  was  ample  evi- 
dence that  we  had  not  yet  reached  an  ideal  method. 
The  Murphy  button  is  an  excellent  device  in  the  per- 
formance of  cholecystenterostomy  and  other  opera- 
tions. 

Dr.  Grant  believes  that  any  surgeon  of  ordinary 
skill'  with  his  device,  after  having  the  two  surfaces  of 
the  bowel  directly  opposed,  can  suture  them  without 
soiling  the  peritoneum  or  letting  them  slip  away. 

Surgical  Interference  in  Rectal  Disorders. — Dr.  J- 
McFadden  Gaston,  of  Atlanta,  Ga.,  read  a  paper  on 
this  subject.  After  outlining  the  anatomy  of  the  rec- 
tum, the  author  said  it  is  a  mooted  point  in  regard  to 
the  practicability  of  eradicating  rectal  troubles  of  syphi- 
litic origin  by  medication,  and  with  the  present  light 
on  the  subject  it  seems  justifiable  to  resort  to  such  a 
surgical  measure  as  the  condition  indicates,  while  con- 
stitutional treatment  is  being  carried  out  in  the  case. 
There  are  instances  of  supposed  development  of  spe- 
cific disease  in  the  form  of  stricture  of  the  rectum, 
after  the  lapse  of  many  years  subsequent  to  any  syphi- 
litic contamination,  and  some  authors  claim  their  abil- 
ity to  diagnosticate  specific  stricture  even  without  a 
previous  history  of  primary  syphilis.  Strictures  of  the 
rectum  from  fibrinous  depositions  in  its  walls  call  for 
division  or  excision  of  the  structures  involved.  When 
carcinomatous  induration  of  the  rectal  tissues  is  de- 
tected early,  there  is  encouragement  to  undertake  an 
operation,  but  after  the  breaking  down  of  the  neoplasm 
with  infiltration  of  surrounding  structures,  no  benefit 
is  derived  from  excision  of  the  parts  involved.  The 
rectum  affords  material  for  surgical  work  of  the  most 
important  character,  and  it  should  not  be  relegated  to 
those  professing  to  deal  with  so-called  orificial  surgery. 
Dr.  Gaston  is  fully  impressed  with  the  conviction  that 
many  cases  find  their  way  into  the  hands  of  quacks 
which  ought  to  be  treated  by  members  of  the  regular 


medical  profession,  and  preferably  by  those  who  have 
made  a  special  study  of  rectal  diseases  and  are  prepared 
to  treat  properly  all  the  surgical  disorders  of  the  rec- 
tum. Reference  was  then  made  to  a  paper  by  Dr. 
Gerster,  read  before  the  American  Surgical  Associa- 
tion, upon  the  surgery  of  the  rectum,  in  1893. 

The  burning  and  urgent  appeal  to  the  surgeon  to- 
day is  for  a  definite  settlement  of  the  issue  as  to  active 
interference  in  cases  of  pronounced  cancer  of  the  rec- 
tum. Shall  we  content  ourselves  with  the  mere  pallia- 
tive measure  of  inguinal  colotomy  and  leave  the  dis- 
eased structures  untouched,  as  urged  by  Dr.  Mathews 
in  his  paper  before  the  American  ^Iedical  Association, 
or  shall  we  endeavor  to  remove  all  the  tissues  involved 
by  extirpation,  as  recommended  by  Dr.  Gerster?  The 
full  statistics  of  results  in  the  hands  of  skilled  opera- 
tors ought  to  be  collected  and  a  fair  analysis  made  be- 
fore a  final  adjudication  of  the  question  can  be  reached. 
The  materials  for  such  a  comparison  should  be  ob- 
tained from  cancer  hospitals  in  this  and  other  countries, 
as  well  as  from  general  hospitals  receiving  and  treating 
this  class  of  patients,  and  being  grouped  together  a 
fair  inference  may  be  drawn  as  to  the  feasiblity  of  ac- 
tive interference  in  any  case  of  carcinoma  of  the  rec- 
tum. 

Dr.  J.  M.  Mathews  said  the  essayist  incidentally 
alluded  to  fissure  of  the  rectum  giving  rise  to  re- 
flexes. He  was  glad  he  mentioned  this  simply  to  em- 
phasize the  point,  that  to  have  reflexes  from  the  rectum 
we  must  have  a  pathological  condition.  The  so-called 
orificial  surgeons  had  run  wild  with  reflexes  from  the 
normal  rectum,  and  as  a  consequence  many  respec- 
table citizens  in  his  own  city  had  lost  healthy  rectums. 
In  regard  to  stricture  of  the  rectum,  his  observation 
has  been  that  benign  rectal  stricture  is  very  seldom 
met  with.  There  were  cases,  however,  mentioned  by 
authorities,  but  Dr.  Mathews  had  failed  to  find  them. 
If  he  does  find  it,  it  is  simply  an  annular  constriction 
of  the  mucous  membrane,  which  is  easily  dissipated. 
It  does  not  require  excision.  When  the  surgeon  intro- 
duces his  finger  into  the  rectum  and  finds  stricture 
there,  it  betokens  one  of  three  serious  diseases — syphilis, 
tuberculosis,  or  cancer,  and  the  patient  should  not  be 
turned  aside  with  a  jesting  remark  that  he  has  a  rectal 
stricture.  It  is  a  serious  thing.  He  maintains  that  sixty 
per  cent,  of  the  cases  of  stricture  of  the  rectum  arise 
from  syphilis,  or  are  the  result  of  it.  He  had  asked 
his  professional  friends  to  investigate  this  matter  and 
make  known  their  investigations.  The  responses  he 
had  received  were  nearly  all  in  the  affirmative.  He 
regards  stricture  of  the  rectum  as  more  frequent  than 
either  cancer  or  tubercle. 

With  reference  to  excision  oi  the  rectum  for  a  can- 
cer that  has  blocked  the  rectum  to  the  sigmoid  flex- 
ure, in  nearly  every  instance  we  have  systemic  infec- 
tion. This  being  the  case,  can  the  man  be  cured  by 
surgical  interference  ?  He  wished,  like  Dr.  Gaston,  we 
could  successfully  remove  the  rectum  for  cancer,  but 
he  doubts  it. 

Dr.  H.  M.  Nash,  of  Norfolk,  Va.,  had  seen  a  num- 
ber of  cases  of  ulcer  of  the  rectum  cured  by  dilatation 
of  the  sphincters  and  topical  applications.  He  uses  the 
Sims  speculum,  placing  the  patient  in  the  exaggerated 
Sims  position,  which  gives  the  operator  all  the  room  he 
wants  for  manipulation  in  the  rectum. 

Dr.  Gaston,  in  closing,  congratulated  Dr.  Mathews 
on  his  attitude  of  masterly  inactivity  in  a  great  many 
cases  of  carcinoma  of  the  rectum. 

Surgery  of  the  Biliary  Ducts. — Dr.  W.  E.  B.  Davis,  » 
of  Birmingham,  Ala.,  contributed  a  paper  with  this  ti- 
tle. He  reviewed  the  operative  procedures  practised 
on  the  biliary  passages,  and  recommended  for  cases 
of  obstruction  from  stone  in  the  common  and  hepatic 
ducts  that  the  obstruction  should  be  removed,  and  that 
no  attempt  be  made  to  suture  the  incision  in  the  duct  or 
ducts.  His  e.xperiments  with  animals  had  demonstrated 
that  the  field  of  operation  will  be  walled  off,  and  that 


November  30,  1895] 


MEDICAL    RECORD. 


no  general  inflammation  will  occur  after  this  treatment. 
He  had  tested  the  value  of  gauze  in  draining  bile  in 
injuries  of  the  gall- bladder  and  ducts,  and  reported  cases 
where  he  had  removed  the  gall-bladder  without  tying 
the  duct  by  packing  with  iodoform  gauze.  The  animals 
got  well.  In  other  instances  where  he  incised  the  gall- 
bladder and  ducts  and  packed  with  gauze  around  the 
openings,  no  stitches  being  used,  the  animals  recov- 
ered. Complete  walling  off  of  the  general  cavity  was 
noted  when  the  abdomen  of  the  animals  was  reopened. 
The  experiments  of  Dr.  Davis  demonstrate  conclusive- 
ly that  the  peritoneum  is  capable  of  taking  care  of 
a  small  amount  of  bile,  but  that  large  quantities  or 
the  constant  extravasation  of  it  will  produce  a  fatal 
peritonitis  usually  in  from  twenty  four  to  forty-eight 
hours. 

Management  of  Cases  which  have  Rfcovered  from 
Appendiceal  Abscess  in  which  the  Appendix  was  not 
Bemoved. — Dr.  John  D.  S.  Davis,  of  Birmingham, 
Ala.,  read  a  paper  on  this  subject.  The  jiractice 
of  dealing  with  appendiceal  abscess  by  simply  evac- 
uating the  pus  and  draining  the  cavity  thoroughly 
without  any  very  extensive  search,  or  the  breaking 
up  of  adhesions  in  order  to  find  the  appendix,  has 
been  adopted  by  a  large  number  of  the  leading  op- 
erators for  some  time.  More  recently  some  of  the 
leading  surgeons  have  advocated,  in  all  cases,  that  the 
operation  should  be  made  comph  te  ;  that  all  adhesions 
should  be  freed  and  the  appendix  removed.  One  lead- 
ing abdominal  surgeon,  who  has,  perhaps,  done  more 
work  in  pelvic  surgery  than  any  other  man  in  this 
country,  has  advocated  this  plan  of  treatment  in  most 
vigorous  terms.  In  a  large  proportion  of  cases  of  pus 
in  the  tubes  and  ovaries  gonorrhoea  has  been  an  im- 
portant factor  in  its  production.  Such  pus  is  not  sep- 
tic and  is  not  calculated  to  give  rise  to  so  dangerous  a 
general  inflammation  as  infection  from  an  appendicitis 
or  an  appendiceal  abscess.  It  is  a  notable  fact  that  a 
ruptured  tube  or  ovary  will  usually  be  followed  by  a 
circumscribed  inflammation.  It  is  the  exception  that 
a  fatal  general  peritonitis  results  from  such  an  acci- 
dent. The  most  fatal  forms  of  peritonitis  are  due  to 
a  ruptured  appendiceal  abscess.  In  fact,  but  few  cases 
are  saved  when  such  an  abscess  ruptures  into  the  gen- 
eral cavity. 

An  operation  on  an  appendiceal  abscess  is  usually 
one  of  the  simplest  of  procedures  and  is  attended  with 
almost  no  danger.  Where  the  inflammation  is  circum- 
scribed and  the  drainage  is  thorough,  nearly  all  cases 
recover.  The  records  of  operations  for  appendiceal 
abscess  show  that  the  great  majority  of  cases  are  cured 
after  evacuation  and  complete  drainage.  Recurrence 
of  the  disease  in  such  cases  is  rare.  The  appendix,  in 
a  large  proportion  of  cases,  having  ruptured  before 
the  abscess  formation,  is  completely  drained  through 
the  abscess  and  permanently  cured.  In  others  the  ap- 
pendix is  destroyed  by  the  inflammation  and  there 
is  nothing  left  of  it  when  the  abscess  is  operated  upon. 
To  make  an  extensive  search  for  the  appendix  is 
liable  to  break  up  adhesions  and  then  allow  escape  of 
septic  fluid  into  the  general  cavity.  Thus  a  very  sim- 
ple condition  may  be  converted  into  one  of  the  most 
serious  that  could  happen  to  the  peritoneal  cavity. 
Dr.  Davis  believes  that  there  cannot  be  much  need  of 
breaking  up  adhesions,  for  they  give  way  in  a  short  time 
after  the  abscess  is  relieved.  In  breaking  up  these  ad- 
hesions, in  addition  to  the  danger  mentioned,  the  sur- 
geon prepares  a  favorable  condition  for  fresh  adhesions, 
with  the  possibility  of  the  bowel  being  fastened  in  a 
position  that  will  produce  pain  and  often  obstruction. 
After  the  abscess  is  thoroughly  cleaned  out,  gauze 
packed  into  the  abscess  cavity  and  between  the  ab- 
scess and  abdominal  wall  will  completely  shut  it  off, 
and  the  chances  for  recovery  will  be  good  in  such 
cases.  Dr.  Davis  does  not  favor  the  breaking  up  of 
adhesions  and  searching  for  the  appendix  in  cases  of 
appendiceal  abscess. 


Memorial  Address. — Dr.  John  A.  Wveth,  of  New 
York  City,  delivered  a  memorial  address  on  "  Dr.  J. 
Marion  Sims  and  His  Work  "  (see  p.  694). 

At  the  close  of  Dr.  Wyeth's  address,  remarks  were 
made  by  Drs.  Robinson,  Wilson,  Nelson,  Marcy,  Engel- 
mann,  Kollock,  Vander  Veer,  Gaston,  Tiffany,  and 
Westmoreland,  eulogizing  Sims,  most  of  whom  were 
personally  acquainted  with  him. 

Comparative  Frequency  of  Stone  in  the  Bladder  in 
the  White  and  Negro  Races. — Dr.  George  Ben  John- 
ston, of  Richmond,  \'a.,  read  a  paper  on  this  subject. 
It  is  commonly  stated  by  writers  on  urinary  diseases 
that  stone  in  the  bladder  is  of  rare  occurrence  in  the 
negro  race.  This  is  so  at  variance  with  his  own  expe- 
rience that  he  has  instituted  an  investigation  either  to 
prove  the  statement  or  to  correct  the  fallacy.  He  se- 
lected the  Southern  States  of  Virginia,  North  Carolina, 
South  Carolina,  Alabama,  Georgia,  Tennessee,  Ken- 
tucky, Florida,  Louisiana,  Mississippi,  Arkansas,  and 
Texas  as  the  field  of  inquiry.  He  selected  four  hun- 
dred representative  practitioners  to  correspond  with  in 
order  to  procure  the  necessary  data.  He  received 
three  hundred  and  thirty-eight  responses,  ninety-four 
of  which  contained  information,  and  the  remainder 
were  negative.  He  succeeded  in  collecting  i,o6S  cases 
of  stone  in  the  bladder.  Of  these,  952  were  in  white 
subjects  and  116  in  negroes.  Ii  is  at  once  observed 
that  the  negro  cases  represent  g  55  ])ercent  of  all  ca.ses 
reported.  This  showing  is  quite  sufficient  to  disprove 
the  idea  of  immunity  which  the  negro  is  supposed  to 
enjoy. 

Geographically  these  stones  were  distributed  as  fol- 
lows :  Alabama,  10  ;  .\rkansas,  ir  ;  Florida,  28  ;  Geor- 
gia, 90  ;  Kentucky,  56  ;  Louisiana,  19  ;  Mississippi,  99  ; 
North  Carolina,  126  ;  South  Carolina,  66  ;  Tennessee, 
128  ;  Texas,  98  ;  Virginia,  430. 

Sex  is  specified  in  780  cases,  and  not  stated  in  280. 
Of  those  in  which  the  sex  is  indicated  there  were  691  in 
males  and  97  in  females,  or  about  seven  times  oftener 
in  males  than  in  females. 

There  were  1S2  cases  not  subjected  to  o])eration,  and 
584  in  which  the  stones  were  removed  by  the  following 
methods  :  Lateral  perineal,  249  ;  medial  perineal,  100  ; 
suprapubic,  138  ;  vaginal  incision,  32  ;  dilatation  of 
female  urethra,  28  ;  crushing,  35,  and  operation  not 
given,  5. 

Of  those  operated  on,  541  recovered  and  43  died. 
No  report  of  operation  in  304  cases.  Dr.  Johnston's 
own  cases  are  incorporated  in  the  foregoing  statistics. 
During  his  twenty  years'  practice  he  has  made  notes  in 
41  cases,  which  is  the  third  largest  list  furnished  by 
any  reporter,  and  what  seemed  to  him  the  enormous 
number  of  cases  in  the  negro  in  the  face  of  its  supposed 
rarity,  caused  him  to  set  on  foot  the  inquiries  leadirig 
up  to  this  paper.  Of  his  41  cases,  there  were  35  in 
whites,  6  in  blacks,  39  in  males,  and  2  in  females. 
Thirty- nine  were  operated  on  and  2  were  refused  op- 
eration on  account  of  advanced  kidney  disease.  Both 
died. 

In  25  cases  lateral  perineal  lithotomy  was  done,  in 
12  suprapubic,  and  in  the  cases  of  the  two  females  the 
urethra  was  dilated  and  fragmentation  practised.  He 
had  no  deaths  following  operation. 

President's  Address. — This  was  delivered  by  Dr.  L. 
McLane  Tii-'i'ANV,  of  Baltimore.  He  said  the  aim  of 
the  Association  is  twofold  :  first,  to  do  advanced  work, 
and  second,  to  bring  it  to  the  notice  of  and  aid  other 
members  of  the  profession.  The  one  complementary  to 
the  other,  neither  complete  alone,  yet  attaining  full  fru- 
ition when  associated.  The  fellowship  of  the  Associa- 
tion is  a  very  extended  one,  embracing  a  territory  of 
many  degrees  of  latitude  by  many  degrees  of  longitude, 
with  infinite  varieties  of  soil,  temperature,  environment, 
etc.,  yet  the  transactions  did  not  show  tho>e  exact  local 
records  from  which  facts  may  be  generalized,  applica- 
ble to  the  whole  area,  or  a  large  part  of  the  area,  from 
which  the  fellowshi])  is  drawn.     It  did  not  seem  reason- 


782 


MEDICAL   RECORD. 


November  30,   1895 


able  to  him  to  suppose  that  a  surgical  operation  done 
among  the  mountains  of  Western  North  Carolina  was 
going  to  behave  quite  the  same  way  that  a  similar  op- 
eration would  if  done  on  the  Gulf  coast  of  Texas.  It 
did  not  seem  reasonable  that  similar  surgical  operations 
on  the  bank  of  the  Mississippi  and  the  central  plateau 
of  Tennessee  would  behave  the  same  way.  Accurately 
kept  charts,  with  exact  and  careful  notes,  would  un- 
questionably show  difference  not  yet  put  on  record  by 
anyone,  from  which  much  clinical  information  could  be 
learned.  Again,  he  questioned  whether  surgical  opera- 
tions undertaken  during  the  great  heat  of  summer,  or 
after  the  long  continuance  of  summer  heat,  would  show 
similar  charts  or  give  like  results  when  compared  with 
operations  upon  patients  not  subjected  to  high  atmos- 
pheric temperature,  either  temporary  or  of  long  contin- 
uance. No  association  has  a  membership  better  situ- 
ated or  more  competent  to  carry  on  a  series  of  such 
investigations. 

Cystotomy  for  Stone. — Dr.  Willis  F.  West.more- 
LAND,  of  Atlanta,  Ga.,  said  that  any  surgeon  of  the 
present  day  who  had  hid  a  long  and  extensive  experi- 
ence in  operating  for  stone  must  acknowledge  that  the 
upper  operation  of  cystotomy  is  better  and  safer. 
Unless  there  is  a  pathological  condition  of  the  blood 
or  infection  of  the  bladder,  as  recognized  by  chemical 
or  microscopic  examination,  the  surgeon  could  decide 
before  operation  what  course  to  pursue.  The  anatomy 
of  this  region,  as  laid  down  by  the  investigations  of 
Strong  and  Peterson  upon  the  cadaver  and  frozen  sec- 
tions, leads  the  surgeon  astray,  and  the  observation  of 
the  practitioner  is  more  to  be  depended  upon  than  any 
literature  we  have  thus  far  relative  to  the  subject.  In 
operations  for  stone,  the  author  said  he  cares  not 
whether  he  sees  the  base  of  the  bladder  ;  that  he  de- 
pends upon  touch,  and  that  therefore  rectal  distention 
might  be  dispensed  with.  Instead  of  rectal  disten- 
tion, he  recommends  that  a  vessel  of  water  be  sus- 
pended three  or  more  feet  above  the  patient,  according 
to  the  amount  of  distention  necessary.  Where  the 
surgeon  desires  to  effect  distention  of  the  bladder  by  a 
vessel,  if  the  bladder  is  ulcerated  at  any  point,  with  a 
thickening  here  or  thinness  there,  it  could  be  done 
without  sudden  force,  and  if  the  patient,  during  the 
operation,  should  sneeze  or  cough,  or  contraction  of 
the  bladder  take  place,  instead  of  contracting  upon  a 
solid  mass  of  fluid,  the  fluid  is  forced  back  into  the 
vessel  and  there  is  practically  no  increase  in  pressure. 

Abdominal  Pregnancy. — Dr.  Cornelius  Kollock,  of 
Cheraw,  S.  C,  read  on  this  subject.  After  referring  to 
the  pathology  of  extra-uterine  foetation  and  the  classi- 
fication of  its  varieties  by  early  writers,  he  reported 
the  following  case  : 

October  18,  1894,  he  saw  for  the  first  time  a  dark 
mulatto,  thirty-four  years  of  age,  the  mother  of  three 
children,  whose  general  health  had  been  good  until 
within  the  last  fifteen  months.  The  abdomen  was  very 
much  distended,  measuring  at  the  umbilicus  sixty- 
three  inches.  Fluctuation  was  evident  and  wave-tap 
very  distinct.  The  patient  atfirmed  that  she  was  preg- 
nant, and  that  she  had  gone  four  months  beyond  the 
actual  period  of  gestation.  After  a  thorough  examination 
laparotomy  was  decided  upon,  and  an  incision  was 
made  four  inches  in  length  below  the  umbilicus.  The 
walls  were  so  thin  that  the  instrument  jienetrated  the 
cavity  before  it  was  certain  that  the  abdominal  muscles 
were  divided.  There  was  a  sudden  and  copious  dis- 
charge of  offensive  matter.  An  immense  fibroid  was 
removed  from  the  anterior  portion  of  the  sac.  The 
cavity  also  contained  a  foetus  weighing  ten  pounds. 
The  placenta  had  undergone  fibroid  degeneration,  with 
only  a  small  part  of  the  placental  tissue  remaining. 
The  patient  was  extremely  weak  when  operated  on. 
She  lived  comfortably  for  five  or  six  weeks  after 
operation,  and  the  doctor  thinks  she  would  be  alive 
to-day  were  it  not  for  the  unfortunate  intervention  of 
intestinal  obstruction. 


Extra  uterine  Pregnancy. — Dr.  J.  T.  Henrv,  of 
Chester,  S.  C,  followed  with  a  paper  in  which  he  re- 
ported a  case  of  extra- uterine  pregnancy.  In  this  case 
the  abdomen  was  freely  opened  and  a  large  dark  mass, 
nearly  as  large  as  the  head  of  an  adult,  came  into  view. 
The  uterus  was  crowded  very  much  forward.  The 
mass  lay  posterior  to  it,  and  was  very  much  adhe- 
rent to  the  fundus  posteriorly  and  to  the  promontory 
of  the  sacrum.  The  fimbria  of  the  right  tube  spread 
out  over  the  covering  of  the  mass.  This  mass  was  with 
some  difficulty  freed  from  its  attachments,  except  that 
portion  to  the  fundus  of  the  uterus,  and  it  was  thought 
best  to  remove  the  uterus  with  it,  which  was  done  after 
tying  and  cutting  the  broad  ligaments.  The  foetus  was 
five  inches  long  and  lay  between  the  placenta  and  the 
uterus,  the  cord  being  attached  to  the  left  margin  of  the 
placenta.  The  abdomen  was  thoroughly  washed  out 
with  sterilized  water  and  closed  without  drainage. 
Patient  sat  up  on  the  fourteenth  day  after  operation, 
and  was  out  of  bed  in  twenty- five  days.  She  has  gained 
twenty-five  pounds  in  weight  since  operation. 

The  Technique  of  the  Buried  Suture. — Dr.  Henry 
O.  Marcy,  of  Boston,  read  the  paper.  The  constant 
receipt  of  letters  from  all  parts  of  the  country,  contain- 
ing inquiries  concerning  the  method  for  the  safe  appli- 
cation of  the  buried  animal  suture,  prompted  the  author 
to  write  this  contribution.  At  the  risk  of  seeming  dog- 
matism, he  would  venture  to  assert  that  aseptic  wounds, 
with  very  few  exceptions,  should  be  primarily  closed 
by  buried  tendon  sutures  and  hermetically  sealed  with 
iodoform  collodion.  Carefully  selected  tendons  are  to 
be  preferred  for  buried  sutures,  since  primarily  their 
anatomical  construction  makes  them  stronger,  more 
compact,  and,  as  a  consequence,  more  resistant  to  the 
softening  processes  which  must  ensue  when  buried  in 
the  living  structures.  When  properly  preserved,  they 
have  not  been  subject  to  bacterial  decomposition,  and 
hence  may  be  sterilized  without  detriment  to  their 
ultimate  elements.  When  tendon  has  been  chromicized, 
it  is  best  preserved  in  a  sterilized  oily  fluid.  Ex- 
perience has  shown  that  by  far  the  best  preserving 
fluid  is  linseed  oil  sterilized  by  heat,  to  which  carbolic 
acid  has  been  added.  Tendon  improves  so  much 
when  thus  kept  that  he  rarely  uses  it  until  it  has  been 
in  carbolic  acid  from  three  to  six  months.  A  method 
far  too  common  has  been  to  preserve  chromicized  cat- 
gut and  tendon  in  absolute  alcohol,  boiled  under  press- 
ure. There  is  no  question  but  that  such  material  is 
absolutely  sterile,  but  the  important  factor  has  been 
singularly  overlooked,  that  by  this  process  the  chromic 
acid  is  dissolved  out  of  the  tendon,  leaving  it  really 
less  valuable  than  if  chromic  acid  had  not  been  used. 

The  infection  of  wounds  may  never  be  absolutely 
prevented,  but  the  experience  of  surgeons  teaches  us 
daily  to  what  a  marvellous  extent  it  can  be  minimized, 
reduced  in  aseptic  wounds,  he  confidently  believes 
even  in  hospital  practice,  to  less  than  five  per  cent. 
Indeed,  not  long  ago,  he  examined  his  own  personal 
experience,  reviewing  six  hundred  operations,  with  only 
two  per  cent,  of  septic  cases,  evidence  ample  to  show 
the  safety  of  the  coaptation  of  wounds  by  means  of  the 
buried  animal  suture. 

One  of  the  interesting  features  of  the  meeting  was 
the  presentation  of  a  gavel  made  from  the  leg  of  the 
operating- table  used  by  Dr.  J.  Marion  Sims  in  his  of- 
fice for  twelve  years  preceding  his  death.  It  was  the 
gift  of  his  son.  Dr.  H.  Marion  Sims. 

Election  of  Officers. — The  following  officers  were 
elected  :  F/csiJc/if,  Dr.  E.  S.  Lewis,  of  New  Orleans, 
La.  ;  J^irsf  I'lce-PrtsiJoit,  Dr.  Joseph  Taber  Johnson, 
of  Washington,  D.  C.  ;  SicoiiJ  Vice-President,  Dr.  Rich- 
ard Douglas,  of  Nashville,  Tenn.  ;  Secretary,  Dr.  W. 
E.  B.  Davis,  of  Birmingham,  .\la.  ;  Treasurer,  Dr.  A. 
M.  Cartledge,  of  Louisville,  Ky.  Place  of  meeting — 
Nashville,  second  Tuesday  in  November,  1896.  Chair- 
man of  Committee  of  Arrangements,  Dr.  W .  D.  Hag- 
gard, of  Nashville,  Tenn. 


November  30,  1895] 


MEDICAL    RECORD. 


783 


NEW    YORK    ACADEMY    OF   MEDICINE. 

Stated  Aleeting,  Noi'emher  7,  i8gj. 

Joseph  D.  Bryant,  M.D.,  President,  in  the  Chair. 

Benefactor  of  the  Academy. — At  the  recommendation 
of  the  council,  it  was  voted  to  place  the  name  of  the 
late  Dr.  Alfred  L.  Loomis  on  the  list  of  benefactors  of 
the  Academy. 

Some  Observations  on  the  Effects  of  Horse  Serum 
Injections. — Dr.  Henry  D.  Chapin  read  the  paper 
(see  p.  721.) 

Pathological  Changes  Bestilting  from  Serum  Injec- 
tions.— Dr.  William  \'issman  in  this  paper  quoted 
several  authorities  to  show  that  the  injection  of  blood 
serum  was  not  altogether  harmless,  and  so  far  as  anti- 
toxin serum  was  concerned  he  should  judge,  from  the 
reports  made,  that  its  effect  was  far  from  indifferent. 
But  since  antitoxin  was  used  almost  exclusively  in 
diphtheria,  it  was  almost  impossible  to  determine  what 
anatomical  lesions  it  produced,  especially  since  nearly 
every  one  of  the  changes  caused  by  antitoxin  or  blood 
serum  when  injected  into  healthy  animals  were  also 
found  in  persons  dying  of  diphtheria  without  antitoxin 
treatment.  A  few  changes,  however,  had  been  observed 
in  man,  brought  about  by  this  agent  independently  of 
diphtheria.  Horse  serum  caused  a  rise  of  temperature 
of  one  to  three  degrees,  acceleration  of  the  circulation, 
often  followed  by  heart  weakness  and  variable  pulse. 
The  exanthema  observed  after  antitoxin  treatment  had 
also  followed  injection  of  simple  horse  serum. 

Among  the  disagreeable  effects  observed  after  the 
injection  of  antitoxm  were  erythema,  hemorrhages  into 
the  skin,  heart  weakness,  pain  in  the  joints,  with  or 
without  swelling  ;  some  had  observed  albuminuria  more 
frequently,  others  less  frequently,  than  usual  for  diph- 
theria. Inasmuch  as  healthy  man  was  not  available 
for  experiments.  Dr.  X'issman  had  used  rabbits,  and 
gave  a  resume  of  his  work.  The  number  experimented 
upon  was  eighteen,  and  a  like  number  was  used  for 
control  purposes.  The  changes  produced  were  nearly 
the  same  in  all  that  were  injected.  A  nodule  devel 
oped,  with  a  radius  of  one  inch  from  the  needle, 
slightly  painful  on  pressure,  beginning  to  disappear  on 
the  second  day.  It  was  sterile.  Little  attention  was 
paid  other  organs  than  the  kidneys,  except  to  note  that 
the  liver  and  spleen  were  somewhat  Sivollen.  In  all 
cases  there  was  injection  of  the  blood-vessels  of  the 
kidneys  and  cloudy  swelling.  The  animals  which  re- 
ceived more  than  one  dose  had  slight  hemorrhages 
into  the  tubules,  but  fatty  metamorphosis  of  the  epi- 
thelial cells  was  not  noticed.  It  was  reasonable  to 
assume  that  since  antitoxin  produced  these  changes  in 
healthy  rabbits,  it  produced  similar  changes  in  chil- 
dren. 

In  conclusion  he  said  that,  since  the  injection  of 
serum  into  rabbits  had  been  shown  by  himself  and 
others  to  cause  acute  nephritis,  it  had  probably  had  a 
similar  effect  in  many  persons,  who  had  only  proble- 
matically received  any  benefit  from  its  influence  on 
diphtheria.  If  all  persons  having  diphtheritic  bacilli  in 
the  fauces  were  treated  with  antitoxin,  many  would  be 
injured  for  an  uncertain  benefit,  for  not  all  would  have 
developed  diphtheria.  If  the  disease  had  gone  sutti- 
cienily  long  (or  a  diagnosis  to  be  made  independent  of 
the  bacillus,  the  antitoxin  (it  had  been  admitted) 
would  have  little  influence.  It  was  jirobable,  there- 
fore, judging  by  experiments  upon  animals,  that  the 
antitoxin  treatment  of  diphtheria  had  increased  rather 
than  diminished  the  death-rate. 

Physiological  Action  of  Serum  Injections. —  Dr.  \V. 
H.  Porter  read  this  pa[  er.  Two  theories  had  been 
advanced  to  explain  the  action  of  scrum  therapy,  the 
chemical  and  the  so-called  vital  theory.  The  chemical 
theory  assumed  that  the  serum,  or  some  of  its  constit- 
uents, directly  neutralized  the  toxins  which  were  es- 
sential to  the  disease  process.     But  this  theory  had  al- 


ready been  about  conclusively  disproved,  and  it  could 
be  discarded  as  of  no  practical  value.  The  so-called 
vital  theory  assumed  that  the  serum  or  some  of  its  con- 
stituents acted  upon  the  living  cells  of  the  body,  either 
rendering  them  insusceptible  to  the  toxic  agents,  or 
enhancing  their  power  to  dispose  of  them  as  substances 
foreign  to  the  normal  economy.  Dr.  Porter  presented 
his  conception  of  the  function  of  the  living  cell,  of  the 
chemical  physiology  of  the  animal  body,  and  on  this 
basis  proceeded  to  study  the  effects  of  serum,  or  modi- 
fied serum,  when  injected  into  the  circulation. 

In  using  horse  serum  we  had  no  means  of  determin- 
ing exactly  the  nature  of  the  fluid  injected,  but  we 
could  assume  that  it  was  mixed  proteids.  It  was 
equivalent  to  introducing  a  foreign  body,  just  as  when 
one  employed  an  inorganic  substance  of  any  kind  for 
hypodermic  injection.  It  had  been  shown  that  blood 
serum  or  its  contained  constituents  was  not  inert,  since 
transference  of  considerable  volumes  from  one  animal 
to  another  caused  rapid  destruction  of  the  red  blood- 
cells.  Whether  this  change  was  brought  about  by  di- 
rect action  upon  the  blood  cells,  or  as  a  foreign  body 
which  had  to  be  taken  up  by  the  living  cell  and  split 
into  simpler  compounds,  had  not  been  accurately  de- 
termined. It  was  highly  probable,  in  the  author's  opin- 
ion, that  the  chemical  proi)erties  of  the  living  cells  were 
overtaxed  in  their  attempt  to  destroy  and  eliminate  the 
serums,  and  this  caused  general  decrease  of  activity  of 
the  cells  throughout  the  body.  This  view  had  been, 
it  seemed,  substantiated  by  the  experiments  of  the  pre- 
vious speakers.  To  establish  the  value  of  serum  ther- 
apy, it  must  be  shown  that,  instead  of  having  the  effect 
just  named,  it  stimulated  the  living  cell  and  caused  it 
to  assume  a  higher  state  of  nutrition  and  chemical  re- 
sistance against  toxic  agents;  further,  to  justify  the 
treatment  it  must  be  shown  that  serum  therapy  accom- 
plished this  purpose  more  thoroughly  than  other  modes 
of  treatment. 

The  facts  were  recalled  that  in  man  diphtheria  was 
likely  to  be  of  mixed  infection  ;  that  antitoxin  was  ex- 
pected to  act  only  in  the  pure  form,  and  early  in  the 
disease.  Yet,  in  the  face  of  these  statements  and  those 
which  had  preceded  them,  innumerable  statistics  were 
being  published  which  appeared  to  prove  that  the  mor- 
tality from  diphtheria  had  been  reduced  by  antitoxin. 
The  real  facts,  however,  seemed  to  him  to  be  as  fol- 
lows :  The  diagnosis  of  diphtheria  had  been  based 
upon  the  i)resence  of  the  Klebs-Loeffler  bacillus  in  the 
throat.  The  presence  of  the  bacillus,  even  in  the  ab- 
sence of  clinical  phenomena,  had  constituted  the  case 
one  of  diphtheria.  This  naturally  swelled  the  total 
cases  of  mild  diphtheria  which  would  get  well  under 
almost  any  rational  treatment.  This  factor  had  in- 
creased the  total  number  of  cases,  while  it  had  decreased 
the  mortality  rate.  Further,  the  severe  cases,  not 
amenable  to  the  antitoxin  treatment,  were  eliminated, 
which  again  helped  lower  the  mortality.  Again,  a  large 
number  of  cases  had  pseudo-membrane,  but  examina- 
tion showed  no  Klebs-Loeftler  bacilli,  and  these  being 
e.xcluded  also  lowered  the  mortality. 

Allowing  for  these  facts.  Dr.  Porter  thought  the  true 
mortality  for  diphtheria  had  not  been  lowered.  On  the 
contrary,  he  thought  it  had  probably  been  raised  since 
the  introduction  of  the  antitoxin  treatment.  Until  all 
these  differences  of  opinion  could  be  scientifically  ad- 
justed, it  was  quite  im])Ossible  to  state  exactly  what  was 
the  true  status  of  serum  therapy,  but  the  weight  of  ev- 
idence pointed  strongly  to  failure  along  the  whole  line. 
Not  but  what  serum  might  have  its  place  in  medicine, 
but  it  would  have  to  assume  the  position  of  other  com- 
])ounds,  which  had  value  in  some  instances  but  were 
not  specifics. 

Serum  in  Health. — Dr.  W.  H.  Park,  in  opening  the 
general  discussion,  said  he  would  keep  closely  to  the 
effect  of  serum,  perhaps  also  serum  antitoxin,  in  health, 
and  not  touch  upon  its  influence  in  disease.  First,  in 
animals,  as  Dr.  Chapin  had  shown,  we  found  moderate 


784 


MEDICAL    RECORD. 


[November  30,  1895 


reduction  of  the  red  blood-cells,  the  number  increasing 
to  the  normal  again  within  one  or  two  weeks.  There 
were  no  broken-down  cells.  From  serum  alone  there 
was  almost  no  reduction  of  the  leucocytes,  perhaps  a 
slight,  very  temporary  reduction  from  antitoxin. 

As  to  the  influence  on  the  kidneys.  Dr.  Van  Arsdale 
had  told  him  that  he  could  see  hardly  any  difference  in 
the  kidneys  of  three  rabbits,  one  having  received  injec- 
tions of  serum,  the  other  of  serum  antito.xin,  the  third 
no  injection.  In  the  case  in  which  he  thought  there 
was  slight  injection,  another  pathologist,  examining  in- 
dependently, expressed  the  opinion  that  there  was  less 
change  than  in  the  othe*  two  cases. 

But  we  had,  fortunately,  not  to  depend  upon  the 
changes  found  in  animals  so  far  as  the  clinical  symp- 
toms went,  for  in  New  York  alone  eight  hundred  and 
twelve  children  had  been  immunized  by  antitoxin 
against  diphtheria.  In  a  few  there  was  rise  of  temper- 
ature ;  ina  few,  a  rash  ;  in  about  one- fifth  there  was  al- 
bumin in  the  urine,  but  this  lasted  only  a  few  days, 
usually  only  forty-eight  hours.  None  of  the  children 
had  shown  permanent  ill  effects.  Only  the  slight 
change  in  the  number  of  the  blood-cells,  mentioned  as 
occurring  in  animals,  was  seen  in  children. 

It  appeared,  then,  that  the  dangers  of  serum  injec- 
tions were  very  slight,  and  were  much  more  than  coun- 
ter-balanced by  the  beneficial  influence  of  antitoxin 
treatment  of  diphtheria. 

Dr.  J.  S.  Billings,  Jr.,  said  he  had  examined  the 
blood  in  over  twenty  cases  of  diphtheria  treated  by  an- 
titoxin, and  in  a  minority  of  the  cases  had  found  slight 
reduction  in  the  number  of  the  red  blood-cells,  no  other 
change  ;  in  only  a  very  few  was  the  reduction  in  the 
red  cells  above  half  a  million  in  a  cubic  millimetre. 
There  was  even  a  greater  reduction  in  the  control  tests, 
cases  of  diphtheria  treated  outside  the  hospitals,  with- 
out antitoxin.  According  to  these  observations  it  would 
appear  that  antitoxin  did  no  harm  to  the  red  blood- 
cells,  and  caused  no  degeneration  of  the  blood. 

Dr.  J.  EwiNG  had  seen  some  reduction  of  the  num- 
ber of  leucocytes  in  diphtheria  treated  by  antitoxin, 
and  a  similar  reduction  in  healthy  rabbits  in  which 
considerable  serum  was  injected,  and  while  the  obser- 
vations were  not  conclusive,  he  wished  to  call  attention 
to  this  as  one  of  the  possible  dangers  in  using  anti- 
toxin. He  had  not  seen  harm  result  from  antitoxin 
treatment  of  diphtheria  at  \\'illard  Parker,  but,  on  the 
contrar}',  it  had  seemed  to  him  to  do  good. 

Dr.  J.  Lewis  S.mith  gave  results  of  antitoxin  treat- 
ment of  diphtheria  at  the  Foundling  Asylum.  The  con- 
clusion arrived  at  was  that  it  had  proven  beneficial  in 
the  cases  of  unmixed  diphtheria,  while  apparent  fail- 
ures were  attributed  to  mixed  infection.  An  unusual 
proportion  of  the  latter  cases  occurred  there. 

Dr.  Vissman  said  the  changes  observed  in  his  ex-, 
periraental  rabbits  were  not  present  in  the  control  rab- 
bits, and  therefore  they  must  be  attributed  to  the  in- 
jections. 

The  Health  of  New  York.— Dr.  H.  M.  Biggs  deliv- 
ered the  Wesley  M.  Carpenter  lecture,  choosing  for  his 
subject  "  The  Health  of  New  York."  Extensive  tabu- 
lated statistics  of  the  moibidity  and  mortality  of  New 
Y'ork  and  large  European  cities  were  shown.  The 
author  presented  not  only  the  figures,  but  analyzed 
them,  and  explained  their  significance  in  relation  to  the 
public  health,  which  was  his  main  purpose  in  writing 
the  paper.  Formerly  the  mortality  rate  of  New  York 
per  thousand  was,  in  round  numbers,  37  ;  tracing  the 
decrease  by  successive  decades,  it  had  fallen  to  28,  and 
finally  for  the  past  year  to  22.7.  While  this  was  the 
real  mortality  rate  of  New  York,  the  corrected  rate  was 
about  26.5  as  made  out  in  London.  The  death-rate  for 
rural  districts  was  less  usually  than  in  the  cities,  and,  it 
might  be  said,  was  less  avoidable,  or  depended  less 
upon  the  art  of  man.  The  reduced  mortality  of  the 
present  over  that  of  the  past  in  New  York  and  other 
cities,  showed  that  the  past  greater  mortality  was  due 


to  preventable  diseases.  The  mortality  rate  for  Lon- 
don was  at  present  considerably  less  than  that  for  New 
York,  and  while  climatic  influences  which  were  unavoid- 
able might  account  for  this  in  part,  yet  there  could  be  no 
doubt  but  that  causes  were  acting  here  which,  with  im- 
proved sanitary  knowledge  and  appliances,  would  disap- 
pear. Liverpool  and  Manchester  had  a  much  higher 
mortality  than  New  York,  while  Surrey  had  a  smaller 
mortality  than  London.  No  city  had  as  great  a  popula- 
tion for  the  same  area  as  New  York  below  the  Harlem 
River,  and  to  a  certain  extent  the  denser  the  population, 
the  more  difficult  it  was  to  avoid  certain  morbific  influ- 
ences. This  rule,  however,  was  not  absolute  even  in 
different  districts  for  New  York.  In  the  Tenth  Ward,  for 
instance,  the  mortality  rate  was  only  20.5,  while  in  some 
other  wards  with  a  much  less  dense  population  the  rate 
was  much  higher.  It  was  a  significant  fact  that  where 
the  mortality  was  greatest  there  was  also,  as  a  rule,  an 
unusually  large  proportion  of  cases  of  preventable  dis- 
eases, such  as  tuberculosis,  diarrhceal  diseases,  bron- 
chitis, pneumonia.  There  was  reason  to  hope  that  the 
death  rate  from  these  diseases,  at  least,  might  be  reduced 
one-third  during  the  next  ten  years.  He  had  the  most 
sanguine  hope  that  New  York,  which  had  once  been  re- 
garded as  an  extremely  unhealthy  city,  would  soon  come 
to  be  noted  for  its  unusual  degree  of  healthfulness. 


^Iicrapcxitic  gliuts. 

Cannabis  Sativa. — My  greatest  experience  has  been 
in  the  treatment  of  phthisis  pulmonalis,  and  here  I  can- 
not speak  of  it  too  highly,  for,  while  it  most  percepti- 
bly relieves  the  cough,  it  aids  the  patient  by  its  stimu- 
lating and  exhilarating  qualities,  supplying  a  remedial 
agent  in  a  manner  which  in  my  opinion  no  other  drug 
can  so  beneficially  do. — Lees. 

Pruritus. — Itching  must  be  treated  empirically,  by 
the  employment  of  electricity,  atropia  subcutaneously, 
or  the  coal-tar  derivatives,  such  as  antipyrin  and  phe- 
nacetin,  in  gradually  increasing  doses. 

McC.\LL-AxDERSOX. 

The  external  causes  of  pruritus  include  local  skin 
diseases  and  parasitic  skin  diseases,  as  well  as  the  pru- 
ritus due  to  changes  in  temperature  and  alterations  in 
blood-pressure.  These  are  frequently  the  causes  of  ir- 
ritation of  the  skin.  Its  treatment  can  be  properly  un- 
dertaken only  when  the  underlying  causes  are  taken 
into  account. — Brooke. 

Water. — When  judiciously  taken  in  half-pint  doses 
as  a  laxative  in  the  morning,  as  a  sedative  at  night,  as 
a  diuretic  with  a  cool  skin,  or  a  diaphoretic  when  the 
skin  is  warm,  as  an  expectorant  or  a  refrigerant,  its 
value  is  remarkable.  It  makes  no  difference  whether 
sulphates  are  taken  in  mineral  waters  at  Epsom,  or 
Carlsbad,  or  dissolved  in  water  by  a  druggist  and  sold 
in  eight-ounce  bottles. — Pve-Smith. 

Psoriasis. — Salicylate  of  soda,  grains  fifteen,  three 
times  daily,  after  or  between  meals.  Stop  it  if  epigas- 
tric pain  is  occasioned. — Crocker. 

Arsenic  is  absolutely  useless  in  eczema. — J.\mieson. 

The  Pyrexia  of  pneumonia  is  brief,  normal  to  the 
disease,  unfavorable  to  microbic  activity,  and  inas- 
much as  the  growth  of  this  germ  was  checked  by  a 
temperature  of  104°,  it  was  not  advisable  to  reduce 
it  when  not  excessive,  and  then  not  below  102." — 
R.  Dougl.^s  Powell. 

Antitoxin  in  Diphtheria. — The  report  on  antitoxin 
treatment  in  Germany,  obtained  by  collective  investi- 
gation, on  a  total  of  10.312  cases  occurring  in  a  )eriod 
of  six  months  from  October  1,  1S94,  gives  very  striking 


November  30,  1895] 


MEDICAL   RECORD. 


78- 


results.  Of  the  whole  number  5,833  weie  treated  with 
serum  and  4,479  without  it.  The  proportion  of  deaths 
in  the  former  group  was  9.6  in  contrast  to  14.7  per 
cent,  in  the  latter.  In  401  cases  of'children  under  the 
age  of  two  years,  in  which  the  serum  treatment  was 
used  on  the  first  and  second  day,  the  mortality  rate 
was  1 1.8,  in  contrast  with  39.7  where  under  similar 
conditions  it  was  not  used.  Of  2,556  children  between 
two  and  ten  years  of  age,  the  death-rate  was  four  per 
cent-  after  antitoxin  treatment,  instead  of  15  2  per 
cent,  in  the  other  group. 

A  New  Method  of  Treating  Pulmonary  Tuberculosis. 
— It  seems  evident  that  the  beneficial  influence  of  beech 
creosote  is  due  to  an  indirect  action  explained  by  the 
stimulation  of  cellular  activity.  It  has  seemed  to  me 
that  the  association  of  the  essential  oil  of  peppermint 
by  inhalation  with  the  administration  of  creosote  or  of 
its  derivatives,  combined  with  a  good  diet,  ought  to  be 
a  rational  method  of  treating  phthisis.  In  1888  I  be- 
gan experiments  in  continuous  inhalations.  The  in- 
spiration should  be  deep  and  held  for  a  moment,  so 
that  the  vapors  of  the  oil  remain  in  contact  with  the 
respiratory  tracts  and  their  consents.  A  given  pro- 
portion of  the  essential  oil  can  be  added  to  the  creo- 
sote and,  absorbed  by  the  stomach,  may  prevent  sec- 
ondary infection  of  the  digestive  tract.  In  43  cases 
there  were  37  cures.  The  bacilli  of  Koch  always  dis- 
appeared from  the  sputa.  Several  cases  of  cure  ex- 
tend over  five  or  six  years.  The  inhalation  apparatus 
is  very  simple,  consisting  in  a  linen  bag  five  centimetres 
long  and  two  wide,  held  under  the  nose  by  two  bands 
passing  over  the  head  or  attached  to  the  ears.  This 
is  wet  every  three  or  four  hours  with  four  or  five  drops 
of  the  oil.  It  is  to  be  worn  day  and  night.  For 
patients  not  far  advanced  a  tube  or  quill  with  the  oil 
upon  a  bit  of  sponge  in  one  end,  can  be  given  to  carry 
in  the  mouth,  as  the  patient  goes  about  When  in- 
haling by  the  nostrils  for  the  first  time  irritant  local 
effect  can  be  prevented  by  the  application  of  vaseline. 
— Dr.  Carasso,  Director  of  Military  Hospital  of 
Genes. 

Evaporated  Milk  for  those  on  a  milk  diet  who  can- 
not take  the  required  quantity.  Heat  the  milk  rapidly 
over  a  flame  easily  regulated.  Diminish  the  heat  be- 
fore the  bulling  point  is  reached,  stirring  all  the  time 
even  after  the  flame  is  extinguished.  Thirty  centi- 
litres can  be  reduced  one-half  in  half  an  hour. — Thin. 

Endocarditis. — As  soon  as  the  heart- sounds  in  acute 
articular  rheumatism  begin  to  grow  muffled,  or  a  bniit 
is  detected,  give  in  addition  to  the  salicylate,  iodide  of 
potassium  0.60  centigram  three  times  daily.  Also 
flying  blisters  over  the  apex  and  along  the  course 
of  the  fourth,  fifth,  and  sixth  intercostal  nerves. — 
Cat  ox,  Sein.  Med. 

Sycosis. — Apply  two  or  three  times  daily  as  a  wash 
with  a  cotton  tampon,  a  one  per  cent,  solution  of  cor- 
rosive sublimate  in  ninety-five  per  cent,  alcohol.  To 
allay  the  irritation  which  may  be  produced,  cover  at 
night  with  an  occlusive  ointment  such  as  that  of  Hebra. 
— Tu.if,  Bui.  Med. 

Nutritive  Enema .  — 

Walcr 150  grams. 

Dry  pL-ptoiie lo  grams. 

Yellow  of  one  egg. 

Glucose 20  grams. 

Sydenham's  laudanum gU.  iv. 

— TOIRNIER. 

Acute  Articular  Rheumatism. — I  use  the  salicylic 
acid  by  inunction.  The  formula  used  by  me  was  that 
of  Bourget,  viz.,  salicylic  acid  ten  parts,  lanolin  ten 
parts,  lard  one  hundred  parts.  Two  drachms  of  the 
pomade  were  rubbed  into  several  areas  on  the  trunk 
and  extremities  every  four  hours,  the  total  daily  in- 
unctions representing  sixty  grains  of  salicylic  acid. 
The  absorption  was  very  rapid,  recjuiring  no  more  than 


ten  minutes  for  the  single  inunction,  and  it  was  unat- 
tended with  any  irritation  of  the  skin.  No  covering 
was  employed. — Kinxicltt. 

Iodine  in  Dermatology. — Good  results  are  obtained 
from  its  topical  use  in  ringworm,  alopecia  circum- 
scripta, and  tinea  versicolor.  In  ulcerative  stomatitis 
fungous  gums,  and  various  chronic  anginas,  painting 
with  tincture  iodme  is  an  efficacious  procedure  at- 
tended by  no  inconvenience. — Comby. 

Dropsy. — 

IJ.    Diuretini gr.  ex. 

Aqu«  menihoe  pip |  ij. 

Spirit  gallici 5  j- 

Eucalyptoli git.  xxv. 

M.    Sig. :  To  be  taken  during  24  hours. 

— Best. 

Nephritis. — I  advise  the  treatment  of  nephritis  by 
inunction  of  an  ointment  of  pilocarpine  nitrate — a  pro- 
cedure advised  by  me  in  joint  disease  in  1882.  I 
in  this  way  secured  a  purely  local  diaphoresis  with 
a  minimum  dose  of  the  alkaloid,  and  without  the  in- 
conveniences and  dangers  which  sometimes  attend  its 
subcutaneous  injection. — MoLLifeRE. 

Flatulence. — For  the  violent  spasmodic  attacks,  with 
great  distention  of  the  stomach  and  bowels,  to  which 
some  sufferers  from  flatulence  are  liable,  the  following 
is  nearly  always  efficacious  : 

B.    Sp.  cajuput 3  'j- 

Sp.  amnion,  aromat 3  ']• 

Sp.  chloroform 3  'j- 

M.  Sig.:  The  antispasmodic  mi.xlure.  One  teaspoonful  in  a 
glass  of  water  every  half  hour  or  every  quarler-hour  until  relief  is 
obtained. 

When  flatulence  is  associated  with  pain  after  food  and 
coated  tongue,  indicating  gastritis,  the  following  pre- 
scription should  be  given  : 

8 .    Potassii  bicarb,  vel  sodii  bicar 3  ij- 

Sp.   amnion,  arom 3  jss. 

Liq.  slrychninte 3  ss. 

Sp.  armoracia;  co.  vel  sp.  caju 3  jss.    3  ij- 

Sp.  chlorofornii 3  j. 

Infus.  calumbae  vel  gentianje  co 3  xlviij. 

M.  Ft.  mist.  Sig.:  A  sixth  part  three  limes  a  day  between  meals. 

— Stephen  Mackenzie. 
Alopecia  after  Fevers. — 

8  .   Alcohol 3  vjss. 

Veralrini gr.  vijss. 

Tinct.   benzoin gtt.  xv. 

Acid  salicyl gr.  vjss. 

M.  S.  :  Apply  locally. 

— Kaposi. 
Pruritus  from  Jaundice. — 

IJ .    Ichlhyol pts.  10. 

Spls.  vin,  red.  dil pts.  40. 

Ether pis.  40. 

M.  S.  :  Apply  locally. 

Menstruation,  which  occurs  in  all  erect  animals,  is 
simply  a  shedding  of  the  superficial  layers  of  the  en- 
dometrium, and  is  a  kindred  process  to  the  moult  in 
birds,  to  the  dropping  of  the  horns  and  hair  in  deer, 
and  to  the  loss  of  dermal  structures  which  occur  perio- 
dically in  so  many  animals. — Johnston. 

Acne  Rosacea.— 

B.    Sulphur  ]irecip 3  j- 

Calaniin:i.>  prcpar 3  ij. 

Zinci  oxidi. 

Giycerini aa  3  j. 

Aqua:  dcslil ad  j  iv. 

M.  Sig.  :  Ft.  lotio.  The  lolion  is  lo  be  shaken,  then  painted  on 
with  a  camul's-hair  brush  at  night. 

In  morning  face  is  washed  with  a  little  warm  water  (no 
soap)  and  powdered  over  with  the  following  : 

3.    .\cidi  borici pis.  10. 

Talc! ■ ins.  15. 

M.  Sig.  :  Fl.  pulv.     To  be  applied  every  morning. 

—  JAMISON. 


786 


MEDICAL   RECORD. 


[November  30,  1895 


Gall-stones. — Statistics  show  that  ten  per  cent,  of 
men,  twenty-five  per  cent,  of  women,  and  thirty- six  per 
cent,  of  the  insane  have  gall-stones.  Of  all  these  only 
one  per  cent,  experience  any  symptoms  therefrom.  For 
such  patients  medicines  are  useless,  and  an  early  diag- 
nosis of  their  condition  is  imperative,  for  they  more 
often  need  reference  to  a  surgical  clinic  than  a  trip  to 
Carlsbad.  They  may  be  divided  into  two  classes:  i. 
Those  with  stones  in  the  cystic  or  gall-bladder.  2. 
Those  with  stones  impacted  in  the  common  bile-duct. 
In  the  former,  jaundice  is  the  exception,  while  in  the 
latter  it  is  present  and  persistent. — Webster. 

Anasarca. — 

5  .   Sodium  borate pts.  4-2. 

Distilled  water pts.  60. 

Pot.  bitartrate pts.  1-2. 

A  tablespoonful  every  two  hours. 

Psoriasis.— 

5.    Ichthyol, 

Salicylic  acid, 

Pyrogallic  acid, 

Aristol aa  gr.  xl. 

Vaselin, 

Lard, 

Lanolin aa  §  j. 

A  powerful  ointment  to  be  used  in  small  quantities. 

Menorrhagia  and  Metrorrhagia. — 

5 .    Extracti  Hydrastis  fluidi 3  ss. 

Extracti  ergotre  fluidi j  j. 

Strychnine  sulphatis §>■•  ij- 

Tincturae  ferri  chloridi 3  jss. 

Sirupi  simplicis q.s.  ad  3  viij. 

M.   Sig.  :    Jj.  t.i.d.  after  meals. 

Biliousness. — 

5  .    Fellis  bovini  purif 3  j. 

Manganesii  sulph.  exsiccat scr.  ij. 

Resinse  podophylli gr.  v. 

M.  et  ft.  pil.  no.  xx.     Sig.  ;  One  pill  three  times  a  day. 

— Da  Costa,  ///  Dominion  Aledical  Monthly. 
Tobacco  Cure. — 

5 .    Chloride  of  gold  and  sodium gr.  jJ-^. 

Strychnine  nitrate gr.  ^j. 

Nitroglycerin gr.  j-Jt,. 

Atropine  sulphate gr.  jj^. 

Tincture  digitalis 3  minims. 

Capsicum gf.  4. 

Salicin gr.  I. 

Cinchonidia  sulphate gr.  i. 

For  one  pill,  to  be  taken  three  times  daily. 

■ — Kempf. 
Tic  Douloureux. — Treatment  consists  in  making  sub- 
cutaneous injections  of  the  following  solution  into  the 
affected  side  of  the  face  :  Distilled  water,  10  grammes 
(25  fluid  drachms)  ;  antipyrin,  4  grammes  (i  drachm)  ; 
hydrochlorate  of  cocaine,  0.03  gramme  (^  grain).  The 
face  sometimes  became  much  swollen,  but  soon  re- 
sumed its  normal  appearance. — Grandclement. 

Phthisis. — The  following  combination  reduces  fever, 
cough,  and  sweating,  and  exerts  a  tonic  influence  : 

3.    Phenacetini gr.  xl. 

Strychnina:  sulphatis g'-  j. 

Ammonii  chloridi 3  j. 

Quininse  sulphatis gr.  x.\xij. 

Pulvis  capsici gr.  x. 

Pulvis  digitalis §''•  vj. 

Ferri  sulphatis gr.  xx. 

Atropine  sulphatis gr.  1-130 

M.   ft.  capsulx  no.  xxxij. 
Sig.     One  capsule  four  times  a  day. 

— Mayes. 
A  Tonic  Aphrodisiac. — 

B.    Strychnia;  sulph grs.  1-32 

Acid,  phosphorici  dil 3  j. 

Aqua;  destil 3  j. 

AL  To  be  taken  in  water  four  tnnes  daily. 

Cimicifuga. — Ten  drop_ doses  of  the  fluid  extract  fre- 
quently repeated  are  said  to  cure  the  headache  attend- 
ing menstruation. 


Lumbricoids. — 

Q .    Santonin 20  grs. 

Podophyllin 5  grs. 

Sugar 30  grs. 

M.  Sig.:  Divide  into  five  powders  ;  give  one  every  four  hours  un- 
til it  acts  freely  on  the  bowels.  The  dose  of  podophyllum  can  be 
varied  according  to  the  age  of  the  child. 

— Deray. 
Pulmonary  Tuberculosis. — 

5.    Creosoti f3ij. 

Alcohol,  rectificat f  |    xvij. 

Glycerin,  pur i\  viij. 

Chloroform f  5  v. 

01.  menth.  pip f  3  ij. 

M.  Sig. :    Tablespoonful  in  sweetened  water  before  each  meal. 

— Carosso,  in  La  Alcdecinc  Moderne. 
Asthma. — 

5 .    Ammon.  brom 3  viij. 

Amnion,  chlor 3  jss. 

Tinct.  lobelioe f  3  iij. 

Spir.  ceth.  comp f  1  j. 

Sir.  acacice ad  f  |   iv. 

M.  Sig. :  Dessertspoonful  in  water  every  hour  or  two  during 
paroxysms. 

— Pepper. 

Too  True. — We  can  give  the  novitiates  at  the  shrine 
o  ^-Esculapius  no  better  greeting  than  that  of  Aberne- 
thy,  "  God  help  you  all." 

Goitre. — Good  results  have  been  obtained  from  the 
parenchymatous  injection  of  :^  to  i  drachm  of  a  mixture 
thus  composed  : 

B.    Iodoform I  part. 

Sulphuric  ether, 

Olive  oil aa  7  parts. 

M. 

— Galee,  in  Revue  de  Laryngologie. 

Lavage. — When  any  obstruction  is  felt,  one  should 
cease  for  the  moment  to  push  the  tube  onward,  and 
the  obstruction,  which  is,  of  course,  merely  spasmodic 
contraction  of  the  pharynx  or  oesophagus,  will  relax 
and  the  procedure  can  be  continued  without  difficulty. 
To  attempt  to  push  the  tube  onward  against  the  spas- 
modic obstruction  causes  the  patient  to  gag,  and  may 
induce  violent  retching,  so  that  the  operation  is  frus- 
trated. The  greatest  difificulty  under  which  to  attempt 
the  introduction  of  the  tube,  is  when  a  bed-ridden  pa- 
tient, who,  for  any  reason,  is  unable  to  sit  erect,  is  the 
subject.  It  is  then  better  to  turn  the  patient  slightly 
upon  the  side,  so  that  if  there  should  be  vomiting  the 
fluids  may  readily  run  out  of  the  mouth.  The  tube 
should  never  be  retained  in  position  while  the  patient 
is  vomiting,  as  it  may  cause  the  entrance  of  the  vomited 
material  into  the  larynx.  However,  very  little  experi- 
ence is  needed  to  teach  one  the  manipulation,  and 
great  skill  is  soon  acquired. —  The  Physician  and  Sur- 
geon. 

Pneumonia. — In  pneumonia  we  have  the  field  where 
digitalis  is  the  remedy /<7/-  excellence.  That  recoveries 
from  this  disease  will  and  do  occur  in  greater  numbers 
when  it  is  treated  by  large  and  persistent  dosage  of 
digitalis,  than  occur  without  its  use,  seems  to  be  the 
growing  belief  in  medical  practice  to-day.  In  con- 
junction with  strychnine,  given  in  physiologic  doses, 
digitalis  is  administered  until  the  pulse  comes  down  to 
90  a  minute.  If  it  can  be  kept  there,  recovery  will  en- 
sue in  a  shorter  time,  as  a  rule,  than  by  the  use  of  other 
methods  of  treatment. — Foster. 

Fowler's  Solution. — Fowler's  solution,  either  in  aque- 
ous form  or  in  the  more  convenient  tablet,  has  been 
found  to  be  an  agent  of  great  therapeutic  value  in  cases 
where  the  mucous  membrane  seems  to  lack  tonicity  in 
the  nose  as  well  as  in  the  lower  respiratory  tract. — 

HlCKEY. 

Lumbago  and  Strain  from  Muscular  Exertion. — 
Tinct.  iodini,  liq.  ammonia;  ;  collodion,  p.  e.,  painted 
on  with  camel's-hair  brush. 


November  30,    1895] 


MEDICAL   RECORD. 


'87 


Corrcsponclencc. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

VESTERD.W'S  MEETING  OF  ROYAL  COLLEGE  SURGEOXS — 

THE     REPORT THE    WOMEN'S     QUESTION HOSPITAL 

STAFFS — RADCLIFFE  INFIRMARY GUY's    HOSPITAL 

MR.    DELMAr's    BEQUEST PUBLIC    HEALTH. 

LoN-DON,  November  8,  1895. 

Yesterday  afternoon  the  annual  meeting  of  the  fel- 
lows and  members  of  the  Royal  College  of  Surgeons  was 
held.  The  report  was  presented  and  a  motion  made 
to  thank  the  Council.  To  this  the  previous  question 
was  offered  as  an  amendment,  on  the  ground  that  the 
Council  had  done  nothing  for  members  calling  for  grat- 
itude. This,  on  being  put  to  the  meeting,  was  carried 
by  17  votes  to  5.  Then  came  on  a  motion  for  certain 
reforms,  advocated  chiefly  from  the  members'  point  of 
^•iew.  On  the  suggestion  of  the  President  the  para- 
graphs were  moved  separately.  The  first  demanded 
that  no  alterations  in  the  constitution  should  be  made 
without  the  consent  of  the  body  corporate  (fellows 
and  members)  convened  to  discuss  them.  This  was 
carried  nem.  con.  The  second  provided  that  the  annual 
general  meetings  should  be  made  statutory,  and  no 
longer  depend  on  the  consent  of  the  Council.  This 
was  carried  with  one  dissentient.  The  third  proposed 
to  increase  the  number  of  councillors  from  twenty-four 
to  thirty-two,  the  eight  additional  ones  to  be  elected 
by  the  memljers.  This  was  carried  with  two  dis- 
sentients. 

The  way  being  thus  cleared,  the  question  of  the  ad- 
mission of  women  to  the  examinations  for  the  college 
diplomas  was  brought  forward.  The  President  said  it 
was  a  verj-  important  question,  and  the  Council  desired 
the  opinion  of  the  meeting  before  coming  to  a  decision. 
He  further  stated  that,  under  the  existing  arrangements, 
no  one  could  be  a  member  without  at  the  same  time 
becoming  a  licentiate  of  the  College  of  Physicians, 
though  of  course  this  was  not  finality,  and  the  agree- 
ment between  the  colleges  might  be  altered.  It  was 
moved  that,  as  many  portals  are  open  to  women,  it  is 
not  expedient  for  this  college  to  admit  them.  An 
amendment  that  they  be  admitted  was  made.  This 
after  discussion  was  defeated  by  58  to  48,  and  the 
original  motion  carried.  Thus  for  the  present  the 
women  are  excluded  from  both  colleges,  but  as  there 
are  good  qualifications  open  to  them,  this  is  really  no 
great  hardship,  for  the  number  of  women  students  is 
small  compared  with  that  of  men.  The  question  ex- 
cites considerable  controversj'  now,  but  not  so  much 
as  formerly,  when  it  was  rather  whether  women  should 
be  prevented  following  a  medical  career.  Now  they 
have  gained  that  point,  and  the  two  parties  take  a  dif- 
ferent stand.  The  one  advocating  the  claims  of  the 
women  affect  to  believe  they  must  carry  every  point ; 
the  other,  more  conservative,  look  upon  the  movement 
as  a  passing  craze  which  will  die  out  of  itself.  With 
such  a  change  of  position  in  the  question  it  is  obvious 
the  heart  is  taken  out  of  discussion.  Looking  at  the 
numbers  voting,  we  see  how  languid  is  the  interest  in 
college  politics  compared  with  what  it  was  at  the  early 
meetings,  when  the  theatre  was  crowded  with  indignant 
and  eloquent  orators  demanding  reforms.  The  Coun- 
cil then  listened,  offered  no  reply,  and  went  on  its  way 
— a  method  of  postponing  the  reforms  which  has  suc- 
ceeded and  will  jjrobably  be  continued.  Neither  the 
fellows  nor  the  members  have  any  control  over  the 
Council.  The  fellows  would  like  the  members  to 
help  them  gain  certain  points,  but  then,  what  would 
they  do  for  members  ?  Nothing.  I  am  sorry  to  see 
that  the  Medical  Press,  which  was  once  the  stanch 
advocate  of  justice  to  members,  came  out  on  Wednes- 


day with  a  "wobbly"  leader  recommending  members 
to  trust  to  the  fellows  for  the  future  and  help  them  in 
the  present.  I  suppose  the  "wobble  "  comes  from  the 
genUeman  who  forgot  to  send  in  his  nomination  paper 
and  so  disappointed  his  party  by  his  dilatoriness,  for 
he  is  understood  to  control  your  contemporary  on 
London  college  politics.  He  had  better  wake  up,  un- 
less he  thinks  editorial  responsibilities  may  be  met  by 
dreams. 

The  question  to  what  extent  the  medical  staff  should 
participate  in  the  management  of  a  hospital  is  not 
always  so  easy  to  determine  as  many  imagine  ;  circum- 
stances alter  cases.  I  have  many  years  of  experience 
under  different  plans.  At  some  hospitals  all  members 
of  the  staff  are  ex-officio  members  of  the  committee,  and 
I  have  seen  this  plan  work  well  even  in  small  institu- 
tions. AMien,  however,  the  staff  is  rather  large,  and 
the  attendance  at  committees  not  more  numerous, 
there  may  arise  a  difficulty.  At  other  hospitals  repre- 
sentatives of  the  staff  have  a  seat  on  the  committee. 
Lately  an  attempt  was  made,  at  the  Radcliffe  Infirmary, 
Oxford,  to  change  to  this  plan  from  the  former,  on  the 
ground  that  the  committee  was  too  unwieldly.  I  can- 
not admit  such  a  plea,  for  I  know  that  the  most  com- 
mon difficulty  is  to  maintain  the  regular  attendance  of 
committeemen.  Some  very  large  hospital  committees, 
however,  only  admit  one  or  two  members  of  the  honor- 
ary staff.  A  clergyman  at  Oxford  declared  he  was 
afraid  to  point  out  the  obvious  dangers  which  might 
result  if  the  staff  could  carry  anything  they  liked.  I 
have  known  no  danger  from  such  a  position,  though  I 
have  seen  great  evils  arise  from  the  staff  being  unable 
to  persuade  the  lay  members  to  adopt  the  best  course. 
The  proposal  at  Oxford  was  rejected  by  23  to  4,  so  it 
must  be  presumed  that  the  staff  continue  to  enjoy  the 
confidence  they  well  deserve. 

Guy's  Hospital  is  losing  about  ^^20,000  a  year 
through  the  falling  of  rents  of  its  landed  propert)-.  'The 
agricultural  depression  is  therefore  seen  to  be  affecting 
the  sick  poor  in  our  cities  as  well  as  the  laborers  on  the 
land.  The  founder  directed  his  endowment  to  be  in- 
vested in  land,  and  at  that  time  nothing  seemed  so  safe 
or  so  little  likely  to  depreciate.  The  lands  produced 
about  ^40,000  a  year  up  to  18S0,  since  which  the  de- 
preciation has  continued,  increasing  to  such  an  extent 
that  at  present  half  the  income  is  swept  away. 

In  these  circumstances  an  appeal  has  been  issued  to 
the  public  for  help,  and  Mr.  Gladstone  has  written  a 
letter  for  circulation  with  the  appeal.  In  a  matter  of 
this  kind  Mr.  Gladstone's  recommendation  will  have 
great  weight  even  with  those  who  are  politically  op- 
posed to  him,  and,  as  you  may  suppose,  when  he  says 
he  has  inquired  into  the  circumstances,  he  pleads  wth 
persuasiveness.  Though  the  committee  have  litho- 
graphed his  letter  for  circulation,  they  have  done  well  to 
enclose  a  printed  copy,  for  his  manuscript  is  none  of 
the  easiest  to  decipher.  London's  boundless  want  is 
side  by  side  with  her  boundless  wealth,  which  must 
therefore  come  to  the  rescue.  Mr.  Gladstone,  who  is 
great  at  figures,  vouches  for  the  economy  of  adminis- 
tration which  distinguishes  Guy's. 

Mr.  F.  O.  T.  Delmar  died  on  October  14th,  and  in 
his  will  left  ^£■90,000  in  trust,  the  interest  of  which  is  to 
be  dinded  among  such  charities  as  his  trustees  select 
from  time  to  time.  Mr.  Delmar  expressed  a  special 
desire  as  to  institutions  for  epileptic  or  cancerous  pa- 
tients, as  well  as  for  the  Royal  Society  for  Preventing 
Cruelty  to  Animals.  The  Middlesex  Hospital  Cancer 
Department  was  founded  in  1792,  and  has  greatly 
benefited  sufferers.  As  the  oldest  and  chief  charity  of  the 
kind  it  is  supposed  a  considerable  share  of  the  amount 
will  fall  to  it,  and  no  institution  can  be  named  which 
would  better  discharge  the  duty  imposed  by  this  mu- 
nificent legacy. 

Diphtheria  is  still  prevalent,  and  some  local  out- 
breaks have  been  sudden  and  rapidly  extending.  The 
number  of  deaths  registered  from  it  last  week  rose  to 


788 


MEDICAL    RECORD. 


[November  30,  1895 


72,  being  34  in  excess  of  the  corrected  decennial  aver- 
age for  that  week  of  the  year. 

Influenza  has  been  threatening,  and  at  Willarden 
many  persons  are  its  victims.  The  out-patient  physi- 
cians at  the  hospitals  are  having  a  heavy  time,  and 
cases  in  the  profession  and  society  are  under  my  no- 
tice. 

OUR   PARIS   LETTER. 

{From  our  Special  Correspondent.) 

SEROPATHIE EXPERIMENTS     AS     A     PROPHYLACTIC    OF 

TETAXUS TRE.\TMENT     OF     CANCER      BY TYPHOID 

FEVER  AND  CHOLERA. 

Paris,  November  5,  1895. 

The  treatment  of  disease  by  injections  of  serum  seems 
to  be  engrossing  scientific  and  professional  attention 
more  than  ever  on  this  side  of  the  ocean.  We  know 
that,  up  to  the  present  day,  all  efforts  to  cure  tetanus  by 
injections  of  antito-xic  serum  have  failed.  These  fail- 
ures are  due  to  the  fact  that  the  injections  can  only  be 
carried  out  at  a  period  when  intoxication  has  long  since 
taken  place,  and  if  the  quantity  of  toxin  is  sufficient,  or 
if  the  toxin  is  sufficiently  active,  nothing  can  annul  the 
effects  of  an  intoxication  that  has  been  going  on  insidi- 
ously and  rapidly  for  some  days.  We  must  therefore 
give  up,  at  least  for  the  present,  all  hope  of  curing  a 
tetanus  once  declared,  but  we  may  diminish  the  num- 
ber of  cases  of  that  disease  by  having  recourse  to  the 
preventive  treatment.  That  is  what  Dr.  Nocard  has 
tried  to  do,  and  with  what  success  we  shall  now  see. 

During  the  first  six  months  of  1895,  Dr.  Xocard  dis- 
tributed to  the  veterinary  surgeons  of  Paris,  1,800  bot- 
tles containing  each  10  c.c,  or  about  one- third  of  an 
ounce  of  anti-tetanic  serum. 

He  recommended  them  to  inject  into  each  animal 
threatened  with  tetanus  consecutive  to  an  operatory  or 
accidental  wound,  10  c.c,  or  about  one-third  of  an 
ounce,  of  the  serum  as  soon  as  possible  after  the  trau- 
matism ;  twelve  or  fifteen  days  after  a  second  injection 
of  the  same  quantity  should  be  made.  The  results 
that  I  have  been  able  to  obtain  were  upon  a  total  of 
three  hundred  and  seventy- five  animals,  each  animal 
having  received  two  injections  at  intervals  of  fifteen 
days.  In  every  case  the  serum  proved  innocuous  and 
no  single  animal  treated  took  tetanus.  It  is  true  that 
sorhe  will  consider  375  cases  very  few  to  determine  the 
efficacy  of  a  preventive  treatment,  especially  when  it  is 
a  question  of  a  disease  as  rare  as  tetanus.  That  ob- 
jection cannot,  however,  stand  against  the  facts  that 
all  the  animals  treated  belonged  to  stables  in  which 
tetanus  had  destroyed  animals  a  few  days  or  a  few 
months  before,  and  many  of  them  were  in  ualls  adjoin- 
ing others  that  had  tetanus  ;  moreover,  in  some  cases 
the  traumatism  was  produced  at  the  same  time  and 
under  the  same  conditions  as  in  others  that,  without 
treatment,  became  tetanic.  Finally,  in  the  six  months 
during  which  the  treatment  lasted.  Dr.  Nocard's 
twenty-six  correspondents,  who  did  not  lose  a  single 
animal  of  the  three  hundred  and  seventy-five  treated, 
observed  fifty-five  cases  of  tetanus  among  those  not 
treated. 

From  this  brief  resume  of  Dr.  Nocard's  work,  we 
may  at  least  conclude  that  if  the  curative  treatment  of 
tetanus  remains  still  to  be  found,  we  may  at  least  re- 
duce in  great  measure  the  number  of  victims  to  that 
terrible  disease,  thanks  to  the  preventive  injections  of 
antitoxic  serum. 

Treatment  of  Cancer. — Having  personally  had  oppor- 
tunity of  testing  the  value  of  injections  of  serum  in  the 
treatment  of  intra- thoracic  cancer,  we  are  able  to  add 
our  own  testimony  to  that  of  Professors  Richet  and 
Hericourt,  whose  personal  observations,  coupled  with 
others  communicated  to  them,  have  enabled  them  to 
formulate  some  general  conclusions  taken  from  a  large 
number  of  cancerous  patients. 

In  the  first  place,  there  is  a  very  marked  diminution 


of  the  pain  so  frequent  in  those  affected  with  malig- 
nant neoplasms  ;  and  this  effect  was  entirely  unexpected. 
In  the  second  place,  cancerous  ulcerations  become  de- 
tergent, take  on  the  appearance  of  a  granulating  wound, 
and  cicaterization  may  take  place  over  considerable  of 
the  affected  area.  A  third  effect  of  the  injections  of 
anticancerous  serum  consists  in  a  notable  diminution 
not  only  of  the  tissues  surrounding  the  tumor,  and  of  the 
lymphatic  ganglia  adjacent  to  the  neoplasm,  but  also  of 
the  tumor  itself.  Finally,  in  some  cases  the  evolution 
of  the  disease  is  retarded  and  at  the  same  time  there  is 
a  decided  amelioration  of  the  general  condition.  En 
resume,  in  four-fifths  of  the  cases  of  cancer  it  is  im- 
possible to  deny  a  real  improvement ;  unfortunately 
the  effects  of  the  serum  stop  short  of  curing,  and  after 
a  certain  time— one  month,  a  month  and  a  half,  two 
months — the  general  health  remains  stationary  and  then 
retrogrades  to  the  starting-point  ;  new  cancerous  de- 
posits appear  and  the  disease  progresses  toward  a  fatal 
termination. 

The  question  naturally  suggests  itself,  is  the  serum  a 
specific  or  not  ?  It  is  difficult  to  reply  with  certainty  ; 
nevertheless,  two  of  the  cases  observed  and  treated  by 
Professors  Richet  and  Hericourt  caused  them  to  incline 
to  the  opinion  that  it  is  a  specific  and  that  the  serum 
from  animals  immunized  is  much  more  active  than  that 
taken  from  healthy  animals.  Our  own  experience  in 
the  case  of  intra  throracic  cancer  above  mentioned,  co- 
incided with  that  of  the  learned  gentlemen.  The 
pains,  which  had  been  so  intense  as  to  cause  the  diag- 
nosis of  tumor  compressing  the  sensitive  roots  of  the 
spinal  nerves  to  be  made,  entirely  disappeared  after 
the  treatment  by  injections  of  anticancerous  serum  was 
begun  and  there  was  a  marked  general  improvement, 
accompanied  by  a  disappearance  of  the  swelling  of  the 
axillary  glands. 

In  conclusion,  it  must  be  now  admitted  that  if  the 
seropathic  treatment  is  not  yet  apt  to  cure  neoplasms 
radically,  it  at  least  ameliorates  them  more  than  any 
other  known  method  ;  perhaps  by  combining  this  treat- 
ment with  operative  measures,  still  more  favorable  re- 
sults may  be  obtained. 

Injections  of  artificial  blood-serum  in  typhoid  fever 
and  cholera  have  given  results  equally  as  satisfactory. 


THE    ISTHMUS    OF   THE  AORTA. 


To  THE  Editor  ' 


MSDICAI,  Rbcord. 


Sir  :  While  reading  the  English  edition  of  Ziegler's 
"  Pathology  "  (p.  107),  I  noticed  the  translator's  note, 
and  after  investigating  the  subject  believe  his  explana- 
tion of  "  isthmus  "  is  not  quite  correct. 

Lancereaux,  in  his  "  Traite  d'Anat,"  Part  ii.,  p.  839, 
says  :  "  At  one  period  of  embryonal  life,  the  true  aorta, 
or  ascending  aorta,  distributes  the  blood  to  the  head 
and  to  the  superior  extremities,  while  the  pulmonary 
artery,  after  having  furnished  two  branches  to  the 
lungs,  continues  with  the  descending  aorta  by  a  pro- 
longation which  later  will  be  the  arterial  canal.  A 
narrow  conduit  connects  the  two  halves  of  the  aortic 
tree  ;  this  is  the  isthmus  of  the  aorta,  habitual  seat  of 
stenoses  of  congenital  origin,"  etc. 

Again,  Professor  Knox,  in  his  "  Manual  of  Human 
Anatomy,"  p.  337,  states  ;  "  The  third  or  descending 
portion  of  the  arch  is  remarkable  for  occasionally  pre- 
senting a  slight  contraction  (connected  with  foetal 
structures)  ;  it  is  here  that  the  aorta  has  been  known 
to  become  spontaneously  obliterated." 

So  also,  we  find  in  Macalister's  "  Text-book  of  Hu- 
man Anatomy,"  p.  346  :  "  This  portion  of  the  aorta 
(descending  arch)  measures  46  mm.  in  length  and  is 
24  mm.  in  diameter,  contracting  suddenly  to  22  mm. 
at  its  termination  (gretnus  ao/Ar)  immediately  beyond 
the  ductus  arteriosus,  etc.  ^ 

A  search  through  a  considerable  number  of  other    J 


I 


November  30,   1895] 


MEDICAL   RECORD. 


789 


authorities,  including  Meckel,  Cruveilhier,  Cloquet, 
Delierre,  Gegenbauer,  Sappey,  Todd  and  Bowman, 
Soemmerring,  and  others  failed  to  reveal  any  other 
references. 

Yours  faithfully, 

Dr.  X . 


THE    CLIMATE    OF    COLORADO. 

To  THE  Editor  of  thb  Medical  Record. 

Sir  :  Residence  of  something  over  a  year  in  Colorado 
serves  to  impress  upon  me  very  forcibly  the  fact  that 
patients  coming  here  with  pulmonary  tuberculosis  are 
much  in  need  of  competent  medical  supervision  after 
their  arrival.  It  is  needless  to  say  that  the  atmospheric 
conditions  differ  very  materially  from  those  at  the  sea- 
level,  and  I  am  certain  that  these  differences  are  not 
appreciated  by  many  of  the  physicians  in  the  East.  A 
considerable  number  of  patients  with  pulmonary  tu- 
berculosis who  come  to  Colorado,  think  that  it  is  sim- 
ply necessary  for  them  to  live  in  this  climate,  and  feel 
that  they  may  pursue  such  life  as  seems  fitting  to  them. 
They  feel  the  stimulus  of  the  clear,  dry  air  and  sun- 
shine, they  are  invigorated  by  the  tonic  qualities  of  the 
atmosphere,  and  are  easily  led  to  commit  grave  indis- 
cretions in  undue  exercise,  unsuitable  food,  and  the 
like.  These  indiscretions  only  too  often  result  disas- 
trously. These  facts  are  well  known  by  the  physicians 
here,  but,  as  I  have  said,  I  am  sure  that  they  are  not 
duly  appreciated  by  many  physicians  in  other  parts  of 
the  country.  I  feel  that  I  can  speak  of  this  with  good 
grace  in  the  columns  of  the  Medical  Record,  as  I  do 
not  myself  treat  pulmonary  tuberculosis. 

The  climate  of  Colorado  is  a  most  valuable  thera- 
peutic agent  which  requires  careful  medical  supervision 
in  its  employment.  All  who  come  here  agree  that  it  is 
the  best  climate  for  permanent  residence  which  the  av- 
erage consumptive  can  obtain.  Throughout  the  State 
are  found  careful,  painstaking,  conscientious  physicians 
who  have  devoted  many  years  to  the  study  of  tubercu- 
losis, and  who  are  well  able  to  bring  to  bear  upon  the 
invalid  every  condition  which  can  aid  in  effecting  a  cure; 
and  it  is  because  I  see  from  riionth  to  month  such  a 
considerable  number  of  patients  coming  from  the  East 
who  do  not  feel  it  necessary  to  place  themselves  under 
medical  supervision,  that  I  feel  impelled  to  again  bring 
the  subject  before  the  profession  in  this  way. 
Very  truly  yours, 


Denver,  Col.,  November  15,  1895 


Ch.\rles  a.  Powers,  M.D. 


A  LONG  SURVIVAL  OF  A  TERRIBLE 
WOUND,  AND  A  STRANGE  COINCIDENCE 
CONNECTED   THEREWITH. 

To  THE  Editor  op  the  Medical  Record. 

Sir  :  About  five  years  ago  I  received  a  letter  from  a 
man  living  in  Pontotoc,  Miss.,  giving  me  a  history  of 
the  condition  in  which  he  found  himself  at  that  date, 
as  a  result  of  a  wound  received  at  the  battle  of  Chicka- 
mauga,  September  19,  1863. 

John  N.  Sloan,  captain  of  a  company  in  one  of  the 
Mississippi  regiments  engaged  in  that  bloody  battle 
(said  to  have  been  the  bloodiest  since  the  invention  of 
gunpowder),  was  struck  by  a  cannon-ball,  which  com- 
pletely tore  away  his  chin  and  lower  jaw,  tongue,  and 
some  of  the  upper  teeth.  His  wound  being  considered 
necessarily  fatal,  when  he  fell  he  was  dragged  a  few 
feet  behind  a  tree,  and  no  further  attention  was  paid 
to  him.  He  was  not  even  carried  to  the  rear  to  a  place 
of  comparative  safety.  From  that  day  to  this  he  has 
lived  upon  liquid  food,  his  nourishment  being  carried 
into  the  upper  end  of  the  exposed  oesophagus  by  means 
of  a  rubber  tube.  Naturally,  I  became  interested  in 
the  condition  of  this  man,  and  made  careful  inquiry  in 


regard  to  the  information  I  had  received,  especially 
through  members  of  my  own  profession  living  near 
him. 

On  the  thirty-second  anniversary  of  the  battle  of 
Chickamauga,  there  was  a  dedication  of  the  National 
Park,  to  which  all  the  survivors  of  both  armies  were 
invited.  I  had  not  visited  the  battle-field  since  the 
fight  in  1S63,  and,  of  course,  felt  some  curiosity  to  go 
over  the  ground  again.  It  was  very  interesting,  and, 
to  me,  a  memorable  occasion.  The  Government  has 
macadamized  the  old  country  roads  that  traversed  that 
section,  not  changing  their  routes  in  any  particular, 
simply  bettering  their  condition. 

The  line  of  battle  was  nearly  eight  miles  long,  and 
as  we  drove  or  walked  over  it,  it  was  certainly  unusual 
to  see  the  men  of  both  sides  in  that  terrible  struggle, 
wandering  together  about  the  various  points  where  their 
commands  had  fought,  and  discussing  incidents  which 
were  so  indelibly  impressed  upon  their  mind  ;  for  when 
a  man  has  stood  face  to  face  with  death,  it  has  oc- 
curred to  me  that  a  profound  impression  is  made  upon 
his  memory,  and  it  needs  but  the  occasion  to  have  it 
clearly  recalled. 

A  doctor  friend,  who  lives  in  Chattanooga,  kindly 
devoted  his  horse  and  buggy  and  his  time  to  me  on 
this  excursion.  We  found  ourselves  about  one  o'clock, 
taking  luncheon  at  Crawfish  Spring  (now  known  as 
Chickamauga  Spring),  one  of  the  most  wonderful 
springs  of  pure,  cold  water  gushing  out  of  the  earth  I 
have  ever  seen.  As  we  had  a  generous  basket  of  lunch- 
eon, and  seeing  four  or  five  ex-Federal  soldiers  who 
looked  hungry,  I  invited  them  to  share  our  basket, 
which  invitation  they  accepted  with  avidity.  As  we 
were  chatting  about  things  in  general,  one  of  the  Union 
soldiers,  a  Mr.  S.  S.  Rich,  who  is  now  living  at  Mo- 
berly.  Mo.,  and  who  was  then  serving  in  a  Kentucky 
regiment,  said  that  in  this  battle  he  had  seen  the  most 
horrible  wound  that  had  ever  come  under  his  observa- 
tion. (As  he  was  an  infantryman  and  had  been  en- 
gaged in  all  the  great  battles  in  the  West  in  a  regiment 
that  made  a  fine  record  for  gallantry,  I  am  sure  he  had 
ample  opportunity  to  see  a  great  many  ghastly  wounds.) 
I  asked  him  on  what  part  of  the  line  he  was,  and  he 
indicated  it  by  the  known  position  in  which  his  divis- 
ion fought  on  that  day.  He  said  that  it  was  a  Con- 
federate soldier  he  had  come  upon  in  a  charge  in 
which  they  were  engaged  ;  and  that  this  man  was  lying 
at  the  root  of  a  tree,  with  his  whole  chin,  lower  jaw, 
and  upper  part  of  his  throat  blown  away,  seemingly  by 
a  shell,  but  that  he  was  still  living.  He  added  that  he 
knew  he  must  have  died,  because  no  man  could  have 
recovered  from  such  a  wound. 

I  knew  that  this  Mississippi  regiment  had  fought 
just  there,  and  that  the  man  of  whom  he  was  speaking 
was  my  patient.  I  had  written  to  the  old  captain 
in  Mississippi  to  be  sure  to  get  to  the  Chickamauga 
reunion,  and  that  we  would  go  over  the  field  and 
find  out  the  place  at  which  he  was  shot.  I  had  then  a 
letter  in  my  pocket  from  him,  saying  that  he  would 
be  there  if  his  health  would  permit.  I  said  to  Mr. 
Rich,  the  ex- Union  soldier,  "  Vou  will  be  surprised 
to  know  that  the  man  did  not  die,  and  that  this  letter 
is  from  that  same  individual.  I  expect  him  at  any  mo- 
ment to  meet  me  in  Chattanooga  or  somewhere  on  the 
field.- 

Vou  may  imagine  his  surprise  on  finding  that  this  man 
had  survived  such  a  horrible  wound.  As  soon  as  I  hand- 
ed him  the  letter  and  said  that  the  man  was  expected 
there,  one  of  the  other  ex-Union  soldiers  of  our  party, 
who  was  from  Indiana,  but  whose  name  I  unfortunate- 
ly failed  to  put  down  at  the  time  and  have  since  for- 
gotten, exclaimed,  "I'll  bet  anything  that  I  saw  that 
same  man  in  the  train  coming  down  to  the  Park  this 
morning  !  A  number  of  old  soldiers  had  gathered 
around  him  and  he  showed  them  the  rubber  tube 
through  which  he  was  fed  by  sticking  it  through  a 
hole  in  his  throat." 


790 


MEDICAL    RECORD, 


[November  30,  1895 


I  unfortunately  could  not  find  my  old  friend  in  the 
tremendous  crowd  that  was  there,  but  I  wrote  to  him 
on  my  return  to  New  York,  and  received  a  letter  stat- 
ing that  he  had  been  there  and  had  found  the  place 
where  he  was  shot,  and  was  very  sorry  he  had  missed 
me. 

Naturally,  this  patient  is  aging  rapidly,  and  now,  al- 
though only  a  little  over  sixty  years  of  age,  by  reason 
of  the  fact  that  he  is  compelled  to  live  upon  a  fluid 
diet,  his  strength  is  failing  him.  He  does  not  belong 
to  that  great  army  of  pensioners  which  draw  regularly 
upon  the  United  States  Treasury,  but  he  is  on  the  pen- 
sion list  of  his  old  comrades  throughout  the  South,  who 
since  the  war,  in  all  her  poverty,  take  care  that  no  in- 
capacitated ex-  Confederate  soldier  shall  suffer  for  the 
necessaries  of  life. 

John  A.  Wyeth,  M.D. 

New  York,  November  20,  1895. 


"^exo  "^nstvumcnts. 


A  RUBBER  BAND  FOR  SECURING  THE  UM- 
BILICAL CORD. 
By  J.  H.  GREENE,  M.D., 

DUBUQUE,    lA. 

I  NOTE  in  a  medical  journal  an  advertisement  of  an  in- 
strument to  secure  the  umbilical  cord.  For  the  past 
five  or  six  years  I  have  used  a  simple  device,  original, 
so  far  as  I  know,  with  myself.  It  is  so  effectual  for  its 
intended  purpose,  so  cleanly,  and  easy  of  application, 
that  I  deem  it  worthy  of  mention.  It  is  the  ordinary 
rubber  band  of  small  size;  and  its  utility  lies  in  its  man- 
ner of  application.  I  use  the  "  No.  S  "  Faber  band, 
approximatively  three-fourths  inch  in  length.  Passing 
it  around  the  umbilical  cord,  it  is  given  two  or  more 
turns  upon  itself.  One  of  the  loops  at  either  end  is 
then  passed  through  its  fellow  and  the  band  drawn  taut 
by  the  finger  through  the  free  loop.  The  cord  is  then 
cut  and  the  free  loop  passed  over  the  end  of  the  cord. 
Its  effectiveness  is  so  self-evident,  further  comment  is 
unnecessary. 


A   NEW   PUMP   AND   CAUTERY. 
By   CHARLES   GRAEFE,    M.D., 

SANDUSKY,   O. 


klEDICAL   SOCIETY. 


rHE  AMERICAN  MEDICAL  ASSOCIATION; 
STATE  MEDICAL  SOCIETY;  SECRETARY 
ASSOCIATION  ;    AND     PRESIDENT  OF 


In  modern  therapeutics  the  application  of  sprays  and 
powders  in  diseases  of  the  throat,  lungs,  and  ears  makes 
it  most  indispensable  for  the  specialist  as  well  as  the 
general  practitioner  who  keeps  abreast  of  the  times,  to 
have  some  means  by  which  he  can  at  all  times  and 
places  fulfil  these  indications.  The  large  pumps  and 
reservoirs  are  not  portable,  the  hand-bulbs  always  un- 
satisfactory, and  such  foot- power  pumps  as  are  on  the 
market  have  not  withstood  criticism. 

After  some  years  of  study,  about  a  year  ago,  with  the 
help  of  Mr.  Waldkirscher,  an  expert  in  pump-making, 
I  had  a  portable  air-pump  and  reservoir  combined 
made,  which  he  had  dubbed  the  "Graefe."  It  is  made 
of  brass,  is  four  inches  long  and  three  inches  in  its 
other  dimensions,  and  weighs  less  than  two  pounds. 
A,  as  will  be  seen  by  the  cut,  is  the  cylinder  of  the 
pump,  roughened  on  its  upper  surface  to  keep  the  foot 
from  slipping.  £  is  the  reservoir  for  compressed  air, 
giving  an  equal  pressure  and  when  controlled  by  a 
valve  cut-off  as  shown  in  the  illustration,  giving  force 
enough  for  blowing  powders,  inflating  the  middle  ear, 


etc.  C  represents  the  nipple  to  which  the  tubing  is 
fastened  for  connection  with  the  atomizer,  and  D  a 
similar  nipple  to  which  an  air-filter  can  be  attached,  or 
tubing,  so  that  the  air  can  be  drawn  from  any  source 
desired,  avoiding  dust,  disease  germs,  etc.  £  repre- 
sents the  hinge  and  spring  upon  which  the  pump 
works. 


In  front  of  the  case  which  I  had  made  for  the  instru- 
ments, will  be  seen  a  gas  cautery,  which  I  invented  a 
number  of  )  ears  ago  but  have  never  brought  before 
the  profession,  because  the  rubber  bulbs  heretofore 
used  for  supplying  compressed  air  have  been  unsatis- 
factory. A  represents  the  point  for  the  gas  connec- 
tion. £  that  for  the  air,  C  the  platinum  bulb,  and  Z> 
the  opening  for  lighting  the  gas.  It  works  perfectly 
with  a  slight  pressure  of  gas  and  air,  and  can  be  han- 
dled by  the  operator  without  assistance.  It  does  away 
with  benzine  and  its  dangers,  the  aleohol  lamp,  and 
the  clogging  of  the  Paquelin  burners,  as  the  platinum 
is  hollow  and  has  no  meshes  in  its  interior. 

I  claim  many  advantages  for  these  instruments,  which 
will  suggest  themselves  to  the  profession,  and  think 
they  will  be  as  indispensable  to  others  as  they  have 
been  in  my  practice,  if  once  used. 

They  are  made  by  the  Waldkirscher  Pump  Co.,  of 
this  city,  and  are  for  sale  by  Meyrowitz,  New  York 
City,  and  Sharp  &  Smith,  Chicago. 


A  Pathological  Medical  Club  has  been  organized  by 
the  junior  class  of  the  Medical  Department  of  the 
University  of  Worcester.  The  club  is  organized  for 
the  purpose  of  securing  pathological  journals  and  liter- 
ature, and  not  literature  and  journals  which  are  patho- 
logical, as  the  title  might  imply.  The  object  is  to  have 
the  members  make  translations  and  abstracts  of  impor- 
tant articles  dealing  with  pathology  and  bacteriology. 
These  are  to  be  read  and  discussed  before  the  club  at 
stated  intervals.  The  idea  is  in  harmony  with  a  sug- 
gestion made  by  Dr.  Bayard  Holmes,  of  Chicago,  that 
there  be  established  medical  libraries  and  library  clubs 
in  connection  with  undergraduate  medical  study.  The 
venture  is  a  novel  one,  but  will  certainly  prove  use- 
ful if  the  students  have  time  to  pursue  it  as  they  should. 

None  in  His. — "  No  1  "  exclaimed  the  fox,  loftily  ;  "  I 
don't  care  for  the  grapes  at  all.  Appendicitis  ?  Not 
on  your  life  1 '" — Detroit  Tribune. 


November  30,  1895] 


MEDICAL    RECORD. 


791 


ptcdicaX  Stems. 

Contagious  Diseases — Weekly  Statemeat Report  of 

cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  November  23,  1S95. 


Tuberculosis   

Typhoid  fever 

Scarlet  fever. 

Cerebro-spinal  meningitis. 

Measles 

Diphtheria 


119 
32 


168 
201 


Syphilitic  Headache. — Foumier  points  out  that  pain 
in  the  head  is  one  of  the  most  frequent  manifestations 
of  secondary  syphilis,  while  the  prodromal  headache  of 
tertiary  encephalopathies  is  universally  recognized  and 
described.  It  is,  however,  unfortunate  that  the  term 
specific  cephalalgia  conveys  to  many  minds  the  impres- 
sion of  a  single  pathological  process,  when,  as  a  matter 
of  clinical  fact,  the  lesions  may  be,  and  often  are,  wide- 
ly diverse  in  their  nature.  The  single  symptom  com- 
mon to  all  is  pain  in  the  head.  Thus,  this  pain  may 
be  due  to  specific  neuralgia,  affecting  one  or  more  of 
the  cranial  nerves,  constituting  what  is  called  neuralgic 
headache.  Or  it  may  be  due  to  a  lesion  in  the  cranial 
bone,  such  as  periostosis,  gummatous  osteoma,  causing 
bone  pain.  Or  it  may  develop  as  neuralgia  without 
bone  lesion,  in  which  case  it  is  often  impossible  to  lo- 
cate it.  In  many  respects  it  differs  not  at  all  from 
headaches  due  to  causes  other  than  syphilis.  Finally, 
there  is  a  headache  which,  though  dependent  on  syph- 
ilis, is  not  syphilitic  in  its  nature  ;  in  other  words,  it  is 
a  parasyphilitic  neurosis.  Syphilitic  neuralgias  are  not 
headaches  in  the  true  sense  of  the  word  ;  the  pain  is 
located  in  the  trunk  or  distribution  of  a  given  nerve, 
and  is  aggravated  by  pressure  upon  certain  portions  of 
this  nerve,  particularly  points  of  emergence.  The 
supraorbital  is  most  frequently  affected,  e.xtreme  ten- 
derness being  elicited  on  pressure  over  the  supraorbi- 
tal notch.  This  pain  may  affect  the  upper  branches  of 
the  fifth  pair,  or  the  auricular  and  mastoid  filaments  of 
the  cervical  plexus,  or  the  occipital  nerve,  but  it  is 
most  frequently  observed  attacking  the  fifth  pair,  and 
has  for  its  type  the  supraorbital  neuralgia.  This  affec- 
tion is  observed  during  the  early  stage  of  the  second- 
ary period — that  is,  in  the  first  si.x  or  eight  months  of 
the  disease.  It  is  impossible  to  state  whether  or  not 
it  is  dependent  upon  organic  lesions.  When  it  occurs 
during  the  tertiary  period,  it  is  nearly  always  due  to  a 
distinct  lesion  ;  often  the  pressure  of  a  gumma  or  bony 
outgrowth.  These  specific  neuralgias  are  character- 
ized by  almost  identically  the  same  symptoms,  depen- 
dent on  neuritis  from  other  causes.  They  have,  how- 
ever, a  tendency  to  become  worse  at  night,  and  yield 
promptly  to  specific  treatment.  Indeed,  the  therapeu- 
tic test  is  the  only  means  of  making  a  positive  diag- 
nosis. 

Pain  due  to  bone  lesions  may  occur  in  the  early 
stages,  during  the  height  of  the  disease,  or  at  a  late 
tertiary  period.  It  is  most  frequent  in  the  tertiary  pe- 
riod, and  is  readily  recognized,  since  the  lesions  are 
gross,  producing  considerable  deformity.  Secondary 
lesions  are  slight,  circumscribed,  and  readily  over- 
looked, especially  when  they  develop  in  the  hairy 
scalp.  They  occur  during  this  early  period  as  perios- 
titis, periostosis,  or  as  ostealgias  characterized  by  cir- 
cumscribed areas  of  hyperjesthesia  without  appreciable 
lesion.  These  lesions  are  very  common,  especially  in 
women,  and  are  usually  overlooked.  The  periostites 
produce  slight  circumscribed  swelling  of  the  bone,  par- 
ticularly in  the  parietal,  temporal,  and  frontal  regions. 
The  involved  areas  are  small — about  the  size  of  a  ten- 


cent  piece,  sometimes  as  large  as  a  fifty-cent  piece — 
very  slightly  raised,  sometimes  obscurely  fluctuating. 
They  are  painful  and  e.xtremely  sensitive.  This  e.xces- 
sive  sensibility  is  a  characteristic  sign.  Periostoses 
offer  the  same  symptoms  and  are  even  more  painful. 
They  are,  however,  more  dense  and  resistant  and  last 
longer.  There  is  true  bony  proliferation  on  the  sur- 
face of  the  bone.  The  ostealgias  are  characterized 
solely  by  pain.  There  is  no  swelling  and  no  appre- 
ciable alteration  of  any  kind.  The  pathological  altera- 
tion occasioning  this  symptom  is  absolutely  unknown. 
The  pain  of  these  bone  affections  is  sometimes  agoniz- 
ing, and  often  radiates  over  a  very  large  surface. 
The  diagnosis  is  founded  upon  careful  and  thorough 
palpation  of  the  entire  cranium. 

Headaches  due  to  syphilitic  affections  of  the  brain 
or  its  envelopes  are  more  diffuse  and  more  deeply 
placed  than  those  dependent  upon  bony  lesions  or 
upon  neuralgia.  It  is  impossible  from  the  symptoms  to 
decide  whether  they  are  dependent  upon  lesions  of  the 
meninges,  the  cerebrum,  the  blood-vessels,  or  whether 
all  these  structures  are  involved.  Clinically,  three 
varieties  are  recognized  :  Secondary  encephal.algia, 
headache  symptomatic  of  cephalic  lesions,  parasyphi- 
litic headache  due  to  hysteria  or  neurasthenia.  By  all 
odds  the  most  important  variety  is  the  migraine  pre- 
ceding grosser  symptoms  of  cerebral  syphilis.  In  cer- 
tainly two-thirds  of  all  the  cases  of  hemiplegia,  amne- 
sia, aphasia,  epilepsy,  coma,  pseudo  -  paralysis,  etc., 
dependent  upon  syphilis,  there  is  this  prodromal  head- 
ache. A  large  percentage  of  these  cases  could  have 
been  saved  from  these  grave  accidents  by  vigorous 
treatment  instituted  during  the  period  of  prodromal 
headache.  This  headache  differs  from  other  cepha- 
lalgias, as,  for  instance,  those  due  to  neuralgia  or  epi- 
cranial rheumatism,  from  the  fact  that  it  is  felt  to  be 
deep  within  the  head.  The  character  of  the  pain 
varies  ;  there  may  be  simply  a  sense  of  weight  and 
mental  hebetude,  or  there  may  be  a  constrictive  pain, 
as  though  the  head  were  screwed  in  a  vice  ;  or,  finally, 
the  sensation  may  resemble  that  produced  by  blows  of 
a  hammer,  the  suffering  being  very  intense  and  the 
pain  being  deeply  placed.  These  three  types  may  be 
associated,  or  may  succeed  each  other.  The  pain  may 
be  sharply  circumscribed  to  an  area  not  larger  than  a 
half-dollar.  In  this  case  it  frequently  indicates  the 
formation  of  a  gumma.  Sometimes  it  is  diffuse,  oc- 
cupying a  general  region,  as  the  frontal,  or  temporal, 
or  parietal,  or  occipital,  or  spread  over  two  or  more  of 
these  legions.  Exceptionally  it  seems  to  involve  the 
whole  head.  The  fronto-parietal  region  is  the  one 
most  freiiuently  subject  to  this  pain.  This  pain  has 
three  characteristics  which  should  at  least  strongly  sug- 
gest its  nature.  There  is  an  habitual  intensity,  some- 
times extraordinary  severity,  of  pain.  It  is  persistent, 
tenacious,  long-lasting  ;  there  are  nocturnal  exacerba- 
tions. Even  in  mild  cases  the  pain  is  less  bearable 
than  the  ordinary  headache  :  it  harasses  the  sufferers, 
making  them  despondent,  morose,  excitable,  sleepless, 
and  interfering  with  general  nutrition  ;  or  it  may  be  so 
severe  as  to  completely  ])rostrate  them.  Excejitionally 
the  pain  amounts  to  a  veritable  anguish,  comparable  in 
intensity  to  that  of  hepatic  or  nephritic  colic.  Noc- 
turnal exacerbations  of  pain,  thougii  the  rule,  are  by 
no  means  invariable.  In  the  secondary  period  this  char- 
acteristic is  most  pronounced  ;  in  the  tertiary  period 
it  may  be  wanting  entirely  ;  indeed,  it  may  hapjien 
that  there  are  nocturnal  remissions.  As  a  rule,  syphi- 
litic cephalalgia  |>recedes  the  grave  developments  of 
brain  syphilis  by  an  interval  of  three  to  six  weeks  ;  it 
is,  however,  not  uncommon  for  this  pain  to  last  three 
to  six  months  ;  excei)tionally  the  pain  may  exhibit  re- 
missions and  exacerbations  for  two  or  three  years. 
Under  the  influence  of  intermittent,  mild,  specific 
treatment,  the  headache  may  be  temporarily  cured,  to 
recur  time  after  time,  till  symptoms  such  as  hemiplegia 
or  epilepsy  show    that   irreparable  damage  has   been 


792 


MEDICAL    RECORD. 


[November  30,  1895 


done.  The  prodromal  headache  is  a  sign  of  inestima- 
ble value,  enabling  a  treatment  to  be  instituted  in  time 
to  prevent  grave  lesions.  This  treatment  should  be 
instituted  early,  should  be  vigorous,  should  be  long 
continued.  It  is  not  sufificient  to  cure  the  headache  ; 
the  underlying  constitutional  taint  must  be  eradicated 
in  so  far  as  this  is  possible. 

This  treatment  should  combine  mercury  and  potas- 
sium iodide,  each  given  in  the  most  active  form  and 
manner  possible.  Every  ten  days  an  injection  of  a  grain 
and  a  half  of  calomel  should  be  given,  repeated  as  often 
as  is  required.  Internally,  the  iodide  of  potassium  is  to 
be  administered,  to  a  woman,  one  to  one  and  one-half 
drachm  a  day  ;  to  a  man,  nearly  twice  this  dose. 
This  treatment  should  be  long  continued,  with  appro- 
priate short  intervals  of  rest,  until  there  is  good  reason 
to  believe  that  there  is  no  likelihood  of  further  recur- 
rence. 

Among  the  parasyphilitic  affections  causing  head- 
ache may  be  mentioned  the  neuralgic  migraine  and  the 
crises  of  pain  often  observed  in  tabes.  The  most  im- 
portant affection,  and  by  far  the  most  common,  is  neu- 
rasthenia. This  is  an  ordinary  sequence  of  syphilis, 
and  among  its  multitudinous  symptoms  none  is  more 
troublesome  or  more  frequent  than  headache.  This 
parasyphilitic  neurasthenic  headache  is  characterized 
by  very  moderate  intensity  ;  it  is  not  really  a  pain,  but 
rather  a  sensation  of  weight  or  constriction,  of  dulled 
or  imperfect  cerebral  action.  As  to  duration,  it  usual- 
ly lasts  several  years.  It  is  present  in  the  morning  on 
rising  ;  is  sometimes  better  after  meals,  but  shortly  re- 
turns with  its  original  intensit)',  or  even  with  a  slight 
excess  of  this  ;  it  is  better  at  night,  so  that  sleep  is  not 
disturbed.  It  is  not  benefited  by  specific  treatment  ; 
it  is  usually  located  in  the  occipital  region  ;  and,  final- 
ly, it  is  usually  associated  with  other  signs  of  neuras- 
thenia. These  are  characteristics  which  sufficiently 
distinguish  the  cephalalgia  from  pain  prodromal  to  the 
recognized  cephalopathies  ;  indeed,  a  headache  which 
has  lasted  for  several  years  almost  certainly  does  not 
belong  to  the  latter  class,  since  apople.xy  or  some  one 
of  the  serious  symptoms  denoting  irreparable  lesion  is 
quite  certain  to  develop  long  before  the  expiration  of  this 
period.  Yet  it  may  well  happen  that  a  differential  diag- 
nosis cannot  be  made.  In  this  case  the  mixed  specific 
treatment  should  be  given  one  thorough  trial.  Should 
it  f^il,  there  should  be  no  further  effort  in  the  direc- 
tion of  attempting  cure  by  this  treatment.  Where  the 
diagnosis  of  parasyphilitic  neurasthenia  is  firmly  es- 
tablished, minute  attention  to  general  hygiene,  a  thor- 
ough hydrotherapy,  especially  with  douches  of  brief 
duration,  or  warm -bath  treatment,  massage,  and  change 
of  surroundings  represent  the  best  methods  of  ultimate- 
ly accomplishing  a  cure.  The  only  drug  which  is  of 
the  least  service,  aside  from  the  tonics  and  nutritives, 
is  bromide  of  potassium  ;  this  sometimes  relieves  the 
headache. —  Therapeutic  Gazette. 

Professor  Konig,  of  Gottingen,  has  been  chosen  to 
fill  the  post  of  the  late  Professor  Bardeleben,  Professor 
of  Surgery  at  Berlin. 

Horse  Meat  in  Germany.— It  is  said  that  nearly  one- 
half  of  the  flesh  consumed  by  the  people  of  Germany, 
in  the  larger  cities,  is  horse  meat.  The  German  butch- 
ers used  to  buy  worn-out  horses  at  five  dollars  to  ten 
dollars  apiece,  but  they  now  have  to  pay  from  forty  to 
fifty  dollars.  Even  at  this  price,  they  are  able  to  fur- 
nish meat  at  about  seven  cents  a  pound.  The  flesh  is 
consumed  salted  and  smoked,  as  well  as  fresh. 

Infant  Stomach  Trouble.— About  seven  times  more 
children,  says  Douglas,  die  from  stomach  and  bowel 
affections  during  the  first  year  of  their  birth  than  during 
the  second  year. 

Dr.  Smith. — The  name  "  Smith  "  is  the  popular  mono- 
syllabic appellation  of  1,284  practising  physicians  in 
the  United  States. 


Sick  or  111. — Mr.  AV.  D.  Howells  discusses,  in  a  hu- 
morous way,  the  fact  that  there  is  a  tendency  in  America 
to  use  the  word  "  ill  "  in  place  of  the  word  "  sick,"  fol- 
lowing the  English  fashion.  To  the  Englishman,  the 
word  sick  implies,  as  we  understand,  a  morbid  state  es- 
pecially connected  with  the  stomach  and  with  nausea. 
The  American  uses  the  word  sick  to  indicate  all  kinds 
of  morbid  states.  The  word  sick  is  a  good,  honest 
Anglo-Saxon  term,  and  has  answered  the  purpose  very 
well  during  these  last  two  hundred  years.  But  Mr. 
Howells  seems  to  think  that  it  has  got  to  go,  and  that 
in  time  there  will  be  no  sick  people  in  America,  but 
only  persons  who  are  ill. 

The  Dangers  of  Thyroid  Feeding. — It  has  come  to 
the  notice  of  physicians,  that  the  thyroid  tablets  are 
being  used  somewhat  by  the  laity,  and  especially  by 
women  who  are  desirous  of  ridding  themselves  of 
superfluous  fat.  Some  dangerous  symptoms  have  been 
observed,  we  are  told,  as  the  result  of  this  treatment. 
Dr.  A.  Eulenberg,  of  Berlin,  reports  a  case  in  which 
the  patient  took  six  tablets  a  day,  with  severe  nervous 
and  cardiac  symptoms  as  the  result.  There  can  be  no 
doubt  that  the  use  of  the  thyroid  tablets  is  dangerous, 
and  should  only  be  employed  under  careful  super- 
vision. 


NEW   BOOKS    RECEIVED. 

While  the  Medical  Record  is  pleased  to  receive  all  new  publi- 
cations which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  tiecessities  are  such  that  it  cannot 
be  considered  under  obligation  to  notice  or  review  any  publication 
received  by  it  which  in  the  judgment  of  its  editor  will  not  be  of  in- 
terest to  its  readers. 

A  Manual  of  Oper.\tive  Surgery.  By  Dr.  Lewis  A.  Stimson. 
Third  Edition.  i2mo,  594  pages.  Illustrated.  Published  by  Lea 
Brothers  &  Co.,  Philadelphia,  Pa. 

Twentieth-Century  Practice.  An  International  Encyclo- 
paedia of  Modern  Medical  Science.  By  Leading  Authorities  of 
Europe  and  America.  Edited  by  Thomas  L.  Stedman,  M.D., 
New  York  City.  In  twenty  volumes.  Vol.  IV.  :  Diseases  of  the 
Vascular  System  and  Thyroid  Gland.  Published  by  William  Wood 
&  Co.,  New  York. 

The  Pathology  and  Surgical  Treatment  of  Tumors.  By 
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half  morocco,  fT.    Published  by  W.  B.  Saunders,  Philadelphia,  Pa. 

State  Commission  in  Lunacy.  Sixth  Annual  Report,  Octo- 
tober  I,  1893,  to  September  30,  1894.  State  of  New  York.  Trans- 
mitted to  the  Legislature  May  24,  1895.  James  B.  Lyon,  State 
Printer. 

The  Art  of  Co.vipounding.  A  Text-book  for  Students,  and  a 
Reference-book  for  Pharmacists  at  the  Prescription  Counter.  By 
Wilbur  L.  Scoville,  Ph.G.  Svo,  264  pages.  Price,  $2.50.  P. 
Blakiston,  Son  &  Co.,  Philadelphia,  Pa. 

Handbook  of  the  Diagnosis  and  Treatment  of  Skin  Dis- 
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and  revised.  !2mo,  577  pages.  Illustrated.  Price,  $2.75.  Pub- 
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Labor.^tory  Manual  of  Inorg.a.nic  Prepakations.  By  H. 
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The  DisE.vsES  of  Children's  Teeth:  their  Prevention 
and  Treatment.  A  Manu.1l  for  Medical  Practitioners  and  Stu- 
dents. By  R.  Denison  Pedley,  M.R.C.S.,  L.D.S.  Eng.,  F.K.C.S. 
Edin.  i2mo,  26S  pages,  illustrated.  Published  in  London  by 
J.  P.  Segg  &  Co.,  and  in  .America  by  S.  S.  While  Dental  Manu- 
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An  A.MERiCAN  Text-book  of  Obstetrics  for  Practitioners 
and  Students.  By  Various  Authors.  Illustrated.  Royal  octavo, 
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The  Practice  of  Medicine.  By  Dr.  William  C.  Goodno. 
With  Sections  of  the  Nervous  System.  By  Dr.  Clarence  Bartlett. 
Vol.  2  :  Diseases  of  the  Circulatoiy,  Respiratoy,  Urinarj-,  and 
Digestive  Systems  ;  Diseases  of  the  Blood,  and  Constitution.al  and 
Parasitic  Diseases.  Royal  octavo,  981  pages.  Illustrated.  Pub- 
lished by  the  Halinemann  Press,  Philadelphia,  Pa. 

Manual  of  Gynecology.  By  Dr.  Henry  T.  Byford.  i2mo, 
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ton, Son  &  Co.,  Philadelphia,  Pa. 


Medical   Record 

A  Weekly  yonrnal  of  Medicine  and  Siiygery 


Vol.  48,  No.  23. 
Whole  No.  1309. 


New  York,  December  7,  1895. 


$5.00  Per  Annum. 
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(DriQinal  5ivticlcs. 

THE   PROGRESS    OF  MEDICINE.  • 
By  EDWARD   G.    JANEWAY,   JI.D., 

NEW  YORK, 

Mr.  President,  Members  of  the  Academy,  Ladies, 
AXD  Gentlemen  :  It  is  my  privilege  to  address  you 
this  evening,  and  while  I  have  felt  that  some  one  with 
more  oratorical  power  might  have  been  chosen,  yet  it 
was  not  possible  to  refuse  the  request  of  the  President, 
who  put  it  in  the  light  of  an  unavoidable  duty.  In 
going  over  the  ground  for  a  subject  which  might  be  of 
general  interest,  and  yet  more,  one  from  which  lessons 
of  importance  to  the  welfare  of  the  Academy  might  be 
drawn,  the  speaker  has  selected  the  progress  of  medi- 
cine. It  is  not  the  intention  to  pass  in  review  the 
gradual  advances  of  medical  science,  but  to  limit  our 
theme  to  a  time  sufficiently  recent  to  be  within  the 
memory  of  a  number,  and  the  knowledge  of  all — that 
of  the  last  thirty  years.  The  theme  will  be  somewhat 
discursively  considered,  in  order  to  touch  on  a  number 
of  points. 

If  we  commence  with  the  study  of  medicine  as  now 
conducted  in  this  city,  and  compare  it  with  that  which 
obtained  thirty  years  ago,  we  will  notice  a  marked  im- 
provement, which,  however,  is  not  perfection,  because 
of  certain  limitations  of  time,  and  of  number  of  stu- 
dents to  be  instructed  within  that  period.  Thirty 
years  ago  the  time  required  for  the  study  of  medicine 
was  three  years,  comprising  two  courses  of  lectures  in 
a  medical  school,  the  last  of  which  was  to  be  in  that  in- 
stitution which  issued  the  diploma.  A  considerable 
part  of  the  study  and  of  the  practical  work  was  sup- 
posed to  be  done  in  the  office  of  a  practitioner  with 
whom  the  student  entered,  and  who  was  usually  too 
busy  to  give  more  than  a  very  slight  oversight  on  the 
progress  of  the  aspirant  for  medical  honors.  Much  of 
the  work  in  those  days,  far  more  than  at  present,  when 
there  is  yet  too  considerable,  was  in  the  direction  of 
what  is  called  teaching,  cramming,  etc.,  consisting  in 
making  the  student  memorize  facts  from  books  and 
lectures,  and  not  education  in  its  truest  sense.  The 
idea  of  the  difference  between  a  true  educator  and  a 
teacher  in  the  ordinary  acceptation  of  the  word,  does 
not  enter  into  the  conception  of  many  medical  stu- 
dents, and  is  possibly  absent  from  the  sphere  of  some 
teachers  of  medicine.  In  the  coming  era  the  demand 
will  more  and  more  be  for  educators,  not  for  the  ordi- 
nary teacher,  who  will  simply  cram  the  student  with 
facts,  theories  of  disease  acceptable  to  himself,  and 
plans  of  treatment  of  which  he  approves,  as  the  only 
possible  things  which  the  student  must  remember. 
The  facts  may  not  all  exist,  the  theories  be  false,  and 
the  plan  of  treatment  one  which  is  but  the  fad  of  the 
present,  or  possibly  even  of  a  past,  to  be  discarded 
later  ;  nevertheless  the  student  is  obliged  to  learn  these 
things.  How  many  a  student  in  afierlife  has  won- 
dered at  the  difficulty  of  shaking  off  false  conceptions 
of  disease  because  of  the  thoroughness  with  which  they 
had  been  ingrafted  during  the  stage  of  pupillage  I  How 
different  this  plan  of  dealing  with  the  youthful  medical 

'  An  anniversary  address  delivered  before  the  New  York  .Academy 
:  Medicine,  November  21,  1895. 


mind  from  that  which  should  obtain  if  the  best  growth 
of  which  each  is  capable  is  to  be  obtained.  The  true 
educator  takes  the  student  (speaking  now  of  one  branch 
as  illustrative)  to  the  disease  as  it  exists  in  the  living 
patients,  showing  him  the  different  aspects  in  which  it 
may  present  itself,  letting  the  student  note  the  condi- 
tion of  the  mind  in  delirium,  scan  the  state  of  the  eye 
and  pupil,  and  of  the  expression  of  the  features,  see 
the  variation  of  temperature,  feel  the  different  charac- 
ters of  the  pulse,  note  the  phases  of  eruption,  listen  to 
the  varying  sounds  to  be  heard  in  the  heart  and  lungs, 
and  palpate  the  conditions  capable  of  such  method  of 
demonstration  in  the  different  parts  of  the  body. 
Moreover,  as  he  trains  the  student  to  observe  he  will 
try  also  to  impress  upon  him  the  importance  of  these 
observations  by  applying  them  to  diagnosis  and  to 
treatment.  But  here  we  can  discern  the  great  and 
radical  difference  between  a  teacher  and  an  educator. 
The  former  will  strive  to  impress  upon  the  student  that 
such  and  such  is  the  case  because  I  say  so,  or  it  is  my 
way  of  doing,  the  ego  being  ever  so  large  as  to  obscure 
the  true  object  of  teaching,  viz.,  to  develop  the  student 
into  a  correct  thinker,  not  a  dwarfed  reproduction  of 
the  teacher.  On  the  other  hand,  the  educator  will  go 
over  the  varied  manifestations,  striving  to  make  the 
student  think  out  first  the  conditions,  and  next  the 
method  of  combating  these,  so  that  with  each  case 
seen  he  may  ever  be  a  better  reasoner,  and  be  more 
capable  of  recognizing  such  subtile  differences  as  may 
determine  this  or  that  to  be  the  preferable  plan  of  pro- 
cedure. 

In  the  death  of  your  late  President,  Dr.  Alfred  L. 
Loomis,  one  of  the  prominent  teachers  and  educators 
has  been  removed.  The  curriculum  of  each  of  the 
medical  colleges  of  this  city  (speaking  for  our  branch 
of  the  profession)  has  been  lengthened,  until  now,  in 
one,  it  consists  of  a  compulsory  four  years'  graded 
course,  extending  over  eight  months  of  the  year,  with  a 
large  portion  of  the  time  devoted  to  laboratory  work 
and  to  practical  study  of  disease.  In  the  other  two 
colleges  for  men  the  compulsorj'  course  is  of  three 
years'  duration,  for  six  months  of  each  year,  with  an 
addition  of  two  months  of  permissory  study  under  the 
direction  of  the  faculty.  The  medical  college  for 
women  has  as  rigid  requirements  as  those  for  men. 

In  all  the  colleges  much  of  the  practical  teaching 
for  which  formerly  an  extra  charge  was  made  is  now 
a  part  of  the  regular  course.  In  by-gone  times  stu- 
dents were  at  times  given  diplomas  entitling  them  to 
practise  medicine,  when  they  had  never  heard  the  mor- 
bid sounds  of  disease,  applied  a  bandage,  or  helped  at 
the  introduction  of  a  new  life,  but  had  only  crammed 
the  theory  of  these  things  from  books.  Each  decade 
has  witnessed  a  striking  improvement  in  this  direction. 
Some  may  say  that  there  were  clinical  lectures  given 
in  all  the  colleges,  but  what  did  those  students  learn, 
who  were  on  the  back  seats  in  a  crowded  amphitheatre, 
of  many  of  the  subjects  presented.  It  should  be 
added  here  that  the  medical  colleges  of  other  cities 
have  also  advanced  in  their  requirements  and  plan 
of  study,  or  have,  as  the  Johns  Hopkins,  only  had 
that  method  of  medical  instruction  ab  initio.  Most  of 
you,  moreover,  realize  the  additional  burdens  which 
have  been  placed  upon  medical  students  in  the  newer 
and  the  more  extended  branches  of  study,  compared 
with  what  obtained  thirty  years  ago.     At  the  present 


794 


MEDICAL    RECORD. 


[December  7,  1895 


time  more  or  less  of  histology,  normal  and  pathological, 
is  required  in  all  our  colleges,  and  in  considerable  de- 
gree this  is  a  practical  course.  In  one  school  compul- 
sory laboratory  study  of  bacteriology  has  been  added. 
Thirty  years  ago  the  former  may  have  been  in  a  meas- 
ure permissible,  were  the  student  so  mindful  and  could 
get  the  opportunity  ;  of  the  latter  practically  nothing 
was  known.  Now,  moreover,  each  of  the  colleges  has 
laboratories  and  microscopes,  the  former  the  gift  in 
each  case  of  some  citizen  (of  this  city),  who  should 
ever  have  pleasure  in  the  contemplation  of  having 
done  his  share  in  placing  our  medical  colleges  in  the 
position  of  truer  educational  centres.  Volumes  are 
now  written  upon  the  subject  of  bacteriology  in  each 
language,  where  formerly  none  existed,  and  the  impor- 
tance of  this  new  branch  constantly  increases.  Yet 
there  is  a  singular  confession  of  our  ignorance  to  be 
made  here.  AVe  are  as  yet  unable  to  teach  the  student 
the  name,  or  to  know  ourselves  the  organism  productive 
of  some  of  the  most  contagious  of  diseases. 

With  the  growth  of  knowledge  in  different  directions 
there  has  come  more  or  less  of  a  necessity  of  separat- 
ing the  teaching  faculty  of  our  colleges  into  those  de- 
voting themselves  to  the  scientific  subjects  and  those 
who  teach  what  are  called  the  practical  branches. 
Formerly  a  professor  might  teach  physiology  or  pathol- 
ogy, and  at  the  same  time  practise  medicine  ;  but,  ow- 
ing to  the  rapid  and  widening  growth  in  these  branches, 
some  of  the  colleges  have  the  professors  of  these  chairs 
devote  themselves  to  the  study  of  the  subject  and  not 
engage  in  practice,  in  consequence  of  the  inability  to 
do  their  best  work  under  the  distractions  incidental  to 
the  practice  of  medicine.  The  growth  of  physiological 
chemistry  is  so  considerable,  and  the  study  of  pathol- 
ogy, and  especially  of  bacteriology,  is  so  time-robbing, 
that  in  case  the  professor  desires  to  be  an  educator  he 
must  devote  himself  to  the  subject.  My  object  in  thus 
briefly  bringing  before  you  this  matter,  its  importance, 
and  the  necessity  which  exists  or  will  exist  in  all  our 
medical  schools  of  having  men  devote  their  time  to 
the  consideration  and  teaching  of  these  scientific  sub- 
jects, instead  of  making  them  accessory  to  the  practice 
of  medicine,  is  to  call  attention  to  the  necessity  of  urg- 
ing the  endowment  of  these  chairs  on  scientific  sub- 
jects in  such  colleges  as  have  not  the  means  of  properly 
remunerating  these  chairs.  The  professor  of  what  is 
called  a  practical  subject  is  enabled  to  improve  his  po- 
sition and  to  increase  the  pecuniary  return  from  the 
work  and  time  he  bestows  on  teaching. 

Hence  the  necessity  exists,  and  the  question  comes 
from  whence  are  the  colleges  to  obtain  their  endow- 
ment fund  ?  In  Germany  the  government  provides, 
but  in  our  country  we  must  look  to  our  wealthy  citi- 
zens not  alone  to  build  colleges  and  laboratories,  but 
also,  what  is  of  more  importance,  to  endow  chairs  in 
these  institutions,  at  least  those  of  a  scientific  nature. 
At  a  recent  meeting  of  the  American  Academy  of  Med- 
icine resolutions  were  adopted  which  looked  toward 
the  discouraging  the  building  of  any  more  hospitals 
and  dispensaries,  on  the  ground  that  enough,  or  more 
than  enough,  already  existed,  and  that  their  effect  was 
to  interfere  with  the  returns  which  the  number  of  phy- 
sicians now  in  this  country  should  obtain  from  the 
practice  of  their  profession.  It  may  well  be  asked  also 
if  there  are  not  too  many  medical  colleges,  especially 
those  in  small  cities,  turning  out  too  many  physicians, 
some  of  them  poorly  equipped  for  their  work,  but  yet 
competitors  with  the  better  educated  for  a  livelihood. 

However,  the  establishment  in  different  States  of  the 
requirement  of  a  license  from  a  body  of  examiners  ap- 
pointed directly  or  indirectly  by  the  State,  and  issued 
only  after  an  examination,  has  acted  in  some  degree  as 
a  safety-valve,  for  a  fair  percentage  of  candidates  fall 
short  of  the  requirements.  The  practice  of  medicine, 
moreover,  owing  to  a  license  being  required  in  most  of 
our  neighboring  States  from  its  own  board,  is  hedged 
with  more  restrictions  than  formerly,  and  it  is  a  matter 


for  consideration  whether  some  inter-State  courtesy  or 
reciprocity  will  not  be  a  necessity.  New  Jersey,  I  am. 
told,  will  allow  a  licentiate  of  New  York  to  file  his  cer- 
tificate from  the  latter  State  and  practise  thereon,  but  he 
must  pay  double  the  fee  over  what  would  be  required 
if  he  passed  an  examination. 

It  behooves  rae  to  speak  with  emphasis  upon  the  ben- 
efit the  medical  profession  has  received  from  the  em- 
ployment of  efficient  trained  nurses.  The  Bellevue 
Hospital  training-school  is  the  parent  institution,  and 
only  tweaty  odd  years  old. 

Two  schools  now  exist  for  the  teaching  of  those 
graduates  of  medicine  who  wish  to  avail  themselves  of 
the  rich  clinical  material  in  New  York  City  in  a  short 
space  of  time.  Few  of  us  appreciate  the  immense 
strides  in  our  knowledge  of  some  departments  of  med- 
icine. In  no  branch  have  greater  achievements  been 
reached  than  in  neurology.  Numerous  systematic 
treatises  now  exist  upon  the  subject,  several  authors 
being  members  of  the  Academy,  and  it  is  taught  as  a 
special  course  instead  of,  as  formerly,  being  grouped 
with  general  medicine. 

Thirty  years  ago  multiple  neuritis  was  unknown,  the 
most  astute  observers  considering  the  manifestations  as 
indicating  a  subacute  general  spinal  paralysis,  and 
writing  the  methods  of  diagnosis  of  this  complaint. 
To-day  a  medical  student  is  readily  taught  the  means 
of  discrimination,  and  in  that  bygone  time  not  a  few 
cases  of  cured  progressive  muscular  atrophy  and  loco- 
motor ataxia  were  to  be  referred  not  to  the  cure  of 
these  latte*"  conditions,  but  to  a  mistake  between  those 
conditions  and  a  disease  not  then  recognized.  Grad- 
ually, too,  in  these  years  the  term  neurasthenia,  first 
employed  by  a  member  of  this  Academy,  has  come  into 
general  use.  The  monotony  of  having  only  malaria 
for  obscure  states  of  the  system  has  been  wonderfully 
relieved  by  the  complex  of  conditions  comprised  un- 
der this  head,  and  with  lithsemia  they  divide  the  de- 
batable ground. 

I  fear  that  a  number  of  my  hearers  have  never  read 
the  book  upon  spinal-cord  troubles  which  was  much 
resorted  to  in  those  days,  the  brochure  of  the  lamented 
and  brilliant  Brown-Sequard.  In  this  work  we  were 
taught  to  distinguish  between  meningitis,  myelitis,  con- 
gestion of  the  cord,  and  reflex  paralysis.  This  was  a 
very  simple  matter  compared  with  the  terms  and  the 
diseases  of  the  spinal  cord  which  the  student  must  to- 
day comprehend.  I  shall  not  weary  such  of  my  audi- 
tors as  may  not  be  familiar  with  the  long  list.  We  are 
indebted  for  the  progress  to  many  workers,  each  adding 
something  to  the  structure,  though  no  name  stands  out 
so  prominently  in  the  whole  field  as  that  of  the  late 
distinguished  French  physician,  Professor  Charcot. 
So  much  has  he  been  identified,  both  by  writing  and 
teaching,  with  diseases  of  the  nervous  system,  that 
many  are  unaware  that  he  contributed  articles  on  the 
diseases  of  the  liver  and  kidneys  ;  and,  in  fact,  after 
Moneret,  was  the  next  to  employ  the  term  fever  inter- 
mittent hepatic  of  biliary  obstruction,  years  before 
lectures  were  delivered  and  articles  written  about  this 
condition  in  English  ;  at  a  time,  in  fact,  when  most  of 
our  text  books  were  teaching  that  fever  did  not  occur 
with  biliary  colic  and  pointed  to  some  other  condition. 
Pardon  me  for  the  digression,  but  I  thought  that  this 
brief  notice  might  be  of  interest. 

In  no  direction  have  greater  advances  occurred, 
moreover,  than  in  the  ability  to  locate  the  area  of  dis- 
turbance in  the  brain.  The  fight  for  localization  was  a 
long  and  arduous  one,  whose  beginnings  date  beyond 
this  era,  in  the  discovery  of  the  connection  between 
aphasia  and  disease  of  the  third  frontal  convolution 
of  the  left  side.  Yet  he  v>-ho  reads  an  article  on 
aphasia  of  to-day,  and  such  a  masterly  one  as  that 
contained  in  Trousseau's  clinical  lectures,  will  note 
the  growth  of  our  knowledge  on  this  subject.  The 
writer  recalls  the  amazement  of  a  friend  well  versed  in 
neurological    knowledge  at  the  time,  on   noticing  the 


December  7,    1S95] 


MEDICAL    RECORD 


795 


record  of  an  autopsy  in  a  case  of  aphasia,  in  which  the 
lesion  was  found  in  the  left  temporo-sphenoidal  lobe, 
and  his  insistance  that  a  mistake  had  been  made  in  not 
noticing  some  connection  of  the  disease  with  the  third 
frontal.  This  is  an  illustration  of  the  importance  of 
paj-ing  great  attention  to  such  cases  as  deviate  from 
the  general  type  and  the  ordinary  phenomena  of  a 
recognized  disease  ;  for  he  who  carefully  scans  all  the 
features  of  such  a  case  with  sufficient  knowledge  may 
discern  a  new  law  or  bring  to  light  a  subdivision  of 
importance.  We  now  understand  word-deafness  and 
its  relation  to  disease  of  the  temporo-sphenoidal  lobe. 
Had  my  friend,  who  made  the  autopsy  in  that  case, 
also  been  possessed  of  all  the  facts  in  the  ante-mortem 
history,  he  might  have  been  one  of  the  earliest  describ- 
ers  of  word-deafness.  Moreover,  we  have  been  very 
considerably  indebted  to  vivisection  for  the  advance  in 
this  direction.  Without  this  method  of  investigation 
the  writer  cannot  see  how  the  increase  of  knowledge 
which  has  occurred  would  have  been  possible.  Un- 
doubtedly it  has  required  the  careful  and  painstaking 
research  of  numerous  autopsies  on  those  dying  of  dis- 
ease of  the  brain,  to  confirm  in  the  human  being  the 
observations  made  on  the  lower  animals  ;  but  these 
alone  would  not  have  sufficed  to  place  the  theory  upon 
a  firm  foundation.  The  brain  surgery  of  to  day  is  in 
consequence  a  very  different  affair  from  that  which 
obtained  in  the  sixties.  In  certain  instances  we  feel 
that  it  has  led  enthusiasts  too  far,  and  that  a  certain 
proportion  of  such  operative  interferences  might  far 
better  not  have  been  attempted.  Our  distinguished 
e.x-president,  Dr.  Jacobi,  has  drawn  attention  to  this  in 
his  address  "  Non  nocere."  Yet  the  outcome  has  been 
that  lives  have  been  saved  by  the  ablation  of  tumors, 
by  the  opening  of  abscesses,  and  by  the  removal  of  clot, 
whose  location  was  only  recognizable  by  study  of  rules 
growing  out  of  the  work  of  Hitzig,  Ferrier,  Munk,  and 
others. 

The  railroad  spine,  or  concussion,  has  also  been  a 
product  of  these  last  thirty  years,  Erichsen  having 
launched  the  term  greatly  to  the  regret  of  numerous 
railroad  companies  and  corporations,  who  have  been  in 
many  cases  mulcted  of  large  sums  owing  to  the  elas- 
ticity of  the  term.  A  disease  indeed  with  varied  symp- 
toms, but  having  in  one  respect  a  close  resemblance  to 
dipsomania,  viz.,  in  that  a  certain  proportion  of  the 
cases  are  best  treated  and  restored  by  the  gold  cure. 
So,  too,  in  this  connection  there  was  recorded  unfortu- 
nately that  first  instance  of  abnormally  high  tempera- 
ture in  the  case  of  the  young  lady  thrown  from  her 
horse,  and  while  the  temperatures  recorded  in  her  case, 
and  some  more  remarkable  of  subsequent  dates,  have 
always  puzzled  the  writer  and  many  of  his  friends,  they 
believe  them  only  explainable  by  juggling  with  the 
thermometer. 

Not  alone  has  the  list  of  diseases  of  the  spinal  cord 
been  increased  by  our  expanding  knowledge,  but  many 
of  supposed  functional  character  have  been  found  to 
be  of  organic  nature  ;  the  difficulty  earlier  having 
been  the  lack  of  autopsies  in  appropriate  cases,  and  in 
addition  the  want  of  accurate  methods  of  investiga- 
tion in  such  a  structure  as  the  spinal  cord.  Within 
this  period  also  the  choked  disk  became  noted  as  a 
pathognomonic  sign  of  tumor  of  the  brain,  and  though 
it  was  soon  discovered  that  tumor  of  the  brain  might 
occur  without  this,  yet  it  took  considerably  longer  to 
dispel  the  idea  that  tumor  was  the  cause  of  trouble 
should  a  choked  disk  be  found.  So  much  was  this  the 
case  that  when  one  had  been  noted,  and  the  subsequent 
course  of  events  demonstrated  the  inaccuracy  of  the 
statement,  attempts  were  made  to  draw  a  distinction 
between  the  ajjpearanccs  in  the  two  conditions.  N'ow 
we  know  that  the  condition  is  not  pathognomonic. 
However,  later  on  we  will  allude  to  this  same  sort  of 
error  in  disease  of  another  organ.  The  first  observer 
draws  attention  to  the  existence  of  a  certain  s:ate  in 
some  disease,  others  note  the  same  thing,  and  soon  an 


enthusiast,  or  better,  a  dogmatist,  announces  such  a  con- 
dition is  a  sign  of  such  a  disease,  and  years  are  spent 
in  undoing  the  evil. 

The  term  myxoedema  has  also  come  into  use,  indica- 
tive of  a  disorder  not  dreamed  of  thirty  years  ago,  and 
it  illustrates  the  method  of  discovery  of  relationship 
between  an  organ  and  a  state  of  the  system  long  over- 
looked, and  for  which  a  remedial  measure  has  been 
found  in  the  feeding  of  the  sheep's  thyroid.  The  names 
of  Gull,  Ord,  Horsley,  and  Murray  stand  out  promi- 
nently in  the  gradual  description,  recognition,  under- 
standing of  the  pathology,  and  treatment  of  this  state. 

It  has  been  a  matter  of  interest,  too,  to  note  how  little 
of  apparent  notice  our  German  friends  took  in  a 
diseased  condition  worked  up  by  English  physicians  ; 
though  Kocher,  of  Berne,  in  describing  the  results  of 
the  removal  of  the  thyroid  described  myxoedema  and 
helped  to  bring  into  relief  the  true  cause  of  the  com- 
plaint. 

The  method  of  mediate  percussion  introduced  by 
Avenburger,  and  that  of  auscultation  taught  by  Laennec, 
gave,  in  addition  to  the  other,  though  not  so  essential, 
means  of  examination,  an  early  insight  into  tlie  diseases 
of  the  heart  and  of  the  lungs  long  before  the  period  of 
which  I  write.  The  chief  additions  to  our  knowledge 
during  this  period  have  been  by  the  explanations  bac- 
teriology has  given  as  to  the  etiology  of  disease.  Of 
course,  pathological  examinations  have  gradually  in- 
creased our  comprehension  of  the  intimate  changes  of 
disease,  but  no  such  marked  increase  as  has  been  noted 
in  the  case  of  the  nervous  system  has  occurred. 

Actinomycosis  has  been  made  out.  Explorations 
with  needle  and  syringe  have  enabled  us  to  tell  at  an 
early  date  the  nature  of  fluids  in  the  chest  and  peri- 
cardium. Moreover,  I  believe  that  this  method  was 
more  employed  in  New  York  at  an  early  period  than 
abroad,  and  though  liable  to  abuse  by  careless  use  of 
unclean  instruments,  or  by  lack  of  forethought  as  to  the 
nature  of  the  process  for  which  used,  it  has  proved  of 
marked  benefit.  The  introduction  of  aspiration  by 
Dieulafoy  has  simplified  the  withdrawal  of  fluid  from  the 
pleura  and  from  the  pericardium,  while  free  drainage 
has  gradually  helped  to  cure  cases  of  empyema  in  a 
shortened  period  of  time.  We  understand,  moreover, 
ulcerative  endocarditis,  have  had  the  terms  tachycardia 
and  bradycardia  replace  the  simple  names  of  rapid  and 
slow  heart.  Moreover,  it  seems  to  the  speaker  that  at 
the  present  time  greater  attention  is  given  to  a  consid- 
eration of  the  condition  of  the  heart  muscle,  and  the 
importance  of  the  study  of  this  as  contrasted  with  that 
of  the  adventitious  sounds  or  murmurs  which  were  for- 
merly so  apt  to  monopolize  attention,  or  else  receive 
too  considerable  thought. 

The  use  of  the  stomach-tube  for  investigation  and 
for  treatment  of  disorders  of  this  viscus  has  been  the 
means  of  widening  our  knowledge  of  stomach  disor- 
ders, and  also  of  proving  a  very  important  aid  in  bring- 
ing about  cure  or  amelioration  of  its  diseases.  This 
is  sufficiently  familiar  to  you,  as  is  no  doubt  that  other 
production  of  erroneous  diagnostic  rules  based  upon 
its  employment.  For  no  sooner  was  it  found  that  free 
hydrochloric  acid  was  absent  from  the  stomach  in  cases 
of  carcinoma,  than  it  was  assumed  that  the  absence  of 
free  hydrochloric  acid  meant  carcinoma.  The  dog- 
matist laid  down  the  law  on  an  insufficient  basis,  only 
to  discover  later  that  the  methods  were  at  times  inac- 
curate, and  that  other  conditions  could  at  times  pro- 
duce the  same  result. 

Perhaps  no  greater  improvement  in  our  considera- 
tion of  abdominal  disorders  has  taken  place  than  in 
the  recognition  of  appendicitis  as  a  diseased  condition 
of  frequent  occurrence,  and  that  a  very  large  jiroportion 
of  what  had  been  formerly  termed  perityphlitis  in  a 
loose  way,  was  in  reality  periappendicit-'s,  and  that  the  ex- 
udate in  the  majority  of  these  cases  was  intra-peritoneal. 
Moreover,  it  lias  proved  the  means  of  lessening  largely 
the  cases  of  so-called  idiopathic  peritonitis,  the  ma- 


796 


MEDICAL    RECORD. 


[December  7,  1F95 


jority  of  them  being  dependent  upon  perforations  or 
disease  of  this  apparently  unnecessary  (unless  to  the 
surgeon)  portion  of  our  anatomy.  A  former  member 
of  this  Academy,  Dr.  Willard  Parker,  laid  down  the 
rules  of  guidance  for  perityphlitic  abscess — and  it  was 
reserved  for  another,  Dr.  McBurney,  to  urge  the  im- 
portance of  the  early  operation  in  the  cases  of  appendi- 
citis. Moreover,  from  what  has  come  to  my  knowledge 
here,  compared  with  that  of  which  I  have  information 
on  this  subject  abroad,  I  believe  that  the  surgeons  and 
physicians  of  New  York  City  and  of  the  United  States 
have  had  a  much  truer  conception  of  the  process  and 
of  its  proper  treatment  than  have  those  of  other  coun- 
tries. In  fact  they  have  only  within  a  recent  period 
waked  up  to  a  just  realization  of  this  matter.  It  has 
hardly  been  necessary  to  remind  you  of  this  advance 
in  view  of  the  number  of  times  that  you  have  been  ad- 
dressed upon  it.  So,  again,  the  recovery  from  tuber- 
cular peritonitis  as  a  result  of  a  simple  laparotomy  is  a 
progress  whose  real  explanation  eludes  us  as  yet. 

When  we  come  to  consider  the  etiology  of  disease, 
and  particularly  of  the  infectious  disorders,  we  at  once 
appreciate  our  true  conception  of  these  conditions. 
Thirty  years  ago  we  were  still  as  those  who  see  through 
a  glass,  darkly,  in  this  matter,  though  in  the  past  there 
had  ever  been  those  who  felt  the  need  of  some  organ- 
ized body  with  life  and  capability  of  division,  to  explain 
this  infectiousness  and  contagion.  Any  who  will  look 
up  the  literature  of  influenza  will  be  struck  by  the 
soundness  of  reasoning  of  some  of  the  observers  of 
epidemics  of  this  disease  in  the  last  century — a  sound- 
ness of  reasoning  that  ought  to  put  the  blush  on  the 
cheek  of  some  writers  on  influenza,  who  indulged  in 
speculations  as  to  the  cause  of  the  disease  when  it 
made  its  first  reappearance  some  five  years  ago.  For 
this  purpose  I  can  commend  Symes  Thompson's  his- 
torical survey,  and  particularly  the  extracts  from  Gray 
and  Haygarth,  and  the  statement  of  Heberdeen  about 
Haygarth's  communication  in  reference  to  the  outbreak 
of  1782.  It  would  take  too  long  to  reproduce  here 
Haygarth's  method  of  reasoning  in  his  own  words,  but 
it  is  of  particular  interest  to  note  that  his  communica- 
tion in  regard  to  the  outbreak  of  1782  was  not  pub- 
lished until  1803,  on  the  occasion  of  another  epidemic. 

Haygarth  gives  the  following  interesting  reason  for 
the  publication  of  his  communication,  after  twenty 
years,  regarding  the  influenza  of  1782,  and  his  reasons 
for  considering  the  influenza  to  be  due  to  contagion  : 
"  The  contagious  nature  of  the  influenza  had,  as  I 
thought,  been  sufficiently  proved  by  many  physicians. 
But  a  contrary  and,  as  I  think,  a  very  per- 
nicious opinion,  has  lately  been  supported  by  physi- 
cians of  great  respectability,  and  authors  of  the  highest 
reputation,  not  indeed  in  tliis,  but  in  other  enlightened 
nations,  have  ascribed  not  only  this,  but  many  other 
epidemics,  even  the  plague  itself,  to  a  morbid  constitu- 
tion of  the  atmosphere,  independent  of  contagion. 
To  determine  whether  this  doctrine  be  true  or  false  is 
of  the  highest  importance  to  mankind.  Knowledge  in 
this  instance  is  power.  So  far  as  it  can  be  proved  that 
a  disease  is  produced  by  contagion,  human  wisdom  can 
prevent  the  mischief.  But  the  morbid  constitution  of 
the  atmosphere  cannot  possibly  be  corrected  or  con- 
trolled by  man." 

The  younger  members  of  the  Academy  will  not  re- 
member the  long  controversy  regarding  the  possible 
infectious  character  of  tuberculosis,  including  phthisis. 
There  was  only  a  small  minority  of  physicians  who  ad- 
mitted this  prior  to  18S2,  when  Koch  announced  his 
discovery  of  the  germ  of  tubercular  affections.  As 
often  happens,  not  a  few  of  the  laity,  judging  from 
what  came  under  their  observation  from  time  to  time, 
had  accepted  the  theory  ;  moreover,  there  was  a  strange 
superstition,  or  perhaps  fancy  would  be  a  better  word, 
in  different  parts  of  the  country,  that  in  case  an  invalid 
with  the  disease  could  give  the  malady  to  an  animal  he 
might  recover.     This  idea  was  undoubtedly  founded 


upon  the  observation  that  at  times  one  of  the  lower 
animals,  in  contact  with  a  person  suffering  with  phthisis, 
contracted  the  disease.  Moreover,  even  after  Koch 
had  announced  his  discovery,  and  even  after  its  con- 
firmation by  many  different  observers,  it  required  still 
much  controversy  to  cause  its  more  general  acceptance. 
As  so  often  happens,  those  physicians  who  made  a 
special  study  of  the  disease  were  found  in  certain  in- 
stances the  most  difficult  to  convert.  Especially  were 
such  arguments  used  as,  that  we  have  had  charge  of  a 
hospital  for  the  disease  (Brompton  Hospital),  or  a  hos- 
pital in  which  the  disease  was  treated,  and  neither  our 
house  staff,  our  nurses,  nor  our  attendants,  nor  other 
inmates,  were  affected  in  any  such  manner  as  to  prove 
the  idea.  This  is  the  argument  always  used  by  those 
who  dislike  to  admit  the  force  of  reasoning  relating  to 
improving  conditions  dependent  upon  acceptance  of  a 
theory  adverse  to  business  interests,  or  to  theories  pre- 
viously taught  and  held.  As  a  theory  it  has  proved 
dangerous,  because  those  who  have  become  ill  in  this 
way  are  not  to  be  looked  for  among  the  present  work- 
ers in  places  of  nuisance,  nor  in  the  case  cited  in  hos- 
pitals and  wards  for  consumptives.  They  have  either 
given  up  their  places  or  have  been  laid  where  alone  the 
tombstone  will  speak.  The  writer  had  in  his  earlier 
practice  collected  a  number  of  instances  pointing  to- 
ward the  dissemination  of  phthisis  from  sick  to  the 
well  in  families,  in  houses,  in  institutions,  and  in  one 
case  from  one  patient  to  four  successive  dogs.  In 
coming  to  the  conclusion  some  years  before  he  pub- 
lished his  conviction  that  there  was  a  contagious  ele- 
ment in  phthisis,  he  found  very  few  among  the  leaders 
of  medical  thought  in  this  city  who  accepted  the  idea. 
And  even  after  Koch  promulgated  his  proofs  about 
the  tubercle  bacillus,  the  statement  was  that  this  germ 
found  favorable  soil  in  the  diseased  parts,  was  not 
cause,  but  simply  concomitant  —  the  same  argument 
which  had  been  used  years  before  by  some  dermatol- 
ogists to  prove  that  the  parasite  in  parasitic  skin  dis- 
eases was  not  cause,  but  only  an  outcome  of  a  favor- 
able nidus. 

At  the  present  time  but  few  deny  the  infectiousness 
of  tubercle.  Thirty  years  ago  there  was  still  much  ar- 
gument as  to  the  unity  of  tubercle  and  of  varied  tuber- 
cular affections,  and  much  question  existed  as  to  the 
relationship  between  miliary  tubercle  and  tubercular 
pneumonia,  or,  as  it  was  called,  tubercular  infiltration. 
Anatomical  differences  were  drawn,  by  means  of  which 
we  should  discriminate.  How  simple  it  seems  to  the 
student  of  to-day,  as  contrasted  with  that  one  of  thirty 
years  ago.  The  attempt  was  made  by  this  and  that 
reason  to  make  plain  what  the  professor  himself  was 
not  assured  of.  Moreover,  this  discovery  of  Koch's  has, 
by  assigning  a  definite  cause  for  the  tubercular  affec- 
tions, drawn  attention  to  the  necessity  of  preventive 
measures  in  dealing  with  the  excreta  which  contain  the 
bacilli.  The  prevalence  of  phthisis  is  so  great,  the 
apathy  as  regards  careful  attention  to  this  matter  on 
the  part  of  some  of  our  profession  is  still  so  consider- 
able, and  the  numbers  of  those  ill  adapted  to  resist  the 
inroads  of  so  prevailing  and  insidious  an  enemy,  ow- 
ing to  inherited  or  acquired  weak  frames,  is  so  great, 
that  we  do  not  wonder  that,  notwithstanding  our  knowl- 
edge of  the  bacillus  is  thirteen  years  old,  at  the  death- 
rate  from  this  cause.  The  writer  calculated  that  there 
must  be  nearly  fifteen  thousand  cases  of  the  disease  in 
New  York  City,  and  that  a  very  considerable  portion 
of  these  are  peripatetic.  Yet  in  preparing  a  paper  on 
overcrowding,  for  the  County  Association,  two  years 
ago,  he  was  gratified  to  find  that  both  in  New  York 
and  in  Philadelphia  the  number  of  deaths  from  phthisis 
had  diminished  instead  of  increasing  during  the  last 
ten  years,  as  contrasted  with  those  gone  before.  Nor 
could  this  diminution  be  ascribed  satisfactorily  to  other 
causes.  We  hope  to  see  a  careful  statistical  table  on 
this  subject  at  no  distant  date,  which  shall  comprise 
most  of  the  large  cities,  in  order  that  we  may  be  better 


December  7,  1895] 


MEDICAL    RECORD. 


■97 


able  to  judge  as  to  this  improvement.  And  it  is  hoped 
by  the  writer  that  each  member  of  the  Academy  will 
do  all  in  his  power  to  teach  those  suffering  with  the 
malady,  or  their  friends,  the  importance  of  destroying 
the  secretion  from  the  affected  parts,  and  thus  aid  the 
efforts  made  in  this  direction  by  the  Board  of  Health. 
We  do  not  expect  to  see  the  disease  completely  eradi- 
cated, but  we  feel  that  with  medical  insistance  and  the 
increase  of  popular  knowledge  in  this  regard,  that  we 
shall  witness  a  much  more  considerable  check  to  the 
ravages  of  this  fell  destroyer. 

We  cannot  believe  that  the  density  of  population  per- 
mitted in  New  York  City,  twenty  or  twenty-four  families 
on  a  twenty-five  by  one  hundred  foot  lot,  betokens 
medical  progress,  nor  does  it  point  to  as  successful  an 
issue  in  the  struggle  with  tuberculosis  and  other  infec- 
tious diseases  as  may  be  the  case  in  less  crowded  places, 
providing  that  equal  vigorous  measures  are  adopted 
looking  to  the  destruction  of  the  bacillus.  The  fif- 
teen, twenty,  and  more  story  high  office  buildings  are 
also  fraught  with  danger  in  the  same  direction.  So 
many  people  are  brought  together  in  confined  areas 
that  one  tubercular  invalid,  if  careless,  has  much  greater 
chance  of  spreading  the  disease.  The  papers  point  at 
these  lofty  structures,  attempting  to  compel  tribute  from 
the  sky,  with  civic  pride,  but  we  feel  that  they  are  an 
added  source  of  detriment  to  health  and  cannot  be  con- 
sidered as  medical  progress. 

Koch  may  justly  be  proud  of  his  position  in  aiding  in 
the  progress  of  medicine.  A  practising  country  physi- 
cian outside  of  the  university,  studying  carefully  with 
Cohn  microscopic  botany,  he  discovered  first  the  link 
which  was  sought  to  complete  the  life-history  of  the 
bacillus  of  anthrax,  a  matter  which  was  needed  to  throw 
light  upon  its  method  of  entrance  into  the  system.  This 
was  the  existence  of  "dauersporen."  Then  he  worked 
out  much  about  septicaemia,  and  later  cholera  as  well  as 
tuberculosis  yielded  up  to  his  search  the  cause  of  their 
being.  Moreover  he,  more  than  any  other,  taught  the 
true  method  of  bacteriological  research.  Many  names 
admit  of  honor  in  this  regard.  Pasteur,  his  predecessor, 
for  his  long  work  in  the  same  direction  ;  Eberth,  discov- 
erer of  typhoid  germ  ;  Fehleisen,  of  the  erysipelas  coc- 
cus; Laveran,  of  the  malarial  Plasmodium;  Obermeer, 
of  the  relapsing  fever  spirachele  ;  Nicolaier,  of  the  teta- 
nus bacillus  ;  Hansen,  of  leprosy  bacillus  ;  Loeftler  and 
Klebs,  of  the  diphtheria  bacillus  ;  Frankel,  of  the 
pneumococcus  ;  and  Friedlander,  of  the  first  variety 
superseded  in  great  measure  by  Frankel.  Moreover,  a 
variety  of  germs  capable  of  exciting  suppuration  have 
been  made  out  by  different  observers,  Ogston,  Rosen- 
bach,  Passet,  and  others.  Finally,  it  has  been  reserved 
for  Kitasato,  the  Japanese  bacteriologist  who  had 
worked  with  Koch  and  who  had  with  Nicolaier  studied 
the  tetanus  bacillus,  to  work  out  the  bacillus  of  the 
plague.  He  went  to  China  to  engage  in  those  studies, 
which  resulted  in  the  discovery,  conducting  them  ac- 
cording to  the  rules  laid  down  by  Koch.  This  cer- 
tainly betokens  medical  progress,  and  how  gratified 
would  Haygarth  be,  were  he  living,  to  know  that  this 
argument  was  correct,  though  the  finding  of  the  organ- 
ism had  occurred  over  one  hundred  years  after  his  ut- 
terance. More  surprised  he  would  be  to  know  that  the 
discoverer  was  a  Japanese,  for  the  plague  organism, 
while  Pfieffer  had  unravelled  the  secret  of  influenza  in 
finding  a  bacillus  as  cause. 

If,  without  going  into  detail  with  each  of  these,  we 
ask  whence  the  gain  from  this  knowledge,  we  may 
well  answer,  much  in  every  way.  The  discovery  of 
the  cholera  spirillum  has  put  in  the  hands  of  sani- 
tary authorities  a  means  of  distinguishing  the  disease 
at  an  early  period,  and  of  taking  precautions  in  con- 
sequence of  certain  knowledge  that  formerly  would 
have  required  time  and  the  development  of  addi- 
tional cases.  In  this  way,  aside  from  the  value  attach- 
ing to  knowledge  in  the  abstract,  it  has  proved  of 
immense   importance   and  will   gain   in   this   respect. 


should  the  immunization  experiments  meet  continued 
success. 

With  reference  to  typhoid  fever  we  are  enabled  to 
know  more  accurately  the  conditions  favorable  to  the 
life  of  its  causative  organism,  and  thus  to  increase  our 
means  of  preventing  its  spread.  This  knowledge,  alas  I 
has  robbed  us  of  some  of  the  satisfaction  with  which 
we  eat  raw  oysters  in  the  fall  of  the  year,  when  typhoid 
germs  are  being  discharged  from  sewers  whose  open- 
ings in  rivers  may  be  near  the  floats  on  which  the  oys- 
ter is  being  fattened  or  freshened.  Medical  progress 
may  demand  that  oysters  shall  be  freshened  only  in 
such  places  as  shall  be  free  from  liability  to  typhoid 
contamination.  Previous  to  the  discovery  of  this  or- 
ganism much  of  what  we  now  know  had  been  adduced 
by  careful  and  painstaking  study  of  the  method  of  ori- 
gin of  the  disease  ;  and  it  has  served  to  direct  atten- 
tion away  from  sewer-pipes,  defective  traps,  etc.,  to 
what  was  eaten  and  more  particularly  drunk,  water  and 
milk  as  the  main  sources  of  etiological  importance.  As 
far  as  the  writer  can  see,  our  knowledge  of  the  pneumo- 
coccus is  as  yet  of  scientific  interest  more  particularly, 
though  it  serves  to  prove  the  right  of  those  who,  as  my 
former  distinguished  and  revered  colleague,  the  late 
Professor  Austin  Flint,  claimed  pneumonia  as  an  in- 
fectious disease  prior  to  the  discovery  of  an  organism 
— and  also  for  possible  antitoxin  production.  The 
proof  of  the  existence  of  germs  causative  of  suppura- 
tion has  in  part  helped  to  revolutionize  surgery.  We  say 
in  part,  because  prior  to  the  proof  such  far-seeing  men 
as  Lister  had  reasoned  out  the  probability,  and  laid 
down  rules  for  the  prevention  of  their  entrance  in  op- 
erations, etc.  Rules  which  are  now  discarded,  because 
the  surgeon  has  learned  the  value  of  cleanliness. 
Cleanliness  is  next  to  godliness  is  the  motto,  but  alas  I 
in  bygone  times  the  lack  of  cleanliness  on  the  part  of 
the  surgeon  led  many  a  poor  soul  to  learn  the  myster- 
ies of  another  world.  The  writer  dreads  to  think  of 
the  number  who  have  succumbed  in  this  city,  prior  to 
the  era  of  aseptic  and  antiseptic  surgery. 

The  treatment  of  internal  diseases  has  not  apparently 
made  so  considerable  an  advance  as  has  the  surgical. 
This  is  entirely  owing  to  the  fact  that  asepsis  has  al- 
lowed the  surgeon  to  achieve  results  impossible  previ- 
ously. Yet,  when  we  come  to  consider  that  the  phy- 
sician aims  at  two  entirely  different  results  as  the  issue 
of  his  increased  knowledge  of  the  etiology  and  course 
of  disease,  we  will  be  struck  by  the  progress  which  has 
occurred.  He  aims,  in  the  first  place,  to  prevent  the 
spread  of  contagious  and  infectious  disorders,  and 
through  foresight,  so  far  as  may  be,  to  forestall  the  in- 
fluence of  deteriorating  conditions  in  individual  cases. 
On  the  other  hand,  his  duty  is  to  carry  the  individual 
patient  through  his  sickness,  whatever  it  may  be. 

Though  much  of  the  work  of  protecting  the  com- 
munity has  been  placed  upon  boards  of  health,  yet  it 
must  be  recognized  that  these  owe  their  origin,  devel- 
opment, and  efficient  activity  to  medical  men.  A  large 
measure  of  advice  has  still  to  be  given  by  the  practi- 
tioner to  the  families  under  his  care,  as  to  the  proper 
methods  of  procedure  against  contagion.  We  have  not 
been  able  as  yet  to  secure  so  effective  a  protection 
against  the  other  dangerous  contagious  disorders  as 
vaccination  has  achieved  against  small-pox.  In  this 
city,  during  the  last  thirty  years,  a  study  of  the  statistics 
will  show  a  remarkable  gain  in  this  regard  by  the  es- 
tablishment of  a  pennanent  corps  of  vaccinators  under 
the  control  of  the  Board  of  Health.  Previously  to 
1875,  when  an  epidemic  of  small- pox  occurred,  then  a 
corps  of  physicians  was  assigned  to  the  work  of  gratu- 
itous vaccination  among  the  poor  of  the  city.  Since 
that  date  a  permanent  corps  has  been  maintained,  and 
it  can  be  proven  by  the  results  to  be  the  only  wise 
course  in  a  large  city.  The  epidemic  of  1874  died  out 
in  1876,  and  while  since  outbreaks  occur  from  time  to 
time,  when  enough  unprotected  people  exist  to  form  a 
chain  after  the  exposure  of  the  first  to  the  exciting 


798 


MEDICAL    RECORD. 


[December  7,  1895 


cause,  yet  these  have  not  attained  the  magnitade  for- 
merly possible.  A  careful  study  of  the  statistics  of 
small-pox  in  New  York  City  will  convince  any  reason- 
able person,  not  alone  of  the  immense  value  of  vaccina- 
tion, but  also  that  a  permanent  corps  of  vaccinators 
employed  by  the  city  is  as  essential  for  the  control  of 
the  disease.  Fortunately,  the  vaccination  law  is  not 
compulsory  in  this  city,  and  hence  the  anti-vaccination 
cranks  have  never  been  able  to  reach  any  considerable 
number  nor  obtain  any  marked  influence.  They  are 
like  the  smut  on  the  com  in  a  field  with  a  large  crop, 
here  and  there  a  dark  spot,  in  the  wonderful  progress 
of  prevention  in  this  disease  achieved  in  this  city  dur- 
ing the  past  twenty  years.  But  this  era  has  been 
marked  by  the  attempt  to  control  other  diseases  by  a 
protective  influence  not  like  vaccination.  Pasteur, 
who  had  obtained  successful  results  in  dealing  with 
animals  by  the  use  of  attenuated  virus,  succeeded  in 
his  attempts  to  find  a  means  of  immunizing  animals 
against  the  hydrophobia  by  the  use  of  attenuated  poi- 
son derived  from  the  desiccated  spinal  cord  of  rabbits. 
He  also  applied  this  method  to  human  beings,  with  a 
result  which  has  given  him  world-wide  fame.  Inso- 
much as  in  both  vaccination  and  in  inoculation  for 
small-pox  the  germ  itself  is  introduced,  grows,  and  by 
producing  on  the  one  hand  vaccinia  and  on  the  other 
a  mild  attack  of  small-pox,  we  may  question  whether 
in  these  protective  vaccinations  against  hydrophobia, 
with  gradually  increasing  strength  of  virus,  it  is  not  a 
gradual  toxin  introduction  rather  than  of  the  germ  of 
hydrophobia  which  has  not  so  far  been  isolated. 

Since  this  time  numerous  workers  have  endeavored 
to  solve  the  question  of  immunity.  The  results  of 
vaccination,  the  fact  that  human  beings  and  animals  re- 
cover from  infectious  diseases,  and  that  one  attack  of 
some  infectious  diseases  protects  for  more  or  less  of  a 
lifetime  against  subsequent  exposures,  and  in  other  dis- 
eases against  a  speedy  return,  led  to  the  search  for  the 
method  of  cure  and  of  a  means  of  immanization  against 
diseases  of  this  nature.  It  was  reserved  for  Behring  to 
study  out  and  bring  to  public  notice  the  demonstration 
that  the  blood  serum  contained  in  tetanus  and  in  diph- 
theria a  substance  which  has  been  termed  antitoxin, 
which  in  each  of  these  diseases  had  the  property  to  so 
far  antagonize  the  toxin  of  disease  as  if  injected  previ- 
ously, with  or  very  shortly  after  the  toxin  in  sufficient 
quantity  and  strength,  to  prevent  the  poisoning  of  the 
system  by  the  toxin.  Kitasato  worked  with  him  in  the 
study  of  the  tetanus  immunity.  Thus  was  laid  the  foun- 
dation for  the  serum  therapy  of  diphtheria  and  of  teta- 
nus. In  the  case  of  diphtheria,  because  of  the  frequent 
occurrence  of  the  disease,  because  of  its  severity  and 
of  the  number  of  deaths  due  to  it,  this  method  of  treat- 
ment has  acquired  world-wide  attention.  When  we 
consider  the  number  of  deaths  from  diphtheria,  includ- 
ing croup,  occurring  in  New  York  each  year,  this  city 
has  a  vital  interest  in  the  matter.  The  Board  of  Health, 
at  the  suggestion  of  Dr.  Biggs,  and  with  the  co-opera- 
tion of  Dr.  Prudden  and  the  work  of  Dr.  W.  H.  Park, 
his  assistant,  began  and  continue  the  production  of  this 
antitoxin  gratuitously  for  the  poor.  At  the  meeting  of 
this  Academy  on  April  3d  of  this  year  the  subject  was 
presented  to  the  members,  and  the  results  then  achieved 
at  the  Willard  Parker  Hospital  and  in  the  city  detailed. 
Such  arguments  as  could  be  urged  in  opposition  were 
presented  by  Dr.  Winters.  Since  that  time  the  use  of 
antitoxin  has  continued,  and  the  speaker  said  he  could 
not  allow  this  opportunity  to  pass  by  without  stating  the 
reasons  why,  when  asked,  he  advocates  its  use.  The 
statistics  of  the  death-rate  from  diphtheria  and  croup  in 
Paris  prior  to  and  since  the  use  of  antitoxin  serum, 
which  is  there  prepared  by  Roux,  who,  after  Behring, 
principally  drew  the  attention  of  the  profession  to  its 
value,  are  so  strikingly  favorable  that,  till  disproved,  no 
other  should  be  needed.  So  again,  the  statistics  on  the 
same  subject  furnished  by  institutions  and  physicians 
in  Germany  in  the  great  majority  are  arguments  for  its 


use.  A  very  able  paper  by  Professor  William  H.  Welch, 
of  Johns  Hopkins  University,  embodies  his  views,  and 
is  based  upon  a  careful  study  of  seven  thousand  cases 
treated  by  this  means.  The  result  is  decidedly  confirm- 
atory of  its  merits.  Moreover,  a  number  of  physicians, 
in  whose  judgment  and  ability  the  speaker  has  confi- 
dence, have  stated  to  him  its  favorable  effect  in  ex- 
tremely severe  individual  cases  of  the  disease.  The 
papers  presented  at  the  meeting  of  the  Academy  on 
April  3d  are  arguments  for  its  employment.  More  re- 
cent statistics  than  these  in  journals  of  recent  date  con- 
firm me  as  an  advocate  for  its  employment.  The  oc- 
currence of  forty-three  deaths  from  diphtheria  and 
ero,vip  in  this  city  during  the  week  ending  November  9th 
make  the  speaker  fear  that  this  method  is  not  receiving 
a  prompt  and  fair  trial.  Moreover,  previous  to  this  date 
the  deaths  from  the  disease  have  not  decreased  as  have 
those  in  Paris. 

We  would  not  be  understood  as  stating  that  there 
are  never  any  disagreeable  sides  to  this  treatment. 
These  the  advocates  of  the  method  admit,  but  the 
speaker  does  not  believe  that  all  the  evils  which  follow 
the  use  of  antitoxin  are  of  necessity  due  to  the  anti- 
toxin. When  we  consider  that  the  horses  used  for 
the  production  of  antitoxin  are  of  a  very  different 
constitution,  though  young  and  free  from  disease  so  far 
as  can  be  made  out,  yet  the  fact  that  some  serums  far 
more  than  others  are  attended  by  urticaria,  and  by 
joint  pain  or  rheumatic-like  attacks,  suggest  the  idea 
that  if  one  set  of  observers  find  results  at  variance  with 
those  of  the  rest  or  many  of  the  rest,  we  have  a  right  to 
conclude  that  some  of  the  differences  are  dependent 
upon  the  horse  from  which  the  serum  has  been  ob- 
tained. The  possibility  that  some  of  the  horses  had 
rheumatism  is  suggested.  Neither  should  such  dis- 
tresses as  are  to  be  fairly  attributed  to  it  be  allowed  to 
outweigh  the  advantages,  when  employed  early. 

Tetanus  is  fortunately  a  comparatively  rare  disease, 
so  that  the  same  interest  does  not  attach  to  the  use  of 
the  serum  therapy  for  the  possible  cure  of  this  disease. 
Yet  the  results  obtained  by  animal  experimentation 
stand  on  the  same  footing  of  success  as  is  the  case  with 
the  diphtheria  antitoxin.  However,  there  is  the  differ- 
ence that  the  amount  required  is  larger  and  greater 
the  longer  the  symptoms  have  existed.  The  cases  so 
far  treated  in  tetanus  give  a  hope  that,  early  and 
promptly  employed,  success  may  at  times  be  obtained 
to  a  greater  degree  than  would  otherwise  be  the  case. 
Yet  it  will  require  a  very  careful  gathering  of  statistics 
to  inform  us  of  the  absolute  value  of  the  remedy. 

Experiments  in  animals  have  also  been  made  with 
the  organism  and  toxin  of  cholera,  and  recently  exper- 
iments made  in  India  seem  to  show  that  Hafkeine 
has  succeeded  in  proving  a  probability  that  he  has 
immunized  those  exposed  against  this  disease. 

Claims  are  now  being  made  for  the  success  of  this 
method  for  other  infectious  diseases — pneumonia,  ty- 
phoid— and  more  recently  for  the  pus-exciting  organ- 
isms. There  is  undoubtedly  much  of  promise  in  this 
field,  but  a  liability  also  to  allow  our  enthusiasm,  due 
to  the  success  in  one  or  more  directions,  to  lead  us  astray 
in  claiming  too  much  or  against  a  process  for  which  it 
is  not  calculated  to  prove  serviceable. 

For  the  last  few  years,  associated  with  the  struggle 
to  prove  that  carcinoma  and  sarcoma  are  not  simply 
outcomes  of  the  bodily  development,  as  a  result  of  un- 
used embryonal  tissue  stored  up  in  some  nook  of  the 
body, but  are  due  to  the  influence  of  a  parasite,  animal- 
icular  or  vegetable,  there  has  gone  on  an  attempt  to 
check  its  growth  by  the  use  of  toxins  of  erysipelas, 
etc.,  or  the  serum  of  animals  treated  with  such  toxin. 
Our  colleague.  Dr.  Cooley.  has  been  an  enthusiastic 
worker  in  this  direction,  and  feels  confident  of  some 
success  from  his  work.  The  writer  has  not  personally 
been  able  to  witness  a  case  which  has  turned  out  suc- 
cessfully, though  he  has  had  them  subjected  to  the 
trial.     In  view  of  the  fact  that  successes  have  occurred, 


December  7,  1893] 


MEDICAL   RECORD. 


799 


it  seems  that  '.ve  will  be  obliged  to  assume  in  these 
cases  a  difference  of  structure  or  of  etiological  substra- 
tum, such  as  does  not  reveal  itself  to  the  microscopist. 
The  writer  trusts  that  either  by  the  means  now  used, 
or  by  the  intervention  of  some  additional  agencies,  we 
may  be  enabled  to  add  to  the  progress  of  medicine  in 
other  directions  that  of  having  achieved  a  victory  over 
the  malignant  tumors. 

The  attempt  to  cure  consumption  (tuberculosis)  has 
been  oft  repeated,  and  in  view  of  the  prevalence  of  the 
disease,  which  kills  five  thousand  people  annually  in 
round  numbers  in  New  York  City  alone,  no  wonder  is 
excited  by  the  frequent  appearance  of  a  new  method 
for  which  great  promise  is  made.  Thus,  of  late  years 
especially,  the  hot-air  inhalation,  the  Bourgeron  car- 
bonic-acid and  sulphuretted-hydrogen  injection,  and  last 
the  tuberculin  plan,  have  come  successively  before  the 
medical  and  lay  public  with  great  pretensions.  The 
two  former  quickly  sank  to  their  proper  level  of  ineffi- 
cacy  ;  but  the  latter  came  heralded  by  the  name  of 
one  who  has  done  so  much  for  the  medical  progress  of 
the  last  twenty  years  that  it  was  not  alone  the  hope  for 
a  cure  of  this  dreaded  disease,  but  interest  that  the 
discoverer  of  the  germ  of  origin  of  the  disease  might 
also  be  the  finder  of  the  means  of  its  destruction,  that 
gave  intensification  to  the  announcement.  We  must 
regret  the  eager  stri%ing  to  be  the  first  to  use  this  new 
remedy,  product  of  difficult  and  prolonged  research  on 
the  part  of  its  renowned  projector,  which  rather  marred 
its  introduction.  At  present  it  is  but  little  used,  though 
there  are  those  who.  like  my  friend,  Dr.  Trudeau,  are 
making  continued  tests  in  those  who  desire  to  make 
trial  of  it  ;  and  I  am  told  that  Professor  Koch  is  himself 
still  at  work  endeavoring  to  secure  some  method  by 
which  it  may  be  employed  with  success.  The  writer, 
and  I  have  no  doubt  all  his  auditors,  wish  him  Ciod- 
speed  in  his  efforts.  As  it  is,  we  find  no  better  method 
for  the  cure  so  far  than  the  effort  to  develop  the  pa- 
tient's internal  powers  of  resistance  by  suitable  climate, 
air  as  free  as  possible  from  the  germs  of  suppuration, 
improved  nutrition,  and  appropriate  medication  in 
such  better  atmosphere  where  as  much  as  possible  an 
out-door  life  may  be  led. 

A  visit  to  the  sanitarium  at  Saranac  Lake  would  well 
repay  each  of  my  auditors.  The  cottage  plan  has  been 
adopted  except  in  the  oldest  structures,  each  holding 
four  inmates,  with  a  common  living-room  and  a  separate 
bed-room.  The  outlook  is  over  an  unbroken  forest,  save 
a  hill,  to  protect  from  the  worst  winds,  situated  behind. 
Here  eighty  patients  receive  treatment  and  board  for  a 
price  which  has  to  be  supplemented  by  the  gifts  of  the 
charitably  disposed.  Moreover,  in  his  laboratory  there 
Dr.  Trudeau  continues  his  experimentations  upon  tu- 
berculosis. This  laboratory  is  a  surprise  to  those  who 
have  not  seen  it  before  ;  it  is  the  gift  of  the  late  Mr. 
George  Cooper  to  replace  one  which  had  been  burned. 

Not  alone  has  the  present  era  witnessed  the  intro- 
duction of  these  new  agencies,  of  which  our  fathers  in 
medicine  did  not  even  dream,  and  at  which  they  would 
have  stood  aghast,  but  it  has  largely  increased  the  num- 
ber of  agencies  to  be  used  in  disease.  It  has  become  a 
habit  to  decry  the  use  of  the  coal-tar  series  in  the  treat- 
ment of  febrile  disorders,  but  the  writer  has  found  them, 
judiciously  used  in  appropriate  cases,  of  service,  and  he 
does  not  hesitate  to  say  that  he  still  sanctions  their  em- 
ployment under  these  conditions.  How  can  we  admit 
the  claim  of  those  who  formerly  saw  great  results  from 
their  use,  and  now  say  that  they  have  no  value  ?  Many 
undoubtedly  have  employed  excessive  doses,  and  have 
attempted  their  employment  in  such  doses  unguarded, 
in  unsuitable  cases,  with  at  times  unfavorable  results, 
but  this  is  no  argument  against  the  statement  made 
above,  nor  to  their  own  previous  claims.  No  one 
method  of  treatment  can  be  at  all  times  applicable  to 
all  cases.  While  this  is  true,  the  very  general  trend  of 
medical  work  in  fevers  has  been  to  substitute  the  use 
of  cold  water  in  one  or  another  way  for  the  medicinal 


agencies  in  bringing  about  a  reduction  of  temperature. 
First,  sponging  and  use  of  the  coil,  then  the  pack,  and 
now  more  than  formerly  the  use  of  the  tub-bath  is  the 
plan  adopted.  The  use  of  the  tub-bath  is  not  alone 
for  reduction  of  temperature,  which  does  not  of  neces- 
sity occur,  but  as  much  for  its  effect  on  the  circulation, 
nervous  system,  and  with  a  view  to  prevent  the  ill 
effects  brought  about  by  the  stagnation  of  the  circula- 
tion in  the  lungs  and  limbs.  But  in  this  connection 
how  much  better  would  the  ounce  of  prevention  be 
than  the  pound  of  cure.  Certainly  we  must  urge  that 
boards  of  health,  so  far  as  is  possible,  shall  have  the 
power  to  inspect  the  water-supply,  of  all  communities, 
and  also  of  ever)' kind,  of  each  dairy  furnishing  milk  for 
consumption  in  their  towns  or  cities — and  in  case  there 
is  a  suspicion  that  the  conditions  are  liable  to  be  dan- 
gerous as  regards  any  water-supply,  whether  used  for 
washing  milk  cans  or  otherwise,  that  they  prohibit  such 
dairy  from  suppljing  milk  so  long  as  such  danger  ex- 
ists. If  such  inspection  had  been  effective  with  a  law 
of  the  above  nature,  the  outbreaks  of  typhoid  fever  in 
Stamford  and  New  Milford,  Conn.,  and  in  Montclair, 
N.  J.,  and  Watertown,  N.  Y.,  would  have  been  pre- 
vented. These  were  all  due  to  water- contamination  of 
milk,  said  only  to  have  come  about  by  washing  cans. 

It  would  require  too  much  of  time  and  impose  on  your 
indulgence  should  I  go  over  the  list  of  new  remedies 
of  a  strictly  medicinal  nature  which  have  come  into  use, 
as  strophanthus,  iodoform,  sulphonal,  trional,  ichthyol, 
cocaine,  etc.,  not  to  speak  of  the  change  which  has  in 
particular  resulted  from  the  success  of  the  thyroid  feed- 
ing to  make  up  for  the  deficiency  of  the  normal  secre- 
tion from  the  gland,  as  bone  marrow  in  anaemia,  supra- 
renal capsules  in  Addison's  disease,  the  use  of  extracts 
of  certain  organs  in  diseases  of  those  organs,  further 
than  to  say  that  our  credulity  is  largely  borrowed  on  at 
times  by  the  reports  which  are  in  circulation  and  also 
in  print.  If  some  of  these  remedies  are  so  efficacious, 
why  not  resort  to  the  raw  egg,  from  which  certainly  the 
whole  system  of  the  chicken  is  built  up — bones,  blood, 
brain,  spinal  cord,  muscles,  etc.  The  old-fashioned  egg- 
nog  had  a  virtue  evidently  based  upon  a  theory  of 
which  our  grandmothers  were  ignorant,  when  they 
would  administer  this  to  a  convalescent.  Moreover, 
those  who  ascribe  such  dangerous  bilious-producing 
properties  to  the  yolk  of  egg,  in  many  cases  the  result 
of  this  syllogism,  bile  is  yellow,  yolk  of  egg  is  yellow, 
hence  yolk  of  egg  is  liable  to  induce  biliousness,  must 
beware  how  they  slander  so  powerful  a  food.  The 
growth  of  specialism  has  undoubtedly  tended  to  medi- 
cal progress,  and  this  has  been  largely  an  affair  in  cer- 
tain directions  during  these  past  thirty  years.  There 
are  some  parts  of  the  body  which  more  than  others  call 
for  special  treatment,  because  the  dexterity  acquired  by 
constant  practice  makes  one  largely  excel  another  who 
is  more  occasional  in  his  work.  The  eye,  the  ear,  the 
nose,  and  throat  claim  attention,  and  gynecology  and 
andrology  have  come  to  be  branches  of  sjiecial  study. 
Moreover,  the  field  of  internal  medicine  is  split  up  into 
subdivisions  under  the  control  of  specialists  and  espe- 
cialists  ;  hence  we  have  neurologists,  cardiologists,  pneu- 
mologists,  gastrologists,  enterologists,  hepatologists, 
haematologists  ;  and  not  to  lengthen  this  list  of  words, 
which  are  deserved  if  not  applied,  those  who  devote 
themselves  to  the  latter  end. 

The  writer  does  not  believe,  except  in  some  of  the 
fields  to  a  certain  extent,  that  a  man  can  be  a  first-rate 
specialist  who  has  not  had  a  broad  enough  foundation 
of  knowledge  to  appreciate  the  relationship  between 
diseased  states  of  organs  and  the  secondary  results  of 
such  states,  both  on  the  general  economy  and  upon 
other  organs,  as  well  as  the  reverse  of  this.  And  it  is 
also  true  that  many  specialists  have  been  obliged  to  ex- 
tend the  sphere  of  their  work  because  of  this  interde- 
pendence of  parts.  The  aurist  and  oculist  find  that 
the  brain  will  claim  attention,  and  that  the  condition  of 
the  general  health  is  of  great  importance.     Moreover, 


8oo 


MEDICAL    RECORD. 


[December  7,  1895 


it  is  the  writer's  conviction  that  by  considering  too  ex- 
clusively the  disorders  of  one  part  all  morbid  phe- 
nomena are  liable  to  be  referred  to  errors  of  this  part. 
The  speaker  would  not  advocate  giving  up  specialties, 
but  he  would  advise  young  medical  men  not  to  start  as 
specialists  until  they  have  acquired  a  broad  general 
knowledge  of  the  effects  of  disease  upon  the  body. 

Along  with  the  growth  of  specialism  has  come  with 
the  progress  of  our  time  the  medical  expert.  He  ex- 
isted before,  but  not  to  the  extent  that  he  has  of  late 
years.  The  medical  profession  is  at  times  surprised  to 
find  who  are  experts  upon  certain  questions,  and  also  to 
find  what  diametrically  opposed  opinions  experts  will 
express  in  regard  to  the  same  condition  of  affairs. 
One  expert  will  swear  that  a  man  was  insane  because 
at  such  and  such  a  time  he  did  so  and  so,  acted  in 
such  a  way,  spoke  such  words,  saw  perhaps  hallucina- 
tions, or  what  were  regarded  as  these ;  while  another 
alienist  or  neurologist  will  explain  these  as  compatible 
with  sanity.  In  a  trial  some  ten  years  ago  three  ex- 
perts called  for  the  defence  in  a  case  of  nervous  trouble 
due  to  an  injury  to  the  spinal  column  resulting  from  a 
fall,  each  swore  that  the  man  had  a  complaint  different 
from  what  his  associate  had  considered  it,  and  all  swore 
that  he  did  not  have  what  the  speaker  and  Professor 
Sayre  swore  to,  viz.,  that  he  had  Pott's  disease  and 
subsequent  pachymeningitis.  Moreover,  one  of  these 
medical  expert  neurologists  wrote  an  article  in  which 
he  took  us  to  task  for  the  character  of  our  testimony. 
An  autopsy  in  the  case  two  years  after  the  trial  showed 
Pott's  disease. 

The  patient  won  his  suit  and  recovered  $25,000 
damages.  It  does  not,  however,  do  for  the  lawyers  to 
rail  at  us  in  view  of  the  court  after  court  to  which  cases 
are  taken  and  retaken,  the  judgments  upset  and  con- 
firmed, to  be  upset  on  appeal,  and  the  court  of  highest 
resort  not  infrequently  divided  in  its  decision,  and  at 
times  even  practically  deciding  against  the  judicial 
soundness  of  an  opinion  previously  promulgated.  We 
may  well  say  to  the  lawyer,  don't  point  your  hoary 
finger  at  us,  but  correct  your  own  infirmities  which  are 
many,  including  the  tendency  to  ever-recurring  delay 
and  postponement,  the  bctc  noire  of  the  medical  witness. 

Whether  in  the  future  some  plan  can  be  devised 
which  will  avoid  this  conflict  of  testimony,  by  arrang- 
ing for  the  selection  of  several  physicians  so  chosen 
that  they  shall  represent  the  best  attainable  medical 
intelligence  upon  the  condition  of  the  person  about 
which  there  is  a  dispute,  may  be  open  to  question, 
owing  to  the  laws  relating  to  trial  by  jury.  There  is, 
however,  not  the  least  doubt  about  the  desirability  of 
such  a  change.  A  medical  expert  who  goes  on  the 
stand  for  a  particular  side,  no  matter  how  firm  his 
intention  of  telling  the  truth,  the  whole  truth,  and 
nothing  but  the  truth,  is  very  apt  to  be  biassed  in  favor 
of  the  view  advocated  by  his  attorney,  and  moreover, 
to  be,  in  a  measure,  unwittingly  antagonistic  to  the 
lawyer  of  the  opposite  side,  who  is  to  cross-examine 
him.  Expecting  an  attack  upon  the  opinions  he  has 
expressed,  he  mentally  endeavors  to  foresee  the  method 
of  meeting  such  attack. 

In  view  of  the  facts  which  I  have  so  briefly  touched 
upon,  showing  the  progress  of  medicine  in  so  many 
directions,  requiring  of  the  busy  practitioner,  as  well  as 
of  the  medical  student,  increased  effort  to  keep  up 
with  the  ever-increasing  mass  of  knowledge,  and  of 
which  he  may  readily  find  the  information  in  the  books 
and  journals  belonging  to  the  Academy  of  Medicine  ; 
it  does  seem  as  if  this  Academy  might  be  able  to  give 
to  its  fellows,  without  encroaching  in  the  least  upon  the 
provinces  of  the  laboratories  attached  to  our  medical 
colleges — a  laboratory  in  which  there  might  be  the 
means  of  investigation  of  the  different  pathological 
discharges,  and  in  which  there  should  be  also  exempli- 
fications of  the  recent  advances  in  scientific  research. 
By  reading,  he  is  told  what  someone  else  has  seen  and 
done.      I    would  have    him   part    owner    of   property 


in  which  he  could  witness  the  thing  itself.  How  ex- 
tensive such  a  laboratory  should  be  would  become  a 
matter  for  discussion  after  it  had  been  decided  to  have 
a  laboratory.  The  writer  believes  that  upon  a  proper 
presentation  of  the  advantages  likely  to  accrue,  not  only 
to  the  physician  himself  but  also  to  his  patients,  from 
his  increased  efficiency,  funds  could  be  secured  from 
those  of  the  members  interested  in  the  best  welfare  of 
the  Academy,  and  also  from  those  friends  of  the 
Academy  who  are  neither  members  nor  physicians — 
citizens  of  New  York  desirous  that  its  medical  institu- 
tion shall  be  the  best  equipped  for  their  work  of  any  in 
the  land  or  world. 

Objection  may  be  urged  against  this  plan  upon  the 
ground  that  a  debt  exists  at  the  present  time,  and  that 
funds  are  needed  for  the  library,  which  should  be  ex- 
tinguished before  any  new  enterprise  is  undertaken. 
Then  let  us  endeavor  to  extinguish  this  debt,  to  secure 
our  laboratory,  if  the  members  decide  that  they  wish 
one,  and  to  obtain  as  large  a  library  fund  as  possible, 
even  a  library  and  laboratory  building,  if  our  friends 
will  avail  themselves  of  the  opportunity  of  bestowing 
upon  a  hard-worked  profession  the  means  for  its  truest 
recreation. 


A  NEW  AND  ORIGINAL  METHOD  OF  OB- 
TAINING MATERIAL  FOR  SKIN-GRAFT- 
ING.' 

By   ZERA  J.    LUSK,  M.D., 

W.\RSAW,    N.    Y. 

Among  the  various  methods  of  obtaining  material  for 
skin-grafting,  none  are  so  universally  employed  at  the 
present  time  as  those  of  Reverdin  and  Thiersch.  The 
credit  of  healing  raw  granulating  surfaces  by  the  appli- 
cation of  minute  pieces  of  cutaneous  epithelium  is  gen- 
erally conceded  to  Reverdin,'^  who  published  his  dis- 
covery and  experience  about  twenty-six  years  ago. 
The  subsequent  methods  reported,  differ  only  in  the 
manner  and  source  of  procuring  epithelial  tissue.  Dr. 
C.  B.  Kibbler,'  of  Corry,  Pa.,  reports  having  had  excel- 
lent results  with  thin  slices  of  calloused  or  indurated 
epithelial  tissue  taken  from  the  palmar  surface  of  the 
hands  or  plantar  surface  of  feet,  recording  several 
cases  successfully  treated  after  this  method.  Especial 
emphasis  was  placed  on  its  being  easily  obtained,  caus- 
ing no  pain  or  discomfort  to  the  donor. 

Dr.  John  T.  Hogden  ^  claims  to  have  successfully 
used  "  scrapings  of  epithelium  and  shavings  of  corns.'' 
The  success  of  these  methods  has  been  frequently 
verified  by  published  reports,  all  of  which  indicate  that 
healthy  granulating  tissue,  by  some  inherent  power, 
imparts  life  to  cuticular  epithelium.  The  contempla- 
tion of  this  fact,  under  circumstances  which  I  will 
hereafter  describe,  suggested  an  experiment  which 
proved  eminently  successful  in  a  recent  case  of  mine, 
where  nearly  six  hundred  square  inches  of  raw  granu- 
lating surface  was  healed  in  less  than  six  weeks  by 
grafts  furnished  by  patient. 

On  January  14th,  Emile  Silskey,  native  of  Russia, 
twenty-three  years  of  age,  robust  constitution,  laborer 
at  Hawley  Salt  Works,  was  trying  to  separate  a  salt 
crust  adhering  to  the  bottom  of  the  pan,  when  the 
heavy  iron  bar,  which  they  use,  slid  without  the  ex- 
pected resistance  under  the  crust  and  he  lost  his  bal- 
ance, falling  head  foremost  into  a  pan  of  boiling  brine. 
Those  working  near  hurried  to  his  assistance,  and  had 
nearly  succeeded  in  getting  him  out  when  they  lost 
their  grip  and  he  fell  backward  again  into  the  boiling 
brine.  By  another  effort  they  succeeded  in  getting 
him  out. 

I  saw  him  very  soon  after   the  accident.     He  was 

I"  Read  before  the  New  York  State  Medical  .Association,  October 
17.  1895. 
=>  Bulletin  de  la  Soc.  Chirurg  .  1869.     Gazette  des  Hopiiau.x.  1870. 
'  Railway  Suv«eon,  .\ugust  14.  1894,  vol.  i. .  p.  126 
^  Internationa!  Cyclopedia  of  Surgery,  vol.  ii. ,  p.  28S. 


December  7,  1895] 


MEDICAL    RECORD. 


801 


lying  on  his  back  with  no  covering  except  a  sheet 
loosely  thrown  over  the  lower  part  of  the  body.  Great 
bags  filled  with  serum  hung  from  his  sides  and  other 
parts  of  the  body.  Both  arms  were  completely  stripped 
of  epithelium,  which  hung  in  shreds  about  the  wrists, 
having  been  scraped  down  in  his  efforts  to  get  out  of 
the  pan.  The  thick  calloused  skin  of  the  palmar  sur- 
face of  both  hands  was  torn  and  in  shreds.  The  dor- 
sal surfaces  were  covered  with  sacks  full  of  serum. 
There  was  a  raw,  bleeding  surface  six  inches  wide  ex- 
tending from  the  left  arm  to  the  middle  of  the  right 
scapulae  ;  one  of  the  same  character  and  size  covered 
the  lumbar  regions.  The  buttocks  were  covered  with 
large  blisters,  but  more  superficially.  The  skin  on  the 
lower  extremities  hung  in  shreds,  bleeding  in  many 
places,  especially  about  the  knee  and  ankle  joints. 
The  genitals  were  very  oedematous,  and  covered  with 
bullae.  There  were  numerous  small  vesicles  on  the 
face  and  neck,  and  large  erythematous  patches  over 
the  chest  and  abdomen,  but  no  vesication  except  in 
the  right  infra-clavicular  region,  where  there  was  a 
blister  four  inches  in  diameter.  It  is  unnecessary  to 
state  that  there  was  profound  constitutional  disturb- 
ance, and  that  no  hopes  of  his  recovery  were  enter- 
tained. 

However,  after  a  liberal  use  of  strychnine  hypo- 
derraically,  together  with  the  application  of  artificial 
heat,  his  pulse  became  stronger,  when  dressings  were 
hurriedly  applied,  and  he  was  left  in  the  care  of  com- 
petent nurses.  The  gravity  of  this  case  may  be  un- 
derstood when  we  consider  that  the  area  of  burned 
surface  covered  more  than  two-thirds  of  the  body — 
indeed,  there  was  no  part  where  the  blush  of  super-heat 
was  absent ;  yet,  contrary  to  expectation  and  prece- 
dent, recovery  has  taken  place.     His  condition  seemed 


<;-^ 


hopeless  until  February  nth,  when  favorable  symp- 
toms appeared,  and  for  the  first  time  I  thought  the 
man  might  possibly  get  well.  He  was  extremely 
emaciated,  with  nearly  one-fourth  of  his  body  a  raw 
granulating  surface.  The  only  cutaneous  covering  on 
the  left  leg  was  seven  inches  wide  at  the  trochanter 
major,  narrowing  to  two  inches  at  the  knee,  covering 


one-third  of  the  leg  to  within  two  inches  above  the 
ankle.  The  right,  eleven  inches  wide  below  the  tro- 
chanter, narrowing  to  a  point  two  inches  above  the 
right  knee,  commencing  two  and  a  half  inches  below, 
covered  one-third  of  the  leg,  narrowing  to  one  inch 
over  the  ankle.  The  right  knee,  from  two  and  one- 
half  inches  below  to  two  inches  above,  had  no  dermal 
covering  ;    left    the    same,  except  two   inches   on   the 


outer  surface.  The  upper  extremities  were  covered 
only  by  narrow  strips  on  the  outer  aspect,  except  at 
the  elbows,  both  of  which  were  denuded  of  skin.  An 
elliptical  space  over  the  lumbar  region,  five  by  nine 
inches,  and  one  of  about  the  same  diameter  over  the 
left  shoulder,  were  without  dermal  protection.  There 
were  in  many  places  deep  gangrenous  sloughs,  the 
underlying  tissues  resuming  a  more  healthy  appear- 
ance. The  question  now  was,  where  could  material 
be  obtained  sufficient  to  heal  these  large  ulcerating 
surfaces.  None  could  be  i)rovided  by  the  patient.  I 
could  not  utilize  the  Thiersch  method,  as  no  one  could 
be  found  who  would  consent  to  give  strips  of  skin. 

I  made  a  beginning  on  February  13th,  by  applying 
eight  grafts  taken  from  the  indurated  tissue  on  the  pal- 
mar surface  of  the  liand  of  an  attendant.  The  next 
day,  when  I  wanted  to  repeat  the  operation  he  declined, 
said  his  "  hand  was  tender,"  that  I  had  "  cut  too  close, 
and  though  it  did  not  bleed,  was  sore."  As  nothing 
more  could  be  done,  I  concluded  to  await  the  results 
of  the  grafts  made  the  day  before. 

In  the  meantime,  while  reviewing  the  various  methods 
employed,  an  idea  occurred  to  me,  suggested  by  the 
following  condition  :  There  were  numerous  patches  of 
exfoliated  epithelium,  the  remains  of  vesication.  They 
were  hard,  dry,  and  crisp,  having  for  nearly  five  weeks 
been  separated  from  the  cutis.  Why  could  not  this 
material  be  utilized  for  skin-grafting  ?  I  had  faith  to 
believe  that  it  could,  and  on  February  i6th,  in  the 
presence  of  attendants  and  others  I  made  grafts,  using 
the  following  material  :  Attached  to  the  dorsum  of  the 


802 


MEDICAL   RECORD. 


[December  7,  1895 


right  foot  by  one  edge,  the  other  being  free  and  raised 
one-fourth  inch,  was  a  patch  of  dry  exfoliated  epithe- 
lium, extending  nearly  across  over  the  surface,  near  the 
distal  end  of  the  metatarsal  bones  ;  the  floating  part 
was  from  one  to  one  and  a  half  inch  wide.  From 
this  I  clipped  off  a  piece  one  inch  square,  softened  and 
sterilized  it  in  warm  boric-acid  water,  and  divided  it 
into  twelve  grafts,  which  were  applied  to  the  anterior 
granulating  surface  of  left  thigh.  The  result  was  em- 
inently satisfactory.  Seven  out  of  the  twelve  grafts 
took,  and  rapidly  developed  into  vigorous  islands  of 
skin.  The  subsequent  treatment  consisted  in  using 
this  dried  epithelial  tissue  with  which  these  large  raw 
surfaces  were  covered  with  substantial  skin,  by  April 

I  St. 

The  man  began  sitting  up  a  few  days  prior  to  this 
date,  and  with  the  attendant's  aid  could  walk  about 


^: 


K 


L 

1 

1^^ 

L 

J/ 

V^ 

^^ 

/ 

the  room.  He  improved  rapidly  during  the  month  of 
April,  and  on  May  1st  began  doing  light  work  at  the 
salt  works. 

The  following  experiments  were  made  in  the  pres- 
ence of  my  assistant  and  others  :  A  little  to  the  right 
and  two  inches  below  the  trochanter  major  of  the  left 
leg,  there  was  a  raw  surface  three  and  one-half  inches 
in  diameter.  At  the  proximal  end  of  the  great  toe 
there  was  a  dry,  bleached  patch  of  epithelium  which 
had  been  thoroughly  isolated  from  the  body  seven 
weeks,  being  held  only  by  ends  of  hair.  With  this  ma- 
terial this  raw  surface  was  completely  healed  in  twenty- 
one  days. 

At  the  spring  meeting  of  the  Wyoming  County 
Medical  Association,  I  had  the  pleasure  of  exhibiting 
my  case,  and  reporting  the  method  of  treatment.  Dr. 
Roswell  Park,  of  Buffalo,  who  was  present  as  our 
guest,  complimented  me  on  ray  discoverj',  comment- 
ing  particularly   upon   the   integrity  and  firmness   of 


skin,  the  perfect  use  of  the  joints,  and  the  entire  ab- 
sence of  cicatricial  contraction. 

In  reporting  my  case  I  mentioned  the  difficulty  ex- 
perienced in  properly  shaving  the  skin  in  the  Thiersch 
method,  and  how  liable  we  are  to  snip  too  deep  in  that 
of  Reverdin.  I  also  made  the  following  statement, 
which  I  have  since  verified,  which  was  that  the  epider- 
mis raised  by  vesication  could  be  successfully  employed 
in  skin-grafting.  By  this  method  the  cuticle  is  sepa- 
rated from  the  cutis,  giving  us  the  ideal  material — in- 
deed the  same  employed  with  successful  results  in  the 
case  reported.  An  opportunity  of  demonstrating 
practically  this  method  occurred  on  August  3d,  when 
I  was  consulted  by  Mrs.  J.I ,  married,  aged  fifty- 
two,  housekeeper,  who  had  a  large  varicose  ulcer  two 
and  a  half  inches  in  diameter,  three  inches  above  the 
ankle  on  the  outer  surface  of  the  left  leg.  She  had 
worn  elastic  hose  and  tried  all  kinds  of  ointments  for 
the  last  eight  years.  The  granulations  were  unhealthy 
and  bathed  with  a  foul-smelling  discharge.  The  treat- 
ment consisted  first  in  thorough  curettement,  followed 
by  stimulating  applications,  so  that  by  August  13th 
the  granulations  appeared  healthy.  A  surface  on  the 
left  thigh  near  the  anterior  superior  spinous  process, 
was  made  aseptic,  on  which  was  applied  a  piece  of  em- 
plastrum  cantharides  two  inches  long  by  one  inch  wide 
(it  being  first  moistened  with  carbolized  oil).  Vesica- 
tion was  produced  in  six  hours,  when  the  plaster  was 
carefully  removed.  The  epithelium  was  detached  at 
the  edges  of  the  blister,  washed  in  boric-acid  solution, 
after  which  all  moisture  was  absorbed  with  sterilized 
cotton,  and  it  was  suspended  in  a  four-ounce  salt 
mouth  bottle  (aseptic  cotton  being  used  for  a  stopper), 
and  kept  at  a  temperature  between  55°  and  70°  F.  It 
was  thoroughly  dry  in  three  days,  when  a  piece  one 
inch  square  was  divided,  making  twelve  grafts,  which 
were  applied  in  the  usual  way.  The  results  were  ex- 
tremely gratifying.  Nine  of  the  twelve  grafts  took 
nicely  and  grew  rapidly,  so  that  by  September  3d  this 
ulcerated  surface  was  healed,  having  a  substantial  epi- 
thelial covering. 

A  great  many  experiments  have  been  made  to  ascer- 
tain the  limit  of  vitality  of  the  skin  after  its  removal. 
Dr.  J.  H.  Girdner '  claims  to  have  successfully  used 
grafts  removed  six  hours  after  death,  from  the  body  of 
a  young  man  who  died  from  hemorrhage.  Dr.  E.  P. 
Brewer,-  of  Norwich,  Conn.,  found  that  thirty  six  hours 
was  the  limit  of  vitality,  out  of  eight  trials  in  which  he 
used  pieces  of  skin  from  amputated  limbs.  George  S. 
Marten '  experimented  with  grafts  kept  at  different 
temperatures,  claiming  that  grafts  retained  their  vital- 
ity ninety  six  hours,  at  a  temperature  just  above  32° 
F. ;  that  confined  air  gave  better  results  than  free  air. 

I  can  see  no  practical  object  of  the  first  two  experi- 
ments, for  very  soon  after  death  chemical  changes  oc- 
cur by  which  ptomaines  are  formed,  which  would  de- 
stroy the  vitality  of  the  skin,  even  making  it  dangerous 
for  experimental  use.  So  far  as  the  temperature  is 
concerned  in  maintaining  the  vitality  of  grafts,  if  they 
are  properly  separated,  sterilized,  and  dried,  they  can 
be  kept  almost  indefinitely  at  a  temperature  between 
40°  and  90°  F.,  and  before  using  they  sho'ald  be  soft- 
ened and  sterilized,  preferably  in  warm  boric-acid 
water  ;  and  when  applied  to  a  healthy  granulating  sur- 
face they  will  become  revitalized,  developing  rapidly 
into  substantial  tissue  coverings. 

Just  how  these  small  epithelial  grafts  are  revitalized 
when  applied  to  granulating  surfaces,  has  never  been 
fully  explained.  In  an  article  on  "  Leucocytes  and 
Nuclein,"  under  the  head  of  "  Nutrition,"  Dr.  T.  O. 
Summers,*  of  St.  Louis,  writes  : 

"  The  conversion  into  tissue,  or  imparting  molecular 
activity  to  material  lifeless  in  itself,  is  a  wonderful  phe- 


1  Medic.^i.  Record,  voL  .\.\.,  p.  no 

'Ibid.,  vol.  x.xi.,  p.  483. 

'  Encyclop.tdia  of  Surgerj-,  vol.  i. ,  p.  543. 

I  Journal  of  tlie  American  Medical  Association, 


P-  963- 


December 


5] 


MEDICAL    RECORD. 


803 


nomenon.  We  cannot  explain  the  affinities  by  which 
certain  kinds  of  pabulum  are  accepted  and  rejected 
by  the  several  tissue-cells  of  the  body.  We  know  this, 
however,  that  the  change  that  goes  on  is  the  elabora- 
tion of  a  vitalized,  celluiized  substance  which  is  capa- 
ble of  entering  at  once  into  tissue  as  soon  as  it  meets 
the  various  cells  which  have  this  power  of  elective  as- 
similation." 

In  briefly  reviewing,  I  desire  to  report  the  following 
observations  :  i.  The  best  results  were  obtained  from 
the  thin  transparent  epithelial  tissue.  It  made  no  dif- 
ference, whether  one  or  both  edges  were  attached,  just 
as  satisfactory  results  followed  the  use  of  dried  patches, 
with  no  attachment  except  at  distal  ends  of  hair.  2. 
The  certainty  of  their  attachment  when  properly  ap- 
plied, and  rapid  development.  3.  The  absence  of  cica- 
tricial contraction,  the  skin  being  loose,  and  in  many 
places,  especially  on  back  and  thighs,  so  natural  as  to 
require  close  examination  to  discover  its  artificial 
nature. 


THE    TYPHOID-FEVER  EPIDEMIC   IX  STAM- 
FORD   IX    1895— ORIGIX    AXD    COURSE.' 

By   F.  SCHAVOIR,  M.D., 


ALTH    OFFICER,    ST.\JtFORD,    CT. 


About  the  middle  of  April,  1895,  when  the  genera 
sanitary  condition  of  Stamford  seemed  to  be  in  a  very 
satisfactory  state,  there  were  noticed  by  the  physicians 
of  the  city  a  number  of  typhoid-fever  cases,  all  arising 
at  about  the  same  time.  A  casual  exchange  of  observa- 
tions quickly  disclosed  the  fact  that  there  were  a  large 
number  of  cases  existing,  and  the  remarkable  number 
of  children  affected  led  to  the  conclusion  that  an 
article  of  food  consumed  by  children  as  well  as  adults 
must  be  the  carrier  for  infection.  Milk  being  such  an 
article  it  was  readily  ascertained  that  these  cases  had 
been  supplied  almost  without  exception  by  one  dealer 
named  B . 

A  meeting  of  the  physicians  was  called  at  the  office 
of  the  health  officer,  and  an  informal  report  on  Sun- 
day, April  2 1  St,  showed  that  there  were  eighty  cases 
then  existing.  The  origin  of  the  infection  being  so 
forcibly  suggested,  the  milk-dealer  was  at  once  directed 
to  stop  selling  milk  and  an  investigation  was  instituted. 
It  was  ascertained  that  B — —  did  not  own  a  single 
cow,  but  purchased  all  his  milk  from  three  dairymen, 

who  delivered  their  supply  in  cans  furnished  by  B , 

and  kept  at  his  place,  where  they  were  washed  when 
empty  and  then  sent  to  the  dairymen.  The  premises 
where  the  empty  cans  were  washed,  and  where  the  milk 
was  kejjt  until  delivery,  are  located  in  a  thickly  inhab- 
ited, low,  and  poorly  drained  vicinity.  The  so-called 
dairy  consisted  of  a  small  frame  structure,  containing 
a  stable,  wagon-shed,  and  a  tank  with  a  pump  and  well. 
The  well  is  what  is  known  as  a  dug  well,  walled  up 
with  stones  not  cemented,  and  covered  with  a  loose 
board  platform  six  inches  above  the  ground.  The 
well  was  thirteen  and  a  half  feet  deep,  and  the  water 
stood  within  one  foot  and  nine  inches  of  the  surface  of 
the  ground.  All  the  houses  in  the  vicinity  were  pro- 
vided with  privies,  one  very  foul  one  was  situated 
twenty- five  feet  west  of  the  well  and  on  somewhat 
higher  ground. 

An  inquiry  into  the  conditions  of  the  dairies  from 

which  the  milk  was  supplied  to  dealer  B showed 

them  to  be  in  good  sanitary  condition,  and  although  no 
original  case  of  typhoid  fever  could  be  traced,  there  is 
overwhelming  presumptive  evidence  that  the  origin  of 
the  epidemic  must  have  been  in  that  well.  By  the 
middle  of  July,  1895,  there  were  reported'4o6  cases,  of 
these  352  occurred  in  families  who  received  their  milk- 
supply  from  B .    Twelve  were  known  to  have  used 

it  at  the  cafe  supplied  by  him,  2  obtained  milk  at  a 

'  Read  before  the  New  York  Academy  of  Medicine,  Section  on 
Paediatrics,  November  14.  1895. 


bakery  supplied  by  him,  and  2  obtained  B 's  milk 

in  other  indirect  ways,  making  a  total  of  368  cases,  or 
95]3[f  per  cent,  of  the  total  number  of  undoubted  pri- 
mary cases. 

The  ages  of  the  affected  persons  were  as  follows  : 

Under  5 . .        68   From  30  to  35 33 

From    5  to  10 72        "     33  "  40 15 

"     10  "  15 54       "    40  "  45 14 

"     15  "  20 42        "     45  "  50 6 

"     20  ■'  25 56    Over  50 10 

"     25  '^  30 36 

The  number  of  males  and  females  was  about  the 
same. 

The  number  of  cases  reported  as  to  date  were  : 

From  April  15th  to  22d •  -  72 

•'          "     23d    "  2qth 7S 

"         "     3olh  "  May  6ih 47 

"     May  7th       "     '•     13th 164 

"        "  I4ih     "     "    28th 33 

"         "28th     "  July  isth 12 

Of  the  cases  of  children  under  ten  years  of  age  the 
reports  were  as  follows  : 

April  iSth  to  22d 20 

"    23d    "29111 21 

"     30lh  •'  May  6ih iS 

May  7th  "     "'   13th 56 

"     14th  "     "     2Sth S 

'■     2gtli  ■'  July  15th 17 

The  number  of  deaths  from  typhoid  fever  up  to 
July  8th  were  27  :  the  ages  of  these  fatal  cases  were  as 
follows  : 


Under  $ 1    From  20  to  30 13 

From  5  to  10 i         "     30  "'  40 9 

'•    ID  "  15 o        "     40  "  50 o 

"   15    "  20 I         '■     50  and  over 2 

The  dates  of  death  were  :  April  27th,  2  ;  May  ist, 
2  ;  May  3d,  i  ;  May  4th,  i  ;  May  5th,  i  ;  May  9th,  i  ; 
May  10th,  1  ;  May  12th,  2  ;  May  13th,  i  ;  May  14th, 
2  ;  May  15th,  i  ;  May  i6th,  i  ;  May  23d,  i  ;  May  26th, 
I  ;  May  28th,  i  ;  June  2d,  2  ;  June  3d,  i  ;  June  4th, 
I  ;  June  9th,  2  ;  June  12th,  i  ;  June  14th,  i. 

One  child  dying  on  May  15th,  and  another  on  May 
26th. 

It  is  a  noteworthy  fact  that  in  some  families  every 
member  was  stricken  down  with  the  disease,  and  I 
have  personal  knowledge  of  one  house  where  there 
existed  nine  cases,  two  households  with  seven  each, 
and  several  with  five  cases. 

When  the  extent  of  the  epidemic  was  fully  realized, 
a  meeting  of  the  Health  Board  was  called,  and  a  re- 
lief committee  organized.  The  Hon.  Edwin  F.  Sco- 
field,  Mayor  of  Stamford,  was  elected  chairman  of  the 
relief  committee  ;  Dr.  Samuel  Pierson,  secretary  ;  and 
Mr.  E.  C.  Willard,  Superintendent  of  Schools,  treas- 
urer. An  appeal  to  the  citizens  was  issued,  and  within 
a  very  short  time  the  sum  of  $5,000  was  raised  for  the 
relief  of  the  sufferers  from  the  epidemic.  With  the 
fund  a  temporary  hospital  was  established,  about  fifty 
trained  nurses  were  engaged  to  take  care  of  the  sick  in 
the  hospital  as  well  as  in  the  families  where  it  was 
otherwise  impossible  to  procure  proper  care,  and  it  is 
to  the  devotion  and  skill  of  these  nurses  that  we  must 
largely  attribute  the  small  death-rate  of  the  epidemic. 

The  temporary  hosjiital  as  well  as  the  St.  John's 
Hospital  did  noble  work,  and  those  in  charge  deserve 
the  highest  praise  and  the  thanks  of  the  community  for 
their  untiring  devotion. 

Medicines  and  articles  of  food  were  provided  to  the 
needy,  and  though  a  good  deal  of  distress  was  caused 
by  the  epidemic  the  work  of  the  relief  committee  did 
wonders  to  alleviate  it.  The  physicians  were  notified 
by  the  health  officer  that  disinfectants  would  be  fur- 
nished free  of  charge  to  any  person  or  family  present- 
ing a  physician's   order   for   the   same.     Instructions 


8o4 


MEDICAL    RECORD. 


[December  7,  1895 


were  given  to  the  people  how  to  avoid  infection,  and 
every  possible  precaution  was  used  to  limit  the  disease. 

After  the  cessation  of  the  epidemic  all  the  premises 
where  cases  had  existed  were  systematically  disinfected 
as  far  as  feasible,  and  into  the  privy  vaults,  cess-pools, 
and  drains  were  introduced  disinfectants  to  destroy 
the  germs  wherever  they  could  be  reached.  At  the 
same  time  circulars  were  issued  to  all  the  inhabitants, 
cautioning  them  against  the  use  of  well-water  without 
previous  sterilization  by  boiling  ;  besides  this  numer- 
ous wells  were  ordered  closed. 

It  is  a  fact  that  since  the  epidemic  not  more  than 
ten  cases  per  month  have  been  reported,  although  we 
have  just  passed  through  the  period  of  the  year  when 
typhoid  fever  is  most  prevalent. 


THE    CLINICAL    HISTORY    OF    THE    STAM- 
FORD TYPHOID-FEVER  EPIDEMIC 

By  SAMUEL   PIERSON,    M.D., 

In  attempting  a  clinical  history  of  the  Stamford  ty- 
phoid-fever epidemic,  which  would  be  of  any  value  for 
its  statistics,  method  of  treatment  and  results,  it  is 
manifest  that  a  history  of  each  case,  as  reported  by  the 
attending  physician,  is  necessary.  To  achieve  this 
result  the  following  plan  has  been  adopted  : 

From  the  physician's  reports  to  the  Health  Officer  a 
list  was  made  of  all  cases,  together  with  the  name  of 
the  attending  physician.  The  different  physicians 
were  then  personally  seen,  and  each  case  was  gone 
over  in  detail,  noting  all  symptoms,  complications, 
treatment,  etc.,  and  from  these  reports  were  tabulated 
the  various  results  herein  given.  By  this  method  the 
absolute  reliability  of  the  figures  is  assured. 

From  April  15th  to  May  6th,  two  weeks  after  the 
sale  of  the  infected  milk  was  stopped,  253  cases  were 
reported  ;  after  this  date  the  number  rapidly  decreased, 
showing  that  in  the  early  cases  the  poison  was  much 
more  active  than  in  the  later  ones.  During  the  ne.xt 
three  weeks  only  135  more  cases  were  reported,  and 
nearly  all  of  these  were  of  distinctly  milder  type. 

From  this  time  until  the  middle  of  June,  20  more 
cases  were  reported,  and  some  of  these  were  secondary 
casts,  being  nurses  and  members  of  the  family  having 
the  care  of  the  sick,  making  the  total  number  of  cases 
406. 

The  differential  diagnosis  was  at  first  somewhat 
difficult,  as  many  cases  had  distinct  chills,  followed  by 
fever  and  sweating,  recurring  daily.  Malarial  possi- 
bilities were  eliminated  by  large  doses  of  quinine,  which 
usually  had  no  effect  upon  the  temperature  ;  in  nearly 
all  the  cases  the  diagnosis  was  not  considered  certain 
until  the  rash  or  diarrhoea  appeared  ;  so  it  is  certain 
that  no  malarial  cases  are  included  among  those  re- 
ported as  typhoid. 

Ten  cases  were  infected  by  drinking  a  single  glass  of 
milk  ;  one  of  these,  a  very  malignant  case,  was  under 
my  care  in  the  hospital  ;  the  patient  had  high  tem- 
perature, delirium,  repeated  hemorrhage,  and  finally 
died  of  perforation  thirty  days  from  the  beginning  of 
his  disease.  The  autopsy  showed  perforation  of  the 
ileum  about  twelve  inches  from  the  ileo-ca;cal  valve, 
numerous  ulcers  of  the  lower  part  of  the  ileum,  spleen 
much  enlarged,  general  peritonitis.  This  case  is  inter- 
esting as  showing  virulent  infection  from  very  slight 
exposure. 

Sixty-nine  cases  were  under  ten  years,  and  65  were 
under  five.  Statistics  show  that  sporadic  typhoid  is 
almost  unheard  of  in  children  under  three  years  of 
age.  The  large  number  of  children  infected  in  this 
epideniic  would  show  that  where  the  poison  is  over- 
whelming they  too  succumb. 

>  Read  before  the  New  York  .-Vcademy  of  Medicine,  Section  P.-edia- 
trics,  November  14,  1895. 


The  period  of  incubation  was  somewhat  uncertain, 
but  the  majority  were  under  fourteen  days.  The  long- 
est of  which  I  have  personal  knowledge  was  twenty- 
eight  days.  Nose-bleed  was  not  a  very  constant  symp- 
tom, but  was  present  in  117  cases,  twenty-eight  per 
cent,  of  all  ;  it  was  more  frequent  in  children  than  in 
adults.  Diarrhoea  was  present  in  364  cases,  eighty- 
nine  per  cent,  of  all,  and  was  usually  followed  by  con- 
stipation in  the  second  and  third  week.  In  some  cases 
constipation  was  present  from  the  start.  Tympanites 
was  noted  in  297  cases,  seventy-three  per  cent,  of  all, 
but  rarely  was  it  a  very  serious  or  troublesome  symp- 
tom. The  rash  was  very  constant,  and  was  present  in 
360  cases,  eighty-eight  per  cent,  of  all,  varying  in 
amount  from  a  few  scattered  spots  on  the  trunk  to 
hundreds  of  petechial  spots  all  over  the  body  ;  in  the 
majority  of  cases  the  rash  was  only  on  the  trunk. 
Delirium,  more  or  less  active,  was  present  in  142  cases, 
thirty-five  per  cent,  of  all.  Hemorrhage  occurred  in 
73  cases,  17.9  per  cent,  of  all.  Of  these  cases  61  re- 
covered and  12  died.  This  percentage  is  largely  in 
excess  of  any  reports  that  I  have  been  able  to  find,  and 
seems  to  have  been  due  to  the  virulence  of  the  poison  ; 
it  occurred  repeatedly  in  several  cases,  and  12  of  the 
fatal  cases  had  one  or  more  attacks. 

Bronchitis  or  pneumonia  occurred  in  40  cases,  9.8 
per  cent,  of  all,  and  a  very  annoying  bronchial  cough 
was  present  in  many  more. 

Relapse  and  reinfection  occurred  in  26  cases,  6.4 
per  cent,  of  all.  The  majority  of  cases  that  recovered 
terminated  by  lysis  rather  than  crisis.  I  can  recall  no 
typical  text- book  case  in  temperature  range.  Many 
ran  a  continuous  high  temperature  for  four  or  five 
weeks  without  complication,  or  apparent  cause.  A 
sudden  fall  in  temperature  was  invariably  the  pre- 
cursor of  some  complication,  usually  hemorrhage.  In 
many  cases,  apparently  convalescent,  the  temperature 
would  suddenly  shoot  up  and  remain  elevated  for  sev- 
eral days,  and  then  slowly  return  to  normal.  This 
recrudescence  was  supposed  to  be  due  to  reinfection. 
These  cases  were  often  given  full  doses  of  quinine 
without  favorable  results.  In  the  severe  cases  the 
temperature  ran  high,  from  104°  to  106°  F.,  with  irreg- 
ular remissions,  and  it  was  frequently  noticed  that  the 
high  temperature  gave  the  patients  no  discomfort,  nor 
did  it  seem  to  have  any  specially  bad  effect  on  heart 
or  nervous  system. 

Acute  nephritis  occurred  in  9  cases,  4  of  which  were 
fatal. 

Delivery  at  term  occurred  in  2  cases  ;  both  died. 
One  was  delivered  in  the  latter  part  of  the  second  week 
of  her  typhoid  ;  rash,  diarrhoea  and  enlarged  spleen 
were  present  at  the  time  ;  the  presentation  was  breech, 
but  the  labor  was  not  severe  ;  the  lochia  was  normal, 
and  involution  good,  but  the  patient  died  one  week 
after  delivery,  of  exhaustion.  The  child  is  still  alive 
and  well.  The  other  was  delivered  during  the  stage 
of  incubation.  The  typhoid  symptoms,  rash  and  diar- 
rhoea, soon  developed.  Abscess  of  both  breasts  oc- 
curred, and  the  patient  died  of  exhaustion  three  weeks 
after  delivery. 

Abortion  from  the  third  to  the  fifth  month  in  6 
cases,  all  recovered.  Pregnancy  in  4  cases  was  not 
disturbed  by  the  fever,  although  the  temperature  and 
symptoms  were  of  average  severity.  Perforation  oc- 
curred 7  times,  with  six  deaths,  one  recovery.  A  short 
account  of  this  case  may  be  of  interest. 

The  patient  was  a  woman,  aged  thirty-eight.  She 
had  been  ill  three  weeks  with  a  most  malignant  attack, 
had  suftered  three  hemorrhages,  the  last  two  days 
before  the  perforation.  Suddenly  in  the  night  she  was 
seized  with  intense  pain  in  the  right  inguinal  region, 
which  she  described  as  more  severe  than  any  she  ever 
experienced  ;  this  was  followed  by  nausea  and  vomit- 
ing. When  I  saw  her,  a  half  hour  later,  she  was  al- 
most in  collapse  ;  thready  pulse,  cold  perspiration, 
semi  ■  comatose  ;    abdomen    markedly    distended    and 


December  7,  1S95] 


MEDICAL    RECORD. 


805 


very  tender.  Under  free  stimulation,  hypodermics  of 
morphia,  and  ice-bags,  she  finally  rallied.  The  next 
day  the  abdomen  was  still  greatly  distended.  Recov- 
ery finally  occurred  after  twelve  week'  illness.  This 
patient  also  had  a  mild  type  of  insanity,  lasting  for 
some  weeks  after  recover}',  but  which  has  now  entirely 
disappeared. 

Phlebitis  in  a  mild  form  was  seen  in  several  cases. 
In  one  otherwise  mild  case  there  was  an  intense  phle- 
bitis of  the  internal  saphenous  vein,  great  swelling  and 
tenderness  of  the  leg,  and  entire  inability  to  use  the 
leg  for  weeks  after  convalescence  was  established.  At 
present  the  leg  is  still  one-third  larger  than  its  fellow, 
but  no  hardness  can  be  made  out  over  the  course  of 
the  vein. 

Many  ambulatory  cases  were  seen  ;  one  of  these  died 
of  sepsis  the  day  after  coming  under  observation. 
There  were  quite  a  number  of  abortive  cases  that, 
after  a  usual  onset  and  unmistakable  symptoms,  in  the 
second  week  would  soon  return  to  normal.  The  con- 
dition of  the  spleen  was  noted  in  so  few  cases  that  it  is 
not  worth  recording.  Dry  and  cracked  tongue  and 
sordes  were  rarely  seen  in  cases  that  received  proper 
care  and  nursing. 

Of  the  40  cases  which  came  under  my  care  at  St. 
John's  Hospital  and  the  temporary  hospital  adjoining, 
nearly  all  were  of  a  severe  t)pe.  One  aborted  at  the 
fifth  month  during  the  second  week  of  the  fever  ;  the 
temperature  at  the  time  was  105°  F.,  the  placenta  was 
adherent,  and  the  hemorrhage  free.  After  removing 
the  placenta  by  peeling  off  the  adherent  portion  with 
the  finger,  the  uterus  was  thoroughly  curetted,  washed 
out  with  boiled  water,  and  packed  with  iodoform 
gauze.  There  was  profound  shock  following  the  oper- 
ation, and  while  the  specific  temperature  remained 
there  was  never  any  symptom  of  uterine  infection. 
Lochia  normal  and  without  odor  throughout. 

Several  cases  had  repeated  reinfection,  delirium,  in- 
continence of  fceces  and  urine,  and  15  of  the  40  had 
hemorrhage.  Heroic  stimulation  was  used  in  4  cases  ; 
three  pints  of  whiskey  each,  daily,  for  eight  days. 
There  were  four  deaths  among  the  40,  but  of  these 
two  were  in  collapse  on  admission  and  died  in  a  few 
hours,  one  from  perforation,  one  from  hemorrhage. 
The  third,  a  baby,  twenty-two  months  old,  died  of 
bronchi  is  within  twenty-four  hours  of  admission,  so 
that  really  only  one  patient  died  under  treatment,  2.5 
per  cent,  of  all.  One  child  of  twelve  years  had  twenty 
boils  on  different  parts  of  the  body. 

Autopsy  was  performed  in  three  cases  ;  one  on  a 
child  of  twenty-two  months,  who  died  of  bronchitis, 
was  made  by  Dr.  Northrup  and  will  be  reported  by 
him.  Another  was  in  the  case  already  mentioned,  who 
died  of  perforation  on  the  thirtieth  day  ;  both  showed 
the  characteristic  lesions. 

The  last  was  upon  the  lamented  Dr.  Edwin  J.  Meeks, 
whose  case  presented  some  unusual  points  of  interest. 
His  was  the  longest  undoubted  period  of  incubation, 
twenty-eight  days  from  the  last  drinking  of  the  infected 
milk  to  the  first  onset  of  symptoms.  He  was  removed 
to  the  Presbyterian  Hospital,  New  York,  for  treatment, 
and  the  record  there  shows  rapid  pulse  and  high  tem- 
perature from  the  start,  on  which  tubbing  had  no  ef- 
fect. During  the  latter  part  of  the  second  week  the 
temperature  ran  lower,  but  reinfection  occurred  a  few 
days  later,  with  sustained  temperature  between  104° 
and  105°  F.,  persistent  rash,  repeated  hemorrhage,  and 
general  sepsis,  followed  by  death  twenty-eight  days  after 
admission.  The  autopsy  showed  e.xtensive  ulceration 
in  the  lower  two  feet  of  the  ileum,  and  a  few  ulcers 
were  also  found  in  caecum  and  ascending  colon.  The 
ulcers  were  ragged  and  extended  to  the  muscular  layer, 
in  one  instance  only  the  peritoneal  covering  remained. 
In  the  six  feet  of  ileum  above  this  there  was  a  later 
crop  of  lesions,  a  general  swelling  and  sloughing  of  the 
Peyer's  patches  ;  large  blood-clots  were  found  in  this 
part  of  the  intestine  ;  the  spleen  was  much  enlarged. 


There  were  in  all  twenty- seven  deaths,  including  that 
of  Dr.  E.  J.  Meeks  and  blisses  Clark  and  Begg,  nurses, 
who  died  in  the  Xew  Haven  Hospital,  martyrs  to  their 
profession.  This  would  give  a  mortality  of  6.6  per 
cent,  in  406  cases,  which  is  very  much  below  the  aver- 
age in  severe  epidemics. 

The  causes  of  death  were — confinement,  2  ;  perfora- 
tion, 5  ;  hypostatic  pneumonia,  6  ;  exhaustion  from 
hemorrhage,  8  ;  toxaemia  early  in  disease,  3  :  nephri- 
tis, 3- 

The  general  treatment  employed  varied  greatly. 
One  physician,  who  treated  fourteen  cases  without  a 
death,  gave  absolutely  no  drugs  or  treatment  of  any 
kind  for  any  symptom  or  complication  ;  no  baths,  no 
heart  stimulants,  no  antipyretics,  no  attempt  to  check 
excessive  diarrhoea  or  hemorrhage,  and  very  slight  reg- 
ulation of  diet.  Four  of  these  cases  had  hemorrhage, 
and  five  relapses  or  reinfection.  The  plan  generally 
followed  was  to  give  a  cathartic  at  the  commencement 
of  the  disease,  usually  calomel.  By  some  this  drug 
was  used  in  small  doses  throughout.  At  the  hospital 
we  relied  entirely  on  enemas  of  warm  water  for  consti- 
pation after  the  first  week. 

No  tub  baths  were  used  during  the  epidemic  for  the 
reason  that  the  majority  of  cases  were  in  very  poor 
families  where  the  household  conveniences  were  so 
limited  that  even  ordinary  care  was  difficult.  At  the 
hospital  and  annex  it  was  a  physical  impossibility  to 
carry  out  this  treatment  with  the  nurses  at  our  com- 
mand, so  that  such  results  as  we  had  were  attained 
without  this  means,  considered  so  indispensable  by 
many.  Personally  I  saw  only  6  cases,  out  of  80  or  90, 
where  it  seemed  to  me  bathing  would  have  been  de- 
sirable in  relieving  high  temperature,  delirium,  bron- 
chitis, and  flagging  heart. 

Alcohol  and  ice-water,  sponging  and  rubber-blanket 
baths  were  generally  used,  and  certainly  had  a  decided 
effect  in  reducing  temperature,  quieting  delirium,  and 
inducing  sleep. 

The  experience  with  the  coal-tar  antipyretics  was 
the  usual  one  of  sweating  and  depression  ;  but  later  on 
in  the  epidemic  I  found  that  in  all  except  septic  cases 
one-half  grain  doses  of  phenacetine,  repeated  every 
hour  when  the  temperature  was  above  103°  P.,  would 
act  promptly,  and  without  sweating  or  depression,  in 
reducing  it  one  or  two  degrees. 

Intestinal  antisepsis  was  attempted  by  most  of  the 
physicians ;  the  drugs  most  used  were  calomel,  car- 
bolic acid,  bismuth,  salicylate  and  subnitrate,  and  salol. 
At  the  hospital  this  treatment  was  early  abandoned  in 
favor  of  large  draughts  of  cold  water,  except  in  those 
cases  where  the  diarrhoea  was  very  profuse,  when  bis- 
muth and  opium  were  given.  For  hemorrhage,  free 
hypodermics  of  morphine  were  the  main  reliance.  Er- 
gotole,  also  by  hypodermics,  was  used  in  some  cases,  as 
were  the  vegetable  astringents  hamamelis,  tannic  acid, 
and  the  like  ;  ice-bags  to  the  abdomen  and  moderate 
alcoholic  stimulation  did  good  service.  For  tympa^ 
nites,  turpentine  stupes  and  sometimes  small  turpentine 
enemas  were  used. 

Digitalis  was  rarely  used  as  a  heart  stimulant ;  our 
main  reliance  was  on  strychnia  by  hypodermic  or  per 
Oram  in  from  5V  to  ^V  grain  doses  every  four  hours,  for 
lasting  effect.  For  quick  action,  nitro- glycerine,  grain 
tJj  every  hour,  and  alcohol. 

One  physician  reports  brilliant  results  from  protonu- 
clein,  grains  five  every  three  hours,  and  further  states  that 
since  he  began  its  use,  late  in  the  epidemic,  he  had  no 
complications  whatever,  and  in  many  cases  the  progress 
of  the  disease  has  been  checked,  temperature  and  other 
symptoms  subsiding  early  in  the  second  week.  It  is  to 
be  regretted  that  this  remedy,  to  fully  test  it,  could  not 
have  been  used  early  in  the  epidemic  when  all  the  cases 
were  of  more  severe  type. 

The  usual  rule  during  convalescence  was  to  keep  the 
patient  in  bed  and  withhold  solid  food  for  one  week  af- 
ter temperature  was  normal  ;  but  in  some  cases  in  which 


8o6 


MEDICAL    RECORD. 


[December  7,  1S95 


moderate  temperature  persisted  with  no  apparent  cause  ; 
if  the  tongue  was  clean,  the  eruption  had  disappeared, 
and  the  tympanites  and  diarrhoea  had  ceased,  solid 
food  was  allowed  ;  usually  a  normal  temperature  was 
soon  observed.  Apparently  the  temperature  was  due 
to  post-typhoid  anaemia. 

The  striking  characteristics  of  the  epidemic  may  be 
summarized  as  follows  : 

I.  Its  source  traced  to  contaminated  milk,  the  sale 
of  which  was  cut  off  within  one  week  from  its  first  ap- 
pearance. 2.  The  almost  complete  cessation  of  new 
cases  within  two  weeks  after  the  sale  of  milk  was 
stopped,  showing  that  incubation  is  usually  not  more 
than  fourteen  days.  3.  The  large  proportion  of  patients 
having  well-marked  rash,  eighty-eight  per  cent.  4.  The 
large  number  of  young  children  infected,  sixty- nine 
under  ten  years  and  sixty-five  under  five.  5.  The  unusual 
number  of  hemorrhagic  cases,  17.9  per  cent.  6.  The 
low  death-rate,  6.6  per  cent.,  which  was  attained  with- 
out the  use  of  tub  baths  in  any  case.  The  best  results 
claimed  for  this  method  of  treatment  being  seven  per 
cent.  7.  That  the  general  history  of  the  cases  proves 
it  to  have  been  an  epidemic  of  virulent  type. 

In  conclusion,  my  thanks  are  due  to  each  physician 
in  Stamford  for  his  cordial  co-operation,  without  which 
it  would  have  been  impossible  to  have  given  a  clinical 
history  of  the  Stamford  typhoid- fever  epidemic. 


THE    NEUROLOGICAL    ASPECT    OF 
ASTHENOPIA. 


By   H.    GKADLE,    M.D., 


CHICAGO,  ILL. 
PROFESSOR    OF    CLINICAL    OPHTHALMOLOGY,    NORTHWEST 


In  the  extensive  literature  on  the  influence  of  eye-strain 
upon  the  nervous  system,  but  little  mention  is  made  of 
any  other  factors  concerned  except  the  refractive  con- 
dition of  the  eyes.  Some  authors,  indeed,  write  as  if 
the  various  nervous  symptoms  observed  in  some  patients, 
in  consequence  of  an  ocular  defect,  weie  the  inevitable 
results  of  such  a  cause.  Yet  a  critical  study  of  any 
series  of  patients  with  anomalies  of  refraction  shows 
that  other  circumstances  besides  the  optic  condition 
must  be  taken  into  consideration  in  order  to  account 
for  the  variability  of  the  subjective  complaints.  For 
why  is  it  that  the  same  degree  of  optic  imperfection 
causes  only  fatigue  of  the  eyes  and  blurring  of  sight  in 
one  person,  while  in  others  it  leads  to  headaches  of  vari- 
ous types  and  other  nervous  symptoms  ?  and  why  is  it 
that  some  persons  can  tolerate  without  discomfort  an 
amount  of  refractive  error  which  forces  others  to  the  use 
of  glasses  ? 

The  case-book  of  any  oculist  can  furnish  numerous 
illustrations  of  different  forms  of  headaches,  of  a  feel- 
ing of  dull  pressure  i;i  the  head,  of  spells  of  dizziness, 
and  even  of  nausea,  due  to  eye-strain.  The  ocular  ori- 
gin of  these  complaints  can  be  easily  proven  in  proper 
cases  by  the  permanent  relief  afforded  by  spectacles 
correcting  the  optic  defect.  These  cases  are  so  com- 
mon that  illustrative  instances  from  my  own  practice 
would  be  superfluous.  But,  alternating  with  these  pa- 
tients, every  oculist  sees  also  many  people  who,  with 
the  same  degree  of  refractive  anomaly,  do  not  complain 
of  any  annoyance  beyond  fatigue  or  discomfort  in  the 
eyes  on  close  work  and  blurring  of  sight.  If  we  ex- 
tend our  observation  to  those  patients  who  do  not  call 
on  us  on  account  of  asthenopic  symptoms,  but  whose 
eyes  we  examine  in  the  course  of  other  diseases,  or 
whom  advancing  age  compels  to  apply  for  glasses,  we 
will  find  that  nervous  symptoms  in  consequence  of  op- 
tic anomalies  are,  after  all,  not  as  common  as  an  exclu- 
sive office-observation  might  suggest.  Compared  with 
the  frequency  of  optic  anomalies  as  shown  by  all  sys- 
tematic examinations  of  schools  and  military  recruits, 


patients  with  nervous  symptoms  resulting  from  eye- 
strain represent  but  a  small  minority  of  ametropes.' 
Moreover,  if  we  study  the  refraction  of  people  who  do 
not  complain  of  asthenopia,  we  will  find  a  very  noticea- 
ble percentage  with  low  degrees  of  hypermetropia  or 
astigmatism  who  are  not  annoyed  at  all  by  their  defect. 

It  is  thus  taught  by  actual  observation  that  refractive 
errors  (outside  of  simple  myopia)  disturb  the  majority 
of  ametropes  only  by  the  fatigue  of  the  eyes  and  un- 
steadiness of  sight  which  they  cause,  and  that  the  lower 
degrees  ~  do  not,  as  a  rule,  interfere  to  any  practical  ex- 
tent with  the  use  of  the  eyes.  There  is,  however,  a 
small  class  of  patients  who  are  sensitive  to  the  lowest 
measurable  optic  anomaly,  and  in  whom  eye-strain  can 
lead  to  various  nervous  symptoms. 

For  the  purposes  of  this  paper  it  maybe  well  to  term 
that  degree  of  discomfort  which  is  the  regular  and  in- 
evitable consequence  of  a  given  refractive  error  normal 
asthenopia,  and  to  refer  to  the  eye  distress  in  excess  of 
this  limit  or  due  to  unproportionately  small  optic  ano- 
malies, as  well  as  to  any  resulting  nervous  symptoms,  as 
excessive,  unproportionate,  or  exaggerated  asthenopia. 
It  must  be  understood,  of  course,  that  there  are  all  pos- 
sible degrees  of  exaggerated  asthenopia,  and  that  there 
exists  no  sharp  dividing  line  between  normal  and  un- 
proportionate  eye-strain. 

If  we  compare  the  general  health  of  ametropes  with 
normal  asthenopia  with  that  of  patients  complaining  of 
unjiroportionate  symptoms,  we  will  find  the  former  rep- 
resenting the  more  perfect  physical  type  of  mankind. 
If  hence  an  anomaly  which,  according  to  its  degree,  is 
either  tolerated  without  discomfort,  or  causes  only  lo- 
cal fatigue  and  distress  in  healthy  persons,  leads  to 
much  greater  discomfort  or  even  distant  nervous  dis- 
turbances in  certain  patients,  we  cannot  but  conclude 
that  in  the  latter  class  other  factors  besides  the  refrac- 
tion are  concerned  in  the  etiology.  This  view  is  con- 
firmed by  the  history  of  those  patients  in  whom  the 
unproportionate  asthenopia  began  abruptly  after  the 
occurrence  of  unfavorable  environment,  or  followed 
some  debilitating  disease.  It  is  also  confirmed  by  the 
possibility  of  recovery  from  the  exaggerated  form  of 
asthenopia  while  the  refractive  error  remains  the  same. 

Inquiries  concerning  the  health,  past  history,  and 
habits  of  patients  with  unproportionate  asthenopia  re- 
veal that  many  of  them  possess  the  so-called  "  ner- 
vous "  or  neurotic  disposition.  Their  nervous  system 
reacts  to  impressions  made  upon  it  in  a  different  man- 
ner from  that  of  average  healthy  subjects.  Many  are 
excessively  disturbed  by  minor  annoyances  of  sensory 
or  mental  nature.  They  may  complain  inordinately  of 
trifles  like  the  pressure  of  the  spectacles  on  the  nose,  or 
of  any  itching  skin  lesion  present  at  the  time.  Indeed 
this  irritability  coincides  with  the  popular  notion  of 
"nervousness."  Of  course,  those  persons  who  have 
cultivated  mental  discipline  may  not  betray  the  annoy- 
ance produced  by  trifling  causes,  but  they  feel  it  sub- 
jectively. Emotions  are  very  easily  aroused  in  most  of 
these  people,  and  in  some  the  emotional  activity  is  re- 
vealed at  the  time  by  vaso-motor  and  cardiac  disturb- 
ances. Quite  often  such  patients  have  poorly  developed 
muscles.  Even  if  strong  for  momentary  eft'orts  they 
tire  easily.  But  neither  this  one  nor  any  of  the  other 
evidences  of  the  neurotic  disposition  are  present  in  all 
instances. 

There  is  nothing  characteristic  about  the  nutrition  of 
these  patients,  at  least  in  the  case  of  adults.  Among  the 
children  of  this  class  I  have,  however,  found  a  large 
proportion  delicate  and  below  average  weight. 

In  some  instances  more  definite  proof  of  an  unstable 

'  It  is  well  to  call  attention  again  to  the  fact  that  most  eyes  are  hy- 
permetropic at  birth,  according  to  numerous  observers  (Ely,  Schleich, 
Horstnian,  and  others),  and  that  hypermetropia  is  the  predominant 
state  of  refraction  during  early  childhood. 

2  On  the  strength  of  my  own  experience  I  would  state  the  average 
limit  of  tolerance  to  H.  and  Ast,  without  annoyance,  at  about  two  Di- 
optrics up  to  tlie  tenth  year,  .about  1.5  D.  up  to  the  thirtieth  year,  and 
perhaps  0.75-1  D.  at  the  fortieth  year  of  life.  Myopic  astigmatism  is 
rarely  tolerated  after  puberty  if  it  exceeds  1.25  D. 


December  7,  1895] 


MEDICAL   RECORD. 


807 


nervous  system  is  given  by  the  history  of  past  (or  even 
present)  nervous  affections,  such  as  chorea  (or  habit 
spasm)  in  childhood,  or  nervous  prostration  at  some 
period  of  life.  The  more  thorough  the  neurological 
training  of  the  observer,  the  more  readily  will  he  detect 
in  many  of  these  patients  evidences  of  an  imperfect  con- 
dition of  the  nervous  system.  Yet  it  must  not  be  ex- 
pected that  we  can  demonstrate  the  neurotic  tendency 
in  every  case  of  unproportionate  asthenopia.  In  some 
we  can  only  infer  it  through  the  family  history.  A  few 
times  I  have  seen  the  hidden  neurotic  tendency  mani- 
fest itself  later  in  life  by  the  occurrence  of  nervous  affec- 
tions, although  the  examination  made  when  the  patient 
applied  for  glasses  on  account  of  e.xaggerated  astheno- 
pia did  not  show  any  anomalies  of  the  nervous  system 
at  that  time. 

Just  as  we  may  find  all  gradations  from  normal  to 
highly  exaggerated  asthenopia,  so,  too,  will  we  find 
transitions  from  the  normal  stability  of  the  nervous 
system  through  slight ''  nervousness  "  up  to  extreme  want 
of  nervous  resistance.  I  have,  however,  observed  but 
little  connection  between  unproportionate  asthenopia 
— in  the  sense  employed  in  this  paper — and  hysteria. 
For  I  am  referring  now  only  to  those  cases  in  which  all 
the  symptoms  are  removed  by  correction  of  the  optic 
error.  It  is  true,  some  few  of  my  patients  belonging 
to  this  category  have  been  hysterical  subjects,  but  not 
any  large  proportion.  On  the  other  hand,  asthenopia, 
often  associated  with  muscular  anomalies,  is  not  a  rare 
condition  dependent  on  hysteria,  but  this  form  is  not 
remediable  by  glasses. 

The  condition  of  the  nervous  system  manifested  by 
unproportionate  asthenopia  may  result  from  a  number 
of  different  influences.  While  I  have  tried  to  inform 
myself  regarding  the  causes  leading  to  this  state  in 
most  of  my  patients,  my  preserved  records  are  not  suf- 
ficiently complete  or  uniform  to  be  presented  correctly 
in  a  statistic  form.  My  statements,  however,  are  based 
on  the  examination  of  about  three  thousand  cases  of 
hypermetropia  and  astigmatism,  of  which  between  one- 
fourth  and  one-third  complained  of  exaggerated  or 
unproportionate  asthenopia.  This  figure  does  not  rep- 
resent the  real  proportion  between  normal  and  e.xag- 
gerated asthenopia  in  a  community,  since  a  large  num- 
ber of  ametropes  without  nervous  symptoms  are  fitted 
with  glasses  by  opticians  and  are  not  seen  by  any  ocu- 
list. 

Perhaps  the  most  frequent  etiological  condition  lead- 
ing to  exaggerated  asthenopia  is  inherited  instability  of 
the  nervous  system.  For  obvious  reasons  it  is  difficult 
to  learn  much  regarding  the  family  history  of  adults  in 
office  examinations,  but  in  the  case  of  children  brought 
by  their  parents,  inquiry  reveals  very  often  the  exist- 
ence of  the  neurotic  disposition  in  one  of  the  parents. 
It  is,  of  course,  necessary  to  inquire  systematically  for 
headaches,  chorea,  asthma,  and  other  morbid  reflexes, 
nervous  spells,  and  nervous  prostration.  I  have  met 
but  little  with  organic  disease  of  the  nervous  system  in 
these  family  histories,  probably  because  it  is  much  less 
common  than  functional  neuroses.  Parental  alcohol- 
ism has  likewise  played  a  very  small  role.  My  inter- 
pretation of  the  results  of  these  inquiries  may  be 
questioned  on  the  ground  that  a  neurotic  parent  can  be 
found  in  many  families,  the  children  of  which  do  not 
suffer  of  exaggerated  asthenoi)ia.  I  know  of  no  statis- 
tics to  prove  or  disprove  this  view.  But  I  have  often 
noticed  the  coincidence  that  the  family  history  was 
especially  bad  in  the  more  pronounced  cases  of  unpro- 
portionate or  exaggerated  asthenopia.  I  have  further- 
more been  led  to  think  that  in  children,  who  have  not 
yet  been  exposed  to  the  vicissitudes  of  adult  life, 
heredity  is  a  more  important  factor  than  when  exag- 
gerated asthenopia  appears  later  in  life. 

Even  in  the  absence  of  hereditary  disposition  the 
neurotic  basis  of  exaggerated  asthenopia  may  be 
created  by  various  diseases.  Of  acute  infections  I  have 
often  seen  measles  the  precursor  of  asthenopia,  unpro- 


portionate to  the  age  or  the  optic  defect  of  the  patient. 
This  applies  also  to  influenza,  as  seen  in  the  last  few 
years.  As  to  typhoid  fever,  tuberculosis,  and  other  de- 
bilitating diseases,  I  have  only  seen  that  patients  were 
made  more  sensitive  by  them  to  moderate  refractive 
errors  than  they  had  been  previously,  but  I  have  not 
seen  them  followed  by  nervous  disturbances. 

Of  coexisting  diseases  none  have  as  often  prepared 
the  way  for  exaggerated  asthenopia,  within  my  expe- 
rience, as  antemia  and  chlorosis.  The  importance  of 
the  impoverished  blood  I  have  often  seen  illustrated  by 
recovery  from  exaggerated  asthenopia  in  consequence 
of  hygienic  measures  and  the  use  of  iron.  I  have  rec- 
ords of  numerous  young  people  who,  after  their  recov- 
ery from  anaemia,  could  either  lay  aside  their  glasses 
entirely  (in  the  case  of  weaker  numbers),  or  were  at 
least  able  to  dispense  with  them  e.xcept  in  reading ; 
while  previously  they  had  found  their  continuous  use 
essential  for  their  comfort. 

Not  very  often,  but  at  least  in  a  dozen  instances, 
does  my  case-book  show  that  children  who  had  re- 
quired glasses  were  again  comfortable  without  them 
after  a  hypertrophy  of  the  pharyngeal  tonsil  had  been 
removed  by  an  operation. 

Functional  disturbances  of  digestion,  especially 
symptoms  referable  to  the  stomach,  were  frequently 
mentioned  by  my  patients.  From  some  it  was  learned 
that  the  more  pronounced  their  dyspeptic  complaints, 
the  more  conscious  they  became  of  their  eye-strain.  In 
a  few  instances  under  my  observation  the  asthenopic 
symptoms  diminished  or  ceased  entirely  after  recovery 
from  the  digestive  disturbances.  The  dyspepsia,  as  far 
as  I  was  able  to  learn,  was  in  very  few  of  these  patients 
indicative  of  serious  gastro- intestinal  disease,  but  gen- 
erally of  the  type  of  nervous  dyspepsia. 

I  have  found,  besides  these  patients,  representatives 
of  all  the  different  forms  of  neurasthenic  manifesta- 
tions. But  I  do  not  claim  that  any  large  proportion  of 
patients  with  unproportionate  or  exaggerated  astheno- 
pia present  manifest  neurasthenia  to  any  pronounced 
extent. 

Although  in  more  than  one- half  of  the  patients  with 
the  more  pronounced  exaggeration  of  symptoms,  sys- 
tematic inquiry  showed  some  other  abnormal  reactions 
on  the  part  of  the  nervous  system,  or  some  deviations 
from  the  standard  of  perfect  nervous  health,  still  in 
others  no  further  evidences  of  nervous  disturbances 
could  be  ascertained  at  the  time  of  the  examination. 
In  these  persons  the  asthenopia  out  of  proportion  to 
the  optic  defect,  or  nervous  symptoms  induced  by  eye- 
strain, seem  to  me  in  themselves  evidence  of  imper- 
fect health  of  the  nervous  system. 

The  disposition  to  exaggerated  asthenopia  can  be 
fostered  by  unhygienic  habits.  The  histories  I  have 
collected  mention  but  too  often  the  baneful  influence 
of  persistent  eyework,  confinement  indoors,  and  lack 
of  muscular  exercise.  It  is  common  ophthalmic  expe- 
rience that  asthenopic  complaints — normal  or  exag- 
gerated— increase  with  the  amount  of  eyework.  An 
optic  defect  which  is  tolerated  without  symptoms  by  a 
healthy  person,  who  does  not  use  his  eyes  much,  may 
begin  to  annoy  him  as  soon  as  he  taxes  his  eyes  with 
more  work.  Moreover,  asthenopic  complaints  started 
by  the  use  of  the  eyes  at  short  distances  can  persist 
after  reading  or  other  work  has  been  discontinued  for 
hours,  or  even  for  a  few  days.  In  illustration  of  this 
fact  I  have  seen  some  elderly  presbyopic  people,  with 
ideal  emmetropic  eyes,  complain  of  more  or  less  steady 
discomfort  even  during  the  period  of  rest  of  the  eyes, 
on  account  of  the  strain  while  reading,  and  have  re- 
moved such  persistent  annoyance  by  the  use  of  proper 
reading-glasses.  Personal  observations,  however,  have 
led  me  to  consider  continuous  eyework  rather  as  a 
condition  which  makes  the  exaggerated  asthenopia 
manifest  than  as  a  productive  factor  in  its  etiology. 
For  I  have  repeatedly  enabled  patients  to  continue  their 
eyework  without  the  use,  or  at  least  without  the  steady 


8o8 


MEDICAL    RECORD. 


[December  7,    1895 


use,  of  glasses,  after  inducing  them  to  take  up  more 
outdoor  exercise.  The  influence  of  confinement  in- 
doors, and  insufficient  muscular  exercise,  is  also  shown 
by  the  vocations  principally  represented  among  my  pa- 
tients, viz.,  bookkeepers,  typewriters,  and  other  office- 
employees,  female  teachers,  advanced  pupils,  and  girls 
of  comfortable  circumstances  leading  an  indolent  life 
at  home.  While,  besides,  I  have  seen  occasional  in- 
stances among  many  other  business  pursuits,  it  has 
certainly  seemed  noticeable  how  very  few  of  the  patients 
with  exaggerated  asthenopia  do  manual  labor.  Yet  I 
see  normal  asthenopia  quite  often  among  the  laboring 
classes,  and  do  find  exaggerated  forms  of  eye- strain 
among  their  children  raised  in  the  large  city,  and 
among  their  wives  who  are  closely  confined  in  the 
house. 

According  to  some  of  my  histories,  the  unproportion- 
ate  eye-strain  was  first  observed  after  long  periods  of 
interrupted  sleep,  especially  in  nursing  mothers.  Men- 
tal worry  has  also  figured  to  a  small  extent  in  my 
records. 

The  observations  upon  which  this  paper  is  based 
suggest  that  the  duty  of  the  physician  is  not  entirely 
fulfilled  if  he  contents  himself  with  a  prescription  for 
glasses  for  the  relief  of  unproportionate  or  excessive 
asthenopia.  Whatever  real  benefit  can  be  obtained 
from  spectacles  the  patient  should  certainly  receive. 
But  glasses,  after  all,  are  merely  optic  "crutches," 
which  in  vigorous  health  are  not  necessitated  by  the 
lower  degrees  of  ametropia.  Whenever  we  find  the 
complaints  of  the  patient  out  of  proportion  to  his  optic 
defect,  we  should  also  search  for  the  influences  which 
have  undermined  his  powers  of  resistance,  and  remedy 
them  if  possible.  For,  by  fortifying  his  health  at  the 
time  when  the  first  indications  of  nervous  weakness  are 
manifested,  we  can  guard  him  against  subsequent  other 
nervous  accidents  which  glasses  cannot  remedy. 


guogvcsB  of  iJtXcdiaxl  J»cicucc. 

Syphilis  and  Blood  Serum.— Dr.  Vieviorovski  has  made 
some  experiments  on  the  treatment  of  primary  syphilis 
by  means  of  blood-serum  from  individuals  affected  with 
gummata  or  other  tertiary  forms  of  the  disease.  Blood 
was  obtained  from  the  median  basilic  vein  and  serum 
prepared  from  it.  Five  patients  were  experimented 
upon,  all  of  whom  were  suffering  from  the  symptoms  of 
the  early  stage  of  syphilis.  The  primary  symptoms  dis- 
disappeared  under  this  treatment,  but  it  had  no  effect 
upon  the  development  of  secondary  symptoms,  and  the 
experiment  may  be  considered  a  failure. 

Transmission  of  Typhoid  Fever  by  the  Air.— In- 
vestigations on  this  subject  have  been  made  by  Dr. 
Licard,  of  Beziers,  whose  plan  of  experimenting  was  to 
have  patients  suffering  from  this  disease  breathe  through 
tubes  into  water  that  had  first  been  sterilized.  Speci- 
mens of  water  thus  treated  were  frequently  found  to 
yield  the  bacilli  under  cultivation.  The  bacilli  were 
not  always  found,  but  this  is  not  a  matter  of  surprise 
when  it  is  considered  that  the  best  bacteriologists  fre- 
quently fail  to  find  them  under  conditions  strongly 
suggestive  of  their  presence.  Dr.  Licard's  result's 
were,  however,  sufficiently  uniform  to  warrant  an  in- 
ference that  the  expired  breath  of  typhoid  patients,  like 
that  from  those  having  typhus,  may  serve  as  a  channel 
for  fever  infection.  The  vast  majority  of  typhoid  infec- 
tions have  their  origin  in  a  contaminated  water-supjih , 
but  every  observer  has  been  puzzled  more  or  less  by 
cases  of  the  disease  which  have  arisen  apart  from  any 
known  inculpation  of  the  drinking-water.  These  cases 
of  obscure  origin  may  originate  from  two  causes  whose 
bacillar  contact  is  atmospheric — not  simply  by  means 


of  the  breath  of  the  sick,  but  also  by  emanations  from 
sewers,  cess-pools,  and  other  receptacles  of  typhoid  de- 
jections. 

Beriberi. — Three  cases,  that  varied  greatly  in  clin- 
ical outline,  were  recently  reported  by  Dr.  J.  Hill 
Abram  before  the  Liverpool  Medical  Institution.  The 
disease  is  uncommon  in  Europeans,  and  women  and 
children  usually  escape.  Weakness,  inability  to  stand, 
unsteadiness  in  walking,  ability  to  go  only  a  step  or 
two  without  assistance,  were  the  first  symptoms  com- 
plained of  by  a  sea-captain,  thirty-six  years  of  age. 
There  was  marked  ataxic  gait  ;  and  the  man  could  not 
stand  with  the  feet  together,  even  when  the  eyes  were 
open.  Slight  ataxia  was  present  in  the  arms.  Muscu- 
lar power  was  poor  in  the  upper  and  lower  extremities, 
especially  in  the  extensors  of  the  forearms  and  flexors 
of  the  ankle  ;  wrist-drop  and  foot-drop  were  therefore 
present.  The  patient  was  unable  to  rise  in  bed  with- 
out assistance  ;  the  grasp  was  weak.  There  was  cold- 
ness in  the  limbs,  and  sensations  of  pins  and  needles. 
Pain,  touch,  heat,  and  cold,  all  forms  of  sensations, 
though  usually  distinctly  recognized,  were  markedly 
delayed  in  the  legs  up  to  Poupart's  ligament ;  the  delay 
in  the  arms  was  less,  and  sensibility  normal  above  the 
elbow.  Marked  tenderness  in  the  calves  existed  on 
deep  pressure,  in  the  posterior  surfaces  of  the  thighs, 
and  the  flexor  aspects  of  the  forearms.  There  was 
absence  of  knee-jerk,  of  wrist-  and  elbow-jerk.  Super- 
ficial and  organic  reflexes  were  present.  The  trouble 
began  by  a  feeling  of  lassitude  and  pains  all  over  the 
body,  followed  by  oedema  gradually  extending  up  to 
the  knee  ;  disappearance  of  this  after  five  days  in  bed, 
and  gradual  increase  of  pain  and  paralysis.  There  was 
marked  palpitation  during  this  time.  The  second  case 
was  the  mate  on  the  same  vessel.  The  symptoms  were 
slight  ataxia,  leg  muscles  weak,  no  obvious  wrist-drop, 
sensation  delayed,  marked  muscular  tenderness  in 
lower  limbs,  all  reflexes  present,  heart  enlarged,  and 
double  aortic  bruit.  His  trouble  began  by  pain  in  the 
back,  which  had  been  present  in  some  degree  for  about 
twelve  months.  Then  there  was  oedema  in  the  left  leg 
followed  by  general  dropsy.  Pains  in  the  limbs,  and 
unsteadiness  and  weakness  in  the  legs  and  arms  came 
on  later.  The  third  case,  the  ship's  carpenter,  was 
practically  well  when  seen  ;  calf  muscles  were  tender, 
and  the  man  complained  of  tiring  easily.  In  all  these 
cases  of  peripheral  neuritis  the  trouble  had  begun  in 
the  legs,  not  the  arms,  as  in  alcoholic  neuritis.  The 
men  were  total  abstainers,  just  home  from  a  two 
months'  stay  on  the  coast  of  Brazil,  and  without  evi- 
dence of  malarial  sporoziion  in  their  blood,  which  was 
carefully  examined.  The  diagnosis  of  beriberi  was 
therefore  plain.  The  treatment  consisted  of  absolute 
rest  in  bed,  good  feeding,  the  administration  of  iron, 
strychnia,  and  massage.  The  morbid  anatomy  of  beri- 
beri is  practically  limited  to  the  nerves,  the  muscles, 
and  the  heart.  The  nerves  show  the  characteristic 
parenchymatous  inflammation,  and  the  muscles  and 
heart  varying  degrees  of  fatty  degeneration  (Scheube. 
Baelz^  Pekelharing.  and  Winkler).  The  disease  pre- 
vails endemically  in  Japan,  India,  Burmah,  Java,  Cey- 
lon, and  the  Malayan  Archipelago,  the  west  coast  of 
Africa,  and  South  America.  Excessive  proportion  of 
rice,  fish,  impure  water,  etc.,  have  been  considered 
predisposing  causes.  The  exciting  cause  is  now  looked 
upon  as  an  organism,  and  the  nerve  changes  as  due  to 
the  absorption  of  a  toxin,  the  organism  not  being 
present  in  the  nerves  themselves. 


Typhoid  Fever  in  Connecticut. — The  report  of  the 
Connecticut  Board  of  Health  for  October  shows  an 
unusual  prevalence  of  typhoid  fever  in  the  State.  Out 
of  168  towns  in  the  State,  the  disease  is  recorded  in  50, 
the  total  number  of  cases  reported  being  189. 


December  7,  1895] 


MEDICAL    RECORD. 


809 


Medical    Record: 

A  Weekly  yournal  of  Medicine  and  Surgery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 

WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth   Street. 


New  York,  December  7,   1895. 


ELUSIVE    KIDNEY   DISEASE. 

There  are  circumstances  in  the  study  of  disease  well 
calculated  to  mislead  the  most  careful  physician. 
Among  them  are  those  vague  symptoms  of  small  value 
as  isolated  facts,  often  set  down  and  cavalierly  dis- 
missed as  neurasthenic  or  hysterical,  and  not  taken 
into  account  when  summing  up  evidence.  Another 
class,  also  dangerous  to  the  diagnostician,  are  symp- 
toms that  point  directly  to  the  confirmation  of  a  pre- 
conceived idea.  These  obscure  diagnosis  and  delay 
proper  treatment.  The  patient  who  does  not  sleep 
very  well,  eat  very  well,  or  see  very  well,  may  no 
doubt  be  neurasthenic  or  hysterical.  On  the  other 
hand,  insomnia,  disorders  of  vision,  and  digestive  dis- 
turbances are  associated  also  with  organic  changes 
that  it  is  wise  to  recognize  early.  Added  to  the  dis- 
comforts already  mentioned,  there  may  be  headache, 
mental  depression,  rheumatic  pains,  or  neuralgia  ;  or 
more  marked  nervous  symptoms,  loss  of  memory,  ano- 
rexia, nausea,  vomiting,  frequent  urination,  and  attacks 
of  diarrhoea.  In  any  new  case  presenting  these  feat- 
ures, wholly  or  in  part,  the  urine  is  analyzed  as  a  mat- 
ter of  course,  not  once,  but  many  times.  Results  are 
negative :  no  albumin,  etc.,  and  kidney  disease  is 
therefore  eliminated.  Another  complains  of  auditory 
troubles,  loss  of  strength  that  interferes  with  the  busi- 
ness of  life  and  with  personal  obligations,  of  drowsy, 
dull,  stupid  attacks,  and  some  fever  afternoons.  Tem- 
perature may  be  subnormal  mornings,  rising  to  100°, 
101°,  or  102°  F.  toward  evening  ;  or  it  may  be  one  or 
two  degrees  above  normal  in  the  morning,  and  one  or 
two  degrees  still  higher  in  the  afternoon.  Again,  the 
only  variation  may  be  a  subnormal  temperature  morn- 
ings. These  temperature  variations  may  continue  for 
days,  weeks,  or  months,  at  intervals.  Urinalysis  re- 
veals nothing.  There  is  growing  weakness,  however, 
pallor,  some  loss  of  weight,  and  even  night-sweats. 
What  is  really  the  matter  ?  Tuberculosis  ?  Cancer  ? 
Irregular  malarial  fever  ?  Causes  wide  of  the  mark  are 
sought  for  the  emaciation,  the  constant  weakness,  and 
the  change  in  the  character.  The  symptoms  mean  so 
little  or  so  much,  that  a  correct  diagnosis  is  made  per- 
haps for  the  first  time  on  the  day  of  the  patient's 
death.  Just  as  life  is  ending,  or  perhaps  later,  a  cause 
is  suddenly  discovered  for  apparently  insignificant  and 
unexplainable  phenomena. 

What  Bartels  calls  a  "  singular  nephritis  "   in   de- 
scribing it,  can  give  rise  to  this  varied  and  irregular 


train  of  symptoms.  Interstitial  nephritis,  often  the 
most  misleading  and  elusive  of  renal  disorders,  devel- 
ops insidiously,  perhaps  by  jumps  and  starts,  and  in 
unexpected  ways.  It  is  one  of  the  most  stealthy  of  all 
diseases  in  its  approach.  Dropsy  does  not  occur, 
though  there  is  often  oedema  of  the  eyelids,  and  some- 
times of  the  ankles.  Disturbances  of  the  nervous 
system  are  very  marked,  and  appear  early.  The  most 
amiable  and  sanguine  dispositions  may  become  mor- 
bidly depressed,  peevish,  suspicious,  and  impatient, 
with  sometimes  hyper-excitation  of  the  nervous  system 
almost  maniacal  in  character,  and  suicidal  tendencies 
may  also  develop.  In  no  form  of  kidney  trouble  are 
uraemic  accidents  (Charcot)  and  hemorrhages  (Millard) 
so  common.  Hemorrhages  may  be  from  the  nose,  the 
stomach,  and  into  the  cranial  cavity.  In  in  cases  of 
death  from  apoplexy  at  St.  George's  Hospital,  inter- 
stitial nephritis  existed  in  55.  Apathy  and  semi-tor- 
pidity of  physical  and  mental  powers  occur  in  the  ad- 
vanced stages.  Coma  is  more  likely  to  exist  than 
epileptic  seizures.  Patients  often  appear  to  get  well 
after  acute  attacks  ;  then  all  the  sjTnptoms  return, 
weakness  increases,  and  death  may  take  place  from 
pure  exhaustion.  The  duration  of  the  disease  cannot 
be  known,  since  there  is  no  necessary  relation  between 
the  development  of  the  kidney  lesions  and  the  appear- 
ance of  the  symptoms.  Certain  foreign  writers  seem 
to  believe  that  the  limit  of  duration  lies  somewhere  be- 
tween ten  and  twenty  years. 

The  urine  may  be  examined  at  frequent  intervals  for 
days,  weeks,  and  months,  without  albumin  being  dis- 
covered. The  quantity  is  always  small,  and  often  in 
fully  developed  cases  it  is  temporarily  absent  alto- 
gether. When  detected,  it  is  usually  in  the  evening 
urine.  Dieulafoy  regards  albuminuria  as  a  very  unre- 
liable symptom  of  Bright's  disease.  In  sixty  cases  un- 
der treatment  in  his  wards  during  recent  years,  albu- 
minuria was  absent  in  one-fourth.  That  nephritis 
really  existed  was  often  proved  post  mortem.  Millard 
calls  it  crude  to  base  a  diagnosis  upon  its  presence, 
and  quotes  Semmola  :  "  We  must  absolutely  give  up 
the  idea  still  current  in  practice,  that  albuminuria  must 
always  exist  with  nephritis."  And  Francis  Delafield 
states  that  though  albumin  is  a  very  common  symp- 
tom of  renal  disease,  it  is  least  abundant  and  least 
constant  in  certain  special  forms  of  it,  of  which  inter- 
stitial nephritis  is  one.  But  how  about  specific  grav- 
ity ?  Is  it  unaltered  ?  Does  this  also  defy  all  precon- 
ceived opinions  ?  Listen  again  to  Delafield,  in  "  Pep- 
per's System  of  Medicine  "  :  "  Atrophied  kidneys  give 
rise  to  a  great  variety  of  clinical  histories.  It  is  impos- 
sible to  describe  all  the  ways  in  which  the  disease  may 
begin  and  run  its  course,  but  some  of  them  may  be 
enumerated."  Ten  such  ways  are  then  described. 
This  is  one  :  "  For  several  months  the  patients  do  not 
feel  well ;  the  appetite  is  lost,  there  is  nausea,  occa- 
sional vomiting,  they  become  pale,  anaemic,  do  not 
sleep  well  at  night,  are  irritable  and  easily  worried, 
and  are  troubled  with  headache.  The  urine  continues 
normal,  or  is  of  low  specific  gravity,  or  contains  a  little 
albumin.  They  suddenly  become  worse  and  the  regu- 
lar symptoms  are  developed."  In  pronounced  cases 
specific  gravity  ranges  from  i.oio  to  1.016.  With  heart 
failure  and  consequent  diminution  of   the  volume  of 


8io 


MEDICAL    RECORD. 


[December  7,  1895 


urine  the  specific  gravity  rises  somewhat,  and  may  even 
approach  again  the  normal  standard,  after  having  re- 
mained for  years  constantly  reduced  (Purdy).  Dela- 
field  says  the  urine  is  regularly  increased  and  of  low 
specific  gravity  (others  say,  "  usually,"  "  generally  "),  ex- 
cept in  uraemic  attacks,  when  it  is  diminished  ;  uremic 
attacks  may  come  on  when  the  patient  is  passing  from 
thirty  to  forty  ounces  of  urine  of  a  specific  gravity  of 
1.020.  The  urine  itself  is  clear,  often  pellucid,  and 
sometimes  soapy-looking.  Tests  show  that  it  has  lost 
much  of  its  toxic  property.  Deposits  are  remarkably 
free  from  cellular  elements.  When  epithelia  appear,  it 
is  the  exception  and  not  to  be  expected  (Millard). 
The  regular  and  absolute  amount  of  urea  suffers  dimi- 
nution from  the  beginning.  Phosphates  are  also  dimin- 
ished, almost  constantly  (Purdy).  Uric  acid  is  in- 
creased and  calcium  oxalate,  both  of  which  are  often 
to  be  noted  together.  Occasional  hyaline  casts  are 
often  the  only  evidence,  as  far  as  the  urine  is  con- 
cerned, of  interstitial  nephritis.  Hypertrophy  of  the 
left  auricle  of  the  heart  is  a  frequent  complication  ; 
but  Dr.  Delafield  has  not  found  it  in  as  large  a  propor- 
tion of  cases  in  New  York  as  it  is  described  by  Eng- 
lish and  German  writers. 

The  most  important  symptom  is  constant  weakness. 
Next  in  order  is  headache.  Then  comes  digestive  dis- 
turbances, anorexia,  nausea,  vomiting,  flatulence,  and 
so-called  bilious  attacks.  Intractable  rheumatic  pains 
and  persistent  neuralgia  are  both  highly  suggestive  of 
interstitial  nephritis.  Ralph  states  that  this  intense 
pain  has  often  led  him  to  a  correct  diagnosis.  It  is 
well  known  that  disorders  of  vision  are  common,  with 
or  without  discoverable  lesions.  Minor  symptoms 
are  :  Auditory  troubles,  vertigo,  itching  of  the  skin, 
muscular  twitchings,  cramps  in  the  calves,  especially  at 
night,  and  sensitiveness  to  cold,  especially  of  the  lower 
limbs. 

What  to  do  when  this  elusive  kidney  disease  is  strong- 
ly suspected  or  actually  discovered  ?  Remove  all  strain 
from  the  heart,  arteries,  and  kidneys.  Life  must 
henceforth  be  quiet,  yet  interesting,  with  gentle  but 
not  excessive  exercise.  Cold  and  damp  are  distinctly 
dangerous.  The  ideal  condition  demands  a  resi- 
dence in  some  warm,  equable  climate  from  November 
till  April.  Treatment  is  hygienic  and  symptomatic, 
combining  knowledge  and  experience  and  that  superior 
insight  known  as  common-sense. 


and  of  women  are  dwelt  upon,  the  smallness  of  her 
head,  and  the  expansiveness  of  her  imagination  ;  the 
fact  that  she  has  made  no  great  mark  in  literature, 
science,  or  art  is  again  thrust  ungallantly  into  the  argu- 
ment. So  far,  he  says,  the  making  of  medical  women 
has  not  led  to  the  production  of  any  scientific  results. 
Medical  practice  requires  power  of  thought  and  the 
capacity  for  work.  Few  male  students  unite  both  gifts, 
and  how  much  fewer,  the  Professor  asserts,  the  female 
students,  in  whom  thought  is  so  inextricably  mixed 
with  emotion.  The  writer  would  not  even  admit  that 
women  should  become  specialists  in  the  eye  and  the 
ear,  or  the  throat,  since  he  says,  in  order  to  become 
good  specialists,  they  must  first  of  all  acquire  the 
knowledge  and  assume  the  responsibilities  of  a  general 
practitioner.  But  Professor  Albert  would  not  exclude 
woman  entirely  from  medical  work.  He  kindly  rec- 
ognizes the  many  admirable  peculiarities  of  woman — 
her  constant  willingness,  her  tenderness,  her  deep  sym- 
pathy for  the  suffering,  her  sharp  observation,  etc.  He 
would  have  woman  educated  so  as  to  be  able  to  take 
the  position  of  a  kind  of  medical  assistant,  a  grade  a 
little  higher  than  the  nurse,  and  little  lower  than  the 
doctor.  A  young  woman  should,  for  example,  receive 
training  in  a  public  school,  then  spend  some  years  in 
special  training  in  various  directions,  as  nurse  in  the 
hospital,  as  midwife,  as  head-nurse,  as  assistant  in  op- 
erations upon  the  eye,  ear,  throat,  teeth,  and  so  on. 
She  might  be  taught  how  to  deal  with  cases  of  urgency, 
such  as  sudden  acute  attacks  of  disease  or  poisoning, 
and  she  should  understand  the  elements  of  medicine 
and  surgery,  midwifery  and  gynecology,  besides  some 
physics,  chemistry,  anatomy,  and  physiology.  Professor 
Albert  would  give  to  this  presumably  most  useful  class 
the  title  of  "  Heilfrau." 

We  fear  that  Professor  Albert's  protest  against  the 
admission  of  women  to  the  medical  profession  is  some- 
what belated.  His  arguments  are  true  enough  for  the 
large  majority  of  women,  but  there  is  always  a  percent- 
age of  the  gentler  sex  who  possess  qualities  which  en- 
able them  to  work  successfully  as  physicians.  This  has 
already  been  proven,  and  needs  no  argument.  Whether, 
by  giving  them  freer  opportunities,  this  percentage  will 
become  larger,  it  remains  for  the  future  to  determine. 
But,  at  any  rate,  we  see  no  advantage  in  constructing 
a  category  of  "  Heilfrauen,"  who  could  never  be  more 
than  trained  nurses.  In  fact,  the  good  trained  nurse  is 
already  a  Heilfrau,  and  possesses  all  the  qualifications 
which  Professor  Albert  has  indicated. 


WOMEN    HEALERS    VS.   WOMEN    DOCTORS. 

A  CELEBRATED  surgeon  in  Vienna,  Hofrath  Professor 
E.  Albert,  has  recently  published  a  monograph  upon 
the  subject  of  women  and  the  study  of  medicine,  in 
which  he  makes  a  very  elaborate  argument  against  the 
admission  of  women  to  the  medical  art.  Professor  Al- 
bert's kind  of  reasoning  is  not  a  particularly  new  one. 
All  professional  careers,  he  says,  from  the  beginning  of 
the  world,  have  been  pursued  by  men  alone.  Since  the 
origin  of  mankind,  woman  has  had  only  one  purpose, 
to  bring  children  into  the  world,  to  nurse  them,  and  to 
care  for  them  ;  hence,  concludes  the  Professor,  this 
must  be  the  purpose  for  which  women  were  born.  The 
difference  between  the  mental  characteristics  of  men 


Asafoetida  in  Obstetrics,— Warman  {Der  Frauenarzt, 
August,  1S95)  finds  that  this  drug  is  a  most  valuable 
therapeutic  agent  in  midwifery.  It  is  a  direct  sedative 
to  the  pregnant  uterus,  and  exercises  no  evil  influence 
over  the  general  system.  It  is  of  particular  value  when 
abortion  is  imminent,  as  it  controls  uterine  irritability. 
On  the  other  hand,  it  is  of  no  use  as  a  prophylactic 
agent  in  such  cases,  and  must  not  be  relied  upon  when 
the  abortion  has  proceeded  so  far  as  to  require  manual 
interference.  In  habitual  constipation,  and  also  in  ner- 
vous conditions  during  pregnancy,  asafanida  is  highly 
beneficial. 


December  7,   1895] 


MEDICAL    RECORD. 


811 


AN   ANTI-NOISE  LEAGUE. 

The  city  of  New  York  should  turn  itself  reverently 
toward  the  town  of  Phoenix,  Ariz.,  a  place  little  known 
to  fame,  but  worthy  of  it.  The  citizens  of  that  pro- 
gressive municipality  have  organized  what  is  called  an 
"  anti-noise  league."  Whether  this  is  meant  to  sup- 
press the  rumbling  of  heavy  drays  over  the  cobbled 
streets,  or  the  thunderous  jars  of  elevated  trains 
through  the  public  thoroughfares,  or  simply  to  prevent 
the  irritating  effect  of  the  noise  of  pistols  and  shot- 
guns discharged  by  excited  citizens,  we  do  not  know  ; 
but,  whatever  the  specific  purpose,  the  general  object 
is  a  most  praiseworthy  one.  There  have  been  rtiany 
attempts  to  suppress  the  noise  of  this  metropolis,  but 
so  far  without  avail.  Perhaps  it  is  because  the  at- 
tempts have  not  been  organized,  and  perhaps  because 
it  is  difficult  to  get  statistical  evidence  that  noise  is  del- 
eterious to  the  public  health.  Noise  is  like  tobacco  :  it 
is  a  slow  poison,  and  however  much  harm  it  does,  it 
does  not  do  it  dramatically  or  sensationally  ;  therefore 
it  does  not  appeal  to  the  reporter  and  the  chiefs  of  the 
Sunday  press.  We  can  only  infer  from  analogy  that 
the  continual  impact  of  dissonant  sounds  upon  the  hu- 
man ear  must  have  some  slight  exhausting  effect,  even 
though  these  sounds  do  not  always  rise  into  conscious- 
ness. 


EARLY  MARRIAGES. 

The  recent  marriage  of  a  young  woman  of  wealth,  aged 
eighteen,  to  a  young  man  of  title,  has  given  rise  to 
infinite  discussion  on  matrimonial  alliances  and  matri- 
mony in  general.  So  far  as  we  have  noticed,  however, 
none  of  the  commentators  upon  the  great  current 
hymenial  events  have  brought  up  the  question  of  early 
marriage  in  its  relation  to  health.  Yet  this  is  perhaps 
one  of  the  most  important  of  the  subjects  which  could 
possibly  concern  those  proposing  to  enter  the  new 
estate.  It  seems  almost  pathetic  that  not  one  of  the 
reporters  on  the  daily  press  came  across  the  striking 
remark  of  Dr.  Clouston  to  the  effect  that  "  the  young 
man  who  marries  before  his  beard  is  fairly  grown, 
breaks  a  law  of  nature,  and  sins  against  posterity." 
The  subject  of  early  marriage,  and  the  proper  time,  so 
far  as  age  is  concerned,  for  marriage,  has  often  been 
discussed,  and  medical  opinions  upon  the  matter  are 
numerous  enough.  Very  few  physicians,  however, 
have  really  investigated  the  matter  in  the  careful 
method  which  physiological  science  demands.  Dr. 
Mathews  Duncan  is  one  of  these  few.  A  short  time 
before  he  died  he  wrote  some  elaborate  article  bearing 
upon  this  subject,  and  from  his  studies  and  his  experi- 
ence he  drew  the  conclusion  that  below  twenty  years 
of  age  woman  is  immature.  If  she  marries  before  that 
time,  she  runs  considerable  risk  of  proving  sterile.  If 
she  bears  a  child,  she  runs  a  comparatively  high  risk  of 
dying  in  childbirth.  In  addition  to  this,  he  found  that 
an  early  marriage  had  other  disadvantages  associated 
with  a  more  frequent  tendency  to  have  uterine  dis- 
orders. 

The  most  elaborate  statistical  investigation  of  the 
subject,  how^ever,  has  been  made  by  Josef  Carosi,  of 
Buda-Pesth.  His  investigation  was  a  purely  statistical 
one,  based   upon  the  percentages  of  deaths,  diseases, 


the  births,  and  so  on,  in  connection  with  age  and  mar- 
riage. He  concluded  that  immature  persons  have  a 
tendency  to  bring  forth  a  degenerate  stock  ;  in  other 
words,  that  persons  who  marry  before  they  are  mature 
have  a  larger  percentage  of  cripples,  consumptives, 
idiots,  and  criminals.  The  age  of  maturity  is  placed  at 
twenty  for  the  woman,  and  for  the  man,  at  twenty-five. 

Dr.  Farr  states,  in  his  "  Vital  Statistics,"  that  the  mor- 
tality among  wives  under  twenty  years  is  much  higher 
than  that  among  wives  in  the  period  between  twenty 
and  thirty,  and  this  same  author  found  that  the  mor- 
tality-rate from  accouchements  between  the  ages  of 
fifteen  and  twenty-five  was  i  in  149,  while  between  the 
ages  of  thirty  and  thirty-five  it  was  i  in  235.  Such 
statistics  were  collected,  however,  before  the  day  of 
antiseptics,  and  it  is  possible  that  they  might  tell  a  dif- 
ferent story  now. 

According  to  a  writer  in  The  Hospital,  the  experi- 
ence of  breeders  of  all  kinds  bears  out  the  view  that 
the  progeny  of  immature  animals  has  a  tendency  to  be 
weaker  than  those  of  mature.  Against  all  this  may  be 
offset  the  fact  that  a  great  many  people  who  marry 
young  have  healthy  children  and  live  happy  lives,  and 
the  further  fact  that  if  marriage  is  prolonged  too  late, 
perhaps  even  more  disastrous  results  might  occur,  to 
the  woman,  at  least. 

The  facts  regarding  early  marriages  in  India  might 
also  be  cited,  as  showing  that  they  do  not,  at  least 
particularly,  change  the  character  of  the  race. 


THE  ARMY   MEDICAL   SERVICE. 

We  learn  from  our  English  contemporaries  that  the 
present  head  of  the  English  army.  Lord  Wolseley,  is 
inclined  to  carry  out  the  same  policy  toward  the  army 
medical  service  which  was  adopted  by  his  predecessor! 
namely,  that  of  snubbing  and  keeping  down,  whenever 
opportunity  offers,  the  medical  officers.  At  a  recent 
inspection  in  Dublin,  Lord  Wolseley  objected  to  the 
medical  corps  carrying  swords,  because,  he  said,  they 
were  only  civilians. 

The  army  officers  do  not  seem  to  keep  in  touch  with 
the  spirit  of  the  times,  which  tends  constantly  to  bring 
into  greater  prominence  the  work  of  civilians,  and  to 
attract  into  civil  life  the  best  minds  of  every  civilized 
country.  In  particular,  the  standard  of  education  and 
intelligence  in  the  medical  profession  is  everywhere 
steadily  rising,  while  we  judge  from  the  various  ex- 
hibitions of  the  intelligence  of  army  and  naval  services 
that  these  branches  are  not  any  longer  drawing  the 
best  class  of  men  into  them.  Yet,  in  the  apparently 
desperate  effort  to  maintain  the  prestige  of  the  army 
and  navy,  the  officers  do  all  they  can  by  artificial  regu- 
lation to  keep  down  men  who  are,  by  education  and 
natural  intelligence,  their  eciuals,  and  jterhaps  their  su- 
periors. We  believe  that,  in  the  end,  the  importance 
and  social  value  of  the  medical  services  in  our  armies 
and  navies  will  be  recognized  at  their  true  worth,  and, 
meanwhile,  we  hope  that  the  contest  will  be  kept  up 
until  justice  is  secured. 


Peekskill   has  a  new   hospital,   the    Helping    Hand 
Hospital. 


8l2 


MEDICAL    RECORD. 


[December  7,  1895 


'^cxDS  of  the  '©aXccli. 

St.   Joseph's   Hospital,   New  York. — Dr.  John  Dom- 
ing has  been  appointed    consulting  physician   to    St. 
Joseph's  Hospital. 
The  Presbyterian  Hospital,  New  York,  in  Debt. — 

The  expenses  of  the  Presbyterian  Hospital  during  the 
past  year  exceeded  its  receipts  by  $97,625.71,  and  the 
usual  appeal  for  donations  is  in  order.  In  this  connec- 
tion it  may  be  proper  to  quote  a  remark  made  by  Mr. 
J.  C.  Carter,  at  the  recent  anniversary  of  the  Woman's 
Hospital  of  this  city  :  "  The  whole  chain  of  charitable 
institutions  ought  to  be  put  under  a  system.  If  persons 
able  to  give  to  charity  could  be  assured  that  their  gifts 
would  be  made  judicious  use  of  they  would  give  more 
freely."  In  other  words,  too  much  so-called  hospital 
charity  sometimes  brings  its  own  reward. 

Association  of  Assistant  Physicians  of  Hospitals  for 
the  Insane. — The  second  meeting  of  this  Associa- 
tion was  held  at  the  Michigan  Asylum  for  the  Insane, 
Kalamazoo,  Mich.,  October  24,  1895.  The  member- 
ship, originally  composed  of  medical  officers  of  the 
staffs  of  asylums  of  Michigan,  Illinois,  and  Iowa,  was 
extended  to  include  the  assistant  superintendents  and 
assistant  physicians  of  all  asylums.  The  next  meeting 
will  be  held  at  the  Asylum,  at  Independence,  la.,  dur- 
ing May,  1896. 

The  Alvarenga  Prize.— The  College  of  Physicians  of 
Philadelphia  announces  that  the  next  award  of  the  Al- 
varenga  Prize,  amounting  to  about  one  hundred  and 
eighty  dollars,  will  be  made  on  July  14,  1896.  Essays 
intended  for  competition  may  be  upon  any  subject  in 
medicine,  but  cannot  have  been  published,  and  must  be 
received  by  the  Secretary  of  the  College  on  or  before 
May  I,  1896.  Each  essay  must  be  sent  without  signa- 
ture, but  must  be  plainly  marked  with  a  motto  and  be 
accompanied  by  a  sealed  envelope  having  on  its  outside 
the  motto  of  the  paper,  and  within  it  the  name  and  ad- 
dress of  the  author.  It  is  a  condition  of  competition 
that  the  successful  essay,  or  a  copy  of  it,  shall  remain  in 
possession  of  the  College  ;  other  essays  will  be  returned 
upon  application  within  three  months  after  the  award. 
The  Alvarenga  prize  for  1895  has  been  awarded  to  Dr. 
Guy  Hinsdale,  of  Philadelphia,  for  his  essay  entitled 
"  Syringomyelia." 

The  Idaho  Medical  Society. — In  a  notice  of  the  an- 
nual meeting  of  this  Society,  in  a  recent  issue,  it  was 
stated  that  the  President  is  Dr.  W.  D.  Springer,  and  the 
Secretary,  Dr.  C.  L.  Sweet.  The  positions  are  re- 
versed :  Dr.  Sweet  is  President,  and  Dr.  Springer,  Sec- 
retary. 

Noble  Doctors.  —  Count  de  Goyan,  a  prominent 
royalist  of  France,  has  taken  the  degree  of  Doctor  of 
Medicine.  So  also  has  the  Duke  de  Rivoli  as  well  as 
Count  de  Sinety,  and  Baron  Henry  de  Rothschild  is 
said  also  to  be  a  medical  student. 

New  Hospital  Organization. — The  attending  physi- 
cians and  surgeons  of  Bellevue,  and  those  of  the  other 
hospitals  belonging  to  this  city,  have  organized  them- 
selves into  an  association. 

The  Ovary. — Absent  in  body,  but  present  in  spirit. 


Ophthalmic  Consultations  Free. — On  the  front  adver- 
tising page  of  a  leading  local  medical  journal  of  a 
neighboring  city  appears  the  announcement  of  doctor, 
optician,  and  jeweller,  all  in  one,  who  gives  free  consul- 
tations to  all  applicants.  This  may  be  business,  but  it 
is  not  ethics.     We  cannot  serve  two  masters. 

London  Physicians'  Fees. — The  weekly  paper,  Ti't- 
bits,  states  that  not  a  few  fashionable  doctors  in  Lon- 
don make  from  $1,500  to  $2,500  a  day  for  weeks 
together  ;  that  some  half-dozen  of  London  medical  men 
make  $200,000  a  year. 

Muscular  Strength  of  Woman. — Dr.  J.  H.  Kellogg,  of 
Battle  Creek,  has  devised  what  he  calls  a  "  universal 
dynamometer,"  and  he  has  published  a  very  long  list 
of  tables  showing  the  strength  of  the  different  groups 
of  muscles  of  the  body  in  men  and  women.  He  states 
that  the  relative  strength  of  the  muscles  of  the  thighs 
and  legs  in  women  is  greater  than  that  in  men.  These 
statements,  according  to  the  medical  press,  agree  with 
the  facts  shown  by  Quetelet  and  Sargent,  that  the 
thigh  is  not  only  proportionately,  but  actually,  larger 
in  women  than  in  men.  This  increase  in  size  of  the 
thigh  is,  in  fact,  one  of  the  earliest  of  all  the  sexual 
characteristics,  of  a  physical  nature,  which  appear  as 
the  girl  approaches  puberty,  and  it  seems  to  be  due  to 
greater  development  of  muscles  as  well  as  to  the  great 
accumulation  of  adipose  tissue.  The  fact  of  the  rela- 
tively greater  strength  of  the  thigh  and  leg  muscles  in 
woman  might  easily  be  seized  upon  by  those  who  favor 
the  bicycle  for  women,  since  it  is  the  thigh  muscles 
especially  which  are  brought  into  play  in  that  sport. 

Changes  in  the  Stafi  of  the  Philadelphia  Hospital. — 
Dr.  William  B.  Porter  has  resigned  after  twenty-five 
years,  and  Dr.  Alfred  C.  Wood  has  been  appointed  as 
his  successor  ;  Dr.  J.  C.  DeCosta  has  been  appointed 
surgeon,  and  Dr.  E.  B.  Sangree,  pathologist.  Dr. 
Copeland,  who  was  formerly  pathologist,  has  accepted 
a  chair  in  the  Vanderbilt  University,  at  Nashville. 

Medical  Department  of  the  American  University. — 
It  is  announced  that  the  Rev.  Christian  B.  Stemen, 
Professor  of  Surgery  in  the  Fort  Wayne  College  of 
Medicine,  has  been  authorized  to  develop  and  organ- 
ize the  Medical  Department  of  the  American  Univer- 
sity, at  Washington,  D.  C. 

Typhoid  Fever  again  threatens  to  become  epidemic 
in  Chicago.  More  than  one  thousand  five  hundred 
cases  occurred  in  one  week. 

Homoeopathy. — According  to  Dr.  J.  Lester  Keep, 
there  are  in  the  United  States  6  National  societies  and 
I  sectional  society  of  homoeopaths,  143  State  societies, 
112  homoeopathic  hospitals,  59  dispensaries,  35  homoeo- 
pathic medical  journals,  20  colleges,  and  14,000  prac- 
titioners. In  England  a  new  homoeopathic  hospital  has 
just  been  opened,  which  cost  in  its  construction  and 
appointments  over  a  quarter  of  a  million  dollars. 
The  practice  of  homoeopathy,  he  says,  has  gained  a 
strong  foothold  in  Mexico,  where  a  law  has  been  re- 
cently adopted  placing  both  schools  of  medicine  on  an 
equal  footing. 

Dr.  J.  N.  Bloom  succeeds  the  late  Dr.  Edward  R. 
Palmer  to  the  Chair  of  Genito-urinary  Diseases  in  the 
University  of  Louisville. 


December  7,  1S95] 


MEDICAL    RECORD. 


^Icuicius  and  Iloticcs. 

Twentieth  Century  Practice.  An  International  En- 
cyclopaedia of  Modern  Medical  Science  by  leading  authori- 
ties of  Europe  and  America.  Edited  by  Thom.as  L. 
Stedm.an,  M.D.,  New  York  Citv.  In  Twenty  A'oluraes. 
Vol.  IV.,  Diseases  of  the  Vascular  System  and  Thvroid 
Gland.     New  York  :  \Villiam  Wood  &  Co.     1S95. 

The  fourth  volume  of  this  work  begins  with  a  lucid  exposi- 
tion of  diseases  of  the  heart  and  pericardium  by  Professor 
^Vhittaker,  of  Cincinnati.  The  article  is  an  exhaustive 
treatise  on  cardiac  affections,  occupying  a  little  more  than 
half  of  the  volume.  It  evidences  on  the  part  of  the  author 
not  only  a  practical  knowledge,  derived  from  long  experi- 
ence, of  this  most  difficult  subject,  but  also  an  unusually  ex- 
tensive acquaintance  with  the  literature.  Dr.  Whittaker  is 
well  known  as  a  clear  and  direct  writer,  and  he  has  put  his 
best  work  into  this  treatise.  \Ve  can  recall  no  monograph 
on  cardiac  affections  since  the  appearance  of  Fothergill's 
classic  which  has  presented  the  subject  in  a  clearer  light  and 
in  a  more  instructive  manner  than  this.  The  only  fault  we 
have  to  find  is  the  absence  of  a  bibliography  such  as  is  usual 
in  encyclopaedic  articles.  However,  the  treatise  itself  is  such 
a  finished  product  that  the  reader  hardly  feels  the  need  of 
references  to  other  wof4cs. 

The  second  article,  of  equal  merit,  though  naturally  not 
of  equal  length,  is  one  on  diseases  of  the  blood-vessels, 
written  by  the  leading  English  authority  on  the  subject,  Dr. 
Ernest  Sansom,  of  London.  The  interesting  and  important 
topics  of  atheroma,  arteriosclerosis,  and  aneurysm  are  here 
presented  in  a  way  that  leaves  nothing  to  be  desired.  The 
section  on  diseases  of  the  veins  is  also  deserving  of  special 
mention. 

Dr.  Bertrand  Dawson,  also  of  London,  is  the  autlior  of  a 
comparatively  brief  article  on  diseases  of  the  lymphatic  ves- 
sels. We  do  not  know  this  writer,  whose  reputation  on  this 
side  of  the  water  is  not  as  great  as  that  of  the  other  con- 
tributors to  the  volume.  His  article,  however,  is  a  good 
one,  and  a  perusal  of  it  forces  us  to  admit  that  the  editor  has 
made  a  wise  selection  in  securing  Dr.  Dawson  as  one  of  the 
collaborators. 

The  closing  article  of  the  volume  is  one  on  diseases  of  the 
thyroid  gland,  written  by  Dr.  George  R.  Murray,  of  New- 
castle-on-Tyne.  The  author  includes  among  his  subjects, 
in  addition  to  myxoedema,  cretinism,  and  goitre,  exophthal- 
mic goitre,  which  he  regards  as  essentially  an  affection  of 
the  thyroid  gland.  The  neurologists  will  probably  dispute 
this  point  with  him,  but  we  must  confess  that  he  advances  a 
goodly  array  of  arguments  in  defence  of  his  position.  The 
most  interesting  section,  by  far.  of  this  article  is,  however, 
that  on  mj-xoedema.  of  which  Dr.  Murray  has  the  right  to 
speak  with  authority,  since  it  is  to  him  that  we  owe  the  suc- 
cessful treatment  by  means  of  thyroid  extract.  The  article 
has  the  freshness  characteristic  of  all  writings  in  which  origi- 
nal discoveries  are  described  at  first  hand.  The  illustra- 
tions showing  the  results  of  treatment  in  some  of  Dr.  Mur- 
ray's early  cases  are  striking  witnesses  to  the  efficacy  of 
thyroid  extract  in  this  disfiguring  disease. 

Analele  Institului  de  Patologie  si  de  Bacteriol- 
OGiE  din  Blcakesti.  \'ictor  Babes.  Profesor  la  Fac- 
ultatea  de  Medicina  Bucuresci.  1S94. 
This  work,  published  in  the  two  languages,  Roumanian  and 
French,  gives  the  results  of  pathological  and  bacteriological 
work  done  in  the  Bucliarest  Institute.  It  is  the  fourth  vol- 
ume of  the  series  of  such  reports.  There  are  a  number  of 
colored  plates  dealing  with  bacteriological  subjects. 

The   Pathology  and  Treatment  of  ^'ENEREAL  Dis- 
ease?.   By  Robert  W.  Taylor,  M.D.,  Clinical  Profes- 
sor of  \'enereal  Diseases  at  the  College  of  Physicians  and 
Surgeons  (Columbia   College),   New  York:    Surgeon    to 
Bellevue  Hospital,  and  Consulting  Surgeon  to  City  (Cliar- 
ity)  Hospital,  New  York.     With  Two  Hundred  and  Thirty 
Illustrations  and  Seven  Colored    Plates.     Philadelphia  : 
Lea  Brothers  S:  Co.     1895. 
A  work  upon  a  subject  of  this  kind  must  of  necessity  lose 
something  when  the  responsibility  for  the  views  contained  is 
shared  by  two  authors. 

Dr.  Taylor  is,  therefore,  to  be  congratulated  upon  being 
the  author  of  his  own  book,  and  it  appears  that  this  is  all 
his  own,  with  the  exception  of  a  chapter  upon  syphilis  of  the 
eye,  which  was  originally  written  by  the  late  Dr.  Loring  for 
Bumstead's  work,  and  the  chapter  on  syphilis  of  the  ear, 
which   is   credited   in   the   preface   to  Dr.  J.  A.  Andrews. 


While  based  upon  "  Bumstead  and  Taylor"  this  can  in 
nowise  be  regarded  as  a  revision  or  reproduction,  but  is  a 
new  work  stamped  throughout  with  the  author's  individual- 
ity, though  here  and  there,  notably  in  the  chapter  upon  af- 
fections of  the  nervous  system,  portions  have  been  retained 
which  are  as  true  and  appropriate  to-day  as  when  they  were 
written  for  the  older  joint  treatise.  Many  changes  have  oc- 
curred since  their  collaboration,  and  the  advances  in  knowl- 
edge, whether  due  to  modem  discoveries,  bacteriological 
investigations,  improved  surgical  methods,  or  newer  and 
better  modes  of  treatment  find  an  adequate  reflection  in 
these  pages. 

It  is  not  a  work  to  be  taken  up  lightly.  Indeed  its  weight 
is  the  first  thing  that  strikes  one  who  has  been  in  the  habit 
of  reaching  down  his  well-worn  copy  of  Bumstead  and  Tay- 
lor. He  finds  1,000  pages  instead  of  S35,  but  not  so  many 
more  words  to  the  page,  whose  space  is  freely  encroached 
upon  by  pictures  ;  hence  it  must  be  the  added  weight  of 
the  words  themselves. 

The  illustrations,  while  lending  beaut>-  and  attractiveness, 
and  proving  the  advance  which  has  been  made  in  this  direc- 
tion since  1S79,  may  carry  with  them,  too,  a  certain  weight. 
Not  only  are  the  plates  numerous,  but  many  of  them  are 
excellent,  especially  some  of  the  colored  drawings,  and 
those  showing  palmar  lesions ;  while  that  on  page  60S,  a  re- 
production from  the  plate  illustrating  the  author's  article  in 
the  Cutaneous  and  Genito-Urinary  Journal  of  1890,  fails  to 
give  any  clear  idea  of  the  condition  present.  It  is  impossible 
within  our  limits  to  discuss  the  author's  views  upon  the 
leading  unsettled  questions  in  venereal  diseases.  We  can 
only  say  that  he  has  stated  them  clearly  and  unequivocally, 
whUe  giving  at  the  same  time  the  opinions  of  those  who  dif- 
fer with  him. 

The  work  is  one  which  reflects  much  credit  upon  its  au- 
thor. 

A  Plea  for  a  Simpler  Life.  By  George  S.  Keith, 
M.D.,  F.R.C.P.E.  London:  Adam  &  Charles  Black. 
1895. 

After  fifty-five  years  a  physician,  and  once  associated  with 
Sir  James  Simpson  in  practice,  the  author  now  points  out 
some  of  the  evils  which  have  afllected  medicine  during  the 
present  century. 

Though  most  readers  of  this  little  book  may  not  agree 
with  all  of  the  author's  views,  still  no  one  can  be  harmed 
by  reading  it,  and  if  the  advice  is  followed  to  give  less 
medicine  and  pay  more  attention  to  diet,  their  patients  will 
undoubtedly  be  the  gainers.  Americans,  however,  need 
such  advice  perhaps  less  than  their  English  cousins. 

Atlas  of  the  Diseases  of  the  Skin.    In  a  Series  of  illus- 
trations from  the  Original  Drawings,  with  Descriptive  Let- 
terpress.   By  H.  Radcliffe  Crocker,  M.D.,  F.R.C.P.; 
Fasciculus  XII.     Edinburgh  and  London  :  Young  J.  Pent- 
land.     New  York  :   Macmillan  &  Co. 
The  subject  of  purpuric  erythema  is  illustrated  by  a  figure 
of  peliosis  rheumatica,  and  one  of  erythema  haemorrhagi- 
cum,  both  excellent,  one  showing  the  arm,  the  other  the 
leg.     "£czema"has  three  figures:  one  of  E.  pustulosum 
with  crusts  over  a  man's  face  ;  one  of  E.  urbrum  of  the  leg, 
designated  as  scrofulosorum  ;  and  a  small  figure  represent- 
ing the  early  stage  of  Paget's  disease  of  the  nipple. 

Psoriasis  follicularis  occupies  the  whole  of  the  next  plate 
in  a  striking  figure,  in  which  follicular  elements  scattered 
here  and  there  are  almost  overshadowed  by  circinate  and 
gyrate  forms.  Under  "  Telangiectoses"  there  are  two  in- 
teresting representations  of  rather  rare  conditions  ;  one  the 
telangiectic  form  of  erythematous  lupus  upon  the  checks  ; 
the  second  figure  showing  small  multiple  telangiectoses 
scattered  over  a  girl's  face. 

In  the  text,  wliich  usually  contains  an  account  of  the  case 
from  which  the  portrait  was  made,  it  states  that  electrolysis 
is  the  proper  treatment,  but  that  "  the  patient  was  too 
young  for  electrolysis  to  be  attempted,"  patient  then  be- 
ing seven  years  of  age.  The  writer  would  state  that  he  has 
repeatedly  operated  by  this  method  upon  multiple  telan- 
giectoses in  youthful  subjects  as  well  as  upon  various  forms 
of  naevi  in  infancy,  and  knows  of  no  contra-indication. 

Fibroma  and  F.  pendulum  have  characteristic  pictures 
calculated  to  cause  a  layman  to  exclaim  "  How  terrible  !  " 
Adenoma  sebaceum,  a  rare  condition,  which  Rayer  called 
Vegetations  vasculaircs  and  X'idal  designated  as  Navi  vas- 
culaires  et papillaires,  is  shown  occupying  its  characteristic 
location,  the  central  portion  of  the  face.  Fig.  z  shows  a 
follicular  fibroma  of  the  back  from  the  same  patient.  The 
present  fasciculus  is  quite  up  to  the  standard  of  those  pre- 
viously received  and  mentioned  in  these  columns. 


8i4 


MEDICAL   RECORD. 


[December  7,  i* 


Physical,  Intellectual,  and  Moral  Advantages  of 
Chastity.  By  M.  L.  Holbrook,  M.D.,  Editor  of  77/1? 
Journal  of  Hygiene  and  Herald  of  Health,  etc.  New  York  : 
M.  L.  Holbrook-  &  Co.     London  :   L.  M.  Fowler  &  Co. 

The  author  believes  such  books  will  eventually  do  for  purity 
what  works  on  agriculture  are  doing  for  fanning  interests, 
etc.  "What  I  Know  About  Farming"  once  did  much  to- 
ward adding  to  the  attractions  of  life,  and  made  one  more 
resigned  to  struggle  on.  What  the  author  knows  about 
chastity  may  not  produce  such  results.  What  "  he  most 
desires,"  as  he  says  in  his  preface,  is  to  inspire  "  especially 
the  young,"  etc.  In  our  opinion  parents  had  better  read 
the  book  carefully  before  entrusting  it  to  the  son  or  daughter 
for  their  sexual  education.  There  are  many  truths  in  the 
book,  and  they  are  often  told  openly  and  plainly. 

Anatomy  of  the  Human  Head  and  Neck.  Graphically 
illustrated  and  Described  by  Dr.  Schmidt.  Revised  and 
Edited  by  William  S.  Furneaux,  Author  of  "  Animal 
Physiology,"  "The  Outer  World,"  etc.  New  York: 
Thomas  Whittaker. 

Model  of  superimposed  parts,  giving  to  the  young  an  ex- 
cellent idea  of  anatomy.  It  might  be  used  to  advantage  by 
the  first-year  inedical  student  for  reference  and  ready  re- 
minder. 

Whittaker's  Anatomical  Model.  A  Pictorial  Repre- 
sentation of  the  Human  Frame  and  its  Organs.  With  De- 
scriptive Text  by  Dr.  Schmidt.  English  Edition,  by 
William  S.  Furneaux.   New  York  :  Thomas  Whittaker. 

This  is  intended  for  school  children,  to  take  the  place  of 
plaster  models.  Children  old  enough  not  to  tear  out  the 
viscera  might  profit.  There  is  not  sufficient  scientific  ac- 
curacy and  detail  for  medical  students  at  all  advanced. 
The  descriptive  text  is  very  simple. 

A  Hand-book  of  Medical  Diagnosis  for  Students. 
By  James  B.  Herrick,  A.B.,  M.D.,  Adjunct  Professor 
of  Medicine,  Rush  Medical  College  ;  Professor  of  Medi- 
cine, Northwestern  University  Woman's  Medical  School  ; 
Attending  Physician  to  Cook  County  Hospital  ;  Assistant 
Attending  Physician  to  Presbyterian  Hospital,  Chicago. 
Philadelphia  :  Lea  Brothers  &  Co.     1895. 

This  is  a  very  well  arranged  guide  to  diagnosis,  and  one 
that  ought  to  be  of  great  assistance  to  the  advanced  student, 
for  whom  it  is  primarily  intended,  or  to  the  young  practi- 
tioner when  confronted  with  a  puzzling  case.  The  author 
deals  with  all  the  aids  to  diagnosis — chemical,  microscopical, 
and  physical — and  illustrates  his  work  with  excellent  cuts. 
There  are  two  colored  plates  of  the  blood  in  malarial  and 
other  diseases. 

Rapport  et  Memoires  sur  l'Education  des  Enfants 

NORMAUX    et   ANORMAUX.      Par    DOCTEUR    E.    SEGUIN. 

Preface  par  BouRNEVlLLE,  Medecin  de  la  Section  des 
Enfants  de  Bicetre.  Paris  :  Bureaux  du  Progres  Mddical. 
1895. 

Dr.  Seguin's  well-known  book  appears  in  French  transla- 
tion as  the  third  volume  of  the  Bibliothique  d'Jiilucation 
specialc,  in  the  hope  that  its  valuable  precepts  and  elabo- 
rated principles,  so  successful  in  the  education  of  idiots  and 
deaf-mutes,  may  be  brought  to  the  careful  consideration 
of  directors  of  schools  and  of  teachers,  and  thus  in  time  be- 
come also  the  privilege  of  ordinary  normal  children.  In  the 
preface  is  the  certificate  of  Esquirol  and  Guervant  as  to  Se- 
guin's great  success  in  a  case  observed  by  them  ;  and  also 
an  account  of  the  lamented  author's  death  in  1880,  and  the 
speeches  made  at  his  funeral  by  Brockett,  Wilbur,  Brown, 
and  Marion  Sims. 

The  book  is  divided  into  four  parts.  The  first  treats  of 
the  education  of  the  child  during  its  nursery  years  ;  the 
Salles  d'Asile,  or  school,  where  poor  children  from  the  age 
of  three  to  six  or  seven  acquire  ordinary  knowledge  ;  the 
Jardins  des  Enfants,  or  kindergartens  ;  and  education  in 
the  Physiological  School  for  children.  A  most  interesting 
and  instructive  chapter  is  devoted  to  the  education  of  hand, 
eye,  ear,  muscles,  touch,  taste,  etc.,  according  to  tlie  well- 
known  principle,  "  There  is  nothing  in  the  mind  that  was 
not  first  in  the  senses."  Toys  and  object-lessons  are  of 
great  importance  in  physiological  education.  What  normal 
children  do  spontaneously  is  an  indication  of  how  they  may 
be  led  into  knowledge.  To  learn  through  doing  is  their 
natural  method  of  mental  development.  Destruction  of 
toys,  etc.,  has  a  meaning  other  than  wilfulness  ;  it  comes 
from  a  desire  for  knowledge,  just  as  the  apparently  senseless 
proceeding  common  to  infants  of  touching  all  objects  with 


the  tongue  is  the  first  effort  toward  an  acquaintance  with 
the  outside  world.  Part  II.  treats  of  the  education  of 
deaf-mutes  in  different  parts  of  the  world,  and  of  the  good 
Abbe  de  I'Epee,  who,  when  sixty  years  old,  opened  a  school 
in  1770,  to  teach  deaf-mutes  to  hear  with  their  eyes  and 
speak  out  loud.  In  Part  III.,  methods  and  schools  for 
the  instruction  of  idiots  in  different  civilized  countries  are 
described  and  fully  explained.  Then,  in  Part  IV.,  popu- 
lar education  as  usually  carried  on  is  critically  reviewed  and 
the  philosophic  author's  own  principles  of  general  education 
given  with  force  and  convincing  logic.  Two  memoirs'  close 
the  book  :  one,  on  the  psycho-physiological  training  of  the 
idiot  eye  ;  and  the  other  on  the  psycho-physiological  educa- 
tion of  the  idiot  hand,  both  illustrating  a  system  of  human 
development  that  Seguin  was  first  to  put  into  actual  practice 
and  publish  to  the  world.  It  must  never  be  forgotten  that 
the  late  Dr.  Seguin  passed  the  richest  and  ripest  years  of 
his  life  and  labors  in  the  L'nitcd  States,  and  that  America 
shares  with  France  the  honor  of  appreciating  him  while  he 
lived.  In  any  language  and  any  country,  whatever  he  has 
written  must,  of  necessity,  retain  its  original  and  perma- 
nent value. 

Pregnancy,  Labor,  and  the  Puerperal  State.  By 
Egbert  H.  Grandin,  M.D.,  Consulting  Obstetric  Sur- 
geon to  the  New  York  Maternity  Hospital  ;  Consulting 
Gynecologist  to  the  French  Hospital,  etc.  ;  and  George 
W.  J.A.RMAN,  M.D.,  Obstetric  Surgeon  to  the  New  York 
Maternity  Hospital  ;  Gynecologist  to  the  Cancer  Hospi- 
tal, etc.  Illustrated  witl'  Forty-one  Photographic  Plates, 
pp.  261.  Philadelphia  :  The  F.  A.  Davis  Company. 
London  :  F.  J.  Rebman.     1895. 

The  favorable  reception  accorded  to  the  previous  volume 
on  obstetric  surgery  by  the  same  authors  would  alone  insure 
a  similar  one  for  its  companion.  When  the  two  are  pub- 
lished together,  which  we  understand  is  the  intention,  the 
present  monograph  will  form  the  first  part  of  a  work  on  ob- 
stetrics. 

The  subjects  discussed,  though  less  attractive  to  many 
readers  than  those  treated  so  ably  in  the  "  Obstetric  Sur- 
gery," are  nevertheless  set  forth  in  a  thoroughly  practical 
as  well  as  pleasing  manner.  The  history  of  successful  books 
in  this  age  of  competition,  whether  in  fiction  or  in  science, 
proves  that  it  is  not  so  much  originality  which  wins  many 
readers  as  it  is  the  presentation  of  familiar  facts  in  a  fresh 
and  attractive  form.  This  the  authors  have  succeeded  in 
doing  even  when  dealing  with  apparently  outworn  themes. 
The  central  idea  of  their  former  work — facts  as  opposed  to 
themes — is  kept  steadily  in  view  throughout.  For  example, 
every  medical  student  can  rattle  off  glibly  the  signs  and 
symptoms  of  normal  cregnancy,  but  only  the  mature  ac- 
coucheur realizes  how  often  "  all  signs  fail."  In  Chapter  I, 
attention  is  called  to  numerous  minor  points,  which  are  sel- 
dom or  never  referred  to  in  ths  text -books,  and  yet  are  of 
vital  importance  at  the  bedside.  The  anomalies  of  men- 
struation, foetal  movements  as  felt  by  the  examiner,  soften- 
ing of  the  entire  cervix,  rather  than  the  tip  alone,  and  other 
practical  hints  will  be  noted.  The  short  section  on  the  care 
of  pregnant  women  (pp.  27  to  31)  is  replete  with  sensible 
advice.  Chapter  II.  is  devoted  to  a  comprehensive  review 
of  the  pathology  of  pregnancy,  the  introductory  section  on 
the  pernicious  vomiting  of  pregnancy  being  especially  help- 
ful. Chapter  III.,  on  obstetric  palpation,  pelvimetry,  etc., 
is  richly  illustrated  and  contains  a  large  amount  of  useful 
information  condensed  within  a  few  pages. 

Part  II.  is  devoted  to  labor  and  includes  four  chapters  on 
the  mechanism  and  clinical  course  of  labor,  the  manage- 
ment of  normal  and  abnormal  labor,  and  the  care  of  the 
new-born.  The  general  practitioner  will  find  the  third 
chapter  of  great  value,  since  it  is  filled  with  hints  which 
represent  the  results  of  years  of  experience  in  the  lying-in 
chamber.  As  an  example  of  its  judicious  teaching  reference 
may  be  made  to  the  use  of  ergot  after  delivery  (pp.  161 ,  162), 
and  of  chloroform  during  labor  (pp.  144,  145).  The  details 
of  the  first  examination  of  the  parturient  are  presented  most 
happily  in  the  same  chapter.  The  concluding  chapters  on 
the  normal  and  p.itliologic.al  puerperium  are  most  com- 
mend.able.  It  is  impossible  in  the  brief  space  allowed  to 
us  to  call  attention  to  all  their  excellent  points.  The  reader 
will  note  as  especially  good  in  Chapter  I.  the  remarks  on 
nursing  (p.  211),  and  on  artificial  feeding.  In  Chapter  II. 
the  etiology  of  puerperal  septicaemia  is  discussed  at  length 
in  the  light  of  recent  bacteriological  investigations.  The 
symptoms  are  graphically  set  forth,  and  the  remarks  on 
diagnosis  (pp.  236,  237)  are  clear  and  practical.  The  con- 
cluding section  on  mastitis  is  brief,  but  full  of  useful  sug- 
gestions. 


i 


December  7,    1S95] 


MEDICAL   RECORD. 


815 


One  of  the  most  prominent  features  of  the  book  is  the 
number  of  plates,  especially  those  illustrating  the  mana<re- 
ment  of  labor.  This  is  a  favorite  method  of  supplementtnc 
medical  teaching  at  the  present  day,  and  whatever  criti° 
cisms  may  be  urged  against  it  on  the  ground  of  proprietv, 
It  cannot  be  denied  that  a  single  photograph  showing  ex- 
actly hoiv  a  thing  is  done  is  worth  pages  of  description 
They  certamly  add  to  the  value  of  the  present  volume,  es- 
pecially with  the  class  of  readers  for  whom  it  is  intended. 
The  favorable  criticisms  applied  to  the  literary  stvle,  ar- 
rangement of  the  subject-matter,  and  the  general  make-up 
of  the  '•  Obstetric  Surgery"  can  only  be  repeated,  and  wc 
prophesy  for  it  an  equal  success. 


^ocictu  2>cports. 

:\[EDICAL  AXD  CHIRURGICAL  F.A.CULTY  OF 
THE   STATE    OF    MARYLAND. 

Semi- Annual  Meeting,  held  at  Belaire,  Md.,  November 
ig  and  20,  iSgj. 

The  meeting  was  called  to  order  with  Dr.  C.  Birnie, 
Vice-President,  in  the  chair,  and  Dr.  A.  K.  Bond! 
Secretary.  The  Society  was  welcomed  by  Hon.  Walter 
Preston,  of  the  Belair  bar,  and  Dr.  W.  L.  Smith,  of 
Jarretsville,  President  of  the  Harford  County  Medical 
Association,  and  was  responded  to  by  Dr.  C   Birnie 

The  Surgical  Treatment  of  Laryngeal  Tuberculosis.— 
This  was  the  subject  of  remarks  by  Dr.  John  N.  Mac- 
kenzie, of  Baltimore.  He  referred  to  the  papers  read 
before  the  American  Laryngological  and  British  Laryn- 
gological  Societies  on  this  subject.  Krause,  of  Berlin, 
and  Hering,  of  Warsaw,  had  done  the  best  work  on 
this  subject.  The  surgical  treatment  of  tuberculosis  of 
the  laryn.x  is  carried  out  by  total  and  by  partial  curette- 
ment  of  the  lesions,  with  the  application  of  lactic  acid. 
Usually  the  tissues  are  first  curetted  out  with  specially 
prepared  instruments,  and  then  the  acid  is  rubbed  in. 
The  Germans  use  a  fifty  per  cent,  solution  of  lactic 
acid,  while  others  use  it  pure,  and  some  operators  rub 
the  acid  in  without  curetting,  provided  ulcerations 
exist,  for  the  acid  will  not  go  through  the  intact 
mucous  membrane.  The  tissues  may  also  be  injected 
with  a  solution  of  the  acid.  The  results  of  this  treat- 
ment by  curetting  and  lactic  acid  are  wonderful.  The 
ulcers  may  heal  even  when  the  lungs  are  far  gone. 
When  the  infiltration  is  circumscribed  and  in  the  epi- 
glottis, portions  of  the  tissue  may  be  e.xcised.  The 
subsequent  treatment  is  to  paint  the  surface  with  pyok- 
tanin,  or  lactic  acid  may  be  used.  Sometimes  the 
whole  diseased  area  is  not  easy  to  get  at.  These 
wounds  generally  heal  very  well.  Sometimes  there  is 
hemorrhage,  but  this  may  be  stopped  by  application  of 
equal  parts  of  lactic  acid  and  perchloride  of  iron. 
Some  operators  use  the  scissors  to  cut  off  the  diseased 
part  when  this  is  possible,  and  some  use  the  electroly- 
sis, putting  one  pole  in  the  lesion  and  the  other  on  the 
neck.  The  galvano-cautery  is  also  used.  In  stenosis 
intubation  has  been  suggested,  and  tracheotomy  is  a 
last  resort  in  some  conditions,  but  this  is  only  justifiable 
to  prevent  suffocation.  Thyrotomy  has  been  practised 
under  some  circumstances,  and  even  it  has  been  pro- 
posed to  extirpate  the  whole  organ.  As  the  disease  is 
rarely  primary  in  the  larynx  (only  about  five  cases 
having  been  reported)  this  operation  is  not  advisable. 
Such  cases  usually  die.  Most  observers  agree  that  the 
effect  of  this  treatment  is  beneficial  to  the  lung  disease, 
and  a  few  have  the  opposite  view,  but  it  seems  rational 
that  it  must  do  good.  It  does  not  effect  a  cure,  but  it 
does  prolong  life.  Relapses  occur.  In  hectic  fever, 
and  when  the  disease  is  diffuse,  this  operation  is  contra- 
indicated. 

Dr.  William  B.  Canfield  thought  these  facts  very 
interesting  for  the  specialist  and  general  practitioner. 


He  would  like  to  know  something  of  the  technique  of 
these  operations.  How  strong  was  the  cocaine  solution 
used  before  curetting  and  how  applied? 

Dr.  Mackenzie  said  this  was  very  simple.  The 
cocaine  was  in  ten  to  twenty  per  cent,  solution,  and 
the  pyoktanin  used  was  a  two  per  cent,  solution. 
Special  instruments  had  been  devised  by  Hering,  of 
Warsaw,  and  he  had  sent  for  some,  but  the  cureuing 
and  application  of  the  lactic  acid  was  not  difficult. 

Management  of  Advancing  Corneal  Ulceration  in 
GonorrhcBal  Ophthalmia.— This  was  the  subject  of  a 
paper  by  Dr.  Hiram  Woods,  of  Baltimore.  The  dan- 
ger in  this  disease  lies  in  the  involvement  of  the  cornea, 
and  this  danger  is  in  proportion  to  the  extent  of  the 
inflammation  in  the  ocular  membrane,  and  is  greater 
the  earlier  the  cornea  is  affected.  Corneal  trouble 
may  come  from — r,  interference  with  the  circulation  ; 
2,  direct  infection  ;  and  3,  ])ressure  on  the  cornea 
from  pus  or  the  swollen  eyelids.  The  latter  is  most 
usually  met  with.  The  pus  must  be  let  out.  To  pre- 
vent infiltration  use  leeches,  cold,  and  scarification. 
Nitrate  of  silver  may  also  be  used  in  the  strength  of 
ten  grains  to  the  ounce.  This  should  be  applied  very 
thoroughly.  The  crayon-stick  may  be  applied  once  in 
twenty  four  hours.  Dr.  Woods  said  further  that  just 
as  most  of  the  curable  cases  of  blennorrhoea  yielded  to 
the  two  per  cent,  silver  solution,  so  most  of  the  man- 
ageable cases  of  corneal  complications  are  amenable  to 
milder  methods  than  cauterization.  At  the  other  ex- 
treme stand  cases  hopeless  from  the  beginning.  A 
small  area  of  infection  rapidly  destroys  the  weakened 
cornea.  Efforts  to  stop  its  progress,  successful  usually 
in  primary  infection,  not  only  fail,  but  seem  harmful. 
Probably  defective  vascular  supply  is  the  trouble.  Be- 
tween the  two  there  is  a  third  class,  to  which  the  cases 
he  related  belong.  The  presence  of  purulent  inflam- 
mation demands  something  more  than  corneal  disin- 
fection. 

Tears  of  the  Cervix  Uteri ;  their  Significance  and 
Repair. — This  was  the  subject  of  a  paper  by  Dr.  J.  M. 
Hundley,  of  Baltimore.  He  thought  surgeons  were 
too  ready  to  repair  torn  cervices  when  often  the  mere 
suturing  of  the  laceration  was  not  so  much  needed  as 
strong  tonics  and  attention  to  the  general  health.  He 
recited  cases  tending  to  show  that  the  cervix  had  been 
sewed  up  too  tight,  and  related  other  cases  showing 
that  the  cervix  would  often  heal  kindly  after  a  difficult 
birth,  even  when  it  was  badly  torn,  without  operative 
interference.  He  thought  it  was  meddlesome  surgery 
to  be  too  ready  to  operate  on  every  little  tear,  and  to 
attribute  every  kind  of  ill  feeling  a  woman  had  to  a 
small  tear  in  the  cervix.  These  tears  came  most 
usually  from  the  use  of  the  forceps,  and  were  at  times 
not  to  be  prevented. 

Dr.  John  Morris,  of  Baltimore,  said  this  was  a 
most  sensible  and  practical  paper.  He  had  had  a  large 
number  of  labor  cases  in  his  professional  life,  and  many 
times  he  had  applied  the  forceps,  and  he  endorsed  Dr. 
Hundley's  remarks  thoroughly.  Too  often  such  inter- 
ference is  meddlesome. 

Dr.  a.  K.  Bond,  of  Baltimore,  had  delivered  a 
woman  in  whom  he  had  found  a  dense  band  of  tissue 
across  the  cervix,  and  when  he  examined  it  he  found 
it  was  the  result  of  suturing  an  old  tear,  the  stitches 
having  been  put  through  the  canal.  He  cut  this 
fibrous,  cicatricial  band  and  the  labor  proceeded  with- 
out complication.  He  related  a  case  of  lacerated  cer- 
vix where  the  tear  was  constantly  sujipurating  and  at 
the  birth  of  a  child  its  eyes  became  infected  with  this 
matter.  He  asked  what  was  the  connection  between  a 
lacerated  cervix  and  defective  lactation. 

Dk.  John  Neff,  of  Baltimore,  related  several  cases 
of  difficult  labor  which  he  delivered  after  great  trouble, 
and  in  which  a  laceration  healed  without  operation 
and  one  in  which  pregnancy  followed. 

Dr.  \\'oods  said  that  because  a  new-born  infant  had 
ophthalmia,  it  did  not  follow  that  the  mother  had  had 


8i6 


MEDICAL    RECORD. 


[December  7,  1895 


gonorrhoea.  It  might  be  a  non-specific  ophthalmia 
which  usually  gets  well  with  little  or  no  trouble.  In  the 
cases  related  by  Dr.  Bond,  Dr.  Woods  thought  that  the 
child  might  have  had  inherited  syphilis  or  some  post- 
partum affection  not  from  the  mother. 

Dr.  Bond  said  he  had  eliminated  both  of  these 
sources. 

Dr.  Morris  said  he  thought  Dr.  Bond's  ideas  were 
heretical.  He  thought  some  other  trouble  must  have 
affected  the  infant's  eyes  than  the  mere  lacerated  cervix. 

An  Epidemic  of  Typhoid  Among  Children. — This  was 
the  subject  of  a  paper  by  Dr.  A.  K.  Bond,  of  Balti- 
more. These  cases  he  had  seen  in  an  institution  for 
destitute  children,  and  the  ages  were  from  seven  to 
nineteen.  There  were  twelve  cases  in  all.  The  fever 
lasted  longer  in  the  younger  children,  and  the  tempera- 
ture was  also  higher.  There  were  usually  headache 
but  no  delirium  worth  mentioning.  There  were  some 
nervous  symptoms  noticed  in  some  of  the  patients  ; 
one  was  slightly  deaf  for  a  few  days  and  several  had 
nosebleed.  Rose  spots  were  observed  in  all  but  three 
cases.  There  was  no  marked  tympanites  in  any  case, 
and  only  slight  iliac  gurgling.  The  bowels  were 
neither  markedly  loose  nor  costive,  and  in  only  a  few  in- 
stances were  the  characteristic  t}'phoid  stools  observed. 
The  spleen  was  enlarged  in  one  case,  and  in  one  case 
there  was  albuminuria  for  a  few  days.  No  casts  were 
found.  In  all  but  two  cases  there  was  considerable 
catarrh  of  the  lungs.  In  all  these  cases  the  tongue 
was  coated,  but  the  hard,  dry  character  as  seen  in  adults 
was  not  observed  here.  There  was  not  much  emacia- 
tion. In  one  case  there  was  gangrene  of  the  mouth. 
The  treatment  was  begun  with  thorough  purging  with 
castor-oil  and  calomel.  The  sweet  spirit  of  nitre  and 
sponging  was  used,  and  in  two  cases  baths  and  douches 
were  tried,  but  they  were  given  up  later.  The  nour- 
ishment was  looked  after  very  carefully ;  a  cupful  of 
milk  was  given  every  two  or  three  hours  in  the  day,  and 
through  the  night  when  necessary,  and  in  some  cases 
pepsin  was  also  given.  Small  doses  of  Epsom  salt, 
from  a  half  drachm  to  a  drachm,  were  given  during 
the  illness  to  keep  the  bowels  clean.  It  is  not  easy  to 
trace  the  cause  of  epidemics  in  a  city.  There  were  two 
buildings,  both  having  the  same  water  and  milk-supply, 
and  nothing  could  be  proved  on  either.  The  follow- 
ing conclusions  were  drawn  from  a  study  of  these 
cases':  i.  That  children  often  bear  high  temperatures 
well  in  typhoid  fever.  2.  That  bathing  (in  full  bath) 
should  be  very  judiciously  applied,  if  at  all.  3.  That 
the  disease  in  children  under- five  years  of  age  may  eas- 
ily be  mistaken  for  other  digestive  disorders  or  for 
bronchitis.  4.  That  albuminuria  coming  on  during 
the  fever  does  not  necessarily  lessen  the  chances  of  a 
favorable  issue.  5.  That  gangrene  of  the  mouth,  if 
superficial,  may  sometimes  be  cured  by  permanganate 
of  potassium  lotions.  6.  That  careful  consideration 
should  be  given  to  the  furtherance  of  digestion,  as 
by  the  use  of  pepsin  and  acid  ;  and  also  to  the  pre- 
vention of  the  accumulation  of  unwholesome  or  hard- 
ened faeces  in  the  intestines,  as  by  the  systematic  and 
judicious  employment  of  Epsom  salt  in  the  manner 
above  indicated. 

Dr.  J.  W.  Scott,  of  Belair,  asked  why  Dr.  Bond  pre- 
ferred Epsom  salt  to  calomel. 

Dr.  William  Les  spoke  of  the  atypical  cases  occur- 
ring in  children,  and  quoted  authorities  on  the  subject. 

Dr.  Charles  Bag  lev,  of  Bagley,  thought  that  Ep- 
som salt  was  a  very  important  part  of  the  treatment. 
Active  purgation  might  cause  hemorrhage,  and  that 
should  be  considered  before  strong  cathartics  were 
given. 

Dr.  Bond  said,  in  reply  to  Dr.  Scott,  that  he  gave  the 
Epsom  salt  because  he  did  not  wish  to  salivate  with 
calomel,  and  he  thought  the  salt  was  a  belter  purgative 
in  these  cases. 

Dr.  James  A.  Steuart,  Secretary  of  the  State  Board 
of  Health,  said  that  it  was  difficult  to  trace  these  cases 


and  the  cause  of  the  disease,  and  it  is  hard  to  find  the 
bacillus  in  water,  but  if  the  water  contains  sewage  of 
course  it  is  unfit  to  be  used. 

The  Radical  Cure  of  Ingninal  Hernia  in  a  Child  by 
the  Implantation  of  a  Section  of  Aseptic  Sponge  to  Oc- 
clude the  Internal  Ring. — This  was  the  subject  of  re- 
marks by  Dr.  Walter  B.  Platt,  of  Baltimore,  who 
also  e.\hibited  the  patient.  The  boy  came  to  him 
last  August  with  an  inguinal  hernia  like  an  old  man's. 
He  had  used  different  kinds  of  trusses.  He  was  seven 
years  of  age.  Dr.  Platt  tried  the  worsted  truss,  but 
but  with  no  results.  He  then  decided  to  operate  by  a 
plan  of  which  he  had  never  heard,  though  it  might  not 
be  original.  He  opened  the  inguinal  canal  in  the  usu- 
al way,  reduced  the  hernia,  and  then  he  took  a  small 
piece  of  sponge,  washed  it  thoroughly  and  by  boil- 
ing he  made  it  thoroughly  aseptic,  and  put  it  in 
the  conjoined  ring  and  sewed  it  in  here,  with  the 
idea  of  keeping  the  hernia  in  place  and  having  the 
sponge  organized.  It  is  not  possible  to  speak  of  a  cure 
as  the  operation  has  been  done  only  three  months,  but 
so  far  the  boy  can  run  about  and  play,  and  the  hernia 
stays  up,  and  the  sponge  has  caused  no  disturbance,  so 
it  must  be  organized  by  this  time.  Macewen  says  that 
only  about  forty  per  cent,  of  the  cases  operated  on  in 
the  usual  way  are  cured  after  two  and  half  years.  If 
this  case  turns  out  well  he  shall  treat  all  other  children 
afflicted  with  the  same  kind  of  hernia  in  the  same  way. 
The  idea  is  new  to  him,  and  he  hopes  it  will  be  suc- 
cessful. 

A  Critical  Review  of  Modern  Operations  for  Haemor- 
rhoids.— This  was  the  subject  of  a  paper  by  Dr.  S.  T. 
Earle,  of  Baltimore.  He  briefly  related  the  various 
methods  of  operation  and  then  described  the  modifica- 
tion of  Outerbridge's  operation,  which  he  preferred. 
He  gave  a  demonstration  of  the  clamp  and  manner  of 
suturing,  and  said  it  gave  less  discomfort  than  other 
operations. 

Dr.  C.  M.  Ellis,  of  Elkton,  asked  if  Dr.  Earle  did 
preliminary  dilatation  of  the  stricture  before  operation. 

Dr.  Earle  said  he  rarely  did  this,  for  no  matter  if 
dilatation  was  practised  there  was  always  a  certain 
amount  of  burning  of  the  rectum  after  the  operation 
that  demanded  a  hypodermic  injection  of  morphia,  but 
if  it  is  a  bad  case  with  many  hemorrhoids  he  does  dilate 

A  Case  for  Diagnosis. — Dr.  C.  H.  Hollingsworth, 
of  Belair,  then  presented  a  case  in  which  he  needed 
help.  The  boy  was  seven  years  of  age,  and  was  taken 
sick  about  six  months  ago  with  pleurisy  on  the  left 
side  followed  by  a  pneumonia  of  that  side,  and  then 
that  all  cleared  up  and  there  was  a  pleurisy  of  the  right 
side,  and  that  cleared  up,  and  the  boy  was  going  on 
well  to  recovery  when  he  was  suddenly  taken  with 
severe  pains  in  the  back  of  the  neck  and  had  a  severe 
pain  down  the  back,  and  now  his  head  is  bowed  for- 
ward and  he  cannot  straighten  it ;  he  cannot  put  his 
feet  to  the  ground,  cannot  use  his  hands  very  much,  and 
can  lie  in  the  same  position  but  for  a  few  moments 
only.  His  weight  fell  oft'  at  first,  but  now  he  has  re- 
gained about  three  pounds,  due  to  the  tonic  treatment, 
but  he  seems  to  be  no  better  in  other  respects.  There 
were  hard  nodules  or  lumps  in  the  abdomen  which 
seemed  to  disappear  on  purging.  The  sterno-clavicular 
and  sterno-costal  articulations  are  all  enlarged  and  pain- 
ful. 

Dr.  W.  F.  a.  Kemp,  of  Baltimore,  said  it  was  not 
easy  to  express  an  opinion  from  a  cursory  examination, 
but  he  was  inclined  to  think  it  was  tuberculosis, 
although  the  swollen  articulations  looked  a  little  like  a 
gouty  diathesis.  He  suggested  an  examination  of  the 
urine  microscopically  and  also  of  the  sputum. 

The  Clinical  Course  of  Forty-seven  Cases  of  Com- 
plete Extirpation  of  the  Uterus  for  Carcinoma. — This 
was  the  subject  of  a  paper  by  Dr.  A\'.  W.  Russell,  of 
the  Johns  Hopkins  Hospital,  in  which  he  gave  statis- 
tics on  the  results  of  the  operation  in  these  cases  and 
explained  the  manner  of  operation  and  the  danger  of 


December  7,  1895] 


MEDICAL   RECORD. 


817 


secondary  deposits  depending  on  the  situation  of  the 
primary  lesion.  It  may  pass  from  the  uterus  to  the 
bladder  in  front,  to  the  rectum  behind,  or  even  to  the 
vaginal  mucous  membrane  or  to  the  ovaries,  and  he 
spoke  of  the  results  of  early  operations.  In  answer  to 
Dr.  Kemp,  he  said  that  only  one  case  was  living  forfive 
years  after  operation,  but  that  Boldt  had  reported  a  case 
that  lived  for  seventeen  years  after  total  extirpation  of 
the  uterus  for  carcinoma. 


NEW    YORK    COUNTY    MEDICAL     ASSOCIA- 
TION. 

Stated  Meeting,  November  18,  iSg^. 

Sa.mvel  B.  AV.  McLeod,  M.D.,  Presidext,  ix    the 
Cn.-iiR. 

Some  Eesults  of  Experimentation  with  a  New  Anti- 
septic Fluid. — Dr.  Hi  r.B.\RD  W.  Mitchell  read  a 
paper  with  this  title.  After  giving  an  interesting  and 
rather  full  description  of  his  extensive  experience  with 
the  new  antiseptic  fluid,  he  stated  that  it  was  simply  a 
solution  of  halogen  salts  chemically  combined. 

Dr.  Vox  Doxhoff  asked  what  were  the  ingredients, 
and  as  Dr.  Mitchell's  answer  did  not  appear  to  him  to 
be  sufficiently  specific,  he  asked  if  it  was  a  secret  rem- 
edy, and  Dr.  Hinton  seconded  his  motion  that  the  sub- 
ject be  not  further  discussed  until  the  question  had 
been  answered. 

Dr.  Mitchell  replied  that  he  did  not  remember 
just  the  ingredients,  but  that  the  remedy  was  not  secret, 
and  he  would  hand  the  formula  to  the  President  when 
he  obtained  it  from  the  chemist.  The  therapeutic 
value  of  the  halogen  salts,  he  said,  was  known  to  all. 
Taken  in  nearly  equal  proportion  and  mixed  by  the 
chemist,  there  seemed  to  be  a  rearrangement  of  the 
atoms  of  the  salts  in  the  solution,  and  the  resultant  was 
a  straw-colored  fluid,  acid  reaction,  specific  gravity  of 
about  1.023,  strong  odor  of  chlorine,  slightly  acid  taste. 

About  two  years  ago  a  chemist,  a  friend  of  his,  brought 
him  the  fluid,  which  he  said  was  good  for  almost  every- 
thing, and  among  the  things  which  he  named  specially 
were  ulcerative  and  suppurative  processes,  and  gonor- 
rhoea! and  syphilitic  lesions.  Dr.  Mitchell  first  tried  it 
on  a  large,  broken,  painful  carbuncle  of  the  neck,  and 
by  next  morning  the  inflammation  had  about  half  sub- 
sided, and  by  the  fifth  day  the  patient  was  practically 
well.  He  then  got  permission  of  Dr.  Taylor,  of  the 
Vanderbilt  Clinic,  to  try  it  in  thirty  cases  of  gonorrhoea. 
It  was  difficult  to  apply  the  treatment  in  these  patients 
satisfactorily,  and  the  results  were  hardly  co'inplete,  yet 
in  many  rapid  benefit  had  followed.  He  then,  through 
the  courtesy  of  Dr.  Taylor,  selected  about  thirty-five 
cases  of  lesions  of  syphilis  in  various  stages,  and  of 
chancroid.  In  all  cases,  whether  of  phagedenic  bubo, 
indurated  chancre,  or  other  sore,  the  results  were  ex- 
tremely satisfactory,  the  lesions  healed  without  diffi- 
culty in  a  short  time.  The  same  was  true  of  cases 
seen  in  the  venereal  wards  of  the  City  Hospital,  through 
the  courtesy  of  Dr.  Sturgis  and  Dr.  A.  M.  Phelps. 
The  sores  healed  in  an  unusually  short  time  whenever 
the  treatment  could  be  carried  out.  There  were  about 
twenty  cases  of  chancroid  of  the  vulva,  some  old  syph- 
ilitic lesions  of  the  leg,  gonorrhoea,  etc.  \'aricose 
ulcers  also  did  well,  but  owing  to  their  nature  required 
more  attention.  At  the  suggestion  of  Dr.  Steinach, 
the  fluid  was  injected  from  four  directions  into  a  large 
but  unbroken  bubo,  and  this  dispersed  without  going 
on  to  form  an  ulcer.  Two  or  three  cases  of  extensive 
epithelioma  of  the  face,  extending  down  to  the  bone, 
were  treated,  the  ulcerative  process  was  arrested,  gran- 
ulation took  place,  and  by  further  aid  of  a  plastic 
operation  the  raw  surface  was  nearly  or  quite  covered 
by  the  time  the  patients  left  the  hospital.  Endometritis 
and  ulcerative  tonsillitis  had  likewise  been  treated  suc- 


cessfully, and  even  carcinoma  of  the  cervix  had  disap- 
peared in  one  case  in  which  he  had  tried  the  fluid.  In 
six  cases  of  pulmonary  tuberculosis,  the  diagnosis  be- 
ing based  on  physical  lesions,  presence  of  tubercle 
bacilli,  and  the  usual  symptoms,  the  fluid  was  given  in- 
ternally, drachm  and  a  half  at  a  dose,  three  times  a 
day,  and  in  all  the  subjective  and  physical  symptoms 
disappeared. 

Wherever  possible,  in  external  lesions,  the  parts  were 
bathed  in  the  fluid  once  or  more  a  day,  and  in  addition 
were  kept  wet  by  gauze  or  dressings  dipped  in  the 
fluid.  Its  presence  caused  the  tenaceous  membranes 
on  ulcers  to  dissolve,  and  a  healthy  granulating  surface 
to  spring  up  and  to  rapidly  heal.  In  the  treatment  of 
gonorrhoea  in  women  and  cervical  lesions,  it  was 
poured  in  through  a  rubber  speculum,  and  after  re- 
maining a  few  minutes  was  allowed  to  run  out  ;  more 
was  poured  in,  finally  the  parts  were  cleansed  by  cotton 
probe  and  the  vagina  tamponed  with  gauze  soaked  in 
the  fluid. 

Dr.  C.  J.  MacGuire,  who  had  helped  carry  out  the 
treatment  in  some  of  the  cases  in  the  City  Hospital, 
said  that  in  the  case  of  epitheliomatous  ulcers  of  the 
face  the  fluid  had  the  effect  in  two  months  to  reduce 
the  ulcer  from  a  diameter  of  six  inches  to  an  inch  and 
a  half.     The  patient  then  left  the  hospital. 

Diafi^osis  and  Treatment  of  Gout. — Dr.  L.  F.  Bishop 
read  this  paper.  He  said  :  In  a  previous  paper  we 
dwelt  upon  the  theory  and  distribution  of  gout.  Now 
we  propose  to  study  as  a  more  practical  outcome  the 
means  of  its  recognition  and  the  application  of  a  prop- 
er plan  of  management.  The  diagnosis  divides  itself 
into  that  of  acute  attacks  and  of  the  gouty  habit  or 
constitution.  Acute  gout  arising  for  the  first  time  in  a 
young  person,  is  comparatively  uncommon  in  the  ex- 
perience of  American  practitioners,  therefore  it  might 
easily  be  overlooked.  The  points  to  be  considered  are 
the  time  of  the  attack,  usually  in  the  small  hours  of 
the  night,  the  location  of  the  pain,  usually  in  the 
metatarso-phalangeal  joint  of  the  great  toe.  The  char- 
acter of  the  inflammation  with  its  intense  hypere- 
mia, and,  most  characteristic  of  all,  the  fact  that  the  in- 
flammation is  followed  by  desquamation.  An  acute 
attack  usually  lasts,  with  intermission  during  the  day- 
light hours,  for  from  five  to  eight  days. 

Diagpnosis  of  Suppressed  Gout. — This  is  a  term  ap- 
plied to  a  series  of  symptoms  not  typical  of  gout,  but 
which  occur  in  a  gouty  person,  and  which  from  strong 
negative  and  positive  evidence  we  believe  to  be  gouty 
in  origin.  These  attacks  are  worthy  of  close  study,  be- 
cause they  must  occur  sometimes  in  our  practice  and 
can  so  easily  be  overlooked.  They  may  immediately 
follow  an  attack  of  acute  gout,  or  replace  an  attack. 
The  patient  may  have  severe  vomiting,  pain,  diarrhoea, 
and  profound  depression,  or  there  may  be  cardiac 
trouble  manifested  by  dyspna-a,  irregular  action  of  the 
heart,  and  pain  referred  to  that  organ  or  to  the  left 
shoulder.  We  should  remember  at  all  times  these  at- 
tacks of  suppressed  gout,  because  they  may  occur  inde- 
pendently of  articular  gout.  The  difficulty  of  diagno- 
sis is  great,  but  it  should  be  borne  in  mind  as  the  pos- 
sible cause  of  some  of  the  obscure,  severe,  and  often 
fatal  cardiac  attacks  accompanied  by  extreme  dyspnoea, 
with  failure  of  the  heart's  action  in  force  and  rhythm 
which  we  sometimes  encounter.  These  are  apt  to  be 
uniformly  put  down  to  uraemia,  but  in  the  absence  of 
albumin  and  of  typical  signs  of  kidney  disease,  the 
possible  gouty  factor  should  be  considered. 

The  diagnosis  of  chronic  gout  following  a  series  of 
acute  attacks  is  a  simple  matter  on  account  of  the  char- 
acteristic joint  deformity.  Hospital  reports  in  this 
country  show  a  frequent  diagnosis  of  chronic  diffuse 
nephritis,  and  rarely  that  of  gout.  It  would  seem  that 
many  of  these  cases  were  ])rimarily  a  gouty  sclerosis 
of  the  vessels,  and  that  the  r.ephritis  was  secondary. 
The  distinction  in  mortality  reports  is  not  important, 
but   if   the   lithffimia  could    be   recognized    early    the 


8i8 


MEDICAL   RECORD. 


[December  7,  1S95 


sclerosis  might  be  avoided  with  its  fatal  kidney  com- 
plications. This  involves  the  early  detection  of  the 
gouty  diathesis,  which  is  a  condition  representing  many 
various  pictures.  It  is  perhaps  best  approached  by  a 
consideration  of  some  of  the  more  irregular  manifesta- 
tions. These  may  be  nervous,  gastric,  cutaneous,  pul- 
monary, or  may  affect  the  organs  of  special  sense. 
These  irregular  manifestations  are  as  often  due  to 
hereditary  tendencies  as  to  acquired  gout  ;  hence  we 
see  them  often  in  very  young  persons.  The  gouty  habit 
or  lithic  state  may  even  appear  in  infants. 

Skin  affections  are  among  the  most  frequent  irregu- 
lar manifestations.  Eczema  is  recognized  by  all  as 
such.  Psoriasis  is  believed  by  Dr.  L.  Duncan  Bulkley 
to  be  more  frequently  due  to  this  cause  than  to  any 
other  single  constitutional  vice.  Chronic  bronchitis  is 
frequently  gouty,  and  is  modified  only  by  gouty  manage- 
ment. The  most  serious  manifestation  of  the  gouty 
constitution  is  the  gradual  production  of  sclerosis  of 
the  vessels  and  of  the  valves  of  the  heart.  It  is  in  the 
avoidance  of  this  condition  that  the  early  recognition 
and  management  of  gout  is  most  important.  Gastro- 
intestinal disorders  of  gouty  origin  are  characterized 
by  constipation,  headache,  a  dirty  tongue,  and  the  usual 
S)-mptoms  of  biliousness,  but  with  all  these  symptoms 
exaggerated  and  prolonged.  The  nervous  manifesta- 
tions are  very  numerous,  migraine  perhaps  most  com- 
mon, but  there  may  be  symptoms  referred  to  particular 
nerves  as  due  to  a  true  neuritis  or  to  neuralgia.  A  very 
frequent  form  is  the  tingling  and  formication  in  elderly 
people. 

Thus  the  nervous  manifestations  may  be  immedi- 
ately due  to  the  deposition  of  sodium  urate  circulating 
in  the  blood  and  coming  in  contact  with  the  nervous 
elements,  or  the  symptoms  may  be  due  to  a  secondary 
effect  of  the  gouty  ravages  upon  the  tissues  in  the 
neighborhood  of  nerves,  or  upon  the  blood-vessels  by 
which  the  large  nervous  centres  are  nourished. 

Haig's  observations  upon  migraine  have  attracted 
wide-spread  attention,  but  it  would  be  a  mistake  to 
attribute  every  case  to  uric  acid  due  to  gouty  ravages 
upon  the  vessels.  There  may  be  cerebral  symptoms, 
such  as  a  definite  failure  of  power,  lasting  for  a  few 
days  or  weeks,  attacks  of  dizziness,  and  all  the  symp- 
toms that  go  with  cerebral  endoarteritis. 

Gout  is  said  to  cause  deafness  by  the  deposit  of 
urates  between  the  layers  of  the  drum  of  the  ear. 
Gouty  subjects,  either  on  account  of  the  constitutional 
vice  or  the  debility  which  diminishes  their  power  of 
resistance,  are  specially  liable  to  catarrhal  inflamma- 
tions of  the  nose,  throat,  and  larynx. 

Treatment.  —  The  word  management,  as  a  name 
given  to  our  efforts  to  bring  about  a  cure  of  gout,  is 
better  than  the  word  treatment,  because  treatment 
carries  with  it  a  trace  of  an  idea  of  a  specific  plan  of 
medication.  It  has  often  been  said  before,  and  we  say 
it  again,  that  management  of  gout  is  chiefly  a  question 
of  hygiene,  but  we  must  not  fall  into  the  error  of  sup- 
posing that  the  hygienic  treatment  is  easy  of  accom- 
plishment. The  cure  of  a  disease  by  the  modification 
of  a  patient's  surroundings  and  the  habits  and  actions 
of  his  organs,  may  well  tax  the  patience,  knowledge, 
and  ingenuity  of  a  physician.  Hygienic  treatment  in- 
cludes not  only  the  modification  of  his  mode  of  life, 
food,  and  drink,  but  the  skilful  use  of  such  drugs  as 
are  directed  to  the  improvement  of  the  physical  action 
of  the  organs,  for  it  does  not  seem  quite  philosophical 
to  include  tonics,  blood-ft)ods,  and  laxatives  under  the 
head  of  a  drug  treatment  of  the  disease  proper. 

The  question  of  food  arises  first.  Dr.  W.  H. 
Draper's  experience  negatives  the  definite  line  drawn 
between  carbohydrates  and  proteids.  The  safest 
hypothesis  ujjon  which  we  can  work  is  that  in  gout 
there  is  an  impairment  of  the  chemical  powers  of  the 
body,  which  in  different  persons  affects  somewhat  dif- 
ferent processes.  Each  case  must  be  worked  for  it- 
self, but  it  will  be  often  found  that  the  food  most  suit- 


able to  a  particular  case  will  contain  a  good  proportion 
of  proteids,  or  even  that  proteids  are  better  borne  than 
carbohydrates.  Much  depends  upon  the  form  of  the 
disease.  Sugars  and  sweets  of  all  kinds  are  definitely 
bad,  and  fermented  liquors  must  be  interdicted.  In- 
dulgence in  wine  or  improper  food  may  bring  on  a 
definite  attack  of  gout,  or  is  more  likely  to  bring  on 
eructations  of  wind  with  gastric  pain,  or  some  of  the 
nervous  or  irregular  S3'mptoms.  Potatoes  tax  a  weak 
digestion  very  heavily,  and  might  perhaps  be  the  first 
thing  cut  off.  The  fact  is  that  our  knowledge  of 
chemistry  is  not  sufficiently  complete  for  our  theory  to 
dictate  absolutely  to  our  practice.  The  best  working 
theory  is  that  by  not  overtaxing  the  digestion  with 
carbohydrates,  its  forces  are  more  at  liberty  to  take 
care  of  the  proteids.  The  use  we  make  of  water  is 
important.  Nearly  all  chemical  operations  are  carried 
on  with  water  as  a  vehicle  for  the  chemical  agents  and 
reagents.  Every  chemist  knows  that  in  seeking  a 
chemical  result  the  reaction  of  the  fluid — that  is,  its 
degree  of  acidity  or  alkalinity — is  important.  Now,  by 
supplying  to  the  system  water  in  abundant  quantities, 
especially  if  it  tends  to  modify  favorably  the  reaction 
of  the  system,  we  are  certainly  benefiting  the  en- 
feebled chemistry  of  the  gouty  body.  Lithia  seems  to 
be  of  value,  but  its  action  is  probably  not,  as  was  for- 
merly supposed,  principally  by  increasing  the  solubility 
of  sodium  urate,  but  it  seems  to  have  a  catalytic  action 
— that  is,  by  its  presence  it  favors  the  actions  and  re- 
actions of  the  fluids  of  the  body  to  a  degree  out  of  pro- 
portion to  its  amount.  However,  it  should  be  given  in 
an  appreciable  amount,  and  not  by  means  of  mineral 
waters,  in  which  it  has  been  detected  by  a  spectro- 
scope. There  is  no  magic  in  native  mineral  waters. 
Artificial  waters  are  just  as  good,  and  have  the  advan- 
tage of  a  definite  formula  and  safety  from  the  possible 
infection  of  a  rural  spring.  We  would  not  deprive  a 
patient  on  this  account  of  the  locality  benefits  of 
watering-places.  But  scientific  truth  is  not  modified 
by  the  popular  belief  in  nature's  magic  combinations 
in  the  bowels  of  the  earth.  The  verdict  of  the  labo- 
ratory upon  the  absence  of  any  such  combination  in 
native  waters  is  positive. 

Thus  we  see  that  gout  is  a  disease  which  may  mani- 
fest itself  in  a  great  many  different  ways,  and  the  rec- 
ognition and  management  of  which  must  always  be  of 
great  interest  to  physicians  in  every  department  of  the 
profession. 

Dr.  M.ax  Einhorn  thought  recent  investigations 
had  made  it  doubtful  whether  the  theory  of  the  uric 
acid  diathesis  as  the  cause  of  gout,  which  had  been 
accepted  so  long,  was  correct.  It  was  accepted  by 
some  authufities,  however,  that  there  was  some  matter 
present  in  the  circulation,  the  nature  of  which  we  did 
not  yet  know,  v.'hich  caused  gout.  But  it  had  been 
proven  that  uric  acid  was  not  excreted  in  smaller 
amounts  by  gouty  people  than  by  others,  and  that  also 
there  was  no  retention  of  uric  acid  in  the  blood.  But 
it  was  true  that  uric  acid  was  found  in  the  joints  of 
gouty  people,  and  it  was  thought  that  the  uric  acid  in 
the  blood,  present  in  small  amounts,  crystallized  there. 
But  the  uric  acid  itself  was  not  the  origin  of  the 
disease. 

For  a  long  time  it  was  believed  that  the  diet  should 
consist  only  of  vegetable  matter,  or  of  foods  which 
contained  little  of  the  albuminates,  because  these  were 
supposed  to  cause  so  much  uric  acid.  This  theory  had 
not  been  proven.  Even  albuminates  in  large  quanti- 
ties did  not  necessarily  increase  the  amount  of  uric 
acid.  It  had  been  found  that  the  uric  acid  which  was 
excreted  took  its  origin  really  from  nuclein,  or  sub- 
stances which  contained  nucleated  elements.  It  was 
not  a  sign  of  suboxidation.  Still,  the  empirical  points 
of  the  past  were  true  to-day.  It  had  been  found  that 
the  patient's  tendency  to  gout  was  lessened  by  out-door 
life  and  exercise,  and  since  gout  was  oftenest  present 
in  the  well-to-do,  it   was  necessary  to  caution   them 


December  7,  1895] 


MEDICAL   RECORD. 


810 


against  eating  too  much,  and  to  advise  the  use  of  plenty 
of  water  to  wash  out  the  waste  matters. 

An  Enormous  Clinical  Fact. — Dr.  L.  D.  Bclkley 
said  that  however  one  might  regard  gout  in  the  labora- 
tory, it  was  at  least  an  enormous  clinical  fact,  and  the 
more  we  recognized  it  the  more  we  would  benefit  our 
patients.  He  had  long  ago  ceased  to  look  for  actual 
joint  diseases  in  his  skin  patients  with  a  gouty  ten- 
dency. He  saw  skin  manifestations  of  the  disease  in 
the  absence  of  enlarged  or  inflamed  joints  every  day. 
He  who  looked  upon  gout  as  only  a  joint  disease  would 
never  recognize  its  true  position  in  medicine.  The 
chain  of  factors  which  culminated  in  the  joint  lesion 
should  be  broken  long  before  reaching  such  an  extent. 
Clinically,  we  did  see  uric  acid  and  urates  in  enormous 
quantities  in  the  urine  of  gouty  patients.  Eczema 
occurred  frequently  in  children  of  gouty  parents,  and 
in  one  generation  there  might  be  joint  lesions,  while  in 
another  the  skin  was  affected. 

Dr.  Bulkley  corroborated  the  author's  statement 
with  regard  to  mineral  springs.  He  had  visited  many 
of  them,  and  had  become  convinced  that  few  of  them 
were  better  than  Croton  water.  The  temperature,  how- 
ever, had  something  to  do  with  their  efficacy,  for  they 
were  usually  taken  hot.  We  little  realized  how  impor- 
tant it  was  to  give  water  in  the  right  quantity,  at  the 
right  temperature,  and  at  the  right  time.  Add  to  this 
the  regulation  of  the  patient's  habits  relating  to  exer- 
cise, meals,  and  sleep,  as  carried  out  at  mineral  spring 
resorts.  As  to  lithia,  he  did  not  use  it  much,  but  fre- 
quently employed  acetate  of  potash.  He  found  many 
gouty  people  taking  soda  and  common  salt,  and  the 
consequence  was  a  deposit  of  urate  of  soda.  Potash 
salts  had  no  such  tendency  to  become  deposited  in  the 
joints.  He  did  not  think  we  appreciated  sufficiently 
the  harmfulness  of  alcohol  in  various  forms,  including 
even  wine.  Haig's  work  was  a  most  interesting  one, 
and  his  suggestion  to  cut  off  red  meats  and  use  white 
meats,  had  been  adopted  by  Dr.  Bulkley  with  benefi- 
cial results.  Dr.  Bishop's  remark  that  management 
was  better  than  treatment  in  gout,  deser\-ed  to  be 
emphasized. 

Dr.  F.  J.  QuiXL.\N  had  several  times  seen  gouty 
manifestations  in  the  throat  and  ear  which  cleared  up 
under  anti-gout  remedies. 

Dr.  Bishop  made  a  few  closing  remarks,  and  ex- 
pressed regret  that  there  had  not  been  time  to  read  the 
whole  paper,  as  much  of  the  unread  portion  had  a 
bearing  on  the  subsequent  discussion. 

Fnnctions  of  the  Cerebro-spinal  Fluid. — Dr.  James 
A.  Campell  read  a  paper,  the  full  title  of  which  was  : 
"  Some  Notes  on  the  Functions  of  the  Cerebro-spinal 
Fluid,  Gathered  from  Lectures  delivered  at  thfe  Faculte 
de  Medecine,  Paris."  Although  the  lectures  were  deliv- 
ered as  far  back  as  18S3-84,  by  the  late  Professor 
Sappe,  he  said  they  had  not  been  published,  and  he 
thought  the  facts  expressed  would  be  of  some  interest, 
since  they  showed  the  fallacy  of  some  statements  in 
more  recent  works  on  anatomy.  The  arachnoid,  Sappe 
said,  could  be  inflated,  but  it  contained  no  fluid,  and 
there  was  no  communication  between  it  and  the  ven- 
tricles. Some  had  claimed  there  was  such  communica- 
tion, but  their  error  was  due  to  cutting  across  the  vein 
of  Gallian  which  the  arachnoid  surrounded.  Briefly 
expressed,  the  function  of  the  cerebro-spinal  fluid  was 
to  regulate  the  capacity  of  the  skull  and  spinal  canal. 
Before  closure  of  the  fontanelles  it  could  be  noticed 
that  with  inspiration  there  was  less  blood  in  the  skull, 
during  expiration  more,  and  the  amount  varied  also  with 
the  heart-beat.  After  the  cranial  bones  had  become 
hardened,  there  could  be  no  variation  in  the  capacity 
with  the  pulsations  and  respiration,  and  now  the  inter- 
vertebral spaces  acted  as  numerous  fontanelles,  allowing 
expansion  of  the  cerebro-spinal  fluid  within  the  me- 
ninges. A  function  of  the  fluid,  of  considerable  impor- 
tance, was  to  refill  the  space  in  the  event  of  nervous 
atrophy. 


NEAV  YORK  ACADEMY   OF   MEDICINE. 

Stated  Meeting,  November  21,  jSgj. 

Joseph  D.  Bryaxt,  M.D.,  President,  in  the  Chair. 

It  being  the  forty  eighth  anniversary  meeting,  the 
President  e.xplained  to  the  audience,  composed  in  no 
small  part  of  the  lay  public,  the  purposes  of  the  Acad- 
emy and  the  work  which  it  had  already  accomplished. 
The  membership  numbered  eight  hundred,  and  was 
steadily  increasing.  As  a  manifestation  of  their  earnest 
effort,  and  that  of  their  friends,  they  had  established  a 
library  of  fifty-five  thousand  volumes,  which  as  a  med- 
ical library  was  only  second  in  size  to  the  largest  one 
in  the  United  States,  that  of  the  Surgeon- General's 
office  at  Washington,  which  was  under  the  support  of 
the  Government. 

Anniversary  Discourse,  "Progress  in  Medicine."  — 
Dr.  Edward  G.  Janewav  delivered  the  anniversarj- 
discourse,  about  an  hour  in  length,  on  progress  in 
medicine.  The  subject  was  limited  to  the  medicine  of 
the  last  thirty  years.  He  first  spoke  of  medical  teach- 
ing and  instruction,  the  advance  relating  to  longer 
course  of  study  and  replacing  teachers  largely  by  nu- 
merous educators  who  instructed  the  students  in  labo- 
ratorj-  work,  in  anatomy,  and  at  the  bedside  of  the 
patient.  Histology,  pathology,  and  bacteriology,  which 
thirty  years  ago  had  scarcely  received  any  attention 
in  a  medical  course,  had  come  to  take  prominent 
positions.  In  this  connection  it  was  suggested  that 
the  instructors  in  the  more  strictly  scientific  branches 
should  receive  salaries  through  endowments,  as  their 
labor,  unlike  that  of  the  clinical  teacher,  was  not  of  a 
kind  which  increased  their  income  through  general 
practice.  In  the  monarchies  of  Europe  these  instruc- 
tors and  investigators  were  compensated  by  govern- 
ment. It  was  different  here,  where  colleges  had  to 
depend  upon  private  endowments  and  fees  to  meet  ex- 
penses. 

Medical  examining  boards  had  acted  in  some  degree 
as  safety-valves  against  the  turning  out  of  so  many 
poorly  educated  doctors  by  innumerable  colleges.  -An- 
other advance  related  to  training-schools  for  nurses, 
that  at  Bellevue  being  mentioned  in  particular. 

Many  systematic  treatises  had  been  brought  out  on 
diseases  which  thirty  years  ago  scarcely  had  a  name. 
This  was  especially  true  in  the  department  of  diseases 
of  the  nervous  system.  Charcot  was  mentioned  for  his 
distinguished  work.  We  were  indebted  not  a  little  to 
vinsection  for  advance  in  the  location  of  brain  areas, 
etc.  In  diseases  of  the  heart  we  had  advanced  beyond 
giving  attention  only  to  murmurs,  which  often  were  of 
adventitious  character.  Formerly  we  spoke  of  peri- 
typhlitis, and  knew  nothing  of  appendicitis,  which 
must  have  destroyed  many  lives  that  were  saved  to-day 
by  surgical  interference.  In  this  matter  the  profession 
abroad  was  behind  New  York  surgeons  several  years. 
Recovery  from  tubercular  peritonitis  as  a  result  of  lap- 
arotomy was  an  advance  whose  real  explanation  yet 
eluded  us.  The  discovery,  by  Koch,  of  the  tubercle 
bacillus  was  in  itself  a  marked  advance,  and  had  led  to 
other  long  strides  forward.  It  had  shown  the  necessity 
for  the  destruction  of  the  sputa  of  tubercular  patients, 
the  avoidance  of  food  containing  tubercle  bacilli,  etc. 
Dr.  Janeway  said  that  notwithstanding  the  disappoint- 
ment with  tuberculin,  he  understood  that  Dr.  Trudeau, 
in  this  country,  and  Dr.  Koch  himself  still  had  hope  of 
obtaining  from  it  remedial  pr^^erties  free  from  objec- 
tionable features,  and  had  not  ceased  their  investiga- 
tions in  this  line.  The  discovery  of  the  bacterial  ori- 
gin of  many  diseases  had  led  to  the  adoption  of 
measures  more  or  less  efficient  in  preventing  their 
spread  and  in  their  cure.  While  Lister  had  done  a 
good  work,  a  much  greater  stride  forward  was  taken 
when  the  surgeon  learned  the  value  of  asepsis  as  se- 
cured through  cleanliness  of  instruments,  dressings, 
and  person.     Indeed  one  was  appalled  to  think  of  the 


820 


MEDICAL 


number  of  lives  sacrificed  in  previous  years  through 
want  of  knowledge  on  the  part  of  surgeons  of  the  value 
of  cleanliness. 

Lines  of  investigation  which  promised  much  thera- 
peutically related  to  serum,  toxin,  and  antitoxin  therapy. 
Dr.  Janeway  was  of  opinion  that  in  diphtheria  anti- 
toxin had  proven  itself  efficient  as  shown  by  collective 
and  individual  statistics,  and  believed  time  would  en- 
able us  to  avoid  any  harmful  results  of  the  serum. 
Reference  was  made  to  the  epidemic  of  small-pox  in 
the  city  in  1874,  and  the  opinion  was  expressed  that 
any  one  on  studying  the  statistics  of  small-pox  in  New 
York  prior  to  1875,  ^"d  since  that  period,  when  a  corps 
of  vaccinators  was  established,  would  be  convinced 
that  by  vaccination  we  were  able  to  control  this  dis- 
ease. Dr.  Janeway  himself  had  not  had  success  with 
toxins  in  the  treatment  of  sarcoma,  but  Dr.  Coley's  ex- 
perience had  been  encouraging  in  that  direction,  and 
also  led  us  to  hope  that  a  cure  might  yet  be  found  for 
carcinoma. 

It  had  become  somewhat  the  custom  to  decry  the 
coal-tar  derivatives  in  the  treatment  of  fevers,  but  the 
writer  did  not  hesitate  to  recommend  their  use  in  suit- 
able cases.  The  control  of  typhoid  fever  by  water- 
baths  was  noted,  but  a  better  thing  was  prevention  of 
epidemics  by  Boards  of  Health  inspecting  the  water- 
supply. 

The  growth  of  specialism  had  tended  largely  toward 
the  advance  of  medicine.  While  he  believed  in  spe- 
cialties he  would  not  advise  young  men  to  take  them 
up  until  they  had  acquired  a  broad  knowledge  of  gen- 
eral medicine.  The  evil  of  conflicting  testimony  in 
courts  by  medical  experts  was  mentioned,  together 
with  the  remedy  which  had  been  suggested  of  having 
the  experts  appointed  by  law  to  pass  impartially  upon 
the  diagnosis  and  such  medical  points  as  were  brought 
before  them.  Whatever  might  be  done,  there  was  not 
the  least  doubt  but  what  a  change  was  desirable  in  our 
medical  testimony. 

Dr.  Janeway  thought  it  would  be  well  if  the  Acad- 
emy, through  donations,  were  enabled  to  establish  a 
laboratory  in  which  investigations  could  be  carried  on. 
How  extensive  such  a  laboratory  should  be,  would  be 
a  proper  subject  for  discussion  after  it  had  been  de- 
cided to  have  one.  If  it  were  contended  that  the 
library  should  first  be  placed  on  a  solider  foundation, 
let  us  hasten  with  that  good  work. 

The  President  said  they  had  listened  to  a  classical 
discourse  on  progress  in  medicine  from  the  highest 
authority,  and  before  declaring  the  meeting  adjourned 
he  invited  the  audience  to  stay  for  refreshments  and  to 
inspect  the  library  and  building. 


Syphilis  of  Larynx.  —  An  early  diagnosis  of  syphilis 
of  the  larynx  is  important,  as  in  this  stage  it  can  be 
satisfactorily  treated,  while  neglected  tertiary  lesions 
are  often  incurable,  except,  perhaps,  by  radical  surgical 
measures. — Anderson. 

Examination  of  Virgines  Intactse.— The  bimanual 
examination  of  7'irgiws  intache  should  always  assume 
the  form  of  a  recto-abdqjninal  palpation.  There  is  no 
need  in  these  cases  of  a  vaginal  examination  ;  the  fin- 
ger in  the  rectum  will  teach  us  all  we  wish  to  know 
concerning  uterus,  tubes,  and  ovaries.  The  only  diffi- 
culty to  be  overcome  is  to  identify  the  cervix  ;  a  little 
practice  will  enable  us  to  master   this  detail. — Ede- 

P.OHLS. 

Intra  -  cranial  Hemorrhage.  —  Intra  -  cranial  hemor- 
rhage is  regarded  as  a  very  natural  accident  in  Bright's 
disease,  atheroma,  and  hemorrhagic  pachymeningitis. 


RECORD.  [December  7,  1895 

Tuberculous  Iritis. —  i.  Tuberculous  iritis  must  be 
distinguished  from  other  varieties  of  iritis.  2.  This 
form  of  iritis  is  premonitory  of  the  appearance  of  tu- 
berculous nodules  elsewhere.  3.  Its  invasion  is  insidi- 
ous, slow,  and  with  but  little  local  reaction,  but  is  ac- 
companied by  numerous  posterior  synechise.  4.  The 
absence  of  pathognomonic  symptoms  makes  the  diag- 
nosis difficult.  5.  The  tendency  to  spontaneous  heal- 
ing of  miliary  tuberculosis  of  the  iris  depends  upon  the 
natural  resistance  of  the  iris  tissue.  The  encapsulation 
of  the  tubercle  and  the  rapid  obliteration  of  its  nutri- 
ent capillaries  favor  its  isolation  and  the  protection  of 
the  healthy  tissues. — \'igxet. 

Shock  is  a  disturbance  of  the  functions  of  the  ner- 
vous system,  induced  suddenly  by  a  violent  stimula- 
tion made  directly  on  the  nerve-centres,  or  indirectly 
through  the  peripheral  nerves,  whereby  the  harmony 
of  action  of  the  great  nervous  centres,  more  especially 
of  the  sympathetic  ganglia,  and  through  them  of  the 
various  organs  of  the  body,  becomes  deranged.  It  is 
essentially  a  depression  of  nerve-force,  and  bears  in  ef- 
fect the  same  relation  to  the  nervous  system  as  syn- 
cope to  the  vascular. — Connery. 

Black  Eye. — There  is  nothing  to  compare  with  the 
tincture  or  strong  infusion  of  capsicum  annuum  mixed 
with  an  equal  bulk  of  mucilage  or  gum  arabic,  and 
with  the  addition  of  a  few  drops  of  glycerine.  This 
should  be  painted  all  over  the  bruised  surface  with  a 
camel's-hair  pencil  and  allowed  to  dry  on,  a  second  or 
third  coating  being  applied  as  soon  as  the  first  is  dry. 
If  done  as  soon  as  the  injury  is  inflicted,  this  treatment 
will  invariably  prevent  blackening  of  the  bruised  tis- 
sue. The  same  remedy  has  no  equal  in  rheumatic 
stiff  neck. 

Dislocation  of  Ulnar  Nerve. — Dislocation  of  the  ul- 
nar nerve  at  the  elbow  is  a  comparatively  rare  affec- 
tion, occurring  independently  of  fractures  or  disloca- 
tions of  the  bones  of  the  elbow,  and  may  result  from 
direct  violence,  or  from  muscular  effort  or  violent 
flexion  of  the  arm  at  the  elbow,  causing  laceration  of 
the  fascia  which  holds  the  nerve  in  its  groove  at  the 
back  of  the  inner  condyle  of  the  humerus.  The  sjTiip- 
toms  resulting  from  this  injury — pain,  tingling  in  the 
parts  supplied  by  the  ulnar  nerve,  and  a  certain  amount 
of  disability  of  the  elbow — are  usually  more  marked 
immediately  after  the  injury,  but  the  symptoms  usually 
become  less  marked  in  a  short  time,  in  many  cases 
very  little  permanent  disability  seems  to  follow,  the 
nerve  accustoming  itself  to  its  new  position.  Very 
rarely  a  neuritis  is  developed.  In  view  of  the  possi- 
bility of  the  development  of  a  neuritis,  it  seems  wise  to 
replace  the  dislocated  nerve  and  fix  it  in  its  normal 
position  as  soon  as  possible  after  the  injury.  The  most 
satisfactory  method  of  securing  the  nerve  seems  to  be 
that  practised  by  Mr.  MacCormick,  who  exposed  the 
ulnar  nerve,  and  having  made  a  bed  for  the  nerve  by 
dividing  the  fibrous  structures  behind  the  inner  con- 
dyle of  the  humerus,  fixed  it  in  its  usual  position  by 
two  kangaroo-tendon  loops  passed  through  the  inner 
margin  of  the  triceps  tendon  and  somewhat  loosely 
around  the  ner\e  ;  several  sutures  were  also  used  to 
unite  the  divided  margin  of  the  fascial  expansion  of 
the  triceps  tendon  superficial  and  the  nerve.  In  all 
cases  where  the  nerve  was  exposed  and  sutured  in  its 
normal  position  the  result  was  satisfactory,  and  the  dis- 
location did  not  recur,  and  in  no  case  is  it  recorded 
that  neuritis  developed  in  the  nerve  as  a  result  of 
operative  treatment. — Wh.\rton. 

Ozsena. — 

Pure  glycerine 70  gr.immes 

Borax 20  grammes 

Distilled  water 30  grammes 

S. — Use  as  a  nasal  spray  two  or  three  limes  a  day. 

— 2Couveiiux  RemMes. 


December  7,  1895] 


MEDICAL    RECORD. 


821 


Ctiiitcal  5cpnvtmcnt. 

A  CASE  OF  CORTICAL  HEMORRHAGE  WITH 

RUPTURE  INTO  A  LATERAL  VENTRICLE. 

By  H.  a.   ROVSTER,  A.B.,  M.D., 

RALEIGH,   N.  C. 

The  following  case,  which  occurred  during  my  term  in 
the  medical  service  of  Mercy  Hospital,  Pittsburgh  is 
deemed  worthy  of  record.  It  possessed  some  anoma- 
lous features  of  interest,  made  clearer  afterward  by  the 
autopsy. 

Mrs.  Louisa  L was  picked   up  on  the  streets  in 

convulsions  and  admitted  to  the  hospital,  on  March  22, 
1S95,  with  no  history  except  the  statement  from  a  man' 
who  came  with  her,  that  she  was  about  sixty  years  of 
age,  and  that  she  had  had  these  "  spells  "  before.  (As 
will  be  seen,  this  was  rather  misleading  than  helpful 
for  the  purposes  of  diagnosis.)  Condition  on  admis- 
sion :  Deep  coma  ;  stertorous  breathing  ;  cheeks  flap- 
ping evenly,  and  mouth  not  drawn  ;  froth  on  lips  and  a 
little  blood  at  corners  of  mouth  (found  subsequently  to 
have  been  due  to  previous  efforts  at  separating  the  jaws 
with  a  spoon)  ;  face  pale  ;  no  especial  odor  of  the 
breath  ;  pupils  equal,  at  first  contracted,  then  dilated  ; 
head  and  eyes  strongly  deviated  to  the  right  ;  moves 
left  leg  but  not  the  right,  and  the  right  arm  seems  a 
trifle  rigid  ;  pulse  very  irregular  and  weak,  becoming 
fuller  afterward—"  hard  arteries  ;  "  second  pulmonic 
sound  accentuated,  but  no  murmur  ;  temperature  in 
right  a.xilla,  96.2°  F.,  in  left  axilla,  97.4°  F.  Analysis 
of  a  small  quantity  of  urine  showed  some  phosphates, 
no  albumin,  no  sugar.  A  diagnosis  was  made  of  cerebral 
hemorrhage  on  the  left  side  of  the  brain  in  the  motor 
region  of  cortex  for  arm  and  leg.  Death  occurred 
forty-five  minutes  after  admission. 

The  autopsy,  by  Dr.  J.  W.  Boyce,  revealed  an  exten- 
sive cortical  hemorrhage  on  the  left  side,  involving  the 
leg  and  arm  centres,  with  rupture  downward  into  the  left 
lateral  ventricle.  The  ventricle  itself  was  filled  with 
clots,  and  there  were  points  of  minute  hemorrhages  in 
its  walls. 

The  diagnosis  of  this  case  was  based  upon  three  im- 
portant observations,  to  which  particular  attention  will 
be  called.  Two  of  these  symptoms,  at  least,  were 
somewhat  at  variance  with  authoritative  statements  on 
the  subject. 

First,  there  was  a  difference  of  temperature  between 
the  two  a^xilL-e,  the  temperature  of  the  paralyzed  side 
being  1.2°  lower.  To  insure  accuracy,  three  different 
thermometers  were  used,  allowed  to  remain  seven 
minutes  in  each  axilla,  and  the  mean  temperature 
taken.  These  observations  were  made  within  an  hour 
after  the  attack.  No  explanation  could  be  offered  for 
the  anomaly.  Usually,  when  any  difference  is  noted, 
the  paralyzed  side,  owing  probably  to  vaso-motor  par- 
alysis, is  distinctly  warmer  just  after  the  attack,  becom- 
ing after  some  days  or  weeks  of  the  same  temperature 
as  the  opposite  side,  or  colder,  as  atrophy  takes  place.' 
This  difference  of  temperature  between  the  two  sides 
in  apoplexy  seems  to  be  rarely  looked  for,  and  even 
then  not  always  found.  References  to  it  in  medical 
literature  are  extremely  rare.  Most  of  the  text-books 
have  ignored  it  completely,  their  authors  possibly  re- 
garding it  as  either  of  little  value  as  a  diagnostic  sign, 
or  unworthy  of  any  notice  at  all.  Edes  -  mentions  a 
case  of  crcssed  hemiplegia  reported  by  Johnson,  where 
the  temperature  was  a  degree  higher  on  the  paralyzed 
side  of  the  body,  and,  also,  one  (exact  location  of  lesion 
not^  stated)  reported  by  Allbutt  with  a  difference  of 
1.6  .  With  these  two  exceptions,  no  cases  in  which 
this  phenomenon  had  been  noted,  were  found  in  an  ex- 
tensive search  among  the  writings  of  many  authorities. 

'  Edes:  Pepper's  System  of  Medicine,  vol.  v.,  p.  937. 
^  Loc.  cit. 


The  second  point  considered  in  the  diagnosis  was 
the  conjugate  deviation  of  the  head  and  eyes,  an  ob- 
servation commonly  made  and  certainly  one  of  great 
importance.  There  seems  to  be  no  perfectly  constant 
relation  between  the  lateral  inclination  and  the  half  of 
the  brain  affected,  though,  in  most  instances,  the  eyes 
are  turned  toward  the  injured  side,  /.c,  they  look  to- 
ward the  lesion  and  away  from  the  affected  side  of  the 
body.^  In  the  case  under  consideration  the  condition 
was  just  the  opposite,  the  head  and  eyes  being  directed 
toward  the  right  (the  paralyzed)  side.  Ferguson'-  has 
reported  a  case  in  which  the  patient  presented  con- 
jugate deviation  toward  the  paralyzed  side,  and  which 
he  accounted  for  by  the  fact,  found  at  the  autopsy,  that 
the  fibres  for  the  head  and  eyes  in  the  internal  capsule 
were  not  involved.  The  exact  clinical  significance  of 
conjugate  deviation  has  apparently  not  been  deter- 
mined. Landouzy  considers  it  to  be  chiefly  connected 
with  a  lesion  of  the  lower  temporal  lobe  ;  Osier  as- 
sociates it  with  cortical  lesions  ;  while  Musser  regards  it 
as  one  of  the  diagnostic  symptoms  of  hemorrhage  into 
the  ventricles. 

A  third  observation  of  interest  was  the  rigidity  of  the 
arm  on  the  paralyzed  side.  The  true  meaning  of  this 
condition  did  not  suggest  itself  during  the  investigation 
of  the  case,  and  it  was  not  until  afterward,  while  study- 
ing the  subject,  that  my  attention  was  called  to  it. 
StriimpelP  says  :  "  In  contrast  to  the  usual  laxness  of 
the  arms  and  legs  during  the  apoplectic  coma  is  th«;  tonic 
rigidity  sometimes  seen  in  the  extremities,  particularly 
on  the  side  opposite  to  the  hemorrhage.  This  symp- 
tom seems  to  be  especially,  although  not  exclusively, 
connected  with  a  bursting  of  the  escaping  blood  into  a 
lateral  ventricle." 

In  regard  to  the  source  of  the  blood  when  hemor- 
rhage takes  place  into  a  ventricle,  Osier  states  that  it 
rarely  comes  from  the  vessels  of  the  plexuses  or  from 
the  walls  of  the  ventricles.  Almost  all  the  cases  of 
ventricular  hemorrhage  he  has  seen  in  adults  were 
caused  by  a  rupture  of  blood  in  the  neighborhood  of 
the  caudate  nucleus.  According  to  Hughlings  Jack- 
son, ventricular  hemorrhage  is  only  occasionally  found. 
When  it  does  occur,  the  blood,  he  says,  breaks  through, 
in  the  vast  majority  of  cjses,  from  the  corpus  striatum 
or  the  optic  thalamus,  and  there  is  usually  a  convulsion 
followed  by  profound  coma,  coming  on  after  the  hemi- 
plegic  seizure.  In  such  cases  a  grave  prognosis  is  al- 
ways to  be  given. 

3J3  West  Morgan  Street. 


A  CASE   OF   TRAUMATIC    NEURASTHENIA.* 
By   CHARLES   E.  NAMMACK,    M.D., 

SfRGEON  OF   rOLICE,   NEW  YORK   CITV. 

Patrolm.vn    G ,    thirty-one    years    old.    United 

States,  an  athlete,  who,  previous  to  his  appointment  to 
the  police  force,  had  been  a  gymnasium  instructor, 
was  assigned  to  duty  October  12,  1892,  at  Union 
Square,  during  the  passage  of  the  Centennial  parade. 
A  fire  engine  weighing  several  tons,  and  drawn  by  three 
horses  abreast,  formed  part  of  the  pageant.  The  horses 
took  fright  at  the  dense  crowd  of  spectators,  and  the 
driver  lost  control   of  them.     They  dashed  toward  the 

people,  and  Patrolman  G ,  realizing  the  great  danger, 

sprang  for  the  bridles,  and  succeeded,  by  an  almost 
superhuman  effort,  in  stopping  the  terrified  animals 
within  a  few  feet  from  the  closely  massed  on-lookers. 
He  was  the  hero  of  the  hour  with  the  press  and  the 
public,  and  was  next  day  promoted  to  the  grade  of 
roundsman  in  recognition  of  his  bravery.  He  sustained 
no  immediate  physical  injury,  but  received  a  profound 

'  Strllmpell  :  Te.\t-book  of  Medicine,  p.  729. 
2  Alienist  and  Neurologist.  '  1  Loc.  oil. 

'  Patient  presented  before  tlie  -New   York   Neurological  Society, 
November  5,  1895. 


822 


MEDICAL    RECORD. 


[December  7,  i< 


psychical  shock,  the  symptoms  of  which  were  at  first 
swallowed  up  in  his  naturally  great  joy  at  the  success 
of  his  brave  effort.  One  week  later,  he  was  obliged  to 
consult  his  family  physician  on  account  of  a  severe  pain 
in  the  chest.  He  was  treated  for  two  months  without 
relief,  and  then  went  to  Dr.  Loomis,  whose  diagnosis 
was  strain  and  shock,  and  who  ordered  him  absolute 
rest.  In  the  spring  of  1894,  he  consulted  Dr.  C.  L. 
Dana,  who  advised  him  to  go  to  Germany  for  hydro- 
pathic treatment.  He  accordingly  obtained  leave  of 
absence,  went  to  Europe,  and  saw  Dr.  Leyden,  of  Ber- 
lin, who  sent  him  to  Thalheim.  He  remained  abroad 
from  June,  1S94,  to  October  12,  1895. 

Patient  states  that  he  was  perfectly  well  up  to  the 
date  of  the  incident  first  referred  to.  He  is  not  aware 
of  any  hereditary  nervous  taint,  nor  of  any  family  tu- 
berculosis. He  has  never  been  rheumatic,  syphilitic, 
or  alcoholic.  He  has  enjoyed  rest  and  freedom  from 
anxiety  since  his  nervous  shock  to  a  degree  unknown 
to  other  similar  sufferers  who  have  a  prospective  claim 
for  damages  against  somebody,  because  the  commis- 
sioners of  police  have  kindly  allowed  him  ample  time 
to  recover,  with  full  pay  therefor.  He  remained  on 
duty,  despite  the  initial  traumatic  strain,  for  some  time 
after  the  occurrence,  and  until  the  development  of 
other  symptoms.  Of  the  latter,  the  first  noticed  was  a 
diminished  power  of  persistent  mental  and  physical  ap- 
plication. Then  developed  a  nervous  irritability,  and 
although  his  promotion  had  relieved  him  of  the  monot- 
ony of  continually  patrolling  the  same  post,  he  found  it 
impossible  to  take  up  his  new  duties  with  any  vim.  Men- 
tal exaltation  became  marked,  and  the  re-iteration  of 
the  story  of  his  heroism  worked  him  up  to  a  pitch  of 
excitement  foreign  to  his  temperament.  Insomnia  be- 
came most  distressing.  Pain,  except  that  in  the  chest, 
was  not  severe.  Hyperesthesia  and  paresthesia  were 
not  noticed.  He  did  not  observe  any  diminution  of 
vision,  hearing,  smell,  or  taste.  His  principal  subjective 
symptoms  were  (i)  pain  over  the  heart  on  exertion,  with 
(2)  dyspnoea;  (3)  weakness  in  the  legs;  (4)  profuse 
sweating  ;  and  (5)  insomnia. 

Examination,  October  23,  1895,  Three  Years  after 
Accident. — Pain  and  temperature  sense  normal.  Tac- 
tile sensibility  slightly  impaired.  He  cannot  distin- 
guish pencil-point  from  end  of  finger.  Pain  conduction 
is  not  delayed.  Hyperaesthesia  is  wanting.  Examina- 
tion of  the  visual  fields,  by  Dr.  Leroy  Pope  ^^'alker, 
shows  decided  contraction  of  each,  with  the  existence 
of  the  shifting  type  (Verschiebungstypus)  of  contraction, 
due  to  the  fact  that  the  peripheral  portions  of  the  field 
speedily  become  fatigued.  Color  perception  is  fairly 
good.  There  is  no  motor  weakness,  and  there  are  no 
abnormal  pupillary  reactions.  Hearing  is  not  dimin- 
ished, but  hyperacusis  is  shown  by  patient's  inability  to 
listen  to  band  concerts,  which  he  formerly  enjoyed. 
Smell  and  taste  are  not  affected.  Pharyngeal  reflex  is 
normal.  Station  and  gait  are  both  good  ;  no  Romberg 
symptom  ;  some  tremor  of  hands,  but  none  of  the  face, 
tongue,  or  eyelids.  Dynamometer  :  Right  hand,  75  ; 
left  hand,  70,  but  grows  weaker  with  each  successive 
test,  showing  that  the  muscles  are  easily  fatigued. 
Knee-jerks  are  slightly  exaggerated.  The  skin  does 
not  perspire  freely  at  this  examination,  nor  is  it  unduly 
dry.  Pulse,  96  sitting,  104  walking,  and  114  after  walk- 
ing two  thousand  four  hundred  feet  in  twenty  minutes, 
which  is  as  fast  as  he  is  able  to  go.  Pulse  on  the  two 
sides  was  synchronous,  and  the  neuralgic  cardiac  re- 
action of  Dana  could  not  be  demonstrated.  Respira- 
tions, 24.  Temperature  under  the  tongue,  99°  F. 
Heart  action  weak  ;  no  enlargement ;  no  valvular  dis- 
ease. Patient  complains  of  cold  extremities,  and  of 
flashes  of  heat  followed  by  local  flushings.  Slight  irri- 
tation of  skin  leads  to  persistent  redness,  but  no  actual 
dermographia.  Appetite,  stomach,  and  bowels  are 
normal,  but  his  weight  has  fallen  from  two  hundred 
and  twenty  to  one  hundred  and  seventy-five  pounds. 
Micturition  is  not  vigorously  performed,  the  stream  es- 


caping without  any  force,  and  needing  a  straining  effort 
at  the  end  to  evacuate  the  bladder.  Urine  is  free  from 
albumin,  sugar,  casts,  or  excess  of  phosphates.  Sexual 
desire  is  weak,  but  power  is  preserved,  although  satis- 
faction in  the  act  is  lacking,  being  replaced  by  an  aug- 
mentation of  the  nervous  irritability. 

The  diagnosis  in  this  case  lies  between  traumatic 
neurasthenia,  traumatic  hysteria,  and  simulation.  The 
last  was  excluded  by  the  absence  of  motive  therefor, 
absence  of  striking  symptoms,  and  absence  of  efforts  to 
exaggerate  existing  slight  symptoms.  Hysteria  was 
excluded  by  the  absence  of  anaesthesia,  or  other  stig- 
mata of  hysteria,  such  as  paralysis,  contracture  or  spasm, 
and  absence  of  paroxysmal  phenomena.  Although  the 
case  has  now  continued  over  three  years,  improvement 
has  been  slowly  progressive,  and  the  patient  has  had  the 
benefit  of  skilful  treatment  at  home  and  abroad.  He 
has  had  none  of  the  vexations  and  excitement  incident 
to  medico-legal  cases  of  this  character.  His  own  ob- 
servation of  his  case  has  given  him  the  opinion  that 
hydrotherapy  has  been  of  more  benefit  than  any  other 
therapeutical  procedure. 


CASE   OF    DIPHTHERIA  TREATED    WITH 
ANTITOXIN. 

By  W.  V.  GAGE,  M.D., 


Glenn  H ,  male,  aged  eleven.     The  case  was  first 

seen  October  26,  1S95.  The  child  then  had  a  pulse  of 
120  :  temperature,  104°  F.  The  throat  was  congested 
and  red  :  tonsils  swollen  ;  faint  bluish  film  on  both 
tonsils.     No  diagnosis  made  at  the  time. 

October  27th. — Pulse,  112;  temperature,  102^  F.  ; 
patches  distinctly  formed,  yellowish- gray  in  color.  No 
diagnosis  was  made,  but  in  view  of  the  possibility  of  it 
being  found  to  be  diphtheria  I  wired  to  Omaha  for 
antitoxin  serum. 

October  28th. — There  is  a  patch  on  each  tonsil  well 
formed,  thick,  dense,  and  adherent  ;  pulse,  no;  tem- 
perature, 102°  F.  .A.t  10.15  -'^•^i-  3-  diagnosis  of  diph- 
theria was  now  made,  and  an  injection  of  antitoxin  was 
given,  one-half  of  the  contents  of  the  vial,  in  anterior 
surface  of  each  thigh.  11.30  a.m.  :  Pulse,  88  ;  temper- 
ature, 99.6°.  12  .M.  :  Pulse,  88  ;  temperature,  99.3°. 
2  P.M.  :  Pulse,  88  ;  temperature,  100°.  4  P..M. :  Pulse, 
104  ;  temperature,  100°.  7  p.m.  :  Pulse,  90  ;  tempera- 
ture, 96.5°. 

October  29th.  8  .\.m. — Pulse,  84  ;  temperature,  97.8°. 
2  P.M.  :  Pulse,  88  ;  temperature,  99.7°.  8  p.m.  :  Pulse, 
84  ;  temperature,  99^. 

October  30th,  9  a.m.— Pulse,  So  ;  temperature,  98  5°. 
2  P.M.  :  Pulse,  So  ;  temperature,  97.8°.  6  p.m.  :  Pulse, 
76  ;  temperature,  96.8°. 

October  31st,  10  A.M. — Pulse,  78  ;  temperature,  97.8°. 
5  P.M.  :  Pulse,  S4  ;   temperature,  98.1°. 

November  ist,  10  a.m. — Pulse,  84 ;  temperature,  98.5°. 

The  child  recovered  without  complications,  except  a 
subnormal  temperature  on  the  first,  third,  and  fourth 
days,  when  strychnine  and  brandy  were  exhibited. 

Two  cases  of  diphtheria  in  this  town  terminated 
fatally  a  few  days  prior  to  the  occurrence  of  first 
symptoms  in  this  case. 


An  Immortal  Item. — .\bout  once  a  year  an  item,  re- 
garding a  report  to  the  British  Medical  .\ssociation  on 
the  relative  longevity  of  drinkers  and  abstainers,  goes 
the  round  of  the  medical  press.  The  fallacy  of  the 
figures  giving  a  longer  life  to  habitual  drinkers  than  to 
total  abstainers  has  been  repeatedly  exposed,  but  the 
item  lives  on,  to  the  consolation  and  encouragement  of 
all  indulgers. 


December  7,  1895] 


MEDICAL    RECORD. 


82- 


OTorvesponcTence. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE    BRADSH.WV    LECTURE    AT    THE     COLLEGE    OF    PHV- 

SICIAXS NEW      VASO-DILATORS — CLINICAL     SOCIETY 

—  SCPRA-PUBIC        OPERATIONS  —  INTUSSUSCEPTION 

THROUGH    Meckel's     diverticulum — fragilitas 

OSSIUM — drugs    for    cerebral    TUMORS — MEDICAL 

SOCIETY EXHIBITION  OF  CASES "a  DOCTORS' WAR  " 

"  RETURN  CASES  "  FROM  FEVER  HOSPITALS EPI- 
DEMIOLOGICAL SOCIETY MEDICO- CHIRURGICAL  DE- 
BATES  POSTURE    DURING    AN.ESTHESIA ABERDEEN 

UNIVERSITY CARLVLE's    DYSPEPSIA. 

London,  November  15,  1S95. 

The  Bradshaw  lecture  at  the  Royal  College  of  Physi- 
cians was  delivered  on  Tuesday  (12th)  by  the  Downing 
Professor  of  Cambridge,  Dr.  Bradbury,  who  devoted  it 
to  introducing  to  the  profession  some  new  vasodilators 
which  he  has  been  investigating.  The  effects  of 
nitro-glycerine  and  some  other  nitro-compounds  are 
powerful  and  too  transient,  and  a  search  has  been 
made  for  other  medicines  to  replace  them,  but  hitherto 
with  little  success.  Dr.  Bradbury,  therefore,  deter- 
mined on  renewed  research  in  this  direction,  and 
gave  an  account  of  his  work.  The  alcohol  nitrates 
were  the  most  promising,  but  he  also  examined  those  of 
the  sugars,  starch,  cellulose,  etc.  The  bodies  which 
seem  most  likely  to  prove  of  practical  use  are  erythrol 
tetranitrate  and  manitol  hexanitrate,  and  both  act  sim- 
ilarly to  nitro-glycerine,  but  are  weaker,  and  their  effect 
is  more  prolonged.  The  action  does  not  begin  so  soon 
as  that  of  the  other  nitrates,  but  lasts  longer.  Obviously 
such  a  medicament  may  be  of  considerable  service,  and 
it  is  possible  that  "  high  tension,"  to  which  some  attach 
so  much  importance,  might  be  controlled  for  a  certain 
period  by  a  drug  having  such  influence.  But  whether, 
as  was  hinted,  tension  could  be  thus  kept  permanently 
reduced  without  ill-effect  is  a  point  that  demands  full 
consideration  before  thoughtful  practitioners  will  care 
to  resort  to  such  a  method  of  treatment.  At  present 
no  ill-effects  have  followed  the  administration  of  these 
nitrates,  but  caution  is  evidently  needed,  and  it  is  to  be 
hoped  that  they  will  not  be  resorted  to  by  routine,  es- 
pecially as  Dr.  Bradbury  will  continue  his  researches. 
We  may  safely  wait  until  the  pharmacological  and 
therapeutical  properties  of  these  nitrates  are  more  per- 
fectly determined,  and  the  limits  within  which  they  may 
be  properly  given  indicated.  The  erythrol  nitrate  Dr. 
Bradbury  employs  in  a  solution  of  i  in  60.  The  ma- 
nitol nitrate,  one  per  cent.  The  dose  of  the  former  is 
one  drachm  in  one  ounce  of  water,  of  the  latter  1)3  to  2 
drachms  in  water.  The  solutions  are  stable  and  unirri- 
tating.  1  would  suggest  that  both  solutions  should  be 
of  the  same  strength,  and  one  per  cent,  is  at  present  the 
favorite  for  solutions,  to  which  it  is  conveniently  applied. 
The  relative  potency  of  drugs  is  more  easily  remem- 
bered and  more  important  to  prescribers  than  the 
strength  of  pharmaceutical  preparations. 

At  the  Clinical  Society  the  first  subject  was  supra- 
pubic prostatectomy,  a  propos  of  two  cases  by  Mr.  Moul- 
lin.  In  one  a  calculus,  about  the  size  of  a  penny, 
filled  the  pouch  ;  in  the  other  there  were  eighteen 
small  calculi  worn  by  attrition.  In  each  case  there 
was  a  good  deal  of  upgrowth  of  the  prostate,  which  was 
removed  and  the  route  made  as  level  as  possible. 
There  was  no  constitutional  disturbance  in  either  case, 
and  union  was  aided  byaninstrument,  similar  to  a  double 
truss,  to  keep  the  deep  surfaces  together.  Mr.  Buck- 
stone  Browne  considered  that  removal  of  the  prostate 
greatly  increased  the  risk,  but  Mr.  Moullin  held  that 
ablation  of  the  middle  lobe,  if  the  urine  remained  acid, 
did  not  add  much  to  the  risk,  and  he  was  supported  by 
Mr.  Golding  Bird. 


A  case  of  intussusception  through  Meckel's  diver- 
ticulum was  then  related.  After  this  came  a  curious 
case  of  fragilitas  ossium,  with  a  record  of  several 
spontaneous  fractures,  in  all  of  which,  except  one,  firm 
union  had  occurred.  In  that  one  (the  femur),  after 
unnecessary  violence  at  the  hands  of  a  bone-setter,  no 
union  took  place.  Later,  two  of  the  united  fractures 
became  again  disunited,  and  one  of  them  became  the 
seat  of  sarcoma.  Some  more  or  less  similar  cases  were 
mentioned,  but  none  in  which  disunion  had  taken  place 
after  years  of  union. 

That  drug  treatment  could  cure  a  cerebral  glioma 
would  seem  to  be  an  untenable  proposition,  but  Dr. 
Althaus  related  a  case  in  which  he  believed  this  had 
occurred,  and  was  a  clear  reply  to  the  therapeutic 
nihilists  who  did  not  know  how  to  use  remedies.  He 
admitted  it  was  the  only  case  he  had  heard  of.  •  The 
diagnosis  of  tumor  seemed  clear,  but  the  question 
whether  it  was  syphilitic  was  naturally  raised.  Both 
Dr.  Althaus  and  the  usual  attendant  disbelieved  thi.s, 
and  could  find  no  trace  of  such  infection.  Still  we 
know  how  accidental  infection  may  sometimes  occur 
and  leave  hardly  any  trace,  while  we  have  no  evidence 
that  drugs  can  influence  other  cerebral  growths.  The 
treatment  was  by  mercury  and  iodide,  and  the  response 
was  rapid,  but  several  relapses  occurred  and  eventually 
complete  recovery.  Of  course  it  cannot  be  said  to  be 
impossible  for  drugs  to  influence  non-syphilitic  growths. 
Mercury  and  iodide  would  perhaps  be  the  most  likely  to 
do  so,  but  there  is  such  a  lack  of  evidence  that  doubts 
are  only  natural.  Dr.  Wilson  related  a  remarkable 
case  in  which  it  was  thought  a  cerebral  tumor  or  de- 
posit, probably  tubercular,  was  present  in  a  boy  of 
twelve.  He  was  treated  with  perchloride  of  mercury 
and  iodide,  but  steadily  got  worse  and  was  sent  to  the 
seaside,  on  the  assumption  that  it  must  be  tubercular. 
After  four  or  five  months  he  began  to  improve,  and 
ultimately  got  quite  well.  In  some  doubtful  cases  of 
disease  of  the  tongue  or  oesophagus  we  now  and  again 
see  great  improvement  follow  mercurial  treatment, 
though  later  on  there  is  renewed  activity  and  malig- 
nancy is  established.  Still,  perhai)S  we  have  been  too 
hopeless  and  must,  at  any  rate,  give  our  patients  the 
benefit  of  any  doubt. 

The  first  clinical  evening  for  the  session  at  the  Med- 
ical Society  was  on  Monday,  when  some  interesting 
cases  were  on  view.  There  was  a  man  of  twenty-five 
who  had  been  treated  with  supra-renal  extract  for 
Addison's  disease.  He  recovered  strength  enough  to 
go  to  the  seaside,  but  relapsed.  The  treatment  is  to 
be  resumed,  and  will  show  whether  the  improvement 
was  due  to  the  extract  or  to  one  of  those  remissions 
which  so  often  occur  in  this  disease.  Another  case 
was  mentioned  in  which  improvement  for  a  time  oc- 
curred, but  ultimately  the  usual  course  was  resumed 
until  death. 

A  man  of  forty-nine  was  shown  who  had  been  oper- 
ated on  for  naso-pharyngeal  growth,  the  upper  jaw 
having  been  detached  and  tilted  out  of  the  way  to 
make  room  and  replaced  after  removal  of  the  tumor. 
The  right  carotid  had  also  been  exposed  so  as  to  be 
prepared  for  severe  hemorrhage,  but  this  proved  to  be 
unnecessary.  Mr.  Moullin  had  performed  a  similar 
operation,  but  instead  of  exposing  the  carotid,  did  a 
]jreliminary  tracheotomy.  Mr.  Walsham  preferred  ob- 
taining access  by  dividing  the  soft  palate  and  re- 
moving part  of  the  hard  palate,  and  Mr.  Wallis  ad- 
vocated this  less  serious  operation.  The  last-named 
surgeon  showed  a  man  for  whom  he  had  wired  a 
fractured  patella  with  an  excellent  result,  and  he  also 
exhibited  a  wired  patella  met  with  in  the  dissecting- 
room  which  showed  how  capital  union  may  follow  this 
operation. 

Mr.  .Swinford  Edwards  had  present  a  patient  who 
had  fallen  from  a  third- story  window  on  to  some  rail- 
ings. A  terrible  wound  in  the  lumbar  region,  lacera- 
tion of  the  kidney,  and  severe  hemorrhage,  to  say  noth- 


824 


MEDICAL    RECORD. 


[December  7,    1895 


ing  of  broken  ribs,  resulted.  The  injured  kidnej'  was 
removed  and  the  man  recovered. 

Other  exhibits  were  congenital  imbecility  with  defi- 
ciency of  chest-wall  and  heart  disease,  periostitis  of 
tibia,  spina  bifida  occulta,  postero  lateral  sclerosis,  etc.: 
altogether  an  interesting  series. 

LoNDOX,  November  22,   1895. 

It  seems  we  are  in  for  another  expedition  to  Ashantee, 
which,  like  the  last,  will  be  essentially  "  a  doctors'  war." 
A  day  or  two  ago  it  was  hoped  an  arrangement  would 
be  made,  but  some  troops  and  stores  have  already  been 
embarked  and  more  will  quickly  follow.  The  Loficet 
has  engaged  a  special  correspondent  to  go  out  who  has 
experience  of  the  climate,  so  we  may  expect  reliable 
information  in  due  course.  But  what  a  slur  on  our 
boasted  civilization,  it  seems,  that  its  resources  must  be 
directed  to  the  massacre  of  the  uncivilized.  And  "  a 
doctors'  war  "  is  likely  to  incur  sad  losses  among  the 
white  troops. 

We  have  had  much  talk  of  late  about  "  return  cases  " 
from  our  infectious  hospitals,  and  the  subject  has  been 
appropriately  brought  before  the  Epidemiological  So- 
ciety. These  are  cases  that  occur  in  a  family  soon  af- 
ter the  return  of  a  member  who  has  been  in  such 
hospital.  The  medical  officers  of  health  and  the  super- 
intendents of  the  hospitals  who  were  present  did  not 
dispute  that  such  cases  occur.  The  important  ques- 
tion would  seem  to  be  how  soon  a  patient  ceases  to  be 
infective,  and  differences  have  been  noticed.  Some 
think  a  properly  disinfected  convalescent  may  safely 
return  earlier  than  others  suppose.  Scarlet  fever  seems 
to  linger  longer  than  some  other  diseases  of  the  class, 
but  the  differences  of  desquamation  deserve  considera- 
tion. 

A  recent  report  of  a  sub-committee  of  the  Asylums 
Board  shows  io6  "  return "  cases  in  the  two  years 
1S93  and  1894.  During  those  two  years  30,227  patients, 
who  had  had  scarlet  fever  or  diphtheria  in  those  hos- 
pitals were  discharged.  This  gives  one  "  return  "  for 
every  285.  The  conclusion  of  the  committee  is  that 
no  appreciable  number  of  infections  have  taken  place 
from  the  discharged  patients.  But  this  conclusion  may 
be  dissented  from  on  several  grounds.  The  figures  are 
compiled  from  the  statistics  of  only  half  the  number  of 
officers  of  health,  and  93  cases  seem  to  have  come  from 
only  five  districts.  It  s;ems  to  me,  too.  that  other  impor- 
tant points  should  be  investigated,  and  that  this  is  a  case 
in  which  an  eminent  statistician  might  extract  important 
lessons  from  the  figures,  to  be  confirmed,  perhaps,  by 
examination  of  more  extensive  numbers.  The  Epide- 
miological Society  was  an  excellent  one  to  which  to 
submit  the  question,  and  Dr.  T.  W.  Thompson,  who 
read  the  paper,  is  an  inspector  of  the  Local  Government 
Board,  which  office  should  give  him  experience  in  such 
matters.  He  admitted  that  a  certain  proportion  of 
''return  cases"  may  at  times  be  due  to  carelessness  in 
discharging  patients  or  to  some  other  fault  of  adminis- 
tration, whether  on  the  part  of  the  hospital  officials,  or 
of  those  responsible  for  the  disinfection  of  the  patients' 
homes  and  effects.  At  the  same  time  he  thinks  some 
more  obscure  factors  are  probably  at  work  which  are 
bound  up  with  the  natural  history  of  scarlet  fever. 
Clearly  there  is  room  for  the  investigation  of  the  epide- 
miologists. 

The  Royal  Medical  and  Chirurgical  Society  will  have 
four  special  debates  this  session,  induced,  doubtless,  by 
the  success  of  the  plan  when  tried  last  year.  The  first 
of  these  will  be  on  possibilities  as  to  latency  of  para- 
sitic germs  in  animal  tissues  in  hydrophobia,  erj'sip- 
elas,  syphilis,  leprosy,  ringworm,  tuberculosis,  and 
other  diseases.  If  that  should  not  be  a  wide  enough 
field  for  discussion,  I  hardly  know  what  would.  Mr. 
Jonathan  Hutchinson  is  president  this  year,  and  will,  I 
hear,  in  opening  the  debate,  endeavor  to  define  its  aim 
and  scope.  I  hope  he  may  be  able  to  restrict  the  other 
speakers  to  the  limits  he  may  lay  down,  or  they  may 
wander  over  wide,  unfertile  fields. 


At  this  same  society  the  adjourned'  discussion  on 
posture  during  anaesthesia,  which  I  have  already  men- 
tioned, came  off  last  week.  Though  not  without  in- 
terest, the  debate  seemed  hardly  of  sufficient  impor- 
tance to  have  called  for  an  adjournment.  The  paper 
read  at  the  previous  meeting  was  by  Dr.  Hewitt  and 
Mr.  Shield.  The  authors  laid  down  a  number  of 
propositions  as  to  the  effect  of  posture,  most  of  which 
were  familiar  and  few  of  which  were  controverted. 
The  paper  was  a  long  one,  and  dealt  fully  with  the 
subject.  There  was  really  no  time  left  for  discussion  ; 
hence  the  adjournment.  An  obvious  result  of  ad- 
journing is  that  the  speeches  take  too  much  the  char- 
acter of  prepared  articles,  and  have  therefore  less  life 
and  naturalness  than  when  made  on  the  spur  of  the 
moment.  Drs.  Hewitt  and  Shield  had  dealt  with  :  i. 
The  posture  of  the  head  in  relation  to  the  trunk  :  2, 
the  influence  of  gravity  on  the  circulation  and  respira- 
tion ;  3,  the  several  surgical  postures  ;  4,  the  posture 
after  the  operation  :  as  to  which  it  was  recommended, 
in  the  absence  of  contra-indication,  to  at  once  turn  the 
patient  on  the  side.  Mr.  Gill  thought  some  of  the 
dangers  named  by  the  authors  were  really  \tT\  slight, 
e.g.,  that  in  the  supine  posture,  with  the  head  extended, 
it  was  very  rare  for  blood  to  find  entrance  into  the  lar- 
ynx. 

At  the  adjourned  meeting  Dr.  Spicer  advocated 
operating  in  the  throat  in  the  erect  posture,  to  facili- 
tate illumination.  In  these  cases  Mr.  Spencer  Watson 
thought  local  anaesthesia  should  be  trusted,  and  Sir  W. 
Dalby  talked  of  its  being  "  common  knowledge  "  that 
he  had  long  removed  adenoids  in  the  sitting  posture. 
The  "  common  knowledge  "  is  scarcely  bounded  by  his 
practice,  though  perhaps  it  may  to  some  extent  em- 
brace it. 

Dr.  Sansom,  in  a  somewhat  tedious  speech,  evidently 
got  up  for  the  occasion,  referred  to  his  own  work  on 
the  subject,  and  said  he  knew  no  condition  of  cardiac 
disease  which  by  itself  forbade  anaesthetics,  and  it  ap- 
peared to  him  that  strong  hearts  were  more  likely  to 
succumb  than  weak  ones.  He  urged  that  both  circu- 
lation and  respiration  should  be  watched  ;  he  regarded 
the  recommendations  of  the  Hyderabad  commission  as 
dangerous. 

Mr.  Woodhouse  Braine  was  in  favor  of  anaesthetizing 
the  patient  in  bed  and  then  remoWng  him  to  the  oper- 
ating theatre,  in  opposition  to  the  authors,  who  had  ad- 
vised anaesthetizing  on  the  table. 

Dr.  Leonard  Hill,  speaking  as  a  physiologist,  at- 
tributed chloroform  shock  primarily  to  dilatation  of  the 
heart,  i.e.,  cardiac  failure,  after  which  respiration  may 
continue,  and  this  he  called  "  post-mortem  respiration." 
The  only  resource  was  rhythmical  compression  of  the 
heart  to  force  the  blood  out.  This  did  not  occur  in 
ether  narcosis.  Failure  of  respiration  was  not  danger- 
ous so  long  as  the  heart  acted  well.  He  described  an- 
other state  due  to  changes  in  the  splanchnic  vaso- 
motor system.  Great  dilatation  here  leads  to  collapse 
by  the  withdrawal  of  the  blood  from  the  heart.  In 
this  condition  pressure  on  the  abdomen  or  inversion 
might  be  useful,  but  could  only  make  matters  worse  in 
the  former  state.  The  tone  of  the  vaso-motor  system 
he  found  varied  in  animals  just  as  it  does  in  man. 

Dr.  Bowles  referred  to  experiments  he  had  made 
forty  years  ago,  said  pulling  the  tip  of  the  tongue  did 
not  affect  the  back  of  it,  urged  the  necessity  of  accu- 
rate dosage,  and  declared  that  so-called  sthenic  apo- 
plexy is  only  incipient  suffocation,  and  that  its  stertor 
and  other  symptoms  all  disappeared  on  turning  the  pa- 
tient on  his  side.  This  last  statement  is  important  if 
true.  The  anaesthetists  had  much  to  say,  but  showed 
considerable  differences  of  opinion.  These  specialists 
seem  only  second  in  acute  differences  to  the  dermatol- 
ogists, who  at  present  are  the  most  remarkably  "  happy 
family  "  in  the  profession. 

Scotland  has  shown  that  it  can  take  on  considerable 
enthusiasm.     The  quarter-centenary  of  Aberdeen  L^ni- 


December  7,  1S95] 


MEDICAL   RECORD. 


825 


versity  gave  occasion  to  a  celebration  rather  unusual  so 
far  north.  For  enlargement  of  the  buildings  the  late 
Dr.  Charles  Mitchell,  of  Newcastle,  had  contributed 
munificent  sums,  amounting  in  all  to  some  ^?3o,ooo. 
The  Government  added  as  much,  and  the  Town  Coun- 
cil some  yj" 1 0,000.  Day  after  day  teachers,  students, 
friends,  and  donors  joined  in  various  plans  of  celebrat- 
ing the  quarter-centenary  and  the  opening  of  the  new 
buildings.  Of  course  a  number  of  honorary  degrees — 
D.D.'s  and  LL.D.'s — were  conferred.  More  interesting 
to  observe  was  the  closing  fancy-dress,  torchlight  pro- 
cession in  which  some  seven  hundred  students  took 
part.  This  seems  a  triumph  for  Scottish  learning  and 
enthusiasm. 

Carlyle  was  not  exactly  an  amiable  man.  Most  of  his 
disagreeable  ways  have  been  put  down  to  dyspepsia, 
which  no  doubt  troubled  him.  No  one  need  wonder 
that  it  did  after  reading  a  revelation  lately  made  by  Sir 
R.  Quain,  who  at  one  time  attended  him  and  who  says, 
"  The  only  remedy  which  I  could  get  him  to  take  was 
gray  powder.  Gray  powder  was  his  favorite  drug  when 
he  had  that  wretched  dyspepsia  to  which  he  was  sub- 
ject, and  which  was  fully  accounted  for  by  the  fact  that 
he  was  particularly  fond  of  very  nasty  gingerbread. 
Many  times  I  have  seen  him  sitting  in  the  chimney 
corner,  smoking  a  clay  pipe  and  eating  his  gingerbread." 
I  question  whether  this  revelation,  unimportant  as  it 
is,  may  not  set  others  parading  the  habits  of  distin- 
guished patients,  and  I  hope  Sir  Richard  is  not  growing 
garrulous. 


doctor  is  most  frequently  the  one  consulted.  He  is 
especially  asked  what  company  is  the  most  desirable. 
A  doctor  who  is  sufficiently  appreciated  by  one  of  sev- 
eral companies  for  which  he  e.xamines  to  receive  a  fair 
fee  for  his  services,  is  also  governed  by  the  business  of 
the  transaction,  for  with  him,  too,  "  business  is  busi- 
ness ;  "  so  that  in  the  end  the  reduction  of  fees  may 
not  be  as  good  a  business  policy  as  it  at  first  appears. 
N.  W.  Reich.ard,  M.D. 


THE    POLICY    OF    REDUCED    FEES    FOR    IN- 
SURANCE  EXAMINATIONS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  news  column  of  the  Medical  Record, 
November  i6,  1895,  occurs  an  announcement  that  one 
of  the  leading  life  insurance  companies  of  your  city  has 
proposed  a  new  schedule  of  fees  for  examinations  for 
insurance,  and  that  the  country  doctor  is  protesting 
vigorously  against  the  reduction.  The  first  part  of  the 
statement  is  true,  for  we  are  in  receipt  of  a  letter  in- 
forming us  of  the  change.  The  second  part  is  equally 
so,  for  at  least  one  county  medical  society  of  which  I 
have  knowledge  has  entered  its  protest.  Your  article 
adds  that  such  matters  are  pure  business.  That  is  the 
plain  fact  of  the  matter,  for  if  the  leading  insurance 
companies,  or  some  of  them,  are  satisfied  with  three- 
dollar  examinations,  why  should  the  doctors  object  ? 
Some  assessment  companies  and  fraternal  associations 
have  always  been  satisfied  with  two-dollar  examina- 
tions. If  the  leading  companies,  or  any  one  of  them, 
expect  to  get  five  dollars'  worth  of  time,  care,  and  in- 
formation for  $3,  as  a  matter  of  pure  business,  will 
they  get  it  ?  In  country  practice,  and  even  in  towns 
•of  considerable  size,  the  bulk  of  the  examinations  are 
for  policies  of  $3,000  or  less.  Policies  for  $5,000  are 
less  common.  Examinations  for  $10,000  are  not  nu- 
merous ;  and  examinations  for  $25,000  are  exceptional. 

Such  being  the  case,  one  of  the  leading  companies 
of  New  York  City  has  reduced  a  considerable  number 
of  its  medical  examiners  to  three-dollar  men.  My  ex- 
perience is  that  when  a  company's  agent  gets  into  a 
new  field,  he  not  infrequently  calls  on-  his  company's 
appointed  medical  examiner  to  get  what  information 
he  can,  and  he  frequently  obtains  valuable  information 
from  this  source.  In  a  matter  of  pure  business,  when 
an  agent  of  a  three-dollar  company  calls  on  a  three- 
dollar  examiner,  who  also  examines  for  a  comj^any 
which  pays  him  $5,  what  will  be  the  value  of  the  in- 
formation the  agent  gets  ? 

Again,  the  examinations  for  the  smaller  amounts  are 
made  for  policies  on  the  lives  of  mechanics,  artisans, 
clerks,  etc.,  who  have  not  studied  the  subject  of  insur- 
ance and  will  not  sign  an  application  for  insurance  un- 
til they  consult  some  one  of  their  friends.     The  family 


%exo  %nstvxxmtnt3. 


A  DOUBLE-CURRENT  RECTAL  IRRIGATOR  : 
REPORT    OF   CASES. 

Bv  ROBERT   COLEMAN   KEMP,  M.D., 

NBW  YORK  Cnv. 
SURGEON  TO  THE  CHt'KCH    INF1RM.\RV   AND  DISPENSARY. 

I  SHOULD  preface  this  article  by  stating  that  this  irri- 
gator is  made  either  of  soft  or  of  hard  rubber.  I  shall 
first  describe  the  latter.  This  instrument  consists  of  a 
hard-rubber  tube,  with  conical  end,  shape  of  a  rectal 
bougie,  and  about  five  inches  long.  It  is  closed 
throughout  except  at  two  points.  On  the  upper  sur- 
face of  the  tube,  just  posterior  to  the  tip,  is  an  opening 
for  the  entering  current  to  pass  into  the  bowel.  On 
the  lower  surface,  about  half  an  inch  posterior  to  this, 
is  a  somewhat  larger  opening  for  the  passage  of  the  re- 
turn current.  The  outer  end  of  the  tube  is  closed  by 
a  rubber  cap  which  screws  in  place.  This  is  perfo- 
rated by  a  longitudinal  tube,  the  outer  end  of  which  is 
furnished  with  a  tip  for  the  attachment  of  the  tube  of 
a  fountain  syringe.  The  inner  end  of  this  longitudi- 
nal tube  screws  into  the  tip  of  the  main  tube  (within), 
and  is  arranged  to  conduct  the  entering  current  into 
the  bowel  through  the  upper  opening.  The  return 
current  passes  through  the  lower  opening,  through  the 
lower  part  of  the  main  tube,  and  down  into  the  bed- 
pan through  a  short  curved  tube  which  is  screwed  into 
the  lower  part  of  the  cap.  This 
curved  tube  has  an  attachment  for 
a  soft-rubber  tube  to  carry  off  the 
outflow.  The  instrument  is  so 
made  that  the  calibre  of  the  return 
current  is  greater  than  that  of  the 
entering.  The  irrigator  can  be 
readily  taken  apart,  cleaned,  and 
disinfected.  The  hard-rubber  in- 
strument is  made  in  four  sizes,  by 
the  Ford  Instrument  Company. 
No.  I,  external  diameter  of  the 
tube,  J4  inch  ;  No.  2.  yi  inch  ;  No. 
3,  ^4  inch  ;  No.  4,  J-s  inch. 

For  general  use  No.  2  is  the 
most  practical.  The  larger  sizes 
are  only  applicable  for  some  special 
case,  as  washing  out  fecal  accumu- 
lations, etc. 

I  should  state  that  the  first  in- 
strument that  was  made  was  or- 
dered by  Dr.  William  H.  Thomson, 
for  a  special  case,  at  the  Ford  In- 
strument Co.,  about  seven  months 
ago,  after  a  suggestion  and  model 
made  by  me  for  him.  This  was  of 
hard  rubber  and  size  No.  2. 

The  soft-rubber  irrigator  consists  of  a  soft-rubber 
tube  five  inches  long  and  which  firmly  grips  a  tip  of 
hard  rubber.  This  tip  is  partially  hollow  and  has  an 
opening  above,  which  lies  closely  against  the  upper 
opening  of  the  soft  tube.  A  small  longitudinal  hard- 
rubber  tube  passes  through  the  centre  of  the  soft  tube 


826 


MEDICAL    RECORD. 


[December  7,  1895 


and  screws  into  the  hollow  tip,  and  through  this  cen- 
tral tube  the  entering  current  passes  into  the  tip  and 
up  into  the  bowel.  There  is  an  opening  for  the  return 
current  below,  as  in  the  other  instrument  ;  but  the  re- 
turn current  passes  out  on  all  sides  of  the  central  tube, 
so  even  if  the  sphincter  contracts  on  the  soft  tube  the 
escape  will  not  be  prevented.  The  outer  cap  is  of 
hard  rubber  perforated  for  the  longitudinal  tube,  and 
with  the  curved  collecting-tube  as  in  the  other  instru- 
ment. This  cap  fits  firmly  against  the  soft  tube.  The 
external  diameter  of  the  soft  tube  is  5^  of  an  inch,  or 
No.  2.  It  can  be  ordered  in  other  sizes  if  desired. 
The  soft  tube  can  be  replaced  at  a  trifling  expense, 
when  worn  out.  The  hard  tube  is  unquestionably 
more  durable,  but  in  some  cases  somewhat  more  pain- 
ful to  use.  The  soft  tube  can  also  be  readily  taken 
apart  and  disinfected. 

For  use  in  the  lower  part  of  rectum,  the  semi-oblique 
(sitting)  posture,  with  the  openings  just  inside  the 
sphincter.  For  higher  up,  the  dorsal  position,  or  hips 
slightly  elevated.  The  height  of  the  current  can  also 
be  regulated  by  douche-bag,  and  by  checking  the  re- 
turn current.  It  will  be  found,  at  times,  that  at  the 
commencement  of  the  irrigation  the  mucous  membrane 
of  the  bowel  will  stop  the  openings,  until  there  is  a 
small  amount  of  fluid  in  the  bowel.  Slightly  turning 
the  instrument,  or  pushing  it  in  slightly  and  then  with- 
drawing it,  will  free  it  from  this  obstruction.  In  in- 
troducing the  irrigator  it  should  be  well  lubricated  and 
inserted  gently.  In  high  irrigation  I  generally  insert 
it  the  full  length  (five  inches)  up  to  the  cap.  I  shall 
briefly  report  a  few  cases  : 

Case     I. — W.    M ■,    male,    aged    twenty- eight  ; 

chronic  cystitis,  strictures,  nocturnal  irritability  of 
bladder,  one  of  the  worst  symptoms.  Under  cocaine, 
meatotomy,  internal  urethrotomy  of  strictures  at  2J2 
and  3'i  inches  up  to  32.  Stricture  at  6  inches,  ad- 
vised operation  and  bladder  drainage.  Patient  re- 
fused. Gradual  dilatation  to  32.  Later  No.  30  as  reg- 
ular size.  Persistent  irrigation  of  bladder,  alkalies, 
suppositories,  etc.  Nocturnal  irritability  continued  in 
spite  of  all  treatment.  I  suggested  to  patient  a  trial  of 
the  continuous  hot  current  just  before  retiring,  using 
about  a  gallon,  as  hot  as  could  be  borne.  He  reported 
almost  immediate  relief,  only  urinating  thereafter  once 
or  twice  during  the  night,  when  previously  he  had  done 
so-  every  two  hours. 

Case  II. — W.  B. ,  male,  aged  thirty-one  ;  chronic 

colitis ;  enlarged  spleen  (malarial).  History  dated 
back  for  three  years.  The  patient  had  had  no  medical 
treatment  for  splenic  enlargement,  and  had  been  taking 
salol,  bismuth-subgallate,  and  high  injections  of  boric 
for  the  colitis  on  his  own  responsibility.  About  every 
two  weeks  there  was  an  acute  exacerbation  of  the  co- 
litis with  considerable  mucus  and  a  little  blood.  The 
margin  of  the  spleen  extended  one  and  a  half  inch  to 
the  right  of  the  umbilicus  and  one  and  a  quarter  inch 
below.  The  enema  with  the  soft  tube  always  ex- 
hausted the  patient,  and  did  not  seem  satisfactorily  to 
remove  the  mucus,  etc. 

Treatment. — Warburg  tincture  without  aloes,  alter- 
nating with  quinine  and  ginger;  boric  injections  with 
the  double-current  irrigator.  The  spleen  in  five  weeks 
contracted  one  and  a  half  inch  horizontally  and  verti- 
cally, and  the  colitis  improved  radically,  and  there  was 
no  exhaustion  following  use  of  the  instrument. 

Case  III. — G.  B ,  male,  aged  thirty-one.     Acute 

urcemia.  Fecal  accumulation  in  the  sigmoid.  I  was 
called  in  by  the  family  physician  to  see  this  case.  Pa- 
tient was  in  collapse  ;  nearly  complete  suppression  of 
urine  ;  a  large  accumulation  of  freces  in  the  sigmoid. 
Calomel,  compound  jalap,  salts,  etc.,  had  been  given. 
Enemata  with  the  long,  soft  tube  had  been  given  a 
number  of  times  with  no  effect,  as  none  could  be  re- 
tained. With  hot  normal  salt  solution  the  fceces  were 
washed  out  without  difficulty,  the  irrigation  being  con- 
tinued for  some  time  after.     Stimulants  were  occasion- 


ally added  to  the  irrigating  fluid.  The  patient  reacted 
nicely  and  the  kidneys  also  acted.  The  case,  however, 
died  several  days  later,  of  nephritis.  I  cite  this  case 
as  several  conditions  may  be  of  interest. 

Case  IV. — B ,  aged  sixty-four,  male.     Retention 

of  urine.  I  made  a  number  of  vain  attempts  to  pass 
several  soft  catheters,  there  being  severe  spasm  at  the 
neck  of  the  bladder.  I  happened  to  have  no  other  in- 
struments at  the  dispensary.  After  using  the  hot  irri' 
gation  for  a  few  minutes,  the  first  instrument  tried 
slipped  in  without  difficulty. 

Case  V. — Through  the  courtesy  of  Dr.  Francis  Dela- 
field,  the  irrigator  has  recently  been  used  at  Roosevelt 
Hospital  in  a  case  of  colitis  following  typhoid  fever. 
Dr.  Sumner,  the  house  physician,  has  kindly  furnished 
me  with  notes  on  the  case  : 

A.  W ,  female,  aged  nineteen.  Admitted  Sep- 
tember 28,  1895.  Typhoid,  mild  type.  Usual  treat- 
ment as  at  Roosevelt.  First  hemorrhage  October  12th. 
Drugs  used,  nitrate  of  silver,  bismuth  et  pepsin,  emul- 
sion turpentine,  strychnine,  whiskey,  etc. 

October  17th. — Involuntary  evacuations,  etc.  Salol 
and  castor-oil  added,  also  tincture  opii  deodorized. 

October  2 2d. — Last  hemorrhage.  Involuntary  defe- 
cation continued  from  this  time  on.  There  were  ten 
to  twelve  movements  a  day,  watery,  with  mucus.  Tem- 
perature kept  io2°-io3°  F. 

November  sth. — Bichloride  irrigation,  i  to  10,000 
ordered  by  irrigator.  Salol,  castor-oil,  and  opium 
stopped. 

November  6th. — Bichloride  irrigation  i  to  10,000. 
Portions  of  false  membrane  came  away  with  the  injec- 
tion. No  more  irrigation.  From  this  time  the  diar- 
rhoea decreased  ;  temperature  gradually  fell  to  nor- 
mal. 

On  November  nth  there  were  only  two  voluntary 
stools,  and  on  November  17th  the  patient  sat  up  for 
the  first  time. 

Case  VI. — Dr.  S ,  aged  thirty-eight.     Patient  of 

Dr.  Charles  T.  Parker.  Two  months  ago  Allingham's 
operation  on  both  sides  for  severe  hiemorrhoids.  Mu- 
cous membrane  sloughed  on  both  sides  of  rectum,  there 
being  on  each  side  a  foul  ulcer  two  inches  in  diameter  ; 
bowel  dark  in  color,  highly  congested  ;  severe  pain  on 
movements  ;  patient  confined  to  bed.  Three  weeks  ago 
irrigation  with  cold  boric  injections  morning  and  night. 

November  25th. — Examination  by  speculum,  one  ul- 
cer entirely  healed,  the  other  half  its  original  size,  and 
healthy.  No  pain  on  defecation  ;  congestion  nearly 
disappeared.     Patient  attends  to  his  profession. 

Case  VII. — J.  H ,  male,  aged  thirty-two.  Pa- 
tient of  Dr.  Charles  T.  Parker.  Prostate  enlarged  and 
acutely  tender.  Pressure  causes  desire  to  urinate. 
Irritability  at  neck  of  bladder.  Frequent  urinations 
during  the  day,  and  especially  troublesome  at  night. 

Treatment. — Cold  water  injections,  continuous  cur- 
rent for  fifteen  or  twenty  minutes,  morning  and  night  ; 
no  other  treatment.  The  patient  writes  to  the  doctor 
that  at  present  he  sleeps  nearly  all  night,  and  urinates 
about  every  five  hours  during  the  day.  The  irrigation 
has  been  used  for  three  weeks. 

The  use  of  the  irrigator  has  also  been  suggested  in 
rectal  ulcers,  pelvic  inflammation  (post-uterine),  etc.,  as 
an  adjunct  to  other  methods  of  treatment. 

449   PaKK    A'l'ENUE. 


Anticancrin. — The  promoters  of  a  German  erysipelas 
serum  for  cancer  treatment  have  adopted  the  proprie- 
tary name  "anticancrin  "  for  their  product.  Drs.  Em- 
merich and  Scholl  could  have  saved  themselves  this 
trouble  ;  clinical  reports,  including  the  records  of  their 
own  tests,  show  that  their  serum  possesses  no  special 
value — and,  anyway,  we  will  not  need  their  serum  in 
this  country,  as  we  have  long  had  it  available  from 
domestic  laboratories. — Southern  Medieal  Record. 


December  7,  1S95] 


MEDICAL    RECORD. 


S27 


AN     IMPROVED    SYRIXGE    FOR    INFILTRA- 
TION  AN.ESTHESIA. 

By  BRANSFORD  LEWIS,  M.D., 


During  the  past  year  I  have  been  making  large  use 
of  Schleich's  method  of  producing  local  anaesthesia 
by  infiltrating  tissues  with  innocuous  solutions  of  salt, 
morphine,  cocaine,  etc.,  the  anaesthetic  effect  resulting 
from  the  method  of  applying  the  fluid  rather  than  from 
the  drug  or  drugs  employed  in  it.  It  has  been  a  source 
of  great  satisfaction  to  both  me  and  the  patients  on 
whom  it  was  used.  The  minuteness  of  strength  of 
drug  employed '  removes  every  element  of  danger  from 
that  source,  even  though  a  large  quantity  of  the  solu- 
tion be  injected  ;  and  the  completeness  and  prompt- 
ness of  the  effect  are  advantages  readily  eWdent. 

But  I  have  met  with  one  objection  that  has  restricted 
the  use  of  the  method  in  a  marked  degree.  It  is  the 
fact  that,  no  matter  how  easily  and  satisfactorily  it  may 
be  employed  in  the  superficial  structures,  where  there 
are  no  large  vessels  in  danger  of  being  punctured  with 
the  hypodermic  needle,  when  one  is  injecting  in  the 
depths  of  a  wound  in  the  neighborhood  of  large  arte- 
ries or  veins,  as  in  enu- 
cleating bubo-glands 
immediately  above 
the  femoral  vessels, 
etc.,  the  likelihood  of 
running  the  needle 
into  one  of  them  and 
producing  disastrous 
results  is  not  a  fan- 
cied one. 

By  means  of  the 
needles  represented 
in  the  cut  I  have 
been  enabled  to  do 
away  with  this  dif- 
ficulty. They  are 
blunt  -  pointed,  and 
made  of  German  sil- 
ver, so  that,  though 
of  sufficient  stiffness 
to  be  thrust  into  the 
connective  tissues  of 
a  wound  after  the 
skin  has  been  severed, 
they  would  not  in- 
jure a  blood-vessel  if 
pushed  against  one. 

The  anxsthesia  is 
begun,  therefore,  with 
the  sharp  steel  needle, 
and  continued  with 
either  of  the  two  sil- 
ver ones.  The  choice 
between  the  latter  de- 
pends on  whether  a 
curved  or  straight 
needle  is  more  con- 
veniently used. 

The  advantages  offered  by  this  improvement  have 
shown  themselves  to  be  eminently  practical  and  service- 
able, and,  in  my  estimation,  will  advance  the  scope  and 
usefulness  of  the  method  to  a  great  degree.  This  in- 
strument was  made  for  me  by  "  A.  S.  .\loe  Co.,"  of  St. 
Louis,  Mo. 

1006  Olive  Street. 


gt^cdical  Stems. 

Contagious  Diseases— Weekly   Statement Report  of 

cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitar)-  Bureau,  Health  Department,  for  the  week 
ending  November  30.  180". 


I'ranslord  Lewis  intillracion  Synnge. 


The  Sixth  International  Congress  of  Otolo^  will  be 
held  in  London,  in  1S99. 

'For  technique  see  Schleich's  Sehmerzlose  Operationen.  Berlin; 
or  my  paper  on  The  Infiltration  Method  of  Local  Anaijtiiesia  in 
Genito-urinary  Surgery,  Tri-State  Medical  Journal,  July.  1895. 


Tuberculosis I  102  99 

Typhoid  fever i  21  8 

Scarlet  fever j  :;o  1 

Cerebro-spinal  meningitis 0  i 

Measles 167  14 

Diphtheria 172  22 

Leprosy i  o 

The  History  of  a  Patient  Cured  by  Tuberculin. — In 

1S90.  a  patient  suffering  from  phthisis,  with  cough, 
night-sweats,  haemoptysis,  and  progressive  emaciation, 
came  under  the  care  of  Professor  Robert  Koch.  After 
fifty-two  weeks  of  repeated  tuberculin  inoculations  he 
was  discharged,  apparently  cured.  Five  years  later  all 
the  old  symptoms  returned,  and  in  a  short  time  he  died 
of  haemoptysis.  At  the  autopsy,  which  is  reported  by 
Dr.  Adami,  in  the  Montreal  Medical  Journal,  the  lungs 
were  examined,  and  found  to  be  practically  healed,  so 
far  as  the  original  lesion  was  concerned  :  that  is  to 
say,  the  apices  of  both  lungs  showed  well-marked 
fibroid  changes,  and  contained  encapsuled  caseous 
nodules.  Throughout  the  rest  of  the  lungs,  however, 
a  fresh  process  had  started  up.  which  was  the  cause  of 
the  patient's  death. 

The  Publication  of  Patients'  Pictures. — A  St.  Louis 
surgeon  has  been  sued  for  $15,000  damages  for  the 
publication  of  the  portrait  of  one  of  his  patients  in 
connection  with  the  report  of  the  case.  The  surgeon 
was  granted  the  pri\-ilege  of  taking  a  photograph  of  the 
child,  but  the  mother  claims  it  was  for  his  personal  use. 
and  there  was  no  permission  asked  for  or  given  that  it 
should  be  published. 

A  Proposed  Memorial  to  Sir  Andrew  Clark. — The 
proposal  to  invite  medical  men  to  subscribe  for  a  memo- 
rial to  the  late  Sir  Andrew  Clark,  is  meeting  with  some 
opposition  from  a  portion  of  the  London  profession, 
headed  by  the  Medical  Press  and  Circular.  It  is  ob- 
jected to  the  plan  of  a  general  subscription  that  Sir 
.-Vndrew  Clark  was  a  wealthy  man  who  owed  his  repu- 
tation as  much  to  the  patronage  of  the  great  as  he  did 
to  his  medical  ability,  and  that  it  "  would  be  absurd  to 
ask  the  general  practitioner,  who  finds  a  good  deal  of 
difficulty  in  making  both  ends  meet,  to  subscribe  to  a 
memorial  to  a  man  who  was  making  ^15,000  a  year, 
and  who,  although  immensely  rich,  left  nothing  to  the 
London  Hospital,  to  which  he  owed  so  much  of  his 
success."  Despite  the  opposition,  however,  a  sum  of 
$15,000  has  already  been  raised.  But  the  project  of 
appealing  individually  to  each  member  of  the  profession 
will  probably  be  abandoned. 

Sudden  Death  from  Cardiac  Syphilis. — At  a  recent 
meeting  of  the  Clinical  Society  of  London,  Sir  Dyce 
Duckworth  reported  the  case  of  a  strongly  built  man, 
thirty-five  years  of  age,  who  was  walking  in  the  street, 
carrying  his  little  boy,  when  he  suddenly  fell  down  and 
expired.  The  body  was  carried  to  St.  Bartholomew's 
Hospital,  and  was  examined  two  days  later.  A  very 
meagre  antecedent  historj'  was  obtained,  which  threw 
no  light  on  the  nature  of  the  case.  There  was  evidence 
of  old  syphilitic  disease  on  the  tongue  and  on  the 
glans  penis.  A  small  gumma  was  found  in  the  left 
lung.  The  heart  weighed  twenty-two  ounces,  and  had 
firm  adhesions  to  the  pericardium,  both  at  the  ape.\ 
and  at  the  base.  The  right  ventricle  was  hypertro- 
phied  and  dilated.  The  valves  were  natural.  The 
left  ventricle  was  hypertrophied  and  dilated.     There 


828 


MEDICAL    RECORD. 


[December  7,  1895 


was  a  round  depression  in  its  wall  above  the  apex, 
the  diameter  of  a  shilling,  covered  by  long  adhesions. 
This  was  due  to  a  thinning  of  the  wall,  with  much 
endocardial  thickening.  A  large  aneurismal  pouch 
was  found  behind  the  posterior  cusp  of  the  mitral 
valve.  This  appeared  from  without  as  a  tumor  grow- 
ing from  the  base  of  the  heart,  completely  covering 
the  left  auricle.  Its  walls  were  one-half  inch  thick, 
and  the  pericardium  was  closely  adherent  over  it. 
On  section,  the  muscle  was  found  to  be  replaced  by 
tough  fibrous  tissue,  with  foci  of  gelatinous  matter. 
The  endocardium  was  greatly  thickened  and  fibrous. 
Microscopic  e.xamination  proved  it  to  be  gummatous  in 
nature,  with  patches  of  caseation.  The  smaller  arteries 
showed  signs  of  endarteritis.  These  appearances  indi- 
cated plainly  a  recent  gummatous  growth  at  the  base  of 
the  left  ventricle,  and  a  similar,  but  older,  one  near  the 
ape.x  of  that  cavity.  The  fact  of  sudden  death  as  a 
frequent  occurrence  in  cases  of  this  nature  was  alluded 
to,  and  it  was  pointed  out  that  these  clinical  features 
were  but  little  known  and  necessarily  but  seldom  recog- 
nized. The  morbid  anatomy  was  well  understood. 
The  speaker  had  collected  particulars  of  fourteen  simi- 
lar cases,  some  of  them  reported  in  this  country,  but 
none  communicated  to  this  Society.  Death  occurred 
almost,  if  not  quite,  suddenly  in  eight  of  these  cases. 
The  disease  was  rare  in  women,  only  one  of  the  four- 
teen having  occurred  in  that  sex.  The  mean  age  of  all 
the  patients  was  thirty-two  years.  Many  of  the  cases 
appeared  to  have  been  previously  devoid  of  urgent 
symptoms.  In  some  there  had  been  pericardial  pain. 
It  was  pointed  out  that  graver  symptoms  were  to  be 
expected  when  fibrotic  changes  followed  on  the  evolu- 
tion of  the  gummatous  growths,  and  when  they  led  to 
aneurisms  of  the  ventricular  walls.  The  valves  were 
usually  not  involved,  and  hence  murmurs  were  not  to 
be  met  with  as  in  the  case  of  rheumatic  endocarditis. 
The  ventricles  and  their  septum  were  the  common 
sites  of  these  growths.  Tendency  to  fatal  and  sudden 
syncope  was  probably  explicable  by  the  fact  that  en- 
darteritis affected  the  coronary  arteries  in  part,  and 
possibly  by  the  occurrence  of  embolisms  from  the 
softening  contents  of  aneurisms  into  coronary  arterial 
branches,  the  ventricular  walls  degenerating  in  conse- 
quence and  becoming  gradually  intolerant  of  strain. 
The  great  object  was  to  make  an  early  diagnosis  when 
possible,  and  to  seek  for  syphilitic  concomitants  in 
cases  where  there  were  obvious  cardiac  symptoms,  such 
as  palpitation,  or  infrequency  of  pulse,  hypertrophy, 
dilatation,  etc.,  and  no  signs  of  involvement  of  the 
valves.  The  treatment  was  to  employ  iodide  of  potas- 
sium in  full  doses. 

The  Substitution  of  Vaccinia  Serum  for  Vaccine 
Lymph. — Drs.  Hlava  and  Houl  have  investigated  the 
immunizing  and  curative  properties  of  vaccinia  serum, 
in  order  to  see  whether,  by  the  use  of  it,  vaccination 
could  not  be  done  away  with,  and  inoculation  be  made 
to  take  its  place.  The  experiments  were  made  by  tak- 
ing serum  from  the  vesicles  of  calves  suffering  from 
vaccinia,  and  also  by  taking  the  serum  from  the  blood 
of  these  animals.  It  was  found  that  a  mixture  of  serum, 
plasma,  and  blood,  when  injected  into  children,  i)re- 
vented  the  subsequent  development  in  these  children 
of  vaccinia.  No  experiments  have  been  made  with 
small-pox,  but  it  is  hoped  that  a  method  may  be  pro- 
vided by  which  inoculation  can  be  made  to  take  the 
place  of  vaccination,  and  thus  do  away  with  all  the  ac- 
cidents that  occur  in  the  application  of  this  method. 

Biborate  of  Sodium  in  Epilepsy. — Since  Dr.  Gowers 
first  introduced  this  drug  as  a  remedy  in  certain  cases 
of  epilepsy,  various  observers  have  from  time  to  time 
published  observations  on  its  effects.  Among  these 
are  Stewart  Lockie,  Risien  Russell,  James  Taylor,  and 
Alexander  in  this  country,  Folsom  and  Jones  in  the 
United  States,  and  Mairet,  Fere,  and  others  in  France. 
The  last-mentioned  observer  has  recently  published  in 


the  Revue  de  MMccinc  an  account  of  an  extensive  series 
of  observations  of  the  effects  of  borax  in  epilepsy,  the 
result  of  which  is  to  show  that,  while  in  certain  cases 
benefit  is  conferred  by  the  use  of  the  drug,  in  most 
cases  the  disadvantages  are  such  as  to  more  than  coun- 
terbalance the  slight  benefits,  .\ltogether  122  cases 
were  treated,  and  of  these  87  derived  practically  no 
benefit ;  but  in  some  cases  benefit  was  experienced. 
In  6  of  these  cases  the  benefit  was  doubtful  on  account 
of  the  short  duration  of  the  trial  ;  in  7  patients  ame- 
lioration was  followed  by  relapse  ;  and  in  1 1  cases  im- 
provement resulted  from  the  use  of  borax,  but  not  so 
marked  as  the  improvement  following  the  use  of  bro- 
mides. The  third  chief  group  consisted  of  11  cases 
in  which  undoubted,  and  in  some  cases  remarkable, 
benefit  resulted  from  the  use  of  borax,  all  the  more 
noteworthy  because  of  the  absence  of  benefit  from  bro- 
mide in  large  doses  in  some  of  those  same  cases.  Full 
details  of  the  treatment  and  its  effect  in  these  cases  are 
given,  and  the  tolerance  of  large  doses  of  the  drug  in 
certain  cases  is  striking.  Dr.  Fere  next  considers  the 
various  drawbacks  to  the  treatment  under  the  name  of 
"borism."  Intestinal  troubles  he  found  to  be  most 
troublesome — nausea,  vomiting,  and  anorexia;  but  in 
certain  cases  the  administration  of  borax  in  glycerine 
instead  of  in  water  obviated  this  drawback.  Dryness 
of  the  skin,  and  redness  and  inflammation  of  the  mu- 
cous membranes  were  also  produced.  Dryness  of  the 
hair  also  followed,  and  in  some  cases  loss  of  hair  re- 
sulted, but  only  temporarily.  The  most  frequent  form 
of  skin  eruption  was  a  kind  of  eczema  answering  to  the 
description  in  most  particulars  of  seborrhceic  eczema ; 
in  other  cases  the  eruption  consisted  of  reddish  patches 
which  desquamated  ;  while  in  still  another  class  the 
eruption  was  papular  and  accompanied  by  prurigo  of 
varying  intensity.  This  also  was  sometimes  followed 
by  desquamation.  In  some  cases  a  condition  of  great 
weakness  succeeded  prolonged  treatment,  this  being 
the  result,  apparently,  partly  of  the  toxic  effect  of  the 
drug  and  partly  of  the  anorexia  which  followed  its  use. 
These  different  effects,  it  may  be  mentioned,  have  for 
the  most  part  been  mentioned  by  other  observers,  but 
another  much  more  serious  result  is  alluded  to  in  this 
paper  as  following  the  use  of  borax  in  certain  cases. 
This  is  an  effect  upon  the  kidneys,  giving  rise  to  the 
presence  of  albumin  in  the  urine,  and  as  a  rule  accom- 
panied by  oedema  of  the  face  and  extremities,  so  that 
in  all  cases  in  which  borax  is  given  in  anything  like 
full  doses  it  is  essential  that  a  careful  watch  should  be 
kept  upon  the  state  of  the  urine.  In  one  of  the  cases 
under  Dr.  Fere's  observation  unijmia  and  hyperpyrexia 
developed  and  the  patient  died.  The  kidneys  were 
found  to  be  inflamed.  The  general  facts  in  the  paper 
indicate  that,  while  borax  is  not  as  a  rule  to  be  com- 
pared to  the  bromides  in  regard  to  its  efficacy  in  the 
treatment  of  epilepsy,  still  there  are  cases  which,  while 
intractable  by  the  bromides,  are  very  remarkably  bene- 
fited by  borax,  but  that  the  drug  whenever  it  is  given 
in  large  doses  has  certain  disadvantages,  and  even  dan- 
gers, which  should  be  carefully  guarded  against. —  The 
Lancet. 

Pasteur's  Will  was  a  very  simple  document.  It  read 
as  follows  :  "  This  is  ray  testament.  I  leave  to  my 
wife  all  that  the  law  allows  me.  May  my  children 
never  forsake  the  path  of  duty,  and  alvays  cherish  for 
their  mother  the  tenderness  she  so  richly  merits.     L. 

P.\STECR." 

The  Skeleton  of  Paracelsus. — The  bones  of  Paracel- 
sus have  been  several  times  exhumed  from  several 
different  places.  The  last  and  most  authentic  exhu- 
mation took  place  in  18S7,  and  the  results  of  an  exami- 
nation of  the  bones  have  been  described  by  Dr.  Aberle, 
of  Salzburg.  According  to  this  author,  Paracelsus  was 
a  dwarf,  being  barely  five  feet  in  height,  with  a  skull 
much  below  the  average  size,  deformed  and  thickened 
by  the  effects  of  rickets. 


Medical   Record 

A  IVeek/y  yoitynal  of  Medicine  and  Suygery 


Vol.  48,  No.  24. 
Whole  No.  1310. 


New  York.  December  14,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


(Dcifliual  ^vticTcs. 

AN.\LYSIS  OF  ONE  HUNDRED  AND  FIFTY- 
SIX  ADMISSIONS  TO  THE  ST.  LAWRENCE 
STATE  HOSPITAL,  WITH  ESPECIAL  RE- 
FERENCE   TO  ACUTE    INSANITY. 

By  J.  M.  MOSHER,  M.D., 

FIRST  ASSISTANT  .^HVSrCIAN,  ST,  LAWKH.SCE  STATE  HOSPITAL,  OGDENSDURG,  N.  Y. 

The  great  population  of  chronic  cases  in  a  large  pub- 
lic hospital  for  the  insane  misleads  the  superficial  ob- 
server as  to  its  possible  curative  functions,  and  over- 
shadows the  results  of  treatment  prevailing  in  the  few- 
wards  organized  and  disciplined  for  the  application  of 
remedial  measures  to  patients  who  present  prospect 
of  recovery.  The  custom  of  including  in  the  same  fig- 
ures an  overwhelming  number  of  chronic  with  a  few 
acute  cases,  and  the  adoption  of  tables  of  classification 
which  ignore  the  vital  distinction  between  these  two 
classes,  vitiate  statistics  and  result  in  injustice  to  the  in- 
stitution, and  misapprehension  as  to  the  merits  and 
successes  of  its  administration. 

To  overcome  in  some  measure  this  difficulty,  the 
present  contribution  treats  the  admissions  to  the 
•women's  department  of  the  St.  Lawrence  State  Hos- 
pital during  the  last  fiscal  year  apart  from  the  perma- 
nent population,  and  seeks  to  establish  some  basis 
upon  which  to  justify  the  methods  for  the  relief  of  pa- 
tients whose  history  and  condition,  when  received  in 
the  hospital,  lead  to  the  hope  of  cure. 

In  order  to  differentiate  plainly  functional  from  or- 
ganic conditions,  the  following  supplemental  table  of 
classification  has  been  adopted,  in  which  this  distinc- 
tion is  made  the  prominent  feature  : 

Classification  of  Ixsanitv. 

a.  Psychoses  : 

1.  Mental  disorders  with  pronounced  physical  de- 

bility. 

a.  Acute  delirium. 

b.  Acute  stupor. 

2.  Mental  disorders  without  pronounced  physical 

debility.     (Confusional  insanity.) 
a.  Acute  melancholia. 
h.  Acute  mania. 

c.  Subacute  melancholia. 

d.  Subacute  mania. 

b.  Psychic  De(.enera tions  : 

1.  Mental  degenerations  of  diathetic  origin. 

a.  Primary  delusional  insanity. 
/'.  Periodic  and  circular  insanity. 
c.   Recurrent  insanity. 

2.  Mental  degenerations  with   organic  disease  of 

the  brain. 
a.  General  paralysis. 
/'.  Chronic  endarteritis  without  senility. 
(.  Senile  insanity. 
</.   Epileptic  insanity. 

e.  Terminal  dementia. 

During  the  fiscal  year  from  October  \,  1894.  to  Sep- 
tember 30,  1895,  inclusive,  there  were  156  admissions 
of  women.  Of  these,  i  patient  was  a  victim  of  the 
opium  habit  and   was  classified   as  not  insane,  7  pa- 


tients were  classified  as  idiots  or  imbeciles,  and  2 
patients  were  admitted  twice  during  the  year.  Of  the 
146  cases  remaining,  59  were  classified  among  the 
psychoses,  or  curable  forms,  and  87  among  the  de- 
generations, or  incurable  forms. 

In  the  second  class,  that  of  the  degenerative  forms, 
have  been  included  the  chronic  delusional  manias 
and  melancholias,  the  periodic  forms,  and  the  in- 
sanities depending  upon  organic  disease.  The  term 
recurrent  insanity  has  been  used  to  indicate  cases 
characterized  by  three  or  more  attacks  of  insanity 
in  which  the  fact  of  periodicity  is  in  doubt.  Re- 
coveries from  the  recurrent  attacks  have  not  been  re- 
garded in  the  table  of  results.  In  the  class  of  mental 
disorders  depending  upon  organic  disease,  it  has  been 
found  necessary  to  give  due  consideration  to  the 
various  forms  of  chronic  inflammation  or  degenera- 
tion of  the  blood-vessels.  Chronic  endarteritis,  or 
arterio-capillary  fibrosis,  may  be  regarded  as  one  of 
the  degenerations  of  old  age,  but  it  has  also  been 
found  as  a  distinct  disease  at  a  period  of  life  in  which 
senility  could  not  be  claimed.  Several  patients  of  this 
class,  under  sixty  years  of  age,  have  presented  various 
mental  manifestations,  usually  with  indications  of  de- 
mentia, and  also  with  few  or  many  of  the  physical 
deteriorations  usually  accepted  as  the  natural  condi- 
tions of  old  age.  In  a  few  instances  these  patients 
have  so  far  improved  as  to  be  discharged  from  the 
hospital  ;  in  other  cases,  chronicity  has  been  positively 
established ;  and  in  others  death  has  resulted  from 
apoplexies,  or  apoplectiform,  or  uraemic  conditions. 
In  the  early  differentiation  of  these  cases,  attention 
has  been  given  on  the  physical  side  to  organic  lesions 
of  the  heart,  to  prominence  and  tortuosity  of  the 
radial  pulse,  prominent  blood-vessels  at  exposed  sur- 
faces, wrinkled  and  attenuated  cutaneous  structures, 
arcus  senilis,  and  changes  in  the  bones.  Although 
improvement  has  occasionally  resulted  to  such  degree 
that  it  has  been  possible  to  discharge  the  patient  from 
the  hospital,  its  temporary  nature  has  been  considered 
and  the  cases  have  not  been  included  in  the  table  of  re- 
sults. 

Within  the  limits  of  the  present  contribution  con- 
sideration of  the  curable  cases  only  is  feasible.  Of  the 
!;9  cases  so  classified,  37  have  attained  such  period  of 
development  as  to  render  the  result  of  the  disease  cer- 
tain ;  12  patients  still  under  treatment  are  regarded  as 
in  the  acute  or  developing  stage  of  the  disease,  in 
whom,  during  the  presence  of  the  element  of  prob- 
ability, it  has  been  thought  best  not  to  anticipate  the 
result.  Of  the  37  determined  cases,  25  have  recovered, 
6  have  died,  2  have,  in  all  j^robability,  become  chronic, 
and  4  have  been  discharged  improved.  The  percent- 
age of  actual  recoveries  is  thus  67};^,  and  the  percent- 
age of  deaths,  upon  the  whole  number  of  recoverable 
cases  admitted,  has  been  slightly  over  ten  per  cent.  ; 
upon  the  whole  number  of  admissions  three  per  cent. 

Acute  Delirium — Nine  Cases. — The  term  acute  de- 
lirium has  been  ap|)lied  to  cases  hitherto  generally 
described  as  acute  delirious  mania,  sometimes  acute 
delirious  melancholia,  but  recently  in  several  instances 
acute  delirium.  The  great  motor  or  mental  excite- 
ment, whose  emotional  manifestations  may  be  either 
depressing  or  exhilarating,  is  not  considered  to  justify 
a  distinction  between  the  terms  mania  and  melancholia 
in  the  presence  of  the   great  physical  prostration  of 


8.-,o 


MEDICAL    RECORD. 


[December   14,  1895 


which  the  delirium  appears  as  a  symptom.  The  dif- 
ferentiation of  this  form  of  mental  disorder  has  been 
variously  made  upon  i,  a  pathological  basis  ;  '  2,  a 
symptomatological  basis  ;  -  3,  a  diathesis  ;  ^  4,  the  gen- 
erally fatal  result.^ 

Dr.  H.  C.  Wood  {!oc.  cit.)  draws  attention  to  the  vari- 
ous forms  of  disease  comprehended  by  different  writers 
under  the  term  of  acute  delirium,  and  seeks  to  differ- 
entiate cases  involving  organic  cerebral  disease  from 
those  whose  recovery  demonstrates  their  functional 
character.  He  deplores  the  necessity  of  invoking  the 
result  to  the  aid  of  the  diagnosis,  but  finds  no  symp- 
toms for  their  differentiation,  and  shows  especially  the 
failure  of  a  characteristic  temperature  curve,  to  which 
Regis  (loc.  cit.)  attaches  great  importance.  Between 
the  recoverable  cases  defined  as  the  "  culmination  of 
active  nervous  exhaustion  with  a  psychical  explosion,"^ 
and  the  fatal  cases  resulting  from  acute  periencephali- 


and  hard.  The  temperature  attained  only  a  moderate 
degree,  and  in  no  case  was  there  marked  pyrexia  or 
hyperpyrexia  unless  from  complication.  Active  hallu- 
cinations of  the  senses,  with  entire  incoherence  and 
great  restlessness,  were  prominent  in  all  cases,  fre- 
quently showed  periodicity,  with  intervals  of  calm  of 
shorter  or  longer  duration,  during  which  there  occa- 
sionally appeared  an  entire  remission  with  approxima- 
tion to  a  normal  mental  state.  The  short  duration  of 
the  active  stage  and  the  speedy  convalescence  of  the 
recoverable  cases  were  features  of  the  disease.  To 
contrast  with  these  cases  the  hospital  can  refer  to  the 
record  of  only  one  case  of  acute  periencephalitis.'  In 
this  case  the  temperature  was  not  elevated  above  that 
of  the  cases  of  acute  delirium  now  under  consideration, 
and  the  only  symptomatological  difference  was  the 
report  of  a  longer  duration  of  the  disease  before  ad- 
mission (one  month),  a  fact  of  uncertain  and  indefinite 


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Case  1037.— Acute  Delii 


In  the  nine  cases  observed  during  the  past  year  at 
the  St.  Lawrence  Hospital  there  have  been  many  points 
of  similarity.  The  disease  began  suddenly  in  patients 
whose  previous  condition  gave  no  intimation  to  the 
ordinary  observer  of  departure  from  health.  In  the 
eight  cases  of  which  definite  information  was  received, 
the  longest  duration  preceding  admission  was  two 
weeks  and  the  shortest  was  two  days.  There  was  ex- 
treme and  rapidly  increasing  physical  prostration,  gen- 
erally attaining  the  typical  typhoid  state.  The  i)ulse 
was  accelerated  and  weak,  the  tongue  and  mouth  were 
parched  and  dirty,  the  bowels  constipated,  the  abdo- 
men collapsed  and  without  resilience,  and  the  skin  dry 

*  H.  C.  Wood:  An  Explication  of  Acute  Delirium,  Anierican  Jour- 
nal of  the  Medical  Sciences.  April,  1895. 

^  Regis:  Practical  Manual  of  Mental  Medicine,  p.  165. 
'  Bevan-Lewis  :  Text-Book  ot  Mental  Diseases,  p.  172. 

*  .Savage  ;  Insanity  and  Allied  Neuroses,  p.  93  ;  Klaudsley  :  Pathol- 
ogy of  Mind,  p.  272  ;  Bevan-Lewis,  loc.  cit.,  p.  172. 

'  Dr.  John  B.  Chapin,  quoted  by  Dr.  Wood,  loc.  cit. 


The  principles  of  treatment  of  these  cases  were 
seclusion,  rest,  abundance  of  nutritious  food,  stimu- 
lants, and  tonics.  Contrary  to  the  methods  of  treat- 
ment usually  advocated,  hypnotics  were  not  used.'- 

The  patients  were  placed  in  bed  in  a  retired  and 
moderately  darkened  room.  Nurses  were  detailed  for 
day  and  night  service,  and  instructions  were  given  at 
the  outset  for  the  administration  of  liquid  diet,  prefer- 
ably milk,  whenever  the  patient  could  be  induced  to 
accept  it.  Advantage  was  taken  of  the  quiet  intervals, 
and  coercive  measures  were  entirely  prohibited,  or  in 
some  instances  reduced  to  a  minimum.     In  one  case 

'  St.  Lawrence  State  Ho.«pita!,  Eighth  Annual  Report,  p.  119. 

"  Regis  (loc.  cit.)  :  The  Use  of  the  Usual  Sedatives  and  Hypnot- 
ics. 

Blandford,  Insanity  and  its  Treatment,  p.  251 :  "  By  chloral  or  the 
combination  of  it  with  bromide  of  potassium,  sleep  may  be  procured 
in  the  majority  of  cases,  and  in  my  experience,  deaths  from  exhaus- 
tion have  been  greatly  diminished." 

Bucknill  and  Tuke,  Manual  of  Psychological  Medicine,  4th  ed.,  p. 
736  ;  "  Beware  of  Hypnotics." 


December   14,  1895] 


MEDICAL    RECORD. 


only  was  forcible  feeding  with  the  nasal  tube  attempted, 
and  the  result  was  not  thought  to  have  justified  this 
proceeding.  The  administration  of  laxatives  was  an 
initial  procedure,  enteroclysis  was  occasionally  found 
of  value,  and  stimulants  and  tonics  were  given  at  the 
earliest  possible  opportunity.  Under  favorable  condi- 
tions prolonged  warm  baths  were  found  to  promote 
sleep.  Convalescence  was  managed  by  properly  regu- 
lated exercise  and  the  occasional  administration  of 
electricity  and  massage. 

Case  1937.  Aiut::  Delirium  unth  Complicating  Pul- 
monary Emphysema. — Woman,  aged  fifty-three,  widow  ; 
nativity,  Canada  ;  occupation,  housewife,  midwife  : 
cause,  overwork. 

Family  history  :  two  sisters  insane  ;  one  son  has 
asthma.  Personal  history  :  patient  has  been  strong  ex- 
cept for  asthma.  Two  and  one-half  years  before  ad- 
mission she  had  pneumonia,  and  her  health  since  that 


Case  rgoo.  Acute  Delirium  vith  Accidental  Scald 
during  Plunge  Bath,  follcnced  by  Marked  Reaction  and 
Imprazement,  and  resulting  in  Recovery. — Woman,  aged 
fifty-one  ;  widowed  ;  nati\-ity.  New  York  :  occupation, 
housewife.  Causes :  predisposing,  ner\-ous  tempera- 
ment and  climacteric  :  exciting,  death  of  husband  and 
financial  losses. 

Family  history  good.  Personal  history  :  Patient  has 
been  of  nervous  temperament  and  easily  startled,  but 
always  strong  and  capable.  Her  husband  died  about 
ten  years  before  her  admission  to  the  hospital,  and 
rjoney  losses  were  sustained  in  the  disposition  of  her 
estate.  During  the  six  months  preceding  admission 
she  appeared  in  her  usual  health,  except  that  on  one  or 
two  occasions  she  seemed  distracted.  One  week  be- 
fore admission  active  mental  symptoms  were  noted,  and 
five  days  later  she  became  suddenly  excited  and  delir- 
ious. 


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Case  I9CO.— .*cute  D«lu 


time  has  not  been  good.  During  a  period  directly  pre- 
ceding admission  to  the  hospital,  patient  attended  as 
nurse  three  cases  of  confinement  in  succession,  and  in 
each  case,  besides  caring  for  baby  and  mother,  at- 
tended to  the  household  duties,  often  working  at  the 
wash-tub  until  late  at  night.  The  present  attack  began 
suddenly  while  she  was  thus  employed,  a  few  days  be- 
fore admission. 

The  features  of  the  case  were  persistent  refusal  of 
food  and  medicine,  and  complicating  asthma.  Patient 
was  admitted  to  the  hospital  February  25,  1895,  *"d 
accepted  only  a  small  amount  of  nourishment  from 
that  time  until  the  evening  of  March  3d,  when  she  be- 
gan to  drink  milk.  In  the  succeeding  week  the  excite- 
ment subsided,  and  with  an  intervening  period  of 
loquacity  without  delusions,  she  passed  from  delirium 
to  a  rational  and  intelligent  mental  condition.  Conval- 
escence was  rapid  and  she  was  discharged  recovered 
April  4,  1895. 


The  features  of  the  case  devolved  upon  an  accident- 
al scald,  sustained  during  the  administration  of  a  bath 
on  the  evening  of  January  iSth,  seven  days  after  admis- 
sion. Febrile  reaction  followed  and  the  patient  was 
physically  prostrated,  but  there  was  no  active  delirium 
after  the  day  following  the  accident.  The  mental 
symptoms  disappeared  promptly,  but  convalescence  was 
somewhat  prolonged  during  the  healing  of  the  super- 
ficial wounds.  Patient  was  discharged  recovered  April 
5,  1895,  three  months  after  admission. 

Case  i960.  Acute  Delirium  Complicated  by  Excessive 
Drugging. — Woman,  aged  nineteen,  single  ;  nativity, 
New  Vork  ;  occupation,  student  ;  cause,  overstudy. 

Family  and  personal  history  good.  The  invasion 
was  sudden  and  occurred  two  weeks  before  admission. 
The  patient  had  been  industrious  at  study,  and,  as  the 
first  manifestation,  she  became  loquacious  and  con- 
fused. In  five  days  she  had  developed  an  actively  de- 
lirious state.     During  the  two  weeks  preceding  admis- 


8.C!2 


MEDICAL    RECORD. 


[December  14,  1895 


sion,  hypnotics  had  been  administered  in  large  doses, 
including  bromide,  morphine,  sulphonal,  and  hyoscy- 
amin  ;  on  the  night  before  admission  ether  was  admin- 
istered. Patient  had  had  quiet  intervals,  but  they  had 
become  less  frequent.  She  had  accepted  all  food,  but 
had  rapidly  emaciated.  At  the  time  of  admission  she 
was  restless,  active,  incoherent,  almost  constantly  in 
motion,  and  presented  the  usual  physical  manifestations 
of  acute  delirium.  The  pupils  were  so  widely  dilated 
that  the  red  retinal  reflex  could  be  seen  with  the  naked 
eye.  Whiskey  was  freely  administered,  and  on  April 
3d,  five  days  after  admission,  the  frenzy  had  changed  to 
a  state  of  exhilaration  with  rambling  talk  and  laughter. 
After  discontinuance  of  the  stimulants  this  gradually 
ceased  and  the  patient  soon  became  intelligent  and 
steady.  Recovery  was  delayed  by  a  period  of  relapse 
lasting  about  one  week.  Patient  was  discharged  from 
the  hospital  June  7,  1S95,  ten  weeks  after  admission. 


influenza,  and  reduced  to  a  condition  of  critical  debility, 
with  sleeplessness  and  refusal  of  food.  Improvement 
began  in  the  second  week,  and  convalescence  followed. 
Patient  was  discharged  recovered  June  8,  1895. 

Case  2212.  Acute  Delirium. — Woman,  aged  thirty- 
nine,  single  ;  nativity.  New  York  ;  occupation,  do- 
mestic ;  alleged  cause,  continued  excitement  over 
religion. 

Family  history  good.  Personal  history  :  Patient  re- 
ported to  have  been  eccentric  upon  the  subject  of 
religion.  Present  attack  followed  a  visit  with  "two 
ladies  who  called  themselves  faith  curists,"  and  the 
night  before  the  attack,  which  began  suddenly  one 
week  before  her  admission,  she  was  said  to  have  at- 
tended one  of  their  meetings  devoted  to  prayer  and 
song,  "  and  the  excitement  was  sufficient  to  bring 
about  the  present  state  of  affairs."  She  then  became 
excited  and  threatened  violence,  and  presented  marked 


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Cass  i960. — Acute  Delit 


Case  1856.  Afufe  DcHriuin  of  Puerperal  Origin. 
Relapse  during  Attack  of  Epidemic  Influenza,  folloived 
by  Recovery. — Woman,  aged  thirty-three,  married; 
nativity.  United  States  ;  occupation,  housewife. 

No  history.  Said  to  have  been  insane  one  week  be- 
fore admission.  Patient  was  of  large  frame,  of  great 
strength,  and  weighed  about  two  hundred  and  fifty 
pounds.  At  time  of  admission  the  breasts  were  dis- 
tended with  milk.  On  account  of  her  unusual  strength, 
difficulty  was  experienced  in  caring  for  her,  and  the 
observation  of  symptoms  was  incomplete.  She  was 
admitted  to  the  hospital  November  10,  1894,  and  the 
excitement  continued  for  about  two  months.  There 
then  developed  acute  parotitis  of  the  left  side,  and 
there  was  marked  physical  debility.  During  the  period 
of  excitement  chloral  was  used.  Upon  the  disajijiear- 
ance  of  the  parotid  swelling  she  became  quieter,  but 
passed  through  a  prolonged  period  of  irritability  and 
mental  confusion,  with  melancholy  and  a  tendency  to 
catalepsy.     March  14th  she  was  prostrated  by  epidemic 


physical  symptoms — "  tenderness  of  spine,  irritable 
stomach,  constipation  of  bowels,  coated  tongue,  and 
headache." 

Patient  was  admitted  to  the  hospital  July  23,  1S95, 
and  the  excitement  continued  for  one  week.  She  then 
obtained  a  fair  amount  of  sleep,  and  became  quiet, 
dull,  and  confused.  In  September  she  was  conval- 
escent, and  at  the  time  of  this  writing  (October  i,  1895) 
arrangements  have  been  made  for  her  discharge,  ten 
weeks  after  admission. 

Case  2168.  Acute  Delirium. — Woman,  aged  forty- 
two  ;  married  ;  nativity.  New  York  ;  occupation,  house- 
wife ;  causes  :  predisposing,  heredity,  apprehension  of 
insanity  ;  exciting,  overwork,  and  caring  for  sick  hus- 
band. 

Family  history  very  bad  :  One  brother  and  one 
sister  now  in  St.  Lawrence  State  Hospital  ;  another 
brother  has  been  insane  ;  parricide  has  been  committed 
by  one  member  of  the  family  ;  mother  is  a  defective 
and  in  the  county  almshouse. 


December   14,    1895] 


MEDICAL    RECORD. 


Personal  history  :  Patient  is  said  to  have  had  several 
previous  attacks,  and  to  have  been  constantly  appre- 
hensive of  insanity.  At  the  time  of  admission,  June 
18,  1895,  she  had  been  insane  for  two  weeks,  and  had 
shown  marked  homicidal  and  suicidal  tendencies,  with 
rapidly  developing  incoherence  and  confusion,  sleep- 
lessness, and  loss  of  strength  and  weight.  Under  the 
usual  treatment  she  responded  slowly,  and  at  the  time 
of  this  writing  (October  i,  1895)  she  is  stronger  and 
able  to  be  up  and  about  every  day,  but  is  dull,  con- 
fused, and  excitable,  rarely  speaking,  and  often  attempt- 
ing to  injure  herself. 

Case  1886.  Acute  Delirium  with  Chronic  Nephritis 
and  Partial  Honiplegia. — Woman,  aged  thirty-five  ; 
married  ;  nativity,  Canada ;  occupation,  housewife.' 
Alleged  causes  :  Frequent  child-bearing,  hemiplegia. 

History :  Patient  was  reported  to  have  been  in  poor 
health  for  years,  and  to  have  been  prostrated  by  an  attack 


admission  to  the  hospital,  and  had  been  characterized 
by  great  excitability  and  motor  restlessness,  religious 
delusions,  incoherence  of  thought  and  speech,  and 
suicidal  desire.  There  was  marked  physical  prostra- 
tion. The  delirious  condition  lasted  one  week  ;  pa- 
tient then  became  dull  and  groaned  a  great  deal.  She 
has  since  become  stronger  and  brighter,  is  up  and 
a.bout  every  day,  answers  simple  questions  with  intel- 
ligence, smiles  when  talking,  but  still  shows  the  post- 
insane  hebetude.  She  was  admitted  to  the  hospital 
August  16,  1895,  and  at  the  time  of  this  writing  has 
been  under  observation  six  weeks. 

Case  2254.  Acute  Delirium. — Woman,  aged  forty- 
seven  ;  single  ;  nativity,  Ireland  ;  occupation,  house- 
keeper.    Alleged  cause  :  Menopause. 

No  history  accompanied  this  patient,  except  the  in- 
definite statement  that  she  had  been  maniacal,  and  that 
the  insanity  had  developed  "  a  few  months  "  before  ad- 


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Case  2195.— Acute  Stupor. 


of  hemiplegia  in  January,  1894.  Shehad  been  submitted 
to  worry  over  business  matters.  Two  weeks  before 
admission  (December  21,  1894)  excitement  developed 
suddenly,  with  paroxysms,  usually  in  the  afternoon,  of 
great  severity,  and  separated  by  intervals  of  stupidity. 
Albuminuria  and  casts  were  determined.  Excitement 
subsided  in  two  weeks,  and  patient  passed  into  a  con- 
dition of  urremic  stupor  which  continued  for  several 
months.  Diuretic  and  laxative  treatment  with  hydro- 
therapy were  persistently  applied,  and  at  the  time  of 
writing  patient  is  able  to  be  up  and  about,  answers 
simple  questions,  reads,  but  appears  incapable  of  great 
mental  effort,  and  is  dull  and  inactive. 

Case  2230.  Acute  Delirium. — Woman,  aged  thirty- 
nine  ;  married  ;  nativity.  New  York  ;  occupation,  house- 
keeper. Alleged  causes  :  Domestic  troubles  and  deser- 
tion by  husband. 

Family  history  :  Mother  died,  aged  seventy-five,  with 
senile  dementia.  History  of  patient's  illness  indefinite. 
Her  disease  was  said  to  have  begun  ten  days  before 


mission.  She  was  admitted  to  the  hospital  September 
II,  1895,  in  delirious  condition,  and  became  (juiet  in 
two  weeks.  On  September  28th  she  was  dressed  and 
about  the  ward,  but  she  continues  insomnious  and  de- 
pressed. She  answers  questions  intelligently,  and  her 
general  condition  is  favorable. 

Acute  Stupor— Five  Cases.— Although  there  are  too 
few  cases  of  stupor  to  justify  inviolate  conclusions, 
their  features  appear  to  distinguisli  a  separate  class. 
In  recent  origin  and  in  pronounced  physical  manifesta- 
tions they  ajjproximate  the  conditions  of  acute  de- 
lirium. From  the  latter  they  were  distinguished  by 
some  slower  development,  by  more  profound  mental 
"  reductions,"' by  absence  of  remissions,  and  by  less 
favorable  results.  The  element  of  combined  physical 
and  mental  prostration  separates  them  from  other  dis- 
eases of  which  stupor  is  an  occasional  accompaniment. 
From  so-called  stuporous  melancholia  they  differ  in 
genesis,  in  period  of  incubation,  in  duration,  and  in 

'  Bevan-Lewis  :  Text-book  of  Menl.ll  Disease. 


834 


MEDICAL    RECORD. 


[December  14,  1895 


their  course.  The  presence  of  engrossing  delusions  to 
which  all  other  mental  operations  are  subordinate  was 
not  determined.  The  occasional  occurrence  of  tem- 
porary restlessness  and  agitation  suggest  more  properly 
affinity  with  a  general  mental  perturbation  of  acute 
delirium,  which,  in  some  cases,  appeared  during  the 
initial  stage. 

Sustaining  and  stimulating  methods  of  treatment 
were  adopted.  The  difference  in  mental  manifesta- 
tions between  the  delirious  and  the  stuporous  states 
are  regarded,  and  location  upon  an  open  ward  rather 
than  seclusion  was  thought  to  be  desirable,  for  its  pos- 
sible benefit  in  stimulation  of  object-consciousness. 

Case  1839.  Acute  Stupor  with  Albuminuria. — 
Woman,  aged  thirty-seven  ;  married  ;  nativity,  New 
York  ;  occupation,  housewife. 

No  definite  history  accompanied  this  patient.  Her 
mother  and  sister  were  said  to  have  been  insane,  and 
the  present  attack  to  have  existed  for  two  months. 
At  the  time  of  admission  she  was  stolid  and  stuporous, 
and  in  poor  physical  condition.  The  pulse  was  feeble, 
rapid,  and  its  tension  elevated.  The  tongue  was 
parched  and  coated,  and  the  bowels  were  loaded.  She 
continued  in  this  debilitated  state  for  three  months  ; 
she  then  changed  suddenly,  became  bright  and  active, 


perature  was  normal ;  pulse  88,  feeble,  and  with  ele- 
vated tension  ;  pupils  contracted  and  with  limited 
reaction  ;  skin  anremic  ;  tongue  moist,  stained,  and 
coated  ;  there  was  a  thick  secretion  in  the  mouth,  and 
the  breath  was  offensive.  She  was  admitted  to  the 
hospital  March  22,  1895,  and  on  the  evening  of  April 
2d  had  two  fits  of  hysterical  character.  She  then  im- 
proved rapidly,  and  was  discharged  recovered  April 
20,  1S95,  one  month  after  admission.  Tonic  and  laxa- 
tive treatment,  including  strychnine,  iron,  and  arsenic, 
was  adopted. 

Case  2195.  Acute  Stupor. — Woman,  aged  thirty- 
five  ;  married  ;  nativity,  Canada  ;  occupation,  house- 
wife. Causes  :  Care  of  insane  husband  and  (probably) 
specific  disease. 

Patient  was  admitted  to  the  hospital  July  4,  1895, 
with  a  record  of  insanity  of  three  months'  duration. 
She  had  had  the  care  of  her  husband,  who  was  suffer- 
ing from  general  paralysis  and  had  been  committed  to 
an  institution  for  the  insane  shortly  before  her  ad- 
mission. At  the  time  of  admission  she  was  drowsy 
and  dull,  barely  able  to  speak,  and  in  poor  physical 
condition.  The  temperature  was  subnormal  ;  the 
pulse  rapid,  irregular,  and  of  low  tension  ;  the  pupils 
dilated  and  unequal  ;  and  the  tongue  irritable,  swollen, 


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entered  upon  convalescence,  gained  in  weight  and 
strength,  and  on  April  2,  1S95,  six  months  after  ad- 
mission, was  discharged  recovered.  The  albumin 
detected  at  first  in  the  urine  disappeared.  The  treat- 
ment included  rest,  quiet,  tonic  stimulants,  and  elec- 
tricity. 

Case  1957.  Acute  Stupor  with  Hystcro-epilepsy  cind 
{probably)  Excessive  Drugging. — Woman,  aged  twenty- 
eight  ;  married  ;  nativity,  Canada  ;  occupation,  house- 
wife. 

No  history  accompanied  the  patient,  except  that 
attack  of  insanity  began  one  month  before  admission. 
At  the  time  of  admission  she  was  stuporous  ;  the  tem- 


furrowed,  clean,  moist,  and  steady.  Functional  de- 
rangement of  the  heart  was  determined.  The  abdo- 
men was  solid  and  its  percussion-note  flat.  Acting 
upon  the  suggestion  offered  by  the  husband's  disease, 
a  course  of  antisyphilitic  treatment  was  experimentally 
adopted.  Gastric  irritability  followed  and  was  con- 
trolled by  the  exhibition  of  belladonna.  On  the  morn- 
ing of  July  Sth,  discoloration  by  blood  was  noticed 
from  the  angle  of  the  mouth  along  the  chin  and  on  the 
bedding.     The  night  nurse  had  not  seen  a  convulsion. 

Physical  Examination. — Motion  impaired.  Legs  : 
Extension  and  flexion,  with  forced  resistance,  ac- 
complished,   showing    fair   strength    on    first   attempt, 


I 


December   14,  1S95] 


MEDICAL   RECORD. 


835 


with  ensuing  rapid  exhaustion  and  great  weakness. 
Gait  :  Shuffling  and  staggering  ;  Romberg's  symptom 
present.  Sensation,  apparently  normal  as  to  quality 
and  location.  Reflexes  :  Knee-jerk  present  but  not 
invariable — not  elicited  after  two  or  three  responses  ; 
ankle  clonus  absent ;  plantar  reflex  weak.  General  con- 
dition of  quick  exhaustion  with  preservation  of  function. 

Patient  now  began  to  improve  and,  after  preliminary 
loss  in  weight,  gained  in  strength  and  nutrition.  She  was 
discharged  September  21st,  ten  weeks  after  admission. 

C.\SE  2155.  Acute  Stupor. — ^Voman,  aged  thirty- 
six  ;  married  ;  nativity,  Pennsylvania  ;  occupation, 
housewife.  Cause  :  Irregular  menstruation  and  cli- 
macteric (early  menopause  a  family  trait). 

Family  history  good.  The  first  sickness  was  noticed 
May  16,  1895,  and  the  first  symptoms  of  insanity  May 
25th.  Patient  thought  she  had  done  some  great  wrong 
and  must  kill  herself  to  make  it  right.  She  attempted 
to  drown  herself,  to  cut  her  throat,  and  to  hang  her- 
self. She  was  in  a  stuporous  state  at  the  time  of  ad- 
mission, but  by  an  effort  was  able  to  answer  a  few 
questions.  The  temperature  was  normal,  the  pulse 
rapid  and  feeble,  the  tongue  coated,  the  eyelids  were 
drooping,  and  the  eyes  heavy  and  expressionless.  The 
bowels  were  loaded.  Patient  failed  rapidly,  and  on 
July  loth  was  fed  with  the  tube.  The  milk  and  whis- 
key thus  given  were  rejected.  Lavage  was  then  under- 
taken and  an  abundance  of  sour-smelling,  slimy  mucus, 
and  two  hardened  and  undigested  milk-curds  were 
washed  from  the  stomach.  Predigested  milk  with 
whiskey  was  then  given  through  the  tube  and  retained. 
This  procedure  was  repeated  at  regular  intervals,  but 
patient  failed  steadily,  and  on  the  morning  of  July  13th 
died,  five  weeks  after  admission.  Autopsy  was  not  per- 
mitted. 

Case  1855.  Acute  Stupor  with  Chronic  uVasai  Ca- 
tarrh and  Hypertrophy. — Woman,  aged  forty-six  ;  mar- 
ried ;  nativity,  New  York  ;  occupation,  housewife. 
.Mleged  cause,  injury. 

Family  history,  one  paternal  aunt  insane.  The  first 
symptom  followed  a  fall  from  a  ladder.  Patient's  back 
was  injured,  and  she  lay  helpless  for  some  time.  She 
complained  of  pain  in  the  back  and  head,  and  had  been 
subject  to  periods  of  confusion  in  which  she  lost  her- 
self and  was  bewildered.  She  then  became  melancholy 
and  attempted  suicide.  Stupor  developed  and  con- 
tinued with  alternating  periods  of  lucidity.  The  men- 
tal symptoms  date  from  four  months  before  admission. 
When  admitted  she  was  stupid  and  debilitated.  The 
tongue  was  clean  and  moist,  the  pulse  feeble,  circula- 
tion sluggish,  temperature  normal,  and  body  emaciated. 
The  abdomen  was  tense,  and  the  bowels  were  loaded. 
Albumin,  casts,  blood,  epithelium,  and  leucocytes  were 
found  in  the  urine.  Patient  was  given  liquid  diet, 
stimulants,  iron,  and  strychnine,  and  absolute  rest  in 
bed  was  enforced.  She  showed  no  tendency  to  im- 
provement, failed  steadily,  and  died  one  month  after 
admission.     Autopsy  was  not  permitted. 

Acute  and  Subacute  Insanities — Forty-five  cases. 
The  distinctions  of  the  subacute  and  acute  from  the 
hyperacute  forms  have  already  been  indicated.  Of  the 
former,  a  few  cases  of  special  interest  are  appended, 
the  tables  and  charts  showing  the  general  results  of 
treatment  in  these  more  common  forms  of  recent  in- 
sanity. It  has  been  found  advisable  to  surround  these 
patients  with  quiet  and  cheerful  conditions,  and  to 
avoid  classification  upon  the  basis  of  turbulence  or 
peacefulness.  Sedatives  were  used  in  moderation 
where  indicated,  but  most  frequently  sulphonal  and  tri- 
onal  were  relied  upon  to  promote  sleep,  together  with 
hydrotherapeutic  measures,  muscular  exercise,  and  mas- 
sage. 

Case  1951.  Acute  Melancholia. — AVoman,  aged 
thirty-five  ;  married  ;  nativity,  New  York  ;  occupation, 
housewife.  .\lleged  causes :  religious  matters  and 
uterine  troubles. 

Patient  was  first  admitted  to  the  hospital  November 


3,  1893,  after  an  illness  of  three  months'  duration. 
She  presented  active  changeable  personal  delusions 
with  aural  hallucinations,  which  gradually  disappeared, 
and  she  was  discharged  June  5,  1894.  She  was  read- 
mitted March  15,  1895,  with  a  repetition  of  the  pre- 
vious history  and  an  impulse  to  drown  herself  and  her 
child.  She  was  in  poor  physical  condition,  and  ap- 
peared anaemic.  Repeated  examinations  of  the  blood 
showed  an  average  of  three  and  one  half  millions  of 
red  corpuscles,  eight  thousand  leucocytes,  and  forty- 
five  per  cent,  of  haemoglobin.  Stained  specimens  by 
both  Reider's  and  Ehrlich's  methods  showed  crenation 
and  poikilocytosis  of  the  red  disks,  with  occasional  ir- 
regularities and  disintegration  of  the  neutrophilic  white 
cells.  Tonic  treatment  with  arsenic  and  iron  appeared 
of  temporary  benefit,  but  the  general  course  of  the  dis- 
ease was  unfavorable,  and  during  the  last  week  in  Au- 
gust the  patient  manifested  the  characteristic  contract- 
ures and  spasms  of  tetany.  She  failed  rapidly  and 
died  September  5,  1895,  after  the  development  of  hy- 
perpyrexia.    Autopsy  was  not  permitted. 

Cases  1932  and  1993.  Acute  Melancholia  tcith  Auto- 
intoxication.— Woman,  aged  twenty-nine  ;  married;  na- 
tivity, Canada  ;  occupation,  housewife. 

Patient  was  first  admitted  to  the  hospital  February 
19,  1895,  with  history  of  insanity  of  three  and  one-half 
months'  duration.  She  was  debilitated  and  stupid,  and 
writhed  and  groaned  as  if  in  great  pain.  The  abdo- 
men was  very  sensitive,  and  she  stated  that  there  had 
been  no  evacuation  from  the  bowels  for  a  long  time. 
She  did  not  enter  freely  into  conversation,  and  delu- 
sions were  not  ascertained.  Attention  was  directed  to 
the  enteric  condition,  and  scybalous  masses  were  at 
once  removed.  Improvement  began  promptly,  but  pa- 
tient showed  some  mental  weakness  and  soon  expressed 
the  idea  that  she  was  a  source  of  contamination  to 
others,  and  that  she  should  be  removed  from  the  hos- 
pital. Later  her  conversation  continually  turned  to 
the  subject  of  snakes  ;  at  first  she  said  she  was  full  of 
snakes,  that  her  fingers  and  toes  were  snakes,  and 
finally  that  she,  herself,  was  a  snake.  These  delusions 
were  partially  controlled,  and  against  the  advice  of  her 
physicians  she  was  prematurely  removed  from  the  hos- 
pital by  her  husband.  Upon  her  return  home  she 
acted  upon  her  delusions,  left  the  house,  and  crept  and 
rolled  about  on  the  ground  in  verification  of  her  idea. 
She  was  recommitted  to  the  hospital  in  four  days. 
After  an  initial  period  of  debility  and  confusion  she 
again  improved,  her  delusions  disappeared,  and  on  Au- 
gust 29,  1895,  six  months  after  the  first  admission,  she 
was  discharged  recovered.  During  treatment  in  the 
hospital  she  gained  in  weight  twenty  pounds. 

Case  2158.  .Icute  Melancholia.  —  Woman,  aged 
thirty  ;  married  ;  nativity,  unascertained  ;  occupation, 
housewife.  Alleged  cause,  ill-health  following  child- 
birth. 

Patient  was  said  to  have  been  insane  for  three 
months  before  admission  to  the  hospital.  At  the  time 
of  admission  she  was  depressed  and  debilitated,  but  in- 
telligent. Her  condition  was  then  complicated  by  a 
functional  intention  tremor,  which  disappeared  in  a 
few  days.'  The  treatment  adopted  included  tonics, 
stimulants,  massage,  electricity,  and  quiet.  Patient  im- 
proved steadily,  and  was  discharged  recovered  after 
ten  weeks,  having  gained  in  weight  ten  pounds.  Her 
improvement  in  physical  health  continued  after  her 
discharge  from  the  hospital. 

Case  1955.  Acute  Mania. — Woman,  aged  forty- 
eight  ;  widowed  ;  nativity,  Ireland  ;  occupation,  house- 
keeper.    Exciting  cause  :  syphilis. 

At  the  time  of  admission  she  was  in  fair  physical 
condition  and  in  a  state  of  active  mania.  Under  spe- 
cific treatment  she  improved  rapidly,  gained  in  weight 
twenty  pounds,  and  was  discharged  recovered  in  five 
months. 

'  Dr.  James  Hcndrie  Lloyd  :  Hysterical  Tremor  and  Hysterical 
Anore.xia,  American  Journal  of  the  Medical  Sciences,  July,  1853. 


836 


MEDICAL    RECORD. 


[December  14,  1895 


Case  1976.  Acute  Mania. — Woman,  aged  thirty- 
four  ;  married  ;  nativity,  Vermont ;  occupation,  pros- 
titute. 

Patient  was  admitted  in  a  state  of  active  mania  with 
slight  physical  deterioration.  She  was  said  to  have 
been  insane  for  one  week,  and  showed  marked  delusions 
of  exaltation.  She  was  placed  upon  a  course  of  spe- 
cific treatment  and  improved  rapidly,  gaining  in  weight, 
in  five  months,  twenty  pounds. 

Case  1863.  Acute  Mania. — Woman,  aged  forty-one  ; 
married  ;  nativity,  Ireland  ;  occupation,  housewife. 
Alleged  cause  :  family  troubles,  death  of  son. 

No  history  accompanied  the  patient.  She  was  ac- 
tively excited  at  the  time  of  admission,  and  afterward 
was  subject  to  sudden  outbreaks  of  mental  and  motor 
disturbance,  with  resistance  to  care  and  the  appearance 
of  controlling  delusions,  which  were  not  expressed. 
She  did  not  improve.  She  was  admitted  to  the  hos- 
pital November  r4,  1895.  In  May,  after  a  prolonged 
period  of  excitement,  she  became  depressed  and  re- 
mained in  bed.  During  the  last  week  in  May  she  suf- 
fered from  severe  and  intractable  diarrhoea.  On  the 
morning  of  May  30th,  her  right  leg  became  suddenly 
cold,  pale,  and  paralyzed,  with  some  cyanotic  discolor- 
ation. No  heart  murmur  was  detected.  The  pulse 
was  weak,  and  the  temperature  varied  from  99°  to 
101°  F.  during  the  day.  Urinalysis  revealed  urates 
and  albumin. 

On  the  following  morning,  at  half-past  seven  o'clock, 
she  collapsed,  the  heart-beat  could  not  be  determined, 
the  pupils  were  widely  dilated,  the  skin  became  sallow 
and  livid,  there  were  a  few  gasps,  and  without  convul- 
sion or  coma  she  died  in  an  hour. 

The  autopsy  showed  general  sclerosis  of  the  brain, 
thrombosis  of  the  great  longitudinal  sinus,  gangrenous 
enteritis,  and  thrombosis  of  the  right  popliteal  artery. 
Search  for  a  plug  in  the  abdominal  vessels  was  unavail- 
ing, although  the  existence  of  such  was  strongly  indi- 
cated. 

The  following  tables  have  been  made  upon  the 
basis  of  completed  cases,  with  the  purpose  of  avoiding 


the  element  of  probability.  The  results  are  not  in 
variance  with  those  previously  published,'  but  verify 
them  by  greater  detail.  Of  necessity  they  included 
cases  admitted  to  the  hospital  during  the  last  months 
of  the  fiscal  year,  as  well  as  during  the  earlier  period. 
They  reveal  the  impossibility  of  securing  definite 
data  in  the  space  of  a  year,  relating  to  diseases  whose 
natural  course  covers  a  greater  time.  This  uncer- 
tainty is  especially  shown  in  Cases  1841  and  1857,  ad- 
mitted at  the  beginning  of  the  5  ear  and  not  yet  de- 
termined. 

These  patients  have  both  passed  through  attacks  of 
acute  mania  of  prolonged  duration,  and  have  attained 
the  state  of  post-maniacal  hebetude,  in  which  the  fore- 
cast for  chronicity  or  cure  is  involved  in  obscurity. 
Further  study  of  these  cases  during  the  succeeding 
year  will  remove  many  elements  of  doubt  and  render 
insignificant  the  number  of  uncompleted  cases. 

Gynecological  complications  have  not  been  dis- 
cussed, because  there  have  been  no  cases  whose  gyne- 
cological aspects  appeared  directly  related  to  the 
course  of  the  disease.  The  minor  ailments  of  women 
have  had  proper  attention  and  treatment,  and  their 
correction  has  been  a  factor  in  the  restoration  of 
health. 

It  has  been  sought  by  this  paper  to  remove  the  un- 
certainties of  statistics  by  the  consideration  of  individ- 
ual cases,  and  to  emphasize  the  curative  and  hospital 
functions  of  an  institution  for  the  insane.  In  some 
measure  is  revealed  the  great  demand  made  by  the  re- 
coverable class  of  patients  ;  the  need  of  close  physical 
diagnosis,  of  the  arrangement  of  wards  for  isolation 
and  separation  of  disquieting  elements,  refinement  of 
diet,  and  skilful  attention  of  qualified  trained  nurses. 
The  success  has  been  encouraging,  and  the  results 
justify  the  still  greater  development  of  the  medical 
work  of  the  institution.  The  hope  may  be  indulged 
that  the  attention  of  the  practising  physician  will  be 
attracted,  and  that  public  hospitals  for  the  insane  shall 
receive,  as  is  their  due,  the  emphatic  and  steady  sup- 
port of  the  general  profession. 


T.\BLE  I. — Acute  Deliriu: 


1937 
1900. 
i960 
1856. 
2212. 
216S. 
18S6. 
2230. 
2254 


l*=™y-  Improved   Dealh      I"  Hospital, 


Yes. 4  days. 


Yes. 
\'es. 
Yes. 
Yes. 


Poor. 

Not  good. 

Good. 

Good. 


2  day: 
2  weeks. 

I  week. 

I  week. 
2  weeks. 
2  weeks. 

10  days. 
Indefinite. 


si  weeks. 
3  months. 
10  weeks. 
7  months. 
3  months. 


Complication,  pulmonary  emphysema. 
Recovery  following  scald. 
Excessive  drugging  before  admission  ;  ether. 
Relapse  following  epidemic  influenza. 
Rapid  Improvement. 

4  months.    \'ery  bad  heredity. 

9  months Chronic  nephritis  ;  hemiplegia. 

3  weeks |  Admission  September  nth  ;  convalescence  begun. 

6  weeks.    ' .Admission  .August  i6th  ;  convalescence  begun. 


5 


Cases,  9  ;  completed  cases,  7  ;  recoveries,  5  ;  deaths,  o.      Percentage  of  recoveries  to  completed  cases,  7ii.     Average  gain  in  weight. 
H  pounds.     Average  duration  before  admission  (8  cases),  9  days.     Averj^e  period  under  treatment  of  5  recovered  cases,  14  weeks. 


1839. 
«957- 
2195. 

1855- 
2155. 


Table  2. — Acute  Stupor. 


ered.     Improved    Ueath. 


I  In  Hospital, 
I     Prospect. 


Yes. 
Yes, 
Yes. 


1 2  months.  ,5*  months 

.-. 1  month.       I  month. 

, 3  months.     3  months. 

Yes,   1 3  months. 

Yes.   I I  month. 


Gain  in 
Weight. 


Pounds, 

iS 


Bromism  ;  hystero-epilepsy. 
16        Specific. 

26  days |No  autopsy ;  exhaustion. 

I  month No  autopsy  ;  e.xhaustion. 


Cases,  5  ;  recoveries,  3  ;  deaths,  2      Percentage  of  recoveries,  60.     Percents^e  of  deaths,  40.     Average  duration  before  admission,  » 
months.     Average  period  under  treatment  of  3  recovered  cases,  3  months. 


St,  Lawrence  State  Hospital,  Sixth  and  Eighth  Annual  Reports. 


December  14,  1895] 


MEDICAL   RECORD 


S37 


-.\CLTE  Mela.nchol: 


Case  No. 

Recov- 
ered. 

Im- 
proved. 

Dea-i. 

In  HospitaL 
Prospect. 

Before 
.Admission. 

Under 
TreaanenL 

Gainia 
WdghL 

189I 

Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 

2  months. 
3i  months. 
6  months. 

3  weeks. 
10  days. 
2  days. 

3  months. 
I  year. 

4  months. 
6  months. 
45  months. 
8  months. 
I S  months. 
6  months. 

6  months. 
I  year. 

7  months. 
I  year. 
Sdays. 

4  months. 
Sev.  mos. 
2  months. 
6i  months. 

2  months. 
S  months. 

5  «  months 

2  months. 

3  months. 

3  months. 
10  weeks. 

6  montns. 
7  weeks. 
7  weeks. 

10  weeks. 
2  months. 
6  months. 

I  year. 
S  months. 
S  months 

4  months. 
6  weeks. 
6  weeks. 
6  weeks. 
6  weeks. 
6  weeks. 
3  weeks. 

Pounds. 

1932  and  1933. 
1973 

17 
10 

2026   

6 

2027 

29 

215S 

2176 

Yes. 

17 

2216 

Yes. 
Yes. 

Yes.  ' 

Yes. 

Yes. 

1S3S 

1848 

195 1 

1834 

Poor.* 
Good. 

Good.f 
Good.+ 

? 

2174 

2226 

222S 

2256 

2260 

2265 

Exophthalmic  goitre  ;  stupor. 

Auto-intoxication  ;  limited  delusion. 

Second  attack. 

Puerperal. 

Second  attack  ;  laceration  of  wrist. 

Yalvular  disease  of  heart. 

Hysterical  intention  tremor. 

Nosi  algia. 

Anseraia  ;  irregular  heart ;  phthisis. 

Carcinoma ;  cerebral  softening. 

Exhau?ted  on  admission  ;  bromism. 

Anxmia  ;  tetany  ;  exhaustion. 

Dementia  and  fixed  delusions. 

Thyroid  treatment. 

Resistive  and  stuporous. 

Thyroid  treatment. 

Goitre ;  phthisis  ;  gaining  rapidly. 

Suicidal  frenzy. 

1  mproving. 

Bromism. 

Delusions  of  persecution. 

Improring. 


Cases.  23  ;  completed  cases,  i6;  recoveries,  lo;  deaths,  3.  Percentage  of  recoveries  to  completed  cases.  62}.  Average  gain  in 
weight  of  7  recovered  cases,  i6i  pounds.  Average  duration  before  admission,  5*  months.  Average  period  imder  treatment  of  S  recov- 
ered cases,  4  months. 

Table  4.— .\ccte  Mania. 


I  RccoT-       Im- 
ered.    1  proved. 


In  Hospital,  Before      - 

Prospect.        .^idmission. 


Weight. 


•  90i 
192S 

'955- 
1976. 
19S0. 
1863. 
184.. 
1867. 
1944- 
200;. 


Yes ...     10  weeks. 

Yes 6  months. 

Yes 3  weeks. 

Yes.    I  week. 

Yes I  week. 

Yes.     S  months. 

2  week;. 

10  days. 

1  month. 

2  weeks 
3  days. 

6  weeks. 
I  week, 
a  few  days. 
5  Weeks. 
I  month. 


Fair. 

Fair. 

Fair. 

... Poor. 

2173 Good. 

22 14 Good. 

2223 1  Good. 

2233 ? 

2263 Hopeful. 

2159 Good. 


5  months  14  Latent  phthisis. 

4  months.         30  Hysteria. 

5  months.         20  Specific. 

6  mouths.         20  Specific. 
6  months.          35 

6  months Marantic  thrombosis. 

I  year Recovery  from  similar  previous  attack. 

I  year Recovery  from  similar  previous  attack. 

7  months 

5  months.    Paroxysms  of  excitement ;  delusions. 

4  months ImproN-ing. 

3  months.    Lactation  :  second  attack. 

7  weeks Practically  recovered  ;  rheumatism. 

6  weeks Specific. 

2  weeks.     Puerperal  eclampsia. 

4  months.  ; Goitre ;  improving. 


Cases,  16  ;  completed  cases,  6  ;  recovered,  5 ;  died.  i.      Percentage  of  recoveries  to  completed  cases,  83.     Average  gain  in  weight  in  5 
i.ered  cases,  24  pounds.     Average  duration  before  admission,  6  weeks.     Average  period  under  treatment  of  5  recovered  cases,  5  months. 

Table  5.— StJBACirrit  Insasitv. 


Re-  Im-        Death,  i  '"  Hospiul,         Before 

oveied.    proved.  Prospect.        Admission. 


I  I  : 

2006 Poor I  month. 

2192 ...    Yes 6  weeks. 

1824 Yes 8  months. 

2210 Yes 4  months. 

1954 I 14  months. 

2224 Yes... 1 5  months. 

I  I  <  ! 


Growing  demented. 

Incurable  physical  disease.     Removed  prematurely. 

Organic  heart  disease. 

Second  attack.     Chronic  rheumatism. 

Active  neurasthenia.      Removed  prematurely. 

Removed  Prematurely. 


Cases,  6.     Recovered,  2.     Improved,  2.     Deaths,  o. 


Average  duration  before  admission,  8i  months. 


Table  6.— Summart. 


Cases 
Completed  cases 

Recoveries. 

Per  cent,  recoveries  on  completed  cases 

Deaths 

Per  cent,  deaths. 


Average  gain  in  weight  of  recovered  cases It  pounds.  17  pounds.    16^  pounds.    24  pounds.   6^  pounds.    15  pounds. 

Duration  before  admission 9  days  2  months.     5^  months      6  weeks.      8^  months.    3J  months. 

Period  under  treatment  of  recovered  cases 14  »veeks.      3  months.       4  months.     5  months.    14  weeks.      4    months. 


*  Chronicity  established. 


t  Two  cases  to  be  soon  discharged. 


MEDICAL    RECORD. 


[December  14,  1895 


THE  PALLIATIVE  TREATMENT  OF  GONOR- 
RHCEIC  TUBAL  DISEASE.' 

By  \V.  R.  PRYOR,  M.D., 

PROFESSOR    OF  GYNECOLOGY,   NEW  YORK   POLYCLINIC  ;   FELLOW  OF  THE   AMERI- 
CAN  GYNECOLOGICAL  SOCIETY. 

I  THINK  it  may  be  accepted  as  indisputable  that 
radical  cure  of  inflamed  tissues,  in  which  the  process 
has  gone  so  far  as  to  produce  pus,  can  be  surely  ef- 
fected by  their  removal  only.  This  is  especially  true 
where  suppuration  takes  place  in  pre-formed  sacs. 
The  practice  among  surgeons  is  to  remove  all  tubes 
and  ovaries  of  gonorrhceal  infection,  and  some  of  us, 
myself  among  the  number,  always  remove  the  uterus 
also  where  both  adnexa  are  destroyed,  as  the  hys- 
terectomy not  only  gives  a  more  permanent  cure  and 
smoother  convalescence,  but  the  mortality  is  lower. 

So  much,  then,  for  the  best  plan  of  treatment  of  cases 
of  gonorrhceal  endometritis  with  bilateral  suppurative 
tubal  complications.  But  nowhere  in  the  whole  sphere 
of  surgical  procedures  do  extraneous  conditions  so 
modify  the  indicated  treatment  as  in  destructive  dis- 
eases of  the  adnexa  uteri.  The  endometrium  being  a 
lymphoid  organ,  is,  in  function,  intimately  associated 
with  other  organs  of  similar  kind,  and  marked  tissue 
changes  throughout  the  body  follow  hysterectomy.  In 
young  girls  a  distressing  neurasthenia,  marked  by 
melancholia,  is  often  seen  ;  the  external  genitals  and 
vagina  shrink,  and  copulation  becomes  painful ;  the 
woman  no  longer  menstruates,  and  the  increased 
monthly  intra-vascular  tension  normal  to  menstruation 
finds  no  relief,  but  produces  headaches  and  hysteria. 
SHch  are  the  very  common  results  of  removal  of  the 
uterus  and  adnexa. 

So  then,  single  women  wish  to  be  as  other  women, 
menstruating  ;  and  wives  as  other  wives.  And  we  are 
often  forced  into  doing  incomplete  palliative  work  in 
order  to  preserve  to  the  woman  certain  physiological 
states  and  to  avoid  premature  menopause. 

So  far  as  the  palliative  surgical  treatment  of  the 
pelvic  complications  of  gonorrhceal  infection  is  in- 
volved, three  conditions  may  be  described  :  Acute  sal- 
pingitis with  acute  pelvic  peritonitis,  old  chronic  tubal 
disease  with  recurrent  attacks  of  acute  inflammation,  and 
cases  in  which  hydrosalpinx,  or  pyosalpinx,  has  resulted. 
Acute  Salpingitis. — Seventeen  cases  with  first  attacks 
have'  been  seen.  In  all  there  was  enlargement  of  one 
or  both  tubes,  great  tenderness,  acute  pain,  tempera- 
ture, often  tympanites  and  vomiting.  In  all  curettage 
of  the  acutely  inflamed  uterus  was  made,  acting  upon 
the  belief  that  here  started  the  infection,  and  here 
should  it  be  first  attacked  ;  just  as  the  adenitis  as- 
sociated with  a  chancroid  disappears  when  the  spe- 
cific virus  is  destroyed  early.  These  acutely  inflamed 
tubes  are  deeply  injected,  appear  almost  necrotic,  but 
upon  section  the  inflammatory  process  seems  to  be 
almost  wholly  in  the  walls  of  the  tube,  the  lumen  but 
slightly,  or  not  at  all,  distended  by  purulent  accumula- 
tion. I  believe  in  the  resistant  power  of  these  highly 
vitalized  organs,  and  have  no  hesitancy  in  stating  that 
if  the  proper  sort  of  curettage  be  done  early  a  radical 
cure  of  the  tubal  inflammation  often  results.  Of  the 
1 7  cases  so  treated  but  3  required  removal  of  the  af- 
fected tubes.  And  it  is  significant  that  all  of  these  3 
were  seen  after  the  infection  had  lasted  over  a  week. 
The  remaining  14,  so  far  as  I  could  discover,  entirely 
recovered.  All  pain  and  tenderness  disappeared,  and 
upon  examination  no  sensitive  spot,  no  tubal  enlarge- 
ment remained.  They  all  menstruated  painlessly  and 
normally  after  the  operation.  So,  then,  I  invariably 
curette  these  acute  cases,  but  in  a  manner  a  little  dif- 
ferent from  that  commonly  employed.  Eor  the  tech-, 
nique  of  the  operation  I  must  refer  you  to  the  "  Trans- 
actions of  the  New  York  Obstetrical  Society,"  November 
5,  1895- 

'  Read  before  the  Genito-Urinary  Section,  Academy  of  Medicine, 
November  12,  1895. 


There  are  certain  of  these  acute  cases  which  have 
been  of  longer  duration,  but  which  yet  present  acute 
symptoms.  The  lesions  are  still  those  of  an  interstitial 
infection,  with  much  enlarged  tubes,  recent  lymph 
about  the  adnexa,  as  well  as  slight  accumulation  of 
muco-purulent  fluid  in  the  tubes.  The  fimbriated  ends 
are  occluded,  but  the  uterine  openings  still  open.  Such 
cases  occupy  the  mid-state  between  the  most  acute  and 
those  presenting  true  pyosalpinx.  In  such  cases  we 
get  the  greatest  relief  from  the  curettage,  supplemented 
by  opening  the  posterior  cul-de-sac.  After  curetting 
the  culde-sac  is  opened  in  the  median  line  by  a  cres- 
centic  incision.  The  adhesions  are  broken  up,  and 
the  coils  of  intestine,  tubes,  ovaries,  omentum,  and 
uterus  are  separated.  The  pelvis  is  then  filled  by  iodo- 
form gauze,  in  very  much  the  same  way  as  a  Mikulicz 
dressing  is  made  from  above.  The  procedure  seeks 
the  isolation  of  the  infected  area,  as  well  as  removal  of 
the  original  and  continuous  source  of  infection  from 
the  endometrium.  The  results  are  very  beautiful  in- 
deed. I  have  applied  this  procedure  in  but  seven  cases, 
and  not  one,  so  far  as  I  know,  has  relapsed.  There  re- 
mains for  some  time  more  or  less  thickening  about  the 
aflfected  tubes,  and  so  long  as  this  can  be  detected  the 
use  of  vaginal  tampons  of  ichthyol,  ten  per  cent.,  in 
boroglyceride,  ninety  per  cent.,  is  indicated. 

Recurrent  Chronic  Salpingitis. — These  cases  are 
exceedingly  common.  Apparently  the  gonococcus  has 
little  pyogenic  power  in  certain  women,  and  produces 
catarrhal  inflammations  only.  If  we  examine  tubes 
thus  affected  we  find  them  during  an  attack  much  con- 
gested, and  with  the  matted  fimbriae  and  adhesions 
•vhirh  indicate  old  infections.  There  is  not  often  re- 
jent  lymph,  and  they  do  not  commonly  contain  pus. 
The  walls  of  the  tubes  are  thickened,  but  dense  and 
hard.  There  is  a  process  of  fibrosis  going  on.  For 
these  women  we  can  do  the  least.  Although  they  have 
a  tissue  resistance  which  does  not  conduce  to  pus-for- 
mation, or  a  limited  pyogenic  invasion  has  taken  place, 
the  very  character  of  the  changes  insures  a  maintenance 
of  the  infection.  Their  uteri  also  are  dense  and  firm, 
and  the  curettage  which  we  here  do,  although  thoroughly 
cleansing  the  inside  of  the  uterus,  has  little  or  no  effect 
upon  the  tubal  disease.  Still  it  is  indicated  as  a  means  to 
remove  one  focus  of  infection.  I  have  latterly,  within 
the  year,  opened  the  cul-de-sac  of  these  women,  broken 
up  adhesions,  replaced  a  possibly  adherent  retroposed 
uterus,  and  drained  by  gauze  the  lowest  part  of  the 
cul-de-sac.  A  temporary  benefit  is  always  obtained, 
and  much  relief  of  local  symptoms.  But,  as  I  said,  the 
repair  power  of  these  fibroid  tissues  is  much  damaged, 
and  I  shall  always  expect  women  thus  affected  to  have 
pennanent  symptoms  of  tenderness  and  pain.  I  have 
never  seen  a  pus-tube  form  in  such  tissue.  We  see 
these  uteri  and  tubes  in  old  prostitutes,  and  very  often 
there  are  multiple  broad  ligament  cysts  associated  with 
the  other  changes.  The  menstruation  is  scanty,  the 
uterus  being  commonly  atrophic. 

Hydrosalpinx  and  Pyosalpinx. — These  are  certainly 
cysts  of  retention  only — the  one  simple,  the  other  pur- 
ulent. Although  believing  firmly  that  radical  cure  of 
suppuration  in  a  preformed  sac  can  be  with  certainty 
accomplished  by  extirpation  of  the  sac  only,  yet  I  must 
confess  I  am  wonderfully  pleased  with  the  treatment  I 
shall  describe. 

Here,  also,  the  uterus  is  curetted  and  packed.  The 
cul-de-sac  is  opened,  and  as  little  disturbance  of  exist- 
ing adhesions  made  as  is  possible.  The  wall  of  matted 
viscera  above  these  tubes  should  be  left  alone.  A  wide 
opening  is  made  in  the  cul- de-sac,  with  perhaps  a  cru- 
cial cut  down  the  vagina — an  abundance  of  room 
must  be  secured.  Seeing  the  distended  tubes  we 
puncture  them  with  scissors.  As  the  pus  escapes  we 
introduce  the  fingers  and  widely  tear  open  the  tubes. 
The  pelvis  is  not  washed  out,  but  the  tubes  are  wiped 
dry  with  iodoform  gauze,  and  the  entire  field  of  oper- 
ation cleaned  in  a  similar  way.    We  now  pack  the  tubal 


December   14,  1S95] 


MEDICAL   RECORD. 


839 


cavities  full  of  gauze.  It  is  a  pelvic  Mikulicz  we  make, 
and  every  exposed  tissue  has  gauze  against  it.  Two  to 
four  yards  of  gauze  are  often  used,  securing  not  only 
absorption  of  fluids,  but  pressure  as  well.  Rapidly  and 
progressively  these  tubes  atrophy.  No  longer  are  acute 
auto-infections  possible — you  have  prevented  that  by 
your  curettage.  And  even  though  a  faulty  and  incom- 
plete technique  shall  have  left  an  unopened  pocket 
somewhere,  yet  is  there  abundant  provision  for  drain- 
age in  case  it  breaks. 

Now,  gentlemen,  these  women  are  gonorrhoeic,  and 
when  symptomatically  cured  are  prone  to  seek  the 
causes  of  their  trouble.  This  we  must,  if  possible,  pre- 
vent ;  and  if  coition  can  be  stopped,  no  return  of  trouble 
is  seen. 

In  all  these  cases  in  which  the  tubes  are  affected, 
and  in  which  the  cul-de-sac  is  opened,  the  function  of 
the  tubes,  so  far  as  gestation  is  involved,  is  gone,  and 
fortunately  so  ;  for  were  it  possible  for  the  ovum  to 
enter  the  tubes  extra-uterine  pregnancy  might  result. 

What  I  am  striving  to  do  is  to  give  the  surgeon,  as 
well  as  the  general  physician,  who  cannot  obtain  the 
aid  of  a  specialist,  certain  procedures  which  will  in 
most  cases  effect  a  cure  ;  to  furnish  them  with  methods 
of  treatment  better  than  the  poultice  and  opium  of  the 
timidly  incompetent,  and  yet  not  so  severe  and  muti- 
lating as  the  salpingo  oophorectomy  or  ablation.  There 
is  a  middle  ground  upon  which  we  can  stand,  and  the 
best  of  us  must  sometimes  occupy  it. 

Although  the  ablation  of  uterus  and  adnexa  gives 
but  three  per  cent,  mortality,  there  are  some  things 
dearer  to  some  women  than  life.  And  it  is  to  furnish 
that  measure  of  relief  with  that  hope  of  recovery  to 
just  such  women  that  I  have  worked  along  this  line  of 
conservative  treatment  of  the  pelvic  complications  of 
gonorrhoea.  And  I  make  it  a  rule  in  all  such  cases  to 
lay  before  my  patient  a  general  statement  of  the  limi- 
tations of  such  procedure.  Rarely  will  one  be  found 
who  does  not  grasp  at  the  possibility  of  relief  without 
danger  and  without  mutilation.  Were  it  possible  to 
prevent  reinfection  in  these  women,  could  one  seal 
thern  against  coition,  I  firmly  believe  that  the  vast  pro- 
portion of  them  (and  I  estimate  the  percentage  at 
eighty)  would  never  have  a  recurrence  of  acute  trouble. 
But  one  great  advantage  these  palliative  measures  give 
the  surgeon  when  applied  in  acute  cases,  and  in  cases 
presenting  pyosalpinx  :  they  enable  him  to  temporize 
and  to  do  a  radical  operation  when  he,  not  the  disease, 
elects. 

Certainly  our  results  will  be  still  better  when  we  can 
tide  over  that  stage  in  disease  during  which  the  emunc- 
tories  are  taxed  to  the  utmost  to  eliminate  toxins,  when 
the  heart  is  embarrassed,  and  extensive  visceral  lesions 
exist. 

Assuredly  I  offer  you  procedures  which  are  better 
than  the  old  let-alone  policy  ;  for  the  latter  sought 
physical  ease  by  means  of  narcotics  and  allowed  a  de- 
structive infection  to  run  riot  in  the  woman's  most  im- 
portant organs.  The  pelvic  complications  of  gonorrhoea 
in  women  are  surgical  diseases,  and  should  be  met  by 
surgical,  not  medicinal,  measures.  We  can  now  do  this 
with  safety  and  success. 


Quackery  in  Connecticut.— The  New  Haven  County 
Medical  Association  has  passed  a  set  of  resolutions  de- 
claring that  other  States  are  rejecting  by  their  examin- 
ing boards  incompetents  who  are  admitted  to  practice 
in  Connecticut  without  examination  ;  that,  in  conse- 
quence, the  State  is  becoming  a  dumping-ground  for 
undesirable  practitioners.  The  Association  suggests 
that  the  State  Committee  on  Legislation  be  instructed  to 
advocate  an  amendment  of  the  law,  so  that  all  candi- 
dates for  registration  as  doctors  under  the  medical 
practice  act  be  required  to  pass  an  examination,  as  is 
now  the  case  in  most  of  the  States  in  the  Union. 


THE  REMISSIONS  OF  GENERAL  PARALYSIS. 
By  WHITMORE  STEELE,  M.D., 

FORMERLY  ASSISTANT  PHV51C1AX,  LTICA  STATE  HOSPITAI,  FOR  THE  INSANE  ; 
PHYSICIANTO  THE  PRESB\TERIA,N  HOSPITAL,  OUT-PATIENT  DEPARTMENT  ;  .MEM- 
BER OF  THE  NEW  YORK  NEUROLOGICAL  SOCIETY,   ETC. 

Whether  we  look  upon  general  paralysis  as  a  disease 
which  is  inflammatory  in  origin,  or  with  Schitle  con- 
sider it  primarily  a  vaso-motor  disturbance,  or  with 
still  other  observers,  look  toward  the  nerve  elements  as 
the  initiatory  seat  of  the  disease,  the  phenomenon  of  a 
remission,  or  sometimes  several  of  them,  seen  during 
its  course,  presents  an  interesting,  and  at  times  puz- 
zling, clinical  picture.  When  we  consider  that  we  find 
post  mortem,  in  this  disease,  a  destruction  of  neurons, 
extensive  and  irreparable,  together  with  a  wide-spread 
and  permanent  alteration  in  blood-vessels  and  stroma, 
this  phenomenon  of  apparent  recovery,  although  often 
only  partial,  becomes  one  worthy  of  study  in  regard  to 
its  causes,  their  nature,  and  significance.  A  point 
worthy  of  note  is  that  remissions  rarely  occur  in  any 
but  recent  cases  of  general  paralysis,  which  fact  leads 
us  to  infer  that  the  primary  changes  that  occur  in  this 
disease  are  more  in  the  nature  of  so-called  functional 
disorder,  affecting  nutrition  and  the  like.  Opportunity 
for  post-mortem  examination  in  the  first  stages  of  gen- 
eral paralysis  is  not  very  frequent.  Berkeley '  has 
recently  reported  the  lesions  found  in  a  patient  who 
died  only  nine  months  after  the  beginning  of  his  dis- 
ease. The  changes  found  in  this  case  were  undoubtedly 
more  extensive  than  those  which  would  be  found  in  a 
general  paralytic  whose  disease  was  running  its  regular, 
somewhat  chronic  course,  but  who  had  died  of  some 
intercurrent  complaint.  The  case  reported  was  prob- 
ably one  of  the  variety  spoken  of  by  Mickle  as  gallop- 
ing paresis,  rapid  in  onset  and  destructive  from  the 
beginning.  Berkeley  found,  on  examination,  marked 
vascular  changes,  degeneration  of  the  vessel-walls,  and 
a  general  disturbance  of  the  lymph-current.  He  as- 
sumed from  this  condition  that  there  had  been  a  de- 
generation of  the  neurons,  consequent  upon  a  deficient 
supply  of  nutriment  ;  in  short,  a  disturbed  cellular 
metabolism.  The  extreme  shortness  of  the  course  of 
the  disease  in  this  patient  did  not  permit  any  of  the 
phenomena  of  a  remission  to  be  present.  And  the  in- 
terest of  the  case  consists  in  the  early  and  rapid  tissue 
destruction  which  was  found. 

A  brief  rhum^  of  the  latest  pathological  findings  in 
general  paralysis  is  desirable  at  this  point,  in  order  to 
consider  in  a  satisfactory  manner  the  nature  of  the  re- 
mission. 

Mickle^  divides  the  lesions,  according  to  their  loca- 
tion, into  cortical,  vascular,  and  changes  in  the  neu- 
roglia. The  vascular  changes  are  distention  of  vessels 
with  blood,  an  increase  of  nuclei  in  the  walls  of  the 
vessels,  together  with  a  colloid  degeneration.  The 
blood-vessels  are  dilated  and  tortuous,  the  lymph- 
spaces  are  filled  with  lymph-corpuscles,  and  there  is 
sometimes  a  formation  of  new  blood- vessels.  In  the 
neuroglia  there  is  hyperplasia  and  hypertrophy  ;  an  in- 
crease of  nuclei,  and  a  formation  of  spider-cells,  colloid 
degeneration  and  atrophy.  In  the  neurons  there  are 
granular,  fatty,  and  pigmentary  degeneration  ;  sclerotic 
and  atrophic  alterations  in  nuclei  ;  vacuolation  and 
calcification  of  cells,  with  atrophy  of  the  nerve-fibres. 
According  to  Kronthal,  these  lesions  are  wide-spread, 
but  more  marked  in  the  anterior  part  of  the  parietal 
lobes,  and  in  the  frontal  lobes. 

We  see  then,  from  this  cursory  and  hasty  survey  of 
the  pathological  findings  in  general  paralysis,  that  we 
have  to  deal  with  a  disease  which,  fairly  early  in  its 
course,  involves  the  vital  elements  of  the  brain  in  a  de- 
structive process.  The  tissues  attacked  are,  after  a 
time,  injured  in  an  irreparable  manner. 

Assuming  the  view  that  in  the  beginning  there  is  a 

'  American  Journal  of  Insanity,  J.anuary,  1895.) 
'  Dictionary  of  Psychological  Medicine;  ( 


840 


MEDICAL    RECORD. 


[December   14,    i! 


nutritional  disturbance,  varying  in  duration  and  caus- 
ing a  functional  disorder  of  the  neurons,  with  a  conse- 
quent inhibition  of  their  normal  activity,  we  then  have 
produced  the  early  psychic  changes  which  are  usually 
seen,  such  as  amnesia,  partial  or  complete,  diminu- 
tion in  attention  and  volition,  lessened  muscular  power, 
insomnia,  blunting  of  the  ethical  and  moral  sense,  and 
a  general  disturbance  of  the  relations  of  the  ego  with 
its  environment. 

This  stage  of  general  paralysis  is  that  in  which  the 
remissions  are  more  frequent  and  last  for  a  longer 
time,  in  some  cases  going  on  to  apparent  recovery. 

However,  the  remissions  of  this  period  of  the  dis- 
ease are  less  noticed,  because  of  the  physician  not 
being  consulted  so  early  in  regard  to  treatment,  and 
thus  not  coming  under  his  observation,  except,  pos- 
sibly, as  cases  of  neurasthenia,  or  other  milder  dis- 
order. May  we  not  look  on  the  remissions  occurring 
in  this  stage  as  due  to  restoration  of  vascular  and 
nutritional  activity,  with  a  consequent  return  to  normal 
function  of  the  neuron,  which  as  yet  has  undergone  no 
organic  change  ? 

Hodge  has  shown  that  this  functional  disturbance 
so-called,  this  fatigue  of  the  neuron,  if  carried  to  an 
extreme  degree,  will  be  followed  by  vacuolation  and 
disintegration  within  the  cell  protoplasm,  from  which 
condition,  it  is  probable,  recuperation  never  takes 
place.  It  is  fair  to  presume  that  some  cases  of  general 
paralysis  could  be  checked  were  the  patients  to  be 
treated  at  this  early  stage  of  their  disease  and  the  re- 
mission be  made  the  threshold  to  permanent  recovery. 

What,  however,  can  be  said  of  the  cases  we  meet, 
further  advanced  in  their  course,  but  yet  in  which 
well-marked  remissions  occur  ?  How  shall  we  explain 
the  return  to  activity  of  a  brain,  part  of  the  structure  of 
which  at  least  has  been  permanently  injured  ?  It  must 
be  assumed  in  these  cases  that,  although  we  have  a 
change  in  all  the  elements  of  the  brain,  the  most  ex- 
tensive changes  are  those  present  in  the  vascular 
system  and  the  neuroglia ;  and  that,  although  the 
neurons  are  affected  to  some  extent,  many  possibly  de- 
stroyed, there  is  yet  a  possibility  of  the  absorption  of 
the  exudate,  a  renewed  activity  of  lymph-currents,  and 
a  consequent  improved  nutrition  of  nerve-cells,  with 
at  least  a  partial  restoration  of  the  individual  to  mental 
activity.  Clinically,  it  will  be  found  the  remissions  are 
not  as  complete,  and  the  renewed  cerebral  activity  as 
niarked,  in  those  cases  where  the  remission  occurs  later 
in  the  course  of  the  disease.  So  we  must  suspect  a 
certain  amount  of  injury  has  been  done  the  neurons 
which  is  irreparable,  and  which  causes  permanent 
changes  in  the  higher  faculties,  the  residuum  of  feeble- 
mindedness being  commensurate  with  the  destruction 
accomplished  by  the  disease.  What  is  called  by  Batty 
Tuke  '  the  limit  of  functional  activity  changes  "  has 
been  reached,  and  even  transcended,  in  a  certain  pro- 
portion of  the  cerebral  cells. 

Thus  far  the  remissions  of  general  paralysis  have 
been  considered,  only  in  those  cases  where  the  disease 
was  supposed  to  have  begun  in  the  vascular  system, 
with  nutritional  defects  occurring  as  a  consequence. 
The  hypothesis  of  the  lesion  being  primarily  cellular, 
must  now  be  considered  in  connection  with  the  sub- 
ject. Very  decided  deleterious  effects  are  produced 
by  extreme  exhaustion  of  the  neurons,  with  insufficient 
excretion  of  the  substances  evolved  during  the  season 
of  hyper-activity.  Bouchard  has  written  extensively  of 
this  in  his  book  on  Auto-intoxication,  so  also  has  Rog- 
ers.^ The  possibility  of  a  tox;\;mia,  with  organic  dis- 
ease of  the  kidney  as  its  starting-point,  has  been  care- 
fully studied  by  Bristowe,-  quite  recently.  In  eighty- 
eight  per  cent,  of  the  general  paralytics  examined  post- 
mortem, he  found  granular  kidneys,  while  in  only 
fifty-five  per  cent,  of  other  forms  of  insanity  was  there 
found  any  trouble  with  the  kidneys.     These  toxic  sub- 

'  Archives  de  Physiologic,  1893. 
'Journal  of  Mental  Science,  April,  1895. 


Stances,  in  addition  to  their  destructive  action,  un- 
doubtedly inhibit  the  function  of  the  lymphatics  and 
blood-vessels,  with  an  aggravation  of  deleterious  effects 
already  existing. 

In  the  Morrison  lectures  for  1894,  Batty  Tuke  has 
elaborated  this  idea,  and  presents  there  in  detail  the 
forms  of  insanity  induced  by  these  causes.  Remis- 
sions which  occur  in  the  course  of  a  general  paralysis 
which  is  supposed  to  be  dependent  primarily  on  cellular 
disorder,  may  be  looked  upon  as  a  cessation,  tem- 
porary as  a  rule,  of  the  pernicious  over-activity  of  the 
neuronic  elements,  together  with  an  increased  excretion 
of  toxic  material  through  the  vascular  and  lymphatic 
systems,  inducing  a  general  improvement  in  tissue 
metabolism. 

In  considering  the  remissions  of  general  paralysis, 
and  in  noting  their  fiequenc)',  we  must  bear  in  ipind 
how  frequently  alcoholic  or  pseudo-paralysis  is  mis- 
taken for  the  genuine  disease.  The  recovery  from 
seemingly  hopeless  conditions  in  these  pseudo-cases  is 
more  complete. 

The  somatic  condition  is  often  more  marked  in  its 
disorder  than  is  the  mental.  The  delusions  are  apt  to 
be  less  expansive  ;  the  prodromic  period  is  shorter, 
and  the  remission  goes  on,  as  a  rule,  to  recovery,  where 
abstinence  from  alcohol  is  practised.  This  class  of 
cases  are  hard  of  diagnosis  at  times,  and  may  often  be 
passed  upon  as  general  paralysis.  When  they  recover, 
as  they  usually  do,  they  are  tabulated  often  as  cured 
paresis.  Mickle  has  found,  that  in  cases  of  chronic 
general  paralysis  with  a  strong  hereditary  history,  the 
duration  of  the  disorder  is  longest,  the  remissions  are 
more  frequent  and  complete.  In  two  of  the  cases  I 
append,  this  observation  will  be  found  to  be  borne  out. 
The  following  cases,  some  of  which  were  observed  dur- 
ing a  service  at  the  Utica  State  Hospital,  are  interest- 
ing in  connection  with  the  present  subject,  showing  as 
they  do  periods  of  remission  varying  in  length  from 
months  to  years.  They  also  show  different  degrees  of 
mental  improvement,  from  a  feeble-minded,  non-de- 
lusional state,  to  one  of  a  nearly  complete  restoration 
to  vigor  of  mind. 

Case  I. — H.  C.  L ,   male,  thirty   years   of   age, 

married,  no  children.  No  alcoholic  history,  indefinite 
specific  history,  hereditary  tendency  rather  strong.  At 
the  time  of  his  admission  was  incoherent,  excitable,  and 
very  tremulous.  Four  months  previous  to  admission 
to  the  hospital  the  disease  had  first  manifested  itself 
actively.  Disease  apparently  began  with  an  attack  of 
unconsciousness,  followed  by  aphasia  and  left  side 
hemiplegia.  He  gradually  recovered  from  paralysis, 
and  for  a  period  of  four  months  was  feeble  minded  and 
incoherent  in  speech.  At  this  time  his  mental  symp- 
toms gradually  cleared  up,  somatic  condition  improved, 
and  with  the  exception  of  a  slight  feeble-minded  state, 
he  seemed  in  normal  health.  He  remained  in  good 
condition  for  nearly  two  months,  then  had  another  apo- 
plectiform attack,  from  which  he  slowly  recovered. 

Case  II. — F.  T— ,  male,  aged    fifty- six,   married, 

no  children.  For  twenty  nine  years  had  used  alcohol 
excessively.  He  had  been  treated  at  a  "  Keeley 
cure  "  institute  previous  to  coming  under  observation. 
From  this  place  he  had  graduated  "  cured,"  but  with 
all  the  symptoms  of  general  paralysis.  He  had  the  de- 
lusion that  he  was  a  detective  in  the  employ  of  the 
post-ofiice,  and  that  he  could  drink  half  a  barrel  of 
whiskey  a  day.  After  a  month  of  treatment  his  delu- 
sions disappeared,  his  bodily  condition  improved,  and 
for  over  a  year  he  remained  in  a  normal  mental  state. 

Case  III. — W.  H.  W ,  male,  aged  forty-eight,  sin- 
gle, clerk.  Six  weeks  previous  to  coming  under  treat- 
ment was  noticed  to  be  dull  and  stupid  in  his  actions. 
For  two  or  three  years  previous  to  this  he  had  gradu- 
ally changed  in  his  disposition.  He  arose  in  a  revival 
meeting  at  one  time,  and  announced  he  had  converted 
thirty  people  ;  this  aroused  considerable  enthusiasm, 
until  he  said  that  the  conversions  were  accomplished 


December   14,  1895] 


MEDICAL   RECORD. 


841 


by  means  of  pork  and  beans  from  his  boarding-house. 
Shortly  after  this  mental  and  physical  symptoms  of 
paresis  appeared,  and  he  was  confined  in  the  hospital. 
After  admission  he  had  several  paretic  seizures,  after 
which  he  improved  slowly.  For  three  years  he  was  in 
a  state  of  fairly  good  mental  health,  with  the  exception 
of  a  slight  feeble-mindedness.  He  then  was  again  taken 
with  paretic  convulsions,  and  after  two  weeks  of  abso- 
lute dementia  he  died.  The  length  of  the  remission  is 
rather  remarkable  in  this  case. 

Case  IV. — J.  C.  M- ■,  male,  thirty-seven  years  of 

age,  married,  one  child.  History  of  syphilis  present. 
On  coming  under  observation  he  presented  all  the 
symptoms,  mental  and  physical,  of  general  paralysis. 
After  three  months  improved  very  much,  and  for  one 
year  was,  with  the  exception  of  a  little  feeble  minded- 
ness,  in  a  normal  condition.  At  the  end  of  this  time 
he  became  incoherent  and  confused,  had  several  pare- 
tic seizures,  which  were  followed  by  slight  improvement, 
less  in  degree  than  at  first. 

Case  V. — H.    K ,  female,  thirty- eight   years  of 

age,  married,  dissolute  in  habits,  alcoholic,  and  proba- 
bly syphilitic  ;  when  first  seen  was  maniacal  and  violent. 
This  condition  continued  for  two  weeks,  when  she  im- 
proved, became  quiet  and  rational.  The  remission 
lasted  three  months,  when  she  again  became  maniacal. 
She  again  improved  and  went  home  from  the  hospital, 
contrary  to  advice.  She  remained  at  home  for  two 
years  in  an  apparently  normal  mental  state,  but  disso- 
lute habits  being  renewed  her  disease  returned,  and 
shortly  after  her  readmission  to  treatment  she  died  in 
a  paretic  seizure. 

Case  VI. — Male,  aged  thirty-eight,  painter  by  occu- 
pation, married.  Alcoholic  history.  One  year  and  a 
half  before  coming  under  observation  had  shown  signs 
of  insanity.  He  developed  grandiose  ideas  and  at 
times  was  violent.  After  six  months  in  this  state,  he 
improved  and  recovered  his  normal  faculties,  according 
to  his  family.  For  one  year  this  state  of  improvement 
continued,  and  then  all  the  former  symptoms  came  on, 
together  with  a  rapidly  increasing  dementia. 

C.\SE  Vn. — G.    L ,  aged  thirty-six,  married,  no 

children  ;  alcoholic  historj-  and  probably  syphilitic. 
Four  years  before  coming  under  observation  was  mel- 
ancholic, threatened  suicide,  and  at  times  was  violent. 
This  condition  gradually  grew  worse,  and  all  the  physi- 
cal and  mental  signs  of  paresis  developed. 

In  this  state  he  remained  for  a  year,  then  improved 
and  his  mind  apparently  assumed  its  normal  condition. 
For  over  a  year  he  followed  his  occupation  of  clerk  and 
appeared  entirely  recovered.  Then  business  reverses 
assailed  him,  and  gradually  he  failed  again.  At  pres- 
ent is  delusional,  grandiose  in  conversation  and  typi 
cally  paretic. 


ftuietude  and  Longevity. — That  quietude  conduces 
to  longevity  seems  to  be  demonstrated  by  the  record  of 
longevity  in  Philadelphia,  a  matter  on  which  the  city 
prides  itself  considerably.  During  the  first  half  of  this 
year  the  obituary  columns  of  the  Ledger  contained 
death  notices  of  two  hundred  and  thirty-four  women 
and  one  hundred  and  eighty  men  who  had  lived  to  or 
beyond  eighty  years  of  age.  The  greater  part  of  the 
deaths  were  of  residents  of  Philadelphia.  Thirty 
women  and  twenty-six  men  lived  to  or  beyond  ninety 
years  of  age.  The  extreme  ages  reached  were  ninety- 
nine  years  by  one  woman  and  ninety-six  years  by 
three  men. 

A  Wise  Precaution. — An  ordinance  for  the  regulation 
of  bicycle  riding  which  is  under  consideration  by  the 
San  Francisco  City  Council,  prohibits  bicyclists  from 
carrying  on  their  machines  any  child  under  the  age  of 
six  years.  This  is  the  outcome  of  the  recent  crusade 
by  the  Society  for  the  Prevention  of  Cruelty  to  Chil- 
dren. 


TUBERCULOSIS  OF  THE  KNEE  JOINT." 
Bv  RICHARD  C.  NEWTON,  M.D., 

MONTCLAIR,   N.  J. 

The  study  of  the  etiology  of  this  affection  presents' 
many  interesting  points,  and  raises  many  questions 
which  are  as  yet  difficult  or  impossible  of  solution. 

That  the  knee-joint,  which  is  probably  injured  more 
often  than  any  other  articulation  in  the  body,  should 
so  seldom  be  the  seat  of  tubercular  disease  as  com- 
pared to  the  hips — the  proportion  being.  Dr.  Park-  tells 
us,  one  to  five — seems  at  first  sight  quite  peculiar. 
The  explanation  may  be  offered  that  the  blood-supply 
to  the  knee  is  greater  than  to  the  hip,  and  that  owing 
to  the  greater  extent  of  synovial  membrane  in  the 
former  joint,  there  is  a  greater  number  of  lymphatics 
present,  so  that  not  only  are  the  articular  structures 
better  nourished,  but  elimination  and  removal  of  mor- 
bific matters  are  more  readily  and  more  thoroughly  ac- 
complished. Be  this  as  it  may,  the  fact  remains  that, 
with  all  the  injuries,  abrasions,  contusions,  and  strains 
to  which  the  joint  is  subjected,  it  is  comparatively 
rarely  the  seat  of  tuberculous  disease,  whereas  the  hip, 
a  much  more  deeply  placed  and  better  protected  artic- 
ulation, and  one  that  is  in  consequence  less  frequently 
injured  by  blows,  falls,  contusions,  and  sfrains,  is  com- 
paratively often  afflicted  with  tuberculosis. 

Again,  what  is  the  rationale  of  the  development  of 
tubercular  disease  in  any  joint  ?  It  seems  to  be  gen- 
erally admitted  by  surgeons  that  the  bacillus  of  Koch 
is  present  and  is  the  causative  factor  in  every  case  of 
tuberculous  arthritis. 

The  question  naturally  arises,  how  does  this  bacillus 
find  its  way  into  the  joints  .'  Is  it  present  at  birth,  or  is 
it  subsequently  introduced  ?  Those  pathologists  who 
deny  the  hereditability  of  tuberculosis  are  driven  to 
say  that  the  bacilli  have  found  their  way  into  the  body 
through  the  lungs,  by  inhalation,  or  into  the  alimen- 
tary canal,  with  the  food  or  drink,  and  have  been  taken 
up  by  the  blood-vessels  or  by  the  lymphatics,  and  car- 
ried about  in  the  body  until  at  last  they  find  lodgement 
in  or  near  a  joint  ;  in  which  sooner  or  later  they  take 
on  an  active  role  and  tubercular  disease  is  set  up  in 
that  locality. 

What  has  determined  this  disposition  of  the  specific 
organisms  ?  Why  were  they  not  arrested  in  the  lungs, 
pleura,  stomach,  the  bronchial  or  mesenteric  glands,  to 
set  up  their  destructive  processes  there  ?  Again  we 
cannot  answer  ;  we  can  only  say  that  in  a  very  large 
number  of  cases  they  probably  are  so  arrested.  In 
the  early  years  cf  life  tabes  mesenterica  is  compara- 
tively common,  and  must  be  many  times  more  frequent 
than  tuberculous  arthritis,  and  this  fact  is  naturally 
brought  forward  in  proof  of  the  communicability  of  tu- 
berculosis by  food,  particularly  milk. 

The  weight  of  opinion  seems  to  be,  however,  in  favor 
of  the  hypothesis  that  the  bacillus  is  handed  down 
from  parent  to  offspring,  and  that  in  infancy  it  exists 
in  the  body,  where  it  may  lie  dormant  for  an  indefinite 
time.  Accidental  causes,  such  as  trauma,  malnutri- 
tion, or  the  advent  of  other  pathogenic  microbes,  as  eg., 
those  of  scarlatina,  pneumonia,  or  la  grippe,  starting  it 
into  action. 

It  is  even  claimed  by  some  ^  that  the  bacillus  may 
remain  latent  in  the  body  through  an  entire  lifetime, 
and  be  transmitted  to  the  succeeding  generation,  in 
which  it  may  develop  some  form  of  tuberculosis.  Dr. 
Solly  said,  in  an  admirable  paper  read  before  the  last 
meeting  of  the  American  Climatological  .Association, 
and  published  in  the  .imcrican  Journal  of  the  Medieal 
Sciences  for  August,  r895  :  "That  the  bacilli  can  be 
transmitted  not  only  from  the  parents,  but  also  occa- 
sionally from  the  grandparents,  is  very  probable.     The 

'  A  Part  of  the  Ann\ial  Report  of  tliu  Commi'.tec-  on  Surppry  of  the 
Orange  Mountain  Medical  >ociely,  read  before  that  body  November 
I,  1895. 

2  Medical  News.  Philadelphia.  September  28.  1S95   page  363. 

>  American  Journal  of  the  MedicaJ  Sciences,  August,  1895,  page  361 


MEDICAL   RECORD. 


December  14,  1895 


revelations  of  autopsies  which  show  tuberculosis  of 
glands,  etc.,  in  persons  who  were  believed  to  have  no 
evident  tuberculosis,  and  who  died  from  other  causes, 
and  the  probability  of  many  of  the  surgical  tubercu- 
loses of  children  being  due  to  latent  bacilli,  which  gave 
rise  to  no  symptoms  until  a  traumatism  furnished  the 
inflammatory  products  for  the  bacilli  to  feed  upon,  to 
retire  again  into  innocuous  desuetude  with  the  rest 
given  by  splints,  etc.,  to  the  inflamed  parts,  renders  it 
almost  if  not  quite  certain  that  bacillary  infection  may 
be  transmitted  through  a  silent  generation." 

As  tending  further  to  demonstrate  that  the  bacilli  are 
frequently  born  in  human  beings  and  not  acquired  by  in- 
halation or  otherwise.  Dr.  Solly  quotes  the  remarks  of  Dr. 
Currier  in  a  discussion  before  the  New  York  Academy 
of  Medicine,  in  1892,  in  which  it  is  asserted  that  foetal 
tuberculosis  does  occur,  and  that  the  bacillus  is  found 
in  the  ova  and  in  the  testicles  of  tubercular  subjects, 
albeit  these  organs  themselves  may  be  structurally 
healthy.  Add  to  this  the  latent  tuberculosis  demon- 
strated by  Bollinger  and  others  in  twelve  per  cent,  of 
their  autopsies  upon  children,  and  the  powerful  weight 
of  Baumgarten's  authority  ;  and  it  seems  more  reason- 
able at  least  to  assert  that  the  bacillus  is  present  in  per- 
sona propria  in  the  bodies  of  a  certain  proportion  of 
its  human  victims  at  birth.  The  presence  of  the  germ 
in  the  fcetus  is  to  ray  mind  an  unanswerable  argument 
in  favor  of  this  belief. 

If  we  admit  all  that  is  asserted  above,  we  are  still 
quite  in  the  dark  as  to  why  tubercular  adenitis,  arthritis, 
and  meningitis  develop  so  much  more  frequently,  rela- 
tively in  children  and  pulmonary  tuberculosis  in  adults. 
However,  such  is  the  fact.  Perhaps  we  might  assert 
that  the  hereditary  tuberculoses  are  prone  to  show 
themselves  in  the  more  distant  structures  of  the  econ- 
omy, whereas  the  acquired  forms  will  more  probably 
find  lodgement  and  accomplish  their  destructive  work 
in  the  air-passages,  into  which  they  have  been  drawn 
with  the  inspired  air. 

This  view  would  seem  to  receive  confirmation  from 
a  statement  made  by  Dr.  Janeway,'  in  the  discussion 
just  spoken  of,  to  wit  :  that  in  the  year  1S90,  there 
were  five  thousand  four  hundred  and  ninety-two  deaths 
from  phthisis  (which  means  presumably  only  pulmonary 
phthisis)  in  New  York  City,  of  which  only  two  hun- 
dred and  forty-three,  or  less  than  four  and  one-half  per 
cent.;  were  children  under  ten  years  of  age.  Whereas 
we  are  told  ■  that  the  mortality  from  tuberculosis  (gen- 
eral) is  greatest  in  the  human  subject  during  the  first 
year  of  life. 

It  will  not  be  proper  to  consume  more  time  in  this 
discussion  on  the  question  of  the  etiology  of  tubercular 
arthritis  ;  let  me  sum  up  by  saying  that  the  weight  of 
testimony  is  overwhelmingly  in  favor  of  the  statement 
that  the  child  is  born  with  tubercular  bacilli  already  in 
his  body,  probably  in  his  glandular  system  ;  that  an  in- 
jury to  one  of  the  large  joints  sets  up  inflammatory  ac- 
tion there  ;  that  the  bacillus  is  present  at  the  seat  of 
this  morbid  process,  either  having  been  there  since 
uterine  life,  or  perhaps,  which  is  more  probable,  is 
brought  there  in  the  circulation  or  by  the  lymph-canals 
and  finds  lodgement  and  pabulum.  That  the  germ 
comes  to  the  knee  as  often,  probably  oftener,  than  to 
the  hip,  but  owing  to  the  superior  innervation  and  cir- 
culation of  this  joint,  only  sets  up  a  morbid  process 
one-fifth  as  often  in  the  former  joint  as  in  the  latter. 

If  the  rationale  of  the  causation  of  tuberculosis  of 
the  knee  is  difficult  of  explanation,  the  early  diagnosis 
is  equally  difficult.  The  ideal  time  to  treat  tubercular 
arthritis  has  passed  when  the  lesions  are  sufficiently 
pronounced  to  make  the  diagnosis  sure.  Valuable 
time  is  so  generally  lost  before  the  true  nature  of  an 
arthritis  is  recognized,  that  a  certain  means  of  early 
diagnosis  would  be  well-nigh  invaluable,  not  only  as 

'  Transactions  New  York  Academy  of  Medicine,  1893,  pa£;e  28. 
■^  Professor  Osier,  American  Text-booli  of  tfie  Diseases  of  Children, 
JS93.  pages  95,  101. 


regards  the  ultimately  curative  treatment  of  the  lesion, 
but  also  the  prevention  of  much  suffering,  a  probable 
long  confinement  of  the  sufferer  to  his  bed,  and  in  many 
cases  at  least  the  risk  of  his  life. 

I  am  not  without  hopes  that  the  suggestion  made  by 
Professor  Klebs,^  that  tuberculin  should  be  used  for 
diagnostic  purposes  on  the  human  subject  in  a  manner 
similar  to  its  present  employment  by  the  veterinarians 
upon  cattle  suspected  of  tubercular  infection,  may  in 
time  be  rendered  feasible.  At  the  present  moment  it 
would  hardly  seem  practicable,  because  the  injection  of 
tuberculin  into  cattle  already  infected  sets  up  a  febrile 
action,  which  would  perhaps  lead  to  great  activity  on 
the  part  of  the  tubercle  bacilli  if  already  present  in  the 
organism.  In  other  words,  if  it  acted  in  a  similar  way 
in  children,  it  might  accelerate  or  even  develop  tuber- 
cular inflammation,  and  is  therefore,  in  the  present  stage 
of  our  knowledge,  an  unwarrantable  liberty  to  take  with 
the  well-being  of  the  child. 

Good  authorities,  including  Professor  Koch  himself, 
have  condemned  the  use  of  tuberculin  upon  the  human 
subject  for  diagnostic  purposes.  Also  I  might  add  that 
a  further  study  of  the  ultimate  results  of  the  injections 
of  tuberculin  into  cattle,  for  diagnostic  purposes,  is 
needed. 

Up  to  this  time  it  would  appear  that  those  cattle 
which  develop  reaction  after  the  tuberculin  injection 
are  slaughtered,  instead  of  being  kept  under  observa- 
tion and  the  ultimate  good  or  bad  effect  of  the  proced- 
ure noted.  So  far  as  I  am  aware,  the  precise  nature  of 
the  febrile  movement  set  up  by  the  inoculation  has  not 
been  determined.  The  inference,  however,  is,  that  it  is, 
or  may  be,  a  phase  of  tubercular  disease.  The  sugges- 
tion of  Professor  Klebs,  however,  may  bear  valuable 
fruit  in  some  other  direction. 

The  ordinary  rules  of  diagnosis  for  knee-joint  dis- 
eases are  so  familiar  to  you  all  that  I  will  not  take  up 
time  in  recapitulating  them. 

As  to  the  treatment,  it  seems  to  be,  mainly,  rest  to  the 
joint,  and  nourishment  to  the  patient.  Operation  will 
seldom  be  necessary  if  the  cases  are  properly  treated 
early  enough,  and  the  nourishment  of  the  patient  is 
maintained  at  its  highest  standard.  Tubercular  disease 
of  the  joints  is  a  self-limited  one  as  a  rule.  According 
to  Dr.  Gibney's'  figures  its  duration  is  three  and  one- 
half  to  four  years. 

I  cannot  take  any  more  time  with  the  details  of 
treatment,  medical  and  surgical,  the  proper  considera- 
tion of  which  would  call  forth  a  very  full  and  elaborate 
paper.  I  will  close  by  calling  your  attention  to  the 
fact  that  the  moderate  and  localized  action  of  tubercu- 
lar infection  in  the  joints  and  glands,  as  compared  to 
the  more  dangerous  and  fatal  course  of  the  same  dis- 
ease when  it  attacks  the  lungs  or  intestines,  has  led  to 
the  enunciation  of  some  important  hypotheses. 

Mr.  Keetley  ^  has  said  "  Time  will  kill  local  tubercu- 
losis unassisted  by  the  surgeon." 

Mr.  Watson  Cheyne  ^  pointed  out  in  his  lecture,  de- 
livered at  the  Royal  College  of  Surgeons  in  June,  1S92, 
''that  in  the  human  body  the  tubercle  bacillus  has  often 
a  hard  struggle  for  existence,  and  often  very  little  is  re- 
quired to  turn  the  scale  in  favor  of  recovery." 

Konig,  of  Gottingen,"'  affirms  that  with  our  improved 
methods  of  treatment  at  least  one-half  of  the  cases  of 
bone  tuberculosis  recover  without  operation. 

Osier,  after  commenting  upon  the  comparatively  be- 
nign course  of  what  he  calls  scrofulo-tubercular  mani- 
festations, i.e.,  tuberculosis  of  skin,  bones,  or  glands,  says 
that  it  has  been  suggested  that  these  lesions  depend 
upon  the  action  of  an  attenuated  virus,  and  adds  "  an 
attempt  has  been  made  by  writers,  particularly  Morfan, 
to  show  that  the  scrofulo-tubercular  lesions,  when 
recovered    from,    confer   a   sort  of  immunity  to  pul- 

'  Journal  of  the  American  Medical  Association,  October  12,  1895. 

-Transactions  New  York  Academy  of  Medicine.  1S93,  p.  6. 

'■•  Wood's  Medical  and  Surgical  Monographs,  vol.  iv.,  iSSg. 

<  Year- Book  ol  Treatment.  1S93.  p.  267. 

■■■Sajou's  Annual  Universal  Medical  Science,  1895,  vol.  iii.,  H.  191 


December   14,  1895] 


MEDICAL    RECORD. 


843 


monary  tuberculosis,  but  the  evidence  is  not  yet  very 
strong." 

Adhering  to  the  hypothesis  which  has  been  advanced 
in  the  early  part  of  this  paper,  it  might  be  said  that 
the  so-called  scrofulo- tuberculosis  lesions  are  the  out- 
breaks of  inherited  tuberculosis,  and  owe  the  compara- 
tive mildness  of  their  course,  when  contrasted  with 
pulmonary  or  intestinal  phthisis,  to  the  fact  that  the 
causative  bacilli  have  been  a  long  time  in  the  system, 
which  has  acquired  a  partial,  in  some  cases  probably  a 
complete,  immunity  against  them.  Whereas  in  the  ac- 
quired form  of  phthisis  the  bacilli  attack  an  organism 
quite  unprepared  (whose  cells  have  had  no  opportunity 
to  elaborate  the  saving  antito.xin)  and  quickly  over- 
whelm the  entire  system. 

This  view  is  also  supported  by  the  fact  that  the  num- 
ber of  bacilli  in  and  about  a  tubercular  joint  is  often  so 
small ;  showing  that,  in  spite  of  the  months  or  years  in 
which  they  have  had  an  opportunity  to  multiply  in  the 
economy,  they  have  actually  increased  very  slowly,  if 
at  all,  and  that  in  their  contest  with  the  phagocytes 
they  have  lost  much  of  their  virility  and  probably  num- 
bers of  them  have  perished. 

The  natural  history  of  syphilis  affords  numerous 
similar  examples.  The  acquired  form  of  the  disease  is 
prompt,  ostentatious,  and  violent  in  its  action;  the  in- 
herited form,  on  the  other  hand,  is  gradual,  uncertain, 
and  stealthy  in  its  advent  and  duration.  It  may  de- 
velop, and  it  may  not,  in  the  offspring  of  luetic  parents. 
If  it  does  develop  its  site  is  apt  to  be  in  the  bones  or 
deeper  structures,  and  recovery  may  be  spontaneous. 

As  the  good  surgeon  Gross'  was  wont  to  assert  that 
all  scrofula  was  inherited  tuberculosis,  even  so  now  the 
leading  minds  in  medicine  affirm  the  same  thing,  we 
endeavor  to  e.xplain  what  this  great  observer  noted  and 
commented  upon  so  accurately  and  clearly. 


A  CASE  OF  TEMPORARY  AMBLYOPIA   FROM 
CHOCOLATE. 

By  CASEY  A.   WOOD,  M.D., 

t'ROFESSOR    OF    OPHTHALMOLOGY     IS    THE     I'O^T-GHAI'UATE     MEDICAL     SCHO>^L, 
CHICAGO,  ILL. 

Visual  defects,  both  temporary  and  permanent,  are 
not  uncommon  as  the  result  of  alcoliolism,  nicotinism, 
and  indulgence  in  "  high  "  game  and  other  forms  of 
food  impregnated  with  the  products  of  decomposition  ; 
but,  strange  to  say,  one  rarely  or  never  meets  with  an 
amblyopia  or  an  amaurosis  the  result  of  excessive  tea-, 
coffee-,  chocolate-,  or  cocoa-drinking — not  even  in  tliose 
who  are  otherwise  easily  affected  by  these  beverages. 
The  following  history  furnishes  an  exception  to  this  rule : 

Dr.  S ,  aged  fifty-four,  has  a  family  history  of  gout, 

from  which  he  himself  also  suffers  upon  occasions,  but 
apart  from  lliat  he  is,  and  for  years  past  has  been,  in 
fairly  good  health.  Owing  to  this  gouty  habit  lie  has 
always  exercised  great  care  in  his  diet,  particularly 
since  sad  experience  has  taught  him  that  the  slightest 
indulgence  in  alcohol  or  indigestible  food  is  likely  to 
be  followed  by  inflamed  toe-joints  and  other  indica- 
tions of  activity  upon  the  part  of  his  hereditary  enemy. 
He  cannot,  for  example,  drink  more  than  a  single  glass 
of  Rhine  wine  without  bringing  on  an  attack  of  acute 
gout.  He  exhibited,  however,  one  symptom-complex 
the  cause  and  nature  of  which  remained,  until  about  a 
year  ago,  an  impenetrable  mystery.  At  irregular  peri- 
ods, sometimes  every  week,  sometimes  at  much  longer 
intervals,  he  suffered  from  severe  headaches  closely  re- 
sembling migraine.  Their  course  and  character  were 
about  as  follows  :  The  trouble  began  witii  awheel-like, 
confused,  whitish  (not  colored)  mass  rotating  in  front 
of  both  eyes.  This  body  gradually  increased  in  size 
and  density  until  the  whole  field  of  vision  was  covered 
.md  he  became  practically  blind.     For  ten  minutes  not 

'  System  of  Surgery,  vol.  i.,  p.  287. 


even  the  largest  objects  could  be  perceived  ;  there  was 
merely  perception  of  shadows  or  ability  to  count  fin- 
gers at  a  few  inches.  After  a  short  time  outlines  of 
the  neighboring  houses,  of  carriages  and  wagons,  and 
finally  of  human  beings  on  the  street,  began  to  loom 
up.  In  half  an  hour  smaller  objects  were  visible 
through  the  gloom.  In  from  three-quarters  of  an  hour 
to  an  hour  the  large  scotoma  seemed  to  entirely  dis- 
solve and  the  patient  could  see  as  well  as  ever.  This 
attack  was  always  accompanied  by  vertigo,  intense 
nausea,  severe  pain  in,  and  a  sense  of  pressure  upon, 
the  head.  Altogether  the  patient  has  had  over  a  hun- 
dred such  attacks,  some  of  them  very  severe,  from  the 
effects  of  which  he  did  not  recover  until  the  next  day, 
while  others  might  be  regarded  as  partial  or  incom- 
plete seizures,  from  which  he  recovered  in  a  few  hours. 
In  every  instance  the  illness  resembled  the  description 
just  given. 

During  the  twenty  years  that  cover  the  period  of 
these  attacks  he  has  been  treated  for  all  sorts  of  ail- 
ments, with  all  kinds  of  remedies,  by  men  in  all  parts 
of  America  and  Europe,  and  with  \  ery  little  success. 
The  attacks  have  been  attributed  to  the  influence  of 
gout,  wine-drinking,  indulgence  in  \arious  forms  of 
indigestible  food,  to  dyspepsia,  to  tobacco,  to  eye- 
strain, and  to  "derangement  of  the  liver,"  for  all  of 
which  evils  he  has  been  at  various  times,  secioidtiin 
artem,  vigorously  treated.  The  late  Dr.  W.  F.  Smith 
and  the  writer  of  this  labored  long  and  faithfully  to 
render  his  visual  acts  as  comfortable  as  possible,  but 
the  migraine  persisted  and  the  amblyopia  visited  him 
as  regularly  as  before.  As  far  back  as  18S2,  he  had 
suspected  the  agent  that  "  upsets  his  stomach  "  to  be 
candy,  because  as  long  as  he  refrained  from  eating 
sweetmeats  of  any  sort  he  seemed  to  be  almost  free 
from  the  attacks.  One  day,  about  two  years  ago,  he 
purchased  some  vanilla  chocolate  for  his  children,  and 
as  he  is  very  fond  of  that  comestible  in  any  form,  he 
ate  a  small  piece.  He  was  riding  on  a  cable  car  at  the 
time  ;  when  he  reached  the  corner  where  he  was  to 
alight  a  partial  attack  came  on,  and  he  was  obliged  to 
sit  on  the  edge  of  the  pavement  and  wait  until  the 
blindness  passed  off  before  he  was  able  to  make  his 
way  home.  This  incident  aroused  his  suspicions  of 
the  evil  effects  of  chocolate.  Subsequent  observation, 
extending  over  the  next  year,  proved  to  him  that  it 
was  the  chocolate /^c/-  sc  that  induced  the  attacks. 

Vanilla,  unless  associated  with  chocolate,  does  not 
affect  him.  He  often  drinks  it  in  his  coffee  and  eats  it 
with  cake  and  puddings  without  the  slightest  ill  effect. 
Nor  does  cocoa  bring  on  his  headache.  Nor  do  any 
of  the  spices,  lik-e  cinnamon,  present  in  some  choco- 
lates, alone  affect  him.  Candy  of  any  kind,  as  long  as 
it  is  not  mixed  or  flavored  with  chocolate,  he  can  eat 
with  impunity.  Chocolate  in  blocks,  or  as  creams,  or 
in  cakes,  or  in  suspension  as  a  drink,  or  in  ice-cream 
invariably  precipitates  an  attack,  whose  severity  is  in 
proportion  to  the  amount  of  the  chocolate  ingested 
He  has  been  able  to  associate  every  seizure  he  has  had 
for  the  past  few  years  with  the  previous  eating  or 
drinking  of  chocolate  in  some  form,  and  he  has  had  no 
attack  not  preceded  by  indulgence  in  cliocolate.  He 
seemed  very  positive  that  a  moderate  indulgence  in 
cocoa  does  not  affect  him. 

I  tried  to  induce  him  to  make  some  further  experi- 
ments with  himself,  having  in  mind  the  possibility  of 
isolating  the  particular  agent  or  agents  in  the  choco- 
late which  liad  jjroduced  the  amblyopia  ;  but  although 
he  is  a  man  devoted  to  science,  he  did  not  feel  inclined 
to  suffer  from  such  blindness,  nausea,  and  headaches 
for  the  purpose  of  settling  this  cjuestion.  It  is  now 
over  a  year  since  he  has  had  a  seizure,  and  this  free- 
dom from  attacks  dates  from  the  lime  when  he  fore- 
swore indulgence  in  any  form  of  chocolate. 

It  is  highly  probable  that  the  patient  exhibits  an 
idiosyncrasy  against  theobromine  when  that  alkaloid  is 
taken  by  him  in  sufficiently  large  doses.     The  insuffi- 


844 


MEDICAL    RECORD. 


[December   14,    i! 


ciency  of  the  dose  and  its  lack  of  concentration  is  the 
reason  he  was  not  affected  by  the  ordinary  cocoa  of 
commerce,  which  contains  much  less  theobromine  than 
chocolate,  and  is  often  adulterated  with  ground  rice, 
sugar,  barley,  etc. 

Whether  the  amblyopia  be  regarded  as  directly  the 
result  of  the  chocolate-poisoning,  or  whether  it  be  con- 
sidered as  part  of  the  so-called  scotoma  scintillans,  mat- 
ters very  little.  It  establishes  beyond  a  reasonable 
doubt  the  claim  of  Hocken '  that  chocolate  occasion- 
ally affects  the  visual  centres.  Yet  with  this  exception 
1  have  been  unable  to  find  elsewhere  more  than  vague 
references  to  the  toxic  effects  of  cocoa  or  chocolate,  so 
far  as  the  eyes  are  concerned. 

Hutchinson,'  however,  reports  a  case  of  caffein  am- 
blyopia, the  symptoms  of  which  resemble  those  of  the 
amblyopia  of  quinine  intoxication,  and  caffein  is  said 
to  be  chemically  identical  with  theobromine. 


^L-OQicss  ot  I^^Xedical  .Science. 

Non  specific  Lesions  in  Syphilitics. — A  common  error 
is  that  many  ills  occurring  in  a  syphilitic  subject  are 
treated  as  though  they  were  of  syphilitic  origin.  The 
fact  that  a  patient  has  syphilis  does  not  exempt  him 
from  non-specific  disorders,  yet  the  physician  is  very 
apt  to  jump  to  the  conclusion  that  such  disorders  are 
the  result  of  the  syphilis,  and  to  treat  them  accordingly. 
In  many  cases  lesions  on  the  tongue  and  oral  mucous 
membrane  in  syphilitics  remain  unaffected  by  specific 
treatment,  and  the  fact  should  be  borne  in  mind  that 
similar  lesions  may  occur  in  persons  who  have  not  had 
syphilis,  as  the  result  of  digestive  disturbance.  Even 
if  they  are  syphilitic,  such  lesions  may  persist  in  spite 
of  specific  remedies,  unless  the  digestive  errors  are  cor- 
rected. 

Leguminous  Alimentation  in  Diseases  of  Digestion 
and  Nutrition. — Dr.  Bovet  refers  to  the  apparent  con- 
nection between  richness  in  albumin,  or  the  nitrogeneous 
elements  of  plants,  and  organic  phosphorus,  these  two 
seeming  to  run  parallel.  In  the  leguminos*  they  are 
found  in  greatest  proportion.  One  consequence  of  the 
association  of  phosphates  with  albumin  (vegetable), 
and 'the  "diffusibility  "  of  phosphoric  acid,  is  that  food 
of  this  character  (leguminous)  is  very  readily  dissolved 
and  digested  in  the  alimentary  canal,  even  in  the  ab- 
sence of  the  usual  ferments.  The  presence  of  a  rela- 
tively large  amount  of  potash  salts  in  this  food  is  also 
noted.  In  the  laboratory  of  Professor  Hayem  a  dog 
was  fed  for  thirteen  days  on  an  exclusive  diet  of 
"legumine,"  a  soup  free  from  salt.  The  result  was 
first  a  marked  decrease  in  its  weight,  amounting  to  one- 
tenth.  An  analysis  of  the  gastric  juice  at  the  beginning 
and  end  of  the  experiment  showed  a  marked  increase 
in  two  most  important  values,  namely,  hydrochloric 
acid  and  chlorine.  This  may  be  interpreted  as  in- 
creased digestive  power.  A  similar  experiment  on  a 
patient,  aged  forty-two,  suffering  from  chronic  gastritis, 
slight  dilatation,  and  loss  of  motor  power  of  the  stom- 
ach, weakness  and  emaciation,  showed  results  altogether 
comparable  to  the  above.  At  the  beginning  the  gas- 
tric juice,  although  highly  acid,  was  free  from  hydro- 
chloric acid.  At  the  end  of  two  months  the  total  acid 
ity  was  not  increased,  while  hydrochloric  acid  was 
present  in  almost  normal  amount.  Digestion  (pre- 
viously slow  and  painful)  no  longer  inconvenienced  the 
patient.  Neurasthenia  was  lessened,  and  she  slept 
eight  hours  daily  without  awaking,  something  she  had 
not  done  for  a  long  time  previously.  In  this  case  a 
certain^ addition  of  leguminous  aliment  was  made  to  the 
otherwise  unaltered  ordinary  diet.     The  author  there- 

'  Casey  A.  Wood  :  The  Toxic  Amblvopins,  Part  i.,  p.ige  13. 
'  Reviewed  in  Hirscliberg's  Centralhlatt  Itir  I'kt.  .Aiigcnheilkunde. 
1887,  page  240. 


fore  considers  leguminous  food  suitable  and  valuable 
as  aliment  in  similar  cases,  and  also  in  diabetes  and 
obesity. —  T/ie  British  Medical  Journal. 

Hypertrophied  Prostate  and  Resection  of  the  Vas 
Deferens. — At  the  French  Surgical  Congress  recently 
held  in  Paris,  M.  Guyon  read  a  paper  on  the  above 
subject.  He  said  that  the  solidarity  existing  between 
the  testicles  and  the  prostate  gland  was  purely  func- 
tional, for  the  circulation  and  enervation  of  both  of 
these  glands  were  independent,  and  different  in  their 
origin.  It  was  consequently  natural  to  suppose  that  the 
physiological  isolation  of  these  organs  by  the  suppres- 
sion of  the  vas  deferens  would  be  sufficient  to  obtain 
effects  analogous  to  those  realized  from  ablation  of  the 
testicles  He  practised,  last  June,  bilateral  resection  of 
the  vas  deferens  on  two  patients,  the  first  of  whom  had 
suffered  for  ten  years  from  incomplete  retention,  and 
when,  last  summer,  he  consulted  the  speaker,  mic- 
tion became  so  imperious  that  the  catheter  had  to  be 
constantly  used,  and  which  more  than  once  wounded 
the  canal  in  effecting  a  passage  through  the  prostatic 
portion  of  the  urethra.  Rectal  examination  revealed 
considerable  hypertrophy  of  the  prostate.  A  few  days 
after  the  operation  the  frequency  of  miction  diminished 
notably,  and  the  catheter  could  be  passed  with  more 
ease.  At  the  end  of  a  month  the  gland  had  decreased 
in  volume.  The  second  patient  came  to  him  in  about 
the  same  condition,  and  the  operation  gave  a  certain 
relief,  but  the  prostate  had  not  changed  much  in  vol- 
ume. In  both  patients  the  testicles  remained  normal. 
His  colleague,  ?*I.  Leguen,  performed  the  same  op- 
eration on  a  patient  a  month  later,  who  had  suffered 
from  complete  retention  for  a  month  previously.  The 
results  of  the  operation  were  quickly  manifest  ;  the 
man  was  able  to  dispense  with  the  use  of  the  cathe- 
ter for  ten  days  at  a  time,  a  month  after  the  resection. 
In  concluding,  M.  Guyon  said  that  the  above  operation, 
although  it  could  not  pretend  to  the  radical  cure  of 
hypertrophy  of  the  prostate  as  that  of  total  castration, 
yet  it  might  take  rank  among  those  measures  addressed 
to  certain  complications  of  prostatism. 

Simple  Manner  of  Overcoming  the  Catarrh  Conse- 
quent on  the  Administration  of  Potassium  Iodide. — Dr. 

Cohen  (  TI>c  Lancet)  has  often  observed  that  patients 
taking  iodide  of  potassium  suffered  in  a  marked  degree 
from  "  iodism,"  the  chief  symptoms  being  coryza  with 
a  sometimes  profuse  discharge,  sneezing,  pains  over  the 
frontal  sinuses,  swelling  of  any  part  of  the  mucous 
membrane  of  the  mouth,  and  a  sense  of  heat  in  the 
chest.  The  foregoing  phenomena  are  identical  with 
those  attendant  upon  the  inhalation  of  free  iodine 
(Mitchell  Bruce),  and  it  has  been  observed  that  one  is 
more  likely  to  be  attacked  with  catarrh  if  the  iodide  of 
potassium  contains  free  iodine  as  an  impurity.  This 
seems  to  justify  the  belief  that  the  catarrh  of  iodism  is 
due  either  to  iodine  being  secreted  by  the  salivary 
glands,  or  to  the  circumstance  that  iodide  of  potassium 
is  broken  up  in  the  mouth  after  its  secretion  and  free 
iodine  liberated.  The  latter  view  is  supported  by 
Schmiedeberg,  who  has  proved  that  iodide  of  potas- 
sium in  the  presence  of  carbonic  acid  is  decomposed, 
the  latter  being  abundant  in  the  expired  air  in  the  re- 
gion of  the  salivary  glands.  AVliile  taking  charge  of 
Dr.  Herschell's  outpatients  at  the  Natioral  Hospital 
for  Diseases  of  the  Heart,  the  writer  has  been  able  to 
stop  the  catarrh  in  three  well-marked  cases  by  adding  to 
the  mixture  (being  in  each  case  ten  grains  of  iodide  of 
potassium  and  half  an  ounce  of  water)  five  minims  per 
dose  of  tincture  of  belladonna,  his  object  being  to  re- 
duce the  salivary  secretion,  and  in  each  case  the  result 
was  satisfactory.  Any  antisialagogue  would  doubless 
have  a  similar  effect,  but  belladonna  is,  in  his  opinion, 
the  most  useful,  as  it  can  easily  be  given  in  the  form  of 
a  mixture  with  the  iodide,  and  in  the  small  dose  that  is 
used  in  such  cases,  it  counterbalances  the  so  called 
■'  depressant  "  action  of  the  potassium. 


December  14.  1895] 


MEDICAL   RECORD. 


845 


Medical    Record: 

A  Weekly  Journal  of  Aledicinc  and  Surgery. 


GEORGE   F.  SHR-\DY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO..  43,  45  &  47  East  Tenth   Street. 


New  York,  December  14,   1895. 


REFORM     IX    THE    DEPARTMENT    OF 
PUBLIC   CHARITIES. 

In  the  early  days  of  the  present  reform  administration 
of  our  city  government,  we  took  occasion  to  suggest, 
from  a  medical  standpoint,  the  qualifications  which  the 
Commissioners  should  have  for  the  proper  performance 
of  their  duties.  We  stated  that  the  affairs  of  this 
department  were  threefold  in  character,  viz. :  i,  Medi- 
cal supervision  of  hospitals  ;  2,  supervision  of  the  pen- 
itentiary and  its  inmates  ;  and  3,  the  general  business 
of  both  branches  of  the  senice.  A  thoroughly  quali- 
fied commission  would  therefore  consist  of  a  physician, 
an  expert  in  the  care  and  management  of  criminals, 
and  a  business  man.  The  appointments  which  soon 
followed  were  made  on  the  old  lines,  and  the  outcome 
is  what  was  anticipated.  Not  only  no  reforms  in  the 
management  of  the  institutions  of  the  Department  have 
been  made,  but  a  most  deplorable  muddle  of  the  medi- 
cal service  has  been  created  which  has  aroused  the 
opposition  of  the  entire  profession. 

The  separation  of  the  Department,  under  the  law  of 
last  winter,  into  two  Departments,  one  of  Charities,  and 
the  other  of  Corrections,  and  the  necessity  of  the  ap- 
pointment of  three  Commissioners  of  Charities,  raises 
again  the  question  of  the  qualifications  of  the  new 
Commissioners.  The  events  of  the  last  few  weeks  in 
the  management  of  the  medical  service  of  the  hospitals 
of  the  Department  emphasize  our  previous  arguments 
in  favor  of  having  in  the  Commission  at  least  one  com- 
petent physician. 

We  are  only  too  familiar  with  the  objections  which 
laymen  will  raise,  viz.,  that  medical  men  never  agree, 
and  hence  a  Medical  Commissioner  will  prove  to  be  a 
disturbing  element  in  hospital  management.  We  might 
reply  that  it  would  be  quite  impossible  for  a  medical 
member  of  the  Commission  to  create  in  our  profession 
a  greater  and  more  general  dissatisfaction  with  the 
management  of  the  hospitals  than  has  the  present 
Commission  of  laymen.  But  we  shall  not  quibble  over 
matters  of  so  little  importance.  Our  contention  is 
based  on  the  undisputed  principle  which  should  gov- 
ern all  appointments  in  the  Civil  Service,  viz.,  the  in- 
dividual qualification  of  the  person  appointed  to  per- 
form the  duties  of  his  office  in  a  manner  best  adapted 
to  secure  from  that  office  the  largest  amount  of  public 
good.  It  follows  that  the  man  who  is  best  qualified 
f^T  any  position  in  the  Civil  Service  is  one  who  to 


honesty,  education,  mental  capacity,  and  industry,  adds 
the  greatest  familiarity  with  all  the  duties  of  the  office 
to  which  he  is  appointed.  This  formula  is  the  very 
comer- stone  of  all  our  Civil  Service  regulations. 

Let  us  apply  the  above  principle  to  the  selection  of  a 
Commissioner  for  a  Department  composed  chiefly  of  hos- 
pitals. It  must  certainly  be  admitted  that  a  medical  man 
has  far  more  special  knowledge  of  the  affairs  of  an  hospi- 
tal than  a  layman  of  even  the  highest  intelligence,  who 
has  not  devoted  himself  to  hospital  management.  If,  in 
addition,  the  physician  has  had  a  large  personal  expe- 
rience in  the  internal  sersdce  of  hospitals,  and  has  a 
high  rank  in  his  profession,  can  there  be  any  doubt  that 
the  public  interests  would  demand  his  selection  ? 

But,  it  will  be  asked,  can  a  physician  be  found  who 
has  had  the  necessary  hospital  experience,  and  has  the 
confidence  of  the  medical  profession,  and  who  would 
serve  if  appointed  ?  We  answer  yes  ;  there  are  at  all 
times  available  physicians  in  this  city,  of  age,  experi- 
ence, and  reputable  standing,  who  would  serve,  and 
whose  appointment  would  be  received  with  profound 
satisfaction  by  the  medical  profession  and  the  public. 
And  we  may  add  that  such  physicians  would,  by  their 
large  knowledge  of  the  medical  profession,  and  the  re- 
quirements of  hospitals,  harmonize  all  interests,  and 
avoid  the  disgraceful  dilemma  with  which  the  present 
Commission  is  wrestling. 

We  do  not  hesitate  to  affirm  that  the  present  evils 
which  afflict  the  Department  of  Charities  are  due  to  the 
absence  from  the  councils  of  the  Commission  of  a  com- 
petent medical  member.  Nor  will  those  great  funda- 
mental reforms  on  which  the  future  renovation  and 
elevation  of  the  Charities  service  depends  be  effected 
until  the  head  of  the  Department  is  itself  renovated 
and  elevated  by  the  appointment  of  at  least  one  thor- 
oughly qualified  medical  Commissioner. 


MIRACULOUS  CURES. 
The  annual  pilgrimage  to  Lourdes  in  August  last  was 
larger  and  attracted  more  attention  than  any  that  has 
taken  place  for  many  years.  This  was  possibly  in  a 
measure  the  result  of  the  advertisement,  so  to  say,  of  the 
Grotto  in  Zola's  latest  work,  or  perhaps  it  was  a  protest 
of  believers  against  the  almost  contemptuous  scepticism 
therein  avowed.  .\s  was  to  be  anticipated  from  the 
greater  concourse  of  people  and  the  greater  exaltation 
of  the  expectant  multitude  of  sick,  the  number  of  cures 
obtained  through  the  agency  of  the  miraculous  waters 
was  larger  than  usual.  That  in  very  many  cases  these 
cures  are  genuine  and  permanent,  there  can  be,  in  the 
face  of  a  mass  of  competent  testimony,  no  question 
whatever.  How  these  cures  are  effected  we  cannot 
say.  The  statement  that  the  healing  takes  place 
through  the  influence  of  the  mind  upon  the  body,  that 
it  is  a  result  of  expectant  attention,  is  satisfactory  as 
far  as  sound  goes,  but  it  explains  nothing.  The  argu- 
ment-closing contention  that  the  miracles  of  Lourdes 
are  an  evidence  of  divine  favor  and  that  the  cures  are 
from  the  hand  of  God,  is  too  inclusive.  Phenomena 
of  the  same  order,  the  genuineness  of  which  are  at- 
tested by  competent  medical  witnesses,  have  been  ob- 
served in  faith-cure  conventicles  and  Christian-science 


846 


MEDICAL    RECORD. 


[December   14,  1895 


homes,  and  if  the  recoveries  at  Lourdes  are  super- 
natural, so  Tiust  be  faith-healing  and  the  cures 
wrought  by  Francis  Schlatter.  Furthermore,  miracu- 
lous cures  took  place  in  the  temples  of  ^Esculapius  ages 
ago,  in  apparently  the  same  manner  as  now  at  Lourdes, 
and  votive  tablets  on  the  walls  of  the  temples  bore 
witness  to  the  miraculous  restoration  of  sight  to  the 
blind  and  to  cures  wrought  by  the  hands  of  the 
gods. 

Dr.  Edward  Berdoe,  of  London,  writes  of  these 
miracles  of  healing  in  the  October  number  of  the 
Nineteenth  Century,  and  discusses  the  explanation  of 
them  as  far  as  they  can  be  explained.  He  quotes 
Charcot,  who  regarded  faith- cure  as  an  ideal  method, 
often  succeeding  where  other  means  have  failed,  but 
says  that,  while  of  a  scientific  order,  its  domain  is 
limited  ;  for,  "  to  produce  its  effects,  it  must  be  ap- 
plied to  those  cases  which  demand  for  their  cure  no 
intervention  beyond  the  power  which  the  mind  has 
over  the  body.  Purely  dynamic  diseases  are  cured  by 
this  means,  but  not  organic  maladies.  Ulcers  and 
tumors  may  be  caused  to  disappear  if  such  lesions  be 
of  the  same  nature  as  paralysis  and  other  disorders  of 
motion  and  sensation."  The  writer  refers  to  an  analy- 
sis made  by  Littre  of  seven  miracles  which  took  place 
at  the  tomb  of  St.  Louis  in  the  thirteenth  century.  In 
this  analysis  he  says  Littre  states  the  simple  facts  as 
given  in  the  chronicles  of  the  period,  and  endeavors  to 
give  a  pathological  interpretation  of  them.  He  notices> 
in  the  first  place,  that  at  the  moment  of  cure  the  pa- 
tient felt  a  sharp  pain  ;  the  part  affected  seemed  to  be 
stretched,  and  sometimes  a  sort  of  cracking  sensation 
in  the  bone  was  experienced  ;  then  movements  be- 
came impossible,  although  the  lengthening  of  the  limb 
and  the  possibility  of  moving  it  freely  were  not  expe- 
rienced immediately.  The  cracking  of  the  bone  is 
just  what  the  surgeon  finds  when  he  moves  a  joint 
which  has  become  fixed  by  disuse  ;  without  breaking 
down  these  adhesions  he  can  do  nothing  to  restore  the 
articulation.  In  cases  of  rheumatic  paralysis  a  similar 
state  of  things  is  observed.  Of  course,  in  the  accounts 
of  the  healing  at  the  tomb  of  St.  Louis  we  expect  to 
find  errors  and  exaggerations  due  to  the  preoccupation 
and  ignorance  of  those  who  wrote  the  reports,  but  we 
at  once  recognize  the  cracking  and  the  pain  as  genuine 
pathological  details  ;  we  should  not  expect  a  natural 
cure  without  these  symptoms.  M.  Littre  explains  that 
we  have  here  a  muscular  action  of  the  affected  part  ; 
the  muscle  contracts  energetically  ;  it  breaks  down  the 
pathological  adhesions  if  they  exist ;  it  restores  the 
bones  violently  to  their  place.  What  the  surgeon  has 
to  do  with  his  hand  is  here  done  by  an  influence  ex- 
erted on  the  muscles  themselves,  and  in  a  far  more 
beneficent  manner  than  surgery  can  effect.  The  excit- 
ing cause  of  these  energetic  contractions  is  that  which 
we  find  in  all  miracles  of  this  sort— a  strong  persuasion, 
a  complete  confidence.  "  It  is  the  brain  and  feeling 
generated  by  the  mind  which  give  strength  to  the  per- 
son who  thinks  strongly.  A  gouty  man,  who  has  long 
hobbled  about  on  his  crutch,  finds  his  legs  and  power 
to  run  with  them  if  pursued  by  a  wild  bull.  The 
feeblest  invalid,  under  the  influence  of  delirium  or 
other  strong  excitement,  will  astonish  her  nurse  by  the 
sudden  accession  of  strength  she  may  exhibit;." 


THE  USE  OF  SHORT-HAND  IX  MEDICINE. 

What  seems  at  first  glance  to  be  a  curious  little  side- 
path  in  the  history  of  medicine  and  of  medical  asso- 
ciations, is  the  establishment  in  England  a  jxar  ago  of 
the  Society  of  Medical  Phonographers.  What  in  the 
world,  one  is  tempted  to  exclaim,  does  a  physician  want 
with  short-hand  I  Hasn't  he  enough  to  do  without 
burdening  his  mind  with  a  new  art,  and  one  that  can 
have  no  relation  whatever  to  the  science  or  art  of 
medicine  ?  But  the  arguments  of  the  founder  and 
supporters  of  this  new  society,  which  now  numbers 
nearly  two  hundred  in  its  membership,  cannot  be  thus 
dismissed  off-hand.  The  mere  fact  of  the  existence 
of  such  an  association  is  an  evidence  that  those  who 
use  short-hand  find  it  so  helpful  to  them  that  they  are 
willing  to  be  at  some  pains  to  extend  its  benefits  to 
others.  In  his  inaugural  address  before  the  Society, 
the  President,  Dr.  Gowers,  presented  the  claims  which 
the  science  of  phonography  has  to  the  attention  of 
medical  men,  old  practitioners  as  well  as  first-year 
students  ;  and  possibly  it  may  help  along  the  work, 
which  we  cannot  but  regard  as  a  good  one,  if  we  re- 
view briefly  the  speaker's  arguments  for  the  benefit  of 
those  who  may  never  have  heard  of  the  Society  of 
Medical  Phonographers. 

The  need  for  writing,  for  a  written  record,  is  abso- 
lute in  medicine  as  in  every  science  that  rests  on  ob- 
servation, for  memory  cannot  be  trusted,  and  immedi- 
ate record  can  alone  make  observation  effective.  But 
with  the  aid  of  short-hand  twice  the  amount  of  record 
that  is  possible  with  long  hand  can  be  made,  and  yet 
there  will  remain  a  longer  time  in  which  to  observe. 
Furthermore,  many  fleeting  events  which  might  escape 
record  in  long  hand  can  be  noted  and  preserved  in 
memory  forever  by  the  winged  characters  of  phonog- 
raphy. As  was  well  said  by  the  Bishop  of  Hereford, 
in  a  letter  read  at  this  same  meeting  :  "  Short-hand  puts 
a  new  instrument  into  the  hand  of  the  observer,  an  in- 
strument which  must  be  specially  valuable  when  you 
have  to  deal  with  subtle  and  quickly  changing  phe- 
nomena." 

Thus  the  observer,  having  the  means  at  hand  for  re- 
cording the  evanescent  phenomena,  gradually  acquires 
the  habit  of  looking  for  them  and  observing  them. 
Short-hand  is  like  a  lens  that  brings  to  the  conscious- 
ness of  the  observer  many  minute  but  most  important 
points,  that  would  possibly  otherwise  escape  him.  The 
often-quoted  words  of  Bacon,  that  "writing  maketh  an 
exact  man,"  acquire  a  fuller  significance  when  the 
writing  is  shorthand  writing. 

But  the  use  of  short-hand  does  not  stop  at  the  record 
of  observation.  "  It  is  equally  available,"  says  Dr. 
Gowers,  "  with  the  same  saving  of  time  and  labor,  in  the 
processes  of  comparison  of  observations,  of  epitomiz- 
ing the  facts  observed  by  others,  and  in  all  the  prelimi- 
nary work  of  composition.  Indeed,  I  have  frequently 
written  the  final  copy  in  short-hand  ;  tyjJewriters  tran- 
scribe it  with  accuracy." 

It  may  be  thought  that  these  remarks  have  little  ap- 
plication to  the  work  of  the  practitioner,  but,  on  the 
contrary,  the  value  of  short-hand  in  medicine  finds,  per- 
haps, its  greatest  expression  in  the  aid  it  can  give  to  the 
practitioner.     "  Without   the  use  of  writing,  the  facts 


December   14,  1895] 


MEDICAL    RECORD. 


847 


that  pass  before  him  will  leave  only  a  transient  furrow 
on  the  sands  of  unaided  meraorj',  vanishing  for  the 
most  part  when  new  facts  disturb  the  surface,  or  at 
most  leaving  but  a  slight  modification  in  mental  ten- 
dency. The  vast  effect  of  unrecorded — and  therefore 
unconsidered — '  experience  '  is  too  often  a  warping  of 
judgment  by  the  influence  of  some  striking  but  ex- 
ceptional fact,  conspicuous  in  vague  outline  in  the 
memory,  while  the  conditions  essential  to  its  interpre- 
tation are  forgotten.  Only  habitual,  immediate  record 
can  preser\-e  from  these  dangers  the  '  personal  science  ' 
on  which  depends  the  work  of  the  practitioner  and  the 
welfare  of  his  patients.  For  this  result  the  record  of 
that  which  is  observed  must  of  course  be  utilized,  and 
so  arranged  that  its  value  shall  not  be  lost.  Yet  the 
mere  process  of  record  gives,  as  we  have  seen,  precision 
to  observation,  and  secures  retention  not  otherwise  to 
be  obtained." 

Of  course,  there  are  objections  that  may  be  urged 
against  the  use  of  short-hand,  but  the  drawbacks  are 
slight  in  comparison  to  the  advantages  of  the  accom- 
plishment. The  contention  that  note-taking  weakens 
the  memory  is  an  objection  that  applies  equally  to  the 
taking  of  long-hand  notes.  Few  men,  if  any,  have  a 
memory  that  never  plays  them  false  ;  and,  moreover,  it 
is  the  experience  of  most  people  that  writing  down  a 
fact  helps  to  fix  it  in  the  memory.  Another  objection, 
and  really  the  only  one  of  any  real  force,  is  that  neither 
the  student  nor  the  practitioner  can  spare  the  time  nec- 
essary for  the  acquirement  of  a  ready  knowledge  of 
short-hand.  But  anyone  can  learn  to  write  with  sufficient 
rapidity,  say  three  times  that  of  long-hand,  by  prac- 
tising two  hours  a  day  for  two  months,  and  the  one 
hundred  and  twenty  hours  thus  spent  will  be  saved 
and  repaid  several  times  over  in  the  next  two  years. 
Short-hand  is  illegible  is  another  objection  urged 
against  it.  But  the  experience  of  those  who  use  it  is 
that  it  is  not  illegible  when  written  carefully  and  at  a 
moderate  speed.  The  notes  of  a  stenographer  making 
a  verbatim  report  of  a  political  meeting  may  perhaps 
be  illegible  to  all  but  himself ;  but  short-hand  can  be 
written  with  three  times  the  speed  of  long-hand  and  be 
fully  as  legible,  not  alone  to  the  writer  but  to  all  pho- 
nographers,  as  long-hand. 

Dr.  Cowers  deserves  ihe  thanks  of  all  who  are  inter- 
ested in  the  advance  of  medical  science  and  of  indi- 
vidual progress  for  his  disinterested  labors  in  promot- 
ing the  diffusion  of  a  knowledge  of  short-hand  among 
members  of  the  profession,  and  we  hope  that  he  will 
find  his  reward  in  the  prosperity  of  the  Society  which 
he  has  founded,  and  which  has  honored  itself  in  choos- 
ing him  as  its  first  presiding  officer. 


Dr.  S.  Arthur  Bosanko,  of  Leadville,  Colo.,  died  in 
that  city  on  November  23d,  of  pneumonia.  Dr.  Bo- 
sanko was  born  in  Aurora,  Canada,  November  25, 
1855.  He  received  his  medical  education  at  the  Uni- 
versity College  of  Victoria  and  the  University  of  To- 
ronto, receiving  degrees  from  both  colleges,  .\fter 
practising  for  a  time  in  Michigan  he  removed  to  Colo- 
rado, where  he  resided  up  to  the  time  of  his  death.  He 
leaves  a  widow  and  one  son. 


Medical  Staff  of  the  Board  of  Fire  Comniissioners. 
— The  Medical  Staff  of  the  Board  of  Fire  Commission- 
ers of  New  York  City,  consisting  of  four  gentlemen, 
have  resigned,  and  a  new  set  of  physicians  have  been 
appointed.  The  salary  for  these  positions  is  §2,000  a 
year.  The  following  are  the  new  appointees :  Dr. 
Fred.  A.  Lyons,  Dr.  Edwin  B.  Ramsdell,  and  Dr.  Fran- 
cis M.  Banta. 

Microscopical  Diagnosis  of  Infections  Diseases. — 
The  city  of  Paris  has  gone  a  step  further  than  the  city 
of  New  York,  and  has  decreed  that  the  diagnosis  of  all 
diseases  due  to  known  micro-organisms  shall  hence- 
forth be  undertaken  at  the  bacteriological  laboratory 
of  the  city,  and  that  any  practitioner  can  send  his  speci- 
mens there  and  have  the  examinations  made  g mil's . 

The  New  York  School  of  Clinical  Medicine,  lo- 
cated at  328  West  Forty-second  Street,  and  modelled 
after  the  Berlin  Docenter  \'erein,  has  just  issued  its 
first  announcement.  An  important  feature  of  the  new 
school  is  the  fact  that  the  classes  being  small  and  lim- 
ited, the  matriculates  act  as  assistants  and  have  an  op- 
portunity to  personally  study  the  cases  under  the  guid- 
ance of  the  teachers.  The  names  of  most  of  the  faculty 
are  familiar,  having  been  connected  with  the  leading 
hospitals  and  schools  as  professors  and  instructors. 
Those  thus  far  appointed  are — Professors,  Beck,  Bushe, 
Dessau,  Garrigues,  Goelet,  Gottheil,  Oppenheimer, 
Skeel,  Valentine,  Weiss,  and  Zemansky  ;  .\ssociate  Pro- 
fessors, Louis  Fischer,  George  Lindenmyer.  The  secre- 
tary of  the  faculty  is  Dr.  Ferdinand  C.  Valentine. 

Dr.  Charles  W.  Allen's  Article  on  "  Erysipelas,"  in 
our  issue  of  November  23d,  was  not  read  before  the 
American  Medical  Association,  but  at  the  recent  meet- 
ing of  the  American  Dermatological  Association. 

Adulterated  Boots  and  Ulcerated  Throats. — Adul- 
teration has  spread  to  everything,  and  it  has  not  even 
spared  the  shoe.  According  to  a  London  contempo- 
rary there  are  such  things  as  "  adulterated  boots." 
Certain  classes  of  cheap  boots  are  said  to  be  made  up 
with  a  kind  of  spongy  diaphragm  of  shavings  and  sugar 
between  the  inner  and  outer  sole.  This  spongy  dia- 
phragm, once  damp,  never  gets  dry,  and  as  the  result, 
people  who  wear  these  shoes  are  liable  to  sore  throats, 
rheumatism,  colds,  and  so  forth. 

Maragliano  Semm — We  learn  from  \\\<t  Boston  Medi- 
cal and  Sui:^iial  Joiiinal  that  an  Italian  physician  of 
this  city,  who  attended  the  recent  Medical  Congress  in 
Rome,  brought  home  with  him  some  of  the  antituber- 
cular  serum  prepared  by  Professor  Maragliano.  He 
has  used  it  with,  as  is  claimed,  favorable  results  in 
three  cases.  The  impression,  however,  gained  from 
European  exchanges,  is  that  this  .serum  is  of  no  value. 

Sanitary  Science  is  extending  its  domain  every  day. 
The  city  of  Montpellier,  in  France,  has  given  perem))- 
tory  orders  that  no  article  of  food  shall  be  delivered 
by  the  grocers  and  butchers  of  that  town  unless  it  is 
wrapped  up  in  clean  wrapping-paper,  and  this  new 
wrapping-paper  must  not  be  colored. 

A  Fee  in  the  hand  is  worth  two  in  the  book. 


848 


MEDICAL    RECORD. 


[December  14,  1895 


The  Therapeutical  Laboratory  attached  to  the  ward 
of  the  Hopital  Cochin,  which  used  to  be  under  the 
charge  of  the  late  Dujardin-Beaumetz,  has  been  trans- 
ferred to  the  Hopital  de  la  Pitie.  It  will  be  under  the 
charge  of  Dr.  Albert  Robin. 

Dr.  Harrison  Allen  has  received  the  title  of  Emeri- 
tus Professor  of  Comparative  Anatomy  in  the  Univer- 
sity of  Pennsylvania. 

Mr.  Young  J.  Pentland,  of  Edinburgh,  is  the  only 
medical  man  in  Great  Britain  and  Ireland  who  has 
subscribed  to  the  Index  Medicus. 

Physicians  and  Euthanasia. — The  Medical  Magazine 
calls  attention  to  the  fact  that  at  a  certain  Medico- 
Legal  Congress,  held  in  this  city  last  summer,  a  lawyer 
read  a  paper  in  which  he  maintained  the  right  of  the 
physician  to  end  the  agony  of  a  patient  whose  recov- 
ery was  impossible,  by  giving  drugs  ;  and  he  added 
that  he  knew  physicians  who  did  follow  such  practice. 
The  Chicago  Times-Herald,  commenting  upon  this, 
said  :  "  It  may  be  conceded  that  in  a  few  cases,  such 
as  acute  mania  or  hydrophobia,  where  the  patient  is 
suffering  from  a  pitiless  malady  without  hope  of  relief 
short  of  death,  the  physician  has  taken  the  responsibil- 
ity of  ending  the  agony  by  administering  an  over-dose 
of  opiates.  It  is  well  known  that  during  the  war  sur- 
geons sometimes  gave  the  coup  de  grace  to  tortured  vic- 
tims of  battle."  The  Medical  Magazine  expresses  re- 
gret that  the  medical  press  in  this  country  should  not 
attack  the  statement  with  the  vigor  that  they  expected, 
and  wonders  if  American  physicians  do  really  thus  pro- 
duce euthanasia.  We  suspect  that  the  real  reason  why 
the  American  medical  press  did  not  notice  the  discus- 
sion referred  to  was  because  it  did  not  seem  worth 
while  to  pay  attention  to  such  criticisms. 

United  Medical  Societies.— The  Chicago  Practition- 
ers' Club  and  the  Doctors'  Club  have  united  under  the 
title' of  the  Physicians'  Club. 

Dr.  John  S.  Billings,  United  States  Army,  retired,  lias 
been  presented  with  a  purse  of  $10,000  by  physicians, 
in  recognition  of  his  valuable  services  in  issuing  the 
Index  Catalogue. 

Thanks. — The  New  York  Medical  Record  has 
come  to  our  table  for  so  many  years  that  we  miss  it  if 
it  is  a  day  late,  and  without  it  something  would  be 
seriously  lacking  in  the  enjoyment  of  professional  life. 
We  have  become  so  acquainted  with  the  spirit  of  its 
editorials  that  we  have  found  pleasure  in  alternately 
agreeing  and  disagreeing  with  its  utterances.  It  is  so 
old  and  so  familiar  a  friend  that  we  at  all  times  feel  the 
most  perfect  composure  and  ease  in  praising  and  abus- 
ing it.  While  it  now  takes  a  seeming  relish  and  pleas- 
ure in  assailing  the  railway  surgeon,  still  we  have  be- 
come so  educated  that  its  complaining  murmurs  of 
disapprobation  rather  soothe  and  lull  us  with  the 
thought :  "  Oh,  it  is  the  Record."  We  have,  however, 
never  doubted  its  able  conduction  nor  its  great  capac- 
ity for  usefulness.  It  has  been  a  great  educator  in  our 
country,  and  while  we  reproach  it  at  times,  still  we 
fully  ap])reciate  its  greatness. —  The  Railway  Surgeon. 

The  French  Congress  of  Surgery.— This  Congress, 
which  met  in  Paris  recently,  is  spoken  of  as  being  a 
scientific  success,  but  we  note  from  our  Paris  contem- 


poraries that  there  were  certain  phases  of  the  affair 
that  were  not  entirely  pleasant.  The  visitors  com- 
plained that  the  Paris  surgeons  did  not  give  them  good 
opportunities  to  see  the  work  in  the  great  city  hospi- 
tals, and  a  still  more  bitter  cry  went  up  from  the  fact 
that  the  sessions  of  the  Congress  began  at  eight  o'clock 
in  the  morning,  at  which  time,  we  are  informed,  all 
good  Parisians  are  in  bed.  The  consequence  was  that 
at  the  time  when  the  scientific  work  began,  only  thirty 
or  forty  out  of  the  two  hundred  members  of  the  Con- 
gress were  present.  Eight-o'clock  sessions  of  scientific 
meetings  would  certainly  not  be  popular  in  this  coun- 
try, particularly  the  day  after  the  banquet. 

The  organization  of  the  scientific  work  seems  to 
have  been  well  planned,  and  the  Congress  discussed 
nearly  every  surgical  question,  beginning  in  the  head 
and  ending  in  the  toes.  The  surgical  treatment  of  the 
lungs,  of  the  heart,  of  affections  of  the  stomach,  of  the 
liver,  and  of  the  kidneys,  of  the  urethra  and  genito- 
urinary organs,  diseases  of  the  joints,  fractures- — in  fact, 
the  French  Congress  of  Surgery  spread  itself  out  over  the 
whole  human  anatomy,  and  a  perusal  of  the  proceed- 
ings is  suggestive  of  a  systematic  treatise  on  the  surgi- 
cal art.  A  number  of  new  cases,  results  of  difficult 
operations  in  the  various  surgical  fields,  were  reported, 
but  we  do  not  find  any  particularly  new  methods  of 
treatment  suggested. 

Suits  Against  Physicians. — A  suit  for  $20,000  dam- 
ages against  Dr.  W.  O.  Roberts,  of  Louisville,  was  re- 
cently thrown  out  of  court,  and  in  a  suit  for  $5,000, 
brought  against  Dr.  L.  S.  McMurtry,  the  jury  awarded 
Dr.  McMurtry  a  counter-claim  of  $500  for  services 
rendered  the  patient. 

A  New  Laboratory  for  the  University  of  Pennsyl- 
vania.— On  December  4th,  the  Pepper  Laboratory  of 
Clinical  Medicine,  connected  with  the  Hospital  of  the 
University  of  Pennsylvania,  was  formally  opened.  Dr. 
J.  S.  Billings,  director  of  the  University  Hospital,  pre- 
sented the  building  to  the  University  in  the  name  of  Dr. 
Pepper,  and  Professor  W.  H.  Welch  delivered  the 
principal  address.  Drs.  Draper,  Delafield,  and  Jane- 
way,  of  New  York,  and  Drs.  Osier  and  Abel,  of  Balti- 
more, were  present. 

Obituary  Notes. — Dr.  D.  M.  Miller,  of  Elizabeth, 
N.  J.,  died  on  December  3d. — Dr.  John  A.  Jones 
died  at  his  home  in  Mansfield,  O.,  on  December  3d, 
aged  sixty- four. 

The  New  York  State  Board  of  Health  and  Infected 
Milk.— The  Board  of  Heahh  of  the  State  of  New  York 
has  decided  to  submit  and  recommend  to  the  Legisla- 
ture a  bill  forbidding  the  sale  of  milk  containing 
tubercle  bacilli.  The  bill  will  require  those  who  sell 
milk  to  show  that  their  cows  are  free  from  the  disease 
in  question.  A  proof  will  consist  of  a  certificate,  issued 
by  the  Board  or  its  authorized  agents,  after  an  exami- 
nation made  by  competent  persons. 

Bureau  of  Public  Health.— In  the  House  of  Repre- 
sentatives, Mr.  Mahon,  of  Pennsylvania,  has  introduced 
a  bill  establishing  a  Bureau  of  Public  Health  in  the 
Treasury  Department,  to  provide  measures  of  security 
against  the  introduction  of  contagious,  and  spread  of 
epidemic,  diseases. 


December  ]4.  1895] 


MEDICAL    RECORD. 


849 


ii'cuicxus  and  iloticcs. 


Medical  Diagxosis  with  Special  Reference  to 
Practical  Medicine.  By  J.  M.  DaCosta,  M.D., 
LL.D.,  President  College  of  Physicians  of  Philadelphia. 
Eighth  Edition.  8vo,  pp.  1104.  Philadelphia  :  J.  B.  Lip- 
pincott  Co.     1895. 

This  well-know-n  and  classical  work  appears  in  its  eighth 
edition  considerably  amplified  and  altered  in  its  various 
parts.  The  general  arrangement  is  the  same  as  in  former 
editions,  the  diseases  being  classified  in  accordance  with 
their  more  prominent  clinical  features,  rather  than  arbitrar- 
ily arranged  in  reference  to  their  leading  pathological  le- 
sions. Nothing  is  left  to  be  desired  by  the  student  who 
wishes  to  study  salient  features  in  comparison  with  others 
common  to  similar  diseases.  The  lines  of  disiinction  are 
clearly  drawn  by  the  hand  of  a  master,  and  the  student  is 
led  to  that  line  of  broad  and  conservative  reasoning  that  is 
in  itself  a  special  mental  training  for  a  conception  of  the 
higher  duties  of  his  calling  as  a  discriminative  and  accurate 
diagnostician.  There  is  also  incorporated  whatever  of  purely 
bacteriological  interest  that  is  valuable  for  the  leading  pur- 
poses of  the  talented  and  broad-minded  author.  The  in- 
troduction of  a  number  of  additional  original  cuts  gives  a 
special  value  to  this  admirable  treatise. 

The  P.\thologv  and  Scrgic.-vl  Treatment  of  Tum- 
ors. By  N.  Sexn,  M.D.,  Ph.D.,  LL.D..  Professor  of 
Practice  of  Surger\"  and  Clinical  Surgery.  Rush  Medical 
College.  8vo,  pp.  709.  Philadelphia  :  W.  B.  Saunders. 
1S95. 

The  appearance  of  such  a  work  as  tiie  one  indicated  in 
this  title  is  most  opportune.  The  well-known  capabilities 
of  the  author,  his  large  clinical  opportunities,  and  his  pains- 
taking investigation  of  pathological  phenomena,  eminently 
fit  him  for  the  task  he  has  undertaken.  There  is  no  doubt- 
ing the  fact  that  the  special  department  of  surgical  pathol- 
ogy of  which  the  volume  treats  has  hitherto  been  much 
neglected,  and  that  the  time  is  ripe  for  its  wider  considera- 
tion and  its  more  accurate  study.  This  condition  has  been 
very  satisfactorily  met  by  the  exhaustive  manner  in  which 
the  whole  subject  is  studied  in  its  broader  general  aspects, 
as  well  as  its  detailed  modifications  as  applied  to  special 
forms.  In  design  and  execution  the  work  is  such  as  will 
appeal  to  every  student  who  appreciates  the  logical  exam- 
ination of  facts  and  the  practical  exemplification  of  well- 
digested  clinical  observation.  The  general  complexion  of 
the  work  is  didactic,  and  considering  its  aim  to  impress 
leading  facts,  is  excusably  reiterative  and  dogmatic.  Scat- 
tered throughout  the  text  are  italicized  sentences  and  para- 
graphs that  are  impressed  upon  the  reader  as  axioms,  and  as 
such  serve  an  excellent  purpose.  The  division  of  tumors  is 
on  a  purely  histogenetic  basis,  and  their  study  is  conducted 
on  clinical  lines  as  well.  The  author  does  not  believe  in  the 
de  novo  origin  of  tumors,  but  very  ingeniously  and  quite 
satisfactorily  proves  that  they  are  also  due  to  the  develop- 
ment of  a  matrix  of  embryonic  cells,  and  that  there  is  noth- 
ing whatever  in  the  microbic  theories.  The  broad  distinc- 
tion between  the  benign  and  malignant  tumors,  in  that  the 
former  is  always  encapsulated  and  the  latter  infiltrating,  is 
impressively  stated  with  many  necessary  repetitions.  Each 
particular  variety  of  growth  is  minutely  described  from  his- 
togenetic, anatomical,  and  clinical  stand-points,  with  a  liber- 
ality of  illustration  which  creates  a  most  attractive  feature. 
The  descriptions  of  operative  procedures  are  also  profusely 
illustrated,  and  many  show  the  different  stages  in  a  manner 
that  cannot  fail  to  be  highly  instructive  to  the  practical  sur- 
geon. Altogether  it  is  a  broad  book,  full  of  interesting  facts, 
eminently  sound  in  its  pathology,  and  founded  on  an  excep- 
tionally large  experience  of  a  conscientious  and  painstaking 
observer. 

A  Manual  of  Operative  Surcerv.  By  Lewis  A.  Stim- 
?ON,  B.A.,  M.D.,  Suigeon  to  New  York,  Bellevue,  and 
Hudson  Street  Hospitals,  and  John  Ro<;ers,  Jr.,  B.A., 
M.D  ,  Assistant  Demonstrator  of  Anatomy,  College  of 
Physicians  and  Surgeons.  New  York.  Third  Edition. 
i2mo,  pp.  59S.    Philadelphia:  Lea  Brothers  &  Co.    1895. 

This  compact,  tersely  written  manual  has  been  almost  re- 
written in  the  laudable  effort  to  note  the  important  changes 
in  the  science  and  practice  of  operative  surgery  during  the 
past  ten  years.  A  number  of  the  useless  operations  de- 
scribed in  former  editions  have  been  omitted,  and  a  num- 
ber of  new  ones  which  have  proved  valuable  have  been  in- 


serted, notably  those  referring  to  the  abdomen  and  cranium. 
The  illustrations  are  plentiful,  and  the  descriptions  of  tech- 
nique are  admirable  for  their  clearness. 

Bulletin  (No.  8)  of  the  Harvard  Medical  Alu.mni 
Association.  Report  of  the  Fifth  Annual  .Meeting  held 
in  Boston,  June  25,  1895. 
We  are  always  glad  to  read  these  after-dinner  speeches, 
even  if  we  cannot  always  laugh  where  [laughter]  is  indicat- 
ed. One  can  learn  much  from  them,  and  it  is  interesting  to 
know  just  where  the  Harvard  man  puts  in  his  applause. 
The  general  style  of  the  bulletin  is  surely  attractive  and 
creditable.  The  .Association  appears  to  be  in  a  verj-  healthy 
state. 

Supplement  to  the  International  Encyclop.cdia  of 
Surgery.  Edited  by  John  .■\shhur5T,  Jr.,  .NLD., 
LL.D.,  Philadelphia.  One  royal  octavo,  pp.  1136.  New 
York  :  William  Wood  &  Co.     1S95. 

This  large  volume,  corresponding  in  size  with  the  original 
ones  which  comprise  the  well-known  series  of  the  Interna- 
tional Encyclopedia  of  Surgery,  forms  a  becoming  and  ex- 
haustive supplement  of  that  work  in  presenting  the  latest 
and  more  advanced  views  of  eminent  authors  on  the  various 
topics  of  newer  interest  in  progressive  modern  surgery.  No 
less  than  forty-eight  contributors  have  written  articles  on 
fifty-five  different  subjects,  that  have  been  specially  studied 
with  the  view  of  bringing  them  up  to  date  in  all  esscnti.il 
and  practical  particulars.  In  such  a  view  the  work  is  a  good 
and  useful  supplement  to  any  treatise  on  surgery,  and  as 
a  volume  by  itself  it  surveys  a  field  of  recent  experience 
that  is  broad  enough  to  give  it  a  value,  essentially  and  pe- 
culiarly its  own,  as  a  leading  text-book  for  the  progressive 
surgeon  and  advanced  student.  The  arrangement  of  sub- 
jects has  been  judiciously  made  by  the  editor,  and  the  spaces 
assigned  to  the  nxiters  are  in  accordance  with  the  import- 
ance of  the  subjects  on  the  one  hand,  and  the  amount  of 
new  material  to  be  digested  on  the  other.  Commencing 
with  a  well-written  digest,  by  Dr.  H.  C.  Ernst,  of  the  more 
recent  views  on  inflammations,  and  more  particularly  from 
a  bacteriological  stand-point,  there  naturally  follows  one 
on  Wounds  and  Wound  Treatment,  by  Dr.  Kammerer. 
This  is  a  thoroughly  exhaustive  article,  and  gives  ample  evi- 
dence of  a  practical  knowledge  of  the  subject.  The  pains- 
taking thoroughness  of  Dr.  Kiliani  in  his  chapter  on  Dis- 
eases Complicating  Wounds  will  be  fully  appreciated  by  the 
reader.  The  experiences  of  Professor  Conner  in  gunshot 
wounds  will  carry  their  due  weight,  giving  in  small  compass 
the  really  essential  methods  of  their  modern  treatment.  Dr. 
Packard,  on  Poisoned  Wounds,  presents  some  new  and  in- 
teresting facts  connected  with  their  causes  and  treatment, 
especially  such  as  are  received  in  dissection  and  operation. 
Dr.  Gaston,  in  his  article  on  Hydrophobia,  speaks  earnestly, 
if  not  convincingly,  of  Pasteur's  preventive  method.  Dr. 
Forcheimer,  in  a  short  chapter  on  Scrofula  and  Tuberculo- 
sis, lays  the  groundwork  for  the  detailed  treatment  of  their 
numerous  manifestations  as  given  by  the  writers  who  follow. 
Dr.  Lewis  Smith's  article  on  Rachitis  lays  down  those 
broader  principles  on  which  the  more  strictly  medical  treat- 
ment is  founded.  Dr.  Wharton,  on  .Abscesses  and  Ulcers, 
appropriately  endorses  the  value  of  Thiersch's  method  as 
well  as  that  of  skin  transplantation  in  selected  cases.  Gan- 
grene and  gangrenous  diseases  is  the  topic  discussed  by  Dr. 
E.  M.  Moore,  in  his  usually  comprehensive  and  exhaustive 
style.  Dr.  Bouffleur  contributes  an  exceedingly  practical 
article  on  Anesthesia,  which  shows  wide  reading  and  close 
observation.  The  more  recent  and  approved  methods  of 
Amputation,  special  and  gener.il,  arc  treated  by  the  scholarly 
editor.  The  chapter  on  Tumors,  by  Dr.  Curtis,  is  one  of  the 
leading  features  of  the  work,  and  is  filled  with  all  the  new- 
est observations  on  this  always  interesting  topic.  Dr.  J. 
William  White,  on  \'enere.nl  Diseases,  confines  himself 
mostly  to  the  manngemcnt  of  gonorrhoeal  affections,  and 
leans  strongly  to  the  antiseptic  management  of  all  urethral 
discharges. 

Dr.  Sturgis,  in  treating  of  the  non-specific  venereal  sore, 
verv-  properly  dwells  on  the  ver)'  radical  measures  for  its  ar- 
rest, while  Dr.  Win  Harlingen,  on  Syphilis,  is  eq;ially  happy 
in  his  cleirly  presented  views  reg.irding  diagnosis.  Dr.  J. 
Abbott  Cantrell's  chapter  on  Dise.-.scs  of  the  Skin  and  its 
Appendages  has  a  unique  value,  in  that  it  groups  together 
some  of  the  rarer  and  more  interesting  forms  of  these  affec- 
tions in  a  way  that  is  eminently  satisfactory.  Dr.  Ashhurst. 
in  an  article  on  Diseases  of  the  Cellular  Tissue,  gives  a  very 
clear  account  of  a  set  of  troubles  that  are  seldom  grouped 
together.  Following  these  are  chapters  on  general  and  spe- 
cial injuries  of  the  blood-vessels,  lymphatics,  nerves,  bursx. 


8-^o 


MEDICAL   RECORD. 


[December  14,  1S95 


bones,  joints,  head,  back,  nose,  ear,  face,  throat,  neck, 
oesophagus,  and  chest,  by  various  leading  authorities.  The 
articles  on  Intubation,  by  Dr.  H.  W.  Wharton,  on  In- 
juries and  Diseases  of  the  Abdomen,  by  Dr.  Van  Der  Veer, 
and  on  Intestinal  Obstruction,  by  the  Editor,  are  especially 
worthy  of  careful  reading  and  earnest  study.  Dr.  Hunter 
McGuire's  Discussion  of  Diseases  of  the  Bladder  and  Prostate 
is  short  and  to  the  point,  especially  in  so  far  as  he  omits  all 
reference  to  the  absurd  method  of  castration  for  enlarged 
prostate.  Dr.  Keyes  still  leans  to  lithotrity  as  the  usual 
method  of  treatment  of  vesical  calculus,  and  makes  some 
capital  and  suggestive  remarks  concerning  the  true  value  of 
supra-pubic  lithotomy.  The  chapter  on  Injuries  and  Dis- 
eases of  the  Urethra,  by  Dr.  Thomas  R.  Neilson,  gives  a 
very  interesting  account  of  the  principles  and  practice  of 
urethroscopy  as  an  efficient  aid  to  treatment.  The  Inju- 
ries and  Diseases  of  the  Male  Genital  Organs,  by  Dr.  G.  \V. 
Davis,  goes  very  thoroughly  into  the  whole  subject,  and  com- 
presses in  a  comparatively  small  compass  for  easy  reference 
a  large  amount  of  practical  information.  The  technique  of 
Abdominal  Ovariotomy  is  presented  from  the  modern  stand- 
point by  Dr.  Charles  B.  Penrose,  and  deserved  attention  is 
given  to  supra-vaginal  hysterectomy  for  uterine  cancer.  Dr. 
Robert  P.  Harris  treats  very  fully  of  the  indications  and 
methods  of  modern  C^esarean  Section  and  Symphyseotomy. 
Dr.  Theophilus  Parvin  follows  with  Injuries  and  Diseases  of 
the  Female  Genitals,  and  among  other  appropriate  things  in 
keeping  with  the  general  design  of  his  topic,  very  clearly  de- 
scribes Tait's  new  operation  for  ruptured  perineum ;  Wenck- 
el's  posterior  colporrhaphia  ;  Martin's  elytrorrhaphia  ; 
Sanger's  perinorrhaphy,  and  Sanger's  substitute  for  Emmet's 
cervix  operation.  Lastly,  Dr.  Edward  Cowles  offers  some 
excellent  plans  for  the  construction  of  the  larger  and  smaller 
hospitals  on  an  aseptic  basis.  The  volume  is  profusely  illus- 
trated from  original  drawings  and  contains  a  well-executed 
chromo-lithographic  plate  of  ulcerating  mammary  carcino- 
ma. 

History  of  Epidemics,  with  Reference  to  Animal 
Epidemics.  By  Dr.  B.  M.  Lersch,  Berlin.  1896.  Pp. 
4855.  Published  by  S.  Karger. 
The  writer  says  in  his  preface  that  the  history  of  epidemics, 
from  the  oldest  time  up  to  the  present,  furnishes  to  the 
thoughtful  physician  much  instruction  upon  the  hygienic 
questions  of  to-day.  There  is  no  doubt  about  this,  and  we 
think  that  the  author  has  supplied  us  with  an  extremely 
interesting  and  valuable  work.  The  history  begins  with 
the  references  to  epidemics  in  the  earliest  times  in  Egypt, 
Babylon,  and  China,  but  the  systematic  descriptions  of 
epidemics  date  back  no  further  than  the  Athenian  pest  of 
about  430  B.C.  The  author  goes  on  from  this  time,  century 
by  century,  describing  the  principal  epidemics  that  have 
occurred,  mainly  in  Europe.  It  is  a  sad  record  of  the  suffer- 
ings' of  human  beings  through  ignorance  of  how  to  live 
healthfully,  and  how  to  prevent  the  spreading  of  disease 
when  it  has  attacked  a  community. 


A  Noble  Epitaph.— The  scientific  record  of  Pasteur 
is  thus  summed  up  on  a  marble  tablet  which  was  re- 
cently set  up  by  order  of  the_  Paris  Municipal  Council 
in  the  old  laboratory  of  the  Ecole  Normale  : 
Ici  FUT  LE  Labor ATOiRE  de  Pasteur. 

1S37. — P'ermentations. 

1S60. — Gcneratione  spontanees, 

1S65. — Maladies  des  vins  et  des 

186S. — Maladies  des  vers  4  soie. 

iSSi. — Virus  et  vaccins. 

1SS5. — Prophylaxie  de  la  rage. 

A  New  Journal  on  Diseases  of  Children. — We  have 
received  the  first  number,  dated  January  i,  1S96,  of 
Pediatrics,  a  journal  that  will  speedily  win  for  itself  the 
favor  of  workers  in  children's  diseases,  if  it  succeeds 
in  maintaining  the  excellence  of  its  initial  number.  The 
editor  is  Dr.  George  A.  Carpenter,  of  London,  and  the 
owner  Dr.  Dillon  Brown,  of  this  city.  The  staff  of 
collaborators  includes  such  well-known  names  as  Ja- 
cobi,  Forchheimer,  Eve,  lioas,  Grandin,  J.  Nevins  Hyde, 
Dawson  Williams,  Joseph  Collins,  and  Gowers.  The 
contributors  to  this  first  number  are  Jacobi,  Fruitnight, 
Lilienthal,  Phelps,  Sutherland,  Manges,  and  Collins. 
The  cover  of  the  journal  is  strikingly  original  and  neat, 
and  the  illustrations  are  very  good. 


^ocictij  Reports. 


MEDICAL    SOCIETY    OF    THE    COUNTY    OF 
NEW  YORK. 

Adjourned  Annual  and  Staled  Meetings,  November  25, 
1893. 

Egbert   H.  Grandin,   M.D.,   Later   E.   D.  Fisher, 
M.D.,  IN  the  Chair. 

Annual  Dues. — On  motion  of  the  treasurer,  Dr.  John 
S.  Warren,  the  annual  dues  were  made  three  dollars, 
as  usual.  The  comitia  was  empowered  to  expend 
such  money  as  was  necessary  to  defray  the  expenses  of 
the  Society. 

Report  of  the  Committee  on  Hygiene. — Dr.  George 
B.  Fowler  read  the  report.  He  first  pointed  out  the 
earnest  efforts  of  the  city  authorities  to  keep  the  streets 
clean,  and  the  needed  aid  which  the  Board  of  Health 
had  given  the  Street  Commissioner,  by  allowing  him  a 
sum  of  money  to  meet  a  prospective  deficiency  in 
his  department.  The  health  and  hygienic  condition 
of  the  city  was  almost  wholly  in  the  hands  of  the 
Health  Department,  and  with  the  proper  support  of 
the  medical  profession,  there  could  be  no  doubt  but 
what  it  would  yet  largely  control  many  forms  of  disease 
which  at  present  added  greatly  to  the  death-rate. 
During  the  past  twenty-five  years  the  death-rate  had 
been  gradually  reduced  from  33  to  20  per  thousand. 
The  new  tenement-house  work  was  destined  not  only 
to  reduce  the  mortality  among  the  poor,  but  also  to 
increase  the  standard  of  intelligence  and  citizenship. 
The  importance  of  the  public  baths  was  dwelt  upon, 
the  only  one  in  the  city  having  ten  baths  had  been 
used  during  the  three  years  of  its  existence  219,- 
000  times.  A  number  of  these  were  to  be  erected 
through  the  city,  fifty  by  one  hundred  feet,  each  to 
contain  eighty-six  baths.  There  were  also  to  be  estab- 
lished as  many  as  one  hundred  public  urinals  and 
water-closets. 

The  next  subject  touched  upon  was  the  use  of  anti- 
toxin by  the  Board  of  Health  for  the  purpose  of  curing 
and  preventing  the  spread  of  diphtheria.  The  reports 
from  European  countries,  and  from  Dr.  Biggs,  of  the 
Health  Department  in  this  city,  appeared  to  show  very 
favorable  results  from  antitoxin,  but  Dr.  Fowler 
thought  they  were  not  yet  conclusive.  We  were  not 
justified  in  accepting  laboratory  and  special  hospital 
experiments  while  ignoring  the  results  of  vast  clinical 
experience.  We  had  to  await  further  observations, 
meanwhile  testing  the  value  of  modem  me  \ods  in 
order  to  keep  abreast  the  times. 

The  Medical  Directory. — Dr.  Daniel  Le.  is.  Edi- 
tor of  the  Medical  Directory,  read  his  rep  rt.  An 
additional  expense  had  been  assumed  in  publ  hing  the 
list  of  physicians  in  New  York  State,  New  J  sey,  and 
Connecticut,  yet  there  was  a  balance  to  th  credit  of 
the  Society  of  $152.  The  book  had  a  wider  circulation 
than  any  previous  year.  Members  were  requested  to 
notify  the  editor  of  any  errors  or  alterations  which 
should  be  made. 

Address  ofthe  Retiring  President. — Dr.  Egbert  H. 
Graxdi.>j,  in  relinquishing  the  office  of  president  to  his 
successor,  said  : 

Gentlemen  ;  The  Society  year  which  is  expiring,  it 
seems  to  me,  may  rank  with  its  predecessors  in  that  it 
has  maintained  the  Medical  Society  of  the  County  of 
New  York  as  the  leading  society  in  the  world  holding 
stated  meetings.  The  membership  has  been  increased 
by  one  hundred  and  one.  Lleath  has  laid  his  hand 
upon  us  with  more  frequency  than  usual,  fifteen  of  the 
members  having  passed  to  their  reward,  each  in  his 
sphere  having  achieved  something  for  the  good  of  hu- 
manity and,  in  particular,  of  this  community,  and  each 
meriting  the  words  "  Well  done,  thou  good  and  faithful 


December  14,  1895] 


MEDICAL   RECORD. 


servant."  The  attendance  at  the  meetings  has  been  of 
the  most  gratifying  nature.  The  scientific  papers  pre- 
sented have  been  of  a  high  order  of  merit,  brief  and 
practical,  and  the  selection  of  the  papers  has  been  with 
the  aim  of  interesting  the  various  special  lines  of  work 
which  are  cultivated  by  the  members  of  the  Society. 
The  special  meeting  held  to  protest  against  official  folly 
as  exemplified,  in  particular,  by  coroners,  has  borne  fruit 
in  that  it  proved  that  this  Society  did  not  propose  to 
allow  indignity  to  be  inflicted  on  its  members  without 
forcible  protest.  The  coroner  system,  however,  is  still 
with  us.  And  yet  this  office  is  gradually  hanging  itself, 
on  which  occurrence  this  community  may  possess  a  sys- 
tem worthy  of  the  age  in  which  we  live,  instead  of  one 
which  is  the  constant  laughing- stock  of  the  country. 
Under  the  revised  constitution  the  legislators  at  Albany 
should  find  no  difficulty  in  abolishing  an  office  which  is 
as  useless  as  it  is  ludicrous. 

Sufficient  influence  was  in  control  at  Albany  last  win- 
ter to  side-track  your  resolution  protesting  against  the 
wording  of  the  law  which  prevents  a  medical  man  serv- 
ing as  president  of  the  Board  of  Health  of  this  city. 
The  contention  that  this  clause  of  the  law  is  unconsti- 
tutional appears  valid,  in  that  it  makes  special  e.xemp- 
tion  against  the  citizen.  Further  still,  it  must  be  ob- 
vious that  a  medical  man  is  from  education  better 
qualified  to  serve  as  president  of  a  Board  of  Health 
than  the  average  bank  president,  clerk,  politician,  or 
what  not.  A  medical  president  of  the  Board  of  Health, 
were  the  emolument  of  the  office  sufficient  to  enable  a 
medical  man  of  the  right  calibre  to  accept,  would  not 
only  add  lustre  to  the  board,  but  carry  the  conviction 
that  political  influence  could  play  no  part  in  matters 
affecting  the  health  of  the  city,  whether  it  lay  in  the 
abatement  of  nuisances  or  the  selection  of  competent 
subordinates. 

The  suggestions  of  your  standing  committees  on  Ethics 
and  Prize  Essay  are  so  fresh  in  your  minds,  that  I  need 
do  no  more  than  acquiesce  ;  and  yet,  while  referring  to 
this  matter  of  committees,  I  would  state  my  conviction 
that  the  interests  of  the  Society  require  that  the  chair- 
men of  the  committees  on  Ethics  and  of  Hygiene 
should  be  members  of  the  Comitia,  in  order  that  the 
officers  of  the  Society  may  be  in  constant  touch  and 
sympathy  with  these  committees. 

The  report  of  your  counsel  proves  that,  under  the 
law  signed  by  a  liberal-minded  Governor  last  spring,  the 
Society  is  beginning  to  rid  the  community  of  the  quacks 
and  the  impostors  who  fatten  on  the  credulity  of  the 
populace,  too  often  to  its  injury,  if  not  death.  Abortion- 
ists we  are  as  yet  unable  to  reach  owing  to  the  difficulty 
of  securing  evidence,  although  the  leniency  shown  these 
offenders  by  the  legal  officers  of  the  county,  even  though 
indicted,  might  well  make  us  sceptical  as  to  the  utility 
of  causing  arrest,  had  we  evidence.  In  accordance  with 
instructions  received  from  the  Society  steps  have  been 
taken,  and  the  effort  will  be  continued,  to  prosecute 
druggists  who,  holding  no  degree  in  medicine,  practise 
and  prescribe  over  the  counter.  Of  course  you  ap[)re- 
oiate  the  fact  that  all  this  entails  the  expenditure  of 
considerable  money,  but  the  counsel  believes  that  at 
the  end  of  the  year  the  receipts  from  fines  will  jiracti- 
cally  make  the  legal  bureau  of  the  Society  self-support- 
ing. Even  if  the  reverse  proves  to  be  the  case,  the  good 
accomplished  justifies  the  Society  in  the  extra  outlay 
involved.  It  is  to  be  regretted  that  in  this  county  we 
have  not  the  same  power  as,  I  am  informed,  obtains  in 
at  least  another,  of  regulating  the  practice  of  midwives. 
Since  these  women,  owing  to  the  nature  of  our  popula- 
tion, must  exist,  the  community  should  insist  that  they 
possess  at  least  the  requisite  qualifications,  such  as  ob- 
tain in  Austria,  for  example.  Not  only  does  [uierperal 
sepsis  still  exist  in  this  city,  owing  largely  to  the  ignor- 
ance of  the  midwives,  but  ophthalmia  iteonati,  with  its 
frightful  consequences,  cannot  be  stamped  out.  While 
it  is  not  within  my  province  to  make  suggestions,  I 
would  express  the  hope  that  the  Society  may  see  fit  to 


endeavor  to  secure  proper  legislation,  looking  to  the 
registration  of  midwives  after  suitable  examination. 
The  Medical  Directory  of  the  Society  has  this  year  been 
enlarged,  as  has  been  stated  by  the  Editor,  so  that  the 
necessity  for  the  publication  of  any  other  ceases  to 
exist.  Just  so  long  as  this  Directory  is  given  free  of 
charge  to  the  members  of  the  Society  it  is  impossible  to 
eliminate  what  in  the  opinion  of  many  members  is  ob- 
jectionable, that  is  to  say,  the  advertising  pages.  To 
express  the  opinion  of  an  individual  in  regard  to  this 
question,  I  think  it  might  be  well  to  have  future  issues 
published  without  advertising  matter,  and  that  copies 
should  be  sold  at  as  low  a  rate  as  will  pay  the  expense 
of  publication. 

At  the  last  meeting  of  the  Society  action  was  taken 
on  an  appeal  from  a  decision  of  the  Comitia,  and  the 
Society  endorsed  the  precedent,  that  it  was  responsible 
for  remarks  made  by  its  members,  irrespective  of  the 
nature  of  the  remarks.  It  would  appear  to  me  that 
this  precedent  is  an  exceedingly  dangerous  one  to  es- 
tablish, although,  as  a  member  of  this  Society,  I  favor 
as  strongly  as  anyone  the  protection  of  the  rights  of 
the  members.  The  way  out  of  the  difficulty  is  for  the 
Society  to  hold  executive  sessions,  where  the  greatest 
possible  latitude  of  speech  would  be  allowable  ;  at  any 
rate,  members  should  be  instructed  to  remember  that, 
under  the  By-Laws,  the  officers  of  the  Society,  consti- 
tuting the  executive  committee,  should  be  consulted  in 
reference  to  matters  which  might  lead  to  litigation  be- 
fore such  matters  are  introduced  in  public  meeting. 

At  the  same  meeting  a  temperate  protest  against 
what  many  members  of  the  Society  deem  an  outrage, 
was  presented  and  accepted  by  practically  an  unani- 
mous vote.  The  matter  of  the  protest  is  one  which 
allows  of  honest  difference  of  opinion,  and  yet  it  is  one 
which,  speaking  from  the  stand-point  of  an  unpreju- 
diced individual,  was  bound  sooner  or  later  to  force  it- 
self on  the  attention  of  this  Society.  In  my  address 
on  the  occasion  when  I  assumed  the  position  of  high 
honor  which  I  am  on  the  point  of  relinquishing,  I  en- 
deavored to  show  you  how,  if  you  each  exerted  your 
influence,  you  could  most  effectively  and  powerfully 
mould  public  opinion  in  the  direction  which,  as  profes- 
sional men,  you  wish.  I  endeavored  to  point  out  to 
you  that  one  reason  why  you  carried  little  influence 
was  because  you  little  realized  your  power  in  obtaining 
your  rights  by,  as  a  body,  insisting  upon  them.  Now 
that  I  am  about  to  make  the  i)arting  words  in  my  ca- 
reer from  a  position  of  public  honor  and  of  great  trust, 
you  will  pardon  my  frankness  if  I  go  further  and  tell 
you  that  outrage  is  inflicted  upon  you,  and  you  do  not 
gain  what  you  deserve,  because  you  do  not  act  together 
for  the  good  of  one  another.  In  the  fifteen  years 
that  I  have  lived  and  practised  among  and  with  you  I 
would  have  you  believe  that  it  has  not  been  with  closed 
eyes,  even  as  I  assert  that  it  has  been  on  an  entirely  in- 
dependent basis.  I  naturally  feel,  therefore,  that  the 
conclusions  I  have  reached  should  be  definitely  stated, 
even  though  not  one  of  you  here  present  to-night  can 
agree  with  me. 

In  the  years  I  have  spent  in  this  city  I  have  seen 
the  gradual  evolution  of  a  monopoly  in  medical  circles 
such  as,  if  it  be  not  strangled,  will  render  it  difficult 
for  all  but  the  favored  few  to  secure  a  livelihood  out  of 
the  practice  of  medicine  and  of  surgery.  I  have  seen 
the  dispensary  arise  in  all  quarters  of  the  city,  sup- 
posedly endowed  for  the  care  of  the  worthy  poor  ;  I 
have  seen  hospitals  stretching  out  their  tentacles  so  as 
to  include  even  the  care  of  the  worthy  rich,  although, 
under  the  ground  of  their  endowments,  they  were  only 
entitled  to  help  the  needy.  Meantime  the  general 
practitioner — the  bone  and  the  sinew  of  our  profession 
— has  seen  his  income  dwindle  and  his  patients  grow 
beautifully  less,  his  panacea  being  the  reading  of  the 
glowing  annual  reports  of  dispensary  and  hospital, 
showing  the  good  done  supposedly  to  the  worthy  poor, 
and  to  these  alone.     I  am  far  from  deriding  the  value 


MEDICAL   RECORD. 


[December   14,  1895 


of  both  hospital  and  of  dispensary  ;  on  the  contrary, 
were  I  rich  beyond  the  needs  of  those  dependent  on 
me,  I  might  be  tempted  to  open  and  to  endow  both 
hospital  and  dispensary.  Conducted,  however,  they 
would  be  on  the  following  cardinal  principles  :  Only 
those  entitled  by  reason  of  poverty  could  gain  entrance, 
and  the  physicians  and  the  surgeons  and  the  internes 
who  cared  for  these  poverty-stricken  sick  would  re- 
ceive remuneration  for  the  services  rendered.  The 
laborer  is  worthy  of  his  hire,  even  though  he  be  a 
medical  man.  When,  if  it  so  happened,  the  medical 
staff  had  dispute  with  Boards  of  Governors,  right  and 
equity  being  on  their  side,  I  would  not  tolerate,  in  the 
event  of  resignation  for  principle,  the  prompt  filling  of 
position  by  other  medical  men,  giving  rise  to  the  utter- 
ance on  the  part  of  Boards  of  Governors,  "  the  places 
are  easily  filled  !  "  I  would  expect  the  colleagues  of 
those  who  resigned  to  stand  up  for  the  principle  at 
stake,  and  to  make  Boards  of  Governors  the  servants 
instead  of  the  masters  of  medical  men.  On  the  medi- 
cal man  falls  the  labor,  the  anxious  nights  and  days 
full  of  the  greatest  of  all  responsibilities — that  of  hu- 
man life  !  Why,  pray,  should  the  medical  man  bear 
the  trying  burden  only  to  receive  that  treatment  which 
even  the  dumb  animal  would  protest  against  ?  Stand 
together,  therefore,  brethren,  where  principle  is  at 
stake,  and  do  not  so  quickly  fill  the  places  left  vacant 
because  of  principle. 

So  much  for  the  solution  of  the  dispensary  and  the 
incorporated  hospital  abuse  as  viewed  by  a  man  who 
can  talk  freely  because  he  is  untrammelled. 

Next,  as  regards  the  public  hospitals  of  this  city. 
The  sympathy  of  this  Society  is  certainly  with  the 
cause  of  higher  education.  Whatever  will  tend  to  turn 
out  a  better  class  of  medical  practitioners  will  ever  re- 
ceive the  sanction  and  the  active  support  of  the  Medi- 
cal Society  of  the  County  of  New  York.  As  members 
of  this  Society  and  of  the  profession  of  medicine,  we 
are  proud  of  the  record  of  our  institutions  for  medical 
instruction.  We  realize  that  this  city  is  destined  to 
become  the  chief  centre  of  medical  instruction  in  the 
world  ;  toward  that  end  we  all  labor.  But  as  members 
of  the  medical  profession,  can  we  rest  satisfied  with 
seeing  a  monopoly  grow  up  in  our  midst,  a  hydra- 
headed  trust  against  which  our  ancestors  long  ago  pro- 
tested ?  We  are  all  tax-payers,  are  we  not  entitled  to 
equa^  representation  ?  When  I  say  2ve,  I  mean  the 
general  practitioner. 

Who  is  it  that  earns  his  living,  often  literally,  by  the 
sweat  of  his  brow?  It  is  not  the  successful  hospital 
surgeon  or  the  professor  in  the  medical  school,  whose 
salary  suffices  to  lift  him  above  anxiety  about  the 
bread  and  the  butter  of  his  wife  and  his  little  ones.  It 
is  the  general  practitioner,  and  what  with  the  illegiti- 
mate lending  of  aid  to  the  well-to-do  by  hospitals  and 
dispensaries,  and  the  filling  of  private  rooms  in  the 
former  by  those  whose  means  and  positions  do  not 
lend  justification  ;  and  what  with  the  passing  of  the 
charity  hospitals  beyond  the  reach  of  the  average  prac- 
titioner, who  needs  the  experience  there  to  be  secured 
and  the  eclat  of  the  titles,  and  who  is  just  as  solicitous 
for  the  well-being  of  the  wards  of  the  Commissioners  of 
Public  Charities  as  his  more  favored  brother,  the  pro- 
fessor, can  possibly  be  ;  if  this  sucking  of  everything 
into  the  maelstrom  of  monopoly  goes  on,  what,  I  would 
ask  you,  is  to  become  of  you,  the  general  practitioner? 

From  my  stand-point,  again  an  unbiassed  one,  for  I 
have  given  up  teaching  and  hospital  appointment, 
each  and  every  one  of  you  should  have  the  privilege  of 
competing  for  positions  in  the  public  hospitals,  so  that 
you  as  well  may  acquire  experience  and  do  that  which 
the  minority  are  now  alone  able  to  do — show  your  ever- 
])resent  solicitude  for  the  health  and  the  well-being  of  the 
wards  of  the  city.  Further  still,  as  individuals,  it  seems 
to  me  you  should  exercise  your  undoubted  influence  in 
securing  the  appointment  of  Commissioners  of  Public 
Charities   who,  in  matters  which   concern    the   entire 


medical  profession,  should  seek  the  advice  of  the  many 
instead  of  being  under  the  domination  of  the  few. 
The  unselfish  aim  of  the  many  is  a  safer  guide  than  the 
self-seeking  aim  of  the  few.  The  entire  profession 
feels  a  live  interest  in,  we  will  say,  the  welfare  of  the 
babes  on  Randall's  Island,  and  the  voice  of  the  entire 
profession  might  well  be  raised  in  protest  against  exist- 
ing abuses,  whether  these  abuses  be  due  to  parsimony 
or  to  negligence. 

The  utterance  of  these  stray  thoughts  will  be  par- 
doned, I  trust,  in  the  face  of  the  fact  that  I  would  deem 
myself  dishonest  did  I  not  express  them.  I  am  not 
placing  myself  at  variance  with  the  opinion  of  any 
other  to  whom  I  willingly  grant  the  credit  of  honest 
difference  of  opinion.  I  only  crave  exactly  the  same 
indulgence. 

Gentlemen,  for  the  favor  shown  me,  for  the  cordial 
cooperation  granted  me,  for  the  indulgence  extended 
me,  I  tender  my  thanks.  Whatever  has  been  accom- 
plished this  year,  the  credit  is  yours. 

You  have  chosen  as  my  successor  in  office  a  man 
who  has  ever  proved  faithful  to  trust,  and  therefore  he 
will  serve  you  well.  You  have  selected  a  man  who  has 
earned  deserved  reputation,  and  therefore  he  will  add 
lustre  to  the  records  of  the  Society.  Fearless  and  im- 
partial, he  will  maintain  you  where  I  trust  I  have  left 
you— on  the  topmost  wave  of  prosperity  and  of  re- 
nown. 

It  remains  for  me  to  declare  the  adjourned  annual 
meeting  adjourned  sine  die,  and  to  introduce  the  Presi- 
dent, Dr.  Edward  D.  Fisher. 

Address  of  the  President-Elect. — Dr.  Edward  D 
Fisher,  in  assuming  the  duties  of  presiding  officer  for 
the  current  year,  thanked  the  Society  for  the  honor 
which  it  had  conferred  upon  him.  He  mentioned 
briefly  the  objects  of  the  Society  and  the  duties  of  the 
officers.  The  influence  of  the  Society  was  great,  and 
should  not  be  thrown  with  undue  consideration  on 
either  side  of  any  question  of  importance  which  might 
be  presented  to  it.  We  must  resist  being  carried  away 
by  impulse.  Papers  -presented  before  it  should  be  of 
general  interest,  touching  directly  upon  general  medi- 
cine. 

Committees. — Dr.  Fisher  appointed  the  following 
committees  :  On  Hygiene,  Drs.  J.  W.  Brannan,  E.  S. 
Peck,  E.  Le  Fevre,  G.  W.  Jacoby,  Dillon  Brown  ;  on 
Ethics,  Drs.  T.  E.  Satterthwaite,  J.  B.  Tuttle,  B.  J. 
Knapp,  N.  E.  Brill,  H.  Stern  ;  Prize  Essay,  Drs.  W.  H. 
Katzenbach,  D.  B.  Delavan,  J.  E.  Weeks  ;  Auditing, 
Drs.  V.  P.  Gibney,  George  Woolsey. 

Some  Intra-nas'al  Causes  of  Headache. — Dr.  J.\mes 
E.  H.  Nichols  read  the  paper.  A  study  of  the  causes 
of  headache  as  given  in  the  text-books  on  general 
medicine  failed  to  reveal  an  adequate  conception  by 
general  writers  of  the  frequent  etiological  bearings 
which  nasal  disease  had  on  this  distressing  aftliction. 
Sinkler  and  Wood  were  quoted  ;  also  Foster's  Dictiori- 
ary.  On  the  other  hand,  rhinologists  and  laryngologists 
frequently  saw  cases  of  headache  in  which  the  cause 
was  a  disordered  or  diseased  condition  of  the  structures 
within  the  nasal  cavities.  Attempts  had  been  made  to 
localize  the  disease  by  the  area  in  which  pain  was  felt. 
in  most  cases  accompanied  by  tenderness  on  pressure. 
After  quoting  Head  on  these  areas,  he  said  that  while 
they  were  undoubtedly  present,  they  were  not  suf- 
ficiently definite  to  be  of  much  value  in  diagnosis. 

Ethmoidal  disease  was  much  more  common  than  we 
had  been  apt  to  suppose,  and  longer  and  more  obscure  in 
its  course.  It  was  not  necessary  that  there  should  be 
a  profuse  nasal  discharge  to  indicate  ethmoidal  disease, 
but  the  situation  of  the  exit  of  pus,  and  its  intermit- 
tency  and  [lersistency  were  the  points  most  valuable  in 
clearing  up  such  cases.  A  woman,  aged  twenty-seven, 
had  suffered  nearly  twenty  years  from  periodically  re- 
curring headaches  of  an  extreme  type,  coming  on 
nearly  every  week.  The  day  following  the  crisis  of  the 
attack  there  would  be  a  discharge  of  thin  muco  pus,  not 


December    14,  1895] 


MEDICAL   RECORD. 


853 


of  large  ciuantity,  and  not  malodorous,  and  then  there 
would  be  comparative  freedom  until  another  attack. 
Examination  at  the  time  of  the  attack  showed  the  right 
middle  turbinated  hyperasmic  and  pressing  hard  on  the 
septum,  muco-pus  coursing  down.  The  head  pain  was 
over  nearly  the  entire  right  side.  The  anterior  ex- 
tremity of  the  middle  turbinated  body  was  removed, 
and  the  ethmoidal  cells  entered.  These  were  broken 
down,  irrigated,  and  the  frontal  sinus  was  also  washed 
out.  Immediate  relief  was  experienced,  and  after  further 
treatment  she  was  cured.  He  had  notes  of  several 
similar  cases,  in  all  of  which  the  headache  disappeared 
as  soon  as  the  passages  were  opened  and  exit  given  the 
retained  secretions.  The  headaches,  he  said,  were  not 
sympathetic  or  referred  pains,  but  were  due  to  pressure 
of  the  retained  secretions,  and  were  purely  of  mechani- 
ical  origin.  The  author  accepted  the  theory  that  the 
seat  of  pain  in  headache  was  not  in  the  cortex,  but  in 
the  meninges,  and  was  due  to  vascular  dilatation,  produc- 
ing intra-cranial  pressure  and  compression  of  the  dura. 

Several  cases  were  cited,  showing  disease  of  various 
localized  areas  in  the  nose,  in  all  of  which  the  chief 
symptom  was  headache.  In  one,  the  headache  disap- 
peared after  removal  of  a  piece  of  spongy,  syphiloma- 
tous  tissue  springing  from  the  septum  and  obstructing 
the  superior  meatus.  In  another  case  a  school-boy  had 
suffered  from  continued  headache  on  the  right  side, 
which  disappeared  on  removing  a  spur  of  bony  tissue 
springing  from  the  septum,  projecting  into  the  middle 
turbinated,  of  traumatic  origin.  This,  the  author  said, 
could  be  recorded  as  a  caseof  hyperfesthetic  congestion 
induced  by  mechanical  pressure.  The  next  case  was 
one  of  recurrent  attacks  of  nasal  stoppage,  followed  by 
profuse  discharge  of  viscid  f^uid  from  right  nostril,  due 
to  cyst  of  the  inferior  turbinated,  removal  of  which 
cured  attacks  of  severe  frontal  and  orbital  headache, 
most  marked  on  same  side. 

Such  of  the  very  obscure  causes  of  pressure  as  myxo- 
mata,  hypertrophied  turbinated  bodies,  and  extreme 
deviations  of  the  septum,  need  hardly  be  mentioned, 
but  the  obscurer  cases  of  disease  of  the  accessory  si- 
nuses must  be  thoroughly  searched  out.  Of  the  latter 
kind  the  author  related  two  cases. 

It  was  a  conclusion  from  his  observation  that  head- 
aches were  more  frequently  of  nasal  origin  than  was 
generally  suspected  ;  that  they  were  in  the  main  of 
congestive  variety,  and  due  to  interference  with  the 
circulation  of  the  dura  mater  by  pressure  at  some  point 
in  the  nasal  cavity,  or  accessory  sinuses,  induced  by 
retained  secretions  and  by  hypertrophies  of  the  mem- 
brane or  abnormalities  of  osseous  structure.  The 
pressure  was  generally  on  some  branch  of  the  ophthal- 
mic vein.  Abnormal  conditions  in  the  inferior  meatus 
induced  free  pains,  but  not  cephalalgia.  Headaches  in 
which  the  area  of  intensity  was  about  the  orbit  were 
most  apt  to  be  due  to  disease  of  the  ethmoid  cells  and 
antrum.  Successive  attacks  of  a  similar  nature  were 
generally  of  nasal  origin. 

Dk.  Andrew  H.  Smith  thought  the  explanation  of 
headaches  given  by  the  author  was  hardly  broad  enough 
to  cover  the  entire  field.  It  was  well  known  how  often 
headache  was  reflex  in  origin  from  a  distant  centre  ; 
why  not  sometimes  from  a  nearer  point,  as  the  nasal 
passages.  All  were  probably  familiar  with  the  head- 
ache which  was  sometimes  produced  very  suddenly  by 
irritation  of  the  nasal  membrane  on  passing  into  the 
cold  air,  and  he  thought  this  was  of  reflex  origin  rather 
than  of  obstructive  origin  as  described  in  the  paper. 
Headache  from  pungent  odors  was  another  example  of 
reflex  rather  than  obstructive  headache. 

Regarding  the  seat  of  the  headache,  he  recalled  the 
case  of  a  gentleman  in  whom  it  was  in  the  occipital 
portion,  while  the  cause  was  disease  in  the  frontal  sinus. 
The  headache  ceased  with  discharge  of  fluid  from  the 
frontal  sinus. 

Dr.  a.  Edward  Davis  made  some  remarks  and  con- 
firmed the  diagnosis  in  one  of  Dr.  Nichol's  cases,  and 


the  discussion  was  continued  by  Drs.   Mayer,   M.  L. 
Foster,  and  Me>erhof. 

Report  of  Special  Committee. — The  special  commit- 
tee appointed  at  the  last  meeting  to  present  the  resolu- 
tions then  adopted,  condemning  the  new  arrangement 
for  appointing  medical  boards  in  the  public  hospitals, 
to  the  mayor  and  to  the  commissioners,  reported  that 
copies  of  the  resolutions  had  been  sent  the  gentlemen, 
but  no  answer  had  been  received,  and  the  mayor  had 
declined  to  see  the  subcommittee  which  had  called  upon 
him.  The  report  was  received  and  the  committee  dis- 
charged with  thanks. 

Civil  Service  and  Hospital  Appointments. — The  fol- 
lowing notice  had  been  printed  on  the  card  announc- 
ing the  meeting  : 

Resolved,  That  the  Medical  Society  of  the  County  of 
New  York  respectfully  urges  his  honor  Mayor  Strong 
to  place  all  appointments  of  visiting  and  assistant  phy- 
sicians and  surgeons,  and  all  salaried  resident  medical 
officers  to  all  the  hospitals,  asylums,  and  other  institu- 
tions now  governed  by  the  Commissioners  of  Charities 
and  Correction,  under  civil  service  rules. 

Dr.  N.  E.  Brill  moved  the  adoption  of  the  resolu- 
tion. 

Dr.  F.  R.  Sturgis  seconded  the  motion.  He  said 
we  did  not  come  here  as  sore-heads  because  we  had 
lost  positions.  The  Commissioners  of  Charities  had  a 
perfect  right  to  make  the  dismissals.  But  we  wished 
to  protest  against  the  mode  of  making  the  new  appoint- 
ments. The  old  method  had  at  least  a  semblance  of 
fairness.  Every  member  of  the  profession  could  pre- 
sent himself  as  a  candidate  under  that  method,  although 
it  was  well  known  that  the  question  of  whether  he  be 
given  the  position  depended  not  a  little  upon  political 
influence.  Under  the  new  method  no  man  who  was 
not  favored  by  his  connection  with  one  of  three  medi- 
cal schools  stood  more  than  one  chance  in  four  of  get- 
ting the  slightest  consideration  in  his  desire  to  serve 
the  city  and  reap  the  benefit  of  hospital  experience. 
In  the  matter  of  the  recommendations  from  the  fourth' 
division  of  Bellevue,  supposed  to  represent  the  general 
profession,  the  Commissioners  could  hardly  be  expected 
to  act  impartially.  It  was  said  the  change  had  been 
made  in  the  interests  of  medical  education.  If  this 
was  the  purpose  of  the  Commissioners,  they  had  tran- 
scended their  functions.  As  a  matter  of  fact  it  was 
made  in  the  interests  of  a  medical  monopoly,  and  was 
planned  by  a  few  men  connected  with  colleges,  which 
in  the  past  had  done  all  they  could  to  prevent  the  ad- 
vance of  medical  education  by  opposing  laws  provid- 
ing for  a  State  Board  of  Examiners  and  regulating  the 
practice  of  medicine.  Forty  years  ago  a  society  was 
formed  in  this  city  by  a  few  medical  men,  whose  aim 
was  to  control  all  hospital  appointments  and  consulta- 
tion practice.  If  the  general  profession  today  did  not 
give  heed  to  the  warning,  they  would  find  their  prac- 
tice pass  into  the  hands  of  this  limited  circle,  or  en- 
gulfed in  the  public  dispensaries  and  hospitals. 

Dr.  Warden  opposed  the  adoption  of  the  resolution, 
more  especially  because  if  it  were  adopted  the  present 
appointees  could  not  be  removed. 

Dr.  a.  p.  Dudley  opposed  it  for  the  same  reason, 
and  also  because  the  demand  would  not  be  heeded, 
and  our  position  would  be  worse  than  if  it  had  not  been 
made. 

After  a  few  more  remarks  the  resolution  was  adopted. 

Dr.  J.  Blake  White  moved  that  a  committee,  con- 
sisting of  Drs.  Roosa,  Pryor,  and  R.  A.  Murray,  be  ap- 
pointed to  present  a  copy  of  the  resolution  to  the 
mayor.     Carried. 


The  Correspondence  of  the  Insane. — The  Assistant 
Postmaster  (leneral  has  given  the  opinion  that  the  au- 
thorities of  Insane  Asylums  have  the  right  to  withhold 
letters  from  patients  when  it  seems  necessary  to  do  so. 


^54 


MEDICAL   RECORD. 


[December  74,  1895 


NEW  YORK  ACADEMY  OF    MEDICINE. 
SECTION  ON  OBSTETRICS  AND  GYNECOLOGY. 

Stated  Meeting,  November  28,  i8gs- 

Henry  C.  Coe,  M.D.,  Chairman. 

A  Contribution  to  the  Study  of  Lactation  Atrophy  of 
the  Uterus. — Dr.  H.  N.  \'ineberg  read  a  paper  on  this 
subject.  It  was  singular  that  in  this  country  lactation 
atrophy  of  the  uterus  had  received  no  attention  ;  in- 
deed the  condition  seemed  here  to  have  escaped  ob- 
servation. The  opinion  commonly  prevailed  that  the 
uterus  never  returned  after  childbirth  to  the  virginal 
size,  unless  as  a  result  of  pathological  change. 

The  condition  under  consideration  was  not  that 
which  was  usually  known  here  as  hyperinvolution.  It 
was  the  form  of  super-  or  hyperinvolution  accompany- 
ing lactation,  with  or  without  amenorrhoea,  in  which 
the  reduction  in  size  was  temporary  only,  the  return  to 
the  normal  size  being  in  some  cases  dependent  on  return 
of  menstruation,  in  others  on  regeneration  of  tissue 
while  lactation  was  still  going  on. 

The  author's  attention  had  been  drawn  to  the  con- 
dition a  few  years  ago,  at  the  Mt.  Sinai  Dispensary, 
where  he  was  struck  by  the  small  size  of  the  uterus 
found  in  a  great  number  of  nursing  women.  In  the 
majority  there  was  no  indigestion,  malnutrition,  trouble 
with  lactation,  or  other  disturbance.  Further  observa- 
tion taught  him  that  the  atrophy  was  only  temporary, 
the  uterus  again  increasing  in  size.  With  the  return  of 
menstruation  conception  was  likely  to  occur  again,  and 
in  some  it  took  place  before  recurrence  of  menstrua- 
tion. 

The  two  principal  European  writers  on  the  subject 
were  Engstrom  and  Thorn,  and  they  were  at  variance 
as  to  the  causation,  the  former  attributing  it  to  atrophy, 
similar  to  what  occurred  in  constitutional  diseases,  like 
syphilis,  while  the  latter  regarded  it  as  a  normal  pro- 
cess usually,  and  occurring  even  in  robust  women  with 
hygienic  surroundings.  Dr.  Vineberg's  observations 
tended  to  confirm  Thorn's  views.  Regarding  what 
should  be  considered  an  atrophic  uterus,  the  bear- 
ing organ  should  measure  7.5  to  8  ctm.  Falling  be- 
low that,  it  could  be  regarded  as  atrophic,  and  surely 
so  when  it  fell  below  half  the  size  of  the  nulliparous 
uterus,  as  he  had  known  it  to  do. 

Tjtvo  varieties  of  atrophy  had  been  recognized,  the 
eccentric  and  the  concentric,  but  they  were  really  dif- 
ferences in  degree.  According  to  his  observation  the 
process  affected  both  the  body  and  cervi.x,  and  when 
the  cervix  was  larger  than  the  body  it  was  apt  to  be 
due  to  some  pathological  change,  such  as  that  pro- 
duced by  laceration.  He  could  not  in  his  cases  de- 
monstrate noticeable  changes  in  the  size  of  the  ovaries. 
Regarding  how  soon  lactation  atrophy  might  show  it- 
self, it  had  been  demonstrable  even  as  soon  as  the 
twenty-first  day,  his  own  measurements  showed  it  pres- 
ent at  a  period  from  seven  weeks  to  twenty  months. 
Bimanual  palpation  by  an  experienced  man  gave 
more  reliable  information  than  the  sound  alone.  In 
fact  in  eccentric  atrophy  the  sound  was  apt  to  indicate 
the  depth  of  the  normal  uterus.  In  his  cases  the  mini- 
mum depth  of  the  uterus  was  4,  the  maximum  8  ctm. 

These  women  were  not  anasmic  ;  out  of  fourteen 
cases  in  which  the  blood  was  examined  the  number  of 
red  blood-cells  fell  below  the  normal  only  in  one. 
Anemic  women  were  more  likely  to  have  subinvolu- 
tion. The  degree  of  atrophy  in  phthisis  had  commonly 
been  overestimated.  Dr.  Vineberg  had  seen  a  number 
of  instances  of  conception  take  place  during  lactation, 
without  intervention  of  the  menstrual  flow. 

Our  views  of  the  anatomico-pathological  anatomy  of 
the  uterus  had  to  undergo  a  change  in  the  light  of  re- 
cent research.  Several  authors  were  quoted,  but  in 
general  Dr.  Vineberg  agreed  with  Saenger.  Muscular 
fibres  of  the  uterus  did  not  completely  disappear  dur- 
ing involution,  but  simply  atrophied,  the  function  of 


lactation  promoting  this  physiological  process.  Just 
how  it  did  so  was  a  matter  on  which  opinions  differed, 
but  it  was  probably  through  nervous  influence.  The 
progress  could  be  carried  too  far,  yet  out  of  at  least 
two  hundred  cases  of  lactation  atrophy  seen  by  Dr. 
Vineberg  there  had  been  only  two  or  three  instances 
in  which  there  had  been  permanent  hyperinvolution. 
He  recalled  one  case  in  which  the  atrophied  uterus  re- 
quired twenty-five  months  to  regain  its  normal  size. 

In  the  treatment  of  lactation  atrophy  keep  up  good 
nutrition,  and  do  not  allow  the  patient  to  nurse  the 
child  longer  than  the  usual  period.  Dr.  Vineberg 
thought  many  of  the  disturbances  following  pregnancy 
could  be  avoided  if  the  physician  would  make  it  a  rule 
to  see  his  patients  once  a  week,  or  two  weeks,  for  three 
or  more  months  subsequently. 

In  calling  for  discussion,  the  Chairman  mentioned 
two  practical  points  ;  the  duty  of  the  physician  to  see 
the  patient  several  weeks  after  delivery  ;  and  the  treat- 
ment of  hyperinvolution. 

Mothers,  Nurse  your  own  Children. — Dr.  Ralph 
Waldo  said  it  was  his  custom  to  urge  upon  his  patients 
the  necessity  for  nursing  their  own  children,  not  only 
for  the  benefit  of  the  child,  but  because  it  hastened  in- 
volution. When  mothers  did  not  nurse  their  own  chil- 
dren the  uterus  was  apt  to  remain  in  a  state  of  subin- 
volution. 

The  Chairman  remarked  that  subinvolution  was 
supposed  usually  to  follow  laceration  of  the  cervix  : 
yet,  as  the  author  had  shown,  the  uterus  was  sometimes 
unusually  small,  and  a  little  further  explanation  of 
these  cases  might  be  well. 

Dr.  Vineberg  said  it  was  true  that  often  where 
there  was  marked  laceration  of  the  cervix  the  body  of 
the  uterus  was  small,  although  the  cervix  might  be 
large,  even  larger  than  the  body  of  the  organ.  But 
where  there  was  no  laceration  the  cervix  atrophied  in 
proportion  to  the  body.  Dr.  Waldo's  remarks  coin- 
cided with  the  point  made  in  the  paper,  that  it  should 
be  the  earnest  desire  of  the  accoucheur  to  bring  about 
this  hyperinvolution.  A  uterus  which  was  the  size  of 
the  normal  organ  by  the  twelfth  week  of  lactation 
had  not  undergone  the  full  degree  of  involution. 

Venous  Thrombosis  as  a  Cause  of  Sudden  Death  in 
the  Puerperium. — Dr.  Elizabeth  Cushier  read  the 
paper,  giving  the  histories  of  two  cases  of  sudden 
death  from  thrombosis  or  embolism  some  days  after 
delivery,  and  collating  a  number  of  others.  Her  own 
two  cases  were  seen  in  187S.  The  first  was  in  a  stout 
woman,  who  had  entered  the  infirmary  for  her  sixth 
confinement.  The  labor  was  normal,  but  a  few  hours 
after  labor  she  experienced  a  severe  pain  and  the 
uterus  was  found  at  the  umbilicus.  No  clot  was  dis- 
covered. Ergot  was  given.  The  temperature  at  no 
time  exceeded  99.5°  F.;  pulse,  80.  The  temperature, 
pulse,  and  respiration  were  about  normal  on  the  ninth 
day,  and  she  was  permitted  to  sit  up.  About  eleven 
o'clock  Dr.  Cushier  was  sent  for  in  haste  ;  the  patient 
had  fainted.  She  found  her  unconscious,  eyes  fixed, 
pupils  dilated,  pulse  full  and  regular,  violent  respira- 
tory efforts.  Consciousness  soon  returned,  but  soon 
the  heart  ceased  to  beat,  and  the  patient  gasped  for  air  ; 
the  faradic  current  restored  consciousness  for  a  little, 
and  she  spoke  intelligently,  then  turned  on  her  side, 
when  the  heart  and  respiration  ceased.  The  attack 
had  lasted  not  longer  than  half  an  hour.  Autopsy, 
four  hours  after  death,  showed  venous  clots  in  uterine 
and  ovarian  vessels,  also  clot  occluding  the  pulmonary 
vein  and  causing  distention  of  the  right  ventricle. 

The  other  case  was  similar,  but  the  patient  had  been 
under  observation  from  the  fourth  month  of  pregnancy, 
and  the  urine  had  contained  some  albumin,  the  quan- 
tity increasing  toward  the  end  of  gestation.  Labor 
was  slow,  tendency  to  uterine  relaxation,  small  child, 
not  much  loss  of  blood,  rather  free  lochial  discharge, 
and  rather  tardy  diminution  in  size  of  the  uterus, 
otherwise  the  lying-in  was  normal.     The  patient  sat 


December  14,  1S95] 


MEDICAL   RECORD. 


855 


up  for  a  short  time  on  the  ninth  day.  On  the  morn- 
ing of  the  tenth  Dr.  Cushier  was  called  in  haste,  and 
on  arriving  found  the  patient  dead.  She  had  risen, 
sat  on  a  vessel,  uttered  a  cry,  fallen  over,  and  died  in  a 
few  moments.  Autopsy  was  made  under  difficulties, 
the  kidneys  were  large  and  pale,  but  microscopic  ex- 
amination was  not  made  owing  to  the  fact  that  by 
accident  they  were  placed  in  wrong  fluid.  The  uterus 
was  rather  large,  but  the  only  clots  found  were  in  the 
saphenous  vein  of  the  leg  and  in  the  pulmonary  artery, 
extending  as  far  as  its  second  division. 

The  object  of  the  paper  was  to  emphasize  the  im- 
portance of  a  knowledge  of  the  facts  connected  with 
these  cases  with  a  view  to  their  prevention.  The  cases 
collected  by  Sperling  and  by  herself  were  used  to 
show  the  frequent  association  of  the  accident  and 
thrombosis  of  distant  veins  ;  that  venous  thrombosis 
was  the  result  of  changes  in  the  blood  ;  and  that  the 
blood  coagulation  might  be  prevented.  The  factors 
which  favored  blood  coagulation  in  the  veins  of  the 
puerperal  woman  were  several  :  changes  due  to  exhaus- 
tive hemorrhage  ;  to  septic  material  in  the  veins  and 
lymphatics  ;  formation  of  thrombi  in  the  uterine  si- 
nuses previous  to  labor,  as  a  result  of  partial  separation 
of  the  placenta,  when  hemorrhage,  instead  of  being 
controlled  by  contraction  of  the  uterine  fibres,  must  be 
arrested  by  coagulation  of  blood.  The  cases  quoted 
from  Sperling,  about  thirty-five  in  number,  and  those 
collated  by  herself,  about  twenty  in  number,  showed 
one  or  more  of  these  factors  present  as  a  rule.  The 
frequent  association  of  phlegmasia  was  to  be  especially 
emphasized,  as  it  was  present  in  at  least  twenty-eight 
or  fifty  per  cent,  of  the  number  collated. 

In  analyzing  the  cases  with  reference  to  the  possibil- 
ity of  foreseeing,  and  perhaps  preventing,  this  accident 
of  childbirth,  note,  i,  pre-e.xisting  infection  ;  2,  as- 
sociation of  the  accident  with  premature  separation 
of  the  placenta,  and  probably  formation  of  thrombi  in 
the  uterine  sinuses  preceding  labor  ;  3,  general  condi- 
tions which  tended  to  interfere  with  normal  retractility 
of  the  uterus,  and  the  danger  of  powerful  uterine  con- 
tractions where  inertia  had  previously  existed. 

The  Chairman,  on  calling  for  discussion,  remarked 
on  the  fact  that  sudden  death  in  these  cases  occurred 
not  immediately  after  labor,  but  several  days  after  ; 
also  on  the  custom  of  some  of  letting  the  patient  rise 
within  twelve  hours  after  labor,  and  the  possible  bear- 
ing this  might  have  on  the  accident,  or  at  least  upon 
the  responsibility  reflected  upon  the  physician. 

Dr.  ViNEBERG  had  seen  none  of  the  cases  under  dis- 
cussion. He  thought  we  should  be  guided  by  the  con- 
dition of  the  uterus  in  deciding  upon  the  time  when 
the  patient  should  be  allowed  to  get  up,  and  not  follow 
any  fixed  rule  as  to  time,  say  the  customary  one  of  the 
tenth  day.  He  had  sometimes  allowed  the  woman  to 
sit  up  before  he  thought  it  was  advisable,  on  account 
of  the  condition  of  the  uterus,  and  nearly  always  some 
trouble  had  followed.  Where  phlegmasia  alba  dolens 
had  occurred  his  impression  had  been  that  there  was 
some  form  of  infection.  His  custom  was  to  examine 
the  uterus  frequently  to  see  that  contraction  had  oc- 
curred and  that  involution  was  going  on  satisfactorily. 

Dr.  Ralph  Waldo  had  observed  that  in  Dr.  Cush- 
ier's  two  cases  the  uterus  had  remained  large.  Like  in 
many  obscure  subjects,  he  thought  there  were  a  num- 
ber of  etiological  factors  here.  In  many  cases  of  labor 
there  was  a  tendency  to  thrombosis,  especially  in  the 
extremities,  and  thrombi  becoming  dislodged  might 
go  to  the  lungs  and  prove  fatal.  In  view  of  the  ob- 
scurity of  the  cases  he  thought  we  were  hardly  justi- 
fied in  making  a  diagnosis  of  thrombus  of  the  pul- 
monary vein  unless  proven  by  autopsy.  He  would  in- 
sist upon  keeping  a  patient  abed  as  long  as  the  uterus 
was  large,  or  there  were  thrombi  in  that  organ  or  the 
veins.  He  believed  the  notion  that  a  woman  should 
always  get  up  by  the  ninth  day  had  cost  many  lives. 
The  patient  should  be  allowed  to  get  up  and  go  about 


only  after  having  returned  to  normal  condition,  just  as 
after  some  disease. 

Dr.  George  W.  Jarman  said  that  when  he  was  hos- 
pital interne  he  had  seen  a  number  of  cases  of  phle- 
bitis after  gynecological  operations,  and  a  few  of  these 
patients  had  died,  not  of  the  phlebitis,  but  of  sepsis, 
which  was  believed  to  have  caused  the  phlebitis,  but 
out  of  the  entire  number  he  could  recall  none  in  which 
there  was  thrombosis  of  the  pulmonary  arterj'.  He 
would  ask  why  this  should  be  if  in  pulmonary  throm- 
bosis or  embolism  during  the  puerperium  it  was  due  to 
breaking  away  of  clot  from  the  veins  of  the  extremities. 
He  mentioned  a  case  seen  with  Dr.  Kennedy  in  which 
pulmonary  thrombosis  following  labor  was  suspected 
from  sudden  collapse,  cyanosis,  rapid  pulse,  etc.,  but 
the  breathing  was  different,  and  on  inquiring  for  the 
cause  he  found  that  the  untrained  nurse  had  injected 
a  solution  of  carbolic  acid  into  the  rectum  instead  of 
into  the  vagina,  as  directed  by  Dr.  Kennedy.  As  soon 
as  he  introduced  his  fingers  and  let  it  flow  out,  the  pa- 
tient rapidly  recovered. 

The  Chairman  recalled  a  case  in  which  symptoms 
similar  to  those  described  by  Dr.  Cushier  occurred 
twice  on  giving  intra-uterine  douche  about  the  fifth 
day  after  labor. 

Dr.  Cushier  said  that  formerly  she  did  not  keep  pa- 
tients abed  as  long  after  labor  as  at  present,  and  some 
unpleasant  symptoms  were  to  be  attributed  to  that  fact ; 
but  she  believed  in  going  by  the  condition,  not  by  the 
day.  Regarding  Dr.  Jarman's  question,  she  did  not 
attempt  to  answer  it  in  full,  but  stated  that  sometimes 
in  phlebitis  not  associated  with  the  puerperium  in- 
farction of  the  lungs  occurred. 


THE    NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Mectitig,  October  23,  iSgs- ' 

George  P.  Biggs,  M.D.,  President,  in  the  Chair. 

Fibro-adenoma  of  the  Liver. — Dr.  Warren  Coleman 
presented  such  a  specimen.  The  tumor  was  removed 
from  a  man,  aged  sixty-eight,  who  died  in  Bellevue 
Hospital,  and  its  presence  was  not  suspected  until  the 
liver  had  been  cut  into.  The  liver  was  cirrhotic  and 
fatty,  and  markedly  bile-stained.  Its  left  lobe  was 
very  large — so  large,  indeed,  that  it  led  during  life  to 
the  assumption  that  a  tumor  existed  in  this  situation. 
It  measured  19 "j  ctm.  in  its  vertical  diameter,  6.25 
ctm.  in  its  antero-posterior  diameter,  and  13  ctm. 
from  its  left  edge  to  the  transverse  fissure.  The  fibro- 
adenoma was  situated  in  the  right  lobe  of  the  liver, 
near  to  its  posterior  surface,  and  in  the  region  of  the 
larger  bile- ducts  where  they  converge  to  form  the 
right  hepatic  duct.  It  was  spheroidal  in  shai)e,  and 
measured  approximately  3  ctm.  by  3  ctm.  It  had  a 
solid,  white,  somewhat  translucent  appearance,  and  a 
dense,  hard  feel.  Its  relation  to  the  blood-vessels  and 
bile  ducts  made  it  seem  as  if  fibrous  septa  ran  off  into 
the  surrounding  liver  tissue.  It  cut  hard  at  the 
autopsy,  and  the  diagnosis  lay  at  first  between  pri- 
mary carcinoma  originating  in  the  bile-ducts  and 
gumma.  Microscopic  examination,  however,  showed  the 
tumor  to  be  a  fibro-adenoma.  There  was  nothing  note- 
worthy in  the  appearance  of  the  section,  except  that 
portions  of  the  liver  substance  had  been  inclosed  by 
outlying  bands  of  connective  tissue.  The  gallbladder 
was  full,  the  left  hepatic  duct  having  remained  open. 
The  common  duct  was  also  open,  but  somewhat  ob- 
structed by  an  enlarged  pancreas  and  adjacent  lym- 
phatic glands.  The  heart  weighed  twenty  ounces. 
Its  walls  were  soft  and  the  cavities  dilated,  though  the 
valves  were  normal.  There  was  a  thrombosis  in  the 
right  auricle.  The  lungs  contained  dark  liquid  blood. 
The  first  division  of  the  pulmonary  artery  going  to 
the  upper  lobe  of  the  left  lung  contained  an  embolus 


8^6 


MEDICAL    RECORD. 


[December   14,  i! 


which  blocked  its  lumen,  while  the  first  division  of  the 
pulmonary  artery  to  the  lower  lobe  of  the  right  lung 
also  contained  an  embolus.  The  pleural  cavities  con- 
tained a  small  amount  of  clear  liquid. 

The  patient's  history,  while  in  the  hospital,  was 
closely  followed.  Only  such  portions  of  it,  however, 
as  relate  to  the  specimen  were  given.  The  heart  and 
lungs  were  reported  negative  on  physical  examination. 
The  liver  was  enlarged  and  extended  below  the  free 
border  of  the  ribs  for  one  and  a  half  to  two  inches. 
Its  edge  was  sharp.  The  left  lobe  was  more  enlarged 
than  the  right,  e.xtending  two-thirds  of  the  way  from 
the  ensiform  cartilage  to  the  umbilicus.  The  con- 
sistency of  the  liver  was  firm.  The  patient  died  sud- 
denly. The  nurse  had  taken  his  temperature  and  had 
left  him  comfortable.  In  passing  the  bed  a  few  mo- 
ments later  he  found  the  patient  suffering  from  intense 
dyspnoea  and  his  pulse  imperceptible.  Death  oc- 
curred within  a  i'evr  minutes,  and  was  to  be  explained 
by  the  pulmonary  embolism. 

Dr.  Coleman  said  it  had  been  impossible  for  him  to 
consult  the  literature  of  the  subject,  and  the  books  at 
his  disposal  gave  but  a  reference  to  adenomata  of  the 
liver.  Welch  states,  in  Flint's  "  Practice  of  Medicine," 
that  adenomata  of  the  liver  present  themselves  in  two 
forms — either  as  a  vascular  hyperplasia  of  the  liver 
substance  or  as  an  atypical  growth  of  bile-ducts  in  a 
nodular  form.  So  far  as  his  personal  experience  went, 
the  speaker  said  adenoma  of  the  liver  had  been  rare, 
this  being  the  first  instance  he  had  met  with.  He  de- 
sired to  express  his  thanks  to  Dr.  E.  P.  Shelby,  Jr.,  for 
preparing  the  sections  of  the  tumor. 

The  President  said  that  he  had  only  seen  one  ade- 
noma of  the  liver,  and  that  very  recently.  In  this  case, 
at  autopsy,  a  small  primary  tumor  had  been  found  in 
the  right  lobe,  projecting  slightly  above  the  surface, 
and  measuring  about  i^i  ctm.  in  diameter.  It  was 
whitish  in  color  and  distinctly  outlined.  The  cause 
of  death  had  been  puerperal  septicemia,  the  subject  a 
young  adult.  Microscopical  examination  had  shown 
the  growth  to  be  a  pure  and  simple  adenoma  of  the 
liver  tissue. 

Dr.  Colem.ax  said  that  in  his  case  there  had  been 
no  suspicion  during  life  of  the  existence  of  such  a  tu- 
mor in  the  liver. 

Multiple  Rupture  of  the  Liver. — Dr.  George  P. 
Biggs  presented  portions  of  a  liver.  Three  distinct 
ruptures  were  found.  The  specimen  had  been  re- 
moved from  a  man  who,  while  intoxicated,  had  fallen 
from  a  height  of  thirty  or  forty  feet,  and  had  struck 
on  his  right  side.  That  evening  he  had  become  ner- 
vous ;  his  temperature  had  been  99°  F.,  and  his  pulse 
76.  Toward  evening  of  the  following  day  his  tem- 
perature rose  to  103.2°  F.,  the  pulse  was  76,  and  the 
respirations  36.  He  then  presented  pretty  well-marked 
symptoms  of  delirium  tremens.  Sedatives  had  but  lit- 
tle effect.  Shortly  before  death  his  temperature  rose 
to  109°  F.  His  death  was  evidently  due  to  delirium 
tremens.  Examination  during  life  showed  no  fractures 
of  bones,  and  no  distinct  evidence  of  internal  injury, 
excepting,  perhaps,  a  fracture  of  the  base  of  the  brain. 
The  autopsy  presented  no  fracture  of  the  base— only 
CEdema  of  the  brain.  About  a  teacupful  of  blood  was 
found  in  the  peritoneal  cavity,  distributed  in  every 
direction.  It  was  firmly  coagulated  and  quite  adher- 
ent to  the  intestinal  wall.  The  source  of  this  hemor- 
rhage was  found  to  be  the  liver,  which  was  consider- 
ably enlarged  and  very  fatty.  The  longest  rupture 
was  in  the  upper  border  of  the  right  lobe  ;  it  measured 
S'i  ctm.  in  length  by  i'^  ctm.  in  depth.  The  line  of 
rupture  was  covered  over  with  a  firm  fibrinous  coagu- 
lum  which  had  checked  the  hemorrhage  completely. 
Another  rupture  was  found  on  the  under  surface  of  the 
right  lobe.  It  measured  3  ctm.  in  length  by  }{  ctm. 
in  depth.  This  also  was  covered  over  with  a  very 
firmly  adherent  blood-clot.  The  third  and  most  ex- 
tensive rupture  measured   7'j   ctm.   in  length,  and   2 


ctm.  in  depth.  It  began  in  the  right  lobe  of  the  liver' 
just  at  the  junction  of  the  gall-bladder  with  the  liver 
substance,  and  midway  between  the  neck  and  the  fun- 
dus of  the  gall-bladder,  and  extended  along  the  side 
of  the  gall-bladder  nearly  to  the  neck,  then  across  the 
portion  of  liver  tissue  between  the  fissure,  the  right 
and  left  lobes,  and  the  fissure  of  the  gall-bladder. 
The  walls  of  the  gall  bladder  were  everywhere  infil- 
trated with  blood,  the  blood  having  been  confined  for 
a  time  beneath  the  peritoneum,  and  dissecting  its  way 
out  to  the  gall-bladder.  This  rupture  was  also  covered 
over  by  a  firm  blood-clot. 

The  case  is  of  interest,  for  if  the  man  had  not  died 
of  delirium  tremens  he  would  have,  in  all  probability, 
recovered  from  his  fall  in  spite  of  the  three  ruptures  in 
the  liver. 

Ruptured  Ectopic  Gestation. — Dr.  Biggs  then  pre- 
sented a  specimen  of  ruptured  ectopic  gestation.  Death 
had  been  due  to  internal  hemorrhage,  the  true  condition 
not  having  been  recognized  at  all  until  the  autopsy. 
The  patient  was  a  Scotch  woman,  who  first  came  under 
observation  on  October  15th.  She  had  had  three  chil- 
dren and  one  miscarriage.  Six  days  before  coming 
under  observation,  while  two  months  pregnant,  she  had 
experienced  pain  in  the  back  and  abdomen,  and  had 
gone  to  bed.  She  expelled  some  "  red  lumps  "  from 
the  vagina,  and  thinking  it  was  a  miscarriage  she  had 
had  no  medical  treatment.  The  pain  in  the  abdomen 
had,  however,  continued,  and  there  was  constant,  though 
moderate,  bleeding  from  the  vagina.  Her  condition 
becoming  serious  she  was  taken  to  the  hospital.  On 
admission  her  temperature  was  100°  F.  ;  pulse,  70  ; 
respirations,  20.  She  was  verj'  anaemic,  supposedly 
from  the  amount  of  blood  discharged  from  the  vagina. 
She  complained  of  pain  in  the  abdomen  and  tender- 
ness over  the  hypogastric  region.  The  abdominal  wall 
contained  a  thick  layer  of  adipose  tissue,  precluding 
anything  being  learned  by  palpation.  On  the  evening 
of  her  admission  to  the  hospital  the  uterus  was  cu- 
retted. The  cervix  was  sufficiently  dilated  to  admit  of 
the  entrance  of  the  curette.  The  uterus  measured 
three  and  a  half  inches.  A  small  quantity  of  odorless 
material  was  removed  by  the  curette,  and  a  strip  of 
iodoform  gauze  was  placed  in  the  uterus.  The  tem- 
perature fell  to  99°  F.  after  the  curetting.  On  the  fol- 
lowing day  the  temperature  was  99°  F.,  the  pulse,  120, 
and  the  respirations,  40.  She  had  passed  a  very  rest- 
less night.  That  evening  the  temperature  was  101.2° 
F.,  the  pulse,  144,  and  the  respirations,  40  ;  and  on 
the  following  day  the  temperature  was  102.2°  F.  ;  pulse, 
146  and  thready,  and  respirations,  36.  She  was  sup- 
posed at  this  time  to  have  septic  peritonitis,  originating 
in  the  uterus  or  from  a  ruptured  tube.  An  ice-coil  was 
applied,  and  the  packing  in  the  uterus  removed,  and 
found  to  be  perfectly  odorless.  At  noon  of  the  second 
day  in  the  hospital  the  temperature  was  104°  F.  She 
was  given  an  intra-uterine  douche,  without  any  effect 
on  the  temperature.  She  vomited  almost  constantly. 
The  dext  day  the  temperature  was  still  high,  and  the 
distention  of  the  abdomen  had  increased.  She  died 
the  following  morning.  At  the  autopsy  the  abdominal 
cavity  was  found  completely  filled  with  blood.  It  was 
estimated  that  eight  pints  of  fluid  blood  were  taken 
out  of  the  abdominal  cavity.  In  addition  to  this  the 
entire  hypogastric  and  pelvic  regions  were  filled  with 
a  firm  coagulum  of  blood,  which  appeared  to  have  been 
at  first  partially  confined.  The  ectopic  gestation  was 
found  to  have  been  in  the  upper  portion  of  the  left 
Fallopian  tube,  and  the  remains  of  the  foetus  were  visi- 
ble in  the  interior  of  the  sac.  The  sac,  distended  with 
the  hemorrhage,  measured  7  ctm.  in  length,  5  ctm. 
transversely,  and  3'.'  ctm.  vertically.  The  uterus  was 
9  ctm.  long,  5'j  wide  at  the  fundus,  and  3'.'  ctm.  at 
the  cervix. 

Dr.  Henry  Power  said  that  he  had  looked  up  the 
literature  of  the  subject  of  rupture  of  the  internal  vis- 
cera, and  had  found   that  the  late  Dr.  B.  A.  Watson 


December   14,  1S95] 


MEDICAL    RECORD. 


^57 


had  experimented  on  one  hundred  and  sixty- two  dogs, 
with  the  idea  of  injuring  by  concussion  the  spinal  col- 
umn chiefly.  He  had  allowed  the  animals  to  drop 
from  a  height.  His  observations  showed  no  injury  to 
the  brain  and  spinal  cord,  but  a  large  number  of  rupt- 
ures in  the  kidneys,  lungs,  spleen,  and  other  organs. 

Dr.  H.  S.  Stearns  asked  if  these  ruptures  referred 
to  by  Dr.  Biggs  had  not  been  really  quite  superficial, 
and  if  the  greater  part  of  the  apparent  depth  were  not 
due  to  ecchymosis.  There  was  an  unusual  amount  of 
repair  considering  the  short  time  that  had  elapsed  be- 
tween the  injury  and  the  man's  death. 

Dr.  Biggs  said  that  certainly  two  of  the  ruptures 
were  quite  superficial. 

The  Society  then  went  into  executive  session. 


DEPRESSED  FRACTURE  OF  THE  SKULL  ; 
TRAUMATIC  AMNESIC  APHASIA:  RECOV- 
ERY  WITHOUT    OPERATION. 

By     GEORGE     H.    WILLIAMS,     M.D.,     M.R.C.S.      ENG., 
L.R.C.P.    EDIN. 


Ox  October  2d,  J.  M ,  a  young  man,  aged  nineteen, 

was  hit  on  the  left  side  of  his  head  by  a  stone,  during 
an  altercation  with  another  man.  Two  days  later  he 
was  brought  to  the  Highland  Hospital  by  Dr.  Sutton, 
of  East  Fishkill,  and  placed  in  ray  charge,  pending  the 
result  of  his  injury.  The  patient  was  able  to  walk  from 
the  station,  some  half-mile  distant.  Dr.  Sutton  reported 
that  on  the  afternoon  of  the  injury  he  was  called,  and 
found  the  patient  in  an  unconscious  condition,  with  a 
slight  hemorrhage  from  the  left  ear,  and  was  informed 
that  the  blow  was  followed  almost  immediately  by  a 
convulsive  attack  lasting  nine  minutes  ;  patient  was  in 
this  unconscious  state  some  four  hours,  recovering 
slowly,  and  seemingly  much  dazed.  On  admission  to 
hospital,  October  4th,  the  patient,  a  powerful  young  man, 
seemed  still  dazed  and  heavy  mentally,  and  was  unable 
to  answer  questions.  There  was  an  effusion  on  the 
left  side  of  the  head  about  two  and  a  half  inches  above 
the  upper  margin  of  the  left  ear,  there  was  conjunctival 
effusion  and  loss  of  hearing  on  same  side,  watch  heard 
only  when  pressed  against  ear.  Pressure  over  the 
effusion  elicited  pain.  There  was  some  loss  of  power 
in  the  opposite  hand.  The  pulse  was  slow  but  regu- 
lar—44. 

Treatment. — Patient  put  to  bed,  left  side  of  head 
shaved  and  ice-cap  applied.  Diet — malted  milk  and 
beef  juice  every  alternate  hour.  Five  grains  of  calomel 
administered  and  repeated  in  six  hours.  Ordered  ten 
grains  of  potassium  bromide  every  three  hours.  For 
the  next  two  days  patient's  condition  remained  much 
the  same. 

On  October  7th,  the  effusion  having  somewhat  disap- 
peared under  treatment,  we  could  make  out  a  decided 
depression  of  the  external  table  of  the  skull  over  the 
lower  parietal  bone  involving  the  squamous  suture  and 
the  upper  temporal  region,  altogether  the  size  of  a  sil- 
ver dollar,  with  pain  on  pressure  in  this  region.  Pa- 
tient was  unable  to  tell  his  name  or  answer  (|uestions  ; 
when  asked  to  write  his  name  he  wrote  it  slovly  but 
fairly  well  ;  when  asked  for  his  friend's  name  who  ac- 
companied him  to  hospital  he  could  neither  tell  nor 
write  it;  could  not  tell  his  home,  but  muttered  some- 
thing beginning  with  a  B.,  which  I  learned  later  was 
Cape  Breton,  N.  S. 

To-day  for  the  first  time  I  recognized  his  condition  as 
one  of  amnesic  aphasia.  He  had  been  closely  watched 
day  and  night  during  his  stay  here.  On  this  afternoon, 
the  fifth  from  the  injury,  I  saw  him  about  four  o'clock. 


About  an  hour  after  I  was  hastily  summoned  by  the 
matron,  who  told  me  the  patient  had  had  a  convulsive 
attack  during  my  absence,  lasting  some  ten  minutes  or 
more  ;  although  the  pulse  was  more  rapid  than  when  I 
saw  him  there  were  no  other  fresh  symptoms.  About 
7  P.M.  he  had  another  attack,  which  I  witnessed  ;  it  was 
epileptiform  in  character,  the  head  was  turned  to  the 
right,  the  eyes  were  rolled  upward  and  outward  toward 
the  right,  pupils  dilated  but  regular,  the  hands  were 
clenched  and  the  arms  strongly  flexed,  there  was  a 
bloody  saliva  dribbling  from  his  mouth,  and  inspiration 
and  expiration  were  short  and  quick,  accompanied  by  a 
series  of  gurgling  sounds.  This  attack  was  shorter  than 
the  last,  persisting  for  only  about  five  minutes.  Patient 
soon  recovered  and  seemed  as  before.  A  consultation 
of  the  staff  was  called  and  the  advisability  of  trephin- 
ing discussed;  it  was  decided  to  wait  further  develop- 
ments. I  left  the  patient  about  11  p.m.  ;  up  to  this  time 
he  had  no  further  seizures. 

The  night  nurse  informed  me  that  during  the  early 
morning  he  had  three  short  attacks  within  an  hour, 
each  lasting  only  a  few  seconds.  The  next  day  pa- 
tient's condition  seemed  as  before,  so  the  former  treat- 
ment was  continued.  On  October  9th  my  friend,  Dr. 
Allison,  of  the  Matteawan  State  Asylum,  saw  the  pa- 
tient with  me,  and  corroborated  the  diagnosis  of  am- 
nesic aphasia  of  traumatic  origin,  probably  due  to  con- 
cussion of  the  cells  in  the  third  frontal  convolution. 
On  examination  this  day  he  was  able  to  tell  the  time, 
said  "'Fifteen,"  and  after  a  time"  twelve,"  it  being 
a  quarter  to  twelve.  Could  not  read  aloud,  or  tell  letters, 
or  name  objects  shown  him,  although  he  said  he  knew 
what  they  were  perfectly  well. 

October  loth.— When  asked  if  he  was  better,  patient 
said  "Yes."  This  seemed  one  of  the  few  words  he 
could  say.  Tells  time  thus,  "  Half-past,"  and  after  a  time, 
"three."  Knew  the  name  of  a  quarter  today  when  he 
saw  it,  and  said  "Ten  "  when  shown  a  ten  cent  piece. 
Writes  his  own  name  well,  as  from  the  first ;  can't  tell  or 
write  his  friend's  name.  The  hearing  is  better,  can 
hear  watch  an  inch  from  the  left  ear.  Tongue  is 
cleaner  ;  pulse  still  slow,  44  to  4S.  When  shown  a  key 
and  asked  what  it  was  he  could  not  tell,  but  pointed  tow- 
ard the  door  and  went  through  the  motion  of  unlock- 
ing. Could  not  say  watch,  or  kniff,  or  other  articles 
when  asked  what  they  were,  but  said  he  knew  what 
they  were. 

The  effusion  over  temporal  region  was  less,  and  the 
depression  quite  marked  at  the  upper  margin  ;  it  was 
three  inches  above  the  upper  part  of  the  left  ear,  a  little 
behind  the  ear,  and  quite  an  inch  and  a  half  either 
way.     The  conjunctival  effusion  was  less. 

October  nth. — Answers  questions  better  to-day; 
otherwise  his  condition  is  much  as  yesterday  ;  when 
shown  the  watch  could  not  name  it ;  when  asked  the 
time,  it  being  five  minutes  to  twelve,  said,  "  Five,"  and 
after  some  time  "twelve."  Cannot  say  to  ;  tongue  is 
cleaner.  Complained  of  feeling  hungry  for  the  first 
time.  He  was  reading  the  paper  at  my  visit,  and  said 
he  knew  what  it  was  all  about,  but  could  not  tell  me. 

October  12th. —  Treatment  as  before;  pulse  52. 
Sleeps  well  ;  bowels  still  sluggish.  At  my  visit  this 
morning  patient  seemed  brighter.  The  patient  in  the 
next  bed — singularly  enough  another  case  of  depressed 
fracture,  but  without  symptoms — informed  me  that  he 
had  carried  on  ([uite  a  conversation  with  the  man,  and 
found  he  could  answer  (|uestions  better.  On  trying 
him  with  the  watcli  and  asking  him  what  it  was,  he  said 
"  Watch  ;  "  asked  what  time  it  was,  he  said  "  Ten — ten," 
it  being  ten  minutes  to  ten.  Was  able  to  call  a  key, 
knife,  and  all  other  objects  shown  him.  Said  his 
friend's  name,  of  whom  I  had  often  ([uestioned  him, 
was  Jones,  but  could  not  write  it.  ('.rasp  in  the  right 
hand  is  stronger.  He  does  not  remember  the  name  of 
the  man  who  struck  him,  and  acknowledges  that  he 
was  not  altogether  sober  at  the  time.  From  this  time 
on  his  jecovery  was  uninterrupted.     On  October  14th 


MEDICAL   RECORD. 


[December  14,  1895 


his  hearing  was  normal  and  his  general  condition  good. 
A  plaster  cast  of  the  left  side  of  the  head,  taken  five 
weeks  after,  shows  the  depression  still  strongly  marked. 
Remarks. — Injuries  to  the  head  are  always  of  interest 
to  the  surgeon,  and  this  case  had  additional  interest, 
presenting  as  it  did  decided  depression  and  well- 
marked  amnesia,  and  goes  to  show  that  conservative 
treatment  was  the  best  in  this  case.  Of  course,  had  the 
convulsive  attacks  been  more  lasting  one  would  have 
operated  at  once.  The  rationale  of  the  convulsive  at- 
tacks I  cannot  explain,  but  think  the  amnesia  was  due 
rather  to  concussion  of  the  cells  in  Broca's  convolution 
than  to  either  a  ruptured  vessel  and  effusion,  or  to  em- 
bolic plugging  in  this  neighborhood,  as  the  recovery 
was  so  speedy  and  complete.  The  loss  of  power  in 
the  opposite  arm,  together  with  hemorrhage  from  the  ear, 
I  think  were  certainly  due  to  a  ruptured  blood-vessel, 
as  the  depression  in  the  skull  was  over  the  arm  and 
hand  centre.  An  unusual  anxiety  was  added  to  the 
case  for  the  reason  that  in  the  event  of  a  fatal  termina- 
tion of  the  injury  its  medico-legal  relation  might  have  be- 
come complicated  by  surgical  interference.  There  was 
a  criminal  aspect  as  well  as  a  medical  one  to  consider, 
and  during  the  occurrence  of  the  convulsive  seizures  it 
was  a  serious  question  to  determine  just  how  far  the 
responsibility  of  the  surgeon  e.xtended.  The  welfare 
of  the  patient  was  a  prime  consideration,  yet  an  unu- 
sual anxiety  must  always  attend  the  operative  treatment 
of  all  severe  injuries  inflicted  criminally,  and  which  may 
result  in  the  death  of  the  person  assaulted. 


A    CASE    OF  SPLENIC  MYELOGENOUS    LEU- 
KAEMIA NOT  CURED  BY  BONE  MARRO\V. 

By  CHARLES  E.  NAMMACK,  M.D., 

ATTEMDING  PHYSICIAN,    OUT-PATIENT    DEPARTMENT,    NEW   YORK   HOSPITAL. 

Florence  S ,  twenty-three  years  of  age,  native  of 

England,  was  admitted  to  the  hospital  March  n,  1895, 
in  the  service  of  Dr.  George  L.  Peabody,  who  has 
kindly  permitted  me  to  use  her  clinical  history  while 
in  the  wards.  Her  previous  personal  history  was  to 
the  effect  that  she  had  been  treated  unsuccessfully, 
for  eighteen  months  prior  to  her  admission,  for  anaemia! 
Her,  habits  were  temperate.  She  menstruated  regularly 
and  painlessly.     Her  family  history  was  negative. 

The  symptoms  on  admission  were  headache,  marked 
vomiting,  fever,  prostration,  breathlessness  on  exertion, 
and  insomnia. 

Examination.— Pulse,  112  ;  respirations,  36  ;  temper- 
ature, io2/„-°  F.,  mouth  ;  lungs,  normal  ;  heart,  accen- 
tration  of  pulmonary  second  sound  ;  action  rapid,  but 
regular  and  strong.  Liver  normal.  Spleen  extends 
one  inch  to  the  right  of  the  median  line  and  to  mid- 
way between  pubes  and  umbilicus.  Urine  shows  a 
trace  of  albumin,  also  hyaline  and  granular  casts. 
Blood  count  shows  the  red  corpuscles  to  number 
2.520,000,  and  the  leucocytes  760,000,  a  proportion  of 
about  3  to  I.     Hremoglobin,  fifty  per  cent. 

Treatment  ordered  was  tablet  of  protonuclein  every 
four  hours,  and  bone-marrow  spread  on  bread,  taken 
at  meal  time. 

.A.pril  4th.— Blood  count :  red  corpuscles,  2,680,000  ; 
white,  864,000,  about  3  to  i.  Haemoglobin,  fifty  per 
cent.  Patient  is  relieved  of  all  symptoms  except  dysp- 
ncea  on  slight  exertion,  although  blood  examination 
does  not  show  improvement.  Patient  feels  decidedly 
better  and  leaves  for  convalescent  home  at  Summit, 
N.  J.  She  remained  at  Summit  for  a  month,  then  re- 
turned to  the  hospital  and  was  referred  to  the  writer's 
class  in  the  out-patient  service.  At  this  time  her  only 
suffering  was  from  shortness  of  breath  on  exertion. 
She  had  had  one  attack  of  nose-bleed,  but  no  other 
mucous  hemorrhage.  The  spleen  was  still  enlarged 
and  its  notched  anterior  border  extended  to  the  rit^ht 


of  median  line.  Blood  examination  showed  the  ratio 
of  white  to  red  corpuscles  to  be  about  i  to  3.  It  also 
showed  deficiency  of  haemoglobin,  and  the  presence  of 
nucleated  red  blood-cells.  The  pulmonary  physical 
signs  were  normal,  the  shortness  of  breath  being  due 
to  deficient  oxygenation  owing  to  the  oligocythemia. 
The  cardiac  apex  was  not  displaced.  The  liver  was 
not  enlarged.  The  urine  showed  a  trace  of  albumin. 
Patient  admitted  some  difficulty  of  vision,  and  ophthal- 
moscopic examination  by  Dr.  Walker  showed  neuro- 
retinitis  in  each  eye.  In  the  right  eye  there  was  a 
large  hemorrhage  near  the  macula.  Vision  =  OD  |  J  ; 
OS  =  \%.  Hearing  was  acute.  Temperature,  normal. 
No  enlarged  lymph  glands  could  be  found.  No  oedema. 
No  dropsical  effusion.  She  was  ordered  Fowler's  solu- 
tion, to  be  gradually  increased  to  ten  drops  three  times 
a  day,  but  as  this  remedy  caused  vomiting,  diarrha-a, 
and  pufiiness  of  face,  it  was  stopped.  Through  the 
kindness  of  a  leading  drug  firm  of  this  city  she  was  gra- 
tuitously furnished  with  bone-marrow,  and  a  friend  ob- 
tained board  for  her  in  the  country  during  July. 

It  was  thought  that  these  measures  fulfilled  the 
therapeutic  indications,  and  the  outcome  was  awaited 
with  interest  and  the  hope  that  the  case  might  prove 
an  exception  to  the  rule,  that  the  disease  is  almost 
always  progressive  despite  the  most  carefully  directed 
treatment.'  This  hope  was  strengthened  by  the  favor- 
able reports  relative  to  the  use  of  bone-marrow.- 

Of  the  cases  referred  to  in  these  reports,  that  of 
Bigger''  most  nearly  resembles  our  case,  and  is  reported 
by  him  as  a  case  of  leucocythemia  apparently  cured. 

On  August  5,  1895,  she  returned  to  town  and  exami- 
nation showed  that  the  spleen  was  smaller,  that  the 
ratio  of  corpuscles  was  as  one  white  to  ten  red.  No 
nucleated  red  corpuscles  could  be  found.  Haemoglobin 
decidedly  improved.  She  then  went  to  live  on  Long 
Island,  in  a  locality  where  malaria  prevails.  She  devel- 
oped immediately  intermittent  fever  of  the  tertian  type,  \ 
and  on  August  29th  was  readmitted  to  the  hospital  for 
treatment.  The  digestive  disturbance  associated  with 
her  malarial  fever  prevented  the  administration  of  bone- 
marrow  until  October  loth,  when  its  use  was  renewed. 
Blood  count  at  this  time  showed  a  ratio  of  one  white  to 
nine  red  blood-cells.  During  the  run  of  the  intermit- 
tent fever  her  spleen  had  markedly  increased  in  size, 
and  with  the  subsidence  of  the  fever  the  organ  di- 
minished, until  its  anterior  border  extended  only  to  the 
former  position,  namely,  about  one  inch  to  the  right  of 
median  line  of  abdomen. 

On  October  31st  Dr.  Thomas  S.  South  worth  kindly 
examined  her  blood  for  me,  and  found  hiemoglobin, 
forty-eight  per  cent.,  ratio  of  white  to  red  cells  as  one 
to  thirteen,  abundant  myelocytes,  and  numerous  nucle- 
ated red  cells. 

At  the  present  time  she  is  taking  Warburg's  tincture, 
Pearson's  solution  of  arsenic,  which  seems  to  be  better 
borne  than  Fowler's  solution,  and  Caswell,  Massey  & 
Co.'s  preparation  of  bone-marrow. 

29  East  Twentv-foukth  Street. 


POTASSIUM    PERMANGANATE    IN    OPIUM 
POISONING. 

Dr.  J.  T.  M.  Lindsay,  of  Cuero,  Texas,  writes  :  "  On 
the  2 1  St  day  of  October  I  was  called  to  see  a  patient, 

Mrs.    Annie  A ,  of  this  city,  at  about  11.30  a.m., 

who  had  (as  reported)  taken  nearly  a  teaspoonful  of 
morphine.  I  was  near  the  place,  making  my  visits  to 
some  sick  patients  in  the  neighborhood,  when  called. 
On  my  arrival  I  found  this  woman  (middle-aged)  in  a 
Osier:  American  Text-book  of  Practice  of  Medicine,  voL  ii.,  p. 

Henry  Hun :  New  York  Medical  Journal,  January  I2.  1895,   p. 
35.     Allan  McLane  Hamilton  :  New  York  Medical  Journal,  January 
12,  1S95.  p.  44. 
"  Lancet,  September  22,  1S94,  p.  682. 


226. 


December   14,    1S95] 


MEDICAL   RECORD. 


859 


comatose  condition.  I  had  her  face  bathed  in  cold 
water,  and  kept  her  in  a  sitting  posture,  and  at  the 
same  time  administered  potassium  permanganate  inter- 
nally. The  effect  of  the  morphine  was  rapidly  counter- 
acted, and  in  thirty  or  forty  minutes  I  had  her  walking 
the  floor  of  the  room  supported  by  myself  and  her 
husband.  I  made  her  drink  several  cups  of  coffee,  and 
in  an  hour's  time  I  had  her  outdoors,  where  she  could 
get  fresh  air  and  plenty  of  it,  and  within  three  hours 
after  administration  of  the  potassium  permanganate  she 
was  able  to  resume  her  usual  occupations." 


IXTESTIX.\L    ANASTOMOSIS    BY  THE    MUR- 
PHY BUTTON. 

Bv  MILO  BUEL  WARD,  M.D., 

TOPEKA,    KAN. 

The  following  case  may  be  of  sufificient  interest  to  the 
profession  to  justify  its  publication  : 

Mrs.     McC ,    Irish     birth,     aged    twenty  •  nine, 

mother  of  one  child  of  seven  years,  with  a  history  of 
pelvic  disease  extending  over  a  period  of  several  years, 
much  of  the  time  incapacitating  her  from  household 
duties,  and  under  treatment  for  the  same  almost  con- 
stantly for  the  past  five  years. 

No  history  of  miscarriage  was  obtained,  but  her  at- 
tending physician  had  suspected  gonorrhoeal  infection 
to  be  the  cause  of  the  primary  infection.  There  was, 
however,  no  positive  proof  obtainable,  which  left  this 
feature  of  the  case  to  rest  entirely  upon  suspiction. 

I  first  saw  the  patient  in  consultation  with  Dr.  Munn, 
of  this  city,  September  29th  of  this  year.  At  this  time 
she  was  bedridden,  the  result  of  continuous  uterine 
hemorrhage,  also  extreme  tenderness  of  the  abdominal 
organs,  making  it  quite  impossible  to  remain  in  the 
upright  position.  Upon  examination,  I  found  the  pel- 
vis completely  filled  with  solid  exudate,  entirely  oblit- 
erating the  outlines  of  the  uterus.  The  patient's  suffer- 
ing was  intense.  A  very  careful  bimanual  examination 
caused  great  pain.  She  was  reduced  to  complete  in- 
validism. The  pulse  was  very  rapid,  and  the  tempera- 
ture from  100°  to  101°  F.  There  was  serious  bloating 
of  the  intestines  much  of  the  time,  but  the  bowels  had 
been  kept  open  by  the  frequent  use  of  saline  laxatives. 
The  diagnosis  reached  was  chronic  endometritis,  very 
serious  in  character,  and  salpingo-ovaritis,  with  proba- 
ble intestinal  complications.  The  patient  was  brought 
to  my  hospital  on  the  following  day  and  hastily  pre- 
pared for  surgical  interference. 

On  the  morning  of  October  ist,  under  ether  anaes- 
thesia, and  assisted  by  Drs.  Munn  and  Frankenburger, 
of  this  city,  and  Dr.  W.  G.  Vest,  of  Montezuma,  la., 
who  was  visiting  my  hospital  at  that  time,  I  did  the 
following  operation  :  With  the  patient  in  lithotomy 
position,  the  uterus  was  dilated  with  Goodell's  dilator, 
and  with  the  sharp  curette  the  endometrium  was 
thoroughly  curetted,  irrigated,  and  packed  with  iodo- 
form gauze.  This  completed,  the  patient  was  placed 
in  dorsal  decubitus  for  the  purpose  of  removing  the 
pelvic  masses.  The  omentum  was  found  universally 
adherent,  requiring  forced  separation  from  the  pelvic 
organs.  The  intestines  were  firmly  adherent  to  the 
fundus  of  the  uterus  and  pelvic  tumors.  After  they 
were  separated,  it  was  found  that  several  inches  of  the 
sigmoid  flexure  was  greatly  thickened  and  nearly  gan- 
grenous, and  severed  almost  completely  in  one  place, 
being  only  held  by  the  mesentery  portion.  Two  oval- 
shaped  holes  were  also  found  in  this  portion  of  the  gut, 
about  one-half  inch  in  diameter,  extending  through  the 
serous  and  muscular  coats,  resembling  a  punch-hole  in 
sole  leather.  The  wall  of  the  intestine  was  one-half  inch 
thick  at  the  point  where  it  had  broken  in  twain.  Hot 
towels  were  applied  to  the  intestine  outside  of  the  ab- 
domen during  the  removal  of  the  pelvic  masses.  The 
enucleation  of  these  tumors  was  more   difficult   than 


words  can  describe,  and  can  only  be  appreciated  by 
those  who  have  been  so  unfortunate  as  to  deal  with 
this  character  of  disease.  The  bleeding  was  very  pro- 
fuse, causing  great  shock  to  the  patient,  and  giving  us 
much  concern,  for  fear  that  we  would  not  be  able  to 
keep  her  alive  long  enough  to  reach  her  bed.  Hypo- 
dermic injections  were  quite  freely  used,  and,  after 
irrigating  the  peritoneal  cavity  with  normal  salt  solu- 
tion, the  patient  seemed  to  rally  enough  to  justify  an 
attempt  to  complete  the  necessary  surgery.  I  packed 
the  pelvis  with  iodoform  gauze,  which  controlled  the 
bleeding,  while  I  turned  my  attention  to  the  intestine. 
My  first  plan  was  to  attempt  to  unite  the  intestine,  after 
repairing  the  ragged  and  almost  gangrenous  edges  by 
the  Lembert  suture  method.  But  owing  to  the  great 
thickness  of  the  wall  and  also  the  holes  above  men- 
tioned in  other  parts  of  the  intestine,  it  was  found  im- 
possible to  proceed  in  this  manner.  A  large-sized 
Murphy  button  was  immediately  brought,  and  six 
inches  of  the  intestine  resected  and  an  end  to  end 
anastomosis  made.  The  wall  of  each  end  of  the  intes- 
tine, where  it  was  severed,  was  about  one-third  of  an 
inch  in  diameter,  making  the  introduction  of  the  but- 
ton extremely  difficult.  It  would  perhaps  have  been 
much  easier  to  have  removed  more  of  the  intestine  in 
order  to  have  reached  a  point  where  it  was  more  nearly 
normal  in  thickness,  but  it  did  not  seem  advisable  to 
sacrifice  more  of  that  portion  of  the  gut  if  possible  to 
avoid  it.  Contrary  to  the  usual  custom,  and  the  ad- 
vice of  Dr.  Murphy,  I  sutured  around  nearly  the  en- 
tire intestine  with  silk,  believing  it  would  afford  addi- 
tional support.  The  pelvic  gauze  was  then  removed, 
intestines  replaced,  and  thorough  irrigation  with  a  very 
warm  salt  solution  was  again  resorted  to.  I  then 
thoroughly  packed  the  pelvis  with  iodoform  gauze,  and 
closed  the  upper  angle  of  the  incision  with  silkworm 
gut  sutures,  completing  the  entire  operative  procedure 
in  one  hour  and  twenty  minutes.  Without  knowing 
the  exact  time  occupied  in  doing  the  anastomosis,  it  is 
at  least  safe  to  say  that  not  more  than  fifteen  minutes 
were  occupied  in  this  part  of  the  operation.  The  pa- 
tient was  placed  in  bed  and  restoratives  used,  but  she 
did  not  react  satisfactorily  for  twenty-four  hours. 
Twenty- two  hours  after  the  operation  I  removed  the 
pelvic  packing,  which  had  served  the  double  purpose 
of  controlling  the  hemorrhage  and  draining  the  ab- 
domen. A  small  quantity  of  iodoform  gauze  was  again 
introduced  into  the  incision  and  carefully  forced  down 
toward  the  pelvis,  the  gauze  not  being  removed  for 
forty-eight  hours.  The  dressings  were  from  this  time 
on  removed  and  fresh  gauze  introduced  every  twenty- 
four  hours,  allowing  the  incision  to  heal  by  granula- 
tion. The  first  ten  days  were  spent  in  extreme  anxi- 
ety, but  at  the  same  time  the  patient  had  so  many 
favorable,  intermingled  with  unfavorable,  symptoms, 
that  there  seemed  good  reason  for  hope  of  her  final 
recovery. 

A  review  of  the  daily  record  relative  to  the  care  of 
this  patient  would  be  too  lengthy  to  publish  in  this 
connection.  After  ten  days  had  elapsed,  the  patient 
seemed  to  give  promise  of  certain  recovery,  and  had  no 
untoward  symptoms  from  this  time  on.  The  button 
was  passed  on  the  eighteenth  day,  following  the  ad- 
ministration of  a  generous  dose  of  castor-oil.  The 
incision  was  entirely  healed  in  four  weeks,  and  she  re- 
turned to  her  home  in  five  weeks  after  the  operation, 
being  able  to  walk  off  as  sprightly  as  ever  before  in 
her  life,  and  says  she  is  entirely  well.  Her  appetite 
and  digestion  could  not  be  more  perfect.  She  was 
permitted  to  have  regular  diet  after  the  button  made 
its  appearance. 

The  special  features  in  this  case,  making  it  one  of 
unusual  interest,  are  :  the  danger  of  procrastinating 
surgical  interference  in  cases  of  such  severe  chronic 
disease  ;  the  great  gravity  of  the  pelvic  oi)eration  caus- 
ing so  much  shock  that  the  doctor  in  charge  of  the 
anaesthetic  expressed  the  fear  that  she  would  die  on 


86o                                                    MEDICAL  RECORD.                      [December   14,  1895 

the  table  before  the  pelvic  masses  could  be  completely  Uterine  Inertia  can  at  times  be  remedied  by  a  gly- 

removed  ;  and   the  anastomosis  of  so  thick  an   intes-  cerine  suppository. — Cowax. 

tinal  wall.  t                      ^  .       ,           ,              ■      ,      •,    ■                 r 

If  there  are  surgeons  who  question  the  value  of  this  -Lavaire.-i.  Stimulates  the  gastric  glands  in  cases  of 

wonderful  device,  Murphy's  intestinal  button,  a  knowl-  ^^/.o^^"^  g^^tric  catarrh,  especially  in  those  instances 

edge  of  this  one  case  ought  to  convert   them  without  ^^^'^h  are  associated  with   excessive  secretion  of  mu- 

further  controversy.     It  is  the  writer's  opinion  that  no  ^f '     .^-  Strengthens   the    enfeebled    gastric  muscular 

other   method   would    have    resulted    saiisfactorily   in  fibres  in  cases  of  insufficiency  or  atony.     3.  Increases 

dealing  with   this  abnormally  thickened    intestine   in  Pe"staltic  action.     4-  ^\  ith   the    improvement   in    the 

connection  with  such  trying  circumstances.  ^one  of  the  walls  of  the  stomach,  associated  intestinal 

disorders  such  as  constipation  may  also  be  overcome. 
— Joseph. 

Vomiting    of   Pregnancy. — The   medicines    recom- 

^TtCfJTlJCtltiC   '+tilltS  mended    for   persistent    vomiting   are    numerous   and 

"^                                '^            '  varied,  including  alcohol,  alkalies,  tincture  of  iodine 

(5  to  10  drops  in  water),  tincture  of  nux  vomica,  pep- 
Atrophic  Rhinitis. — In  atrophic  rhinitis  the  diluted  sin,  ingluvin,  cannabis  indica,  orexine.  purgatives,  bel- 
peroxide  solution  serves  a  double  purpose,  eliminating  ladonna,  ipecac,  lavage  of  the  stomach,  chloroform, 
the  stench  by  breaking  up  the  decomposing  matter,  menthol,  cocaine,  potassium  bromide,  opium,  caffeine, 
and  helping — by  the  liberation  of  the  gas  and  the  con-  chloral,  strontium  bromide,  oxalate,  carbonate,  or 
sequent  formation  of  bubbles — to  loosen  the  crusts,  valerianate  of  cerium,  ether,  serum,  inhalation  of  oxy- 
The  cotton-tipped  probe  is  of  the  greatest  service  in  gen,  blisters  over  the  epigastrium,  ice  to  the  spine,  and 
dislodging  these  dried  masses  and  wiping  away  strings  ether  spray  to  the  abdomen  or  spine.  Blood-letting 
of  tenacious  mucus.  has  done  real  service  in  some  cases.  Electricity  has 
Eczema  of  Nose.— In  eczema  of  the  nose  occurring  often  been  applied,  and  is  now  becoming  very  popular, 
just  at  the  junction  of  the  integument  and  mucous  Among  the  medicines  employed  by  the  author  are 
membrane,  and  associated  with  an  interstitial  keratitis,  calomel  in  small  doses,  creosote,  pyroligneous  acid, 
the  effects  of  the  sirup  of  the  iodide  of  iron  in  appro-  'a"'^"^  (20  ctg.  daily),  smoking  of  tobacco,  resorcin, 
priate  doses  are  most  striking.  Such  cases,  which  are  Phosphate  of  calcium,  and  mercury.  Rectal  enemata 
so  frequently  met  with  in  a  dispensary  practice  among  ^^^  "^eful  when  the  patient  becomes  very  weak.  The 
children  of  low  vitality,  are  rarely  benefited  by  local  'o^al  treatment  consists  in  scarification  of  the  cervix, 
applications  alone  leeches  applied  to  the  cervix,  the  introduction  of  a 
,  small  sound  for  5  to  6  ctm.,  cauterization  of  the  cervix 
Alumnol.— Alumnol,  in  two  per  cent,  solution,  either  by  nitrate  of  silver  (i  to  10),  and  correction  of  retrover- 
alone  or  combined  with  menthol,  and  m  certain  cases  gion  if  that  condition  be  present.  If  all  of  these  means 
with  a  small  percentage  of  cocaine,  is  extremely  ser-  faO^  and  the  patient  is  losing  in  weight  every  day,  it  is 
viceable  in  relaxed  conditions  of  the  larynx.  justifiable  to  produce  an  abortion,  or  premature  de- 
Rhinitis. — Cod-liver  oil,  the  hypophosphites,  etc.,  livery.  In  the  severe  cases  this  procedure  should  not 
will  do  more  for  the  cure  of  rhinitis  in  scrofulous  chil-  be  delayed  too  long,  otherwise  the  patient  may  be  too 
dren  than  any  simple  local  application.  weak  to  rally  after  the  operation. — Demelin. 

Itching  in  Eczema. — Fluid  extract  of  jaborandi  lo-  Neurasthenia. — 

cally  applied. — G.W.Robinson.  5.   Acid  phosphate 3j. 

Diabetes.— Boric  acid,  seven  grains,  thrice  daily.  |^[;  ^l^^^^T\x<v^xi.''.'.'.'.'.' '.'.'.'.'.'.'.'.'. .'.'''.''.'.  |ss.' 

— MOCKTON.  Tr.  nucis vomic gr.  x. 

Sciatica.— Salol,  gramme  0.5  to  gramme  i.e.  Aqu^'"".^'!V.'.'.V. . ■.'.:.■.. '.  ■.'..■.■.:■.. ■.■.■.:::;d  fss. 

ASCHENBACH.  pf    jojig       gjg  .   -^^  \,^  (3;.^^  ;„  ^^^^^  ^^  ,  j  ^  j,_  jj^^j  g  p  j, 

CMorosis. — In  true  idiopathic  chlorosis,  where  iron  — Clark. 

is  ineffectual,  sulphur  will  produce  a  marked  ameliora-  t«„o«,^v,^„        \    i             i          ■      j                      r      -u 

tion.     After  using  sulphur  iron  can  again  be  resorted  /•e'^corrhffia.-A  leucorrhoea  inodorous,  or  of  mild 

to,  and  it  becomes  very  beneficial.-ScHULTz.  "^"h  Persisting  during  the  climacteric,  accompanied 

_  by  increasing  hemorrhage,  is  suspicious,  and  demands 

The  Analgesic  Antithermics.— The   following   con-  investigation.      A    leucorrhoea   profuse,    of   peculiarly 

elusions  were  drawn  at  the  French  Congress  of  Inter-  fetid  odor,  grumous.  excoriating,    appearing  early   or 

nal    Medicine:     i.    The    numerous    remedies   which  late   during  the  climacteric,  with  profuse  hemorrhage, 

compose  the  rather  ill-defined  group  of  analgesic  anti-  is  reasonable  evidence    of  cancer   of   the   cervix.     A 

thermics  are  characterized  by  their  protoplasmic   ac-  leucorrhoea,    moderate    in    amount,    ill-smelling    (the 

tion— their  action  of  the  blood,  and  especially  their  peculiarly  fetid  odor  of  cancer   of   the   cervix    being 

nerve-action.     2.  The  preponderance  or  the  exaggera-  absent),  accompanied  by  hemorrhage,  suggests  cancer 

tion  of  the  one  or  the  other  of  these  actions  is  connect-  of  the  corpus  uteri.     A    leucorrhoeal    discharge    with 

ed  \vith  their  chemical  constitution,  and  determine  the  hemorrhage,  containing  material  like  the  washings  of 

differences  of  their  therapeutic  effects  and   the  acci-  meat,  is  said  to  indicate  sarcoma.     A  watery  discharge, 

dents  that  they  may  produce.     3.  They  are  only  em-  as  a  rule,  occurring  during  menstruation,  odorlessor 

ployed,  in  the  great  majority  of  instances,  against  a  sin-  of    little    odor,    persisting,    accompanied    by    profuse 

gle    symptom— elevation    of    temperature  or  pain.     4.  hemorrhage,    indicates    fibroids  ;    with    little    or    no 

As  antithermics,  or  rather  antihyperthermics,  they  may  hemorrhage,  polypi.     Profuse  bloody  discharges  com- 

have,  in  certain  cases,  a  favorable  action.     Most  often  ing  on  gradually  with  declining  menstruation,  ceasing 

they  are  useless  or  dangerous.     5.  As  analgesics,  they  usually  with  the  menstrual  flow,  point  to  fibroids.     Per- 

occupy  an  important  place  and  one  which  is  incontest-  sistent  profuse  discharges  of  blood  occurring  spontane- 

ed  in   the   treatment  of    pain. — Schmitt,   Gazette   c/rs  ously,  arising  from  sudden  exercise  or  coition,  occur- 

Hopttatix,  September,  1S95.  ring,  as  a  rule,  after  the  menopause,  indicate  cancer. — 

Chopparro  Amargoso,  belonging  to  the  same  order  as  ^^'^"• 

quassia,  a  thorny  bush  growing  in   Texas,  of  which  a  Typhoid  Fever.— Whenever  the  thermometer   regis- 

fliiid  extract  is  made,  is  said  to  be  tonic  in  small  doses,  ters  102.2°,  or  over,  the  bath  is  resorted  to,  and  again 

stimulant  in  large,  and  a  palliative  remedy  in   dysen-  in  half  an  hour  ;  if  below  102°  and  above  101°  F.,  it  is 

tery.     Mixon.  repeated  in  an  hour;  if  below  101°  and  above    100° 


December   14,  1895] 


MEDICAL    RECORD. 


861 


it  is  repeated  in  two  hours  ;  if  below  100°  F.,  the  pa- 
tient is  put  into  the  bath  again  in  three  hours  ;  but 
whenever  102.2°  F.  is  reached,  the  bath  is  repeated, 
and  so  on  until  the  temperature  does  not  go  above  the 
tath  point. — Tyson. 

Cascara  Sa^rada  is  useful  in  rheumatism. 

HUNIOOX. 

Influenza. — 

B.     Quinins  sulph ...     I], 

Pulv.  digitalis, 

Pulv.  scill.i; a5  gr.  xx. 

Ext.  opii gr.  V. 

Ext.  glycyrrhizae q.s. 

M.  et  ft.  pil.   No.  xx.\.     Sig. :  Take  a  pill  four  times  daily. 

— Pepper. 
Membranous  Croup. — 

IJ .    Ilydrarg.  chlor.  mit §■■•']• 

Sodii  bicarb gr.  xxiv. 

Pulv.   ipecac gr-  j- 

Pulv.  pepsina; gr.  xxiv. 

M.   et  ft.  chart.  No.  xij.     Sig.:  One  powder  every  two  hours. 

— St.arr. 
Bronchitis. — 

IJ .   .Vmmonium  chlorid., 

Sodium  iodid aa     3  i'j. 

Syrup  of  tolu. 

Syrup  of  senega iSa    fj  iss. 

If  a  spasmodic  element  be  present,  sodium  iodide, 
.2'-  grains,  may  be  added  to  each  dose. — Eshxer. 

Delirium  Tremens. — 

IJ.    Potass,  brumid., 

Sodii  bromid aa  gr.  xv. 

Chloral  hydrat g"".  x. 

Tinct.  Zingiberis TT^  x. 

Tinct.  capsici 111,  v. 

Spir.  ammonii  arom 3  j- 

Aq jij. 

M.   Sig.  :    Dose,  a  dessertspoonful. 

—  Vanderbilt  Clinic. 

Rheumatism. — The  author  does  not  believe  that  the 
■changes  in  the  joints  in  the  cases  of  rheumatism  ex- 
amined by  him  are  caused  by  direct  bacterial  invasion. 
He  considers  that  they  are  caused  by  the  action  of 
loxic  substances,  which,  under  certain  conditions,  exert 
their  influence  on  the  joints,  and  he  believes  that  we 
must  consider  as  causative  factors  not  only  the  toxins 
of  those  microorganisms  which  we  regard  as  the  in 
fective  agents,  but  also  those  chemico  toxic  substances 
which  are  produced  indirectly  by  bacterial  activity. — 
Choostek. 

Hypertrophies. —  i.  Hypertrophies  due  to  obstacles 
in  the  heart  itself.  This  condition  is  typically  repre- 
sented by  lesions  of  the  valves.  2.  Hypertrophies  due 
to  increased  resistance  in  the  vascular  system.  3. 
Hypertrophies  due  to  diseases  of  the  heart  muscle  it- 
sell,  from  infection,  overstrain,  degeneration,  etc.  4. 
Hypertrophies  due  to  affections  of  the  nervous  system. 
— Whittakek. 

Night-sweats. — 

I{ .    Kxt.  secal.  cornuti 3.0. 

Spir.  dilut., 
Glycerini, 

Aq.  dest fill  5.0. 

M.    Sig.  :   For  subcutaneous  injection  :    I  c.c.  at  bcd-linic. 

GdLDKNB.-VCH. 

Alleged  Reflex  Causes  of  Nervous  Diseases. —  i.  The 
essential  feature  in  the  production  of  many  neuroses  is 
the  neuropathic  state — the  degeneracy — of  the  subject. 
2.  In  hysterical  subjects  suggestion  plays  an  important 
part  both  in  the  development  and  cure  of  the  symp- 
toms. 3.  Disease  of  any  organ  may  give  rise  to  re- 
ferred pain  in  some  definite  area,  but  not  to  other  ner- 
vous disturbances,  except  as  a  secondary  result  of 
local  disease  of  the  organ.  This  local  disease  mani- 
fests itself  by  the  ordinary  local  symptoms,  and  the 
nervous  phenomena  are  due  to  exhaustion,  anaemia,  in- 
toxication, etc.     4    In  a  few  rare  cases  injury  of  a  sen- 


sory nerve  may  give  rise  to  epileptiform  seizures.  5. 
Surgical  operations  for  the  relief  of  nervous  symptoms 
should  never  be  performed  unless  there  are  clear  indi- 
cations, apart  from  such  symptoms,  for  an  operation. 

— KXAPP. 

Yeast  Nucleins  in  Tuberculosis. —  i.  In  cases  of  pul- 
monary tuberculosis  with  cavities  it  does  no  good.  2. 
It  may  retard  the  progress  of  longstanding  cases,  so 
long  as  secondary  infection  with  pyogenic  germs  does 
not  occur.  3.  A  temporary  cure  (the  cases  have  not 
been  long  enough  under  observation  to  say  more)  may 
be  obtained  in  early  cases  of  small  area.  4.  It  has 
proved  satisfactory  in  urinary  tuberculosis.  Finally, 
the  nucleins  in  other  substances  may  act  equally  well 
as  yeast  nucleinic  acid. — Vaugha.x. 

Faith. — Dr.  Mackay,  in  his  work  on  "  Popular  De- 
lusions," relates  that,  when  the  Prince  of  Orange  was 
besieging  the  town  of  Breda,  his  army  became  so  seri- 
ously afflicted  with  the  scurvy  as  to  be  threatened  with 
annihilation.  When  ail  legitimate  remedies  failed  he 
caused  a  decoction  of  chamomile,  wormwood,  and 
camphor  to  be  made,  and  announced  it  to  his  army  as  a 
wonderful  remedy  brought  from  the  East  with  much 
danger  and  toil,  and  that  a  single  drop  of  it,  mixed 
with  a  gallon  of  water,  was  an  absolute  specific  for 
their  disease.  The  result  equalled  their  expectation, 
and  the  measure  of  success  was  exactly  equal  to  the 
measure  of  the  faith. 

Tonsillitis. — If  you  find  that  the  patient  cannot  open 
the  mouth  you  may  almost  invariably  exclude  diphthe- 
ria, and  suspect  one  of  the  inflammatory  non-diphtherit- 
ic forms  of  angina. — Massei. 

Chronic  Enlargement  of  the  Tonsils  will  be  benefited 
by  painting  every  other  day  with  a  mixture  of  one- 
third  compound  tincture  of  iodine  to  two-thirds  glyc- 
erine. 

Typhoid  Fever.— The  tympany  of  enteric  fever  can 
often  be  favorably  influenced  by  rectal  injections  of 
from  five  to  six  ounces  of  ice-water,  retained  for  some 
time  in  the  bowel. 

Peritonitis. — i.  Mechanical  irritation  of  the  mucous 
membrane  by  which  it  becomes  abraded,  or  its  vitality 
lowered,  as  by  indigestible  food  or  foreign  bodies  ; 
and,  in  the  latter  case,  by  strangulation  from  a  band  or 
a  hernia.  2.  Chemical  poisons,  both  organic  and  inor- 
ganic, by  their  injurious  effects  tend  to  lower  the  re- 
sisting power  of  the  lymph  tissue  to  the  invading 
germs,  provided  the  poison  be  not  directly  fatal  to 
them.  3.  Retardation  or  obliteration  of  the  normal 
intestinal  peristalsis,  preventing  the  gut  from  casting 
out  its  invaders.  A  great  increase  in  the  number  of 
bacilli  by  which  the  lymph-cells  are  overpowered,  or  a 
diminished  number  of  the  defending  cells,  or  their  low 
vitality  enable  the  bacilli  to  pass  into  the  peritoneal 
cavity,  and  by  reproducing  themselves  in  sufficient 
numbers  cause  a  general  peritonitis.  That  the  fore- 
going is  the  etiology  of  many  cases  of  peritoneal  in- 
flammation  is  now  a  demonstrated  fact. 

— Chilus-Macdonald. 


A  Brave  Physician — The  latest  addition  to  the  roll 
of  gallant  actions  performed  by  medical  men  is  that  of 
Dr.  Charles  Toller,  of  Ilfracombe,  who,  during  the 
recent  heavy  gale  which  raged  on  our  west  coast,  and  at 
the  imminent  risk  of  his  life,  descended  by  means  of  a 
rope  a  cliff  on  the  Lee  Bay  Rocks,  which  are  one  hun- 
dred and  fifty  feet  in  height,  in  order  to  apply  restora- 
tives to  an  apparently  drowned  person.  Strenuous 
efforts  were  made  by  Dr.  Toller  to  restore  animation, 
and  the  patient  partially  rallied,  but  ex|)ired  a  few  min- 
utes before  being  landed  at  Ilfracombe  in  the  lifeboat 
which  had  been  sent  to  the  rescue. —  The  Lancet. 


862 


MEDICAL    RECORD. 


[December   14,  1895 


[ew  instruments. 


A  HEAD  REST  FOR   THE    JAVAL  OPHTHAL- 
MOMETER. 

By  frank  D.    SKEEL,   M.D., 


The  following  is  a  description  of  an  experiment  made 

with  a  view  to  improving  the  present  form  of  head-rest 

in  the  Javal  ophthalmometer. 

Some  time  ago  I  suggested  to  Messrs.  Fox  and 
Stendicke  that  some 
such  improvement 
should  be  made,  and 
this  engraving  will 
show  the  results  of 
their  efforts.  Two  sup- 
ports are  provided, 
against  which  the  fore- 
head rests,  each  carry- 
ing a  small  screen 
which  shields  the  eye 
from  cross  lights.  The 
distance  between  these 
supports  is  adjustable 
and  is  regulated  by 
a  screw  shown  above. 
The  eye-screen  is 
mounted  on  a  curved 
arm  and  swings  from 
side  to  side  to   cover 

either  eye.     The  details  can  be  readily  seen   in   the 

engraving. 


LONG  FLEXIBLE  DOUBLE-CURRENT  TUBE 
FOR  HIGH  IRRIGATION  OF  BOWEL,  ALSO 
DOUBLE-CURRENT  IRRIGATORS  FOR  IN- 
FANTS. 

By   ROBERT  COLEMAN  KEMP,   M.D., 


This  flexible  irrigator  is  a  modification  of  the  soft-rub- 
ber rectal  irrigator  described  in  the  Medical  Record 
of  December  7th.  The  outer  tube  is  of  soft  rubber — 
diameter,  j  of  an  inch — the  inner  longitudinal  tube  is  of 
linen.  The  linen  tube  is  riveted  in  a  hollow  tip,  and 
this  tip  unscrews  from  the  outer  tube.  To  clean  the 
instrument  unscrew  the  tip,  and  withdraw  the  central 
tube.  The  outer  cap,  etc.,  is  similar  to  that  in  the  in- 
strument previously  described.  This  irrigator  is  twelve 
inches  long.  It  can  be  made  longer  if  desired.  The 
Ford  Instrument  Co.  also  make  a  short  rectal  irrigator 
similar  to  this,  a  flexible  double-  current  irrigator—  diam- 
eter, l  of  an  inch  ;  length,  8  inches — is  made  for  infants  ; 
also  a  short  flexible  irrigator  four  inches  long.  There 
is  also  a  hard-rubber  irrigator,  and  one  of  soft  rubber — 
diameter,  |  of  an  inch — in  construction,  similar  to  those 
described  December  7th.  In  these  small  irrigators, 
however,  the  conducting  tube  is  of  metal-copper. 
They  may  be  plated  or  made  of  silver  or  aluminum, 
which  would  increase  the  expense.  I  have  found  that 
in  these  small  tubes  the  hard-rubber  conducting  tube 
cannot  be  made  sufficiently  small  enough  and  of  inter- 
nal calibre  to  furnish  a  good  current.  Note,  however, 
the  linen  tube,  which  can  be  substituted  for  metal. 
In  connection  with  this  article  I  mention  an  adult  rectal 
irrigator,  external  tube  of  soft  rubber,  internal  tube  of 
copper.  It  can  be  bent  to  suit  operator,  is  soft,  and  yet 
under  his  control. 

449  Park  Avenub. 


(3rorresp0n(Tence. 


EXPERT    TESTIMONY  IN    LUNACY   CASES. 

To  THH  Editor  op  the  Medical  Record. 

Sir  :  My  attention  has  been  called  to  an  editorial  in 
your  issue  of  November  23d,  entitled  "  The  Commis- 
sioner of  Lunacy  as  an  Expert,"  which,  if  permitted  to 
stand  uncorrected,  would  do  me  a  great  injustice,  and 
which,  in  view  of  my  pleasant  personal  relations  with 
the  editor  of  the  Medical  Record,  I  must  assume  was 
written  under  a  misapprehension  as  to  the  law  and  the 
fact  in  the  matter  rather  than  in  a  spirit  of  unfriendly 
criticism. 

The  law  relating  to  the  "  commitment  of  the  insane 
by  criminal  process  "  provides,  among  other  things,  in 
substance,  that  whenever  any  person  accused  of  the 
crime  of  arson,  murder,  or  attempt  at  murder,  or  high- 
way robber}',  shall  have  been  acquitted  on  trial  upon 
the  ground  of  insanity,  the  jury  shall  bring  in  a  special 
verdict  to  that  effect,  and  so  state  in  its  finding,  and 
the  court  before  whom  such  trial  is  had  shall  order 
such  person  to  be  committed  to  some  State  lunatic 
asylum,  there  to  remain  for  observation  and  care  until 
such  time  as,  in  the  judgment  of  a  justice  of  the 
Supreme  Court,  founded  upon  satisfactory  evidence,  it 
is  safe,  legal,  and  right  to  discharge  him. 

From  this  it  will  be  clearly  apparent  that  the  Com- 
mission in  Lunacy  has  no  power  either  to  prolong  the 
detention  or  cause  the  discharge  of  a  person  committed 
to  an  asylum  pursuant  to  the  statute  cited  and  held  on 
what  is  known  as  a  "criminal  order."  A  discharge 
from  custody  in  such  a  case  can  only  be  m.ade  by  a 
judge  of  the  Supreme  Court,  who,  upon  receipt  of  no- 
tice from  the  superintendent  of  the  asylum  that  the 
patient  is  restored  to  his  right  mind,  must  determine  if 
it  is  safe,  legal,  and  right  to  discharge  him.  The  only 
possible  jurisdiction  the  lunacy  commission  would  have 
over  a  so-called  criminal  case  would  be  to  interfere  in 
his  behalf  if  it  had  reason  to  believe  that  he  was  cruelly 
or  negligently  treated.  Furthermore,  the  views  of 
judges,  as  well  as  of  governors  of  the  State,  respecting 
the  relations  of  the  Lunacy  Commission  to  such  cases 
may  be  inferred  from  the  fact  that  these  high  officials 
have  frequently  designated  the  medical  member  of  the 
Commission  as  a  special  commissioner  to  determine 
the  mental  condition  of  persons  charged  with  crime, 
and  in  whose  behalf  a  plea  of  mental  unsoundness  has 
been  made.  Carlos  F.  MacDoxald. 

The  Cambridge,  334  Fifth  Avenue, 
New  York,  December  3,  1895. 

[We  give  place  to  this  communication  from  our  distin- 
guished correspondent  with  an  acknowledgment  on  our 
part  that  the  article  was  written  under  a  misapprehen- 
sion of  the  law  as  it  now  stands  and  cheerfully  disavow 
any  motive  for  unfriendly  personal  criticism. — Ed.] 


LENGTH  AND  POSITION  OF  THE  APPENDIX. 

To  the  Editor  of  the  Medical  Record. 

Sir  :  Contributions  to  the  subject  of  the  anatomy  of 
the  appendix  vermiformis,  like  that  of  Dr.  Byron  Rob- 
inson's to  the  Medical  Record  for  November  30, 1S95, 
are  so  valuable  that  their  authors  are  presumably  glad 
to  have  any  possible  source  of  error  pointed  out.  In 
making  observations,  it  will  be  observed  that  appen- 
dices become  lax  and  elongated  after  the  period  of 
rigor  mortis  has  passed,  and  Dr.  Robinson's  measure- 
ments were  made  without  reference  to,  or  at  least  state- 
ment of,  that  point. 

It  is  also  probable  that  the  post  rigor-raortis  relaxa- 
tion of  the  bowel  allows  the  appendix  to  hang  into  the 
pelvic  cavity  much  more  after  than  it  does  in  life. 
All  of  us  who  are  engaged  in  abdominal  surgery  find 


December  14,    1895] 


MEDICAL   RECORD. 


86- 


the  appendix  in  the  pelvic  cavity  occasionally,  but  in 
operative  work,  or  in  palpation  of  normal  appendices 
through  the  abdominal  walls,  I  do  not  find  nearly  so 
large  a  proportion  of  appendices  in  the  pelvic  cavity 
as  Dr.  Robinson  finds  in  the  post-mortem  examina- 
tions. In  making  accurate  palpation  of  the  normal 
appendix  through  the  abdominal  walls,  it  is  necessary 
to  carry  the  caecum  quite  high  in  order  to  roll  the  ap- 
pendix out,  so  that  we  can  press  it  against  the  psoas 
and  iliacus  muscles  for  fixation,  and  this  movement 
may  lift  some  appendices  out  of  the  pelvis  ;  but  cer- 
tain it  is  that  there  are  few  normal  appendices  which 
cannot  be  found  behind  the  csecum  when  we  are  ready 
to  fix  them  against  the  pelvic  wall  for  palpation. 

Robert  T.  Morris,  M.D. 

New  York,  December  i,  1895. 


after  the  new  process  had  been  carefully  watched  for 
some  time,  "When  you  get  through  experimenting 
with  the  new  combination,  we  will  have  the  patient 
etherized  and  proceed  with  the  operation."  It  was 
not  a  flattering  success. 

The  three  principal  objections  to  the  use  of  the 
combination,  according  to  my  experience,  are.  i.  The 
length  of  time  it  takes  to  satisfactorily  anesthetize  a 
susceptible  patient,  the  time  being  longer,  as  a  rule, 
than  when  no  oxygen  is  used.  2.  Its  utter  inefficacy 
in  many  instances.  3.  The  danger  of  depending  en- 
tirely upon  the  quantity  of  oxygen  in  the  combination 
as  a  trustworthy  heart  and  lung  stimulant. 
Respectfully, 
Joseph  Willia.m  Stickler,  M.D. 

Orange.  N.  J,  December  2,  1893. 


LIMITATION    OF     SERVICE    IX     THE    CITY 
HOSPITALS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  At  the  annual  meeting  of  the  County  Medical 
Society  the  discussion  that  took  place  in  reference  to 
the  appointments  in  the  city  charitable  institutions,  a 
gentleman  who  was  for  some  time  in  the  service  of  the 
city  hospital  remarked,  that  formerly  the  field  for  an  ap- 
pointment was  open  to  everybody,  but  admitted  that  the 
candidate  must  have  had  political  influence.  That  dis- 
tinctly proves  that  the  field  was  not  open  to  everybody  ; 
that  the  candidate  must  have  been  and  continue  to  be 
the  tool  of  a  political  wire-puller.  He  further  remarked 
that  at  present  the  appointments  are  controlled  by  a 
medical  trust,  and  only  friends  and  members  who  have 
served  the  trust's  purpose  are  open  for  appointment. 
In  comparing  the  two  I  rather  prefer  (although  I  be- 
lieve it  is  unfair  and  unjust)  that  the  appointment 
should  be  in  the  hands  of  the  medical  trust  than  those 
of  the  politicians.  I  consider  the  appointment  of  civil 
service  just,  but  some  restrictions  should  be  made  ;  that 
is,  a  candidate  for  examination  should  be  an  American 
citizen,  and  at  least  a  resident  of  the  city  of  New  York 
for  three  or  five  years,  and  practice  medicine  for  five 
years.  Then  the  service  of  visiting  and  assistant  phy- 
sicians and  surgeons  should  be  limited  to  a  term  of  five 
years  and  only  be  permissible  to  serve  two  terms,  as 
this  service  is  only  for  the  purpose  of  gaining  experi- 
ence. Five  years  is  ample  for  that  purpose,  and  by  lim- 
iting the  term  of  service  it  will  give  an  opportunity  to 
a  greater  number  of  the  medical  profession  to  gain  this 
valuable  experience. 

Leonard  Landes,  M.D. 

New  York,  November  30,  1S55. 


CHLOROFORM  AND  ETHER  WITH  OXYGEN 


To  THE  Editor  i 


Medical  Record. 


Sir  :  Dr.  Cole,  in  the  Medical  Record  of  October 
1 2th,  reported  some  observations  on  the  use  of  oxygen 
and  ether  in  combination.  In  the  issue  of  November 
2d,  Dr.  R.  C.  Newton  says  :  "  The  valuable  and  in- 
structive paper  of  my  friend,  Dr.  Cole,  in  your  issue  of 
the  1 2th  ultimo,  will  doubtless  set  many  other  surgeons 
to  experimenting  with  oxygen  combined  with  ether." 
Several  years  ago  it  occurred  to  me  that  such  a  com- 
bination would  be  most  desirable,  for  the  reasons  given 
by  Dr.  Cole.  To  satisfy  myself  of  the  correctness  of 
my  supposition  I  obtained  a  cylinder  of  pure  oxygen 
and  administered  it  in  combination  with  chloroform  to 
several  private  patients.  In  one  or  two  instances  it 
seemed  to  work  admirably,  but  in  others  it  was  not  as 
satisfactory  as  chloroform  alone.  However,  I  was  sat- 
isfied that  the  principle  of  the  combination  was  correct, 
so  I  demonstrated  before  some  of  the  surgical  staff  of 
the  Orange  Memorial  Hospital.  Ether  was  the  an- 
esthetic used  on  that  occasion.     The  comment  was. 


^ed:icaX  gtcms. 

Contagious  Diseases— Weekly  Statement Report  of 

cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  December  7,  1S95. 

I    Cases.    '   Deaths. 


Tuberculosis   1  76  112 

Typhoid  fever 26  7 

Scarlet  fever 64  3 

Cerebro-spinal  meningi  lis 2  o 

Measles 224  16 

Diphtheria 38::  22 

Small-po.x I  o 

Color-blindness  and  Atavism. — A  recent  writer,  M. 
Dubois,  throws  out  a  suggestion  that  will  probably  be 
new  to  most  of  our  readers.  It  is  recognized  by  as- 
tronomers that  there  are  three  classes  of  stars — first,  the 
bluish-white  stars,  of  which  Sirius  and  Regulus  are  ex- 
amples. More  than  half  of  all  known  stars  belong  to 
this  class.  In  these  stars  combustion  is  at  its  maximum, 
and  their  atmosphere  consists  of  superheated  hydro- 
gen and  certain  metallic  vapors.  The  second  class, 
of  yellow  stars,  has  for  typical  representatives  Capella 
and  our  own  sun.  They  are  less  hot  than  the  first 
class,  and  the  hydrogen  lines  in  their  spectrum  are  not 
so  conspicuous  as  in  the  case  of  the  white  stars.  This 
class  contains  about  33.5  per  cent,  of  all  known  stars. 
The  third  class  are  the  red  stars,  and  of  these  Betelgeux 
is  the  representative.  They  are  in  a  later  stage  of  cool- 
ing than  the  second  class,  and  the  violet  rays  are  defi- 
cient. This  class  includes  about  eight  per  cent,  of 
known  stars.  From  these  known  facts  it  is  conjectured 
that  colorblindness  (or  insusceptibility  to  the  red  rays 
of  light)  may  possibly  be  a  case  of  atavism — a  "  nega- 
tive inheritance  from  that  time  long  ago  when  the  eye 
of  our  ancestors  was  not  yet  sensitive  to  red  rays,  which 
were  almost  entirely  wanting  in  the  white  stage  of  the 
sun."  This  is  a  startling  theory,  but  it  suggests  a  plausi- 
ble explanation  of  what  is  such  a  mysterious  fact — viz., 
that  color-blindness  should  so  uniformly  take  the  form 
of  insusceptibility  to  the  red  rays.  Atavism  is  without 
doubt  a  principle  of  wide  application,  and  may  be 
fairly  relied  upon  to  explain  many  apparently  inexplica- 
ble facts.  We  will  not  venture  to  pronounce  upon  the 
correctness  of  its  application  in  the  present  instance, 
but  at  least  the  theory  is  a  bold  and  ingenious  one,  and, 
if  accepted,  would  tend  toward  that  unifying  of  knowl- 
edge which  is  the  aim  of  science.  Color-blindness, 
regarded  as  an  isolated  phenomenon,  is  mysterious, 
but  if  it  be  a  case  of  atavism  it  takes  its  place  in  the 
scheme  of  ordered  knowledge. —  T/ie  Lancet. 

The  Edinburgh  Boyal  University  has  received  lega- 
cies to  the  amount  of  $375,000. 


864 


MEDICAL   RECORD 


[December   14,  1S95 


Treatment  of  Electrical  Injuries. — The  numerous 
deaths  among  the  staffs  employed  in  the  electrical  light- 
ing works  in  Paris  has  attracted  the  attention  of  the 
Minister  of  Public  Works,  who  has  asked  the  Academy 
of  Medicine  to  draw  up  directions  concerning  the  treat- 
ment of  those  injured  by  contact  with  the  wires,  and 
also  concerning  the  technical  precautious  to  be  taken. 
The  medical  treatment  formulated  by  the  Academy  is 
the  same  for  injury  from  electrical  shock,  no  matter 
what  the  nature  of  the  current  inflicting  the  injury  may 
be.  But  the  technical  precautions  differ  according  to  the 
nature  of  the  current.  If  the  person  injured  remains  in 
contact  with  the  electrical  conductors,  the  assistant  who 
extricates  the  injured  person  must  be  careful  before  com- 
mencing operations  to  have  dry  hands  and  wear  a  pair 
of  thick  flannel  or  stuff  gloves,  and  not  to  take  hold 
of  the  injured  person  by  a  region  in  perspiration.  In 
non-interrupted  currents  the  electrical  conducting  wires 
must  not  be  cut.  When  the  wire  is  cut  it  must  be  cut 
in  two  places.  The  medical  treatment  consists  of  plac- 
ing the  injured  person  where  there  is  plenty  of  air, 
loosening  the  clothes,  rhythmic  traction  of  the  tongue, 
rubbing  the  body,  etc.  M.  Dupuy  Dutemps  has  for- 
warded these  directions  to  the  prefects,  urging  them 
to  make  them  known,  especially  among  engineers  and 
staff  of  the  Fonts  et  Chaussees  entrusted  with  the  elec- 
trical lighting  of  streets,  to  the  directors  of  electrical 
stations,  municipal  authorities,  medical  men,  and  dis- 
pensing chemists.  The  instructions  corresponding  to 
the  respective  currents  will  be  pasted  on  the  wooden 
structures  to  'nch  th"  Doles  are  fixed. — British  Medi- 
cal 'yournal. 

The  French  Army  Medical  Service. — There  seems  to 
be  a  great  deal  of  trouble  in  connection  with  the  med- 
ical services  of  the  armies  and  navies  of  civilized  na- 
tions. The  fundamental  difficulty  in  all  cases,  is  the 
antagonism  between  the  regular  army  officers,  who 
wish  to  control  everything,  and  the  medical  officers, 
who  wish  to  have  independent  control  and  authority 
over  the  branches  of  work  for  which  they  are  responsi- 
ble. The  latest  disturbance  has  developed  in  France. 
Dr.  Noel  has  written  to  the  Bulletin  Medical  a  protest 
against  the  new  methods  adopted  for  the  French  med- 
ical service  of  the  army.  By  recent  orders,  control  of 
the  whole  of  the  personnel  connected  with  the  Corps  de 
SanW  has  been  turned  over  to  the  military  officers 
pro'per,  and  the  authority  is  taken  away  from  the  med- 
ical and  sanitary  officers.  Dr.  Noel  says  that  in  armies 
that  are  still  dominated  by  the  feudal  spirit,  where 
caste  sentiment  persists,  and  where  the  militant  officer 
regards  himself  as  a  superior  being,  ambulances  are 
commanded  by  cavalry  officers.  This  occurs,  for  ex- 
ample, in  Germany,  Austria,  and  Russia.  In  the  more 
modern  armies,  in  which  the  organization  is  not  modi- 
fied to  suit  this  peculiar  traditional  spirit  of  caste,  such 
is  not  the  case,  and  he  instances  the  armies  of  Italy, 
Si^'itzerland,  England,  and  Japan.  Dr.  Noel  does  not 
place  the  army  of  the  United  States  among  those  in 
which  the  feudal  spirit  has  been  extinguished,  and  he 
is,  we  presume,  justified  in  holding  such  an  opinion. 
He  protests,  in  the  strongest  terms,  against  a  rule 
which  imposes  upon  the  medical  officers  duties,  but 
does  not  give  them  the  authority  to  discharge  them. 

Strychnine  in  Pneumonia. — In  the  report  of  the 
Surgeon-General  of  the  Navy,  Commodore  J.  R.  Tryon, 
of  a  year  ago,  mention  was  made  of  the  apparently 
favorable  results  of  the  hypodermic  injection  of  strych- 
nine in  the  treatment  of  lobar  pneumonia.  In  his  re- 
port just  issued.  Dr.  Tryon  says,  that  the  favorable 
opinion  entertained  of  the  value  of  this  drug  in  the 
treatment  of  pneumonia  has  been  further  strengthened 
by  the  experience  of  its  use  during  the  past  year. 
Forty-five  cases  of  acute  lobar  pneumonia  were  treated 
in  the  Naval  Hospital  in  Brooklyn  during  the  past  two 
years,  with  but  three  deaths,  a  mortality  of  only  6.0  per 
cent. 


NEW   BOOKS   RECEIVED. 

While  the  Medical  Record  is  pleased  to  receive  all  new  puhli- 
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promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  cannot 
be  considered  under  obligation  to  notice  or  review  any  publication 
received  by  it  which  in  the  judgnunt  of  its  editor  will  not  be  of  in- 
terest to  its  readers. 

Medical  Record  Visiting  List  for  1896. 

Electro-Ther.apeutical  Practice  I'.y  Chas.  S.  Neiswan-. 
ger.  Ph.G.  i2mo.  So  pages.  Illustrated.  Published  by  E.  H. 
Colegrove  &  Co.,  Chicago,  111. 

Elementary  Technique  in  Histology  and  Bacteriology. 
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Published  by  E.  H.  Colegrove  &  Co.,  Chicago,  HI. 

A.N  Elementary  Course  in  Experimf.ntal  and  Analyti- 
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pages.  Illustrated.  Price,  $3.  Published  by  E.  H.  Colegrove 
&  Co.,  Chicago,  III. 

.•V  Manual  of  Syphilis  and  the  Venereal  Dise.ases.  By 
Drs.  James  Nevins  Hyde  and  Frank  H.  Montgomery.  i2nio, 
618  pages.  Illustrated.  Price,  .$2.50.  Published  by  W.  B. 
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Pregnancy.  L.aeor,  and  the  Puerperal  State.  By  Egbert 
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pages.  Illustrated.  Price,  $2.50  net.  Published  by  the  F.  S.. 
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The  International  Ency'CLop.bdia  of  Surgery.  A  Sys- 
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LL.D.  Illustrated  with  Chromo- Lithographs  and  Wood-Cuts.  In 
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tavo, 1082  pages.     Published  by  William  Wood  &  Co.,  New  York. 

The  Principles  .\nd  Pk.\ctice  ok  Medicine.  Designed  for 
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trated.    Published  by  D.  Appleton  &  Co.,  New  York  City. 

Materia  Medica  and  Therapeutics,  %vith  Especial  Refer- 
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paces.  Price — extra  cloth.  .*5  net  ;  sheep,  $5.75.  Published  by 
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Practical  Urinalysis  and  Urinary  Di.agnosis.  A  Manual 
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Price,  $2.75.  Published  by  P.  Blakiston,  Son  &  Co.,  Philadel- 
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2j-  61/.     Published  by  Oliver  &  Boyd,  Edinburgh,  Scotland. 

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E.  H.  Colegrove  &  Co..  Chicago,  111. 

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Medical   Record 

A  Weekly  jfouynal  of  Medicine  and  Surgery 


Vol.  48,  No.  25. 
Whole  No.  1311. 


New  York,  December  21,  1895. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©ngiual  Articles. 


A  COXTRIBUTION  TO  THE  STUDY  OF 
HEREDITARY  CEREBELLAR  AND  HERED- 
ITARY SPINAL  ATAXIA,  WITH  THE  HIS- 
TORY OF  AN  ATYPICAL  CASE  OF  THE 
FIRST- NAMED    DISEASE. 

By  JOSEPH   COLLINS,    M.D., 


'ISiriNG   PHYSICIA 


CITV   HOSPITAL  (NERVOUS  DEPARTMENT). 


During  the  past  few  years  there  have  appeared  many 
contributions  to  the  literature  of  that  constantly  in- 
creasing class,  the  family  and  hereditary  diseases  of 
the  nervous  system.  A  class  that  now  includes  Fried- 
reich's disease,  Thomsen's  disease,  hereditary  chorea, 
the  various  forms  of  familiary  and  hereditary  spinal, 
myopathic,  and  neurotic  muscular  atrophy,  hereditary 
spastic  spinal  paralysis  and  diplegias,  a  form  of  pro- 
gressive bulbar  palsy,  diabetes  mellitus,  and  perhaps 
other  diseases.  None  of  these  contributions  are  of 
greater  interest  than  those  which  have  been  grouped 
under  the  caption  of  hereditary  cerebellar  ata.\ia.  Like 
a  number  of  other  diseases  that  have  recently  been 
raised  to  a  separate  entity,  examples  of  this  family  dis- 
ease, hereditary  cerebellar  ataxia,  have  been  seen  from 
time  to  time  in  the  past,  but  they  have  been  looked 
upon  as  non-conforming  or  atypical  cases  of  hereditary 
spinal  ataxia  or  Friedreich's  disea3e,  and  as  such  have 
not  been  subjected  to  the  careful  scrutiny  and  exam- 
ination which  they  deserved. 

The  first  cases  carefully  observed  were  by  Eraser, 
who  recorded  them  in  the  Ghisgcnu  Medical  Journal, 
page  90,  1880.  On  one  of  his  cases  a  careful  autopsy 
was  made  by  the  renowned  pathologist,  Joseph  Coates. 
Fraser's  cases  are  now  considered  among  the  funda- 
mental observations  of  the  disease. 

It  was  Nonne's'  great  merit,  that  he,  finding  himself 
in  the  presence  of  three  such  cases,  all  of  the  same 
family,  recognized  the  necessity  of  separating  it  from 
hereditary  spinal  ataxia,  not  only  because  of  radical 
points  of  difference  in  its  symptomatology,  but  of  vari- 
ance in  time  of  development  and  in  the  mode  of  its 
occurrence.  An  autopsy  of  one  of  his  cases  showed 
that  this  autonomy  was  established  by  the  pathological 
findings,  which  differed  materially  from  those  constantly 
found  in  cases  of  Friedreich's  disease.  A  year  later  a 
paper  by  Sanger  Brown,-  containing  a  large  number  of 
observations  of  family  ataxia,  included  a  report  of  no 
less  than  six  cases  of  this  disease.  To  this  paper  of 
Brown  were  appended  valuable  remarks  by  Ornierod, 
of  London,  and  Bernhardt,  of  Berlin.  A  point  of  great 
value  in  these  commentaries  was  the  emphasis  both 
writers  laid  on  the  necessity  of  considering  many  ot 
Brown's  observations  as  cases  entirely  apart  from  Fried- 
reich's disease.  Since  that  time  reports  of  cases  have 
been  made  by  Klippel  and  Durante,'  by  Brissaud  and 
Londe  *  and  by  Londe  '  in  which  the  symptomatology 

'Archiv.  t  PsychiaL  u.  Nervenheilk.,  1891.  vol.  x.\ii..  p.  2^3 

»  Brain,  Part  Iviii.,  1892. 

'  Rev.  de  Mud..  October,  1892,  p.  743. 

«  Rev.  Neurologiqne,  ie9+ 

^  Ibid,,  October  i,  1894. 


has  been  so  definite  as  to  lead  observers  to  place  these 
cases  unreservedly  in  the  category  of  hereditary  cere- 
bellar ataxia. 

In  addition  to  these  a  number  of  cases  have  been  re- 
ported which  will  be  mentioned  farther  on  in  this  arti- 
cle, in  which  the  symptoms  were  intermediary  between 
hereditary  spinal  and  hereditary  cerebellar  ataxia,  or 
which  included  symptoms  outside  of  these  two  dis- 
eases. These  latter  cases  furnish  great  opportunity  for 
study,  reflection,  and  investigation. 

Two  years  after  the  publication  of  Nonne's  paper, 
Marie,  in  discussing  the  former's  cases  in  connection 
with  the  interesting  series  of  cases  reported  by  Sanger 
Brown,  and  the  cases  of  Eraser,  and  of  Klippel  and  Du- 
rante, suggested  the  name  hereditary  cerebellar  ataxia 
in  contra-distinction  to  hereditary  ataxia,  which  is  the 
name  universally  given  to  the  disease  first  described  by 
Friedreich'  in  1863.  A  name  which  is  associated  ana- 
tomically and  historically  with  lesion  in  the  spinal 
cord.  .\nd  this  for  two  reasons  :  in  the  first  place,  be- 
cause the  constant  attending  lesions  of  this  disease  are 
spinal,  and  secondly,  because  Friedreich  described,  and 
for  a  long  time  considered,  these  cases  as  anomalous 
forms  of  tabes  or  locomotor  ataxia.  And  although  the 
anatomical  investigations  of  Schultze,-  Kahler  and 
Pick,  and  others  soon  attested  the  incorrectness  of 
Friedreich's  view,  they  at  the  same  time  put  the  disease 
on  a  firm  anatomical  basis. 

The  name  hereditary  cerebellar  ataxia,  its  sponsor 
considered,  would  not  only  indicate  the  important  clini- 
cal manifestation,  the  ataxia,  but  would  impress  the 
kind  of  ataxia,  viz.,  cerebellar,  while  it  would  also 
suggest  the  sine  ijua  non  of  its  genesis :  heredity. 
Furthermore,  it  was  suggested  by  the  fact  that  in  the 
cases  of  this  disease  that  had  come  to  autopsy  the  most 
manifest  lesion  was  in  the  cerebellum.  Although  Ma- 
rie's designation  is  a  satisfactory  one  thus  far,  it  should 
not  necessarily  be  considered  a  permanent  one,  as  there 
have  already  appeared  observations  to  show  that  a 
strikingly  similar  condition  (if  not  quite  the  same)  may 
develop  without  any  hereditary  antecedents  or  conse- 
quences. 

These  cases  will  be  referred  to  later.  In  fact  it 
is  probable  that  heredity,  in  the  proper  and  literal  in- 
terpretation of  the  term,  is  not  an  absolutely  neces- 
sary antecedent.  If  it  be  granted  that  the  case  re- 
ported herewith  is  an  example  of  this  disease  (an 
atypical  e.xample),  the  occurrence  of  the  disease  with- 
out defective  heritage  must  likewise  be  admitted.  That 
is,  no  such  or  analogous  condition  existed  in  the  im- 
mediate antecedents  extending  back  as  far  as  the  grand- 
parents. That  it  is  a  family  disease,  however,  is  indi- 
cated by  the  occurrence  of  it  in  all  the  children  of  the 
family,  viz.,  two.  . 

It  does  not  seem  necessary  to  dwell  on  the  distmc- 
tion  between  familiary  and  hereditary  diseases.  That 
a  disease  may  occur  in  a  family  without  being  in  the 
strict  sense  hereditary,  must  be  conceded.  It  is  be- 
lieved to  have  been  proven  that  the  germ  plasm  may 
be  defecrive  in  its  primary  constituent,  or  during  its 
development,  without  the  source  of  its  origin  being  dis- 
eased. 

The  name  hereditary  cerebellar  ataxia  is  applied, 
therefore,  to  a  class  of  diseases  in  which  heredity  is  the 

I  Virchows  Archiv,  vol.  lutvi.,  p.  408. 
'Ibid.,  vol.  Ixviii.,  1887. 


866 


MEDICAL    RECORD. 


[December  21,  1895 


g  enetic  factor,  ataxia  the  clinical,  and  the  cerebellum  the 
seat  of  the  most  important  pathological  change.  The 
n  ame  is  the  same  as  that  given  to  Friedreich's  disease 
(  hereditary  ataxia)  with  the  interposition  of  the  word 
c  erebellar.  The  latter,  indeed,  may  be  called  heredi- 
t  ary  spinal  ataxia,  the  former  hereditary  cerebellar 
a  taxia,  while  those  cases  which  conform  to  neither  type, 
th  e  cases  described  by  Nonne  as  transition  forms,  and 
with  which  the  cases  of  Menzel,  Erb,  and  my  own 
m  ay  be  reckoned,  may  be  considered  as  cerebello- 
spinal hereditary  ataxia,  or  hereditary  cerebro-spinal 
ataxia.  The  latter  name  especially  when  psychical  and 
other  symptoms  pointing  to  cerebral  defect  are  promi- 
nent. 

It  is  more  than  probable  that  such  cases  will  be 
fo  und  to  exist  and  Nonne's  recent  contribution,'  in 
which  he  describes  six  cases,  would  seem  to  point  in 
this  direction.  Hereditary  cerebellar  ataxia  differs  from 
he  reditary  spinal  ataxia  not  only  in  its  symptomatology, 
but  in  its  etiology  and  course.  The  former  seems  to  de- 
velop in  the  period  extending  from  late  youth  up  to  ma- 
turity, although  it  may  develop  in  earliest  infancy."  In 
this  it  differs  very  materially  from  the  spinal  form  in 
which  the  great  majority  of  the  cases  develop  during  the 
cycle  between  childhood  and  adolescence.  That  the 
former  may  develop  in  infancy  is  shown  by  Eraser's 
cases,  in  which  the  disease  began  in  the  third  or  fourth 
year.  As  Eraser's  cases  were  the  first  on  record  and  with 
autopsy,  this  fact  is  important.  So  far  as  any  conclu- 
sions may  be  drawn  from  the  small  number  of  cases 
published,  it  would  seem  that  the  former  had  been  ob- 
served oftener  in  males  than  in  females,  the  proportion 
being  relatively  similar  to  that  of  hereditary  spinal 
ataxia.  This  is  in  keeping  with  a  fact  which  is  gener- 
ally conceded,  that  in  all  of  the  family  and  hereditary 
diseases  of  the  nervous  system  males  are  more  fre- 
quently affected  than  the  opposite  sex.  As  in  heredi- 
tary spinal  ataxia  the  familiary  or  hereditary  element 
is  all  that  we  can  find  bearing  on  the  occurrence  of  the 
disease. 

Like  in  a  great  many  other  protal  or  teratological 
diseases,  an  antecedent  or  coincident  history  of  tuber- 
cle may  be  discovered  in  the  family.  This  can  have 
no  other  significance  than  a  general  one,  viz.,  the  prev- 
alence of  this  infectious  disease  and  the  greater  vul- 
nerability of  those  handicapped  by  inheritancy  or  by 
acquisition.  The  fact  that  a  tubercular  history  has 
been  found  relatively  more  frequently  in  the  ante- 
cedents of  hereditary  cerebellar  ataxia  than  in  he- 
reditary spinal,  is  in  keeping  with  the  universal  knowl- 
edge that  tuberculosis  is  much  more  common  during 
the  epoch  when  the  former  occurs  than  it  is  with  the 
latter. 

Factors  which  may  be  considered  incidental  have 
been  remarked  by  some  reporters,  such  as  psychical 
trauma  (Nonne),  the  occurrence  of  infectious  disease 
(Londe,  Marie),  etc.  Naturally,  such  conditions  may 
precipitate  or  aggravate  incipient  symptoms  so  as  to 
render  those  previously  unnoticed  quite  perceptible. 

In  none  of  the  cases  reported  thus  far  has  parental 
syphilis  played  any  part.  The  entailment  of  neurotic 
inebriety  has,  however,  been  noticed  as  it  has  in  heredi- 
tary spinal  ataxia. 

The  etiology  of  hereditary  spinal  ataxia  is  practi- 
cally similar  to  this,  with  the  exception  that  direct  in- 
heritance has  been  traced  only  in  a  few  instances,  while 
the  familiary  occurrence  of  the  disease  is  rarely,  if  ever, 
absent.  Moreover,  it  is  supposed  by  many  to  be  not 
only  familiary,  but  congenital.  Nevertheless,  Fried- 
reich himself,  and  recently  Schultze,'''  have  stated  that 
the  familiary  character  may  be  absent. 

T^e  difference  in  the  symptomatology  of  the  two 
diseases  is  set  forth  in  the  following  parallel  col- 
umns : 

'  Archiv.  f.  Psychiat. ,  etc.,  vol.  xxvii.,  part  2,  p.  479. 
^  Resold:  Zeitschr.  f.  Nervenheilk. ,  vol.  v.,  pp.  2  and  3. 
'  Zeitschr.  f.  Nervenheilk.,  vol.  v.,  parts  i  and  2. 


Hereditarv    Cerebellar 
Ataxia. 

1.  Gait  :  Uncertain,  reeling  ; 
gait  of  one  inebriated.  Patient 
frequently  walks  with  body  bent 
forward  and  the  head  tlirown 
backward,  and  the  feet  wide 
apart. 

Does  not  have  to  watch  the 
feet.     Feet  wide  apart. 

2.  Station  :  Romberg  symp- 
tom absent. 

3.  Titubation  and  inco-ordi- 
natioii  and  loss  of  dexterity  in 
the  upper  extremities.  Chorei- 
form movements  exaggerated  on 
voluntary  effort ;  "  intentional." 

4.  Not  infrequently  oscilla- 
tions or  jerky  movements  of  the 
head,  less  often  of  the  trunk. 

5.  Exaggerated  contraction  of 
the  mimetic  muscles  on  speak- 
ing. 

6.  Ataxia  is  very  muchjless,  or 
disappears  when  the  patient  is 
lying,  but  the  inco- ordination 
persists. 

7.  Speech:  Hesitating, 
abrupt,  explosive,  ataxic,  de- 
fective. 


8.  Eyes  :  Twitching  of  the 
eyeballs  very  common,  but  not 
nystagmus.  Optic  atrophy,  pro- 
gressive choroiditis,  paralysis  or 
paresis  of  the  external  recti 
sometimes. 

9.  Myotatic  irritability  in- 
creased ;  reflexes  exaggerated, 
such  as  knee-jerks  ;  often  ankle 
clonus. 

10.  Mental  shortcomings  vary- 
ing from  slight  psychical  dis- 
turbances up  to  a  consider.able 
degree  of  dementia. 

11.  Deformities  of  the  ex- 
tremities and  spine,  such  as  pied 
bot  or  scoliosis,  do  not  occur  or 
are  most  rare. 


Hereditary   Spinal  Ataxia. 

1.  Gradual  impairment  of  co- 
ordination, first  in  legs,  after- 
ward in  arms.  Later  in  the  dis- 
ease the  patient  may  reel  as  if 
under  the  influence  of  alcohol. 

A  quick  backward  and  for- 
ward balancing  movement. 

2.  Station  :  Closure  of  eyes, 
as  a  rule,  increases  the  unsteadi- 
ness ;  this  may  be  absent. 

3.  Titubation  of  upper  ex- 
tremities very  uncommon.  Ir- 
regularity in  voluntar)'  move- 
ments of  arms  and  fingers. 

4.  Frequently  jerky,  irregular 
movements  of  head  and  neck. 
Sometimes  like  an  irregular  tre- 
mor. 

5.  Mimetic  muscles  do  not 
show  ordinarily  over]-  contrac- 
tion. 

6.  Ataxia  is  not  so  great  when 
the  patient  is  lying. 


7.  Affection  of  speech  may  be 
absent ;  when  it  does  occur  is  a 
late  symptom,  and  consists  of  an 
eliding  of  syllables  and  an  occa- 
sional hesitation. 

8.  Nystagmus  is  a  very  com- 
mon symptom,  but  it  may  be 
lacking. 


9.  Myotatic  irritability  is  lost. 
Knee-jerks  may  be  present  in 
the  beginning  of  the  disease,  but 
they  soon  disappear.  Ankle 
clonus  is  never  present. 

10.  Mentally,  normal.  Very 
rarely  any  defect. 

11.  Deformities  of  the  ex- 
tremities such  as  pied  bot  and 
spinal  curvature,  very  common.  . 


These  are  the  principal  symptoms  of  these  two  fa- 
miliary diseases.  There  are  additional  symptoms,  but 
they  do  not  occur  with  sufficient  regularity  to  justify 
considering  them  a  part  of  the  clinical  picture.  It  will 
be  seen  that,  even  in  parallel  columns,  the  symptoma- 
tology of  the  two  diseases  does  not  appear  to  be  so  radi- 
cally different.  This  will  convey  some  idea  of  how 
similar  some  of  the  cases  seem  in  reality.  They  are 
both  family  and  progressive  diseases.  There  is  prac- 
tically the  same  titubation  in  the  gait,  the  same  insta- 
bility, and  the  same  loss  of  co-ordination  and  choreic 
movements  of  the  hands,  and  perhaps,  also,  of  the 
face.  The  appearance  of  the  face  both  when  in  repose 
and  on  speaking  furnished  a  minor  point  of  difference  : 
in  hereditary  cerebellar  ataxia  there  is  a  look  of  aston- 
ishment habitual  to  the  features,  and  over-action  of  the 
mimetic  muscles  when  the  patient  speaks  or  betrays 
emotion.  This  has  not  been  considered  a  phenome- 
non of  Friedreich's  disease. 

It  is  in  the  condition  of  the  deep  reflexes  that 
these  two  diseases  differ  materially.  In  the  former 
they  are  always  present  and  frequently  exaggerated  ; 
in  the  latter  they  are  often  absent,  at  least  after  the  dis- 
ease is  de^-eloped,  and  no  typical  case  has  been  record- 
ed in  which  they  were  found  increased.  The  presence 
of  even  the  slightest  clonus  of  the  foot  indicates  a  spas- 
tic condition  to  which  the  anatomical  conditions  exist- 
ing in  Friedreich's  disease  are  inimical.  To  show  the 
great  importance  that  is  attached  to  the  state  of  the 
tendon  reflexes  as  a  diagnostic  factor,  it  may  be  per- 
mitted to  quote  from  Brissaud,  who,  lecturing  on  a  pa- 
tient with  hereditary  cerebellar  ataxia  (in  whom  there 


December  21,  1895] 


MEDICAL    RECORD. 


867 


•were  no  visual  troubles  and  the  presence  of  scoliosis), 
said,  "  En  somme,  si  j'ai  elimine  la  Maladie  de  Fried- 
reich, c'est  pour  la  seule  raison  que  les  reflexes  rotu- 
liens  sont  exageres." 

The  remaining  symptomatology  in  which  they  differ 
materially  are  the  ocular  and  the  mental  conditions. 
Whereas  such  ocular  symptoms  as  diplopia,  dischro- 
matopsia,  achromatopsia,  contraction  of  the  visual  field, 
and  loss  of  light  and  accommodative  reaction,  all  point- 
ing to  optic  nerve  lesion,  have  been  found  in  several  cases 
of  hereditary  cerebellar  ataxia,  these  are  most  uncom- 
mon manifestations  in  hereditary  spinal  ataxia.  In  fact, 
it  must  be  said  that,  whereas  cases  of  the  latter  disease 
have  been  reported  in  which  there  has  been  diplopia 
and  loss  of  light  reflex,  optic  atrophy  never  occurs. 

Cases  of  hereditary  cerebellar  ataxia  in  which  there 
has  been  no  real  involvement  of  the  optic  nerve  have 
been  reported,  so  that,  although  it  constitutes  a  very 
important  line  of  demarcation  between  cerebellar  and 
spinal  ataxia,  its  absence  should  not  convey  the  non- 
existence of  the  former  disease.  Marie,  and  following 
him  Brissaud,'  have  both  laid  undue  stress  on  the  eye- 
symptoms  in  hereditary  cerebellar  ataxia,  the  former 
going  so  far  as  to  say  that  if  the  eye-symptoms  are  lack- 
ing the  diagnosis  cannot  be  made  with  certainty. 

Londe,  whose  monograph  on  the  subject  aims  to  en- 
compass all  that  has  been  written  on  the  subject  of 
hereditary  cerebellar  ataxia  up  to  the  date  of  its  publi- 
cation, emphasizes  the  belief  that  visual  disturbances, 
ocular,  motor,  or  sensory,  which  Marie  considers  pa- 
thognomonic, do  not  constitute  an  essential  feature  of 
the  disease,  and  that  in  typical  cases  the  symptom  pict- 
ure may  be  reduced  to  its  simplest  expression  :  gen- 
eral inco-ordination,  with  conservation  or  exaggeration 
of  the  tendon  reflexes. 

A  careful  examination  of  the  records  of  the  reported 
cases  shows  that  in  some  there  were  no  ocular  symp- 
toms, and  in  others  very  slight  departures  from  the  nor- 
mal.'^ Brissaud  proposes  to  call  these  cases  in  which  oc- 
ular symptoms  are  wanting,  varietes  frustes  of  hereditary 
cerebellar  ataxia.  We  do  not  admit  the  necessity  or 
propriety  of  such  subdivision. 

The  history  of  the  case  which  I  wish  to  communi- 
cate is  as  follows  :  A  boy  eleven  years  of  age,  of  mixed 
English  and  Irish  parentage.  The  parents  are  living 
and  in  good  health.  There  is  no  history  or  manifes- 
tation of  syphilis  in  either  parent.  No  disease  like 
the  one  from  which  the  child  is  suffering,  nor  any 
symptom  complex  resembling  it,  can  be  traced  in  any 
of  the  ancestry.  His  paternal  grandfather  and  grand- 
mother both  died  of  consumption.  Five  paternal  aunts 
died  in  childhood,  all  with  some  tubercular  manifesta- 
tions, and  his  only  paternal  uncle  has  hip  (tubercular?) 
disease.  Thus  it  will  be  seen  that  there  is  a  most  pro- 
nounced tendency  to  the  transmission  of  a  constitu- 
tional condition  favorable  to  tuberculosis.  There  is 
no  history  of  defective  mental  or  physical  development, 
or  the  possession  of  morbid  atavistic  traits  in  any  of 
the  patient's  immediate  family.  He  is  the  second  of 
two  children.  The  fact  that  the  mother  has  not  con- 
ceived in  the  past  eleven  years,  although  she  and  her 
husband  are  apparently  normal  and  vigorous,  indicates 
relative  unfecundity  which  bespeaks  degeneration. 
The  child  born  previous  to  the  patient  was  a  girl,  who 
died  at  the  end  of  her  second  year.  The  parents  say 
that  she  had  a  "  sort  of  a  paralysis,"  that  her  eyes 
"danced  "  continually,  that  she  was  very  "backward," 
never  having  learned  to  say  words,  to  walk,  or  to  use 
her  hands.  She  had  two  or  three  attacks  of  convul- 
sions, and  finally  died  during  an  attack.  The  child 
did  not  look  natural,  the  back  of  the  head  was  flat  and 
the  forehead  was  bulging.  This  is  ([uoted  practically 
verbatim  from  the  account  given  by  the  mother,  and 
can  be  taken,  I  believe,  to  mean  that  the  first  child  was 
defective  in  a  way  similar  to  the  patient  here  described, 

'  Lemons.  Salpetriere.  1893-94. 

'•'  Oulmont :  Mereredi  Med.,  No.  9,  1895. 


only  that  the  defect  was  greater  and  showed  itself 
earlier.  The  "  sort  of  a  paralysis  "  spoken  of  by  the 
mother  was  in  all  probability  extreme  inco-ordination 
of  the  extremities,  which  prevented  it  from  learning  to 
creep,  to  walk,  or  to  use  its  hands.  The  fact  that  the 
child  could  move  all  four  extremities  speaks  in  favor 
of  this  view  and  against  the  supposition  of  any  real 
paralysis.  The  "  dancing  "  of  the  eyes  indicates  that 
nystagmus  was  very  marked,  just  as  the  "  backward- 
ness "  implies  defective  mentality. 

Between  the  first  and  second  pregnancies  there  was 
a  space  of  two  years.  The  pregnancy  with  the  present 
patient  terminated  with  a  normal  delivery.  The  child 
never  had  spasms  ;  the  teeth  began  to  appear  at  the 
proper  time,  and  when  he  was  a  year  old  he  began  to 
walk.  The  mother  says  that  he  began  to  walk  and 
talk  at  about  the  customary  time.  Since  his  third  or 
fourth  year  it  has  been  remarked  that  he  was  "  stiff  in 
his  joints,"  that  he  took  "short  steps"  and  was  "contin- 
ually tumbling  ;  "  "'but  he  was  always  a  great  runner  and 
walker,"  but  was  not  able  to  climb  like  other  boys. 
When  he  was  four  years  of  age  it  was  noticed  that  he 
was  short-sighted,  a  condition  which  was  on  the  in- 
crease, and  since  then  he  has  worn  glasses.  He  has 
had  measles,  pertussis,  and  scarlatina,  all  in  a  very 
temperate  form  and  without  the  slightest  after-effect 
from  any  of  them.  When  he  was  five  years  of  age  he 
began  going  to  school,  but  in  the  following  six  years 
he  has  not  been  able  to  progress  beyond  the  grade  in 
which  he  started,  except  after  the  first  two  years  he  was 
once  promoted,  but  later  he  had  to  be  put  back,  and 
now  at  eleven  years  he  is  still  in  the  baby  class,  or 
was  until  a  short  time  ago,  when  he  was  returned  with 
the  advice  that  it  was  impossible  to  make  any  progress 
with  him. 

In  April,  1894,  in  his  tenth  year,  the  mother  says  he 
had  an  attack  in  which  he  was  unable  to  use  the  left 
side  of  the  body.  Although  he  could  move  the  ex- 
tremities, the  left  arm  and  leg  were  very  clumsy  and 
the  hand  lost  all  its  dexterity.  At  this  time  speech 
was  very  indistinct.  This  seeming  exacerbation  of  in- 
co-ordination has  recurred  a  few  times  since  then,  two 
or  three  times  under  my  own  observation  ;  sometimes 
on  one  side,  sometimes  on  the  other,  but  more  fre- 
quently on  the  left.  And  more  than  once  has  it  been 
diagnosticated  as  St.  Vitus's  dance.  The  hands  and 
fingers  are  often  blue  and  extremely  cold,  and  slight 
depressions  of  temperature  make  him  very  cold.  It  is 
quite  impossible  to  keep  him  warm  in  winter.  He 
complains  of  general  fatigue,  and  of  numbness  and 
occasional  cramps  in  legs ;  but  not  of  pain.  About  a 
year  ago,  after  having  returned  from  a  walk  with  his 
father,  he  felt  ill  and  vomited  a  great  amount  of  clotted 
blood.  The  hcematemesis  continued  for  three  or  four 
days.  Some  months  ago  he  had  a  fall  from  a  flight  of 
steps  and  since  then  they  think  he  is  worse. 

Examination.  —  A  moderately  tall,  anaemic  boy. 
Face  has  an  aged,  astonished,  or  frowning  appearance 
which  is  heightened  by  the  powerful  convex  lenses 
which  he  wears.  Face  looks  somewhat  asymmetrical, 
the  right  side  being  slightly  more  innervated  than  the 
left.  Under  the  influence  of  the  emotions,  particularly 
those  of  depression,  there  is  over-activity  of  the  mi- 
metic muscles,  the  face  becomes  a  mass  of  wrinkles 
and  takes  on  an  elf-like  expression. 

He  stands  with  the  body  bent  forward  and  the  chin 
pushed  out,  and  with  the  feet  wide  apart.  Station  is 
quite  as  well  preserved  with  the  eyes  closed  as  open. 
No  Romberg.  The  gait  is  shambling,  uncertain,  titu- 
bating. This  is  most  conspicuous  when  he  endeavors 
to  walk  within  a  narrow  space  or  to  avoid  successive 
obstacles.  He  falls  with  the  greatest  readiness.  Lack 
of  co-ordination  is  very  manifest  on  attempts  at  pur- 
posive movements  with  the  hands,  worse  with  the  left ; 
while  with  the  right  hand  there  is  a  great  deal  of  titu- 
bation.  When  he  attempts  movements  requiring  some 
dexterity,  such  as  picking  up  successively  a  number  of 


868 


MEDICAL    RECORD. 


[December  21,  1895 


coins  and  retaining  them  in  the  hand,  grasping  and 
holding  a  pencil  to  write,  etc.,  clumsiness  and  inco- 
ordination are  particularly  manifest,  while  the  ataxia 
of  the  upper  extremities  is  seen  distinctly  when  he  puts 
the  tip  of  the  finger  on  the  apex  of  the  nose.  This  is 
more  marked  with  the  left  hand  than  the  right.  De- 
fective co-ordination  of  the  lower  extremities  is  seen 


Fig.  I. — Facial  Expression. 

best  when  he  attempts  to  go  upstairs,  to  run,  and  to 
step  over  anything.  When  he  lies  on  his  back  pur- 
posive movements  with  the  lower  extremities  are  much 
more  accurate.  The  tendon  reflexes  are  all  more 
active  than  normal.  The  knee-jerks  are  exaggerated 
and  there  is  varying  ankle  clonus  on  both  sides  ;  some- 
times this  latter  is  well  marked,  while  at  other  times 
it  cannot  be  brought  out.  The  triceps  reflex  is  lively, 
and  muscular  contraction  to  mechanical  stimulus  is  pro- 
nounced, such  as  is  obtained  by  tapping  the  exten- 
sors of  the  forearm.  The  lower  extremities  resist  some- 
what passive  motion.  There  seems  to  be  an  inability 
on  the  part  of  the  patient  to  relax  the  contraction  of  the 
muscles,  which  gives  an  impression  of  passive  rigidity. 
Then  the  contraction  will  disappear.  So  it  cannot  be 
said  that  there  is  real  spasticity.  The  muscular  strength 
of  the  upper  extremities  is  very  considerably  dimin- 
ished, especially  the  extensors,  and  the  grip  of  the  hands 
is  very  slight,  he  being  scarcely  able  to  make  the  dyna- 
mometer register.  The  muscles  of  the  back  and  thighs 
are  also  weak,  and  this  is  strikingly  manifest  when  he 
attempts  to  rise  from  the  completely  prone  posture. 
He  gets  up  very  like  a  patient  with  dystrophy  of  the 
pseudo-hypertrophic  type,  except  that  the  crawling  up 
the  thighs  and  trunk  is  not  so  pronounced.  The  mus- 
cles feel  flabby  and  pultaceous  ;  when  the  tissues  on  the 
back  of  the  forearm  are  pinched  up  there  is  none  of 
that  characteristic  muscular  resistance,  and  the  mass 
lifted  up  is  perfectly  translucent,  yet  the  contour  of  the 
extremities  is  well  rounded,  and  there  is  no  atrophy  of 
individual  parts  of  the  body. 

Careful  examination  of  the  sensory  sphere  fails  to 
reveal  any  constant  deviation  from  normal.  The 
mother  says  that  sometimes  in  the  morning  he  com- 
plains of  headache,  and  is  excessively  sensitive  to  touch 
on  being  handled  or  rubbed,  but  it  has  been  impossible 
for  me  to  corroborate  this.  There  is  no  vesical  weak- 
ness, and  aside  from  slight  constipation  the  bowels  are 
normal.  Muscle  sense  intact.  The  disturbance  of 
speech  is  most  striking,  but  a  somewhat  diflicult  one 
to  describe.  The  sound  is  abrupt  and  the  articula- 
tion defective.     The  Unguals  and  labials  are  often  not 


sufficiently  constructed  to  be  recognizable.  When  he 
attempts  long  words  or  tries  to  say  several  words,  one 
after  the  other,  they  get  jumbled  up  and  it  is  quite  im- 
possible to  recognize  the  words.  There  is  none  of  the 
scanning  of  multiple  sclerosis,  but  rather  abrupt,  forci- 
ble ejaculation  attended  by  very  perceptible  effort  of 
the  muscles  of  expression.  "  Explosiveness,"  ''  abrupt- 
ness," and  ataxia  are  the  three  prominent  character- 
istics. 

Examination  of  the  eyes  reveals  a  paleness  of  the 
disk  which  Dr.  W.  A.  Holden,  who  examined  the  eyes, 
considers  to  be  within  physiological  conditions,  and 
slowly  progressing  choroiditis.  It  is  difficult  to  speak 
positively  as  to  whether  there  is  dyschromatopsia  or 
not,  but  it  is  certain  that  there  is  no  achromatopsia. 
The  pupils  are  wide,  alike  on  both  sides,  and  respond 
slowly  to  light  and  accommodation.  There  is  a  pro- 
gressive myopia.  Forcible  side  to  side  movements  of 
the  eyeballs  are  accompanied  by  slight  jerky  move- 
ments which  are  not  sufficiently  rhythmical  to  be  des- 
ignated nystagmus.  The  movements  of  the  eyeballs 
are  free  in  every  direction,  but  outward  rotation  is 
much  less  vigorous  and  complete  than  it  is  normally. 
There  would  seem  to  be  no  defect  in  the  function  of 
the  other  cranial  nerves  except  the  asymmetry  of  the 
face,  which  has  already  been  mentioned,  the  exagger- 
ated condition  on  display  of  the  emotions,  and  the 
fact  that  he  cannot  whistle.  This  last  does  not  seem 
to  be  due  to  inability  to  pucker  the  lips,  for  that  he 
can  do,  but  to  the  lack  of  reciprocal  action  between 
the  muscles  of  the  lips,  the  cheeks,  and  the  respiratory 
muscles.  It  is  also  worthy  of  remark  that  until  a  year 
or  two  ago  he  could  whistle.  There  is  an  irregular 
tremor  of  the  tongue.  Senses  of  smell,  taste,  and  hear- 
ing are  apparently  intact. 

As  has  been  said  before,  he  is  deficient  mentally,  but 
he  is  not  demented  nor  idiotic  by  any  means.  He 
would  seem  to  have  receptive  faculties  and  a  consider- 
able capacity  for  memory  ;  but  in  power  or  process  of 
association  he  would  seem  to  be  entirely  lacking.  He 
has  rational  likes  and  dislikes,  and  has,  apparently, 
ideas  of  right,  of  wrong,  of  possession,  etc.  He  an- 
swers questions  rationally,  and  also  asks  questions  be- 
coming a  child  of  much  fewer  years.  Yet,  withal,  he 
has  never  been  able  to  put  letters  together  so  as  to 
form  words,  nor  to  develop  sufficient  faculties  to  write 
simple  sentences,  although  he  could  write  his  name. 
He  has  a  bad  temper,  is  easily  provoked,  does  not  like 
to  be  contradicted,  and  can  be  led  more  easily  than 
dominated.  He  has  no  capacity  for  attention.  One 
may  try  in  the  most  forcible  and  praiseworthy  manner 
to  hold  his  attention,  but  after  holding  it  for  a  moment 
it  flits.     There  are  no  objective  sensory  troubles. 

The  genital  organs  are  extremely  undeveloped,  the 
penis  like  an  infant's,  and  only  one  testicle  can  be  felt. 
The  skin  is  dry,  the  hair  falls  out  more  than  normally, 
and  it  is  said  that  he  does  not  perspire.  He  becomes 
fatigued  rather  easily,  and  oftentimes  he  is  very  drowsy 
and  will  sleep  in  the  day.  There  is  a  deformity  of  the 
right  foot,  a  typical  so-called  pied-bot,  which  is  shown 
in  the  accompanying  illustration.  This  deformity  has 
not  yet  been  noticed  by  the  parents,  nor  is  it  to  be  re- 
marked in  the  patient's  gait.  The  shoes  that  he  wears 
are  of  a  pair. 

The  course  of  the  disease  has  been  a  progressive  one 
even  since  the  patient  has  been  under  my  observation. 
The  fact  that  when  the  parents  first  brought  him  for 
treatment  it  was  stated  that  symptoms  dated  from  the 
fall  already  mentioned,  may  be  taken  as  evidence  that 
the  disease  has  made  a  considerable  progress  in  that 
time.  It  is  unnecessary,  probably,  to  add  that  fall  was 
incidental  to  the  disease,  and  not  rite  zersd.  The  de- 
fective formation  of  bodily  heat  ;  the  consequent  de- 
pressed vitality  ;  the  increasing  inco  ordination  of  gait, 
of  movements,  of  speech  ;  the  retrogression  of  mental 
acquisition  ;  the  increasing  loss  of  muscular  strength, 
all  so  to  show  that  the  anatomical  conditions  at  the 


December  21,  if^95] 


MEDICAL   RECORD. 


869 


bottom  of  his  disease  are  not  only  preventing  anything 
like  normal  somatic  and  mental  development  as  had  gone 
on  up  until  three  or  four  years  ago,  but  that  there  is  an 
actual  retrograde  process  at  work.  The  muscles  re- 
spond to  the  galvanic  and  faradic  current,  sluggishly 
of  course,  considering  the  pronounced  lack  of  develop- 
ment, especially  of  the  extensors,  and  there  is  normal 


conditions  which  are  found  so  frequently  in  hereditarj' 
spinal  ataxia  as  to  be  considered  of  considerable  diag- 
nostic importance.  Such  is  the  pied-bot,  a  form  of 
talipes  dependent  upon  defective  action,  paresis,  and 
subsequent  contracture  in  the  peroneal  group  of  mus- 
cles. It  is  more  than  probable,  however,  that  a  history 
of  this  deformity  will  be  found  in  subsequent  reports  of 


polar  relationships.  Faradic  irritability  of  some  of  the 
nerves,  notably  the  musculo-spiral,  is  diminished. 

To  recapitulate  briefly  the  salient  points  of  this  case  : 
I.  .\bsence  of  direct  hereditary  transmission.  Evidence 
of  its  being  familiary,  a  sister,  in  all  probability,  suffered 
from  the  same  disease.  2.  Onset  in  early  childhood. 
The  accompanying  photograph  is  evidence  that  in  in- 
fancy the  child  was  free  from  the  manifestations  of  the 
disease.  3.  Disturbance  of  co-ordination  manifested  in 
all  four  extremities.  Titubation  of  the  hands  and  feet. 
4.  Gait:  feet  wide  apart,  reeling,  incoordinate.  5.  In- 
creased tendon  reflexes  ;  exaggerated  knee-jerks  and 
ankle  clonus.  6.  Marked  disturbance  of  speech,  ex- 
plosive, inco-ordinate  ;  articulation  very  defective.  7. 
Profound  deviation  of  intellect  ;  associative  faculties 
lacking  ;  defective  in  attention.  8.  Absence  of  sensory 
disturbance  and  intactness  of  the  sphincters.  9.  Pro- 
gressive loss  of  muscular  strength  and  tonus.  10. 
Shrivelled  appearance  of  skin,  lack  of  perspiration, 
senile,  position  of  body  and  staring  expression  of  coun- 
tenance. 

Thus  it  will  be  seen  that  in  some  points  it  differs 
very  radically  from  hereditary  spinal  ataxia  or  Fried- 
reich's disease,  combined  lateral  and  posterior  sclerosis  ; 
while  other  of  its  s)Tnptoms  point  in  no  uncertain  way 
to  this  disease.  But  the  fact  is  that  the  case  presents 
characteristics  directly  inimical  to  the  postulated  patho- 
logical condition  of  this  disease.  In  brief  these  con- 
tradictory symptoms  are  :  i.  The  exaggerated  tendon 
reflexes,  knee  jerks,  and  ankle  clonus.  In  Friedreich's 
disease  the  tendon  reflexes  are  diminished  or  absent, 
particularly  after  the  disease  has  been  absent  for  some 
time.  A  case  in  which  ankle  clonus  was  an  accompani- 
ment has  never  been  described.  2.  The  absence  of 
nystagmus.    3.  The  striking  defect  of  the  mind. 

The  extremely  early  onset  (Friedreich's  disease 
comes  on  generally  between  the  tenth  and  fifteenth 
years),  the  absence  of  sensory  symptoms,  the  intensity 
of  inco-ordination  in  the  upper  extremities,  and  the  tit- 
ubation are  likewise  uncommon  concomitants  of  Fried- 
reich's disease. 

On  the  other  hand,  this  patient  shows  symptoms  and 


cases  of  hereditar)-  cerebellar  ataxia,  as  Erb  has  already 
observed  it  in  two  atypical  cases.' 

In  regard  to  the  musculature  this  patient  would  seem 
to  differ  from  cases  of  either  hereditary  spinal  ataxia  or 
hereditary  cerebellar  ataxia.  In  the  former  muscular 
power  is  usually  normal,  even  after  the  ataxia  has  be- 


come well  pronounced,  and  although  it  sometimes  be- 
comes impaired  in  the  course  of  the  disease,  the  flexors 
suffer  more  than  the  extensors.     Wasting  of  the  mus- 

'  Neurologisches  Cenrralb..  1890,  p.  37S. 


870 


MEDICAL   RECORD. 


[December  21,  1895 


cles  is  very  slight.'  In  the  latter  disease  Londe,-  in  his 
analysis  of  all  the  cases  on  record,  reached  the  con- 
clusion that  the  subjective  sensation  of  fatigue  and 
feebleness  of  muscular  force  is  but  slightly  diminished  ; 
and  when  it  is  diminished  it  is  but  the  consequence  of 
hospitalization  and  prolonged  inability  to  give  the  mus- 
cles their  proper  stimulation.  Nevertheless,  in  Menzel's 
cise  (a  so-called  intermediary  case)  there  was  remark- 
able diminution  of  muscular  force  in  the  upper  e.xtremi- 
ties.  The  deficiencies  of  musculature  which  are  so 
striking  in  mj'  case  cannot  be  attributed  to  the  above- 
mentioned  factors.  To  my  mind  they  should  be  re- 
ferred to  defective  formation  either  in  the  primary 
constituent  of  the  muscle  fibre,  or  of  later  origin.  I 
shall  return  to  a  discussion  of  this  later. 

On  the  other  hand,  it  differs  from  the  cases  described 
by  Xonne,  Brown,  }!rissaud  and  I.onde,  Marie,  eta!., 
which  have  been  grouped  under  the  title  of  hereditary 
cerebellar  ataxia,  in  that  there  is  absence  of  direct 
hereditary  transmission,  as  well  as  by  the  early  mani- 
festation of  the  disease.  In  these  latter  cases  many  of 
them  manifested  the  symptoms  first  some  time  after 
puberty.  And  as  has  been  previously  mentioned,  optic 
atrophy  was  a  frequent  accompaniment.  Yet  it  should 
be  conspicuously  mentioned  that  in  the  first  authenti- 
cated case  on  record,  Eraser's  first  observation,  the  dis- 
ease began  gradually  at  about  the  fourth  year.  When 
the  patient  was  seven  years  of  age  the  staggering  had 
become  very  persistent,  and  he  was  obliged  to  leave 
school.  In  this  case,  moreover,  the  opthalmoscope 
showed  conditions  very  subject  to  the  personal  element 
of  the  observer  :  pale  papillae,  irregularity  of  their  con- 
tour with  venous  congestion  in  certain  points  :  arteries 
contracted.  Muddy  and  opaque  aspect  of  the  choroid. 
Except  in  the  absence  of  oscillations  of  the  head  and 
the  mental  defect,  the  case  herewith  reported  resembles 
very  closely  the  case  of  Eraser. 

There  have  been  a  number  of  cases  of  familiary 
ataxia  described,  notably  one  by  Menzel,'  another  by 
SeeligmuUer,''  and  two  by  Erb,'  to  which  this  case  has 
some  resemblance.  These  cases  have  been  referred  to 
bv  Nonne  and  others  as  transition  cases  between 
Friedreich's  disease  and  hereditary  cerebellar  ataxia. 

In  Menzel's  case  the  disease  began  when  the  patient 
was  thirty  years  of  age.  Of  six  brothers  and  sisters, 
three  were  affected  similarly  to  the  patient.  The 
prominent  symptoms  were  ataxia  of  the  four  extremi- 
ties ;  rotation  of  the  head  to  the  right,  with  associated 
movements  in  the  face  ;  speech  slow  and  explosive  : 
])upils  large  and  sluggish  to  light  and  accommodation  ; 
marked  Romberg  ;  exaggeration  of  the  knee-jerks  ;  no 
sensory  troubles.  Anatomically,  there  was  found  de- 
generation of  the  posterior  columns  and  roots,  as  well 
as  atrophy  of  the  anterior  roots  in  the  lumbar  cord; 
degeneration  of  the  columns  of  GoU  and  Burdach,  of 
the  direct  pyramidal  and  lateral  cerebellar  tracts 
throughout  the  rest  of  the  cord  and  in  the  medulla. 
The  pons  and  cerebellum  were  atrophic,  and  in  the 
latter  Purkinje's  cells  were  very  deficient. 

The  recitation  of  this  case  shows  wherein  it  differs 
from  the  accompanying  observation.  It  is  particularly 
in  the  age  of  the  patient,  the  mental  condition,  and  the 
severe  contractures.  Otherwise  my  patient  has  in  com- 
mon with  it  the  exaggerated  knee-jerks,  the  slow  and 
explosive  speech,  and  the  very  nearly  normal  condition 
of  the  eyes.  The  case,  therefore,  conforms  neither  to 
the  type  of  cases  described  under  the  name  hereditary 
cerebellar  ataxia,  nor  to  those  constituting  Friedreich's 
disease.  Eurthermore,  its  symptomatology  is  quite 
dilferent  from  the  symptomatology  of  such  familiary 
diseases  as  cerebral  diplegia,  as  described  by  Sachs,  by 
Ereud,  and  by  others  ;  from  paraplegia  ataxo-spas- 
modic  of  Gowers,  and  familiary  spasmodic  paraplegia 
which  has  been  described  by  many  writers. 

'  Gowers :  Diseases  of  the  Nervous  System,  vol.  i.,  p.  464. 

'  Loc   cit  '  .^rchiv  f.  Psychiat. ,  vol.  xxii.,  1891,  p.  161. 

*  Ibid.,  vol.  X.  ;  Ibid.,  vol.  xxvii.,  p.  749. 


It  is  advisable  also  to  contrast  it  with  the  symptom- 
atology of  six  cases  recently  described  by  Nonne.* 
He  sums  up  his  conclusions  in  these  cases  as  follows  : 
"  The  disease  developed  in  patients  without  any  hered- 
itary condition  existing  in  the  family.  It  may  follow  a 
disease  of  the  brain,  as  we  have  seen  it  after  a  sun- 
stroke. The  most  important  symptoms  are  :  i.  A 
static  and  locomotoric,  not  purely  ataxic,  disturbance 
of  co-ordination  of  the  extremities,  of  the  trunk  and 
phonating  speech  muscles,  with  intact  power  of  mim- 
icry. 2.  Insufficiency  of  the  external  eye  muscles,  with 
normal  condition  of  the  pupils  and  absence  of  nystag- 
mus and  change  in  the  optic  nerve.  3.  Increase  of 
patellar  tendon  reflex  without  accompanying  rigidity 
of  the  muscles.  4.  Absence  of  disturbance  of  sensi- 
bility and  absence  of  sphincter  disturbance.  5.  In- 
tactness  of  (or  slight  perversion  of)  the  intelligence." 

The  sjTnptoms  in  one  of  the  patients  which  the 
author  details  reached  a  standstill.  Nonne  is  of  the 
opinion  that  we  have  in  these  cases  to  deal  with  the 
sequences  of  an  affection  of  the  brain,  the  result  of 
some  toxic  agency  of  exogenetic  origin.  He  looks 
upon  these  cases  as  still  another  transition  form  be- 
tween Friedreich's  disease,  hereditary  cerebellar  ataxia, 
atrophy  of  the  cerebellum,  the  cases  previously  de- 
scribed by  him  (which  Nonne  does  not  consider  to  be- 
long in  the  title  suggested  by  Marie,  on  account  of  the 
wide-spread  atrophy  of  the  central  nervous  found  in 
one  of  his  cases),  as  well  as  the  cases  published  hereto- 
fore as  "  mixed  forms  "  of  these  diseases. 

The  only  criticism  that  will  be  offered  on  these  last 
cases  of  Nonne  is,  that  whereas  some  of  these  six  cases 
appear  to  belong  properly  to  so-called  "  transition 
forms,"  some  of  them,  such  for  instance  as  the  one 
coming  on  after  sunstroke,  can  be  explained  by  the 
previous  existence  of  an  encephalitis.  They  differ  es- 
sentially in  some  points  from  the  case  herewith  re- 
ported. Particularly  in  the  intactness  of  intelligence, 
the  absence  of  any  familiary  history.  In  common  with 
it  they  have  the  early  beginning,  the  abnormal  liveli- 
ness of  the  tendon  reflexes,  the  absence  of  eye-s}Tiip- 
toms,  the  absence  of  sensory  and  sphincter  disturbance, 
etc. 

The  symptoms  of  the  patient  herein  described  can  be, 
most  rationally  and  logically  explained,  when  more  ex- 
tensive defect  of  the  nervous  system  is  postulated  than 
exists  in  either  hereditary  spinal  or  hereditary  cerebellar 
ataxia.  In  the  former  disease  there  is  sclerosis  and 
shrinking  of  the  posterior  columns  of  the  spinal  cord, 
and  of  the  columns  of  Goll  and  Burdach,  analogous  to 
that  found  in  tabes.  In  addition  a  similar  pathologi- 
cal process  goes  on  in  the  crossed  pyramidal  tracts,  in 
Gower's  tract,  in  the  direct  cerebellar  tract,  in  the  me- 
dullary bridge  of  Lissauer  ;  and  with  these  there  is  a 
diminution  of  the  cells  of  Clarke's  columns.  The 
lesions  in  the  latter  disease  are  pronouncedly  in  the 
cerebellum,  and  consist  of  a  reduction  in  weight  and 
volume  which  is  associated  with  a  thinning  of  the  gray 
layer  and  a  lessening  in  number  of  the  cells  of  Purkinje. 
Naturally,  with  such  a  lesion  there  are  others  of  such 
fibres  or  bundles  of  fibres  the  neurons  of  which  are 
situated  in  the  degenerated  areas  of  the  cerebellum. 
The  projection  fibres  of  the  cerebellum  are,  happily, 
now  very  much  better  known  than  they  were  a  few 
years  ago,  even  although  we  are  still  in  the  dark  as  to 
their  connections  and  functions.  Therefore,  just  what 
these  outlying  lesions  are,  or  what  they  will  be  found 
to  be,  cannot  yet  be  said. 

The  patient,  R.  L ,  has  symptoms  which  cannot 

be  explained  by  either  set  of  lesions  or  by  both  com- 
bined. The  retrocession  of  slight  mental  attainment 
at  the  sixth  or  seventh  year,  and  the  lack  of  mental 
development  in  the  five  years  following  on  that  age — 
years  in  which  children  make  more  radical  mental  prog- 
ress than  at  any  other  period  of  their  existence  ;  a 
period  when  they  acquire  ideas  of  spoken  and  written 

'  Archiv  f.  PsychiaL,  vol.  xxvii.,  1895. 


December  21,  1895] 


MEDICAL    RECORD. 


871 


language,  of  moral  and  social  relationships,  when  there 
is  an  enormous  awakening  as  to  their  being  and  func- 
tion— point  unmistakably  to  lack  of  cerebral  develop- 
ment which  we  believe  could  be  called  a  lesion  if  it 
were  possible  to  examine  it. 

The  psychical  condition  of  the  child  at  the  present 
time  forms  an  interesting  subject  for  study.  His  pos- 
sessions and  lackings  in  this  line  have  before  been 
commented  on  in  some  detail,  but  it  may  be  well  to 
repeat  that  it  is  the  neural  processes  underlying  atten- 
tion, association,  and  comple.x  memories  that  he  is 
strikingly  deficient  in.  These  qualities  of  the  mind 
we  believe  to  be  subserved  principally  by  the  great 
system  of  association  fibres  or  tracts.  And  the  fact 
that  these  mental  attributes  are  deficient  and  unde- 
velopable is  in  evidence  that  the  neural  processes  on 
which  they  are  dependent  are  lacking.  Other  symp- 
toms, such  as  the  decided  e.xaggeration  of  myotatic 
irritability,  the  lack  of  readiness  in  the  rela.xation  of 
muscular  contraction,  are  explained  most  naturally  by 
defect  in  the  system  of  long  projection  fibres,  which 
interrupts  in  part  the  inhibitory  activity  of  the  cere- 
brum on  the  former  and  interferes  with  the  conduc- 
tivity of  impulses  necessary  to  the  latter. 

Taking  the  symptoms  which  this  patient  presents 
in  their  entirety,  it  seems  to  me  that  they  bespeak  a 
defective  formation  of  the  nervous  system,  not  of  any 
individual  portion  such  as  certain  parts  of  the  cord  or 
the  cerebellum,  but  of  the  entire  cerebro-spinal  and 
sympathetic  nervous  system.  In  fact,  if  we  take  our 
perspective  from  the  broad  view-point  of  the  develop- 
ment of  the  nervous  system,  it  is  not  difficult  to  conceive 
how  some  perversion  of  the  germ  plasm  destined  for 
the  portion  of  that  part  of  the  epiblast  from  which  the 
nervous  system  is  to  develop,  may  cause  a  deficiency 
in  the  proper  development  of  the  nervous  system. 
Such  a  defect,  by  very  virtue  of  its  protal  origin,  would 
not  be  limited  to  any  individual  part  of  the  nervous 
system,  but  would  be  manifested  throughout  it.  That 
is,  it  would  not  be  alone  in  the  central  neuron,  in  the 
projection  and  association  fibres  which  are  built  from 
them,  but  in  the  peripheral  neuron  as  well. 

The  condition  of  the  musculature  of  the  patient  R. 

L I  consider  of  no  small  importance  in  bearing 

on  the  process  underlying  his  disease.  As  has  been 
said,  the  contours  of  the  extremities  are  quite  normal  in 
appearance.  There  is  neither  apparent  atrophy  nor 
hypertrophy.  The  fact  that  the  musculature  is  de- 
ficient is  conveyed  by  what  has  been  said  concerning 
the  way  in  which  he  rises  from  a  lying  posture.  Then, 
when  it  comes  to  an  examination  of  the  muscles,  it  is 
seen  that  in  some  parts  of  the  body,  such  as  on  the 
back  of  the  forearms,  they  are  strikingly  deficient,  as 
is  shown  by  the  translucency  of  the  jiarts  when  the 
tissues  are  pinched  up,  by  the  extremely  small  amount 
of  muscular  tissue  which  can  be  recognized  by  the 
touch  in  these  parts  and  by  the  rapidity  with  which  the 
upper  extremities  become  fatigued. 

That  the  muscles  exist,  and  that  there  is  no  de- 
generation in  the  muscles,  is  shown  by  their  behavior 
to  the  electrical  tests.  That  is,  it  would  seem  that 
some  groups  of  muscles  are  represented  in  miniature. 
This  is  not  the  result  of  disuse,  or  of  disease  of  the 
muscles  themselves,  but  is,  I  believe,  the  result  of  de- 
fective formation  consecutive  to  deficient  protal  distri- 
bution of  peripheral  neurons.  I  am  aware  that  this 
theory  leaves  unexplained  the  integrity  of  the  sensory 
system,  but  the  fact  that  it  is  intact  should  not  prevent 
an  attempt  at  furnishing  a  rational  explanation  of  ex- 
isting defects. 

The  absence  of  sensible  perspiration,  the  condition 
of  the  skin  and  appendages,  to  which  attention  has 
been  called,  bespeak  shortcomings  in  the  performance 
of  its  duties  by  the  sympathetic  nervous  system.  We 
have,  therefore,  in  this  case  symiitoms  which,  although 
partaking  of  the  symptomatology  of  both  hereditary 
cerebellar  and  hereditary  spinal  ataxia,  has  in  addition 


certain  conditions  which  are  dependent  upon  a  more 
extensive  defect  in  the  nervous  system  than  either  of 
these  two  diseases  has  been  found  associated  with. 
The  purpose  of  this  report  is  to  show  that  cases  such  as 
this  cannot  be  encompassed  by  unvarying  boundaries. 

It  also,  I  think,  goes  to  show,  as  Xonne  has  pointed 
out,  that  there  exist  clinically  cases  which  vary  in  their 
clinical  manifestations  from  the  picture  produced  by 
cerebellar  atrophy,  through  the  category  of  his  original 
cases,  through  the  cases  described  under  hereditary 
cerebellar  ataxia,  to  the  many  transition  forms  that 
have  been  described,  and  that  these  cases  can  be  dif- 
ferentiated clinically  from  hereditary  spinal  ataxia. 

I  deem  it  a  privilege  to  thank  Professor  C.  L.  Dana, 
in  whose  clinic  at  the  Post-graduate  Medical  School  this 
patient  was  found,  not  alone  for  the  consent  given  to 
study  the  case,  but  for  valuable  suggestions  made  while 
studying  it. 


A     CHEMICAL     AND      EXPERI.MENTAL     RE- 
SEARCH ON  "ANTIPHTHISIN"  (KLEBS'S). 
By  E.  L.  TRLDE.VU,  M.D., 

AND 

E.  K.  BALDWIN,  M.D., 

SARA.NAC    LAKE,    N.    V. 

In  spite  of  the  ill  repute  into  which  Koch's  tubercu- 
lin so  quickly  fell,  many  investigators,  struck  with  the 
specific  and  selective  influence  which  it  exercises  on 
the  lesions  of  experimental  tuberculosis,  as  well  as  with 
some  favorable  clinical  observations  noted  in  certain 
types  of  the  pulmonary  disease  treated  by  tuberculin, 
have  persevered  in  its  further  study  and  have  attempted 
to  analyze  its  constituents,  to  do  away  with  the  mani- 
festly dangerous  products  contained  in  liquid  cultures 
of  the  tubercle  bacillus,  and  if  possible  to  separate 
some  pure  substance  which  might  favorably  influence 
the  tuberculous  process,  or  produce  in  men  and  animals 
a  certain  degree  of  immunity. 

Koch,'  shortly  after  his  announcement  of  the  discov- 
ery of  tuberculin,  published  the  result  of  his  attempts 
to  purify  this  substance,  claiming,  however,  for  the 
product  he  obtained  no  therapeutical  advantage  over 
crude  tuberculin.  Kuhne~made  a  chemical  analysis 
of  its  component  parts,  and  found  that  the  active  sub- 
stances present  in  it  are  of  the  nature  of  albumoses. 

Baumgarten^  obtained  temporary  cures  of  eye  tuber- 
culosis in  the  rabbit  by  treatment  with  tuberculin.  Tru- 
deau  '  demonstrated,  by  the  treatment  of  the  experi- 
mental disease  in  the  rabbit's  eye,  that  the  substg-nces 
which  bring  about  reaction  and,  under  certain  experi- 
mental conditions,  even  temporary  cure,  are  to  be 
found  in  the  filtrate  of  liquid  cultures,  and  not  in  a 
solution  or  suspension  of  the  washed  bodies  of  dead 
bacilli,  and  that  the  heat  used  in  making  Kocli's  tuber- 
culin ijrecipitates  some  of  the  proteids  present  in  the 
cold  filtrate.  The  studies  of  Hunter''  and  Klebs' 
were  directed  more  particularly  toward  the  separation 
by  chemical  methods  of  the  injurious  from  the  possibly 
curative  elements  of  tuberculin. 

In  a  communication  made  in  1892,' and  in  an  ex- 
haustive and  more  recent  publication  on  this  subject, 
Klebs  claims,  by  chemical  methods  which  he  describes, 
to  have  separated  from  tuberculin,  and  later  from  the 
filtrate  of  over-ripe  liquid  cultures,  a  product  which, 
owing  to  its  specific  germicidal  action,  is  capable  of 
killing  the  tubercle  bacillus  even  when  intrenched  in 

'Koch  :  Deutsch.  Med.  VVoch.,  October  22,  1891. 
■'  KUhne:  Zeitsch.  f.  BioloKif,  1892,  xii. ,  No.  3. 

•  Baumgarten  :  Deutsch.  Klin.  Woch.,  1891,  N'o.  19. 

'  Trudeau :  Transactions  of  the  Association  of  American  Physicians, 
May  24,  1892. 
»  Hunter :  British  Medical  Jonmal,  July  25,  1891. 

•  E.  Klebs :  Deutsch.  Med.  Wochenschrift,  April  14.  1892. 

'  E.  Klebs:  Die  Causale  Behandlung  der  Tuberculose,  1894,  pp. 
578-81. 


872 


MEDICAL    RECORD. 


[December  21,   1895 


the  living  tissues  of  infected  men  and  animals,  and  thus 
curing  the  disease. 

According  to  Klebs's  observations,  the  cure  is  brought 
about,  not,  as  Ko:h  thought,  by  the  power  of  the  spe- 
cific product  to  incite  a  reactionary  effort  on  the  part  of 
the  body  cells,  but  directly  and  solely  through  its  germi- 
cidal influence  on  the  tubercle  bacillus.  Klebs,  having 
observed  that  tubercle  bacilli  in  cultures  die  when  a 
certain  period  in  their  cultivation  is  reached,  holds  that 
they  perish  because  they  produce  toward  the  end  of 
their  existence  in  the  culture  medium  a  peculiar  ger- 
micidal substance  which  destroys  them  ;  that,  by  the 
chemical  processes  he  describes,  he  has  obtained  this 
specific  substance  freed  from  the  poisonous  alkaloids 
and  albumoses  also  produced  by  the  microbes  during 
their  growth,  and  present  in  tuberculin  ;  that  he  has 
succeeded  in  separating  from  over-ripe  cultures  this 
germicidal  substance,  which  he  calls  "  sozalbumose," 
and  that  it  is  the  natural  specific  for  this  dreaded  dis- 
ease. 

Such  deductions,  if  proved  correct,  would  have  so 
important  a  bearing,  not  only  upon  our  existing  knowl- 
edge of  the  tubercle  bacillus  and  of  the  treatment  of 
tuberculosis,  but  upon  the  etiology  and  treatment  of 
many  other  bacterial  diseases  as  well,  that  a  study  of 
the  claims  made  for  "  antiphthisin,"  both  from  the 
chemical  and  experimental  stand-points,  and  of  the 
theory  upon  which  these  claims  are  based,  was  under- 
taken by  us  at  the  Saranac  Laboratory  for  the  Study  of 
Tuberculosis,  and  an  answer  to  the  following  questions 
sought : 

I  St.  Can  a  specific  substance,  differing  chemically  from 
the  albumoses  already  known  to  be  contained  in  the  filtrate 
of  liquid  cultures  of  tubercle  bacilli,  be  separated  from 
such  cultures  in  a  state  of  purity  by  the  cheinical  methods 
proposed  and  described  by  Dr.  Klebs  ? 

As  the  directions  given  by  Dr.  Klebs  for  the  prep- 
aration of  "  antiphthisin  "  were  evidently  intended  to  be 
sufScient  for  the  guidance  of  others  who  might  desire 
to  prepare  this  substance,  we  preferred  not  to  limit  our 
chemical  study  to  an  analysis  of  his  own  product,  but 
to  include  in  our  research  a  test  of  the  chemical  prob- 
lems involved  in  the  process  of  manufacture  as  laid 
down  by  him. 

In  order  to  ascertain  the  nature  of  "  antiphthisin"  we 
prepared  large  quantities  of  it  according  to  the  direc- 
tions given,  which  were  closely  followed. 

"  Antiphthisin  "  is  stated  by  Klebs  to  resemble  "  tu- 
berculocidin  "  (the  name  given  to  a  former  prepara- 
tion), but  is  made  directly  from  the  fluid  filtered  from 
the  over-ripe  bouillon  cultures  without  heat,  instead 
of  from  crude  tuberculin,  as  is  the  latter.  The  same 
method  is  used  in  both,  but  the  "  antiphthisin  "  pre- 
sumably contains  more  of  the  active  albuminoid  sub- 
stances, because  some  are  removed  by  heat  in  the  man- 
ufacture of  tuberculin,  from  which  "  tuberculocidin  " 
is  made. 

Kiihne  '  examined  100  c.c.  of  Klebs's  "  tuberculoci- 
din "  and  found  a  small  amount  of  deutero-albumose 
and  traces  of  peptone  as  the  ingredients,  excepting  the 
phenol  used  to  preserve  it  and  inorganic  salts.  The 
albumoses,  etc.,  resembled  those  contained  in  the  pep- 
tone of  the  culture  medium,  though  possibly  derived 
from  the  bacilli.  The  important  step  in  making  these 
modifications  of  tuberculin  is  said  by  Klebs  to  be  the 
removal  of  harmful,  fever-producing  substances  by  pre- 
cipitation with  sodium-bismuth-iodide  (a  reagent  used 
to  separate  alkaloids)  in  acetic  acid  solution.  The 
useful  germicidal  substances  are  assumed  to  be  retained 
in  the  filfate,  which  is  then  treated  with  XaOH  to 
remove  the  bismuth.  This  being  filtered  off,  absolute 
alcohol  is  added  to  the  filtrate.  The  resulting  precipi- 
tate collected  and  dissolved  in  water  is  called  "anti- 
phthisin." This  is  preserved  in  o.;  per  cent,  trikresol, 
and  is  made  of  1,  \,  or  -^^  bulk  of  the  original  culture 
fluid. 

'  Kuhne  :  Loc.  cit. ,  p.  232. 


We  first  procured  some  potassium-bismuth-iodide 
through  the  kindness  of  Professor  C.  E.  Colby  (Colum- 
bia College,  School  of  Mines),  and  with  this  made  sev- 
eral samples  of  "antiphthisin."  Later,  with  sodium- 
bismuth-iodide  prepared  by  ourselves,  we  made  larger 
quantities. 

Seven  flasks  containing  900  c.c,  covered  with  thick 
pellicles  beginning  to  sink,  and  all  showing  a  rich 
growth  of  ripe,  pure  cultures  grown  from  December  20, 
1894,  to  February'  18,  1895 — eight  and  a  half  weeks — on 
peptone-bouillon,  were  filtered  free  ofbicilii,  and  12  c.c. 
of  trikresol,  twenty  percent,  solution  in  glycerine,  added 
as  a  preservative.  After  standing  twenty- four  hours 
sodium-bismuth  iodide  was  added  until  no  further  pre- 
cipitation occurred,  the  reagent  being  first  treated  with 
sodium  acetate  and  acetic  acid.  To  avoid  great  ex- 
cess, the  quantity  of  the  precipitant  needed  was  first 
closely  determined  by  titration  three  times  with  5  c.c. 
of  the  culture  fluid.  The  bulky,  red  precipitate  was 
settled  and  filtered  ;  the  filtrate  tested  gave  no  fur- 
ther precipitate  with  NaBilj;  NaOH  (norm.)  added 
until  reaction  just  alkaline  ;  warmed,  settled,  and  fil- 
tered, free  of  Bi  (0H)3  ;  to  the  clear  filtrate  absolute 
alcohol  added  until  no  further  opalescence  produced. 
The  final  precipitate,  washed  with  absolute  alcohol  and 
dried,  was  readily  dissolved  in  70  c.c.  distilled  water. 

Examination. 

Color — light     straw    (resembled    "  tuberculocidin "     obtained    in 

market). 
Odor — none  (without  trikresol). 
Reaction — slightly  alkaline. 

+  heat  =  O  +  acetic  acid  =  O  (absence  of  albumin). 
-H  NaOH  -f  CuSoi  =  rose  color  distinct  (indicative  of  albumoses 
or  peptones). 
4-  (NHi)2  SO4  (saturated)  =  opalescence  (albumoses  ?  ). 
+  NaCl     (saturated)  =  O  -^  acetic    acid  =  opalescence     (deutero- 
albumoses  ?). 
+  PtCli  (excess)  =  opalescence  (not  found  by  Klebs). 
4-  NaBilj  +  acetic   acid  =  precipitate  (the  first  was  evidently  in- 
complete— not  found  by  Klebs). 
+  HCl  +  H2S  (warmed)  =  0-— (absence  of  Bi). 
-f-  HNOs  (cone.)  -f  starch  paste  =:  O  (absence  of  I). 

The  above  reactions  and  others  indicated  that  we 
were  dealing  with  an  albumose,  or  peptone-like  body, 
which  was  incompletely  precipitated  by  the  first  treat- 
ment with  sodium-bismuth-iodide.  The  whole  quantity 
remaining  was  therefore  again  treated  with  sodium-bis- 
muth-iodide in  acetic  acid.  This  time  there  was  much 
less  "antiphthisin,"  and  by  a  third  treatment  it  was 
possible  to  completely  remove  all  of  it — no  proteid  be- 
ing left. 

These  results  show  the  absence  of  any  substance  dif- 
ferent from  the  albumoses  already  described  by  Kiihne 
as  deutero-albumose,  produced  by  the  bacilli  in  very 
small  quantities. 

Klebs  thinks  this  substance  to  be  elaborated  by  the 
bacilli  in  growing.  To  test  this  point  we  treated  some 
unplanted  bouillon  by  the  same  method  above  described. 

Two  hundred  and  fifty  cubic  centimetres  gave  a  res- 
idue identical  in  appearance  and  reactions  with  that 
obtained  from  the  cultures.  It  was,  however,  less  in 
quantity  than  that  obtained  from  cultures  of  same  bulk. 

As  it  was  evident  that  some  of  the  albumoses,  etc.,  in 
the  original  culture — i.e.,  contained  in  the  peptone  or 
meat  extract — might  be  in  the  product  called  "  anti- 
phthisin," we  prepared  some  from  peptone-free  cultures, 
grown  on  the  asparagine  fluid  suggested  by  Schweinitz,- 
475  c.c.  of  this  gave  a  trace  of  antiphthisin,"  which 
from  its  reactions  resembled  a  deutero-albumose.  Ob- 
viously this  must  have  been  derived  from  the  bacilli, 
because  a  control  experiment  with  the  culture  fluid 
gave  nothing.  A  second  treatment  of  the  presumably 
pure  "antiphthisin  "  with  sodium-bismuth-iodide  com- 
pletely precipitated  the  proteid  substances. 

Some  experiments  witli  deutero-albumose  were  next 
made  to  determine  whether  this  is  incompletely  pre- 
cipitated by  sodium-bismuth-iodide.     This   substance 

'  Schweinitz  :   New  York  Medical  Journal,  Februarys.  '^W- 


December  21,  1S95] 


MEDICAL   RECORD. 


S7. 


was  prepared  in  a  fairly  pure  condition  from  Witte's 
peptone  by  the  method  of  Kiihne  and  Chittenden.  It 
was  then  made  up  into  the  usual  bouillon  culture  medium 
mixture,  being  substituted  for  the  peptone  in  like  pro- 
portion. When  treated  with  sodium-bismuth-iodide, 
etc.,  a  small  residue,  identical  in  its  appearance  and 
chemical  reactions  to  the  "  antiphthisin  "  obtained  from 
ripe  cultures,  was  found  to  be  present. 

A  similar  proteid  residue  was  obtained  from  a  mixt- 
ure of  Liebig's  extract  of  meat,  sodium  chloride,  and 
glycerine  in  the  usual  proportions  for  culture  media. 
Meat  extract  is  known  to  contain  a  small  quantity  of 
albumoses. 

Some  experiments  with  the  object  of  determining  the 
reason  for  this  incomplete  precipitation  of  albumoses, 
particularly  deutero-albumose,  incline  us  to  think  it  due 
to  several  causes.  It  may  be  due  partly  to  the  pres- 
ence of  neutral  salts  in  which  these  albumoses  are  very 
soluble,  and  possibly  because  of  slight  solubility  in  ex- 
cess of  the  reagent.  The  amount  of  acetic  acid  pres- 
ent seemed  to  bear  no  relation  to  the  amount  of  "an- 
tiphthisin "  produced.  By  careful  precipitation  it  was 
possible  to  remove  all  the  albumoses  in  the  first  treat- 
ment. 

The  components  of  tuberculin,  so  far  as  known,  can 
be  best  compared  with  those  of  "  antiphthisin  "  by  the 
following  table  : 


r 


From  the 
culture   ] 
medium  -{ 
u  n  a  1  -   I 
tered. 


f  Glycerine. 
I    Inorganic  salts. 
I   Extractives  {rom  meat. 
Albuminat. 


Albumoses 


Tuberculin 
(crude) 


(^  Peptone. 


(  proto- 
•  hetero- 
f  deutero- 


From  the 
bacilli 


I 


f  Albuminat    (?)     (doubtless    a    nucleo- 

I        proteid). 

I    ■' Acroo-albumoses"  (Kiihne). ' 
as  a  re-  ■{   Deutero-albumose  (small  amount), 
suit    of   I    Peptone  (possible  trace).' 
growth.    I    Alkaloids  (?).'- 

[^  Protein  (?)  from  bodies  of  the  bacilli. 


f  Inoi^anic  salts. 
-Antiphthisin"    and      Cewero-al- ^  (z-^ry   small   amount  and 
"Tuberculocidin."       )   „  ^"'"°'"  "       partly  from  the  culture 
Peptone  (?)  (      mediuAi). 
[  Trikresol. 

Many  animal  tests  were  made  with  "  antiphthisin  " 
of  one-tenth  volume  of  original  culture  fluid.  Doses 
from  0.5  c.c.  to  3  c.c.  seldom  produced  appreciable  ef- 
fects on  tubercular  guinea-pigs  and  rabbits  when  ad- 
ministered at  various  stages  in  the  disease.  In  doses  of 
5  c.c.  elevation  of  temperature  was  produced,  and  one 
pig  was  killed  by  that  dose,  showing  characteristic  tu- 
berculin-reaction lesions.  Ten  cubic  centimetres  caused 
marked  congestion  in  the  tubercular  eye  of  a  rabbit, 
with  a  temperature  rise  of  from  102°  F.  to  105°  F. 

The  effects  of  large  doses  of  "  antiphthisin  "  were 
similar  in  all  respects  to  those  produced  by  small  doses 
of  tuberculin. 

It  is  interesting  to  note  in  this  connection  that 
Mathes^  found  that  deutero-albumose  (and  others) 
made  from  Witte's  peptone,  jjroduced  effects  on  tuber- 
cular animals  identical  to  those  of  tuberculin  when 
given  in  sufficient  quantity.     We  have  confirmed  this. 

2d.  //as  "antiphthisin"  any  germicidal  action  on  the 
tubercle  bacillus  in  vitreo  i 

Six  cubic  centimetres  of  a  suspension  of  a  virulent 
culture  of  tubercle  bacilli  on  serum  having  been  made 
in  water,  0.5  c.c.  was  injected  subcutaneously  in  the  thigh 
of  four  control  pigs.  Three  cubic  centimetres  of  the 
same  suspension  were  now  mixed  in  a  little  sterilized 
beaker  with  3  c.c.  of  pure  "  antiphthisin  "  prepared  by 
us  as  stated  above,  allowed  to  stand  six  hours  at  the 
room  temperature,  and  i  c.c.  of  the  mixture  injected  into 

'  Kiihne  :  Loc.  cit. 

-  Crookshank  and  Herroun  :  Journal  of  Physiology,  vol.  xii. 

'  -Mathes  :  Deutsch.  .\rch.  t  klin.  Med.,  S.  A.,  1894. 


five  pigs  in  the  same  manner  as  in  the  controls.  All 
the  animals  died  within  two  months. 

The  average  life  of  the  controls  was  fifty  days.  The 
average  life  of  the  test  animals  receiving  the  cultures 
which  had  been  left  six  hours  in  contact  with  "'  anti- 
phthisin "  was  thirty-nine  days.  The  lesions  of  the  test 
animals  differed  in  no  appreciable  manner  from  those 
noted  in  the  controls. 

3d.  Do  "  tuberculocidin  "  or  "  antiphthisin  "  exert  any 
curative  influence  oi'er  the  course  of  experimental  tuber- 
culosis in  the  guinea-pig  I 

Twelve  guinea-pigs  were  each  inoculated  in  the  in- 
ner aspect  of  the  thigh,  subcutaneously,  with  0.5  c.c. 
of  an  emulsion  made  from  tubercular  glands  and  peri- 
toneal tubercles  taken  from  a  rabbit  dead  with  acute 
tuberculosis.  Six  were  kept  as  controls,  and  treat- 
ment of  the  other  six  was  begun  by  injecting  subcu- 
taneously on  the  following  day,  in  each,  0.25  c.c.  "an- 
tiphthisin "  one-tenth  cone. 

Injections  were  continued  every  second  or  third  day 
and  the  dose  gradually  increased,  so  that  within  a 
month  the  animals  were  receiving  each  1.5  c.c.  "an- 
tiphthisin." The  dose  was  then  reduced  to  i  c.c,  and 
injected  at  intervals  of  two  or  three  days  until  death. 

The  average  duration  of  life  for  the  control  animals 
was  thirty-nine  days  ;  for  the  treated,  thirty-three  days. 
In  two  of  the  treated  animals  the  extensive  tubercular 
lesions  found  in  all  showed  bluish  congestive  areas  such 
as  are  usually  seen  in  tubercular  guinea-pigs  injected 
with  Koch's  tuberculin.  Otherwise  the  post-mortem 
appearances  were  about  the  same  in  both  sets  of  guinea- 

P'g^-  .    .  .  ,  .      „ 

A  similar  experiment  was  also  made  with  tubercu- 
locidin "  purchased  in  open  market,  with  materially  the 
same  results. 

4th.  /s  the  death  of  the  germs  in  over-ripe  cultures  due 
to  the  formation  of  a  specific  germicidal  substance  in  suck 
cultures,  or  to  some  other  cause  1 

Dr.  Klebs's  observation  that  if  a  culture  medium  in 
which  tubercle  bacilli  have  once  developed  be  replanted 
no  growth  will  occur,  was  several  times  confirmed  by 
us.  In  testing  carefully,  however,  such  a  medium  be- 
fore planting,  and  after  the  germs  have  ceased  to  de- 
velop on  it,  it  was  observed  that  its  reaction  had  be- 
come markedly  changed. 

Peptonized  glycerinated  bouillon  ready  to  plant  with 
tubercle  bacilli  should  be  either  neutral  or  faintly  alka- 
line, but  after  an  abundant  crop  of  the  bacilli  has  de- 
veloped on  its  surface  it  may  be  noticed  that  its  reac- 
tion has  become  more  or  less  markedly  acid,  according 
to  the  depth  of  the  culture  medium  in  the  tlask  and  the 
richness  of  the  growth.  Whether  this  acidity  is  brought 
about  merely  by  the  abstraction  from  the  medium  of 
some  of  its  alkaline  constituents  for  the  needs  of  the 
growing  germs,  or  by  the  addition  to  it  of  an  acid  sub- 
stance produced  as  the  result  of  the  microbes'  meta- 
bolism, has  not  yet  been  accurately  determined,  and 
the  cause  of  this  acidity  offers  a  subject  for  further 
study  ;  but  as  "  antiphthisin  "  is  alkaline,  no  germicidal 
influence  can  be  claimed  for  it  on  that  ground.  It 
seemed  to  us  not  improbable  that  the  failure  to  obtain 
a  second  growth  on  such  a  medium,  if  replanted,  might 
be  due  simply  to  its  acid  reaction  alone,  and  the  fol- 
lowing experiment  to  determine  the  correctness  of  this 
hypothesis  was  therefore  made  : 

Having  grown  cultures  of  tubercle  bacilli  on  pepto- 
nized glycerinated  bouillon  for  seven  weeks,  until  the 
thick  pellicle  formed  by  the  germs  began  to  look  humid 
and  sink  at  the  sides,  a  few  drops  of  a  sterilized  solu- 
tion of  XaOH  was  added  to  the  culture  fluid  until 
the  acid  reaction  found  to  be  present  in  it  was  changed 
to  a  perfectly  neutral  one.  'I'his  neutralized  medium 
was  then  filtered  through  a  previously  well-sterilized 
Kitasato  filter  into  small  sterilized  flasks.  Fresh  plants 
of  actively  growing  tubercle  bacilli  were  made  in  all  of 
these,  and  the  entire  lot  placed  in  the  thermostat  at 
39°  C.     No  contaminations  occurred,  and,  as  is  not  un- 


874 


MEDICAL    RECORD. 


[December  21,  1895 


commonly  observed  in  the  cultivation  of  the  tubercle 
bacillus,  but  little  growth  took  place  during  the  first 
two  weeks.  From  that  time,  however,  the  pellicles  be- 
gan to  spread  and  thicken  in  the  usual  way,  and  five 
weeks  from  the  day  of  planting  the  entire  surface  of 
the  flask  was  covered  with  a  rich  growth. 

Conclusions. — i.  The  substance  made  according  to 
Klebs's  published  method,  and  called  by  him  '"anti- 
phthisin,"  resembles  deutero-albumoses  in  its  chemical 
reactions,  and  can  be  precipitated  by  sodium-bismuth- 
iodide.  Hence  it  has  no  peculiarity  of  behavior  to 
that  reagent  to  distinguish  it,  and  as  a  similar  substance 
can  be  obtained  from  unplanted  bouillon,  it  cannot  be 
considered  an  altogether  specific  product  of  the  tuber- 
cle bacillus. 

"  Antiphthisin,"  prepared  according  to  Klebs's  pub- 
lished method,  is  practically  highly  diluted  tuberculin, 
and  its  physiological  effect  on  animals,  when  given  in 
sufficient  doses,  is  the  same  as  tuberculin. 

2.  "Antiphthisin"  possesses,  under  the  conditions 
stated  above,  no  germicidal  power  on  the  tubercle 
bacillus  which  can  be  demonstrated  in  vitreo. 

3.  When  applied  to  animals,  as  stated  above,  neither 
"  tuberculocidin  "  nor  "  antiphthisin  "  had  any  curative 
influence  over  the  course  of  experimental  tuberculosis 
in  the  guinea-pig. 

4.  Since  cultures  of  the  tubercle  bacillus  become 
acid  as  they  grow,  and,  furthermore,  since  the  addition 
without  heat  of  a  little  alkali  to  a  filtered  culture  medi- 
um upon  which  bacilli  have  ceased  to  grow  renders  it 
again  fit  for  the  development  of  a  second  crop  of  germs 
so  long  as  any  nutriment  remains,  it  may  be  inferred 
that  the  limitation  of  the  growth  of  the  tubercle  bacillus 
in  such  a  culture  medium  is  most  likely  due  to  the 
acidity  induced  in  the  medium,  rather  than  to  any  spe- 
cific germicidal  substance  produced  therein. 


A  PRACTICAL  METHOD  OF  MEASURING 
AND  REGISTERING  THE  TRUE  THERA- 
PEUTIC DOSE  OF  INDUCTION-COIL  CUR- 
RENTS. 


Bv   S.    H.  MOXELL,   M.D., 

B.IOOKLVN,  N.    V. 


A  FORMER  paper  by  the  present  author  described  a  new 
induction-coil  apparatus  with  a  number  of  original  im- 
provements designed  by  me  to  increase  precision  and 
efficiency.  In  this  second  paper  I  now  present  to  the 
medical  profession  my  method  of  dose  measurement 
and  registration,  which,  so  far  as  inquiry  discloses,  is 
the  first  practical  method  with  a  scientific  basis. 

I  am  met  at  the  outset  of  my  proposition  to  measure 
and  record  induced  medical  currents  by  the  curt  re- 
mark that  it  cannot  be  done.  With  this  declaration 
before  us,  let  us  review  a  group  of  contemporary  state- 
ments upon  the  subject  of  faradic  dosage.  The  author- 
ity for  each  will  be  easily  recognized  by  all  familiar 
with  the  literature  of  electro-therapeutics. 

1.  "A  bar  to  the  progress  of  faradism  is  the  impos- 
sibility of  satisfactory  therapeutic  measurement.  Edel- 
mann's  faradimeter  is  incomplete  and,  I  must  even  add, 
misleading  as  a  physiological  or  therapeutic  measure." 

2.  "  The  Edelraann  faradimeter,  which  is  not  by  any 
means,  as  was  intended,  a  measure  of  faradic  electricity, 
is  too  complicated  and  expensive  for  the  practitioner, 
.  .  .  and  is  merely  a  deceptive  snare  for  physiologi- 
cal or  therapeutic  purposes.  The  strength  of  the  cur- 
rent would  be  far  better  appro.ximated  by  indicating  the 
nature  of  the  coil  and  the  resistance  offered  than  by 
the  volt  scale  of  this  faradimeter." 

3.  '  Unfortunately  we  have  no  means  of  measuring 
accurately  the  dose  of  faradism,  the  only  means  at  our 
command  being  the  millimetre  scale  placed  at  the  side 
of  the  coils.  This  is  a  very  rude  method,  indeed,  but  it 
is  all  we  have  at  present." 


4.  "  It  is  much  to  be  regretted  that  we  have  no  means 
of  accurately  measuring  the  therapeutic  dosage  of  the 
faradic  currant." 

5.  "  The  old  attempt  to  measure  the  faradic  dose  by 
a  coil  movable  over  a  primary  core,  on  a  graduated 
scale,  was  so  unscientific  and  inadequate  as  to  be  ridicu- 
lous." 

6.  "  It  is  the  ability  to  record  the  doses  of  the  cur- 
rent to  which  must  be  ascribed  the  rapid  progress  of 
galvanism.  To  give  the  necessary  impetus  to  faradism 
we  must  obtain  this  same  precision,  .  .  .  and  tow- 
ard this  end  my  efforts  have  been  directed  ever  since  I 
realized  how  seriously  this  valuable  remedy  was  affected 
by  its  vagueness  and  uncertainty  ;  and  as  early  as  1886 
I  sought  to  approximate  dosage  by  a  defining  and  pre- 
cising of  details." 

7.  "  The  precise  measurement  of  the  faradic  current 
for  therapeutic  purposes  has  not  as  yet  been  satisfacto- 
rily attained.  The  method  heretofore  in  vogue,  of  meas- 
uring on  a  scale  the  distance  the  secondary  coil  is  ad- 
vanced over  the  primary,  is  inaccurate  and  delusive — in 
fact,  means  nothing — since  the  battery  current  varies 
with  use  ;  and  no  estimate  is  taken  of  the  variable  re- 
sistance encountered  in  the  external  circuit,  which  is 
altered  by  the  location  of  the  electrodes,  by  their  size, 
and  by  the  distance  between  them.  The  fact  that  this 
current  possesses  the  same  two  qualities  as  the  galvanic 
current— pressure  and  volume — makes  it  evident  that 
we  must  in  some  manner  estimate  the  relative  voltage 
and  amperage  of  the  current  employed  in  order  to  ar- 
•rive  at  a  practical  conclusion  of  its  comparative  value." 

The  striking  remark  of  Engelraann's,  which  closes 
the  second  comment  cited  above,  although  not  ob- 
served by  the  writer  previous  to  the  preparation  of  this 
article,  foreshadows  what  is  substantially  accomplished 
by  the  method  to  be  described  in  this  paper,  and  which 
was  originated  by  me,  January  29,  1S94.  My  method 
also  takes  into  account  what  is  suggested  as  necessary 
in  comment  number  seven,  but  before  proceeding  with 
descriptive  details,  certain  relative  facts  require  to  be 
understood.  These  are  as  follows :  No  automatic 
meter  or  measuring  instrument  is  required  to  select  the 
proper  dose  of  faradism  for  a  patient,  or  to  adjust  it  to 
the  needs  of  therapeutic  use.  Direct  currents  need 
such  an  indicator,  but  induced  currents  do  not.  The 
educated  skill  of  the  operator  regulates  the  dose,  and 
does  it  adequately.  The  existing  need  is  for  a  stand- 
ard system  of  recording  the  dose  administered,  and 
thus  impart  uniform  value  to  the  reports  of  clinical 
cases,  and  introduce  precision  and  definiteness  into  the 
special  literature  of  the  subject. 

The  accepted  dose  measurer  of  the  constant  current 
is  the  milliamperemeter,  adopted  universally  within  half 
a  decade,  and  which  in  general  estimation  has  lifted  the 
galvanic  current  from  empiricism  and  placed  its  thera- 
peutics on  a  scientific  basis.  Let  us,  therefore,  note 
exactly  what  the  milliamperemeter  accomplishes  and 
what  part  it  plays  in  the  dose  record,  in  order  that  we 
may  better  understand  the  problem  before  us  in  at- 
tempting to  measure  and  record  the  dose  of  induction 
currents. 

To  enable  separate  observers  to  compare  and  repeat 
results  in  clinical  cases  treated  by  galvanism,  we  should 
take  into  account  every  factor  which  affects  the  action 
of  the  current.  A  comprehensive  record  must  neces- 
sarily inform  us  then,  on  the  following  points  :  i.  Sur- 
face area  or  type  of  electrodes — which  range  from 
needles,  sounds,  tips,  etc.,  to  small  or  large  pads,  or 
water-baths,  or  may  be  clay,  copper,  zinc,  carbon, 
platinum,  steel,  tin,  brass  ;  or  covered  with  sponge, 
cotton,  felt,  etc.,  determining  conducting  power  and 
density  of  the  current.  2.  Situation  of  both  positive 
and  negative  electrodes  during  treatment.  3.  Tissues 
treated  and  their  pathological  state,  symptomatic  con- 
ditions, etc.  4.  Time  and  frequency  of  administra- 
tion. 5.  Reading  of  the  milliamperemeter,  or  current 
volume. 


December  21,  1895] 


MEDICAL   RECORD. 


875 


Clinical  reports  of  these  particulars,  with  results  of 
treatment,  would  be  complete  ;  and  while  of  the  vari- 
ous factors  the  meter  furnishes  but  one,  it  supplies  the 
last  essential  to  the  dosage  of  galvanism. 

When  we  enter  upon  the  problem  of  faradic  dosage 
we  find  the  factors  no  fewer,  but  differing  in  character. 
These  are  now  :  i.  Character  of  the  current,  as  deter- 
mined by  the  coil  employed.  2.  Description  of  elec- 
trodes and  their  situation  during  treatment.  3.  Rate 
of  current  interruption.  4.  Tissues  treated,  condition, 
etc.  5.  Current  strength.  6.  Time  and  frequency  of 
application. 

The  missing  link  in  our  clinical  record  is  a  means  to 
state  the  current  strength.  We  can  sufficiently  indi- 
cate the  rest.  How  shall  we  measure  the  current 
strength  ?  Now,  certain  features  enter  into  the  meas- 
urement of  a  constant  current  which  are  eliminated 
from  the  case  of  an  interrupted  or  alternating  current. 
The  therapeutic  requirements  of  the  two  are  inherently 
dissimilar.  The  galvanic  current  is  silent  in  its  flow 
and  physiological  activity.  Without  observing  the  de- 
flection of  the  galvanometer  needle,  or  making  other 
test,  we  may  be  in  doubt  whether  or  not  the  battery  is 
in  action  until  the  current  is  strong  enough  to  be  felt 
by  the  patient,  and  as  a  guide  to  treatment  the  patient's 
sensations  are  incompetent.  The  predominating  qual- 
ity of  the  direct  current  is  volume — its  voltage  being 
relatively  small  in  medical  uses — and  "  volume  "  can- 
not be  determined  by  the  eye  or  ear  of  the  operator. 
On  the  other  hand,  the  induction  apparatus,  through 
its  break-piece,  which  is  the  essential,  the  very  life  of 
this  form  of  electricity,  gives  forth  to  the  ear  and  sight 
unmistakable  evidence  of  action  ;  and  its  current  is  one 
of  predominating  force,  of  insignificant  volume,  chiefly 
mechanical  in  its  physiological  effects,  and  nearly  de- 
void of  chemical  properties.  It  therefore  requires  no 
peculiar  safeguard,  like  the  milliamperemeter,  against 
an  excess  of  electrolytic  or  cautery  action  within  the 
tissues.  Moreover,  owing  to  the  feeble  power  of  dis- 
sociation possessed  by  the  constant  current,  an  enor- 
mous range  of  uncertainty  enters  into  every  galvanic 
application  without  a  meter  in  the  circuit  ;  for  the 
actual  current  strength  —  i.e.,  dose — from  the  same 
number  of  cells  and  with  the  same  electrodes  will 
vary  greatly  with  the  degree  of  resistance  of  the  skin, 
etc.,  so  that  similar  conditions  of  E.  M.  F.  are  no 
guide  whatever  to  similar  doses  and  effects.  With 
the  galvanic  current,  with  either  5,  10,  20,  or  40  cells 
E.  M.  F.,  and  with  the  electrodes  in  a  glass  of  water, 
I  can  cause  the  meter  to  vary  from  2  to  250  M.  A., 
without  altering  the  electrodes  or  the  battery,  simply 
by  lessening  the  resistance  of  the  water. 

The  nature  of  the  induction  current,  however,  is  such 
that  little  of  this  great  variability  occurs  in  clinical 
applications  when  similar  conditions  of  treatment  are 
repeated.  A  given  E.  M.  F.  will  produce  a  definite 
current  strength  from  a  given  induction  coil,  and  repeat 
it  under  the  same  conditions  as  often  as  desired.  The 
influence  of  slightly  varying  skin  resistances  of  differ- 
ent parts  of  the  surface  of  the  body  is  insignificant  in 
the  case  of  the  higher  voltage  and  penetrating  capacity 
of  currents  from  induction-coil  apparatus.  We  have, 
in  fact,  but  two  practical  conditions  of  resistance  to 
consider  in  faradic  therapeutics,  viz.,  the  greater  gen- 
eral resistance  of  the  skin  in  external  treatment,  and 
the  lesser  resistance  of  the  moist,  mucous  surfaces  of 
the  cavities  of  the  body.  Thus  presented,  we  observe 
that  the  problem  of  faradic  dose-measurement,  or  means 
of  record,  is  much  simpler  than  was  that  of  the  now 
solved  problem  of  galvanic  dose-measurement  ;  for  if 
we  can  by  any  means  indicate  the  electrical  or  mechan- 
ical energy  of  our  induced  currents  under  conditions 
identical  with  their  clinical  administration,  we  are  as- 
sured of  obtaining  the  same  energy  for  therapeutic 
uses  and  repeating  it  upon  patient  after  patient  with 
substantial  accuracy.  A  standard  indicator  of  current 
strength  will  accordingly  serve  as  a  subsequent  dose- 


register   for   future   applications   from   all  similar  ap- 
paratus. 

The  methods  so  far  suggested  for  measuring  the  dose 
of  induction-coil  currents  are  as  follows  : 

1.  A  strip  of  suitable  material,  wood,  celluloid,  or 
vulcanite,  is  placed  at  the  side  of  the  coil  and  marked 
in  fractions  of  inches,  or  of  the  decimal  scale.  The 
current  increases  in  strength  as  the  coil  overlaps  the 
primary,  and  the  dosage  is  taken  to  be  the  extent  of 
overlap  during  the  seance.  The  capabilities  of  meas- 
urement are  exhausted  when  the  overlap  is  complete, 
and  the  record  must  be  alike  for  one  or  four  cells,  or 
No.  36  or  No.  16  wire  coils.  It  is  not  surprising  that 
this  attempt  tomeasure  current  strength  by  a  foot-rule 
was  never  scientifically  successful. 

2.  The  graphic  method  of  marking  the  current 
waves  ;  a  purely  fanciful  idea  adapted  for  black-board 
illustration  of  certain  currents  characterized  by  suffi- 
cient amperage  to  operate  the  tracing-pencil,  but 
neither  practicable  outside  of  the  expert's  hands,  nor 
capable  of  demonstration  at  all  with  the  currents  of 
higher  tension  and  frequency  and  consequently  smaller 
amperage  now  performing  so  much  of  the  therapeutic 
work  of  improved  induction  apparatus. 

3.  The  Edelmann  faradimeter. 

The  name  faradimeter  is  felicitous  and  suggestive 
of  a  proper  method,  but  it  has  never  reached  a  more 
practical  stage  of  development  for  ordinary  use  than 
have  ships  for  navigating  the  air.  It  is  a  complicated, 
expensive,  though  highly  scientific,  meter  for  the  volt- 
age of  the  current  in  short  circuit ;  and  since  thera- 
peutic applications  involve  the  interposition  of  body 
tissues  this  instrument  has  no  relation  whatever  to  a 
physiological  unit. 

4.  Micro-coulombs  were  asserted  to  be  the  electrical 
unit  by  which  to  express  faradic  measurement,  but 
when  we  turn  to  the  coulombmeter  for  aid  we  are 
practically  where  the  faradimeter  left  us. 

5.  Voltmeters,  ammeters,  and  wattmeters  that  fill 
successfully  their  proper  places  in  measurements  of 
large  commercial  currents,  do  not  supply  us  with  any 
means  to  meter  the  small  currents  of  medical  coils. 
If  a  miniature  wattmeter  could  be  made  to  work  it 
would  be  too  expensive  for  geceral  use. 

6.  Rate  of  interruption. 

It  is  assumed  that  if  this  is  stated  in  mathematical 
terms  a  certain  amount  of  precision  will  be  secured. 
Other  factors,  however,  affect  the  question  of  dosage 
too  materially  to  place  dependence  solely  upon  know- 
ing the  frequency  of  the  periods. 

This  brings  us  to  consideration  of  the  method  pro- 
posed and  successfully  employed  by  me  for  upward  of 
a  year.  It  is  a  method  which,  in  my  hands,  has  passed 
beyond  the  nascent  stage  of  hopeful  theory  into  the 
practical  demonstration  of  constant  and  satisfactory 
use.  The  method  was  first  made  possible  when  I  in- 
troduced my  non-inductive  fluid  current  controllers 
into  the  secondary  circuit.  They  easily  supersede 
in  value  all  previous  methods  of  regulating  current 
strength. 

The  switch  board  of  my  induction  apparatus  presents 
a  rapid  interrupter  (vibrations  of  10,000  to  30,000  per 
minute)  ;  a  slow  vibrator  capable  of  adjustment  from 
about  two  thousand  periods  per  minute  down  to  less  than 
one  period  per  second  ;  a  cell  selector  throwing  into  cir- 
cuit from  one  to  six  cells  at  will ;  an  eight-button  com- 
pound coil  selector  ;  a  pole  reverser  and  a  metallic 
rheostat  governing  the  primary  current.  This  consists 
of  a  perpendicular  column  seven  inches  in  height, 
wound  with  German-silver  wire  of  definite  resistance, 
making  twenty  turns  to  each  inch  of  column.  At- 
tached to  it  is  a  registration  scale  to  denote  every  wind 
of  wire  from  zero  to  140,  and  permit  a  record  of 
position  in  every  degree  of  use.  This  scale  is  also  an 
advance  in  accuracy  of  record,  first  suggested  by  me. 
But  the  peculiar  novelty  introduced  in  this  apparatus 
is  the  author's  secondary  circuit   rheostat,  which  con- 


876 


MEDICAL    RECORD. 


[December  21,  1895 


sists  of  the  glass  tubes  seen  at  the  left  of  the  switch- 
board and  marked  respectively  i  and  2.  They  con- 
tain prepared  fluids  of  great  resistance  (much  greater 
than  water),  and  are  the  first  competent  controllers 
successfully  applied  to  the  secondary  current  of  a 
medical  induction  battery.  The  capacity  of  the  first 
(one  megohm)  is  sufficient  to  control  the  full  coil,  high- 
tension  current,  and  reduce  the  perception  of  it  to 
zero  in  the  most  delicate  external  applications  to  a  pa- 
tient. 

The  second  tube  possesses  a  much  lower  resistance, 
for  currents  of  less  penetrative  force.  Each  tube  is 
scaled  in  ohms  of  their  actual  resistance,  measured 
and  calibrated  for  me  by  Professor  F.  B.  Crocker,  of 
Columbia  College,  New  York.  The  rationale  of  my 
method  is  now  extremely  simple.  The  fluids  in  one 
or  both  tubes,  and  at  certain  heights  of  the  movable 
contact  rod,  varying  with  the  primary  E.  M.  F.  and 
current  density,  entirely  nullify  the  patient's  per- 
ception of  the  activity  of  the  induced  currents, /.^.,  con- 
trol them,  and  reduce  their  physiological  and  thera- 
peutic manifestation  to  zero,  and  afterward  regulate 
them  to  any  strength  we  desire.  What  resistance  to 
the  energy  of  any  given  current  does  it  require  to  do 
this  ?  The  answer  to  this  question  is  the  solution  of 
faradic  dosage. 

The  scale  referring  to  tube  No.  i  shows  the  total 
resistance  of  its  four  and  a  half  inches  of  fluid  column 
to  be  one  megohm.  As  the  movable  electrode  descends 
in  the  tube  the  resistance  lessens  until  it  is  only  900, 
800,  600,  400,  200  thousand  ohms,  and  so  on  down  to 
the  minimum,  when  the  electrodes  of  the  rheostat  are 
nearest  contact.  The  great  resistance  of  this  tube  is 
designed  to  regulate  the  higher  tension  currents  of  the 
compound  coil,  which,  in  this  apparatus,  I  have  caused 
to  be  placed  invisibly  behind  the  switch-board  and 
fixed  in  complete  overlap  upon  the  primary  helix. 
This  coil  is  immovable  and  does  away  with  former 
sledge  methods  of  sliding  coils  on  and  off,  while  it  gen- 
erates at  all  times  the  maximum  of  inductive  influence. 

Tube  No.  2  is  of  much  lower  resistance,  ranging 
from  55,000  ohms  down  to  a  residual  resistance  of 
4,000  ohms,  and  is  suited  to  the  regulation  of  currents 
of  small  voltage,  from  short,  coarse  coils,  or  other  ap- 
plications where  great  tolerance  exists,  as  within  the 
pelvis.  An  additional  turn  of  a  switch  also  cuts  out 
these'  secondary  rheostats  and  furnishes  all  currents 
direct  from  the  coils,  in  case  this  is  desired.  The  me- 
tallic rheostat  in  the  primary  circuit  then  regulates  the 
dosage  by  altering  the  E.  M.  F.,but  this  rheostat  takes 
no  part  in  my  special  method  of  dose  registration. 

In  my  method,  in  applying  a  given  current  strength 
to  a  patient,  it  is  simply  considered  that  the  energy  at 
first  wholly  absorbed  within  the  secondary  rheostat, 
when  perception  of  the  current  is  nullified  on  its  pas- 
sage through  the  rheostat  to  the  patient,  is  transferred 
from  the  controUing  grasp  of  the  rheostat  to  exert  an 
equivalent  energy  within  the  tissues  when  the  descent 
of  the  movable  rod  in  the  tube  reduces  resistance  pro- 
portionate to  its  descent,  and  in  exact  proportion  raises 
the  current  strength  in  the  part  of  the  circuit  between 
the  applied  electrodes..  In  other  words,  as  the  restraint 
of  the  current  falls  in  the  rheostat  its  released  energy 
rises  in  the  patient,  and  by  measuring  the  degree  of  re- 
straint we  find  the  equivalent  of  the  released  energy. 

"  Things  which  are  equal  to  the  same  thing  are  equal 
to  each  other,"  and  knowing  the  graduated  resistance 
in  electrical  units  of  ohms  interposed  and  removed 
from  the  secondary  circuit  at  will,  our  knowledge  of 
Ohms's  law  substantially  defines  for  us  the  values  of 
therapeutic  dosage.  We  have  only  to  let  a  portion  of 
the  measured  rheostat  substitute  itself  for  the  patient's 
tissues  while  we  at  first  test  the  degree  of  energy  to  em- 
ploy, and  next  to  pass  on  the  same  current  value  to  the 
patient,  to  arrive  at  a  very  practical  measure  of  the 
dose  administered.  The  resistance  of  the  body  is  com- 
pensated in  the  process  and  causes  no  error,  and  the 


battery  E.  M.  F.  is  unaltered  during  the  dose  regula- 
tion. 

Before  describing  further  the  details  of  my  method, 
it  is  proper  to  cite  the  authority  for  the  electrical  meas- 
urements which  constitute  the  scientific  basis  of  accu- 
racy claimed  by  me  above. 

"  New  York,  December  17,  1894. 

"  Dr.  S.  H.  Moxell.  De.\r  Sir  :  I  return  herewith 
the  two  tubes  containing  liquid  resistances  which  you 
submitted  to  me.  I  have  calibrated  each  tube  and  pro- 
vided it  with  a  scale  which  shows  its  electrical  resist- 
ance in  ohms  for  every  position  of  the  movable  elec- 
trode. My  opinion  in  regard  to  these  devices  is  as 
follows  :  I.  A  liquid  resistance  is  a  very  simple  and 
convenient  means  of  obtaining  very  high  resistance  for 
medical  use.  2.  By  changing  the  liquid  the  range  of 
resistance  may  be  varied  from  several  megohms  to  a 
fraction  of  an  ohm.  3.  The  screw  adjustment  of  the 
electrode  enables  the  resistance  to  be  gradually  varied 
to  any  value,  without  the  sudden  shock  which  occurs 
when  resistance  coils  are  cut  out.  4.  The  resistance 
is  non-inductive,  hence  there  is  no  reaction  against  or 
distortion  of  the  current,  which  is  very  important  in 
connection  with  induction  (faradic)  coils.  5.  A  short 
circuit  cannot  occur,  the  electrodes  being  arranged  so 
that  it  is  impossible  for  them  to  come  in  contact,  where- 
as there  is  serious  danger  of  short  circuit  in  resistance 
coils  with  high-tension  currents.  6.  The  resistance  is 
practically  definite  and  constant,  provided  the  tempera- 
ture remains  nearly  the  same.  With  the  small  currents 
ordinarily  used  the  heating  effect  is  small,  but  if  neces- 
sary the  temperature  can  be  tested  by  a  small  thermom- 
eter and  kept  constant  or  allowed  for.  7.  The  effects 
of  polarization  and  electrolysis  are  insignificant,  since 
the  potential  is  high  and  the  current  is  alternating  in 
the  case  of  induction-coils,  with  which  these  resistances 
are  to  be  used.  S.  The  liquid  does  not  appear  to  be 
affected  by  the  action,  or  to  change  in  any  way,  but  it 
is  of  course  impossible  without  actual  trial  to  tell  what 
effect  might  occur  in  a  long  period  of  time.  Any  dif- 
ficulty of  this  kind  might  be  overcome  by  renewing  the 
liquid  occasionally. 

"  Yours  truly, 

"  F.  B.  Crocker, 

"  Professor  of  Electrical  Etigineering, 
Columbia  College. " 

While  therefore  the  once  proposed  scale  of  fractions 
of  inches  was  a  purely  fictitious  and  ridiculous  travesty 
upon  scientific  dose-measurement,  the  author's  method 
is  a  comparative  record  of  the  current  strength  and  not 
a  mere  fragment  of  a  tailor's  yard-stick.  As  such  a  re- 
sistance register  and  rheostat  is  of  general  applicability, 
and  may  be  placed  by  all  instrument-makers  upon  high- 
grade  batteries  and  properly  standardized  for  clinical 
use,  it  may  be  fairly  claimed  that  the  general  adoption 
of  my  method  would  supply  the  long-expressed  need 
for  precision  in  faradic  dose  records. 

To  illustrate  the  method  let  us  hold,  for  example, 
two  ordinary  electrodes  in  the  hands,  select  for  our 
coil  one  thousand  five  hundred  yards  of  No.  36  wire, 
and  employ  very  slow  interruptions  of,  say,  seventy  per 
minute.  We  raise  the  rod  in  tube  i  to  its  full  height 
and  switch  four  cells  into  circuit.  Gradually  lowering 
the  contact  rod,  we  note  the  point  where  the  current 
becomes  first  perceptible  to  sensation.  It  is  at  700,000 
ohms  resistance  on  the  scale.  Taking  this  as  our  zero 
unit,  we  continue  to  lower  the  rod  until  muscular  con- 
tractions are  produced  as  strong  as  we  desire.  The 
rheostat  now  indicates  but  100,000  ohms,  showing 
that  600,000  ohms  of  resistance  have  been  removed  from 
the  passage  of  the  current  into  our  arm  muscles,  which 
feel  and  respond  to  the  force  previously  expended 
within  the  rheostat.  If  now  I  record  the  facts  :  Coil, 
1,500  yards  of  No.  36  wire.  Interruptions,  70.  E.  M.  F., 
four  cells.  Dose,  600,000  ohms,  small  sponge  electrodes 
in  hands,  positive  in  right  ;  I  can  repeat  the  exact  ap- 


December  21,  1895] 


MEDICAL   RECORD. 


877 


plication  and  muscular  effect  whenever  and  as  often  as 
wished,  even  should  the  cells  deteriorate  by  use  so  as 
to  require  five  or  six  cells  to  equal  the  energy  recorded. 
There  is  no  parallel  to  this  precision  of  record  to  be 
found  in  the  literature  of  faradic  electricity.  The 
method  allows  for  all  possible  variations  in  treatment. 

Again,  using  a  short,  coarse  coil,  one  hundred  and 
fifty- four  yards  of  Xo.  21  wire,  for  instance,  we  obtain 
sensation  with  a  given  contact  at  36,000  ohms  resistance 
of  tube  2  :  and  full  tolerance  is  reached  when  but  4,000 
ohms  remain.  The  given  dose  is  therefore  the  elec- 
trical energy  represented  in  overcoming  32,000  ohms 
of  resistance  with  the  current  quantity  value  indicated 
by  the  capacity  of  the  wire  in  the  induction-coil.  It  is 
not  essential  to  know  the  galvanic  amperage  of  differ- 
ent sizes  of  wire  with  a  corresponding  voltage,  for  we 
are  not  dealing  with  galvanic  but  with  induced  cur- 
rents, in  which  volume  is  subordinate  to  potential  and 
kinetic  energy  ;  and  our  different  coils — long,  medium, 
short,  fine,  and  coarse — take  on  a  definite  individual 
identity  under  habitual  use  which  serves  the  expert  as 
a  practical  expression  of  their  quantity  values.  Our 
second  record  reads  with  electrodes  same  as  before, 
but  a  more  rapid  rate  :  Coil,  154  yards  No.  21  ;  fre- 
quency, 300  ;  cells,  two  ;  dose,  32,000  ohms. 

In  the  last  case  the  lower  voltage  is  seen  to  be  com- 
mensurate with  the  greater  volume  conducted  by  the 
coarse  wire,  while  the  previous  high  voltage  of  the 
long  fine-wiie  current  was  proportioned  to  the  ex- 
tremely diminished  volume  induced  through  it. 

In  making  a  vaginal  bipolar  application  with  a  very 
rapidly  interrupted  high-tension  sedative  current  we 
use  tube  2,  with  its  low  resistance,  owing  to  the  enor- 
mous tolerance  of  the  tissues  treated. 

An  illustrative  clinical  record  reads  as  follows  :  Vag. 
bipolar  sedation,  coil,  1500,  No.  36.  Rapid  vibrator, 
E.  M.  F.  4  cells.  Dose,  45,000  ohms,  twenty  minutes, 
daily. 

If  this  seems  to  express  a  small  dose  (an  inadequate 
estimate  of  the  great  tolerance  of  the  pelvic  tissues),  it 
must  be  remembered  that  it  is  the  difference  between 
zero  sensation  and  the  maximum  current  strength  ad- 
ministered with  electrodes  applied  in  actual  treatment, 
which  is  recorded  as  the  dose,  and  not  the  difference 
between  the  sensitive  nerve  filaments  of  the  hand  and 
tissues  whose  dulness  of  sensation  and  low  resistance 
to  current  diffusion  permits  them  to  accept  with  com- 
fort and  benefit  an  application  which  would  be  painful 
on  the  surface  of  the  skin.  If  the  dose  was  reckoned 
from  a  zero  obtained  in  one  arbitrary  manner,  say,  by 
touching  the  electrodes  with  the  finger  or  thumb  before 
applying  them  to  the  patient,  it  would  bear  no  genuine 
relation  to  the  dosage  of  larger  contact  areas,  of  differ- 
ent varieties  of  electrodes  and  different  parts  of  the 
body. 

To  be  a  scientific  and  universal  method  it  must  an- 
swer for  all  conditions  of  treatment,  and  my  method 
does  this  jjerfectly.  The  use  of  a  single  cell,  or  of  any 
number  up  to  six  (the  battery  contains  six  cells),  will 
determine  the  zero  at  a  higher  or  lower  point  on  the 
scale,  and  the  same  cells,  as  they  deteriorate,  in  time  will 
alter  their  E.  M  F.  ;  but  these  variations  do  not  alter 
the  accuracy  of  my  dose  record,  which  is  the  difference 
between  the  minimum  and  maximum  rheostat  readings 
independent  of  the  number  of  cells  it  takes  to  furnish 
the  given  inductive  force. 

The  difference,  also,  in  power  to  penetrate  tissue  re- 
sistance will  create  a  different  zero  point  for  each 
length  and  size  of  wire,  even  with  the  same  E.  M.  F. 
inducing  force  and  same  electrodes  ;  but  with  standard 
coils,  a  standard  method  of  finding  the  actual  zero 
point  in  all  cases,  with  any  coil,  with  any  number  of 
the  battery  cells  at  any  period  of  their  life,  my  method 
furnishes  a  flexible,  permanent,  and  accurate  measure- 
ment of  the  true  therapeutic  dose.  Its  adaptability  to 
varying  conditions  of  current  volume,  voltage,  resist- 
ance, and  density  removes  all  sources  of  error. 


This  method,  carried  out  in  its  fullest  detail,  is  par- 
ticularly applicable  to  the  records  of  clinicians  and 
other  observers  whose  investigations  require  an  exact 
comparison  of  results.  In  general  practice  the  physi- 
cian will  soon  familiarize  himself,  at  least  approxi- 
mately, with  the  position  of  the  rheostat  for  various 
zero  readings,  just  as  the  skilled  book-keeper  soon  re- 
members the  ledger  pages  of  his  accounts  ;  so  that 
actual  tests  for  zero  will  be  unnecessary  except,  per- 
haps, in  the  first  treatment  of  a  new  case.  If  the  full 
dose  record  is  considered  sujjerfluous  for  the  physi- 
cian's own  records  in  his  ordinary  office  work,  a  modi- 
fication will  furnish  satisfactory  notes  for  personal  ref- 
erence. In  using  the  modified  method  which  I  suggest, 
we  need  not  repeatedly  calculate  the  actual  dose  ad- 
ministered, but  simply  note  the  conditions  under  which 
the  maximum  current  was  applied  by  recording  the 
lowest  reading  of  the  scale.  For  example  :  Coil,  icoo, 
No.  36.  Rapid  V.  ;  cells  5  :  scale  6000  ;  tube  2  :  vag. 
bipolar,  20  minutes.  There  is  no  expert  electro- thera- 
peutist equipped  with  similar  apparatus  who,  on  read- 
ing this  record,  could  not  instantly  apply  the  same 
treatment  with  the  same  dose,  though  he  were  a  thou- 
sand miles  away.  The  use  of  initials  for  full  words 
will,  of  course,  abbreviate  the  record  in  our  private 
case- books  and  be  equally  intelligible  to  our  under- 
standing. 

My  resistance  scales,  therefore,  clearly  supply  to  in- 
duced currents  a  dose  indicator  as  practical  in  their 
case  as  the  milliametre  is  in  the  case  of  direct  currents, 
and  complete  the  hitherto  imperfect  record  of  faradic 
administrations.  Of  the  other  factors  requiring  report 
for  purposes  of  uniformity  in  clinical  observations,  the 
character  of  the  electrodes  can  always  be  identified 
by  sizes,  numbers,  or  names,  as  in  makers'  catalogues. 
Quantity  and  quality,  the  elements  of  induced  currents 
subordinate  to  their  energy  and  pressure  force,  are,  as 
we  have  seen,  sufficiently  expressed  by  reference  to  the 
particular  coil  employed.  A  more  exact  description 
will  hardly  be  required  by  experts  in  electro- therapy. 
As  the  trained  electrician  becomes  accustomed  to  the 
quantitative  and  qualitative  differences  in  effect  be- 
tween every  coil  in  his  apparatus,  whether  500,  i,oco, 
or  1,500  yards  of  No.  36  wire,  or  Soo  or  500  yards  of 
No.  32  wire,  down  to  shorter  coils  of  No.  21  or  18  size, 
he  accurately  knows  the  characteristics  of  currents 
from  them  all,  and  utilizes  their  diverse  properties  with 
intelligence  and  precision. 

It  would  add  no  tlierapeutic  value  to  his  knowledge 
if  the  current  volume,  per  wire,  was  noted  by  a  meter 
in  terms  of  amperage,  or  the  E.  M.  F.  in  volts. 

There  now  remains  but  one  factor  of  dosage  still  sur- 
rounded by  vagueness  and  lack  of  precision  in  theor\-, 
although  clearly  defined  enough  for  practical  purposes. 
This  relates  to  the  record  of  the  rate  of  current  inter- 
ruption, a  very  important  part  of  the  matter  indeed. 
Very  low  ratio  (50  to  300)  can,  however,  be  stated  in 
comparative  figures,  while  very  rapid  interruption  does 
not  reciuire  a  numerical  term  to  express  its  frequency. 
Speed,  as  stated  in  mere  figures  per  minute,  is  so  in- 
volved with  other  qualities  of  adjustment,  evenness, 
constancy,  length  of  period,  etc.,  that  the  advantage  of 
a  mathematical  record  can  be  greatly  overestimated. 

I  have  referred  to  this  in  other  of  my  writings,  and  it 
is  out  of  place  to  dwell  on  tliis  jwint  at  i)resent,  though 
it  is  one  of  peculiar  interest.  A  closely  related  feature, 
however,  may  claim  our  attention  briefly. 

It  is  the  ideal  of  some  who  have  sought  to  define 
faradic  dosage  by  rate  of  interruption,  and  who  have 
devoted  much  time  and  si)e(i;il  thoupht  to  the  im- 
provement of  faradic  ap]>aratus,  to  construct  an  in- 
dependent interrupter,  actuated  by  a  current  separate 
from  that  which  supplies  the  inducing  force. 

The  reason  for  thii  lies  in  tlic  fact  that  every  change 
in  the  regulation  of  current  strength  made  in  the  pii- 
mary  circuit  varies  the  rate  and  force  of  the  inter- 
rupter in  instruments  as  generally  made.     A  prominent 


878 


MEDICAL    RECORD. 


[December  21,  i{ 


writer  has  ably  argued  the  advantages  of  such  a 
method,  and  states  that  it  can  be  adapted  to  every 
kind  of  contact-breaker,  the  motor  power  for  the 
rheotome  being  furnished  by  a  single  separate  cell. 
The  importance  of  steadfast  E.  M.  F.  and  unvarying 
evenness  of  interruption  throughout  all  gradations 
of  the  induced  current  strength,  is  so  great,  so  essential 
to  the  satisfactory  employment  of  faradic  electricity, 
that  no  battery  not  providing  for  independent  second- 
ary current  control  can  be  considered  as  representing 
the  advanced  progress  of  to-day. 

Manufacturers  of  medical  batteries,  however,  do  not 
all  agree  with  the  writer  who  advocates  the  separate 
cell  for  the  interrupter,  and  are  well-nigh  unanimous 
in  declaring  that  the  mechanical  obstacles  to  the 
device  are  insurmountable  in  practice.  The  theory  is 
correct,  but  makers  have  failed  to  apply  it  successfully 
to  the  spring  vibrators  in  common  use.  My  apparatus 
easily  surmounts  the  difficulty  ;  furnishing  not  alone 
one  cell  to  actuate  the  break-piece,  but  places  six  at 
our  disposal  at  will,  as  independently  as  any  theorist 
aould  desire.  My  k)rmer  article  describing  the  im- 
proved induction  apparatus  designed  by  me,  referred 
to  this  feature  at  some  length,  but  I  wish  to  emphasize 
again  the  far-reaching  importance  of  the  secondary 
rheostats  which  accomplish  this  purpose  in  my  battery, 
and  to  state  further  that,  were  their  usefulness  and  in- 
fluence restricted  to  mere  regulation  of  induced  cur- 
rent strength,  without  jarring  or  irregularity,  or  change 
in  the  primary  flow,  the  advantage  they  would  thus 
contribute  to  clinical  handling  of  both  patient  and 
battery  would  alone  stamp  this  apparatus  as  without 
an  equal  in  therapeutic  convenience  and  capabilities. 
That  beyond  this  these  rheostats  make  possible  a  prac- 
tical dose  record,  is  proof  of  their  fundamental  neces- 
sity to  a  perfect  instrument.  If  still  unconvinced  that 
they  are  indispensable,  let  us  attempt  to  adjust  a  slowly 
interrupted  induced  current — say  fifty  periods  per  min- 
ute— to  a  dosage  of  strength  sufficient  to  produce 
powerful  but  painless,  rhythmical,  and  non-tiring  con- 
tractions of  certain  arm  muscles,  with  a  gradual  and 
even  decrease  to  scarcely  perceptible  sensation.  With 
the  ordinary  interrupter,  sliding  coil,  or  primary  rheo- 
stat, it  cannot  be  done,  even  with  the  costliest  appli- 
ance in  the  market.  With  my  apparatus  it  is  done  in- 
stantly and  with  the  most  striking  success.  As  an 
object-lesson  in  the  inadequacy  of  old  methods  of  cur- 
rent regulation,  and  of  the  superior  efficiency  of  my 
secondary  rheostats,  it  leaves  nothing  open  for  argu- 
ment. Professor  Crocker's  letter  appreciatively  sums 
up  the  rest. 

£65  Union  Stbeet,  Brookl^'n. 


A  Slap  at  the  Bacteriologists. — These  are  useful 
assistants,  but  they  are  tyrannical  masters,  and  the  re- 
sults of  a  given  treatment  must  after  all  be  judged,  not 
in  the  laboratory,  but  in  the  hospital  ward  and  the  sick- 
room. A  check  must  be  imposed  on  garrulous  bacte- 
riologists who  show  a  disposition  to  ride  the  cock- 
horse among  us.  We  are  grateful  to  them  for  such 
assistance  as  it  may  be  in  their  power  to  render  to 
medical  science,  but  we  cannot  allow  them  to  dictate  to 
us  what  conclusions  we  are  to  draw  from  clinical  in- 
vestigation. Bacteriological  statements  are  matters  of 
inference,  but  clinical  observations  are  facts  ;  facts,  too, 
which  concern  us  more  nearly  than  the  interesting,  but 
too  often  contradictory,  deductions  which  foreign  labo- 
ratory men  foist  upon  us  at  the  point  of  the  scalpel. 

A  Naval  Hospital  Corps.— Surgeon-General  J.  R. 
Tryon  recommends  the  establishment  of  a  hospital 
corps  for  the  navy,  the  limiting  of  the  number  of  re- 
cruiting stations,  and  establishing  a  rendezvous  at  the 
Brooklyn  Navy  Yard,  and  another  at  the  Mare  Island 
Navy  Yard. 


INFLUENCE  OF  BILE  ON  THE  PROTEOLYTIC 

ACTION    OF    PANCREATIC   JUICE. 

By  E.  K.  RACHFORD,  M.D., 

PROFESSOR  OF  PHYSIOLOGY  IN  THE  MEDICAL  COLLEGE  OF  OHIO. 

F.   H.  SOUTHG.VTE,  M.D., 

ASSISTANT  IM  JHYSIOLOGY  IN  THE  MEDICAL  COLLEGE  OF  OHIO. 

The  experiments  recorded  in  this  paper  were  planned 
for  the  purpose  of  throwing  some  light  on  the  proteo- 
lytic action  of  pancreatic  juice,  under  the  conditions 
which  normally  exist  in  the  duodenum.  In  brief,  the 
questions  which  these  experiments  were  planned  to  in- 
quire into  are  as  follows  :  i.  Does  the  presence  of 
hydrochloric  acid  combined  with  proteids  influence  fa- 
vorably or  unfavorably  the  action  of  pancreatic  juice  on 
these  proteids  ?  2.  Does  bile,  when  added  to  neutral 
proteids,  influence  favorably  or  unfavorably  the  action 
of  pancreatic  juice  on  these  proteids  ?  3.  Does  bile, 
when  added  to  acid  proteids,  influence  favorably  or 
unfavorably  the  action  of  pancreatic  juice  on  these 
proteids  ?  4.  Does  pancreatic  juice,  acting  alone  on 
neutral  proteids,  have  greater  or  less  proteolytic  power 
than  when  acting  under  the  conditions  found  in  the 
nonnal  duodenum,  that  is  to  say,  when  acting  in  the 
presence  of  bile  and  combined  hydrochloric  acid  ? 

It  is  claimed  for  these  experiments  that  they  are  the 
first  work  of  this  kind  which  has  been  done  with  pure 
pancreatic  juice,  and  for  this  reason,  if  for  no  other, 
they  are  deserving  of  some  attention. 

The  classic  work  of  Chittendon  in  this  field  was 
done  with  pancreatic  extracts,  and  for  these  extracts 
his  work  is  conclusive.  But  neither  Chittendon, 
Kuhne,  Lea,  nor  other  investigators  in  this  field  have 
attempted  any  systematic  research  with  pure  pancre- 
atic juice. 

While  it  is  not  claimed  that  observations  made  with 
pancreatic  juice  are  more  reliable  than  those  made 
with  pancreatic  extracts,  it  is  claimed  that  these,  the 
first  systematic  experiments  ever  made  on  the  proteo- 
lytic action  of  pancreatic  juice,  deserve  some  consider- 
ation, even  though  this  field  has  been  so  ably  worked 
with  pancreatic  extracts. 

Method. — The  pancreatic  juice  was  used  immedi- 
ately after  it  was  obtained  from  the  rabbit.  One  rab- 
bit, as  a  rule,  would  furnish  sufficient  juice  for  an  ex- 
periment. The  juice  was  obtained  by  the  method' 
devised  by  one  of  us  (Rachford),  and  first  published 
in  the  Journal  of  Physiology  (vol.  xii..  No.  i,  1S91). 
The  proteid  used  in  these  experiments  was  the  one 
recommended  by  Chittendon,  which  he  describes  ^  as 
"  purified  and  dried-blood  fibrin,  prepared  by  thor- 
ough washing  with  water,  extraction  with  cold  and 
boiling  alcohol,  and  lastly  with  ether.  It  was  then 
ground  to  a  coarse  powder  and  dried  at  100°  to  110° 
C."  The  digestive  mixtures  containing  the  pancreatic 
juice  and  other  fluids,  as  noted  in  the  tabulated  experi- 
ments, were  kept  at  40°  C.  for  from  four  to  ten  hours. 
These  mixtures  were  then  filtered  through  weighed 
filters,  and    the   residue  (fibrin)  left   upon   the   filters 

>  Make  an  abdominal  incision  in  the  linea  alba,  two  and  one-h.^lf 
inches  long.  Bring  the  duodenum,  which  is  readily  found  high  up  in 
the  right  hypochondriac  region,  through  lliis  opening,  run  down  the 
g\it  to  a  point  where  the  peritoneum  binds  it  so  closely  that  it  w  ill  not 
come  through  the  opening,  and  just  at  this  point  will  be  found  the 
pancreatic  duct,  as  it  runs  through  a  leaf  of  the  pancreas  to  the  small 
intestine.  Resect  two  inches  of  the  intestine  at  this  point,  leaving  its 
mesenteric  attachment ;  tie  the  cut  ends  of  the  intestine  above  and 
below,  and  drop  them  in  the  cavity,  bringing  the  resected  portion 
through  the  abdominal  wound.  The  abdominal  wound  is  now  par- 
tially closed  by  stitches,  leaving  only  sufficient  opening  for  the  me- 
sentery running  to  the  resected  gut.  This  resected  gut  is  now  laid 
open  opposite  the  mesenteric  attachment  and  spread  out  ou  the  ab- 
domin.il  wall.  The  ends  of  the  gut  are  clamped  .ind  its  lateral  mar- 
gins packed  with  absorbent  cotton  to  prevent  bleeding.  Insert  a 
small  glass  cannula  through  the  pancreatic  papflla  into  the  pancreatic 
duct,  and  cover  the  exposed  mucous  membrane  with  absorbent  cotton 
saturated  with  common  salt  solution.  The  flow  of  juice  begins  at 
once  and  continues  from  four  to  si.x  hours.  In  this  manner  about  one 
cubic  centimetre  of  jnice,  uniform  and  powerful  in  physiologic  action, 
may  be  collected. 

2  This  method  is  described  in  Chittendon's  Studies  in  Physiolog- 
ical Chemistry,  vol.  i.,  p.  77. 


December  21,  1895] 


:\IEDICAL    RECORD. 


879 


was  thoroughly  dried.  After  forty-eight  hours  of  dry- 
ing they  were  again  weighed  ;  the  weight  of  the  filter 
being  subtracted  from  this  weight  would  give  the 
weight  of  the  undigested  fibrin.  Six  grains  of  the 
fibrin  were  used  in  each  experiment,  and  the  difference 
between  this  and  the  undigested  residue  would  repre- 
sent the  amount  of  fibrin  digested,  and  would  therefore 
measure  the  proteolytic  power  of  the  digestive  mixture 
which  did  the  work. 


i 

^ure    Pancre-  | 

aric   Juice,     i 

Minims. 

Waier. 
Minims. 

Hydrochloric      rl'^I^o?"      Fibrin 
..Acid.   0..    Per      *^'"^- ?"'""        Used. 
Cent.  Soluticn.         Minims.         '^'^""• 

1      Fibrin 
Digested. 
Grains. 

Ex  PER 

l.ME.NT    I. 

Time,  4*  Hours. 

3 

30 

3ss. 

50 

6 

I'd 

3          1 

So 

3  ss. 

6 

'lo 

3 

60 

50 

6 

2, 

no 

6 

lis 

EXPER 

IMENT   2. 

Time,  4  Hours 

10 

50 

3  ss. 

50       1 

6 

2I 

10 

bo 

Z  ss. 

1 

6 

Is 

lo' 

60 

50 

6 

II 

10 

no 

6 

I? 

EXPERI 

MENT   3. 

Time,  6f  Hours 

5 

30 

3  ss. 

50 

6 

4 

5 

80 

3ss. 

6 

3j 

S 

60 

50 

6 

3- 

5 

no 

6 

3l 

EXPER 

.MEN  r  ^. 

Time,  6^  Hours 

6 

30 

3  S5. 

50 

6 

1    2V0 

6 

80 

3  Si. 

6 

2|'=„- 

6 

60 

50 

6 

2-j^j 

6 

no 

6 

1      2h 

EXPER 

IMENT    5. 

Time,  6  Hours 

7 

30 

Z  SS. 

50       1 

6 

3 

7 

So 

Z  ss. 

6 

2} 

7 

60 

50 

6 

2} 

7 

no 

6 

- 

ExPER 

IMENT   6. 

Time,  8  Hours. 

4 

30 

3  ss. 

i        50 

6 

2 

4 

80 

3  ss. 

6 

li 

4 

60 



i        50 

6 

ij 

4 

no 

1 

6 

I 

Ex  PER 

MENT    7. 

Time,  10  Hours 

9 

3  SS. 

5° 

6 

,i 

9 

50 

3  SS. 

6 

2 

9 

30 

50 

6 

2 

9 

So 

6 

li 

ExPER 

IMENT   8. 

Time,  8  Hours 

8 

1          3  SS. 

i        ^ 

6 

It 

8 

50 

1         3ss. 

6 

it 

8 

30 

.... 

50 

6 

li 

8 

80 

1          .... 

6 

ij 

FXPEH 

IMENT    9. 

Time,  6  Hours 

10 

3  Si. 

1        s      ' 

6 

2i 

10 

50 

3  f  s. 

\     ....      1 

6 

1} 

10 

30 

1       50       1 

6 

2 

10 

So 

6 

i5 

ExPER 

MENT    10. 

Time,  6  Hours 

12 

3  SS. 

50 

6 

3 

■  2 

50 

Z  ss. 

6 

2; 

12 

3° 

1.... 

50 

6 

2i 

12 

So 

KXPEK 

IMENT    II. 

Time,  7  Hour; 

6 

2 

4 

3  Si. 

50       1 

6 

!    ^ 

4 

5'' 

6 

,     '^■ 

4 

30 

50 

6 

r. 

4 

So 

1 

6 

1 

EXIER 

IMENT    12 

Time,  6  Hours. 

10 

3  SS. 

50 

6 

3 

10 

50 

3  ss. 

6 

i': 

10 

50 

50 

6 

2', 

10 

So 

6 

2: 

With  this  table  before  us  we  can  now  study  the  q.ues- 
tions  which  these  experiments  were  planned  to  investi- 
gate. 


I.  Does  the  presence  of  hydrochloric  acid  combined 
with  proteids  influence  favorably  or  unfavorably  the  ac- 
tion of  pancreatic  juice  on  these  proteids  ?  In  answer 
to  this  question,  Chitt«ndon,  working  with  pancreatic 
extracts,  says  :  '  "  Experiments  made  in  my  laboratory 
have  shown  that  as  soon  as  free  acid,  especially  hydro- 
chloric acid,  is  present  in  a  solution  containing  tripsin, 
then  proteolytic  action  is  at  once  stopped.  When,  how- 
ever, acids,  especially  organic  acids,  are  present  in  a  di- 
gestive mixture  containing  an  excess  of  proteid  matter, 
so  that  the  solution  contains  no  free  acid  (or  better  with 
the  proteid  matter  only  partially  saturated  with  acid), 
then  tripsin  will  continue  to  manifest  its  peculiar  prote- 
olytic power,  although  to  a  considerable  lessened  ex- 
tent." In  our  experiments  we  have  found  that  the  pro- 
teol)tic  action  of  pancreatic  juice  on  fibrin  is  quite  as 
strong  in  a  one-thirtieth  per  cent,  hydrochloric-acid  so- 
lution as  it  is  in  a  neutral  solution.  If  there  is  any  dif- 
ference, in  fact,  it  is  in  favor  of  the  hydrochloric-acid 
solution.  In  only  three  (1,4,  and  12)  of  the  twelve  ex- 
periments did  the  pancreatic  juice  in  neutral  solution 
do  more  work  than  the  pancreatic  juice  acting  in  acid 
solutions.  In  two  (S  and  9)  experiments  the  same 
work  was  done  in  the  acid  as  in  the  neutral  mixture  : 
while  in  seven  (2,  3,  5,  6,  7,  10,  and  11)  experiments 
slightly  more  work  was  done  in  the  acid  mixture  than 
in  the  neutral.  From  these  observations  we  conclude 
that  the  proteolytic  action  of  pancreatic  juice  is  not  re- 
tarded by  the  presence  of  a  small  percentage  of  hydro- 
chloric acid — such,  for  example,  as  existed  in  our  ex- 
periments and  probably  also  exists  in  the  normal 
duodenum. 

We  are  encouraged  to  publish  this  observation, 
iconoclastic  as  it  may  seem,  because  some  comparative 
anatomy  -  studies  made  by  one  of  us  (Rachford)  lead 
to  the  same  conclusion.  In  these  studies  it  was  found 
that  tlesh-eating  animals  had  the  common  opening  for 
their  bile  and  pancreatic  ducts  very  near  the  pyloris, 
and  that  the  more  exclusively  flesh-eating  the  animal 
was  the  nearer  to  the  pyloris  was  this  common  open- 
ing. If  the  acid  contents  of  the  stomach  destroyed  the 
proteolytic  action  of  the  pancreatic  juice,  it  is  needless 
to  say  that  the  opening  of  the  pancreatic  duct  would 
not  approach  the  stomach  in  the  exclusively  carnivor- 
ous animals,  even  though  such  an  arrangement  might 
best  serve  the  purposes  of  fat  digestion.^ 

2.  Does  bile  when  added  to  neutral  proteids  influence 
favorably  or  unfavorably  ihe  action  of  pancreatic  juice 
on  these  proteids  ?  In  answer  to  this  question,  from 
experiments  made  with  pancreatic  extracts,  Chittendon^ 
says  "  the  addition  of  bile  to  a  neutral  pancreatic  juice 
(pancreatic  extract)  causes  but  little  change  in  its  pro- 
teolytic action."  "  A  slightly  increased  action  is  the 
only  effect  produced  on  the  tripsin." 

In  our  experiments  we  have  found  that  the  addition 
of  bile  to  pancreatic  juice  very  decidedly  expedites 
the  proteolytic  action  of  pancreatic  juice  on  neutral 
fibrin.  In  one  experiment  only  (4)  did  the  pancreatic 
juice  do  more  work  acting  alone  than  it  did  acting  in 
the  presence  of  bile,  and  this  result  being  at  variance 
with  all  the  other  experiments  was  probably  due  to 
some  unavoidable  error  of  technic.  But  if  we  average 
the  results  in  the  other  eleven  experiments  we  find  that 
the  proteolytic  ^ction  of  pancreatic  juice  on  neutral 
fibrin  was  increased  one-fourth  by  the  addition  of  bile. 
Pancreatic  juice  acting  alone  digested,  on  the  average, 
one  and  five-sixths  grain  of  neutral  fibrin,  while  pan- 
creatic juice  acting  in  the  presence  of  bile  digested,  on 
the  average,  two  and  three-sixths  grains  of  neutral  fibrin. 
We  conclude,  therefore,  that  bile,  in  the  duodenum  as 
well  as  in  our  experiments,  materially  e.\pedites  the  pro- 
teolytic action  of  pancreatic  juice.  This  conclusion  is 
sustained  by  the  comparative  anatomy  research  previ- 

■  Digestive  Proteolysis.     Carlwright  Lectures.  1894. 

■'  The  Comparative  .-\natomy  of  the  Bile  and  Pancreatic  Ducts  in 
Mammals  from  the  Physiological  Stand-point  of  Fat  Digestion.  Medi- 
cine. Chicago.January,  1804. 

'  Studies  in  Physiological  Chemistry,  vol  u,  p.  136. 


88o 


MEDICAL    RECORD. 


[December  21,  1F95 


ously  referred  to.  In  this  study  it  was  demonstrated 
that  there  was  a  preliminary  mixing  of  the  bile  and  pan- 
creatic juice  before  entering  the  dug^enurn  in  all  flesh- 
eating  animals,  audit  is  not  probable  that  tTiis  arrange- 
ment has  been  brought  about  exclusively  by  the 
physiologic  laws  of  fat  digestion. 

3.  Does  bile  when  added  to  acid  proteids  influence 
favorably  or  unfavorably  the  action  of  pancreatic 
juice  on  these  proteids  ?  In  answer  to  this  question, 
Chittendon^  says  :  "  In  the  presence  of  combined  hy- 
drochloric acid,  the  bile  salts  produced  no  effect  what- 
ever :  the  trypsin  was  entirely  without  action."  Our 
experiments  lead  us  to  the  conclusion  that  bile  very 
greatly  aids  pancreatic  juice  in  its  proteolytic  action 
on  acid  fibrin.  We  found  in  eleven  out  of  twelve  ex- 
periments, that  the  proteolytic  action  of  pancreatic 
juice  on  acid  fibrin  was  increased  by  the  addition  of 
bile.  Pancreatic  juice  acting  alone  digested,  in  the 
average,  one  and  fourteen  -  sixteenth  grain  of  acid 
fibrin,  while  in  the  presence  of  bile,  the  same  pancre- 
atic juice  in  the  same  time  digested  two  and  nine-six- 
teenth grains  of  acid  fibrin,  a  difference  of  eleven- 
sixteenth  grain.  In  other  words,  the  presence  of  the 
bile  enabled  the  pancreatic  juice  to  do  one- third  more 
work  on  acid  proteids  than  it  could  have  done  alone. 
Here  again  the  conclusions  from  our  laboratory  exper- 
iments are  in  accord  with  those  which  may  be  drawn 
from  the  fact  in  comparative  anatomy  above  men- 
tioned, viz.:  the  more  exclusively  carnivorous  the  ani- 
mal the  more  closely  does  the  common  opening  of  the 
bile  and  pancreatic  ducts  approach  the  pyloris. 

4.  Does  pancreatic  juice  acting  alone  on  neutral 
proteids  (fibrin,  etc.)  have  greater  or  less  proteolytic 
power  than  when  acting  under  the  conditions  found  in 
the  normal  duodenum — that  is  to  saj',  in  the  presence 
of  bile  and  combined  hydrochloric  acid  ?  The  answer 
to  this  question  is  to  be  found  in  the  combined  an- 
swers of  the  questions  which  have  preceded  it.  To 
facilitate  conclusions,  the  following  averages  are  taken 
from  the  experiments  above  outlined  :  Pancreatic  juice 
digested  i|-  grains  of  fibrin.  Pancreatic  juice  +  Hcl 
digested  iff  grains  of  fibrin.  Pancreatic  juice  -1-  bile 
digested  2|  grains  of  fibrin.  Pancreatic  juice  -I-  Hcl 
-f  bile  digested  2^'^  grains  of  fibrin. 

If  the  propositions  in  this  outline  be  true,  one  may 
read  at  a  glance  some  rather  startling  physiologic 
facts.'  a.  A  small  amount  of  hydrochloric  acid  does 
not  retard  the  proteolytic  action  of  pancreatic  juice  on 
proteids.  />.  The  pressure  of  bile  greatly  increases  the 
proteolytic  action  of  pancreatic  juice  on  both  neutral 
and  acid  proteids.  c.  Pancreatic  juice  acting  in  the 
presence  of  bile  and  hydrochloric  acid  can  accomplish 
more  work  in  digesting  proteids  than  can  pancreatic 
juice  acting  alone,  or  acting  in  the  presence  of  either 
hydrochloric  acid  or  bile.  That  is  to  say  that  pancre- 
atic juice  -r  bile  +  hydrochloric  acid  can  accomplish 
more  work  in  proteolysis  than  can  any  other  known 
pancreatic  digestive  mixture. 

It  is  an  exceedingly  interesting  fact  that  although  hy- 
drochloric acid  does  not  measurably  increase  the  pro- 
teolytic action  of  pancreatic  juice,  yet  in  the  presence 
of  bile  it  enables  pancreatic  juice  to  do  more  work  in 
proteolysis  than  it  could  do  in  the  presence  of  bile 
alone.'  In  the  normal  duodenum  of  the  carnivorous 
animal  we  find  that  nature  has  provided  that  pancre- 
atic juice  shall  act  under  precisely  those  conditions 
which  we  have  found,  by  our  experiments,  best  serve 
the  purposes  of  proteolytic  digestion.  That  is  to  say, 
p.\ncreatic  juice  in  the  normal  duodenum  of  the  car- 
nivorous animal  acts  in  the  presence  of  both  bile  and 
hydrochloric  acid. 

If  the  experiments  and  conclusions  set  forth  in  this 
paper  be  true,  we  can  understand  from  the  standpoint 

'  Studies  in  Physiological  Chemistry. 

^  This  is  in  strange  accord  with  the  fact  demonstated  by  one  of  us 
(Rachford).  Journal  of  Physiology,  vol.  xii  .  No.  i.  i8oi.  viV:  Pancre- 
atic juice  can  do  more  fat  splitting  in  the  presence  of  bile  and  hydro- 
chloric acid  than  it  can  in  the  presence  of  eitlier  of  them  alone. 


of  proteolytic,  as  well  as  from  the  standpoint  of  fat 
digestion,'  why  the  bile  and  pancreatic  ducts  have  not 
only  been  united,  but  have  had  their  common  opening 
placed  near  the  pyloris  in  all  animals  e.xclusively  car- 
nivorous. 

323    BsOA-DWA^■. 


gvoovcs5  of  pXccUcal  J>cicttcc. 

Strabotomy.  —  Dr.  Landolt  considers  the  advance- 
ment of  the  antagonistic  muscle  a  much  more  valuable 
surgical  procedure  for  the  relief  of  squint  than  tenot- 
omy of  the  squinting  muscle.  Even  in  cases  of  simple 
insufficiency  of  convergence  or  divergence,  where  tenot- 
omy is  admissible,  the  results  of  the  latter  are  often  un- 
satisfactory, because  a  considerable  portion  of  the  ad- 
ducting  or  abducting  power  is  lost.  When  the  squint  is 
excessive  tenotomy  is  often  inconvenient  on  other 
grounds.  In  the  operation  of  advancement  the  excur- 
sions of  the  eye  are  always  increased,  without  any  loss  in 
the  power  of  the  antagonist.  Moreover,  both  conver- 
gence and  divergence  gain  more  by  this  operation  than 
by  tenotomy.  Finally,  the  operation  of  advancement 
never  causes  any  disfigurement.  Tenotomy  may  be  con- 
sidered in  cases  of  motor  insufficiency,  latent  squint,  or 
squint  of  a  low  degree,  according  to  most  modern 
opthalmologists  ;  but  Landolt  believes  that  in  all  three 
classes  of  cases  advancement  offers  greater  advantages. 
It  has  never  in  his  hands  caused  an  over-correction  of 
the  defect.  It  must,  however,  be  generally  done  on 
both  eyes. — A'ei..'  York  Medical  Journal. 

Plaster-of-Paris  Bandage — To  Remove  Easily. — In 

La  Semaine  MeJuak,  No.  3,  1895,  L.  Gigli  recom- 
mends a  plan  to  facilitate  the  disagreeable  task  of 
removing  a  plaster-of-Paris  bandage  which  is  worth 
considering.  After  applying  the  usual  layer  of  cotton 
around  the  limb  a  layer  of  parchment  paper  previously 
moistened  and  wrung  out  is  wrapped  above  this  and 
then  a  large-sized  cord  well  rubbed  with  vaseline  is 
placed  upon  this  in  the  direction  that  one  wishes  to  saw 
open  the  apparatus.  Over  this  the  plaster  bandage  is 
laid  on.  When,  in  the  course  of  time,  the  dressing  is 
to  be  removed,  this  cord,  whose  ends  have  been  tied 
together,  is  loosened  and  one  end  tied  to  a  thin  steel 
wire  which  has  been  nicked  at  close  and  regular  inter- 
vals and  the  wire  drawn  through.  Each  end  of  this 
wire  is  attached  to  a  handle  and  with  a  backward  and 
forward  motion  the  plaster  is  at  once  sawed  through, 
after  which  the  dressing  may  be  immediately  laid  oil. 
— Albany  Annals. 


A  Judge  Scores  "  Vitapathy." — The  following  strong 
denunciation  of  a  so-called  "  vitapath,"  who  was  arrested 
and  fined  (by  Judge  Dusiin,  of  Cincinnati)  for  prac- 
tising without  a  license,  has  been  published.  The 
judge,  who  was  doubtless  actuated  by  the  fact  that  a 
man  was  known  to'  have  recently  died  without  medical 
attention  other  than  that  of  the  prisoner,  said,  in  pro- 
nouncing sentence:  "Men  who  knowingly  go  into  a 
sick-room  and  prevent  anything  being  done  for  a  dying 
man  by  silly  incantations  and  la\ingon  of  hands  are 
responsible  for  his  death  and  ought  to  be  on  a  par  with 
a  murderer  in  the  eyes  of  the  law,  God  help  the  dying 
man  who  relies  upon  you  or  any  of  the  so-called  gradu- 
ates of  quackery.  Vou  speak  of  vitapathy  being  of  a 
higher  power  than  medicine,  and  you  say  you  ordain 
ministers  at  the  same  time  you  matriculate  vitapathic 
physicians.  Your  methods  are  an  insult  to  intelligence, 
their  practice  is  a  criminal  abuse  of  ignorance,  and 
your  college  a  disgrace  to  civilization." 

'  In  the  comparative  anatomy  paper,  above  noted,  the  influence 
which  the  physiologic  laws  of  ial  digestion  may  have  h.td  in  deter- 
mining the  arrangement  of  these  ducts  h.ts  been  fully  considered. 


December  21,  1895] 


MEDICAL    RECORD. 


881 


Medical   Record: 

A  Weekly  yonrnal  of  Medicine  and  Stngery. 


GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  December  21,   1895. 


OLD  NATIVE  REMEDIES. 

Dr.  Hexrv  S.  Purdon,  of  Belfast,  Ireland,  contributes 
to  the  Dublin  Journal  of  Medical  Science  an  article 
upon  the  above  subject.  He  states  that  in  the  Belfast 
vegetable  market  there  is  a  stall  presided  over  by  a 
herbalist,  and  that  many  Belfast  citizens  still  prefer  the 
advice  and  treatment  of  this  man  to  that  of  the  regis- 
tered and  qualified  physicians.  Dr.  Purdon  makes 
this  fact  the  text  of  some  remarks  upon  the  value  of 
some  of  the  vegetable  remedies  that  he  found  at  the 
herbalist's  stall,  and  that  are  still  popular  among  the 
people. 

Saint- John's-wort  is  a  herb  that  is  recognized  by  its 
yellow  flower,  and  is  commonly  called  the  "  Rose  of 
Sharon."  This  was  formerly  used  internally  in  the 
form  of  a  decoction  for  colic  and  gastric  disorders,  and 
also  for  ague.  Locally,  the  leaves  were  often  made 
into  an  ointment  with  lard  and  used  as  a  dressing  for 
wounds.  The  Calamus  aromaticus,  or  sweet- flag,  was 
once  strongly  recommended  by  Dr.  Graves  as  a  sheet- 
anchor  in  malaria,  in  doses  of  from  twenty  to  si.xty 
grains.  The  common  carrot,  or  rather  its  seed,  is  still 
largely  used  as  a  carminative  and  stimulant,  while  the 
carrot  poultice  is  popular  as  an  application  in  ulcers. 
The  scarlet //■////<•/■/?(•/,  called  also  the  shepherd's-water- 
glass,  is  still  used  in  some  places  as  a  remedy  for  chronic 
or  muscular  rheumatism.  One  of  the  more  popular 
remedies,  and  one  which  we  find  used  in  this  countrj-, 
is  the  mountain-sage.  Decoctions  of  this  are  given  to 
promote  perspiration  and  to  cure  colds  and  bronchial 
troubles.  Dr.  Purdon  says,  with  a  certain  amount  of 
naivet/,  that  tansy  is  still  largely  grown  in  cottage  gar- 
dens, and  he  noticed  it  on  stall  in  the  market,  "it 
being  considered  an  emmenagogue  of  much  power  and 
largely  used  by  herbalists."  We  regret  to  say  that  it  is 
largely  used  by  herbalists  and  others  in  this  country 
also.  The  herb  yarrow  is  used  to  a  great  e.xtent  by 
the  poorer  class,  as  an  aromatic  tonic,  and  it  was  for- 
merly given  in  urethritis.  The  technical  name,  Acliil- 
lea  millefolium,  is  derived  from  Achilles,  who  is  sup- 
posed to  have  learned  its  virtues  from  his  master, 
Chiron,  the  Centaur.  The  couch-grass,  Triticum  repens, 
or  dog-grass  as  it  is  also  called,  is  one  of  the  most  use- 
ful of  the  herb  remedies,  and  is  still  popular  in  modem 
hospitals,  as  well  as  in  country  districts.  Walnut 
leaves  are  sold,  and  have  been  sold  for  many  years,  to 
be  used  in  an  infusion,   internally  and  externally,  for 


scrofulous  afifections.  The  older  physicians  thought 
that  the  walnut  had  a  singular  power  of  healing  foul 
ulcers  and  sores.  Doubtless  this  is  due  to  the  tannin 
which  is  contained  in  it. 

A  survey  of  the  drugs  just  mentioned,  and  their  al- 
leged properties,  does  not  give  one  a  very  high  opinion 
of  the  powers  of  the  herbalist.  The  fact  is,  that  the 
day  of  teas  and  decoctions  and  infusions  and  old- 
woman's  remedies  of  that  character  is  gone  by  entirely. 
While  we  still  have  some  powerful  drugs,  such  as  fox- 
glove, among  domestic  remedies,  the  vast  majority  of 
the  herbs  sold  for  various  disorders  are  of  slight  po- 
tency. Used  as  they  often  are  in  the  form  of  hot  teas 
and  infusions,  they  have  some  value  perhaps  as  stimu- 
lants and  diuretics,  but  this  value  is  really  very  slight. 
The  elder  novelists  who  constructed  romances  in  which 
some  wonderful  physician  or  mysterious  witch  pro- 
duces an  extraordinary  cure  by  the  use  of  some  secret 
herb,  gathered  by  the  light  of  the  moon,  would  now 
find  their  occupation  gone  if  they  conformed  their 
tales  to  any  degree  of  reason  and  probability.  The 
great  secrets  of  the  modern  medical  art,  so  far  as  drugs 
are  concerned,  have  been  brought  out  by  the  chemist 
and  physiologist  rather  than  discovered  by  the  botanist 
or  herbalist. 


"  URANALYSIS  "  AND  "  SYMPHYSEOTOMY." 

Ol'r  esteemed  contemporary,  the  Medical  Neics,  has  a 
reprehensible  habit  of  misspelling  a  good  many  words 
and  an  obstinacy  in  holding  out,  even  when  convicted 
of  error  by  every  other  authority  as  well  as  by  incon- 
trovertible facts.  The  editor  has  been  quite  put  to  it 
of  late  to  find  a  reason  for  his  unreasoning  and  un- 
reasonable dislike  of  the  two  excellent  words  at  the 
head  of  these  lines,  but  now  he  is  happy,  for  he  thinks 
he  has  on  his  side  the  Rev.  Dr.  Skeat,  the  author 
of  the  "  Etymological  Dictionary  "  (which  he  miscalls 
Etymologic  Dictionary).  It  seems  he  wrote  to  Dr.  Skeat, 
asking  him  what  he  thought  of  the  coinage  of  the  word 
uranalysis,  and  received  the  reply  :  "  I  need  not  say 
that  uranalysis  means  '  analysis  of  ure  ; '  whatever  '  ure  ' 
means  I  do  not  know."  We  fear  Homer  was  nodding 
when  he  penned  that  epistle,  for  surely  Dr.  Skeat 
must  have  heard  of  ovpov,  oipfui,  ovpdiTj,  and  oipaxos. 
If  the  Greek  language  sanctioned  the  formation  of  the 
word  oipaxoi,  surely  Dr.  Skeat  ought  not  to  make  funny 
over  uranalysis,  of  analogous  derivation,  especially 
when  the  word  has  the  sanction  of  such  an  excellent 
and  usually  reliable  authority  as  the  author  of  Gould's 
"  Medical  Dictionary."'  Even  if  we  had  not  such  good 
authority  for  the  use  of  the  word,  we  would  prefer  it  to 
the  wretched  hybrid  urinalysis,  half  Latin,  half  Greek, 
and  altogether  an  abomination.  We  are  sorry  to  note, 
however,  that  in  Dr.  Gould's  dictionary  this  word  (for 
both  are  given  there)  is  incorrectly  stated  to  be  de- 
rived from  two  Greek  words."  We  wonder  what  Dr. 
Skeat  would  say  to  that  etymology  ?  We  trust  the 
editor  of  the  Medical  Nncs  will  ask  him  in  his  next 
letter. 

As  to  the  spelling  of  symphyseotomy  (for  our  esteemed 

1  Uranalysis  (u-ran-al'-is  is)  [oifor,  urine ;  iliAwit.  analysis].  Urine 
analysis. 

>  Urinalysis  (urin-al'-is-is)  [oSpoi-,  urine:  A»<ri«,  loosing).  The 
analysis  of  the  urine. 


882 


MEDICAL    RECORD. 


[December  21,  1895  • 


contemporary  called  for  light  on  this  point  also),  Dr. 
Skeat  is  more  happy  ;  he  writes  :  "  It  is  not  the  case 
that  Greek  compounds  are  formed  from  genitives. 
They  are  formed  from  stems.  Every  Greek  scholar 
knows  all  about  it  ;  it  is  not  a  question  of  '  opinion  '  at 
all,  but  of  simple /acA."  This  time,  we  are  glad  to  say. 
Dr.  Skeat  is  absolutely  right,  and  we  trust  our  esteemed 
philologic(al)  friend  will  heed  the  admonition  and 
spell  symphyseotomy  with  an  e.  The  stem  of  ^vai%  we 
need  hardly  tell  the  erudite  editor  of  our  esteemed 
contemporary,  is  <^uo-£.  The  genitive  of  the  word  (we 
mention  the  genitive,  for  it  shows  us  the  stem  from 
which  the  compound  is  formed)  was  once  <t>v(Tto';,  and 
that  is  why  we  have  physiology,  a  word  of  very  ancient 
coinage.  But  when  sytnpJiysis  was  made,  the  Attic  had 
won  a  predominance  over  the  Ionic,  and  the  genitive 
of  ^u'cris  was  <^ucr€(i)s,  and  the  stem  was,  and  is,  <^i)cre. 
That  is  why  it  is  correct  to  write  symphyseotomy.  The 
lexicographer  above  mentioned,  to  whose  authority  we 
have  appealed  in  the  case  of  uranalysis,  seems  to  have 
had  a  confused  idea  of  the  presence  of  an  e  in  the 
Attic  stem  of  <^uo-«,  for  we  find  that  he  gives  the  pref- 
erence to  such  spelling  as  symphys^al,  epiphyseal,  epi- 
physitis, and  the  like,  but,  strangely  enough,  not  to 
symphyseotomy.  We  cannot  understand  the  e.xception 
as  regards  this  word.  The  editor  ought  really  to  bring 
the  lexicographer  to  task  for  his  inconsistency. 


Dr.  L ,  of  L ,  Ky.,  has   been  arrested  for 

running  off  with  a  girl  of  sixteen,  both  on  time. 

"  Dr.    M ,  of   M ,   Ky.,  has   been   sued   for 

$10,000  for  breach  of  promise,  but  is  still  practising. 

"  Dr.   N ,   of   L ,   Ark.,  has   been   sued   for 

$20,000  for  alienating  a  lady's  affections. 

"  Dr.  O ,  of  the  same  town,  was  killed  on  No- 
vember ist  for  doing  the  same  thing  as  respects  an- 
other lady. 

"Dr.  P ,  of  C ,  111.,  has   been  arrested  and 

sent  to  an  asylum  for  announcing  that  Chicago  is  the 
New  Jerusalem. 

Dr.  Q ,   of  C ,  O.,  has  been  arrested  for 

sending  to  a  patient  a  dun  on  a  postal  card." 

The  news  thus  gathered  from  the  Mississippi  Valley 
and  the  region  of  the  Great  Divide,  shows  an  unquiet- 
ness  in  the  life  of  the  Ameiican  doctor  which  must 
startle  those  who  live  in  the  placid  regions  of  the  East. 
Within  the  space  of  two  months  we  find  records  of  six 
murderous  and  fatal  assaults,  six  criminal  arrests  or 
suits,  and  two  fatal  poisonings. 

Some  of  our  contemporaries  print  these  items  as 
though  they  represented  the  news  of  the  profession. 
We  hope  and  believe,  however,  that  most  of  the  dis- 
creditable and  criminal  acts  thus  reported  relate  to 
men  who  are  not  really  educated  and  qualified  physi- 
cians. It  would  be  better  if  medical  journalism  left 
such  matters  to  the  daily  press,  and  confined  its  news 
to  the  records  of  scientific  work. 


CRIMINAL    NEWS. 

One  of  the  features  of  the  new  medical  journalism  is 
the  reproduction  of  the  likenesses  of  contemporaries 
who  have  achieved  the  distinction  of  being  president 
of  a  medical  society,  a  railway  surgeon,  or  a  real  pro- 
fessor. Another  even  more  interesting  phase  of  this 
evolution  is  the  medical  news  column,  in  which  the 
personal  life  of  the  every-day  doctor  is  told  with  all  its 
tragedies  and  vicissitudes.  The  stories  are  presented 
with  no  waste  of  words,  but  with  conciseness  and  point 
that  suggest  much  to  the  imagination,  and  yet  leave 
little  to  add  to  the  reality. 

"  Dr.   B ,  of    I ,   Okla.,   was  fatally  shot  on 

November  ist  by  his  fourteen-year-old  son,"  is  an 
example  of  the  modern  style  of  current  medical  news. 

"  Dr.  C ,  of  C ,  Ind.,  died  on  November  8th 

of  an  overdose  of  morphine."     "Dr.  D ,  of  M , 

Ariz.,  was  shot  by  a  sheriff  who  came  to  arrest  him." 

The  record  continues  :  "  Dr.  E ,  of  D ,  Tex., 

injected  three  grains  of  strychnine  into  his  arm  by  mis- 
take, instead  of  cocaine — a  drug  to  which  he  was  ad- 
dicted.    He  died  within  an  hour. 

"  Dr.    F ,   of    S ,    Ind.,    was    shot    by    Mr. 

Thompson,  of   the  same  place.     Mr.    Thompson  had 

spoken  derogatively  of  the  doctor's  skill,  and  Dr.  F 

had  expostulated  with  him,  using  a  cane. 

"  Dr.  G ,  of  D ,  Tex.,  was  shot  by  Mr.  Hard- 
castle,  of  the  same  place,  for  causes  not  stated. 

Dr.  H ,  of  S ,  Ky.,  has  been  put  in  jail  for 

intoxication  and  wife-beating.  If  he  had  lived  in  Lon- 
don he  could  have  gotten  off  for  $3. 

"  Dr.  K ,  of  N ,  Mo.,  killed  a  man  on  October 

27th  with  a  gun.     The  man  was  a  burglar. 


AN    UNKNOWN    MEDICAL    HERO. 

We  have  often  in  these  columns  referred  to  the  injus- 
tice which  has  been  done  by  society  to  the  claims  of 
physicians,  as  compared  with  those  of  persons  of  other 
callings.  The  great  memorials  in  the  past  have  been 
put  up  to  those  who  made  a  name  in  wars,  politics,  art, 
and  literature.  Measured  by  the  actual  benefit  done 
to  mankind,  the  progress  in  the  comfort  of  life,  secu- 
rity, and  happiness,  the  names  of  many  comparatively 
obscure  physicians  should  stand  foremost.  Sir  Rich- 
ard Quain  voices  this  sentiment,  and  in  connection  with 
it  describes  the  obscurity  into  which  the  name  of  Dr 
Snow  has  fallen.  To  this  physician,  says  Sir  Richard, 
Great  Britain  owes,  first,  its  immunity  from  epidemic 
cholera  for  the  last  quarter  of  a  century,  and,  of 
course,  for  all  future  time.  Through  preserving  Great 
Britain  from  cholera,  he  has  saved  millions  of  lives. 
In  Sir  Richard  Quain's  words,  Dr.  Snow  "made  us 
masters  of  the  deadly  plague  of  cholera.  Dr.  Snow 
thereby  saved  millions  of  lives.  The  sole  reward  which 
England  has  conferred  upon  him  is  midnight  obscu- 
rity." "  If  he  had  been  a  soldier,"  he  continues,  "  in- 
stead of  a  doctor,  if  he  had  slain  his  thousands,  instead 
of  saving  his  millions,  every  town  would  have  hailed 
him  as  a  hero,  and  the  nation  would  have  honored  his 
memory  with  monuments  more  enduring  than  brass." 
Dr.  Snow's  work,  so  far  as  it  concerned  this  point,  con- 
sisted in  his  discovering  that  cholera  was  a  water-born 
disease.  In  that  discovery  lay  the  secret  of  its  prac- 
tical extirpation  and  prevention.  As  long  as  people 
drink  pure  water  they  will  not  have  cholera.  This  sim- 
ple truth,  which  modern  science  has  abundantly  con- 


December  21,   1895] 


MEDICAL    RECORD. 


firmed,  was  discovered  and  taught  by  Dr.  Snow.  It 
was,  furthermore,  discovered,  not  by  accident,  but  by 
long  and  patient  research,  and  the  addition  of  fact  to 
fact  and  argument  to  argument.  Sir  Richard  Quain 
adds  that  he  hopes  to  live  until  he  has  seen  a  monu- 
ment erected  to  the  memory  of  Dr.  Snow,  and  he  pro- 
poses that  the  memorial  be  in  the  form  of  a  drinking 
fountain  on  the  Thames  Embankment.  As  the  Hospi- 
tal remarks,  in  reference  to  this  matter,  the  medical 
profession  is  not  altogether  blameless,  so  far  as  Dr. 
Snow  is  concerned.  We  fear  that  there  are  really  very 
few  of  us  who  do  not  belong  to  those  who  never  knew 
or  had  forgotten  that  there  was  such  a  man.  Further- 
more, those  who  do  remember  him  will  perhaps  also 
remember  that,  in  his  lifetime,  his  discovery  was  op- 
posed by  a  man  of  such  prominence  as  the  late  Sir 
William  Gull. 

We  are  glad  to  see  Sir  Richard  take  up  the  cudgels 
in  behalf  of  Dr.  Snow,  and  trust  that  he  will  succeed  in 
showing  to  contemporary  civilization  the  merit  of  that 
physician's  work. 


PHYSICIANS    AND    THE    CONFIDENCES    OF 
THEIR   PATIENTS. 

The  Circuit  Court  of  Michigan  has  recently  decided 
that  a  physician  is  obliged  to  testify  in  regard  to  the 
ailments  of  his  patients,  in  a  court,  if  called  upon  to  do 
so.  The  question  came  up  over  the  application  of  a 
life  insurance  company,  which  had  assured  the  person 
for  $20,000.  The  company  learned  after  the  issue  of 
the  policy  that  the  applicant  had  misrepresented  his 
physical  condition,  and  it  began  a  suit  to  annul  the 
policy.  Courts  have  often  discussed  this  question, 
whether  physicians  shall  be  compelled  to  disclose  facts 
regarding  the  condition  of  their  patients,  and  various 
decisions  have  been  made,  sometimes  one  way,  some- 
times another.  The  rulings  in  this  State,  at  one  time, 
were  that  the  physician  should  be  compelled  to  dis- 
close things  that  did  not,  in  anyway,  throw  discredit  or 
shame  upon  the  patient,  and  this  seems  a  reasonable 
method  of  dealing  with  the  matter.  No  reputable  phy- 
sician, in  any  event,  whatever  the  law,  would  disclose 
to  the  public  facts  which  were  confided  to  him  in  con- 
fidence, and  which  would  reflect  injury  upon  his  patient 
if  made  public.  No  human  laws  could  compel  physi- 
cians to  do  this,  and,  therefore,  it  would  be  much  better 
to  have  laws  that  could  be  carried  out. 


An  Exploring  Trip  under  the  Direction  of  Two 
Alumni  of  the  Medical  Department  of  the  University  of 
Pennsylvania.— Dr.  William  H.  Furness,  3d,  and  Dr.  H. 
M.  Hiller,  both  members  of  the  Class  of  '91,  have 
started  for  the  South  Sea  Islands,  where  they  will 
spend  at  least  a  year  in  collecting  ethnological  and 
archaeological  specimens  for  the  University.  Should 
the  field  prove  fruitful,  it  is  probable  that  their  stay 
may  be  prolonged  to  two  years.  After  arriving  at  San 
Francisco  they  will  sail  for  Yokohama,  touching  at 
Honolulu.  They  will  proceed  to  Singapore,  and  from 
there  will  take  passage  for  the  Philippine  Islands,  visit- 
ing other  groups  of  the  East  Indian  and  South  Pacific 
Archipelagos  in  a  chartered  vessel. 


Bcxus  of  tlie  "^leefe. 

The  Improvements  in  the  College  of  Physicians  and 
Surgeons.— It  is  reported  that  the  new  buildings  which 
are  to  be  added  to  the  College  of  Physicians  and  Sur- 
geons of  Columbia  will  be  finished  by  the  end  of  the 
winter.  The  additions  consist  in  an  e.\tension  to  the 
main  building  of  the  college,  which  is  to  be  used  for 
the  Institute  of  Anatomy,  and  a  building  to  the  west 
of  it,  which  is  connected  with,  and  an  extension  of,  the 
Sloane  Maternity  Hospital.  The  Vanderbilt  Clinic 
has  been  enlarged  to  twice  its  original  size,  and  the  two 
upper  floors  are  to  be  devoted  to  the  study  of  pathol- 
ogy and  bacteriology. 

Medical  Examiners'  Fees.— Our  esteemed  contempo- 
rary. Puck,  has  a  very  striking  cartoon,  a  propos  of  the 
Holmes  case,  upon  the  subject  of  insurance  companies 
and  their  employees.  The  point  of  the  cartoon  is  that 
these  companies  are  so  eager  to  insure  everybody  and 
to  make  money  that  they  are  careless  in  their  methods 
and  secure  cheap  and  incompetent  men  as  their  agents. 
The  recent  general  cut  in  the  prices  for  medical  exami- 
ners' fees  we  have  already  spoken  of,  and  stated  that 
it  was,  we  presumed,  a  purely  business  matter,  and  if 
they,  the  companies,  could  get  good  men  for  a  lower 
price  they  had  the  right  to  do  so.  But,  in  the  light 
of  recent  events,  it  seems  that  it  is  not  likely  they  can 
get  good  men.  Insurance  companies  had  better  try 
and  economize  in  some  other  way  than  by  cheapening 
the  price  paid  to  their  agents  for  careful  examinations 
of  people  that  are  to  be  insured. 

The  Sero-therapy  Treatment  of  Cancer.  —  Messrs. 
Hericourt  and  Richet  return  to  the  subject  of  the  sero- 
therapy treatment  of  cancer.  In  an  article  read  in 
September  before  the  Academy  of  Sciences  of  Paris, 
they  state  that  they  have  continued  their  method  of 
treatment  since  their  first  report  in  April  last,  and  they 
have  reached  the  following  results  :  After  the  injec- 
tions the  pains  from  cancerous  tumors  diminish  almost 
immediately,  and  these  pains  continue  to  diminish  for 
a  considerable  time.  The  ulcerations  become  less,  and 
the  tendency  to  hemorrhage  also  is  less  marked.  The 
tumor  decreases  in  size,  and,  in  fine,  the  evolution  of 
the  disease  is  retarded  and  the  general  state  im|)roved. 
But,  unfortunately,  this  amelioration  does  not  end  in 
cure.  At  the  end  of  about  two  months  a  gradual  re- 
turn of  the  symptoms  takes  place.  They  therefore 
say,  in  conclusion,  that  while  the  treatment  by  sero- 
therapy does  not  cure  cancer,  it  does  ameliorate  the 
condition  to  a  degree  greater  than  any  other  known 
treatment. 

Further  Gifts  to  the  University  of  Chicago. —  Miss 
Helen  Culver  has  given  to  the  Chicago  University 
$1,000,000,  and  Mr.  John  I).  Rockefeller  promises 
$2,000,000.  Miss  Culver's  gift  is  to  be  used  for  biolog- 
ical teaching  and  investigations.  The  result  of  these 
new  gifts  will  probably  be  the  organization  of  a  medi- 
cal school. 

The  Best  Symptom  in  any  patient  is  prompt  pay  ;  as, 
long  as  it  lasts  you  need  not  care  what  else  ails  him, 
unless  he  is  likely  to  die. 


MEDICAL    RECORD. 


[December  21,  li 


Dr.  J.  Edwin  Michael,  a  well-known  surgeon  of 
Baltimore,  died  in  that  city  on  December  6th,  aged 
forty-seven.  At  the  time  of  his  death,  Dr.  Michael 
was  Dean  of  the  University  of  Maryland  and  Presi- 
dent of  the  Medical  and  Chirurgical  Society  of  the 
State. 

Alcoholism  in  France. — The  question  of  "  alcohol- 
ism," which  has  been  much  discussed  in  this  city,  in 
connection  with  Sunday  closing,  is  exciting  great  at- 
tention in  France,  on  much  broader  grounds.  Some 
of  the  most  prominent  scientists  and  public  men  in 
France  are  directing  their  inquiries  to  combating  the 
increase  of  alcoholism  in  that  country.  Their  investi- 
gations bring  out  some  curious  facts.  They  show,  for 
example,  that  in  England,  since  1852,  there  has  been  a 
diminution  of  the  consumption  of  alcohol  from  286 
litres  per  head  per  year  to  270  litres  in  1892,  and  that 
in  Sweden  the  consumption  per  head  has  diminished 
one-half.  If  we  are  not  mistaken,  the  figures  show  that 
in  this  country  the  consumption  of  alcohol  per  head 
has  steadily  increased. 

St.  Luke's  Hospital  and  its  Pathological  Depart- 
ment.— At  a  recent  meeting  of  the  Board  of  Managers 
of  St.  Luke's  Hospital  the  following  resolutions  were 
passed  : 

"  That  the  matter  of  the  completion  of  the  proposed 
pathological  building  and  its  equipment  be  referred  to 
the  Building  Committee  with  power. 

"  Further,  That  in  the  opinion  of  this  Board  a  sum 
of  not  less  than  $200,000  should  be  obtained  and  set 
apart  for  the  endowment  of  the  pathological  depart- 
ment, and  that  special  gifts  should  be  obtained,  if  pos- 
sible, for  the  equipment  of  this  department. 

"  Further,  That  the  matter  of  endowment  of  the 
pathological  department  be  referred  to  the  Executive 
Committee,  with  power  to  appoint  a  special  committee 
on  this  subject  from  the  members  of  the  Board." 

The  hospital  has  just  received  $20,000  for  the  en- 
dowment of  beds. 

An  Office  Thief. — On  Saturday,  December  7th,  a 
pocket- case  of  instruments  was  stolen  from  the  office 
of  Dr.  Ettinger,  of  this  city,  by  a  sneak  thief  in  the 
guise  of  a  patient  waiting  for  the  doctor.  He  was  a 
man  five  feet  eight  inches  tall,  dark  eyes  and  mus- 
tache, slight  of  build,  and  with  prominent  features. 
Dress  was  rather  shabby  ;  had  a  dark  derby  and  over- 
coat. From  appearance  and  language  was  born  here, 
of  Hebrew  e.vtraction. 

The  St.  Louis  Academy  of  Medical  and  Surgical  Sci- 
ences.— An  association  with  the  above  title  was  organ- 
ized on  November  6,  1895.  In  order  to  become  a 
member  of  the  Academy  one  must  possess  a  good  liter- 
ary and  medical  education.  As  evidence  of  his  liter- 
ary qualifications  and  ability  as  a  scientific  worker  he 
must  deposit  with  his  application  a  thesis,  a  patho- 
logical specimen  with  descriptive  text,  a  drawing  of  a 
normal  or  abnormal  specimen  with  text,  or  some  other 
evidence  of  his  worth.  The  evidence  is  passed  upon 
by  the  Committee  on  Credentials.  If  the  evidence  is 
accepted  the  ballot  is  taken.  Membership  in  the  soci- 
ety is  to  be  limited  to  fifty.  The  following  officers  were 
elected  for  the  ensuing  year :  President,  Dr.  George 
W.  Cale,  Jr. ;   Vice-Presidents,  Drs.  James  Moores  Ball 


and  Arthur  E.  Mink  ;  Secretary,  Dr.  Emory  Lanphear  ; 
Treasurer,  Dr.  Wellington  Adams. 

Albany  Medical  College  Alumni  Association  of 
Greater  New  York. — A  large  number  of  the  graduates 
of  the  Albany  Medical  College,  resident  in  this  and 
adjoining  cities,  met  at  the  residence  of  Dr.  Hanks, 
No.  776  Madison  Avenue,  on  the  evening  of  December 
5th,  and  organized  an  association  with  the  above  title. 
The  following  officers  were  elected  :  President,  Dr. 
John  W.  Warner ;  Vice-President,  Dr.  Horace  T. 
Hanks  ;  Secretary,  Dr.  Warren  C.  Spaulding  ;  Assist- 
ant Secretary,  Dr.  R.  F.  Macfarlane,  of  Long  Island 
City  ;  Treasurer,  Dr.  Allen  T.  Fitch.  The  first  annual 
dinner  is  to  be  given  Thursday,  January  9,  1896. 

The  Loomis  Hospital  and  Dispensary. — Drs.  A.  Alex- 
ander Smith  and  Henry  F.  Walker  are  the  consulting 
physicians  of  the  Loomis  Hospital  and  Dispensary  for 
Consumptives,  at  230  West  Thirty-eighth  Street.  Dr. 
Charles  McBurney  is  consulting  surgeon  ;  Dr.  William 
^L  Polk,  consulting  gynecologist  ;  Dr.  Warren  Cole- 
man, pathologist  ;  Drs.  Henry  P.  Loomis  and  Charles 
E.  Quimby  are  visiting  physicians  ;  and  Dr.  Joseph 
Carlisle  De  Vries  is  house  physician.  The  officers  of 
the  Board  of  Managers  are  :  President,  Mrs.  Richard 
Irvin  ;  J^ice-PresiJcnt,  Mrs.  Henry  Chapman  ;  Treas- 
urer, Mrs.  Alfred  L.  Loomis  ;  Secretary,  Mrs.  John  A. 
Lowery. 

Regulation  of  Medical  Practice  in  Washington. — A 

bill  has  been  introduced  into  the  United  States  Senate 
to  regulate  the  practice  of  medicine  in  the  District  of 
Columbia.  A  Board  for  Examination  and  License  is 
provided  for. 

Dr.  Thomas  Taylor,  of  Washington,  D.C.,  has  been 
awarded  a  gold  medal  by  the  International  Society  of 
Hygiene  in  recognition  of  the  value  of  his  investigation 
of  butters,  fats,  and  mushrooms  in  the  United  States. 

Another  Hospital  for  the  Insane  in  Illinois. — At  its 
last  regular  session  the  Illinois  Legislature  provided  for 
the  establishment  of  a  new  insane  asylum,  to  be  called 
the  Illinois  Western  Hospital  for  the  Insane.  $100,000 
has  been  appropriated  for  the  purchase  of  a  site. 

Begulation  of  Maternity  Hospitals  in  Connecticat. — 
At  the  last  session  of  the  General  Assembly  of  Connec- 
ticut a  law  was  passed  forbidding  any  person  to  keep 
a  maternity  hospital,  unless  he  had  previously  obtained 
a  license  therefor,  issued  by  the  Mayor  or  Board  of 
Health,  or  Health  Officer,  where  any  such  place  was 
situated.  Records  of  the  inmates  and  of  the  births, 
deaths,  discharges,  etc.,  must  be  kept,  and  must  be  ac- 
cessible to  inspection. 

The  American  Medical  Review  is  the  title  of  a  new 
monthly  journal  published  in  this  city,  and  edited  by 
Dr.  Daniel  Lewis.  The  contents  of  the  first  number 
are  well  arranged  and  the  general  appearance  of  this 
new  journal  is  most  promising.  We  wish  it  every 
success. 

The  Medical  Department  of  the  Navy  consists  of  one 
hundred  and  seventy  members  when  its  ranks  are 
filled.  There  are  at  this  time  fourteen  vacancies,  and 
nobody  seems  to  want  to  get  in,  at  least  no  one  who  is 
worth  having. 


December  21,   1895] 


MEDICAL    RECORD. 


88; 


^octctij  ^Icpofts. 

NEW   YORK   ACADEMY    OF    MEDICINE. 

SECTION  ON  GENERAL  SURGERY. 

Stated  Meeting,  December  g,  iSgj. 

B.  F.^RQUHAR  Curtis,  M.D.,  Ch.\irm.\n. 

Bloodless  Amputation  of  Shoulder-joint. — This  was  the 
history  of  a  case  in  which  the  transversalis  colli,  supra- 
scapular and  subclavian  arteries  (third  division),  were 
tied,  under  cocaine  anaesthesia,  with  subsequent  blood- 
less amputation  of  the  shoulder. 

Dr.  John  A.  Wveth  reported  the  case  as  follows  : 
John  S ,  aged  thirty-one,  by  occupation  a  grocery- 
man,  with  no  early  personal  or  family  history  which 
throws  any  light  on  this  case,  came  under  my  care,  Oc- 
tober 2,  1895,  in  the  New  York  Polyclinic  Medical 
School  and  Hospital. 

In  1889  he  had  received  an  injury  of  the  left  arm 
near  the  shoulder-joint,  which  he  considered  a  fracture, 
from  which  he  recovered  with  some  stiffness  of  the 
joint.  He  noticed  nothing  of  interest  beyond  this  un- 
til 1S93,  when,  in  descending  from  the  deck  0/  a  ship, 
he  caught  hold  of  a  rope  to  prevent  himself  from  fall- 
ing, and  severely  strained  this  same  arm,  and  remem- 
bers having  heard  a  ripping  sound,  followed  by  great 
pain.  The  arm  has  never  been  right  since.  Four  or 
five  months  after  this  injury  he  noticed  it  began  to 
swell.  It  was  not  excessively  painful,  except  on  sud- 
den motion. 

When  I  saw  him  first,  on  October  2,  1895,  there  was 
a  large,  round  swelling,  which  occupied  the  upper  end 
of  the  humerus,  the  deltoid  region,  and  extended 
somewhat  over  the  end  of  the  clavicle  and  scapula. 
On  October  5th,  under  chloroform  anesthesia,  I  made 
an  exploratory  incision  for  the  purpose  of  getting  a 
specimen  for  microscopical  examination.  Cutting 
directly  down  through  the  deltoid  muscle,  I  came  im- 
mediately into  a  large,  vascular,  osteo-sarcoma,  which 
had  hollowed  out  the  medullary  canal  and  substance 
of  the  head  of  the  humerus,  into  which  I  passed  two  or 
three  fingers  very  readily.  The  bone  gave  way  with  a 
peculiar  crackling  sound,  like  the  breaking  of  an  egg- 
shell, and  was  followed  by  profuse  hemorrhage,  whicn 
could  only  be  arrested  after  raiiidly  packing  the  cavity 
wiih  at  least  three  yards  of  sterilized  gauze  ;  over  this 
an  Esmarch  elastic  bandage  was  carried.  This  hem 
orrhage  greatly  weakened  the  patient,  and  by  October 
9tli  1  became  alarmed  about  his  condition  of  anaemia, 
ami  injected  into  the  right  median  cephalic  vein  a  pint 
and  I  half  of  hot  saline  solution,  one  drachm  of  salt  to 
a  quart  of  water.  Tliis  was  followed  by  a  rapid  im- 
provement in  the  heart  action,  fuller  pulse,  better  ap- 
petite, and  increasing  strength.  There  was,  however, 
considerable  hemorrhage  whenever  the  packing  in  the 
tumor  was  changed  ;  so  much  so  that,  on  October 
15th,  in  order  t  >  control  this  bleeding  and  to  dispense 
with  the  packing,  wliich  was  so  tight  that  it  caused 
him  a  great  deal  of  suffering.  I  tied  the  left  transver- 
salis colli  and  suprascapular,  and  the  left  subclavian  ar- 
tery, in  the  third  surgical  division.  The  operation  was 
not  easy  of  accomplishment,  by  reason  of  the  great 
swelling  of  the  shoulder,  which  lifted  the  clavicle  fully 
an  inch  higher  than  the  normal  position,  and  prevented 
the  manipulation  of  the  parts,  displacing  the  clavicle 
and  shoulder  on  account  of  the  great  ])ain.  The  jia- 
tient  could  not  tolerate  any  pressure  upon  the  shoul- 
der. I  was  afraid  to  administer  ether  or  chloroform 
on  account  of  his  exhausted  condition  and,  believing 
I  could  tie  these  arteries  by  the  judicious  employ- 
ment of  cocaine,  it  was  done.  In  the  entire  pro- 
cedure, twenty-five  minims  of  a  four  per  cent,  solution 
were  employed.      The   operation    was   quite  tedious, 


and  the  subclavian  artery,  when  finally  exposed,  was 
two  and  a  half  inches  from  the  surface  of  the  wound, 
and  deep  below  the  clavicle,  where  it  was  caught  up  by 
an  aneurism  needle  and  tied.  The  patient  lost  prac- 
tically no  blood  from  the  incision  in  the  tumor  after 
this  operation. 

On  October  20th,  under  ether  anaesthesia,  I  made  a 
rapid,  bloodless  amputation  of  the  shoulder-joint  by  the 
method  which  I  first  employed  in  doing  this  operation 
in  18S9.  The  operation  consists  in  the  insertion  of 
two  steel  pins  about  fourteen  inches  long  and  less 
than  a  quarter  of  an  inch  in  diameter.  The  anterior 
one  passes  through  the  skin  and  part  of  the  pectoralis 
majoralis  muscle,  well  back  behind  the  level  of  the 
shoulder-joint.  Not  more  than  one  and  a  half  inch 
of  this  pin  should  be  concealed  by  the  tissues  it  perfo- 
rates. Over  the  spine  of  the  scapular,  well  up  behind 
the  joint,  the  second  pin  is  passed,  taking  hold  of  noth- 
ing but  the  integument,  and,  may  be,  a  little  of  the  sur- 
face of  the  trapezius  muscle.  Around  the  shoulder, 
over  the  clavicle  and  scapula,  and  behind  the  pins,  the 
points  of  which  are  shielded  by  bits  of  cork,  strong 
rubber  tubing  is  tightly  wound  four  or  five  times  and 
then  tied.  The  amputation  can  then  be  made  at  leisure, 
disarticulation  completed,  and  the  vessels  taken  up  at 
will.  The  operation  is  entirely  bloodless,  and  the 
tourniquet  need  not  be  removed  until  the  procedure  is 
completed.  It  is  always  advisable,  however,  to  loosen 
the  tourniquet  before  the  final  suturing  in  order  to  see 
that  no  important  bleeding  points  have  been  over- 
looked. 

I  have  performed  three  operations  of  a  similar  nature 
by  this  method,  and  a  number  of  others  have  been 
done  b)'  competent  surgeons,  without  hemorrhage  in 
any  instance.  It  was  the  em])!oynient  of  this  hiethod 
in  shoulder-joint  amputations  which  led  me  to  employ 
it  in  amputations  at  the  hip-joint,  of  which  I  have  done 
seven,  with  no  hemorrhage  in  any  case,  and  only  one 
death  from  the  operation.  The  tourniquet  remains  in 
position  until  the  operation  is  nearly  completed. 

In  the  present  case,  it  being  one  of  malignant  tumor, 
and  as  the  soft  parts  up  to  the  level  of  the  joint  seemed 
to  be  involved,  I  did  not  endeavor  to  cover  the  joint 
surface  with  cutaneous  flaps.  It  was  my  intention,  as 
soon  as  the  wound  began  to  granulate  and  the  patient 
recovered  sufficiently,  to  infect  it  with  some  septic  or- 
ganism, preferably  with  streptococci  erysipelatis,  and 
on  November  19th  an  injection  of  five  minims  of  a 
pure  culture  of  Fehleisen's  coccus  was  made.  They 
were  repeated  every  other  day,  gradually  increasing  the 
dose  by  three  minims  until  twenty-six  minims  were  in- 
jected. So  far.  however,  no  regular  erysipelas  has  been 
precipitated.  He  has  had  septic  chills,  with  exacerba- 
tions of  temjierature  following,  which  on  one  occasion 
reached  40.7°  C.  (105.5'^  F.).  These  injections  have 
been  discontinued  for  the  time  being,  and,  despite  the 
severe  ordeal  he  has  undergone,  the  i)atient  has  gained 
flesh  and  weight,  and  does  not  look  like  the  same  indi- 
vidual that  came  to  me  on  October  2d. 

The  specimen,  which  is  here  presented,  shows  an 
osteo  sarcoma  of  the  ujiper  end  of  the  humerus.  There 
is  no  sign  of  recurrence  of  the  neoplasm. 

Carcinoma  of  the  Sectum ;  Excision  by  the  Kraske 
Method.— I  )K.  HiiWARD  Lii.if.n  i  hai.,  in  presenting 
the  patient,  said  the  case  exenqililied  the  fact  that  car- 
cinoma of  the  rectum  was  not  necessarily  very  malig- 
nant. The  patient  was  a  man,  forty-five  years  of  age, 
and  had  had  of  his  knowledge  cancer  of  the  rectum 
for  one  year.  When  Dr.  Lilienthal  first  saw  him  he 
regarded  the  case  as  practically  inoperable,  for  the 
ischio-rectal  fat  was  involved,  together  with  the  rectum 
extending  well  up.  But  the  man  absolutely  refused 
colotomy  and  wished  the  diseased  tissues  removed. 
He  was  an  alcoholic,  took  ether  badly,  hemorrhage 
was  great,  and  Dr.  Lilienthal  was  compelled  to  hurry 
the  operation,  with  the  result  ihat  some  tissue  at  the 
side  which  felt  harder  than  normal  was  left,  although 


886 


MEDICAL   RECORD. 


[December  21,  1S95 


it  may  not  have  been  carcinomatous.  The  posterior 
urethra  was  also  involved  and  was  attacked  during  the 
operation.  In  spite  of  the  extent  of  the  operation  the 
patient  rapidly  recovered,  and  during  the  past  three 
months  had  been  working  at  his  trade  as  a  plasterer. 
The  operation  was  done  last  June.  The  bowel  moved 
only  once  a  day,  and  gave  no  warning.  He  complained 
only  of  loss  of  erectile  power  of  the  penis,  due  proba- 
bly to  involvement  of  the  urethra  by  the  disease  and 
the  operation.  There  was  one  suspicious  spot  where 
the  anus  had  been  which  looked  like  a  recurrence,  but 
it  could  be  removed,  with  the  probability  of  a  long  lease 
of  life. 

Old  Dislocation  of  Shoulder. — Dr.  C.  L.  Gibson  pre- 
sented a  boy,  eighteen  years  of  age,  who  had  sustained 
dislocation  of  the  left  shoulder  at  the  age  of  twelve. 
There  was  now  very  considerable  motion  in  spite  of 
the  dislocation.  The  muscles  were  markedly  atrophied, 
the  ligaments  relaxed,  so  that  dislocation  could  be 
made  to  take  place  in  different  directions.  In  view  of 
the  fair  use  of  the  arm,  he  doubted  whether  any  of  the 
procedures  suggested  in  these  cases  would  be  advisable. 

Congenital  Dislocation  at  the  Knee. — Dr.  Thomas 
H.  Manley  presented  a  case  of  what  seemed  an  un- 
usual type  of  congenital  dislocation — an  infant,  born 
four  months  ago,  forceps  used  to  hasten  delivery,  no 
manipulation  of  the  limbs.  Everything  went  well  until 
the  child  was  two  weeks  old,  when  the  mother  observed 
something  wrong  about  the  knee.  Examination  showed 
dislocation,  falling  down  of  the  condyles  of  the  femur 
into  the  popliteal  space,  upward  and  forward  displace- 
ment of  the  tibia.  There  was  no  paralysis,  no  vascular 
disturbance.  The  child  was  able  to  move  the  limb  for- 
ward and  backward  to  considerable  degree.  Dr.  Man- 
ley  had  found  but  two  cases  of  similar  dislocation  on 
record.  When  the  child  got  older  and  stronger  he 
would  make  an  effort  to  get  the  bones  into  normal 
position.  It  might  be  necessary  to  divide  ligaments, 
perhaps  also  the  hamstring. 

Aneurism  of  Subclavian  Artery,  Probably  Traumatic. 
— Dr.  Manley  also  presented  a  man,  about  thirty-eight 
years  of  age,  who  had  sustained  an  injury  of  the  shoul- 
der on  board  ship  two  years  ago,  which  laid  him  up 
a  few  days.  A  month  later  there  was  loss  of  power  in 
the  left  arm.  This  improved.  A  year  and  a  half  ago 
he  had  pain  in  the  neck  and  weakness  of  left  arm,  and 
soon  noticed  a  throbbing  tumor  near  the  clavicle.  The 
tumor  was  visible,  there  was  a  distinct  upward  and  for- 
ward motion  of  the  clavicle  with  the  pulsations  ;  it  was 
evidently  an  aneurism,  probably  of  the  second  part  of 
the  subcla\-ian  artery,  and,  it  was  believed,  due  to  the 
former  trauma.  There  was  a  specific  history,  but  a 
doctor  had  applied  treatment  by  rest  for  nearly  a  year 
and  large  doses  of  iodide  of  potassium.  The  patient's 
health  became  reduced,  and  when  Dr.  Manley  saw  him 
he  decided  to  try  tentative  measures,  allowing  him  to 
go  about  and  apply  massage  to  the  tumor  in  a  manner 
to  favor,  if  possible,  formation  of  clot,  and  spontaneous 
cure.     The  general  health  had  improved. 

Supra  -  malleolar  Osteotomy  for  Flat-foot. —  Dr. 
Willy  Meyer  presented  a  girl,  aged  twenty-three,  on 
whom  he  had  performed  supra-malleolar  osteotomy  for 
flat-foot  in  1893,  an  operation  regarding  which  he  was 
enthusiastic  at  that  time.  In  all  he  had  performed  it 
ten  times  on  five  cases.  This  patient  was  allowed  to 
get  up  without  a  support  about  the  thirty- second  day, 
and  had  a  good  arch  on  the  left  foot,  not  quite  so  good 
on  the  right,  and  having  no  support,  she  placed  too 
much  weight  on  the  left  foot  and  developed  pain,  call- 
ing for  further  operation  about  two  months  later  by 
Dr.  Gerster.  The  right  foot  remained  in  good  posi- 
tion. Some  months  later,  with  the  aid  of  Dr.  Whit- 
man, the  position  of  the  left  foot  was  corrected,  plaster 
applied,  and  afterward  the  ^Vhitman  splint  was  worn. 
The  result  had  been  very  satisfactory,  and  to-day  the 
patient  could  go  about  without  the  splint.  Dr.  Meyer 
would  now  always  try  physiological  treatment,  as  dis- 


cussed at  the  last  meeting  of  the  Section,  before  resort- 
ing to  supra-malleolar  osteotomy  in  flat-foot,  and 
thought  the  latter  operation  would  be  required  only  in 
marked  cases. 

Weak  and  Stronger  Solutions  of  Cocaine.  —  The 
Chairm.^n  said,  in  relation  to  Dr.  Wyeth's  case,  that  he 
had  used  cocaine  ansesthesia  even  in  exploratory  lapa- 
rotomy and  in  gastrotomy.  If  it  were  carefully  em- 
ployed it  would  enable  us  to  dispense  with  general 
anaesthesia  for  operations  of  considerable  severity  in 
patients  in  whom  general  anaesthesia  was  contraindi- 
cated. 

Dr.  D.wiD  GooDwiLLiE  preferred  a  two  per  cent. 
solution  to  four  per  cent.,  as  described  by  Dr.  Wyeth, 
and  in  operations  on  the  face  had  found  it  act  ad- 
mirably. 

Dr.  Willy  Meyer  would  not  like  to  risk  four  per 
cent,  solution  hypodermically,  as  he  had  seen  alarming 
symptoms  of  poisoning  from  even  small  doses.  Dur- 
ing the  past  two  years  he  added  a  one-hundredth  of  a 
grain  of  nitro-glycerine  in  order  to  counteract  the  ill 
effects  of  the  cocaine  on  the  brain.  Such  advance  had 
been  made  in  the  use  of  cocaine  that  now,  as  practised 
in  Germany,  one-fifth  to  one-tenth  per  cent,  solution 
was  found  sufficient.  A  small  amount  of  morphine 
could  be  added. 

Dr.  Thomas  Maxley  had  used  cocaine  in  major 
operations  on  the  extremities,  genital  tract,  periphaial 
tumors,  etc.  Alcohol  seemed  to  increase  its  analgesic 
influence  and  diminish  its  toxic  effect.  He  used  a  one 
per  cent,  solution  of  cocaine,  and  in  no  case  adminis- 
tered more  than  one  grain  by  injection.  It  destroyed 
the  pain-sense  but  not  the  feel-sense. 

Dr.  Wveth  said  he  had  been  a  strong  believer  in 
cocaine  anaesthesia  since  its  first  introduction,  and  had 
used  it  in  many  hundreds  of  operations  of  all  grades  of 
severity.  He  alwajss  employed  a  four  per  cent,  solu- 
tion, and  had  seen  no  toxic  effects,  but  it  should  be 
remembered  that  he  employed  only  one  or  two  minims 
in  one  place,  and  during  an  extensive  operation  did 
not  axceed  twenty-five  minims.  The  application  was 
made  at  intervals  as  the  operation  proceeded.  He  had 
tried  weaker  solutions,  but  preferred  the  four  per  cent. 
Dr.  Gibson  had  once  tried  the  weak  solution  and  had 
to  give  it  up  because  the  nurses  and  patients  com- 
plained that  it  was  not  efficient  in  deadening  pain. 

Dr.  Dawearn"  said  that  where  cocaine  had  produced 
death,  respiration  had  failed  before  the  heart.  Nitro- 
glycerine and  whiskey  counteracted  the  evil  effects  of 
the  cocaine  by  dilating  the  cerebral  blood-vessels,  and 
it  was  his  custom  to  precede  the  use  of  cocaine  by  a 
large  draught  of  brandy  or  whiskey  if  the  operation 
were  of  any  gravity. 

Dr.  Lilienthal  mentioned  the  fact  that  patients 
were  apt  to  flinch  when  it  came  to  tying  arteries,  and 
Dr.  Wyeth  corroborated  this  statement,  expressing  the 
opinion  that  the  vaso-motor  nerves  must  carry  some 
sensory  fibres. 

Dr.  Dawbarn,  referring  to  Dr.  Lilienthal's  case  of 
resection  of  the  rectum,  wished  to  place  himself  on 
record  as  being  in  favor  of  inguinal  colotomy  in  every 
case  of  cancer  of  the  rectum.  The  danger  was  but 
slight,  not  more  than  five  per  cent,  mortality  ;  it  would 
prolong  life  and  make  it  much  more  comfortable  if  the 
disease  below  could  not  be  removed.  It  facilitated 
healing  in  operable  cases.  The  colotomy  wound  would 
close  of  its  own  accord  after  a  time. 

Dr.  Royal  Whitman  said,  in  regard  to  Dr.  Man- 
ley's  case  of  congenital  dislocation  at  the  knee,  that  he 
had  seen  a  good  many  cases  of  the  kind.  Instead  of 
waiting  for  age,  it  would  be  wiser,  he  thought,  to 
bring  the  proper  articulating  surfaces  into  position  at 
once  and  try  to  retain  them  there. 

Dr.  Manlev  said  the  hamstrings  were  contracted, 
and  he  thought  it  better  to  wait  until  the  child  was 
three  months  old,  by  which  time  it  would  be  stronger, 
before  operating. 


December  21,  1895] 


MEDICAL   RECORD. 


887 


Dr.  Wyeth  had  not  examined  Dr.  Manley's  case  of 
aneurism,  but  in  nearly  all  cases  of  supposed  aneurism 
of  the  first  part  of  the  subclavian  the  real  origin  was 
from  the  ascending  or  transverse  portion  of  the  arch  of 
the  aorta,  and  when  that  was  true  the  treatment  was  very 
different.  If  only  the  subclavian  were  involved,  he 
would  tie  the  artery  in  its  third  division.  If  that  did 
not  succeed  he  would  try  introducing,  and  leaving  in, 
pins  twelve  to  twenty-four  hours,  repeating  it  two  or 
three  times,  in  order  to  produce  a  coagulum.  The  pa- 
tient should  have  e.xplained  to  him  the  possibility  of 
embolism  arising  from  it. 

Two  Successful  Hip-joint  Amputations,  the  Second  of 
which  was  Performed  by  a  New  Method. — Dr.  F.  Til- 
den  Brown  read  the  histories  of  the  cases.  The  first 
was  one  of  round-cell  sarcoma  of  the  left  biceps  fem- 
oris  in  a  man,  aged  twenty-two,  who  was  admitted  to 
the  Presbyterian  Hospital,  December,  1894.  The  ori- 
gin was  in  an  injury  6f  the  knee  twelve  years  before. 
During  the  operarion  the  pelvis  was  brought  to  the  end 
of  the  table,  and  a  low  sand-bag  was  placed  under  the 
left  buttock.  Esmarch's  bandage  was  not  used,  through 
fear  of  disseminating  sarcomatous  elements,  but  the 
limb  was  held  nearly  perpendicular  a  few  minutes  be- 
fore piercing  the  thigh  with  new  -j\  inch  mattress 
needles,  and  applying  above  them  the  rubber  tubing 
after  the  adaptation  of  Wyeth.  The  Furneaux-Jordan 
incision  was  made,  and  amputation  completed  twenty- 
five  minutes  after  commencing  the  operation.  The 
whole  leg  was  left  for  leverage  during  its  manipulations 
by  his  assistant.  The  femoral  artery  was  ligated  with 
silk,  the  other  vessels  with  catgut.  The  wound  was 
closed  without  drainage.  The  patient  made  a  good 
recovery. 

The  haemostatic  effect  of  the  rubber  tubing,  supported 
by  the  transfixing  needles,  was  all  that  could  be  desired. 
But  an  objection  to  the  method  was  noticed  in  that  the 
skin  and  muscles  about  the  joint  were  made  so  tense 
and  hard  by  compression  of  the  tubing  that  the  region 
was  much  more  inaccessible  to  instruments  and  fingers. 
Even  after  disarticulation  the  margin  of  the  cotyloid 
cavity  was  difficult  to  trim  up  for  the  same  reason. 
Apparently  recognizing  this  fault.  Dr.  AVyeth  proposed 
to  adopt  Lanphear's  suggestion  to  insert  the  cuter  pin 
at  a  higher  point,  so  that  the  rubber  tubing  would  be 
held  in  the  notch  just  below  the  anterior  superior  spine 
of  the  ilium. 

The  second  case  was  one  of  tubercular  osteo-arthritis 
of  the  hip  in  a  female,  aged  twenty-seven,  admitted 
June,  1895,  discharged  August,  1895.  The  disease  had 
probably  started  from  a  fall  four  years  before.  It  was 
proposed  to  excise  the  joint  if  the  condition  found 
justified  it,  otherwise  to  amputate.  July  nth  an  in- 
cision was  begun,  one-half  inch  below  the  anterior 
superior  spinous  process  of  the  ilium,  prolonged  down- 
ward in  the  intermuscular  septum  between  the  sarto- 
rius  and  rectus  on  the  inner  side,  and  tensor  vagina 
femoris  and  glutei  on  the  outer.  This  afforded  excel- 
lent access  to  the  capsular  ligament,  with  scarcely 
any  bleeding.  A  cavity  with  considerable  tubercular 
debris  was  here  cleared  out.  Opening  the  capsule, 
advanced  tubercular  disease  was  found.  The  condi- 
tions of  disease  in  the  joint  and  muscles,  and  weakened 
condition  of  patient,  were  not  thought  favorable  for 
excision.  The  thigh  was  held  perpendicularly,  one  jaw 
of  a  specially  made  clamp  was  i)assed  through  the 
existing  incision,  guided  by  the  finger,  under  the  sar- 
torius  and  under  the  femoral  vessels  close  to  Poupart's 
ligament,  the  other  jaw  being  outside  the  wound  and 
bearing  upon  the  cutaneous  surface  overlying  the  ves- 
sels. As  the  clamp  was  moderately  lightened  and  the 
limb  lowered,  pulsation  in  the  femoral  ceased.  The 
application  of  the  clamp  had  required  but  a  moment. 
Its  tip  had  been  sheathed  with  rubber  tubing,  possibly 
an  unnecessary  precaution  against  injuring  the  vessels. 
He  then  proceeded  with  the  amputation,  extending  the 
existing  incision  along  the  outer  border  of  the  rectus 


downward  to  the  bone,  stripping  off  remaining  attach- 
ments to  joint  and  femur.  A  circular  skin  cuff  was 
cut  and  turned  back,  and  the  muscles  severed  to  the 
bone  by  circular  incision.  Some  of  the  small  branches 
of  the  sciatic  required  the  application  of  pressure  for- ' 
ceps,  but  the  femoral  vessels  and  their  branches  were 
absolutely  dry  on  their  proximal  side.  The  remaining 
steps  of  the  operation  were  not  unusual.  The  patient 
had  made  a  good  recovery,  although  still  a  victim  of 
pulmonary  tuberculosis. 

The  following  were  points  of  merit  in  this  operation  : 
I.  The  incision  permitted  the  best  exposure  of  the 
joint  through  tissues  which  contained  no  vessels  or 
nerves  of  importance,  and  the  same  incision  served  for 
the  easy  adjustment  of  a  clamp  upon  the  femoral  ves- 
sels before  advancing  to  the  critical  stages  of  the  opera- 
tion. 2.  The  angled  shape  of  the  clamp  was  such  that 
while  it  securely  compressed  only  the  femoral  artery 
and  vein  between  their  sheath  and  overlying  skin,  it 
serv-ed  at  the  same  time  as  inward  retractor  for  the 
sartorius  muscle,  and  the  instrument  was  wholly  out 
of  the  operative  field.  Esmarch's  bandage  could  be 
applied  up  to  the  groin  and  yet  space  remain  for  the 
incision  and  clamp.  3.  The  continuation  of  the  in- 
cision was  in  a  line  where  there  was  a  minority  of  the 
arterial  branches  of  the  sciatic.  4.  The  open  wound 
and  its  final  suture  were  most  accessible  to  the  op- 
erator. 5.  Belief  that  this  operation,  including  the  pe- 
riod of  anesthesia,  could  be  performed  in  a  shorter 
time  than  any  of  those  where  the  danger  from  hemor- 
rhage was  as  thoroughly  guarded  against. 

Dr.  Wyeth  said  he  thought  the  device  of  Dr.  Brown, 
connected  with  that  particular  operation  in  which 
there  was  tubercular  destruction  of  the  head  of  the 
femur,  and  in  which  an  exploratory  incision  had  to  be 
made  at  first,  with  the  possibility  of  being  followed  by 
amputation  as  a  second  part  of  the  operation,  was  very 
clever.  It  seemed  to  him,  however,  that  the  same 
amount  of  anemia  might  have  been  obtained  by  simple 
deligation  of  the  femoral  artery  and  vein.  It  was  a  very 
easy  matter  to  tie  the  femoral  artery  under  cocaine, 
and  therefore  he  could  see  no  particular  merit  in  the 
instrument  presented,  although  it  was  an  ingenious  one. 
In  amputation  at  the  hip  for  tumor  below  that  region, 
he  thought  the  method  was  not  an  advance  forward 
but  backward.  It  did  not  control  a  great  part  of  the 
hemorrhage,  and  this  was  now  considered  a  chief  cause 
of  shock.  The  mattress  needles  and  rubber  tubing, 
the  needle  inserted  high  up,  was  the  most  satisfactory 
method.  He  was  a  very  strong  advocate  of  catgut  in 
tying  arteries,  and  had  not  had  secondary  hemorrhage 
therefrom. 

Dr.  Dawb.\rn  said  that  in  all  hip-joint  amputations 
he  hamstringed  his  patients  in  order  to  prevent  retrac- 
tion of  the  muscles  and  their  unecjual  length  and  pock- 
eting after  division.  This  saved  time  spent  in  suturing 
them  on  a  common  level. 

Dr.  Brown  said  the  old  form  of  incision  in  hip- 
joint  amputation  would  not,  as  did  his,  permit  of  liga- 
tion of  the  femoral  vessels,  but  a  second  incision  would 
have  to  be  made.  He  thought  a  possible  objection  to 
the  mattress  needles  and  constriction  by  rubber  tubing 
was  injury  to  the  vaso-motor  sup|)ly. 

Post-mortem  Examination  of  the  Parts  Involved  in  a 
Bassini  Operation  for  Inguinal  Hernia  Six  Weeks  af- 
ter its  Performance. — Dr.  George  E.  Brewer  reported 
the  case,  as  it  was  unusual  to  have  opportunity  to  ex- 
amine the  united  parts  so  short  a  time  after  the  Bassini 
operation.  The  manner  in  which  the  several  structures 
had  adhered  together  was  described. 


The  Treatment  of  Torticollis. — Dr.  Weiss  recom- 
mends the  use  of  curare  in  this  disorder.  He  employs 
a  filtered  solution  of  curare,  of  the  strength  of  two 
grains  to  three  drachms  of  sterilized  water.  This  is 
given  in  doses  of  from  fifteen  to  thirty  minims. 


MEDICAL   RECORD. 


[December  21,  i! 


THE   NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  N^avcmber  ij,  iSqj. 

George  P.  Biggs,  M.D.,  President.  ■ 

Intestinal  Perforation — Dr.  F.  M.  Jeffries  presented 
three  specimens  of  intestinal  perforation.  The  first 
was  from  a  man  who  had  been  taken  to  St.  Vincent's 
Hospital  on  November  9th.  When  found  by  the  am- 
bulance surgeon  he  had  refused  to  talk,  and  had  been 
suffering  from  abdominal  pain.  The  pupils  had  been 
dilated  and  the  pulse  weak  and  rapid.  On  admission 
his  temperature  was  103°  F. ;  pulse,  136  ;  respiration, 
24.  He  had  some  colicky  pain  for  a  short  time,  and 
more  or  less  constant  vomiting  of  greenish  mucus. 
Constipation  was  present.  His  temperature  fell  on  the 
third  day  after  admission  to  98°  F.,  but  just  before 
death  it  rose  to  105.6°  F.  The  abdomen  was  at  first 
retracted,  but  on  the  second  day  it  was  distended,  and 
percussion  showed  flatness  on  the  sides.  A  diagnosis 
of  intestinal  perforation  was  made.  At  the  autopsy  a 
large  quantity  of  yellowish  fluid  was  found  in  the  ab- 
dominal cavity,  the  intestines  were  matted  together 
by  lymph,  and  there  was  a  perforation  eight  inches 
from  the  ileo-ca;cal  valve.  There  was  a  recent  pleurisy 
over  the  left  lung,  and  a  hypostatic  congestion  of  both 
lungs.  The  pericardial  cavity  contained  about  two 
ounces  of  dark  reddish-brown  liquid.  The  valves  of 
the  heart  were  normal  :  the  muscle-wall  was  pale 
and  thin.  The  liver  showed  moderate  cirrhosis.  The 
spleen  was  fairly  normal.  The  capsule  of  the  kidney 
was  non-adherent,  and  presented  a  smooth,  glistening 
surface  ;  the  epithelium  was  swollen. 

The  second  case  was  a  woman,  fifty  years  of  age, 
who  had  been  brought  to  Bellevue  Hospital  suffering 
from  alcoholism,  and  consequently  very  little  of  the 
previous  history  could  be  ascertained.  It  was  learned, 
however,  that  about  one  week  previous  to  admission 
she  had  fallen  and  struck  the  right  side.  The  vomit- 
ing was  continuous  at  first,  and  consisted  of  the  con- 
tents of  the  stomach  ;  later  on,  it  contained  biliary 
matter.  There  were  great  pain  and  tenderness  over  the 
entire  abdomen  with  considerable  enlargement  in  the 
right  hypochondriac  region.  On  admission  the  tem- 
perature was  104^  F.,  the  pulse  thready  and  irregular, 
and^  there  was  evident  peritonitis  and  shock.  Cathar- 
tics and  purgative  enemata  were  given  with  little  re- 
sult. The  autopsy  showed  fatty  infiltration  of  the 
heart,  interstitial  nephritis,  and  suppurative  peritonitis 
with  perforation  about  seven  feet  from  the  ileum. 
There  was  also  a  large  uterine  tumor. 

The  third  case  was  an  Italian  woman,  who  had  been 
found  dead  in  her  room.  The  autopsy  showed  some 
oedema  of  the  brain.  The  cavities  of  the  heart  were 
dilated,  and  the  walls  infiltrated  with  fat.  On  opening 
the  abdomen  a  large  quantity  of  e.xtremely  offensive 
yellowish  fluid  bathed  the  intestines.  The  latter  con- 
tained yellowish  freces,  and  there  were  a  number  of 
ulcers,  with  perforations  in  two  or  three  situations. 

General  Miliary  Tuberculosis.— Dr.  Jeffries  also  pre- 
sented a  case  of  general  miliary  tuberculosis.  The 
pa.ient  was  a  negro,  who  at  the  time  of  admission  had 
a  high  temperature.  So  far  as  could  be  ascertained 
he  had  enjoyed  good  health  up  to  twelve  weeks  ago. 
The  autoi)sy  showed  miliarv  tubercles. 

Hydronephrosis.— Dr.  J.^mes  Ewing  presented  two 
cases.  The  first  specimen  had  been  removed  from  a 
woman  about  forty  years  of  age.  As  was  often  the 
case,  the  condition  had  been  entirely  overlooked  dur- 
ing life.  The  usual  symptom  of  a  line  of  tympany 
running  down  over  the  course  of  the  tumor,  produced 
by  the  colon  being  pressed  forward  by  the  tumor,  was 
absent  in  this  case  because  there  was  a  well-marked 
meso-colon  which  allowed  of  the  large  intestine  being 
pushed  to  one  side.  The  hydronephrosis  was  due  to 
cancer  of  the  uterus.  It  was  estimated  that  a  pressure 
of  about  one  pound   would    have   been   sufficient   to 


empty  the  pelvis  of  the  kidney,  showing  that  the  press- 
ure that  had  caused  the  hydronephrosis  had  been 
slight.  There  was  the  usual  dilatation  of  the  pelvis 
and  flattening  of  the  kidney,  and  the  cavity  was  di- 
vided into  several  compartments  by  hypertrophy  of  the 
septa  of  the  original  organ.  Microscopical  examina- 
tion of  these  septa  showed  a  new  growth,  and  at  either 
end  the  remains  of  the  kidney  showed  epithelioma. 
The  tubules  themselves  were  nearly  normal,  except 
that  they  were  dilated.  The  tumor  contained  nearly 
normal  urine.  In  the  urine  a  single  specimen  of  worm 
was  found  under  the  microscope.  It  resembled  closely 
the  filaria  sanguinis,  but  the  worm  had  not  been  defi- 
nitely identified. 

The  second  specimen  had  been  removed  from  a 
subject  in  the  anatomical  department  of  the  college. 
Death  was  supposed  to  have  been  due  to  cirrhosis  of  the 
liver,  showing  that  this  condition  had  been  overlooked 
also  during  life.  In  this  case  the  distended  colon 
passed  over  the  tumor.  The  sac  measured  2S  ctm.  in 
one  diameter  and  42  ctm.  in  another.  The  contents 
were  not  urine,  but  a  fluid  which  became  almost  solid 
on  boiling  it.  It  contained  a  large  quantity  of  blood, 
and  in  a  portion  of  the  tumor  were  a  number  of  blood- 
clots,  showing  that  death  had  been  due  to  hemorrhage 
into  this  large  mass.  There  was  an  almost  entire 
atrophy  of  the  kidney  substance.  The  ureter  was  per- 
vious up  to  within  one  or  two  inches  of  the  pehns  of 
the  kidney.  This  sac  also  contained  septa,  but  much 
thinner  than  in  the  first  specimen.  The  tubules  in  the 
other  kidney  were  much  hypertrophied,  showing  that 
this  kidney  had  been  doing  double  duty  for  a  number 
of  years. 

Cystic  Tumor  in  the  Kidney  of  a  Bullock. — Dr. 
George  P.  Biggs  presented  a  kidney  from  a  bullock 
showing  the  very  marked  lobulation  of  these  kidneys. 
In  one  end  was  a  large  raultilocular  cystic  tumor  con- 
taining a  clear  amber-colored  fluid.  The  remaining 
portion  of  the  kidney  tissue  appeared  to  be  normal. 
Such  cysts,  the  speaker  said,  were  not  very  uncommon 
in  sheep,  and  wtrt  usually  regarded  as  congenital. 

Mitral  Stenosis  Confounded  with  Uraemia. — Dr.  Biggs 
then  presented  a  heart  removed  from  a  woman,  thirty- 
three  years  of  age,  who  had  lived  only  about  two  hours 
after  admission  to  the  New  York  Hospital.  She  had 
been  sick  for  about  two  weeks.  On  admission  there 
was  acute  oedema  of  the  lungs,  and  the  heart-sounds 
were  feeble.  The  urine  contained  a  large  percentage 
of  albumin  and  numerous  casts,  and  was  of  low  specific 
gravity.  The  clinical  diagnosis  had  been  uraemia  com- 
plicating pregnancy,  but  Dr.  Biggs  said  he  had  ventured 
on  the  diagnosis  of  mitral  stenosis,  and  this  had  been 
confirmed  by  the  autopsy.  The  uterus  contained  a 
well-developed  foetus  of  about  eight  months.  The 
other  organs  showed  an  extreme  degree  of  chronic  ve- 
nous congestion.  The  heart  was  distinctly  hypertroph- 
ied, and  both  cavities  were  markedly  dilated.  The 
wall  of  the  left  ventricle  was  rather  thinner  than  nor- 
mal. The  right  ventricle  was  both  dilated  and  hyper- 
trophied, the  wall  in  many  places  being  3^  cira.  thick. 
The  valves  of  the  right  side  were  perfectly  normal. 
The  aortic  cusps  were  slightly  thickened  and  retracted. 
The  mitral  valve  showed  a  marked  degree  of  stenosis, 
not  admitting  the  tip  of  the  little  finger.  The  left  auri- 
cle was  considerably  dilated  and  hypertrophied.  The 
speaker  said  that  he  had  based  his  diagnosis  of  mitral 
stenosis  on  the  history  of  acute  cedema,  the  expectora- 
tion of  blood-serum,  and  the  recollection  of  another 
similar  case  seen  some  years  previously.  In  this  pre- 
vious case  there  had  been  no  cardiac  murmurs,  the 
woman  had  been  pregnant  and  had  given  a  history  of 
attacks  of  sudden  and  alarming  pulmonary  oedema 
coming  on  only  during  pregnancy.  Dr.  Janeway  had 
stated  that  the  cardiac  murmurs  would  appear  if  car- 
diac stimulants  were  administered,  and  this  had  proved 
to  be  the  case.  It  became  necessan,-  in  this  instance  to 
induce  premature   labor.     She  recovered.     This  con- 


December  21,  1S95] 


MEDICAL   RECORD. 


889 


dirion,  Dr.  Biggs  said,  of  rapid  and  irregular  heart  ac- 
tion without  murmurs  often  led  a  physician  seeing  the 
case  then  for  the  first  time  to  mistake  the  real  condi- 
tion. He  recalled  a  recent  case  of  this  kind  in  which 
one  well-known  physician  had  repeatedly  examined  the 
heart  and  had  stated  that  there  was  positively  no  heart 
disease  present,  and  yet  death  had  occurred  from  this 
cause  shortly  afterward.  Pregnancy  decidedly  aggra- 
vates these  symptoms,  and  the  question  of  inducing 
premature  labor  or  abortion  claims  careful  considera- 
tion. 

Dr.  Ewixg  remarked  that  the  specimen  from  a  bul- 
lock showed  the  difference  between  congenital  and  ac- 
quired tumors  ;  the  congenital  tumors  showed  lobula- 
tion and  division,  while  the  acquired  tumors  had  a 
more  dense  capsule  about  the  cyst,  and  showed  the  re- 
mains of  the  original  kidney  tissue. 

Zaryokinesis. — Dr.  T.  S.  Ely  exhibited  under  the 
microscope  a  specimen  of  frog's  blood  showing  karyo- 
kinesis.  One  white  corpuscle  was  shown  in  which  the 
chromozones  had  been  collected  together  in  the  centre, 
and  another  in  which  the  chromozones  were  just  sepa- 
rating from  each  other.  Dr.  Ely  said  that  karyokinesis 
had  been  first  definitely  studied  in  1889  by  Sprank,  who 
had  found  it  in  blood  from  frogs,  and  from  human  be- 
ings. In  human  blood  it  should  be  found  in  about  one 
on  a  thousand  of  the  white  corpuscles.  Sprank  had 
also  observed  it  in  leucsemia.  It  was  believed  that  the 
small  mononuclear  leucocytes  were  the  ones  which 
underwent  this  change,  the  polynuclear  leucocytes  be- 
ing now  looked  upon  as  having  originated  from  the 
mononuclear  leucocytes  probably  by  a  process  of  sub- 
division. If  it  could  be  shown  that  the  so-called  tran- 
sition stages  among  the  leucocytes  were  definitely  de- 
rived from  the  small  mononuclear  leucocytes,  and  that 
they  then  gave  rise  to  the  polynuclear  leucocytes  by  a 
process  of  direct  cell  division,  the  polynuclear  leuco- 
cytes would  have  to  be  regarded  as  degenerate  cells. 
The  polynuclear  leucocytes  were  much  more  com- 
monly found  in  pus,  and  recent  investigations  of  Janof- 
sky  went  to  show  that  the  cells  which  migrate  in  sup- 
purative inflammation  were  for  the  most  part  mononu- 
clear leucocytes,  and  that  in  the  formation  of  the 
polynuclear  leucocyte,  or  the  typical  pus  cell,  the  pro- 
cess is  one  of  direct  cell  division,  and  not  a  process  of 
karyokinesis. 


Heat-stroke  in  the  Navy. — During  the  past  year 
fifty-five  cases  of  heat- exhaustion  among  the  engineer 
force  of  the  United  States  Navy  have  been  reported, 
the  greatest  number  of  cases  appearing  on  the  follow- 
ing vessels:  Bennington,  11  ;  Bancroft,  8;  Columbia, 
6  ;  Amphitrite,  5  ;  Raleigh,  5.  In  his  annual  report 
just  issued.  Dr.  Tryon  says  that  these  figures  are  sig- 
nificant and  merit  attention  by  the  department.  The 
average  temperature  of  the  engine-rooms  of  modem 
ships,  under  ordinary  cruising  conditions  may  range 
from  106"  F.,  with  hatches  large  and  open  like  the 
Charleston,  to  152°  in  badly  arranged  and  closed  ships 
like  the  Amphitrite.  In  the  fire-rooms  the  average 
temperature  under  the  above  conditions  may  range 
from  124°  in  ships  with  only  one  set  of  fires  in  each 
fire-room,  like  the  Charleston,  to  189°,  when  the  fire- 
room  is  between  two  sets  of  fires,  like  the  Cincin- 
nati and  Amphitrite.  In  the  case  of  the  Cincinnati, 
when  only  one  set  of  fires  is  used  in  each  fire- 
room,  the  average  temperature  is  reduced  from  1S9 
to  159°.  The  result  of  these  high  temperatures,  to- 
gether with  overwork  and  other  trying  conditions,  is 
plainly  shown  by  the  number  of  disabilities  in  the  En- 
gineer Corps  attributed  to  this  cause.  Since  January 
I,  1894,  eleven  chief  engineers  and  three  past-assistant 
engineers  have  been  or  are  now  on  sick  leave,  and  of 
this  number  six  have  been  recommended  for  retirement 
and  two  have  died. 


CTinicat  department 

THE    DIAGNOSIS    AND   TREATMENT    OF 
FRACTURES.! 

By  W.  L.  HUGHLETT,  M.D., 


Ix  the  whole  domain  of  medicine  and  surgery  there  is 
no  class  of  cases  that  call  for  greater  knowledge  and 
skill  on  the  part  of  the  general  practitioner  than  cases 
of  fracture,  none  that  so  frequently  get  the  members 
of  our  profession  involved  in  suits  for  damages.  While 
we  are  rarely  called  upon  to  perform  operations  of 
great  magnitude,  any  of  us  are  liable  at  any  time  to  be 
called  to  attend  the  most  serious  fractures  that  can 
occur ;  we  should  therefore  be  prepared  to  render 
promptly  such  service  as  may  secure  for  the  patient 
useful  limbs  and  for  ourselves  commendation  rather 
than  censure  and  lawsuits.  It  is  to  be  regretted  that 
there  is  no  fixed  standard,  and  that  our  leading  men 
differ  so  materially  on  this  subject.  The  best  thing 
for  us  to  do  is  to  master  thoroughly  the  anatomy  and 
physiology  of  the  human  body,  so  that  when  bones  are 
broken  we  may  have  at  least  knowledge  enough  to  re- 
store the  fragments  to  a  normal  position,  and  skill 
enough  to  confine  them  favorably  for  nature's  beautiful 
reparative  processes.  The  diagnosis  of  fractures  is 
not  always  easy.  It  takes  no  special  skill  to  tell  that 
a  bone  is  broken  if  the  fracture  be  in  the  shaft  of  a 
long  bone,  or  of  a  rib,  or  a  depressed  fracture  of  the 
skull  ;  but  when  fractures  run  into  the  joints,  involve 
the  epiphysis,  are  intra-capsular,  occur  at  the  base  of 
the  skull  or  in  the  vertebrae,  diagnosis  is  sometimes 
verv  difficult.  It  is  often  difficult  to  say  whether  a 
fracture  of  the  long  bones  is  oblique,  transverse,  simple, 
or  comminuted.  I  assisted  in  a  case  of  amputation  of 
the  thigh  (when  a  student),  the  patient  being  a  large 
negro  man  who  had  been  run  over  by  a  car  wheel ; 
this  case  was  diagnosed  by  several  competent  surgeons 
as  one  of  severe  comminuted  fracture.  After  the  limb 
had  been  removed  I  made  a  dissection  and  found  a 
simple  transverse  fracture  of  the  middle  one-third  of 
the  thigh.  This  man's  leg  might  have  been  saved  had 
a  correct  diagnosis  been  made.  The  symptoms  of 
fracture,  as  a  rule,  if  in  a  limb,  are  quickly  noted. 
There  will  be  loss  of  function,  swelling  about  the  in- 
jured part,  deformity  caused  by  muscular  contraction, 
pain  increased  by  attempts  at  motion,  and  generally 
crepitus  on  motion.  We  shall  also  have  a  history  of 
severe  blow,  fall,  or  violent  exercise.  (.V  few  years  ago 
I  treated  a  young  man  for  fractured  thigh  caused  by 
running  a  base  in  a  game  of  ball ;  simple  muscular 
force.) 

The  most  serious  error  in  diagnosis  is  to  confound  a 
fracture  with  a  dislocation.  This  is  most  likely  to  oc- 
cur at  the  shoulder,  the  elbow,  and  hip.  If  we  know 
we  have  a  fracture  to  deal  with  a  few  days  may  be  al- 
lowed to  elapse  until  swelling  has  subsided,  but  if  there 
is  doubt,  in  my  opinion  the  best  practice  is  to  put  the  pa- 
tient under  the  influence  of  an  anesthetic  and  settle 
the  diagnosis.  In  this  way  a  dislocation  is  readily  re- 
duced, or  if  we  find  we  are  dealing  with  a  fracture  we 
get  more  accurate  knowledge.  If  we  fear  any  heart 
or  kidney  complication  we  may  often  use  morphia  and 
atropia  hypodermically,  instead  of  chloroform  or  ether. 
In  the  case  of  children  I  always  prefer,  and  nearly 
always  use,  chloroform.  Anx-sthetics  carefully  admin- 
istered promptly  relieve  the  nervous  shock  and  pain 
and  permit  of  thorough  manipulation  when  required. 
Not  only  is  this  a  great  consideration,  but  if  we  are 
ready  with  our  apparatus  we  can  at  once  apply  the 
dressings  and  the  patient  rouses  to  find  the  dreaded 
operarion  of  bone-setting  all  over,  much  to  his  delight. 

'  Read  before  the  East  Coast  Line  Surgical  Association,  at  their 
meeting  at  St.  Augustine,  Fla.,  September  4,  1895. 


890 


MEDICAL   RECORD. 


[December  21,  1895 


No  man  can  be  really  expert  or  scientific  in  the  diag- 
nosis of  fracture  unless  he  be  thoroughly  acquainted 
with  the  anatomy  of  the  parts,  not  only  with  the  bony 
structures  involved,  but  the  muscles,  nerves,  and  blood- 
vessels as  well.  I  have  seen  paralysis  result  from  the 
nerve  being  caught  in  the  callus  of  a  fractured  hu- 
merus, and  death  has  resulted  from  simple  fractures 
from  emboli  or  thrombus  forming  in  the  vessels.  I 
know  of  one  case  where  fracture  of  the  femur  by  a 
pistol-ball  caused  aneurism  of  the  femoral  artery,  a 
spicula  of  bone  having  pierced  that  vessel.  Occasion- 
ally we  see  gangrene  following  fractures,  the  nerve 
and  blood  supply  having  been  cut  off. 

It  is  necessary,  then,  that  we  not  only  be  very  careful 
in  handling  injured  parts,  but  cautiously  to  consider  all 
the  accidenft  that  may  occur  in  the  course  of  treat- 
ment. Unless  we  are  dealing  with  a  complete  fracture, 
extreme  care  is  required  in  handling  the  affected  parts. 
For  instance,  a  partly  fractured  clavicle  had  better  be 
left  alone  than  made  complete,  as  callus  is  quickly 
thrown  out  at  the  point  of  attachment  and  union  takes 
place  with  less  deformity.  An  impacted  fracture  of 
the  neck  of  the  femur  or  humerus  had  also  better  be 
left  alone — unless  there  is  great  deformity.  A  f»w 
years  ago  a  boy  was  brought  to  me  with  a  complete 
fracture  of  the  ulna,  in  the  middle  third,  and  a  green- 
stick  fracture  of  the  radius,  so  that  his  forearm  was 
bow-shaped.  I  put  him  under  chloroform  and  cau- 
tiously attempted  to  straighten  the  arm.  In  spite  of 
caution  and  gentleness  I  snapped  the  radius,  and  so 
made  a  complete  fracture  of  both  bones  ;  I  dressed  the 
arm  at  once,  and  fortunately  the  boy  made  a  good  re- 
covery. I  do  not  see  that  this  accident  could  have 
been  avoided  ;  however,  if  the  boy  had  not  recovered 
with  a  good  arm,  I  should  no  doubt  have  been  charged 
with  results.  I  would  like,  also,  to  impress  upon  you 
that  a  common  fracture  with  children — fracture  of  the 
clavicle — may  be  easily  overlooked.  I  have  seen  two 
cases  that  were  entirely  overlooked  by  me  on  first  ex- 
amination. In  these  cases  there  is  sometimes  no  pain 
and  no  deformity.  As  in  one  of  these  cases,  the  child 
was  found  running  around  complaining  of  nothing  ex- 
cept slight  pain  in  the  shoulder-joint.  If  asked  to 
throw  a  stone,  however,  they  will  either  not  attempt  it, 
or  if  they  attempt  to  do  so  they  will  cry  out  with  pain 
at  the  seat  of  fracture  ;  the  second  day  diagnosis  will 
be  easier  because  some  swelling  will  have  taken  place. 

When  called,  then,  to  any  case  that  is  injured — 
though  to  all  appearances  slight — let  us  not  be  hasty  in 
forming  or  giving  out  opinions,  but  consider  every 
question  involved  not  only  for  our  own  safety,  but  to 
satisfy  clamorous  friends.  In  doubt  resort  to  anes- 
thesia, and  never  make  a  business  of  promising  brilliant 
results,  because  experience  teaches  that  while  as  a  rule 
all  fractures  do  well,  and  sometimes  most  unpromising 
cases  are  followed  with  remarkable  results,  yet  in  many 
simple  cases  we  have  accidents  and  bad  results  that 
cannot  be  foreseen. 

There  is  another  point  that  must  not  be  overlooked  : 
fractures  that  occur  in  railroad  accidents  are  generally 
more  serious  than  those  from  ordinary  causes  ;  the  force 
is  violent,  shock  is  great,  and  injury  generally  more  ex- 
tensive than  external  appearances  indicate.  Those  of 
us  who  have  had  occasion  to  amputate  for  railroad 
fractures  generally  find  the  bones  broken  and  split  up 
far  beyond  the  point  of  injury. 

Now  as  to  treatment.  The  reparative  process  which 
nature  institutes  to  repair  a  broken  bone  is  something 
wonderful.  In  the  museum  of  the  Medical  College  of 
Virginia  is  a  femur  that  had  been  fractured  in  the 
middle  third.  It  had  never  been  set,  or  if  set,  not 
properly.  The  fragments  had  been  separated  about 
two  inches  and  remained  so.  Nature  took  the  case 
in  her  own  skilful  hands,  threw  out  a  bridge  of  bone 
between  these  separated  fragments  and  created  as  firm 
and  strong  union  as  though  the  fragments  had  been 
set  in  perfect  juxtaposition. 


We  also  see  in  the  lower  animals  fractured  limbs 
repaired  without  apparatus.  Let  us  then  remember 
that  nature  will  repair  the  damage  if  we  give  her  a 
chance. 

I  do  not  deem  it  necessary  here  to  dwell  upon  the 
varieties  of  fracture,  or  the  nomenclature  of  the  sub- 
ject ;  suffice  it  to  say  that  in  railroad  surgery  we  shall 
have  chiefly  to  deal  with  compound  fractures,  espe- 
cially such  as  involve  the  joints.  A  few  years  ago  a 
compound  comminuted  fracture  almost  invariably 
called  for  amputation  ;  now,  thanks  to  asepsis,  antisep- 
tics, and  greater  skill,  amputation  is  the  exception,  not 
the  rule.  I  shall  speak  briefly  of  the  materials  used 
for  splints  and  the  treatment  of  the  fractures  most  fre- 
quently encountered. 

Of  material.  Of  first  importance  is  plaster  of  Paris 
(dental  plaster  preferred),  then  may  follow  shaped 
wooden  splints,  perforated  tin  or  zinc,  Levis's  splint, 
Russian  felt,  wooden  boards  and  strips,  leather,  card- 
board, starch  bandages,  adhesive  plaster,  elastic  band- 
ages, etc.  If  we  have  access  to  any  or  all  of  these 
things  we  would  be  likely  to  choose  a  splint  ready 
made,  but  unfortunately  we  are  often  called  to  out-of- 
the-way  places  ;  then  the  ingenuity  of  the  surgeon  is 
taxed,  and  he  is  frequently  compelled  to  make  out  of 
rough  boards  or  some  other  handy  material  the  needed 
splints.  I  have  used  pieces  of  cigar-boxes,  orange- 
boxes,  and  other  handy  material,  well  padded  with 
layers  of  absorbent  cotton,  with  just  as  perfect  result  as 
could  be  desired.  The  plaster- of- Paris  bandage,  in  my 
opinion,  is  the  most  valuable  single  material  at  our  com- 
mand. We  will  now  consider  some  of  the  more  fre- 
quent fractures  and  their  treatment. 

Fractures  of  the  skull  are  serious  in  proportion  to 
injury  of  its  contents.  Bryant  says  that  "  slight  fract- 
ure of  the  skull  with  concussion  is  more  dangerous 
than  compound  fracture  with  no  injury  to  contents.'' 

When  the  fragments  are  depressed  they  should  be 
elevated  at  once  ;  if  there  are  symptoms  of  congestion 
large  doses  of  bromide  may  be  given,  patient  kept  in  a 
dark  room,  and  cooling  applications  applied  to  head. 
Fractures  at  the  base  of  the  skull  are  always  serious — 
mortality  about  fifty  per  cent.  They  are  nearly  always 
accompanied  by  severe  constitutional  disturbance, 
bleeding  from  the  nose  and  ears,  frequently  by  a  dis- 
charge of  watery  serum  from  the  ears,  now  known  to  be 
cerebro-spinal  fluid.    Treatment  must  be  symptomatic. 

Fracture  of  the  clavicle,  Roberts  says,  is  successfully 
treated  without  apparatus  if  the  patient  will  go  to  bed 
and  remain  on  the  back  ;  this  position  is  strongly  ad- 
vised in  the  case  of  young  ladies,  as  deformity  is  found 
to  be  less  than  when  any  form  of  apparatus  is  used.  I 
have  generally  used  Sayres's  apparatus  with  good  results. 
In  one  case,  at  the  suggestion  of  Dr.  Worley,  I  used  the 
figure-of-S  bandage  across  the  shoulders  with  a  good 
result.  I  recall  one  case  of  a  girl  who  would  not  allow 
any  bandage  or  apparatus  ;  she  had  a  very  good  result — 
deformity  hardly  noticeable. 

Fractured  ribs  are  best  treated  with  wide  adhesive 
straps  entirely  encircling  the  chest ;  this  compels  dia- 
phragmatic breathing  and  relieves  the  pain  incident 
to  ordinary  respiratory  movements.  Fracture  of  the 
scapula  is  likewise  best  treated  with  adhesive  straps  or 
wide  bandage. 

Fracture  of  the  spinal  column  in  any  part  is  a  seri- 
ous lesion,  as  pressure  from  depressed  or  displaced 
bone  is  liable  to  cause  paralysis,  and  confinement  to 
bed  causes  bed-sores  and  exhaustion.  When  caused 
by  diseased  conditions  extension  and  the  plaster  jacket 
may  give  some  relief,  but  in  direct  injuries  from  acci- 
dent exploratory  incision,  with  elevation  of  fragments 
and  removal  of  spiculaj  of  bone  seems  the  rational 
course  :  the  subsequent  treatment  being  directed  to 
injury  of  the  cord. 

Fractures  of  the  pelvis  are  always  serious,  and  the 
possibility  of  injury  to  the  contained  organs  must  be 


December  21,  1895] 


MEDICAL    RECORD. 


borne  in  mind.  They  can  only  be  treated  on  the  ex- 
pectant plan. 

Fracture  of  the  humerus  at  or  near  the  surgical  neck 
is  infrequent,  though  it  sometimes  occurs,  and  is  likely 
to  be  confounded  with  subglenoid  dislocation.  When 
satisfied  that  we  are  dealing  with  a  fracture,  the  arm 
should  be  fixed  in  an  immovable  apparatus,  a  wedge- 
shaped  wad  of  absorbent  cotton  placed  in  the  axifla, 
and  arm  bound  firmly  to  body  with  a  wide  bandage, 
the  forearm  being  supported  with  a  sling.  "  Fractures 
of  the  shaft  of  the  humerus  are  satisfactorily  treated 
with  moulded  splints  of  gutta-percha,  felt,  or  Le\'is's 
perforated  tin,  well  padded  ;  the  forearm  to  be  carried 
in  a  sling." 

It  is  in  the  shaft  of  this  bone  and  the  shaft  of  the 
femur  where  we  most  often  have  no  union,  or  bad 
union  with  a  large  callus.  I  am  of  opinion  that  this 
can  be  explained  on  the  ground  of  greater  mobility 
of  the  parts  and  the  constant  tendency  of  attached 
muscles  to  separate  the  fragments.  These  conditions 
create  more  or  less  irritation  continually  about  the 
point  of  injury,  and  in  consequence  we  have  an  abnor- 
mal production  of  callus  and  imperfect  bony  union. 
The  treatment  quoted  is  on  good  authority,  but  I  think 
creates  in  the  mind  of  the  young  surgeon  an  idea  that 
should  not  exist,  that  is,  that  the  fracture  is  simple  and 
treatment  also  simple.  If  we  would  secure  good  union 
in  these  long  bones  we  must  put  the  injured  parts  at  per- 
fect rest,  and  confine  them  so  for  at  least  six,  and,  bet- 
ter, eight  weeks  before  they  are  disturbed  in  any  way. 
It  is  better  practice  to  keep  on  a  perfectly  fitting  ap- 
paratus for  one  or  two  weeks  longer  than  might  be  ab- 
solutely necessar)',  than  to  remove  them  and  run  the 
risk  of  recurring  fracture.  I  permitted  one  patient 
with  a  fractured  thigh  to  get  on  crutches  in  ten  weeks, 
as  there  seemed  to  be  firm  union.  Unfortunately  his 
crutch  slipped,  causing  him  to  get  a  severe  fall,  which 
again  fractured  the  thigh  in  the  same  place,  necessitat- 
ing another  lay  up  of  ten  or  twelve  weeks. 

Fractures  of  the  lower  third  of  the  humerus  and  the 
upper  third  of  the  radius  and  ulna,  involving,  as  they 
frequently  do,  the  elbow-joint,  are  serious  accidents. 
We  are  generally  confronted  by  a  greatly  swollen  con- 
dition of  things,  and  confused  as  to  diagnosis.  Ham- 
ilton's practice  was  to  apply  cold  applications  until  the 
swelling  subsided,  then  to  put  up  the  arm  in  the  flexed 
position,  and  on  or  before  the  seventh  day  to  begin 
gentle  passive  motion  as  a  preventive  of  anchylosis. 
No  doubt  this  treatment  worked  well,  or  it  would  not 
have  been  advised  by  so  eminent  an  authority  ;  how- 
ever, the  minds  of  men  are  widening  ar.d  the  science 
of  surgery  advancing.  An  entire  change  in  this  treat- 
ment is  now  advised.  Allis,  of  Philadelphia,  and 
Thorn,  of  Toledo,  now  advocate  the  extended  posi- 
tion, with  perfect  immobility  of  the  joint,  until  motion 
can  be  made  without  causing  pain.  By  demonstration 
Thorn  claims  this  position  to  be  anatomically  correct, 
and  by  reasoning,  as  well  as  by  experience,  concludes 
as  follows  ; 

"  If  the  joint  structures  are  not  encroached  upon, 
certainly  there  can  be  no  necessity  for  submitting  the 
parts  to  the  chances  of  torturing  the  patient.  Rest 
for  the  injured  parts  to  prevent  inflammation,  rest  for 
the  inflamed  parts  to  hasten  recovery.  Do  not  treat 
what  does  not  exist.  If  the  joint  is  not  injured,  anchy- 
losis cannot  obtain  ;  if  it  is  injured,  rest  is  what  it 
needs." 

To  my  mind  the  greatest  bugbear  in  the  treatment 
of  fractures  is  the  fear  of  anchylosis,  and  the  greatest 
torture  to  the  patient  usually  comes  from  the  unneces- 
sary efforts  made  to  prevent  it.  I  say  to  my  patients 
when  there  is  freedom  from  pain  begin  to  use  the  joint, 
not  before.  Then  time  and  voluntary  effort  will  com- 
plete the  cure.  From  a  personal  letter  I  quote  Dr. 
Thorn  as  follows  :  "  To  my  mind,  doctor,  the  most 
important  contention  is  that  against  passive  motion." 

If  after  firm  bony  union  has  taken  place,  and  gentle 


passive  motion  been  tried,  we  find  that  we  still  have  a 
seriously  anchylosed  joint,  we  may  proceed,  under  anss- 
thesia,  to  break  up  adhesions  and  restore  the  function 
of  the  joint.  This,  however,  in  a  large  percentage  of 
cases,  will  fail,  and  then  our  only  other  resort  is  to  re- 
sect the  joint.  I  assisted  in  one  case  where  forcible 
effort  was  made,  under  anaesthesia,  to  break  up  adhe- 
sions in  the  elbow-joint,  but  the  operation  only  did 
temporary  good  ;  generally  these  operations  would  be 
followed  by  more  or  less  inflammation,  after  the  subsi- 
dence of  which  we  found  our  joint  again  anchylosed. 
In  fracture  of  the  upper  third  of  the  ulna  it  should  be 
remembered  that  dislocation  of  the  head  of  the  radius 
may  take  place  in  the  course  of  repair  ;  it  is  therefore 
necessary  to  confine  this  fracture  in  a  plaster  dressing, 
a  good  plan  being  to  place  the  arm  in  a  flexed  position 
and  carry  dressing  from  a  point  above  the  condyles  to 
the  middle  third  of  the  forearm.  This  dressing  should 
prevent  rotation,  and  as  far  as  possible  prevent  con- 
traction of  the  ulna,  which  is  supposed  to  cause  the 
dislocation  of  the  comparatively  loose  attachment  of 
the  head  of  the  radius  in  its  normal  position.  Fract- 
ures of  the  lower  forearm  are  frequent ;  they  should 
be  promptly  reduced  and  held  in  place  by  well  padded 
splints  ;  care  should  be  taken  against  undue  pressure 
on  the  blood-vessels  at  the  wrist.  The  wooden  splints 
should  be  held  in  place  by  elastic  bandages  or  straps. 
In  case  a  plaster  dressing  is  used  it  should  be  split  up 
as  soon  as  the  plaster  sets,  for  any  considerable  amount 
of  swelling  under  an  unyielding  plaster  cast  may  be 
the  cause  of  serious  injury.  Fractures  about  the  wrist- 
joint  should  be  treated  on  the  same  general  principles 
suggested  for  the  elbow-joint — perfect  rest  and  local 
measures  to  allay  inflammation.  Fractures  of  the  meta- 
carpal and  phalangeal  bones  are  satisfactorily  treated 
by  light  board  splints,  well  shaped  and  wadded  to  fit 
the  hand. 

We  may  now  briefly  consider  fractures  of  the  lower 
extremity.  Fractures  of  the  neck  of  the  femur,  whether 
intra-  or  extra-  capsular,  require  considerable  time  for 
repair.  Bonnet's  trough  splint,  with  moderate  exten- 
sion, seems  of  all  the  older  methods  to  be  the  best. 
Professor  Despres,  in  his  "  Treatise  on  Fractures," 
claims  that  no  splint  is  superior.  In  my  opinion  the 
plaster  cast  enveloping  the  hips  and  carried  down  the 
injured  thigh  to  the  middle  third  is  the  apparatus  par 
excellence  for  this  accident.  This  at  once  immobilizes 
the  joint,  and  with  slight  extension  is  all  that  can  be 
desired.  It  must  be  remembered  that  this  accident  is 
most  frequent  in  the  aged,  consequently  repair  is  slow 
and  seldom  by  firm  bony  union.  Bryant  says  :  "  Gen- 
tle traction  can  be  practised  for  two  or  three  weeks, 
after  which  patients  may  be  allowed  a  little  exercise  on 
crutches,  as  long  confinement  in  bed  may  lead  to  bed- 
sores and  exhaustion."  It  seems,  however,  to  me  a  mis- 
take to  allow  any  motion  in  these  fractures  under  six 
or  eight  weeks  ;  in  nearly  every  case  of  ununited  fract- 
ure that  I  have  seen  we  find  a  history  of  early  effort  at 
motion,  which,  no  doubt,  had  disturbed  the  reparative 
process.  The  fracture-bed,  so  highly  recommended  by 
some,  is  only  within  the  reach  of  a  few,  hence  I  need 
only  mention  it.  On  any  bed,  where  a  fracture  of  the 
thigh  is  to  be  treated,  it  is  well  to  put  a  wide,  smooth 
board  under  the  mattress  to  prevent  sagging  of  the 
body.  There  are  various  methods  of  treatment  for 
fractures  of  the  shaft  of  the  femur.  After  a  study  of 
many  methods  I  am  disposed  to  think  that  those  worthy 
of  special  mention  are  the  long  external  splint  and 
Buck's  extension  apparatus.  I  have  lately  treated  two 
cases  of  fracture  in  the  middle  third  by  a  combination 
of  these  two  methods  with  most  satisfactory  results. 
There  is  scarcely  over  half  an  inch  shortening,  and  no 
deformity  to  speak  of  in  either  case.  I  prepare  the  bed 
and  the  patient  as  directed  for  Buck's  extension,  ele- 
vate the  foot  of  the  bed  four  to  six  inches,  then  apply 
the  pulley  and  weight  for  extension.  The  limb  is  then 
set  in  as  natural  a  position  as  possible,  and  a  long  exter- 


MEDICAL    RECORD. 


[December  21,  1895 


nal  padded  board  splint  is  applied.  For  a  grown  man 
I  make  this  splint  about  four  inches  wide,  and  long 
enough  to  reach  from  the  axilla  to  a  little  below  the 
foot.  The  splint  is  held  in  place  by  three  wide,  many- 
tailed  bandages,  placed  one  around  the  chest,  one 
around  the  thigh  over  seat  of  fracture,  and  the  other 
around  lower  third  of  leg,  made  to  confine  the  foot  if 
there  is  tendency  of  the  foot  to  turn  inward,  which  I 
have  found  generally  to  be  the  case. 

This  apparatus  is  simple,  easily  applied,  and  has  given 
me  excellent  results. 

In  four  or  five  weeks,  or  after  union  has  taken  place, 
I  remove  the  external  splint  and  apply  a  plaster  cast 
at  the  same  time,  removing  nearly  all  the  weights  used 
for  extension.  I  do  not  think  it  good  practice  to  allow 
a  man  to  walk  on  a  thigh  that  has  been  fractured  inside 
of  twelve  weeks  ;  from  the  experience  that  I  have  had 
I  am  sure  that  firm  bony  union  does  not  take  place  in 
much  less  time,  and  no  doubt  some  of  the  shortening 
and  deformity  in  this  fracture  is  due  to  the  weight  put 
upon  the  hardly  consolidated  callus.  I  insist  that  nat- 
ure have  time  to  do  her  perfect  work. 

Fracture  of  the  lower  third  of  the  femur,  involving 
the  condyles  and  the  knee-joint,  do  best  put  up  in  some 
immovable  apparatus,  the  limb  in  a  slightly  flexed  posi- 
tion. When  the  fragments  of  the  lower  third  of  the 
femur  are  displaced  by  the  contraction  of  the  gastroc- 
nemii  muscles  Bryant  advises  division  of  the  tendo 
Achillis.  Dr.  Thorn's  rule  for  passive  motion  at  the  el- 
bow-joint applies  as  well  to  the  knee-joint. 

Fracture  of  the  patella  is  of  frequent  occurrence,  and 
the  fact  that  there  is  such  a  variety  of  apparatus  for  its 
treatment  shows  that  the  best  surgeons  are  not  agreed. 
Drs.  Senn  and  Fluhrer  advocate  wiring,  Bryant  and 
Roberts  the  posterior  padded  splint  with  elastic  straps. 
Wiring  promises  bony  union,  and  possibly  a  stronger 
joint,  but  it  converts  a  simple  into  a  compound  fracture 
with  the  possibility  of  septic  infection.  Treatment  by 
splints  and  bandages  secures  only  ligamentous  union, 
with  some  impairment  of  function,  but  no  material  dan- 
ger to  life.  The  treatment  by  hooks,  screws,  and  other 
similar  devices  is  not  good  surgery  ;  they  are  painful 
and  endanger  the  patient  to  septic  infection.  The 
average  surgeon  will  do  better  with  his  posterior  splint, 
elastic  bands,  and  subsequently  the  plaster  bandage, 
than  experimenting  with  other,  perhaps  more  scientific, 
methods.  The  operation  of  wiring,  while  perhaps  the 
ideal  method,  calls  for  considerable  skill,  and  certainly 
is  not  without  danger.  I  assisted  in  a  New  York  hos- 
pital in  wiring  a  simple  transversely  fractured  patella, 
but  never  saw  the  patient  after  the  operation.  It  was 
whispered  around  that  he  went  the  way  of  all  flesh. 

Fractures  of  the  tibia  and  fibula  are  common.  Sim- 
ple fractures  of  the  fibula  in  the  lower  two-thirds  may 
be  satisfactorily  treated  by  simply  bandaging  the  leg, 
the  tibia  acting  as  a  splint,  and  resting  in  the  recum- 
bent position.  In  fracture  in  the  upper  third  of  the 
fibula,  near  the  head,  the  limb  should  be  flexed  and  kept 
so  ;  then  may  occur  separation  of  the  fragments  requir- 
ing wiring. 

Fractures  of  both  bones  of  the  leg  do  well  either  in 
splints,  fracture-box,  or  plaster  cast.  The  best  appa- 
ratus that  I  have  any  account  of  is  that  advised  by  Pro- 
fessor Despres.  This  is  a  plaster  splint  which  does 
not  encase  the  limb,  but  is  applied  laterally. 

Strips  of  prepared  plaster  bandage  of  required  length, 
and  two  to  three  inches  wide,  are  soaked  a  few  minutes 
in  warm  water,  an  assistant  holds  the  limb  in  proper 
position,  the  bones  being  set  ;  we  then  take  one  of  these 
strips,  and  beginning  just  below  the  knee  on  either  the 
inner  or  outer  side  of  the  leg,  it  is  carried  down  one 
side  around  (or  under)  the  foot  and  up  the  other  side, 
additional  plaster  is  rubbed  on  this,  then  another  layer 
of  bandage,  and  so  on  until  a  good  strong  splint  is 
moulded  to  the  leg.  The  leg  is  held  steady  for  twenty 
minutes,  or  until  the  plaster  has  hardened,  which  is  then 
held  in  place  by  three  elastic  strips^one  at  the  top, 


one  about  the  fracture,  and  one  at  the  ankle.  This  ap- 
paratus allows  the  patient  to  take  any  desired  position 
in  bed,  prevents  displacement  of  fragments,  and  allows 
of  frequent  examination  and  dressings  in  case  of  com- 
pound fracture  without  changing  the  apparatus.  The 
elastic  bands  give  way  for  swelling  and  contract  as  the 
limb  shrinks,  so  that  even  pressure  is  maintained.  This 
apparatus  need  not  be  changed  during  the  whole  course 
of  repair  of  a  simple  fracture  of  the  leg. 

Fractures  about  the  ankles,  as  with  other  joints,  re- 
quire immovable  apparatus  and  perfect  rest.  I  prefer 
the  plaster  cast.  This  should  not  be  applied,  however, 
until  swelling  has  subsided,  and  even  then  it  is  well  to 
split  the  cast  to  allow  for  any  swelling  that  may  occur. 

Fractures  of  the  metatarsal  and  phalangeal  bones  of 
the  foot,  if  not  compound,  do  well  in  an  old  easy-fitting 
shoe  split  through  the  top  to  allow  for  swelling,  bound 
with  an  ordinary  roller  bandage.  When  compound  I 
have  used  thin  pieces  of  board  padded  to  fit  the  bot- 
tom of  foot  held  in  place  by  adhesive  strap  and  band- 
age. 

I  have  thus  briefly  suggested  a  treatment  for  the 
fractures  most  commonly  met  with.  After  all,  the  suc- 
cessful treatment  of  a  fracture  depends  largely  upon  the 
knowledge  and  ingenuity  of  the  surgeon,  for  it  is  pos- 
sible to  have  a  bad  result  from  the  use  of  the  most  sci- 
entific apparatus  available,  and  a  good  result  without 
any.  With  reference  to  the  treatment  of  compound 
fractures — as  before  indicated — great  change  has  taken 
place.  We  no  longer  amputate  every  limb  that  happens 
to  have  severe  compound  fracture.  However  bad  the 
fracture,  if  the  blood  and  nerve-supply  is  not  cut  off 
there  is  always  some  chance  to  save  the  limb.  In  sim- 
ple compound  fracture,  that  is,  where  the  opening 
through  the  skin  is  small,  slight  comminution  of  bone 
and  slight  hemorrhage,  the  wound  should  be  closed 
with  adhesive  plaster  or  antiseptic  collodion  (iodoform 
or  aristol  collodion)  and  fracture  treated  as  simple. 
When  there  has  been  severe  comminution  of  bone,  some 
hemorrhage,  where  dirt  of  any  kind  has  entered  the 
wound,  it  should  be  left  open  and  treated  antiseptically  ; 
finely  powdered  iodoform  or  boracic  acid  kept  con- 
stantly applied.  AVhen  pus  forms  it  should  be  let  out 
and  parts  irrigated  with  carbolized  water. 

If  free  arterial  bleeding  occur  the  vessels  should  be 
secured  if  possible,  and  closed  by  torsion  or  ligature, 
the  wound  enlarged  if  necessary  for  this  purpose. 
Should  the  vessel  lie  very  deep,  as  in  the  calf  of  the  leg 
or  upper  forearm,  it  may  be  ligated  above  the  seat  of 
injury,  as  it  has  been  demonstrated  that  the  ligation  o: 
vessels  does  not  much  retard  the  repair  of  fractures.  In 
case  the  plaster  cast  is  used  for  compound  fractures,  a 
window  should  always  be  left  over  the  seat  of  fracture  to 
permit  frequent  examination  and  dressing.  When  from 
destruction  of  tissue — threatening  gangrene— or  exten- 
sive injury  likely  to  render  the  limb  useless,  amputation 
may  be  performed,  the  sooner  the  better.  In  that  un- 
fortunate class  of  cases — ununited  fractures — various 
methods  of  repair  are  in  use.  These  consist  of  dowel 
pins  of  ivory  and  bone,  screws,  nails,  silver  wire,  bone 
rings,  etc.  Dr.  N.  Senn  advocates  and  uses  bone  rings. 
It  occurs  to  me  that  strong  silver  wire  thrown  around 
the  fragments  would  answer  the  same  purpose  as  the 
bone  rings,  and  could  be  much  more  readily  removed 
after  union  had  taken  place. 

It  must  be  borne  in  mind  that  certain  acquired  or 
constitutional  diseases  play  an  important  part  in  the 
repair  of  fractures.  Syphilis,  rheumatism,  scrofula, 
tuberculosis,  rachitis,  lithiasis,  etc.,  may  collectively  or 
separately  prevent  union  even  when  the  fragments  are 
most  favorably  adjusted.  We  have  all  seen  in  scrofu- 
lous and  strumous  subjects  diseased  conditions  of  bone 
refuse  to  heal  under  any  form  of  local  treatment,  until 
the  patient  was  put  on  suitable  constitutional  treatment. 
We  have  seen  rheumatic  arthritis  set  up  in  a  joint  and 
so  erode  the  heads  of  the  bones  that  anchylosis  of  the 
worst  form  has  been  produced.     We  have  seen  gravel 


December  21,  1895] 


MEDICAL    RECORD. 


produced  in  the  bladder  from  excess  of  uric-acid  com- 
pounds and  long  confinement  on  the  back.  Syphilis,  of 
course,  in  any  stage,  but  more  especially  in  the  tertiary 
one,  would  seriously  complicate  the  treatment  of  any 
fracture. 

I  must  conclude  this  paper,  but  before  doing  so  I 
wish  to  call  attention  to  the  application  of  the  plaster 
bandage.  I  have  seen  some  very  bungling  work  with 
plaster,  but  when  carefully  applied  it  is  the  ideal  splint. 
Excellent  plaster  bandages  are  made  ready  for  use  by 
Johnson  &  Johnson,  New  York,  but  any  surgeon  with 
a  little  time  on  his  hands  can  prepare  his  own.  Strips 
of  cheese-cloth  or  crinoline,  two  or  three  yards  long 
and  two  to  three  inches  wide,  rubbed  full  of  fine  dental 
plaster  and  rolled  up  as  an  ordinary  bandage,  answer 
every  purpose.  In  preparing  a  limb  for  a  plaster  cast 
some  little  care  is  necessarj-.  The  limb  should  be 
washed  and  dried  thoroughly,  any  sore  spots  covered 
with  a  little  subnitrate  of  bismuth,  then  vaseline  or 
olive-oil  rubbed  on.  The  limb  now  being  ready, 
should  be  smoothly  bandaged  with  soft  flannel  over 
the  entire  part  we  expect  to  enclose.  I  usually  use  two 
layers  of  bandage.  The  plaster  bandage  is  then  soaked 
for  a  few  minutes  in  warm  water  and  is  ready  for 
winding  around  the  limb.  Over  each  layer  of  bandage 
I  rub  a  little  extra  plaster,  the  same  having  been  pre- 
viously prepared  to  a  creamy  consistence  in  a  handj' 
vessel.  The  cast  is  now  allowed  to  set.  If  we  are 
likely  to  have  swelling,  I  split  the  cast  at  once,  other- 
wise it  is  left  alone.  In  removing  the  cast  for  purposes 
of  examination,  or  when  from  shrinking  of  the  limb  it 
has  become  loose  and  needs  to  be  made  smaller,  I  cut 
carefully  through  the  plaster,  then  with  scissors  cut 
through  the  flannel  bandage.  We  generally  find  the 
bandage  has  become  attached  to  the  plaster  cast  and 
has  formed  a  nice  padding  for  the  splint. 

A  plaster  cast,  when  properly  made,  is  very  strong. 
They  are  generally  made  twice  as  heavy  as  is  neces- 
sary, adding  unnecessary  weight  and  inconvenience  ; 
but  I  believe  that  greater  care  in  constructing  will 
remedy  these  objections. 


AN   ANEXCEPHALOUS    MONSTER. 
By  RICHARD  H.  WOOD,  M.D., 

CLIO,  MICH. 

With  so  many  cases  of  monstrosities  before  us  it  may 
well  be  questioned  whether  it  is  necessary  to  refer 
to  such  common  occurrences.  But  inasmuch  as  the 
one  I  have  to  report  resembles  so  closely  the  cases  re- 
lated by  Dr.  Boweman,  of  Ontario,  and  Dr.  Hinman, 
of  Michigan,  I  offer  it  in  the  hope  that  it  may  aid 
those  who  are  competent  to  properly  classify  these  ab- 
normalities and  to  bring  out  some  knowledge  of  their 
etiology. 

Mrs.  G ,  aged  thirty,  farmer's  wife,  was  taken 

with  labor  pains  about  5  p.m.  I  was  called  at  6  p.m. 
She  claimed  that  her  time  was  up  a  week  before. 
Found  abdomen  fully  distended,  and  palpation  re- 
vealed foetus  lying  transversely  in  uterus.  Os  rigid, 
like  a  hard  rubber  ring,  with  a  few  nodules  along 
the  margin,  and  dilated  to  the  size  of  a  half-dollar. 
Pains  being  slight  I  gave  uterine  sedative  and  went 
home.  Summoned  again  at  11  p.m.  to  find  that  mem- 
branes had  ruptured  and  an  unusual  amount  of  liquor 
amnii  had  escaped.  With  some  difficulty  the  feet  were 
reached  and  brought  down  through  the  partly  dilated 
OS,  and  in  about  two  hours  a  dead  foetus  was  delivered. 
It  consisted  of  a  monstrosity  of  the  anencephalous 
type.  It  had  been  dead  perhaps  a  week.  The  shoul- 
ders were  large  and  well  developed.  The  integument 
of  the  upper  extremities  was  sound.  The  lower  ex- 
tremities were  small  and  the  legs  long,  but  the  bones 
were  not  at  all  ossified,  and  the  integument  upon  the 
lower  extremities  was  broken  and  exfoliated  in  patches. 


The  sex,  barely  discernible,  was  female.  The  nails  on 
the  fingers  were  plain,  but  those  on  the  toes  were  hardly 
perceptible  owing  to  lack  of  development.  The  eyes 
looked  almost  upwards,  the  nose  was  broad  and  flat- 
tened. The  head  was  wanting  in  its  posterior  aspect, 
neither  scalp,  occipital,  nor  parietal  bones  being  present. 
There  was  nothing  like  a  cerebrum.  A  thin  mem- 
brane, transparent,  covered  this  posterior  cavity,  and 
on  the  integument,  at  its  junction  with  this  membrane, 
was  a  narrow  fringe  of  long  dark  hair.  The  bones  of 
the  face  were  quite  solid  and  could  be  felt  through  the 
membrane  from  behind.  This  monstrosity  weighed 
about  four  and  a  half  pounds.  The  placenta  was  only 
four  inches  in  diameter,  perfectly  circular,  and  of  un- 
usual thickness.  The  cord  was  attacked  at  the  centre. 
The  mother  had  a  specific  taint,  and  had  been  suffering 
for  weeks  from  a  profuse  purulent  discharge. 


POISONING  BY  OYSTERS. 
By  J.  N.  BELL,  M.D., 

DBTHOIT,    MICH. 

The  following  case  of  oyster  poisoning  occurred  re- 
cently in  my  practice.  I  was  called  hurriedly,  on  the 
morning  of  October  7th  last,  to  attend  the  family  of 

Mr.  F ,  three   of  the   members  of  whom — father, 

mother,  and  daughter — were  suffering  from  incessant 
vomiting  and  griping  pains  in  the  abdomen,  the  mother 
being  in  a  state  of  collapse. 

Upon  inquir)-  as  to  what  they  had  eaten  for  supper 
the  evening  before,  I  found  that  they  had  partaken  of 
stewed  oysters  (canned). 

A  fourth  member  of  the  family,  a  little  giri,  aged 
three,  who  had  not  eaten  any  of  the  oysters,  but  had 
partaken  quite  freely  of  the  broth,  was  not  even  nau- 
seated. 

Bismuth,  subnitrate,  hypodermic  injections  of  morph. 
sulph.,  and  brisk  catharsis  constituted  the  treatment. 
All  recovered  within  twenty- four  hours. 

The  point  of  interest  in  this  case  is  that  the  toxic 
principle  was  undoubtedly  contained  in  the  substance 
of  the  oyster  itself,  and  was  not  developed  in  the  proc- 
ess of  cannins. 


SEVERE  SPASMODIC  MUSCULAR  CONTRAC- 
TIONS DUE  TO  REFLEX  IRRITATION 
FROM  CICATRICIAL  TISSUE. 

Bv  HENRY  H.  SCHROEDER,  M.D.. 

NEW  VORfC. 

AVhii.e  acting  as  resident  physician  for  the  Glenwood 
Hot  Springs  Company,  Colorado,  last  summer,  the  fol- 
lowing interesting  case  came  to  my  notice.  One  of 
the  local  physicians  in  the  neighboring  town  had  oper- 
ated for  ingrowing  toe-nail,  and  five  or  six  days  later 
noticed  considerable  suppuration  and  fetor  about  the 
wound,  which,  however,  by  the  end  of  the  second  week 
after  the  operation,  healed  under  antiseptic  treatment. 
About  fourteen  days  after  healing  occurred  I  was  re- 
quested by  the  physician  to  meet  him  in  consultation, 
as  the  patient  had  been  having  spasms  daily  for  the 
past  week.  The  patient  was  a  giri,  twenty  years  of 
age,  and,  when  I  saw  her,  was  somewhat  ansmic,  al- 
though previous  to  operation  she  had  been  healthy 
and  vigorous.  At  the  moment  of  my  arrival  she  was 
having  a  violent  spasm  of  the  muscles  of  the  left  leg 
(the  operation  was  upon  the  toe  of  the  right  foot). 
^V^lile  manipulating  the  leg  the  spasm  suddenly 
shifted  to  the  larynx,  causing  a  distressing  and  alarm- 
ing dyspnoea  similar  to  that  caused  by  a  very  aggra- 
vated attack  of  globus  hystericus.  .  In  spite  of  large 
and  repeated  doses   of   chloral,  bromides,  and   mor- 


894 


MEDICAL    RECORD. 


[December  21,    1895 


phine,  this  condition  had  come  on  every  evening  and 
lasted  through  the  night,  the  spasms  alternately  affect- 
ing the  glottis  and  legs.  Further  examination  showed 
that  the  toe  which  had  been  the  seat  of  operation  was 
red,  swollen,  and  extremely  painful  to  the  touch. 

Discarding  the  view  held,  that  the  paroxysms  were 
due  to  ptomaine  poisoning,  since  the  wound  had 
healed  fourteen  days  previously  and  there  were  no 
signs  of  pus,  I  advised  the  immediate  application  to 
the  toe  of  a  sedative  ointment  made  up  of  opium, 
belladonna,  and  cocaine  in  generous  proportions,  with 
lanolin  and  vaseline  as  a  base,  and  if  this  proved  in- 
effectual, as  I  very  much  feared  it  would,  the  excision 
of  the  large  amount  of  cicatricial  tissue  which  was  a 
result  of  the  suppuration  and  excessive  granulation 
after  operation. 

The  attending  physician  told  me  two  or  three  days 
later  that  the  convulsive  seizures  had  ceased  shortly 
after  the  application  of  the  ointment,  and  that  the  toe 
had  lost  all  redness,  swelling,  and  tenderness. 

A  few  weeks  later  a  chair  happening  to  fall  upon 
the  toe  it  again  become  swollen  and  subjected  to  in- 
creased pressure  from  the  cicatrix,  which  occasioned  a 
return  of  the  spasms.  The  trouble,  however,  quickly 
yielded  to  the  local  treatment. 

230  WaST  0.>-E   HUXDRKD  AND  ThI RTV-FI FTH  STREET. 


HEREDITY    AS    AN    ETIOLOGICAL    FACTOR 
IN  EPILEPSY. 

By  a.  H    HENDERSON,  M.D., 

MONE,   SHAN   STATES,   BJR:\IA. 

The  following  struck  me  as  an  interesting  set  of  cases 
in  proof  of  heredity  rather  than  contagion  as  a  factor 
in  the  spread  of  leprosy  : 

Case  I. — A  man,  aged  twenty-two,  well  developed, 
presented  himself  with  a  slight  scaly  appearance  on 
parts  of  his  arms  and  slightly  hypertrophied  spots  of 
about  half  an  inch  in  diameter  on  his  upper  lip.  The 
first  symptoms  appeared  on  the  outer  part  of  his  thigh 
nine_  years  ago,  where  in  one  year  two  ulcers  appeared, 
healing  in  three  months,  and  leaving  scars  now  visible. 
Now  the  skin  in  several  places  is  roughened  and  in- 
clined to  be  scaly. 

Case  II. — A  girl,  aged  fifteen,  sister  of  patient  men- 
tioned in  Case  I.,  with  tubercles  on  both  ate  nasi  and 
lobes  of  both  ears,  together  with  an  offensive  ozena. 
The  disease  commenced  eight  years  ago  on  the  outer 
part  of  the  thigh  as  a  white  scaly  spot,  which  increased 
in  size.  The  feet  are  now  swollen,  and  there  are  ulcers 
on  the  plantar  surfaces.  This  case  led  me  to  inquire 
into  the  family  history. 

Case  III. — The  father  of  above  mentioned  patients 
had  presented  the  same  symptoms  for  thirty  years.  He 
had  ulcerations  all  over  his  body.  One  of  the  toes  had 
gone,  in  fact  his  was  a  typical  cass  of  leprosy.  The 
interesting  part  is  that  the  wife,  the  mother  of  both 
children,  is  perfectly  healthy. 

The  popular  feeling  here  is  strongly  in  favor  of  the 
view  that  leprosy  is  spread  by  contagion.  I  presume 
It  may  spread  in  both  ways,  though  as  far  as  my  ex- 
perience goes,  heredity,  rather  than  contagion,  has  to 
bear  the  blame. 


The  Medical  Profession  in  Russia,— Russia  has 
I5-740  qualified  doctors,  310  of  whom  do  not  practise, 
giving  one  doctor  to  S,ooo  persons  throughout  the  em- 
pire. As  by  far  the  greater  number  of  the  doctors  live 
in  the  cities,  and  the  urban  population  of  Russia  is 
only  fourteen  per  cent,  of  the  whole,  the  peasants  are 
poorly  provided  with  medical  assistance.  One-fifth  of 
the  total  number  of  doctors  are  in  the  army  or  navy, 
and  five  hundred  and  fifty-three  are  women. 


Correspondence. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 

MEETING      OF      GENERAL      MEDICAL       COUNCIL CLEFT 

palate — INJURY  TO  BRACHIAL  PLEXUS — SOME  EX- 
HIBITS AT  THE  CLINICAL  SOCIETY — THE  SALVA- 
TION army's  SHELTERS — EDINBURGH  COLLEGE  OF 
SURGEONS — THE    HUXLEY    MEMORIAL. 

London,  November  29,  1895. 

The  General  Medical  Council  has  been  sitting  during 
the  week,  but  whether  its  work  has  been  worth  the 
cost  is  a  question  that  perturbs  many.  On  Tuesday 
the  President  delivered  his  address,  which  follows  the 
lines  of  its  predecessors.  Then  the  question  of  increas- 
ing the  direct  representatives  of  the  profession  was  the 
next  most  interesting  topic.  It  came  tip  in  connection 
with  the  petition  of  the  British  Medical  Association,  and 
may  be  said  to  have  made  some  progress,  inasmuch  as 
two  more  members  voted  for  it  than  on  the  last  occasion 
on  which  it  was  considered.  The  plan  has  never  com- 
mended itself  to  the  Council  as  a  body,  which  finds  its 
numbers  quite  large  enough,  and  many  feel  too  large. 
The  plan,  in  fact,  was  but  the  scheme  of  a  fraction  of 
the  profession,  though  a  noisy  one,  and  but  for  the 
careful  conduct  of  the  representatives  would  have  been 
found  ridiculous.  Its  shortcomings  are  inherent  in 
the  plan,  one  of  the  most  inadequate  for  reforming  the 
council. 

Dr.  Glover  brought  forward  the  inadequate  require- 
ments respecting  midwifery  cases,  on  which  also  the 
British  Medical  Association  had  a  petition  in  accord- 
ance with  the  resolution  passed  at  the  last  annual  meet- 
ing. It  appeared,  however,  that  the  petition  had  not 
been  properly  adopted  and  forwarded  by  the  executive 
of  the  association  and  had  to  be  withdrawn.  So  the 
scandal,  as  many  deem  it,  of  insufficient  instruction  in 
midwifery,  still  adheres  to  certain  qualifying  bodies. 

The  person  who  was  struck  oflf  the  register  for  his 
conduct  in  regard  to  Count  Mattei's  nostrum  applied 
for  a  reconsideration  of  the  ruling,  but  without  success. 

On  Wednesday  the  case  of  the  Apothecaries'  Hall,  in 
Ireland,  came  up,  and  was  subsequently  considered  in 
a  different  aspect.  I  have  already  informed  your 
readers  of  some  of  the  peculiarities  of  this  case.  There 
is  no  doubt  that  a  dead-set  has  been  made  at  the  Hall 
(through  its  conjunction  with  the  Surgeons'  College)  with 
a  view  of  extinguishing  it.  It  is  scarcely  to  be  denied 
that  this  corporation  could  well  be  spared,  as,  too,  could 
some  others.  The  Hall  ought  not  to  have  obtained  the 
position  of  a  qualifying  body,  but  having  obtained  it 
and  exercised  it  lawfully,  is  natually  unwilling  to  be 
disfranchised  by  a  side  wind. 

The  Hall  faculty  applied  to  the  Council  to  appoint  for 
it  examiners  in  surgery,  as  was  done  for  the  London 
Hall,  and  opposition  to  this  was,  of  course,  offered,  with 
much  talk  about  the  power  to  do  so  and  its  limits.  At 
length  it  was  agreed  to  obtain  the  opinion  of  the  stand- 
ing counsel  on  several  points,  postponing  a  decision  to 
the  end  of  the  week,  so  I  cannot  report  it  to  day. 

The  disciplinary  powers  of  the  qualifying  bodies  were 
discussed  in  a  rambling  way,  and  eventually  a  resolu- 
tion was  carried  instructing  the  Executive  Committee 
to  report  to  the  Council  at  its  next  meeting. 

The  results  of  visitations  and  examinations  were  con- 
sidered. As  usual  a  number  of  returns  and  other  of- 
ficial documents  were  produced  and  some  other  cases 
for  the  judicial  powers  of  the  Council  investigated. 

The  sad  case  of  a  medical  man  who  was  alleged  to 
have  caused  the  death  of  a  woman  through  negligence 
or  want  of  skill  when  attending  her  in  labor,  occupied 
the  courts  on  Monday  and  Tuesday.  The  defence  was 
illness,  for  which  he  had  taken  chloral.  A  verdict  of 
guilty  was  found,  and  the  judge,  taking  into  consider- 


December  21,  1895] 


MEDICAL   RECORD. 


89= 


ation  extenuating  circumstances,  pronounced  a  sentence 
of  imprisonment,  without  hard  labor,  for  three  months. 
He  stated  that  had  intoxication  led  to  the  sad  result,  as 
was  at  first  alleged,  the  sentence  would  probably  have 
been  a  year's  imprisonment  at  hard  labor. 

The  best  time  to  operate  for  cleft  palate  seems  un- 
settled, some  surgeons  recommending  early  operation, 
others  advising  some  delay.  On  Monday,  Mr.  Owen 
read  to  the  Medical  Society  of  London  notes  of  five 
cases  on  which  he  had  operated  this  year  and  of  which 
four  were  completely  successful,  one  of  the  patients 
being  only  eight  months  of  age.  Mr.  Owen  is  decid- 
edly in  favor  of  early  operation,  but  he  recommended 
spring  and  summer  as  the  most  favorable  seasons,  as 
then  the  children  may  be  taken  into  the  open  air,  a 
point  to  which  he  attaches  great  importance. 

Mr.  Morgan  demurred  to  this  early  interference  and 
thought  a  delay  until  the  child  was  two  years  of  age 
would  be  better,  and  at  that  age  no  serious  defect  of 
speech  would  have  arisen. 

Mr.  Glutton  remarked  that  the  age  for  operating  de- 
pended less  on  the  extent  of  the  cleft  than  on  the  shape 
of  the  palate  and  thickness  of  the  tissues.  The  flaps, 
he  said,  could  be  brought  down  without  undue  tension 
when  the  palate  was  arched,  but  when  it  was  flattened 
the  difficulty  was  much  greater.  He  had  observed  im- 
provement in  the  voice  follow  operation  later  in  life. 
This  would  depend  greatly  on  the  length  of  the  hard 
palate,  which  when  short  might  not  catch  the  laryn- 
geal vibrations. 

Mr.  Davies-Colley  said  the  flap  operation  which  he 
devised  so  diminished  tension  that  union  of  the  hard 
palate  could  be  relied  on  to  follow,  but  union  of  the 
soft  palate  might  fail  for  a  time.  He  was  much  in 
favor  of  early  operation,  not  only  for  the  sake  of  the 
perfection  of  speech,  but  to  prevent  the  facial  deformity 
which  occurred  in  long-standing  cases. 

Mr.  A.  Lane  insisted  on  securing  sufficient  room  and 
advised  cutting  through  the  united  lip  should  it  be 
necessary. 

Mr.  Walsham  recommended  that  the  edges  of  the 
flap  should  not  be  pared  until  the  end  of  the  operation, 
so  as  to  have  the  surfaces  fresh. 

At  the  same  meeting  Dr.  Beevor  related  a  couple  of 
cases  in  which  it  was  thought  the  brachial  plexus  had 
been  injured.  There  was  paralysis  of  all  the  muscles 
of  the  arm  and  loss  of  sensation  along  the  outer  surface 
of  arm  and  forearm.  The  small  muscles  of  the  hand, 
the  flexors  of  the  thumb  and  fingers  were  not  paralyzed. 

Among  a  series  of  interesting  cases  exhibited  at 
the  last  meeting  of  the  Clinical  Society  I  may  specify 
one  shown  by  Dr.  Buzzard  (President),  of  early  Char- 
cot's disease,  benign  form,  in  a  woman  aged  thirty- 
eight.  No  destructive  changes  have  at  present  ap- 
peared. Twenty  months  ago  the  right  foot  swelled 
greatly,  but  without  pain,  the  tarsal  joint  being  affected 
and  containing  fluid  ;  six  months  ago  the  whole  left 
lower  limb  swelled  without  pain.  At  present  the  left 
is  much  enlarged  and  there  is  great  laxity  of  the  liga- 
ments of  this  joint.  But  for  the  absence  of  pain  such 
cases  would  probably  often  be  classed  as  rheumatic 
arthritis,  of  which  a  case  was  shown  by  Dr.  H.  Camp- 
bell, the  chief  lesions  being  limited  to  the  elbows,  but 
there  was  grating  in  the  wrists  and  in  the  temporo-max- 
illary  articulations. 

Mr.  O.  Paget  showed  a  case  of  myositis  ossificans  in 
a  child  five  years  of  age,  who  was  minus  the  first  pha- 
langes, the  metacarpals  articulating  direct  with  the 
second.  The  thumbs  were  normal.  The  pectorals 
were  ossified  at  their  insertion  and  the  latissimus  dorsi 
along  its  outer  border.  The  sterno-mastoids  were 
affected  in  the  same  way.  There  was  a  node  on  one  of 
the  ribs  and  another  on  the  forehead.  No  history  of 
gout  or  rheumatism. 

Mr.  Glutton  showed  a  boy  in  whom  the  tibia  was 
absent,  and  there  were  other  malformations  ;  also  a  pho- 
tograph of  a  similar  case. 


A  decision  has  at  last  been  obtained  on  the  Salvation 
Army's  Shelter  case.  The  magistrate  has  granted  a 
prohibition  order.  For  two  years  and  a  half  this  shel- 
ter has  been  more  or  less  before  the  public  as  a  centre 
for  spreading  infectious  fevers.  But  for  the  energetic 
medical  officer  of  health.  Dr.  Waldo,  this  danger  would 
have  continued  unabated.  More  than  one  thousand 
persons  were  crowded  into  a  space  only  enough  for 
four  hundred,  and  when  a  vagrant  with  small-pox  en- 
tered the  result  was  easy  to  foresee.  It  appears  that 
this  charitable  part  of  the  Salvationists'  social  scheme 
was  more  than  self-supporting.  It  is  strange  but  true 
that  the  promoters  object  to  be  put  under  the  same 
control  as  common  lodging-houses,  but  they  must  sub- 
mit. Some  two  years  ago  the  Local  Government 
Board  sent  Dr.  Airey  to  inspect  the  several  shelters, 
but  his  report  has  not  been  made  public.  If  the  sup- 
pression be  due  to  the  fears  of  the  late  government, 
the  present  Cabinet  may  be  expected  to  have  no  need 
for  such  reticence.  There  is  no  general  election  at 
hand,  and  the  public  health  should  be  a  strong  plat- 
form in  the  government  programme. 

The  Edinburgh  College  of  Surgeons  was  founded 
nearly  four  hundred  years  ago,  and,  as  pointed  out  in 
the  Scotsman,  is  the  oldest  medical  corporation  in  Scot- 
land. I  lately  reported  the  quarter  centenary  of  Aber- 
deen L'^niversity.  Both  these  bodies  started  in  the 
reign  of  Jamie  IV.  of  Scotland,  himself  "  ane  singular 
guid  chirurgeon,"  so  that  the  princes  now  following 
the  craft  have  a  capital  precedent  for  their  actions. 

On  Wednesday  there  was  a  meeting  of  those  inter- 
ested in  promoting  a  memorial  to  the  late  Professor 
Huxley.  It  was  resolved  to  erect  a  statue  in  the  Mu- 
seum of  Natural  History,  to  provide  a  medal  in  con- 
nection with  the  Royal  College  of  Science,  and  to 
devote  the  balance  of  subscriptions  to  the  futherance 
of  biology. 


OUR   PARIS   LETTER. 

(From  oar  Special  Correspoadent.) 
TREATMENT    AXD    PROPHYLAXIS   OF    DISEASE  BY  HYPO- 
DERMIC    INJECTIONS — THE    GLYCERO-PHOSPHATES — 
SEROPATHIE      AND     VACCINATION  —  ANECDOTE     OF 
RICORD    AND    INOCULATION,    ETC. 

Paris,  November  23,  1895. 

Immunization  and  seropathie  are  more  than  ever  en- 
grossing attention,  not  only  in  the  laboratories  and  at 
the  Ecole  de  Medecine,  but  with  the  profession  at  large. 
To  day  in  the  treatment  of  disease,  whether  prophylac- 
tic or  curative,  the  Pravaz  syringe  is  rapidly  taking  the 
place  of  the  Meritt.  Whether  this  would  be  an  advan- 
tage may  be  open  to  question  ;  it  is,  however,  quite 
certain  that  the  abscesses  and  erythematous  eruptions 
frequently  observed  after  the  free  use  of  the  hypoder- 
mic syringe,  are  of  quite  as  much  moment  as  the  dis- 
ordered stomachs  and  constitutional  symptoms  so  often 
seen  after  the  exhibition  of  drugs.  When  we  arrive  at 
the  prevention  of  syphilis  by  this  method,  inoculation 
will  have  indeed  reached  perfection. 

A  favorite  injection  with  the  Parts  profession  just 
now  is  the  glycero-phosphate  of  lime,  soda,  or  iron, 
whose  introduction  is  due  to  Professor  Albert  Robin. 
His  experiments  were  made  chiefly  with  the  glycero- 
phosphate of  lime,  which  is  used  with  some  success  in 
tuberculosis,  anaemia,  and  neurasthenia,  the  ordinary 
dose  being  from  twenty  to  thirty  centigrammes  injected 
every  morning,  and  continued  for  at  least  several  weeks 
without  interruption  ;  if  the  benefit  is  marked  at  the 
end  of  that  time,  it  is  well  to  stop  the  injections  for  one 
week  and  then  begin  again,  and  these  periods  of  alter- 
nate rest  and  treatment  have  sometimes  to  be  kept  up 
for  several  months. 

But  let  us  look  for  a  moment  at  the  effects  of  vac- 
cine serum,  or  serum  vaainuum,  as  it  is  termed  by  Pro- 
fessor Hlava  and  Dr.  Houl,  of  Prag,  who  have  been 


896 


MEDICAL    RECORD. 


[December  21,  1895 


endeavoring  to  solve  a  problem  of  vast  importance  to 
science  as  well  as  to  preventive  medicine,  namely,  re- 
place the  inoculation  of  animal  virus  by  injections  of 
serum  taken  from  an  animal  made  refractory  to  vac- 
cinia. 

A  first  serum  is  prepared  in  the  following  manner  : 
two  heifers  are  vaccinated  and  their  lymph  secured  on 
the  fourth  day  after  inoculation  ;  it  is  proved  that  they 
are  immunized  against  vaccinia  by  a  double  revaccina- 
tion  without  success.  After  bleeding  them  the  serum 
of  their  blood  is  taken  up.  This  serum  is  injected  to 
three  heifers  without  morbid  reaction  ;  vaccinated 
afterward,  one  of  them  remains  healthy,  the  other  two 
present  pustules,  but  small,  withered,  and  having  a  dry 
appearance. 

Thirteen  children  are  submitted  to  the  same  experi- 
ment ;  they  support  the  dose  injected  (i  to  2^^  centi- 
metres cubes,  from  15  to  35  drops  for  each  kilo  or  two 
pounds  of  weight)  very  well.  These  children  are  sub- 
sequently revaccinated  ;  six  remain  without  pustules, 
on  the  others  they  are  rare. 

In  the  first  experience  the  evolution  of  vaccinia  was 
disturbed  by  gathering  the  lymph  on  the  fourth  day. 

In  a  second  series  of  experiments  the  disease  was 
left  to  develop  itself  freely  on  the  animal  in  order  to 
take  the  serum  only  after  it  was  cured.  Five  heifers 
receive  this  serum  by  injection  ;  this  inoculation  being 
followed  by  an  eruption  of  small  dry  pustules  without 
special  character.  But  on  five  children  treated  in  this 
manner  vaccinia  was  well  developed.  These  facts  show 
plainly  that  the  serum  taken  at  the  end  of  the  disease 
is  less  active  than  that  taken  earlier.  A  third  series  of 
experiments  were  then  made  with  the  complete  blood 
of  the  animal  mixed  with  citrate  of  soda,  and  taken  on 
the  fourth  day  after  inoculation.  This  liquid  immun- 
ized perfectly  two  heifers  against  vaccinia  ;  a  third 
animal  did  not  resist  it  because  the  dose  injected  was 
insufficient.  On  the  children  it  produced  an  elevation 
of  temperature,  38.6°  C.  to  39.5°  C.  ;  or  about  100.2°  F. 
to  101°  F.,  but  prevented  the  breaking  out  of  vaccinia. 

These  experiments  are  certainly  interesting  and  merit 
the  attention  of  all  thinking  men.  They  can,  however, 
only  as  yet  be  considered  a  step  in  the  right  direction. 
They  have  not  decided  the  crucial  questions  :  Does 
vaccinal  serum  possess  immunizing  properties  against 
small-pox,  and  Has  the  method  by  injections — as  a 
method — any  advantage  over  that  usually  employed  ? 

While  on  the  subject  of  inoculation,  it  may  be  inter- 
esting to  recall  how  Ricord  nearly  lost  his  great  reputa- 
tion as  an  authority.  The  question  arising  whether  the 
virus  of  a  secondary  syphilitic  ulcer  could  produce  the 
disease,  was  appealed  to  Ricord,  who  unhesitatingly  de- 
cided in  the  negative — little  suspecting  that  a  trap  was 
being  laid  for  him  by  a  rival  professor  and  a  distin- 
guished editor  who  is  still  living.  They  proposed  to 
inoculate  a  healthy  monkey  ;  to  this  Ricord  agreed,  and 
accordingly  all  met  at  the  hospital  a  few  days  later,  in- 
cluding the  monkey,  who  was  duly  inoculated  from  a 
patient  in  the  syphilitic  wards  having  a  secondary  syph- 
ilitic ulcer.  In  a  few  weeks  the  monkey  was  thoroughly 
saturated  with  the  poison  and  left  to  die.  to  the  great 
mortification  of  "Ricord,  who  was  just  then  entering 
upon  the  apogee  of  his  fame.  The  experiment  was  not 
repeated  until  some  time  later,  with  tertiary  syphilitic 
virus,  which,  it  is  now  well  known,  can  also  produce 
syphilitic  symptoms  after  inoculation. 


Failure  of  the  Oregon  Medical  Law. — According  to 
the  Medical  Sentinel  the  recently  enacted  law  regulat- 
ing the  practice  of  medicine  in  Oregon  seems  likely  to 
prove  ineffective.  It  is  stated  that  a  Chinaman,  who 
was  practising  without  a  license  in  Portland,  was  ar- 
rested and  tried  three  times  before  he  could  be  con- 
victed, and  then  only  had  to  pay  a  fine  of  $50.  An- 
other irregular  practitioner  was  tried  and  acquitted. 


PRIVATE    MEDICAL    COLLEGES    AND    PUB- 
LIC   HOSPITALS. 

To  THB  Editor  of  the  Medicai.  Record. 

Sir  :  Confusion  exists  in  the  minds  of  many  physicians 
and  others  as  to  the  exact  relation  which  the  medical  col- 
leges bear  to  the  public  hospitals.  The  undergraduate 
medical  colleges  which  recently  induced  the  city's  au- 
thorities to  turn  over  all  the  public  hospitals  to  them,  and 
who  absolutely  control  their  medical  boards,  have,  as  a 
matter  of  fact,  no  right  whatever  to  exercise  such  control. 
These  colleges  are  private  stock  companies,  chartered 
by  the  State,  and  conducted  as  any  other  stock  company 
for  the  sole  benefit  of  the  stock-holders.  Thej'  advertise, 
and  hold  out  every  inducement  possible  to  get  students 
to  attend  them — more  students,  larger  dividends,  more 
reputation,  and  more  consultations  from  the  students — 
which  means  more  cash  income  to  the  stock-holders, 
who  are  the  professors.  In  other  words  they  are  con- 
ducted as  business  enterprises,  and  are  in  no  sense 
charitable  institutions  or  public  benefits,  except  as  any 
other  stock  company  honestly  conducted  is  a  public 
benefit. 

They  cannot  lay  claim  even  to  a  desire  for  better  ed- 
ucated physicians,  for  they  fought  the  State  legislature, 
inch  by  inch,  in  its  efforts  to  raise  the  standard  of  med- 
ical education,  and  require  a  preliminary  examination 
of  the  applicant  for  matriculation,  for  fear  students 
would  be  driven  away  and  the  income  of  the  professors 
be  reduced. 

We  mention  these  facts,  not  in  a  sense  of  criticism, 
nor  do  we  arraign  the  colleges  for  adopting  the  same 
business  methods  of  other  corporations  engaged  in 
money-making  ;  but  they  are  mentioned  to  show  that 
these  medical  colleges  must  take  their  places  along 
with  all  other  business  firms. 

The  public  hospitals  are  built  and  maintained  by 
taxation  of  all  the  citizens,  and  all  the  citizens  ought, 
therefore,  to  have  equal  rights  to  enjoy  all  the  benefits 
to  be  had  from  them.  Their  wards  should  be  open  to 
receive  any  citizen  for  care  and  treatment  who  is  qual- 
ified to  receive  it  by  reason  of  his  ascertained  inability 
to  care  for  himself. 

Appointments  to  positions  on  the  medical  boards  of 
these  hospitals  should  be  equally  open  to  competition 
by  all  the  citizens  of  the  city  ;  none  should  be  rendered 
ineligible  for  any  reason  except  by  their  demonstrated 
lack  of  skill  and  experience  to  perform  the  professional 
duties  of  such  positions.     This  is  only  common  justice. 

Instead,  we  have  to-day  a  condition  of  things  which 
is  not  only  an  insult  to  nearly  four  thousand  physicians 
in  this  city,  but  that  actually  robs  them  of  the  right  to 
even  compete  for  a  place  on  the  medical  board  of  a 
public  hospital. 

Three  or  four  men,  each  a  "  boss  "  in  one  of  these 
private  medical  corporations,  got  together  and,  taking 
advantage  of  the  ignorance  of  the  Maj'or  and  some  of 
the  Charity  Commissioners,  and  by  promising  influence 
to  aid  in  retaining  another,  secured  the  passage  of  the 
outrageous  resolution. 

Hereafter  no  physician  is  eligible  to  be  a  member  of 
the  staff  of  a  city  hospital,  which  he  is  taxed  to  support, 
unless  he  has  a  "  pull  "  with  a  "  boss  "  of  one  of  these 
private  corporations  and  is  willing  to  wear  his  collar. 

By  this  resolution  of  the  Commissioners  a  still 
greater  injustice  was  done  :  the  old  medical  boards  of 
the  public  hospitals  were  turned  out,  and  it  is  true  that 
some  of  the  men  who  had  proper  "  pulls  "  were  reap- 
pointed, but  in  a  number  of  instances  men  of  excellent 
professional  standing,  and  a  record  of  years  of  faithful 
service  in  the  hospitals,  were  replaced  by  young  and 
recent  graduates,  who  were  the  relatives  of  the  "  bosses  " 
or  their  immediate  henchmen. 

The  Commissioners  of  the  Department  of  Charities 
and  Correction  have  no  more  right  to  disqualify  a 
number  of  competent  physicians  from  the  right  to 
perform  the  duties  of  attending  professionally  the  in- 


December  21,   1895] 


MEDICAL    RECORD. 


897 


mates  of  the  public  hospitals  because  they  have  not  the 
proper  "  pull "  with  certain  medical  bosses,  than  the 
Commissioners  of  the  Dock  Department  have  to  show 
favoritism  in  letting  contracts  for  building  the  city's 
piers  and  disqualifying  certain  contractors,  because 
they  have  not  the  proper  "pull"  with  a  political 
"boss." 

In  one  case  the  lowest  bidder  should  build  the  pier, 
and  in  the  other  the  man  best  qualified,  after  a  civil 
service  examination,  should  attend  the  sick. 

And   this  is  all  done  under  the  name  of  "  reform." 
But  where  does  its  twin  sister,  "  Fair  Play,"  come  in  ? 
An  Imparti.al  Outsider. 


gXetlicaX  gtems. 

Contagious  Diseases — Weekly  Statement — -Report  of 
cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  December  14,  1895. 


Tuberculosis   .' 

T)'phoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis !  ' 

Measles *4* 

Diphtheria '52 

Croup ° 


Cases. 

Deaths. 

78 
18 
76 

102 
6 
6 

Micro-organisms   on   Coins. — The  Jinue  tfHygiene 
publishes  an  interesting  account  of  some  experiments 
made  at  the  bacteriological  laboratory  of  the  Military 
Hospital  of  the  Dey  at  Algiers.    Dr.  H.  Vincent  explains 
that  money  is  specially  liable  to  be  contaminated  by 
saliva,  pus,  pathological  secretions,  dust,  and  the  mor- 
bid germs  that  may  be  found  in  dirty  pockets  or  on 
dirty  fingers.     He  does  not  think,  however,  that  evi- 
dence of  this  danger  can  be  easily  obtained  by  placing 
dirty  coins  in  culture  broth.     The  investigations  at  the 
Dey  Hospital  were  conducted  in  a  different  manner. 
A  piece  of  cotton-wool  about  the  size  of    a  pea  was 
dipped  in  water  and  sterilized.     Pieces  of  wool  thus 
prepared  were  seized  with  pincers  that  had  been  held 
in  a  flame  and  were  gently  passed  over  the  coin  to  be 
examined.     The  pieces  of  wool  were  then  placed  in 
culture  broths  and  kept  in  a  temperature  of  35     C. 
The   product,   which    soon    contained    various   micro- 
organisms, was  sown  anew  in  gelatine  plaques  so  as  to 
isolate  the  bacteria.     In  other  cases  it  was  inoculatea 
in  doses  varying  from  one  to  five  cubic  centimetres,  m 
the  blood  or  under  the  skin  of  rabbits,  guinea-pigs, 
and  white  rats.     A  lengthy  description  of  the  methods 
employed   and    the    results   obtained    is   given.      The 
number   of   bacteria   found    on    the  surface   of   coins 
varied   very   considerably  — on   silver  and   gold  from 
four  hundred  and  sixty  to  thirty-five  hundred,  and  on 
copper  a  still  larger  number.     To  destroy  many  of  the 
non- pathogenic  microbes  some  experiments  were  made 
at  a  temperature  of  37^   C.     The  injection  of  mixed 
cultures  from  coins  only  produced  death  or  serious 
results   in    about   one  out  of   every  ten   inoculations. 
Death  was  sometimes  rapid,  with  symptoms  of  acute 
septicemia.     In  one  case  tuberculosis  was  conimuni- 
cated  to  a  rabbit  by  a  piece  of  wool  which  had  been 
passed  over  a  ten-centime  copper  coin.    In  another  case 
there  was  slight  tetanus.     There  can  be  no  doubt  that 
germs  of  disease  are  often  to  be  found  on  the  sur- 
face  of   coins  — notably  the  microbe  of   suppuration, 
the  staphylococcus  pyogenes,  and  the  streptococcus. 
Nevertheless,  as  the  experiments  were  repeated  they 
proved  that  there  were  fewer  infectious  germs  than 
had  been  anticipated.     Another  series  of  experiments 
was  then  made  which  demonstrated  that,  though  coins 


are  often  contaminated  they  possess  in  themselves 
antiseptic  qualities  which  greatly  reduce  the  risk.  If 
pathogenic  germs  are  placed  on  coins  it  is  seen  that 
they  do  not  live  long.  The  time  varies  according  to 
the  temperature  and  the  nature  of  the  metal.  In  a 
cold  temperature  the  germs  of  typhoid  fever  and  the 
Friedlander  bacillus  are  killed  in  eighteen  hours  if 
placed  on  a  sterilized  copper  or  silver  coin  ;  and  the 
pyocyanic  bacillus  and  that  of  green  diarrhoea  in 
twenty-four  hours.  At  a  temperature  of  a  pocket, 
about  36°  C,  the  bacilli  of  typhoid  fever,  of  blue  pus, 
of  diphtheria,  and  the  streptococcus  are  destroyed  in 
less  than  six  hours.  The  bacilli  of  diphtheria  are 
among  the  most  tenacious,  and  in  cold  will  live  three 
days  on  silver  and  six  days  on  bronze.  Gold,  of 
course,  is  less  antiseptic,  and  the  Eberth  bacillus  will 
live  five  days  and  that  of  diphtheria  six  days  on  a  gold 
coin  in  a  temperature  of  20"  C.  At  a  damp  tempera- 
ture of  36°  C.  the  destruction  of  the  microbes  is  very 
rapid,  and  that  is  the  temperature  which  often  prevails 
in  the  pockets  of  clothes. 

Ogdensburg'  (N.  Y.)  Medical  Society.— At  a  regular 
meeting  of  the  Ogdensburg  Medical  Society,  held  at 
the  residence  of  Dr.  G.  Madill,  the  following  resolu- 
tions were  unanimously  adopted  : 

Whereas,  We,  the  members  of  the  Ogdensburg  Medi- 
cal Society,  have  learned  with  deep  regret  that  Drs.  J. 
M.  Mosher  and  Robert  Cook,  active  members  of  this 
society  and  of  the  Medical  Staff  of  the  St.  Lawrence 
State  Hospital,  are  to  sever  their  connection  with  our 
society  to  enter  private  practice  in  their  special  lines  ; 
we  realize  we  are  to  lose  the  genial  companionship, 
the  able  and  active  co-operation  of  two  of  our  most  es- 
timable and  efficient  members  ;  be  it 

Resolve  J,  That  we  tender  them  a  dinner,  as  an  expres- 
sion of  our  good-will  and  fellowship  and  as  a  tribute  of 
our  high  appreciation  of  their  scientific  and  professional 
attainments.  And  be  it  further  resolved,  that  we  be- 
lieve that  any  community  in  which  they  may  locate  can 
place  every  confidence  and  reliance  in  their  professional 
skill,  honor,  and  integrity. 

Resolved,  That  a  copy  of  these  Resolutions  be  spread 
on  the  minutes  of  this  Society,  and  a  copy  be  sent  to 
each  of  the  gentlemen.  Also,  that  copies  be  sent  to 
the  medical  press  for  publication. 

B.  F.  Sherman,  M.D.. 
President. 


A  Visit  to  Professor  Kitasato's  Institute  for  Infectious 
Diseases.— Dr.  J.  M.  .\tkinson,  colonial  surgeon.  Hong 
Kon<'  sends  the  following  account  of  a  visit  to  Kita- 
sato's'laboratory  to  The  Latuet :  On  July  zSth  I  visited 
this  institution  and  was  shown  around  by  Professor 
Kitasato,  Dr.  Nakagawa.  a  Japanese  gentleman  who  is 
a  graduate  in  medicine  of  New  York  University,  acting 
as  interpreter.  Professor  Kitasato,  although  having  an 
intimate  knowledge  of  German,  does  not  speak  Eng- 
lish We  first  proceeded  to  the  laboratory,  and  I  was 
shown  the  following  specimens:  i.  Tubercle  bacilli; 
2  Plasmodium  malariw  ;  3,  pneumococcus  (Frankel  s)  ; 
4'  LOffler's  bacillus  ;  5,  tetanus  bacillus ;  6,  bacillus 
anthracis;  7.  plague  bacillus;  8,  lepra  bacillus;  9, 
typhus  fever  (enteric  fever)  bacillus  ;  10,  cholera  bacil- 
lus •  and  II,  gonococcus.  Professor  Kitasato's  method 
of  obtaining  the  plasmodium  malarix  is  first  to  fix  the 
specimen  with  a  one  per  cent,  solution  of  corrosive 
sublimate,  afterward  staining  with  a  saturated  solution 
of  eosin  in  absolute  alcohol,  and  then  with  Liiffler's  solu- 
tion of  methylene  blue.  With  reference  to  diphtheria 
I  had  a  long  conversation  with  Prolessor  Kitasato. 
He  has  succeeded  in  obtaining  an  antitoxin  much 
stronger  than  any  yet  used.  To  show  this,  9  c.c.  of  his 
serum  are  all  that  he  injects  to  cure  a  case  of  diph- 
theria -  with  Roui's  serum,  on  the  other  hand,  it  is 
necessary  to  use  as  much  as  100  c.c.  He  can  obuin 
this  from  the  blood  of  a  horse,  but  prefers  that  of  a 
sheep      I  was  shown  large  pieces  of  diphtheritic  mem- 


MEDICAL    RECORD. 


[December  21,  1895 


brane  which  had  been  coughed  up  by  patients  who  had 
been  injected  with  this  antitoxin.  The  "  tetanus  ba- 
cillus "  was  a  beautiful  specimen,  and  is  shaped  some- 
what like  a  clove,  the  head  being  the  spore,  and  is 
stained  red  with  carbolized  fuchsin,  the  body  of  the 
bacillus  being  stained  blue.  The  sixth  specimen 
showed  the  spore  formation  very  well,  the  spores  being, 
as  in  the  previous  case,  stained  with  fuchsin  and  the 
bacilli  with  methylene  blue.  The  plague  bacilli  are  very 
distinctive,  and  are  exactly  similar  to  those  which  were 
obtained  this  year  from  the  few  plague  cases  which 
have  occurred  in  Hong  Kong.  They  are  of  an  oval 
shape,  presenting  two  deeply-stained  poles  with  a  clear 
non-stained  interval  between  them.  The  simplest  way 
to  obtain  the  plague  bacilli  is  to  take  some  of  the  juice 
from  one  of  the  affected  lymphatic  glands,  smear  it  on 
a  cover-glass,  and,  after  fixing,  stain  with  eosin  or 
methylene  blue.  Bacilli  are  found  to  be  present  in  great 
numbers  ;  they  are  almost  identical  in  appearance 
with  those  of  chicken  cholera.  The  bacillus  of  enteric 
fever,  which  was  quite  new  to  me,  presents  a  deeply 
stained  body  with  a  number  of  fine  filamentous  proc- 
esses passing  off  from  it  ;  none  of  these  are  branched. 
The  specimen  was  from  a  culture  obtained  from  the 
faeces  in  a  typhoid  fever  case.  After  this  I  was  taken 
round  the  menagerie,  where  there  was  a  large  number 
of  animals — guinea-pigs,  dogs,  rabbits,  mice,  monkeys, 
etc.,  for  the  purposes  of  inoculation,  investigation,  etc.  ; 
and  finally  I  visited  the  wards.  In  one  room  there 
were  two  patients  convalescent  from  diphtheria,  who 
had  been  injected  with  Professor  Kitasato's  antitoxin  ; 
in  another  ward  he  showed  me  a  case  of  leprosy  in 
which  the  tubercles  were  disappearing  under  the  influ- 
ence of  an  antitoxin  which  he  is  now  investigating.  In 
another  ward  there  was  a  child  with  traumatic  tetanus  ; 
this  case  was  also  On  a  fair  road  to  recovery,  the  seiz- 
ures being  much  less  since  the  injection  of  a  tetanus 
antitoxin,  and  the  temperature  having  fallen  after  each 
injection.  There  were  also  some  twelve  cases  of  phthi- 
sis. Just  off  the  wards  there  was  a  Lyons  steam  disin- 
fector.  The  laboratory  was  furnished  with  every 
requisite,  and  one  could  not  but  be  convinced  that 
here,  in  the  middle  of  Tokio,  some  excellent  scientific 
research  is  being  carried  on  by  Professor  Kitasato  and 
his  assistants. 

Eapy  Exposure  of  Occultism.— There  is  an  organiza- 
tion in  Boston  known  as  the  Society  of  Psychical  Re- 
search. The  other  evening,  at  one  of  the  meetings,  a 
certain  person,  said  to  possess  remarkable  occult  pow- 
ers, volunteered  to  give  an  exhibition,  which  offer  was 
gladly  accepted  by  the  society.  The  "  professor  "  was 
a  woman,  slightly  built,  with  pallid  cheeks  and  dark 
raven  hair.  One  of  the  members,  while  not  particu- 
larly sceptical,  thought  he  would  try  a  little  experiment 
on  his  own  account,  so  before  going  to  the  meeting  he 
provided  himself  with  some  pieces  of  phosphorescent 
paper,  that  in  the  dark  lit  up  like  a  glow-worm.  This 
he  tore  into  small  pieces,  and,  just  before  the  lights 
were  extinguished,  contrived  to  place  three  or  four  bits 
of  the  paper  on  the  "  professor's  "  head.  Then  he  sat 
down  and  waited.  When  the  room  was  dark  the  "  pro- 
fessor's "  cranium  emitted  a  pale  light,  visible  to  every- 
one in  the  room  but  the  "  professor  "  herself.  In  a 
few  minutes  the  phenomena  began,  but,  strange  to  re- 
late, when  a  tambourine  in  one  corner  of  the  room  be- 
gan to  sound,  the  illuminated  was  there  also,  and  the 
moving  about  of  the  operator  could  be  easily  traced. 
The  suppressed  mirth  told  the  "  professor  "  something 
was  wrong,  and  when  the  light  was  turned  on  and  the 
paper  discovered,  the  remarks  made  were  far  from 
spiritual.  There  were  no  more  manifestations  that 
night. 

The  Number  of  Epileptics  in  the  State  of  New  York 
Available  for  Craig  Colony.— Quite  recently  the  State 
Board  of  Charities,  through  their  representative.  Dr. 
Charles  S.  Hoyt,  canvassed  the  State  to  determine  the 


number  of  epileptics  in  county  and  city  asylums  and 
almshouses  available  for  transfer  to  the  newly  organ- 
ized Craig  Colony  for  epileptics  in  Livingston  County. 
Dr.  Hoyt  reported  four  hundred  and  twenty-seven  pa- 
tients in  these  institutions.  Feeling  that  this  number 
by  no  means  represented  the  actual  number  of  epileptics 
available  for  admission  to  the  colony,  Dr.  Frederick 
Peterson,  the  president  of  the  board  of  managers  of 
Craig  Colony,  has  instituted  a  special  separate  inquiry 
among  all  sorts  of  public  and  charitable  institutions, 
such  as  almshouses,  hospitals,  homes,  protectories, 
orphan  asylums,  and  the  like,  and  the  figures  presented 
by  him  in  this  more  extended  canvass  are  as  follows  : 

Epileptics  in  County  Poorhouses 194 

"         "   City  Almshouses 13 

"        "  New  York  County  Almsliouse,  Hospitals,  Homes, 

etc 246 

"         "  Kings  County  Almshouse,  etc 39 

"         "  various  other  public  and  charitable  institutions  in 

the  St.ite  (exclusive  of  almshouses) 70 

Total 562 

In  addition  to  these  562  epileptics  a  careful  inquiry 
elicited  the  fact  that  there  are  nearly  one  thousand 
epileptics  in  insane  asylums  throughout  the  State,  of 
whom,  at  the  very  lowest  estimate,  fifteen  per  cent,  are 
available  for  residence  under  the  moderate  restrictions 
of  Craig  Colony,  making  an  additional  150  patients. 
Moreover,  nearly  one  hundred  letters  have  been  received 
by  officers  of  the  colony  from  epileptics  not  in  alms- 
houses, asylums,  or  other  institutions,  but  nevertheless 
poverty-stricken  and  eking  out  some  sort  of  miserable 
existence  on  the  charity  of  friends.  The  number  of 
those  then  immediately  available  for  the  beneficent  ad- 
vantages of  Craig  Colony  may  be  recapitulated  thus  : 

Number  of  epileptics  available  for  Craig  Colony  in]poorhouses, 

hospitals,  and  other  public  institutions  in  the  State 562 

Number  available  from  insane  asylums  (a  moderate  estimate).  150 
Number  of   dependent  epileptics  not   in  institutions,   already 

applicants 100 

Total S12 

It  need  hardly  be  said  that  these  figures  really  fall  short 
of  the  actual  number  of  epileptics  in  the  State  of  New 
York  who  should  ultimately  receive  the  benefits  of  the 
State's  newest  and  greatest  charity,  for  physicians  fa- 
miliar with  the  services  in  out-door  departments  of  hos- 
pitals and  in  the  poor  dispensaries  of  our  cities,  know 
that  very  large  numbers  of  epileptics  come  under  their 
observation  every  year,  epileptics  without  occupation, 
dependent  upon  charity  and  occasional  temporary  em- 
ployment, or  supported  in  idleness  and  misery  by  hard- 
working but  equally  poor  relatives  ;  and  it  is  safe  to 
say  that  the  number  of  these  deserving  unfortunates  in 
New  York  City  alone  must  aggregate  between  three 
and  four  hundred. 

Suicide  in  Its  Medical  and  Its  Moral  Aspects. — It  has 

been  noted  that  a  tendency  to  suicide  has  recently  been 
somewhat  unusually  prevalent.  The  regular,  though 
happily  never  frequent,  connection  between  solar  heat 
and  this  form  of  crime  has  been  repeatedly  observed, 
and  may,  without  undue  straining  of  logical  conditions, 
be  accepted,  at  all  events  as  far  as  it  goes,  as  a  working 
hypothesis  founded  on  accurate  observation.  When 
we  go  further  and  seek  to  explain  the  hypothesis  itself, 
however,  we  are  still  conscious  of  the  insufficiency  of 
our  data.  The  theory  by  which  Dr.  Haig  would  asso- 
ciate mental  depression  with  blood  vascular  tension 
due  to  uric  acid  is  indeed  helpful  in  its  measure,  as  it 
is  certainly  ingenious.  The  measure  of  assistance  tow- 
ard a  sufficient  explanation  is,  nevertheless,  in  both 
cases,  very  meagre.  It  is  evident  that  in  the  case  of 
most  persons  a  wide  desert  of  despondency  intervenes 
between  the  state  of  mind  which  corresponds  to  a  hard 
pulse  and  overladen  tissues  and  the  last  fatal  folly  of 
despair.  Save  in  the  case  of  insane  or  weak-minded 
persons,  it  is  hardly  possible  to  conceive  that  men  can 


December  21,  1S95] 


MEDICAL    RECORD. 


be  impelled  to  suicide  by  purely  physical  conditions, 
which  are,  after  all,  so  common  as  hardly  to  be  re- 
garded as  abnormal  except  by  the  scientifically  edu- 
cated mind.  We  would  by  no  means  overlook  the  ne- 
cessity of  treating  these  cases  by  appropriate  means, 
but  we  are  none  the  less  assured  that  the  reckless  will 
which  induces  men  to  convert  a  weariness  of  life  into  a 
purpose  of  self-destruction  does  not  depend  upon  mere 
atmosphere  or  mal-excretion.  Where  they  are  free  to 
operate,  the  reserves  of  moral  sense,  thought,  and  reso- 
lution have  either  been  previously  exhausted  or  have 
not  been  drawn  upon.  A  feeling  of  personal  loss  or  a 
morbid  fear  of  such  has  obliterated  the  sense  of  human 
relationship.  The  interest  of  dependent  or  associated 
neighbors  and  of  relatives  is  forgotten.  Self-love,  not 
social  duty,  is  the  impelling  force.  We  have  not  much 
hope  that  persons  in  this  mood  will  be  greatly  influ- 
enced by  changes  of  weather  or  by  purely  physical 
treatment.  We  would  rely  more  upon  the  full  and 
frank  assertion  of  the  duty  and  utility  of  all  human 
beings  to  each  other,  and  to  the  Providence  essentially 
friendly  to  men  which  called  them  into  being.  Suicide 
is,  after  all,  a  moral  failure,  an  evidence  of  the  mastery 
of  mistrust,  an  act  of  rebellion  against  the  authority  of 
patience.  Obviously  no  drug,  no  social  reform  even, 
can  effectually  cure  it,  unless  they  be  aided  in  the  first 
place  by  a  frank  and  full  recognition  of  man's  moral 
relation  and  responsibility. —  The  Lancet. 

Prolonged  Hiccough. — Dr.  Ferguson  reports  a  severe 
and  prolonged  case  of  hiccough  in  a  man,  aged  thirty- 
three,  which  lasted  for  seventy-two  hours  without  ces- 
sation, except  during  short  periods  while  under  chloro- 
form anaesthesia  (  The  Lancet).  The  case  was  treated 
unavailingly  by  chloral,  camphor,  ether,  aromatic  spirit 
of  ammonia,  tincture  of  opium,  morphine  hypodermi- 
cally  (gr.  J^),  tincture  of  belladonna,  ice,  and  galvan- 
ism to  the  phrenics,  and  ice  to  the  spine.  The  patient 
was  in  a  critical  condition,  no  nourishment  had  been 
taken  for  many  hours,  cyanosis  was  intense,  while  the 
hiccough  was  continuous  and  violent.  As  a  last  re- 
source a  hypodermic  injection  was  administered  con- 
taining morphine,  gr.  ^2,  and  atropine,  gr.  ^V-  The 
same  quantity  of  morphine  had  been  already  injected 
without  producing  any  further  effect  than  a  little 
drowsiness.  In  five  minutes  the  patient  was  fast 
asleep  and  the  hiccough  had  entirely  ceased.  In  two 
hours  symptoms  of  poisoning  developed,  the  face  and 
lips  being  cyanosed  and  the  breathing  stertorous,  slow, 
and  labored.  Tickling  the  soles  of  the  feet  restored 
consciousness,  so  that  he  answered  questions  and 
swallowed  some  coffee.  After  another  hour's  sleep  his 
breathing  became  so  obstructed  that  he  was  again 
awakened,  this  time  with  far  less  difficulty  than  before. 
Next  morning  he  complained  of  nothing  except  some 
stiffness  of  the  neck  and  difficulty  in  swallowing,  and 
in  a  few  days  he  regained  his  normal  condition.  There 
was  no  return  of  the  hiccough. 

Grief  from  a  Medical  Stand-point. — The  nervous  sys- 
tem requires  complete  rest  after  blows  caused  by  sor- 
row. Recent  medical  observations  show  that  the  phys- 
ical results  of  depressing  emotions  are  similar  to  those 
caused  by  bodily  accidents,  fatigue,  chill,  partial  star- 
vation, and  loss  of  blood.  Birds,  moles,  and  dogs, 
which  apparently  died  in  consequence  of  capture,  and 
from  conditions  that  correspond  in  human  beings  to 
acute  nostalgia  and  "broken  heart,"  were  examined 
after  death  as  to  the  condition  of  their  internal  organs, 
and  it  was  found  that  the  nutrition  of  the  tissues  had 
been  interfered  with,  and  the  substance  proper  of  vari- 
ous vital  organs  had  undergone  the  same  kind  of  de- 
generation as  that  brought  about  by  phosphorus  or  the 
germs  of  infectious  disease.  The  poison  of  grief  is 
more  than  a  man.  To  urge  work,  study,  travel,  the 
vain  search  for  amusements,  is  both  useless  and  dan- 
gerous. For  a  time  the  whole  organism  is  overthrown, 
and  temporary  seclusion  is  imperative  for  proper  read- 


justment. Grief  cannot  be  ignored,  neither  can  it  be 
cheered  up.  It  must  be  accepted  and  allowed  to  wear 
itself  away.  Readjustment  comes  slowly.  Sorrow, 
grief,  and  all  great  misfortunes  should  be  regarded  as 
conditions  similar  to  acute  infectious  diseases,  which 
they  resemble  in  result ;  and,  later,  as  convalescence 
from  such  diseases.  Seclusion,  rest,  sleep,  appropriate 
food,  fresh  air,  sunshine,  interests  that  tax  neither  mind 
nor  body,  these  are  requirements  in  this  class  of  ill- 
ness.— Charlotte  Medical  Journal. 

Death  in  a  Hospital  Bath. — A  strange  death  formed 
the  subject  of  an  inquest  at  Portsmouth  recently.  A 
man,  aged  thirty-two,  was  sent  as  an  applicant  for  ad- 
mission to  the  Royal  Hospital  at  Landport.  He  was 
suffering  from  bronchitis  in  both  lungs,  and,  having 
been  examined  by  the  house  surgeon,  was  sent  to  get  a 
bath  and  go  to  bed.  The  water  was  from  90°  to  100° 
F.  in  temperature,  and  one  of  the  nurses  asked  him  be- 
fore he  was  left  if  he  was  subject  to  fainting  fits,  to 
which  he  replied  in  the  negative.  He  had  been  in  the 
bath-room  about  ten  minutes  when  a  nurse,  requiring 
something  from  the  compartment,  sent  a  lad  to  get  it. 
The  latter  found  the  deceased  under  the  water  and  at 
once  ran  for  assistance.  The  man  was,  however,  quite 
dead,  and  he  had  not  the  appearance  of  asphyxia  from 
drowning.  A  necropsy  revealtd  a  ruptured  aneurism. 
—  TheLajicct. 

Fake  Hospitals  in  Chicago.— The  British  Medical 
Journal  is  informed  by  its  Chicago  correspondent  that 
a  crusade  has  been  started  against  the  so-called  "  fake  " 
hospitals  which  have  come  into  existence  of  late  years. 
To  the  end  of  effectually  getting  at  the  evil,  the  Couri- 
cil  has  had  presented  an  ordinance,  a  draft  of  which  is 
here  submitted.  Whether  or  not  the  restrictions  are 
drawn  close  enough  to  affect  the  illegitimate  massage 
establishment  or  not  must  be  left  to  the  thought  of  the 
reader  : 

Section  i.  That  it  shall  be  unlawful  for  any  person, 
firm,  association,  or  corporation  other  than  the  regu- 
larly constituted  authorities  of  the  State  of  Illinois,  or 
the  county  of  Cook,  or  the  city  of  Chicago,  to  open, 
conduct,  manage,  or  maintain  any  hospital  as  herein- 
after defined  within  the  corporate  limits  of  the  city  of 
Chicago  without  first  obtaining  a  permit  therefor,  to 
be  issued  by  the  Commissioner  of  Health  of  the  city  of 
Chicago,  upon  the  written  application  of  such  person, 
firm,  association,  or  corporation,  which  application 
shall  state  the  location,  or  proposed  location,  of  such 
hospital,  the  purposes  for  which  it  is  to  be  opened, 
conducted,  or  maintained,  the  accommodations  or  pro- 
posed accommodations  for  the  inmates  thereof,  the 
nature  and  kind  of  treatment  given  or  proposed  to  be 
given  therein,  and  the  name  and  address  of  the  chief 
surgeon,  physician,  or  intended  chief  physician  or  sur- 
geon attendant  thereat. 

Section  2.  It  shall  be  the  duty  of  the  said  Commis- 
sioner of  Health,  upon  the  presentation  of  such  appli- 
cation, to  make  or  cause  to  be  made  strict  inquiry  into 
the  facts  set  out  in  such  application,  and  if  upon  such 
inquiry  he  shall  find  that  such  hospital  is  or  is  intended 
to  be  constructed  so  as  to  afford  proper  accommoda- 
tion for  the  care  of  the  persons  received  or  proposed 
to  be  received  therein,  and  that  the  chief  physician 
or  surgeon,  or  intended  chief  physician  or  surgeon 
attendant  thereat,  gives  or  is  under  agreement  to 
thereafter  give  such  attendance  thereat  as  does  or  will 
render  him  responsible  professionally  for  the  medi- 
cal or  surgical  treatment  given  or  to  be  given  to  any 
and  all  persons  thereat,  and  that  such  chief  physician 
or  surgeon  is  regularly  authorized  to  act  as  such  un- 
der the  laws  of  the  State  of  Illinois,  and  upon  the  pay- 
ment to  said  Commissioner  of  Health  of  a  license,  per- 
mit, inspection,  orexamination  fee  of  .  .  .  dollars,  he 
shall  issue  a  permit  in  the  name  of  the  City  of  Chicago 
to  such  applicant  to  open,  conduct,  manage,  or  main- 
tain a  hospital  at  the  place  and  in  the  manner  and  for 


900 


MEDICAL    RECORD. 


[December  21,   1895 


the  purpose  in  such  application  mentioned,  which  said 
permit  shall  cease  and  be  operative  the  31st  day  of 
December  next  following  the  issue  thereof. 

Section  j.  It  shall  be  the  duty  of  such  person,  firm, 
association,  or  corporation  permitted  as  aforesaid  to 
open,  conduct,  or  maintain  a  hospital  within  the  cor- 
porate limits  of  the  city  of  Chicago  to  make  a  report 
to  the  said  Commissioner  of  Health  on  or  before  the 
5  th  day  of  each  calendar  month,  showing  a  complete 
record  of  such  hospital  during  the  preceding  month, 
including  the  number  of  inmates  received,  discharged, 
and  died  during  the  month,  causes  of  death,  and  such 
other  information  as  may  be  necessary  to  an  intelligent 
sanitary  supervision  of  the  establishment  ;  such  record 
to  be  furnished  on  blanks  prepared  and  supplied  by 
the  Commissioner  of  Health,  verified  by  the  affidavits 
or  affirmation  of  the  chief  physician  or  surgeon  or 
superintendent  attendant  thereat. 

Section  4.  Every  hospital  permitted  as  aforesaid  shall 
at  all  times  be  open  to  the  inspection  of  the  said  Com- 
missioner of  Health,  or  his  duly  appointed  assistants  or 
inspectors. 

Section  j.  The  Commissioner  of  Health  of  the  city 
of  Chicago  is  hereby  authorized  and  empowered  to  in- 
spect, or  cause  inspection  to  be  made,  whenever  and 
as  often  as  he  may  deem  proper,  of  any  hospital  per- 
mitted as  aforesaid  within  the  corporate  limits  of  the 
city  of  Chicago,  and  if,  upon  any  such  inspection,  he 
shall  find  the  same  to  be  conducted,  managed,  or 
maintained  in  violation  of  the  terms  of  the  application 
for  the  permit  under  which  the  same  was  opened,  con- 
ducted, managed,  or  maintained,  or  in  violation  of  any 
of  the  health  or  sanitary  ordinances,  rules,  or  regula- 
tions of  said  city  of  Chicago,  then  and  in  that  event 
he  is  hereby  authorized  and  empowered  to  revoke  any 
such  license  issued  for  the  opening,  conduct,  manage- 
ment, or  maintenance  of  the  same. 

Section  6.  Any  person  or  persons,  or  corporation 
other  than  the  regularly  constituted  authorities  of  the 
State  of  Illinois,  county  of  Cook,  or  city  of  Chicago, 
opening,  conducting,  managing,  or  maintaining  a  hos- 
pital as  hereinafter  defined  within  the  corporate  limits 
of  the  city  of  Chicago  without  first  having  obtained  a 
permit  therefor  as  provided  in  Section  2  of  this  ordi- 
nance, or  after  a  revocation  of  such  permit  under  the 
authority  conferred  in  Section  5  of  this  ordinance, 
or  in  violation  of  any  of  the  provisions  of  this  ordi- 
nance, shall  be  and  is  hereby  declared  to  be  guilty  of 
maintaining  a  nuisance,  and  upon  conviction  thereof 
shall  be  fined  in  a  sum  not  less  than  .     dollars 

nor  more  than     .     .     .     dollars. 

Section  7.  For  the  purposes  of  this  ordinance  a  hos- 
pital is  hereby  defined  to  mean  any  place  or  establish- 
ment used  for  the  reception  or  care  of  the  sick,  injured, 
or  dependent,  including  women  awaiting  confinement, 
or  used  for  the  medical  or  surgical  treatment  of  mental 
or  physical  disease  or  injury. 

Section  8.  This  ordinance  shall  take  effect  and  be  in 
force  from  and  after  its  passage  and  due  publication. 

International  Institute  of  Serotherapy. — The  treat- 
ment of  diphtheria  and  other  diseases  by  antitoxic  se- 
rums has  taken  hold  in  France  to  such  e.xtent  that 
it  has  been  proposed  to  create  an  International  Insti- 
tute of  Sero-therapeutics  for  the  purpose  of  guarantee- 
ing to  the  profession  the  purity  and  strength  of  the 
serums  required.  It  is  said  that  some  of  the  serums 
sent  out  from  certain  laboratories  are  greatly  wanting 
in  these  qualities.  The  proposal  is  to  place  the  Insti- 
tute in  Switzerland,  in  order  that  international  jealousy 
may  be  avoided. — Medical  Press. 

The  Plague  in  China. — The  plague,  during  its  recent 
outbreak  in  China,  was  the  immediate  cause  of  two 
thousand  five  hundred  and  fifty  deaths,  and  of  the  emi- 
gration of  one  hundred  thousand  Chinese.  The  per- 
centage of  Europeans  who  recovered  was  eighty-two, 
while  that  of  Orientals  was  as  low  as  twelve. 


Treatment  of  Acute  Bronchitis  of  Infancy. — Dr.  Per- 
rier  directs  that  in  the  very  acute  forms  of  bronchitis 
in  children  the  chest  should  be  rubbed  with  oil ;  warm 
drinks  should  be  given,  particularly  hot  milk.  Some- 
times, if  there  is  much  oppression,  it  is  well  to  apply  a 
thin  and  light  but  mild  mustard  plaster.  If  the  stom- 
ach is  loaded  with  partially  digested  food  an  emetic  of 
powdered  ipecac,  i  to  2  grains,  and  syrup  of  ipecac,  i 
ounce,  may  be  given,  in  the  dose  of  a  teaspoonful 
every  ten  minutes  till  the  desired  effect  is  produced, 
and  if  the  fever  is  high  i  or  2  grains  of  the  hydro- 
chlorate  of  quinine  may  be  given  in  a  little  coffee. 
The  air  of  the  room  should  be  moderately  warm  and 
moist,  but  it  is  most  important  that  the  ventilation  be 
good.  As  the  disease  progresses,  if  bronchial  secretion 
becomes  very  profuse,  the  following  prescription  may 
be  used : 

B .  O.xide  of  antimony R'  •  ss. 

Syrup  of  senega 3  )■ 

Syrup  of  acacia 3   ij. 

M.  Sig.  :  A  teaspoonful  ever}'  two  hours. 

Or  this  may  be  replaced  by 

5-  Terpine  hydrate gr.  ij.-iv. 

Brandy \  i j. 

Syrup  of  cinchona 3   ss. 

Syrup  of  orange "   ij. 

M.  Sig.  :   A  teaspoonful  every  two  hours. 

Often  an  emetic  will  aid  in  relieving  the  lungs  of 
mucus.  During  the  day  a  little  additional  brandy  or 
red  wine  may  be  given  as  a  stimulant.  In  those  cases 
in  which  frequent  attacks  of  bronchitis  follow  one  an- 
other it  is  useful  to  give  the  child  warm  baths,  followed 
by  cold  sponging,  and  this,  in  turn,  by  active  friction 
of  the  skin  in  drying  the  body.  Malt  extract  should 
be  given  with  each  meal,  and  a  teaspoonful  of  the 
following  prescription  ordered  three  times  a  day  : 

g.  Arsenate  of  sodium gr.  j- 

Distilled  water 3   vi. 

M.  Sig.  :  K  teaspoonful  after  meals. 

If,  notwithstanding  these  measures,  the  child  fails  to 
improve,  it  must  be  taken  to  a  dry  climate. —  Therapeu- 
tic Gazette. 

Eace  and  Disease — Investigations  in  reference  to 
this  interesting  subject,  by  Dr.  John  S.  Billings,  include 
a  special  study  of  ten  thousand  Jewish  families,  in  all 
fifty  thousand  persons,  and  near  views  of  Germans. 
Irish,  and  the  colored  race,  with  the  following  results, 
that  are  probable  conclusions  for  the  United  States. 
The  colored  race  is  shorter-lived  than  the  white,  with 
a  very  high  infantile  death-rate.  It  is  especially  liable 
to  tuberculosis  and  pneumonia  ;  less  liable  than  the 
white  race  to  malaria,  yellow  fever,  and  cancer.  The 
Irish  have  rather  a  low  death-rate  among  young  chil- 
dren, but  a  very  high  one  among  adults,  due  in  part 
to  tuberculosis,  pneumonia,  and  alcoholism.  Germans 
appear  to  be  particularly  liable  to  disorders  of  the  di- 
gestive organs  and  to  cancer.  Jews  have  a  low  death- 
rate  and  more  than  average  longevity.  They  are  less 
affected  than  other  races  by  consumption,  pneumonia, 
and  alcoholism,  but  are  especially  liable  to  diabetes,  lo- 
comotor ataxia,  and  certain  other  diseases  of  the  ner- 
vous system. 

The  Pennsylvania  Colony  Farm  for  Epileptics — The 
project  of  establishing  a  colony  for  epileptics,  where 
country  living  and  farm  work,  judiciously  apportioned, 
would  constitute  the  principal  therapeutic  treatment, 
which  has  been  under  consideration  for  some  time,  has 
at  length  assumed  a  definite  shape.  The  court  has 
granted  a  charter  for  the  "  Pennsylvania  Colony  Farm 
for  Epileptics,"  and  the  corporators  have  organized, 
November  13th,  by  the  election  of  Dr.  Wharton  Sinkler, 
President.  Among  the  directors  are  Drs.  Charles  K. 
Mills,  James  C.  Wilson,  and  Whirton  Sinkler.  A  char- 
itable gentleman  of  Philadelphia  has  offered  to  give 
$50,000  for  the  erection  of  suitable  buildings,  provided 
that  the  farm  be  secured  before  January  i,  1896. — Bos- 
ton Medical  and  Surg^ical  Journal. 


Medical   Record 

A  Weekly  jfouynal  of  Medicine  and  Surgery 


Vol.  48,  No.  26. 
Whole  No.  1312. 


New  York.  December  28,  1895. 


$5.00  Per  Annum. 
Single  Copies,  icc. 


©vigiual  J^vticlcs. 

THE  "DIAPHRAGM  PHENOMENON"  AND 
ITS   IMPORTANCE   IN  CLINICAL  MEDICINE. 

By  MORITZ  LITTEN,  M.D., 

PROFESSOR  IK  THE  L'Nl^'ERSrTV  OF  BERLIN. 

The  object  of  this  communication  is  to  call  the  notice 
of  my  colleagues  to  a  new  motor  phenomenon  exhibited 
by  the  diaphragm,  which  has  hitherto  escaped  atten- 
tion. It  being  a  physiological  utterance  of  the  normal 
organism,  we  are  able  plainly  to  observe  its  course  dur- 
ing each  individual  respiration,  neither  previous  meas- 
ures nor  artificial  light  being  required.  I  first  published 
a  short  description  of  this  "  diaphragm  phenomenon  " 
in  1892,  and  now,  after  three  more  years  of  work,  I 
again  bring  forward  the  subject  on  account  of  its  great 
practical  and  scientific  importance,  which  has  not  so  far 
met  with  sufficient  recognition.  All  who  once  have  had 
occasion,  in  my  lectures,  to  witness  this  phenomenon, 
both  students  and  practitioners,  have  fully  realized  the 
value  of  this  new  aid  to  diagnosis,  and  have  since  made 
use  of  it  in  all  cases.  Add  to  this  the  great  conven- 
ience offered  for  examining  a  large  number  of  individ- 
uals, for  military  and  polyclinic  purposes,  for  instance, 
or  in  life  insurance. 

By  the  term  "  diaphragm  phenomenon  "  I  understand 
the  visible  expression  of  the  gradual  detachment,  dur- 
ing its  inspiratory  descent,  of  the  diaphragm  from  the 
walls  of  the  thora.x,  and  its  gradual  apposition  to  the 
thoracic  walls  while  it  rises  during  expiration. 

Remark .  This  line,  visibly  progressing  downward 
during  inspiration,  and  upward  during  expiration,  may 
be  graphically  illustrated  by  this  schematic  drawing  :  7", 
to  signify  the  thoracic  wall,  and  a,  h^  c,  d, 
positions  successively  occupied  by  the  di- 
aphragm during  an  inspiration.  The  di- 
aphragm should  be  imagined  consisting  of 
'  a  perpendicular  portion  closely  adjoining 
^  ,  the  walls  of  the  thorax — from  which  it  is 
separated  by  a  capillary  space — and  of  a 
..  i'  horizontal  part  intervening  between  the 
.thoracic  and  abdominal  cavities.  .At  the 
-'outset  of  an  inspiration  the  diaphragm's 
position  is  at  a,  a  :  now,  in  the  course  of 
inspiration  the  upper  part  of  its  perpen- 
dicular portion  becomes  detached  from 
the  wall,  while  the  lower  parts  (at  b,  .-,  d) 
still  cling  to  it.  .Kx  the  same  time  the  horizontal  por- 
tion presses  downward.  The  position  of  the  diaphragm 
at  this  juncture  is  represented  by  the  dotted  line  /',  b. 
During  the  following  phase  of  the  same  inspiration  the 
perpendicular  portion  at  h  is  detached,  c  and  d  yet  re- 
maining adherent  to  the  wall  ;  the  position  c,  c  is  thus 
assumed.  Finally  c  becomes  detached,  leaving  the  di- 
aphragm in  the  position  of  extreme  inspiration,  </,  d.  It 
is  the  progressive  detachment  at  a,  b,  c,  d  of  the  dia- 
phragm from  the  thoracic  walls  that  finds  visible  ex- 
pression in  the  so  -  called  diaphragm  phenomenon. 
Precisely  the  reverse  takes  place  in  the  course  of  an 
expiration. 

This  physiological  process,  which  is  repeated  during 
each  respiration,  is  plainly  marked  on  the  thoracic  wall, 
hj  the  regular  rising  and  falling  of  a  peculiar  shadon7 


line,  caused  by  the  motion  of  the  diaphragm  and  de- 
noting its  momentaty  position.  .\s  a  regular  and 
physiological  accompaniment  to  the  act  of  respiration, 
this  line  may  be  observed  on  the  chest  of  every  indi- 
vidual, healthy  or  diseased,  unless  morbid  processes  be 
present  that  interfere  with  the  mobility  of  the  dia- 
phragm. It  passes  down  along  the  thorax  at  an  acute 
angle  with  the  ribs,  in  the  shape  of  a  straight  horizontal 
shadow  or  a  wavy  undulation,  starting  on  either  side  at 
about  the  sixth  intercostal  space,  and  descending  several 
interspaces,  sometimes  as  far  as  the  costal  margin,  dur- 
ing a  deep  inspiration.  During  expiration  it  again  rises 
to  its  original  position.  During  forced  respiration  the 
excursions  of  the  diaphragm  comprise  two  or  three  in- 
tercostal spaces,  2f  to  2|  inches  being  the  medium  ;  in 
superficial  breathing,  on  the  other  hand,  no  more  than 
one  interspace  or  one  and  a  half  are  covered.  The 
visible  motion  of  the  diaphragm  may  comprise  the  en- 
tire breadth  of  the  sides  of  the  thorax,  being  evident 
from  the  axillar  line  to  the  margin  of  the  sternum  when 
the  patient  is  recumbent  on  his  back,  or  from  the  hinder 
axillar  line  to  the  vertebral  column  when  he  is  resting 
on  his  chest,  or  better  still  on  knees  and  elbows. 
Sometimes  this  phenomenon  is  more  plainly  marked  on 
the  right  side  than  on  the  left,  but  I  have  also  observed 
the  reverse. 

.\lthough  a  practised  eye  will  be  able  to  make  it  out, 
whatever  the  position  of  the  body,  yet  it  is  most  plainly 
visible  when  the  patient  is  so  placed  that  the  part  of 
the  body  concerned,  i.e.,  the  costal  region  below  the 
seventh  rib,  receives  the  most  light  (if  possible  in  a  tan- 
gential direction).  For  this  purpose  the  patient  is 
made  to  lie  on  his  back,  his  head  but  slightly  sup- 
ported, opposite  the  window  to  which  his  face  is  turned, 
while  at  a  distance  of  three  or  four  feet  the  observer, 
with  his  back  toward  the  window,  scans  his  chest  at  an 
angle  of  forty-five  degrees.  Now,  when  the  patient 
fetches  a  deep  breath  a  broad  shadow  is  seen  to  travel 
down  and  up,  coincident  with  each  inspiration  and  ex- 
piration ;  no  one,  after  having  one  time  plainly  seen 
this,  can  fail  to  easily  recognize  it  in  future.  I  wish  to 
emphatically  state  here,  in  the  face  of  prejudice,  that 
this  is  not  a  matter  of  fine  clinical  distinctions,  but  that 
I  am  speaking  of  a  phenomenon  which  whoever  cares 
to  see  cannot  help  seeing.  The  only  conditions  to  be 
observed  are  :  horizontal  position  of  the  patient,  good 
light,  and  deep  breathing. 

From  a  scientific  point  of  view  it  is  highly  interesting 
to  be  able,  accurately  and  without  any  trouble,  to 
watch  the  alternate  movements  of  the  diaphragm.  But 
the  subject  has  a  practical  bearing,  too,  in  regard  to 
medical  instruction,  both  physiological — the  concealed 
action  of  the  diaphragm,  hitherto  visible  only  in  vivi- 
sected animals,  being  now  rendered  apparent  to  the  stu- 
dent in  the  live  human  being — and  clinical  ;  the  be- 
ginner being  enabled  to  himself  verify  the  correctness 
of  his  percu.ssing,  instead  of  blindly  acquiescing  in  the 
corrections  of  his  teacher  on  the  strength  of  the  latter's 
authority. 

The  appreciation  of  another  important  clinical  fact, 
the  respiratory  shifting  of  the  abdominal  organs,  is  great- 
ly advanced  by  our  phenomenon.  Among  these  organs 
those  situated  immediately  beneath  the  diaphragm  par- 
take of  its  motions  and  may  in  their  turn  rhythmically 
displace  others.  These  movements  can  be  seen  and 
felt.     They  are  owing,  needless  to  say.  to  the  muscular 


902 


MEDICAL    RECORD. 


[December  28,    1895 


action  of  the  midriff.  Where  its  mobility  is  diminished 
or  absent,  there  the  motion  of  these  organs  is  corre- 
spondingly arrested.  This  knowledge  has  been  turned 
to  a  diagnostic  account  long  ago  in  regard  to  liver  and 
spleen,  and  recently  in  regard  to  the  kidneys.  It  is  in- 
teresting to  observe  both  movements,  of  the  diaphragm 
and  of  the  organs,  simultaneously,  the  former  by  sight, 
the  latter  by  sight  or  touch.  Thus  the  stomach,  or  a  coil 
of  the  intestine,  or  the  liver,  may  be  seen  to  move  in  time 
with  the  diaphragm  ;  the  same  observation  is  made  in  bi- 
manual palpation  of  the  kidneys.  If,  with  a  pencil,  you 
mark  on  the  skin  the  limits  of  the  visible  excursion  of  the 
diaphragm,  the  upper  line  (about  over  the  seventh  rib) 
denotes  the  expiratory  position  ;  the  lower  line  (ninth 
rib,  about)  the  inspiratory.  Both  correspond  to  the 
inferior  margin  of  the  lungs,  or  in  other  words  to  the 
superior  surface  of  the  liver.  The  normal  excursion 
of  the  diaphragm  amounting  to  2|  to  2f  inches  on  an 
average,  you  can  tell  at  a  glance  whether  the  lungs  ex- 
pand in  the  normal  way,  and  whether  their  margins  oc- 
cupy the  right  position. 

A  great  saving  of  time  is  thus  effected  by  this  method 
of  examination  ;  the  volume  of  the  lungs  is  easily  as- 
certained, and  the  vital  capacity  gauged  more  rapidly 
and  better  than  by  measuring  the  chest  circumference 
and  the  amount  of  air  aspirated.  A  smaller  excursion 
than  the  average  two  and  a  half  inches  bears  a  pathog- 
nomonic significance,  provided  the  patient  drew  as 
deep  a  breath  as  he  could.  Mostly  in  these  cases  em- 
physema is  present,  whereby  the  diaphragm's  position 
is  one  or  two  intercostal  spaces  further  down  (in  the 
mamillary  line),  or  even  as  low  as  the  costal  margin, 
where  it  is  never  found  under  normal  conditions.  An 
impeded  excursion  of  the  diaphragm  may  be  further, 
owing  to  general  debility — it  is  not  found  depressed  in 
that  case,  but  at  its  normal  altitude — or  to  circum- 
stances allowing  of  costal  respiration  only.  Thus  it 
will  be  greatly  diminished  in  the  last  months  of  preg- 
nancy. In  very  fleshy  individuals  it  is  mostly  not  visi- 
ble at  all. 

It  is  in  unilateral  trouble  that  my  method  achieves 
its  greatest  triumphs,  the  difference  between  the  dia- 
phragm's movements  on  either  side  striking  the  eye. 
If  the  phenomenon  is  totally  absent  on  one  side,  where- 
as on  the  other  it  is  normal  in  extent  and  situation, 
then  there  is  either  a  considerable  effusion  of  liquid  or 
of  aiy  present  in  one  pleural  cavity  (empyema,  pleu- 
ritis  exudativa,  hydro-,  hsemato-,  pneumo  thorax),  or 
else  we  have  a  case  of  pneumonia  of  the  inferior  lobe. 
In  the  latter  affection,  as  well  as  in  empyema  and  in 
pyo-pneumo-thorax,  the  action  of  the  diaphragm,  owing 
to  the  infiltration  of  its  muscular  substance,  is  entirely 
suspended  on  the  diseased  side  ;  in  the  case  of  serous 
effusion,  slight  motions  of  the  diaphragm  are  often  vis- 
ible abnormally  far  downward. 

At  any  rate,  one  glance  at  the  chest  is  enough  to  tell 
whether,  and  to  what  extent,  the  muscle  is  confined  in 
its  movements.  In  the  case  of  extensive  attachment 
of  the  diaphragm  to  the  lungs,  or  to  the  spleen  and  the 
liver,  and  especially  in  cicatricial  retraction  of  the 
thorax,  the  motion  will  be  still  visible  on  one  side, 
though  much  retracted.  Where  there  is  an  area  of 
dulness  in  the  lower  part  of  the  thorax  not  owing  to 
the  liver  or  the  spleen,  and  where  the  phenomenon  is 
visible  notwithstanding,  though  to  a  lesser  degree, 
above  the  dulness,  there  can  be  no  doubt  as  to  the 
subphrenic  position  of  the  trouble — a  subphrenic  ab- 
scess thus  being  revealed.  Further  evidence  as  to  the 
nature  of  the  dulness  is  obtained  by  a  probatory 
puncture.  If  pus  is  then  produced  the  diagnosis  is 
assured. 

In  the  presence  of  tumors  within  the  thorax,  the  dia- 
phragm, if  visible  at  all,  will  be  seen  very  low  down. 
In  several  cases  of  mediastinal  and  pulmonary  tumor 
we  were  able  to  distinctly  perceive  it,  though  its  mo- 
tion was  much  hampered  ;  this  was  the  case  especially 
where  the  disease  was  situated  in  the  inferior  lobe.     In 


the  presence  of  large  tumors  of  the  spleen  and  of  the 
liver  we  have  in  many  cases  seen  the  phenomenon  most 
plainly  ;  once  only  was  it  totally  lacking,  in  a  case  of 
enormous  melanotic  degeneration  of  the  liver.  (The 
organ  weighed  36  pounds.)  It  was  never  to  be  per- 
ceived in  extensive  ascites,  diffuse  peritonitis,  or  in 
ileus  with  considerable  meteorisms  of  the  intestine. 
In  one  case  of  acquired  diaphragmatic  hernia  there 
was  clear  tympanitic  percussion  sound  above  the  visible 
phenomenon,  whereas  in  pneumo-thorax  it  is  invisible, 
owing  to  the  inspiratory  in-drawing  of  the  intercostal 
spaces  being  rendered  impossible.  In  the  same  way, 
there  will  be  no  trace  of  the  phenomenon  in  unilateral 
paralysis  of  the  phrenic  nerve. 

My  method  is  of  great  service  in  judging  of  the  ac- 
tion of  the  lungs  after  pleuritic  effusions  and  after  in- 
juries. The  more  pleuritic  adhesions  have  formed  and 
the  firmer  they  are,  the  less  clearly  is  it  visible  ;  by  com- 
paring it  with  the  other  side  we  get  a  pretty  definite 
idea  of  the  degree  to  which  the  lung's  action  is  inter- 
fered with.  On  the  other  hand,  in  many  doubtful 
cases  of  the  after-effects  of  accidents,  it  has  been  possi- 
ble in  this  way  to  ascertain  with  positive  certainty 
that  there  was  no  impediment  to  respiration,  i.e.,  to  the 
inflation  and  mobility  of  the  lungs.  1  have  thus  re- 
peatedly in  forensic  cases  where  the  injured  party 
claimed  to  be  unable  to  breathe  properly  (for  instance 
in  consolidated  fractures  of  the  ribs),  found  occasion 
to  expose  a  fraud  on  the  ground  of  our  phenomenon 
showing  no  alteration.  It  serves  as  a  reliable  guide, 
too,  in  forming  an  unbiassed  judgment  in  regard  to 
therapeutic  effects,  especially  in  pneumo-therapeutics, 
improvement  in  the  action  of  the  lungs  being  infallibly 
discerned.  In  many  instances  of  emphysema  and  pleu- 
ritic effusion  treated  by  means  of  a  Steinhoff  appara- 
tus, we  were  thus  enabled  to  gauge  the  measure  of  suc- 
cess achieved.  The  superior  and  inferior  limits  of  the 
"phenomenon  '"  should  be  marked  with  lunar  caustic 
at  the  beginning  of  a  treatment,  then  in  emphysema  you 
may,  if  successful,  see  the  phenomenon  extend  beyond 
these  lines  in  a  couple  of  weeks. 

Since  I  made  the  discovery,  in  1891,  that  this  phe- 
nomenon was  a  regular  physiological  occurrence  com- 
mon to  all  human  beings,  all  the  patients  of  my  poly- 
clinic (to  the  number  of  5,000  to  6,000  a  year)  have  been 
examined  with  a  view  to  this,  and  it  has  been  found  in 
every  case  unless  counteracted  by  some  morbid  proc- 
ess or  other.  I  am  sorry  to  see  that  my  efforts  to 
promulgate  this  knowledge '  have  not  so  far  attracted 
that  amount  of  attention  which  the  matter  undoubtedly 
deserves.  I  trust  that  all  medical  men  who  will  take 
the  small  pains  to  really  see  this  phenomenon,  will  ap- 
preciate it  and  give  it  a  place  alongside  of  the  other 
methods  of  physical  diagnosis. 


Exercising  the  Chicago  Police.  —  Dr.  Hawley,  of 
Chicago,  has  obtained  the  consent  of  Mayor  Swift  and 
the  Chief  of  Police  to  the  introduction  of  a  system  of 
athletic  drill  into  the  Police  Department,  for  the  pur- 
pose of  developing  agility,  skill,  and  endurance  among 
the  policemen  of  the  city,  and  increasing  their  strength. 
It  is  hoped,  also,  that  the  general  health  of  the  force 
will  be  increased,  so  that  there  will  be  a  smaller  aggre- 
gate loss  from  sick-leave. 

To  Suppress  Press  Notices  of  Suicide. — It  is  stated 
in  the  Hospital  that  the  Medical  Society  of  Berne  has 
inaugurated  a  scheme,  which  it  would  be  as  well  if 
other  places  would  also  adopt ;  this  is  the  suppression 
of  press  notices  of  cases  of  suicide.  It  has  been  ob- 
served that  suicides  have  so  frequently  been  "sug- 
gested "  by  these  notices  that  the  measure  seems  a 
salutary  one  from  this  point  of  view. 

'  Deutsche  medic.  Wochensctirifl,  189a,  No.  13,  and  1893  (W. 
Becher). 


December   28,  1895] 


MEDICAL   RECORD. 


903 


A  STUDY  OF  THE  INFECTIOUSNESS  OF 
THE  DUST  IN  THE  ADIRONDACK  COT- 
TAGE  SANITARIUM. 

By  IRWIN  H.  HANCE,  M.D., 

NEW  YORK. 

Associated  with  our  increasing  knowledge  of  germ 
life  and  the  practical  application  of  bacteriology  tow- 
ard solving  the  causes  of  disease  and  tracing  back  to 
its  fountain-head  the  source  of  any  infection,  there  exists 
among  the  laity  and  also  some  physicians  an  intense  fear, 
sometimes  amounting  to  mania,  that  they  are  continu- 
ally exposing  themselves  to  an  invisible  danger  which 
is  lurking  about  them  in  the  food  they  eat,  the  water 
they  drink,  and  the  air  they  breathe.  The  most  dreaded 
nightmare  of  them  all  is  the  fear  of  becoming  infected 
with  the  germs  of  tuberculosis.  No  one  can  deny  the 
presence  of  this  danger  in  a  great  many  places  ;  but 
oftentimes  in  the  places  where  popular  opinion  consid- 
ers it  greatest  it  is  actually  less  to  be  dreaded  than  in 
other  localities  where  with  the  external  appearances  of 
refinement  and  cleanliness  there  exist  the  most  favor- 
able conditions  for  the  permanent  lodgement  of  infec- 
tious material  in  the  dust. 

This  fear  of  infection  from  tubercular  germs  has  be- 
come so  general  and  reached  such  a  climax  that  the 
poor  tubercular  patient  whose  mental  and  physical  suf- 
fering is  already  extreme  must  carry  around  with  him 
an  added  burden  of  anxiety  and  care,  since  people  look 
upon  him  as  a  dangerous  character  in  the  home  or  com- 
munity. It  is  within  the  writer's  experience  that  par- 
ents have  refused  to  have  their  children  return  home 
lest  some  other  member  of  the  family  might  be  infected; 
and  men  have  found  it  difficult  to  hire  flats  in  New 
York  City  or  Brooklyn  when  they  wished  to  make  a 
home  for  a  dying  wife  or  child.  In  one  instance  a  phy- 
sician wrote  to  have  his  former  patient  kept  in  Saranac 
Lake  until  she  died,  as  he  thought  that  was  the  only 
way  of  avoiding  possible  infection  for  the  other  mem- 
bers of  her  family  ;  in  the  end  she  was  taken  home  to 
die  in  a  hospital. 

S'lch  heartless  actions  are  due  to  a  great  extent 
to  the  ignorance  of  people  concerning  the  real  dangers 
of  infection,  and  their  lack  of  knowledge  as  to  how 
they  can  be  avoided.  In  their  blind  ignorance  they 
think  to  avoid  an  apparent  danger,  little  dreaming  how 
much  more  frequent  and  dangerous  are  the  daily  ex- 
posures to  the  same  diseases  in  their  social  intercourse, 
travels  and  amusements. 

For  these  reasons  it  has  seemed  a  fitting  time  to  make 
some  experiments  on  this  subject  to  determine  how 
great  the  danger  of  infection  is  in  a  large  community 
of  consumptives  where  all  sanitary  measures  are  en- 
forced as  regards  the  care  and  disinfection  of  sputa. 

Two  facts  have  been  positively  affirmed  by  previous 
experiments  :  i.  Buildings  for  consumptives,  prisons, 
private  dwellings,  and  public  conveyances  do  become 
j  infected  with  tubercular  germs.  2.  A  tuberculous  pa- 
tient is  absolutely  free  from  the  danger  of  infecting 
others  by  contact ;  it  is  the  product  of  their  excre- 
tions which  is  the  dangerous  factor.  Destroy  these 
and  the  house  or  home  of  the  consumptive  is  no  longer 
dangerous. 

All  investigators  have  established  the  first  of  these 
two  statements,  none  more  thoroughly  than  Cornet,' 
reference  to  whose  work  will  be  made  later  in  this  pa- 
per. 

The  second  statement  has  also  been  repeatedly 
proven  ;  but  among  the  laity  and  also  some  physicians 
it  is  so  dimly  comprehended  that  time  will  not  be  lost 
in  quoting  some  of  the  investigators  and  their  experi- 
ments. 

Two  Italian  investigators,  Celli  and  Guarnieri,  found 
the  expired  air  of  tubercular  patients  free  from  tuber- 
cle bacilli  ;  and  also  that  air  blown  by  a  bellows  over 

'  Comet :  Die  Verbreitung  der  Tuberkelbacillen^Iausserhalb  des 
Korpers.     Zeitschrift  f.  Hygii  n»,  B.  5.     1888. 


and  through  sputum  very  rich  in  bacilli  remained  free 
from  bacilli. 

Fr.  Miiller,'  Sormain  and  Brugnatelli,'  Charrin  and 
Karth,^  Cadeac  and  Malet,^  all  found  the  expired  air 
non-infectious. 

For  two  months  Tappeiner  '  had  a  woman  with  ad- 
vanced phthisis  cough  through  an  opening  into  a  wood- 
en box  in  which  were  two  guinea-pigs  ;  at  the  end  of 
that  time  they  were  killed  and  found  sound. 

Cornet^  states  that  the  expired  air  "  never  and  under 
no  conditions  contains  tubercle  bacilli  or  their  spores." 

Since,  then,  personal  contact  with  a  tuberculer  patient 
is  free  from  danger,  whence  is  the  source  of  the  infec- 
tious material  ?  For  all  practical  purposes  it  is  con- 
tained in  the  sputum,  which  becomes  dangerous  and 
capable  of  infecting  when  dried  and  pulverized.  In 
its  moist  state  it  is  harmless  ;  therefore,  if  tubercular 
patients  are  careless  and  dirty  about  their  sputum  they 
are  dangerous,  not  alone  to  themselves,  but  to  all  who 
come  in  contact  with  them. 

Knowing  these  facts,  and  taking  pains  to  make  them 
clear  to  the  patients  in  the  sanitarium,  it  may  well  be 
said,  after  five  years  of  personal  observation,  that  the 
rules  concerning  the  care  and  disinfection  of  sputum 
have  been  since  its  inception  and  are  to-day  most  care- 
fully carried  out  there.  Occasionally  a  very  sick  or 
careless  patient  does  transgress  the  rules,  but  this  oc- 
curs very  seldom  for  such  a  large  institution. 

In  order  to  test  the  efficacy  of  the  system,  a  com- 
plete examination  of  the  group  of  buildings  was  made, 
some  of  which  have  been  occupied  eleven  years  by 
consumptives.  In  every  instance  dust  from  the  dark- 
est and  most  likely  to  be  infected  spots  was  taken  ;  for 
if  infected,  the  management  was  most  desirous  of  know- 
ing it. 

The  experiments  were  done  at  Dr.  Trudeau's  request 
and  under  his  supervision  at  the  Saranac  Laborator)' 
for  the  Study  of  Tuberculosis.  They  were  arranged  in 
two  groups,  the  details  of  which  were  as  follows  :  First 
group  of  four  buildings  consisted  of  the  main  build- 
ing (parlor,  sitting-room,  and  public  library)  ;  the  in- 
firmary, where  all  the  acutely  sick  are  sent  ;  the  "  Red 
Cottage,"  which  was  the  oldest  on  the  grounds,  and 
the  "  Penfold,"  the  most  recently  built  cottage.  One 
square  yard  of  dust  from  each  of  these  buildings  was 
collected  and  inoculated  into  ten  guinea  pigs.  Second 
group  consisted  of  thirteen  cottages,  from  each  of 
which  half  a  square  yard  of  dust  was  taken  and  in- 
oculated into  three  guinea  pigs  ;  thus  the  second  batch 
of  pigs  received  proportionately  a  larger  quantity  of 
dust  than  the  first. 

The  technique  was  as  follows  :  Sterilized  cotton 
swabs  moistened  with  sterilized  water  were  used  to 
collect  the  dust  from  the  walls,  backs  of  pictures,  and 
darkest  corners  of  the  rooms  ;  i  to  2  c.c.  more  of  steril- 
ized water  was  added  to  cleanse  the  cotton  of  the  dust. 
The  swabs  were  then  stjueezed  in  a  piece  of  coarse 
sterilized  gauze,  and  an  eijual  share  of  the  whole  dust, 
suspended  in  water,  inoculated  into  each  guinea  pig  ; 
all  inoculations  were  made  into  the  abdominal  walls, 
extraperitoneal.  Save  for  any  infections  in  the  dust,  all 
other  sources  of  contamination  were  excluded  by  thor- 
ough antiseptic  precautions. 

The  animals  were  kept  from  one  to  three  months 
and  then  killed.  Any  enlarged  glands  or  suspicious 
areas  were  carefully  examined  for  tubercle  bacilli,  and 
the  diagnosis  of   tuberculosis   only  made  when  these 

I  Fr.  M Ciller:  Ucbcr  die  diagnostischc  Bedeutung  der  Tuberkel- 
bacillcn.  WUrzlnirg.  1883.  Verhandlungen  der  mcd.  phys.  Gesell- 
schafl  zu  ^Vur7.I.u^^^  N.  F.  Bd.  viii.  .,       „      ,„    , 

'  Sormain  and  Brugnatelli  ;  Sludi  sperimcntali  sub  bacillo  dclla  tu- 
berculiisi,  1883.  .  ... 

» Charrin  and  Karlh :  Virulence  de  la  tuberculose  suivant  les  hu- 
meurs  et  les  tissues  dcs  tubcrculeaux.     Revue  de  Mt-d.,  1885.  No.  8. 

<  Cadeac  and  Malet  :  litude  experimcntale  dc  la  transmission  de  la 
luberculote  par  I'air  expire-  et  lalmosphtre.     Revue  de  Mcd  ,  1887, 

No   7 

'Tappeiner:  Meran  zur  Frage  der  ConlagiositUt  der  Tuberkeln. 
Archiv.  fur  Medicin.  Bd  xxix..  S.  59.     , 

«Corntt:  Loco  citato. 


904 


MEDICAL    RECORD. 


[December  28,  1895 


were  found.  In  the  painstaking  details  of  these  pro- 
longed experiments,  the  writer  wishes  to  express  the 
appreciation  of  the  assistance  given  him  by  Dr.  S.  W. 
Hewetson,  who  aided  him  materially  in  the  work. 

The  results  are  shown  in  the  following  table,  which 
is  arranged  under  the  same  heading  as  in  Cornet's  work 
in  order  to  compare  the  results  : 


11 

Of  which  Died  of 

Died  of  Infectious 
Diseases. 

•ta 

Places. 

Tubercu- 
losis. 

Other  In- 
fectious 
Diseases. 

All  Told. 

In  per 
centage  to 
Inoculated 
Animals. 

ll 

of  Dust 
Used. 

Main  Building: 
Parlor,  Sitting 
Room  and  Li- 
brary  

Infirmary 

Red  Cotuge. . 

Penfold 

Loomis 

McAlpin 

First  Stokes  . . 

Second  Stokes 

Green 

Lea    

3 
3 
3 
3 
4 
3 
3 
3 
3 
3 
3 
3 
3 

5 

3 

0 

3 
5 

10         ,     9 
30             7 
50         ,     5 

0         '     3 
0         1     3 
0             3 
0             3 
0               4 

Sq.  Yard. 

>i 

H 

Spruce 

Trudeau 

Pine 

Sunshine 

Schiff    

Dodge 

Strauss  

Out-building. . 

3 
3 
3 
3 

3 
3 

\ 

a 

Thus  of. . . 

8. 

5 

4 

9 

"•" 

72 

In  all  81  pigs  were  inoculated  with  from  2  to  3  c.c. 
of  sterilized  water  with  the  dust  in  suspension  ;  of  these 
only  4  or  4.9  per  cent,  died  of  other  infectious  diseases 
on  the  third  to  sixth  day  and  5  of  tuberculosis.  These 
five  constituted  just  one-half  of  the  number  of  pigs  in- 
oculated with  dust  from  the  "  Red  Cottage,"  a  small 
cottage  holding  two  patients,  always  occupied  by  the 
sickest  men,  one  of  whom  had  been  complained  of  by 
his  room-mate  for  spitting  around  the  cottage.  The 
five  pigs  lived  sixty  days,  were  then  killed,  and  although 
tuberculosis  was  present  in  the  omentum,  spleen,  liver, 
and  lungs,  they  were  well  nourished  and  strong,  appar- 
ently showing  a  diminished  virulency  of  the  infecting 
germs. 

The  infection  of  this  cottage  demonstrates  two  things  : 
first,  how  easily  a  patient  by  carelessness  and  disobedi- 
ence of  rules  (probably  due  to  his  very  weak,  sickly 
condition)  may  render  a  cottage  dangerous  to  himself 
as  well  as  to  others  ;  second,  that  the  technique  of  the 
experiment  was  faultless. 

It  brings  out,  however,  in  stronger  contrast  the  suc- 
cessful results  of  the  experiment  as  a  whole,  since  six- 
teen buildings  out  of  seventeen,  inhabited  by  consump- 
tives for  so  long  a  period  as  ten  years,  were  absolutely 
free  from  infectious  material.  This  is  the  more  strik- 
ing when  we  consider  the  great  vitality  and  virulence 
of  the  tubercle  bacilli,  .Stone  '  having  proven  by  inocu- 
lation of  rabbits  that  dried  sputum  after  the  lapse  of 
three  years  was  capable  of  inducing  tuberculosis. 

With  this  array  of  negative  results  a  most  conclusive 
proof  is  given  that  a  body  of  consumptives  need  not 
infect  the  houses  they  occupy  when  their  excretions 
are  destroyed.  To  attain  this  end  it  requires  that  each 
new  patient  should  be  carefully  instructed  concerning 
the  disposal  of  his  sputum,  and  close  supervision  of 
them  all  be  maintained. 

Then  each  patient  feels  that  he  endangers  himself 
as  well  as  the  others  by  not  obeying  the  rules  ;  if  any- 
one becomes  careless  in  the  matter  it  is  quickly  reported 
to  the  medical  authority  by  one  or  more  members  of 
the  sanitarium,  everyone  appreciating  fully  the  grave 
consequences  of  possibly  infecting  the  cottages  or  pub- 
lic rooms. 

The  methods  used  are  to  burn  all  cuspidors  daily, 
and  the  Japanese  napkins  as  soon  after  using  as  possi- 

'  A.  K.  Stone  ;  .American  Journal  of  the  Medical  Sciences,  March, 


ble  ;  never  to  expectorate  except  into  the  large  sanitary 
cuspidors  when  about  the  main  buildings,  or  the  small 
individual  hand  cuspidors.  Paper  napkins  are  used  in 
the  infirmary  in  hemorrhage  cases  or  where  patients 
are  too  feeble  to  get  up  on  their  elbows  so  as  to  spit  into 
the  cuspidor  ;  these  are  used  but  once,  then  placed  in 
a  pasteboard  receptacle  and  the  whole  thing  burned 
several  times  a  day.  During  the  greater  portion  of  the 
year  fires  are  burning  in  every  cottage,  and  the  patients 
burn  everything  in  the  stove  or  fireplace. 

In  summer  a  barrel  with  some  moist  sawdust  in  the 
bottom  is  placed  in  an  out-building,  and  the  cuspidors 
and  napkins  are  carried  to  this  barrel,  which  is  satu- 
rated with  kerosene  and  burned  three  times  a  week. 
One-fourth  of  a  square  yard  of  dust  from  this  building 
was  inoculated  into  one  guinea-pig,  which  remained 
healthy.  A  properly  constructed  crematory  is  much 
needed,  but  too  costly  at  present  to  build.  The  cuspidors 
used  are  made  by  Seabury  &  Johnson,  and  of  two  sizes  : 
one,  the  hand  cuspidor,  for  individual  use,  and  the  other, 
a  much  larger  size,  for  the  piazzas  and  public  rooms. 
The  latter  are  placed  in  covered  wooden  boxes  about 
four  feet  from  the  floor  ;  these  are  easily  taken  down 
and  cleansed.  By  this  arrangement  patients  cannot 
spit  at  a  cuspidor  from  a  distance,  and  the  mass  of 
sputum  is  not  blown  over  the  edges  of  the  cuspidor  by 
the  wind,  as  happened  at  first  when  uncovered  cuspi- 
dors were  placed  upon  the  floors. 

It  is  perhaps  too  much  to  suppose  that  all  particles 
of  infectious  materials  are  thus  destroyed  ;  where 
seventy  to  eighty  small  hand  cuspidors  are  in  daily  use 
there  may  be  some  slight  soiling  of  a  stand  or  the  linen 
covers  on  which  the  cuspidors  are  placed  ;  also  in 
coughing  some  small  masses  of  sputum  may  be  vio- 
lently expelled.  These  sources  of  contamination  must 
be  small,  and  are  fraught  with  less  danger  by  frequently 
washing  the  tin  frames  for  the  cuspidors,  and  the  cot- 
tage plan  of  housing  patients,  thereby  avoiding  the  evils 
of  overcrowding. 

Besides  the  destruction  of  the  sputum,  other  factors 
equally  important  have  served  as  auxiliary  means  of 
keeping  the  cottages  free  from  infection,  not  alone  with 
tubercle  bacilli,  but  also  other  germs  :  these  are  the  con- 
struction of  the  cottages,  which  are  built  so  as  to  insure 
thorough  ventilation  ;  the  immense  volume  of  airspace 
allotted  to  each  patient — this  is  secured  by  large  open- 
ings from  the  various  bedrooms  into  the  sitting-room, 
which  communicates  with  the  outside  air  by  transoms 
opening  above  the  piazza  roofs  ;  the  smooth,  hard- 
wood wainscoating,  7  to  8  feet  high,  around  the  whole 
cottage,  permitting  of  thorough  cleansing  with  soap 
and  water  ;  the  absence  of  wall-papers,  the  upper 
walls  and  ceilings  being  heavily  sized  and  then  painted, 
rendering  these  also  easily  cleansed  ;  the  plain,  simple 
furnishings — iron  hospital  beds,  rugs,  and  hard-wood 
floors,  and  as  few  tapestries  as  possible  ;  lastly,  the 
large  area  of  window  surface,  allowing  the  sun's  rays 
and  strong  light  free  access  to  all  parts  of  the  cottage. 
Added  clinical  proof  of  the  non-infectious  character  of 
the  dust  may  be  deduced  from  the  fact,  that  not  one  of 
the  twenty  to  twenty-five  attendants  has  ever  developed 
tuberculosis  ;  and  also  that  no  patient  who  was  ad- 
mitted suffering  from  pulmonary  disease  without  the 
bacilli  being  present  ever  subsequently  developed 
them. 

How  do  these  results  compare  with  those  of  other 
experimenters  ? 

Heron '  inoculated  one  hundred  guinea-pigs  with 
dust  taken  from  various  sources  in  the  City  of  London 
Hospital  for  Diseases  of  the  Chest.  In  the  greater 
number  of  experiments  "  a  piece  of  dust  was  introduced 
into  the  sub-peritoneal  tissue  ;  "  in  some  a  solution  of 
dust  in  sterilized  water  was  injected  into  the  pigs. 
Twenty-six  pigs,  twenty-six  per  cent.,  died  of  "either 
intense  inflammation  spreading  from  site  of  inoculation 

>  G.  A.  Heron  :  The  Relation  of  Dust  in  Hospitals  to  Tuberculous 
Infection.     Lancet,  No.  3,671,  January  6,  1894. 


December  28,  1895] 


MEDICAL  RECORD. 


905 


or  septicaemia."  Of  the  remaining  seventy-four,  two 
pigs  (both  inoculated  with  dust  in  solution),  or  2.7  per 
cent.,  died  of  tuberculosis.  The  dust  in  each  case 
came  from  '"the  tower  of  the  hospital  which  acts  as 
up-cast  shaft,"  and  was  dark  and  unventilated.  It 
would  seem  as  though  the  implantation  of  a  piece  of 
dust  was  too  small  to  place  too  great  reliance  on  nega- 
tive results. 

Cornet,'    seven    years   ago,    gave    us   the  following 
table  : 

=  ■3        OfTheseDiedof        D«<lof  Infecuou.^ 


Other  In- 
fectious    All  Told. 
Diseases. 


In  seven  hospitals 94 

In    three    insane    asy- 

In  two  prisons 14 

Inhalation  rooms 4 

Dwellings      of     private 

tubercular  patients . .  .     1 70 
Polyclinic,  orphan   asy- 
lum, etc 2S 

Surgical  wards 3 

Streets  and  hygienic  in- 

Streets  alone 

Thus  of 39a 


In  the  hospitals  47.6  per  cent,  of  the  pigs  not  dying 
of  acute  infection  developed  tuberculosis  ;  in  private 
dwellings,  43.6  per  cent.  ;  in  insane  asylums,  17.6  per 
cent. 

M.  Kirchner,"  in  examining  the  garrison  lazaret  of 
one  of  the  army  stations,  experimented  on  forty-two 
pigs  by  inoculation  with  dust  suspended  in  bouillon  or 
implantation  of  dust-infected  sponge  in  abdomen. 
Twenty-six,  or  61.9  per  cent.,  died  from  the  operation 
and  infection  of  wound.  Sixteen,  or  38.1  percent., 
remained  alive.  One  of  the  sixteen  developed  tuber- 
culosis. 

The  writer  secured  the  dust  from  a  large  city  hos- 
pital out  of  the  wards  occupied  by  male  and  female 
tubercular  patients.  From  male  ward  were  inoculated 
three  pigs  with  one-half  square  yard  of  dust.  From 
female  ward  were  inoculated  three  pigs  with  one-half 
square  yard  of  dust.  From  female  ward  were  again  in- 
oculated three  pigs  with  little  less  than  one-half  square 
yard  of  dust.  Of  male  ward  pigs,  one  died  ;  of  female 
(first  lot)  all  three  died  ;  of  second  lot  one  died  of  an 
intense  cellular  inflammation  much  resembling  a  malig- 
nant oedema.  All  these  died  on  the  first  to  third  day 
after  inoculation.  The  four  living  pigs  were  killed  in 
sixty  days,  and  one  of  those  inoculated  with  dust  from 
female  ward  had  well  advanced  tuberculosis  ;  thus, 
twenty-five  per  cent,  of  the  pigs  remaining  alive  de- 
veloped tuberculosis,  while  55.5  per  cent,  died  of  acute 
infection,  some  of  which  might  have  developed  tuber- 
culosis. In  these  wards  the  beds  werecarbolized  once 
a  week  ;  the  floors  washed  daily  and  scrubbed  twice  a 
week  ;  the  walls  rekalsomined  every  six  weeks,  and 
Seabury  &  Johnson's  cuspidors  used,  which  were 
changed  twice  a  day.  In  the  female  wards,  however, 
long  pieces  of  cheese-cloth  were  given  to  the  sickest 
and  weakest  patients,  which  were  used  as  a  roll  to  spit 
into,  and  would  last  a  patient  from  four  to  eight  hours. 
This,  in  all  probability,  was  the  source  of  infection. 

A  close  perusal  of  these  results  shows  that  the  care- 
ful disinfection  of  the  sputum  has  been  productive  of 
good  results,  but  not  yet  fully  satisfactory,  since  in  each 
experiment  the  dust  has  been  infected  with  tubercle 
bacilli.  Of  far  more  importance,  however,  is  the  fact 
that  the  dust  was  infected  to  such  a  virulent  degree 
with  other  germs  ;  to-day  we  know  how  much  more 
serious  are  the  cases  of  tuberculosis  with  mixed  infec- 

'  Comet ;  loco  citato. 

"  M.  Kirchner :  Einige  Untersuchungen  von  Staub  auf  Tuberkel- 
bacillen.     Zeitschrift  f.  Hyg.  u.  Inf.  Krank,  B.  19.  S.  153.  1895. 


tion  than  are  those  of  simple  tuberculosis  ;  that  the 
latter  may  quickly  be  changed  into  the  former  when 
patients  must  live  in  an  atmosphere  laden  with  infec- 
tious germs  is  scarcely  to  be  wondered  at,  inasmuch 
as,  according  to  the  above  experimenters,  three  hun- 
dred and  sixteen  out  of  five  hundred  and  forty-three 
inoculated  pigs  (or  58.1  per  cent.)  were  killed  by  some 
form  of  infectious  disease,  the  germs  of  which  were 
contained  in  the  dust. 

Mixed  infection  is  a  most  important  factor  in  rela- 
tion to  a  tubercular  patient's  condition,  whether  this 
arise  from  without  by  inhaling  the  germs  of  a  heavily 
infected  atmosphere,  or  is  the  result  of  an  inflammatory 
process  in  the  lungs.  To  it  may  be  attributed  the  sud- 
den and  rapid  changes  for  the  worse  in  patients,  who 
were  doing  well  under  proper  climatic  surroundings, 
after  a  sojourn  of  two  to  four  weeks  in  a  large  city. 

May  not  the  condition  of  "  hospitalism  "  met  with 
among  the  internes  of  the  large  hospital,  and  so  fre- 
quently the  precursor  of  tuberculosis,  also  be  due  to  the 
same  cause  ? 

A  few  words  concerning  the  best  means  of  disinfect- 
ing sputum.  Fire  is  unquestionably  the  very  best  dis- 
infectant, but  patented  cuspidors  are  expensive  ;  in 
place  of  these  any  cheap  material,  old  pieces  of  linen, 
Japanese  napkins,  or  even  pieces  of  newspaper  can  be 
used.  If  such  are  made  use  of  they  never  should  be 
used  but  once,  then,  after  being  placed  in  some  suit- 
able receptacle,  they,  with  the  receptacle,  should  all  be 
burned  together.  In  a  word,  nothing  into  which  a 
patient  has  expectorated  should  ever  be  handled  again, 
and  should  not  be  allowed  to  dry.  M.  Kirchner'  has 
shown,  by  inoculation-experiments,  that  sterilization  for 
one-half  hour  is  a  thoroughly  efficacious  disinfectant. 

Dry  heat  (100°  C),  however,  must  be  applied  for 
several  hours  (Schill  and  Fisher).^  The  same  ex- 
perimenters give  their  conclusions  concerning  the  dis- 
infecting powers  of  various  antiseptics  as  follows  : 
Sublimate  solutions  cannot  be  considered  suitable  for 
disinfection  of  masses  of  tubercular  sputum.  Abso- 
lute alcohol  gives  indifferent  results.  Equal  parts  of  a 
five  per  cent,  carbolic  acid  solution  and  the  amount  of 
daily  sputum  will  destroy  with  certainty  the  tubercle 
bacilli  and  spores  in  the  sputum. 

Delepine  and  Ransome"  have  shown,  by  inoculation- 
experiments,  that  solutions  of  chlorinated  lime,  i  to  10 
and  I  to  100  will  satisfactorily  disinfect  the  walls  of 
infected  rooms,  or  bed-linen  and  clothing  that  has  been 
infected. 

It  is  to  be  hoped  that  formaline  will  prove  an  effi- 
cient disinfectant  owing  to  its  easy  applicability  and  its 
non-corrosive  action  upon  metals.  The  most  power- 
ful and  at  the  same  time  freely  obtainable  agents  are  the 
sun's  rays  and  diffused  day-light.  They  can  be  used  by 
everybody,  and  have  been  proven  to  be  the  most  effi- 
cient disinfectant  known. 

It  has  been  the  writer's  aim  to  enlighten  the  public 
mind  concerning  the  freedom  from  danger  of  contact 
with  tubercular  patients,  where  the  necessary  sanitary 
precautions  are  taken  to  destroy  all  sputum.  This  is 
shown  by  the  positive  proof  that,  with  the  exception  of 
one  cottage  where  cause  for  infection  was  discovered,  all 
the  cottages,  the  infirmary  and  public  sitting-rooms  of 
a  community  of  eighty  tubercular  patients  were  found 
free  from  tubercular  infected  dust. 

Since  Koch's  discovery  of  the  tubercle  bacillus  and 
the  subsequent  proof  that  it  alone  is  the  cause  of  the 
wide-spread  contagion  of  tuberculosis,  the  enforced 
improved  hygienic  laws  and  the  dissemination  of  the 
knowledge  of  successful  preventive  measures  have  been 

'  M.  Kirchner :  Ueber  die  Nothwcniligkcit  ii  die  beste  Art  dei 
sputums-desinfection  bei  Lungentuberculose.  Zeitschrift  f.  Hyg.  u. 
Inf.  Krank.     Leipzic,  1892.  »"•.  349-  , 

»  Schill  and  Fisher  ;  Ueber  die  Desinfection  des  Auswurfes  der 
Phthisiker.  Mittheilungen  aus  dem  Kaiscrlichen  Gensundheitsamte, 
Bd.  iL.  S.  133,  1884. 

>  Delepine  and  Ransome :  A  Report  on  the  Disinfection  of  Tuber- 
cle-infected Houses.  British  Medical  Journal.  No.  1781,  p.  349,  Feb- 
ruary 16,  1895. 


9o6 


MEDICAL   RECORD. 


[December  28,  1895 


productive  of  good  results  as  shown  by  the  mortality 
tables  of  various  countries,  viz.  ;  In  New  York  State  the 
mortality  in  1889  was  120  per  1,000,  whereas  in  1894  it 
was  only  108  46  per  1,000. 

Much  more  can  and  will  be  accomplished  within  the 
next  few  years  by  education  of  the  public  and  preven- 
tive legal  measures  ;  along  with  our  efforts,  however,  to 
prevent  those  who  are  tuberculous  from  infecting  their 
lellow-men  let  us  at  the  same  time  look  out  for  their 
well-being  and  try  to  save  the  lives  of  many  of  them. 
How  better  can  we  accomplish  this  than  by  patterning 
after  the  sanitarium  where  sun-light,  fresh  air,  good 
food,  and  out-of-door  life,  with  separate  cottages  for 
each  group  of  four  or  five  patients,  allow  them  the  best 
chance  of  recovery. 

On  the  question  of  comfort,  on  the  question  of  pure 
air,  free  from  all  germs  of  disease,  on  the  question  of 
economy,  on  the  question  of  hygiene,  and  finally  on  the 
whole  question  of  humanitarian  principles,  how  much 
better  off  is  the  lingering  consumptive  in  the  open 
country  or  in  the  mountains  than  he  who  is  cooped  up 
within  four  walls  of  a  city  hospital  with  a  measured 
cubic  foot  of  air-space,  spending  his  days  and  nights  in 
an  atmosphere  artificially  ventilated  with  air  that  is 
already  contaminated. 

130  WUST    SEVBKTV-TrtIRD   STREET, 


A  CASE  OF  GENERAL  ANALGESIA,  WITH 
SYMPTOMS  OF  SCLEROSIS  OF  THE  PY- 
RAMIDAL TRACTS  AND  OF  THE  COLUMNS 
OF  GOLL. 

By  PEARCE  BAILEY,  M.D., 


The  following  case,  on  account  of  the  unusual  associ- 
ation of  its  s>Tnptoms,  and  the  absolute  and  general 
loss  of  all  sensibility  to  pain,  merits  description,  al- 
though there  is  no  accompanying  pathological  report, 
and  although  any  explanation  of  the  symptom  complex 
must  be  more  or  less  conjectural. 

The  patient  is  a  man  sixty  years  of  age,  a  carpenter 
by  trade.  There  is  no  hereditary  taint  discoverable, 
with'  the  exception  of  a  facial  tic  in  a  parent.  A 
venereal  sore  was  contracted  in  early  youth,  not  fol- 
lowed by  secondaries.  Alcohol  and  tobacco  have 
been  used  to  excess.  The  patient  was  always  robust 
until  twenty  years  ago,  when  symptoms  referable  to 
the  nervous  system  first  made  themselves  felt.  These 
earliest  symptoms,  which  were  consequent  upon  a  se- 
vere shock  caused  by  falling  from  a  boat  into  the 
river,  consisted  in  slight  headache,  dizziness,  impair- 
ment of  memory,  and  nausea.  The  first  serious  symp- 
tom, however,  came  on  twelve  years  ago,  when  his  left 
leg  became  numb  and  paralyzed  for  two  weeks.  This 
condition  soon  improved,  only  to  return  again  a  little 
later.  The  subsequent  improvement  in  his  leg  has 
been  incomplete.  Six  years  ago,  the  right  leg  became 
similarly  affected,  until  now  one  leg  is  as  bad  as  the 
other.  He  was  able  to  continue  light  carpentering 
work  until  one  or  two  years  ago,  when  he  noticed  that 
his  hands  had  become  too  uncertain  in  their  move- 
ments to  allow  him  to  use  the  hammer.  He  would  hit 
his  fingers  as  often  as  the  nail,  but  these  misdirected 
blows  caused  him  no  pain.  Thus,  one  or  two  years 
ago,  his  hands  had  become  ataxic  and  had  lost  their 
sensibility  to  pain.  At  the  same  time  he  was  obliged 
to  use  a  cane  for  walking,  owing  to  ataxia  and  rigidity 
of  his  legs. 

There  has  been  gradual  loss  of  sexual  power  ;  blad- 
der and  rectal  control  unimpaired.  Such  is  the  his- 
tory which  the  man  furnishes.  A  slowly  progressive 
involvement  of  muscular  power,  of  muscular  co-ordi- 
nation and  of  sensibility  to  pain.  No  active  pains,  no 
trophic  disturbances,  no  loss  of  bladder  or  rectum  con- 


trol. A  more  definite  statement  of  the  order  of  oc- 
currence of  the  individual  symptoms  is  not  obtainable. 

The  examination  of  the  patient  shows  us  a  man  of 
medium  frame,  fairly  well  nourished.  There  is  an  ex- 
tensive cicatrix  on  the  back  of  the  neck,  the  result  of 
a  carbuncle  six  years  ago.  There  is  a  double  inguinal 
hernia.  The  thoracic  and  abdominal  organs  appear 
normal,  with  the  possible  exception  of  a  slight  rough- 
ening of  the  first  sound  of  the  heart  at  the  apex.  The 
mental  condition  of  the  patient  is  unimpaired  :  he  is 
not  at  all  of  an  emotional  or  neurasthenic  type.  His 
intelligence  is  such  as  might  be  expected  in  an  ordi- 
nary carpenter.  He  can  read  and  keeps  interested  and 
informed  on  the  affairs  of  the  times.  He  has  never 
given  any  evidences  of  mental  disease. 

The  ocular  muscles  act  normally,  except  slight 
drooping  of  the  left  eyelid.  The  pupils  react  to  light 
and  during  accommodation.  The  left  pupil  under- 
goes a  relative  change  in  size  from  time  to  time.  At 
times  it  is  smaller,  and  again  larger,  than  the  right. 
The  optic  disks  are  somewhat  pale,  but  no  atrophy  is 
present.  There  is  no  limitation  of  the  visual  fields. 
There  is  no  impairment  of  smell.  The  sense  of  taste 
is  accurate,  although  at  the  very  tip  of  the  tongue  it 
may  not  be  as  acute  as  in  a  normal  individual.  The 
patient  himself  has  never  noticed  any  gustatory  ab- 
normalities. Occasionally  there  may  be  observed  a 
slight  twitching  of  the  muscles  supplied  by  the  right 
seventh  nerve.  The  motor  abnormalities  are  those 
ordinarily  met  with  in  ataxic  paraplegia,  where  there  is  a 
degeneration  of  the  motor  tract  together  with  the  pos- 
terior median  columns,  and  perhaps  the  cerebellar  tract. 

The  most  serious  interference  with  volitional  move- 
ment is  ataxia.  It  is  marked  in  the  hands,  and  so 
much  so  in  the  feet,  that  the  patient  requires  two  canes 
in  order  to  walk.  This  inco  ordination  in  the  legs 
exists  to  such  a  degree  that,  in  executing  intended 
movements,  it  assumes  to  a  certain  extent  the  charac- 
ter of  an  intention  tremor.  There  is  also  a  loss  of  the 
sense  of  position  in  the  lower  extremities.  With 
closed  eyes  the  patient  can  with  difficulty  indicate  the 
position  of  his  limbs. 

Associated  with  these  disturbances  of  motion,  there 
is  comparative  weakness  of  all  four  extremities  ;  while 
there  is  no  true  paralysis,  the  muscles  quickly  become 
fatigued.  Under  such  circumstances,  may  now  and 
then  be  observed  fibrillary  twitchings.  None  of  the 
muscles  are  atrophied,  and  all  react  normally  to  fara- 
dism.  The  joints  of  the  lower  extremities  are  some- 
what stiff,  owing  to  slight  contractures  of  the  surround- 
ing muscles.  The  gait  has  the  combined  characteristics 
of  ataxia  with  slight  spastic  paraplegia.  Romberg's 
symptom  is  well  marked.  Trophic  disturbances  are 
entirely  absent,  and  there  are  neither  secretory  abnor- 
malities nor  changes  in  capillary  circulation.  The 
wrist,  elbow,  and  knee  jerks  are  active.  No  clonus. 
The  abdominal  and  plantar  reflexes  do  not  respond  to 
stimulation  ;  the  cremasteric  react  fairly  well  for  a 
man  of  his  age. 

The  chief  claim  to  attention  which  is  advanced  by 
the  patient  consists  in  the  changes  in  sensation.  Tac- 
tile sensibility  is  slightly  impaired.  Very  light  touches 
with  a  camel'shair  brush  are  not  felt,  and  the  mark- 
ings of  the  testhesionieter  are  perhaps  a  little  higher 
than  normal.  This  change,  however,  is  extremely 
slight  ;  such  as  it  is,  it  is  universal. 

Heat  and  cold  are  readily  differentiated.  There  is 
no  delay  in  the  conduction  of  the  sensation  of  touch. 
The  patient  can  readily  differentiate  objects  of  differ- 
ent weights,  and  also  can  distinguish  between  different 
degrees  of  pressure.  Localization  of  touch  every- 
where good.  But  there  is  complete  loss  of  the  sense 
of  pain  in  the  whole  cutaneous  surface,  in  the  mucous 
membranes  and  conjunctiva,  in  the  nerve  -  trunks, 
muscles,  and  joints.  In  no  part  of  the  body,  from  the 
soles  of  the  feet  to  the  top  of  the  head,  can  pricking, 
cutting,  or  burning  elicit  any  evidences  of  pain. 


December  28,  1895] 


MEDICAL   RECORD. 


907 


Forcible  crushing  of  the  muscles  and  rough  hyper- 
extension  of  the  joints  produce  no  sensations  other 
than  those  of  contact  and  movement.  While  the  pa- 
tient's attention  was  attracted  in  another  direction,  a 
needle  was  thrust  into  the  ulnar  nerve  at  the  elbow. 
Inquiry  elicited  that  the  patient  felt  a  "  pushing,"  but 
no  pain.  The  mucous  membranes  share  in  this  anal- 
gesia. Pricks  on  the  tongue,  lips,  and  inner  surface  of 
the  cheeks  cause  no  pain.  Water,  hot  enough  to  be 
painful  to  the  hands  of  an  ordinary  individual,  is 
swallowed  by  the  patient  with  composure. 

Irritation  of  the  posterior  pharyngeal  wall  causes  a 
feeling  of  nausea  and  slight  refle.x.  Pressure  on  the 
conjunctivae  causes  no  pain,  and  there  is  a  slight  reflex 
on  the  right  side  only.  Strong  faradic  currents  are 
unable  to  produce  any  evidences  of  discomfort.  The 
sleep  phenomenon  of  Striimpell  cannot  be  produced. 

Thus,  to  briefly  resume,  the  case  exhibits  symptoms 
of  a  slowly  progressive  spastic  paralysis,  combined  with 
ataxia,  of  all  four  extremities,  and  an  absolute  and  gen- 
eral analgesia. 

The  diagnostic  possibilities  embrace  a  wholly  func- 
tional disease,  an  organic  disease  to  which  are  super- 
imposed functional  sensory  symptoms,  or  a  wholly 
organic  disease.  Everything  speaks  against  the  symp- 
tom complex  being  of  an  entirely  functional  nature. 
Besides  the  close  adherence,  as  far  as  the  motor  symp- 
toms are  concerned,  to  a  recognized  clinical  type  of 
spinal  degeneration,  the  man  has  been  for  five  years  in 
the  Almshouse  and  is  slowly  but  steadily  growing  worse. 
There  have  occurred  neither  sudden  improvements  nor 
sudden  accessions  of  new  symptoms,  and  I  think  it 
can  be  safely  asserted  that  the  motor  symptoms  at 
least  have  an  organic  basis.  Such  was  the  opinion  of 
most  of  the  gentlemen  who  saw  the  case  at  the  New 
York  Neurological  Society.  The  hypothesis  that  the 
analgesia  is  a  functional  addition  to  an  organic  disease 
is  unsatisfactory.  Hysterical  analgesia  of  the  entire 
cutaneous  and  mucous  surfaces  is  rarely  seen  outside 
of  coma  ;  when  it  occurs  as  a  permanent  condition,  as 
in  cases  reported  by  Striimpell,'  Raymond,"  and  others, 
it  is  usually  associated  with  changes  in  other  forms  of 
sensation,  to  which  are  invariably  added  other  hysterical 
stigmata,  such  as  anosmia,  ageusia,  limitation  of  the 
fields  of  vision,  etc.  General  anaesthesia;  have  also 
been  reported  during  the  course  of  psychoses.  Kruken- 
burg*  had  such  a  case  (autopsy  negative)  with  nearly 
complete  sensory,  cutaneous,  and  psychic  anaesthesia. 
Berkeley''  reports  a  similar  condition  in  which  hysteria 
could  be  excluded.  Berkeley  had  another  case  of 
complete  an;csthesia  which  he  attributed  to  a  specific 
neuritis  with  central  changes  in  the  medulla  and  cord. 

Heyne^  saw  gradually  develop,  after  typhoid  fever,  a 
cutaneous  anaesthesia  which  began  in  the  hands  and 
feet,  and  which  became  general  with  the  exception  of 
the  conjunctiva;,  associated  with  loss  of  taste  and  smell, 
and  without  limitation  of  the  visual  field.  This  case, 
resulting  in  recovery,  is  rather  suggestive  of  a  multiple 
neuritis. 

These  cases  mentioned,  together  with  articles  by 
Klaatsch,**  Meynert,"  Von  Zicmssen,*  and  Prescot," 
comprise  the  chief  references  which  I  have  been  able 
to  find  relative  to  the  subject.  The  sensory  changes 
in  our  case  are  totally  dissimilar  to  those  of  the  cases 
cited  ;  consequently  this  analgesia  cannot  be  classed 
with  any  recognized  form  of  functional  sensory  change. 
The  analgesia  which  has  been  observed  in  criminals, 
degenerates,  and  the  insane,  cannot  explain  the  case 
under  discussion,  and  all  the  symptoms  speak  against 
the  presence  of  a  neuritis. 

1  Deutsch.  Arch,  filr  kl.  Med. .  1878. 

^  Revue  de  Med.,  1891  ;  also  Bui.  mud.,  1893. 

»  Deutsch.  Arch.  fUr  kl.  Med.,  1890. 

*  Brain,  1891. 

»  Deutsch.  Arch.  Vdr  kl.  Med.,  Bd.  47. 

•  Allg.  Zeit.  fiir  Psych. ,  1879. 
'  Lyon  mcd.,  1878. 

»  Deutsch.  Arch,  f'lr  kl.  med. ,  Bd   47. 

»  Journal  of  Nervous  and  Mental  Diseases.  1895. 


The  third  possible  hypothesis  is  that  both  sensory  and 
motor  symptoms  depend  on  an  organic  cause.  The  motor 
symptoms  unquestionably  point  to  an  interference  of  the 
conducting  power  of  the  motor  tracts,  of  the  columns 
of  GoU,  and  perhaps  of  the  direct  cerebellar  tract. 
They  constitute  a  very  complete  and  typical  picture  of 
the  so-called  "mixed  sclerosis"  or  "ataxic  paraplegia." 
If  sensation  in  the  head  were  not  involved,  the  associa- 
tion of  symptoms  might  possibly  be  explained  by  the 
assumption  that  Gower's  tract,  which  is  now  generally 
believed  to  transmit  painful  sensations,  was  destroyed 
as  well.  But  degenerations  of  sensory  tracts  do  not  re- 
sult in  complete  and  permanent  anaesthesia  ;  and,  more- 
over, the  path  for  sensations  from  the  anterior  part  of 
the  cranial  surface  is  by  the  fifth  nerve,  which  is  in  the 
pons  varolii  ;  although  the  descending  root  of  the  tri- 
geminus reaches  as  low  as  the  second  cervical  segment, 
its  complete  degeneration  was  found  by  Oppenheim,' 
in  a  case  where  there  was  no  mention  of  sensory  symp- 
toms. 

A  case  reported  by  Spaeth-  resembles  the  present 
one  more  than  any  in  literature.  The  autopsy  revealed 
a  syringo-myelia  extending  from  the  first  cervical  seg- 
ment to  the  lumbar  enlargement  of  .the  cord.  There 
was  anaesthesia  of  all  four  extremities  and  the  trunk, 
combined  with  loss  of  the  sense  of  position  and  ataxia. 
The  patient  could  walk  fairly  well,  and  there  was  but 
slight  loss  of  muscular  power.  But  in  that  case  sensa- 
tion in  the  head  and  neck  was  normal.  Since  in  my 
case  sensibility  to  pain  is  involved  in  these  parts  also, 
central  changes,  if  they  exist,  would  necessarily  be 
situated  in  the  pons  in  such  a  way  as  to  implicate  the 
fifth  nerve  without  seriously  infringing  upon  the  oculo- 
motorius. 

It  would  be  unwarrantable  to  assert  that  a  lesion 
could  occur  in  the  pons  in  such  a  way  as  to  cause 
the  symptoms  of  the  case  which  has  been  described  ; 
while  such  a  lesion  might  cause  all,  it  probably  would 
cause  more. 

Still  another  possible  explanation  would  be  a  pri- 
mary degeneration  of  those  tracts  of  the  spinal  cord, 
which  have  to  do  with  muscular  co-ordination  and 
movement,  to  which  has  been  added  a  lesion  of  the 
pons,  completely  destroying  the  pain-sense  conducting 
fibres. 

Of  the  three  hypotheses,  no  one  is  satisfactory.  The 
diagnosis  of  cases,  which  have  neither  clinical  counter- 
parts nor  pathological  proof,  must  be  at  best,  as  stated 
in  the  opening  line  of  this  paper,  conjectural. 

All  the  motor  symptoms  point  to  structural  changes 
in  the  cerebro-spinal  axis  ;  and  to  the  assumption  that 
the  loss  of  sensibility  to  pain  is  in  some  way  dependent 
on  an  organic  cause,  should  be  given  serious  consider- 
ation. 

6j  Ws^ir  Fiftieth  Street. 


Insafficient  Hospital  Accomiaodation  in  Paris — It  is 

reported  that  the  strain  on  lio.spital  accommodations  in 
Paris  is  so  great  that  of  69.899  applications  for  admission 
made  at  the  Bureau  Central  in  1893,  there  were  38,689 
refusals  due  to  want  of  beds. 

Weigh  the  Baby. — .\  valuable  means  of  ascertaining 
the  progress  of  a  child,  which  is  too  often  neglected, 
is  regular  weighing.  ,\  child,  from  birth  to  six  months 
of  age,  should  be  weighed  weekly,  as  by  this  means, 
almost  to  the  exclusion  of  all  others,  we  can  tell  how 
the  child  is  developing.  During  the  first  week  there  is 
generally  loss  in  weight,  but  by  the  end  of  the  second 
week  the  child  should  hive  regained  its  birth  weight, 
and  if  there  is  a  gain  of  less  than  four  ounces  weekly, 
or  a  stationary  weight,  we  know  there  is  some  fault 
with  its  nutrition,  either  in  the  quantity  or  quality  of 
the  milk  which  it  receives,  or  its  power  of  assimilation. 

— TOWLEV. 

I  BeiL  zur  I.*hre  der  T.ibcs  Dorsalis.  JTubingen,  1864.  j 
'  Neurolog.  Centralblatt.,  i888.J_ 


9o8 


MEDICAL    RECORD. 


[December  28,  1895 


SOME  OBSERVATIONS  ON  HYDROPHOBIA 
AND  HYSTERO- HYDROPHOBIA.  ILLUS- 
TRATED BY  TWO  CASES. 

By  F.  W.  a.  FABRICIUS,  M.D., 

NEW  YORK. 


BX-HOUSE   PHYSICIAN, 


Hydrophobia,  or  rabies,  sometimes  called  lyssa  on  the 
Continent,  constitutes  a  disease  which  is  rapidly  fading 
from  the  medical  horizon,  due,  in  a  measure,  to  the  re- 
cent advances  made  in  prophylactic  bacteriology,  and 
in  some  respects  to  certain  improved  regulations  in  our 
sanitary  code  governing  the  supervision  of  stray  and 
vagrant  animals. 

Although  the  true  nature  of  the  exciting  factor  of 
this  terrible  nervous  disease  remains  still  a  matter  sui> 
judice,  the  universal  opinion  leans  toward  the  fact  that 
it  is  a  germ,  whose  isolation  offers  unusual  difficulties, 
possibly  belonging  to  the  anaerobiotic  variety,  whose 
cultivation  and  germination  can  only  be  effectual  after 
a  more  or  less  complete  exclusion  of  oxygen.  Essen- 
tially it  reacts  as  a  bacterium,  varying  like  the  anthrax 
bacillus  in  resistance  to  certain  chemical  reagents 
•while  under  the  influence  of  attenuation.  The  charac- 
ter of  the  poison  seems  to  be  of  a  distinctly  proteid  nat- 
ure, inducing,  when  transmitted  into  the  organism,  a 
characteristic  form  of  acute  toxaemia  recognized  as 
ptomaine  poisoning. 

Owing  to  the  infrequent  occurrence  of  rabies  in  pri- 
vate practice,  some  members  of  the  profession  deny 
the  existence  of  such  a  disease,  merely  classifying  it 
among  the  symptomatic  neurotic  disturbances  ;  the 
researches  of  the  late  Mr.  Pasteur,  however,  prove  be- 
yond a  doubt  that  it  is  an  acute  infectious  and  conta- 
gious disease,  with  a  distinct  period  of  incubation,  di- 
rectly traceable  to  an  infection  from  subjects  dying 
with  the  disease,  running  a  definite  course,  and  pre- 
senting symptoms  of  su;h  grave  psychical  disturbance 
as  occur  in  no  other  nervous  affection.  Of  course, 
cases  may  turn  up  where  the  infection  was  incomplete 
and  the  resistance  of  the  individual  very  high  ;  it  is  only 
natural  under  these  conditions  that  the  general  course 
of  the  disease  is  altered,  but  the  etiological  factors  re- 
maip  the-same. 

A  good  proportion  of  the  so-called  cases  of  hydro- 
phobia result  from  the  bites  of  dogs,  not  mad,  but 
simply  excited  or  epileptic  ;  the  prognosis  in  such  in- 
dividuals is  generally  favorable.  But  this  does  not 
constitute  true  rabies  ;  here  we  have  to  deal  with  a 
pathophobia,  an  hysterical  manifestation,  whose  symp- 
toms at  times  so  closely  coincide  with  those  of  the  or- 
dinary type  that  the  errors  in  diagnosis  must  of  neces- 
sity be  numerous  ;  the  cognizance  of  this  statement 
renders  the  statistics  of  the  Pasteur  immunization 
treatment  almost  valueless. 

The  rabic  ptomaine  chemically  bears  a  striking  rela- 
tion to  the  snake-poison  in  certain  respects  ;  they  dif- 
fer, however,  in  important  particulars  physiologically. 
The  former  enters  the  organism  from  without  as  the  re- 
sult of  an  infection,  the  latter  is  produced  in  the  ani- 
mal carrying  it  and  stored  away  in  the  dental  canals  of 
the  fangs.  The  striking  similarity  in  action  of  these 
two  powerful  organic  poisons  will  be  illustrated  in  the 
near  future  by  some  interesting  experiments  as  soon  as 
they  are  completed. 

Studying  the  following  two  cases  side  by  side,  but 
little  difficulty  will  be  encountered  in  establishing  a 
diagnosis  ;  taken  individually,  however,  considerable 
doubt  might  be  expressed  as  to  the  true  nature  of  the 
disease. 

Case  I. — C.  A ,  twenty-eight  years  of  age,  a  tin- 
smith by  occupation,  entered  Bellevue  Hospital  Oc- 
tober 31,  1893,  with  an  every-day  history  of  miasmatic 
poisoning  of  rather  a  mild  type.  He  appeared  to  be  in 
excellent  physique  and  regular  in  his  habits.  The  family 
history  was  negative.     He  enjoyed   very  good  health 


up  to  three  or  four  days  before  admission,  when  he 
noticed  a  slight  chill  followed  by  a  dull,  boring  head- 
ache, considerable  pain  in  the  back  and  limbs,  and  an 
uncomfortable  feeling  of  oppression  over  the  precor- 
dial region.  At  night  he  was  restless  and  uneasy,  and 
considerably  depressed.  Several  grains  of  quinine  only 
added  to  his  distress,  till  he  was  forced  to  apply  for 
treatment. 

On  admission  to  the  hospital  patient  was  able  to  give 
a  clear  account  of  himself,  but  did  so  in  an  absent- 
minded  manner.  His  countenance  was  pale,  and  ex- 
pressed anxiety  and  apprehension.  The  pupils  were 
widely  dilated,  responding  both  to  light  and  accommo- 
dation. Tongue  was  coated  and  tremulous,  pulse  rapid, 
full  and  regular,  temperature  99°  F.  per  mouth.  In- 
creased patellar  reflex  and  ankle  clonus,  fine  tremor  of 
hands.  He  was  of  irritable  disposition  and  seemed 
quite  agitated.  Physical  examination  proved  negative 
beyond  a  moderately  enlarged  spleen.  The  case  was 
looked  upon  as  an  irregular  type  of  malaria,  and 
promptly  treated  with  ten-grain  doses  of  the  bimuriate 
of  quinine  every  three  hours,  with  five  grains  of  calo- 
mel in  the  form  of  tablet  triturate  at  bedtime.  A  thor- 
ough microscopical  examination  of  the  blood  failed  to 
reveal  the  plasmodia  or  malarial  pigment,  and,  as  the 
symptoms  augmented  in  severity,  the  further  adminis- 
tration of  quinine  was  suspended  and  the  s)-mptomatic 
plan  of  treatment  adopted.  During  the  night  he  was 
very  restless,  dozing  off  now  and  then  only  to  wake  up 
with  violent  starts  and  jerks.  He  passed  seven  ounces 
of  pale  clear  urine  containing  a  trace  of  albumin.  The 
pulse  toward  morning  had  lost  in  tension,  but  gained 
in  rapidity  ;  respiration  seemed  normal,  a  trifle  heavy. 
At  noon  slight  cyanosis  was  noticed  on  ears,  but  its 
presence  could  not  be  accounted  for  after  a  thor- 
ough physical  examination.  Sensorium  began  to  suf- 
fer, and  toward  evening  mental  obfuscation  became 
quite  marked.  During  a  sponge  bath  a  small  red  scar 
was  detected  on  ulnar  side  of  right  hand,  tender  to  the 
touch  and  surrounded  by  a  small  area  of  inflamed  tis- 
sues. He  complained  of  sharp,  lancinating  pains  or- 
iginating at  this  spot  and  shooting  up  the  right  arm 
toward  the  axilla. 

The  affected  area  was  painted  wth  iodine  and  the 
whole  arm  bandaged  up  with  a  wet  carbolic  dressing, 
to  prevent  further  extension  of  the  yet  circumscribed 
lymphangitis.  A  little  whiskey  with  water  he  swallowed 
with  considerable  difficulty,  followed  immediately  by 
an  explosive  fit  of  coughing  expelling  the  fluid  through 
mouth  and  nose.  To  allay  the  increasing  restlessness 
a  hypodermic  injection  of  morphine,  gr.  \.  and  atropine, 
gr.  -fi^,  was  administered,  which  produced  little  or  no 
sedative  effect.  He  never  slept  during  the  night,  but 
only  tossed  about  in  an  uneasy  manner,  mumbling  in- 
coherently. At  times  he  would  point  toward  the  walls 
and  then  cover  his  eyes  as  if  frightened  :  he  thought 
he  saw  black  figures  moving  about  the  room,  which 
threatened  to  kill  him.  In  order  to  check  this  growing 
mental  excitation  the  hypodermic  injection  was  re- 
peated after  the  lapse  of  three  and  a  half  hours.  At  no 
time  had  the  temperature  risen  above  99.8°  F.  ;  the 
pulse,  however,  indicated  considerable  nervous  tension. 
During  the  night  he  vomited  several  times,  which 
caused  so  much  distress  that  patient  refused  all  nour- 
ishment, which  was  then  administered  per  rectum. 
Toward  morning  the  nurse  served  a  little  milk  in  a 
cup,  which  he  attempted  to  drink.  But  no  sooner  had 
the  fluid  touched  his  lips,  when  he  shook  from  head 
to  foot,  his  muscles  contracted,  respiration  ceased 
abruptly,  eyes  fixed,  widely  opened  and  staring,  face 
cyanotic  deepening  into  purple,  larynx  elevated  as 
during  the  act  of  deglutition,  pulled  up  tightly  against 
the  lower  jaw  in  a  tetanic  spasm.  The  expression  of 
his  countenance  at  this  time  appeared  so  ferocious  and 
hideous  that  it  baffles  all  description,  resembling  more 
a  wild  beast  than  a  reasonable  human  being.  After 
tliirty-five  seconds  the  muscles  suddenly  relaxed,  the 


December  28,  1892J 


MEDICAL   RECORD. 


909 


head  fell  back  on  the  pillow,  and  respiration  was  re- 
sumed with  a  violent  puffing  out  of  the  retained  air, 
while  the  perspiration  just  rolled  off  his  body,  com- 
pletely wetting  his  bedclothes.  Some  coffee  was  then 
offered  to  him,  but  it  had  hardly  touched  his  lips,  when 
the  frightful  scene  repeated  itself  in  all  its  details.  The 
distorted  features  with  the  bloodshot  eyes,  the  severe 
laryngeal  spasms,  and  the  intense  agony  depicted  on  his 
countenance,  together  with  the  inflamed  scar,  suddenly 
suggested  a  diagnosis  which  had  not  even  been  sus- 
pected. His  friend  was  instantly  sent  for,  and  he  stated 
that  about  seven  months  ago  patient  had  been  attacked 
and  bitten  by  a  mad  dog,  which  was  killed  and  re- 
moved by  the  Health  Department.  He  readily  identi- 
fied the  scar  on  the  hand.  Here  may  be  mentioned 
that  the  mere  sight  of  fluid  did  not  induce  those  laryn- 
geal spasms  ;  on  the  contrary  the  patient  made  frantic 
exertions  to  drink,  the  thirst  being  necessarily  severe 
with  such  profuse  perspiration  ;  after  the  third  attempt 
he  began  to  realize  his  position  and  quietly  objected. 
Later  on  he  was  painfully  conscious  of  the  effect  foods, 
solid  or  liquid,  produced  ;  the  mere  thought  of  trying  to 
swallow  would  then  precipitate  an  attack. 

In  the  intervals  between  the  paroxysms  the  anxious, 
apprehensive  look  and  the  mute  appeal  for  help  con- 
stituted such  a  spectacle  that  it  will  never  be  forgotten. 
The  spasms  now  resulted  from  the  slightest  irritation, 
and  were  always  ushered  in  by  a  general  tremor  fol- 
lowed by  a  stiffening  of  the  muscles  without  any  ten- 
dency toward  opisthotonos.  During  a  sudden  inspira- 
tory effort  the  larynx  jumped  up  in  an  instant,  and 
remained  fixed  in  this  position  from  thirty  to  sixty- five 
seconds.  Sometimes  the  upper  part  of  the  body  was 
jerked  upward  and  forward,  the  patient  seemingly 
making  violent  efforts  to  breathe.  Blood-stained  foam 
gathered  on  his  lips,  his  face  almost  purplish-black, 
when  suddenly  the  patient  collapsed,  utterly  exhausted, 
the  foam  rolling  out  of  his  mouth  and  the  perspiration 
streaming  off  his  body.  The  absorptive  processes  of 
his  organism  must  have  come  to  a  standstill,  for  within 
the  last  twenty- four  hours  he  had  received  subcutane- 
oubly  five  grains  of  morphine  and  one-half  grain  of 
hyoscine.  Notwithstanding  these  powerful  sedatives 
the  attacks  grew  more  frequent,  but  gradually  lessened 
in  duration  and  intensity.  Chloroform,  at  first  of  some 
use,  soon  had  to  be  discontinued,  owing  to  the  ex- 
hausted condition  of  the  heart  and  the  prolongation  of 
the  succeeding  spasms.  His  efforts  at  resistance  grad- 
ually grew  weaker.  At  times  he  opened  and  shut  his 
mouth  and  gnashed  his  teeth.  Toward  evening  of  the 
third  day  he  had  three  slight  convulsions,  with  loss  of 
consciousness  during  from  three  to  five  minutes.  The 
thermometer  now  registered  102.4°  per  rectum  ;  pulse 
ranging  from  140  to  210  per  minute,  very  weak,  almost 
imperceptible  during  a  spasm.  .\t  no  time  did  he  try 
to  bite  the  attendants,  but  continually  ground  his  teeth, 
with  foam  covering  his  mouth.  During  the  last  six 
hours  his  countenance  had  changed  terribly,  so  that 
his  most  intimate  friend  hardly  recognized  him.  His 
face  was  very  pale,  eyes  sunken,  and  his  features  com- 
pletely relaxed.  He  had  another  convulsion,  and  died 
from  respiratory  paralysis  three  days  after  admission. 

The  second  case  presents  phenomena  which  simulate 
closely  the  true  type  of  rabies,  but  differ  from  this  in 
essential  particulars,  which,  when  considered  together, 
at  once  throws  it  into  the  class  of  hysterias  conveni- 
ently called  hystero-hydrophobia. 

C.^SE  n.— F.  L ,  hostler,  aged  twenty-eight,  was 

transferred  to  Bellevue  Hospital  with  the  diagnosis  of 
hydrophobia.  On  examination,  the  patient,  a  powerful 
fellow,  was  found  to  be  struggling  severely  with  four 
attendants,  who  experienced  great  difficulty  in  con- 
trolling his  violence.  He  was  shouting  and  yelling 
incessantly,  while  the  foam  just  rolled  out  his  mouth, 
snapping  and  biting  most  viciously  at  the  nearest  per- 
sons. He  jerked  and  jumped  about  on  the  stretcher 
with  almost  uncontrollable  strength,  exposing  a  deeply 


flushed  face,  which  with  its  wild,  rolling  eyes,  dilated 
pupils,  and  distorted  features,  certainly  presented  a 
terrifying  spectacle.  The  surface  temperature  seemed 
to  indicate  a  considerable  expenditure  of  animal  heat, 
the  thermometer  registering,  however,  only  101.5°  P^'' 
rectum.  The  pulse  was  full  and  bounding,  of  rather 
high  tension  and  very  rapid  ;  respirations  appeared  cor- 
respondingly increased.  The  highest  pitch  of  maniacal 
e.Kcitement  was  induced  by  the  mere  suggestion  of 
water,  which  when  dashed  into  his  face  would  instantly 
precipitate  a  paro.xysm  of  laryngismus  ushered  in  by  a 
loud  scream,  followed  by  a  spasm  of  the  glottis,  during 
which  the  patient  threw  himself  about  violently,  utter- 
ing loud  shrieks.  These  spasms  only  seemed  to  last  a 
few  seconds,  but  fretjuently  repeated  themselves  with- 
out the  slightest  irritation,  broken  at  times  by  short 
ejaculations  of  :  "I  see  them  come,  help  me  !  They 
are  biting  me,  hear  them  not !  "  etc. 

A  little  milk  offered  to  him  in  a  cup  he  drank  rav- 
enously, with  not  the  slightest  difficulty  ;  water,  how- 
ever, almost  threw  him  into  convulsions.  At  times  he 
emitted  a  hoarse  bark  and  made  fierce  attempts  to  bite 
the  attendants.  How  long  this  stage  of  excitement 
would  have  continued  is  impossible  to  tell  ;  according 
to  reliable  information,  it  had  already  lasted  two  hours 
prior  to  his  admission.  A  hypodermic  of  one  third 
grain  of  morphine  and  one-fiftieth  grain  of  hyoscyamine 
was  administered,  resulting  within  forty  minutes  in  a 
deep  sleep,  from  which  he  awoke  after  several  hours 
greatly  exhausted. 

Friends  stated  that  he  had  been  addicted  to  the 
regular  use  of  alcohol  for  the  past  three  months,  and 
that  about  a  week  ago  patient  had  been  bitten  by  a 
dog,  which,  he  supposed,  suffered  from  hydrophobia. 
Since  that  time  he  had  lived  in  constant  fear  and  anxi- 
ety, walking  about  greatly  depressed  and  melancholy, 
drinking  considerably  all  along.  About  seven  days 
after  the  bite,  just  recovering  from  a  debauch,  he  sud- 
denly lost  all  control  over  himself,  said  that  he  was 
going  mad,  that  he  had  hydrophobia,  etc.,  till  his  re- 
moval to  the  hospital  became  an  absolute  necessity.  On 
examining  the  hand,  a  small  lacerated  wound  was  dis- 
covered, which  had  undergone  repair  in  several  places. 
The  whole  area  with  surrounding  healthy  tissue  was 
excised  and  thoroughly  sterilized  with  the  thermo- 
cautery, the  wound  was  then  allowed  to  heal  up  by 
granulation. 

The  patient  still  expressed  some  anxiety,  but  calmed 
down  completely  by  the  use  of  bromides  with  capsicum 
and  strychnine  ;  he  was  discharged  alter  an  uneventful 
recovery  six  days  after  admission  ;  when  examined  a 
year  later  he  was  in  excellent  health  and  no  longer 
troubled  by  any  fears. 

The  most  important  differential  points  to  be  consid- 
ered may  briefly  be  summarized  as  follows  : 

1.  Direct  infection  by  an  animal  suffering  from  or 
dying  with  hydrophobia.  The  rabic  poison,  contained 
primarily  only  in  the  buccal  or  nasal  secretions,  may  lie 
dormant  for  three  days,  the  animal  being  apparently 
well  ;  a  bite  at  this  stage  will  call  forth  rabies  of  un- 
diminished virulence.  The  disease  is  spread  by  fomites 
only  by  direct  inoculation  into  wound. 

2.  Distinct  period  of  incubation  varying  from  three 
to  six  months. 

3.  Characteristic  clinical  history  :  1st  stage  :  Pro- 
dromal period,  two  to  three  days.  2d  stage  :  Melan- 
cholia, one  to  two  days.  3d  stage  :  Mania,  one  to  two 
days.  4th  stage  :  Paralysis,  asthenia,  one  to  three 
days. 

4.  Termination  almost  invariably  fatal  on  the  fourth 
to  fifth  day. 

5.  Reproduction  of  the  disease  by  implanting  a  frag- 
ment of  the  medulla  from  an  animal  jjerishing  with 
rabies  into  the  cerebral  cavity  of  a  sound  animal,  when 
the  characteristic  phenomena  will  show  themselves  with 
unerring  certainty  on  the  fourteenth  day  from  the  in- 
oculation. 


9IO 


MEDICAL    RECORD. 


[December  28,  1895 


6.  Violent  laryngeo-pharyngeal  crisis  ;  spasms  of  the 
respiratory  muscles,  particularly  the  diaphragm  ;  occur- 
rence of  convulsions  and  delirium  ;  intense  nervous 
prostration  ;  inflammation  of  the  cicatrix  with  a  ten- 
dency toward  lymphatic  involvement  ;  unusual  toler- 
ance toward  powerful  sedatives. 

The  rabic  poison  appears  to  possess  a  great  affinity 
for  the  medulla  oblongata,  and  to  a  less  extent  for  the 
motor  centres  in  the  brain.  The  violence  of  the  symp- 
toms, the  profound  nervous  disturbance  centring  on 
the  respiratory  nucleus,  with  the  obscure  pathologic 
lesions,  so  closely  suggest  tetanus  that,  were  it  not  for 
the  history  of  specific  infection,  the  early  delirium,  and 
the  predominating  laryngeal  spasms,  an  absolute  diag- 
nosis could  not  easily  be  maintained. 


SYPHILIS    VS.  TUBERCULOSIS.     REPORT  OF 
A   CASE. 

By  R.   ABRAHAMS,  M.D., 

DISTRICT  PHYSiriAN  TO   MOUNT  SINAI   HOSPITAL  ;    ASSISTANT   IN  THE   SKIN   DH 
PARTMEiNT   OF   THE    MOUNT   SINAI   HOSPITAL   DISPENSARY. 

The  association  of  two  infectious  or  contagious  dis- 
eases in  one  individual  at  one  and  the  same  time,  is  a  fact 
familiar  to  every  practising  physician.  Instances  of  such 
combinations  are  plentiful,  namely  :  diphtheria  and  scar- 
latina, measles  and  scarlet  fever,  measles  and  whoop- 
ing-cough, typhoid  and  pneumonia,  etc.  On  the  other 
hand,  a  conflict  or  antagonism  between  certain  infec- 
tious or  contagious  diseases,  in  the  sense  that  in  the  soil 
wherein  the  roots  of  one  infectious  disease  are  spreading 
the  seed  of  another  infection  cannot  be  planted,  or  if 
planted,  cannot  flourish  with  perfect  impunity  to  the 
first,  either  condition,  as  yet,  belongs  to  the  realm  of 
theory. 

In  the  following  case  an  antagonism  between  syphilis 
and  tuberculosis  seemed  to  be  established  : 

John  K ,  a  Pole,  aged  thirty-five,  with  no  knowl- 
edge of  a  family  history,  but  with  a  distinct  recollec- 
tion of  repeated  attacks  of  gonorrhoea,  came  to  this 
country  about  five  years  ago.  At  that  time  he  enjoyed 
excellent  health.  He  was  engaged  as  a  miner  some- 
where in  the  Pennsylvania  coal  mines,  but  scarcely 
worked  a  year  underground  when  he  began  to  suffer 
from  an  annoying  dry  cough.  Thinking  that  the  trouble 
was  caused  by  the  coal  dust  he  went  to  work  on  a  farm. 
In  a  comparatively  short  time  the  cough  ceased,  and  he 
returned  to  the  mines.  The  cough  soon  reappeared, 
and  finally  he  suffered  a  very  profuse  pulmonary  hem- 
orrhage. The  blood  frightened  him,  and  he  came  to 
New  York.  When  I  saw  him  he  was  pale,  emaciated  ; 
the  skin  was  dry  ;  hands  and  feet  cold  ;  appetite  very 
capricious  ;  bowels  very  irregular — diarrhoea  alternat- 
ing with  constipation  ;  intense  cough  with  bloody 
mucous  expectoration  ;  breathing  accelerated  ;  some 
dyspnoea  ;  pulse  weak  ;  there  were  exhausting  night- 
sweats  with  mild  rise  of  temperature  in  the  evening. 
The  sputa  contained  abundant  bacilli.  Physical  ex- 
amination disclosed  flatness  above  and  below' the  right 
clavicle  ;  subcrepitant  and  mucous  rales  and  bronchial 
breathing.  Mucous  rales  were  heard  all  over  the  chest. 
The  patient  was  put  on  creosote.  The  mode  of  ad- 
ministering the  drug  was  one  I  have  found  to  work 
well,  namely,  starting  with  two  drops,  t.i.d.,  and  in- 
creasing the  daily  dose  by  one  drop,  the  increased  dose 
to  be  taken  before  dinner.  The  best  vehicle  is  milk, 
and  the  best  time  for  taking  the  medicine,  in  my  ex- 
perience, is  before  meals.  This  patient  ran  up  his 
dose  to  one  drachm,  t.i.d.  The  good  effects  of  this 
excellent  drug  were  quite  appreciable,  the  night-sweats 
stopped,  the  appetite  improved,  the  cough  was  less  dis- 
tressing, and  the  expectoration  was  less  profuse,  al- 
though the  lesion  in  the  lung  apparently  remained  un- 
altered. 


I  lost  sight  of  the  patient  now  for  about  ten  weeks, 
and  when  he  returned  he  was  found  to  have  contracted 
syphilis.  The  initial  lesion  was  situated  on  the  glans 
penis,  extending  a  short  distance  to  the  prepuce.  The 
lymphatic  glands  in  the  inguinal  region  were  indu- 
rated and  enlarged,  the  lymphatic  vessels  along  the 
dorsum  of  the  penis  felt  like  thin  cords.  The  pa- 
tient complained  of  nocturnal  headache  and  rheu- 
matic or  lancinating  pains  in  the  bones.  The  general 
appearance  x>i  the  patient  at  the  time  was  not  particu- 
larly bad,  although  he  claimed  that  he  was  rapidly  los- 
ing health  and  strength.  The  chancre,  with  its  asso- 
ciate pains  in  the  bones  and  headache,  yielded  nicely 
to  mercurial  plaster  and  iodide  of  sodium.  Eight 
weeks  subsequent  to  the  appearance  of  the  primary 
lesion  I  was  called  in  a  hurry  to  see  the  man  at  a  lodg- 
ing house.  He  looked  wretched.  I  was  informed  that 
about  4  P.M.  he  was  seized  with  a  violent  chill,  which 
lasted  nearly  an  hour.  His  temperature  at  9  p.m.  was 
104.5°  F.  ;  there  was  a  dry  and  coated  tongue  ;  respi- 
rations, 30  to  the  minute  ;  pulse  about  120,  and  weak. 
The  cough  was  not  unusually  severe.  I  prescribed 
quinine  and  digitalis.  The  next  morning  the  tempera- 
ture was  101°  F.,  the  pulse  and  respiration  much  bet- 
ter. 

In  the  afternoon  the  chill  was  repeated,  the  tem- 
perature rose  again,  the  pulse  and  respiration  followed 
the  same  type  as  that  of  the  preceding  evening.  The 
following  morning  there  was  the  same  improvement  in 
the  patient's  condition  as  in  the  preceding  morning. 
On  looking  carefully  over  his  body,  I  noticed  for  the 
first  time  a  faint  roseola  on  the  chest  and  abdomen. 
The  appearance  of  the  eruption  explained  to  my  mind 
the  chill  and  fever.  This  systemic  disturbance  con- 
tinued for  five  days  ;  every  day  the  eruption  became 
more  and  more  pronounced  and  more  and  more  dif- 
fused. At  the  end  of  this  period,  the  temperature  fell 
to  the  normal  ;  the  eruption  then  extended  almost 
over  the  entire  body. 

The  roseola  was  of  the  mixed  variety,  that  which  is 
commonly  called  maculo-papular  syphilide.  The  pap- 
ules were  well  defined,  sharply  outlined,  firm,  some 
large  and  some  small.  There  was  an  extremely  char- 
acteristic angina. 

Up  to  this  day  the  treatment  consisted  in  stimulat- 
ing and  nourishing  food  ;  from  this  time  on  it  was  rig- 
idly antisyphilitic. 

The  patient  received  fifty  mercurial  inunctions. 
Very  often  iodide  of  sodium  was  added  to  the  mercury. 
The  only  other  remedy  he  took  was  cod-liver  oil.  It 
is  needless  to  state  that  all  the  secondary  symptoms  and 
the  traces  left  of  the  primary  lesion  vanished  under 
this  treatment.  But  what  was  more  wonderful  was 
that,  from  the  very  start  of  the  evolution  of  the  sec- 
ondary period,  and  all  along  through  this  energetic  spe- 
cific treatment,  all  the  signs  of  consumption,  one  by 
one,  disappeared.  Night-sweats  stopped  ;  the  evening 
fever  abated  ;  the  cough  and  expectoration  became  in- 
significant ;  the  appetite  returned  ;  the  patient  gained 
flesh  and  strength  ;  and  what  is  more,  at  the  end  of  the 
fifty  days'  treatment,  a  physical  examination  revealed 
no  trace,  absolutely  none,  of  existing  phthisis  ;  the  per- 
cussion-note was  normal  instead  of  flat ;  the  breathing 
was  normal  in  place  of  bronchial  ;  all  rales  were  gone, 
the  sputa  failed  to  show  bacilli,  so  that  as  far  as  I  could 
see,  the  man  was  cured  of  his  tuberculosis.  I  kept  him 
for  a  couple  of  months  under  observation.  Occasion- 
ally he  required  a  dose  of  iodide,  but  I  could  not  see 
any  need  for  treating  anything  but  syphilis.  The  pa- 
tient to-day  is  in  Poland. 

Occasionally  I  hear  from  him  that  he  enjoys  the  best 
of  health. 

The  case  has  seemed  to  me  of  surpassing  interest, 
and  for  that  reason  I  have  entered  into  the  history  with 
more  minuteness  than  is  usual  with  reports  of  such 
cases. 

156  Clintcn  Street. 


December  28,    1895] 


MEDICAL    RECORD. 


911 


A  RARE  ANOMALY  OF  THE    BRACHIAL  AR- 
TERY. 

By  EUGENE  R.  CORSON.  B.S..  M.D., 


A  NEGRO,  about  fifty-five  years  of  age,  presented  him- 
self at  my  office  for  some  slight  ailment.  His  appear- 
ance of  great  age  led  me  to  examine  him  carefully. 
His  hair  was  perfectly  white,  his  face  much  wrinkled, 
the  arcus  senilis  well  marked,  and  the  artery  at  the 
wrist  evidently  atheromatous.  The  temporal  artery 
was  sinuous  and  hard,  and  the  pulsation  very  noticea- 
ble. The  heart-beat  was  forcible,  and  the  heart-sounds 
pronounced,  but  without  any  murmur.  He  complained 
of  a  strong  pulsation  in  the  left  arm,  which  directed  ray 
attention  to  the  brachial  artery.  To  my  surprise,  I 
found  it  to  be  subcutaneous  and  outside  the  deep  fas- 
cia. From  its  origin  at  the  lower  border  of  the  teres 
major  to  the  bend  of  the  elbow,  it  could  be  picked  up 
between  the  fingers  and  compressed,  stopping  all  cir- 
culation in  the  forearm  and  hand.  It  was  markedly 
atheromatous.  I  happened  to  have  some  spring-catch 
clothes-pins  on  my  table,  and  with  them  I  easily  caught 
up  the  vessel  and  controlled  the  circulation.  I  made 
the  accompanying  rough  sketch.     The  brachial  on  the 


Fractures. — In  the  case  of  a  fracture  near  a  joint 
there  is  generally  a  double  injury.  The  joint  is  dam- 
aged more  or  less  by  the  same  force  that  fractures  the 
bone.  We  have  then  not  a  simple  fracture,  but  a  fract- 
ure plus  a  sprain,  and  therefore  in  the  ordinary  methods 
of  treating  these  cases  the  fracture  is  treated  well 
enough,  but  the  sprain  is  neglected.  Rest  alone  does 
not  cause  ankylosis,  but  if  the  sprained  joint  be  put 
up  in  plaster  for  some  weeks,  it  will  take  as  many  weeks 
of  massage  to  make  it  useful.  The  two  injuries  should 
be  treated  simultaneously. — Miller. 

A  separation  of  the  epiphysis  of  the  femur  can  occur 
without  giving  rise  to  many  definite  signs  or  symptoms, 
and,  on  the  other  hand,  may  be  serious  enough  to  ne- 
cessitate active  surgical  interference.  It  appears  to  be 
good  surgery  to  remove  a  piece  of  the  bone  if  the  parts 
cannot  be  approximated,  and  there  is  no  danger  of  ar- 
rest of  development  incurred  thereby.  There  does  not 
seem  to  be  any  callus  of  consequence  thrown  out  when 
the  fracture  has  been  reduced  and  it  is  probable  that 
immediate  union  takes  place. — Elsner. 


right  side  was  normal.  The  arteries  in  the  lower  ex- 
tremities seemed  to  be  in  their  places,  though  athero- 
matous. 

The  man  was  intelligent  and  was  more  certain  of  his 
age  than  most  of  his  race,  and  he  assured  me  he  was 
not  over  fifty-five  years  of  age.  He  certainly  looked 
as  old  as  his  arteries,  and  was  evidently  a  marked  case 
of  premature  senility.  As  I  have  shown  in  my  paper 
on  "  The  Vital  Equation  of  the  Colored  Race,"  arterio- 
sclerosis and  atheroma  are  common  with  them  ;  no- 
where have  I  seen  such  striking  pictures  of  senility  in 
the  comparatively  young. 

This  anomaly  of  the  brachial  artery  must  be  a  very 
rare  one,  as  I  have  not  succeeded  in  finding  any  men- 
tion of  it  in  the  literature  on  the  subject.  As  is  well- 
known,  the  bifurcation  of  the  brachial  high  up  into  the 
radial  and  ulnar  is  not  uncommon,  nor  its  swerving 
from  the  inner  border  of  the  biceps  toward  the  inner 
condyle  of  the  humerus  to  curve  around  a  prominence 
of  bone,  and  then  finally  to  pass  outward,  through  or 
beneath  the  pronator  radii  teres  to  the  bend  of  the 
elbow. 

In  the  large  work  of  Bourgery,  Paris,  1834,  there  is 
figured  a  radial  and  ulnar  artery  outside  the  deep  fascia, 
with  the  brachial  in  its  normal  position.  This  does 
not  seem  so  remarkable,  however,  as  where  the  larger 
vessel  has  jumped  the  track.  It  has  therefore  seemed 
to  me  worthy  of  mention. 

X15  JoNot  Strbct.  : 


The  factors  entering  into  the  limitations  of  motion 
after  intra-  and  extra-articular  fractures  are  :  First,  bad 
positions  of  the  bony  fragments,  within  or  without  the 
joint,  the  direct  result  of  injury  ;  second,  bony  out- 
growth, exostosis,  the  result  of  inflammatory  processes 
following  the  injury,  whether  arising  in  the  reparative 
callus  or  not  ;  third,  other  inflammatory  changes,  mostly 
the  formation  of  firm  bands,  both  within  or  without  the 
joint,  including  the  filling  up  of  fossa  with  fibrous  de- 
posits ;  fourth,  the  obliteration  of  the  tendon  surface 
of  muscles  moving  the  joints. — Carmalt. 

Goitre. — Kocher  has  now  nine  hundred  cases  which 
have  been  operated  upon  in  one  hospital,  and  in  none 
of  them  has  cachexia  strumipriva  ever  occurred,  except 
in  a  single  case  where  after  extirpation  of  half  of  the 
goitre,  the  other  half  proved  to  be  atrophied. 

Bams. — I.  Fresh,  superficial  burns,  as  well  as  deep 
ones,  can  heal  under  antiseptic  treatment  without  the 
production  of  pus.  2.  If  pus  is  produced,  the  wound 
is  disinfected,  and  the  course  remains  the  same  as  if 
non-infected.  But  if  the  pus  is  of  long  standing  and 
the  wound  begins  to  granulate,  then  disinfection  is  not 
possible.  3.  To  disinfect  widespread  burns  an  anxs- 
thetic  will  often  be  necessary,  and  to  this  end  chloro- 
form is  best  suited.  4.  If  the  wound  is  non-purulent, 
the  unnecessary  use  of  an  antiseptic  hinders  the  heal- 
ing process.  5.  Antisepsis  is  the  best  analgesic.  6. 
Bums   heal   rapidly    under   the   antiseptic   treatment. 


912 


MEDICAL    RECORD. 


[December  28,  1! 


Burns  of  the  second  degree  require  eight  days  ;  of  the 
third  degree,  from  two  to  three  weeks.  7.  Burns  of 
the  second  and  third  degree  heal  without  trace  remain- 
ing ;  of  the  fourth  degree,  cause  a  scar,  which  does  not 
retract,  while  this  will  be  smoother  the  less  the  amount 
of  pus. 

Cleaning  Rusty  Instruments.— Broder  gives  the  fol- 
lowing as  an  effective  method  of  cleaning  rusty  instru- 
ments. Fill  a  suitable  vessel  with  a  saturated  solution 
of  chloride  of  tin  in  distilled  water,  immerse  the  rusty 
instruments  and  let  them  remain  over  night.  Rub  dry 
with  chamois  after  rinsing  in  running  water,  and  they 
will  be  of  a  bright  silvery  whiteness. — Joitrnal  of  the 
British  Dental  Association. 

Abortive  Treatment  of  Gonorrhoea  is  not  too  late  if 
the  slight  secretion  is  hardly  colored  and  more  mu- 
coid than  purulent ;  if  the  margin  of  the  meatus  is  not 
swollen  and  but  slightly  tinted  with  an  erythematous 
redness. — Diday. 

Indications  for  Operative  Interference  in  Gall-blad- 
der.—i.  In  cases  of  repeated  attacks  of  biliary  colic, 
apparently  due  to  gall-stones,  which,  not  yielding  to 
medical  treatment,  are  wearing  out  the  patient's 
strength.  2.  In  perforation  from  ulceration.  3.  When 
there  is  suppuration  in  the  neighborhood  of  the  gall- 
bladder set  up  by  gall-stones.  4.  In  empyema  of  the 
gall-bladder,  which  is  usually  accompanied  by  peritoni- 
tis. 5.  In  dropsy  of  the  gall-bladder.  6.  In  obstruc- 
tive jaundice,  when  there  is  reason  to  think  that  the 
common  duct  is  occluded  by  gall- stones. — Robsox. 

Deaths  Under  Chloroform.— Two  deaths  from  chloro- 
form anaesthesia  have  recently  occurred  in  Berlin,  in 
both  of  which  there  were  heart  lesion,  which  might 
have  been  recognized  during  life. 

Changes  in  the  Blood  in  SyphUis.— In  1889  Sem- 
mola  advanced  the  following  propositions:  i.  Consti- 
tutional progressive  syphilis  not  treated  with  mercury 
causes  a  diminution  of  haemoglobin  and  of  red  corpus- 
cles. 2.  If  a  syphilitic  person  in  whom  this  diminution 
is  observed  is  treated  with  mercury  from  the  first  day 
of  treatment,  there  is  an  increase  of  haemoglobin  and  of 
red  corpuscles.  3.  If,  however,  the  mercurial  treat- 
ment is  continued  longer  than  necessary,  so  that  the 
mercury  loses  its  specific  power,  its  toxic  action  will 
prodhce  a  diminution  of  hsmoglobin  and  red  corpus- 
cles. 4,  If  mercury  is  given  a  healthy  subject,  there 
appears  to  be  a  rapid  diminution  of  haemoglobin  and 
red  corpuscles.  Justus  comes  to  the  following  conclu- 
sions :  i._  In  untreated  syphilis  the  hemoglobin  is  more 
or  less  diminished,  and  this  diminution  varies  with  the 
severity  of  the  disease  and  its  tendency  to  spontaneous 
recovery.  2.  A  sudden  diminution  of  haemoglobin  fol- 
lows inunction  or  injection  of  a  large  dose  of  mercury. 
(This  is  directly  contradictory  to  Semmola's  statement.) 
3.  The  diminution  caused  by  mercury  varies  according 
to  the  severity  of  the  disease  and  to  the  condition  of 
the  nutrition  ;  with  injections  of  mercury  the  fall  of 
haemoglobin  can  be  repeated  after  several  injections.  4. 
The  cure  of  the  syphilitic  lesion  begins  when  the  fall 
of  haemoglobin  ceases,  and  is  followed  by  a  rise.  5. 
The  sudden  fall  of  hemoglobin  due  to  mercurial  treat- 
ment is  a  specific  peculiarity  of  the  blood  of  syphilitic 
persons  only,  and  does  not  take  place  in  healthy  indi- 
viduals, or  in  other  diseases.  6.  This  specific  reaction 
of  the  blood  is  established  at  the  time  when  swelling 
of  the  gland  occurs  ;  it  disappears  at  the  time  when 
the  e.xisting  syphilitic  lesions  attain  the  height  of  their 
development.  Justus  concludes  that  a  specific  change 
occurs  in  the  blood  of  syphilitic  persons,  and  this 
points  to  a  specific  means  of  treatment  applicable  only 
to  the  blood  of  syphilitic  individuals.  This  specific 
condition  of  the  blood,  established  by  the  action  of 
mercury,  precedes  the  affection  of  other  organs,  and 
the  disappearance  of  this  specific  reaction,  or  the  invo- 
lution of  the  specific  blood  change,  occurs  before  retro- 


grade changes  appear  in  other  organs,  if  syphilis  is 
not  treated  the  evolution  of  the  fall  of  haemoglobin, 
and  also  the  slow  increase  of  the  same  afterward,  are 
seen  ;  if  the  disease  is  treated  the  fall  of  haemoglobin 
is  greater  and  more  sudden,  and  the  rise  is  also  quicker. 
The  cure  by  mercury  is  in  all  cases  not  absolute,  but 
only  varies  according  to  the  duration  of  time.  The 
application  of  the  above  statements  to  the  diagnosis  is 
as  follows  :  In  doubtful  cases,  and  in  cases  of  late 
syphilis  with  a  fresh  train  of  symptoms,  a  diminution  of 
haemoglobin,  after  inunction  or  injection  of  mercury,  is 
characteristic    of  syphilis. — British   Medical  Journal. 

Aortic  Aneurism. — After  a  thorough  resume  of  this 
subject  the  author  concludes  that  aneurisms  of  the 
thoracic  aorta  may  be  most  safely  attacked,  after  medi- 
cal treatment  has  failed,  by  the  introduction  of  a  small 
quantity  of  inelastic  wire.  Abdominal  aneurisms  may 
first  be  explored  through  a  celiotomy  wound,  so  as  to 
determine  their  exact  nature  and  relations,  after  which 
the  question  of  treatment  will  depend  on  their  situation. 
It  may  be  impossible  to  use  other  means  than  that 
pointed  out  for  the  thoracic  variety,  or  the  other 
methods  of  temporary  or  permanent  ligation  may  be 
resorted  to,  according  to  the  conditions  revealed  by 
the  exploration. — Bristow.  J 

Anaesthetics. — Gurlt  continues  his  statistics  upon  the  i 

use  of  anaesthetics  in  the  German  clinics,  and  reports  ; 

on  a  collection  of  five  years,  with  i  death  to  2,909  ' 

cases  for  chloroform,  and  i  death  to  6,004  cases  for 
ether.  But  there  is  also  to  be  charged  to  the  ether  a 
certain  number  of  deaths  from  pneumonia,  which  is 
especially  likely  to  be  fatal  after  laparotomy. 

Appendicitis. — Relapsing  or  recurrent  appendicitis 
is  marked  by  periods  of  inflammation  similar  to  the 
primary  attack,  and  recurring  at  longer  or  shorter  in- 
tervals. It  exposes  the  individual  who  suffers  from  it 
to  peritonitis  by  perforation  or  without  it,  and  in  the 
intervals  he  is  never  free  from  danger.  The  etiology 
of  the  disease  is  not  clear.  The  recurrent  attacks  seem 
at  times  to  be  favored  by  mechanical  causes — foreign 
bodies,  adhesions — but  the  immediate  cause  of  the  in- 
flammatory process  is  unknown.  The  only  curative 
treatment  is  excision  of  the  appendix. — Challiol. 

Cancer. — In  a  case  where  the  bone  has  become  in- 
volved, secondary  to  cancer  of  the  breast,  Aikmann 
obtained  decided  relief  of  pain  by  the  administration 
of  salicylate  of  sodium,  in  doses  of  ten  grains,  three 
times  a  day.  Large  doses  of  opium  had  been  given  in 
vain. 

Erysipelas. — 

5.    Potass,  iodidi, 

Tincl.  ferri  chloridi, 

Syr.  aurantii aa    |  j. 

Aq.  purae |  iij. 

M.     Sig.  :  One  teaspoonful  in  water  four  times  a  day. 

To  Prevent  Rust. — One  per  cent,  of  common  baking 
soda  put  into  the  water  in  which  instruments  are  boiled, 
in  order  to  sterilize  them,  will,  to  a  great  extent,  if  not 
totally,  prevent  rusting. 

Cause  of  Varicocele.— There  are  three  principal 
causes  :  First. — .\nything  that  impairs  the  general 
vigor  of  the  part,  as  :  i,  Lak  of  proper  support  from 
relaxed  scrotum  ;  2,  masturbation  ;  3,  abuse  of  venery, 
ungratified  desires,  etc.;  4,  chronic  orchitis,  or  repeated 
attacks  of  acute  orchitis.  Second. — Anything  that 
produces  pressure,  as:  i,  Abdominal  tumors;  2,  en- 
larged inguinal  glands  ;  3,  hernia  :  4,  trusses,  or  belts 
worn  around  the  waist ;  5,  accumulation  of  fat  in  the 
omentum  and  mesentery.  Third. — Anything  that  pro- 
duces prolonged  muscular  effort,  as  :  i,  Prolonged 
riding  on  horseback  ;  2,  prolonged  rowing  :  3,  pro- 
longed exercise  in  running  or  waltzing  ;  4,  excessive 
and  violent  muscular  effort ;  whooping-cough,  some- 
times.— Rand.  ""        * 


December  28,    1895] 


MEDICAL    RECORD. 


91: 


Varicocele. — Varicocele  occurs  on  the  left  side  in  a 
proportion  or  ratio  of  20  to  i.  There  are  four  good 
reasons  for  its  frequency:  i.  The  left  testicle  hangs 
lower  in  the  scrotum,  and  thus  the  veins  support  a 
heavier  column  of  blood.  2.  The  spermatic  veins  of 
the  left  side  are  pressed  by  the  sigmoid  flexure  of  the 
colon  when  distended.  3.  The  spermatic  veins  of  the 
left  side  join  the  renal  vein  at  a  right  angle  to  the  cur- 
rent of  blood,  thus  impeding  the  rapid  return  of  blood 
from  the  left  testicle  and  veins.  4.  The  left  spermatic 
vein  is  by  some  authorities  stated  to  be  poorly  supplied 
with  valves. — Raxd. 

Multiple  Warts  of  Face. — 

Sulphuris  sublim 3  '*'. 

Glycerini 3  jss. 

Ac  acet 3  ijss. 

S.  :  Apply  locally  to  each  wart.  The  warts  dry  up  and  then 
drop  '->ft.     The  treatment  may  be  continued  for  several  days. 

— K.\P05I. 

Slipping  of  Obstetric  Forceps. — If  the  forceps  slips 
when  properly  applied  it  means  that  the  case  is  not  adapt- 
ed for  delivery  with  forceps  ;  i.e.,  the  forceps  is  contra- 
indicated,  and  its  further  use  will  result  only  in  doing 
harm.  Fenestrated  forceps  blades  slip  just  as  badly  as 
do  solid  blades,  if  the  head  is  too  large  :  any  forceps 
will  slip  if  it  does  not  fit  the  head.  If  the  forceps  slips 
while  strong  traction  is  being  made,  the  child's  skull 
will  surely  be  fractured.  If  the  child  must  be  born 
head  first,  because  version  is  impossible,  and  if  forceps 
cannot  deliver,  the  cephalotribe  is  the  best  instrument 
for  obtaining  a  hold  on  the  head  firm  enough  to  accom- 
plish delivery.  Oscillation  will  cause  advance  when 
straight  traction  fails. — Tucker. 

Anal  Fissure. — Several  cases  of  anal  fissure  were 
treated  with  pure  ichthyol  applied  with  a  brush  twice 
daily,  and  also  after  each  defecation.  The  cure  was 
rapid  in  every  instance.  The  same  treatment  is  recom- 
mended in  the  case  of  fissures  of  the  vulva  and  vagina. 

— WiLLIGEX. 

Abortion. — Threatened  abortion  should  be  treated  by 
absolute  rest,  with  opium  or  viburnum  prunifolium. 
Where  hemorrhage  occurs  without  dilatation  of  the  os 
and  cervi.x  the  antiseptic  tampon  is  indicated.  When 
hemorrhage  is  present  and  a  finger  can  be  inserted  the 
uterus  should  be  emptied  by  the  finger,  accompanied  by 
antiseptic  irrigation.  If  the  hemorrhage  is  considera- 
ble and  only  partial  dilatation  is  present,  the  finger  is 
the  safest  instrument  to  complete  dilatation.  In  many 
cases,  if  the  patient  be  kept  clean,  the  membranes  and 
placenta  will  be  expelled  without  interference  and  with- 
out injury.  In  all  cases  ergot  should  be  used  in  daily 
doses  during  the  first  week.  The  use  of  the  sharp  cu- 
rette is  not  encouraged.  Vaginal  douches  after  abor- 
tion should  be  given  for  positive  indications  only. 

— J  AC  LB. 

Chloroform  Collapse. — Stretch  the  sphincter  ani  with 
thumbs  or  speculum.  (Suggested  by  Dr.  Daily,  New 
York  Medical  Times,  February,  1893.  for  morjihine 
narcosis.) — Dcke. 

Anal  Fissure. — Palliative  : 

8.    Ext.  bellad gr.  i  to  i. 

Cocaine  hydrochl gr.  i  to  i- 

01.  theob gr.  X. 

For  a  suppository  10  be  used  half  an  hour  before  an  enema  is 
given. 

— Adler. 

K.    Ext.  conii I  iJ-_ 

01.  ricini 3  "j- 

Ung.  lanolin    ad  3  ij. 

Apply  to  parts  l>efore  and  after  passage. 

— Cripps. 

Eectal  Hemorrhage  in  Women. — Elevate  extremities 
and  pelvis  for  twelve  to  twenty-four  hours.  Remove 
hemorrhoids  with  the  wire  ecraseur  after  paralyzing 
the  sphincter. — Brown  (of  Stoneham,  Mass.). 


Hemorrhoids. — Sitz-bath  and  washing  with  water  at 
120°  to  130°  F.  Insert  into  anus  cotton  tampon  wet 
with  two  per  cent,  cocaine  before  and  after  stool.  Di- 
late with  Trelat's  two-bladed  speculum.  Extirpate  only 
as  a  last  resort. — Reclus. 

Rectal  Abscess. — Early  free  incision  under  anesthe- 
sia, irrigate  with  1-5,000  mercuric  solution,  introduce 
finger  and  break  down  bridges,  loculi,  etc.,  inject  per- 
oxide of  hydrogen,  divulse  sphincter  with  dilator. — 
M.\THEW3  {Mat/ic-u's's  Medical  Quarterly). 

Strychnine  nitrate,  gr.  -^,  as  a  muscular  tonic  in 
labor. — Russell. 

Ether  Administration. — Use  a  Clover  inhaler,  but 
get  a  larger  air-bag  than  is  usually  supplied.  It  is 
easiest  to  get  good  anaesthesia  by  rotating  the  reservoir 
until  the  indicator  reaches  the  figure  2  until  patient  is 
under,  afterward  keeping  it  midway  between  i  and  o. 
The  quantity  of  ether  is  less,  but  the  resulting  anaes- 
thesia is  complete. — Freem.\x  {Bristol  Medicc-Chirur- 
gical  Joiirrui!.  September,  1895). 

The  Porte-Canstiqne  should  be  kept  most  scrupu- 
lously clean — the  nitrate  of  silver  stick  washed  each 
time  after  using. 

Electro-magnet  applied  over  the  arm  detects,' by  a 
sticking  pain,  the  situation  of  a  needle  embedded 
nearly  a  centimetre  in  the  subcutaneous  fatty  tissue. — 
Ulrich  {Hospitals- Tidende,  ii.,  35). 

Nose-bleed. — .A.pply  on  the  end  of  a  sound  wrapped 
with  cotton  a  three  per  cent,  solution  of  trichloracetic 
acid.  A  twenty  per  cent,  cocaine  solution  can  be 
added  to  prevent  pain. — Cozz.alino  {Journal  de  Me'd. 
de  Paris). 

Migraine. — Each  night  for  a  long  time  fifteen  grains 
of  salicylate  of  soda  in  coffee. — MObius  (  Ther.  Mortals., 
ii.,  1895). 

Suppurative  Adenitis  of  the  Groin. —  i.  The  opera- 
tive field  is  shaved  and  rendered  surgically  clean  in 
the  usual  manner.  2.  A  few  drops  of  a  four  per  cent, 
solution  of  cocaine  are  injected  beneath  the  skin  where 
the  puncture  is  to  be  made.  3.  A  straight  sharp- 
pointed  bistoury  is  then  thrust  well  into  the  most  prom- 
inent part  of  the  tumor  until  pus  tlows.  4.  .-Ml  of  the 
pus  is  forced  out  through  this  opening  by  firm  but 
gentle  pressure,  as  this  procedure  is,  as  a  rule,  very 
painful.  5.  The  abscess  cavity  is  irrigated  with  pure 
peroxide  of  hydrogen  until  it  returns  particularly  clear. 
6.  It  is  then  irrigated  with  i  to  5,000  bichloride  of 
mercury  solution,  all  of  which  is  carefully  squeezed 
out.  7.  The  now  thoroughly  cleansed  abscess  cavity 
is  completely  filled,  but  not  painfully  distended,  with 
ten  per  cent,  iodoform  ointment  by  means  of  an  ordi- 
nary conical  glass  syringe,  previously  warmed  in  hot 
water.  8.  A  cold  wet  bichloride  dressing  is  applied 
with  a  fairly  firm  spica  bandage,  the  cold  congealing 
the  ointment  at  the  wound,  and  thus  preventing  its 
escape  into  the  dressing. — Fontau. 

Mixture  for  Local  Anaesthesia. — The  following  mixt- 
ure is  given  for  local  anaesthesia,  applied  as  a  spray  : 

8 .    Chloroform 10  parts. 

Ether 15  pans. 

Menthol '  pa". 

The  anaesthesia  resulting    from    the  application    lasts 
about  five  minutes. — I.e  Ger.wt. 


In  Good  Old  Days. — Dr.  Laudar  Brunton  used  to  re- 
late  that    when    he    was    the    secretary    of  the 


Medical  Society  he  discovered  by  the  old  records  that 
one  evening  had  been  given  in  that  society  to  the  dis- 
cussion of  the  subject :  "  Did  .\dam  Have  a  Navel  or 
Not?"  and  another  to  the  question  of  "Eve's  Physi- 
ology while  in  Paradise."  Our  medical  societies  to- 
day are  less  speculative  and  more  practical. 


914 


MEDICAL   RECORD. 


[December  28,  1895 


Medical   Record: 

A  Weekly  yournal  of  Medicine  and  Sitrgcry. 


GEORGE  F.  SHRADY,  A.M.,  M.D.,  Editor. 


Publishers 
WM.  WOOD  &  CO..  43,  45,  &  47  East  Tenth  Street. 


New  York,  December  28,  1895. 


THE    PAST    AND    THE     FUTURE    OF     THE 

MEDICAL  RECORD. 
In  closing  another  of  the  many  volumes  of  the  Medi- 
cal Record  we  take  the  usual  opportunities  for  not- 
ing the  part  which  the  journal  has  taken  in  chronicling 
the  history  of  medicine  throughout  the  world  during 
the  period  terminated  by  the  present  issue.  Although 
this  comprises  but  half  the  year,  the  occasion  may 
warrant  a  general  reference  to  the  work  of  1895  with 
the  completion  of  the  two  volumes  published  during 
that  time. 

Notwithstanding  no  great  discoveries  have  been  made 
there  has  been  substantial  progress  along  the  new  lines 
of  thought  and  study  made  possible  by  previous  original 
investigations.  In  every  department  there  has  been  a 
healthful  and  conservative  effort  to  conscientiously  ver- 
ify preconceived  opinions,  on  the  one  hand,  or  to  modi- 
fy them,  on  the  other.  Without  desiring  to  disparage 
the  great  advances  constantly  being  made  in  surgery, 
we  are  more  than  pleased  to  acknowledge  that  medi- 
cine proper  is  rapidly  gaining  in  the  race  for  those 
more ,  distinctive  and  more  substantial  triumphs  so 
long  monopolized  by  her  twin  sister.  The  study  of 
bacteriology  in  connection  with  the  hitherto  unknown 
causes  of  many  medical  diseases  and  the  promising 
future  of  sero-therapy  will  tend  to  keep  alive  anticipa- 
tions that  can  scarcely  be  too  extravagant  for  any  pos- 
sible realization. 

In  attempting  to  review  in  detail  the  reasons  for  such 
general  statements  we  feel  that  we  would  be  going 
over  ground  already  covered  by  all  such  as  have 
attentively  and  studiously  read  the  Medical  Record. 
To  refer,  even  in  a  casual  way,  to  the  number  of  arti- 
cles published,  the  variety  of  subjects  treated,  the  multi- 
tudinous and  widespread  sources  from  which  they  have 
emanated,  and  their  practical  and  timely  characters, 
would  occupy  unnecessary  space,  and  be  a  useless 
reiteration  of  welldeironstrated  facts.  The  credit 
side  of  the  account  in  such  matters  is  given  in  our  In- 
dex. Therein  is  shown  not  only  what  has  been  pub- 
lished in  these  columns  during  the  past  six  months, 
but  what  has  been  done  by  all  the  notable  workers  in 
this  country  and  elsewhere.  We  may  safely  venture 
to  say  that  there  is  hardly  a  topic  of  any  practical 
character  in  any  of  the  departments  of  medicine  or 
surgsry  which  has  not  been  noticed  either  in  full  as 
special  contributed  material  or  in  abstract  from  simi- 
lar articles  in  other  journals,  domestic  and  foreign. 


In  keeping  with  this  desire  to  chronicle  the  broad 
and  impartial  history  of  progressive  medicine  in  every 
line,  we  have  aimed  to  give  each  branch  its  due  atten- 
tion in  the  hope  that  no  man,  whatever  his  special 
work  may  be,  can  fail  to  find  in  the  Medical  Record 
something  that  may  interest  and  instruct  him,  and 
make  it  worth  his  while  to  read  and  profit  by  a  pro- 
fessedly cosmopolitan  journal. 

The  success  of  the  Medical  Record  as  shown  by  a 
subscription  list  far  larger  than  any  in  this  country,  and. 
equal  to  that  of  the  leading  foreign  journals  ;  its  influ- 
ence as  an  exponent  of  advanced  medical  opinion  ;  its 
careful  verification  of  facts  before  presentation  ;  its 
impartial  judgment  on  all  matters  affecting  the  true 
and  honorable  relations  of  physicians  as  a  body ;  its 
disposition  to  give  the  humblest  and  most  obscure  con- 
tributor an  audience  in  the  interests  of  truth  and  fair 
play,  and  its  freedom  from  any  commercial  benefits 
other  than  those  that  centre  upon  the  business  prosper- 
ity of  a  thoroughly  independent  journal,  have  abun- 
dantly proved  that  such  a  periodical  managed  for  the 
profession  and  by  the  profession  has  abundantly  vin- 
dicated its  right  to  exist  and  to  continue. 

We  trust  also  that  it  may  not  appear  unbecoming  in 
us  to  refer  to  the  readers  of  the  Medical  Record,  scat- 
tered as  they  are  over  every  country  throughout  the  civil- 
ized world,  and  to  say  that  we  are  proud  of  our  friends 
and  of  their  practical  appreciation  of  our  efforts.  They 
compose  an  audience  worthy  of  our  highest  endeavor, 
not  only  workers  themselves,  but  keenly  alive  to  the 
work  of  others.  It  is  the  common  experience  of  writers 
for  its  columns  that  more  earnest  correspondence  is  in- 
vited concerning  articles  written  and  ideas  advanced 
than  is  possible  through  any  other  legitimate  medium. 
The  writer  from  Oregon  thus  reaches  the  reader  in 
Arabia,  and  the  questioner  from  New  York  may  receive 
answers  simultaneously  from  Patagonia,  Japan,  or 
Siberia. 

It  will  also  interest  the  many  friends  of  the  Medi- 
cal Record  to  know  that  its  circulation  has  increased 
so  greatly  that  it  is  no  longer  possible  to  print  it  from 
type.  To  maintain  its  high  standard  as  a  medical 
newspaper  its  forms  have  to  be  kept  open  each  week 
until  the  last  moment  and  then  printed  in  the  most 
expeditious  manner. 

To  meet  the  recjuirements  thus  made  necessary  we 
shall,  beginning  with  the  new  year,  set  the  type  for 
the  Medical  Record  by  machine  and  electrotype  the 
pages  as  fast  as  they  are  made  up.  These  electrotype 
I)lates  will  then  be  transferred  to  modern  perfecting 
presses  and  the  whole  large  edition  run  off  between  six 
o'clock  on  Thursday  evening  and  daybreak  of  Friday. 
As  soon  as  the  last  form  begins  to  come  off  the  press 
it  is  rapidly  tranferred  to  the  bindery  in  lots  of  one 
thousand  for  folding  and  wiring. 

It  should  be  known  and  appreciated  that  while  the 
issue  of  a  weekly  medical  journal  of  anywhere  from 
5,000  to  10,000  copies  is  comparatively  a  simple  mat- 
ter, only  a  printer  and  binder  can  thoroughly  under- 
stand the  difficulties  which  have  to  be  overcome  in 
getting  out  practically  in  about  twenty  hours  an  edition 
so  large  as  that  of  the  Medical  Record.  \Viih  the 
great  changes  we  have  referred  to,  however,  the  Medi- 
cal Record  will  be  able  still  to  maintain  its  position 


December  28,  1895] 


MEDICAL    RECORD. 


915 


ahead  of  all  competitors  in  the  promptness  of  its  issue  ; 
furthermore,  they  insure  the  printing  of  the  paper 
every  week  from  absolutely  new  and  perfect  type 
plates. 

The  Medical  Record  will  thus  be,  we  believe, 
the  only  medical  journal  in  the  world  printed  from 
electrotype  plates  and  on  modem  newspaper  perfecting 
presses.  It  marks  an  epoch  in  the  literature  of  medi- 
cine of  which  the  profession  in  American  may  well  be 
proud,  for  to  their  liberal  support  and  appreciation 
of  the  efforts  of  the  editor  and  publishers  it  is  due. 
N'or  can  we  omit  our  grateful  acknowledgments  to  the 
local  medical  journals,  many  of  them  most  ably  edited 
and  worthy  of  the  generous  support  of  their  constitu- 
ency, for  the  uniformly  kind  and  hearty  endorsement 
they  have  accorded  the  Medical  Record. 

With  an  editorial  staff  comprising  a  number  of 
learned  and  able  men,  with  large  experience  and  long 
training,  and  medically  educated  reporters  of  excep- 
tional merit,  with  special  correspondents  established 
in  most  of  the  leading  centres  of  medicine  in  the 
world,  with  an  unstinting  expenditure  in  every  direc- 
tion when  possible  results  may  seem  to  justify,  it  is 
hoped  still  further  to  merit  the  approval  of  the  pro- 
fession. 


HOW  EXPERT  TESTIMONY  COULD  BE  MADE 
VALUABLE. 

The  recent  case  of  Hannigan,  who  was  adjudged  insane 
on  a  trial  for  murder,  committed  to  an  asylum,  and 
subsequently  declared  perfectly  sane  by  the  asylum 
superintendent,  emphasizes  the  absurdity  of  the  pres- 
ent system  of  expert  testimony.  We  do  not  pretend 
to  offer  any  opinion  as  to  the  real  guilt  of  the  slayer, 
whether  the  act  of  shooting  in  cold  blood  was,  under 
the  strong  provocation  of  the  case,  justifiable  or  not, 
but  simply  to  refer  to  the  apparently  inappropriate 
character  of  the  plea  for  the  defence.  We  simply  note 
the  fact  that  the  plea,  based  on  the  opinion  of  experts, 
evidently  had  no  foundation  in  fact.  It  is  beyond 
question  that  such  was  due  entirely  to  the  confusion 
created  in  the  minds  of  the  jury  by  the  degree  and 
character  of  the  swearing  of  those  scientific  gentlemen 
who  were  engaged  to  do  the  best  for  their  respective 
sides.  It  is  easy  to  see  how  questions  concerning 
strictly  scientific  probabilities  can  be  so  ingeniously 
framed  as  to  bring  out  telling  facts  in  support  of  any 
medical  or  legal  theory,  and  yet  not  in  the  slightest 
degree  affect  the  real  honesty  of  the  answers,  nor 
ostensibly  impugn  the  proper  motives  of  the  witnesses. 
It  thus  frequently  happens  that  trials  based  mainly 
on  the  theories  of  experts  become  a  travesty  of  jus- 
tice, and  by  technically  overruling  conservatively  quali- 
fying circumstances  defeat,  the  real  end  in  view,  ob- 
taining "the  truth,  the  whole  truth,  and  nothing  but 
the  truth."  Hence  there  appears  more  ground  than 
we  are  first  willing  to  admit,  for  the  oft-repeated 
assertions  that  experts  can  be  made  to  swear  to  any- 
thing to  contradict  each  other,  and  to  prove  opposite 
probabilities.  Even  the  so-called  intelligent  jury, 
hemmed  within  the  boundaries  of  legally  admitted 
testimony  and  barred  by  the  rulings  of  what  is  judi- 
cially considered   "irrelevant,    incompetent,  and   un- 


natural ;  "  are  as  likely  to  go  wrong  as  right  in  arriving 
at  a  just  verdict. 

Under  such  circumstances  there  is  no  need  of  argu- 
ment to  prove  that  it  is  absolutely  impossible  to  obtain 
strictly  impartial  testimony.  On  former  occasions  we 
have  frequently  suggested  a  remedy  for  such  acknowl- 
edged defects  in  our  medico-legal  systems  in  the  crea- 
tion of  a  commission  of  experts  that  should  be  strictly 
impartial,  should  take  testimony  for  both  sides,  should 
properly  reconcile  apparently  conflicting  opinions,  and 
should  directly  advise  with  the  court  on  all  the  essen- 
tial points  involved  in  a  given  case.  We  take  this  oc- 
casion to  reiterate  our  views  on  this  subject,  needing  no 
better  text  for  their  earnest  advocacy  than  the  one 
which  has  just  presented  itself. 


EARLY    RISING   AND   INSANITY. 

The  great  poets  of  the  world  have  always  sung  in 
praise  of  sleep  : 

•' sore  labor's  bath, 

Balm  of  hurt  minds." 

They  have  always  consistently  opposed  the  habit  of 
early  rising,  except  in  so  far  as  they  have  depicted 
(writing  by  the  light  of  the  lamp)  the  glories  of  the 
morning  and  the  suggestive  promises  of  a  beautiful 
sunrise.  The  Scriptures  are  also  on  the  side  of  pro- 
longing slumber  : 

■'  Yet  a  little  sleep,  a  little  slumber,  a  little  folding 
of  the  hands  to  sleep,"  says  Solomon. 

But  the  habits  of  modern  civilization  and  the  tradi- 
tions of  family  life  have  been  steadily  set  against  these 
poetical  and  scriptural  ideals.  In  whatever  else  men 
differ,  or  in  whatever  other  way  they  err,  it  is  agreed 
that  the  habit  of  early  rising  is  seemly,  advantageous, 
and  necessary. 

The  statement,  therefore,  by  a  prominent  alienist 
and  superintendent  of  a  large  insane  asylum,  that  early 
rising  promotes  insanity,  comes  with  a  terrible  shock 
upon  the  serenity  of  established  beliefs  and  long-cher- 
ished customs.  Dr.  Selden  H.  Talcott,  of  Middle- 
town,  N.  Y.,  however,  supplements  this  statement  of 
his  by  arguments  of  no  mean  weight.  He  calls  atten- 
tion to  the  relative  frequency  with  which  farmers,  their 
wives,  daughters,  and  sons  become  insane.  The  cause 
of  this  has  heretofore  been  thought  to  be  their  isolated 
lives,  their  hard  work,  and  perhaps  the  excessive  use 
of  pie  and  potatoes  ;  yet  these  have  never  seemed  quite 
adequate  explanations,  when  one  considers  the  fact 
that  the  fanner  has  constantly  fresh  air,  abundant  ex- 
ercise, no  undue  excitement  or  mental  strain,  and  rela- 
tively little  alcoholism  and  syphilis.  So  that  Dr.  Tal- 
cott's  view  is,  at  least,  a  helpful  one,  in  the  way  of  ex- 
plaining the  psychopathic  tendencies  of  the  ordinary 
agriculturist.  He  states  that  the  excessively  early 
hours  of  rising,  which  are  customary  among  the  farm- 
ers, and  which  hours  are  imposed  upon  their  sons  and 
daughters  and  wives,  prevent  a  sutiicient  amount  of 
rest.  Growing  children,  he  thinks,  in  ])articular,  suffer 
from  "  the  artificial  cut  off  "  which  li  applied  so  rigidly 
to  their  lives. 

The  suggestion  of  Dr.  Talcott  is  valuable  from  an- 
other point  of  view,  because  the  particular  cause  of  in- 


gib 


MEDICAL    RECORD. 


[December  28,  1895 


sanity  to  which  he  refers  is  one  that  can  be  so  easily 
and  comfortably  combated.  It  is  not  like  the  en- 
forced abstinence  from  alcohol,  and  tea  and  tobacco, 
high  thinking,  and  all  the  other  ordinary  comforts  or 
luxuries  of  civilization.  The  diminution  of  insanity 
by  staying  in  bed  later  mornings  is  a  task  to  which  all 
will  address  themselves  with  pleasure,  and  we  believe 
that  every  farmer's  boy  will  have  a  sense  of  particular 
kindness  toward  the  physician  who  has  discovered  this 
new  method  for  preventing  possible  mental  disorders. 
We  might  readjust  the  well-known  lines  of  Sir  William 
Jones,  for  the  benefit  of  the  farmer,  somewhat  as  fol- 
lows : 

"  Eight  hours  to  sleep,  to  soothing  pleasures  seven, 
Nine  to  the  farm  allot,  and  all  to  heaven." 


THE    TREATMENT    OF  CHRONIC   PROGRES- 
SIVE   RHEUMATISM. 

This  condition,  commonly  known  as  rheumatic  gout, 
arthritis  deformans,  and  rheumatoid  arthritis,  is  far 
more  distressing  to  the  patient  than  it  is  interesting  to 
the  physician.  As  a  potent  cause  of  many  kinds  of 
suffering,  however,  it  is  raised  of  necessity  to  a  posi- 
tion of  dignity,  and  one  worthy  of  careful  study.  A 
little  paper  by  Cantagrel,  in  Mt'deciiie  Modi-rne,  October 
16,  1895,  emphasizes  the  importance  of  certain  well- 
known  facts  and  brings  into  view  others  less  generally 
recognized.  Rheumatic  gout  or  chronic  progressive 
rheumatism  is  a  disease  of  general  nutrition  and  thus 
differs  widely  from  acute  articular  rheumatism,  now  be- 
lieved to  be  an  infectious  process.  It  occurs  at  all 
ages,  in  all  climates,  though  its  most  marked  influence 
appears  between  forty  and  sixty.  Women  suffer  more 
often  than  men.  Heredity,  direct  or  indirect,  is  a  power- 
ful factor  in  its  production.  It  is  found  in  families  where 
there  has  been  gout,  phthisis,  or  Bright's  disease,  and 
is  called  into  activity  by  damp  and  cold,  by  exposure 
and  hardships,  by  overwork  and  strain.  The  first  ne- 
cessity is  perfect  hygiene  :  warm  clothing,  flannel 
next  the  skin,  woollen  sheets,  and  possibly  a  change  of 
residence  and  also  of  climate.  Diet  must  be  arranged 
to  suit  special  requirements.  Above  all,  the  patient 
must  not  be  forgotten  in  the  study  of  the  disease. 
Massage  and  rabbings  with  alcohol  are  of  service. 

Of  remedies,  cod-liver  oil  is  the  best,  together  with 
iron,  arsenic,  and  the  iodo-tannic  wine  of  Nourry.  For 
pain,  antipyrin,  salol,  salophen,  and  colchicum  are  of 
chief  reliance.  Charcot  gave  large  doses  of  alkalies 
combined  with  quinine — thirty  or  forty  grammes  daily 
of  bicarbonate  of  soda  for  weeks  at  a  time.  Between 
the  intervals  of  acute  painful  attacks  general  nutrition 
should  be  improved  by  means  of  iodides  and  arsenic. 
This  is  the  only  real  treatment,  this  improvement  and 
modification  of  nutrition,  and  it  should  be  begun  early 
and  continued  late  for  a  very  long  time,  indefinitely. 
The  iodo-tannic  wine  of  Nourry  possesses  special  ad- 
vantages. Tannin  acts  as  a  powerful  tonic  and  enables 
the  stomach  to  assimilate  readily  the  dose  of  iodine. 
Arsenic  does  not  always  give  such  good  results,  for  it 
sometimes  increases  the  pain.  To  obviate' this  diffi- 
culty M.  G.  de  Mussy  has  devised  a  plan  of  arsenical 
baths,    to    be    used    upon    the   subsidence    of    acute 


symptoms.  One  to  eight  grammes  of  arseniate  of 
soda  and  one  hundred  or  one  hundred  and  fifty 
grammes  of  bicarbonate  of  soda  are  dissolved  for 
each  bath.  At  the  same  time  tonics  are  adminis- 
tered— quinine,  iodide  of  potassium,  or  vin  de  Nourrj*. 
Baths  seem  to  be  of  benefit  because  of  their  heat: 
hot  mud  baths  are  equally  serviceable.  The  writer 
Cantagrel  considers  that  this  very  hopeless  disease 
is  not  without  hope  ;  iodide  inwardly,  arsenical  baths 
outwardly.  Pain  may  be  made  to  disappear  at  the 
end  of  two  or  three  weeks.  Deformity  and  stiffness, 
under  the  influence  of  the  internal  iodide  and  the 
external  arsenic,  together  with  the  prudent  use  of  mas- 
sage and  rhythmical  movements,  cannot  be  expected  to 
show  much  improvement  earlier  than  three  or  four 
months.  It  must  be  remembered  that  rheumatic  gout 
(chronic  progressive  rheumatism)  is  a  condition  that  is 
partly  degenerative  and  partly  inflammatory.  It  is 
possible  to  arrest  it  and  prevent  acute  attacks. 


^cius  of  the  'Wi,tzk. 

No  Medical  Commissioner  of  Charity.  — Mayor  Strong 
has  declined  to  appoint  a  medical  commissioner  of 
charity,  a  political  laymen  having  been  given  the  posi- 
tion. His  Honor  very  significantly  says  :  "  I  am  s/ill 
a  reformer." 

A  Change  of  Heart — Our  esteemed  contemporary, 
the  Medical  Xe:i's,  for  some  time  of  Philadelphia,  is  to 
remove  its  editorial  offices  to  this  city  on  the  first  of 
the  year,  thereby  showing  its  appreciation  of  the  greit 
fact  that  there  is  but  one  medical  centre  in  this  coun- 
try, and  that  the  metropolis.  Under  date  of  July  27. 
1895,  a  propos  of  the  temporary  removal  of  another 
Philadelphia  journal  to  this  town,  the  Medical  News 
remarked  :  "  We  learn  with  regret  that  our  most  es- 
teemed contemporary,  the  Medical  and  Surgical  Re- 
porter, in  order  to  be  nearer  the  printing-office  of  its 
new  publisher,  has  moved  its  editorial  offices  to  New 
York.  We  are  sorry  that  business  reasons  should  force 
it  to  exchange  the  Medical  atmosphere  of  its  life  long 
home  for  one  of  such  uncongenial  surroundings.  It  is 
indeed  true  that  the  footings  of  our  clearing-house 
transactions  do  not  equal  those  of  our  self-complaisant 
sister  city."  We  are  surprised  that  our  esteemed  con- 
temporary's views  have  so  changed  in  five  short  months 
that  it  will  even  come  away  "from  the  printing-office  of 
its  publishers  in  order  to  breathe  the  congenial  atmos- 
phere of  this  centre  of  medical  thought  and  activity. 

The  Harlem  Uedical  Association  Dinner  was  held  at 
the  Harlem  Casino,  December  21st.  Dr.  -Samuel  E_ 
Gibbs  presided  in  '"  Quaint  Club  "  style  and  deftly 
joined  to  the  speeches  the  following  members  :  Drs. 
Malcolm  McLean,  Charles  A.  Clinton,  Thomas  H. 
Manley,  Edward  Fridenberg,  M.  C.  O'Brien,  E.  Clark 
Tracey,  Emil  Mayer,  A.  H.  Leary,  John  Shrady,  F. 
M.  Nye,  Richard  Van  Santvoord,  W.  M.  Leszynsky, 
and  Ferdinand  C.  Valentine. 

Prevention  and  Cure. — .\n  ounce  of  soap  is  worth  a 
pound  oi  pus. 


December  28,  1895] 


MEDICAL    RECORD. 


917 


A  Case  of  auadrnplets.— Dr.  Frank  A.  Stahl  reports 
in  the  Journal  of  the  American  Medical  Association  of 
December  14th,  the  history  of  a  case  of  quadruplets. 
He  gives  with  it  a  very  striking  picture  of  the  babies, 
side  by  side,  James,  Patrick,  Bridget,  and  Catherine. 
They  are  all  nice-looking  babies,  but,  unfortunately, 
they  were  born  dead.  The  children  were  all  born  be- 
tween three  and  six  o'clock,  and  the  labor  was  natural. 
The  mother  is  thirty-three  years  of  age,  had  had  six 
children,  all  born  alive  but  one  ;  she  had  had  no  previ- 
ous multiple  births.  Dr.  Stahl  says  that  a  case  of 
quadruplets  occurs  but  once  in  three  hundred  and  fifty 
thousand  to  four  hundred  thousand  births. 

Airol  is  a  drug  which  is  said  to  be  an  improvement 
upon  dermatol,  bismuth,  iodoform,  etc.  It  is  a  com- 
pound of  bismuth,  gallic  acid,  and  iodine  ;  a  green 
powder,  tasteless,  odorless,  and  insoluble. 

United  States  Marine  Hospital  Examinations. — There 
will  be  held  at  Washington,  D.  C,  on  February  10,  1896, 
a  competitive  examination  of  candidates  for  appoint- 
ment to  the  position  of  Assistant  Surgeon  in  the  United 
States  Marine  Hospital  Service.  Candidates  are  re- 
quired to  be  not  less  than  twenty-one  years  of  age,  and 
no  appointment  is  made  of  any  candidate  over  thirty 
years  of  age.  They  must  be  graduates  of  a  reputable 
medical  college,  and  furnish  testimonials  as  to  charac- 
ter. Successful  candidates,  having  made  the  required 
grade,  are  appointed  in  order  of  merit  as  vacancies 
arise  during  the  succeeding  year.  There  is  at  present 
one  vacancy.  The  salary  of  an  Assistant  Surgeon  is 
$1,600  per  annum,  together  with  furnished  quarters, 
light,  and  fuel. 

Fuller  information  may  be  obtained  by  addressin'g 
the  Surgeon-General  of  the  Marine  Hospital  Service, 
Washington,  D.  C. 

A  Diplomatic  Doctor  to  Increase  the  Ranks. — The 
Nicaraguan  Legation  in  Washington,  D.C.,  has  been 
closed.  The  Nicaraguan  Government  revoked  the 
credentials  of  Dr.  Horatio  Guzeman  as  its  diplomatic 
representative  to  the  United  States,  and  he  at  once 
closed  the  legation. 

The  Wilhelm  Meyer  Memorial. — The  death  of  Pro- 
fessor Hans  Wilhelm  Meyer,  of  Copenhagen,  has  been 
followed  by  a  movement  of  a  somewhat  unusual  char- 
acter. It  has  become  a  matter  of  history  that  Dr. 
Meyer  was  the  first  to  actually  recognize  the  condition 
known  as  adenoid  hypertrophy  at  the  vault  of  the 
pharynx,  to  warn  against  its  dangers,  and  to  propose 
the  means  for  its  prompt  and  effective  cure.  The  re- 
sult of  Dr.  Meyer's  teaching  has  been  to  bring  urgently 
needed  relief  to  many  thousands  of  children  in  every 
civilized  country  in  the  world,  and  it  is  safe  to  say  that 
there  is  no  man  of  our  time  to  whom  the  present  gen- 
eration owes  a  deeper  debt  of  gratitude.  It  is  proposed 
to  erect  a  memorial  statue  to  Dr.  Meyer  in  Copenhagen, 
from  small  nominal  subscriptions  to  be  collected  from  the 
patients  and  physicians  who  have  been  benefited  by  Dr. 
Meyer's  work.  An  international  committee,  consisting  of 
one  representative  from  each  of  the  principal  countries  of 
Europe  and  from  the  United  States,  has  been  organized 
abroad,  the  representative  in  each  case  being  the  presi- 
dent of  the  national  laryngological  or  otological  asso- 
ciation of  his  respective  country,  an     he  is  authorized 


to  effect  such  local  organization  as  may  seem  expedient. 
The  representative  of  the  United  States  is  the  presi- 
dent of  the  American  Laryngological  Association,  un- 
der whose  direction  the  establishment  of  a  national 
committee  is  being  rapidly  perfected. 

The  College  and  Clinical  Record  will  be  hereafter 
known  under  the  name  of  Dunglison's  College  and 
Clinical  Record ;  a  Monthly  Journal  of  Practical  Medi- 
cine. 

Nitrites  in  Infective  Diseases. — Dr.  Petrone,  an 
Italian  physician,  finds  that  rabbits  live  twice  as  long 
after  having  been  inoculated  with  rabies,  if  they  re- 
ceive hypodermic  injections  of  nitrite  of  sodium.  He 
has  used  the  same  substance  in  syphilis  and  other  in- 
fectious diseases,  and  thinks  that  it  has  a  power  against 
infections. 


SAMUEL    FLEET    SPEIR,  M.D., 


Dr.  Samuel  Fleet  Speir,  of  Brooklyn,  died  at  his 
sanitarium,  162  Montague  Street,  in  his  fifty  seventh 
year.  His  illness  had  lasted  nearly  a  year,  beginning 
with  cancer  and  ending  with  blood-poisoning,  inflam- 
mation, and  hemorrhage  of  the  stomach.  He  had 
been  confined  to  his  bed  only  two  weeks.  Dr.  Speir 
was  the  son  of  Robert  Speir,  a  leading  merchant  in 
this  city  fifty  years  ago.  His  mother  was  Hannah 
Fleet  Speir,  a  lineal  descendant  of  Captain  Thomas 
Fleet,  of  Northport,  L.  I.,  who  was  a  son  of  Sir  Thomas 
Fleetwood,  of  the  British  navy,  and  dropped  the  sec- 
ond syllable  from  his  name  when  he  came  to  America 
and  settled  at  Northport,  in  1650.  Dr.  Speir  was  born 
in  the  old  Fleet  mansion,  at  Fulton  and  Gold  Streets, 
on  April  9,  1838.  In  1857  he  entered  the  medical 
department  of  the  University  of  New  York,  and  was 
graduated  three  years  later  with  high  honors,  carrying 
off  the  Mott  gold  medal  and  the  Van  Buren  prize,  and 
also  the  Wood  prize  from  Bellevue  Hospital.  After 
his  graduation  he  passed  eighteen  months  in  profes- 
sional travel  in  Europe,  and  on  his  return,  under  the 
direction  of  the  Sanitary  Commission,  he  went  to  the 
front  with  three  assistants  and  rendered  valuable  ser- 
vice in  the  Array  of  the  Potomac. 

Among  the  best  known  works  from  his  pen  are  "  Use 
of  the  Microscope  in  Differential  Diagnosis  of  Morbid 
Growth,"  and  "  New  Method  of  Arresting  Hemorrhage 
by  the  Use  of  Artery  Constrictor."  His  essay  on  the  last- 
named  subject  won  him  a  prize  from  the  Medical  So- 
ciety of  the  State  of  New  York.  He  was  a  member  of 
the  American  Medical  Association,  the  New  York  State 
Medical  Society,  the  New  York  Pathological  Society, 
the  Kings  County  Medical  Society,  a  fellow  of  the 
New  York  Academy  of  Medicine,  and  a  member  of  the 
New  York  Journal  Association.  He  served  by  invita- 
tion as  a  member  of  the  International  Medical  Con- 
gress in  Philadelphia  in  1876.  He  was  the  surgeon  of 
the  Brooklyn  Eye  and  Ear  Infirmary  as  far  back  as 
1864,  and  had  been  identified  with  the  work  of  the 
Brooklyn  Hospital  for  the  last  twenty-five  years.  He 
was  Demonstrator  of  .Vnatomy  at  the  Long  Island  Col- 
lege Hospital,  and  was  the  founder  of  the  Dispensary 
of  the  Helping  Hand.  Dr.  Speir  was  an  enthusiastic 
sportsman  and  a  great  lover  of  dogs  and  horses.  He 
was  the  founder  of  the  Robins  Island  Gun  Club,  which 
was  organized  in  1881.  He  was  married  to  I'rances  S., 
a  daughter  of  Peter  A.  Hegeman  of  this  city,  in  1869. 
She  and  one  daughter  survive  him. 


9i8 


MEDICAL    RECORD. 


[December  28,  1895 


gfOfivcsB  of  HXiedical  Science. 

Surgical  Scarlet  Fever. — Dr.  McGraw  reminds  us 
that  surgical  operations  render  children  exceedingly 
susceptible  to  scarlet  fever.  In  a  resume  of  the  sub- 
ject in  Warren's  recent  work  on  "  Surgical  Pathology 
and  Therapeutics,"  numerous  high  authorities  are 
cited  to  substantiate  this  assertion.  Sir  James  Paget, 
Horsley,  Thomas  Smith,  and  others  describe  cases  of 
this  character.  Smith,  indeed,  in  forty-three  cases  of 
lithotomy  in  children,  had  the  operation  followed  in  no 
less  than  ten  by  an  outbreak  of  scarlet  fever.  Warren 
concludes  that  "  a  certain  number,  and  probably  a 
majority  of  cases  of  so-called  surgical  scarlet  fever  are 
cases  of  genuine  scarlatina."  In  Guy's  Hospital,  in 
1879,  four  cases  were  observed  in  succession  under  the 
care  of  different  surgeons,  and  in  consequence  thereof 
operations  on  children  were  temporarily  postponed.  In 
that  hospital,  during  a  series  of  years,  nearly  thirty 
cases  of  scarlatina  were  observed  in  children  after 
operations,  and  Goodheart,  after  careful  investigation, 
has  no  doubt  of  the  correctness  of  the  diagnosis.  Hil- 
lier  remarks  that  in  the  hospital  for  sick  children,  of 
the  children  who  contract  scarlatina,  a  very  large  pro- 
portion have  been  the  subjects  of  a  surgical  operation 
within  a  week  before  the  rash  appears.  Although  the 
evidence  in  support  of  these  views  is  overwhelming, 
there  have  nevertheless  been  many  doubters  as  to  the 
specific  character  of  the  disease  in  these  cases.  Hoffa, 
a  German  authority,  quoted  by  Warren,  has  attempted 
an  analysis  of  the  cases  reported,  and  divides  them 
into  four  types  : 

I  Cases  followed  by  a  vaso-motor  disturbance  and 
characterized  by  a  transient  erythema  of  urticaria.  2. 
Toxic  erythema,  due  to  absorption  from  recent  wounds. 
These  are  transient  in  character  and  vanish  within 
twenty-four  hours.  The  absorption  of  antiseptics,  such 
as  corrosive  sublimate,  may  cause  some  of  these  erup- 
tions. 3.  Eruptions  due  to  profound  septic  intoxica- 
tions. These  are  various  in  kind  and  irregular  in  char- 
acter. They  may  last  for  several  days.  4.  Cases  of 
genuine  scarlatina. 

Dr.  McGraw  reports  a  case  which  might  readily  be 
considered  one  of  surgical  scarlet  fever.  A  boy,  fif- 
teen years  of  age,  was  seized  on  February  15th  with 
symptoms  of  appendicitis  and  was  operated  upon  on 
the  19th.  The  operation  was  successful,  and  no  septic 
symptoms  appeared  throughout.  On  the  23d  scarlatina 
mide  its  appearance,  from  which  he  died  on  March  ist. 
The  autopsy  showed  that  death  did  not  occur  from 
septic  poisoning  or  from  any  abdominal  complication. 
The  value  of  this  history  is  in  the  demonstrated  fact 
that  this  case  of  surgical  scarlet  fever,  in  the  person  of 
a  lad  who  was  said  to  have  had  scarlatina  before,  did 
not  originate  in  septicaemia  or  pyasmia.  There  was  not 
one  of  the  three  physicians  who  were  present  at  the 
autopsy  who  was  not  surprised  at  the  entire  freedom  of 
inflammatory  material  exhibited  by  the  abdominal 
cavity.  Putting  aside  those  cases  of  septic  eruptions 
in  which  the  evanescent  and  partial  character  of  the 
rash  and  the  absence  of  other  symptoms  make  the 
diagnosis  easy,  the  author  doubts  whether  the  so-called 
surgical  scarlet  fevers  ever  differ  in  nature  from  those 
termed  idiopathic.  He  is  fully  in  accord  with  Sir 
James  Paget,  who  insists  upon  the  specific  contagion 
in  these  cases,  notwithstanding  the  fact  that  the  some- 
what disorderly  appearance  of  the  symptoms  in  surgical 
cases  has  led  to  the  belief  that  they  are  not  genuine 
scarlatina.  A  grave  responsibility  rests  upon  the  sur- 
geon in  these  cases.  A  mistake  in  diagnosis,  or  a  belief 
in  the  non-contagious  character  of  the  disease,  will 
tend  to  spread  it  broadcast  in  the  family  and  in  the 
community.— A rr/iirrs  of  Ffdia/n'is. 

Diet  in  the  Etiology  and  Treatment  of  Diseases  of 
the  Skin. — An  interesting  discussion  on   this   subject 


took  place  at  a  recent  meeting  in  England  (  The  Brit- 
ish Medical  Journal).  Dr.  Allan  Jamieson  directed 
attention,  first,  to  the  articles  of  food  known  to  influ- 
ence skin  diseases  ;  secondly,  to  the  maladies  of  the 
skin  which  could  be  produced  or  modified  by  diet; 
and  thirdly,  to  dietetics  as  a  means  of  treatment  in  der- 
matology. Some  articles  of  food  produced  their  effect 
at  once,  as  in  the  example  of  shell-fish,  and  these  acted 
probably  by  toxic  conditions  of  the  blood,  though 
there  was  the  remarkable  and  unexplained  factor  of 
idiosyncrasy  which  came  into  play.  But  far  more  fre- 
quently the  action  of  foods  was  slow  and  prolonged, 
and  their  precise  mode  of  action  was  even  more  diffi- 
cult of  explanation.  Referring  to  certain  articles  of 
diet.  Dr.  Jamieson  thought  that  alcohol  seemed  to  pro- 
duce a  too  ready  penetrability  of  the  skin,  as  witnessed 
by  the  liability  to  sweating  and  the  clammy  fingers  of 
topers.  Alcohol  was  not  liable  to  produce  skin  dis- 
eases, but  it  certainly  aggravated  some  disorders. 
Second  in  importance  only  to  alcohol  comes  tea,  and  it 
has  been  shown  that  tea  when  taken  too  hot,  too  strong, 
and  in  excess  causes  cold  hands  and  feet  and  a  shrink- 
age of  the  integument,  in  addition  to  gastro-intestinal 
disturbance.  Dr.  White,  of  Boston,  has  shown  that 
strawberries  and  other  fruits  containing  acid  in  abun- 
dance are  liable  to  produce  eczema.  Persistent  omission 
of  green  vegetables  from  the  dietary  causes  relaxation 
of  the  cutaneous  vessels,  and  in  extreme  cases  scurvy. 
It  had  long  been  known  that  persons  presenting  a  pal- 
lor of  the  surface  and  other  evidences  of  mal-nutrition 
and  deficient  food  are  predisposed  to  eczema.  As  re- 
gards the  diseases  of  the  skin  influenced  by  diet,  cer- 
tain of  them  could  be  at  once  eliminated,  such  as  para- 
sitic diseases,  scleroderma  and  most  hereditary  dis- 
orders, herpes  zoster,  and  some  others.  But  there  re- 
mained a  large  number  which  are  undoubtedly  so  in- 
fluenced. Eczema  could  be  produced  and  modified 
by  unsuitable  diet,  drinking  large  quantities  of  cold 
water,  and  other  articles.  Dr.  Jamieson  mentioned 
hurrying  over  breakfast  as  a  predisposing  cause  of  the 
disease  in  school  children.  Psoriasis  was  aggravated 
by  alcohol,  and  he  had  seen  this  disease  invade  the 
surface  more  rapidly  under  the  administration  of  this 
article.  The  influence  of  diet  on  lichen  planus  had 
not  been  fully  investigated,  but  this  disease  often  arose 
in  overfed,  obese  women.  Boils  were  undoubtedly 
sometimes  due  indirectly  to  diet,  although  the  disease 
was  essentially  a  local  one.  A  sudden  change  from  a 
poor  to  a  luxurious  diet,  or  rice  versd,  was  capable  of 
producing  the  malady.  Acne  is  very  often  associated 
with  a  spare  diet,  such  as  that  which  schoolgirls  were 
encouraged  to  take.  Lupus  is  often  associated  with  a 
distaste  for  fat.  The  cause  of  the  increase  of  cancer 
during  the  last  half  century,  as  shown  by  Heath's  sta- 
tistics, was  ascribed  by  Yeo  to  the  increased  consump- 
tion of  butcher's  meat,  but  he  thought  it  ought  rather  to 
be  ascribed  to  the  undoubted  increase  in  the  consump- 
tion of  tea.  He  thought  that  the  abuse  of  this  article 
during  the  period  of  growth  was  the  cause  of  the  in- 
crease of  cancer.  The  subject  of  diet  in  treatment 
was  a  very  large  one.  Very  different  diets  were  called 
for  in  the  various  diseases,  always  allowing  for  idiosyn- 
crasy. Alcohol  and  the  regulation  of  animal  food-stuffs 
were  the  most  important.  The  latter,  which  contained 
iron,  were  very  important  for  the  treatment  of  the  anae- 
mia which  often  accompanied  acne  and  other  skin 
affections. 

Dr.  Walter  G.  Smith  said  that  we  have  no  certain 
knowledge  of  the  real  action  of  diet  on  conditions 
of  the  skin.  It  is  difficult  enough  to  trace  the  action 
of  drugs,  and  still  more  difiicult  in  the  case  of  foods. 
The  influence  of  diet  in  skin  diseases  was,  he  believed, 
much  less  important  than  is  generally  thought,  and 
after  all  it  might  be  best  to  adopt  the  rule  that  what 
most  people  eat  agrees  with  them  most,  and  what  a 
healthy  person  finds  appetizing  agrees  with  him  best. 
There  are,  however,  three  ways  in  which  food  may  per- 


December  28,  1895] 


MEDICAL    RECORD. 


919 


haps   influence    skin    conditions  :    i.  By  lowering  the 
general  nutrition — e^.,  in  scorbutic  and  purpuric  con- 
ditions, and   those  due  to   a  parasite  which    finds   in 
lowered  vitality  a  more  suitable  condition  for  growth  and 
multiplication.     2.  Reflex  condition — ^.g.,  from   stom- 
ach to  skin,  as  in  over-eating  or  taking  unsuitable  food. 
These  conditions  were  brought  about  either  by  a  vaso- 
motor or  a  purely  nervous  mechanism.     Urticaria  and 
nearly  all   such   skin  conditions   are  known  by  their 
transitory  character.     They  may  be  dealt  with  by   a 
visit  to   Carlsbad,  but  may  equally  well  be  treated  at 
home  by  purgatives,  a  good  cook,  and  regulating  the 
quantity  and  kind  of  the  diet.     3.  Toxic  conditions  of 
the  blood — e.g.,  the  effects  of  tinned  or  unwholesome 
foods,  and   the  hyperaemia   of  the  skin  produced   by 
full  doses  of  alcohol.     It  must  not  be  forgotten  that 
the  skin  is  the  avenue  for  the  elimination  of  certain 
substances — e.g.,  copaiba   and   other   oleo- resins,  and 
highly  seasoned  foods,  which  are  liable  to  produce  ery- 
thematous rashes.     Turning  next  to  the  different  dis- 
eases of  the  skin.  Dr.  W.  G.  Smith  thought  they  might 
be  grouped  into  three  classes  :  i.  Cutaneous  diseases 
acknowledged  to  be  influenced  by  diet,  such  as  the 
erytheniata,  acne  rosacea,  and   perhaps  acne  vulgaris. 
2.    Diseases   which   might  possibly   be   influenced  by 
diet,    such   as   psoriasis   and   some   cases   of  eczema, 
though  he  had  never  been  able  to  satisfy  himself  that 
eczema  was  ever  affected  by  diet.     3.  Cutaneous  dis- 
eases, which  are  certainly  not  produced  or  modified  by 
food — e.g.,  herpes  and  lichen  ruber.    The  effect  of  diet 
on  leprosy  had  never  been  satisfactorily  proved,  nor,  in 
his  experience,  had  boils  ever  arisen  or  been  modified 
by  dietetic  conditions.    The  fact  that  people  now  con- 
sumed one  hundred  and  thirty-six  pounds  of  butcher's 
meat  per  head  per  annum,  as  compared  with  forty-six 
pounds  formerly,  had  been  advanced  as  a  cause  for  the 
increase   of  certain  diseases  ;  but  he  would  point  out 
that  men  probably  consumed  three-fourths  more  meat 
(and  alcohol  too)  than  women,  and  he  would  like  to  ask 
whether  these  diseases  were  three-fourths  more  common 
in  the  former.     As  regards  salt  meat,  which  was  held 
to  be  so  bad  for  skin  diseases,  he  had  given  it  to  his 
skin    patients   without   harm.     Alcohol,  undoubtedly, 
might  sometimes  increase  the  itching  and  congestion 
of  the  skin  ;  but  in  reference  to  its  supposed  effect  in 
producing  skin  diseases  he  would  point  out  that  the 
Parsees  in  India  were  not  exempt  from  such  maladies. 
If  the  skin  disorder  were  secondary  to  diabetes,  gas- 
tric or  other  derangements,  these,  of  course,  must  be 
treated ;  but  as  long  as  practitioners  differed  so  widely 
and  so  oppositely  it  was  impossible  to  believe  that  diet 
had  any  important  effect  on  the  skin  condition  itself. 
By  way  of  summary  Dr.  W.  G.  Smith  stated  his  belief 
— (i)  that  very  few  skin  diseases   were  directly  pro- 
duced  by   food   (though    diet    may   aggravate    some 
already  in  existence) ;  (2)  that  the  diseases  so  arising 
are  always  erythematous  and  transitory  ;  (3)  that  diet 
has  no  influence  on  the  cure  of  skin  diseases,  even  of 
acne  ;  and  (4)  that  the  only  practical  rules  necessary 
are   tg   exercise   moderation   and    temperance   in    all 
things,    and    especially    in    alcohol,   to    regulate    the 
bowels,  and  to  cure  the  anamia  if  present. 

Dr.  Radcliffe  Crocker  agreed  with  Dr.  W.  G.  Smith 
in  thinking  that  the  influence  of  diet  had  been  exag- 
gerated. He  thought  that  salt  meat  and  some  other 
unwholesome  articles  acted  chiefly  by  producing  gastro- 
intestinal catarrh.  The  cooking  and  mode  of  prepara- 
tion were  even  more  important  than  the  article.  As 
regards  the  effect  of  alcohol,  it  differed  widely  in  the 
different  forms  of  alcohol ;  thus  beer  and  port  wine 
might  do  harm  when  well-diluted  spirit  would  do 
good.  Boils  sometimes  occurred  in  states  of  lowered 
vitality,  sometimes  in  very  healthy  persons. 

Treatment  of  Advanced  Cases  of  Phthisis. — Dr.  Otis 
summarizes  the  therapeutic  agents  which  are  best  cal- 
culated to  alleviate  the  lingering  sufferings  of  the  last 


stage  of  phthisis.     He  calls  attention  to  the  frequent 
presence  of  sepsis,  and  holds  that  all  treatment  in  these 
cases  must  be  symptomatic.     The  diminished  lung  ca- 
pacity necessitates  an  airy  room,  in  which   sunlight  is 
required  as  a  tonic  antiseptic.     Feeding  is  a  difficult 
question  ;  in  bad  cases  there  must  be  frequent  adminis- 
tration of   easily  or  partially  digested  food.     Pepsin, 
charcoal  and  bismuth  tablets  may  be  of  much  service. 
Malt  and  creosote,  with  cod-liver  oil  in  the  absence  of 
fever,  should  be  given,  and  alcohol  is  to  be  used  freely. 
Fever  should  not  be  treated  unless  causing  unpleasant 
symptoms ;  inunction  of  guaiacol  reduces  the  temper- 
ature verj-  effectually,  but  is  severely  depressant.     Rest 
in  bed,  with  light  nourishment  and  a  glass  of  cognac 
half  an  hour  or  so  before  the  expected  rise,  has  a  fa- 
vorable effect  on   the   temperature.     Antipyretics  (of 
which   phenacetin   and   sodium  salicylate  appear  the 
best)  should  be  employed  if  at  all  to  prevent  the  rise  of 
temperature  rather  than  to  lower  it  after  it  has  risen. 
Sweating  is  best  controlled  by  agaracin  in  doses  of  ^j 
grain  and  upward  ;  it  is  free  from  the  after-effects  of 
atropine.     The  distressing  cough  is  due  partly  to  the 
presence  of  material  in  cavities,  partly  to  the  irritability 
of  the  mucous  membranes  of  the  upper  air-passages. 
That  from  the  latter  cause  can  be  much  alleviated,  as 
Dettweiler  has  pointed  out,  by  establishing  a  habit  of 
self-restraint  in  the  patient.     Medicinally,  codeia  in  one 
per  cent,  solution  is  the  best  agent.     The  morning  par- 
oxysm of  coughing  is  necessary  for  expectoration  of 
the  products  accumulated  during  the  night ;  it  can  be 
shortened  and  at  the  same  time  made  easy  and  effect- 
ual by  administering  a  glass  of  some  warm   alkaline 
drink  with  a  little  brandy  or  rum  in  it.     Cough  from 
catarrh  of  the  upper  air-passages  is  often  relieved  by 
local  applications.     Vomiting  may  result  from  digestive 
disturbances  or  laryngeal   irritation,  and  will   require 
different  treatment  in   each   case.     The  various  pains 
from  which  the  patients  suffer  are  best  relieved  by  paint- 
ing equal  parts  of  glycerine  and  guaiacol  over  the  af- 
fected area.     Pleuritic  pain  at  the  base  of  the  chest 
should  be  treated  by  strapping,  as  suggested  by  Rob- 
erts.    Diarrhoea,  when  septic,  indicates  salicylic  acid 
or   naphthol  ;    when    due   to   tuberculous   ulceration, 
opium  and  bismuth,  with  an  astringent  ;  this  form  re- 
quires careful  dieting  with  peptonoids  or  peptonized 
milk.     Hemoptysis  calls  for  the  same  treatment  as  in 
early  cases  ;  Darenberg  recommends  the  application  of 
ice  to  the  testicles  or  vulva  for  five  minutes  twice  a  day. 
Insomnia  may  be  relieved  by  light  nourishment  or  a 
little   stimulant   at  bedtime  ;  if  these   fail,  trional   or 
chloralamid  are  the  most  satisfactory  hypnotics.     Oide- 
ma  of  the  lower  extremities  can  only  be  alleviated  by 
position,  gentle  friction  with  alcohol   and  water,   and 
wrapping  the  limbs  in  cotton  wool.     The  mouth  and 
lips  should  be  cleaned  with  an  alkaline  wash.     The 
anaemia  calls  for  iron  whenever  it  can  be  borne.     For 
the   cardiac   debility   strychnine   is  invaluable.  —  T/ie 
British  Medical  Journal. 

Eecent  Observations  on  Carcinoma  of  the  Stomach. — 

Dr.  Klemm  summarizes  his  opinion  on  the  subject  as 
follows:  I.  The  treatment  of  these  tumors  differs  in  no 
respect  from  that  of  cancer  elsewhere.  It  is  purely 
surgical.  2.  Operation  is  to  be  recommended  when 
possible,  before  the  tumor  is  palpable.  3.  Examina- 
tion should  only  be  made  under  deep  narcosis,  and  an 
exploratory  incision  made  if  required.  4.  Those  cases 
only  should  be  recommended  for  resection  of  the  py- 
lorus where  the  tumor  is  freely  movable,  and  there  is 
no  metastatic  involvement.  5.  If  these  conditions  are 
not  present,  the  formation  of  a  fistula  between  the 
stomach  and  jejunum  is  indicated.  6.  This  operation 
should  not  be  delayed  until  the  patient  is  nearly  dead 
of  hunger,  and  the  knife  then  used  as  a  last  resource, 
for  the  mortality  is  then  much  greater.  Langenbuch 
has  subjected  three  patients  to  total  extirpation  of  the 
stomach  for  extensive  carcinoma.     Of  these  one  only, 


920 


MEDICAL    RECORD. 


[December  28,  i< 


a  woman  of  fifty- eight,  survived.  In  this  case  the  por- 
tion removed  represented  seven- eighths  of  the  stomach. 
The  pylorus  was  stitched  to  the  remains  of  the  cardiac 
orifice,  making  a  cavity  about  the  size  of  a  hen's  egg. 
Fearing  lest  the  sutures  might  give  way,  the  new  stom- 
ach was  fixed  in  the  abdominal  wound  by  passing  be- 
hind it  a  piece  of  iodoform  gauze  ;  the  rest  of  the  ab- 
dominal wound  was  closed.  The  operation  lasted  one 
hour  and  a  half.  Milk  was  given  in  the  evening,  and  meat 
on  the  third  day.  Convalescence  was  rapid,  and  cure 
was  accomplished  in  three  weeks.  Levy  describes  an 
operation  which  he  has  devised  for  removing  the  oesoph- 
ageal extremity  of  the  stomach  in  cases  of  malignant 
disease.  So  far,  the  operation  has  been  performed  on 
cadavers  and  dogs  only.  The  brief  outlines  of  the  op- 
eration are  :  i.  Incision  through  the  abdominal  wall, 
beginning  in  the  middle  line  at  the  ensiform  cartilage 
and  extending  to  a  finger's  breadth  below  the  navel, 
which  is  passed  on  its  left  side,  and  from  this  extremity 
of  the  wound  a  second  incision  is  carried  at  a  right  an- 
gle through  the  right  rectus  muscle.  2.  Isolation  of  the 
cardia  by  cutting  through  the  adjacent  portion  of  the 
lesser  omentum  and  applying  double  ligatures  to  the  ar- 
teria  and  vena  coronaria  ventriculi  sinistra.  3.  Isola- 
tion of"  the  lower  part  of  the  oesophagus  after  dividing 
the  serous  covering  around  the  cardia  with  scissors.  4. 
Excision  of  the  cardia  and  union  of  the  cut  surfaces. 
The  oesophagus  is  divided,  a  portion  at  a  time,  and 
united  to  the  stomach  wound  as  it  is  cut.  Without  this 
precaution  the  divided  end  of  the  CESophagus  disap- 
pears in  the  foramen  oesophageum,  and  suture  is  then 
scarcely  possible.  Rosenheim  confirms  the  conclusions 
as  to  the  presence  of  lactic  acid  not  being  a  pathogno- 
monic sign  of  cancer.  He  found  it  only  in  fifty-five 
per  cent,  of  all  cases.  Lactic  acid,  therefore,  is  an  in- 
constant phenomenon,  this  acid  existing  for  a  time, 
after  which  it  subsides,  to  reappear  later  on.  Lactic- 
acid  fermentation  disappears  more  particularly  as  soon 
as  the  motor  functions  of  the  stomach  are  markedly  im- 
proved, which  is  the  case  especially  after  performing 
gastro  enterostomy. —  The  Hospital. 

The  Dangers  of  Murphy's  Button. — A  compilation  re- 
cently published,  of  several  cases  where  the  intestine 
was  united  by  the  Murphy  button,  gives  interesting  data 
as  to  the  practical  effect  of  this  appliance.  In  one  case, 
where  death  occurred  with  symptoms  of  obstruction, 
the  opening  of  the  button  was  plugged  with  hardened 
faeces.  In  another,  the  button  was  removed  by  a  sec- 
ond operation  from  the  proximal  side  of  the  anasto- 
mosis. Again,  death  occurred  from  intestinal  gangrene 
at  the  site  of  the  button,  possibly  from  the  manner  in 
which  it  was  applied  (too  close  approximation  of  the 
edges)  or  its  extreme  size  and  weight.  In  another  case 
the  button  was  found  on  the  proximal  side  of  the  end- 
to-end  resection  at  the  autopsy.  In  two  cases  of  gas- 
tro-enterostomy  the  button  was  found  after  death  in 
the  stomach — one  patient  living  ten  days,  the  other 
two  to  three  months.  It  is  evident  from  the  above  that 
the  danger  of  retention  of  the  button  is  a  real  one, 
notwithstanding  the  successful  cases  reported.  Its 
principal  claim  is  that  it  can  be  applied  rapidly,  which 
is  true.  This  will  restrict  its  use  to  those  cases  where 
the  most  rapid  operation  possible  is  indicated,  where 
speed  is  required  at  all  hazard,  and  other  risks  must 
be  ignored  on  account  of  the  limited  time  at  the  dis- 
posal of  the  operator  on  account  of  the  condition  of 
the  patient.  The  button  itself  is  an  appliance  which 
should  be  properly  made,  and  the  technique  of  its  ap- 
plication thoroughly  understood.  There  can  be  little 
question  that  the  use  of  the  larger  Murphy  button  is, 
in  the  hands  of  most  operators,  safer  than  anastomoses 
by  suture  in  cases  where  the  condition  of  the  patient 
renders  haste  necessary.  But,  on  the  other  hand,  it  is 
for  just  this  class  of  cases  that  the  anastomoses  by  ab- 
sorbable plates — the  bone  plates  of  Senn,  or  the  vege- 
table plates  advocated   by  Dawbarn — have   been  de- 


vised. Anastomosis  by  these  plates  takes  very  litde 
more  time  than  by  the  Murphy  button,  and  has  the  ad- 
vantages of  providing  a  free  opening,  and  of  being  free 
from  the  danger  of  remaining  on  the  proximal  side  of 
the  anastomosis  as  a  foreign  body  in  the  stomach  or  in- 
testine. Again,  the  danger  of  producing  pressure  gan- 
grene of  the  opposed  edges  is  greater  in  a  mechanical 
appliance  of  the  size  and  weight  of  the  button,  and  its 
unyielding  metallic  catch  will  allow  no  relaxation  of 
its  grip,  if  once  too  firmly  made.  Over  the  lateral  or 
end-to-end  anastomosis  by  suture  alone,  the  plates  have 
the  advantage  of  greater  ease  and  rapidity  of  applica- 
tion, a  fact  which  renders  their  use  the  method  chosen 
in  the  majority  of  cases  which  fall  into  the  hands  of 
the  average  surgeon.  To  recapitulate,  then,  although 
we  must  admit  that  when  the  patient  is  capable  of  sus- 
taining a  long  operation  and  the  surgeon  possesses  ex- 
ceptional skill  in  dealing  with  these  cases,  anastomosis 
by  suture  is  the  ideal  method  ;  for  the  majority  of  cases, 
in  the  hands  of  the  average  surgeon,  Senn's  plates  are 
to  be  preferred.  The  use  of  the  Murphy  button  has 
been  shown  to  possess  inherent  disadvantages  which 
should  restrict  its  use  to  those  cases  in  which  it  is  neces- 
sary to  hasten  in  order  that  the  patient  may  survive  the 
shock  of  the  operation. —  T/ie  Boston  Medical  and  Sur- 
gical Journal. 

Analgesic  Action  of  Bicarbonate  of  Soda  in  Diges- 
tive Disorders — Dr.  Linossier  claims  that  a  diagnosis 
of  hyper-acid  dyspepsia,  made  by  the  fact  that  bicar- 
bonate of  soda  relieves  the  distress  after  eating,  is  en- 
tirely erroneous.  He  asserts  that  this  agent  may  afford 
relief  in  other  conditions  than  hyper-acidity,  and  gives 
the  following  as  his  opinions  :  i.  If  a  gastric  crisis  fol- 
lowing a  few  hours  after  meal  is  relieved  by  large  doses 
of  bicarbonate  of  soda,  it  does  not  follow  that  the  dis- 
stress  is  due  to  hyper-acidity.  2.  The  analgesic  action 
of  this  drug  may  be  used  in  most  cases  of  gastric  crisis 
occurring  regularly  some  hours  after  meals,  even  when 
the  train  of  symptoms  or  gastric  analysis  eliminates  the 
possibility  of  excess  of  hydrochloric  acid. 

The  drug  is  best  given  j ust  before  the  usual  meal  time, 
in  doses  of  from  0.50  to  2  grains,  and  may  be  repeated  if 
the  sedative  action  is  only  short-lived.  The  same  rules 
are  to  be  followed  in  the  treatment  of  cases  due  to 
hyper-acidity,  save  that  the  dose  is  less,  though  there 
need  be  no  hesitancy  in  increasing  it  if  the  calmative 
effect  is  not  produced.  It  will  be  found  advantageous 
in  most  cases  to  dissolve  the  salt  in  very  warm  water, 
the  excitomotor  action  of  the  water  accentuating  the 
effects  of  the  salt.  The  author  insists  on  the  fact  that 
the  cases  amenable  to  soda  are  those  recurring  periodi- 
cally toward  the  end  of  digestion.  The  latest  cases  are, 
in  general,  the  ones  most  easily  cured.  Those  occur- 
ring immediately  after  meals,  or  that  are  continuous, 
are  not  relieved,  as  a  rule.  Among  the  digestive  dis- 
orders produced  some  time  after  meals  may  be  men- 
tioned the  insomnia  of  dyspeptics.  In  many  cases  radi- 
cal relief  is  obtained  by  the  ingestion  of  4  to  S  grains 
of  the  bicarbonate  four  or  five  hours  after  the  last 
meal,  as  Glenard  has  already  remarked.  In  some  pa- 
tients, unfortunately,  the  salt  rapidly  loses  its  effect  and, 
though  the  doses  are  quickly  increased,  it  is  only  effi- 
cacious for  a  few  days.  In  others,  again,  it  can  be 
used  indefinitely  with  good  results. — Medical  Rcvie-iV. 

Genito-urinary  Complications  Due  to  Influenza. — Dr. 

Lamaripie  has  recently  studied  this  class  of  complica- 
tions. According  to  him,  the  poison  acts  very  often 
on  the  kidneys.  {^The  Xcw  York  Medical  Journal!) 
In  the  simplest  cases  there  is  a  somewhat  intense  in- 
flammation of  the  glomeruli,  with  slight  albuminuria, 
which  lasts  for  several  days  and  then  disappears  with- 
out leaving  any  traces,  and  without  modifying  the 
progress  of  the  disease.  In  other  cases,  fortunately 
much  rarer,  it  produces  serious  nephritis,  which  from 
the  start  exposes  the  patients  to  symptoms  of  renal  in- 
sufficiency, and  death  from  ursemia  may  be  very  rapid. 


December  28,  1895] 


MEDICAL   RECORD. 


921 


However,  the  nephritis  of  influenza  is  recovered  from 
in  the  majority  of  cases  ;  but  it  may  also  pass  into  the 
subacute  or  chronic  state.  M.  Lamarque  says  that 
there  may  be  two  forms  of  nephritis  in  influenza,  the 
hemorrhagic  and  the  albuminous.  In  the  first  form 
haematuria  is  the  first  sjTnptom  ;  in  the  second  form 
acute  Bright's  disease,  with  albuminuria  and  a  more  or 
less  extensive  oedema,  is  observed.  Fiessinger,  says 
the  writer,  was  the  first  to  describe  grippal  nephritis, 
and  in  his  work  on  grippal  infection  he  admits  the  ex- 
istence of  transitory  inflammation  of  the  glomeruli 
with  albuminuria,  of  acute  hemorrhagic  nephritis  with- 
out oedema,  and  of  acute  Bright's  disease.  The  renal 
complications  of  influenza  have  been  studied  also  by 
Leyden,  Diard,  Turoche,  and  others.  Comby  and  Le 
Gendre  have  published  observations  showing  that  grip- 
pal haematuria  may  be  due  to  simple  fluxion.  The 
bladder  mav  be  the  seat  of  congestive  symptoms,  ac- 
cording to  Fiessinger,  which  manifest  themselves  by  a 
frequent  desire  to  urinate  and  by  trouble  during  mic- 
turition. There  is  sometimes  haematuria,  and  it  may 
supervene  independently  of  any  application  of  blisters. 
According  to  Comby,  cystitis  may  be  persistent,  but 
usually  it  disappears  at  the  same  time  with  the  influ- 
enza. Fenwick  has  observed  atony  of  the  bladder 
rather  frequently,  especially  in  subjects  whose  bladders 
have  been  very  much  distended  during  the  height  of 
the  disease.  This  author  also  insists  on  the  relative 
frequency  of  catarrh  of  the  prostatic  portion  of  the 
urethra,  with  neuralgic  radiations.  These  symptoms 
are  also  observed  among  women. 

Gottschalk  has  seen  uterine  hemorrhage  supervene 
on  the  first  or  on  the  second  day  in  influenza,  accom- 
panied by  lumbar  and  sacral  pains  and  by  dysuria. 
The  uterus  was  tumefied,  softened,  and  very  sensitive. 
This  author  also  admits  the  existence  of  an  infectious 
metritis.  The  hemorrhages  last  for  five  to  eight  days. 
Influenza  predisposes  the  patients  to  puerperal  infec- 
tion, and  suppurative  symptoms  may  also  set  in  during 
pregnancy.  Abortion  and  premature  delivery  have 
also  been  observed  during  the  later  epidemics  of  influ- 
enza and  this  is  attributed  to  the  cough  and  to  hyper- 
thermia. These  two  factors,  says  the  wnter,  may  have 
an  influence  in  certain  cases,  but  it  is  certam  that  the 
congestive  troubles  directly  produced  by  the  influenza 
play  a  very  important  part.  As,  on  the  other  hand, 
congestion  cannot  explain  the  symptoms  of  suppura- 
ation  and  of  septicemia,  we  must  attribute  them  to  in- 
fection. The  hemorrhages  depend  on  acute  endome- 
tritis and  they  may  occur  in  women  who  have  under- 
gone ablation  of  the  Fallopian  tubes  and  of  the  ovaries. 
With  regard  to  puerperal  infection,  it  depends  on  the 
streptococcus.  Lesions  of  the  testicle  are  not  very 
rare,  and  they  may  or  may  not  be  coincident  with  ure- 
thritis. 

The  Meaning  of  Casts  in  the  Urine  Without  Albu- 
min.—According  to  Ur.  Bremer,  of  St.  Louis,  a  person 
who  constantly  or  periodically  passes  urine  containing 
casts  even  without  albumin,  or  perhaps  with  albumin 
in  chemically  demonstrable  quantity,  is  not  in  good 
health.  Such  a  person  has  a  damaged  constitution  ; 
his  kidneys  are,  to  say  the  least,  vulnerable,  and  he  is 
prone  to  contract  and  to  succumb  to  other  diseases. 
The  irritative  process  which  gives  rise  to  the  formation 
of  casts  may  not  amount  to  an  actual  state  of  inflamma. 
tion,  and  there  may  not  be  the  recognized  signs  ot  luiiy 
developed  kidney-disease,  and  yet  the  subjective  symp- 
toms may  be  very  pronounced.  These  symptoms  are 
often  unaccountable  to  the  attending  physician  because 
sufficient  importance  is  not  attached  to  the  presence  o 
casts  in  the  urine  of  such  persons.  In  a  number  of 
cases  periodic,  intermittent  albuminuria  is  the  feature, 
and  the  albumin  is  in  evidence  0">y  ^>^«"  ^.  "":"„tX 
of  unusual  severity  has  set  in.  Such  patients  may  be 
considered  to  have  vulnerable  kidneys.  'or  a  ong 
time  such  patients  may  not  present  any  albuminuria, 


the  casts  only  being  demonstrable  ;  or  even  these  may 
disappear,  and  the  urine  be  absolutely  normal;  yet 
there  is  a  dormant  pathological  condition  which  may 
be  aggravated  into  activity.  The  diagnosis  of  vulner- 
able kidney  may  be  doubted  by  other  physicians 
Aside  from  examinations  which  are  based  on  chemical 
analysis  exclusivelv,  there  are  several  reasons  why  the 
search  for  casts  m'ay  be  negative  :  First,  microscopical 
incompetency  :  second,  the  kidney  trouble  may  hav^e 
become  latent  and  the  casts  may  be  really  absent  ;  thud, 
insufficient  instrumental  equipment— the  centrifuge 
should  always  be  used  ;  fourth,  the  examiner,  even  if  he 
find  casts,  may  not  attach  any  importance  to  them  it 
unaccompanied  bv  albuminuria.  Among  other  reasons 
why  the  presence  of  casts  in  the  urine  is  alleged  to  be 
compatible  with  perfect  health  is  the  finding  of  them 
in  the  urine  of  athletes  after  great  muscular  exertion. 
The  athletes  presenting  this  condition  were  certainly 
damaged  men.  The  symptoms  produced  by  this  vul- 
nerable kidney  range  over  the  neuroses,  particularly 
neurasthenia,  inexplicable  gastro-intestinal  manifesta- 
Uons  and  grip  symptoms,  megrim,  and  other  forms  ot 
periodic  headache.— -1/<''/'V'"'  AVr;«'. 

Experiments  on  the  Gall-ducts  and  the  Liver.— Dr 
Nasse  of  Berlin,  has  studied  the  effect  of  extirpation  of 
the  gall-bladder.  Guinea-pigs  and  rabbits  were  unaf- 
fected. He  was  unable  to  corroborate  Oddis  results, 
namely  that  doss  after  removal  of  the  gall-bladder  suf- 
fered great  hunger,  diarrhcEa,  and  emaciation  :  that  later 
there  also  developed  a  dilatation  of  the  gall-ducts. 
None  of  Nasse'sdogs  showed  these  symptoms  or  condi- 
tion He  also  ligated  single  branches  of  the  hepa  ic 
duct  This  caused  an  hypertrophy  of  those  hepatic 
areas  where  the  biliarj-  currents  were  unobstructed. 
In  the  ligated  portions  small  areas  of  necrosis  were 
found,  also  proliferation  of  the  gall-ducts  and  an  in- 
crease of  connective  tissue.  Rapid  atrophy  of  hepatic 
cells  and  shrinking  of  the  affected  lobe  occurred 
This  change  was  complete  in  four  months.  The  lobe 
then  consisted  of  fibrous  connective  tissue  and  gall- 
ducts  In  cases  where  the  obstruction  of  the  ducts  was 
temporary,  the  development  of  ducts  and  connective 
rissue  was  checked,  when  the  ducts  became  again  pat- 
ent Even  liver-cells  regenerated  after  extreme  degen- 
eration.—/>'«/<'«  Medical  and  Surgical  Journal. 

Diagnosis  and  Treatment  of  Perforation  of  Gastric 
Ulcer— Barling  remarks  that  the  incidence  of  perfora- 
tion of  gastric  ulcers  does  not  in  the  least  degree  cor- 
respond to  their  locality.  A  large  majority  o  the 
ulcers  occupy  the  posterior  surface  -"V^riU  fewe; 
ture,  a  few  the  region  of  the  pylorus,  and  a  still  fewer 
number  involve  the  anterior  surface  of  the  ston,^-h; 
whereas,  ulcers  on  the  anterior  surface  per  orate  with 
great  frequency,  those  on  the  posterior  surface  rarely 
fn  proportion  to  their  actual  number,  while  hose  on 
the  lesser  curvature  perforate  comparatively  often 
TuJ^ity  -^r^dical  Magazine).  The  explanation  o 
his  varying  tendency  is  found,  first,  in  the  fact  that 
ulcers  on  the  posterior  surface  and,  to  a  lesser  extent, 
tlos  on  the  lisser  curvature,  as  they  advance  tend  to 
become  adherent  to  adjacent  parts,  while  hose  on  the 
anterTor  surface,  because  of  greater  mobility,  rarely 
form  adhesions;' and,  secondly,  because  the  symptoms 
0°  tiers  on  the  anterior  wall  of  the  stomach  being  less 
marked  than  those  of  ulcers  situated  elsewhere,  the 
Sects  of  these  are  less  often  aware  of  their  presence, 
and  are  more  apt  to  be  careless  regarding  the  quality 
and  quantity  of  diet,  whereby  the  ulcer  is  subject  o 
undue  stretching  and  traumatism  which  may  result  in 
perforat  on  In  considering  the  diagnosis,  the  previous 
history  usually  points  to  the  stomach  as  the  seat  of 
fesion  Perfo  ation  usually  takes  place  when  the  stom- 
ach  TsfuU  or  partly  so,  when  the  patient  is  in  a  more 
or  less  vertical  position,  and  frequently  a  ler  some  par- 
ricS  act  or  exertion-stooping,  sneezing,  or  ift.n^ 
of  sot^e  heavy  weight.     The  moment  of  perforation  is 


922 


MEDICAL   RECORD. 


[December  28,  1895 


usually  marked  by  sudden  acute  abdominal  pain,  pro- 
ducing at  times  faintness,  or  even  collapse  or  death. 
Occasionally  there  may  be  slight  vomiting.  The  ab- 
dominal walls  retract  and  the  muscles  become  rigid  ; 
respiration  is  usually  thoracic,  quick,  and  shallow  ;  the 
temperature  subnormal  ;  the  pulse  quick  and  feeble. 
The  symptoms  now  ensuing  depend  upon  the  position 
of  the  ulcer,  the  degree  of  distention  of  the  stomach, 
and  the  position  the  patient  occupies.  The  extrava- 
sating  material  may  spread  widely  into  the  peritoneal 
cavity,  causing  intense  and  rapidly  spreading  peritoni- 
tis, and  death  usually  in  from  twelve  to  seventy-two 
hours  ;  or  it  may  remain  for  a  time  localized  between 
the  stomach  and  liver,  eventually  escaping  from  there 
into  the  generally  peritoneal  cavity,  causing  at  first 
shock,  which  passes  off  ;  and  when  septic  peritonitis 
ensues  from  further  leakage  death  occurs,  usually  in 
four  or  five  days  from  the  time  of  the  seizure  ;  or, 
finally,  the  extravasating  material  may  remain  localized 
under  the  diaphragm,  and  produce  a  subphrenic  ab- 
scess. In  such  a  case,  after  the  shock  passes  away, 
there  ensues  a  period  during  which  the  symptoms  are 
so  slight  as  to  almost  make  one  doubt  the  accuracy  of 
the  diagnosis.  Then  follow  the  general  symptoms  of 
pus-formation  and  the  local  signs  indicating  a  gas-con- 
taining cavity  below  the  diaphragm.  Following  these 
may  come  symptoms  of  septic  invasion  of  the  thorax- 
pleurisy,  empyema,  pneumonia,  or  lung  abscesses.  As 
fully  mnety-five  per  cent,  of  all  cases  left  to  medical 
care  die,  the  only  treatment  that  offers  any  hope  of  re- 
covery is  operation.  Of  thirty-seven  cases  operated 
upon,  thirteen  recovered,  but  he  does  not  suppose  that 
one- third  of  all  the  cases  have  been  saved,  as  many 
unsuccessful  ones  have  probably  not  been  reported. 
Meet  collapse  by  maintaining  horizontal  position,  ex- 
ternal warmth,  enemata  of  warm  fluids  and  stimulants 
and  morphine  hypodermically  ;  nothing  by  the  mouth! 
If  operation  be  declined,  must  depend  upon  recum- 
bency, absolute  rectal  feeding,  and  morphine.  If 
operation  be  determined  upon,  there  must  be  a  suffi- 
cient delay  to  allow  of  recovery  from  shock.  The 
wound  in  the  stomach  is  to  be  closed  by  Lembert  sut- 
ures without  excision  of  the  ulcer,  and  is  to  be  followed 
by  irrigation  of  the  abdominal  cavity.  If  a  subphrenic 
abscess  forms,  it  is  to  be  evacuated  by  an  incision  into 
It  as  directly  as  possible. 

Diagnosis  of  the  Pneumonic  Form  of  Acute  Pulmo 
nary  Tuberculosis.— Drs.  A.  Frankel  and  G  Troie 
state  this  to  be  a  rare  form  of  the  disease.  It  may  be- 
gin with  a  chill,  as  croupous  pneumonia,  or  be  more 
insidious,  or  with  a  series  of  lesser  chills.  The  fever 
soon  becomes  atypical,  more  or  less  remittent  or  inter- 
mittent, which  latter  sign  is  a  certain  diagnostic  point 
to  distinguish  It  from  croupous  pneumonia  Some 
patients  present  labial  herpes.  The  pulse  is  always 
moderate,  and  respiration  less  disturbed  than  one 
would  expect  from  the  lesions.  Instead  of  dyspnoea 
and  cyanosis,  there  is  an  increasing  paleness  of  the 
skin  and  mucous  membranes.  On  auscultation,  signs 
of  considerable  infiltration  of  even  a  whole  lobe  thus 
simulating  a  croupous  pneumonia.  Besides  pronounced 
bronchial  resi)iration,  extensive  crepitation  is  observed 
1  he  most  posterior  portions  of  the  lung,  and  generally 
he  lowest  lobe,  are  the  favorite  sites  of  predilection 
During  the  course  of  the  disease  the  dulness  may  clear 
up  without  signifying  an  actual  resolution,  for  rAles  are 
still  present.  A  complete  or  partial  resolution  may  at 
times  occur.  The  expectoration  is  characteristic  of 
pneumonia,  in  the  majority  of  cases  ;  tenacious  clear 
and  translucent ;  in  a  few  cases  it  is  rust-colored  while 
in  others  it  presented  a  grass-green  coloration 'which 
Iraube  states  to  be  characteristic;  haemoptysis  may 
also  be  present.  Tubercle  bacilli  are  found  in  the 
m,i)ority.  .Albuminuria  is  very  rare.  Ehrlich's  diazo- 
reaction  is  both  of  diagnostic  and  prognostic  impor- 
tance ;  It  was  very  pronounced  in  all  the  fatal  case<= 


but  was  absent  in  those  that  recovered.  Delirium  was 
observed  now  and  then,  even  in  non-alcoholics.  Where 
the  affections  begin  acutely  and  the  expectoration  is 
lacking,  or  pneumonic  and  no  bacilli  can  be  demon- 
strated, diagnosis  is  impossible.  If  it  last  for  some  time, 
then  the  following  points  will  be  of  value  :  Lack  of  a 
typical  or  final  crisis,  frequent  absence  of  dyspnoea  and 
cyanosis,  together  with  the  early  pallidity,  the  green 
color  of  the  expectoration,  and  the  presence  of  tubercle 
bacilli.  The  diazoreaction  in  the  urine  from  the  com- 
mencement ;  rapid  loss  of  strength  and  emaciation. 
The  prognosis  is  very  unfavorable. — New  York  Medi- 
cal Times. 

The  Blood  Alterations  of  Ether  Anaesthesia. — Ac- 
cording to  Dr.  J.  Chalmers  Da  Costa  :  i.  Etherization 
produces  a  marked  diminution  in  the  haemoglobin  of 
the  blood.  2.  The  red  corpuscles  and  the  hemoglobin 
are  especially  affected  in  blood  previously  diseased,  xn 
such  conditions,  for  instance,  as  ansemia.  3.  Irregular 
reports  are  due  to  faulty  observation,  to  th.e  presence 
of  altered  haemoglobin  in  the  blood,  to  the  faulty  aber- 
ration as  to  color  of  a  Fleischl  instrument,  or  to  taking- 
the  blood  before  anaesthesia  is  completed.  4.  The  white 
corpuscles  show  irregular  changes  which  are  not  char- 
acteristic, and  exhibit  variations  not  more  pronounced 
than  would  be  found  in  the  same  number  of  samples 
of  normal  blood  on  different  examinations.  5.  Age 
does  not_  apparently  influence  the  results.  6.  Ether 
pneumonia  may  be  possibly  due,  in  some  instances  at 
least,  to  the  action  of  intense  cold  on  the  lungs,  pro- 
duced by  the  action  of  ether  vapor.  7.  CEdema  of  the 
lungs  may  arise  from  contraction  of  the  pulmonary 
capillaries,  thus  producing  a  loss  of  vis  a  tergo  and 
damming  up  of  blood  in  the  veins.  Furthermore,  the 
same  condition  may  produce  sudden  paralysis  of  the 
heart.  8.  The  often-quoted  observation  as  to  the  effect 
upon  the  haemoglobin  of  shock  and  hemorrhage  re- 
quires enlarged  repetition  upon  human  beings  before 
the  statements  can  be  accepted  that  hemorrhage  causes 
a  great  fall  in  the  amount  of  haemoglobin,  but  that 
shock  does  not  affect  it.  9.  The  chilling  of  the  blood- 
stream may  be  responsible  for  the  nephritis  that  occa- 
sionally follows  etherization.  10.  Prolonged  anesthesia 
profoundedly  deteriorates  the  blood  and  strongly  mili- 
tates against  recovery  ;  hence  rapidity  of  operation  is 
most  desirable. — Mi-dical  Ne^cs. 

Treatment  of  Vaginismus.— Dr.  Madden  states  that 
he  has  based  his  treatment  of  vaginismus  on  certain 
reasons,  and  has  found  it  most  successful  in  these  cases, 
viz.,  first,  the  employment  of  constitutional  nerve  seda- 
tives and  tonics  to  allay  the  general  neurotic  condition  ; 
and,  secondly,  the  application  of  local  nerve-stretching 
to  the  affected  parts.  On  the  latter  point  he  briefly  re- 
capitulates the  steps  of  the  local  procedure  which  he 
has  proved  the  efficacy  of,  and  which  he  would,  there- 
fore, venture  to  recommend  to  other  practitioners. 
First,  then,  the  patient,  properly  prepared  for  an  anti- 
septic vaginal  operation,  and  the  rectum  and  bladder 
evacuated,  is  to  be  etherized  and  placed  in  the  ordinary 
left  lateral  semi-prone  position  ;  secondly,  a  large-sized 
bivalve  vaginal  speculum  is  to  be  introduced,  and  the 
blades  then  fully  expanded  ;  thirdly,  a  tampon  of  anti- 
septic cotton  or  wood  wool,  saturated  in  boroglyceride, 
IS  to-be  passed  in  through  the  speculum,  so  as  to  fill  its 
calibre  from  the  vulva  to  the  roof  of  the  vaginal  vault ; 
fourthly,  the  speculum,  still  widely  expanded,  is  to  be 
forcibly  withdrawn,  so  as  to  overcome  the  contractility 
of  the  parts,  and  at  the  same  time  thoroughly  stretch, 
or  even  slightly  rupture,  the  atfected  nerve-fibres.  In 
so  doing,  some  little  abrasion  of  the  vaginal  walls  may 
possibly  be  occasioned  ;  but  any  hemorrhage  therefrom 
will  be  sufficiently  controlled  by  the  tampon,  on  which 
counter-pressure  should  be  made  during  removal  of 
speculum,  so  as  to  retain  the  included  plug  in  the 
vagina,  where  it  may  be  left  for  at  least  twenty- four 
hours,  and  then,  at   the   same   intervals,  replaced  by 


I 


December  28,  1895] 


MEDICAL    RECORD. 


92: 


other  antiseptic  tampons,  which  should  be  employed 
for  the  next  week  to  maintain  the  patency  of  the  pas- 
sage. Immediately  after  removal  of  these  tampons 
the  vagina  should  on  each  occasion  be  thoroughly 
flushed  out  with  some  antiseptic  injection.  Finally,  if 
at  the  end  of  a  week  any  evidence  of  vaginismus  or 
spasmodic  contraction  should  still  remain,  then  the 
same  procedure  may  be  again  repeated,  after  which  it 
will  probably  be  found  that  the  passage  has  regained 
its  normal  sensibility  and  capacity.  In  some  exceptional 
instances  that  curative  result  may  not  be  thus  obtain- 
able, and  in  such  cases  it  may  possibly  become  neces- 
sary to  resort  to  the  removal  of  any  specially  hyper- 
sesthetic  tissues  in  the  vulva  vaginal  area,  or  else  to 
some  of  the  recent  modifications  of  Sims's  or  Emmett's 
operations  for  vaginismus.  These  procedures  will, 
however,  be  comparatively  seldom  required  by  gynecol- 
ogists, who  may  adopt  the  simpler  and,  according  to 
the  author's  experience,  generally  effectual  plan  of 
treatment  he  has  described. — Provincial  Medical  Jour- 
nal. 

The  Operative  Treatment  of  Spinal  Caries. — Dr. 
Calot  holds  that  in  the  present  state  of  science  it  is  un- 
justifiable to  operate  in  cases  of  paralysis  due  to  Pott's 
disease  of  the  spine,  as  most  of  these  cases  will  recover, 
if  treated  by  prolonged  rest.  Of  twenty  cases  treated 
by  the  author  during  the  last  four  years  by  rest  and 
immobilization,  nineteen  are  either  quite  cured  or  on 
their  way  to  complete  cure,  one  only  having  died  in 
consequence  of  the  rupture  of  a  large  psoas  abscess 
into  the  bladder.  Operative  treatment  is  contra- indi- 
cated in  Pott's  disease  by  the  seat  and  the  extent  of  the 
lesions,  by  the  nature  of  the  tuberculous  process,  and 
by  all  the  risk  attending  surgical  interference.  It  has 
been  stated  that  in  fifty  per  cent,  of  the  recorded  cases 
thus  treated,  death  has  been  due  directly  to  the  opera- 
tion, and  there  is  reason  to  believe  that  the  mortality 
really  amounts  to  between  sixty  and  eighty  per  cent. 
The  author  concludes  that  the  operative  treatment, 
which  is  so  fatal  or  useless  in  a  large  majority  of  cases, 
does  not  afford  in  the  few  successful  cases  better  results 
than  those  obtained  by  strictly  orthopedic  treatment. — 
University  Medical  Magazine. 

Tuberculosis  in  Syphilitics. — According  to  Dr.  Jac- 
quimet,  it  is  quite  frequent  to  see  pulmonary  troubles 
complicate  those  of  syphilis.  These  complications  have 
been  long  recognized,  as  Ambroise  Pare  speaks  of 
them,  but  their  nature  has  been  questioned.  Some 
thought  that  there  was  a  lesion  due  really  to  the  syphi- 
lis, others  regard  it  purely  and  simply  as  phthisis.  It 
has  been  shown  that  the  pulmonary  lesions  occurring  in 
syphilitics  should  be  attributed  to  two  different  causes: 
one  of  a  true  syphilitic  nature,  which,  therefore,  should 
receive  the  antisyphilitic  treatment,  the  other  enters  the 
body  with  tuberculous  manifestations.  Jacquimet  has 
made  a  study  of  the  evolution  of  pulmonary  tuberculo- 
sis in  syphilitics.  If  the  syphilis  exists  in  individuals 
already  attacked  by  pulmonary  tuberculosis,  it  aggra- 
vates the  latter  and  increases  it.  If,  on  the  contrary, 
tuberculosis  develops  in  a  syphilitic,  it  proceeds  in  two 
different  ways  :  it  develops  very  rapidly  if  the  syphilis 
is  in  its  secondary  period,  and,  on  the  contrary,  it  pro- 
ceeds slowly  and  torpidly  if  it  arises  in  the  tertiary 
stage.  Syphilis  plays  a  double  part  in  regard  to  the 
tuberculous  bacillus.  In  weakening  the  system  it  per- 
mits the  development  of  the  bacillus,  and,  on  the  other 
hand,  by  the  lesions  of  the  pulmonary  apparatus,  it 
permits  inoculation  of  the  tubercle  bacillus.  .\s  to  the 
pleurisies  of  the  secondary  period  of  syphilis,  which 
have  been  recently  described,  Jacquimet  agrees  with 
Landouzy,  that  they  are  of  a  bacillary  nature.  The 
diagnosis  between  pulmonary  syphilis  and  pulmonary 
tuberculosis  in  syphilitics  can  only  be  made  by  bacteri- 
ological examination  of  the  expectoration.  The  author 
agrees  with  Landouzy,  in  believing  that  in  the  infec- 
tious group  there  is  none  worse,  none  so  formidable,  as 


the  combination  of  syphilis  and  tuberculosis. —  Union 
Mldicale. 

Forced  Feeding  for  Nine  Years. — Dr.  (iadelius  re- 
cords the  case  of  a  tailor,  a^ed  thirty-two,  an  assiduous 
workman,  slow,  taciturn,  but  amenable  to  reason.  In- 
sanity of  persecution  developed  ;  the  prominent  symp- 
toms being  anxiety  and  insomnia,  with  neglect  of  his 
person  and  refusal  to  take  food.  When  spoken  to  he 
invariably  answered,  in  an  undertone,  "  Fine  weather, 
to-day,"  and,  later  on, ''  I  do  not  know."  Forced  feed- 
ing was  carried  on  uninterruptedly  from  April  24,  1S83, 
toFebruary  12,  1S92,  the  body-weight  increasing  dur- 
ing this  period  from  101  to  160  pounds.  From  April, 
1883,  to  May,  1886,  he  remained  in  a  condition  of  com- 
plete stupor  and  anaesthesia.  The  author  considers  the 
prodromic  delirium  as  a  paranoiac  psychosis  in  a  de- 
generate subject,  and  regards  the  case  as  a  psychosis  of 
exhaustion,  being  practically  a  condition  of  syncope 
from  beginning  to  end.  On  awakening  from  the  stupor, 
the  patient  had  lost  most  of  his  former  knowledge  of 
things  and  places,  but  soon  recovered  it. — Ilygcia. 

Pa-nfol  Digestion  in  the  Hysterical. — Among  the 
interesting  papers  in  the  July  issue  of  the  Liverpool 
Medico  Chirurgical  Journal,  is  one  by  Dr.  T.  R.  Glynn, 
on  painful  digestion  in  hysterical  subjects.  The  symp- 
toms are  somewhat  like  those  of  gastric  ulcer.  Pain, 
especially  after  food  and  relieved  by  vomiting,  and  the 
occasional  ejection  of  blood,  are  confusing  points  of 
resemblance.  Nervous  dyspepsia  is  very  frequently 
met  within  chloro  anaemia.  Chlorotic  young  women 
suffer  from  painful  sensations  and  hypersesthesia  in 
various  parts  :  headache,  tenderness  in  the  head  ; 
backache,  tenderness  along  the  spine  ;  pain  or  tender- 
ness in  the  breasts  and  ovaries  ;  teeth  are  extracted 
for  toothache  ;  there  is  pain  after  food  and  other  stom- 
ach troubles  ;  more  or  less  tenderness  on  pressure  over 
the  epigastrium,  and  perhaps  cutaneous  hyperaesthesia, 
its  area  following  the  distribution  of  the  tender  spots 
characterisric  of  hysteria.  The  great  majority  of  chlo- 
rotic girls  are  hysterical,  presenting  the  stigmata  of 
hysteria.  The  hyperaesthesia  and  neuralgias  in  chloro- 
an^-emia  are  not  directly  due  to  anemia,  but  to  the 
hysterical  condition  dependent  upon  it.  Nervous 
dyspepsia  occurs  in  persons  who  are  simply  hys'erical 
and  not  chlorotic,  and  is  met  with  in  subjects  who  have 
neither  chlorosis  nor  hysteria.  The  chlorotic  girls 
who    are   not   also   hysterical   are  free  from   nervous 

dvspepsia  and  from  pain.     A  case,  B.  H ,  was  sent 

to  the  hospital  for  gastric  ulcer.  For  a  month  there 
had  been  pain  in  the  epigastrium,  back,  and  beneath 
each  breast.  The  pain  was  aching  and  wearing,  in- 
tense after  eating,  coming  on  immediately  after  deglu- 
tition, and  often  keeping  her  awake  at  night.  She 
vomited  three  or  four  times  daily,  with  occasionally  a 
little  blood  in  the  ejected  matter,  and  often  much  bile. 
M.  T ,  also  sent  in  as  a  case  of  gastric  ulcer,  com- 
plained of  vomiting,  and  h;ematemesis.  During  con- 
valescence from  an  acute  illness,  headaches  began,  and 
pains  in  the  back,  under  the  left  breast,  and  in  the  left 
ovary.  Milk  diet  improved  her  somewhat  for  a  time. 
There  was  right  hemianalgesia,  restriction  of  visual 
fields,  various  tender  spots,  exaggerated  knee  jerks,  and 

absence   of   plantar  reflexes.     L ,  very   hysterical, 

neurotic  family  history,  migraine  ever  since  she  could 
remember  ;  was  sent  in  as  a  probable  case  of  catarrh  of 
the  stomach.  She  had  entirely  lost  her  appetite  and 
vomited  continually.  No  food  had  any  taste.  There 
was  hemianalgesia,  restricted  visual  fields,  various  ten- 
der spots,  tremor,  and  loss  of  the  olfactory,  and  of  the 
gustatory  sense.  This  loss  was  an  exaggeration  of  a 
condition  common  in  the  hysterical,  and  often  found  m 
a  marked  degree  in  hysterical  anorexia.  The  pain  in 
nervous  dyspepsia  is  often  very  violent.  In  one  case 
under  observation,  the  amount  of  shock  was  sufticient 
to  suggest  the  possibility  of  intestinal  perforation.  Yet 
the  hysterical  analgesia  was  so  marked  that  the  mser- 


924 


MEDICAL    RECORD. 


[December  28,  il 


tion  of  a  hypodermic  needle  to  introduce  morphia  was 
unnoticed.  It  is  difficult  to  get  patients  to  localize 
pain.  It  is  referred  to  the  end  of  the  sternum,  to  the 
epigastrium,  in  the  back,  under  the  l;ft  breast,  or  it  is 
said  to  stab  through,  or  go  around  the  body.  Where 
pain  is  e.\perienced  on  sn^allowing,  the  referred  pain  is 
felt  over  the  ensiform  cartilage,  i.e.,  over  a  small  area 
supplied  by  the  sensory  root  of  the  sixth  or  seventh 
dorsal  nerves.  The  superficial  pains  follow  the  dis- 
tribution described  by  Dr.  Head,  in  Brain,  Part  LXI., 
in  a  paper  on  "  Disturbances  of  Sensation  with  Special 
Reference  to  the  Pain  of  Visceral  Disease."  They  are 
referred  to  the  surface  of  the  body,  back,  and  front, 
supplied  by  the  sixth,  seventh,  eighth,  and  ninth  sen- 
sory roots,  the  maximum  seats  of  pain  being  distributed 
somewhat  differently  in  different  cases,  over  the  epigas- 
trium, and  lower  dorsal  region.  The  theory  that  the 
mucous  membrane  of  the  stomach,  in  this  form  of  pain- 
ful dyspepsia,  is  in  ahyperEcsthetic  condition,  owing  to 
an  abnormal  state  of  central  gray  matter,  explains  many 
of  the  characters  of  the  affection.  The  swallowing  of 
simple  liquids  gives  pain.  This  symptom  points  to  ex- 
treme sensibility,  that  is  much  more  common  in  nervous 
dyspepsia  than  in  gastric  ulcer.  The  pain  in  the  gas- 
tric neurosis  is  often  severe  at  night.  So  also  is  that  of 
gastric  ulcer,  reaching  its  maximum  intensity  between 
eleven  and  one.  But  the  pain  of  nervous  dyspepsia  is 
frequently  severe  on  waking,  before  breakfast.  In  gas- 
tric ulcer,  hyper^sthetic  cutaneous  areas  are  more 
limited  than  in  nervous  dyspepsia.  Flatulence  is  more 
common  in  nervous  dyspepsia  than  in  gastric  ulcer. 
Pain  in  gastric  ulcer  depends  largely  upon  the  general 
condition  of  the  patient,  and  it  may  be  present  at  one 
time  during  the  disease,  and  absent  at  another.  Hys- 
terical persons  may  also  have  gastric  ulcer,  and  the 
chlorotic  are  predisposed  to  it.  Hysteria,  chlorosis, 
and  gastric  ulcer  are  close  allies.  In  nervous  dys- 
pepsia, treatment  directed  to  the  general  condition 
brings  about  better  results  than  efforts  directed  to  the 
local  or  stomach  troubles.  Absolute  rest  in  bed  is 
necessary,  with  cold  sponging  and  massage,  and  a  diet 
restricted  to  liquids  for  a  day  or  two,  but  quickly  made 
substantial,  varied,  and  generous.  Iron  may  be  needed 
for  anaemia  and  some  sedative  for  pain.  No  benefit  is 
derived  from  alkalies,  acids,  tonics,  antispasmodics, 
antiseptics,  etc.  Drugging  with  nitric  acid  and  pepsin,' 
bismuth  and  carbonate  of  soda,  sulpho  carbolates  and 
salol,  leaves  the  patient  in  much  the  same  condition  for 
months,  or  years.  Then,  too,  it  is  wise  to  remember 
always  that  with  gastric  ulcer  there  may  be  also  a 
strong  neurotic  element  that  is  made  worse  by  an  inter- 
minable course  of  milk  and  lime-water. 

Rickets  and  Convulsions.— Out  of  1,600  rickety  chil- 
dren observed  by  J.  Comby  in  a  Paris  dispensary,  only 
one-tenth  had  convulsions,  while  Henoch  attributes 
tivo-thirds  of  the  cases  of  goitre  spasm  to  rickets.  Al- 
though rickets  is  so  common  in  Paris,  goitre  spasm  is 
very  rare,  and  the  author  believes  there  is  a  relation  of 
cause  and  effect  between  rickets  and  laryngeal  spasm. 
Still  less  is  this  so  with  dentition  (even  when  delayed 
and  perverted  by  rickets).  Among  70,000  children  seen 
during  eleven  years,  Comby  never  saw  convulsions  of 
purely  dental  origin,  and  never  had  occasion  to  lance  the 
gums.  Craniotabes,  sometimes  assumed  as  a  cause  of 
gastric  spasm,  if  looked  for  is  found  with  "  extraordinary 
frequency,"  and  in  cases  where  there  has  never  been  any 
convulsion  or  glottic  spasm.  The  bond  that  unites  the 
two  morbid  states  (rickets  and  convulsions)  is  dyspep- 
sia (dilatation  of  the  stomach,  diarrhoea,  constipation, 
etc.),  with  auto-intoxication,  from  which  arise  all  these 
nervous  disorders,  and  in  a  great  part  even  rickets  \\- 
%m.—L,  ail  lard  s  Medical  Journal. 

Tiie  Hysterical  Breast.-Dr.  GiUes  de  la  Tourette  con- 
siders this  condition  of  much  importance,  not  only  be- 
cause It  is  a  well-defined  manifestation  of  hysteria  but 
also  from  the  fact  that  it  has  given  rise  to  errors  of  diag- 


nosis and  needless  removal  of  the  organ.  It  consists  in 
a  temporary  enlargement  of  the  breast,  with  consider- 
able hyperaesthesia  of  the  skin  covering  the  organ. 
This  hyperesthesia,  liable  to  vary,  becomes  much  more 
marked  during  menstruation  ;  there  is  then  also  more 
swelling,  and  considerable  pain  is  complained  of.  On 
palpation  at  such  a  time  it  is  possible  to  perceive  one 
or  perhaps  two  tumor-like  masses  in  the  substance  of 
the  breast,  about  the  size  of  a  hen's  egg,  but  which  are 
not  painful,  the  hyperesthesia  being  cutaneous.  The 
affection  is  often  of  long  duration,  more  especially  in 
those  cases  where  there  is  faulty  therapeusis,  as  often 
happens.  It  seems  to  depend  on  a  hysterogenous  band 
of  hyperaesthesia  at  the  level  of  the  breast,  which  in- 
duces an  oedema  of  the  connective  tissue  of  the  gland. 
In  this  way  are  produced  the  local  swellings,  and  even 
patches  of  white,  pink,  or  violet  under  the  skin. — Jour- 
nal de  Me'decine. 

The  Causes  of  Death  in  Pneumonia. — Dr.  Bollinger 
maintains  that  croupous  pneumonia  is  a  typical  local 
infectious  disease,  pursuing  in  the  majority  of  cases  a 
very  regular  course.  It  is  not  dangerous  on  account 
of  the  duration  or  the  intensity  of  the  fever.  The  im- 
pairment of  the  function  of  the  lung  is  likennse  insuf- 
ficient to  explain  death.  The  oedema  so  frequently 
found  in  the  parts  of  the  lung  spared  by  the  disease  is 
not  the  result  of  a  passively  increasing  collateral  hyper- 
emia, but  of  cardiac  failure.  The  collapse  symptoms 
in  croupous  pneumonia  and  the  fatal  weakening  of  the 
heart  are  dependent  on  oligemia,  which  leads  to  im- 
paired nutrition  of  the  cardiac  muscle,  already  weak- 
ened by  the  fever  and  the  extra  demands  upon  it. 
Anemia  of  the  brain  may  cause  disturbances  of  inner- 
vation of  the  heart,  and  this  may  be  an  additional 
factor.  The  exudate  into  the  lung  tissue  may  be  lik- 
ened to  a  venesection  produced  by  the  pneumococcus, 
which  in  a  few  days  deprives  the  blood  of  a  large  quan- 
tity of  important  constituents.  The  reason  why  death 
takes  place  so  early,  and  usually  in  the  same  stage  of 
the  disease,  from  the  sixth  to  the  eighth  day  (corre- 
sponding to  the  transition  from  red  to  gray  hepatiza- 
tion), is  probably  because  the  exudate  has  to  attain  a 
certain  acme  before  life  is  imperilled.  If  these  facts 
are  applied  to  therapeusis,  it  follows  that,  in  addition 
to  the  usual  treatment  of  pneumonia,  every  effort  should 
be  made  to  combat  the  oligemia.  Large  quantities  of 
fluids  should  be  supplied  to  the  system  through  every 
available  channel,  even  in  the  form  of  saline  infusions. 
This  should  be  done  at  an  early  period,  before  collapse 
symptoms  have  manifested  themselves. —  Miinchener 
7nedicinishe  Wochenschrift. 

Moist  or  Dry  Asepsis  ?— .\t  a  recent  discussion  Sanger 
raised  this  question  in  a  long  paper,  in  which  he  de- 
scribed 147  cases  of  coeliotomy,  all  treated  with  Tavel's 
soda  solution.  His  results  were  perfectly  satisfactory, 
not  one  succumbing  to  sepsis  out  of  the  six  deaths. 
Three  of  the  sections  showed  no  adhesions.  He  advo- 
cated this  as  the  best  antiseptic  for  keeping  the  peri- 
toneal epithelium  intact.  Zsveifel  acknowledged  him- 
self as  a  devotee  of  the  dry  method.  With  carefully 
applied  dry  antisepsis  he  had  not  a  single  death  to  re- 
cord from  ileitis.  It  is  true  that  he  had  two  cases  that 
showed  symptoms  of  the  chronic  form  of  ileus,  which 
subsequently  was  relieved  by  operation.  He  was  con- 
vinced that  the  moist  antisepsis  had  worse  results  to 
record.  Freund  was  of  opinion  that  improved  surgical 
treatment  or  antiseptic  treatment  would  not  increase 
the  liability  to  ileus  after  laparotomy.  Within  the 
last  five  years  he  had  four  cases  of  ileus,  none  of  which, 
he  was  confident,  were  caused  by  the  operation.  Three 
of  them  were  undoubtedly  due  to  a  catarrhal  process 
which  produced  stenosis  of  the  flexura  sigmoidea,  sub- 
sequently inducing  ileus.  Schauta  said  that  he  could 
record  1,300  cceliotomies.  In  the  first  half  of  these  he 
had  used  moist  asepsis  with  four  deaths  :  with  the  sec- 
ond half,  dry  antiseptics  with  no  deaths.     He  was  of 


December  28,  1895] 


MEDICAL    RECORD. 


925 


opinion  that  moist  or  dry  antiseptics  had  no  effect /<•;■ 
^6'  on  the  production  of  ileus,  but  he  thought  better 
methods  of  operation  with  perfect  asepsis  had  a  con- 
siderable influence  in  its  reduction.  Tauffer  recorded 
348  laparotomies  with  dry  septic  treatment,  and  443 
with  moist  treatment.  In  the  former  series  he  had  two 
deaths  ;  in  the  latter  ten  deaths  to  record. — Aledical 
Press. 

Diet  in  Slight's  Disease. — The  question  of  what  diet 
is  the  most  suitable  in  the  various  forms  of  Brighi's 
disease  has  been,  and  is  still,  a  much- debated  point. 
It  is  particularly  a  question  where  theoretical  views  are 
likely  to  influence  practice.  If  Bright's  disease  is 
looked  upon  as  a  primary  inflammatory  affection  of  the 
kidneys,  articles  of  diet  possessing  diuretic  properties 
will  probably  be  avoided.  If  uraemia  is  considered  to 
be  due  to  failure  on  the  part  of  the  kidneys  to  excrete 
nitrogeneous  extractives,  there  will  be  a  tendency  to 
diminish  as  much  as  possible  the  quantity  of  proteid 
matter  in  the  food.  It  is  more  especially  in  chronic 
Bright's  disease  that  the  question  is  important.  Dr. 
Hirschfeld  discusses  anew  the  various  diets  suitable  in 
this  disease.  He  considers  that  the  albuminuria  is  the 
first  point  that  calls  for  attention,  and  that  all  articles 
of  diet  which  cause  an  unequivocal  increase  in  the 
daily  loss  of  albumin  are  to  be  avoided — for  instance, 
alcohol  and  smoked  meats.  Eggs  are  not  harmful  in 
moderation.  He  points  out  that  although  the  actual 
loss  of  albumin  in  the  urine  may  not  amount  to  more 
than  a  few  grammes  per  diem,  yet  this  loss  cannot  be 
made  up  for  by  increasing  (he  amount  of  proteid  in  the 
food.  Not  only  is  an  increase  of  proteid  in  the  food 
followed  by  an  increase  in  the  albuminuria,  but,  in  ad- 
dition, there  are  increased  amounts  of  nitrogeneous  ex- 
tractives to  be  excreted,  and  thus  more  strain  is  thrown 
on  the  damaged  kidneys.  Although,  of  course,  the  in- 
creased loss  of  albumin  is  much  less  than  the  increase 
of  proteid  in  the  food,  yet  it  is  extremely  doubtful 
whether  any  proteid  is  retained  in  the  body  as  such. 
In  health  it  is  known  that  increased  proteid  food  leads 
to  increased  proteid  metabolism,  and  that,  if  proteid 
metabolism  is  to  be  checked,  it  is  done  most  efficiently 
by  increasing  the  fatty  and  carbo-hydrate  foods.  For 
these  leasons  the  albuminuria  is  not  to  be  combated 
by  increased  proteid  diet.  Many  authorities  on  renal 
disease  lay  but  little  stress  on  the  daily  loss  of  albumin, 
and  think  that,  if  the  general  condition  of  the  patient 
is  improved  by  a  more  liberal  diet,  this  should  be  per- 
severed in  notwithstanding  the  increased  albuminuria. 
Hirschfeld  states  that  a  rich  proteid  diet  is  likely  to 
lead  to  the  retention  of  nitrogeneous  extractives,  since 
the  increased  excretion  of  these  extractives  following 
such  a  diet  occurs  later  in  patients  with  diseased  kid- 
neys than  under  normal  conditions.  Hence  such  a 
diet  might  predispose  to  ura;mia.  Hale  White,  how- 
ever, states  definitely  ("  Med.-Chir.  Trans.,"  vol.  Ixxvi.) 
that  in  his  experience  an  ordinary  full  diet  does  not 
increase  the  liability  to  uraemia,  and  he  quotes  one 
striking  case  in  which  a  patient  developed  severe 
ursemia  on  a  farinaceous  diet,  and  when  these  symp- 
toms became  less  a  full  diet  was  given  without  any 
return  of  ur?emic  symptoms.  Hirschfeld  would  give 
about  6  ounces  of  meat  and  13  ounces  of  bread  daily, 
with  a  liberal  allowance  of  vegetables  and  fruit,  i>^ 
ounce  of  sugar,  and  5  ounces  of  fat,  as  a  typical  diet 
for  a  patient  with  chronic  Bright's  disease.  As  regards 
the  value  of  milk  in  this  disease,  he  points  out  that  it 
may  be  used  in  one  of  three  ways.  First  (as  Karell 
suggested),  in  small  (juantities — i.e.,  two  to  three  pints 
daily,  and  as  the  sole  food.  In  this  way  the  work  of 
the  kidneys  is  reduced  to  a  minimum.  .\t  the  same 
time  it  is  almost  a  starvation  diet,  and  is  mainly  useful 
in  acute  Bright's  and  in  cases  where  there  is  great  fail- 
ure of  appetite.  Secondly,  milk  may  be  given  in  large 
quantities,  say  from  four  to  eight  pints  daily.  This  is 
a  form  of  treatment  much  advocated  by  Germain  S6e 


and  others.  These  observers  state  that  albuminuria 
often  disappears  under  this  regime,  and  does  not  re- 
turn when  a  more  liberal  diet  is  allowed.  Finally,  milk 
may  be  given  in  moderate  quantities  in  addition  to, 
rather  than  in  lieu  of,  the  mixed  diet  recommended 
above. —  The  Practitioner. 


Jiocicty  ilcpovts. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  December  4,  iSg^. 

Joseph     D.    Bryant,    M.D.,    President,    in     the 
Chair. 

Nominations. —  Vice-President,  Drs.  Egbert  H.  Grandin, 
Virgil  P.  Gibney,  R.  W.  Taylor  ;  Trustee,  Dr.  Joseph  E. 
Janvrin  ;  Committee  on  Library,  vacancy  of  four  years, 
Drs.  H.  L.  Collyer,  C.  G.  Coakley,  A.  Rose,  F.  W.  Wig- 
gin  ;  vacancy,  of  five  years,  Drs.  Dillon  Brown,  B.  F. 
Curtis  ;  Committee  on  Admission,  one  to  be  elected,  Drs. 
R.  A.  Murray,  John  Girdner  ;  Five  Delegates  to  the 
State  Medical  Society,  Drs.  W.  S.  Gottheil,  Joseph  Col- 
lins, R.  H.  Sayre,  Ralph  L.  Parsons,  C.  H.  Richardson. 

A  Study  of  the  Infectiousness  of  the  Dust  in  the 
Adirondack  Sanitarium. — Di^.  Irwin  H.  Hance  read 
the  paper  (see  p.  903). 

Discuss: on. — Dr.  E.  G.  Janeway  thought  that 
while  Dr.  Hance  had  taken  very  little  of  our  time  to 
give  us  these  facts,  they  were,  nevertheless,  very  im- 
portant and  had  involved  a  great  deal  of  work.  At  a 
recent  visit  to  the  Sanitarium  he  had  been  impressed 
with  its  absolute  cleanliness,  the  clear  air  about  the 
cottages,  their  excellent  ventilation,  and  the  small  num- 
ber of  inmates  for  the  amount  of  air-space.  In  fact, 
he  would  much  prefer  to  live  in  one  of  these  cottages 
than  at  many  hotels  frequented  by  invalids.  He  felt 
that  the  chances  of  a  patient  sent  there  would  be  bet- 
ter than  at  most  hotels.  He  often  advised  delicate 
people  not  to  resort  to  hotels  frequented  by  invalids, 
unless  the  proprietor  was  known  to  be  extra  careful 
regarding  cleanliness,  etc.  We  must  not  send  our 
pulmonary  invalids  to  places  where  they  are  liable  to 
receive  worse  infection.  Dr.  Janeway  said  he  knew 
from  personal  questioning  of  phthisical  patients  that 
there  were  many  physicians  in  this  city  who  did  not 
warn  their  patients  of  the  possibility  of  infecting 
others  through  the  sputa  and  other  excreta.  If  the 
precautions  taken  at  the  Adirondack  Sanitarium  were 
applied  in  this  city  we  would  have  less  tuberculosis. 
Yesterday,  while  riding  in  a  streetcar  in  Philadelphia, 
he  observed  a  sign  :  "  Passengers  are  positively  pro- 
hibited from  spitting  in  this  car."  This  was  a  good 
warning,  although  it  might  not  always  be  heeded. 

Dr.  Her.man  M.  Biggs  hoped  the  paper  read 
would  prove  of  great  service  to  physicians  and  the 
Board  of  Health  in  combating  tuberculosis  in  New 
York.  It  was  exceedingly  gratifying  to  learn  that  such 
precautions  could  be  taken  in  a  hospital  for  tuberculo- 
sis, which  would  effectually  prevent  danger  of  infec- 
tion. The  experiments  narrated  would  seem  to  indi- 
cate that  fact  in  the  clearest  way. 

A  few  years  ago,  when  the  Board  of  Health  contem- 
plated classifying  tuberculosis  among  the  infectious 
diseases,  a  great  outcry  was  made  by  the  people  and 
physicians  that  it  would  make  these  invalids  a  source 
of  horror  to  their  friends  and  cause  them  to  be  shunned 
as  if  they  were  lepers.  The  fact  appeared  to  have 
been  overlooked  that,  with  proper  precautions,  they 
could  be  rendered  absolutely  innoxious  to  their  asso- 
ciates. But  where  these  precautions  were  not  taken 
there  was  positive  evidence  of  the  greatest  danger  of 
spreading  the  infection.  In  one  of  our  city  hospitals 
as   many  as  eleven   nurses   and  orderlies,    previously 


•926 


MEDICAL   RECORD. 


[December  28.  1895 


healthy,  had  been  dismissed  within  a  little  more  than 
two  years,  because  suffering  from  tuberculosis.  It  was 
due  to  the  fact  that  the  hospital  was  overcrowded,  had 
poor  ventilation,  and  other  conditions  favorable  for 
the  transmission  of  the  disease.  Moreover,  patients 
admitted  with  other  diseases  and  remaining  in  such 
hospitals  a  few  months  often  contracted  tuberculosis. 

The  Health  Department  had  found  it  the  exception 
for  physicians  to  instruct  their  patients  with  tubercu- 
losis as  to  the  danger  of  their  sputa  and  the  necessity 
for  its  safe  disposal.  This  was  nothing  less  than 
criminal  negligence  or  indifference.  One  of  the 
largest  and  best  hospitals  in  the  city  lately  handed  the 
clothing  and  handerchiefs  of  a  man  dying  in  its  wards 
of  tuberculosis  over  to  the  wife  without  first  disinfect- 
ing them,  and  this  woman  herself  knew  that  it  was 
wrong  and  boiled  the  clothes  immediately.  The  peo- 
ple, it  seemed,  were  being  educated  in  advance  of  a 
part  of  the  profession,  for  they  followed  precautions 
which  they  learned  through  the  newspapers  and  with- 
out having  been  instructed  by  the  family  physician. 

Dr.  Biggs  said  it  had  been  a  hope  of  his  for  years 
that  eventually  a  home  for  the  treatment  of  the  poor 
with  tuberculosis  would  be  established  in  the  country. 
The  paper  showed  that  such  a  method  of  caring  for 
these  cases  would  be  safe  and  practical. 

Dr.  H.  p.  Loomis  said  that  ten  years  ago  phthisis 
was  not  thought  of  as  an  infectious  disease,  and  he 
believed  it  was  about  five  years  ago  that  the  patholo- 
gists of  the  Board  of  Health  were  asked  whether 
tuberculosis  should  be  regarded  as  a  source  of  infec- 
tion. To-day  the  laity  understood  perfectly  that  it 
was.  They  were  talking  about  the  dust  in  their  rooms, 
and  he  believed  that  more  of  them  recognized  this 
source  of  danger  than  we  supposed.  It  was  a  satisfac- 
tion to  know  that  there  was  a  place  where  we  could  go  and 
get  absolutely  harmless  air,  even  if  it  did  necessitate  a 
sojourn  at  a  consumptive  sanitarium.  He  had  paid 
many  visits  to  Saranac  Lake,  and  remembered  well 
that  in  the  beginning  the  project  of  establishing  such  a 
sanitarium  met  with  much  opposition,  one  objection 
which  was  suggested  being  that  to  bring  together  so 
■many  patients  with  a  lingering  disease  would  have  a 
■depressing  effect  ;  also  that  after  a  time  the  furniture 
would  become  contaminated  and  prove  dangerous. 
Dr.  Trudeaux  did  not  believe  this,  and  the  paper  read 
by  Pr.  Hance  showed  that  under  the  plan  adopted, 
■of  separate  buildings,  cleanliness,  and  destruction  of 
the  sputum,  the  danger  of  infection  was  very  slight. 

Dr.  Loomis  thought  there  was  no  doubt  but  what 
the  separate  house  plan,  with  cleanliness  and  proper 
disposal  of  the  sputum,  was  best  in  the  management  of 
consumption.  With  one  exception  there  was  no  gen- 
eral hospital  in  the  city  which  would  retain  within  its 
wards  cases  of  tuberculosis,  and  he  believed  the  Com- 
missioners of  Charities  were  about  to  exclude  them 
from  Bellevue.  The  position  of  the  tuberculous  pa- 
tient was  sad  indeed,  as  he  drifted  about  between  the 
Scylla  of  an  agonizing  family  without  means  and  the 
Charybdis  of  a  charity  hospital  with  closed  doors.  In 
view  of  the  safety  secured  against  infection  in  the  Adi- 
rondack Sanitarium,  Dr.  Loomis  thought  the  hospitals 
in  this  city  could  have  separate  buildings  or  wards  in 
which  tuberculous  patients  could  be  treated  without 
danger  to  other  wards.  He  believed  St.  Luke's,  in  its 
new  site,  would  provide  for  this  want,  and  the  example 
ought  to  be  copied  by  other  institutions. 

Dr.  Freudenth.-^l  said  that  at  Montefiore  Home  the 
sputa  was  carefully  destroyed  and  the  ventilation  was 
better  than  at  Bellevue,  yet  cases  of  infection  with 
tuberculosis  did  occur  in  nurses  and  inmates.  This 
might  be  accounted  for  in  part  by  the  fact  that  absolute 
cleanliness  of  patients  and  clothing  was  hardly  possible. 

Tuberculous  Heirlooms  in  Country  Homes.  —  Dr. 
Andrew  H.  S.mith  hoped  this  paper  and  its  warning 
would  reach  country  practitioners  and  people,  for  a 
great  many  houses  in  the  rural  districts,  along  with 


their  ancient  tapestry  and  furniture,  were  hot-beds  for 
the  culture  of  tubercle  bacilli.  Unlike  houses  in  the 
city,  the  contents  were  not  subject  to  change,  but  were 
sometimes  used  by  several  generations.  The  result 
was,  that  not  infrequently  one  after  another  in  the 
house  died  of  tuberculosis,  and  it  was  wrongly  attrib- 
uted to  heredity  instead  of  infection.  They  should 
be  taught  to  leave  their  windows  open  and  to  renovate 
the  furniture.  Regarding  sleeping-cars.  Dr.  Smith  said 
the  sheets  were  cleansed,  but  the  blankets  were  used 
probably  year  after  year  without  disinfection,  and  he 
never  felt  like  permitting  a  patient  going  toward  Sara- 
nac Lake  to  take  a  night  train. 

Infection  in  Hotels. — Dr.  A.  Jacobi  said  he  knew 
from  personal  observation  of  the  negligence  of  a  num- 
ber of  our  hotels  with  regard  to  infectious  diseases. 
He  knew  more  particularly  of  cases  where  diphtheria 
had  occurred  at  intervals  in  the  same  suite  of  rooms  in 
hotels,  due,  no  doubt,  to  want  of  disinfection,  cleanli- 
ness, and  change  of  tapestry,  etc.  Tuberculosis  could 
be  spread  in  the  same  way.  He  thought  there  was 
more  danger  in  the  better  class  of  flats,  where  the  stairs 
were  carpeted  but  seldom  cleaned,  than  in  the  lower 
tenements,  where  no  carpets  existed. 

Dr.  Charles  A.  Leale  said  the  sleeping-cars  going 
north  were  not  the  only  ones  whose  blankets  might 
profitably  be  cleaner,  as  he  had  observed  on  a  trip  to 
Jacksonville.  In  Florida,  too,  he  saw  draperies  and 
carpets  in  hotels  so  contaminated  as  almost  to  produce 
emesis  in  the  healthy. 

Dr.  J.  W.  Brannan  thought  that  since  Dr.  Hance 
had  shown  that  it  was  possible  to  conduct  a  sanitarium 
on  a  clean  principle,  it  ought  to  be  exacted  of  all  insti- 
tutions in  this  country  to  show  a  like  clean  bill  of  health. 

Dr.  a.  Rose  said  that  in  places  in  Europe  visited  by 
him  three  things  were  missing  which  we  had  here, 
namely,  carpets,  dark  bedrooms,  and  a  basement.  It 
would  be  interesting  to  know  how  much  less  tuber- 
culosis we  would  have  if  these  three  things  did  not 
exist. 

Advancing. — The  President  said  that  five  years 
ago,  when  he  was  Health  Commissioner,  he  had  a  ste- 
reotyped letter  sent  out  to  twenty-four  prominent  phy- 
sicians of  the  city,  asking  them  whether  they  thought 
we  were  sufficiently  advanced  to  justify  the  Board  of 
Health  in  classifying  tuberculosis  among  the  infectious 
or  contagious  diseases.  Five  replies  were  received. 
Two  hesitatingly  said  yes  ;  one  was  of  doubtful  tenor  ; 
one  was  long,  earnest,  logical,  and  fully  awake  to  the 
situation  ;  the  fifth  said  no.  The  President  thought 
that  the  discussion  to-night  showed  that  steps  had  been 
taken  which  would  bring  forth  fruit. 

Dr.  Hance,  in  some  closing  remarks,  said  that  prob- 
ably not  one  patient  in  fifty  coming  to  the  Sanitarium 
knew  what  disposition  to  make  of  his  sputa  until  in- 
structed. In  the  village  they  would  not  use  the  sani- 
tarium cuspidor  for  a  time,  but  they  had  so  greatly 
changed  that  about  two  years  ago  the  local  Board  of 
Health  had  made  its  use  obligatory.  That  examination 
of  dust  under  the  microscope  was  a  poor  test  of  its 
infectious  character  was  shown  by  the  fact  that  out  of 
many  specimens  examined  from  one  cottage  he  found 
only  one  tubercle  bacillus,  whereas  inoculation  of 
guinea-pigs  with  this  dust  had  caused  tuberculosis  in 
fifty  per  cent.  In  reply  to  an  interrogatory  by  Dr. 
Brannan  he  said  the  Sanitarium  was  a  charit)',  charging 
a  fixed  price  of  five  dollars  a  week,  while  the  actual 
expense  averaged  about  seven  dollars.  Only  such  cases 
were  received  as  gave  some  promise  of  recovery.  Fresh 
air  was  an  important  part  of  the  treatment,  the  patients 
being  out  of  doors  six  or  eight  hours  daily  during  the 
winter,  and  longer  during  the  summer.  He  also  stated 
that  he  did  not  know  what  was  the  cause  of  death 
in  guinea-pigs  injected  with  the  dust  and  in  which  tu- 
berculosis was  excluded.  Death  usually  took  place  in 
forty- eight  hours,  the  prominent  post- mortem  changes 
being  cedema,  cellulitis,  and  peritonitis. 


December  28,  1895] 


MEDICAL   RECORD. 


9^; 


ing  conditions.  That  these  induce  an  initial  anajmia 
which  is  followed  in  certain  cases  by  degenerative 
changes  in  the  blood-vessels.  That  capillary  hemor- 
rhages result  and  induce  an  excessive  degree  of  anre- 
mia.  That  some  cases  are  due  chiefly  to  external 
bleedings,  which  account  for  all  the  characteristic 
symptoms  and  post-mortem  appearances.  That  the 
treatment  should  be  based  on  etiological  considera- 
tions.— Stockm.\n. 

Napoleon's  Favorite  Prescriptions. — The  following 
are  given  by  Charles  B.  Williams  as  prescriptions  fre- 
quently used  by  Napoleon  I.  : 

(i)  B.  Pulv.  ipecac gr-  "x.x. 

Pulv.  scills, 

Pulv.  ammonije Si  gr.  xl. 

Div.  in  pil.  No.  xxxiv. 
S. — Two  pills  night  and  morning. 

The  above  was  used  for  difficulty  of  breathing,  bron- 
chitis, etc. 

(2)  B  •  Liq.  ammonix^fortioris X"- 

Syrupi  erysemi   |  jf 5. 

Infusionis  tilix  florum 3  'j^^ 

S. — To  be  taken  at  one  dose. 

This  was  used  for  immediate  relief  of  hoarseness. 
The  syrup  of  erysemum  and  the  infusion  of  linden 
flowers  would  be  difficult  to  obtain  at  the  present  day. 
■  and  these  may  be  replaced  as  in  the  following  : 

1{ .     Liq.  ammonia;  forlioris ^X- 

Syrup  acacix 3  J^** 

Aq.  aurantii  flor 3  'J^- 

S. — To  be  taken  at  a  dose. 

—Medical  and  Surgical  Reporter. 

Fever  in  Nephritis. — Fever  may  occur  in  the  course 
of  Blight's  disease  under  three  conditions  :  i,  At  the 
onset  of  acute  nephritis  as  a  result  of  the  infection  or 
into.xication  causing  the  disease,  or  of  the  inflamma- 
tered  every  hour  or  half-hour  until  free  evacuation  oc-  ^^^^  or  degenerative  lesions  in  the  kidneys  themselves  ; 
curs  ;  or  one  grain  is  taken,  then,  if  necessary,  ounce  ^  jj^  ^^  c'ourse  of  acute  or  chronic  Bright's  disease  as 
doses  of  liquor  magnesii  citratis  can  be  given  until  free  a' result  of  various  complications  ;  and,  3,  in  uremia, 
action  of  the  bowels  is  obtained.  The  drug  is  not  a  ^j^^  jg^g^  associated  with  urxmia  may  be  sudden  and 
direct  diuretic  per  se,  but  it  may  act  indirectly  to  a  pronounced,  and  associated  with  coma,  delirium,  or 
slight  extent  simply  by  its  general  stimulating  action  convulsions— eclamptic  fever;  or  it  may  be  more  gen • 
upon  the  emunctories  of  the  entire  body,  thus  favoring  ^j.^,^  ^^^^  lasting,  less  marked,  and  associated  with 
secretion,  excretion,  and  the  elimination  of  intestinal  typhoidal  symptoms — slow  urcemic  fever. — Stengel. 
ptomaines  and  systemic  poisons,  all  of  which  act  un- 
favorably upon  the  secretory  and  excretory  organs 
when  present. — Stewart. 

Inebriety. — Inebriety  is  curable  in  one -third  the 
cases.  The  basis  of  treatment  is  complete  compulsory 
prolonged  abstinence  ;  without  this  method  there  is  no 
chance  of  recovery.     ""  '       '    "  "'       ''^ 


^tterapexitic  gttuts. 

TJlcers  of  the  Cornea. — The  use  of  the  thermo-cautery 
combined  with  the  mydriatic-meiotic  alternation  has, 
in  my  hands,  produced  the  most  gratifying  results  in 
the  treatment  of  corneal  ulcers.  The  following  axiom 
will  be  found  very  useful  :  Use  as  much  eserine  as  pos- 
sible, avoiding  the  causation  of  an  iritis,  and  as  little 
atropine  as  possible,  sufficient  only  to  maintain  a  mo- 
bile pupil.  Lack  of  space  prevents  a  detailed  descrip- 
tion. Be  the  pupil  large  or  small,  it  must  invariably 
first  be  artificially  dilated.  Eserine  should  never  be 
employed  alone  in  this  class  of  cases,  as  iritis  will  be 
the  inevitable  result.  Atropine,  used  by  itself  for  any 
length  of  time  in  ulcer,  increases  tension  ;  nutrition  is 
thereby  impaired,  reparation  retarded,  and  frequently, 
in  severer  forms,  the  eye  in  consequence  perishes. 
Judicious  alternation  keeps  the  iris  in  motion,  and 
maintains  normal  intraocular  pressure  ;  as  a  result 
hearing  is   expedited   and   facilitated. — H.    D.wison- 

SCHW.\RZSCH1LD. 

Creosote. — From  it  two  very  gratifying  results  are 
found  :  I.  It  possesses  undoubted  power  to  relieve  the 
fetor  of  the  expectoration  in  foul-smelling  cases  of 
bronchiectasis  and  phthisical  cavities.  2.  In  small 
doses  (i  to  2  minims  thrice  daily)  it  promotes  the  ap- 
petite and  tends  to  stimulate  the  powers  of  digestion. 
Beyond  this  it  is  not  found  that  it  modifies  in  any 
appreciable  manner  the  ordinary  course  of  phthisis. — 
Crook. 

Calomel. — One  grain  of  thoroughly  triturated  calo- 
mel is  equivalent  to  five  to  ten  grains  of  the  untriturated 
drug.  If  given  for  its  purgative  effect  or  for  its  action 
on  the  liver,  one-tenth  of  a  grain  triturated  is  adminis 


This  abstinence  should  be  sup- 


In  Urine. — There  are  at  least  seven  toxic  substances 
in  the  normal  urine.  These  are:  i,  A  diuretic  sub- 
stance (urea)  ;  2,  a  narcotic  poison  ;  3,  a  sialogogue  ; 
4,  a  temperature- reducing  substance  ;  5  and  6,  convul- 
sants  (one,  doubtless,  potassium)  ;  and  7,  a  poison 
which  causes  contraction  of  the  pupil.— Bouchard. 

Guaiacol.— I.  Guaiacol  is  an  efficient  local  sedative, 


gr.  nj. 
IT!,,  xij. 
i'j. 
5jss. 

3^j- 


plemented  by  treatment  of  the  condition  of  the  ner-  _- ..   .  -.mnlnvpfl   in 

vm,s.;vstem   of  which  inebriety  is  the  symptom.     The  as  shown  by  its  analgesic  power  when  employed   in 

Sn    should  be XcedunTe/ discipline  an^  painful  affections.     2.  It  is  more  potent  when  admin- 

^d  to  In  efficacious  surveillance.     The  duration  of  the  istered  hypodermically  than  when  H  -_  applied  ;o  the 
treatment  should  be  at  least  one  year.— Montvel. 
Sedative  Cough  Mixture  in  Phthisis. — 

IJ .   Codeinje  sulph 

Liq.  atrop.  sulpli 

Liq.  strychniae 

Syr.   tolutani •  ■ 

Infus.  rosse  acidi *d. 

S.— Tablespoon ful  in  a  wineglass  of  water  every  four  or  six 
hours. 

Psoriasis.- Remove  the  scales  by  alkaline  washes, 
and  then  apply  glycerole  of  starch,  oil  of  cade,  of  each 
3>^  ounces  ;  soft  soap,  75  grains  ;  salicylic  acid,  45 
grains.  The  parts  are  washed  with  warm  water  and 
tar  soap  every  three  or  four  days.  In  obstinate  cases 
the  scales  are  removed  and  the  following  ointment  em- 
ployed :  Ichthyol,  pyrogallol,  and  salicylic  acid  of 
each  30  grains  ;  vaselin,  lard,  and  lanolin,  of  each  i 
ounce. — Coffin. 

Pernicious  Anaemia.— That  pernicious  ana;mia  is  not 
a  special  disease,  but  secondary  to  numerous  exhaust- 


skin  surface.  3.  It  has  not,  in  practically  afebrile 
conditions,  produced  any  noticeable  lowering  of  tem- 
perature or  other  unpleasant  effects  in  my  experience. 
4  When  employed  in  febrile  affections,  it  may  cause 
objectionable  effects,  such  as  rigors,  followed  by  high 
temperature.  5.  Guaiacol  seems  to  be  powerless  to 
control  inflammatory  processes,  particularly  when  acute 
in  character. — .Anders. 

Predisposition  of  Persons  to  Consumption.- Many 
people  think  that  consumption  is  inherited,  but  the 
closest  investigation  has  shown  that  it  is  not  inherited, 
and  that  only  the  susceptibility  or  liability  to  the  dis- 
ease is  inherited.  Thus  the  children  of  a  tubercular 
family  do  not  necessarily  inherit  the  disease  itself,  but 
they  inherit  the  constitution,  which,  when  exposed  to 
the  germ  furnishes  a  soil  which  propagates  the  disease 
with  great  rapidity,  and  one  after  the  other  succumbs. 

Cough.— The  obstinate  cough  due  to  a  dilated  heart, 
or  one  affected  at  the  orifices  with  organic  changes,  is 
very  frequent  and  should  be  constantly  kept  in  mind 


928 


MEDICAL   RECORD. 


[December  28,  li 


Not  seldom,  when  I  have  not  known  what  else  to  do,  I 
have  freely  stimulated  a  somewhat  weak  cardiac  action 
and  thus  stopped  a  bad  cough  in  a  few  days. — Robix- 

SON. 

Taches  Bleuatres. — Revilliod  believes  the  spots  to 
be  due  to  the  excrement  of  the  pediculus,  which  he 
states  is  an  insect  of  very  cleanly  habits,  and  that  dur- 
ing the  night  he  leaves  his  usual  seat  at  the  root  of  the 
hair  and  deposits  his  fxces  in  the  adjacent  parts  of  the 
body  !  Bowditch  is  inclined  to  believe  that  IMoursou's 
original  statement  of  the  relation  between  the  pedicu- 
lus and  the  taches  bleuatres  is  undoubtedly  correct. 

Typhoid  Fever.— The  author  concludes  that,  i, 
the  antiseptic  treatment  is  the  rational  one  ;  2,  guaia- 
col  is  a  safe  remedy  and  prevents  the  toxin-poisoning 
of  the  later  stages  ;  3,  it  will  lower  the  temperature 
when  applied  externally  ;  4,  the  typhoid  patients  do 
better  by  keeping  the  bowels  acting  up  to  a  certain 
point,  rather  than  checking  them,  and  will  derive  com- 
fort and  benefit  from  daily  douching  of  the  large  in- 
testine with  warm  or  cold  water. — Hull. 

Acute  Intestinal  Invagination. — i.  Operation  should 
be  resorted  to  as  early  as  possible  after  non- operative 
methods  have  been  thoroughly  tried  without  success. 
2.  After  a  laparotomy  disinvagination  is  of  value  when 
it  can  be  accomplished  without  any  great  difficulty.  If 
the  intestinal  wall  is  suspicious  looking  at  the  point  of 
invagination,  the  peritoneal  cavity  should  be  walled  off 
with  iodoform  gauze,  or  the  particular  portion  of  the 
intestine  should  be  drawn  outside  of  the  abdominal 
wall.  3.  When  disinvagination  is  impossible  the  resec- 
tion of  the  invagination  is  the  least  dangerous  proced- 
ure. 4.  The  resection  of  the  entire  invagination  should 
be  performed  when  the  invaginating  sheath  is  so  mark- 
edly altered  that  there  is  danger  of  perforation.  5.  The 
formation  of  an  anus  prasecernaturalis  or  an  entero-an- 
astomosis  have  usually  no  place  in  these  cases  ;  only  in 
the  presence  of  collapse  is  the  formation  of  an  artificial 
anus  permissible. — Rudygier. 

Chronic  Intestinal  Invagination. — In  chronic  invag- 
ination internal  medication  and  non-operative  methods 
must  be  employed,  but  should  be  abandoned  after  a 
week's  trial.  Disinvagination  is  of  little  avail,  although 
four  successful  cases  have  been  reported — one  at  nine 
months,  two  at  six  months,  and  one  at  ten  weeks.  Re- 
section bf  the  invagination  is  here  also  the  operative 
method  of  choice.  Entero-anastomosis  should  only  be 
undertaken  in  the  presence  of  adhesions.  An  artificial 
anus  should  not  be  thought  of  in  the  treatment  of 
chronic  invagination. — Rudygier. 

_  Tuberculin.— Three  instances  are  cited  in  which 
Koch's  tuberculin  was  used  in  tubercular  affections 
which  were  not  pulmonary— tubercular  cystitis  and 
tubercular  hip-joint  diseases  (two  cases).  From  the 
improvement  which  has  been  noted  in  these  cases  we 
may  conclude  that  there  is  ample  justification  for  its  use 
in  the  positive,  although  sometimes  necessarily  more  or 
less  transitory,  immunizing  influence. — Denison. 


Schleich's  Method  of  Local  Anaesthesia.  — Dr.  Theoph- 
ilus  Parvin,  at  the  last  meeting  of  the  County  Medi- 
cal Society,  read  a  paper  on  "Schleich's  Method  of 
Local  Ancesthesia"  by  subcutaneous  and  parenchy- 
matous injections  of  weak  cocaine-morphine  solut- 
ions, and  demonstrated  the  effect  in  bis  own  person, 
by  allowing  an  incision  of  an  inch  in  length  to  be 
made  in  his  forearm  and  to  be  stitched  up,  under  its 
influence,  in  the  presence  of  the  society.  He  declared 
it  to  be  an  absolutely  painless  procedure  and  predicted 
great  future  usefulness  for  this  method  in  surgery,  and 
that  at  least  fifty  per  cent,  of  the  operations  now  done 
under  general  anesthetics  will  ultimately  be  done  by 
this  method,  which  he  declared  suitable  even  for  major 
operations.— j^fx/t?//  Medical  and  Surgical  Journal. 


^mctticat  Items. 

Contagious  Diseases — 'Weekly  Statement Report  of 

cases  and  deaths  from  contagious  diseases  reported  to 
the  Sanitary  Bureau,  Health  Department,  for  the  week 
ending  December  21,  1895. 


Tuberculosis    go 

Typhoid  fever 

Scarlet  fever ai 

Cerebro-spinal  meningitis 

Measles ,      234 

Diphtheria '       ^^s 

Small-pox 


112 
13 


Naso-pharyngeal  Catarrh  and  One  of  Its  Causes.— 

Post-nasal  catarrh  is    so  frequent  in  this  country  thai 
when  European  authors  speak  of  American  catarrh  they 
mean  this  affection.    Dr.  VV.  Freudenthal,  of  New  York, 
in  a  paper  read  in  the  section  on  Laryngology  and  Otol- 
ogy at  the  forty- sixth  annual  meeting  of  the  American 
Medical  Association  (Some  Points  Regarding  the  Etiol- 
ogy and  Treatment  of  Post- nasal  Catarrh,  with  Remarks 
on  Hygiene  of  the  Respiratory  Organs.— Tyi^-  Journal 
of  the  American  Medical  Association,  November  9,  1895) 
shows  that  the  causes  of  the  catarrh — as  it  is  generally 
called — depend  on  conditions  which    heretofore  have 
not  received  the  attention  they  deserve.     The  naso- 
pharynx has  the  function  of  impregnating  the  inspired 
air  with  humidity,  and  the  importance  of  this  moisten- 
ing process  has  been  demonstrated  by  Aschenbrandt's 
experiments.     Dr.  Freudenthal  repeated  these  experi- 
ments  with    Aschenbrandt's   apparatus,    not    only   in 
healthy,  but  also  in  pathological  cases.     He  found  that 
in  cases  in  which  the  nose  had  been  galvano-cauterized, 
in  which  the  patient  had  been  suffering  from  hay-fever,' 
or  those  in  which  there  were  adenoid  vegetations,  there 
was  a  diminution  of  moisture  for  the  inhaled  air.    In  the 
latter  cases  the  air  became  normally  moistened  again 
when  passing  through  the  naso-pharynx  after  the  lym- 
phoid tissue  had  been  removed.     Of  the  several  condi- 
tions which  prevent  the  retro-pharynx  from  performing 
its   function,  there    is    one  which  is   most   important, 
namely:    the  faulty  manner  in  which  our  houses  are 
heated  in  winter.    The  atmosphere  of  a  room  in  winter 
should  be  kept  moderately  humid,  it  should  contain  be- 
tween 50°  and  60°  F.  relative  humidity  ;  the  lowest  point 
should  never  go  below  40°  F.     Dr.  Freudenthal  tested 
many  New  York  houses  during  the  last  two  winters, 
and  never  found  a  relative  humidity  of  even  50°  F.  ; 
when  the   outside   temperature  was  about   30°  F.    he 
never  saw  even  40°  F.     The  highest  point  reached  was 
30°  F. ;   but   25°,   20°,   even    iS°    F.  relative  humid- 
ity, was  nothing  unusual  when  the  weather  was  very 
cold.     Even  in  one  of  our  best-arranged  hospitals  the 
relative  humidity  seldom  reached  40"  F.     It  is  impos- 
sible to  say  how  very  detrimental  this  state  of  things  is. 
The  mucous  membranes  of  the  air-passages  require  a 
certain  humidity  of  the  air  in  order  to  keep  up  their 
functions.     If  this  humidity  is  wanting  they  will  in  time 
themselves   become  drj',  even  in  summer.     It   would 
appear  to  be  of  much  more  importance  to  suspend  on 
the  wall  of  our  room  a  hygrometer  than  a  thermometer, 
and  to  regulate  the  humidity  of  the  atmosphere  of  our 
houses  in  winter  by  some  means  or  another. 

The  Signs  of  Death.— The  following  are  the  signs  on 
which  a  medical  man  should  rely  as  furnishing  the  best 
evidence  of  the  reality  of  death,  prior  to  the  com- 
mencement of  putrefactive  changes,  namely :  the 
absence  of  circulation  and  respiration  ;  the  gradual 
cooling  of  the  body,  the  extremities  cooling  first  and 
the  trunk  last ;  gradual  supervention  of  rigor  mortis  ; 
the  production  of  post-mortem  stains  or  ecchymoses. 


December  28,  1895] 


MEDICAL    RECORD. 


929 


In  184S  Bouchut  found  that  in  all  cases  of  apparent  ing  to  enter  the  medical  profession  appeared  to  him  to 

death,  although  the  contractions  of  the  heart  were  re-  be  quite  unworthy.     Up  to  one  hundred  and  fifty  years 

duced  in  force  and  frequency,  by  auscultation,  he  was  ago,  midwifery  had  been  entirely  in  the  hands  of  wom- 

able  to  detect  the  pulsations'of  the  heart,  and  so  dis-  en,  but  they  had  done  absolutely  nothing  to  advance 

tinguish  apparent  from  real  death.     The  careful  use  of  its  practice,  and  it  had  been  left  to  a  man — .\mbroise 

the  stethoscope  by  a  medical  man  will  enable  him  to  Pare — to  introduce  turning,  while  the  invention  of  the 

distinguish  a  living  from  a  dead  body.     Certain  forms  forceps  had  been  due  also  to  a  man— Chamberlen.     In 

of  rigidity  that  may  occur  during  life  may  be  mistaken  America  women  had  practised  medicine  for  fifty  years, 

for  rigor  mortis.     Rigidity  during  life  may  occur  from  but  he  was  not  aware  that  they  had  made  any  contribu- 

tetanus,  apoplexy,  catalepsy,   syncope,    asphy.xia,   and  tion  to  our  knowledge,  and  in  the  subject  of  children, 

hysterical   spasm;  but   the' three   striking  differences  which  was  supposed  to  be  one  for  the  study  of  which 


from  cadaveric  rigidity  are  presented  as  follows  :  i, 
The  warmth  of  the  body  is  preserved  ;  2,  the  whole  of 
the  body  becomes  equally  rigid  at  the  same  moment, 
due  to  the  occurrence  of  a  general  muscular  spasm 
(with  rigor  mortis  the  rigidity  usually  commences  in 
the  muscles  of  the  neck  and  lower  jaw,  and  then  grad- 


thev  were  particularly  adapted,  he  had  failed  to  find 
any  contribution  to  practical  medicine  made  by  a  woni- 
an.  Dr.  Douglas  Powell  said  that  there  was  nothing  in 
the  practice  of  medicine  that  men  could  not  do  as  well 
as,  or  better  than,  women.  The  profession  was  over- 
stocked already,  and   to  dilute  it  or  further  overstock 


ually  affects  the  other  parts  of  the  body)  :  3.  if  a  joint  it  with  women  would  only  tend  to  cheapen  and  degrade 

be  forcibly  bent,  such  as  the  arm  at  the  elbow,  the  it.     The  College  was  looked  upon  as  a  referee  in  ques- 

limb  will  if  in  a  state  of  spasm  from  disease,  return  to  tions  of  public  health  and  many  social  questions,  and 

its  ori<nnal  position  when  the  force  is  removed,  whereas  he  thought  it  would  be  a  very  grave  thing  for  them  to 

if  it  be  in  a  state  of  ri^or  mortis  it  will  not  return.—  decide  that  it  was  advisable  tliat  women  should  enter 

British  Medical  Journal.  the  medical  profession  ;  the  question  had  never  been 

debated  in  a  medical  body  possessed  of  such  authority 

In    Honor   of  Stephen  Girard.— A  tablet     m  com-  ^^  ^^^  College.     The  duties  of  a  woman   lay  in   the 

memoration  of  the  courage  and  humanity  displayed  by  j^o^gghold,  and  in  bearing,  rearing,  and  educating  chil- 

Stephen  Girard  during  the  epidemic  of  yellow  fever  ^^^^      gj^'  j^^gg  Russell  Revnolds  said  that  women 


prevailing  in  Philadelphia  in  the  year  1793  was  un- 
veiled in  Girard  College  in  Philadelphia  a  few  days  ago. 
The  incident  discloses  a  phase  of  character  in  the  phi- 
lanthropist not  generally  understood.  During  the  fever 
epidemic  he  abandoned  his  business  and  his  luxurious 
home,  and  assumed  the  superintendency  of  a  yellow- 
fever  hospital.  He  took  up  the  work  others  recoiled 
from,  hired  nurses,  brought  order  out  of  chaos,  and  did 
the  work  because  it  was  his  duty. 

Abuse  of  Medical  Charity  in  Brighton.— The  people 
of  Brighton  are  being  attacked  regarding  the  abuse  of 
medicai  charities  there.  Brighton  is  one  of  the  richest 
towns  in  England,  yet  the  statistics  show  that  out  of 
the  150,000  of  its  inhabitants  38,113  patients  were  last 
year  admitted  to  the  various  hospitals  and  dispensaries. 

An  Antiseptic  Dressing. — During  the  recent  war  the 
Japanese   army  surgeons  made  use  of  a  dressing  con 


were  physically,  mentally,  and  morally  unfitted  for  the 
practice  of  medicine.  Sir  Richard  Quain  said  that  it 
seemed  to  him  that  men  were  becoming  effeminate, 
and  women  masculine,  and  we  do  not  wonder  that  he 
thought  so  when  looking  around  on  the  old  women 
who  were  opposing  the  petition  and  trying  to  stem  the 
tide.  The  petition  was  rejected  by  a  vote  of  59  to  50. 
A  similar  petition  was  rejected  eighteen  years  ago.  by 
68  votes  to  18.  The  next  time  it  will  undoubtedly  be 
granted. 

A  Handsome  Legacy. — Sir  Henry  Thompson  has  re- 
cently received  by  legacy,  from  a  relative  and  patient. 
property  to  the  value  of  $500,000.  It  is  not  often  that 
similar  windfalls,  or  anything  approaching  them,  accrue 
to  medical  men.  who  as  a  rule  are  more  accustomed  to 
abuse  than  gratitude,  and  when  they  do  occur  they  are 
generally,  as  happened  in  the  present  instance,  con- 

_,_^ >-     o  ,r        1,  A  tested  by  some  disappointed  relative.     Sir  Henry  was. 

sisting  of  the  ash  of  rice- straw.     After  the  wouna  was     ^^^,^^^^  successful  in  his  contest  to  sustain  the  will, 
cleansed  this  ash  was  freely  applied,  and  over  it  sub-     ^^^  ^^^  •^^^^.  ^^^^  j^,^  possession  of  the  property, 
limate  gauze  or  linen  was  placed  and  retained  by  a  ^         ,  , 

bandage  The  antiseptic  properties  of  the  ash  are  CongenitalSyphilis.— The  Pans  correspondent  of  the 
attributed  largely  to  the  presence  of  potassium  carbon-  Medical  Press  reports  a  clinical  lecture  on  this  affec- 
ate.  The  ash  is  also  a  good  dehydrater,  and  tends  to  ,ion,  delivered  in  a  hospital  for  syphilis^  in  that  city. 
dry  the  wound. 


Antiseptic  Ointments.  —  Professor  Breslau  has  re- 
cently published  a  paper  in  which  he  gives  the  results 
of  a  long  series  of  experiments,  very  carefully  con- 
ducted, into  the  relative  efliiciency  of  antiseptic  oint- 
ments. He  tried  menstrua,  oil,  vaseline,  fat,  lanohne, 
anhydrous  lanoline,  and  cold  cream.  He  came  to  the 
conclusion  that,  of  all  these,  carbolized  lanoline  and 
carbolized  cold  cream  were  much  the  best.  As  anti- 
septic agents,  he  tried  corrosive  sublimate,  resorcin 
silver  nitrate,  boric  acid  and  salicylic  acid,  and  noted 
the  same  fact,  i.e ,  that  all  of  them  were  more  efficient 
with  lanoline  or  cold  cream  as  a  menstruum  than  in  any 
other  way.  The  professor  also  tested  many  of  the  oint- 
ments used  in  practiw,  such  as  ungt.  zinci,  ungt.  hyd., 
and  unguentum  hydrargyri  ammoniaii.  and  found  the 
mercurial  preparations  alone  effectual.— JA  ..■/<"'  I  rcss 

The  Royal  CoUege  of  Physicians  and  the  Ladies- 
Many  physicians  of  England  recently  presented  a  peti- 
rion  to  the  Royal  College  of  Physicians,  praying  that 
women  be  admitted  to  the  licentiateship,  and  the  dis- 
cussion on  the  request  was  the  occasion  fora  number      ^^.  -•-^-■, "phenomena  of  syphilis  in   the  infant 

seat  is  generally  the  palm  of  the  hands  an-"  *■- 
the  feet.     The  gravity  of  the  pemphigu 


The  lecturer,  whose  name  the  correspondent  does  not 
give,  said  that  the  manifestations  of  congenital  syphilis 
have  for  fundamentil  characters  :  i.  The  infection  is 
not  the  result  of  penetration  through  the  lymphatic 
system  ;  2,  there  are  no  primary  sores  ;  3,  it  affects  the 
whole  organism,  externally  and  internally. 

The  influence  of  the  father  on  the  syphilis  of  the 
child  has  been  notably  exaggerated,  but  it  is  neverthe- 
less certain.  ,  •,•      r    1. 

The  influence  of  the  mother  on  the  syphilis  of  the 
infant  is  absolutely  certain,  independently  of  all  pater- 
nal disease.  According  to  Kassowitz.  a  diseased 
mother  could  infect  her  children  for  ten  years  But 
Barensprung  affirms  that  tertiary  syphilis  of  the  mother 
has  no  influence  on  the  foetus,  while  Diday  pretends 
that  the  offspring  is  not  guaranteed  by  the  absence  of 
secondary  or  tertiary  symptoms  of  the  mother.  When 
both  parents  are  syphilitic,  infection  of  the  fcKtus  is 
regarded  as  certain  by  the  majority  of  authors.  The 
cutaneous  manifestations  of  infantile  syphilis  consist 
in  lesions  of  the  skin,  the  mucous  membrane,  and  the 
viscera.     The  eruptions  on  the  skin  are  varied. 

Pemphigus.— One  of  the  first  and  most  characteris- 


Its 


Charies  West  moved   '^^^J"^^  P^"""    „^"  „  in  wish       •»"•  '-»'      Th^  crravitv  of  the  pemphigus  is  consider- 
said  that  the  motives  which  influenced  women  in  wisti 


930 


MEDICAL    RECORD. 


[December  28,  1895 


able,  it  takes  long  to  get  well,  and  frequently  the  child 
succumbs  from  cachexia. 

Roseola. — Found  on  the  abdomen,  the  chest,  and  the 
inside  of  the  limbs  ;  the  spots,  at  first  bright  red,  as- 
sume a  salmon  color  and  do  not  disappear  by  pressure. 
Mucous  Patches. — Found  around  the  natural  orifices, 
these  lesions  produce  fissures  and  vegetations  when  the 
treatment  is  neglected. 

Vesicles-Pustules. — Resembling  impetigo  both  in  ap- 
pearance and  in  situation.  They  are  met  with  on  the 
face,  around  the  nose,  eyelids,  forehead  ;  these  vesicles 
secrete  a  purulent  liquid  from  an  ulcerated  base. 

Coryza. — One  of  the  most  frequent  lesions  of  con- 
genital syphilis.  At  first  a  kind  of  cold  in  the  head, 
hindering  the  respiration  and  suction,  subsequently  a 
serous  discharge  is  perceived,  obliging  the  infant  to 
breathe  by  the  mouth  on  account  of  the  congested 
mucous  membrane  of  the  narines. 

The  visceral  lesions  have  been  described  by  many 
writers.  The  organs  usually  attacked  are  the  lungs, 
the  liver,  and  the  testicle.  The  two  former  are  filled 
with  nodes  producing  subacute  inflammation,  while 
the  latter  is  attacked  by  chronic  inflammation,  marked 
by  peri-tubular  and  peri-vascular  sclerosis  ;  the  organ 
is  of  stony  hardness  and  hypertrophied  ;  later  atrophy 
sets  in,  leaving  but  a  trace  of  the  gland. 

The  osseous  lesions  affect  principally  the  cranium, 
and  more  especially  the  parietal  bones,  where  tuber- 
osities are  formed,  giving  a  singular  aspect  to  the  head. 
The  treatment  of  infantile  syphilis  is  simple  enough. 
It  suffices  to  rub  in  daily  a  small  quantity  (about  the 
size  of  a  nut)  of  mercurial  ointment  on  the  abdomen, 
the  calves  of  the  legs,  and  the  chest.  If  cutaneous 
syphilides  exist,  a  bath  of  corrosive  sublimate  is  or- 
dered, and  for  the  mucous  patches,  calomel  ointment. 

Alcoholism  and  Longevity.— \Vhen  we  look  abroad 
over  the  world  and  take  a  bird's-eye  view  of  the  evil 
effects  of  intemperance  in  its  various  aspects,  its  pro- 
duction of  disease  and  death,  the  destruction  of  happi- 
ness and  home,  pauperism  and  crimes  innumerable, 
with  general  demoralization,  we  are  astonished  that 
any  thinking  man,  much  less  a  physician,  should  come 
to  the  conclusion  that  drinking  men  and  drunkards 
enjoy  greater  longevity  than  total  abstainers. — Dr.  T. 
B.  Greeley  in  Medical  Progress. 

Princess  and  Physician.— There  is  in  Vienna  at  pres- 
ent an  Armenian  princess  named  Beglarion,  only 
twenty-six  years  old,  who  is  a  doctor  of  medicine. 
Her  father  is  wealthy,  and  to  be  able  better  to  practise 
the  science  she  has  acquired  in  Tiflis,  Switzerland,  and 
Salzburg,  she  is  going  to  build  a  hospital  on  his  estate — 
small  to  begin  with,  but  with  hopes  of  making  it  a 
big  concern  in  time.  In  Vienna  she  has  been  received 
with  open  arms  by  the  circle  which  is  still  in  excite- 
ment after  the  attack  by  Professor  Albrecht  upon 
woman's  right  to  study,  and  she  will  deliver  a  lecture 
on  the  question  of  woman's  rights  in  Armenia.  When 
a  little  girl  she  was  often  present  when  the  peasant 
women  on  lier  father's  estate  brought  their  sick  chil- 
dren to  her  mother,  asking  her  to  advise  and  help 
She  often  said  to  herself,  "  If  mother  had  learned  what 
the  doctor  knows,  she  could  help  them  instead  of  send- 
ing them  home  crying."  Then  on  a  box  someone 
gave  her  was  the  picture  of  a  wounded  soldier,  whose 
grateful  eyes  rested  on  the  nurse  bandaging  his  wound 
This  picture  moved  the  child's  fancy  to  such  a  degree 
that  she  promised  herself  solemnly  over  and  over 
again  that  she  would  be  a  nurse  when  she  grew  up.  and 
she  hoped  a  war  would  break  out  about  that  time. 
It  was  not  difficult  to  obtain  permission  to  attejid  the 
girls'  grammar  school  at  Tiflis,  and  afterward  her 
mother  rewarded  her  for  studying  hard  by  t^oine  to 
Berne  with  lier. 

\Vhen  Mile.  Beglarion  returned  home  from  Berne 
for  her  holidays  in  1892,  as  a  young  medical  student 
the  Russian  doctors  allowed  her  to  work  in  the  chol- 


era hospitals,  where  she  did  excellent  service  with  a 
number  of  other  women  doctors,  who  have  been 
praised  by  the  Russian  Home  Department.  When  she 
came  home  with  her  doctor's  diploma  in  her  pocket, 
the  sick  from  far  and  near  flocked  to  her  father's 
house  to  consult  her.  On  Sundays,  she  always  had 
some  seventy  patients,  and  thirty  on  week  days. 
"Three  months  ago,  she  went  to  Salzburg  to  act  as  as- 
sistant in  Madame  Rosa  Kerschbaumer*s   eye   hospi- 

Decrease  of  Leprosy  in  Norway.— Leprosy  is,  to  all 
appearance,  very  much  on  the  decrease  in  Norway. 
There  were  about  3,000  lepers  in  that  country  in  1856  ; 
in  the  latter  end  of  1892  there  were  only  900  cases. 
Dr.  Kaurin's  statistics  recently  published  on  this  ques- 
tion, show  that  a  strict  segregation  of  lepers  is  important 
for  the  eradication  of  the  disease. 

Necessity  of  Frequent  Visits.— The  Supreme  Court 
of  California  (Todd  vs.  Myers,  40  Cal.,  355),  in  an  ac- 
tion brought  by  a  physician  for  professional  services — 
the  defence  being  that  the  visits  were  too  frequent  and 
not  necessary— rules  that  "  The  defendant  having  ad- 
mitted the  employment  of  the  plaintiff  as  a  physician 
to  treat  his  wife  and  children,  the  plaintiff  was  the 
proper  judge  of  the  necessity  of  frequent  visits,  and,  in 
the  absence  of  proof  to  the  contrary,  the  Court  will 
presume  that  all  the  professional  visits  made  were 
deemed  necessary  and  were  properly  made.  It  would 
be  a  dangerous  doctrine  for  the  sick  to  require  a  phy- 
sician to  be  able  to  prove  the  necessity  of  each  visit 
before  he  can  recover  for  his  services.  This  is  neces- 
sarily a  matter  of  judgment,  and  one  concerning  which 
no  one  save  the  attending  physician  can  decide.  It 
depends  not  only  upon  the  condition  of  the  patient, 
but  in  some  degree  upon  the  course  of  treatment 
adopted." 

First  Aid  in  Accidents  by  Electricity.— The  follow- 
ing hints  may  prove  useful  in  giving  first  aid  to  a  per- 
son injured  by  an  electrical  current:  1.  The  current 
should  be  shut  off  at  once  if  the  means  are  at  hand,  and 
the  person  called  upon  understands  how  to  do  it.  2. 
If  this  cannot  be  done,  be  careful  not  to  touch  the  in- 
jured person's  body  with  the  hand.  If  no  india- 
rubber  gloves  are  at  hand,  the  body  should  be  dragged 
away  from  the  wires  by  the  coat  tails,  or  the  coat 
should  be  taken  off  and  folded  (a  dry  cloth  may  be 
used  for  the  purpose),  when  the  injured  person  may 
be  grasped  through  it  and  dragged  away.  3.  When  it 
is  not  possible  to  remove  the  injured  person  from  the 
wires,  raise  that  part  of  the  body  that  is  in  contact  with 
the  earth  or  the  wire  from  it,  using  the  covered  hand. 
This  will  break  the  current,  and  it  will  generally  be 
possible  then  to  get  the  body  away.  4.  If  this  cannot 
be  done,  take  a  dry  cloth  and  place  it  between  the  body 
and  the  ground,  and  then  disentangle  the  body  from 
the  wires.  5.  If  the  body  is  freed  from  the  wires,  re- 
move all  the  clothing  from  the  neck  and  treat  the  in- 
jured person  as  one  drowned.  Open  the  mouth  and 
grasp  the  tongue,  which  should  be  covered  with  a 
cloth  ;  then  pull  the  tongue  forward  and  gradually  al- 
low it  to  fall  back  ;  this  movement  should  be  repeated 
sixteen  times  a  minute.  Take  care  that  the  root  of  the 
tongue  is  thoroughly  moved.  6.  The  bystanders  should 
not  be  allowed  to  give  the  injured  person  spirits  or 
wine. — Medical  Press. 

Widespread  Tuberculosis  in  the  Animal  Kingdom. 

Professor  Delepine,  writing  on  this  subject,  has  shown 
that — taking  very  large  numbers  as  the  basis  of  his  es- 
tiraate^at  least  sixteen  per  cent,  of  cattle  are  afflicted 
with  this  disease  ;  and  that,  whereas  in  some  districts 
it  may  be  comparatively  rare,  there  are  parts  in  which 
a  non-tuberculous  cow  is  the  exception.  Pigs  also  are 
affected  in  the  same  manner,  although  not  to  the  same 
extent,  about  one  in  every  thirty-six  being  attacked  by 
the  disease.     Cats  and  dogs  are  also  subject  to  tuber- 


December  28,  1895] 


MEDICAL   RECORD. 


culo,sis,  and  it  is  to  be  feared,  from  their  exceeding 
friendliness,  may  be  a  source  of  danger  to  children 
with  whom  they  play.  Although  the  form  of  tubercu- 
losis with  which  poultry  are  affected  differs  in  some 
particulars  from  that  of  man,  it  is  a  very  common  dis- 
ease, and  commits  great  ravages  in  poultry-yards.  But 
any  animal  which  conforms  with  man's  habit  of  dwell- 
ing under  artificial  shelter,  is  apt  to  contract  tuberculo- 
sis ;  and  so  it  is  that  whether  they  be  monkeys,  camels, 
giraffes,  antelopes,  llamas,  lions,  tigers,  foxes,  tapirs, 
zebras,  etc.,  they  all,  according  to  Professor  Delepine, 
are  liable  to  tuberculosis  when  they  are  kept  in  men- 
ageries.—  The  Hospital. 

Negro  Stiicides  are  Rare. — A  remarkable  character- 
istic of  the  colored  population  of  the  city  is  the  fact  that 
the  proportion  of  them  who  commit  suicide,  who  solicit 
alms  or  free  lodging,  and  who  are  arrested,  is  much  small- 
er than  among  any  other  class  of  people.    -\  colored  sui- 
cide is  a  rarity,  and,  while  the  officials  of  the  Coroners' 
office  admit  that  there  are  some,  they  cannot  remember 
when  fhey  had  the  last  case  of  the  kind.     There  are  on 
an  average  about  one  hundred  and  twenty-five  cases  of 
suicide  reported  to  the  coroner  annually,  and  of  these  less 
than  five  would  be  colored.     Deputy  Coroner  Dugan, 
who  has  been  in  the  office  for  many  years,  can  remember 
but  a  few  cases  of  colored  suicides.     The  natural  light- 
heartedness  and  sunny  temperament  of  the   colored 
people  may  be  given  as  their  great  safeguard  against 
suicide.     Reverses  and   disappointments,  which   in  a 
more  sensitive  class  of  people  would  result  in  despond- 
ency and  eventual  self-destruction,  are  laughed  aside 
by  the  negro,  who  habitually  looks  on  the  bright  side 
of  life,  and  manages  to  get  enjoyment  out  of  whatever 
comes  his  way.     While  the  mere  fact  of  being  out  of 
work  does  not  affect  the  colored  people  enough  to 
drive  them  to  suicide,  the  evidence  of  their  natural  in- 
dustry cannot  be  better  illustrated  than  by  makmg  note 
of  the  small  proportion  of  them  who  ask  alms  or  seek 
lodgings  in  the  city  station-houses.     A  colored  tramp 
is  more  of  a  novelty  than  a  colored  suicide.     They  are 
neariy  always  willing  to  work  at  anything  that  tunis 
up,  and  all  are,  as  a  rule,  self-sustaining.— /'/4//a'/«'//'*'a 
Record. 

A  Cry  for  a  Clean  Sweep. — Is  it  not  time  that  we 
had  a  radical  reformation  of  the  Department  of  Chan- 
ties and  Correction— head,  root,  and  branch  ?  Will  the 
Mavor,  instead  of  yielding  to  the  importunities  of  so- 
cial'and  political  friends,  listen  to  the  facts  presented 
by  men  who  have  served  for  years  in  the  city  hospitals, 
and  who  know  upon  whom  the  responsibility  rests  for 
the  condition  of  these  institutions,  and  to  those  whq 
have  been  interested  in  practical  charity  in  the  city. 
and  who  have  come  in  contact  with  the  mismanage- 
ment  of   this   depaiiment '      Vou   cannot   hope,    Mr. 
Mayor,  to  have  any  reform  in  this  department,  even 
when  you  have  appointed  a  third   commissioner.     A 
clean  sweep  must  be  made,  and  should  be  made,  in 
order  to  give  the  medical  profession  the  proper  repre- 
sentation. The"  reorganization,"  so  far,  appears  merely 
as  an  attempt  of  the  one  man  who  has  been  the  head 
and  front  of  the  mismanagement  of  the  hospitals  under 
the  old   rigime,  to  make  a  semblance  of  reform.     In 
order  to  do  this  he  can  now  point  to  his  record— the 
dismissal  of  a  hundred  doctors  or  so.     But,  while  the 
doctors  have  been  dismissed,  the  old  "  heelers,'  incom- 
petent superintendents,  and  other  worthless  employees 
of  the  department  still  fatten  at  the  public  cnb.     No 
one  except  the  medical  men  who  have  had  occasion  to 
come  in  contact  with  the  Commissioners  of  Chanties 
and  Correction,  can  appreciate  the  treatment  that  has 
been  accorded  the  members  of  the  past  medical  boards 
by  these  persons.     Whenever  a  reform  was  suggested, 
the  report  has  been  pigeonholed  ;  and  the  men  who 
have  urged  it  have  been  told,  in  anything  but  a  Ches- 
terfieldian  vein,  that  if  they  did  not  like  the  way  things 
were  managed  in  the  department,  they  had  better  re- 


sign ;  that  there  were  a  dozen  ready  to  fill  the  vacancy ; 
and  as  their  friends  had  been  sarisfied,  the  Commission- 
ers would  like  the  opportunity  of  satisfying  someone 
else's  friends.     It  is  time  that  medical  men  were  al- 
lowed the  pri\-ilege  of  living  up  to  the  rules  of  the  de- 
partment they  serve.     .\t  present  an  adverse  report  is 
still  simply  pigeonholed  ;  and  if  an  attempt  is  made  to 
prove  the  facts,  the  man  or  men  who  take  that  step  are 
disciplined  and  dismissed.     The  cry  that  went  up  from 
the  Commissioners,  whenever  they  were  approached 
with  these  statements  of  imperfect  management,  has 
been  that  they  have  "done  no  wrong."     But  they  must 
have  known   that  their  appointees  were  incompetent. 
"  Reform  in  the  medical  boards  "  in  this  way  is  absurd 
because  it  tries  to  begin  at  the  wrong  end.     The  re- 
form should  have  begun  at  the  head  of  the  adminis- 
trative force,  and  should  have  been  made  to  extend 
down  to  the  meanest  employee  who  goes  to  make  up  the 
ring  that  has  so  far  controlled  this  department.     If  the 
Mayor  is  really  in  earnest  in  carrj-ing  out  reform,  he 
should  sweep  this  department  quite  clean,  and  gi%e  us 
a  set  of  Commissioners,  none  of  whom  is  bound  by  the 
methods  of  the  old  regime  or  by  the  ties  of  promises 
made  to  political  leaders.     Give  us  two  more  men  of 
the  same  stamp  as  Commissioner  Faure.  and  let  one  of 
them  be  a  medical  man,  and  not  a  politician,  medical 
or  otherwise,  and  then  we  may  at  last  see  the  hospitals 
run  pro  bono  publico,  instead  of  for  the  good  and  ad- 
vantao-e  of  those  who  are  in  supreme  control.     The 
medical  profession  as  a  body  should  insist  upon  this  ; 
it  could  easily  control  sufficient  influence  to  compel  a 
clean  sweep  in  the  Charity  Board,  and  a  remodelling  of 
the  plan  of  reorganization  on  a  plane  of  just  apportion- 
ment.    The  protests  of  the  County  Societies  should  be 
followed  by  public  protests  from  medical  men,  as  well 
as  by  protests  from  their  friends  and  patients,  against 
unjust  discrimination,  unequal  representation,  and  mis- 
management in  the  executive  offices.— -J wr/^an  Medt- 
co-Surgkal  Bulletin.      (.\las  '.    all  appeals   have   been 
useless  and  the  cry  has  not  been  heeded.— Ed.) 

Comparative  Vitality  of  the  Sexes.— It  is  the  com- 
mon impression  that  men  are  not  only  less  subject  to 
iUness,  but  are  longer  lived,  than   women.     The  life 
ubles  of  insurances  companies,  however,  show  that  the 
term  of  life  of  women  is  slightly  longer  than  that  of 
men      The  difference  in  the  mortahty- rates  during  the 
first  few  years  of  life  is  striking.    During  the  first  year, 
the  mortality  among  males  is  decidedly  greater  than 
among  females.     Although  more  boys  are  born  than 
girls  the  proportions  are  reduced  to  almost  even  terms 
it  the  end  of  the  first  year  by  the  excessive  male  mor- 
tality     Even  during  the  first  four  years  the  morulity 
among  males  exceeds   that   aaiong  females,  notwith- 
standing the  fact   that  there  are  practically  no   dis- 
tinctions made  in  the  management  of  the  two  sexes. 
Both  are  subject  to  the  same  conditions,  are  dressed 
virtually  the   same,  and   receive  the   same  food.     At 
about   five  years   the   comparative   death-rate  among 
eirls  begins  to  increase.     This  has  been  attnbuted  to 
The  fact  that  boys  of  this  age  are  more  in  the  open  air. 
The  mortality  in  both  sexes  diminishes  from  this  time 
until  the  twelfth  year,  when  it  attains  Us  lowest  point. 
It  then  steadily  rises,  being  larger  in  each  successive 
year      Between  the   twelfth   and    sixteenth    years   the 
death-rate    among   giHs   increases   more   rapidly  than 
among  boys  :  but  after  the  sixteenth  year,  for  several 
years  the  rate  of  increase  is  more  rapid  on  the  male 
side  '  The  explanations  that   have  been   offered   for 
these  peculiarities  are  not  wholly  satisfactory  ;  but  one 
fact  is  clear,  that  during  early  years  females  possess  a 
greater   tenacity   of    life   than    do   mtA^%.— Maryland 
Medicai  Journal. 

The  Action  of  Vaccinia  Serum.- Hlava  and  Houl 
have  been  investigating  the  immunizing  and  curative 
properties  of  vaccinia  serum,  with  a  view  to  substitut- 
ing its  subcutaneous  injection  for  inoculation  with  am- 


932 


MEDICAL    RECORD. 


[December  28,    18^)5 


mal  lymph,  which  has  the  disadvantages  of  uncertainty 
in  action,  rapid  loss  of  protective  power,  and  occasional 
serious  complications  {Wiener  klinische  Rioidschau, 
October  6  and  13,  1895).  They  employed  three  differ- 
ent methods  of  preparing  the  serum  from  calves  :  (A) 
The  animals  were  inoculated  with  vaccinia  ;  in  four 
days  the  resulting  pustules  were  pricked  and  the  lymph 
collected  ;  subsequently  a  second  and  third  injection 
of  stronger  lymph  were  made,  without  causing  any 
pustulation  or  rise  of  temperature  ;  the  serum  was  col- 
lected about  a  fortnight  after  the  last  injection.  (B) 
Inoculation  as  in  A  ;  no  lymph  collected  ;  first  reinocu- 
lation  caused  a  rise  of  temperature,  second  none ; 
serum  collected  fifteen  days  after  the  latter.  (C)  Serum, 
plasma,  and  blood — the  latter  two  mixed  with  two  per 
cent,  sodium  citrate — taken  from  the  calf  four  days 
after  inoculation.  E.xperiments  were  made  with  all 
these  upon  calves,  and  then,  no  ill  effects  having  been 
observed,  upon  children.  The  serum  was  injected,  and 
at  the  same  time  or  subsequently  the  children  were  in- 
oculated with  vaccinia.  Serum  B  was  found  too  weak 
to  produce  much  effect,  though  the  vaccine  vesicles 
were  not  so  well  developed  as  if  it  had  not  been  used  ; 
3  to  10  c.c.  of  serum  A  prevented  the  development 
of  vaccine  vesicles  in  6  children  out  of  13  on  whom  it 
was  tried  ;  the  injection  of  serum  C  to  the  extent  of 
0.6  to  i.o  c.c.  per  kilo  of  body  weight  entirely  pre- 
vented the  action  of  vaccine  lymph  inoculated  four 
days  later.  (The  experiments  with  blood  and  plasma 
are  not  j'et  published.)  Experiments  have  not  yet 
been  tried  in  variola  ;  if  they  succeed,  Hlava  and  Houl 
claim  to  have  prepared  a  serum  which  will  replace  in- 
oculation with  vaccine  lymph.  It  is  immaterial  whether 
the  serum  contains  an  antitoxin  or  the  "  vaccinia  germ  ;  " 
if  the  latter  is  the  case,  the  method  approaches  that  of 
vaccination  with  an  impoverished  pure  cultivation. — 
British  Medical  Journal. 

The  Differential  Diagnosis  of  Inflammatory  and  Xon- 
inflammatory  Effusions. — M.  Rivalta,  of  Rome,  has 
employed  a  simple  test  on  which  he  places  great  reli- 
ance, in  determining  whether  an  exudate  is  of  inflam- 
matory or  non-inflammatory  origin.  With  this  object, 
he  removes,  with  an  ordinary  hypodermic  syringe,  some 
of  the  suspected  fluid.  Two  hundred  grammes  of  dis- 
tilled water  is  poured  into  a  large  glass,  to  the  latter 
two  drops  of  anhydrous  acetic  acid  is  added,  and  a 
drop  of  the  fluid  to  be  examined  is  dropped  into  the 
mixture.  It  can  be  noted,  in  case  the  fluid  is  of  inflam- 
matory origin,  that  the  suspected  drop  in  descending 
to  the  bottom  of  the  glass,  assumes  a  white-bluish  col- 
oration and  a  spiral  form  like  the  smoke  from  a  cigar. 
This  phenomenon  may  be  repeated  each  time  a  drop  of 
the  suspected  fluid  is  introduced  into  the  glass.  If  a 
little  more  acetic  acid  be  added  to  the  glass  the  precipi- 
tate formed  at  once  disappears,  thus  permitting  the 
conclusion  that  the  precipitate  was  not  mucine,  inso- 
much as  the  latter  is  insoluble  in  an  excess  of  acetic 
acid.  M.  Rivalta  concluded  that  the  substance  pres- 
ent in  the  inflammatory  exudate  is  a  nucleo-albumin 
produced  from  the  protoplasm  of  the  leucocytes  and 
pus-corpuscles.  The  foregoing  method  of  examination, 
when  applied  to  transudates  of  non-inflammatory  origin, 
constantly  yields  negative  results. — Semaine  Mt'ilieale, 
May  15,  1895. 

Broadbent  on  Diagnosis. — In  his  recent  address  upon 
Medicine  before  the  British  Medical  Association,  Sir 
William  Broadbent,  in  discussing  the  important  subject 
of  diagnosis,  made  use  of  the  following  words  :  The 
basisof  therapeutics  is  diagnosis,  the  grasp  of  the  actual 
condition  underlying  the  symptoms  or  phenomena,  and 
the  greater  our  command  of  powerful  remedies,  and  the 
more  precise  our  knowledge  of  their  effects  and  of  the 
mode  in  which  these  effects  are  produced,  the  more 
important  does  accurac}-  in  diagnosis  become.  A  diag- 
nosis, to  be  real,  implies  not  only  the  recognition  of  the 
disease  which  may  be  present  and  an  accurate  apprecia- 


tion of  the  morbid  changes  which  have  taken  place  in 
various  organs,  it  embraces  a  knowledge  of  the  nature 
and  intensity  of  the  pathological  processes  which  have 
been  and  are  in  operation,  and  of  the  causes  that  set 
them  going,  and  also  of  the  results  to  which  they  tend. 
A  further  element,  moreover,  enters  into  the  considera- 
tion :  an  estimate,  by  the  aspect  of  the  patient,  by  the 
pulse  and  temperature,  and  by  other  subjective  and  ob- 
jective indications,  of  the  impression  made  on  the  sys- 
tem, and  of  the  resistance  which  it  is  capable  of  to  the 
lethal  tendencies  of  the  disease.  Year  by  year  we  see 
improvement  in  this  respect  :  not  only  that  hospital 
physicians  and  teachers  endeavor  to  carry  diagnosis  to 
a  greater  pitch  of  accuracy  and  a  higher  point  of  re- 
finement than  ever  before,  but  that  the  entire  body  of 
medical  men  are  trained,  by  improved  education  and 
systematic  clinical  teaching,  to  appreciate  and  to  prac- 
tise careful  diagnosis  in  their  daily  work.  Diagnosis, 
we  may  say,  has  reached  an  extraordinary  degree  of 
advancement.  There  are,  no  doubt,  still  new  fields  to 
conquer,  but  in  the  recognition  of  diseases,  local  and 
general,  there  is  not  much  which  concerns  the  human 
race  which  remains  to  be  done.  The  same  degree  of 
knowledge,  however,  does  not  extend  to  morbid  pro- 
cesses. Our  comprehension  of  the  significance  and 
essential  character  of  inflammation  is  by  no  means  com- 
plete and  satisfactory.  The  part  which  fever  plays  and 
the  place  which  it  holds  among  the  phenomena  of  dis- 
ease is  far  from,  being  fully  understood.  It  cannot  have 
been  intended  by  nature  for  the  destruction  of  the  sub- 
ject, and  we  can  see  distinctly  that  in  some  cases  it 
forms  a  part  of  the  defensive  operations  ;  possibly,  in- 
deed, its  general  tendency  is  defensive,  by  promoting 
the  production  of  phygocytes,  or  possibly  a  certain  ele- 
vation of  temperature  may  be  fatal  to  maleficent  organ- 
isms which  have  taken  possession  of  the  blood  or  tissues. 
We  are  not  certain,  indeed,  whether  the  heat  producing 
oxidation  in  the  structures  receives  its  stimulus  from, 
or  takes  place  at  the  bidding  of,  the  nervous  centres  : 
or,  on  the  other  hand,  is  due  to  the  enfeeblement  of  the 
restraint  which  they  normally  exercise  over  it  ;  or 
whether  it  defies  control  by  the  thermotaxic  nervous 
centres. 


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•  Injuries  and  Diseases  of  the  Genital  and  Urinary  Or- 
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SrECT.\CLES  and  Eyeglasses  :  Their  Forms,  Mounting,  and 
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phia,  Fa. 


INDEX. 


Abdomen,  gunshot  wound  of  the,  67,  491, 
741 ;   surgery  of  contusions  of  the,  647. 

Abdominal  incision,  678. 

Abdominal  section,  some  conditions  requir- 
ing special  care  after,  440. 

Aberdeen  University,  quarter-cententry  of, 
S24. 

Abortion,  after-treatment  of,  336  ;  conduct 
of  the  physician  in  a  case  of,  26,  178; 
diagnosis  and  chronology  of,  444 ;  indi- 
cations for  the  induction  of,  310 ;  treat- 
ment of  threatened,  913  ;  tubal,  318. 

Abrahams,  R.,  syphilis  r x  tuberculosis,  910. 

Abscess,  iliac,  treatment  of.  26. 

Accidents,  police  attention  to  alleged  trivial, 
486. 

Acetanilid,  antiseptic  properties  of,  716. 

Achylia  gastrica,  5,  192.  205. 

Acidity  of  the  organic  and  other  fluids, 
method  of  expressing  the,  4S3. 

Acne  rosacea,  treatment  of,  392,  395,  785. 

Aconite,  pathognomonic  symptoms  of  poi- 
soning by,  357. 

Acromegaly  and  gigantism,  89. 

Addison's  disease,  supra-renal  extract  in, 
380,  823. 

Adenoid  forceps,  175. 

Adenoid  growths  in  the  naso-pharvnx.  296, 

675- 

Adulterated  boots  and  ulcerated  throats,  847. 

Adulteration  of  drugs,  521. 

Advertising,  genius  in,  418. 

Age,  inherited,  ^64. 

Air-passages,  upper,  tuberculosis  of  the,  99. 

Albu,  Albert,  notice  of  book  by,  598. 

Albumin  in  the  urine,  domestic  test  for,  599. 

Alcohol,  benefits  of  abstention  from,  6S1  ; 
consumption  of,  in  France,  140,  S84; 
influence  of,  on  sexual  perversions,  epi- 
lepsy, and  other  psychic  anomalies,  232  ; 
injurious  effects  of,  717  ;  properties  of,  in 
wines  and  liquors,  533. 

Alcoholism  and  longevity,  930;  ij>ecac  for 
insomnia  of,  91. 

Alkalinity  of  the  organic  and  other  fluids, 
method  of  expressing  the,  483. 

Allen,  Charles  W,,  erysipelas  in  its  etiologi- 
cal relation  to  preceding  skin  lesion,  and 
its  local  treatment,  723. 

AUport,  Frank,  new  celia  forceps,  70. 

Alopecia  after  acute  diseases,  treatment  of, 
311,  785;  diagnosis  and  treatment  of, 
386. 

Amblyopia  and  amaurosis,  hysterical,  56, 
256  ;  caused  by  chocolate.  843. 

Ambulance  organization  in  Berlin.  143. 

American  Uermalological  Association,  525. 

American  Humane  Association,  34. 

American  Laryngological  Society,  95. 

American  medicine,  .\ustrian  view  of,  539. 

American  Neurological  Association,  57. 

Ames.  Frederick  H.  S.,  maternal  impres- 
sions, 719. 

Amputation,  bloodless,  at  the  shoulder-joint, 
885  ;  two  successful  cases  of,  at  the  hip- 
joint,  887. 

Anaemia,  formula  for,  357  ;  i)ernicious,  425, 

9-7- 

Anasthesia,  chloroform,  deaths  from,  522  ; 
ether,  blood  alteration  of,  922  ;  from 
oxygen  and  chloroform  or  ether.  505, 
642,  863;  hysterical,  in  a  man,  57; 
infiltration,  an  improved  syringe  for, 
827  ;  local,  Sclileich's  method  of,  928; 
posture  during,  S24. 

Anaesthetic,  a  new,  4S7. 

Anal  fissure,  treatment  of,  913;  fistula, 
treatment  of,  67S. 

Ana!ge-ia,  general,  with  symptoms  of  scler- 
osis of  the  pyramidal  tract  and  of  the 
columns  of  Goll,  906. 

Anasarca,  formula  for,  780. 

Anastomosis,  intestinal.  Maunsell's  method 
of,  605;  intestinal,  with  the  Murphy 
button,  77S,  859;  intestinal,  with  the 
Murphy  button,  dangers  of,  920. 


Anderson,  Dr.  R.  B.,  judicial  persecution  of, 

466,  753. 
.\ndrews,  Alfred  J. ,  holders  to  use  with  the 

dynamometer,  248. 
Andronesco,  C.  I.,  notice  of  book  by,  130. 
.■\nencephalous  monsters,  309,  893. 
Aneurism,  abdominal,  713;  of  the  aorta,  165, 
167,  l6S,  912  ;  of  the  aorta,  dissecting, 
rupturing  into  the  pericardium,  713  ;   of 
the  subclavian,  8S6  ;  of  the  superior  pan- 
creatico  duodenalis,  170. 
Angina.  Ludwig's,  99. 
Angioma  cavernosum  of  the  spleen,  418. 
Angiokeratoma  of  the  scrotum,  525. 
Animals  and  plants,  fundamental  difference 

between,  377. 
Ankle-joint,  diseases  of  the,  606. 
Ankylosis   true,  352. 
Ano,  fistula  in,  treatment  of,  26. 
Anthracosis,  pulmonary,  477. 
Anticancrin,  826. 
Anti-noi.se  league,  811. 
Antiphthisin,  78,  871. 
Antipyretics,    the   analgesic,   860 ;    use   and 

abuse  of,  72. 
.-^.ntipyrin,  mandelate  of,  344. 
Antiquities,  medical,  393. 
Antiseptic  dressings,  929  ;  fluid,  a  new,  S17. 
Antitoxin  of  diphtheria,  action  of,  upon  the 
kidneys,   374  ;  curative  value  of,   194  ; 
phenol  as  a  preservative  of,  571  ;  pres. 
enf  status  of,  in  London,  107. 
.\ntitoxin  of  tetanus,  273. 
Antivenene,  162. 
Antiviviseclion  and  polo,  551. 
Antrum,   empyema  of  the,   600 ;  empyema 

of  the,  of  tuberculous  origin,  592. 
Aort.a,  aneurism  of  the,  165,  167,  168,  912; 
dissecting  aneurism  of  the,  rupturing  into 
the  pericardium,    713  ;    the  isthmus   of 
the.  7S8. 
Appendicitis,   304     912  ;  a  curious  case  of, 
289  ;  during  pregnancy  and  labor,  609  ; 
experimental,  627  ;  indication  for  opera- 
tion, 716;  in  pregnant  women,  diagno- 
sis and  treatment  of,  407  ;  new  iheory 
of,  757  ;  perforative,  with  general  per- 
forative peritonitis,  375  ;  recovery  from, 
without  removal  of  the  appendix,  781  ; 
rheumatism  as  a  cause  of,  373,  749  ;  sur- 
gical treatment  of,  26  ;  treatment  of,  678. 
Appendix,  a  piece  of  bone  in  the,  639  ;  anat- 
omy of  the,   757  ;  foreign  body  in  the, 
172;     hernia   of    the,    388;     intestine 
constricted     by     the,     555  ;     inversion 
of  the,  304  ;  length  and  position  of  the, 
862. 
.\plirodisiac,  tonic,  786- 
Apoplexy,  27,  429. 
Argyll- Robertson  pupil,  677. 
Aristocratic  doctors,  576. 
Army,  medical  sen-ice  of  the,  811;   of  the, 

in  France,  864. 
Army  ration,  the.  773. 
Army,  vacancies  in  the  medical  corps  of  the, 

582.  , 

Aronson,  Dr.  Alexander  I.,  resolutions  on  the 

death  of,  56. 
Arteries,  torsion  instead  of  ligatures  of  the, 

285. 
Arteritis,  obliterative,  in  a  boy,  340. 
Arthritis,  chronic  rheumatic,  formula  for,  358. 
Ascites,  formula  for,  533. 
Asepsis,  moist  or  dry,  924. 
Ashhurst,  John,  Jr.,  notice  of  book  edited 

by,  849. 
Ashmead,   Albert  S.,  another  cholera  ship, 

Asiari,  Dr.  Giacomo,  hundredth  birthday  of, 

4'.5-  ,  , 

Asphyxia  of  the  newborn,  211.  763. 

Asthenopia,  gold  spectacles  as  a  cause  of,  571; 
neurological  aspect  of,  806. 

Asthma,  formula  for,  392,  677,  786. 

Asylum  abuses  in  Germany,  234.  537.  5°°  '> 
practice,  routine  medication  in,  516. 

Ataxia,  Friedreich's.  85;  hereditary  cerebel- 
lar, 709,  865  ;  hereditary  spinal,  865. 


-Athetosis,  operative  treatment  of,  277. 

.■\thletes.  medical,  19;  stimulants  for,  775. 

Athletics,  danger  of  excess  in,  756. 

Autoscope,  the,  675. 

Axis-adjustment,  a  new  method  of  deliver- 
ing the  placenta,  225. 

.\yers,  Edward  A.,  diagnosis  and  chronology 
of  abortions,  444. 


B 

Babcock,  Robert  H.,  some  considerations 
with  regard  to  the  senile  heart,  649. 

Babes,  Victor,  notice  of  book  edited  by,  813. 

Bacteriological  diagnosis,  754;.  researches, 
practice  of  medicine  in  the  light  of,  577, 
600. 

Bacteriology,  caution  in  regard  to  undue  re- 
liance upon,  S78 ;    progress  in,  70. 

Bailey,  Dr.,  account-book  of,  598. 

Bailey.  Pearce,  a  case  of  general  analgesia, 
with  symptoms  of  sclerosis  of  the  py- 
ramid.^1  tracts  and  of  the  coluitms  of 
Goll,  906. 

Baillon,  Dr..  death  of,  236. 

Baldness  and  dyspepsia,  684. 

Baldwin.  E.  R.,  a  chemical  and  experimental 
research  on  antiphthisin,  871. 

Ballantyne.  J.  W.,  notice  of  book  by,  129. 

Balls-Headley,  W.,  notice  of  book  by,  93. 

Bambas,  Joannes  Ch.,  death  of,  3S0. 

Bannan,  Theresa,  bicycling  for  women,  142. 

Bardeleben.  Professor  Henry  .\dolf,  death 
of,  452,  487.  . 

Barkan.  Louis,  potassium  permanganate  m 
pulmonary  phthisis,  66. 

Barney,  Joseph  N.,  acute  traumatic  tetanus, 
Chopart's  operation,  death,  3S2. 

Harrington,  Dr.  Frank  E.,  death  of.  631. 

Barry,  James,  a  woman  army  surgeon,  344, 
754. 

Baruch,  Simon,  clinical  aspect  of  dyspepsia, 

Bashore,  Harvey  B..  geology,  339. 

Bassini  operation   for    hernia,   post-mortem 

examination   of  parts   involved    in,   six 

weeks  after  its  performance,  S87. 
Bates,  \V.  H.,  gold  spectacles  as  a  cause  of 

asthenopia.  571. 
Bath,  death  in  a,  S99. 
Bathing  and  disease  of  the  ear,  90. 
Baths,  public,  in  New  York  City,  344. 
Bavari-i,  qnackery  in,  715. 
Baylies,  E.  B.,  acute  cedenia  of  the  larynx, 

714. 
Beatty,  W.  Kirker.  trephining  for  fractured 

skull,  492  ;  case  of  acute  atrophy  of  the 

liver,  273. 
Beglarion,  Mile.,  an  .■\rmcnian  princess  and 

physician,  930. 
Behring's  law  of  immunity,  389. 
Belgium,  professional  dignity  in,  416. 
Bell    J    N.,  poisoning  by  oysters,  893. 
Bennett,  C.  L.,  religion,  disturbed  industry, 

and  suicide,  394. 
Bequests  to  Massachusetts  institutions,  416. 
Beriberi,  808  ;  another  ship  with,  496. 
Berlin,  ambulance  organization  in.  143. 
Berry,    William   B  ,    where    shall   our   con- 
sumptive patients  be  sent  ?  49 
Bicycle  and  medical  practice,   127  ;  face,  a 
'  new    explanation    of  the,    308  ;  from  a 

medic-il  standpoint.  464  ;  specialist,  702. 
Bicycling  for  inv.ilids  and  doctors,  415;   for 

women,  142;  in  hay-fever,  142. 
liicyclisls,  rules  for,  573. 
Bile,  influence  of,  on  the  proteolytic  action 

of  the  jiancrealic  juice,  878. 
Bile-duct,  congenital  obliteration  of  the,  565  ; 

surgery  of  the,  780. 
Biliousness,  formula  for,  786. 
Billings  John  S..  notice  of  book  by,   204; 

retirement  of,  487. 


934 


INDEX. 


[December,   28,    1895 


Bissell,  J-  Dougal,  a  contribution  to  the 
study  of  the  nature,  cause,  and  treat- 
ment of  suspended  animation  in  the 
new  born,  763. 

Black,  D.  Campbell,  notice  of  book  by,  633. 

Black  eye,  treatment  of,  820. 

Blackford,  Charles  Minor,  Jr.,  alkaline  in- 
jections in  gonorrhoea,  535. 

Bladder,  absorption  of  drugs  by  the,  576 ; 
comparative  frequency  of  stone  in  the, 
in  the  white  and  negro  races,  781  ;  cys- 
totomy for  stone  in  the.  782  ;  drainage 
of  the,  357  ;  hernia  of  the,  564  ;  rupture 
of,  associated  with  myelitis,  173;  stone 
in  the,  a  hiding-place  for,  352  ;  tuber- 
culosis of  the,  supra- pubic  cystotomy  for, 
562. 

Blech,  Gustavus,  successful  treatment  of 
enuresis  noctuma  by  the  test  operation, 
418. 

Bleyer,  J.  Mount,  nuclein  is  nature's  anti- 
toxin, 437. 

Blindness,  prevention  of,  through  legislative 
enactment,  103. 

Blood,  absorption  of,  from  the  peritoneal 
cavity,  221  ;  alkalinity  of  the,  and  in- 
fection, 662 ;  alterations  of,  in  ether 
anxsthesia,  922 ;  examination  of  the, 
685 ;  improved  hjematocrit  method  of 
examination  of,  222  ;  in  Bright's  disease, 
562  ;  in  chronic  cyanosis,  ig6 ;  nucle- 
ated red  corpuscles  of  the,  196. 

Blood-changes  in  neurasthenia,  321. 

Blood-platelets  in  functional  nervous  diseases, 
126. 

Boas,  I.,  notice  of  book  by,  201. 

Bone,  deformities  resulting  from  acute  infec- 
tions in,  613. 

Bone-grafting,  716. 

Bone  marrow,  a  case  of  splenic  myelogenous 
leukaemia  not  cured  by,  S58  :  therapeutic 
use  of  the  extract  of,  576. 

Bone-setters  and  natural  doctors,  413. 

Book- borrowers,  medical,  360. 

Book  Notices  : 

American  Laryngological  Society,  transac- 
tions of  the  sixteenth  annual  meeting, 
94- 
Accouchement,  ruptures  de  I'uterus  et  du 
vagin  pendant,  par  C.  I.  Andronesco, 
130. 
Appendicitis,  lectures  on,  by  R.  T.  Morris, 

633. 
Anatomical   model,    Whittaker's,   by  Dr. 

Schmidt,  814. 
Antitoxins    and   blood-serum  therapy,  by 

G.  E.  Krieger,  202. 
Anuario  de  la  clinica  privada  del  Dr.  Far- 
gas,  346. 
Atlas  of  clinical  medicine,   by  B.    Bram- 

well,  634. 
Baby,  care  of  the,  by  J.  P.  Crozer  Griffith, 

597- 
Bacteriologist,  laboratory  guide   for    the, 

by  L.  Frothingham,  202. 
Bader  Almanach,  131. 
Barnjum   bar  bell  drill,    by  R.    Tait   Mc- 

Kenzie,  238. 
Beaudelocque,  fonctionnement  de  la  maison 

d'accouchements,  par  A.-Pinard,  129. 
Bladder  and  urethra,  diseases  of  the  female, 

by  II.  A.  Kelly,  634. 
Boston   and   Philadelpliia,   vital   statistics 

of,  by  J.  S.  Billings,  204. 
Boston  City  Hospital,  medical  and  surgical 

reports  of  the,  561. 
Braithwaite's  Restrospect,  vol.  cxi.,  345. 
Brown  Sequard,  la  methode,  par  M.  Bra, 

202. 
Bucaresci,    Anale  Institului  de    Bacterio- 

logie  din,  813. 
Bulletin   No.    8  of  the   Harvard  Medical 

Alumni  Association,  849. 
Buried  alive,  by  C.  F.  llartmann,  204. 
Case   recorder    in   general    medicine   and 

gynecology,  l)y  S.  B.  Lyon,  346. 
Cell,  the,  by  Oscar  Hertwig,  345. 
Chastity,   advantages  of,   by   M.    L.  Hoi- 

brook.  814. 
Children,  homoeopathic  treatment  of  dis- 
eases of,  by  R.  N.  Tooker,.202. 
Children,  nervous  diseases  of,  by  B.  Sachs, 

129. 
Clinical  manual,  by  A.  MacFarlane,  634. ^ 


Book  Notices  : 

Compendium  medical,  petit,  par  A.  Bossu, 

203. 
Cookery,   spirit  of,    by  J.   L.    W.   Thudi- 

chum,  130. 
Counter-irritation,  theory  and  practice  of 

by  H.  C.  Gillies,  635. 
Cutaneous  medicine,   by  L.    A.   Duhring 

669. 
Cystite  et  infection  urinaire,  par  M.  Mel 

chior,  202. 
Demon  possession,  by  J.  L.  Nevins,  201. 
Diagnosis,  handbook  of  medical,  by  J.  B 

Herrick,  814. 
Diagnosis,  medical,  by  J.   M.  Da  Costa 

849. 
Diagnostic  chirurgical,  par  Duplay,  Roch 

ard,  et  Demoulin,  94. 
Dietetics,  practical,  by  W.  G.  Thompson 

56  r. 
Ear,  diseases  of  the,  by  E.  B.  Dench,  93. 
Education  des  enfants  normaux   et   anor 

maux,  par  E.  Seguin,  814. 
Electro-therapeutics,   manual  of,  by  C._T, 

Hood,  706. 
Epidemics,  history  of,    with   reference   to 

animal  epidemics,  by  B.  M.   Lersch 

850. 
Epidemics,  prevention  of,  by  R.  McNeil, 

597- 
Eye  in  its  relation  to  health,  by  Chalmer 

Prentice,  345. 
Febre  amarella,    o   quarto   centenario  da, 

palo  Dr.  Carlos  Seidl,  345. 
Foetus,  diseases  and  deformities  of,  by  J. 

W.  Ballantyne,  129. 
Foot,  deformities  of  the,  by  Walsham  and 

Hughes,  203. 
Formulaire     des     specialites    pharmaceu- 

tiques,  par  M.  Gautier,  238. 
Fractures,  treatment    of,  by  massage   and 

mobilization,    by  Just    Lucas-Cham- 

pionniere,  203. 
Gehbrorgans,     statistische     Beitriige    zur 

Pathologie  des,  von  P.  Kruschewsky, 

59?- 
German  vade-mecum,  by  R.  S.  Rosenthal, 

129 
Gout  and  its  cure,  by  J.  C.  Burnett,  94. 
Great  Britain,  climates  and  baths  of,  705. 
Gynecology,  medical,  by  A.   J.  C.   Skene, 

93- 
Head  and  neck,   anatomy  of  the,  by    D. 

Schmidt,  814. 
Histology,  pathological,  elements   of,   by 

A.  Weichselbaum,  201. 
Homceopathy,  modern  medicine  and,  by  J. 

B.  Roberts,  633. 
Hypnotism,  by  J.  M.  Cocke,  201. 
Ileus,  studier  over  cetiologien  og  palholo- 

glen  af,  af  Joha  Nicolaysen,  346. 

Immunity,  by  G.  M.  Sternberg,  93. 

Index  Catalogue  of  the  Library  of  the  Sur- 
geon-General's Office,  561. 

Indigestion,  by  George  Herschell,  130. 

Intestin.iltractus,  Auto-intoxicationes  des, 
von  A.  Albu,  598. 

Judischer  Aerzte,  Gesehichte  der,  von  R. 
Landau,  237. 

LeFort,  Leon,  oeuvres  de,  237. 

Leprosy  in  its  clinical  and  pathological  as- 
pects, by  G.  A.  Hansen,  669. 

Life,  dynamics  of,  by  W.  R.  Gowers,  598. 

Liver,  diseases  of  the,   by  J.   C.   Burnett, 

633. 
London   Homoeopathic    Hospital  reports, 

vol.  iv.,  345. 
Magenkrankheiten,  Diagiiostik  und  Thera- 

pie,  von  I.  Boas,  201. 
Marine    Hospital   Service,  report    of   the 

Surgeon-General  of,  for  1893,  345. 
Massage,  therapeutics  of,  by  A.  S.  Eccles, 

705. 
Materia  medica  and  therapeutics,  by  C.  H. 

Leonard,  633. 
Materia  medica,  manual  of  organic,  by  J. 

M.  Maisch,  635. 
Materia  medica,  modern,  by  O.  Roth,  598. 
Medicaci6n   antitermica    en   los   procesos 

febriles  agudos,  por  J.  Queralto,  346. 
Medical  Register  of  New  York,  New  Jer- 
sey, and  Connecticut,  597. 
Medicine,  a  text  book  of  practical,  by  A. 

L.  Loomis,  705. 


Book  Notices  : 

Membres,  affections  chirurgicales  des,  par 

D.  PoUaillon,  237. 

Michigan,  returns  of  births,  marriages,  and 

deaths  in,  during  1893,237. 
Mind,  pathology  of  the,  by  H.   Maudsly, 

201. 
Neuroses  of  childhood,  some  physiological 

characters  in  the,  by  B.  K.   Rachford, 

634- 

Nervous  diseases,  text-book  of,  edited  by 
F.  X.  Dercum,  705. 

Nervous  system,  clinical  lectures  on  dis- 
eases of  the,  by  W.  R.  Gowers,  633. 

New  Jersey  State  Hospitals,  annual  re- 
ports of,  for  1894,  94. 

Obstetrics,  manual  of,  by  A.  F.  A.  King, 
598  ;  science  and  art  of,  by  T.  Par- 
vin,  561. 

Oftalmologia  clinica,  por  el  Dr.  Enrique 
Lopez,  346. 

Patologia  e  terapia  chirurgica,  dal  Dur- 
ante, 94. 

Pathologic  und  Therapie,  Lehrbuch  der 
vergleichenden,  von  G.  Schneidemiihl, 

705. 
Pathology  and  morbid  anatomy,  by  T.  H. 

Green,  598. 
Patologia  e  terapia  chirurgica,  trattato  di, 

del  F.  Durante,  598. 
Pelvic  organs  in  women,  symptoms  simula- 
ting disease  of  the,  by  A.   Rabagliati, 

129. 
Personality,    diseases   of,    by    Th.    Ribot, 

129. 
Personal  reminiscences   and  recollections, 

by  S.  C.  Busey,  598. 
Pharmacopoeia,  the  extra,  by  Martindale 

and  Westcott,  201. 
Phthisique,  traitement  hygienique  du,  par 

E.  P.  Leon-Petit,  706. 
Physician's  account-book;  by  Dr.   Bailey, 

598. 
Physiology,  text-book  of,  by  M.   Foster, 

706. 
Pregnancy,   ectopic,    by    J.    C.    'Webster, 

93- 
Pregnancy,  labor,  and  the  puerperal  state, 

byE.  H.  Grandin,  814. 
Prostitution,  history  of,  by  W.  W.  Sanger, 

203. 
Pulmonary  invalids,  exercise  and  food  for, 

by  C.  Denison,  633. 
Railway  Surgeons,  American  Academy  of, 

report  of  first  meeting,  345. 
Respiration    und     Circulation,     Untersu- 

chungen   iiber,  von   Dr.   A.    Loewy, 

130. 
Salpetriere,  traite    clinique   et    therapeu- 

tique  d'apres  I'enseignement  de  la,  par 

Giles  de  la  Tourette,  202. 
Sanitary  reports,  abstract  of,  vol.  ix.,  203. 
Serotherapie  antidiphtherique,  raanuel  de, 

par  M.  Funck,  345. 
Sexual  organs,  disorders  of  the  male,  by  E. 

Fuller,  705. 
Skiascopy,  by  Edward  Jackson,  345. 
Skin,   atlas  of  diseases  of  the,  by   S.    R. 

Crocker,  203,  561,  813. 
Skin  diseases,  pathology  and  treatment  of, 

by  Kaposi,  94. 
Simple  life,  plea  for,  by  G.  S.  Keith,  813. 
Southern  Surgical  and  Gjmecological  -As- 
sociation, transactions  of  the,  204. 
Speech,  disorders  of,  by  John  Wyllie,  59S. 
Surgery,   operative,  manual   of,  by  L.   A. 

Stimson  and  J.  Rogers,  Jr. ,  S49. 
Surgery,  operative,  text-book  of,  by  Theo- 
dore Kocher,  237. 
Surgery,  supplement  to  the  International 

Encyclop.iKlia  of,  edited  by  John  Ash- 
hurst,  Jr.,  849. 
Surgery,  system  of,  edited  by  F.  S.  Dennis, 

203. 
Surgery,  system  of,  edited  by  F.   Treves, 

561. 
Sympathetic  nervous  system,  chart  of  the, 

by  Byron  Robinson,  345. 
Therapeutics,    physical    and    natural,   by 

Hayem  and  Hare.  669. 
Therapeutics,  text-book  of   practical,    by 

H.  A.  Hare,  561. 
Therapie,  Encyclopadie  der,  herausgegeben 
von  Oscar  Liebreich,  345. 


December  28,  1895] 


Book  Notices  : 

Transactions  of  the  American  Association 
of  Obstetricians  and  Gynecologists  for 
1894,  237. 

Transactions  of  the  Amencan  Laryngo- 
logies! Society,  94. 

Transactions  of  the  Medical  Society  of  the 
State  of  California.  561. 

Transactions  of  the  Medical  Society  of  the 
State  of  Pennsylvania,  561. 

Transactions  of  the  New  York  State  Medi- 
cal Association  for  1894,  345. 

Transactions  of  the  Ohio    State  Society, 

598- 
Transactions  of  the  Southern  Surgical  and 

Gynecological  Association,  204. 
Tumors,  pathology  and  surgical  treatment 

of,  by  N.  Senn,  849. 
Twentieth  Century  Practice,  edited  by  T. 

L.  Stedman,  237,  813. 
Urethra,  chirurgie  de  1',  de  la  vessie  et  de 

la  prostate,  par  Rochet,  202. 
Uric  acid  as  a  fictor  in  the  causation  of 

disease,  by  A.  Haig,  597. 
Uric-acid  diathesis,  by  F.  Levison,  597. 
Urine  in   health   and  disease,   by    D.    C. 

Black,  633. 
Venereal  diseases,  pathologj'  and  treatment 

of,  by  R.  W.  Taylor.  813. 
Vital  force,  science  of,  by  W.  R.  Dunham, 

597- 
Vital  Statistics  of  the  New  England  States, 

summary  of,  345. 
Water-supplies,  filtration  of  public,  by  A. 

Hayem,  204. 
Wisconsin  State  Board  of  Hcilth,  fifteenth 

report  of  the,  94. 
Women,  evolution  of  diseases  of,  by  Balls- 

Headley,  93. 
Wounds,     aseptic   treatment     of,    by    C. 

Schimmelbusch,  237. 
Wounds,  ulcers,  and  abscesses,  treatment 

of,  by  W.  Watson  Cheyne,  238. 
Year-book  of  treatment  for  1895,  94. 
Books,  tuberculosis  in,  485. 
Booth,  J.  Arthur,  hysterical  amblyopia  and 

amaurosis  treated  by  hypnotism,  256. 
Borst.  Dr.  Elman  H.,  death  of,  704. 
Bosanko,  Dr.  S.  Artl  ur,  death  of,  847. 
Bossu,  Antonin,  notice  of  book  by,  203. 
Boteler,  William  Clarence,  glioma,  303. 
Bowel,  spontaneous  rupture  of,  493. 
Bowerman,    Albert   C,    an    anencephalous 

monster,  309. 
Bra,  M.,  notice  of  book  by,  202. 
Brachial  artery,   rare  anomaly  of  the,  91 1  ; 

plexus,  injury  to  the,  895. 
Bradshaw,  John  H  ,  acute  thyroiditis,  640. 
Bradshaw  lecture  at  the   Royal   College    of 

Physicians,  823. 
Brain,  aculeinflammationof  the,  592  ;  corti- 
cal hemorrhage  with  rupture  into  a  lat- 
eral ventricle,  821  ;  cortical  localiza- 
tion, 59;  cystic  tumor  of  the,  710; 
diagnosis  of  interstitial  inflammation  of 
the,  60s  :  <l>^"ble,  and  dual  personality, 
574  ;  drug  treatment  of  a  glioma  of  the, 
823  ;  epilepsy  from  old  abscess  of  the, 
628  ;  extensive  traumatic  lesion  of  the, 
with  very  meagre  objective  symptoms, 
512;  hemorrhage  in  the,  820;  injuryof, 
and  consciousness,  559  ;  surgery  of  the, 
122,  385,  750;  tumors  of  the,  63,  346, 
387  ;  weight  of,  in  the  sane  and  insane, 

378- 

Braithwaite,  James,  notice  of  Retrospect 
edited  by,  345. 

Bramwell,  Byron,  notice  of  book  by,  634. 

Brandegee,  William  P.,  a  new  adenoid  for- 
ceps, 175.  . 

Breast,  carcinoma  of  the,  672  ;  excision  of 
the,  284;  the  hysterical,  924. 

Breen,  A.  E.,  the  Catholic  Church  and  abor- 
tion, 71. 

Bremer,  Eudwig,  blood-changes  in  ntnras- 
thenia,   321. 

Brendon,  E.  V.,  bacteriological  diagnosis, 
754. 

Bridgeport,  a  series  of  cases  of  multiple  neu- 
ritis in  infants  in,  656,  71 1. 

Bright's  disease,  diet  in,  925 ;  the  blood  in, 
562. 

Bristowe,    Dr.    John    Syer,    death    of,   379, 

430 


INDEX. 

Briti.sh  Association   for  the  Advancement  of 

Science.  416,  494. 
British    Laryngological,     Rhinological,    and 

Otological  Association,  271. 
British  Medical   .\ssociation,  233,  240,  250, 

276,311,319,348,393,419,499. 
British  practitioner,  guarding  the  morals  of, 

45'.  539.  632. 
Bromide  eruptions,  526,  622. 
Bronchitis,  treatment  of,  357,  358,  392,  86r, 

900. 
Bronchus,  peanut  in  the  left,  68  ;  removal  of 
an  intubation-tube  from  the,  by  trache- 
otomy, 641. 
Brown.  James  Spencer,  a  new  needle,  69. 
Brunton,  Dr.    Lauder,    promotion   of,   430, 

647. 
Bubo,  treatment  of,  302,  913. 
Buchanan,  J.  J. ,  rupture  of  the  tendon  of  the 

quadriceps  extensor  femoris,  625. 
Buck,    Albert     H.,    comparatively   painless 

mastoid  disease,  73. 
Bulklev,  L.  Duncan,  sleep  in  its  relations  to 

diseases  of  the  skin,  688. 
BuUard,  William  L.,  accidents  to  the  eye 
while   chopping   with   a  hoe,    67  ;    the 
electro-magnet  for  the  removal  of  for- 
eign bodies  from  the  eye,  496. 
Burnett,  J.  Compton,  notice  of  book  by,  94, 

663. 
Burns,   picric  acid    for,    756;  treatment  of, 

428,  911. 
Burbank,  Dr.  .V.  11.,  death  of,  127. 
Burrall,  F.  A  ,  are  we  likely  to  have  any 
more   epidemics   of  Asiatic   cholera  in 
New  York  ?  83. 
Busey,  Samuel  C,  notice  of  book  by,  598. 
Byron,   Dr.   John    M.,  resolutions    on    the 
death  of,  91. 


Cable,  Dr.  W.  W.,  death  of,  307. 

Cabot,  John,  case  of  ichthyosis  congenita 
with  some  unusual  features,  10. 

Cadmium,  action  of  the  salts  of,  on  cold- 
blooded animals,  140. 

Cadwallader,  R  ,  a  family  history  of  hydro- 
cele, 383. 

CKcum.  anatomy  of  the,  757  ;  displaced,  with 
volvulus,  569. 

Czesarean  section  vs.  symphyseotomy,  208. 

Calculus,  vesical,  a  hiding-place  for,  352 ; 
vesical,  cystotomy  for,  7S2  :  vesical,  in 
the  white  and  negro  races,  7S1. 

Calomel,  927. 

Campbell,  Dr.  John  Law,  obituary  of,  452. 

Canadian  Medical  Association,  384. 

Cancer,  antitoxin  of,  235,  7S8.  S83  ;  chemis- 
try of,  423 ;  discussion  on,  602  ;  etiology 
of,  682 ;  in  husband  and  wife,  383  ;  is  it 
inoculable?  449;  nature  of,  423,  716; 
of  the  brco-st,  recurrent,  318  ;  of  the  duo- 
denum, 52  ;  of  the  lung.  167  ;  of  the 
(Esophagus,  166,168;  of  the  pia  mater, 
169  ;  of  the  skin,  treatment  of,  387  ;  of 
the  stomach  with  free  hydrochloric  acid, 
601  ;  present  state  of  our  knowledge  of, 
459;  study  of,  269;  treatment  of,  216, 
235.  464,  788, 

Cancer  Hospital  of  London,  scandal  at  the, 

495-  , 

Cancer  institute,  advertisement  of  a,  302. 

Canon,  a  silly  and  untruthful,  684. 

Capsule  knife,  the  curved,  643. 

Carbolic  acid,  poisoning  from,  antidotal  ef- 
fect of  alc'ihol  in,  741. 

Carbuncle,  .ibortion  of,  679. 

Carcinoma,  see  Cmxer. 

Cardiocentesis,  491. 

Carlvbid,  524. 

Carter,  Surgeon-Major  Ileniy  John,  death 
of,  70. 

Case,  Dr.  W.  P.,  death  of,  70 

Cast,  plaster,  horizontal  position  for  apply- 
ing, 213. 

Ca.stration  for  hypertrophied  prostate,  165  ; 
vaginal,  459. 

Cataract,  artificial  ripening  of,  462;  com- 
plications in,  462  ;  knife-needle  for  dis- 
cission'of  capsule  after  extraction  of,  467. 

Catarrh,  nasal  and  faucial,  formula  for,  358  ; 
nasfj-pharyngeal,  are  of  the  causes  of, 
928. 


935 

Cat -bite,  hydrophobic  form,  523. 
Catheters,  lubricant  for,  311  ;  the  largest, 

always.  174. 
Catholic  Church  and  abortion,  71. 
Cautery,  a  new,  790. 
Cell-motion,  Leonard's  method  of  detecting, 

231. 
Centenarians,  a  census  of,  in   France,  360, 

393- 
Cephalopagus,  210. 
Cerebellar  ataxia,  hereditary,  700. 
Cerebellum,  tumor  of  the,  63,  228. 
Cerebritis,  interstitial,  dia.gnosis  of,  605. 
Cerebrospinal   fluid,  functions   of  the,  819; 

sclerosis,  multiple,  30. 
Cervix  uteri,  tears  of  the,  815  ;  treatment  of 

lacerated,  324. 
Cesspools,  disinfection  of,  533. 
Championniere,  Dr.    Just    Lucas,  notice   of 

book  by,  203. 
Chancre,  auto  inoculation   of,    311;   lesions 
that  may  simulate,  755  ;  of  the  lip,  131 ; 
of  the  tonsil,  446. 
Chancroids,  treatment  of.  357,  755"'  "■^^'• 

ment  of,  in  women,  539,  645, 
Chandler,  Dr.  Thomas  Henderson,  death  of, 

343. 
Chapin,  Henry   Dwight.  some   observations 
upon  the  effects  of  horse-serum  injec- 
tion.s,  721,  783. 
Charaka  Lamhita,  53S. 
Charcot's  disease,  895. 

Charities,  abuse  of  medical,  298,  535,  536 ; 
reform  in  the  Department  of  Public, 
845  ;  State  and  local,  19. 
Cheesman,  ,Hobart,  incubation  period  of 
chicken-pox  delayed  by  measles,  and 
parotitis  following  chicken-pox,  123,  ^ 
Chest,  combinations  of  morbid  conditions  of 
the,  87.  ,   ,.         o 

Cheyne,  W.  Watson,  notice  of  Iwok  by,  23S. 
Chicago,    Department   of   Health   in,   162 ; 
fake  hospitals  in,  899  ;  medical  inspect- 
ors in,  704. 
Chicken-pox  and  measles,  123. 
Child-bearing,  prevention  of  uterine  disease 

due  to,  397. 
Children,  empyema  in,  612;   intestinal  ob- 

struction  in,  4S4. 
Chimpanzee,  brain  of  a,  58. 
China,  hospitals  and  medical  practitioners  in, 
451;    medical   mission   work   in.    776; 
morphine  habit  in,  379. 
Chinamen,  dead,  as  freight,  612. 
Chlo'al,  413;  and  opium-poisoning,  23;  in 

the  treatment  of  insomnia,  359. 
Chloroform   and    oxygen    anasthesia,    642 
S63  ;  deaths  from,  522  ;  discoverer  of, 
533 ;    dropper,    68  ;   narcosis,   fatal  ef- 
fects of  fear  in,  679. 
Chocolate,  temporary  amblyopia  from,  843. 
Cholecystenterolomy,  indications  for,  755. 
Cholelithiasis,  318. 

Cholera,   iS  ;  and  quarantine,   164;  m   Eu- 
rope and  the  Ea.-.t,  343;   in  Japan,  163; 
in  Korea,  495  ;  in  New  York,  possibil- 
ity of  having  an   epidemic,  S3  ;  infan- 
tum,tre.itment  of,  43,  311  ;  inoculations 
against,  523  ;  morbus,  formula  for,  392  ; 
treatment  of,  33;  water-borne,  502. 
Chopparro  amargoso,  860, 
Chordee,  formula  for,  428. 
Chorea.  677  ;  nature  and  treatment  of,  148. 
Choroid  plexus  of  a  h^rse,  tumors  from  the, 

X71. 
Chutmucks,  the  Order  of,  522. 
Cicatricial  tissue,  severe  spasmodic  muscular 
contractions,    due   to     reflex     irritation 
from,  893. 
Cigarette  habit,  103. 

Cilia  forceps,  70.  i.  j  -    r 

Circumcision,    easy    and   ready   method_ot. 

Civilization,  the  thumb  as  an  initial  factor 
of,  188. 

Clark.  Sir  Andrew,  memorial  to,  736,  827. 

Clavicle,  dislocation  of  the,  533. 

Cleveland,  the  w.-iler-supply  of,  308. 

Climate  and  Health,  a  new  government  pub- 
lication, 703. 

Climates  and  baths  of  Great  Britain,  report 
on,  680. 

Club  foot.  459. 

Cocada,  the,  502. 


936 


INDEX. 


December  28,  i{ 


Cocaine  and  morphine,  antagonism  between, 
104,  433  ;  recovery  from  a  large  dose 
of,  392  ;  use  of,  prior  to  the  administra- 
tion of  chloroform,  267. 

Coccyx,  unusual  deformity  of  the,  286. 

Cocke,  James  M.,  notice  at  book  by,  201. 

Cod-liver  oil,  453. 

Coeliotomy  for  pus-tubes,  hysterectomy  fol- 
lowing, 456  ;  in  general  suppurative 
peritonitis,  455  ;  new  phase  of,  459  ; 
prevention  of  thirst  after,  455  ;  vagina), 
314- 

Coins,  microbes  on,  897. 

Cole,  Carter  S.,  a  preliminary  report  on  the 
use  of  oxygen  gas  with  ether  for  anaes- 
thesia. 505. 

Cole,  W.  F. ,  a  tympanotome,  683. 

Colectomy.  356. 

Colemaji.  Warren,  a  piece  of  bone  in  the 
appendix  verraiformis,  639. 

Colic,  flatulent,  formula  for,  393  ;  hepatic 
and  nephritic,  treatment  of,  392. 

Collins,  Clement  C,  the  country  practition- 
er, 178. 

Collins,  Joseph,  a  contribution  to  the  study 
of  hereditary  cerebellar  and  hereditary 
spinal  ataxia,  S65. 

Colorado,  the  climate  of,  789. 

Color-blindness  and  atavism,  863. 

Colotomy,  356. 

Colpotomy.  anterior,  314. 

Comitia  minora  of  the  New  York  County 
Medical  Society,  appeal  from  a  deci- 
sion of  the.  490. 

Confidences  of  patients,  sacredness  of,  883. 

■'  Confined,  successfully,"  503. 

Congress,  International  Medical,  in  Moscow, 

738.  776- 

Con^jresses,  international,  reform  in,  19. 

Conjunctivitis,  diphtheritic,  treatment,  716  ; 
formula  for,  677. 

Conrad,  Dr.  Harry  B..  death  of,  596,  632. 

Constipation,  chronic,  formula  for,  392.  677; 
congenital,  563 ;  in  infants,  formula 
for,  392. 

Consulting  practice,  alleged  failure  of,  in 
New  York,  594. 

Consumptive  patients,  where  shall  they  be 
=ent,  49. 

Contatjious  diseases,  weekly  statement,  34,  72, 
107,  143,  179,  216,  252,  28S,  324,  360, 
396,  432,  46S,  49S,  537.  574.  612,  645, 
684,  719,  756,  791.  827,  863.  897    92S. 

Continental  Anglo-American  Medical  So- 
ciety, 27. 

Continuous  fever,  so-called,  etiology  of.  88. 

Convulsions  in  rickets,  524 ;  produced  by 
d™S*.  533- 

Cork,  battle  of  the  clubs  at,  466. 

Cornea,  treatment  of  ulcers  of  the,  267,  301, 
429,  927. 

Corns,  soft,  treatment  of,  272. 

Corset,  aluminum,  744. 

Corson,  Eugene  R.,  a  rare  anjmlay  of  the 
brachial  artery,  91 1. 

Coryza,  acute,  formulae  for,  358  ;  acute,  in 
nurslings.  504. 

Cotlam,  G.  G.,  a  case  of  cardiocentesis,  491. 

Coudert,  Frank  Edmonds,  a  case  of  opium 
and  chloral-poisoning,  23. 

Cough,  treatment  of  obstinate,  701. 

Counter-prescribing.  305. 

Cowl,  W.  Y. .  improved  means  for  the 
hematocrit  method  of  blood  examina- 
tion, 222 

Co.\,  Dr.  Timothy  B.,  dealh  of,  631. 

Craig  epileptic  colony.  53S  ;  number  of  ep- 
ileptics available  for  the.  898. 

Cranio-rachi-schisis  with  double  formation  of 
the  face,  401. 

Craniotomy,  496 ;   and  the  law,  141  ;  ethics 

„      °f.  319,  395. 

Cranium,  hyperostosis  of  the,  59 ;  signs  of 
pressure  within  the,  533. 

Crawford.  Sir  Thomas,  death  of,  68l. 

Cremation  in  the  United  States,  344. 

Creosote  carbonate  and  oleo-creosote,  thera- 
(jcutics  of,  464. 

Crime  and  criminals,  scientific  treatment  of, 
604  ;  increase  of,  in  France,  662. 

Criminals,  experiments  on,  720 ;  insane, 
shall  they  be  imprisoned  or  put  to  death  ? 
37  :  social  and  le^al  status  of,  and  the 
philosophy  of  reformation,  606. 


Crocker,  H.  Radcliffe,  notice  of  book  by, 
203,  561.  S13. 

Croton-oU,  the  vesicating  constituent  of,  234. 

Croup,  treatment  of,  311,  677,  861. 

Curare,  a  substitute  for,  487. 

Currie,  D.  A.,  labial  retractor,  70 

Cyanosis,  the  blood  in  chronic,  196. 

Cyclers,  advice  to  intending.  684. 

Cycling,  contra-indications  to,  755;  dangers 
of.  503  ;  posture  in,  524. 

Cystitis,  gonorrhoeal,  389 

Cystotomy,  first  case  of  supra-pubic.  412; 
for  stone,  782  ;  supra-pubic,  for  tuber- 
cular ulceration,  562. 


Da  Costa,  J.  M.,  notice  of  bDok  by,  849. 

Daltonism  and  atavism,  S63. 

Dancing  sickness,  epidemic  of,  343. 

Davison.  W.  \. .  irrigations  in  acate  gonor- 
rhcea,  122. 

Davis.  A  A.,  inversion  of  uterus  of  five  days' 
standing — successful  reduction.  5SS. 

Dawbam,  Robert  H.  M..  a  curious  case  of 
appendicitis,  289  ;  appendicitis,  497. 

Deafness,  chronic  catarrhal  and  suppurative, 
a  new  operation  for,  636;  from  intra- 
nasal disease.  337. 

Death,  signs  of.  928  ;  sudden,  from  cardiac 
syphilis.  S27 ;  sudden,  from  venous 
thrombosis  in  the  puerperium,  854. 

Death-certificate   signing  one's  own,  177. 

Deciduoma.  malignant.  318. 

Dees.  W.  W.,  a  self-retaining  nasal  specu- 
lum,  137. 

Deformities,  postural,  of  the  trunk,  treat- 
ment of.  by  means  of  rapid  and  thorough 
physical  development,  427 ;  resulting 
from  acute  infections  in  bone,  613. 

Degenerates,  deformities  of  the  hard  palate 
in,  747. 

Degeneration  and  genius.  Coleridge  on,  216. 

Delirium  tremens,  formula  for.  861. 

Delmar.  Mr.  F.  O.  T.,  bequest  of,  787. 

Delusion  of  stifl^ened  extremities  treated  by 
extension.  17^. 

Dementia,  paralytic,  and  tabes,  association 
of,  480. 

De  Mund,  John  T. ,  tartar  emetic  in  tedious 
labor,  491. 

Dench.  Edward  Bradford,  notice  of  book 
by,  93- 

Denison,  Charles,  a  shorter  scale  .for  the 
thermometer.  497 ;  antiphthisis,  78 : 
notice  of  book  by.  633. 

Dennis,  Frederic  S.,  notice  of  book  edited 
by,  203. 

Denver.  Home  for  Consumptives  in,  575; 
the  healer  in.  774. 

Dercum,  Francis  X. ,  notice  of  book  edited 
by,  705. 

Dermatology,  new  remedies  in.  3S7. 

Dermoid  cysts  and  pregnancy,  465  ;  coccy- 
geal, 679. 

Diabetes,  bronzed,  278. 

Diabetes  mellitus,  codeine  in,  132;  digestive 
troubles  of.  565  ;  morphinism  and.  707  ; 
neuro-chemical  aspect  of.  230 ;  patho- 
genesis of,  564  ;  phenylhydrazin  -  hy- 
drochlorate  in  the  diagnosis  of,  443 ; 
pregnancy  associated  with,  109,  131  ; 
test  for  incipient,  504  ;  therapeutics  of, 
6o5:   uranium  nitrate  in,  278. 

Diagnosis,  Broadbent  on,  932. 

Diaphragm,  calcareous  plate  in  the,  171  ; 
perforation  of,  in  gastric  ulcer.  159: 
jihenomenon,  importance  of,  in  clinical 
medicine,  901. 

Diarrhiei.  formula  for,  393.  676,  677 ; 
mornins;,  22  :  summer,  treatment  of,  43. 

Diazo-reaction,  42*1. 

Diet  adapted  to  the  management  of  senile 
heart,  267  ;  in  Bright's  disease,  925. 

Digestion,  disordered,  the  sensation  of  the 
stomach  in.  500 ;  painful,  in  the  hys- 
terical, 923. 

Digitalis,  large  dose  of.  24 

Diller,  Theodore,  the  association  of  tabes 
and  paralytic  dementia,  4S0. 

Diphtheria  aajuired  in  the  laboratory,  91 ; 
antitoxin  treatment  of,  194,  465,  523, 
7S4,    822  ;  antitoxin    treatment    of,    in 


Berlin,  593  ;  application  in,  677  ;  bac- 
teriological diagnosis  of,  754  ;  cardiac 
paralysis  after,  750;  discussion  on,  be- 
fore the  British  Medical  Association, 
276  ;  laboratory  of,  in  Paris,  410  ;  leu- 
cocytosis  in,  392  :  prophylaxis  of,  140, 
523  ;  recent  studies  on,  599. 

Disease,  structural,  the  beginning  of,  646. 

Disinfection  of  localities,  68  ;  of  rooms  after 
infectious  diseases,  521  ;  of  vaults  and 
cesspools,  533. 

Dispensaries  in  St.  Louis,  379. 

Dispensary, the,  a  disease  of  the  body  politic, 
645. 

Doctor,  an  original,  180;  what  constitutes 
the  well  qualified,  769. 

Doctors'  bill-,  the  Dean  of  Norwich  on,  414. 

Doctors,  three  kinds  of.  576. 

Dodson,  L.  W. ,  a  well-marked  case  of  Kahl- 
baum's  so-called  katatonia,  25. 

Doege,  Karl  W. ,  parovarian  cyst  complicat- 
ed by  the  passage  of  renal  calculi,  372. 

Dosing,  reckless  self-,  594. 

Drake,  Daniel,  career  of,  463. 

Dropsy,  essential.  25  ;  formula  for,  785. 

Drug  eruptions.  526,  530.  531,  622. 

Druggist.  French,  and  science.  269. 

Drugs,  adulteration  of.  521. 

Drunkard,  habitual,  definition  of,  235. 

Drunkards,  treatment  of  habitual,  in  Aus- 
tria, 683. 

Drury,  Dr.  George,  assault  upon,  163. 

Duhring,  Louis  A.,  notice  of  book  by,  669. 

Dunham,  W.  R.,  notice  of  book  by,  597. 

Duodenum,  peculiar  ulcer  of  the,  167  ;  per- 
forating ulcer  of  the,  317  ;  primary  car- 
cinoma of  the,  52. 

Duplay,  Simon,  notice  of  book  by,  94. 

Duplex  personality,  324. 

Durante,  Francesco,  notice  of  book  by,  94, 
598. 

Dust,  infectiousness  of  the,  in  the  Adiron- 
dack Cottage  Sanitarium.  903,  925. 

Dynamometer,  holders  for  the,  24S. 

Dysentery,  formula  for,  311,  393. 

Dysmenorrhoea,  mechanical,  387  ;  membra- 
nous, treatment  of,  677  ;  opium  in,  674  ; 
treatment  of.  340. 

Dyspepsia  and  baldness.  684  ;  clinical  aspect 
of.  469  ;  examination  of  urine  in,  392. 

Dystocia,  fcetal,  334. 


Ear.  abscesses  of  the  external  auditory  canal 
followed  by  perichondritis  auriculae,  494  ; 
deafness  from  chronic  catarrhal  and  sup- 
purative inflammation  of  the,  a  ntw 
operation  for,  636  ;  death  in  the  tym- 
panum. 126,  132  ;  disease  of  the,  and 
bathing,  90;  the,  in  the  exanthemata, 
396 ;  multiple  abscesses  of  the  external 
auditory  canal,  followed  by  perichon- 
dritis auriculx.  238;  removal  of  the 
membrana  tympani  and  ossicles,  386 ; 
Reraaud's  di>ea-se  of  the,  52;  ;  tincture 
of  iodine  in  chronic  suppurative  inflam- 
mation of  the  middle.  29. 

Eccles.  A.  Symons,  notice  of  book  by,  705. 

Echinococcus  c\  sts  of  the  liver,  pleura,  omen- 
tum, mesentery,  peritoneum,  and  blad- 
der, 411. 

Eczema,  generalized.  140  :  of  the  face,  treat- 
ment of.  392 ;  treatment  of.  860, 

Edinburgh  College  of  Surgeons,  895. 

Editions  of  medical  men,  new,  306, 

Effusions,  diagnosis  of  inflammatory  and 
non-intiimmatory,  952. 

Einhorn.  Max,  achylia  ga-trica,  5.  205  ;  on 
functional  disorders  of  the  stomach  ac- 
companied   with   hyper  secretion,    602, 

724-  .    . 

Electricity,  accidents  from,  first  aid  in.  930  ; 
and  cats  180;  physiological  action  of 
j1eriodic.1l  induced  currents,  72,  1 77, 
360;  practical  method  of  measuring  and 
registering  the  true  therapeutic  dose  of 
induction-coil  currents,  S74  ;  treatment 
of  injuries  from,  864. 

Electrolysis,  value  and  limits  of,  in  derma- 
tology, 527. 

Electro-magnet  for  the  removal  of  foreign 
bodies  from  the  eye,  496. 


December  28,  1895] 


INDEX. 


93; 


Electrotherapy  as  a  means  of  diagnosis   in 

g\-necology,  313. 
Elliot,  George  T.,  two  cases  of  an  unusual 
papulo-pustular  and  fungoid  bromide  of 
potassium  eruption  in  babies,  622. 
Elliott,  George  R.,  the  question  of  an  inter- 
national language,  2S7. 
Elliott,  Hiram,  simple  melancholia,  477. 
Ellis,  R  ,  therapeutic  progress,  a  slower  pace 

necessary,  118. 
Ely,  John  Slade,  the  dominant  influence  in 
the  medical  progress  of  the  nineteenth 
century,  145. 
Emphysema,    subcutaneous,    from   straining 

during  parturition,  647. 
Empyema   in    children    612 ;    treatment  of. 
26  ;  use  of  curette  in  operations  (or,  635. 
Encephalitis,  acute  non- suppurative,  592. 
Endocarditis,  acute  rheumatic,  treatment  of, 
74S  ;  in    country    practice.  660 ;    rheu- 
matic, rest  in   the   treatment   of,  284; 
treatment  of,  785. 
Endometritis,  fetid,  of  old  women.  88. 
Endothelioma  of  the  pia  mater,  169 
Enema,  nutritive,  785. 
Engel,     Carl,     craniotomy,     496 ;    rational 

"  treatment  of  erysipelas,  23. 
Enuresis,  nocturnal,  prevention  of,  56;  suc- 
cessful treatment  of,  by  the  test  opera- 
tion, 418  ;  treatment  of,  74S. 
Epididymitis,  double  suppurating,  171. 
Epilepsy    from    old    cerebral    abscess,    628 ; 
heredity    in.   894;    infantile   causes    of, 
612;    medical    treatment    of    operated 
cases.    590  ;    senile,     and    Griesinger's 
symptom    of  basilar    thrombosis,    749  ; 
sodium    biborate    in,    828 ;    strontium 
bromide    in,     358;     toxicity    in,    460; 
trephining  for  traumatic,  151. 
Epileptics  available   for  the  Craig  Colony, 
89S  :  Pennsylvania  colony  farm  for.  900. 
Epiph)seal  separations  in  children,  5S5,  606. 
Epistaxis,  124.  913. 

Epithelioma    following    skin-grafting.    170; 
formula  of  Marsden's  paste  for,  679;  of 
the  resophagus,  166,  168. 
Erdmann,  John  F.,  some  fractures  and  epi- 
physeal   separations    of    the    upper   ex- 
tremities in  children,  585.  606. 
Erysipelas,    532;     formula    for,  429,    912; 
honey  in,  501 ;  in  its  etiological  relation 
to  preceding  skin  lesion,  723  ;  rational 
treatment  of,  23. 
Erythropsia,  128. 

Eskridge,  J.  T.,  tumor  and  large  cyst  of  the 
cerel>ellum,  with  symptoms  extending 
over  many  years,  228. 
Ether,  administration  of,  913;  anaesthesia, 
blood  changes  in,  922  ;  and  oxygen  gas 
for  ana;~thesia,  505,  863. 
Ethics,  medical,  a  point  of,  519;  in  London, 

632. 
Ethmoid  disease  leading  to  cerebral  abscess 

and  death.  97. 
Europe,  mortality  in  the  chief  cities  of,  dur- 
ing 1894.  344-     ,    .^         .       „ 
Euthanasia,  a  layman's  idea  of,  37!>. 
Evans.  T.  C,  adenoid  growths  of  the  naso- 
pharynx,   296;     two    tracheotomies   for 
laryngeal  cellulitis,  637. 
Examiners,   insurance,  reduced  fees  of,  703, 

825,  883. 
Exanthemata,  the  ear  in  the,  395. 
Exophthalmic  goitre,  thyroiilectomy  for,  284; 
with  monocular  symptoms  and  unilateral 
thyroid  hypertrophy,  46. 
Exophthalmos  due  to  intra  orbital  cyst,  265. 
Expert  testimony,  as  viewed  in  Illinois,  198  ; 

how  it  could  be  made  valual)le.  915. 
Eye,  electro-magnet  for  removal  of  foreign 
bodies  from  the,  212,  383.496;  emergen- 
cy treatment  in  acute  diseases  and  in- 
juries of  the,  600  ;  exophthalmos  due  to 
intra-orbital  cyst,  265  ;  headaches  due 
to  errors  of  refraction,  502  :  hysterical 
affections  of  the.  treated  by  hypnotism, 
256  ;  iron  splinters  in  the,  67  ;  manage- 
ment of  advancing  corneal  ulceration  in 
gonorrliceal  ophthalmia,  815;  neuro- 
logical aspect  of  asthenopia,  806;  rheu- 
matism and  gout  in  relation  to  the,  462 ; 
temporary  amblyopia  from  chocolate, 
843  ;  treatment  of  corneal  ulcer,  267, 
301  ;   treatment  of  black,  820. 


Fabricius,  F.«{W.  Antoninus,  isolation  or 
thermoplegia,  155;  some  observations 
on  hydrophobia  and  hystero  -  hydro- 
phobia, 908. 

Face,  appearance  of  the,  during  etheriration, 

Fahrney,  Elmsr  C,  a  shorter  scale  for  the 
thermometer,  322. 

Faith,  cure  of  scur\7  by,  861. 

Fargas.  Dr.,  notice  of  book  by,  346. 

Feeding-cup,  the  glass  syringe  as  a,  539. 

Feeding,  forced,  for  9  years,  923  ;  of  infants, 
artificial,  260. 

Feet,  treatment  of  blisters  of  the,  677. 

Felon,  nitric  acid  for  a,  590. 

Femur,  bending  of  the  neck  of  the,  427  ; 
causes  of  shortening  of  the.  678 ;  fract- 
ure of  the,  349  ;  fracture  of  the  iieck  of 
the,  treatment  of,  605  ;  traumatic  sep- 
aration of  the  lower  epiphysis  of  the, 

475-  ...  1     •  .    ., 

Fencing  from  a  hygienic  standpoint.  72. 
Fever,  alcohol  in,  717;  eruptive,  the  co- 
existence of,  347  ;  hydrotherapy  m,  357  ; 
new  treatment  for,  500;  treatment  of, 
without  food,  antipyretics,  or  alcohol, 
541.  , 

Fibroids  cured  by  thyroid  gland,  775:   when 

to  operate  upon,  453. 
Fields,  Dr.  C.  M.,  death  of.  92. 
Filters,  danger  of,  70.  „,,„_, 

Fire  Commissions,  medical  staff  of  the  Board 

of,  847 

Fischer,  Louis,  treatment  of  summer  com- 
plaint. 43. 

Fisher.  Myron  E.,  a  case  of  placenta  prsvia, 

240.  f    £    o 

Fistula  in  ano.  310  :  treatment  of,  67J). 
Fitzpatrick,  Charles  B.,  preliminary  note  on 
the  use  of  phenol  as  a  preservative  ot 
diphtheria  antitoxin,  571. 
Flat-foot,   716;  cure  of,  744!  supra-malle- 

olar  osteotomy  for.  886. 
Flatulence,  cause  and  treatment  of,  197,  322. 
7S5.  ,  . 

Flint,    Austin,    Jr..    observations  on   peine 

contractions,  583,  605. 
Floating  kidney,  351.  .        ,, 

Florida   penaltv  for  circulaimg  false  reports 

concerning  infectious  diseases  in,  288. 
Fluids,   organic,    method  of   expressing  the 
degree  of  acidity  or  alkalinity  of  the,  4S3. 
Foetus   position  of,  in  the  uterus,  316. 
Folliculitis,  agminate,  of  par.%sitic  origin,  531. 
Foreign  bodies  in  the  throat,  684. 
Formaline,  522.         ,,      ,   .  , 

Foster.  M..  notice  of  book  by,  706. 
Fractures,  diagnosis  and  treatment  of,  8)59; 
indications  for  treatment  of,  429;  ol 
the  femur,  349.  <^S;  °^  "•«  "PP*"'  '" 
tremities  in  children,  585.  606;  prog- 
nosis of,  755;  significance  of  fissure,  ot 
the  articular  ends  ol  the  long  bones,  458  ; 
the  element  of  vascular  compression  in 
treatment  of,  458;  treatment  of.  679, 91  '- 
France,  alcoholism  in.  884;  foreign  mc<lical 
students  in.   124;  increase  of  crime  in. 

Fraser.^bonald  B.,  antidotal  effect  of  alco- 
hol in  carbolic-acid  poisoning.  741. 

Free.  James  E..  endocarditis  in  country 
practice,  660. 

Freeman,  Leonard,  trephining  for  traumatic 
epilepsy,  151. 

French  Surgical  Congress    84». 

Fri.-irs' balsam,  explanntion  of  efficacy  of.  3i7- 

Fridenlwrg,  Percy,  a  case  of  exophthalmic 
goitre  with  monocular  symptorns  and 
unilateral  thyroid  hypertrophy,  46. 

Friedreich's  ataxia,  85. 

Frothingl.am,  Langdon,   notice  of  book  b). 

Fuller,  Eugene,  notice  of  book  by,  705. 
Fuller.  Stephen  E.,  resolution  on  the  death 

FuIle°rton^Erskine  B.,  treatment  of  cholera, 

Fulton.'   J.    A.,    the   use   of  the  curette  in 

operations  for  empyema,  635. 
Funck,  M..  notice  of  book  by,  34S- 
Fungus  cerebri,  treatment  of,  679. 
Furuncles,  treatment  of.  360,  678,  679. 


Gage,  W.  v.,  case  of  diphtheria  treated  with 

antitoxin,  S22. 
Galactogogues,  20. 

Gall-bladder  and  liver,  experiments   on  the. 

921;   distended,    and  movable    kidney, 

confusion  between,    160  ;  large  calculus 

of  the,  316. 

Gall-ducts,  catarrh  of,  formula  for.  357. 

Galloway,    D.     H.,    alkaline    injections    in 

gonorrhoea,  643. 
Galloway,   William  A.,  craniotomy  and  the 

law,  141. 
Gall  stones,  treatment  of,  786. 
Ganglion,  treatment  of.  533. 
Gangrene  of  the  skin  apparently  caused  by 

sodium  salicylate.  530. 
Garrod.  A.  E.,  notice  of  book  edited  by,  705. 
Gastrectomy,  428. 
Gastritis,  diseases  of  the  mouth,  nose,  and 

throat  as  etiological  factors  in.  462. 
Gastro-succorrhcea   conlinua   chronica,  602, 

724. 
Gauss,  Dr.  Henry,  death  of,  236. 
Gautier,  M.,  notice  of  book  by,  238. 
Genius  and  degeneration,  Coleridge  on,  216. 
Geology,  a  medical  collateral,  339. 
German    Naturalists    and    Physicians.    Con- 
gress of.  647. 
Germany,  medical  reform  in,  740. 
Gestation,  extr.-i-uterine,  568,601,674,  716, 

7S2,  S56.  . 

Gibbons,  John  T..  a  new  percussion  hammer. 

Gigantism  and  acromegaly,  89. 
Gihon.  Dr.  A.  L  ,  retirement  of.  488. 
Gilliam,  D.   To<!,  self  retaining  perineal  re- 
tractor. 138. 
Gillies.  H.  Cameron,  notice  of  book  by,  635. 
Girard,  Stephen,  tablet  in  honor  of,  929. 
Girls,  management  of,  at  puberty,  315. 
Glands,  the  duellos,  720. 
Gleavcs,  C.  W.,  a  young  mother,  715. 
Glioma,  drug  treatment  of,  823  ;  successlul 

treatment  of,  303.  . 

Glycosuria,    increase   of.    666;    morphinism 

and,  707.  . 

Goelet.  Augustin  H.  ligature  earner  for  the 
pedicle  of  abdominal  tumors.  68  :  physio- 
logical action  of  periodic  induced   cur- 
rents. 72.  360. 
Goitre,  desiccated  thyroids  in,  95 ;    formula 
for,  786 ;  in  a  white  mouse,  168 ;  exoph- 
thalmic, 423. 
Gold,  alterative  properties  of,  453. 
Goldstein,  Samuel,  a  new  nasal  septum  knile, 
644  •  abscesses  of  the  external  auditory 
canal,   followed  by  perichondritis   auri- 
cula, 494- 
Golfer's  elbow.  703.  ... 

Gonococcus,  clinical  and  bacterioscopic  study 
of,  30;  new  culture  medium  for  the,  391. 
Gonorrhoea,  alkaline  injections  in,  338,  430, 
535i  643:  immunity  to,   310;   m  man, 
389;    in  women,   313,   389.    755-    838; 
irrigations  in,  122  ;  test  of  a  cure  of,  260  ; 
treatment  of,    122,   338,  428,  430,  535, 
570,  643  :  treatment  of  ardor  urm.x-  ol, 
677  •  tubal,  p.illiativc  treatment  of,  83S  ; 
when  may  one  who  has  hai  the  disease 
marry  ?  722. 
Goodfellow,  Dr..  death  of,  359. 
Gout,  definition  of  irregular,  357  ;  diagnosis 

.ind  treatment  of,  817. 
Gowers,  W.  K.,  notice  of  liook  by,  5981  633- 
Gradle,  H..  the  neurological   aspect  of  as- 
thenopia, 806 
Graefe.  Charles,  new  pump  and  cautery,  790. 
Graefe  medal,  award  of,  to  Dr.   Th.  Leber, 

Grafting,  membrane  of  hens  egg  '".  «6o. 
Grandin,  Fgbert  H.,  notice  of  book  by.  814  , 

where  principal  blame  should  rest,  719. 
Grate  setters'  neurosis,  55. 
Graves,  Dr.  Ezra,  death  of,  20. 
Gray,    Frank    D.,    j^erforative    apiiendicitis 

with  general  purulent  peritonitis,  375. 
Greek  as  an  international  medical  language, 

163.  178,  215,  287,  389.  467.  574.  H». 

(ireene^yii  ,  a  rubber  band  for  securing 

the  umbilical  cord,  790. 
Green,  T.  Henry,  notice  of  book  by,  598. 


938 


INDEX. 


[December  28,  1895 


Greene,  W.  T.,  the  question  of  an  interna- 
tional language,  642. 

Gresham,  Secretary,  the  case  of  the  late,  90. 

Grief,  medical  view  of,  899 

Griffith,  J.  B.  Crozer,  notice  of  book  by,  597. 

Grimm,  A.  S.,  periostitis  and  necrosis  of  the 
ribs  following  typhoid  fever,  381. 

Gross,  M.,  the  stomach-douche  and  its  uses, 

43°- 

Ground,  William  E. ,  the  causes  and  preven- 
tion of  puerperal  sepsis,  543. 

Growing  pains,  16. 

Guaiacol,  action  of,  927 ;  by  hypodermic 
injection,  422. 

Gunshot  wound  of  the  abdomen,  operation 
for,  67  ;  of  the  at)domen.  purulent  peri- 
tonitis following,  741  ;  of  the  heart  and 
lungs,  171. 

Gynecology,  electrotherapy  as  a  means  of 
diagnosis  in,  313. 


H 


Haematocrit  method  of  blood  examination, 
222. 

Haemogallol,  607. 

Haemoptysis,  treatment  of,  179. 

Hagan,  Dr.  Thomas  S  ,  death  of,  127. 

Hahnemann,  proposed  monument  to,  666. 

Haig,  Alexander,  notice  of  book  by,  597. 

Hall,  A.  Llewellyn,  treatment  of  corneal  ul- 
cer, 301. 

Hall,  Henry  D. ,  death  of,  20. 

Hall,  H.  C,  plastic  operation  on  the  penis 
and  scrotum,  409. 

Hall,  Rufus  B.,  some  of  the  conditions  re- 
quiring special  care  alter  abdominal  sec- 
tion, 440. 

Hammond,  Graeme  M.,  a  report  of  a  series 
of  cases  of  multiple  neuritis  in  infants 
in  Bridgeport,  656,  711. 

Hance,  Irwin  H.,  a  suily  of  the  infectious- 
ness of  the  dust  in  the  Adirondack  Cot- 
tage Sanitarium,  933,  925. 

Hansen,  G.  Armauer,  notice  of  book  by.  669. 

Hare,  Hobart  Amory,  notice  of  book  by, 
561,  669. 

Hartford  Medical  Society,  new  building  for 
the,  559. 

Hartmann,  Franz,  notice  of  book  by,  204. 

Hartwig,  Marcell,  essential  dropsy,  25. 

Harvard  Medical  College,  President  Eliot 
on,  704. 

Hay-fever,  palliative  treatment  of,  484. 

Hayem,  Georges,  notice  of  book  by,  669. 

Hayw9od.  C.  E. .  honey  in  erysipelas,  301. 

Hazen,  Allen,  notire  of  book  by.  204. 

Head,  injuries  to  the,  operative  treatment 
of,  386. 

Headache,  menstrual,  cimicifuga  for,  786; 
ocular,  502;  some  intranasal  causes  of. 
852;  syphilitic,  791;  walking  backward 
for,  518. 

Health,  a  menace  to  the  national,  270 ;  a 
menace  to  the  public.  55S. 

Hearing,  impairment  of,  from  liypertrophied 
tonsil,  324. 

Heart,  causes  of  hypertrophy  of  the,  86 1  ; 
diseases  of,  and  menstruation.  304;  dis- 
ease of  the,  complicating  pregnancy  and 
labor,  210,  62S  ;  disease  of.  treatment 
of,  392;  gunshot  wound  of  the,  171  ; 
hypertrophy  of  the,  170;  hypertrophy 
and  valvular  lesion  of  the,  165,  171  ; 
idiopathic  rupture  of  the,  i5o:  infec- 
tious endocarditis  of  the  tricuspid  v.alve, 
417;  irregularity  of  the,  in  childhood, 
232  ;  irregularity  of  the.  in  the  obese, 
268  ;  mercury  in  disease  of  the,  622  ; 
mitral  atenosis  confounded  with  uraemia, 
888 ;  post-diphtheritic  paralysis  of  the, 
750;  Schott  treatment  of  disease  of  the, 
677 ;  the  senile,  461  ;  senile,  dietetic 
management  of  the,  267 ;  senile,  some 
considerations  with  regard  to,  649  ;  sud- 
den death  from  syphilis  of.  S27  ;  suture 
of,  663;  syphiloma  of,  681;  tlie,  in 
the  phthisical,  521  ;  treatment  of  ner- 
vous disturbances  of,  after  influenza,  412. 

Heat-stroke,  155  ;  in  the  U.  S.  Navy,  889. 

Heineman,  Henry,  twin-birth,  275. 

Hemorrhage  aliimnol  in,  755  ;  antipyrin  in, 
232.  678;  postpartum,  429;  pulmo- 
nary, treatment  of,  179. 


Hemorrhoids,  application  for,  679  ;  modern 
operations  for,  8l6  ;  nature  of,  755  ; 
new  operation  for,  463  ;  surgical  treat- 
ment of,  458. 

Henderson.  A.  H.,  heredity  as  an  etiological 
factor  in  epilepsy,  894. 

Heredity,  the  study  of,  143. 

Hernia,  Australian  or  O'Hara  operation  for 
the  radical  cure  of.  366,  388;  amputa- 
tion of  omentum  in,  331  ;  antiquity  of 
the  use  of  trusses  in,  679 ;  disadvantages 
of  non-absorbable  sutures  in  operations 
for,  744 ;  imbrication  or  lap  joint 
method,  458  ;  modification  of  the  in- 
vagination method  for  the  radical  cure 
of,  196  ;  of  the  appendix,  3X8  ;  of  the 
sigmoid  flexure,  357  :  radical  cure  of,  by 
the  intra- pelvic  method,  458;  radical 
cure  of  inguinal,  by  implantation  of  a 
sponge,  occluding  the  internal  ring, 
816;  post-mortem  observation  of  a  case 
treated  by  the  Bassini  method,  887 ; 
silver  sutures  in  operations  for,  429; 
treatment  of  the  cord  in  operations  for, 
1504;   vesical,  564. 

Hero,  an  unknown  medical,  S82. 

Herpes  zoster,  formula  for,  677. 

Herrick.  James  B.,  notice  of  book  by,  814. 

Herschell,  George,  notice  of  book  by,  130. 

Hertwig.  Oscar,  notice  of  book  by,  345. 

Hiccough  in  the  new-bom  a  symptom  of 
syphilis,  213 ;  prolonged,  899 ;  snuff 
for,  590. 

Higgms,  F.  W.,  the  ethics   of  craniotomy, 

395- 

Himowich,  A.  A.,  the  coexistence  of  erup- 
tive fevers,  347. 

Hinman,  G.  K.,  an  anencephalous  monster, 

309- 
Hip,  two  successful  amputations  at  the,  887. 
Hip-disease,    387 ;    open-air    treatment    of, 

174;   reduction  of  moderate  deformity 

in,  13,  29 
Hippopyrrliine,  342. 
Histology,   a  new  mounting   medium,    317  ; 

method  of  preserving  the  epithelia  of  the 

gastro-intestinal  tract,  31S. 
Hitz,  Henry  B.,  chancre  of  the  tonsil,  446. 
Hoge,   M.   D.,  angioma  cavernosura  of  the 

spleen,  418. 
Holbrook,  M.  L.,  notice  of  book  by,  814. 
Holtzclaw.  C. ,  chloroform  dropper,  68. 
Homoeopathy,  812. 
Hood,  C.  T. ,  notice  of  hook  by,  706. 
Hopkins,  F.  E.,  acute  cedema  of  the  larynx, 

552- 

Hoppe-Seyler,  Professor,  death  of,  3S0, 
4S7. 

Horse-serum  injections,  eflects  of,  721,  7S3. 

Hospital,  corps  and  the  .State  miUtia,  486; 
for  the  colored  race  in  New  York.  127  ; 
medical  management  of.  787  ;  on 
wheels,  468 ;  staff  and  board  of  man- 
agers, quxrrel  between,  622  ;  Sunday  in 
England    70 

Hospitals,  fake,  in  Chicago,  899  ;  grievances 
of  nurses  in  534 1  limitation  of  service 
in.  S63  ;  New  York  City,  reorganiza- 
tion of  the.  593,  595,  601,  629,  631,  644, 
656.  6S2,  719,  738.  S53,  863,  896,  931. 

Hot  Springs,  drumming  for  doctors  at,  198. 

Hotels,  infection  in.  926. 

Howard.  J    T.,  how  to  get  practice,  32. 

Howitt,  H.,  an  operative  procedure  for  spina 
bifida,  263. 

Hrdlicka,  A.,  a  case  of  extensive  traumatic 
brain  lesion  with  very  meagre  objective 
symptoms.  512. 

Hubbard.  S  Dana,  cases  simulating  typhus 
fever,  21. 

Hughes,  M.  E  ,  acute  laryngitis,  123. 

Hughes,  William  Kent,  notice  of  book  by, 
203. 

Hughlett,  W.  L.,  diagnosis  and  treatment 
of  fractures,  889. 

Humerus,  congenital  displacement  of  the, 
672. 

Humnhrey,  W.  D.,  primary  post-partum 
h-morrhage,  puerperal  septicajmia,  and 
death.  204. 

Hupp,  Frank  Lemoyne,  tracheal-tube  guide, 
13S. 

Hutchinson.  Woods,  some  of  the  disadvan- 
tages of  specialism,  518. 


Huxley,  the  late  Professor  Thomas  Henry, 
55,  139;  memorial  to,  249,  895. 

Hyams  case,  the,  91. 

Hydatids  of  the  placenta.  387. 

Hydramnios  and  spina  bifida,  24. 

Hydroaaestivale,  526. 

Hydrocele,  family  history  of,  383. 

Hydronephrosis,  888. 

Hydrophobia  and  hystero  hydrophobia,  908 ; 
from  a  cat-bite,  523. 

Hygiene  of  the  future.  139;  report  of  the 
Committee  on,  of  the  Medical  Society  of 
the  County  of  New  York,  850. 

Hyperchlorhydria,  602,  724. 

Hyperemesis,  formula  for  relief  of,  311. 

Hyperthermia,  apparent,  286. 

Hypnotism  in  hysterical  eye  troubles,  256; 
the  passing  of,  775. 

Hypochondriasis,  a  study  of,  605,  733. 

Hypodermic  medication,  895. 

Hysterectomy,  abdominal,  a  new  method  of, 
520;  for  puerperal  sepsis,  454;  follow- 
ing coeliotomy  for  pus  tubes,  456  ;  intra- 
or  extra  peritoneal  treatment  of  the  ped- 
icle, 260. 

Hysteria,  a  study  of,  605  ;  and  hypochondri- 
asis, a  study  of,  733  ;  diagnosis  of,  46  i ; 
toxicity  in,  460 ;  painful  digestion  in, 
923  ;  the  breast  in,  924. 

Hysterical  amblyopia  and  amaurosis,  hyp- 
notism in,  256. 


Ice  cream  poisoning,  12S. 

Ichthyosis  congenita,  case  of,  10 ;  relation  of 
the  epitrichial  layer  of  the  epidermis  to, 
529. 

Idaho  Medical  Society,  703. 

Ilium,  comminuted  fracture  of  the,  464. 

Illinois  Medical  Journal,  523. 

Immunity  from  snake- poisoning,  31 ;  some 
recent  views  of,  498. 

India,  sanitation  in,  573. 

Indigestion,  analgesic  action  of  sodium  bi- 
carbonate in,  920;  and  sluggish  liver, 
formula  for,  357. 

Inebriates,  probationary  curative  detention 
of,  680 ;  the  rights  of,  502  ;  treatment  of 
habiual,  in  Austria,  683. 

Inebriety,  curability  of,  927;  in  America,  703. 

Infancy,  paralysis  of,  562. 

Infanticide,  medico-legal  points  in  regard  to, 
700. 

Infants,  artificial  feeding  of,  260  ;  treatment 
of  acute  bronchitis  in,  900. 

Infection,  alkalinity  of  the  blood  and,  662  ; 
in  the  school,  prevention  of,  523. 

Infectious  diseases,  disinfection  of  rooms 
after,  521;  microscopical  diagnosis  of, 
by  the  health  authorities  of  Paris,  S47  ; 
nervous  sequelae  of,  629. 

Infectious  hospitals,  return  cases  from,  824. 

Influenza,  circulatory  lesions  in,  502;  for- 
mula for,  861  ;  genito-urinary  complica- 
tions in.  920  ;  sequelae  of,  462  ;  the  cost 
of,  176;  treatment  of  nervous  heart 
troubles  following,  412. 

Innominate  artery,  successful  ligature  of  the, 
236. 

Insane  and  sane,  weight  of  the  brain  in,  378  ; 
Association  of  Assistant  Physicians  of 
Hospitals  for  the,  812  ;  commitment  of 
the,  414,  535  ;  criminals,  shall  they  be 
imprisoned  or  put  to  death  ?  37  ;  in 
Scotl.inl,  653  ;  requirements  for  phy- 
sicians in  asylums  for  the,  643  ;  ruling 
concerning  the  correspondence  of  the, 
S53  ;  trouble  of  the  German  asylums  for 
"le,  234.  537.  580. 

Insanity,  acute,  analysis  of  156  cases  of.  S29; 
and  phthisis,  64;  artificial  fever  for.  97; 
drink  as  a  factor  in  the  production  of, 
681  ;  in  the  medical  profession,  500; 
physiological  epochs  that  predispose  to, 
549;  the  pulse  in.  5S,  179;  traumatic, 
successful  operations  for,  456, 

Insomnia,  remedies  for,  24S.  331  ;  of  fevers, 
formula  for,  677  :  tob.icco.  751. 

Insurance  examiners,  new  scale  of  fees  for, 
701,  825,  883  ;  medical,  504. 

Intestine,  acute  infectious  disease,  with  le- 
sions of,  170;  anastomo-is  of  the.  354  ; 
anastomo^is   of  the,  with    the    Murphy 


December  28,  1895] 


INDEX. 


939 


button,  77S,  S59  ;  constricted  by  the 
vermiform  appendix,  555  ;  diagnosis  of 
rapture  of  the,  232,  310  :  intussuscep- 
tion through  Meckel's  diverticulum, S23; 
invagination  of,  928  ;  Maunsell's  method 
of  anastomosis  of  the,  605  ;  obstruction 
of,  in  children,  484 ;  perforation  of  the, 
888  ;  resection  of  the,  324,  779  ;  treat- 
ment of  stab  wounds  of  the,  777. 

Intubation,  introductor  and  extractor  for, 
141 ;  report  of  cases  of,  294. 

Iodine,  use  of,  in  dermatology,  785. 

lodism,  prevention  of,  844. 

Iowa  State  Association  of  Railway  Surgeons, 

739- 
Iritis,  tuberculous,  820. 
Iron,  assimilation  of,  by  the  organism,  607 ; 

in  food,  756. 
Irrigator,  double-current  rectal,  862. 
Isham,  Dr.  Nelson,  death  of^  451. 
Isolation  or  thermoplegia,  155. 
Italy,  medical   students   in,  395  ;  misery  in, 

451- 


Jackson,  Edward,  notice  of  book  by,  345. 

Jackson,  Ilughlings,  presentation  to,  596. 

Jackson,  James  Caleb,  death  of,  127. 

Jaisohn,  Philip,  alkaline  injections  for  the 
treatment  of  gonorrhoea,  338. 

Janeway,  Edward  G.,  the  progress  of  medi- 
cine, 793,  819. 

Jarvis,  Dr.  William  Chapman,  death  of,  163. 

Jarvis,  William  C,  obituary  of,  308. 

Jaw,  the  human,  force  of  the,  91. 

Jenner  Centenary  in  Russia,  271,  756. 

Johnson.  Samuel  J.,  sterilized  milk  and 
free  lunch,  321. 

Joints,  dry  heat  in  the  treatment  of  diseases 
of,  456  ;  operative  interference  in  tuber- 
cular disease  of  the,  669  ;  restoration 
of  function  after  fracture,  297. 

Jones,  John  A.,  death  of,  S48, 

Jones,  Louis  H.,  the  cause  of  flatulence, 
322. 

Jones.  Mary  A.  Dixon,  intra-  or  extra-perito- 
neal treatment  of  the  pedicle  in  hyster- 
ectomy, 260. 

Journeys,  the  dangers  of  long,  719. 

Judson,  A.  B.,  reduction  of  moderate  de- 
grees of  deformity  in  hip  disease,  13, 
29. 


Kahn,  Solomon  G.,  intiammation  of  the  ute- 
rine appendage^,  4S2. 
Kaposi.  Moriz,  notice  of  book  by,  94. 
Karj'okinesis,  889. 
Katatonia,  a  weU-marked  case  of  so-called, 

25- 
Kearney,  Thomas  J.,  ethics  of  craniotomy, 

3'9- 
Keith,  George  S.,  notice  of  book  by,  813. 
Keith,  Thomas,  death  of,  632.  682. 
Kelly,  Howard  A.,  notice  of  pamphlet  by, 

634- 
Keloid,  treatment  of,  678. 
Kelsey,  Charles  B.,  the  limits  of  diseases  of 

the  rectum  as  a  specialty,  658. 
Kemp,   Robert    Coleman,  a   double-current 

rectal  irrigator,  825,  S62. 
Kent,  James  L.,  along  survival  of  injury  to 

the  spinal  cord  in  the   cervical  region, 

490- 

Kershner,  Medical  Inspector,  the  case  of, 
630. 

Kidney,  congenital  absence  of  the  right,  169  ; 
cystic  tumor  of,  m  a  bullock,  888  ; 
elusive  disease  of  the.  S09 ;  floating. 
35'  ;  growth  in  the  pelvis  of  the,  31 ; 
hygiene  of  the.  520  ;  movable,  and  dis- 
tended gall-bladder,  confusion  between, 
160  ;  nephrotomy  for  stone  in  the,  285. 

King,  A.  F.  A.,  notice  of  book  by,  598. 

King,  John  C,  cerebral  tuberculosis  in 
adults,   253. 

King's  College,  London,  sectarianism  of, 
717. 

Kitasato,  Ur.  S.,  502  ;  a  visit  to  the  labor- 
atory of.  897. 

Knapp,  .Nfark  I.,  a  new  and  improved  steth- 
oscope, 682. 


Knee-joint,  congenital  dislocation  of  the, 
8S6 ;  loose  body  in  the,  381  ;  tubercu- 
losis of  the,  841. 

Kneipp,  Pastor,  the  medical  practice  of, 
720. 

Knives,  disinfection  of,  429,  580. 

Knox,  R.  \V.,  a  phimosis  case,  175. 

Klingensnuth,  I.  P.,  curative  value  of  diph- 
theria antitoxin,  194. 

Kocher,  Theodore,  notice  of  book  by,  237. 

Koehler,  George  F.,  a  large  dose  of  digita- 
lis, 24. 

Korea,  cholera  in,  495. 

Kraurosis  vulvae,  treatment  of,  357. 

Krieger,  G.  E. ,  notice  of  book  by,  202. 

Kruschewsky,  Paul,  notice  of  book  by,  598. 


L,abial  retractor,  70. 

Labor,  appendicitis  during,  609;  manage- 
ment of  heart  disease  during,  628  ;  sub- 
cutaneous emphysema  from  straining 
during,  647  ;  tedious,  tartar  emetic  in, 
491. 

Lactation,  atrophy  of  the  uterus,  854  ;  men- 
struation and  ovulation  in,  392. 

L.andau,  Richard,  notice  of  book  by,  237. 

Landes,  Leonard,  limitation  of  service  in  the 
city  hospitals,  863. 

Language,  the  question  of  an  international, 
163,  178,  215,  287,  389,  467,  574,  642, 

7«9,  775-  .     ,  .        , 

Lanphear,  Emory,  abdominal  section  for 
extra-uterine  pregnancy,  370. 

Laparotomy  for  extra  -  utenne  pregnancy, 
370 ;  for  pus-tubes,  hysterectomy  fol- 
lowing, 456  ;  in  general  suppurative 
peritonitis,  455  ;  prevention  of  thirst 
after,  455. 

Larrey,  Baron,  death  of,  632,  642. 

Laryngeal  cellulitis,  tracheotomy  for,  637. 

Laryngitis,  acute,  123  ;  from  a  rhinological 
stand-point,  464. 

Larynx,  acute  cedema  of  the,  552,  714  ;  car- 
cinoma of  the,  operative  treatment  of, 
672  ;  iodide  of  potassium  in  the  diagno- 
■  sis  of  diseases  of  the,  i  ;  lipomata  of 
the,  96  ;  surgical  treatment  of  tubercu- 
losis of  the,  815  ;  syphilis  of  the,  820; 
tuberculosis  of  the,  100. 

Latin  as  she  is  spoke  and  wrote,  215. 

Lavage,  technique  of,  786. 

Law,  James,  the  extinction  of  tuberculosis 
in  herds,  730,  743. 

Law,  medical,  of  New  York  State,  17,  34, 

'07- 

Lawrence.  F.  F.,  double  ovanotomy  in  a 
woman  seventy-one  years  of  age,  205. 

Laws  of  interest  to  physicians,  157. 

Layman,  Ur.  William  S.,  death  of.  3S0. 

Lederman,  M.  D.,  sarcoma  of  the  nasal  cav- 
ity :  ligation  of  both  external  carotids  ; 
decide<i  beneficial  effect.  771. 

Leflingivell.  AUiert,  the  American  Humane 
Ass<icialion,  34. 

Leguminous  alimentation  in  disorders  of  di- 
gestion and  nutrition,  844. 

Lehlbach,  Charles  F.  G  ,  death  of,  270 ; 
resolutions  on  the  death  of,  635. 

Lejars,  Felix,  notice  of  book  edited  by,  237. 

Lenhart,  C.  M  ,  tubercular  peritonitis,  590. 

Lennox,  Richmond,  death  of,  776. 

Leonard,  C.  Henti.  notice  of  book  by,  633. 

Leprosy  in  Iceland,  128;  in  New  York, 
487  ;  in  Norway,  504,  930 ;  study  of 
the  treatment  of,  56, 

Lersch,  B.  M.,  notice  of  book  by.  850. 

Lesser,  A.  Mona;,  the  treatment  of  fevers 
without  food,  antipyretics,   or  alcohol, 

54'  , 

Letters  from  London,  31,  70,  139,  176,  249. 

319.  358.  393.  430.  466,  494.  534.  572. 

608,   6!?o,   717.    753.    7S7.    823.    894; 

from  Paris,  32.  140.  573,  641,  788,  895. 
Leucocytosis  in  diphtheria,  392. 
Leucorrhrra,  diagnostic  significance  of,  860. 
Leuk.xmia  splenic  myelogenous,   not    cured 

by  bone  marrow,  858. 
Levison,  F.,  notice  of  book  by,  597. 
Lewinthal,  David  C,  a  new  introductor  and 

extractor  for  intubating  the  larynx,  141. 
Lewis,  Brausford,  an  improved  syringe   for 

infiltration  anjesthesia,  827. 


L«wis,  Denslow,  what  should  be  the  policy 

of  the  State  toward  prostitution  ?  651. 

Liebreich,  Oscar,  notice  of  work  edited  by, 

345 
Life,  origin  of^  717. 
Ligature-carrier  for  the  pedicle  of  abdominal 

tumors,  68. 
Ligatures,    absorption    of,    331 ;  animal,   in 

1847,  537  ;  torsion  instead  of,  285. 
Lightning,  deaths  from,  720. 
Limbs,  legal  value  of  destroyed.  756. 
Lindsay,  J.  T.  M..  potassium  permanganate 

in  opium  poisoning,  858. 
Linsley,  J.  H.,  some  suggestions  concerning 

the  examination  of  the  blood,  685. 
Lip,  chancre  of  the,  131. 
Liquor-selling,    Sunday,     from     a    doctor's 

stand-point,  485. 
Lister.  Sir  Joseph,  presentation  to,  250. 
Lithotomy,  supra-pubic,  716. 
Litten,  Moritz,  the  diaphragm  phenomenon 

and  its  imponauice  in  clinical  medicine, 

901. 
Liver,  abscess  of  the,  165,  317  ;  case  of  acute 

atrophy  of  the,  274  :  displacements  of 

the,    664  ;  fibro-adenoma  of  the,  855 ; 

lacer's,  569  ;  rupture  of  the,  712,  856. 
Localization,  cerebral,  59. 
Lockwood,  Charles  E.,  a  study  of  hysteria 

and  hypochondrosis,  733. 
Locomotor  ataxy,  etiology  of,  520. 
Loennrot,   Dr.    Elias,   the   medical   poet  of 

Finland,  416. 
Ijoevry,  A.,  notice  of  book  by,  130. 
London,  letters  from,  31,  70.  139,  176,  249, 

3 '9.  358.  393.  430.  466,  494.  534.  572. 

608,  6S0,  717,  753.  787-  823.  894- 
Long,  J.  W.,  improved  uterine  dilalor,  213. 
Longevity,  quietude  conducive  to,  84 1. 
Longman,  Sir  Thomas,  death  of,  6S0. 
Loomis,  Dr.  Alfred  L.,  notice  of  book  by, 

705. 
Lojjez,  Enriques,  notice  of  book  by,  346. 
Loretin,  422, 

Los  Angeles  Polyclinic,  a  new  medical  jour- 
nal, 703. 
Lourdes.  the  miiacles  at,  343,  450,  845. 
Lower.  W.  E.,  spontaneous  ruptuie  of  the 

bowel,  493. 
Ludwig's  angina,  99. 
Lumbago,  application  for,  786 ;  nature  and 

treatment  of,  594. 
l.umbricoids,  anthelmintic  for,  786. 
Lunacy,   New  York   State  Commission  on, 
126,   596  ;    refjort  of  the  British  Com- 
missioners in.    467  ;    the  Commissioner 

of.  as  an  expert,  738,  862. 
Lung,  cancer  of  the,  167  ;  consolidation  of, 

from  obliteration  of  the  left  bronchus  by 

a  small  aneuri.sni,  135;  gunshot  wound 

of  the,  171  ;  lut>erculo.'is  of.  see  Tiiber- 

culosts,  pulmonary  ;  vicarious  menstrua- 
tion through  the,  179. 
Lupus    erythematosus    dis-seminalus,     526 ; 

treatment  of,  755  ;  verrucosus,  676. 
Lusk,  Zera  J.,  a  new  and  original  method  of 

obtaining  material  for  skin-grafting,  80a 
Lyniphadenonia.  426. 
Lymphosarcoma,  general,  135. 
Lyon,  S.  B.,  notice  olcase  recorded  by,  346. 

M 

McCourt,  P.  J.,  medical  terminology,  115, 
136. 

McClain,  W.  A.,  psychology  of  neurasthe- 
nia, 78 ;  routine  medication  in  asylum 
practice    516 

McCuUough,  John  W.  S.,  an  anencephalous 
monster,  310. 

McCully.  S.  E.,  prostatitis,  288. 

McDonald,  A.  C,  morphine  poisoning,  466. 

McGilliiuddy,  T.  J.,  diet  and  systematic 
muscular  exercise  in  the  treatment  of 
tutierculosis,  654,  676. 

McKennan,  Dr.  Thomas,  death  of,  27a 

McKenzie    R.  Tail,  notice  of  book  by,  238. 

McLane  Hospital,  576. 

McMahon,  A.  Ernest,  vaginal  hysterectomy 
for  carcinoma  ol  the  neck  of  the  ulenis, 
205. 

Mc.N'eil,  Roger,  notice  of  Iwok  by,  597. 

Macartney.  W.  N.,  a  lubstitute  for  the  tra- 
chea tube,  St4- 


940 


INDEX. 


[December  28,  1895 


MacDonaH,  Carlos  F.,  expert  testimony  in 

lunac)'  cases,  862. 
MacFarlane,   Andrew,  notice   of  book   by, 

634- 

Mackie,  Dr.  Benjamin  S.,  death  of,  164. 

Mackenzie,  Sir  William,  death  of,  754 

MacLure,  Dr.  Wm. ,  the  character  of,  740. 

Madison,  Erby  H.,  cancer  of  the  prostate 
gland,  715. 

Maisch,  John  M. ,  notice  of  book  by,  635. 

Malaria,  date  of  the  discovery  of  the  parasite 
of,  645;  anarcotine  in,  419;  in  Paris, 
32  ;  parasite  of,  400,621,  756  :  pathol- 
ogy of,  676;  the  mosquito  as  the  inter- 
mediate host  of  the  parasite  of,  423. 

Mahgnant  tumors,  discussion  on,  602. 

Malingerers,  literature  for,  502. 

Malingering  and  miracles,  575. 

Maloney,  Frank  W.,  maternal  impression, 
465,  66S. 

Malpractice,  medico-legal  points  in  regard 
to,  6S4. 

Mammary  gland,  treatment  of  tumors  of,  606. 

Manley,  Thomas  H.,  the  Australian  or 
O'Hara  operation  for  the  radical  cure  of 
hernia,  366,  388. 

Marasmus,  358,  678. 

Marriage,  early,  811. 

Marrow,  bone-,  failure  of,  in  a  case  of  splenic 
myelogenous  leukaemia,  858. 

Martindate,  J.  H.,  diagnostic  transillumina- 
tion of  the  septum  nasi,  69. 

Martindale,  William,  notice  of  book  by,  201. 

Massy,  Surgeon-Genefal,  death  of,  6S0. 

Mastoid  disease,  comparatively  painless,  73 ; 
treatment  of  acute,  462. 

Mastoid  retractor,  105. 

Masturbation  in  the  adult,  442. 

Materialism,  Dr.   Beale's  argument  against, 

in- 

Maternal  impression,  465,  61 1,  668,  718. 

Matheny,  R.C.,  pecuUarcase  of  trismus,  742. 

Mather,  Frederic  G.,  new  laws  of  interest  to 
physicians,  157. 

Maudsly,  Henry,  notice  of  book  by,  201. 

Mayo,  C.  H..  removal  of  an  intubation-tube 
from  the  bronchus  by  tracheotomy,  641, 

Measles  and  chicken-po.x,  123. 

Medical  and  Chirurgical  Faculty  of  the  State 
of  Maryland,  815. 

Medical  bibliography,  666. 

Medical  centre,  the  world's,  198. 

Medical  degrees  in  Russia,  737. 

Medical  fees  in  Russia,  745. 

Medical  journahsm,  bogus,  702. 

Medical  law  of  New  York  State,  17,  34,  107. 

Medical  libraries  and  medical  colleges,  667. 

Medical  men.  insult  to,  by  the  London  School 
Board,  358  ;  mortality  of,  775  ;  pen- 
sions for,  522. 

Medical  mission  work  in  China,  776. 

Medical  practice  in  Missouri,  55S. 

Medical  profession,  rise  of  the,  275. 

Medical  progress,  proofs  of,  508 ;  in  the 
nineteenth  century,  dominant  influence 
in.  145. 

Medical  Record,  enlargement  of  the,  17  ; 
the  past  and  future  of  the,  914. 

Medical  reform  and  medical  tariff  in  Ger- 
many, 740. 

Medical  service  army.  Si i :  army,  in  France, 
S64, 

Medical  societies,  duties  of,  468  ;  plethora 
of,  19. 

Medical  Society  of  New  Jersey,  103. 

Medical  Society  of  the  County  of  New  York, 
489.  644,  850 

Medical  Temperance  Association,  Continen- 
tal, 668. 

Medical  treatment,  free,  with  tea,  645. 

Medicine,  address  in,  before  British  Medical 
Association,  243;   progress  of,  793,  819. 

Medulla,  sarcoma  of  the,  385. 

Meisenbach,  A.  H.,  traumatic  separation 
(compound)  of  the  lower  epiphysis  of  the 
femur,  475. 

Melancholia  cured  by  intra-nasal  operation, 
97  ;  simple,  477. 

Melchior,  Max,  notice  of  book  by,  202. 

Membranes,  birth  of  child  without  rupture 
of  the,  432. 

Meninges,  spinal,  puncture  of  the,  592. 

Meningitis,  pseudo-,  468 ;  tubercular,  re- 
covery from,  31. 


Menorrhagia,  formula  for.  786. 

Menstruation  and  heart  disease,  304  ;  cold 
bathing  during,  429 ;  headache  of,  cimi- 
cifuga  in,  786  ;  importance  of,  in  deter- 
mining mental  irresponsibility,  88;  nature 
of.  7S5  ;  vicarious,  through  lungs.  179. 

Mental  affections,  therapeutic  value  of  water 
in  certain,  404. 

Meralgia  paraesthetica,  701. 

Mescal  button,  physiological  action  of,  558. 

Mesentery,  chyle  cysts  of  the,  501  ;  lesions 
of  the,  31. 

Metric  system  in  England,  272. 

Metritis,  cough  in,  428. 

Metrorrhagia,  formula  for,  786. 

Mettler,  Hanison.  Are  work  and  worry 
causes  of  nervous  affections  ?  332. 

Meyer.  Wilhelm,  memorial  to,  250. 

Michael,  Dr.  J.  Edwin,  death  of,  8S4. 

Microbes  in  the  air,  426  ;  on  coins,  897. 

Midwifery,  antiseptic,  489. 

Midwives.  dividing  fees  with,  538  ;  registra- 
tion of,  in  England.  241,  245,  449. 

Milk,  artificial,  560;  chemical  and  patho- 
logical characteristics  of,  448;  evapo- 
rated, 785  ;  Health  Board  regulations 
concerning  infected,  848 ;  transmission 
of  tuberculosis  through,  743. 

Miller,  D.  J.  Milton,  primary  carcinoma  of 
the  head  of  the  pancreas,  with  hour- 
glass contraction  of  the  stomach,  simu- 
lating during  life  pyloric  stenosis,  301. 

Miller,  D.  M..  death  o'f.  848. 

Miller,  H.  T.,  failure  of  thyroid  extract  in 
myxcedema,  24. 

Miller,  W.  H.  F.,  some  aspects  of  the  new 
woman  from  a  medical  stand-point,  177. 

Milliken,  Samuel,  tendon  grafting,  581,  599. 

Mimesis,  auto-,  65. 

Mind,  the  mystery  of.  718. 

Mineral  waters,  therapeutic  uses  of,  421, 

Miraculous  cures,  450,  575,  774,  845. 

Mississippi  \'alley  Medical  Association,  453. 

Missouri,  regulation  of  medical  practice  in. 
558. 

Mitchell,  S. ,  the  electro-magnet  for  the 
removal  of  iron  particles  from   the  eye, 

383. 

Monell,  S.  H..  a  practical  method  of  measur- 
ing and  regi'^tering  the  true  therapeutic 
dose  of  induction-coil  currents,  874. 

Money  and  unclean  hands.  702. 

Monsters,  anencephalous.  309,  492,  893. 

Monuments  to  foreigners  in  .\merica.  666. 

Moor,  William,  potassium  permanganate  in 
morphine  poisoning.  6ii. 

Moos,  Dr.  Salomon,  death  of,  270. 

Morris,  Rob't  T. ,  length  and  position  of  the 
appendix,  862  ;  notice  of  book  by,  633. 

Morphine  and  cocaine,  antagonism  between, 
104,  433  ;  poisoning  by,  466  ;  poisoning 
by,  forced  respiration  in,  768 :  poison- 
ing by.  potassium  permanganate  in,  61 1. 

Morphinism  in  China,  379  ;  in  the  aged,  607  ; 
in  women,  673  ;  some  remarks  on,  692, 
707  ;  treatment  of,  676, 

Mortality,[infantile,  in  Paris,  573  ;  of  medi- 
cal men,  775. 

Morton,  Walter  A.,  death  of,  164. 

Moscow,  International  Medical  Congress  in. 

738.  776. 

Moser,  W.,  Leonard's  method  of  detecting 
cell-motion,  231. 

Moser,  W. ,  peanut  in  the  left  bronchus,  68 ; 
the  alleged  parasite  of  malaria,  621. 

Mosher,  J.  M.,  analysis  of  156  admissions  to 
the  St.  Lawrence  State  Hospital,  with 
especial  reference  to  acute  insanity,  S29. 

Mosquito  as  the  intermediate  host  of  the  mal- 
arial parasite,  423. 

Moss,  Thomas  J.,  the  abuse  of  public  char- 
ities, as  seen  from  a  humanitarian  stand- 
point, 536. 

Mother,  a  young,  715. 

Mouth,  epithelioma  of  the  roof  of  the,  744. 

Munde,  Paul  F.,  appendicitis  during  preg- 
nancy and  labor,  609. 

Murphy  button  in  intestinal  anastomosis, 
77S,  S59  ;  dangers  of,  920. 

Murray,  Dwight  H.,  intestine  constricted  by 
vermiform  appendix,  operation,  recov- 
ery- 555- 

Murray,  H.  Montague,  notice  of  book  re- 
vised by.  598. 


Mursick,  Dr.  George  A.,  death  of,  631. 
Muscular  contractions,  spasmodic,  caused  by 
reflex  irritation   from  cicatricial  tissue, 

893. 
Music  as  a  therapeutic  measure.  573. 
Mycetoma  of  the  foot,  530. 
Myelitis  and  ruptiu-e  of  the  bladder,  173.    '''j 
Myers,  R.  P.,  loose  body  in  the  knee-joint. 

381. 
Myositisossificans  in  a  child  five  vearsof  age, 

J'95- 
Myringotome,  a  new,  215, 
Myxcedema,  thyroid  treatment  of,   24,    180, 

277. 


Nammack,  Charles  E.,  a  case  of  splenic 
myelogenous  leukaemia  not  cured  \  by 
bone-marrow.  858;  a  case  of  traumatic 
neurasthenia,  745,  821 ;  umbilical  hemor- 
rhage in  newly  born  infants,  191,  207. 

Nasal  speculum,  self-retaining,  137. 

Naso-pharynx,  adenoid  growths  in  the,  296 ; 
removal  of  a  growth  of  the.  823. 

National  Guard,  medical  department  of  the, 

703- 

Navy,  report  of  the  Surgeon  General  of  the, 
665. 

Neck,  organs  of  the,  533. 

Needle,  a  new,  69. 

Nelson,  Dr.  Judson  C  ,  death  of,  92. 

Neoplasms,  multiple,  of  the  lung,  mediastinal, 
and  mesenteric  glands,  liver,  and  stom- 
ach, 168. 

Nephrectomy,  3S8 ;  for  pyonephrosis,  671. 

Nephritis,  elusive,  809  ;  fever  in,  927  :  sup- 
purative, 679  ;  treatment  of,  785. 

Nephropexy  by  tendon,  235. 

Nephrotomy  for  stone,  285. 

Nerves,  lesions,  post-mortem  of  the,  424 ;  re- 
section of  the  buccal,  for  neuralgia,  285. 

Nerve-tissue,  some  of  the  more  recent  meth- 
ods of  staining.  460. 

Nervous  diseases,  are  work  and  worry  causes 
of,  332 ;  reflex  causes  of,  677,  861  ; 
therapeutic  value  of  water  in,  404. 

Nervous  sequelae  of  infectious  disease,  629, 

Nervous  system  as  a  factor  in  disease,  461. 

Neuralgia  of  dental  origin,  392  ;  parsesthetic, 
of  the  thigh,l70i  ;  resection  of  the  buccal 
nerve  for,  285. 

Neurasthenia,  blood-changes  in,  321  ;  for- 
mula for,  S60;  psychology  of,  78;  toxic- 
ity in,  460;  traumatic,  745,  S21. 

Neurectomy,  intra-cranial,  for  chronic  tic 
douloureux,  706. 

Neuritis,  arsenical  multiple,  2S4  ;  multiple, 
in  infants,  656,  711  ;  of  the  brachial 
plexus  following  pneumonia,  "09 ;  pe- 
ripheral, 424. 

Nevins,  Tohn  L.,  notice  of  book  by,  201. 

New-born,  hiccough  in  the,  a  symptom  of 
syphilis,  213  ;  suspended  animation  in 
the,  211,  763;  umbilical  hemorrhage  in 
the,  191,  207. 

New  Jersey,  medical  examination  in.  55  ; 
metlical  examiners  of,  162  ;  Medical  So- 
ciety of.  105. 

Newton,  Richard  C.  chloroform  with  oxy. 
gen,  640 ;  tuberculosis  of  the  knee- 
joint.  841. 

New  York  .\cademy  of  Medicine,  136.  566, 
669.  783,  819  ;  Section  on  General 
Medicine,  205,  607  ;  Section  on  General 
Surgery,  284,  671.  744,  SS5  ;  Section  on 
Obstetrics  and  Gynecology,  207,  S54 ; 
Section  on  Orthopedic  Surgery,  427  ; 
Section  on  Public  Health,  742. 

New  York  County  Medical  Association,  388, 
675,  S17. 

New  York  Neurological  Society,  709,  745. 

New  York  Pathological  Society,  165,  316, 
569.  711,  855,  8S8. 

New  York  School  of  Clinical  Medicine,  847. 

New  York  State  Medical  .Association,  599. 

New  York  State,  medical  law  of,  17,  34,  107  ; 
mortality  in.  343  ;  the  hospitals  of,  307. 

New  York,  the  health  of,  7S4. 

News,  criminal,  in  medical  journals,  882. 

Nichols,  J.  B.,  a  method  of  expressing  the 
degree  of  acidity  or  alkalinity  of  organic 
and  other  fluids,  4S3.    . 


December  28,  1895] 


INDEX. 


Nichok.  William  R..  axis  adjustment,  anew 
and  rational  method  of  delivering  the 
placenta,  225. 

Nicolaysen,  Johan,  notice  of  book  by,  346. 

Night-sweats,  formula  for,  861. 

Nipples,  painful  fissuresof,  treatment  of,  429. 

Nitrous  oxide,  death  from,  648. 

Noises,  unnecessar)-,  53. 

Nose,  a  new  septun\  knife,  644  ;  anew  saw  for 
use  in  the,  645  ;  application  in  catarrh 
of  the,  677 ;  cork  splints  for  deflected 
septum,  376  ;  deafness  from  disease  of 
the,  337  ;  diagnostic  transillamination 
of  the  septum,  69  ;  disease  of  the,  some 
of  the  more  important  therapeutic  prin- 
ciples in,  98  ;  eczema  of  the,  treatment 
of,  860 ;  electrolysis  for  reduction  of 
spurs  of  the  septum,  96  ;  Fowler's  solu- 
tion as  a  tonic  for  the  mucosa  of  the, 
786  ;  relation  of  adenoids  to  catarrh  of 
the,  675  ;  sarcoma  of,  favorable  results 
of  ligation  of  both  external  carotids, 
771  ;  some  intra-nasal  causes  of  head- 
ache, 852 ;  treatment  of  deflected  sep- 
tum, 463  ;  tuberculosis  of  the,  lOO. 
Nuclein    is   nature's    antitoxin,    437,    6u  ; 

therapeutic  uses  of,  463. 
Nurses,  complaints  of,  in  London  hospitals, 

572. 
Nutrition,    leguminous  alimentation  in    dis- 
orders of,  844. 

O 


Obesity  and  cardiac  irregularity,  268. 
Obstetric  practice,  asafceiida  in,  810 ;  impor- 
tance of  asepsis  in,  489. 
Obstetrical  paralysis,  65. 
Occultism,  easy  exposure  of.  S9S. 
Occupations,  choice  of,  539. 
CEsophagus,  epithelioma  of  the,    166,    168; 
foreign  bodies  in  the,  601 ;  varices  of 
the,  565. 
Ogdensburg  Medical  Society,  action  of,  con- 
cerning departing  members,  897. 
O'Hara   operation  for    the    radical    cure  of 

hernia,  366,  388. 
Ohio,  doctors'  campaign  in,  668. 
Old  age,  double  ovariotomy  in,  205  ;  fetid  en- 
dometritis in,  88  ;  morphinism  in,  607. 
Old  folks.  siUy,  395. 
Omentum,  the  gastro-hepatic.  181. 
Onuf,  B.,  double  formation  of  the  face  with 
cranio-rachischisis  involving  the  whole 
vertebral  column,  401. 
Operation,  risks  of  performing  an,  without 

the  patient's  consent,  412. 
Opium,  addiction  to,  692,  707  ;  and  chloral, 
poisoning  by,  23  ;  poisoning  by,  potas- 
Mum   perm.^nganate  in,  858 ;   use  of,  in 
old  age,  607. 
Ophthalmia,    gonorrhceal.    management    of 
advancing   corneal  ulceration    in,   815  ; 
purulent,  formula  for,  755. 
Ophthalmometer,  head  rest  for  the,  862. 
Ophthalmometrv.  387. 
Opticians,  refracting,  26. 
Orbital  and  exiraocuUr    tumors,  some  un- 
usual cases  of.  650. 
Ord,  W.  M.,  notice  of  book  edited  by,  705 
Order,  a  new  independent,  522. 
Oregon,  failure  of  the  mc<lical  law  in,  896. 
Orificial    surge jn,    alleged    achievements   of 

the,  540. 
Osteoarthropathy,   hypertrophic  pulmonary, 

426. 

Osteopathy,  90.  .  ,    „        r 

Oslrom,  Homer  I.,  uterine  volsellum  for  use 
in  vaginal  hysterec  omy.  13!!. 

Otology,  International  Congress  of,  596. 

Ovaries,  effect  of  removal  of,  upon  the  sex- 
ual appetite,  273. 

Ovariotomy,  effect  of  removal  of,  upon  the 
voice,  272  ;  double,  in  a  woman  seventy- 
one  years  of  age,  205.  ,  .,      .  , 

Ovarv  in  the  pelvic  cavity,  calcification  ol 
an    49Z  ;  muliilocular  cyst  of  the,  673. 

Overtoil,  Krank,  contu-ion  and  laceration  of 
anteri  >r  va^inil  wall  and  urethra,  382. 

Oxygen  gas  with  chloroform  or  ether  for  an- 
.-tsthesia,  50;,  6*2.  '^''.V 

Oy>ters  and  typh  .id  fever,  557  ;  poisoning 
by,  893. 

Ozsena,  formula  for,  820. 


Pachymeningitis  interna  lisemorrhigica,  64. 
Packard,  C.  W.,  inversion  of  the  uterus  of 
hve   days'    standing  ^  successful  reduc- 
tion, 588. 
Page,  Harlan  M.,  a  case  of  pilonidal  fistul.-i, 
465  ;  echinoeoccus   cysts   of   the    liver, 
pleura,  omentum,  mesentery,  peritone- 
um, and  bladder,  411. 
Pains,  growing.  16. 

Palate,  cleft,   when   to   operate  upon,  895  ; 

deformities  of  the,  in  degenerates.  747. 

Palmer,  Edward  R.,  death  of,  55;  meeting 

in  memoi-y  of  the  late,  740. 
Pancreas,  pathology  of.  15  ;   primary  carci- 
noma of  the  head  of  the,  301. 
Pancreatic  juice,   inlluence   of  bile    on   the 

proteolytic  action  of,  878. 
Papilloma  of  the  nasal  septum,  102. 
Paracelsus,  the  skeleton  of,  828. 
Paralyses  of  infancy,  562. 
Paralysis,  infantile,  correction  of  deformities 

following,  581,  599  ;  obstetrical,  65. 
Paranoiac,  a  menace  to  society,  4S9. 
Paraplegia,  Pott's,  159. 
Paresis  and  tabes,  association  of,  480 ;  is  it 
a    microbic    disease?  616;    relation    of 
syphilis   to,   344;    remissions   of,    839; 
some  statistics  on,  34. 
Paris,  letters  from.  32,   140,  573,  641,  788. 

895. 
Park,  Koswell,  on  the  deformities  and  mal- 
formations resulting   from  acute  infec- 
tions in  bone,  613. 
Parotitis  and  chicken-pox,  123. 
Parovarian  cyst  complicated  by  the   passage 

of  renal  calculi,  372. 
Partridge,  Edward  L.,  pregnancy  associated 

with  diabetes,  109,  131. 
Parturition,  diseases  of,  104. 
Parvin,  Theophilus,  notice  of  book  by,  561. 
Pasteur,  M.   Louis,  death  of.  641  ;    funeral 
of.  523  ;  last  illness  of,  646  ;  memorial 
tablet  to,  set  up  by  the  Paris  Municipal 
Council,  850;  obituary  of,  488 ;  the  last 
will  of,  828. 
Patella,  excision  of,  for  sarcoma,  753  ;  suture 
of  fractured.  284  ;   total  extirpation  of 
the,  448  ;  treatment  of  fracture  of  the, 
66.' 216. 
Pathological  medical  club.  790. 
Pathology,  influence  of,  in  medical  progress, 

'45- 

Patients,  a  doctor  with  two  million,  557. 

Pediatrics,  a  new  journal.  850. 

Pelvic  contractions,    observations  on,    583, 

605- 
Pelvic  hematocele  and  hsematoma.  568. 
Pelvic  peritonitis  and  cellulitis.  568. 
Pelvis,  abscesses  of  the,  318. 
Penis  and  scrotum,  plastic  operation  on,  409. 
Pennsylvania  colony  farm  for  epileptics,  900. 
Pensions  to  medical  mtn,  522. 
Percussion  hammer,  a  new,  359. 
Pericardium,  adherent,  a   physical    sign  of, 
234;    dissecting  aneurism  of  the  aorta 
rupturing  into  the,  713  ;  suture  of,  628. 
Perineal  retractor,  self  retaining,  138. 
Perineum,  laceration  of  the,  566. 
Peritoneum,    absorption    of   blood     through 
the,   221  ;   and   tran,versalis  fascia,  dis- 
tinction   between,    716  ;  irrigation   and 
drainage  of  the,  455  ;  to  peritoneum,  a 
surgical  mistake,  S33- 
Peritonitis,  etiology  ol,  861  ;    general  sup- 
purative, cceliolomy  in,  455;  microbiol- 
ogy  of  acute,    15:    purulent,   following 
gunshot  wound  of  the  abdomen,  741  ; 
tutwrcular.  4i;4.  59"- 
Perkins.  J.  M. ,  an  enceph.ilous  monster,  492. 
Peroneal  muscular  atrophy.  65. 
Personality,  duplex,  324,  574- 
Pertussis,  formula  for,  393. 
Petit,  E.  P.  Leon,  notice  of  book  by,  70b. 
Petrifaction  of  the  dead,  575- 
Pettit,  L.  C,  is  paresis  a  microl.ic  disease i- 

616;  some  statistics  on  paresis,  34. 
Pharmacopoia.  British,  proposed  revision  of 

the,  3t,  421. 
Pharmacy,  legitimate,  453. 
Pharyngeal  abscess,  retro-,  317- 
Pharyngitis,  chronic,  formula  for.  677. 
Pharynx,    lymphoid    hypertrophies    of    the 


vault  of  the  pharynx,  675  ;  tuberculosis 
of  the,  100. 

Phenylhydrazin-hydrochlorate  in  the  diagno- 
sis of  diabetes  mcllitus,  443. 

Phillips,  Horace,  therapeutic  value  of  water 
in  the  treatment  of  some  nervous  and 
mental  conditions,  404. 

Phillips,  S.  Latimer,  cause  and  treatment  of 
corneal  ulcers,  267. 

Phimosis  case,  175- 

Phonographers,  Society  of  Medical,  306. 

Phthisis  and  insanity,  64;  following  chan- 
cre, 131 ;  mixed  infection  in,  751  ;  seda- 
tive cough  mixture  in,  927  ;  see  also 
Tuberculosis. 

Physical  training  as  a   therapeutic  measure. 

Physician  and  pharmacist,  relation  of.  104; 
imprisonment    of  a,  for    negligent  pre- 
scription, 92. 
Physiologists,  congress  of,  559. 
Physiology,  address   in,  before    the    British 

Medical  Association.  247. 
Physometra,  592. 

Pia  mater,  endothelioma  of  the,  169. 
Piano  playing  and  neuroses,  92. 
Pierson.  Samuel,  clinical  history' of  the  Stain- 

ford  typhoid-fever  epidemic,  804. 
Pilonidal  fistula,  465. 
Pinard.  Adolphe,  notice  of  book  by.  129. 
Pirogoff  Museum  in  St.  Petersburg,  596. 
Pityriasis  versicolor,  formula  for,  311. 
Placenta,  a  new  method  of  delivery  of  the, 
225 ;  diseased,  711;  hydatids  of,  387 ; 
prsevia.  a  case  of,  240. 
Plague  in  China,  503,  900. 
Plants  and   animals,  fundamental   difference 

between,  377. 
Plasterof-Paris  bandage,  how  to  remove,  SSo. 
Pleura,  calcareous  deposit  in  the,  316. 
Pleurisy,  relation  between  serous,  and  tuber- 
culosis, 662. 
Pneumonia,     blood-letting  ;for.    45 ;    causes 
of  death  in.  924;  digit.alis  in,  786;  dis- 
cussion   on    acute    lobar,     before     the 
British  Medical  Association.  27S;  neu- 
ritis  of   the  brachial    plexus  following, 
709  ;    pyrexia  of,    748  ;     strychnine  in, 
S64  ;  successful  treatment  of,  22. 
Poet,  a  medical,  595. 

Pohly,  .-Mbert,  a  case  »f  multiple  abscess  of 
the  external  auditory  canal,  followed  by 
perichondritis  auricuhu.  23S. 
Poisoning  by  tinned  food,  575. 
Police  surgeonship,  examinations  for,  450. 
Pollailar,  Ur  ,  notice  of  liouk  by,  237. 
Pons,  localization  of  lesions  in  the,  59. 
Pope,  the  health  of  the,  415. 
Porter,  Sir  Oeorge.  death  of,  70. 
Portraits  of  medical  men,  739. 
Post-partum  hemorrhage,  ptimary,  204. 
Pott's  paraplegia,  159. 

Powers.  C.  .-V.,  the  climate  of  Colorado,  789. 
Practice,  how  to  begin,  54  ;  h"w  to  get,  32  ; 
of  medicine  in  the  light  of  bacteriological 
researches,  577,  600. 
Practitioner,  the  country,  178. 
Practitioners  Society  of  New  Vork,  131,  706. 
Pregnancy  and  labor  complicaled  by  cardiac 
disease,  210;   appendicitis  during,  609; 
a-sociated  with  diabetes.  109,  131  ;  der- 
moid  cysts     coniplicaiing.    465;    diag- 
nosis and  treatment  of  appendicitis  dur- 
ing. 407  ;  diseasesof,  104  ;  e^tra  uterine, 
:io,    568,  boi,  674,  716,    782;    extra- 
uterine,   abdominal     section    for,    370; 
extrauterine,     ruptured.     8!;6 ;    extra- 
uterine,   parovarian    cyst  mistaken  for, 
372  ;  extra-uterine,  twin,  144 ;  manage- 
ment of  heart  disease  in.  02S  ;  remedies 
to  be    avoidc'l    in.    393;    vomiting    of, 
electricity  in,  268 ;  vomiiing  of,  reme- 
dies for,  860. 
Prentice.  Chaliner.  notice  of  lioi>k  by.  345. 
Presbyterian  Hospital  running  into  debt,  8l2. 
Prescription,  legibility  of  the.  556. 
Preston,  Ceorge  J.,  ca>esof  brain  lunior,  346. 
Preltyman.  ?.  S..  theeliology  of  cancer,  682. 
Prince,  John  A  ,  calcilicalnin    of   an    ovary 
lying  free  in  the  pelvic  cavil  y.  492  ;   der- 
moid cysts  and  Diegiiaiiiy,  465. 
Prize,  Alvarenza.  812  ;  for  e>-.ay  on  hygiene, 
236;  for  e>says  en  >mall-pox  and    vac- 
cination, 756';   Hodgkin-,  awaid  of  the, 


942 


INDEX. 


[December  28,  1895 


lignant  disease  of  the,  645;   ulceration     Scarlet    fever,  contagion  of,  717;    sur<ncal 
of,  678;  vaginal  resection  6f  the,  563.  918.  "       ' 


199;   of  the  French  Institute,  award  of 
the,  736  ;  Patrick  Stewart,  award  of  the, 

247  ;    the  Samuel  D.  Gross,  748 ;    the     Regents  of  the  University,  representative"'of,  Schavoir,   F.,  origin  and  course  of  the  ty. 
Weber- Parkes,  306  ;  WiUiam  F.  Jenks             in  New  York,   306 ;  preliminary  exami-  phoid   fever   epidemic   in    Stamford    m 

memorial,  award  of,  236,  342.  nations  of  the,  for  medical  students,  631.  1895.  803. 

Proben,    Charles   I.,    exophthalmos  due   to     Registration,  reciprocity  in.  106,  179,  251.  Schede,  Professor,  call  of,  to  Bonn    64C 

intra-orbital  cyst,  265.  Reichard,  N.  W.,  the  policy  of  reduced  fees  Schimmelbusch,   Dr.,  death  of,  W? -notice 

Proegler,  Carl,  a   cas«  of  tetanus   (trismus)  for  insurance  examinations,  825.  of  book  by,  237.  ' 

with  recovery.  494.  Remedies,  our  native.  881.  Schlatter,  Francis,  the  Denver  healer   774. 

Repair,  the  process  of,  422.  Schmidt,  Dr. .  notice  of  books  by,  814    .cj^ 

Respiration,  inhibition  in  physiology  of,  58.  Schneidemuhl,   G.,  notice  of  book  by,  -jo^ 

Reynaud's  disease  of  the  ears,  525.  School,  prevention  of  infection  in  the,  \zj,.'^. 

Rheumatism  as  a  cause  of  appendicitis,  373  ;  Schroeder,     Henry    H.,    severe    spasmodic 
appendicitis  in,   749  ;    causes  of  acute,  muscular  contractions  due  to  reflex  inl- 

and  relation    to   other   affections,   281 ;  tation  from  cicatricial  tissue.  893 

cause  of    the  pains  in,    861  ;    chronic,  Schumpert,  T.  E.,  treatment  of  fracture  of 
formula  for,   678 ;  cimicifuga   in,   344  ;  the  patella,  66. 

gonorrhoeal.  677  ;  inunction  of  salicylic  Sciatica,  nitroglycerin  in,  750. 

acid  in,  785  ;  salicylic  acid  extemally'in,  Science  and  the  French  druggist,  269. 

94  ;  the  Secretary  of  Agriculture  on,  432  ;  Sclerosis,     amyatrophic    lateral!     64.     710; 
treatment  of,  392  ;  treatment  of,  by  bee-  combined,'  a  possible  case  of   745  •  mul- 

s'ings.  339.  tiple,  and  tabes,  64.  '  ' 

Rhmitis,  treatment  of,  860.  Scott,  Dr.  Edward,  death  of.  343. 

Rhinoplasty  in  India,  349.  Scrotum  and  penis,  plastic  oj^ration  on  the, 
Ribot,  Th..  notice  of  book  by,  129.  409  ;  angiokeratoma  of  the,  525. 

Ribs,  periostitis  and  necrosis  of  the,  follow-  S^uin,  E.,  notice  of  book  by,  814 

ing  typhoid  fever,  381.  Seidl,  Carlos,  notice  of  book  by,  3^5. 

Rice,  Clarence  C,  importance  of  administer-  Semeleder,  Dr.,  medical  language,  574. 

ing  iodide  of  potassium  in  laryngeal  dis-  c---  ;-   ■  ■  -    - 

eases  of  doubtfij  diagnosis,  i. 
Richardson,  John  B.,  epistaxis,  124. 
Richardson.  Sir   B.  W.,  and  scientific  accu- 
racy, 359. 
Rickets  and  convulsions,  924. 
Ried,  Professor  Franz  von.  death  of,  216. 
death  of,  668. 


Profession,  a  blood  thirsty,  360. 
Progress  of  medicine,  793,  819. 

Progress,  proofs  of,  508;  surgical,  the  story 
of,  559- 

Prostate  gland,  cancer  of  the,  715;  early 
symptom  of  disease  of  the,  286  ;  hyper- 
trophy of  the,  castration  for,  165 ;  hyper- 
trophied,  resection  of  the  vas  deferens 
in,  844;  surgical  prevention  of  hyper- 
trophy of  the,  503. 

Prostatectomy,  suprapubic,  823. 

Prostatitis,  288. 

Prostitution,  what  shall  be  the  policy  of  the 
State  toward?  65 1. 

Provident  associations,  575. 

Pruritus,  treatment  of,  358,  7S4,  785. 

Pryor,  W.R.,  new  method  of  treating  adher- 
ent retroposed  uteri.  76  ;  palliative  treat- 
ment of  gonorrhreic  tubal  disease,  838. 

Pseudo-diphtheria,  recent  studies  on,  599. 

Psoriasis,  treatment  of,  678,  784,  786,  927. 

Psychology,  experimental,  iii  ;  in  medicine, 
460. 

Psychosis,  traumatic,  in  a  horse,  305. 

Ptomaines,  poisoning  by,  249. 

Puerperal  sepsis,  causes  and  prevention  of, 
54,  ■ 


curative  treatment    of,   753  ;  hys-     Riley,  Professor  C.  V., 

terectomy  for,  454  ;  in  a  dog,  569 ;  pre-     Roberts,  Tohn  B.,  notice  of  book  by,  633. 
vention    of,    in   private   practice,    312  ;     Robinsoni   Beverley,   rheumatism  as  a  cau 


of  appendicitis,  373. 
Robinson,   BvTon,  notice  of  chart  by,  345  ; 


Seminal  emissions,  treatment  of,  677. 
Senile  epilepsy  and  Griesinger's  symptom  of 

basilar  thrombosis,  749. 
Senile  heart.   461  ;   dietetic  management  of 
the,  267  ;  some  considerations  with  re- 
gard to  the,  649. 
Senn,  N.,  notice  of  books  by,  849. 
Septum  knife,  a  new,  644. 
Septum   narium,   cork   splint    for   deflected 

376. 
Serum,  horse-,  effects  of  injections  of,  721 
..  „...  783- 

the  appendix  and  cjecum  in,  128;  adult     Serum-therapy,    788,    895;     discussion    on 
post-mortems,  with   anew  theory  as  to  419;    International   Institute   of,   900; 

the  cause  of  appendicitis,  757  ;  the  gas-  priority  in,  774  ;  progress  of,  18.' 

tro-hepatic  omentum,  181.  Sewage,  flooding  of  London  basements  by 

Rochet,  v..  notice  of  book  by.  202.  534  ;  organisms  and  disease,  252  ' 

Rockwell.  .\.    D.,  nature  and  treatment  of    Sex,  correlated  variability  in  the  organs  of, 
chorea,  14S ;  the  physiological  action  of  716.  ' 

periodical  induced  currents,  177.  Sexual   appetite,    effect    of   removal    of  the 

Rogers.  John,  Jr.,  notice  of  book  by,  849.  ovaries  upon,  273 ;  derangements  in  the 

Rose.   A.,  the  question  of  an  international  male,  how  to  diagnosticate,  457. 

language,  2S7.  467,  719;  alkaline  injec-     Seymour,  Abbey  J.,  death  of,  596,  632 
tions  in  gonorrhoea,  430  Seymour,    William   Watkyns,   total  removal 

Rosenthal,  Rich.  S.,  notice  of  book  by,  129.  of  the  tongue  by  Kocher's  method,  569. 

Ross,  John  W. ,  an  easy  and  ready  method  of    Shastid,  Thomas  H.,   a   new  operation   for 
circumcision,  323.  chronic  catarrhal  and  .suppurative  deaf- 

Roth,  Otto,  notice  of  book  by,  59S.  nes.s,  636. 

Round  ligaments,  intra-abdominal  shortening     Shelby.  E.  T.,  maternal  impression,  611. 

of  the,  459.  Sherman,  11.  G.,  electromagnet  for  there- 

Royal  College  of  Physicians,  establishment  moval   of  foreign  bodies  from   the  eve, 

of,  396  ;  women's  petition  to.  753,  929.  212. 

Royal  College  of  Surgeons,  annual  meeting     Shock,  nature  of,  820. 

of,  787;  women's  petition  to  the,  787.       Shorthandin  medicine,  846. 
Roj-ster,   H.   A.,  a  case  of  cortical  hemor-     Shoulder,  bloodless  amputation  at  the,  885  ; 
rhage  with  rupture  into  a  lateral  ventri-  congenital  dislocation  of  the    427  •  old' 

cle,  S21.  dislocation  of  the.  886. 

Ruhrah,  John,  gunshot  wound  of  the  abdo-  Shrady.  John,  notice  of  book  edited  bv.  507 
men,  followed  by  purulent  peritonitis,  Shuckburg,  Dr.  Richard,  author  of '"V'anke-' 
operation,  recover)',  741.  Doodle,"  703. 

„,,,•.■        ,  ,  ...  Rush  monument  fund,  4S7,  522.  Sick  or  ill,  702 

SLf"°i>".!^^='r",°f',''^,f'^",^^««'>=J"'^«'     Russell,  W.H..  the  conduct  of  the  physician     Sigmoid  flexure,  new  method  of  examining 

in  a  case  of  criminal  abortion.  178.  the.   342. 

Russia,  medical  degrees  in,  737 ;  medical  ed-  Simmons.  William  H.,  gunshot  wound  of 
ucation  for  women  in,  42  ;  medical  fees  the  abdomen,  491. 

'"'.  .7-1^5 ;    medical    profession    in,   S94 ;     Sims,  Dr.  J.  Marion,  and  his  work,  694. 

540;  syphilis  in,     Sinus  pyoemia  and  jugular  thrombosis,  126. 


surgical  treatment  of,  314. 

Puerperium,  infection  in  the,  391 ;  sudden 
death  from  venous  thrombosis  in  the, 
854. 

Pulmonary  medication,  direct  intra-,  278. 

Pulse  in  insanity,  179. 

Pump,  a  new,  790. 

Punton,  J.,  the  present  status  of  antitoxin  in 
London,  107. 

Purpuric  eruption  apparently  caused  by  so- 
dium salicylate,  530. 

Putnam,  William  E  ,  treatment  of  typhoid 
fever,  348. 

Pyonephrosis,  nephrectomy  for,  671. 


Quackery  in  Bavaria,  715  ;  in  Connecticut, 

S39  ;  in  P.iris,  573. 
Quacks,  advertising,  what  shall  be  done  with  ? 

54- 
Queralto,  J.,  notice  of  book  by,  346. 


R 


Rabagliati,  A.,  notice  of  book  by,  129. 
Rabies,  serum-therapy  of,  560;   the  first  in- 
oculation against,  641. 
Race  and  disease,  900. 
Rachford,  B.  K..  influence   of  bile   on   the 


87S ;  notice  of  a  book  by,  634. 

Railway  hospital,  the  first  in  the  United 
States,  452  ;  for  the  East,  377 ;  hy- 
giene, 557,  559;  liability  of  a,  for  medi- 
cal services,  415  ;  sanitation,  180;  spine, 
57  ;  Surgeons,  New  York  State  Associ- 
tion  of,  776. 

Ramsey,  Douglas  C,  report  of  cases  in  brain 
surgery,  122. 

Rand,  Henry  W.,  death  of,  343  ;  resolutions 
on  the  death  of,  646. 

Ramson,  J  15.,  shall  insane  criminals  be  im- 
prisoned or  put  to  death  ?  37. 

Ration,  the  army,  773. 

Reasoner.  Richard,  death  of,  164. 

Reciprocity  in  registration,  106.  179,  251. 


suicide  and  crime 


163  ;  university  students  in,  nS. 
Russian,  translation  from  the,  524. 
Rust,  prevention  and  removal  of.  912. 


accessory,   suppurative   disease 


Sachs,  B.,  notice  of  hook  by,  129. 
Salicylate   of   sodium,    eruption   apparently 
caused  by,  530. 
,,,    -  ,,   .,-         .       ■         ,•.•"--'■         Salicylic  acid,  absorption  of,  92. 

riv  fy'='"°"'='    f    ";«.    316:     Salpingitis.  482,    567;    gonofrhreal,  pallia- 

double  current   irr.gaor   for    the,   S25,  tive  treatment  of,  S38. 

862  ;  Kraske  s  method  of  excision  of  the,     Salvation  Army  and  sm.ill-pox,  249,  394. 
ckU    TX  °f /'^^''^f  °   ">?•  ^  «  ^Pe-     S.anger,  Wm.  W.,  notice  of  book  by,  203. 
cialty,  658;  new  method  of  examining     Sanitarv  science,  54a 

he   342  ;  prolapse  of,  428  ;  surgical  in-     Sarcoma,  chemistry  of,  423  ;  of  the  medulla, 
terference  in  disorders  of  the,  780;  to-  ,3/  • 'i-'j  ,  "   '  c  i.icuuua, 

tal  extirpation  of,  14  ;  treatment  of  ma-     Saw,  a  new  nasal,  645. 


»32- 

Sinuses, 

97- 

Skcel.  Frank  D.,  a  head-rest  for  the  Javal 
ophthalmometer,  862. 

Skene,  .-Vlexander  J.  C.,  notice  of  book  by, 
.93- 

Skin,  arsenic  in  diseases  of  the,  •/17;  cancer 
of  the,  early  treatment  of,  3S7  ;  diet  in 
the  etiology  and  treatment  of  disease  of 
the,  918;  lesions  of  the,  etiological  re- 
lation of  erysipelas  to.  723 ;  new  rem- 
edies for  disease  of  the,  387  ;  sleep  in  its 
relation  to  disease  of  the,  688. 

Skin-grafting,  epithelioma  following,  170  • 
new  method  o(  obt.aining  material  for, 
605.  Soo. 

Skull,  depressed  fracture  of  the,  with  am- 
nesic aphasia,   S57;   gunshot  wound 'of 


December  28,  1895] 


INDEX. 


the.  569 ;  indications  for  resection  of 
the,  310  ;  repair  after  bone-flap  opera- 
tion in  the,  285  ;  trephiniag  for  fract- 
ured, 492. 

Sleep  for  nine  days,  576  ;  in  its  relation  to 
diseases  of  the  skin,  688;  new  theory 
of,  161. 

Sloan,  T.  W.,  horizontal  position  for  apply- 
ing plaster  casts,  213. 

Sloughs,  application  to  bad,  755. 

Small,  Sidney  I.,  Friedreich's  ataxia.  85. 

Small-pox  and  the  salvation  army,  249,  394, 
895  ;  and  vaccinia,  425. 

Smith,  A.  Alexander,  the  practice  of  medi- 
cine in  the  light  of  bacteriological  re- 
searches, 577,  6txx 

Smith,  Andrew  H.,  the  use  of  the  differen- 
tial stethoscope  in  the  study  of  cardiac 
murmurs,   121. 

Smith,   E.  H. ,  cancer  in  husband  and  wife, 

383- 
Smith,  Frederick  G.,  palliative  treatment  of 

hav  fever,  4S4. 
Smith,  George  \V. ,  modem  Greek  as  an  in- 
ternational medical  language,  178. 
Smith,  J.  Laphom,  effect  of  removal  of  the 

ovaries  upon  the  sexual  appetite,  273. 
Smoking,  increase  of,  40a 
Snake-poison,   antitoxin  of,   162,  421,   S23> 

576. 
Southern  Surgical  and   Gynecological  Asso- 
ciation, 777. 
Southgate,    F.    H.,  blood   absorption    from 
the  peritoneal  cavity,  221  ;  influence  of 
bile  on  the  proteolytic  action  of  pan- 
creatic juice,  878. 
Specialism,  some   of  the  disadvantages   of, 

518. 
Spelling  deformation,  148. 
Spina  bifida,  operative  procedure  for,  263. 
Spinal  cord,   injury  to,   a  long  survival   of, 
490  ;  lumbar  puncture  of  the  subarach- 
noid space,  746. 
Spine,  caries  of,  open  air  treatment  of,  174  ; 
caries  of,  operative  treatment  of,  923  ; 
paraplegia  in  caries   of  the,   159;  sur- 
gery of  the  cervical,  354. 
Spleen,  angioma  cavemosum,  418;  enlarged, 
in   pneumonia    and    pericarditis,    173  ; 
successful  excision  of  the,  668. 
Splenectomy,  357. 

Sprain  of  the  foot,  treatment  of,  533. 
Sprains  treatment  of.  by  massage,  341. 
Spratling,  Edgar  J.,  delusion  of  stiffened  ex- 
tremities   treated    by   extension,    173  ; 
ma'iturbation  in  the  adult,  442. 
Spratling,   William   PhUip,  a  brief  study  of 
the  physiological  epochs  that  predispose 
to  insanity,  549. 
Sprecher,  D.  B. ,  successful  use  of  antitoxm 
for  diphtheria  in  country  practice,  465. 
St    LouLs  Academy  of  Medical  and  Surgical 
Sciences  of,  884;  free  dispensaries   m, 
379. 
St.    Luke's    Hospital,    pathological   depart- 
ment of,  884. 
St.  Petersburg,  Women's  Medical  Institute 

in,  664. 
St.  Vincent's  Hospital,  death  of  the  Sister 

Superior  of,  48S. 
Stab-wounds  of  the  intestines,  treatment  of, 

777- 
Stamford,  epidemic  of  typhoid  fever  in,  803, 

804. 

State  Medicine,  388. 

Stedman,  Thomas  L.,  notice  of  book  edited 
by,   237,  813.  ,     .      ■ 

Steele,  Whitmore,  commitment  of  the  in- 
sane, 53s  ;  the  remissions  of  general  pa- 
ralysis. S39. 

Sterilized  milk  and  free  lunch,  321. 

Sternberg,  George  M.,  notice  of  book  by, 
93  ;  the  proofs  of  progress,  508. 

Stemberger,  Edwin,  what  constitutes  the 
well-qualified  doctor,  769. 

Stethoscope,  an  improvetl,  6S2  ;  differential, 
in  the  study  of  cardiac  murmurs,  121. 

Stewart,  A.  H.,  importance  of  fresh  air  ard 
exercise  in  the  treatment  of  tuberculo- 
sis. 546.  , 

Stewart,  D.  D.,  persistent  absence  of  the 
gastric  secretory  function,  192. 

Stewart,  R.  W,,  a  new  urethrometer,  683. 

Stickler,  Joseph   William,   chloroform   and 


ether  with  oxygen,  S63 ;  some  original 

investigations   showing  the  antagonism 

between  morphine  and  cocaine,  433. 

Stimson,  Lewis  A.,  notice  of  book  by,  849 

Stimulants  for  athletes,  775. 

Stinson,  J.  Coplin,  treatment  of  fibro-myo- 

matoqs  uteri,  77. 
Stomach,  cancer  of,  free  hydrochloric  acid 
in,  601  ;  cancer  of  the.  recent   obsena- 
■   tions  on,  919;  cancer  of  the,  treatment 
of,  679 ;   functional  disorders  of  the.  ac- 
companied  with    hyper-secretion.   602, 
724  ;  lavage  of  the,  S60  ;  persistent  ab- 
sence of  the  secretory  function  of  the, 
5,  192,  205  ;  the  sensation  of  the,  and 
disordered  digestion,  500  ;  ulcer  of  the, 
171  ;  ulcer  of,  diagnosis  and  treatment 
of  perforation  of,    921  ;    ulcer  of,  per- 
foration   of   the   diaphragm     in,    IS9  1 
ulcer    of  the,  possibly  caused  by  hot 
water,  676. 
Stomach-douche  and  its  use,  430. 
Strabotomy,  SJ'o. 
Strychnine,  delirium  from,  537. 
Study.   Joseph   N. ,  operation    for    gunshot 

wound  of  the  abdomen,  67. 
Stupor,  thyroid  feeding  in,  387. 
Subarachnoid  space,  lumbar  puncture  of  the, 

746. 
Subclavian  artery,  anatomical  guide  to  the, 

240  ;  aneurism  of  the,  SS6. 
Suicide  and  crime,  comparative  statistics  of, 
540;  cau?es  of,  394  ;  in  its  medical  and 
moral  aspects  *9S ;  in  Russia,  25 1  ; 
in  the  United  States  217  ;  Professor 
Heine  on,  500  :  rare  among  negroes, 
931. 
Suprarenal  extract,  305,  75 1  ;  m  Addison's 

disease,  38'3. 
Surgeon,  the  morals  of  a,  524. 
Surgery,  address  in,  before  the  British  Medi- 
cal Association,  245. 
Surgical  progress  the  story  of,  559. 
Suture,  buried,  technique   of  the,  782  ;  dis- 
advantages of  non-absorbable,  in  hernia 
operations,  744. 
Swiss  universities,  summer  attendance  at,  684. 
Sycosis,  treatment  of,  429.  679,  785. 
Symphyseotomy,  410;    a  well  formed  word, 

881 ;  z'S.  Csesarean  section.  208. 
Syncope  during  ether  narcosis  alcohol  to  be 

avoided  in,  533. 
Syphilis,   apoplexy  due  to,  26;  changes  in, 
the  blood  in,  912;  changes  in   the  fe- 
male genitals  due  to,  360;  congenital, 
929;    headache    in,    791;    non-specific 
lesions  in  the  subjects  of,  844  ;  serum- 
therapy  of,  722,  808  ;  treatment  of,  457  ; 
fj.  tuberculosis,  910,  923. 
Syringe,  theBransford  Lewis  infiltration,  S27. 
Syringomelia,  423. 


943 

Therapeutic  traditions,  some,  450. 

Thirst,  after  coeliotomy.  prevention  of,  455. 

Thistle.  W.  B..  elimin'ative  and  antiseptive 
treatment  of  typhoid  fever,  361. 

Thomason.  J.  W. .'report  of  a  case  involving 
the  question  of  the  diagnosis  and  of  the 
proper  treatment  of  appendicitis  in 
pregnant  women,  407. 

Thompson,  John  A.,  deafness  from  intra- 
nasal dUease.  337. 

Thompson,  W.  G.  notice  of  book  by.  561. 

Thomsen's  disease,  pathology  of,  540. 

Thomer,  Max.  a  new  mastoid  retractor,  105. 

Throat,  foreign  bodies  in  the,  684. 

Thrombosis,  venous  sudden  death  from,  in 
the  puerperium.  854. 

Thudichum,  J.  L  W.,  notice  of  book  by,  130. 

Thumb  as  an  "initial  factor  of  civilization.  188. 

Th>T0id  feeding,  dangers  of.  792  ;  in  stupor, 
387  :  miscellaneous  uses  of,  416. 

Thyroid  gland,  treatment  of  neoplasms  of  the. 


Tabes  and  multiple  sclerosis.  64  ;  and  para- 
lytic dementia,  association  of,  480  ;  early 

sign  of,  538  ;  etiology  of,  520. 
Tachcs  blenatres  928 
Tapeworm,  treatment  of,  173,  520. 
Tartar  emetic  in  tedious  labor,  491. 
Tattoo  marks,  removal  of,  717.  756. 
Taylor,  T.  E.,  symphyseotomy,  410. 
Taylor,  Robert  W.,  notice  of  book  by,  81 3. 
Tea,  effects  of,  upon  digestion,  632. 
Temperance  Congress  in  England.  68 1. 
Temporo-maxillary  joint,   ankylosis  of  the, 

6S1. 
Tendon  of  the  quadriceps  extensor  femons, 

rupture  of  the.  625. 
Tendon  grafting,  581,  599. 
Terminology,  medical,  115,  136. 
Tetanus,    a   case    of.    with    recovery,    494 ; 

cured  by  antitoxin,  273  ;  traumatic.  382  ; 

traumatic,  with  urethral  spasm,  381, 
Tetany,  105. 
Texas  fever.  468. 
Thayer.  C    C,  the  neuro-chemical  aspect  ol 

'diabetes.  230. 
'•  The  woman  who  did,"  704. 
Thermometer,  a  shorter  scale  for  the,  322, 

497. 
Thermometer-case,  auto  sterilizing,  497. 
Therapeutic  progress,  a  slower  pace  neces- 
sary.  II 8. 


Thyroidectomy,      423;      for     exophthalmic 

goitre,  2S4. 
Thyroiditis  acute,  14O,  640. 
Tic  douleureux,  intra-cranial  neurectomy  for, 

706  ;  treatment  of,  393,  7S6. 
Timmerman.  C.  F.,  a  case  of  tetanus  cured 

with  antitoxin.  273. 
Tingley,  Hilbert  B.,  atrophy  of  the  uterus 

640. 
Tinned  food,  to  avoid  poisoning  by,  575. 
Titchener,  E.  B.,  experimental  psychology, 

Tobacco  and  religion.  55  ;  cure  of  the  habit, 
786;  insomnia  from,  751. 

Toller.  Dr.  Charles,  brave  act  of,  632,  861. 

Tolstoi,  a  medical  disciple  of,  503. 

Tongue,  rhythmic  tractions  of  the,  4:9  ;  to- 
tal removal  of  the,  569. 

Tonsillitis  acute,  and  the  rheumatic  state, 
96 :  chronic  lacunar,  16  ;  diagnosis  of 
the  form  of,  861 ;  sodium  salicylate  for, 

Tonaf",  chancre  of  the.  446  ;  hypertrophied, 
impairment   of  hearing  from,    324 ;  re- 
moral  of  the,  97  ;  pathology  of  the,  32 ; 
tut)erculosis  of  the,  125- 
Tooker,  Robert  N..  notice  of  book  by,  ao2. 
Toothache,  epidemic  of  580. 
Torsion  instead  of  ligatures  2S5. 
Torticollis  treatment  of.  887. 
Tourette.  Gilesdela.  notice  ofbookby,  202. 
Townsend,  Dr.  Franklin,  death  of,  668. 
Trachea  tube,  a  guide  for,  138  :  a  substitute 

for  the,  514. 
Tracheotomy,    first    incision    causes    anaes- 
thesia, 533  ;  for  laryngeal  cellulitis  637  ; 
removal  of  an  inlub.ition-tube  from  the 
bronchus  tiv,  641.  * 

Training  in  England  and  America,  75b. 
Treves    Frederick,  notice  of  book  edited  Dy, 

561. 
Tricophytcsis  formula  for,  428. 
Tricuspi'd  valve  disease,  417- 
Triplets  =03.  , .  ,„.     . 

Tri  State'Me-lical  Society  of  Io»-a,  Illinois 

and  Missouri,  667. 
Trismus,  a  peculiar  case  of,  742. 
Trudeau,    E.    L,    a   chemical   and    experi- 
mental research  nn  anliphthisin,  871. 
Trusses,  antiquity,  679. 
Tryon,  Dr.  J.  R  .  honors  to,  667. 
Tubal  abortion,  318. 
Tubercular  sinuses  irjection  for,  755. 
Tuberculin,  928;  history  of  a  patient  cured 

Tuber'culosi's  acute  miiary,  140;  and  the 
librarv,4S5;  animal.  930;  articu'ar,  op- 
erative interference  m,  669 :  bacteno- 
scopic  examination  for.  by  the  Hcalih 
Department,  574  ;  l-ovine,  104  ;  bovine, 
extinction  of.  in  herds.  730.  743  '•  ^"'- 
bral  in  adults  253  =  -l^gnosis  of  the 
pneumonic  form  of  acute  pulmonary, 
022  •  diet  and  exercise  in  the  treatment 
of  6i;4.  676  ;  f<esh  air  and  exercise  in 
the  treatment  of,  546;  general  miliary, 
888-  guai.icol  in,  2S1 ;  hor^e-senim 
treatment  ..f.  463;  hospitals  for,  393. 
461  :  infection  of  country  hou««5.  926  ; 
laryngeal,  surgical  treatment  of,  815  : 
local  71 7-.  meningeal,  recovery  after 
trephining  for,  75'  J  mortality  from,  in 


944 


INDEX. 


[December  28,  1895 


German  cities,  627  ;  mortality  from,  in 
New  York,  740;  of  the  knee-joint,  841  ; 
of  the  peritoneum,  454;  of  the  skin, 
etiology  of,  531;  of  the  upper  air- 
passages,  99  ;  peritoneal,  590  ;  prophy- 
laxis of,  56 ;  pulmonary,  67S  ;  pulmo- 
nary, cannabis  sativa  in,  784 ;  pulmonary, 
creosote  in,  383,  67S  ;  pulmonary,  in  an 
infant,  172;  pulmonary,  infection  not 
conveyed  in  the  breath,  7^5;  pulmon- 
ary-, p,;ppermint  in,  7S5  ;  pulmonary, 
^potassium  permanganate  m,  66 ;  pul- 
^-^  monary,  treatment  of,  7S6  ;  pulmonary, 
treatment  of  advanced  cases  of,  919  ; 
relation  between  serous  pleurisy  and, 
662 ;  relation  of  bovine  to  human, 
742  ;  relation  of  vicarious  menstruation 
through  the  lungs  to,  179;  serum-ther- 
apy of,  281  ;  the  direct  cause  of,  462  ; 
the  heart  in,  521  ;  tonsillar,  125  ;  trans- 
mission of,  by  bedbugs  717;  vesical, 
supra  pubic  cystotomy  for,  562 ;  vs. 
syphilis,  910,  923  :  yeast  fungi  in,  422, 
S:6i. 

Tucker,  Ervin  A. ,  fostal  dystocia,  334. 

Tumors,  malignant,  discussion  on,  602  ;  of 
the  brain,  63. 

Turbinated  body,  necrosis  of  the,  loi. 

Twins,  89,  275. 

Twin  tubal  pregnancy,  144. 

Tympanotome,  a  new,  683. 

Typhlitis,  acute,  429. 

Typhoid  fever,  abortive  treatment  of,  461 ; 
and  oysters,  557;  bathing  in,  3S6,  860; 
early  bath  treatment  of,  16;  elimination 
and  antiseptic  treatment  of,  361  ;  epi- 
demic of,  in  Stamford,  803,  804;  in 
children,  an  epidemic  of,  S16  ;  in  Con- 
necticut, S08  ;  medicinal  treatment  of, 
461  ;  periostitis  and  necrosis  of  the  ribs 
following,  381  ;  serum-therapy  of,  233  ; 
spread  by  watercress,  72 ;  suit  for  dam- 
ages for  contracting,  628  ;  the  cost  of, 
2S8  ;  transmission  of,  by  the  air,  808 ; 
treatment  of,  34S,  928. 

Typhus  fever,  cases  simulating,  21. 


U 


Ulcers  of  the  leg,  treatment  of,  457  ;  oxygen 
treatment  of,  344. 

Ulerythema  sycosiforme,  532. 

Ulnar  nerve,  dislocation  of  the,  820. 

Umbilical  cord,  rubber  band  for  securing 
the.  790. 

Umbilical  tiemorrhage  in  newly  born  infants, 
^191,  207. 

Uraemia,  acute,  387 ;  mitral  stenosis  con- 
founded with,  8SS. 

Uranaly.sis,  a  well-formed  word,  SSl. 

Uranium  nitrate  in  diabetes  mellitus,  278. 

Uretercystoscope,  Casper's,  744. 

Ureteritis,  gonorrhceal,  389. 

Ureterotomy,  diagnostic,  448. 

Ureters,  surgery  of  the.  i6i. 

Urethra,  absorption  of  drugs  by  the,  576  ; 
supernumerary,  32. 

Urethritis,  posterior,  389. 

Urethronieter,  a  new,  683. 

Urethroscopy  in  chronic  urethritis,  153; 
practical,  325. 

Uric  acid  diathesis,  piperazin  in,  3SS. 

Uricacidaemia,  employment  of  the  term,  395. 

Urine,  domestic  test  for  albumin  in  the,  599  ; 
incontinence  of,  treatment  of,  42!S,  677  ; 
meaning  of  casts  in  the,  without  albu- 
min, 920;  toxic  substances  in  the,  927. 

Urticaria  pigmentosa,  532. 

Utah  State  Medical  Society,  740. 

Uterus,  atrophy  of  the,  640,  754,  S54  ;  can- 
cer of  the,  566  ;  changes  in,  during  the 
third  stage  of  labor,  316;  complete  ex- 
tirpation of,  for  cancer,  S16  ;  diagnosis 
and  treatment  of  retro-displacements  of, 
384;  dilator  of  the,  213  ;  displacements 
of  the,  567  ;  early  diagnosis  and  treat- 
ment of  cancer  of  the,  315  ;  fibroids  of 
the,  cceliotomy  for,  210  ;  fibroids  of  the, 
cured  by  thyroid  gland,  775;  fibroids  of 
the,  treatment  of.  77  ;  fibroids  of  the, 
when  to  operate  upon,  453  ;  gonorrheal 
endocervicitis  and  endometritis,  390 ;  im- 
proved nozzle  for  syringing  the,  676 ;  in- 
fiammation  of  the  appendages  of  the, 


482  ;  intra-abdominal  shortening  of  the 
round  ligaments,  459;  inversion  of  the, 
of  five  days'  standing,  5S8 ;  lactation 
atrophy  of  the,  S54  ;  mechanism  and 
treatment  of  complete  prolapse,  663  ; 
position  of  the  fcetus  in,  316;  preven- 
tion of  disease  of  the,  due  to  child-bear- 
ing. 397  ;  relief  of  rigid  os  during  labor. 
533  '•>  retroposed  adherent,  new  method 
of  treating,  76 ;  rupture  of  the,  673  ; 
tears  of  the  cervix,  S15  ;  treatment  of 
disease  of  the,  by  vibrations,  751  ;  treat- 
ment of  lacerated  cervi.\.  324  ;  tympan- 
ites of  the,  592  ;  vaginal  hysterectomy 
for  cancer  of  the  cervix,  203. 


Vaccination,  a  claim  to  priority  in,  500; 
compulsory,  737 ;  some  of  the  benefits 
of,  501. 

Vaccine  business,  a  State  in  the,  234. 

Vaccinia  and  small  pox,  425. 

Vaccinia  serum,  substitution  of,  for  vaccine 
lymph,  828,  S95,  931. 

Vagina,  atresia  and  stenosis  of  the,  602  ; 
bactericidal  properties  in  the  secretion 
of  during  pregnancy,  429  ;  bacteriology 
of  the,  m  the  new-born,  716  ;  contusion 
and  laceration  of,  382. 

Vaginal,  gjTiecology,  conservative,  210. 

Vaginismus,  treatment  of.  922. 

Vaginitis,  gonorrhceal,  3S9. 

Valentine,  Ferdinand  C. ,  the  largest  cathe- 
ter always,  174;  the  question  of  an  in- 
ternational language,  297  ;  urethroscopy 
in  chronic  urethritis,  153. 

Vallardi,  Dr.  Francesco,  death  of,  631. 

Van  Fleet,  Frank,  abuse  of  medical  charities, 
298. 

Varicocele,  cause  of,  912. 

Varicose  veins,  treatment  of  ruptured,  755. 

Vaso  dilators,  some  new.  823. 

Vaso  motor  disturbances,  relation  of,  to  dis- 
ease of  the  upper  air-tract.  io2. 

Vas  deferens,  resection  of  the,  in  hypertro- 
phied  prostate,  844. 

Vaults,  disinfection  of,  533. 

Vertebr.-E,  caries  of  the,  operation  for,  716. 

Vertiz,  Dr.,  nuclein  is  nature's  antitoxin, 
611. 

Vesiculitis,  chronic  seminal,  with  hemor- 
rhage, 457. 

Victoria  cross,  bestowal  of,  on  Surgeon- 
Captain  Whitchurch,  249. 

Vineberg,  Hiram  N.,  one  cause  of  atrophy 
of  the  uterus,  754. 

Virgines  intactae,  examination  of,  820. 

Vissman,  William,  action  of  diphtheria  an- 
titoxin upon  the  kidneys,  374. 

Vitapathy.  a  judge  scores,  SSo. 

Vivisectionist.  the  anti-,  and  the  Queen  of 
Italy,  501. 

Voice,  effect  of  ovariotomy  upon  the,  272. 

Volsellum,  uterine,  for  use  in  vaginal  hyste- 
rectomy, 138. 

Volvulus  with  displaced  c;i2cum,  569. 

Vomiting  of  pregnancy,  electricity  in,  26S  ; 
of  pregnancy,  remedies  for,  S60  ;  treat- 
ment of,  311,  340. 

Voorhees,  James  D.,  two  cases  of  morphine- 
poisoning  treated  principally  by  forced 
respiration,  768. 

Vulvitis,  gonorrhceal,  389. 


W 


Waldo,  H.  L.,  Latin  as  she  is  spoke  and 
wrote,  215. 

Walker,  Henry  Freeman,  some  remarks  on 
the  morphine  habit,  692,  707. 

Walker  Memorial  Hall,  576. 

Walsliam,  W.  J.,  notice  of  book  by,  203. 

Wangelin,  Hugo  E.,  traumatic  tetanus  with 
urethral  spasm,  381. 

War,  a  doctor's,  824. 

Ward,  Milo  Buel.  intestinal  anastomosis  by 
the  Murphy  button,  859. 

Warner,  Frederick  M.,  obituary  of,  560; 
report  of  intubation  cases  by,  294  ;  res- 
olutions on  the  death  of,  647,  667. 

Warts,  removal  of,  from  the  face,  913. 

Water,  therapeutical  value  of,  in  some  ner- 


vous  and  mental  conditions,   404 ;   vs. 

germicidal  solutions  in  surgery,   105. 
Webster.  J.  Clarence,  notice  of  book  by,  93. 
Weeks,  John  E.,  knife-nee'ilefor  discission  of 

the  capsule  after  cataract  extraction. 467. 
Weichselbaum,  Anton,  notice  of  book   by, 

201. 
Weir,    James,   Jr..    suicide    in    the    United 

States,  217. 
Weiss.   Julius,  the  dispensary,  a  disease    of 

the  body  politic,  645. 
Welch,  William  H. ,  apparent  hj-pei  thermia, 

2.^6. 

Wells,  J.  Hunter,  cholera  in  Korea,  493. 

Westcott,  W.  Wynn,  notice  of  book  by,  201. 

Whiskey  cure,  anotlier.  668. 

White  Cross  Society  in  Italy,  667. 

Whitehead,  W.  R.,  the  thumb  as  an  initial 
factor  of  civilization,  188. 

Wilbur,  W.  J.  B.,  death  of,  20. 

Wiles,  F.  M.,  requirements  for  insane  asylum 
physician,  643. 

Williams,  Cornelius,  a  new  myringotome, 
215  ;  the  curved  capsule  knife,  643. 

Williams,  E.  H.,  Sir  B.  W.  Richardson  and 
scientific  accuracy,  359. 

Williams,  George  H. .  depiessed  fracture  of 
the  skull,  traumatic  amnesic  aphasia,  re- 
covery without  operation,  857. 

Williams,  Herbert  Upham,  infectious  endo- 
carditis of  the  tricuspid  valve,  417. 

Williams,  Isaac  E.,  treatment  of  gonorrhoea, 
.  S70. 

Winter,  Francis  A.,  the  value  of  phtnyl- 
hydrazin  hydrochlorate  in  the  diagnosis 
of  diabetes  mellitus,  443. 

Wisconsin,  new  anatomy  law  in,  647. 

Witham.  A.  X.,  hydramnios  and  spina  bifida, 
24- 

Wives,  doctors',  and  professional  confidences, 
486. 

WoUmann,  Dr.  Marcus,  resolutions  on  the 
death  of,  379. 

WoLseley,  Lord,  offensive  attitude  toward 
medical  men.  681. 

Woman,  a.  in  the  British  Indian  medical 
service.  344,  754  ;  physician,  a  deter- 
mined Russian,  235  ;  the  new,  from  a 
medical  stand-point,  177. 

Women  healers  vs.  women  doctors,  Sio ; 
medical  education  of,  452;  medical  ex- 
amination for,  in  England,  249;  mor- 
phinism in,  673 ;  muscular  strength  of, 
8i2  ;  perfect  types  of,  524  ;  petition  of, 
for  admission  to  the  Royal  College  of 
Surgeons,  7S7  ;  petition  of,  for  admis- 
sion to  the  Royal  College  of  Physi- 
cians, 753,  929  ;  school  of  medicine  for, 
in  St.  Petersburg,  42,  164. 

Wood,  Casey  A.,  temporary  amblyopia  from 
chocolate,  S43. 

Wood,  Richard  11.,  an  anencephalous  mon- 
ster, 893. 

Wood,  rotten,  as  a  cause  of  disease,  599. 

Work  and  worry  as  causes  of  nervous  affec- 
tions, 332. 

Worthington,  J.  C,  successful  treatment  of 
pneumonia  by  cold  applications,  guaia- 
col,  and  strychnine,  22. 

Wossidlo.  H.  R  ,  practical  urethroscopy,  325. 

Wound,  long  survival  of  a  terrible,  7S9 ; 
treatment  of  foul  and  sloughing,  716. 

Writers'  cramp,  65. 

Wyeih,  John  A.,  a  bit  of  ancient  history, 
537  ;  Dr.  J.  Marion  Sims  and  his  work, 
694 ;  long  survival  of  a  terrible  wound, 
789. 

Wylie,  W.  Gill,  prevention  of  uterine  dis- 
ease due  to  child-bearing.  397. 

Wyllie,  John,  notice  of  book  by,  59S. 

V 

Vankee  Doodle,  the  author  of,  703. 
Veasl  fungi  in  tuberculosis,  422. 
Yellow  fever  in  Brazil,  12S. 
Young,  Dr.  John  S,,  death  of,  487,  631. 
Young,  H.  Dudley,  a  new  nasal  saw,  645. 


Zabriskie,  Dr.  John  Lord,  death  of.  704. 
Zwisohn,    L.    \V.,    morning   diarrhiea,   22 ; 
reciprocity  in  r^istralion,  251. 


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